2020 Bright Formulary

(List of Covered Drugs)

Bright Health Individual and Family Plans

Colorado

PLEASE READ: This document contains information about the drugs Bright Health covers in their Individual and Family plans.

This formulary was updated on 11/23/2020. For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the i counter Welcome to Bright

Enclosed you will find a list of the drugs included in our Bright Health Individual and Family plans from January 1, 2020 - December 31, 2020. As you review, be sure to have your medications on hand so you can confirm your prescriptions are covered and compare dosage and pricing of the drugs you take.

Keep in mind, this document includes a comprehensive list of drugs (formulary) included in our Individual and Family plans. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

As a Bright Health Member, you must generally use in-network pharmacies to fill your prescriptions. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the 2020 calendar year.

Have a Bright day!

Sincerely, Your Bright Health Team

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the ii counter Frequently Asked Questions:

What is a Formulary (drug list)? A formulary is a list of covered drugs selected by Bright Health in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Bright Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, and the prescription is filled at a Bright Health network pharmacy.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. These types of changes may occur without notice to you. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money, or we can ensure your safety. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by Bright Health, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find the drugs you take in the formulary:

1. Medical Condition The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug.

2. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index at the end of the formulary. The Index provides an alphabetical list of all the drugs included in

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the iii counter this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Bright Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Bright Health requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Bright Health before you fill your prescriptions. If you don’t get approval, Bright Health may not cover the drug.

• Quantity Limits: For certain drugs, Bright Health limits the amount of the drug that we will cover. For example, Bright Health provides 15 tablets every 25 days per prescription for Zolpidem Tartrate 5mg. This may be in addition to a standard one-month or three- month supply.

• Step Therapy: In some cases, Bright Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Bright Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Bright Health will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website, www.brighthealthplan.com. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Bright Health to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Bright Health’s formulary?” for information about how to request an exception.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the iv counter What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Bright Health does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Bright Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Bright Health.

• You can ask Bright Health to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Bright Health Formulary? You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Bright Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Bright Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.

For more information If you have questions about Bright Health please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the v counter Our Formulary (drug list) The formulary below provides coverage information about the drugs covered by our Bright Individual and Family plans. If you have trouble finding your drug in the list, turn to the Index at the end of the formulary. The first column of the chart lists the drug name. Brand name drugs are capitalized and generic drugs are listed in lower-case italics. The second column of the chart, Drug Tier, tells you which tier the drug falls under. Drug tiers are how we divide prescription drugs into different levels of cost. How much you will pay will depend on your individual plan, however, here’s what the drug tier tells you. • Tier 1: Preventative drugs with no member cost share under the Affordable Care Act • Tier 2: Generic Drugs • Tier 3: Preferred Brand Drugs • Tier 4: Non-Preferred Brand Drugs • Tier 5: Specialty Drugs

The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the vi counter There. Now that’s Brighter.

This formulary was updated on 11/23/2020. For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the vii counter Bright Health Colorado

CURRENT AS OF 12/1/2020

Drug Name Drug Tier Requirements/Limits *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended 2 release 24 hour 1 mg, 2 mg, 3 mg, 4 mg *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 2 QL (30 EA per 30 days) mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 2 QL (30 EA per 30 days) 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 2 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 2 mg dextroamphetamine sulfate oral tablet 10 2 mg, 5 mg methamphetamine hcl oral tablet 5 mg 2 *Analeptics*** caffeine citrate intravenous solution 60 2 mg/3ml caffeine citrate oral solution 20 mg/ml 2 caffeine-sodium benzoate injection solution 2 125-125 mg/ml *Stimulants - Misc.***

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1 Drug Name Drug Tier Requirements/Limits methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 2 QL (30 EA per 30 days) 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 2 QL (30 EA per 30 days) 40 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 2 QL (30 EA per 30 days) 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 2 QL (30 EA per 30 days) 36 mg, 54 mg methylphenidate hcl oral solution 10 2 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 20 2 mg, 5 mg methylphenidate hcl oral tablet chewable 2 QL (180 EA per 30 days) 10 mg, 2.5 mg, 5 mg modafinil oral tablet 100 mg, 200 mg 2 PA *AMINOGLYCOSIDES* *Aminoglycosides*** amikacin sulfate injection solution 1 2 gm/4ml, 500 mg/2ml gentamicin in saline intravenous solution 2 0.8-0.9 mg/ml-% gentamicin sulfate injection solution 10 2 mg/ml, 40 mg/ml gentamicin sulfate intravenous solution 10 2 mg/ml neomycin sulfate oral tablet 500 mg 2 streptomycin sulfate intramuscular solution 2 reconstituted 1 gm tobramycin inhalation nebulization solution 5 PA; SP 300 mg/5ml tobramycin sulfate injection solution 10 2 mg/ml, 80 mg/2ml *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies***

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2 Drug Name Drug Tier Requirements/Limits HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (2 EA per 28 days) INJECTOR KIT 40 MG/0.4ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 5 PA; SP; QL (2 EA per 28 days) MG/0.4ML, 40 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED 5 PA; SP; QL (6 EA per 28 days) SYRINGE KIT 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (2 EA per 28 days) INJECTOR KIT 40 MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (6 EA per 28 days) INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 5 PA; SP; QL (2 EA per 28 days) MG/0.4ML, 40 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED 5 PA; SP; QL (6 EA per 28 days) SYRINGE KIT 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 50 2 QL (60 EA per 30 days) mg celecoxib oral capsule 400 mg 2 QL (30 EA per 30 days) *Nonsteroidal Anti- Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed 2 release 50-0.2 mg, 75-0.2 mg

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3 Drug Name Drug Tier Requirements/Limits *Nonsteroidal Anti- Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg 2 diclofenac sodium er oral tablet extended 2 release 24 hour 100 mg diclofenac sodium oral tablet delayed 2 release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 2 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg 2 etodolac oral tablet 400 mg, 500 mg 2 ibuprofen oral suspension 100 mg/5ml 2 ibuprofen oral tablet 400 mg, 600 mg, 800 2 mg indomethacin oral capsule 25 mg, 50 mg 2 ketoprofen oral capsule 50 mg 2 QL (180 EA per 30 days) ketoprofen oral capsule 75 mg 2 QL (120 EA per 30 days) ketorolac tromethamine oral tablet 10 mg 2 QL (20 EA per 5 days) meloxicam oral suspension 7.5 mg/5ml 2 meloxicam oral tablet 15 mg, 7.5 mg 2 nabumetone oral tablet 500 mg 2 QL (120 EA per 30 days) nabumetone oral tablet 750 mg 2 QL (60 EA per 30 days) naproxen dr oral tablet delayed release 2 375 mg, 500 mg naproxen oral tablet 250 mg, 375 mg, 500 2 mg naproxen sodium oral tablet 275 mg, 550 2 mg sulindac oral tablet 150 mg, 200 mg 2 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg 2 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION 25 5 PA; QL (8 ML per 28 days) MG/0.5ML

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4 Drug Name Drug Tier Requirements/Limits ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL (8 ML per 28 5 PREFILLED SYRINGE 25 MG/0.5ML days) ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL (4 ML per 28 5 PREFILLED SYRINGE 50 MG/ML days) ENBREL SUBCUTANEOUS SOLUTION 5 PA; SP; QL (8 EA per 28 days) RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS PA; SP; QL (4 ML per 28 5 SOLUTION AUTO-INJECTOR 50 MG/ML days) *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule 50- 2 300-40 mg, 50-325-40 mg butalbital-apap-caffeine oral tablet 50-325- 2 40 mg butalbital-aspirin-caffeine oral capsule 50- 2 325-40 mg TENCON ORAL TABLET 50-325 MG 4 *Salicylates*** aspirin adult low strength oral tablet 1 OTC; QL (100 EA per 30 days) delayed release 81 mg aspirin oral tablet 325 mg 1 OTC; QL (30 EA per 30 days) aspirin oral tablet delayed release 325 mg 1 OTC; QL (30 EA per 30 days) goodsense aspirin oral tablet chewable 81 1 OTC; QL (100 EA per 30 days) mg salsalate oral tablet 500 mg 2 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300- 2 QL (390 EA per 30 days) 15 mg acetaminophen-codeine #3 oral tablet 300- 2 QL (390 EA per 30 days) 30 mg acetaminophen-codeine #4 oral tablet 300- 2 QL (390 EA per 30 days) 60 mg acetaminophen-codeine oral solution 120- 2 12 mg/5ml butalbital-apap-caff-cod oral capsule 50- 2 300-40-30 mg

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5 Drug Name Drug Tier Requirements/Limits *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 2 10-325 mg/15ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 2 QL (180 EA per 30 days) 325 mg hydrocodone-ibuprofen oral tablet 5-200 2 QL (180 EA per 30 days) mg, 7.5-200 mg *Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg 2 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 2 PA; QL (10 EA per 30 days) 75 mcg/hr hydromorphone hcl oral liquid 1 mg/ml 2 hydromorphone hcl oral tablet 2 mg, 4 mg, 2 QL (240 EA per 30 days) 8 mg hydromorphone hcl rectal suppository 3 4 mg levorphanol tartrate oral tablet 2 mg 2 methadone hcl injection solution 10 mg/ml 2 METHADONE HCL INTENSOL ORAL 2 CONCENTRATE 10 MG/ML methadone hcl oral solution 10 mg/5ml, 5 2 mg/5ml methadone hcl oral tablet 10 mg 2 QL (240 EA per 30 days) methadone hcl oral tablet 5 mg 2 methadone hcl oral tablet soluble 40 mg 2 QL (9 EA per 30 days) METHADOSE ORAL TABLET SOLUBLE 2 QL (9 EA per 30 days) 40 MG morphine sulfate (concentrate) oral 2 solution 100 mg/5ml morphine sulfate (pf) injection solution 0.5 2 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous solution 2 10 mg/ml, 15 mg/ml, 4 mg/ml morphine sulfate (pf) intravenous solution 4 2 mg/ml morphine sulfate er oral tablet extended 2 QL (90 EA per 30 days) release 100 mg, 15 mg, 30 mg, 60 mg

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6 Drug Name Drug Tier Requirements/Limits morphine sulfate injection solution 10 2 mg/ml, 8 mg/ml morphine sulfate intravenous solution 1 2 mg/ml, 150 mg/30ml morphine sulfate oral solution 10 mg/5ml, 2 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg 2 QL (180 EA per 30 days) morphine sulfate rectal suppository 10 mg, 4 20 mg, 5 mg morphine sulfate rectal suppository 30 mg 3 oxycodone hcl oral capsule 5 mg 2 QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 2 mg/5ml oxycodone hcl oral solution 5 mg/5ml 2 oxycodone hcl oral tablet 10 mg, 15 mg, 2 QL (180 EA per 30 days) 20 mg, 30 mg, 5 mg tramadol hcl er (biphasic) oral tablet 2 QL (30 EA per 30 days) extended release 24 hour 300 mg tramadol hcl er oral tablet extended 2 QL (30 EA per 30 days) release 24 hour 100 mg, 200 mg tramadol hcl oral tablet 50 mg 2 QL (240 EA per 30 days) *Opioid Combinations*** ENDOCET ORAL TABLET 2.5-325 MG 2 ENDOCET ORAL TABLET 5-325 MG 2 QL (360 EA per 30 days) oxycodone-acetaminophen oral solution 5- 2 325 mg/5ml oxycodone-acetaminophen oral tablet 10- 2 QL (180 EA per 30 days) 325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 2.5- 2 325 mg oxycodone-acetaminophen oral tablet 5- 2 QL (360 EA per 30 days) 325 mg oxycodone-aspirin oral tablet 4.8355-325 2 QL (240 EA per 30 days) mg oxycodone-ibuprofen oral tablet 5-400 mg 2 QL (240 EA per 30 days) *Opioid Partial Agonists*** buprenorphine hcl injection solution 0.3 2 PA; SP mg/ml buprenorphine hcl-naloxone hcl sublingual 2 PA; QL (60 EA per 30 days) film 12-3 mg, 8-2 mg PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

7 Drug Name Drug Tier Requirements/Limits buprenorphine hcl-naloxone hcl sublingual 2 PA; QL (90 EA per 30 days) film 2-0.5 mg, 4-1 mg buprenorphine hcl-naloxone hcl sublingual 1 QL (90 EA per 30 days) tablet sublingual 2-0.5 mg, 8-2 mg SUBOXONE SUBLINGUAL FILM 12-3 3 PA; QL (60 EA per 30 days) MG, 8-2 MG SUBOXONE SUBLINGUAL FILM 2-0.5 3 PA; QL (90 EA per 30 days) MG, 4-1 MG *ANDROGENS-ANABOLIC* *Anabolic Steroids*** oxandrolone oral tablet 10 mg, 2.5 mg 2 PA *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 2 PA mg methyltestosterone oral capsule 10 mg 2 PA testosterone cypionate intramuscular 2 PA solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular 2 PA solution 200 mg/ml testosterone transdermal gel 25 mg/2.5gm 2 PA (1%) *ANORECTAL AGENTS* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA 100 2 MG/60ML *Rectal Steroids*** hydrocortisone acetate rectal suppository 2 QL (12 EA per 30 days) 30 mg PROCTO-PAK RECTAL CREAM 1 % 2 PROCTOZONE-HC RECTAL CREAM 2.5 2 % *ANTHELMINTICS* *Anthelmintics*** EMVERM ORAL TABLET CHEWABLE 100 4 QL (12 EA per 365 days) MG ivermectin oral tablet 3 mg 2 QL (10 EA per 30 days) PIN-X ORAL TABLET CHEWABLE 720.5 2 OTC MG

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8 Drug Name Drug Tier Requirements/Limits *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended 2 release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 2 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 2 60 mg isosorbide mononitrate oral tablet 10 mg, 2 20 mg MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 2 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 4 2 % NITRO-DUR TRANSDERMAL PATCH 24 4 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended 2 release 9 mg nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 2 mcg/ml-% nitroglycerin sublingual tablet sublingual 2 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 2 mg/hr nitroglycerin translingual solution 0.4 2 mg/spray *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 30 2 mg, 5 mg, 7.5 mg hydroxyzine hcl intramuscular solution 25 2 AGE (Max 64 Years) mg/ml, 50 mg/ml hydroxyzine hcl oral syrup 10 mg/5ml 2 AGE (Max 64 Years) hydroxyzine hcl oral tablet 10 mg, 25 mg, 2 AGE (Max 64 Years) 50 mg

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9 Drug Name Drug Tier Requirements/Limits hydroxyzine pamoate oral capsule 100 mg, 2 AGE (Max 64 Years) 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg 2 *Benzodiazepines*** alprazolam oral tablet 0.25 mg, 0.5 mg, 1 2 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 2 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml 2 diazepam oral solution 5 mg/5ml 2 diazepam oral tablet 10 mg, 2 mg, 5 mg 2 lorazepam oral concentrate 2 mg/ml 2 QL (150 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 oxazepam oral capsule 15 mg 2 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 2 mg, 150 mg quinidine gluconate er oral tablet extended 2 release 324 mg quinidine sulfate er oral tablet extended 2 release 300 mg quinidine sulfate oral tablet 200 mg, 300 2 mg *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) pf intravenous 2 solution 100 mg/5ml mexiletine hcl oral capsule 150 mg, 200 2 mg, 250 mg *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 2 mg, 50 mg propafenone hcl er oral capsule extended 2 release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 2 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200 mg, 400 mg 2

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10 Drug Name Drug Tier Requirements/Limits dofetilide oral capsule 125 mcg, 250 mcg, 5 500 mcg *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 100-50 MCG/DOSE, 250- 50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 3 QL (12 GM per 30 days) 45-21 MCG/ACT fluticasone-salmeterol aerosol powder breath activated 100-50 mcg/dose 3 QL (60 EA per 30 days) inhalation 100-50 mcg/dose fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 2 QL (1 EA per 30 days) 113-14 mcg/act fluticasone-salmeterol aerosol powder breath activated 232-14 mcg/act inhalation 2 QL (1 EA per 30 days) 232-14 mcg/act fluticasone-salmeterol aerosol powder breath activated 250-50 mcg/dose 3 QL (60 EA per 30 days) inhalation 250-50 mcg/dose fluticasone-salmeterol aerosol powder breath activated 500-50 mcg/dose 3 QL (60 EA per 30 days) inhalation 500-50 mcg/dose fluticasone-salmeterol aerosol powder breath activated 55-14 mcg/act inhalation 2 QL (1 EA per 30 days) 55-14 mcg/act ipratropium-albuterol inhalation solution 2 0.5-2.5 (3) mg/3ml *Beta Adrenergics*** albuterol sulfate er oral tablet extended 2 release 12 hour 4 mg, 8 mg albuterol sulfate hfa inhalation aerosol 3 QL (36 GM per 30 days) solution 108 (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 2 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml 2

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11 Drug Name Drug Tier Requirements/Limits levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 2 ST mg/0.5ml, 1.25 mg/3ml metaproterenol sulfate oral syrup 10 2 mg/5ml metaproterenol sulfate oral tablet 10 mg, 2 20 mg SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 2 mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg 2 VENTOLIN HFA INHALATION AEROSOL 3 QL (36 GM per 30 days) SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 2 0.02 % SPIRIVA HANDIHALER INHALATION 3 QL (30 EA per 30 days) CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 3 QL (4 GM per 30 days) 2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg 2 montelukast sodium oral tablet 10 mg 2 montelukast sodium oral tablet chewable 4 2 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg 2 *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET 250 MCG, 500 4 QL (30 EA per 30 days) MCG *Steroid Inhalants*** ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

12 Drug Name Drug Tier Requirements/Limits ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 3 QL (13 GM per 30 days) 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 2 QL (120 ML per 30 days) mg/2ml, 0.5 mg/2ml, 1 mg/2ml *Xanthines*** theophylline er oral tablet extended release 2 12 hour 450 mg theophylline er oral tablet extended release 2 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml 2 *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 2 mg *Direct Factor Xa Inhibitors*** ELIQUIS DVT/PE STARTER PACK ORAL 3 QL (74 EA per 30 days) TABLET THERAPY PACK 5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3 QL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 3 QL (60 EA per 30 days) 2.5 MG, 20 MG *Heparins And Heparinoid- Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 2 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection 2 solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 2 PA mg/3ml PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

13 Drug Name Drug Tier Requirements/Limits enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 2 PA mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 2 PA mg/0.4ml, 7.5 mg/0.6ml *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 150 MG, 75 4 PA; QL (60 EA per 30 days) MG *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 NAYZILAM NASAL SOLUTION 5 5 QL (10 EA per 30 days) MG/0.1ML *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended 2 release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended 2 release 12 hour 100 mg, 200 mg, 400 mg carbamazepine oral suspension 100 2 mg/5ml carbamazepine oral tablet 200 mg 2 carbamazepine oral tablet chewable 100 2 mg gabapentin oral capsule 100 mg, 300 mg, 2 400 mg gabapentin oral solution 250 mg/5ml 2 gabapentin oral tablet 600 mg, 800 mg 2 LAMICTAL ODT ORAL KIT 25 & 50 & 2 100 MG lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 2 300 mg, 50 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

14 Drug Name Drug Tier Requirements/Limits lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, 42 x 50 mg & 2 14x100 mg lamotrigine oral tablet 100 mg, 150 mg, 2 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 2 mg levetiracetam er oral tablet extended 2 release 24 hour 500 mg, 750 mg levetiracetam intravenous solution 500 2 mg/5ml levetiracetam oral solution 100 mg/ml 2 levetiracetam oral tablet 1000 mg, 250 2 mg, 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 4 PA 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML 4 PA pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 2 PA 75 mg pregabalin oral solution 20 mg/ml 2 PA primidone oral tablet 250 mg, 50 mg 2 topiramate oral capsule sprinkle 15 mg, 25 2 mg topiramate oral tablet 100 mg, 200 mg, 25 2 mg, 50 mg zonisamide oral capsule 100 mg, 25 mg, 2 50 mg *Carbamates*** felbamate oral suspension 600 mg/5ml 5 felbamate oral tablet 400 mg, 600 mg 2 *Hydantoins*** DILANTIN ORAL CAPSULE 30 MG 4 phenytoin oral suspension 125 mg/5ml 2 phenytoin oral tablet chewable 50 mg 2 phenytoin sodium extended oral capsule 2 100 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 2 mg/ml

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

15 Drug Name Drug Tier Requirements/Limits *Succinimides*** CELONTIN ORAL CAPSULE 300 MG 3 ethosuximide oral capsule 250 mg 2 ethosuximide oral solution 250 mg/5ml 2 *Valproic Acid*** divalproex sodium er oral tablet extended 2 release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed 2 release sprinkle 125 mg divalproex sodium oral tablet delayed 2 release 125 mg, 250 mg, 500 mg valproic acid oral capsule 250 mg 2 valproic acid oral solution 250 mg/5ml 2 *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 2 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 2 30 mg, 45 mg *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended 2 release 12 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended 2 release 24 hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg 2 *Modified Cyclics*** nefazodone hcl oral tablet 100 mg, 150 2 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 2 50 mg *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg 2 tranylcypromine sulfate oral tablet 10 mg 2 *Selective Serotonin Reuptake Inhibitors (Ssris)***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

16 Drug Name Drug Tier Requirements/Limits citalopram hydrobromide oral solution 10 2 mg/5ml citalopram hydrobromide oral tablet 10 2 mg, 20 mg citalopram hydrobromide oral tablet 40 mg 2 QL (30 EA per 30 days) escitalopram oxalate oral solution 5 2 mg/5ml escitalopram oxalate oral tablet 10 mg, 5 2 QL (45 EA per 30 days) mg escitalopram oxalate oral tablet 20 mg 2 QL (30 EA per 30 days) fluoxetine hcl oral capsule 10 mg, 20 mg, 2 40 mg fluoxetine hcl oral capsule delayed release 2 QL (4 EA per 28 days) 90 mg fluoxetine hcl oral solution 20 mg/5ml 2 paroxetine hcl er oral tablet extended 2 release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 2 30 mg, 40 mg sertraline hcl oral concentrate 20 mg/ml 2 sertraline hcl oral tablet 100 mg, 25 mg, 2 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release 2 QL (60 EA per 30 days) particles 20 mg, 30 mg, 60 mg venlafaxine hcl er oral capsule extended 2 release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 2 37.5 mg, 50 mg, 75 mg *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 25 mg, 2 50 mg amitriptyline hcl oral tablet 100 mg, 150 2 AGE (Max 64 Years) mg, 75 mg clomipramine hcl oral capsule 25 mg, 50 2 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 2 QL (60 EA per 30 days) 150 mg, 25 mg, 50 mg, 75 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

17 Drug Name Drug Tier Requirements/Limits doxepin hcl oral capsule 10 mg, 100 mg, 2 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml 2 imipramine hcl oral tablet 10 mg, 25 mg, 2 50 mg imipramine pamoate oral capsule 100 mg, 2 75 mg imipramine pamoate oral capsule 125 mg, 2 AGE (Max 64 Years) 150 mg nortriptyline hcl oral capsule 10 mg, 25 2 mg, 50 mg nortriptyline hcl oral capsule 75 mg 2 AGE (Max 64 Years) nortriptyline hcl oral solution 10 mg/5ml 2 trimipramine maleate oral capsule 100 mg, 2 25 mg, 50 mg *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 2 mg *Biguanides*** metformin hcl er oral tablet extended 2 release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 2 mg, 850 mg *Diabetic Other*** GLUCAGON EMERGENCY INJECTION 1 KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp- 4) Inhibitors*** alogliptin benzoate oral tablet 12.5 mg, 25 2 ST; QL (30 EA per 30 days) mg, 6.25 mg JANUVIA ORAL TABLET 100 MG, 25 3 QL (30 EA per 30 days) MG, 50 MG *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 3 QL (60 EA per 30 days) 50-500 MG PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

18 Drug Name Drug Tier Requirements/Limits JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50- 3 QL (30 EA per 30 days) 1000 MG, 50-500 MG *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML FIASP PENFILL SUBCUTANEOUS 3 SOLUTION CARTRIDGE 100 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 3 UNIT/ML insulin asp prot & asp flexpen subcutaneous suspension pen-injector (70- 3 30) 100 unit/ml insulin aspart flexpen subcutaneous 3 solution pen-injector 100 unit/ml insulin aspart penfill subcutaneous solution 3 cartridge 100 unit/ml insulin aspart prot & aspart subcutaneous 3 suspension (70-30) 100 unit/ml insulin aspart subcutaneous solution 100 3 unit/ml LANTUS SUBCUTANEOUS SOLUTION 4 100 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 3 OTC 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS 3 OTC SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS 3 OTC SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS 3 OTC SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 3 OTC UNIT/ML NOVOLIN R RELION INJECTION 3 OTC SOLUTION 100 UNIT/ML

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

19 Drug Name Drug Tier Requirements/Limits NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- 3 INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS 3 SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS 3 SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 3 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 3 QL (2.4 ML per 28 days) MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 3 QL (1.2 ML per 28 days) MCG/0.02ML TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 3 QL (2 ML per 28 days) MG/0.5ML *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg 2 repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2 *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 2 mg, 2.5-500 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 2 AGE (Max 64 Years) mg, 2.5-500 mg, 5-500 mg *Sulfonylureas*** glimepiride oral tablet 1 mg, 2 mg, 4 mg 2 glipizide er oral tablet extended release 24 2 QL (60 EA per 30 days) hour 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg 2 glyburide micronized oral tablet 1.5 mg, 3 2 AGE (Max 64 Years) mg, 6 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

20 Drug Name Drug Tier Requirements/Limits glyburide oral tablet 1.25 mg, 2.5 mg, 5 2 AGE (Max 64 Years) mg *Sulfonylurea- Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30- 2 2 mg, 30-4 mg *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 2 15-500 mg, 15-850 mg *Thiazolidinediones*** pioglitazone hcl oral tablet 15 mg, 30 mg, 2 QL (30 EA per 30 days) 45 mg *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5- 2 0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5- 2 0.025 mg loperamide hcl oral capsule 2 mg 2 loperamide hcl oral liquid 1 mg/5ml 2 OTC *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG 4 deferiprone oral tablet 500 mg 5 PA FERRIPROX ORAL SOLUTION 100 5 PA; SP MG/ML FERRIPROX ORAL TABLET 500 MG 5 PA *Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml, 2 4 mg/10ml naloxone hcl injection solution cartridge 2 0.4 mg/ml naloxone hcl injection solution prefilled 3 syringe 2 mg/2ml

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

21 Drug Name Drug Tier Requirements/Limits naltrexone hcl oral tablet 50 mg 2 NARCAN NASAL LIQUID 4 MG/0.1ML 3 *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 mg 2 QL (60 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml 2 ondansetron hcl oral tablet 24 mg, 4 mg, 8 2 mg ondansetron oral tablet dispersible 4 mg, 8 2 mg *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg 2 scopolamine transdermal patch 72 hour 1 2 QL (10 EA per 30 days) mg/3days trimethobenzamide hcl oral capsule 300 2 AGE (Max 64 Years) mg *Antiemetics - Miscellaneous*** dronabinol oral capsule 10 mg, 2.5 mg, 5 2 mg *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg, 80 mg 2 ST *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 2 mg/5ml griseofulvin microsize oral tablet 500 mg 2 griseofulvin ultramicrosize oral tablet 125 2 mg, 250 mg nystatin oral tablet 500000 unit 2 terbinafine hcl oral tablet 250 mg 2 *Triazoles***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

22 Drug Name Drug Tier Requirements/Limits fluconazole oral suspension reconstituted 2 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 200 mg, 50 2 QL (30 EA per 30 days) mg fluconazole oral tablet 150 mg 2 itraconazole oral capsule 100 mg 5 PA voriconazole oral tablet 200 mg, 50 mg 5 PA *ANTIHISTAMINES* *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 mg 2 diphenhydramine hcl injection solution 50 2 mg/ml diphenhydramine hcl oral elixir 12.5 2 mg/5ml *Antihistamines - Non- Sedating*** cetirizine hcl oral solution 1 mg/ml 2 QL (300 ML per 30 days) cetirizine hcl oral tablet 10 mg, 5 mg 2 OTC; QL (30 EA per 30 days) eq allergy relief oral tablet 10 mg 2 OTC; QL (30 EA per 30 days) fexofenadine hcl oral tablet 180 mg 2 OTC; QL (30 EA per 30 days) fexofenadine hcl oral tablet 60 mg 2 OTC; QL (60 EA per 30 days) *Antihistamines - Phenothiazines*** promethazine hcl injection solution 25 2 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml 2 AGE (Max 64 Years) promethazine hcl oral tablet 12.5 mg, 25 2 AGE (Max 64 Years) mg, 50 mg PROMETHEGAN RECTAL SUPPOSITORY 2 QL (12 EA per 30 days) 12.5 MG, 25 MG, 50 MG *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml 2 cyproheptadine hcl oral tablet 4 mg 2 *ANTIHYPERLIPIDEMICS*

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

23 Drug Name Drug Tier Requirements/Limits *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 2 QL (120 EA per 30 days) gm *Bile Acid Sequestrants*** cholestyramine light oral powder 4 2 gm/dose cholestyramine oral powder 4 gm/dose 2 QL (378 GM per 30 days) colestipol hcl oral granules 5 gm 2 colestipol hcl oral tablet 1 gm 2 PREVALITE ORAL POWDER 4 GM/DOSE 2 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 130 2 mg, 134 mg, 200 mg, 43 mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg 2 fenofibrate oral tablet 145 mg, 160 mg, 48 2 mg, 54 mg fenofibric acid oral capsule delayed release 2 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg 2 FIBRICOR ORAL TABLET 105 MG, 35 2 MG gemfibrozil oral tablet 600 mg 2 TRIGLIDE ORAL TABLET 160 MG 2 PA *Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 $0 copay for members age 40 2 mg through 75 atorvastatin calcium oral tablet 40 mg 2 atorvastatin calcium oral tablet 80 mg 2 QL (30 EA per 30 days) fluvastatin sodium oral capsule 20 mg, 40 $0 copay for members age 40 2 mg through 75 $0 copay for members age 40 lovastatin oral tablet 10 mg, 20 mg, 40 mg 2 through 75 pravastatin sodium oral tablet 10 mg, 20 $0 copay for members age 40 2 mg, 40 mg, 80 mg through 75 rosuvastatin calcium oral tablet 10 mg, 5 $0 copay for members age 40 2 mg through 75

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

24 Drug Name Drug Tier Requirements/Limits rosuvastatin calcium oral tablet 20 mg, 40 2 mg simvastatin oral tablet 10 mg, 20 mg, 40 $0 copay for members age 40 2 mg, 5 mg through 75 simvastatin oral tablet 80 mg 2 *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 mg 2 QL (30 EA per 30 days) *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 2 mg NIACOR ORAL TABLET 500 MG 2 *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 2 mg, 5-20 mg, 5-40 mg trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2- 2 QL (30 EA per 30 days) 240 mg, 4-240 mg *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5- 2 6.25 mg captopril-hydrochlorothiazide oral tablet 2 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 2 10-25 mg, 5-12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 2 mg, 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 2 10-12.5 mg, 20-12.5 mg, 20-25 mg moexipril-hydrochlorothiazide oral tablet 2 15-12.5 mg, 15-25 mg, 7.5-12.5 mg quinapril-hydrochlorothiazide oral tablet 2 10-12.5 mg, 20-12.5 mg, 20-25 mg PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

25 Drug Name Drug Tier Requirements/Limits *Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 2 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 2 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 2 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 2 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 2 30 mg, 40 mg, 5 mg perindopril erbumine oral tablet 2 mg, 4 2 mg, 8 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 2 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 2 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg 2 *Agents For Pheochromocytoma*** phenoxybenzamine hcl oral capsule 10 mg 2 PA *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 2 mg *Angiotensin Ii Receptor Antag & Thiazide/Thiazide- Like*** candesartan cilexetil-hctz oral tablet 16- 2 QL (30 EA per 30 days) 12.5 mg, 32-12.5 mg, 32-25 mg irbesartan-hydrochlorothiazide oral tablet 2 150-12.5 mg, 300-12.5 mg losartan potassium-hctz oral tablet 100- 2 12.5 mg, 100-25 mg, 50-12.5 mg olmesartan medoxomil-hctz oral tablet 20- 2 QL (30 EA per 30 days) 12.5 mg, 40-12.5 mg, 40-25 mg telmisartan-hctz oral tablet 40-12.5 mg, 2 QL (30 EA per 30 days) 80-12.5 mg, 80-25 mg PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

26 Drug Name Drug Tier Requirements/Limits valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 2 320-25 mg, 80-12.5 mg *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16 mg, 32 2 QL (30 EA per 30 days) mg, 4 mg, 8 mg irbesartan oral tablet 150 mg, 300 mg, 75 2 QL (30 EA per 30 days) mg losartan potassium oral tablet 100 mg 2 QL (30 EA per 30 days) losartan potassium oral tablet 25 mg, 50 2 QL (60 EA per 30 days) mg olmesartan medoxomil oral tablet 20 mg, 2 QL (30 EA per 30 days) 40 mg, 5 mg telmisartan oral tablet 20 mg, 40 mg, 80 2 QL (30 EA per 30 days) mg valsartan oral tablet 160 mg, 40 mg, 80 2 QL (60 EA per 30 days) mg valsartan oral tablet 320 mg 2 QL (30 EA per 30 days) *Angiotensin Ii Receptor Ant- Ca Channel Blocker- Thiazides*** amlodipine-valsartan-hctz oral tablet 10- 160-12.5 mg, 10-160-25 mg, 10-320-25 2 mg, 5-160-12.5 mg, 5-160-25 mg olmesartan-amlodipine-hctz oral tablet 20- 5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 2 40-5-12.5 mg, 40-5-25 mg *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 2 0.3 mg clonidine transdermal patch weekly 0.1 2 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet 1 mg, 2 mg 2 methyldopa oral tablet 250 mg, 500 mg 2 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 2 4 mg, 8 mg PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

27 Drug Name Drug Tier Requirements/Limits prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 2 terazosin hcl oral capsule 1 mg, 10 mg, 2 2 mg, 5 mg *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 2 mg, 50-25 mg bisoprolol-hydrochlorothiazide oral tablet 2 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg metoprolol-hydrochlorothiazide oral tablet 2 100-25 mg, 100-50 mg, 50-25 mg nadolol-bendroflumethiazide oral tablet 40- 2 5 mg, 80-5 mg propranolol-hctz oral tablet 40-25 mg, 80- 2 25 mg *Direct Renin Inhibitors*** aliskiren fumarate oral tablet 150 mg, 300 2 QL (30 EA per 30 days) mg TEKTURNA ORAL TABLET 150 MG, 300 3 QL (30 EA per 30 days) MG *Dopamine D1 Receptor Agonists*** CORLOPAM INTRAVENOUS SOLUTION 5 10 MG/ML *Reserpine*** reserpine oral tablet 0.1 mg, 0.25 mg 2 *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet 25 mg, 50 mg 2 *Vasodilators*** hydralazine hcl injection solution 20 mg/ml 2 hydralazine hcl oral tablet 10 mg, 100 mg, 2 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg 2 *ANTI-INFECTIVE AGENTS - MISC.*

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

28 Drug Name Drug Tier Requirements/Limits *Anti-Infective Agents - Misc.*** metronidazole in nacl intravenous solution 2 5-0.79 mg/ml-% metronidazole oral capsule 375 mg 2 metronidazole oral tablet 250 mg, 500 mg 2 tinidazole oral tablet 250 mg, 500 mg 2 trimethoprim oral tablet 100 mg 2 XIFAXAN ORAL TABLET 200 MG 4 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG 4 QL (90 EA per 30 days) *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral 2 suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 2 400-80 mg, 800-160 mg *Antiprotozoal Agents*** atovaquone oral suspension 750 mg/5ml 2 *Carbapenem Combinations*** imipenem-cilastatin intravenous solution 2 reconstituted 250 mg, 500 mg *Carbapenems*** meropenem intravenous solution 2 reconstituted 1 gm, 500 mg *Leprostatics*** dapsone oral tablet 100 mg, 25 mg 2 *Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 2 mg, 75 mg clindamycin palmitate hcl oral solution 2 reconstituted 75 mg/5ml *Oxazolidinones*** linezolid intravenous solution 600 2 mg/300ml linezolid oral suspension reconstituted 100 2 mg/5ml

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

29 Drug Name Drug Tier Requirements/Limits linezolid oral tablet 600 mg 2 QL (28 EA per 14 days) SIVEXTRO ORAL TABLET 200 MG 4 PA; SP *Polymyxins*** polymyxin b sulfate injection solution 2 reconstituted 500000 unit *ANTIMALARIALS* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250- 2 100 mg atovaquone-proguanil hcl oral tablet 62.5- 2 QL (30 EA per 30 days) 25 mg *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 2 500 mg DARAPRIM ORAL TABLET 25 MG 5 PA; SP hydroxychloroquine sulfate oral tablet 200 2 mg mefloquine hcl oral tablet 250 mg 2 primaquine phosphate oral tablet 26.3 mg 4 pyrimethamine oral tablet 25 mg 5 PA; SP quinine sulfate oral capsule 324 mg 2 *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** MESTINON ORAL SOLUTION 60 3 PA MG/5ML pyridostigmine bromide er oral tablet 2 extended release 180 mg pyridostigmine bromide oral solution 60 2 PA mg/5ml pyridostigmine bromide oral tablet 60 mg 2 *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRUP 60 MG/5ML 3 PA pyridostigmine bromide er oral tablet 2 extended release 180 mg pyridostigmine bromide oral solution 60 2 PA mg/5ml PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

30 Drug Name Drug Tier Requirements/Limits pyridostigmine bromide oral tablet 60 mg 2 *ANTIMYASTHENIC/CHOLINE RGIC AGENTS* MESTINON ORAL SYRUP 60 MG/5ML 3 PA pyridostigmine bromide er oral tablet 2 extended release 180 mg pyridostigmine bromide oral solution 60 2 PA mg/5ml pyridostigmine bromide oral tablet 60 mg 2 *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE 150-300 MG 4 *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg 2 isoniazid oral syrup 50 mg/5ml 2 isoniazid oral tablet 100 mg, 300 mg 2 pyrazinamide oral tablet 500 mg 2 rifampin oral capsule 150 mg, 300 mg 2 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** carboplatin intravenous solution 50 2 SP mg/5ml cisplatin intravenous solution 50 mg/50ml 2 SP oxaliplatin intravenous solution 100 2 SP mg/20ml, 50 mg/10ml oxaliplatin intravenous solution 2 SP reconstituted 100 mg, 50 mg *Androgen Biosynthesis Inhibitors*** abiraterone acetate oral tablet 250 mg 5 PA; SP ZYTIGA ORAL TABLET 250 MG, 500 MG 5 PA; SP *Antiadrenals*** LYSODREN ORAL TABLET 500 MG 3 PA; SP *Antiandrogens***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

31 Drug Name Drug Tier Requirements/Limits bicalutamide oral tablet 50 mg 2 flutamide oral capsule 125 mg 2 nilutamide oral tablet 150 mg 2 SP *Antiestrogens*** FARESTON ORAL TABLET 60 MG 5 PA; SP tamoxifen citrate oral tablet 10 mg, 20 mg 1 toremifene citrate oral tablet 60 mg 5 PA; SP *Antimetabolites*** ADRUCIL INTRAVENOUS SOLUTION 2 SP 500 MG/10ML capecitabine oral tablet 150 mg, 500 mg 5 PA; SP fluorouracil intravenous solution 1 2 SP gm/20ml, 2.5 gm/50ml, 500 mg/10ml mercaptopurine oral tablet 50 mg 2 methotrexate oral tablet 2.5 mg 2 methotrexate sodium (pf) injection solution 2 50 mg/2ml methotrexate sodium injection solution 50 2 mg/2ml methotrexate sodium injection solution 2 reconstituted 1 gm TABLOID ORAL TABLET 40 MG 5 PA; SP *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 1 MG, 2 MG, 4 PA; SP 3 MG, 4 MG *Antineoplastic - Monoclonal Antibodies*** ERBITUX INTRAVENOUS SOLUTION 4 PA; SP 100 MG/50ML HERCEPTIN INTRAVENOUS SOLUTION 5 PA; SP RECONSTITUTED 150 MG, 440 MG *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG 4 PA; SP SUTENT ORAL CAPSULE 12.5 MG, 25 4 PA; SP MG, 50 MG

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

32 Drug Name Drug Tier Requirements/Limits *Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 5 PA; SP MG CAPRELSA ORAL TABLET 100 MG, 300 5 PA; SP MG erlotinib hcl oral tablet 100 mg, 150 mg, 5 PA; SP 25 mg imatinib mesylate oral tablet 100 mg, 400 5 PA; SP mg IMBRUVICA ORAL CAPSULE 140 MG 5 PA; SP INLYTA ORAL TABLET 1 MG, 5 MG 5 PA; SP lapatinib ditosylate oral tablet 250 mg 4 PA LENVIMA (10 MG DAILY DOSE) ORAL PA; SP; QL (30 EA per 30 4 CAPSULE THERAPY PACK 10 MG days) LENVIMA (12 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 4 CAPSULE THERAPY PACK 3 X 4 MG days) LENVIMA (14 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 4 CAPSULE THERAPY PACK 10 & 4 MG days) LENVIMA (18 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 CAPSULE THERAPY PACK 10 MG & 2 X 4 days) 4 MG LENVIMA (20 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 4 CAPSULE THERAPY PACK 2 X 10 MG days) LENVIMA (24 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 CAPSULE THERAPY PACK 2 X 10 MG & 4 days) 4 MG LENVIMA (4 MG DAILY DOSE) ORAL PA; SP; QL (30 EA per 30 4 CAPSULE THERAPY PACK 4 MG days) LENVIMA (8 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 4 CAPSULE THERAPY PACK 2 X 4 MG days) SPRYCEL ORAL TABLET 100 MG, 140 4 PA; SP MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 5 PA; SP MG, 25 MG TYKERB ORAL TABLET 250 MG 4 PA; SP XALKORI ORAL CAPSULE 200 MG, 250 4 PA; SP MG ZYKADIA ORAL TABLET 150 MG 4 PA; SP *Antineoplastic Antibiotics***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

33 Drug Name Drug Tier Requirements/Limits bleomycin sulfate injection solution 2 SP reconstituted 15 unit, 30 unit doxorubicin hcl intravenous solution 2 2 SP mg/ml doxorubicin hcl intravenous solution 2 SP reconstituted 10 mg, 50 mg doxorubicin hcl liposomal intravenous 2 SP injectable 2 mg/ml epirubicin hcl intravenous solution 200 2 SP mg/100ml, 50 mg/25ml idarubicin hcl intravenous solution 10 2 SP mg/10ml, 20 mg/20ml, 5 mg/5ml *Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg 2 INTRON A INJECTION SOLUTION 5 PA; SP 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 5 PA; SP 18000000 UNIT, 50000000 UNIT *Aromatase Inhibitors*** anastrozole oral tablet 1 mg 2 exemestane oral tablet 25 mg 2 letrozole oral tablet 2.5 mg 2 QL (30 EA per 30 days) *Estrogen Receptor Antagonist*** FASLODEX INTRAMUSCULAR 3 PA; SP SOLUTION 250 MG/5ML fulvestrant intramuscular solution 250 3 PA; SP mg/5ml *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 2 mg, 25 mg, 5 mg *Imidazotetrazines*** TEMODAR INTRAVENOUS SOLUTION 5 PA; SP RECONSTITUTED 100 MG temozolomide oral capsule 100 mg, 140 5 PA; SP mg, 180 mg, 20 mg, 250 mg, 5 mg *Lhrh Analogs*** PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

34 Drug Name Drug Tier Requirements/Limits ELIGARD SUBCUTANEOUS KIT 22.5 4 PA; SP MG, 30 MG, 45 MG, 7.5 MG leuprolide acetate injection kit 1 mg/0.2ml 5 PA; SP LUPRON DEPOT (1-MONTH) 5 PA; SP INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 4 PA; SP MG LUPRON DEPOT (4-MONTH) 4 PA; SP INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) 4 PA; SP INTRAMUSCULAR KIT 45 MG *Mitotic Inhibitors*** ABRAXANE INTRAVENOUS 3 SP SUSPENSION RECONSTITUTED 100 MG docetaxel (non-alcohol) intravenous 3 SP solution 160 mg/8ml docetaxel intravenous concentrate 20 2 SP mg/ml, 80 mg/4ml docetaxel intravenous solution 20 mg/2ml, 2 SP 80 mg/8ml etoposide intravenous solution 100 mg/5ml 2 SP teniposide intravenous solution 10 mg/ml 3 SP vinblastine sulfate intravenous solution 1 2 SP mg/ml VINCASAR PFS INTRAVENOUS 2 SP SOLUTION 1 MG/ML vincristine sulfate intravenous solution 1 2 SP mg/ml vinorelbine tartrate intravenous solution 10 2 SP mg/ml, 50 mg/5ml *Nitrogen Mustards*** cyclophosphamide injection solution 2 SP reconstituted 1 gm, 2 gm, 500 mg cyclophosphamide oral capsule 25 mg, 50 2 mg ifosfamide intravenous solution 1 gm/20ml, 2 SP 3 gm/60ml ifosfamide intravenous solution 2 SP reconstituted 1 gm LEUKERAN ORAL TABLET 2 MG 3 PA; SP PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

35 Drug Name Drug Tier Requirements/Limits melphalan hcl intravenous solution 2 SP reconstituted 50 mg melphalan oral tablet 2 mg 2 SP *Nitrosoureas*** BICNU INTRAVENOUS SOLUTION 3 SP RECONSTITUTED 100 MG carmustine intravenous solution 2 SP reconstituted 100 mg GLEOSTINE ORAL CAPSULE 10 MG, 100 5 PA; SP MG, 40 MG GLEOSTINE ORAL CAPSULE 5 MG 5 SP GLIADEL WAFER IMPLANT WAFER 7.7 3 SP MG *Progestins- Antineoplastic*** DEPO-PROVERA INTRAMUSCULAR 4 SP SUSPENSION 400 MG/ML megestrol acetate oral suspension 40 2 mg/ml megestrol acetate oral tablet 20 mg, 40 2 mg *Retinoids*** tretinoin oral capsule 10 mg 2 PA; SP *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 mg 5 PA; SP *Topoisomerase I Inhibitors*** topotecan hcl intravenous solution 4 5 SP mg/4ml *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG 4 PA; SP *ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate injection solution 1 2 mg/ml PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

36 Drug Name Drug Tier Requirements/Limits benztropine mesylate oral tablet 0.5 mg, 1 2 mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml 2 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 2 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg 2 amantadine hcl oral syrup 50 mg/5ml 2 amantadine hcl oral tablet 100 mg 2 bromocriptine mesylate oral capsule 5 mg 2 bromocriptine mesylate oral tablet 2.5 mg 2 *Antiparkinson Monoamine Oxidase Inhibitors*** rasagiline mesylate oral tablet 0.5 mg, 1 2 mg selegiline hcl oral capsule 5 mg 2 selegiline hcl oral tablet 5 mg 2 *Decarboxylase Inhibitors*** carbidopa oral tablet 25 mg 2 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended 2 release 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 2 25-100 mg, 25-250 mg carbidopa-levodopa oral tablet dispersible 2 10-100 mg, 25-100 mg, 25-250 mg *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 2 ST; QL (30 EA per 30 days) mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 2 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 2 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

37 Drug Name Drug Tier Requirements/Limits *Peripheral Comt Inhibitors*** entacapone oral tablet 200 mg 2 *ANTIPSYCHOTICS/ANTIMAN IC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended 2 release 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 2 300 mg, 600 mg lithium carbonate oral tablet 300 mg 2 lithium oral solution 8 meq/5ml 2 *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20 mg, 40 mg, 2 60 mg, 80 mg *Benzisoxazoles*** paliperidone er oral tablet extended release 2 PA 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg risperidone oral solution 1 mg/ml 2 risperidone oral tablet 0.25 mg, 0.5 mg, 1 2 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 2 1 mg, 2 mg, 3 mg, 4 mg *Butyrophenones*** haloperidol decanoate intramuscular 2 solution 100 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 2 mg/ml haloperidol lactate oral concentrate 2 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 2 mg, 2 mg, 20 mg, 5 mg *Dibenzodiazepines*** clozapine oral tablet 100 mg, 200 mg, 25 2 mg, 50 mg clozapine oral tablet dispersible 100 mg, 2 12.5 mg, 150 mg, 200 mg, 25 mg *Dibenzothiazepines***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

38 Drug Name Drug Tier Requirements/Limits quetiapine fumarate oral tablet 100 mg, 2 200 mg, 25 mg, 300 mg, 400 mg, 50 mg *Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 25 2 mg, 5 mg, 50 mg *Phenothiazines*** chlorpromazine hcl oral tablet 10 mg, 100 2 mg, 200 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 2 25 mg/ml fluphenazine hcl injection solution 2.5 2 mg/ml fluphenazine hcl oral concentrate 5 mg/ml 2 fluphenazine hcl oral elixir 2.5 mg/5ml 2 fluphenazine hcl oral tablet 1 mg, 10 mg, 2 2.5 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 2 mg, 8 mg prochlorperazine edisylate injection 2 solution 10 mg/2ml prochlorperazine maleate oral tablet 10 2 mg, 5 mg prochlorperazine rectal suppository 25 mg 2 thioridazine hcl oral tablet 10 mg, 100 mg, 2 25 mg, 50 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 2 mg, 5 mg *Quinolinone Derivatives*** aripiprazole oral solution 1 mg/ml 2 PA aripiprazole oral tablet 10 mg, 15 mg, 2 2 QL (30 EA per 30 days) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet dispersible 10 mg, 2 PA 15 mg *Thienbenzodiazepines*** olanzapine intramuscular solution 2 reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 2 mg, 20 mg, 5 mg, 7.5 mg *Thioxanthenes***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

39 Drug Name Drug Tier Requirements/Limits thiothixene oral capsule 1 mg, 10 mg, 2 2 mg, 5 mg *ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 2 QL (30 EA per 30 days) 600-300 mg abacavir-lamivudine-zidovudine oral tablet 2 QL (60 EA per 30 days) 300-150-300 mg ATRIPLA ORAL TABLET 600-200-300 3 QL (30 EA per 30 days) MG COMPLERA ORAL TABLET 200-25-300 3 QL (30 EA per 30 days) MG efavirenz-emtricitab-tenofovir oral tablet 3 QL (30 EA per 30 days) 600-200-300 mg emtricitabine-tenofovir df oral tablet 200- 3 QL (30 EA per 30 days) 300 mg GENVOYA ORAL TABLET 150-150-200- 3 SP; QL (30 EA per 30 days) 10 MG KALETRA ORAL TABLET 100-25 MG 3 QL (360 EA per 30 days) KALETRA ORAL TABLET 200-50 MG 3 QL (180 EA per 30 days) lamivudine-zidovudine oral tablet 150-300 2 QL (60 EA per 30 days) mg lopinavir-ritonavir oral solution 400-100 2 QL (450 ML per 30 days) mg/5ml PREZCOBIX ORAL TABLET 800-150 MG 3 QL (30 EA per 30 days) TRUVADA ORAL TABLET 100-150 MG, 3 QL (30 EA per 30 days) 133-200 MG, 167-250 MG, 200-300 MG *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL SOLUTION 20 3 QL (1840 ML per 30 days) MG/ML SELZENTRY ORAL TABLET 150 MG, 300 3 QL (120 EA per 30 days) MG SELZENTRY ORAL TABLET 25 MG 3 QL (240 EA per 30 days) SELZENTRY ORAL TABLET 75 MG 3 QL (60 EA per 30 days) *Antiretrovirals - Fusion Inhibitors***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

40 Drug Name Drug Tier Requirements/Limits FUZEON SUBCUTANEOUS SOLUTION 5 SP; QL (60 EA per 30 days) RECONSTITUTED 90 MG *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 MG 4 QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 4 QL (60 EA per 30 days) 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG 3 SP; QL (60 EA per 30 days) TIVICAY ORAL TABLET 50 MG 5 SP; QL (30 EA per 30 days) *Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG 3 QL (120 EA per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML 3 QL (300 ML per 30 days) atazanavir sulfate oral capsule 150 mg, 2 QL (60 EA per 30 days) 200 mg atazanavir sulfate oral capsule 300 mg 2 QL (30 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG 3 QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG 3 QL (180 EA per 30 days) fosamprenavir calcium oral tablet 700 mg 2 QL (120 EA per 30 days) INVIRASE ORAL CAPSULE 200 MG 3 QL (300 EA per 30 days) INVIRASE ORAL TABLET 500 MG 3 QL (120 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML 3 QL (1575 ML per 28 days) NORVIR ORAL CAPSULE 100 MG 3 QL (360 EA per 30 days) NORVIR ORAL SOLUTION 80 MG/ML 3 QL (450 ML per 30 days) PREZISTA ORAL SUSPENSION 100 3 QL (480 ML per 30 days) MG/ML PREZISTA ORAL TABLET 150 MG 3 QL (240 EA per 30 days) PREZISTA ORAL TABLET 600 MG 3 QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG 3 QL (480 EA per 30 days) PREZISTA ORAL TABLET 800 MG 3 QL (30 EA per 30 days) ritonavir oral tablet 100 mg 2 QL (360 EA per 30 days) VIRACEPT ORAL TABLET 250 MG 3 QL (300 EA per 30 days) VIRACEPT ORAL TABLET 625 MG 3 QL (120 EA per 30 days) *Antiretrovirals - Rti-Non- Nucleoside Analogues*** EDURANT ORAL TABLET 25 MG 3 QL (60 EA per 30 days) efavirenz oral capsule 200 mg 2 QL (90 EA per 30 days)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

41 Drug Name Drug Tier Requirements/Limits efavirenz oral capsule 50 mg 2 QL (360 EA per 30 days) efavirenz oral tablet 600 mg 2 QL (30 EA per 30 days) INTELENCE ORAL TABLET 100 MG 5 QL (120 EA per 30 days) INTELENCE ORAL TABLET 200 MG 5 QL (60 EA per 30 days) INTELENCE ORAL TABLET 25 MG 5 QL (480 EA per 30 days) nevirapine er oral tablet extended release 2 24 hour 100 mg nevirapine er oral tablet extended release 2 QL (30 EA per 30 days) 24 hour 400 mg nevirapine oral suspension 50 mg/5ml 2 nevirapine oral tablet 200 mg 2 QL (60 EA per 30 days) *Antiretrovirals - Rti- Nucleoside Analogues- Purines*** abacavir sulfate oral solution 20 mg/ml 5 QL (900 ML per 30 days) abacavir sulfate oral tablet 300 mg 2 QL (60 EA per 30 days) didanosine oral capsule delayed release 2 125 mg, 200 mg, 250 mg, 400 mg VIDEX ORAL SOLUTION 5 QL (603 ML per 30 days) RECONSTITUTED 2 GM *Antiretrovirals - Rti- Nucleoside Analogues- Pyrimidines*** emtricitabine oral capsule 200 mg 5 QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 200 MG 5 QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML 5 lamivudine oral solution 10 mg/ml 2 QL (900 ML per 30 days) lamivudine oral tablet 150 mg, 300 mg 2 QL (60 EA per 30 days) *Antiretrovirals - Rti- Nucleoside Analogues- Thymidines*** stavudine oral capsule 15 mg, 20 mg, 30 2 QL (60 EA per 30 days) mg, 40 mg zidovudine oral capsule 100 mg 2 QL (180 EA per 30 days) zidovudine oral syrup 50 mg/5ml 2 QL (1800 ML per 30 days) zidovudine oral tablet 300 mg 2 QL (60 EA per 30 days)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

42 Drug Name Drug Tier Requirements/Limits *Antiretrovirals - Rti- Nucleotide Analogues*** tenofovir disoproxil fumarate oral tablet 2 QL (30 EA per 30 days) 300 mg VIREAD ORAL TABLET 150 MG, 200 5 QL (30 EA per 30 days) MG, 250 MG *Cmv Agents*** valganciclovir hcl oral tablet 450 mg 2 PA *Hepatitis B Agents*** adefovir dipivoxil oral tablet 10 mg 2 PA; SP BARACLUDE ORAL SOLUTION 0.05 5 PA; SP MG/ML entecavir oral tablet 0.5 mg, 1 mg 2 PA; SP EPIVIR HBV ORAL SOLUTION 5 MG/ML 4 SP; QL (1800 ML per 30 days) lamivudine oral tablet 100 mg 2 SP; QL (90 EA per 30 days) *Hepatitis C Agents*** PEGASYS PROCLICK SUBCUTANEOUS 5 PA; SP SOLUTION 135 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 5 PA; SP 180 MCG/ML REBETOL ORAL SOLUTION 40 MG/ML 5 PA; SP RIBASPHERE ORAL TABLET 200 MG 2 PA; SP RIBASPHERE RIBAPAK ORAL TABLET 5 PA; SP THERAPY PACK 400 & 600 MG RIBATAB ORAL TABLET 600 MG 2 PA; SP ribavirin oral capsule 200 mg 2 PA; SP *Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg 2 acyclovir oral suspension 200 mg/5ml 2 acyclovir oral tablet 400 mg, 800 mg 2 valacyclovir hcl oral tablet 1 gm, 500 mg 2 *Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125 mg, 250 mg, 2 500 mg *Influenza Agents***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

43 Drug Name Drug Tier Requirements/Limits rimantadine hcl oral tablet 100 mg 2 *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 mg, 2 QL (10 EA per 5 days) 45 mg, 75 mg oseltamivir phosphate oral suspension 2 QL (120 ML per 5 days) reconstituted 6 mg/ml *ASSORTED CLASSES* *Chelating Agents*** DEPEN TITRATABS ORAL TABLET 250 4 SP MG penicillamine oral tablet 250 mg 4 SP *Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 2 25 mg cyclosporine modified oral solution 100 2 mg/ml cyclosporine oral capsule 100 mg, 25 mg 2 GENGRAF ORAL SOLUTION 100 MG/ML 2 SANDIMMUNE ORAL SOLUTION 100 4 PA MG/ML *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 5 PA; SP MG, 2.5 MG, 20 MG, 25 MG, 5 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 2 mg mycophenolate mofetil oral tablet 500 mg 2 mycophenolate sodium oral tablet delayed 2 PA release 180 mg, 360 mg *Irrigation Solutions*** TIS-U-SOL IRRIGATION SOLUTION 2 *Macrolide Immunosuppressants*** RAPAMUNE ORAL SOLUTION 1 MG/ML 3 PA

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

44 Drug Name Drug Tier Requirements/Limits sirolimus oral solution 1 mg/ml 3 PA sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 2 PA tacrolimus oral capsule 0.5 mg, 1 mg, 5 2 mg *Potassium Removing Resins*** KIONEX ORAL SUSPENSION 15 2 GM/60ML sodium polystyrene sulfonate rectal 2 suspension 30 gm/120ml *Purine Analogs*** AZASAN ORAL TABLET 100 MG, 75 MG 4 PA azathioprine oral tablet 50 mg 2 *BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 2 3.125 mg, 6.25 mg labetalol hcl oral tablet 100 mg, 200 mg, 2 300 mg *Beta Blockers Cardio- Selective*** acebutolol hcl oral capsule 200 mg, 400 2 mg atenolol oral tablet 100 mg, 25 mg, 50 mg 2 betaxolol hcl oral tablet 10 mg, 20 mg 2 bisoprolol fumarate oral tablet 10 mg, 5 2 mg metoprolol succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 2 QL (45 EA per 30 days) 50 mg metoprolol succinate er oral tablet 2 QL (60 EA per 30 days) extended release 24 hour 200 mg metoprolol tartrate intravenous solution 5 2 mg/5ml metoprolol tartrate oral tablet 100 mg, 25 2 mg, 50 mg *Beta Blockers Non- Selective***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

45 Drug Name Drug Tier Requirements/Limits nadolol oral tablet 20 mg, 40 mg, 80 mg 2 pindolol oral tablet 10 mg, 5 mg 2 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 2 ST 80 mg propranolol hcl oral solution 20 mg/5ml, 40 2 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 2 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 120 MG, 160 2 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120 mg, 160 mg, 2 80 mg sotalol hcl oral tablet 120 mg, 160 mg, 240 2 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 2 5 mg *CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** AFEDITAB CR ORAL TABLET EXTENDED 2 RELEASE 24 HOUR 30 MG, 60 MG amlodipine besylate oral tablet 10 mg, 2.5 2 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 2 240 MG, 300 MG diltiazem hcl er beads oral capsule 2 extended release 24 hour 300 mg, 420 mg diltiazem hcl er coated beads oral capsule 2 extended release 24 hour 360 mg diltiazem hcl er oral capsule extended 2 release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended 2 release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 2 mg, 90 mg felodipine er oral tablet extended release 2 24 hour 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 2 PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

46 Drug Name Drug Tier Requirements/Limits MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 2 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20 mg, 30 mg 2 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 2 60 MG nifedipine er oral tablet extended release 2 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 2 90 mg nimodipine oral capsule 30 mg 2 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 2 34 mg, 40 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 2 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 2 200 mg, 240 mg, 300 mg verapamil hcl er oral capsule extended 2 QL (30 EA per 30 days) release 24 hour 360 mg verapamil hcl er oral tablet extended 2 release 120 mg, 180 mg, 240 mg verapamil hcl intravenous solution 2.5 2 mg/ml verapamil hcl oral tablet 120 mg, 40 mg, 2 80 mg *CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution 0.05 mg/ml 2 digoxin oral tablet 125 mcg, 250 mcg 2 *CARDIOVASCULAR AGENTS - MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

47 Drug Name Drug Tier Requirements/Limits amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5- 2 10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg *Prostaglandin Vasodilators*** VENTAVIS INHALATION SOLUTION 10 4 PA; SP MCG/ML, 20 MCG/ML *Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 4 PA; SP 1.5 MG, 2 MG, 2.5 MG *Pulmonary Hypertension - Endothelin Receptor Antagonists*** ambrisentan oral tablet 10 mg, 5 mg 5 PA; SP bosentan oral tablet 125 mg, 62.5 mg 4 PA; SP LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; SP TRACLEER ORAL TABLET 125 MG, 62.5 4 PA; SP MG *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg 5 PA; SP *CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg 2 cefadroxil oral suspension reconstituted 2 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm 2 cephalexin oral capsule 250 mg, 500 mg 2 cephalexin oral suspension reconstituted 2 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

48 Drug Name Drug Tier Requirements/Limits *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250 mg, 500 mg 2 cefaclor oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg 2 cefuroxime axetil oral tablet 250 mg, 500 2 mg *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg 2 cefdinir oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml cefditoren pivoxil oral tablet 400 mg 3 cefixime oral suspension reconstituted 200 2 mg/5ml cefpodoxime proxetil oral suspension 2 reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 2 200 mg ceftibuten oral capsule 400 mg 4 SUPRAX ORAL SUSPENSION 4 RECONSTITUTED 500 MG/5ML *CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** NECON 10/11 (28) ORAL TABLET 35 1 MCG *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG- 1 MCG alyacen 1/35 oral tablet 1-35 mg-mcg 1 APRI ORAL TABLET 0.15-30 MG-MCG 1 AVIANE ORAL TABLET 0.1-20 MG-MCG 1

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

49 Drug Name Drug Tier Requirements/Limits CHATEAL ORAL TABLET 0.15-30 MG- 1 MCG CYCLAFEM 1/35 ORAL TABLET 1-35 1 MG-MCG DASETTA 1/35 ORAL TABLET 1-35 MG- 1 MCG DELYLA ORAL TABLET 0.1-20 MG-MCG 1 drospiren-eth estrad-levomefol oral tablet 1 3-0.02-0.451 mg drospirenone-ethinyl estradiol oral tablet 1 3-0.03 mg EMOQUETTE ORAL TABLET 0.15-30 1 MG-MCG ENSKYCE ORAL TABLET 0.15-30 MG- 1 MCG ethynodiol diac-eth estradiol oral tablet 1- 1 50 mg-mcg FALMINA ORAL TABLET 0.1-20 MG- 1 MCG GIANVI ORAL TABLET 3-0.02 MG 1 GILDESS 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG GILDESS FE 1.5/30 ORAL TABLET 1.5- 1 30 MG-MCG JUNEL 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG- 1 MCG JUNEL FE 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG- 1 MCG KELNOR 1/50 ORAL TABLET 1-50 MG- 1 MCG KURVELO ORAL TABLET 0.15-30 MG- 1 MCG LARIN 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG LESSINA ORAL TABLET 0.1-20 MG-MCG 1 levonorgestrel-ethinyl estrad oral tablet 1 0.15-30 mg-mcg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

50 Drug Name Drug Tier Requirements/Limits LEVORA 0.15/30 (28) ORAL TABLET 1 0.15-30 MG-MCG LOW-OGESTREL ORAL TABLET 0.3-30 1 MG-MCG LUTERA ORAL TABLET 0.1-20 MG-MCG 1 marlissa oral tablet 0.15-30 mg-mcg 1 MONO-LINYAH ORAL TABLET 0.25-35 1 MG-MCG NECON 0.5/35 (28) ORAL TABLET 0.5- 1 35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 1 MG-MCG NECON 1/50 (28) ORAL TABLET 1-50 1 MG-MCG norethin ace-eth estrad-fe oral tablet 1-20 1 mg-mcg(24) norethin-eth estradiol-fe oral tablet 1 chewable 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25- 1 35 mg-mcg NORTREL 0.5/35 (28) ORAL TABLET 1 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1- 1 35 MG-MCG ORSYTHIA ORAL TABLET 0.1-20 MG- 1 MCG PIRMELLA 1/35 ORAL TABLET 1-35 1 MG-MCG PORTIA-28 ORAL TABLET 0.15-30 MG- 1 MCG RECLIPSEN ORAL TABLET 0.15-30 MG- 1 MCG SPRINTEC 28 ORAL TABLET 0.25-35 1 MG-MCG SRONYX ORAL TABLET 0.1-20 MG-MCG 1 SYEDA ORAL TABLET 3-0.03 MG 1 ZARAH ORAL TABLET 3-0.03 MG 1 ZOVIA 1/35E (28) ORAL TABLET 1-35 1 MG-MCG

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

51 Drug Name Drug Tier Requirements/Limits *Combination Contraceptives - Transdermal*** XULANE TRANSDERMAL PATCH 1 PA WEEKLY 150-35 MCG/24HR *Combination Contraceptives - Vaginal*** ELURYNG VAGINAL RING 0.12-0.015 1 PA MG/24HR etonogestrel-ethinyl estradiol vaginal ring 1 PA 0.12-0.015 mg/24hr NUVARING VAGINAL RING 0.12-0.015 1 PA MG/24HR *Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE 1 QL (1 EA per 300 days) DEVICE *Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE 1 QL (1 EA per 300 days) DEVICE *Emergency Contraceptives*** ELLA ORAL TABLET 30 MG 1 levonorgestrel oral tablet 0.75 mg 1 TAKE ACTION ORAL TABLET 1.5 MG 1 OTC *Extended-Cycle Contraceptives - Oral*** ASHLYNA ORAL TABLET 0.15-0.03 1 &0.01 MG levonorgest-eth estrad 91-day oral tablet 1 0.1-0.02 & 0.01 mg QUASENSE ORAL TABLET 0.15-0.03 MG 1 *Progestin Contraceptives - Implants*** NEXPLANON SUBCUTANEOUS 1 QL (1 EA per 300 days) IMPLANT 68 MG

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

52 Drug Name Drug Tier Requirements/Limits *Progestin Contraceptives - Injectable*** medroxyprogesterone acetate 1 QL (1 ML per 90 days) intramuscular suspension 150 mg/ml *Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE 1 QL (1 EA per 300 days) INTRAUTERINE DEVICE 19.5 MG LILETTA (52 MG) INTRAUTERINE 1 QL (1 EA per 300 days) INTRAUTERINE DEVICE 19.5 MCG/DAY MIRENA (52 MG) INTRAUTERINE 1 QL (1 EA per 300 days) INTRAUTERINE DEVICE 20 MCG/24HR SKYLA INTRAUTERINE INTRAUTERINE 1 QL (1 EA per 300 days) DEVICE 13.5 MG *Progestin Contraceptives - Oral*** ERRIN ORAL TABLET 0.35 MG 1 HEATHER ORAL TABLET 0.35 MG 1 NORA-BE ORAL TABLET 0.35 MG 1 *Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 1 mg-mcg CYCLAFEM 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG DASETTA 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG ENPRESSE-28 ORAL TABLET 50-30/75- 1 40/ 125-30 MCG norgestim-eth estrad triphasic oral tablet 1 0.18/0.215/0.25 mg-35 mcg NORTREL 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG PIRMELLA 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG TRINESSA (28) ORAL TABLET 1 0.18/0.215/0.25 MG-35 MCG TRI-SPRINTEC ORAL TABLET 1 0.18/0.215/0.25 MG-35 MCG

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

53 Drug Name Drug Tier Requirements/Limits TRIVORA (28) ORAL TABLET 50- 1 30/75-40/ 125-30 MCG VELIVET ORAL TABLET 0.1/0.125/0.15 1 -0.025 MG *CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release 5 particles 3 mg cortisone acetate oral tablet 25 mg 2 DEPO-MEDROL INJECTION 4 SUSPENSION 20 MG/ML DEXAMETHASONE INTENSOL ORAL 4 CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml 2 dexamethasone oral tablet 0.5 mg, 0.75 2 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate 2 injection solution 10 mg/ml, 120 mg/30ml hydrocortisone oral tablet 10 mg, 20 mg, 5 2 mg methylprednisolone oral tablet 16 mg, 32 2 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy 2 pack 4 mg prednisolone oral solution 15 mg/5ml 2 prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 2 base) mg/5ml PREDNISONE INTENSOL ORAL 4 CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5ml 2 prednisone oral tablet 1 mg, 10 mg, 2.5 2 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 mg 2 (21), 10 mg (48), 5 mg (21), 5 mg (48) *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg 2 *COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

54 Drug Name Drug Tier Requirements/Limits benzonatate oral capsule 100 mg 2 *Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 2 mg/5ml *Antitussive-Expectorant*** cheratussin ac oral syrup 100-10 mg/5ml 2 OTC *Decongestant & Antihistamine*** promethazine vc oral syrup 6.25-5 mg/5ml 2 promethazine-phenylephrine oral syrup 2 6.25-5 mg/5ml *Iodine Expectorants*** SSKI ORAL SOLUTION 1 GM/ML 3 *Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization 2 solution 0.9 %, 10 %, 3 %, 7 % *Mucolytics*** acetylcysteine inhalation solution 10 %, 20 2 % *Non-Narc Antitussive- Antihistamine*** promethazine-dm oral solution 6.25-15 2 mg/5ml *Non-Narc Antitussive- Decongestant- Antihistamine*** pseudoeph-bromphen-dm oral syrup 30-2- 2 10 mg/5ml *Opioid Antitussive- Antihistamine*** promethazine-codeine oral solution 6.25- 2 10 mg/5ml *Opioid Antitussive- Decongestant- Antihistamine***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

55 Drug Name Drug Tier Requirements/Limits promethazine vc/codeine oral syrup 6.25- 2 5-10 mg/5ml *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *Cyclin-Dependent Kinases (Cdk) Inhibitors*** IBRANCE ORAL CAPSULE 100 MG, 125 5 PA; SP MG, 75 MG IBRANCE ORAL TABLET 100 MG, 125 5 PA; SP MG, 75 MG *CYSTIC FIBROSIS AGENT - COMBINATIONS*** *Cystic Fibrosis Agent - Combinations*** ORKAMBI ORAL PACKET 100-125 MG, PA; SP; QL (56 EA per 28 4 150-188 MG days) ORKAMBI ORAL TABLET 100-125 MG, 5 PA; SP 200-125 MG *DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external foam 1 % 2 clindamycin phosphate external gel 1 % 2 clindamycin phosphate external lotion 1 % 2 clindamycin phosphate external solution 1 2 % clindamycin phosphate external swab 1 % 2 erythromycin external gel 2 % 2 erythromycin external pad 2 % 2 erythromycin external solution 2 % 2 *Acne Combinations*** adapalene-benzoyl peroxide external gel 2 ST 0.1-2.5 % benzoyl peroxide-erythromycin external gel 2 5-3 % clindamycin phos-benzoyl perox external 2 gel 1-5 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

56 Drug Name Drug Tier Requirements/Limits *Acne Products*** adapalene external cream 0.1 % 2 AGE (Max 34 Years) adapalene external gel 0.1 %, 0.3 % 2 AGE (Max 34 Years) adapalene external lotion 0.1 % 2 AGE (Max 34 Years) AMNESTEEM ORAL CAPSULE 10 MG, 20 2 PA MG, 40 MG QL (45 GM per 30 days); AGE AVITA EXTERNAL GEL 0.025 % 2 (Max 34 Years) CLARAVIS ORAL CAPSULE 10 MG, 20 2 PA MG, 30 MG, 40 MG isotretinoin oral capsule 10 mg, 20 mg, 30 2 PA mg, 40 mg MYORISAN ORAL CAPSULE 10 MG, 20 2 PA MG, 30 MG, 40 MG QL (45 GM per 30 days); AGE tretinoin external cream 0.05 %, 0.1 % 2 (Max 34 Years) QL (45 GM per 30 days); AGE tretinoin external gel 0.01 % 2 (Max 34 Years) ZENATANE ORAL CAPSULE 10 MG, 20 2 PA MG, 30 MG, 40 MG *Antibiotics - Topical*** gentamicin sulfate external cream 0.1 % 2 gentamicin sulfate external ointment 0.1 % 2 mupirocin external ointment 2 % 2 *Antifungals - Topical Combinations*** clotrimazole-betamethasone external 2 QL (90 GM per 30 days) cream 1-0.05 % clotrimazole-betamethasone external lotion 2 QL (60 ML per 30 days) 1-0.05 % nystatin-triamcinolone external cream 2 100000-0.1 unit/gm-% nystatin-triamcinolone external ointment 2 100000-0.1 unit/gm-% *Antifungals - Topical*** NYAMYC EXTERNAL POWDER 100000 2 UNIT/GM nystatin external cream 100000 unit/gm 2 nystatin external ointment 100000 unit/gm 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

57 Drug Name Drug Tier Requirements/Limits nystatin external powder 100000 unit/gm 2 NYSTOP EXTERNAL POWDER 100000 2 UNIT/GM *Anti-Inflammatory Agents - Topical*** diclofenac sodium transdermal gel 1 % 2 *Antineoplastic Antimetabolites - Topical*** fluorouracil external cream 5 % 2 fluorouracil external solution 2 %, 5 % 2 *Antipruritics - Topical*** doxepin hcl external cream 5 % 4 *Antipsoriatics - Systemic*** acitretin oral capsule 10 mg, 17.5 mg, 25 5 PA mg methoxsalen rapid oral capsule 10 mg 2 PA; SP *Antipsoriatics*** calcipotriene external cream 0.005 % 2 calcipotriene external ointment 0.005 % 2 calcipotriene external solution 0.005 % 2 calcitriol external ointment 3 mcg/gm 2 PA *Antiseborrheic Products*** selenium sulfide external lotion 2.5 % 2 selenium sulfide external shampoo 2.25 % 2 *Antivirals - Topical*** acyclovir external ointment 5 % 5 PA *Burn Products*** mafenide acetate external packet 5 % 2 silver sulfadiazine external cream 1 % 2 SSD EXTERNAL CREAM 1 % 2 *Corticosteroids - Topical*** alclometasone dipropionate external cream 2 0.05 % alclometasone dipropionate external 2 ointment 0.05 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

58 Drug Name Drug Tier Requirements/Limits amcinonide external cream 0.1 % 4 amcinonide external lotion 0.1 % 4 amcinonide external ointment 0.1 % 4 betamethasone dipropionate aug external 2 QL (100 GM per 30 days) cream 0.05 % betamethasone dipropionate aug external 2 QL (120 ML per 30 days) lotion 0.05 % betamethasone dipropionate aug external 2 QL (100 GM per 30 days) ointment 0.05 % betamethasone dipropionate external 2 QL (90 GM per 30 days) cream 0.05 % betamethasone dipropionate external 2 QL (120 ML per 30 days) lotion 0.05 % betamethasone dipropionate external 2 QL (90 GM per 30 days) ointment 0.05 % betamethasone valerate external cream 2 QL (90 GM per 30 days) 0.1 % betamethasone valerate external foam 2 0.12 % betamethasone valerate external lotion 0.1 2 QL (120 ML per 30 days) % betamethasone valerate external ointment 2 QL (90 GM per 30 days) 0.1 % clocortolone pivalate external cream 0.1 % 4 desonide external cream 0.05 % 2 QL (120 GM per 30 days) desonide external lotion 0.05 % 2 desonide external ointment 0.05 % 2 QL (120 GM per 30 days) desoximetasone external cream 0.05 %, 2 QL (200 GM per 30 days) 0.25 % desoximetasone external gel 0.05 % 2 QL (120 GM per 30 days) desoximetasone external ointment 0.05 % 2 QL (120 GM per 30 days) desoximetasone external ointment 0.25 % 2 QL (200 GM per 30 days) diflorasone diacetate external cream 0.05 2 QL (120 GM per 30 days) % diflorasone diacetate external ointment 2 QL (120 GM per 30 days) 0.05 % fluocinolone acetonide external cream 0.01 2 QL (120 GM per 30 days) %, 0.025 % fluocinolone acetonide external ointment 2 QL (120 GM per 30 days) 0.025 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

59 Drug Name Drug Tier Requirements/Limits fluocinolone acetonide external solution 2 0.01 % fluocinolone acetonide scalp external oil 2 0.01 % fluocinonide external ointment 0.05 % 2 QL (120 GM per 30 days) fluocinonide external solution 0.05 % 2 QL (120 ML per 30 days) flurandrenolide external cream 0.05 % 2 PA fluticasone propionate external cream 0.05 2 QL (120 GM per 30 days) % fluticasone propionate external lotion 0.05 2 % fluticasone propionate external ointment 2 QL (120 GM per 30 days) 0.005 % halobetasol propionate external cream 2 QL (100 GM per 30 days) 0.05 % halobetasol propionate external ointment 2 QL (100 GM per 30 days) 0.05 % hydrocortisone butyr lipo base external 2 cream 0.1 % hydrocortisone butyrate external ointment 2 0.1 % hydrocortisone butyrate external solution 2 0.1 % hydrocortisone external cream 1 % 2 QL (120 GM per 30 days) hydrocortisone external cream 2.5 % 2 hydrocortisone external lotion 2.5 % 2 QL (120 ML per 30 days) hydrocortisone external ointment 1 %, 2.5 2 QL (90 GM per 30 days) % hydrocortisone valerate external cream 0.2 2 QL (120 GM per 30 days) % hydrocortisone valerate external ointment 2 QL (120 GM per 30 days) 0.2 % mometasone furoate external cream 0.1 % 2 mometasone furoate external ointment 0.1 2 % mometasone furoate external solution 0.1 2 % prednicarbate external ointment 0.1 % 2 QL (120 GM per 30 days) scalacort external lotion 2 % 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

60 Drug Name Drug Tier Requirements/Limits triamcinolone acetonide external aerosol 2 PA solution 0.147 mg/gm triamcinolone acetonide external cream 2 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 2 0.025 %, 0.1 % triamcinolone acetonide external ointment 2 0.025 %, 0.1 %, 0.5 % *Emollients*** ammonium lactate external cream 12 % 2 ammonium lactate external lotion 12 % 2 lactic acid external lotion 10 % 2 *Imidazole-Related Antifungals - Topical*** clotrimazole external cream 1 % 2 clotrimazole external solution 1 % 2 econazole nitrate external cream 1 % 2 QL (85 GM per 30 days) ketoconazole external cream 2 % 2 ketoconazole external shampoo 2 % 2 oxiconazole nitrate external cream 1 % 2 *Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external cream 5 % 2 QL (12 EA per 28 days) *Keratolytic/Antimitotic Agents*** podofilox external solution 0.5 % 2 *Local Anesthetics - Topical*** lidocaine external ointment 5 % 2 QL (50 GM per 30 days) lidocaine external patch 5 % 2 PA lidocaine hcl external cream 3 % 2 QL (85 GM per 30 days) lidocaine hcl external lotion 3 % 2 QL (100 ML per 30 days) lidocaine hcl external solution 4 % 2 QL (100 ML per 30 days) lidocaine hcl urethral/mucosal external gel 2 QL (90 ML per 30 days) 2 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

61 Drug Name Drug Tier Requirements/Limits lidocaine hcl urethral/mucosal external 2 QL (90 ML per 30 days) prefilled syringe 2 % *Macrolide Immunosuppressants - Topical*** tacrolimus external ointment 0.03 %, 0.1 2 % *Rosacea Agents*** metronidazole external cream 0.75 % 2 metronidazole external gel 0.75 % 2 metronidazole external lotion 0.75 % 2 *Scabicides & Pediculicides*** lindane external shampoo 1 % 2 malathion external lotion 0.5 % 2 permethrin external cream 5 % 2 spinosad external suspension 0.9 % 2 ST; QL (120 ML per 30 days) *Topical Anesthetic Combinations*** lidocaine-prilocaine external cream 2.5-2.5 2 QL (30 GM per 30 days) % *Topical Steroid Combinations*** calcipotriene-betameth diprop external 2 ST; QL (120 GM per 30 days) ointment 0.005-0.064 % *DIAGNOSTIC PRODUCTS* *Diagnostic Drugs*** GLUCAGEN DIAGNOSTIC INJECTION 4 SOLUTION RECONSTITUTED 1 MG *Diagnostic Tests*** DIASTIX IN VITRO STRIP 3 OTC ONETOUCH ULTRA IN VITRO STRIP 3 OTC; QL (200 EA per 30 days) ONETOUCH VERIO IN VITRO STRIP 3 OTC; QL (200 EA per 30 days) *Multiple Urine Tests*** CHEMSTRIP 9 IN VITRO STRIP 3 OTC KETO-DIASTIX IN VITRO STRIP 3 OTC

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

62 Drug Name Drug Tier Requirements/Limits *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* *Dietary Management Product Combinations*** virt-vite forte oral tablet 2.5-25-2 mg 2 *Nutritional Supplements*** PKU AIR15 GOLD ORAL LIQUID 3 PA; OTC PKU AIR15 GREEN ORAL LIQUID 3 PA; OTC PKU AIR15 YELLOW ORAL LIQUID 3 PA; OTC PKU AIR20 GOLD ORAL LIQUID 3 PA; OTC PKU AIR20 GREEN ORAL LIQUID 3 PA; OTC PKU AIR20 YELLOW ORAL LIQUID 3 PA; OTC PKU COOLER 10 ORAL LIQUID 3 PA; OTC PKU COOLER 15 ORAL LIQUID 3 PA; OTC PKU COOLER 20 ORAL LIQUID 3 PA; OTC PKU EXPRESS ORAL PACKET 3 PA; OTC PKU EXPRESS20 ORAL PACKET 3 PA; OTC PKU GEL ORAL PACKET 3 PA; OTC PKU SPHERE 20 ORAL PACKET 3 PA; OTC *DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 3 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 3 63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT *DIRECT-ACTING P2Y12 INHIBITORS*** *Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (60 EA per 30 days)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

63 Drug Name Drug Tier Requirements/Limits *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended 2 QL (60 EA per 30 days) release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg 2 methazolamide oral tablet 25 mg, 50 mg 2 *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5- 2 50 mg spironolactone-hctz oral tablet 25-25 mg 2 triamterene-hctz oral capsule 37.5-25 mg 2 triamterene-hctz oral tablet 37.5-25 mg, 2 75-50 mg *Loop Diuretics*** bumetanide injection solution 0.25 mg/ml 2 bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 2 ethacrynic acid oral tablet 25 mg 2 furosemide injection solution 10 mg/ml 2 furosemide oral solution 10 mg/ml, 8 2 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 2 mg torsemide oral tablet 10 mg, 100 mg, 20 2 mg, 5 mg *Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg 2 spironolactone oral tablet 100 mg, 25 mg, 2 50 mg *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg 2 chlorthalidone oral tablet 25 mg, 50 mg 2 hydrochlorothiazide oral capsule 12.5 mg 2 hydrochlorothiazide oral tablet 12.5 mg, 25 2 mg, 50 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

64 Drug Name Drug Tier Requirements/Limits indapamide oral tablet 1.25 mg, 2.5 mg 2 *ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral tablet 10 mg, 40 2 QL (30 EA per 30 days) mg, 5 mg alendronate sodium oral tablet 35 mg, 70 2 QL (4 EA per 28 days) mg risedronate sodium oral tablet 150 mg 2 QL (1 EA per 28 days) risedronate sodium oral tablet 30 mg, 5 2 QL (30 EA per 30 days) mg risedronate sodium oral tablet 35 mg 2 *Calcitonins*** calcitonin (salmon) nasal solution 200 2 unit/act *Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg 2 *Growth Hormones*** GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION PA; Coverage only for 18 RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 5 years of age and younger; SP MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG GENOTROPIN MINIQUICK PA; Coverage only for 18 SUBCUTANEOUS SOLUTION 4 years of age and younger; SP RECONSTITUTED 2 MG GENOTROPIN SOLUTION RECONSTITUTED 5 MG 5 PA SUBCUTANEOUS 5 MG GENOTROPIN SUBCUTANEOUS PA; Coverage only for 18 4 SOLUTION RECONSTITUTED 12 MG years of age and younger; SP *Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 calcitriol oral solution 1 mcg/ml 2 doxercalciferol oral capsule 0.5 mcg, 1 2 PA mcg, 2.5 mcg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

65 Drug Name Drug Tier Requirements/Limits paricalcitol oral capsule 1 mcg, 2 mcg, 4 2 PA mcg *Insulin-Like Growth Factors (Somatomedins)*** INCRELEX SUBCUTANEOUS SOLUTION 4 PA; SP 40 MG/4ML *Rank Ligand (Rankl) Inhibitors*** PROLIA SUBCUTANEOUS SOLUTION 5 PA; SP PREFILLED SYRINGE 60 MG/ML *Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl oral tablet 60 mg 1 PA *Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 4 PA; SP mcg/ml, 500 mcg/ml SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 4 PA; SP MG/0.2ML, 90 MG/0.3ML *Vasopressin*** desmopressin ace rhinal tube nasal 2 solution 0.01 % desmopressin ace spray refrig nasal 2 solution 0.01 % desmopressin acetate injection solution 4 2 PA; SP mcg/ml desmopressin acetate oral tablet 0.1 mg, 2 0.2 mg *ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 2 0.5-0.1 mg, 1-0.5 mg JINTELI ORAL TABLET 1-5 MG-MCG 2 QL (28 EA per 28 days) norethindrone-eth estradiol oral tablet 0.5- 2 QL (28 EA per 28 days) 2.5 mg-mcg *Estrogens*** estradiol oral tablet 0.5 mg, 1 mg, 2 mg 2 AGE (Max 64 Years)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

66 Drug Name Drug Tier Requirements/Limits estradiol transdermal patch twice weekly QL (8 EA per 28 days); AGE 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 2 (Max 64 Years) mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, QL (4 EA per 28 days); AGE 2 0.06 mg/24hr, 0.075 mg/24hr, 0.1 (Max 64 Years) mg/24hr estradiol valerate intramuscular oil 20 2 mg/ml, 40 mg/ml estropipate oral tablet 0.75 mg, 1.5 mg, 3 2 AGE (Max 64 Years) mg *FLUOROQUINOLONES* *Fluoroquinolones*** CIPRO ORAL SUSPENSION 4 RECONSTITUTED 250 MG/5ML (5%) ciprofloxacin hcl oral tablet 100 mg, 250 2 mg, 500 mg, 750 mg ciprofloxacin oral suspension reconstituted 2 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 2 mg FACTIVE ORAL TABLET 320 MG 4 levofloxacin oral tablet 250 mg, 500 mg, 2 750 mg moxifloxacin hcl oral tablet 400 mg 2 ofloxacin oral tablet 400 mg 2 *GASTROINTESTINAL AGENTS - MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule 300 mg 2 ursodiol oral tablet 250 mg, 500 mg 2 *Gastrointestinal Antiallergy Agents*** cromolyn sodium oral concentrate 100 2 mg/5ml *Gastrointestinal Stimulants*** PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

67 Drug Name Drug Tier Requirements/Limits metoclopramide hcl oral solution 5 mg/5ml 2 metoclopramide hcl oral tablet 10 mg, 5 2 mg *Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** alosetron hcl oral tablet 0.5 mg, 1 mg 2 PA *Inflammatory Bowel Agents*** APRISO ORAL CAPSULE EXTENDED 4 QL (120 EA per 30 days) RELEASE 24 HOUR 0.375 GM balsalazide disodium oral capsule 750 mg 2 DIPENTUM ORAL CAPSULE 250 MG 4 PA mesalamine er oral capsule extended 2 QL (120 EA per 30 days) release 24 hour 0.375 gm mesalamine oral tablet delayed release 1.2 2 QL (120 EA per 30 days) gm mesalamine oral tablet delayed release 2 QL (180 EA per 30 days) 800 mg mesalamine rectal enema 4 gm 2 QL (1680 ML per 28 days) sulfasalazine oral tablet 500 mg 2 sulfasalazine oral tablet delayed release 2 500 mg *Intestinal Acidifiers*** enulose oral solution 10 gm/15ml 2 generlac oral solution 10 gm/15ml 2 *Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule 2 667 mg calcium acetate (phos binder) oral tablet 2 667 mg PHOSLYRA ORAL SOLUTION 667 3 PA MG/5ML sevelamer carbonate oral packet 0.8 gm, 2 PA 2.4 gm sevelamer carbonate oral tablet 800 mg 2 PA *Tumor Necrosis Factor Alpha Blockers***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

68 Drug Name Drug Tier Requirements/Limits CIMZIA PREFILLED SUBCUTANEOUS 5 PA; SP; QL (1 EA per 28 days) KIT 2 X 200 MG/ML CIMZIA STARTER KIT SUBCUTANEOUS PA; SP; QL (3 EA per 180 5 KIT 6 X 200 MG/ML days) CIMZIA SUBCUTANEOUS KIT 2 X 200 5 PA; SP; QL (1 EA per 28 days) MG *GENITOURINARY AGENTS - MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** dutasteride oral capsule 0.5 mg 2 finasteride oral tablet 5 mg 2 *Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended 2 release 24 hour 10 mg CARDURA XL ORAL TABLET EXTENDED 4 RELEASE 24 HOUR 4 MG tamsulosin hcl oral capsule 0.4 mg 2 *Anti-Infective Genitourinary Irrigants*** neomycin-polymyxin b gu irrigation 2 solution 40-200000 *Citrates*** CYTRA-3 ORAL SYRUP 550-500-334 2 OTC MG/5ML potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 2 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 2 1100-334 mg/5ml sod citrate-citric acid oral solution 500-334 2 mg/5ml *Genitourinary Irrigants*** acetic acid irrigation solution 0.25 % 2 sorbitol irrigation solution 3 %, 3.3 % 2 sorbitol-mannitol irrigation solution 2.7- 2 0.54 gm/100ml

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

69 Drug Name Drug Tier Requirements/Limits *Interstitial Cystitis Agents*** ELMIRON ORAL CAPSULE 100 MG 5 PA *Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 2 200 mg *GLYCOPEPTIDES*** *Glycopeptides*** vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 500 mg, 750 2 mg *GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 2 mg *Gout Agents*** allopurinol oral tablet 100 mg, 300 mg 2 colchicine oral tablet 0.6 mg 2 *Uricosurics*** probenecid oral tablet 500 mg 2 *HEMATOLOGICAL AGENTS - MISC.* *Bradykinin B2 Receptor Antagonists*** icatibant acetate subcutaneous solution 30 4 PA; SP mg/3ml *C1 Inhibitors*** BERINERT INTRAVENOUS KIT 500 5 PA; SP UNIT *Cyclopentyltriazolopyrimidin e (Cptp) Derivatives*** BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (60 EA per 30 days) *Hematorheologic Agents*** pentoxifylline er oral tablet extended 2 QL (90 EA per 30 days) release 400 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

70 Drug Name Drug Tier Requirements/Limits *Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100 mg, 50 mg 2 *Platelet Aggregation Inhibitor Combinations*** aspirin-dipyridamole er oral capsule 2 QL (60 EA per 30 days) extended release 12 hour 25-200 mg *Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25 mg, 50 mg, 75 2 AGE (Max 64 Years) mg *Quinazoline Agents*** anagrelide hcl oral capsule 0.5 mg, 1 mg 2 *Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 300 mg 2 clopidogrel bisulfate oral tablet 75 mg 2 QL (30 EA per 30 days) prasugrel hcl oral tablet 10 mg, 5 mg 2 QL (30 EA per 30 days) *HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution 1000 2 mcg/ml *Erythropoiesis-Stimulating Agents (Esas)*** PROCRIT INJECTION SOLUTION 40000 5 PA; SP UNIT/ML PROCRIT SOLUTION 10000 UNIT/ML 5 PA INJECTION 10000 UNIT/ML PROCRIT SOLUTION 2000 UNIT/ML 5 PA INJECTION 2000 UNIT/ML PROCRIT SOLUTION 20000 UNIT/ML 5 PA INJECTION 20000 UNIT/ML PROCRIT SOLUTION 3000 UNIT/ML 5 PA INJECTION 3000 UNIT/ML PROCRIT SOLUTION 4000 UNIT/ML 5 PA INJECTION 4000 UNIT/ML *Erythropoietins***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

71 Drug Name Drug Tier Requirements/Limits PROCRIT INJECTION SOLUTION 40000 5 PA; SP UNIT/ML PROCRIT SOLUTION 10000 UNIT/ML 5 PA INJECTION 10000 UNIT/ML PROCRIT SOLUTION 2000 UNIT/ML 5 PA INJECTION 2000 UNIT/ML PROCRIT SOLUTION 20000 UNIT/ML 5 PA INJECTION 20000 UNIT/ML PROCRIT SOLUTION 3000 UNIT/ML 5 PA INJECTION 3000 UNIT/ML PROCRIT SOLUTION 4000 UNIT/ML 5 PA INJECTION 4000 UNIT/ML *Folic Acid/Folates*** folic acid oral tablet 1 mg 1 QL (30 EA per 30 days) folic acid oral tablet 400 mcg, 800 mcg 1 OTC; QL (30 EA per 30 days) *Granulocyte Colony- Stimulating Factors (G- Csf)*** NEULASTA SUBCUTANEOUS SOLUTION 5 PA; SP PREFILLED SYRINGE 6 MG/0.6ML ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 5 PA; SP 480 MCG/0.8ML *HEMOSTATICS* *Hemostatics - Systemic*** aminocaproic acid oral tablet 1000 mg, 500 4 PA mg tranexamic acid oral tablet 650 mg 2 *HEPATITIS C AGENT - COMBINATIONS*** *Hepatitis C Agent - Combinations*** MAVYRET ORAL TABLET 100-40 MG 5 PA; SP sofosbuvir-velpatasvir oral tablet 400-100 5 PA mg VOSEVI ORAL TABLET 400-100-100 4 PA; SP MG *HYPNOTICS*

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

72 Drug Name Drug Tier Requirements/Limits *Barbiturate Hypnotics*** phenobarbital oral elixir 20 mg/5ml 2 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 2 mg, 97.2 mg *Benzodiazepine Hypnotics*** temazepam oral capsule 15 mg, 22.5 mg, 2 30 mg, 7.5 mg *Non-Benzodiazepine - Gaba- Receptor Modulators*** zaleplon oral capsule 10 mg, 5 mg 2 QL (30 EA per 30 days) zolpidem tartrate oral tablet 10 mg, 5 mg 2 QL (30 EA per 30 days) *LAXATIVES* *Bowel Evacuant Combinations*** GAVILYTE-C ORAL SOLUTION 1 RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION 1 RECONSTITUTED 236 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 2 GM GOLYTELY ORAL SOLUTION 3 QL (1 EA per 365 days) RECONSTITUTED 227.1 GM MOVIPREP ORAL SOLUTION $0 copay for members age 50 4 RECONSTITUTED 100 GM through 74 peg 3350/electrolytes oral solution 1 reconstituted 240 gm peg-3350/electrolytes oral solution 1 reconstituted 236 gm peg-3350/electrolytes/ascorbat oral $0 copay for members age 50 4 solution reconstituted 100 gm through 74 peg-kcl-nacl-nasulf-na asc-c oral solution $0 copay for members age 50 4 reconstituted 100 gm through 74 SUPREP BOWEL PREP KIT ORAL $0 copay for members age 50 4 SOLUTION 17.5-3.13-1.6 GM/177ML through 74 *Laxatives - Miscellaneous*** lactulose oral solution 10 gm/15ml 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

73 Drug Name Drug Tier Requirements/Limits polyethylene glycol 3350 oral powder 17 2 gm/scoop *Saline Laxative Mixtures*** OSMOPREP ORAL TABLET 1.102-0.398 4 GM *MACROLIDES* *Azithromycin*** azithromycin intravenous solution 2 reconstituted 500 mg azithromycin oral packet 1 gm 2 azithromycin oral suspension reconstituted 2 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 2 600 mg *Clarithromycin*** clarithromycin er oral tablet extended 2 release 24 hour 500 mg clarithromycin oral suspension 2 reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 2 *Erythromycins*** ERY-TAB ORAL TABLET DELAYED 4 RELEASE 333 MG ERYTHROCIN STEARATE ORAL TABLET 4 250 MG erythromycin base oral capsule delayed 2 release particles 250 mg erythromycin base oral tablet 250 mg, 500 2 mg erythromycin ethylsuccinate oral tablet 400 4 mg *Fidaxomicin*** DIFICID ORAL TABLET 200 MG 4 PA *MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** BD SWAB SINGLE USE REGULAR PAD 3 OTC

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

74 Drug Name Drug Tier Requirements/Limits BD SWABS SINGLE USE BUTTERFLY 3 OTC PAD *Cervical Caps*** FEMCAP VAGINAL DEVICE 22 MM, 26 1 QL (1 EA per 300 days) MM, 30 MM *Condoms - Female*** FC2 FEMALE CONDOM 1 OTC *Diaphragms*** CAYA VAGINAL DIAPHRAGM 1 QL (1 EA per 300 days) OMNIFLEX DIAPHRAGM VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % *Glucose Monitoring Test Supplies*** DEXCOM G4 PLAT PED RCV/SHARE 3 DEVICE DEXCOM G4 PLAT PED RECEIVER 3 DEVICE DEXCOM G4 PLATINUM RCV/SHARE 3 DEVICE DEXCOM G4 PLATINUM RECEIVER 3 DEVICE DEXCOM G4 PLATINUM TRANSMITTER 3 DEXCOM G4 SENSOR 3

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

75 Drug Name Drug Tier Requirements/Limits DEXCOM G5 MOB/G4 PLAT SENSOR 3 DEXCOM G5 MOBILE RECEIVER DEVICE 3 DEXCOM G5 MOBILE TRANSMITTER 3 DEXCOM G5 RECEIVER KIT DEVICE 3 DEXCOM G6 RECEIVER DEVICE 3 DEXCOM G6 SENSOR 3 DEXCOM G6 TRANSMITTER 3 DIASCREEN 10 3 OTC ONETOUCH CLUB LANCETS FINE PT 3 OTC ONETOUCH COMBO PACK 3 OTC ONETOUCH DELICA LANCETS 30G 3 OTC ONETOUCH DELICA LANCETS 33G 3 OTC ONETOUCH DELICA LANCING DEV 3 OTC ONETOUCH DELICA PLUS LANCET30G 3 OTC ONETOUCH DELICA PLUS LANCET33G 3 OTC ONETOUCH DELICA PLUS LANCING 3 OTC ONETOUCH FINEPOINT LANCETS 3 OTC ONETOUCH PING METER REMOTE 3 OTC SUPPLIES ONETOUCH SURESOFT LANCING DEV 3 OTC ONETOUCH ULTRA 2 KIT W/DEVICE 3 OTC; QL (1 EA per 365 days) ONETOUCH ULTRA CONTROL IN VITRO 3 OTC SOLUTION ONETOUCH ULTRA MINI KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH ULTRALINK KIT W/DEVICE 3 OTC; QL (1 EA per 365 days) ONETOUCH ULTRASOFT LANCETS 3 OTC ONETOUCH VERIO FLEX SYSTEM KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH VERIO IN VITRO 3 OTC SOLUTION ONETOUCH VERIO IQ SYSTEM KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH VERIO KIT W/DEVICE 3 OTC; QL (1 EA per 365 days) ONETOUCH VERIO REFLECT KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH VERIO SYNC SYSTEM KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

76 Drug Name Drug Tier Requirements/Limits *Needles & Syringes*** BD VEO INSULIN SYRINGE U/F 31G X 3 OTC 15/64" 1 ML NOVOFINE 32G X 6 MM 3 OTC *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER PLUS FLO-VU 3 FLEXICHAMBER CHILD MASK/SMALL 3 OPTICHAMBER FACE MASK-SMALL 3 OTC PEDIATRIC PANDA MASK 3 OTC *MIGRAINE PRODUCTS* *Ergot Combinations*** ergotamine-caffeine oral tablet 1-100 mg 2 QL (40 EA per 28 days) *Migraine Combinations*** isometheptene-caffeine-apap oral tablet 2 65-20-325 mg *Migraine Products*** dihydroergotamine mesylate nasal solution 2 QL (8 ML per 30 days) 4 mg/ml MIGRANAL NASAL SOLUTION 4 MG/ML 2 QL (8 ML per 30 days) *Selective Serotonin Agonists 5-Ht(1)*** eletriptan hydrobromide oral tablet 20 mg, 2 ST 40 mg naratriptan hcl oral tablet 1 mg, 2.5 mg 2 QL (9 EA per 30 days) rizatriptan benzoate oral tablet 10 mg, 5 2 QL (12 EA per 30 days) mg rizatriptan benzoate oral tablet dispersible 2 QL (12 EA per 30 days) 10 mg, 5 mg sumatriptan nasal solution 20 mg/act, 5 2 PA mg/act sumatriptan succinate oral tablet 100 mg, 2 QL (9 EA per 30 days) 25 mg, 50 mg sumatriptan succinate subcutaneous 2 PA; QL (10 ML per 30 days) solution 6 mg/0.5ml sumatriptan succinate subcutaneous 2 PA; QL (10 ML per 30 days) solution auto-injector 6 mg/0.5ml zolmitriptan oral tablet 2.5 mg, 5 mg 2 QL (6 EA per 30 days) PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

77 Drug Name Drug Tier Requirements/Limits zolmitriptan oral tablet dispersible 2.5 mg, 2 QL (6 EA per 30 days) 5 mg *MINERALS & ELECTROLYTES* *Fluoride*** fluoritab oral tablet chewable 1.1 (0.5 f) $0 copay for 5 yrs of age and 1 mg younger sodium fluoride oral solution 1.1 (0.5 f) $0 copay for 5 yrs of age and 1 mg/ml younger sodium fluoride oral tablet chewable 0.55 $0 copay for 5 yrs of age and 1 (0.25 f) mg, 1.1 (0.5 f) mg younger sodium fluoride oral tablet chewable 2.2 (1 1 f) mg *Magnesium*** magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 40 2 gm/1000ml *Potassium*** KLOR-CON M15 ORAL TABLET 4 EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET 2 EXTENDED RELEASE 20 MEQ K-TAB ORAL TABLET EXTENDED 2 RELEASE 20 MEQ potassium chloride crys er oral tablet 2 extended release 10 meq, 20 meq potassium chloride er oral capsule 2 extended release 10 meq, 8 meq potassium chloride er oral tablet extended 2 release 10 meq, 20 meq, 8 meq potassium chloride intravenous solution 0.4 meq/ml, 10 meq/50ml, 2 meq/ml, 20 2 meq/100ml, 40 meq/100ml potassium chloride oral packet 20 meq 2 potassium chloride oral solution 20 2 meq/15ml (10%), 40 meq/15ml (20%) *Sodium*** sodium chloride intravenous solution 0.9 % 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

78 Drug Name Drug Tier Requirements/Limits *MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine viscous hcl mouth/throat solution 2 2 % *Anti-Infectives - Throat*** clotrimazole mouth/throat troche 10 mg 2 nystatin mouth/throat suspension 100000 2 unit/ml *Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat 2 solution 0.12 % *Saliva Stimulants*** pilocarpine hcl oral tablet 5 mg, 7.5 mg 2 *Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat 2 paste 0.1 % *MULTIVITAMINS* *Ped Multi Vitamins W/Fl & Fe*** multi-vit/fluoride/iron oral solution 0.25-10 2 mg/ml multi-vitamin/fluoride/iron oral solution 2 0.25-10 mg/ml *Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.5 mg/ml 2 multivitamin/fluoride oral tablet chewable 2 0.25 mg, 0.5 mg, 1 mg MVC-FLUORIDE ORAL TABLET 2 CHEWABLE 1 MG *Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution 0.25-10 2 mg/ml *Ped Vitamins Acd W/ Fluoride*** PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

79 Drug Name Drug Tier Requirements/Limits tri-vit/fluoride oral solution 0.5 mg/ml 2 vitamins acd-fluoride oral solution 0.25 2 mg/ml *Prenatal Mv & Min W/Fe- Fa*** CITRANATAL B-CALM ORAL 20-1 MG & 3 2 X 25 MG CITRANATAL RX ORAL TABLET 27-1 3 MG PRENATABS RX ORAL TABLET 29-1 MG 2 *MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg 2 carisoprodol oral tablet 350 mg 2 AGE (Max 64 Years) chlorzoxazone oral tablet 500 mg 2 cyclobenzaprine hcl oral tablet 10 mg, 5 2 AGE (Max 64 Years) mg metaxalone oral tablet 400 mg 2 AGE (Max 64 Years) methocarbamol oral tablet 500 mg, 750 2 AGE (Max 64 Years) mg orphenadrine citrate er oral tablet 2 AGE (Max 64 Years) extended release 12 hour 100 mg tizanidine hcl oral capsule 2 mg, 4 mg, 6 2 QL (90 EA per 30 days) mg tizanidine hcl oral tablet 2 mg, 4 mg 2 QL (90 EA per 30 days) *Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg, 25 2 mg, 50 mg *NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 % 2 QL (30 ML per 30 days) ipratropium bromide nasal solution 0.06 % 2 QL (15 ML per 30 days) *Nasal Antihistamines*** azelastine hcl nasal solution 0.1 %, 0.15 % 2 *Nasal Steroids***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

80 Drug Name Drug Tier Requirements/Limits budesonide nasal suspension 32 mcg/act 2 QL (8.43 GM per 30 days) FLONASE SENSIMIST NASAL OTC; QL (15.8 ML per 30 2 SUSPENSION 27.5 MCG/SPRAY days) flunisolide nasal solution 25 mcg/act 2 QL (50 ML per 30 days) (0.025%) fluticasone propionate nasal suspension 50 2 QL (16 GM per 30 days) mcg/act triamcinolone acetonide nasal aerosol 55 2 mcg/act *NEPRILYSIN INHIB (ARNI)- ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)- Angiotensin Ii Recept Antag Comb*** ENTRESTO ORAL TABLET 24-26 MG, 3 PA; QL (60 EA per 30 days) 49-51 MG, 97-103 MG *NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet 50 mg 5 SP *Neuromuscular Blocking Agent - Neurotoxins*** DYSPORT INTRAMUSCULAR SOLUTION 5 PA; SP RECONSTITUTED 300 UNIT *OPHTHALMIC AGENTS* *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** SIMBRINZA OPHTHALMIC 4 QL (8 ML per 30 days) SUSPENSION 1-0.2 % *Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic 2 solution 22.3-6.8 mg/ml *Beta-Blockers - Ophthalmic*** betaxolol hcl ophthalmic solution 0.5 % 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

81 Drug Name Drug Tier Requirements/Limits BETOPTIC-S OPHTHALMIC 3 PA SUSPENSION 0.25 % carteolol hcl ophthalmic solution 1 % 2 levobunolol hcl ophthalmic solution 0.5 % 2 metipranolol ophthalmic solution 0.3 % 2 timolol maleate ophthalmic solution 0.25 2 %, 0.5 % *Cycloplegic Mydriatics*** atropine sulfate ophthalmic solution 1 % 2 cyclopentolate hcl ophthalmic solution 1 %, 2 2 % HOMATROPAIRE OPHTHALMIC 2 SOLUTION 5 % tropicamide ophthalmic solution 0.5 %, 1 2 % *Miotics - Cholinesterase Inhibitors*** PHOSPHOLINE IODIDE OPHTHALMIC 3 SOLUTION RECONSTITUTED 0.125 % *Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 2 %, 4 % *Ophthalmic Antiallergic*** azelastine hcl ophthalmic solution 0.05 % 2 QL (6 ML per 30 days) cromolyn sodium ophthalmic solution 4 % 2 epinastine hcl ophthalmic solution 0.05 % 2 olopatadine hcl ophthalmic solution 0.1 %, 2 0.2 % *Ophthalmic Antibiotics*** bacitracin ophthalmic ointment 500 2 unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % 2 erythromycin ophthalmic ointment 5 2 mg/gm gatifloxacin ophthalmic solution 0.5 % 2 gentamicin sulfate ophthalmic ointment 0.3 2 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

82 Drug Name Drug Tier Requirements/Limits gentamicin sulfate ophthalmic solution 0.3 2 % levofloxacin ophthalmic solution 0.5 % 2 PA moxifloxacin hcl ophthalmic solution 0.5 % 2 ofloxacin ophthalmic solution 0.3 % 2 tobramycin ophthalmic solution 0.3 % 2 *Ophthalmic Anti-Infective Combinations*** bacitracin-polymyxin b ophthalmic 2 ointment 500-10000 unit/gm neomycin-polymyxin-gramicidin 2 ophthalmic solution 1.75-10000-.025 polymyxin b-trimethoprim ophthalmic 2 solution 10000-0.1 unit/ml-% *Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 % 2 *Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution 2 % 2 *Ophthalmic Decongestants*** naphazoline hcl ophthalmic solution 0.1 % 2 *Ophthalmic Local Anesthetics*** ALTACAINE OPHTHALMIC SOLUTION 2 0.5 % proparacaine hcl ophthalmic solution 0.5 % 2 *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** flurbiprofen sodium ophthalmic solution 2 0.03 % ketorolac tromethamine ophthalmic 2 solution 0.4 %, 0.5 % *Ophthalmic Selective Alpha Adrenergic Agonists*** apraclonidine hcl ophthalmic solution 0.5 2 %

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

83 Drug Name Drug Tier Requirements/Limits brimonidine tartrate ophthalmic solution 2 0.15 %, 0.2 % *Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic 2 ointment 1 % BLEPHAMIDE S.O.P. OPHTHALMIC 3 OINTMENT 10-0.2 % neomycin-polymyxin-dexameth ophthalmic 2 ointment 3.5-10000-0.1 neomycin-polymyxin-dexameth ophthalmic 2 suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic 2 suspension 3.5-10000-1 sulfacetamide-prednisolone ophthalmic 2 solution 10-0.23 % tobramycin-dexamethasone ophthalmic 2 QL (5 ML per 30 days) suspension 0.3-0.1 % *Ophthalmic Steroids*** dexamethasone sodium phosphate 2 ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 2 % FML OPHTHALMIC OINTMENT 0.1 % 3 PRED MILD OPHTHALMIC 3 SUSPENSION 0.12 % prednisolone acetate ophthalmic 2 suspension 1 % prednisolone sodium phosphate ophthalmic 2 solution 1 % *Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic solution 2 10 % *Prostaglandins - Ophthalmic*** bimatoprost ophthalmic solution 0.03 % 2 QL (5 ML per 30 days) latanoprost ophthalmic solution 0.005 % 2 QL (5 ML per 30 days) travoprost (bak free) ophthalmic solution 2 QL (5 ML per 30 days) 0.004 % travoprost ophthalmic solution 0.004 % 2 QL (5 ML per 30 days) PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

84 Drug Name Drug Tier Requirements/Limits *OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % 2 *Otic Anti-Infectives*** ofloxacin otic solution 0.3 % 2 *Otic Steroid-Anti-Infective Combinations*** CIPRO HC OTIC SUSPENSION 0.2-1 % 4 PA CIPRODEX OTIC SUSPENSION 0.3-0.1 4 % ciprofloxacin-dexamethasone otic 2 suspension 0.3-0.1 % neomycin-polymyxin-hc otic solution 3.5- 2 10000-1 neomycin-polymyxin-hc otic suspension 2 3.5-10000-1 *Otic Steroids*** fluocinolone acetonide otic oil 0.01 % 2 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** *Passive Immunizing Agents - Combinations*** HYQVIA SUBCUTANEOUS KIT 10 4 PA; SP GM/100ML, 2.5 GM/25ML, 5 GM/50ML HYQVIA SUBCUTANEOUS KIT 20 5 PA; SP GM/200ML, 30 GM/300ML *PASSIVE IMMUNIZING AGENTS* *Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR SOLUTION 5 PA; SP 100 MG/ML, 50 MG/0.5ML *PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

85 Drug Name Drug Tier Requirements/Limits amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 2 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 2 amoxicillin oral tablet chewable 125 mg, 2 250 mg ampicillin oral capsule 250 mg, 500 mg 2 ampicillin oral suspension reconstituted 2 125 mg/5ml, 250 mg/5ml *Natural Penicillins*** penicillin v potassium oral solution 2 reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 2 500 mg *Penicillin Combinations*** amoxicillin-pot clavulanate er oral tablet 2 extended release 12 hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 2 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250- 2 125 mg, 500-125 mg amoxicillin-pot clavulanate oral tablet 875- 2 QL (28 EA per 14 days) 125 mg amoxicillin-pot clavulanate oral tablet 2 chewable 200-28.5 mg, 400-57 mg AUGMENTIN ORAL SUSPENSION 3 PA RECONSTITUTED 125-31.25 MG/5ML *Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 2 500 mg *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** *Phosphodiesterase 4 (Pde4) Inhibitors*** PA; SP; QL (60 EA per 30 OTEZLA ORAL TABLET 30 MG 4 days)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

86 Drug Name Drug Tier Requirements/Limits *POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** KIONEX ORAL SUSPENSION 15 2 GM/60ML sodium polystyrene sulfonate rectal 2 suspension 30 gm/120ml *PROGESTINS* *Progestins*** medroxyprogesterone acetate oral tablet 2 10 mg, 2.5 mg, 5 mg norethindrone acetate oral tablet 5 mg 2 progesterone micronized oral capsule 100 2 mg, 200 mg *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *Alcohol Deterrents*** acamprosate calcium oral tablet delayed 2 release 333 mg disulfiram oral tablet 250 mg, 500 mg 2 *Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 2 10-25 mg, 5-12.5 mg *Cholinomimetics - Ache Inhibitors*** donepezil hcl oral tablet 10 mg, 23 mg, 5 2 mg donepezil hcl oral tablet dispersible 10 mg, 2 5 mg galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 2 mg galantamine hydrobromide oral tablet 12 2 mg, 4 mg, 8 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

87 Drug Name Drug Tier Requirements/Limits rivastigmine tartrate oral capsule 1.5 mg, 2 3 mg, 4.5 mg, 6 mg *Movement Disorder Drug Therapy*** tetrabenazine oral tablet 12.5 mg, 25 mg 5 PA; SP *Multiple Sclerosis Agents - Interferons*** AVONEX INTRAMUSCULAR KIT 30 MCG 5 PA; SP AVONEX PEN INTRAMUSCULAR AUTO- 5 PA; SP INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 5 PA; SP MCG/0.5ML BETASERON SUBCUTANEOUS KIT 0.3 3 PA MG *Multiple Sclerosis Agents*** glatiramer acetate subcutaneous solution 2 PA; SP prefilled syringe 20 mg/ml, 40 mg/ml GLATOPA SUBCUTANEOUS SOLUTION 2 PA; SP PREFILLED SYRINGE 20 MG/ML *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution 2 mg/ml 2 PA memantine hcl oral tablet 10 mg, 5 mg 2 QL (60 EA per 30 days) memantine hcl oral tablet 28 x 5 mg & 21 2 QL (49 EA per 365 days) x 10 mg *Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 2 mg, 2-25 mg, 4-10 mg, 4-25 mg *Psychotherapeutic And Neurological Agents - Misc.*** ergoloid mesylates oral tablet 1 mg 4 PA pimozide oral tablet 1 mg, 2 mg 2 *Smoking Deterrents***

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

88 Drug Name Drug Tier Requirements/Limits bupropion hcl er (smoking det) oral tablet $0 limited to 2 treatment 1 extended release 12 hour 150 mg cycles/year $0 limited to 2 treatment CHANTIX CONTINUING MONTH PAK 1 cycles/year; QL (60 EA per 30 ORAL TABLET 1 MG days) $0 limited to 2 treatment CHANTIX ORAL TABLET 0.5 MG, 1 MG 1 cycles/year; QL (60 EA per 30 days) CHANTIX STARTING MONTH PAK ORAL $0 limited to 2 treatment 1 TABLET 0.5 MG X 11 & 1 MG X 42 cycles/year goodsense nicotine mouth/throat lozenge 4 OTC; $0 limited to 2 1 mg treatment cycles/year; OTC OTC; $0 limited to 2 NICORELIEF MOUTH/THROAT GUM 4 1 treatment cycles/year; OTC; MG QL (810 EA per 365 days) OTC; QL (810 EA per 365 nicotine polacrilex mouth/throat gum 2 mg 1 days) OTC; $0 limited to 2 nicotine polacrilex mouth/throat gum 4 mg 1 treatment cycles/year; OTC; QL (810 EA per 365 days) nicotine polacrilex mouth/throat lozenge 2 OTC; $0 limited to 2 1 mg treatment cycles/year; OTC nicotine step 3 transdermal patch 24 hour OTC; $0 limited to 2 1 7 mg/24hr treatment cycles/year; OTC nicotine transdermal patch 24 hour 14 OTC; $0 limited to 2 1 mg/24hr treatment cycles/year; OTC OTC; $0 limited to 2 nicotine transdermal patch 24 hour 21 1 treatment cycles/year; OTC; mg/24hr QL (90 EA per 365 days) NICOTROL INHALATION INHALER 10 $0 limited to 2 treatment 1 MG cycles/year NICOTROL NS NASAL SOLUTION 10 $0 limited to 2 treatment 1 MG/ML cycles/year *Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE 0.5 MG 4 PA; SP *PULMONARY FIBROSIS AGENTS*** *Pulmonary Fibrosis Agents*** PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

89 Drug Name Drug Tier Requirements/Limits ESBRIET ORAL CAPSULE 267 MG 4 PA; SP *RESPIRATORY AGENTS - MISC.* *Cftr Potentiators*** KALYDECO ORAL TABLET 150 MG 4 PA; SP *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 5 PA; SP 1 MG/ML *SEROTONIN MODULATORS*** *Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 2 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 2 50 mg *SODIUM-GLUCOSE CO- TRANSPORTER 2 INHIBITOR- BIGUANIDE COMB*** *Sodium-Glucose Co- Transporter 2 Inhibitor- Biguanide Comb*** SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 3 QL (60 EA per 30 days) MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 3 QL (30 EA per 30 days) MG, 12.5-1000 MG, 25-1000 MG, 5- 1000 MG *STEROIDS - MOUTH/THROAT/DENTAL*** *Steroids - Mouth/Throat/Dental*** triamcinolone acetonide mouth/throat 2 paste 0.1 % *SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet 500 mg 4

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

90 Drug Name Drug Tier Requirements/Limits *TETRACYCLINES* *Tetracyclines*** demeclocycline hcl oral tablet 150 mg, 300 2 mg doxycycline hyclate oral capsule 100 mg, 2 50 mg doxycycline hyclate oral tablet 100 mg, 20 2 mg doxycycline monohydrate oral capsule 100 2 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension 2 reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 150 2 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 2 mg, 75 mg tetracycline hcl oral capsule 250 mg, 500 2 mg *THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg 2 propylthiouracil oral tablet 50 mg 2 *Thyroid Hormones*** ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 3 300 MG, 60 MG, 90 MG EUTHYROX ORAL TABLET 25 MCG 2 LEVO-T ORAL TABLET 25 MCG 2 levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 2 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 2 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 2 mcg, 50 mcg NATURE-THROID ORAL TABLET 16.25 2 MG, 32.5 MG

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

91 Drug Name Drug Tier Requirements/Limits np thyroid oral tablet 15 mg 2 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 3 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 100 MCG 2 *TOXOIDS* *Toxoid Combinations*** ADACEL INTRAMUSCULAR 1 SUSPENSION 5-2-15.5 LF-MCG/0.5 BOOSTRIX INTRAMUSCULAR 1 SUSPENSION 5-2.5-18.5 LF-MCG/0.5 DAPTACEL INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 23-15-5 and younger diphtheria-tetanus toxoids dt intramuscular $0 copay for 18 years of age 1 suspension 25-5 lfu/0.5ml and younger INFANRIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 25-58-10 and younger KINRIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION and younger PEDIARIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION and younger PENTACEL INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION RECONSTITUTED and younger TDVAX INTRAMUSCULAR SUSPENSION $0 copay for 19 years of age 1 2-2 LF/0.5ML and older TENIVAC INTRAMUSCULAR $0 copay for 19 years of age 1 INJECTABLE 5-2 LFU and older *ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg 2 dicyclomine hcl oral solution 10 mg/5ml 2 dicyclomine hcl oral tablet 20 mg 2 *Belladonna Alkaloids*** hyoscyamine sulfate oral tablet 0.125 mg 2 hyoscyamine sulfate oral tablet dispersible 2 0.125 mg hyoscyamine sulfate sublingual tablet 2 sublingual 0.125 mg

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

92 Drug Name Drug Tier Requirements/Limits *H-2 Antagonists*** cimetidine hcl oral solution 300 mg/5ml 2 cimetidine oral tablet 200 mg, 300 mg, 2 400 mg, 800 mg famotidine intravenous solution 20 mg/2ml 2 famotidine oral suspension reconstituted 2 40 mg/5ml famotidine oral tablet 20 mg, 40 mg 2 ranitidine hcl oral capsule 150 mg, 300 mg 2 ranitidine hcl oral syrup 75 mg/5ml 2 ranitidine hcl oral tablet 150 mg, 300 mg 2 *Misc. Anti-Ulcer*** CARAFATE ORAL SUSPENSION 1 4 PA GM/10ML sucralfate oral suspension 1 gm/10ml 2 PA sucralfate oral tablet 1 gm 2 *Proton Pump Inhibitors*** DEXILANT ORAL CAPSULE DELAYED 3 ST; QL (30 EA per 30 days) RELEASE 30 MG, 60 MG lansoprazole oral capsule delayed release 2 QL (30 EA per 30 days) 30 mg omeprazole oral capsule delayed release 2 QL (60 EA per 30 days) 10 mg, 20 mg, 40 mg pantoprazole sodium oral tablet delayed 2 QL (60 EA per 30 days) release 20 mg, 40 mg *Quaternary Anticholinergics*** glycopyrrolate oral tablet 1 mg, 2 mg 2 methscopolamine bromide oral tablet 2.5 2 mg, 5 mg *Ulcer Drugs - Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg 2 *URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** fosfomycin tromethamine oral packet 3 gm 4 methenamine hippurate oral tablet 1 gm 2

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

93 Drug Name Drug Tier Requirements/Limits MONUROL ORAL PACKET 3 GM 4 nitrofurantoin macrocrystal oral capsule 2 AGE (Max 64 Years) 100 mg, 50 mg nitrofurantoin monohyd macro oral capsule 2 AGE (Max 64 Years) 100 mg nitrofurantoin oral suspension 25 mg/5ml 2 AGE (Max 64 Years) *URINARY ANTISPASMODICS* *Urinary Antispasmodic - Antimuscarinic (Anticholinergic)*** darifenacin hydrobromide er oral tablet 2 ST extended release 24 hour 15 mg, 7.5 mg oxybutynin chloride er oral tablet extended 2 release 24 hour 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 2 oxybutynin chloride oral tablet 5 mg 2 tolterodine tartrate er oral capsule 2 ST extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 2 ST trospium chloride er oral capsule extended 2 ST release 24 hour 60 mg trospium chloride oral tablet 20 mg 2 ST *Urinary Antispasmodic - Antimuscarinics (Antichol)***(New) darifenacin hydrobromide er oral tablet 2 ST extended release 24 hour 15 mg, 7.5 mg oxybutynin chloride er oral tablet extended 2 release 24 hour 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 2 oxybutynin chloride oral tablet 5 mg 2 tolterodine tartrate er oral capsule 2 ST extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 2 ST trospium chloride er oral capsule extended 2 ST release 24 hour 60 mg trospium chloride oral tablet 20 mg 2 ST

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

94 Drug Name Drug Tier Requirements/Limits *Urinary Antispasmodics - Cholinergic Agonists*** bethanechol chloride oral tablet 10 mg, 25 2 mg, 5 mg, 50 mg *Urinary Antispasmodics - Cholinergic Agonists*** (New) bethanechol chloride oral tablet 10 mg, 25 2 mg, 5 mg, 50 mg *Urinary Antispasmodics - Direct Muscle Relaxants*** flavoxate hcl oral tablet 100 mg 2 *Urinary Antispasmodics - Direct Muscle Relaxants*** (New) flavoxate hcl oral tablet 100 mg 2 *VACCINES* *Bacterial Vaccine Combinations** MENHIBRIX INTRAMUSCULAR $0 copay for 18 years of age SOLUTION RECONSTITUTED 5-5-2.5 1 and younger MCG *Bacterial Vaccines*** ACTHIB INTRAMUSCULAR SOLUTION $0 copay for 18 years of age 1 RECONSTITUTED and younger BEXSERO INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE HIBERIX INJECTION SOLUTION $0 copay for 18 years of age 1 RECONSTITUTED 10 MCG and younger MENACTRA INTRAMUSCULAR 1 INJECTABLE MENOMUNE SUBCUTANEOUS 1 INJECTABLE MENVEO INTRAMUSCULAR SOLUTION 1 RECONSTITUTED PEDVAX HIB INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 7.5 MCG/0.5ML and younger

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

95 Drug Name Drug Tier Requirements/Limits PNEUMOVAX 23 INJECTION 1 INJECTABLE 25 MCG/0.5ML PREVNAR 13 INTRAMUSCULAR 1 QL (5 ML per 365 days) SUSPENSION TRUMENBA INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE *Mixed Vaccine Combinations*** COMVAX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 7.5-5 MCG/0.5ML and younger *Viral Vaccine Combinations*** M-M-R II SUBCUTANEOUS INJECTABLE 1 PROQUAD SUBCUTANEOUS $0 copay for 18 years of age 1 SUSPENSION RECONSTITUTED and younger TWINRIX INTRAMUSCULAR $0 copay for 19 years of age 1 SUSPENSION 720-20 ELU-MCG/ML and older TWINRIX INTRAMUSCULAR $0 copay for 19 years of age SUSPENSION PREFILLED SYRINGE 1 and older 720-20 ELU-MCG/ML *Viral Vaccines*** AFLURIA INTRAMUSCULAR 1 SUSPENSION AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML ENGERIX-B INJECTION SUSPENSION 1 10 MCG/0.5ML, 20 MCG/ML ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 1 MCG/ML FLUAD INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 1 0.5 ML FLUBLOK INTRAMUSCULAR SOLUTION 1 FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION 1 PREFILLED SYRINGE 0.5 ML

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

96 Drug Name Drug Tier Requirements/Limits FLUCELVAX QUADRIVALENT 1 INTRAMUSCULAR SUSPENSION FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLULAVAL QUADRIVALENT 1 INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUVIRIN INTRAMUSCULAR 1 SUSPENSION FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 1 ML FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.7 ML FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN- 1 INJECTOR 9 MCG/STRAIN FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 1 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.25 ML GARDASIL 9 INTRAMUSCULAR 1 SUSPENSION GARDASIL 9 INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL 1 U/0.5ML $0 copay for 18 years of age IPOL INJECTION INJECTABLE 1 and younger RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 1 5 MCG/0.5ML

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

97 Drug Name Drug Tier Requirements/Limits ROTARIX ORAL SUSPENSION $0 copay for 18 years of age 1 RECONSTITUTED and younger $0 copay for 18 years of age ROTATEQ ORAL SOLUTION 1 and younger SHINGRIX INTRAMUSCULAR $0 copay for 19 years of age SUSPENSION RECONSTITUTED 50 1 and older; QL (1 EA per 1 MCG/0.5ML day) VAQTA INTRAMUSCULAR SUSPENSION 1 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1 1350 PFU/0.5ML ZOSTAVAX SUBCUTANEOUS $0 copay for 19 years of age SUSPENSION RECONSTITUTED 19400 1 and older UNT/0.65ML *VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** terconazole vaginal cream 0.4 %, 0.8 % 2 *Spermicides*** OPTIONS CONCEPTROL VAGINAL GEL 1 OTC 4 % TODAY SPONGE VAGINAL 1000 MG 1 OTC VCF VAGINAL CONTRACEPTIVE 1 OTC VAGINAL GEL 4 % *Vaginal Anti-Infectives*** CLEOCIN VAGINAL SUPPOSITORY 100 4 MG clindamycin phosphate vaginal cream 2 % 2 metronidazole vaginal gel 0.75 % 2 *Vaginal Estrogens*** estradiol vaginal cream 0.1 mg/gm 2 *VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 2 QL (4 EA per 30 days) mg/0.3ml

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

98 Drug Name Drug Tier Requirements/Limits EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 4 QL (4 EA per 30 days) MG/0.3ML *Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 2 mg *VITAMINS* *Vitamin B-3*** niacin oral tablet 500 mg 2 OTC *Vitamin B-6*** pyridoxine hcl oral tablet 25 mg, 50 mg 2 OTC *Vitamin D*** vitamin d (ergocalciferol) oral capsule 1.25 2 mg (50000 ut) vitamin d3 oral capsule 1.25 mg (50000 2 OTC ut)

PA- Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

99 Index

A alogliptin benzoate ...... 18 ASMANEX (30 METERED abacavir sulfate ...... 42 alosetron hcl ...... 68 DOSES)...... 13 abacavir sulfate-lamivudine alprazolam ...... 10 ASMANEX (60 METERED ...... 40 ALTACAINE ...... 83 DOSES)...... 13 abacavir-lamivudine- ALTAVERA ...... 49 ASMANEX HFA ...... 13 zidovudine ...... 40 alyacen 1/35 ...... 49 aspirin ...... 5 abiraterone acetate ...... 31 alyacen 7/7/7 ...... 53 aspirin adult low strength .. 5 ABRAXANE ...... 35 amantadine hcl ...... 37 aspirin-dipyridamole er ... 71 acamprosate calcium ...... 87 ambrisentan ...... 48 atazanavir sulfate ...... 41 acarbose ...... 18 amcinonide...... 59 atenolol...... 45 acebutolol hcl ...... 45 amikacin sulfate ...... 2 atenolol-chlorthalidone ... 28 acetaminophen-codeine ... 5 amiloride hcl ...... 64 atomoxetine hcl ...... 1 acetaminophen-codeine #2 amiloride- atorvastatin calcium ...... 24 ...... 5 hydrochlorothiazide .... 64 atovaquone ...... 29 acetaminophen-codeine #3 aminocaproic acid ...... 72 atovaquone-proguanil hcl 30 ...... 5 amiodarone hcl ...... 10 ATRIPLA ...... 40 acetaminophen-codeine #4 amitriptyline hcl ...... 17 atropine sulfate ...... 82 ...... 5 amlodipine besy-benazepril AUGMENTIN ...... 86 acetazolamide ...... 64 hcl ...... 25 AVIANE ...... 49 acetazolamide er ...... 64 amlodipine besylate ...... 46 AVITA ...... 57 acetic acid ...... 69, 85 amlodipine besylate- AVONEX ...... 88 acetylcysteine...... 55 valsartan...... 26 AVONEX PEN ...... 88 acitretin ...... 58 amlodipine-atorvastatin .. 48 AVONEX PREFILLED ...... 88 ACTHIB ...... 95 amlodipine-valsartan-hctz 27 AZASAN ...... 45 acyclovir ...... 43, 58 ammonium lactate ...... 61 azathioprine ...... 45 ADACEL ...... 92 AMNESTEEM ...... 57 azelastine hcl ...... 80, 82 adapalene ...... 57 amoxicillin ...... 85, 86 azithromycin ...... 74 adapalene-benzoyl peroxide amoxicillin-pot clavulanate B ...... 56 ...... 86 bacitracin ...... 82 adefovir dipivoxil ...... 43 amoxicillin-pot clavulanate bacitracin-polymyxin b ... 83 ADEMPAS ...... 48 er ...... 86 bacitra-neomycin- ADRUCIL ...... 32 amphetamine-dextroamphet polymyxin-hc ...... 84 ADVAIR DISKUS ...... 11 er ...... 1 baclofen ...... 80 ADVAIR HFA ...... 11 amphetamine- balsalazide disodium ...... 68 AEROCHAMBER PLUS FLO- dextroamphetamine ...... 1 BARACLUDE ...... 43 VU ...... 77 ampicillin ...... 86 BASAGLAR KWIKPEN ...... 19 AFEDITAB CR ...... 46 anagrelide hcl ...... 71 BD SWAB SINGLE USE AFLURIA ...... 96 anastrozole ...... 34 REGULAR ...... 74 AFLURIA PRESERVATIVE apraclonidine hcl ...... 83 BD SWABS SINGLE USE FREE ...... 96 aprepitant ...... 22 BUTTERFLY ...... 75 albuterol sulfate ...... 11 APRI...... 49 BD VEO INSULIN SYRINGE albuterol sulfate er ...... 11 APRISO...... 68 U/F ...... 77 albuterol sulfate hfa...... 11 APTIVUS ...... 41 benazepril hcl...... 26 alclometasone dipropionate aripiprazole ...... 39 benazepril- ...... 58 ARMOUR THYROID...... 91 hydrochlorothiazide ..... 25 alendronate sodium ...... 65 ASHLYNA ...... 52 benzonatate ...... 55 alfuzosin hcl er ...... 69 ASMANEX (120 METERED benzoyl peroxide- aliskiren fumarate ...... 28 DOSES) ...... 12 erythromycin ...... 56 allopurinol ...... 70 benztropine mesylate 36, 37

100 BERINERT ...... 70 calcium acetate (phos chlorthalidone ...... 64 betamethasone dipropionate binder) ...... 68 chlorzoxazone ...... 80 ...... 59 candesartan cilexetil ...... 27 cholestyramine ...... 24 betamethasone dipropionate candesartan cilexetil-hctz 26 cholestyramine light ...... 24 aug ...... 59 capecitabine ...... 32 cilostazol ...... 71 betamethasone valerate .. 59 CAPRELSA ...... 33 cimetidine ...... 93 BETASERON ...... 88 captopril ...... 26 cimetidine hcl ...... 93 betaxolol hcl ...... 45, 81 captopril- CIMZIA ...... 69 bethanechol chloride ...... 95 hydrochlorothiazide .... 25 CIMZIA PREFILLED ...... 69 BETOPTIC-S ...... 82 CARAFATE ...... 93 CIMZIA STARTER KIT ..... 69 bexarotene ...... 36 carbamazepine...... 14 CIPRO ...... 67 BEXSERO ...... 95 carbamazepine er ...... 14 CIPRO HC ...... 85 bicalutamide ...... 32 carbidopa ...... 37 CIPRODEX ...... 85 BICNU ...... 36 carbidopa-levodopa ...... 37 ciprofloxacin ...... 67 bimatoprost ...... 84 carbidopa-levodopa er .... 37 ciprofloxacin hcl ...... 67, 82 bisoprolol fumarate ...... 45 carbinoxamine maleate .. 23 ciprofloxacin-ciproflox hcl er bisoprolol- carboplatin ...... 31 ...... 67 hydrochlorothiazide ..... 28 CARDURA XL ...... 69 ciprofloxacin- bleomycin sulfate ...... 34 carisoprodol...... 80 dexamethasone ...... 85 BLEPHAMIDE S.O.P...... 84 carmustine ...... 36 cisplatin ...... 31 BOOSTRIX ...... 92 carteolol hcl ...... 82 citalopram hydrobromide 17 bosentan ...... 48 CARTIA XT ...... 46 CITRANATAL B-CALM...... 80 BOSULIF ...... 33 carvedilol ...... 45 CITRANATAL RX ...... 80 BRILINTA ...... 63, 70 CAYA ...... 75 CLARAVIS...... 57 brimonidine tartrate ...... 84 cefaclor ...... 49 clarithromycin ...... 74 bromocriptine mesylate ... 37 cefadroxil ...... 48 clarithromycin er ...... 74 budesonide ...... 13, 54, 81 cefdinir ...... 49 CLEOCIN ...... 98 bumetanide ...... 64 cefditoren pivoxil ...... 49 clindamycin hcl...... 29 buprenorphine hcl ...... 7 cefixime ...... 49 clindamycin palmitate hcl 29 buprenorphine hcl-naloxone cefpodoxime proxetil ...... 49 clindamycin phos-benzoyl hcl ...... 7, 8 cefprozil ...... 49 perox ...... 56 bupropion hcl ...... 16 ceftibuten ...... 49 clindamycin phosphate .. 56, bupropion hcl er (smoking cefuroxime axetil ...... 49 98 det) ...... 89 celecoxib ...... 3 clocortolone pivalate ...... 59 bupropion hcl er (sr) ...... 16 CELONTIN ...... 16 clomipramine hcl ...... 17 bupropion hcl er (xl) ...... 16 cephalexin ...... 48 clonazepam ...... 14 buspirone hcl ...... 9 cetirizine hcl ...... 23 clonidine ...... 27 butalbital-apap-caff-cod ... 5 CHANTIX ...... 89 clonidine hcl...... 27 butalbital-apap-caffeine ... 5 CHANTIX CONTINUING clopidogrel bisulfate ...... 71 butalbital-aspirin-caffeine . 5 MONTH PAK ...... 89 clorazepate dipotassium.. 10 BYETTA 10 MCG PEN ...... 20 CHANTIX STARTING MONTH clotrimazole ...... 61, 79 BYETTA 5 MCG PEN ...... 20 PAK ...... 89 clotrimazole-betamethasone C CHATEAL...... 50 ...... 57 cabergoline ...... 65 CHEMET ...... 21 clozapine ...... 38 caffeine citrate...... 1 CHEMSTRIP 9 ...... 62 codeine sulfate ...... 6 caffeine-sodium benzoate . 1 cheratussin ac...... 55 colchicine ...... 70 calcipotriene ...... 58 chlordiazepoxide- colchicine-probenecid ..... 70 calcipotriene-betameth amitriptyline ...... 87 colestipol hcl ...... 24 diprop ...... 62 chlorhexidine gluconate .. 79 COLOCORT ...... 8 calcitonin (salmon) ...... 65 chloroquine phosphate ... 30 COMPLERA ...... 40 calcitriol ...... 58, 65 chlorothiazide ...... 64 COMVAX ...... 96 chlorpromazine hcl ...... 39 CORLOPAM ...... 28

101 cortisone acetate ...... 54 DEXCOM G4 PLATINUM docetaxel (non-alcohol) .. 35 CREON ...... 63 TRANSMITTER...... 75 dofetilide ...... 11 CRIXIVAN ...... 41 DEXCOM G4 SENSOR ..... 75 donepezil hcl ...... 87 cromolyn sodium ..... 67, 82 DEXCOM G5 MOB/G4 PLAT dorzolamide hcl ...... 83 cyanocobalamin ...... 71 SENSOR ...... 76 dorzolamide hcl-timolol mal CYCLAFEM 1/35 ...... 50 DEXCOM G5 MOBILE ...... 81 CYCLAFEM 7/7/7 ...... 53 RECEIVER ...... 76 doxazosin mesylate ...... 27 cyclobenzaprine hcl ...... 80 DEXCOM G5 MOBILE doxepin hcl ...... 18, 58 cyclopentolate hcl ...... 82 TRANSMITTER...... 76 doxercalciferol ...... 65 cyclophosphamide ...... 35 DEXCOM G5 RECEIVER KIT doxorubicin hcl ...... 34 cyclosporine ...... 44 ...... 76 doxorubicin hcl liposomal 34 cyclosporine modified ..... 44 DEXCOM G6 RECEIVER ... 76 doxycycline hyclate ...... 91 cyproheptadine hcl ...... 23 DEXCOM G6 SENSOR ..... 76 doxycycline monohydrate 91 CYTRA-3 ...... 69 DEXCOM G6 TRANSMITTER dronabinol ...... 22 D ...... 76 drospiren-eth estrad- DALIRESP ...... 12 DEXILANT ...... 93 levomefol ...... 50 danazol ...... 8 dextroamphetamine sulfate drospirenone-ethinyl dantrolene sodium ...... 80 ...... 1 estradiol ...... 50 dapsone ...... 29 dextroamphetamine sulfate duloxetine hcl ...... 17 DAPTACEL ...... 92 er ...... 1 dutasteride ...... 69 DARAPRIM ...... 30 DIASCREEN 10...... 76 DYSPORT ...... 81 darifenacin hydrobromide er DIASTIX ...... 62 E ...... 94 diazepam ...... 10 econazole nitrate ...... 61 DASETTA 1/35 ...... 50 diclofenac potassium ...... 4 EDURANT ...... 41 DASETTA 7/7/7...... 53 diclofenac sodium ...... 4, 58 efavirenz ...... 41, 42 deferiprone ...... 21 diclofenac sodium er ...... 4 efavirenz-emtricitab- DELYLA ...... 50 diclofenac-misoprostol ...... 3 tenofovir ...... 40 demeclocycline hcl ...... 91 dicloxacillin sodium ...... 86 eletriptan hydrobromide . 77 DEPEN TITRATABS ...... 44 dicyclomine hcl ...... 92 ELIGARD ...... 35 DEPO-MEDROL ...... 54 didanosine ...... 42 ELIQUIS ...... 13 DEPO-PROVERA ...... 36 DIFICID ...... 74 ELIQUIS DVT/PE STARTER desipramine hcl ...... 17 diflorasone diacetate ...... 59 PACK ...... 13 desmopressin ace rhinal digoxin ...... 47 ELLA ...... 52 tube ...... 66 dihydroergotamine mesylate ELMIRON ...... 70 desmopressin ace spray ...... 77 ELURYNG ...... 52 refrig ...... 66 DILANTIN ...... 15 EMOQUETTE ...... 50 desmopressin acetate ..... 66 diltiazem hcl ...... 46 emtricitabine...... 42 desonide ...... 59 diltiazem hcl er ...... 46 emtricitabine-tenofovir df 40 desoximetasone ...... 59 diltiazem hcl er beads .... 46 EMTRIVA ...... 42 dexamethasone ...... 54 diltiazem hcl er coated EMVERM ...... 8 DEXAMETHASONE beads ...... 46 enalapril maleate ...... 26 INTENSOL ...... 54 DIPENTUM...... 68 enalapril- dexamethasone sodium diphenhydramine hcl ...... 23 hydrochlorothiazide ..... 25 phosphate ...... 54, 84 diphenoxylate-atropine ... 21 ENBREL ...... 4, 5 DEXCOM G4 PLAT PED diphtheria-tetanus toxoids ENBREL SURECLICK ...... 5 RCV/SHARE ...... 75 dt ...... 92 ENDOCET ...... 7 DEXCOM G4 PLAT PED dipyridamole...... 71 ENGERIX-B ...... 96 RECEIVER ...... 75 disopyramide phosphate . 10 enoxaparin sodium.... 13, 14 DEXCOM G4 PLATINUM disulfiram ...... 87 ENPRESSE-28 ...... 53 RCV/SHARE ...... 75 divalproex sodium ...... 16 ENSKYCE ...... 50 DEXCOM G4 PLATINUM divalproex sodium er...... 16 entacapone ...... 38 RECEIVER ...... 75 docetaxel ...... 35 entecavir ...... 43

102 ENTRESTO ...... 81 fenofibrate micronized .... 24 fosfomycin tromethamine 93 enulose ...... 68 fenofibric acid ...... 24 fosinopril sodium ...... 26 epinastine hcl ...... 82 fentanyl ...... 6 fosinopril sodium-hctz .... 25 epinephrine ...... 98 FERRIPROX ...... 21 fulvestrant ...... 34 EPIPEN JR 2-PAK ...... 99 fexofenadine hcl ...... 23 furosemide ...... 64 epirubicin hcl ...... 34 FIASP ...... 19 FUZEON ...... 41 EPIVIR HBV ...... 43 FIASP FLEXTOUCH ...... 19 G eplerenone ...... 28 FIASP PENFILL ...... 19 gabapentin ...... 14 eq allergy relief ...... 23 FIBRICOR ...... 24 galantamine hydrobromide ERBITUX ...... 32 finasteride ...... 69 ...... 87 ergoloid mesylates ...... 88 flavoxate hcl ...... 95 galantamine hydrobromide ergotamine-caffeine ...... 77 flecainide acetate ...... 10 er ...... 87 erlotinib hcl ...... 33 FLEXICHAMBER CHILD GARDASIL 9 ...... 97 ERRIN ...... 53 MASK/SMALL ...... 77 gatifloxacin ...... 82 ERY-TAB ...... 74 FLONASE SENSIMIST ..... 81 GAVILYTE-C ...... 73 ERYTHROCIN STEARATE .. 74 FLUAD ...... 96 GAVILYTE-G...... 73 erythromycin ...... 56, 82 FLUAD QUADRIVALENT... 96 GAVILYTE-N WITH FLAVOR erythromycin base ...... 74 FLUBLOK ...... 96 PACK ...... 73 erythromycin ethylsuccinate FLUBLOK QUADRIVALENT 96 gemfibrozil ...... 24 ...... 74 FLUCELVAX QUADRIVALENT generlac ...... 68 ESBRIET ...... 90 ...... 97 GENGRAF ...... 44 escitalopram oxalate ...... 17 fluconazole ...... 23 GENOTROPIN ...... 65 estradiol ...... 66, 67, 98 fludrocortisone acetate ... 54 GENOTROPIN MINIQUICK 65 estradiol valerate ...... 67 FLULAVAL QUADRIVALENT gentamicin in saline ...... 2 estradiol-norethindrone acet ...... 97 gentamicin sulfate 2, 57, 82, ...... 66 flunisolide ...... 81 83 estropipate ...... 67 fluocinolone acetonide ... 59, GENVOYA ...... 40 ethacrynic acid ...... 64 60, 85 GIANVI ...... 50 ethambutol hcl ...... 31 fluocinolone acetonide scalp GILDESS 1.5/30 ...... 50 ethosuximide ...... 16 ...... 60 GILDESS FE 1.5/30 ...... 50 ethynodiol diac-eth estradiol fluocinonide ...... 60 GILENYA ...... 89 ...... 50 fluoritab ...... 78 glatiramer acetate ...... 88 etodolac ...... 4 fluorometholone ...... 84 GLATOPA ...... 88 etodolac er ...... 4 fluorouracil ...... 32, 58 GLEOSTINE...... 36 etonogestrel-ethinyl fluoxetine hcl ...... 17 GLIADEL WAFER ...... 36 estradiol ...... 52 fluphenazine decanoate .. 39 glimepiride ...... 20 etoposide ...... 35 fluphenazine hcl ...... 39 glipizide ...... 20 EUTHYROX ...... 91 flurandrenolide ...... 60 glipizide er ...... 20 exemestane ...... 34 flurbiprofen sodium ...... 83 glipizide-metformin hcl ... 20 ezetimibe ...... 25 flutamide ...... 32 GLUCAGEN DIAGNOSTIC 62 F fluticasone propionate60, 81 GLUCAGON EMERGENCY . 18 FACTIVE ...... 67 fluticasone-salmeterol .... 11 glyburide ...... 21 FALMINA...... 50 fluvastatin sodium ...... 24 glyburide micronized ...... 20 famciclovir ...... 43 FLUVIRIN ...... 97 glyburide-metformin ...... 20 famotidine ...... 93 FLUZONE HIGH-DOSE .... 97 glycopyrrolate ...... 93 FARESTON ...... 32 FLUZONE HIGH-DOSE GOLYTELY ...... 73 FASLODEX ...... 34 QUADRIVALENT ...... 97 goodsense aspirin ...... 5 FC2 FEMALE CONDOM ..... 75 FLUZONE QUADRIVALENT 97 goodsense nicotine ...... 89 felbamate ...... 15 FML ...... 84 granisetron hcl ...... 22 felodipine er ...... 46 folic acid ...... 72 griseofulvin microsize ..... 22 FEMCAP ...... 75 fondaparinux sodium ..... 14 griseofulvin ultramicrosize fenofibrate ...... 24 fosamprenavir calcium ... 41 ...... 22

103 guanfacine hcl ...... 27 imipramine pamoate ...... 18 ketorolac tromethamine ... 4, guanfacine hcl er ...... 1 imiquimod ...... 61 83 H INCRELEX ...... 66 KINRIX ...... 92 halobetasol propionate .... 60 indapamide ...... 65 KIONEX ...... 45, 87 haloperidol ...... 38 indomethacin ...... 4 KLOR-CON M15 ...... 78 haloperidol decanoate ..... 38 INFANRIX ...... 92 KLOR-CON M20 ...... 78 haloperidol lactate ...... 38 INLYTA ...... 33 K-TAB ...... 78 HAVRIX ...... 97 insulin asp prot & asp KURVELO ...... 50 HEATHER ...... 53 flexpen ...... 19 KYLEENA ...... 53 heparin sodium (porcine) 13 insulin aspart ...... 19 L heparin sodium (porcine) pf insulin aspart flexpen ..... 19 labetalol hcl ...... 45 ...... 13 insulin aspart penfill ...... 19 lactic acid ...... 61 HERCEPTIN ...... 32 insulin aspart prot & aspart lactulose ...... 73 HIBERIX ...... 95 ...... 19 LAMICTAL ODT ...... 14 HOMATROPAIRE ...... 82 INTELENCE ...... 42 lamivudine...... 42, 43 HUMIRA ...... 3 INTRON A ...... 34 lamivudine-zidovudine .... 40 HUMIRA PEN ...... 3 INVIRASE ...... 41 lamotrigine ...... 15 HUMIRA PEN-CD/UC/HS IPOL ...... 97 lamotrigine er ...... 14 STARTER ...... 3 ipratropium bromide . 12, 80 lansoprazole ...... 93 HUMIRA PEN-PS/UV/ADOL ipratropium-albuterol ..... 11 LANTUS ...... 19 HS START ...... 3 irbesartan ...... 27 lapatinib ditosylate ...... 33 hydralazine hcl ...... 28 irbesartan- LARIN 1.5/30 ...... 50 hydrochlorothiazide ...... 64 hydrochlorothiazide .... 26 latanoprost ...... 84 hydrocodone- ISENTRESS ...... 41 leflunomide ...... 4 acetaminophen ...... 6 isometheptene-caffeine- LENVIMA (10 MG DAILY hydrocodone-homatropine apap ...... 77 DOSE) ...... 33 ...... 55 isoniazid ...... 31 LENVIMA (12 MG DAILY hydrocodone-ibuprofen .... 6 isosorbide dinitrate ...... 9 DOSE) ...... 33 hydrocortisone ...... 54, 60 isosorbide dinitrate er ...... 9 LENVIMA (14 MG DAILY hydrocortisone acetate ..... 8 isosorbide mononitrate ..... 9 DOSE) ...... 33 hydrocortisone butyr lipo isosorbide mononitrate er . 9 LENVIMA (18 MG DAILY base ...... 60 isotretinoin ...... 57 DOSE) ...... 33 hydrocortisone butyrate .. 60 isradipine ...... 46 LENVIMA (20 MG DAILY hydrocortisone valerate ... 60 itraconazole ...... 23 DOSE) ...... 33 hydromorphone hcl ...... 6 ivermectin ...... 8 LENVIMA (24 MG DAILY hydroxychloroquine sulfate J DOSE) ...... 33 ...... 30 JANUMET ...... 18 LENVIMA (4 MG DAILY hydroxyurea ...... 34 JANUMET XR ...... 19 DOSE) ...... 33 hydroxyzine hcl ...... 9 JANUVIA ...... 18 LENVIMA (8 MG DAILY hydroxyzine pamoate ..... 10 JINTELI ...... 66 DOSE) ...... 33 hyoscyamine sulfate ...... 92 JUNEL 1.5/30 ...... 50 LESSINA ...... 50 HYQVIA ...... 85 JUNEL 1/20 ...... 50 LETAIRIS ...... 48 I JUNEL FE 1.5/30 ...... 50 letrozole ...... 34 IBRANCE ...... 56 JUNEL FE 1/20 ...... 50 leucovorin calcium ...... 34 ibuprofen ...... 4 K LEUKERAN ...... 35 icatibant acetate ...... 70 KALETRA ...... 40 leuprolide acetate ...... 35 idarubicin hcl ...... 34 KALYDECO ...... 90 levalbuterol hcl ...... 12 ifosfamide ...... 35 KELNOR 1/50 ...... 50 levetiracetam ...... 15 imatinib mesylate ...... 33 ketoconazole ...... 61 levetiracetam er ...... 15 IMBRUVICA ...... 33 KETO-DIASTIX ...... 62 levobunolol hcl ...... 82 imipenem-cilastatin ...... 29 ketoprofen ...... 4 levofloxacin ...... 67, 83 imipramine hcl ...... 18

104 levonorgest-eth estrad 91- MATZIM LA ...... 47 metoprolol tartrate...... 45 day ...... 52 MAVYRET ...... 72 metoprolol- levonorgestrel ...... 52 meclizine hcl ...... 22 hydrochlorothiazide ..... 28 levonorgestrel-ethinyl medroxyprogesterone metronidazole .... 29, 62, 98 estrad ...... 50 acetate ...... 53, 87 metronidazole in nacl ..... 29 LEVORA 0.15/30 (28) ..... 51 mefloquine hcl ...... 30 mexiletine hcl ...... 10 levorphanol tartrate ...... 6 megestrol acetate ...... 36 midodrine hcl ...... 99 LEVO-T ...... 91 meloxicam ...... 4 MIGRANAL ...... 77 levothyroxine sodium ...... 91 melphalan ...... 36 MINITRAN ...... 9 LEVOXYL...... 91 melphalan hcl ...... 36 minocycline hcl ...... 91 LEXIVA ...... 41 memantine hcl ...... 88 minoxidil ...... 28 lidocaine ...... 61 MENACTRA ...... 95 MIRENA (52 MG) ...... 53 lidocaine hcl ...... 61 MENHIBRIX ...... 95 mirtazapine ...... 16 lidocaine hcl (cardiac) pf . 10 MENOMUNE ...... 95 misoprostol ...... 93 lidocaine hcl MENVEO ...... 95 M-M-R II ...... 96 urethral/mucosal ... 61, 62 meprobamate ...... 10 modafinil ...... 2 lidocaine viscous hcl ...... 79 mercaptopurine ...... 32 moexipril- lidocaine-prilocaine ...... 62 meropenem ...... 29 hydrochlorothiazide ..... 25 LILETTA (52 MG) ...... 53 mesalamine ...... 68 mometasone furoate ...... 60 lindane ...... 62 mesalamine er ...... 68 MONO-LINYAH ...... 51 linezolid ...... 29, 30 MESNEX ...... 36 montelukast sodium ...... 12 liothyronine sodium ...... 91 MESTINON ...... 30, 31 MONUROL ...... 94 lisinopril ...... 26 metaproterenol sulfate ... 12 morphine sulfate ...... 7 lisinopril- metaxalone ...... 80 morphine sulfate hydrochlorothiazide ..... 25 metformin hcl ...... 18 (concentrate) ...... 6 lithium ...... 38 metformin hcl er ...... 18 morphine sulfate (pf) ...... 6 lithium carbonate ...... 38 methadone hcl ...... 6 morphine sulfate er ...... 6 lithium carbonate er ...... 38 METHADONE HCL INTENSOL MOVIPREP ...... 73 loperamide hcl ...... 21 ...... 6 moxifloxacin hcl...... 67, 83 lopinavir-ritonavir ...... 40 METHADOSE ...... 6 multi-vit/fluoride ...... 79 lorazepam ...... 10 methamphetamine hcl ...... 1 multi-vit/fluoride/iron ..... 79 losartan potassium ...... 27 methazolamide ...... 64 multivitamin/fluoride ...... 79 losartan potassium-hctz .. 26 methenamine hippurate.. 93 multi-vitamin/fluoride/iron lovastatin...... 24 methimazole ...... 91 ...... 79 LOW-OGESTREL ...... 51 methocarbamol ...... 80 mupirocin ...... 57 loxapine succinate ...... 39 methotrexate ...... 32 MVC-FLUORIDE ...... 79 LUPRON DEPOT (1-MONTH) methotrexate sodium ..... 32 mycophenolate mofetil ... 44 ...... 35 methotrexate sodium (pf) 32 mycophenolate sodium ... 44 LUPRON DEPOT (3-MONTH) methoxsalen rapid ...... 58 MYORISAN...... 57 ...... 35 methscopolamine bromide N LUPRON DEPOT (4-MONTH) ...... 93 nabumetone ...... 4 ...... 35 methyldopa ...... 27 nadolol...... 46 LUPRON DEPOT (6-MONTH) methylphenidate hcl ...... 2 nadolol-bendroflumethiazide ...... 35 methylphenidate hcl er ..... 2 ...... 28 LUTERA ...... 51 methylphenidate hcl er (cd) naloxone hcl ...... 21 LYRICA ...... 15 ...... 2 naltrexone hcl ...... 22 LYSODREN ...... 31 methylphenidate hcl er (la) 2 naphazoline hcl ...... 83 M methylprednisolone ...... 54 naproxen ...... 4 mafenide acetate ...... 58 methyltestosterone ...... 8 naproxen dr ...... 4 magnesium sulfate ...... 78 metipranolol ...... 82 naproxen sodium ...... 4 malathion ...... 62 metoclopramide hcl ...... 68 naratriptan hcl ...... 77 marlissa ...... 51 metoprolol succinate er .. 45 NARCAN ...... 22

105 nateglinide ...... 20 norethindrone acetate .... 87 ONETOUCH DELICA NATURE-THROID...... 91 norethindrone-eth estradiol LANCETS 30G ...... 76 NAYZILAM ...... 14 ...... 66 ONETOUCH DELICA NECON 0.5/35 (28) ...... 51 norethin-eth estradiol-fe . 51 LANCETS 33G ...... 76 NECON 1/35 (28) ...... 51 norgestimate-eth estradiol ONETOUCH DELICA NECON 1/50 (28) ...... 51 ...... 51 LANCING DEV ...... 76 NECON 10/11 (28) ...... 49 norgestim-eth estrad ONETOUCH DELICA PLUS nefazodone hcl ...... 16, 90 triphasic...... 53 LANCET30G ...... 76 neomycin sulfate ...... 2 NORTREL 0.5/35 (28) .... 51 ONETOUCH DELICA PLUS neomycin-polymyxin b gu 69 NORTREL 1/35 (21) ...... 51 LANCET33G ...... 76 neomycin-polymyxin- NORTREL 7/7/7 ...... 53 ONETOUCH DELICA PLUS dexameth ...... 84 nortriptyline hcl ...... 18 LANCING ...... 76 neomycin-polymyxin- NORVIR ...... 41 ONETOUCH FINEPOINT gramicidin ...... 83 NOVOFINE ...... 77 LANCETS ...... 76 neomycin-polymyxin-hc . 84, NOVOLIN 70/30 ...... 19 ONETOUCH PING METER 85 NOVOLIN 70/30 RELION . 19 REMOTE ...... 76 NEULASTA ...... 72 NOVOLIN N ...... 19 ONETOUCH SURESOFT nevirapine ...... 42 NOVOLIN N RELION ...... 19 LANCING DEV ...... 76 nevirapine er ...... 42 NOVOLIN R ...... 19 ONETOUCH ULTRA ...... 62 NEXAVAR ...... 32 NOVOLIN R RELION ...... 19 ONETOUCH ULTRA 2 ...... 76 NEXPLANON ...... 52 NOVOLOG ...... 20 ONETOUCH ULTRA niacin ...... 99 NOVOLOG FLEXPEN ...... 20 CONTROL ...... 76 niacin er NOVOLOG MIX 70/30 ..... 20 ONETOUCH ULTRA MINI . 76 (antihyperlipidemic)..... 25 NOVOLOG MIX 70/30 ONETOUCH ULTRALINK .. 76 NIACOR ...... 25 FLEXPEN ...... 20 ONETOUCH ULTRASOFT nicardipine hcl ...... 47 NOVOLOG PENFILL ...... 20 LANCETS ...... 76 NICORELIEF ...... 89 np thyroid ...... 92 ONETOUCH VERIO .... 62, 76 nicotine ...... 89 NUVARING ...... 52 ONETOUCH VERIO FLEX nicotine polacrilex ...... 89 NYAMYC ...... 57 SYSTEM ...... 76 nicotine step 3 ...... 89 nystatin ...... 22, 57, 58, 79 ONETOUCH VERIO IQ NICOTROL ...... 89 nystatin-triamcinolone.... 57 SYSTEM ...... 76 NICOTROL NS ...... 89 NYSTOP ...... 58 ONETOUCH VERIO REFLECT NIFEDICAL XL ...... 47 O ...... 76 nifedipine er ...... 47 octreotide acetate ...... 66 ONETOUCH VERIO SYNC nifedipine er osmotic ofloxacin ...... 67, 83, 85 SYSTEM ...... 76 release ...... 47 olanzapine...... 39 OPTICHAMBER FACE MASK- nilutamide ...... 32 olmesartan medoxomil ... 27 SMALL ...... 77 nimodipine ...... 47 olmesartan medoxomil-hctz OPTIONS CONCEPTROL .. 98 nisoldipine er ...... 47 ...... 26 ORKAMBI ...... 56 NITRO-BID ...... 9 olmesartan-amlodipine-hctz orphenadrine citrate er ... 80 NITRO-DUR ...... 9 ...... 27 ORSYTHIA ...... 51 nitrofurantoin ...... 94 olopatadine hcl ...... 82 oseltamivir phosphate .... 44 nitrofurantoin macrocrystal omega-3-acid ethyl esters OSMOPREP ...... 74 ...... 94 ...... 24 OTEZLA ...... 86 nitrofurantoin monohyd omeprazole ...... 93 oxaliplatin ...... 31 macro ...... 94 OMNIFLEX DIAPHRAGM .. 75 oxandrolone ...... 8 nitroglycerin ...... 9 ondansetron ...... 22 oxazepam...... 10 nitroglycerin er ...... 9 ondansetron hcl ...... 22 oxiconazole nitrate ...... 61 nitroglycerin in d5w ...... 9 ONETOUCH CLUB LANCETS oxybutynin chloride ...... 94 NORA-BE ...... 53 FINE PT ...... 76 oxybutynin chloride er .... 94 norethin ace-eth estrad-fe ONETOUCH COMBO PACK 76 oxycodone hcl ...... 7 ...... 51 oxycodone-acetaminophen 7

106 oxycodone-aspirin ...... 7 PKU AIR15 GOLD ...... 63 probenecid ...... 70 oxycodone-ibuprofen ...... 7 PKU AIR15 GREEN ...... 63 prochlorperazine ...... 39 P PKU AIR15 YELLOW ...... 63 prochlorperazine edisylate paliperidone er ...... 38 PKU AIR20 GOLD ...... 63 ...... 39 pantoprazole sodium ...... 93 PKU AIR20 GREEN ...... 63 prochlorperazine maleate 39 PARAGARD INTRAUTERINE PKU AIR20 YELLOW ...... 63 PROCRIT ...... 71, 72 COPPER ...... 52 PKU COOLER 10 ...... 63 PROCTO-PAK ...... 8 paricalcitol ...... 66 PKU COOLER 15 ...... 63 PROCTOZONE-HC ...... 8 paroxetine hcl...... 17 PKU COOLER 20 ...... 63 progesterone micronized . 87 paroxetine hcl er ...... 17 PKU EXPRESS ...... 63 PROLIA ...... 66 PEDIARIX ...... 92 PKU EXPRESS20 ...... 63 promethazine hcl ...... 23 PEDIATRIC PANDA MASK . 77 PKU GEL ...... 63 promethazine vc ...... 55 PEDVAX HIB ...... 95 PKU SPHERE 20 ...... 63 promethazine vc/codeine 56 peg 3350/electrolytes ..... 73 PNEUMOVAX 23 ...... 96 promethazine-codeine .... 55 peg-3350/electrolytes ..... 73 podofilox ...... 61 promethazine-dm ...... 55 peg- polyethylene glycol 3350 74 promethazine- 3350/electrolytes/ascorba polymyxin b sulfate ...... 30 phenylephrine ...... 55 t ...... 73 polymyxin b-trimethoprim PROMETHEGAN ...... 23 PEGASYS ...... 43 ...... 83 propafenone hcl...... 10 PEGASYS PROCLICK ...... 43 POMALYST ...... 32 propafenone hcl er ...... 10 peg-kcl-nacl-nasulf-na asc-c PORTIA-28 ...... 51 proparacaine hcl ...... 83 ...... 73 potassium chloride...... 78 propranolol hcl ...... 46 penicillamine ...... 44 potassium chloride crys er propranolol hcl er ...... 46 penicillin v potassium...... 86 ...... 78 propranolol-hctz ...... 28 PENTACEL ...... 92 potassium chloride er ..... 78 propylthiouracil ...... 91 pentoxifylline er ...... 70 potassium citrate er ...... 69 PROQUAD ...... 96 perindopril erbumine ...... 26 potassium citrate-citric acid pseudoeph-bromphen-dm 55 permethrin ...... 62 ...... 69 PULMOZYME ...... 90 perphenazine ...... 39 PRADAXA ...... 14 pyrazinamide ...... 31 perphenazine-amitriptyline pramipexole dihydrochloride pyridostigmine bromide . 30, ...... 88 ...... 37 31 phenazopyridine hcl ...... 70 pramipexole dihydrochloride pyridostigmine bromide er phenelzine sulfate ...... 16 er ...... 37 ...... 30, 31 phenobarbital ...... 73 prasugrel hcl ...... 71 pyridoxine hcl ...... 99 phenoxybenzamine hcl .... 26 pravastatin sodium ...... 24 pyrimethamine ...... 30 phenytoin ...... 15 prazosin hcl ...... 28 Q phenytoin sodium...... 15 PRED MILD ...... 84 QUASENSE ...... 52 phenytoin sodium extended prednicarbate ...... 60 quetiapine fumarate ...... 39 ...... 15 prednisolone ...... 54 quinapril hcl ...... 26 PHOSLYRA ...... 68 prednisolone acetate ...... 84 quinapril- PHOSPHOLINE IODIDE .... 82 prednisolone sodium hydrochlorothiazide ..... 25 pilocarpine hcl ...... 79, 82 phosphate ...... 54, 84 quinidine gluconate er .... 10 pimozide ...... 88 prednisone ...... 54 quinidine sulfate ...... 10 pindolol ...... 46 PREDNISONE INTENSOL . 54 quinidine sulfate er ...... 10 PIN-X ...... 8 pregabalin ...... 15 quinine sulfate ...... 30 pioglitazone hcl ...... 21 PRENATABS RX ...... 80 R pioglitazone hcl-glimepiride PREVALITE ...... 24 raloxifene hcl ...... 66 ...... 21 PREVNAR 13 ...... 96 ramipril ...... 26 pioglitazone hcl-metformin PREZCOBIX ...... 40 ranitidine hcl ...... 93 hcl ...... 21 PREZISTA ...... 41 RAPAMUNE ...... 44 PIRMELLA 1/35 ...... 51 primaquine phosphate .... 30 rasagiline mesylate ...... 37 PIRMELLA 7/7/7 ...... 53 primidone ...... 15 REBETOL ...... 43

107 RECLIPSEN ...... 51 sotalol hcl (af) ...... 46 tenofovir disoproxil RECOMBIVAX HB...... 97 spinosad ...... 62 fumarate ...... 43 repaglinide ...... 20 SPIRIVA HANDIHALER .... 12 terazosin hcl ...... 28 reserpine ...... 28 SPIRIVA RESPIMAT ...... 12 terbinafine hcl ...... 22 REVLIMID ...... 44 spironolactone ...... 64 terbutaline sulfate ...... 12 RIBASPHERE ...... 43 spironolactone-hctz ...... 64 terconazole ...... 98 RIBASPHERE RIBAPAK .... 43 SPRINTEC 28 ...... 51 testosterone ...... 8 RIBATAB ...... 43 SPRYCEL ...... 33 testosterone cypionate ..... 8 ribavirin ...... 43 SRONYX ...... 51 testosterone enanthate ..... 8 RIFAMATE ...... 31 SSD ...... 58 tetrabenazine ...... 88 rifampin...... 31 SSKI ...... 55 tetracycline hcl ...... 91 riluzole ...... 81 stavudine ...... 42 theophylline ...... 13 rimantadine hcl ...... 44 streptomycin sulfate ...... 2 theophylline er ...... 13 risedronate sodium ...... 65 SUBOXONE...... 8 thioridazine hcl ...... 39 risperidone ...... 38 sucralfate ...... 93 thiothixene ...... 40 ritonavir ...... 41 sulfacetamide sodium..... 84 timolol maleate ...... 46, 82 rivastigmine tartrate ...... 88 sulfacetamide-prednisolone tinidazole ...... 29 rizatriptan benzoate ...... 77 ...... 84 TIS-U-SOL ...... 44 ropinirole hcl ...... 37 sulfadiazine ...... 90 TIVICAY ...... 41 rosuvastatin calcium . 24, 25 sulfamethoxazole- tizanidine hcl ...... 80 ROTARIX ...... 98 trimethoprim ...... 29 tobramycin ...... 2, 83 ROTATEQ ...... 98 sulfasalazine ...... 68 tobramycin sulfate ...... 2 S sulindac ...... 4 tobramycin-dexamethasone salsalate ...... 5 sumatriptan ...... 77 ...... 84 SANDIMMUNE...... 44 sumatriptan succinate .... 77 TODAY SPONGE ...... 98 scalacort ...... 60 SUPRAX ...... 49 tolterodine tartrate ...... 94 scopolamine ...... 22 SUPREP BOWEL PREP KIT 73 tolterodine tartrate er ..... 94 selegiline hcl ...... 37 SUTENT ...... 32 topiramate ...... 15 selenium sulfide ...... 58 SYEDA ...... 51 topotecan hcl ...... 36 SELZENTRY ...... 40 SYNAGIS ...... 85 toremifene citrate ...... 32 SEREVENT DISKUS ...... 12 SYNJARDY ...... 90 torsemide ...... 64 sertraline hcl ...... 17 SYNJARDY XR ...... 90 TRACLEER ...... 48 sevelamer carbonate ...... 68 SYNTHROID ...... 92 tramadol hcl ...... 7 SHINGRIX ...... 98 T tramadol hcl er ...... 7 sildenafil citrate ...... 48 TABLOID ...... 32 tramadol hcl er (biphasic) . 7 silver sulfadiazine ...... 58 tacrolimus ...... 45, 62 trandolapril ...... 26 SIMBRINZA ...... 81 TAKE ACTION ...... 52 trandolapril-verapamil hcl er simvastatin ...... 25 tamoxifen citrate ...... 32 ...... 25 sirolimus ...... 45 tamsulosin hcl ...... 69 tranexamic acid ...... 72 SIVEXTRO ...... 30 TARCEVA ...... 33 tranylcypromine sulfate .. 16 SKYLA ...... 53 TAZTIA XT...... 47 travoprost ...... 84 sod citrate-citric acid ...... 69 TDVAX ...... 92 travoprost (bak free) ...... 84 sodium chloride ...... 55, 78 TEKTURNA ...... 28 trazodone hcl ...... 16, 90 sodium fluoride ...... 78 telmisartan ...... 27 tretinoin ...... 36, 57 sodium polystyrene telmisartan-hctz ...... 26 triamcinolone acetonide . 61, sulfonate ...... 45, 87 temazepam ...... 73 79, 81, 90 sofosbuvir-velpatasvir ..... 72 TEMODAR ...... 34 triamterene-hctz...... 64 SOMATULINE DEPOT ...... 66 temozolomide ...... 34 trifluoperazine hcl ...... 39 sorbitol ...... 69 TENCON ...... 5 trifluridine ...... 83 sorbitol-mannitol ...... 69 teniposide ...... 35 TRIGLIDE ...... 24 SORINE ...... 46 TENIVAC ...... 92 trihexyphenidyl hcl ...... 37 sotalol hcl ...... 46 trimethobenzamide hcl ... 22

108 trimethoprim ...... 29 VELIVET ...... 54 WIDE-SEAL DIAPHRAGM 80 trimipramine maleate ..... 18 venlafaxine hcl ...... 17 ...... 75 TRINESSA (28) ...... 53 venlafaxine hcl er ...... 17 WIDE-SEAL DIAPHRAGM 85 TRI-SPRINTEC ...... 53 VENTAVIS ...... 48 ...... 75 tri-vit/fluoride ...... 80 VENTOLIN HFA ...... 12 WIDE-SEAL DIAPHRAGM 90 tri-vit/fluoride/iron ...... 79 verapamil hcl ...... 47 ...... 75 TRIVORA (28)...... 54 verapamil hcl er ...... 47 WIDE-SEAL DIAPHRAGM 95 tropicamide ...... 82 VIDEX ...... 42 ...... 75 trospium chloride ...... 94 vinblastine sulfate ...... 35 X trospium chloride er ...... 94 VINCASAR PFS ...... 35 XALKORI ...... 33 TRULICITY ...... 20 vincristine sulfate ...... 35 XARELTO ...... 13 TRUMENBA...... 96 vinorelbine tartrate ...... 35 XIFAXAN ...... 29 TRUVADA ...... 40 VIRACEPT ...... 41 XULANE ...... 52 TWINRIX ...... 96 VIREAD...... 43 Z TYKERB ...... 33 virt-vite forte ...... 63 zafirlukast ...... 12 U vitamin d (ergocalciferol) 99 zaleplon ...... 73 UNITHROID ...... 92 vitamin d3 ...... 99 ZARAH ...... 51 ursodiol ...... 67 vitamins acd-fluoride ..... 80 ZARXIO ...... 72 V voriconazole ...... 23 ZENATANE ...... 57 valacyclovir hcl ...... 43 VOSEVI...... 72 ZENPEP ...... 63 valganciclovir hcl...... 43 W zidovudine ...... 42 valproic acid ...... 16 warfarin sodium ...... 13 ziprasidone hcl ...... 38 valsartan ...... 27 WIDE-SEAL DIAPHRAGM 60 zolmitriptan ...... 77, 78 valsartan- ...... 75 zolpidem tartrate ...... 73 hydrochlorothiazide ..... 27 WIDE-SEAL DIAPHRAGM 65 zonisamide ...... 15 vancomycin hcl ...... 70 ...... 75 ZOSTAVAX ...... 98 VAQTA ...... 98 WIDE-SEAL DIAPHRAGM 70 ZOVIA 1/35E (28) ...... 51 VARIVAX ...... 98 ...... 75 ZYKADIA ...... 33 VCF VAGINAL WIDE-SEAL DIAPHRAGM 75 ZYTIGA ...... 31 CONTRACEPTIVE ...... 98 ...... 75

109