Unitedhealthcare Community Plan of Nebraska – Heritage Health Effective Date: 9/2/2021

Preferred Drug List (PDL)

UnitedHealthcare Community Plan of Nebraska – Heritage Health Effective Date: 9/2/2021

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability, religion or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] You can send a complaint at any time. We will acknowledge your complaint in writing within ten (10) calendar days of receipt . A decision will be sent to you no later than 90 calendar days from receipt of your complaint. You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call Member Services at 1-800-641-1902, TTY 711, Monday – Friday, 7:00 a.m. – 7:00 p.m. CT (6:00 a.m. – 6:00 p.m. MT). We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call Member Services at 1-800-641-1902, TTY 711, Monday – Friday, 7:00 a.m. – 7:00 p.m. CT (6:00 a.m. – 6:00 p.m. MT).

CSNE15MC4035987_002 UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad, religión o nacionalidad. Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o nacionalidad, puede enviar una queja a: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] Puede enviar una queja en cualquier momento. Reconoceremos su queja por escrito dentro de los diez (10) días calendario después de recibirla. Se le enviará a usted una decisión a más tardar 90 días calendario a partir de la recepción de su queja. Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame a Servicios para Miembros al 1-800-641-1902, TTY 711, de lunes a viernes, 7:00 a.m. – 7:00 p.m. CT (6:00 a.m. – 6:00 p.m. MT). Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame a Servicios para Miembros al 1-800-641-1902, TTY 711, de lunes a viernes, 7:00 a.m. – 7:00 p.m. CT (6:00 a.m. – 6:00 p.m. MT). INTRODUCTION This Preferred Drug List (PDL) Reference Guide gives you information that explains how covered medications are selected; exclusions and limitations; and steps to take when a medication is not included on the PDL.

It also gives you at-a-glance specifics on the medications and the coverage level for each to assist you when prescribing for your patients with UnitedHealthcare Community Plan pharmacy benefits.

The drugs on our PDL are reviewed and approved for inclusion by our Pharmacy and Therapeutics (P&T) Committee to provide the most clinically appropriate and cost-effective medications for UnitedHealthcare Community Plan patients. The Committee is comprised of UnitedHealthcare Community Plan medical directors and pharmacists, as well as physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or our affiliates.

The P&T Committee meets quarterly to discuss pharmaceutical selection and pharmacy program management. Decisions are posted at UHCCommunityPlan.com and communicated quarterly by newsletter to all participating physicians who receive the PDL. This edition incorporates drugs added to the PDL since the last edition, as well as revisions to the prescribing information based on changes in pharmacotherapy.

i strengths/dosage forms of the referenced product are not OVERVIEW included. Our PDL is organized into sections. Each section includes therapeutic groupings identified by either a drug class or Example: disease category. citalopram 40 mg tabs Celexa tabs Products with lower case text indicate the generic formulation. Product entries with all capital letters indicate a brand name formulation of the product. Unless PRODUCT SELECTION exceptions are noted, all applicable dosage forms and strengths are included in the PDL. CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an PDL PRODUCT DESCRIPTIONS outpatient pharmacy benefit. The evaluation includes all or Please see the following examples of how medication some of the following: strengths and dosage forms that we provide coverage for • Safety are described in the PDL. Any strength and dosage • Efficacy exceptions that do not follow these examples are noted in • Comparison studies the PDL. •Approved indications • Adverse effects STRENGTH • Contraindications/warnings/precautions Products covered include all strengths associated with the • Pharmacokinetics dosage form of the cited product. • Patient administration/compliance considerations • Medical outcome and pharmaco-economic studies Example:

When a new drug is considered for PDL inclusion, it is carvedilol (generic COREG) reviewed relative to similar drugs currently included in the PDL. This review process may result in deletion of a drug All strengths of Coreg would be covered by this listing. from a particular therapeutic class in an effort to continually promote prescription of the most clinically EXTENDED RELEASE AND DELAYED useful and cost-effective drugs. RELEASE Extended-release and delayed-release products require their All information in the PDL is provided as a reference for own entry. drug therapy selection based on the patient’s benefit plan coverage. Specific drug selection for an individual patient Example: rests with the prescriber. diltiazem ER (generic CARDIZEM CD) OUTPATIENT PRESCRIPTION DRUG MEDICATIONS DOSAGE FORMS Medically necessary outpatient prescription drugs are Dosage forms covered will be consistent with the category covered when prescribed by a provider licensed to and use where listed. prescribe federal legend drugs or medicines. Some drugs are covered only with prior authorization. Eligibility for Example: outpatient prescription drug benefits and copayments are based on the patient’s benefit plan. See the listing for each ciprofloxacin neomycin/polymyxin/ hydrocortisone drug or the Prior Authorization section for more (generic CORTISPORIN) information.

As listed in the Otic section, the previous example is limited to the otic solution and suspension. In this example, OVER-THE-COUNTER the ophthalmic solution, ointment and topical cream cannot MEDICATIONS be assumed to be on the list unless there are entries for The PDL covers select over-the-counter (OTC) products. these products in the Ophthalmic and Dermatology sections You are encouraged to prescribe OTC medications when of the PDL. clinically appropriate.

When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other

ii GENERIC SUBSTITUTION LIMITATIONS The PDL requires generic substitution on the majority of products when a generic equivalent is available. DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members may receive MAXIMUM ALLOWABLE COST PRICING up to a one-month supply of a specific medication per The UnitedHealthcare Community Plan Maximum prescription order or prescription refill. A medication may Allowable Cost (MAC) pricing list sets a ceiling price for be reordered or refilled when ninety percent (90%) of the the reimbursement of certain multisource prescription medication has been utilized for a controlled substance and drugs. This price will typically cover most generics but not eighty-five percent (85%) of the medication has been necessarily the branded versions of the same drug. The utilized for a non-controlled substance. If a claim is products selected for inclusion on the MAC list are submitted before 90% percent of the medication has been commonly prescribed and dispensed and have usually gone used for a controlled substance or submitted before 85% of through the Food and Drug Administration (FDA) review the medication has been used for a non controlled and approval process. substance, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. BRAND NAME DRUGS The PDL prior authorization list does not include branded items where a generic equivalent is covered. However, QUANTITY LIMITATIONS brand name drugs may be covered in certain situations by Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. See the requesting prior authorization. If a brand name drug is Prior Authorization section for more details. medically necessary, please submit a prior authorization request. See the Prior Authorization section for more details. EFFICIENT MEDICATION DOSING QUANTITY LIMITATIONS UnitedHealthcare Community Plan’s Efficient Medication PLAN EXCLUSIONS AND Dosing Program is designed to consolidate medication LIMITATIONS dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. EXCLUSIONS The following drug categories are excluded from coverage The limits for the program are based on FDA approval for under the outpatient pharmacy benefit and are not part of dosing and the availability of the total daily dose in the the PDL. least amount of tablets or capsules. Quantity limits in the prescription claims processing system will limit the • Drug Efficacy Study Implementation (DESI) “less dispensing to consolidate dosing. The pharmacy claims than fully effective” drug products processing system will prompt the pharmacist to request a • Anti-obesity agents new prescription order from the physician. • Experimental/ research drugs • Cosmetic drugs • Immunization agents STEP THERAPY • Nutritional/diet supplements Step therapy requires a trial of one drug before advancing • Blood and blood plasma products to other drugs. Certain drugs on the PDL are routinely • Fertility promotion agents covered only after a sufficient trial of an indicated first-line • Erectile dysfunction agents agent has been adequately tried and failed. While lower • Cosmetic hair growth agents cost PDL alternatives may be appropriate in many • Drugs from manufacturers that do not participate instances, other non- PDL alternatives are available with in the Fee-For-Service Medicaid Drug Rebate prior authorization. Please see the Prior Authorization section for more details. Program • Diagnostic products • Medical supplies and Durable Medical Equipment MEDICATIONS REQUIRING DIAGNOSIS (DME) except: syringes, needles, lancets, alcohol UnitedHealthcare Community Plan requires that the swabs, spacers, preferred diabetes test strips, peak diagnosis for prescriptions in certain classes match the flow meters (Astech, Assess, Peak Air brands, FDA-approved use or a use supported by current published maximum two per year), vaporizer (limit of 1 per evidence. Drugs in scope will list “Diagnosis required” in 3 years), humidifier (limit of 1 per 3 years) the Requirements and Limits section on the PDL. • Mirena The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the iii prescriber to verify the diagnosis and submit it on the claim. PRIOR AUTHORIZATION OF Suggestions will be reviewed at the next available P&T Committee meeting. NON-PDL MEDICATIONS Thank you. The drugs in the PDL have been selected to provide the most clinically appropriate and cost-effective medication options for our members. There may be occasions where an NOTICE unlisted drug is needed for the proper medical management This PDL is not intended to be a substitute for the of a specific patient. In those instances, please submit a prior authorization request. knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. You can get prior authorization request forms by visiting http://www.uhccommunityplan.com/health- The information in this PDL and its appendices is provided professionals.html and entering your state, or by calling the by UnitedHealthcare Community Plan for the convenience UnitedHealthcare Community Plan Pharmacy Department of care providers. UnitedHealthcare Community Plan does at 800-310-6826. not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. To obtain authorization, you must fax the appropriate Prior Authorization form to the UnitedHealthcare Community The drug names listed here are the registered and/or Plan Pharmacy Department: unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Fax: 866-940-7328 UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes NON-PDL DRUGS – 3-DAY TEMPORARY and not intended to imply any affiliation. SUPPLY OVERRIDES Please note that this PDL is updated periodically. If To help ensure the use of PDL drugs, all non-PDL drugs viewing this PDL online, note that changes may appear should be discussed with the prescribing physician. When a prior to their effective date to allow for notification. patient cannot reach their physician immediately and there UnitedHealthcare Community Plan assumes no is an immediate need for the medication, the claim responsibility for the actions or omissions of any care processing system will accept an override to permit a provider based upon reliance, in whole or in part, on the one-time dispensing of a 3-day supply of the newly information contained herein. The care provider should prescribed non-PDL drug. consult the drug manufacturer’s product literature or standard references for detailed information. The pharmacy must submit a claim for a 3-day supply, with National guidelines can be found on the National a Prior Authorization (PA) Type of “8” and Prior Guideline Clearinghouse site at http://www.guideline.gov. Authorization number of “00000000120.”

Availability is subject to the patient’s benefit plan. For assistance, pharmacies may call 800-310-6826.

PDL SUGGESTIONS Providers who wish to propose PDL suggestions can forward the request along with supporting clinical documentation from medical literature to the UnitedHealthcare Community Plan Director of Pharmacy Services by either mail or email:

UnitedHealthcare Community Plan Attn: Director of Pharmacy Services 1001 Brinton Road Pittsburgh, PA 15221 Email: [email protected]

iv UnitedHealthcare Community Plan of Nebraska – Heritage Health

Table of Contents Analgesics...... 4 Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 9 Anesthetics...... 15 Anesthetics - Drugs for Numbing...... 16 Anti-Addiction/Substance Abuse Treatment Agents...... 17 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence...... 19 Antiandrogens - Hormone Suppressants...... 20 Antibacterials...... 20 Antibacterials - Drugs to Treat Bacterial Infections...... 24 Anticonvulsants...... 25 Anticonvulsants - Drugs to Treat Seizures...... 28 Antidementia Agents...... 28 Antidepressants...... 29 Antiemetics...... 31 Antiemetics - Drugs to Treat Nausea and Vomiting...... 32 Antifungals...... 33 Antifungals - Drugs to Treat Fungal Infections...... 34 Antigout Agents...... 35 Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs...... 35 Anti-HIV Agents, Other - HIV Drugs...... 35 Antimigraine Agents...... 36 Antimigraine Agents - Drugs to Treat Migraines...... 37 Antimyasthenic Agents...... 37 Antimycobacterials...... 37 Antineoplastics...... 38 Antineoplastics - Drugs to Treat Cancer...... 42 Antineoplastics, Other - Chemotherapy Agents...... 42 Antiparasitics...... 42 Antiparasitics - Drugs to Treat Parasitic Infections...... 43 Antiparkinson Agents...... 44 Antipsychotics...... 46 Antispasmodics, Urinary - Bladder Control Drugs...... 48 Antispasticity Agents...... 48 Antivirals...... 49 Anxiolytics...... 53 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs...... 53 Bipolar Agents...... 54 1 Blood Formation Modifiers - Blood Formation Drugs...... 54 Blood Glucose Regulators...... 54 Blood Glucose Regulators - Drugs to Regulate Blood Sugar...... 58 Blood Products and Modifiers...... 58 Blood Products and Modifiers - Drugs to Treat Blood Disorders...... 60 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders...... 61 Cardiovascular Agents...... 62 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions...... 70 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs...... 71 Central Nervous System Agents...... 71 Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis...... 74 Dental and Oral Agents...... 75 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions...... 75 Dermatological Agents...... 76 Dermatological Agents - Drugs to Treat Skin Conditions...... 86 Diabetic/Endocrine Blood: Glucose Monitoring...... 90 Electrolytes/Minerals/Metals/Vitamins...... 91 Enzyme Inhibitors - Chemotherapy Agents...... 99 Enzyme Replacements/Modifiers - Drugs to Treat Enzyme Deficiency...... 99 Estrogens - Hormone Replacement/Modifying Drugs...... 100 Gastrointestinal Agents...... 100 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions...... 103 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 114 Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment...... 115 Genitourinary Agents...... 116 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...... 118 Glycemic Agents - Diabetic Drugs...... 118 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...... 118 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)...... 119 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)...... 120 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)...... 120 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones...... 129 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)...... 130 Hormonal Agents, Suppressant (Adrenal)...... 132 Hormonal Agents, Suppressant (Pituitary)...... 132 Hormonal Agents, Suppressant (Thyroid)...... 132 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones...... 133 Immune Suppressants - Immune System Drugs...... 133 Immunological Agents...... 133 Immunological Agents - Drugs that Stimulate or Suppress the Immune System...... 137 2 Inflammatory Bowel Disease Agents...... 138 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease...... 139 Metabolic Bone Disease Agents...... 139 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions...... 140 Miscellaneous Therapeutic Agents...... 140 Molecular Target Inhibitors - Chemotherapy Agents...... 153 Monoclonal Antibodies - Chemotherapy Agents...... 154 Multiple Sclerosis Agents - Multiple Sclerosis Drugs...... 155 Not Specified...... 155 Ophthalmic Agents...... 155 Ophthalmic Agents - Drugs to Treat Eye Conditions...... 160 Otic Agents...... 164 Otic Agents - Drugs to Treat Ear Conditions...... 164 Respiratory Tract/Pulmonary Agents...... 165 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 173 Skeletal Muscle Relaxants...... 185 Sleep Disorder Agents...... 185 Sleep Disorder Agents - Drugs for Sedation and Sleep...... 187 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies...... 188 Vaccines...... 193

3 Preferred Agents Non-Preferred Agents Analgesics Nonsteroidal Anti-inflammatory Drugs ADVIL JUNIOR STRENGTH (brand for sm ibuprofen jr) - Tier 2 ADVIL LIQUI-GELS MINIS (brand for gnp ibuprofen) - Tier 2; PA ALEVE ORAL TABLET (brand for sm naproxen sodium) - Tier 2 ADVIL MIGRAINE (brand for gnp ibuprofen) - Tier 2; PA all day pain relief (generic for MEDIPROXEN) - Tier 1 ADVIL ORAL CAPSULE (brand for gnp ibuprofen) - Tier 2; PA all day relief (generic for MEDIPROXEN) - Tier 1 ARTHROTEC (brand for diclofenac-misoprostol) - Tier 2; PA celecoxib oral (generic for CELEBREX) - Tier 1 CAMBIA - Tier 2; PA diclofenac sodium oral - Tier 1 CATAFLAM (brand for diclofenac potassium) - Tier 2; PA ec-naproxen (generic for EC-NAPROSYN) - Tier 1 CELEBREX (brand for celecoxib) - Tier 2; PA ibuprofen (generic for IBU) - Tier 1 DAYPRO (brand for oxaprozin) - Tier 2; PA ibu-200 (generic for ADDAPRIN) - Tier 1 DICLOFENAC - Tier 2; PA ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL DICLOFENAC PATCH 1.3% - Tier 2; PA JUNIOR STRENGTH) - Tier 1 diclofenac potassium (generic for CATAFLAM) - Tier 1; PA diclofenac sodium er - Tier 1; PA ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier diclofenac sodium external gel 1 % (generic for ASPERCREME 1 ARTHRITIS PAIN) - Tier 1; PA ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 diclofenac sodium external solution - Tier 1; PA ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR diclofenac-misoprostol (generic for ARTHROTEC) - Tier 1; PA STRENGTH) - Tier 1 diflunisal oral - Tier 1; PA ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS DUEXIS (brand for ibuprofen-famotidine) - Tier 2; PA ADVIL) - Tier 1 EC-NAPROSYN (brand for ec-naproxen) - Tier 2; PA ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR etodolac - Tier 1; PA STRENGTH) - Tier 1 etodolac er - Tier 1; PA ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1 FELDENE (brand for piroxicam) - Tier 2; PA; QL ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - fenoprofen calcium oral capsule 400 mg (generic for NALFON) - Tier 1; Tier 1 PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS fenoprofen calcium oral tablet (generic for NALFON) - Tier 1; PA ADVIL) - Tier 1 FLECTOR (brand for diclofenac epolamine) - Tier 2; PA ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 flurbiprofen oral tablet 100 mg - Tier 1; PA ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1 ibuprofen oral capsule 200 mg (generic for ADVIL) - Tier 1; PA indomethacin oral capsule 25 mg, 50 mg - Tier 1 ibuprofen-famotidine (generic for DUEXIS) - Tier 1; PA INFANTS ADVIL (brand for sm infants ibuprofen) - Tier 2 INDOCIN - Tier 2; PA infants ibuprofen (generic for INFANTS ADVIL) - Tier 1 indomethacin er - Tier 1; PA ketorolac tromethamine oral - Tier 1; QL ketoprofen er - Tier 1; PA meclofenamate sodium oral - Tier 1; DX2RX ketoprofen oral capsule 50 mg, 75 mg - Tier 1; PA mediproxen (generic for MEDIPROXEN) - Tier 1 KETOROLAC TROMETHAMINE NASAL - Tier 2; PA; QL meloxicam oral tablet (generic for MOBIC) - Tier 1 LICART - Tier 2; PA MOTRIN CHILDRENS (brand for gnp ibuprofen childrens) - Tier 2 LODINE (brand for etodolac) - Tier 2; PA MOTRIN INFANTS DROPS (brand for sm infants ibuprofen) - Tier 2 mefenamic acid oral - Tier 1; PA nabumetone oral (generic for RELAFEN) - Tier 1 meloxicam oral capsule (generic for VIVLODEX) - Tier 1; PA; QL naproxen oral tablet - Tier 1 MOBIC (brand for meloxicam) - Tier 2; PA naproxen oral tablet delayed release (generic for EC-NAPROSYN) - MOTRIN IB ORAL CAPSULE (brand for gnp ibuprofen) - Tier 2; PA Tier 1 NALFON (brand for fenoprofen calcium) - Tier 2; PA naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier NAPRELAN (brand for naproxen sodium er) - Tier 2; PA 1 NAPROSYN (brand for naproxen) - Tier 2; PA sulindac oral - Tier 1 naproxen oral suspension (generic for NAPROSYN) - Tier 1; PA naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg (generic for NAPRELAN) - Tier 1; PA NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents naproxen sodium oral tablet 275 mg - Tier 1; PA naproxen sodium oral tablet 550 mg (generic for ANAPROX DS) - Tier 1; PA naproxen-esomeprazole (generic for VIMOVO) - Tier 1; PA oxaprozin (generic for DAYPRO) - Tier 1; PA PENNSAID - Tier 2; PA piroxicam oral (generic for FELDENE) - Tier 1; PA; QL RELAFEN (brand for nabumetone) - Tier 2; PA RELAFEN DS - Tier 2; PA SPRIX (brand for ketorolac tromethamine) - Tier 2; PA; QL VIMOVO (brand for naproxen-esomeprazole) - Tier 2; PA VIVLODEX (brand for meloxicam) - Tier 2; PA; QL ZIPSOR - Tier 2; PA ZORVOLEX - Tier 2; PA

Opioid Analgesics, Long-acting buprenorphine hcl sublingual - Tier 1; QL; AL BELBUCA - Tier 2; PA; QL; AL fentanyl - Tier 1; PA; QL CONZIP (brand for tramadol hcl er) - Tier 2; PA; ST; QL hydromorphone hcl oral tablet (generic for DILAUDID) - Tier 1; QL DILAUDID ORAL (brand for hydromorphone hcl) - Tier 2; PA; QL morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - hydrocodone bitartrate er - Tier 1; PA; QL Tier 1; QL hydromorphone hcl er - Tier 1; PA; QL morphine sulfate er (generic for MS CONTIN) - Tier 1; PA; QL hydromorphone hcl oral liquid (generic for DILAUDID) - Tier 1; PA; QL morphine sulfate oral - Tier 1; QL hydromorphone hcl rectal - Tier 1; PA; QL oxycodone hcl oral solution - Tier 1; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL oxycodone hcl oral tablet - Tier 1; QL levorphanol tartrate oral - Tier 1; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; ST; QL methadone hcl intensol (generic for METHADONE HCL INTENSOL) - Tier tramadol hcl er oral tablet extended release 24 hour - Tier 1; ST; QL 1; PA; QL tramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL; AL methadone hcl oral - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents methadose oral concentrate 10 mg/ml (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL methadose oral tablet soluble (generic for METHADOSE) - Tier 1; PA; QL methadose sugar-free (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL morphine sulfate (pf) injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml - Tier 1; PA morphine sulfate er beads - Tier 1; PA; QL morphine sulfate rectal - Tier 1; PA; QL MS CONTIN (brand for morphine sulfate er) - Tier 2; PA; QL NUCYNTA - Tier 2; PA; QL NUCYNTA ER - Tier 2; PA; QL OXAYDO - Tier 2; PA; QL OXYCODONE HCL ER - Tier 2; PA; QL oxycodone hcl oral capsule - Tier 1; PA; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; PA; QL oxymorphone hcl - Tier 1; PA; QL oxymorphone hcl er - Tier 1; PA; QL QDOLO - Tier 2; PA; QL ROXICODONE (brand for oxycodone hcl) - Tier 2; PA; QL tramadol hcl er (biphasic) - Tier 1; PA; ST; QL TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; ST; QL tramadol hcl oral tablet 100 mg - Tier 1; PA; QL ULTRAM (brand for tramadol hcl) - Tier 2; PA; QL; AL XTAMPZA ER - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 7 Preferred Agents Non-Preferred Agents Opioid Analgesics, Short-acting acetaminophen-codeine #2 - Tier 1; QL; AL ACTIQ (brand for fentanyl citrate) - Tier 2; PA acetaminophen-codeine #3 - Tier 1; QL; AL ALLZITAL (brand for butalbital-acetaminophen) - Tier 2; PA; QL acetaminophen-codeine #4 - Tier 1; QL; AL apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA; acetaminophen-codeine oral solution - Tier 1; QL QL; AL acetaminophen-codeine oral tablet - Tier 1; QL; AL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; PA; QL bac (generic for BAC) - Tier 1; QL BUPAP (brand for butalbital-acetaminophen) - Tier 2; PA butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) butalbital-acetaminophen capsule 50-300 mg oral - Tier 1; PA; QL - Tier 1; QL BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL - Tier 2; butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for PA; QL ESGIC) - Tier 1; QL butalbital-acetaminophen oral tablet 25-325 mg (generic for ALLZITAL) - butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL Tier 1; PA; QL butalbital-aspirin-caffeine - Tier 1; QL codeine sulfate - Tier 1; QL; AL butalbital-acetaminophen oral tablet 50-300 mg (generic for BUPAP) - endocet (generic for ENDOCET) - Tier 1; QL Tier 1; PA hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; butalbital-apap-caff-cod - Tier 1; PA; QL QL butalbital-apap-caffeine oral capsule 50-300-40 mg (generic for hydrocodone-acetaminophen oral tablet - Tier 1; QL FIORICET) - Tier 1; PA hydrocodone-ibuprofen - Tier 1; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; PA; oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 QL mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL butorphanol tartrate nasal - Tier 1; PA; QL TENCON (brand for butalbital-acetaminophen) - Tier 2; QL ESGIC (brand for butalbital-apap-caffeine) - Tier 2; PA; QL tramadol-acetaminophen (generic for ULTRACET) - Tier 1; QL; AL fentanyl citrate (pf) injection solution 50 mcg/ml - Tier 1; PA fentanyl citrate buccal lozenge on a handle (generic for ACTIQ) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents FENTANYL CITRATE BUCCAL TABLET - Tier 2; PA FENTORA (brand for fentanyl citrate) - Tier 2; PA FIORICET (brand for butalbital-apap-caffeine) - Tier 2; PA FIORICET/CODEINE (brand for butalbital-apap-caff-cod) - Tier 2; PA; QL LORTAB - Tier 2; PA; QL meperidine hcl oral - Tier 1; PA; QL pentazocine-naloxone hcl - Tier 1; PA; QL PERCOCET (brand for oxycodone-acetaminophen) - Tier 2; PA; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL; AL ULTRACET (brand for tramadol-acetaminophen) - Tier 2; PA; QL; AL VTOL LQ - Tier 2; PA ZEBUTAL (brand for butalbital-apap-caffeine) - Tier 2; PA; QL Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; TYLENOL EXTRA STRENGTH TABLET 500 MG ORAL 500 MG (brand QL for pain reliever extra strength) - Tier 2; PA; QL 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen childrens - Tier 1; QL acetaminophen childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral liquid 160 mg/5ml (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL acetaminophen oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml - Tier 1; QL acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen rapid tabs child - Tier 1 acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1; QL arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1; QL childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for migraine formula) - Tier 2 EXCEDRIN MIGRAINE (brand for migraine formula) - Tier 2 EXCEDRIN TENSION HEADACHE (brand for ra tension headache) - Tier 2 fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1; QL fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL FEVERALL INFANTS - Tier 2; QL FEVERALL JUNIOR STRENGTH - Tier 2; QL headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL mapap oral capsule - Tier 1; QL menstrual pain relief (generic for PAMPRIN MAX PAIN FORMULA) - Tier 1 migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1; QL non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 12 Preferred Agents Non-Preferred Agents pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain reliever extra strength oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever oral tablet (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 13 Preferred Agents Non-Preferred Agents pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 PANADOL CHILDRENS (brand for non-aspirin childrens) - Tier 2; QL PANADOL EXTRA (brand for ra tension headache) - Tier 2 PANADOL EXTRA STRENGTH (brand for pain reliever extra strength) - Tier 2; QL PANADOL INFANTS (brand for non-aspirin childrens) - Tier 2; QL PHARBETOL EXTRA STRENGTH (brand for pain reliever extra strength) - Tier 2; QL PHARBETOL ORAL TABLET 325 MG (brand for meijer aspirin free) - Tier 2; QL rapid melts junior oral tablet dispersible 160 mg - Tier 1 sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL tension headache (generic for EXCEDRIN TENSION HEADACHE) - Tier 1 TYLENOL EXTRA STRENGTH TABLET 500 MG ORAL 500 MG (brand for pain reliever extra strength) - Tier 2; QL TYLENOL FOR CHILDREN + ADULTS (brand for non-aspirin childrens) - Tier 2; QL TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for non-aspirin childrens) - Tier 2; QL TYLENOL ORAL TABLET 325 MG (brand for meijer aspirin free) - Tier 2; QL TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for meijer jr st aspirin free) - Tier 2; QL TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for eq 8hr arthritis pain relief) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs aspirin tri-buffered (generic for BUFFERIN) - Tier 1 BUFFERIN (brand for tri-buffered aspirin) - Tier 2 salsalate oral - Tier 1; QL tri-buffered aspirin (generic for BUFFERIN) - Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers APADAZ (brand for benzhydrocodone-acetaminophen) - Tier 2; PA; QL BENZHYDROCODONE-ACETAMINOPHEN - Tier 2; PA; QL Anesthetics Local Anesthetics anecream external cream (generic for ANECREAM) - Tier 1; QL AGONEAZE - Tier 2; PA blue tube/ aloe (generic for ANECREAM) - Tier 1; QL ANODYNE LPT - Tier 2; PA glydo (generic for GLYDO) - Tier 1 ASTERO - Tier 2; PA lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL DERMACINRX LIDOGEL - Tier 2; PA; QL lidocaine hcl external cream 3 % - Tier 1 LDO PLUS - Tier 2; PA lidocaine hcl urethral/mucosal external gel - Tier 1; QL LIDO BDK (brand for prilolid) - Tier 2; PA lidocaine hcl urethral/mucosal external prefilled syringe (generic for lidocaine external ointment 5 % - Tier 1; PA; QL GLYDO) - Tier 1 lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; PA; QL lidocaine viscous hcl - Tier 1; QL lidocaine hcl external solution - Tier 1; PA lidocaine-prilocaine external cream - Tier 1; QL lidocaine hcl mouth/throat - Tier 1; PA LIDOCANNA - Tier 2 lidocaine-prilocaine external kit (generic for LIDO BDK) - Tier 1; PA lidopin external cream 3 % - Tier 1 LIDOCAINE-TETRACAINE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents LMX 4 (brand for lidocaine) - Tier 2; QL LIDODERM (brand for lidocaine) - Tier 2; PA; QL LIDOPRIL - Tier 2; PA LIDOPRIL XR - Tier 2; PA LIDO-PRILO CAINE PACK (brand for prilolid) - Tier 2; PA LIVIXIL PAK (brand for prilolid) - Tier 2; PA PLIAGLIS EXTERNAL CREAM (brand for lidocaine-tetracaine) - Tier 2; PA premium lidocaine - Tier 1; PA; QL PRILOLID - Tier 2; PA PRILOVIX - Tier 2; PA PRILOVIX LITE - Tier 2; PA PRILOVIX LITE PLUS - Tier 2; PA PRILOVIX PLUS - Tier 2; PA PRILOVIX ULTRALITE - Tier 2; PA PRILOVIX ULTRALITE PLUS - Tier 2; PA RELADOR PAK (brand for prilolid) - Tier 2; PA RELADOR PAK PLUS (brand for prilolid) - Tier 2; PA SYNERA - Tier 2; PA VEXATROL - Tier 2; PA Anesthetics - Drugs for Numbing Local Anesthetics cough drops mouth/throat lozenge 5.4 mg (generic for CEPACOL APRIZIO PAK (brand for priloheal plus 30) - Tier 2; PA; QL SORE THROAT) - Tier 1 APRIZIO PAK II (brand for priloheal plus 30) - Tier 2; PA; QL COCAINE HCL NASAL - Tier 2; PA FLEXIN - Tier 2; PA GEBAUERS PAIN EASE - Tier 2; PA GEBAUERS SPRAY AND STRETCH - Tier 2; PA GOPRELTO - Tier 2; PA NUMBRINO (brand for goprelto) - Tier 2; PA PRILOHEAL PLUS 30 - Tier 2; PA; QL PRILOVIXIL - Tier 2; PA; QL PRIZOPAK II (brand for priloheal plus 30) - Tier 2; PA; QL REAL HEAL-I (brand for priloheal plus 30) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents SKYADERM-LP (brand for priloheal plus 30) - Tier 2; PA; QL ZERUVIA - Tier 2; PA Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium - Tier 1; QL disulfiram oral tablet 250 mg - Tier 1; QL disulfiram oral tablet 500 mg - Tier 1 naltrexone hcl oral - Tier 1; AL Opioid Dependence buprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1; BUNAVAIL - Tier 2; PA; QL; AL QL; AL buprenorphine hcl-naloxone hcl sublingual film (generic for SUBOXONE) - SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; QL; Tier 1; PA; QL; AL AL buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr (generic for BUTRANS) - Tier 1; PA; QL buprenorphine transdermal patch weekly 7.5 mcg/hr (generic for BUTRANS) - Tier 1; PA; ST; QL BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR (brand for buprenorphine) - Tier 2; PA; QL BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR (brand for buprenorphine) - Tier 2; PA; ST; QL LUCEMYRA - Tier 2; PA; QL ZUBSOLV - Tier 2; PA; QL; AL

Opioid Reversal Agents naloxone hcl injection - Tier 1 KLOXXADO - Tier 2; PA NARCAN - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents Smoking Cessation Agents APO-VARENICLINE - Tier 2; PA; QL; AL bupropion hcl er (smoking det) - Tier 1; PA; QL; AL CHANTIX (brand for apo-varenicline) - Tier 2; PA; QL; AL CHANTIX CONTINUING MONTH PAK (brand for apo-varenicline) - Tier 2; PA; QL; AL CHANTIX STARTING MONTH PAK - Tier 2; PA; QL; AL habitrol (generic for HABITROL) - Tier 1; PA; QL; AL NICODERM CQ (brand for nicotine) - Tier 2; PA; QL; AL nicotine step 1 (generic for HABITROL) - Tier 1; PA; QL; AL nicotine step 2 (generic for NICODERM CQ) - Tier 1; PA; QL; AL nicotine step 3 (generic for NICODERM CQ) - Tier 1; PA; QL; AL nicotine transdermal kit 21-14-7 mg/24hr - Tier 1; PA; QL; AL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; PA; QL; AL nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; PA; QL; AL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; PA; QL; AL NICOTROL - Tier 2; PA; QL; AL NICOTROL NS - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 18 Preferred Agents Non-Preferred Agents Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Smoking Cessation Agents - Deterrents mini nicotine (generic for KLS QUIT2) - Tier 1; PA; QL; AL NICORETTE (brand for gnp nicotine polacrilex) - Tier 2; PA; QL; AL NICORETTE MINI (brand for cvs nicotine polacrilex) - Tier 2; PA; QL; AL NICORETTE STARTER KIT (brand for px stop smoking aid) - Tier 2; PA; QL; AL nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; PA; QL; AL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; PA; QL; AL nicotine mini (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; PA; QL; AL nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; PA; QL; AL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; PA; QL; AL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; PA; QL; AL quit2 (generic for KLS QUIT2) - Tier 1; PA; QL; AL quit4 (generic for KLS QUIT4) - Tier 1; PA; QL; AL THRIVE (brand for px stop smoking aid) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 19 Preferred Agents Non-Preferred Agents Antiandrogens - Hormone Suppressants Antineoplastics - Drugs to Treat Cancer ORGOVYX - Tier 2; PA; SP Antibacterials Aminoglycosides neomycin sulfate oral - Tier 1 ARIKAYCE - Tier 2; PA; SP; QL HUMATIN (brand for paromomycin sulfate) - Tier 2; PA paromomycin sulfate oral (generic for HUMATIN) - Tier 1; PA ZEMDRI - Tier 2; PA Antibacterials, Other CLEOCIN VAGINAL SUPPOSITORY - Tier 2 CLEOCIN ORAL (brand for clindamycin hcl) - Tier 2; PA clindamycin hcl oral (generic for CLEOCIN) - Tier 1 CLEOCIN VAGINAL CREAM (brand for clindamycin phosphate) - Tier 2; clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1 PA clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1 daptomycin intravenous solution reconstituted 350 mg - Tier 1; PA CLINDESSE - Tier 2 FLAGYL (brand for metronidazole) - Tier 2; PA FIRVANQ - Tier 2 fosfomycin tromethamine (generic for MONUROL) - Tier 1; PA linezolid oral tablet (generic for ZYVOX) - Tier 1; QL HIPREX (brand for methenamine hippurate) - Tier 2; PA; QL methenamine hippurate (generic for HIPREX) - Tier 1; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA metronidazole external (generic for ROSADAN) - Tier 1; QL MACROBID (brand for nitrofurantoin monohyd macro) - Tier 2; PA metronidazole oral tablet - Tier 1 MACRODANTIN (brand for nitrofurantoin macrocrystal) - Tier 2; PA nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1 METROCREAM (brand for metronidazole) - Tier 2; PA; QL METROGEL (brand for metronidazole) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 20 Preferred Agents Non-Preferred Agents nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - METROLOTION (brand for metronidazole) - Tier 2; PA; QL Tier 1 metronidazole oral capsule (generic for FLAGYL) - Tier 1; PA NUVESSA - Tier 2 metronidazole vaginal (generic for VANDAZOLE) - Tier 1; PA rosadan external cream (generic for ROSADAN) - Tier 1; QL MONUROL (brand for fosfomycin tromethamine) - Tier 2; PA rosadan external gel (generic for ROSADAN) - Tier 1; QL nitrofurantoin - Tier 1; PA tinidazole oral - Tier 1; PA NORITATE - Tier 2; PA trimethoprim oral - Tier 1; QL SIVEXTRO ORAL - Tier 2; PA; QL vandazole (generic for VANDAZOLE) - Tier 1 SOLOSEC - Tier 2; PA VANCOCIN (brand for vancomycin hcl) - Tier 2; PA VANCOCIN HCL (brand for vancomycin hcl) - Tier 2; PA vancomycin hcl oral (generic for VANCOCIN HCL) - Tier 1; PA XENLETA ORAL - Tier 2; PA; QL XIFAXAN - Tier 2; PA ZYVOX ORAL SUSPENSION RECONSTITUTED (brand for linezolid) - Tier 2; PA ZYVOX ORAL TABLET (brand for linezolid) - Tier 2; PA; QL

Beta-lactam, Cephalosporins cefadroxil oral capsule - Tier 1 cefaclor - Tier 1; PA cefadroxil oral suspension reconstituted - Tier 1 cefaclor er - Tier 1; PA cefdinir - Tier 1 cefadroxil oral tablet - Tier 1; PA cefprozil - Tier 1 cefixime (generic for SUPRAX) - Tier 1; PA cefuroxime axetil - Tier 1 cefpodoxime proxetil - Tier 1; PA cephalexin oral capsule - Tier 1 cephalexin oral tablet - Tier 1; PA cephalexin oral suspension reconstituted - Tier 1 KEFLEX (brand for cephalexin) - Tier 2; PA SUPRAX (brand for cefixime) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents Beta-lactam, Penicillins amoxicillin - Tier 1 amoxicillin-potassium clavulanate er - Tier 1; PA amoxicillin-potassium clavulanate oral suspension reconstituted 200- amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400- 28.5 mg/5ml, 400-57 mg/5ml - Tier 1 57 mg - Tier 1; PA amoxicillin-potassium clavulanate oral suspension reconstituted 250- AUGMENTIN (brand for amoxicillin-pot clavulanate) - Tier 2; PA 62.5 mg/5ml (generic for AUGMENTIN) - Tier 1 AUGMENTIN ES-600 (brand for amoxicillin-pot clavulanate) - Tier 2; PA amoxicillin-potassium clavulanate oral suspension reconstituted 600- 42.9 mg/5ml (generic for AUGMENTIN ES-600) - Tier 1 amoxicillin-potassium clavulanate oral tablet 250-125 mg, 875-125 mg - Tier 1 amoxicillin-potassium clavulanate oral tablet 500-125 mg (generic for AUGMENTIN) - Tier 1 ampicillin - Tier 1 dicloxacillin sodium - Tier 1 penicillin v potassium - Tier 1

Macrolides azithromycin oral (generic for ZITHROMAX) - Tier 1 clarithromycin er - Tier 1; PA clarithromycin oral - Tier 1 DIFICID - Tier 2; PA erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml E.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA (generic for E.E.S. GRANULES) - Tier 1 E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; PA ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; PA ERYPED 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA ERY-TAB (brand for erythromycin base) - Tier 2; PA ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; PA erythromycin base - Tier 1; PA erythromycin ethylsuccinate oral suspension reconstituted 400 mg/5ml (generic for ERYPED 400) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 22 Preferred Agents Non-Preferred Agents erythromycin ethylsuccinate oral tablet (generic for E.E.S. 400) - Tier 1; PA erythromycin oral (generic for ERY-TAB) - Tier 1; PA ZITHROMAX ORAL (brand for azithromycin) - Tier 2; PA ZITHROMAX TRI-PAK (brand for azithromycin) - Tier 2; PA ZITHROMAX Z-PAK (brand for azithromycin) - Tier 2; PA Quinolones ciprofloxacin hcl oral - Tier 1 BAXDELA INTRAVENOUS - Tier 2; PA levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1 BAXDELA ORAL - Tier 2; PA; QL CIPRO (brand for ciprofloxacin hcl) - Tier 2; PA levofloxacin oral solution - Tier 1; PA; QL moxifloxacin hcl oral - Tier 1; PA ofloxacin oral - Tier 1; PA Sulfonamides sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1; BACTRIM (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL QL BACTRIM DS (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL sulfadiazine oral - Tier 1; PA; QL Tetracyclines avidoxy - Tier 1 ACTICLATE (brand for doxycycline hyclate) - Tier 2; PA doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1 coremino (generic for COREMINO) - Tier 1; PA doxycycline hyclate oral tablet - Tier 1 demeclocycline hcl - Tier 1; PA doxycycline monohydrate oral capsule 100 mg (generic for DORYX (brand for doxycycline hyclate) - Tier 2; PA MONDOXYNE NL) - Tier 1 DORYX MPC - Tier 2; PA doxycycline monohydrate oral capsule 50 mg - Tier 1 doxycycline (generic for ORACEA) - Tier 1; PA doxycycline monohydrate oral suspension reconstituted (generic for doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg - VIBRAMYCIN) - Tier 1 Tier 1; PA doxycycline monohydrate oral tablet - Tier 1 doxycycline hyclate oral tablet delayed release 200 mg, 50 mg (generic minocycline hcl oral (generic for MINOCIN) - Tier 1 for DORYX) - Tier 1; PA mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG Tier 1 - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents morgidox oral (generic for MORGIDOX) - Tier 1 doxycycline monohydrate oral capsule 150 mg - Tier 1; PA doxycycline monohydrate oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL; AL minocycline hcl er oral tablet extended release 24 hour (generic for COREMINO) - Tier 1; PA MINOLIRA - Tier 2; PA mondoxyne nl oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA NUZYRA ORAL - Tier 2; PA ORACEA (brand for doxycycline) - Tier 2; PA SOLODYN (brand for minocycline hcl er) - Tier 2; PA TARGADOX (brand for doxycycline hyclate) - Tier 2; PA tetracycline hcl oral - Tier 1; PA VIBRAMYCIN (brand for doxycycline hyclate) - Tier 2; PA XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL; AL Antibacterials - Drugs to Treat Bacterial Infections Antibacterials, Other - Antibiotics antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1 alcohol prep pads external 70 % - Tier 1; PA; QL antibiotic pain/scar (generic for NEOSPORIN + PAIN RELIEF MAX FEM PH - Tier 2; PA ST) - Tier 1 iodine tincture external tincture 2 % - Tier 1; PA antibiotic/pain relief external ointment 1 % (generic for NEOSPORIN + LUGOLS STRONG IODINE - Tier 2; PA PAIN RELIEF MAX ST) - Tier 1 methenamine mandelate oral - Tier 1; PA bacitracin external ointment 500 unit/gm - Tier 1 bacitracin zinc external - Tier 1 bacitracin zinc first aid - Tier 1 bacitracin zinc-aloe - Tier 1 first aid antibiotic external ointment 1 % (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg- unit (generic for NEOSPORIN ORIGINAL) - Tier 1 medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1 NEOSPORIN + PAIN RELIEF MAX ST (brand for ra antibiotic + pain relief) - Tier 2 NEOSPORIN ORIGINAL (brand for sm triple antibiotic) - Tier 2 triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1 triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1 triple antibiotic pain relief (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic plus (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic plus max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic/pain (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic+pain relief (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 Anticonvulsants Anticonvulsants, Other felbamate oral suspension (generic for FELBATOL) - Tier 1; QL; AL BRIVIACT ORAL - Tier 2; PA; QL felbamate oral tablet (generic for FELBATOL) - Tier 1; QL ELEPSIA XR - Tier 2; PA lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL EPIDIOLEX - Tier 2; PA; SP; QL; AL lamotrigine oral tablet chewable 25 mg, 5 mg (generic for LAMICTAL) - FELBATOL ORAL SUSPENSION (brand for felbamate) - Tier 2; PA; QL; Tier 1; QL; AL AL lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT- FELBATOL ORAL TABLET (brand for felbamate) - Tier 2; PA; QL BLUE) - Tier 1; QL FINTEPLA - Tier 2; PA; QL lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- FYCOMPA - Tier 2; PA; QL GREEN) - Tier 1; QL KEPPRA ORAL SOLUTION (brand for levetiracetam) - Tier 2; PA; QL; AL lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- KEPPRA ORAL TABLET (brand for levetiracetam) - Tier 2; PA; QL ORANGE) - Tier 1; QL KEPPRA XR (brand for levetiracetam er) - Tier 2; PA; QL levetiracetam oral solution (generic for KEPPRA) - Tier 1; QL; AL LAMICTAL ODT (brand for lamotrigine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 25 Preferred Agents Non-Preferred Agents levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL LAMICTAL ORAL TABLET (brand for lamotrigine) - Tier 2; PA; QL roweepra (generic for ROWEEPRA) - Tier 1; QL LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG (brand for subvenite (generic for SUBVENITE) - Tier 1; QL lamotrigine) - Tier 2; PA; QL; AL subvenite starter kit-blue (generic for SUBVENITE STARTER KIT- LAMICTAL STARTER (brand for lamotrigine starter kit-green) - Tier 2; BLUE) - Tier 1; QL PA; QL subvenite starter kit-green (generic for SUBVENITE STARTER KIT- LAMICTAL XR (brand for lamotrigine er) - Tier 2; PA; QL GREEN) - Tier 1; QL lamotrigine er (generic for LAMICTAL XR) - Tier 1; PA; QL subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- lamotrigine oral kit (generic for LAMICTAL ODT) - Tier 1; PA; QL ORANGE) - Tier 1; QL lamotrigine oral tablet dispersible (generic for LAMICTAL ODT) - Tier 1; topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - PA; QL Tier 1; QL; AL levetiracetam er (generic for KEPPRA XR) - Tier 1; PA; QL topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL QUDEXY XR (brand for topiramate er) - Tier 2; PA; QL valproic acid oral - Tier 1; QL SPRITAM - Tier 2; PA; QL TOPAMAX (brand for topiramate) - Tier 2; PA; QL TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; QL; AL topiramate er (generic for QUDEXY XR) - Tier 1; PA; QL TROKENDI XR - Tier 2; PA; QL XCOPRI - Tier 2; PA; QL XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; ST; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL Calcium Channel Modifying Agents CELONTIN - Tier 2; QL ZARONTIN (brand for ethosuximide) - Tier 2; PA; QL ethosuximide oral (generic for ZARONTIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 26 Preferred Agents Non-Preferred Agents Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam oral tablet (generic for ONFI) - Tier 1; PA; QL clobazam oral suspension (generic for ONFI) - Tier 1; PA diazepam rectal (generic for DIASTAT PEDIATRIC) - Tier 1; QL DIASTAT ACUDIAL (brand for diazepam) - Tier 2; PA; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL DIASTAT PEDIATRIC (brand for diazepam) - Tier 2; PA; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL gabapentin oral solution 250 mg/5ml (generic for NEURONTIN) - Tier 1; NAYZILAM - Tier 2; PA; QL PA; QL phenobarbital oral - Tier 1; QL GABITRIL (brand for tiagabine hcl) - Tier 2; PA; QL; AL primidone oral (generic for MYSOLINE) - Tier 1; QL MYSOLINE (brand for primidone) - Tier 2; PA; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; AL NEURONTIN (brand for gabapentin) - Tier 2; PA; QL vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL ONFI ORAL SUSPENSION (brand for clobazam) - Tier 2; PA ONFI ORAL TABLET (brand for clobazam) - Tier 2; PA; QL SABRIL (brand for vigabatrin) - Tier 2; PA; SP; QL SYMPAZAN - Tier 2; PA VALTOCO 10 MG DOSE - Tier 2; PA; QL VALTOCO 15 MG DOSE - Tier 2; PA; QL VALTOCO 20 MG DOSE - Tier 2; PA; QL VALTOCO 5 MG DOSE - Tier 2; PA; QL vigabatrin (generic for SABRIL) - Tier 1; PA; SP; QL

Sodium Channel Agents carbamazepine er oral capsule extended release 12 hour (generic for APTIOM - Tier 2; PA; QL CARBATROL) - Tier 1; QL BANZEL ORAL SUSPENSION (brand for rufinamide) - Tier 2; PA; QL; AL carbamazepine er oral tablet extended release 12 hour (generic for BANZEL ORAL TABLET (brand for rufinamide) - Tier 2; PA; QL TEGRETOL-XR) - Tier 1; QL; AL CARBATROL (brand for carbamazepine er) - Tier 2; PA; QL carbamazepine oral suspension (generic for TEGRETOL) - Tier 1; QL; DILANTIN INFATABS (brand for phenytoin) - Tier 2; PA; QL AL DILANTIN ORAL CAPSULE 100 MG (brand for phenytoin sodium carbamazepine oral tablet (generic for EPITOL) - Tier 1; QL extended) - Tier 2; PA; QL carbamazepine oral tablet chewable - Tier 1; QL; AL DILANTIN ORAL SUSPENSION (brand for phenytoin) - Tier 2; PA; QL DILANTIN ORAL CAPSULE 30 MG - Tier 2; QL OXTELLAR XR - Tier 2; PA; QL epitol (generic for EPITOL) - Tier 1; QL PHENYTEK (brand for phenytoin sodium extended) - Tier 2; PA; QL oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; QL; rufinamide oral suspension (generic for BANZEL) - Tier 1; PA; QL; AL AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 27 Preferred Agents Non-Preferred Agents oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL; AL TEGRETOL ORAL SUSPENSION (brand for carbamazepine) - Tier 2; phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL PA; QL; AL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; TEGRETOL ORAL TABLET (brand for carbamazepine) - Tier 2; PA; QL QL TEGRETOL-XR (brand for carbamazepine er) - Tier 2; PA; QL; AL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - TRILEPTAL ORAL SUSPENSION (brand for oxcarbazepine) - Tier 2; PA; Tier 1; QL QL; AL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL TRILEPTAL ORAL TABLET (brand for oxcarbazepine) - Tier 2; PA; QL; rufinamide oral tablet (generic for BANZEL) - Tier 1; PA; QL AL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL VIMPAT ORAL - Tier 2; PA; QL; AL ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other DIACOMIT - Tier 2; PA; SP; QL; AL Antidementia Agents Antidementia Agents, Other ergoloid mesylates oral - Tier 1; PA; QL NAMZARIC - Tier 2; PA; QL Cholinesterase Inhibitors donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1 ARICEPT ORAL TABLET 10 MG, 5 MG (brand for donepezil hcl) - Tier 2; donepezil hcl oral tablet dispersible - Tier 1; QL PA EXELON (brand for rivastigmine) - Tier 2; QL ARICEPT ORAL TABLET 23 MG (brand for donepezil hcl) - Tier 2; PA; QL donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; PA; QL galantamine hydrobromide - Tier 1; PA; QL galantamine hydrobromide er (generic for RAZADYNE ER) - Tier 1; PA; QL RAZADYNE ER (brand for galantamine hydrobromide er) - Tier 2; PA; QL rivastigmine (generic for EXELON) - Tier 1; PA; QL rivastigmine tartrate - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 28 Preferred Agents Non-Preferred Agents N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl oral tablet - Tier 1; QL memantine hcl er (generic for NAMENDA XR) - Tier 1; PA; QL memantine hcl oral solution 2 mg/ml - Tier 1; PA; QL NAMENDA TITRATION PAK (brand for memantine hcl) - Tier 2; PA; QL NAMENDA XR (brand for memantine hcl er) - Tier 2; PA; QL Antidepressants Antidepressants, Other bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL; AL APLENZIN - Tier 2; PA; QL; AL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 mg (generic for WELLBUTRIN XL) - Tier 1; QL; AL HOUR 450 MG - Tier 2; PA; QL; AL bupropion hcl oral - Tier 1; QL; AL chlordiazepoxide-amitriptyline - Tier 1; PA; AL mirtazapine oral tablet (generic for REMERON) - Tier 1; QL; AL FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL; AL perphenazine-amitriptyline - Tier 1; AL mirtazapine oral tablet dispersible (generic for REMERON SOLTAB) - Tier 1; PA; QL olanzapine-fluoxetine hcl (generic for SYMBYAX) - Tier 1; PA; QL; AL REMERON (brand for mirtazapine) - Tier 2; PA; QL; AL REMERON SOLTAB (brand for mirtazapine) - Tier 2; PA; QL SPRAVATO (56 MG DOSE) - Tier 2; PA; QL SPRAVATO (84 MG DOSE) - Tier 2; PA; QL SYMBYAX (brand for olanzapine-fluoxetine hcl) - Tier 2; PA; QL; AL WELLBUTRIN SR (brand for bupropion hcl er (sr)) - Tier 2; PA; QL; AL WELLBUTRIN XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL; AL

Monoamine Oxidase Inhibitors tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL; AL EMSAM - Tier 2; PA; QL; AL MARPLAN - Tier 2; PA; QL; AL NARDIL (brand for phenelzine sulfate) - Tier 2; PA; QL; AL PARNATE (brand for tranylcypromine sulfate) - Tier 2; PA; QL; AL phenelzine sulfate oral (generic for NARDIL) - Tier 1; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 29 Preferred Agents Non-Preferred Agents SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide oral solution - Tier 1; QL BRISDELLE (brand for paroxetine mesylate) - Tier 2; PA; QL citalopram hydrobromide oral tablet (generic for CELEXA) - Tier 1; QL; CELEXA (brand for citalopram hydrobromide) - Tier 2; PA; QL; AL AL DESVENLAFAXINE ER - Tier 2; PA; QL; AL escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL; desvenlafaxine succinate er (generic for PRISTIQ) - Tier 1; PA; QL; AL AL EFFEXOR XR (brand for venlafaxine hcl er) - Tier 2; PA; QL; AL fluoxetine hcl oral capsule 10 mg, 20 mg (generic for PROZAC) - Tier escitalopram oxalate oral solution - Tier 1; PA; QL 1; QL; AL FETZIMA - Tier 2; PA; QL; AL fluoxetine hcl oral solution - Tier 1; QL FETZIMA TITRATION - Tier 2; PA; QL; AL fluvoxamine maleate - Tier 1; QL; AL fluoxetine hcl (pmdd) - Tier 1; PA; QL paroxetine hcl (generic for PAXIL) - Tier 1; QL; AL fluoxetine hcl oral capsule 40 mg (generic for PROZAC) - Tier 1; PA; QL; sertraline hcl oral concentrate (generic for ZOLOFT) - Tier 1; QL AL sertraline hcl oral tablet (generic for ZOLOFT) - Tier 1; QL; AL fluoxetine hcl oral capsule delayed release - Tier 1; PA; QL trazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QL; AL fluoxetine hcl oral tablet - Tier 1; PA; QL; AL venlafaxine hcl - Tier 1; QL; AL fluvoxamine maleate er - Tier 1; PA; QL venlafaxine hcl er oral capsule extended release 24 hour (generic for LEXAPRO (brand for escitalopram oxalate) - Tier 2; PA; QL; AL EFFEXOR XR) - Tier 1; QL; AL nefazodone hcl - Tier 1; PA; QL; AL paroxetine hcl er (generic for PAXIL CR) - Tier 1; PA; QL; AL paroxetine mesylate (generic for BRISDELLE) - Tier 1; PA; QL PAXIL (brand for paroxetine hcl) - Tier 2; PA; QL; AL PAXIL CR (brand for paroxetine hcl er) - Tier 2; PA; QL; AL PEXEVA - Tier 2; PA; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL; AL PROZAC (brand for fluoxetine hcl) - Tier 2; PA; QL; AL trazodone hcl oral tablet 300 mg - Tier 1; PA; QL; AL TRINTELLIX - Tier 2; PA; QL; AL venlafaxine hcl er oral tablet extended release 24 hour - Tier 1; PA; QL; AL VIIBRYD - Tier 2; PA; QL; AL VIIBRYD STARTER PACK - Tier 2; PA; QL ZOLOFT ORAL CONCENTRATE (brand for sertraline hcl) - Tier 2; PA; QL ZOLOFT ORAL TABLET (brand for sertraline hcl) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 30 Preferred Agents Non-Preferred Agents Tricyclics amitriptyline hcl oral - Tier 1; QL; AL ANAFRANIL (brand for clomipramine hcl) - Tier 2; PA; QL; AL amoxapine - Tier 1; QL; AL clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; PA; QL; AL desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL; AL imipramine pamoate - Tier 1; PA; QL; AL doxepin hcl oral capsule - Tier 1; QL; AL NORPRAMIN (brand for desipramine hcl) - Tier 2; PA; QL; AL doxepin hcl oral concentrate - Tier 1; QL PAMELOR (brand for nortriptyline hcl) - Tier 2; PA; QL; AL imipramine hcl oral - Tier 1; QL protriptyline hcl - Tier 1; PA; QL; AL nortriptyline hcl oral capsule (generic for PAMELOR) - Tier 1; QL; AL trimipramine maleate oral - Tier 1; PA; QL; AL nortriptyline hcl oral solution - Tier 1; QL Antiemetics Antiemetics, Other BONINE (brand for cvs motion sickness relief) - Tier 2 ANTIVERT - Tier 2; PA DICLEGIS (brand for doxylamine-pyridoxine) - Tier 2; DX2RX; QL BONJESTA - Tier 2; PA; QL doxylamine-pyridoxine (generic for DICLEGIS) - Tier 1; DX2RX; QL compro (generic for COMPRO) - Tier 1; PA driminate (generic for DRIMINATE) - Tier 1 GIMOTI - Tier 2; PA meclizine hcl oral (generic for BONINE) - Tier 1 metoclopramide hcl oral tablet dispersible - Tier 1; PA metoclopramide hcl oral solution - Tier 1 prochlorperazine (generic for COMPRO) - Tier 1; PA metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1 promethegan rectal suppository 50 mg - Tier 1; PA motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1 REGLAN (brand for metoclopramide hcl) - Tier 2; PA motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier scopolamine (generic for TRANSDERM-SCOP (1.5 MG)) - Tier 1; PA 1 TRANSDERM-SCOP (1.5 MG) (brand for scopolamine) - Tier 2; PA motion sickness relief oral tablet chewable 25 mg (generic for trimethobenzamide hcl oral - Tier 1; PA BONINE) - Tier 1 motion-time (generic for BONINE) - Tier 1 perphenazine oral - Tier 1; DX2RX; QL; AL prochlorperazine maleate oral - Tier 1 promethazine hcl oral - Tier 1 promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1 promethegan rectal suppository 12.5 mg, 25 mg (generic for PROMETHEGAN) - Tier 1 travel ease (generic for BONINE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Emetogenic Therapy Adjuncts aprepitant oral (generic for EMEND TRI-PACK) - Tier 1 AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED - Tier 2; PA aprepitant oral capsule 80 & 125 mg (generic for EMEND TRI-PACK) - AKYNZEO ORAL - Tier 2; PA Tier 1 aprepitant oral capsule 125 mg, 40 mg - Tier 1; PA aprepitant oral capsule 80 mg (generic for EMEND) - Tier 1 EMEND ORAL (brand for aprepitant) - Tier 2; PA dronabinol (generic for MARINOL) - Tier 1; AL EMEND TRI-PACK (brand for aprepitant) - Tier 2; PA ondansetron hcl oral solution - Tier 1; QL granisetron hcl oral - Tier 1; PA ondansetron hcl oral tablet 4 mg (generic for ZOFRAN) - Tier 1; QL MARINOL (brand for dronabinol) - Tier 2; PA; AL ondansetron hcl oral tablet 8 mg - Tier 1; QL palonosetron hcl intravenous solution 0.25 mg/2ml - Tier 1; PA ondansetron odt - Tier 1 SANCUSO - Tier 2; PA SUSTOL - Tier 2; PA VARUBI (180 MG DOSE) - Tier 2; PA ZOFRAN (brand for ondansetron hcl) - Tier 2; PA; QL ZUPLENZ - Tier 2; PA

Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea (generic for EMETROL) - Tier 1 EMETROL (brand for gnp nausea relief) - Tier 2 nausea control (generic for EMETROL) - Tier 1 nausea relief (generic for EMETROL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 32 Preferred Agents Non-Preferred Agents Antifungals 3 day (generic for MONISTAT 3) - Tier 1 ANCOBON (brand for flucytosine) - Tier 2; PA clotrimazole mouth/throat - Tier 1 CRESEMBA ORAL - Tier 2; PA fluconazole oral (generic for DIFLUCAN) - Tier 1 DIFLUCAN (brand for fluconazole) - Tier 2; PA griseofulvin microsize oral - Tier 1 flucytosine oral (generic for ANCOBON) - Tier 1; PA miconazole 1 combo pack (generic for MONISTAT 1 COMBO PACK) - griseofulvin ultramicrosize - Tier 1; PA Tier 1; QL GYNAZOLE-1 - Tier 2; PA; QL miconazole 1 vaginal kit 1200 & 2 mg & % (generic for MONISTAT 1 itraconazole oral (generic for SPORANOX) - Tier 1; PA COMBO PACK) - Tier 1; QL ketoconazole oral - Tier 1; PA miconazole 3 - Tier 1 NOXAFIL ORAL SUSPENSION - Tier 2; PA miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for NOXAFIL ORAL TABLET DELAYED RELEASE (brand for posaconazole) MONISTAT 3 COMBO PACK APP) - Tier 1; QL - Tier 2; PA; AL ORAVIG - Tier 2; PA miconazole 3 combo pack app (generic for MONISTAT 3 COMBO posaconazole (generic for NOXAFIL) - Tier 1; PA; AL PACK APP) - Tier 1; QL SPORANOX (brand for itraconazole) - Tier 2; PA miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for SPORANOX PULSEPAK (brand for itraconazole) - Tier 2; PA MONISTAT 3 COMBO PACK APP) - Tier 1; QL terconazole vaginal suppository - Tier 1; PA miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 TOLSURA - Tier 2; PA miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) VFEND (brand for voriconazole) - Tier 2; PA - Tier 1 voriconazole oral (generic for VFEND) - Tier 1; PA miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 nystatin mouth/throat - Tier 1 nystatin oral - Tier 1 terbinafine hcl oral - Tier 1 terconazole vaginal cream - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1; 3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - PA Tier 1 athletes foot external aerosol powder 2 % (generic for CRUEX antifungal external cream 2 % (generic for CAVILON) - Tier 1 PRESCRIPTION STRENGTH) - Tier 1; PA antifungal external powder (generic for DESENEX) - Tier 1 athletes foot powder spray external aerosol powder 2 % (generic for antifungal foot care (generic for LAMISIL AT) - Tier 1 CRUEX PRESCRIPTION STRENGTH) - Tier 1; PA antifungal miconazole (generic for CAVILON) - Tier 1 AZOLEN TINCTURE - Tier 2; PA athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1 CORTI-SAV - Tier 2; PA athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1 CRUEX PRESCRIPTION STRENGTH (brand for ra atheletes foot) - Tier athletes foot external powder 2 % (generic for DESENEX) - Tier 1 2; PA CAVILON (brand for sm antifungal miconazole) - Tier 2 DESENEX JOCK ITCH (brand for ra atheletes foot) - Tier 2; PA clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 FUNGOID TINCTURE - Tier 2; PA clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL hydrocortisone-iodoquinol (generic for DERMAZENE) - Tier 1; PA clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL iodoquinol-hc-aloe polysacch - Tier 1; PA clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL KETODAN EXTERNAL KIT - Tier 2; PA DESENEX EXTERNAL POWDER (brand for gnp miconazorb af) - Tier LOPROX EXTERNAL KIT - Tier 2; PA 2 foot care (terbinafine) (generic for LAMISIL AT) - Tier 1 GYNE-LOTRIMIN (brand for clotrimazole) - Tier 2; QL GYNE-LOTRIMIN 3 (brand for gnp clotrimazole 3) - Tier 2 jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1 LAMISIL AT EXTERNAL CREAM (brand for qc athletes foot) - Tier 2 LAMISIL AT JOCK ITCH (brand for qc athletes foot) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents LOTRIMIN AF EXTERNAL POWDER 2 % (brand for gnp miconazorb af) - Tier 2 micaderm (generic for CAVILON) - Tier 1 MICATIN (brand for sm antifungal miconazole) - Tier 2 miconazole antifungal (generic for CAVILON) - Tier 1 miconazole nitrate external (generic for CAVILON) - Tier 1 miconazorb af (generic for DESENEX) - Tier 1 MYCOZYL AP (brand for gnp miconazorb af) - Tier 2 terbinafine hcl external (generic for LAMISIL AT) - Tier 1 terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1 tioconazole 1 vaginal ointment 6.5 % (generic for MONISTAT 1-DAY) - Tier 1 tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1 ZEASORB-AF (brand for gnp miconazorb af) - Tier 2 Antigout Agents allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL COLCHICINE ORAL CAPSULE - Tier 2; PA; QL colchicine-probenecid - Tier 1; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL MITIGARE (brand for colchicine) - Tier 2; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL probenecid - Tier 1; QL febuxostat (generic for ULORIC) - Tier 1; PA; QL GLOPERBA - Tier 2; PA; QL ULORIC (brand for febuxostat) - Tier 2; PA; QL ZYLOPRIM (brand for allopurinol) - Tier 2; PA; QL Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs Antivirals - Drugs to Treat Viral Infections CABENUVA - Tier 2; PA Anti-HIV Agents, Other - HIV Drugs Antivirals - Drugs to Treat Viral Infections VOCABRIA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 35 Preferred Agents Non-Preferred Agents Antimigraine Agents Acute rizatriptan benzoate oral tablet - Tier 1; QL almotriptan malate - Tier 1; PA; QL rizatriptan benzoate oral tablet dispersible - Tier 1 AMERGE (brand for naratriptan hcl) - Tier 2; PA; QL sumatriptan nasal (generic for IMITREX) - Tier 1 eletriptan hydrobromide (generic for RELPAX) - Tier 1; PA; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) frovatriptan succinate (generic for FROVA) - Tier 1; PA; QL - Tier 1 IMITREX NASAL (brand for sumatriptan) - Tier 2; PA sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1 IMITREX ORAL (brand for sumatriptan succinate) - Tier 2; PA; QL IMITREX STATDOSE REFILL (brand for sumatriptan succinate refill) - Tier 2; PA IMITREX STATDOSE SYSTEM (brand for sumatriptan succinate) - Tier 2; PA IMITREX SUBCUTANEOUS (brand for sumatriptan succinate) - Tier 2; PA MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL MAXALT-MLT (brand for rizatriptan benzoate) - Tier 2; PA naratriptan hcl (generic for AMERGE) - Tier 1; PA; QL ONZETRA XSAIL - Tier 2; PA RELPAX (brand for eletriptan hydrobromide) - Tier 2; PA; QL REYVOW - Tier 2; PA; QL; AL sumatriptan-naproxen sodium (generic for TREXIMET) - Tier 1; PA; QL TOSYMRA - Tier 2; PA; QL TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA; QL ZEMBRACE SYMTOUCH - Tier 2; PA ZOLMITRIPTAN NASAL - Tier 2; PA; QL zolmitriptan oral tablet (generic for ZOMIG) - Tier 1; PA; QL zolmitriptan oral tablet dispersible - Tier 1; PA ZOMIG (brand for zolmitriptan) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 36 Preferred Agents Non-Preferred Agents Ergot Alkaloids MIGERGOT - Tier 2; QL CAFERGOT (brand for ergotamine-caffeine) - Tier 2; PA dihydroergotamine mesylate nasal (generic for MIGRANAL) - Tier 1; PA ERGOMAR - Tier 2; PA ergotamine-caffeine (generic for CAFERGOT) - Tier 1; PA MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA Prophylactic AJOVY - Tier 2; PA; QL AIMOVIG - Tier 2; PA; QL EMGALITY - Tier 2; PA; QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL timolol maleate oral - Tier 1; PA; QL Antimigraine Agents - Drugs to Treat Migraines Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist - Migraine Drugs NURTEC - Tier 2; PA; QL; AL UBRELVY - Tier 2; ST; QL; AL Antimyasthenic Agents Parasympathomimetics pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL MESTINON (brand for pyridostigmine bromide) - Tier 2; PA; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; pyridostigmine bromide oral tablet 30 mg - Tier 1; PA; QL QL pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL Antimycobacterials Antimycobacterials, Other dapsone oral - Tier 1; QL MYCOBUTIN (brand for rifabutin) - Tier 2; PA; QL rifabutin (generic for MYCOBUTIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents Antituberculars cycloserine oral - Tier 1; QL MYAMBUTOL (brand for ethambutol hcl) - Tier 2; PA; QL ethambutol hcl oral tablet 100 mg - Tier 1 PRETOMANID - Tier 2; PA; QL ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QL isoniazid oral - Tier 1; QL PASER - Tier 2; QL PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1; QL rifampin oral - Tier 1; QL SIRTURO - Tier 2; QL; AL TRECATOR - Tier 2; QL Antineoplastics Alkylating Agents cyclophosphamide oral capsule - Tier 1 EVOMELA - Tier 2; PA CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 oxaliplatin intravenous solution 200 mg/40ml - Tier 1; PA LEUKERAN - Tier 2 TEMODAR ORAL (brand for temozolomide) - Tier 2; PA; SP; QL MATULANE - Tier 2; SP; QL VALCHLOR - Tier 2; PA; SP; QL MYLERAN - Tier 2 temozolomide - Tier 1; SP; QL Antiandrogens abiraterone acetate oral tablet 500 mg (generic for ZYTIGA) - Tier 1; abiraterone acetate oral tablet 250 mg (generic for ZYTIGA) - Tier 1; PA; SP; QL; AL SP; QL; AL bicalutamide (generic for CASODEX) - Tier 1; AL CASODEX (brand for bicalutamide) - Tier 2; PA; AL flutamide - Tier 1; AL ERLEADA - Tier 2; PA; SP; QL XTANDI ORAL CAPSULE - Tier 2; SP; QL; AL NILANDRON (brand for nilutamide) - Tier 2; PA; AL XTANDI ORAL TABLET - Tier 2; SP nilutamide (generic for NILANDRON) - Tier 1; PA; AL ZYTIGA ORAL TABLET 250 MG (brand for abiraterone acetate) - Tier NUBEQA - Tier 2; PA; SP; QL 2; SP; QL; AL YONSA - Tier 2; PA; SP; QL ZYTIGA ORAL TABLET 500 MG (brand for abiraterone acetate) - Tier 2; PA; SP; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents Antiangiogenic Agents REVLIMID - Tier 2; SP; QL POMALYST - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL Antiestrogens/Modifiers tamoxifen citrate oral - Tier 1; QL; AL EMCYT - Tier 2; PA FARESTON (brand for toremifene citrate) - Tier 2; PA; QL; AL SOLTAMOX - Tier 2; PA; QL toremifene citrate (generic for FARESTON) - Tier 1; PA; QL; AL Antimetabolites hydroxyurea oral (generic for HYDREA) - Tier 1 gemcitabine hcl intravenous solution 1 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, mercaptopurine oral - Tier 1 200 mg/2ml - Tier 1; PA TABLOID - Tier 2; PA; AL HYDREA (brand for hydroxyurea) - Tier 2; PA ONUREG - Tier 2; PA; SP PURIXAN - Tier 2; PA Antineoplastics, Other arsenic trioxide intravenous solution 12 mg/6ml (generic for TRISENOX) - Tier 1; PA daunorubicin hcl - Tier 1; PA IDHIFA - Tier 2; PA; SP; QL KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG - Tier 2; PA LONSURF - Tier 2; PA; SP; QL NINLARO - Tier 2; PA; SP; QL PEMAZYRE - Tier 2; PA; SP; QL TAZVERIK - Tier 2; PA TRISENOX (brand for arsenic trioxide) - Tier 2; PA VYXEOS - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 39 Preferred Agents Non-Preferred Agents XPOVIO (100 MG ONCE WEEKLY) - Tier 2; PA; SP XPOVIO (40 MG ONCE WEEKLY) - Tier 2; PA; SP XPOVIO (40 MG TWICE WEEKLY) - Tier 2; PA; SP XPOVIO (60 MG ONCE WEEKLY) - Tier 2; PA; SP XPOVIO (60 MG TWICE WEEKLY) - Tier 2; PA; SP XPOVIO (80 MG ONCE WEEKLY) - Tier 2; PA; SP XPOVIO (80 MG TWICE WEEKLY) - Tier 2; PA; SP; QL ZOLINZA - Tier 2; PA; SP; QL Aromatase Inhibitors, 3rd Generation anastrozole oral (generic for ARIMIDEX) - Tier 1; PA; QL; AL ARIMIDEX (brand for anastrozole) - Tier 2; PA; QL; AL exemestane (generic for AROMASIN) - Tier 1; QL; AL AROMASIN (brand for exemestane) - Tier 2; PA; QL; AL letrozole oral (generic for FEMARA) - Tier 1; DX2RX; QL; AL FEMARA (brand for letrozole) - Tier 2; DX2RX; QL; AL Enzyme Inhibitors etoposide oral - Tier 1 HYCAMTIN ORAL - Tier 2; PA; SP; QL Molecular Target Inhibitors ERIVEDGE - Tier 2; SP; QL AFINITOR (brand for everolimus) - Tier 2; PA; SP; QL IBRANCE ORAL CAPSULE - Tier 2; SP; QL AFINITOR DISPERZ - Tier 2; PA; SP; QL IBRANCE ORAL TABLET - Tier 2; SP BALVERSA - Tier 2; PA; SP; QL JAKAFI - Tier 2; SP; QL BRAFTOVI - Tier 2; PA; SP; QL LYNPARZA - Tier 2; SP; QL COPIKTRA - Tier 2; PA; SP; QL MEKINIST - Tier 2; SP; QL COTELLIC - Tier 2; PA; SP; QL SUTENT (brand for sunitinib malate) - Tier 2; SP; QL DAURISMO - Tier 2; PA; SP; QL TAFINLAR - Tier 2; SP; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - Tier VENCLEXTA - Tier 2; SP; QL 1; PA; SP; QL VENCLEXTA STARTING PACK - Tier 2; SP; QL FARYDAK - Tier 2; PA; SP; QL ZEJULA - Tier 2; SP; QL INQOVI - Tier 2; PA; SP INREBIC - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL KISQALI FEMARA(200 MG DOSE) - Tier 2; PA; SP; QL KOSELUGO - Tier 2; PA; SP; AL MEKTOVI - Tier 2; PA; SP; QL NEXAVAR - Tier 2; PA; SP; QL ODOMZO - Tier 2; PA; SP; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL ROZLYTREK - Tier 2; PA; SP; QL; AL RUBRACA - Tier 2; PA; SP; QL RYDAPT - Tier 2; PA; SP; QL STIVARGA - Tier 2; PA; SP; QL sunitinib malate (generic for SUTENT) - Tier 1; PA; SP; QL TALZENNA - Tier 2; PA; SP; QL TIBSOVO - Tier 2; PA; SP; QL VERZENIO - Tier 2; PA; SP; QL; AL VITRAKVI - Tier 2; PA; SP; QL ZELBORAF - Tier 2; PA; SP; QL ZYDELIG - Tier 2; PA; SP; QL Monoclonal Antibody/Antibody-Drug Conjugate RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1600-26800 MG - UT/13.4ML - Tier 2; PA Retinoids bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL PANRETIN - Tier 2; PA TARGRETIN - Tier 2; PA; SP; QL tretinoin oral - Tier 1; SP; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents Treatment Adjuncts leucovorin calcium oral - Tier 1; QL leucovorin calcium injection solution 100 mg/10ml - Tier 1; PA MESNEX ORAL - Tier 2; SP; QL Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents ALKERAN ORAL (brand for melphalan) - Tier 2; PA melphalan (generic for ALKERAN) - Tier 1; PA Antimetabolites - Chemotherapy Agents XELODA (brand for capecitabine) - Tier 2; SP; QL capecitabine (generic for XELODA) - Tier 1; PA; SP; QL Antineoplastics, Other - Chemotherapy Agents KYMRIAH - Tier 2; PA LUTATHERA - Tier 2; PA Antineoplastics, Other - Chemotherapy Agents Antineoplastics - Drugs to Treat Cancer ABECMA - Tier 2; PA LUMAKRAS - Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL Antiparasitics Anthelmintics ivermectin oral (generic for STROMECTOL) - Tier 1 albendazole oral (generic for ALBENZA) - Tier 1; PA ALBENZA (brand for albendazole) - Tier 2; PA BILTRICIDE (brand for praziquantel) - Tier 2; PA EMVERM - Tier 2; PA praziquantel oral (generic for BILTRICIDE) - Tier 1; PA STROMECTOL (brand for ivermectin) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents Antiprotozoals atovaquone (generic for MEPRON) - Tier 1; PA; QL ALINIA ORAL TABLET (brand for nitazoxanide) - Tier 2; PA; QL; AL BENZNIDAZOLE - Tier 2; DX2RX; QL atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; PA; QL chloroquine phosphate oral - Tier 1; QL COARTEM - Tier 2; PA; QL hydroxychloroquine sulfate oral tablet 200 mg (generic for DARAPRIM (brand for pyrimethamine) - Tier 2; PA; SP; QL PLAQUENIL) - Tier 1; QL hydroxychloroquine sulfate tablet 100 mg oral - Tier 1; PA KRINTAFEL - Tier 2; QL; AL hydroxychloroquine sulfate tablet 300 mg oral - Tier 1; PA mefloquine hcl - Tier 1; QL hydroxychloroquine sulfate tablet 400 mg oral - Tier 1; PA pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1; MALARONE (brand for atovaquone-proguanil hcl) - Tier 2; PA; QL QL MEPRON (brand for atovaquone) - Tier 2; PA; QL primaquine phosphate - Tier 1 NEBUPENT (brand for pentamidine isethionate) - Tier 2; PA; QL pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL nitazoxanide oral (generic for ALINIA) - Tier 1; PA; QL; AL PLAQUENIL (brand for hydroxychloroquine sulfate) - Tier 2; PA; QL QUALAQUIN (brand for quinine sulfate) - Tier 2; PA quinine sulfate oral (generic for QUALAQUIN) - Tier 1; PA

Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs EGATEN - Tier 2; PA; AL Antiprotozoals - Protozoal Infection Drugs LAMPIT - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 43 Preferred Agents Non-Preferred Agents Pediculicides/Scabicides - Scabies and Lice Drugs lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice solution combination kit (generic for CVS LICE SOLUTION) - Tier 1 lice solution kit (generic for CVS LICE SOLUTION) - Tier 1 lice treatment external shampoo 0.33-4 % (generic for RID LICE KILLING SHAMPOO) - Tier 1 RID LICE KILLING SHAMPOO (brand for eql lice killing max st) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 stop lice complete treatment (generic for CVS LICE SOLUTION) - Tier 1 Antiparkinson Agents Anticholinergics benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 44 Preferred Agents Non-Preferred Agents Antiparkinson Agents, Other amantadine hcl oral - Tier 1; QL COMTAN (brand for entacapone) - Tier 2; PA; QL carbidopa-levodopa-entacapone (generic for STALEVO 50) - Tier 1; entacapone (generic for COMTAN) - Tier 1; PA; QL QL GOCOVRI - Tier 2; PA; QL NOURIANZ - Tier 2; PA; QL ONGENTYS - Tier 2; PA; QL OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK - Tier 2; PA OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL STALEVO 100 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 125 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 150 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 200 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 50 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 75 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL TASMAR (brand for tolcapone) - Tier 2; PA; QL tolcapone (generic for TASMAR) - Tier 1; PA; QL Dopamine Agonists pramipexole dihydrochloride (generic for MIRAPEX) - Tier 1; QL APOKYN - Tier 2; PA; SP; QL ropinirole hcl - Tier 1; QL bromocriptine mesylate oral (generic for PARLODEL) - Tier 1; PA; QL KYNMOBI - Tier 2; PA; SP; QL KYNMOBI TITRATION KIT - Tier 2; PA; SP; QL MIRAPEX (brand for pramipexole dihydrochloride) - Tier 2; PA; QL MIRAPEX ER (brand for pramipexole dihydrochloride er) - Tier 2; PA; QL NEUPRO - Tier 2; PA; QL PARLODEL (brand for bromocriptine mesylate) - Tier 2; PA; QL pramipexole dihydrochloride er (generic for MIRAPEX ER) - Tier 1; PA; QL ropinirole hcl er - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa er - Tier 1; QL carbidopa oral (generic for LODOSYN) - Tier 1; PA; QL carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL carbidopa-levodopa oral tablet dispersible - Tier 1; PA; QL DUOPA - Tier 2; PA INBRIJA - Tier 2; PA; SP; QL LODOSYN (brand for carbidopa) - Tier 2; PA; QL RYTARY - Tier 2; PA; QL SINEMET (brand for carbidopa-levodopa) - Tier 2; PA; QL Monoamine Oxidase B (MAO-B) Inhibitors selegiline hcl oral - Tier 1; QL AZILECT (brand for rasagiline mesylate) - Tier 2; PA; QL rasagiline mesylate oral (generic for AZILECT) - Tier 1; PA; QL XADAGO - Tier 2; PA; QL ZELAPAR - Tier 2; PA; QL Antipsychotics 1st Generation/Typical chlorpromazine hcl oral tablet - Tier 1; DX2RX; QL; AL chlorpromazine hcl oral concentrate - Tier 1; PA fluphenazine decanoate injection - Tier 1; DX2RX HALDOL DECANOATE (brand for haloperidol decanoate) - Tier 2; fluphenazine hcl injection - Tier 1; DX2RX; AL DX2RX; QL fluphenazine hcl oral concentrate - Tier 1; DX2RX; AL haloperidol lactate oral - Tier 1; PA; QL; AL fluphenazine hcl oral elixir - Tier 1; DX2RX; AL molindone hcl - Tier 1; PA; QL; AL fluphenazine hcl oral tablet - Tier 1; DX2RX; QL; AL haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; DX2RX; QL haloperidol oral - Tier 1; DX2RX; QL; AL loxapine succinate - Tier 1; DX2RX; QL; AL pimozide - Tier 1; AL thioridazine hcl oral - Tier 1; DX2RX; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 46 Preferred Agents Non-Preferred Agents thiothixene - Tier 1; DX2RX; QL; AL trifluoperazine hcl - Tier 1; DX2RX; QL; AL

2nd Generation/Atypical ABILIFY MAINTENA - Tier 2; PA; QL; AL ABILIFY (brand for aripiprazole) - Tier 2; DX2RX; QL; AL aripiprazole oral tablet (generic for ABILIFY) - Tier 1; DX2RX; QL; AL ABILIFY MYCITE - Tier 2; PA; QL; AL INVEGA SUSTENNA - Tier 2; PA; QL; AL ABILIFY MYCITE MAINTENANCE KIT - Tier 2; PA INVEGA TRINZA - Tier 2; PA; QL; AL ABILIFY MYCITE STARTER KIT - Tier 2; PA olanzapine oral tablet (generic for ZYPREXA) - Tier 1; DX2RX; QL; AL aripiprazole oral solution - Tier 1; PA; QL; AL PERSERIS - Tier 2; PA; QL; AL aripiprazole oral tablet dispersible - Tier 1; PA; QL; AL quetiapine fumarate (generic for SEROQUEL) - Tier 1; DX2RX; QL; AL ARISTADA - Tier 2; PA; QL RISPERDAL CONSTA - Tier 2; PA; QL ARISTADA INITIO - Tier 2; PA; QL; AL risperidone oral solution (generic for RISPERDAL) - Tier 1; DX2RX; asenapine maleate (generic for SAPHRIS) - Tier 1; PA; QL; AL QL; AL CAPLYTA - Tier 2; PA; QL; AL risperidone oral tablet (generic for RISPERDAL) - Tier 1; DX2RX; QL; FANAPT - Tier 2; PA; QL; AL AL FANAPT TITRATION PACK - Tier 2; PA; AL ziprasidone hcl (generic for GEODON) - Tier 1; DX2RX; QL; AL GEODON ORAL (brand for ziprasidone hcl) - Tier 2; DX2RX; QL; AL INVEGA (brand for paliperidone er) - Tier 2; PA; QL; AL LATUDA - Tier 2; PA; QL; AL NUPLAZID - Tier 2; PA; QL; AL olanzapine oral tablet dispersible (generic for ZYPREXA ZYDIS) - Tier 1; PA; QL; AL paliperidone er (generic for INVEGA) - Tier 1; PA; QL; AL quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA; QL; AL REXULTI - Tier 2; PA; QL; AL RISPERDAL (brand for risperidone) - Tier 2; DX2RX; QL; AL risperidone oral tablet dispersible 0.25 mg - Tier 1; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 47 Preferred Agents Non-Preferred Agents risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg - Tier 1; PA; QL; AL SAPHRIS (brand for asenapine maleate) - Tier 2; PA; QL; AL SECUADO - Tier 2; PA; QL; AL SEROQUEL (brand for quetiapine fumarate) - Tier 2; DX2RX; QL; AL SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL; AL VRAYLAR - Tier 2; PA; QL; AL ZYPREXA ORAL (brand for olanzapine) - Tier 2; DX2RX; QL; AL ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; QL; AL Treatment-Resistant clozapine oral tablet 100 mg, 25 mg, 50 mg (generic for CLOZARIL) - clozapine oral tablet 200 mg (generic for CLOZARIL) - Tier 1; PA; QL; AL Tier 1; DX2RX; QL; AL clozapine oral tablet dispersible - Tier 1; PA; AL CLOZARIL ORAL TABLET 100 MG, 25 MG (brand for clozapine) - Tier 2; DX2RX; QL; AL CLOZARIL ORAL TABLET 200 MG (brand for clozapine) - Tier 2; PA; QL; AL CLOZARIL ORAL TABLET 50 MG (brand for clozapine) - Tier 2; DX2RX; QL; AL VERSACLOZ - Tier 2; PA; QL Antispasmodics, Urinary - Bladder Control Drugs Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions GEMTESA - Tier 2; PA; QL Antispasticity Agents baclofen oral - Tier 1 DANTRIUM ORAL (brand for dantrolene sodium) - Tier 2; PA tizanidine hcl oral tablet - Tier 1 dantrolene sodium oral - Tier 1; PA OZOBAX - Tier 2; PA tizanidine hcl oral capsule (generic for ZANAFLEX) - Tier 1; PA ZANAFLEX (brand for tizanidine hcl) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 48 Preferred Agents Non-Preferred Agents Antivirals Anti-cytomegalovirus (CMV) Agents valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL PREVYMIS ORAL - Tier 2; PA; QL VALCYTE (brand for valganciclovir hcl) - Tier 2; PA; QL valganciclovir hcl oral solution reconstituted (generic for VALCYTE) - Tier 1; PA; QL ZIRGAN - Tier 2; PA; QL Anti-hepatitis B (HBV) Agents entecavir (generic for BARACLUDE) - Tier 1; SP; QL adefovir dipivoxil (generic for HEPSERA) - Tier 1; PA; SP; QL BARACLUDE (brand for entecavir) - Tier 2; PA; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; PA; SP; QL EPIVIR HBV ORAL TABLET (brand for lamivudine) - Tier 2; PA HEPSERA (brand for adefovir dipivoxil) - Tier 2; PA; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; PA VEMLIDY - Tier 2; PA; SP; QL Anti-hepatitis C (HCV) Agents MAVYRET - Tier 2; PA; SP; QL; AL EPCLUSA ORAL TABLET 200-50 MG - Tier 2; PA; SP; QL; AL ribavirin oral - Tier 1; PA; QL EPCLUSA ORAL TABLET 400-100 MG (brand for sofosbuvir-velpatasvir) SOFOSBUVIR-VELPATASVIR - Tier 2; SP; QL; AL - Tier 2; PA; ST; SP; QL; AL VOSEVI - Tier 2; PA; SP; QL; AL HARVONI ORAL PACKET - Tier 2; PA; SP; QL; AL HARVONI ORAL TABLET 45-200 MG - Tier 2; PA; SP; QL; AL HARVONI ORAL TABLET 90-400 MG (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL LEDIPASVIR-SOFOSBUVIR - Tier 2; PA; SP; QL SOVALDI ORAL PACKET - Tier 2; PA; SP; QL; AL SOVALDI ORAL TABLET 200 MG - Tier 2; PA; SP; QL; AL SOVALDI ORAL TABLET 400 MG - Tier 2; PA; SP; QL VIEKIRA PAK - Tier 2; PA; SP; QL ZEPATIER - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents Antiherpetic Agents acyclovir external ointment (generic for ZOVIRAX) - Tier 1; QL acyclovir external cream (generic for ZOVIRAX) - Tier 1; PA; QL acyclovir oral capsule - Tier 1 acyclovir oral suspension (generic for ZOVIRAX) - Tier 1; PA; AL acyclovir oral tablet - Tier 1 DENAVIR - Tier 2; PA famciclovir oral - Tier 1 SITAVIG - Tier 2; PA valacyclovir hcl oral tablet 1 gm (generic for VALTREX) - Tier 1; QL VALTREX ORAL TABLET 1 GM (brand for valacyclovir hcl) - Tier 2; PA; valacyclovir hcl oral tablet 500 mg (generic for VALTREX) - Tier 1 QL VALTREX ORAL TABLET 500 MG (brand for valacyclovir hcl) - Tier 2; PA ZOVIRAX EXTERNAL (brand for acyclovir) - Tier 2; PA; QL ZOVIRAX ORAL (brand for acyclovir) - Tier 2; PA; AL Anti-HIV Agents, Integrase Inhibitors (INSTI) BIKTARVY - Tier 2; DX2RX; QL DOVATO - Tier 2; PA; QL GENVOYA - Tier 2; DX2RX; QL; AL JULUCA - Tier 2; PA; QL ISENTRESS HD - Tier 2; DX2RX; QL TIVICAY PD - Tier 2; PA ISENTRESS ORAL PACKET - Tier 2; DX2RX ISENTRESS ORAL TABLET - Tier 2; DX2RX; QL ISENTRESS ORAL TABLET CHEWABLE - Tier 2; DX2RX; QL STRIBILD - Tier 2; DX2RX; QL TIVICAY - Tier 2; DX2RX Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA - Tier 2; DX2RX ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; DX2RX DELSTRIGO - Tier 2; DX2RX; QL efavirenz (generic for SUSTIVA) - Tier 1; PA EDURANT - Tier 2 efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; DX2RX; QL efavirenz-emtricitab-tenofovir (generic for ATRIPLA) - Tier 1; DX2RX INTELENCE ORAL TABLET 100 MG, 200 MG (brand for etravirine) - Tier etravirine (generic for INTELENCE) - Tier 1; QL 2; PA; QL INTELENCE ORAL TABLET 25 MG - Tier 2; DX2RX; QL nevirapine - Tier 1; PA PIFELTRO - Tier 2; DX2RX; QL nevirapine er (generic for VIRAMUNE XR) - Tier 1; PA SUSTIVA (brand for efavirenz) - Tier 2; PA SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; QL VIRAMUNE (brand for nevirapine) - Tier 2; PA VIRAMUNE XR (brand for nevirapine er) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 50 Preferred Agents Non-Preferred Agents Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate (generic for ZIAGEN) - Tier 1; DX2RX COMBIVIR (brand for lamivudine-zidovudine) - Tier 2; DX2RX abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; DX2RX emtricitabine (generic for EMTRIVA) - Tier 1; DX2RX abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1 EMTRIVA (brand for emtricitabine) - Tier 2; DX2RX CIMDUO - Tier 2; DX2RX; QL EPIVIR (brand for lamivudine) - Tier 2; DX2RX DESCOVY - Tier 2; PA; QL; AL EPZICOM (brand for abacavir sulfate-lamivudine) - Tier 2; DX2RX emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; DX2RX RETROVIR ORAL (brand for zidovudine) - Tier 2; DX2RX lamivudine oral solution (generic for EPIVIR) - Tier 1; DX2RX stavudine oral capsule 15 mg, 20 mg, 40 mg - Tier 1; PA lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; TEMIXYS - Tier 2; PA; QL DX2RX TRIZIVIR (brand for abacavir-lamivudine-zidovudine) - Tier 2; PA lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; DX2RX TRUVADA (brand for emtricitabine-tenofovir df) - Tier 2; DX2RX ODEFSEY - Tier 2; DX2RX; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; PA tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; DX2RX TRIUMEQ - Tier 2; DX2RX VIREAD ORAL TABLET 300 MG (brand for tenofovir disoproxil fumarate) VIREAD ORAL POWDER - Tier 2 - Tier 2; DX2RX zidovudine (generic for RETROVIR) - Tier 1; DX2RX ZIAGEN (brand for abacavir sulfate) - Tier 2; DX2RX Anti-HIV Agents, Other FUZEON - Tier 2; DX2RX; QL; AL RUKOBIA - Tier 2; PA; QL; AL SELZENTRY - Tier 2; DX2RX TYBOST - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents Anti-HIV Agents, Protease Inhibitors (PI) atazanavir sulfate (generic for REYATAZ) - Tier 1; DX2RX APTIVUS - Tier 2; PA EVOTAZ - Tier 2; DX2RX; QL CRIXIVAN - Tier 2; PA LEXIVA ORAL SUSPENSION - Tier 2; DX2RX fosamprenavir calcium (generic for LEXIVA) - Tier 1; PA lopinavir-ritonavir oral solution (generic for KALETRA) - Tier 1; DX2RX INVIRASE - Tier 2; PA PREZCOBIX - Tier 2; QL KALETRA (brand for lopinavir-ritonavir) - Tier 2; DX2RX PREZISTA - Tier 2 LEXIVA ORAL TABLET (brand for fosamprenavir calcium) - Tier 2; PA lopinavir-ritonavir oral tablet (generic for KALETRA) - Tier 1; PA NORVIR - Tier 2; PA REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; DX2RX REYATAZ ORAL PACKET - Tier 2; PA ritonavir (generic for NORVIR) - Tier 1; PA SYMTUZA - Tier 2; PA; QL VIRACEPT - Tier 2; PA

Anti-influenza Agents oseltamivir phosphate oral (generic for TAMIFLU) - Tier 1; QL RELENZA DISKHALER - Tier 2; PA; QL rimantadine hcl - Tier 1; PA TAMIFLU (brand for oseltamivir phosphate) - Tier 2; PA; QL XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 1 X 40 MG - Tier 2; PA XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 X 20 MG - Tier 2; PA; QL XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 1 X 80 MG - Tier 2; PA XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 X 40 MG - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents Anxiolytics Anxiolytics, Other buspirone hcl oral - Tier 1 meprobamate - Tier 1; PA hydroxyzine hcl oral - Tier 1; QL VISTARIL (brand for hydroxyzine pamoate) - Tier 2; PA; QL hydroxyzine pamoate oral - Tier 1; QL Benzodiazepines alprazolam oral tablet (generic for XANAX) - Tier 1 alprazolam er (generic for XANAX XR) - Tier 1; PA chlordiazepoxide hcl - Tier 1 alprazolam intensol - Tier 1; PA clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL alprazolam oral tablet dispersible - Tier 1; PA diazepam oral solution - Tier 1 alprazolam xr (generic for XANAX XR) - Tier 1; PA diazepam oral tablet (generic for VALIUM) - Tier 1 ATIVAN ORAL (brand for lorazepam) - Tier 2; PA lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1 clonazepam oral tablet dispersible - Tier 1; PA; QL lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM clorazepate dipotassium - Tier 1; PA INTENSOL) - Tier 1 diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; PA lorazepam oral tablet (generic for ATIVAN) - Tier 1 diazepam oral concentrate (generic for DIAZEPAM INTENSOL) - Tier 1; PA KLONOPIN (brand for clonazepam) - Tier 2; PA; QL LOREEV XR - Tier 2; PA midazolam hcl oral - Tier 1; PA; QL oxazepam - Tier 1; PA TRANXENE-T (brand for clorazepate dipotassium) - Tier 2; PA VALIUM (brand for diazepam) - Tier 2; PA XANAX (brand for alprazolam) - Tier 2; PA XANAX XR (brand for alprazolam xr) - Tier 2; PA

Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs Central Nervous System Agents - Drugs to Treat Nerve Conditions QELBREE - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents Bipolar Agents Mood Stabilizers divalproex sodium oral (generic for DEPAKOTE) - Tier 1; QL; AL DEPAKOTE (brand for divalproex sodium) - Tier 2; PA; QL; AL lithium carbonate er (generic for LITHOBID) - Tier 1; QL; AL DEPAKOTE ER (brand for divalproex sodium er) - Tier 2; PA; QL lithium carbonate oral - Tier 1; QL; AL DEPAKOTE SPRINKLES (brand for divalproex sodium) - Tier 2; PA; QL; AL divalproex sodium er (generic for DEPAKOTE ER) - Tier 1; PA; QL EQUETRO - Tier 2; PA; QL LITHOBID (brand for lithium carbonate er) - Tier 2; PA; QL; AL Blood Formation Modifiers - Blood Formation Drugs Blood Products and Modifiers - Drugs to Treat Blood Disorders EMPAVELI - Tier 2; PA; QL Blood Glucose Regulators Antidiabetic Agents acarbose oral (generic for PRECOSE) - Tier 1; QL ACTOPLUS MET (brand for pioglitazone hcl-metformin hcl) - Tier 2; PA; BYETTA 10 MCG PEN - Tier 2; DX2RX; QL QL BYETTA 5 MCG PEN - Tier 2; DX2RX; QL ACTOS (brand for pioglitazone hcl) - Tier 2; PA; QL FARXIGA - Tier 2; DX2RX ADLYXIN - Tier 2; PA; QL glimepiride (generic for AMARYL) - Tier 1; QL ADLYXIN STARTER PACK - Tier 2; PA; QL glipizide er (generic for GLUCOTROL XL) - Tier 1; QL ALOGLIPTIN BENZOATE - Tier 2; PA; QL; AL glipizide ir - Tier 1; QL ALOGLIPTIN-METFORMIN HCL - Tier 2; PA; QL; AL glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; PA; QL; AL glipizide-metformin hcl - Tier 1; QL AMARYL (brand for glimepiride) - Tier 2; PA; QL glyburide micronized (generic for GLYNASE) - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL glyburide oral - Tier 1; QL CYCLOSET - Tier 2; PA; QL glyburide-metformin - Tier 1; QL DUETACT (brand for pioglitazone hcl-glimepiride) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents GLYXAMBI - Tier 2; QL; AL GLUCOTROL XL (brand for glipizide er) - Tier 2; PA; QL INVOKAMET - Tier 2; PA; QL GLUMETZA (brand for metformin hcl er (mod)) - Tier 2; PA; QL INVOKANA - Tier 2; DX2RX; QL GLYNASE (brand for glyburide micronized) - Tier 2; PA; QL JANUMET - Tier 2; QL; AL INVOKAMET XR - Tier 2; PA; QL JANUMET XR - Tier 2; QL; AL JENTADUETO XR - Tier 2; PA; QL; AL JANUVIA - Tier 2; QL; AL KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; QL; AL JARDIANCE - Tier 2; DX2RX; QL KOMBIGLYZE XR - Tier 2; PA; QL; AL JENTADUETO - Tier 2; QL; AL metformin hcl er (mod) (generic for GLUMETZA) - Tier 1; PA; QL metformin hcl er - Tier 1; QL metformin hcl er (osm) - Tier 1; PA; QL metformin hcl oral tablet - Tier 1; QL metformin hcl oral solution (generic for RIOMET) - Tier 1; PA; QL pioglitazone hcl (generic for ACTOS) - Tier 1; QL miglitol - Tier 1; PA repaglinide - Tier 1; QL nateglinide - Tier 1; PA; QL SYNJARDY - Tier 2; QL; AL NESINA (brand for alogliptin benzoate) - Tier 2; PA; QL; AL TRADJENTA - Tier 2; QL; AL ONGLYZA ORAL TABLET 2.5 MG - Tier 2; PA; QL TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ONGLYZA ORAL TABLET 5 MG - Tier 2; PA; QL; AL MG/0.5ML, 1.5 MG/0.5ML - Tier 2; QL OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; QL; AL TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 OZEMPIC - Tier 2; PA; QL MG/0.5ML, 4.5 MG/0.5ML - Tier 2 pioglitazone hcl-glimepiride (generic for DUETACT) - Tier 1; PA; QL VICTOZA - Tier 2; DX2RX; QL pioglitazone hcl-metformin hcl (generic for ACTOPLUS MET) - Tier 1; PA; XIGDUO XR - Tier 2; PA; QL QL PRECOSE (brand for acarbose) - Tier 2; PA; QL QTERN - Tier 2; PA; QL RIOMET (brand for metformin hcl) - Tier 2; PA; QL RYBELSUS - Tier 2; PA; QL SEGLUROMET - Tier 2; PA; QL SOLIQUA - Tier 2; PA; QL STEGLATRO - Tier 2; PA; QL STEGLUJAN - Tier 2; PA; QL SYMLINPEN 120 - Tier 2; PA; QL SYMLINPEN 60 - Tier 2; PA; QL SYNJARDY XR - Tier 2; PA; QL tolbutamide - Tier 1; PA; QL TRIJARDY XR - Tier 2; PA XULTOPHY - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents Glycemic Agents BAQSIMI ONE PACK - Tier 2; PA diazoxide oral (generic for PROGLYCEM) - Tier 1; PA; QL BAQSIMI TWO PACK - Tier 2; PA GLUCAGEN HYPOKIT - Tier 2; PA glucagon emergency kit 1 mg injection - Tier 1 GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - PROGLYCEM (brand for diazoxide) - Tier 2; QL Tier 2; PA GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; PA GVOKE HYPOPEN 1-PACK - Tier 2; PA GVOKE HYPOPEN 2-PACK - Tier 2; PA GVOKE PFS - Tier 2; PA Insulins FIASP PENFILL - Tier 2 ADMELOG (brand for insulin lispro) - Tier 2; PA; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML - Tier 2 SUBCUTANEOUS (brand for insulin lispro (1 unit dial)) - Tier 2; PA HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML INJECTOR 100 UNIT/ML (brand for insulin lispro (1 unit dial)) - Tier 2; SUBCUTANEOUS (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QL QL AFREZZA - Tier 2; PA HUMALOG MIX 50/50 - Tier 2 APIDRA SOLOSTAR - Tier 2; PA HUMALOG MIX 50/50 KWIKPEN - Tier 2 APIDRA VIAL - Tier 2; PA HUMALOG MIX 75/25 - Tier 2 BASAGLAR KWIKPEN - Tier 2; PA; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) FIASP - Tier 2; PA - Tier 2 FIASP FLEXTOUCH - Tier 2; PA HUMALOG SUBCUTANEOUS SOLUTION (brand for insulin lispro) - HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Tier 2; QL 200 UNIT/ML - Tier 2; PA HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2 LYUMJEV - Tier 2; PA HUMULIN 70/30 KWIKPEN - Tier 2 LYUMJEV KWIKPEN - Tier 2; PA HUMULIN 70/30 VIAL - Tier 2; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA HUMULIN N KWIKPEN - Tier 2 NOVOLIN 70/30 FLEXPEN RELION - Tier 2; PA HUMULIN N VIAL - Tier 2; QL NOVOLIN 70/30 RELION - Tier 2; PA; QL HUMULIN R U-500 KWIKPEN - Tier 2; PA NOVOLIN 70/30 VIAL - Tier 2; PA; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2 NOVOLIN N FLEXPEN - Tier 2; PA HUMULIN R VIAL - Tier 2; QL NOVOLIN N FLEXPEN RELION - Tier 2; PA INSULIN ASP PROT & ASP FLEXPEN - Tier 2 NOVOLIN N RELION - Tier 2; PA; QL INSULIN ASPART - Tier 2 NOVOLIN N VIAL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents INSULIN ASPART FLEXPEN - Tier 2 NOVOLIN R FLEXPEN - Tier 2; PA INSULIN ASPART PENFILL - Tier 2 NOVOLIN R FLEXPEN RELION - Tier 2; PA INSULIN ASPART PROT & ASPART - Tier 2 NOVOLIN R RELION - Tier 2; PA; QL INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 NOVOLIN R VIAL - Tier 2; PA; QL UNIT/ML SUBCUTANEOUS - Tier 2 SEMGLEE - Tier 2; PA INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 TOUJEO MAX SOLOSTAR - Tier 2; PA UNIT/ML SUBCUTANEOUS - Tier 2; QL TOUJEO SOLOSTAR - Tier 2; PA INSULIN LISPRO JUNIOR KWIKPEN - Tier 2 TRESIBA - Tier 2; PA INSULIN LISPRO PROT & LISPRO - Tier 2 TRESIBA FLEXTOUCH - Tier 2; PA INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS - Tier 2 INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS - Tier 2; QL LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS - Tier 2; QL LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS - Tier 2 LANTUS U-100 VIAL - Tier 2 LEVEMIR U-100 FLEXTOUCH - Tier 2 LEVEMIR U-100 VIAL - Tier 2 NOVOLOG 70/30 FLEXPEN RELION (brand for insulin asp prot & asp flexpen) - Tier 2 NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2 NOVOLOG FLEXPEN RELION (brand for insulin aspart flexpen) - Tier 2 NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2 NOVOLOG MIX 70/30 RELION (brand for insulin aspart prot & aspart) - Tier 2 NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2 NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2 NOVOLOG RELION (brand for insulin aspart) - Tier 2 NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents Blood Glucose Regulators - Drugs to Regulate Blood Sugar Glycemic Agents - Diabetic Drugs glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL glucose oral tablet chewable 4-6 gm-mg (generic for DEX4) - Tier 1 soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL Blood Products and Modifiers Anticoagulants ELIQUIS - Tier 2; QL ARIXTRA (brand for fondaparinux sodium) - Tier 2; PA ELIQUIS DVT/PE STARTER PACK - Tier 2; QL fondaparinux sodium (generic for ARIXTRA) - Tier 1; PA enoxaparin sodium (generic for LOVENOX) - Tier 1; QL FRAGMIN - Tier 2; PA heparin sodium (porcine) - Tier 1 LOVENOX (brand for enoxaparin sodium) - Tier 2; PA; QL heparin sodium (porcine) pf - Tier 1 SAVAYSA - Tier 2; PA; QL jantoven (generic for JANTOVEN) - Tier 1 ZONTIVITY - Tier 2; PA; QL PRADAXA ORAL CAPSULE 110 MG - Tier 2 PRADAXA ORAL CAPSULE 150 MG, 75 MG - Tier 2; QL warfarin sodium oral (generic for JANTOVEN) - Tier 1 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG - Tier 2; QL XARELTO ORAL TABLET 2.5 MG - Tier 2; DX2RX; QL XARELTO STARTER PACK - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 58 Preferred Agents Non-Preferred Agents Blood Products and Modifiers, Other anagrelide hcl (generic for AGRYLIN) - Tier 1 AGRYLIN (brand for anagrelide hcl) - Tier 2; PA ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, EPOGEN - Tier 2; PA; SP; QL 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML - Tier 2; PA; SP; FULPHILA - Tier 2; PA; SP; QL QL GRANIX - Tier 2; PA; SP; QL ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED MULPLETA - Tier 2; PA; SP; QL SYRINGE - Tier 2; PA; SP; QL NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE - Tier 2; PA; DROXIA - Tier 2 SP; QL LEUKINE - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP; QL MOZOBIL - Tier 2; PA; SP; QL OXBRYTA - Tier 2; PA; SP NEULASTA - Tier 2; PA; SP; QL PROCRIT - Tier 2; PA; SP; QL NEULASTA ONPRO - Tier 2; PA; SP; QL PROMACTA ORAL PACKET 12.5 MG - Tier 2; PA; SP; QL NEUPOGEN INJECTION SOLUTION - Tier 2; SP; QL PROMACTA ORAL PACKET 25 MG - Tier 2; PA; SP PROMACTA ORAL TABLET - Tier 2; DX2RX; SP; QL SIKLOS - Tier 2; PA RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, UDENYCA - Tier 2; PA; SP; QL 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; SP; QL ZARXIO - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; SP ZIEXTENZO - Tier 2; PA; SP Hemostasis Agents aminocaproic acid oral (generic for AMICAR) - Tier 1; QL AMICAR (brand for aminocaproic acid) - Tier 2; PA; QL tranexamic acid oral (generic for LYSTEDA) - Tier 1; DX2RX; QL LYSTEDA (brand for tranexamic acid) - Tier 2; DX2RX; QL Platelet Modifying Agents BRILINTA ORAL TABLET 60 MG - Tier 2 aspirin-dipyridamole er - Tier 1; PA; QL BRILINTA ORAL TABLET 90 MG - Tier 2; QL DOPTELET - Tier 2; PA; SP; QL CABLIVI - Tier 2; PA; SP; QL EFFIENT (brand for prasugrel hcl) - Tier 2; PA; QL cilostazol - Tier 1; QL PLAVIX (brand for clopidogrel bisulfate) - Tier 2; PA; QL clopidogrel bisulfate oral tablet 300 mg - Tier 1 TAVALISSE - Tier 2; PA; SP; QL clopidogrel bisulfate oral tablet 75 mg (generic for PLAVIX) - Tier 1; QL dipyridamole oral - Tier 1; QL prasugrel hcl (generic for EFFIENT) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents Blood Products and Modifiers - Drugs to Treat Blood Disorders Hemostasis Agents - Drugs to Stop Bleeding COAGADEX - Tier 2; SP; QL ADVATE - Tier 2; PA; SP; QL NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT - Tier 2; SP UNIT - Tier 2; PA; SP NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1500 ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT - Tier 2; SP; QL UNIT, 500 UNIT - Tier 2; PA; SP; QL NUWIQ - Tier 2; SP; QL ELOCTATE - Tier 2; PA; SP; QL ESPEROCT - Tier 2; PA; SP JIVI - Tier 2; PA; SP; QL; AL KOVALTRY - Tier 2; PA; SP; QL MONONINE - Tier 2; PA; SP; QL PROFILNINE - Tier 2; PA; SP; QL REBINYN - Tier 2; PA; SP; QL THROMBOGEN - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Hemostasis Agents - Drugs to Stop Bleeding ALPHANATE - Tier 2; SP; QL ADYNOVATE - Tier 2; PA; SP; QL; AL BENEFIX - Tier 2; SP; QL AFSTYLA - Tier 2; PA; SP; QL CORIFACT - Tier 2; PA; SP; QL ALPROLIX - Tier 2; PA; SP; QL HEMLIBRA - Tier 2; SP; QL FEIBA - Tier 2; PA; SP; QL HUMATE-P - Tier 2; SP; QL HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, NOVOSEVEN RT - Tier 2; SP; QL 1700 UNIT, 250 UNIT - Tier 2; PA; SP; QL WILATE - Tier 2; SP; QL HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT - XYNTHA - Tier 2; SP; QL Tier 2; PA; SP XYNTHA SOLOFUSE - Tier 2; SP; QL IDELVION - Tier 2; PA; SP; QL IXINITY (brand for rixubis) - Tier 2; PA; SP; QL KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT - Tier 2; PA; SP; QL KOATE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT - Tier 2; PA; SP KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT - Tier 2; PA; SP; QL KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT - Tier 2; PA; SP KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 3000 UNIT, 500 UNIT - Tier 2; PA; SP; QL KOGENATE FS INTRAVENOUS KIT 2000 UNIT, 250 UNIT - Tier 2; PA; SP monsels ferric subsulfate - Tier 1; PA OBIZUR - Tier 2; PA; SP; QL RECOMBINATE - Tier 2; PA; SP; QL RECOTHROM - Tier 2; PA RECOTHROM SPRAY KIT - Tier 2; PA RIXUBIS - Tier 2; PA; SP; QL TRETTEN - Tier 2; PA; SP; QL VONVENDI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents Cardiovascular Agents Alpha-adrenergic Agonists clonidine (generic for CATAPRES-TTS-1) - Tier 1 CATAPRES-TTS-1 (brand for clonidine) - Tier 2; PA clonidine hcl oral - Tier 1; QL CATAPRES-TTS-2 (brand for clonidine) - Tier 2; PA guanfacine hcl - Tier 1; QL CATAPRES-TTS-3 (brand for clonidine) - Tier 2; PA methyldopa - Tier 1; QL droxidopa (generic for NORTHERA) - Tier 1; PA; SP; QL midodrine hcl - Tier 1; QL NORTHERA (brand for droxidopa) - Tier 2; PA; SP; QL Alpha-adrenergic Blocking Agents doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL CARDURA (brand for doxazosin mesylate) - Tier 2; PA; QL prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL DIBENZYLINE (brand for phenoxybenzamine hcl) - Tier 2; PA; QL MINIPRESS (brand for prazosin hcl) - Tier 2; PA; QL phenoxybenzamine hcl oral (generic for DIBENZYLINE) - Tier 1; PA; QL Angiotensin II Receptor Antagonists irbesartan (generic for AVAPRO) - Tier 1; QL ATACAND (brand for candesartan cilexetil) - Tier 2; PA; QL losartan potassium oral (generic for COZAAR) - Tier 1; QL AVAPRO (brand for irbesartan) - Tier 2; PA; QL olmesartan medoxomil oral (generic for BENICAR) - Tier 1; QL BENICAR (brand for olmesartan medoxomil) - Tier 2; PA; QL valsartan (generic for DIOVAN) - Tier 1; QL candesartan cilexetil (generic for ATACAND) - Tier 1; PA; QL COZAAR (brand for losartan potassium) - Tier 2; PA; QL DIOVAN (brand for valsartan) - Tier 2; PA; QL EDARBI - Tier 2; PA; QL MICARDIS (brand for telmisartan) - Tier 2; PA; QL telmisartan (generic for MICARDIS) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL ACCUPRIL (brand for quinapril hcl) - Tier 2; PA; QL enalapril maleate oral tablet (generic for VASOTEC) - Tier 1; QL ALTACE (brand for ramipril) - Tier 2; PA; QL fosinopril sodium - Tier 1; QL captopril oral - Tier 1; PA; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL enalapril maleate oral solution (generic for EPANED) - Tier 1; PA; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL EPANED (brand for enalapril maleate) - Tier 2; PA; QL ramipril (generic for ALTACE) - Tier 1; QL LOTENSIN (brand for benazepril hcl) - Tier 2; PA; QL moexipril hcl - Tier 1; PA; QL perindopril erbumine - Tier 1; PA; QL PRINIVIL (brand for lisinopril) - Tier 2; PA; QL QBRELIS - Tier 2; PA; QL trandolapril - Tier 1; PA; QL VASOTEC (brand for enalapril maleate) - Tier 2; PA; QL ZESTRIL (brand for lisinopril) - Tier 2; PA; QL

Antiarrhythmics amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - amiodarone hcl oral tablet 100 mg (generic for PACERONE) - Tier 1; PA; Tier 1; QL QL disopyramide phosphate (generic for NORPACE) - Tier 1; QL BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL flecainide acetate - Tier 1; QL MULTAQ - Tier 2; PA; QL mexiletine hcl oral - Tier 1; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL NORPACE CR - Tier 2; QL PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL propafenone hcl - Tier 1; QL propafenone hcl er (generic for RYTHMOL SR) - Tier 1; PA; QL quinidine gluconate er - Tier 1; QL RYTHMOL SR (brand for propafenone hcl er) - Tier 2; PA; QL quinidine sulfate - Tier 1; QL SOTYLIZE - Tier 2; PA sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents Beta-adrenergic Blocking Agents atenolol oral (generic for TENORMIN) - Tier 1; QL acebutolol hcl oral - Tier 1; PA; QL bisoprolol fumarate oral - Tier 1; QL betaxolol hcl oral - Tier 1; PA; QL carvedilol (generic for COREG) - Tier 1; QL BYSTOLIC (brand for nebivolol hcl) - Tier 2; PA; QL labetalol hcl oral - Tier 1; QL carvedilol phosphate er (generic for COREG CR) - Tier 1; PA; QL metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL COREG (brand for carvedilol) - Tier 2; PA; QL metoprolol tartrate oral (generic for LOPRESSOR) - Tier 1; QL COREG CR (brand for carvedilol phosphate er) - Tier 2; PA; QL propranolol hcl er (generic for INDERAL LA) - Tier 1; QL CORGARD (brand for nadolol) - Tier 2; PA; QL propranolol hcl oral - Tier 1; QL HEMANGEOL - Tier 2; PA; QL INDERAL LA (brand for propranolol hcl er) - Tier 2; PA; QL INDERAL XL - Tier 2; PA; QL INNOPRAN XL - Tier 2; PA; QL KAPSPARGO SPRINKLE - Tier 2; PA; QL LOPRESSOR (brand for metoprolol tartrate) - Tier 2; PA; QL nadolol oral (generic for CORGARD) - Tier 1; PA; QL pindolol - Tier 1; PA; QL TENORMIN (brand for atenolol) - Tier 2; PA; QL TOPROL XL (brand for metoprolol succinate er) - Tier 2; PA; QL Calcium Channel Blocking Agents, Dihydropyridines amlodipine besylate oral (generic for NORVASC) - Tier 1; QL felodipine er - Tier 1; PA; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL isradipine - Tier 1; PA; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; KATERZIA - Tier 2; PA; QL QL nicardipine hcl oral - Tier 1; PA; QL nifedipine oral - Tier 1; PA; QL nimodipine oral - Tier 1; PA; QL nisoldipine er - Tier 1; PA; QL NORVASC (brand for amlodipine besylate) - Tier 2; PA; QL NYMALIZE - Tier 2; PA; AL PROCARDIA XL (brand for nifedipine er osmotic release) - Tier 2; PA; QL SULAR (brand for nisoldipine er) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 64 Preferred Agents Non-Preferred Agents Calcium Channel Blocking Agents, Nondihydropyridines cartia xt (generic for CARTIA XT) - Tier 1; QL CALAN SR (brand for verapamil hcl er) - Tier 2; PA; QL diltiazem hcl er - Tier 1; QL CARDIZEM (brand for diltiazem hcl) - Tier 2; PA; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL CARDIZEM CD (brand for diltiazem hcl er coated beads) - Tier 2; PA; QL diltiazem hcl er coated beads oral capsule extended release 24 hour CARDIZEM LA - Tier 2; PA; QL (generic for CARTIA XT) - Tier 1; QL diltiazem hcl er coated beads oral tablet extended release 24 hour diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL (generic for MATZIM LA) - Tier 1; PA; QL dilt-xr - Tier 1; QL matzim la (generic for MATZIM LA) - Tier 1; PA; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL TIAZAC (brand for diltiazem hcl er beads) - Tier 2; PA; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL verapamil hcl er oral capsule extended release 24 hour (generic for verapamil hcl er oral tablet extended release (generic for CALAN SR) - VERELAN) - Tier 1; PA; QL Tier 1; QL VERELAN (brand for verapamil hcl er) - Tier 2; PA; QL verapamil hcl oral - Tier 1; QL VERELAN PM (brand for verapamil hcl er) - Tier 2; PA; QL Cardiovascular Agents, Other acetazolamide er - Tier 1; QL ACCURETIC (brand for quinapril-hydrochlorothiazide) - Tier 2; PA; QL acetazolamide oral - Tier 1; QL ALDACTAZIDE (brand for spironolactone-hctz) - Tier 2; PA; QL amiloride-hydrochlorothiazide - Tier 1; QL aliskiren fumarate (generic for TEKTURNA) - Tier 1; PA; QL amlodipine besylate-benazepril hcl - Tier 1; QL amlodipine-atorvastatin (generic for CADUET) - Tier 1; PA; QL amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1; QL amlodipine-valsartan-hctz (generic for EXFORGE HCT) - Tier 1; PA; QL amlodipine-olmesartan (generic for AZOR) - Tier 1; QL ATACAND HCT (brand for candesartan cilexetil-hctz) - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL AVALIDE (brand for irbesartan-hydrochlorothiazide) - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL AZOR (brand for amlodipine-olmesartan) - Tier 2; PA; QL bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL BENICAR HCT (brand for olmesartan medoxomil-hctz) - Tier 2; PA; QL digitek (generic for DIGITEK) - Tier 1; QL BIDIL - Tier 2; PA; QL digox (generic for DIGITEK) - Tier 1; QL CADUET (brand for amlodipine-atorvastatin) - Tier 2; PA; QL digoxin oral (generic for DIGITEK) - Tier 1; QL candesartan cilexetil-hctz (generic for ATACAND HCT) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL CORLANOR - Tier 2; PA; QL ENTRESTO - Tier 2; PA; QL; AL DEMSER (brand for metyrosine) - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL DIOVAN HCT (brand for valsartan-hydrochlorothiazide) - Tier 2; PA; QL irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL EXFORGE (brand for amlodipine besylate-valsartan) - Tier 2; PA; QL losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL EXFORGE HCT (brand for amlodipine-valsartan-hctz) - Tier 2; PA; QL olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; QL HYZAAR (brand for losartan potassium-hctz) - Tier 2; PA; QL pentoxifylline er - Tier 1; QL KERENDIA - Tier 2; PA; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL LANOXIN ORAL TABLET 125 MCG, 250 MCG (brand for digoxin) - Tier ranolazine er (generic for RANEXA) - Tier 1; ST; QL 2; PA; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL LOTENSIN HCT (brand for benazepril-hydrochlorothiazide) - Tier 2; PA; triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL QL valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL LOTREL (brand for amlodipine besy-benazepril hcl) - Tier 2; PA; QL MAXZIDE (brand for triamterene-hctz) - Tier 2; PA; QL MAXZIDE-25 (brand for triamterene-hctz) - Tier 2; PA; QL metoprolol-hydrochlorothiazide - Tier 1; PA; QL metyrosine (generic for DEMSER) - Tier 1; PA; QL MICARDIS HCT (brand for telmisartan-hctz) - Tier 2; PA; QL olmesartan-amlodipine-hctz (generic for TRIBENZOR) - Tier 1; PA; QL RANEXA (brand for ranolazine er) - Tier 2; PA; ST; QL TARKA (brand for trandolapril-verapamil hcl er) - Tier 2; PA; QL TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL TEKTURNA HCT - Tier 2; PA; QL telmisartan-amlodipine (generic for TWYNSTA) - Tier 1; PA; QL telmisartan-hctz (generic for MICARDIS HCT) - Tier 1; PA; QL TENORETIC 100 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL TENORETIC 50 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL trandolapril-verapamil hcl er - Tier 1; PA; QL TRIBENZOR (brand for olmesartan-amlodipine-hctz) - Tier 2; PA; QL TWYNSTA (brand for telmisartan-amlodipine) - Tier 2; PA; QL VASERETIC (brand for enalapril-hydrochlorothiazide) - Tier 2; PA; QL VECAMYL - Tier 2; PA; QL ZESTORETIC (brand for lisinopril-hydrochlorothiazide) - Tier 2; PA; QL ZIAC (brand for bisoprolol-hydrochlorothiazide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 66 Preferred Agents Non-Preferred Agents Diuretics, Loop bumetanide oral (generic for BUMEX) - Tier 1; QL BUMEX (brand for bumetanide) - Tier 2; PA; QL furosemide oral - Tier 1; QL EDECRIN (brand for ethacrynic acid) - Tier 2; PA; QL torsemide - Tier 1; QL ethacrynic acid (generic for EDECRIN) - Tier 1; PA; QL LASIX (brand for furosemide) - Tier 2; PA; QL Diuretics, Potassium-sparing amiloride hcl oral - Tier 1; QL ALDACTONE (brand for spironolactone) - Tier 2; PA; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL CAROSPIR - Tier 2; PA; QL DYRENIUM (brand for triamterene) - Tier 2; PA; QL eplerenone (generic for INSPRA) - Tier 1; PA; QL INSPRA (brand for eplerenone) - Tier 2; PA; QL triamterene oral (generic for DYRENIUM) - Tier 1; PA; QL Diuretics, Thiazide chlorthalidone - Tier 1; QL DIURIL - Tier 2; PA; QL hydrochlorothiazide oral - Tier 1; QL indapamide - Tier 1; QL metolazone - Tier 1; QL Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ANTARA - Tier 2; PA QL fenofibrate micronized oral capsule 130 mg, 43 mg - Tier 1; PA; QL fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; QL fenofibrate oral capsule 150 mg, 50 mg (generic for LIPOFEN) - Tier 1; fenofibrate oral tablet 145 mg, 48 mg (generic for TRICOR) - Tier 1; PA; QL QL fenofibrate oral tablet 120 mg, 40 mg (generic for FENOGLIDE) - Tier 1; fenofibrate oral tablet 160 mg, 54 mg - Tier 1; QL PA; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL fenofibric acid oral capsule delayed release (generic for TRILIPIX) - Tier 1; PA; QL FENOGLIDE (brand for fenofibrate) - Tier 2; PA; QL LIPOFEN (brand for fenofibrate) - Tier 2; PA; QL LOPID (brand for gemfibrozil) - Tier 2; PA; QL TRICOR (brand for fenofibrate) - Tier 2; PA; QL

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL ALTOPREV - Tier 2; PA; QL lovastatin oral - Tier 1; QL CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL pravastatin sodium - Tier 1; QL EZALLOR SPRINKLE - Tier 2; PA; QL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL fluvastatin sodium - Tier 1; PA; QL simvastatin oral (generic for ZOCOR) - Tier 1; QL fluvastatin sodium er (generic for LESCOL XL) - Tier 1; PA; QL LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA; QL LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL LIVALO - Tier 2; PA; QL ZOCOR (brand for simvastatin) - Tier 2; PA; QL ZYPITAMAG - Tier 2; PA; QL Dyslipidemics, Other cholestyramine light (generic for PREVALITE) - Tier 1; QL colesevelam hcl (generic for WELCHOL) - Tier 1; PA; QL cholestyramine oral (generic for QUESTRAN) - Tier 1; QL COLESTID (brand for colestipol hcl) - Tier 2; PA; QL colestipol hcl oral tablet (generic for COLESTID) - Tier 1; QL COLESTID FLAVORED (brand for colestipol hcl) - Tier 2; PA; QL ezetimibe (generic for ZETIA) - Tier 1; QL colestipol hcl oral granules (generic for COLESTID) - Tier 1; PA; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QL colestipol hcl oral packet (generic for COLESTID) - Tier 1; PA; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; QL ezetimibe-simvastatin (generic for VYTORIN) - Tier 1; PA; QL prevalite (generic for PREVALITE) - Tier 1; QL icosapent ethyl (generic for VASCEPA) - Tier 1; PA; QL JUXTAPID - Tier 2; PA; SP; QL LOVAZA (brand for omega-3-acid ethyl esters) - Tier 2; PA; QL NEXLETOL - Tier 2; PA; QL NEXLIZET - Tier 2; PA; QL NIASPAN (brand for niacin er (antihyperlipidemic)) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents PRALUENT - Tier 2; PA; SP; QL; AL QUESTRAN (brand for cholestyramine) - Tier 2; PA; QL QUESTRAN LIGHT (brand for cholestyramine light) - Tier 2; PA; QL REPATHA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML - Tier 2; PA; SP; QL; AL REPATHA SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML - Tier 2; PA; SP; QL REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML - Tier 2; PA; SP; QL VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL WELCHOL (brand for colesevelam hcl) - Tier 2; PA; QL ZETIA (brand for ezetimibe) - Tier 2; PA; QL

Vasodilators, Direct-acting Arterial hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg - Tier 1; QL GONITRO - Tier 2; PA isosorbide dinitrate oral tablet 5 mg (generic for ISORDIL ISORDIL TITRADOSE (brand for isosorbide dinitrate) - Tier 2; PA TITRADOSE) - Tier 1 isosorbide dinitrate tablet 40 mg oral (generic for ISORDIL TITRADOSE) - isosorbide dinitrate tablet 40 mg oral (generic for ISORDIL Tier 1; PA TITRADOSE) - Tier 1 NITRO-BID - Tier 2; PA; QL isosorbide mononitrate - Tier 1; QL NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 isosorbide mononitrate er - Tier 1; QL MG/HR, 0.4 MG/HR, 0.6 MG/HR (brand for nitroglycerin) - Tier 2; PA minitran (generic for MINITRAN) - Tier 1 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual (generic for NITROSTAT) - Tier 1 - Tier 2; PA; QL nitroglycerin transdermal (generic for MINITRAN) - Tier 1 nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; PA RECTIV - Tier 2; PA; QL NITROLINGUAL (brand for nitroglycerin) - Tier 2; PA NITROMIST - Tier 2; PA NITROSTAT (brand for nitroglycerin) - Tier 2; PA

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs isoxsuprine hcl oral tablet 10 mg - Tier 1; PA Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibric acid oral tablet (generic for FIBRICOR) - Tier 1; PA; QL FIBRICOR (brand for fenofibric acid) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions VERQUVO - Tier 2; PA; QL Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; QL; AL ADHANSIA XR - Tier 2; PA; QL; AL atomoxetine hcl (generic for STRATTERA) - Tier 1; QL; AL clonidine hcl er (generic for KAPVAY) - Tier 1; PA; QL; AL dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; QL; AL CONCERTA (brand for methylphenidate hcl er) - Tier 2; PA; QL; AL dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; QL; AL COTEMPLA XR-ODT - Tier 2; PA; QL; AL guanfacine hcl er (generic for INTUNIV) - Tier 1; QL; AL DAYTRANA - Tier 2; PA; QL; AL methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL; AL mg (generic for APTENSIO XR) - Tier 1; QL; AL FOCALIN XR (brand for dexmethylphenidate hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 INTUNIV (brand for guanfacine hcl er) - Tier 2; PA; QL; AL mg, 54 mg (generic for CONCERTA) - Tier 1; QL; AL JORNAY PM - Tier 2; PA; QL; AL methylphenidate hcl oral solution (generic for METHYLIN) - Tier 1 KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL; AL methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1 METHYLIN (brand for methylphenidate hcl) - Tier 2; PA QUILLICHEW ER - Tier 2; AL methylphenidate hcl er (cd) - Tier 1; PA; QL; AL methylphenidate hcl er (la) (generic for RITALIN LA) - Tier 1; PA; QL; AL methylphenidate hcl er (xr) oral capsule extended release 24 hour 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg (generic for APTENSIO XR) - Tier 1; PA; QL; AL methylphenidate hcl er oral tablet extended release 10 mg, 20 mg - Tier 1; PA; QL; AL methylphenidate hcl er oral tablet extended release 24 hour - Tier 1; PA methylphenidate hcl er oral tablet extended release 72 mg (generic for RELEXXII) - Tier 1; PA; QL; AL methylphenidate hcl oral tablet chewable - Tier 1; PA QUILLIVANT XR - Tier 2; PA relexxii (generic for RELEXXII) - Tier 1; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents RITALIN (brand for methylphenidate hcl) - Tier 2; PA RITALIN LA (brand for methylphenidate hcl er (la)) - Tier 2; PA; QL; AL STRATTERA (brand for atomoxetine hcl) - Tier 2; PA; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2; PA; AL AL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2; PA; Tier 1; QL; AL QL; AL VYVANSE ORAL CAPSULE - Tier 2; QL; AL ADZENYS ER (brand for amphetamine er) - Tier 2; PA; AL VYVANSE ORAL TABLET CHEWABLE - Tier 2 ADZENYS XR-ODT - Tier 2; PA; QL; AL AMPHETAMINE ER - Tier 2; PA; AL amphetamine sulfate (generic for EVEKEO) - Tier 1; PA; AL AZSTARYS - Tier 2; PA DESOXYN (brand for methamphetamine hcl) - Tier 2; PA; AL DEXEDRINE (brand for dextroamphetamine sulfate er) - Tier 2; PA; AL dextroamphetamine sulfate (generic for ZENZEDI) - Tier 1; PA; AL dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1; PA; AL DYANAVEL XR - Tier 2; PA; AL EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; AL EVEKEO ODT - Tier 2; PA; AL methamphetamine hcl (generic for DESOXYN) - Tier 1; PA; AL MYDAYIS - Tier 2; PA; AL PROCENTRA (brand for dextroamphetamine sulfate) - Tier 2; PA; AL ZENZEDI - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents Central Nervous System, Other AUSTEDO - Tier 2; DX2RX; ST; SP; QL EXSERVAN - Tier 2; PA; QL caffeine citrate oral - Tier 1; QL; AL FIRDAPSE - Tier 2; PA; SP; QL NUEDEXTA - Tier 2; PA; QL GRALISE - Tier 2; PA; QL RUZURGI - Tier 2; PA; SP; QL; AL HORIZANT - Tier 2; PA; QL tetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; QL INGREZZA - Tier 2; PA; SP; QL; AL RILUTEK (brand for riluzole) - Tier 2; PA riluzole (generic for RILUTEK) - Tier 1; PA TIGLUTIK - Tier 2; PA; QL XENAZINE (brand for tetrabenazine) - Tier 2; DX2RX; SP; QL Fibromyalgia Agents duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL; AL mg (generic for CYMBALTA) - Tier 1; QL; AL DRIZALMA SPRINKLE - Tier 2; PA; QL; AL pregabalin (generic for LYRICA) - Tier 1; QL duloxetine hcl oral capsule delayed release particles 40 mg - Tier 1; PA; QL; AL LYRICA (brand for pregabalin) - Tier 2; PA; QL LYRICA CR (brand for pregabalin er) - Tier 2; PA; QL pregabalin er (generic for LYRICA CR) - Tier 1; PA; QL SAVELLA - Tier 2; PA; QL; AL SAVELLA TITRATION PACK - Tier 2; PA; QL Multiple Sclerosis Agents AVONEX PEN - Tier 2; SP; QL AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL AVONEX PREFILLED - Tier 2; SP; QL AUBAGIO - Tier 2; PA; SP; QL BETASERON - Tier 2; SP; QL BAFIERTAM - Tier 2; PA; SP; QL COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 20 MG/ML (brand for glatiramer acetate) - Tier 2; SP; QL MG/ML (brand for glatiramer acetate) - Tier 2; PA; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; SP dalfampridine er (generic for AMPYRA) - Tier 1; PA; SP; QL KESIMPTA - Tier 2; ST; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; PA; SP; QL TECFIDERA ORAL CAPSULE DELAYED RELEASE (brand for EXTAVIA - Tier 2; PA; SP; QL dimethyl fumarate) - Tier 2; SP; QL GILENYA - Tier 2; PA glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP; QL glatopa (generic for GLATOPA) - Tier 1; PA; SP; QL MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG - Tier 2; PA; SP; QL PLEGRIDY - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; PA; SP; QL REBIF - Tier 2; PA; SP; QL REBIF REBIDOSE - Tier 2; PA; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; PA; SP; QL TECFIDERA STARTER PACK (brand for dimethyl fumarate starter pack) - Tier 2; PA; SP VUMERITY - Tier 2; PA; SP; QL ZEPOSIA - Tier 2; PA; SP; QL; AL ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; QL; AL ZEPOSIA STARTER KIT - Tier 2; PA; SP; QL; AL Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions BRONCHITOL - Tier 2; PA; QL BRONCHITOL TOLERANCE TEST - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents Dental and Oral Agents chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier cevimeline hcl (generic for EVOXAC) - Tier 1; PA; QL 1; QL EVOXAC (brand for cevimeline hcl) - Tier 2; PA; QL oralone (generic for ORALONE) - Tier 1; QL PERIDEX (brand for chlorhexidine gluconate) - Tier 2; PA; QL periogard (generic for PERIOGARD) - Tier 1; QL SALAGEN (brand for pilocarpine hcl) - Tier 2; PA; QL pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions AQUORAL (brand for oral relief spray) - Tier 2; PA cherry cough drops (generic for DENTIVA) - Tier 1; PA cherry menthol drops (generic for DENTIVA) - Tier 1; PA honey lemon drops (generic for DENTIVA) - Tier 1; PA menthol drops (generic for DENTIVA) - Tier 1; PA MUCOSITISRX - Tier 2; PA SALIVAMAX - Tier 2; PA sore throat mouth/throat lozenge 6-10 mg (generic for DENTIVA) - Tier 1; PA XEROSTOMIA RELIEF SPRAY (brand for oral relief spray) - Tier 2; PA Dental and Oral Agents ANBESOL MAXIMUM STRENGTH MOUTH/THROAT GEL (brand for intense toothache pain relief) - Tier 2; PA HURRICAINE MOUTH/THROAT GEL (brand for intense toothache pain relief) - Tier 2; PA instant oral pain relief max (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA LOLLICAINE (brand for intense toothache pain relief) - Tier 2; PA oral analgesic max st mouth/throat gel (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA oral anesthetic max str (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 75 Preferred Agents Non-Preferred Agents oral pain relief mouth/throat gel 20 % (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA Dermatological Agents Acne and Rosacea Agents accutane (generic for ACCUTANE) - Tier 1; PA; QL; AL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL; AL acitretin (generic for SORIATANE) - Tier 1 ABSORICA LD - Tier 2; PA; QL amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL; AL ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL AVITA (brand for tretinoin) - Tier 2; QL; AL adapalene external cream (generic for DIFFERIN) - Tier 1; PA; QL azelaic acid external (generic for FINACEA) - Tier 1; QL adapalene external gel (generic for DIFFERIN) - Tier 1; PA; QL benzoyl peroxide-erythromycin (generic for BENZAMYCIN) - Tier 1; adapalene-benzoyl peroxide external gel (generic for EPIDUO) - Tier 1; QL PA; QL claravis (generic for AMNESTEEM) - Tier 1; PA; QL; AL AKLIEF - Tier 2; PA; AL clindamycin phos-benzoyl perox external gel 1.2-5 % (generic for ALTRENO - Tier 2; PA; AL NEUAC) - Tier 1; QL ARAZLO - Tier 2; PA DIFFERIN EXTERNAL LOTION - Tier 2; QL ATRALIN (brand for tretinoin) - Tier 2; PA; QL; AL isotretinoin oral (generic for AMNESTEEM) - Tier 1; PA; QL; AL BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL myorisan (generic for AMNESTEEM) - Tier 1; PA; QL; AL BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - tretinoin external cream (generic for AVITA) - Tier 1; QL; AL Tier 2; PA; QL tretinoin external gel 0.01 % (generic for RETIN-A) - Tier 1; QL; AL BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL tretinoin external gel 0.025 % (generic for AVITA) - Tier 1; QL; AL clindamycin phos-benzoyl perox external gel 1.2-2.5 % (generic for zenatane (generic for AMNESTEEM) - Tier 1; PA; QL; AL ACANYA) - Tier 1; PA; QL clindamycin phosphate-benzoyl peroxide external gel 1-5 % (generic for BENZACLIN) - Tier 1; PA; QL clindamycin-tretinoin (generic for VELTIN) - Tier 1; PA; QL DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL DIFFERIN EXTERNAL GEL (brand for adapalene treatment) - Tier 2; PA; QL EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents EPIDUO FORTE - Tier 2; PA; QL FABIOR (brand for tazarotene) - Tier 2; PA; QL FINACEA (brand for azelaic acid) - Tier 2; PA; QL MIRVASO - Tier 2; PA; QL neuac external gel (generic for NEUAC) - Tier 1; PA; QL ONEXTON - Tier 2; PA; QL RETIN-A (brand for tretinoin) - Tier 2; PA; QL; AL RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) - Tier 2; PA; QL; AL RETIN-A MICRO PUMP EXTERNAL GEL 0.04 % (brand for tretinoin microsphere pump) - Tier 2; PA; QL; AL RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; AL RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % - Tier 2; PA; QL; AL RETIN-A MICRO PUMP EXTERNAL GEL 0.1 % (brand for tretinoin microsphere) - Tier 2; PA; QL; AL RHOFADE - Tier 2; PA SORIATANE (brand for acitretin) - Tier 2; PA tazarotene external cream (generic for TAZORAC) - Tier 1; PA; QL TAZAROTENE EXTERNAL FOAM - Tier 2; PA; QL TAZORAC EXTERNAL CREAM 0.1 % (brand for tazarotene) - Tier 2; PA; QL TAZORAC EXTERNAL GEL 0.05 % - Tier 2; PA; QL tretinoin external gel 0.05 % (generic for ATRALIN) - Tier 1; PA; QL; AL tretinoin microsphere (generic for RETIN-A MICRO) - Tier 1; PA; QL; AL tretinoin microsphere pump (generic for RETIN-A MICRO) - Tier 1; PA; QL; AL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 77 Preferred Agents Non-Preferred Agents Dermatitis and Pruitus Agents ala-cort external cream 2.5 % - Tier 1 ala-cort external cream 1 % (generic for AVEENO ANTI-ITCH MAX ST) - anti-dandruff (generic for SELSUN BLUE) - Tier 1 Tier 1; PA clobetasol prop emollient base - Tier 1; QL alclometasone dipropionate - Tier 1; PA; QL clobetasol propionate e - Tier 1; QL amcinonide external cream - Tier 1; PA clobetasol propionate external cream (generic for TEMOVATE) - Tier amcinonide external lotion - Tier 1; PA 1; QL APEXICON E - Tier 2; PA; QL clobetasol propionate external gel - Tier 1; QL beser external lotion (generic for BESER) - Tier 1; PA; QL clobetasol propionate external ointment (generic for TEMOVATE) - betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier 1; Tier 1; QL PA; QL clobetasol propionate external solution - Tier 1; QL betamethasone dipropionate external cream - Tier 1; PA; QL dandruff shampoo external lotion (generic for SELSUN BLUE) - Tier 1 betamethasone dipropionate external lotion - Tier 1; PA EUCRISA - Tier 2; ST; AL betamethasone dipropionate external ointment - Tier 1; PA; QL fluticasone propionate external cream - Tier 1; QL betamethasone valerate external cream - Tier 1; PA; QL fluticasone propionate external ointment - Tier 1; QL betamethasone valerate external foam (generic for LUXIQ) - Tier 1; PA; halobetasol propionate external cream - Tier 1; QL QL halobetasol propionate external ointment - Tier 1; QL betamethasone valerate external lotion - Tier 1; PA hydrocortisone anti-itch external cream 0.5 % - Tier 1 betamethasone valerate external ointment - Tier 1; PA; QL hydrocortisone cream 1 % external (rx) 1 % (generic for AVEENO BRYHALI - Tier 2; PA; QL ANTI-ITCH MAX ST) - Tier 1 CAPEX - Tier 2; PA hydrocortisone cream 1 % external (rx) 1 % (generic for AVEENO clobetasol propionate emulsion (generic for TOVET) - Tier 1; PA; QL ANTI-ITCH MAX ST) - Tier 1; QL clobetasol propionate external foam (generic for OLUX) - Tier 1; PA; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1 clobetasol propionate external liquid (generic for CLOBEX SPRAY) - Tier hydrocortisone external lotion 2.5 % - Tier 1 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH clobetasol propionate external lotion (generic for CLOBEX) - Tier 1; PA; RELIEF MAX STR) - Tier 1 QL hydrocortisone external ointment 2.5 % - Tier 1 clobetasol propionate external shampoo (generic for CLODAN) - Tier 1; instacort 5 - Tier 1 PA; QL mometasone furoate external - Tier 1; QL CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL selenium sulfide external lotion - Tier 1 CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL triamcinolone acetonide external cream - Tier 1; QL clocortolone pivalate (generic for CLODERM) - Tier 1; PA; QL triamcinolone acetonide external lotion 0.025 % - Tier 1 clodan external shampoo (generic for CLODAN) - Tier 1; PA; QL triamcinolone acetonide external lotion 0.1 % - Tier 1; QL CLODERM (brand for clocortolone pivalate) - Tier 2; PA; QL triamcinolone acetonide external ointment 0.025 % - Tier 1 CORDRAN EXTERNAL CREAM 0.05 % (brand for flurandrenolide) - Tier triamcinolone acetonide external ointment 0.1 %, 0.5 % - Tier 1; QL 2; PA; QL triamcinolone acetonide ointment 0.05 % external (generic for CORDRAN EXTERNAL LOTION (brand for flurandrenolide) - Tier 2; PA; TRITOCIN) - Tier 1 QL triderm (generic for TRIDERM) - Tier 1; QL CORDRAN EXTERNAL OINTMENT (brand for flurandrenolide) - Tier 2; PA CUTIVATE (brand for fluticasone propionate) - Tier 2; PA; QL DERMA-SMOOTHE/FS BODY (brand for fluocinolone acetonide body) - Tier 2; PA; QL DERMA-SMOOTHE/FS SCALP (brand for fluocinolone acetonide scalp) - Tier 2; PA DESONATE (brand for desonide) - Tier 2; PA; QL desonide external (generic for DESOWEN) - Tier 1; PA; QL DESOWEN (brand for desonide) - Tier 2; PA; QL desoximetasone external cream (generic for TOPICORT) - Tier 1; PA; QL desoximetasone external gel (generic for TOPICORT) - Tier 1; PA; QL desoximetasone external liquid (generic for TOPICORT SPRAY) - Tier 1; PA desoximetasone external ointment (generic for TOPICORT) - Tier 1; PA; QL desrx (generic for DESRX) - Tier 1; PA; QL diflorasone diacetate external cream - Tier 1; PA; QL diflorasone diacetate external ointment - Tier 1; PA DIPROLENE (brand for betamethasone dipropionate aug) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents DIPROLENE AF (brand for betamethasone dipropionate aug) - Tier 2; PA; QL doxepin hcl external (generic for PRUDOXIN) - Tier 1; PA; QL ELIDEL (brand for pimecrolimus) - Tier 2; PA; QL fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; PA; QL fluocinolone acetonide external - Tier 1; PA; QL fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; PA fluocinonide emulsified base - Tier 1; PA; QL fluocinonide external - Tier 1; PA; QL flurandrenolide external cream (generic for NOLIX) - Tier 1; PA; QL flurandrenolide external lotion (generic for NOLIX) - Tier 1; PA; QL flurandrenolide external ointment (generic for CORDRAN) - Tier 1; PA fluticasone propionate external lotion (generic for BESER) - Tier 1; PA; QL halcinonide (generic for HALOG) - Tier 1; PA; QL HALOBETASOL PROPIONATE EXTERNAL FOAM - Tier 2; PA; QL; AL HALOG EXTERNAL CREAM (brand for halcinonide) - Tier 2; PA; QL HALOG EXTERNAL OINTMENT - Tier 2; PA; QL HALOG EXTERNAL SOLUTION - Tier 2; PA hydrocortisone butyr lipo base (generic for LOCOID LIPOCREAM) - Tier 1; PA; QL hydrocortisone butyrate - Tier 1; PA; QL hydrocortisone cream 1 % external (rx) 1 % (generic for AVEENO ANTI- ITCH MAX ST) - Tier 1; PA hydrocortisone external ointment 0.5 % - Tier 1; PA hydrocortisone valerate - Tier 1; PA; QL IMPEKLO - Tier 2; PA; AL KENALOG EXTERNAL (brand for triamcinolone acetonide) - Tier 2; PA; QL LEXETTE (brand for halobetasol propionate) - Tier 2; PA; QL; AL LOCOID (brand for hydrocortisone butyrate) - Tier 2; PA; QL LOCOID LIPOCREAM (brand for hydrocortisone butyr lipo base) - Tier 2; PA; QL LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents nolix (generic for NOLIX) - Tier 1; PA; QL OLUX (brand for clobetasol propionate) - Tier 2; PA; QL OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL PANDEL - Tier 2; PA pimecrolimus (generic for ELIDEL) - Tier 1; PA; QL prednicarbate - Tier 1; PA PROTOPIC (brand for tacrolimus) - Tier 2; PA; QL; AL PRUDOXIN (brand for doxepin hcl) - Tier 2; PA; QL PSORCON - Tier 2; PA; QL selenium sulfide external shampoo - Tier 1; PA SELRX (brand for selenium sulfide) - Tier 2; PA SYNALAR (brand for fluocinolone acetonide) - Tier 2; PA; QL tacrolimus external (generic for PROTOPIC) - Tier 1; PA; QL; AL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL TEXACORT - Tier 2; PA TOPICORT (brand for desoximetasone) - Tier 2; PA; QL TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA tovet external foam (generic for TOVET) - Tier 1; PA; QL triamcinolone acetonide external aerosol solution (generic for KENALOG) - Tier 1; PA; QL triamcinolone acetonide ointment 0.05 % external (generic for TRITOCIN) - Tier 1; PA triamcinolone in absorbase (generic for TRITOCIN) - Tier 1; PA TRIANEX (brand for triamcinolone in absorbase) - Tier 2; PA TRIDESILON (brand for desonide) - Tier 2; PA; QL tritocin (generic for TRITOCIN) - Tier 1; PA ULTRAVATE - Tier 2; PA VANOS (brand for fluocinonide) - Tier 2; PA; QL ZONALON (brand for doxepin hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 81 Preferred Agents Non-Preferred Agents Dermatological Agents, Other calcipotriene external cream (generic for DOVONEX) - Tier 1; QL ALDARA (brand for imiquimod) - Tier 2; PA; QL calcipotriene external ointment (generic for CALCITRENE) - Tier 1 AMELUZ - Tier 2; PA calcipotriene external solution - Tier 1; QL ANALPRAM HC (brand for hydrocort-pramoxine (perianal)) - Tier 2; PA CARAC (brand for fluorouracil) - Tier 2; QL ANALPRAM HC SINGLES (brand for hydrocort-pramoxine (perianal)) - clotrimazole-betamethasone external cream - Tier 1; QL Tier 2; PA FLUOROURACIL EXTERNAL CREAM 0.5 % - Tier 2; QL ANALPRAM-HC (brand for hydrocortisone ace-pramoxine) - Tier 2; PA fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1 CALCIPOTRIENE EXTERNAL FOAM - Tier 2; PA; QL fluorouracil external solution - Tier 1 calcipotriene-betameth diprop external ointment (generic for TACLONEX) imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL - Tier 1; PA; QL; AL nystatin-triamcinolone - Tier 1 calcipotriene-betameth diprop external suspension (generic for silver sulfadiazine external (generic for SSD) - Tier 1; QL TACLONEX) - Tier 1; PA; QL ssd (generic for SSD) - Tier 1; QL CALCITRENE (brand for calcipotriene) - Tier 2; PA calcitriol external (generic for VECTICAL) - Tier 1; PA; QL clotrimazole-betamethasone external lotion - Tier 1; PA CONDYLOX - Tier 2; PA diclofenac sodium external gel 3 % - Tier 1; PA; QL DOVONEX (brand for calcipotriene) - Tier 2; PA; QL DUOBRII - Tier 2; PA EFUDEX (brand for fluorouracil) - Tier 2; PA ENSTILAR - Tier 2; PA EPIFOAM - Tier 2; PA hydrocortisone ace-pramoxine (generic for PRAMOSONE) - Tier 1; PA hydrocort-pramoxine (perianal) (generic for ANALPRAM HC) - Tier 1; PA imiquimod external cream 3.75 % (generic for ZYCLARA) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents IMIQUIMOD PUMP - Tier 2; PA; QL LEVULAN KERASTICK - Tier 2; PA methoxsalen rapid - Tier 1; PA NEO-SYNALAR EXTERNAL CREAM - Tier 2; PA; QL podofilox external - Tier 1; PA pramosone external cream 1-1 % - Tier 1; PA PRAMOSONE EXTERNAL CREAM 1-2.5 % (brand for hydrocortisone ace-pramoxine) - Tier 2; PA PRAMOSONE EXTERNAL LOTION - Tier 2; PA PRAMOSONE EXTERNAL OINTMENT - Tier 2; PA PROCORT - Tier 2; PA PROCTOFOAM HC - Tier 2; PA; QL QBREXZA - Tier 2; PA; AL QUTENZA - Tier 2; PA QUTENZA (2 PATCH) - Tier 2; PA QUTENZA (4 PATCH) - Tier 2; PA SILVADENE (brand for silver sulfadiazine) - Tier 2; PA; QL SORILUX (brand for calcipotriene) - Tier 2; PA; QL TACLONEX EXTERNAL OINTMENT (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL; AL TACLONEX EXTERNAL SUSPENSION (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL VECTICAL (brand for calcitriol) - Tier 2; PA; QL VEREGEN - Tier 2; PA; QL XERESE - Tier 2; PA ZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL ZYCLARA PUMP (brand for imiquimod pump) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents Pediculicides/Scabicides lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1 crotan - Tier 1; PA lice treatment external liquid 1 % (generic for NIX CREME RINSE) - ivermectin external cream (generic for SOOLANTRA) - Tier 1; PA; QL Tier 1 ivermectin external lotion - Tier 1; PA lice treatment external lotion 1 % - Tier 1 lindane - Tier 1; PA; QL permethrin external - Tier 1 malathion (generic for OVIDE) - Tier 1; PA NATROBA (brand for spinosad) - Tier 2; PA OVIDE (brand for malathion) - Tier 2; PA SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL spinosad (generic for NATROBA) - Tier 1; PA Topical Anti-infectives clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1 ACZONE (brand for dapsone) - Tier 2; PA; QL clindacin-p (generic for CLINDACIN ETZ) - Tier 1 AMZEEQ - Tier 2; PA; QL clindamycin phosphate external solution - Tier 1 CENTANY (brand for mupirocin) - Tier 2; PA; QL clindamycin phosphate external swab (generic for CLINDACIN ETZ) - ciclodan (generic for CICLODAN) - Tier 1; PA Tier 1 ciclopirox external (generic for CICLODAN) - Tier 1; PA clotrimazole external cream (generic for DESENEX) - Tier 1 ciclopirox olamine external cream (generic for LOPROX) - Tier 1; PA; QL erythromycin external (generic for ERYGEL) - Tier 1 ciclopirox olamine external suspension (generic for LOPROX) - Tier 1; PA ketoconazole external cream - Tier 1 ciclopirox treatment - Tier 1; PA ketoconazole external shampoo - Tier 1 CLEOCIN-T (brand for clindamycin phosphate) - Tier 2; PA mupirocin external (generic for CENTANY) - Tier 1; QL CLINDAGEL (brand for clindamycin phosphate) - Tier 2; PA; QL nyamyc (generic for NYAMYC) - Tier 1 clindamycin phosphate external foam (generic for EVOCLIN) - Tier 1; PA nystatin external - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents nystop (generic for NYAMYC) - Tier 1 clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; PA CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL - Tier 2; PA; QL clindamycin phosphate gel 1 % external (generic for CLINDAGEL) - Tier 1; PA; QL clotrimazole external solution (generic for FUNGICURE INTENSIVE/NAILGUARD) - Tier 1; PA; QL dapsone external gel 5 % (generic for ACZONE) - Tier 1; PA; QL DAPSONE EXTERNAL GEL 7.5 % - Tier 2; PA; QL econazole nitrate external - Tier 1; PA; QL ERTACZO - Tier 2; PA ery - Tier 1; PA ERYGEL (brand for erythromycin) - Tier 2; PA EVOCLIN (brand for clindamycin phosphate) - Tier 2; PA EXTINA (brand for ketoconazole) - Tier 2; PA gentamicin sulfate external - Tier 1; PA JUBLIA - Tier 2; PA KERYDIN (brand for tavaborole) - Tier 2; PA ketoconazole external foam (generic for KETODAN) - Tier 1; PA ketodan external foam (generic for KETODAN) - Tier 1; PA KLARON (brand for sulfacetamide sodium (acne)) - Tier 2; PA LOPROX EXTERNAL CREAM (brand for ciclopirox olamine) - Tier 2; PA; QL LOPROX EXTERNAL SHAMPOO (brand for ciclopirox) - Tier 2; PA LOPROX EXTERNAL SUSPENSION (brand for ciclopirox olamine) - Tier 2; PA LULICONAZOLE - Tier 2; PA LUZU (brand for luliconazole) - Tier 2; PA mafenide acetate external (generic for SULFAMYLON) - Tier 1; PA MENTAX (brand for butenafine hcl) - Tier 2; PA mupirocin calcium - Tier 1; PA; QL naftifine hcl - Tier 1; PA NAFTIN (brand for naftifine hcl) - Tier 2; PA oxiconazole nitrate (generic for OXISTAT) - Tier 1; PA; QL OXISTAT EXTERNAL CREAM (brand for oxiconazole nitrate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents OXISTAT EXTERNAL LOTION - Tier 2; PA sulfacetamide sodium (acne) (generic for KLARON) - Tier 1; PA SULFAMYLON - Tier 2; PA tavaborole (generic for KERYDIN) - Tier 1; PA VUSION (brand for miconazole-zinc oxide-petrolat) - Tier 2; PA XEPI - Tier 2; PA Dermatological Agents - Drugs to Treat Skin Conditions dibucaine (perianal) (generic for NUPERCAINAL) - Tier 1 americerin (generic for AMERICERIN) - Tier 1; PA DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL ana-lex (generic for ANA-LEX) - Tier 1; PA DR SMITHS DIAPER - Tier 2; QL AVAR CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; PA DR SMITHS DIAPER QUICK RELIEF - Tier 2; QL AVAR LS CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; hydrocortisone acetate external (generic for GYNECORT 10) - Tier 1 PA NUPERCAINAL (brand for dibucaine (perianal)) - Tier 2 AVAR-E EMOLLIENT (brand for sulfacetamide sodium-sulfur) - Tier 2; PA AVAR-E GREEN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA AVAR-E LS (brand for sulfacetamide sodium-sulfur) - Tier 2; PA BENZOIN - Tier 2; PA benzoin compound (generic for STERI-STRIP COMPOUND BENZOIN) - Tier 1; PA bp 10-1 - Tier 1; PA bp cleansing wash - Tier 1; PA hydrocerin (generic for AMERICERIN) - Tier 1; PA lidocaine-hydrocort (perianal) (generic for LIDOCORT) - Tier 1; PA lidocaine-hydrocortisone ace kit 3-2.5 % rectal - Tier 1; PA; QL LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL - Tier 2; PA lidocaine-hydrocortisone ace rectal kit 2-2 % (generic for ANA-LEX) - Tier 1; PA lidocaine-hydrocortisone ace rectal kit 3-0.5 % - Tier 1; PA lidocaine-hydrocortisone ace rectal kit 3-1 % - Tier 1; PA; QL LIDOCORT (brand for lidocaine-hydrocort (perianal)) - Tier 2; PA minerin creme (generic for AMERICERIN) - Tier 1; PA NEUAC EXTERNAL KIT - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 86 Preferred Agents Non-Preferred Agents NUTRASEB - Tier 2; PA PLEXION CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; PA PROMISEB - Tier 2; PA PROSILK EXTERNAL - Tier 2; PA salicylic acid-cleanser - Tier 1; PA SORBIDON HYDRATE (brand for hydrocerin) - Tier 2; PA sss 10-5 - Tier 1; PA sulfacetamide sodium-sulfur external cream 10-2 % (generic for AVAR-E LS) - Tier 1; PA sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR-E EMOLLIENT) - Tier 1; PA sulfacetamide sodium-sulfur external emulsion (generic for AVAR CLEANSER) - Tier 1; PA sulfacetamide sodium-sulfur external liquid - Tier 1; PA sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1; PA sulfacetamide sodium-sulfur external pad 10-4 % (generic for SUMAXIN) - Tier 1; PA sulfacetamide sodium-sulfur external suspension - Tier 1; PA sulfacetamide sod-sulfur wash (generic for SUMADAN WASH) - Tier 1; PA sulfacetamide-sulfur in urea - Tier 1; PA SULFACLEANSE 8/4 (brand for sulfacetamide sodium-sulfur) - Tier 2; PA sulfamez wash - Tier 1; PA SUMADAN - Tier 2; PA SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA SUMADAN XLT - Tier 2; PA SUMAXIN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA SUMAXIN CP - Tier 2; PA; QL SYNALAR (CREAM) - Tier 2; PA; QL SYNALAR (OINTMENT) - Tier 2; PA; QL TOVET EXTERNAL KIT - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents Dermatological Agents - Skin Agents ABREVA (brand for hm docosanol) - Tier 2; QL ALEVAMAX - Tier 2; PA cerovel (generic for CEROVEL) - Tier 1; QL ALOE VESTA DAILY MOISTURIZER - Tier 2; PA corn & callus remover (generic for COMPOUND W) - Tier 1 ATOPICLAIR (brand for alevamax) - Tier 2; PA docosanol external (generic for ABREVA) - Tier 1; QL avo cream (generic for AVO CREAM) - Tier 1; PA GENADUR EXTERNAL (brand for liquid bandage) - Tier 2 BENSAL HP - Tier 2; PA gormel 10 (generic for NUTRAPLUS) - Tier 1; QL BESER EXTERNAL KIT - Tier 2; PA; QL hemorrhoidal rectal ointment 0.25-3-14-71.9 % - Tier 1 BIAFINE (brand for foraxa) - Tier 2; PA hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 CLINDACIN ETZ EXTERNAL KIT - Tier 2; PA hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 CLINDACIN PAC - Tier 2; PA INTENSIVE HEALING) - Tier 1 CLODAN EXTERNAL KIT - Tier 2; PA hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE COPASIL EXTERNAL (brand for cvs scar) - Tier 2; PA HEALING) - Tier 1 DERMELLE (brand for cvs scar) - Tier 2; PA hydrocortisone-aloe external cream 0.5 % - Tier 1 DEXERYL (brand for alevamax) - Tier 2; PA hydrocortisone-aloe max st external cream 1 % (generic for ELETONE (brand for alevamax) - Tier 2; PA CORTIZONE-10 INTENSIVE HEALING) - Tier 1 FORAXA - Tier 2; PA NUTRAPLUS (brand for urea 10 hydrating) - Tier 2; QL HALUCORT - Tier 2; PA urea external cream 40 % - Tier 1; QL HPR PLUS EXTERNAL CREAM (brand for alevamax) - Tier 2; PA urea external lotion (generic for CEROVEL) - Tier 1; QL hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 urea hydrating - Tier 1 INTENSIVE HEALING) - Tier 1; PA ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE UREMEZ-40 - Tier 2; QL HEALING) - Tier 1; PA wart remover external liquid 17 % (generic for COMPOUND W) - Tier hydrocortisone-aloe cream 1 % external (generic for CORTIZONE-10 1 INTENSIVE HEALING) - Tier 1; PA HYLATOPIC PLUS (brand for alevamax) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 88 Preferred Agents Non-Preferred Agents wart remover maximum strength external liquid (generic for KELARX (brand for cvs scar) - Tier 2; PA COMPOUND W) - Tier 1 KERALYT EXTERNAL GEL 6 % (brand for salicylic acid) - Tier 2; PA; QL KERALYT EXTERNAL SHAMPOO (brand for salicylic acid) - Tier 2; PA; QL lavare wound wash (generic for MICROCYN) - Tier 1; PA MIMYX (brand for alevamax) - Tier 2; PA moisturel - Tier 1; PA NEOSALUS EXTERNAL CREAM (brand for alevamax) - Tier 2; PA NEOSALUS EXTERNAL LOTION (brand for bromi-lotion) - Tier 2; PA NEO-SYNALAR EXTERNAL KIT - Tier 2; PA NUVAIL - Tier 2; PA OASIS ULTRA TRI-LAYER MATRIX EXTERNAL SHEET 7X10CM - Tier 2; PA PRUCLAIR (brand for alevamax) - Tier 2; PA PRUMYX (brand for alevamax) - Tier 2; PA RECEDO (brand for cvs scar) - Tier 2; PA REMIGEN - Tier 2; PA RESORCINOL-SULFUR - Tier 2; PA ROSADAN EXTERNAL KIT - Tier 2; PA SALEX (brand for salicylic acid) - Tier 2; PA; QL salicylic acid external foam (generic for SALVAX) - Tier 1; PA salicylic acid external gel (generic for KERALYT) - Tier 1; PA; QL salicylic acid external shampoo (generic for KERALYT) - Tier 1; PA; QL salicylic acid wart remover (generic for VIRASAL) - Tier 1; PA; QL SALVAX (brand for salicylic acid) - Tier 2; PA SCARCIN EXTERNAL GEL - Tier 2; PA SCARCIN EXTERNAL LIQUID - Tier 2; PA SCARSILK EXTERNAL - Tier 2; PA SONAFINE (brand for foraxa) - Tier 2; PA STRATA CTX - Tier 2; PA STRATA MARK - Tier 2; PA STRATA TRIZ (brand for cvs scar) - Tier 2; PA STRATA XRT - Tier 2; PA SYNALAR TS - Tier 2; PA; QL TETRIX (brand for alevamax) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 89 Preferred Agents Non-Preferred Agents urea external cream 39 % (generic for UREDEB) - Tier 1; PA urea external cream 41 % (generic for UTOPIC) - Tier 1; PA uredeb (generic for UREDEB) - Tier 1; PA UTOPIC (brand for urea) - Tier 2; PA VIRASAL (brand for salicylic acid wart remover) - Tier 2; PA; QL XERAC AC - Tier 2; PA XERALUX (brand for alevamax) - Tier 2; PA xurea (generic for UREDEB) - Tier 1; PA ZILXI - Tier 2; PA; QL Diabetic/Endocrine Blood: Glucose Monitoring ACCU-CHEK MULTICLIX LANCETS (brand for reality trigger lancets) ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite - Tier 2; QL device/lancets) - Tier 2; PA CHEMSTRIP K (brand for ketone test) - Tier 2; QL ACCU-CHEK MULTICLIX LANCETS (brand for reality trigger lancets) - KETONE TEST - Tier 2; QL Tier 2; PA; QL KETOSTIX (brand for ketone test) - Tier 2; QL ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite LANCETS (brand for reality trigger lancets) - Tier 2; QL device/lancets) - Tier 2; PA SAFE-T-LANCE (brand for reality trigger lancets) - Tier 2; QL COMFORT TOUCH LANCETS 31G (brand for reality trigger lancets) - TRUEPLUS LANCETS 30G (brand for reality trigger lancets) - Tier 2; Tier 2; PA QL COMFORT TOUCH PLUS LANCETS 30G (brand for reality trigger TRUEPLUS SAFETY LANCETS 28G (brand for reality trigger lancets) lancets) - Tier 2; PA - Tier 2; QL GENTLE-LET PLATFORMS (brand for lancet transporter case) - Tier 2; PA LANCETS - Tier 2; PA ONETOUCH SURESOFT LANCING DEVICE (brand for lancet transporter case) - Tier 2; PA PENLET II BLOOD SAMPLER (brand for select-lite device/lancets) - Tier 2; PA PENLET II REPLACEMENT CAP (brand for lancet transporter case) - Tier 2; PA PSS SELECT PLATFORMS (brand for lancet transporter case) - Tier 2; PA SAFE-T-LANCE (brand for reality trigger lancets) - Tier 2; PA TRUEPLUS LANCETS 30G (brand for reality trigger lancets) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 90 Preferred Agents Non-Preferred Agents TRUEPLUS SAFETY LANCETS 28G (brand for reality trigger lancets) - Tier 2; PA

Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement CARBAGLU - Tier 2; SP; QL CLINPRO 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA cavarest (generic for CAVAREST) - Tier 1 ENDARI - Tier 2; PA DENTA 5000 PLUS (brand for sodium fluoride) - Tier 2; QL FLUORIDEX (brand for sodium fluoride 5000 ppm) - Tier 2; PA DENTAGEL (brand for sf) - Tier 2 FLUORIDEX ENHANCED WHITENING (brand for sodium fluoride 5000 easygel - Tier 1 ppm) - Tier 2; PA klor-con (generic for KLOR-CON) - Tier 1; QL FLUORIDEX SENSITIVITY RELIEF (brand for sodium fluoride 5000 klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL sensitive) - Tier 2; PA klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL klor-con m15 (generic for KLOR-CON M15) - Tier 1; PA; QL klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL K-TAB (brand for potassium chloride er) - Tier 2; PA; QL nafrinse (generic for NAFRINSE) - Tier 1; QL potassium chloride crys er oral tablet extended release 15 meq (generic potassium chloride crys er oral tablet extended release 10 meq for KLOR-CON M15) - Tier 1; PA; QL (generic for KLOR-CON M10) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 91 Preferred Agents Non-Preferred Agents potassium chloride crys er oral tablet extended release 20 meq PREVIDENT 5000 BOOSTER PLUS (brand for sodium fluoride 5000 (generic for KLOR-CON M20) - Tier 1; QL ppm) - Tier 2; PA potassium chloride er (generic for KLOR-CON 10) - Tier 1; QL PREVIDENT 5000 ENAMEL PROTECT (brand for sodium fluoride 5000 potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL sensitive) - Tier 2; PA potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml PREVIDENT 5000 ORTHO DEFENSE (brand for sodium fluoride 5000 (20%) - Tier 1; QL ppm) - Tier 2; PA potassium citrate er (generic for UROCIT-K 10) - Tier 1 PREVIDENT 5000 SENSITIVE (brand for sodium fluoride 5000 sensitive) PREVIDENT (brand for sf) - Tier 2 - Tier 2; PA PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2 sodium fluoride 5000 enamel (generic for FLUORIDEX SENSITIVITY PREVIDENT 5000 PLUS (brand for sodium fluoride) - Tier 2; QL RELIEF) - Tier 1; PA sf (generic for CAVAREST) - Tier 1 sodium fluoride 5000 ppm dental paste (generic for CLINPRO 5000) - Tier sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL 1; PA sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; sodium fluoride 5000 sensitive (generic for FLUORIDEX SENSITIVITY QL RELIEF) - Tier 1; PA sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 UROCIT-K 10 (brand for potassium citrate er) - Tier 2; PA PLUS) - Tier 1; QL UROCIT-K 15 (brand for potassium citrate er) - Tier 2; PA sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; UROCIT-K 5 (brand for potassium citrate er) - Tier 2; PA QL sodium fluoride dental gel (generic for CAVAREST) - Tier 1 sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1; QL sodium fluoride oral tablet chewable - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 92 Preferred Agents Non-Preferred Agents Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs abatron af (generic for ABATRON AF) - Tier 1 calcium 500 +d3 (generic for OS-CAL EXTRA D3) - Tier 1; PA calcium/minerals/vitamin d - Tier 1 calcium 500/d oral tablet chewable - Tier 1; PA fe c tab (generic for ICAR-C) - Tier 1 CHROMAGEN (brand for iron complex) - Tier 2; PA ferrex 150 (generic for FERREX 150) - Tier 1 CORVITE 150 ORAL TABLET (brand for corvite fe) - Tier 2; PA ferric x-150 (generic for FERREX 150) - Tier 1 corvite fe (generic for CORVITE 150) - Tier 1; PA HEMATRON-AF (brand for tl-hem 150) - Tier 2 FERIVAFA - Tier 2; PA HEMAX (brand for tl-hem 150) - Tier 2 ferraplus 90 - Tier 1; PA ICAR-C (brand for iron-vitamin c) - Tier 2 FOLIVANE-F - Tier 2; PA iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1 GALZIN ORAL CAPSULE 25 MG - Tier 2; PA iron 100/c (generic for ICAR-C) - Tier 1 GALZIN ORAL CAPSULE 50 MG - Tier 2; PA; QL K-PHOS - Tier 2; QL INTEGRA F - Tier 2; PA mag-g - Tier 1 IROSPAN 24/6 - Tier 2; PA MAGNEBIND 300 - Tier 2 kelp oral tablet 0.15 mg - Tier 1; PA magnesium oxide oral tablet 400 (241.3 mg) mg (generic for K-PHOS NO 2 - Tier 2; PA MAGNESIUM-OXIDE) - Tier 1 NIFEREX (brand for corvite fe) - Tier 2; PA magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 NUFERA (brand for corvite fe) - Tier 2; PA myferon 150 (generic for FERREX 150) - Tier 1 OS-CAL EXTRA D3 (brand for gnp calcium 500 +d3) - Tier 2; PA myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 oyster shell calcium + d oral tablet 500-400 mg-unit (generic for NU-IRON (brand for polysaccharide iron complex) - Tier 2 OYSTERCAL-D) - Tier 1; PA NU-MAG - Tier 2 oyster shell calcium + d3 (generic for OYSTERCAL-D) - Tier 1; PA poly-iron 150 (generic for FERREX 150) - Tier 1 oyster shell calcium/vit d3 (generic for OYSTERCAL-D) - Tier 1; PA poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 WILZIN - Tier 2; PA polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide-iron complex (generic for FERREX 150) - Tier 1 SLOW-MAG - Tier 2 SLOWMAG MG MUSCLE/HEART - Tier 2 tl-hem 150 (generic for ABATRON AF) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 93 Preferred Agents Non-Preferred Agents Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2 clovique (generic for CLOVIQUE) - Tier 1; PA; SP; QL deferasirox (generic for EXJADE) - Tier 1; PA; SP; QL deferiprone (generic for FERRIPROX) - Tier 1; PA; SP; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; EXJADE (brand for deferasirox) - Tier 2; PA; SP; QL SP; QL FERRIPROX (brand for deferiprone) - Tier 2; PA; SP; QL FERRIPROX TWICE-A-DAY - Tier 2; PA; QL JADENU (brand for deferasirox) - Tier 2; PA; SP; QL JADENU SPRINKLE (brand for deferasirox) - Tier 2; PA; SP; QL JYNARQUE - Tier 2; PA; SP; QL SAMSCA (brand for tolvaptan) - Tier 2; PA; SP; QL SYPRINE (brand for trientine hcl) - Tier 2; PA; SP; QL TOLVAPTAN ORAL TABLET 15 MG - Tier 2; PA; SP; QL tolvaptan oral tablet 30 mg (generic for JYNARQUE) - Tier 1; PA; SP; QL trientine hcl (generic for CLOVIQUE) - Tier 1; PA; SP; QL

Phosphate Binders calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; QL AURYXIA - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; FOSRENOL ORAL PACKET - Tier 2; PA QL FOSRENOL ORAL TABLET CHEWABLE (brand for lanthanum sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; QL carbonate) - Tier 2; PA; QL lanthanum carbonate (generic for FOSRENOL) - Tier 1; PA; QL PHOSLYRA - Tier 2; PA; QL RENAGEL (brand for sevelamer hcl) - Tier 2; PA; QL RENVELA (brand for sevelamer carbonate) - Tier 2; PA; QL sevelamer carbonate oral packet (generic for RENVELA) - Tier 1; PA; QL sevelamer hcl - Tier 1; PA; QL VELPHORO - Tier 2; PA; QL Potassium Binders LOKELMA - Tier 2; PA; QL sodium polystyrene sulfonate - Tier 1; PA sps - Tier 1 VELTASSA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 94 Preferred Agents Non-Preferred Agents Vitamins ACTIVITE - Tier 2; QL b complex plus c (generic for ALLBEE/C) - Tier 1; PA childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1 b complex-c oral capsule - Tier 1; PA childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier balanced b100 - Tier 1; PA 1 beta carotene oral capsule 25000 unit - Tier 1; PA COMPLETENATE - Tier 2; QL bp vit 3 (generic for TALIVA) - Tier 1; PA daily multiple vitamins (generic for TAB-A-VITE) - Tier 1 b-plex - Tier 1; PA daily vitamins (generic for TAB-A-VITE) - Tier 1 CITRANATAL B-CALM - Tier 2; PA; QL daily vite (generic for TAB-A-VITE) - Tier 1 CITRANATAL BLOOM - Tier 2; PA daily vites (generic for TAB-A-VITE) - Tier 1 C-NATE DHA - Tier 2; PA; QL daily-vite (generic for TAB-A-VITE) - Tier 1 cod liver oil oral capsule , 1250-135 unit, 4000-200 unit - Tier 1; PA DIALYVITE (brand for activite) - Tier 2; QL COD LIVER OIL ORAL OIL - Tier 2; PA COMPLETE NATAL DHA - Tier 2; PA; QL DIALYVITE 800 ORAL TABLET (brand for nephro vitamins) - Tier 2; CONCEPT DHA (brand for virt-c dha) - Tier 2; PA; QL QL CONCEPT OB - Tier 2; PA; QL dino-life w/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1 DIALYVITE/ZINC - Tier 2; PA ELDERTONIC (brand for senior tonic) - Tier 2 ELFOLATE PLUS (brand for l-methylfolate-b6-b12) - Tier 2; PA essential one daily (generic for TAB-A-VITE) - Tier 1 ELITE-OB - Tier 2; PA; QL essentials (generic for TAB-A-VITE) - Tier 1 ENBRACE HR - Tier 2; PA; QL foltabs 800 - Tier 1 ENFAMIL EXPECTA - Tier 2; PA; QL FOLTRATE (brand for vitamin b12-folic acid) - Tier 2 fabb (generic for VIRT-GARD) - Tier 1; PA full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 1 MG - Tier 2; PA healthy hair/skin/nails (generic for TAB-A-VITE) - Tier 1 FLORIVA PLUS (brand for polyvitamin/fluoride) - Tier 2; PA LORID - Tier 2; QL FOLGARD RX (brand for westab mini) - Tier 2; PA M-NATAL PLUS - Tier 2; QL FOLIVANE-OB - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 95 Preferred Agents Non-Preferred Agents multi vitamin (generic for TAB-A-VITE) - Tier 1 foltanx (generic for FOLTANX) - Tier 1; PA multi vitamin w/d-3 (generic for TAB-A-VITE) - Tier 1 HYLAVITE - Tier 2; PA multiple vitamin-folic acid (generic for TAB-A-VITE) - Tier 1 l-methylfolate-b6-b12 (generic for FOLTANX) - Tier 1; PA multiple vitamins essential (generic for TAB-A-VITE) - Tier 1 MEPHYTON (brand for phytonadione) - Tier 2; PA; QL multi-vitamin (generic for TAB-A-VITE) - Tier 1 MYNATAL PLUS - Tier 2; PA; QL multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1 MYNATAL-Z - Tier 2; PA; QL multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg NEONATAL + DHA - Tier 2; PA; QL (generic for QUFLORA PEDIATRIC) - Tier 1 NEONATAL COMPLETE ORAL TABLET 27-1 MG - Tier 2; PA multi-vitamin/fluoride/iron - Tier 1 NEONATAL PLUS (brand for prenatal plus/iron) - Tier 2; PA mynephrocaps (generic for MYNEPHRON) - Tier 1 NEONATAL VITAMIN (brand for multi prenatal) - Tier 2; PA; QL MYNEPHRON (brand for triphrocaps) - Tier 2 NEPHPLEX RX - Tier 2; PA NEOMULTIVITE (brand for gnp essential one daily) - Tier 2 NESTABS - Tier 2; PA; QL nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL NESTABS DHA - Tier 2; PA; QL nephronex oral tablet (generic for NEPHRONEX) - Tier 1; QL NESTABS ONE - Tier 2; PA; QL NEPHRO-VITE (brand for nephro vitamins) - Tier 2; QL niacin flush free oral capsule 400-100 mg - Tier 1; PA NEPHRO-VITE RX (brand for activite) - Tier 2; QL NICOMIDE (brand for nicotinamide) - Tier 2; PA once daily (generic for TAB-A-VITE) - Tier 1 nicotinamide oral (generic for NICOMIDE) - Tier 1; PA one daily (generic for TAB-A-VITE) - Tier 1 NIVA-PLUS (brand for prenatal plus/iron) - Tier 2; PA; QL one-daily multi vitamins (generic for TAB-A-VITE) - Tier 1 no flush niacin oral capsule - Tier 1; PA one-daily multi-vitamin oral tablet (generic for TAB-A-VITE) - Tier 1 OB COMPLETE - Tier 2; PA; QL phytonadione oral (generic for MEPHYTON) - Tier 1; QL OB COMPLETE ONE - Tier 2; PA; QL prenatal tablet 27-1 mg oral (generic for NEONATAL PLUS) - Tier 1; OB COMPLETE PETITE - Tier 2; PA; QL QL OB COMPLETE PREMIER - Tier 2; PA; QL OB COMPLETE/DHA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 96 Preferred Agents Non-Preferred Agents prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; OBSTETRIX DHA - Tier 2; PA; QL QL one daily womens health oral tablet (generic for HM VITA-MINI MULTI preplus (generic for NEONATAL PLUS) - Tier 1; QL COMPLETE) - Tier 1; PA RENAL (brand for triphrocaps) - Tier 2 ONE VITE WOMENS - Tier 2; PA; QL RENAL MULTIVITAMIN FORMULA (brand for nephro vitamins) - Tier ONE VITE WOMENS PLUS - Tier 2; PA 2; QL pnv tabs 29-1 (generic for PRENATABS RX) - Tier 1; PA; QL renal-vite (generic for DIALYVITE 800) - Tier 1; QL pnv-dha (generic for ZATEAN-PN DHA) - Tier 1; PA; QL rena-vite (generic for DIALYVITE 800) - Tier 1; QL pnv-omega (generic for ZATEAN-PN PLUS) - Tier 1; PA; QL senior tonic (generic for ELDERTONIC) - Tier 1 POLY-VI-FLOR - Tier 2; PA stress formula (generic for TAB-A-VITE) - Tier 1 POLY-VI-FLOR/IRON - Tier 2; PA tab-a-vite (generic for TAB-A-VITE) - Tier 1 PREMESISRX - Tier 2; PA; QL tab-a-vite/beta carotene (generic for TAB-A-VITE) - Tier 1 PRENATABS RX (brand for prenatal plus iron) - Tier 2; PA; QL thera (generic for TAB-A-VITE) - Tier 1 prenatal 19 oral tablet - Tier 1; PA; QL thera-tabs (generic for TAB-A-VITE) - Tier 1 prenatal 19 oral tablet chewable - Tier 1; PA triphrocaps (generic for MYNEPHRON) - Tier 1 prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier 1; virt-caps (generic for MYNEPHRON) - Tier 1 PA; QL VITASURE - Tier 2; QL prenatal plus iron (generic for PRENATABS RX) - Tier 1; PA; QL vp-vite rx (generic for NEPHRONEX) - Tier 1; QL prenatal tablet 27-1 mg oral (generic for NEONATAL PLUS) - Tier 1; PA WESTAB PLUS - Tier 2; QL PRENATE - Tier 2; PA; QL WEST-VITE W/FOLIC ACID - Tier 2; QL PRENATE AM - Tier 2; PA; QL XVITE - Tier 2; QL PRENATE DHA - Tier 2; PA; QL zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1 PRENATE ELITE - Tier 2; PA; QL PRENATE ESSENTIAL - Tier 2; PA; QL PRENATE MINI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 97 Preferred Agents Non-Preferred Agents PRENATE PIXIE - Tier 2; PA; QL PRENATE RESTORE - Tier 2; PA; QL PRENATVITE RX - Tier 2; PA QUFLORA FE - Tier 2; PA QUFLORA FE PEDIATRIC - Tier 2; PA QUFLORA GUMMIES - Tier 2; PA QUFLORA PEDIATRIC ORAL SOLUTION (brand for polyvitamin/fluoride) - Tier 2; PA QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG (brand for multivitamin/fluoride) - Tier 2; PA RELNATE DHA - Tier 2; PA; QL SELECT-OB - Tier 2; PA; QL SELECT-OB+DHA - Tier 2; PA; QL SE-NATAL 19 - Tier 2; PA; QL STUART ONE - Tier 2; PA; QL super b complex/c (generic for ALLBEE/C) - Tier 1; PA super b complex/vitamin c (generic for ALLBEE/C) - Tier 1; PA super b/c - Tier 1; PA SUPERVITE - Tier 2; PA TALIVA (brand for bp vit 3) - Tier 2; PA TARON-C DHA (brand for virt-c dha) - Tier 2; PA; QL THRIVITE RX - Tier 2; PA; QL TRINATAL RX 1 - Tier 2; PA; QL TRISTART DHA - Tier 2; PA; QL TRISTART ONE - Tier 2; PA TRI-VI-FLOR (brand for tri-vi-floro) - Tier 2; PA TRI-VI-FLORO - Tier 2; PA VINATE ONE (brand for trinatal rx 1) - Tier 2; PA; QL virt-c dha (generic for CONCEPT DHA) - Tier 1; PA; QL virt-gard (generic for VIRT-GARD) - Tier 1; PA virt-nate dha (generic for VIVA DHA) - Tier 1; PA; QL virt-pn dha (generic for ZATEAN-PN DHA) - Tier 1; PA; QL virt-pn plus (generic for ZATEAN-PN PLUS) - Tier 1; PA; QL VITAFOL FE+ - Tier 2; PA; QL VITAFOL GUMMIES - Tier 2; PA; QL VITAFOL STRIPS - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents VITAFOL ULTRA - Tier 2; PA; QL VITAFOL-NANO - Tier 2; PA; QL VITAFOL-OB (brand for mynatal plus) - Tier 2; PA; QL VITAFOL-OB+DHA - Tier 2; PA; QL VITAFOL-ONE - Tier 2; PA; QL VITAL-D RX - Tier 2; PA VITAMEZ (brand for bp vit 3) - Tier 2; PA vitamin b complex-c - Tier 1; PA VITATHELY WITH GINGER (brand for prenatal plus/iron) - Tier 2; PA VIVA DHA (brand for relnate dha) - Tier 2; PA; QL vp-pnv-dha - Tier 1; PA; QL westab max (generic for FOLBIC) - Tier 1; PA westab mini (generic for VIRT-GARD) - Tier 1; PA ZATEAN-PN DHA (brand for virt-pn dha) - Tier 2; PA; QL

Enzyme Inhibitors - Chemotherapy Agents Antineoplastics - Drugs to Treat Cancer TRUSELTIQ (100MG DAILY DOSE) - Tier 2; PA; SP TRUSELTIQ (125MG DAILY DOSE) - Tier 2; PA; SP TRUSELTIQ (50MG DAILY DOSE) - Tier 2; PA; SP TRUSELTIQ (75MG DAILY DOSE) - Tier 2; PA; SP Enzyme Replacements/Modifiers - Drugs to Treat Enzyme Deficiency Enzyme Replacements/Modifiers - Enzyme Replacements/Modifying Drugs ENZADYNE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents Estrogens - Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones MYFEMBREE - Tier 2; PA; QL; AL NEXTSTELLIS - Tier 2; PA Gastrointestinal Agents Anti-Constipation Agents AMITIZA (brand for lubiprostone) - Tier 2; QL; AL KRISTALOSE (brand for lactulose) - Tier 2; PA constulose - Tier 1; QL lactulose oral packet (generic for KRISTALOSE) - Tier 1; PA enulose - Tier 1 LUBIPROSTONE - Tier 2; PA; QL; AL generlac - Tier 1 MOTEGRITY - Tier 2; PA; QL lactulose encephalopathy - Tier 1 RELISTOR ORAL - Tier 2; PA; QL; AL lactulose oral solution - Tier 1; QL RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML - Tier 2; PA; QL LINZESS - Tier 2; QL; AL RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML - Tier 2; PA MOVANTIK - Tier 2; QL SYMPROIC - Tier 2; PA; QL; AL TRULANCE - Tier 2; PA; QL; AL ZELNORM - Tier 2; PA; QL; GE; AL Anti-Diarrheal Agents diphenoxylate-atropine oral liquid - Tier 1 alosetron hcl (generic for LOTRONEX) - Tier 1; PA; QL diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1; QL anti-diarrheal oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1; loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL PA IMODIUM A-D ORAL LIQUID (brand for goodsense anti-diarrheal) - Tier 2; PA LOMOTIL (brand for diphenoxylate-atropine) - Tier 2; PA; QL loperamide hcl oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1; PA loperamide hcl oral suspension (generic for IMODIUM A-D) - Tier 1; PA LOTRONEX (brand for alosetron hcl) - Tier 2; PA; QL MOTOFEN - Tier 2; PA MYTESI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents opium - Tier 1; PA; QL VIBERZI - Tier 2; PA; QL; AL XERMELO - Tier 2; PA; SP; QL Antispasmodics, Gastrointestinal dicyclomine hcl oral capsule - Tier 1; QL chlordiazepoxide-clidinium (generic for LIBRAX) - Tier 1; PA dicyclomine hcl oral solution - Tier 1 CUVPOSA - Tier 2; PA dicyclomine hcl oral tablet - Tier 1; QL LIBRAX (brand for chlordiazepoxide-clidinium) - Tier 2; PA glycopyrrolate oral - Tier 1 methscopolamine bromide oral - Tier 1; PA Gastrointestinal Agents, Other GATTEX - Tier 2; PA; SP; QL amoxicill-clarithro-lansopraz - Tier 1; PA; QL gavilyte-c - Tier 1 CHENODAL - Tier 2; PA; SP; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR CLENPIQ - Tier 2; PA; QL PACK) - Tier 1; QL gavilyte-g (generic for GAVILYTE-G) - Tier 1; PA; QL HELIDAC THERAPY - Tier 2 GOLYTELY (brand for peg-3350/electrolytes) - Tier 2; PA; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL PACK) - Tier 1; QL MYALEPT - Tier 2; PA; SP; QL PYLERA - Tier 2; QL NULYTELY LEMON-LIME (brand for peg 3350-kcl-na bicarb-nacl) - Tier ursodiol oral capsule 300 mg - Tier 1 2; PA; QL ursodiol oral tablet (generic for URSO 250) - Tier 1 OCALIVA - Tier 2; PA; SP; QL OMECLAMOX-PAK - Tier 2; PA; QL OSMOPREP - Tier 2; PA peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1; PA; QL peg-3350/electrolytes/ascorbat (generic for MOVIPREP) - Tier 1; PA; QL peg-kcl-nacl-nasulf-na asc-c (generic for MOVIPREP) - Tier 1; PA; QL PLENVU - Tier 2; PA RELTONE (brand for ursodiol) - Tier 2; PA SUPREP BOWEL PREP KIT - Tier 2; PA TALICIA - Tier 2; PA URSO 250 (brand for ursodiol) - Tier 2; PA URSO FORTE (brand for ursodiol) - Tier 2; PA URSODIOL ORAL CAPSULE 200 MG, 400 MG - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents Histamine2 (H2) Receptor Antagonists acid controller (generic for PEPCID AC) - Tier 1 acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; PA; acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1 QL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL cimetidine hcl - Tier 1; PA; QL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1 cimetidine oral (generic for TAGAMET HB) - Tier 1; PA; QL famotidine oral tablet 20 mg, 40 mg (generic for PEPCID) - Tier 1; QL heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; famotidine orig st (generic for PEPCID AC) - Tier 1 PA; QL heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier nizatidine oral capsule - Tier 1; PA; QL 1 PEPCID (brand for px acid reducer max st) - Tier 2; PA; QL heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1 nizatidine oral solution - Tier 1; QL Irritable Bowel Syndrome Agents BYLVAY - Tier 2; PA; SP BYLVAY (PELLETS) - Tier 2; PA; SP Protectants CARAFATE ORAL SUSPENSION (brand for sucralfate) - Tier 2; QL CARAFATE ORAL TABLET (brand for sucralfate) - Tier 2; PA; QL misoprostol oral (generic for CYTOTEC) - Tier 1; QL CYTOTEC (brand for misoprostol) - Tier 2; PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; PA; QL Proton Pump Inhibitors acid reducer oral capsule delayed release 20.6 (20 base) mg - Tier 1; ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL QL ACIPHEX SPRINKLE - Tier 2; PA acid reducer oral tablet delayed release 20 mg (generic for PRILOSEC DEXILANT - Tier 2; PA; QL OTC) - Tier 1 esomeprazole magnesium (generic for NEXIUM) - Tier 1; PA; QL omeprazole magnesium oral capsule delayed release - Tier 1; QL lansoprazole oral (generic for PREVACID 24HR) - Tier 1; PA; QL omeprazole magnesium oral tablet delayed release (generic for NEXIUM (brand for gnp esomeprazole magnesium) - Tier 2; PA; QL PRILOSEC OTC) - Tier 1 omeprazole-sod bicarbonate (generic for ZEGERID) - Tier 1; PA; QL omeprazole oral capsule delayed release - Tier 1; QL omeprazole-sodium bicarb oral capsule 20-1100 mg (generic for pantoprazole sodium oral (generic for PROTONIX) - Tier 1; QL ZEGERID) - Tier 1; PA; QL PRILOSEC OTC (brand for acid reducer) - Tier 2 omeprazole-sodium bicarbonate (generic for ZEGERID) - Tier 1; PA; QL PREVACID (brand for lansoprazole) - Tier 2; PA; QL PREVACID 24HR (brand for eql lansoprazole) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents PREVACID SOLUTAB (brand for lansoprazole) - Tier 2; PA; QL PRILOSEC - Tier 2; PA; QL PROTONIX ORAL (brand for pantoprazole sodium) - Tier 2; PA; QL RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE - Tier 2; PA rabeprazole sodium oral tablet delayed release (generic for ACIPHEX) - Tier 1; PA; QL ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Bowel Treatment Drugs belladonna alkaloids-opium - Tier 1; PA; QL DONNATAL (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA pb-hyoscy-atropine-scopolamine (generic for DONNATAL) - Tier 1; PA phenobarbital-belladonna alk (generic for DONNATAL) - Tier 1; PA PHENOHYTRO (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs acid gone (generic for ACID GONE) - Tier 1 alvimopan (generic for ENTEREG) - Tier 1; PA adult 50+ probiotic (generic for DERMACINRX PROBITRAN) - Tier 1 DERMACINRX PROBITRAN (brand for cvs probiotic) - Tier 2; PA adult probiotic (generic for DERMACINRX PROBITRAN) - Tier 1 ENTEREG (brand for alvimopan) - Tier 2; PA advanced antacid max st (generic for ALMACONE DOUBLE PRODIGEN - Tier 2; PA STRENGTH) - Tier 1; QL PROVAD - Tier 2; PA almacone double strength (generic for ALMACONE DOUBLE ZELAC - Tier 2; PA STRENGTH) - Tier 1; QL alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 103 Preferred Agents Non-Preferred Agents antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid & gas relief (generic for MINTOX) - Tier 1; QL antacid advanced (generic for MINTOX) - Tier 1; QL antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas (generic for MINTOX) - Tier 1; QL antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas max strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 antacid extra strength oral suspension (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 antacid extra strength oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid fast relief (generic for MINTOX) - Tier 1; QL antacid i (generic for MINTOX) - Tier 1; QL antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid liquid (generic for MINTOX) - Tier 1; QL antacid m (generic for MINTOX) - Tier 1; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid maximum strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid regular strength oral suspension (generic for MINTOX) - Tier 1; QL antacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium carbonate antacid oral suspension - Tier 1; QL calcium carbonate antacid oral tablet - Tier 1 calcium carbonate antacid oral tablet chewable (generic for CAL- GEST ANTACID) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents calcium carbonate oral tablet chewable 500 mg (generic for CAL- GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 comfort gel (generic for MINTOX) - Tier 1; QL comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL digestive probiotic capsule oral (generic for DERMACINRX PROBITRAN) - Tier 1 dairy aid (generic for LACTAID) - Tier 1 dairy relief fast acting oral tablet 9000 unit (generic for LACTAID FAST ACT) - Tier 1 dairy relief oral tablet 3000 unit (generic for LACTAID) - Tier 1 enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 FLEET ENEMA (brand for enema) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents gas relief oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief oral suspension (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral tablet chewable - Tier 1 gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for qc gas relief extra strength) - Tier 2 GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for eq gas relief extra strength) - Tier 2 GAS-X ULTRA STRENGTH (brand for simethicone ultra strength) - Tier 2 GAVISCON - Tier 2 GAVISCON EXTRA RELIEF FORMULA (brand for heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for qc heartburn antacid) - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1; QL geri-mox (generic for MINTOX) - Tier 1; QL heartburn antacid (generic for ACID GONE) - Tier 1 heartburn antacid ex st (generic for ACID GONE) - Tier 1 heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1 heartburn relief oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 infant gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants simethicone (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 107 Preferred Agents Non-Preferred Agents LACTAID (brand for ra dairy aid) - Tier 2 LACTAID FAST ACT ORAL TABLET (brand for lactose fast acting relief) - Tier 2 lactase enzyme (generic for LACTAID) - Tier 1 lactase enzyme ultra str (generic for LACTAID FAST ACT) - Tier 1 lactase fast acting (generic for LACTAID FAST ACT) - Tier 1 lacto-pectin (generic for DERMACINRX PROBITRAN) - Tier 1 lactose fast acting relief oral tablet (generic for LACTAID FAST ACT) - Tier 1 long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 MAALOX MAX ORAL SUSPENSION (brand for antacid iii) - Tier 2; QL MAALOX MULTI SYMPTOM MAX ST (brand for antacid iii) - Tier 2; QL mag-al plus (generic for MINTOX) - Tier 1; QL mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mega probiotic (generic for DERMACINRX PROBITRAN) - Tier 1 meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mi-acid gas relief - Tier 1 milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 milk of magnesia concentrate - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mintox plus - Tier 1 PHAZYME (brand for eq gas relief extra strength) - Tier 2 PHAZYME ULTRA STRENGTH (brand for simethicone ultra strength) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for ra milk of magnesia) - Tier 2 probiotic blend (generic for DERMACINRX PROBITRAN) - Tier 1 probiotic colon care (generic for DERMACINRX PROBITRAN) - Tier 1 probiotic complex (generic for DERMACINRX PROBITRAN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents probiotic maximum strength (generic for DERMACINRX PROBITRAN) - Tier 1 probiotic oral capsule (generic for DERMACINRX PROBITRAN) - Tier 1 probiotic pearls ex st (generic for DERMACINRX PROBITRAN) - Tier 1 ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 RESTORA (brand for cvs probiotic) - Tier 2 RISAQUAD (brand for cvs probiotic) - Tier 2 RISAQUAD-2 (brand for cvs probiotic) - Tier 2 saline enema (generic for FLEET ENEMA) - Tier 1 senior probiotic (generic for DERMACINRX PROBITRAN) - Tier 1 simeped (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 simethicone oral (generic for GAS-X EXTRA STRENGTH) - Tier 1 simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 smooth antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sodium bicarbonate oral tablet - Tier 1 surelac (generic for LACTAID) - Tier 1 TUMS (brand for calcium carbonate) - Tier 2 TUMS CHEWY BITES (brand for calcium antacid extra strength) - Tier 2 TUMS E-X 750 (brand for calcium antacid extra strength) - Tier 2 TUMS EXTRA STRENGTH 750 (brand for calcium antacid extra strength) - Tier 2 TUMS LASTING EFFECTS (brand for calcium carbonate) - Tier 2 TUMS SMOOTHIES (brand for calcium antacid extra strength) - Tier 2 TUMS ULTRA 1000 (brand for gnp antacid ultra strength) - Tier 2 ultra dairy digestive (generic for LACTAID FAST ACT) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs probiotic) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 109 Preferred Agents Non-Preferred Agents Laxatives - Bowel Treatment Drugs clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; SUTAB - Tier 2; PA QL COLACE (brand for mm stool softener laxative) - Tier 2; QL col-rite oral capsule 250 mg - Tier 1; QL daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 docu (generic for DOCU LIQUID) - Tier 1; QL docu liquid (generic for DOCU LIQUID) - Tier 1; QL docusate mini (generic for DOCUSOL MINI) - Tier 1; QL docusate sodium oral capsule (generic for DOK) - Tier 1; QL docusate sodium oral liquid 50 mg/5ml (generic for DOCU LIQUID) - Tier 1; QL docusate sodium oral syrup - Tier 1 docusate sodium oral tablet (generic for DOK) - Tier 1 DOCUSOL MINI (brand for docusate mini) - Tier 2; QL dok oral capsule (generic for DOK) - Tier 1; QL dok oral tablet (generic for DOK) - Tier 1 dss (generic for DOK) - Tier 1; QL enema mineral oil (generic for FLEET OIL) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL EVAC (brand for natural psyllium seed) - Tier 2 fiber laxative - Tier 1 fiber laxative + calcium - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 110 Preferred Agents Non-Preferred Agents fiber oral powder 28.3 %, 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 30.9 % - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 625 mg - Tier 1 fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1 fiber therapy oral tablet 625 mg - Tier 1 fiber-caps - Tier 1 fiber-lax - Tier 1 FLEET OIL (brand for sm mineral oil) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; QL gentlelax (generic for CLEARLAX) - Tier 1; QL glycolax (generic for CLEARLAX) - Tier 1; QL KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1 laxaclear (generic for CLEARLAX) - Tier 1; QL laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for gavilax) - Tier 2; QL mm clearlax (generic for CLEARLAX) - Tier 1; QL mm stool softener laxative (generic for DOK) - Tier 1; QL natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 %, 48.57 % (generic for METAMUCIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents natural fiber supplement (generic for EVAC) - Tier 1 natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; QL PEDIA-LAX ORAL LIQUID - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; QL purelax oral powder (generic for CLEARLAX) - Tier 1; QL silace oral liquid (generic for DOCU LIQUID) - Tier 1; QL silace oral syrup - Tier 1 smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL sorbitol oral - Tier 1 stool softener laxative oral capsule (generic for DOK) - Tier 1; QL stool softener oral capsule 100 mg (generic for DOK) - Tier 1; QL stool softener oral capsule 250 mg - Tier 1; QL stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral tablet 100 mg (generic for DOK) - Tier 1 Laxatives - Drugs to treat Constipation chocolate laxative pieces (generic for EX-LAX) - Tier 1 AVEDANA GLYCERIN (ADULT) (brand for glycerin (adult)) - Tier 2; PA chocolated laxative (generic for EX-LAX) - Tier 1 citrate of magnesia (generic for CITROMA) - Tier 1; QL citroma (generic for CITROMA) - Tier 1; QL CITRUCEL - Tier 2 docusate calcium (generic for SURFAK) - Tier 1 docuzen (generic for SENEXON-S) - Tier 1 easy-lax plus (generic for SENEXON-S) - Tier 1 EX-LAX (brand for chocolated laxative) - Tier 2 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 geri-kot (generic for SENOKOT) - Tier 1 glycerin (adult) rectal suppository 2 gm (generic for AVEDANA GLYCERIN (ADULT)) - Tier 1 glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin adult rectal suppository 2 gm (generic for AVEDANA GLYCERIN (ADULT)) - Tier 1 glycerin child rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin child rectal suppository 1.2 gm - Tier 1 glycerin childrens (generic for PEDIA-LAX) - Tier 1 glycerin pediatric rectal suppository 1.2 gm - Tier 1 laxacin (generic for SENEXON-S) - Tier 1 laxative max str - Tier 1 laxative maximum strength oral tablet 25 mg - Tier 1 laxative oral tablet chewable 15 mg (generic for EX-LAX) - Tier 1 laxative pills (generic for SENNA SMOOTH) - Tier 1 laxative pills max st - Tier 1 laxative pills oral tablet 25 mg - Tier 1 laxative regular strength (generic for SENNA SMOOTH) - Tier 1 magnesium citrate oral solution (generic for CITROMA) - Tier 1; QL natural laxative (generic for SENOKOT) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENOKOT) - Tier 1 natural vegetable laxative (generic for SENOKOT) - Tier 1 p col-rite (generic for SENEXON-S) - Tier 1 PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for cvs glycerin child) - Tier 2 PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENOKOT) - Tier 1 senna laxative (generic for SENOKOT) - Tier 1 senna oral liquid - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 113 Preferred Agents Non-Preferred Agents senna oral syrup 8.8 mg/5ml - Tier 1 senna oral tablet (generic for SENOKOT) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1 senna-lax (generic for SENOKOT) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENOKOT) - Tier 1 senna-time (generic for SENOKOT) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1 SENOKOT (brand for goodsense senna laxative) - Tier 2 SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2 SENOKOT S (brand for senna-time s) - Tier 2 soluble fiber therapy - Tier 1 stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment BRINEURA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 114 Preferred Agents Non-Preferred Agents Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment CREON - Tier 2; QL BUPHENYL (brand for sodium phenylbutyrate) - Tier 2; PA; SP; QL CYSTAGON - Tier 2; SP; QL CARNITOR ORAL (brand for levocarnitine) - Tier 2; PA NITYR - Tier 2; DX2RX; SP; QL CARNITOR SF (brand for levocarnitine) - Tier 2; PA RAVICTI - Tier 2; PA; SP; QL CERDELGA - Tier 2; PA; SP; QL sapropterin dihydrochloride (generic for KUVAN) - Tier 1; PA; SP; QL CEREZYME - Tier 2; PA STRENSIQ - Tier 2; PA; SP; QL CHOLBAM - Tier 2; PA; SP; QL TEGSEDI - Tier 2; PA; SP; QL cromolyn sodium oral (generic for GASTROCROM) - Tier 1; PA; QL VYNDAMAX - Tier 2; PA; SP; QL CRYSVITA SUBCUTANEOUS SOLUTION 20 MG/ML, 30 MG/ML - Tier VYNDAQEL - Tier 2; PA; SP; QL 2; PA ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL CYSTADANE - Tier 2; PA; SP; QL ZENPEP - Tier 2; QL ELELYSO - Tier 2; PA EVRYSDI - Tier 2; PA; SP; QL GALAFOLD - Tier 2; PA; SP; QL GASTROCROM (brand for cromolyn sodium) - Tier 2; PA; QL KANUMA - Tier 2; PA KEVEYIS - Tier 2; PA; SP; QL KUVAN (brand for sapropterin dihydrochloride) - Tier 2; PA; SP; QL levocarnitine oral solution (generic for CARNITOR) - Tier 1; PA levocarnitine oral tablet (generic for CARNITOR) - Tier 1; PA levocarnitine sf (generic for CARNITOR) - Tier 1; PA miglustat (generic for ZAVESCA) - Tier 1; PA; SP; QL NEXVIAZYME - Tier 2; PA nitisinone (generic for ORFADIN) - Tier 1; PA; SP; QL ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 115 Preferred Agents Non-Preferred Agents PALYNZIQ - Tier 2; PA; SP; QL PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 4200-14200 UNIT - Tier 2; PA; QL PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600- 8800 UNIT, 37000-97300 UNIT - Tier 2; PA PERTZYE - Tier 2; PA; QL PROCYSBI - Tier 2; PA; SP; QL sodium phenylbutyrate oral (generic for BUPHENYL) - Tier 1; PA; SP; QL VIOKACE - Tier 2; PA; QL VPRIV - Tier 2; PA Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL darifenacin hydrobromide er - Tier 1; PA; QL oxybutynin chloride oral - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; QL solifenacin succinate (generic for VESICARE) - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL TOVIAZ - Tier 2; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL flavoxate hcl - Tier 1; PA; QL GELNIQUE - Tier 2; PA; QL MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER - Tier 2; PA MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL OXYTROL - Tier 2; PA; QL OXYTROL FOR WOMEN - Tier 2; PA; QL tolterodine tartrate (generic for DETROL) - Tier 1; PA; QL tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA; QL trospium chloride - Tier 1; PA; QL trospium chloride er - Tier 1; PA; QL VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL VESICARE LS - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents Benign Prostatic Hypertrophy Agents alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL; GE AVODART (brand for dutasteride) - Tier 2; PA; QL; GE dutasteride oral (generic for AVODART) - Tier 1; QL; GE CARDURA XL - Tier 2; PA; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL; GE; CIALIS ORAL TABLET 5 MG (brand for tadalafil) - Tier 2; PA; QL; GE AL dutasteride-tamsulosin hcl (generic for JALYN) - Tier 1; PA; QL tamsulosin hcl (generic for FLOMAX) - Tier 1; PA; QL FLOMAX (brand for tamsulosin hcl) - Tier 2; PA; QL terazosin hcl - Tier 1; QL JALYN (brand for dutasteride-tamsulosin hcl) - Tier 2; PA; QL PROSCAR (brand for finasteride) - Tier 2; PA; QL; GE; AL RAPAFLO (brand for silodosin) - Tier 2; PA; QL silodosin (generic for RAPAFLO) - Tier 1; PA; QL tadalafil oral tablet 5 mg (generic for CIALIS) - Tier 1; PA; QL; GE UROXATRAL (brand for alfuzosin hcl er) - Tier 2; PA; QL; GE Genitourinary Agents, Other bethanechol chloride oral - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL ELMIRON - Tier 2; PA; QL LITHOSTAT - Tier 2; PA penicillamine oral (generic for CUPRIMINE) - Tier 1; PA; SP; QL THIOLA (brand for tiopronin) - Tier 2; PA; SP; QL THIOLA EC - Tier 2; PA; SP; QL tiopronin oral (generic for THIOLA) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 117 Preferred Agents Non-Preferred Agents Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 me/naphos/mb/hyo1 (generic for UROGESIC-BLUE) - Tier 1; PA azo tabs (generic for PHENAZO) - Tier 1 TRIMO-SAN VAGINAL GEL 0.025-0.01 % - Tier 2; PA phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL URELLE (brand for uroav-81) - Tier 2; PA phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 URIMAR-T - Tier 2; PA phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier URO-458 - Tier 2; PA 1; QL UROGESIC-BLUE (brand for me/naphos/mb/hyo1) - Tier 2; PA phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier uro-mp (generic for VILAMIT MB) - Tier 1; PA 1; QL VILAMIT MB (brand for uro-mp) - Tier 2; PA PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL VILEVEV MB (brand for uroav-81) - Tier 2; PA urin ds (generic for UTIRA-C) - Tier 1; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 UTIRA-C (brand for urin ds) - Tier 2; QL Glycemic Agents - Diabetic Drugs Blood Glucose Regulators - Drugs to Regulate Blood Sugar ZEGALOGUE - Tier 2; PA Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) DECADRON (brand for dexamethasone) - Tier 2 ACTHAR - Tier 2; PA; SP; QL dexamethasone oral elixir - Tier 1 ALKINDI SPRINKLE - Tier 2; PA; AL dexamethasone oral solution - Tier 1 CORTEF (brand for hydrocortisone) - Tier 2; PA dexamethasone oral tablet (generic for DECADRON) - Tier 1 dexamethasone intensol - Tier 1; PA fludrocortisone acetate oral - Tier 1; QL dexamethasone oral tablet therapy pack (generic for HIDEX 6-DAY) - Tier hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - 1; PA Tier 1 EMFLAZA - Tier 2; PA; SP; QL methylprednisolone oral tablet 32 mg, 4 mg (generic for MEDROL) - HEMADY - Tier 2; PA Tier 1 HIDEX 6-DAY (brand for dexamethasone) - Tier 2; PA methylprednisolone oral tablet therapy pack (generic for MEDROL) - MEDROL - Tier 2; PA Tier 1 methylprednisolone oral tablet 16 mg, 8 mg (generic for MEDROL) - Tier prednisolone oral solution - Tier 1 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 118 Preferred Agents Non-Preferred Agents prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml - MILLIPRED - Tier 2; PA Tier 1 ORAPRED ODT (brand for prednisolone sodium phosphate) - Tier 2; PA prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml PEDIAPRED (brand for prednisolone sodium phosphate) - Tier 2; PA (generic for PEDIAPRED) - Tier 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml - Tier prednisone oral tablet - Tier 1 1; PA prednisone oral tablet therapy pack - Tier 1 prednisolone sodium phosphate oral tablet dispersible (generic for SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG - ORAPRED ODT) - Tier 1; PA Tier 2; DX2RX prednisone intensol - Tier 1; PA prednisone oral solution - Tier 1; PA RAYOS - Tier 2; PA TAPERDEX 12-DAY - Tier 2; PA TAPERDEX 6-DAY (brand for dexamethasone) - Tier 2; PA TAPERDEX 7-DAY - Tier 2; PA

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin ace spray refrig - Tier 1; QL chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; PA desmopressin acetate oral (generic for DDAVP) - Tier 1; QL DDAVP ORAL (brand for desmopressin acetate) - Tier 2; PA; QL desmopressin acetate spray - Tier 1; QL DESMOPRESSIN ACETATE NASAL - Tier 2; PA GENOTROPIN - Tier 2; PA; SP; QL EGRIFTA SV - Tier 2; PA; SP; QL GENOTROPIN MINIQUICK - Tier 2; PA; SP; QL HUMATROPE - Tier 2; PA; SP; QL INCRELEX - Tier 2; PA; SP; QL novarel intramuscular solution reconstituted 10000 unit (generic for NOCDURNA - Tier 2; PA; QL NOVAREL) - Tier 1; PA NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN- NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 INJECTOR 10 MG/1.5ML, 5 MG/1.5ML - Tier 2; PA; SP UNIT - Tier 2; PA; SP; QL NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN- NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QL INJECTOR 15 MG/1.5ML, 30 MG/3ML - Tier 2; PA; SP; QL NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QL NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; PA; SP OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED - Tier 2; PA; SP; QL pregnyl (generic for NOVAREL) - Tier 1; PA SAIZEN - Tier 2; PA; SP; QL SAIZENPREP - Tier 2; PA; SP; QL SEROSTIM - Tier 2; PA; SP; QL STIMATE (brand for desmopressin acetate) - Tier 2; PA ZOMACTON - Tier 2; PA; SP; QL ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP; QL ZORBTIVE - Tier 2; PA; SP; QL Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM - Tier 2; PA; SP; QL CERVIDIL - Tier 2; PA methergine (generic for METHERGINE) - Tier 1; QL PREPIDIL - Tier 2; PA methylergonovine maleate oral (generic for METHERGINE) - Tier 1; QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids oxandrolone oral - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 120 Preferred Agents Non-Preferred Agents Androgens danazol oral - Tier 1; QL ANDRODERM - Tier 2; PA; QL testosterone cypionate intramuscular (generic for DEPO- ANDROGEL PUMP (brand for testosterone) - Tier 2; PA; QL; GE TESTOSTERONE) - Tier 1; QL ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 testosterone enanthate intramuscular - Tier 1; QL MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%) (brand for testosterone) - Tier testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic 2; PA; QL; GE for ANDROGEL PUMP) - Tier 1; QL; GE ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%) (brand for testosterone) - Tier 2; PA; GE DEPO-TESTOSTERONE (brand for testosterone cypionate) - Tier 2; PA; QL FORTESTA (brand for testosterone) - Tier 2; PA JATENZO ORAL CAPSULE 158 MG, 198 MG - Tier 2; PA JATENZO ORAL CAPSULE 237 MG - Tier 2; PA; QL METHITEST - Tier 2; PA; QL methyltestosterone oral - Tier 1; PA; QL NATESTO - Tier 2; PA TESTIM (brand for testosterone) - Tier 2; PA; GE testosterone transdermal gel 10 mg/act (2%) (generic for FORTESTA) - Tier 1; PA testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; ST; GE testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%) (generic for ANDROGEL) - Tier 1; PA; QL; GE testosterone transdermal gel 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; GE testosterone transdermal solution - Tier 1; PA VOGELXO (brand for testosterone) - Tier 2; PA; GE VOGELXO PUMP (brand for testosterone) - Tier 2; PA; ST; GE XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/0.5ML, 50 MG/0.5ML - Tier 2; PA XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/0.5ML - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents Estrogens afirmelle (generic for AFIRMELLE) - Tier 1 ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1 ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL amabelz (generic for AMABELZ) - Tier 1; PA; QL alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL amethyst tablet 90-20 mcg oral (generic for AMETHYST) - Tier 1; PA; QL amethia (generic for AMETHIA) - Tier 1; QL ANGELIQ - Tier 2; PA; QL amethyst tablet 90-20 mcg oral (generic for AMETHYST) - Tier 1; QL ANNOVERA - Tier 2; PA; QL apri (generic for APRI) - Tier 1 BIJUVA - Tier 2; PA; QL aranelle - Tier 1; QL CLIMARA (brand for estradiol) - Tier 2; PA; QL ashlyna (generic for AMETHIA) - Tier 1; QL CLIMARA PRO - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1 COMBIPATCH - Tier 2; PA; QL aubra eq (generic for AFIRMELLE) - Tier 1 DELESTROGEN - Tier 2; PA; QL aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL DIVIGEL - Tier 2; PA; QL aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1 dolishale (generic for AMETHYST) - Tier 1; PA; QL aurovela 24 fe - Tier 1 dotti (generic for DOTTI) - Tier 1; PA; QL aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1 ELESTRIN - Tier 2; PA aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 ESTRACE (brand for estradiol) - Tier 2; PA; QL aviane (generic for AFIRMELLE) - Tier 1 estradiol transdermal patch twice weekly (generic for DOTTI) - Tier 1; PA; ayuna (generic for ALTAVERA) - Tier 1 QL azurette (generic for AZURETTE) - Tier 1 estradiol vaginal tablet (generic for YUVAFEM) - Tier 1; PA; QL BALCOLTRA - Tier 2; QL estradiol valerate intramuscular (generic for DELESTROGEN) - Tier 1; balziva (generic for BALZIVA) - Tier 1; QL PA; QL BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; QL estradiol-norethindrone acet (generic for AMABELZ) - Tier 1; PA; QL blisovi 24 fe - Tier 1 ESTRING - Tier 2; PA; QL blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1 EVAMIST - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 FEMHRT (brand for norethindrone-eth estradiol) - Tier 2; PA; QL briellyn (generic for BALZIVA) - Tier 1; QL FEMRING - Tier 2; PA; QL camrese (generic for AMETHIA) - Tier 1; QL fyavolv (generic for FYAVOLV) - Tier 1; PA; QL camrese lo (generic for CAMRESE LO) - Tier 1; QL jinteli (generic for FYAVOLV) - Tier 1; PA; QL caziant - Tier 1; QL LOESTRIN FE 1.5/30 (brand for norethin ace-eth estrad-fe) - Tier 2; PA charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL LOESTRIN FE 1/20 (brand for norethin ace-eth estrad-fe) - Tier 2; PA chateal (generic for ALTAVERA) - Tier 1 lyllana (generic for DOTTI) - Tier 1; PA; QL chateal eq (generic for ALTAVERA) - Tier 1 MENEST - Tier 2; PA; QL cryselle-28 - Tier 1; QL MENOSTAR - Tier 2; PA; QL cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL mimvey (generic for AMABELZ) - Tier 1; PA; QL cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL MINASTRIN 24 FE (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL cyred (generic for APRI) - Tier 1 MINIVELLE (brand for estradiol) - Tier 2; PA; QL cyred eq (generic for APRI) - Tier 1 norethindrone-eth estradiol (generic for FYAVOLV) - Tier 1; PA; QL dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; PA; QL; GE dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL PREFEST - Tier 2; PA; QL daysee (generic for AMETHIA) - Tier 1; QL PREMARIN VAGINAL - Tier 2; PA; QL delyla (generic for AFIRMELLE) - Tier 1 taysofy (generic for GEMMILY) - Tier 1; PA; QL DEPO-ESTRADIOL - Tier 2; QL tyblume - Tier 1; PA desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1 VAGIFEM (brand for estradiol) - Tier 2; PA; QL drospiren-eth estrad-levomefol (generic for BEYAZ) - Tier 1; QL VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL drospirenone-ethinyl estradiol (generic for OCELLA) - Tier 1 yuvafem (generic for YUVAFEM) - Tier 1; PA; QL DUAVEE - Tier 2; QL elinest - Tier 1; QL eluryng (generic for ELURYNG) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents emoquette (generic for APRI) - Tier 1 enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL enskyce (generic for APRI) - Tier 1 estarylla (generic for ESTARYLLA) - Tier 1 estradiol oral (generic for ESTRACE) - Tier 1; QL estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL estradiol vaginal cream (generic for ESTRACE) - Tier 1; QL ESTROSTEP FE - Tier 2; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE falmina (generic for AFIRMELLE) - Tier 1 fayosim (generic for FAYOSIM) - Tier 1; QL femynor (generic for ESTARYLLA) - Tier 1 gemmily (generic for GEMMILY) - Tier 1; QL GENERESS FE (brand for norethin-eth estradiol-fe) - Tier 2; QL hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1 hailey 24 fe - Tier 1 hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1 hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 iclevia (generic for ICLEVIA) - Tier 1; QL introvale (generic for ICLEVIA) - Tier 1; QL isibloom (generic for APRI) - Tier 1 jaimiess (generic for AMETHIA) - Tier 1; QL jasmiel (generic for JASMIEL) - Tier 1 jolessa (generic for ICLEVIA) - Tier 1; QL juleber (generic for APRI) - Tier 1 junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL junel 1/20 (generic for AUROVELA 1/20) - Tier 1 junel fe (generic for AUROVELA FE 1/20) - Tier 1 kaitlib fe (generic for KAITLIB FE) - Tier 1; QL kalliga (generic for APRI) - Tier 1 kariva (generic for AZURETTE) - Tier 1 kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL kurvelo (generic for ALTAVERA) - Tier 1 larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents larin 1/20 (generic for AUROVELA 1/20) - Tier 1 larin 24 fe - Tier 1 larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1 larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 larissia (generic for AFIRMELLE) - Tier 1 layolis fe (generic for KAITLIB FE) - Tier 1; QL leena - Tier 1; QL lessina (generic for AFIRMELLE) - Tier 1 levonest (generic for ENPRESSE-28) - Tier 1; QL levonorgest-eth est & eth est (generic for FAYOSIM) - Tier 1; QL levonorgest-eth estrad 91-day (generic for ICLEVIA) - Tier 1; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1 levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (generic for AMETHYST) - Tier 1; QL levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1 lillow (generic for ALTAVERA) - Tier 1 LO LOESTRIN FE - Tier 2; QL LOESTRIN 1.5/30 (21) (brand for norethindrone acet-ethinyl est) - Tier 2; QL LOESTRIN 1/20 (21) (brand for norethindrone acet-ethinyl est) - Tier 2 lojaimiess (generic for CAMRESE LO) - Tier 1; QL loryna (generic for JASMIEL) - Tier 1 LOSEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; QL low-ogestrel - Tier 1; QL lo-zumandimine (generic for JASMIEL) - Tier 1 lutera (generic for AFIRMELLE) - Tier 1 marlissa (generic for ALTAVERA) - Tier 1 merzee (generic for GEMMILY) - Tier 1; QL mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 125 Preferred Agents Non-Preferred Agents microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1 microgestin 24 fe - Tier 1 microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1 microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 mili (generic for ESTARYLLA) - Tier 1 MIRCETTE (brand for viorele) - Tier 2 mono-linyah (generic for ESTARYLLA) - Tier 1 NATAZIA - Tier 2; QL necon 0.5/35 (28) - Tier 1; QL nikki (generic for JASMIEL) - Tier 1 norethin ace-eth estrad-fe oral capsule (generic for GEMMILY) - Tier 1; QL norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1 norethin ace-eth estrad-fe oral tablet chewable (generic for CHARLOTTE 24 FE) - Tier 1; QL norethindrone acet-ethinyl est oral tablet 1.5-30 mg-mcg (generic for AUROVELA 1.5/30) - Tier 1; QL norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg (generic for AUROVELA 1/20) - Tier 1 norethin-eth estradiol-fe (generic for WYMZYA FE) - Tier 1; QL norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1 norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg- 25 mcg (generic for TRI-LO-ESTARYLLA) - Tier 1 norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg- 35 mcg (generic for TRI FEMYNOR) - Tier 1; QL nortrel 0.5/35 (28) - Tier 1; QL nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL nylia 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL nymyo (generic for ESTARYLLA) - Tier 1 ocella (generic for OCELLA) - Tier 1 orsythia (generic for AFIRMELLE) - Tier 1 philith (generic for BALZIVA) - Tier 1; QL pimtrea (generic for AZURETTE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL portia-28 (generic for ALTAVERA) - Tier 1 PREMARIN ORAL - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1 QUARTETTE (brand for levonorgest-eth est & eth est) - Tier 2; QL reclipsen (generic for APRI) - Tier 1 rivelsa (generic for FAYOSIM) - Tier 1; QL SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; QL SEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; QL setlakin (generic for ICLEVIA) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1 simpesse (generic for AMETHIA) - Tier 1; QL sprintec 28 (generic for ESTARYLLA) - Tier 1 sronyx (generic for AFIRMELLE) - Tier 1 syeda (generic for OCELLA) - Tier 1 tarina 24 fe - Tier 1 tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1 tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1 TAYTULLA (brand for norethin ace-eth estrad-fe) - Tier 2 tilia fe - Tier 1; QL tri femynor (generic for TRI FEMYNOR) - Tier 1; QL tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL tri-legest fe - Tier 1; QL tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1 tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1 tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1 tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1 tri-mili (generic for TRI FEMYNOR) - Tier 1; QL tri-nymyo (generic for TRI FEMYNOR) - Tier 1; QL tri-previfem (generic for TRI FEMYNOR) - Tier 1; QL tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL trivora (28) (generic for ENPRESSE-28) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 127 Preferred Agents Non-Preferred Agents tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1 tydemy (generic for TYDEMY) - Tier 1; QL velivet - Tier 1; QL vestura (generic for JASMIEL) - Tier 1 vienva (generic for AFIRMELLE) - Tier 1 viorele (generic for AZURETTE) - Tier 1 volnea (generic for AZURETTE) - Tier 1 vyfemla (generic for BALZIVA) - Tier 1; QL vylibra (generic for ESTARYLLA) - Tier 1 wera - Tier 1; QL wymzya fe (generic for WYMZYA FE) - Tier 1; QL xulane - Tier 1; QL; GE YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2 YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2 zafemy - Tier 1; QL; GE zarah (generic for OCELLA) - Tier 1 zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL zovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL zumandimine (generic for OCELLA) - Tier 1 Progestins camila (generic for CAMILA) - Tier 1 AYGESTIN (brand for norethindrone acetate) - Tier 2; PA; QL deblitane (generic for CAMILA) - Tier 1 CRINONE - Tier 2; PA ELLA - Tier 2 DEPO-PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; errin (generic for CAMILA) - Tier 1 QL heather (generic for CAMILA) - Tier 1 DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL incassia (generic for CAMILA) - Tier 1 hydroxyprogesterone caproate intramuscular oil (generic for MAKENA) - jencycla (generic for CAMILA) - Tier 1 Tier 1; DX2RX; SP; QL lyleq (generic for CAMILA) - Tier 1 MAKENA (brand for hydroxyprogesterone caproate) - Tier 2; DX2RX; SP; lyza (generic for CAMILA) - Tier 1 QL medroxyprogesterone acetate intramuscular suspension (generic for medroxyprogesterone acetate intramuscular suspension prefilled syringe DEPO-PROVERA) - Tier 1; QL (generic for DEPO-PROVERA) - Tier 1; PA; QL megestrol acetate oral suspension 625 mg/5ml - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 128 Preferred Agents Non-Preferred Agents medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; progesterone intramuscular - Tier 1; PA QL PROMETRIUM (brand for progesterone) - Tier 2; DX2RX; QL megestrol acetate oral suspension 40 mg/ml - Tier 1; QL PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; QL megestrol acetate oral tablet - Tier 1 nora-be (generic for CAMILA) - Tier 1 norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1 norlyda (generic for CAMILA) - Tier 1 norlyroc (generic for CAMILA) - Tier 1 progesterone oral (generic for PROMETRIUM) - Tier 1; DX2RX; QL sharobel (generic for CAMILA) - Tier 1 SLYND - Tier 2 tulana (generic for CAMILA) - Tier 1

Selective Estrogen Receptor Modifying Agents raloxifene hcl (generic for EVISTA) - Tier 1; QL EVISTA (brand for raloxifene hcl) - Tier 2; PA; QL OSPHENA - Tier 2; PA; QL; GE Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Estrogens - Hormone Replacement/Modifying Drugs COVARYX (brand for est estrogens-methyltest) - Tier 2; PA; QL COVARYX HS (brand for est estrogens-methyltest) - Tier 2; PA; QL EEMT (brand for est estrogens-methyltest) - Tier 2; PA; QL est estrogens-methyltest (generic for COVARYX HS) - Tier 1; PA; QL est estrogens-methyltest ds (generic for COVARYX) - Tier 1; PA; QL est estrogens-methyltest hs (generic for COVARYX HS) - Tier 1; PA; QL FALESSA - Tier 2; PA; QL TWIRLA - Tier 2; PA; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1 AFTERPILL (brand for levonorgestrel) - Tier 2 econtra ez (generic for AFTERA) - Tier 1 econtra one-step (generic for AFTERA) - Tier 1 levonorgestrel (generic for AFTERA) - Tier 1 my choice (generic for AFTERA) - Tier 1 my way (generic for AFTERA) - Tier 1 new day (generic for AFTERA) - Tier 1 opcicon one-step (generic for AFTERA) - Tier 1 option 2 (generic for AFTERA) - Tier 1 PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2 react (generic for AFTERA) - Tier 1 take action (generic for AFTERA) - Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tablet 100 mcg oral (generic for EUTHYROX) - CYTOMEL (brand for liothyronine sodium) - Tier 2; PA; QL Tier 1 euthyrox (generic for EUTHYROX) - Tier 1; PA; QL levothyroxine sodium tablet 100 mcg oral (generic for EUTHYROX) - levo-t (generic for EUTHYROX) - Tier 1; PA; QL Tier 1; QL LEVOTHYROXINE SODIUM ORAL CAPSULE - Tier 2; PA; QL levothyroxine sodium tablet 112 mcg oral (generic for EUTHYROX) - SYNTHROID (brand for levothyroxine sodium) - Tier 2; PA; QL Tier 1 THYQUIDITY - Tier 2; PA levothyroxine sodium tablet 112 mcg oral (generic for EUTHYROX) - TIROSINT (brand for levothyroxine sodium) - Tier 2; PA; QL Tier 1; QL TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 levothyroxine sodium tablet 125 mcg oral (generic for EUTHYROX) - MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 Tier 1 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML - Tier 2; levothyroxine sodium tablet 125 mcg oral (generic for EUTHYROX) - PA; QL Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 130 Preferred Agents Non-Preferred Agents levothyroxine sodium tablet 137 mcg oral (generic for EUTHYROX) - TIROSINT-SOL ORAL SOLUTION 37.5 MCG/ML, 44 MCG/ML, 62.5 Tier 1 MCG/ML - Tier 2; PA levothyroxine sodium tablet 137 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 150 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 150 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 175 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 175 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 200 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 200 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 25 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 25 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 300 mcg oral (generic for LEVO-T) - Tier 1 levothyroxine sodium tablet 300 mcg oral (generic for LEVO-T) - Tier 1; QL levothyroxine sodium tablet 50 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 50 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 75 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 75 mcg oral (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium tablet 88 mcg oral (generic for EUTHYROX) - Tier 1 levothyroxine sodium tablet 88 mcg oral (generic for EUTHYROX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 131 Preferred Agents Non-Preferred Agents levoxyl (generic for EUTHYROX) - Tier 1; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL unithroid (generic for EUTHYROX) - Tier 1; QL Hormonal Agents, Suppressant (Adrenal) LYSODREN - Tier 2; QL ISTURISA - Tier 2; PA; SP; QL Hormonal Agents, Suppressant (Pituitary) cabergoline - Tier 1; QL ELIGARD - Tier 2; PA; SP; QL leuprolide acetate injection - Tier 1; PA; SP; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL LUPANETA PACK - Tier 2; PA; SP; QL LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; MYCAPSSA - Tier 2; PA; QL PA; SP; QL SANDOSTATIN (brand for octreotide acetate) - Tier 2; PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; SYNAREL - Tier 2; PA; AL PA; SP; QL TRIPTODUR - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL ORIAHNN - Tier 2; ST; QL; AL ORILISSA - Tier 2; PA; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral (generic for TAPAZOLE) - Tier 1; QL TAPAZOLE (brand for methimazole) - Tier 2; PA; QL propylthiouracil oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 132 Preferred Agents Non-Preferred Agents Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYROID (brand for np thyroid) - Tier 2; QL NATURE-THROID ORAL TABLET 65 MG (brand for thyroid) - Tier 2; PA; np thyroid (generic for ARMOUR THYROID) - Tier 1; QL QL WESTHROID ORAL TABLET 65 MG (brand for thyroid) - Tier 2; PA; QL WP THYROID ORAL TABLET 65 MG (brand for thyroid) - Tier 2; PA; QL Immune Suppressants - Immune System Drugs Immunological Agents - Drugs that Stimulate or Suppress the Immune System LUPKYNIS - Tier 2; PA; SP; QL Immunological Agents Angioedema Agents BERINERT - Tier 2; PA; SP; QL CINRYZE - Tier 2; PA; SP FIRAZYR (brand for icatibant acetate) - Tier 2; SP; QL icatibant acetate (generic for SAJAZIR) - Tier 1; PA; SP; QL HAEGARDA - Tier 2; PA; SP; QL KALBITOR - Tier 2; PA; SP RUCONEST - Tier 2; PA; SP; QL sajazir (generic for SAJAZIR) - Tier 1; PA; SP; QL TAKHZYRO - Tier 2; PA; SP; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 133 Preferred Agents Non-Preferred Agents Immunoglobulins HEPAGAM B - Tier 2; PA HYPERHEP B - Tier 2; PA HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML - Tier 2; PA HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT - Tier 2; PA IMOGAM RABIES-HT (brand for kedrab) - Tier 2; PA KEDRAB - Tier 2; PA NABI-HB - Tier 2; PA OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML - Tier 2; PA RHOGAM ULTRA-FILTERED PLUS - Tier 2; PA Immunological Agents, Other OTEZLA - Tier 2; PA; ST; SP; QL ACTEMRA ACTPEN - Tier 2; PA; SP; QL SYNAGIS - Tier 2; PA; SP; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL XOLAIR - Tier 2; PA; SP; QL ARCALYST - Tier 2; PA; SP; QL BENLYSTA SUBCUTANEOUS - Tier 2; PA; SP; QL COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML - Tier 2; DX2RX; SP; QL COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML - Tier 2; DX2RX; SP; QL COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 MG/0.5ML - Tier 2; PA; SP DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 134 Preferred Agents Non-Preferred Agents DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML - Tier 2; PA; SP; AL DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP; QL; AL ILARIS - Tier 2; PA; SP; QL ILUMYA - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL KINERET - Tier 2; PA; SP; QL OLUMIANT ORAL TABLET 1 MG - Tier 2; PA; SP OLUMIANT ORAL TABLET 2 MG - Tier 2; PA; SP; QL ORALAIR - Tier 2; PA ORALAIR ADULT STARTER PACK - Tier 2; PA ORALAIR CHILDRENS STARTER PACK - Tier 2; PA ORENCIA CLICKJECT - Tier 2; PA; SP; QL ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL RIDAURA - Tier 2; PA; QL RINVOQ - Tier 2; PA; SP; QL SILIQ - Tier 2; PA; SP; QL SKYRIZI - Tier 2; PA; SP SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL SKYRIZI PEN - Tier 2; PA; SP; QL STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL TALTZ - Tier 2; PA; SP; QL; AL TREMFYA - Tier 2; PA; SP; QL XELJANZ ORAL SOLUTION - Tier 2; PA; QL XELJANZ ORAL TABLET - Tier 2; PA; SP; QL XELJANZ XR - Tier 2; PA; SP; QL Immunostimulants ACTIMMUNE - Tier 2; PA; SP; QL INTRON A - Tier 2; PA; SP; QL PEGASYS - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 135 Preferred Agents Non-Preferred Agents Immunosuppressants azathioprine oral (generic for IMURAN) - Tier 1 ARAVA (brand for leflunomide) - Tier 2; PA; QL cyclosporine modified oral capsule 100 mg, 25 mg (generic for ASTAGRAF XL - Tier 2; PA GENGRAF) - Tier 1 AZASAN - Tier 2; PA ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML - Tier 2; SP; CELLCEPT (brand for mycophenolate mofetil) - Tier 2; PA QL CIMZIA - Tier 2; PA; SP; QL ENBREL SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; cyclosporine modified oral capsule 50 mg - Tier 1; PA DX2RX; SP; QL cyclosporine modified oral solution (generic for GENGRAF) - Tier 1; PA ENBREL SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; cyclosporine oral (generic for SANDIMMUNE) - Tier 1; PA DX2RX; SP; QL ENSPRYNG - Tier 2; PA; SP ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier ENVARSUS XR - Tier 2; PA 2; DX2RX; SP; QL gengraf oral solution (generic for GENGRAF) - Tier 1; PA IMURAN (brand for azathioprine) - Tier 2; PA ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED - Tier 2; mycophenolate mofetil oral suspension reconstituted (generic for DX2RX; SP; QL CELLCEPT) - Tier 1; PA everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for mycophenolate sodium (generic for MYFORTIC) - Tier 1; PA ZORTRESS) - Tier 1 MYFORTIC (brand for mycophenolate sodium) - Tier 2; PA gengraf oral capsule (generic for GENGRAF) - Tier 1 NEORAL (brand for cyclosporine modified) - Tier 2; PA HUMIRA PEN-PEDIATRIC UC START - Tier 2; DX2RX; SP; QL OTREXUP - Tier 2; PA HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; DX2RX; SP; QL PROGRAF ORAL (brand for tacrolimus) - Tier 2; PA HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 RAPAMUNE (brand for sirolimus) - Tier 2; PA MG/0.8ML, 80 MG/0.8ML - Tier 2; DX2RX; SP; QL RASUVO - Tier 2; PA HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 REDITREX - Tier 2; PA; AL MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 SANDIMMUNE ORAL (brand for cyclosporine) - Tier 2; PA MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; DX2RX; SP; QL SIMPONI - Tier 2; PA; SP; QL leflunomide oral (generic for ARAVA) - Tier 1; QL sirolimus oral solution (generic for RAPAMUNE) - Tier 1; PA methotrexate oral - Tier 1 TREXALL - Tier 2; PA methotrexate sodium - Tier 1 XATMEP - Tier 2; PA methotrexate sodium (pf) - Tier 1 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG (brand for mycophenolate mofetil oral capsule (generic for CELLCEPT) - Tier 1 everolimus) - Tier 2; PA mycophenolate mofetil oral tablet (generic for CELLCEPT) - Tier 1 sirolimus oral tablet (generic for RAPAMUNE) - Tier 1 tacrolimus oral (generic for PROGRAF) - Tier 1 ZORTRESS ORAL TABLET 1 MG - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 136 Preferred Agents Non-Preferred Agents Vaccines ACTHIB - Tier 2; PA BCG VACCINE - Tier 2; PA BEXSERO - Tier 2; PA ENGERIX-B - Tier 2; PA GARDASIL 9 - Tier 2; PA HAVRIX - Tier 2; PA HIBERIX - Tier 2; PA IMOVAX RABIES - Tier 2; PA IPOL - Tier 2; PA IXIARO - Tier 2; PA MENACTRA - Tier 2; PA MENQUADFI - Tier 2; PA MENVEO - Tier 2; PA M-M-R II - Tier 2; PA PEDVAX HIB - Tier 2; PA RABAVERT - Tier 2; PA RECOMBIVAX HB - Tier 2; PA ROTARIX - Tier 2; PA ROTATEQ - Tier 2; PA SHINGRIX - Tier 2; PA STAMARIL - Tier 2; PA TRUMENBA - Tier 2; PA TWINRIX - Tier 2; PA TYPHIM VI - Tier 2; PA VAQTA - Tier 2; PA VARIVAX - Tier 2; PA YF-VAX - Tier 2; PA Immunological Agents - Drugs that Stimulate or Suppress the Immune System Immunizing Agents, Passive - Immune System Drugs HYPERTET S/D - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 137 Preferred Agents Non-Preferred Agents Vaccines AFLURIA QUADRIVALENT - Tier 2 BIOTHRAX - Tier 2; PA FLUAD QUADRIVALENT - Tier 2 HEPLISAV-B - Tier 2; PA FLUARIX QUADRIVALENT - Tier 2 SAPHNELO - Tier 2; PA FLUCELVAX QUADRIVALENT - Tier 2 VAXCHORA - Tier 2; PA FLULAVAL QUADRIVALENT - Tier 2 FLUMIST QUADRIVALENT - Tier 2 FLUZONE HIGH-DOSE QUADRIVALENT - Tier 2 FLUZONE QUADRIVALENT - Tier 2 PNEUMOVAX 23 - Tier 2; QL; AL PREVNAR 13 - Tier 2; QL; AL Inflammatory Bowel Disease Agents Aminosalicylates APRISO (brand for mesalamine er) - Tier 2; QL ASACOL HD (brand for mesalamine) - Tier 2; PA; QL CANASA (brand for mesalamine) - Tier 2; QL AZULFIDINE (brand for sulfasalazine) - Tier 2; PA; QL mesalamine oral tablet delayed release 1.2 gm (generic for LIALDA) - AZULFIDINE EN-TABS (brand for sulfasalazine) - Tier 2; PA; QL Tier 1; QL balsalazide disodium (generic for COLAZAL) - Tier 1; PA; QL mesalamine-cleanser (generic for ROWASA) - Tier 1; QL COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL DIPENTUM - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; PA; QL mesalamine er oral capsule 0.375 gm (generic for APRISO) - Tier 1; PA; QL mesalamine oral capsule delayed release 400 mg (generic for DELZICOL) - Tier 1; PA; QL mesalamine oral tablet delayed release 800 mg (generic for ASACOL HD) - Tier 1; PA; QL mesalamine rectal - Tier 1; PA; QL PENTASA - Tier 2; PA; QL ROWASA (brand for mesalamine-cleanser) - Tier 2; PA; QL SFROWASA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 138 Preferred Agents Non-Preferred Agents Glucocorticoids budesonide oral (generic for ENTOCORT EC) - Tier 1 ANUSOL-HC EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; hydrocortisone (perianal) (generic for PROCTO-PAK) - Tier 1; QL PA; QL hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) budesonide er (generic for UCERIS) - Tier 1; PA - Tier 1; QL CORTENEMA (brand for hydrocortisone) - Tier 2; PA; QL procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL CORTIFOAM - Tier 2; PA procto-pak (generic for PROCTO-PAK) - Tier 1; QL ENTOCORT EC (brand for budesonide) - Tier 2; PA proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL ORTIKOS - Tier 2; PA; QL; AL PROCTOCORT EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; PA; QL UCERIS (brand for budesonide er) - Tier 2; PA Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Glucocorticoids - Drugs to Treat Inflammation anucort-hc (generic for ANUSOL-HC) - Tier 1; PA ANUSOL-HC RECTAL (brand for anucort-hc) - Tier 2; PA HEMMOREX-HC (brand for anucort-hc) - Tier 2; PA hydrocortisone acetate rectal (generic for ANUSOL-HC) - Tier 1; PA PROCTOCORT RECTAL (brand for hydrocortisone acetate) - Tier 2; PA Metabolic Bone Disease Agents alendronate sodium oral tablet 10 mg, 35 mg - Tier 1; QL ACTONEL (brand for risedronate sodium) - Tier 2; PA; QL alendronate sodium oral tablet 70 mg (generic for FOSAMAX) - Tier 1; alendronate sodium oral solution - Tier 1; PA; QL QL ATELVIA (brand for risedronate sodium) - Tier 2; PA; QL calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL BONIVA (brand for ibandronate sodium) - Tier 2; PA; QL calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL doxercalciferol oral - Tier 1; PA calcitriol oral solution (generic for ROCALTROL) - Tier 1; QL; AL FORTEO (brand for teriparatide (recombinant)) - Tier 2; PA cinacalcet hcl oral tablet 30 mg, 90 mg (generic for SENSIPAR) - Tier FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL 1; PA; QL; AL FOSAMAX PLUS D - Tier 2; PA; QL cinacalcet hcl oral tablet 60 mg (generic for SENSIPAR) - Tier 1; NATPARA - Tier 2; PA; SP; QL DX2RX; QL; AL paricalcitol oral (generic for ZEMPLAR) - Tier 1; PA ibandronate sodium oral (generic for BONIVA) - Tier 1; QL RAYALDEE - Tier 2; PA; QL TERIPARATIDE (RECOMBINANT) - Tier 2; SP; QL risedronate sodium - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 139 Preferred Agents Non-Preferred Agents ROCALTROL ORAL CAPSULE (brand for calcitriol) - Tier 2; PA; QL ROCALTROL ORAL SOLUTION (brand for calcitriol) - Tier 2; PA; QL; AL SENSIPAR ORAL TABLET 30 MG, 90 MG (brand for cinacalcet hcl) - Tier 2; PA; QL; AL SENSIPAR ORAL TABLET 60 MG (brand for cinacalcet hcl) - Tier 2; DX2RX; QL; AL TYMLOS - Tier 2; PA; SP; QL ZEMPLAR ORAL (brand for paricalcitol) - Tier 2; PA

Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Other PARSABIV - Tier 2; PA Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA DEVICE (brand for element compact control 3) - ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for element compact Tier 2 test) - Tier 2; PA ACCU-CHEK COMPACT PLUS CONTROL (brand for element ACCU-CHEK COMPACT PLUS (brand for element compact test) - Tier 2; compact control 3) - Tier 2 PA ACCU-CHEK GUIDE CONTROL (brand for element compact control ACCU-CHEK GUIDE TEST STRIPS (brand for kroger blood glucose) - 3) - Tier 2 Tier 2; PA; QL ACCU-CHEK SMARTVIEW CONTROL (brand for element compact ACCU-CHEK GUIDE TEST STRIPS (brand for element compact test) - control 3) - Tier 2 Tier 2; PA ACCUTREND GLUCOSE CONTROL (brand for element compact ACCU-CHEK SMARTVIEW (brand for element compact test) - Tier 2; PA control 3) - Tier 2 ACCU-CHEK TENDER 1 INFUSION - Tier 2; PA acne (generic for CLEARSKIN) - Tier 1 ACCUTREND GLUCOSE (brand for element compact test) - Tier 2; PA acne control cleanser (generic for CLEARSKIN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 140 Preferred Agents Non-Preferred Agents acne medication 10 external lotion - Tier 1 ACE AEROSOL CLOUD ENHANCER (brand for filter air pp) - Tier 2; PA; acne medication 5 external lotion - Tier 1 QL ALCOHOL PREP PADS PAD - Tier 2; QL ACESO AG - Tier 2; PA ALCOHOL PREP PADS PAD 70 % - Tier 2; QL ACUNOL (brand for bhi skin eczema relief) - Tier 2; PA ANASPAZ (brand for ed-spaz) - Tier 2; QL ADULT AEROSOL MASK - Tier 2; PA; QL antibiotic (generic for BACITRAYCIN PLUS) - Tier 1 ADVANCED GLUCOSE TEST (brand for element compact test) - Tier 2; antifungal (tolnaftate) (generic for TINACTIN) - Tier 1 PA antifungal external cream 1 % (generic for TINACTIN) - Tier 1 AEROCHAMBER PLUS FLO-VU (brand for pro comfort spacer adult) - anti-fungal external powder (generic for LOTRIMIN AF) - Tier 1 Tier 2; PA; QL antifungal tolnaftate (generic for TINACTIN) - Tier 1 AEROCHAMBER PLUS FLO-VU LARGE (brand for pro comfort spacer arthritis pain relieving - Tier 1; QL adult) - Tier 2; PA; QL aspirin adults (generic for BAYER ASPIRIN) - Tier 1; QL aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL AEROCHAMBER PLUS FLO-VU SMALL (brand for pro comfort spacer aspirin ec (generic for BAYER ASPIRIN) - Tier 1; QL adult) - Tier 2; PA; QL aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1; AEROCHAMBER PLUS FLO-VU W/MASK (brand for pro comfort spacer QL adult) - Tier 2; PA; QL aspirin oral (generic for ST JOSEPH LOW DOSE) - Tier 1; QL aminoamrms - Tier 1; PA ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for aminoreliefrms - Tier 1; PA aspirin ec low dose) - Tier 2; QL ANTIVENIN LATRODECTUS MACTANS - Tier 2; PA aspirin rectal - Tier 1 ANTIVENIN MICRURUS FULVIUS - Tier 2; PA atabex dha 200 - Tier 1 ARIDA (brand for cvs anti-microbial silver) - Tier 2; PA athletes foot (tolnaftate) external aerosol powder 1 % (generic for athletes foot spray (generic for TINACTIN) - Tier 1; PA ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 AZADROX (brand for cvs anti-microbial silver) - Tier 2; PA AZALGIA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 141 Preferred Agents Non-Preferred Agents athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) - BAYER ASPIRIN TABLET 325 MG ORAL (brand for ra pain relief aspirin) Tier 1 - Tier 2; PA; QL athletes foot powder spray external aerosol powder 1 % (generic for benzepro external foam 5.3 % - Tier 1; PA ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 BENZEPRO FOAMING CLOTHS (brand for bpo foaming cloths) - Tier 2; bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1 PA BAYER ASPIRIN ORAL TABLET DELAYED RELEASE (brand for px BHI URI-CONTROL - Tier 2; PA enteric aspirin) - Tier 2; QL BLOOD GLUCOSE TEST IN VITRO STRIP - Tier 2; PA BAYER ASPIRIN TABLET 325 MG ORAL (brand for ra pain relief BLOOD GLUCOSE TEST STRIPS (brand for element compact test) - Tier aspirin) - Tier 2; QL 2; PA BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier BLUESTAR - Tier 2; PA 2; QL BREATHE EASE NEB MASK/CHILD - Tier 2; PA; QL BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL BREATHE EASE NEB MASK/INFANT - Tier 2; PA; QL BD ULTRA-FINE PEN NEEDLES (brand for sure comfort pen needles) BREXAFEMME - Tier 2; PA; QL - Tier 2; QL BUBBLES THE FISH II PEDI MASK (brand for filter air pp) - Tier 2; PA; BENZAC AC WASH (brand for bp wash) - Tier 2 QL bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1 CAMINO PRO COMPLETE/GLYTACTIN - Tier 2; PA bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1; QL CARETOUCH 2 CPAP HOSE HANGER (brand for filter air pp) - Tier 2; bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL PA; QL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 CARETOUCH CPAP & BIPAP HOSE (brand for filter air pp) - Tier 2; PA; capsaicin external cream (generic for DERMACINRX PENETRAL) - QL Tier 1; QL CARETOUCH CPAP MASK WIPES (brand for filter air pp) - Tier 2; PA; capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL QL capzix (generic for ZOSTRIX HP) - Tier 1; QL CARETOUCH CPAP PRE-WASH SOLN (brand for filter air pp) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 142 Preferred Agents Non-Preferred Agents CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact CARETOUCH CPAP TUBE BRUSH (brand for filter air pp) - Tier 2; PA; control 3) - Tier 2 QL childrens aspirin oral tablet chewable 81 mg (generic for ST JOSEPH CARETOUCH MONITOR SYSTEM (brand for kroger blood glucose) - LOW DOSE) - Tier 1; QL Tier 2; PA; QL c-lax laxative (generic for EX-LAX ULTRA) - Tier 1 CARETOUCH TEST (brand for element compact test) - Tier 2; PA clearskin (generic for CLEARSKIN) - Tier 1 CARETOUCH UNIVERSL CPAP FILTER (brand for filter air pp) - Tier 2; dha - Tier 1 PA; QL double antibiotic (generic for POLYSPORIN) - Tier 1 CAYA - Tier 2; PA EASIVENT (brand for pro comfort spacer adult) - Tier 2; QL COLCIGEL (brand for arnicare) - Tier 2; PA EASIVENT MASK LARGE (brand for pro comfort spacer adult) - Tier COLLATYL (brand for cvs anti-microbial silver) - Tier 2; PA 2; QL COMFORT TOUCH INSULIN PEN NEED (brand for easy comfort pen needles) - Tier 2; PA; QL EASIVENT MASK MEDIUM (brand for pro comfort spacer adult) - Tier CONTOUR MONITOR (brand for kroger blood glucose) - Tier 2; PA; QL 2; QL CONTOUR CONTROL SOLUTION (brand for easy plus ii control) - Tier 2; EASIVENT MASK SMALL (brand for pro comfort spacer adult) - Tier 2; PA QL CONTOUR MONITOR (brand for liberty blood glucose meter) - Tier 2; EASYMAX 15 LEVEL 2 CONTROL (brand for element compact PA; QL control 3) - Tier 2 CONTOUR NEXT EZ KIT W/DEVICE (brand for kroger blood glucose) - EASYMAX 15 LEVEL 2-3 CONTROL (brand for element compact Tier 2; PA; QL control 3) - Tier 2 CONTOUR NEXT LINK KIT W/DEVICE (brand for kroger blood glucose) - GLUCOSE CONTROL SOLUTIONS (brand for element compact Tier 2; PA; QL control 3) - Tier 2 CONTOUR NEXT MONITOR KIT W/DEVICE (brand for kroger blood ED-SPAZ - Tier 2; QL glucose) - Tier 2; PA; QL enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL CONTOUR NEXT ONE KIT - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 143 Preferred Agents Non-Preferred Agents EX-LAX ULTRA (brand for goodsense womens laxative) - Tier 2 CONTOUR NEXT TEST STRIPS (brand for element compact test) - Tier eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE 2; PA COMFORT) - Tier 1 CONTOUR TEST STRIPS (brand for element compact test) - Tier 2; PA fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL CROFAB - Tier 2; PA FLEET BISACODYL - Tier 2 D-CARE BLOOD GLUCOSE (brand for element compact test) - Tier 2; folic acid oral tablet 1 mg - Tier 1; QL PA foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER D-CARE GLUCOMETER (brand for kroger blood glucose) - Tier 2; PA; SPRAY) - Tier 1 QL fungi-guard (generic for TINACTIN) - Tier 1 DX1 ORAGENOMIC DNA SCREEN (brand for medicated dna collection gentle laxative oral tablet delayed release 5 mg (generic for EX-LAX 2) - Tier 2; PA ULTRA) - Tier 1 DX2 ORAGENOMIC DNA SCREEN (brand for medicated dna collection 2) - Tier 2; PA gentle laxative rectal suppository 10 mg (generic for THE MAGIC EASY TOUCH TEST (brand for element compact test) - Tier 2; PA BULLET) - Tier 1; QL EASYMAX 15 TEST (brand for element compact test) - Tier 2; PA gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1 EASYMAX CONTROL (brand for easy trak control) - Tier 2; PA GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for EASYMAX NG BLOOD GLUCOSE (brand for kroger blood glucose) - Tier element compact control 3) - Tier 2 2; PA; QL h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; BLOOD GLUCOSE TEST STRIPS (brand for element compact test) - Tier QL 2; PA hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL EASYMAX V BLOOD GLUCOSE (brand for liberty blood glucose meter) - hyoscyamine sulfate oral elixir - Tier 1; QL Tier 2; PA; QL hyoscyamine sulfate oral solution - Tier 1 EBASE CONTROLLER KIT (brand for filter air pp) - Tier 2; PA; QL hyoscyamine sulfate oral tablet (generic for LEVSIN) - Tier 1; QL ECZEMOL (brand for bhi skin eczema relief) - Tier 2; PA EXACTECH R-S-G TEST (brand for element compact test) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 144 Preferred Agents Non-Preferred Agents hyoscyamine sulfate oral tablet dispersible (generic for ANASPAZ) - EXACTECH TEST (brand for element compact test) - Tier 2; PA Tier 1; QL FILTER AIR PP - Tier 2; PA; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL FLEXICHAMBER (brand for pro comfort spacer adult) - Tier 2; PA; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL FLEXICHAMBER ADULT MASK/SMALL - Tier 2; PA hyosyne oral elixir - Tier 1; QL FLEXICHAMBER CHILD MASK/LARGE - Tier 2; PA hyosyne oral solution - Tier 1 FLEXICHAMBER CHILD MASK/SMALL - Tier 2; PA INSPIREASE (brand for pro comfort spacer adult) - Tier 2; QL FORTISCARE CONTROL (brand for easy plus ii control) - Tier 2; PA INSPIREASE RESERVOIR BAGS - Tier 2; QL FORTISCARE G1 TEST STRIP (brand for element compact test) - Tier 2; jock itch max st (generic for ODOR EATERS FOOT/SNEAKER PA SPRAY) - Tier 1 FORTISCARE T1 GLUCOSE SYSTEM (brand for liberty blood glucose jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER meter) - Tier 2; PA; QL SPRAY) - Tier 1 FORTISCARE TEST (brand for element compact test) - Tier 2; PA laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) FREESTYLE PRECISION NEO SYSTEM (brand for kroger blood - Tier 1 glucose) - Tier 2; PA; QL laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - FREESTYLE PRECISION NEO TEST (brand for element compact test) - Tier 1; QL Tier 2; PA LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL GELSYN-3 - Tier 2; PA LEVSIN ORAL (brand for hyoscyamine sulfate) - Tier 2; QL GLUCOSE CONTROL SOLUTION IN VITRO LIQUID (brand for easy trak LEVSIN/SL (brand for oscimin) - Tier 2; QL control) - Tier 2; PA magnesium oxide oral tablet 400 mg - Tier 1 GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION HIGH , LOW MASK VORTEX/CHILD/FROG - Tier 2 (brand for easy plus ii control) - Tier 2; PA MASK VORTEX/TODDLER/LADYBUG - Tier 2 GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION NORMAL MEDISENSE GLUCOSE KETONE CONTR (brand for element (brand for easy trak control) - Tier 2; PA compact control 3) - Tier 2 GLUCOSE METER TEST STRIPS - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 145 Preferred Agents Non-Preferred Agents MEDISENSE HI/MID/LOW CONTROL (brand for element compact GLYTACTIN COMPLETE 10PE - Tier 2; PA control 3) - Tier 2 HCU EASY (brand for menopause formula) - Tier 2; PA MEDISENSE HIGH/LOW CONTROL (brand for element compact HOME PAP KIT - Tier 2; PA control 3) - Tier 2 HUMATROPEN FOR 12MG (brand for inject-ease) - Tier 2; PA MEDISENSE MID CONTROL (brand for element compact control 3) - HUMATROPEN FOR 24MG (brand for inject-ease) - Tier 2; PA Tier 2 HUMATROPEN FOR 6MG (brand for inject-ease) - Tier 2; PA NEUTEK 2TEK CONTROL (brand for element compact control 3) - HYLAFEM - Tier 2; PA Tier 2 HYMOVIS - Tier 2; PA NULEV (brand for ed-spaz) - Tier 2; QL INSPIRACHAMBER/LARGE (brand for pro comfort spacer adult) - Tier 2; OMNIFLEX DIAPHRAGM - Tier 2; QL; GE PA; QL ONETOUCH ULTRA TEST STRIPS (brand for element compact test) - INSPIRACHAMBER/MEDIUM (brand for pro comfort spacer adult) - Tier Tier 2; QL 2; PA; QL ONETOUCH ULTRA 2 KIT W/DEVICE (brand for kroger blood INSPIRACHAMBER/MOUTHPIECE (brand for pro comfort spacer adult) - glucose) - Tier 2; QL Tier 2; PA; QL ONETOUCH ULTRA CONTROL (brand for element compact control INSPIRACHAMBER/SMALL (brand for pro comfort spacer adult) - Tier 2; 3) - Tier 2 PA; QL ONETOUCH ULTRA MINI KIT W/DEVICE (brand for kroger blood INSULIN PEN NEEDLES 29G X 12.7MM (brand for ultiguard safepack glucose) - Tier 2; QL pen needle) - Tier 2; PA; QL ONETOUCH VERIO KIT W/DEVICE (brand for kroger blood glucose) - INSULIN PEN NEEDLES 29G X 12MM , 29G X 5MM , 29G X 8MM , 31G Tier 2; QL X 5 MM , 31G X 6 MM , 31G X 8 MM - Tier 2; PA; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for kroger INSULIN PEN NEEDLES 30G X 8 MM , 32G X 5 MM (brand for pen blood glucose) - Tier 2; QL needles) - Tier 2; PA; QL ONETOUCH VERIO IN VITRO SOLUTION (brand for element INSULIN PEN NEEDLES 32G X 4 MM (brand for qc unifine pentips) - Tier compact control 3) - Tier 2 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 146 Preferred Agents Non-Preferred Agents ONETOUCH VERIO TEST STRIPS (brand for element compact test) - INSULIN PEN NEEDLES 32G X 6 MM (brand for sure comfort pen Tier 2; QL needles) - Tier 2; PA; QL ONETOUCH VERIO IQ SYSTEM (brand for kroger blood glucose) - INSULIN PEN NEEDLES 33G X 4 MM (brand for easy comfort pen Tier 2; QL needles) - Tier 2; PA; QL ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for kroger INSULIN SYRINGES 27G X 1/2" 0.5 ML (brand for insulin syringe) - Tier blood glucose) - Tier 2; QL 2; PA; QL ONETOUCH VERIO SYNC SYSTEM (brand for kroger blood glucose) INSULIN SYRINGES 27G X 1/2" 1 ML (brand for safety insulin syringes) - - Tier 2; QL Tier 2; PA; QL oscimin (generic for LEVSIN) - Tier 1; QL INSULIN SYRINGES 28G X 1/2" 0.5 ML, 30G X 1/2" 0.3 ML, 30G X 5/16" oscimin sr (generic for LEVBID) - Tier 1; QL 0.3 ML (brand for sure comfort insulin syringe) - Tier 2; PA; QL PANOXYL (brand for bp wash) - Tier 2 INSULIN SYRINGES 28G X 1/2" 1 ML, 29G X 1/2" 1 ML (brand for poly bacitracin (generic for POLYSPORIN) - Tier 1 preferred plus insulin syringe) - Tier 2; PA; QL poly bacitracin external ointment (generic for POLYSPORIN) - Tier 1 INSULIN SYRINGES 28G X 5/16" 1 ML, 29G X 5/16" 1 ML, 30G X 3/8" POLYSPORIN (brand for bacitracin-polymyxin b) - Tier 2 0.5 ML - Tier 2; PA; QL PRECISION GLUCOSE CONTROL (brand for element compact INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for kroger insulin syringe) control 3) - Tier 2 - Tier 2; PA; QL PRECISION GLUCOSE CONTROL SOLN (brand for element compact INSULIN SYRINGES 29G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML (brand for control 3) - Tier 2 global inject ease insulin syr) - Tier 2; PA; QL PRECISION GLUCOSE KETONE CONTR (brand for element INSULIN SYRINGES 30G X 1/2" 0.5 ML, 31G X 15/64" 0.5 ML (brand for compact control 3) - Tier 2 techlite insulin syringe) - Tier 2; PA; QL PRECISION GLUCOSE/KETONE CONTR (brand for element INSULIN SYRINGES 30G X 1/2" 1 ML (brand for true comfort pro insulin compact control 3) - Tier 2 syr) - Tier 2; PA; QL prenatal dha - Tier 1 INSULIN SYRINGES 30G X 5/16" 0.5 ML (brand for easy comfort insulin syringe) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 147 Preferred Agents Non-Preferred Agents QUINTET CONTROL HIGH/NORMAL (brand for element compact INSULIN SYRINGES 30G X 5/16" 1 ML (brand for gnp insulin syringe) - control 3) - Tier 2 Tier 2; PA; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR INSULIN SYRINGES 31G X 15/64" 0.3 ML (brand for global easy glide EYES REDNESS RELIEF) - Tier 1; QL insulin syr) - Tier 2; PA; QL sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC INSULIN SYRINGES 31G X 5/16" 0.5 ML (brand for topcare ultra comfort LOW DOSE) - Tier 1; QL ins syr) - Tier 2; PA; QL SOLARTEK GLUCOSE CONTROL (brand for element compact INSULIN SYRINGES 31G X 5/16" 1 ML (brand for careone insulin control 3) - Tier 2 syringe) - Tier 2; PA; QL ST JOSEPH LOW DOSE (brand for ra aspirin adult low strength) - Tier KROGER BLOOD GLUCOSE KIT - Tier 2; PA; QL 2; QL KROGER TEST - Tier 2; PA sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1; MACRILEN - Tier 2; PA; SP; QL QL MEDICATED DNA COLLECTION - Tier 2; PA SYMAX-SL (brand for oscimin) - Tier 2; QL MEDICATED DNA COLLECTION 2 - Tier 2; PA SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL METOPIRONE - Tier 2; PA the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL MICRODOT PEN NEEDLE (brand for clickfine pen needles) - Tier 2; PA; TINACTIN EXTERNAL CREAM (brand for eq athletes foot (tolnaftate)) QL - Tier 2 MICRODOT TEST (brand for element compact test) - Tier 2; PA tolnaftate antifungal (generic for TINACTIN) - Tier 1 MM EASY TOUCH GLUCOSE METER (brand for kroger blood glucose) - tolnaftate external cream (generic for TINACTIN) - Tier 1 Tier 2; PA; QL tolnaftate external powder (generic for LOTRIMIN AF) - Tier 1 MODERNA COVID-19 VACCINE - Tier 2; PA; QL TRUECONTROL GLUCOSE CONT LEV 0 (brand for element MORCIN - Tier 2; PA compact control 3) - Tier 2 MSUD EASY (brand for menopause formula) - Tier 2; PA TRUECONTROL GLUCOSE CONT LEV 1 (brand for element NEODOT THERMOMETER - Tier 2; PA; QL compact control 3) - Tier 2 NEUTEK 2TEK TEST (brand for element compact test) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 148 Preferred Agents Non-Preferred Agents womans laxative (generic for EX-LAX ULTRA) - Tier 1 NICAPRIN (brand for nicazyme) - Tier 2; PA womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1 NICAZYME - Tier 2; PA womens laxative oral tablet delayed release 5 mg (generic for EX-LAX NORDIPEN 5 INJECTION DEVICE (brand for inject-ease) - Tier 2; PA ULTRA) - Tier 1 NORDIPEN DELIVERY SYSTEM (brand for inject-ease) - Tier 2; PA ZOSTRIX HP (brand for cvs capsaicin hp) - Tier 2; QL NOVOTWIST PEN NEEDLE 32G X 5 MM (brand for pen needles) - Tier 2; PA; QL NYVEPRIA - Tier 2; PA OASIS ULTRA MATRIX FENESTRATED EXTERNAL SHEET 3X7CM - Tier 2; PA OASIS WOUND MATRIX FENESTRATED EXTERNAL SHEET 3X7CM - Tier 2; PA OMNITROPE PEN 5 INJ DEVICE (brand for inject-ease) - Tier 2; PA OMNIVEX - Tier 2; PA ONETOUCH ULTRALINK (brand for kroger blood glucose) - Tier 2; PA; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; PA; QL ONETOUCH VERIO IN VITRO SOLUTION HIGH (brand for easy plus ii control) - Tier 2; PA ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; PA; QL OPTIUM BLOOD GLUCOSE MONITOR (brand for kroger blood glucose) - Tier 2; PA; QL OPTIUM GLUCOSE MONITOR SYSTEM (brand for liberty blood glucose meter) - Tier 2; PA; QL OPTIUM TEST (brand for element compact test) - Tier 2; PA OPTIUMEZ TEST (brand for element compact test) - Tier 2; PA ORLADEYO - Tier 2; PA; QL; AL OVACE PLUS (brand for sodium sulfacetamide) - Tier 2; PA OVACE PLUS WASH (brand for sodium sulfacetamide wash) - Tier 2; PA OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2; PA PALFORZIA (12 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (120 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (160 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (20 MG DAILY DOSE) - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 149 Preferred Agents Non-Preferred Agents PALFORZIA (200 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (240 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (3 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (300 MG MAINTENANCE) - Tier 2; PA; SP PALFORZIA (300 MG TITRATION) - Tier 2; PA; SP PALFORZIA (40 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (6 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA (80 MG DAILY DOSE) - Tier 2; PA; SP PALFORZIA INITIAL ESCALATION - Tier 2; PA; SP PARI ALTERA NEBULIZER HANDSET (brand for filter air pp) - Tier 2; PA; QL PARI BABY CONVERSION KIT (brand for filter air pp) - Tier 2; PA; QL PARI ERAPID NEBULIZER HANDSET (brand for filter air pp) - Tier 2; PA; QL PARI TREK S COMBO PACK (brand for spiro pd) - Tier 2; PA PARI VORTEX ADULT MASK (brand for filter air pp) - Tier 2; PA; QL PFIZER-BIONTECH COVID-19 VACC - Tier 2; PA; QL PH STRIPS - Tier 2; PA PHEXXI - Tier 2; PA; QL PKU EASY (brand for menopause formula) - Tier 2; PA PKU EASY MICROTABS - Tier 2; PA podocon - Tier 1; PA PRECISION LINK (brand for kroger blood glucose) - Tier 2; PA; QL PRECISION PCX (brand for element compact test) - Tier 2; PA PRECISION PCX PLUS TEST (brand for element compact test) - Tier 2; PA PRECISION POINT OF CARE TEST (brand for element compact test) - Tier 2; PA PRECISION QID MONITOR (brand for liberty blood glucose meter) - Tier 2; PA; QL PRECISION QID TEST (brand for element compact test) - Tier 2; PA PRECISION SOF-TACT MONITOR (brand for liberty blood glucose meter) - Tier 2; PA; QL PRECISION SOF-TACT TEST (brand for element compact test) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 150 Preferred Agents Non-Preferred Agents PRECISION XTRA (brand for liberty blood glucose meter) - Tier 2; PA; QL PRECISION XTRA BLOOD GLUCOSE (brand for element compact test) - Tier 2; PA PRECISION XTRA MONITOR (brand for liberty blood glucose meter) - Tier 2; PA; QL PREMIUM BLOOD GLUCOSE TEST - Tier 2; PA PRO DNA COLLECTION (brand for medicated dna collection 2) - Tier 2; PA PROFESSIONAL DNA COLLECTION - Tier 2; PA PROLEVA - Tier 2; PA PRONEB ULTRA FILTER SET (brand for filter air pp) - Tier 2; PA; QL PSORIZIDE FORTE (brand for bhi skin eczema relief) - Tier 2; PA PSORIZIDE ULTRA (brand for bhi skin eczema relief) - Tier 2; PA QUINTET AC BLOOD GLUCOSE (brand for liberty blood glucose meter) - Tier 2; PA; QL QUINTET AC BLOOD GLUCOSE TEST (brand for element compact test) - Tier 2; PA QUINTET BLOOD GLUCOSE SYSTEM (brand for liberty blood glucose meter) - Tier 2; PA; QL QUINTET BLOOD GLUCOSE TEST (brand for element compact test) - Tier 2; PA RAPID GEL RX - Tier 2; PA RELION TRUE MET AIR GLUC METER (brand for kroger blood glucose) - Tier 2; PA; QL RELION TRUE METRIX TEST STRIPS (brand for element compact test) - Tier 2; PA RELION ULTIMA GLUCOSE SYSTEM (brand for kroger blood glucose) - Tier 2; PA; QL RELION ULTIMA TEST (brand for element compact test) - Tier 2; PA REPLACEMENT FILTERS - Tier 2; PA; QL RX-SPECIMEN COLLECTION - Tier 2; PA SEVENFACT - Tier 2; PA; SP; AL sodium sulfacetamide (generic for OVACE PLUS) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 151 Preferred Agents Non-Preferred Agents sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1; PA SOLOX (brand for cvs anti-microbial silver) - Tier 2; PA SPEEDGEL RX (brand for arnicare) - Tier 2; PA sulfacetamide sodium external (generic for OVACE PLUS WASH) - Tier 1; PA TEGADERM AG MESH EXTERNAL PAD 2"X2" , 4"X8" , 8"X8" - Tier 2; PA TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2; PA TRANZGEL (brand for arnicare) - Tier 2; PA TRAUMEEL EXTERNAL (brand for calendula) - Tier 2; PA TRAUMEEL ORAL (brand for bhi skin eczema relief) - Tier 2; PA TRUE FOCUS BLOOD GLUCOSE STRIP - Tier 2; PA TRUE METRIX AIR GLUCOSE METER (brand for kroger blood glucose) - Tier 2; PA; QL TRUE METRIX GO GLUCOSE METER (brand for kroger blood glucose) - Tier 2; PA; QL TRUE METRIX METER KIT (brand for kroger blood glucose) - Tier 2; PA; QL TRUETRACK BLOOD GLUCOSE (brand for liberty blood glucose meter) - Tier 2; PA; QL TRUETRACK TEST (brand for element compact test) - Tier 2; PA TUBING/WING TIP - Tier 2; PA; QL TYLACTIN COMPLETE 15 PE - Tier 2; PA TYR EASY (brand for menopause formula) - Tier 2; PA ULTIMA - Tier 2; PA; QL ULTRA HERS RX - Tier 2; PA ULTRA HIS - Tier 2; PA ULTRA PCOS - Tier 2; PA UNISTRIP CONTROL (brand for easy plus ii control) - Tier 2; PA UNISTRIP1 GENERIC (brand for element compact test) - Tier 2; PA VASCULERA (brand for nicazyme) - Tier 2; PA VORTEX HOLD CHMBR/MASK/CHILD (brand for spiro pd) - Tier 2; PA VORTEX HOLD CHMBR/MASK/TODDLER (brand for spiro pd) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 152 Preferred Agents Non-Preferred Agents VORTEX VALVED HOLDING CHAMBER (brand for pro comfort spacer adult) - Tier 2; PA; QL WELLMIND VERTIGO (brand for bhi skin eczema relief) - Tier 2; PA WIDE-SEAL DIAPHRAGM 60 - Tier 2; PA WIDE-SEAL DIAPHRAGM 65 - Tier 2; PA WIDE-SEAL DIAPHRAGM 70 - Tier 2; PA WIDE-SEAL DIAPHRAGM 75 - Tier 2; PA WIDE-SEAL DIAPHRAGM 80 - Tier 2; PA WIDE-SEAL DIAPHRAGM 85 - Tier 2; PA WIDE-SEAL DIAPHRAGM 90 - Tier 2; PA WIDE-SEAL DIAPHRAGM 95 - Tier 2; PA XYZBAC - Tier 2; PA XYZMUNE - Tier 2; PA ZOKINVY - Tier 2; PA; SP; QL ZYVEXOL - Tier 2; PA ZYVIT - Tier 2; PA Molecular Target Inhibitors - Chemotherapy Agents Antineoplastics - Drugs to Treat Cancer ALECENSA - Tier 2; SP; QL ALUNBRIG - Tier 2; PA; SP; QL CAPRELSA - Tier 2; SP; QL AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG - Tier 2; PA imatinib mesylate (generic for GLEEVEC) - Tier 1; SP; QL AYVAKIT ORAL TABLET 25 MG, 50 MG - Tier 2; PA; SP IMBRUVICA - Tier 2; SP; QL BOSULIF - Tier 2; PA; SP; QL INLYTA - Tier 2; SP; QL BRUKINSA - Tier 2; PA; SP; QL LENVIMA (10 MG DAILY DOSE) - Tier 2; SP; QL CABOMETYX - Tier 2; PA; SP; QL LENVIMA (12 MG DAILY DOSE) - Tier 2; SP; QL CALQUENCE - Tier 2; PA; SP; QL LENVIMA (14 MG DAILY DOSE) - Tier 2; SP; QL COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (18 MG DAILY DOSE) - Tier 2; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (20 MG DAILY DOSE) - Tier 2; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (24 MG DAILY DOSE) - Tier 2; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; SP; QL FOTIVDA - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 153 Preferred Agents Non-Preferred Agents LENVIMA (8 MG DAILY DOSE) - Tier 2; SP; QL GAVRETO - Tier 2; PA; SP; QL SPRYCEL - Tier 2; SP; QL GILOTRIF - Tier 2; PA; SP; QL TAGRISSO - Tier 2; SP; QL GLEEVEC (brand for imatinib mesylate) - Tier 2; PA; SP; QL VOTRIENT - Tier 2; SP; QL ICLUSIG ORAL TABLET 10 MG, 30 MG - Tier 2; PA; SP ICLUSIG ORAL TABLET 15 MG, 45 MG - Tier 2; PA; SP; QL IRESSA - Tier 2; PA; SP; QL lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL NERLYNX - Tier 2; PA; SP; QL QINLOCK - Tier 2; PA; SP RETEVMO - Tier 2; PA; SP; AL TABRECTA - Tier 2; PA; SP; QL TARCEVA (brand for erlotinib hcl) - Tier 2; PA; SP; QL TASIGNA - Tier 2; PA; SP; QL TEPMETKO - Tier 2; PA; QL TUKYSA - Tier 2; PA; SP; QL TURALIO - Tier 2; PA; SP; QL TYKERB (brand for lapatinib ditosylate) - Tier 2; PA; SP; QL UKONIQ - Tier 2; PA VIZIMPRO - Tier 2; PA; SP; QL XALKORI - Tier 2; PA; SP; QL XOSPATA - Tier 2; PA; SP; QL Monoclonal Antibodies - Chemotherapy Agents Antineoplastics - Drugs to Treat Cancer IMFINZI INTRAVENOUS SOLUTION 500 MG/10ML - Tier 2; PA JEMPERLI - Tier 2; PA MARGENZA - Tier 2; PA OPDIVO INTRAVENOUS SOLUTION 240 MG/24ML - Tier 2; PA TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML - Tier 2; PA TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG - Tier 2; PA ZYNLONTA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 154 Preferred Agents Non-Preferred Agents Multiple Sclerosis Agents - Multiple Sclerosis Drugs Central Nervous System Agents - Drugs to Treat Nerve Conditions PONVORY - Tier 2; PA; SP; QL PONVORY STARTER PACK - Tier 2; PA; SP; QL Not Specified EXEM - Tier 2; PA SILATRIX - Tier 2; PA WELIREG - Tier 2; PA Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL bimatoprost ophthalmic - Tier 1; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; QL LUMIGAN - Tier 2; PA; QL travoprost (bak free) (generic for TRAVATAN Z) - Tier 1; PA; QL VYZULTA - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL XELPROS - Tier 2; PA ZIOPTAN - Tier 2; PA; QL Ophthalmic Agents, Other altafrin (generic for ALTAFRIN) - Tier 1 bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; atropine sulfate ophthalmic ointment - Tier 1 PA atropine sulfate ophthalmic solution 1 % (generic for ISOPTO BLEPHAMIDE (brand for sulfacetamide-prednisolone) - Tier 2; PA ATROPINE) - Tier 1; QL BLEPHAMIDE S.O.P. - Tier 2; PA COMBIGAN - Tier 2; QL CEQUA - Tier 2; PA; QL cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL Tier 1; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL CYSTARAN - Tier 2; PA; SP; QL CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (brand for dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL cyclopentolate hcl) - Tier 2; PA ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL CYCLOGYL OPHTHALMIC SOLUTION 1 % (brand for cyclopentolate neomycin-polymyxin-dexameth ophthalmic ointment (generic for hcl) - Tier 2; PA; QL MAXITROL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 155 Preferred Agents Non-Preferred Agents neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 cyclopentolate hcl ophthalmic solution 0.5 %, 2 % (generic for (generic for MAXITROL) - Tier 1 CYCLOGYL) - Tier 1; PA phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1 CYSTADROPS - Tier 2; PA; SP; QL RESTASIS - Tier 2 dorzolamide hcl-timolol mal pf (generic for COSOPT PF) - Tier 1; PA; QL RESTASIS MULTIDOSE - Tier 2 LACRISERT - Tier 2; PA ROCKLATAN - Tier 2; DX2RX; ST; QL LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.5 sulfacetamide-prednisolone ophthalmic solution - Tier 1 MG/0.05ML - Tier 2; PA TOBRADEX OPHTHALMIC OINTMENT - Tier 2 MAXITROL (brand for neomycin-polymyxin-dexameth) - Tier 2; PA XIIDRA - Tier 2 neomycin-polymyxin-hc ophthalmic - Tier 1; PA neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; PA OXERVATE - Tier 2; PA; SP; QL PRED-G - Tier 2; PA PRED-G S.O.P. - Tier 2; PA TOBRADEX OPHTHALMIC SUSPENSION (brand for tobramycin- dexamethasone) - Tier 2; PA TOBRADEX ST - Tier 2; PA tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; PA ZYLET - Tier 2; PA Ophthalmic Anti-allergy Agents cromolyn sodium ophthalmic - Tier 1 ALOCRIL - Tier 2; PA ALOMIDE - Tier 2; PA azelastine hcl ophthalmic - Tier 1; PA bepotastine besilate (generic for BEPREVE) - Tier 1; PA BEPREVE (brand for bepotastine besilate) - Tier 2; PA epinastine hcl - Tier 1; PA LASTACAFT - Tier 2; PA olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; PA PATADAY OPHTHALMIC SOLUTION 0.1 % (brand for eye allergy itch/redness rel) - Tier 2; PA PATADAY OPHTHALMIC SOLUTION 0.2 % (brand for eye allergy itch relief) - Tier 2; PA ZERVIATE - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 156 Preferred Agents Non-Preferred Agents Ophthalmic Anti-Infectives ak-poly-bac (generic for POLYCIN) - Tier 1 AZASITE - Tier 2; PA; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1 bacitracin ophthalmic - Tier 1; PA ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1 BESIVANCE - Tier 2; PA erythromycin ophthalmic - Tier 1 BLEPH-10 (brand for sulfacetamide sodium) - Tier 2; PA gentak - Tier 1 CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA gentamicin sulfate ophthalmic - Tier 1 gatifloxacin ophthalmic (generic for ZYMAXID) - Tier 1; PA ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1 KLARITY-A - Tier 2; PA; QL polycin (generic for POLYCIN) - Tier 1 levofloxacin ophthalmic - Tier 1; PA polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1 MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA tobramycin ophthalmic (generic for TOBREX) - Tier 1 moxifloxacin hcl (2x day) (generic for MOXEZA) - Tier 1; PA trifluridine - Tier 1; QL moxifloxacin hcl ophthalmic solution (generic for VIGAMOX) - Tier 1; PA NATACYN - Tier 2; PA neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1; PA neomycin-polymyxin-gramicidin - Tier 1; PA neo-polycin (generic for NEO-POLYCIN) - Tier 1; PA OCUFLOX (brand for ofloxacin) - Tier 2; PA POLYTRIM (brand for polymyxin b-trimethoprim) - Tier 2; PA sulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1; PA TOBREX - Tier 2; PA VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA ZYMAXID (brand for gatifloxacin) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 157 Preferred Agents Non-Preferred Agents Ophthalmic Anti-inflammatories ALREX - Tier 2 ACULAR (brand for ketorolac tromethamine) - Tier 2; PA diclofenac sodium ophthalmic - Tier 1 ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA fluorometholone (generic for FML LIQUIFILM) - Tier 1 ACUVAIL - Tier 2; PA ketorolac tromethamine ophthalmic solution 0.5 % (generic for bromfenac sodium (once-daily) - Tier 1; PA ACULAR) - Tier 1 BROMSITE - Tier 2; PA MAXIDEX - Tier 2 dexamethasone sodium phosphate ophthalmic - Tier 1; PA PRED MILD - Tier 2 DEXYCU - Tier 2; PA DUREZOL - Tier 2; PA EYSUVIS - Tier 2; PA; QL FLAREX - Tier 2; PA flurbiprofen sodium - Tier 1; PA FML - Tier 2; PA FML FORTE - Tier 2; PA FML LIQUIFILM (brand for fluorometholone) - Tier 2; PA ILEVRO - Tier 2; PA INVELTYS - Tier 2; PA ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1; PA LOTEMAX (brand for loteprednol etabonate) - Tier 2; PA LOTEMAX SM - Tier 2; PA loteprednol etabonate (generic for LOTEMAX) - Tier 1; PA NEVANAC - Tier 2; PA PRED FORTE (brand for prednisolone acetate p-f) - Tier 2; PA prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; PA prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; PA prednisolone sodium phosphate ophthalmic - Tier 1; PA PROLENSA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 158 Preferred Agents Non-Preferred Agents Ophthalmic Beta-Adrenergic Blocking Agents BETIMOL - Tier 2; QL betaxolol hcl ophthalmic - Tier 1; PA; QL levobunolol hcl - Tier 1; QL BETOPTIC-S - Tier 2; PA; QL timolol maleate ophthalmic gel forming solution (generic for carteolol hcl - Tier 1; PA; QL TIMOPTIC-XE) - Tier 1; QL ISTALOL (brand for timolol maleate) - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for timolol maleate ocudose (generic for TIMOPTIC OCUDOSE) - Tier 1; PA; TIMOPTIC) - Tier 1; QL QL timolol maleate ophthalmic solution 0.5 % (daily) (generic for ISTALOL) - Tier 1; PA; QL timolol maleate pf (generic for TIMOPTIC OCUDOSE) - Tier 1; PA; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL TIMOPTIC OCUDOSE - Tier 2; PA; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL Ophthalmic Intraocular Pressure Lowering Agents, Other brimonidine tartrate ophthalmic solution 0.2 % - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL apraclonidine hcl - Tier 1; PA; QL dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier AZOPT (brand for brinzolamide) - Tier 2; PA; QL 1; QL brimonidine tartrate ophthalmic solution 0.15 % (generic for ALPHAGAN ISOPTO CARPINE (brand for pilocarpine hcl) - Tier 2; QL P) - Tier 1; PA; QL methazolamide oral - Tier 1; QL brinzolamide (generic for AZOPT) - Tier 1; PA; QL pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1; QL IOPIDINE - Tier 2; PA; QL RHOPRESSA - Tier 2; ST; QL SIMBRINZA - Tier 2; PA; QL TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 159 Preferred Agents Non-Preferred Agents Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs altalube (generic for ALTALUBE) - Tier 1; QL bimatoprost external (generic for LATISSE) - Tier 1; PA; QL artificial eye (generic for ALTALUBE) - Tier 1; QL FLUORESCEIN SODIUM/BENOXINATE - Tier 2; PA artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1; HYPOCYN - Tier 2; PA QL LATISSE (brand for bimatoprost) - Tier 2; PA; QL artificial tears ophthalmic solution (generic for GENTEAL TEARS) - MYDRIACYL (brand for tropicamide) - Tier 2; PA Tier 1 PAREMYD - Tier 2; PA artificial tears ophthalmic solution 0.5-0.6 %, 1.4 %, 5-6 mg/ml - Tier 1 tropicamide ophthalmic solution 1 % (generic for MYDRIACYL) - Tier 1; astringent eye drops (generic for VISINE-AC) - Tier 1; QL PA BIOLLE TEARS (brand for eq restore plus lubricant eye) - Tier 2 carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) - Tier 1 dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL eye drops long lasting (generic for SYSTANE) - Tier 1; QL eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye drops ophthalmic solution 0.05-0.25 % (generic for VISINE-AC) - Tier 1; QL eye lubricant (generic for ALTALUBE) - Tier 1; QL for sty relief (generic for ALTALUBE) - Tier 1; QL GENTEAL SEVERE - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 160 Preferred Agents Non-Preferred Agents GENTEAL TEARS MODERATE PF (brand for artificial tears pf) - Tier 2 GENTEAL TEARS NIGHT-TIME (brand for cvs nighttime dry-eye relief) - Tier 2; QL GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 % (brand for sm artificial tears) - Tier 2 GENTEAL TEARS PF (brand for artificial tears pf) - Tier 2 GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL HYPOTEARS (brand for cvs nighttime dry-eye relief) - Tier 2; QL ISOPTO TEARS - Tier 2 lubricant drops fast act (generic for SYSTANE) - Tier 1; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for SYSTANE HYDRATION PF) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - Tier 1 lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye pm (generic for ALTALUBE) - Tier 1; QL lubricant pm (generic for ALTALUBE) - Tier 1; QL lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricating eye drops ophthalmic solution 0.5-0.9 % (generic for REFRESH OPTIVE) - Tier 1 lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 161 Preferred Agents Non-Preferred Agents lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 lubricating/dry eye (generic for REFRESH OPTIVE) - Tier 1 natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL polyvinyl alcohol ophthalmic - Tier 1 PURALUBE (brand for cvs nighttime dry-eye relief) - Tier 2; QL REFRESH LACRI-LUBE (brand for cvs nighttime dry-eye relief) - Tier 2; QL REFRESH OPTIVE OPHTHALMIC SOLUTION (brand for lubricating eye drops) - Tier 2 REFRESH OPTIVE PF - Tier 2 REFRESH P.M. (brand for cvs nighttime dry-eye relief) - Tier 2; QL REFRESH PLUS (brand for eq restore plus lubricant eye) - Tier 2 REFRESH RELIEVA (brand for lubricating eye drops) - Tier 2 REFRESH RELIEVA PF OPHTHALMIC SOLUTION 0.5-0.9 % - Tier 2 REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2 relief eye drops (generic for VISINE-AC) - Tier 1; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1 restore pm (generic for ALTALUBE) - Tier 1; QL SYSTANE (brand for goodsense ultra lubricant drop) - Tier 2; QL SYSTANE COMPLETE (brand for lubricant eye drops) - Tier 2; QL SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2 SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE NIGHTTIME (brand for cvs nighttime dry-eye relief) - Tier 2; QL SYSTANE OVERNIGHT THERAPY - Tier 2; QL SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE ULTRA (brand for goodsense ultra lubricant drop) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 162 Preferred Agents Non-Preferred Agents SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL tears pure (generic for GENTEAL TEARS) - Tier 1 tropicamide ophthalmic solution 0.5 % - Tier 1 ultra fresh (generic for ULTRA FRESH) - Tier 1 ultra fresh pm (generic for ALTALUBE) - Tier 1; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL VISINE ADVANCED RELIEF (brand for eye drops maximum relief) - Tier 2; QL VISTA GEL DRY EYE RELIEF - Tier 2; QL VISTA MEIBO TEARS (brand for lubricant eye drops) - Tier 2; QL VISTA TEARS (brand for goodsense ultra lubricant drop) - Tier 2; QL

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs ALAWAY (brand for cvs eye itch relief) - Tier 2 CYCLOMYDRIL - Tier 2; PA ALAWAY CHILDRENS ALLERGY (brand for cvs eye itch relief) - Tier VISINE (brand for eye allergy relief) - Tier 2; PA 2 ZADITOR (brand for cvs eye itch relief) - Tier 2; PA eye itch relief (generic for ALAWAY) - Tier 1 ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1 NAPHCON-A (brand for eye allergy relief) - Tier 2 Ophthalmic Antibiotics - Drugs to treat Eye Infections BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2; PA POVIDONE-IODINE OPHTHALMIC - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 163 Preferred Agents Non-Preferred Agents Otic Agents acetic acid otic - Tier 1 CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA neomycin-polymyxin-hc otic - Tier 1 CIPRO HC - Tier 2; PA ofloxacin otic - Tier 1 CIPRODEX (brand for ciprofloxacin-dexamethasone) - Tier 2; PA ciprofloxacin hcl otic (generic for CETRAXAL) - Tier 1; PA ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; PA CIPROFLOXACIN-FLUOCINOLONE PF - Tier 2; PA; QL CORTISPORIN-TC - Tier 2; PA DERMOTIC (brand for fluocinolone acetonide) - Tier 2; PA; QL flac (generic for FLAC) - Tier 1; PA; QL fluocinolone acetonide otic (generic for FLAC) - Tier 1; PA; QL hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1; PA OTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA; QL Otic Agents - Drugs to Treat Ear Conditions Otic Agents - Drugs for the Ear CLEARCANAL EARWAX SOFTENER (brand for cvs ear wax removal OTIPRIO - Tier 2; PA system) - Tier 2 ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear drops earwax aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 164 Preferred Agents Non-Preferred Agents ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal kit otic solution 6.5 % (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 Respiratory Tract/Pulmonary Agents Antihistamines all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1 all day allergy relief (generic for ZYRTEC ALLERGY) - Tier 1; PA allergy (cetirizine) (generic for KLS ALLER-TEC) - Tier 1 allergy relief oral capsule 10 mg (generic for ZYRTEC ALLERGY) - Tier 1; allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1 PA allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) - azelastine hcl nasal solution 0.15 % - Tier 1; PA Tier 1; QL azelastine-fluticasone (generic for DYMISTA) - Tier 1; PA allergy medication (generic for BANOPHEN) - Tier 1; QL carbinoxamine maleate oral solution - Tier 1; PA; QL allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL carbinoxamine maleate oral tablet 4 mg - Tier 1; PA; QL allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL carbinoxamine maleate oral tablet 6 mg (generic for RYVENT) - Tier 1; ALLERGY) - Tier 1; QL PA allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL cetirizine hcl oral solution 5 mg/5ml (generic for KLS ALLER-TEC allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER- CHILDRENS) - Tier 1; PA TEC) - Tier 1 allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1; cetirizine hcl oral tablet chewable (generic for WAL-ZYR CHILDRENS) - QL Tier 1; PA allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1 CLARINEX (brand for desloratadine) - Tier 2; PA allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA desloratadine oral tablet (generic for CLARINEX) - Tier 1; PA DIPHEDRYL ALLERGY) - Tier 1; QL desloratadine oral tablet dispersible 5 mg - Tier 1; PA allergy relief childrens oral tablet chewable 12.5 mg (generic for DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA BENADRYL ALLERGY CHILDRENS) - Tier 1; QL KARBINAL ER - Tier 2; PA allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL levocetirizine dihydrochloride oral solution (generic for XYZAL ALLERGY allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA 24HR CHILDRENS) - Tier 1; PA DIPHEDRYL ALLERGY) - Tier 1; QL olopatadine hcl nasal (generic for PATANASE) - Tier 1; PA allergy relief oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1 PATANASE (brand for olopatadine hcl) - Tier 2; PA allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL RYCLORA (brand for dexchlorpheniramine maleate) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 165 Preferred Agents Non-Preferred Agents allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL ryvent (generic for RYVENT) - Tier 1; PA ALLERGY CHILDRENS) - Tier 1; QL ZYRTEC ALLERGY ORAL CAPSULE (brand for gnp all day allergy relief) allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1 - Tier 2; PA allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1 aller-tec (generic for KLS ALLER-TEC) - Tier 1 anti-hist allergy (generic for BANOPHEN) - Tier 1; QL aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL azelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1 banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL banophen oral tablet (generic for BANOPHEN) - Tier 1; QL BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for cvs allergy relief childrens) - Tier 2; QL BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE (brand for gnp allergy relief) - Tier 2; QL BENADRYL ALLERGY ORAL TABLET (brand for qc complete allergy medicine) - Tier 2; QL BENADRYL ALLERGY ULTRATABS (brand for qc complete allergy medicine) - Tier 2; QL cetirizine hcl oral solution 1 mg/ml (generic for KLS ALLER-TEC CHILDRENS) - Tier 1 cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1 childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL clemastine fumarate oral tablet 2.68 mg - Tier 1; QL complete allergy (generic for BANOPHEN) - Tier 1; QL complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1; QL complete allergy relief (generic for BANOPHEN) - Tier 1; QL cyproheptadine hcl oral - Tier 1; QL DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2; QL diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphen - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 166 Preferred Agents Non-Preferred Agents di-phen - Tier 1; QL diphenhist (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral elixir - Tier 1; QL diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral tablet chewable (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL dye-free allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL geri-dryl (generic for BANOPHEN) - Tier 1; QL h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1 levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1 liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1 NARAMIN (brand for cvs allergy relief childrens) - Tier 2; QL pharbedryl (generic for BANOPHEN) - Tier 1; QL siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL total allergy (generic for BANOPHEN) - Tier 1; QL total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL ZYRTEC ALLERGY ORAL TABLET (brand for hm all day allergy) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 167 Preferred Agents Non-Preferred Agents Anti-inflammatories, Inhaled Corticosteroids ASMANEX (120 METERED DOSES) - Tier 2; QL ALVESCO - Tier 2; PA; QL; AL ASMANEX (14 METERED DOSES) - Tier 2; QL ARMONAIR DIGIHALER - Tier 2; PA; QL; AL ASMANEX (30 METERED DOSES) INHALATION AEROSOL ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH POWDER BREATH ACTIVATED 110 MCG/INH - Tier 2; QL; AL ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT - Tier 2; PA; ASMANEX (30 METERED DOSES) INHALATION AEROSOL QL; AL POWDER BREATH ACTIVATED 220 MCG/INH - Tier 2; QL ASMANEX HFA - Tier 2; PA; QL; AL ASMANEX (60 METERED DOSES) - Tier 2; QL BECONASE AQ - Tier 2; PA ASMANEX (7 METERED DOSES) - Tier 2; QL; AL budesonide inhalation (generic for PULMICORT) - Tier 1; PA; QL FLOVENT HFA - Tier 2; QL FLOVENT DISKUS - Tier 2; PA; QL fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1 flunisolide nasal - Tier 1; PA PULMICORT FLEXHALER - Tier 2; QL mometasone furoate nasal (generic for NASONEX) - Tier 1; PA NASONEX (brand for mometasone furoate) - Tier 2; PA OMNARIS - Tier 2; PA PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA; QL QNASL - Tier 2; PA QNASL CHILDRENS - Tier 2; PA QVAR REDIHALER - Tier 2; PA; QL SINUVA - Tier 2; PA XHANCE - Tier 2; PA ZETONNA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 168 Preferred Agents Non-Preferred Agents Antileukotrienes montelukast sodium oral tablet (generic for SINGULAIR) - Tier 1; QL ACCOLATE (brand for zafirlukast) - Tier 2; PA; QL montelukast sodium oral tablet chewable 4 mg, 5 mg (generic for montelukast sodium oral packet (generic for SINGULAIR) - Tier 1; PA; SINGULAIR) - Tier 1; QL; AL QL; AL SINGULAIR ORAL PACKET (brand for montelukast sodium) - Tier 2; PA; QL; AL SINGULAIR ORAL TABLET (brand for montelukast sodium) - Tier 2; PA; QL SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG (brand for montelukast sodium) - Tier 2; PA; QL; AL zafirlukast (generic for ACCOLATE) - Tier 1; PA; QL zileuton er - Tier 1; PA; QL ZYFLO - Tier 2; PA; QL Bronchodilators, Anticholinergic ATROVENT HFA - Tier 2; QL INCRUSE ELLIPTA - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL LONHALA MAGNAIR REFILL KIT - Tier 2; PA; QL ipratropium bromide nasal - Tier 1 LONHALA MAGNAIR STARTER KIT - Tier 2; PA; QL SPIRIVA HANDIHALER - Tier 2; QL SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT - Tier 2; PA; QL SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT - Tier 2; PA TUDORZA PRESSAIR - Tier 2; PA; QL YUPELRI - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 169 Preferred Agents Non-Preferred Agents Bronchodilators, Sympathomimetic albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, ADRENALIN INJECTION SOLUTION 1 MG/ML - Tier 2; PA 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml - Tier 1 albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% (generic for PROAIR HFA) - Tier 1; PA INHALATION - Tier 2 ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier MCG/ACT INHALATION - Tier 2; PA 1 albuterol sulfate oral tablet - Tier 1; PA albuterol sulfate oral syrup - Tier 1 arformoterol tartrate (generic for BROVANA) - Tier 1; PA; QL epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML EPIPEN JR 2-PAK) - Tier 1; QL (brand for epinephrine) - Tier 2; PA; QL epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (brand AUVI-Q) - Tier 1; QL for epinephrine) - Tier 2; PA PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2 BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL SEREVENT DISKUS - Tier 2; QL epinephrine injection solution auto-injector 0.15 mg/0.15ml (generic for AUVI-Q) - Tier 1; PA; QL epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for EPIPEN JR 2-PAK) - Tier 1; PA; QL epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for AUVI-Q) - Tier 1; PA; QL epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for AUVI-Q) - Tier 1; PA EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 170 Preferred Agents Non-Preferred Agents LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT - Tier 2; PA PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL PROAIR DIGIHALER - Tier 2; PA; AL PROAIR RESPICLICK - Tier 2; PA PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA STRIVERDI RESPIMAT - Tier 2; PA; QL SYMJEPI - Tier 2; PA; QL terbutaline sulfate oral - Tier 1; PA VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA XOPENEX NEB (brand for levalbuterol hcl) - Tier 2; PA XOPENEX CONCENTRATE (brand for levalbuterol hcl) - Tier 2; PA XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA Cystic Fibrosis Agents BETHKIS (brand for tobramycin) - Tier 2; DX2RX; SP CAYSTON - Tier 2; PA KITABIS PAK (brand for tobramycin) - Tier 2; DX2RX; SP; QL KALYDECO ORAL PACKET - Tier 2; PA; SP; QL; AL PULMOZYME - Tier 2; PA; SP; QL KALYDECO ORAL TABLET - Tier 2; PA; SP; QL TOBI PODHALER - Tier 2; DX2RX; SP; QL; AL ORKAMBI ORAL PACKET - Tier 2; PA; SP; QL; AL ORKAMBI ORAL TABLET - Tier 2; PA; SP; QL; AL SYMDEKO - Tier 2; PA; SP; QL; AL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL tobramycin inhalation nebulization solution 300 mg/4ml (generic for BETHKIS) - Tier 1; DX2RX; SP tobramycin nebulization solution 300 mg/5ml inhalation (generic for KITABIS PAK) - Tier 1; PA; SP tobramycin nebulization solution 300 mg/5ml inhalation (generic for KITABIS PAK) - Tier 1; PA; SP; QL TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP; QL TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG - Tier 2; PA; SP; QL; AL TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 & 75 MG - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 171 Preferred Agents Non-Preferred Agents Mast Cell Stabilizers cromolyn sodium inhalation - Tier 1; QL Phosphodiesterase Inhibitors, Airways Disease THEO-24 - Tier 2; QL DALIRESP - Tier 2; PA; QL theophylline - Tier 1; QL theophylline er - Tier 1; QL Pulmonary Antihypertensives ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP; QL ADEMPAS - Tier 2; PA; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; SP; QL alyq (generic for ALYQ) - Tier 1; PA; SP; QL sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL DX2RX; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL TRACLEER 62.5 MG, 125 MG (brand for bosentan) - Tier 2; SP; QL OPSUMIT - Tier 2; PA; SP; QL TYVASO - Tier 2; SP; QL ORENITRAM - Tier 2; PA; SP; QL TYVASO REFILL - Tier 2; SP; QL REVATIO ORAL SUSPENSION RECONSTITUTED (brand for sildenafil TYVASO STARTER - Tier 2; SP; QL citrate) - Tier 2; PA; SP; QL VENTAVIS - Tier 2; SP; QL REVATIO ORAL TABLET (brand for sildenafil citrate) - Tier 2; DX2RX; SP; QL sildenafil citrate oral suspension reconstituted (generic for REVATIO) - Tier 1; PA; SP; QL tadalafil (pah) (generic for ALYQ) - Tier 1; PA; SP; QL TRACLEER 32 MG - Tier 2; PA; SP; QL UPTRAVI INTRAVENOUS - Tier 2; PA UPTRAVI ORAL - Tier 2; PA; SP; QL Pulmonary Fibrosis Agents OFEV - Tier 2; DX2RX; SP; QL ESBRIET - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 172 Preferred Agents Non-Preferred Agents Respiratory Tract Agents, Other acetylcysteine inhalation - Tier 1 CLARINEX-D 12 HOUR - Tier 2; PA FASENRA PEN - Tier 2; PA; SP; QL; AL ribavirin inhalation (generic for VIRAZOLE) - Tier 1; PA NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; VIRAZOLE (brand for ribavirin) - Tier 2; PA SP; QL NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; SP; QL promethazine vc - Tier 1; QL; AL promethazine-phenylephrine - Tier 1; QL; AL Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions 12 hour decongestant nasal (generic for GILTUSS SEVERE SINUS) - benzonatate oral capsule 150 mg - Tier 1; PA Tier 1 despec dm - Tier 1; PA 12 hour nasal decongestant nasal (generic for GILTUSS SEVERE despec dm-g - Tier 1; PA SINUS) - Tier 1 TESSALON PERLES (brand for benzonatate) - Tier 2; PA; QL; AL 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - tussin cf cough & cold oral syrup 5-10-100 mg/5ml - Tier 1; PA Tier 1 virtussin dac - Tier 1; PA; QL 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 4-WAY FAST ACTING (brand for hm nose drops) - Tier 2 4-WAY MENTHOL (brand for hm nose drops) - Tier 2 AFRIN NODRIP ORIGINAL (brand for 12 hour nasal spray) - Tier 2 AFRIN SALINE NASAL MIST (brand for gnp nasal moisturizing) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 173 Preferred Agents Non-Preferred Agents AFRIN SINUS (brand for 12 hour nasal spray) - Tier 2 altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1 AYR (brand for gnp nasal moisturizing) - Tier 2 AYR SALINE NASAL (brand for saline) - Tier 2 AYR SALINE NASAL NO-DRIP (brand for saline) - Tier 2 BABY AYR SALINE (brand for gnp nasal moisturizing) - Tier 2 benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; AL benzonatate oral capsule 200 mg - Tier 1; QL; AL deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 MUCINEX CHILDRENS STUFFY NOSE (brand for 12 hour nasal spray) - Tier 2 MUCINEX SINUS-MAX CLEAR & COOL (brand for 12 hour nasal spray) - Tier 2 MUCINEX SINUS-MAX SINUS/ALLRGY (brand for 12 hour nasal spray) - Tier 2 nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal four (generic for 4-WAY FAST ACTING) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for gnp nasal moisturizing) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 174 Preferred Agents Non-Preferred Agents nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray anti-drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1 nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for hm nose drops) - Tier 2 no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 non-pseudo sinus decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal decongest (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal solution 1 % (generic for 4-WAY FAST ACTING) - Tier 1 OCEAN FOR KIDS (brand for gnp nasal moisturizing) - Tier 2 OCEAN NASAL SPRAY (brand for gnp nasal moisturizing) - Tier 2 phenylephrine hcl oral (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 promethazine-dm - Tier 1; QL; AL pseudoephedrine-bromphen-dm - Tier 1; QL; AL saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 175 Preferred Agents Non-Preferred Agents saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 sinus pe decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1 sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1 sinus/congestion relief pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for ra sinus/congestion relief pe) - Tier 2 SUDAFED PE SINUS CONGESTION (brand for ra sinus/congestion relief pe) - Tier 2 Antihistamines - Allergy Drugs allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy & congestion oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief/nasal decongest oral tablet extended release 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy/congestion relief oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL CLARITIN-D 24 HOUR (brand for allergy relief/nasal decongest) - Tier 2; AL lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 176 Preferred Agents Non-Preferred Agents Antihistamines - Drugs to Treat Allergies aller-chlor (generic for CHLOR-TRIMETON) - Tier 1; QL 24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; PA; QL allerclear (generic for KLS ALLERCLEAR) - Tier 1 ALAVERT (brand for qc allergy relief) - Tier 2; PA allergy 4 hour (generic for CHLOR-TRIMETON) - Tier 1; QL ALLEGRA ALLERGY ORAL TABLET 180 MG (brand for ra allergy relief) - allergy childrens oral syrup (generic for CLARITIN ALLERGY Tier 2; PA; QL CHILDRENS) - Tier 1 ALLEGRA ALLERGY ORAL TABLET 60 MG (brand for aller-ease) - Tier allergy oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; QL 2; PA allergy oral tablet extended release 12 mg (generic for CHLOR- aller-ease (generic for KLS ALLER-FEX) - Tier 1; PA; QL TRIMETON ALLERGY) - Tier 1; QL aller-fex (generic for KLS ALLER-FEX) - Tier 1; PA; QL allergy rel child (loratadine) (generic for CLARITIN ALLERGY allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; PA; QL CHILDRENS) - Tier 1 allergy relief childrens oral tablet chewable 5 mg (generic for CLARITIN) - allergy relief (loratadine) (generic for KLS ALLERCLEAR) - Tier 1 Tier 1; PA allergy relief 4-hour (generic for CHLOR-TRIMETON) - Tier 1; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; Tier 1 PA; QL allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier 1; ALLERGY CHILDRENS) - Tier 1 PA allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; allergy relief oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; PA QL allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS ALLER- allergy relief oral tablet extended release 12 mg (generic for CHLOR- FEX) - Tier 1; PA; QL TRIMETON ALLERGY) - Tier 1; QL CLARITIN CHILDRENS (brand for cvs allergy relief childrens) - Tier 2; PA childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - CLARITIN ORAL TABLET CHEWABLE (brand for cvs allergy relief Tier 1 childrens) - Tier 2; PA chlor-pheniramine (generic for CHLOR-TRIMETON) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 177 Preferred Agents Non-Preferred Agents chlorpheniramine maleate er (generic for CHLOR-TRIMETON CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for ALLERGY) - Tier 1; QL qc allergy relief) - Tier 2; PA chlorpheniramine maleate oral (generic for CHLOR-TRIMETON) - Tier fexofenadine hcl oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; QL 1; PA; QL chlortabs (generic for CHLOR-TRIMETON) - Tier 1; QL fexofenadine hcl oral tablet 60 mg (generic for ALLEGRA ALLERGY) - CHLOR-TRIMETON (brand for ed chlorped jr) - Tier 2; QL Tier 1; PA CHLOR-TRIMETON ALLERGY (brand for cvs allergy relief) - Tier 2; fexofenadine hydrochloride (generic for KLS ALLER-FEX) - Tier 1; PA; QL QL loratadine allergy relief oral tablet dispersible 10 mg (generic for CLARITIN ALLERGY CHILDRENS (brand for ra loratadine) - Tier 2 ALAVERT) - Tier 1; PA CLARITIN ORAL TABLET (brand for allergy relief) - Tier 2 loratadine childrens oral tablet chewable (generic for CLARITIN) - Tier 1; CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG - Tier 2 PA ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; QL HISTEX PD (brand for triprolidine hcl) - Tier 2 loratadine oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; loradamed (generic for KLS ALLERCLEAR) - Tier 1 PA loratadine allergy relief oral tablet 10 mg (generic for KLS TRIAMINIC ALLERCHEWS (brand for qc allergy relief) - Tier 2; PA ALLERCLEAR) - Tier 1 loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1 loratadine childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1 loratadine oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1 loratadine oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 m-hist pd (generic for PEDIACLEAR PD CHILDRENS) - Tier 1 pediaclear pd childrens (generic for PEDIACLEAR PD CHILDRENS) - Tier 1 pharbechlor (generic for CHLOR-TRIMETON) - Tier 1; QL triprolidine hcl oral liquid 0.313 mg/ml - Tier 1 triprolidine hcl oral liquid 0.625 mg/ml (generic for PEDIACLEAR PD CHILDRENS) - Tier 1 triprolidine hcl oral liquid 0.938 mg/ml (generic for HISTEX PD) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 178 Preferred Agents Non-Preferred Agents Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - Tier 1; QL NASACORT ALLERGY 24HR (brand for goodsense nasal allergy spray) - Tier 2; QL NASACORT ALLERGY 24HR CHILDREN (brand for goodsense nasal allergy spray) - Tier 2; QL nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER- CORT) - Tier 1; QL nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; QL Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; QL AIRDUO DIGIHALER - Tier 2; PA; QL; AL ADVAIR HFA - Tier 2; QL AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; ANORO ELLIPTA - Tier 2; QL PA; QL; AL COMBIVENT RESPIMAT - Tier 2; QL AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT PA; QL; AL - Tier 2; QL AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; DULERA INHALATION AEROSOL 50-5 MCG/ACT - Tier 2 PA; QL; AL ipratropium-albuterol - Tier 1; QL asthmanefrin refill - Tier 1; PA STIOLTO RESPIMAT - Tier 2 BEVESPI AEROSPHERE - Tier 2; PA; QL SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2 BREO ELLIPTA - Tier 2; PA; QL BREZTRI AEROSPHERE - Tier 2; PA; QL BUDESONIDE-FORMOTEROL FUMARATE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 179 Preferred Agents Non-Preferred Agents DUAKLIR PRESSAIR - Tier 2; PA; QL fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; PA; QL; AL S2 (RACEPINEPHRINE) - Tier 2; PA TRELEGY ELLIPTA - Tier 2; PA; QL; AL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL NASALCROM (brand for cromolyn sodium) - Tier 2; QL Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour decongestant oral (generic for SUDAFED SINUS g tussin ac - Tier 1; PA; QL; AL CONGESTION 12HR) - Tier 1 guaiatussin ac - Tier 1; PA; QL; AL 12 hour nasal decongestant (generic for SUDAFED SINUS guaifenesin ac - Tier 1; PA; QL; AL CONGESTION 12HR) - Tier 1 guaifenesin-codeine - Tier 1; PA; QL; AL adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG HYCODAN (brand for hydromet) - Tier 2; PA; QL DM CHILD) - Tier 1 hydrocodone polst-cpm polst er - Tier 1; PA; QL altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; hydrocodone-homatropine (generic for HYCODAN) - Tier 1; PA; QL QL; AL hydromet (generic for HYCODAN) - Tier 1; PA; QL chest congest/cough child (generic for DELSYM CGH/CHEST CONG maxi-tuss ac - Tier 1; PA; QL; AL DM CHILD) - Tier 1 promethazine vc/codeine - Tier 1; PA; QL chest congestion relief dm oral syrup (generic for ROBAFEN DM promethazine-codeine - Tier 1; PA; QL; AL COUGH CLEAR) - Tier 1; QL; AL promethazine-phenyleph-codeine - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 180 Preferred Agents Non-Preferred Agents childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - TUSSICAPS - Tier 2; PA; QL Tier 1; AL virtussin a/c - Tier 1; PA; QL; AL childrens cough (generic for DELSYM CGH/CHEST CONG DM virtussin ac w/alc - Tier 1; PA; QL; AL CHILD) - Tier 1 childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cough & chest congestion (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 decongestant 12hour max st oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 DELSYM CGH/CHEST CONG DM CHILD (brand for eq tussin dm max daytime) - Tier 2 DELSYM COUGH/CHEST CONGEST DM (brand for eq tussin dm max daytime) - Tier 2 dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 181 Preferred Agents Non-Preferred Agents dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL DIMETAPP COLD RELIEF CHILDRENS (brand for hm cold & cough childrens) - Tier 2; QL; AL DIMETAPP COLD/ALLERGY (brand for childrens cold & allergy) - Tier 2; AL DIMETAPP DM COLD/COUGH (brand for hm cold & cough childrens) - Tier 2; QL; AL dm maximum adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 ENDACOF-DM (brand for hm cold & cough childrens) - Tier 2; QL; AL genaphed (generic for SUDOGEST) - Tier 1; QL geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL HYPERSAL (brand for sodium chloride) - Tier 2 MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for eq tussin dm max daytime) - Tier 2 MUCINEX COUGH CHILDRENS (brand for eq tussin dm max daytime) - Tier 2 MUCINEX FAST-MAX DM MAX (brand for eq tussin dm max daytime) - Tier 2 mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 182 Preferred Agents Non-Preferred Agents mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 nasal decongestant 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for eq tussin dm max daytime) - Tier 2 rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL rynex pse - Tier 1; AL siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL sodium chloride inhalation nebulization solution 0.9 % - Tier 1; QL sodium chloride inhalation nebulization solution 10 %, 3 % - Tier 1 sodium chloride inhalation nebulization solution 7 % (generic for HYPERSAL) - Tier 1 SUDAFED (brand for eql nasal decongestant) - Tier 2; QL SUDAFED CHILDRENS - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 183 Preferred Agents Non-Preferred Agents SUDAFED SINUS CONGESTION (brand for eql nasal decongestant) - Tier 2; QL SUDAFED SINUS CONGESTION 12HR (brand for pseudoephedrine hcl er) - Tier 2 sudogest 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine maximum strength (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 tussin cough dm sugar free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm cough/chest cong (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max oral liquid 20-400 mg/20ml (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max st (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 184 Preferred Agents Non-Preferred Agents Skeletal Muscle Relaxants chlorzoxazone - Tier 1 AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL carisoprodol oral tablet 250 mg (generic for SOMA) - Tier 1; PA cyclobenzaprine hcl oral tablet 7.5 mg (generic for FEXMID) - Tier 1 carisoprodol oral tablet 350 mg (generic for SOMA) - Tier 1; PA; QL methocarbamol oral - Tier 1 carisoprodol-aspirin-codeine - Tier 1; PA; QL; AL cyclobenzaprine hcl er (generic for AMRIX) - Tier 1; PA FEXMID (brand for cyclobenzaprine hcl) - Tier 2; PA LORZONE (brand for chlorzoxazone) - Tier 2; PA metaxalone - Tier 1; PA NORGESIC FORTE - Tier 2; PA orphenadrine citrate er - Tier 1; PA orphenadrine-asa-caffeine (generic for ORPHENGESIC FORTE) - Tier 1; PA ORPHENGESIC FORTE (brand for norgesic forte) - Tier 2; PA SKELAXIN (brand for metaxalone) - Tier 2; PA SOMA ORAL TABLET 250 MG (brand for carisoprodol) - Tier 2; PA SOMA ORAL TABLET 350 MG (brand for carisoprodol) - Tier 2; PA; QL VANADOM (brand for carisoprodol) - Tier 2; PA; QL Sleep Disorder Agents Sleep Promoting Agents temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG (brand for 1; QL zolpidem tartrate er) - Tier 2; PA zaleplon - Tier 1 AMBIEN CR ORAL TABLET EXTENDED RELEASE 6.25 MG (brand for zolpidem tartrate oral tablet 10 mg (generic for AMBIEN) - Tier 1 zolpidem tartrate er) - Tier 2; PA; QL zolpidem tartrate oral tablet 5 mg (generic for AMBIEN) - Tier 1; QL AMBIEN ORAL TABLET 10 MG (brand for zolpidem tartrate) - Tier 2; PA AMBIEN ORAL TABLET 5 MG (brand for zolpidem tartrate) - Tier 2; PA; QL BELSOMRA - Tier 2; PA; QL; AL DAYVIGO - Tier 2; PA; QL; AL doxepin hcl oral tablet (generic for SILENOR) - Tier 1; PA; AL EDLUAR - Tier 2; PA; QL estazolam - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 185 Preferred Agents Non-Preferred Agents eszopiclone (generic for LUNESTA) - Tier 1; PA; QL; AL flurazepam hcl - Tier 1; PA HALCION (brand for triazolam) - Tier 2; PA HETLIOZ - Tier 2; PA; SP; QL HETLIOZ LQ - Tier 2; PA; SP; QL; AL LUNESTA (brand for eszopiclone) - Tier 2; PA; QL; AL ramelteon (generic for ROZEREM) - Tier 1; PA; QL; AL RESTORIL (brand for temazepam) - Tier 2; PA; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QL; AL SILENOR (brand for doxepin hcl) - Tier 2; PA; AL temazepam oral capsule 22.5 mg, 7.5 mg (generic for RESTORIL) - Tier 1; PA; QL triazolam - Tier 1; PA zolpidem tartrate er oral tablet extended release 12.5 mg (generic for AMBIEN CR) - Tier 1; PA zolpidem tartrate er oral tablet extended release 6.25 mg (generic for AMBIEN CR) - Tier 1; PA; QL zolpidem tartrate sublingual - Tier 1; PA; QL Wakefulness Promoting Agents armodafinil (generic for NUVIGIL) - Tier 1; PA; QL; AL modafinil (generic for PROVIGIL) - Tier 1; PA; QL; AL NUVIGIL (brand for armodafinil) - Tier 2; PA; QL; AL PROVIGIL (brand for modafinil) - Tier 2; PA; QL; AL SUNOSI - Tier 2; PA; QL WAKIX - Tier 2; PA; QL XYREM - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 186 Preferred Agents Non-Preferred Agents Sleep Disorder Agents - Drugs for Sedation and Sleep Sleep Disorders, Other - Drugs for Sleeping night time sleep aid (generic for SIMPLY SLEEP) - Tier 1; QL XYWAV - Tier 2; PA; QL nighttime sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1; QL nighttime sleep aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 nighttime sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; QL rest simply (generic for SIMPLY SLEEP) - Tier 1; QL SIMPLY SLEEP (brand for sleep aid (diphenhydramine)) - Tier 2; QL sleep aid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; QL sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1; QL sleep aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleep aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; QL sleep aid nighttime oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; QL sleep aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; QL sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; QL sleep ii (generic for SIMPLY SLEEP) - Tier 1; QL sleep tabs (generic for SIMPLY SLEEP) - Tier 1; QL sleepaid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 187 Preferred Agents Non-Preferred Agents sleep-aid max st (generic for UNISOM SLEEPGELS) - Tier 1; QL sleep-aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleep-aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; QL sleep-aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleep-aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; QL sleeptime oral capsule (generic for WAL-SLEEP Z) - Tier 1 z-sleep oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs adc/f (0.5mg/ml) - Tier 1 ACTIFLOVIT EAR HEALTH (brand for balance b-100) - Tier 2; PA animal shapes complete (generic for CEROVITE JR) - Tier 1 ACTIVE FE - Tier 2; PA animal shapes kids first (generic for DINO-LIFE) - Tier 1 ADRENAL C FORMULA (brand for pan-c 500/bioflavonoids) - Tier 2; PA animal shapes/iron (generic for CEROVITE JR) - Tier 1 advanced stress formula/zinc - Tier 1; PA ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; AQUADEKS ORAL LIQUID - Tier 2; PA QL ascorbic acid oral powder - Tier 1; PA BACMIN (brand for vitrum 50+ senior multi) - Tier 2; QL b complex formula 1 oral tablet (generic for BIG 100) - Tier 1; PA biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b complex-biotin-fa (generic for BIG 100 (BIOTIN)) - Tier 1; PA b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL b-100 complex cr (generic for ENDUR-B) - Tier 1; PA BPROTECTED PEDIA POLY-VITE (brand for poly-vita) - Tier 2 balance b-100 (generic for CVS BALANCED B50) - Tier 1; PA BPROTECTED PEDIA POLY-VITE/FE (brand for poly-vita/iron) - Tier balance b-50 (generic for BIG 100 (BIOTIN)) - Tier 1; PA 2 balanced b-100 cr (generic for ENDUR-B) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 188 Preferred Agents Non-Preferred Agents c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL balanced b-100 oral tablet (generic for BIG 100) - Tier 1; PA calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL balanced b50 (generic for CVS BALANCED B50) - Tier 1; PA calcium 600+d oral tablet 600-200 mg-unit - Tier 1; QL balanced b-50 oral tablet (generic for BIG 100 (BIOTIN)) - Tier 1; PA calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL balanced b-50 tr (generic for ENDUR-B) - Tier 1; PA calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1 biotin forte oral tablet 5 mg - Tier 1; PA calcium carbonate-vitamin d oral tablet 600-200 mg-unit - Tier 1; QL biotin oral capsule 5000 mcg (generic for MERIBIN) - Tier 1; PA calcium fast dissolution - Tier 1; QL biotin oral tablet 5 mg - Tier 1; PA calcium high potency - Tier 1; QL calcium-folic acid plus d - Tier 1; PA calcium high potency/vitamin d - Tier 1; QL cal-mag aspartate - Tier 1; PA calcium oral tablet 1500 (600 ca) mg - Tier 1; QL CORVITA - Tier 2; PA calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; QL CORVITE 150 ORAL TABLET 150-1.25 MG - Tier 2; PA calcium plus vitamin d oral tablet 600-200 mg-unit - Tier 1; QL DECARA K - Tier 2; PA CENTRUM FLAVOR BURST KIDS (brand for zoo friends) - Tier 2; QL DERMACINRX RIBOTIN-E (brand for vitrum 50+ senior multi) - Tier 2; CENTRUM KIDS (brand for zoo friends) - Tier 2; QL PA; QL cerovite jr (generic for CEROVITE JR) - Tier 1 DIALYVITE 3000 - Tier 2; PA chewable childrens vitamin (generic for CEROVITE JR) - Tier 1 DIALYVITE 5000 - Tier 2; PA childrens animal shapes (generic for CEROVITE JR) - Tier 1 DIALYVITE SUPREME D - Tier 2; PA childrens chewable vitamins (generic for DINO-LIFE) - Tier 1 DRISDOL (brand for vitamin d (ergocalciferol)) - Tier 2; PA; QL; AL childrens chewables/iron (generic for LAND BEFORE TIME EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ - Tier 2; MULTIVITAMIN) - Tier 1 PA; QL childrens complete oral tablet chewable 18 mg (generic for CEROVITE ELFOLATE (brand for l-methylfolate calcium) - Tier 2; PA JR) - Tier 1 FERIVA 21/7 - Tier 2; PA childrens vitamins/iron (generic for LAND BEFORE TIME FERRALET 90 - Tier 2; PA; QL MULTIVITAMIN) - Tier 1 ferrous sulfate oral syrup - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 189 Preferred Agents Non-Preferred Agents crush vitamin c drops (generic for CRUSH VITAMIN C DROPS) - Tier FLORIVA ORAL LIQUID - Tier 2; PA; QL 1 FOLITE - Tier 2; PA; QL daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA HEMATOGEN FA - Tier 2; PA CAROTENE) - Tier 1; QL ICAR-C PLUS (brand for fe c tab plus) - Tier 2; PA daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA INFUVITE PEDIATRIC - Tier 2; PA CAROTENE) - Tier 1; QL inner ear plus (generic for CVS BALANCED B50) - Tier 1; PA DAYAVITE - Tier 2; QL iron oral tablet 200 (65 fe) mg (generic for FEOSOL) - Tier 1; PA DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for vitamin iron oral tablet extended release 142 (45 fe) mg (generic for SLOW FE) - d3) - Tier 2 Tier 1; PA DERMACINRX ZINTREXYL-C (brand for vitrum 50+ senior multi) - k-tan plus (generic for K-TAN PLUS) - Tier 1; PA Tier 2; QL lipoflavovit (generic for CVS BALANCED B50) - Tier 1; PA dino-life (generic for DINO-LIFE) - Tier 1 l-methylfolate (generic for ELFOLATE) - Tier 1; PA effer-k oral tablet effervescent 25 meq - Tier 1; QL l-methylfolate calcium oral (generic for ELFOLATE) - Tier 1; PA ergocalciferol oral capsule (generic for DRISDOL) - Tier 1; QL; AL M.V.I. PEDIATRIC - Tier 2; PA ferocon (generic for TRICON) - Tier 1 mega multiple/chelated mineral (generic for CVS BALANCED B50) - Tier ferosul (generic for FEROSUL) - Tier 1; QL 1; PA ferotrinsic (generic for TRICON) - Tier 1 MERIBIN (brand for biotin maximum strength) - Tier 2; PA ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier MIFEPREX (brand for mifepristone) - Tier 2; PA 1; QL mifepristone (generic for MIFEPREX) - Tier 1; PA ferrous sulfate oral tablet delayed release 325 (65 fe) mg - Tier 1; QL OBSTETRIX EC - Tier 2; PA; QL FOLITIN-Z (brand for vitrum 50+ senior multi) - Tier 2; QL OBTREX - Tier 2; PA; QL foltrin (generic for TRICON) - Tier 1 ORACIT - Tier 2; PA gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; pot & sod cit-cit ac - Tier 1; PA QL PRO HERS RX - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 190 Preferred Agents Non-Preferred Agents gummy multivitamin kids (generic for CENTRUM FLAVOR BURST PRO HIS RX - Tier 2; PA KIDS) - Tier 1; QL PRO PCOS RX - Tier 2; PA iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL purevit dualfe plus (generic for K-TAN PLUS) - Tier 1; PA klor-con/ef - Tier 1; QL risanoid plus (generic for CVS BALANCED B50) - Tier 1; PA K-PHOS-NEUTRAL (brand for phosphorous) - Tier 2; QL se-tan plus (generic for K-TAN PLUS) - Tier 1; PA k-prime - Tier 1; QL SLOW FE (brand for iron high-potency) - Tier 2; PA little ones childrens (generic for DINO-LIFE) - Tier 1 slow release iron oral tablet extended release 143 (45 fe) mg - Tier 1; PA lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL stress formula/zinc (generic for LYSIPLEX PLUS) - Tier 1; PA multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA TARON FORTE - Tier 2; PA CAROTENE) - Tier 1; QL tricitrates - Tier 1; PA MULTIPRO - Tier 2 TRIFERIC HEMODIALYSIS PACKET - Tier 2; PA urosex (generic for ALLERWELL ALLERGY FORMULA) - Tier 1; PA multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - VENTRIXYL FE (brand for vitrum 50+ senior multi) - Tier 2; PA; QL Tier 1; QL vitamin b-2 oral tablet 100 mg - Tier 1; PA niacin er oral capsule extended release 250 mg - Tier 1; QL vitamin c er oral capsule extended release - Tier 1; PA niacin er oral capsule extended release 500 mg - Tier 1 VITA-RX DIABETIC VITAMIN - Tier 2; PA niacin oral tablet 100 mg - Tier 1 zinc gluconate oral tablet 50 mg - Tier 1; PA NUTRICAP (brand for vitrum 50+ senior multi) - Tier 2; QL zinc oral lozenge - Tier 1; PA nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL zinc oral tablet 50 mg - Tier 1; PA one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL POLY-VI-SOL (brand for poly-vita) - Tier 2 POLY-VITE PEDIATRIC - Tier 2 potassium citrate-citric acid - Tier 1 REQ 49+ (brand for vitrum 50+ senior multi) - Tier 2; QL sod citrate-citric acid - Tier 1 stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 191 Preferred Agents Non-Preferred Agents STROVITE FORTE ORAL TABLET (brand for vitrum 50+ senior multi) - Tier 2; QL STROVITE ONE (brand for vitrum 50+ senior multi) - Tier 2; QL tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL TRICON (brand for foltrin) - Tier 2 tri-vite/fluoride - Tier 1 v-c forte (generic for VIC-FORTE) - Tier 1 VENEXA (brand for vitrum 50+ senior multi) - Tier 2; QL VENEXA FE (brand for vitrum 50+ senior multi) - Tier 2; QL vic-forte (generic for VIC-FORTE) - Tier 1 virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL vitamin c drops mouth/throat lozenge 60 mg (generic for CRUSH VITAMIN C DROPS) - Tier 1 vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c-rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QL; AL vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamins acd-fluoride - Tier 1 vitamins complete childrens (generic for CEROVITE JR) - Tier 1 VITAROCA PLUS (brand for vitrum 50+ senior multi) - Tier 2; QL VITRAMYN (brand for vitrum 50+ senior multi) - Tier 2; QL VITRANOL FE (brand for vitrum 50+ senior multi) - Tier 2; QL VITREXYL (brand for vitrum 50+ senior multi) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 192 Preferred Agents Non-Preferred Agents VITREXYL + IRON (brand for vitrum 50+ senior multi) - Tier 2; QL zoo friends (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL zoo friends complete (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL zoo friends gummies (generic for DINO-LIFE) - Tier 1 zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1 ZYVANA - Tier 2 Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs aqueous vitamin e (generic for SOLUVITA E) - Tier 1 b-12 oral tablet 1000 mcg, 500 mcg - Tier 1; PA b-1 - Tier 1; QL b12 quick dissolve - Tier 1; PA b6 - Tier 1; QL NASCOBAL - Tier 2; PA; QL cyanocobalamin solution 1000 mcg/ml injection - Tier 1 vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg - Tier 1; cyanocobalamin solution 1000 mcg/ml injection - Tier 1; QL PA e-400-clear - Tier 1; QL vitamin b12 oral tablet 1000 mcg - Tier 1; PA natural vitamin e - Tier 1; QL pyridoxine hcl oral tablet 50 mg - Tier 1; QL soluvita e (generic for SOLUVITA E) - Tier 1 thiamine hcl oral - Tier 1; QL vitamin b-6 oral tablet 100 mg, 50 mg - Tier 1; QL vitamin e oral capsule 400 unit - Tier 1; QL vitamin e oral solution 15 unit/0.3ml (generic for SOLUVITA E) - Tier 1

Vaccines Immunological Agents - Drugs that Stimulate or Suppress the Immune System JANSSEN COVID-19 VACCINE - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 194 Index of Drugs 12 hour decongestant nasal...... 173 acarbose oral...... 54 acetaminophen infants oral suspension 12 hour decongestant oral...... 180 ACCOLATE...... 169 160 mg/5ml...... 10 12 hour nasal decongestant...... 180 ACCU-CHEK AVIVA DEVICE...... 140 acetaminophen oral liquid 160 mg/5ml...... 10 12 hour nasal decongestant nasal...... 173 ACCU-CHEK AVIVA PLUS TEST STRIPS 140 acetaminophen oral liquid 500 mg/15ml...... 10 12 hour nasal relief spray...... 173 ACCU-CHEK COMPACT PLUS...... 140 acetaminophen oral solution 160 mg/5ml, 12 hour nasal spray...... 173 ACCU-CHEK COMPACT PLUS 325 mg/10.15ml, 650 mg/20.3ml...... 10 24 hour nasal allergy...... 179 CONTROL...... 140 acetaminophen oral suspension 160 24hr allergy relief...... 177 ACCU-CHEK FASTCLIX LANCET KIT...... 90 mg/5ml, 650 mg/20.3ml...... 10 3 day...... 33 ACCU-CHEK GUIDE CONTROL...... 140 acetaminophen oral tablet 325 mg...... 10 3 day vaginal...... 34 ACCU-CHEK GUIDE TEST STRIPS...... 140 acetaminophen oral tablet 500 mg...... 10 3-day vaginal vaginal cream 2 %...... 34 ACCU-CHEK MULTICLIX LANCETS...... 90 acetaminophen oral tablet chewable 160 4-WAY FAST ACTING...... 173 ACCU-CHEK SMARTVIEW...... 140 mg...... 10 4-WAY MENTHOL...... 173 ACCU-CHEK SMARTVIEW CONTROL.... 140 acetaminophen rapid tabs child...... 10 8 hour arthritis pain reliever...... 9 ACCU-CHEK SOFTCLIX LANCET acetaminophen rectal suppository 120 mg.. 10 8 hour arthritis relief...... 9 DEVICE KIT...... 90 acetaminophen rectal suppository 650 mg.. 10 8 hour pain relief oral tablet extended ACCU-CHEK TENDER 1 INFUSION...... 140 acetaminophen-codeine #2...... 8 release 650 mg...... 9 ACCUPRIL...... 63 acetaminophen-codeine #3...... 8 8 hour pain reliever...... 9 ACCURETIC...... 65 acetaminophen-codeine #4...... 8 8 hr arthritis pain relief...... 9 accutane...... 76 acetaminophen-codeine oral solution...... 8 8hr arthritis pain relief...... 9 ACCUTREND GLUCOSE...... 140 acetaminophen-codeine oral tablet...... 8 8hr muscle aches & pain...... 9 ACCUTREND GLUCOSE CONTROL...... 140 acetazolamide er...... 65 abacavir sulfate...... 51 ACE AEROSOL CLOUD ENHANCER...... 140 acetazolamide oral...... 65 abacavir sulfate-lamivudine...... 51 acebutolol hcl oral...... 64 acetic acid otic...... 164 abacavir-lamivudine-zidovudine...... 51 ACESO AG...... 141 acetylcysteine inhalation...... 173 abatron af...... 93 acetaminophen 8 hour...... 9 acid controller...... 102 ABECMA...... 42 acetaminophen 8 hours...... 9 acid gone...... 103 ABILIFY...... 47 acetaminophen 8hr arth pain...... 9 acid reducer oral capsule delayed release ABILIFY MAINTENA...... 47 acetaminophen 8hr musc ache...... 10 20.6 (20 base) mg...... 102 ABILIFY MYCITE...... 47 acetaminophen childrens...... 10 acid reducer oral tablet 10 mg...... 102 ABILIFY MYCITE MAINTENANCE KIT...... 47 acetaminophen childrens oral suspension acid reducer oral tablet 200 mg...... 102 ABILIFY MYCITE STARTER KIT...... 47 160 mg/5ml...... 10 acid reducer oral tablet delayed release 20 abiraterone acetate oral tablet 250 mg...... 38 acetaminophen childrens oral tablet mg...... 102 abiraterone acetate oral tablet 500 mg...... 38 chewable 160 mg...... 10 ACIPHEX...... 102 ABREVA...... 88 acetaminophen er...... 10 ACIPHEX SPRINKLE...... 102 ABSORICA...... 76 acetaminophen ex st oral liquid 500 acitretin...... 76 ABSORICA LD...... 76 mg/15ml...... 10 acne...... 141 acamprosate calcium...... 17 acetaminophen ex st oral tablet 500 mg...... 10 acne control cleanser...... 141 ACANYA...... 76 acetaminophen extra strength...... 10 acne medication 10 external lotion...... 141

195 acne medication 5 external lotion...... 141 ADMELOG SOLOSTAR SOLUTION PEN- AGONEAZE...... 15 ACTEMRA ACTPEN...... 134 INJECTOR 100 UNIT/ML AGRYLIN...... 59 ACTEMRA SUBCUTANEOUS...... 134 SUBCUTANEOUS...... 56 AIMOVIG...... 37 ACTHAR...... 118 ADRENAL C FORMULA...... 188 AIRDUO DIGIHALER...... 179 ACTHIB...... 137 ADRENALIN INJECTION SOLUTION 1 AIRDUO RESPICLICK 113/14...... 179 ACTICLATE...... 23 MG/ML...... 170 AIRDUO RESPICLICK 232/14...... 179 ACTIFLOVIT EAR HEALTH...... 188 adult 50+ probiotic...... 103 AIRDUO RESPICLICK 55/14...... 179 ACTIMMUNE...... 135 ADULT AEROSOL MASK...... 141 AJOVY...... 37 ACTIQ...... 8 adult probiotic...... 103 AKLIEF...... 76 ACTIVE FE...... 188 adult tussin cough & chest...... 180 ak-poly-bac...... 157 ACTIVELLA...... 122 ADVAIR DISKUS...... 179 AKYNZEO INTRAVENOUS SOLUTION ACTIVITE...... 95 ADVAIR HFA...... 179 RECONSTITUTED...... 32 ACTONEL...... 139 advanced antacid max st...... 103 AKYNZEO ORAL...... 32 ACTOPLUS MET...... 54 ADVANCED GLUCOSE TEST...... 141 ala-cort external cream 1 %...... 78 ACTOS...... 54 advanced stress formula/zinc...... 188 ala-cort external cream 2.5 %...... 78 ACULAR...... 158 ADVATE...... 60 ALAVERT...... 177 ACULAR LS...... 158 ADVIL JUNIOR STRENGTH...... 4 ALAWAY...... 163 ACUNOL...... 141 ADVIL LIQUI-GELS MINIS...... 4 ALAWAY CHILDRENS ALLERGY...... 163 ACUVAIL...... 158 ADVIL MIGRAINE...... 4 albendazole oral...... 42 acyclovir external cream...... 50 ADVIL ORAL CAPSULE...... 4 ALBENZA...... 42 acyclovir external ointment...... 50 ADYNOVATE...... 61 albuterol sulfate hfa aerosol solution 108 acyclovir oral capsule...... 50 ADZENYS ER...... 72 (90 base) mcg/act inhalation...... 170 acyclovir oral suspension...... 50 ADZENYS XR-ODT...... 72 ALBUTEROL SULFATE HFA AEROSOL acyclovir oral tablet...... 50 AEROCHAMBER PLUS FLO-VU...... 141 SOLUTION 108 (90 BASE) MCG/ACT ACZONE...... 84 AEROCHAMBER PLUS FLO-VU LARGE. 141 INHALATION...... 170 adapalene external cream...... 76 AEROCHAMBER PLUS FLO-VU SMALL..141 albuterol sulfate inhalation nebulization adapalene external gel...... 76 AEROCHAMBER PLUS FLO-VU W/MASK solution (2.5 mg/3ml) 0.083%, 0.63 adapalene-benzoyl peroxide external gel.... 76 ...... 141 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml...... 170 adc/f (0.5mg/ml)...... 188 AFINITOR...... 40 ALBUTEROL SULFATE NEBULIZATION ADCIRCA...... 172 AFINITOR DISPERZ...... 40 SOLUTION (5 MG/ML) 0.5% INHALATION ADDERALL...... 72 afirmelle...... 122 ...... 170 ADDERALL XR...... 72 AFLURIA QUADRIVALENT...... 138 albuterol sulfate nebulization solution (5 adefovir dipivoxil...... 49 AFREZZA...... 56 mg/ml) 0.5% inhalation...... 170 ADEMPAS...... 172 AFRIN NODRIP ORIGINAL...... 173 albuterol sulfate oral syrup...... 170 ADHANSIA XR...... 71 AFRIN SALINE NASAL MIST...... 173 albuterol sulfate oral tablet...... 170 ADLYXIN...... 54 AFRIN SINUS...... 173 alclometasone dipropionate...... 78 ADLYXIN STARTER PACK...... 54 AFSTYLA...... 61 alcohol prep pads external 70 %...... 24 ADMELOG...... 56 aftera...... 130 ALCOHOL PREP PADS PAD...... 141 AFTERPILL...... 130 ALCOHOL PREP PADS PAD 70 %...... 141

196 ALDACTAZIDE...... 65 allergy oral liquid 12.5 mg/5ml...... 165 allergy relief/nasal decongest oral tablet ALDACTONE...... 67 allergy oral tablet 25 mg...... 165 extended release 24 hour...... 176 ALDARA...... 82 allergy oral tablet 4 mg...... 177 allergy relief-d oral tablet extended release ALECENSA...... 153 allergy oral tablet extended release 12 mg 177 24 hour 10-240 mg...... 176 alendronate sodium oral solution...... 139 allergy rel child (loratadine)...... 177 allergy spray 24 hour nasal aerosol...... 179 alendronate sodium oral tablet 10 mg, 35 allergy relief (cetirizine) oral tablet 10 mg.. 165 allergy/congestion relief oral tablet mg...... 139 allergy relief (loratadine)...... 177 extended release 24 hour 10-240 mg...... 176 alendronate sodium oral tablet 70 mg...... 139 allergy relief 4-hour...... 177 aller-tec...... 166 ALEVAMAX...... 88 allergy relief adult...... 165 allopurinol oral...... 35 ALEVE ORAL TABLET...... 4 allergy relief cetirizine...... 165 ALLZITAL...... 8 alfuzosin hcl er...... 117 allergy relief child...... 177 almacone double strength...... 103 ALINIA ORAL TABLET...... 43 allergy relief childrens oral liquid 12.5 almotriptan malate...... 36 aliskiren fumarate...... 65 mg/5ml...... 165 ALOCRIL...... 156 ALKERAN ORAL...... 42 allergy relief childrens oral syrup 5 mg/5ml 177 ALOE VESTA DAILY MOISTURIZER...... 88 ALKINDI SPRINKLE...... 118 allergy relief childrens oral tablet chewable ALOGLIPTIN BENZOATE...... 54 all day allergy oral tablet 10 mg...... 165 12.5 mg...... 165 ALOGLIPTIN-METFORMIN HCL...... 54 all day allergy relief...... 165 allergy relief childrens oral tablet chewable ALOGLIPTIN-PIOGLITAZONE...... 54 all day pain relief...... 4 5 mg...... 177 ALOMIDE...... 156 all day relief...... 4 allergy relief d-24...... 176 ALORA...... 122 ALLEGRA ALLERGY ORAL TABLET 180 allergy relief oral capsule 10 mg...... 165 alosetron hcl...... 100 MG...... 177 allergy relief oral capsule 25 mg...... 165 ALPHAGAN P...... 159 ALLEGRA ALLERGY ORAL TABLET 60 allergy relief oral liquid 12.5 mg/5ml, 25 ALPHANATE...... 61 MG...... 177 mg/10ml...... 165 ALPHANINE SD INTRAVENOUS aller-chlor...... 177 allergy relief oral tablet 10 mg...... 165, 177 SOLUTION RECONSTITUTED 1000 UNIT.60 allerclear...... 177 allergy relief oral tablet 180 mg...... 177 ALPHANINE SD INTRAVENOUS allerclear d-24hr...... 176 allergy relief oral tablet 25 mg...... 165 SOLUTION RECONSTITUTED 1500 aller-cort...... 179 allergy relief oral tablet 4 mg...... 177 UNIT, 500 UNIT...... 60 aller-ease...... 177 allergy relief oral tablet 60 mg...... 177 alprazolam er...... 53 aller-fex...... 177 allergy relief oral tablet chewable 12.5 mg.165 alprazolam intensol...... 53 allergy & congestion oral tablet extended allergy relief oral tablet dispersible 10 mg..177 alprazolam oral tablet...... 53 release 24 hour 10-240 mg...... 176 allergy relief oral tablet extended release alprazolam oral tablet dispersible...... 53 allergy (cetirizine)...... 165 12 mg...... 177 alprazolam xr...... 53 allergy 24hour indoor/outdoor...... 165 allergy relief(cetirizine)...... 166 ALPROLIX...... 61 allergy 24-hr...... 177 allergy relief/indoor/outdoor oral tablet 10 ALREX...... 158 allergy 4 hour...... 177 mg...... 166 ALTACE...... 63 allergy childrens oral liquid...... 165 allergy relief/indoor/outdoor oral tablet 180 altafrin...... 155 allergy childrens oral syrup...... 177 mg...... 177 altalube...... 160 allergy medication...... 165 allergy relief/nasal decong...... 176 altamist spray...... 174 allergy oral capsule 25 mg...... 165 altarussin dm...... 180

197 altavera...... 122 amlodipine besylate-benazepril hcl...... 65 ANBESOL MAXIMUM STRENGTH ALTOPREV...... 68 amlodipine besylate-valsartan...... 65 MOUTH/THROAT GEL...... 75 ALTRENO...... 76 amlodipine-atorvastatin...... 65 ANCOBON...... 33 alum & mag hydroxide-simeth...... 103 amlodipine-olmesartan...... 65 ANDRODERM...... 121 alumina-magnesia-simethicone...... 103 amlodipine-valsartan-hctz...... 65 ANDROGEL PUMP...... 121 ALUNBRIG...... 153 amnesteem...... 76 ANDROGEL TRANSDERMAL GEL 20.25 ALVESCO...... 168 amoxapine...... 31 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), alvimopan...... 103 amoxicill-clarithro-lansopraz...... 101 40.5 MG/2.5GM (1.62%)...... 121 alyacen 1/35...... 122 amoxicillin...... 22 ANDROGEL TRANSDERMAL GEL 50 alyacen 7/7/7...... 122 amoxicillin-potassium clavulanate er...... 22 MG/5GM (1%)...... 121 alyq...... 172 amoxicillin-potassium clavulanate oral anecream external cream...... 15 amabelz...... 122 suspension reconstituted 200-28.5 mg/5ml, anefrin spray...... 174 amantadine hcl oral...... 45 400-57 mg/5ml...... 22 ANGELIQ...... 122 AMARYL...... 54 amoxicillin-potassium clavulanate oral animal shapes complete...... 188 AMBIEN CR ORAL TABLET EXTENDED suspension reconstituted 250-62.5 mg/5ml. 22 animal shapes kids first...... 188 RELEASE 12.5 MG...... 185 amoxicillin-potassium clavulanate oral animal shapes/iron...... 188 AMBIEN CR ORAL TABLET EXTENDED suspension reconstituted 600-42.9 mg/5ml. 22 ANNOVERA...... 122 RELEASE 6.25 MG...... 185 amoxicillin-potassium clavulanate oral ANODYNE LPT...... 15 AMBIEN ORAL TABLET 10 MG...... 185 tablet 250-125 mg, 875-125 mg...... 22 ANORO ELLIPTA...... 179 AMBIEN ORAL TABLET 5 MG...... 185 amoxicillin-potassium clavulanate oral antacid & anti-gas oral suspension 200- ambrisentan...... 172 tablet 500-125 mg...... 22 200-20 mg/5ml...... 103 amcinonide external cream...... 78 amoxicillin-potassium clavulanate oral antacid & anti-gas oral suspension 400- amcinonide external lotion...... 78 tablet chewable 200-28.5 mg, 400-57 mg....22 400-40 mg/5ml...... 103 AMELUZ...... 82 AMPHETAMINE ER...... 72 antacid & gas relief...... 104 AMERGE...... 36 amphetamine sulfate...... 72 antacid advanced...... 104 americerin...... 86 amphetamine-dextroamphetamine...... 72 antacid advanced max st...... 104 amethia...... 122 amphetamine-dextroamphetamine er...... 72 antacid anti-gas...... 104 amethyst tablet 90-20 mcg oral...... 122 ampicillin...... 22 antacid anti-gas ex st oral suspension 400- AMICAR...... 59 AMPYRA...... 73 400-40 mg/5ml...... 104 amiloride hcl oral...... 67 AMRIX...... 185 antacid anti-gas max strength...... 104 amiloride-hydrochlorothiazide...... 65 AMZEEQ...... 84 antacid anti-gas reg strength...... 104 aminoamrms...... 141 ANAFRANIL...... 31 antacid calcium...... 104 aminocaproic acid oral...... 59 anagrelide hcl...... 59 antacid calcium rich...... 104 aminoreliefrms...... 141 ana-lex...... 86 antacid extra strength oral suspension...... 104 amiodarone hcl oral tablet 100 mg...... 63 ANALPRAM HC...... 82 antacid extra strength oral tablet chewable amiodarone hcl oral tablet 200 mg, 400 mg.63 ANALPRAM HC SINGLES...... 82 160-105 mg...... 104 AMITIZA...... 100 ANALPRAM-HC...... 82 antacid extra strength oral tablet chewable amitriptyline hcl oral...... 31 ANASPAZ...... 141 750 mg...... 104 amlodipine besylate oral...... 64 anastrozole oral...... 40 antacid fast relief...... 104

198 antacid i...... 104 antifungal tolnaftate...... 141 ARAVA...... 136 antacid iii...... 104 anti-gas oral capsule 180 mg...... 105 ARAZLO...... 76 antacid kids...... 104 anti-hist allergy...... 166 ARCALYST...... 134 antacid liquid...... 104 anti-nausea...... 32 arformoterol tartrate...... 170 antacid m...... 104 ANTIVENIN LATRODECTUS MACTANS..141 ARICEPT ORAL TABLET 10 MG, 5 MG...... 28 antacid maximum...... 104 ANTIVENIN MICRURUS FULVIUS...... 141 ARICEPT ORAL TABLET 23 MG...... 28 antacid maximum strength...... 104 ANTIVERT...... 31 ARIDA...... 141 antacid maximum strength oral tablet anucort-hc...... 139 ARIKAYCE...... 20 chewable 1000 mg...... 104 ANUSOL-HC EXTERNAL...... 139 ARIMIDEX...... 40 antacid oral suspension 200-200-20 ANUSOL-HC RECTAL...... 139 aripiprazole oral solution...... 47 mg/5ml, 400-400-40 mg/10ml...... 104 APADAZ...... 15 aripiprazole oral tablet...... 47 antacid oral tablet chewable 1000 mg...... 104 apap-caff-dihydrocodeine oral capsule...... 8 aripiprazole oral tablet dispersible...... 47 antacid oral tablet chewable 500 mg...... 105 APEXICON E...... 78 ARISTADA...... 47 antacid oral tablet chewable 750 mg...... 105 APIDRA SOLOSTAR...... 56 ARISTADA INITIO...... 47 antacid plus antigas...... 105 APIDRA VIAL...... 56 ARIXTRA...... 58 antacid plus anti-gas relief...... 105 APLENZIN...... 29 armodafinil...... 186 antacid regular strength oral suspension... 105 APOKYN...... 45 ARMONAIR DIGIHALER...... 168 antacid regular strength oral tablet APO-VARENICLINE...... 18 ARMOUR THYROID...... 133 chewable...... 105 apraclonidine hcl...... 159 ARNUITY ELLIPTA INHALATION antacid ultra strength oral tablet chewable aprepitant oral...... 32 AEROSOL POWDER BREATH 1000 mg...... 105 aprepitant oral capsule 125 mg, 40 mg...... 32 ACTIVATED 100 MCG/ACT, 200 antacid/anti-gas...... 105 aprepitant oral capsule 80 & 125 mg...... 32 MCG/ACT, 50 MCG/ACT...... 168 antacid/anti-gas max st...... 105 aprepitant oral capsule 80 mg...... 32 AROMASIN...... 40 antacid/antigas oral suspension 200-200- apri...... 122 arsenic trioxide intravenous solution 12 20 mg/5ml...... 105 APRISO...... 138 mg/6ml...... 39 antacid/gas relief max st...... 105 APRIZIO PAK...... 16 arthritis pain oral tablet extended release ANTARA...... 67 APRIZIO PAK II...... 16 650 mg...... 11 antibiotic...... 24, 141 APTENSIO XR...... 71 arthritis pain relief oral tablet extended antibiotic pain/scar...... 24 APTIOM...... 27 release 650 mg...... 11 antibiotic/pain relief external ointment 1 %...24 APTIVUS...... 52 arthritis pain reliever oral...... 11 anti-dandruff...... 78 AQUADEKS ORAL LIQUID...... 188 arthritis pain relieving...... 141 anti-diarrheal oral liquid 1 mg/7.5ml...... 100 aqueous vitamin e...... 193 ARTHROTEC...... 4 antifungal (tolnaftate)...... 141 AQUORAL...... 75 artificial eye...... 160 antifungal external cream 1 %...... 141 aranelle...... 122 artificial tears ophthalmic ointment...... 160 antifungal external cream 2 %...... 34 ARANESP (ALBUMIN FREE) INJECTION artificial tears ophthalmic solution ...... 160 antifungal external powder...... 34 SOLUTION 100 MCG/ML, 200 MCG/ML, artificial tears ophthalmic solution 0.5-0.6 anti-fungal external powder...... 141 25 MCG/ML, 40 MCG/ML, 60 MCG/ML...... 59 %, 1.4 %, 5-6 mg/ml...... 160 antifungal foot care...... 34 ARANESP (ALBUMIN FREE) INJECTION ASACOL HD...... 138 antifungal miconazole...... 34 SOLUTION PREFILLED SYRINGE...... 59 ascomp-codeine...... 8

199 ascorbic acid oral powder...... 188 athletes foot (tolnaftate) external aerosol AUVI-Q INJECTION SOLUTION AUTO- ascorbic acid oral tablet 500 mg...... 188 powder 1 %...... 141 INJECTOR 0.3 MG/0.3ML...... 170 asenapine maleate...... 47 athletes foot (tolnaftate) external cream 1 AVALIDE...... 65 ashlyna...... 122 %...... 141 AVAPRO...... 62 ASMANEX (120 METERED DOSES)...... 168 athletes foot external aerosol powder 2 %... 34 AVAR CLEANSER...... 86 ASMANEX (14 METERED DOSES)...... 168 athletes foot external cream 1 %...... 34 AVAR LS CLEANSER...... 86 ASMANEX (30 METERED DOSES) athletes foot external powder 2 %...... 34 AVAR-E EMOLLIENT...... 86 INHALATION AEROSOL POWDER athletes foot powder spray external aerosol AVAR-E GREEN...... 86 BREATH ACTIVATED 110 MCG/INH...... 168 powder 1 %...... 142 AVAR-E LS...... 86 ASMANEX (30 METERED DOSES) athletes foot powder spray external aerosol AVEDANA GLYCERIN (ADULT)...... 112 INHALATION AEROSOL POWDER powder 2 %...... 34 aviane...... 122 BREATH ACTIVATED 220 MCG/INH...... 168 athletes foot spray...... 142 avidoxy...... 23 ASMANEX (60 METERED DOSES)...... 168 ATIVAN ORAL...... 53 AVITA...... 76 ASMANEX (7 METERED DOSES)...... 168 atomoxetine hcl...... 71 avo cream...... 88 ASMANEX HFA...... 168 ATOPICLAIR...... 88 AVODART...... 117 aspirin adults...... 141 atorvastatin calcium oral...... 68 AVONEX PEN...... 73 aspirin childrens...... 141 atovaquone...... 43 AVONEX PREFILLED...... 73 aspirin ec...... 141 atovaquone-proguanil hcl...... 43 AYGESTIN...... 128 aspirin ec oral tablet 325 mg...... 141 ATRALIN...... 76 AYR...... 174 aspirin oral...... 141 ATRIPLA...... 50 AYR SALINE NASAL...... 174 ASPIRIN ORAL TABLET DELAYED atropine sulfate ophthalmic ointment...... 155 AYR SALINE NASAL NO-DRIP...... 174 RELEASE 81 MG...... 141 atropine sulfate ophthalmic solution 1 %....155 ayuna...... 122 aspirin rectal...... 141 ATROVENT HFA...... 169 AYVAKIT ORAL TABLET 100 MG, 200 aspirin tri-buffered...... 15 AUBAGIO...... 73 MG, 300 MG...... 153 aspirin-dipyridamole er...... 59 aubra...... 122 AYVAKIT ORAL TABLET 25 MG, 50 MG.. 153 ASTAGRAF XL...... 136 aubra eq...... 122 AZADROX...... 142 ASTERO...... 15 AUGMENTIN...... 22 AZALGIA...... 142 asthmanefrin refill...... 179 AUGMENTIN ES-600...... 22 AZASAN...... 136 astringent eye drops...... 160 aurodryl allergy childrens...... 166 AZASITE...... 157 atabex dha 200...... 141 aurophen childrens...... 11 azathioprine oral...... 136 ATACAND...... 62 aurovela 1.5/30...... 122 azelaic acid external...... 76 ATACAND HCT...... 65 aurovela 1/20...... 122 azelastine hcl nasal solution 0.1 %, 137 atazanavir sulfate...... 52 aurovela 24 fe...... 122 mcg/spray...... 166 ATELVIA...... 139 aurovela fe 1.5/30...... 122 azelastine hcl nasal solution 0.15 %...... 166 atenolol oral...... 64 aurovela fe 1/20...... 122 azelastine hcl ophthalmic...... 156 atenolol-chlorthalidone...... 65 AURYXIA...... 94 azelastine-fluticasone...... 166 atheletes foot...... 34 AUSTEDO...... 73 AZILECT...... 46 athletes foot (terbinafine)...... 34 AUVI-Q INJECTION SOLUTION AUTO- azithromycin oral...... 22 INJECTOR 0.15 MG/0.15ML...... 170 azo...... 118

200 azo tabs...... 118 balanced b-50 tr...... 189 BENZAC AC WASH...... 142 AZOLEN TINCTURE...... 34 BALCOLTRA...... 122 BENZACLIN...... 76 AZOPT...... 159 balsalazide disodium...... 138 BENZACLIN WITH PUMP...... 76 AZOR...... 65 BALVERSA...... 40 BENZAMYCIN...... 76 AZSTARYS...... 72 balziva...... 122 benzepro external foam 5.3 %...... 142 AZULFIDINE...... 138 banophen oral capsule 25 mg...... 166 BENZEPRO FOAMING CLOTHS...... 142 AZULFIDINE EN-TABS...... 138 banophen oral tablet...... 166 BENZHYDROCODONE- azurette...... 122 BANZEL ORAL SUSPENSION...... 27 ACETAMINOPHEN...... 15 b complex formula 1 oral tablet ...... 188 BANZEL ORAL TABLET...... 27 BENZNIDAZOLE...... 43 b complex plus c...... 95 BAQSIMI ONE PACK...... 56 BENZOIN...... 86 b complex-biotin-fa...... 188 BAQSIMI TWO PACK...... 56 benzoin compound...... 86 b complex-c oral capsule...... 95 BARACLUDE...... 49 benzonatate oral capsule 100 mg...... 174 b-1...... 193 BASAGLAR KWIKPEN...... 56 benzonatate oral capsule 150 mg...... 174 b-100 complex cr...... 188 BAXDELA INTRAVENOUS...... 23 benzonatate oral capsule 200 mg...... 174 b-12 oral tablet 1000 mcg, 500 mcg...... 193 BAXDELA ORAL...... 23 benzoyl peroxide-erythromycin...... 76 b12 quick dissolve...... 193 BAYER ASPIRIN ORAL TABLET benztropine mesylate oral...... 44 b6...... 193 DELAYED RELEASE...... 142 bepotastine besilate...... 156 BABY AYR SALINE...... 174 BAYER ASPIRIN TABLET 325 MG ORAL 142 BEPREVE...... 156 bac...... 8 BCG VACCINE...... 137 BERINERT...... 133 bacitracin external...... 142 BD AUTOSHIELD DUO PEN NEEDLES... 142 BESER EXTERNAL KIT...... 88 bacitracin external ointment 500 unit/gm..... 24 BD ULTRA-FINE INSULIN SYRINGES..... 142 beser external lotion...... 78 bacitracin ophthalmic...... 157 BD ULTRA-FINE PEN NEEDLES...... 142 BESIVANCE...... 157 bacitracin zinc external...... 24 BECONASE AQ...... 168 beta carotene oral capsule 25000 unit...... 95 bacitracin zinc first aid...... 24 BELBUCA...... 6 BETADINE OPHTHALMIC PREP...... 163 bacitracin zinc-aloe...... 24 belladonna alkaloids-opium...... 103 betamethasone dipropionate aug...... 78 bacitracin-polymyxin b ophthalmic...... 157 BELSOMRA...... 185 betamethasone dipropionate external bacitra-neomycin-polymyxin-hc...... 155 BENADRYL ALLERGY CHILDRENS cream...... 78 baclofen oral...... 48 ORAL LIQUID...... 166 betamethasone dipropionate external lotion 78 BACMIN...... 188 BENADRYL ALLERGY CHILDRENS betamethasone dipropionate external BACTRIM...... 23 ORAL TABLET CHEWABLE...... 166 ointment...... 78 BACTRIM DS...... 23 BENADRYL ALLERGY ORAL TABLET.....166 betamethasone valerate external cream...... 78 BAFIERTAM...... 73 BENADRYL ALLERGY ULTRATABS...... 166 betamethasone valerate external foam...... 78 balance b-100...... 188 benazepril hcl oral...... 63 betamethasone valerate external lotion...... 78 balance b-50...... 188 benazepril-hydrochlorothiazide...... 65 betamethasone valerate external ointment.. 78 balanced b100...... 95 BENEFIX...... 61 BETAPACE...... 63 balanced b-100 cr...... 188 BENICAR...... 62 BETAPACE AF...... 63 balanced b-100 oral tablet ...... 188 BENICAR HCT...... 65 BETASERON...... 73 balanced b50...... 189 BENLYSTA SUBCUTANEOUS...... 134 betatemp childrens...... 11 balanced b-50 oral tablet ...... 189 BENSAL HP...... 88 betaxolol hcl ophthalmic...... 159

201 betaxolol hcl oral...... 64 BLUESTAR...... 142 BUBBLES THE FISH II PEDI MASK...... 142 bethanechol chloride oral...... 117 BONINE...... 31 budesonide er...... 139 BETHKIS...... 171 BONIVA...... 139 budesonide inhalation...... 168 BETIMOL...... 159 BONJESTA...... 31 budesonide oral...... 139 BETOPTIC-S...... 159 bosentan...... 172 BUDESONIDE-FORMOTEROL BEVESPI AEROSPHERE...... 179 BOSULIF...... 153 FUMARATE...... 179 bexarotene...... 41 bp 10-1...... 86 BUFFERIN...... 15 BEXSERO...... 137 bp cleansing wash...... 86 bumetanide oral...... 67 BEYAZ...... 122 bp vit 3...... 95 BUMEX...... 67 BHI URI-CONTROL...... 142 bp wash external liquid 2.5 %...... 142 BUNAVAIL...... 17 BIAFINE...... 88 b-plex...... 95 BUPAP...... 8 bicalutamide...... 38 b-plex plus...... 189 BUPHENYL...... 115 BIDIL...... 65 BPROTECTED PEDIA POLY-VITE...... 189 buprenorphine hcl sublingual...... 6 BIJUVA...... 122 BPROTECTED PEDIA POLY-VITE/FE..... 189 buprenorphine hcl-naloxone hcl sublingual BIKTARVY...... 50 BRAFTOVI...... 40 film...... 17 BILTRICIDE...... 42 BREATHE EASE NEB MASK/CHILD...... 142 buprenorphine hcl-naloxone hcl sublingual bimatoprost external...... 160 BREATHE EASE NEB MASK/INFANT...... 142 tablet sublingual...... 17 bimatoprost ophthalmic...... 155 BREO ELLIPTA...... 179 buprenorphine transdermal patch weekly biocel...... 189 BREXAFEMME...... 142 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr. 17 BIOLLE TEARS...... 160 BREZTRI AEROSPHERE...... 179 buprenorphine transdermal patch weekly BIOTHRAX...... 138 briellyn...... 123 7.5 mcg/hr...... 17 biotin forte oral tablet 5 mg...... 189 BRILINTA ORAL TABLET 60 MG...... 59 bupropion hcl er (smoking det)...... 18 biotin oral capsule 5000 mcg...... 189 BRILINTA ORAL TABLET 90 MG...... 59 bupropion hcl er (sr)...... 29 biotin oral tablet 5 mg...... 189 brimonidine tartrate ophthalmic solution bupropion hcl er (xl) oral tablet extended bisacodyl ec...... 142 0.15 %...... 159 release 24 hour 150 mg, 300 mg...... 29 bisacodyl laxative...... 142 brimonidine tartrate ophthalmic solution 0.2 BUPROPION HCL ER (XL) ORAL TABLET bisacodyl rectal...... 142 %...... 159 EXTENDED RELEASE 24 HOUR 450 MG..29 bisoprolol fumarate oral...... 64 BRINEURA...... 114 bupropion hcl oral...... 29 bisoprolol-hydrochlorothiazide...... 65 brinzolamide...... 159 buspirone hcl oral...... 53 BLEPH-10...... 157 BRISDELLE...... 30 butalbital-acetaminophen capsule 50-300 BLEPHAMIDE...... 155 BRIVIACT ORAL...... 25 mg oral...... 8 BLEPHAMIDE S.O.P...... 155 bromfenac sodium (once-daily)...... 158 BUTALBITAL-ACETAMINOPHEN blisovi 24 fe...... 122 bromocriptine mesylate oral...... 45 CAPSULE 50-300 MG ORAL...... 8 blisovi fe 1.5/30...... 122 BROMSITE...... 158 butalbital-acetaminophen oral tablet 25- blisovi fe 1/20...... 122 BRONCHITOL...... 74 325 mg...... 8 BLOOD GLUCOSE TEST IN VITRO BRONCHITOL TOLERANCE TEST...... 74 butalbital-acetaminophen oral tablet 50- STRIP...... 142 BROVANA...... 170 300 mg...... 8 BLOOD GLUCOSE TEST STRIPS....142, 144 BRUKINSA...... 153 butalbital-acetaminophen oral tablet 50- blue tube/ aloe...... 15 BRYHALI...... 78 325 mg...... 8

202 butalbital-apap-caff-cod...... 8 calcitriol external...... 82 CAMINO PRO COMPLETE/GLYTACTIN.. 142 butalbital-apap-caffeine oral capsule 50- calcitriol oral capsule...... 139 camrese...... 123 300-40 mg...... 8 calcitriol oral solution...... 139 camrese lo...... 123 butalbital-apap-caffeine oral capsule 50- calcium 500 +d3...... 93 CANASA...... 138 325-40 mg...... 8 calcium 500/d oral tablet chewable...... 93 candesartan cilexetil...... 62 butalbital-apap-caffeine oral tablet...... 8 calcium 600 oral tablet 1500 (600 ca) mg.. 189 candesartan cilexetil-hctz...... 65 butalbital-asa-caff-codeine...... 8 calcium 600+d oral tablet 600-200 mg-unit 189 capecitabine...... 42 butalbital-aspirin-caffeine...... 8 calcium acetate (phos binder)...... 94 CAPEX...... 78 butorphanol tartrate nasal...... 8 calcium acetate oral tablet 667 mg...... 94 CAPLYTA...... 47 BUTRANS TRANSDERMAL PATCH calcium antacid...... 105 CAPRELSA...... 153 WEEKLY 10 MCG/HR, 15 MCG/HR, 20 calcium antacid ex st...... 105 capsaicin external cream...... 142 MCG/HR, 5 MCG/HR...... 17 calcium antacid extra strength...... 105 capsaicin hp...... 142 BUTRANS TRANSDERMAL PATCH calcium carbonate antacid oral suspension105 captopril oral...... 63 WEEKLY 7.5 MCG/HR...... 17 calcium carbonate antacid oral tablet...... 105 capzix...... 142 BYDUREON BCISE AUTOINJECTOR...... 54 calcium carbonate antacid oral tablet CARAC...... 82 BYETTA 10 MCG PEN...... 54 chewable...... 105 CARAFATE ORAL SUSPENSION...... 102 BYETTA 5 MCG PEN...... 54 calcium carbonate oral tablet 1500 (600 CARAFATE ORAL TABLET...... 102 BYLVAY...... 102 ca) mg...... 189 CARBAGLU...... 91 BYLVAY (PELLETS)...... 102 calcium carbonate oral tablet chewable carbamazepine er oral capsule extended BYSTOLIC...... 64 1250 (500 ca) mg...... 189 release 12 hour...... 27 c 500/rose hips...... 189 calcium carbonate oral tablet chewable carbamazepine er oral tablet extended CABENUVA...... 35 500 mg...... 105 release 12 hour...... 27 cabergoline...... 132 calcium carbonate-vitamin d oral tablet carbamazepine oral suspension...... 27 CABLIVI...... 59 600-200 mg-unit...... 189 carbamazepine oral tablet...... 27 CABOMETYX...... 153 calcium fast dissolution...... 189 carbamazepine oral tablet chewable...... 27 CADUET...... 65 calcium high potency...... 189 CARBATROL...... 27 CAFERGOT...... 37 calcium high potency/vitamin d...... 189 carbidopa oral...... 46 caffeine citrate oral...... 73 calcium oral tablet 1500 (600 ca) mg...... 189 carbidopa-levodopa er...... 46 CALAN SR...... 65 calcium oyster shell oral tablet 1250 (500 carbidopa-levodopa oral tablet...... 46 calcipotriene external cream...... 82 ca) mg...... 189 carbidopa-levodopa oral tablet dispersible...46 CALCIPOTRIENE EXTERNAL FOAM...... 82 calcium plus vitamin d oral tablet 600-200 carbidopa-levodopa-entacapone...... 45 calcipotriene external ointment...... 82 mg-unit...... 189 carbinoxamine maleate oral solution...... 166 calcipotriene external solution...... 82 calcium/minerals/vitamin d...... 93 carbinoxamine maleate oral tablet 4 mg.... 166 calcipotriene-betameth diprop external calcium-folic acid plus d...... 189 carbinoxamine maleate oral tablet 6 mg.... 166 ointment...... 82 cal-gest antacid...... 106 carboxymethylcellulose sodium ophthalmic calcipotriene-betameth diprop external cal-mag aspartate...... 189 ...... 160 suspension...... 82 CALQUENCE...... 153 CARDIZEM...... 65 calcitonin (salmon) nasal...... 139 CAMBIA...... 4 CARDIZEM CD...... 65 CALCITRENE...... 82 camila...... 128 CARDIZEM LA...... 65

203 CARDURA...... 62 cefprozil...... 21 chewy not chalky flavor...... 106 CARDURA XL...... 117 cefuroxime axetil...... 21 childrens acetaminophen...... 11 CARETOUCH 2 CPAP HOSE HANGER... 142 CELEBREX...... 4 childrens allergy oral liquid 12.5 mg/5ml.... 166 CARETOUCH CONTROL SOL LEVEL 2.. 142 celecoxib oral...... 4 childrens animal shapes...... 189 CARETOUCH CPAP & BIPAP HOSE...... 143 CELEXA...... 30 childrens apap...... 11 CARETOUCH CPAP MASK WIPES...... 143 CELLCEPT...... 136 childrens aspirin oral tablet chewable 81 CARETOUCH CPAP PRE-WASH SOLN.. 143 CELONTIN...... 26 mg...... 143 CARETOUCH CPAP TUBE BRUSH...... 143 CENTANY...... 84 childrens chewable vitamins...... 189 CARETOUCH MONITOR SYSTEM...... 143 CENTRUM FLAVOR BURST KIDS...... 189 childrens chewables/ex c...... 95 CARETOUCH TEST...... 143 CENTRUM KIDS...... 189 childrens chewables/iron...... 189 CARETOUCH UNIVERSL CPAP FILTER. 143 cephalexin oral capsule...... 21 childrens cold & allergy...... 180 carisoprodol oral tablet 250 mg...... 185 cephalexin oral suspension reconstituted.... 21 childrens complete oral tablet chewable 18 carisoprodol oral tablet 350 mg...... 185 cephalexin oral tablet...... 21 mg...... 189 carisoprodol-aspirin-codeine...... 185 CEQUA...... 155 childrens cough...... 181 CARNITOR ORAL...... 115 CERDELGA...... 115 childrens loratadine...... 177 CARNITOR SF...... 115 CEREZYME...... 115 childrens mucus relief cough...... 181 CAROSPIR...... 67 cerovel...... 88 childrens non-aspirin...... 11 carteolol hcl...... 159 cerovite jr...... 189 childrens silapap...... 11 cartia xt...... 65 CERVIDIL...... 120 childrens vitamins/extra c...... 95 carvedilol...... 64 cetirizine hcl oral solution 1 mg/ml...... 166 childrens vitamins/iron...... 189 carvedilol phosphate er...... 64 cetirizine hcl oral solution 5 mg/5ml...... 166 childs non-aspirin...... 11 CASODEX...... 38 cetirizine hcl oral tablet...... 166 chlordiazepoxide hcl...... 53 CATAFLAM...... 4 cetirizine hcl oral tablet chewable...... 166 chlordiazepoxide-amitriptyline...... 29 CATAPRES-TTS-1...... 62 CETRAXAL...... 164 chlordiazepoxide-clidinium...... 101 CATAPRES-TTS-2...... 62 cevimeline hcl...... 75 chlorhexidine gluconate mouth/throat...... 75 CATAPRES-TTS-3...... 62 CHANTIX...... 18 chloroquine phosphate oral...... 43 cavarest...... 91 CHANTIX CONTINUING MONTH PAK...... 18 chlor-pheniramine...... 177 CAVILON...... 34 CHANTIX STARTING MONTH PAK...... 18 chlorpheniramine maleate er...... 177 CAYA...... 143 charlotte 24 fe...... 123 chlorpheniramine maleate oral...... 178 CAYSTON...... 171 chateal...... 123 chlorpromazine hcl oral concentrate...... 46 caziant...... 123 chateal eq...... 123 chlorpromazine hcl oral tablet...... 46 cefaclor...... 21 CHEMET...... 94 chlortabs...... 178 cefaclor er...... 21 CHEMSTRIP K...... 90 chlorthalidone...... 67 cefadroxil oral capsule...... 21 CHENODAL...... 101 CHLOR-TRIMETON...... 178 cefadroxil oral suspension reconstituted...... 21 cherry cough drops...... 75 CHLOR-TRIMETON ALLERGY...... 178 cefadroxil oral tablet...... 21 cherry menthol drops...... 75 chlorzoxazone...... 185 cefdinir...... 21 chest congest/cough child...... 180 chocolate laxative pieces...... 112 cefixime...... 21 chest congestion relief dm oral syrup...... 180 chocolated laxative...... 112 cefpodoxime proxetil...... 21 chewable childrens vitamin...... 189 CHOLBAM...... 115

204 cholestyramine light...... 68 CLARITIN ALLERGY CHILDRENS...... 178 clindamycin phosphate vaginal...... 20 cholestyramine oral...... 68 CLARITIN CHILDRENS...... 178 clindamycin phosphate-benzoyl peroxide chorionic gonadotropin intramuscular...... 119 CLARITIN ORAL TABLET...... 178 external gel 1-5 %...... 76 CHROMAGEN...... 93 CLARITIN ORAL TABLET CHEWABLE.... 178 clindamycin-tretinoin...... 76 CIALIS ORAL TABLET 5 MG...... 117 CLARITIN REDITABS ORAL TABLET CLINDESSE...... 20 ciclodan...... 84 DISPERSIBLE 10 MG...... 178 CLINPRO 5000...... 91 ciclopirox external...... 84 CLARITIN REDITABS ORAL TABLET clobazam oral suspension...... 27 ciclopirox olamine external cream...... 84 DISPERSIBLE 5 MG...... 178 clobazam oral tablet...... 27 ciclopirox olamine external suspension...... 84 CLARITIN-D 24 HOUR...... 176 clobetasol prop emollient base...... 78 ciclopirox treatment...... 84 c-lax laxative...... 143 clobetasol propionate e...... 78 cilostazol...... 59 CLEARCANAL EARWAX SOFTENER...... 164 clobetasol propionate emulsion...... 78 CILOXAN...... 157 clearlax oral powder 17 gm/scoop...... 110 clobetasol propionate external cream...... 78 CIMDUO...... 51 clearskin...... 143 clobetasol propionate external foam...... 78 cimetidine hcl...... 102 clemastine fumarate oral tablet 2.68 mg.... 166 clobetasol propionate external gel...... 78 cimetidine oral...... 102 CLENPIQ...... 101 clobetasol propionate external liquid...... 78 CIMZIA...... 136 CLEOCIN ORAL...... 20 clobetasol propionate external lotion...... 78 cinacalcet hcl oral tablet 30 mg, 90 mg...... 139 CLEOCIN VAGINAL CREAM...... 20 clobetasol propionate external ointment...... 79 cinacalcet hcl oral tablet 60 mg...... 139 CLEOCIN VAGINAL SUPPOSITORY...... 20 clobetasol propionate external shampoo..... 79 CINRYZE...... 133 CLEOCIN-T...... 84 clobetasol propionate external solution...... 79 CIPRO...... 23 CLIMARA...... 123 CLOBEX...... 79 CIPRO HC...... 164 CLIMARA PRO...... 123 CLOBEX SPRAY...... 79 CIPRODEX...... 164 CLINDACIN ETZ EXTERNAL KIT...... 88 clocortolone pivalate...... 79 ciprofloxacin hcl ophthalmic...... 157 clindacin etz external swab...... 84 CLODAN EXTERNAL KIT...... 88 ciprofloxacin hcl oral...... 23 CLINDACIN PAC...... 88 clodan external shampoo...... 79 ciprofloxacin hcl otic...... 164 clindacin-p...... 84 CLODERM...... 79 ciprofloxacin-dexamethasone...... 164 CLINDAGEL...... 84 clomipramine hcl oral...... 31 CIPROFLOXACIN-FLUOCINOLONE PF...164 clindamycin hcl oral...... 20 clonazepam oral tablet...... 53 citalopram hydrobromide oral solution...... 30 clindamycin palmitate hcl...... 20 clonazepam oral tablet dispersible...... 53 citalopram hydrobromide oral tablet...... 30 clindamycin phos-benzoyl perox external clonidine...... 62 CITRANATAL B-CALM...... 95 gel 1.2-2.5 %...... 76 clonidine hcl er...... 71 CITRANATAL BLOOM...... 95 clindamycin phos-benzoyl perox external clonidine hcl oral...... 62 citrate of magnesia...... 112 gel 1.2-5 %...... 76 clopidogrel bisulfate oral tablet 300 mg...... 59 citroma...... 112 clindamycin phosphate external foam...... 84 clopidogrel bisulfate oral tablet 75 mg...... 59 CITRUCEL...... 112 clindamycin phosphate external lotion...... 84 clorazepate dipotassium...... 53 claravis...... 76 clindamycin phosphate external solution..... 85 clotrimazole 3...... 34 CLARINEX...... 166 clindamycin phosphate external swab...... 85 clotrimazole 7...... 34 CLARINEX-D 12 HOUR...... 173 CLINDAMYCIN PHOSPHATE GEL 1 % clotrimazole external cream...... 85 clarithromycin er...... 22 EXTERNAL...... 85 clotrimazole external solution...... 85 clarithromycin oral...... 22 clindamycin phosphate gel 1 % external...... 85 clotrimazole mouth/throat...... 33

205 clotrimazole vaginal...... 34 colesevelam hcl...... 68 CONTOUR NEXT MONITOR KIT clotrimazole-betamethasone external COLESTID...... 68 W/DEVICE...... 143 cream...... 82 COLESTID FLAVORED...... 68 CONTOUR NEXT ONE KIT...... 143 clotrimazole-betamethasone external lotion.82 colestipol hcl oral granules...... 68 CONTOUR NEXT TEST STRIPS...... 143 clovique...... 94 colestipol hcl oral packet...... 68 CONTOUR TEST STRIPS...... 144 clozapine oral tablet 100 mg, 25 mg, 50 mg 48 colestipol hcl oral tablet...... 68 CONZIP...... 6 clozapine oral tablet 200 mg...... 48 COLLATYL...... 143 COPASIL EXTERNAL...... 88 clozapine oral tablet dispersible...... 48 col-rite oral capsule 250 mg...... 110 COPAXONE SUBCUTANEOUS CLOZARIL ORAL TABLET 100 MG, 25 COMBIGAN...... 155 SOLUTION PREFILLED SYRINGE 20 MG...... 48 COMBIPATCH...... 123 MG/ML...... 73 CLOZARIL ORAL TABLET 200 MG...... 48 COMBIVENT RESPIMAT...... 179 COPAXONE SUBCUTANEOUS CLOZARIL ORAL TABLET 50 MG...... 48 COMBIVIR...... 51 SOLUTION PREFILLED SYRINGE 40 C-NATE DHA...... 95 COMETRIQ (100 MG DAILY DOSE)...... 153 MG/ML...... 73 COAGADEX...... 60 COMETRIQ (140 MG DAILY DOSE)...... 153 COPIKTRA...... 40 COARTEM...... 43 COMETRIQ (60 MG DAILY DOSE)...... 153 CORDRAN EXTERNAL CREAM 0.05 %.....79 COCAINE HCL NASAL...... 16 comfort gel...... 106 CORDRAN EXTERNAL LOTION...... 79 cod liver oil oral capsule , 1250-135 unit, comfort gel antacid anti-gas oral CORDRAN EXTERNAL OINTMENT...... 79 4000-200 unit...... 95 suspension 400-400-40 mg/5ml...... 106 COREG...... 64 COD LIVER OIL ORAL OIL...... 95 COMFORT TOUCH INSULIN PEN NEED.143 COREG CR...... 64 codeine sulfate...... 8 COMFORT TOUCH LANCETS 31G...... 90 coremino...... 23 COLACE...... 110 COMFORT TOUCH PLUS LANCETS 30G. 90 CORGARD...... 64 COLAZAL...... 138 COMPLERA...... 50 CORIFACT...... 61 COLCHICINE ORAL CAPSULE...... 35 complete allergy...... 166 CORLANOR...... 65 colchicine oral tablet...... 35 complete allergy medicine oral capsule..... 166 corn & callus remover...... 88 colchicine-probenecid...... 35 complete allergy relief...... 166 CORTEF...... 118 COLCIGEL...... 143 COMPLETE NATAL DHA...... 95 CORTENEMA...... 139 COLCRYS...... 35 COMPLETENATE...... 95 CORTIFOAM...... 139 cold & allergy...... 181 compro...... 31 CORTI-SAV...... 34 cold & allergy childrens oral elixir 1-15 COMTAN...... 45 CORTISPORIN-TC...... 164 mg/5ml...... 181 CONCEPT DHA...... 95 CORVITA...... 189 cold & cough childrens oral liquid 2.5-1-5 CONCEPT OB...... 95 CORVITE 150 ORAL TABLET...... 93 mg/5ml...... 181 CONCERTA...... 71 CORVITE 150 ORAL TABLET 150-1.25 cold & cough dm childrens oral liquid 2.5-1- CONDYLOX...... 82 MG...... 189 5 mg/5ml...... 181 constulose...... 100 corvite fe...... 93 cold/cough...... 181 CONTOUR CONTROL SOLUTION...... 143 COSENTYX SUBCUTANEOUS cold/cough childrens...... 181 CONTOUR MONITOR...... 143 SOLUTION AUTO-INJECTOR 150 MG/ML cold/cough dm childrens oral liquid 2.5-1-5 CONTOUR NEXT EZ KIT W/DEVICE...... 143 ...... 134 mg/5ml...... 181 CONTOUR NEXT LINK KIT W/DEVICE.... 143 cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 181

206 COSENTYX SUBCUTANEOUS cyclafem 1/35...... 123 daily vites...... 95 SOLUTION PREFILLED SYRINGE 150 cyclafem 7/7/7...... 123 daily-vite...... 95 MG/ML...... 134 cyclobenzaprine hcl er...... 185 dairy aid...... 106 COSENTYX SUBCUTANEOUS cyclobenzaprine hcl oral tablet 10 mg, 5 dairy relief fast acting oral tablet 9000 unit.106 SOLUTION PREFILLED SYRINGE 75 mg...... 185 dairy relief oral tablet 3000 unit...... 106 MG/0.5ML...... 134 cyclobenzaprine hcl oral tablet 7.5 mg...... 185 dalfampridine er...... 73 COSOPT...... 155 CYCLOGYL OPHTHALMIC SOLUTION DALIRESP...... 172 COSOPT PF...... 155 0.5 %, 2 %...... 155 danazol oral...... 121 COTELLIC...... 40 CYCLOGYL OPHTHALMIC SOLUTION 1 dandruff shampoo external lotion...... 79 COTEMPLA XR-ODT...... 71 %...... 155 DANTRIUM ORAL...... 48 cough & chest congestion...... 181 CYCLOMYDRIL...... 163 dantrolene sodium oral...... 48 cough childrens...... 181 cyclopentolate hcl ophthalmic solution 0.5 dapsone external gel 5 %...... 85 cough drops mouth/throat lozenge 5.4 mg...16 %, 2 %...... 155 DAPSONE EXTERNAL GEL 7.5 %...... 85 cough/chest congestion dm...... 181 cyclopentolate hcl ophthalmic solution 1 %156 dapsone oral...... 37 cough/chest dm childrens oral liquid...... 181 cyclophosphamide oral capsule...... 38 daptomycin intravenous solution COVARYX...... 129 CYCLOPHOSPHAMIDE ORAL TABLET.....38 reconstituted 350 mg...... 20 COVARYX HS...... 129 cycloserine oral...... 38 DARAPRIM...... 43 COZAAR...... 62 CYCLOSET...... 54 darifenacin hydrobromide er...... 116 CREON...... 115 cyclosporine modified oral capsule 100 mg, dasetta 1/35...... 123 CRESEMBA ORAL...... 33 25 mg...... 136 dasetta 7/7/7...... 123 CRESTOR...... 68 cyclosporine modified oral capsule 50 mg. 136 daunorubicin hcl...... 39 CRINONE...... 128 cyclosporine modified oral solution...... 136 DAURISMO...... 40 CRIXIVAN...... 52 cyclosporine oral...... 136 DAYAVITE...... 190 CROFAB...... 144 CYMBALTA...... 73 DAYHIST ALLERGY 12 HOUR RELIEF....166 cromolyn sodium inhalation...... 172 cyproheptadine hcl oral...... 166 DAYPRO...... 4 cromolyn sodium nasal...... 180 cyred...... 123 daysee...... 123 cromolyn sodium ophthalmic...... 156 cyred eq...... 123 DAYTRANA...... 71 cromolyn sodium oral...... 115 CYSTADANE...... 115 DAYVIGO...... 185 crotan...... 84 CYSTADROPS...... 156 D-CARE BLOOD GLUCOSE...... 144 CRUEX PRESCRIPTION STRENGTH...... 34 CYSTAGON...... 115 D-CARE GLUCOMETER...... 144 crush vitamin c drops...... 189 CYSTARAN...... 156 DDAVP ORAL...... 119 cryselle-28...... 123 CYTOMEL...... 130 deblitane...... 128 CRYSVITA SUBCUTANEOUS SOLUTION CYTOTEC...... 102 DECADRON...... 118 20 MG/ML, 30 MG/ML...... 115 daily fiber oral capsule 0.52 gm...... 110 DECARA K...... 190 CUPRIMINE...... 117 daily multiple vitamins...... 95 DECARA ORAL CAPSULE 250 MCG CUTIVATE...... 79 daily multivitamins/iron...... 190 (10000 UT)...... 190 CUVPOSA...... 101 daily vitamin formula+iron...... 190 decongestant 12hour max st oral tablet cyanocobalamin solution 1000 mcg/ml daily vitamins...... 95 extended release 12 hour 120 mg...... 181 injection...... 193 daily vite...... 95 deep sea nasal spray...... 174

207 deferasirox...... 94 desmopressin acetate spray...... 119 DIALYVITE SUPREME D...... 190 deferasirox granules...... 94 desogestrel-ethinyl estradiol...... 123 DIALYVITE/ZINC...... 95 deferiprone...... 94 DESONATE...... 79 DIASTAT ACUDIAL...... 27 DELESTROGEN...... 123 desonide external...... 79 DIASTAT PEDIATRIC...... 27 DELSTRIGO...... 50 DESOWEN...... 79 diazepam intensol...... 53 DELSYM CGH/CHEST CONG DM CHILD 181 desoximetasone external cream...... 79 diazepam oral concentrate...... 53 DELSYM COUGH/CHEST CONGEST DM181 desoximetasone external gel...... 79 diazepam oral solution...... 53 delyla...... 123 desoximetasone external liquid...... 79 diazepam oral tablet...... 53 DELZICOL...... 138 desoximetasone external ointment...... 79 diazepam rectal...... 27 demeclocycline hcl...... 23 DESOXYN...... 72 diazoxide oral...... 56 DEMSER...... 66 despec dm...... 174 DIBENZYLINE...... 62 DENAVIR...... 50 despec dm-g...... 174 dibucaine (perianal)...... 86 DENTA 5000 PLUS...... 91 desrx...... 79 DICLEGIS...... 31 DENTAGEL...... 91 DESVENLAFAXINE ER...... 30 DICLOFENAC...... 4 DEPAKOTE...... 54 desvenlafaxine succinate er...... 30 DICLOFENAC PATCH 1.3%...... 4 DEPAKOTE ER...... 54 DETROL...... 116 diclofenac potassium...... 4 DEPAKOTE SPRINKLES...... 54 DETROL LA...... 116 diclofenac sodium er...... 4 DEPEN TITRATABS...... 117 dexamethasone intensol...... 118 diclofenac sodium external gel 1 %...... 4 DEPO-ESTRADIOL...... 123 dexamethasone oral elixir...... 118 diclofenac sodium external gel 3 %...... 82 DEPO-PROVERA...... 128 dexamethasone oral solution...... 118 diclofenac sodium external solution...... 4 DEPO-SUBQ PROVERA 104...... 128 dexamethasone oral tablet...... 118 diclofenac sodium ophthalmic...... 158 DEPO-TESTOSTERONE...... 121 dexamethasone oral tablet therapy pack... 118 diclofenac sodium oral...... 4 DERMACINRX LIDOGEL...... 15 dexamethasone sodium phosphate diclofenac-misoprostol...... 4 DERMACINRX PROBITRAN...... 106 ophthalmic...... 158 dicloxacillin sodium...... 22 DERMACINRX RIBOTIN-E...... 190 DEXEDRINE...... 72 dicyclomine hcl oral capsule...... 101 DERMACINRX ZINTREXYL-C...... 190 DEXERYL...... 88 dicyclomine hcl oral solution...... 101 DERMA-SMOOTHE/FS BODY...... 79 DEXILANT...... 102 dicyclomine hcl oral tablet...... 101 DERMA-SMOOTHE/FS SCALP...... 79 dexmethylphenidate hcl...... 71 DIFFERIN EXTERNAL CREAM...... 76 DERMELLE...... 88 dexmethylphenidate hcl er...... 71 DIFFERIN EXTERNAL GEL...... 76 DERMOTIC...... 164 dextroamphetamine sulfate...... 72 DIFFERIN EXTERNAL LOTION...... 76 DESCOVY...... 51 dextroamphetamine sulfate er...... 72 DIFICID...... 22 DESENEX EXTERNAL POWDER...... 34 dextromethorphan-guaifenesin oral syrup..181 diflorasone diacetate external cream...... 79 DESENEX JOCK ITCH...... 34 DEXYCU...... 158 diflorasone diacetate external ointment...... 79 desipramine hcl oral...... 31 dha...... 144 DIFLUCAN...... 33 desloratadine oral tablet...... 166 DIACOMIT...... 28 diflunisal oral...... 4 desloratadine oral tablet dispersible 5 mg..166 DIALYVITE...... 95 digestive probiotic capsule oral...... 106 desmopressin ace spray refrig...... 119 DIALYVITE 3000...... 190 digitek...... 66 DESMOPRESSIN ACETATE NASAL...... 119 DIALYVITE 5000...... 190 digox...... 66 desmopressin acetate oral...... 119 DIALYVITE 800 ORAL TABLET...... 95 digoxin oral...... 66

208 dihydroergotamine mesylate nasal...... 37 dipyridamole oral...... 59 DOVATO...... 50 DILANTIN INFATABS...... 27 disopyramide phosphate...... 63 DOVONEX...... 82 DILANTIN ORAL CAPSULE 100 MG...... 27 disulfiram oral tablet 250 mg...... 17 doxazosin mesylate oral...... 62 DILANTIN ORAL CAPSULE 30 MG...... 27 disulfiram oral tablet 500 mg...... 17 doxepin hcl external...... 80 DILANTIN ORAL SUSPENSION...... 27 DITROPAN XL...... 116 doxepin hcl oral capsule...... 31 DILAUDID ORAL...... 6 DIURIL...... 67 doxepin hcl oral concentrate...... 31 diltiazem hcl er...... 65 divalproex sodium er...... 54 doxepin hcl oral tablet...... 185 diltiazem hcl er beads...... 65 divalproex sodium oral...... 54 doxercalciferol oral...... 139 diltiazem hcl er coated beads oral capsule DIVIGEL...... 123 doxycycline...... 23 extended release 24 hour...... 65 dm maximum adult...... 182 doxycycline hyclate oral capsule...... 23 diltiazem hcl er coated beads oral tablet docosanol external...... 88 doxycycline hyclate oral tablet...... 23 extended release 24 hour...... 65 docu...... 110 doxycycline hyclate oral tablet delayed diltiazem hcl oral...... 65 docu liquid...... 110 release 100 mg, 150 mg, 75 mg...... 23 dilt-xr...... 65 docusate calcium...... 112 doxycycline hyclate oral tablet delayed dimaphen dm cold/cough...... 181 docusate mini...... 110 release 200 mg, 50 mg...... 23 DIMETAPP COLD RELIEF CHILDRENS.. 182 docusate sodium oral capsule...... 110 DOXYCYCLINE HYCLATE ORAL TABLET DIMETAPP COLD/ALLERGY...... 182 docusate sodium oral liquid 50 mg/5ml...... 110 DELAYED RELEASE 80 MG...... 23 DIMETAPP DM COLD/COUGH...... 182 docusate sodium oral syrup...... 110 doxycycline monohydrate oral capsule 100 dimethyl fumarate oral...... 73 docusate sodium oral tablet...... 110 mg...... 23 dimethyl fumarate starter pack...... 73 DOCUSOL MINI...... 110 doxycycline monohydrate oral capsule 150 dino-life...... 190 docuzen...... 112 mg...... 23 dino-life w/extra c...... 95 dofetilide...... 63 doxycycline monohydrate oral capsule 50 DIOVAN...... 62 dok oral capsule...... 110 mg...... 24 DIOVAN HCT...... 66 dok oral tablet...... 110 doxycycline monohydrate oral capsule 75 DIPENTUM...... 138 dolishale...... 123 mg...... 24 diphedryl allergy...... 166 donepezil hcl oral tablet 10 mg, 5 mg...... 28 doxycycline monohydrate oral suspension diphen...... 166 donepezil hcl oral tablet 23 mg...... 28 reconstituted...... 24 di-phen...... 166 donepezil hcl oral tablet dispersible...... 28 doxycycline monohydrate oral tablet...... 24 diphenhist...... 167 DONNATAL...... 103 doxylamine-pyridoxine...... 31 diphenhydramine hcl oral capsule...... 167 DOPTELET...... 59 DR SMITHS ADULT BARRIER diphenhydramine hcl oral elixir...... 167 DORYX...... 23 EXTERNAL OINTMENT...... 86 diphenhydramine hcl oral liquid 12.5 DORYX MPC...... 23 DR SMITHS DIAPER...... 86 mg/5ml...... 167 DORZOLAMIDE HCL SOLUTION 2 % DR SMITHS DIAPER QUICK RELIEF...... 86 diphenhydramine hcl oral tablet...... 167 OPHTHALMIC...... 159 driminate...... 31 diphenhydramine hcl oral tablet chewable. 167 dorzolamide hcl solution 2 % ophthalmic... 159 DRISDOL...... 190 diphenoxylate-atropine oral liquid...... 100 dorzolamide hcl-timolol mal...... 156 DRIZALMA SPRINKLE...... 73 diphenoxylate-atropine oral tablet...... 100 dorzolamide hcl-timolol mal pf...... 156 dronabinol...... 32 DIPROLENE...... 79 dotti...... 123 drospiren-eth estrad-levomefol...... 123 DIPROLENE AF...... 79 double antibiotic...... 144 drospirenone-ethinyl estradiol...... 123

209 DROXIA...... 59 ear wax removal...... 164 EFFER-K ORAL TABLET droxidopa...... 62 ear wax removal drops...... 164 EFFERVESCENT 10 MEQ, 20 MEQ...... 190 dry-eye relief nighttime...... 160 ear wax removal kit...... 164 effer-k oral tablet effervescent 25 meq...... 190 dss...... 110 ear wax removal system...... 164 EFFEXOR XR...... 30 DUAKLIR PRESSAIR...... 179 earwax removal...... 165 EFFIENT...... 59 DUAVEE...... 123 earwax removal drops...... 165 EFUDEX...... 82 DUETACT...... 54 earwax removal kit otic solution 6.5 %...... 165 EGATEN...... 43 DUEXIS...... 4 EASIVENT...... 144 EGRIFTA SV...... 119 DULERA INHALATION AEROSOL 100-5 EASIVENT MASK LARGE...... 144 ELDERTONIC...... 95 MCG/ACT, 200-5 MCG/ACT...... 180 EASIVENT MASK MEDIUM...... 144 ELELYSO...... 115 DULERA INHALATION AEROSOL 50-5 EASIVENT MASK SMALL...... 144 ELEPSIA XR...... 25 MCG/ACT...... 180 EASY TOUCH TEST...... 144 ELESTRIN...... 123 duloxetine hcl oral capsule delayed release easygel...... 91 ELETONE...... 88 particles 20 mg, 30 mg, 60 mg...... 73 easy-lax plus...... 112 eletriptan hydrobromide...... 36 duloxetine hcl oral capsule delayed release EASYMAX 15 LEVEL 2 CONTROL...... 144 ELFOLATE...... 190 particles 40 mg...... 73 EASYMAX 15 LEVEL 2-3 CONTROL...... 144 ELFOLATE PLUS...... 95 DUOBRII...... 82 EASYMAX 15 TEST...... 144 ELIDEL...... 80 DUOPA...... 46 EASYMAX CONTROL...... 144 ELIGARD...... 132 DUPIXENT SUBCUTANEOUS SOLUTION EASYMAX NG BLOOD GLUCOSE...... 144 elinest...... 123 PEN-INJECTOR 200 MG/1.14ML...... 134 EASYMAX V BLOOD GLUCOSE...... 144 ELIQUIS...... 58 DUPIXENT SUBCUTANEOUS SOLUTION EBASE CONTROLLER KIT...... 144 ELIQUIS DVT/PE STARTER PACK...... 58 PEN-INJECTOR 300 MG/2ML...... 134 EC-NAPROSYN...... 4 ELITE-OB...... 95 DUPIXENT SUBCUTANEOUS SOLUTION ec-naproxen...... 4 ELLA...... 128 PREFILLED SYRINGE...... 135 econazole nitrate external...... 85 ELMIRON...... 117 DUREZOL...... 158 econtra ez...... 130 ELOCTATE...... 60 dutasteride oral...... 117 econtra one-step...... 130 eluryng...... 123 dutasteride-tamsulosin hcl...... 117 ECZEMOL...... 144 EMCYT...... 39 DX1 ORAGENOMIC DNA SCREEN...... 144 ed chlorped jr...... 178 EMEND ORAL...... 32 DX2 ORAGENOMIC DNA SCREEN...... 144 ed-apap...... 11 EMEND TRI-PACK...... 32 DYANAVEL XR...... 72 EDARBI...... 62 EMETROL...... 32 dye-free allergy relief...... 167 EDARBYCLOR...... 66 EMFLAZA...... 118 DYMISTA...... 167 EDECRIN...... 67 EMGALITY...... 37 DYRENIUM...... 67 EDLUAR...... 185 EMGALITY (300 MG DOSE)...... 37 E.E.S. 400...... 22 ED-SPAZ...... 144 emoquette...... 123 E.E.S. GRANULES...... 22 EDURANT...... 50 EMPAVELI...... 54 e-400-clear...... 193 EEMT...... 129 EMSAM...... 29 ear drops...... 164 efavirenz...... 50 emtricitabine...... 51 ear drops earwax aid...... 164 efavirenz-emtricitab-tenofovir...... 50 emtricitabine-tenofovir df...... 51 ear wax kit...... 164 efavirenz-lamivudine-tenofovir...... 50 EMTRIVA...... 51

210 EMVERM...... 42 ENVARSUS XR...... 136 ERYPED 400...... 22 enalapril maleate oral solution...... 63 ENZADYNE...... 99 ERY-TAB...... 22 enalapril maleate oral tablet...... 63 EPANED...... 63 ERYTHROCIN STEARATE...... 22 enalapril-hydrochlorothiazide...... 66 EPCLUSA ORAL TABLET 200-50 MG...... 49 erythromycin base...... 22 ENBRACE HR...... 95 EPCLUSA ORAL TABLET 400-100 MG...... 49 erythromycin ethylsuccinate oral ENBREL SUBCUTANEOUS SOLUTION ephrine nose drops...... 174 suspension reconstituted 200 mg/5ml...... 22 25 MG/0.5ML...... 136 EPIDIOLEX...... 25 erythromycin ethylsuccinate oral ENBREL SUBCUTANEOUS SOLUTION EPIDUO...... 76 suspension reconstituted 400 mg/5ml...... 22 AUTO-INJECTOR...... 136 EPIDUO FORTE...... 76 erythromycin ethylsuccinate oral tablet...... 22 ENBREL SUBCUTANEOUS SOLUTION EPIFOAM...... 82 erythromycin external...... 85 CARTRIDGE...... 136 epinastine hcl...... 156 erythromycin ophthalmic...... 157 ENBREL SUBCUTANEOUS SOLUTION epinephrine injection solution auto-injector erythromycin oral...... 23 PREFILLED SYRINGE...... 136 0.15 mg/0.15ml...... 170 ESBRIET...... 172 ENBREL SUBCUTANEOUS SOLUTION epinephrine solution auto-injector 0.15 escitalopram oxalate oral solution...... 30 RECONSTITUTED...... 136 mg/0.3ml injection...... 170 escitalopram oxalate oral tablet...... 30 ENDACOF-DM...... 182 epinephrine solution auto-injector 0.3 ESGIC...... 8 ENDARI...... 91 mg/0.3ml injection...... 170 esomeprazole magnesium...... 102 endocet...... 8 EPIPEN 2-PAK...... 170 ESPEROCT...... 60 enema...... 106 EPIPEN JR 2-PAK...... 170 essential one daily...... 95 enema disposable...... 106 epitol...... 27 essentials...... 95 enema mineral oil...... 110 EPIVIR...... 51 est estrogens-methyltest...... 129 enema ready-to-use...... 106 EPIVIR HBV ORAL SOLUTION...... 49 est estrogens-methyltest ds...... 129 enema rectal enema 16-6 gm/133ml, 19-7 EPIVIR HBV ORAL TABLET...... 49 est estrogens-methyltest hs...... 129 gm/118ml...... 106 eplerenone...... 67 estarylla...... 124 ENEMEEZ MINI...... 110 EPOGEN...... 59 estazolam...... 185 ENFAMIL EXPECTA...... 95 EPZICOM...... 51 ESTRACE...... 124 ENGERIX-B...... 137 EQUETRO...... 54 estradiol oral...... 124 enoxaparin sodium...... 58 ergocalciferol oral capsule...... 190 estradiol transdermal patch twice weekly...124 enpresse-28...... 124 ergoloid mesylates oral...... 28 estradiol transdermal patch weekly...... 124 enskyce...... 124 ERGOMAR...... 37 estradiol vaginal cream...... 124 ENSPRYNG...... 136 ergotamine-caffeine...... 37 estradiol vaginal tablet...... 124 ENSTILAR...... 82 ERIVEDGE...... 40 estradiol valerate intramuscular...... 124 entacapone...... 45 ERLEADA...... 38 estradiol-norethindrone acet...... 124 entecavir...... 49 erlotinib hcl...... 153 ESTRING...... 124 ENTEREG...... 106 errin...... 128 ESTROSTEP FE...... 124 enteric aspirin...... 144 ERTACZO...... 85 eszopiclone...... 185 ENTOCORT EC...... 139 ery...... 85 ethacrynic acid...... 67 ENTRESTO...... 66 ERYGEL...... 85 ethambutol hcl oral tablet 100 mg...... 38 enulose...... 100 ERYPED 200...... 22 ethambutol hcl oral tablet 400 mg...... 38

211 ethosuximide oral...... 26 eye drops advanced relief...... 160 felodipine er...... 64 ethynodiol diac-eth estradiol...... 124 eye drops allergy relief...... 160 FEM PH...... 24 etodolac...... 4 eye drops long lasting...... 160 FEMARA...... 40 etodolac er...... 4 eye drops ophthalmic solution 0.05 %...... 145 FEMHRT...... 124 etonogestrel-ethinyl estradiol...... 124 eye drops ophthalmic solution 0.05-0.1-1-1 FEMRING...... 124 etoposide oral...... 40 %...... 160 femynor...... 124 etravirine...... 50 eye drops ophthalmic solution 0.05-0.25 %160 fenofibrate micronized oral capsule 130 EUCRISA...... 80 eye itch relief...... 163 mg, 43 mg...... 67 euthyrox...... 130 eye lubricant...... 160 fenofibrate micronized oral capsule 134 EVAC...... 110 EYSUVIS...... 158 mg, 200 mg, 67 mg...... 67 EVAMIST...... 124 EZALLOR SPRINKLE...... 68 fenofibrate oral capsule 134 mg, 200 mg, EVEKEO...... 72 ezetimibe...... 68 67 mg...... 67 EVEKEO ODT...... 72 ezetimibe-simvastatin...... 68 fenofibrate oral capsule 150 mg, 50 mg...... 67 everolimus oral tablet 0.25 mg, 0.5 mg, fabb...... 95 fenofibrate oral tablet 120 mg, 40 mg...... 67 0.75 mg...... 136 FABIOR...... 77 fenofibrate oral tablet 145 mg, 48 mg...... 67 everolimus oral tablet 2.5 mg, 5 mg, 7.5 FALESSA...... 129 fenofibrate oral tablet 160 mg, 54 mg...... 67 mg...... 40 falmina...... 124 fenofibric acid oral capsule delayed release 67 EVISTA...... 129 famciclovir oral...... 50 fenofibric acid oral tablet...... 70 EVOCLIN...... 85 famotidine oral suspension reconstituted FENOGLIDE...... 67 EVOMELA...... 38 40 mg/5ml...... 102 fenoprofen calcium oral capsule 400 mg...... 4 EVOTAZ...... 52 famotidine oral tablet 10 mg...... 102 fenoprofen calcium oral tablet...... 4 EVOXAC...... 75 famotidine oral tablet 20 mg, 40 mg...... 102 FENSOLVI (6 MONTH)...... 132 EVRYSDI...... 115 famotidine orig st...... 102 fentanyl...... 6 EXACTECH R-S-G TEST...... 144 FANAPT...... 47 fentanyl citrate (pf) injection solution 50 EXACTECH TEST...... 144 FANAPT TITRATION PACK...... 47 mcg/ml...... 8 EXCEDRIN EXTRA STRENGTH...... 11 FARESTON...... 39 fentanyl citrate buccal lozenge on a handle... 8 EXCEDRIN MIGRAINE...... 11 FARXIGA...... 54 FENTANYL CITRATE BUCCAL TABLET...... 8 EXCEDRIN TENSION HEADACHE...... 11 FARYDAK...... 40 FENTORA...... 9 EXELON...... 28 FASENRA PEN...... 173 FERIVA 21/7...... 190 EXEM...... 155 fast relief laxative...... 145 FERIVAFA...... 93 exemestane...... 40 fayosim...... 124 ferocon...... 190 EXFORGE...... 66 fe c tab...... 93 ferosul...... 190 EXFORGE HCT...... 66 febuxostat...... 35 ferotrinsic...... 190 EXJADE...... 94 FEIBA...... 61 FERRALET 90...... 190 EX-LAX...... 112 felbamate oral suspension...... 25 ferraplus 90...... 93 EX-LAX ULTRA...... 145 felbamate oral tablet...... 25 ferrex 150...... 93 EXSERVAN...... 73 FELBATOL ORAL SUSPENSION...... 25 ferric x-150...... 93 EXTAVIA...... 73 FELBATOL ORAL TABLET...... 25 FERRIPROX...... 94 EXTINA...... 85 FELDENE...... 4 FERRIPROX TWICE-A-DAY...... 94

212 ferrous sulfate oral syrup...... 190 FINTEPLA...... 25 flunisolide nasal...... 168 ferrous sulfate oral tablet 325 (65 fe) mg... 190 FIORICET...... 9 fluocinolone acetonide body...... 80 ferrous sulfate oral tablet delayed release FIORICET/CODEINE...... 9 fluocinolone acetonide external...... 80 325 (65 fe) mg...... 190 FIRAZYR...... 133 fluocinolone acetonide otic...... 164 FETZIMA...... 30 FIRDAPSE...... 73 fluocinolone acetonide scalp...... 80 FETZIMA TITRATION...... 30 first aid antibiotic external ointment 1 %...... 24 fluocinonide emulsified base...... 80 fever reducer/pain reliever...... 11 first aid antibiotic external ointment 3.5- fluocinonide external...... 80 fever reducing childrens...... 11 400-5000 , 3.5-400-5000 mg-unit...... 24 FLUORESCEIN SODIUM/BENOXINATE.. 160 feverall adults...... 11 FIRVANQ...... 20 FLUORIDEX...... 91 feverall childrens...... 11 flac...... 164 FLUORIDEX ENHANCED WHITENING...... 91 FEVERALL INFANTS...... 11 FLAGYL...... 20 FLUORIDEX SENSITIVITY RELIEF...... 91 FEVERALL JUNIOR STRENGTH...... 11 FLAREX...... 158 fluorometholone...... 158 FEXMID...... 185 flavoxate hcl...... 116 FLUOROURACIL EXTERNAL CREAM 0.5 fexofenadine hcl oral tablet 180 mg...... 178 flecainide acetate...... 63 %...... 82 fexofenadine hcl oral tablet 60 mg...... 178 FLECTOR...... 5 fluorouracil external cream 5 %...... 82 fexofenadine hydrochloride...... 178 FLEET BISACODYL...... 145 fluorouracil external solution...... 82 FIASP...... 56 FLEET ENEMA...... 106 fluoxetine hcl (pmdd)...... 30 FIASP FLEXTOUCH...... 56 FLEET OIL...... 111 fluoxetine hcl oral capsule 10 mg, 20 mg.....30 FIASP PENFILL...... 56 FLEET PEDIATRIC...... 112 fluoxetine hcl oral capsule 40 mg...... 30 fiber laxative...... 110 FLEXICHAMBER...... 145 fluoxetine hcl oral capsule delayed release. 30 fiber laxative + calcium...... 110 FLEXICHAMBER ADULT MASK/SMALL.. 145 fluoxetine hcl oral solution...... 30 fiber laxative oral capsule 0.52 gm...... 110 FLEXICHAMBER CHILD MASK/LARGE... 145 fluoxetine hcl oral tablet...... 30 fiber laxative oral tablet 500 mg...... 112 FLEXICHAMBER CHILD MASK/SMALL... 145 fluphenazine decanoate injection...... 46 fiber oral capsule 0.52 gm...... 110 FLEXIN...... 16 fluphenazine hcl injection...... 46 fiber oral powder 28.3 %, 48.57 %...... 110 FLOMAX...... 117 fluphenazine hcl oral concentrate...... 46 fiber oral powder 30.9 %...... 111 FLORIVA ORAL LIQUID...... 190 fluphenazine hcl oral elixir...... 46 fiber oral powder 58.6 %...... 111 FLORIVA ORAL TABLET CHEWABLE fluphenazine hcl oral tablet...... 46 fiber oral tablet 500 mg...... 112 0.25 MG, 1 MG...... 95 flurandrenolide external cream...... 80 fiber oral tablet 625 mg...... 111 FLORIVA PLUS...... 95 flurandrenolide external lotion...... 80 fiber therapy oral capsule 0.52 gm...... 111 FLOVENT DISKUS...... 168 flurandrenolide external ointment...... 80 fiber therapy oral powder 28.3 %...... 111 FLOVENT HFA...... 168 flurazepam hcl...... 186 fiber therapy oral tablet 500 mg...... 112 FLUAD QUADRIVALENT...... 138 flurbiprofen oral tablet 100 mg...... 5 fiber therapy oral tablet 625 mg...... 111 FLUARIX QUADRIVALENT...... 138 flurbiprofen sodium...... 158 fiber-caps...... 111 FLUCELVAX QUADRIVALENT...... 138 flutamide...... 38 fiber-lax...... 111 fluconazole oral...... 33 fluticasone propionate external cream...... 80 FIBRICOR...... 70 flucytosine oral...... 33 fluticasone propionate external lotion...... 80 FILTER AIR PP...... 145 fludrocortisone acetate oral...... 118 fluticasone propionate external ointment..... 80 FINACEA...... 77 FLULAVAL QUADRIVALENT...... 138 fluticasone propionate nasal...... 168 finasteride oral tablet 5 mg...... 117 FLUMIST QUADRIVALENT...... 138

213 fluticasone-salmeterol inhalation aerosol FORTISCARE G1 TEST STRIP...... 145 gas relief extstrength...... 106 powder breath activated 100-50 mcg/dose, FORTISCARE T1 GLUCOSE SYSTEM.... 145 gas relief infants...... 106 250-50 mcg/dose, 500-50 mcg/dose...... 180 FORTISCARE TEST...... 145 gas relief infants drops...... 106 FLUTICASONE-SALMETEROL FOSAMAX...... 139 gas relief oral capsule 125 mg...... 106 INHALATION AEROSOL POWDER FOSAMAX PLUS D...... 139 gas relief oral capsule 180 mg...... 106 BREATH ACTIVATED 113-14 MCG/ACT, fosamprenavir calcium...... 52 gas relief oral suspension...... 107 232-14 MCG/ACT, 55-14 MCG/ACT...... 180 fosfomycin tromethamine...... 20 gas relief oral tablet chewable...... 107 fluvastatin sodium...... 68 fosinopril sodium...... 63 gas relief oral tablet chewable 125 mg...... 107 fluvastatin sodium er...... 68 fosinopril sodium-hctz...... 66 gas relief ultra strength...... 107 fluvoxamine maleate...... 30 FOSRENOL ORAL PACKET...... 94 gas relief ultstrength...... 107 fluvoxamine maleate er...... 30 FOSRENOL ORAL TABLET CHEWABLE...94 GASTROCROM...... 115 FLUZONE HIGH-DOSE QUADRIVALENT 138 FOTIVDA...... 153 GAS-X EXTRA STRENGTH ORAL FLUZONE QUADRIVALENT...... 138 FRAGMIN...... 58 CAPSULE...... 107 FML...... 158 FREESTYLE PRECISION NEO SYSTEM.145 GAS-X EXTRA STRENGTH ORAL FML FORTE...... 158 FREESTYLE PRECISION NEO TEST...... 145 TABLET CHEWABLE...... 107 FML LIQUIFILM...... 158 FROVA...... 36 GAS-X ULTRA STRENGTH...... 107 foaming antacid oral tablet chewable 80-20 frovatriptan succinate...... 36 gatifloxacin ophthalmic...... 157 mg...... 106 full spectrum b/vitamin c...... 96 GATTEX...... 101 FOCALIN...... 71 FULPHILA...... 59 gavilax oral powder...... 111 FOCALIN XR...... 71 fungi-guard...... 145 gavilyte-c...... 101 FOLGARD RX...... 95 FUNGOID TINCTURE...... 34 gavilyte-g...... 101 folic acid oral tablet 1 mg...... 145 furosemide oral...... 67 gavilyte-n with flavor pack...... 101 FOLITE...... 190 FUZEON...... 51 GAVISCON...... 107 FOLITIN-Z...... 190 fyavolv...... 124 GAVISCON EXTRA RELIEF FORMULA... 107 FOLIVANE-F...... 93 FYCOMPA...... 25 GAVISCON EXTRA STRENGTH...... 107 FOLIVANE-OB...... 95 g tussin ac...... 182 GAVRETO...... 153 foltabs 800...... 95 gabapentin oral capsule...... 27 GEBAUERS PAIN EASE...... 16 foltanx...... 95 gabapentin oral solution 250 mg/5ml...... 27 GEBAUERS SPRAY AND STRETCH...... 16 FOLTRATE...... 96 gabapentin oral tablet...... 27 GELNIQUE...... 116 foltrin...... 190 GABITRIL...... 27 GELSYN-3...... 145 fondaparinux sodium...... 58 GALAFOLD...... 115 GELUSIL...... 107 foot & sneaker...... 145 galantamine hydrobromide...... 28 gemcitabine hcl intravenous solution 1 foot care (terbinafine)...... 34 galantamine hydrobromide er...... 28 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, 200 for sty relief...... 160 GALZIN ORAL CAPSULE 25 MG...... 93 mg/2ml...... 39 FORAXA...... 88 GALZIN ORAL CAPSULE 50 MG...... 93 gemfibrozil oral...... 67 FORFIVO XL...... 29 GARDASIL 9...... 137 gemmily...... 124 FORTEO...... 139 gas relief antiflatuent...... 106 GEMTESA...... 48 FORTESTA...... 121 gas relief drops infants...... 106 GENADUR EXTERNAL...... 88 FORTISCARE CONTROL...... 145 gas relief extra strength...... 106 genaphed...... 182

214 GENERESS FE...... 124 glipizide xl...... 54 GLYNASE...... 55 generlac...... 100 glipizide-metformin hcl...... 54 GLYTACTIN COMPLETE 10PE...... 145 gengraf oral capsule...... 136 GLOPERBA...... 35 GLYXAMBI...... 55 gengraf oral solution...... 136 GLUCAGEN HYPOKIT...... 56 GOCOVRI...... 45 GENOTROPIN...... 119 GLUCAGON EMERGENCY INJECTION GOLYTELY...... 101 GENOTROPIN MINIQUICK...... 119 SOLUTION RECONSTITUTED...... 56 GONITRO...... 70 gentak...... 157 glucagon emergency kit 1 mg injection...... 56 GOPRELTO...... 16 gentamicin sulfate external...... 85 GLUCAGON EMERGENCY KIT 1 MG gormel 10...... 88 gentamicin sulfate ophthalmic...... 157 INJECTION...... 56 GRALISE...... 73 GENTEAL SEVERE...... 160 GLUCOSE CONTROL SOLUTION IN granisetron hcl oral...... 32 GENTEAL TEARS MODERATE PF...... 160 VITRO LIQUID...... 145 GRANIX...... 59 GENTEAL TEARS NIGHT-TIME...... 161 GLUCOSE CONTROL SOLUTION IN griseofulvin microsize oral...... 33 GENTEAL TEARS OPHTHALMIC VITRO SOLUTION...... 145 griseofulvin ultramicrosize...... 33 SOLUTION 0.1-0.2-0.3 %...... 161 GLUCOSE CONTROL SOLUTION IN guaiatussin ac...... 182 GENTEAL TEARS PF...... 161 VITRO SOLUTION HIGH , LOW...... 145 guaicon dms...... 182 GENTEAL TEARS SEVERE DAY/NIGHT. 161 GLUCOSE CONTROL SOLUTION IN guaifenesin ac...... 182 gentle laxative oral tablet delayed release VITRO SOLUTION NORMAL...... 145 guaifenesin-codeine...... 182 5 mg...... 145 GLUCOSE CONTROL SOLUTIONS...... 144 guaifenesin-dm oral syrup...... 182 gentle laxative rectal suppository 10 mg.... 145 GLUCOSE METER TEST STRIPS...... 145 guanfacine hcl...... 62 gentle laxative womens...... 145 glucose oral tablet chewable 4 gm...... 58 guanfacine hcl er...... 71 gentlelax...... 111 glucose oral tablet chewable 4-6 gm-mg..... 58 gummy dinos...... 190 GENTLE-LET PLATFORMS...... 90 GLUCOTROL XL...... 54 gummy multivitamin kids...... 190 GENVOYA...... 50 GLUMETZA...... 55 GVOKE HYPOPEN 1-PACK...... 56 GEODON ORAL...... 47 glyburide micronized...... 55 GVOKE HYPOPEN 2-PACK...... 56 geri-dryl...... 167 glyburide oral...... 55 GVOKE PFS...... 56 geri-kot...... 113 glyburide-metformin...... 55 GYNAZOLE-1...... 33 geri-lanta...... 107 glycerin (adult) rectal suppository 2 gm..... 113 GYNE-LOTRIMIN...... 34 geri-mox...... 107 glycerin (infants & children) rectal GYNE-LOTRIMIN 3...... 34 geri-tussin dm...... 182 suppository 1 gm...... 113 habitrol...... 18 GILENYA...... 73 glycerin (pediatric) rectal suppository 1 gm113 HAEGARDA...... 133 GILOTRIF...... 154 glycerin adult rectal suppository 2 gm...... 113 hailey 1.5/30...... 124 giltuss severe sinus...... 174 glycerin child rectal suppository 1 gm...... 113 hailey 24 fe...... 124 GIMOTI...... 31 glycerin child rectal suppository 1.2 gm..... 113 hailey fe 1.5/30...... 124 glatiramer acetate...... 73 glycerin childrens...... 113 hailey fe 1/20...... 124 glatopa...... 73 glycerin pediatric rectal suppository 1.2 gm halcinonide...... 80 GLEEVEC...... 154 ...... 113 HALCION...... 186 glimepiride...... 54 glycolax...... 111 HALDOL DECANOATE...... 46 glipizide er...... 54 glycopyrrolate oral...... 101 halobetasol propionate external cream...... 80 glipizide ir...... 54 glydo...... 15

215 HALOBETASOL PROPIONATE HEMOFIL M INTRAVENOUS SOLUTION HUMATROPEN FOR 12MG...... 146 EXTERNAL FOAM...... 80 RECONSTITUTED 1000 UNIT, 1700 HUMATROPEN FOR 24MG...... 146 halobetasol propionate external ointment.... 80 UNIT, 250 UNIT...... 61 HUMATROPEN FOR 6MG...... 146 HALOG EXTERNAL CREAM...... 80 HEMOFIL M INTRAVENOUS SOLUTION HUMIRA PEN-PEDIATRIC UC START..... 136 HALOG EXTERNAL OINTMENT...... 80 RECONSTITUTED 500 UNIT...... 61 HUMIRA PEN-PSOR/UVEIT STARTER....136 HALOG EXTERNAL SOLUTION...... 80 hemorrhoidal rectal ointment 0.25-3-14- HUMIRA SUBCUTANEOUS PEN- haloperidol decanoate intramuscular...... 46 71.9 %...... 88 INJECTOR KIT 40 MG/0.4ML, 40 haloperidol lactate oral...... 46 hemorrhoidal rectal suppository 0.25-3- MG/0.8ML, 80 MG/0.8ML...... 136 haloperidol oral...... 46 85.5 %...... 88 HUMIRA SUBCUTANEOUS PREFILLED HALUCORT...... 88 HEPAGAM B...... 134 SYRINGE KIT 10 MG/0.1ML, 20 HARVONI ORAL PACKET...... 49 heparin sodium (porcine)...... 58 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, HARVONI ORAL TABLET 45-200 MG...... 49 heparin sodium (porcine) pf...... 58 80 MG/0.8ML, 80 MG/0.8ML & HARVONI ORAL TABLET 90-400 MG...... 49 HEPLISAV-B...... 138 40MG/0.4ML...... 136 HAVRIX...... 137 HEPSERA...... 49 HUMULIN 70/30 KWIKPEN...... 56 HCU EASY...... 146 HETLIOZ...... 186 HUMULIN 70/30 VIAL...... 56 headache formula...... 11 HETLIOZ LQ...... 186 HUMULIN N KWIKPEN...... 56 headache relief extra str...... 11 HIBERIX...... 137 HUMULIN N VIAL...... 56 headache relief oral tablet 250-250-65 mg.. 11 HIDEX 6-DAY...... 118 HUMULIN R U-500 KWIKPEN...... 56 healthy hair/skin/nails...... 96 HIPREX...... 20 HUMULIN R U-500 VIAL heartburn antacid...... 107 HISTEX PD...... 178 (CONCENTRATED)...... 56 heartburn antacid ex st...... 107 HOME PAP KIT...... 146 HUMULIN R VIAL...... 56 heartburn prevention oral tablet 10 mg...... 102 honey lemon drops...... 75 HURRICAINE MOUTH/THROAT GEL...... 75 heartburn relief ex st...... 107 HORIZANT...... 73 HYCAMTIN ORAL...... 40 heartburn relief oral tablet 10 mg...... 102 HPR PLUS EXTERNAL CREAM...... 88 HYCODAN...... 182 heartburn relief oral tablet 200 mg...... 102 HUMALOG JUNIOR KWIKPEN...... 56 hydralazine hcl oral...... 69 heartburn relief oral tablet chewable 160- HUMALOG KWIKPEN SUBCUTANEOUS HYDREA...... 39 105 mg...... 107 SOLUTION PEN-INJECTOR 100 UNIT/ML.56 hydrocerin...... 86 heather...... 128 HUMALOG KWIKPEN SUBCUTANEOUS hydrochlorothiazide oral...... 67 h-e-b aspirin...... 146 SOLUTION PEN-INJECTOR 200 UNIT/ML.56 hydrocodone bitartrate er...... 6 h-e-b childrens allergy...... 167 HUMALOG MIX 50/50...... 56 hydrocodone polst-cpm polst er...... 182 HELIDAC THERAPY...... 101 HUMALOG MIX 50/50 KWIKPEN...... 56 hydrocodone-acetaminophen oral solution HEMADY...... 118 HUMALOG MIX 75/25...... 56 7.5-325 mg/15ml...... 9 HEMANGEOL...... 64 HUMALOG MIX 75/25 KWIKPEN...... 56 hydrocodone-acetaminophen oral tablet...... 9 HEMATOGEN FA...... 191 HUMALOG SUBCUTANEOUS SOLUTION.56 hydrocodone-homatropine...... 182 HEMATRON-AF...... 93 HUMALOG SUBCUTANEOUS SOLUTION hydrocodone-ibuprofen...... 9 HEMAX...... 93 CARTRIDGE...... 56 hydrocortisone (perianal)...... 139 HEMLIBRA...... 61 HUMATE-P...... 61 hydrocortisone ace-pramoxine...... 82 HEMMOREX-HC...... 139 HUMATIN...... 20 hydrocortisone acetate external...... 86 HUMATROPE...... 119 hydrocortisone acetate rectal...... 139

216 hydrocortisone anti-itch external cream 0.5 hydroxyprogesterone caproate ibuprofen ib oral tablet chewable 100 mg...... 5 %...... 80 intramuscular oil...... 128 ibuprofen infants oral suspension 50 hydrocortisone butyr lipo base...... 80 hydroxyurea oral...... 39 mg/1.25ml...... 5 hydrocortisone butyrate...... 80 hydroxyzine hcl oral...... 53 ibuprofen jr oral tablet 100 mg...... 5 hydrocortisone cream 1 % external (rx) 1 hydroxyzine pamoate oral...... 53 ibuprofen junior...... 5 %...... 80 HYLAFEM...... 146 ibuprofen junior strength...... 5 hydrocortisone external cream 0.5 %, 2.5 HYLATOPIC PLUS...... 88 ibuprofen oral capsule 200 mg...... 5 %...... 80 HYLAVITE...... 96 ibuprofen oral suspension 100 mg/5ml...... 5 hydrocortisone external lotion 2.5 %...... 80 HYMOVIS...... 146 ibuprofen oral tablet 200 mg...... 5 hydrocortisone external ointment 0.5 %...... 80 hyoscyamine sulfate er...... 146 ibuprofen oral tablet 400 mg, 600 mg, 800 hydrocortisone external ointment 1 %...... 80 hyoscyamine sulfate oral elixir...... 146 mg...... 5 hydrocortisone external ointment 2.5 %...... 80 hyoscyamine sulfate oral solution...... 146 ibuprofen-famotidine...... 5 hydrocortisone oral tablet 10 mg, 20 mg, 5 hyoscyamine sulfate oral tablet...... 146 ICAR-C...... 93 mg...... 118 hyoscyamine sulfate oral tablet dispersible146 ICAR-C PLUS...... 191 hydrocortisone plus external cream 1 %...... 88 hyoscyamine sulfate sl...... 146 icatibant acetate...... 133 hydrocortisone rectal enema 100 mg/60ml 139 hyoscyamine sulfate sublingual...... 146 iclevia...... 124 hydrocortisone valerate...... 80 hyosyne oral elixir...... 146 ICLUSIG ORAL TABLET 10 MG, 30 MG...154 hydrocortisone/aloe...... 88 hyosyne oral solution...... 146 ICLUSIG ORAL TABLET 15 MG, 45 MG...154 hydrocortisone/aloe max str...... 88 HYPERHEP B...... 134 icosapent ethyl...... 68 hydrocortisone-acetic acid...... 164 HYPERRAB INJECTION SOLUTION 1500 IDELVION...... 61 hydrocortisone-aloe cream 1 % external...... 88 UNIT/5ML, 300 UNIT/ML...... 134 IDHIFA...... 39 hydrocortisone-aloe external cream 0.5 %...88 HYPERRHO S/D INTRAMUSCULAR iferex 150 forte...... 93 hydrocortisone-aloe max st external cream SOLUTION PREFILLED SYRINGE 1500 ILARIS...... 135 1 %...... 88 UNIT...... 134 ILEVRO...... 158 hydrocortisone-iodoquinol...... 34 HYPERSAL...... 182 ILUMYA...... 135 hydrocort-pramoxine (perianal)...... 82 HYPERTET S/D...... 137 imatinib mesylate...... 154 hydromet...... 182 HYPOCYN...... 161 IMBRUVICA...... 154 hydromorphone hcl er...... 6 HYPOTEARS...... 161 IMFINZI INTRAVENOUS SOLUTION 500 hydromorphone hcl oral liquid...... 6 HYSINGLA ER...... 6 MG/10ML...... 154 hydromorphone hcl oral tablet...... 6 HYZAAR...... 66 imipramine hcl oral...... 31 hydromorphone hcl rectal...... 6 ibandronate sodium oral...... 139 imipramine pamoate...... 31 hydroxychloroquine sulfate oral tablet 200 IBRANCE ORAL CAPSULE...... 40 imiquimod external cream 3.75 %...... 82 mg...... 43 IBRANCE ORAL TABLET...... 40 imiquimod external cream 5 %...... 82 hydroxychloroquine sulfate tablet 100 mg ibu-200...... 5 IMIQUIMOD PUMP...... 82 oral...... 43 ibuprofen...... 5 IMITREX NASAL...... 36 hydroxychloroquine sulfate tablet 300 mg ibuprofen childrens oral tablet chewable IMITREX ORAL...... 36 oral...... 43 100 mg...... 5 IMITREX STATDOSE REFILL...... 36 hydroxychloroquine sulfate tablet 400 mg ibuprofen ib childrens...... 5 IMITREX STATDOSE SYSTEM...... 36 oral...... 43 ibuprofen ib oral tablet 200 mg...... 5 IMITREX SUBCUTANEOUS...... 36

217 IMODIUM A-D ORAL LIQUID...... 100 instant oral pain relief max...... 75 INSULIN SYRINGES 31G X 15/64" 0.3 ML IMOGAM RABIES-HT...... 134 INSULIN ASP PROT & ASP FLEXPEN...... 56 ...... 148 IMOVAX RABIES...... 137 INSULIN ASPART...... 56 INSULIN SYRINGES 31G X 5/16" 0.5 ML.148 IMPEKLO...... 80 INSULIN ASPART FLEXPEN...... 56 INSULIN SYRINGES 31G X 5/16" 1 ML....148 IMURAN...... 136 INSULIN ASPART PENFILL...... 57 INTEGRA F...... 93 INBRIJA...... 46 INSULIN ASPART PROT & ASPART...... 57 INTELENCE ORAL TABLET 100 MG, 200 incassia...... 128 INSULIN LISPRO (1 UNIT DIAL) MG...... 50 INCRELEX...... 119 SOLUTION PEN-INJECTOR 100 UNIT/ML INTELENCE ORAL TABLET 25 MG...... 50 INCRUSE ELLIPTA...... 169 SUBCUTANEOUS...... 57 INTRON A...... 135 indapamide...... 67 INSULIN LISPRO JUNIOR KWIKPEN...... 57 introvale...... 124 INDERAL LA...... 64 INSULIN LISPRO PROT & LISPRO...... 57 INTUNIV...... 71 INDERAL XL...... 64 INSULIN LISPRO SOLUTION 100 INVEGA...... 47 INDOCIN...... 5 UNIT/ML SUBCUTANEOUS...... 57 INVEGA SUSTENNA...... 47 indomethacin er...... 5 INSULIN PEN NEEDLES 29G X 12.7MM..146 INVEGA TRINZA...... 47 indomethacin oral capsule 25 mg, 50 mg...... 5 INSULIN PEN NEEDLES 29G X 12MM , INVELTYS...... 158 indoor/outdoor allergy rlf...... 167 29G X 5MM , 29G X 8MM , 31G X 5 MM , INVIRASE...... 52 infant gas relief...... 107 31G X 6 MM , 31G X 8 MM...... 146 INVOKAMET...... 55 INFANTS ADVIL...... 5 INSULIN PEN NEEDLES 30G X 8 MM , INVOKAMET XR...... 55 infants gas relief...... 107 32G X 5 MM...... 146 INVOKANA...... 55 infants ibuprofen...... 5 INSULIN PEN NEEDLES 32G X 4 MM...... 146 iodine tincture external tincture 2 %...... 25 infants pain & fever...... 11 INSULIN PEN NEEDLES 32G X 6 MM...... 146 iodoquinol-hc-aloe polysacch...... 34 infants pain relief drops...... 12 INSULIN PEN NEEDLES 33G X 4 MM...... 147 IOPIDINE...... 159 infants pain/fever...... 12 INSULIN SYRINGES 27G X 1/2" 0.5 ML...147 IPOL...... 137 infants simethicone...... 107 INSULIN SYRINGES 27G X 1/2" 1 ML...... 147 ipratropium bromide inhalation...... 169 INFUVITE PEDIATRIC...... 191 INSULIN SYRINGES 28G X 1/2" 0.5 ML, ipratropium bromide nasal...... 169 INGREZZA...... 73 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML.... 147 ipratropium-albuterol...... 180 INLYTA...... 154 INSULIN SYRINGES 28G X 1/2" 1 ML, irbesartan...... 62 inner ear plus...... 191 29G X 1/2" 1 ML...... 147 irbesartan-hydrochlorothiazide...... 66 INNOPRAN XL...... 64 INSULIN SYRINGES 28G X 5/16" 1 ML, IRESSA...... 154 INQOVI...... 40 29G X 5/16" 1 ML, 30G X 3/8" 0.5 ML...... 147 iron 100/c...... 93 INREBIC...... 40 INSULIN SYRINGES 29G X 1/2" 0.3 ML...147 iron oral tablet 200 (65 fe) mg...... 191 INSPIRACHAMBER/LARGE...... 146 INSULIN SYRINGES 29G X 1/2" 0.5 ML, iron oral tablet 325 (65 fe) mg...... 191 INSPIRACHAMBER/MEDIUM...... 146 31G X 5/16" 0.3 ML...... 147 iron oral tablet extended release 142 (45 INSPIRACHAMBER/MOUTHPIECE...... 146 INSULIN SYRINGES 30G X 1/2" 0.5 ML, fe) mg...... 191 INSPIRACHAMBER/SMALL...... 146 31G X 15/64" 0.5 ML...... 147 IROSPAN 24/6...... 93 INSPIREASE...... 146 INSULIN SYRINGES 30G X 1/2" 1 ML...... 147 ISENTRESS HD...... 50 INSPIREASE RESERVOIR BAGS...... 146 INSULIN SYRINGES 30G X 5/16" 0.5 ML.147 ISENTRESS ORAL PACKET...... 50 INSPRA...... 67 INSULIN SYRINGES 30G X 5/16" 1 ML....147 ISENTRESS ORAL TABLET...... 50 instacort 5...... 80 ISENTRESS ORAL TABLET CHEWABLE.. 50

218 isibloom...... 124 jencycla...... 128 KEPPRA ORAL TABLET...... 25 isoniazid oral...... 38 JENTADUETO...... 55 KEPPRA XR...... 25 ISOPTO ATROPINE...... 156 JENTADUETO XR...... 55 KERALYT EXTERNAL GEL 6 %...... 89 ISOPTO CARPINE...... 159 jinteli...... 124 KERALYT EXTERNAL SHAMPOO...... 89 ISOPTO TEARS...... 161 JIVI...... 60 KERENDIA...... 66 ISORDIL TITRADOSE...... 70 jock itch external cream 1 %...... 34 KERYDIN...... 85 isosorbide dinitrate oral tablet 10 mg, 20 jock itch max st...... 148 KESIMPTA...... 73 mg, 30 mg...... 70 jock itch spray powder...... 148 ketoconazole external cream...... 85 isosorbide dinitrate oral tablet 5 mg...... 70 jolessa...... 124 ketoconazole external foam...... 85 isosorbide dinitrate tablet 40 mg oral...... 70 JORNAY PM...... 71 ketoconazole external shampoo...... 85 isosorbide mononitrate...... 70 JUBLIA...... 85 ketoconazole oral...... 33 isosorbide mononitrate er...... 70 juleber...... 124 ketodan external foam...... 85 isotretinoin oral...... 77 JULUCA...... 50 KETODAN EXTERNAL KIT...... 34 isoxsuprine hcl oral tablet 10 mg...... 70 junel 1.5/30...... 124 KETONE TEST...... 90 isradipine...... 64 junel 1/20...... 124 ketoprofen er...... 5 ISTALOL...... 159 junel fe...... 124 ketoprofen oral capsule 50 mg, 75 mg...... 5 ISTURISA...... 132 JUXTAPID...... 68 KETOROLAC TROMETHAMINE NASAL...... 5 itraconazole oral...... 33 JYNARQUE...... 94 ketorolac tromethamine ophthalmic ivermectin external cream...... 84 kaitlib fe...... 124 solution 0.4 %...... 158 ivermectin external lotion...... 84 KALBITOR...... 133 ketorolac tromethamine ophthalmic ivermectin oral...... 42 KALETRA...... 52 solution 0.5 %...... 158 IXIARO...... 137 kalliga...... 124 ketorolac tromethamine oral...... 5 IXINITY...... 61 KALYDECO ORAL PACKET...... 171 KETOSTIX...... 90 JADENU...... 94 KALYDECO ORAL TABLET...... 171 ketotifen fumarate ophthalmic...... 163 JADENU SPRINKLE...... 94 KANUMA...... 115 KEVEYIS...... 115 jaimiess...... 124 KAPSPARGO SPRINKLE...... 64 KEVZARA...... 135 JAKAFI...... 40 KAPVAY...... 71 KINERET...... 135 JALYN...... 117 KARBINAL ER...... 167 KISQALI (200 MG DOSE)...... 40 JANSSEN COVID-19 VACCINE...... 193 kariva...... 124 KISQALI (400 MG DOSE)...... 41 jantoven...... 58 KATERZIA...... 64 KISQALI (600 MG DOSE)...... 41 JANUMET...... 55 KAZANO...... 55 KISQALI FEMARA (400 MG DOSE)...... 41 JANUMET XR...... 55 KEDRAB...... 134 KISQALI FEMARA (600 MG DOSE)...... 41 JANUVIA...... 55 KEFLEX...... 21 KISQALI FEMARA(200 MG DOSE)...... 41 JARDIANCE...... 55 KELARX...... 88 KITABIS PAK...... 171 jasmiel...... 124 kelnor 1/35...... 124 KLARITY-A...... 157 JATENZO ORAL CAPSULE 158 MG, 198 kelnor 1/50...... 124 KLARON...... 85 MG...... 121 kelp oral tablet 0.15 mg...... 93 KLONOPIN...... 53 JATENZO ORAL CAPSULE 237 MG...... 121 KENALOG EXTERNAL...... 80 klor-con...... 91 JEMPERLI...... 154 KEPPRA ORAL SOLUTION...... 25 klor-con 10...... 91

219 klor-con m10...... 91 KYPROLIS INTRAVENOUS SOLUTION lansoprazole oral...... 102 klor-con m15...... 91 RECONSTITUTED 10 MG...... 39 lanthanum carbonate...... 94 klor-con m20...... 91 labetalol hcl oral...... 64 LANTUS SOLOSTAR SOLUTION PEN- klor-con/ef...... 191 LACRISERT...... 156 INJECTOR 100 UNIT/ML KLOXXADO...... 17 LACTAID...... 107 SUBCUTANEOUS...... 57 KOATE INTRAVENOUS SOLUTION LACTAID FAST ACT ORAL TABLET...... 108 LANTUS U-100 VIAL...... 57 RECONSTITUTED 1000 UNIT, 250 UNIT...61 lactase enzyme...... 108 lapatinib ditosylate...... 154 KOATE INTRAVENOUS SOLUTION lactase enzyme ultra str...... 108 larin 1.5/30...... 124 RECONSTITUTED 500 UNIT...... 61 lactase fast acting...... 108 larin 1/20...... 124 KOATE-DVI INTRAVENOUS SOLUTION lacto-pectin...... 108 larin 24 fe...... 125 RECONSTITUTED 1000 UNIT...... 61 lactose fast acting relief oral tablet...... 108 larin fe 1.5/30...... 125 KOATE-DVI INTRAVENOUS SOLUTION lactulose encephalopathy...... 100 larin fe 1/20...... 125 RECONSTITUTED 500 UNIT...... 61 lactulose oral packet...... 100 larissia...... 125 KOGENATE FS INTRAVENOUS KIT 1000 lactulose oral solution...... 100 LASIX...... 67 UNIT, 3000 UNIT, 500 UNIT...... 61 LAMICTAL ODT...... 25 LASTACAFT...... 156 KOGENATE FS INTRAVENOUS KIT 2000 LAMICTAL ORAL TABLET...... 25 latanoprost ophthalmic...... 155 UNIT, 250 UNIT...... 61 LAMICTAL ORAL TABLET CHEWABLE LATISSE...... 161 KOMBIGLYZE XR...... 55 25 MG, 5 MG...... 26 LATUDA...... 47 KONSYL DAILY FIBER ORAL POWDER LAMICTAL STARTER...... 26 lavare wound wash...... 89 100 %...... 111 LAMICTAL XR...... 26 laxacin...... 113 konsyl daily fiber oral powder 28.3 %...... 111 LAMISIL AT EXTERNAL CREAM...... 34 laxaclear...... 111 KORLYM...... 120 LAMISIL AT JOCK ITCH...... 34 laxative max str...... 113 KOSELUGO...... 41 lamivudine oral solution...... 51 laxative maximum strength oral tablet 25 KOVALTRY...... 60 lamivudine oral tablet 100 mg...... 49 mg...... 113 K-PHOS...... 93 lamivudine oral tablet 150 mg, 300 mg...... 51 laxative oral powder 17 gm/scoop...... 111 K-PHOS NO 2...... 93 lamivudine-zidovudine...... 51 laxative oral tablet chewable 15 mg...... 113 K-PHOS-NEUTRAL...... 191 lamotrigine er...... 26 laxative oral tablet delayed release 5 mg...148 k-prime...... 191 lamotrigine oral kit...... 26 laxative pills...... 113 KRINTAFEL...... 43 lamotrigine oral tablet...... 26 laxative pills max st...... 113 KRISTALOSE...... 100 lamotrigine oral tablet chewable 25 mg, 5 laxative pills oral tablet 25 mg...... 113 KROGER BLOOD GLUCOSE KIT...... 148 mg...... 26 laxative rectal suppository 10 mg...... 148 KROGER TEST...... 148 lamotrigine oral tablet dispersible...... 26 laxative regular strength...... 113 K-TAB...... 91 lamotrigine starter kit-blue...... 26 layolis fe...... 125 k-tan plus...... 191 lamotrigine starter kit-green...... 26 LDO PLUS...... 15 kurvelo...... 124 lamotrigine starter kit-orange...... 26 LEDIPASVIR-SOFOSBUVIR...... 49 KUVAN...... 115 LAMPIT...... 43 leena...... 125 KYMRIAH...... 42 LANCETS...... 90 leflunomide oral...... 136 KYNMOBI...... 45 LANOXIN ORAL TABLET 125 MCG, 250 LENVIMA (10 MG DAILY DOSE)...... 154 KYNMOBI TITRATION KIT...... 45 MCG...... 66 LENVIMA (12 MG DAILY DOSE)...... 154

220 LENVIMA (14 MG DAILY DOSE)...... 154 levonorgestrel-ethinyl estrad oral tablet lice killing maximum strength...... 44 LENVIMA (18 MG DAILY DOSE)...... 154 0.1-20 mg-mcg...... 125 lice maximum strength...... 44 LENVIMA (20 MG DAILY DOSE)...... 154 levonorgestrel-ethinyl estrad oral tablet lice solution combination kit ...... 44 LENVIMA (24 MG DAILY DOSE)...... 154 0.15-30 mg-mcg...... 125 lice solution kit...... 44 LENVIMA (4 MG DAILY DOSE)...... 154 levonorgestrel-ethinyl estrad oral tablet 90- lice treatment creme rinse...... 84 LENVIMA (8 MG DAILY DOSE)...... 154 20 mcg...... 125 lice treatment external liquid 1 %...... 84 LESCOL XL...... 68 levonorg-eth estrad triphasic...... 125 lice treatment external lotion 1 %...... 84 lessina...... 125 levora 0.15/30 (28)...... 125 lice treatment external shampoo 0.33-4 %...44 LETAIRIS...... 172 levorphanol tartrate oral...... 6 LIDO BDK...... 15 letrozole oral...... 40 levo-t...... 130 lidocaine external cream 4 %...... 15 leucovorin calcium injection solution 100 LEVOTHYROXINE SODIUM ORAL lidocaine external ointment 5 %...... 15 mg/10ml...... 42 CAPSULE...... 130 lidocaine external patch 5 %...... 15 leucovorin calcium oral...... 42 levothyroxine sodium tablet 100 mcg oral..130 lidocaine hcl external cream 3 %...... 15 LEUKERAN...... 38 levothyroxine sodium tablet 112 mcg oral..130 lidocaine hcl external solution...... 15 LEUKINE...... 59 levothyroxine sodium tablet 125 mcg oral..130 lidocaine hcl mouth/throat...... 15 leuprolide acetate injection...... 132 levothyroxine sodium tablet 137 mcg oral lidocaine hcl urethral/mucosal external gel.. 15 levalbuterol hcl inhalation...... 170 ...... 130, 131 lidocaine hcl urethral/mucosal external LEVALBUTEROL HFA INHALATION levothyroxine sodium tablet 150 mcg oral..131 prefilled syringe...... 15 AEROSOL 45 MCG/ACT...... 170 levothyroxine sodium tablet 175 mcg oral..131 lidocaine viscous hcl...... 15 LEVBID...... 148 levothyroxine sodium tablet 200 mcg oral..131 lidocaine-hydrocort (perianal)...... 86 LEVEMIR U-100 FLEXTOUCH...... 57 levothyroxine sodium tablet 25 mcg oral....131 lidocaine-hydrocortisone ace kit 3-2.5 % LEVEMIR U-100 VIAL...... 57 levothyroxine sodium tablet 300 mcg oral..131 rectal...... 86 levetiracetam er...... 26 levothyroxine sodium tablet 50 mcg oral....131 LIDOCAINE-HYDROCORTISONE ACE levetiracetam oral solution...... 26 levothyroxine sodium tablet 75 mcg oral....131 RECTAL GEL...... 86 levetiracetam oral tablet...... 26 levothyroxine sodium tablet 88 mcg oral....131 lidocaine-hydrocortisone ace rectal kit 2-2 levobunolol hcl...... 159 levoxyl...... 131 %...... 86 levocarnitine oral solution...... 115 LEVSIN ORAL...... 148 lidocaine-hydrocortisone ace rectal kit 3- levocarnitine oral tablet...... 115 LEVSIN/SL...... 148 0.5 %...... 86 levocarnitine sf...... 115 LEVULAN KERASTICK...... 83 lidocaine-hydrocortisone ace rectal kit 3-1 levocetirizine dihydrochloride oral solution.167 LEXAPRO...... 30 %...... 86 levocetirizine dihydrochloride oral tablet.... 167 LEXETTE...... 80 lidocaine-prilocaine external cream...... 15 levofloxacin ophthalmic...... 157 LEXIVA ORAL SUSPENSION...... 52 lidocaine-prilocaine external kit...... 15 levofloxacin oral solution...... 23 LEXIVA ORAL TABLET...... 52 LIDOCAINE-TETRACAINE...... 15 levofloxacin oral tablet...... 23 LIALDA...... 138 LIDOCANNA...... 15 levonest...... 125 LIBRAX...... 101 LIDOCORT...... 86 levonorgest-eth est & eth est...... 125 LICART...... 5 LIDODERM...... 15 levonorgest-eth estrad 91-day...... 125 lice killing...... 44 lidopin external cream 3 %...... 16 levonorgestrel...... 130 lice killing max st...... 44 LIDOPRIL...... 16 lice killing max strength...... 44 LIDOPRIL XR...... 16

221 LIDO-PRILO CAINE PACK...... 16 long acting nasal spray...... 174 LORZONE...... 185 lillow...... 125 long lasting antacid...... 108 losartan potassium oral...... 62 lindane...... 84 long lasting nasal spray...... 174 losartan potassium-hctz...... 66 linezolid oral suspension reconstituted...... 20 LONHALA MAGNAIR REFILL KIT...... 169 LOSEASONIQUE...... 125 linezolid oral tablet...... 20 LONHALA MAGNAIR STARTER KIT...... 169 LOTEMAX...... 158 LINZESS...... 100 LONSURF...... 39 LOTEMAX SM...... 158 liothyronine sodium oral...... 132 loperamide hcl oral capsule...... 100 LOTENSIN...... 63 LIPITOR...... 68 loperamide hcl oral liquid 1 mg/7.5ml...... 100 LOTENSIN HCT...... 66 LIPOFEN...... 67 loperamide hcl oral suspension...... 100 loteprednol etabonate...... 158 lipoflavovit...... 191 LOPID...... 67 LOTREL...... 66 liquid acetaminophen...... 12 lopinavir-ritonavir oral solution...... 52 LOTRIMIN AF EXTERNAL POWDER 2 %.. 34 liquid allergy relief...... 167 lopinavir-ritonavir oral tablet...... 52 LOTRONEX...... 100 liquid pain relief...... 12 LOPRESSOR...... 64 lovastatin oral...... 68 lisinopril oral...... 63 LOPROX EXTERNAL CREAM...... 85 LOVAZA...... 68 lisinopril-hydrochlorothiazide...... 66 LOPROX EXTERNAL KIT...... 34 LOVENOX...... 58 lithium carbonate er...... 54 LOPROX EXTERNAL SHAMPOO...... 85 low-ogestrel...... 125 lithium carbonate oral...... 54 LOPROX EXTERNAL SUSPENSION...... 85 loxapine succinate...... 46 LITHOBID...... 54 loradamed...... 178 lo-zumandimine...... 125 LITHOSTAT...... 117 lorata-d...... 176 LUBIPROSTONE...... 100 little ones childrens...... 191 loratadine allergy relief oral tablet 10 mg... 178 lubricant drops fast act...... 161 LIVALO...... 68 loratadine allergy relief oral tablet lubricant drops long last...... 161 LIVIXIL PAK...... 16 dispersible 10 mg...... 178 lubricant drops ophthalmic solution...... 161 l-methylfolate...... 191 loratadine childrens oral solution 5 mg/5ml 178 lubricant eye drops (pf) ophthalmic solution l-methylfolate calcium oral...... 191 loratadine childrens oral syrup 5 mg/5ml... 178 0.4-0.3 %...... 161 l-methylfolate-b6-b12...... 96 loratadine childrens oral tablet chewable... 178 lubricant eye drops (pf) ophthalmic solution LMX 4...... 16 lorata-dine d...... 176 0.5 %...... 161 LO LOESTRIN FE...... 125 loratadine oral syrup 5 mg/5ml...... 178 lubricant eye drops ophthalmic solution LOCOID...... 80 loratadine oral tablet 10 mg...... 178 0.4-0.3 %...... 161 LOCOID LIPOCREAM...... 80 loratadine oral tablet dispersible 10 mg..... 178 lubricant eye drops ophthalmic solution 0.5 LODINE...... 5 loratadine-d...... 176 %...... 161 LODOSYN...... 46 loratadine-d 24hr...... 176 lubricant eye drops ophthalmic solution 0.6 LOESTRIN 1.5/30 (21)...... 125 lorazepam intensol...... 53 %...... 161 LOESTRIN 1/20 (21)...... 125 lorazepam oral concentrate 2 mg/ml...... 53 lubricant eye drops pf...... 161 LOESTRIN FE 1.5/30...... 125 lorazepam oral tablet...... 53 lubricant eye nighttime...... 161 LOESTRIN FE 1/20...... 125 LORBRENA...... 154 lubricant eye ophthalmic solution 0.4-0.3 % lojaimiess...... 125 LOREEV XR...... 53 ...... 161 LOKELMA...... 94 LORID...... 96 lubricant eye pm...... 161 LOLLICAINE...... 75 LORTAB...... 9 lubricant pm...... 161 LOMOTIL...... 100 loryna...... 125 lubricating eye drop...... 161

222 lubricating eye drops ophthalmic solution LYSTEDA...... 59 MAVENCLAD (7 TABS)...... 74 0.4-0.3 %...... 161 LYUMJEV...... 57 MAVENCLAD (8 TABS)...... 74 lubricating eye drops ophthalmic solution LYUMJEV KWIKPEN...... 57 MAVENCLAD (9 TABS)...... 74 0.5-0.9 %...... 161 lyza...... 128 MAVYRET...... 49 lubricating eye/overnight...... 161 M.V.I. PEDIATRIC...... 191 MAXALT...... 36 lubricating plus...... 161 MAALOX MAX ORAL SUSPENSION...... 108 MAXALT-MLT...... 36 lubricating plus eye drops...... 162 MAALOX MULTI SYMPTOM MAX ST...... 108 MAXIDEX...... 158 lubricating tears...... 162 MACRILEN...... 148 MAXITROL...... 156 lubricating tears eye drops...... 162 MACROBID...... 20 maxi-tuss ac...... 182 lubricating/dry eye...... 162 MACRODANTIN...... 20 MAXZIDE...... 66 LUCEMYRA...... 17 mafenide acetate external...... 85 MAXZIDE-25...... 66 LUCENTIS INTRAVITREAL SOLUTION mag-al plus...... 108 MAYZENT...... 74 PREFILLED SYRINGE 0.5 MG/0.05ML.....156 mag-al plus xs...... 108 MAYZENT STARTER PACK ORAL LUGOLS STRONG IODINE...... 25 mag-g...... 93 TABLET THERAPY PACK 0.25 MG...... 74 LULICONAZOLE...... 85 MAGNEBIND 300...... 93 m-dryl...... 167 LUMAKRAS...... 42 magnesium citrate oral solution...... 113 me/naphos/mb/hyo1...... 118 LUMIGAN...... 155 magnesium oxide oral tablet 400 (241.3 meclizine hcl oral...... 31 LUNESTA...... 186 mg) mg...... 93 meclofenamate sodium oral...... 5 LUPANETA PACK...... 132 magnesium oxide oral tablet 400 mg...... 148 MEDICATED DNA COLLECTION...... 148 LUPKYNIS...... 133 magnesium-oxide...... 93 MEDICATED DNA COLLECTION 2...... 148 LUPRON DEPOT (1-MONTH)...... 132 MAKENA...... 128 medi-first triple antibiotic...... 25 LUPRON DEPOT (3-MONTH)...... 132 MALARONE...... 43 mediproxen...... 5 LUPRON DEPOT (4-MONTH) malathion...... 84 MEDISENSE GLUCOSE KETONE INTRAMUSCULAR KIT 30MG...... 132 mapap acetaminophen extra str...... 12 CONTR...... 148 LUPRON DEPOT (6-MONTH) mapap arthritis pain...... 12 MEDISENSE HI/MID/LOW CONTROL...... 148 INTRAMUSCULAR KIT 45MG...... 132 mapap childrens...... 12 MEDISENSE HIGH/LOW CONTROL...... 148 LUPRON DEPOT-PED (1-MONTH)...... 132 mapap oral capsule...... 12 MEDISENSE MID CONTROL...... 148 LUPRON DEPOT-PED (3-MONTH)...... 132 MARGENZA...... 154 MEDROL...... 118 LUTATHERA...... 42 MARINOL...... 32 medroxyprogesterone acetate lutera...... 125 marlissa...... 125 intramuscular suspension...... 128 LUXIQ...... 80 MARPLAN...... 29 medroxyprogesterone acetate LUZU...... 85 MASK VORTEX/CHILD/FROG...... 148 intramuscular suspension prefilled syringe 128 lyleq...... 128 MASK VORTEX/TODDLER/LADYBUG.....148 medroxyprogesterone acetate oral...... 128 lyllana...... 125 MATULANE...... 38 mefenamic acid oral...... 5 LYNPARZA...... 41 matzim la...... 65 mefloquine hcl...... 43 LYRICA...... 73 MAVENCLAD (10 TABS)...... 73 mega multiple/chelated mineral...... 191 LYRICA CR...... 73 MAVENCLAD (4 TABS)...... 73 mega probiotic...... 108 lysiplex plus oral tablet...... 191 MAVENCLAD (5 TABS)...... 74 megestrol acetate oral suspension 40 LYSODREN...... 132 MAVENCLAD (6 TABS)...... 74 mg/ml...... 129

223 megestrol acetate oral suspension 625 metformin hcl er...... 55 methylphenidate hcl er oral tablet extended mg/5ml...... 129 metformin hcl er (mod)...... 55 release 72 mg...... 71 megestrol acetate oral tablet...... 129 metformin hcl er (osm)...... 55 methylphenidate hcl oral solution...... 71 meijer antacid...... 108 metformin hcl oral solution...... 55 methylphenidate hcl oral tablet...... 71 MEKINIST...... 41 metformin hcl oral tablet...... 55 methylphenidate hcl oral tablet chewable.... 71 MEKTOVI...... 41 methadone hcl intensol...... 6 methylprednisolone oral tablet 16 mg, 8 mg meloxicam oral capsule...... 5 methadone hcl oral...... 6 ...... 118 meloxicam oral tablet...... 5 methadose oral concentrate 10 mg/ml...... 6 methylprednisolone oral tablet 32 mg, 4 mg melphalan...... 42 methadose oral tablet soluble...... 7 ...... 118 memantine hcl er...... 29 methadose sugar-free...... 7 methylprednisolone oral tablet therapy memantine hcl oral solution 2 mg/ml...... 29 methamphetamine hcl...... 72 pack...... 118 memantine hcl oral tablet...... 29 methazolamide oral...... 159 methyltestosterone oral...... 121 MENACTRA...... 137 methenamine hippurate...... 20 metoclopramide hcl oral solution...... 31 MENEST...... 125 methenamine mandelate oral...... 25 metoclopramide hcl oral tablet...... 31 MENOSTAR...... 125 methergine...... 120 metoclopramide hcl oral tablet dispersible... 31 MENQUADFI...... 137 methimazole oral...... 132 metolazone...... 67 menstrual pain relief...... 12 METHITEST...... 121 METOPIRONE...... 148 MENTAX...... 85 methocarbamol oral...... 185 metoprolol succinate er...... 64 menthol drops...... 75 methotrexate oral...... 136 metoprolol tartrate oral...... 64 MENVEO...... 137 methotrexate sodium...... 136 metoprolol-hydrochlorothiazide...... 66 meperidine hcl oral...... 9 methotrexate sodium (pf)...... 136 METROCREAM...... 20 MEPHYTON...... 96 methoxsalen rapid...... 83 METROGEL...... 20 meprobamate...... 53 methscopolamine bromide oral...... 101 METROLOTION...... 20 MEPRON...... 43 methyldopa...... 62 metronidazole external...... 21 mercaptopurine oral...... 39 methylergonovine maleate oral...... 120 metronidazole oral capsule...... 21 MERIBIN...... 191 METHYLIN...... 71 metronidazole oral tablet...... 21 merzee...... 125 methylphenidate hcl er (cd)...... 71 metronidazole vaginal...... 21 mesalamine er oral capsule 0.375 gm...... 138 methylphenidate hcl er (la)...... 71 metyrosine...... 66 mesalamine oral capsule delayed release methylphenidate hcl er (xr) oral capsule mexiletine hcl oral...... 63 400 mg...... 138 extended release 24 hour 10 mg...... 71 m-hist pd...... 178 mesalamine oral tablet delayed release 1.2 methylphenidate hcl er (xr) oral capsule mi-acid gas relief...... 108 gm...... 138 extended release 24 hour 15 mg, 20 mg, mibelas 24 fe...... 125 mesalamine oral tablet delayed release 30 mg, 40 mg, 50 mg, 60 mg...... 71 micaderm...... 35 800 mg...... 138 methylphenidate hcl er oral tablet extended MICARDIS...... 62 mesalamine rectal...... 138 release 10 mg, 20 mg...... 71 MICARDIS HCT...... 66 mesalamine-cleanser...... 138 methylphenidate hcl er oral tablet extended MICATIN...... 35 MESNEX ORAL...... 42 release 18 mg, 27 mg, 36 mg, 54 mg...... 71 miconazole 1 combo pack...... 33 MESTINON...... 37 methylphenidate hcl er oral tablet extended miconazole 1 vaginal kit 1200 & 2 mg & %.. 33 metaxalone...... 185 release 24 hour...... 71 miconazole 3...... 33

224 miconazole 3 applicator vaginal kit 200 & 2 mineral oil rectal enema ...... 111 mondoxyne nl oral capsule 100 mg...... 24 mg-% (9gm)...... 33 minerin creme...... 86 mondoxyne nl oral capsule 75 mg...... 24 miconazole 3 combo pack app...... 33 mini nicotine...... 19 mono-linyah...... 126 miconazole 3 combo pack vaginal kit 200 & MINIPRESS...... 62 MONONINE...... 60 2 mg-% (9gm)...... 33 minitran...... 70 monsels ferric subsulfate...... 61 miconazole 7...... 33 MINIVELLE...... 126 montelukast sodium oral packet...... 169 miconazole 7 day treatment...... 33 MINOCYCLINE HCL ER ORAL CAPSULE montelukast sodium oral tablet...... 169 miconazole antifungal...... 35 EXTENDED RELEASE 24 HOUR...... 24 montelukast sodium oral tablet chewable 4 miconazole nitrate external...... 35 minocycline hcl er oral tablet extended mg, 5 mg...... 169 miconazole nitrate vaginal...... 33 release 24 hour...... 24 MONUROL...... 21 miconazorb af...... 35 minocycline hcl oral...... 24 MORCIN...... 148 MICRODOT PEN NEEDLE...... 148 MINOLIRA...... 24 morgidox oral...... 24 MICRODOT TEST...... 148 minoxidil oral...... 69 morphine sulfate (concentrate) oral microgestin 1.5/30...... 125 mintox maximum strength...... 108 solution 100 mg/5ml, 20 mg/ml...... 7 microgestin 1/20...... 125 mintox plus...... 108 morphine sulfate (pf) injection solution 10 microgestin 24 fe...... 126 MIRALAX ORAL POWDER...... 111 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml.. 7 microgestin fe 1.5/30...... 126 MIRAPEX...... 45 morphine sulfate er...... 7 microgestin fe 1/20...... 126 MIRAPEX ER...... 45 morphine sulfate er beads...... 7 midazolam hcl oral...... 53 MIRCETTE...... 126 morphine sulfate oral...... 7 midodrine hcl...... 62 mirtazapine oral tablet...... 29 morphine sulfate rectal...... 7 MIFEPREX...... 191 mirtazapine oral tablet dispersible...... 29 MOTEGRITY...... 100 mifepristone...... 191 MIRVASO...... 77 motion sickness oral tablet 50 mg...... 31 MIGERGOT...... 37 misoprostol oral...... 102 motion sickness relief oral tablet 50 mg...... 31 miglitol...... 55 MITIGARE...... 35 motion sickness relief oral tablet chewable miglustat...... 115 mm arthritis pain...... 12 25 mg...... 31 migraine formula...... 12 mm cetirizine hcl...... 167 motion-time...... 31 migraine relief...... 12 mm clearlax...... 111 MOTOFEN...... 100 MIGRANAL...... 37 MM EASY TOUCH GLUCOSE METER.....148 MOTRIN CHILDRENS...... 5 mili...... 126 mm stool softener laxative...... 111 MOTRIN IB ORAL CAPSULE...... 5 milk of magnesia...... 108 M-M-R II...... 137 MOTRIN INFANTS DROPS...... 5 milk of magnesia concentrate...... 108 M-NATAL PLUS...... 96 MOVANTIK...... 100 MILLIPRED...... 118 MOBIC...... 5 MOVIPREP...... 101 mimvey...... 126 modafinil...... 186 MOXEZA...... 157 MIMYX...... 89 MODERNA COVID-19 VACCINE...... 148 moxifloxacin hcl (2x day)...... 157 MINASTRIN 24 FE...... 126 moexipril hcl...... 63 moxifloxacin hcl ophthalmic solution...... 157 mineral oil enema...... 111 moisturel...... 89 moxifloxacin hcl oral...... 23 mineral oil heavy oral...... 111 molindone hcl...... 46 MOZOBIL...... 59 MINERAL OIL ORAL OIL...... 111 mometasone furoate external...... 80 m-pap...... 12 mineral oil oral oil ...... 111 mometasone furoate nasal...... 168 MS CONTIN...... 7

225 MSUD EASY...... 148 mycophenolate mofetil oral suspension naproxen oral tablet...... 5 MUCINEX CHILDRENS FREEFROM reconstituted...... 136 naproxen oral tablet delayed release...... 5 ORAL LIQUID 5-100 MG/5ML...... 182 mycophenolate mofetil oral tablet...... 136 naproxen sodium er oral tablet extended MUCINEX CHILDRENS STUFFY NOSE...174 mycophenolate sodium...... 136 release 24 hour 375 mg, 500 mg...... 5 MUCINEX COUGH CHILDRENS...... 182 MYCOZYL AP...... 35 NAPROXEN SODIUM ER ORAL TABLET MUCINEX FAST-MAX DM MAX...... 182 MYDAYIS...... 72 EXTENDED RELEASE 24 HOUR 750 MG....5 MUCINEX SINUS-MAX CLEAR & COOL.. 174 MYDRIACYL...... 162 naproxen sodium oral tablet 220 mg...... 5 MUCINEX SINUS-MAX SINUS/ALLRGY.. 174 MYFEMBREE...... 100 naproxen sodium oral tablet 275 mg...... 5 MUCOSITISRX...... 75 myferon 150...... 93 naproxen sodium oral tablet 550 mg...... 6 mucus & cough relief child...... 182 myferon 150 forte...... 93 naproxen-esomeprazole...... 6 mucus & cough relief childrens...... 182 MYFORTIC...... 136 NARAMIN...... 167 mucus relief cough children...... 182 MYLERAN...... 38 naratriptan hcl...... 36 mucus relief cough childrens...... 182 MYNATAL PLUS...... 96 NARCAN...... 17 mucus relief dm max oral liquid...... 182 MYNATAL-Z...... 96 NARDIL...... 29 mucus relief dm oral liquid...... 182 mynephrocaps...... 96 NASACORT ALLERGY 24HR...... 179 MULPLETA...... 59 MYNEPHRON...... 96 NASACORT ALLERGY 24HR CHILDREN 179 MULTAQ...... 63 myorisan...... 77 nasal allergy 24 hour...... 179 multi vitamin...... 96 MYRBETRIQ ORAL SUSPENSION nasal allergy nasal aerosol 55 mcg/act...... 179 multi vitamin w/d-3...... 96 RECONSTITUTED ER...... 116 nasal allergy spray...... 179 multiple vitamin-folic acid...... 96 MYRBETRIQ ORAL TABLET EXTENDED nasal decongestant 12 hour...... 183 multiple vitamins essential...... 96 RELEASE 24 HOUR...... 116 nasal decongestant 12hr...... 183 multiple vitamins/iron...... 191 MYSOLINE...... 27 nasal decongestant max st...... 183 MULTIPRO...... 191 MYTESI...... 100 nasal decongestant oral tablet 30 mg...... 183 multi-vitamin...... 96 NABI-HB...... 134 nasal decongestant oral tablet extended multi-vitamin/fluoride...... 96 nabumetone oral...... 5 release 12 hour 120 mg...... 183 multivitamin/fluoride oral tablet chewable nadolol oral...... 64 nasal decongestant pe max st...... 174 0.25 mg, 0.5 mg, 1 mg...... 96 nafrinse...... 91 nasal decongestant pe oral tablet 10 mg... 174 multi-vitamin/fluoride/iron...... 96 naftifine hcl...... 85 nasal decongestant spray...... 174 multi-vitamin/iron...... 191 NAFTIN...... 85 nasal four...... 174 mupirocin calcium...... 85 NALFON...... 5 nasal mist nasal solution...... 174 mupirocin external...... 85 naloxone hcl injection...... 17 NASAL MOIST NASAL SOLUTION...... 174 my choice...... 130 naltrexone hcl oral...... 17 nasal moisturizing spray...... 174 my way...... 130 NAMENDA TITRATION PAK...... 29 nasal relief...... 175 MYALEPT...... 101 NAMENDA XR...... 29 nasal relief moisturizing...... 175 MYAMBUTOL...... 38 NAMZARIC...... 28 nasal spray...... 175 MYCAPSSA...... 132 NAPHCON-A...... 163 nasal spray 12 hour...... 175 MYCOBUTIN...... 37 NAPRELAN...... 5 nasal spray anti-drip...... 175 mycophenolate mofetil oral capsule...... 136 NAPROSYN...... 5 nasal spray extra moist...... 175 naproxen oral suspension...... 5 nasal spray extra moisturizing...... 175

226 nasal spray fast acting...... 175 neomycin-bacitracin zn-polymyx...... 157 NEUPOGEN INJECTION SOLUTION nasal spray moisturizing...... 175 neomycin-polymyxin-dexameth ophthalmic PREFILLED SYRINGE...... 59 nasal spray no drip...... 175 ointment...... 156 NEUPRO...... 45 nasal spray saline...... 175 neomycin-polymyxin-dexameth ophthalmic NEURONTIN...... 27 nasal spray sinus...... 175 suspension 3.5-10000-0.1 ...... 156 NEUTEK 2TEK CONTROL...... 148 NASALCROM...... 180 neomycin-polymyxin-gramicidin...... 157 NEUTEK 2TEK TEST...... 148 NASCOBAL...... 193 neomycin-polymyxin-hc ophthalmic...... 156 NEVANAC...... 158 NASONEX...... 168 neomycin-polymyxin-hc otic...... 164 nevirapine...... 50 NATACYN...... 157 NEONATAL + DHA...... 96 nevirapine er...... 50 NATAZIA...... 126 NEONATAL COMPLETE ORAL TABLET new day...... 130 nateglinide...... 55 27-1 MG...... 96 NEXAVAR...... 41 NATESTO...... 121 NEONATAL PLUS...... 96 NEXIUM...... 102 NATPARA...... 139 NEONATAL VITAMIN...... 96 NEXLETOL...... 68 NATROBA...... 84 neo-polycin...... 157 NEXLIZET...... 68 natural daily fiber...... 111 neo-polycin hc...... 156 NEXTSTELLIS...... 100 natural fiber...... 111 NEORAL...... 136 NEXVIAZYME...... 115 natural fiber laxative oral powder 58.6 %... 111 NEOSALUS EXTERNAL CREAM...... 89 niacin er (antihyperlipidemic)...... 68 natural fiber oral capsule 0.52 gm...... 111 NEOSALUS EXTERNAL LOTION...... 89 niacin er oral capsule extended release natural fiber oral powder 28.3 %, 48.57 %. 111 NEOSPORIN + PAIN RELIEF MAX ST...... 25 250 mg...... 191 natural fiber supplement...... 111 NEOSPORIN ORIGINAL...... 25 niacin er oral capsule extended release natural laxative...... 113 NEO-SYNALAR EXTERNAL CREAM...... 83 500 mg...... 191 natural laxative/stool soft...... 113 NEO-SYNALAR EXTERNAL KIT...... 89 niacin flush free oral capsule 400-100 mg... 96 natural senna laxative...... 113 NEO-SYNEPHRINE COLD/ALLRGY EXT.175 niacin oral tablet 100 mg...... 191 natural tears pf...... 162 NEPHPLEX RX...... 96 NIASPAN...... 68 natural vegetable...... 112 nephro vitamins...... 96 NICAPRIN...... 148 natural vegetable fiber...... 112 nephronex oral tablet...... 96 nicardipine hcl oral...... 64 natural vegetable laxative...... 113 NEPHRO-VITE...... 96 NICAZYME...... 149 natural vitamin e...... 193 NEPHRO-VITE RX...... 96 NICODERM CQ...... 18 natura-lax...... 112 NERLYNX...... 154 NICOMIDE...... 96 NATURE-THROID ORAL TABLET 65 MG 133 NESINA...... 55 NICORETTE...... 19 nausea control...... 32 NESTABS...... 96 NICORETTE MINI...... 19 nausea relief...... 32 NESTABS DHA...... 96 NICORETTE STARTER KIT...... 19 NAYZILAM...... 27 NESTABS ONE...... 96 nicotinamide oral...... 96 NEBUPENT...... 43 neuac external gel...... 77 nicotine gum mouth/throat gum 2 mg...... 19 necon 0.5/35 (28)...... 126 NEUAC EXTERNAL KIT...... 86 nicotine gum mouth/throat gum 4 mg...... 19 nefazodone hcl...... 30 NEULASTA...... 59 nicotine gum mouth/throat lozenge 2 mg..... 19 NEODOT THERMOMETER...... 148 NEULASTA ONPRO...... 59 nicotine gum mouth/throat lozenge 4 mg..... 19 NEOMULTIVITE...... 96 NEUPOGEN INJECTION SOLUTION...... 59 nicotine mini...... 19 neomycin sulfate oral...... 20 nicotine mouth/throat gum 2 mg...... 19

227 nicotine mouth/throat gum 4 mg...... 19 nitrofurantoin...... 21 norethindrone acetate oral...... 129 nicotine mouth/throat lozenge 2 mg...... 19 nitrofurantoin macrocrystal...... 21 norethindrone acet-ethinyl est oral tablet nicotine mouth/throat lozenge 4 mg...... 19 nitrofurantoin monohydrate macrocrystals... 21 1.5-30 mg-mcg...... 126 nicotine polacrilex mini...... 19 nitroglycerin sublingual...... 70 norethindrone acet-ethinyl est oral tablet 1- nicotine polacrilex mouth/throat...... 19 nitroglycerin transdermal...... 70 20 mg-mcg...... 126 nicotine step 1...... 18 nitroglycerin translingual...... 70 norethindrone oral...... 129 nicotine step 2...... 18 NITROLINGUAL...... 70 norethindrone-eth estradiol...... 126 nicotine step 3...... 18 NITROMIST...... 70 norethin-eth estradiol-fe...... 126 nicotine transdermal kit 21-14-7 mg/24hr.....18 NITROSTAT...... 70 NORGESIC FORTE...... 185 nicotine transdermal patch 24 hour 14 NITYR...... 115 norgestimate-eth estradiol...... 126 mg/24hr, 7 mg/24hr...... 18 NIVA-PLUS...... 96 norgestimate-ethinyl estradiol triphasic oral nicotine transdermal patch 24 hour 21 NIVESTYM...... 59 tablet 0.18/0.215/0.25 mg-25 mcg...... 126 mg/24hr...... 18 nizatidine oral capsule...... 102 norgestimate-ethinyl estradiol triphasic oral nicotine transdermal system...... 18 nizatidine oral solution...... 102 tablet 0.18/0.215/0.25 mg-35 mcg...... 126 NICOTROL...... 18 no drip nasal relief...... 175 NORITATE...... 21 NICOTROL NS...... 18 no drip nasal spray...... 175 norlyda...... 129 nifedipine er...... 64 no flush niacin oral capsule...... 96 norlyroc...... 129 nifedipine er osmotic release...... 64 NOCDURNA...... 119 NORPACE...... 63 nifedipine oral...... 64 nolix...... 80 NORPACE CR...... 63 NIFEREX...... 93 non-aspirin...... 12 NORPRAMIN...... 31 night time sleep aid...... 187 non-aspirin 8 hour...... 12 NORTHERA...... 62 nighttime dry-eye relief...... 162 non-aspirin childrens...... 12 nortrel 0.5/35 (28)...... 126 nighttime sleep aid max st...... 187 non-aspirin extra strength...... 12 nortrel 1/35 (21)...... 126 nighttime sleep aid oral capsule 25 mg...... 187 non-aspirin jr strength...... 12 nortrel 1/35 (28)...... 126 nighttime sleep aid oral tablet 25 mg...... 187 non-aspirin pain relief...... 12 nortrel 7/7/7...... 126 nikki...... 126 non-pseudo sinus decongestant...... 175 nortriptyline hcl oral capsule...... 31 NILANDRON...... 38 nora-be...... 129 nortriptyline hcl oral solution...... 31 nilutamide...... 38 NORDIPEN 5 INJECTION DEVICE...... 149 NORVASC...... 64 nimodipine oral...... 64 NORDIPEN DELIVERY SYSTEM...... 149 NORVIR...... 52 NINLARO...... 39 NORDITROPIN FLEXPRO nose drops extstrength...... 175 nisoldipine er...... 64 SUBCUTANEOUS SOLUTION PEN- nose drops nasal decongest...... 175 nitazoxanide oral...... 43 INJECTOR 10 MG/1.5ML, 5 MG/1.5ML.....119 nose drops nasal solution 1 %...... 175 nitisinone...... 115 NORDITROPIN FLEXPRO NOURIANZ...... 45 NITRO-BID...... 70 SUBCUTANEOUS SOLUTION PEN- novarel intramuscular solution NITRO-DUR TRANSDERMAL PATCH 24 INJECTOR 15 MG/1.5ML, 30 MG/3ML...... 119 reconstituted 10000 unit...... 119 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 norethin ace-eth estrad-fe oral capsule...... 126 NOVAREL INTRAMUSCULAR SOLUTION MG/HR, 0.6 MG/HR...... 70 norethin ace-eth estrad-fe oral tablet...... 126 RECONSTITUTED 5000 UNIT...... 119 NITRO-DUR TRANSDERMAL PATCH 24 norethin ace-eth estrad-fe oral tablet HOUR 0.3 MG/HR, 0.8 MG/HR...... 70 chewable...... 126

228 NOVOEIGHT INTRAVENOUS SOLUTION NUEDEXTA...... 73 OB COMPLETE...... 96 RECONSTITUTED 1000 UNIT, 2000 NUFERA...... 93 OB COMPLETE ONE...... 96 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT...... 60 NU-IRON...... 93 OB COMPLETE PETITE...... 96 NOVOEIGHT INTRAVENOUS SOLUTION NULEV...... 149 OB COMPLETE PREMIER...... 96 RECONSTITUTED 1500 UNIT...... 60 NULYTELY LEMON-LIME...... 101 OB COMPLETE/DHA...... 96 NOVOLIN 70/30 FLEXPEN...... 57 NU-MAG...... 93 OBIZUR...... 61 NOVOLIN 70/30 FLEXPEN RELION...... 57 NUMBRINO...... 16 OBSTETRIX DHA...... 96 NOVOLIN 70/30 RELION...... 57 NUPERCAINAL...... 86 OBSTETRIX EC...... 191 NOVOLIN 70/30 VIAL...... 57 NUPLAZID...... 47 OBTREX...... 191 NOVOLIN N FLEXPEN...... 57 NURTEC...... 37 OCALIVA...... 101 NOVOLIN N FLEXPEN RELION...... 57 NUTRAPLUS...... 89 OCEAN FOR KIDS...... 175 NOVOLIN N RELION...... 57 NUTRASEB...... 86 OCEAN NASAL SPRAY...... 175 NOVOLIN N VIAL...... 57 NUTRICAP...... 191 ocella...... 126 NOVOLIN R FLEXPEN...... 57 nutrifac zx...... 191 OCTAGAM INTRAVENOUS SOLUTION NOVOLIN R FLEXPEN RELION...... 57 NUTROPIN AQ NUSPIN 10...... 119 30 GM/300ML...... 134 NOVOLIN R RELION...... 57 NUTROPIN AQ NUSPIN 20...... 119 octreotide acetate...... 132 NOVOLIN R VIAL...... 57 NUTROPIN AQ NUSPIN 5...... 119 OCUFLOX...... 157 NOVOLOG 70/30 FLEXPEN RELION...... 57 NUVAIL...... 89 ODEFSEY...... 51 NOVOLOG FLEXPEN...... 57 NUVARING...... 126 ODOMZO...... 41 NOVOLOG FLEXPEN RELION...... 57 NUVESSA...... 21 OFEV...... 172 NOVOLOG MIX 70/30 FLEXPEN...... 57 NUVIGIL...... 186 ofloxacin ophthalmic...... 157 NOVOLOG MIX 70/30 RELION...... 57 NUWIQ...... 60 ofloxacin oral...... 23 NOVOLOG MIX 70/30 VIAL...... 57 NUZYRA ORAL...... 24 ofloxacin otic...... 164 NOVOLOG PENFILL...... 57 nyamyc...... 85 olanzapine oral tablet...... 47 NOVOLOG RELION...... 57 nylia 7/7/7...... 126 olanzapine oral tablet dispersible...... 47 NOVOLOG U-100 VIAL...... 57 NYMALIZE...... 64 olanzapine-fluoxetine hcl...... 29 NOVOSEVEN RT...... 61 nymyo...... 126 olmesartan medoxomil oral...... 62 NOVOTWIST PEN NEEDLE 32G X 5 MM 149 nystatin external...... 85 olmesartan medoxomil-hctz...... 66 NOXAFIL ORAL SUSPENSION...... 33 nystatin mouth/throat...... 33 olmesartan-amlodipine-hctz...... 66 NOXAFIL ORAL TABLET DELAYED nystatin oral...... 33 olopatadine hcl nasal...... 167 RELEASE...... 33 nystatin-triamcinolone...... 83 olopatadine hcl ophthalmic...... 156 np thyroid...... 133 nystop...... 85 OLUMIANT ORAL TABLET 1 MG...... 135 NUBEQA...... 38 NYVEPRIA...... 149 OLUMIANT ORAL TABLET 2 MG...... 135 NUCALA SUBCUTANEOUS SOLUTION OASIS ULTRA MATRIX FENESTRATED OLUX...... 81 AUTO-INJECTOR...... 173 EXTERNAL SHEET 3X7CM...... 149 OLUX-E...... 81 NUCALA SUBCUTANEOUS SOLUTION OASIS ULTRA TRI-LAYER MATRIX OMECLAMOX-PAK...... 101 PREFILLED SYRINGE...... 173 EXTERNAL SHEET 7X10CM...... 89 omega-3-acid ethyl esters...... 68 NUCYNTA...... 7 OASIS WOUND MATRIX FENESTRATED omeprazole magnesium oral capsule NUCYNTA ER...... 7 EXTERNAL SHEET 3X7CM...... 149 delayed release...... 102

229 omeprazole magnesium oral tablet delayed ONETOUCH VERIO IN VITRO SOLUTION ORENCIA CLICKJECT...... 135 release...... 102 ...... 149 ORENCIA SUBCUTANEOUS...... 135 omeprazole oral capsule delayed release..102 ONETOUCH VERIO IN VITRO SOLUTION ORENITRAM...... 172 omeprazole-sod bicarbonate...... 102 HIGH...... 149 ORFADIN...... 115 omeprazole-sodium bicarb oral capsule 20- ONETOUCH VERIO IQ SYSTEM...... 149 ORGOVYX...... 20 1100 mg...... 102 ONETOUCH VERIO KIT W/DEVICE...... 149 ORIAHNN...... 132 omeprazole-sodium bicarbonate...... 102 ONETOUCH VERIO REFLECT KIT ORILISSA...... 132 OMNARIS...... 168 W/DEVICE...... 149 ORKAMBI ORAL PACKET...... 171 OMNIFLEX DIAPHRAGM...... 149 ONETOUCH VERIO SYNC SYSTEM...... 149 ORKAMBI ORAL TABLET...... 171 OMNITROPE PEN 5 INJ DEVICE...... 149 ONETOUCH VERIO TEST STRIPS...... 149 ORLADEYO...... 149 OMNITROPE SUBCUTANEOUS ONEXTON...... 77 orphenadrine citrate er...... 185 SOLUTION CARTRIDGE...... 119 ONFI ORAL SUSPENSION...... 27 orphenadrine-asa-caffeine...... 185 OMNITROPE SUBCUTANEOUS ONFI ORAL TABLET...... 27 ORPHENGESIC FORTE...... 185 SOLUTION RECONSTITUTED...... 120 ONGENTYS...... 45 orsythia...... 126 OMNIVEX...... 149 ONGLYZA ORAL TABLET 2.5 MG...... 55 ORTIKOS...... 139 once daily...... 97 ONGLYZA ORAL TABLET 5 MG...... 55 OS-CAL EXTRA D3...... 93 ondansetron hcl oral solution...... 32 ONUREG...... 39 oscimin...... 149 ondansetron hcl oral tablet 4 mg...... 32 ONZETRA XSAIL...... 36 oscimin sr...... 149 ondansetron hcl oral tablet 8 mg...... 32 opcicon one-step...... 130 oseltamivir phosphate oral...... 52 ondansetron odt...... 32 OPDIVO INTRAVENOUS SOLUTION 240 OSENI...... 55 one daily...... 97 MG/24ML...... 154 OSMOLEX ER ORAL TABLET ER 24 one daily womens health oral tablet ...... 97 opium...... 100 HOUR THERAPY PACK...... 45 ONE VITE WOMENS...... 97 OPSUMIT...... 172 OSMOLEX ER ORAL TABLET ONE VITE WOMENS PLUS...... 97 option 2...... 130 EXTENDED RELEASE 24 HOUR...... 45 one-daily multi vitamins...... 97 OPTIUM BLOOD GLUCOSE MONITOR... 149 OSMOPREP...... 101 one-daily multi-vitamin oral tablet...... 97 OPTIUM GLUCOSE MONITOR SYSTEM.149 OSPHENA...... 129 one-daily multi-vitamin/iron...... 191 OPTIUM TEST...... 149 OTEZLA...... 135 one-daily/iron...... 191 OPTIUMEZ TEST...... 149 OTIPRIO...... 165 ONETOUCH SURESOFT LANCING ORACEA...... 24 OTOVEL...... 164 DEVICE...... 90 ORACIT...... 191 OTREXUP...... 136 ONETOUCH ULTRA 2 KIT W/DEVICE..... 149 oral analgesic max st mouth/throat gel...... 75 OVACE PLUS...... 149 ONETOUCH ULTRA CONTROL...... 149 oral anesthetic max str...... 75 OVACE PLUS WASH...... 149 ONETOUCH ULTRA MINI KIT W/DEVICE 149 oral pain relief mouth/throat gel 20 %...... 75 OVACE WASH...... 149 ONETOUCH ULTRA TEST STRIPS...... 149 ORALAIR...... 135 OVIDE...... 84 ONETOUCH ULTRALINK...... 149 ORALAIR ADULT STARTER PACK...... 135 oxaliplatin intravenous solution 200 ONETOUCH VERIO FLEX SYSTEM KIT ORALAIR CHILDRENS STARTER PACK. 135 mg/40ml...... 38 W/DEVICE...... 149 oralone...... 75 oxandrolone oral...... 120 ORAPRED ODT...... 119 oxaprozin...... 6 ORAVIG...... 33 OXAYDO...... 7

230 oxazepam...... 53 pain relief childrens oral tablet chewable PALFORZIA (40 MG DAILY DOSE)...... 150 OXBRYTA...... 59 160 mg...... 12 PALFORZIA (6 MG DAILY DOSE)...... 150 oxcarbazepine oral suspension...... 27 pain relief extra st...... 12 PALFORZIA (80 MG DAILY DOSE)...... 150 oxcarbazepine oral tablet...... 27 pain relief extra strength...... 13 PALFORZIA INITIAL ESCALATION...... 150 OXERVATE...... 156 pain relief infants oral suspension 160 paliperidone er...... 47 oxiconazole nitrate...... 85 mg/5ml...... 13 palonosetron hcl intravenous solution 0.25 OXISTAT EXTERNAL CREAM...... 85 pain relief oral liquid 500 mg/15ml...... 13 mg/2ml...... 32 OXISTAT EXTERNAL LOTION...... 85 pain relief oral tablet 325 mg...... 13 PALYNZIQ...... 115 OXTELLAR XR...... 28 pain relief oral tablet 500 mg...... 13 PAMELOR...... 31 oxybutynin chloride er...... 116 pain relief oral tablet extended release 650 PANADOL CHILDRENS...... 14 oxybutynin chloride oral...... 116 mg...... 13 PANADOL EXTRA...... 14 OXYCODONE HCL ER...... 7 pain relief regular st...... 13 PANADOL EXTRA STRENGTH...... 14 oxycodone hcl oral capsule...... 7 pain relief regular strength...... 13 PANADOL INFANTS...... 14 oxycodone hcl oral concentrate 100 pain relief/rapid burst...... 13 PANCREAZE ORAL CAPSULE DELAYED mg/5ml...... 7 pain relieve child dye-free...... 13 RELEASE PARTICLES 10500-35500 oxycodone hcl oral solution...... 7 pain reliever childrens oral suspension 160 UNIT, 16800-56800 UNIT, 21000-54700 oxycodone hcl oral tablet...... 7 mg/5ml...... 13 UNIT, 4200-14200 UNIT...... 116 oxycodone-acetaminophen oral tablet 10- pain reliever ex st oral liquid 500 mg/15ml...13 PANCREAZE ORAL CAPSULE DELAYED 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 pain reliever ex st oral tablet 500 mg...... 13 RELEASE PARTICLES 2600-8800 UNIT, mg...... 9 pain reliever ex st oral tablet extended 37000-97300 UNIT...... 116 OXYCONTIN...... 7 release 650 mg...... 13 PANDEL...... 81 oxymorphone hcl...... 7 pain reliever extra strength oral tablet 250- PANOXYL...... 150 oxymorphone hcl er...... 7 250-65 mg...... 13 PANRETIN...... 41 OXYTROL...... 116 pain reliever extra strength oral tablet 500 pantoprazole sodium oral...... 102 OXYTROL FOR WOMEN...... 116 mg...... 13 PAREMYD...... 162 oyster shell calcium + d oral tablet 500-400 pain reliever infants oral suspension 160 PARI ALTERA NEBULIZER HANDSET.... 150 mg-unit...... 93 mg/5ml...... 13 PARI BABY CONVERSION KIT...... 150 oyster shell calcium + d3...... 93 pain reliever oral tablet...... 13 PARI ERAPID NEBULIZER HANDSET..... 150 oyster shell calcium/vit d3...... 93 pain reliever plus...... 13 PARI TREK S COMBO PACK...... 150 OZEMPIC...... 55 pain-off...... 14 PARI VORTEX ADULT MASK...... 150 OZOBAX...... 48 PALFORZIA (12 MG DAILY DOSE)...... 149 paricalcitol oral...... 139 p col-rite...... 113 PALFORZIA (120 MG DAILY DOSE)...... 149 PARLODEL...... 45 PACERONE...... 63 PALFORZIA (160 MG DAILY DOSE)...... 149 PARNATE...... 29 pain & fever child...... 12 PALFORZIA (20 MG DAILY DOSE)...... 149 paromomycin sulfate oral...... 20 pain & fever childrens oral suspension 160 PALFORZIA (200 MG DAILY DOSE)...... 149 paroxetine hcl...... 30 mg/5ml...... 12 PALFORZIA (240 MG DAILY DOSE)...... 150 paroxetine hcl er...... 30 pain & fever infants...... 12 PALFORZIA (3 MG DAILY DOSE)...... 150 paroxetine mesylate...... 30 pain relief childrens oral suspension 160 PALFORZIA (300 MG MAINTENANCE)....150 PARSABIV...... 140 mg/5ml...... 12 PALFORZIA (300 MG TITRATION)...... 150 PASER...... 38

231 PATADAY OPHTHALMIC SOLUTION 0.1 perphenazine-amitriptyline...... 29 pilocarpine hcl oral...... 75 %...... 156 PERSERIS...... 47 pimecrolimus...... 81 PATADAY OPHTHALMIC SOLUTION 0.2 PERTZYE...... 116 pimozide...... 46 %...... 156 PEXEVA...... 30 pimtrea...... 126 PATANASE...... 167 PFIZER-BIONTECH COVID-19 VACC...... 150 pindolol...... 64 PAXIL...... 30 PH STRIPS...... 150 pioglitazone hcl...... 55 PAXIL CR...... 30 pharbechlor...... 178 pioglitazone hcl-glimepiride...... 55 pb-hyoscy-atropine-scopolamine...... 103 pharbedryl...... 167 pioglitazone hcl-metformin hcl...... 55 pediaclear pd childrens...... 178 PHARBETOL EXTRA STRENGTH...... 14 PIQRAY (200 MG DAILY DOSE)...... 41 PEDIA-LAX ORAL LIQUID...... 112 PHARBETOL ORAL TABLET 325 MG...... 14 PIQRAY (250 MG DAILY DOSE)...... 41 PEDIA-LAX RECTAL SUPPOSITORY 1 PHAZYME...... 108 PIQRAY (300 MG DAILY DOSE)...... 41 GM...... 113 PHAZYME ULTRA STRENGTH...... 108 pirmella 1/35...... 126 PEDIAPRED...... 119 phenazo oral tablet 200 mg...... 118 pirmella 7/7/7...... 127 PEDVAX HIB...... 137 phenazo oral tablet 95 mg...... 118 piroxicam oral...... 6 peg 3350 oral powder...... 112 phenazopyridine hcl oral tablet 100 mg..... 118 PKU EASY...... 150 peg 3350-kcl-na bicarb-nacl...... 101 phenazopyridine hcl oral tablet 200 mg..... 118 PKU EASY MICROTABS...... 150 peg-3350/electrolytes...... 101 phenelzine sulfate oral...... 29 PLAN B ONE-STEP...... 130 peg-3350/electrolytes/ascorbat...... 101 phenobarbital oral...... 27 PLAQUENIL...... 43 PEGASYS...... 135 phenobarbital-belladonna alk...... 103 PLAVIX...... 59 peg-kcl-nacl-nasulf-na asc-c...... 101 PHENOHYTRO...... 103 PLEGRIDY...... 74 PEMAZYRE...... 39 phenoxybenzamine hcl oral...... 62 PLEGRIDY STARTER PACK...... 74 penicillamine oral...... 117 phenylephrine hcl ophthalmic...... 156 PLENVU...... 101 penicillin v potassium...... 22 phenylephrine hcl oral...... 175 PLEXION CLEANSER...... 87 PENLET II BLOOD SAMPLER...... 90 PHENYTEK...... 28 PLIAGLIS EXTERNAL CREAM...... 16 PENLET II REPLACEMENT CAP...... 90 phenytoin infatabs...... 28 PNEUMOVAX 23...... 138 PENNSAID...... 6 phenytoin oral suspension 125 mg/5ml...... 28 pnv tabs 29-1...... 97 pentamidine isethionate inhalation...... 43 phenytoin oral tablet chewable...... 28 pnv-dha...... 97 PENTASA...... 138 phenytoin sodium extended...... 28 pnv-omega...... 97 pentazocine-naloxone hcl...... 9 PHEXXI...... 150 podocon...... 150 pentoxifylline er...... 66 philith...... 126 podofilox external...... 83 PEPCID...... 102 PHILLIPS MILK OF MAGNESIA ORAL poly bacitracin...... 150 PERCOCET...... 9 SUSPENSION 400 MG/5ML...... 108 poly bacitracin external ointment ...... 150 PERDIEM OVERNIGHT RELIEF...... 113 PHOSLYRA...... 94 polycin...... 157 PERFOROMIST...... 171 PHOSPHA 250 NEUTRAL...... 191 polyethylene glycol 3350 oral powder...... 112 PERIDEX...... 75 phosphorous...... 191 polyethylene glycol 3350-grx oral powder 112 perindopril erbumine...... 63 phospho-trin 250 neutral...... 191 poly-iron 150...... 93 periogard...... 75 phytonadione oral...... 97 poly-iron 150 forte...... 93 permethrin external...... 84 PIFELTRO...... 50 polymyxin b-trimethoprim...... 157 perphenazine oral...... 31 pilocarpine hcl ophthalmic...... 159 polysaccharide iron complex...... 93

232 polysaccharide iron forte...... 93 prasugrel hcl...... 59 prednisone oral solution...... 119 polysaccharide-iron complex...... 93 pravastatin sodium...... 68 prednisone oral tablet...... 119 POLYSPORIN...... 150 praziquantel oral...... 42 prednisone oral tablet therapy pack...... 119 POLYTRIM...... 157 prazosin hcl oral...... 62 PREFEST...... 127 POLY-VI-FLOR...... 97 PRECISION GLUCOSE CONTROL...... 150 pregabalin...... 73 POLY-VI-FLOR/IRON...... 97 PRECISION GLUCOSE CONTROL SOLN150 pregabalin er...... 73 polyvinyl alcohol ophthalmic...... 162 PRECISION GLUCOSE KETONE CONTR150 pregnyl...... 120 POLY-VI-SOL...... 191 PRECISION GLUCOSE/KETONE CONTR150 PREMARIN ORAL...... 127 POLY-VITE PEDIATRIC...... 191 PRECISION LINK...... 150 PREMARIN VAGINAL...... 127 POMALYST...... 39 PRECISION PCX...... 150 PREMESISRX...... 97 PONVORY...... 155 PRECISION PCX PLUS TEST...... 150 PREMIUM BLOOD GLUCOSE TEST...... 151 PONVORY STARTER PACK...... 155 PRECISION POINT OF CARE TEST...... 150 premium lidocaine...... 16 portia-28...... 127 PRECISION QID MONITOR...... 150 PREMPHASE...... 127 posaconazole...... 33 PRECISION QID TEST...... 150 PREMPRO...... 127 pot & sod cit-cit ac...... 191 PRECISION SOF-TACT MONITOR...... 150 PRENATABS RX...... 97 potassium chloride crys er oral tablet PRECISION SOF-TACT TEST...... 150 prenatal 19 oral tablet...... 97 extended release 10 meq...... 91 PRECISION XTRA...... 150 prenatal 19 oral tablet chewable...... 97 potassium chloride crys er oral tablet PRECISION XTRA BLOOD GLUCOSE.....151 prenatal dha...... 151 extended release 15 meq...... 91 PRECISION XTRA MONITOR...... 151 prenatal oral tablet 27-0.8 mg...... 97 potassium chloride crys er oral tablet PRECOSE...... 55 prenatal plus iron...... 97 extended release 20 meq...... 91 PRED FORTE...... 158 prenatal tablet 27-1 mg oral...... 97 potassium chloride er...... 92 PRED MILD...... 158 prenatal vitamin plus low iron...... 97 potassium chloride oral packet...... 92 PRED-G...... 156 PRENATE...... 97 potassium chloride oral solution 20 PRED-G S.O.P...... 156 PRENATE AM...... 97 meq/15ml (10%), 40 meq/15ml (20%)...... 92 prednicarbate...... 81 PRENATE DHA...... 97 potassium citrate er...... 92 prednisolone acetate ophthalmic...... 158 PRENATE ELITE...... 97 potassium citrate-citric acid...... 191 prednisolone acetate p-f...... 158 PRENATE ESSENTIAL...... 97 POVIDONE-IODINE OPHTHALMIC...... 163 prednisolone oral solution...... 119 PRENATE MINI...... 97 PRADAXA ORAL CAPSULE 110 MG...... 58 prednisolone sodium phosphate PRENATE PIXIE...... 97 PRADAXA ORAL CAPSULE 150 MG, 75 ophthalmic...... 158 PRENATE RESTORE...... 98 MG...... 58 prednisolone sodium phosphate oral PRENATVITE RX...... 98 PRALUENT...... 68 solution 10 mg/5ml, 20 mg/5ml...... 119 PREPIDIL...... 120 pramipexole dihydrochloride...... 45 prednisolone sodium phosphate oral preplus...... 98 pramipexole dihydrochloride er...... 45 solution 15 mg/5ml, 25 mg/5ml...... 119 PRETOMANID...... 38 pramosone external cream 1-1 %...... 83 prednisolone sodium phosphate oral PREVACID...... 102 PRAMOSONE EXTERNAL CREAM 1-2.5 solution 6.7 (5 base) mg/5ml...... 119 PREVACID 24HR...... 102 %...... 83 prednisolone sodium phosphate oral tablet PREVACID SOLUTAB...... 102 PRAMOSONE EXTERNAL LOTION...... 83 dispersible...... 119 prevalite...... 69 PRAMOSONE EXTERNAL OINTMENT...... 83 prednisone intensol...... 119 PREVIDENT...... 92

233 PREVIDENT 5000 BOOSTER PLUS...... 92 probiotic maximum strength...... 108 PROMETRIUM...... 129 PREVIDENT 5000 DRY MOUTH...... 92 probiotic oral capsule ...... 109 PROMISEB...... 87 PREVIDENT 5000 ENAMEL PROTECT...... 92 probiotic pearls ex st...... 109 PRONEB ULTRA FILTER SET...... 151 PREVIDENT 5000 ORTHO DEFENSE...... 92 PROCARDIA XL...... 64 propafenone hcl...... 63 PREVIDENT 5000 PLUS...... 92 PROCENTRA...... 72 propafenone hcl er...... 63 PREVIDENT 5000 SENSITIVE...... 92 prochlorperazine...... 31 propranolol hcl er...... 64 previfem...... 127 prochlorperazine maleate oral...... 31 propranolol hcl oral...... 64 PREVNAR 13...... 138 PROCORT...... 83 propylthiouracil oral...... 132 PREVYMIS ORAL...... 49 PROCRIT...... 59 PROSCAR...... 117 PREZCOBIX...... 52 PROCTOCORT EXTERNAL...... 139 PROSILK EXTERNAL...... 87 PREZISTA...... 52 PROCTOCORT RECTAL...... 139 PROTONIX ORAL...... 103 PRIFTIN...... 38 PROCTOFOAM HC...... 83 PROTOPIC...... 81 PRILOHEAL PLUS 30...... 16 procto-med hc...... 139 protriptyline hcl...... 31 PRILOLID...... 16 procto-pak...... 139 PROVAD...... 109 PRILOSEC...... 103 proctozone-hc...... 139 PROVENTIL HFA...... 171 PRILOSEC OTC...... 103 PROCYSBI...... 116 PROVERA...... 129 PRILOVIX...... 16 PRODIGEN...... 109 PROVIGIL...... 186 PRILOVIX LITE...... 16 PROFESSIONAL DNA COLLECTION...... 151 PROZAC...... 30 PRILOVIX LITE PLUS...... 16 PROFILNINE...... 60 PRUCLAIR...... 89 PRILOVIX PLUS...... 16 progesterone intramuscular...... 129 PRUDOXIN...... 81 PRILOVIX ULTRALITE...... 16 progesterone oral...... 129 PRUMYX...... 89 PRILOVIX ULTRALITE PLUS...... 16 PROGLYCEM...... 56 pseudoephedrine hcl 12 hr...... 183 PRILOVIXIL...... 16 PROGRAF ORAL...... 136 pseudoephedrine hcl er...... 183 primaquine phosphate...... 43 PROLENSA...... 158 pseudoephedrine hcl oral tablet 30 mg...... 183 primidone oral...... 27 PROLEVA...... 151 pseudoephedrine-bromphen-dm...... 175 PRINIVIL...... 63 PROMACTA ORAL PACKET 12.5 MG...... 59 PSORCON...... 81 PRISTIQ...... 30 PROMACTA ORAL PACKET 25 MG...... 59 PSORIZIDE FORTE...... 151 PRIZOPAK II...... 16 PROMACTA ORAL TABLET...... 59 PSORIZIDE ULTRA...... 151 PRO DNA COLLECTION...... 151 promethazine hcl oral...... 31 PSS SELECT PLATFORMS...... 90 PRO HERS RX...... 191 promethazine hcl rectal...... 31 PULMICORT FLEXHALER...... 168 PRO HIS RX...... 191 promethazine vc...... 173 PULMICORT SUSPENSION...... 168 PRO PCOS RX...... 191 promethazine vc/codeine...... 183 PULMOZYME...... 171 PROAIR DIGIHALER...... 171 promethazine-codeine...... 183 PURALUBE...... 162 PROAIR HFA...... 171 promethazine-dm...... 175 purelax oral powder...... 112 PROAIR RESPICLICK...... 171 promethazine-phenyleph-codeine...... 183 purevit dualfe plus...... 191 probenecid...... 35 promethazine-phenylephrine...... 173 PURIXAN...... 39 probiotic blend...... 108 promethegan rectal suppository 12.5 mg, PYLERA...... 101 probiotic colon care...... 108 25 mg...... 31 pyrazinamide oral...... 38 probiotic complex...... 108 promethegan rectal suppository 50 mg...... 31 PYRIDIUM...... 118

234 pyridostigmine bromide er...... 37 quit2...... 19 RECOTHROM...... 61 pyridostigmine bromide oral solution...... 37 quit4...... 19 RECOTHROM SPRAY KIT...... 61 pyridostigmine bromide oral tablet 30 mg.... 37 QUTENZA...... 83 RECTIV...... 70 pyridostigmine bromide oral tablet 60 mg.... 37 QUTENZA (2 PATCH)...... 83 REDITREX...... 136 pyridoxine hcl oral tablet 50 mg...... 193 QUTENZA (4 PATCH)...... 83 redness relief ophthalmic solution 0.012- pyrimethamine oral...... 43 QVAR REDIHALER...... 168 0.2 %...... 151 QBRELIS...... 63 RABAVERT...... 137 REFRESH LACRI-LUBE...... 162 QBREXZA...... 83 RABEPRAZOLE SODIUM ORAL REFRESH OPTIVE OPHTHALMIC QDOLO...... 7 CAPSULE SPRINKLE...... 103 SOLUTION...... 162 QELBREE...... 53 rabeprazole sodium oral tablet delayed REFRESH OPTIVE PF...... 162 QINLOCK...... 154 release...... 103 REFRESH P.M...... 162 QNASL...... 168 raloxifene hcl...... 129 REFRESH PLUS...... 162 QNASL CHILDRENS...... 168 ramelteon...... 186 REFRESH RELIEVA...... 162 QTERN...... 55 ramipril...... 63 REFRESH RELIEVA PF OPHTHALMIC QUALAQUIN...... 43 RANEXA...... 66 SOLUTION 0.5-0.9 %...... 162 QUARTETTE...... 127 ranolazine er...... 66 REFRESH TEARS...... 162 QUDEXY XR...... 26 RAPAFLO...... 117 REGLAN...... 31 QUESTRAN...... 69 RAPAMUNE...... 136 RELADOR PAK...... 16 QUESTRAN LIGHT...... 69 RAPID GEL RX...... 151 RELADOR PAK PLUS...... 16 quetiapine fumarate...... 47 rapid melts junior oral tablet dispersible RELAFEN...... 6 quetiapine fumarate er...... 47 160 mg...... 14 RELAFEN DS...... 6 QUFLORA FE...... 98 rasagiline mesylate oral...... 46 RELENZA DISKHALER...... 52 QUFLORA FE PEDIATRIC...... 98 RASUVO...... 136 relexxii...... 71 QUFLORA GUMMIES...... 98 RAVICTI...... 116 relief eye drops...... 162 QUFLORA PEDIATRIC ORAL SOLUTION. 98 RAYALDEE...... 139 RELION TRUE MET AIR GLUC METER...151 QUFLORA PEDIATRIC ORAL TABLET RAYOS...... 119 RELION TRUE METRIX TEST STRIPS.... 151 CHEWABLE 0.25 MG, 0.5 MG...... 98 RAZADYNE ER...... 28 RELION ULTIMA GLUCOSE SYSTEM..... 151 QUILLICHEW ER...... 71 react...... 130 RELION ULTIMA TEST...... 151 QUILLIVANT XR...... 71 ready-to-use enema rectal enema ...... 109 RELISTOR ORAL...... 100 quinapril hcl...... 63 REAL HEAL-I...... 16 RELISTOR SUBCUTANEOUS SOLUTION quinapril-hydrochlorothiazide...... 66 REBIF...... 74 12 MG/0.6ML...... 100 quinidine gluconate er...... 63 REBIF REBIDOSE...... 74 RELISTOR SUBCUTANEOUS SOLUTION quinidine sulfate...... 63 REBIF REBIDOSE TITRATION PACK...... 74 8 MG/0.4ML...... 100 quinine sulfate oral...... 43 REBIF TITRATION PACK...... 74 RELNATE DHA...... 98 QUINTET AC BLOOD GLUCOSE...... 151 REBINYN...... 60 RELPAX...... 36 QUINTET AC BLOOD GLUCOSE TEST... 151 RECEDO...... 89 RELTONE...... 101 QUINTET BLOOD GLUCOSE SYSTEM... 151 reclipsen...... 127 REMERON...... 29 QUINTET BLOOD GLUCOSE TEST...... 151 RECOMBINATE...... 61 REMERON SOLTAB...... 29 QUINTET CONTROL HIGH/NORMAL...... 151 RECOMBIVAX HB...... 137 REMIGEN...... 89

235 RENAGEL...... 94 RETROVIR ORAL...... 51 rivastigmine...... 28 RENAL...... 98 REVATIO ORAL SUSPENSION rivastigmine tartrate...... 28 RENAL MULTIVITAMIN FORMULA...... 98 RECONSTITUTED...... 172 rivelsa...... 127 renal-vite...... 98 REVATIO ORAL TABLET...... 172 RIXUBIS...... 61 rena-vite...... 98 REVLIMID...... 39 rizatriptan benzoate oral tablet...... 36 RENVELA...... 94 REXULTI...... 47 rizatriptan benzoate oral tablet dispersible...36 repaglinide...... 55 REYATAZ ORAL CAPSULE...... 52 ROBITUSSIN COUGH+CHEST CONG REPATHA SUBCUTANEOUS SOLUTION REYATAZ ORAL PACKET...... 52 DM ORAL LIQUID 20-400 MG/20ML...... 183 AUTO-INJECTOR 140 MG/ML...... 69 REYVOW...... 36 ROCALTROL ORAL CAPSULE...... 139 REPATHA SUBCUTANEOUS SOLUTION RHOFADE...... 77 ROCALTROL ORAL SOLUTION...... 140 CARTRIDGE 420 MG/3.5ML...... 69 RHOGAM ULTRA-FILTERED PLUS...... 134 ROCKLATAN...... 156 REPATHA SUBCUTANEOUS SOLUTION RHOPRESSA...... 159 ropinirole hcl...... 45 PREFILLED SYRINGE 140 MG/ML...... 69 ribavirin inhalation...... 173 ropinirole hcl er...... 45 REPLACEMENT FILTERS...... 151 ribavirin oral...... 49 rosadan external cream...... 21 REQ 49+...... 191 RID LICE KILLING SHAMPOO...... 44 rosadan external gel...... 21 RESORCINOL-SULFUR...... 89 RIDAURA...... 135 ROSADAN EXTERNAL KIT...... 89 rest simply...... 187 rifabutin...... 37 rosuvastatin calcium...... 68 RESTASIS...... 156 rifampin oral...... 38 ROTARIX...... 137 RESTASIS MULTIDOSE...... 156 RILUTEK...... 73 ROTATEQ...... 137 RESTORA...... 109 riluzole...... 73 ROWASA...... 138 restore plus lubricant eye...... 162 rimantadine hcl...... 52 roweepra...... 26 restore pm...... 162 RINVOQ...... 135 ROXICODONE...... 7 RESTORIL...... 186 RIOMET...... 55 ROZEREM...... 186 RETACRIT INJECTION SOLUTION 10000 risanoid plus...... 191 ROZLYTREK...... 41 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, RISAQUAD...... 109 RUBRACA...... 41 4000 UNIT/ML, 40000 UNIT/ML...... 59 RISAQUAD-2...... 109 RUCONEST...... 133 RETACRIT INJECTION SOLUTION 20000 risedronate sodium...... 139 rufinamide oral suspension...... 28 UNIT/ML...... 59 RISPERDAL...... 47 rufinamide oral tablet...... 28 RETEVMO...... 154 RISPERDAL CONSTA...... 47 RUKOBIA...... 51 RETIN-A...... 77 risperidone oral solution...... 47 RUZURGI...... 73 RETIN-A MICRO GEL 0.04 %, 0.1 %...... 77 risperidone oral tablet...... 47 RX-SPECIMEN COLLECTION...... 151 RETIN-A MICRO PUMP EXTERNAL GEL risperidone oral tablet dispersible 0.25 mg.. 47 RYBELSUS...... 55 0.04 %...... 77 risperidone oral tablet dispersible 0.5 mg, 1 RYCLORA...... 167 RETIN-A MICRO PUMP EXTERNAL GEL mg, 2 mg, 3 mg, 4 mg...... 47 RYDAPT...... 41 0.06 %...... 77 RITALIN...... 71 rynex dm...... 183 RETIN-A MICRO PUMP EXTERNAL GEL RITALIN LA...... 72 rynex pe...... 183 0.08 %...... 77 ritonavir...... 52 rynex pse...... 183 RETIN-A MICRO PUMP EXTERNAL GEL RITUXAN HYCELA SUBCUTANEOUS RYTARY...... 46 0.1 %...... 77 SOLUTION 1600-26800 MG -UT/13.4ML....41 RYTHMOL SR...... 63

236 ryvent...... 167 SCARSILK EXTERNAL...... 89 SENSIPAR ORAL TABLET 30 MG, 90 MG S2 (RACEPINEPHRINE)...... 180 scopolamine...... 31 ...... 140 SABRIL...... 27 SEASONIQUE...... 127 SENSIPAR ORAL TABLET 60 MG...... 140 SAFE-T-LANCE...... 90 SECUADO...... 48 SEREVENT DISKUS...... 171 SAFYRAL...... 127 SEGLUROMET...... 55 SEROQUEL...... 48 SAIZEN...... 120 SELECT-OB...... 98 SEROQUEL XR...... 48 SAIZENPREP...... 120 SELECT-OB+DHA...... 98 SEROSTIM...... 120 sajazir...... 133 selegiline hcl oral...... 46 sertraline hcl oral concentrate...... 30 SALAGEN...... 75 selenium sulfide external lotion...... 81 sertraline hcl oral tablet...... 30 SALEX...... 89 selenium sulfide external shampoo...... 81 se-tan plus...... 191 salicylic acid external foam...... 89 SELRX...... 81 setlakin...... 127 salicylic acid external gel...... 89 SELZENTRY...... 51 sevelamer carbonate oral packet...... 94 salicylic acid external shampoo...... 89 SEMGLEE...... 57 sevelamer carbonate oral tablet...... 94 salicylic acid wart remover...... 89 SE-NATAL 19...... 98 sevelamer hcl...... 94 salicylic acid-cleanser...... 87 senexon-s...... 113 SEVENFACT...... 151 saline enema...... 109 senior probiotic...... 109 sf...... 92 saline mist spray...... 175 senior tonic...... 98 sf 5000 plus...... 92 saline nasal spray...... 175 senna lax...... 113 SFROWASA...... 138 SALIVAMAX...... 75 senna laxative...... 113 sharobel...... 129 salsalate oral...... 15 senna oral liquid...... 113 SHINGRIX...... 137 SALVAX...... 89 senna oral syrup 8.8 mg/5ml...... 113 SIGNIFOR...... 132 SAMSCA...... 94 senna oral tablet...... 114 SIKLOS...... 59 SANCUSO...... 32 senna plus oral tablet...... 114 silace oral liquid...... 112 SANDIMMUNE ORAL...... 136 senna s...... 114 silace oral syrup...... 112 SANDOSTATIN...... 132 senna smooth...... 114 siladryl allergy...... 167 SAPHNELO...... 138 senna-docusate sodium...... 114 SILATRIX...... 155 SAPHRIS...... 48 senna-extra...... 114 sildenafil citrate oral suspension sapropterin dihydrochloride...... 116 senna-lax...... 114 reconstituted...... 172 SAVAYSA...... 58 senna-plus...... 114 sildenafil citrate oral tablet 20 mg...... 172 SAVELLA...... 73 senna-s...... 114 SILENOR...... 186 SAVELLA TITRATION PACK...... 73 senna-tabs...... 114 SILIQ...... 135 sb arthritis pain relief...... 14 senna-time...... 114 silodosin...... 117 sb aspirin oral tablet delayed release...... 151 senna-time s...... 114 siltussin-dm alcohol free...... 183 sb docusate sodium/senna...... 113 sennazon...... 114 SILVADENE...... 83 sb lice killing max st...... 44 SENOKOT...... 114 silver sulfadiazine external...... 83 sb pain reliever childrens...... 14 SENOKOT EXTRA STRENGTH...... 114 SIMBRINZA...... 159 sb pain reliever ex st...... 14 SENOKOT S...... 114 simeped...... 109 SCARCIN EXTERNAL GEL...... 89 simethicone oral...... 109 SCARCIN EXTERNAL LIQUID...... 89 simethicone ultra strength...... 109

237 simliya...... 127 sleep-aid nighttime oral capsule 25 mg...... 188 soft glucose...... 58 simpesse...... 127 sleep-aid nighttime oral capsule 50 mg...... 188 SOLARTEK GLUCOSE CONTROL...... 152 SIMPLY SLEEP...... 187 sleep-aid oral capsule 25 mg...... 188 solifenacin succinate...... 116 SIMPONI...... 136 sleep-aid oral capsule 50 mg...... 188 SOLIQUA...... 55 simvastatin oral...... 68 sleeptime oral capsule...... 188 SOLODYN...... 24 SINEMET...... 46 SLOW FE...... 191 SOLOSEC...... 21 SINGULAIR ORAL PACKET...... 169 slow release iron oral tablet extended SOLOX...... 152 SINGULAIR ORAL TABLET...... 169 release 143 (45 fe) mg...... 191 SOLTAMOX...... 39 SINGULAIR ORAL TABLET CHEWABLE 4 SLOW-MAG...... 93 soluble fiber therapy...... 114 MG, 5 MG...... 169 SLOWMAG MG MUSCLE/HEART...... 93 SOLU-CORTEF INJECTION SOLUTION sinus 12 hour...... 183 SLYND...... 129 RECONSTITUTED 100 MG...... 119 sinus congestion max strength...... 183 smooth antacid ex st oral tablet chewable soluvita e...... 193 sinus nasal spray...... 176 750 mg...... 109 SOMA ORAL TABLET 250 MG...... 185 sinus pe decongestant...... 176 smooth antacid extra st...... 109 SOMA ORAL TABLET 350 MG...... 185 sinus relief ext st...... 176 smooth lax oral powder...... 112 SOMAVERT...... 132 sinus relief extra strength...... 176 sod citrate-citric acid...... 191 SONAFINE...... 89 sinus/congestion relief pe...... 176 sodium bicarbonate oral tablet...... 109 SOOLANTRA...... 84 SINUVA...... 168 sodium chloride inhalation nebulization SORBIDON HYDRATE...... 87 sirolimus oral solution...... 136 solution 0.9 %...... 183 sorbitol oral...... 112 sirolimus oral tablet...... 136 sodium chloride inhalation nebulization sore throat mouth/throat lozenge 6-10 mg... 75 SIRTURO...... 38 solution 10 %, 3 %...... 183 SORIATANE...... 77 SITAVIG...... 50 sodium chloride inhalation nebulization SORILUX...... 83 SIVEXTRO ORAL...... 21 solution 7 %...... 183 sotalol hcl (af)...... 63 SKELAXIN...... 185 sodium fluoride 5000 enamel...... 92 sotalol hcl oral...... 63 SKYADERM-LP...... 16 sodium fluoride 5000 plus...... 92 SOTYLIZE...... 63 SKYRIZI...... 135 sodium fluoride 5000 ppm dental cream...... 92 SOVALDI ORAL PACKET...... 49 SKYRIZI (150 MG DOSE)...... 135 sodium fluoride 5000 ppm dental paste...... 92 SOVALDI ORAL TABLET 200 MG...... 49 SKYRIZI PEN...... 135 sodium fluoride 5000 sensitive...... 92 SOVALDI ORAL TABLET 400 MG...... 49 sleep aid (diphenhydramine)...... 187 sodium fluoride dental cream...... 92 SPEEDGEL RX...... 152 sleep aid max st...... 187 sodium fluoride dental gel...... 92 spinosad...... 84 sleep aid nighttime oral capsule 25 mg...... 187 sodium fluoride mouth/throat...... 92 SPIRIVA HANDIHALER...... 169 sleep aid nighttime oral capsule 50 mg...... 187 sodium fluoride oral solution 1.1 (0.5 f) SPIRIVA RESPIMAT INHALATION sleep aid nighttime oral tablet 25 mg...... 187 mg/ml...... 92 AEROSOL SOLUTION 1.25 MCG/ACT.....169 sleep aid oral capsule 50 mg...... 187 sodium fluoride oral tablet chewable...... 92 SPIRIVA RESPIMAT INHALATION sleep aid oral tablet 25 mg...... 187 sodium phenylbutyrate oral...... 116 AEROSOL SOLUTION 2.5 MCG/ACT...... 169 sleep ii...... 187 sodium polystyrene sulfonate...... 94 spironolactone oral...... 67 sleep tabs...... 187 sodium sulfacetamide...... 151 spironolactone-hctz...... 66 sleepaid (diphenhydramine)...... 187 sodium sulfacetamide wash...... 151 SPORANOX...... 33 sleep-aid max st...... 187 SOFOSBUVIR-VELPATASVIR...... 49 SPORANOX PULSEPAK...... 33

238 SPRAVATO (56 MG DOSE)...... 29 STRATA CTX...... 89 sulfacetamide sodium-sulfur external SPRAVATO (84 MG DOSE)...... 29 STRATA MARK...... 89 cream 10-5 %...... 87 sprintec 28...... 127 STRATA TRIZ...... 89 sulfacetamide sodium-sulfur external SPRITAM...... 26 STRATA XRT...... 89 emulsion...... 87 SPRIX...... 6 STRATTERA...... 72 sulfacetamide sodium-sulfur external liquid. 87 SPRYCEL...... 154 STRENSIQ...... 116 sulfacetamide sodium-sulfur external lotion sps...... 94 stress formula...... 98 10-5 %...... 87 sronyx...... 127 stress formula/iron...... 191 sulfacetamide sodium-sulfur external pad ssd...... 83 stress formula/zinc...... 191 10-4 %...... 87 sss 10-5...... 87 STRIBILD...... 50 sulfacetamide sodium-sulfur external ST JOSEPH LOW DOSE...... 152 STRIVERDI RESPIMAT...... 171 suspension...... 87 STALEVO 100...... 45 STROMECTOL...... 42 sulfacetamide sod-sulfur wash...... 87 STALEVO 125...... 45 STROVITE FORTE ORAL TABLET...... 191 sulfacetamide-prednisolone ophthalmic STALEVO 150...... 45 STROVITE ONE...... 192 solution...... 156 STALEVO 200...... 45 STUART ONE...... 98 sulfacetamide-sulfur in urea...... 87 STALEVO 50...... 45 SUBOXONE...... 17 SULFACLEANSE 8/4...... 87 STALEVO 75...... 45 subvenite...... 26 sulfadiazine oral...... 23 STAMARIL...... 137 subvenite starter kit-blue...... 26 sulfamethoxazole-trimethoprim oral...... 23 stavudine oral capsule 15 mg, 20 mg, 40 subvenite starter kit-green...... 26 sulfamez wash...... 87 mg...... 51 subvenite starter kit-orange...... 26 SULFAMYLON...... 86 STEGLATRO...... 55 sucralfate oral suspension...... 102 sulfasalazine oral...... 138 STEGLUJAN...... 55 sucralfate oral tablet...... 102 sulfatrim pediatric...... 23 STELARA SUBCUTANEOUS...... 135 SUDAFED...... 183 sulindac oral...... 6 STIMATE...... 120 SUDAFED CHILDRENS...... 183 SUMADAN...... 87 stimulant laxative oral tablet 8.6-50 mg...... 114 SUDAFED PE CONGESTION ORAL SUMADAN WASH...... 87 STIOLTO RESPIMAT...... 180 TABLET 10 MG...... 176 SUMADAN XLT...... 87 STIVARGA...... 41 SUDAFED PE SINUS CONGESTION...... 176 sumatriptan nasal...... 36 stool softener laxative oral capsule...... 112 SUDAFED SINUS CONGESTION...... 183 sumatriptan succinate oral...... 36 stool softener oral capsule 100 mg...... 112 SUDAFED SINUS CONGESTION 12HR...184 sumatriptan succinate refill...... 36 stool softener oral capsule 240 mg...... 114 sudogest 12 hour...... 184 sumatriptan succinate subcutaneous...... 36 stool softener oral capsule 250 mg...... 112 sudogest maximum strength...... 184 sumatriptan-naproxen sodium...... 36 stool softener oral capsule 50 mg...... 112 sudogest oral tablet 30 mg...... 184 SUMAXIN...... 87 stool softener oral tablet 100 mg...... 112 SULAR...... 64 SUMAXIN CP...... 87 stool softener oral tablet 8.6-50 mg...... 114 sulfacetamide sodium (acne)...... 86 sunitinib malate...... 41 stool softener pls laxative...... 114 sulfacetamide sodium external...... 152 SUNOSI...... 186 stool softener plus laxative...... 114 sulfacetamide sodium ophthalmic...... 157 super b complex/c...... 98 stool softener/laxative...... 114 sulfacetamide sodium-sulfur external super b complex/vitamin c...... 98 stool softener/stimulant...... 114 cream 10-2 %...... 87 super b/c...... 98 stop lice complete treatment...... 44 SUPERVITE...... 98

239 suphedrine maximum strength...... 184 SYSTANE CONTACTS...... 162 TARKA...... 66 suphedrine oral tablet 30 mg...... 184 SYSTANE HYDRATION PF...... 162 TARON FORTE...... 192 suphedrine oral tablet extended release 12 SYSTANE NIGHTTIME...... 162 TARON-C DHA...... 98 hour 120 mg...... 184 SYSTANE OVERNIGHT THERAPY...... 162 TASIGNA...... 154 SUPRAX...... 21 SYSTANE PRESERVATIVE FREE...... 162 TASMAR...... 45 SUPREP BOWEL PREP KIT...... 101 SYSTANE ULTRA...... 162 tavaborole...... 86 sure result sr relief...... 152 SYSTANE ULTRA PF...... 162 TAVALISSE...... 59 surelac...... 109 tab-a-vite...... 98 taysofy...... 127 SUSTIVA...... 50 tab-a-vite/beta carotene...... 98 TAYTULLA...... 127 SUSTOL...... 32 tab-a-vite/iron...... 192 tazarotene external cream...... 77 SUTAB...... 112 TABLOID...... 39 TAZAROTENE EXTERNAL FOAM...... 77 SUTENT...... 41 TABRECTA...... 154 TAZORAC EXTERNAL CREAM 0.1 %...... 77 syeda...... 127 TACLONEX EXTERNAL OINTMENT...... 83 TAZORAC EXTERNAL GEL 0.05 %...... 77 SYMAX-SL...... 152 TACLONEX EXTERNAL SUSPENSION..... 83 taztia xt...... 65 SYMAX-SR...... 152 tacrolimus external...... 81 TAZVERIK...... 39 SYMBICORT...... 180 tacrolimus oral...... 136 tears pure...... 163 SYMBYAX...... 29 tadalafil (pah)...... 172 TECENTRIQ INTRAVENOUS SOLUTION SYMDEKO...... 171 tadalafil oral tablet 5 mg...... 117 1200 MG/20ML...... 154 SYMFI...... 50 TAFINLAR...... 41 TECFIDERA ORAL CAPSULE DELAYED SYMFI LO...... 50 TAGRISSO...... 154 RELEASE...... 74 SYMJEPI...... 171 take action...... 130 TECFIDERA STARTER PACK...... 74 SYMLINPEN 120...... 55 TAKHZYRO...... 133 TEGADERM AG MESH EXTERNAL PAD SYMLINPEN 60...... 55 TALICIA...... 101 2"X2" , 4"X8" , 8"X8"...... 152 SYMPAZAN...... 27 TALIVA...... 98 TEGRETOL ORAL SUSPENSION...... 28 SYMPROIC...... 100 TALTZ...... 135 TEGRETOL ORAL TABLET...... 28 SYMTUZA...... 52 TALZENNA...... 41 TEGRETOL-XR...... 28 SYNAGIS...... 135 TAMIFLU...... 52 TEGSEDI...... 116 SYNALAR...... 81 tamoxifen citrate oral...... 39 TEKTURNA...... 66 SYNALAR (CREAM)...... 87 tamsulosin hcl...... 117 TEKTURNA HCT...... 66 SYNALAR (OINTMENT)...... 87 TAPAZOLE...... 132 telmisartan...... 62 SYNALAR TS...... 89 TAPERDEX 12-DAY...... 119 telmisartan-amlodipine...... 66 SYNAREL...... 132 TAPERDEX 6-DAY...... 119 telmisartan-hctz...... 66 SYNERA...... 16 TAPERDEX 7-DAY...... 119 temazepam oral capsule 15 mg, 30 mg..... 186 SYNJARDY...... 55 TARCEVA...... 154 temazepam oral capsule 22.5 mg, 7.5 mg. 186 SYNJARDY XR...... 55 TARGADOX...... 24 TEMIXYS...... 51 SYNTHROID...... 132 TARGRETIN...... 41 TEMODAR ORAL...... 38 SYPRINE...... 94 tarina 24 fe...... 127 TEMOVATE...... 81 SYSTANE...... 162 tarina fe 1/20...... 127 temozolomide...... 38 SYSTANE COMPLETE...... 162 tarina fe 1/20 eq...... 127 TENCON...... 9

240 tenofovir disoproxil fumarate...... 51 theophylline er...... 172 TIROSINT-SOL ORAL SOLUTION 100 TENORETIC 100...... 66 thera...... 98 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 TENORETIC 50...... 66 thera-tabs...... 98 MCG/ML, 137 MCG/ML, 150 MCG/ML, TENORMIN...... 64 thiamine hcl oral...... 193 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, tension headache...... 14 THIOLA...... 117 50 MCG/ML, 75 MCG/ML, 88 MCG/ML..... 132 TEPMETKO...... 154 THIOLA EC...... 117 TIROSINT-SOL ORAL SOLUTION 37.5 terazosin hcl...... 117 thioridazine hcl oral...... 46 MCG/ML, 44 MCG/ML, 62.5 MCG/ML...... 132 terbinafine hcl external...... 35 thiothixene...... 46 TIVICAY...... 50 terbinafine hcl oral...... 33 THRIVE...... 19 TIVICAY PD...... 50 terbinafine hydrochloride external cream 1 THRIVITE RX...... 98 tizanidine hcl oral capsule...... 48 %...... 35 THROMBOGEN...... 60 tizanidine hcl oral tablet...... 48 terbutaline sulfate oral...... 171 THYQUIDITY...... 132 tl-hem 150...... 93 terconazole vaginal cream...... 33 tiadylt er...... 65 TOBI NEBULIZER...... 171 terconazole vaginal suppository...... 33 tiagabine hcl...... 27 TOBI PODHALER...... 171 TERIPARATIDE (RECOMBINANT)...... 140 TIAZAC...... 65 TOBRADEX OPHTHALMIC OINTMENT... 156 TESSALON PERLES...... 176 TIBSOVO...... 41 TOBRADEX OPHTHALMIC SUSPENSION TESTIM...... 121 TIGLUTIK...... 73 ...... 156 testosterone cypionate intramuscular...... 121 TIKOSYN...... 63 TOBRADEX ST...... 156 testosterone enanthate intramuscular...... 121 tilia fe...... 127 tobramycin inhalation nebulization solution testosterone transdermal gel 1.62 %, 20.25 timolol maleate ocudose...... 159 300 mg/4ml...... 171 mg/act (1.62%)...... 121 timolol maleate ophthalmic gel forming tobramycin nebulization solution 300 testosterone transdermal gel 10 mg/act solution...... 159 mg/5ml inhalation...... 171 (2%)...... 121 timolol maleate ophthalmic solution 0.25 TOBRAMYCIN NEBULIZATION testosterone transdermal gel 12.5 mg/act %, 0.5 %...... 159 SOLUTION 300 MG/5ML INHALATION.... 171 (1%)...... 121 timolol maleate ophthalmic solution 0.5 % tobramycin ophthalmic...... 157 testosterone transdermal gel 20.25 (daily)...... 159 tobramycin-dexamethasone...... 156 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), timolol maleate oral...... 37 TOBREX...... 157 40.5 mg/2.5gm (1.62%)...... 121 timolol maleate pf...... 159 tolbutamide...... 55 testosterone transdermal gel 50 mg/5gm TIMOPTIC...... 159 tolcapone...... 45 (1%)...... 121 TIMOPTIC OCUDOSE...... 159 tolnaftate antifungal...... 152 testosterone transdermal solution...... 121 TIMOPTIC-XE...... 159 tolnaftate external cream...... 152 tetrabenazine...... 73 TINACTIN EXTERNAL AEROSOL...... 152 tolnaftate external powder...... 152 tetracycline hcl oral...... 24 TINACTIN EXTERNAL CREAM...... 152 TOLSURA...... 33 TETRIX...... 89 tinidazole oral...... 21 tolterodine tartrate...... 116 TEXACORT...... 81 tioconazole 1 vaginal ointment 6.5 %...... 35 tolterodine tartrate er...... 116 THALOMID...... 39 tioconazole-1...... 35 TOLVAPTAN ORAL TABLET 15 MG...... 94 the magic bullet...... 152 tiopronin oral...... 117 tolvaptan oral tablet 30 mg...... 94 THEO-24...... 172 TIROSINT...... 132 TOPAMAX...... 26 theophylline...... 172 TOPAMAX SPRINKLE...... 26

241 TOPICORT...... 81 TRAZIMERA INTRAVENOUS SOLUTION triamterene-hctz...... 66 TOPICORT SPRAY...... 81 RECONSTITUTED 150 MG...... 154 TRIANEX...... 81 topiramate er...... 26 trazodone hcl oral tablet 100 mg, 150 mg, triazolam...... 186 topiramate oral capsule sprinkle...... 26 50 mg...... 30 TRIBENZOR...... 66 topiramate oral tablet...... 26 trazodone hcl oral tablet 300 mg...... 30 tri-buffered aspirin...... 15 TOPROL XL...... 64 TRECATOR...... 38 tricitrates...... 192 toremifene citrate...... 39 TRELEGY ELLIPTA...... 180 TRICON...... 192 torsemide...... 67 TREMFYA...... 135 TRICOR...... 67 TOSYMRA...... 36 TRESIBA...... 57 triderm...... 81 total allergy...... 167 TRESIBA FLEXTOUCH...... 57 TRIDESILON...... 81 total allergy medicine...... 167 tretinoin external cream...... 77 trientine hcl...... 94 TOUJEO MAX SOLOSTAR...... 57 tretinoin external gel 0.01 %...... 77 tri-estarylla...... 127 TOUJEO SOLOSTAR...... 57 tretinoin external gel 0.025 %...... 77 TRIFERIC HEMODIALYSIS PACKET...... 192 tovet external foam...... 81 tretinoin external gel 0.05 %...... 77 trifluoperazine hcl...... 47 TOVET EXTERNAL KIT...... 87 tretinoin microsphere...... 77 trifluridine...... 157 TOVIAZ...... 116 tretinoin microsphere pump...... 77 trihexyphenidyl hcl...... 44 TRACLEER 32 MG...... 172 tretinoin oral...... 41 TRIJARDY XR...... 55 TRACLEER 62.5 MG, 125 MG...... 172 TRETTEN...... 61 TRIKAFTA ORAL TABLET THERAPY TRADJENTA...... 55 TREXALL...... 136 PACK 100-50-75 & 150 MG...... 171 tramadol hcl er (biphasic)...... 7 TREXIMET...... 36 TRIKAFTA ORAL TABLET THERAPY TRAMADOL HCL ER ORAL CAPSULE TREZIX...... 9 PACK 50-25-37.5 & 75 MG...... 171 EXTENDED RELEASE 24 HOUR...... 7 tri femynor...... 127 tri-legest fe...... 127 tramadol hcl er oral tablet extended triamcinolone acetonide external aerosol TRILEPTAL ORAL SUSPENSION...... 28 release 24 hour...... 7 solution...... 81 TRILEPTAL ORAL TABLET...... 28 tramadol hcl oral tablet 100 mg...... 7 triamcinolone acetonide external cream...... 81 tri-linyah...... 127 tramadol hcl oral tablet 50 mg...... 7 triamcinolone acetonide external lotion TRILIPIX...... 67 tramadol-acetaminophen...... 9 0.025 %...... 81 tri-lo-estarylla...... 127 trandolapril...... 63 triamcinolone acetonide external lotion 0.1 tri-lo-marzia...... 127 trandolapril-verapamil hcl er...... 66 %...... 81 tri-lo-mili...... 127 tranexamic acid oral...... 59 triamcinolone acetonide external ointment tri-lo-sprintec...... 127 TRANSDERM-SCOP (1.5 MG)...... 31 0.025 %...... 81 trimethobenzamide hcl oral...... 31 TRANXENE-T...... 53 triamcinolone acetonide external ointment trimethoprim oral...... 21 tranylcypromine sulfate...... 29 0.1 %, 0.5 %...... 81 tri-mili...... 127 TRANZGEL...... 152 triamcinolone acetonide mouth/throat...... 75 trimipramine maleate oral...... 31 TRAUMEEL EXTERNAL...... 152 triamcinolone acetonide ointment 0.05 % TRIMO-SAN VAGINAL GEL 0.025-0.01 % 118 TRAUMEEL ORAL...... 152 external...... 81 TRINATAL RX 1...... 98 TRAVATAN Z...... 155 triamcinolone in absorbase...... 81 TRINTELLIX...... 30 travel ease...... 31 TRIAMINIC ALLERCHEWS...... 178 tri-nymyo...... 127 travoprost (bak free)...... 155 triamterene oral...... 67 triphrocaps...... 98

242 triple antibiotic...... 25 TRUETRACK BLOOD GLUCOSE...... 152 tussin dm max oral liquid 20-400 mg/20ml.184 triple antibiotic max st...... 25 TRUETRACK TEST...... 152 tussin dm max st...... 184 triple antibiotic original...... 25 TRULANCE...... 100 tussin dm oral syrup 100-10 mg/5ml...... 184 triple antibiotic pain relief...... 25 TRULICITY SUBCUTANEOUS SOLUTION TWINRIX...... 137 triple antibiotic plus...... 25 PEN-INJECTOR 0.75 MG/0.5ML, 1.5 TWIRLA...... 129 triple antibiotic plus max st...... 25 MG/0.5ML...... 55 TWYNSTA...... 66 triple antibiotic/pain...... 25 TRULICITY SUBCUTANEOUS SOLUTION tyblume...... 128 triple antibiotic+pain relief...... 25 PEN-INJECTOR 3 MG/0.5ML, 4.5 TYBOST...... 51 tri-previfem...... 127 MG/0.5ML...... 55 tydemy...... 128 triprolidine hcl oral liquid 0.313 mg/ml...... 178 TRUMENBA...... 137 TYKERB...... 154 triprolidine hcl oral liquid 0.625 mg/ml...... 178 TRUSELTIQ (100MG DAILY DOSE)...... 99 TYLACTIN COMPLETE 15 PE...... 152 triprolidine hcl oral liquid 0.938 mg/ml...... 178 TRUSELTIQ (125MG DAILY DOSE)...... 99 TYLENOL EXTRA STRENGTH TABLET TRIPTODUR...... 132 TRUSELTIQ (50MG DAILY DOSE)...... 99 500 MG ORAL 500 MG...... 14 TRISENOX...... 39 TRUSELTIQ (75MG DAILY DOSE)...... 99 TYLENOL FOR CHILDREN + ADULTS...... 14 tri-sprintec...... 127 TRUSOPT...... 159 TYLENOL ORAL SUSPENSION 160 TRISTART DHA...... 98 TRUVADA...... 51 MG/5ML...... 14 TRISTART ONE...... 98 TUBING/WING TIP...... 152 TYLENOL ORAL TABLET 325 MG...... 14 tritocin...... 81 TUDORZA PRESSAIR...... 169 TYLENOL ORAL TABLET CHEWABLE TRIUMEQ...... 51 TUKYSA...... 154 160 MG...... 14 TRI-VI-FLOR...... 98 tulana...... 129 TYLENOL ORAL TABLET EXTENDED TRI-VI-FLORO...... 98 TUMS...... 109 RELEASE 650 MG...... 14 tri-vite/fluoride...... 192 TUMS CHEWY BITES...... 109 TYMLOS...... 140 trivora (28)...... 127 TUMS E-X 750...... 109 TYPHIM VI...... 137 tri-vylibra...... 127 TUMS EXTRA STRENGTH 750...... 109 TYR EASY...... 152 tri-vylibra lo...... 128 TUMS LASTING EFFECTS...... 109 TYVASO...... 172 TRIZIVIR...... 51 TUMS SMOOTHIES...... 109 TYVASO REFILL...... 172 TROKENDI XR...... 26 TUMS ULTRA 1000...... 109 TYVASO STARTER...... 172 tropicamide ophthalmic solution 0.5 %...... 163 TURALIO...... 154 UBRELVY...... 37 tropicamide ophthalmic solution 1 %...... 163 TUSSICAPS...... 184 UCERIS...... 139 trospium chloride...... 116 tussin cf cough & cold oral syrup 5-10-100 UDENYCA...... 59 trospium chloride er...... 116 mg/5ml...... 176 UKONIQ...... 154 TRUE FOCUS BLOOD GLUCOSE STRIP 152 tussin cough dm sugar free...... 184 ULORIC...... 35 TRUE METRIX AIR GLUCOSE METER....152 tussin cough/chest congest oral syrup 100- ULTIMA...... 152 TRUE METRIX GO GLUCOSE METER.... 152 10 mg/5ml...... 184 ultra dairy digestive...... 109 TRUE METRIX METER KIT...... 152 tussin dm cough/chest cong...... 184 ultra fresh...... 163 TRUECONTROL GLUCOSE CONT LEV 0152 tussin dm cough/chest oral syrup 10-100 ultra fresh pm...... 163 TRUECONTROL GLUCOSE CONT LEV 1152 mg/5ml...... 184 ULTRA HERS RX...... 152 TRUEPLUS LANCETS 30G...... 90 tussin dm max adult...... 184 ULTRA HIS...... 152 TRUEPLUS SAFETY LANCETS 28G...... 90 tussin dm max daytime...... 184 ultra lubricant drop...... 163

243 ultra lubricating eye drops...... 163 valacyclovir hcl oral tablet 1 gm...... 50 VEMLIDY...... 49 ULTRA PCOS...... 152 valacyclovir hcl oral tablet 500 mg...... 50 VENCLEXTA...... 41 ULTRACET...... 9 VALCHLOR...... 38 VENCLEXTA STARTING PACK...... 41 ULTRAM...... 7 VALCYTE...... 49 VENEXA...... 192 ULTRAVATE...... 81 valganciclovir hcl oral solution VENEXA FE...... 192 UNISTRIP CONTROL...... 152 reconstituted...... 49 venlafaxine hcl...... 30 UNISTRIP1 GENERIC...... 152 valganciclovir hcl oral tablet...... 49 venlafaxine hcl er oral capsule extended unithroid...... 132 VALIUM...... 53 release 24 hour...... 30 UPTRAVI INTRAVENOUS...... 172 valproic acid oral...... 26 venlafaxine hcl er oral tablet extended UPTRAVI ORAL...... 172 valsartan...... 62 release 24 hour...... 30 urea external cream 39 %...... 89 valsartan-hydrochlorothiazide...... 66 VENTAVIS...... 172 urea external cream 40 %...... 90 VALTOCO 10 MG DOSE...... 27 VENTOLIN HFA...... 171 urea external cream 41 %...... 90 VALTOCO 15 MG DOSE...... 27 VENTRIXYL FE...... 192 urea external lotion...... 90 VALTOCO 20 MG DOSE...... 27 verapamil hcl er oral capsule extended urea hydrating...... 90 VALTOCO 5 MG DOSE...... 27 release 24 hour...... 65 ureacin-10...... 90 VALTREX ORAL TABLET 1 GM...... 50 verapamil hcl er oral tablet extended uredeb...... 90 VALTREX ORAL TABLET 500 MG...... 50 release...... 65 URELLE...... 118 VANADOM...... 185 verapamil hcl oral...... 65 UREMEZ-40...... 90 VANCOCIN...... 21 VEREGEN...... 83 URIMAR-T...... 118 VANCOCIN HCL...... 21 VERELAN...... 65 urin ds...... 118 vancomycin hcl oral...... 21 VERELAN PM...... 65 urinary pain relief oral tablet 95 mg...... 118 vandazole...... 21 VERQUVO...... 71 URO-458...... 118 VANOS...... 81 VERSACLOZ...... 48 UROCIT-K 10...... 92 VAQTA...... 137 VERZENIO...... 41 UROCIT-K 15...... 92 VARIVAX...... 137 VESICARE...... 116 UROCIT-K 5...... 92 VARUBI (180 MG DOSE)...... 32 VESICARE LS...... 116 UROGESIC-BLUE...... 118 VASCEPA...... 69 vestura...... 128 uro-mp...... 118 VASCULERA...... 152 VEXATROL...... 16 urosex...... 192 VASERETIC...... 66 VFEND...... 33 UROXATRAL...... 117 VASOTEC...... 63 VIBERZI...... 101 URSO 250...... 101 VAXCHORA...... 138 VIBRAMYCIN...... 24 URSO FORTE...... 101 v-c forte...... 192 vic-forte...... 192 URSODIOL ORAL CAPSULE 200 MG, VECAMYL...... 66 VICTOZA...... 55 400 MG...... 101 VECTICAL...... 83 VIEKIRA PAK...... 49 ursodiol oral capsule 300 mg...... 101 vegetable lax+stool softener...... 114 vienva...... 128 ursodiol oral tablet...... 101 velivet...... 128 vigabatrin...... 27 UTIRA-C...... 118 VELPHORO...... 94 vigadrone...... 27 UTOPIC...... 90 VELTASSA...... 94 VIGAMOX...... 157 VAGIFEM...... 128 VELTIN...... 77 VIIBRYD...... 30

244 VIIBRYD STARTER PACK...... 30 VITAFOL GUMMIES...... 98 VIVELLE-DOT...... 128 VILAMIT MB...... 118 VITAFOL STRIPS...... 98 VIVLODEX...... 6 VILEVEV MB...... 118 VITAFOL ULTRA...... 98 VIZIMPRO...... 154 VIMOVO...... 6 VITAFOL-NANO...... 99 VOCABRIA...... 35 VIMPAT ORAL...... 28 VITAFOL-OB...... 99 VOGELXO...... 121 VINATE ONE...... 98 VITAFOL-OB+DHA...... 99 VOGELXO PUMP...... 121 VIOKACE...... 116 VITAFOL-ONE...... 99 volnea...... 128 viorele...... 128 VITAL-D RX...... 99 VONVENDI...... 61 VIRACEPT...... 52 VITAMEZ...... 99 voriconazole oral...... 33 VIRAMUNE...... 50 vitamin b complex-c...... 99 VORTEX HOLD CHMBR/MASK/CHILD.... 152 VIRAMUNE XR...... 50 vitamin b-12 oral tablet 100 mcg, 1000 VORTEX HOLD VIRASAL...... 90 mcg, 250 mcg, 500 mcg...... 193 CHMBR/MASK/TODDLER...... 152 VIRAZOLE...... 173 vitamin b12 oral tablet 1000 mcg...... 193 VORTEX VALVED HOLDING CHAMBER.152 VIREAD ORAL POWDER...... 51 vitamin b-2 oral tablet 100 mg...... 192 VOSEVI...... 49 VIREAD ORAL TABLET 150 MG, 200 MG, vitamin b-6 oral tablet 100 mg, 50 mg...... 193 VOTRIENT...... 154 250 MG...... 51 vitamin c drops mouth/throat lozenge 60 vp-pnv-dha...... 99 VIREAD ORAL TABLET 300 MG...... 51 mg...... 192 VPRIV...... 116 virt-c dha...... 98 vitamin c er oral capsule extended release 192 vp-vite rx...... 99 virt-caps...... 98 vitamin c oral tablet 500 mg...... 192 VRAYLAR...... 48 virt-gard...... 98 vitamin c/rose hips oral tablet 500 mg...... 192 VTOL LQ...... 9 virt-nate dha...... 98 vitamin c-rose hips oral tablet 500 mg...... 192 VUMERITY...... 74 virt-phos 250 neutral...... 192 vitamin d (ergocalciferol) oral capsule 1.25 VUSION...... 86 virt-pn dha...... 98 mg (50000 ut)...... 192 vyfemla...... 128 virt-pn plus...... 98 vitamin d3 oral capsule 250 mcg (10000 ut) vylibra...... 128 virtussin a/c...... 184 ...... 192 VYNDAMAX...... 116 virtussin ac w/alc...... 184 vitamin e oral capsule 400 unit...... 193 VYNDAQEL...... 116 virtussin dac...... 176 vitamin e oral solution 15 unit/0.3ml...... 193 VYTORIN...... 69 VISBIOME HIGH POTENCY ORAL vitamins acd-fluoride...... 192 VYVANSE ORAL CAPSULE...... 72 CAPSULE...... 109 vitamins complete childrens...... 192 VYVANSE ORAL TABLET CHEWABLE...... 72 VISINE...... 163 VITAROCA PLUS...... 192 VYXEOS...... 39 VISINE ADVANCED RELIEF...... 163 VITA-RX DIABETIC VITAMIN...... 192 VYZULTA...... 155 VISTA GEL DRY EYE RELIEF...... 163 VITASURE...... 99 WAKIX...... 186 VISTA MEIBO TEARS...... 163 VITATHELY WITH GINGER...... 99 warfarin sodium oral...... 58 VISTA TEARS...... 163 VITRAKVI...... 41 wart remover external liquid 17 %...... 90 VISTARIL...... 53 VITRAMYN...... 192 wart remover maximum strength external vita s forte...... 192 VITRANOL FE...... 192 liquid...... 90 vitacel...... 192 VITREXYL...... 192 WELCHOL...... 69 vitachew multiple vitamin...... 192 VITREXYL + IRON...... 192 WELIREG...... 155 VITAFOL FE+...... 98 VIVA DHA...... 99 WELLBUTRIN SR...... 29

245 WELLBUTRIN XL...... 29 XELJANZ ORAL TABLET...... 135 XTANDI ORAL TABLET...... 38 WELLMIND VERTIGO...... 153 XELJANZ XR...... 135 xulane...... 128 wera...... 128 XELODA...... 42 XULTOPHY...... 55 westab max...... 99 XELPROS...... 155 xurea...... 90 westab mini...... 99 XENAZINE...... 73 XVITE...... 99 WESTAB PLUS...... 99 XENLETA ORAL...... 21 XYNTHA...... 61 WESTHROID ORAL TABLET 65 MG...... 133 XEPI...... 86 XYNTHA SOLOFUSE...... 61 WEST-VITE W/FOLIC ACID...... 99 XERAC AC...... 90 XYOSTED SUBCUTANEOUS SOLUTION WIDE-SEAL DIAPHRAGM 60...... 153 XERALUX...... 90 AUTO-INJECTOR 100 MG/0.5ML, 50 WIDE-SEAL DIAPHRAGM 65...... 153 XERESE...... 83 MG/0.5ML...... 121 WIDE-SEAL DIAPHRAGM 70...... 153 XERMELO...... 101 XYOSTED SUBCUTANEOUS SOLUTION WIDE-SEAL DIAPHRAGM 75...... 153 XEROSTOMIA RELIEF SPRAY...... 75 AUTO-INJECTOR 75 MG/0.5ML...... 121 WIDE-SEAL DIAPHRAGM 80...... 153 XHANCE...... 168 XYREM...... 186 WIDE-SEAL DIAPHRAGM 85...... 153 XIFAXAN...... 21 XYWAV...... 188 WIDE-SEAL DIAPHRAGM 90...... 153 XIGDUO XR...... 55 XYZBAC...... 153 WIDE-SEAL DIAPHRAGM 95...... 153 XIIDRA...... 156 XYZMUNE...... 153 WILATE...... 61 XIMINO...... 24 YASMIN 28...... 128 WILZIN...... 93 XOFLUZA (40 MG DOSE) ORAL TABLET YAZ...... 128 wixela inhub...... 180 THERAPY PACK 1 X 40 MG...... 52 YF-VAX...... 137 womans laxative...... 153 XOFLUZA (40 MG DOSE) ORAL TABLET YONSA...... 38 womens gentle laxative...... 153 THERAPY PACK 2 X 20 MG...... 52 YUPELRI...... 169 womens laxative oral tablet delayed XOFLUZA (80 MG DOSE) ORAL TABLET yuvafem...... 128 release 5 mg...... 153 THERAPY PACK 1 X 80 MG...... 52 ZADITOR...... 163 WP THYROID ORAL TABLET 65 MG...... 133 XOFLUZA (80 MG DOSE) ORAL TABLET zafemy...... 128 wymzya fe...... 128 THERAPY PACK 2 X 40 MG...... 52 zafirlukast...... 169 XADAGO...... 46 XOLAIR...... 135 zaleplon...... 186 XALATAN...... 155 XOPENEX CONCENTRATE...... 171 ZANAFLEX...... 48 XALKORI...... 154 XOPENEX HFA...... 171 zarah...... 128 XANAX...... 53 XOPENEX NEB...... 171 ZARONTIN...... 26 XANAX XR...... 53 XOSPATA...... 154 ZARXIO...... 59 XARELTO ORAL TABLET 10 MG, 15 MG, XPOVIO (100 MG ONCE WEEKLY)...... 39 ZATEAN-PN DHA...... 99 20 MG...... 58 XPOVIO (40 MG ONCE WEEKLY)...... 40 ZAVESCA...... 116 XARELTO ORAL TABLET 2.5 MG...... 58 XPOVIO (40 MG TWICE WEEKLY)...... 40 ZEASORB-AF...... 35 XARELTO STARTER PACK...... 58 XPOVIO (60 MG ONCE WEEKLY)...... 40 ZEBUTAL...... 9 XATMEP...... 136 XPOVIO (60 MG TWICE WEEKLY)...... 40 ZEGALOGUE...... 118 XCOPRI...... 26 XPOVIO (80 MG ONCE WEEKLY)...... 40 ZEGERID...... 103 XCOPRI (250 MG DAILY DOSE)...... 26 XPOVIO (80 MG TWICE WEEKLY)...... 40 ZEJULA...... 41 XCOPRI (350 MG DAILY DOSE)...... 26 XTAMPZA ER...... 7 ZELAC...... 109 XELJANZ ORAL SOLUTION...... 135 XTANDI ORAL CAPSULE...... 38 ZELAPAR...... 46

246 ZELBORAF...... 41 ZOLMITRIPTAN NASAL...... 36 ZYCLARA PUMP...... 83 ZELNORM...... 100 zolmitriptan oral tablet...... 36 ZYDELIG...... 41 ZEMBRACE SYMTOUCH...... 36 zolmitriptan oral tablet dispersible...... 36 ZYFLO...... 169 ZEMDRI...... 20 ZOLOFT ORAL CONCENTRATE...... 30 ZYKADIA...... 42 ZEMPLAR ORAL...... 140 ZOLOFT ORAL TABLET...... 30 ZYLET...... 156 zenatane...... 77 zolpidem tartrate er oral tablet extended ZYLOPRIM...... 35 ZENPEP...... 116 release 12.5 mg...... 186 ZYMAXID...... 157 ZENZEDI...... 72 zolpidem tartrate er oral tablet extended ZYNLONTA...... 154 ZEPATIER...... 49 release 6.25 mg...... 186 ZYPITAMAG...... 68 ZEPOSIA...... 74 zolpidem tartrate oral tablet 10 mg...... 186 ZYPREXA ORAL...... 48 ZEPOSIA 7-DAY STARTER PACK...... 74 zolpidem tartrate oral tablet 5 mg...... 186 ZYPREXA ZYDIS...... 48 ZEPOSIA STARTER KIT...... 74 zolpidem tartrate sublingual...... 186 ZYRTEC ALLERGY ORAL CAPSULE...... 167 ZERUVIA...... 17 ZOMACTON...... 120 ZYRTEC ALLERGY ORAL TABLET...... 167 ZERVIATE...... 156 ZOMACTON (FOR ZOMA-JET 10)...... 120 ZYTIGA ORAL TABLET 250 MG...... 38 ZESTORETIC...... 66 ZOMIG...... 36 ZYTIGA ORAL TABLET 500 MG...... 38 ZESTRIL...... 63 ZONALON...... 81 ZYVANA...... 193 ZETIA...... 69 ZONEGRAN...... 28 ZYVEXOL...... 153 ZETONNA...... 168 zonisamide oral...... 28 ZYVIT...... 153 ZIAC...... 66 ZONTIVITY...... 58 ZYVOX ORAL SUSPENSION ZIAGEN...... 51 zoo friends...... 193 RECONSTITUTED...... 21 ZIANA...... 77 zoo friends complete...... 193 ZYVOX ORAL TABLET...... 21 zidovudine...... 51 zoo friends gummies...... 193 ZIEXTENZO...... 59 zoo friends plus extra c...... 99 zileuton er...... 169 zoo friends plus iron...... 193 ZILXI...... 90 ZORBTIVE...... 120 zinc gluconate oral tablet 50 mg...... 193 ZORTRESS ORAL TABLET 0.25 MG, 0.5 zinc oral lozenge...... 193 MG, 0.75 MG...... 136 zinc oral tablet 50 mg...... 193 ZORTRESS ORAL TABLET 1 MG...... 136 ZIOPTAN...... 155 ZORVOLEX...... 6 ziprasidone hcl...... 48 ZOSTRIX HP...... 153 ZIPSOR...... 6 zovia 1/35 (28)...... 128 ZIRGAN...... 49 zovia 1/35e (28)...... 128 ZITHROMAX ORAL...... 23 ZOVIRAX EXTERNAL...... 50 ZITHROMAX TRI-PAK...... 23 ZOVIRAX ORAL...... 50 ZITHROMAX Z-PAK...... 23 z-sleep oral capsule 25 mg...... 188 ZOCOR...... 68 ZUBSOLV...... 17 ZOFRAN...... 32 zumandimine...... 128 ZOKINVY...... 153 ZUPLENZ...... 32 ZOLINZA...... 40 ZYCLARA...... 83

247