Your Guide to Benefits

2021 Preferred Formulary Guide

Please see the inside cover for a list of all the plans this formulary applies to. This document contains information about the drugs covered in your prescription drug benefit plan.

Important Contacts

For more information about your prescription drug coverage, call the phone number listed on your BlueCross BlueShield of Tennessee Member ID card. For information about your home delivery prescription, call 1-877-673-9165.

Visit bcbst.com We look at all reconsiderations on a case- by-case basis. Your Evidence of Coverage or member handbook has details on your › Find a pharmacy in your network rights to file reconsiderations. › Look up lower-cost prescription Fax all information to 1-888-343-4232. alternatives Or send a written request to: › Compare your pricing and options Pharmacy Management Reconsiderations BlueCross BlueShield of Tennessee If You Want Us to Rethink 1 Cameron Hill Circle Your Request Chattanooga, TN 37402-2555 Please provide the following information You or your doctor may ask to reconsider with your request: any of these things: › Patient name and cardholder › A denial of a drug benefit ID number

› Limits on a drug quantity › Physician name and phone number

› The details needed for prior › Drug and diagnosis information authorization

› Getting a non-covered drug approved

You’ll need written reasons from your doctor about why we should rethink your situation.

Check often for updates, as this list is subject to change. | 2021 Preferred Formulary i Understanding the Formulary Drug List

This formulary drug list will help you understand the drugs your plan covers. The drugs in this formulary are listed by common categories, then alphabetically. They’re placed into cost levels known as tiers. Some drugs have notes with letters next to them. The letters refer to certain pharmacy benefit programs. To make sure that prescriptions are used safely, some drugs have additional requirements you’ll need to meet before we can cover your prescription. Those drugs will have an abbreviation next to the drug name to let you and your doctor know there are additional requirements.

For more information on how to fill your prescriptions, please refer to your Evidence of Coverage or member handbook on bcbst.com or call the phone number listed on your BlueCross Member ID card.

Abbreviation Description Affordable Care Act means drugs with the ACA indicator may be available to you at no out-of- ACA pocket cost depending on your plan. Check your Evidence of Coverage or member handbook for plan details. Age Requirement Prior authorization is required for members 17 years of age and younger. Your AGE-A doctor must request a coverage review with BlueCross by submitting the request digitally through CoverMyMeds, calling 1-800-924-7141, or faxing 1-888-343-4232.

Limited Distribution means drugs may only be available at certain pharmacies. For more LD information, please call us at the phone number listed on your Member ID card.

Morphine Milligram Equivalent Your plan measures how strong each medicine is compared to morphine and limits the combined total, or MME. Prior authorization is required for members who take MME greater than 120 mg equivalents of morphine a day. Your doctor must request a coverage review with BlueCross by submitting the request digitally through CoverMyMeds, calling 1-800-924-7141, or faxing 1-888-343-4232. Prior Authorization may be required for certain drugs. Your doctor must request a coverage review PA with BlueCross by submitting the request digitally through CoverMyMeds, calling 1-800-924-7141, or faxing 1-888-343-4232.

QL Quantity Limit means you may have coverage for a limited amount of a specific drug.

Specialty Drug includes drugs for chronic, serious diseases such as hepatitis C, multiple sclerosis, SPRx arthritis, hemophilia and other conditions. Some plans may cover specialty drugs at different benefit levels or may require the use of a network specialty pharmacy. Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Your doctor must request a ST coverage review with BlueCross by submitting the request digitally through CoverMyMeds, calling 1-800-924-7141, or faxing 1-888-343-4232. Please refer to the list included on page iv for drugs that require step therapy. Some plans do not cover these drugs. Check your Evidence of Coverage guide or Member Handbook # for plan details, including additional requirements.

ii 2021 Preferred Formulary | Check often for updates, as this list is subject to change. What’s a Drug Tier?

Tiers are the different cost levels you pay for a prescription drug. Each tier is assigned a cost (copay, deductible or coinsurance), which your employer or health plan determines. This is how much you will pay when you fill a prescription. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Check your Evidence of Coverage or member handbook for plan details.

Drug Tiers

Generic Drugs Generic Drugs have the same strength and active ingredients as the brand name – but typically are the most affordable and offer you the lowest available copayment or coinsurance. The Tier 1 active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand drug. To help lower your out-of-pocket costs, we encourage you to choose a generic medication whenever possible. Look for these drugs under “Tier 1” in this formulary. Preferred Brand Drugs Preferred Brand Drugs will usually have a slightly higher copay or coinsurance than generic drugs, but less than a non-preferred brand drug under your plan. These drugs are designated Tier 2 preferred brand because they have been proven to be safe, effective, and more affordable compared to other brand or over-the-counter drugs that treat the same condition. Look for these drugs under “Tier 2” in this formulary. Non-Preferred Brand Drugs Non-Preferred Brand Drugs are those that generally have generic alternatives and/or one or more preferred options within the same drug class. You will usually pay the highest copay or Tier 3 coinsurance for a non-preferred drug under your plan. These drugs are listed as non-preferred because they have not been found to be any more effective than available generics, preferred brands, or over-the-counter drugs. Look for these drugs under “Tier 3” in this formulary.

Check often for updates, as this list is subject to change. | 2021 Preferred Formulary iii Step Therapy Requirements

Step Therapy requires you to first try certain drugs to treat your medical condition before we cover another drug for that condition. This chart lists the drugs that require step therapy before your plan will cover the medication.

Medication(s) Requiring Step Therapy Step Therapy Requirements

Trial and failure of a generic Angiotensin II Blocker (ARB), including candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, Edarbi irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, Edarbyclor olmesartan, olmesartan-hydrochlorothiazide, , telmisartan - hydrochlorothiazide, valsartan and valsartan-hydrochlorothiazide

Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Trial and failure of Fiasp, Fiasp FlexTouch, or Novolog Humalog Junior KwikPen Insulin Lispro Insulin Lispro Kwikpen Lyumjev Lyumjev KwikPen

Humulin Trial and failure of Novolin

Proventil HFAQL Trial and failure of albuterol sulfate HFAQL, ProAir RespiClickQL, Xopenex HFAQL or Ventolin HFAQL

Trial and failure of two anticonvulsant products or one anticonvulsant product Epidiolex specifically indicated for Lennox Gastaut Syndrome or Dravet Syndrome

Pentasa Trial and failure of generic balsalazide, mesalamine, or sulfasalazine

For certain medical conditions, it is best practice to try a Tier 2 Preferred Drug before your plan will cover a Tier 3 Non-Preferred Drug.

iv 2021 Preferred Formulary | Check often for updates, as this list is subject to change.

Where to Get Your Prescriptions Filled

You’ll need to show your Member ID card when you have a prescription filled. You may have to pay part of the cost for prescription medicines and supplies. Check your Evidence of Coverage or member handbook for specifics.

Network Pharmacies

Our pharmacy networks include many retail drug store chains and independent pharmacies across the country. If your medication isn’t for managing a long-term condition, the prescription is typically written for less than a 30-day supply. (See the Retail 90 and Home Delivery Network sections for information on 90-day supplies).

It’s important that you always use an in-network pharmacy. If you don’t, you’ll have to pay all of the costs for your prescription. If you’re outside Tennessee, you can find a pharmacy in our nationwide network. Check your Evidence of Coverage or member handbook for your pharmacy network details.

vi 2021 Preferred Formulary | Check often for updates, as this list is subject to change. How to find a network Home Delivery pharmacy: You can sign up for home delivery and have your prescription delivered right to your door. › Go to bcbst.com. Home Delivery is for prescriptions with a • Sign up for BlueAccessSM, 30-day (one-month) or a 90-day (three-month) our secure member portal. supply.* Call 1-877-673-9165 to get started.

• Click on Find a Doctor. With home delivery you get:

• Click on Pharmacy and select › FREE standard shipping** your Pharmacy Network. › Access to a pharmacist 24/7 Or › Automatic refill reminders so you’re › Call Member Service at the less likely to miss a dose number on the back of your › Extended payment plan available Member ID card.

Specialty Pharmacies Retail 90 Networks

Some serious medical conditions need Through Retail 90 Networks you can specialty drugs. They may be given at the get up to a 90-day (three-month) supply doctor’s office or at home. Our specialty of your prescriptions.* pharmacies are a special network of vendors, › With a three-month supply, you're less experienced in managing these specialty likely to miss a dose, and you don't have drugs and supporting you and your doctor. to refill as often, which can save you time You and your doctor can find a list of and money. specialty pharmacies at bcbst.com.

› If you use a pharmacy that’s not part of Specialty drugs: your Retail 90 Network, you’re limited to › Usually require a prior authorization a 30-day (one-month) supply. › Usually are limited to a 30-day supply › These networks are made up of some local pharmacies and drug store chains. › Are usually only available from Ask your pharmacy if they’re part of specialty pharmacies in our network. your Retail 90 Network. Check your Evidence of Coverage or member handbook for your pharmacy network details.

* Your doctor will need to write your prescription for a 90-day supply. ** Standard shipping costs are included.

Check often for updates, as this list is subject to change. | 2021 Preferred Formulary vii Tips for Using Your Prescription Drug Benefits

Talk with your doctor.

Doctors are your partners, so discuss every aspect of your treatment, including the selection of drugs. The more you know, the better choices you can make.

› Ask your doctor to check the list of drugs your plan covers before prescribing a medicine.

› Give your doctor a list of all the medicines you take. Include medicines that don’t need a prescription. This helps them choose medicines that work well together.

› Advertising, social media or the internet may not be your best source of information. Discuss all your concerns with your doctor.

viii 2021 Preferred Formulary | Check often for updates, as this list is subject to change. Ask for generic drugs. Use over-the-counter (OTC) medicines to save money. The U.S. Food and Drug Administration (FDA) requires generic drugs to have › OTC medicines are sold without the same quality, strength and purity a prescription. as brand-name drugs. › Some prescription drugs may not be › Generic drugs work the same as covered under your plan because there is brand name drugs, but cost less. an OTC available that works just as well. › Talk to your doctor about the different › Don’t switch from a prescription drug to kinds of generic drugs. an OTC without talking with your doctor. › The formulary drug list has different tiers (levels) of drugs that you can use Be safe with your prescriptions. (see “What’s a Drug Tier?” on page iii).

› You pay less for generic drugs almost › Never share prescription drugs — even if every time. it’s for a member of the family.

› Under most BlueCross plans, if you › Keep all medicines safe from children, out request a brand name drug that has of sight and out of reach. Lock them away, a generic equivalent, you pay the cost if possible. difference between the generic and › Don’t stop using a prescription without brand name drug. Check your Evidence talking to the doctor. of Coverage or member handbook to see if this applies to your plan. › Follow up with the doctor about any side effects. Talk to your pharmacist. Some prescriptions need an Your pharmacist can answer questions approval for coverage. about the drugs you take, help you avoid harmful drug interactions, and help you › Some prescriptions require prior select appropriate, lower-cost generics and authorization or step therapy. preferred brands whenever available. › Some drugs have limits on the amount of › Have all of your family’s prescriptions them that your plan will pay for. filled at the same pharmacy. › Network doctors usually know this and › By knowing all your prescriptions, your know how to get authorizations. However, pharmacist can make sure all of your you may want to show this formulary drugs work well together. This can help drug list to your doctor — especially if you keep you and your family safe. use an out-of-network doctor or a doctor outside Tennessee.

Check often for updates, as this list is subject to change. | 2021 Preferred Formulary ix

2021 Preferred Formulary

Table of Contents

Anti - Infectives ...... 2 Antineoplastic & Immunosuppressant Drugs ...... 13 Autonomic & Cns Drugs, Neurology & Psych ...... 18 Cardiovascular, Hypertension & Lipids ...... 40 Dermatologicals/Topical Therapy ...... 53 Diagnostics & Miscellaneous Agents ...... 64 Ear, Nose & Throat Medications ...... 72 Endocrine/Diabetes ...... 73 Gastroenterology ...... 90 Immunology, Vaccines & Biotechnology ...... 97 Musculoskeletal & Rheumatology ...... 103 Obstetrics & Gynecology ...... 105 Ophthalmology ...... 115 Respiratory, Allergy, Cough & Cold ...... 120 Urologicals ...... 127 Vitamins, Hematinics & Electrolytes ...... 129

1 Drug Name Drug Tier Requirements/Limits Anti - Infectives Agents ANCOBON ORAL CAPSULE Tier 3 mucous membrane troche Tier 1 CRESEMBA ORAL CAPSULE Tier 3 DIFLUCAN ORAL SUSPENSION FOR Tier 3 RECONSTITUTION DIFLUCAN ORAL TABLET Tier 3 fluconazole oral suspension for reconstitution Tier 1 fluconazole oral tablet Tier 1 flucytosine oral capsule Tier 1 microsize oral suspension Tier 1 griseofulvin microsize oral tablet Tier 1 griseofulvin ultramicrosize oral tablet Tier 1 itraconazole oral capsule Tier 1 itraconazole oral solution Tier 1 oral tablet Tier 1 NOXAFIL ORAL SUSPENSION Tier 3 NOXAFIL ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) nystatin oral suspension Tier 1 nystatin oral tablet Tier 1 ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL Tier 3 TABLET posaconazole oral tablet,delayed release (dr/ec) Tier 1 SPORANOX ORAL SOLUTION Tier 3 SPORANOX PULSEPAK ORAL CAPSULE Tier 3 terbinafine hcl oral tablet Tier 1 VFEND ORAL SUSPENSION FOR Tier 3 RECONSTITUTION VFEND ORAL TABLET Tier 3 voriconazole oral suspension for reconstitution Tier 1 voriconazole oral tablet Tier 1 Antivirals abacavir oral solution Tier 1

2 Drug Name Drug Tier Requirements/Limits abacavir oral tablet Tier 1 abacavir-lamivudine oral tablet Tier 1 SPRx abacavir-lamivudine-zidovudine oral tablet Tier 1 acyclovir oral capsule Tier 1 acyclovir oral suspension 200 mg/5 ml Tier 1 acyclovir oral tablet Tier 1 adefovir oral tablet Tier 1 amantadine hcl oral capsule Tier 1 amantadine hcl oral solution Tier 1 amantadine hcl oral tablet Tier 1 APTIVUS (WITH VITAMIN E) ORAL SOLUTION Tier 3 APTIVUS ORAL CAPSULE Tier 3 atazanavir oral capsule Tier 1 SPRx ATRIPLA ORAL TABLET Tier 3 SPRx BARACLUDE ORAL SOLUTION Tier 3 BARACLUDE ORAL TABLET Tier 3 BIKTARVY ORAL TABLET Tier 3 SPRx CABENUVA INTRAMUSCULAR Tier 3 SPRx SUSPENSION,EXTENDED RELEASE CIMDUO ORAL TABLET Tier 3 SPRx COMBIVIR ORAL TABLET Tier 3 COMPLERA ORAL TABLET Tier 3 SPRx CRIXIVAN ORAL CAPSULE 200 MG Tier 3 DELSTRIGO ORAL TABLET Tier 3 SPRx DESCOVY ORAL TABLET Tier 3 SPRx didanosine oral capsule,delayed release(dr/ec) Tier 1 DOVATO ORAL TABLET Tier 3 SPRx EDURANT ORAL TABLET Tier 3 oral capsule Tier 1 efavirenz oral tablet Tier 1 efavirenz-emtricitabin-tenofov oral tablet Tier 1 SPRx efavirenz-lamivu-tenofov disop oral tablet Tier 1 SPRx emtricitabine oral capsule Tier 1 emtricitabine-tenofovir (tdf) oral tablet 100-150 Tier 1 SPRx mg, 133-200 mg, 167-250 mg

3 Drug Name Drug Tier Requirements/Limits emtricitabine-tenofovir (tdf) oral tablet 200-300 Tier 1 SPRx; ACA mg EMTRIVA ORAL CAPSULE Tier 3 EMTRIVA ORAL SOLUTION Tier 3 entecavir oral tablet Tier 1 EPCLUSA ORAL TABLET Tier 2 PA; SPRx EPIVIR HBV ORAL SOLUTION Tier 3 EPIVIR HBV ORAL TABLET Tier 3 EPIVIR ORAL SOLUTION Tier 3 EPIVIR ORAL TABLET Tier 3 EPZICOM ORAL TABLET Tier 3 SPRx EVOTAZ ORAL TABLET Tier 3 SPRx famciclovir oral tablet Tier 1 FLUMADINE ORAL TABLET Tier 3 fosamprenavir oral tablet Tier 1 FUZEON SUBCUTANEOUS RECON SOLN Tier 3 SPRx GENVOYA ORAL TABLET Tier 3 SPRx HARVONI ORAL PELLETS IN PACKET Tier 2 PA; SPRx HARVONI ORAL TABLET Tier 2 PA; SPRx HEPSERA ORAL TABLET Tier 3 INTELENCE ORAL TABLET Tier 3 INVIRASE ORAL TABLET Tier 3 ISENTRESS HD ORAL TABLET Tier 3 SPRx ISENTRESS ORAL POWDER IN PACKET Tier 3 SPRx ISENTRESS ORAL TABLET Tier 3 SPRx ISENTRESS ORAL TABLET,CHEWABLE Tier 3 SPRx JULUCA ORAL TABLET Tier 3 SPRx KALETRA ORAL SOLUTION Tier 3 KALETRA ORAL TABLET Tier 3 lamivudine oral solution Tier 1 lamivudine oral tablet Tier 1 lamivudine-zidovudine oral tablet Tier 1 LEDIPASVIR-SOFOSBUVIR ORAL TABLET Tier 2 PA; SPRx LEXIVA ORAL SUSPENSION Tier 3 LEXIVA ORAL TABLET Tier 3

4 Drug Name Drug Tier Requirements/Limits lopinavir- oral solution Tier 1 MAVYRET ORAL TABLET Tier 2 PA; SPRx oral suspension Tier 1 nevirapine oral tablet Tier 1 nevirapine oral tablet extended release 24 hr Tier 1 NORVIR ORAL CAPSULE Tier 3 NORVIR ORAL POWDER IN PACKET Tier 3 NORVIR ORAL SOLUTION Tier 3 NORVIR ORAL TABLET Tier 3 ODEFSEY ORAL TABLET Tier 3 SPRx oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 180 days) oseltamivir oral suspension for reconstitution Tier 1 QL (180 ML per 180 days) PIFELTRO ORAL TABLET Tier 3 SPRx PREZCOBIX ORAL TABLET Tier 3 SPRx PREZISTA ORAL SUSPENSION Tier 3 SPRx PREZISTA ORAL TABLET Tier 3 SPRx RELENZA DISKHALER INHALATION BLISTER WITH Tier 3 QL (20 EA per 180 days) DEVICE RETROVIR ORAL CAPSULE Tier 3 REYATAZ ORAL CAPSULE Tier 3 SPRx REYATAZ ORAL POWDER IN PACKET Tier 3 SPRx rimantadine oral tablet Tier 1 ritonavir oral tablet Tier 1 RUKOBIA ORAL TABLET EXTENDED RELEASE 12 Tier 3 SPRx HR SELZENTRY ORAL SOLUTION Tier 3 SELZENTRY ORAL TABLET Tier 3 SOFOSBUVIR-VELPATASVIR ORAL TABLET Tier 2 PA; SPRx stavudine oral capsule Tier 1 STRIBILD ORAL TABLET Tier 3 SPRx SUSTIVA ORAL CAPSULE Tier 3 SUSTIVA ORAL TABLET Tier 3 SYMFI LO ORAL TABLET Tier 3 SPRx SYMFI ORAL TABLET Tier 3 SPRx

5 Drug Name Drug Tier Requirements/Limits SYMTUZA ORAL TABLET Tier 3 SPRx TAMIFLU ORAL CAPSULE 30 MG Tier 3 QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG Tier 3 QL (10 EA per 180 days) TAMIFLU ORAL SUSPENSION FOR Tier 3 QL (180 ML per 180 days) RECONSTITUTION TEMIXYS ORAL TABLET Tier 3 SPRx tenofovir disoproxil fumarate oral tablet Tier 1 TIVICAY ORAL TABLET Tier 3 SPRx TIVICAY PD ORAL TABLET FOR SUSPENSION Tier 3 SPRx TRIUMEQ ORAL TABLET Tier 3 SPRx TRIZIVIR ORAL TABLET Tier 3 TRUVADA ORAL TABLET Tier 3 ST; SPRx TYBOST ORAL TABLET Tier 3 valacyclovir oral tablet Tier 1 VALCYTE ORAL RECON SOLN Tier 3 VALCYTE ORAL TABLET Tier 3 valganciclovir oral recon soln Tier 1 valganciclovir oral tablet Tier 1 VALTREX ORAL TABLET Tier 3 VEMLIDY ORAL TABLET Tier 3 SPRx VIRACEPT ORAL TABLET Tier 3 VIRAMUNE ORAL SUSPENSION Tier 3 VIRAMUNE XR ORAL TABLET EXTENDED Tier 3 RELEASE 24 HR VIREAD ORAL POWDER Tier 3 VIREAD ORAL TABLET Tier 3 VOSEVI ORAL TABLET Tier 2 PA; SPRx XOFLUZA ORAL TABLET Tier 3 QL (2 EA per 180 days) ZERIT ORAL CAPSULE Tier 3 ZIAGEN ORAL SOLUTION Tier 3 ZIAGEN ORAL TABLET Tier 3 zidovudine oral capsule Tier 1 zidovudine oral syrup Tier 1 zidovudine oral tablet Tier 1 ZOVIRAX ORAL SUSPENSION Tier 3

6 Drug Name Drug Tier Requirements/Limits Cephalosporins cefaclor oral capsule Tier 1 cefaclor oral suspension for reconstitution Tier 1 cefaclor oral tablet extended release 12 hr Tier 1 cefadroxil oral capsule Tier 1 cefadroxil oral suspension for reconstitution Tier 1 cefadroxil oral tablet Tier 1 cefdinir oral capsule Tier 1 cefdinir oral suspension for reconstitution Tier 1 cefditoren pivoxil oral tablet Tier 1 cefixime oral capsule Tier 1 cefixime oral suspension for reconstitution Tier 1 cefpodoxime oral suspension for reconstitution Tier 1 cefpodoxime oral tablet Tier 1 cefprozil oral suspension for reconstitution Tier 1 cefprozil oral tablet Tier 1 cefuroxime axetil oral tablet Tier 1 cephalexin oral capsule Tier 1 cephalexin oral suspension for reconstitution Tier 1 cephalexin oral tablet Tier 1 SUPRAX ORAL CAPSULE Tier 3 SUPRAX ORAL SUSPENSION FOR Tier 3 RECONSTITUTION SUPRAX ORAL TABLET,CHEWABLE Tier 3 & Other Macrolides azithromycin oral packet Tier 1 azithromycin oral suspension for reconstitution Tier 1 azithromycin oral tablet Tier 1 clarithromycin oral suspension for reconstitution Tier 1 clarithromycin oral tablet Tier 1 clarithromycin oral tablet extended release 24 hr Tier 1 DIFICID ORAL SUSPENSION FOR Tier 3 RECONSTITUTION DIFICID ORAL TABLET Tier 3 e.e.s. 400 oral tablet Tier 1

7 Drug Name Drug Tier Requirements/Limits E.E.S. GRANULES ORAL SUSPENSION FOR Tier 3 RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR Tier 3 RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR Tier 3 RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 Tier 1 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) 500 MG erythrocin (as stearate) oral tablet Tier 1 ethylsuccinate oral suspension for Tier 1 reconstitution erythromycin ethylsuccinate oral tablet Tier 1 erythromycin oral capsule,delayed release(dr/ec) Tier 1 erythromycin oral tablet Tier 1 erythromycin oral tablet,delayed release (dr/ec) Tier 1 ZITHROMAX ORAL PACKET Tier 3 ZITHROMAX ORAL SUSPENSION FOR Tier 3 RECONSTITUTION ZITHROMAX ORAL TABLET Tier 3 Miscellaneous Antiinfectives AEMCOLO ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) albendazole oral tablet Tier 1 ALBENZA ORAL TABLET Tier 3 ALINIA ORAL SUSPENSION FOR Tier 3 RECONSTITUTION ALINIA ORAL TABLET Tier 3 ARAKODA ORAL TABLET Tier 3 ARIKAYCE INHALATION SUSPENSION FOR Tier 3 PA; LD; SPRx NEBULIZATION atovaquone oral suspension Tier 1 atovaquone-proguanil oral tablet Tier 1 BILTRICIDE ORAL TABLET Tier 3 CAYSTON INHALATION SOLUTION FOR Tier 3 PA; LD; SPRx NEBULIZATION

8 Drug Name Drug Tier Requirements/Limits chloroquine phosphate oral tablet Tier 1 CLEOCIN HCL ORAL CAPSULE Tier 3 CLEOCIN PEDIATRIC ORAL RECON SOLN Tier 3 hcl oral capsule Tier 1 clindamycin pediatric oral recon soln Tier 1 COARTEM ORAL TABLET Tier 3 CYCLOSERINE ORAL CAPSULE Tier 3 dapsone oral tablet Tier 1 DARAPRIM ORAL TABLET Tier 3 PA; SPRx ethambutol oral tablet Tier 1 FLAGYL ORAL CAPSULE Tier 3 FLAGYL ORAL TABLET Tier 3 hydroxychloroquine oral tablet Tier 1 isoniazid oral solution Tier 1 isoniazid oral tablet Tier 1 ivermectin oral tablet Tier 1 KITABIS PAK INHALATION SOLUTION FOR Tier 2 SPRx; QL (280 ML per 30 days) NEBULIZATION KRINTAFEL ORAL TABLET Tier 3 linezolid oral suspension for reconstitution Tier 1 QL (14 day supply per 30 days) linezolid oral tablet Tier 1 QL (14 day supply per 30 days) MALARONE ORAL TABLET Tier 3 MALARONE PEDIATRIC ORAL TABLET Tier 3 mefloquine oral tablet Tier 1 MEPRON ORAL SUSPENSION Tier 3 metronidazole oral capsule Tier 1 metronidazole oral tablet Tier 1 MYAMBUTOL ORAL TABLET Tier 3 MYCOBUTIN ORAL CAPSULE Tier 3 NEBUPENT INHALATION RECON SOLN Tier 3 neomycin oral tablet Tier 1 nitazoxanide oral tablet Tier 1 paromomycin oral capsule Tier 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET Tier 3 pentamidine inhalation recon soln Tier 1

9 Drug Name Drug Tier Requirements/Limits PLAQUENIL ORAL TABLET Tier 3 praziquantel oral tablet Tier 1 PRETOMANID ORAL TABLET Tier 3 PRIFTIN ORAL TABLET Tier 3 primaquine oral tablet Tier 1 pyrazinamide oral tablet Tier 1 pyrimethamine oral tablet Tier 1 PA; SPRx QUALAQUIN ORAL CAPSULE Tier 3 quinine sulfate oral capsule Tier 1 rifabutin oral capsule Tier 1 RIFADIN ORAL CAPSULE 150 MG, 300 MG Tier 3 RIFAMATE ORAL CAPSULE 300-150 MG Tier 3 rifampin oral capsule Tier 1 RIFATER ORAL TABLET 50-120-300 MG Tier 3 SIRTURO ORAL TABLET Tier 3 SPRx SOLOSEC ORAL GRANULES DEL RELEASE IN Tier 3 PACKET STROMECTOL ORAL TABLET Tier 3 tinidazole oral tablet Tier 1 TOBI INHALATION SOLUTION FOR Tier 3 SPRx; QL (280 ML per 30 days) NEBULIZATION tobramycin in 0.225 % nacl inhalation solution for Tier 1 SPRx; QL (280 ML per 30 days) nebulization TRECATOR ORAL TABLET Tier 3 XIFAXAN ORAL TABLET 200 MG Tier 3 XIFAXAN ORAL TABLET 550 MG Tier 2 ZYVOX ORAL SUSPENSION FOR Tier 3 QL (14 day supply per 30 days) RECONSTITUTION ZYVOX ORAL TABLET Tier 3 QL (14 day supply per 30 days) Penicillins amoxicillin oral capsule Tier 1 amoxicillin oral suspension for reconstitution Tier 1 amoxicillin oral tablet Tier 1 amoxicillin oral tablet,chewable Tier 1 amoxicillin-pot clavulanate oral suspension for Tier 1 reconstitution

10 Drug Name Drug Tier Requirements/Limits amoxicillin-pot clavulanate oral tablet Tier 1 amoxicillin-pot clavulanate oral tablet extended Tier 1 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable Tier 1 ampicillin oral capsule Tier 1 AUGMENTIN ES-600 ORAL SUSPENSION FOR Tier 3 RECONSTITUTION AUGMENTIN ORAL SUSPENSION FOR Tier 3 RECONSTITUTION AUGMENTIN ORAL TABLET Tier 3 AUGMENTIN XR ORAL TABLET EXTENDED Tier 3 RELEASE 12 HR oral capsule Tier 1 penicillin v potassium oral recon soln Tier 1 penicillin v potassium oral tablet Tier 1 Quinolones CIPRO ORAL SUSPENSION,MICROCAPSULE Tier 3 RECON CIPRO ORAL TABLET Tier 3 CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR Tier 3 ciprofloxacin hcl oral tablet Tier 1 ciprofloxacin oral suspension,microcapsule recon Tier 1 FACTIVE ORAL TABLET Tier 3 levofloxacin oral solution Tier 1 levofloxacin oral tablet Tier 1 moxifloxacin oral tablet Tier 1 ofloxacin oral tablet Tier 1 Sulfa's & Related Agents BACTRIM DS ORAL TABLET Tier 3 BACTRIM ORAL TABLET Tier 3 sulfadiazine oral tablet Tier 1 sulfamethoxazole-trimethoprim oral suspension Tier 1 sulfamethoxazole-trimethoprim oral tablet Tier 1 sulfatrim oral suspension Tier 1 avidoxy oral tablet Tier 1

11 Drug Name Drug Tier Requirements/Limits demeclocycline oral tablet Tier 1 doxycycline hyclate oral capsule Tier 1 doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1 doxycycline hyclate oral tablet,delayed release Tier 1 (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule Tier 1 doxycycline monohydrate oral suspension for Tier 1 reconstitution doxycycline monohydrate oral tablet Tier 1 oral capsule Tier 1 minocycline oral tablet Tier 1 NUZYRA ORAL TABLET Tier 3 PA oral capsule Tier 1 VIBRAMYCIN ORAL CAPSULE Tier 3 VIBRAMYCIN ORAL SUSPENSION FOR Tier 3 RECONSTITUTION VIBRAMYCIN ORAL SYRUP Tier 3 Urinary Tract Agents fosfomycin tromethamine oral packet Tier 1 FURADANTIN ORAL SUSPENSION Tier 3 HIPREX ORAL TABLET Tier 3 MACROBID ORAL CAPSULE Tier 3 MACRODANTIN ORAL CAPSULE Tier 3 methenamine hippurate oral tablet Tier 1 methenamine mandelate oral tablet Tier 1 MONUROL ORAL PACKET Tier 3 nitrofurantoin macrocrystal oral capsule Tier 1 nitrofurantoin monohyd/m-cryst oral capsule Tier 1 nitrofurantoin oral suspension Tier 1 PRIMSOL ORAL SOLUTION Tier 3 trimethoprim oral tablet Tier 1 Vancomycin FIRVANQ ORAL RECON SOLN Tier 3 VANCOCIN ORAL CAPSULE Tier 3 vancomycin oral capsule Tier 1

12 Drug Name Drug Tier Requirements/Limits Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet Tier 1 MESNEX ORAL TABLET Tier 3 & Antispasmodics IBRANCE ORAL TABLET 125 MG Tier 3 PA; SPRx Antineoplastic & Immunosuppressant Drugs abiraterone oral tablet Tier 1 PA; SPRx AFINITOR DISPERZ ORAL TABLET FOR Tier 3 PA; SPRx SUSPENSION AFINITOR ORAL TABLET Tier 3 PA; SPRx ALECENSA ORAL CAPSULE Tier 3 PA; SPRx ALKERAN ORAL TABLET Tier 3 ALUNBRIG ORAL TABLET Tier 3 PA; SPRx ALUNBRIG ORAL TABLETS,DOSE PACK Tier 3 PA; SPRx oral tablet Tier 1 ACA ARIMIDEX ORAL TABLET Tier 3 AROMASIN ORAL TABLET Tier 3 ASTAGRAF XL ORAL CAPSULE,EXTENDED Tier 3 SPRx RELEASE 24HR AYVAKIT ORAL TABLET Tier 3 PA; LD; SPRx AZASAN ORAL TABLET Tier 3 azathioprine oral tablet Tier 1 BALVERSA ORAL TABLET Tier 3 PA; LD; SPRx bexarotene oral capsule Tier 1 SPRx oral tablet Tier 1 BOSULIF ORAL TABLET Tier 3 PA; SPRx BRAFTOVI ORAL CAPSULE Tier 3 PA; LD; SPRx BRUKINSA ORAL CAPSULE Tier 3 PA; LD; SPRx CABOMETYX ORAL TABLET Tier 3 PA; LD; SPRx CALQUENCE ORAL CAPSULE Tier 3 PA; LD; SPRx capecitabine oral tablet Tier 1 SPRx CAPRELSA ORAL TABLET Tier 3 PA; LD; SPRx CASODEX ORAL TABLET Tier 3

13 Drug Name Drug Tier Requirements/Limits CELLCEPT ORAL CAPSULE Tier 3 CELLCEPT ORAL SUSPENSION FOR Tier 3 RECONSTITUTION COMETRIQ ORAL CAPSULE Tier 3 SPRx COPIKTRA ORAL CAPSULE Tier 3 PA; LD; SPRx COTELLIC ORAL TABLET Tier 3 PA; LD; SPRx oral capsule Tier 1 cyclophosphamide oral tablet Tier 1 cyclosporine modified oral capsule Tier 1 cyclosporine modified oral solution Tier 1 cyclosporine oral capsule Tier 1 DAURISMO ORAL TABLET Tier 3 PA; SPRx DROXIA ORAL CAPSULE Tier 3 EMCYT ORAL CAPSULE Tier 3 ENSPRYNG SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx ERIVEDGE ORAL CAPSULE Tier 3 PA; SPRx ERLEADA ORAL TABLET Tier 2 PA; SPRx erlotinib oral tablet Tier 1 PA; SPRx etoposide oral capsule Tier 1 everolimus (antineoplastic) oral tablet Tier 1 PA; SPRx everolimus (immunosuppressive) oral tablet Tier 1 SPRx exemestane oral tablet Tier 1 ACA FARESTON ORAL TABLET Tier 3 FARYDAK ORAL CAPSULE Tier 3 PA; SPRx FEMARA ORAL TABLET Tier 3 flutamide oral capsule Tier 1 FOTIVDA ORAL CAPSULE Tier 3 PA; SPRx GAVRETO ORAL CAPSULE Tier 3 PA; SPRx gengraf oral capsule Tier 1 gengraf oral solution Tier 1 GILOTRIF ORAL TABLET Tier 3 PA; SPRx GLEEVEC ORAL TABLET Tier 3 PA; SPRx GLEOSTINE ORAL CAPSULE Tier 3 HYCAMTIN ORAL CAPSULE Tier 3 SPRx HYDREA ORAL CAPSULE Tier 3

14 Drug Name Drug Tier Requirements/Limits hydroxyurea oral capsule Tier 1 IBRANCE ORAL CAPSULE Tier 3 PA; SPRx IBRANCE ORAL TABLET 100 MG, 75 MG Tier 3 PA; SPRx ICLUSIG ORAL TABLET Tier 3 PA; SPRx IDHIFA ORAL TABLET Tier 3 PA; LD; SPRx imatinib oral tablet Tier 1 PA; SPRx IMBRUVICA ORAL CAPSULE Tier 3 PA; SPRx IMBRUVICA ORAL TABLET Tier 3 PA; SPRx IMURAN ORAL TABLET Tier 3 INLYTA ORAL TABLET Tier 3 PA; SPRx INQOVI ORAL TABLET Tier 3 PA; SPRx INREBIC ORAL CAPSULE Tier 3 PA; LD; SPRx IRESSA ORAL TABLET Tier 3 PA; SPRx JAKAFI ORAL TABLET Tier 3 PA; SPRx KISQALI FEMARA CO-PACK ORAL TABLET Tier 3 PA; SPRx KISQALI ORAL TABLET Tier 3 PA; SPRx KOSELUGO ORAL CAPSULE Tier 3 PA; SPRx lapatinib oral tablet Tier 1 PA; SPRx LENVIMA ORAL CAPSULE Tier 3 PA; SPRx letrozole oral tablet Tier 1 LEUKERAN ORAL TABLET Tier 2 leuprolide subcutaneous kit Tier 1 PA; SPRx LONSURF ORAL TABLET Tier 3 PA; SPRx LORBRENA ORAL TABLET Tier 3 PA; SPRx LUPKYNIS ORAL CAPSULE Tier 3 PA; SPRx LYNPARZA ORAL TABLET Tier 3 PA; SPRx LYSODREN ORAL TABLET Tier 3 MATULANE ORAL CAPSULE Tier 3 SPRx megestrol oral suspension Tier 1 megestrol oral tablet Tier 1 MEKINIST ORAL TABLET Tier 3 PA; SPRx MEKTOVI ORAL TABLET Tier 3 PA; LD; SPRx melphalan oral tablet Tier 1 mercaptopurine oral tablet Tier 1 methotrexate sodium (pf) injection recon soln Tier 1

15 Drug Name Drug Tier Requirements/Limits methotrexate sodium (pf) injection solution Tier 1 methotrexate sodium injection solution Tier 1 methotrexate sodium oral tablet Tier 1 MYCAPSSA ORAL CAPSULE,DELAYED Tier 3 PA; SPRx RELEASE(DR/EC) mycophenolate mofetil oral capsule Tier 1 mycophenolate mofetil oral suspension for Tier 1 reconstitution mycophenolate mofetil oral tablet Tier 1 mycophenolate sodium oral tablet,delayed Tier 1 release (dr/ec) MYFORTIC ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) MYLERAN ORAL TABLET Tier 3 NEORAL ORAL CAPSULE Tier 3 NEORAL ORAL SOLUTION Tier 3 NERLYNX ORAL TABLET Tier 3 PA; LD; SPRx NEXAVAR ORAL TABLET Tier 3 PA; LD; SPRx NILANDRON ORAL TABLET Tier 3 SPRx nilutamide oral tablet Tier 1 SPRx NINLARO ORAL CAPSULE Tier 3 PA; SPRx NUBEQA ORAL TABLET Tier 2 PA; LD; SPRx octreotide acetate injection solution Tier 1 PA; SPRx octreotide acetate injection syringe Tier 1 PA; SPRx ODOMZO ORAL CAPSULE Tier 3 PA; LD; SPRx ONUREG ORAL TABLET Tier 3 PA; SPRx ORGOVYX ORAL TABLET Tier 3 PA; SPRx PEMAZYRE ORAL TABLET Tier 3 PA; LD; SPRx PIQRAY ORAL TABLET Tier 3 PA; SPRx PROGRAF ORAL CAPSULE Tier 3 PROGRAF ORAL GRANULES IN PACKET Tier 3 PURIXAN ORAL SUSPENSION Tier 3 SPRx QINLOCK ORAL TABLET Tier 3 PA; LD; SPRx RAPAMUNE ORAL SOLUTION Tier 3 RAPAMUNE ORAL TABLET Tier 3 RETEVMO ORAL CAPSULE Tier 3 PA; SPRx

16 Drug Name Drug Tier Requirements/Limits ROZLYTREK ORAL CAPSULE Tier 3 PA; LD; SPRx RUBRACA ORAL TABLET Tier 3 PA; LD; SPRx RYDAPT ORAL CAPSULE Tier 3 PA; SPRx SANDIMMUNE ORAL CAPSULE Tier 3 SANDIMMUNE ORAL SOLUTION Tier 3 SANDOSTATIN INJECTION SOLUTION Tier 3 PA; SPRx SIGNIFOR SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx SIKLOS ORAL TABLET Tier 3 oral solution Tier 1 sirolimus oral tablet Tier 1 SOLTAMOX ORAL SOLUTION Tier 3 ACA SPRYCEL ORAL TABLET Tier 3 SPRx STIVARGA ORAL TABLET Tier 3 PA; SPRx SUTENT ORAL CAPSULE Tier 3 PA; SPRx SYNRIBO SUBCUTANEOUS RECON SOLN Tier 3 PA; SPRx TABLOID ORAL TABLET Tier 3 TABRECTA ORAL TABLET Tier 3 PA; SPRx oral capsule Tier 1 TAFINLAR ORAL CAPSULE Tier 3 PA; SPRx TAGRISSO ORAL TABLET Tier 3 PA; LD; SPRx TALZENNA ORAL CAPSULE Tier 3 PA; SPRx oral tablet Tier 1 ACA TARCEVA ORAL TABLET Tier 3 PA; SPRx TARGRETIN ORAL CAPSULE Tier 3 SPRx TARGRETIN TOPICAL GEL Tier 3 SPRx TASIGNA ORAL CAPSULE Tier 3 PA; SPRx TAZVERIK ORAL TABLET Tier 3 PA; SPRx TEMODAR ORAL CAPSULE Tier 3 PA; SPRx temozolomide oral capsule Tier 1 PA; SPRx TEPMETKO ORAL TABLET Tier 3 PA; SPRx THALOMID ORAL CAPSULE Tier 3 PA; SPRx TIBSOVO ORAL TABLET Tier 3 PA; SPRx toremifene oral tablet Tier 1 tretinoin (antineoplastic) oral capsule Tier 1 TREXALL ORAL TABLET Tier 3

17 Drug Name Drug Tier Requirements/Limits TUKYSA ORAL TABLET Tier 3 PA; SPRx TURALIO ORAL CAPSULE Tier 3 PA; LD; SPRx TYKERB ORAL TABLET Tier 3 PA; LD; SPRx UKONIQ ORAL TABLET Tier 3 PA; SPRx VENCLEXTA ORAL TABLET Tier 3 PA; LD; SPRx VENCLEXTA STARTING PACK ORAL Tier 3 PA; SPRx TABLETS,DOSE PACK VERZENIO ORAL TABLET Tier 3 PA; LD; SPRx VITRAKVI ORAL CAPSULE Tier 3 PA; LD; SPRx VITRAKVI ORAL SOLUTION Tier 3 PA; LD; SPRx VIZIMPRO ORAL TABLET Tier 3 PA; SPRx VOTRIENT ORAL TABLET Tier 3 PA; SPRx XALKORI ORAL CAPSULE Tier 3 PA; SPRx XELODA ORAL TABLET Tier 3 SPRx XERMELO ORAL TABLET Tier 3 PA; LD; SPRx XOSPATA ORAL TABLET Tier 3 PA; LD; SPRx XPOVIO ORAL TABLET Tier 3 PA; LD; SPRx XTANDI ORAL CAPSULE Tier 2 PA; SPRx XTANDI ORAL TABLET Tier 2 PA; SPRx YONSA ORAL TABLET Tier 2 PA; SPRx ZEJULA ORAL CAPSULE Tier 3 PA; LD; SPRx ZELBORAF ORAL TABLET Tier 3 PA; SPRx ZOLINZA ORAL CAPSULE Tier 3 SPRx ZORTRESS ORAL TABLET Tier 3 SPRx ZYDELIG ORAL TABLET Tier 3 PA; SPRx ZYKADIA ORAL TABLET Tier 3 PA; SPRx ZYTIGA ORAL TABLET Tier 2 PA; SPRx Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal buprenorphine-naloxone sublingual film Tier 1 QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet Tier 1 QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM Tier 3 QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET Tier 2 QL (90 EA per 30 days) Anticonvulsants

18 Drug Name Drug Tier Requirements/Limits APTIOM ORAL TABLET Tier 3 BANZEL ORAL SUSPENSION Tier 3 BANZEL ORAL TABLET Tier 3 BRIVIACT ORAL SOLUTION Tier 3 ST BRIVIACT ORAL TABLET Tier 3 ST oral capsule, er multiphase 12 hr Tier 1 carbamazepine oral suspension Tier 1 carbamazepine oral tablet Tier 1 carbamazepine oral tablet extended release 12 hr Tier 1 carbamazepine oral tablet,chewable Tier 1 CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 Tier 3 HR CELONTIN ORAL CAPSULE Tier 3 clobazam oral suspension Tier 1 clobazam oral tablet Tier 1 clonazepam oral tablet Tier 1 clonazepam oral tablet,disintegrating Tier 1 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE Tier 3 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED Tier 3 REL SPRINKLE DIACOMIT ORAL CAPSULE Tier 3 PA; SPRx DIACOMIT ORAL POWDER IN PACKET Tier 3 PA; SPRx DIASTAT ACUDIAL RECTAL KIT Tier 3 DIASTAT RECTAL KIT Tier 3 diazepam rectal kit Tier 1 DILANTIN EXTENDED ORAL CAPSULE Tier 2 DILANTIN INFATABS ORAL TABLET,CHEWABLE Tier 2 DILANTIN KAPSEAL ORAL CAPSULE Tier 2 DILANTIN ORAL CAPSULE Tier 2 DILANTIN-125 ORAL SUSPENSION Tier 2 divalproex oral capsule, delayed rel sprinkle Tier 1 divalproex oral tablet extended release 24 hr Tier 1 divalproex oral tablet,delayed release (dr/ec) Tier 1

19 Drug Name Drug Tier Requirements/Limits EPIDIOLEX ORAL SOLUTION Tier 3 ST; SPRx epitol oral tablet Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 Tier 3 HR ethosuximide oral capsule Tier 1 ethosuximide oral solution Tier 1 felbamate oral suspension Tier 1 felbamate oral tablet Tier 1 FELBATOL ORAL SUSPENSION Tier 3 FELBATOL ORAL TABLET Tier 3 FINTEPLA ORAL SOLUTION Tier 3 PA; SPRx FYCOMPA ORAL TABLET Tier 3 gabapentin oral capsule Tier 1 PA; QL (180 EA per 30 days) gabapentin oral solution Tier 1 PA; QL (2160 ML per 30 days) gabapentin oral tablet 600 mg Tier 1 PA; QL (180 EA per 30 days) gabapentin oral tablet 800 mg Tier 1 PA; QL (120 EA per 30 days) GABITRIL ORAL TABLET Tier 3 KEPPRA ORAL SOLUTION Tier 3 KEPPRA ORAL TABLET Tier 3 KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR KLONOPIN ORAL TABLET Tier 3 LAMICTAL ODT ORAL TABLET,DISINTEGRATING Tier 3 LAMICTAL ODT STARTER (BLUE) ORAL TABLET Tier 3 DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET Tier 3 DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL Tier 3 TABLET DISINTEGRATING, DOSE PK LAMICTAL ORAL TABLET Tier 3 LAMICTAL ORAL TABLET, CHEWABLE Tier 3 DISPERSIBLE LAMICTAL STARTER (BLUE) KIT ORAL Tier 3 TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL Tier 3 TABLETS,DOSE PACK

20 Drug Name Drug Tier Requirements/Limits LAMICTAL STARTER (ORANGE) KIT ORAL Tier 3 TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE Tier 3 24HR LAMICTAL XR STARTER (BLUE) ORAL TABLET Tier 3 EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET Tier 3 EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (ORANGE) ORAL TABLET Tier 3 EXTENDED REL,DOSE PACK lamotrigine oral tablet Tier 1 lamotrigine oral tablet disintegrating, dose pk Tier 1 lamotrigine oral tablet extended release 24hr Tier 1 lamotrigine oral tablet, chewable dispersible Tier 1 lamotrigine oral tablet,disintegrating Tier 1 lamotrigine oral tablets,dose pack Tier 1 levetiracetam oral solution Tier 1 levetiracetam oral tablet Tier 1 levetiracetam oral tablet extended release 24 hr Tier 1 LYRICA CR ORAL TABLET EXTENDED RELEASE 24 Tier 2 PA; QL (30 EA per 30 days) HR 165 MG, 82.5 MG LYRICA CR ORAL TABLET EXTENDED RELEASE 24 Tier 2 PA; QL (60 EA per 30 days) HR 330 MG LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 Tier 2 PA; QL (90 EA per 30 days) MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG Tier 2 PA; QL (60 EA per 30 days) LYRICA ORAL SOLUTION Tier 2 PA; QL (900 ML per 30 days) MYSOLINE ORAL TABLET Tier 3 NEURONTIN ORAL CAPSULE Tier 3 PA; QL (180 EA per 30 days) NEURONTIN ORAL SOLUTION Tier 3 PA; QL (2160 ML per 30 days) NEURONTIN ORAL TABLET 600 MG Tier 3 PA; QL (180 EA per 30 days) NEURONTIN ORAL TABLET 800 MG Tier 3 PA; QL (120 EA per 30 days) ONFI ORAL SUSPENSION Tier 3 ONFI ORAL TABLET Tier 3 oxcarbazepine oral suspension Tier 1 oxcarbazepine oral tablet Tier 1

21 Drug Name Drug Tier Requirements/Limits OXTELLAR XR ORAL TABLET EXTENDED RELEASE Tier 2 24 HR PEGANONE ORAL TABLET 250 MG Tier 3 oral elixir Tier 1 phenobarbital oral tablet Tier 1 PHENYTEK ORAL CAPSULE Tier 3 oral suspension Tier 1 phenytoin oral tablet,chewable Tier 1 phenytoin sodium extended oral capsule Tier 1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, Tier 1 PA; QL (90 EA per 30 days) 25 mg, 50 mg, 75 mg pregabalin oral capsule 225 mg, 300 mg Tier 1 PA; QL (60 EA per 30 days) pregabalin oral solution Tier 1 PA; QL (900 ML per 30 days) pregabalin oral tablet extended release 24 hr 165 Tier 1 PA; QL (30 EA per 30 days) mg, 82.5 mg pregabalin oral tablet extended release 24 hr 330 Tier 1 PA; QL (60 EA per 30 days) mg oral tablet Tier 1 QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR Tier 2 roweepra oral tablet Tier 1 roweepra xr oral tablet extended release 24 hr Tier 1 rufinamide oral suspension Tier 1 SABRIL ORAL POWDER IN PACKET Tier 3 LD SABRIL ORAL TABLET Tier 3 LD SPRITAM ORAL TABLET FOR SUSPENSION Tier 3 subvenite oral tablet Tier 1 subvenite starter (blue) kit oral tablets,dose pack Tier 1 subvenite starter (green) kit oral tablets,dose Tier 1 pack subvenite starter (orange) kit oral tablets,dose Tier 1 pack TEGRETOL ORAL SUSPENSION Tier 3 TEGRETOL ORAL TABLET Tier 3 TEGRETOL XR ORAL TABLET EXTENDED RELEASE Tier 3 12 HR tiagabine oral tablet Tier 1

22 Drug Name Drug Tier Requirements/Limits TOPAMAX ORAL CAPSULE, SPRINKLE Tier 3 TOPAMAX ORAL TABLET Tier 3 topiramate oral capsule, sprinkle Tier 1 topiramate oral capsule,sprinkle,er 24hr Tier 1 topiramate oral tablet Tier 1 TRILEPTAL ORAL SUSPENSION Tier 3 TRILEPTAL ORAL TABLET Tier 3 TROKENDI XR ORAL CAPSULE,EXTENDED Tier 2 RELEASE 24HR valproic acid (as sodium salt) oral solution Tier 1 valproic acid oral capsule Tier 1 VALTOCO NASAL SPRAY,NON-AEROSOL Tier 3 vigabatrin oral powder in packet Tier 1 LD vigabatrin oral tablet Tier 1 LD vigadrone oral powder in packet Tier 1 VIMPAT ORAL SOLUTION Tier 2 VIMPAT ORAL TABLET Tier 2 ZARONTIN ORAL CAPSULE Tier 3 ZARONTIN ORAL SOLUTION Tier 3 ZONEGRAN ORAL CAPSULE Tier 3 zonisamide oral capsule Tier 1 Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 3 LD; SPRx AZILECT ORAL TABLET Tier 3 benztropine oral tablet Tier 1 bromocriptine oral capsule Tier 1 bromocriptine oral tablet Tier 1 carbidopa oral tablet Tier 1 carbidopa-levodopa oral tablet Tier 1 carbidopa-levodopa oral tablet extended release Tier 1 carbidopa-levodopa oral tablet,disintegrating Tier 1 carbidopa-levodopa-entacapone oral tablet Tier 1 COMTAN ORAL TABLET Tier 3 DUOPA J-TUBE INTESTINAL PUMP SUSPENSION Tier 3 SPRx ELDEPRYL ORAL CAPSULE Tier 3

23 Drug Name Drug Tier Requirements/Limits entacapone oral tablet Tier 1 LODOSYN ORAL TABLET Tier 3 MIRAPEX ER ORAL TABLET EXTENDED RELEASE Tier 3 24 HR MIRAPEX ORAL TABLET Tier 3 NEUPRO TRANSDERMAL PATCH 24 HOUR Tier 3 NOURIANZ ORAL TABLET Tier 3 LD; SPRx PARLODEL ORAL CAPSULE Tier 3 PARLODEL ORAL TABLET Tier 3 pramipexole oral tablet Tier 1 pramipexole oral tablet extended release 24 hr Tier 1 rasagiline oral tablet Tier 1 REQUIP ORAL TABLET Tier 3 REQUIP XL ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR ropinirole oral tablet Tier 1 ropinirole oral tablet extended release 24 hr Tier 1 selegiline hcl oral capsule Tier 1 selegiline hcl oral tablet Tier 1 SINEMET ORAL TABLET Tier 3 STALEVO 100 ORAL TABLET Tier 3 STALEVO 125 ORAL TABLET Tier 3 STALEVO 150 ORAL TABLET Tier 3 STALEVO 200 ORAL TABLET Tier 3 STALEVO 50 ORAL TABLET Tier 3 STALEVO 75 ORAL TABLET Tier 3 TASMAR ORAL TABLET Tier 3 tolcapone oral tablet Tier 1 trihexyphenidyl oral elixir Tier 1 trihexyphenidyl oral tablet Tier 1 ZELAPAR ORAL TABLET,DISINTEGRATING Tier 3 Migraine & Cluster Headache Therapy AIMOVIG AUTOINJECTOR SUBCUTANEOUS Tier 2 PA AUTO-INJECTOR AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 2 PA INJECTOR

24 Drug Name Drug Tier Requirements/Limits AJOVY SYRINGE SUBCUTANEOUS SYRINGE Tier 2 PA almotriptan malate oral tablet Tier 1 QL (18 EA per 30 days) ALSUMA SUBCUTANEOUS PEN INJECTOR Tier 3 QL (8 ML per 30 days) AMERGE ORAL TABLET Tier 3 QL (18 EA per 30 days) ascomp with codeine oral capsule Tier 1 PA; MME BUPAP ORAL TABLET Tier 3 QL (120 EA per 30 days) butalbital compound w/codeine oral capsule Tier 1 PA; MME butalbital-acetaminop-caf-cod oral capsule Tier 1 MME butalbital-acetaminophen oral tablet 50-300 mg, Tier 1 QL (120 EA per 30 days) 50-325 mg butalbital-acetaminophen-caff oral capsule Tier 1 QL (120 EA per 30 days) butalbital-acetaminophen-caff oral tablet Tier 1 QL (120 EA per 30 days) butalbital-aspirin-caffeine oral capsule Tier 1 QL (120 EA per 30 days) butalbital-aspirin-caffeine oral tablet Tier 1 QL (120 EA per 30 days) CAFERGOT ORAL TABLET Tier 3 codeine-butalbital-asa-caff oral capsule Tier 1 PA; MME D.H.E.45 INJECTION SOLUTION Tier 3 dihydroergotamine injection solution Tier 1 dihydroergotamine nasal spray,non-aerosol Tier 1 QL (8 ML per 30 days) eletriptan oral tablet Tier 1 QL (18 EA per 30 days) EMGALITY PEN SUBCUTANEOUS PEN INJECTOR Tier 2 PA EMGALITY SYRINGE SUBCUTANEOUS SYRINGE Tier 2 PA ERGOMAR SUBLINGUAL TABLET Tier 3 ergotamine-caffeine oral tablet Tier 1 ESGIC ORAL CAPSULE Tier 3 QL (120 EA per 30 days) ESGIC ORAL TABLET Tier 3 QL (120 EA per 30 days) FIORICET ORAL CAPSULE Tier 3 QL (120 EA per 30 days) FIORINAL ORAL CAPSULE 50-325-40 MG Tier 3 QL (120 EA per 30 days) FIORINAL-CODEINE #3 ORAL CAPSULE 30-50- Tier 3 PA; MME 325-40 MG frovatriptan oral tablet Tier 1 QL (18 EA per 30 days) IMITREX NASAL SPRAY,NON-AEROSOL Tier 3 QL (12 EA per 30 days) IMITREX ORAL TABLET Tier 3 QL (18 EA per 30 days) IMITREX STATDOSE PEN SUBCUTANEOUS PEN Tier 3 QL (12 ML per 30 days) INJECTOR 4 MG/0.5 ML

25 Drug Name Drug Tier Requirements/Limits IMITREX STATDOSE PEN SUBCUTANEOUS PEN Tier 3 QL (8 ML per 30 days) INJECTOR 6 MG/0.5 ML IMITREX STATDOSE REFILL SUBCUTANEOUS Tier 3 QL (12 ML per 30 days) CARTRIDGE 4 MG/0.5 ML IMITREX STATDOSE REFILL SUBCUTANEOUS Tier 3 QL (8 ML per 30 days) CARTRIDGE 6 MG/0.5 ML IMITREX SUBCUTANEOUS SOLUTION Tier 3 QL (8 ML per 30 days) isometh-dichloral-acetaminophn oral capsule Tier 1 MAXALT ORAL TABLET Tier 3 QL (18 EA per 30 days) migergot rectal suppository Tier 1 MIGRANAL NASAL SPRAY,NON-AEROSOL Tier 3 QL (8 ML per 30 days) naratriptan oral tablet Tier 1 QL (18 EA per 30 days) NURTEC ODT ORAL TABLET,DISINTEGRATING Tier 2 PA; QL (16 EA per 30 days) RELPAX ORAL TABLET Tier 3 QL (18 EA per 30 days) rizatriptan oral tablet Tier 1 QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol Tier 1 QL (12 EA per 30 days) sumatriptan succinate oral tablet Tier 1 QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 Tier 1 QL (12 ML per 30 days) mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 Tier 1 QL (8 ML per 30 days) mg/0.5 ml sumatriptan succinate subcutaneous pen injector Tier 1 QL (12 ML per 30 days) 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector Tier 1 QL (8 ML per 30 days) 6 mg/0.5 ml sumatriptan succinate subcutaneous solution Tier 1 QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe Tier 1 QL (8 ML per 30 days) tencon oral tablet Tier 1 QL (120 EA per 30 days) zebutal oral capsule Tier 1 QL (120 EA per 30 days) oral tablet Tier 1 QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days) ZOMIG NASAL SPRAY,NON-AEROSOL Tier 3 QL (12 EA per 30 days) Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 Tier 2 PA; LD; SPRx HR ARICEPT ORAL TABLET Tier 3

26 Drug Name Drug Tier Requirements/Limits AUSTEDO ORAL TABLET Tier 3 PA; LD; SPRx dalfampridine oral tablet extended release 12 hr Tier 1 PA; SPRx donepezil oral tablet Tier 1 donepezil oral tablet,disintegrating Tier 1 EVRYSDI ORAL RECON SOLN Tier 3 PA; SPRx FIRDAPSE ORAL TABLET Tier 3 PA; LD; SPRx galantamine oral capsule,ext rel. pellets 24 hr Tier 1 galantamine oral solution Tier 1 galantamine oral tablet Tier 1 HORIZANT ORAL TABLET EXTENDED RELEASE Tier 3 INGREZZA INITIATION PACK ORAL Tier 3 PA; SPRx CAPSULE,DOSE PACK 40 MG (7)- 80 MG (21) INGREZZA INITIATION PACK ORAL Tier 3 PA; LD; SPRx CAPSULE,DOSE PACK 40 MG (7)- 80 MG (21) INGREZZA ORAL CAPSULE Tier 3 PA; LD; SPRx KEVEYIS ORAL TABLET Tier 3 PA; SPRx memantine oral capsule,sprinkle,er 24hr Tier 1 memantine oral solution Tier 1 memantine oral tablet Tier 1 MEMANTINE ORAL TABLETS,DOSE PACK Tier 3 NAMENDA ORAL TABLET Tier 3 NAMENDA TITRATION PAK ORAL TABLETS,DOSE Tier 3 PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR Tier 2 DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER Tier 2 24HR NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE Tier 2 PACK NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR Tier 2 NUEDEXTA ORAL CAPSULE Tier 3 RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS Tier 3 24 HR rivastigmine tartrate oral capsule Tier 1 rivastigmine transdermal patch 24 hour Tier 1 RUZURGI ORAL TABLET Tier 3 PA; SPRx

27 Drug Name Drug Tier Requirements/Limits TEGSEDI SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx tetrabenazine oral tablet Tier 1 PA; SPRx XENAZINE ORAL TABLET Tier 3 PA; LD; SPRx Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet 10 mg, 20 mg Tier 1 carisoprodol oral tablet Tier 1 QL (120 EA per 30 days) carisoprodol-aspirin oral tablet Tier 1 QL (240 EA per 30 days) carisoprodol-aspirin-codeine oral tablet Tier 1 PA; MME chlorzoxazone oral tablet 500 mg Tier 1 QL (180 EA per 30 days) cyclobenzaprine oral tablet Tier 1 QL (90 EA per 30 days) DANTRIUM ORAL CAPSULE Tier 3 dantrolene oral capsule Tier 1 FEXMID ORAL TABLET Tier 3 QL (90 EA per 30 days) meprobamate oral tablet 200 mg Tier 1 QL (360 EA per 30 days) meprobamate oral tablet 400 mg Tier 1 QL (180 EA per 30 days) MESTINON ORAL SYRUP Tier 3 MESTINON ORAL TABLET Tier 3 MESTINON TIMESPAN ORAL TABLET EXTENDED Tier 3 RELEASE metaxalone oral tablet 800 mg Tier 1 QL (90 EA per 30 days) methocarbamol oral tablet 500 mg Tier 1 QL (240 EA per 30 days) methocarbamol oral tablet 750 mg Tier 1 QL (160 EA per 30 days) orphenadrine citrate oral tablet extended release Tier 1 QL (60 EA per 30 days) pyridostigmine bromide oral syrup Tier 1 pyridostigmine bromide oral tablet 60 mg Tier 1 pyridostigmine bromide oral tablet extended Tier 1 release ROBAXIN-750 ORAL TABLET 750 MG Tier 3 QL (160 EA per 30 days) SKELAXIN ORAL TABLET Tier 3 QL (90 EA per 30 days) SOMA ORAL TABLET Tier 3 QL (120 EA per 30 days) tizanidine oral capsule Tier 1 tizanidine oral tablet Tier 1 ZANAFLEX ORAL CAPSULE Tier 3 ZANAFLEX ORAL TABLET Tier 3 Narcotic Analgesics

28 Drug Name Drug Tier Requirements/Limits acetaminophen-caff-dihydrocod oral capsule Tier 1 PA; MME acetaminophen-codeine oral solution 120-12 Tier 1 PA; MME mg/5 ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet Tier 1 PA; MME ACTIQ BUCCAL LOZENGE ON A HANDLE Tier 3 PA; MME BELBUCA BUCCAL FILM Tier 2 PA; QL (60 EA per 30 days) buprenorphine transdermal patch weekly Tier 1 PA; QL (4 EA per 28 days) butorphanol nasal spray,non-aerosol Tier 1 PA; MME BUTRANS TRANSDERMAL PATCH WEEKLY Tier 3 PA; QL (4 EA per 28 days) codeine sulfate oral tablet Tier 1 PA; MME DEMEROL ORAL TABLET Tier 3 PA; MME DILAUDID ORAL LIQUID Tier 3 PA; MME DILAUDID ORAL TABLET Tier 3 PA; MME diskets oral tablet,soluble Tier 1 PA; MME DOLOPHINE ORAL TABLET 10 MG, 5 MG Tier 3 PA; MME DURAGESIC TRANSDERMAL PATCH 72 HOUR Tier 3 PA; MME endocet oral tablet Tier 1 PA; MME citrate buccal lozenge on a handle Tier 1 PA; MME fentanyl transdermal patch 72 hour Tier 1 PA; MME FENTORA BUCCAL TABLET, EFFERVESCENT Tier 3 PA; MME hydrocodone-acetaminophen oral solution Tier 1 PA; MME hydrocodone-acetaminophen oral tablet Tier 1 PA; MME hydrocodone-ibuprofen oral tablet Tier 1 PA; MME hydromorphone oral liquid Tier 1 PA; MME hydromorphone oral tablet Tier 1 PA; MME hydromorphone rectal suppository Tier 1 PA; MME IBUDONE ORAL TABLET 10-200 MG Tier 3 PA; MME ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 PA; MME KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 Tier 3 PA; MME MG, 40 MG, 50 MG, 60 MG, 80 MG levorphanol tartrate oral tablet 2 mg Tier 1 PA; MME lorcet hd oral tablet 10-325 mg Tier 1 PA; MME LORTAB ELIXIR ORAL SOLUTION Tier 3 PA; MME meperidine oral solution Tier 1 PA; MME

29 Drug Name Drug Tier Requirements/Limits meperidine oral tablet Tier 1 PA; MME methadone intensol oral concentrate Tier 1 PA; MME methadone oral concentrate Tier 1 PA; MME methadone oral solution Tier 1 PA; MME methadone oral tablet Tier 1 PA; MME methadone oral tablet,soluble Tier 1 PA; MME methadose oral concentrate Tier 1 PA; MME methadose oral tablet,soluble Tier 1 PA; MME morphine concentrate oral solution Tier 1 PA; MME morphine oral capsule, er multiphase 24 hr Tier 1 PA; MME morphine oral capsule,extend.release pellets Tier 1 PA; MME morphine oral solution Tier 1 PA; MME morphine oral tablet Tier 1 PA; MME morphine oral tablet extended release Tier 1 PA; MME morphine rectal suppository Tier 1 PA; MME MS CONTIN ORAL TABLET EXTENDED RELEASE Tier 3 PA; MME NORCO ORAL TABLET 10-325 MG, 5-325 MG, Tier 3 PA; MME 7.5-325 MG NUCYNTA ER ORAL TABLET EXTENDED RELEASE Tier 2 PA; MME 12 HR NUCYNTA ORAL TABLET Tier 2 PA; MME oxycodone oral capsule Tier 1 PA; MME oxycodone oral concentrate Tier 1 PA; MME oxycodone oral solution Tier 1 PA; MME oxycodone oral tablet Tier 1 PA; MME oxycodone-acetaminophen oral tablet 10-325 Tier 1 PA; MME mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet Tier 1 PA; MME oxymorphone oral tablet Tier 1 PA; MME oxymorphone oral tablet extended release 12 hr Tier 1 PA; MME pentazocine-naloxone oral tablet Tier 1 PA; MME PERCOCET ORAL TABLET Tier 3 PA; MME PRIMLEV ORAL TABLET Tier 3 PA; MME ROXICODONE ORAL TABLET Tier 3 PA; MME tramadol oral tablet 50 mg Tier 1 PA; MME

30 Drug Name Drug Tier Requirements/Limits tramadol oral tablet extended release 24 hr Tier 1 PA; MME tramadol oral tablet, er multiphase 24 hr Tier 1 PA; MME tramadol-acetaminophen oral tablet Tier 1 PA; MME TREZIX ORAL CAPSULE Tier 3 PA; MME ULTRACET ORAL TABLET Tier 3 PA; MME ULTRAM ER ORAL TABLET EXTENDED RELEASE Tier 3 PA; MME 24 HR ULTRAM ORAL TABLET Tier 3 PA; MME verdrocet oral tablet Tier 1 PA; MME vicodin hp oral tablet Tier 1 PA; MME XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 2 PA; MME CRUSH) xylon 10 oral tablet Tier 1 PA; MME Non-Narcotic Analgesics ANAPROX DS ORAL TABLET Tier 3 ARTHROTEC 50 ORAL TABLET,IR,DELAYED Tier 3 REL,BIPHASIC ARTHROTEC 75 ORAL TABLET,IR,DELAYED Tier 3 REL,BIPHASIC aspirin oral tablet Tier 1 ACA aspirin oral tablet,chewable Tier 1 ACA aspirin oral tablet,delayed release (dr/ec) 325 Tier 1 ACA mg, 81 mg CELEBREX ORAL CAPSULE Tier 3 celecoxib oral capsule Tier 1 choline,magnesium salicylate oral liquid Tier 1 DAYPRO ORAL TABLET Tier 3 diclofenac potassium oral tablet Tier 1 diclofenac sodium oral tablet extended release 24 Tier 1 hr diclofenac sodium oral tablet,delayed release Tier 1 (dr/ec) diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days) diclofenac-misoprostol oral tablet,ir,delayed Tier 1 rel,biphasic diflunisal oral tablet Tier 1 DISALCID ORAL TABLET Tier 3

31 Drug Name Drug Tier Requirements/Limits EC-NAPROSYN ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) etodolac oral capsule Tier 1 etodolac oral tablet Tier 1 etodolac oral tablet extended release 24 hr Tier 1 FELDENE ORAL CAPSULE Tier 3 fenoprofen oral tablet Tier 1 flurbiprofen oral tablet Tier 1 ibu oral tablet Tier 1 ibuprofen oral suspension Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 INDOCIN ORAL SUSPENSION Tier 3 INDOCIN RECTAL SUPPOSITORY Tier 3 indomethacin oral capsule Tier 1 indomethacin oral capsule, extended release Tier 1 ketoprofen oral capsule Tier 1 ketoprofen oral capsule,ext rel. pellets 24 hr Tier 1 KETOROLAC NASAL SPRAY,NON-AEROSOL Tier 3 SPRx ketorolac oral tablet Tier 1 LODINE ORAL TABLET Tier 3 LUCEMYRA ORAL TABLET Tier 3 meclofenamate oral capsule Tier 1 mefenamic acid oral capsule Tier 1 meloxicam oral suspension Tier 1 meloxicam oral tablet Tier 1 MOBIC ORAL TABLET Tier 3 nabumetone oral tablet Tier 1 NALFON ORAL CAPSULE Tier 3 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 Tier 3 HR 375 MG, 500 MG NAPRELAN ORAL TABLET EXTENDED RELEASE Tier 3 NAPROSYN ORAL SUSPENSION Tier 3 NAPROSYN ORAL TABLET Tier 3 naproxen oral suspension Tier 1 naproxen oral tablet Tier 1

32 Drug Name Drug Tier Requirements/Limits naproxen oral tablet,delayed release (dr/ec) Tier 1 naproxen sodium oral tablet 275 mg, 550 mg Tier 1 oxaprozin oral tablet Tier 1 piroxicam oral capsule Tier 1 REVIA ORAL TABLET Tier 3 salsalate oral tablet Tier 1 SPRIX NASAL SPRAY,NON-AEROSOL Tier 3 SPRx sulindac oral tablet Tier 1 tolmetin oral capsule Tier 1 tolmetin oral tablet Tier 1 tri-buffered aspirin oral tablet Tier 1 ACA VOLTAREN-XR ORAL TABLET EXTENDED RELEASE Tier 3 24 HR 100 MG Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution Tier 1 QL (2 units per 1 claim) naloxone injection syringe Tier 1 QL (2 units per 1 claim) naltrexone oral tablet Tier 1 NARCAN NASAL SPRAY,NON-AEROSOL Tier 3 QL (2 units per 1 claim) Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR Tier 2 SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR Tier 2 SUSPENSION,EXTENDED REL SYRING ABILIFY MYCITE ORAL TABLET WITH SENSOR Tier 3 PA; AGE-A AND PATCH ABILIFY MYCITE STARTER KIT ORAL TABLET Tier 3 PA; AGE-A WITH SENSOR, STRIP, POD ABILIFY ORAL TABLET Tier 3 PA; AGE-A ADDERALL ORAL TABLET Tier 3 alprazolam intensol oral concentrate Tier 1 QL (90 ML per 30 days) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg Tier 1 QL (90 EA per 30 days) alprazolam oral tablet 2 mg Tier 1 QL (150 EA per 30 days) alprazolam oral tablet extended release 24 hr Tier 1 QL (60 EA per 30 days) alprazolam oral tablet,disintegrating 0.25 mg, Tier 1 QL (90 EA per 30 days) 0.5 mg, 1 mg

33 Drug Name Drug Tier Requirements/Limits alprazolam oral tablet,disintegrating 2 mg Tier 1 QL (150 EA per 30 days) AMBIEN CR ORAL TABLET,EXT RELEASE Tier 3 MULTIPHASE AMBIEN ORAL TABLET Tier 3 amitriptyline oral tablet Tier 1 amitriptyline-chlordiazepoxide oral tablet Tier 1 amoxapine oral tablet Tier 1 ANAFRANIL ORAL CAPSULE Tier 3 aripiprazole oral solution Tier 1 PA; AGE-A aripiprazole oral tablet Tier 1 PA; AGE-A aripiprazole oral tablet,disintegrating Tier 1 PA; AGE-A ARISTADA INITIO INTRAMUSCULAR Tier 2 SUSPENSION,EXTENDED REL SYRING ARISTADA INTRAMUSCULAR Tier 2 SUSPENSION,EXTENDED REL SYRING armodafinil oral tablet Tier 1 PA asenapine maleate sublingual tablet Tier 1 PA; AGE-A ATIVAN ORAL TABLET 0.5 MG, 1 MG Tier 3 QL (90 EA per 30 days) ATIVAN ORAL TABLET 2 MG Tier 3 QL (150 EA per 30 days) atomoxetine oral capsule Tier 1 bupropion hcl oral tablet Tier 1 bupropion hcl oral tablet extended release 24 hr Tier 1 150 mg, 300 mg bupropion hcl oral tablet sustained-release 12 hr Tier 1 buspirone oral tablet Tier 1 CELEXA ORAL TABLET Tier 3 chlordiazepoxide hcl oral capsule Tier 1 QL (120 EA per 30 days) oral tablet Tier 1 citalopram oral solution Tier 1 citalopram oral tablet Tier 1 clomipramine oral capsule Tier 1 clonidine hcl oral tablet extended release 12 hr Tier 1 clorazepate dipotassium oral tablet 15 mg Tier 1 QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75 mg, 7.5 Tier 1 QL (90 EA per 30 days) mg clozapine oral tablet Tier 1 PA; AGE-A

34 Drug Name Drug Tier Requirements/Limits clozapine oral tablet,disintegrating Tier 1 PA; AGE-A CLOZARIL ORAL TABLET Tier 3 PA; AGE-A CYMBALTA ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) DAYTRANA TRANSDERMAL PATCH 24 HOUR Tier 2 desipramine oral tablet Tier 1 desvenlafaxine succinate oral tablet extended Tier 1 release 24 hr DEXEDRINE SPANSULE ORAL CAPSULE, Tier 3 EXTENDED RELEASE 15 MG dexmethylphenidate oral capsule,er biphasic 50- Tier 1 50 dexmethylphenidate oral tablet Tier 1 dextroamphetamine oral capsule, extended Tier 1 release dextroamphetamine oral solution Tier 1 dextroamphetamine oral tablet Tier 1 dextroamphetamine-amphetamine oral Tier 1 capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet Tier 1 diazepam intensol oral concentrate Tier 1 QL (120 ML per 30 days) diazepam oral concentrate Tier 1 QL (120 ML per 30 days) diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) Tier 1 QL (600 ML per 30 days) diazepam oral tablet Tier 1 QL (120 EA per 30 days) DORAL ORAL TABLET Tier 3 QL (30 EA per 30 days) doxepin oral capsule Tier 1 doxepin oral concentrate Tier 1 duloxetine oral capsule,delayed release(dr/ec) Tier 1 EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE Tier 3 24HR EMSAM TRANSDERMAL PATCH 24 HOUR Tier 3 ergoloid oral tablet Tier 1 escitalopram oxalate oral solution Tier 1 escitalopram oxalate oral tablet Tier 1 estazolam oral tablet 1 mg Tier 1 QL (60 EA per 30 days)

35 Drug Name Drug Tier Requirements/Limits estazolam oral tablet 2 mg Tier 1 QL (30 EA per 30 days) eszopiclone oral tablet Tier 1 FANAPT ORAL TABLET Tier 3 PA; AGE-A FANAPT ORAL TABLETS,DOSE PACK Tier 3 PA; AGE-A fluoxetine oral capsule Tier 1 fluoxetine oral capsule,delayed release(dr/ec) Tier 1 fluoxetine oral solution Tier 1 fluoxetine oral tablet Tier 1 fluphenazine hcl oral concentrate Tier 1 fluphenazine hcl oral elixir Tier 1 fluphenazine hcl oral tablet Tier 1 flurazepam oral capsule Tier 1 QL (30 EA per 30 days) fluvoxamine oral capsule,extended release 24hr Tier 1 fluvoxamine oral tablet Tier 1 GEODON ORAL CAPSULE Tier 3 PA; AGE-A guanfacine oral tablet extended release 24 hr Tier 1 guanidine oral tablet Tier 1 HALCION ORAL TABLET Tier 3 QL (60 EA per 30 days) haloperidol lactate oral concentrate Tier 1 haloperidol oral tablet Tier 1 imipramine hcl oral tablet Tier 1 imipramine pamoate oral capsule Tier 1 INTUNIV ER ORAL TABLET EXTENDED RELEASE Tier 3 24 HR INVEGA ORAL TABLET EXTENDED RELEASE 24HR Tier 3 PA; AGE-A INVEGA SUSTENNA INTRAMUSCULAR SYRINGE Tier 3 INVEGA TRINZA INTRAMUSCULAR SYRINGE Tier 3 KAPVAY ORAL TABLET EXTENDED RELEASE 12 Tier 3 HR LATUDA ORAL TABLET Tier 2 PA; AGE-A LEXAPRO ORAL TABLET Tier 3 lithium carbonate oral capsule Tier 1 lithium carbonate oral tablet Tier 1 lithium carbonate oral tablet extended release Tier 1 lithium citrate oral solution Tier 1

36 Drug Name Drug Tier Requirements/Limits LITHOBID ORAL TABLET EXTENDED RELEASE Tier 3 lorazepam intensol oral concentrate Tier 1 QL (150 ML per 30 days) lorazepam oral concentrate Tier 1 QL (150 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg Tier 1 QL (90 EA per 30 days) lorazepam oral tablet 2 mg Tier 1 QL (150 EA per 30 days) loxapine succinate oral capsule Tier 1 LUNESTA ORAL TABLET Tier 3 maprotiline oral tablet Tier 1 MARPLAN ORAL TABLET Tier 3 metadate er oral tablet extended release Tier 1 methamphetamine oral tablet Tier 1 METHYLIN ORAL SOLUTION Tier 3 methylphenidate hcl oral capsule, er biphasic 30- Tier 1 70 methylphenidate hcl oral capsule,er biphasic 50- Tier 1 50 methylphenidate hcl oral solution Tier 1 methylphenidate hcl oral tablet Tier 1 methylphenidate hcl oral tablet extended release Tier 1 methylphenidate hcl oral tablet extended release Tier 1 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable Tier 1 midazolam oral syrup 2 mg/ml Tier 1 mirtazapine oral tablet Tier 1 mirtazapine oral tablet,disintegrating Tier 1 modafinil oral tablet Tier 1 PA MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR Tier 2 NARDIL ORAL TABLET Tier 3 oral tablet Tier 1 NORPRAMIN ORAL TABLET Tier 3 nortriptyline oral capsule Tier 1 nortriptyline oral solution Tier 1 NUPLAZID ORAL CAPSULE Tier 3 PA; SPRx NUPLAZID ORAL TABLET Tier 3 PA; SPRx NUVIGIL ORAL TABLET Tier 3 PA

37 Drug Name Drug Tier Requirements/Limits olanzapine oral tablet Tier 1 PA; AGE-A olanzapine oral tablet,disintegrating Tier 1 PA; AGE-A olanzapine-fluoxetine oral capsule Tier 1 PA; AGE-A oxazepam oral capsule Tier 1 QL (120 EA per 30 days) paliperidone oral tablet extended release 24hr Tier 1 PA; AGE-A PAMELOR ORAL CAPSULE Tier 3 PARNATE ORAL TABLET Tier 3 paroxetine hcl oral tablet Tier 1 paroxetine hcl oral tablet extended release 24 hr Tier 1 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR PAXIL ORAL SUSPENSION Tier 3 PAXIL ORAL TABLET Tier 3 perphenazine oral tablet Tier 1 perphenazine-amitriptyline oral tablet Tier 1 PERSERIS ABDOMINAL SUBCUTANEOUS Tier 2 SUSPENSION,EXTENDED REL SYRING PEXEVA ORAL TABLET Tier 3 phenelzine oral tablet Tier 1 pimozide oral tablet Tier 1 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 procentra oral solution Tier 1 protriptyline oral tablet Tier 1 PROVIGIL ORAL TABLET Tier 3 PA PROZAC ORAL CAPSULE Tier 3 quazepam oral tablet Tier 1 QL (30 EA per 30 days) quetiapine oral tablet Tier 1 PA; AGE-A quetiapine oral tablet extended release 24 hr Tier 1 PA; AGE-A QUILLICHEW ER ORAL TABLET,CHEW,IR- Tier 2 ER.BIPHASIC24HR QUILLIVANT XR ORAL SUSPENSION,EXT REL Tier 2 24HR,RECON ramelteon oral tablet Tier 1 REMERON ORAL TABLET Tier 3 REMERON SOLTAB ORAL Tier 3 TABLET,DISINTEGRATING

38 Drug Name Drug Tier Requirements/Limits RESTORIL ORAL CAPSULE 15 MG Tier 3 QL (60 EA per 30 days) RESTORIL ORAL CAPSULE 22.5 MG, 30 MG Tier 3 QL (30 EA per 30 days) RESTORIL ORAL CAPSULE 7.5 MG Tier 3 QL (120 EA per 30 days) REXULTI ORAL TABLET Tier 3 PA; AGE-A RISPERDAL CONSTA INTRAMUSCULAR Tier 3 SUSPENSION,EXTENDED REL RECON RISPERDAL ORAL SOLUTION Tier 3 PA; AGE-A RISPERDAL ORAL TABLET Tier 3 PA; AGE-A risperidone oral solution Tier 1 PA; AGE-A risperidone oral tablet Tier 1 PA; AGE-A risperidone oral tablet,disintegrating Tier 1 PA; AGE-A RITALIN ORAL TABLET Tier 3 ROZEREM ORAL TABLET Tier 3 SAPHRIS SUBLINGUAL TABLET Tier 3 PA; AGE-A SARAFEM ORAL TABLET 10 MG, 20 MG Tier 3 seconal sodium oral capsule Tier 1 SECUADO TRANSDERMAL PATCH 24 HOUR Tier 3 PA; AGE-A SEROQUEL ORAL TABLET Tier 3 PA; AGE-A SEROQUEL XR ORAL TABLET EXTENDED RELEASE Tier 3 PA; AGE-A 24 HR sertraline oral concentrate Tier 1 sertraline oral tablet Tier 1 STRATTERA ORAL CAPSULE Tier 3 SYMBYAX ORAL CAPSULE Tier 3 PA; AGE-A temazepam oral capsule 15 mg Tier 1 QL (60 EA per 30 days) temazepam oral capsule 22.5 mg, 30 mg Tier 1 QL (30 EA per 30 days) temazepam oral capsule 7.5 mg Tier 1 QL (120 EA per 30 days) thioridazine oral tablet Tier 1 thiothixene oral capsule Tier 1 tranylcypromine oral tablet Tier 1 trazodone oral tablet Tier 1 triazolam oral tablet 0.125 mg Tier 1 QL (120 EA per 30 days) triazolam oral tablet 0.25 mg Tier 1 QL (60 EA per 30 days) trifluoperazine oral tablet Tier 1 trimipramine oral capsule Tier 1

39 Drug Name Drug Tier Requirements/Limits TRINTELLIX ORAL TABLET Tier 3 VALIUM ORAL TABLET Tier 3 QL (120 EA per 30 days) venlafaxine oral capsule,extended release 24hr Tier 1 venlafaxine oral tablet Tier 1 venlafaxine oral tablet extended release 24hr Tier 1 VIIBRYD ORAL TABLET Tier 2 VIIBRYD ORAL TABLETS,DOSE PACK Tier 2 VRAYLAR ORAL CAPSULE Tier 3 PA; AGE-A VRAYLAR ORAL CAPSULE,DOSE PACK Tier 3 PA; AGE-A VYVANSE ORAL CAPSULE Tier 2 VYVANSE ORAL TABLET,CHEWABLE Tier 2 WELLBUTRIN SR ORAL TABLET SUSTAINED- Tier 3 RELEASE 12 HR WELLBUTRIN XL ORAL TABLET EXTENDED Tier 3 RELEASE 24 HR XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG Tier 3 QL (90 EA per 30 days) XANAX ORAL TABLET 2 MG Tier 3 QL (150 EA per 30 days) XANAX XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 QL (60 EA per 30 days) HR zaleplon oral capsule Tier 1 zenzedi oral tablet 10 mg, 5 mg Tier 1 ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, Tier 3 30 MG, 7.5 MG ziprasidone hcl oral capsule Tier 1 PA; AGE-A ZOLOFT ORAL CONCENTRATE Tier 3 ZOLOFT ORAL TABLET Tier 3 zolpidem oral tablet Tier 1 zolpidem oral tablet,ext release multiphase Tier 1 ZYPREXA ORAL TABLET Tier 3 PA; AGE-A ZYPREXA RELPREVV INTRAMUSCULAR Tier 3 SUSPENSION FOR RECONSTITUTION ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING Tier 3 PA; AGE-A Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents oral tablet Tier 1 BETAPACE AF ORAL TABLET Tier 3

40 Drug Name Drug Tier Requirements/Limits BETAPACE ORAL TABLET Tier 3 disopyramide phosphate oral capsule Tier 1 dofetilide oral capsule Tier 1 flecainide oral tablet Tier 1 mexiletine oral capsule Tier 1 MULTAQ ORAL TABLET Tier 3 NORPACE CR ORAL CAPSULE, EXTENDED Tier 3 RELEASE NORPACE ORAL CAPSULE Tier 3 pacerone oral tablet Tier 1 propafenone oral capsule,extended release 12 hr Tier 1 propafenone oral tablet Tier 1 quinidine gluconate oral tablet extended release Tier 1 quinidine sulfate oral tablet Tier 1 RYTHMOL SR ORAL CAPSULE,EXTENDED Tier 3 RELEASE 12 HR sorine oral tablet Tier 1 sotalol af oral tablet Tier 1 sotalol oral tablet Tier 1 SOTYLIZE ORAL SOLUTION Tier 3 TIKOSYN ORAL CAPSULE Tier 3 Antihypertensive Therapy ACCUPRIL ORAL TABLET Tier 3 ACCURETIC ORAL TABLET Tier 3 acebutolol oral capsule Tier 1 ADALAT CC ORAL TABLET EXTENDED RELEASE Tier 3 ALDACTAZIDE ORAL TABLET Tier 3 ALDACTONE ORAL TABLET Tier 3 aliskiren oral tablet Tier 1 ALTACE ORAL CAPSULE Tier 3 amiloride oral tablet Tier 1 amiloride-hydrochlorothiazide oral tablet Tier 1 oral tablet Tier 1 amlodipine-benazepril oral capsule Tier 1 amlodipine-olmesartan oral tablet Tier 1

41 Drug Name Drug Tier Requirements/Limits amlodipine-valsartan oral tablet Tier 1 amlodipine-valsartan-hcthiazid oral tablet Tier 1 ATACAND HCT ORAL TABLET Tier 3 ATACAND ORAL TABLET Tier 3 oral tablet Tier 1 atenolol-chlorthalidone oral tablet Tier 1 AVALIDE ORAL TABLET Tier 3 AVAPRO ORAL TABLET Tier 3 AZOR ORAL TABLET Tier 3 benazepril oral tablet Tier 1 benazepril-hydrochlorothiazide oral tablet Tier 1 BENICAR HCT ORAL TABLET Tier 3 BENICAR ORAL TABLET Tier 3 betaxolol oral tablet Tier 1 BIDIL ORAL TABLET Tier 3 bisoprolol fumarate oral tablet Tier 1 bisoprolol-hydrochlorothiazide oral tablet Tier 1 bumetanide oral tablet Tier 1 BYSTOLIC ORAL TABLET Tier 2 CALAN SR ORAL TABLET EXTENDED RELEASE Tier 3 candesartan oral tablet Tier 1 candesartan-hydrochlorothiazid oral tablet Tier 1 oral tablet Tier 1 captopril-hydrochlorothiazide oral tablet Tier 1 CARDIZEM CD ORAL CAPSULE,EXTENDED Tier 3 RELEASE 24HR CARDIZEM LA ORAL TABLET EXTENDED RELEASE Tier 3 24 HR CARDIZEM ORAL TABLET Tier 3 CARDURA ORAL TABLET Tier 3 CARDURA XL ORAL TABLET EXTENDED RELEASE Tier 3 24HR cartia xt oral capsule,extended release 24hr Tier 1 oral tablet Tier 1 carvedilol phosphate oral capsule, er multiphase Tier 1 24 hr

42 Drug Name Drug Tier Requirements/Limits CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 Tier 3 MG CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY Tier 3 CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY Tier 3 CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY Tier 3 chlorothiazide oral tablet Tier 1 chlorthalidone oral tablet Tier 1 clonidine hcl oral tablet Tier 1 clonidine transdermal patch weekly Tier 1 clorpres oral tablet 0.1-15 mg, 0.2-15 mg Tier 1 CLORPRES ORAL TABLET 0.3-15 MG Tier 3 COREG CR ORAL CAPSULE, ER MULTIPHASE 24 Tier 2 HR COREG ORAL TABLET Tier 3 CORGARD ORAL TABLET Tier 3 COZAAR ORAL TABLET Tier 3 DIBENZYLINE ORAL CAPSULE Tier 3 diltiazem hcl oral capsule,ext.rel 24h degradable Tier 1 diltiazem hcl oral capsule,extended release 12 hr Tier 1 diltiazem hcl oral capsule,extended release 24 hr Tier 1 diltiazem hcl oral capsule,extended release 24hr Tier 1 diltiazem hcl oral tablet Tier 1 diltiazem hcl oral tablet extended release 24 hr Tier 1 dilt-xr oral capsule,ext.rel 24h degradable Tier 1 DIOVAN HCT ORAL TABLET Tier 3 DIOVAN ORAL TABLET Tier 3 DIURIL ORAL SUSPENSION Tier 3 doxazosin oral tablet Tier 1 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR DYAZIDE ORAL CAPSULE 37.5-25 MG Tier 3 DYRENIUM ORAL CAPSULE Tier 3 EDARBI ORAL TABLET Tier 3 ST EDARBYCLOR ORAL TABLET Tier 3 ST EDECRIN ORAL TABLET Tier 3

43 Drug Name Drug Tier Requirements/Limits enalapril maleate oral tablet Tier 1 enalapril-hydrochlorothiazide oral tablet Tier 1 EPANED ORAL SOLUTION Tier 3 eplerenone oral tablet Tier 1 epoprostenol (glycine) intravenous recon soln Tier 1 PA; SPRx epoprostenol intravenous recon soln Tier 1 PA; SPRx eprosartan oral tablet Tier 1 ethacrynic acid oral tablet Tier 1 EXFORGE HCT ORAL TABLET Tier 3 EXFORGE ORAL TABLET Tier 3 oral tablet extended release 24 hr Tier 1 FLOLAN INTRAVENOUS RECON SOLN Tier 3 PA; SPRx oral tablet Tier 1 fosinopril-hydrochlorothiazide oral tablet Tier 1 furosemide oral solution Tier 1 furosemide oral tablet Tier 1 guanfacine oral tablet Tier 1 hydralazine oral tablet Tier 1 hydrochlorothiazide oral capsule Tier 1 hydrochlorothiazide oral tablet Tier 1 HYZAAR ORAL TABLET Tier 3 indapamide oral tablet Tier 1 INDERAL LA ORAL CAPSULE,EXTENDED RELEASE Tier 3 24 HR INDERAL XL ORAL CAPSULE,EXTENDED RELEASE Tier 3 24HR INSPRA ORAL TABLET Tier 3 irbesartan oral tablet Tier 1 irbesartan-hydrochlorothiazide oral tablet Tier 1 isradipine oral capsule Tier 1 labetalol oral tablet Tier 1 LASIX ORAL TABLET Tier 3 LEVATOL ORAL TABLET Tier 3 lisinopril oral tablet Tier 1 lisinopril-hydrochlorothiazide oral tablet Tier 1

44 Drug Name Drug Tier Requirements/Limits LOPRESSOR HCT ORAL TABLET Tier 3 LOPRESSOR ORAL TABLET Tier 3 losartan oral tablet Tier 1 losartan-hydrochlorothiazide oral tablet Tier 1 LOTENSIN HCT ORAL TABLET Tier 3 LOTENSIN ORAL TABLET Tier 3 LOTREL ORAL CAPSULE Tier 3 matzim la oral tablet extended release 24 hr Tier 1 MAXZIDE ORAL TABLET Tier 3 MAXZIDE-25MG ORAL TABLET Tier 3 methyldopa oral tablet Tier 1 methyldopa-hydrochlorothiazide oral tablet Tier 1 metolazone oral tablet Tier 1 metoprolol succinate oral tablet extended release Tier 1 24 hr metoprolol ta-hydrochlorothiaz oral tablet Tier 1 metoprolol tartrate oral tablet Tier 1 MICARDIS HCT ORAL TABLET Tier 3 MICARDIS ORAL TABLET Tier 3 MINIPRESS ORAL CAPSULE Tier 3 minoxidil oral tablet Tier 1 moexipril oral tablet Tier 1 nadolol oral tablet Tier 1 nadolol-bendroflumethiazide oral tablet Tier 1 oral capsule Tier 1 oral capsule Tier 1 nifedipine oral tablet extended release Tier 1 nifedipine oral tablet extended release 24hr Tier 1 nimodipine oral capsule Tier 1 oral tablet extended release 24 hr Tier 1 NORVASC ORAL TABLET Tier 3 olmesartan oral tablet Tier 1 olmesartan-amlodipin-hcthiazid oral tablet Tier 1 olmesartan-hydrochlorothiazide oral tablet Tier 1 ORENITRAM ORAL TABLET EXTENDED RELEASE Tier 3 PA; SPRx

45 Drug Name Drug Tier Requirements/Limits perindopril erbumine oral tablet Tier 1 phenoxybenzamine oral capsule Tier 1 pindolol oral tablet Tier 1 prazosin oral capsule Tier 1 PRINIVIL ORAL TABLET Tier 3 PROCARDIA ORAL CAPSULE Tier 3 PROCARDIA XL ORAL TABLET EXTENDED Tier 3 RELEASE 24HR propranolol oral capsule,extended release 24 hr Tier 1 propranolol oral solution Tier 1 propranolol oral tablet Tier 1 propranolol-hydrochlorothiazid oral tablet Tier 1 quinapril oral tablet Tier 1 quinapril-hydrochlorothiazide oral tablet Tier 1 ramipril oral capsule Tier 1 REMODULIN INJECTION SOLUTION Tier 3 PA; SPRx oral tablet Tier 1 spironolacton-hydrochlorothiaz oral tablet Tier 1 SULAR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR Tier 3 taztia xt oral capsule,extended release 24 hr Tier 1 TEKTURNA HCT ORAL TABLET Tier 3 TEKTURNA ORAL TABLET Tier 3 telmisartan oral tablet Tier 1 telmisartan-amlodipine oral tablet Tier 1 telmisartan-hydrochlorothiazid oral tablet Tier 1 TENORETIC 100 ORAL TABLET Tier 3 TENORETIC 50 ORAL TABLET Tier 3 TENORMIN ORAL TABLET Tier 3 terazosin oral capsule Tier 1 tiadylt er oral capsule,extended release 24 hr Tier 1 TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 Tier 3 HR timolol maleate oral tablet Tier 1

46 Drug Name Drug Tier Requirements/Limits TOPROL XL ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR torsemide oral tablet Tier 1 trandolapril oral tablet Tier 1 trandolapril-verapamil oral tablet, ir - er, biphasic Tier 1 24hr treprostinil sodium injection solution Tier 1 PA; SPRx triamterene oral capsule Tier 1 triamterene-hydrochlorothiazid oral capsule Tier 1 triamterene-hydrochlorothiazid oral tablet Tier 1 TRIBENZOR ORAL TABLET Tier 3 TWYNSTA ORAL TABLET Tier 3 valsartan oral tablet Tier 1 valsartan-hydrochlorothiazide oral tablet Tier 1 VASERETIC ORAL TABLET Tier 3 VASOTEC ORAL TABLET Tier 3 veletri intravenous recon soln Tier 1 PA; SPRx verapamil oral capsule, 24 hr er pellet ct Tier 1 verapamil oral capsule,ext rel. pellets 24 hr Tier 1 verapamil oral tablet Tier 1 verapamil oral tablet extended release Tier 1 VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 Tier 3 HR VERELAN PM ORAL CAPSULE, 24 HR ER PELLET Tier 3 CT ZESTORETIC ORAL TABLET Tier 3 ZESTRIL ORAL TABLET Tier 3 ZIAC ORAL TABLET Tier 3 Cardiac Glycosides digitek oral tablet Tier 1 digox oral tablet Tier 1 digoxin oral solution Tier 1 digoxin oral tablet Tier 1 LANOXIN ORAL TABLET Tier 2 Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 2 SPRx

47 Drug Name Drug Tier Requirements/Limits ALPHANATE INTRAVENOUS RECON SOLN Tier 3 SPRx ALPHANINE SD INTRAVENOUS RECON SOLN Tier 3 SPRx ALPROLIX INTRAVENOUS RECON SOLN Tier 3 SPRx AMICAR ORAL SOLUTION Tier 3 AMICAR ORAL TABLET Tier 3 aminocaproic acid oral solution Tier 1 aminocaproic acid oral tablet Tier 1 ARIXTRA SUBCUTANEOUS SYRINGE Tier 3 aspirin-dipyridamole oral capsule, er multiphase Tier 1 12 hr BENEFIX INTRAVENOUS RECON SOLN Tier 3 SPRx BRILINTA ORAL TABLET Tier 2 CABLIVI INJECTION KIT Tier 3 PA; LD; SPRx cilostazol oral tablet Tier 1 clopidogrel oral tablet Tier 1 COAGADEX INTRAVENOUS RECON SOLN Tier 3 SPRx CORIFACT INTRAVENOUS RECON SOLN Tier 3 SPRx dipyridamole oral tablet Tier 1 DOPTELET (10 TAB PACK) ORAL TABLET Tier 3 PA; SPRx DOPTELET (15 TAB PACK) ORAL TABLET Tier 3 PA; LD; SPRx DOPTELET (30 TAB PACK) ORAL TABLET Tier 3 PA; SPRx EFFIENT ORAL TABLET Tier 3 ELIQUIS DVT-PE TREAT 30D START ORAL Tier 2 TABLETS,DOSE PACK ELIQUIS ORAL TABLET Tier 2 ELOCTATE INTRAVENOUS RECON SOLN Tier 2 SPRx enoxaparin subcutaneous solution Tier 1 enoxaparin subcutaneous syringe Tier 1 FEIBA NF INTRAVENOUS RECON SOLN Tier 3 SPRx fondaparinux subcutaneous syringe Tier 1 FRAGMIN SUBCUTANEOUS SOLUTION Tier 3 FRAGMIN SUBCUTANEOUS SYRINGE Tier 3 HEMLIBRA SUBCUTANEOUS SOLUTION Tier 3 SPRx HEMOFIL M HIGH INTRAVENOUS RECON SOLN Tier 3 SPRx HEMOFIL M LOW INTRAVENOUS RECON SOLN Tier 3 SPRx

48 Drug Name Drug Tier Requirements/Limits HEMOFIL M MID INTRAVENOUS RECON SOLN Tier 3 SPRx HEMOFIL M SUPER HIGH INTRAVENOUS RECON Tier 3 SPRx SOLN hep flush-10 (pf) intravenous solution Tier 1 heparin (porcine) injection cartridge Tier 1 heparin (porcine) injection solution Tier 1 heparin (porcine) injection syringe Tier 1 heparin lock flush (porcine) intravenous solution Tier 1 100 unit/ml heparin lock flush (porcine) intravenous syringe Tier 1 heparin lock flush intravenous solution Tier 1 heparin lockflush(porcine)(pf) intravenous syringe Tier 1 heparin, porcine (pf) injection solution Tier 1 heparin, porcine (pf) injection syringe 5,000 Tier 1 unit/0.5 ml HEPARIN, PORCINE (PF) INJECTION SYRINGE Tier 3 5,000 UNIT/ML heparin, porcine (pf) intravenous solution Tier 1 heparin, porcine (pf) intravenous syringe Tier 1 heparin, porcine (pf) subcutaneous syringe Tier 3 HUMATE-P INTRAVENOUS RECON SOLN Tier 3 SPRx jantoven oral tablet Tier 1 JIVI INTRAVENOUS RECON SOLN Tier 2 SPRx KOATE INTRAVENOUS RECON SOLN Tier 3 SPRx KOGENATE FS INTRAVENOUS RECON SOLN Tier 2 SPRx KOVALTRY INTRAVENOUS RECON SOLN Tier 2 SPRx LOVENOX SUBCUTANEOUS SOLUTION Tier 3 LOVENOX SUBCUTANEOUS SYRINGE Tier 3 MEPHYTON ORAL TABLET Tier 3 MULPLETA ORAL TABLET Tier 3 PA; SPRx NOVOEIGHT INTRAVENOUS RECON SOLN Tier 2 SPRx NOVOSEVEN RT INTRAVENOUS RECON SOLN Tier 3 SPRx pentoxifylline oral tablet extended release Tier 1 phytonadione (vitamin k1) oral tablet 5 mg Tier 1 PLAVIX ORAL TABLET Tier 3 PRADAXA ORAL CAPSULE Tier 3

49 Drug Name Drug Tier Requirements/Limits prasugrel oral tablet Tier 1 PROFILNINE INTRAVENOUS RECON SOLN Tier 3 SPRx PROMACTA ORAL POWDER IN PACKET Tier 3 SPRx PROMACTA ORAL TABLET Tier 3 SPRx REBINYN INTRAVENOUS RECON SOLN Tier 3 SPRx RECOMBINATE INTRAVENOUS RECON SOLN Tier 3 SPRx RIXUBIS INTRAVENOUS RECON SOLN Tier 3 SPRx SEVENFACT INTRAVENOUS RECON SOLN Tier 3 SPRx TAVALISSE ORAL TABLET Tier 3 PA; LD; SPRx oral tablet Tier 1 WILATE INTRAVENOUS RECON SOLN Tier 3 SPRx XARELTO DVT-PE TREAT 30D START ORAL Tier 2 TABLETS,DOSE PACK XARELTO ORAL TABLET Tier 2 XYNTHA INTRAVENOUS SOLUTION Tier 3 SPRx XYNTHA SOLOFUSE INTRAVENOUS SYRINGE Tier 3 SPRx ZONTIVITY ORAL TABLET Tier 3 Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet Tier 1 ANTARA ORAL CAPSULE Tier 3 atorvastatin oral tablet 10 mg, 20 mg Tier 1 ACA atorvastatin oral tablet 40 mg, 80 mg Tier 1 CADUET ORAL TABLET Tier 3 cholestyramine (with sugar) oral powder Tier 1 cholestyramine (with sugar) oral powder in Tier 1 packet cholestyramine light oral powder Tier 1 cholestyramine light oral powder in packet Tier 1 colesevelam oral powder in packet Tier 1 colesevelam oral tablet Tier 1 COLESTID FLAVORED ORAL PACKET Tier 3 COLESTID ORAL GRANULES Tier 3 COLESTID ORAL TABLET Tier 3 colestipol oral granules Tier 1 colestipol oral packet Tier 1

50 Drug Name Drug Tier Requirements/Limits colestipol oral tablet Tier 1 CRESTOR ORAL TABLET Tier 3 ezetimibe oral tablet Tier 1 ezetimibe- oral tablet Tier 1 fenofibrate micronized oral capsule Tier 1 fenofibrate nanocrystallized oral tablet Tier 1 fenofibrate oral tablet Tier 1 fenofibric acid (choline) oral capsule,delayed Tier 1 release(dr/ec) fenofibric acid oral tablet Tier 1 FENOGLIDE ORAL TABLET Tier 3 FIBRICOR ORAL TABLET Tier 3 fluvastatin oral capsule Tier 1 ACA fluvastatin oral tablet extended release 24 hr Tier 1 ACA gemfibrozil oral tablet Tier 1 icosapent ethyl oral capsule Tier 1 JUXTAPID ORAL CAPSULE Tier 3 PA; LD; SPRx LESCOL ORAL CAPSULE 20 MG, 40 MG Tier 3 LESCOL XL ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR LIPITOR ORAL TABLET Tier 3 LIPOFEN ORAL CAPSULE Tier 3 LIVALO ORAL TABLET Tier 2 LOPID ORAL TABLET Tier 3 oral tablet Tier 1 ACA LOVAZA ORAL CAPSULE Tier 3 niacin oral tablet 500 mg Tier 1 niacin oral tablet extended release 24 hr Tier 1 NIACOR ORAL TABLET Tier 3 NIASPAN EXTENDED-RELEASE ORAL TABLET Tier 3 EXTENDED RELEASE 24 HR omega-3 acid ethyl esters oral capsule Tier 1 PRALUENT PEN SUBCUTANEOUS PEN INJECTOR Tier 2 PA PRAVACHOL ORAL TABLET 20 MG, 40 MG Tier 3 pravastatin oral tablet Tier 1 ACA

51 Drug Name Drug Tier Requirements/Limits prevalite oral powder Tier 1 prevalite oral powder in packet Tier 1 QUESTRAN LIGHT ORAL POWDER Tier 3 QUESTRAN ORAL POWDER Tier 3 QUESTRAN ORAL POWDER IN PACKET Tier 3 REPATHA PUSHTRONEX SUBCUTANEOUS Tier 2 PA WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS PEN Tier 2 PA INJECTOR REPATHA SYRINGE SUBCUTANEOUS SYRINGE Tier 2 PA oral tablet 10 mg, 5 mg Tier 1 ACA rosuvastatin oral tablet 20 mg, 40 mg Tier 1 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 Tier 1 ACA mg simvastatin oral tablet 80 mg Tier 1 TRICOR ORAL TABLET Tier 3 TRILIPIX ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) VASCEPA ORAL CAPSULE Tier 2 VYTORIN 10-10 ORAL TABLET Tier 3 VYTORIN 10-20 ORAL TABLET Tier 3 VYTORIN 10-40 ORAL TABLET Tier 3 VYTORIN 10-80 ORAL TABLET Tier 3 WELCHOL ORAL POWDER IN PACKET Tier 3 WELCHOL ORAL TABLET Tier 3 ZETIA ORAL TABLET Tier 3 ZOCOR ORAL TABLET Tier 3 Miscellaneous Cardiovascular Agents CORLANOR ORAL SOLUTION Tier 3 CORLANOR ORAL TABLET Tier 3 ENTRESTO ORAL TABLET Tier 3 RANEXA ORAL TABLET EXTENDED RELEASE 12 Tier 3 HR ranolazine oral tablet extended release 12 hr Tier 1 VERQUVO ORAL TABLET Tier 3 VYNDAMAX ORAL CAPSULE Tier 3 PA; SPRx

52 Drug Name Drug Tier Requirements/Limits VYNDAQEL ORAL CAPSULE Tier 3 PA; SPRx Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED Tier 3 RELEASE ISOCHRON ORAL TABLET EXTENDED RELEASE Tier 3 ISORDIL ORAL TABLET Tier 3 ISORDIL TITRADOSE ORAL TABLET Tier 3 isosorbide dinitrate oral tablet Tier 1 isosorbide dinitrate oral tablet extended release Tier 1 oral tablet Tier 1 isosorbide mononitrate oral tablet extended Tier 1 release 24 hr MINITRAN TRANSDERMAL PATCH 24 HOUR Tier 3 nitro-bid transdermal ointment Tier 1 NITRO-DUR TRANSDERMAL PATCH 24 HOUR Tier 3 nitroglycerin oral capsule, extended release Tier 1 nitroglycerin sublingual tablet Tier 1 nitroglycerin transdermal patch 24 hour Tier 1 nitroglycerin translingual spray,non-aerosol Tier 1 NITROLINGUAL TRANSLINGUAL SPRAY,NON- Tier 3 AEROSOL NITROMIST TRANSLINGUAL AEROSOL,SPRAY Tier 3 NITROSTAT SUBLINGUAL TABLET Tier 3 nitro-time oral capsule, extended release Tier 1 Dermatologicals/Topical Therapy Antipsoriatic / Antiseborrheic acitretin oral capsule Tier 1 calcipotriene scalp solution Tier 1 calcipotriene topical cream Tier 1 calcipotriene topical ointment Tier 1 calcipotriene- topical ointment Tier 1 calcipotriene-betamethasone topical suspension Tier 1 calcitriol topical ointment Tier 1 COAL TAR TOPICAL SOLUTION Tier 3

53 Drug Name Drug Tier Requirements/Limits COSENTYX (2 SYRINGES) SUBCUTANEOUS Tier 3 PA; SPRx SYRINGE COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN Tier 3 PA; SPRx INJECTOR COSENTYX PEN SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx COSENTYX SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx drithocreme hp topical cream Tier 1 ENSTILAR TOPICAL FOAM Tier 2 hydrocortisone-pramoxine topical cream Tier 1 OVACE PLUS SHAMPOO TOPICAL SHAMPOO Tier 3 OVACE PLUS TOPICAL CREAM Tier 3 OVACE PLUS TOPICAL LOTION Tier 3 OVACE PLUS WASH TOPICAL CLEANSER, GEL Tier 3 OVACE TOPICAL CLEANSER Tier 3 selenium sulfide topical lotion Tier 1 selenium sulfide topical shampoo 2.25 % Tier 1 SILIQ SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 Tier 2 PA; SPRx ML SKYRIZI SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SPRx SORIATANE ORAL CAPSULE Tier 3 STELARA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx sulfacetamide sodium topical cleanser Tier 1 sulfacetamide sodium topical shampoo Tier 1 TACLONEX TOPICAL OINTMENT Tier 3 TACLONEX TOPICAL SUSPENSION Tier 2 TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS Tier 2 PA; SPRx AUTO-INJECTOR TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS Tier 2 PA; SPRx AUTO-INJECTOR TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 2 PA; SPRx INJECTOR TALTZ SYRINGE SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx TREMFYA SUBCUTANEOUS AUTO-INJECTOR Tier 2 PA; SPRx TREMFYA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx Antivirals

54 Drug Name Drug Tier Requirements/Limits acyclovir topical cream Tier 1 Burn Therapy SILVADENE TOPICAL CREAM Tier 3 silver sulfadiazine topical cream Tier 1 ssd topical cream Tier 1 Keratolytics PODOCON TOPICAL LIQUID Tier 3 SALEX TOPICAL SHAMPOO Tier 3 salicylic acid topical cream Tier 1 salicylic acid topical cream,extended release Tier 1 salicylic acid topical film forming liquid w/appl Tier 1 salicylic acid topical foam Tier 1 salicylic acid topical liquid Tier 1 salicylic acid topical lotion Tier 1 salicylic acid topical lotion,extended release Tier 1 salicylic acid topical shampoo Tier 1 salicylic acid-ceramides no.1 topical kit,cleanser Tier 1 and cream er Miscellaneous Dermatologicals CONDYLOX TOPICAL GEL Tier 3 diclofenac sodium topical gel 3 % Tier 1 QL (100 GM per 30 days) doxepin topical cream Tier 1 DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx EFUDEX TOPICAL CREAM Tier 3 ELIDEL TOPICAL CREAM Tier 2 EUCRISA TOPICAL OINTMENT Tier 3 fluorouracil topical cream 5 % Tier 1 fluorouracil topical solution Tier 1 HYDRO 40 TOPICAL FOAM Tier 3 KERALAC TOPICAL CREAM Tier 3 LOUTREX TOPICAL CREAM Tier 3 methoxsalen oral capsule,liqd-filled,rapid rel Tier 1 OXSORALEN ULTRA ORAL CAPSULE,LIQD- Tier 3 FILLED,RAPID REL 10 MG

55 Drug Name Drug Tier Requirements/Limits PANRETIN TOPICAL GEL Tier 3 pimecrolimus topical cream Tier 1 podofilox topical solution Tier 1 prudoxin topical cream Tier 1 REGRANEX TOPICAL GEL Tier 3 silver nitrate applicators topical stick Tier 1 silver nitrate topical solution 10 % Tier 1 tacrolimus topical ointment Tier 1 URAMAXIN TOPICAL GEL Tier 3 VALCHLOR TOPICAL GEL Tier 3 PA; SPRx VEREGEN TOPICAL OINTMENT Tier 3 ZONALON TOPICAL CREAM Tier 3 Therapy For Acne adapalene topical cream Tier 1 adapalene topical gel Tier 1 adapalene topical gel with pump Tier 1 adapalene-benzoyl peroxide topical gel with Tier 1 pump amnesteem oral capsule Tier 1 ARAZLO TOPICAL LOTION Tier 2 PA avita topical cream Tier 1 PA azelaic acid topical gel Tier 1 AZELEX TOPICAL CREAM Tier 3 BENZAMYCIN TOPICAL GEL Tier 3 BENZEFOAM TOPICAL FOAM Tier 3 BENZEPRO (MICROSPHERES) TOPICAL CLEANSER Tier 3 benzepro topical towelette Tier 1 benzoyl peroxide topical cleanser 7 % Tier 1 benzoyl peroxide topical foam Tier 1 bpo topical gel Tier 1 claravis oral capsule Tier 1 CLEOCIN T TOPICAL LOTION Tier 3 CLEOCIN T TOPICAL SOLUTION Tier 3 clindacin p topical swab Tier 1 CLINDAGEL TOPICAL GEL, ONCE DAILY Tier 3

56 Drug Name Drug Tier Requirements/Limits clindamycin phosphate topical foam Tier 1 clindamycin phosphate topical gel Tier 1 clindamycin phosphate topical lotion Tier 1 clindamycin phosphate topical solution Tier 1 clindamycin phosphate topical swab Tier 1 clindamycin-benzoyl peroxide topical gel Tier 1 clindamycin-benzoyl peroxide topical gel with Tier 1 pump EPIDUO FORTE TOPICAL GEL WITH PUMP Tier 2 EPIDUO TOPICAL GEL WITH PUMP Tier 2 ery pads topical swab Tier 1 erygel topical gel Tier 1 erythromycin with ethanol topical gel Tier 1 erythromycin with ethanol topical solution Tier 1 erythromycin-benzoyl peroxide topical gel Tier 1 EVOCLIN TOPICAL FOAM Tier 3 FABIOR TOPICAL FOAM Tier 3 PA FINACEA TOPICAL FOAM Tier 2 FINACEA TOPICAL GEL Tier 2 METROCREAM TOPICAL CREAM Tier 3 METROLOTION TOPICAL LOTION Tier 3 metronidazole topical cream Tier 1 metronidazole topical gel Tier 1 metronidazole topical gel with pump Tier 1 metronidazole topical lotion Tier 1 myorisan oral capsule Tier 1 neuac topical gel Tier 1 PACNEX TOPICAL CLEANSER Tier 3 PLEXION CLEANSING CLOTHS TOPICAL PADS, Tier 3 MEDICATED PLEXION TOPICAL CLEANSER Tier 3 PLEXION TOPICAL CREAM Tier 3 PLEXION TOPICAL LOTION Tier 3 RETIN-A TOPICAL CREAM Tier 3 PA rosadan topical cream Tier 1

57 Drug Name Drug Tier Requirements/Limits rosadan topical gel Tier 1 ROSANIL TOPICAL CLEANSER Tier 3 rosula cleansing cloths topical pads, medicated Tier 1 ROSULA TOPICAL CLEANSER Tier 3 sss 10-5 topical cream Tier 1 sss 10-5 topical foam Tier 1 sulfacetamide sodium-sulfur topical cleanser Tier 1 sulfacetamide sodium-sulfur topical cream Tier 1 sulfacetamide sodium-sulfur topical lotion Tier 1 sulfacetamide sodium-sulfur topical pads, Tier 1 medicated sulfacetamide sodium-sulfur topical suspension Tier 1 sulfacetamide sod-sulfur-urea topical cleanser Tier 1 SUMAXIN TOPICAL PADS, MEDICATED Tier 3 tazarotene topical cream Tier 1 PA TAZORAC TOPICAL CREAM Tier 3 PA TAZORAC TOPICAL GEL Tier 3 PA tretinoin microspheres topical gel Tier 1 PA tretinoin microspheres topical gel with pump Tier 1 PA tretinoin topical cream Tier 1 PA tretinoin topical gel Tier 1 PA TRETIN-X CREAM KIT TOPICAL COMBO PACK Tier 3 PA TRETIN-X TOPICAL CREAM Tier 3 PA VANOXIDE-HC TOPICAL SUSPENSION Tier 3 zenatane oral capsule Tier 1 Topical Anesthetics ethyl chloride topical aerosol,spray Tier 1 glydo mucous membrane jelly in applicator Tier 1 lidocaine hcl mucous membrane jelly Tier 1 lidocaine hcl mucous membrane jelly in Tier 1 applicator lidocaine hcl mucous membrane solution 4 % (40 Tier 1 mg/ml) lidocaine hcl-hydrocortison ac topical cream Tier 1 lidocaine topical adhesive patch,medicated 5 % Tier 1 QL (90 EA per 30 days)

58 Drug Name Drug Tier Requirements/Limits lidocaine topical ointment Tier 1 QL (100 GM per 30 days) lidocaine viscous mucous membrane solution Tier 1 lidocaine-prilocaine topical cream Tier 1 QL (60 GM per 30 days) lidocort topical cream Tier 1 LIDODERM TOPICAL ADHESIVE Tier 3 QL (90 EA per 30 days) PATCH,MEDICATED SYNERA TOPICAL PATCH, MEDICATED SELF- Tier 3 HEATING Topical Antibacterials ALTABAX TOPICAL OINTMENT Tier 3 CENTANY TOPICAL OINTMENT Tier 3 CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 Tier 3 MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % Tier 3 gentamicin topical cream Tier 1 gentamicin topical ointment Tier 1 hydrocortisone-iodoquinol-aloe topical cream in Tier 1 packet KLARON TOPICAL SUSPENSION Tier 3 mafenide acetate topical packet Tier 1 mupirocin calcium topical cream Tier 1 mupirocin topical ointment Tier 1 NEO-SYNALAR KIT TOPICAL CREAM Tier 3 NEO-SYNALAR TOPICAL CREAM Tier 3 sulfacetamide sodium (acne) topical suspension Tier 1 SULFAMYLON TOPICAL CREAM Tier 3 SULFAMYLON TOPICAL PACKET Tier 3 Topical ciclodan topical cream Tier 1 ciclodan topical solution Tier 1 ciclopirox topical cream Tier 1 ciclopirox topical gel Tier 1 ciclopirox topical shampoo Tier 1 ciclopirox topical solution Tier 1 ciclopirox topical suspension Tier 1 ciclopirox-ure-camph-menth-euc topical solution Tier 1

59 Drug Name Drug Tier Requirements/Limits clotrimazole-betamethasone topical cream Tier 1 clotrimazole-betamethasone topical lotion Tier 1 econazole topical cream Tier 1 ERTACZO TOPICAL CREAM Tier 3 EXELDERM TOPICAL CREAM Tier 3 EXELDERM TOPICAL SOLUTION Tier 3 EXODERM TOPICAL LOTION Tier 3 EXTINA TOPICAL FOAM Tier 3 ketoconazole topical cream Tier 1 ketoconazole topical foam Tier 1 ketoconazole topical shampoo Tier 1 ketodan topical foam Tier 1 LOPROX TOPICAL SHAMPOO Tier 3 naftifine topical cream Tier 1 naftifine topical gel Tier 1 NAFTIN TOPICAL GEL Tier 3 nyamyc topical powder Tier 1 nystatin topical cream Tier 1 nystatin topical ointment Tier 1 nystatin topical powder Tier 1 nystatin- topical cream Tier 1 nystatin-triamcinolone topical ointment Tier 1 nystop topical powder Tier 1 oxiconazole topical cream Tier 1 OXISTAT TOPICAL LOTION Tier 3 VUSION TOPICAL OINTMENT Tier 3 XOLEGEL TOPICAL GEL Tier 3 Topical Antivirals acyclovir topical ointment Tier 1 DENAVIR TOPICAL CREAM Tier 3 ZOVIRAX TOPICAL CREAM Tier 2 ZOVIRAX TOPICAL OINTMENT Tier 3 Topical ALA-SCALP TOPICAL LOTION Tier 3 alclometasone topical cream Tier 1

60 Drug Name Drug Tier Requirements/Limits alclometasone topical ointment Tier 1 amcinonide topical cream Tier 1 amcinonide topical lotion Tier 1 apexicon e topical cream Tier 1 AQUA GLYCOLIC HC TOPICAL COMBO PACK Tier 3 betamethasone dipropionate topical cream Tier 1 betamethasone dipropionate topical lotion Tier 1 betamethasone dipropionate topical ointment Tier 1 betamethasone valerate topical cream Tier 1 betamethasone valerate topical foam Tier 1 betamethasone valerate topical lotion Tier 1 betamethasone valerate topical ointment Tier 1 betamethasone, augmented topical cream Tier 1 betamethasone, augmented topical gel Tier 1 betamethasone, augmented topical lotion Tier 1 betamethasone, augmented topical ointment Tier 1 CAPEX TOPICAL SHAMPOO Tier 3 clobetasol scalp solution Tier 1 clobetasol topical cream Tier 1 clobetasol topical foam Tier 1 clobetasol topical gel Tier 1 clobetasol topical lotion Tier 1 clobetasol topical ointment Tier 1 clobetasol topical shampoo Tier 1 clobetasol topical spray,non-aerosol Tier 1 clobetasol-emollient topical cream Tier 1 clobetasol-emollient topical foam Tier 1 CLOBEX TOPICAL LOTION Tier 3 CLOBEX TOPICAL SHAMPOO Tier 3 CLOBEX TOPICAL SPRAY,NON-AEROSOL Tier 3 CLOCORTOLONE PIVALATE TOPICAL CREAM Tier 3 clodan topical shampoo Tier 1 CLODERM TOPICAL CREAM Tier 3 CORDRAN TAPE LARGE ROLL TOPICAL TAPE Tier 3 CORDRAN TOPICAL CREAM Tier 3

61 Drug Name Drug Tier Requirements/Limits CORDRAN TOPICAL LOTION Tier 3 CORDRAN TOPICAL OINTMENT Tier 3 CUTIVATE TOPICAL CREAM Tier 3 CUTIVATE TOPICAL LOTION Tier 3 DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL Tier 3 DERMA-SMOOTHE/FS SCALP OIL SCALP OIL Tier 3 DESONATE TOPICAL GEL Tier 3 desonide topical cream Tier 1 desonide topical gel Tier 1 desonide topical lotion Tier 1 desonide topical ointment Tier 1 DESOWEN TOPICAL CREAM Tier 3 DESOWEN TOPICAL LOTION Tier 3 desoximetasone topical cream Tier 1 desoximetasone topical gel Tier 1 desoximetasone topical ointment Tier 1 desoximetasone topical spray,non-aerosol Tier 1 diflorasone topical cream Tier 1 diflorasone topical ointment Tier 1 DIPROLENE (AUGMENTED) TOPICAL OINTMENT Tier 3 fluocinolone and shower cap scalp oil Tier 1 fluocinolone topical cream Tier 1 fluocinolone topical oil Tier 1 fluocinolone topical ointment Tier 1 fluocinolone topical solution Tier 1 fluocinonide topical cream Tier 1 fluocinonide topical gel Tier 1 fluocinonide topical ointment Tier 1 fluocinonide topical solution Tier 1 fluocinonide-e topical cream Tier 1 fluocinonide-emollient topical cream Tier 1 flurandrenolide topical cream Tier 1 flurandrenolide topical lotion Tier 1 flurandrenolide topical ointment Tier 1 propionate topical cream Tier 1

62 Drug Name Drug Tier Requirements/Limits topical lotion Tier 1 fluticasone propionate topical ointment Tier 1 halcinonide topical cream Tier 1 halobetasol propionate topical cream Tier 1 halobetasol propionate topical ointment Tier 1 HALOG TOPICAL CREAM Tier 3 HALOG TOPICAL OINTMENT Tier 3 HALOG TOPICAL SOLUTION Tier 3 hydrocortisone butyrate topical cream Tier 1 hydrocortisone butyrate topical lotion Tier 1 hydrocortisone butyrate topical ointment Tier 1 hydrocortisone butyrate topical solution Tier 1 hydrocortisone butyr-emollient topical cream Tier 1 hydrocortisone topical cream 2.5 % Tier 1 hydrocortisone topical lotion 2.5 % Tier 1 hydrocortisone topical ointment 2.5 % Tier 1 hydrocortisone valerate topical cream Tier 1 hydrocortisone valerate topical ointment Tier 1 KENALOG TOPICAL AEROSOL Tier 3 LOCOID LIPOCREAM TOPICAL CREAM Tier 3 LOCOID TOPICAL LOTION Tier 3 LUXIQ TOPICAL FOAM Tier 3 topical cream Tier 1 mometasone topical ointment Tier 1 mometasone topical solution Tier 1 OLUX TOPICAL FOAM Tier 3 OLUX-E TOPICAL FOAM Tier 3 PANDEL TOPICAL CREAM Tier 3 prednicarbate topical cream Tier 1 prednicarbate topical ointment Tier 1 PSORCON TOPICAL CREAM Tier 3 SYNALAR CREAM KIT TOPICAL CREAM Tier 3 SYNALAR OINTMENT KIT TOPICAL COMBO Tier 3 PACK,OINTMENT AND CREAM SYNALAR TOPICAL CREAM Tier 3

63 Drug Name Drug Tier Requirements/Limits SYNALAR TOPICAL SOLUTION Tier 3 SYNALAR TS TOPICAL KIT Tier 3 TEMOVATE TOPICAL CREAM Tier 3 TEMOVATE TOPICAL OINTMENT Tier 3 TEXACORT TOPICAL SOLUTION Tier 3 TOPICORT TOPICAL CREAM 0.05 % Tier 3 TOPICORT TOPICAL GEL Tier 3 TOPICORT TOPICAL OINTMENT 0.05 % Tier 3 TOPICORT TOPICAL SPRAY,NON-AEROSOL Tier 3 TOVET EMOLLIENT TOPICAL FOAM Tier 1 triamcinolone acetonide topical aerosol Tier 1 triamcinolone acetonide topical cream Tier 1 triamcinolone acetonide topical lotion Tier 1 triamcinolone acetonide topical ointment Tier 1 trianex topical ointment Tier 1 triderm topical cream Tier 1 VANOS TOPICAL CREAM Tier 3 VERDESO TOPICAL FOAM Tier 3 Topical SANTYL TOPICAL OINTMENT Tier 3 Topical Scabicides / Pediculicides ELIMITE TOPICAL CREAM Tier 3 EURAX TOPICAL CREAM Tier 3 lindane topical shampoo Tier 1 malathion topical lotion Tier 1 NATROBA TOPICAL SUSPENSION Tier 3 OVIDE TOPICAL LOTION Tier 3 topical cream Tier 1 spinosad topical suspension Tier 1 ULESFIA TOPICAL LOTION Tier 3 Diagnostics & Miscellaneous Agents Anorexiants ADIPEX-P ORAL CAPSULE Tier 3 # ADIPEX-P ORAL TABLET Tier 3 #

64 Drug Name Drug Tier Requirements/Limits benzphetamine oral tablet Tier 1 # CONTRAVE ORAL TABLET EXTENDED RELEASE Tier 3 # diethylpropion oral tablet Tier 1 # diethylpropion oral tablet extended release Tier 1 # LOMAIRA ORAL TABLET Tier 3 # phendimetrazine tartrate oral capsule, extended Tier 1 # release phendimetrazine tartrate oral tablet Tier 1 # phentermine oral capsule Tier 1 # phentermine oral tablet Tier 1 # QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR Tier 3 # SAXENDA SUBCUTANEOUS PEN INJECTOR Tier 3 # XENICAL ORAL CAPSULE Tier 3 # Inhaler Assisting Devices ACE AEROSOL CLOUD ENHANCER SPACER Tier 3 AEROCHAMBER MINI SPACER Tier 3 AEROCHAMBER MV SPACER Tier 3 AEROCHAMBER PLUS FLOW-VU SPACER Tier 3 AEROCHAMBER PLUS FLOW-VU,L MSK SPACER Tier 3 AEROCHAMBER PLUS FLOW-VU,M MSK SPACER Tier 3 AEROCHAMBER PLUS FLOW-VU,S MSK SPACER Tier 3 AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 3 AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 3 AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 3 AEROCHAMBER PLUS Z STAT SPACER Tier 3 AEROCHAMBER WITH FLOWSIGNAL SPACER Tier 3 AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 3 AEROTRACH PLUS SPACER Tier 3 AEROVENT PLUS SPACER Tier 3 BREATHERITE MDI SPACER SPACER Tier 3 BREATHERITE SPACER-MASK, NEO. SPACER Tier 3 BREATHERITE SPACER-MASK,ADULT SPACER Tier 3 BREATHERITE SPACER-MASK,CHILD SPACER Tier 3 BREATHERITE SPACER-MASK,INFANT SPACER Tier 3 BREATHERITE SPACER-MASK,S.CHLD SPACER Tier 3

65 Drug Name Drug Tier Requirements/Limits BREATHERITE VALVED MDI CHAMBER SPACER Tier 3 BREATHERITE VALVED MDI SPACER SPACER Tier 3 CLEVER CHOICE CHAMBER-LRG MASK SPACER Tier 3 CLEVER CHOICE CHAMBER-MED MASK SPACER Tier 3 CLEVER CHOICE CHAMBER-SM MASK SPACER Tier 3 COMPACT SPACE CHAMBER SPACER Tier 3 COMPACT SPACE CHAMBER-LRG MASK SPACER Tier 3 COMPACT SPACE CHAMBER-MED MASK SPACER Tier 3 COMPACT SPACE CHAMBER-SM MASK SPACER Tier 3 EASIVENT HOLDING CHAMBER SPACER Tier 3 EASIVENT MASK LARGE DEVICE Tier 3 EASIVENT MASK MEDIUM DEVICE Tier 3 EASIVENT MASK SMALL DEVICE Tier 3 FLEXICHAMBER SPACER Tier 3 FLEXICHAMBER-LG CHILD MASK DEVICE Tier 3 FLEXICHAMBER-SM ADULT MASK DEVICE Tier 3 FLEXICHAMBER-SM CHILD MASK DEVICE Tier 3 INSPIRACHAMBER SPACER Tier 3 INSPIRACHAMBER WITH MASK-LARGE SPACER Tier 3 INSPIRACHAMBER WITH MASK-MED SPACER Tier 3 INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 3 LITE TOUCH-MEDIUM MASK DEVICE Tier 3 LITEAIRE MDI CHAMBER SPACER Tier 3 LITETOUCH-LARGE MASK DEVICE Tier 3 LITETOUCH-SMALL MASK DEVICE Tier 3 MICROCHAMBER SPACER Tier 3 MICROSPACER SPACER Tier 3 MOUTHPIECE DEVICE Tier 3 ONE WAY VALVED MOUTHPIECE DEVICE Tier 3 OPTICHAMBER ADULT MASK-LARGE DEVICE Tier 3 OPTICHAMBER DIAMOND LG MASK SPACER Tier 3 OPTICHAMBER DIAMOND VHC SPACER Tier 3 OPTICHAMBER DIAMOND-MED MSK SPACER Tier 3 OPTICHAMBER DIAMOND-SML MASK SPACER Tier 3 PANDA MASK DEVICE Tier 3

66 Drug Name Drug Tier Requirements/Limits PEAK AIR PEAK FLOW METER DEVICE Tier 3 PEDIATRIC MEDIUM MASK DEVICE Tier 3 PEDIATRIC PANDA MASK DEVICE Tier 3 PEDIATRIC SMALL MASK DEVICE Tier 3 POCKET CHAMBER SPACER Tier 3 PRIMEAIRE SPACER Tier 3 PRO COMFORT SPACER-ADULT MASK SPACER Tier 3 PRO COMFORT SPACER-CHILD MASK SPACER Tier 3 PROCHAMBER SPACER Tier 3 RITEFLO AEROCHAMBER SPACER Tier 3 SIDESTREAM PEDIATRIC FACE MASK DEVICE Tier 3 SILICONE MASK - INFANT DEVICE Tier 3 SILICONE MASK - PEDIATRIC DEVICE Tier 3 SPACE CHAMBER SPACER Tier 3 Irrigating Solutions aqua care sodium chloride irrigation solution Tier 1 aqua care sterile water irrigation solution Tier 1 lactated ringers irrigation solution Tier 1 neomycin-polymyxin b gu irrigation solution Tier 1 PHYSIOLYTE IRRIGATION SOLUTION Tier 3 PHYSIOSOL IRRIGATION IRRIGATION SOLUTION Tier 3 ringer's irrigation solution Tier 1 SORBITOL IRRIGATION SOLUTION Tier 3 SORBITOL-MANNITOL TRANSURETHRAL Tier 3 SOLUTION tis-u-sol pentalyte irrigation irrigation solution Tier 1 Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 1 acetic acid irrigation solution Tier 1 AGRYLIN ORAL CAPSULE Tier 3 anagrelide oral capsule Tier 1 ANTABUSE ORAL TABLET 250 MG, 500 MG Tier 3 bd posiflush normal saline 0.9 injection syringe Tier 1 bd pre-filled normal saline injection syringe Tier 1 BUPHENYL ORAL POWDER Tier 3

67 Drug Name Drug Tier Requirements/Limits BUPHENYL ORAL TABLET Tier 3 caffeine citrate oral solution Tier 1 CARBAGLU ORAL TABLET, DISPERSIBLE Tier 3 CARNITOR (SUGAR-FREE) ORAL SOLUTION Tier 3 CARNITOR ORAL SOLUTION Tier 3 CARNITOR ORAL TABLET Tier 3 cevimeline oral capsule Tier 1 CHEMET ORAL CAPSULE Tier 3 deferasirox oral granules in packet Tier 1 SPRx deferasirox oral tablet Tier 1 SPRx deferasirox oral tablet, dispersible Tier 1 SPRx deferiprone oral tablet Tier 1 SPRx disulfiram oral tablet Tier 1 oral capsule Tier 1 PA; SPRx etidronate disodium oral tablet Tier 1 EVOXAC ORAL CAPSULE Tier 3 EXJADE ORAL TABLET, DISPERSIBLE Tier 3 LD; SPRx FERRIPROX ORAL TABLET Tier 3 SPRx JADENU ORAL TABLET Tier 3 SPRx levocarnitine (with sugar) oral solution Tier 1 levocarnitine oral solution 100 mg/ml Tier 1 levocarnitine oral tablet Tier 1 LITHOSTAT ORAL TABLET Tier 3 midodrine oral tablet Tier 1 monoject 0.9% sodium chloride injection syringe Tier 1 monoject prefill advanced ns injection syringe Tier 1 nitisinone oral capsule Tier 1 SPRx NITYR ORAL TABLET Tier 3 LD; SPRx normal saline flush injection syringe Tier 1 NORTHERA ORAL CAPSULE Tier 3 PA; SPRx ORFADIN ORAL CAPSULE Tier 3 LD; SPRx OXBRYTA ORAL TABLET Tier 3 PA; LD; SPRx pilocarpine hcl oral tablet 5 mg Tier 1 RADIOGARDASE ORAL CAPSULE Tier 3 RAVICTI ORAL LIQUID Tier 3 SPRx

68 Drug Name Drug Tier Requirements/Limits RILUTEK ORAL TABLET Tier 3 riluzole oral tablet Tier 1 risedronate oral tablet 30 mg Tier 1 SALAGEN (PILOCARPINE) ORAL TABLET 5 MG Tier 3 sodium chlor 0.9% bacteriostat injection solution Tier 1 sodium chloride 0.9 % (flush) injection syringe Tier 1 sodium chloride injection syringe Tier 1 sodium chloride irrigation solution Tier 1 sodium phenylbutyrate oral powder Tier 1 sodium phenylbutyrate oral tablet Tier 1 THIOLA EC ORAL TABLET,DELAYED RELEASE Tier 3 SPRx (DR/EC) THIOLA ORAL TABLET Tier 3 SPRx TIGLUTIK ORAL SUSPENSION Tier 3 SPRx tiopronin oral tablet Tier 1 SPRx water for irrigation, sterile irrigation solution Tier 1 ZOKINVY ORAL CAPSULE Tier 3 PA; SPRx Phenylketonuria (Pku) Nutritional Products EAA SUPPLEMENT ORAL POWDER IN PACKET Tier 3 GLYTACTIN 10 PE COMPLETE ORAL BAR Tier 3 GLYTACTIN 15 PE BETTERMILK ORAL POWDER Tier 3 IN PACKET GLYTACTIN 15 PE COMPLETE ORAL BAR Tier 3 GLYTACTIN 20PE BETTERMILK LITE ORAL Tier 3 POWDER IN PACKET GLYTACTIN RESTORE 10 PE LITE ORAL LIQUID Tier 3 GLYTACTIN RESTORE 10 PE LITE ORAL POWDER Tier 3 IN PACKET GLYTACTIN RESTORE 10 PE ORAL LIQUID Tier 3 GLYTACTIN RESTORE 5 PE ORAL POWDER IN Tier 3 PACKET GLYTACTIN RTD 10 PE ORAL LIQUID Tier 3 GLYTACTIN RTD 15 PE ORAL LIQUID Tier 3 GLYTACTIN SWIRL 15 PE ORAL POWDER IN Tier 3 PACKET LANAFLEX ORAL POWDER IN PACKET Tier 3

69 Drug Name Drug Tier Requirements/Limits LOPHLEX ORAL POWDER IN PACKET Tier 3 PERIFLEX ADVANCE ORAL POWDER Tier 3 PERIFLEX INFANT ORAL POWDER Tier 3 PERIFLEX JUNIOR ORAL POWDER Tier 3 PERIFLEX LQ PKU ORAL LIQUID Tier 3 PHENACTIN AA PLUS 20 PE ORAL LIQUID 8 Tier 3 GRAM-74 KCAL/100 ML PHENEX-1 ORAL POWDER Tier 3 PHENEX-2 ORAL POWDER Tier 3 PHENYLADE 40 ORAL POWDER IN PACKET Tier 3 PHENYLADE 60 ORAL POWDER Tier 3 PHENYLADE 60 ORAL POWDER IN PACKET Tier 3 PHENYLADE AMINO ACIDS ORAL POWDER Tier 3 PHENYLADE AMINO ACIDS ORAL POWDER IN Tier 3 PACKET PHENYLADE ESSENTIAL ORAL POWDER Tier 3 PHENYLADE ESSENTIAL ORAL POWDER IN Tier 3 PACKET PHENYLADE GMP MIX-IN ORAL POWDER Tier 3 PHENYLADE GMP MIX-IN ORAL POWDER IN Tier 3 PACKET PHENYLADE GMP ORAL POWDER Tier 3 PHENYLADE GMP ORAL POWDER IN PACKET Tier 3 PHENYLADE GMP READY ORAL LIQUID Tier 3 PHENYLADE MTE AMINO ACIDS ORAL POWDER Tier 3 PHENYLADE MTE AMINO ACIDS ORAL POWDER Tier 3 IN PACKET PHENYLADE PHEBLOC ORAL POWDER IN PACKET Tier 3 phenylade phebloc oral tablet Tier 1 PHENYL-FREE 1 ORAL POWDER Tier 3 PHENYL-FREE 2 PKU ORAL POWDER Tier 3 PHENYL-FREE 2HP PKU ORAL POWDER Tier 3 PHLEXY-10 DRINK MIX POWDER ORAL POWDER Tier 3 IN PACKET PHLEXY-10 ORAL TABLET Tier 3 PKU AIR20 ORAL LIQUID IN PACKET Tier 3

70 Drug Name Drug Tier Requirements/Limits PKU COOLER 10 ORAL SUSPENSION Tier 3 PKU COOLER 15 ORAL SUSPENSION Tier 3 PKU COOLER 20 ORAL SUSPENSION Tier 3 PKU EASY MICROTABS ORAL GRANULES Tier 3 DELAYED RELEASE PKU EASY ORAL TABLET Tier 3 PKU EXPRESS15 ORAL POWDER IN PACKET Tier 3 PKU EXPRESS20 ORAL POWDER IN PACKET Tier 3 PKU GEL POWDER ORAL POWDER IN PACKET Tier 3 PKU LOPHLEX ORAL LIQUID IN PACKET Tier 3 PKU PERIFLEX EARLY YEARS ORAL POWDER Tier 3 PKU PERIFLEX JUNIOR PLUS ORAL POWDER Tier 3 PKU SPHERE20 ORAL POWDER IN PACKET Tier 3 PKU TRIO ORAL POWDER Tier 3 XPHE MAXAMAID ORAL POWDER Tier 3 xphe maxamum oral powder Tier 1 XPHE MAXAMUM ORAL POWDER IN PACKET Tier 3 Smoking Deterrents bupropion hcl (smoking deter) oral tablet Tier 1 ACA extended release 12 hr CHANTIX CONTINUING MONTH BOX ORAL Tier 3 ACA TABLET CHANTIX ORAL TABLET Tier 3 ACA CHANTIX STARTING MONTH BOX ORAL Tier 3 ACA TABLETS,DOSE PACK NICODERM CQ TRANSDERMAL PATCH 24 HOUR Tier 3 ACA nicorelief buccal gum 2 mg Tier 1 ACA NICORETTE BUCCAL GUM 2 MG Tier 3 ACA nicorette buccal gum 4 mg Tier 1 ACA NICORETTE BUCCAL LOZENGE Tier 3 ACA NICORETTE BUCCAL MINI LOZENGE Tier 3 ACA (polacrilex) buccal gum Tier 1 ACA nicotine (polacrilex) buccal lozenge Tier 1 ACA nicotine (polacrilex) buccal mini lozenge Tier 1 ACA nicotine transdermal patch 24 hour Tier 1 ACA nicotine transdermal patch, td daily, sequential Tier 1 ACA

71 Drug Name Drug Tier Requirements/Limits NICOTROL INHALATION CARTRIDGE Tier 3 ACA NICOTROL NS NASAL SPRAY,NON-AEROSOL Tier 3 ACA quit 2 buccal gum Tier 1 ACA quit 2 buccal lozenge Tier 1 ACA quit 4 buccal gum Tier 1 ACA quit 4 buccal lozenge Tier 1 ACA stop smoking aid buccal lozenge Tier 1 ACA Ear, Nose & Throat Medications Miscellaneous Agents ARESTIN DENTAL CARTRIDGE Tier 3 nasal aerosol,spray Tier 1 azelastine nasal spray,non-aerosol Tier 1 chlorhexidine gluconate mucous membrane Tier 1 mouthwash CLINPRO 5000 DENTAL PASTE Tier 3 denta 5000 plus dental cream Tier 1 dentagel dental gel Tier 1 fluoride (sodium) dental cream Tier 1 fluoride (sodium) dental gel Tier 1 fluoride (sodium) dental paste Tier 1 FLUORIDEX DAILY DEFENSE DENTAL PASTE Tier 3 FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE Tier 3 nasal spray,non-aerosol Tier 1 olopatadine nasal spray,non-aerosol Tier 1 oralone dental paste Tier 1 ORAMAGICRX MUCOUS MEMBRANE Tier 3 MOUTHWASH paroex oral rinse mucous membrane mouthwash Tier 1 PATANASE NASAL SPRAY,NON-AEROSOL Tier 3 PERIDEX MUCOUS MEMBRANE MOUTHWASH Tier 3 periogard mucous membrane mouthwash Tier 1 pilocarpine hcl oral tablet 7.5 mg Tier 1 PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE Tier 3 PREVIDENT 5000 DRY MOUTH DENTAL GEL Tier 3

72 Drug Name Drug Tier Requirements/Limits PREVIDENT 5000 ENAMEL PROTECT DENTAL Tier 3 PASTE PREVIDENT 5000 ORTHO DEFENSE DENTAL Tier 3 PASTE PREVIDENT 5000 PLUS DENTAL CREAM Tier 3 PREVIDENT 5000 SENSITIVE DENTAL PASTE Tier 3 PREVIDENT DENTAL GEL Tier 3 PREVIDENT DENTAL SOLUTION Tier 3 SALAGEN (PILOCARPINE) ORAL TABLET 7.5 MG Tier 3 sf 5000 plus dental cream Tier 1 sf dental gel Tier 1 sodium fluoride 5000 dry mouth dental gel Tier 1 sodium fluoride 5000 plus dental cream Tier 1 sodium fluoride-pot nitrate dental paste Tier 1 triamcinolone acetonide dental paste Tier 1 Miscellaneous Otic Preparations acetic acid otic (ear) solution Tier 1 ciprofloxacin hcl otic (ear) dropperette Tier 1 DERMOTIC OIL OTIC (EAR) DROPS Tier 3 flac otic oil otic (ear) drops Tier 1 fluocinolone acetonide oil otic (ear) drops Tier 1 hydrocortisone-acetic acid otic (ear) drops Tier 1 ofloxacin otic (ear) drops Tier 1 Otic Steroid / Antibiotic CIPRO HC OTIC (EAR) DROPS,SUSPENSION Tier 3 CIPRODEX OTIC (EAR) DROPS,SUSPENSION Tier 2 ciprofloxacin- otic (ear) Tier 1 drops,suspension CORTISPORIN-TC OTIC (EAR) Tier 3 DROPS,SUSPENSION neomycin-polymyxin-hc otic (ear) Tier 1 drops,suspension neomycin-polymyxin-hc otic (ear) solution Tier 1 OTOVEL OTIC (EAR) SOLUTION Tier 2 Endocrine/Diabetes Adrenal Hormones

73 Drug Name Drug Tier Requirements/Limits ACTHAR INJECTION GEL Tier 3 PA; SPRx CORTEF ORAL TABLET Tier 3 cortisone oral tablet 25 mg Tier 1 decadron oral tablet Tier 1 dexamethasone intensol oral drops Tier 1 dexamethasone oral elixir Tier 1 dexamethasone oral solution Tier 1 dexamethasone oral tablet Tier 1 EMFLAZA ORAL SUSPENSION Tier 3 PA; LD; SPRx EMFLAZA ORAL TABLET Tier 3 PA; LD; SPRx fludrocortisone oral tablet Tier 1 hydrocortisone oral tablet Tier 1 MEDROL (PAK) ORAL TABLETS,DOSE PACK Tier 3 MEDROL ORAL TABLET Tier 3 oral tablet Tier 1 methylprednisolone oral tablets,dose pack Tier 1 millipred dp oral tablets,dose pack Tier 1 millipred oral tablet Tier 1 ORAPRED ODT ORAL TABLET,DISINTEGRATING Tier 3 PEDIAPRED ORAL SOLUTION Tier 3 oral solution Tier 1 prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 Tier 1 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral Tier 1 tablet,disintegrating prednisone intensol oral concentrate Tier 1 prednisone oral solution Tier 1 prednisone oral tablet Tier 1 prednisone oral tablets,dose pack Tier 1 veripred 20 oral solution Tier 1 Antithyroid Agents methimazole oral tablet Tier 1 propylthiouracil oral tablet Tier 1 SSKI ORAL SOLUTION Tier 3

74 Drug Name Drug Tier Requirements/Limits TAPAZOLE ORAL TABLET Tier 3 Blood Glucose Monitoring Devices & Supplies BREEZE 2 TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days) CONTOUR NEXT TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days) CONTOUR TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days) ONETOUCH ULTRA BLUE TEST STRIP STRIP Tier 2 QL (102 EA per 30 days) ONETOUCH VERIO TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days) Glucose Elevating Agents BAQSIMI NASAL SPRAY,NON-AEROSOL Tier 2 diazoxide oral suspension Tier 1 GLUCAGEN DIAGNOSTIC KIT INJECTION RECON Tier 2 SOLN GLUCAGEN HYPOKIT INJECTION RECON SOLN Tier 2 GLUCAGON (HCL) EMERGENCY KIT INJECTION Tier 2 RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) Tier 2 INJECTION RECON SOLN glucose oral tablet,chewable 4 gram Tier 1 GLUTOSE-45 ORAL GEL Tier 3 GVOKE HYPOPEN 1-PACK SUBCUTANEOUS Tier 2 AUTO-INJECTOR GVOKE HYPOPEN 2-PACK SUBCUTANEOUS Tier 2 AUTO-INJECTOR GVOKE PFS 1-PACK SYRINGE SUBCUTANEOUS Tier 2 SYRINGE GVOKE PFS 2-PACK SYRINGE SUBCUTANEOUS Tier 2 SYRINGE PROGLYCEM ORAL SUSPENSION Tier 3 TRUEPLUS GLUCOSE ORAL GEL IN PACKET Tier 3 Insulin Syringes/Miscellaneous Durable Medical Equ 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/2" 1ST TIER UNILET COMFORTOUCH 28 GAUGE Tier 2 ACCU-CHEK FASTCLIX LANCET DRUM Tier 2 ACCU-CHEK SAFE-T-PRO Tier 2

75 Drug Name Drug Tier Requirements/Limits ACCU-CHEK SOFTCLIX LANCETS Tier 2 ACTI-LANCE LANCETS 23 GAUGE Tier 2 ADVANCED TRAVEL LANCETS 30 GAUGE Tier 2 ADVOCATE LANCET 30 GAUGE Tier 2 ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/2", 31 GAUGE X 3/16", 33 GAUGE X 5/32" alcohol pads topical pads, medicated Tier 1 QL (300 EA per 30 days) alcohol prep pads topical pads, medicated Tier 1 QL (300 EA per 30 days) ALCOHOL SWABS TOPICAL PADS, MEDICATED Tier 2 QL (300 EA per 30 days) ALTERNATE SITE LANCET Tier 2 ASSURE HAEMOLANCE PLUS 1.2 MM Tier 3 ASSURE LANCE 25 GAUGE Tier 2 ASSURE LANCE PLUS 21 GAUGE Tier 2 BD ALCOHOL SWABS TOPICAL PADS, Tier 2 QL (300 EA per 30 days) MEDICATED BD AUTOSHIELD DUO PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD ECLIPSE NEEDLE 25 GAUGE X 1" Tier 2 QL (1000 EA per 30 days) BD FILTER NEEDLE-5 MICRON NEEDLE Tier 2 QL (1000 EA per 30 days) BD INSULIN SYRINGE (HALF UNIT) SYRINGE Tier 2 QL (1000 EA per 30 days) BD INSULIN SYRINGE SYRINGE 1 ML 25 X 1" Tier 2 QL (1000 EA per 30 days) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", Tier 2 QL (1000 EA per 30 days) 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 BD INTEGRA NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD MICROTAINER LANCET 30 GAUGE Tier 2 BD NOKOR ADMIX NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD PRECISIONGLIDE NEEDLE Tier 2 QL (1000 EA per 30 days) BD PRECISIONGLIDE NON-STERILE NEEDLE 18 Tier 2 QL (1000 EA per 30 days) GAUGE X 1 1/2" BD REGULAR BEVEL NEEDLES NEEDLE 18 GAUGE X 1", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 22 Tier 2 QL (1000 EA per 30 days) GAUGE X 1 1/2", 22 GAUGE X 1", 25 GAUGE X 5/8" BD SAFETYGLIDE NEEDLE NEEDLE 22 GAUGE X 1 Tier 2 QL (1000 EA per 30 days) 1/2"

76 Drug Name Drug Tier Requirements/Limits BD SHORT BEVEL NEEDLES NEEDLE 18 GAUGE X Tier 2 QL (1000 EA per 30 days) 1 1/2" BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/2" BD ULTRA FINE LANCETS Tier 2 BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD ULTRA-FINE MINI PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD ULTRA-FINE NANO PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD ULTRA-FINE SHORT PEN NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 Tier 2 QL (1000 EA per 30 days) GAUGE X 15/64", 1 ML 31 GAUGE X 15/64" BLUNT NEEDLE, DISPOSABLE NEEDLE 18 X 1 1/2 Tier 2 QL (1000 EA per 30 days) " BULLSEYE MINI SAFETY LANCETS 21 GAUGE Tier 2 CAREFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4" Tier 2 QL (1000 EA per 30 days) CAREONE THIN LANCET Tier 2 CLEVER CHEK LANCETS Tier 2 CLICKFINE PEN NEEDLE NEEDLE 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/4" COAGUCHEK LANCETS Tier 2 COLOR LANCETS Tier 2 COMFORT EZ PEN NEEDLES NEEDLE 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 5/16" COMFORT LANCETS Tier 2 CONTOUR LINK KIT Tier 2 QL (1 EA per 365 days) CONTOUR METER Tier 2 QL (1 EA per 365 days) CONTOUR METER KIT Tier 2 QL (1 EA per 365 days) CONTOUR NEXT EZ METER Tier 2 QL (1 EA per 365 days) CONTOUR NEXT EZ METER KIT Tier 2 QL (1 EA per 365 days) CONTOUR NEXT LINK 2.4 KIT Tier 2 QL (1 EA per 365 days) CONTOUR NEXT LINK KIT Tier 2 QL (1 EA per 365 days) CONTOUR NEXT METER Tier 2 QL (1 EA per 365 days) CONTOUR NEXT ONE METER Tier 2 QL (1 EA per 365 days) DEXCOM G4 RECEIVER Tier 3 QL (1 EA per 365 days) DEXCOM G4 RECEIVER PEDIATRIC Tier 3 QL (1 EA per 365 days)

77 Drug Name Drug Tier Requirements/Limits DEXCOM G4 RECEIVER-SHARE (PED) Tier 3 QL (1 EA per 365 days) DEXCOM G4 RECEIVER-SHARE KIT Tier 3 QL (1 EA per 365 days) DEXCOM G4 TRANSMITTER DEVICE Tier 3 QL (1 EA per 90 days) DEXCOM G5 RECEIVER Tier 3 QL (1 EA per 365 days) DEXCOM G5 TRANSMITTER DEVICE Tier 3 QL (1 EA per 90 days) DEXCOM G5-G4 SENSOR DEVICE Tier 3 QL (12 EA per 84 days) DEXCOM G6 RECEIVER Tier 3 QL (1 EA per 365 days) DEXCOM G6 SENSOR DEVICE Tier 3 QL (9 EA per 90 days) DEXCOM G6 TRANSMITTER DEVICE Tier 3 QL (1 EA per 90 days) DEXCOM RECEIVER Tier 3 QL (1 EA per 365 days) DROPLET LANCETS Tier 2 DROPLET PEN NEEDLE NEEDLE 32 GAUGE X Tier 2 QL (1000 EA per 30 days) 5/32" EASY COMFORT LANCETS Tier 2 EASY COMFORT PEN NEEDLES NEEDLE 31 Tier 2 QL (1000 EA per 30 days) GAUGE X 3/16" EASY TOUCH ALCOHOL PREP PADS TOPICAL Tier 2 QL (300 EA per 30 days) PADS, MEDICATED EASY TOUCH FLIPLOCK NEEDLE NEEDLE 22 Tier 2 QL (1000 EA per 30 days) GAUGE X 3/4", 25 GAUGE X 1 1/2" EASY TOUCH HYPODERMIC NEEDLE NEEDLE 32 Tier 2 QL (1000 EA per 30 days) GAUGE X 5/16" EASY TOUCH INSULIN SYRINGE SYRINGE 0.5 ML Tier 2 QL (1000 EA per 30 days) 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16 EASY TOUCH NEEDLE 31 GAUGE X 1/4", 31 Tier 2 QL (1000 EA per 30 days) GAUGE X 3/16", 31 GAUGE X 5/16" EXEL HYPODERMIC NEEDLES NEEDLE 27 GAUGE Tier 2 QL (1000 EA per 30 days) X 1/2" e-z ject lancets 26 gauge Tier 1 EZ SMART LANCETS Tier 2 FIFTY50 SAFETY SEAL LANCETS 30 GAUGE Tier 2 FINE 30 UNIVERSAL LANCETS Tier 2 FINGERSTIX LANCETS Tier 2 FLOW-EZE VENTED NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days) FORA V10-V12-D10-D20 STRP-LNCT COMBO Tier 3 PACK FORACARE LANCETS Tier 2

78 Drug Name Drug Tier Requirements/Limits FREESTYLE LANCETS Tier 2 FREESTYLE LIBRE 14 DAY READER Tier 3 QL (1 EA per 365 days) FREESTYLE LIBRE 14 DAY SENSOR KIT Tier 3 QL (6 EA per 90 days) FREESTYLE LIBRE 2 READER Tier 3 QL (1 EA per 365 days) FREESTYLE LIBRE 2 SENSOR KIT Tier 3 QL (6 EA per 90 days) FREESTYLE UNISTIK 2 Tier 2 GLUCOCOM LANCETS 28 GAUGE, 33 GAUGE Tier 2 HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 Tier 2 QL (1000 EA per 30 days) GAUGE X 1/2", 31 GAUGE X 1/4" HEALTHY ACCENTS UNILET LANCET Tier 2 HUBER SAFETY NEEDLES (DISP.) NEEDLE Tier 2 QL (1000 EA per 30 days) HYPODERMIC NEEDLES NEEDLE 18 GAUGE X 1 Tier 2 QL (1000 EA per 30 days) 1/2", 23 GAUGE X 1" INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/2", 31 GAUGE X 5/16" INCONTROL SUPER THIN LANCETS Tier 2 INCONTROL ULTRA THIN LANCETS Tier 2 INJECT EASE LANCETS 28 GAUGE Tier 2 INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 29 Tier 2 QL (1000 EA per 30 days) GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 29 , 1/2 ML 30 GAUGE, 1/2 ML 31 GAUGE X 15/64" INSUPEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days) INVACARE LANCETS Tier 2 KETO-DIASTIX STRIP Tier 2 QL (102 EA per 30 days) KETONE URINE TEST STRIP Tier 2 QL (102 EA per 30 days) KETOSTIX STRIP Tier 2 QL (102 EA per 30 days) lancets Tier 2 LANCETS 30 GAUGE, 33 GAUGE Tier 2 LANCETS,THIN Tier 2 LANCETS,ULTRA THIN 26 GAUGE Tier 2 LIFESHIELD BLUNT CANNULA NEEDLE Tier 2 QL (1000 EA per 30 days) LITE TOUCH LANCETS 33 GAUGE Tier 2 MEDISENSE THIN LANCETS Tier 2

79 Drug Name Drug Tier Requirements/Limits MEDLANCE PLUS LANCETS 25 GAUGE Tier 2 MEDLANCE PLUS SPECIAL BLADE Tier 3 MICRO THIN LANCETS Tier 2 MICROLET LANCET Tier 2 MINI ULTRA-THIN II NEEDLE Tier 2 QL (1000 EA per 30 days) MONOJECT BLOOD COLLECTION NEEDLE 20 Tier 2 QL (1000 EA per 30 days) GAUGE X 1" MONOJECT HYPODERMIC NEEDLES NEEDLE 18 Tier 2 QL (1000 EA per 30 days) GAUGE X 1" MONOJECT MEDICATION TRANSF NDL NEEDLE Tier 2 QL (1000 EA per 30 days) MONOJECT ULTRA COMFORT INSULIN SYRINGE Tier 2 QL (1000 EA per 30 days) MONOLET THIN LANCETS Tier 2 MULTI-DRAW NEEDLE NEEDLE 20 GAUGE X 1" Tier 2 QL (1000 EA per 30 days) MYGLUCOHEALTH LANCETS Tier 2 NEEDLES, HUBER DISPOSABLE NEEDLE Tier 2 QL (1000 EA per 30 days) NOKOR NEEDLE NEEDLE 16 GAUGE X 1" Tier 2 QL (1000 EA per 30 days) NOVA SAFETY LANCETS 28 GAUGE Tier 2 NOVA SUREFLEX LANCETS Tier 2 NOVOFINE 32 NEEDLE Tier 2 QL (1000 EA per 30 days) NOVOFINE AUTOCOVER NEEDLE Tier 2 QL (1000 EA per 30 days) NOVOFINE PLUS NEEDLE Tier 2 QL (1000 EA per 30 days) NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN Tier 3 OMNIPOD DASH 5 PACK POD SUBCUTANEOUS Tier 2 CARTRIDGE ON CALL LANCET Tier 2 ON CALL PLUS LANCET Tier 2 ONETOUCH DELICA LANCETS Tier 2 ONETOUCH ULTRA2 METER Tier 2 QL (1 EA per 365 days) ONETOUCH ULTRA2 METER KIT Tier 2 QL (1 EA per 365 days) ONETOUCH ULTRAMINI KIT Tier 2 QL (1 EA per 365 days) ONETOUCH ULTRASOFT LANCETS Tier 2 ONETOUCH VERIO FLEX METER Tier 2 QL (1 EA per 365 days) ONETOUCH VERIO FLEX START KIT Tier 2 QL (1 EA per 365 days) ONETOUCH VERIO IQ METER Tier 2 QL (1 EA per 365 days) ONETOUCH VERIO IQ METER KIT Tier 2 QL (1 EA per 365 days)

80 Drug Name Drug Tier Requirements/Limits ONETOUCH VERIO METER Tier 2 QL (1 EA per 365 days) ONETOUCH VERIO REFLECT METER Tier 2 QL (1 EA per 365 days) ONETOUCH VERIO REFLECT START KIT Tier 2 QL (1 EA per 365 days) ON-THE-GO LANCETS Tier 2 PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 5/16" PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 2 QL (1000 EA per 30 days) GAUGE X 5/32" PENTIPS NEEDLE 31 GAUGE X 1/4", 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 5/16" PHASEAL PROTECTOR DEVICE 20 MM Tier 2 QL (1000 EA per 30 days) POLY HUB NEEDLE NEEDLE 18 GAUGE X 1" Tier 2 QL (1000 EA per 30 days) PRECISION XTRA B-KETONE STRIP Tier 2 QL (102 EA per 30 days) PRESSURE ACTIVATED LANCETS 21 GAUGE Tier 2 PRO COMFORT LANCET 30 GAUGE Tier 2 PRODIGY LANCETS 28 GAUGE Tier 2 PRODIGY TWIST TOP LANCET Tier 2 RELIAMED LANCET 28 GAUGE Tier 2 RELIAMED SAFETY SEAL LANCETS 28 GAUGE Tier 2 RELION NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days) RELION PEN NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days) RELION THIN LANCETS Tier 2 RELION ULTRA THIN PLUS LANCETS Tier 2 RIGHTEST GL300 LANCETS Tier 2 SAFETY LANCETS 21 GAUGE Tier 2 SAFETY SEAL LANCETS 28 GAUGE Tier 2 SAFETY-LET LANCETS Tier 2 SINGLE-LET Tier 2 SMART SENSE LANCETS 26 GAUGE, 33 GAUGE Tier 2 SMARTEST LANCET Tier 2 SOFT TOUCH LANCETS Tier 2 SOLUS V2 LANCETS 30 GAUGE Tier 2 STERILANCE TL 30 GAUGE Tier 2 SUPER THIN LANCETS 30 GAUGE Tier 2

81 Drug Name Drug Tier Requirements/Limits SURE COMFORT INSULIN SYRINGE SYRINGE 1 Tier 2 QL (1000 EA per 30 days) ML 30 GAUGE X 5/16 SURE COMFORT LANCETS 28 GAUGE Tier 2 SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE Tier 2 QL (1000 EA per 30 days) X 1/2", 31 GAUGE X 3/16" SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X Tier 2 QL (1000 EA per 30 days) 1/2" SURE-LANCE 28 GAUGE Tier 2 SURE-TOUCH LANCET Tier 2 SURGUARD2 SAFETY NEEDLE 18 GAUGE X 1" Tier 2 QL (1000 EA per 30 days) TECHLITE LANCETS 25 GAUGE Tier 2 TECHLITE PEN NEEDLE NEEDLE 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 5/16" TOPCARE UNIVERSAL1 LANCET Tier 2 TRUEPLUS INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 2 QL (1000 EA per 30 days) GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 TRUEPLUS LANCETS Tier 2 TRUEPLUS PEN NEEDLE NEEDLE 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 2 QL (1000 EA per 30 days) GAUGE X 5/32" ULTICARE SYRINGE 0.5 ML 30 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days) ULTILET BASIC LANCETS Tier 2 ULTILET CLASSIC LANCETS , 30 GAUGE Tier 2 ULTILET LANCETS 28 GAUGE Tier 2 ULTILET PEN NEEDLE NEEDLE 29 GAUGE Tier 2 QL (1000 EA per 30 days) ULTILET SAFETY LANCETS Tier 2 ULTRA COMFORT INSULIN SYRINGE SYRINGE Tier 2 QL (1000 EA per 30 days) 1/2 ML 28 GAUGE ULTRA THIN LANCETS 28 GAUGE, 31 GAUGE Tier 2 ULTRA THIN PLUS LANCETS Tier 2 ULTRA TLC LANCETS Tier 2 ULTRALANCE LANCETS 26 GAUGE Tier 2 ULTRA-THIN II (SHORT) PEN NDL NEEDLE Tier 2 QL (1000 EA per 30 days) ULTRA-THIN II INS PEN NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days)

82 Drug Name Drug Tier Requirements/Limits UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31 Tier 2 QL (1000 EA per 30 days) GAUGE X 5/16" UNIFINE PENTIPS PLUS NEEDLE 31 GAUGE X Tier 2 QL (1000 EA per 30 days) 3/16", 31 GAUGE X 5/16" UNILET COMFORTOUCH LANCET 26 GAUGE Tier 2 UNILET EXCELITE II LANCET Tier 2 UNILET EXCELITE LANCET Tier 2 UNILET GP LANCET Tier 2 UNILET LANCET 28 GAUGE Tier 2 UNISTIK 3 EXTRA LANCET Tier 2 UNISTIK CZT LANCET 23 GAUGE Tier 2 UNISTIK SAFETY 30 GAUGE Tier 2 UNISTIK TOUCH LANCETS 28 GAUGE Tier 2 UNIVERSAL 1 LANCETS 26 GAUGE Tier 2 V-GO 20 DEVICE Tier 2 V-GO 30 DEVICE Tier 2 V-GO 40 DEVICE Tier 2 Insulin Therapy ADMELOG SOLOSTAR U-100 INSULIN Tier 3 ST SUBCUTANEOUS INSULIN PEN ADMELOG U-100 INSULIN LISPRO Tier 3 ST SUBCUTANEOUS SOLUTION AFREZZA INHALATION CARTRIDGE WITH Tier 3 INHALER APIDRA SOLOSTAR U-100 INSULIN Tier 3 ST SUBCUTANEOUS INSULIN PEN APIDRA U-100 INSULIN SUBCUTANEOUS Tier 3 ST SOLUTION FIASP FLEXTOUCH U-100 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN FIASP PENFILL U-100 INSULIN SUBCUTANEOUS Tier 2 CARTRIDGE FIASP U-100 INSULIN SUBCUTANEOUS Tier 2 SOLUTION HUMALOG JUNIOR KWIKPEN U-100 Tier 3 ST SUBCUTANEOUS INSULIN PEN, HALF-UNIT

83 Drug Name Drug Tier Requirements/Limits HUMALOG KWIKPEN INSULIN SUBCUTANEOUS Tier 3 ST INSULIN PEN HUMALOG MIX 50-50 INSULN U-100 Tier 3 SUBCUTANEOUS SUSPENSION HUMALOG MIX 50-50 KWIKPEN Tier 3 SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25 KWIKPEN Tier 3 ST SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25(U-100)INSULN Tier 3 ST SUBCUTANEOUS SUSPENSION HUMALOG U-100 INSULIN SUBCUTANEOUS Tier 3 ST CARTRIDGE HUMALOG U-100 INSULIN SUBCUTANEOUS Tier 3 ST SOLUTION HUMULIN 70/30 U-100 INSULIN Tier 3 ST SUBCUTANEOUS SUSPENSION HUMULIN 70/30 U-100 KWIKPEN Tier 3 ST SUBCUTANEOUS INSULIN PEN HUMULIN N NPH INSULIN KWIKPEN Tier 3 ST SUBCUTANEOUS INSULIN PEN HUMULIN N NPH U-100 INSULIN Tier 3 ST SUBCUTANEOUS SUSPENSION HUMULIN R REGULAR U-100 INSULN INJECTION Tier 3 ST SOLUTION HUMULIN R U-500 (CONC) INSULIN Tier 2 SUBCUTANEOUS SOLUTION HUMULIN R U-500 (CONC) KWIKPEN Tier 2 SUBCUTANEOUS INSULIN PEN INSULIN LISPRO PROTAMIN-LISPRO Tier 3 ST SUBCUTANEOUS INSULIN PEN INSULIN LISPRO SUBCUTANEOUS INSULIN PEN Tier 3 ST INSULIN LISPRO SUBCUTANEOUS INSULIN PEN, Tier 3 ST HALF-UNIT INSULIN LISPRO SUBCUTANEOUS SOLUTION Tier 3 ST LANTUS SOLOSTAR U-100 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN LANTUS U-100 INSULIN SUBCUTANEOUS Tier 2 SOLUTION

84 Drug Name Drug Tier Requirements/Limits LEVEMIR FLEXTOUCH U-100 INSULN Tier 2 SUBCUTANEOUS INSULIN PEN LEVEMIR U-100 INSULIN SUBCUTANEOUS Tier 2 SOLUTION LYUMJEV KWIKPEN U-100 INSULIN Tier 3 ST SUBCUTANEOUS INSULIN PEN LYUMJEV KWIKPEN U-200 INSULIN Tier 3 ST SUBCUTANEOUS INSULIN PEN LYUMJEV U-100 INSULIN SUBCUTANEOUS Tier 3 ST SOLUTION NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS Tier 2 SUSPENSION NOVOLIN 70-30 FLEXPEN U-100 Tier 2 SUBCUTANEOUS INSULIN PEN NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN Tier 2 PEN NOVOLIN N NPH U-100 INSULIN Tier 2 SUBCUTANEOUS SUSPENSION NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN Tier 2 PEN NOVOLIN R REGULAR U-100 INSULN INJECTION Tier 2 SOLUTION NOVOLOG FLEXPEN U-100 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN NOVOLOG MIX 70-30 U-100 INSULN Tier 2 SUBCUTANEOUS SOLUTION NOVOLOG MIX 70-30FLEXPEN U-100 Tier 2 SUBCUTANEOUS INSULIN PEN NOVOLOG PENFILL U-100 INSULIN Tier 2 SUBCUTANEOUS CARTRIDGE NOVOLOG U-100 INSULIN ASPART Tier 2 SUBCUTANEOUS SOLUTION SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN Tier 2 TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS Tier 2 INSULIN PEN TOUJEO SOLOSTAR U-300 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS Tier 2 INSULIN PEN

85 Drug Name Drug Tier Requirements/Limits TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS Tier 2 INSULIN PEN TRESIBA U-100 INSULIN SUBCUTANEOUS Tier 2 SOLUTION Miscellaneous Hormones ANADROL-50 ORAL TABLET 50 MG Tier 3 PA ANDRODERM TRANSDERMAL PATCH 24 HOUR Tier 3 PA ANDROID ORAL CAPSULE 10 MG Tier 3 PA BRAVELLE INJECTION RECON SOLN Tier 3 # cabergoline oral tablet Tier 1 calcitonin (salmon) nasal spray,non-aerosol Tier 1 calcitriol oral capsule Tier 1 calcitriol oral solution Tier 1 CERDELGA ORAL CAPSULE Tier 3 PA; SPRx CETROTIDE SUBCUTANEOUS KIT Tier 3 # cinacalcet oral tablet Tier 1 SPRx danazol oral capsule Tier 1 DDAVP NASAL SOLUTION Tier 3 DDAVP ORAL TABLET Tier 3 DEPO-TESTOSTERONE INTRAMUSCULAR OIL Tier 3 PA desmopressin nasal spray with pump Tier 1 desmopressin nasal spray,non-aerosol Tier 1 desmopressin oral tablet Tier 1 doxercalciferol oral capsule Tier 1 FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE Tier 3 # GALAFOLD ORAL CAPSULE Tier 3 PA; LD; SPRx GANIRELIX SUBCUTANEOUS SYRINGE Tier 3 # GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN Tier 3 # INJECTOR GONAL-F RFF SUBCUTANEOUS RECON SOLN Tier 3 # GONAL-F SUBCUTANEOUS RECON SOLN Tier 3 # ISTURISA ORAL TABLET Tier 3 PA; SPRx JYNARQUE ORAL TABLET Tier 3 SPRx JYNARQUE ORAL TABLETS, SEQUENTIAL Tier 3 SPRx KORLYM ORAL TABLET Tier 3 PA; SPRx

86 Drug Name Drug Tier Requirements/Limits KUVAN ORAL POWDER IN PACKET Tier 3 SPRx KUVAN ORAL TABLET,SOLUBLE Tier 3 SPRx MENOPUR SUBCUTANEOUS RECON SOLN Tier 3 # METHITEST ORAL TABLET Tier 3 PA methyltestosterone oral capsule Tier 1 PA MIACALCIN INJECTION SOLUTION Tier 2 miglustat oral capsule Tier 1 LD; SPRx MYALEPT SUBCUTANEOUS RECON SOLN Tier 3 PA; LD; SPRx NATPARA SUBCUTANEOUS CARTRIDGE Tier 3 PA; LD; SPRx ORILISSA ORAL TABLET Tier 2 PA OVIDREL SUBCUTANEOUS SYRINGE Tier 3 # OXANDRIN ORAL TABLET Tier 3 PA oxandrolone oral tablet Tier 1 PA PALYNZIQ SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx paricalcitol oral capsule Tier 1 PREGNYL INTRAMUSCULAR RECON SOLN Tier 3 # ROCALTROL ORAL CAPSULE Tier 3 ROCALTROL ORAL SOLUTION Tier 3 SAMSCA ORAL TABLET Tier 3 SPRx sapropterin oral powder in packet Tier 1 SPRx sapropterin oral tablet,soluble Tier 1 SPRx SENSIPAR ORAL TABLET Tier 3 SPRx SOMAVERT SUBCUTANEOUS RECON SOLN Tier 3 PA; SPRx STRENSIQ SUBCUTANEOUS SOLUTION Tier 2 PA; LD; SPRx SYNAREL NASAL SPRAY,NON-AEROSOL Tier 3 testosterone cypionate intramuscular oil Tier 1 PA testosterone enanthate intramuscular oil Tier 1 PA testosterone transdermal gel Tier 1 PA testosterone transdermal gel in metered-dose Tier 1 PA pump testosterone transdermal gel in packet Tier 1 PA TESTRED ORAL CAPSULE 10 MG Tier 3 PA tolvaptan oral tablet 30 mg Tier 1 SPRx ZAVESCA ORAL CAPSULE Tier 3 LD; SPRx ZEMPLAR ORAL CAPSULE Tier 3

87 Drug Name Drug Tier Requirements/Limits Non-Insulin Hypoglycemic Agents acarbose oral tablet Tier 1 ACTOPLUS MET ORAL TABLET Tier 3 ACTOS ORAL TABLET Tier 3 AMARYL ORAL TABLET Tier 3 AVANDIA ORAL TABLET Tier 3 BYDUREON BCISE SUBCUTANEOUS AUTO- Tier 2 INJECTOR BYDUREON SUBCUTANEOUS PEN INJECTOR 2 Tier 2 MG/0.65 ML BYETTA SUBCUTANEOUS PEN INJECTOR Tier 2 CYCLOSET ORAL TABLET Tier 3 DUETACT ORAL TABLET Tier 3 FARXIGA ORAL TABLET Tier 2 glimepiride oral tablet Tier 1 glipizide oral tablet Tier 1 glipizide oral tablet extended release 24hr Tier 1 glipizide-metformin oral tablet Tier 1 GLUCOPHAGE ORAL TABLET Tier 3 GLUCOPHAGE XR ORAL TABLET EXTENDED Tier 3 RELEASE 24 HR GLUCOTROL ORAL TABLET Tier 3 GLUCOTROL XL ORAL TABLET EXTENDED Tier 3 RELEASE 24HR glyburide micronized oral tablet Tier 1 glyburide oral tablet Tier 1 glyburide-metformin oral tablet Tier 1 GLYNASE ORAL TABLET Tier 3 GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG Tier 3 GLYXAMBI ORAL TABLET Tier 2 INVOKAMET ORAL TABLET Tier 2 INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR INVOKANA ORAL TABLET Tier 2 JANUMET ORAL TABLET Tier 2

88 Drug Name Drug Tier Requirements/Limits JANUMET XR ORAL TABLET, ER MULTIPHASE 24 Tier 2 HR JANUVIA ORAL TABLET Tier 2 JARDIANCE ORAL TABLET Tier 2 JENTADUETO ORAL TABLET Tier 2 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR metformin oral solution Tier 1 metformin oral tablet Tier 1 metformin oral tablet extended release 24 hr Tier 1 Generic for Glucophage XR miglitol oral tablet Tier 1 nateglinide oral tablet Tier 1 OZEMPIC SUBCUTANEOUS PEN INJECTOR Tier 2 pioglitazone oral tablet Tier 1 pioglitazone-glimepiride oral tablet Tier 1 pioglitazone-metformin oral tablet Tier 1 PRANDIN ORAL TABLET 1 MG, 2 MG Tier 3 PRECOSE ORAL TABLET Tier 3 repaglinide oral tablet Tier 1 repaglinide-metformin oral tablet Tier 1 RIOMET ER ORAL SUSPENSION,EXTENDED REL Tier 3 RECON RIOMET ORAL SOLUTION Tier 3 RYBELSUS ORAL TABLET Tier 2 STARLIX ORAL TABLET 120 MG, 60 MG Tier 3 SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR Tier 3 SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR Tier 3 SYNJARDY ORAL TABLET Tier 2 SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR TRADJENTA ORAL TABLET Tier 2 TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR TRULICITY SUBCUTANEOUS PEN INJECTOR Tier 2 XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR

89 Drug Name Drug Tier Requirements/Limits Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 3 CYTOMEL ORAL TABLET Tier 3 euthyrox oral tablet Tier 1 levo-t oral tablet Tier 1 oral tablet Tier 1 levoxyl oral tablet Tier 1 liothyronine oral tablet Tier 1 np thyroid oral tablet Tier 1 SYNTHROID ORAL TABLET Tier 3 THYROLAR-1 ORAL TABLET Tier 3 THYROLAR-1/2 ORAL TABLET Tier 3 THYROLAR-1/4 ORAL TABLET Tier 3 THYROLAR-2 ORAL TABLET Tier 3 THYROLAR-3 ORAL TABLET Tier 3 TIROSINT ORAL CAPSULE Tier 3 TIROSINT-SOL ORAL SOLUTION Tier 3 unithroid oral tablet Tier 1 westhroid oral tablet Tier 1 Gastroenterology Antidiarrheals & Antispasmodics chlordiazepoxide-clidinium oral capsule Tier 1 CUVPOSA ORAL SOLUTION Tier 3 dicyclomine oral capsule Tier 1 dicyclomine oral solution Tier 1 dicyclomine oral tablet Tier 1 diphenoxylate-atropine oral liquid Tier 1 diphenoxylate-atropine oral tablet Tier 1 DONNATAL ORAL ELIXIR Tier 3 DONNATAL ORAL TABLET Tier 3 glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 hyoscyamine sulfate oral drops Tier 1 hyoscyamine sulfate oral elixir Tier 1 hyoscyamine sulfate oral tablet Tier 1

90 Drug Name Drug Tier Requirements/Limits hyoscyamine sulfate oral tablet extended release Tier 1 12 hr hyoscyamine sulfate oral tablet,disintegrating Tier 1 hyoscyamine sulfate sublingual tablet Tier 1 LEVBID ORAL TABLET EXTENDED RELEASE 12 HR Tier 3 LEVSIN ORAL TABLET Tier 3 LEVSIN/SL SUBLINGUAL TABLET Tier 3 LIBRAX (WITH CLIDINIUM) ORAL CAPSULE Tier 3 LOMOTIL ORAL TABLET Tier 3 methscopolamine oral tablet Tier 1 MOTOFEN ORAL TABLET Tier 3 MYTESI ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) NULEV ORAL TABLET,DISINTEGRATING Tier 3 phenobarb-hyoscy-atropine-scop oral elixir 16.2- Tier 1 0.1037 -0.0194 mg/5 ml phenobarb-hyoscy-atropine-scop oral tablet Tier 1 propantheline oral tablet 15 mg Tier 1 Miscellaneous Gastrointestinal Agents ACTIGALL ORAL CAPSULE 300 MG Tier 3 alosetron oral tablet Tier 1 AMITIZA ORAL CAPSULE Tier 3 anucort-hc rectal suppository Tier 1 ANUSOL-HC RECTAL SUPPOSITORY Tier 3 aprepitant oral capsule Tier 1 aprepitant oral capsule,dose pack Tier 1 AURYXIA ORAL TABLET Tier 3 AZULFIDINE EN-TABS ORAL TABLET,DELAYED Tier 3 RELEASE (DR/EC) AZULFIDINE ORAL TABLET Tier 3 balsalazide oral capsule Tier 1 bisacodyl oral tablet,delayed release (dr/ec) Tier 1 ACA oral capsule,delayed,extend.release Tier 1 budesonide oral tablet,delayed and ext.release Tier 1 calcium acetate(phosphat bind) oral capsule Tier 1 calcium acetate(phosphat bind) oral tablet Tier 1

91 Drug Name Drug Tier Requirements/Limits CANASA RECTAL SUPPOSITORY Tier 2 CESAMET ORAL CAPSULE 1 MG Tier 3 CHENODAL ORAL TABLET Tier 3 LD; SPRx CHOLBAM ORAL CAPSULE Tier 3 PA; SPRx CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx KIT CIMZIA SUBCUTANEOUS SYRINGE KIT Tier 3 PA; SPRx citrate of magnesia oral solution Tier 1 ACA clearlax oral powder Tier 1 ACA clearlax oral powder in packet Tier 1 ACA CLENPIQ ORAL SOLUTION Tier 2 ACA COLAZAL ORAL CAPSULE Tier 3 COMPAZINE ORAL TABLET Tier 3 COMPAZINE RECTAL SUPPOSITORY Tier 3 compro rectal suppository Tier 1 constulose oral solution Tier 1 CORTENEMA RECTAL ENEMA Tier 3 CORTIFOAM RECTAL FOAM Tier 3 CREON ORAL CAPSULE,DELAYED Tier 2 RELEASE(DR/EC) cromolyn oral concentrate Tier 1 CYSTADANE ORAL POWDER Tier 3 SPRx dronabinol oral capsule Tier 1 dulcolax (magnesium hydroxide) oral suspension Tier 1 ACA EMEND ORAL CAPSULE Tier 3 EMEND ORAL CAPSULE,DOSE PACK Tier 3 ENTOCORT EC ORAL Tier 3 CAPSULE,DELAYED,EXTEND.RELEASE enulose oral solution Tier 1 FOSRENOL ORAL POWDER IN PACKET Tier 3 FOSRENOL ORAL TABLET,CHEWABLE Tier 3 GASTROCROM ORAL CONCENTRATE Tier 3 GATTEX 30-VIAL SUBCUTANEOUS KIT Tier 3 PA; SPRx GATTEX ONE-VIAL SUBCUTANEOUS KIT Tier 3 PA; SPRx gavilyte-c oral recon soln Tier 1 ACA

92 Drug Name Drug Tier Requirements/Limits gavilyte-g oral recon soln Tier 1 ACA gavilyte-n oral recon soln Tier 1 ACA generlac oral solution Tier 1 gentle laxative (bisacodyl) oral tablet,delayed Tier 1 ACA release (dr/ec) GOLYTELY ORAL POWDER IN PACKET 227.1- Tier 3 ACA 21.5-6.36 GRAM GOLYTELY ORAL RECON SOLN Tier 3 granisetron hcl oral tablet Tier 1 hemmorex-hc rectal suppository Tier 1 hydrocortisone acetate rectal suppository Tier 1 hydrocortisone rectal enema Tier 1 hydrocortisone topical cream with perineal Tier 1 applicator hydrocortisone-pramoxine rectal cream 1-1 % Tier 1 kionex (with sorbitol) oral suspension 15-19.3 Tier 1 gram/60 ml KRISTALOSE ORAL PACKET Tier 2 lactulose oral solution Tier 1 lanthanum oral tablet,chewable Tier 1 laxaclear oral powder Tier 1 ACA laxative (bisacodyl) oral tablet,delayed release Tier 1 ACA (dr/ec) laxative peg 3350 oral powder Tier 1 ACA lidocaine hcl-hydrocortison ac rectal cream Tier 1 lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, Tier 1 3-1 % (7 gram) lidocaine-hydrocortisone-aloe rectal gel Tier 1 lidocaine-hydrocortisone-aloe rectal kit Tier 1 LINZESS ORAL CAPSULE Tier 2 LOTRONEX ORAL TABLET Tier 3 magnesium citrate oral solution Tier 1 ACA MARINOL ORAL CAPSULE Tier 3 mesalamine oral capsule,extended release 24hr Tier 1 mesalamine oral tablet,delayed release (dr/ec) Tier 1 mesalamine rectal enema Tier 1

93 Drug Name Drug Tier Requirements/Limits mesalamine rectal suppository Tier 1 mesalamine with cleansing wipe rectal enema kit Tier 1 metoclopramide hcl oral solution Tier 1 metoclopramide hcl oral tablet Tier 1 MOVANTIK ORAL TABLET Tier 2 NULYTELY LEMON-LIME ORAL RECON SOLN Tier 3 ACA NULYTELY WITH FLAVOR PACKS ORAL RECON Tier 3 ACA SOLN 420 GRAM OCALIVA ORAL TABLET Tier 3 PA; LD; SPRx ondansetron hcl oral solution Tier 1 ondansetron hcl oral tablet Tier 1 ondansetron oral tablet,disintegrating Tier 1 peg 3350-electrolytes oral recon soln Tier 1 ACA peg-3350 with flavor packs oral recon soln Tier 1 ACA peg-electrolyte soln oral recon soln Tier 1 ACA peg-prep oral kit Tier 1 ACA PENTASA ORAL CAPSULE, EXTENDED RELEASE Tier 2 ST PHOSLYRA ORAL SOLUTION Tier 2 phosphate laxative oral liquid Tier 1 ACA polyethylene glycol 3350 oral powder Tier 1 ACA polyethylene glycol 3350 oral powder in packet Tier 1 ACA powderlax oral powder in packet Tier 1 ACA prochlorperazine maleate oral tablet Tier 1 prochlorperazine rectal suppository Tier 1 PROCTOCORT RECTAL SUPPOSITORY Tier 3 procto-med hc topical cream with perineal Tier 1 applicator procto-pak topical cream with perineal applicator Tier 1 proctosol hc topical cream with perineal Tier 1 applicator proctozone-hc topical cream with perineal Tier 1 applicator REGLAN ORAL TABLET Tier 3 RELISTOR SUBCUTANEOUS SOLUTION Tier 3 RELISTOR SUBCUTANEOUS SYRINGE Tier 3 RENAGEL ORAL TABLET Tier 3

94 Drug Name Drug Tier Requirements/Limits RENVELA ORAL POWDER IN PACKET Tier 3 RENVELA ORAL TABLET Tier 3 ROWASA RECTAL ENEMA KIT Tier 3 scopolamine base transdermal patch 3 day Tier 1 sevelamer carbonate oral powder in packet Tier 1 sevelamer carbonate oral tablet Tier 1 sevelamer hcl oral tablet Tier 1 sodium polystyrene (sorb free) oral suspension 15 Tier 1 gram/60 ml sodium polystyrene sulfonate oral powder Tier 1 SOLESTA IMPLANT GEL FOR IMPLANT IN Tier 3 SYRINGE sps (with sorbitol) oral suspension Tier 1 sps (with sorbitol) rectal enema Tier 1 SUCRAID ORAL SOLUTION Tier 3 sulfasalazine oral tablet Tier 1 sulfasalazine oral tablet,delayed release (dr/ec) Tier 1 SUPREP BOWEL PREP KIT ORAL RECON SOLN Tier 2 ACA SYNDROS ORAL SOLUTION Tier 3 TIGAN ORAL CAPSULE Tier 3 TRANSDERM-SCOP TRANSDERMAL PATCH 3 Tier 3 DAY trilyte with flavor packets oral recon soln Tier 1 ACA trimethobenzamide oral capsule Tier 1 UCERIS ORAL TABLET,DELAYED AND Tier 3 EXT.RELEASE URSO 250 ORAL TABLET Tier 3 URSO FORTE ORAL TABLET Tier 3 ursodiol oral capsule Tier 1 ursodiol oral tablet Tier 1 VELPHORO ORAL TABLET,CHEWABLE Tier 2 VIBERZI ORAL TABLET Tier 3 VIOKACE ORAL TABLET Tier 3 ZENPEP ORAL CAPSULE,DELAYED Tier 2 RELEASE(DR/EC) ZOFRAN ORAL TABLET Tier 3

95 Drug Name Drug Tier Requirements/Limits Ulcer Therapy amoxicil-clarithromy-lansopraz oral combo pack Tier 1 CARAFATE ORAL SUSPENSION Tier 3 CARAFATE ORAL TABLET Tier 3 cimetidine hcl oral solution Tier 1 cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1 CYTOTEC ORAL TABLET Tier 3 DEXILANT ORAL CAPSULE,BIPHASE DELAYED Tier 3 RELEAS magnesium oral capsule,delayed Tier 1 release(dr/ec) esomeprazole magnesium oral granules dr for Tier 1 susp in packet famotidine oral suspension Tier 1 famotidine oral tablet 40 mg Tier 1 lansoprazole oral capsule,delayed release(dr/ec) Tier 1 30 mg lansoprazole oral tablet,disintegrat, delay rel Tier 1 misoprostol oral tablet Tier 1 NEXIUM ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) NEXIUM PACKET ORAL GRANULES DR FOR SUSP Tier 3 IN PACKET nizatidine oral capsule Tier 1 nizatidine oral solution Tier 1 OMECLAMOX-PAK ORAL COMBO PACK Tier 2 oral capsule,delayed release(dr/ec) Tier 1 pantoprazole oral granules dr for susp in packet Tier 1 pantoprazole oral tablet,delayed release (dr/ec) Tier 1 PEPCID ORAL TABLET 40 MG Tier 3 PREVACID ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) 30 MG PREVACID SOLUTAB ORAL Tier 3 TABLET,DISINTEGRAT, DELAY REL PRILOSEC ORAL SUSP,DELAYED RELEASE FOR Tier 3 RECON

96 Drug Name Drug Tier Requirements/Limits PROTONIX ORAL GRANULES DR FOR SUSP IN Tier 3 PACKET PROTONIX ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) 20 MG rabeprazole oral tablet,delayed release (dr/ec) Tier 1 sucralfate oral suspension Tier 1 sucralfate oral tablet Tier 1 Immunology, Vaccines & Biotechnology Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION Tier 2 PA; SPRx SOLUTION ARANESP (IN POLYSORBATE) INJECTION Tier 2 PA; SPRx SYRINGE EPOGEN INJECTION SOLUTION Tier 2 PA; SPRx FULPHILA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx MACRILEN ORAL RECON SOLN Tier 3 SPRx MIRCERA INJECTION SYRINGE Tier 2 PA; SPRx MOZOBIL SUBCUTANEOUS SOLUTION Tier 3 SPRx NEULASTA ONPRO SUBCUTANEOUS SYRINGE, Tier 2 PA; SPRx W/ WEARABLE INJECTOR NEULASTA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx NEUPOGEN INJECTION SOLUTION Tier 2 SPRx NEUPOGEN INJECTION SYRINGE Tier 2 SPRx NYVEPRIA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx PROCRIT INJECTION SOLUTION Tier 2 PA; SPRx RETACRIT INJECTION SOLUTION Tier 2 PA; SPRx UDENYCA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx ZARXIO INJECTION SYRINGE Tier 2 SPRx ZIEXTENZO SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx Growth Hormones NORDITROPIN FLEXPRO SUBCUTANEOUS PEN Tier 3 PA; SPRx INJECTOR Interferons AUBAGIO ORAL TABLET Tier 3 SPRx AVONEX INTRAMUSCULAR PEN INJECTOR KIT Tier 2 SPRx AVONEX INTRAMUSCULAR SYRINGE KIT Tier 2 SPRx

97 Drug Name Drug Tier Requirements/Limits BETASERON SUBCUTANEOUS KIT Tier 3 SPRx BETASERON SUBCUTANEOUS RECON SOLN Tier 3 SPRx COPAXONE SUBCUTANEOUS SYRINGE Tier 2 SPRx dimethyl fumarate oral capsule,delayed Tier 1 SPRx release(dr/ec) EXTAVIA SUBCUTANEOUS KIT Tier 3 SPRx EXTAVIA SUBCUTANEOUS RECON SOLN Tier 3 SPRx GILENYA ORAL CAPSULE Tier 2 SPRx glatiramer subcutaneous syringe Tier 1 SPRx glatopa subcutaneous syringe Tier 1 SPRx KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR Tier 3 SPRx MAYZENT ORAL TABLET Tier 2 SPRx MAYZENT STARTER PACK ORAL TABLETS,DOSE Tier 2 SPRx PACK PEGASYS SUBCUTANEOUS SOLUTION Tier 2 SPRx PEGASYS SUBCUTANEOUS SYRINGE Tier 2 SPRx PEGINTRON SUBCUTANEOUS KIT Tier 3 SPRx PLEGRIDY INTRAMUSCULAR SYRINGE Tier 2 SPRx PLEGRIDY SUBCUTANEOUS PEN INJECTOR Tier 2 SPRx PLEGRIDY SUBCUTANEOUS SYRINGE Tier 2 SPRx POMALYST ORAL CAPSULE Tier 3 PA; LD; SPRx REBIF (WITH ALBUMIN) SUBCUTANEOUS Tier 2 SPRx SYRINGE REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR Tier 2 SPRx REBIF TITRATION PACK SUBCUTANEOUS Tier 2 SPRx SYRINGE REVLIMID ORAL CAPSULE Tier 3 PA; LD; SPRx ribavirin oral capsule Tier 1 PA; SPRx ribavirin oral tablet Tier 1 PA; SPRx SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 Tier 3 SPRx MCG TECFIDERA ORAL CAPSULE,DELAYED Tier 3 SPRx RELEASE(DR/EC) VUMERITY ORAL CAPSULE,DELAYED Tier 2 SPRx RELEASE(DR/EC) ZEPOSIA ORAL CAPSULE Tier 2 SPRx; PA

98 Drug Name Drug Tier Requirements/Limits ZEPOSIA STARTER KIT ORAL CAPSULE,DOSE Tier 2 SPRx; PA PACK ZEPOSIA STARTER PACK ORAL CAPSULE,DOSE Tier 2 SPRx; PA PACK Interleukins ACTIMMUNE SUBCUTANEOUS SOLUTION Tier 3 SPRx ALDARA TOPICAL CREAM IN PACKET Tier 3 ARCALYST SUBCUTANEOUS RECON SOLN Tier 3 PA; SPRx ILARIS (PF) SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx imiquimod topical cream in packet 5 % Tier 1 INTRON A INJECTION RECON SOLN Tier 3 SPRx INTRON A INJECTION SOLUTION Tier 3 SPRx KINERET SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx Vaccines & Miscellaneous Immunologicals ACTHIB (PF) INTRAMUSCULAR RECON SOLN Tier 3 ACA ADACEL(TDAP ADOLESN/ADULT)(PF) Tier 3 ACA INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) Tier 3 ACA INTRAMUSCULAR SYRINGE AFLURIA QD 2020-21(3YR UP)(PF) Tier 2 ACA INTRAMUSCULAR SYRINGE AFLURIA QD 2020-21(6-35MO)(PF) Tier 2 ACA INTRAMUSCULAR SYRINGE AFLURIA QUAD 2020-2021(6MO UP) Tier 2 ACA INTRAMUSCULAR SUSPENSION ASTRAZENECA COVID19 VAC(UNAPP) Tier 2 ACA INTRAMUSCULAR SUSPENSION BCG VACCINE, LIVE (PF) PERCUTANEOUS Tier 3 ACA SUSPENSION FOR RECONSTITUTION BEXSERO INTRAMUSCULAR SYRINGE Tier 3 ACA BIOTHRAX INTRAMUSCULAR SUSPENSION Tier 3 ACA BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION Tier 3 ACA BOOSTRIX TDAP INTRAMUSCULAR SYRINGE Tier 3 ACA CUTAQUIG SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx CUVITRU SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx DAPTACEL (DTAP PEDIATRIC) (PF) Tier 3 ACA INTRAMUSCULAR SUSPENSION

99 Drug Name Drug Tier Requirements/Limits ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA ENGERIX-B (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR Tier 3 ACA SYRINGE FLUAD 2020-2021 (65 YR UP)(PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUAD QUAD 2020-21(65Y UP)(PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUARIX QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUBLOK QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUCELVAX QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUCELVAX QUAD 2020-2021 INTRAMUSCULAR Tier 2 ACA SUSPENSION FLULAVAL QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUMIST QUAD 2020-2021 NASAL NASAL SPRAY Tier 2 ACA SYRINGE FLUZONE HIGHDOSE QUAD 20-21 PF Tier 2 ACA INTRAMUSCULAR SYRINGE FLUZONE QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SUSPENSION FLUZONE QUAD 2020-2021 (PF) Tier 2 ACA INTRAMUSCULAR SYRINGE FLUZONE QUAD 2020-2021 INTRAMUSCULAR Tier 2 ACA SUSPENSION GAMMAGARD LIQUID INJECTION SOLUTION Tier 3 PA; SPRx GAMMAKED INJECTION SOLUTION Tier 3 PA; SPRx GAMUNEX-C INJECTION SOLUTION Tier 3 PA; SPRx GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA GRASTEK SUBLINGUAL TABLET Tier 2 PA HAVRIX (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA HAVRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA HIBERIX (PF) INTRAMUSCULAR RECON SOLN Tier 3 ACA

100 Drug Name Drug Tier Requirements/Limits HIZENTRA SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx HIZENTRA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx HYQVIA SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR Tier 3 ACA RECON SOLN INFANRIX (DTAP) (PF) INTRAMUSCULAR Tier 3 ACA SUSPENSION INFANRIX (DTAP) (PF) INTRAMUSCULAR Tier 3 ACA SYRINGE IPOL INJECTION SUSPENSION Tier 3 ACA IXIARO (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA JANSSEN COVID-19 VACCINE (EUA) Tier 2 ACA INTRAMUSCULAR SUSPENSION KINRIX (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA KINRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA MENACTRA (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA MENQUADFI (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA MENVEO A-C-Y-W-135-DIP (PF) Tier 3 ACA INTRAMUSCULAR KIT M-M-R II (PF) SUBCUTANEOUS RECON SOLN Tier 3 ACA MODERNA COVID-19 VACCINE (EUA) Tier 2 ACA INTRAMUSCULAR SUSPENSION ODACTRA SUBLINGUAL TABLET Tier 3 PA ORALAIR SUBLINGUAL TABLET 300 INDX Tier 3 PA REACTIVITY PALFORZIA (LEVEL 1) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 2) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 3) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 4) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 5) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 6) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 7) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 8) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 9) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA (LEVEL 10) ORAL CAPSULE, SPRINKLE Tier 3 PA; SPRx PALFORZIA INITIAL DOSE ORAL CAPSULE, Tier 3 PA; SPRx SPRINKLE

101 Drug Name Drug Tier Requirements/Limits PALFORZIA LEVEL 11 MAINTENANCE ORAL Tier 3 PA; SPRx POWDER IN PACKET PEDIARIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA PENTACEL (PF) INTRAMUSCULAR KIT Tier 3 ACA PENTACEL ACTHIB COMPONENT (PF) Tier 3 ACA INTRAMUSCULAR RECON SOLN PENTACEL DTAP-IPV COMPNT (PF) Tier 3 ACA INTRAMUSCULAR SUSPENSION PFIZER COVID-19 VACCINE (EUA) INTRAMUSCULAR SUSPENSION FOR Tier 2 ACA RECONSTITUTION PNEUMOVAX-23 INJECTION SOLUTION Tier 3 ACA PNEUMOVAX-23 INJECTION SYRINGE Tier 3 ACA PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA PROQUAD (PF) SUBCUTANEOUS SUSPENSION Tier 3 ACA FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR Tier 3 ACA SUSPENSION RABAVERT (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA FOR RECONSTITUTION RAGWITEK SUBLINGUAL TABLET Tier 3 PA RECOMBIVAX HB (PF) INTRAMUSCULAR Tier 3 ACA SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR Tier 3 ACA SYRINGE ROTARIX ORAL SUSPENSION FOR Tier 3 ACA RECONSTITUTION ROTATEQ VACCINE ORAL SOLUTION Tier 3 ACA SHINGRIX (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA FOR RECONSTITUTION SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR Tier 3 ACA RECONSTITUTION STAMARIL (PF) SUBCUTANEOUS SUSPENSION Tier 3 ACA FOR RECONSTITUTION TDVAX INTRAMUSCULAR SUSPENSION Tier 3 ACA TENIVAC (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

102 Drug Name Drug Tier Requirements/Limits TENIVAC (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA TETANUS,DIPHTHERIA TOX PED(PF) Tier 3 ACA INTRAMUSCULAR SUSPENSION TICE BCG INTRAVESICAL SUSPENSION FOR Tier 3 ACA RECONSTITUTION TRUMENBA INTRAMUSCULAR SYRINGE Tier 3 ACA TWINRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA TYPHIM VI INTRAMUSCULAR SOLUTION Tier 3 ACA TYPHIM VI INTRAMUSCULAR SYRINGE Tier 3 ACA VAQTA (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA VAQTA (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA VARIVAX (PF) SUBCUTANEOUS SUSPENSION Tier 3 ACA FOR RECONSTITUTION VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF Tier 3 ACA UNIT VAXELIS (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA VAXELIS (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA VIVOTIF ORAL CAPSULE,DELAYED Tier 3 ACA RELEASE(DR/EC) 2 BILLION UNIT XEMBIFY SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR Tier 3 ACA RECONSTITUTION Musculoskeletal & Rheumatology Gout Therapy allopurinol oral tablet Tier 1 colchicine oral tablet Tier 1 febuxostat oral tablet Tier 1 probenecid oral tablet Tier 1 probenecid-colchicine oral tablet Tier 1 ULORIC ORAL TABLET Tier 2 ZYLOPRIM ORAL TABLET Tier 3 Osteoporosis Therapy ACTONEL ORAL TABLET Tier 3 alendronate oral solution Tier 1 alendronate oral tablet Tier 1

103 Drug Name Drug Tier Requirements/Limits ATELVIA ORAL TABLET,DELAYED RELEASE Tier 3 (DR/EC) BINOSTO ORAL TABLET, EFFERVESCENT Tier 3 BONIVA ORAL TABLET Tier 3 EVISTA ORAL TABLET Tier 3 FORTEO SUBCUTANEOUS PEN INJECTOR 20 Tier 3 SPRx MCG/DOSE (600MCG/2.4ML) FOSAMAX ORAL TABLET Tier 3 FOSAMAX PLUS D ORAL TABLET Tier 3 ibandronate oral tablet Tier 1 raloxifene oral tablet Tier 1 ACA risedronate oral tablet 150 mg, 35 mg, 5 mg Tier 1 risedronate oral tablet,delayed release (dr/ec) Tier 1 TERIPARATIDE SUBCUTANEOUS PEN INJECTOR Tier 3 TYMLOS SUBCUTANEOUS PEN INJECTOR Tier 3 Other Rheumatologicals ACTEMRA ACTPEN SUBCUTANEOUS PEN Tier 2 PA; SPRx INJECTOR ACTEMRA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx ARAVA ORAL TABLET Tier 3 BENLYSTA SUBCUTANEOUS AUTO-INJECTOR Tier 3 PA; SPRx BENLYSTA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx DEPEN TITRATABS ORAL TABLET Tier 3 D-PENAMINE ORAL TABLET Tier 3 ENBREL MINI SUBCUTANEOUS CARTRIDGE Tier 2 PA; SPRx ENBREL SUBCUTANEOUS RECON SOLN Tier 2 PA; SPRx ENBREL SUBCUTANEOUS SOLUTION Tier 2 PA; SPRx ENBREL SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx ENBREL SURECLICK SUBCUTANEOUS PEN Tier 2 PA; SPRx INJECTOR HUMIRA PEN CROHNS-UC-HS START Tier 2 PA; SPRx SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN PSOR-UVEITS-ADOL HS Tier 2 PA; SPRx SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN INJECTOR Tier 2 PA; SPRx KIT

104 Drug Name Drug Tier Requirements/Limits HUMIRA SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SPRx HUMIRA(CF) PEDI CROHNS STARTER Tier 2 PA; SPRx SUBCUTANEOUS SYRINGE KIT HUMIRA(CF) PEN CROHNS-UC-HS Tier 2 PA; SPRx SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN PEDIATRIC UC Tier 2 PA; SPRx SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN PSOR-UV-ADOL HS Tier 2 PA; SPRx SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN SUBCUTANEOUS PEN Tier 2 PA; SPRx INJECTOR KIT HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SPRx KEVZARA SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx KEVZARA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx leflunomide oral tablet Tier 1 OLUMIANT ORAL TABLET Tier 3 PA; SPRx ORENCIA CLICKJECT SUBCUTANEOUS AUTO- Tier 3 PA; SPRx INJECTOR ORENCIA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx OTEZLA ORAL TABLET Tier 2 PA; SPRx OTEZLA STARTER ORAL TABLETS,DOSE PACK Tier 2 PA; SPRx penicillamine oral tablet Tier 1 RIDAURA ORAL CAPSULE Tier 3 RINVOQ ORAL TABLET EXTENDED RELEASE 24 Tier 2 PA; SPRx HR SAVELLA ORAL TABLET Tier 2 SAVELLA ORAL TABLETS,DOSE PACK Tier 2 SIMPONI SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx SIMPONI SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx XELJANZ ORAL SOLUTION Tier 2 PA; SPRx XELJANZ ORAL TABLET Tier 2 PA; SPRx XELJANZ XR ORAL TABLET EXTENDED RELEASE Tier 2 PA; SPRx 24 HR Obstetrics & Gynecology Diaphragms And Other Non-Oral Contraceptives CAYA CONTOURED VAGINAL DIAPHRAGM Tier 3 ACA

105 Drug Name Drug Tier Requirements/Limits FC2 FEMALE CONDOM Tier 3 ACA FEMCAP VAGINAL DEVICE Tier 3 ACA WIDE-SEAL DIAPHRAGM 60 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 65 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 70 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 75 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 80 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 85 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 90 VAGINAL Tier 3 ACA DIAPHRAGM WIDE-SEAL DIAPHRAGM 95 VAGINAL Tier 3 ACA DIAPHRAGM Estrogens & Progestins ACTIVELLA ORAL TABLET Tier 3 ALORA TRANSDERMAL PATCH SEMIWEEKLY Tier 3 amabelz oral tablet Tier 1 ANGELIQ ORAL TABLET Tier 3 AYGESTIN ORAL TABLET Tier 3 camila oral tablet Tier 1 ACA CLIMARA PRO TRANSDERMAL PATCH WEEKLY Tier 3 CLIMARA TRANSDERMAL PATCH WEEKLY Tier 3 COMBIPATCH TRANSDERMAL PATCH Tier 2 SEMIWEEKLY covaryx h.s. oral tablet Tier 1 covaryx oral tablet Tier 1 CRINONE VAGINAL GEL 4 % Tier 3 deblitane oral tablet Tier 1 ACA DELESTROGEN INTRAMUSCULAR OIL Tier 3 DEPO-ESTRADIOL INTRAMUSCULAR OIL Tier 3 DEPO-PROVERA INTRAMUSCULAR SUSPENSION Tier 3 DEPO-PROVERA INTRAMUSCULAR SYRINGE Tier 3

106 Drug Name Drug Tier Requirements/Limits DEPO-SUBQ PROVERA 104 SUBCUTANEOUS Tier 3 ACA SYRINGE DIVIGEL TRANSDERMAL GEL IN PACKET Tier 2 dotti transdermal patch semiweekly Tier 1 DUAVEE ORAL TABLET Tier 3 eemt hs oral tablet Tier 1 eemt oral tablet Tier 1 ELESTRIN TRANSDERMAL GEL IN METERED- Tier 3 DOSE PUMP errin oral tablet Tier 1 ACA ESTRACE ORAL TABLET Tier 3 ESTRACE VAGINAL CREAM Tier 3 estradiol oral tablet Tier 1 estradiol transdermal patch semiweekly Tier 1 estradiol transdermal patch weekly Tier 1 estradiol vaginal cream Tier 1 estradiol vaginal tablet Tier 1 estradiol valerate intramuscular oil Tier 1 estradiol-norethindrone acet oral tablet Tier 1 ESTRING VAGINAL RING Tier 3 ESTROGEL TRANSDERMAL GEL IN METERED- Tier 3 DOSE PUMP estrogens-methyltestosterone oral tablet Tier 1 EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL Tier 2 FEMHRT LOW DOSE ORAL TABLET Tier 3 FEMRING VAGINAL RING Tier 3 fyavolv oral tablet Tier 1 ACA heather oral tablet Tier 1 ACA incassia oral tablet Tier 1 ACA jencycla oral tablet Tier 1 ACA jinteli oral tablet Tier 1 ACA lyleq oral tablet Tier 1 ACA lyllana transdermal patch semiweekly Tier 1 lyza oral tablet Tier 1 ACA medroxyprogesterone intramuscular suspension Tier 1 ACA

107 Drug Name Drug Tier Requirements/Limits medroxyprogesterone intramuscular syringe Tier 1 ACA medroxyprogesterone oral tablet Tier 1 MENEST ORAL TABLET Tier 3 MENOSTAR TRANSDERMAL PATCH WEEKLY Tier 3 mimvey oral tablet Tier 1 MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY Tier 2 nora-be oral tablet Tier 1 ACA norethindrone (contraceptive) oral tablet Tier 1 ACA norethindrone acetate oral tablet Tier 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 Tier 1 ACA mg-mcg, 1-5 mg-mcg norlyda oral tablet Tier 1 ACA ORTHO MICRONOR ORAL TABLET Tier 3 PREFEST ORAL TABLET Tier 3 PREMARIN ORAL TABLET Tier 2 PREMARIN VAGINAL CREAM Tier 2 PREMPHASE ORAL TABLET Tier 2 PREMPRO ORAL TABLET Tier 2 micronized oral capsule Tier 1 PROMETRIUM ORAL CAPSULE Tier 3 PROVERA ORAL TABLET Tier 3 sharobel oral tablet Tier 1 ACA tulana oral tablet Tier 1 ACA VAGIFEM VAGINAL TABLET Tier 3 VIVELLE-DOT TRANSDERMAL PATCH Tier 3 SEMIWEEKLY yuvafem vaginal tablet Tier 1 Miscellaneous Ob/Gyn CLEOCIN VAGINAL CREAM Tier 3 CLEOCIN VAGINAL SUPPOSITORY Tier 2 clindamycin phosphate vaginal cream Tier 1 CLINDESSE VAGINAL CREAM,EXTENDED Tier 3 RELEASE eluryng vaginal ring Tier 1 ACA etonogestrel-ethinyl estradiol vaginal ring Tier 1 ACA

108 Drug Name Drug Tier Requirements/Limits fem ph vaginal gel Tier 1 GYNAZOLE-1 VAGINAL CREAM Tier 3 gynol ii vaginal gel Tier 1 ACA INTRAROSA VAGINAL INSERT Tier 2 LUPANETA PACK (1 MONTH) KIT. SYRINGE AND Tier 3 PA; SPRx TABLET LUPANETA PACK (3 MONTH) KIT. SYRINGE AND Tier 3 PA; SPRx TABLET LYSTEDA ORAL TABLET Tier 3 METROGEL VAGINAL VAGINAL GEL Tier 3 metronidazole vaginal gel Tier 1 miconazole-3 vaginal suppository Tier 1 NUVARING VAGINAL RING Tier 3 NUVESSA VAGINAL GEL Tier 3 ORIAHNN ORAL CAPSULE, SEQUENTIAL Tier 2 PA OSPHENA ORAL TABLET Tier 2 RELAGARD VAGINAL GEL Tier 3 vaginal cream Tier 1 terconazole vaginal suppository Tier 1 TODAY CONTRACEPTIVE SPONGE VAGINAL Tier 3 ACA CONTRACEPTIVE SPONGE tranexamic acid oral tablet Tier 1 TRIMO-SAN JELLY VAGINAL GEL Tier 3 TWIRLA TRANSDERMAL PATCH WEEKLY Tier 3 ACA vaginal contraceptive foam vaginal foam Tier 1 ACA vandazole vaginal gel Tier 1 VCF CONTRACEPTIVE FILM VAGINAL FILM Tier 3 ACA VCF CONTRACEPTIVE GEL VAGINAL GEL Tier 3 ACA xulane transdermal patch weekly Tier 1 ACA zafemy transdermal patch weekly Tier 1 ACA Oral Contraceptives & Related Agents afirmelle oral tablet Tier 1 ACA altavera (28) oral tablet Tier 1 ACA alyacen 1/35 (28) oral tablet Tier 1 ACA alyacen 7/7/7 (28) oral tablet Tier 1 ACA

109 Drug Name Drug Tier Requirements/Limits amethia lo oral tablets,dose pack,3 month 0.10 Tier 1 ACA mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month Tier 1 ACA amethyst (28) oral tablet Tier 1 ACA apri oral tablet Tier 1 ACA aranelle (28) oral tablet Tier 1 ACA ashlyna oral tablets,dose pack,3 month Tier 1 ACA aubra eq oral tablet Tier 1 ACA aubra oral tablet Tier 1 ACA aurovela 1.5/30 (21) oral tablet Tier 1 ACA aurovela 1/20 (21) oral tablet Tier 1 ACA aurovela 24 fe oral tablet Tier 1 ACA aurovela fe 1.5/30 (28) oral tablet Tier 1 ACA aurovela fe 1-20 (28) oral tablet Tier 1 ACA aviane oral tablet Tier 1 ACA ayuna oral tablet Tier 1 ACA azurette (28) oral tablet Tier 1 ACA BALCOLTRA ORAL TABLET Tier 3 ACA balziva (28) oral tablet Tier 1 ACA bekyree (28) oral tablet Tier 1 ACA BEYAZ ORAL TABLET Tier 3 blisovi 24 fe oral tablet Tier 1 ACA blisovi fe 1.5/30 (28) oral tablet Tier 1 ACA blisovi fe 1/20 (28) oral tablet Tier 1 ACA briellyn oral tablet Tier 1 ACA camrese lo oral tablets,dose pack,3 month Tier 1 ACA camrese oral tablets,dose pack,3 month Tier 1 ACA caziant (28) oral tablet Tier 1 ACA charlotte 24 fe oral tablet,chewable Tier 1 ACA chateal (28) oral tablet Tier 1 ACA chateal eq (28) oral tablet Tier 1 ACA cryselle (28) oral tablet Tier 1 ACA cyclafem 1/35 (28) oral tablet Tier 1 ACA cyclafem 7/7/7 (28) oral tablet Tier 1 ACA cyred eq oral tablet Tier 1 ACA

110 Drug Name Drug Tier Requirements/Limits cyred oral tablet Tier 1 ACA dasetta 1/35 (28) oral tablet Tier 1 ACA dasetta 7/7/7 (28) oral tablet Tier 1 ACA daysee oral tablets,dose pack,3 month Tier 1 ACA desog-e.estradiol/e.estradiol oral tablet Tier 1 ACA DOLISHALE ORAL TABLET Tier 1 ACA drospirenone-e.estradiol-lm.fa oral tablet Tier 1 ACA drospirenone-ethinyl estradiol oral tablet Tier 1 ACA econtra ez oral tablet Tier 1 ACA; QL (2 EA per 365 days) econtra one-step oral tablet Tier 1 ACA; QL (2 EA per 365 days) elinest oral tablet Tier 1 ACA ELLA ORAL TABLET Tier 3 ACA; QL (2 EA per 365 days) emoquette oral tablet Tier 1 ACA enpresse oral tablet Tier 1 ACA enskyce oral tablet Tier 1 ACA estarylla oral tablet Tier 1 ACA ESTROSTEP FE-28 ORAL TABLET Tier 3 ethynodiol diac-eth estradiol oral tablet Tier 1 ACA falmina (28) oral tablet Tier 1 ACA fayosim oral tablets,dose pack,3 month Tier 1 ACA femynor oral tablet Tier 1 ACA GENERESS FE ORAL TABLET,CHEWABLE Tier 3 gianvi (28) oral tablet 3-0.02 mg Tier 1 ACA hailey 24 fe oral tablet Tier 1 ACA hailey fe 1.5/30 (28) oral tablet Tier 1 ACA hailey fe 1/20 (28) oral tablet Tier 1 ACA hailey oral tablet Tier 1 ACA iclevia oral tablets,dose pack,3 month Tier 1 ACA introvale oral tablets,dose pack,3 month 0.15 Tier 1 ACA mg-30 mcg (91) isibloom oral tablet Tier 1 ACA jaimiess oral tablets,dose pack,3 month Tier 1 ACA jasmiel (28) oral tablet Tier 1 ACA jolessa oral tablets,dose pack,3 month Tier 1 ACA juleber oral tablet Tier 1 ACA

111 Drug Name Drug Tier Requirements/Limits junel 1.5/30 (21) oral tablet Tier 1 ACA junel 1/20 (21) oral tablet Tier 1 ACA junel fe 1.5/30 (28) oral tablet Tier 1 ACA junel fe 1/20 (28) oral tablet Tier 1 ACA junel fe 24 oral tablet Tier 1 ACA kaitlib fe oral tablet,chewable Tier 1 ACA kalliga oral tablet Tier 1 ACA kariva (28) oral tablet Tier 1 ACA kelnor 1/35 (28) oral tablet Tier 1 ACA kelnor 1-50 (28) oral tablet Tier 1 ACA kurvelo (28) oral tablet Tier 1 ACA l norgest/e.estradiol-e.estrad oral tablets,dose Tier 1 ACA pack,3 month larin 1.5/30 (21) oral tablet Tier 1 ACA larin 1/20 (21) oral tablet Tier 1 ACA larin 24 fe oral tablet Tier 1 ACA larin fe 1.5/30 (28) oral tablet Tier 1 ACA larin fe 1/20 (28) oral tablet Tier 1 ACA larissia oral tablet Tier 1 ACA layolis fe oral tablet,chewable Tier 1 ACA leena 28 oral tablet Tier 1 ACA lessina oral tablet Tier 1 ACA levonest (28) oral tablet Tier 1 ACA levonorgestrel oral tablet Tier 1 ACA; QL (2 EA per 365 days) levonorgestrel-ethinyl estrad oral tablet Tier 1 ACA levonorgestrel-ethinyl estrad oral tablets,dose Tier 1 ACA pack,3 month levonorg-eth estrad triphasic oral tablet Tier 1 ACA levora-28 oral tablet Tier 1 ACA lillow (28) oral tablet Tier 1 ACA LO LOESTRIN FE ORAL TABLET Tier 2 ACA LOESTRIN 1.5/30 (21) ORAL TABLET Tier 3 LOESTRIN 1/20 (21) ORAL TABLET Tier 3 LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET Tier 3 LOESTRIN FE 1/20 (28-DAY) ORAL TABLET Tier 3

112 Drug Name Drug Tier Requirements/Limits lojaimiess oral tablets,dose pack,3 month Tier 1 ACA loryna (28) oral tablet Tier 1 ACA LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 Tier 3 MONTH low-ogestrel (28) oral tablet Tier 1 ACA lo-zumandimine (28) oral tablet Tier 1 ACA lutera (28) oral tablet Tier 1 ACA marlissa (28) oral tablet Tier 1 ACA melodetta 24 fe oral tablet,chewable 1 mg-20 Tier 1 ACA mcg(24) /75 mg (4) mibelas 24 fe oral tablet,chewable 1 mg-20 Tier 1 ACA mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet Tier 1 ACA microgestin 1/20 (21) oral tablet Tier 1 ACA microgestin fe 1.5/30 (28) oral tablet Tier 1 ACA microgestin fe 1/20 (28) oral tablet Tier 1 ACA mili oral tablet Tier 1 ACA MINASTRIN 24 FE ORAL TABLET,CHEWABLE Tier 3 MIRCETTE (28) ORAL TABLET Tier 3 mono-linyah oral tablet Tier 1 ACA my choice oral tablet Tier 1 ACA; QL (2 EA per 365 days) my way oral tablet Tier 1 ACA; QL (2 EA per 365 days) NATAZIA ORAL TABLET Tier 3 ACA necon 0.5/35 (28) oral tablet Tier 1 ACA new day oral tablet Tier 1 ACA; QL (2 EA per 365 days) nikki (28) oral tablet Tier 1 ACA noreth-ethinyl estradiol-iron oral tablet,chewable Tier 1 ACA norethindrone ac-eth estradiol oral tablet 1-20 Tier 1 ACA mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet Tier 1 ACA norethindrone-e.estradiol-iron oral Tier 1 ACA tablet,chewable norgestimate-ethinyl estradiol oral tablet Tier 1 ACA nortrel 0.5/35 (28) oral tablet Tier 1 ACA nortrel 1/35 (21) oral tablet Tier 1 ACA nortrel 1/35 (28) oral tablet Tier 1 ACA

113 Drug Name Drug Tier Requirements/Limits nortrel 7/7/7 (28) oral tablet Tier 1 ACA nylia 7/7/7 (28) oral tablet Tier 1 ACA nymyo oral tablet Tier 1 ACA ocella oral tablet Tier 1 ACA opcicon one-step oral tablet Tier 1 ACA; QL (2 EA per 365 days) option-2 oral tablet Tier 1 ACA; QL (2 EA per 365 days) orsythia oral tablet Tier 1 ACA ORTHO TRI-CYCLEN (28) ORAL TABLET Tier 3 ORTHO-NOVUM 7/7/7 (28) ORAL TABLET Tier 3 philith oral tablet Tier 1 ACA pimtrea (28) oral tablet Tier 1 ACA pirmella oral tablet Tier 1 ACA portia 28 oral tablet Tier 1 ACA previfem oral tablet Tier 1 ACA QUARTETTE ORAL TABLETS,DOSE PACK,3 Tier 3 MONTH reclipsen (28) oral tablet Tier 1 ACA rivelsa oral tablets,dose pack,3 month Tier 1 ACA SAFYRAL ORAL TABLET Tier 3 SEASONIQUE ORAL TABLETS,DOSE PACK,3 Tier 3 MONTH setlakin oral tablets,dose pack,3 month Tier 1 ACA simliya (28) oral tablet Tier 1 ACA simpesse oral tablets,dose pack,3 month Tier 1 ACA SLYND ORAL TABLET Tier 3 ACA sprintec (28) oral tablet Tier 1 ACA sronyx oral tablet Tier 1 ACA syeda oral tablet Tier 1 ACA tarina 24 fe oral tablet Tier 1 ACA tarina fe 1/20 (28) oral tablet Tier 1 ACA tarina fe 1-20 eq (28) oral tablet Tier 1 ACA tilia fe oral tablet Tier 1 ACA tri femynor oral tablet Tier 1 ACA tri-estarylla oral tablet Tier 1 ACA tri-legest fe oral tablet Tier 1 ACA

114 Drug Name Drug Tier Requirements/Limits tri-linyah oral tablet Tier 1 ACA tri-lo-estarylla oral tablet Tier 1 ACA tri-lo-marzia oral tablet Tier 1 ACA tri-lo-mili oral tablet Tier 1 ACA tri-lo-sprintec oral tablet Tier 1 ACA tri-mili oral tablet Tier 1 ACA tri-nymyo oral tablet Tier 1 ACA tri-previfem (28) oral tablet Tier 1 ACA tri-sprintec (28) oral tablet Tier 1 ACA trivora (28) oral tablet Tier 1 ACA tri-vylibra lo oral tablet Tier 1 ACA tri-vylibra oral tablet Tier 1 ACA tydemy oral tablet Tier 1 ACA velivet triphasic regimen (28) oral tablet Tier 1 ACA vestura (28) oral tablet Tier 1 ACA vienva oral tablet Tier 1 ACA viorele (28) oral tablet Tier 1 ACA volnea (28) oral tablet Tier 1 ACA vyfemla (28) oral tablet Tier 1 ACA vylibra oral tablet Tier 1 ACA wera (28) oral tablet Tier 1 ACA wymzya fe oral tablet,chewable Tier 1 ACA YASMIN (28) ORAL TABLET Tier 3 YAZ (28) ORAL TABLET Tier 3 zarah oral tablet Tier 1 ACA zovia 1/35e (28) oral tablet Tier 1 ACA zumandimine (28) oral tablet Tier 1 ACA Ophthalmology Antibiotics AZASITE OPHTHALMIC (EYE) DROPS Tier 3 bacitracin ophthalmic (eye) ointment Tier 1 bacitracin-polymyxin b ophthalmic (eye) ointment Tier 1 BESIVANCE OPHTHALMIC (EYE) Tier 2 DROPS,SUSPENSION

115 Drug Name Drug Tier Requirements/Limits BETADINE OPHTHALMIC PREP OPHTHALMIC Tier 3 (EYE) SOLUTION ciprofloxacin hcl ophthalmic (eye) drops Tier 1 erythromycin ophthalmic (eye) ointment Tier 1 gatifloxacin ophthalmic (eye) drops Tier 1 gentak ophthalmic (eye) ointment Tier 1 gentamicin ophthalmic (eye) drops Tier 1 gentamicin ophthalmic (eye) ointment Tier 1 levofloxacin ophthalmic (eye) drops Tier 1 moxifloxacin ophthalmic (eye) drops Tier 1 Generic for Vigamox NATACYN OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic (eye) Tier 1 ointment neomycin-polymyxin-gramicidin ophthalmic (eye) Tier 1 drops neo-polycin ophthalmic (eye) ointment Tier 1 OCUFLOX OPHTHALMIC (EYE) DROPS Tier 3 ofloxacin ophthalmic (eye) drops Tier 1 polycin ophthalmic (eye) ointment Tier 1 polymyxin b sulf-trimethoprim ophthalmic (eye) Tier 1 drops POLYTRIM OPHTHALMIC (EYE) DROPS Tier 3 tobramycin ophthalmic (eye) drops Tier 1 TOBREX OPHTHALMIC (EYE) OINTMENT Tier 3 VIGAMOX OPHTHALMIC (EYE) DROPS Tier 3 Antivirals trifluridine ophthalmic (eye) drops Tier 1 ZIRGAN OPHTHALMIC (EYE) GEL Tier 3 Beta-Blockers betaxolol ophthalmic (eye) drops Tier 1 carteolol ophthalmic (eye) drops Tier 1 levobunolol ophthalmic (eye) drops Tier 1 metipranolol ophthalmic (eye) drops Tier 1 timolol maleate (pf) ophthalmic (eye) dropperette Tier 1 timolol maleate ophthalmic (eye) drops0.25 % Tier 1

116 Drug Name Drug Tier Requirements/Limits timolol maleate ophthalmic (eye) drops0.5 % Tier 1 Generic for Timoptic timolol maleate ophthalmic (eye) gel forming Tier 1 solution TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) Tier 3 DROPPERETTE TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 % Tier 3 TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING Tier 3 SOLUTION Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE OPHTHALMIC (EYE) Tier 3 DROPS 0.125 % Cycloplegic Mydriatics atropine ophthalmic (eye) drops Tier 1 atropine ophthalmic (eye) ointment Tier 1 CYCLOGYL OPHTHALMIC (EYE) DROPS Tier 3 cyclopentolate ophthalmic (eye) drops Tier 1 homatropaire ophthalmic (eye) drops Tier 1 MYDRIACYL OPHTHALMIC (EYE) DROPS Tier 3 PAREMYD OPHTHALMIC (EYE) DROPS Tier 3 tropicamide ophthalmic (eye) drops Tier 1 Direct Acting Miotics ISOPTO CARPINE OPHTHALMIC (EYE) DROPS Tier 3 MIOCHOL-E INTRAOCULAR KIT Tier 3 pilocarpine hcl ophthalmic (eye) drops Tier 1 Miscellaneous Ophthalmologics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 3 azelastine ophthalmic (eye) drops Tier 1 CEQUA OPHTHALMIC (EYE) DROPPERETTE Tier 2 cromolyn ophthalmic (eye) drops Tier 1 CYSTARAN OPHTHALMIC (EYE) DROPS Tier 3 SPRx epinastine ophthalmic (eye) drops Tier 1 fluorescein-proparacaine ophthalmic (eye) drops Tier 1 LACRISERT OPHTHALMIC (EYE) INSERT Tier 3 olopatadine ophthalmic (eye) drops Tier 1 OXERVATE OPHTHALMIC (EYE) DROPS Tier 3 PA; SPRx

117 Drug Name Drug Tier Requirements/Limits proparacaine ophthalmic (eye) drops Tier 1 tetracaine hcl (pf) ophthalmic (eye) drops Tier 1 tetracaine hcl ophthalmic (eye) drops Tier 1 XIIDRA OPHTHALMIC (EYE) DROPPERETTE Tier 2 Non-Steroidal Anti-Inflammatory Agents bromfenac ophthalmic (eye) drops Tier 1 diclofenac sodium ophthalmic (eye) drops Tier 1 flurbiprofen sodium ophthalmic (eye) drops Tier 1 ketorolac ophthalmic (eye) drops Tier 1 PROLENSA OPHTHALMIC (EYE) DROPS Tier 2 Oral Drugs For Glaucoma acetazolamide oral capsule, extended release Tier 1 acetazolamide oral tablet Tier 1 methazolamide oral tablet Tier 1 Other Glaucoma Drugs bimatoprost ophthalmic (eye) drops Tier 1 COMBIGAN OPHTHALMIC (EYE) DROPS Tier 2 COSOPT OPHTHALMIC (EYE) DROPS Tier 3 dorzolamide ophthalmic (eye) drops Tier 1 dorzolamide-timolol ophthalmic (eye) drops Tier 1 latanoprost ophthalmic (eye) drops Tier 1 LUMIGAN OPHTHALMIC (EYE) DROPS Tier 2 miostat intraocular solution Tier 1 MITOSOL OPHTHALMIC (EYE) KIT Tier 3 RHOPRESSA OPHTHALMIC (EYE) DROPS Tier 2 ROCKLATAN OPHTHALMIC (EYE) DROPS Tier 2 travoprost ophthalmic (eye) drops Tier 1 TRUSOPT OPHTHALMIC (EYE) DROPS Tier 3 XALATAN OPHTHALMIC (EYE) DROPS Tier 3 ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE Tier 2 Steroid-Antibiotic Combinations MAXITROL OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION MAXITROL OPHTHALMIC (EYE) OINTMENT Tier 3

118 Drug Name Drug Tier Requirements/Limits neomycin-bacitracin-poly-hc ophthalmic (eye) Tier 1 ointment neomycin-polymyxin b-dexameth ophthalmic Tier 1 (eye) drops,suspension neomycin-polymyxin b-dexameth ophthalmic Tier 1 (eye) ointment neomycin-polymyxin-hc ophthalmic (eye) Tier 1 drops,suspension neo-polycin hc ophthalmic (eye) ointment Tier 1 PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT Tier 3 TOBRADEX OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION tobramycin-dexamethasone ophthalmic (eye) Tier 1 drops,suspension Steroids dexamethasone sodium phosphate ophthalmic Tier 1 (eye) drops DUREZOL OPHTHALMIC (EYE) DROPS Tier 2 FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 ophthalmic (eye) Tier 1 drops,suspension FML FORTE OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION FML LIQUIFILM OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION FML S.O.P. OPHTHALMIC (EYE) OINTMENT Tier 3 LOTEMAX OPHTHALMIC (EYE) DROPS,GEL Tier 2 LOTEMAX OPHTHALMIC (EYE) OINTMENT Tier 2 LOTEMAX SM OPHTHALMIC (EYE) DROPS,GEL Tier 2 loteprednol etabonate ophthalmic (eye) drops,gel Tier 1 loteprednol etabonate ophthalmic (eye) Tier 1 drops,suspension MAXIDEX OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION PRED FORTE OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION

119 Drug Name Drug Tier Requirements/Limits PRED MILD OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION prednisolone acetate ophthalmic (eye) Tier 1 drops,suspension prednisolone sodium phosphate ophthalmic (eye) Tier 1 drops Steroid-Sulfonamide Combinations BLEPHAMIDE OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) Tier 3 OINTMENT sulfacetamide-prednisolone ophthalmic (eye) Tier 1 drops Sulfonamides BLEPH-10 OPHTHALMIC (EYE) DROPS Tier 3 sulfacetamide sodium ophthalmic (eye) drops Tier 1 sulfacetamide sodium ophthalmic (eye) ointment Tier 1 Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 % Tier 3 apraclonidine ophthalmic (eye) drops Tier 1 brimonidine ophthalmic (eye) drops Tier 1 IOPIDINE OPHTHALMIC (EYE) DROPPERETTE Tier 3 Vasoconstrictor Decongestants CYCLOMYDRIL OPHTHALMIC (EYE) DROPS Tier 3 phenylephrine hcl ophthalmic (eye) drops Tier 1 Respiratory, Allergy, Cough & Cold Antihistamine & Antiallergenic Agents adrenalin injection solution Tier 1 ADRENALIN NASAL SOLUTION Tier 3 carbinoxamine maleate oral liquid Tier 1 carbinoxamine maleate oral tablet 4 mg Tier 1 CLARINEX ORAL TABLET Tier 3 clemastine oral tablet 2.68 mg Tier 1 cyproheptadine oral syrup Tier 1 cyproheptadine oral tablet Tier 1

120 Drug Name Drug Tier Requirements/Limits desloratadine oral tablet Tier 1 desloratadine oral tablet,disintegrating Tier 1 DIPHEN ORAL ELIXIR Tier 3 diphenhydramine hcl injection solution Tier 1 diphenhydramine hcl injection syringe Tier 1 epinephrine hcl nasal solution Tier 1 EPINEPHRINE INJECTION AUTO-INJECTOR Tier 1 QL (4 EA per 30 days) epinephrine injection solution Tier 1 epinephrine injection syringe Tier 1 EPIPEN 2-PAK INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days) EPIPEN INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days) EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days) EPIPEN JR INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days) hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 hydroxyzine hcl oral tablet Tier 1 hydroxyzine pamoate oral capsule Tier 1 promethazine oral syrup Tier 1 promethazine oral tablet Tier 1 promethazine rectal suppository Tier 1 promethegan rectal suppository Tier 1 SYMJEPI INJECTION SYRINGE Tier 2 VISTARIL ORAL CAPSULE Tier 3 Cough & Cold Therapy benzonatate oral capsule Tier 1 BROMFED DM ORAL SYRUP Tier 3 -pseudoeph-dm oral syrup Tier 1 CAPCOF ORAL LIQUID Tier 3 CLARINEX-D 12 HOUR ORAL TABLET, ER Tier 3 MULTIPHASE 12 HR codeine-guaifenesin oral liquid Tier 1 g tussin ac oral liquid Tier 1 guaiatussin ac oral liquid Tier 1 guaifenesin ac oral liquid Tier 1 guaifenesin dac oral syrup Tier 1 HYCODAN (WITH HOMATROPINE) ORAL SYRUP Tier 3

121 Drug Name Drug Tier Requirements/Limits hydrocodone-chlorpheniramine oral Tier 1 suspension,extended rel 12 hr hydrocodone-homatropine oral syrup 5-1.5 mg/5 Tier 1 ml hydrocodone-homatropine oral tablet Tier 1 hydromet oral syrup Tier 1 MAR-COF BP ORAL LIQUID Tier 3 MAR-COF CG ORAL LIQUID Tier 3 m-clear wc oral liquid Tier 1 M-END PE ORAL LIQUID Tier 3 promethazine vc oral syrup Tier 1 promethazine-codeine oral syrup Tier 1 promethazine-dm oral syrup Tier 1 promethazine-phenyleph-codeine oral syrup Tier 1 promethazine-phenylephrine oral syrup Tier 1 RESPA-AR ORAL TABLET EXTENDED RELEASE 12 Tier 3 HR rydex oral liquid Tier 1 SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3 TESSALON PERLES ORAL CAPSULE Tier 3 TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE Tier 3 12 HR virtussin ac oral liquid Tier 1 Z-TUSS AC ORAL LIQUID Tier 3 Pulmonary Agents ACCOLATE ORAL TABLET Tier 3 acetylcysteine solution Tier 1 ADCIRCA ORAL TABLET Tier 2 PA; SPRx ADEMPAS ORAL TABLET Tier 3 PA; LD; SPRx ADVAIR DISKUS INHALATION BLISTER WITH Tier 2 DEVICE ADVAIR HFA INHALATION HFA AEROSOL Tier 2 INHALER Generic for ProAir HFA; QL (2 EA albuterol sulfate inhalation hfa aerosol inhaler Tier 1 per 30 days) albuterol sulfate inhalation solution for Tier 1 nebulization

122 Drug Name Drug Tier Requirements/Limits albuterol sulfate oral syrup Tier 1 albuterol sulfate oral tablet Tier 1 albuterol sulfate oral tablet extended release 12 Tier 1 hr alyq oral tablet Tier 1 PA; SPRx oral tablet Tier 1 PA; LD; SPRx ANORO ELLIPTA INHALATION BLISTER WITH Tier 2 DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH Tier 2 DEVICE ASMANEX HFA INHALATION HFA AEROSOL Tier 2 INHALER ASMANEX TWISTHALER INHALATION AEROSOL Tier 2 POWDR BREATH ACTIVATED ATROVENT HFA INHALATION HFA AEROSOL Tier 3 INHALER BERINERT INTRAVENOUS KIT Tier 3 PA; SPRx BEVESPI AEROSPHERE INHALATION HFA Tier 2 AEROSOL INHALER oral tablet Tier 1 PA; SPRx BREO ELLIPTA INHALATION BLISTER WITH Tier 2 DEVICE BROVANA INHALATION SOLUTION FOR Tier 2 NEBULIZATION budesonide inhalation suspension for Tier 1 nebulization budesonide nasal spray,non-aerosol Tier 1 CINRYZE INTRAVENOUS RECON SOLN Tier 3 PA; SPRx COMBIVENT RESPIMAT INHALATION MIST Tier 2 cromolyn inhalation solution for nebulization Tier 1 DALIRESP ORAL TABLET Tier 2 DULERA INHALATION HFA AEROSOL INHALER Tier 2 ELIXOPHYLLIN ORAL ELIXIR Tier 3 ESBRIET ORAL CAPSULE Tier 3 PA; SPRx ESBRIET ORAL TABLET Tier 3 PA; SPRx FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR Tier 3 PA; SPRx FASENRA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

123 Drug Name Drug Tier Requirements/Limits FIRAZYR SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx FLOVENT DISKUS INHALATION BLISTER WITH Tier 2 DEVICE FLOVENT HFA INHALATION HFA AEROSOL Tier 2 INHALER nasal spray,non-aerosol Tier 1 fluticasone propionate nasal spray,suspension Tier 1 fluticasone propion- inhalation blister Tier 1 with device HAEGARDA SUBCUTANEOUS RECON SOLN Tier 3 PA; LD; SPRx icatibant subcutaneous syringe Tier 1 PA; SPRx INCRUSE ELLIPTA INHALATION BLISTER WITH Tier 2 DEVICE ipratropium bromide inhalation solution Tier 1 ipratropium-albuterol inhalation solution for Tier 1 nebulization KALYDECO ORAL GRANULES IN PACKET Tier 3 PA; SPRx KALYDECO ORAL TABLET Tier 3 PA; SPRx levalbuterol hcl inhalation solution for Tier 1 nebulization LONHALA MAGNAIR REFILL INHALATION Tier 2 SOLUTION FOR NEBULIZATION LONHALA MAGNAIR STARTER INHALATION Tier 2 SOLUTION FOR NEBULIZATION metaproterenol oral syrup Tier 1 mometasone nasal spray,non-aerosol Tier 1 oral granules in packet Tier 1 montelukast oral tablet Tier 1 montelukast oral tablet,chewable Tier 1 NUCALA SUBCUTANEOUS AUTO-INJECTOR Tier 3 PA; LD; SPRx NUCALA SUBCUTANEOUS RECON SOLN Tier 3 PA; LD; SPRx NUCALA SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx OFEV ORAL CAPSULE Tier 3 PA; SPRx OPSUMIT ORAL TABLET Tier 2 PA; LD; SPRx ORKAMBI ORAL GRANULES IN PACKET Tier 3 PA; SPRx ORKAMBI ORAL TABLET Tier 3 PA; SPRx

124 Drug Name Drug Tier Requirements/Limits PERFOROMIST INHALATION SOLUTION FOR Tier 2 NEBULIZATION PROAIR RESPICLICK INHALATION AEROSOL Tier 2 QL (2 EA per 30 days) POWDR BREATH ACTIVATED PROVENTIL HFA INHALATION HFA AEROSOL Tier 3 ST; QL (2 EA per 30 days) INHALER PULMICORT INHALATION SUSPENSION FOR Tier 3 NEBULIZATION pulmosal inhalation solution for nebulization Tier 1 PULMOZYME INHALATION SOLUTION Tier 3 SPRx QVAR REDIHALER INHALATION HFA AEROSOL Tier 2 BREATH ACTIVATED REVATIO INTRAVENOUS SOLUTION Tier 3 PA; SPRx REVATIO ORAL SUSPENSION FOR Tier 3 PA; SPRx RECONSTITUTION REVATIO ORAL TABLET Tier 3 PA; SPRx RUCONEST INTRAVENOUS RECON SOLN Tier 3 PA; SPRx SEREVENT DISKUS INHALATION BLISTER WITH Tier 2 DEVICE sildenafil (pulm.hypertension) intravenous Tier 1 PA; SPRx solution sildenafil (pulm.hypertension) oral suspension for Tier 1 PA; SPRx reconstitution sildenafil (pulm.hypertension) oral tablet Tier 1 PA; SPRx SINGULAIR ORAL GRANULES IN PACKET Tier 3 SINGULAIR ORAL TABLET Tier 3 SINGULAIR ORAL TABLET,CHEWABLE Tier 3 sodium chloride inhalation solution for Tier 1 nebulization SPIRIVA RESPIMAT INHALATION MIST Tier 2 SPIRIVA WITH HANDIHALER INHALATION Tier 2 CAPSULE, W/INHALATION DEVICE STIOLTO RESPIMAT INHALATION MIST Tier 2 STRIVERDI RESPIMAT INHALATION MIST Tier 2 SYMBICORT INHALATION HFA AEROSOL Tier 2 INHALER SYMDEKO ORAL TABLETS, SEQUENTIAL Tier 3 PA; SPRx tadalafil (pulm. hypertension) oral tablet Tier 1 PA; SPRx; Generic for Adcirca

125 Drug Name Drug Tier Requirements/Limits TAKHZYRO SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx oral tablet Tier 1 terbutaline subcutaneous solution Tier 1 THEO-24 ORAL CAPSULE,EXTENDED RELEASE Tier 3 24HR theochron oral tablet extended release 12 hr Tier 1 oral elixir Tier 1 theophylline oral solution Tier 1 theophylline oral tablet extended release 12 hr Tier 1 theophylline oral tablet extended release 24 hr Tier 1 TRACLEER ORAL TABLET Tier 3 PA; LD; SPRx TRACLEER ORAL TABLET FOR SUSPENSION Tier 3 PA; LD; SPRx TRELEGY ELLIPTA INHALATION BLISTER WITH Tier 2 DEVICE TRIKAFTA ORAL TABLETS, SEQUENTIAL Tier 3 PA; SPRx TYVASO INHALATION SOLUTION FOR Tier 3 PA; SPRx NEBULIZATION TYVASO INSTITUTIONAL START KIT INHALATION Tier 3 PA; SPRx SOLUTION FOR NEBULIZATION TYVASO REFILL KIT INHALATION SOLUTION FOR Tier 3 PA; SPRx NEBULIZATION TYVASO STARTER KIT INHALATION SOLUTION Tier 3 PA; SPRx FOR NEBULIZATION VENTAVIS INHALATION SOLUTION FOR Tier 3 PA; SPRx NEBULIZATION VENTOLIN HFA INHALATION HFA AEROSOL Tier 2 QL (2 EA per 30 days) INHALER wixela inhub inhalation blister with device Tier 1 XHANCE NASAL AEROSOL BREATH ACTIVATED Tier 3 PA XOPENEX CONCENTRATE INHALATION Tier 3 SOLUTION FOR NEBULIZATION XOPENEX HFA INHALATION HFA AEROSOL Tier 3 ST; QL (2 EA per 30 days) INHALER XOPENEX INHALATION SOLUTION FOR Tier 3 NEBULIZATION YUPELRI INHALATION SOLUTION FOR Tier 3 NEBULIZATION zafirlukast oral tablet Tier 1

126 Drug Name Drug Tier Requirements/Limits Urologicals Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 1 DITROPAN XL ORAL TABLET EXTENDED RELEASE Tier 3 24HR flavoxate oral tablet Tier 1 GELNIQUE TRANSDERMAL GEL IN PACKET Tier 2 MYRBETRIQ ORAL TABLET EXTENDED RELEASE Tier 2 24 HR oxybutynin chloride oral syrup Tier 1 oxybutynin chloride oral tablet Tier 1 oxybutynin chloride oral tablet extended release Tier 1 24hr OXYTROL TRANSDERMAL PATCH SEMIWEEKLY Tier 3 solifenacin oral tablet Tier 1 tolterodine oral capsule,extended release 24hr Tier 1 tolterodine oral tablet Tier 1 trospium oral capsule,extended release 24hr Tier 1 trospium oral tablet Tier 1 VESICARE ORAL TABLET Tier 3 Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin oral tablet extended release 24 hr Tier 1 AVODART ORAL CAPSULE Tier 3 CIALIS ORAL TABLET 2.5 MG Tier 3 # CIALIS ORAL TABLET 5 MG Tier 3 #; QL (15 EA per 60 days) dutasteride oral capsule Tier 1 dutasteride-tamsulosin oral capsule, er Tier 1 multiphase 24 hr finasteride oral tablet 5 mg Tier 1 FLOMAX ORAL CAPSULE Tier 3 JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR Tier 3 PROSCAR ORAL TABLET Tier 3 RAPAFLO ORAL CAPSULE Tier 3 silodosin oral capsule Tier 1 tadalafil oral tablet 2.5 mg Tier 1 #; Generic for Cialis

127 Drug Name Drug Tier Requirements/Limits #; Generic for Cialis; QL (15 EA per tadalafil oral tablet 5 mg Tier 1 60 days) tamsulosin oral capsule Tier 1 UROXATRAL ORAL TABLET EXTENDED RELEASE Tier 3 24 HR Cholinergic Stimulants bethanechol chloride oral tablet Tier 1 Miscellaneous Urologicals alprostadil injection solution Tier 1 CAVERJECT IMPULSE INTRACAVERNOSAL KIT Tier 3 #; QL (8 EA per 30 days) CAVERJECT INTRACAVERNOSAL RECON SOLN Tier 3 #; QL (8 EA per 30 days) CIALIS ORAL TABLET 10 MG, 20 MG Tier 3 #; QL (8 EA per 30 days) CYSTAGON ORAL CAPSULE Tier 3 PA; LD; SPRx EDEX INTRACAVERNOSAL KIT Tier 3 #; QL (8 EA per 30 days) ELMIRON ORAL CAPSULE Tier 3 K-PHOS NO 2 ORAL TABLET Tier 3 K-PHOS ORIGINAL ORAL TABLET,SOLUBLE Tier 3 LEVITRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days) methen-sod phos-meth blue-hyos oral tablet Tier 1 MUSE INTRA-URETHRAL SUPPOSITORY Tier 3 #; QL (8 EA per 30 days) potassium citrate oral tablet extended release Tier 1 PROCYSBI ORAL CAPSULE, DELAYED REL Tier 3 PA; SPRx SPRINKLE PROCYSBI ORAL GRANULES DEL RELEASE IN Tier 3 PA; SPRx PACKET PROSTIN VR PEDIATRIC INJECTION SOLUTION Tier 3 sildenafil oral tablet Tier 1 #; QL (8 EA per 30 days) STAXYN ORAL TABLET,DISINTEGRATING Tier 3 #; QL (8 EA per 30 days) STENDRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days) #; Generic for Cialis; QL (8 EA per tadalafil oral tablet 10 mg, 20 mg Tier 1 30 days) uro-458 oral tablet Tier 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE Tier 3 UROCIT-K 15 ORAL TABLET EXTENDED RELEASE Tier 3 UROCIT-K 5 ORAL TABLET EXTENDED RELEASE Tier 3 vardenafil oral tablet Tier 1 #; QL (8 EA per 30 days)

128 Drug Name Drug Tier Requirements/Limits vardenafil oral tablet,disintegrating Tier 1 #; QL (8 EA per 30 days) VIAGRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days) Urinary Anesthetics phenazopyridine oral tablet 100 mg, 200 mg Tier 1 PYRIDIUM ORAL TABLET Tier 3 Vitamins, Hematinics & Electrolytes Electrolytes EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, Tier 3 20 MEQ effer-k oral tablet, effervescent 25 meq Tier 1 GALZIN ORAL CAPSULE Tier 3 klor-con 10 oral tablet extended release Tier 1 klor-con 8 oral tablet extended release Tier 1 klor-con m10 oral tablet,er particles/crystals Tier 1 klor-con m15 oral tablet,er particles/crystals Tier 1 klor-con m20 oral tablet,er particles/crystals Tier 1 klor-con oral packet Tier 1 klor-con/ef oral tablet, effervescent Tier 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 Tier 3 MEQ, 20 MEQ k-tab oral tablet extended release 8 meq Tier 1 lugols oral solution Tier 1 POTABA ORAL CAPSULE Tier 3 potassium chloride oral capsule, extended release Tier 1 potassium chloride oral liquid Tier 1 potassium chloride oral packet Tier 1 potassium chloride oral tablet extended release Tier 1 potassium chloride oral tablet,er Tier 1 particles/crystals strong iodine oral solution Tier 1 Miscellaneous Vitamins, Hematinics, & Electrolytes DOJOLVI ORAL LIQUID Tier 3 PA; SPRx Vitamins & Hematinics B COMPLEX 1 (WITH FOLIC ACID) ORAL TABLET Tier 1 ACA

129 Drug Name Drug Tier Requirements/Limits b complex-vitamin b12 oral tablet Tier 1 ACA b complex-vitamin c-folic acid oral tablet Tier 1 ACA bal-care dha oral combo pack,tablet and cap,dr Tier 1 b-complex with vitamin c oral tablet Tier 1 ACA calcium pnv oral capsule Tier 1 classic prenatal oral tablet Tier 1 ACA c-nate dha oral capsule Tier 1 complete natal dha oral combo pack Tier 1 cyanocobalamin (vitamin b-12) injection solution Tier 1 dialyvite 800 oral tablet Tier 1 ACA elite-ob oral tablet Tier 1 ergocalciferol (vitamin d2) oral capsule 1,250 Tier 1 mcg (50,000 unit) fluoride (sodium) oral drops Tier 1 ACA fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg Tier 1 ACA sodium fluorid) fluoride (sodium) oral tablet,chewable 1 mg (2.2 Tier 1 mg sod. fluoride) fluoritab oral tablet,chewable 0.5 mg (1.1 mg Tier 1 ACA sodium fluorid) FLURA-DROPS ORAL DROPS 0.25 MG(0.55 MG Tier 3 SOD.FLUOR)/DROP folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg, 800 mcg Tier 1 ACA folivane-ob oral capsule Tier 1 foltabs 800 oral tablet Tier 1 ACA full spectrum b-vitamin c oral tablet Tier 1 ACA ludent fluoride oral tablet,chewable 0.25 mg(0.55 Tier 1 ACA mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) ludent fluoride oral tablet,chewable 1 mg (2.2 mg Tier 1 sod. fluoride) m-natal plus oral tablet Tier 1 multi-vitamin with fluoride oral drops 0.25 mg/ml Tier 1 ACA multivitamin with fluoride oral tablet,chewable Tier 1 ACA multi-vitamin with fluoride oral tablet,chewable Tier 1 ACA 0.25 mg, 0.5 mg

130 Drug Name Drug Tier Requirements/Limits multivitamins with fluoride oral tablet,chewable Tier 1 ACA 0.25 mg, 0.5 mg multivitamins with fluoride oral tablet,chewable Tier 1 1 mg mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 Tier 1 ACA mg mynatal oral capsule Tier 1 mynatal plus oral tablet Tier 1 mynatal-z oral tablet Tier 1 newgen oral tablet Tier 1 pnv 29-1 oral tablet Tier 1 pnv-dha oral capsule Tier 1 pnv-ferrous fumarate-docu-fa oral tablet Tier 1 pnv-omega oral capsule Tier 1 pnv-select oral tablet Tier 1 pr natal 400 ec oral combo pack,tablet and Tier 1 cap,dr pr natal 400 oral combo pack Tier 1 pr natal 430 ec oral combo pack,tablet and Tier 1 cap,dr pr natal 430 oral combo pack Tier 1 prena1 chew oral tablet,chew,ir - dr,biphase Tier 1 prena1 pearl oral capsule,ir - delay rel,biphase Tier 1 prena1 true oral combo pack Tier 1 prenatabs fa oral tablet Tier 1 prenatabs rx oral tablet Tier 1 prenatal formula oral tablet 28 mg iron- 800 mcg Tier 1 ACA prenatal low iron oral tablet Tier 1 prenatal multivitamins oral tablet Tier 1 ACA prenatal one daily oral tablet Tier 1 ACA prenatal oral tablet 28 mg iron- 800 mcg Tier 1 ACA prenatal plus (calcium carb) oral tablet Tier 1 prenatal plus oral tablet Tier 1 prenatal tablet oral tablet Tier 1 ACA prenatal vitamin oral tablet 27 mg iron- 0.8 mg Tier 1 ACA prenatal vitamin plus low iron oral tablet Tier 1

131 Drug Name Drug Tier Requirements/Limits prenatal-u oral capsule Tier 1 preplus oral tablet Tier 1 pretab oral tablet Tier 1 RENA-VITE ORAL TABLET Tier 3 ACA se-natal 19 chewable oral tablet,chewable Tier 1 se-natal-19 oral tablet Tier 1 sodium fluoride 0.25 (0.55) mg s/f, chewable Tier 1 ACA tablet taron-c dha oral capsule Tier 1 trinatal rx 1 oral tablet Tier 1 trinate oral tablet Tier 1 triple vitamin with fluoride oral drops Tier 1 ACA triveen-duo dha oral combo pack Tier 1 tri-vitamin with fluoride oral drops Tier 1 ACA tri-vite with fluoride oral drops Tier 1 ACA virt-c dha oral capsule Tier 1 virt-nate dha oral capsule Tier 1 virt-pn dha oral capsule Tier 1 virt-pn plus oral capsule Tier 1 vitamin b complex-folic acid oral tablet Tier 1 ACA vitamin d2 oral capsule Tier 1 vitamins a,c,d and fluoride oral drops0.25 mg Tier 1 ACA fluor. (0.55 mg)/ml vp-ch plus oral capsule Tier 1 vp-ch-pnv oral capsule Tier 1 westab plus oral tablet Tier 1 westgel dha oral capsule Tier 1 zatean-pn dha oral capsule Tier 1 zatean-pn plus oral capsule Tier 1 zingiber oral tablet Tier 1

132 Index of Drugs

1 ACTOS...... 88 AEROCHAMBER Z-STAT PLUS- 1ST TIER UNIFINE PENTIPS...... 75 acyclovir...... 3, 55, 60 FLW SG...... 65 1ST TIER UNILET ADACEL(TDAP AEROTRACH PLUS ...... 65 COMFORTOUCH ...... 75 ADOLESN/ADULT)(PF) ...... 99 AEROVENT PLUS...... 65 A ADALAT CC ...... 41 AFINITOR ...... 13 abacavir ...... 2, 3 adapalene ...... 56 AFINITOR DISPERZ ...... 13 abacavir-lamivudine ...... 3 adapalene-benzoyl peroxide.. 56 afirmelle ...... 109 abacavir-lamivudine-zidovudine ADCIRCA ...... 122 AFLURIA QD 2020-21(3YR ...... 3 ADDERALL ...... 33 UP)(PF)...... 99 ABILIFY ...... 33 adefovir ...... 3 AFLURIA QD 2020-21(6- ABILIFY MAINTENA...... 33 ADEMPAS...... 122 35MO)(PF)...... 99 ABILIFY MYCITE ...... 33 ADIPEX-P...... 64 AFLURIA QUAD 2020-2021(6MO ABILIFY MYCITE STARTER KIT ..33 ADMELOG SOLOSTAR U-100 UP)...... 99 abiraterone...... 13 INSULIN...... 83 AFREZZA ...... 83 acamprosate ...... 67 ADMELOG U-100 INSULIN AGRYLIN...... 67 acarbose ...... 88 LISPRO ...... 83 AIMOVIG AUTOINJECTOR ...... 24 ACCOLATE...... 122 adrenalin ...... 120 AJOVY AUTOINJECTOR...... 24 ACCU-CHEK FASTCLIX LANCET ADRENALIN ...... 120 AJOVY SYRINGE ...... 25 DRUM ...... 75 ADVAIR DISKUS ...... 122 AKTEN (PF) ...... 117 ACCU-CHEK SAFE-T-PRO ...... 75 ADVAIR HFA ...... 122 ALA-SCALP ...... 60 ACCU-CHEK SOFTCLIX LANCETS ADVANCED TRAVEL LANCETS. 76 albendazole ...... 8 ...... 76 ADVATE ...... 47 ALBENZA ...... 8 ACCUPRIL...... 41 ADVOCATE LANCET ...... 76 albuterol sulfate ...... 122, 123 ACCURETIC ...... 41 ADVOCATE PEN NEEDLE ...... 76 alclometasone...... 60, 61 ACE AEROSOL CLOUD AEMCOLO ...... 8 alcohol pads ...... 76 ENHANCER ...... 65 AEROCHAMBER MINI ...... 65 alcohol prep pads ...... 76 acebutolol...... 41 AEROCHAMBER MV...... 65 ALCOHOL SWABS ...... 76 acetaminophen-caff-dihydrocod AEROCHAMBER PLUS FLOW-VU ALDACTAZIDE ...... 41 ...... 29 ...... 65 ALDACTONE ...... 41 acetaminophen-codeine...... 29 AEROCHAMBER PLUS FLOW- ALDARA ...... 99 acetazolamide...... 118 VU,L MSK ...... 65 ALECENSA ...... 13 acetic acid...... 67, 73 AEROCHAMBER PLUS FLOW- alendronate ...... 103 acetylcysteine ...... 122 VU,M MSK...... 65 alfuzosin ...... 127 acitretin ...... 53 AEROCHAMBER PLUS FLOW- ALINIA...... 8 ACTEMRA ...... 104 VU,S MSK ...... 65 aliskiren ...... 41 ACTEMRA ACTPEN ...... 104 AEROCHAMBER PLUS Z STAT . 65 ALKERAN...... 13 ACTHAR ...... 74 AEROCHAMBER PLUS Z STAT LG allopurinol ...... 103 ACTHIB (PF)...... 99 MSK ...... 65 almotriptan malate ...... 25 ACTIGALL ...... 91 AEROCHAMBER PLUS Z STAT ALORA ...... 106 ACTI-LANCE LANCETS ...... 76 MD MSK ...... 65 alosetron ...... 91 ACTIMMUNE...... 99 AEROCHAMBER PLUS Z STAT SM ALPHAGAN P ...... 120 ACTIQ ...... 29 MSK ...... 65 ALPHANATE ...... 48 ACTIVELLA ...... 106 AEROCHAMBER WITH ALPHANINE SD ...... 48 ACTONEL ...... 103 FLOWSIGNAL ...... 65 alprazolam ...... 33, 34 ACTOPLUS MET ...... 88 alprazolam intensol ...... 33

133 ALPROLIX ...... 48 AMPYRA...... 26 ARTHROTEC 50...... 31 alprostadil...... 128 ANADROL-50 ...... 86 ARTHROTEC 75...... 31 ALSUMA ...... 25 ANAFRANIL ...... 34 ascomp with codeine...... 25 ALTABAX...... 59 anagrelide ...... 67 asenapine maleate ...... 34 ALTACE ...... 41 ANAPROX DS ...... 31 ashlyna ...... 110 altavera (28) ...... 109 anastrozole ...... 13 ASMANEX HFA ...... 123 ALTERNATE SITE LANCET ...... 76 ANCOBON ...... 2 ASMANEX TWISTHALER ...... 123 ALUNBRIG...... 13 ANDRODERM ...... 86 aspirin...... 31 alyacen 1/35 (28) ...... 109 ANDROID ...... 86 aspirin-dipyridamole ...... 48 alyacen 7/7/7 ( 28) ...... 109 ANGELIQ ...... 106 ASSURE HAEMOLANCE PLUS.. 76 alyq ...... 123 ANORO ELLIPTA...... 123 ASSURE LANCE ...... 76 amabelz ...... 106 ANTABUSE ...... 67 ASSURE LANCE PLUS...... 76 amantadine hcl ...... 3 ANTARA ...... 50 ASTAGRAF XL ...... 13 AMARYL...... 88 anucort-hc ...... 91 ASTRAZENECA COVID19 AMBIEN ...... 34 ANUSOL-HC...... 91 VAC(UNAPP)...... 99 AMBIEN CR ...... 34 apexicon e...... 61 ATACAND ...... 42 ambrisentan ...... 123 APIDRA SOLOSTAR U-100 ATACAND HCT ...... 42 amcinonide ...... 61 INSULIN...... 83 atazanavir ...... 3 AMERGE ...... 25 APIDRA U-100 INSULIN ...... 83 ATELVIA ...... 104 amethia ...... 110 APOKYN ...... 23 atenolol ...... 42 amethia lo ...... 110 apraclonidine ...... 120 atenolol-chlorthalidone ...... 42 amethyst (28) ...... 110 aprepitant ...... 91 ATIVAN ...... 34 AMICAR ...... 48 apri ...... 110 atomoxetine ...... 34 amiloride ...... 41 APTIOM ...... 19 atorvastatin ...... 50 amiloride-hydrochlorothiazide APTIVUS...... 3 atovaquone...... 8 ...... 41 APTIVUS (WITH VITAMIN E) ..... 3 atovaquone-proguanil ...... 8 aminocaproic acid ...... 48 aqua care sodium chloride..... 67 ATRIPLA ...... 3 amiodarone ...... 40 aqua care sterile water ...... 67 atropine ...... 117 AMITIZA...... 91 AQUA GLYCOLIC HC ...... 61 ATROVENT HFA ...... 123 amitriptyline ...... 34 ARAKODA...... 8 AUBAGIO ...... 97 amitriptyline-chlordiazepoxide aranelle (28) ...... 110 aubra ...... 110 ...... 34 ARANESP (IN POLYSORBATE) . 97 aubra eq ...... 110 amlodipine ...... 41 ARAVA ...... 104 AUGMENTIN ...... 11 amlodipine-atorvastatin ...... 50 ARAZLO...... 56 AUGMENTIN ES-600 ...... 11 amlodipine-benazepril ...... 41 ARCALYST...... 99 AUGMENTIN XR ...... 11 amlodipine-olmesartan ...... 41 ARESTIN ...... 72 aurovela 1.5/30 (21) ...... 110 amlodipine-valsartan ...... 42 ARICEPT ...... 26 aurovela 1/20 ( 21) ...... 110 amlodipine-valsartan-hcthiazid ARIKAYCE ...... 8 aurovela 24 fe ...... 110 ...... 42 ARIMIDEX ...... 13 aurovela fe 1.5/30 (28) ...... 110 amnesteem...... 56 aripiprazole ...... 34 aurovela fe 1-20 (28) ...... 110 amoxapine ...... 34 ARISTADA...... 34 AURYXIA ...... 91 amoxicil-clarithromy-lansopraz ARISTADA INITIO ...... 34 AUSTEDO ...... 27 ...... 96 ARIXTRA...... 48 AVALIDE...... 42 amoxicillin ...... 10 armodafinil ...... 34 AVANDIA...... 88 amoxicillin-pot clavulanate....10, ARMOUR THYROID ...... 90 AVAPRO ...... 42 11 ARNUITY ELLIPTA...... 123 aviane ...... 110 ampicillin ...... 11 AROMASIN...... 13 avidoxy ...... 11

134 avita ...... 56 BD INSULIN SYRINGE ULTRA- betamethasone dipropionate 61 AVODART...... 127 FINE ...... 76 betamethasone valerate...... 61 AVONEX...... 97 BD INTEGRA NEEDLE ...... 76 betamethasone, augmented.. 61 AYGESTIN...... 106 BD MICROTAINER LANCET ..... 76 BETAPACE ...... 41 ayuna ...... 110 BD NOKOR ADMIX NEEDLE .... 76 BETAPACE AF ...... 40 AYVAKIT...... 13 bd posiflush normal saline 0.9 67 BETASERON...... 98 AZASAN ...... 13 BD PRECISIONGLIDE ...... 76 betaxolol...... 42, 116 AZASITE ...... 115 BD PRECISIONGLIDE NON- bethanechol chloride...... 128 azathioprine...... 13 STERILE ...... 76 BEVESPI AEROSPHERE ...... 123 azelaic acid ...... 56 bd pre-filled normal saline ..... 67 bexarotene ...... 13 azelastine ...... 72, 117 BD REGULAR BEVEL NEEDLES. 76 BEXSERO ...... 99 AZELEX...... 56 BD SAFETYGLIDE NEEDLE ...... 76 BEYAZ ...... 110 AZILECT...... 23 BD SHORT BEVEL NEEDLES..... 77 bicalutamide ...... 13 azithromycin ...... 7 BD SPECIALTY USE NEEDLES... 77 BIDIL ...... 42 AZOR ...... 42 BD ULTRA FINE LANCETS...... 77 BIKTARVY ...... 3 AZULFIDINE...... 91 BD ULTRA-FINE MICRO PEN BILTRICIDE ...... 8 AZULFIDINE EN-TABS...... 91 NEEDLE ...... 77 bimatoprost ...... 118 azurette (28) ...... 110 BD ULTRA-FINE MINI PEN BINOSTO ...... 104 B NEEDLE ...... 77 BIOTHRAX ...... 99 B COMPLEX 1 (WITH FOLIC BD ULTRA-FINE NANO PEN bisacodyl...... 91 ACID) ...... 129 NEEDLE ...... 77 bisoprolol fumarate ...... 42 b complex-vitamin b12...... 130 BD ULTRA-FINE ORIG PEN bisoprolol-hydrochlorothiazide b complex-vitamin c-folic acid NEEDLE ...... 77 ...... 42 ...... 130 BD ULTRA-FINE SHORT PEN BLEPH-10 ...... 120 bacitracin...... 115 NEEDLE ...... 77 BLEPHAMIDE...... 120 bacitracin-polymyxin b ...... 115 BD VEO INSULIN SYRINGE UF . 77 BLEPHAMIDE S.O.P...... 120 baclofen ...... 28 bekyree (28)...... 110 blisovi 24 fe...... 110 BACTRIM ...... 11 BELBUCA ...... 29 blisovi fe 1.5/30 (28)...... 110 BACTRIM DS...... 11 benazepril ...... 42 blisovi fe 1/20 (28) ...... 110 bal-care dha...... 130 benazepril-hydrochlorothiazide BLUNT NEEDLE, DISPOSABLE . 77 BALCOLTRA...... 110 ...... 42 BONIVA...... 104 balsalazide ...... 91 BENEFIX ...... 48 BOOSTRIX TDAP ...... 99 BALVERSA ...... 13 BENICAR ...... 42 bosentan...... 123 balziva (28) ...... 110 BENICAR HCT ...... 42 BOSULIF ...... 13 BANZEL ...... 19 BENLYSTA ...... 104 bpo ...... 56 BAQSIMI ...... 75 BENZAMYCIN ...... 56 BRAFTOVI...... 13 BARACLUDE ...... 3 BENZEFOAM ...... 56 BRAVELLE...... 86 BCG VACCINE, LIVE (PF) ...... 99 benzepro ...... 56 BREATHERITE MDI SPACER .... 65 b-complex with vitamin c ..... 130 BENZEPRO (MICROSPHERES) . 56 BREATHERITE SPACER-MASK, BD ALCOHOL SWABS ...... 76 benzonatate...... 121 NEO...... 65 BD AUTOSHIELD DUO PEN benzoyl peroxide ...... 56 BREATHERITE SPACER- NEEDLE ...... 76 benzphetamine ...... 65 MASK,ADULT ...... 65 BD ECLIPSE...... 76 benztropine ...... 23 BREATHERITE SPACER- BD FILTER NEEDLE-5 MICRON .76 BERINERT ...... 123 MASK,CHILD ...... 65 BD INSULIN SYRINGE ...... 76 BESIVANCE ...... 115 BREATHERITE SPACER- BD INSULIN SYRINGE (HALF BETADINE OPHTHALMIC PREP MASK,INFANT...... 65 UNIT) ...... 76 ...... 116

135 BREATHERITE SPACER- cabergoline ...... 86 CARNITOR ...... 68 MASK,S.CHLD ...... 65 CABLIVI ...... 48 CARNITOR (SUGAR-FREE)...... 68 BREATHERITE VALVED MDI CABOMETYX...... 13 carteolol ...... 116 CHAMBER ...... 66 CADUET ...... 50 cartia xt...... 42 BREATHERITE VALVED MDI CAFERGOT ...... 25 carvedilol ...... 42 SPACER ...... 66 caffeine citrate ...... 68 carvedilol phosphate ...... 42 BREEZE 2 TEST STRIPS ...... 75 CALAN SR ...... 42 CASODEX ...... 13 BREO ELLIPTA...... 123 calcipotriene ...... 53 CATAPRES ...... 43 briellyn ...... 110 calcipotriene-betamethasone 53 CATAPRES-TTS-1...... 43 BRILINTA...... 48 calcitonin (salmon) ...... 86 CATAPRES-TTS-2...... 43 brimonidine ...... 120 calcitriol ...... 53, 86 CATAPRES-TTS-3...... 43 BRIVIACT...... 19 calcium acetate(phosphat bind) CAVERJECT ...... 128 BROMFED DM...... 121 ...... 91 CAVERJECT IMPULSE ...... 128 bromfenac ...... 118 calcium pnv...... 130 CAYA CONTOURED ...... 105 bromocriptine...... 23 CALQUENCE ...... 13 CAYSTON ...... 8 brompheniramine-pseudoeph- camila ...... 106 caziant ( 28) ...... 110 dm ...... 121 camrese ...... 110 cefaclor ...... 7 BROVANA ...... 123 camrese lo ...... 110 cefadroxil ...... 7 BRUKINSA ...... 13 CANASA ...... 92 cefdinir ...... 7 budesonide...... 91, 123 candesartan ...... 42 cefditoren pivoxil ...... 7 BULLSEYE MINI SAFETY LANCETS candesartan-hydrochlorothiazid cefixime ...... 7 ...... 77 ...... 42 cefpodoxime ...... 7 bumetanide ...... 42 CAPCOF...... 121 cefprozil ...... 7 BUPAP ...... 25 capecitabine ...... 13 cefuroxime axetil...... 7 BUPHENYL ...... 67, 68 CAPEX ...... 61 CELEBREX ...... 31 buprenorphine...... 29 CAPRELSA ...... 13 celecoxib...... 31 buprenorphine-naloxone ...... 18 captopril ...... 42 CELEXA...... 34 bupropion hcl ...... 34 captopril-hydrochlorothiazide 42 CELLCEPT ...... 14 bupropion hcl (smoking deter) CARAFATE ...... 96 CELONTIN ...... 19 ...... 71 CARBAGLU ...... 68 CENTANY ...... 59 buspirone ...... 34 carbamazepine...... 19 cephalexin...... 7 butalbital compound w/codeine CARBATROL...... 19 CEQUA ...... 117 ...... 25 carbidopa...... 23 CERDELGA ...... 86 butalbital-acetaminop-caf-cod carbidopa-levodopa ...... 23 CESAMET ...... 92 ...... 25 carbidopa-levodopa- CETROTIDE ...... 86 butalbital-acetaminophen ...... 25 entacapone ...... 23 cevimeline ...... 68 butalbital-acetaminophen-caff carbinoxamine maleate ...... 120 CHANTIX ...... 71 ...... 25 CARDIZEM...... 42 CHANTIX CONTINUING MONTH butalbital-aspirin-caffeine ...... 25 CARDIZEM CD ...... 42 BOX...... 71 butorphanol...... 29 CARDIZEM LA ...... 42 CHANTIX STARTING MONTH BUTRANS ...... 29 CARDURA ...... 42 BOX...... 71 BYDUREON ...... 88 CARDURA XL ...... 42 charlotte 24 fe ...... 110 BYDUREON BCISE ...... 88 CAREFINE PEN NEEDLE ...... 77 chateal (28) ...... 110 BYETTA ...... 88 CAREONE THIN LANCET ...... 77 chateal eq (28) ...... 110 BYSTOLIC ...... 42 carisoprodol ...... 28 CHEMET ...... 68 C carisoprodol-aspirin ...... 28 CHENODAL ...... 92 CABENUVA ...... 3 carisoprodol-aspirin-codeine . 28 chlordiazepoxide hcl...... 34

136 chlordiazepoxide-clidinium.....90 CLEVER CHOICE CHAMBER-LRG COLESTID ...... 50 chlorhexidine gluconate ...... 72 MASK ...... 66 COLESTID FLAVORED ...... 50 chloroquine phosphate ...... 9 CLEVER CHOICE CHAMBER-MED colestipol ...... 50, 51 chlorothiazide ...... 43 MASK ...... 66 COLOR LANCETS ...... 77 chlorpromazine...... 34 CLEVER CHOICE CHAMBER-SM COMBIGAN ...... 118 chlorthalidone ...... 43 MASK ...... 66 COMBIPATCH ...... 106 chlorzoxazone...... 28 CLICKFINE PEN NEEDLE ...... 77 COMBIVENT RESPIMAT ...... 123 CHOLBAM ...... 92 CLIMARA ...... 106 COMBIVIR ...... 3 cholestyramine (with sugar) ...50 CLIMARA PRO ...... 106 COMETRIQ ...... 14 cholestyramine light...... 50 clindacin p...... 56 COMFORT EZ PEN NEEDLES ... 77 choline,magnesium salicylate .31 CLINDAGEL...... 56 COMFORT LANCETS...... 77 CIALIS ...... 127, 128 clindamycin hcl ...... 9 COMPACT SPACE CHAMBER .. 66 ciclodan ...... 59 clindamycin pediatric ...... 9 COMPACT SPACE CHAMBER- ciclopirox ...... 59 clindamycin phosphate... 57, 108 LRG MASK ...... 66 ciclopirox-ure-camph-menth- clindamycin-benzoyl peroxide 57 COMPACT SPACE CHAMBER- euc ...... 59 CLINDESSE...... 108 MED MASK ...... 66 cilostazol...... 48 CLINPRO 5000 ...... 72 COMPACT SPACE CHAMBER-SM CIMDUO ...... 3 clobazam ...... 19 MASK ...... 66 cimetidine...... 96 clobetasol ...... 61 COMPAZINE ...... 92 cimetidine hcl ...... 96 clobetasol-emollient...... 61 COMPLERA...... 3 CIMZIA...... 92 CLOBEX ...... 61 complete natal dha ...... 130 CIMZIA STARTER KIT...... 92 CLOCORTOLONE PIVALATE .... 61 compro ...... 92 cinacalcet ...... 86 clodan...... 61 COMTAN ...... 23 CINRYZE ...... 123 CLODERM ...... 61 CONDYLOX ...... 55 CIPRO ...... 11 clomipramine ...... 34 constulose ...... 92 CIPRO HC ...... 73 clonazepam...... 19 CONTOUR LINK ...... 77 CIPRO XR ...... 11 clonidine ...... 43 CONTOUR METER...... 77 CIPRODEX ...... 73 clonidine hcl...... 34, 43 CONTOUR NEXT EZ METER .... 77 ciprofloxacin ...... 11 clopidogrel ...... 48 CONTOUR NEXT LINK...... 77 ciprofloxacin hcl ...... 11, 73, 116 clorazepate dipotassium...... 34 CONTOUR NEXT LINK 2.4 ...... 77 ciprofloxacin-dexamethasone.73 clorpres...... 43 CONTOUR NEXT METER ...... 77 citalopram ...... 34 CLORPRES ...... 43 CONTOUR NEXT ONE METER . 77 citrate of magnesia ...... 92 clotrimazole ...... 2 CONTOUR NEXT TEST STRIPS . 75 claravis ...... 56 clotrimazole-betamethasone . 60 CONTOUR TEST STRIPS ...... 75 CLARINEX...... 120 clozapine...... 34, 35 CONTRAVE ...... 65 CLARINEX-D 12 HOUR ...... 121 CLOZARIL ...... 35 COPAXONE...... 98 clarithromycin...... 7 c-nate dha...... 130 COPIKTRA...... 14 classic prenatal ...... 130 COAGADEX...... 48 CORDRAN ...... 61, 62 clearlax ...... 92 COAGUCHEK LANCETS ...... 77 CORDRAN TAPE LARGE ROLL . 61 clemastine ...... 120 COAL TAR ...... 53 COREG ...... 43 CLENPIQ ...... 92 COARTEM ...... 9 COREG CR ...... 43 CLEOCIN ...... 108 codeine sulfate...... 29 CORGARD ...... 43 CLEOCIN HCL...... 9 codeine-butalbital-asa-caff .... 25 CORIFACT...... 48 CLEOCIN PEDIATRIC...... 9 codeine-guaifenesin ...... 121 CORLANOR...... 52 CLEOCIN T...... 56 COLAZAL ...... 92 CORTEF ...... 74 CLEVER CHEK LANCETS ...... 77 colchicine ...... 103 CORTENEMA ...... 92 colesevelam ...... 50 CORTIFOAM ...... 92

137 cortisone ...... 74 dalfampridine...... 27 DESONATE ...... 62 CORTISPORIN ...... 59 DALIRESP ...... 123 desonide ...... 62 CORTISPORIN-TC ...... 73 danazol ...... 86 DESOWEN ...... 62 COSENTYX...... 54 DANTRIUM...... 28 desoximetasone ...... 62 COSENTYX (2 SYRINGES) ...... 54 dantrolene ...... 28 desvenlafaxine succinate ...... 35 COSENTYX PEN...... 54 dapsone ...... 9 dexamethasone ...... 74 COSENTYX PEN (2 PENS)...... 54 DAPTACEL (DTAP PEDIATRIC) dexamethasone intensol ...... 74 COSOPT ...... 118 (PF) ...... 99 dexamethasone sodium COTELLIC ...... 14 DARAPRIM ...... 9 phosphate ...... 119 covaryx ...... 106 darifenacin...... 127 DEXCOM G4 RECEIVER...... 77 covaryx h.s...... 106 dasetta 1/35 (28)...... 111 DEXCOM G4 RECEIVER COZAAR ...... 43 dasetta 7/7/7 (28) ...... 111 PEDIATRIC ...... 77 CREON ...... 92 DAURISMO...... 14 DEXCOM G4 RECEIVER-SHARE CRESEMBA ...... 2 DAYPRO ...... 31 (PED) ...... 78 CRESTOR...... 51 daysee ...... 111 DEXCOM G4 RECEIVER-SHARE CRINONE ...... 106 DAYTRANA ...... 35 KIT ...... 78 CRIXIVAN ...... 3 DDAVP ...... 86 DEXCOM G4 TRANSMITTER ... 78 cromolyn ...... 92, 117, 123 deblitane ...... 106 DEXCOM G5 RECEIVER...... 78 cryselle (28) ...... 110 decadron ...... 74 DEXCOM G5 TRANSMITTER ... 78 CUTAQUIG ...... 99 deferasirox...... 68 DEXCOM G5-G4 SENSOR...... 78 CUTIVATE ...... 62 deferiprone ...... 68 DEXCOM G6 RECEIVER...... 78 CUVITRU ...... 99 DELESTROGEN...... 106 DEXCOM G6 SENSOR ...... 78 CUVPOSA ...... 90 DELSTRIGO ...... 3 DEXCOM G6 TRANSMITTER ... 78 cyanocobalamin (vitamin b-12) demeclocycline ...... 12 DEXCOM RECEIVER...... 78 ...... 130 DEMEROL...... 29 DEXEDRINE SPANSULE ...... 35 cyclafem 1/35 (28) ...... 110 DENAVIR ...... 60 DEXILANT ...... 96 cyclafem 7/7/7 (28) ...... 110 denta 5000 plus ...... 72 dexmethylphenidate ...... 35 cyclobenzaprine ...... 28 dentagel...... 72 dextroamphetamine...... 35 CYCLOGYL ...... 117 DEPAKOTE...... 19 dextroamphetamine- CYCLOMYDRIL ...... 120 DEPAKOTE ER ...... 19 amphetamine ...... 35 cyclopentolate ...... 117 DEPAKOTE SPRINKLES...... 19 DIACOMIT ...... 19 cyclophosphamide ...... 14 DEPEN TITRATABS ...... 104 dialyvite 800 ...... 130 CYCLOSERINE ...... 9 DEPO-ESTRADIOL ...... 106 DIASTAT ...... 19 CYCLOSET ...... 88 DEPO-PROVERA...... 106 DIASTAT ACUDIAL ...... 19 cyclosporine ...... 14 DEPO-SUBQ PROVERA 104 ...107 diazepam ...... 19, 35 cyclosporine modified ...... 14 DEPO-TESTOSTERONE ...... 86 diazepam intensol ...... 35 CYMBALTA ...... 35 DERMA-SMOOTHE/FS BODY OIL diazoxide ...... 75 cyproheptadine...... 120 ...... 62 DIBENZYLINE ...... 43 cyred ...... 111 DERMA-SMOOTHE/FS SCALP diclofenac potassium...... 31 cyred eq...... 110 OIL ...... 62 diclofenac sodium .... 31, 55, 118 CYSTADANE ...... 92 DERMOTIC OIL ...... 73 diclofenac-misoprostol ...... 31 CYSTAGON ...... 128 DESCOVY...... 3 dicloxacillin ...... 11 CYSTARAN ...... 117 desipramine ...... 35 dicyclomine...... 90 CYTOMEL ...... 90 desloratadine ...... 121 didanosine ...... 3 CYTOTEC ...... 96 desmopressin...... 86 diethylpropion ...... 65 D desog-e.estradiol/e.estradiol DIFICID...... 7 D.H.E.45...... 25 ...... 111 diflorasone...... 62

138 DIFLUCAN ...... 2 doxercalciferol ...... 86 EASY TOUCH HYPODERMIC diflunisal ...... 31 doxycycline hyclate ...... 12 NEEDLE ...... 78 digitek ...... 47 doxycycline monohydrate...... 12 EASY TOUCH INSULIN SYRINGE digox ...... 47 D-PENAMINE...... 104 ...... 78 digoxin...... 47 drithocreme hp ...... 54 EC-NAPROSYN ...... 32 dihydroergotamine ...... 25 dronabinol ...... 92 econazole ...... 60 DILANTIN ...... 19 DROPLET LANCETS ...... 78 econtra ez ...... 111 DILANTIN EXTENDED ...... 19 DROPLET PEN NEEDLE ...... 78 econtra one-step...... 111 DILANTIN INFATABS ...... 19 drospirenone-e.estradiol-lm.fa EDARBI...... 43 DILANTIN KAPSEAL ...... 19 ...... 111 EDARBYCLOR...... 43 DILANTIN-125 ...... 19 drospirenone-ethinyl estradiol EDECRIN...... 43 DILATRATE-SR ...... 53 ...... 111 EDEX ...... 128 DILAUDID...... 29 DROXIA ...... 14 EDURANT ...... 3 diltiazem hcl ...... 43 droxidopa ...... 68 eemt ...... 107 dilt-xr...... 43 DUAVEE ...... 107 eemt hs...... 107 dimethyl fumarate ...... 98 DUETACT...... 88 efavirenz ...... 3 DIOVAN ...... 43 dulcolax (magnesium hydroxide) efavirenz-emtricitabin-tenofov 3 DIOVAN HCT ...... 43 ...... 92 efavirenz-lamivu-tenofov disop 3 DIPHEN ...... 121 DULERA...... 123 effer-k...... 129 diphenhydramine hcl ...... 121 duloxetine...... 35 EFFER-K...... 129 diphenoxylate-atropine ...... 90 DUOPA...... 23 EFFEXOR XR ...... 35 DIPROLENE (AUGMENTED) .....62 DUPIXENT PEN ...... 55 EFFIENT...... 48 dipyridamole ...... 48 DUPIXENT SYRINGE ...... 55 EFUDEX ...... 55 DISALCID...... 31 DURAGESIC ...... 29 ELDEPRYL ...... 23 diskets ...... 29 DUREZOL ...... 119 ELESTRIN...... 107 disopyramide phosphate ...... 41 dutasteride ...... 127 eletriptan ...... 25 disulfiram ...... 68 dutasteride-tamsulosin...... 127 ELIDEL ...... 55 DITROPAN XL ...... 127 DUTOPROL ...... 43 ELIMITE...... 64 DIURIL ...... 43 DYAZIDE...... 43 elinest...... 111 divalproex...... 19 DYRENIUM ...... 43 ELIQUIS ...... 48 DIVIGEL...... 107 E ELIQUIS DVT-PE TREAT 30D dofetilide ...... 41 e.e.s. 400 ...... 7 START...... 48 DOJOLVI...... 129 E.E.S. GRANULES ...... 8 elite-ob ...... 130 DOLISHALE...... 111 EAA SUPPLEMENT ...... 69 ELIXOPHYLLIN ...... 123 DOLOPHINE ...... 29 EASIVENT HOLDING CHAMBER ELLA...... 111 donepezil ...... 27 ...... 66 ELMIRON ...... 128 DONNATAL ...... 90 EASIVENT MASK LARGE ...... 66 ELOCTATE ...... 48 DOPTELET (10 TAB PACK) ...... 48 EASIVENT MASK MEDIUM ..... 66 eluryng ...... 108 DOPTELET (15 TAB PACK) ...... 48 EASIVENT MASK SMALL ...... 66 EMCYT ...... 14 DOPTELET (30 TAB PACK) ...... 48 EASY COMFORT LANCETS ...... 78 EMEND ...... 92 DORAL ...... 35 EASY COMFORT PEN NEEDLES 78 EMFLAZA ...... 74 dorzolamide...... 118 EASY TOUCH ...... 78 EMGALITY PEN ...... 25 dorzolamide-timolol...... 118 EASY TOUCH ALCOHOL PREP EMGALITY SYRINGE ...... 25 dotti ...... 107 PADS ...... 78 emoquette ...... 111 DOVATO ...... 3 EASY TOUCH FLIPLOCK NEEDLE EMSAM...... 35 doxazosin...... 43 ...... 78 emtricitabine ...... 3 doxepin ...... 35, 55 emtricitabine-tenofovir (tdf) 3, 4

139 EMTRIVA ...... 4 ERLEADA ...... 14 EVAMIST ...... 107 enalapril maleate ...... 44 erlotinib ...... 14 everolimus (antineoplastic) ... 14 enalapril-hydrochlorothiazide.44 errin...... 107 everolimus ENBREL ...... 104 ERTACZO ...... 60 (immunosuppressive) ...... 14 ENBREL MINI...... 104 ery pads ...... 57 EVISTA ...... 104 ENBREL SURECLICK...... 104 erygel...... 57 EVOCLIN ...... 57 endocet ...... 29 ERYPED 200...... 8 EVOTAZ...... 4 ENGERIX-B (PF) ...... 100 ERYPED 400...... 8 EVOXAC ...... 68 ENGERIX-B PEDIATRIC (PF) ... 100 ery-tab ...... 8 EVRYSDI ...... 27 enoxaparin ...... 48 ERY-TAB ...... 8 EXEL HYPODERMIC NEEDLES.. 78 enpresse ...... 111 erythrocin (as stearate) ...... 8 EXELDERM ...... 60 enskyce ...... 111 erythromycin ...... 8, 116 exemestane ...... 14 ENSPRYNG ...... 14 erythromycin ethylsuccinate.... 8 EXFORGE...... 44 ENSTILAR ...... 54 erythromycin with ethanol .... 57 EXFORGE HCT...... 44 entacapone...... 24 erythromycin-benzoyl peroxide EXJADE...... 68 entecavir ...... 4 ...... 57 EXODERM ...... 60 ENTOCORT EC ...... 92 ESBRIET...... 123 EXTAVIA ...... 98 ENTRESTO...... 52 escitalopram oxalate ...... 35 EXTINA...... 60 enulose...... 92 ESGIC ...... 25 e-z ject lancets ...... 78 EPANED ...... 44 esomeprazole magnesium ..... 96 EZ SMART LANCETS ...... 78 EPCLUSA ...... 4 estarylla ...... 111 ezetimibe ...... 51 EPIDIOLEX ...... 20 estazolam ...... 35, 36 ezetimibe-simvastatin ...... 51 EPIDUO...... 57 ESTRACE ...... 107 F EPIDUO FORTE ...... 57 estradiol...... 107 FABIOR ...... 57 epinastine...... 117 estradiol valerate ...... 107 FACTIVE ...... 11 epinephrine ...... 121 estradiol-norethindrone acet falmina (28)...... 111 EPINEPHRINE ...... 121 ...... 107 famciclovir ...... 4 epinephrine hcl ...... 121 ESTRING...... 107 famotidine ...... 96 EPIPEN...... 121 ESTROGEL ...... 107 FANAPT...... 36 EPIPEN 2-PAK ...... 121 estrogens-methyltestosterone FARESTON...... 14 EPIPEN JR...... 121 ...... 107 FARXIGA...... 88 EPIPEN JR 2-PAK...... 121 ESTROSTEP FE-28 ...... 111 FARYDAK...... 14 epitol ...... 20 eszopiclone ...... 36 FASENRA ...... 123 EPIVIR ...... 4 ethacrynic acid ...... 44 FASENRA PEN ...... 123 EPIVIR HBV ...... 4 ethambutol ...... 9 fayosim ...... 111 eplerenone ...... 44 ethosuximide ...... 20 FC2 FEMALE CONDOM ...... 106 EPOGEN ...... 97 ethyl chloride ...... 58 febuxostat...... 103 epoprostenol ...... 44 ethynodiol diac-eth estradiol FEIBA NF ...... 48 epoprostenol (glycine) ...... 44 ...... 111 felbamate ...... 20 eprosartan ...... 44 etidronate disodium ...... 68 FELBATOL...... 20 EPZICOM ...... 4 etodolac...... 32 FELDENE ...... 32 EQUETRO...... 20 etonogestrel-ethinyl estradiol felodipine...... 44 ergocalciferol (vitamin d2).... 130 ...... 108 fem ph ...... 109 ergoloid ...... 35 etoposide...... 14 FEMARA...... 14 ERGOMAR ...... 25 EUCRISA ...... 55 FEMCAP ...... 106 ergotamine-caffeine...... 25 EURAX ...... 64 FEMHRT LOW DOSE ...... 107 ERIVEDGE ...... 14 euthyrox ...... 90 FEMRING ...... 107

140 femynor...... 111 FLOW-EZE VENTED NEEDLE ... 78 fluvastatin ...... 51 fenofibrate ...... 51 FLUAD 2020-2021 (65 YR fluvoxamine ...... 36 fenofibrate micronized...... 51 UP)(PF)...... 100 FLUZONE HIGHDOSE QUAD 20- fenofibrate nanocrystallized ...51 FLUAD QUAD 2020-21(65Y 21 PF ...... 100 fenofibric acid ...... 51 UP)(PF)...... 100 FLUZONE QUAD 2020-2021 ..100 fenofibric acid (choline)...... 51 FLUARIX QUAD 2020-2021 (PF) FLUZONE QUAD 2020-2021 (PF) FENOGLIDE ...... 51 ...... 100 ...... 100 fenoprofen ...... 32 FLUBLOK QUAD 2020-2021 (PF) FML FORTE...... 119 fentanyl ...... 29 ...... 100 FML LIQUIFILM...... 119 fentanyl citrate ...... 29 FLUCELVAX QUAD 2020-2021 FML S.O.P...... 119 FENTORA ...... 29 ...... 100 folic acid ...... 130 FERRIPROX...... 68 FLUCELVAX QUAD 2020-2021 folivane-ob...... 130 FEXMID...... 28 (PF) ...... 100 FOLLISTIM AQ ...... 86 FIASP FLEXTOUCH U-100 fluconazole ...... 2 foltabs 800 ...... 130 INSULIN ...... 83 flucytosine ...... 2 fondaparinux...... 48 FIASP PENFILL U-100 INSULIN .83 fludrocortisone ...... 74 FORA V10-V12-D10-D20 STRP- FIASP U-100 INSULIN...... 83 FLULAVAL QUAD 2020-2021 (PF) LNCT ...... 78 FIBRICOR ...... 51 ...... 100 FORACARE LANCETS ...... 78 FIFTY50 SAFETY SEAL LANCETS FLUMADINE ...... 4 FORTEO ...... 104 ...... 78 FLUMIST QUAD 2020-2021 ...100 FOSAMAX ...... 104 FINACEA ...... 57 flunisolide ...... 124 FOSAMAX PLUS D ...... 104 finasteride ...... 127 fluocinolone ...... 62 fosamprenavir...... 4 FINE 30 UNIVERSAL LANCETS..78 fluocinolone acetonide oil ..... 73 fosfomycin tromethamine ..... 12 FINGERSTIX LANCETS ...... 78 fluocinolone and shower cap . 62 fosinopril ...... 44 FINTEPLA ...... 20 fluocinonide ...... 62 fosinopril-hydrochlorothiazide FIORICET ...... 25 fluocinonide-e ...... 62 ...... 44 FIORINAL ...... 25 fluocinonide-emollient ...... 62 FOSRENOL...... 92 FIORINAL-CODEINE #3...... 25 fluorescein-proparacaine...... 117 FOTIVDA ...... 14 FIRAZYR ...... 124 fluoride (sodium).....72, 130, 132 FRAGMIN ...... 48 FIRDAPSE ...... 27 FLUORIDEX DAILY DEFENSE ... 72 FREESTYLE LANCETS ...... 79 FIRVANQ...... 12 FLUORIDEX SENSITIVITY RELIEF FREESTYLE LIBRE 14 DAY flac otic oil ...... 73 ...... 72 READER ...... 79 FLAGYL ...... 9 fluoritab...... 130 FREESTYLE LIBRE 14 DAY FLAREX ...... 119 fluorometholone ...... 119 SENSOR ...... 79 flavoxate...... 127 fluorouracil ...... 55 FREESTYLE LIBRE 2 READER.... 79 flecainide ...... 41 fluoxetine ...... 36 FREESTYLE LIBRE 2 SENSOR.... 79 FLEXICHAMBER ...... 66 fluphenazine hcl ...... 36 FREESTYLE UNISTIK 2 ...... 79 FLEXICHAMBER-LG CHILD MASK FLURA-DROPS ...... 130 frovatriptan...... 25 ...... 66 flurandrenolide ...... 62 full spectrum b-vitamin c ...... 130 FLEXICHAMBER-SM ADULT flurazepam...... 36 FULPHILA ...... 97 MASK ...... 66 flurbiprofen...... 32 FURADANTIN ...... 12 FLEXICHAMBER-SM CHILD flurbiprofen sodium ...... 118 furosemide ...... 44 MASK ...... 66 flutamide ...... 14 FUZEON ...... 4 FLOLAN...... 44 fluticasone propionate .... 62, 63, fyavolv ...... 107 FLOMAX...... 127 124 FYCOMPA...... 20 FLOVENT DISKUS...... 124 fluticasone propion-salmeterol G FLOVENT HFA...... 124 ...... 124 g tussin ac ...... 121

141 gabapentin ...... 20 glucose ...... 75 hailey 24 fe ...... 111 GABITRIL...... 20 GLUCOTROL ...... 88 hailey fe 1.5/30 ( 28) ...... 111 GALAFOLD ...... 86 GLUCOTROL XL ...... 88 hailey fe 1/20 (28) ...... 111 galantamine...... 27 GLUTOSE-45...... 75 halcinonide ...... 63 GALZIN ...... 129 glyburide...... 88 HALCION ...... 36 GAMMAGARD LIQUID ...... 100 glyburide micronized ...... 88 halobetasol propionate ...... 63 GAMMAKED ...... 100 glyburide-metformin ...... 88 HALOG ...... 63 GAMUNEX-C ...... 100 glycopyrrolate ...... 90 haloperidol ...... 36 GANIRELIX ...... 86 glydo...... 58 haloperidol lactate ...... 36 GARDASIL 9 (PF) ...... 100 GLYNASE ...... 88 HARVONI ...... 4 GASTROCROM ...... 92 GLYSET...... 88 HAVRIX (PF)...... 100 gatifloxacin ...... 116 GLYTACTIN 10 PE COMPLETE . 69 HEALTHY ACCENTS UNIFINE GATTEX 30-VIAL ...... 92 GLYTACTIN 15 PE BETTERMILK PENTIP ...... 79 GATTEX ONE-VIAL ...... 92 ...... 69 HEALTHY ACCENTS UNILET gavilyte-c ...... 92 GLYTACTIN 15 PE COMPLETE . 69 LANCET ...... 79 gavilyte-g ...... 93 GLYTACTIN 20PE BETTERMILK heather ...... 107 gavilyte-n...... 93 LITE ...... 69 HEMLIBRA...... 48 GAVRETO ...... 14 GLYTACTIN RESTORE 10 PE .... 69 hemmorex-hc...... 93 GELNIQUE...... 127 GLYTACTIN RESTORE 10 PE LITE HEMOFIL M HIGH ...... 48 gemfibrozil...... 51 ...... 69 HEMOFIL M LOW ...... 48 GENERESS FE ...... 111 GLYTACTIN RESTORE 5 PE ...... 69 HEMOFIL M MID ...... 49 generlac...... 93 GLYTACTIN RTD 10 PE...... 69 HEMOFIL M SUPER HIGH ...... 49 gengraf ...... 14 GLYTACTIN RTD 15 PE...... 69 hep flush-10 (pf)...... 49 gentak ...... 116 GLYTACTIN SWIRL 15 PE ...... 69 heparin (porcine) ...... 49 gentamicin...... 59, 116 GLYXAMBI ...... 88 heparin lock flush ...... 49 gentle laxative (bisacodyl) ...... 93 GOLYTELY...... 93 heparin lock flush (porcine) ... 49 GENVOYA ...... 4 GONAL-F ...... 86 heparin lockflush(porcine)(pf) 49 GEODON...... 36 GONAL-F RFF...... 86 heparin, porcine (pf)...... 49 gianvi (28) ...... 111 GONAL-F RFF REDI-JECT...... 86 HEPARIN, PORCINE (PF) ...... 49 GILENYA ...... 98 granisetron hcl ...... 93 HEPLISAV-B (PF) ...... 100 GILOTRIF...... 14 GRASTEK ...... 100 HEPSERA ...... 4 glatiramer ...... 98 griseofulvin microsize ...... 2 HIBERIX (PF) ...... 100 glatopa ...... 98 griseofulvin ultramicrosize ...... 2 HIPREX ...... 12 GLEEVEC ...... 14 guaiatussin ac ...... 121 HIZENTRA...... 101 GLEOSTINE...... 14 guaifenesin ac ...... 121 homatropaire ...... 117 glimepiride ...... 88 guaifenesin dac ...... 121 HORIZANT ...... 27 glipizide ...... 88 guanfacine ...... 36, 44 HUBER SAFETY NEEDLES (DISP.) glipizide-metformin...... 88 guanidine ...... 36 ...... 79 GLUCAGEN DIAGNOSTIC KIT ...75 GVOKE HYPOPEN 1-PACK...... 75 HUMALOG JUNIOR KWIKPEN U- GLUCAGEN HYPOKIT ...... 75 GVOKE HYPOPEN 2-PACK...... 75 100 ...... 83 GLUCAGON (HCL) EMERGENCY GVOKE PFS 1-PACK SYRINGE .. 75 HUMALOG KWIKPEN INSULIN 84 KIT ...... 75 GVOKE PFS 2-PACK SYRINGE .. 75 HUMALOG MIX 50-50 INSULN GLUCAGON EMERGENCY KIT GYNAZOLE-1 ...... 109 U-100 ...... 84 (HUMAN) ...... 75 gynol ii ...... 109 HUMALOG MIX 50-50 KWIKPEN GLUCOCOM LANCETS...... 79 H ...... 84 GLUCOPHAGE ...... 88 HAEGARDA ...... 124 HUMALOG MIX 75-25 KWIKPEN GLUCOPHAGE XR ...... 88 hailey ...... 111 ...... 84

142 HUMALOG MIX 75-25(U- hydrocortisone acetate ...... 93 INCONTROL SUPER THIN 100)INSULN...... 84 hydrocortisone butyrate...... 63 LANCETS...... 79 HUMALOG U-100 INSULIN...... 84 hydrocortisone butyr-emollient INCONTROL ULTRA THIN HUMATE-P ...... 49 ...... 63 LANCETS...... 79 HUMIRA...... 105 hydrocortisone valerate ...... 63 INCRUSE ELLIPTA ...... 124 HUMIRA PEN ...... 104 hydrocortisone-acetic acid..... 73 indapamide ...... 44 HUMIRA PEN CROHNS-UC-HS hydrocortisone-iodoquinol-aloe INDERAL LA ...... 44 START ...... 104 ...... 59 INDERAL XL ...... 44 HUMIRA PEN PSOR-UVEITS- hydrocortisone-pramoxine ... 54, INDOCIN ...... 32 ADOL HS ...... 104 93 indomethacin ...... 32 HUMIRA(CF)...... 105 hydromet ...... 122 INFANRIX (DTAP) (PF) ...... 101 HUMIRA(CF) PEDI CROHNS hydromorphone ...... 29 INGREZZA...... 27 STARTER ...... 105 hydroxychloroquine ...... 9 INGREZZA INITIATION PACK ... 27 HUMIRA(CF) PEN ...... 105 hydroxyurea...... 15 INJECT EASE LANCETS ...... 79 HUMIRA(CF) PEN CROHNS-UC- hydroxyzine hcl ...... 121 INLYTA ...... 15 HS ...... 105 hydroxyzine pamoate ...... 121 INQOVI ...... 15 HUMIRA(CF) PEN PEDIATRIC UC hyoscyamine sulfate ...... 90, 91 INREBIC...... 15 ...... 105 HYPODERMIC NEEDLES...... 79 INSPIRACHAMBER ...... 66 HUMIRA(CF) PEN PSOR-UV- HYQVIA ...... 101 INSPIRACHAMBER WITH MASK- ADOL HS ...... 105 HYZAAR...... 44 LARGE ...... 66 HUMULIN 70/30 U-100 INSULIN I INSPIRACHAMBER WITH MASK- ...... 84 ibandronate ...... 104 MED ...... 66 HUMULIN 70/30 U-100 IBRANCE ...... 13, 15 INSPIRACHAMBER WITH MASK- KWIKPEN...... 84 ibu ...... 32 SMALL ...... 66 HUMULIN N NPH INSULIN IBUDONE ...... 29 INSPRA...... 44 KWIKPEN...... 84 ibuprofen ...... 32 INSULIN LISPRO ...... 84 HUMULIN N NPH U-100 INSULIN ibuprofen-oxycodone ...... 29 INSULIN LISPRO PROTAMIN- ...... 84 icatibant...... 124 LISPRO ...... 84 HUMULIN R REGULAR U-100 iclevia ...... 111 INSULIN SYRINGE-NEEDLE U-100 INSULN ...... 84 ICLUSIG ...... 15 ...... 79 HUMULIN R U-500 (CONC) icosapent ethyl...... 51 INSUPEN ...... 79 INSULIN ...... 84 IDHIFA ...... 15 INTELENCE ...... 4 HUMULIN R U-500 (CONC) ILARIS (PF)...... 99 INTRAROSA ...... 109 KWIKPEN...... 84 imatinib ...... 15 INTRON A...... 99 HYCAMTIN ...... 14 IMBRUVICA ...... 15 introvale ...... 111 HYCODAN (WITH imipramine hcl ...... 36 INTUNIV ER ...... 36 HOMATROPINE) ...... 121 imipramine pamoate ...... 36 INVACARE LANCETS ...... 79 hydralazine ...... 44 imiquimod ...... 99 INVEGA ...... 36 HYDREA ...... 14 IMITREX ...... 25, 26 INVEGA SUSTENNA...... 36 HYDRO 40 ...... 55 IMITREX STATDOSE PEN ... 25, 26 INVEGA TRINZA ...... 36 hydrochlorothiazide ...... 44 IMITREX STATDOSE REFILL ..... 26 INVIRASE...... 4 hydrocodone-acetaminophen 29 IMOVAX RABIES VACCINE (PF) INVOKAMET ...... 88 hydrocodone-chlorpheniramine ...... 101 INVOKAMET XR ...... 88 ...... 122 IMURAN...... 15 INVOKANA ...... 88 hydrocodone-homatropine .. 122 incassia ...... 107 IOPIDINE ...... 120 hydrocodone-ibuprofen ...... 29 INCONTROL PEN NEEDLE ...... 79 IPOL ...... 101 hydrocortisone ...... 63, 74, 93 ipratropium bromide ...... 72, 124

143 ipratropium-albuterol ...... 124 junel fe 24 ...... 112 KOVALTRY ...... 49 irbesartan ...... 44 JUXTAPID ...... 51 K-PHOS NO 2 ...... 128 irbesartan-hydrochlorothiazide JYNARQUE ...... 86 K-PHOS ORIGINAL...... 128 ...... 44 K KRINTAFEL ...... 9 IRESSA ...... 15 KADIAN ...... 29 KRISTALOSE...... 93 ISENTRESS...... 4 kaitlib fe...... 112 k-tab ...... 129 ISENTRESS HD ...... 4 KALETRA ...... 4 K-TAB...... 129 isibloom...... 111 kalliga ...... 112 kurvelo (28)...... 112 ISOCHRON ...... 53 KALYDECO...... 124 KUVAN ...... 87 isometh-dichloral- KAPVAY...... 36 L acetaminophn ...... 26 kariva (28) ...... 112 l norgest/e.estradiol-e.estrad isoniazid ...... 9 kelnor 1/35 (28) ...... 112 ...... 112 ISOPTO CARPINE ...... 117 kelnor 1-50 (28)...... 112 labetalol...... 44 ISORDIL...... 53 KENALOG ...... 63 LACRISERT...... 117 ISORDIL TITRADOSE...... 53 KEPPRA ...... 20 lactated ringers ...... 67 isosorbide dinitrate ...... 53 KEPPRA XR ...... 20 lactulose ...... 93 isosorbide mononitrate ...... 53 KERALAC ...... 55 LAMICTAL ...... 20 isradipine ...... 44 KESIMPTA PEN ...... 98 LAMICTAL ODT ...... 20 ISTURISA ...... 86 ketoconazole...... 2, 60 LAMICTAL ODT STARTER (BLUE) itraconazole ...... 2 ketodan ...... 60 ...... 20 ivermectin ...... 9 KETO-DIASTIX ...... 79 LAMICTAL ODT STARTER IXIARO (PF) ...... 101 KETONE URINE TEST ...... 79 (GREEN) ...... 20 J ketoprofen ...... 32 LAMICTAL ODT STARTER JADENU ...... 68 ketorolac...... 32, 118 (ORANGE)...... 20 jaimiess ...... 111 KETOROLAC...... 32 LAMICTAL STARTER (BLUE) KIT JAKAFI ...... 15 KETOSTIX ...... 79 ...... 20 JALYN ...... 127 KEVEYIS...... 27 LAMICTAL STARTER (GREEN) KIT JANSSEN COVID-19 VACCINE KEVZARA ...... 105 ...... 20 (EUA) ...... 101 KINERET ...... 99 LAMICTAL STARTER (ORANGE) jantoven ...... 49 KINRIX (PF) ...... 101 KIT ...... 21 JANUMET...... 88 kionex (with sorbitol) ...... 93 LAMICTAL XR...... 21 JANUMET XR...... 89 KISQALI ...... 15 LAMICTAL XR STARTER (BLUE) 21 JANUVIA ...... 89 KISQALI FEMARA CO-PACK..... 15 LAMICTAL XR STARTER (GREEN) JARDIANCE...... 89 KITABIS PAK ...... 9 ...... 21 jasmiel (28) ...... 111 KLARON ...... 59 LAMICTAL XR STARTER jencycla ...... 107 KLONOPIN...... 20 (ORANGE)...... 21 JENTADUETO ...... 89 klor-con ...... 129 lamivudine ...... 4 JENTADUETO XR ...... 89 klor-con 10...... 129 lamivudine-zidovudine ...... 4 jinteli ...... 107 klor-con 8...... 129 lamotrigine ...... 21 JIVI ...... 49 klor-con m10...... 129 LANAFLEX ...... 69 jolessa ...... 111 klor-con m15...... 129 lancets ...... 79 juleber ...... 111 klor-con m20...... 129 LANCETS ...... 79 JULUCA ...... 4 klor-con/ef ...... 129 LANCETS,THIN ...... 79 junel 1.5/30 (21) ...... 112 KOATE...... 49 LANCETS,ULTRA THIN ...... 79 junel 1/20 (21) ...... 112 KOGENATE FS...... 49 LANOXIN ...... 47 junel fe 1.5/30 ( 28) ...... 112 KORLYM ...... 86 lansoprazole...... 96 junel fe 1/20 (28) ...... 112 KOSELUGO ...... 15 lanthanum ...... 93

144 LANTUS SOLOSTAR U-100 levorphanol tartrate ...... 29 LOESTRIN FE 1/20 ( 28-DAY) ..112 INSULIN ...... 84 levo-t ...... 90 lojaimiess ...... 113 LANTUS U-100 INSULIN ...... 84 levothyroxine ...... 90 LOMAIRA ...... 65 lapatinib ...... 15 levoxyl ...... 90 LOMOTIL ...... 91 larin 1.5/30 (21) ...... 112 LEVSIN ...... 91 LONHALA MAGNAIR REFILL ..124 larin 1/20 (21) ...... 112 LEVSIN/SL...... 91 LONHALA MAGNAIR STARTER larin 24 fe ...... 112 LEXAPRO ...... 36 ...... 124 larin fe 1.5/30 ( 28) ...... 112 LEXIVA ...... 4 LONSURF...... 15 larin fe 1/20 (28) ...... 112 LIBRAX (WITH CLIDINIUM) ..... 91 LOPHLEX ...... 70 larissia ...... 112 lidocaine ...... 58, 59 LOPID...... 51 LASIX ...... 44 lidocaine hcl ...... 58 lopinavir-ritonavir ...... 5 latanoprost ...... 118 lidocaine hcl-hydrocortison ac LOPRESSOR ...... 45 LATUDA ...... 36 ...... 58, 93 LOPRESSOR HCT ...... 45 laxaclear ...... 93 lidocaine viscous ...... 59 LOPROX ...... 60 laxative (bisacodyl)...... 93 lidocaine-hydrocortisone-aloe 93 lorazepam ...... 37 laxative peg 3350 ...... 93 lidocaine-prilocaine ...... 59 lorazepam intensol...... 37 layolis fe ...... 112 lidocort ...... 59 LORBRENA ...... 15 LEDIPASVIR-SOFOSBUVIR ...... 4 LIDODERM ...... 59 lorcet hd ...... 29 leena 28...... 112 LIFESHIELD BLUNT CANNULA . 79 LORTAB ELIXIR...... 29 leflunomide ...... 105 lillow (28) ...... 112 loryna (28) ...... 113 LENVIMA ...... 15 lindane...... 64 losartan ...... 45 LESCOL ...... 51 linezolid ...... 9 losartan-hydrochlorothiazide. 45 LESCOL XL ...... 51 LINZESS ...... 93 LOSEASONIQUE ...... 113 lessina ...... 112 liothyronine ...... 90 LOTEMAX ...... 119 letrozole ...... 15 LIPITOR ...... 51 LOTEMAX SM ...... 119 leucovorin calcium ...... 13 LIPOFEN ...... 51 LOTENSIN...... 45 LEUKERAN ...... 15 lisinopril ...... 44 LOTENSIN HCT...... 45 leuprolide ...... 15 lisinopril-hydrochlorothiazide 44 loteprednol etabonate ...... 119 levalbuterol hcl ...... 124 LITE TOUCH LANCETS ...... 79 LOTREL...... 45 LEVATOL ...... 44 LITE TOUCH-MEDIUM MASK .. 66 LOTRONEX ...... 93 LEVBID ...... 91 LITEAIRE MDI CHAMBER ...... 66 LOUTREX ...... 55 LEVEMIR FLEXTOUCH U-100 LITETOUCH-LARGE MASK...... 66 lovastatin ...... 51 INSULN ...... 85 LITETOUCH-SMALL MASK ...... 66 LOVAZA...... 51 LEVEMIR U-100 INSULIN...... 85 lithium carbonate...... 36 LOVENOX ...... 49 levetiracetam...... 21 lithium citrate ...... 36 low-ogestrel (28) ...... 113 LEVITRA ...... 128 LITHOBID ...... 37 loxapine succinate...... 37 levobunolol...... 116 LITHOSTAT ...... 68 lo-zumandimine (28) ...... 113 levocarnitine ...... 68 LIVALO ...... 51 LUCEMYRA ...... 32 levocarnitine (with sugar)...... 68 LO LOESTRIN FE...... 112 ludent fluoride ...... 130 levofloxacin ...... 11, 116 LOCOID ...... 63 lugols ...... 129 levonest (28)...... 112 LOCOID LIPOCREAM ...... 63 LUMIGAN ...... 118 levonorgestrel...... 112 LODINE ...... 32 LUNESTA ...... 37 levonorgestrel-ethinyl estrad LODOSYN ...... 24 LUPANETA PACK (1 MONTH) 109 ...... 112 LOESTRIN 1.5/30 (21) ...... 112 LUPANETA PACK (3 MONTH) 109 levonorg-eth estrad triphasic LOESTRIN 1/20 (21) ...... 112 LUPKYNIS ...... 15 ...... 112 LOESTRIN FE 1.5/30 (28-DAY) lutera (28) ...... 113 levora-28 ...... 112 ...... 112 LUXIQ ...... 63

145 lyleq ...... 107 mefenamic acid...... 32 methoxsalen ...... 55 lyllana ...... 107 mefloquine ...... 9 methscopolamine ...... 91 LYNPARZA...... 15 megestrol...... 15 methyldopa...... 45 LYRICA ...... 21 MEKINIST ...... 15 methyldopa- LYRICA CR ...... 21 MEKTOVI...... 15 hydrochlorothiazide ...... 45 LYSODREN ...... 15 melodetta 24 fe...... 113 METHYLIN ...... 37 LYSTEDA ...... 109 meloxicam ...... 32 methylphenidate hcl ...... 37 LYUMJEV KWIKPEN U-100 melphalan ...... 15 methylprednisolone ...... 74 INSULIN ...... 85 memantine ...... 27 methyltestosterone...... 87 LYUMJEV KWIKPEN U-200 MEMANTINE ...... 27 metipranolol ...... 116 INSULIN ...... 85 MENACTRA (PF) ...... 101 metoclopramide hcl ...... 94 LYUMJEV U-100 INSULIN ...... 85 M-END PE ...... 122 metolazone ...... 45 lyza ...... 107 MENEST ...... 108 metoprolol succinate...... 45 M MENOPUR...... 87 metoprolol ta-hydrochlorothiaz MACRILEN ...... 97 MENOSTAR ...... 108 ...... 45 MACROBID ...... 12 MENQUADFI (PF)...... 101 metoprolol tartrate ...... 45 MACRODANTIN...... 12 MENVEO A-C-Y-W-135-DIP (PF) METROCREAM ...... 57 mafenide acetate ...... 59 ...... 101 METROGEL VAGINAL ...... 109 magnesium citrate ...... 93 meperidine ...... 29, 30 METROLOTION ...... 57 MALARONE...... 9 MEPHYTON ...... 49 metronidazole...... 9, 57, 109 MALARONE PEDIATRIC ...... 9 meprobamate ...... 28 mexiletine ...... 41 malathion ...... 64 MEPRON ...... 9 MIACALCIN ...... 87 maprotiline ...... 37 mercaptopurine ...... 15 mibelas 24 fe...... 113 MAR-COF BP ...... 122 mesalamine ...... 93, 94 MICARDIS...... 45 MAR-COF CG...... 122 mesalamine with cleansing wipe MICARDIS HCT...... 45 MARINOL ...... 93 ...... 94 miconazole-3 ...... 109 marlissa (28) ...... 113 MESNEX ...... 13 MICRO THIN LANCETS ...... 80 MARPLAN ...... 37 MESTINON ...... 28 MICROCHAMBER...... 66 MATULANE ...... 15 MESTINON TIMESPAN ...... 28 microgestin 1.5/30 ( 21) ...... 113 matzim la...... 45 metadate er ...... 37 microgestin 1/20 (21) ...... 113 MAVYRET...... 5 metaproterenol...... 124 microgestin fe 1.5/30 (28) ....113 MAXALT...... 26 metaxalone ...... 28 microgestin fe 1/20 ( 28) ...... 113 MAXIDEX ...... 119 metformin...... 89 MICROLET LANCET ...... 80 MAXITROL ...... 118 methadone ...... 30 MICROSPACER...... 66 MAXZIDE ...... 45 methadone intensol ...... 30 midazolam ...... 37 MAXZIDE-25MG ...... 45 methadose...... 30 midodrine ...... 68 MAYZENT...... 98 methamphetamine ...... 37 migergot ...... 26 MAYZENT STARTER PACK ...... 98 methazolamide ...... 118 miglitol ...... 89 m-clear wc ...... 122 methenamine hippurate...... 12 miglustat...... 87 meclofenamate...... 32 methenamine mandelate ...... 12 MIGRANAL ...... 26 MEDISENSE THIN LANCETS .....79 methen-sod phos-meth blue- mili ...... 113 MEDLANCE PLUS LANCETS .....80 hyos ...... 128 millipred ...... 74 MEDLANCE PLUS SPECIAL methimazole ...... 74 millipred dp...... 74 BLADE ...... 80 METHITEST...... 87 mimvey ...... 108 MEDROL ...... 74 methocarbamol...... 28 MINASTRIN 24 FE ...... 113 MEDROL (PAK) ...... 74 methotrexate sodium...... 16 MINI ULTRA-THIN II ...... 80 medroxyprogesterone.. 107, 108 methotrexate sodium (pf). 15, 16 MINIPRESS ...... 45

146 MINITRAN...... 53 multivitamin with fluoride ....130 NARCAN...... 33 MINIVELLE ...... 108 multi-vitamin with fluoride ...130 NARDIL ...... 37 minocycline ...... 12 multi-vitamin with fluoride ...130 NATACYN ...... 116 minoxidil...... 45 multivitamins with fluoride...131 NATAZIA ...... 113 MIOCHOL-E...... 117 mupirocin ...... 59 nateglinide ...... 89 miostat ...... 118 mupirocin calcium ...... 59 NATPARA ...... 87 MIRAPEX...... 24 MUSE...... 128 NATROBA...... 64 MIRAPEX ER ...... 24 mvc-fluoride ...... 131 NEBUPENT ...... 9 MIRCERA ...... 97 my choice ...... 113 necon 0.5/35 (28) ...... 113 MIRCETTE ( 28) ...... 113 my way ...... 113 NEEDLES, HUBER DISPOSABLE 80 mirtazapine ...... 37 MYALEPT ...... 87 nefazodone ...... 37 misoprostol...... 96 MYAMBUTOL ...... 9 neomycin ...... 9 MITOSOL ...... 118 MYCAPSSA ...... 16 neomycin-bacitracin-poly-hc 119 M-M-R II (PF) ...... 101 MYCOBUTIN...... 9 neomycin-bacitracin-polymyxin m-natal plus...... 130 mycophenolate mofetil ...... 16 ...... 116 MOBIC ...... 32 mycophenolate sodium ...... 16 neomycin-polymyxin b gu...... 67 modafinil ...... 37 MYDAYIS ...... 37 neomycin-polymyxin b- MODERNA COVID-19 VACCINE MYDRIACYL ...... 117 dexameth ...... 119 (EUA) ...... 101 MYFORTIC ...... 16 neomycin-polymyxin-gramicidin moexipril ...... 45 MYGLUCOHEALTH LANCETS... 80 ...... 116 mometasone ...... 63, 124 MYLERAN ...... 16 neomycin-polymyxin-hc . 73, 119 monoject 0.9% sodium chloride mynatal...... 131 neo-polycin ...... 116 ...... 68 mynatal plus ...... 131 neo-polycin hc...... 119 MONOJECT BLOOD COLLECTION mynatal-z ...... 131 NEORAL ...... 16 ...... 80 myorisan ...... 57 NEO-SYNALAR ...... 59 MONOJECT HYPODERMIC MYRBETRIQ...... 127 NEO-SYNALAR KIT...... 59 NEEDLES ...... 80 MYSOLINE ...... 21 NERLYNX ...... 16 MONOJECT MEDICATION MYTESI...... 91 neuac...... 57 TRANSF NDL ...... 80 N NEULASTA ...... 97 monoject prefill advanced ns..68 nabumetone ...... 32 NEULASTA ONPRO...... 97 MONOJECT ULTRA COMFORT nadolol ...... 45 NEUPOGEN ...... 97 INSULIN ...... 80 nadolol-bendroflumethiazide 45 NEUPRO ...... 24 MONOLET THIN LANCETS ...... 80 naftifine ...... 60 NEURONTIN ...... 21 mono-linyah ...... 113 NAFTIN ...... 60 nevirapine...... 5 montelukast...... 124 NALFON ...... 32 new day ...... 113 MONUROL ...... 12 naloxone ...... 33 newgen ...... 131 morphine...... 30 naltrexone ...... 33 NEXAVAR ...... 16 morphine concentrate ...... 30 NAMENDA ...... 27 NEXIUM ...... 96 MOTOFEN...... 91 NAMENDA TITRATION PAK .... 27 NEXIUM PACKET...... 96 MOUTHPIECE ...... 66 NAMENDA XR...... 27 niacin ...... 51 MOVANTIK ...... 94 NAMZARIC ...... 27 NIACOR ...... 51 moxifloxacin ...... 11, 116 NAPRELAN ...... 32 NIASPAN EXTENDED-RELEASE 51 MOZOBIL ...... 97 NAPRELAN CR ...... 32 nicardipine ...... 45 MS CONTIN ...... 30 NAPROSYN ...... 32 NICODERM CQ ...... 71 MULPLETA ...... 49 naproxen ...... 32, 33 nicorelief...... 71 MULTAQ ...... 41 naproxen sodium ...... 33 nicorette ...... 71 MULTI-DRAW NEEDLE ...... 80 naratriptan...... 26 NICORETTE...... 71

147 nicotine ...... 71 nortrel 1/35 (21) ...... 113 NURTEC ODT ...... 26 nicotine (polacrilex) ...... 71 nortrel 1/35 (28) ...... 113 NUVARING ...... 109 NICOTROL ...... 72 nortrel 7/7/7 ( 28) ...... 114 NUVESSA ...... 109 NICOTROL NS ...... 72 nortriptyline ...... 37 NUVIGIL ...... 37 nifedipine ...... 45 NORVASC ...... 45 NUZYRA ...... 12 nikki (28)...... 113 NORVIR ...... 5 nyamyc ...... 60 NILANDRON ...... 16 NOURIANZ ...... 24 nylia 7/7/7 (28) ...... 114 nilutamide ...... 16 NOVA SAFETY LANCETS ...... 80 nymyo...... 114 nimodipine ...... 45 NOVA SUREFLEX LANCETS ..... 80 nystatin...... 2, 60 NINLARO...... 16 NOVOEIGHT ...... 49 nystatin-triamcinolone ...... 60 nisoldipine ...... 45 NOVOFINE 32 ...... 80 nystop...... 60 nitazoxanide ...... 9 NOVOFINE AUTOCOVER ...... 80 NYVEPRIA...... 97 nitisinone...... 68 NOVOFINE PLUS ...... 80 O nitro-bid ...... 53 NOVOLIN 70/30 U-100 INSULIN OCALIVA ...... 94 NITRO-DUR ...... 53 ...... 85 ocella ...... 114 nitrofurantoin ...... 12 NOVOLIN 70-30 FLEXPEN U-100 octreotide acetate...... 16 nitrofurantoin macrocrystal....12 ...... 85 OCUFLOX ...... 116 nitrofurantoin monohyd/m- NOVOLIN N FLEXPEN ...... 85 ODACTRA ...... 101 cryst...... 12 NOVOLIN N NPH U-100 INSULIN ODEFSEY ...... 5 nitroglycerin ...... 53 ...... 85 ODOMZO ...... 16 NITROLINGUAL ...... 53 NOVOLIN R FLEXPEN ...... 85 OFEV...... 124 NITROMIST ...... 53 NOVOLIN R REGULAR U-100 ofloxacin ...... 11, 73, 116 NITROSTAT ...... 53 INSULN...... 85 olanzapine ...... 38 nitro-time ...... 53 NOVOLOG FLEXPEN U-100 olanzapine-fluoxetine ...... 38 NITYR...... 68 INSULIN...... 85 olmesartan...... 45 nizatidine ...... 96 NOVOLOG MIX 70-30 U-100 olmesartan-amlodipin-hcthiazid NOKOR NEEDLE...... 80 INSULN...... 85 ...... 45 nora-be...... 108 NOVOLOG MIX 70-30FLEXPEN olmesartan-hydrochlorothiazide NORCO ...... 30 U-100 ...... 85 ...... 45 NORDITROPIN FLEXPRO ...... 97 NOVOLOG PENFILL U-100 olopatadine...... 72, 117 noreth-ethinyl estradiol-iron 113 INSULIN...... 85 OLUMIANT ...... 105 norethindrone (contraceptive) NOVOLOG U-100 INSULIN OLUX ...... 63 ...... 108 ASPART ...... 85 OLUX-E ...... 63 norethindrone acetate ...... 108 NOVOPEN ECHO...... 80 OMECLAMOX-PAK ...... 96 norethindrone ac-eth estradiol NOVOSEVEN RT...... 49 omega-3 acid ethyl esters ...... 51 ...... 108, 113 NOXAFIL...... 2 omeprazole ...... 96 norethindrone-e.estradiol-iron np thyroid ...... 90 OMNIPOD DASH 5 PACK POD 80 ...... 113 NUBEQA ...... 16 ON CALL LANCET ...... 80 norgestimate-ethinyl estradiol NUCALA ...... 124 ON CALL PLUS LANCET...... 80 ...... 113 NUCYNTA ...... 30 ondansetron ...... 94 norlyda ...... 108 NUCYNTA ER ...... 30 ondansetron hcl ...... 94 normal saline flush ...... 68 NUEDEXTA ...... 27 ONE WAY VALVED MOUTHPIECE NORPACE...... 41 NULEV...... 91 ...... 66 NORPACE CR ...... 41 NULYTELY LEMON-LIME...... 94 ONETOUCH DELICA LANCETS . 80 NORPRAMIN ...... 37 NULYTELY WITH FLAVOR PACKS ONETOUCH ULTRA BLUE TEST NORTHERA ...... 68 ...... 94 STRIP...... 75 nortrel 0.5/35 (28) ...... 113 NUPLAZID ...... 37 ONETOUCH ULTRA2 METER... 80

148 ONETOUCH ULTRAMINI ...... 80 ORTHO TRI-CYCLEN (28) ...... 114 paliperidone...... 38 ONETOUCH ULTRASOFT ORTHO-NOVUM 7/7/7 (28)...114 PALYNZIQ...... 87 LANCETS ...... 80 oseltamivir ...... 5 PAMELOR...... 38 ONETOUCH VERIO FLEX METER OSPHENA ...... 109 PANDA MASK ...... 66 ...... 80 OTEZLA ...... 105 PANDEL...... 63 ONETOUCH VERIO FLEX START OTEZLA STARTER ...... 105 PANRETIN ...... 56 ...... 80 OTOVEL...... 73 pantoprazole...... 96 ONETOUCH VERIO IQ METER..80 OVACE ...... 54 PAREMYD...... 117 ONETOUCH VERIO METER ...... 81 OVACE PLUS ...... 54 paricalcitol ...... 87 ONETOUCH VERIO REFLECT OVACE PLUS SHAMPOO...... 54 PARLODEL ...... 24 METER ...... 81 OVACE PLUS WASH ...... 54 PARNATE ...... 38 ONETOUCH VERIO REFLECT OVIDE ...... 64 paroex oral rinse ...... 72 START ...... 81 OVIDREL...... 87 paromomycin...... 9 ONETOUCH VERIO TEST STRIPS OXANDRIN ...... 87 paroxetine hcl ...... 38 ...... 75 oxandrolone...... 87 PASER ...... 9 ONFI ...... 21 oxaprozin ...... 33 PATANASE...... 72 ON-THE-GO LANCETS ...... 81 oxazepam ...... 38 PAXIL ...... 38 ONUREG ...... 16 OXBRYTA...... 68 PAXIL CR ...... 38 opcicon one-step ...... 114 oxcarbazepine ...... 21 PEAK AIR PEAK FLOW METER. 67 OPSUMIT ...... 124 OXERVATE...... 117 PEDIAPRED...... 74 OPTICHAMBER ADULT MASK- oxiconazole ...... 60 PEDIARIX (PF) ...... 102 LARGE ...... 66 OXISTAT ...... 60 PEDIATRIC MEDIUM MASK .... 67 OPTICHAMBER DIAMOND LG OXSORALEN ULTRA ...... 55 PEDIATRIC PANDA MASK ...... 67 MASK ...... 66 OXTELLAR XR...... 22 PEDIATRIC SMALL MASK ...... 67 OPTICHAMBER DIAMOND VHC oxybutynin chloride...... 127 PEDVAX HIB (PF)...... 102 ...... 66 oxycodone ...... 30 peg 3350-electrolytes ...... 94 OPTICHAMBER DIAMOND-MED oxycodone-acetaminophen ... 30 peg-3350 with flavor packs .... 94 MSK ...... 66 oxycodone-aspirin ...... 30 PEGANONE ...... 22 OPTICHAMBER DIAMOND-SML oxymorphone...... 30 PEGASYS ...... 98 MASK ...... 66 OXYTROL...... 127 peg-electrolyte soln...... 94 option-2...... 114 OZEMPIC...... 89 PEGINTRON...... 98 ORALAIR ...... 101 P peg-prep ...... 94 oralone ...... 72 pacerone...... 41 PEMAZYRE ...... 16 ORAMAGICRX ...... 72 PACNEX...... 57 PEN NEEDLE ...... 81 ORAPRED ODT ...... 74 PALFORZIA (LEVEL 1) ...... 101 PEN NEEDLE, DIABETIC ...... 81 ORAVIG ...... 2 PALFORZIA (LEVEL 2) ...... 101 penicillamine...... 105 ORENCIA...... 105 PALFORZIA (LEVEL 3) ...... 101 penicillin v potassium ...... 11 ORENCIA CLICKJECT...... 105 PALFORZIA (LEVEL 4) ...... 101 PENTACEL (PF) ...... 102 ORENITRAM...... 45 PALFORZIA (LEVEL 5) ...... 101 PENTACEL ACTHIB COMPONENT ORFADIN...... 68 PALFORZIA (LEVEL 6) ...... 101 (PF) ...... 102 ORGOVYX ...... 16 PALFORZIA (LEVEL 7) ...... 101 PENTACEL DTAP-IPV COMPNT ORIAHNN ...... 109 PALFORZIA (LEVEL 8) ...... 101 (PF) ...... 102 ORILISSA ...... 87 PALFORZIA (LEVEL 9) ...... 101 pentamidine ...... 9 ORKAMBI ...... 124 PALFORZIA (LEVEL 10) ...... 101 PENTASA ...... 94 orphenadrine citrate ...... 28 PALFORZIA INITIAL DOSE ...... 101 pentazocine-naloxone ...... 30 orsythia ...... 114 PALFORZIA LEVEL 11 PENTIPS ...... 81 ORTHO MICRONOR ...... 108 MAINTENANCE ...... 102 pentoxifylline ...... 49

149 PEPCID...... 96 philith ...... 114 pnv-select ...... 131 PERCOCET...... 30 PHLEXY-10 ...... 70 POCKET CHAMBER ...... 67 PERFOROMIST ...... 125 PHLEXY-10 DRINK MIX POWDER PODOCON ...... 55 PERIDEX ...... 72 ...... 70 podofilox...... 56 PERIFLEX ADVANCE ...... 70 PHOSLYRA ...... 94 POLY HUB NEEDLE ...... 81 PERIFLEX INFANT ...... 70 phosphate laxative ...... 94 polycin ...... 116 PERIFLEX JUNIOR ...... 70 PHOSPHOLINE IODIDE ...... 117 polyethylene glycol 3350 ...... 94 PERIFLEX LQ PKU...... 70 PHYSIOLYTE...... 67 polymyxin b sulf-trimethoprim perindopril erbumine ...... 46 PHYSIOSOL IRRIGATION ...... 67 ...... 116 periogard ...... 72 phytonadione (vitamin k1)..... 49 POLYTRIM ...... 116 permethrin ...... 64 PIFELTRO...... 5 POMALYST ...... 98 perphenazine...... 38 pilocarpine hcl...... 68, 72, 117 portia 28 ...... 114 perphenazine-amitriptyline ....38 pimecrolimus ...... 56 posaconazole ...... 2 PERSERIS...... 38 pimozide ...... 38 POTABA ...... 129 PEXEVA ...... 38 pimtrea (28) ...... 114 potassium chloride ...... 129 PFIZER COVID-19 VACCINE pindolol ...... 46 potassium citrate ...... 128 (EUA) ...... 102 pioglitazone ...... 89 powderlax ...... 94 PHASEAL PROTECTOR...... 81 pioglitazone-glimepiride ...... 89 pr natal 400...... 131 PHENACTIN AA PLUS 20 PE .....70 pioglitazone-metformin...... 89 pr natal 400 ec ...... 131 phenazopyridine ...... 129 PIQRAY ...... 16 pr natal 430...... 131 phendimetrazine tartrate ...... 65 pirmella ...... 114 pr natal 430 ec ...... 131 phenelzine ...... 38 piroxicam ...... 33 PRADAXA ...... 49 PHENEX-1 ...... 70 PKU AIR20 ...... 70 PRALUENT PEN...... 51 PHENEX-2 ...... 70 PKU COOLER 10...... 71 pramipexole ...... 24 phenobarb-hyoscy-atropine- PKU COOLER 15...... 71 PRANDIN...... 89 scop ...... 91 PKU COOLER 20...... 71 prasugrel...... 50 phenobarbital ...... 22 PKU EASY ...... 71 PRAVACHOL ...... 51 phenoxybenzamine ...... 46 PKU EASY MICROTABS ...... 71 pravastatin...... 51 phentermine...... 65 PKU EXPRESS15 ...... 71 praziquantel ...... 10 PHENYLADE 40...... 70 PKU EXPRESS20 ...... 71 prazosin ...... 46 PHENYLADE 60...... 70 PKU GEL POWDER ...... 71 PRECISION XTRA B-KETONE ... 81 PHENYLADE AMINO ACIDS .....70 PKU LOPHLEX ...... 71 PRECOSE ...... 89 PHENYLADE ESSENTIAL ...... 70 PKU PERIFLEX EARLY YEARS ... 71 PRED FORTE ...... 119 PHENYLADE GMP ...... 70 PKU PERIFLEX JUNIOR PLUS ... 71 PRED MILD ...... 120 PHENYLADE GMP MIX-IN...... 70 PKU SPHERE20 ...... 71 PRED-G ...... 119 PHENYLADE GMP READY ...... 70 PKU TRIO ...... 71 PRED-G S.O.P...... 119 PHENYLADE MTE AMINO ACIDS PLAQUENIL ...... 10 prednicarbate ...... 63 ...... 70 PLAVIX ...... 49 prednisolone ...... 74 phenylade phebloc...... 70 PLEGRIDY ...... 98 prednisolone acetate...... 120 PHENYLADE PHEBLOC ...... 70 PLEXION...... 57 prednisolone sodium phosphate phenylephrine hcl ...... 120 PLEXION CLEANSING CLOTHS. 57 ...... 74, 120 PHENYL-FREE 1 ...... 70 PNEUMOVAX-23 ...... 102 prednisone...... 74 PHENYL-FREE 2 PKU ...... 70 pnv 29-1...... 131 prednisone intensol...... 74 PHENYL-FREE 2HP PKU ...... 70 pnv-dha ...... 131 PREFEST ...... 108 PHENYTEK...... 22 pnv-ferrous fumarate-docu-fa pregabalin...... 22 phenytoin ...... 22 ...... 131 PREGNYL ...... 87 phenytoin sodium extended ...22 pnv-omega...... 131 PREMARIN ...... 108

150 PREMPHASE...... 108 PRIMLEV ...... 30 propranolol-hydrochlorothiazid PREMPRO ...... 108 PRIMSOL ...... 12 ...... 46 prena1 chew ...... 131 PRINIVIL ...... 46 propylthiouracil...... 74 prena1 pearl ...... 131 PRISTIQ ...... 38 PROQUAD (PF) ...... 102 prena1 true...... 131 PRO COMFORT LANCET ...... 81 PROSCAR ...... 127 prenatabs fa ...... 131 PRO COMFORT SPACER-ADULT PROSTIN VR PEDIATRIC...... 128 prenatabs rx ...... 131 MASK ...... 67 PROTONIX ...... 97 prenatal ...... 131 PRO COMFORT SPACER-CHILD protriptyline ...... 38 prenatal formula ...... 131 MASK ...... 67 PROVENTIL HFA...... 125 prenatal low iron ...... 131 PROAIR RESPICLICK ...... 125 PROVERA ...... 108 prenatal multivitamins ...... 131 probenecid...... 103 PROVIGIL ...... 38 prenatal one daily ...... 131 probenecid-colchicine ...... 103 PROZAC ...... 38 prenatal plus...... 131 PROCARDIA ...... 46 prudoxin ...... 56 prenatal plus (calcium carb) . 131 PROCARDIA XL ...... 46 PSORCON ...... 63 prenatal tablet ...... 131 procentra ...... 38 PULMICORT ...... 125 prenatal vitamin...... 131 PROCHAMBER ...... 67 pulmosal ...... 125 prenatal vitamin plus low iron prochlorperazine ...... 94 PULMOZYME...... 125 ...... 131 prochlorperazine maleate...... 94 PURIXAN ...... 16 prenatal-u...... 132 PROCRIT...... 97 pyrazinamide ...... 10 preplus ...... 132 PROCTOCORT ...... 94 PYRIDIUM ...... 129 PRESSURE ACTIVATED LANCETS procto-med hc ...... 94 pyridostigmine bromide ...... 28 ...... 81 procto-pak ...... 94 pyrimethamine ...... 10 pretab ...... 132 proctosol hc ...... 94 Q PRETOMANID ...... 10 proctozone-hc ...... 94 QINLOCK ...... 16 PREVACID ...... 96 PROCYSBI ...... 128 QSYMIA ...... 65 PREVACID SOLUTAB ...... 96 PRODIGY LANCETS...... 81 QUADRACEL (PF) ...... 102 prevalite ...... 52 PRODIGY TWIST TOP LANCET. 81 QUALAQUIN...... 10 PREVIDENT ...... 73 PROFILNINE...... 50 QUARTETTE...... 114 PREVIDENT 5000 BOOSTER PLUS progesterone micronized...... 108 quazepam ...... 38 ...... 72 PROGLYCEM...... 75 QUDEXY XR ...... 22 PREVIDENT 5000 DRY MOUTH PROGRAF ...... 16 QUESTRAN ...... 52 ...... 72 PROLENSA...... 118 QUESTRAN LIGHT ...... 52 PREVIDENT 5000 ENAMEL PROMACTA ...... 50 quetiapine ...... 38 PROTECT ...... 73 promethazine...... 121 QUILLICHEW ER...... 38 PREVIDENT 5000 ORTHO promethazine vc ...... 122 QUILLIVANT XR...... 38 DEFENSE ...... 73 promethazine-codeine ...... 122 quinapril ...... 46 PREVIDENT 5000 PLUS ...... 73 promethazine-dm ...... 122 quinapril-hydrochlorothiazide 46 PREVIDENT 5000 SENSITIVE....73 promethazine-phenyleph- quinidine gluconate...... 41 previfem ...... 114 codeine ...... 122 quinidine sulfate ...... 41 PREVNAR 13 (PF)...... 102 promethazine-phenylephrine quinine sulfate ...... 10 PREZCOBIX...... 5 ...... 122 quit 2 ...... 72 PREZISTA ...... 5 promethegan ...... 121 quit 4 ...... 72 PRIFTIN ...... 10 PROMETRIUM ...... 108 QVAR REDIHALER ...... 125 PRILOSEC ...... 96 propafenone ...... 41 R primaquine ...... 10 propantheline ...... 91 RABAVERT (PF) ...... 102 PRIMEAIRE...... 67 proparacaine...... 118 rabeprazole...... 97 primidone ...... 22 propranolol ...... 46 RADIOGARDASE ...... 68

151 RAGWITEK ...... 102 RETACRIT ...... 97 ROTATEQ VACCINE ...... 102 raloxifene ...... 104 RETEVMO...... 16 ROWASA ...... 95 ramelteon...... 38 RETIN-A ...... 57 roweepra ...... 22 ramipril...... 46 RETROVIR...... 5 roweepra xr ...... 22 RANEXA ...... 52 REVATIO ...... 125 ROXICODONE ...... 30 ranolazine ...... 52 REVIA ...... 33 ROZEREM...... 39 RAPAFLO...... 127 REVLIMID ...... 98 ROZLYTREK...... 17 RAPAMUNE ...... 16 REXULTI ...... 39 RUBRACA ...... 17 rasagiline ...... 24 REYATAZ ...... 5 RUCONEST ...... 125 RAVICTI...... 68 RHOPRESSA...... 118 rufinamide ...... 22 RAZADYNE ER ...... 27 ribavirin ...... 98 RUKOBIA ...... 5 REBIF (WITH ALBUMIN) ...... 98 RIDAURA ...... 105 RUZURGI ...... 27 REBIF REBIDOSE ...... 98 rifabutin...... 10 RYBELSUS...... 89 REBIF TITRATION PACK ...... 98 RIFADIN ...... 10 RYDAPT ...... 17 REBINYN ...... 50 RIFAMATE ...... 10 rydex ...... 122 reclipsen (28) ...... 114 rifampin ...... 10 RYTHMOL SR ...... 41 RECOMBINATE ...... 50 RIFATER ...... 10 S RECOMBIVAX HB (PF) ...... 102 RIGHTEST GL300 LANCETS ..... 81 SABRIL ...... 22 REGLAN ...... 94 RILUTEK ...... 69 SAFETY LANCETS ...... 81 REGRANEX ...... 56 riluzole ...... 69 SAFETY SEAL LANCETS ...... 81 RELAGARD ...... 109 rimantadine ...... 5 SAFETY-LET LANCETS ...... 81 RELENZA DISKHALER ...... 5 ringer's...... 67 SAFYRAL...... 114 RELIAMED LANCET ...... 81 RINVOQ ...... 105 SALAGEN (PILOCARPINE) .. 69, 73 RELIAMED SAFETY SEAL RIOMET...... 89 SALEX...... 55 LANCETS ...... 81 RIOMET ER ...... 89 salicylic acid ...... 55 RELION NEEDLES ...... 81 risedronate ...... 69, 104 salicylic acid-ceramides no.1.. 55 RELION PEN NEEDLES ...... 81 RISPERDAL ...... 39 salsalate...... 33 RELION THIN LANCETS...... 81 RISPERDAL CONSTA ...... 39 SAMSCA ...... 87 RELION ULTRA THIN PLUS risperidone ...... 39 SANDIMMUNE ...... 17 LANCETS ...... 81 RITALIN ...... 39 SANDOSTATIN ...... 17 RELISTOR ...... 94 RITEFLO AEROCHAMBER ...... 67 SANTYL ...... 64 RELPAX ...... 26 ritonavir ...... 5 SAPHRIS ...... 39 REMERON ...... 38 rivastigmine ...... 27 sapropterin ...... 87 REMERON SOLTAB ...... 38 rivastigmine tartrate ...... 27 SARAFEM ...... 39 REMODULIN ...... 46 rivelsa ...... 114 SAVELLA...... 105 RENAGEL ...... 94 RIXUBIS ...... 50 SAXENDA ...... 65 RENA-VITE ...... 132 rizatriptan ...... 26 scopolamine base...... 95 RENVELA...... 95 ROBAXIN-750 ...... 28 SEASONIQUE ...... 114 repaglinide...... 89 ROCALTROL...... 87 seconal sodium ...... 39 repaglinide-metformin ...... 89 ROCKLATAN ...... 118 SECUADO ...... 39 REPATHA PUSHTRONEX...... 52 ropinirole ...... 24 selegiline hcl ...... 24 REPATHA SURECLICK ...... 52 rosadan...... 57, 58 selenium sulfide ...... 54 REPATHA SYRINGE ...... 52 ROSANIL...... 58 SELZENTRY ...... 5 REQUIP ...... 24 ROSULA ...... 58 SEMPREX-D ...... 122 REQUIP XL...... 24 rosula cleansing cloths...... 58 se-natal 19 chewable...... 132 RESPA-AR...... 122 rosuvastatin ...... 52 se-natal-19 ...... 132 RESTORIL ...... 39 ROTARIX ...... 102 SENSIPAR ...... 87

152 SEREVENT DISKUS ...... 125 sodium fluoride 5000 dry mouth STALEVO 50 ...... 24 SEROQUEL ...... 39 ...... 73 STALEVO 75 ...... 24 SEROQUEL XR ...... 39 sodium fluoride 5000 plus ..... 73 STAMARIL (PF) ...... 102 sertraline ...... 39 sodium fluoride-pot nitrate ... 73 STARLIX...... 89 setlakin ...... 114 sodium phenylbutyrate ...... 69 stavudine ...... 5 sevelamer carbonate...... 95 sodium polystyrene (sorb free) STAXYN ...... 128 sevelamer hcl...... 95 ...... 95 STELARA...... 54 SEVENFACT ...... 50 sodium polystyrene sulfonate 95 STENDRA...... 128 sf 73 SOFOSBUVIR-VELPATASVIR...... 5 STERILANCE TL ...... 81 sf 5000 plus ...... 73 SOFT TOUCH LANCETS ...... 81 STIOLTO RESPIMAT ...... 125 sharobel ...... 108 SOLESTA...... 95 STIVARGA...... 17 SHINGRIX (PF) ...... 102 solifenacin...... 127 stop smoking aid ...... 72 SHINGRIX GE ANTIGEN SOLIQUA 100/33 ...... 85 STRATTERA ...... 39 COMPONENT ...... 102 SOLOSEC ...... 10 STRENSIQ ...... 87 SIDESTREAM PEDIATRIC FACE SOLTAMOX ...... 17 STRIBILD ...... 5 MASK ...... 67 SOLUS V2 LANCETS...... 81 STRIVERDI RESPIMAT...... 125 SIGNIFOR ...... 17 SOMA ...... 28 STROMECTOL ...... 10 SIKLOS ...... 17 SOMAVERT ...... 87 strong iodine ...... 129 sildenafil ...... 128 SORBITOL ...... 67 SUBOXONE...... 18 sildenafil (pulm.hypertension) SORBITOL-MANNITOL...... 67 subvenite ...... 22 ...... 125 SORIATANE ...... 54 subvenite starter (blue) kit .... 22 SILICONE MASK - INFANT ...... 67 sorine ...... 41 subvenite starter (green) kit .. 22 SILICONE MASK - PEDIATRIC ...67 sotalol...... 41 subvenite starter (orange) kit 22 SILIQ ...... 54 sotalol af ...... 41 SUCRAID ...... 95 silodosin ...... 127 SOTYLIZE ...... 41 sucralfate ...... 97 SILVADENE...... 55 SPACE CHAMBER...... 67 SULAR ...... 46 silver nitrate ...... 56 spinosad ...... 64 sulfacetamide sodium .... 54, 120 silver nitrate applicators...... 56 SPIRIVA RESPIMAT ...... 125 sulfacetamide sodium (acne) . 59 silver sulfadiazine ...... 55 SPIRIVA WITH HANDIHALER..125 sulfacetamide sodium-sulfur . 58 simliya (28) ...... 114 spironolactone ...... 46 sulfacetamide sod-sulfur-urea 58 simpesse...... 114 spironolacton-hydrochlorothiaz sulfacetamide-prednisolone .120 SIMPONI ...... 105 ...... 46 sulfadiazine ...... 11 simvastatin ...... 52 SPORANOX...... 2 sulfamethoxazole-trimethoprim SINEMET ...... 24 SPORANOX PULSEPAK ...... 2 ...... 11 SINGLE-LET ...... 81 sprintec (28) ...... 114 SULFAMYLON ...... 59 SINGULAIR ...... 125 SPRITAM ...... 22 sulfasalazine...... 95 sirolimus ...... 17 SPRIX ...... 33 sulfatrim ...... 11 SIRTURO ...... 10 SPRYCEL ...... 17 sulindac ...... 33 SKELAXIN ...... 28 sps (with sorbitol)...... 95 sumatriptan ...... 26 SKYRIZI ...... 54 sronyx ...... 114 sumatriptan succinate ...... 26 SLYND ...... 114 ssd ...... 55 SUMAXIN ...... 58 SMART SENSE LANCETS ...... 81 SSKI...... 74 SUPER THIN LANCETS ...... 81 SMARTEST LANCET...... 81 sss 10-5 ...... 58 SUPRAX...... 7 sodium chlor 0.9% bacteriostat STALEVO 100...... 24 SUPREP BOWEL PREP KIT...... 95 ...... 69 STALEVO 125...... 24 SURE COMFORT INSULIN sodium chloride ...... 69, 125 STALEVO 150...... 24 SYRINGE ...... 82 sodium chloride 0.9 % (flush) .69 STALEVO 200...... 24 SURE COMFORT LANCETS ...... 82

153 SURE COMFORT PEN NEEDLE .82 TAMIFLU ...... 6 TERIPARATIDE ...... 104 SURE-FINE PEN NEEDLES ...... 82 tamoxifen ...... 17 TESSALON PERLES ...... 122 SURE-LANCE ...... 82 tamsulosin ...... 128 testosterone ...... 87 SURE-TOUCH LANCET ...... 82 TAPAZOLE ...... 75 testosterone cypionate...... 87 SURGUARD2 SAFETY ...... 82 TARCEVA...... 17 testosterone enanthate...... 87 SUSTIVA...... 5 TARGRETIN ...... 17 TESTRED ...... 87 SUTENT...... 17 tarina 24 fe ...... 114 TETANUS,DIPHTHERIA TOX syeda ...... 114 tarina fe 1/20 (28) ...... 114 PED(PF) ...... 103 SYLATRON...... 98 tarina fe 1-20 eq (28) ...... 114 tetrabenazine...... 28 SYMBICORT...... 125 TARKA...... 46 tetracaine hcl ...... 118 SYMBYAX ...... 39 taron-c dha ...... 132 tetracaine hcl (pf) ...... 118 SYMDEKO ...... 125 TASIGNA ...... 17 tetracycline ...... 12 SYMFI ...... 5 TASMAR...... 24 TEXACORT ...... 64 SYMFI LO ...... 5 TAVALISSE ...... 50 THALOMID ...... 17 SYMJEPI ...... 121 tazarotene ...... 58 THEO-24 ...... 126 SYMLINPEN 120 ...... 89 TAZORAC ...... 58 theochron ...... 126 SYMLINPEN 60 ...... 89 taztia xt...... 46 theophylline...... 126 SYMTUZA...... 6 TAZVERIK ...... 17 THIOLA...... 69 SYNALAR...... 63, 64 TDVAX ...... 102 THIOLA EC ...... 69 SYNALAR CREAM KIT ...... 63 TECFIDERA ...... 98 thioridazine ...... 39 SYNALAR OINTMENT KIT ...... 63 TECHLITE LANCETS ...... 82 thiothixene ...... 39 SYNALAR TS ...... 64 TECHLITE PEN NEEDLE ...... 82 THYROLAR-1...... 90 SYNAREL ...... 87 TEGRETOL ...... 22 THYROLAR-1/2 ...... 90 SYNDROS ...... 95 TEGRETOL XR ...... 22 THYROLAR-1/4 ...... 90 SYNERA...... 59 TEGSEDI ...... 28 THYROLAR-2...... 90 SYNJARDY ...... 89 TEKTURNA ...... 46 THYROLAR-3...... 90 SYNJARDY XR ...... 89 TEKTURNA HCT ...... 46 tiadylt er ...... 46 SYNRIBO ...... 17 telmisartan ...... 46 tiagabine ...... 22 SYNTHROID...... 90 telmisartan-amlodipine ...... 46 TIAZAC ...... 46 T telmisartan-hydrochlorothiazid TIBSOVO ...... 17 TABLOID ...... 17 ...... 46 TICE BCG ...... 103 TABRECTA...... 17 temazepam ...... 39 TIGAN ...... 95 TACLONEX ...... 54 TEMIXYS...... 6 TIGLUTIK ...... 69 tacrolimus...... 17, 56 TEMODAR ...... 17 TIKOSYN...... 41 tadalafil ...... 127, 128 TEMOVATE...... 64 tilia fe ...... 114 tadalafil (pulm. hypertension) temozolomide ...... 17 timolol maleate ...... 46, 116, 117 ...... 125 tencon ...... 26 timolol maleate (pf)...... 116 TAFINLAR ...... 17 TENIVAC (PF) ...... 102, 103 TIMOPTIC...... 117 TAGRISSO ...... 17 tenofovir disoproxil fumarate .. 6 TIMOPTIC OCUDOSE (PF) ...... 117 TAKHZYRO ...... 126 TENORETIC 100 ...... 46 TIMOPTIC-XE ...... 117 TALTZ AUTOINJECTOR ...... 54 TENORETIC 50 ...... 46 tinidazole ...... 10 TALTZ AUTOINJECTOR (2 PACK) TENORMIN...... 46 tiopronin...... 69 ...... 54 TEPMETKO ...... 17 TIROSINT...... 90 TALTZ AUTOINJECTOR (3 PACK) terazosin ...... 46 TIROSINT-SOL...... 90 ...... 54 terbinafine hcl...... 2 tis-u-sol pentalyte ...... 67 TALTZ SYRINGE ...... 54 terbutaline ...... 126 TIVICAY ...... 6 TALZENNA ...... 17 terconazole ...... 109 TIVICAY PD ...... 6

154 tizanidine ...... 28 TRETIN-X ...... 58 tri-vylibra ...... 115 TOBI ...... 10 TRETIN-X CREAM KIT ...... 58 tri-vylibra lo ...... 115 TOBRADEX ...... 119 TREXALL ...... 17 TRIZIVIR ...... 6 tobramycin ...... 116 TREZIX...... 31 TROKENDI XR ...... 23 tobramycin in 0.225 % nacl.....10 tri femynor...... 114 tropicamide ...... 117 tobramycin-dexamethasone. 119 triamcinolone acetonide... 64, 73 trospium ...... 127 TOBREX ...... 116 triamterene...... 47 TRUEPLUS GLUCOSE ...... 75 TODAY CONTRACEPTIVE triamterene-hydrochlorothiazid TRUEPLUS INSULIN ...... 82 SPONGE ...... 109 ...... 47 TRUEPLUS LANCETS...... 82 tolcapone ...... 24 trianex ...... 64 TRUEPLUS PEN NEEDLE ...... 82 tolmetin...... 33 triazolam...... 39 TRULICITY ...... 89 tolterodine ...... 127 TRIBENZOR...... 47 TRUMENBA ...... 103 tolvaptan ...... 87 tri-buffered aspirin ...... 33 TRUSOPT...... 118 TOPAMAX ...... 23 TRICOR...... 52 TRUVADA ...... 6 TOPCARE UNIVERSAL1 LANCET triderm ...... 64 TUKYSA ...... 18 ...... 82 tri-estarylla ...... 114 tulana ...... 108 TOPICORT ...... 64 trifluoperazine ...... 39 TURALIO ...... 18 topiramate...... 23 trifluridine...... 116 TUSSICAPS ...... 122 TOPROL XL ...... 47 trihexyphenidyl ...... 24 TWINRIX (PF)...... 103 toremifene...... 17 TRIJARDY XR...... 89 TWIRLA ...... 109 torsemide ...... 47 TRIKAFTA ...... 126 TWYNSTA...... 47 TOUJEO MAX U-300 SOLOSTAR tri-legest fe ...... 114 TYBOST ...... 6 ...... 85 TRILEPTAL ...... 23 tydemy ...... 115 TOUJEO SOLOSTAR U-300 tri-linyah ...... 115 TYKERB ...... 18 INSULIN ...... 85 TRILIPIX...... 52 TYMLOS ...... 104 TOVET EMOLLIENT ...... 64 tri-lo-estarylla ...... 115 TYPHIM VI ...... 103 TRACLEER ...... 126 tri-lo-marzia ...... 115 TYVASO...... 126 TRADJENTA ...... 89 tri-lo-mili...... 115 TYVASO INSTITUTIONAL START tramadol...... 30, 31 tri-lo-sprintec ...... 115 KIT ...... 126 tramadol-acetaminophen...... 31 trilyte with flavor packets ...... 95 TYVASO REFILL KIT...... 126 trandolapril...... 47 trimethobenzamide...... 95 TYVASO STARTER KIT ...... 126 trandolapril-verapamil ...... 47 trimethoprim ...... 12 U tranexamic acid...... 109 tri-mili...... 115 UCERIS ...... 95 TRANSDERM-SCOP ...... 95 trimipramine ...... 39 UDENYCA ...... 97 tranylcypromine...... 39 TRIMO-SAN JELLY ...... 109 UKONIQ ...... 18 travoprost...... 118 trinatal rx 1 ...... 132 ULESFIA...... 64 trazodone ...... 39 trinate...... 132 ULORIC ...... 103 TRECATOR ...... 10 TRINTELLIX ...... 40 ULTICARE ...... 82 TRELEGY ELLIPTA...... 126 tri-nymyo ...... 115 ULTICARE PEN NEEDLE ...... 82 TREMFYA ...... 54 triple vitamin with fluoride ...132 ULTILET BASIC LANCETS ...... 82 treprostinil sodium...... 47 tri-previfem (28)...... 115 ULTILET CLASSIC LANCETS...... 82 TRESIBA FLEXTOUCH U-100 ....85 tri-sprintec (28) ...... 115 ULTILET LANCETS ...... 82 TRESIBA FLEXTOUCH U-200 ....86 TRIUMEQ ...... 6 ULTILET PEN NEEDLE ...... 82 TRESIBA U-100 INSULIN...... 86 triveen-duo dha ...... 132 ULTILET SAFETY LANCETS...... 82 tretinoin ...... 58 tri-vitamin with fluoride ...... 132 ULTRA COMFORT INSULIN tretinoin (antineoplastic)...... 17 tri-vite with fluoride ...... 132 SYRINGE ...... 82 tretinoin microspheres ...... 58 trivora (28) ...... 115 ULTRA THIN LANCETS ...... 82

155 ULTRA THIN PLUS LANCETS ....82 VANCOCIN ...... 12 VIGAMOX...... 116 ULTRA TLC LANCETS ...... 82 vancomycin...... 12 VIIBRYD...... 40 ULTRACET ...... 31 vandazole ...... 109 VIMPAT...... 23 ULTRALANCE LANCETS ...... 82 VANOS ...... 64 VIOKACE ...... 95 ULTRAM ...... 31 VANOXIDE-HC ...... 58 viorele (28)...... 115 ULTRAM ER...... 31 VAQTA (PF) ...... 103 VIRACEPT ...... 6 ULTRA-THIN II (SHORT) PEN NDL vardenafil...... 128, 129 VIRAMUNE...... 6 ...... 82 VARIVAX (PF)...... 103 VIRAMUNE XR ...... 6 ULTRA-THIN II INS PEN NEEDLES VASCEPA ...... 52 VIREAD ...... 6 ...... 82 VASERETIC ...... 47 virt-c dha ...... 132 UNIFINE PENTIPS ...... 83 VASOTEC...... 47 virt-nate dha ...... 132 UNIFINE PENTIPS PLUS ...... 83 VAXCHORA VACCINE ...... 103 virt-pn dha ...... 132 UNILET COMFORTOUCH LANCET VAXELIS (PF) ...... 103 virt-pn plus...... 132 ...... 83 VCF CONTRACEPTIVE FILM ...109 virtussin ac ...... 122 UNILET EXCELITE II LANCET.....83 VCF CONTRACEPTIVE GEL .....109 VISTARIL...... 121 UNILET EXCELITE LANCET ...... 83 veletri ...... 47 vitamin b complex-folic acid .132 UNILET GP LANCET ...... 83 velivet triphasic regimen (28) vitamin d2...... 132 UNILET LANCET ...... 83 ...... 115 vitamins a,c,d and fluoride....132 UNISTIK 3 EXTRA LANCET ...... 83 VELPHORO ...... 95 VITRAKVI...... 18 UNISTIK CZT LANCET ...... 83 VEMLIDY ...... 6 VIVELLE-DOT ...... 108 UNISTIK SAFETY ...... 83 VENCLEXTA ...... 18 VIVOTIF...... 103 UNISTIK TOUCH LANCETS ...... 83 VENCLEXTA STARTING PACK .. 18 VIZIMPRO ...... 18 unithroid ...... 90 venlafaxine ...... 40 volnea (28) ...... 115 UNIVERSAL 1 LANCETS ...... 83 VENTAVIS...... 126 VOLTAREN-XR ...... 33 URAMAXIN ...... 56 VENTOLIN HFA ...... 126 voriconazole...... 2 uro-458...... 128 verapamil...... 47 VOSEVI...... 6 UROCIT-K 10 ...... 128 VERDESO...... 64 VOTRIENT ...... 18 UROCIT-K 15 ...... 128 verdrocet ...... 31 vp-ch plus ...... 132 UROCIT-K 5 ...... 128 VEREGEN ...... 56 vp-ch-pnv...... 132 UROXATRAL ...... 128 VERELAN ...... 47 VRAYLAR ...... 40 URSO 250 ...... 95 VERELAN PM ...... 47 VUMERITY...... 98 URSO FORTE ...... 95 veripred 20 ...... 74 VUSION ...... 60 ursodiol ...... 95 VERQUVO ...... 52 vyfemla (28) ...... 115 V VERZENIO ...... 18 vylibra...... 115 VAGIFEM ...... 108 VESICARE ...... 127 VYNDAMAX...... 52 vaginal contraceptive foam .. 109 vestura (28)...... 115 VYNDAQEL ...... 53 valacyclovir ...... 6 VFEND ...... 2 VYTORIN 10-10...... 52 VALCHLOR ...... 56 V-GO 20 ...... 83 VYTORIN 10-20...... 52 VALCYTE ...... 6 V-GO 30 ...... 83 VYTORIN 10-40...... 52 valganciclovir ...... 6 V-GO 40 ...... 83 VYTORIN 10-80...... 52 VALIUM ...... 40 VIAGRA ...... 129 VYVANSE...... 40 valproic acid...... 23 VIBERZI ...... 95 W valproic acid (as sodium salt) ..23 VIBRAMYCIN ...... 12 warfarin ...... 50 valsartan...... 47 vicodin hp ...... 31 water for irrigation, sterile..... 69 valsartan-hydrochlorothiazide 47 vienva ...... 115 WELCHOL...... 52 VALTOCO ...... 23 vigabatrin...... 23 WELLBUTRIN SR ...... 40 VALTREX ...... 6 vigadrone...... 23 WELLBUTRIN XL...... 40

156 wera (28) ...... 115 XPHE MAXAMAID ...... 71 ZERIT ...... 6 westab plus ...... 132 xphe maxamum ...... 71 ZESTORETIC...... 47 westgel dha ...... 132 XPHE MAXAMUM...... 71 ZESTRIL ...... 47 westhroid ...... 90 XPOVIO ...... 18 ZETIA ...... 52 WIDE-SEAL DIAPHRAGM 60 .. 106 XTAMPZA ER ...... 31 ZIAC ...... 47 WIDE-SEAL DIAPHRAGM 65 .. 106 XTANDI ...... 18 ZIAGEN ...... 6 WIDE-SEAL DIAPHRAGM 70 .. 106 xulane ...... 109 zidovudine ...... 6 WIDE-SEAL DIAPHRAGM 75 .. 106 xylon 10 ...... 31 ZIEXTENZO ...... 97 WIDE-SEAL DIAPHRAGM 80 .. 106 XYNTHA ...... 50 zingiber ...... 132 WIDE-SEAL DIAPHRAGM 85 .. 106 XYNTHA SOLOFUSE...... 50 ZIOPTAN (PF)...... 118 WIDE-SEAL DIAPHRAGM 90 .. 106 Y ziprasidone hcl ...... 40 WIDE-SEAL DIAPHRAGM 95 .. 106 YASMIN (28)...... 115 ZIRGAN ...... 116 WILATE ...... 50 YAZ (28) ...... 115 ZITHROMAX ...... 8 wixela inhub ...... 126 YF-VAX (PF) ...... 103 ZOCOR ...... 52 wymzya fe ...... 115 YONSA ...... 18 ZOFRAN ...... 95 X YUPELRI ...... 126 ZOKINVY ...... 69 XALATAN ...... 118 yuvafem...... 108 ZOLINZA ...... 18 XALKORI...... 18 Z zolmitriptan ...... 26 XANAX ...... 40 zafemy ...... 109 ZOLOFT ...... 40 XANAX XR ...... 40 zafirlukast ...... 126 zolpidem ...... 40 XARELTO ...... 50 zaleplon ...... 40 ZOMIG ...... 26 XARELTO DVT-PE TREAT 30D ZANAFLEX ...... 28 ZONALON...... 56 START ...... 50 zarah...... 115 ZONEGRAN ...... 23 XELJANZ...... 105 ZARONTIN ...... 23 zonisamide...... 23 XELJANZ XR ...... 105 ZARXIO...... 97 ZONTIVITY...... 50 XELODA ...... 18 zatean-pn dha ...... 132 ZORTRESS ...... 18 XEMBIFY ...... 103 zatean-pn plus...... 132 zovia 1/35e (28) ...... 115 XENAZINE ...... 28 ZAVESCA ...... 87 ZOVIRAX ...... 6, 60 XENICAL...... 65 zebutal...... 26 Z-TUSS AC ...... 122 XERMELO...... 18 ZEJULA ...... 18 ZUBSOLV ...... 18 XHANCE ...... 126 ZELAPAR ...... 24 zumandimine (28) ...... 115 XIFAXAN ...... 10 ZELBORAF ...... 18 ZYDELIG ...... 18 XIGDUO XR ...... 89 ZEMPLAR ...... 87 ZYKADIA ...... 18 XIIDRA ...... 118 zenatane ...... 58 ZYLOPRIM ...... 103 XOFLUZA...... 6 ZENPEP ...... 95 ZYPREXA ...... 40 XOLEGEL ...... 60 zenzedi ...... 40 ZYPREXA RELPREVV ...... 40 XOPENEX ...... 126 ZENZEDI ...... 40 ZYPREXA ZYDIS ...... 40 XOPENEX CONCENTRATE...... 126 ZEPOSIA ...... 98 ZYTIGA ...... 18 XOPENEX HFA ...... 126 ZEPOSIA STARTER KIT ...... 99 ZYVOX...... 10 XOSPATA ...... 18 ZEPOSIA STARTER PACK ...... 99

157

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com

BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. BlueCross: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats. • Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and(2) written information in other languages. If you need these services, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848- 0298 or 711). If you believe that BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting your Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208 (fax); Nondiscrimination_ [email protected] (email). You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html . BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Tennessee is a Qualified Health Plan Issuer in the Health Insurance Marketplace. Express Scripts, Inc. is an independent company that manages your pharmacy benefits on behalf of BlueCross Blueshield of Tennessee.

RX-11_21PHM1255193 (7/21)