Health Partners Plans CHIP Formulary

2021 Formulary

Introduction be notified through correspondence from Prescription quantities cannot be altered unless the Health Partners Plans Pharmacy approved by the physician, and must be within department when applicable. the limits of the plan’s days’ supply. Health Partners Plans, Inc. is pleased to provide the 2021 KidzPartners Formulary. This Prescribed medications or regimens that are formulary covers members under the Product Selection Criteria non-formulary require prior authorization. KidzPartners (Children’s Health Insurance Program) plan. The drugs listed in the The Health Partners Plans P&T Committee will KidzPartners Formulary are intended to provide consider all FDA approved drugs for inclusion Immediate Need sufficient options to treat the majority of in the formulary. The evaluation process (5/15-day Emergency Supply) patients who require drug therapy in an includes a literature review, and expert opinion ambulatory setting. Excluded from coverage by respected medical professionals. Formal If a member presents at a pharmacy with a are drugs from specific manufacturers who reviews are prepared which typically address prescription which requires prior authorization, have not contracted with the rebate program of the following information: whether for a non-formulary drug or otherwise, the Federal government. 1. Safety and if the prior authorization cannot be 2. Effectiveness processed immediately, Health Partners Plans The drugs listed in the KidzPartners Formulary will allow the pharmacy to dispense an interim have been reviewed and approved by the 3. Comparison studies 4. Approved indications supply of the prescription under the following Health Partners Plans Pharmacy and circumstances: Therapeutics Committee. These drug products 5. Adverse effects have been selected to provide the most 6. Contraindications If the recipient is in immediate need of the clinically appropriate and cost-effective 7. Pharmacokinetics medication in the professional judgment of the medications for KidzPartners members. There 8. Patient compliance considerations pharmacist and if the prescription is for a new may be occasions when an unlisted drug is 9. Medical outcome and medication (one that the recipient has not taken desired for medical management of a specific pharmacoeconomic studies before or that is taken for an acute condition), patient. In those instances, the unlisted Health Partners Plans will allow the pharmacy medication may be requested through Prior When a new drug is considered for formulary to dispense a 5-day supply of the medication to Authorization/ Medical Exception. inclusion, an attempt will be made to examine afford the recipient or pharmacy the opportunity the drug relative to similar drugs currently on to initiate the request for prior authorization. formulary. In addition, entire therapeutic Preface classes are periodically reviewed. This review If the prescription is for an ongoing medication process may result in deletion of a drug(s) in a (one that is continuously prescribed for the The KidzPartners Formulary is organized by particular therapeutic class in an effort to treatment of an illness or condition that is sections, which refer to either a drug/ continually promote the most clinically useful chronic in nature in which there has not been a pharmacologic class or disease state. Each and cost-effective agents. break in treatment for greater than 30 Days), section contains a list of drugs selected to be Health Partners Plans will allow the pharmacy on this formulary. Prescribing a drug product Plan Limits to dispense a 15-day supply of the medication that is available generically is encouraged automatically, unless Health Partners Plans when appropriate. Unless exceptions are mailed to the member, with a copy to the noted, all applicable dosage forms and A maximum of up to a 30-day supply of prescriber, an advance written notice of the strengths of the referenced product generally medication is eligible for coverage. The reduction or termination of the medication at are covered. prescriber is urged to prescribe in amounts that least 10 days prior to the end of the period for adhere to accepted standards of care. The which the medication was previously days’ supply must be accurately determined by authorized. Pharmacy and Therapeutics the dispensing pharmacist to assure (P&T) Committee compliance with plan parameters. Health Partners Plans will respond to the Specific limits based on FDA guidelines, request for prior authorization within 24 hours The actions of the Health Partners Plans medication package inserts and accepted from when the request was received. If the P&T Committee are communicated through standards of care may apply to medication prior authorization is denied, the member is the Provider Newsletter to all physicians treatments under clinical review. entitled to appeal the decision through several and posted on our website. Pharmacy avenues. The 5-day or 15-day requirement providers in the KidzPartners network will does not apply when the pharmacist Health Partners Plans CHIP Formulary Updated 01/01/2021

determines that taking the medication, either When the above two criteria are met, a generic • Medications used for non-FDA approved alone or along with other medication that the can be substituted with the full expectation that indications recipient may be taking, would jeopardize the the substituted product will produce the same • Prescription costs that exceed $1000 health and safety of the recipient. clinical effect and safety profile as the brand per claim name product. • Prescriptions that exceed set plan limits Formulary Product (days’ supply, quantity, cost) State laws or regulation may indicate the ability Descriptions • Prescriptions processed by non-network to practice generic substitution for selected pharmacies

products or categories of drugs. • New-to-market products This formulary lists all specific strengths and dosage forms that are covered. When a • High-end oral and self-administered There are now many brand name products that injectable medications strength or dosage form is specified, only are repackaged or distributed under a generic the product identified will be covered. Other • Medications with Health Partners Plans label. These generic versions should always be P&T Committee approved treatment strengths/ dosage forms of the referenced considered therapeutically equivalent and product are not covered. guidelines substitutable for the source branded product irrespective of rating. To request a prior authorization the For specific questions please contact the physician or a member of his/her staff Health Partners Plans Pharmacy department at Drugs Efficacy Study should contact Health Partners Plans either 215-991-4300. by fax at 866-240-3712, or phone at 215-991- Implementation (DESI) Drugs 4300. All non-emergency requests can be Generic Substitution faxed 24 hours per day; calls should be Health Partners Plans does not reimburse for placed from 9:00 A.M. to 6:00 P.M., Monday DESI drugs. DESI drugs are those drugs first Generic substitution is the process by which a through Friday. marketed between 1938 and 1962 which were generic equivalent is dispensed rather than the approved as safe, but not required to show brand name product. The appropriate use of In the event of an immediate need after effectiveness for FDA product approval. The generic drugs is one method of providing cost business hours, the call should be made to DESI program subsequently made a conscious drug therapy. Health Partners Plans KidzPartners Member Relations at determination of fully effective for most of these will not cover any drugs by companies that do 1-888-888-1212. The call will be evaluated and products and they remain in the marketplace. A not participate in the Federal Rebate Program routed to a pharmacist-on-call. few DESI products remain classified as less or are DESI drugs. Generic drugs must be than fully effective while awaiting final prescribed and dispensed when an A-rated The physician may use the Health Partners administrative disposition. Also classified as generic drug is available. Brand necessary Plans Prior Authorization/Medical Exception DESI are many products listed as identical, prescriptions for drugs with A-rated generics form or a letter of request, but must include the similar, or related to actual DESI products. require prior authorization. following information for quick and appropriate

review to take place: Examples of DESI Drugs include: The MAC list sets a ceiling price for the Midrin • Name and recipient number of member reimbursement of certain multisource Vytone • Date of birth of member prescription drugs. This price will typically cover Anusol HC suppositories • Physician’s name, license number, the acquisition of most generics but not Donnatal and specialty branded versions of the same drug. The Tigan • Physician’s phone and fax numbers products selected for inclusion on the MAC list Naldecon are commonly prescribed and dispensed and • Name of primary care physician if different have usually gone through the FDA’s review and approval process. This process assures Prior Authorization (PA) • Drug name, strength, and quantity the following requirements have been met: of medication To ensure that select medications are utilized • Days supply (duration of therapy) and The generic drug will contain the same active appropriately, Prior Authorization may be number of refills ingredient(s) and be the same strength and required for the dispensing of specific products. • Route of administration dosage form as the brand name counterpart. These medications may require Prior • Diagnosis Authorization for the following reasons: • Medical rationale for request The FDA has given the generic an “A” rating • Formulary medications used, duration and compared to the branded counterpart indicating • Non-formulary medications, or benefit therapy result bioequivalence and has determined the generic exceptions required by medical necessity • Additional clinical information that may is therapeutically equivalent to the referenced • All brand name medications when there is contribute to the review decision brand. The ratings of generic drugs are an A-rated generic equivalent available (e.g., labs) available by referring to the FDA reference • Medications and/or treatments under clinical Approved Drug Products with Therapeutic investigation Upon receiving the Prior Authorization/ Medical Equivalence Evaluations (Orange Book). Exception Request from the prescriber, Health

Health Partners Plans CHIP Formulary Updated 01/01/2021

Partners Plans will render a decision within 24 sumatriptan Imitrex expertise, skill and judgment of the medical hours. The Medical Director will review each triamcinolone acetonide Kenalog-40 provider in his/her choice of prescription drugs. prior authorization request and make the final fondaparinux sodium Arixtra Health Partners Plans does not assume decision. After Medical Director review, the enoxaparin sodium Lovenox responsibility for the actions or omissions of clinical pharmacist will prepare the request for any medical provider based upon reliance, in the denial/approval letter. A denial letter will be Managed Drug Limitations whole or in part, on the information contained mailed to the member or parent/guardian. A herein. The medical provider should consult (MDL) copy of the member denial letter is also faxed the drug manufacturer product literature or to the prescribing physician. standard references for more detailed The United States Food and Drug Administration information. If the Prior Authorization/Medical Exception (FDA) publishes guidelines on the safest and Request is denied, the prescriber can submit a most efficient ways to use certain drugs. Many The information contained in this document is written appeal to Health Partners Plans’ drug products on the KidzPartners Formulary proprietary information subject to a licensing Complaint & Grievance Unit explaining the have quantity limits based upon the dosage agreement. The information may not be copied medical necessity of the medical treatment in described in product labeling. in whole or in part without the written question. At any time during normal business permission of Health Partners Plans. All rights hours, the prescribing physician can discuss Drugs subject to quantity limits may change. reserved. the denial with a clinical pharmacist or can Contact Health Partners Plans’ Pharmacy have a peer to peer discussion with the medical department at 215-991-4300 for more Trade names are the intellectual property of the director. information. respective product owners.

Health Partners Plans Step Therapy Specialty and Injectable Step therapy is a process that encourages the Medication Program use of medications preferred by Health Partners Plans as the first course of treatment. Health Partners Plans supports appropriate use If the preferred medication is not clinically of injectables and has established procedures effective or if the member suffers side effects, for prescribing and suppliers. Under the another medication may be approved as the direction of the Health Partners Plans second course of treatment. Pharmacy department, the physician provider has the primary responsibility for obtaining Editor Prior Authorization for medications included in this program. Call the Health Partners Plans Pharmacy department at 215-991-4300 for Your comments and suggestions regarding the authorization on specialty medications. KidzPartners 2021 Formulary are encouraged. Your input is vital to this formulary’s continued The following specialty and injectable success. All responses will be reviewed and medications, although not limited to, can be considered. Please send your comments to: obtained through the retail pharmacy benefit without prior authorization. Attn: Pharmacy Director Health Partners Plans GENERIC NAME BRAND NAME 901 Market Street, Suite 500 ceftriaxone Rocephin Philadelphia, PA 19107 cyanocobalamin Vitamin B-12 Phone: 215-991-4300 epinephrine Epipen, Epipen  Jr. Internet: www.healthpartnersplans.com fluphenazine decanoate Prolixin Decanoate glucagon Glucagon Notice haloperidol decanoate Haldol Decanoate heparin sodium Heparin The information contained in the KidzPartners Insulin Formulary and its appendices is provided by medroxyprogesterone Depo-Provera acetate 150 mg only Health Partners Plans solely for the methylprednisolone Depo-Medrol convenience of medical providers and our acetate members. Health Partners Plans neither methylprednisolone Solu-Medrol warrants nor assures accuracy of such sod. succ. information, nor is it intended to be penicillin g benzathine Bicillin L.A. comprehensive in nature. This formulary is not penicillin g potassium Pfizerpen intended to be a substitute for the knowledge,

LEGEND TIER DESCRIPTION

1 Preferred

2 Non-Preferred

TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.

You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug.

This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit.

C Custom This drug has unique restrictions.

There is a limit on the amount of this drug that is covered per QLC Quantity Limit (Custom) prescription, or within a specific time frame.

PAGE 4 LAST UPDATED 07/2021 LIST OF COVERED PRESCRIPTION MEDICATIONS

DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ARTHROTEC Non-Preferred diclofenac w/ misoprostol

PA butalbital-aspirin-caffeine 50-325-40 mg Preferred cap QLC Max 18 tabs/caps per month

BUTALBITAL-ASPIRIN-CAFFEINE 50- PA 325-40 MG TAB Preferred QLC Max 18 tabs/caps per butalbital-aspirin-caffeine month CAMBIA Non-Preferred diclofenac potassium (migraine) cataflam Non-Preferred CELEBREX 200 MG CAP Non-Preferred QL 2 / 1 days celecoxib CELEBREX 100 MG CAP Non-Preferred QL 2 / 1 days celecoxib CELEBREX 50 MG CAP Non-Preferred QL 2 / 1 days celecoxib CELEBREX 400 MG CAP Non-Preferred QL 1 / 1 days celecoxib

celecoxib 200 mg cap Preferred QL 2 / 1 days

celecoxib 400 mg cap Preferred QL 1 / 1 days

celecoxib 50 mg cap Preferred QL 2 / 1 days

celecoxib 100 mg cap Preferred QL 2 / 1 days

DAYPRO Non-Preferred QL 3 / 1 days oxaprozin DICLOFENAC Non-Preferred diclofenac DICLOFENAC EPOLAMINE Non-Preferred diclofenac epolamine

diclofenac potassium Non-Preferred QL 4 / 1 days

diclofenac sodium 1.5 % solution Preferred

PAGE 5 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

diclofenac sodium 75 mg tab dr Preferred QL 2 / 1 days

diclofenac sodium 50 mg tab dr Preferred QL 4 / 1 days

diclofenac sodium 25 mg tab dr Preferred QL 4 / 1 days

diclofenac sodium er Non-Preferred QL 2 / 1 days

diclofenac-misoprostol Non-Preferred

diflunisal 500 mg tab Non-Preferred QL 3 / 1 days

DUEXIS Non-Preferred ibuprofen-famotidine

ec-naproxen Non-Preferred QL 2 / 1 days

etodolac 400 mg tab Preferred QL 60 / 30 days

etodolac 300 mg cap Non-Preferred QL 3 / 1 days

etodolac 500 mg tab Non-Preferred QL 2 / 1 days

etodolac 200 mg cap Non-Preferred QL 5 / 1 days

etodolac er Non-Preferred FELDENE Non-Preferred QL 1 / 1 days piroxicam

fenoprofen calcium 600 mg tab Non-Preferred QL 5 / 1 days

fenoprofen calcium 400 mg cap Non-Preferred FLECTOR Non-Preferred diclofenac epolamine

flurbiprofen 100 mg tab Preferred QL 3 / 1 days

flurbiprofen 50 mg tab Preferred QL 3 / 1 days

ibu 600 mg tab Preferred QL 5 / 1 days

ibu 800 mg tab Preferred QL 4 / 1 days

ibu 400 mg tab Preferred QL 6 / 1 days

ibuprofen 800 mg tab Preferred QL 4 / 1 days

ibuprofen 400 mg tab Preferred QL 6 / 1 days

ibuprofen 600 mg tab Preferred QL 5 / 1 days

PAGE 6 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ibuprofen 100 mg/5ml suspension Preferred QLC 30 mL/day

INDOCIN Non-Preferred indomethacin INDOMETHACIN 20 MG CAP Non-Preferred indomethacin

indomethacin 25 mg cap Preferred QL 4 / 1 days

indomethacin 50 mg cap Preferred QL 4 / 1 days

indomethacin er Preferred QL 3 / 1 days

KETOPROFEN 50 MG CAP Non-Preferred ketoprofen KETOPROFEN 75 MG CAP Non-Preferred ketoprofen KETOPROFEN 25 MG CAP Non-Preferred ketoprofen

ketoprofen er Non-Preferred QL 1 / 1 days

KETOROLAC TROMETHAMINE 15.75 MG/SPRAY SOLUTION Non-Preferred ketorolac tromethamine

ketorolac tromethamine 10 mg tab Preferred QLC 20 tablets per 90 days

LICART Non-Preferred diclofenac epolamine

meclofenamate sodium 50 mg cap Non-Preferred QL 4 / 1 days

meclofenamate sodium 100 mg cap Non-Preferred QL 4 / 1 days

mefenamic acid 250 mg cap Non-Preferred meloxicam 5 mg cap Non-Preferred

meloxicam 15 mg tab Preferred QL 1 / 1 days

meloxicam 7.5 mg tab Preferred QL 2 / 1 days

meloxicam 10 mg cap Non-Preferred MOBIC 7.5 MG TAB Non-Preferred QL 2 / 1 days meloxicam MOBIC 15 MG TAB Non-Preferred QL 1 / 1 days meloxicam

nabumetone 750 mg tab Preferred QL 2 / 1 days

PAGE 7 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

nabumetone 500 mg tab Preferred QL 4 / 1 days

NALFON Non-Preferred fenoprofen calcium NAPRELAN Non-Preferred naproxen sodium

naproxen 500 mg tab dr Preferred QL 2 / 1 days

naproxen 375 mg tab Preferred QL 4 / 1 days

naproxen 500 mg tab Preferred QL 3 / 1 days

naproxen 125 mg/5ml suspension Preferred QL 1800 / 30 days

naproxen 250 mg tab Preferred QL 3 / 1 days

naproxen 375 mg tab dr Preferred QL 2 / 1 days

naproxen sodium 550 mg tab Preferred QL 3 / 1 days

naproxen sodium 275 mg tab Preferred QL 3 / 1 days

NAPROXEN SODIUM ER 750 MG TAB ER 24H Non-Preferred naproxen sodium naproxen sodium er 500 mg tab er 24h Non-Preferred naproxen sodium er 375 mg tab er 24h Non-Preferred naproxen-esomeprazole Non-Preferred

oxaprozin Non-Preferred QL 3 / 1 days

PENNSAID Non-Preferred diclofenac sodium (topical)

piroxicam 20 mg cap Preferred QL 1 / 1 days

piroxicam 10 mg cap Preferred QL 1 / 1 days

QMIIZ ODT Non-Preferred meloxicam relafen Non-Preferred RELAFEN DS Non-Preferred nabumetone

salsalate 500 mg tab Preferred QL 6 / 1 days

salsalate 750 mg tab Preferred QL 4 / 1 days

PAGE 8 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SPRIX Non-Preferred ketorolac tromethamine

sulindac 150 mg tab Preferred QL 2 / 1 days

sulindac 200 mg tab Preferred QL 2 / 1 days

TIVORBEX Non-Preferred indomethacin

tolmetin sodium 600 mg tab Non-Preferred QL 3 / 1 days

TOLMETIN SODIUM 200 MG TAB Non-Preferred QL 4 / 1 days tolmetin sodium

tolmetin sodium 400 mg cap Non-Preferred QL 4 / 1 days

VIMOVO Non-Preferred naproxen-esomeprazole magnesium VIVLODEX Non-Preferred meloxicam VOLTAREN Non-Preferred QL 500 / 30 days diclofenac sodium (topical) ZIPSOR Non-Preferred diclofenac potassium ZORVOLEX Non-Preferred diclofenac OPIOID ANALGESICS, LONG-ACTING

ARYMO ER 60 MG TBER DETER QL 60 / 30 days Non-Preferred morphine sulfate PA

ARYMO ER 15 MG TBER DETER QL 90 / 30 days Non-Preferred morphine sulfate PA

ARYMO ER 30 MG TBER DETER QL 60 / 30 days Non-Preferred morphine sulfate PA

BELBUCA QL 60 / 30 days Non-Preferred buprenorphine hcl PA

QL 4 / 28 days buprenorphine 10 mcg/hr patch wk Non-Preferred PA

QL 4 / 28 days buprenorphine 7.5 mcg/hr patch wk Non-Preferred PA

PAGE 9 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 4 / 28 days buprenorphine 5 mcg/hr patch wk Non-Preferred PA

QL 4 / 28 days buprenorphine 15 mcg/hr patch wk Non-Preferred PA

QL 4 / 28 days buprenorphine 20 mcg/hr patch wk Non-Preferred PA

BUTRANS QL 4 / 28 days Preferred buprenorphine PA

QL 30 / 30 days CONZIP Non-Preferred PA tramadol hcl AL1 At least 18 yrs old

DOLOPHINE Non-Preferred PA methadone hcl

DURAGESIC-100 QL 10 / 30 days Non-Preferred fentanyl PA

DURAGESIC-12 QL 10 / 30 days Non-Preferred fentanyl PA

DURAGESIC-25 Non-Preferred PA fentanyl

DURAGESIC-50 QL 10 / 30 days Non-Preferred fentanyl PA

DURAGESIC-75 QL 10 / 30 days Non-Preferred fentanyl PA

EXALGO QL 30 / 30 days Non-Preferred hydromorphone hcl PA

QL 10 / 30 days fentanyl 12 mcg/hr patch 72hr Preferred PA

QL 10 / 30 days fentanyl 100 mcg/hr patch 72hr Preferred PA

QL 10 / 30 days fentanyl 75 mcg/hr patch 72hr Preferred PA

PAGE 10 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 10 / 30 days fentanyl 50 mcg/hr patch 72hr Preferred PA

QL 10 / 30 days fentanyl 37.5 mcg/hr patch 72hr Non-Preferred PA

QL 10 / 30 days fentanyl 62.5 mcg/hr patch 72hr Non-Preferred PA

QL 10 / 30 days fentanyl 25 mcg/hr patch 72hr Preferred PA

QL 10 / 30 days fentanyl 87.5 mcg/hr patch 72hr Non-Preferred PA

hydrocodone bitartrate er Non-Preferred PA

QL 30 / 30 days hydromorphone hcl er Non-Preferred PA

HYSINGLA ER Non-Preferred PA hydrocodone bitartrate

KADIAN 50 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 80 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 10 MG CAP ER 24H QL 60 / 30 days Non-Preferred morphine sulfate PA

KADIAN 200 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 100 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 60 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 40 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 20 MG CAP ER 24H QL 60 / 30 days Non-Preferred morphine sulfate PA

PAGE 11 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

KADIAN 30 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

methadone hcl 10 mg/ml conc Non-Preferred PA

methadone hcl 10 mg tab Non-Preferred PA

methadone hcl 5 mg/5ml solution Non-Preferred PA

methadone hcl 10 mg/5ml solution Non-Preferred PA

methadone hcl 5 mg tab Non-Preferred PA

methadone hcl intensol Non-Preferred PA

METHADOSE 10 MG/ML CONC Non-Preferred PA methadone hcl METHADOSE SUGAR-FREE Non-Preferred PA methadone hcl MORPHABOND ER Non-Preferred PA morphine sulfate

QL 60 / 30 days morphine sulfate er 10 mg cap er 24h Preferred PA

QL 3 / 1 days morphine sulfate er 60 mg tab er Preferred PA

QL 30 / 30 days morphine sulfate er 100 mg cap er 24h Preferred PA

QL 30 / 30 days morphine sulfate er 40 mg cap er 24h Preferred PA

QL 30 / 30 days morphine sulfate er 30 mg cap er 24h Preferred PA

QL 30 / 30 days morphine sulfate er 80 mg cap er 24h Preferred PA

QL 3 / 1 days morphine sulfate er 200 mg tab er Preferred PA

QL 3 / 1 days morphine sulfate er 15 mg tab er Preferred PA

PAGE 12 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days morphine sulfate er 60 mg cap er 24h Preferred PA

QL 30 / 30 days morphine sulfate er 50 mg cap er 24h Preferred PA

QL 60 / 30 days morphine sulfate er 20 mg cap er 24h Preferred PA

QL 3 / 1 days morphine sulfate er 100 mg tab er Preferred PA

QL 3 / 1 days morphine sulfate er 30 mg tab er Preferred PA

MORPHINE SULFATE ER BEADS QL 30 / 30 days Non-Preferred morphine sulfate beads PA

MS CONTIN QL 3 / 1 days Non-Preferred morphine sulfate PA

NUCYNTA ER QL 60 / 30 days Non-Preferred tapentadol hcl PA

OPANA ER Non-Preferred PA oxymorphone hcl

QL 2 / 1 days oxycodone hcl er Non-Preferred PA

OXYCODONE HCL ER 20 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

OXYCODONE HCL ER 40 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

OXYCODONE HCL ER 10 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

OXYCONTIN QL 2 / 1 days Non-Preferred oxycodone hcl PA

oxymorphone hcl er Non-Preferred PA

PAGE 13 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days

tramadol hcl er 300 mg tab er 24h Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl er 200 mg cap er 24h Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl er 100 mg cap er 24h Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl er 300 mg cap er 24h Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl er 100 mg tab er 24h Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl er (biphasic) Non-Preferred PA

AL1 At least 18 yrs old

XTAMPZA ER QL 60 / 30 days Preferred oxycodone PA

ZOHYDRO ER Non-Preferred PA hydrocodone bitartrate OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL Non-Preferred C Opioid safety limits fentanyl citrate apply

AL1 At least 18 yrs old acetaminophen-codeine 120-12 mg/5ml Preferred solution C Opioid safety limits apply

QL 6 / 1 days

acetaminophen-codeine 300-60 mg tab Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

PAGE 14 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 13 / 1 days

acetaminophen-codeine 300-15 mg tab Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

QL 13 / 1 days

acetaminophen-codeine #2 Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

QL 12 / 1 days

acetaminophen-codeine #3 Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

QL 6 / 1 days

acetaminophen-codeine #4 Preferred AL1 At least 18 yrs old

C Opioid safety limits apply ACTIQ 400 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 800 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 200 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 1600 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 600 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 1200 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply APADAZ Non-Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply APAP-CAFF-DIHYDROCODEINE Non-Preferred C Opioid safety limits acetaminophen-caff-dihydrocod apply

AL1 At least 18 yrs old

C Opioid safety limits ascomp-codeine Non-Preferred apply

QLC Max 18 tabs/caps per month BENZHYDROCODONE- ACETAMINOPHEN Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply

PAGE 15 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old

C Opioid safety limits butalbital-apap-caff-cod Non-Preferred apply

QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old

C Opioid safety limits butalbital-asa-caff-codeine Non-Preferred apply

QLC Max 18 tabs/caps per month

butorphanol tartrate 10 mg/ml solution Non-Preferred C Opioid safety limits apply

QL 3 / 1 days CARISOPRODOL-ASPIRIN-CODEINE Non-Preferred AL1 At least 18 yrs old carisoprodol w/ aspirin & codeine C Opioid safety limits apply

QL 3 / 1 days

carisoprodol-aspirin-codeine Non-Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

codeine sulfate 30 mg tab Non-Preferred C Opioid safety limits apply

codeine sulfate 60 mg tab Non-Preferred C Opioid safety limits apply CODEINE SULFATE Non-Preferred C Opioid safety limits codeine sulfate apply DEMEROL 100 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply DILAUDID 1 MG/ML LIQUID Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 2 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 8 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 4 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DSUVIA Non-Preferred C Opioid safety limits sufentanil citrate apply

dvorah Non-Preferred C Opioid safety limits apply

PAGE 16 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 12 / 1 days endocet 7.5-325 mg tab Preferred C Opioid safety limits apply

QL 12 / 1 days endocet 5-325 mg tab Preferred C Opioid safety limits apply

endocet 10-325 mg tab Preferred C Opioid safety limits apply FENTANYL CITRATE 600 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

fentanyl citrate 400 mcg loz handle Non-Preferred C Opioid safety limits apply

fentanyl citrate 1200 mcg loz handle Non-Preferred C Opioid safety limits apply FENTANYL CITRATE 200 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 400 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 800 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 100 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

fentanyl citrate 200 mcg loz handle Non-Preferred C Opioid safety limits apply

fentanyl citrate 600 mcg loz handle Non-Preferred C Opioid safety limits apply

fentanyl citrate 1600 mcg loz handle Non-Preferred C Opioid safety limits apply

fentanyl citrate 800 mcg loz handle Non-Preferred C Opioid safety limits apply FENTORA 600 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 200 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 100 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 800 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 400 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

PAGE 17 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

C Opioid safety limits FIORINAL Non-Preferred apply butalbital-aspirin-caffeine QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old FIORINAL/CODEINE #3 Opioid safety limits Non-Preferred C butalbital-aspirin-caffeine w/cod apply QLC Max 18 tabs/caps per month hydrocodone-acetaminophen 10-325 Non-Preferred C Opioid safety limits mg/15ml solution apply

QL 6 / 1 days hydrocodone-acetaminophen 10-325 mg Preferred tab C Opioid safety limits apply

QL 8 / 1 days hydrocodone-acetaminophen 7.5-325 Preferred mg tab C Opioid safety limits apply hydrocodone-acetaminophen 10-300 mg Preferred C Opioid safety limits tab apply hydrocodone-acetaminophen 7.5-300 Preferred C Opioid safety limits mg tab apply hydrocodone-acetaminophen 5-217 Non-Preferred C Opioid safety limits mg/10ml solution apply hydrocodone-acetaminophen 2.5-325 Preferred C Opioid safety limits mg tab apply hydrocodone-acetaminophen 2.5-108 Non-Preferred C Opioid safety limits mg/5ml solution apply

QL 12 / 1 days hydrocodone-acetaminophen 5-325 mg Preferred tab C Opioid safety limits apply hydrocodone-acetaminophen 5-300 mg Preferred C Opioid safety limits tab apply hydrocodone-acetaminophen 7.5-325 Non-Preferred C Opioid safety limits mg/15ml solution apply

hydrocodone-ibuprofen 10-200 mg tab Non-Preferred C Opioid safety limits apply HYDROCODONE-IBUPROFEN 5-200 MG TAB Non-Preferred C Opioid safety limits hydrocodone-ibuprofen apply

QL 5 / 1 days hydrocodone-ibuprofen 7.5-200 mg tab Non-Preferred C Opioid safety limits apply

PAGE 18 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

hydrocodone-ibuprofen 5-200 mg tab Non-Preferred C Opioid safety limits apply

hydromorphone hcl 4 mg tab Non-Preferred C Opioid safety limits apply HYDROMORPHONE HCL 3 MG SUPPOS Non-Preferred C Opioid safety limits hydromorphone hcl apply

hydromorphone hcl 8 mg tab Non-Preferred C Opioid safety limits apply

hydromorphone hcl 1 mg/ml liquid Non-Preferred C Opioid safety limits apply

hydromorphone hcl 2 mg tab Non-Preferred C Opioid safety limits apply IBUDONE 10-200 MG TAB Non-Preferred C Opioid safety limits hydrocodone-ibuprofen apply

ibudone 5-200 mg tab Non-Preferred C Opioid safety limits apply LAZANDA 100 MCG/ACT SOLUTION Non-Preferred C Opioid safety limits fentanyl citrate apply LAZANDA 400 MCG/ACT SOLUTION Non-Preferred C Opioid safety limits fentanyl citrate apply

levorphanol tartrate 3 mg tab Non-Preferred C Opioid safety limits apply

levorphanol tartrate 2 mg tab Non-Preferred C Opioid safety limits apply

lorcet Non-Preferred C Opioid safety limits apply

QL 6 / 1 days lorcet hd Preferred C Opioid safety limits apply

lorcet plus Non-Preferred C Opioid safety limits apply LORTAB Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply MEPERIDINE HCL 50 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply

meperidine hcl 100 mg tab Non-Preferred C Opioid safety limits apply

meperidine hcl 50 mg tab Non-Preferred C Opioid safety limits apply

PAGE 19 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEPERIDINE HCL 50 MG/5ML SOLUTION Non-Preferred C Opioid safety limits meperidine hcl apply MEPERIDINE HCL 100 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply

morphine sulfate 10 mg/5ml solution Preferred C Opioid safety limits apply MORPHINE SULFATE 5 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply MORPHINE SULFATE 10 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply

morphine sulfate 15 mg tab Preferred C Opioid safety limits apply MORPHINE SULFATE 20 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply MORPHINE SULFATE 30 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply

morphine sulfate 30 mg tab Preferred C Opioid safety limits apply

morphine sulfate 20 mg/5ml solution Preferred C Opioid safety limits apply

morphine sulfate (concentrate) Preferred C Opioid safety limits apply NALOCET Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

QL 6 / 1 days NORCO 10-325 MG TAB Non-Preferred hydrocodone-acetaminophen C Opioid safety limits apply NORCO 5-325 MG TAB Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply NORCO 7.5-325 MG TAB Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply NUCYNTA Non-Preferred C Opioid safety limits tapentadol hcl apply OPANA 5 MG TAB Non-Preferred C Opioid safety limits oxymorphone hcl apply OPANA 10 MG TAB Non-Preferred C Opioid safety limits oxymorphone hcl apply OXAYDO Non-Preferred C Opioid safety limits oxycodone hcl apply

PAGE 20 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

oxycodone hcl 5 mg tab Preferred C Opioid safety limits apply

oxycodone hcl 20 mg tab Preferred C Opioid safety limits apply

oxycodone hcl 100 mg/5ml conc Non-Preferred C Opioid safety limits apply

oxycodone hcl 5 mg cap Non-Preferred C Opioid safety limits apply

oxycodone hcl 10 mg tab Preferred C Opioid safety limits apply

oxycodone hcl 30 mg tab Preferred C Opioid safety limits apply

oxycodone hcl 5 mg/5ml solution Preferred C Opioid safety limits apply

oxycodone hcl 15 mg tab Preferred C Opioid safety limits apply

QL 12 / 1 days oxycodone-acetaminophen 2.5-325 mg Preferred tab C Opioid safety limits apply OXYCODONE-ACETAMINOPHEN 2.5- 300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply oxycodone-acetaminophen 10-325 mg Preferred C Opioid safety limits tab apply

QL 12 / 1 days oxycodone-acetaminophen 7.5-325 mg Preferred tab C Opioid safety limits apply

QL 12 / 1 days oxycodone-acetaminophen 5-325 mg Preferred tab C Opioid safety limits apply

oxycodone-aspirin Non-Preferred C Opioid safety limits apply

oxycodone-ibuprofen Non-Preferred C Opioid safety limits apply

oxymorphone hcl Non-Preferred C Opioid safety limits apply

QL 12 / 1 days pentazocine-naloxone hcl Non-Preferred C Opioid safety limits apply

QL 12 / 1 days PERCOCET 2.5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply

PAGE 21 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 12 / 1 days PERCOCET 7.5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply

QL 12 / 1 days PERCOCET 5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply PERCOCET 10-325 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PRIMLEV Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 7.5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 10-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 10-300 MG/5ML SOLUTION Non-Preferred oxycodone w/ acetaminophen

AL1 At least 18 yrs old QDOLO Non-Preferred tramadol hcl C Opioid safety limits apply ROXICODONE Non-Preferred C Opioid safety limits oxycodone hcl apply SUBSYS Non-Preferred C Opioid safety limits fentanyl apply

AL1 At least 18 yrs old tramadol hcl 50 mg tab Preferred C Opioid safety limits apply

AL1 At least 18 yrs old tramadol hcl 100 mg tab Preferred C Opioid safety limits apply

QL 240 / 30 days

tramadol-acetaminophen Preferred AL1 At least 18 yrs old

C Opioid safety limits apply

QL 12 / 1 days TYLENOL WITH CODEINE #3 Non-Preferred AL1 At least 18 yrs old acetaminophen w/ codeine C Opioid safety limits apply

PAGE 22 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days TYLENOL WITH CODEINE #4 Non-Preferred AL1 At least 18 yrs old acetaminophen w/ codeine C Opioid safety limits apply

QL 240 / 30 days ULTRACET Non-Preferred AL1 At least 18 yrs old tramadol-acetaminophen C Opioid safety limits apply

AL1 At least 18 yrs old ULTRAM Non-Preferred tramadol hcl C Opioid safety limits apply

vicodin hp Non-Preferred C Opioid safety limits apply ANESTHETICS

LOCAL ANESTHETICS

agoneaze Non-Preferred anodyne lpt Non-Preferred APRIZIO PAK Non-Preferred lidocaine-prilocaine-transparent dressing APRIZIO PAK II Non-Preferred lidocaine-prilocaine-transparent dressing dermacinrx empricaine Non-Preferred dermacinrx prizopak Non-Preferred DERMALID Non-Preferred lidocaine-latex adhesive wrap EMPRICAINE-II Non-Preferred lidocaine-prilocaine-transparent dressing GEN7T PLUS 3.5-7 % PATCH Non-Preferred lidocaine-menthol

glydo Preferred AL1 At least 3 yrs old

leva set/occlusive dressing Non-Preferred lido-k Non-Preferred lido-prilo caine pack Non-Preferred

lidocaine 5 % ointment Preferred QL 35.4 / 30 days

lidocaine 5 % patch Preferred QL 30 / 30 days

PAGE 23 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lidocaine hcl 1 % solution Preferred lidocaine hcl 3 % cream Preferred lidocaine hcl 4 % solution Preferred LIDOCAINE HCL 4 % SOLUTION Preferred lidocaine hcl (mouth-throat) lidocaine hcl 3.88 % cream Preferred lidocaine hcl (pf) 1 % solution Preferred

lidocaine hcl urethral/mucosal Preferred AL1 At least 3 yrs old

lidocaine pak Preferred QL 35.4 / 30 days

lidocaine viscous hcl Preferred AL1 At least 3 yrs old

lidocaine-prilocaine 2.5-2.5 % cream Preferred QL 150 / 30 days

lidocaine-prilocaine 2.5-2.5 % kit Non-Preferred QL 150 / 30 days

LIDOCAINE-TETRACAINE 7-7 % CREAM Non-Preferred lidocaine-tetracaine LIDODERM Non-Preferred QL 1 / 1 days lidocaine lidopril Non-Preferred lidopril xr Non-Preferred LIDOTRAL Non-Preferred lidocaine hcl lidozion Non-Preferred liprozonepak Non-Preferred livixil pak Non-Preferred medolor pak Non-Preferred midazolam hcl 2 mg/ml syrup Non-Preferred PLIAGLIS 7-7 % CREAM Non-Preferred lidocaine-tetracaine prikaan Non-Preferred prikaan lite Non-Preferred PRILO PATCH II Non-Preferred lidocaine-prilocaine prilolid Non-Preferred

PAGE 24 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS prilovix Non-Preferred prilovix lite Non-Preferred prilovix lite plus Non-Preferred prilovix plus Non-Preferred PRILOVIXIL Non-Preferred lidocaine-prilocaine-transparent dressing PRIZOPAK II Non-Preferred lidocaine-prilocaine-transparent dressing QUTENZA Non-Preferred capsaicin & cleansing gel QUTENZA (2 PATCH) Non-Preferred capsaicin & cleansing gel QUTENZA (4 PATCH) Non-Preferred capsaicin & cleansing gel relador pak Non-Preferred relador pak plus Non-Preferred SKYADERM-LP Non-Preferred lidocaine-prilocaine-transparent dressing SYNERA Non-Preferred lidocaine-tetracaine zionodil Non-Preferred zionodil 100 Non-Preferred ZTLIDO Non-Preferred lidocaine ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium Preferred QL 6 / 1 days

disulfiram 250 mg tab Preferred QL 1 / 1 days

disulfiram 500 mg tab Preferred QL 1 / 1 days

naltrexone hcl 50 mg tab Preferred VIVITROL Preferred QL 1 / 28 days naltrexone

PAGE 25 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPIOID DEPENDENCE TREATMENTS

BUNAVAIL Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

PA buprenorphine hcl 8 mg sl tab Preferred Maximum 24 mg/day C (total buprenorphine equivalents)

PA buprenorphine hcl 2 mg sl tab Preferred Maximum 24 mg/day C (total buprenorphine equivalents) Maximum 24 mg/day buprenorphine hcl-naloxone hcl Preferred C (total buprenorphine equivalents) LUCEMYRA Non-Preferred QL 16 / 1 days lofexidine hcl PROBUPHINE IMPLANT KIT Non-Preferred buprenorphine hcl SUBLOCADE 100 MG/0.5ML SOLN PRSYR Preferred QLC 0.02 mL/day buprenorphine SUBLOCADE 300 MG/1.5ML SOLN PRSYR Preferred QLC 0.06 mL/day buprenorphine

SUBOXONE Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents) OPIOID REVERSAL AGENTS

LIFEMS NALOXONE Preferred naloxone hcl naloxone hcl 2 mg/2ml soln prsyr Preferred naloxone hcl 0.4 mg/ml soln cart Preferred naloxone hcl 4 mg/10ml solution Preferred naloxone hcl 0.4 mg/ml solution Preferred NALOXONE HCL 2 MG/0.4ML SOLN A- INJ Preferred naloxone hcl

PAGE 26 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NARCAN Preferred naloxone hcl SMOKING CESSATION AGENTS

bupropion hcl er (smoking det) Preferred QL 60 / 30 days

QL 2 / 1 days CHANTIX Preferred varenicline tartrate C Max of 180 days per 365 days

QL 2 / 1 days CHANTIX CONTINUING MONTH PAK Preferred varenicline tartrate C Max of 180 days per 365 days

QL 2 / 1 days CHANTIX STARTING MONTH PAK Preferred varenicline tartrate C Max 1 fill every 180 days NICOTROL Non-Preferred QL 168 / 30 days nicotine NICOTROL NS Non-Preferred QL 60 / 30 days nicotine ZYBAN Non-Preferred QL 60 / 30 days bupropion hcl (smoking deterrent) ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE Non-Preferred QLC 8.4 mL/day amikacin sulfate liposome

gentak Preferred QL 7 / 18 days

gentamicin sulfate 0.1 % cream Preferred gentamicin sulfate 0.1 % ointment Preferred

gentamicin sulfate 0.3 % solution Preferred QL 15 / 18 days

HUMATIN Non-Preferred paromomycin sulfate

neomycin sulfate 500 mg tab Preferred QL 8 / 1 days

paromomycin sulfate 250 mg cap Non-Preferred QL 16 / 1 days

tobramycin 0.3 % solution Preferred QL 5 / 18 days

TOBREX 0.3 % SOLUTION Non-Preferred tobramycin (ophth)

PAGE 27 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TOBREX 0.3 % OINTMENT Non-Preferred QL 3.5 / 18 days tobramycin (ophth) ANTIBACTERIALS, OTHER

BACITRACIN OPHTH OINT 500 Non-Preferred QLC 7 grams per fill UNIT/GM BENZAMYCIN Non-Preferred benzoyl peroxide-erythromycin benzoyl peroxide-erythromycin Preferred CENTANY Non-Preferred mupirocin CENTANY AT Non-Preferred mupirocin CLEOCIN 100 MG SUPPOS Preferred clindamycin phosphate vaginal CLEOCIN 2 % CREAM Non-Preferred clindamycin phosphate vaginal CLEOCIN-T 1 % SWAB Non-Preferred clindamycin phosphate (topical) CLEOCIN-T 1 % LOTION Non-Preferred clindamycin phosphate (topical) CLEOCIN-T 1 % GEL Non-Preferred QL 120 / 30 days clindamycin phosphate (topical) CLINDACIN ETZ 1 % KIT Non-Preferred clindamycin phosphate & cleanser clindacin etz 1 % swab Non-Preferred CLINDACIN PAC Non-Preferred clindamycin phosphate & cleanser clindacin-p Non-Preferred CLINDAGEL Non-Preferred QL 120 / 30 days clindamycin phosphate (topical) clindamycin hcl 75 mg cap Preferred

clindamycin hcl 150 mg cap Preferred QL 12 / 1 days

clindamycin hcl 300 mg cap Preferred QL 6 / 1 days

clindamycin palmitate hcl Preferred QL 120 / 1 days

clindamycin phosphate 1 % solution Preferred QL 120 / 30 days

PAGE 28 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clindamycin phosphate 2 % cream Preferred clindamycin phosphate 1 % swab Preferred

clindamycin phosphate 1 % gel Preferred QL 120 / 30 days

clindamycin phosphate 1 % lotion Preferred CLINDESSE Preferred clindamycin phosphate (one dose) FIRVANQ Preferred vancomycin hcl FLAGYL Non-Preferred metronidazole fosfomycin tromethamine Non-Preferred FURADANTIN Non-Preferred QL 90 / 1 days nitrofurantoin HIPREX Non-Preferred methenamine hippurate HYOPHEN methenamine-hyosc-methylene blue- Non-Preferred benzoic acid-phenyl sal MACROBID Non-Preferred QL 2 / 1 days nitrofurantoin monohyd macro MACRODANTIN 50 MG CAP Non-Preferred nitrofurantoin macrocrystal MACRODANTIN 100 MG CAP Non-Preferred nitrofurantoin macrocrystal MACRODANTIN 25 MG CAP Non-Preferred QL 2 / 1 days nitrofurantoin macrocrystal me/naphos/mb/hyo1 Non-Preferred methenamine hippurate Preferred methenamine mandelate 0.5 gm tab Non-Preferred methenamine mandelate 1 gm tab Non-Preferred METROGEL-VAGINAL Non-Preferred metronidazole vaginal

metronidazole 500 mg tab Preferred QL 4 / 1 days

metronidazole 250 mg tab Preferred QL 120 / 30 days

metronidazole 0.75 % gel Preferred QL 45 / 26 days

PAGE 29 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metronidazole 375 mg cap Non-Preferred MONUROL Non-Preferred fosfomycin tromethamine mupirocin 2 % ointment Preferred mupirocin calcium Non-Preferred

nitrofurantoin Preferred QL 90 / 1 days

nitrofurantoin macrocrystal 25 mg cap Preferred QL 2 / 1 days

nitrofurantoin macrocrystal 100 mg cap Preferred QL 4 / 1 days

nitrofurantoin macrocrystal 50 mg cap Preferred QL 4 / 1 days

nitrofurantoin monohyd macro Preferred QL 2 / 1 days

NUVESSA Non-Preferred metronidazole vaginal phosphasal Non-Preferred SOLOSEC Non-Preferred secnidazole TINDAMAX Non-Preferred tinidazole

tinidazole 250 mg tab Non-Preferred QL 4 / 1 days

tinidazole 500 mg tab Non-Preferred QL 4 / 1 days

urelle Non-Preferred uretron d/s Non-Preferred URIMAR-T methenamine-hyosc-methylene blue-sod Non-Preferred phos-phenyl sal urin ds Non-Preferred uro-458 Non-Preferred UROGESIC-BLUE methenamine-hyoscamine-methylene Non-Preferred blue-sodium phosphate uryl Non-Preferred USTELL methenamine-hyosc-methylene blue-sod Non-Preferred phos-phenyl sal utira-c Non-Preferred

PAGE 30 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VANCOCIN Non-Preferred vancomycin hcl VANCOCIN HCL Non-Preferred vancomycin hcl VANCOMYCIN HCL 250 MG/5ML RECON SOLN Non-Preferred vancomycin hcl

vancomycin hcl 125 mg cap Preferred QL 4 / 1 days

vancomycin hcl 250 mg cap Preferred QL 8 / 1 days

vandazole Non-Preferred QL 70 / days

vilevev mb Non-Preferred XIFAXAN Non-Preferred rifaximin ZINPLAVA Non-Preferred bezlotoxumab BETA-LACTAM, CEPHALOSPORINS

CEFACLOR 250 MG CAP Non-Preferred QL 4 / 1 days cefaclor

cefaclor 500 mg cap Non-Preferred QL 4 / 1 days

cefaclor 250 mg cap Non-Preferred QL 4 / 1 days

CEFACLOR 250 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR 500 MG CAP Non-Preferred QL 4 / 1 days cefaclor CEFACLOR 375 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR 125 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR ER Non-Preferred QL 2 / 1 days cefaclor monohydrate

cefadroxil 1 gm tab Non-Preferred QL 2 / 1 days

CEFADROXIL 1 GM TAB Non-Preferred QL 2 / 1 days cefadroxil

PAGE 31 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

cefadroxil 250 mg/5ml recon susp Preferred QLC 10 mL/day

cefadroxil 500 mg cap Preferred QL 8 / 1 days

cefadroxil 500 mg/5ml recon susp Preferred QLC 20 mL/day

cefdinir 250 mg/5ml recon susp Preferred QL 12 / 1 days

cefdinir 300 mg cap Preferred QL 2 / 1 days

cefdinir 125 mg/5ml recon susp Preferred QL 12 / 1 days

cefixime Non-Preferred

cefpodoxime proxetil 100 mg tab Preferred QL 3 / 1 days

cefpodoxime proxetil 50 mg/5ml recon Non-Preferred QL 40 / 1 days susp

cefpodoxime proxetil 200 mg tab Preferred QL 4 / 1 days

cefpodoxime proxetil 100 mg/5ml recon Non-Preferred QL 40 / 1 days susp

cefprozil 500 mg tab Preferred QL 1 / 1 days

cefprozil 250 mg tab Preferred QL 1 / 1 days

cefprozil 250 mg/5ml recon susp Preferred QL 10 / 1 days

cefprozil 125 mg/5ml recon susp Preferred QL 10 / 1 days

CEFTIN Preferred cefuroxime axetil

ceftriaxone sodium 500 mg recon soln Preferred QL 2 / 1 days

ceftriaxone sodium 10 gm recon soln Preferred QL 1 / 1 days

ceftriaxone sodium 1 gm recon soln Preferred QL 2 / 1 days

ceftriaxone sodium 2 gm recon soln Preferred QL 2 / 1 days

ceftriaxone sodium 250 mg recon soln Preferred QL 2 / 1 days

cefuroxime axetil Preferred QL 2 / 1 days

CEPHALEXIN 250 MG TAB Non-Preferred cephalexin

cephalexin 125 mg/5ml recon susp Preferred QL 80 / 1 days

cephalexin 750 mg cap Non-Preferred

PAGE 32 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

cephalexin 250 mg cap Preferred QL 8 / 1 days

cephalexin 500 mg cap Preferred QL 8 / 1 days

CEPHALEXIN 500 MG TAB Non-Preferred cephalexin

cephalexin 250 mg/5ml recon susp Preferred QL 80 / 1 days

KEFLEX Non-Preferred cephalexin SUPRAX Non-Preferred cefixime BETA-LACTAM, PENICILLINS

amoxicillin 200 mg/5ml recon susp Preferred QL 25 / 1 days

amoxicillin 500 mg cap Preferred QL 4 / 1 days

amoxicillin 250 mg chew tab Preferred QL 4 / 1 days

amoxicillin 500 mg tab Preferred QL 8 / 1 days

amoxicillin 400 mg/5ml recon susp Preferred QL 25 / 1 days

amoxicillin 875 mg tab Preferred QL 4 / 1 days

amoxicillin 125 mg/5ml recon susp Preferred QL 25 / 1 days

amoxicillin 125 mg chew tab Preferred QL 4 / 1 days

amoxicillin 250 mg cap Preferred QL 4 / 1 days

amoxicillin 250 mg/5ml recon susp Preferred QL 25 / 1 days

amoxicillin-pot clavulanate 200-28.5 mg Non-Preferred QL 2 / 1 days chew tab amoxicillin-pot clavulanate 875-125 mg Preferred QL 2 / 1 days tab amoxicillin-pot clavulanate 250-125 mg Preferred QL 3 / 1 days tab amoxicillin-pot clavulanate 500-125 mg Preferred QL 3 / 1 days tab amoxicillin-pot clavulanate 200-28.5 Preferred QL 25 / 1 days mg/5ml recon susp amoxicillin-pot clavulanate 400-57 mg Non-Preferred QL 2 / 1 days chew tab

PAGE 33 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amoxicillin-pot clavulanate 600-42.9 Preferred QL 30 / 1 days mg/5ml recon susp amoxicillin-pot clavulanate 400-57 Preferred QL 25 / 1 days mg/5ml recon susp amoxicillin-pot clavulanate 250-62.5 Preferred QL 750 / 30 days mg/5ml recon susp amoxicillin-pot clavulanate er Non-Preferred ampicillin Preferred AUGMENTIN 250-62.5 MG/5ML RECON SUSP Non-Preferred amoxicillin & pot clavulanate AUGMENTIN 125-31.25 MG/5ML RECON SUSP Non-Preferred amoxicillin & pot clavulanate AUGMENTIN XR Non-Preferred amoxicillin & pot clavulanate BICILLIN L-A 1200000 UNIT/2ML SUSPENSION Preferred QL 4 / 365 days penicillin g benzathine BICILLIN L-A 600000 UNIT/ML SUSPENSION Preferred penicillin g benzathine BICILLIN L-A 2400000 UNIT/4ML SUSPENSION Preferred QL 12 / 365 days penicillin g benzathine

dicloxacillin sodium Preferred QL 8 / 1 days

MOXATAG Non-Preferred amoxicillin penicillin g potassium Preferred penicillin g sodium Preferred penicillin v potassium 125 mg/5ml recon Preferred QL 40 / 1 days soln

penicillin v potassium 500 mg tab Preferred QL 4 / 1 days

penicillin v potassium 250 mg/5ml recon Preferred QL 40 / 1 days soln

penicillin v potassium 250 mg tab Preferred QL 4 / 1 days

pfizerpen Preferred

PAGE 34 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MACROLIDES

AZASITE Non-Preferred azithromycin (ophth)

azithromycin 100 mg/5ml recon susp Preferred QL 25 / 1 days

azithromycin 600 mg tab Preferred QL 2 / 1 days

azithromycin 500 mg tab Preferred QL 10 / 23 days

azithromycin 200 mg/5ml recon susp Preferred QL 25 / 1 days

azithromycin 1 gm packet Preferred QL 3 / 1 days

QL 4 / 1 days azithromycin 250 mg tab Preferred C Max 5 day supply per fill

clarithromycin 250 mg/5ml recon susp Preferred QL 20 / 1 days

clarithromycin 250 mg tab Preferred QL 2 / 1 days

clarithromycin 125 mg/5ml recon susp Preferred QL 20 / 1 days

clarithromycin 500 mg tab Preferred QL 3 / 1 days

clarithromycin er Non-Preferred QL 2 / 1 days

DIFICID Non-Preferred fidaxomicin e.e.s. 400 Non-Preferred E.E.S. GRANULES Preferred erythromycin ethylsuccinate ery Preferred ery-tab Non-Preferred ERYGEL Non-Preferred erythromycin (acne aid) ERYPED 200 Preferred erythromycin ethylsuccinate ERYPED 400 Preferred erythromycin ethylsuccinate ERYTHROCIN STEARATE Non-Preferred erythromycin stearate erythromycin 500 mg tab dr Non-Preferred

PAGE 35 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS erythromycin 2 % pad Preferred erythromycin 250 mg tab dr Non-Preferred erythromycin 2 % solution Preferred erythromycin 333 mg tab dr Non-Preferred erythromycin 2 % gel Non-Preferred

erythromycin 5 mg/gm ointment Preferred QL 7 / 18 days

erythromycin base 500 mg tab dr Non-Preferred erythromycin base 250 mg tab dr Non-Preferred

erythromycin base 250 mg cp dr part Non-Preferred QL 8 / 1 days

erythromycin base 333 mg tab dr Non-Preferred

erythromycin base 500 mg tab Non-Preferred QL 8 / 1 days

erythromycin base 250 mg tab Non-Preferred QL 8 / 1 days

erythromycin ethylsuccinate 400 mg/5ml Non-Preferred recon susp

erythromycin ethylsuccinate 400 mg tab Non-Preferred QL 10 / 1 days

erythromycin ethylsuccinate 200 mg/5ml Non-Preferred recon susp ZITHROMAX 200 MG/5ML RECON SUSP Non-Preferred azithromycin ZITHROMAX 250 MG TAB Non-Preferred C Max 5 day supply per azithromycin fill ZITHROMAX 500 MG TAB Non-Preferred azithromycin ZITHROMAX 100 MG/5ML RECON SUSP Non-Preferred azithromycin ZITHROMAX 1 GM PACKET Non-Preferred azithromycin ZITHROMAX TRI-PAK Non-Preferred azithromycin ZITHROMAX Z-PAK Non-Preferred C Max 5 day supply per azithromycin fill

PAGE 36 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QUINOLONES

AVELOX 400 MG TAB Non-Preferred QL 14 / 30 days moxifloxacin hcl BAXDELA 450 MG TAB Non-Preferred delafloxacin meglumine BESIVANCE Non-Preferred besifloxacin hcl CILOXAN Non-Preferred ciprofloxacin hcl (ophth) CIPRO 250 MG TAB Non-Preferred QL 2 / 1 days ciprofloxacin hcl CIPRO 250 MG/5ML (5%) RECON SUSP Preferred QL 15 / 1 days ciprofloxacin CIPRO 500 MG/5ML (10%) RECON SUSP Preferred QL 15 / 1 days ciprofloxacin CIPRO 500 MG TAB Non-Preferred QL 2 / 1 days ciprofloxacin hcl ciprofloxacin 500 mg/5ml (10%) recon Non-Preferred QL 15 / 1 days susp ciprofloxacin 250 mg/5ml (5%) recon Non-Preferred QL 15 / 1 days susp

ciprofloxacin hcl 100 mg tab Preferred QL 2 / 1 days

ciprofloxacin hcl 500 mg tab Preferred QL 2 / 1 days

ciprofloxacin hcl 0.3 % solution Preferred QL 5 / 18 days

ciprofloxacin hcl 750 mg tab Preferred QL 2 / 1 days

ciprofloxacin hcl 0.2 % solution Non-Preferred

ciprofloxacin hcl 250 mg tab Preferred QL 2 / 1 days

CIPROFLOXACIN-CIPROFLOX HCL ER 500 MG TAB ER 24H Non-Preferred ciprofloxacin-ciprofloxacin hcl gatifloxacin 0.5 % solution Preferred LEVAQUIN 500 MG TAB Non-Preferred QL 1 / 1 days levofloxacin LEVAQUIN 750 MG TAB Non-Preferred QL 1 / 1 days levofloxacin

PAGE 37 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

levofloxacin 25 mg/ml solution Non-Preferred QL 30 / 1 days

levofloxacin 500 mg tab Preferred QL 1 / 1 days

levofloxacin 750 mg tab Preferred QL 1 / 1 days

levofloxacin 0.5 % solution Non-Preferred

levofloxacin 250 mg tab Preferred QL 1 / 1 days

MOXEZA Non-Preferred moxifloxacin hcl (ophth) moxifloxacin hcl 0.5 % solution Non-Preferred

moxifloxacin hcl 400 mg tab Non-Preferred QL 14 / 30 days

moxifloxacin hcl (2x day) Non-Preferred OCUFLOX Non-Preferred ofloxacin (ophth)

ofloxacin 300 mg tab Non-Preferred QL 28 / 26 days

ofloxacin 400 mg tab Non-Preferred QL 28 / 26 days

ofloxacin 0.3 % solution Preferred QL 10 / 7 days

OTIPRIO Non-Preferred ciprofloxacin (otic) VIGAMOX Non-Preferred moxifloxacin hcl (ophth) ZYMAXID Non-Preferred gatifloxacin (ophth) SULFONAMIDES

AVC VAGINAL Non-Preferred sulfanilamide vaginal BLEPH-10 Non-Preferred QL 15 / 18 days sulfacetamide sodium (ophth) KLARON Non-Preferred sulfacetamide sodium (acne) silver sulfadiazine 1 % cream Preferred ssd Preferred

sulfacetamide sodium 10 % solution Preferred QL 15 / 18 days

sulfacetamide sodium 10 % ointment Non-Preferred

PAGE 38 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sulfacetamide sodium (acne) Preferred SULFADIAZINE 500 MG TAB Preferred QL 8 / 1 days sulfadiazine sulfamethoxazole-trimethoprim 200-40 Preferred mg/5ml suspension sulfamethoxazole-trimethoprim 400-80 Preferred mg tab sulfamethoxazole-trimethoprim 800-160 Preferred mg tab sulfatrim pediatric Preferred TETRACYCLINES

AMZEEQ Non-Preferred minocycline hcl micronized (acne) demeclocycline hcl Non-Preferred DORYX Non-Preferred doxycycline hyclate DORYX MPC Non-Preferred doxycycline hyclate DOXYCYCLINE Non-Preferred doxycycline (rosacea) doxycycline hyclate 200 mg tab dr Non-Preferred doxycycline hyclate 75 mg tab dr Non-Preferred

doxycycline hyclate 100 mg tab Preferred QL 60 / 30 days

doxycycline hyclate 150 mg tab Non-Preferred doxycycline hyclate 75 mg tab Non-Preferred doxycycline hyclate 50 mg tab dr Non-Preferred

doxycycline hyclate 100 mg cap Preferred QL 60 / 30 days

doxycycline hyclate 150 mg tab dr Non-Preferred doxycycline hyclate 20 mg tab Preferred DOXYCYCLINE HYCLATE 80 MG TAB DR Non-Preferred doxycycline hyclate doxycycline hyclate 100 mg tab dr Non-Preferred

doxycycline hyclate 50 mg cap Preferred QL 60 / 30 days

PAGE 39 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

doxycycline monohydrate 100 mg tab Preferred QL 2 / 1 days

doxycycline monohydrate 50 mg cap Preferred

doxycycline monohydrate 75 mg tab Preferred QL 2 / 1 days

doxycycline monohydrate 150 mg tab Non-Preferred QL 2 / 1 days

doxycycline monohydrate 75 mg cap Non-Preferred doxycycline monohydrate 150 mg cap Non-Preferred

doxycycline monohydrate 50 mg tab Preferred QL 1 / 1 days

doxycycline monohydrate 25 mg/5ml Preferred recon susp doxycycline monohydrate 100 mg cap Preferred MINOCIN 50 MG CAP Non-Preferred QL 2 / 1 days minocycline hcl minocycline hcl 75 mg tab Non-Preferred

minocycline hcl 75 mg cap Preferred QL 2 / 1 days

minocycline hcl 50 mg tab Non-Preferred

minocycline hcl 50 mg cap Preferred QL 2 / 1 days

minocycline hcl 100 mg tab Non-Preferred

minocycline hcl 100 mg cap Preferred QL 2 / 1 days

minocycline hcl er 45 mg tab er 24h Non-Preferred MINOCYCLINE HCL ER 45 MG CAP ER 24H Non-Preferred minocycline hcl minocycline hcl er 90 mg tab er 24h Non-Preferred minocycline hcl er 135 mg tab er 24h Non-Preferred minocycline hcl er 105 mg tab er 24h Non-Preferred MINOCYCLINE HCL ER 90 MG CAP ER 24H Non-Preferred minocycline hcl minocycline hcl er 80 mg tab er 24h Non-Preferred minocycline hcl er 55 mg tab er 24h Non-Preferred minocycline hcl er 115 mg tab er 24h Non-Preferred minocycline hcl er 65 mg tab er 24h Non-Preferred

PAGE 40 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MINOCYCLINE HCL ER 135 MG CAP ER 24H Non-Preferred minocycline hcl MINOLIRA Non-Preferred minocycline hcl

morgidox 100 mg cap Non-Preferred QL 60 / 30 days

morgidox 50 mg cap Non-Preferred QL 60 / 30 days

MORGIDOX 2 X 100 MG KIT Non-Preferred doxycycline hyclate w/ cleanser MORGIDOX 1 X 50 MG KIT Non-Preferred doxycycline hyclate w/ cleanser MORGIDOX 1 X 100 MG KIT Non-Preferred doxycycline hyclate w/ cleanser NUZYRA 150 MG TAB Non-Preferred omadacycline tosylate ORACEA Non-Preferred doxycycline (rosacea) SOLODYN Non-Preferred minocycline hcl

tetracycline hcl 250 mg cap Preferred QL 120 / 30 days

tetracycline hcl 500 mg cap Preferred QL 120 / 30 days

VIBRAMYCIN 25 MG/5ML RECON SUSP Non-Preferred doxycycline (monohydrate) VIBRAMYCIN 100 MG CAP Non-Preferred QL 60 / 30 days doxycycline hyclate VIBRAMYCIN 50 MG/5ML SYRUP Non-Preferred doxycycline calcium XIMINO Non-Preferred minocycline hcl ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT 100 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 25 MG TAB Non-Preferred QL 2 / 1 days brivaracetam

PAGE 41 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BRIVIACT 50 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 75 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 10 MG/ML SOLUTION Non-Preferred brivaracetam BRIVIACT 10 MG TAB Non-Preferred QL 2 / 1 days brivaracetam DIACOMIT Non-Preferred stiripentol ELEPSIA XR Non-Preferred levetiracetam EPIDIOLEX Non-Preferred cannabidiol FINTEPLA Non-Preferred fenfluramine hcl (anticonvulsant) KEPPRA 500 MG TAB Non-Preferred levetiracetam KEPPRA 1000 MG TAB Non-Preferred levetiracetam KEPPRA 250 MG TAB Non-Preferred levetiracetam KEPPRA 750 MG TAB Non-Preferred levetiracetam KEPPRA 100 MG/ML SOLUTION Non-Preferred levetiracetam KEPPRA XR Non-Preferred levetiracetam

levetiracetam 250 mg tab Preferred QL 4 / 1 days

levetiracetam 500 mg tab Preferred QL 4 / 1 days

levetiracetam 1000 mg tab Preferred QL 4 / 1 days

levetiracetam 750 mg tab Preferred QL 4 / 1 days

levetiracetam 100 mg/ml solution Preferred QL 30 / 1 days

levetiracetam er 750 mg tab er 24h Preferred QL 4 / 1 days

levetiracetam er 500 mg tab er 24h Preferred QL 6 / 1 days

PAGE 42 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NAYZILAM Preferred QL 10 / 30 days midazolam (anticonvulsant) roweepra Preferred roweepra xr Preferred SPRITAM Non-Preferred levetiracetam CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN Non-Preferred methsuximide

ethosuximide 250 mg cap Preferred QL 6 / 1 days

ethosuximide 250 mg/5ml solution Preferred QL 30 / 1 days

ZARONTIN Non-Preferred ethosuximide

zonisamide 100 mg cap Preferred QL 6 / 1 days

zonisamide 25 mg cap Preferred QL 4 / 1 days

zonisamide 50 mg cap Preferred QL 4 / 1 days

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam Preferred DEPAKENE 250 MG CAP Non-Preferred valproic acid DEPAKENE 250 MG/5ML SOLUTION Non-Preferred valproate sodium DEPAKOTE Non-Preferred divalproex sodium DEPAKOTE ER Non-Preferred divalproex sodium DEPAKOTE SPRINKLES Non-Preferred divalproex sodium DIASTAT ACUDIAL Non-Preferred diazepam (anticonvulsant) DIASTAT PEDIATRIC Non-Preferred diazepam (anticonvulsant)

diazepam 10 mg gel Preferred QL 2 / 30 days

diazepam 20 mg gel Preferred QL 2 / 30 days

PAGE 43 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

diazepam 2.5 mg gel Preferred QL 2 / 30 days

divalproex sodium 125 mg tab dr Preferred divalproex sodium 500 mg tab dr Preferred divalproex sodium 250 mg tab dr Preferred divalproex sodium 125 mg cap dr Preferred divalproex sodium er Preferred GABAPAL Non-Preferred gabapentin-lidocaine-silicone

gabapentin 300 mg cap Preferred QL 6 / 1 days

gabapentin 400 mg cap Preferred QL 6 / 1 days

gabapentin 100 mg cap Preferred QL 6 / 1 days

gabapentin 300 mg/6ml solution Preferred

gabapentin 800 mg tab Preferred QL 4 / 1 days

gabapentin 250 mg/5ml solution Preferred

gabapentin 600 mg tab Preferred QL 6 / 1 days

GABITRIL 2 MG TAB Non-Preferred QL 14 / 1 days tiagabine hcl GABITRIL 4 MG TAB Non-Preferred QL 14 / 1 days tiagabine hcl GABITRIL 16 MG TAB Non-Preferred QL 3 / 1 days tiagabine hcl GABITRIL 12 MG TAB Non-Preferred QL 4 / 1 days tiagabine hcl GRALISE 600 MG TAB Non-Preferred gabapentin (once-daily) GRALISE 300 MG TAB Non-Preferred gabapentin (once-daily) LIDOTIN Non-Preferred gabapentin-lidocaine-silicone LIPRITIN gabapentin & lidocaine-prilocaine & Non-Preferred transparent dressing MYSOLINE Non-Preferred primidone

PAGE 44 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEURONTIN Non-Preferred gabapentin ONFI Non-Preferred clobazam PENTICAN Non-Preferred gabapentin & lidocaine phenobarbital 20 mg/5ml solution Preferred phenobarbital 15 mg tab Preferred phenobarbital 100 mg tab Preferred phenobarbital 20 mg/5ml elixir Preferred phenobarbital 32.4 mg tab Preferred phenobarbital 97.2 mg tab Preferred phenobarbital 30 mg tab Preferred phenobarbital 64.8 mg tab Preferred phenobarbital 60 mg tab Preferred phenobarbital 16.2 mg tab Preferred

primidone 50 mg tab Preferred QL 8 / 1 days

primidone 250 mg tab Preferred QL 8 / 1 days

SABRIL 500 MG TAB Non-Preferred vigabatrin SABRIL 500 MG PACKET Non-Preferred QL 120 / 30 days vigabatrin SYMPAZAN Non-Preferred clobazam

tiagabine hcl 16 mg tab Non-Preferred QL 3 / 1 days

tiagabine hcl 12 mg tab Non-Preferred QL 4 / 1 days

tiagabine hcl 2 mg tab Non-Preferred QL 14 / 1 days

tiagabine hcl 4 mg tab Non-Preferred QL 14 / 1 days

valproate sodium 250 mg/5ml solution Preferred valproic acid 250 mg/5ml solution Preferred valproic acid 250 mg cap Preferred VALTOCO 10 MG DOSE Preferred QL 10 / 30 days diazepam (anticonvulsant)

PAGE 45 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VALTOCO 15 MG DOSE Preferred QL 10 / 30 days diazepam (anticonvulsant) VALTOCO 20 MG DOSE Preferred QL 10 / 30 days diazepam (anticonvulsant) VALTOCO 5 MG DOSE Preferred QL 10 / 30 days diazepam (anticonvulsant)

vigabatrin 500 mg packet Non-Preferred QL 120 / 30 days

vigabatrin 500 mg tab Non-Preferred

vigadrone Non-Preferred QL 120 / 30 days

GLUTAMATE REDUCING AGENTS

felbamate 600 mg/5ml suspension Non-Preferred QL 30 / 1 days

felbamate 400 mg tab Non-Preferred QL 9 / 1 days

felbamate 600 mg tab Non-Preferred QL 6 / 1 days

FELBATOL Non-Preferred felbamate FYCOMPA Non-Preferred perampanel LAMICTAL 200 MG TAB Non-Preferred QL 3 / 1 days lamotrigine LAMICTAL 5 MG CHEW TAB Non-Preferred lamotrigine LAMICTAL 25 MG CHEW TAB Non-Preferred lamotrigine LAMICTAL 100 MG TAB Non-Preferred lamotrigine LAMICTAL 25 MG TAB Non-Preferred lamotrigine LAMICTAL 150 MG TAB Non-Preferred QL 3 / 1 days lamotrigine LAMICTAL ODT Non-Preferred lamotrigine LAMICTAL STARTER Non-Preferred lamotrigine LAMICTAL XR Non-Preferred lamotrigine lamotrigine 100 mg tab disp Non-Preferred

PAGE 46 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lamotrigine 21 x 25 mg & 7 x 50 mg kit Non-Preferred lamotrigine 25 mg tab Preferred lamotrigine 200 mg tab disp Non-Preferred

lamotrigine 150 mg tab Preferred QL 3 / 1 days

lamotrigine 42 x 50 mg & 14x100 mg kit Non-Preferred lamotrigine 25 mg tab disp Non-Preferred

lamotrigine 100 mg tab Preferred QL 5 / 1 days

lamotrigine 50 mg tab disp Non-Preferred lamotrigine 25 & 50 & 100 mg kit Non-Preferred lamotrigine 25 mg chew tab Non-Preferred lamotrigine 5 mg chew tab Non-Preferred

lamotrigine 200 mg tab Preferred QL 3 / 1 days

lamotrigine er Non-Preferred lamotrigine starter kit-blue Non-Preferred lamotrigine starter kit-green Non-Preferred lamotrigine starter kit-orange Non-Preferred QUDEXY XR Non-Preferred topiramate

subvenite 200 mg tab Preferred QL 3 / 1 days

subvenite 100 mg tab Preferred subvenite 25 mg tab Preferred

subvenite 150 mg tab Preferred QL 3 / 1 days

subvenite starter kit-blue Non-Preferred subvenite starter kit-green Non-Preferred subvenite starter kit-orange Non-Preferred TOPAMAX Non-Preferred topiramate TOPAMAX SPRINKLE Non-Preferred topiramate

topiramate 15 mg cap sprink Preferred QL 4 / 1 days

topiramate 25 mg cap sprink Preferred QL 4 / 1 days

PAGE 47 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

topiramate 100 mg tab Preferred QL 4 / 1 days

topiramate 50 mg tab Preferred QL 4 / 1 days

topiramate 200 mg tab Preferred QL 4 / 1 days

topiramate 25 mg tab Preferred QL 4 / 1 days

topiramate er Preferred TROKENDI XR 100 MG CAP ER 24H Non-Preferred QL 90 / 30 days topiramate TROKENDI XR 50 MG CAP ER 24H Non-Preferred QL 60 / 30 days topiramate TROKENDI XR 200 MG CAP ER 24H Non-Preferred QL 60 / 30 days topiramate TROKENDI XR 25 MG CAP ER 24H Non-Preferred QL 120 / 30 days topiramate XCOPRI Non-Preferred cenobamate XCOPRI (250 MG DAILY DOSE) Non-Preferred cenobamate XCOPRI (350 MG DAILY DOSE) Non-Preferred cenobamate SODIUM CHANNEL AGENTS

APTIOM Non-Preferred eslicarbazepine acetate BANZEL Non-Preferred rufinamide

carbamazepine 100 mg chew tab Preferred QL 8 / 1 days

carbamazepine 100 mg/5ml suspension Preferred QL 80 / 1 days

carbamazepine 200 mg tab Preferred QL 8 / 1 days

carbamazepine er Preferred QL 4 / 1 days

CARBATROL Non-Preferred carbamazepine DILANTIN 30 MG CAP Preferred QL 9 / 1 days phenytoin sodium extended DILANTIN 125 MG/5ML SUSPENSION Non-Preferred phenytoin

PAGE 48 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DILANTIN 100 MG CAP Preferred QL 12 / 1 days phenytoin sodium extended DILANTIN INFATABS Non-Preferred QL 8 / 1 days phenytoin epitol Preferred

oxcarbazepine 600 mg tab Preferred QL 4 / 1 days

oxcarbazepine 300 mg/5ml suspension Preferred QL 40 / 1 days

oxcarbazepine 150 mg tab Preferred QL 4 / 1 days

oxcarbazepine 300 mg tab Preferred QL 4 / 1 days

OXTELLAR XR Non-Preferred oxcarbazepine PEGANONE Non-Preferred ethotoin PHENYTEK 300 MG CAP Non-Preferred QL 1 / 1 days phenytoin sodium extended PHENYTEK 200 MG CAP Non-Preferred QL 2 / 1 days phenytoin sodium extended

phenytoin 125 mg/5ml suspension Preferred QL 15 / 1 days

phenytoin 50 mg chew tab Preferred QL 8 / 1 days

phenytoin 100 mg/4ml suspension Preferred phenytoin infatabs Preferred

phenytoin sodium extended 100 mg cap Preferred QL 12 / 1 days

phenytoin sodium extended 300 mg cap Preferred QL 1 / 1 days

phenytoin sodium extended 200 mg cap Preferred QL 2 / 1 days

rufinamide Non-Preferred TEGRETOL Non-Preferred carbamazepine TEGRETOL-XR Non-Preferred carbamazepine TRILEPTAL Non-Preferred oxcarbazepine VIMPAT 100 MG TAB Preferred QL 2 / 1 days lacosamide

PAGE 49 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIMPAT 150 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 50 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 200 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 10 MG/ML SOLUTION Non-Preferred lacosamide ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS

ARICEPT Non-Preferred QL 1 / 1 days donepezil hydrochloride

donepezil hcl 10 mg tab disp Non-Preferred QL 1 / 1 days

QL 1 / 1 days donepezil hcl 10 mg tab Preferred PA

QL 1 / 1 days donepezil hcl 5 mg tab Preferred PA

donepezil hcl 5 mg tab disp Non-Preferred QL 2 / 1 days

donepezil hcl 23 mg tab Non-Preferred QL 1 / 1 days

EXELON Non-Preferred QL 1 / 1 days rivastigmine

galantamine hydrobromide 12 mg tab Preferred PA

galantamine hydrobromide 8 mg tab Preferred PA

galantamine hydrobromide 4 mg/ml Non-Preferred solution

galantamine hydrobromide 4 mg tab Preferred PA

galantamine hydrobromide er Non-Preferred NAMZARIC Non-Preferred memantine hcl-donepezil hcl RAZADYNE Non-Preferred galantamine hydrobromide RAZADYNE ER Non-Preferred galantamine hydrobromide

PAGE 50 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

rivastigmine Non-Preferred QL 1 / 1 days

QL 60 / 30 days rivastigmine tartrate Preferred PA

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

QL 2 / 1 days memantine hcl 5 mg tab Preferred PA

QL 60 / 30 days memantine hcl 10 mg tab Preferred PA

memantine hcl 28 x 5 mg & 21 x 10 mg QL 2 / 1 days Preferred tab PA

memantine hcl 10 mg/5ml solution Non-Preferred

QL 10 / 1 days memantine hcl 2 mg/ml solution Non-Preferred PA

memantine hcl er Non-Preferred NAMENDA 5 MG TAB Non-Preferred QL 2 / 1 days memantine hcl NAMENDA 10 MG TAB Non-Preferred QL 60 / 30 days memantine hcl NAMENDA TITRATION PAK Non-Preferred QL 2 / 1 days memantine hcl NAMENDA XR Non-Preferred memantine hcl NAMENDA XR TITRATION PACK Non-Preferred memantine hcl ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

APLENZIN Non-Preferred bupropion hydrobromide

bupropion hcl 100 mg tab Preferred QL 120 / 30 days

bupropion hcl 75 mg tab Preferred QL 120 / 30 days

bupropion hcl er (sr) Preferred QL 60 / 30 days

bupropion hcl er (xl) 300 mg tab er 24h Preferred QL 30 / 30 days

PAGE 51 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS bupropion hcl er (xl) 450 mg tab er 24h Preferred

bupropion hcl er (xl) 150 mg tab er 24h Preferred QL 60 / 30 days

chlordiazepoxide-amitriptyline Preferred QL 6 / 1 days

FORFIVO XL Non-Preferred bupropion hcl

mirtazapine 45 mg tab Preferred QL 1 / 1 days

mirtazapine 7.5 mg tab Preferred QL 1 / 1 days

mirtazapine 15 mg tab Preferred QL 1 / 1 days

mirtazapine 30 mg tab Preferred QL 1 / 1 days

mirtazapine 15 mg tab disp Non-Preferred QL 1 / 1 days

mirtazapine 45 mg tab disp Non-Preferred QL 1 / 1 days

mirtazapine 30 mg tab disp Non-Preferred QL 1 / 1 days

QL 30 / 30 days

olanzapine-fluoxetine hcl Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

perphenazine-amitriptyline 2-25 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine-amitriptyline 4-50 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine-amitriptyline 4-10 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

perphenazine-amitriptyline 2-10 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 52 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REMERON 30 MG TAB Non-Preferred QL 1 / 1 days mirtazapine REMERON 15 MG TAB Non-Preferred QL 1 / 1 days mirtazapine REMERON SOLTAB Non-Preferred QL 1 / 1 days mirtazapine SPRAVATO (56 MG DOSE) Non-Preferred QL 8 / 14 days esketamine hcl SPRAVATO (84 MG DOSE) Non-Preferred QL 12 / 14 days esketamine hcl

QL 30 / 30 days SYMBYAX 6-25 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 3-25 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 12-50 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 6-50 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required WELLBUTRIN SR Non-Preferred QL 60 / 30 days bupropion hcl WELLBUTRIN XL 300 MG TAB ER 24H Non-Preferred QL 30 / 30 days bupropion hcl WELLBUTRIN XL 150 MG TAB ER 24H Non-Preferred QL 60 / 30 days bupropion hcl MONOAMINE OXIDASE INHIBITORS

EMSAM Non-Preferred selegiline MARPLAN Non-Preferred isocarboxazid NARDIL Non-Preferred phenelzine sulfate

PAGE 53 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phenelzine sulfate 15 mg tab Preferred

tranylcypromine sulfate Non-Preferred QL 6 / 1 days

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

BRISDELLE Non-Preferred paroxetine mesylate (vasomotor) CELEXA Non-Preferred QL 45 / 30 days citalopram hydrobromide citalopram hydrobromide 10 mg/5ml Preferred QL 20 / 1 days solution

citalopram hydrobromide 10 mg tab Preferred QL 45 / 30 days

citalopram hydrobromide 20 mg tab Preferred QL 45 / 30 days

citalopram hydrobromide 40 mg tab Preferred QL 45 / 30 days

desvenlafaxine er Non-Preferred DESVENLAFAXINE ER Non-Preferred desvenlafaxine desvenlafaxine succinate er Preferred EFFEXOR XR 150 MG CAP ER 24H Non-Preferred QL 2 / 1 days venlafaxine hcl EFFEXOR XR 37.5 MG CAP ER 24H Non-Preferred QL 1 / 1 days venlafaxine hcl EFFEXOR XR 75 MG CAP ER 24H Non-Preferred QL 3 / 1 days venlafaxine hcl

escitalopram oxalate 5 mg/5ml solution Non-Preferred QL 20 / 1 days

escitalopram oxalate 20 mg tab Preferred QL 1 / 1 days

escitalopram oxalate 5 mg tab Preferred QL 45 / 30 days

escitalopram oxalate 10 mg tab Preferred QL 45 / 30 days

FETZIMA Non-Preferred levomilnacipran hcl FETZIMA TITRATION Non-Preferred levomilnacipran hcl FLUOXETINE HCL 60 MG TAB Non-Preferred fluoxetine hcl fluoxetine hcl 90 mg cap dr Non-Preferred

PAGE 54 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

fluoxetine hcl 20 mg cap Preferred QL 4 / 1 days

fluoxetine hcl 20 mg tab Preferred QL 120 / 30 days

fluoxetine hcl 10 mg cap Preferred QL 3 / 1 days

fluoxetine hcl 60 mg tab Non-Preferred

fluoxetine hcl 20 mg/5ml solution Preferred QL 10 / 1 days

fluoxetine hcl 40 mg cap Preferred QL 2 / 1 days

fluoxetine hcl 10 mg tab Preferred QL 90 / 30 days

fluoxetine hcl (pmdd) 20 mg tab Non-Preferred QL 4 / 1 days

FLUOXETINE HCL (PMDD) 10 MG CAP Preferred QL 3 / 1 days fluoxetine hcl (pmdd) FLUOXETINE HCL (PMDD) 20 MG CAP Preferred QL 4 / 1 days fluoxetine hcl (pmdd)

fluoxetine hcl (pmdd) 10 mg tab Non-Preferred QL 3 / 1 days

fluvoxamine maleate 25 mg tab Preferred QL 1 / 1 days

fluvoxamine maleate 50 mg tab Preferred QL 45 / 30 days

fluvoxamine maleate 100 mg tab Preferred QL 3 / 1 days

fluvoxamine maleate er Non-Preferred KHEDEZLA Non-Preferred desvenlafaxine LEXAPRO 10 MG TAB Non-Preferred QL 45 / 30 days escitalopram oxalate LEXAPRO 5 MG TAB Non-Preferred QL 45 / 30 days escitalopram oxalate LEXAPRO 20 MG TAB Non-Preferred QL 1 / 1 days escitalopram oxalate

maprotiline hcl Non-Preferred QL 2 / 1 days

nefazodone hcl 150 mg tab Non-Preferred QL 120 / 30 days

nefazodone hcl 250 mg tab Non-Preferred QL 2 / 1 days

nefazodone hcl 100 mg tab Non-Preferred QL 2 / 1 days

nefazodone hcl 200 mg tab Non-Preferred QL 3 / 1 days

PAGE 55 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

nefazodone hcl 50 mg tab Non-Preferred QL 2 / 1 days

paroxetine hcl 30 mg tab Preferred QL 2 / 1 days

paroxetine hcl 10 mg tab Preferred QL 45 / 30 days

paroxetine hcl 40 mg tab Preferred QL 45 / 30 days

paroxetine hcl 20 mg tab Preferred QL 45 / 30 days

paroxetine hcl er Non-Preferred paroxetine mesylate Non-Preferred PAXIL 30 MG TAB Non-Preferred QL 2 / 1 days paroxetine hcl PAXIL 10 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL 40 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL 20 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL 10 MG/5ML SUSPENSION Non-Preferred paroxetine hcl PAXIL CR Non-Preferred paroxetine hcl PEXEVA Non-Preferred paroxetine mesylate PRISTIQ Non-Preferred desvenlafaxine succinate PROZAC 40 MG CAP Non-Preferred QL 2 / 1 days fluoxetine hcl PROZAC 10 MG CAP Non-Preferred QL 3 / 1 days fluoxetine hcl PROZAC 20 MG CAP Non-Preferred fluoxetine hcl SARAFEM 10 MG TAB Non-Preferred QL 3 / 1 days fluoxetine hcl (pmdd) SARAFEM 20 MG TAB Non-Preferred fluoxetine hcl (pmdd)

sertraline hcl 50 mg tab Preferred QL 45 / 30 days

sertraline hcl 25 mg tab Preferred QL 45 / 30 days

PAGE 56 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

sertraline hcl 20 mg/ml conc Preferred QL 300 / 30 days

sertraline hcl 100 mg tab Preferred QL 60 / 30 days

trazodone hcl 300 mg tab Preferred QL 2 / 1 days

trazodone hcl 100 mg tab Preferred QL 3 / 1 days

trazodone hcl 50 mg tab Preferred QL 3 / 1 days

trazodone hcl 150 mg tab Preferred QL 3 / 1 days

TRINTELLIX Non-Preferred vortioxetine hbr

venlafaxine hcl Preferred QL 3 / 1 days

venlafaxine hcl er 150 mg tab er 24h Non-Preferred venlafaxine hcl er 37.5 mg tab er 24h Non-Preferred venlafaxine hcl er 225 mg tab er 24h Non-Preferred

venlafaxine hcl er 37.5 mg cap er 24h Preferred QL 1 / 1 days

venlafaxine hcl er 150 mg cap er 24h Preferred QL 2 / 1 days

venlafaxine hcl er 75 mg cap er 24h Preferred QL 3 / 1 days

venlafaxine hcl er 75 mg tab er 24h Non-Preferred QL 90 / 30 days

VIIBRYD Non-Preferred vilazodone hcl VIIBRYD STARTER PACK Non-Preferred vilazodone hcl ZOLOFT 25 MG TAB Non-Preferred QL 45 / 30 days sertraline hcl ZOLOFT 50 MG TAB Non-Preferred QL 45 / 30 days sertraline hcl ZOLOFT 20 MG/ML CONC Non-Preferred QL 10 / 1 days sertraline hcl ZOLOFT 100 MG TAB Non-Preferred QL 60 / 30 days sertraline hcl TRICYCLICS

amitriptyline hcl 150 mg tab Preferred QL 3 / 1 days

amitriptyline hcl 100 mg tab Preferred QL 3 / 1 days

PAGE 57 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

amitriptyline hcl 10 mg tab Preferred QL 3 / 1 days

amitriptyline hcl 25 mg tab Preferred QL 3 / 1 days

amitriptyline hcl 50 mg tab Preferred QL 3 / 1 days

amitriptyline hcl 75 mg tab Preferred QL 3 / 1 days

amoxapine Preferred QL 4 / 1 days

ANAFRANIL 75 MG CAP Non-Preferred QL 90 / 30 days clomipramine hcl ANAFRANIL 25 MG CAP Non-Preferred QL 150 / 30 days clomipramine hcl ANAFRANIL 50 MG CAP Non-Preferred QL 150 / 30 days clomipramine hcl

clomipramine hcl 25 mg cap Non-Preferred QL 150 / 30 days

clomipramine hcl 75 mg cap Non-Preferred QL 90 / 30 days

clomipramine hcl 50 mg cap Non-Preferred QL 150 / 30 days

desipramine hcl 150 mg tab Non-Preferred QL 2 / 1 days

desipramine hcl 50 mg tab Non-Preferred QL 2 / 1 days

desipramine hcl 75 mg tab Non-Preferred QL 2 / 1 days

desipramine hcl 100 mg tab Non-Preferred QL 2 / 1 days

desipramine hcl 10 mg tab Non-Preferred QL 2 / 1 days

desipramine hcl 25 mg tab Non-Preferred QL 2 / 1 days

doxepin hcl 10 mg/ml conc Preferred QL 30 / 1 days

doxepin hcl 75 mg cap Preferred QL 2 / 1 days

doxepin hcl 50 mg cap Preferred QL 2 / 1 days

doxepin hcl 10 mg cap Preferred QL 2 / 1 days

doxepin hcl 100 mg cap Preferred QL 3 / 1 days

doxepin hcl 25 mg cap Preferred QL 2 / 1 days

doxepin hcl 150 mg cap Preferred QL 2 / 1 days

imipramine hcl 25 mg tab Preferred QL 6 / 1 days

PAGE 58 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

imipramine hcl 10 mg tab Preferred QL 6 / 1 days

imipramine hcl 50 mg tab Preferred QL 6 / 1 days

imipramine pamoate Non-Preferred NORPRAMIN Non-Preferred QL 2 / 1 days desipramine hcl

nortriptyline hcl 10 mg cap Preferred QL 3 / 1 days

nortriptyline hcl 10 mg/5ml solution Non-Preferred QL 75 / 1 days

nortriptyline hcl 25 mg cap Preferred QL 3 / 1 days

nortriptyline hcl 50 mg cap Preferred QL 2 / 1 days

nortriptyline hcl 75 mg cap Preferred QL 3 / 1 days

PAMELOR 10 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl PAMELOR 50 MG CAP Non-Preferred QL 2 / 1 days nortriptyline hcl PAMELOR 25 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl PAMELOR 75 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl

protriptyline hcl Non-Preferred QL 6 / 1 days

SURMONTIL Non-Preferred trimipramine maleate TOFRANIL Non-Preferred imipramine hcl trimipramine maleate 50 mg cap Non-Preferred trimipramine maleate 100 mg cap Non-Preferred trimipramine maleate 25 mg cap Non-Preferred ANTIEMETICS

ANTIEMETICS, OTHER

BARHEMSYS Non-Preferred amisulpride (antiemetic) BONJESTA Preferred QL 60 / 30 days doxylamine-pyridoxine

compro Preferred QL 12 / days

PAGE 59 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DICLEGIS Non-Preferred doxylamine-pyridoxine DIMENHYDRINATE 50 MG/ML SOLUTION Non-Preferred dimenhydrinate doxylamine-pyridoxine Non-Preferred GIMOTI Non-Preferred metoclopramide hcl

meclizine hcl 12.5 mg tab Preferred QL 120 / 30 days

meclizine hcl 25 mg tab Preferred QL 120 / 30 days

METOCLOPRAMIDE HCL 10 MG TAB DISP Non-Preferred metoclopramide hcl

metoclopramide hcl 5 mg/5ml solution Preferred QL 40 / 1 days

metoclopramide hcl 10 mg tab Preferred QL 4 / 1 days

metoclopramide hcl 5 mg/ml solution Preferred

metoclopramide hcl 10 mg/10ml solution Preferred QL 40 / 1 days

metoclopramide hcl 5 mg tab Preferred QL 4 / 1 days

metoclopramide hcl 5 mg tab disp Non-Preferred

QL 4 / 1 days

perphenazine 4 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine 2 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine 16 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine 8 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 60 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 6 yrs old phenadoz Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old phenergan 12.5 mg suppos Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old phenergan 25 mg suppos Non-Preferred C Age restriction, clinical PA required

prochlorperazine Preferred QL 12 / days

prochlorperazine edisylate 10 mg/2ml Preferred solution

prochlorperazine maleate 5 mg tab Preferred QL 4 / 1 days

prochlorperazine maleate 10 mg tab Preferred QL 4 / 1 days

AL1 At least 6 yrs old promethazine hcl 50 mg suppos Preferred C Age restriction, clinical PA required

QL 4 / 1 days

promethazine hcl 50 mg tab Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl 25 mg suppos Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl 12.5 mg suppos Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethegan Preferred C Age restriction, clinical PA required REGLAN Non-Preferred metoclopramide hcl scopolamine Non-Preferred TIGAN 300 MG CAP Non-Preferred QL 3 / 1 days trimethobenzamide hcl TIGAN 100 MG/ML SOLUTION Non-Preferred trimethobenzamide hcl

PAGE 61 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRANSDERM SCOP (1.5 MG) Preferred scopolamine TRANSDERM-SCOP (1.5 MG) Preferred scopolamine

trimethobenzamide hcl 300 mg cap Preferred QL 3 / 1 days

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG CAP Non-Preferred QL 2 / 28 days netupitant-palonosetron AKYNZEO 235-0.25 MG/20ML SOLUTION Non-Preferred QLC 2 vials/28 days fosnetupitant choride-palonosetron hcl AKYNZEO 235-0.25 MG RECON SOLN Non-Preferred QLC 2 vials/28 days fosnetupitant choride-palonosetron hcl ALOXI Preferred QLC 10 mL/28 days palonosetron hcl ANZEMET Non-Preferred dolasetron mesylate

aprepitant 80 mg cap Non-Preferred QL 4 / 28 days

aprepitant 80 & 125 mg cap Non-Preferred QL 6 / 28 days

aprepitant 125 mg cap Non-Preferred QL 2 / 28 days

aprepitant 40 mg cap Non-Preferred QL 1 / 30 days

aprepitant 80 & 125 mg misc Non-Preferred CESAMET Non-Preferred nabilone CINVANTI Preferred QLC 36 mL/28 days aprepitant

dronabinol 10 mg cap Non-Preferred QL 90 / 30 days

dronabinol 5 mg cap Non-Preferred QL 180 / 30 days

dronabinol 2.5 mg cap Non-Preferred QL 180 / 30 days

EMEND 150 MG RECON SOLN Non-Preferred QLC 2 vials/28 days fosaprepitant dimeglumine EMEND 125 MG CAP Preferred QL 2 / 28 days aprepitant EMEND 125 MG/5ML RECON SUSP Non-Preferred aprepitant

PAGE 62 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EMEND 80 MG CAP Preferred QL 4 / 28 days aprepitant EMEND 40 MG CAP Preferred QL 1 / 30 days aprepitant EMEND TRI-PACK Preferred QL 6 / 28 days aprepitant fosaprepitant dimeglumine Non-Preferred FOSAPREPITANT DIMEGLUMINE Non-Preferred fosaprepitant dimeglumine granisetron hcl 1 mg/ml solution Preferred granisetron hcl 4 mg/4ml solution Preferred

granisetron hcl 1 mg tab Non-Preferred QLC 2 tablets/day

MARINOL 10 MG CAP Non-Preferred QL 90 / 30 days dronabinol MARINOL 5 MG CAP Non-Preferred QL 180 / 30 days dronabinol MARINOL 2.5 MG CAP Non-Preferred QL 180 / 30 days dronabinol

ondansetron Preferred QL 3 / 1 days

ondansetron hcl 4 mg/5ml solution Preferred QL 50 / 25 days

ondansetron hcl 4 mg tab Preferred QL 3 / 1 days

ondansetron hcl 8 mg tab Preferred QL 3 / 1 days

ondansetron hcl 4 mg/2ml solution Preferred ondansetron hcl 40 mg/20ml solution Preferred

palonosetron hcl 0.25 mg/5ml soln prsyr Preferred QLC 10 mL/28 days

palonosetron hcl 0.25 mg/5ml solution Preferred QLC 10 mL/28 days

PALONOSETRON HCL 0.25 MG/5ML SOLUTION Preferred QLC 10 mL/28 days palonosetron hcl PALONOSETRON HCL 0.25 MG/2ML SOLUTION Preferred palonosetron hcl SANCUSO Non-Preferred QL 4 / 28 days granisetron

PAGE 63 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUSTOL Non-Preferred QLC 1.6 mL/28 days granisetron SYNDROS Non-Preferred dronabinol VARUBI (180 MG DOSE) Non-Preferred rolapitant hcl ZOFRAN 8 MG TAB Non-Preferred QL 3 / 1 days ondansetron hcl ZOFRAN 4 MG TAB Non-Preferred QL 3 / 1 days ondansetron hcl ZOFRAN ODT Non-Preferred QL 3 / 1 days ondansetron ZUPLENZ Non-Preferred ondansetron ANTIFUNGALS

ANCOBON Non-Preferred flucytosine ciclodan 8 % solution Non-Preferred ciclodan 0.77 % cream Non-Preferred CICLODAN CREAM Non-Preferred ciclopirox olamine & cleanser CICLODAN SOLUTION Non-Preferred ciclopirox ciclopirox 0.77 % gel Non-Preferred

ciclopirox 8 % solution Preferred QL 6.6 / 30 days

ciclopirox 1 % shampoo Non-Preferred ciclopirox olamine 0.77 % cream Preferred ciclopirox olamine 0.77 % suspension Preferred CICLOPIROX TREATMENT Non-Preferred ciclopirox

clotrimazole 1 % solution Non-Preferred QL 30 / 24 days

clotrimazole 1 % cream Preferred QL 30 / 7 days

clotrimazole 10 mg troche Preferred QL 5 / 1 days

CLOTRIMAZOLE 1% CREAM (RX) Preferred QL 30 / 7 days

PAGE 64 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CRESEMBA 186 MG CAP Non-Preferred isavuconazonium sulfate DIFLUCAN 40 MG/ML RECON SUSP Non-Preferred fluconazole DIFLUCAN 50 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 200 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 100 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 150 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 10 MG/ML RECON SUSP Non-Preferred fluconazole econazole nitrate 1 % cream Non-Preferred ERTACZO Non-Preferred sertaconazole nitrate EXELDERM Non-Preferred sulconazole nitrate EXTINA Non-Preferred ketoconazole (topical)

fluconazole 40 mg/ml recon susp Preferred QL 10 / 1 days

fluconazole 100 mg tab Preferred QL 2 / 1 days

fluconazole 50 mg tab Preferred QL 2 / 1 days

fluconazole 200 mg tab Preferred QL 2 / 1 days

fluconazole 10 mg/ml recon susp Preferred QL 40 / 1 days

fluconazole 150 mg tab Preferred QL 2 / 1 days

flucytosine 500 mg cap Non-Preferred flucytosine 250 mg cap Non-Preferred griseofulvin microsize 125 mg/5ml Preferred QL 40 / 1 days suspension

griseofulvin microsize 500 mg tab Preferred QL 60 / 30 days

griseofulvin ultramicrosize Non-Preferred QL 3 / 1 days

GYNAZOLE-1 Non-Preferred butoconazole nitrate (one dose)

PAGE 65 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS itraconazole 10 mg/ml solution Non-Preferred itraconazole 100 mg cap Non-Preferred JUBLIA Non-Preferred efinaconazole KERYDIN Non-Preferred tavaborole ketoconazole 2 % foam Non-Preferred ketoconazole 2 % shampoo Preferred ketoconazole 2 % cream Preferred

ketoconazole 200 mg tab Non-Preferred QL 2 / 1 days

LOPROX 0.77 % SUSPENSION Non-Preferred ciclopirox olamine LOPROX 0.77 % KIT Non-Preferred ciclopirox olamine & cleanser LOPROX 1 % SHAMPOO Non-Preferred ciclopirox LOPROX 0.77 % (SUSP) KIT Non-Preferred ciclopirox olamine & cleanser LOPROX 0.77 % CREAM Non-Preferred ciclopirox olamine LULICONAZOLE Non-Preferred luliconazole LUZU Non-Preferred luliconazole MENTAX Non-Preferred butenafine hcl MICONAZOLE 3 Non-Preferred QL 1 / 1 days miconazole nitrate vaginal MICONAZOLE-ZINC OXIDE- PETROLAT Non-Preferred miconazole-zinc oxide-white petrolatum naftifine hcl Non-Preferred NAFTIN Non-Preferred naftifine hcl NATACYN Non-Preferred natamycin NIZORAL Non-Preferred ketoconazole (topical)

PAGE 66 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOXAFIL 40 MG/ML SUSPENSION Non-Preferred posaconazole NOXAFIL 100 MG TAB DR Non-Preferred posaconazole nyamyc Preferred nystatin 100000 unit/gm cream Preferred nystatin 100000 unit/ml suspension Preferred nystatin 100000 unit/gm ointment Preferred nystatin 100000 unit/gm powder Preferred

nystatin 500000 unit tab Preferred QL 6 / 1 days

nystatin-triamcinolone 100000-0.1 Non-Preferred unit/gm-% ointment nystatin-triamcinolone 100000-0.1 Preferred unit/gm-% cream nystop Preferred ONMEL Non-Preferred itraconazole ORAVIG Non-Preferred miconazole (mouth-throat) oxiconazole nitrate Non-Preferred OXISTAT Non-Preferred oxiconazole nitrate PENLAC Non-Preferred ciclopirox posaconazole Non-Preferred SPORANOX Non-Preferred itraconazole SPORANOX PULSEPAK Non-Preferred itraconazole SULCONAZOLE NITRATE Non-Preferred sulconazole nitrate tavaborole Non-Preferred

terbinafine hcl 250 mg tab Preferred QL 90 / 365 days

terconazole 80 mg suppos Non-Preferred QL 3 / 14 days

terconazole 0.4 % cream Non-Preferred QL 45 / 14 days

PAGE 67 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

terconazole 0.8 % cream Non-Preferred QL 20 / 14 days

TOLSURA Non-Preferred itraconazole VFEND Non-Preferred voriconazole voriconazole 200 mg tab Non-Preferred voriconazole 40 mg/ml recon susp Non-Preferred voriconazole 50 mg tab Non-Preferred VUSION Non-Preferred miconazole-zinc oxide-white petrolatum ANTIGOUT AGENTS

allopurinol 300 mg tab Preferred QL 2 / 1 days

allopurinol 100 mg tab Preferred QL 8 / 1 days

QL 90 / 30 days colchicine 0.6 mg tab Preferred PA

QL 90 / 30 days colchicine 0.6 mg cap Preferred PA

colchicine-probenecid Preferred COLCRYS Non-Preferred QL 90 / 30 days colchicine DUZALLO Non-Preferred lesinurad-allopurinol febuxostat Non-Preferred GLOPERBA Non-Preferred colchicine KRYSTEXXA Non-Preferred pegloticase MITIGARE Non-Preferred QL 90 / 30 days colchicine

probenecid Preferred QL 4 / 1 days

ULORIC Non-Preferred febuxostat ZURAMPIC Non-Preferred lesinurad

PAGE 68 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZYLOPRIM 300 MG TAB Non-Preferred QL 2 / 1 days allopurinol ZYLOPRIM 100 MG TAB Non-Preferred allopurinol ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG QL 1 / 28 days Preferred erenumab-aooe PA

AJOVY Non-Preferred QLC 0.05 mL/day fremanezumab-vfrm

EMGALITY QL 2 / 28 days Preferred galcanezumab-gnlm PA

EMGALITY (300 MG DOSE) QL 3 / 30 days Preferred galcanezumab-gnlm PA

NURTEC QL 8 / 30 days Preferred rimegepant sulfate PA

UBRELVY QL 16 / 30 days Non-Preferred ubrogepant PA

ERGOT ALKALOIDS

CAFERGOT Non-Preferred ergotamine w/ caffeine D.H.E. 45 Non-Preferred dihydroergotamine mesylate dihydroergotamine mesylate 4 mg/ml Non-Preferred solution dihydroergotamine mesylate 1 mg/ml Non-Preferred solution ERGOMAR Non-Preferred ergotamine tartrate MIGERGOT Non-Preferred ergotamine w/ caffeine MIGRANAL Non-Preferred dihydroergotamine mesylate

PAGE 69 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROPHYLACTIC

VYEPTI Non-Preferred eptinezumab-jjmr SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate Non-Preferred AMERGE Non-Preferred naratriptan hcl eletriptan hydrobromide Non-Preferred FROVA Non-Preferred frovatriptan succinate frovatriptan succinate Non-Preferred IMITREX 5 MG/ACT SOLUTION Non-Preferred sumatriptan IMITREX 20 MG/ACT SOLUTION Non-Preferred sumatriptan IMITREX 50 MG TAB Non-Preferred sumatriptan succinate IMITREX 25 MG TAB Non-Preferred sumatriptan succinate IMITREX 6 MG/0.5ML SOLUTION Non-Preferred sumatriptan succinate IMITREX 100 MG TAB Non-Preferred sumatriptan succinate IMITREX STATDOSE REFILL Non-Preferred sumatriptan succinate IMITREX STATDOSE SYSTEM Non-Preferred sumatriptan succinate MAXALT 10 MG TAB Non-Preferred rizatriptan benzoate MAXALT-MLT Non-Preferred rizatriptan benzoate

naratriptan hcl Preferred QL 9 / 24 days

ONZETRA XSAIL Non-Preferred sumatriptan succinate RELPAX Non-Preferred eletriptan hydrobromide

REYVOW 100 MG TAB QL 8 / 30 days Non-Preferred lasmiditan succinate PA

PAGE 70 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

REYVOW 50 MG TAB QL 4 / 30 days Non-Preferred lasmiditan succinate PA

rizatriptan benzoate Preferred QL 9 / 30 days

sumatriptan 5 mg/act solution Preferred QL 6 / 24 days

sumatriptan 20 mg/act solution Preferred QL 6 / 24 days

sumatriptan succinate 6 mg/0.5ml soln Preferred prsyr sumatriptan succinate 6 mg/0.5ml soln Preferred QL 2 / 24 days a-inj sumatriptan succinate 4 mg/0.5ml soln Preferred a-inj sumatriptan succinate 6 mg/0.5ml Preferred QL 2 / 24 days solution

sumatriptan succinate 50 mg tab Preferred QL 9 / 24 days

sumatriptan succinate 25 mg tab Preferred QL 9 / 24 days

sumatriptan succinate 100 mg tab Preferred QL 9 / 24 days

sumatriptan succinate refill 4 mg/0.5ml Preferred soln cart sumatriptan succinate refill 6 mg/0.5ml Preferred QL 2 / 24 days soln cart sumatriptan-naproxen sodium Non-Preferred SUMAVEL DOSEPRO Non-Preferred sumatriptan succinate TOSYMRA Non-Preferred sumatriptan TREXIMET Non-Preferred sumatriptan-naproxen sodium ZEMBRACE SYMTOUCH Non-Preferred sumatriptan succinate ZOLMITRIPTAN 5 MG SOLUTION Non-Preferred zolmitriptan zolmitriptan 2.5 mg tab disp Preferred ZOLMITRIPTAN 2.5 MG SOLUTION Non-Preferred zolmitriptan zolmitriptan 5 mg tab Preferred

PAGE 71 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS zolmitriptan 5 mg tab disp Preferred zolmitriptan 2.5 mg tab Preferred ZOMIG 5 MG TAB Non-Preferred zolmitriptan ZOMIG 2.5 MG SOLUTION Preferred zolmitriptan ZOMIG 2.5 MG TAB Non-Preferred zolmitriptan ZOMIG 5 MG SOLUTION Preferred zolmitriptan ZOMIG ZMT Non-Preferred zolmitriptan ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

pyridostigmine bromide 60 mg tab Preferred QL 8 / 1 days

pyridostigmine bromide 60 mg/5ml Preferred solution pyridostigmine bromide er Preferred ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone 25 mg tab Preferred QL 3 / 1 days

dapsone 100 mg tab Preferred QL 1 / 1 days

rifabutin Preferred QL 2 / 1 days

ANTITUBERCULARS

ethambutol hcl 400 mg tab Preferred QL 10 / 1 days

ethambutol hcl 100 mg tab Preferred QL 10 / 1 days

isoniazid 300 mg tab Preferred QL 3 / 1 days

isoniazid 50 mg/5ml syrup Preferred QL 90 / 1 days

isoniazid 100 mg tab Preferred QL 3 / 1 days

PYRAZINAMIDE 500 MG TAB Preferred QL 8 / 1 days pyrazinamide

pyrazinamide 500 mg tab Preferred QL 8 / 1 days

PAGE 72 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

rifampin 300 mg cap Preferred QL 2 / 1 days

rifampin 150 mg cap Preferred QL 2 / 1 days

ANTINEOPLASTICS

ALKYLATING AGENTS

cyclophosphamide 25 mg cap Preferred cyclophosphamide 50 mg cap Preferred LEUKERAN Preferred chlorambucil melphalan Preferred MYLERAN Preferred busulfan TEMODAR 5 MG CAP Non-Preferred temozolomide TEMODAR 180 MG CAP Non-Preferred temozolomide TEMODAR 20 MG CAP Non-Preferred temozolomide TEMODAR 250 MG CAP Non-Preferred temozolomide TEMODAR 140 MG CAP Non-Preferred temozolomide TEMODAR 100 MG CAP Non-Preferred temozolomide

temozolomide Preferred PA

ANTIANDROGENS

abiraterone acetate Preferred PA

QL 1 / 1 days bicalutamide Preferred PA

CASODEX Non-Preferred QL 1 / 1 days bicalutamide ERLEADA Preferred PA apalutamide

flutamide Preferred QL 6 / 1 days

NUBEQA Preferred PA darolutamide

PAGE 73 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XTANDI Preferred PA enzalutamide YONSA Non-Preferred abiraterone acetate ZYTIGA Non-Preferred abiraterone acetate ANTIANGIOGENIC AGENTS

POMALYST Non-Preferred pomalidomide REVLIMID Preferred PA lenalidomide THALOMID 200 MG CAP Preferred PA thalidomide THALOMID 150 MG CAP Preferred thalidomide THALOMID 50 MG CAP Preferred PA thalidomide THALOMID 100 MG CAP Preferred PA thalidomide ANTIESTROGENS/MODIFIERS

EMCYT Preferred estramustine phosphate sodium FARESTON Non-Preferred QL 1 / 1 days toremifene citrate SOLTAMOX Non-Preferred tamoxifen citrate

tamoxifen citrate 20 mg tab Preferred QL 2 / 1 days

tamoxifen citrate 10 mg tab Preferred QL 2 / 1 days

toremifene citrate Non-Preferred QL 1 / 1 days

ANTIMETABOLITES

capecitabine Preferred PA

DROXIA Preferred hydroxyurea (sickle cell anemia) fluorouracil 2 % solution Preferred fluorouracil 5 % cream Preferred

PAGE 74 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluorouracil 5 % solution Preferred HYDREA Non-Preferred hydroxyurea hydroxyurea 500 mg cap Preferred mercaptopurine 50 mg tab Preferred SIKLOS Non-Preferred hydroxyurea (sickle cell anemia) TABLOID Preferred thioguanine XELODA Non-Preferred capecitabine ANTINEOPLASTICS, OTHER

ALUNBRIG 90 MG TAB QL 30 / 30 days Preferred brigatinib PA

ALUNBRIG 90 & 180 MG TAB THPK QL 30 / 30 days Preferred brigatinib PA

ALUNBRIG 180 MG TAB QL 30 / 30 days Preferred brigatinib PA

ALUNBRIG 30 MG TAB QL 60 / 30 days Preferred brigatinib PA

AYVAKIT 200 MG TAB QL 30 / 30 days Preferred avapritinib PA

AYVAKIT 300 MG TAB QL 30 / 30 days Preferred avapritinib PA

AYVAKIT 100 MG TAB QL 30 / 30 days Preferred avapritinib PA

BALVERSA Preferred erdafitinib

BRUKINSA QL 120 / 30 days Preferred zanubrutinib PA

COPIKTRA Preferred PA duvelisib FOTIVDA Non-Preferred QL 21 / 28 days tivozanib hcl

PAGE 75 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HEMANGEOL Preferred PA propranolol hcl IDHIFA Preferred PA enasidenib mesylate INQOVI Non-Preferred QL 5 / 28 days decitabine-cedazuridine INREBIC Preferred PA fedratinib hcl

leucovorin calcium 5 mg tab Preferred QL 3 / 1 days

leucovorin calcium 10 mg tab Preferred QL 2 / 1 days

leucovorin calcium 15 mg tab Preferred QL 1 / 1 days

leucovorin calcium 25 mg tab Preferred QL 1 / 1 days

LONSURF Preferred PA trifluridine-tipiracil LUMAKRAS Non-Preferred sotorasib LYSODREN Preferred mitotane NINLARO Preferred PA ixazomib citrate

PEMAZYRE QL 14 / 21 days Preferred pemigatinib PA

QINLOCK Non-Preferred QL 90 / 30 days ripretinib

RETEVMO 40 MG CAP QL 180 / 30 days Preferred selpercatinib PA

RETEVMO 80 MG CAP QL 120 / 30 days Preferred selpercatinib PA

ROZLYTREK Preferred PA entrectinib RUBRACA Preferred PA rucaparib camsylate RYDAPT Preferred PA midostaurin

TABRECTA QL 120 / 30 days Preferred capmatinib hcl PA

PAGE 76 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

TAZVERIK QL 240 / 30 days Preferred tazemetostat hbr PA

TIBSOVO Preferred PA ivosidenib TRUSELTIQ (100MG DAILY DOSE) Non-Preferred infigratinib phosphate TRUSELTIQ (125MG DAILY DOSE) Non-Preferred infigratinib phosphate TRUSELTIQ (50MG DAILY DOSE) Non-Preferred infigratinib phosphate TRUSELTIQ (75MG DAILY DOSE) Non-Preferred infigratinib phosphate TURALIO Preferred PA pexidartinib hcl VITRAKVI Preferred PA larotrectinib sulfate VIZIMPRO Preferred PA dacomitinib XOSPATA Preferred PA gilteritinib fumarate XPOVIO (100 MG ONCE WEEKLY) Preferred PA selinexor XPOVIO (40 MG ONCE WEEKLY) Preferred PA selinexor XPOVIO (40 MG TWICE WEEKLY) Preferred PA selinexor XPOVIO (60 MG ONCE WEEKLY) Preferred PA selinexor XPOVIO (60 MG TWICE WEEKLY) Preferred PA selinexor XPOVIO (80 MG ONCE WEEKLY) Preferred PA selinexor XPOVIO (80 MG TWICE WEEKLY) Preferred PA selinexor

ZOLADEX 3.6 MG IMPLANT QL 1 / 28 days Preferred goserelin acetate PA

ZOLADEX 10.8 MG IMPLANT QL 1 / 84 days Preferred goserelin acetate PA

PAGE 77 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOLINZA Preferred PA vorinostat AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1 mg tab Preferred QL 1 / 1 days

ARIMIDEX Non-Preferred QL 1 / 1 days anastrozole AROMASIN Non-Preferred QL 1 / 1 days exemestane

exemestane Preferred QL 1 / 1 days

FEMARA Non-Preferred letrozole

letrozole 2.5 mg tab Preferred PA

ENZYME INHIBITORS

ETOPOSIDE 50 MG CAP Preferred etoposide MOLECULAR TARGET INHIBITORS

AFINITOR Preferred PA everolimus AFINITOR DISPERZ Preferred PA everolimus ALECENSA Preferred PA alectinib hcl BOSULIF Preferred PA bosutinib BRAFTOVI Preferred PA encorafenib CABOMETYX Preferred PA cabozantinib s-malate

CALQUENCE QL 60 / 30 days Preferred acalabrutinib PA

CAPRELSA Preferred PA vandetanib COMETRIQ (100 MG DAILY DOSE) Preferred PA cabozantinib s-malate COMETRIQ (140 MG DAILY DOSE) Preferred PA cabozantinib s-malate

PAGE 78 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMETRIQ (60 MG DAILY DOSE) Preferred PA cabozantinib s-malate COTELLIC Preferred PA cobimetinib fumarate DAURISMO Preferred PA glasdegib maleate ERIVEDGE Preferred PA vismodegib

erlotinib hcl Preferred PA

everolimus 2.5 mg tab Non-Preferred PA

everolimus 7.5 mg tab Non-Preferred PA

everolimus 5 mg tab Non-Preferred PA

FARYDAK Preferred PA panobinostat lactate

GAVRETO QL 120 / 30 days Preferred pralsetinib PA

GILOTRIF Preferred PA afatinib dimaleate GLEEVEC Non-Preferred PA imatinib mesylate

IBRANCE QL 30 / 30 days Preferred palbociclib PA

ICLUSIG Preferred PA ponatinib hcl

imatinib mesylate Preferred PA

IMBRUVICA Preferred PA ibrutinib INLYTA Preferred PA axitinib IRESSA Preferred PA gefitinib JAKAFI Preferred PA ruxolitinib phosphate KISQALI (200 MG DOSE) Preferred PA ribociclib succinate

PAGE 79 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KISQALI (400 MG DOSE) Preferred PA ribociclib succinate KISQALI (600 MG DOSE) Preferred PA ribociclib succinate KISQALI FEMARA (400 MG DOSE) Preferred PA ribociclib succinate-letrozole KISQALI FEMARA (600 MG DOSE) Preferred PA ribociclib succinate-letrozole KISQALI FEMARA(200 MG DOSE) Preferred PA ribociclib succinate-letrozole KOSELUGO Preferred PA selumetinib sulfate lapatinib ditosylate Non-Preferred LENVIMA (10 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (12 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (14 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (18 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (20 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (24 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (4 MG DAILY DOSE) Preferred PA lenvatinib mesylate LENVIMA (8 MG DAILY DOSE) Preferred PA lenvatinib mesylate LORBRENA Preferred PA lorlatinib LYNPARZA Preferred PA olaparib MEKINIST Preferred PA trametinib dimethyl sulfoxide MEKTOVI Non-Preferred PA binimetinib NERLYNX Preferred PA neratinib maleate

PAGE 80 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

NEXAVAR QL 4 / 1 days Preferred sorafenib tosylate PA

ODOMZO Preferred PA sonidegib phosphate PIQRAY (200 MG DAILY DOSE) Preferred PA alpelisib PIQRAY (250 MG DAILY DOSE) Preferred PA alpelisib PIQRAY (300 MG DAILY DOSE) Preferred PA alpelisib SPRYCEL Preferred PA dasatinib STIVARGA Preferred PA regorafenib

SUTENT 50 MG CAP QL 1 / 1 days Preferred sunitinib malate PA

SUTENT 25 MG CAP QL 1 / 1 days Preferred sunitinib malate PA

SUTENT 12.5 MG CAP QL 3 / 1 days Preferred sunitinib malate PA

SUTENT 37.5 MG CAP Preferred PA sunitinib malate TAFINLAR Preferred PA dabrafenib mesylate TAGRISSO Preferred PA osimertinib mesylate TALZENNA Preferred PA talazoparib tosylate TARCEVA Non-Preferred PA erlotinib hcl TASIGNA Preferred PA nilotinib hcl TEPMETKO Non-Preferred QL 60 / 30 days tepotinib hcl

TUKYSA QL 120 / 30 days Preferred tucatinib PA

PAGE 81 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TYKERB Preferred PA lapatinib ditosylate UKONIQ Non-Preferred umbralisib tosylate VENCLEXTA Preferred PA venetoclax VENCLEXTA STARTING PACK Preferred PA venetoclax VERZENIO Preferred PA abemaciclib VOTRIENT Preferred PA pazopanib hcl XALKORI Preferred PA crizotinib ZEJULA Preferred PA niraparib tosylate ZELBORAF Preferred PA vemurafenib ZYDELIG Preferred PA idelalisib ZYKADIA Preferred PA ceritinib RETINOIDS

tretinoin 10 mg cap Preferred ANTIPARASITICS

ANTIHELMINTHICS

ivermectin 3 mg tab Preferred IVERMECTIN 0.5 % LOTION Non-Preferred ivermectin (pediculicide) NATROBA Preferred QL 240 / 30 days spinosad SKLICE Non-Preferred QL 234 / 30 days ivermectin (pediculicide)

spinosad Preferred QL 240 / 30 days

ANTIPROTOZOALS

ALINIA 100 MG/5ML RECON SUSP Preferred nitazoxanide

PAGE 82 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ARAKODA Non-Preferred tafenoquine succinate atovaquone-proguanil hcl 62.5-25 mg Preferred QL 3 / 1 days tab atovaquone-proguanil hcl 250-100 mg Preferred QL 1 / 1 days tab

chloroquine phosphate 250 mg tab Preferred QL 2 / 1 days

chloroquine phosphate 500 mg tab Preferred QL 1 / 1 days

COARTEM Preferred artemether-lumefantrine

hydroxychloroquine sulfate 200 mg tab Preferred QL 4 / 1 days

KRINTAFEL Preferred tafenoquine succinate MALARONE 62.5-25 MG TAB Non-Preferred QL 3 / 1 days atovaquone-proguanil hcl MALARONE 250-100 MG TAB Non-Preferred QL 1 / 1 days atovaquone-proguanil hcl

mefloquine hcl Preferred QL 5 / 26 days

nitazoxanide Non-Preferred PLAQUENIL Non-Preferred hydroxychloroquine sulfate PRIMAQUINE PHOSPHATE Preferred QL 2 / 1 days primaquine phosphate

primaquine phosphate Preferred QL 2 / 1 days

QUALAQUIN Non-Preferred quinine sulfate quinine sulfate 324 mg cap Non-Preferred PEDICULICIDES/SCABICIDES

CROTAN Non-Preferred crotamiton ELIMITE Non-Preferred permethrin EURAX Non-Preferred crotamiton lindane Non-Preferred

PAGE 83 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

malathion Non-Preferred QL 118 / 30 days

OVIDE Non-Preferred malathion permethrin 5 % cream Preferred ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate 0.5 mg tab Preferred QL 4 / 1 days

benztropine mesylate 1 mg tab Preferred QL 4 / 1 days

benztropine mesylate 2 mg tab Preferred QL 4 / 1 days

trihexyphenidyl hcl 2 mg tab Preferred QL 7 / 1 days

trihexyphenidyl hcl 5 mg tab Preferred QL 3 / 1 days

trihexyphenidyl hcl 0.4 mg/ml solution Preferred QL 38 / 1 days

ANTIPARKINSON AGENTS, OTHER

amantadine hcl 100 mg tab Preferred QL 4 / 1 days

amantadine hcl 100 mg cap Preferred QL 4 / 1 days

amantadine hcl 50 mg/5ml syrup Preferred QL 40 / 1 days

carbidopa-levodopa-entacapone Non-Preferred COMTAN Non-Preferred entacapone entacapone Preferred GOCOVRI Non-Preferred amantadine hcl NOURIANZ Non-Preferred istradefylline ONGENTYS Non-Preferred opicapone OSMOLEX ER Non-Preferred amantadine hcl STALEVO 100 Non-Preferred carbidopa-levodopa-entacapone STALEVO 125 Non-Preferred carbidopa-levodopa-entacapone

PAGE 84 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STALEVO 150 Non-Preferred carbidopa-levodopa-entacapone STALEVO 200 Non-Preferred carbidopa-levodopa-entacapone STALEVO 50 Non-Preferred carbidopa-levodopa-entacapone STALEVO 75 Non-Preferred carbidopa-levodopa-entacapone TASMAR Non-Preferred QL 3 / 1 days tolcapone

tolcapone Non-Preferred QL 3 / 1 days

DOPAMINE AGONISTS

bromocriptine mesylate 5 mg cap Preferred QL 20 / 1 days

bromocriptine mesylate 2.5 mg tab Preferred QL 20 / 1 days

KYNMOBI Non-Preferred apomorphine hydrochloride MIRAPEX 1 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.75 MG TAB Non-Preferred pramipexole dihydrochloride MIRAPEX 0.25 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.125 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 1.5 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.5 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX ER Non-Preferred pramipexole dihydrochloride NEUPRO Non-Preferred rotigotine PARLODEL Preferred bromocriptine mesylate

pramipexole dihydrochloride 0.75 mg tab Preferred QL 3 / 1 days

pramipexole dihydrochloride 1 mg tab Preferred QL 90 / 30 days

PAGE 85 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pramipexole dihydrochloride 0.125 mg Preferred QL 90 / 30 days tab

pramipexole dihydrochloride 0.25 mg tab Preferred QL 90 / 30 days

pramipexole dihydrochloride 1.5 mg tab Preferred QL 90 / 30 days

pramipexole dihydrochloride 0.5 mg tab Preferred QL 90 / 30 days

pramipexole dihydrochloride er Non-Preferred REQUIP 1 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 3 MG TAB Non-Preferred QL 90 / 30 days ropinirole hydrochloride REQUIP 0.25 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 2 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 4 MG TAB Non-Preferred QL 90 / 30 days ropinirole hydrochloride REQUIP 5 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 0.5 MG TAB Non-Preferred ropinirole hydrochloride REQUIP XL Non-Preferred ropinirole hydrochloride

ropinirole hcl 3 mg tab Preferred QL 90 / 30 days

ropinirole hcl 1 mg tab Preferred QL 3 / 1 days

ropinirole hcl 0.5 mg tab Preferred QL 3 / 1 days

ropinirole hcl 4 mg tab Preferred QL 90 / 30 days

ropinirole hcl 2 mg tab Preferred QL 3 / 1 days

ropinirole hcl 0.25 mg tab Preferred QL 3 / 1 days

ropinirole hcl 5 mg tab Preferred QL 3 / 1 days

ropinirole hcl er Non-Preferred DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 25 mg tab Non-Preferred CARBIDOPA-LEVODOPA 25-250 MG TAB DISP Non-Preferred carbidopa-levodopa

PAGE 86 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARBIDOPA-LEVODOPA 10-100 MG TAB DISP Non-Preferred carbidopa-levodopa carbidopa-levodopa 10-100 mg tab disp Non-Preferred

carbidopa-levodopa 25-250 mg tab Preferred QL 8 / 1 days

CARBIDOPA-LEVODOPA 25-100 MG TAB DISP Non-Preferred carbidopa-levodopa carbidopa-levodopa 25-250 mg tab disp Non-Preferred carbidopa-levodopa 25-100 mg tab disp Non-Preferred

carbidopa-levodopa 10-100 mg tab Preferred QL 20 / 1 days

carbidopa-levodopa 25-100 mg tab Preferred QL 8 / 1 days

carbidopa-levodopa er Preferred QL 12 / 1 days

DUOPA Non-Preferred carbidopa-levodopa INBRIJA Non-Preferred levodopa LODOSYN Non-Preferred carbidopa RYTARY Non-Preferred carbidopa-levodopa SINEMET Non-Preferred carbidopa-levodopa SINEMET CR Non-Preferred carbidopa-levodopa MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT Non-Preferred rasagiline mesylate rasagiline mesylate 0.5 mg tab Non-Preferred rasagiline mesylate 1 mg tab Non-Preferred

selegiline hcl 5 mg cap Preferred QL 2 / 1 days

selegiline hcl 5 mg tab Preferred QL 2 / 1 days

XADAGO Non-Preferred safinamide mesylate ZELAPAR Non-Preferred selegiline hcl

PAGE 87 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE QL 1 / 1 days Non-Preferred loxapine AL1 At least 18 yrs old

QL 5 / 1 days

chlorpromazine hcl 25 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl 10 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

chlorpromazine hcl 200 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl 100 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old chlorpromazine hcl 50 mg/2ml solution Non-Preferred C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl 50 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old chlorpromazine hcl 25 mg/ml solution Non-Preferred C Age restriction, clinical PA required

QL 10 / 26 days fluphenazine decanoate 25 mg/ml Preferred AL1 At least 18 yrs old solution C Age restriction, clinical PA required

QL 20 / 1 days

fluphenazine hcl 2.5 mg/5ml elixir Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 88 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 4 / 1 days

fluphenazine hcl 1 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl 10 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl 5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

fluphenazine hcl 5 mg/ml conc Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl 2.5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl 2.5 mg/ml solution Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 20 / 1 days HALDOL Preferred AL1 At least 18 yrs old haloperidol lactate C Age restriction, clinical PA required

QL 4 / 1 days HALDOL DECANOATE Non-Preferred AL1 At least 18 yrs old haloperidol decanoate C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol 5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 89 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 5 / 1 days

haloperidol 1 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol 20 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol 0.5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol 10 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 9 / 28 days

haloperidol decanoate 50 mg/ml solution Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 28 days haloperidol decanoate 100 mg/ml Preferred AL1 At least 18 yrs old solution C Age restriction, clinical PA required

QL 20 / 1 days

haloperidol lactate 5 mg/ml solution Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 50 / 1 days

haloperidol lactate 2 mg/ml conc Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days loxapine succinate 50 mg cap Preferred AL1 At least 18 yrs old

QL 8 / 1 days loxapine succinate 10 mg cap Preferred AL1 At least 18 yrs old

PAGE 90 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 12 / 1 days loxapine succinate 5 mg cap Preferred AL1 At least 18 yrs old

QL 5 / 1 days loxapine succinate 25 mg cap Preferred AL1 At least 18 yrs old

molindone hcl Non-Preferred AL1 At least 18 yrs old

QL 10 / 1 days

pimozide 1 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

pimozide 2 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl 25 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl 50 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl 100 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl 10 mg tab Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

thiothixene Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

trifluoperazine hcl Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 91 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 2ND GENERATION/ATYPICAL

QL 60 / 30 days ABILIFY 15 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY 20 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY 30 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 60 / 30 days ABILIFY 5 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 60 / 30 days ABILIFY 10 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 60 / 30 days ABILIFY 2 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 1 / 28 days ABILIFY MAINTENA Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE MAINTENANCE KIT Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

PAGE 92 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days ABILIFY MYCITE STARTER KIT Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days

aripiprazole 30 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole 2 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole 5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

aripiprazole 20 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole 15 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole 15 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 25 / 1 days

aripiprazole 1 mg/ml solution Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole 10 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 93 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old ARISTADA 882 MG/3.2ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 3.2 mL/42 days

AL1 At least 18 yrs old ARISTADA 441 MG/1.6ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 1.6 mL/28 days

AL1 At least 18 yrs old ARISTADA 1064 MG/3.9ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 3.9 mL/56 days

AL1 At least 18 yrs old ARISTADA 662 MG/2.4ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 2.4 mL/28 days

AL1 At least 18 yrs old ARISTADA INITIO Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 2.4 mL/42 days

QL 60 / 30 days

asenapine maleate Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days CAPLYTA Non-Preferred AL1 At least 18 yrs old lumateperone tosylate C Age restriction, clinical PA required

QL 60 / 30 days FANAPT Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT TITRATION PACK Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required GEODON 60 MG CAP Non-Preferred ziprasidone hcl

PAGE 94 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 2 / 1 days GEODON 20 MG RECON SOLN Non-Preferred AL1 At least 18 yrs old ziprasidone mesylate C Age restriction, clinical PA required GEODON 80 MG CAP Non-Preferred ziprasidone hcl

AL1 At least 18 yrs old GEODON 20 MG CAP Non-Preferred ziprasidone hcl C Age restriction, clinical PA required

QL 3 / 1 days GEODON 40 MG CAP Non-Preferred AL1 At least 18 yrs old ziprasidone hcl C Age restriction, clinical PA required

QL 30 / 30 days INVEGA 9 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 30 / 30 days INVEGA 1.5 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 60 / 30 days INVEGA 6 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 30 / 30 days INVEGA 3 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

AL1 At least 18 yrs old INVEGA SUSTENNA 234 MG/1.5ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.5 mL/28 days

AL1 At least 18 yrs old INVEGA SUSTENNA 39 MG/0.25ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.25 mL/28 days

PAGE 95 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.75 mL/28 days

AL1 At least 18 yrs old INVEGA SUSTENNA 78 MG/0.5ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.5 mL/28 days

AL1 At least 18 yrs old INVEGA TRINZA 819 MG/2.625ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 2.625 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 410 MG/1.315ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.315 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 273 MG/0.875ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.875 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 546 MG/1.75ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.75 mL/84 days

QL 30 / 30 days LATUDA 20 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

QL 30 / 30 days LATUDA 60 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

QL 60 / 30 days LATUDA 80 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

PAGE 96 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days LATUDA 40 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

AL1 At least 18 yrs old NUPLAZID Non-Preferred pimavanserin tartrate C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine 5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine 10 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

olanzapine 10 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine 20 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine 5 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

olanzapine 10 mg recon soln Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine 15 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine 7.5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 97 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days

olanzapine 2.5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine 15 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine 20 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone er 9 mg tab er 24h Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone er 1.5 mg tab er 24h Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone er 3 mg tab er 24h Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

paliperidone er 6 mg tab er 24h Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old PERSERIS Preferred C Age restriction, clinical risperidone PA required QLC 0.04 mL/day

QL 60 / 30 days

quetiapine fumarate 300 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 98 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days

quetiapine fumarate 25 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

quetiapine fumarate 50 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

quetiapine fumarate 100 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

quetiapine fumarate 200 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days quetiapine fumarate er 200 mg tab er Preferred AL1 At least 18 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days quetiapine fumarate er 400 mg tab er Preferred AL1 At least 18 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days quetiapine fumarate er 300 mg tab er Preferred AL1 At least 18 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days

quetiapine fumarate er 50 mg tab er 24h Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days quetiapine fumarate er 150 mg tab er Preferred AL1 At least 18 yrs old 24h C Age restriction, clinical PA required

PAGE 99 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days REXULTI 4 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 0.25 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 0.5 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 1 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 30 / 30 days REXULTI 2 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 90 / 30 days RISPERDAL 2 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

AL1 At least 18 yrs old RISPERDAL 1 MG/ML SOLUTION Non-Preferred C Age restriction, clinical risperidone PA required QLC 8 mL/day

QL 150 / 30 days RISPERDAL 0.5 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 60 / 30 days RISPERDAL 4 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

PAGE 100 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days RISPERDAL 3 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 150 / 30 days RISPERDAL 1 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 2 / 28 days RISPERDAL CONSTA Preferred AL1 At least 18 yrs old risperidone microspheres C Age restriction, clinical PA required

QL 150 / 30 days

risperidone 0.5 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 0.5 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 150 / 30 days

risperidone 1 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 4 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 3 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 4 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 101 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days

risperidone 1 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 3 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old

risperidone 1 mg/ml solution Preferred C Age restriction, clinical PA required QLC 8 mL/day

QL 60 / 30 days

risperidone 0.25 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone 2 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 150 / 30 days

risperidone 0.25 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days SAPHRIS Non-Preferred AL1 At least 18 yrs old asenapine maleate C Age restriction, clinical PA required

AL1 At least 18 yrs old SECUADO Non-Preferred asenapine C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL 300 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL 400 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

PAGE 102 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days SEROQUEL 50 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 120 / 30 days SEROQUEL 200 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 120 / 30 days SEROQUEL 25 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 90 / 30 days SEROQUEL 100 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 400 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 50 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 30 / 30 days SEROQUEL XR 200 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 30 / 30 days SEROQUEL XR 150 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 300 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

PAGE 103 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old VRAYLAR 1.5 & 3 MG CAP THPK Non-Preferred cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 4.5 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 3 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 6 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 3 / 1 days

ziprasidone hcl Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

ziprasidone mesylate Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 90 / 30 days ZYPREXA 10 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 7.5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 20 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

PAGE 104 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days ZYPREXA 15 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 90 / 30 days ZYPREXA 10 MG RECON SOLN Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 2.5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 2 / 28 days ZYPREXA RELPREVV Preferred AL1 At least 18 yrs old olanzapine pamoate C Age restriction, clinical PA required

QL 30 / 30 days ZYPREXA ZYDIS Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required TREATMENT-RESISTANT

QL 3 / 1 days

clozapine 25 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

clozapine 200 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 270 / 30 days

clozapine 100 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 9 / 1 days

clozapine 100 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 105 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days

clozapine 50 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

clozapine 12.5 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

clozapine 200 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clozapine 150 mg tab disp Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 180 / 30 days

clozapine 25 mg tab Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 270 / 30 days CLOZARIL 100 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 180 / 30 days CLOZARIL 25 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 90 / 30 days CLOZARIL 50 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 120 / 30 days CLOZARIL 200 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 100 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

PAGE 106 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 3 / 1 days FAZACLO 25 MG TAB DISP Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 2 / 1 days FAZACLO 12.5 MG TAB DISP Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 150 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 200 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old VERSACLOZ Non-Preferred clozapine C Age restriction, clinical PA required ANTISPASTICITY AGENTS

baclofen 5 mg tab Preferred QL 120 / 30 days

baclofen 10 mg tab Preferred QL 5 / 1 days

baclofen 20 mg tab Preferred QL 4 / 1 days

BOTOX Preferred PA onabotulinumtoxina DANTRIUM 50 MG CAP Non-Preferred dantrolene sodium DANTRIUM 25 MG CAP Non-Preferred dantrolene sodium

dantrolene sodium 25 mg cap Preferred QL 4 / 1 days

dantrolene sodium 100 mg cap Preferred QL 4 / 1 days

dantrolene sodium 50 mg cap Preferred QL 4 / 1 days

OZOBAX Non-Preferred baclofen

tizanidine hcl 4 mg tab Preferred QL 6 / 1 days

tizanidine hcl 2 mg cap Non-Preferred

PAGE 107 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

tizanidine hcl 2 mg tab Preferred QL 6 / 1 days

tizanidine hcl 4 mg cap Non-Preferred tizanidine hcl 6 mg cap Non-Preferred XEOMIN Non-Preferred incobotulinumtoxina ZANAFLEX Non-Preferred tizanidine hcl ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS 240 MG TAB Preferred PA letermovir PREVYMIS 480 MG TAB Preferred PA letermovir VALCYTE 50 MG/ML RECON SOLN Preferred valganciclovir hcl VALCYTE 450 MG TAB Non-Preferred valganciclovir hcl valganciclovir hcl 450 mg tab Preferred valganciclovir hcl 50 mg/ml recon soln Non-Preferred ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil Preferred BARACLUDE 0.05 MG/ML SOLUTION Preferred QL 20 / 1 days entecavir BARACLUDE 1 MG TAB Non-Preferred QL 1 / 1 days entecavir BARACLUDE 0.5 MG TAB Non-Preferred QL 1 / 1 days entecavir

entecavir Preferred QL 1 / 1 days

EPIVIR HBV 5 MG/ML SOLUTION Preferred lamivudine (hbv) EPIVIR HBV 100 MG TAB Non-Preferred lamivudine (hbv) HEPSERA Preferred adefovir dipivoxil lamivudine 100 mg tab Preferred

PAGE 108 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VEMLIDY Non-Preferred QL 1 / 1 days tenofovir alafenamide fumarate ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA 30 MG TAB Non-Preferred daclatasvir dihydrochloride DAKLINZA 60 MG TAB Non-Preferred daclatasvir dihydrochloride EPCLUSA Non-Preferred QL 28 / 28 days sofosbuvir-velpatasvir HARVONI Non-Preferred ledipasvir-sofosbuvir LEDIPASVIR-SOFOSBUVIR Non-Preferred ledipasvir-sofosbuvir

MAVYRET QL 3 / 1 days Preferred glecaprevir-pibrentasvir PA

SOFOSBUVIR-VELPATASVIR QL 28 / 28 days Preferred sofosbuvir-velpatasvir PA

SOVALDI Non-Preferred sofosbuvir VIEKIRA PAK ombitasvir-paritaprevir-ritonavir- Non-Preferred dasabuvir VOSEVI Non-Preferred QL 1 / 1 days sofosbuvir-velpatasvir-voxilaprevir

ZEPATIER QL 28 / 28 days Preferred elbasvir-grazoprevir PA

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

moderiba Non-Preferred MODERIBA (1200 MG PACK) Non-Preferred ribavirin (hepatitis c) PEGASYS Non-Preferred peginterferon alfa-2a PEGASYS PROCLICK 180 MCG/0.5ML SOLUTION Non-Preferred peginterferon alfa-2a PEGINTRON Non-Preferred QL 4 / 28 days peginterferon alfa-2b

PAGE 109 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REBETOL 40 MG/ML SOLUTION Non-Preferred ribavirin (hepatitis c) RIBASPHERE 400 MG TAB Non-Preferred ribavirin (hepatitis c) RIBASPHERE 600 MG TAB Non-Preferred ribavirin (hepatitis c) ribasphere 200 mg tab Non-Preferred ribasphere 200 mg cap Preferred RIBASPHERE RIBAPAK (1000 PACK) Non-Preferred ribavirin (hepatitis c) RIBASPHERE RIBAPAK (1200 PACK) Non-Preferred ribavirin (hepatitis c)

ribavirin 200 mg tab Non-Preferred QL 7 / 1 days

ribavirin 200 mg cap Preferred QL 7 / 1 days

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY bictegravir-emtricitabine-tenofovir Preferred QL 1 / 1 days alafenamide fumarate GENVOYA elvitegravir-cobicistat-emtricitabine- Preferred QL 1 / 1 days tenofovir alafenamide ISENTRESS 25 MG CHEW TAB Preferred QL 6 / 1 days raltegravir potassium ISENTRESS 100 MG PACKET Preferred raltegravir potassium ISENTRESS 400 MG TAB Preferred QL 2 / 1 days raltegravir potassium ISENTRESS 100 MG CHEW TAB Preferred QL 6 / 1 days raltegravir potassium ISENTRESS HD Non-Preferred QL 2 / 1 days raltegravir potassium STRIBILD elvitegravir-cobicistat-emtricitabine- Non-Preferred QL 1 / 1 days tenofovir df TIVICAY Preferred QL 60 / 30 days dolutegravir sodium TIVICAY PD Preferred QL 180 / 30 days dolutegravir sodium

PAGE 110 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VOCABRIA Non-Preferred QL 30 / 30 days cabotegravir sodium ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA efavirenz-emtricitabine-tenofovir Non-Preferred QL 30 / 30 days disoproxil fumarate COMPLERA emtricitabine-rilpivirine-tenofovir Preferred QL 1 / 1 days disoproxil fumarate DELSTRIGO doravirine-lamivudine-tenofovir Preferred QL 30 / 30 days disoproxil fumarate EDURANT Preferred QL 1 / 1 days rilpivirine hcl

efavirenz 200 mg cap Preferred QL 90 / 30 days

efavirenz 50 mg cap Preferred QL 90 / 30 days

efavirenz 600 mg tab Preferred QL 30 / 30 days

efavirenz-emtricitab-tenofovir Preferred efavirenz-lamivudine-tenofovir Non-Preferred INTELENCE 25 MG TAB Non-Preferred etravirine INTELENCE 200 MG TAB Non-Preferred QL 2 / 1 days etravirine INTELENCE 100 MG TAB Non-Preferred QL 120 / 30 days etravirine

nevirapine 200 mg tab Preferred QL 2 / 1 days

nevirapine 50 mg/5ml suspension Non-Preferred QL 1200 / 30 days

nevirapine er 100 mg tab er 24h Non-Preferred

nevirapine er 400 mg tab er 24h Non-Preferred QL 1 / 1 days

ODEFSEY emtricitabine-rilpivirine-tenofovir Preferred QL 1 / 1 days alafenamide fumarate PIFELTRO Non-Preferred QL 60 / 30 days doravirine RESCRIPTOR 200 MG TAB Non-Preferred QL 180 / 30 days delavirdine mesylate

PAGE 111 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUSTIVA 200 MG CAP Non-Preferred QL 90 / 30 days efavirenz SUSTIVA 50 MG CAP Non-Preferred QL 90 / 30 days efavirenz SUSTIVA 600 MG TAB Non-Preferred QL 30 / 30 days efavirenz SYMFI efavirenz-lamivudine-tenofovir disoproxil Preferred QL 30 / 30 days fumarate SYMFI LO efavirenz-lamivudine-tenofovir disoproxil Preferred QL 30 / 30 days fumarate VIRAMUNE 200 MG TAB Non-Preferred QL 2 / 1 days nevirapine VIRAMUNE 50 MG/5ML SUSPENSION Non-Preferred QL 1200 / 30 days nevirapine VIRAMUNE XR 400 MG TAB ER 24H Non-Preferred QL 1 / 1 days nevirapine ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mg/ml solution Preferred QL 900 / 30 days

abacavir sulfate 300 mg tab Preferred QL 2 / 1 days

abacavir sulfate-lamivudine Preferred QL 1 / 1 days

abacavir-lamivudine-zidovudine Non-Preferred QL 2 / 1 days

CIMDUO Preferred QL 1 / 1 days lamivudine-tenofovir disoproxil fumarate COMBIVIR Non-Preferred QL 2 / 1 days lamivudine-zidovudine

didanosine 400 mg cap dr Non-Preferred QL 1 / 1 days

didanosine 250 mg cap dr Non-Preferred QL 1 / 1 days

emtricitabine Non-Preferred

emtricitabine-tenofovir df Preferred QL 30 / 30 days

EMTRIVA 200 MG CAP Preferred QL 1 / 1 days emtricitabine EMTRIVA 10 MG/ML SOLUTION Preferred QL 720 / 30 days emtricitabine

PAGE 112 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPIVIR 10 MG/ML SOLUTION Non-Preferred lamivudine EPIVIR 300 MG TAB Non-Preferred QL 1 / 1 days lamivudine EPIVIR 150 MG TAB Non-Preferred QL 2 / 1 days lamivudine EPZICOM Non-Preferred QL 1 / 1 days abacavir sulfate-lamivudine

lamivudine 150 mg tab Preferred QL 2 / 1 days

lamivudine 10 mg/ml solution Preferred QL 900 / 30 days

lamivudine 300 mg tab Preferred QL 1 / 1 days

lamivudine-zidovudine Preferred QL 2 / 1 days

RETROVIR 50 MG/5ML SYRUP Non-Preferred zidovudine RETROVIR 100 MG CAP Non-Preferred zidovudine

stavudine 40 mg cap Non-Preferred QL 2 / 1 days

stavudine 15 mg cap Non-Preferred STAVUDINE 15 MG CAP Non-Preferred QL 120 / 30 days stavudine STAVUDINE 40 MG CAP Non-Preferred QL 2 / 1 days stavudine STAVUDINE 30 MG CAP Non-Preferred QL 2 / 1 days stavudine stavudine 20 mg cap Non-Preferred

stavudine 30 mg cap Non-Preferred QL 2 / 1 days

STAVUDINE 20 MG CAP Non-Preferred QL 120 / 30 days stavudine TEMIXYS Non-Preferred lamivudine-tenofovir disoproxil fumarate

tenofovir disoproxil fumarate Preferred QL 30 / 30 days

TRIZIVIR Non-Preferred QL 2 / 1 days abacavir sulfate-lamivudine-zidovudine TRUVADA emtricitabine-tenofovir disoproxil Non-Preferred QL 1 / 1 days fumarate

PAGE 113 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIDEX 2 GM RECON SOLN Preferred QL 1200 / 30 days didanosine VIDEX 4 GM RECON SOLN Preferred didanosine VIDEX EC 250 MG CAP DR Non-Preferred QL 1 / 1 days didanosine VIDEX EC 400 MG CAP DR Non-Preferred QL 1 / 1 days didanosine VIDEX EC 200 MG CAP DR Non-Preferred QL 2 / 1 days didanosine VIDEX EC 125 MG CAP DR Non-Preferred QL 2 / 1 days didanosine VIREAD 200 MG TAB Preferred QL 1 / 1 days tenofovir disoproxil fumarate VIREAD 40 MG/GM POWDER Preferred tenofovir disoproxil fumarate VIREAD 250 MG TAB Preferred QL 1 / 1 days tenofovir disoproxil fumarate VIREAD 150 MG TAB Preferred QL 2 / 1 days tenofovir disoproxil fumarate VIREAD 300 MG TAB Non-Preferred QL 30 / 30 days tenofovir disoproxil fumarate ZERIT 30 MG CAP Non-Preferred QL 2 / 1 days stavudine ZERIT 40 MG CAP Non-Preferred QL 2 / 1 days stavudine ZERIT 20 MG CAP Non-Preferred stavudine ZIAGEN 20 MG/ML SOLUTION Non-Preferred abacavir sulfate ZIAGEN 300 MG TAB Non-Preferred QL 2 / 1 days abacavir sulfate

zidovudine 100 mg cap Preferred QL 180 / 30 days

zidovudine 300 mg tab Preferred QL 60 / 30 days

zidovudine 50 mg/5ml syrup Preferred QL 1800 / 30 days

PAGE 114 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTI-HIV AGENTS, OTHER

CABENUVA 600 & 900 MG/3ML SUSP Non-Preferred QLC 6 mL/28 days cabotegravir & rilpivirine CABENUVA 400 & 600 MG/2ML SUSP Non-Preferred QLC 4 mL/28 days cabotegravir & rilpivirine DESCOVY emtricitabine-tenofovir alafenamide Preferred QL 1 / 1 days fumarate DOVATO Preferred dolutegravir sodium-lamivudine FUZEON Non-Preferred QL 60 / 30 days enfuvirtide JULUCA Preferred QL 1 / 1 days dolutegravir sodium-rilpivirine hcl RUKOBIA Non-Preferred QL 60 / 30 days fostemsavir tromethamine SELZENTRY 20 MG/ML SOLUTION Non-Preferred maraviroc SELZENTRY 25 MG TAB Non-Preferred maraviroc SELZENTRY 75 MG TAB Non-Preferred maraviroc SELZENTRY 300 MG TAB Non-Preferred QL 120 / 30 days maraviroc SELZENTRY 150 MG TAB Non-Preferred QL 2 / 1 days maraviroc TRIUMEQ Preferred QL 1 / 1 days abacavir-dolutegravir-lamivudine TROGARZO Non-Preferred ibalizumab-uiyk TYBOST Non-Preferred QL 1 / 1 days cobicistat ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 250 MG CAP Non-Preferred QL 120 / 30 days tipranavir APTIVUS 100 MG/ML SOLUTION Non-Preferred QL 300 / 30 days tipranavir

atazanavir sulfate 150 mg cap Preferred QL 2 / 1 days

PAGE 115 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

atazanavir sulfate 300 mg cap Preferred QL 1 / 1 days

atazanavir sulfate 200 mg cap Preferred QL 60 / 30 days

CRIXIVAN 200 MG CAP Non-Preferred QL 360 / 30 days indinavir sulfate CRIXIVAN 400 MG CAP Non-Preferred QL 180 / 30 days indinavir sulfate EVOTAZ Preferred QL 1 / 1 days atazanavir sulfate-cobicistat

fosamprenavir calcium Non-Preferred QL 120 / 30 days

INVIRASE 500 MG TAB Non-Preferred QL 120 / 30 days saquinavir mesylate KALETRA 400-100 MG/5ML SOLUTION Preferred QL 400 / 30 days lopinavir-ritonavir KALETRA 100-25 MG TAB Preferred QL 300 / 30 days lopinavir-ritonavir KALETRA 200-50 MG TAB Preferred QL 120 / 30 days lopinavir-ritonavir LEXIVA 700 MG TAB Non-Preferred fosamprenavir calcium LEXIVA 50 MG/ML SUSPENSION Non-Preferred QL 56 / 1 days fosamprenavir calcium lopinavir-ritonavir 100-25 mg tab Non-Preferred lopinavir-ritonavir 200-50 mg tab Non-Preferred lopinavir-ritonavir 400-100 mg/5ml Non-Preferred QL 400 / 30 days solution NORVIR 80 MG/ML SOLUTION Preferred QL 480 / 30 days ritonavir NORVIR 100 MG TAB Non-Preferred ritonavir NORVIR 100 MG PACKET Preferred QL 360 / 30 days ritonavir PREZCOBIX Preferred QL 1 / 1 days darunavir-cobicistat PREZISTA 800 MG TAB Preferred QL 1 / 1 days darunavir ethanolate PREZISTA 100 MG/ML SUSPENSION Preferred QL 12 / 1 days darunavir ethanolate

PAGE 116 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREZISTA 600 MG TAB Preferred QL 2 / 1 days darunavir ethanolate PREZISTA 75 MG TAB Preferred QL 180 / 30 days darunavir ethanolate PREZISTA 150 MG TAB Preferred QL 120 / 30 days darunavir ethanolate REYATAZ 50 MG PACKET Preferred atazanavir sulfate REYATAZ 200 MG CAP Non-Preferred QL 60 / 30 days atazanavir sulfate REYATAZ 150 MG CAP Non-Preferred QL 2 / 1 days atazanavir sulfate REYATAZ 300 MG CAP Non-Preferred QL 1 / 1 days atazanavir sulfate

ritonavir Preferred QL 360 / 30 days

SYMTUZA darunavir-cobicistat-emtricitabine- Non-Preferred QL 30 / 30 days tenofovir alafenamide VIRACEPT 250 MG TAB Non-Preferred QL 270 / 30 days nelfinavir mesylate VIRACEPT 625 MG TAB Non-Preferred QL 120 / 30 days nelfinavir mesylate ANTI-INFLUENZA AGENTS

FLUMADINE Non-Preferred rimantadine hydrochloride

oseltamivir phosphate 30 mg cap Preferred QLC Max 21 day supply every 365 days

oseltamivir phosphate 45 mg cap Preferred QLC Max 21 day supply every 365 days

oseltamivir phosphate 75 mg cap Preferred QLC Max 21 day supply every 365 days oseltamivir phosphate 6 mg/ml recon Preferred QLC Max 21 day supply susp every 365 days RAPIVAB Non-Preferred peramivir RELENZA DISKHALER Preferred zanamivir rimantadine hcl Non-Preferred

PAGE 117 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TAMIFLU Non-Preferred QLC Max 21 day supply oseltamivir phosphate every 365 days XOFLUZA (40 MG DOSE) Non-Preferred baloxavir marboxil XOFLUZA (80 MG DOSE) Non-Preferred baloxavir marboxil ANTIHERPETIC AGENTS

acyclovir 5 % ointment Non-Preferred

acyclovir 200 mg/5ml suspension Preferred QL 50 / 1 days

acyclovir 5 % cream Non-Preferred

acyclovir 800 mg tab Preferred QL 5 / 1 days

acyclovir 400 mg tab Preferred QL 5 / 1 days

acyclovir 200 mg cap Preferred QL 5 / 1 days

DENAVIR Non-Preferred penciclovir

famciclovir 125 mg tab Preferred QL 3 / 1 days

famciclovir 500 mg tab Preferred QL 90 / 30 days

famciclovir 250 mg tab Preferred QL 3 / 1 days

SITAVIG Non-Preferred acyclovir

trifluridine 1 % solution Preferred QL 7.5 / 18 days

valacyclovir hcl 500 mg tab Preferred QL 4 / 1 days

valacyclovir hcl 1 gm tab Preferred QL 4 / 1 days

VALTREX Non-Preferred valacyclovir hcl XERESE Non-Preferred acyclovir-hydrocortisone ZOVIRAX 800 MG TAB Non-Preferred acyclovir ZOVIRAX 5 % OINTMENT Non-Preferred acyclovir topical ZOVIRAX 400 MG TAB Non-Preferred acyclovir

PAGE 118 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOVIRAX 200 MG CAP Non-Preferred QL 5 / 1 days acyclovir ZOVIRAX 200 MG/5ML SUSPENSION Non-Preferred acyclovir ZOVIRAX 5 % CREAM Non-Preferred acyclovir topical ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 5 mg tab Preferred QL 6 / 1 days

buspirone hcl 15 mg tab Preferred QL 4 / 1 days

buspirone hcl 30 mg tab Preferred QL 2 / 1 days

buspirone hcl 10 mg tab Preferred QL 6 / 1 days

buspirone hcl 7.5 mg tab Preferred QL 4 / 1 days

meprobamate Non-Preferred QL 6 / 1 days

BENZODIAZEPINES

QL 3 / 1 days

alprazolam 2 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam 0.5 mg tab disp Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam 0.25 mg tab disp Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam 1 mg tab disp Non-Preferred C Age restriction, clinical PA required

QL 6 / 1 days

alprazolam 1 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

alprazolam 0.25 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

PAGE 119 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days

alprazolam 0.5 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam 2 mg tab disp Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam er Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old ALPRAZOLAM INTENSOL Non-Preferred alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam xr Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old ATIVAN 2 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old ATIVAN 1 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old ATIVAN 0.5 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required ATIVAN 4 MG/ML SOLUTION Non-Preferred lorazepam ATIVAN 2 MG/ML SOLUTION Non-Preferred lorazepam

QL 10 / 1 days

chlordiazepoxide hcl 10 mg cap Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 12 / 1 days

chlordiazepoxide hcl 25 mg cap Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

PAGE 120 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days

clonazepam 2 mg tab disp Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam 1 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam 0.5 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

clonazepam 0.125 mg tab disp Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

clonazepam 0.25 mg tab disp Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

clonazepam 0.5 mg tab disp Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam 2 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

clonazepam 1 mg tab disp Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

clorazepate dipotassium 7.5 mg tab Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

PAGE 121 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days

clorazepate dipotassium 15 mg tab Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required diazepam 5 mg/5ml solution Preferred

QL 4 / 1 days

diazepam 2 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old DIAZEPAM 10 MG/2ML SOLN A-INJ Non-Preferred diazepam C Age restriction, clinical PA required

QL 8 / 1 days

diazepam 5 mg/ml conc Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

diazepam 5 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old diazepam 5 mg/ml solution Non-Preferred C Age restriction, clinical PA required

QL 4 / 1 days

diazepam 10 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old DIAZEPAM 5 MG/ML SOLUTION Non-Preferred diazepam C Age restriction, clinical PA required DIAZEPAM 5 MG/ML inj cartridge Non-Preferred

AL1 At least 21 yrs old DIAZEPAM INJ 5 MG/ML Preferred C Age restriction, clinical PA required

QL 8 / 1 days

diazepam intensol Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

PAGE 122 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 40 / 1 days

DIAZEPAM ORAL SOLN 1 MG/ML Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old KLONOPIN Non-Preferred clonazepam C Age restriction, clinical PA required

QL 5 / 1 days

lorazepam 2 mg/ml conc Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

lorazepam 1 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

lorazepam 0.5 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required lorazepam 4 mg/ml solution Preferred lorazepam 2 mg/ml solution Preferred

QL 4 / 1 days

lorazepam 2 mg tab Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

lorazepam intensol Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

oxazepam 15 mg cap Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

oxazepam 10 mg cap Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

PAGE 123 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 4 / 1 days

oxazepam 30 mg cap Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old TRANXENE-T Non-Preferred clorazepate dipotassium C Age restriction, clinical PA required

QL 6 / 1 days XANAX 1 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 6 / 1 days XANAX 0.25 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 6 / 1 days XANAX 0.5 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 3 / 1 days XANAX 2 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old XANAX XR Non-Preferred alprazolam C Age restriction, clinical PA required BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO Preferred carbamazepine (antipsychotic)

lithium carbonate 150 mg cap Preferred QL 4 / 1 days

lithium carbonate 300 mg cap Preferred QL 4 / 1 days

lithium carbonate 300 mg tab Preferred QL 4 / 1 days

lithium carbonate 600 mg cap Preferred QL 4 / 1 days

lithium carbonate er Preferred QL 4 / 1 days

PAGE 124 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 25 mg tab Preferred QL 3 / 1 days

acarbose 50 mg tab Preferred QL 3 / 1 days

acarbose 100 mg tab Preferred QL 3 / 1 days

ACTOPLUS MET Non-Preferred QL 90 / 30 days pioglitazone hcl-metformin hcl ACTOPLUS MET XR Non-Preferred pioglitazone hcl-metformin hcl ACTOS Non-Preferred QL 30 / 30 days pioglitazone hcl ADLYXIN Non-Preferred lixisenatide ADLYXIN STARTER PACK Non-Preferred lixisenatide alogliptin benzoate Non-Preferred alogliptin-metformin hcl Non-Preferred alogliptin-pioglitazone Non-Preferred AMARYL 2 MG TAB Non-Preferred QL 90 / 30 days glimepiride AMARYL 1 MG TAB Non-Preferred QL 60 / 30 days glimepiride AMARYL 4 MG TAB Non-Preferred QL 60 / 30 days glimepiride AVANDIA Non-Preferred rosiglitazone maleate BYDUREON Non-Preferred QL 4 / 28 days exenatide BYDUREON BCISE Non-Preferred QL 3.4 / 28 days exenatide BYETTA 10 MCG PEN Non-Preferred QL 2.4 / 30 days exenatide BYETTA 5 MCG PEN Non-Preferred QL 1.2 / 30 days exenatide CHLORPROPAMIDE 250 MG TAB Non-Preferred QL 3 / 1 days chlorpropamide

PAGE 125 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CHLORPROPAMIDE 100 MG TAB Non-Preferred QL 7 / 1 days chlorpropamide DUETACT Non-Preferred QL 30 / 30 days pioglitazone hcl-glimepiride FARXIGA Preferred PA dapagliflozin propanediol FORTAMET 500 MG TAB ER 24H Non-Preferred QL 90 / 30 days metformin hcl FORTAMET 1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days metformin hcl

glimepiride 1 mg tab Preferred QL 60 / 30 days

glimepiride 2 mg tab Preferred QL 90 / 30 days

glimepiride 4 mg tab Preferred QL 60 / 30 days

glipizide 10 mg tab Preferred QL 4 / 1 days

glipizide 5 mg tab Preferred QL 4 / 1 days

glipizide er 2.5 mg tab er 24h Preferred QL 8 / 1 days

glipizide er 10 mg tab er 24h Preferred QL 60 / 30 days

glipizide er 5 mg tab er 24h Preferred QL 4 / 1 days

glipizide xl 10 mg tab er 24h Preferred QL 2 / 1 days

glipizide xl 2.5 mg tab er 24h Preferred QL 8 / 1 days

glipizide xl 5 mg tab er 24h Preferred QL 4 / 1 days

glipizide-metformin hcl 2.5-500 mg tab Preferred QL 5 / 1 days

glipizide-metformin hcl 5-500 mg tab Preferred QL 4 / 1 days

glipizide-metformin hcl 2.5-250 mg tab Preferred QL 7 / 1 days

GLUCOPHAGE 850 MG TAB Non-Preferred QL 90 / 30 days metformin hcl GLUCOPHAGE 500 MG TAB Non-Preferred QL 150 / 30 days metformin hcl GLUCOPHAGE 1000 MG TAB Non-Preferred QL 75 / 30 days metformin hcl GLUCOPHAGE XR 500 MG TAB ER 24H Non-Preferred metformin hcl

PAGE 126 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLUCOPHAGE XR 750 MG TAB ER 24H Non-Preferred QL 3 / 1 days metformin hcl GLUCOTROL Non-Preferred glipizide GLUCOTROL XL 2.5 MG TAB ER 24H Non-Preferred glipizide GLUCOTROL XL 5 MG TAB ER 24H Non-Preferred glipizide GLUCOTROL XL 10 MG TAB ER 24H Non-Preferred QL 2 / 1 days glipizide GLUMETZA 1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days metformin hcl GLUMETZA 500 MG TAB ER 24H Non-Preferred QL 90 / 30 days metformin hcl

glyburide 1.25 mg tab Preferred QL 4 / 1 days

glyburide 5 mg tab Preferred QL 4 / 1 days

glyburide 2.5 mg tab Preferred QL 4 / 1 days

glyburide micronized Preferred QL 2 / 1 days

glyburide-metformin Preferred QL 4 / 1 days

GLYNASE Non-Preferred QL 2 / 1 days glyburide micronized GLYSET Non-Preferred miglitol GLYXAMBI Non-Preferred empagliflozin-linagliptin INVOKAMET Preferred PA canagliflozin-metformin hcl INVOKAMET XR Non-Preferred canagliflozin-metformin hcl INVOKANA Preferred PA canagliflozin

JANUMET QL 2 / 1 days Preferred sitagliptin-metformin hcl PA

JANUMET XR 50-1000 MG TAB ER QL 2 / 1 days 24H Preferred sitagliptin-metformin hcl PA

PAGE 127 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

JANUMET XR 100-1000 MG TAB ER QL 1 / 1 days 24H Preferred sitagliptin-metformin hcl PA

JANUMET XR 50-500 MG TAB ER 24H QL 2 / 1 days Preferred sitagliptin-metformin hcl PA

JANUVIA QL 1 / 1 days Preferred sitagliptin phosphate PA

JARDIANCE QL 30 / 30 days Preferred empagliflozin PA

JENTADUETO QL 60 / 30 days Preferred linagliptin-metformin hcl PA

JENTADUETO XR Non-Preferred linagliptin-metformin hcl KAZANO Non-Preferred alogliptin-metformin hcl KOMBIGLYZE XR Non-Preferred saxagliptin-metformin hcl

metformin hcl 500 mg tab Preferred QL 150 / 30 days

metformin hcl 500 mg/5ml solution Non-Preferred

metformin hcl 1000 mg tab Preferred QL 75 / 30 days

metformin hcl 850 mg tab Preferred QL 90 / 30 days

metformin hcl er 500 mg tab er 24h Preferred QL 150 / 30 days

metformin hcl er 750 mg tab er 24h Preferred QL 90 / 30 days

metformin hcl er (mod) 500 mg tab er Non-Preferred QL 90 / 30 days 24h metformin hcl er (mod) 1000 mg tab er Non-Preferred QL 60 / 30 days 24h metformin hcl er (osm) 500 mg tab er Non-Preferred QL 90 / 30 days 24h metformin hcl er (osm) 1000 mg tab er Non-Preferred QL 60 / 30 days 24h miglitol Non-Preferred

nateglinide Preferred QL 3 / 1 days

PAGE 128 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NESINA Non-Preferred alogliptin benzoate ONGLYZA Non-Preferred saxagliptin hcl OSENI Non-Preferred alogliptin-pioglitazone

OZEMPIC (0.25 OR 0.5 MG/DOSE) QL 1.5 / 28 days Preferred semaglutide PA

OZEMPIC (1 MG/DOSE) QL 3 / 28 days Preferred semaglutide PA

QL 30 / 30 days pioglitazone hcl Preferred PA

pioglitazone hcl-glimepiride Non-Preferred QL 30 / 30 days

pioglitazone hcl-metformin hcl Non-Preferred QL 90 / 30 days

PRANDIN 2 MG TAB Non-Preferred QL 240 / 30 days repaglinide PRANDIN 1 MG TAB Non-Preferred QL 120 / 30 days repaglinide PRECOSE Non-Preferred QL 3 / 1 days acarbose QTERN Non-Preferred dapagliflozin-saxagliptin

repaglinide 1 mg tab Preferred QL 120 / 30 days

repaglinide 2 mg tab Preferred QL 240 / 30 days

repaglinide 0.5 mg tab Preferred QL 120 / 30 days

repaglinide-metformin hcl Non-Preferred RIOMET Non-Preferred metformin hcl RIOMET ER Non-Preferred metformin hcl RYBELSUS Non-Preferred QL 30 / 30 days semaglutide SEGLUROMET Non-Preferred QL 60 / 30 days ertugliflozin-metformin hcl

PAGE 129 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STARLIX Non-Preferred QL 3 / 1 days nateglinide STEGLATRO Non-Preferred QL 1 / 1 days ertugliflozin l-pyroglutamic acid STEGLUJAN Non-Preferred ertugliflozin-sitagliptin SYMLINPEN 120 Non-Preferred pramlintide acetate SYMLINPEN 60 Non-Preferred pramlintide acetate SYNJARDY Preferred PA empagliflozin-metformin hcl SYNJARDY XR Non-Preferred empagliflozin-metformin hcl TANZEUM Non-Preferred albiglutide TOLAZAMIDE 500 MG TAB Non-Preferred QL 2 / 1 days tolazamide TOLAZAMIDE 250 MG TAB Non-Preferred QL 4 / 1 days tolazamide

tolbutamide Non-Preferred QL 6 / 1 days

TRADJENTA Preferred PA linagliptin TRIJARDY XR 12.5-2.5-1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 25-5-1000 MG TAB ER 24H Non-Preferred QL 30 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 5-2.5-1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 10-5-1000 MG TAB ER 24H Non-Preferred QL 30 / 30 days empagliflozin-linagliptin-metformin

TRULICITY QL 2 / 28 days Preferred dulaglutide PA

VICTOZA QL 9 / 30 days Preferred liraglutide PA

PAGE 130 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XIGDUO XR Non-Preferred dapagliflozin-metformin hcl GLYCEMIC AGENTS

BAQSIMI ONE PACK Preferred glucagon BAQSIMI TWO PACK Preferred glucagon GLUCAGEN DIAGNOSTIC Preferred QL 2 / 22 days glucagon hcl rdna (diagnostic) GLUCAGEN HYPOKIT Preferred QL 1 / 22 days glucagon hcl (rdna) GLUCAGON EMERGENCY 1 MG KIT Preferred QL 1 / 26 days glucagon (rdna) glucagon emergency 1 mg kit Preferred GVOKE HYPOPEN 1-PACK Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE HYPOPEN 2-PACK Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE PFS Non-Preferred QLC 0.4 mL/30 days glucagon ZEGALOGUE Non-Preferred dasiglucagon hcl INSULINS

ADMELOG Preferred QL 40 / 30 days insulin lispro ADMELOG SOLOSTAR Preferred QL 45 / 30 days insulin lispro AFREZZA 90 X 8 UNIT & 90X12 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 4 & 8 & 12 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 8 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 12 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 4 UNIT POWDER Non-Preferred insulin regular (human)

PAGE 131 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AFREZZA 90 X 4 UNIT & 90X8 UNIT POWDER Non-Preferred insulin regular (human) APIDRA Preferred QL 40 / 30 days insulin glulisine APIDRA SOLOSTAR Preferred QL 45 / 30 days insulin glulisine BASAGLAR KWIKPEN Preferred QL 45 / 30 days insulin glargine FIASP Non-Preferred insulin aspart (with niacinamide) FIASP FLEXTOUCH Non-Preferred insulin aspart (with niacinamide) FIASP PENFILL Non-Preferred insulin aspart (with niacinamide) HUMALOG Non-Preferred QL 40 / 30 days insulin lispro HUMALOG JUNIOR KWIKPEN Non-Preferred QL 45 / 30 days insulin lispro HUMALOG KWIKPEN 200 UNIT/ML SOLN PEN Non-Preferred QL 18 / 23 days insulin lispro HUMALOG KWIKPEN 100 UNIT/ML SOLN PEN Non-Preferred QL 45 / 30 days insulin lispro HUMALOG MIX 50/50 Preferred QL 40 / 30 days insulin lispro protamine & lispro HUMALOG MIX 50/50 KWIKPEN Preferred QL 45 / 30 days insulin lispro protamine & lispro HUMALOG MIX 75/25 Preferred QL 40 / 30 days insulin lispro protamine & lispro HUMALOG MIX 75/25 KWIKPEN Preferred QL 45 / 30 days insulin lispro protamine & lispro HUMULIN R U-500 (CONCENTRATED) Preferred QL 20 / 30 days insulin regular (human) HUMULIN R U-500 KWIKPEN Preferred QL 15 / 30 days insulin regular (human) INSULIN ASP PROT & ASP FLEXPEN insulin aspart protamine & aspart Preferred QL 45 / 30 days (human)

PAGE 132 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INSULIN ASPART Preferred QL 40 / 30 days insulin aspart INSULIN ASPART FLEXPEN Preferred QL 45 / 30 days insulin aspart INSULIN ASPART PENFILL Preferred QL 45 / 30 days insulin aspart INSULIN ASPART PROT & ASPART insulin aspart protamine & aspart Preferred QL 40 / 30 days (human) INSULIN LISPRO Preferred QL 40 / 30 days insulin lispro INSULIN LISPRO (1 UNIT DIAL) Preferred QL 45 / 30 days insulin lispro INSULIN LISPRO JUNIOR KWIKPEN Preferred insulin lispro INSULIN LISPRO PROT & LISPRO Preferred insulin lispro protamine & lispro LANTUS Preferred QL 40 / 30 days insulin glargine LANTUS SOLOSTAR Preferred QL 45 / 30 days insulin glargine LEVEMIR Preferred QL 40 / 30 days insulin detemir LEVEMIR FLEXTOUCH Preferred QL 45 / 30 days insulin detemir LYUMJEV Non-Preferred insulin lispro-aabc LYUMJEV KWIKPEN Non-Preferred insulin lispro-aabc NOVOLOG Preferred QL 40 / 30 days insulin aspart NOVOLOG FLEXPEN Preferred QL 45 / 30 days insulin aspart NOVOLOG MIX 70/30 insulin aspart protamine & aspart Preferred QL 40 / 30 days (human) NOVOLOG MIX 70/30 FLEXPEN insulin aspart protamine & aspart Preferred QL 45 / 30 days (human)

PAGE 133 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLOG PENFILL Preferred QL 45 / 30 days insulin aspart SEMGLEE Non-Preferred insulin glargine SOLIQUA Non-Preferred QLC 18 mL/30 days insulin glargine-lixisenatide TOUJEO MAX SOLOSTAR Non-Preferred QL 12 / 30 days insulin glargine TOUJEO SOLOSTAR Non-Preferred QL 13.5 / 30 days insulin glargine TRESIBA Non-Preferred insulin degludec TRESIBA FLEXTOUCH Non-Preferred insulin degludec XULTOPHY Non-Preferred QLC 15 mL/30 days insulin degludec-liraglutide BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

ARIXTRA Non-Preferred fondaparinux sodium BEVYXXA 40 MG CAP Non-Preferred betrixaban maleate COUMADIN Non-Preferred warfarin sodium ELIQUIS 2.5 MG TAB Preferred QL 2 / 1 days apixaban ELIQUIS 5 MG TAB Preferred QL 4 / 1 days apixaban ELIQUIS DVT/PE STARTER PACK Preferred apixaban

Up to a 180 day supply C every 365 days will be enoxaparin sodium 300 mg/3ml solution Preferred allowed without PA QLC 2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium 100 mg/ml solution Preferred allowed without PA QLC 2 mL/day

PAGE 134 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

Up to a 180 day supply C every 365 days will be enoxaparin sodium 150 mg/ml solution Preferred allowed without PA QLC 2 mL/day

Up to a 180 day supply enoxaparin sodium 120 mg/0.8ml C every 365 days will be Preferred solution allowed without PA QLC 1.6 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium 40 mg/0.4ml solution Preferred allowed without PA QLC 0.8 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium 60 mg/0.6ml solution Preferred allowed without PA QLC 1.2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium 80 mg/0.8ml solution Preferred allowed without PA QLC 1.6 mL/day

fondaparinux sodium Non-Preferred FRAGMIN Non-Preferred dalteparin sodium heparin lock flush 10 unit/ml solution Preferred heparin sodium (porcine) 10000 unit/ml Preferred solution heparin sodium (porcine) 20000 unit/ml Preferred solution heparin sodium (porcine) 1000 unit/ml Preferred solution heparin sodium (porcine) 5000 unit/ml Preferred solution heparin sodium lock flush Preferred jantoven Preferred

Up to a 180 day supply LOVENOX 300 MG/3ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 30 MG/0.3ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 0.6 mL/day

PAGE 135 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

Up to a 180 day supply LOVENOX 150 MG/ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 40 MG/0.4ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 0.8 mL/day

Up to a 180 day supply LOVENOX 60 MG/0.6ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.2 mL/day

Up to a 180 day supply LOVENOX 100 MG/ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 80 MG/0.8ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.6 mL/day

Up to a 180 day supply LOVENOX 120 MG/0.8ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.6 mL/day

PRADAXA Preferred dabigatran etexilate mesylate SAVAYSA Non-Preferred edoxaban tosylate warfarin sodium 7.5 mg tab Preferred warfarin sodium 6 mg tab Preferred warfarin sodium 4 mg tab Preferred warfarin sodium 2 mg tab Preferred warfarin sodium 3 mg tab Preferred warfarin sodium 2.5 mg tab Preferred warfarin sodium 1 mg tab Preferred warfarin sodium 10 mg tab Preferred warfarin sodium 5 mg tab Preferred XARELTO 15 MG TAB Preferred QL 2 / 1 days rivaroxaban

PAGE 136 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XARELTO 10 MG TAB Preferred QL 1 / 1 days rivaroxaban XARELTO 20 MG TAB Preferred QL 1 / 1 days rivaroxaban XARELTO 2.5 MG TAB Preferred QL 2 / 1 days rivaroxaban XARELTO STARTER PACK Preferred QL 51 / 1 years rivaroxaban ZONTIVITY Non-Preferred vorapaxar sulfate BLOOD FORMATION MODIFIERS

ARANESP (ALBUMIN FREE) Non-Preferred darbepoetin alfa EPOGEN Preferred PA epoetin alfa

FULPHILA PA Preferred pegfilgrastim-jmdb QLC 2.4 mL/28 days

GRANIX Preferred PA tbo-filgrastim LEUKINE Non-Preferred sargramostim MIRCERA 150 MCG/0.3ML SOLN PRSYR Non-Preferred methoxy polyethylene glycol-epoetin beta MIRCERA 30 MCG/0.3ML SOLN PRSYR Non-Preferred methoxy polyethylene glycol-epoetin beta NEULASTA Non-Preferred QLC 2.4 mL/28 days pegfilgrastim NEULASTA ONPRO Non-Preferred QLC 2.4 mL/28 days pegfilgrastim NEUPOGEN Preferred PA filgrastim NIVESTYM Preferred PA filgrastim-aafi NPLATE Preferred PA romiplostim

PAGE 137 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NYVEPRIA Non-Preferred QLC 2.4 mL/28 days pegfilgrastim-apgf PROCRIT Non-Preferred epoetin alfa PROMACTA Preferred PA eltrombopag olamine RETACRIT Preferred PA epoetin alfa-epbx TAVALISSE Non-Preferred fostamatinib disodium UDENYCA Non-Preferred QLC 2.4 mL/28 days pegfilgrastim-cbqv ZARXIO Non-Preferred filgrastim-sndz ZIEXTENZO Non-Preferred QLC 2.4 mL/28 days pegfilgrastim-bmez HEMOSTASIS AGENTS

ADVATE antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADYNOVATE antihemophilic factor (recombinant) Preferred PA pegylated AFSTYLA antihemophilic factor (recombinant) Preferred PA single chain ALPHANATE antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANINE SD Preferred PA coagulation factor ix ALPROLIX coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) aminocaproic acid 1000 mg tab Preferred aminocaproic acid 0.25 gm/ml solution Preferred

PAGE 138 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS aminocaproic acid 500 mg tab Preferred BENEFIX Preferred PA coagulation factor ix (recombinant) ELOCTATE antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ESPEROCT 500 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred glycopegylated-exei ESPEROCT 2000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 1000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 1500 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 3000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei FEIBA Non-Preferred antiinhibitor coagulant complex HELIXATE FS Preferred PA antihemophilic factor (recombinant) HEMLIBRA Preferred PA emicizumab-kxwh HEMOFIL M Preferred PA antihemophilic factor (human) HUMATE-P antihemophilic factor/von willebrand Preferred PA factor complex (human) IDELVION coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IXINITY Preferred PA coagulation factor ix (recombinant) JIVI antihemophil fact(rcmb) pegylated-aucl Non-Preferred (bdd-rfviii peg-aucl) KOATE Preferred PA antihemophilic factor (human)

PAGE 139 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOATE-DVI 1000 UNIT RECON SOLN Preferred PA antihemophilic factor (human) KOGENATE FS Preferred PA antihemophilic factor (recombinant) KOGENATE FS BIO-SET Preferred PA antihemophilic factor (recombinant) KOVALTRY antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) MONOCLATE-P Preferred PA antihemophilic factor (human) MONONINE Preferred PA coagulation factor ix NOVOEIGHT antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOSEVEN RT Non-Preferred coagulation factor viia (recombinant) NUWIQ antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) OBIZUR antihemophilic factor (recombinant Non-Preferred porcine) (rpfviii)

phytonadione 5 mg tab Preferred QL 5 / 1 days

PROFILNINE Preferred PA factor ix complex PROFILNINE SD Preferred PA factor ix complex REBINYN coagulation factor ix (recombinant) Non-Preferred glycopegylated RECOMBINATE Preferred PA antihemophilic factor (recombinant) RIXUBIS Preferred PA coagulation factor ix (recombinant) SEVENFACT coagulation factor viia (recombinant)- Non-Preferred jncw tranexamic acid 650 mg tab Preferred

PAGE 140 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VONVENDI Non-Preferred von willebrand factor (recombinant) WILATE antihemophilic factor/von willebrand Preferred PA factor complex (human) XYNTHA antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) PLATELET MODIFYING AGENTS

ADAKVEO Non-Preferred crizanlizumab-tmca AGGRENOX Preferred QL 60 / 30 days aspirin-dipyridamole

aspirin-dipyridamole er Preferred QL 60 / 30 days

ASPIRIN-OMEPRAZOLE 81-40 MG TAB DR Non-Preferred aspirin-omeprazole BRILINTA Preferred QL 60 / 30 days ticagrelor

cilostazol Preferred QL 2 / 1 days

clopidogrel bisulfate 75 mg tab Preferred QL 4 / 1 days

clopidogrel bisulfate 300 mg tab Preferred

dipyridamole 75 mg tab Preferred QL 4 / 1 days

dipyridamole 50 mg tab Preferred QL 8 / 1 days

dipyridamole 25 mg tab Preferred QL 4 / 1 days

DOPTELET Non-Preferred avatrombopag maleate EFFIENT Non-Preferred QL 30 / 30 days prasugrel hcl MULPLETA Non-Preferred lusutrombopag OXBRYTA Non-Preferred QL 90 / 30 days voxelotor

PAGE 141 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PLAVIX Non-Preferred clopidogrel bisulfate

prasugrel hcl Preferred QL 30 / 30 days

YOSPRALA Non-Preferred aspirin-omeprazole CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES Non-Preferred clonidine hcl CATAPRES-TTS-1 Non-Preferred clonidine CATAPRES-TTS-2 Non-Preferred clonidine CATAPRES-TTS-3 Non-Preferred clonidine

clonidine Preferred QL 4 / 22 days

clonidine hcl 0.2 mg tab Preferred QL 8 / 1 days

clonidine hcl 0.3 mg tab Preferred QL 8 / 1 days

clonidine hcl 0.1 mg tab Preferred QL 8 / 1 days

guanfacine hcl 1 mg tab Preferred QL 90 / 30 days

guanfacine hcl 2 mg tab Preferred QL 60 / 30 days

methyldopa Preferred QL 6 / 1 days

METHYLDOPA Preferred QL 6 / 1 days methyldopa

midodrine hcl Preferred QL 90 / 30 days

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA Non-Preferred doxazosin mesylate

doxazosin mesylate 4 mg tab Preferred QL 1 / 1 days

doxazosin mesylate 2 mg tab Preferred QL 1 / 1 days

doxazosin mesylate 1 mg tab Preferred QL 1 / 1 days

doxazosin mesylate 8 mg tab Preferred QL 2 / 1 days

PAGE 142 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MINIPRESS Non-Preferred QL 120 / 30 days prazosin hcl

prazosin hcl 1 mg cap Preferred QL 120 / 30 days

prazosin hcl 5 mg cap Preferred QL 120 / 30 days

prazosin hcl 2 mg cap Preferred QL 120 / 30 days

terazosin hcl Preferred QL 2 / 1 days

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND Non-Preferred candesartan cilexetil AVAPRO 300 MG TAB Non-Preferred QL 30 / 30 days irbesartan AVAPRO 75 MG TAB Non-Preferred QL 30 / 30 days irbesartan AVAPRO 150 MG TAB Non-Preferred QL 60 / 30 days irbesartan BENICAR Non-Preferred QL 30 / 30 days olmesartan medoxomil candesartan cilexetil Non-Preferred COZAAR 50 MG TAB Non-Preferred QL 90 / 30 days losartan potassium COZAAR 100 MG TAB Non-Preferred QL 30 / 30 days losartan potassium COZAAR 25 MG TAB Non-Preferred QL 90 / 30 days losartan potassium DIOVAN 320 MG TAB Non-Preferred QL 30 / 30 days valsartan DIOVAN 160 MG TAB Non-Preferred QL 60 / 30 days valsartan DIOVAN 80 MG TAB Non-Preferred QL 60 / 30 days valsartan DIOVAN 40 MG TAB Non-Preferred QL 60 / 30 days valsartan EDARBI Non-Preferred azilsartan medoxomil EPROSARTAN MESYLATE Non-Preferred eprosartan mesylate

PAGE 143 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

irbesartan 300 mg tab Preferred QL 30 / 30 days

irbesartan 75 mg tab Preferred QL 30 / 30 days

irbesartan 150 mg tab Preferred QL 60 / 30 days

losartan potassium 25 mg tab Preferred QL 90 / 30 days

losartan potassium 100 mg tab Preferred QL 30 / 30 days

losartan potassium 50 mg tab Preferred QL 90 / 30 days

MICARDIS 40 MG TAB Non-Preferred QL 2 / 1 days telmisartan MICARDIS 20 MG TAB Non-Preferred telmisartan MICARDIS 80 MG TAB Non-Preferred QL 1 / 1 days telmisartan

olmesartan medoxomil 40 mg tab Preferred QL 30 / 30 days

olmesartan medoxomil 20 mg tab Preferred QL 30 / 30 days

olmesartan medoxomil 5 mg tab Preferred QL 30 / 30 days

telmisartan 40 mg tab Non-Preferred QL 2 / 1 days

telmisartan 80 mg tab Non-Preferred QL 1 / 1 days

telmisartan 20 mg tab Non-Preferred QL 4 / 1 days

valsartan 80 mg tab Preferred QL 60 / 30 days

valsartan 320 mg tab Preferred QL 30 / 30 days

valsartan 40 mg tab Preferred QL 60 / 30 days

valsartan 160 mg tab Preferred QL 60 / 30 days

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACCUPRIL Non-Preferred QL 60 / 30 days quinapril hcl ALTACE Non-Preferred QL 60 / 30 days ramipril

benazepril hcl 10 mg tab Preferred QL 2 / 1 days

benazepril hcl 40 mg tab Preferred QL 2 / 1 days

PAGE 144 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

benazepril hcl 5 mg tab Preferred QL 2 / 1 days

benazepril hcl 20 mg tab Preferred QL 2 / 1 days

captopril 100 mg tab Preferred QL 3 / 1 days

captopril 25 mg tab Preferred QL 3 / 1 days

captopril 12.5 mg tab Preferred QL 3 / 1 days

captopril 50 mg tab Preferred QL 3 / 1 days

enalapril maleate 10 mg tab Preferred QL 2 / 1 days

enalapril maleate 20 mg tab Preferred QL 2 / 1 days

enalapril maleate 2.5 mg tab Preferred QL 2 / 1 days

enalapril maleate 5 mg tab Preferred QL 2 / 1 days

EPANED No PA required for Non-Preferred C enalapril maleate children under 9 years old

fosinopril sodium Preferred QL 2 / 1 days

lisinopril 5 mg tab Preferred QL 60 / 30 days

lisinopril 10 mg tab Preferred QL 60 / 30 days

lisinopril 20 mg tab Preferred QL 60 / 30 days

lisinopril 30 mg tab Preferred QL 60 / 30 days

lisinopril 40 mg tab Preferred QL 60 / 30 days

lisinopril 2.5 mg tab Preferred QL 60 / 30 days

LOTENSIN Non-Preferred QL 2 / 1 days benazepril hcl moexipril hcl Non-Preferred perindopril erbumine Non-Preferred PRINIVIL Non-Preferred QL 60 / 30 days lisinopril

QBRELIS No PA required for Non-Preferred C lisinopril children under 9 years old

quinapril hcl Preferred QL 60 / 30 days

PAGE 145 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ramipril Preferred QL 60 / 30 days

trandolapril Preferred VASOTEC Non-Preferred QL 2 / 1 days enalapril maleate ZESTRIL Non-Preferred QL 60 / 30 days lisinopril ANTIARRHYTHMICS

amiodarone hcl 400 mg tab Preferred QL 4 / 1 days

amiodarone hcl 200 mg tab Preferred QL 4 / 1 days

BETAPACE Non-Preferred QL 60 / 30 days sotalol hcl BETAPACE AF Non-Preferred QL 60 / 30 days sotalol hcl (afib/afl)

disopyramide phosphate 150 mg cap Preferred QL 10 / 1 days

disopyramide phosphate 100 mg cap Preferred QL 480 / 30 days

flecainide acetate 150 mg tab Preferred QL 2 / 1 days

flecainide acetate 50 mg tab Preferred QL 3 / 1 days

flecainide acetate 100 mg tab Preferred QL 3 / 1 days

mexiletine hcl 200 mg cap Preferred QL 6 / 1 days

mexiletine hcl 150 mg cap Preferred QL 8 / 1 days

mexiletine hcl 250 mg cap Preferred QL 4 / 1 days

pacerone 400 mg tab Preferred QL 4 / 1 days

pacerone 200 mg tab Preferred QL 4 / 1 days

propafenone hcl Preferred QL 3 / 1 days

quinidine sulfate 200 mg tab Preferred QL 6 / 1 days

quinidine sulfate 300 mg tab Preferred QL 6 / 1 days

sorine Preferred QL 60 / 30 days

sotalol hcl 80 mg tab Preferred QL 60 / 30 days

sotalol hcl 160 mg tab Preferred QL 60 / 30 days

PAGE 146 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

sotalol hcl 240 mg tab Preferred QL 60 / 30 days

sotalol hcl 120 mg tab Preferred QL 60 / 30 days

sotalol hcl (af) Preferred QL 60 / 30 days

SOTYLIZE Non-Preferred sotalol hcl BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 400 mg cap Preferred QL 3 / 1 days

acebutolol hcl 200 mg cap Preferred QL 3 / 1 days

atenolol 50 mg tab Preferred QL 2 / 1 days

atenolol 100 mg tab Preferred QL 2 / 1 days

atenolol 25 mg tab Preferred QL 2 / 1 days

betaxolol hcl 20 mg tab Preferred QL 2 / 1 days

betaxolol hcl 10 mg tab Preferred QL 2 / 1 days

bisoprolol fumarate 5 mg tab Preferred QL 4 / 1 days

bisoprolol fumarate 10 mg tab Preferred QL 2 / 1 days

BYSTOLIC Non-Preferred nebivolol hcl

carvedilol 25 mg tab Preferred QL 120 / 30 days

carvedilol 12.5 mg tab Preferred QL 60 / 30 days

carvedilol 3.125 mg tab Preferred QL 60 / 30 days

carvedilol 6.25 mg tab Preferred QL 60 / 30 days

carvedilol phosphate er Non-Preferred COREG 3.125 MG TAB Non-Preferred QL 60 / 30 days carvedilol COREG 25 MG TAB Non-Preferred QL 120 / 30 days carvedilol COREG 6.25 MG TAB Non-Preferred QL 60 / 30 days carvedilol COREG 12.5 MG TAB Non-Preferred QL 60 / 30 days carvedilol

PAGE 147 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COREG CR Non-Preferred carvedilol phosphate CORGARD Non-Preferred nadolol INDERAL LA Non-Preferred QL 1 / 1 days propranolol hcl INDERAL XL Non-Preferred propranolol hcl sustained-release beads INNOPRAN XL Non-Preferred propranolol hcl sustained-release beads KAPSPARGO SPRINKLE Non-Preferred metoprolol succinate

labetalol hcl 200 mg tab Preferred QL 12 / 1 days

labetalol hcl 100 mg tab Preferred QL 14 / 1 days

labetalol hcl 300 mg tab Preferred QL 8 / 1 days

LOPRESSOR Non-Preferred QL 120 / 30 days metoprolol tartrate

metoprolol succinate er Preferred QL 60 / 30 days

metoprolol tartrate 50 mg tab Preferred QL 120 / 30 days

metoprolol tartrate 37.5 mg tab Preferred

metoprolol tartrate 100 mg tab Preferred QL 120 / 30 days

metoprolol tartrate 25 mg tab Preferred QL 120 / 30 days

metoprolol tartrate 75 mg tab Preferred

nadolol 40 mg tab Preferred QL 4 / 1 days

nadolol 20 mg tab Preferred QL 4 / 1 days

nadolol 80 mg tab Preferred QL 4 / 1 days

pindolol Preferred QL 6 / 1 days

propranolol hcl 10 mg tab Preferred QL 8 / 1 days

propranolol hcl 80 mg tab Preferred QL 8 / 1 days

propranolol hcl 40 mg/5ml solution Preferred QL 80 / 1 days

propranolol hcl 40 mg tab Preferred QL 8 / 1 days

PAGE 148 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

propranolol hcl 60 mg tab Preferred QL 8 / 1 days

propranolol hcl 20 mg tab Preferred QL 8 / 1 days

propranolol hcl 20 mg/5ml solution Preferred QL 80 / 1 days

propranolol hcl er Preferred QL 1 / 1 days

TENORMIN Non-Preferred QL 2 / 1 days atenolol

timolol maleate 5 mg tab Non-Preferred QL 3 / 1 days

timolol maleate 20 mg tab Non-Preferred QL 3 / 1 days

timolol maleate 10 mg tab Non-Preferred QL 3 / 1 days

TOPROL XL Non-Preferred QL 60 / 30 days metoprolol succinate CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC Non-Preferred QL 2 / 1 days nifedipine

amlodipine besylate 2.5 mg tab Preferred QL 2 / 1 days

amlodipine besylate 10 mg tab Preferred QL 2 / 1 days

amlodipine besylate 5 mg tab Preferred QL 2 / 1 days

CALAN 120 MG TAB Non-Preferred verapamil hcl CALAN SR 240 MG TAB ER Non-Preferred QL 2 / 1 days verapamil hcl CALAN SR 120 MG TAB ER Non-Preferred QL 1 / 1 days verapamil hcl CALAN SR 180 MG TAB ER Non-Preferred QL 2 / 1 days verapamil hcl CARDIZEM 60 MG TAB Non-Preferred diltiazem hcl CARDIZEM 30 MG TAB Non-Preferred diltiazem hcl CARDIZEM 120 MG TAB Non-Preferred QL 2 / 1 days diltiazem hcl CARDIZEM CD 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads

PAGE 149 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARDIZEM CD 180 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 120 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 300 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days diltiazem hcl coated beads CARDIZEM LA Non-Preferred QL 1 / 1 days diltiazem hcl coated beads

cartia xt 180 mg cap er 24h Preferred QL 1 / 1 days

cartia xt 240 mg cap er 24h Preferred QL 2 / 1 days

cartia xt 300 mg cap er 24h Preferred QL 1 / 1 days

cartia xt 120 mg cap er 24h Preferred QL 1 / 1 days

CONJUPRI Non-Preferred levamlodipine maleate

dilt-xr 240 mg cap er 24h Preferred QL 2 / 1 days

dilt-xr 120 mg cap er 24h Preferred QL 1 / 1 days

dilt-xr 180 mg cap er 24h Preferred QL 1 / 1 days

diltiazem hcl 30 mg tab Preferred QL 4 / 1 days

diltiazem hcl 120 mg tab Preferred QL 2 / 1 days

diltiazem hcl 60 mg tab Preferred QL 4 / 1 days

diltiazem hcl 90 mg tab Preferred QL 3 / 1 days

diltiazem hcl er 60 mg cap er 12h Non-Preferred QL 2 / 1 days

diltiazem hcl er 120 mg cap er 12h Non-Preferred QL 2 / 1 days

diltiazem hcl er 90 mg cap er 12h Non-Preferred QL 2 / 1 days

diltiazem hcl er 180 mg cap er 24h Preferred QL 1 / 1 days

diltiazem hcl er 120 mg cap er 24h Preferred QL 1 / 1 days

diltiazem hcl er 240 mg cap er 24h Preferred QL 2 / 1 days

diltiazem hcl er beads 240 mg cap er Preferred QL 2 / 1 days 24h

PAGE 150 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl er beads 120 mg cap er Preferred QL 1 / 1 days 24h diltiazem hcl er beads 180 mg cap er Preferred QL 1 / 1 days 24h diltiazem hcl er beads 300 mg cap er Preferred QL 1 / 1 days 24h diltiazem hcl er beads 420 mg cap er Preferred QL 1 / 1 days 24h diltiazem hcl er beads 360 mg cap er Preferred QL 1 / 1 days 24h diltiazem hcl er coated beads 420 mg Non-Preferred QL 1 / 1 days tab er 24h diltiazem hcl er coated beads 120 mg Preferred QL 1 / 1 days cap er 24h diltiazem hcl er coated beads 240 mg Preferred QL 60 / 30 days cap er 24h diltiazem hcl er coated beads 180 mg Non-Preferred QL 1 / 1 days tab er 24h diltiazem hcl er coated beads 300 mg Preferred QL 1 / 1 days cap er 24h diltiazem hcl er coated beads 360 mg Preferred QL 1 / 1 days cap er 24h diltiazem hcl er coated beads 180 mg Preferred QL 30 / 30 days cap er 24h diltiazem hcl er coated beads 300 mg Non-Preferred QL 1 / 1 days tab er 24h diltiazem hcl er coated beads 360 mg Non-Preferred QL 1 / 1 days tab er 24h diltiazem hcl er coated beads 240 mg Non-Preferred QL 1 / 1 days tab er 24h

felodipine er Preferred QL 1 / 1 days

isradipine Non-Preferred KATERZIA Non-Preferred amlodipine benzoate

matzim la Non-Preferred QL 1 / 1 days

nicardipine hcl 20 mg cap Non-Preferred QL 6 / 1 days

nicardipine hcl 30 mg cap Non-Preferred QL 4 / 1 days

PAGE 151 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

nifedipine 10 mg cap Preferred QL 4 / 1 days

nifedipine 20 mg cap Preferred QL 4 / 1 days

nifedipine er Preferred QL 2 / 1 days

nifedipine er osmotic release Preferred QL 2 / 1 days

nimodipine 30 mg cap Preferred

nisoldipine er 25.5 mg tab er 24h Non-Preferred QL 1 / 1 days

nisoldipine er 8.5 mg tab er 24h Non-Preferred QL 1 / 1 days

nisoldipine er 30 mg tab er 24h Non-Preferred QL 2 / 1 days

nisoldipine er 20 mg tab er 24h Non-Preferred QL 1 / 1 days

nisoldipine er 34 mg tab er 24h Non-Preferred QL 1 / 1 days

nisoldipine er 17 mg tab er 24h Non-Preferred QL 1 / 1 days

nisoldipine er 40 mg tab er 24h Non-Preferred QL 1 / 1 days

NORVASC Non-Preferred QL 2 / 1 days amlodipine besylate NYMALIZE Non-Preferred nimodipine PROCARDIA Non-Preferred nifedipine PROCARDIA XL Non-Preferred QL 2 / 1 days nifedipine SULAR Non-Preferred QL 1 / 1 days nisoldipine

taztia xt 180 mg cap er 24h Preferred QL 1 / 1 days

taztia xt 240 mg cap er 24h Preferred QL 2 / 1 days

taztia xt 360 mg cap er 24h Preferred QL 1 / 1 days

taztia xt 300 mg cap er 24h Preferred QL 1 / 1 days

taztia xt 120 mg cap er 24h Preferred QL 1 / 1 days

tiadylt er Preferred TIAZAC 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads

PAGE 152 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TIAZAC 300 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 120 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days diltiazem hcl extended release beads TIAZAC 180 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 420 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads

verapamil hcl 120 mg tab Preferred QL 4 / 1 days

verapamil hcl 80 mg tab Preferred QL 4 / 1 days

verapamil hcl 40 mg tab Preferred QL 3 / 1 days

verapamil hcl er 180 mg tab er Preferred QL 2 / 1 days

verapamil hcl er 240 mg cap er 24h Preferred QL 2 / 1 days

verapamil hcl er 240 mg tab er Preferred QL 2 / 1 days

verapamil hcl er 300 mg cap er 24h Preferred

verapamil hcl er 180 mg cap er 24h Preferred QL 2 / 1 days

verapamil hcl er 200 mg cap er 24h Preferred

verapamil hcl er 120 mg cap er 24h Preferred QL 2 / 1 days

verapamil hcl er 360 mg cap er 24h Preferred QL 1 / 1 days

verapamil hcl er 120 mg tab er Preferred QL 1 / 1 days

verapamil hcl er 100 mg cap er 24h Preferred VERELAN 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days verapamil hcl VERELAN 180 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN 120 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN PM Non-Preferred verapamil hcl

PAGE 153 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARDIOVASCULAR AGENTS, OTHER

ACCURETIC Non-Preferred quinapril-hydrochlorothiazide ALDACTAZIDE 50-50 MG TAB Preferred spironolactone & hydrochlorothiazide aliskiren fumarate Non-Preferred

amiloride-hydrochlorothiazide Preferred QL 2 / 1 days

amlodipine besy-benazepril hcl Preferred QL 1 / 1 days

amlodipine besylate-valsartan Preferred amlodipine-atorvastatin Non-Preferred amlodipine-olmesartan Non-Preferred amlodipine-valsartan-hctz Preferred ATACAND HCT Non-Preferred candesartan cilexetil-hydrochlorothiazide

atenolol-chlorthalidone 100-25 mg tab Preferred QL 1 / 1 days

atenolol-chlorthalidone 50-25 mg tab Preferred QL 2 / 1 days

AVALIDE Non-Preferred QL 30 / 30 days irbesartan-hydrochlorothiazide AZOR amlodipine besylate-olmesartan Non-Preferred medoxomil benazepril-hydrochlorothiazide Preferred BENAZEPRIL- HYDROCHLOROTHIAZIDE 5-6.25 MG Preferred TAB benazepril & hydrochlorothiazide BENICAR HCT olmesartan medoxomil- Non-Preferred QL 30 / 30 days hydrochlorothiazide BIDIL Non-Preferred isosorbide dinitrate-hydralazine hcl bisoprolol-hydrochlorothiazide 2.5-6.25 Preferred QL 1 / 1 days mg tab bisoprolol-hydrochlorothiazide 5-6.25 mg Preferred QL 1 / 1 days tab bisoprolol-hydrochlorothiazide 10-6.25 Preferred QL 60 / 30 days mg tab

PAGE 154 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CADUET Non-Preferred amlodipine besylate-atorvastatin calcium candesartan cilexetil-hctz Non-Preferred captopril-hydrochlorothiazide 25-15 mg Non-Preferred QL 3 / 1 days tab captopril-hydrochlorothiazide 25-25 mg Non-Preferred QL 2 / 1 days tab captopril-hydrochlorothiazide 50-15 mg Non-Preferred QL 3 / 1 days tab captopril-hydrochlorothiazide 50-25 mg Non-Preferred QL 2 / 1 days tab CORZIDE Non-Preferred nadolol & bendroflumethiazide digitek Preferred digox Preferred

digoxin 0.05 mg/ml solution Preferred QL 5 / 1 days

digoxin 125 mcg tab Preferred digoxin 250 mcg tab Preferred DIOVAN HCT 320-25 MG TAB Non-Preferred QL 30 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 160-12.5 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 80-12.5 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 320-12.5 MG TAB Non-Preferred QL 30 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 160-25 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide EDARBYCLOR Non-Preferred azilsartan medoxomil-chlorthalidone enalapril-hydrochlorothiazide 10-25 mg Preferred QL 2 / 1 days tab enalapril-hydrochlorothiazide 5-12.5 mg Preferred QL 1 / 1 days tab ENTRESTO Preferred QL 60 / 30 days sacubitril-valsartan EXFORGE Non-Preferred amlodipine besylate-valsartan

PAGE 155 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EXFORGE HCT amlodipine-valsartan- Non-Preferred hydrochlorothiazide fosinopril sodium-hctz Preferred HYZAAR losartan potassium & Non-Preferred QL 30 / 30 days hydrochlorothiazide

irbesartan-hydrochlorothiazide Preferred QL 30 / 30 days

lisinopril-hydrochlorothiazide 20-25 mg Preferred QL 60 / 30 days tab lisinopril-hydrochlorothiazide 10-12.5 mg Preferred QL 30 / 30 days tab lisinopril-hydrochlorothiazide 20-12.5 mg Preferred QL 60 / 30 days tab

losartan potassium-hctz Preferred QL 30 / 30 days

LOTENSIN HCT Non-Preferred benazepril & hydrochlorothiazide LOTREL Non-Preferred QL 1 / 1 days amlodipine besylate-benazepril hcl methyldopa-hydrochlorothiazide Non-Preferred metoprolol-hydrochlorothiazide 100-25 Non-Preferred QL 60 / 30 days mg tab metoprolol-hydrochlorothiazide 50-25 Non-Preferred QL 60 / 30 days mg tab metoprolol-hydrochlorothiazide 100-50 Non-Preferred QL 30 / 30 days mg tab MICARDIS HCT Non-Preferred telmisartan-hydrochlorothiazide moexipril-hydrochlorothiazide 15-25 mg Non-Preferred tab moexipril-hydrochlorothiazide 15-12.5 Non-Preferred mg tab nadolol-bendroflumethiazide 80-5 mg Non-Preferred tab NADOLOL-BENDROFLUMETHIAZIDE 40-5 MG TAB Non-Preferred nadolol & bendroflumethiazide NEXLETOL Non-Preferred bempedoic acid

PAGE 156 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

olmesartan medoxomil-hctz Preferred QL 30 / 30 days

olmesartan-amlodipine-hctz Non-Preferred

pentoxifylline er Preferred QL 3 / 1 days

propranolol-hctz Preferred QL 2 / 1 days

quinapril-hydrochlorothiazide Preferred RANEXA Non-Preferred ranolazine

ranolazine er Preferred PA

spironolactone-hctz Preferred QL 8 / 1 days

TARKA Non-Preferred trandolapril-verapamil hcl TEKTURNA Non-Preferred aliskiren fumarate TEKTURNA HCT Non-Preferred aliskiren-hydrochlorothiazide telmisartan-amlodipine Non-Preferred telmisartan-hctz Non-Preferred TENORETIC 100 Non-Preferred QL 1 / 1 days atenolol & chlorthalidone TENORETIC 50 Non-Preferred QL 2 / 1 days atenolol & chlorthalidone trandolapril-verapamil hcl er Non-Preferred

triamterene-hctz 75-50 mg tab Preferred QL 1 / 1 days

triamterene-hctz 37.5-25 mg cap Preferred QL 2 / 1 days

triamterene-hctz 37.5-25 mg tab Preferred QL 1 / 1 days

TRIBENZOR olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TWYNSTA Non-Preferred telmisartan-amlodipine valsartan-hydrochlorothiazide 320-25 Preferred QL 30 / 30 days mg tab valsartan-hydrochlorothiazide 160-12.5 Preferred QL 60 / 30 days mg tab

PAGE 157 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS valsartan-hydrochlorothiazide 80-12.5 Preferred QL 60 / 30 days mg tab valsartan-hydrochlorothiazide 160-25 Preferred QL 60 / 30 days mg tab valsartan-hydrochlorothiazide 320-12.5 Preferred QL 30 / 30 days mg tab VASERETIC Non-Preferred QL 2 / 1 days enalapril maleate & hydrochlorothiazide ZESTORETIC 20-25 MG TAB Non-Preferred QL 60 / 30 days lisinopril & hydrochlorothiazide ZESTORETIC 20-12.5 MG TAB Non-Preferred QL 60 / 30 days lisinopril & hydrochlorothiazide ZESTORETIC 10-12.5 MG TAB Non-Preferred QL 30 / 30 days lisinopril & hydrochlorothiazide ZIAC Non-Preferred QL 1 / 1 days bisoprolol & hydrochlorothiazide DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide 125 mg tab Preferred QL 4 / 1 days

acetazolamide 250 mg tab Preferred QL 4 / 1 days

acetazolamide er Preferred QL 2 / 1 days

DIURETICS, LOOP

bumetanide 1 mg tab Preferred QL 5 / 1 days

bumetanide 0.5 mg tab Preferred QL 5 / 1 days

bumetanide 2 mg tab Preferred QL 5 / 1 days

furosemide 40 mg tab Preferred QL 15 / 1 days

furosemide 10 mg/ml solution Preferred QL 60 / 1 days

furosemide 80 mg tab Preferred QL 7 / 1 days

furosemide 8 mg/ml solution Preferred QL 75 / 1 days

furosemide 20 mg tab Preferred QL 15 / 1 days

torsemide 10 mg tab Preferred

PAGE 158 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIURETICS, POTASSIUM-SPARING

amiloride hcl 5 mg tab Preferred QL 4 / 1 days

spironolactone 50 mg tab Preferred QL 2 / 1 days

spironolactone 100 mg tab Preferred QL 4 / 1 days

spironolactone 25 mg tab Preferred QL 2 / 1 days

DIURETICS, THIAZIDE

chlorothiazide 500 mg tab Preferred QL 4 / 1 days

chlorothiazide 250 mg tab Preferred QL 4 / 1 days

chlorthalidone Preferred QL 4 / 1 days

DIURIL Preferred QL 40 / 1 days chlorothiazide

hydrochlorothiazide 50 mg tab Preferred QL 120 / 30 days

hydrochlorothiazide 12.5 mg cap Preferred QL 120 / 30 days

hydrochlorothiazide 12.5 mg tab Preferred QL 4 / 1 days

hydrochlorothiazide 25 mg tab Preferred QL 4 / 1 days

indapamide 1.25 mg tab Preferred QL 4 / 1 days

indapamide 2.5 mg tab Preferred QL 2 / 1 days

methyclothiazide Preferred QL 2 / 1 days

metolazone Preferred QL 2 / 1 days

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

ANTARA Non-Preferred fenofibrate micronized

fenofibrate 145 mg tab Preferred QL 1 / 1 days

fenofibrate 200 mg cap Preferred QL 1 / 1 days

fenofibrate 134 mg cap Preferred QL 1 / 1 days

fenofibrate 48 mg tab Preferred QL 1 / 1 days

fenofibrate 50 mg cap Non-Preferred fenofibrate 120 mg tab Non-Preferred

PAGE 159 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

fenofibrate 160 mg tab Preferred QL 1 / 1 days

fenofibrate 40 mg tab Non-Preferred

fenofibrate 54 mg tab Preferred QL 1 / 1 days

fenofibrate 67 mg cap Preferred QL 1 / 1 days

fenofibrate 150 mg cap Non-Preferred

fenofibrate micronized 67 mg cap Preferred QL 1 / 1 days

fenofibrate micronized 43 mg cap Preferred

fenofibrate micronized 134 mg cap Preferred QL 1 / 1 days

fenofibrate micronized 130 mg cap Preferred

fenofibrate micronized 200 mg cap Preferred QL 1 / 1 days

fenofibric acid 135 mg cap dr Preferred fenofibric acid 35 mg tab Non-Preferred fenofibric acid 45 mg cap dr Preferred FENOFIBRIC ACID 35 MG TAB Non-Preferred fenofibric acid FENOFIBRIC ACID 105 MG TAB Non-Preferred fenofibric acid fenofibric acid 105 mg tab Non-Preferred FENOGLIDE Non-Preferred fenofibrate FIBRICOR Non-Preferred fenofibric acid

gemfibrozil 600 mg tab Preferred QL 2 / 1 days

LIPOFEN Non-Preferred fenofibrate LOPID Non-Preferred QL 2 / 1 days gemfibrozil TRICOR Non-Preferred QL 1 / 1 days fenofibrate TRIGLIDE Non-Preferred QL 1 / 1 days fenofibrate TRILIPIX Non-Preferred choline fenofibrate

PAGE 160 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV Non-Preferred lovastatin

atorvastatin calcium 10 mg tab Preferred QL 30 / 30 days

atorvastatin calcium 40 mg tab Preferred QL 30 / 30 days

atorvastatin calcium 80 mg tab Preferred QL 30 / 30 days

atorvastatin calcium 20 mg tab Preferred QL 30 / 30 days

CRESTOR Non-Preferred QL 1 / 1 days rosuvastatin calcium EZALLOR SPRINKLE Non-Preferred rosuvastatin calcium

fluvastatin sodium Non-Preferred QL 30 / 30 days

fluvastatin sodium er Non-Preferred LESCOL XL Non-Preferred fluvastatin sodium LIPITOR Non-Preferred QL 30 / 30 days atorvastatin calcium LIVALO Non-Preferred pitavastatin calcium

lovastatin 20 mg tab Preferred QL 1 / 1 days

lovastatin 40 mg tab Preferred QL 2 / 1 days

lovastatin 10 mg tab Preferred QL 1 / 1 days

PRAVACHOL Non-Preferred QL 1 / 1 days pravastatin sodium

pravastatin sodium Preferred QL 1 / 1 days

rosuvastatin calcium Preferred QL 1 / 1 days

simvastatin 40 mg tab Preferred QL 1 / 1 days

SIMVASTATIN 20 MG/5ML SUSPENSION Non-Preferred simvastatin

simvastatin 20 mg tab Preferred QL 1 / 1 days

simvastatin 5 mg tab Preferred QL 1 / 1 days

PAGE 161 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

simvastatin 10 mg tab Preferred QL 1 / 1 days

simvastatin 80 mg tab Preferred QL 1 / 1 days

ZOCOR 20 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 10 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 40 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 80 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZYPITAMAG Non-Preferred pitavastatin magnesium DYSLIPIDEMICS, OTHER

cholestyramine 4 gm packet Preferred QL 6 / 1 days

cholestyramine 4 gm/dose powder Preferred QLC 54 grams/day

cholestyramine light 4 gm/dose powder Preferred QLC 54 grams/day

cholestyramine light 4 gm packet Preferred QL 6 / 1 days

colesevelam hcl Non-Preferred COLESTID Non-Preferred colestipol hcl COLESTID FLAVORED Non-Preferred colestipol hcl colestipol hcl 5 gm packet Non-Preferred colestipol hcl 1 gm tab Preferred colestipol hcl 5 gm granules Non-Preferred EVKEEZA Non-Preferred evinacumab-dgnb

ezetimibe Preferred QL 30 / 30 days

ezetimibe-simvastatin Non-Preferred

icosapent ethyl Non-Preferred QL 120 / 30 days

JUXTAPID Non-Preferred lomitapide mesylate LOVAZA Non-Preferred omega-3-acid ethyl esters

PAGE 162 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEXLIZET Non-Preferred bempedoic acid-ezetimibe niacin er (antihyperlipidemic) 1000 mg Non-Preferred tab er niacin er (antihyperlipidemic) 750 mg tab Non-Preferred er niacin er (antihyperlipidemic) 500 mg tab Non-Preferred QL 4 / 1 days er NIACOR Non-Preferred niacin (antihyperlipidemic) NIASPAN Non-Preferred niacin (antihyperlipidemic)

omega-3-acid ethyl esters Preferred QL 4 / 1 days

PRALUENT Non-Preferred QL 2 / 28 days alirocumab prevalite 4 gm packet Preferred

prevalite 4 gm/dose powder Preferred QLC 54 grams/day

QUESTRAN Non-Preferred cholestyramine QUESTRAN LIGHT Non-Preferred cholestyramine light REPATHA Non-Preferred QL 3 / 28 days evolocumab REPATHA PUSHTRONEX SYSTEM Non-Preferred evolocumab REPATHA SURECLICK Non-Preferred QL 3 / 28 days evolocumab ROSZET Non-Preferred ezetimibe-rosuvastatin calcium VASCEPA 0.5 GM CAP Non-Preferred QL 240 / 30 days icosapent ethyl VASCEPA 1 GM CAP Non-Preferred QL 120 / 30 days icosapent ethyl VYTORIN Non-Preferred ezetimibe-simvastatin WELCHOL Non-Preferred colesevelam hcl

PAGE 163 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZETIA Non-Preferred QL 30 / 30 days ezetimibe VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl 10 mg tab Preferred QL 4 / 1 days

hydralazine hcl 50 mg tab Preferred QL 4 / 1 days

hydralazine hcl 25 mg tab Preferred QL 4 / 1 days

hydralazine hcl 100 mg tab Preferred QL 3 / 1 days

minoxidil 2.5 mg tab Preferred QL 4 / 1 days

minoxidil 10 mg tab Preferred QL 10 / 1 days

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR Non-Preferred isosorbide dinitrate GONITRO Non-Preferred nitroglycerin ISORDIL TITRADOSE Non-Preferred isosorbide dinitrate

isosorbide dinitrate 10 mg tab Non-Preferred QL 8 / 1 days

isosorbide dinitrate 40 mg tab Non-Preferred

isosorbide dinitrate 20 mg tab Non-Preferred QL 8 / 1 days

isosorbide dinitrate 30 mg tab Non-Preferred QL 8 / 1 days

isosorbide dinitrate 5 mg tab Non-Preferred QL 8 / 1 days

isosorbide dinitrate er Preferred QL 2 / 1 days

isosorbide mononitrate Preferred QL 2 / 1 days

isosorbide mononitrate er 30 mg tab er Preferred QL 3 / 1 days 24h isosorbide mononitrate er 60 mg tab er Preferred QL 2 / 1 days 24h isosorbide mononitrate er 120 mg tab er Preferred QL 2 / 1 days 24h

minitran Non-Preferred QL 1 / 1 days

NITRO-BID Preferred nitroglycerin

PAGE 164 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NITRO-DUR 0.4 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.2 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.1 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.6 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.8 MG/HR PATCH 24HR Non-Preferred nitroglycerin NITRO-DUR 0.3 MG/HR PATCH 24HR Non-Preferred nitroglycerin nitroglycerin 0.3 mg sl tab Preferred

nitroglycerin 0.2 mg/hr patch 24hr Preferred QL 1 / 1 days

nitroglycerin 0.4 mg sl tab Preferred

nitroglycerin 0.1 mg/hr patch 24hr Preferred QL 1 / 1 days

nitroglycerin 0.6 mg/hr patch 24hr Preferred QL 1 / 1 days

nitroglycerin 0.4 mg/spray solution Non-Preferred

nitroglycerin 0.4 mg/hr patch 24hr Preferred QL 1 / 1 days

nitroglycerin 0.6 mg sl tab Preferred

nitroglycerin er 2.5 mg cap er Non-Preferred QL 4 / 1 days

nitroglycerin er 6.5 mg cap er Non-Preferred QL 4 / 1 days

NITROLINGUAL Non-Preferred nitroglycerin NITROMIST Non-Preferred nitroglycerin NITROSTAT Non-Preferred nitroglycerin CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

QL 3 / 1 days ADDERALL 10 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

PAGE 165 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 3 / 1 days ADDERALL 12.5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 3 / 1 days ADDERALL 20 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 2 / 1 days ADDERALL 30 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 120 / 30 days ADDERALL 7.5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 3 / 1 days ADDERALL 15 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 120 / 30 days ADDERALL 5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADZENYS ER Non-Preferred amphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADZENYS XR-ODT Non-Preferred amphetamine C Age restriction, clinical PA required AMPHETAMINE ER Non-Preferred amphetamine

AL1 4 to 17 yrs old amphetamine sulfate Non-Preferred C Age restriction, clinical PA required

PAGE 166 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days

amphetamine-dextroamphet er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine 12.5 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine 10 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine 15 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

QL 120 / 30 days amphetamine-dextroamphetamine 5 mg Preferred AL1 4 to 17 yrs old tab C Age restriction, clinical PA required

QL 60 / 30 days amphetamine-dextroamphetamine 30 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

QL 120 / 30 days amphetamine-dextroamphetamine 7.5 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine 20 Preferred AL1 4 to 17 yrs old mg tab C Age restriction, clinical PA required

AL1 4 to 17 yrs old DESOXYN Non-Preferred methamphetamine hcl C Age restriction, clinical PA required

QL 2 / 1 days DEXEDRINE 5 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

PAGE 167 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days DEXEDRINE 15 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 120 / 30 days DEXEDRINE 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 180 / 30 days

dextroamphetamine sulfate 5 mg tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old dextroamphetamine sulfate 5 mg/5ml Non-Preferred solution C Age restriction, clinical PA required

QL 120 / 30 days

dextroamphetamine sulfate 10 mg tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days dextroamphetamine sulfate er 10 mg Preferred AL1 4 to 17 yrs old cap er 24h C Age restriction, clinical PA required

QL 2 / 1 days dextroamphetamine sulfate er 5 mg cap Preferred AL1 4 to 17 yrs old er 24h C Age restriction, clinical PA required

QL 120 / 30 days dextroamphetamine sulfate er 15 mg Preferred AL1 4 to 17 yrs old cap er 24h C Age restriction, clinical PA required

AL1 4 to 17 yrs old DYANAVEL XR Non-Preferred amphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO ODT Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

PAGE 168 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old methamphetamine hcl Non-Preferred C Age restriction, clinical PA required

AL1 4 to 17 yrs old MYDAYIS Non-Preferred amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old procentra Non-Preferred C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 40 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 10 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 30 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 60 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 20 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 50 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 20 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

PAGE 169 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days VYVANSE 50 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 70 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 40 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 10 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 30 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 90 / 30 days ZENZEDI 20 MG TAB Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 90 / 30 days ZENZEDI 15 MG TAB Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 90 / 30 days

zenzedi 10 mg tab Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days ZENZEDI 2.5 MG TAB Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

PAGE 170 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days

zenzedi 5 mg tab Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days ZENZEDI 30 MG TAB Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

AL1 4 to 17 yrs old ADHANSIA XR Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl 10 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl 40 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 1 / 1 days

atomoxetine hcl 100 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 1 / 1 days

atomoxetine hcl 80 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl 18 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl 25 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 171 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days

atomoxetine hcl 60 mg cap Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old clonidine hcl er Non-Preferred C Age restriction, clinical PA required

QL 60 / 30 days CONCERTA 36 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 27 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 54 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 18 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old COTEMPLA XR-ODT Non-Preferred methylphenidate C Age restriction, clinical PA required

AL1 4 to 17 yrs old DAYTRANA Non-Preferred methylphenidate C Age restriction, clinical PA required

QL 2 / 1 days

dexmethylphenidate hcl Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl er 10 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

PAGE 172 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 2 / 1 days dexmethylphenidate hcl er 15 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl er 25 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl er 5 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl er 35 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl er 20 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl er 40 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 1 / 1 days FOCALIN XR 35 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

PAGE 173 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days FOCALIN XR 25 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 1 / 1 days FOCALIN XR 30 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 20 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 15 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 5 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days

guanfacine hcl er 2 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

guanfacine hcl er 4 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

guanfacine hcl er 3 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

guanfacine hcl er 1 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 174 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days INTUNIV 3 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

QL 60 / 30 days INTUNIV 1 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

QL 30 / 30 days INTUNIV 4 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old KAPVAY Non-Preferred clonidine hcl (adhd) C Age restriction, clinical PA required

QL 90 / 30 days

metadate er Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old METHYLIN Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl 5 mg/5ml solution Preferred C Age restriction, clinical PA required

QL 120 / 30 days

methylphenidate hcl 5 mg chew tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 180 / 30 days

methylphenidate hcl 10 mg chew tab Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl 20 mg tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 175 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days

methylphenidate hcl 5 mg tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl 10 mg/5ml solution Preferred C Age restriction, clinical PA required

QL 120 / 30 days

methylphenidate hcl 2.5 mg chew tab Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl 10 mg tab Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl er 36 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl er 10 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl er 27 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl er 36 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl er 18 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl er 27 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 176 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days

methylphenidate hcl er 54 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl er 20 mg tab er Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

METHYLPHENIDATE HCL ER 72 MG AL1 4 to 17 yrs old TAB ER Non-Preferred C Age restriction, clinical methylphenidate hcl PA required

QL 30 / 30 days

methylphenidate hcl er 18 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl er 54 mg tab er 24h Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (cd) 30 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (cd) 20 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl er (cd) 60 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl er (cd) 40 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (cd) 10 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

PAGE 177 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days methylphenidate hcl er (cd) 50 mg cap Preferred AL1 4 to 17 yrs old er C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl er (la) 60 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (la) 20 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (la) 10 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl er (la) 30 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl er (la) 40 mg cap er Preferred AL1 4 to 17 yrs old 24h C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl er (xr) Non-Preferred C Age restriction, clinical PA required

QL 60 / 30 days QELBREE 200 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old viloxazine hcl (adhd) C Age restriction, clinical PA required

QL 90 / 30 days QELBREE 100 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old viloxazine hcl (adhd) C Age restriction, clinical PA required

QL 60 / 30 days QELBREE 150 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old viloxazine hcl (adhd) C Age restriction, clinical PA required

PAGE 178 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old QUILLICHEW ER Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old QUILLIVANT XR Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old RELEXXII Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

QL 120 / 30 days RITALIN 5 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 90 / 30 days RITALIN 10 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 90 / 30 days RITALIN 20 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 20 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days RITALIN LA 40 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 30 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

PAGE 179 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 2 / 1 days STRATTERA 10 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 2 / 1 days STRATTERA 40 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 2 / 1 days STRATTERA 18 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 1 / 1 days STRATTERA 80 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 1 / 1 days STRATTERA 100 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 1 / 1 days STRATTERA 60 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required CENTRAL NERVOUS SYSTEM, OTHER

ALLZITAL Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month AUSTEDO Preferred PA deutetrabenazine

PA bac Preferred QLC Max 18 tabs/caps per month

bupap Non-Preferred QLC Max 18 tabs/caps per month butalbital-acetaminophen 50-300 mg Non-Preferred QLC Max 18 tabs/caps per cap month

butalbital-acetaminophen 50-300 mg tab Non-Preferred QLC Max 18 tabs/caps per month

PAGE 180 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BUTALBITAL-ACETAMINOPHEN 25- 325 MG TAB Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month

butalbital-acetaminophen 50-325 mg tab Non-Preferred QLC Max 18 tabs/caps per month BUTALBITAL-ACETAMINOPHEN 50- 300 MG CAP Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month

butalbital-apap Non-Preferred QLC Max 18 tabs/caps per month

PA butalbital-apap-caffeine 50-325-40 mg Preferred tab QLC Max 18 tabs/caps per month butalbital-apap-caffeine 50-325-40 mg Non-Preferred QLC Max 18 tabs/caps per cap month butalbital-apap-caffeine 50-300-40 mg Non-Preferred QLC Max 18 tabs/caps per cap month ESGIC 50-325-40 MG TAB Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen-caffeine month

esgic 50-325-40 mg cap Non-Preferred QLC Max 18 tabs/caps per month FIORICET Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen-caffeine month HORIZANT Non-Preferred gabapentin enacarbil INGREZZA 60 MG CAP Preferred PA valbenazine tosylate

INGREZZA 80 MG CAP QL 1 / 1 days Preferred valbenazine tosylate PA

INGREZZA 40 & 80 MG CAP THPK Preferred PA valbenazine tosylate

INGREZZA 40 MG CAP QL 30 / 30 days Preferred valbenazine tosylate PA

tetrabenazine Preferred PA

vanatol lq Non-Preferred QLC 270 mL/30 days

vanatol s Non-Preferred QLC 270 mL/30 days

VTOL LQ Non-Preferred QLC 270 mL/30 days butalbital-acetaminophen-caffeine

PAGE 181 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XENAZINE Non-Preferred tetrabenazine

zebutal Non-Preferred QLC Max 18 tabs/caps per month FIBROMYALGIA AGENTS

CYMBALTA Non-Preferred QL 2 / 1 days duloxetine hcl DRIZALMA SPRINKLE Non-Preferred duloxetine hcl

duloxetine hcl 40 mg cp dr part Non-Preferred QL 1 / 1 days

duloxetine hcl 30 mg cp dr part Preferred QL 2 / 1 days

duloxetine hcl 20 mg cp dr part Preferred QL 2 / 1 days

duloxetine hcl 60 mg cp dr part Preferred QL 2 / 1 days

LYRICA 150 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 20 MG/ML SOLUTION Non-Preferred QLC 30 mL/day pregabalin LYRICA 75 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 100 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 25 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 200 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 50 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 300 MG CAP Non-Preferred QL 2 / 1 days pregabalin LYRICA 225 MG CAP Non-Preferred QL 2 / 1 days pregabalin LYRICA CR 330 MG TAB ER 24H Non-Preferred QL 60 / 30 days pregabalin (once-daily) LYRICA CR 165 MG TAB ER 24H Non-Preferred QL 90 / 30 days pregabalin (once-daily) LYRICA CR 82.5 MG TAB ER 24H Non-Preferred QL 90 / 30 days pregabalin (once-daily)

PAGE 182 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

pregabalin 20 mg/ml solution Preferred QLC 30 mL/day

pregabalin 75 mg cap Preferred QL 3 / 1 days

pregabalin 300 mg cap Preferred QL 2 / 1 days

pregabalin 150 mg cap Preferred QL 3 / 1 days

pregabalin 25 mg cap Preferred QL 3 / 1 days

pregabalin 225 mg cap Preferred QL 2 / 1 days

pregabalin 100 mg cap Preferred QL 3 / 1 days

pregabalin 50 mg cap Preferred QL 3 / 1 days

pregabalin 200 mg cap Preferred QL 3 / 1 days

pregabalin er Non-Preferred SAVELLA Non-Preferred milnacipran hcl SAVELLA TITRATION PACK Non-Preferred milnacipran hcl MULTIPLE SCLEROSIS AGENTS

AMPYRA Non-Preferred QL 60 / 30 days dalfampridine

AUBAGIO QL 30 / 30 days Preferred teriflunomide PA

AVONEX Preferred interferon beta-1a AVONEX PEN Preferred interferon beta-1a AVONEX PREFILLED Preferred interferon beta-1a BAFIERTAM Non-Preferred QL 120 / 30 days monomethyl fumarate BETASERON Preferred interferon beta-1b COPAXONE 20 MG/ML SOLN PRSYR Non-Preferred QL 30 / 30 days glatiramer acetate COPAXONE 40 MG/ML SOLN PRSYR Non-Preferred QL 12 / 28 days glatiramer acetate

PAGE 183 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days dalfampridine er Preferred PA

dimethyl fumarate 240 mg cap dr Preferred PA

dimethyl fumarate 120 mg cap dr Preferred PA

dimethyl fumarate starter pack Preferred PA

EXTAVIA Non-Preferred interferon beta-1b GILENYA 0.5 MG CAP Preferred PA fingolimod hcl GILENYA 0.25 MG CAP Preferred fingolimod hcl

glatiramer acetate 40 mg/ml soln prsyr Preferred QL 12 / 28 days

glatiramer acetate 20 mg/ml soln prsyr Preferred QL 30 / 30 days

glatopa 20 mg/ml soln prsyr Preferred QL 30 / 30 days

glatopa 40 mg/ml soln prsyr Preferred QL 12 / 28 days

KESIMPTA Non-Preferred ofatumumab (ms) LEMTRADA Non-Preferred alemtuzumab (ms) MAVENCLAD (10 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (4 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (5 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (6 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (7 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (8 TABS) Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (9 TABS) Non-Preferred cladribine (multiple sclerosis) MAYZENT 0.25 MG TAB Non-Preferred QL 120 / 30 days siponimod fumarate

PAGE 184 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MAYZENT 2 MG TAB Non-Preferred QL 30 / 30 days siponimod fumarate MAYZENT STARTER PACK Non-Preferred QLC 1 fill per lifetime siponimod fumarate OCREVUS Non-Preferred ocrelizumab PLEGRIDY Non-Preferred peginterferon beta-1a PLEGRIDY STARTER PACK Non-Preferred peginterferon beta-1a PONVORY Non-Preferred QL 30 / 30 days ponesimod PONVORY STARTER PACK Non-Preferred QL 14 / 14 days ponesimod REBIF Preferred interferon beta-1a REBIF REBIDOSE Preferred interferon beta-1a REBIF REBIDOSE TITRATION PACK Preferred interferon beta-1a REBIF TITRATION PACK Preferred interferon beta-1a TECFIDERA Non-Preferred dimethyl fumarate TYSABRI Preferred PA natalizumab VUMERITY Non-Preferred QL 120 / 30 days diroximel fumarate VUMERITY (STARTER) Non-Preferred QLC 1 fill per lifetime diroximel fumarate ZEPOSIA Non-Preferred QL 30 / 30 days ozanimod hcl ZEPOSIA 7-DAY STARTER PACK Non-Preferred QLC 1 fill per lifetime ozanimod hcl ZEPOSIA STARTER KIT Non-Preferred QLC 1 fill per lifetime ozanimod hcl DENTAL AND ORAL AGENTS

chlorhexidine gluconate 0.12 % solution Preferred QL 30 / 1 days

PAGE 185 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS oralone Preferred

pilocarpine hcl 7.5 mg tab Preferred QL 4 / 1 days

pilocarpine hcl 5 mg tab Preferred QL 4 / 1 days

triamcinolone acetonide 0.1 % paste Preferred DERMATOLOGICAL AGENTS

ABSORICA Non-Preferred isotretinoin ABSORICA LD Non-Preferred isotretinoin micronized ACANYA Non-Preferred clindamycin phosphate-benzoyl peroxide accutane Non-Preferred acitretin Non-Preferred ACZONE Non-Preferred dapsone (topical)

AL1 Up to 20 yrs old ADAPALENE 0.1 % SOLUTION Non-Preferred adapalene C Age restriction, clinical PA required

QL 45 / 30 days

adapalene 0.1 % gel Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old adapalene 0.3 % gel Preferred C Age restriction, clinical PA required

QL 45 / 30 days

adapalene 0.1 % cream Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old ADAPALENE 0.3 % GEL PUMP Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old adapalene-benzoyl peroxide 0.1-2.5 % Preferred gel C Age restriction, clinical PA required

AL1 Up to 20 yrs old AKLIEF Non-Preferred trifarotene C Age restriction, clinical PA required

PAGE 186 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALCORTIN A iodoquinol-hydrocortisone-aloe Non-Preferred polysaccharide ALDARA Non-Preferred imiquimod

AL1 Up to 20 yrs old ALTRENO Non-Preferred tretinoin C Age restriction, clinical PA required ammonium lactate 12 % cream Preferred ammonium lactate 12 % lotion Preferred

amnesteem Preferred PA

ARAZLO Non-Preferred tazarotene (acne)

AL1 Up to 20 yrs old ATRALIN Non-Preferred tretinoin C Age restriction, clinical PA required avar-e emollient Non-Preferred avar-e green Non-Preferred

QL 45 / 30 days

avita Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old AZELEX Non-Preferred azelaic acid (acne) C Age restriction, clinical PA required BENSAL HP Non-Preferred salicylic acid BENZACLIN Non-Preferred clindamycin phosphate-benzoyl peroxide BENZACLIN WITH PUMP Non-Preferred clindamycin phosphate-benzoyl peroxide BENZEPRO 5.8 % MISC Non-Preferred benzoyl peroxide BENZEPRO 5.2 % FOAM Non-Preferred benzoyl peroxide benzoyl peroxide 9.8 % foam Preferred bp 10-1 Non-Preferred

PAGE 187 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BP CLEANSING WASH sulfacetamide sodium-sulfur in urea Non-Preferred vehicle BPO Non-Preferred benzoyl peroxide calcipotriene 0.005 % solution Preferred CALCIPOTRIENE 0.005 % FOAM Non-Preferred calcipotriene

calcipotriene 0.005 % cream Preferred QL 60 / 30 days

calcipotriene 0.005 % ointment Preferred QL 60 / 30 days

calcipotriene-betameth diprop Non-Preferred calcitrene Non-Preferred calcitriol 3 mcg/gm ointment Non-Preferred claravis Non-Preferred CLENIA PLUS Non-Preferred sulfacetamide sodium w/ sulfur clindamycin phos-benzoyl perox 1.2-5 % Preferred gel clindamycin phos-benzoyl perox 1.2-2.5 Non-Preferred % gel clindamycin phos-benzoyl perox 1-5 % Preferred gel CLINDAMYCIN PHOS-BENZOYL Non-Preferred PEROX 1-5 % GEL PUMP clindamycin phosphate 1 % foam Non-Preferred

AL1 Up to 20 yrs old clindamycin-tretinoin Non-Preferred C Age restriction, clinical PA required CLOBETEX Non-Preferred desloratadine-clobetasol propionate clotrimazole-betamethasone 1-0.05 % Preferred QL 45 / 28 days cream clotrimazole-betamethasone 1-0.05 % Non-Preferred lotion CORTISPORIN 1 % OINTMENT Non-Preferred bacitracin-polymyxin-neomycin hc

PAGE 188 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CORTISPORIN 3.5-10000-0.5 CREAM Non-Preferred neomycin-polymyxin-hc COSENTYX Non-Preferred secukinumab COSENTYX (300 MG DOSE) Non-Preferred secukinumab COSENTYX SENSOREADY (300 MG) Non-Preferred secukinumab COSENTYX SENSOREADY PEN Non-Preferred secukinumab dapsone 5 % gel Non-Preferred dapsone 7.5 % gel Non-Preferred DAPSONE 7.5 % GEL Non-Preferred dapsone (topical) dermazene Non-Preferred

diclofenac sodium 1 % gel Preferred QL 500 / 30 days

diclofex dc 1.5-0.025 % ther pack Non-Preferred

QL 45 / 30 days DIFFERIN 0.1 % CREAM Preferred AL1 Up to 20 yrs old adapalene C Age restriction, clinical PA required

AL1 Up to 20 yrs old DIFFERIN 0.3 % GEL Non-Preferred adapalene C Age restriction, clinical PA required

AL1 Up to 20 yrs old DIFFERIN 0.1 % LOTION Non-Preferred adapalene C Age restriction, clinical PA required DIPROLENE Non-Preferred QL 50 / 30 days betamethasone dipropionate augmented DOVONEX Non-Preferred QL 2 / 1 days calcipotriene DRYSOL Preferred aluminum chloride DUAC clindamycin phosphate-benzoyl peroxide Non-Preferred (refrigerate) DUOBRII Non-Preferred halobetasol propionate-tazarotene

PAGE 189 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DUPIXENT 300 MG/2ML SOLN PRSYR Non-Preferred QL 8 / 28 days dupilumab DUPIXENT 300 MG/2ML SOLN PEN Non-Preferred dupilumab DUPIXENT 200 MG/1.14ML SOLN PRSYR Non-Preferred QL 4.56 / 28 days dupilumab DUROLANE Preferred PA sodium hyaluronate (viscosupplement) ELIDEL Preferred QL 30 / 24 days pimecrolimus ENSTILAR calcipotriene-betamethasone Non-Preferred dipropionate

AL1 Up to 20 yrs old EPIDUO Non-Preferred adapalene-benzoyl peroxide C Age restriction, clinical PA required

AL1 Up to 20 yrs old EPIDUO FORTE Non-Preferred adapalene-benzoyl peroxide C Age restriction, clinical PA required EUCRISA Preferred PA crisaborole EVOCLIN Non-Preferred clindamycin phosphate (topical)

AL1 Up to 20 yrs old FABIOR Non-Preferred tazarotene (acne) C Age restriction, clinical PA required hydrocortisone (perianal) 1 % cream Preferred hydrocortisone-iodoquinol Non-Preferred ILUMYA Non-Preferred tildrakizumab-asmn imiquimod 3.75 % cream Non-Preferred

imiquimod 5 % cream Preferred QL 48 / 365 days

imiquimod pump Non-Preferred iodoquinol-hc-aloe polysacch Non-Preferred

isotretinoin 10 mg cap Non-Preferred PA

isotretinoin 30 mg cap Non-Preferred PA

PAGE 190 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS isotretinoin 25 mg cap Non-Preferred

isotretinoin 20 mg cap Non-Preferred PA

isotretinoin 40 mg cap Non-Preferred PA

isotretinoin 35 mg cap Non-Preferred LOTRISONE Non-Preferred clotrimazole w/ betamethasone LUXIQ Non-Preferred betamethasone valerate methoxsalen rapid Non-Preferred METHOXSALEN RAPID Non-Preferred methoxsalen rapid

metronidazole 0.75 % cream Preferred QL 45 / 26 days

MICORT-HC Non-Preferred hydrocortisone acetate (topical)

myorisan Preferred PA

NEO-SYNALAR 0.5-0.025 % KIT Non-Preferred neomycin-fluocinolone & emollient NEO-SYNALAR 0.5-0.025 % CREAM Non-Preferred neomycin sulfate-fluocinolone acetonide NEUAC 1.2-5 % KIT clindamycin phosphate-benzoyl peroxide Non-Preferred & moisturizer neuac 1.2-5 % gel Non-Preferred ONEXTON Non-Preferred clindamycin phosphate-benzoyl peroxide OXSORALEN ULTRA Non-Preferred methoxsalen rapid

pimecrolimus Non-Preferred QL 30 / 24 days

PIMECROLIMUS 1 % CREAM Preferred QL 30 / 24 days (Oceanside [68682] labeler only) podofilox 0.5 % solution Preferred procto-pak Preferred PROCTOCORT 1 % CREAM Non-Preferred hydrocortisone (rectal) PROCTOFOAM HC Preferred hydrocortisone acetate w/ pramoxine

PAGE 191 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROTOPIC Preferred QLC 30 grams per fill tacrolimus (topical)

QL 45 / 30 days RETIN-A Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO PUMP Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

rosadan 0.75 % gel Preferred QL 45 / 26 days

rosadan 0.75 % cream Preferred QL 45 / 26 days

Max 60 days supply SANTYL C Preferred per 365 days collagenase QLC 120 grams/30 days

selenium sulfide 2.5 % lotion Preferred SERNIVO Non-Preferred betamethasone dipropionate (topical) SKYRIZI Non-Preferred risankizumab-rzaa SKYRIZI (150 MG DOSE) Non-Preferred risankizumab-rzaa sodium sulfacetamide wash Non-Preferred SORIATANE 25 MG CAP Preferred acitretin SORIATANE 10 MG CAP Preferred acitretin SORILUX Non-Preferred calcipotriene SSS 10-5 10-5 % FOAM Non-Preferred sulfacetamide sodium w/ sulfur sss 10-5 10-5 % cream Preferred STELARA 45 MG/0.5ML SOLUTION Non-Preferred QLC 0.5 mL/28 days ustekinumab STELARA 90 MG/ML SOLN PRSYR Non-Preferred QLC 1 mL/28 days ustekinumab

PAGE 192 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STELARA 45 MG/0.5ML SOLN PRSYR Non-Preferred QLC 0.5 mL/28 days ustekinumab STELARA 130 MG/26ML SOLUTION Non-Preferred QLC 104 mL/56 days ustekinumab (iv) sulfacetamide sod-sulfur wash 9-4 % Non-Preferred liquid sulfacetamide sod-sulfur wash 9-4.5 % Preferred liquid sulfacetamide sodium 10 % liquid Non-Preferred sulfacetamide sodium-sulfur 10-5 % Non-Preferred emulsion sulfacetamide sodium-sulfur 8-4 % Preferred suspension sulfacetamide sodium-sulfur 9-4 % liquid Non-Preferred sulfacetamide sodium-sulfur 10-2 % Non-Preferred liquid sulfacetamide sodium-sulfur 10-2 % Non-Preferred cream sulfacetamide sodium-sulfur 9.8-4.8 % Non-Preferred liquid sulfacetamide sodium-sulfur 10-4 % pad Non-Preferred sulfacetamide sodium-sulfur 9-4.5 % Preferred liquid sulfacetamide sodium-sulfur 10-5 % Non-Preferred cream SUMADAN sulfacetamide sodium-sulfur w/ skin Non-Preferred cleanser SUMADAN WASH Non-Preferred sulfacetamide sodium w/ sulfur SUMADAN XLT Non-Preferred sulfacetamide sodium-sulfur-sunscreen SUMAXIN Non-Preferred sulfacetamide sodium w/ sulfur SUMAXIN CP sulfacetamide sodium-sulfur w/ skin Non-Preferred cleanser SUMAXIN TS Non-Preferred sulfacetamide sodium w/ sulfur

PAGE 193 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUMAXIN WASH Non-Preferred sulfacetamide sodium w/ sulfur TACLONEX calcipotriene-betamethasone Preferred dipropionate

tacrolimus 0.1 % ointment Preferred QLC 30 grams per fill

tacrolimus 0.03 % ointment Preferred QLC 30 grams per fill

TALTZ Preferred PA ixekizumab

AL1 Up to 20 yrs old TAZAROTENE 0.1 % FOAM Non-Preferred tazarotene (acne) C Age restriction, clinical PA required

QL 30 / 30 days

tazarotene 0.1 % cream Non-Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days TAZORAC Preferred AL1 Up to 20 yrs old tazarotene C Age restriction, clinical PA required TOVET 0.05 % KIT clobetasol propionate emulsion foam w/ Non-Preferred moisturizing cream

QL 45 / 30 days

tretinoin 0.025 % gel Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin 0.01 % gel Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin 0.05 % cream Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin 0.025 % cream Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

PAGE 194 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 45 / 30 days

tretinoin 0.1 % cream Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin 0.05 % gel Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere pump Non-Preferred C Age restriction, clinical PA required

urea 40 % lotion Preferred QL 240 / 24 days

urea-c40 Preferred QL 240 / 24 days

VECTICAL Non-Preferred calcitriol (topical) WINLEVI Non-Preferred clascoterone WYNZORA calcipotriene-betamethasone Non-Preferred dipropionate XEPI Non-Preferred ozenoxacin

zenatane Preferred PA

AL1 Up to 20 yrs old ZIANA Non-Preferred clindamycin phosphate-tretinoin C Age restriction, clinical PA required ZYCLARA Non-Preferred imiquimod ZYCLARA PUMP Non-Preferred imiquimod ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

ACTIVE FE Non-Preferred fe carbonyl-fa-b complex-a-c-d-e-min corvita 150 Non-Preferred

PAGE 195 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

effer-k 25 meq effer tab Preferred QL 4 / 1 days

ENDARI Non-Preferred QL 180 / 30 days glutamine (sickle cell) FERAHEME Non-Preferred ferumoxytol FERIVA 21/7 fe asparto gly-vit b12-fa-vit c-dss- Non-Preferred succinic acid-zinc FERIVAFA Non-Preferred iron-vit c-fa-b12-biotin-copper-docusate FERRALET 90 fe carbonyl-fe gluconate-fa-vit b12-vit c- Non-Preferred docusate sodium FERRAPLUS 90 iron-folic acid-vitamin b12-vitamin c- Non-Preferred docusate sodium FERRLECIT sodium ferric gluconate complex in Preferred sucrose ferrocite plus Non-Preferred FOLIVANE-F ferrous fumarate-iron polysaccharide Preferred complex-folic acid-c-b3 FUSION PLUS fe fum-iron polysacch complex-fa-b Non-Preferred cmplx-c-biotin-probiotic FUSION SPRINKLES ferrous fumarate-iron polysaccharide Non-Preferred complex-fa-c-probiotic hematinic plus vit/minerals Preferred hematinic/folic acid Non-Preferred HEMATOGEN FA fe fumarate-vitamin c-vitamin b12-folic Non-Preferred acid hematogen forte Non-Preferred HEMETAB polysaccharide fe complex-fe heme Non-Preferred polypeptide-fa-vit b12 hemocyte-f Non-Preferred

PAGE 196 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS iferex 150 forte Preferred INFED Preferred iron dextran INJECTAFER Non-Preferred ferric carboxymaltose INTEGRA F ferrous fumarate-iron polysaccharide Non-Preferred complex-folic acid-c-b3 IROSPAN 24/6 fe bisglyc-fe polysaccharide-succ acd-b Non-Preferred complex-c-ca-fa

k-effervescent Preferred QL 4 / 1 days

k-vescent Preferred QL 4 / 1 days

klor-con Preferred QL 5 / 1 days

klor-con 10 Preferred QL 5 / 1 days

klor-con m10 Preferred QL 5 / 1 days

klor-con m20 Preferred QL 5 / 1 days

klor-con sprinkle 8 meq cap er Preferred

klor-con sprinkle 10 meq cap er Preferred QL 5 / 1 days

klor-con/ef Preferred QL 4 / 1 days

levocarnitine 1 gm/10ml solution Preferred levocarnitine sf Preferred MONOFERRIC Non-Preferred ferric derisomaltose MULTIGEN fe asparto gly-succin ac-c-threonic ac- Non-Preferred b12-des stom subst MULTIGEN FOLIC fe asparto gly-succinic acd-vit c-threonic Non-Preferred acd-vit b12-fa MULTIGEN PLUS fe asparto gly-fe fumarate-succ acd-c- Non-Preferred threonic acd-b12-fa myferon 150 forte Non-Preferred na ferric gluc cplx in sucrose Preferred

PAGE 197 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEPHRON FA ferrous fumarate w/ fa-dss-b complex-vit Non-Preferred c poly-iron 150 forte Non-Preferred potassium chloride 40 meq/15ml (20%) Preferred QL 60 / 1 days solution

potassium chloride 20 meq packet Preferred QL 5 / 1 days

potassium chloride 20 meq/15ml (10%) Preferred QL 60 / 1 days solution

potassium chloride crys er Preferred QL 5 / 1 days

potassium chloride er 8 meq tab er Preferred QL 5 / 1 days

potassium chloride er 8 meq cap er Preferred

potassium chloride er 20 meq tab er Preferred QL 5 / 1 days

potassium chloride er 10 meq tab er Preferred QL 5 / 1 days

potassium chloride er 10 meq cap er Preferred QL 5 / 1 days

purevit dualfe plus Non-Preferred se-tan plus Non-Preferred sodium bicarbonate 8.4 % solution Preferred sodium chloride 0.9 % solution Preferred sodium fluoride 0.55 (0.25 f) mg chew Preferred QL 4 / 1 days tab

sodium fluoride 1.1 (0.5 f) mg/ml solution Preferred QL 50 / 30 days

sodium fluoride 2.2 (1 f) mg chew tab Preferred QL 1 / 1 days

sodium fluoride 1.1 (0.5 f) mg chew tab Preferred QL 2 / 1 days

TANDEM PLUS fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-zn-mn-cu TARON FORTE fe bisglycinate-fe polysaccharide-vit c-vit Non-Preferred b12-folic acid tl-hem 150 Non-Preferred trigels-f forte Non-Preferred VENOFER Preferred iron sucrose

PAGE 198 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET Preferred succimer

deferasirox Preferred PA

deferasirox granules Preferred PA

deferiprone Non-Preferred EXJADE Non-Preferred deferasirox FERRIPROX Non-Preferred deferiprone FERRIPROX TWICE-A-DAY Non-Preferred deferiprone JADENU Non-Preferred deferasirox JADENU SPRINKLE Non-Preferred deferasirox

kionex 15 gm/60ml suspension Preferred QL 240 / 1 days

kionex powder Preferred QL 60 / 1 days

sodium polystyrene sulfonate 50 Preferred QL 480 / 1 days gm/200ml suspension sodium polystyrene sulfonate 30 Preferred QL 480 / 1 days gm/120ml suspension

sodium polystyrene sulfonate powder Preferred QL 60 / 1 days

sodium polystyrene sulfonate 15 Preferred QL 240 / 1 days gm/60ml suspension

sps Preferred QL 240 / 1 days

TRIFERIC 272 MG PACKET Non-Preferred ferric pyrophosphate citrate PHOSPHATE BINDERS

AURYXIA Non-Preferred ferric citrate calcium acetate 667 mg tab Preferred

calcium acetate (phos binder) Preferred QL 12 / 1 days

FOSRENOL Non-Preferred lanthanum carbonate

PAGE 199 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lanthanum carbonate Non-Preferred PHOSLYRA Preferred calcium acetate (phosphate binder) phospha 250 neutral Preferred phospho-trin 250 neutral Preferred RENAGEL Non-Preferred QL 16 / 1 days sevelamer hcl RENVELA 0.8 GM PACKET Non-Preferred sevelamer carbonate RENVELA 2.4 GM PACKET Non-Preferred sevelamer carbonate RENVELA 800 MG TAB Non-Preferred QL 17 / 1 days sevelamer carbonate sevelamer carbonate 2.4 gm packet Non-Preferred sevelamer carbonate 0.8 gm packet Non-Preferred

sevelamer carbonate 800 mg tab Preferred QL 17 / 1 days

sevelamer hcl 800 mg tab Non-Preferred SEVELAMER HCL 400 MG TAB Non-Preferred sevelamer hcl VELPHORO Non-Preferred sucroferric oxyhydroxide VELTASSA Preferred PA patiromer sorbitex calcium virt-phos 250 neutral Preferred VITAMINS

AZESCHEW PRENATAL/POSTNATAL prenatal without a vit w/ fe fumarate-folic Non-Preferred acid BP VIT 3 folic acid-vitamin b6-vitamin b12-omega Non-Preferred 3 acids-phytosterols C-NATE DHA prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids CENTRATEX ferrous fumarate-fa-b complex-c-zn-mg- Non-Preferred mn-cu

PAGE 200 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS chromagen Non-Preferred CITRANATAL 90 DHA prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred gluconate-dss-fa-dha CITRANATAL ASSURE prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred gluconate-dss-fa-dha CITRANATAL B-CALM prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred gluconate-fa & vit b6 CITRANATAL BLOOM prenatal vit w/ docusate-fe carbonyl-fe Non-Preferred gluconate-folic acid CITRANATAL DHA prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred gluconate-dss-fa-dha CITRANATAL HARMONY prenatal w/o vit a w/ fe fumarate-fe Non-Preferred carbonyl-dss-fa-dha CITRANATAL RX prenatal without vit a w/ fe carbonyl-fe Non-Preferred gluc-docusate-fa COMPLETE NATAL DHA prenatal mv & min w/fe bisglyc-fe prot Preferred succ-fa-ca-omega 3 COMPLETENATE Non-Preferred prenatal vit w/ ferrous fumarate-folic acid CONCEPT DHA prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3 CONCEPT OB prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa CORVITE 150 TAB Non-Preferred iron combinations CORVITE FE Non-Preferred iron combinations

corvite free Preferred QL 1 / 1 days

cyanocobalamin 1000 mcg/ml solution Preferred elite-ob Non-Preferred

PAGE 201 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ENBRACE HR prenatal vit w/ fe glycine cysteinate-fa- Non-Preferred omega 3 fatty acids fa-vitamin b-6-vitamin b-12 Preferred fabb Non-Preferred ferocon Non-Preferred folbee Non-Preferred

folic acid 1 mg tab Preferred QL 4 / 1 days

FOLITE folic acid-vitamin d3-mag cit- Non-Preferred acetylcysteine-ca cit FOLIVANE-OB prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa FOLIVANE-PLUS fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin folplex 2.2 Preferred FOLTRATE Non-Preferred cobalamin combinations hematogen Non-Preferred HEMOCYTE PLUS ferrous fumarate-fa-b complex-c-zn-mg- Non-Preferred mn-cu INTEGRA PLUS fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin M-NATAL PLUS Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid multi-vit/fluoride/iron Preferred multi-vit/iron/fluoride Preferred multi-vitamin/fluoride/iron Preferred MULTIVITAMIN/FLUORIDE 1 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl MULTIVITAMIN/FLUORIDE 0.5 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl

PAGE 202 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MULTIVITAMIN/FLUORIDE 0.25 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl

multivitamins/fluoride Preferred QL 1 / 1 days

nephronex Preferred NESTABS prenatal vit without vit a w/ fe Non-Preferred bisglycinate-folic acid NESTABS DHA prenatal vit without vit a w/ fe Non-Preferred bisglycinate-fa-omeg 3 NESTABS ONE prenatal w/o a w/fe carbonyl-fe bisglyc-l Non-Preferred methylfol-dha NIFEREX Non-Preferred iron combinations niva-fol Preferred NIVA-PLUS Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid NUFERA Non-Preferred iron combinations

nutrifac zx Preferred QL 1 / 1 days

O-CAL FA Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid O-CAL PRENATAL Non-Preferred prenatal vit w/ ferrous fumarate-folic acid OB COMPLETE Non-Preferred prenatal vit w/ iron carbonyl-folic acid OB COMPLETE ONE prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred aspart glyc-fa-fish oil OB COMPLETE PETITE prenatal w/o vit a w/ fe carbonyl-fe Non-Preferred aspart glyc-fa-omega 3 OB COMPLETE PREMIER prenatal vit w/ iron carbonyl-fe aspart Non-Preferred glycinate-fa OB COMPLETE/DHA prenat vit w/ iron carbonyl-fe asp glyc-fa- Non-Preferred omega fatty acid

PAGE 203 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PNV PRENATAL PLUS MULTIVITAMIN Preferred prenatal vit w/ ferrous fumarate-folic acid PNV TABS 20-1 prenatal vit w/ fe bisglycinate chelate- Non-Preferred folic acid PNV TABS 29-1 Preferred QL 1 / 1 days prenatal vit w/ iron carbonyl-folic acid pnv-dha Non-Preferred PNV-DHA+DOCUSATE prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha PNV-OMEGA prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-omega 3 PNV-SELECT prenatal vit w/ ferrous fumarate-l Non-Preferred methylfolate-folic acid PREGEN DHA Non-Preferred prenatal mv & min w/fe carbonyl-fa-dha PRENAISSANCE prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha PRENAISSANCE PLUS prenatal w/o vit a w/ fe carbonyl-dss-fa- Non-Preferred dha PRENATAL Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid PRENATAL 19 CHEW TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid PRENATAL VITAMIN PLUS LOW IRON Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid PRENATAL-U prenatal without a vit w/ fe fumarate-folic Preferred acid PRENATE prenatal multivitamins & minerals w/ l- Non-Preferred methylfolate-fa PRENATE AM prenatal w/ calcium-vit b6-vit b12-folic Non-Preferred acid-ginger

PAGE 204 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRENATE ELITE 20-0.6-0.4 MG TAB prenatal w/ fe asparto glycinate-l Non-Preferred methylfolate-folic acid PRENATE ENHANCE prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-dha PRENATE ESSENTIAL 18-0.6-0.4-300 MG CAP Non-Preferred prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha PRENATE MINI 18-0.6-0.4-350 MG CAP Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe asp glyc-methfol-fa-dha PRENATE PIXIE prenatal w/o a w/ fe asparto glyc-l Non-Preferred methylfolate-fa-dha PRENATE RESTORE prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-dha PRENATRIX Non-Preferred prenatal vit w/ ferrous fumarate-folic acid PRENATRYL Non-Preferred prenatal vit w/ ferrous fumarate-folic acid PREPLUS Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid PRETAB Preferred prenatal vit w/ ferrous fumarate-folic acid PRIMACARE prenatal without a w/ fe asp glyc-l Non-Preferred methylfolate-fa-omega 3 PROVIDA DHA prenatal without a w/fe fum-fe polysacch Non-Preferred complex-fa-dha PROVIDA OB prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa PUREFE OB PLUS prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa

reno caps Preferred QL 1 / 1 days

PAGE 205 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SE-NATAL 19 29-1 MG CHEW TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid SE-NATAL 19 29-1 MG TAB prenatal vit w/ docusate-fe fumarate-folic Non-Preferred acid SELECT-OB 29-1 MG CHEW TAB prenatal vit w/ iron polysaccharide Non-Preferred complex-folic acid SELECT-OB 29-0.6-0.4 MG CHEW TAB prenatal vit w/ iron polysaccharide Non-Preferred cmplx-l methylfolate-fa SELECT-OB+DHA prenatal mv & min w/fe polysaccharide Non-Preferred complex-fa-dha TARON-C DHA prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3 TARON-PREX prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha THRIVITE 19 Non-Preferred multiple vitamins w/ minerals & folic acid THRIVITE RX Non-Preferred QL 1 / 1 days prenatal vit w/ iron carbonyl-folic acid tl gard rx Preferred TRICARE Non-Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid TRICARE PRENATAL DHA ONE 0.8 MG CAP Non-Preferred prenatal multivit-min w/fe-fa tricon Non-Preferred TRINATAL RX 1 Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid

triphrocaps Preferred QL 1 / 1 days

TRISTART DHA prenatal without a w/ fe carbonyl-l Non-Preferred methylfolate-fa-dha TRIVEEN-DUO DHA prenatal mv & min w/fe bisglyc-fe prot Preferred succ-fa-ca-omega 3

PAGE 206 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VENEXA FE Non-Preferred multiple vitamins w/ minerals VINATE DHA RF prenatal without vit a w/ fe fumarate-l Non-Preferred methylfolate-omegas VINATE M prenatal vit w/ selenium-fe fumarate-folic Preferred acid VIRT NATE Non-Preferred prenatal vit w/ ferrous fumarate-folic acid VIRT-C DHA prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3

virt-caps Preferred QL 1 / 1 days

VIRT-FEFA PLUS fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin virt-gard Preferred VIRT-NATE DHA prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids VIRT-PN prenatal vit w/ ferrous fumarate-l Non-Preferred methylfolate-folic acid VIRT-PN DHA prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-dha VIRT-PN PLUS prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-omega 3 VIRT-SELECT prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha virt-vite forte Preferred VIRTPREX prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha

vita s forte Preferred QL 1 / 1 days

vitafol Non-Preferred

PAGE 207 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VITAFOL FE+ 90-1-200 & 50 MG CAP THPK Non-Preferred prenatal vit w/ fe polysacch complex-l methylfol-fa-dha-dss VITAFOL FE+ 90-0.6-0.4-200 MG CAP prenatal vit w/ fe polysacch complex-l Non-Preferred methylfolate-fa-dha VITAFOL GUMMIES prenatal vit w/ ferric phosphate-fa- Non-Preferred omega 3 fatty acids VITAFOL ULTRA prenatal vit w/ fe polysacch complex-l Non-Preferred methylfolate-fa-dha VITAFOL-NANO prenatal w/o a vit w/ fe fumarate-l Non-Preferred methylfolate-folic acid VITAFOL-OB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid VITAFOL-OB+DHA Non-Preferred prenatal mv & min w/fe fumarate-fa-dha VITAFOL-ONE prenatal mv & min w/fe polysaccharide Non-Preferred complex-fa-dha VITRANOL FE Non-Preferred multiple vitamins w/ minerals VITREXATE FE Non-Preferred multiple vitamins w/ minerals VITREXYL + IRON Non-Preferred multiple vitamins w/ minerals vol-care rx Preferred VOL-PLUS Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid VP-PNV-DHA prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids vp-vite rx Preferred westab mini Non-Preferred westab one Non-Preferred WESTAB PLUS Preferred prenatal vit w/ ferrous fumarate-folic acid

PAGE 208 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS WESTGEL DHA prenatal without a w/ fe carbonyl-l Non-Preferred methylfolate-fa-dha ZATEAN-PN DHA prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-dha ZATEAN-PN PLUS prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-omega 3 GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine hcl 10 mg cap Preferred QL 8 / 1 days

dicyclomine hcl 20 mg tab Preferred QL 8 / 1 days

glycopyrrolate 1 mg tab Preferred QL 6 / 1 days

glycopyrrolate 2 mg tab Preferred QL 4 / 1 days

propantheline bromide 15 mg tab Preferred QL 5 / 1 days

GASTROINTESTINAL AGENTS, OTHER

ACTIGALL Non-Preferred QL 90 / 30 days ursodiol amoxicill-clarithro-lansopraz Non-Preferred CHENODAL Non-Preferred chenodiol

diphenoxylate-atropine 2.5-0.025 mg tab Preferred QL 8 / 1 days

diphenoxylate-atropine 2.5-0.025 Preferred QL 40 / 1 days mg/5ml liquid HELIDAC THERAPY metronidazole-tetracycline w/ bismuth Non-Preferred subsalicylate

loperamide hcl 2 mg cap Preferred QL 8 / 1 days

MOTEGRITY Non-Preferred QL 30 / 30 days prucalopride succinate MOVANTIK Non-Preferred QL 1 / 1 days naloxegol oxalate OMECLAMOX-PAK Non-Preferred amoxicillin-clarithromycin w/ omeprazole

PAGE 209 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PYLERA bismuth subcitrate potassium- Non-Preferred metronidazole-tetracycline RELISTOR 8 MG/0.4ML SOLUTION Non-Preferred methylnaltrexone bromide RELISTOR 150 MG TAB Non-Preferred QL 90 / 30 days methylnaltrexone bromide RELISTOR 12 MG/0.6ML SOLUTION Non-Preferred methylnaltrexone bromide SYMPROIC Non-Preferred QL 30 / 30 days naldemedine tosylate TALICIA Non-Preferred amoxicillin-rifabutin-omeprazole URSO 250 Non-Preferred ursodiol URSO FORTE Non-Preferred ursodiol ursodiol 250 mg tab Preferred

ursodiol 300 mg cap Preferred QL 90 / 30 days

ursodiol 500 mg tab Preferred HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 200 mg tab Preferred QL 120 / 30 days

cimetidine 400 mg tab Preferred QL 6 / 1 days

cimetidine 300 mg tab Preferred QL 8 / 1 days

cimetidine 800 mg tab Preferred QL 90 / 30 days

cimetidine hcl 400 mg/6.67ml solution Preferred

cimetidine hcl 300 mg/5ml solution Preferred QL 40 / 1 days

famotidine 20 mg tab Preferred QL 120 / 30 days

famotidine 40 mg/5ml recon susp Preferred famotidine 40 mg/4ml solution Preferred famotidine 200 mg/20ml solution Preferred

famotidine 40 mg tab Preferred QL 2 / 1 days

famotidine 20 mg/2ml solution Preferred

PAGE 210 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FAMOTIDINE PREMIXED Preferred famotidine in nacl nizatidine 300 mg cap Preferred nizatidine 150 mg cap Preferred NIZATIDINE Preferred nizatidine PEPCID 20 MG TAB Non-Preferred famotidine PEPCID 40 MG TAB Non-Preferred QL 2 / 1 days famotidine

ranitidine hcl 75 mg/5ml syrup Preferred QL 40 / 1 days

RANITIDINE HCL 1000 MG/40ML SOLUTION Preferred ranitidine hcl

ranitidine hcl 150 mg/10ml syrup Preferred QL 40 / 1 days

ranitidine hcl 150 mg tab Preferred QL 120 / 30 days

ranitidine hcl 15 mg/ml syrup Preferred QL 40 / 1 days

ranitidine hcl 150 mg cap Non-Preferred QL 4 / 1 days

ranitidine hcl 50 mg/2ml solution Preferred ranitidine hcl 150 mg/6ml solution Preferred

ranitidine hcl 300 mg cap Non-Preferred QL 2 / 1 days

ranitidine hcl 300 mg tab Preferred QL 2 / 1 days

ZANTAC 150 MG/6ML SOLUTION Non-Preferred ranitidine hcl ZANTAC 50 MG/2ML SOLUTION Non-Preferred ranitidine hcl ZANTAC 1000 MG/40ML SOLUTION Non-Preferred ranitidine hcl IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl Non-Preferred

AMITIZA QL 60 / 30 days Preferred lubiprostone PA

LINZESS 145 MCG CAP QL 1 / 1 days Preferred linaclotide PA

PAGE 211 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

LINZESS 290 MCG CAP QL 1 / 1 days Preferred linaclotide PA

LINZESS 72 MCG CAP Non-Preferred QL 1 / 1 days linaclotide LOTRONEX Non-Preferred alosetron hcl

lubiprostone Non-Preferred QL 60 / 30 days

VIBERZI Non-Preferred QL 60 / 30 days eluxadoline ZELNORM Non-Preferred tegaserod maleate LAXATIVES

constulose Preferred QL 120 / 1 days

enulose Preferred QL 120 / 1 days

gavilyte-c Preferred QL 4000 / 30 days

gavilyte-g Preferred QL 4000 / 30 days

gavilyte-n with flavor pack Preferred QL 4000 / 30 days

generlac Preferred QL 120 / 1 days

GOLYTELY 227.1 GM RECON SOLN peg 3350-kcl-sod bicarb-sod chloride- Preferred sod sulfate

lactulose 20 gm/30ml solution Preferred QL 120 / 1 days

lactulose 10 gm/15ml solution Preferred QL 120 / 1 days

lactulose encephalopathy Preferred QL 120 / 1 days

MOVIPREP peg 3350-kcl-nacl-na sulfate-na Preferred ascorbate-ascorbic acid

peg 3350-kcl-na bicarb-nacl Preferred QL 4000 / 30 days

peg 3350/electrolytes Preferred QL 4000 / 30 days

peg-3350/electrolytes Preferred QL 4000 / 30 days

peg-3350/electrolytes/ascorbat Preferred

PAGE 212 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS peg-kcl-nacl-nasulf-na asc-c Preferred polyethylene glycol 3350 17 gm/scoop Preferred QLC 18 grams/day powder

polyethylene glycol 3350 17 gm packet Preferred QL 2 / 1 days

trilyte Preferred QL 4000 / 30 days

TRULANCE Non-Preferred QL 30 / 30 days plecanatide PROTECTANTS

misoprostol 200 mcg tab Preferred QL 4 / 1 days

misoprostol 100 mcg tab Preferred QL 8 / 1 days

sucralfate 1 gm/10ml suspension Preferred QL 40 / 1 days

sucralfate 1 gm tab Preferred QL 4 / 1 days

PROTON PUMP INHIBITORS

ACIPHEX Non-Preferred QL 30 / 30 days rabeprazole sodium ACIPHEX SPRINKLE Non-Preferred rabeprazole sodium DEXILANT Non-Preferred dexlansoprazole esomeprazole magnesium 40 mg packet Non-Preferred

PA required for members under 6 esomeprazole magnesium 40 mg cap dr Preferred C years of age with a history of 120 days supply in the previous 180 days esomeprazole magnesium 20 mg packet Non-Preferred

PA required for members under 6 esomeprazole magnesium 20 mg cap dr Preferred C years of age with a history of 120 days supply in the previous 180 days esomeprazole magnesium 10 mg packet Non-Preferred ESOMEPRAZOLE STRONTIUM 49.3 MG CAP DR Non-Preferred esomeprazole strontium

PAGE 213 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

lansoprazole 30 mg tab dr disp Non-Preferred QL 30 / 30 days

QL 60 / 30 days PA required for lansoprazole 30 mg cap dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for lansoprazole 15 mg cap dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

lansoprazole 15 mg tab dr disp Non-Preferred QL 30 / 30 days

PA required for members under 6 NEXIUM 40 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days PA required for members under 6 NEXIUM 10 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days PA required for members under 6 NEXIUM 5 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days NEXIUM 40 MG CAP DR Non-Preferred esomeprazole magnesium

PA required for members under 6 NEXIUM 2.5 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days NEXIUM 20 MG CAP DR Non-Preferred esomeprazole magnesium

PA required for members under 6 NEXIUM 20 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days

PAGE 214 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days PA required for omeprazole 40 mg cap dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for omeprazole 20 mg cap dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for omeprazole 10 mg cap dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days omeprazole-sodium bicarbonate Non-Preferred

QL 60 / 30 days PA required for pantoprazole sodium 40 mg tab dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for pantoprazole sodium 20 mg tab dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days PREVACID Non-Preferred QL 60 / 30 days lansoprazole PREVACID SOLUTAB Non-Preferred QL 30 / 30 days lansoprazole PRILOSEC 10 MG PACKET Preferred QL 60 / 30 days omeprazole magnesium PRILOSEC 2.5 MG PACKET Non-Preferred QL 2 / 1 days omeprazole magnesium PROTONIX 40 MG TAB DR Non-Preferred QL 2 / 1 days pantoprazole sodium

PAGE 215 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROTONIX 20 MG TAB DR Non-Preferred QL 2 / 1 days pantoprazole sodium PROTONIX 40 MG PACKET Non-Preferred pantoprazole sodium

QL 30 / 30 days PA required for rabeprazole sodium 20 mg tab dr Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days ZEGERID Non-Preferred omeprazole-sodium bicarbonate GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

BUPHENYL Preferred sodium phenylbutyrate CERDELGA Non-Preferred eliglustat tartrate CEREZYME Non-Preferred imiglucerase CHOLBAM Preferred PA cholic acid CREON Preferred pancrelipase (lipase-protease-amylase) ELELYSO Preferred PA taliglucerase alfa miglustat Non-Preferred OCALIVA Non-Preferred obeticholic acid PANCREAZE 4200 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 10500 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 16800 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 2600-8800 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase)

PAGE 216 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PANCREAZE 21000 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PERTZYE Non-Preferred pancrelipase (lipase-protease-amylase) RAVICTI Non-Preferred glycerol phenylbutyrate sodium phenylbutyrate 3 gm/tsp powder Preferred sodium phenylbutyrate 500 mg tab Preferred VIOKACE Non-Preferred pancrelipase (lipase-protease-amylase) VPRIV Non-Preferred velaglucerase alfa ZAVESCA Preferred PA miglustat ZENPEP Preferred pancrelipase (lipase-protease-amylase) GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide er Non-Preferred DETROL Non-Preferred QL 2 / 1 days tolterodine tartrate DETROL LA Non-Preferred QL 1 / 1 days tolterodine tartrate DITROPAN XL 10 MG TAB ER 24H Non-Preferred QL 1 / 1 days oxybutynin chloride DITROPAN XL 5 MG TAB ER 24H Non-Preferred QL 1 / 1 days oxybutynin chloride ENABLEX Non-Preferred darifenacin hydrobromide flavoxate hcl Non-Preferred GELNIQUE Non-Preferred oxybutynin chloride GELNIQUE PUMP Non-Preferred oxybutynin chloride GEMTESA Non-Preferred QL 30 / 30 days vibegron

PAGE 217 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MYRBETRIQ Non-Preferred mirabegron

oxybutynin chloride 5 mg/5ml syrup Preferred QL 20 / 1 days

oxybutynin chloride 5 mg tab Preferred QL 4 / 1 days

oxybutynin chloride er 10 mg tab er 24h Preferred QL 60 / 30 days

oxybutynin chloride er 5 mg tab er 24h Preferred QL 30 / 30 days

oxybutynin chloride er 15 mg tab er 24h Preferred QL 60 / 30 days

OXYTROL Non-Preferred oxybutynin solifenacin succinate Preferred

tolterodine tartrate Preferred QL 2 / 1 days

tolterodine tartrate er Preferred QL 1 / 1 days

TOVIAZ Non-Preferred fesoterodine fumarate

trospium chloride Preferred QL 60 / 30 days

trospium chloride er Non-Preferred QL 1 / 1 days

VESICARE Non-Preferred solifenacin succinate VESICARE LS Non-Preferred solifenacin succinate BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er Preferred QL 1 / 1 days

AVODART Non-Preferred QL 1 / 1 days dutasteride CARDURA XL Non-Preferred doxazosin mesylate (bph) CIALIS 5 MG TAB Non-Preferred QL 30 / 30 days tadalafil CIALIS 2.5 MG TAB Non-Preferred QL 30 / 30 days tadalafil

dutasteride 0.5 mg cap Preferred QL 1 / 1 days

dutasteride-tamsulosin hcl Non-Preferred

PAGE 218 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

finasteride 5 mg tab Preferred QL 1 / 1 days

FLOMAX Non-Preferred QL 2 / 1 days tamsulosin hcl JALYN Non-Preferred dutasteride-tamsulosin hcl PROSCAR Non-Preferred finasteride RAPAFLO Non-Preferred silodosin silodosin Non-Preferred

tadalafil 5 mg tab Non-Preferred QL 30 / 30 days

tadalafil 10 mg tab Non-Preferred

tadalafil 2.5 mg tab Non-Preferred QL 30 / 30 days

tadalafil 20 mg tab Non-Preferred

tamsulosin hcl Preferred QL 2 / 1 days

GENITOURINARY AGENTS, OTHER

bethanechol chloride 25 mg tab Preferred QL 4 / 1 days

bethanechol chloride 50 mg tab Preferred QL 4 / 1 days

bethanechol chloride 10 mg tab Preferred QL 4 / 1 days

bethanechol chloride 5 mg tab Preferred QL 4 / 1 days

CIALIS 10 MG TAB Non-Preferred tadalafil CIALIS 20 MG TAB Non-Preferred tadalafil ELMIRON Preferred QL 3 / 1 days pentosan polysulfate sodium ORACIT Preferred QL 120 / 1 days sodium citrate & citric acid PARAGARD INTRAUTERINE COPPER Preferred copper (iud) phenazopyridine hcl 200 mg tab Preferred phenazopyridine hcl 100 mg tab Preferred potassium citrate er 5 meq (540 mg) tab Preferred QL 10 / 1 days er

PAGE 219 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS potassium citrate er 10 meq (1080 mg) Preferred QL 10 / 1 days tab er potassium citrate er 15 meq (1620 mg) Preferred tab er

sod citrate-citric acid Preferred QL 120 / 1 days

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ALA SCALP Non-Preferred hydrocortisone (topical) ala-cort 1 % cream Non-Preferred alclometasone dipropionate 0.05 % Non-Preferred QL 1 / 1 days cream alclometasone dipropionate 0.05 % Non-Preferred QL 60 / 24 days ointment ALKINDI SPRINKLE Non-Preferred hydrocortisone amcinonide 0.1 % lotion Non-Preferred amcinonide 0.1 % cream Non-Preferred APEXICON E Non-Preferred diflorasone diacetate emollient base beser 0.05 % lotion Non-Preferred BESER 0.05 % KIT Non-Preferred fluticasone-emollient betamethasone dipropionate 0.05 % Preferred QL 45 / 28 days cream betamethasone dipropionate 0.05 % Preferred ointment betamethasone dipropionate 0.05 % Preferred lotion betamethasone dipropionate aug 0.05 % Non-Preferred QL 50 / 30 days ointment betamethasone dipropionate aug 0.05 % Non-Preferred gel betamethasone dipropionate aug 0.05 % Preferred QL 1 / 1 days cream betamethasone dipropionate aug 0.05 % Non-Preferred lotion betamethasone valerate 0.1 % ointment Preferred

PAGE 220 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

betamethasone valerate 0.1 % cream Preferred QL 45 / 24 days

betamethasone valerate 0.12 % foam Non-Preferred

betamethasone valerate 0.1 % lotion Preferred QL 60 / 27 days

BRYHALI Non-Preferred halobetasol propionate CAPEX Non-Preferred fluocinolone acetonide clobetasol prop emollient base Non-Preferred clobetasol propionate 0.05 % liquid Non-Preferred clobetasol propionate 0.05 % shampoo Non-Preferred

clobetasol propionate 0.05 % gel Non-Preferred QL 60 / 24 days

clobetasol propionate 0.05 % lotion Non-Preferred

clobetasol propionate 0.05 % solution Preferred QL 50 / 30 days

clobetasol propionate 0.05 % foam Non-Preferred

clobetasol propionate 0.05 % cream Preferred QL 60 / 27 days

clobetasol propionate 0.05 % ointment Preferred QL 60 / 30 days

clobetasol propionate e Non-Preferred clobetasol propionate emulsion Non-Preferred CLOBEX Non-Preferred clobetasol propionate CLOBEX SPRAY Non-Preferred clobetasol propionate CLOCORTOLONE PIVALATE Non-Preferred clocortolone pivalate CLOCORTOLONE PIVALATE PUMP Non-Preferred clocortolone pivalate CLODAN 0.05 % KIT Non-Preferred clobetasol propionate & cleanser clodan 0.05 % shampoo Preferred CLODERM Non-Preferred clocortolone pivalate CLODERM PUMP Non-Preferred clocortolone pivalate

PAGE 221 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CORDRAN 4 MCG/SQCM TAPE Non-Preferred flurandrenolide CORTEF Non-Preferred hydrocortisone

cortisone acetate 25 mg tab Non-Preferred QL 12 / 1 days

CUTIVATE Non-Preferred fluticasone propionate decadron Non-Preferred DEPO-MEDROL 20 MG/ML SUSPENSION Preferred QL 8 / 1 days methylprednisolone acetate DERMA-SMOOTHE/FS BODY Non-Preferred fluocinolone acetonide DERMA-SMOOTHE/FS SCALP Non-Preferred fluocinolone acetonide DERMATOP Non-Preferred prednicarbate DESONATE Non-Preferred desonide desonide 0.05 % gel Non-Preferred

desonide 0.05 % ointment Non-Preferred QL 60 / 27 days

desonide 0.05 % lotion Non-Preferred QL 118 / 24 days

desonide 0.05 % cream Non-Preferred QL 120 / 24 days

DESOWEN 0.05 % CREAM Non-Preferred desonide desoximetasone 0.25 % ointment Non-Preferred desoximetasone 0.25 % liquid Non-Preferred desoximetasone 0.05 % cream Non-Preferred desoximetasone 0.05 % ointment Non-Preferred desoximetasone 0.05 % gel Non-Preferred desoximetasone 0.25 % cream Non-Preferred desrx Non-Preferred DEXABLISS Non-Preferred dexamethasone dexamethasone 0.5 mg/5ml elixir Preferred

PAGE 222 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEXAMETHASONE 1.5 MG (51) TAB THPK Non-Preferred dexamethasone dexamethasone 0.5 mg/5ml solution Preferred dexamethasone 2 mg tab Preferred dexamethasone 6 mg tab Preferred dexamethasone 0.75 mg tab Preferred dexamethasone 4 mg tab Preferred dexamethasone 1 mg tab Preferred dexamethasone 1.5 mg (21) tab thpk Non-Preferred dexamethasone 1.5 mg tab Preferred DEXAMETHASONE 1.5 MG (35) TAB THPK Non-Preferred dexamethasone dexamethasone 0.5 mg tab Preferred DEXAMETHASONE INTENSOL Preferred dexamethasone dexamethasone sodium phosphate 20 Preferred mg/5ml solution dexamethasone sodium phosphate 120 Preferred mg/30ml solution dexamethasone sodium phosphate 4 Preferred mg/ml solution dexpak 10 day Non-Preferred dexpak 13 day Non-Preferred dexpak 6 day Non-Preferred diflorasone diacetate 0.05 % cream Non-Preferred

diflorasone diacetate 0.05 % ointment Non-Preferred QL 60 / 27 days

DXEVO 11-DAY Non-Preferred dexamethasone ELOCON 0.1 % CREAM Non-Preferred mometasone furoate EMFLAZA Non-Preferred deflazacort

fludrocortisone acetate 0.1 mg tab Preferred QL 2 / 1 days

PAGE 223 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluocinolone acetonide 0.01 % solution Preferred fluocinolone acetonide 0.01 % cream Non-Preferred

fluocinolone acetonide 0.025 % ointment Preferred QL 60 / 30 days

fluocinolone acetonide 0.025 % cream Non-Preferred fluocinolone acetonide body Preferred fluocinolone acetonide scalp Preferred

fluocinonide 0.05 % cream Preferred QL 120 / 24 days

fluocinonide 0.05 % solution Preferred QL 60 / 24 days

fluocinonide 0.05 % ointment Preferred QL 60 / 24 days

fluocinonide 0.05 % gel Non-Preferred QL 60 / 24 days

fluocinonide 0.1 % cream Non-Preferred

fluocinonide emulsified base Non-Preferred QL 60 / 24 days

flurandrenolide Non-Preferred fluticasone propionate 0.05 % cream Preferred

fluticasone propionate 0.005 % ointment Preferred QL 1 / 1 days

fluticasone propionate 0.05 % lotion Non-Preferred halcinonide Non-Preferred

halobetasol propionate 0.05 % ointment Preferred QL 50 / 30 days

HALOBETASOL PROPIONATE 0.05 % FOAM Non-Preferred halobetasol propionate

halobetasol propionate 0.05 % cream Preferred QL 50 / 30 days

HALOG Non-Preferred halcinonide HEMADY Non-Preferred dexamethasone hydrocortisone 2.5 % cream Preferred

hydrocortisone 5 mg tab Preferred QL 12 / 1 days

hydrocortisone 1 % ointment Preferred QL 30 / 7 days

hydrocortisone 20 mg tab Preferred QL 12 / 1 days

PAGE 224 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

hydrocortisone 2.5 % ointment Preferred QL 60 / 30 days

hydrocortisone 1 % cream Preferred QL 60 / 30 days

hydrocortisone 10 mg tab Preferred QL 12 / 1 days

hydrocortisone 2.5 % lotion Preferred QL 118 / 24 days

hydrocortisone (perianal) 2.5 % cream Preferred hydrocortisone butyr lipo base Non-Preferred hydrocortisone butyrate Non-Preferred HYDROCORTISONE BUTYRATE 0.1 % CREAM Non-Preferred hydrocortisone butyrate hydrocortisone in absorbase Non-Preferred

hydrocortisone valerate Preferred QL 60 / 24 days

IMPEKLO Non-Preferred clobetasol propionate KENALOG 40 MG/ML SUSPENSION Preferred triamcinolone acetonide KENALOG 10 MG/ML SUSPENSION Preferred triamcinolone acetonide KENALOG 0.147 MG/GM AERO SOLN Non-Preferred triamcinolone acetonide (topical) LEXETTE Non-Preferred halobetasol propionate LOCOID 0.1 % LOTION Non-Preferred hydrocortisone butyrate LOCOID 0.1 % SOLUTION Non-Preferred hydrocortisone butyrate LOCOID 0.1 % CREAM Non-Preferred hydrocortisone butyrate LOCOID LIPOCREAM hydrocortisone butyrate hydrophilic lipo Non-Preferred base MEDROL 4 MG TAB Non-Preferred methylprednisolone MEDROL 32 MG TAB Non-Preferred QL 2 / 1 days methylprednisolone MEDROL 8 MG TAB Non-Preferred methylprednisolone

PAGE 225 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEDROL 2 MG TAB Non-Preferred QL 4 / 1 days methylprednisolone MEDROL 16 MG TAB Non-Preferred methylprednisolone MEDROL 4 MG TAB THPK Non-Preferred methylprednisolone methylprednisolone 4 mg tab thpk Preferred

methylprednisolone 8 mg tab Preferred QL 4 / 1 days

methylprednisolone 32 mg tab Preferred QL 2 / 1 days

methylprednisolone 16 mg tab Preferred QL 4 / 1 days

methylprednisolone 4 mg tab Preferred QL 4 / 1 days

methylprednisolone acetate 40 mg/ml Preferred QL 4 / 1 days suspension methylprednisolone acetate 80 mg/ml Preferred QL 2 / 1 days suspension methylprednisolone sodium succ 500 Preferred mg recon soln methylprednisolone sodium succ 40 mg Preferred recon soln methylprednisolone sodium succ 1000 Preferred mg recon soln MILLIPRED 5 MG TAB Non-Preferred QL 12 / 1 days prednisolone MILLIPRED DP Non-Preferred prednisolone

mometasone furoate 0.1 % solution Preferred QL 30 / 14 days

mometasone furoate 0.1 % ointment Preferred QL 45 / 19 days

mometasone furoate 0.1 % cream Preferred QL 45 / 30 days

OLUX Non-Preferred clobetasol propionate OLUX-E Non-Preferred clobetasol propionate emulsion ORAPRED ODT Non-Preferred prednisolone sodium phosphate PANDEL Non-Preferred hydrocortisone probutate

PAGE 226 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEDIAPRED Non-Preferred prednisolone sodium phosphate PREDNICARBATE Non-Preferred prednicarbate

prednisolone 15 mg/5ml solution Preferred QL 20 / 1 days

PREDNISOLONE SODIUM PHOSPHATE 30 MG TAB DISP Non-Preferred prednisolone sodium phosphate prednisolone sodium phosphate 10 mg Non-Preferred tab disp prednisolone sodium phosphate 15 mg Non-Preferred tab disp prednisolone sodium phosphate 6.7 (5 Preferred base) mg/5ml solution PREDNISOLONE SODIUM PHOSPHATE 15 MG TAB DISP Non-Preferred prednisolone sodium phosphate prednisolone sodium phosphate 30 mg Non-Preferred tab disp prednisolone sodium phosphate 25 Preferred mg/5ml solution prednisolone sodium phosphate 20 Preferred mg/5ml solution PREDNISOLONE SODIUM PHOSPHATE 10 MG TAB DISP Non-Preferred prednisolone sodium phosphate prednisolone sodium phosphate 10 Preferred mg/5ml solution prednisolone sodium phosphate 15 Preferred QL 20 / 1 days mg/5ml solution

prednisone 20 mg tab Preferred QL 3 / 1 days

prednisone 5 mg (48) tab thpk Preferred QL 8 / 1 days

prednisone 10 mg (21) tab thpk Preferred

prednisone 5 mg (21) tab thpk Preferred QL 8 / 1 days

prednisone 5 mg/5ml solution Preferred QL 60 / 1 days

prednisone 2.5 mg tab Preferred QL 8 / 1 days

PAGE 227 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

prednisone 5 mg tab Preferred QL 8 / 1 days

prednisone 10 mg tab Preferred QL 6 / 1 days

prednisone 10 mg (48) tab thpk Preferred

prednisone 50 mg tab Preferred QL 1 / 1 days

prednisone 1 mg tab Preferred QL 8 / 1 days

PREDNISONE INTENSOL Non-Preferred QL 12 / 1 days prednisone procto-med hc Preferred proctosol hc Preferred proctozone-hc Preferred PSORCON Non-Preferred diflorasone diacetate RAYOS Non-Preferred prednisone SILA III Non-Preferred triamcinolone acetonide-silicone SOLU-CORTEF 100 MG RECON SOLN Preferred hydrocortisone sod succinate SOLU-MEDROL 40 MG RECON SOLN Preferred methylprednisolone sod succ SYNALAR 0.025 % OINTMENT Non-Preferred QL 60 / 30 days fluocinolone acetonide SYNALAR 0.01 % SOLUTION Non-Preferred fluocinolone acetonide SYNALAR 0.025 % CREAM Non-Preferred fluocinolone acetonide SYNALAR (CREAM) Non-Preferred fluocinolone-emollient SYNALAR (OINTMENT) Non-Preferred fluocinolone-emollient SYNALAR TS Non-Preferred fluocinolone acetonide & cleanser TAPERDEX 12-DAY Non-Preferred dexamethasone taperdex 6-day Non-Preferred

PAGE 228 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TAPERDEX 7-DAY Non-Preferred dexamethasone TEMOVATE 0.05 % CREAM Non-Preferred clobetasol propionate TEMOVATE 0.05 % OINTMENT Non-Preferred QL 2 / 1 days clobetasol propionate TEXACORT Non-Preferred hydrocortisone (topical) TOPICORT Non-Preferred desoximetasone TOPICORT SPRAY Non-Preferred desoximetasone tovet 0.05 % foam Non-Preferred

triamcinolone acetonide 0.1 % ointment Preferred QL 456 / 24 days

triamcinolone acetonide 0.025 % Preferred QL 456 / 24 days ointment

triamcinolone acetonide 0.1 % cream Preferred QL 456 / 24 days

triamcinolone acetonide 0.5 % cream Preferred QL 60 / 27 days

triamcinolone acetonide 0.147 mg/gm Non-Preferred aero soln triamcinolone acetonide 0.05 % ointment Preferred triamcinolone acetonide 40 mg/ml Preferred suspension

triamcinolone acetonide 0.025 % lotion Preferred QL 120 / 24 days

triamcinolone acetonide 0.1 % lotion Preferred

triamcinolone acetonide 0.5 % ointment Preferred QL 30 / 24 days

triamcinolone acetonide 0.025 % cream Preferred QL 456 / 24 days

trianex Non-Preferred triderm Non-Preferred tritocin Non-Preferred ULTRAVATE 0.05 % OINTMENT Non-Preferred QL 50 / 30 days halobetasol propionate ULTRAVATE 0.05 % CREAM Non-Preferred halobetasol propionate

PAGE 229 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ULTRAVATE 0.05 % LOTION Non-Preferred halobetasol propionate ULTRAVATE X (CREAM) Non-Preferred halobetasol propionate & lactic acid ULTRAVATE X (OINTMENT) Non-Preferred halobetasol propionate & lactic acid VANOS Non-Preferred fluocinonide ZCORT 7-DAY Non-Preferred dexamethasone HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace spray refrig Preferred QL 15 / 26 days

desmopressin acetate 0.2 mg tab Preferred QL 6 / 1 days

desmopressin acetate 0.1 mg tab Preferred QL 6 / 1 days

desmopressin acetate spray Preferred QL 15 / 26 days

GENOTROPIN Non-Preferred somatropin GENOTROPIN MINIQUICK Non-Preferred somatropin HUMATROPE 12 MG RECON SOLN Non-Preferred somatropin HUMATROPE 6 MG RECON SOLN Non-Preferred somatropin HUMATROPE 24 MG RECON SOLN Non-Preferred somatropin MYFEMBREE Non-Preferred relugolix-estradiol-norethindrone acetate NORDITROPIN FLEXPRO Preferred PA somatropin NUTROPIN AQ NUSPIN 10 Non-Preferred somatropin NUTROPIN AQ NUSPIN 20 Non-Preferred somatropin NUTROPIN AQ NUSPIN 5 Non-Preferred somatropin OMNITROPE Preferred PA somatropin

PAGE 230 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ORIAHNN QL 56 / 28 days elagolix sodium-estradiol-norethindrone Preferred acetate PA SAIZEN Non-Preferred somatropin (non-refrigerated) SAIZEN CLICK.EASY Non-Preferred somatropin (non-refrigerated) SAIZENPREP Non-Preferred somatropin (non-refrigerated) SEROSTIM Non-Preferred somatropin (non-refrigerated) STIMATE Preferred desmopressin acetate ZOMACTON Non-Preferred somatropin ZOMACTON (FOR ZOMA-JET 10) Non-Preferred somatropin ZORBTIVE Non-Preferred somatropin (non-refrigerated) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 Non-Preferred oxymetholone

oxandrolone 10 mg tab Non-Preferred QL 2 / 1 days

oxandrolone 2.5 mg tab Non-Preferred QL 8 / 1 days

ANDROGENS

ANDRODERM Non-Preferred testosterone ANDROGEL 25 MG/2.5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone ANDROGEL 20.25 MG/1.25GM (1.62%) GEL Non-Preferred QL 150 / 30 days testosterone ANDROGEL 50 MG/5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone ANDROGEL 40.5 MG/2.5GM (1.62%) GEL Non-Preferred QL 150 / 30 days testosterone

PAGE 231 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANDROGEL PUMP Non-Preferred QL 150 / 30 days testosterone ANDROID Non-Preferred methyltestosterone AVEED Non-Preferred testosterone undecanoate

DEPO-TESTOSTERONE QL 10 / 30 days Preferred testosterone cypionate PA

FORTESTA Non-Preferred QLC 3.51 grams/day testosterone JATENZO Non-Preferred testosterone undecanoate METHITEST Non-Preferred methyltestosterone

methyltestosterone 10 mg cap Non-Preferred QL 5 / 1 days

NATESTO Non-Preferred testosterone STRIANT Non-Preferred testosterone TESTIM Non-Preferred QL 300 / 30 days testosterone TESTOPEL Preferred PA testosterone TESTOSTERONE 200 MG PELLET Non-Preferred testosterone TESTOSTERONE 100 MG PELLET Non-Preferred testosterone

testosterone 25 mg/2.5gm (1%) gel Non-Preferred QL 300 / 30 days

testosterone 10 mg/act (2%) gel Non-Preferred QLC 3.51 grams/day

testosterone 12.5 mg/act (1%) gel Non-Preferred QL 150 / 30 days

testosterone 50 mg/5gm (1%) gel Non-Preferred QL 300 / 30 days

testosterone 30 mg/act solution Non-Preferred QLC 6 mL/day

testosterone 20.25 mg/1.25gm (1.62%) Non-Preferred QL 150 / 30 days gel

testosterone 40.5 mg/2.5gm (1.62%) gel Non-Preferred QL 150 / 30 days

PAGE 232 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

testosterone cypionate 100 mg/ml QL 10 / 30 days Preferred solution PA

testosterone cypionate 200 mg/ml QL 10 / 30 days Preferred solution PA

testosterone enanthate 200 mg/ml Non-Preferred QL 5 / 30 days solution

TESTOSTERONE TD GEL pump 20.25 QL 150 / 30 days Preferred MG/ACT (1.62%) PA

TESTRED Non-Preferred methyltestosterone VOGELXO Non-Preferred QL 300 / 30 days testosterone VOGELXO PUMP Non-Preferred QL 150 / 30 days testosterone XYOSTED Non-Preferred testosterone enanthate ESTROGENS

ACTIVELLA Non-Preferred estradiol & norethindrone acetate

afirmelle Preferred QL 28 / 28 days

ALORA Preferred estradiol

altavera Preferred QL 1 / 1 days

alyacen 1/35 Preferred QL 1 / 1 days

alyacen 7/7/7 Preferred QL 28 / 28 days

amabelz Non-Preferred amethia Non-Preferred amethia lo Non-Preferred

amethyst Preferred QL 1 / 1 days

ANGELIQ Preferred drospirenone-estradiol ANNOVERA Non-Preferred segesterone acetate-ethinyl estradiol

PAGE 233 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

apri Preferred QL 1 / 1 days

aranelle Preferred QL 1 / 1 days

ashlyna Non-Preferred

aubra Preferred QL 1 / 1 days

aubra eq Preferred QL 1 / 1 days

aurovela 1.5/30 Preferred aurovela 1/20 Preferred aurovela 24 fe Non-Preferred aurovela fe 1.5/30 Preferred aurovela fe 1/20 Preferred

aviane Preferred QL 1 / 1 days

ayuna Preferred QL 28 / 28 days

azurette Preferred QL 1 / 1 days

BALCOLTRA levonorgestrel-ethinyl estradiol-ferrous Non-Preferred bisglycinate

balziva Preferred QL 1 / 1 days

bekyree Preferred QL 1 / 1 days

BEYAZ drospirenone-ethinyl estradiol- Non-Preferred levomefolate calcium BIJUVA Non-Preferred estradiol-progesterone blisovi 24 fe Non-Preferred

blisovi fe 1.5/30 Preferred QL 28 / 28 days

blisovi fe 1/20 Preferred QL 1 / 1 days

briellyn Preferred QL 1 / 1 days

camrese Preferred camrese lo Preferred

caziant Preferred QL 1 / 1 days

PAGE 234 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS charlotte 24 fe Non-Preferred

chateal Preferred QL 1 / 1 days

chateal eq Preferred QL 1 / 1 days

CLIMARA Non-Preferred estradiol CLIMARA PRO Preferred estradiol-levonorgestrel COMBIPATCH Preferred estradiol & norethindrone acetate covaryx Non-Preferred covaryx hs Non-Preferred

cryselle-28 Preferred QL 1 / 1 days

cyclafem 1/35 Preferred QL 1 / 1 days

cyclafem 7/7/7 Preferred QL 28 / 28 days

CYCLESSA Non-Preferred desogestrel-ethinyl estradiol (triphasic)

cyred Preferred QL 1 / 1 days

cyred eq Preferred QL 1 / 1 days

dasetta 1/35 Preferred QL 1 / 1 days

dasetta 7/7/7 Preferred QL 28 / 28 days

daysee Non-Preferred DELESTROGEN Preferred estradiol valerate DEPO-ESTRADIOL Preferred estradiol cypionate desogestrel-ethinyl estradiol 0.15-30 Preferred QL 28 / 28 days mg-mcg tab desogestrel-ethinyl estradiol 0.15- Preferred QL 1 / 1 days 0.02/0.01 mg (21/5) tab DIVIGEL Non-Preferred estradiol dolishale Preferred dotti Non-Preferred

PAGE 235 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS drospiren-eth estrad-levomefol Non-Preferred

drospirenone-ethinyl estradiol Preferred QL 1 / 1 days

eemt Non-Preferred eemt hs Non-Preferred ELESTRIN Preferred estradiol

elinest Preferred QL 1 / 1 days

eluryng Non-Preferred QL 1 / 28 days

emoquette Preferred QL 28 / 28 days

enpresse-28 Preferred QL 1 / 1 days

enskyce Preferred QL 1 / 1 days

est estrogens-methyltest Non-Preferred est estrogens-methyltest ds Non-Preferred est estrogens-methyltest hs Non-Preferred

estarylla Preferred QL 1 / 1 days

ESTRACE 0.1 MG/GM CREAM Non-Preferred QLC 42.5 grams/30 days estradiol vaginal ESTRACE 0.5 MG TAB Non-Preferred estradiol ESTRACE 2 MG TAB Non-Preferred QL 90 / 30 days estradiol ESTRACE 1 MG TAB Non-Preferred QL 90 / 30 days estradiol estradiol 10 mcg tab Preferred

estradiol 0.075 mg/24hr patch tw Preferred QL 8 / 28 days

estradiol 0.05 mg/24hr patch tw Preferred QL 8 / 28 days

estradiol 0.1 mg/gm cream Preferred QLC 42.5 grams/30 days

estradiol 0.05 mg/24hr patch wk Preferred QL 4 / 28 days

estradiol 0.0375 mg/24hr patch tw Preferred QL 8 / 28 days

estradiol 0.0375 mg/24hr patch wk Preferred QL 4 / 28 days

PAGE 236 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

estradiol 0.075 mg/24hr patch wk Preferred QL 4 / 28 days

estradiol 1 mg tab Preferred QL 90 / 30 days

estradiol 0.025 mg/24hr patch wk Preferred QL 4 / 28 days

estradiol 0.06 mg/24hr patch wk Preferred QL 4 / 28 days

estradiol 0.025 mg/24hr patch tw Preferred QL 8 / 28 days

estradiol 2 mg tab Preferred QL 90 / 30 days

estradiol 0.5 mg tab Preferred

estradiol 0.1 mg/24hr patch tw Preferred QL 8 / 28 days

estradiol 0.1 mg/24hr patch wk Preferred QL 4 / 28 days

estradiol valerate 20 mg/ml oil Preferred estradiol valerate 40 mg/ml oil Preferred estradiol-norethindrone acet Non-Preferred ESTRING Preferred estradiol vaginal ESTROGEL Non-Preferred estradiol ESTROPIPATE 1.5 MG TAB Non-Preferred QL 1 / 1 days estropipate ESTROPIPATE 3 MG TAB Non-Preferred QL 3 / 1 days estropipate ESTROPIPATE 0.75 MG TAB Non-Preferred QL 1 / 1 days estropipate ESTROSTEP FE norethindrone acetate-ethinyl estradiol- Non-Preferred QL 1 / 1 days fe ethynodiol diac-eth estradiol 1-35 mg- Preferred QL 1 / 1 days mcg tab ethynodiol diac-eth estradiol 1-50 mg- Preferred QL 28 / 28 days mcg tab

etonogestrel-ethinyl estradiol Non-Preferred QL 1 / 28 days

EVAMIST Non-Preferred estradiol

falmina Preferred QL 1 / 1 days

PAGE 237 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fayosim Non-Preferred FEMHRT Non-Preferred norethindrone acetate-ethinyl estradiol FEMRING Preferred estradiol acetate vaginal

femynor Preferred QL 1 / 1 days

fyavolv Preferred gemmily Non-Preferred GENERESS FE Non-Preferred norethindrone & ethinyl estradiol-fe

gianvi Preferred QL 1 / 1 days

hailey 1.5/30 Preferred hailey 24 fe Non-Preferred hailey fe 1.5/30 Preferred hailey fe 1/20 Preferred iclevia Preferred introvale Preferred

isibloom Preferred QL 1 / 1 days

jaimiess Non-Preferred

jasmiel Preferred QL 28 / 28 days

jevantique lo Non-Preferred jinteli Preferred jolessa Preferred

juleber Preferred QL 1 / 1 days

junel 1.5/30 Preferred QL 1 / 1 days

junel 1/20 Preferred QL 1 / 1 days

junel fe 1.5/30 Preferred QL 1 / 1 days

junel fe 1/20 Preferred QL 1 / 1 days

junel fe 24 Non-Preferred kaitlib fe Non-Preferred

PAGE 238 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

kalliga Preferred QL 28 / 28 days

kariva Preferred QL 1 / 1 days

kelnor 1/35 Preferred QL 1 / 1 days

kelnor 1/50 Preferred QL 1 / 1 days

kurvelo Preferred QL 1 / 1 days

larin 1.5/30 Preferred QL 1 / 1 days

larin 1/20 Preferred QL 1 / 1 days

larin 24 fe Non-Preferred

larin fe 1.5/30 Preferred QL 1 / 1 days

larin fe 1/20 Preferred QL 1 / 1 days

larissia Preferred QL 1 / 1 days

layolis fe Non-Preferred

leena Preferred QL 1 / 1 days

lessina Preferred QL 1 / 1 days

levonest Preferred QL 1 / 1 days

levonorg-eth estrad triphasic Preferred QL 1 / 1 days

levonorgest-eth est & eth est Non-Preferred levonorgest-eth estrad 91-day 0.15-0.03 Non-Preferred &0.01 mg tab levonorgest-eth estrad 91-day 0.15-0.03 Preferred mg tab levonorgest-eth estrad 91-day 0.1-0.02 Non-Preferred & 0.01 mg tab levonorgestrel-ethinyl estrad 0.1-20 mg- Preferred QL 28 / 28 days mcg tab levonorgestrel-ethinyl estrad 90-20 mcg Preferred QL 1 / 1 days tab levonorgestrel-ethinyl estrad 0.15-30 Preferred QL 1 / 1 days mg-mcg tab

levora 0.15/30 (28) Preferred QL 1 / 1 days

PAGE 239 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

lillow Preferred QL 1 / 1 days

LO LOESTRIN FE norethindrone acetate-ethinyl estradiol- Non-Preferred fe fum (biphasic) lo-zumandimine Preferred

loestrin 1.5/30 (21) Non-Preferred QL 1 / 1 days

loestrin 1/20 (21) Non-Preferred QL 1 / 1 days

loestrin fe 1.5/30 Non-Preferred QL 1 / 1 days

loestrin fe 1/20 Non-Preferred QL 1 / 1 days

lojaimiess Non-Preferred lopreeza Non-Preferred

loryna Preferred QL 1 / 1 days

LOSEASONIQUE Non-Preferred levonorgestrel-ethinyl estradiol (91-day)

low-ogestrel Preferred QL 1 / 1 days

lutera Preferred QL 1 / 1 days

lyllana Non-Preferred

marlissa Preferred QL 1 / 1 days

melodetta 24 fe Non-Preferred MENEST 2.5 MG TAB Non-Preferred esterified estrogens MENEST 1.25 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens MENEST 0.625 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens MENEST 0.3 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens MENOSTAR Non-Preferred estradiol mibelas 24 fe Non-Preferred

microgestin 1.5/30 Preferred QL 1 / 1 days

microgestin 1/20 Preferred QL 1 / 1 days

PAGE 240 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS microgestin 24 fe Non-Preferred

microgestin fe 1.5/30 Preferred QL 28 / 28 days

microgestin fe 1/20 Preferred QL 1 / 1 days

mili Preferred QL 1 / 1 days

mimvey Non-Preferred mimvey lo Non-Preferred MINASTRIN 24 FE Non-Preferred norethin acet & estrad-fe MINIVELLE Non-Preferred estradiol MIRCETTE Non-Preferred QL 1 / 1 days desogestrel-ethinyl estradiol (biphasic)

mono-linyah Preferred QL 1 / 1 days

mononessa Preferred QL 1 / 1 days

myzilra Preferred QL 1 / 1 days

NATAZIA Non-Preferred estradiol valerate-dienogest

necon 0.5/35 (28) Preferred QL 1 / 1 days

necon 7/7/7 Preferred QL 28 / 28 days

NEXTSTELLIS Non-Preferred drospirenone-estetrol

nikki Preferred QL 1 / 1 days

norethin ace-eth estrad-fe 1.5-30 mg- Preferred mcg tab norethin ace-eth estrad-fe 1-20 mg- Non-Preferred mcg(24) chew tab norethin ace-eth estrad-fe 1-20 mg- Non-Preferred mcg(24) cap norethin ace-eth estrad-fe 1-20 mg-mcg Preferred QL 1 / 1 days tab norethin ace-eth estrad-fe 1-20 mg- Non-Preferred mcg(24) tab norethin-eth estradiol-fe 0.8-25 mg-mcg Non-Preferred chew tab

PAGE 241 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethin-eth estradiol-fe 0.4-35 mg-mcg Non-Preferred QL 28 / 28 days chew tab norethindrone acet-ethinyl est 1.5-30 Preferred QL 21 / 21 days mg-mcg tab norethindrone acet-ethinyl est 1-20 mg- Non-Preferred mcg(24) chew tab norethindrone acet-ethinyl est 1-20 mg- Preferred QL 1 / 1 days mcg tab norethindrone-eth estradiol Non-Preferred

norgestim-eth estrad triphasic Preferred QL 1 / 1 days

norgestimate-eth estradiol Preferred QL 1 / 1 days

nortrel 0.5/35 (28) Preferred QL 1 / 1 days

nortrel 1/35 (21) Preferred

nortrel 1/35 (28) Preferred QL 1 / 1 days

nortrel 7/7/7 Preferred QL 28 / 28 days

NUVARING Preferred QL 1 / 28 days etonogestrel-ethinyl estradiol nylia 7/7/7 Preferred nymyo Preferred

ocella Preferred QL 1 / 1 days

ogestrel Non-Preferred QL 1 / 1 days

orsythia Preferred QL 28 / 28 days

ORTHO TRI-CYCLEN (28) Non-Preferred QL 28 / 28 days norgestimate-ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO Non-Preferred QL 1 / 1 days norgestimate-ethinyl estradiol (triphasic) ORTHO-CYCLEN (28) Non-Preferred QL 28 / 28 days norgestimate-ethinyl estradiol ORTHO-NOVUM 1/35 (28) Non-Preferred QL 1 / 1 days norethindrone & eth estradiol ORTHO-NOVUM 7/7/7 (28) Non-Preferred QL 28 / 28 days norethindrone-eth estradiol (triphasic)

philith Preferred QL 1 / 1 days

PAGE 242 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

pimtrea Preferred QL 1 / 1 days

pirmella 1/35 Preferred QL 1 / 1 days

pirmella 7/7/7 Preferred QL 28 / 28 days

portia-28 Preferred QL 1 / 1 days

PREFEST Non-Preferred estradiol-norgestimate PREMARIN 0.9 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 0.3 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 0.625 MG/GM CREAM Preferred estrogens, conjugated vaginal PREMARIN 0.45 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 25 MG RECON SOLN Non-Preferred estrogens, conjugated PREMARIN 1.25 MG TAB Preferred estrogens, conjugated PREMARIN 0.625 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMPHASE conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate PREMPRO conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate

previfem Preferred QL 1 / 1 days

QUARTETTE Non-Preferred levonorgestrel-ethinyl estradiol (91-day)

reclipsen Preferred QL 1 / 1 days

rivelsa Non-Preferred SAFYRAL drospirenone-ethinyl estradiol- Non-Preferred levomefolate calcium SEASONIQUE Non-Preferred levonorgestrel-ethinyl estradiol (91-day)

PAGE 243 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS setlakin Preferred simliya Preferred simpesse Non-Preferred

sprintec 28 Preferred QL 1 / 1 days

sronyx Preferred QL 1 / 1 days

syeda Preferred QL 1 / 1 days

tarina 24 fe Non-Preferred

tarina fe 1/20 Preferred QL 1 / 1 days

tarina fe 1/20 eq Preferred QL 1 / 1 days

TAYTULLA Non-Preferred norethin acet & estrad-fe

tilia fe Non-Preferred QL 1 / 1 days

tri femynor Preferred QL 1 / 1 days

tri-estarylla Preferred

tri-legest fe Non-Preferred QL 1 / 1 days

tri-linyah Preferred QL 1 / 1 days

tri-lo-estarylla Preferred QL 1 / 1 days

tri-lo-marzia Preferred QL 1 / 1 days

tri-lo-mili Preferred

tri-lo-sprintec Preferred QL 1 / 1 days

tri-mili Preferred QL 1 / 1 days

tri-nymyo Preferred

tri-previfem Preferred QL 1 / 1 days

tri-sprintec Preferred QL 1 / 1 days

tri-vylibra Preferred QL 1 / 1 days

tri-vylibra lo Preferred QL 1 / 1 days

trinessa (28) Preferred QL 1 / 1 days

trinessa lo Preferred QL 1 / 1 days

PAGE 244 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

trivora (28) Preferred QL 1 / 1 days

TWIRLA Non-Preferred levonorgestrel-ethinyl estradiol TYBLUME Non-Preferred levonorgestrel & eth estradiol tydemy Non-Preferred VAGIFEM Preferred estradiol vaginal

velivet Preferred QL 1 / 1 days

vestura Non-Preferred

vienva Preferred QL 1 / 1 days

viorele Preferred QL 1 / 1 days

VIVELLE-DOT Non-Preferred QL 8 / 28 days estradiol volnea Preferred

vyfemla Preferred QL 1 / 1 days

vylibra Preferred QL 1 / 1 days

wera Preferred QL 1 / 1 days

wymzya fe Non-Preferred QL 1 / 1 days

xulane Preferred QL 3 / 28 days

YASMIN 28 Non-Preferred QL 1 / 1 days drospirenone-ethinyl estradiol YAZ Non-Preferred QL 1 / 1 days drospirenone-ethinyl estradiol yuvafem Preferred

zafemy Preferred QL 3 / 28 days

zarah Preferred QL 1 / 1 days

zovia 1/35 (28) Preferred

zovia 1/35e (28) Preferred QL 1 / 1 days

zumandimine Preferred

PAGE 245 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROGESTERONE AGONISTS/ANTAGONISTS

ELLA Preferred QL 1 / 1 fill ulipristal acetate PROGESTINS

AYGESTIN Non-Preferred QL 90 / 30 days norethindrone acetate

camila Preferred QL 1 / 1 days

CRINONE Non-Preferred progesterone (vaginal)

deblitane Preferred QL 1 / 1 days

DEPO-PROVERA 400 MG/ML SUSPENSION Preferred medroxyprogesterone acetate (antineoplastic) DEPO-PROVERA 150 MG/ML SUSPENSION Preferred medroxyprogesterone acetate (contraceptive) DEPO-PROVERA 150 MG/ML SUSP PRSYR Non-Preferred medroxyprogesterone acetate (contraceptive) DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate Preferred QL 1 / 84 days (contraceptive)

errin Preferred QL 1 / 1 days

heather Preferred QL 1 / 1 days

hydroxyprogesterone caproate 250 Preferred PA mg/ml oil HYDROXYPROGESTERONE CAPROATE 1.25 GM/5ML SOLUTION Preferred PA hydroxyprogesterone caproate (antineoplastic)

incassia Preferred QL 1 / 1 days

jencycla Preferred QL 1 / 1 days

jolivette Preferred QL 1 / 1 days

KYLEENA Preferred levonorgestrel (iud)

PAGE 246 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LILETTA (52 MG) Preferred levonorgestrel (iud) lyleq Preferred

lyza Preferred QL 1 / 1 days

MAKENA 275 MG/1.1ML SOLN A-INJ Preferred PA hydroxyprogesterone caproate MAKENA 250 MG/ML OIL Non-Preferred PA hydroxyprogesterone caproate medroxyprogesterone acetate 2.5 mg Preferred QL 1 / 1 days tab medroxyprogesterone acetate 150 Preferred QL 1 / 84 days mg/ml susp prsyr medroxyprogesterone acetate 150 Preferred QL 1 / 84 days mg/ml suspension

medroxyprogesterone acetate 10 mg tab Preferred QL 3 / 1 days

medroxyprogesterone acetate 5 mg tab Preferred QL 3 / 1 days

megestrol acetate 40 mg tab Preferred QL 8 / 1 days

megestrol acetate 400 mg/10ml Preferred suspension

megestrol acetate 20 mg tab Preferred QL 8 / 1 days

megestrol acetate 40 mg/ml suspension Preferred MIRENA (52 MG) Preferred levonorgestrel (iud) NEXPLANON Preferred etonogestrel

nora-be Preferred QL 1 / 1 days

norethindrone 0.35 mg tab Preferred QL 1 / 1 days

norethindrone acetate 5 mg tab Preferred QL 90 / 30 days

norlyda Preferred QL 1 / 1 days

ORTHO MICRONOR Preferred QL 1 / 1 days norethindrone (contraceptive)

progesterone 200 mg cap Preferred QL 2 / 1 days

progesterone 50 mg/ml oil Preferred

PAGE 247 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

progesterone 100 mg cap Preferred QL 2 / 1 days

PROMETRIUM Non-Preferred QL 2 / 1 days progesterone PROVERA 10 MG TAB Non-Preferred QL 3 / 1 days medroxyprogesterone acetate PROVERA 5 MG TAB Non-Preferred QL 3 / 1 days medroxyprogesterone acetate PROVERA 2.5 MG TAB Non-Preferred medroxyprogesterone acetate

sharobel Preferred QL 1 / 1 days

SKYLA Preferred levonorgestrel (iud) SLYND Non-Preferred drospirenone

tulana Preferred QL 1 / 1 days

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

DUAVEE Non-Preferred conjugated estrogens-bazedoxifene EVISTA Non-Preferred raloxifene hcl

raloxifene hcl Non-Preferred QL 1 / 1 days

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID Preferred thyroid CYTOMEL 5 MCG TAB Preferred QL 4 / 1 days liothyronine sodium CYTOMEL 25 MCG TAB Preferred QL 3 / 1 days liothyronine sodium CYTOMEL 50 MCG TAB Preferred QL 2 / 1 days liothyronine sodium euthyrox Non-Preferred levo-t Preferred levothyroxine sodium 25 mcg tab Preferred levothyroxine sodium 137 mcg tab Preferred levothyroxine sodium 100 mcg cap Non-Preferred

PAGE 248 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levothyroxine sodium 200 mcg recon Non-Preferred soln levothyroxine sodium 25 mcg cap Non-Preferred levothyroxine sodium 175 mcg tab Preferred levothyroxine sodium 112 mcg tab Preferred levothyroxine sodium 150 mcg tab Preferred levothyroxine sodium 125 mcg tab Preferred levothyroxine sodium 50 mcg cap Non-Preferred levothyroxine sodium 100 mcg recon Non-Preferred soln levothyroxine sodium 150 mcg cap Non-Preferred levothyroxine sodium 125 mcg cap Non-Preferred LEVOTHYROXINE SODIUM 100 MCG/5ML SOLUTION Non-Preferred levothyroxine sodium levothyroxine sodium 75 mcg cap Non-Preferred levothyroxine sodium 50 mcg tab Preferred levothyroxine sodium 137 mcg cap Non-Preferred levothyroxine sodium 75 mcg tab Preferred levothyroxine sodium 13 mcg cap Non-Preferred levothyroxine sodium 88 mcg cap Non-Preferred levothyroxine sodium 200 mcg tab Preferred levothyroxine sodium 88 mcg tab Preferred levothyroxine sodium 200 mcg cap Non-Preferred LEVOTHYROXINE SODIUM 200 MCG RECON SOLN Non-Preferred levothyroxine sodium levothyroxine sodium 500 mcg recon Non-Preferred soln levothyroxine sodium 100 mcg tab Preferred levothyroxine sodium 112 mcg cap Non-Preferred levothyroxine sodium 175 mcg cap Non-Preferred levothyroxine sodium 300 mcg tab Preferred levoxyl Preferred

PAGE 249 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

liothyronine sodium 25 mcg tab Preferred QL 3 / 1 days

liothyronine sodium 10 mcg/ml solution Non-Preferred

liothyronine sodium 50 mcg tab Preferred QL 2 / 1 days

liothyronine sodium 5 mcg tab Preferred QL 4 / 1 days

np thyroid Preferred SYNTHROID 50 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 125 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 88 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 175 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 112 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 300 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 137 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 150 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 75 MCG TAB Preferred levothyroxine sodium SYNTHROID 200 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 100 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 25 MCG TAB Non-Preferred levothyroxine sodium THYQUIDITY Non-Preferred levothyroxine sodium thyroid 30 mg tab Preferred thyroid 60 mg tab Preferred thyroid 90 mg tab Preferred thyroid 15 mg tab Preferred thyroid 120 mg tab Preferred

PAGE 250 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TIROSINT Non-Preferred levothyroxine sodium TIROSINT-SOL Non-Preferred levothyroxine sodium TRIOSTAT Non-Preferred liothyronine sodium unithroid Non-Preferred HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline Preferred QL 16 / 30 days

ELIGARD 45 MG KIT QL 1 / 180 days Preferred leuprolide acetate (6 month) PA

ELIGARD 30 MG KIT QL 1 / 120 days Preferred leuprolide acetate (4 month) PA

ELIGARD 7.5 MG KIT QL 1 / 30 days Preferred leuprolide acetate PA

ELIGARD 22.5 MG KIT QL 1 / 90 days Preferred leuprolide acetate (3 month) PA

FENSOLVI (6 MONTH) Non-Preferred QL 1 / 180 days leuprolide acetate (cpp) (6 month)

QL 2 / 28 days leuprolide acetate 1 mg/0.2ml kit Preferred PA

LUPANETA PACK 3.75 & 5 MG KIT QL 1 / 30 days leuprolide acetate & norethindrone Preferred acetate PA

LUPANETA PACK 11.25 & 5 MG KIT QL 1 / 90 days leuprolide acetate & norethindrone Preferred acetate PA

LUPRON DEPOT (1-MONTH) QL 1 / 30 days Preferred leuprolide acetate PA

LUPRON DEPOT (3-MONTH) QL 1 / 90 days Preferred leuprolide acetate (3 month) PA

LUPRON DEPOT (4-MONTH) QL 1 / 120 days Preferred leuprolide acetate (4 month) PA

PAGE 251 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

LUPRON DEPOT (6-MONTH) QL 1 / 180 days Preferred leuprolide acetate (6 month) PA

LUPRON DEPOT-PED (1-MONTH) QL 1 / 30 days Preferred leuprolide acetate (cpp) PA

LUPRON DEPOT-PED (3-MONTH) QL 1 / 90 days Preferred leuprolide acetate (cpp) (3 month) PA

ORGOVYX Non-Preferred QL 90 / 30 days relugolix

ORILISSA 200 MG TAB QL 2 / 1 days Preferred elagolix sodium PA

ORILISSA 150 MG TAB QL 1 / 1 days Preferred elagolix sodium PA

SUPPRELIN LA Non-Preferred histrelin acetate (cpp) SYNAREL Preferred PA nafarelin acetate TRELSTAR MIXJECT 11.25 MG RECON SUSP Non-Preferred QL 1 / 84 days triptorelin pamoate TRELSTAR MIXJECT 3.75 MG RECON SUSP Non-Preferred QL 1 / 28 days triptorelin pamoate TRELSTAR MIXJECT 22.5 MG RECON SUSP Non-Preferred QL 1 / 168 days triptorelin pamoate

TRIPTODUR QL 1 / 168 days Preferred triptorelin pamoate (cpp) PA

VANTAS QL 1 / 365 days Preferred histrelin acetate PA

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 10 mg tab Preferred QL 6 / 1 days

methimazole 5 mg tab Preferred QL 9 / 1 days

PAGE 252 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

propylthiouracil 50 mg tab Preferred QL 9 / 1 days

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT Preferred PA c1 esterase inhibitor (human) CINRYZE Preferred PA c1 esterase inhibitor (human) FIRAZYR Non-Preferred icatibant acetate HAEGARDA Preferred PA c1 esterase inhibitor (human)

icatibant acetate Preferred PA

KALBITOR Preferred PA ecallantide ORLADEYO Non-Preferred berotralstat hcl RUCONEST Preferred PA c1 esterase inhibitor (recombinant) TAKHZYRO Preferred PA lanadelumab-flyo IMMUNE SUPPRESSANTS

ASTAGRAF XL Non-Preferred tacrolimus AVSOLA Non-Preferred infliximab-axxq AZASAN Non-Preferred azathioprine azathioprine 50 mg tab Preferred CELLCEPT 250 MG CAP Non-Preferred mycophenolate mofetil CELLCEPT 500 MG TAB Non-Preferred mycophenolate mofetil CELLCEPT 200 MG/ML RECON SUSP Preferred mycophenolate mofetil CIMZIA Non-Preferred certolizumab pegol

PAGE 253 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CIMZIA PREFILLED Non-Preferred certolizumab pegol CIMZIA STARTER KIT Non-Preferred QLC 1 starter pack/lifetime certolizumab pegol cyclosporine 100 mg cap Preferred cyclosporine 25 mg cap Preferred cyclosporine modified Preferred

ENBREL 25 MG/0.5ML SOLN PRSYR QL 4 / 28 days Preferred etanercept PA

ENBREL 25 MG/0.5ML SOLUTION Preferred PA etanercept

ENBREL 50 MG/ML SOLN PRSYR QL 8 / 28 days Preferred etanercept PA

ENBREL 25 MG RECON SOLN QL 8 / 28 days Preferred etanercept PA

ENBREL MINI QL 8 / 28 days Preferred etanercept PA

ENBREL SURECLICK QL 8 / 28 days Preferred etanercept PA

ENTYVIO Non-Preferred vedolizumab ENVARSUS XR Non-Preferred tacrolimus everolimus 0.5 mg tab Non-Preferred everolimus 0.25 mg tab Non-Preferred everolimus 0.75 mg tab Non-Preferred gengraf Non-Preferred

HUMIRA 10 MG/0.1ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 40 MG/0.4ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 20 MG/0.2ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

PAGE 254 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

HUMIRA 10 MG/0.2ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 20 MG/0.4ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 40 MG/0.8ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 80 MG/0.8ML PEN KIT QL 3 / 28 days Preferred adalimumab PA

HUMIRA PEDIATRIC CROHNS START QL 6 / 28 days 40 MG/0.8ML PREF SY KT Preferred adalimumab PA HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML & 40MG/0.4ML PREF SY QL 2 / 28 days Preferred KT PA adalimumab

HUMIRA PEDIATRIC CROHNS START QL 3 / 28 days 80 MG/0.8ML PREF SY KT Preferred adalimumab PA

HUMIRA PEN QL 2 / 28 days Preferred adalimumab PA

HUMIRA PEN-CD/UC/HS STARTER 40 QL 6 / 28 days MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-CD/UC/HS STARTER 80 QL 3 / 28 days MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-PEDIATRIC UC START QL 3 / 28 days Preferred adalimumab PA

HUMIRA PEN-PS/UV/ADOL HS START QL 4 / 35 days Preferred adalimumab PA

HUMIRA PEN-PSOR/UVEIT STARTER QL 3 / 28 days Preferred adalimumab PA

ILARIS 150 MG RECON SOLN Non-Preferred canakinumab IMURAN Non-Preferred azathioprine

PAGE 255 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INFLECTRA Non-Preferred infliximab-dyyb KEVZARA Non-Preferred sarilumab KINERET Non-Preferred anakinra LUPKYNIS Non-Preferred QL 180 / 30 days voclosporin methotrexate 2.5 mg tab Preferred methotrexate sodium Preferred methotrexate sodium (pf) Preferred mycophenolate mofetil 250 mg cap Preferred mycophenolate mofetil 200 mg/ml recon Non-Preferred susp mycophenolate mofetil 500 mg tab Preferred

mycophenolate sodium 360 mg tab dr Preferred QL 120 / 30 days

mycophenolate sodium 180 mg tab dr Preferred QL 8 / 1 days

MYFORTIC 180 MG TAB DR Non-Preferred QL 8 / 1 days mycophenolate sodium MYFORTIC 360 MG TAB DR Non-Preferred QL 120 / 30 days mycophenolate sodium NEORAL cyclosporine modified (for Non-Preferred microemulsion) OLUMIANT Non-Preferred baricitinib ORENCIA 250 MG RECON SOLN Non-Preferred abatacept ORENCIA 87.5 MG/0.7ML SOLN PRSYR Non-Preferred QL 2.8 / 28 days abatacept ORENCIA 125 MG/ML SOLN PRSYR Non-Preferred QL 4 / 28 days abatacept ORENCIA 50 MG/0.4ML SOLN PRSYR Non-Preferred QL 1.6 / 28 days abatacept ORENCIA CLICKJECT Non-Preferred QL 4 / 28 days abatacept

PAGE 256 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OTREXUP 20 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 17.5 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 12.5 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 10 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 22.5 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 15 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) OTREXUP 25 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) PROGRAF 0.2 MG PACKET Non-Preferred tacrolimus PROGRAF 1 MG CAP Non-Preferred tacrolimus PROGRAF 5 MG CAP Non-Preferred tacrolimus PROGRAF 1 MG PACKET Non-Preferred tacrolimus PROGRAF 0.5 MG CAP Non-Preferred tacrolimus RAPAMUNE Preferred sirolimus RASUVO 25 MG/0.5ML SOLN A-INJ Non-Preferred QLC 2 mL/28 days methotrexate (antirheumatic) RASUVO 15 MG/0.3ML SOLN A-INJ Non-Preferred QLC 1.2 mL/28 days methotrexate (antirheumatic) RASUVO 7.5 MG/0.15ML SOLN A-INJ Non-Preferred QLC 0.6 mL/28 days methotrexate (antirheumatic) RASUVO 30 MG/0.6ML SOLN A-INJ Non-Preferred QLC 2.4 mL/28 days methotrexate (antirheumatic) RASUVO 12.5 MG/0.25ML SOLN A-INJ Non-Preferred QLC 1 mL/28 days methotrexate (antirheumatic) RASUVO 20 MG/0.4ML SOLN A-INJ Non-Preferred QLC 1.6 mL/28 days methotrexate (antirheumatic) RASUVO 22.5 MG/0.45ML SOLN A-INJ Non-Preferred QLC 1.8 mL/28 days methotrexate (antirheumatic)

PAGE 257 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RASUVO 10 MG/0.2ML SOLN A-INJ Non-Preferred QLC 0.8 mL/28 days methotrexate (antirheumatic) RASUVO 17.5 MG/0.35ML SOLN A-INJ Non-Preferred QLC 1.4 mL/28 days methotrexate (antirheumatic) REDITREX Non-Preferred methotrexate (antirheumatic) REMICADE Non-Preferred infliximab RENFLEXIS Non-Preferred infliximab-abda RINVOQ Non-Preferred QL 30 / 30 days upadacitinib SANDIMMUNE 100 MG CAP Non-Preferred cyclosporine SANDIMMUNE 100 MG/ML SOLUTION Preferred cyclosporine SANDIMMUNE 25 MG CAP Non-Preferred cyclosporine SILIQ Non-Preferred brodalumab SIMPONI Non-Preferred golimumab SIMPONI ARIA Non-Preferred golimumab sirolimus 1 mg/ml solution Non-Preferred sirolimus 0.5 mg tab Preferred sirolimus 2 mg tab Preferred sirolimus 1 mg tab Preferred tacrolimus 0.5 mg cap Preferred tacrolimus 5 mg cap Preferred tacrolimus 1 mg cap Preferred TREMFYA Non-Preferred guselkumab TREXALL Non-Preferred methotrexate sodium XATMEP Non-Preferred methotrexate

PAGE 258 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XELJANZ 1 MG/ML SOLUTION Non-Preferred QLC 10 mL/day tofacitinib citrate XELJANZ 5 MG TAB Non-Preferred QL 60 / 30 days tofacitinib citrate XELJANZ 10 MG TAB Non-Preferred QL 60 / 30 days tofacitinib citrate XELJANZ XR Non-Preferred QL 30 / 30 days tofacitinib citrate ZORTRESS Non-Preferred everolimus (immunosuppressant) IMMUNIZING AGENTS, PASSIVE

HYPERRHO S/D 1500 UNIT SOLN PRSYR Preferred rho d immune globulin (human) RHOGAM ULTRA-FILTERED PLUS Preferred rho d immune globulin (human) IMMUNOMODULATORS

ACTEMRA 200 MG/10ML SOLUTION Non-Preferred QLC 40 mL/28 days tocilizumab ACTEMRA 80 MG/4ML SOLUTION Non-Preferred QLC 40 mL/28 days tocilizumab ACTEMRA 400 MG/20ML SOLUTION Non-Preferred QLC 40 mL/28 days tocilizumab ACTEMRA 162 MG/0.9ML SOLN PRSYR Non-Preferred QL 3.6 / 28 days tocilizumab ACTEMRA ACTPEN Non-Preferred QL 3.6 / 28 days tocilizumab ARCALYST Non-Preferred QLC 8 vials/28 days rilonacept CINQAIR Non-Preferred reslizumab ILARIS 150 MG/ML SOLUTION Non-Preferred canakinumab

leflunomide 10 mg tab Preferred QL 1 / 1 days

leflunomide 20 mg tab Preferred QL 5 / 1 days

OTEZLA 30 MG TAB Non-Preferred QL 2 / 1 days apremilast

PAGE 259 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OTEZLA 10 & 20 & 30 MG TAB THPK Non-Preferred apremilast VACCINES

ADACEL tetanus toxoid-diphtheria-acellular Preferred pertussis adsorb (tdap) AFLURIA Preferred influenza virus vaccine split AFLURIA PRESERVATIVE FREE influenza virus vaccine split preservative Preferred free AFLURIA QUADRIVALENT Preferred influenza virus vaccine split quadrivalent BOOSTRIX tetanus toxoid-diphtheria-acellular Preferred pertussis adsorb (tdap) ENGERIX-B 20 MCG/ML SUSPENSION Preferred hepatitis b vaccine (recomb) ENGERIX-B 10 MCG/0.5ML SUSPENSION Preferred hepatitis b vaccine (recomb) FLUAD influenza virus vaccine types a & b Preferred surface antigen adjuvant FLUARIX QUADRIVALENT Preferred influenza virus vaccine split quadrivalent FLUBLOK QUADRIVALENT influenza virus vac recomb Preferred hemagglutinin (ha) quadrivalent FLUCELVAX QUADRIVALENT influenza virus vaccine tissue-cultured Preferred subunit quadrivalent FLULAVAL QUADRIVALENT Preferred influenza virus vaccine split quadrivalent FLUZONE HIGH-DOSE influenza virus vaccine split high-dose Preferred preservative free FLUZONE QUADRIVALENT 0.25 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent FLUZONE QUADRIVALENT SUSPENSION Preferred influenza virus vaccine split quadrivalent

PAGE 260 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUZONE QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent FLUZONE QUADRIVALENT 0.5 ML SUSPENSION Preferred influenza virus vaccine split quadrivalent HAVRIX Preferred hepatitis a vaccine PNEUMOVAX 23 Preferred pneumococcal vac polyvalent PREVNAR 13 pneumococcal 13-valent conjugate Preferred QL 1 / lifetime vaccine RECOMBIVAX HB Preferred hepatitis b vaccine (recomb) SHINGRIX Preferred QL 2 / lifetime zoster vaccine recombinant adjuvanted TWINRIX 720-20 ELU-MCG/ML SUSP PRSYR Preferred hepatitis a (inactivated)-hepatitis b (recombinant) vaccines VAQTA Preferred hepatitis a vaccine INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO Preferred QL 120 / 30 days mesalamine ASACOL HD Non-Preferred QL 6 / 1 days mesalamine AZULFIDINE Non-Preferred sulfasalazine AZULFIDINE EN-TABS Non-Preferred sulfasalazine

balsalazide disodium Preferred QL 9 / 1 days

CANASA Non-Preferred QL 1 / 1 days mesalamine COLAZAL Non-Preferred balsalazide disodium DELZICOL Preferred QL 6 / 1 days mesalamine

PAGE 261 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIPENTUM Non-Preferred olsalazine sodium GIAZO Non-Preferred balsalazide disodium LIALDA Non-Preferred QL 4 / 1 days mesalamine

mesalamine 4 gm enema Preferred QL 60 / 1 days

mesalamine 800 mg tab dr Non-Preferred QL 6 / 1 days

mesalamine 400 mg cap dr Preferred QL 6 / 1 days

mesalamine 1.2 gm tab dr Preferred QL 4 / 1 days

mesalamine 1000 mg suppos Preferred QL 1 / 1 days

mesalamine er Non-Preferred QL 120 / 30 days

mesalamine-cleanser Preferred PENTASA Preferred QL 8 / 1 days mesalamine ROWASA Non-Preferred mesalamine w/ cleanser SFROWASA Non-Preferred mesalamine

sulfasalazine 500 mg tab dr Preferred QL 12 / 1 days

sulfasalazine 500 mg tab Preferred QL 12 / 1 days

GLUCOCORTICOIDS

budesonide 3 mg cp dr part Preferred budesonide er Preferred

colocort Preferred QL 240 / 1 days

ENTOCORT EC Non-Preferred budesonide

hydrocortisone 100 mg/60ml enema Preferred QL 240 / 1 days

ORTIKOS Non-Preferred budesonide UCERIS 2 MG/ACT FOAM Non-Preferred budesonide (intrarectal) UCERIS 9 MG TAB ER 24H Non-Preferred budesonide

PAGE 262 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS METABOLIC BONE DISEASE AGENTS

ACTONEL 150 MG TAB Non-Preferred QL 1 / 28 days risedronate sodium ACTONEL 35 MG TAB Non-Preferred QL 4 / 28 days risedronate sodium ACTONEL 5 MG TAB Non-Preferred QL 30 / 30 days risedronate sodium

alendronate sodium 70 mg/75ml solution Non-Preferred QL 10.7 / 1 days

alendronate sodium 35 mg tab Preferred QL 4 / 28 days

alendronate sodium 40 mg tab Preferred QL 1 / 1 days

alendronate sodium 5 mg tab Preferred QL 1 / 1 days

alendronate sodium 70 mg tab Preferred QL 4 / 28 days

alendronate sodium 10 mg tab Preferred QL 1 / 1 days

ATELVIA Non-Preferred risedronate sodium BINOSTO Non-Preferred alendronate sodium BONIVA Non-Preferred ibandronate sodium calcitonin (salmon) Non-Preferred

calcitriol 0.25 mcg cap Preferred QL 4 / 1 days

calcitriol 0.5 mcg cap Preferred QL 4 / 1 days

CALCITRIOL INJ 1 MCG/ML Preferred

CALCITRIOL ORAL SOLN 1 MCG/ML Non-Preferred QL 60 / 30 days

cinacalcet hcl Preferred QL 2 / 1 days

doxercalciferol 1 mcg cap Non-Preferred doxercalciferol 2.5 mcg cap Non-Preferred doxercalciferol 4 mcg/2ml solution Preferred doxercalciferol 0.5 mcg cap Non-Preferred

ergocalciferol 1.25 mg (50000 ut) cap Preferred QL 8 / 30 days

ETIDRONATE DISODIUM Non-Preferred etidronate disodium

PAGE 263 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EVENITY Non-Preferred romosozumab-aqqg FORTEO Non-Preferred teriparatide (recombinant) FOSAMAX Non-Preferred alendronate sodium FOSAMAX PLUS D Non-Preferred alendronate sodium-cholecalciferol HECTOROL 2 MCG/ML SOLUTION Preferred doxercalciferol HECTOROL 4 MCG/2ML SOLUTION Preferred doxercalciferol ibandronate sodium 3 mg/3ml solution Non-Preferred

ibandronate sodium 150 mg tab Preferred QL 1 / 30 days

MIACALCIN Non-Preferred calcitonin (salmon) PAMIDRONATE DISODIUM 90 MG RECON SOLN Preferred QLC 1 vial/fill pamidronate disodium pamidronate disodium 90 mg/10ml Preferred QLC 10 mL/fill solution PAMIDRONATE DISODIUM 6 MG/ML SOLUTION Preferred QLC 10 mL/fill pamidronate disodium pamidronate disodium 30 mg/10ml Preferred QLC 30 mL/fill solution PAMIDRONATE DISODIUM 30 MG RECON SOLN Preferred QLC 3 vials/fill pamidronate disodium paricalcitol 4 mcg cap Non-Preferred paricalcitol 5 mcg/ml solution Preferred paricalcitol 2 mcg cap Non-Preferred paricalcitol 2 mcg/ml solution Preferred paricalcitol 1 mcg cap Non-Preferred PROLIA Non-Preferred QL 1 / 180 days denosumab RAYALDEE Non-Preferred calcifediol

PAGE 264 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RECLAST Non-Preferred QLC 100 mL/365 days zoledronic acid

risedronate sodium 30 mg tab Non-Preferred QL 30 / 30 days

risedronate sodium 35 mg tab dr Non-Preferred

risedronate sodium 150 mg tab Non-Preferred QL 1 / 28 days

risedronate sodium 35 mg tab Non-Preferred QL 4 / 28 days

risedronate sodium 5 mg tab Non-Preferred QL 30 / 30 days

ROCALTROL 1 MCG/ML SOLUTION Non-Preferred QL 60 / 30 days calcitriol ROCALTROL 0.5 MCG CAP Non-Preferred calcitriol ROCALTROL 0.25 MCG CAP Non-Preferred calcitriol TERIPARATIDE (RECOMBINANT) Non-Preferred teriparatide (recombinant) TYMLOS Non-Preferred abaloparatide

vitamin d (ergocalciferol) Preferred QL 8 / 30 days

XGEVA Non-Preferred QLC 5.1 mL/28 days denosumab ZEMPLAR Non-Preferred paricalcitol

zoledronic acid 5 mg/100ml solution Preferred QLC 100 mL/365 days

ZOLEDRONIC ACID 4 MG RECON SOLN Preferred zoledronic acid ZOLEDRONIC ACID 4 MG/100ML SOLUTION Preferred QLC 400 mL/28 days zoledronic acid

zoledronic acid 4 mg/5ml conc Preferred QLC 20 mL/28 days

ZOMETA 4 MG/5ML CONC Non-Preferred QLC 20 mL/28 days zoledronic acid ZOMETA 4 MG/100ML SOLUTION Non-Preferred QLC 400 mL/28 days zoledronic acid

PAGE 265 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MISCELLANEOUS THERAPEUTIC AGENTS

AEROCHAMBER MV Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU LARGE Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU MEDIUM Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU SMALL Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU W/MASK Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLOW VU Preferred spacer/aerosol-holding chambers BD LUER-LOK SYRINGE Preferred syringe/needle (disp) 3 ml COMP AIR COMPRESSOR NEBULIZER Preferred nebulizers COMPACT SPACE CHAMBER/LG MASK Preferred spacer/aerosol-holding chambers EASIVENT Preferred spacer/aerosol-holding chambers EASIVENT MASK LARGE Preferred spacer/aerosol-holding chambers EASIVENT MASK MEDIUM Preferred spacer/aerosol-holding chambers EASIVENT MASK SMALL Preferred spacer/aerosol-holding chambers

EUFLEXXA QL 12 / 180 days Preferred sodium hyaluronate (viscosupplement) PA

FREESTYLE LIBRE 14 DAY READER continuous blood glucose system Preferred QL 1 / 365 days receiver

PAGE 266 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FREESTYLE LIBRE 14 DAY SENSOR Preferred QL 3 / 30 days continuous blood glucose system sensor FREESTYLE LIBRE 2 READER continuous blood glucose system Preferred receiver FREESTYLE LIBRE 2 SENSOR Preferred continuous blood glucose system sensor FREESTYLE LIBRE READER continuous blood glucose system Preferred QL 1 / 365 days receiver FREESTYLE LIBRE SENSOR SYSTEM Preferred QL 3 / 30 days continuous blood glucose system sensor GEL-ONE Non-Preferred cross-linked hyaluronate GELSYN-3 Preferred PA sodium hyaluronate (viscosupplement) GENVISC 850 Non-Preferred sodium hyaluronate (viscosupplement) HYALGAN Preferred PA sodium hyaluronate (viscosupplement) HYMOVIS Non-Preferred hyaluronan INNOSPIRE ESSENCE NEBULIZER Preferred nebulizers LOKELMA Preferred PA sodium zirconium cyclosilicate MONOJECT HYPODERMIC NEEDLE 18G X 1" MISC Preferred needle (disp) 18 g MONOJECT MAGELLAN SAFETY NDL 18G X 1" MISC Preferred needle (disp) 18 g MONOJECT MAGELLAN SYRINGE 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml MONOJECT SYRINGE 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml MONOVISC Non-Preferred hyaluronan

PAGE 267 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPTICHAMBER DIAMOND Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-LG MASK Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-MD MASK Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-SM MASK Preferred spacer/aerosol-holding chambers ORTHOVISC Non-Preferred hyaluronan PROGESTERONE MICRONIZED POWDER Preferred progesterone micronized (bulk) PROGESTERONE ULTRA MICRONIZED Preferred progesterone micronized (bulk) SODIUM HYALURONATE 20 MG/2ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) sterile water for irrigation Preferred SUPARTZ FX Non-Preferred sodium hyaluronate (viscosupplement) SYNVISC Non-Preferred hylan SYNVISC ONE Non-Preferred hylan TRILOCICLO Non-Preferred triamcinolone acetonide-ciclopirox TRILURON Non-Preferred sodium hyaluronate (viscosupplement) TRIVISC Preferred PA sodium hyaluronate (viscosupplement) VALVED HOLDING CHAMBER Preferred spacer/aerosol-holding chambers VIOS AEROSOL DELIVERY SYSTEM Preferred nebulizers VISCO-3 Preferred PA sodium hyaluronate (viscosupplement) water for irrigation, sterile Preferred

PAGE 268 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ak-poly-bac Preferred QL 7 / days

ATROPINE SULFATE 1 % SOLUTION Preferred QL 5 / 18 days atropine sulfate (ophthalmic) bacitra-neomycin-polymyxin-hc Preferred

bacitracin-polymyxin b Preferred QL 7 / 18 days

BEOVU Non-Preferred brolucizumab-dbll BLEPHAMIDE Non-Preferred QL 1 / 1 days sulfacetamide sod-prednisolone BLEPHAMIDE S.O.P. Non-Preferred QL 7 / 18 days sulfacetamide sod-prednisolone CEQUA Non-Preferred cyclosporine (ophth)

cyclopentolate hcl 0.5 % solution Preferred QL 15 / 30 days

cyclopentolate hcl 2 % solution Preferred QL 15 / 30 days

cyclopentolate hcl 1 % solution Preferred QL 5 / 25 days

EYLEA Preferred PA aflibercept ISOPTO ATROPINE Preferred QL 5 / 18 days atropine sulfate (ophthalmic) LUCENTIS Preferred PA ranibizumab MACUGEN Preferred PA pegaptanib sodium MAXITROL Non-Preferred neomycin-polymy-dexameth neo-polycin Non-Preferred neo-polycin hc Preferred neomycin-bacitracin zn-polymyx Non-Preferred neomycin-polymyxin-dexameth 3.5- Preferred 10000-0.1 ointment neomycin-polymyxin-dexameth 3.5- Preferred QL 5 / 18 days 10000-0.1 suspension

PAGE 269 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

neomycin-polymyxin-gramicidin Non-Preferred QL 10 / 15 days

NEOMYCIN-POLYMYXIN-HC 3.5- Non-Preferred QL 10 / 15 days 10000-1 ophth SUSPENSION phenylephrine hcl 2.5 % solution Preferred polycin Preferred

polymyxin b-trimethoprim Preferred QL 10 / 15 days

POLYTRIM Non-Preferred polymyxin b-trimethoprim PRED-G Preferred gentamicin-prednisolone acetate PRED-G S.O.P. Preferred gentamicin-prednisolone acetate RESTASIS Preferred QL 2 / 1 days cyclosporine (ophth) RESTASIS MULTIDOSE Non-Preferred QL 5.5 / 28 days cyclosporine (ophth)

sulfacetamide-prednisolone Preferred QL 1 / 1 days

TOBRADEX 0.3-0.1 % SUSPENSION Preferred QL 5 / 18 days tobramycin-dexamethasone TOBRADEX 0.3-0.1 % OINTMENT Preferred QL 3.5 / 18 days tobramycin-dexamethasone TOBRADEX ST Non-Preferred tobramycin-dexamethasone

tobramycin-dexamethasone Preferred QL 5 / 18 days

tropicamide 0.5 % solution Preferred QL 15 / 18 days

tropicamide 1 % solution Preferred QL 15 / 18 days

VISUDYNE Preferred PA verteporfin XIIDRA Non-Preferred lifitegrast ZYLET Preferred loteprednol etabonate-tobramycin OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL Non-Preferred QL 5 / 18 days nedocromil sodium (ophth)

PAGE 270 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALOMIDE Preferred QL 10 / 18 days lodoxamide tromethamine azelastine hcl 0.05 % solution Preferred bepotastine besilate Non-Preferred BEPREVE Non-Preferred bepotastine besilate

cromolyn sodium 4 % solution Preferred QL 10 / 18 days

epinastine hcl Non-Preferred LASTACAFT Non-Preferred alcaftadine

olopatadine hcl 0.2 % solution Preferred QL 2.5 / 30 days

olopatadine hcl 0.1 % solution Preferred QL 5 / 25 days

PATADAY Non-Preferred olopatadine hcl PATANOL Non-Preferred olopatadine hcl PAZEO Non-Preferred olopatadine hcl ZERVIATE Non-Preferred cetirizine hcl (ophth) OPHTHALMIC ANTI-INFLAMMATORIES

ACULAR Non-Preferred ketorolac tromethamine (ophth) ACULAR LS Non-Preferred ketorolac tromethamine (ophth) ACUVAIL Non-Preferred ketorolac tromethamine (ophth) ALREX Preferred QL 5 / 18 days loteprednol etabonate bromfenac sodium (once-daily) Non-Preferred BROMSITE Non-Preferred bromfenac sodium (ophth) dexamethasone sodium phosphate 0.1 Preferred QL 5 / 10 days % solution DEXTENZA Non-Preferred dexamethasone (ophth)

PAGE 271 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEXYCU Non-Preferred dexamethasone (ophth) diclofenac sodium 0.1 % solution Non-Preferred DUREZOL Preferred difluprednate EYSUVIS Non-Preferred loteprednol etabonate FLAREX Preferred QL 5 / 18 days fluorometholone acetate

fluorometholone Preferred QL 5 / 18 days

flurbiprofen sodium Preferred QL 5 / 10 days

FML Preferred QL 3.5 / 18 days fluorometholone (ophth) FML FORTE Preferred QL 10 / 30 days fluorometholone (ophth) FML LIQUIFILM Non-Preferred fluorometholone (ophth) ILEVRO Preferred nepafenac ILUVIEN Non-Preferred fluocinolone acetonide (ophth) INVELTYS Non-Preferred loteprednol etabonate

ketorolac tromethamine 0.5 % solution Preferred QL 5 / 18 days

ketorolac tromethamine 0.4 % solution Preferred LOTEMAX 0.5 % SUSPENSION Non-Preferred loteprednol etabonate LOTEMAX 0.5 % OINTMENT Preferred loteprednol etabonate LOTEMAX 0.5 % GEL Non-Preferred loteprednol etabonate LOTEMAX SM Non-Preferred loteprednol etabonate loteprednol etabonate Non-Preferred MAXIDEX Preferred dexamethasone (ophth)

PAGE 272 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEVANAC Preferred nepafenac OMNIPRED Non-Preferred prednisolone acetate (ophth) OZURDEX Non-Preferred dexamethasone (ophth) PRED FORTE Non-Preferred prednisolone acetate (ophth) PRED MILD Preferred QL 5 / 18 days prednisolone acetate (ophth)

prednisolone acetate 1 % suspension Preferred QL 10 / 18 days

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTION Preferred QL 10 / 18 days prednisolone sodium phosphate (ophth) PROLENSA Non-Preferred bromfenac sodium (ophth) RETISERT Non-Preferred fluocinolone acetonide (ophth) TRIESENCE Non-Preferred triamcinolone acetonide (ophth) YUTIQ Non-Preferred fluocinolone acetonide (ophth) OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1 % SOLUTION Preferred QL 15 / 26 days brimonidine tartrate ALPHAGAN P 0.15 % SOLUTION Preferred brimonidine tartrate apraclonidine hcl Non-Preferred AZOPT Non-Preferred QL 10 / 24 days brinzolamide betaxolol hcl 0.5 % solution Non-Preferred BETOPTIC-S Non-Preferred betaxolol hcl (ophth)

brimonidine tartrate 0.15 % solution Non-Preferred QL 15 / 26 days

brimonidine tartrate 0.2 % solution Preferred QL 5 / 18 days

brinzolamide Non-Preferred

PAGE 273 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS carteolol hcl Preferred COMBIGAN Preferred brimonidine tartrate-timolol maleate COSOPT Non-Preferred dorzolamide hcl-timolol maleate COSOPT PF Non-Preferred dorzolamide hcl-timolol maleate

dorzolamide hcl 2 % solution Preferred QL 10 / 18 days

dorzolamide hcl-timolol mal Preferred QL 10 / 18 days

dorzolamide hcl-timolol mal pf Non-Preferred IOPIDINE Non-Preferred apraclonidine hcl ISOPTO CARPINE Non-Preferred pilocarpine hcl ISTALOL Non-Preferred timolol maleate (ophth)

levobunolol hcl Preferred QL 5 / 18 days

methazolamide 25 mg tab Preferred QL 4 / 1 days

methazolamide 50 mg tab Preferred QL 4 / 1 days

PHOSPHOLINE IODIDE Non-Preferred echothiophate iodide

pilocarpine hcl 2 % solution Non-Preferred QL 15 / 18 days

pilocarpine hcl 1 % solution Non-Preferred QL 15 / 18 days

pilocarpine hcl 4 % solution Non-Preferred QL 15 / 18 days

RHOPRESSA Non-Preferred netarsudil dimesylate ROCKLATAN Non-Preferred netarsudil dimesylate-latanoprost SIMBRINZA Preferred QL 8 / 25 days brinzolamide-brimonidine tartrate

timolol maleate 0.5 % solution Preferred QL 5 / 18 days

timolol maleate 0.5 % gel f soln Non-Preferred QL 5 / 18 days

timolol maleate 0.25 % solution Preferred QL 5 / 18 days

PAGE 274 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

timolol maleate 0.5 % (daily) solution Non-Preferred QL 5 / 18 days

timolol maleate 0.25 % gel f soln Non-Preferred QL 5 / 18 days

timolol maleate ocudose Non-Preferred timolol maleate pf Non-Preferred TIMOPTIC Non-Preferred timolol maleate (ophth) TIMOPTIC OCUDOSE Non-Preferred timolol maleate (ophth) TIMOPTIC-XE Non-Preferred timolol maleate (ophth) TRUSOPT Non-Preferred dorzolamide hcl VYZULTA Non-Preferred latanoprostene bunod OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 0.03 % solution Non-Preferred DURYSTA Non-Preferred bimatoprost

latanoprost 0.005 % solution Preferred QL 2.5 / 18 days

LUMIGAN Non-Preferred bimatoprost TRAVATAN Z Non-Preferred QL 5 / 18 days travoprost travoprost (bak free) Non-Preferred XALATAN Non-Preferred latanoprost XELPROS Non-Preferred latanoprost ZIOPTAN Non-Preferred tafluprost OTIC AGENTS

acetasol hc Preferred acetic acid 2 % solution Preferred CIPRO HC Preferred ciprofloxacin-hydrocortisone

PAGE 275 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CIPRODEX Preferred ciprofloxacin-dexamethasone CIPROFLOXACIN-FLUOCINOLONE PF Non-Preferred ciprofloxacin-fluocinolone acetonide COLY-MYCIN S Preferred neomycin-colistin-hc-thonzonium CORTISPORIN-TC Non-Preferred neomycin-colistin-hc-thonzonium hydrocortisone-acetic acid Preferred neomycin-polymyxin-hc 1 % solution Preferred neomycin-polymyxin-hc 3.5-10000-1 Preferred solution NEOMYCIN-POLYMYXIN-HC OTIC Preferred SUSP 3.5 MG/ML-10000 UNIT/ML-1% OTOVEL Non-Preferred ciprofloxacin-fluocinolone acetonide RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO Non-Preferred ciclesonide ARMONAIR DIGIHALER Non-Preferred fluticasone propionate (inhalation) ARMONAIR RESPICLICK 232 Non-Preferred fluticasone propionate (inhalation) ARMONAIR RESPICLICK 55 Non-Preferred fluticasone propionate (inhalation) ARNUITY ELLIPTA Non-Preferred QL 30 / 30 days fluticasone furoate (inhalation) ASMANEX (120 METERED DOSES) Preferred mometasone furoate (inhalation) ASMANEX (14 METERED DOSES) Preferred mometasone furoate (inhalation) ASMANEX (30 METERED DOSES) Preferred mometasone furoate (inhalation) ASMANEX (60 METERED DOSES) Preferred mometasone furoate (inhalation) ASMANEX HFA Non-Preferred mometasone furoate (inhalation)

PAGE 276 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BECONASE AQ Non-Preferred beclomethasone diprop monohyd

budesonide 0.5 mg/2ml suspension Preferred QL 4 / 1 days

budesonide 1 mg/2ml suspension Non-Preferred QL 2 / 1 days

budesonide 0.25 mg/2ml suspension Preferred QL 8 / 1 days

FLOVENT DISKUS Preferred QL 60 / 30 days fluticasone propionate (inhalation) FLOVENT HFA 110 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone propionate hfa FLOVENT HFA 220 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone propionate hfa FLOVENT HFA 44 MCG/ACT AEROSOL Preferred QL 10.6 / 30 days fluticasone propionate hfa

flunisolide 25 mcg/act (0.025%) solution Preferred QL 0.84 / 1 days

fluticasone propionate 50 mcg/act Preferred QL 16 / 20 days suspension Fluticasone Propionate 50 MCG/ACT Preferred QL 16 / 20 days SUSPENSION (Rx) mometasone furoate 50 mcg/act Non-Preferred suspension NASONEX Non-Preferred mometasone furoate (nasal) OMNARIS Non-Preferred ciclesonide (nasal) PULMICORT 0.25 MG/2ML SUSPENSION Non-Preferred budesonide (inhalation) PULMICORT 0.5 MG/2ML SUSPENSION Non-Preferred budesonide (inhalation) PULMICORT 1 MG/2ML SUSPENSION Non-Preferred QL 2 / 1 days budesonide (inhalation) PULMICORT FLEXHALER Preferred QL 1 / 30 days budesonide (inhalation) QNASL Non-Preferred beclomethasone dipropionate (nasal)

PAGE 277 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QNASL CHILDRENS Non-Preferred beclomethasone dipropionate (nasal) QVAR Non-Preferred beclomethasone dipropionate QVAR REDIHALER Preferred QL 10.6 / 30 days beclomethasone dipropionate hfa SINUVA Non-Preferred mometasone furoate (nasal) XHANCE Non-Preferred fluticasone propionate (nasal) ZETONNA Non-Preferred ciclesonide (nasal) ANTIHISTAMINES

ASTEPRO Non-Preferred azelastine hcl azelastine hcl 0.15 % solution Non-Preferred

azelastine hcl 137 mcg/spray solution Preferred QL 30 / 24 days

azelastine hcl 0.1 % solution Preferred QL 30 / 24 days

cetirizine hcl 1 mg/ml solution Preferred QL 10 / 1 days

CLARINEX Non-Preferred desloratadine

cyproheptadine hcl 2 mg/5ml syrup Preferred QL 30 / 1 days

cyproheptadine hcl 4 mg tab Preferred QL 8 / 1 days

desloratadine Non-Preferred

diphenhydramine hcl 12.5 mg/5ml elixir Preferred QL 30 / 1 days

diphenhydramine hcl 50 mg/ml solution Preferred

hydroxyzine hcl 25 mg tab Preferred QL 6 / 1 days

hydroxyzine hcl 10 mg tab Preferred QL 6 / 1 days

hydroxyzine hcl 50 mg tab Preferred QL 6 / 1 days

hydroxyzine hcl 10 mg/5ml syrup Preferred QL 30 / 1 days

hydroxyzine pamoate 50 mg cap Preferred QL 6 / 1 days

hydroxyzine pamoate 100 mg cap Preferred QL 6 / 1 days

PAGE 278 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

hydroxyzine pamoate 25 mg cap Preferred QL 6 / 1 days

levocetirizine dihydrochloride 5 mg tab Preferred QL 30 / 30 days

levocetirizine dihydrochloride 2.5 mg/5ml Non-Preferred solution olopatadine hcl 0.6 % solution Non-Preferred PATANASE Non-Preferred olopatadine hcl (nasal)

AL1 At least 6 yrs old PHENERGAN 50 MG/ML SOLUTION Non-Preferred promethazine hcl C Age restriction, clinical PA required

AL1 At least 6 yrs old PHENERGAN 25 MG/ML SOLUTION Non-Preferred promethazine hcl C Age restriction, clinical PA required

QL 4 / 1 days

promethazine hcl 12.5 mg tab Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required

AL1 At least 6 yrs old

promethazine hcl 6.25 mg/5ml syrup Preferred C Age restriction, clinical PA required QLC 30 mL/day

AL1 At least 6 yrs old

promethazine hcl 6.25 mg/5ml solution Preferred C Age restriction, clinical PA required QLC 30 mL/day

AL1 At least 6 yrs old promethazine hcl 50 mg/ml solution Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl 25 mg/ml solution Preferred C Age restriction, clinical PA required

QL 4 / 1 days

promethazine hcl 25 mg tab Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required VISTARIL Non-Preferred hydroxyzine pamoate

PAGE 279 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTILEUKOTRIENES

ACCOLATE Non-Preferred zafirlukast

montelukast sodium 10 mg tab Preferred QL 1 / 1 days

montelukast sodium 4 mg packet Preferred QL 30 / 30 days

montelukast sodium 4 mg chew tab Preferred QL 30 / 30 days

montelukast sodium 5 mg chew tab Preferred QL 1 / 1 days

SINGULAIR 10 MG TAB Non-Preferred QL 1 / 1 days montelukast sodium SINGULAIR 4 MG CHEW TAB Non-Preferred QL 1 / 1 days montelukast sodium SINGULAIR 4 MG PACKET Non-Preferred QL 30 / 30 days montelukast sodium SINGULAIR 5 MG CHEW TAB Non-Preferred QL 1 / 1 days montelukast sodium

zafirlukast 10 mg tab Non-Preferred QL 4 / 1 days

zafirlukast 20 mg tab Non-Preferred QL 2 / 1 days

zileuton er Non-Preferred ZYFLO Non-Preferred zileuton ZYFLO CR Non-Preferred zileuton BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA Preferred QL 12.9 / 26 days ipratropium bromide hfa INCRUSE ELLIPTA Non-Preferred QL 30 / 30 days umeclidinium bromide ipratropium bromide 0.03 % solution Preferred ipratropium bromide 0.06 % solution Preferred

ipratropium bromide 0.02 % solution Preferred QL 10 / 1 days

LONHALA MAGNAIR REFILL KIT Non-Preferred QL 2 / 1 days glycopyrrolate (inhalation) LONHALA MAGNAIR STARTER KIT Non-Preferred QL 2 / 1 days glycopyrrolate (inhalation)

PAGE 280 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SEEBRI NEOHALER Non-Preferred glycopyrrolate (inhalation) SPIRIVA HANDIHALER Preferred QL 30 / 30 days tiotropium bromide monohydrate SPIRIVA RESPIMAT Preferred QL 4 / 30 days tiotropium bromide monohydrate TUDORZA PRESSAIR Non-Preferred aclidinium bromide YUPELRI Non-Preferred revefenacin BRONCHODILATORS, SYMPATHOMIMETIC

albuterol sulfate 2 mg tab Non-Preferred QL 4 / 1 days

albuterol sulfate 0.63 mg/3ml nebu soln Preferred ALBUTEROL SULFATE (5 MG/ML) 0.5% NEBU SOLN Preferred albuterol sulfate albuterol sulfate (5 mg/ml) 0.5% nebu Preferred soln albuterol sulfate (2.5 mg/3ml) 0.083% Preferred nebu soln

albuterol sulfate 4 mg tab Non-Preferred QL 4 / 1 days

albuterol sulfate 2.5 mg/0.5ml nebu soln Preferred albuterol sulfate 1.25 mg/3ml nebu soln Preferred

albuterol sulfate 2 mg/5ml syrup Preferred QL 40 / 1 days

albuterol sulfate er Non-Preferred QL 4 / 1 days

albuterol sulfate hfa Preferred QLC 2 inhalers/month

ARCAPTA NEOHALER Non-Preferred indacaterol maleate arformoterol tartrate Non-Preferred BROVANA Non-Preferred QL 120 / 30 days arformoterol tartrate EPINEPHRINE 0.3 MG/0.3ML SOLN A- INJ Non-Preferred epinephrine (anaphylaxis) epinephrine 0.15 mg/0.3ml soln a-inj Preferred

PAGE 281 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS epinephrine 0.15 mg/0.15ml soln a-inj Preferred epinephrine 0.3 mg/0.3ml soln a-inj Preferred EPIPEN 2-PAK Non-Preferred epinephrine (anaphylaxis) EPIPEN JR 2-PAK Preferred epinephrine (anaphylaxis) levalbuterol hcl 1.25 mg/0.5ml nebu soln Non-Preferred levalbuterol hcl 0.31 mg/3ml nebu soln Non-Preferred levalbuterol hcl 0.63 mg/3ml nebu soln Non-Preferred levalbuterol hcl 1.25 mg/3ml nebu soln Non-Preferred

levalbuterol tartrate Preferred QL 30 / 30 days

METAPROTERENOL SULFATE 20 MG TAB Non-Preferred QL 4 / 1 days metaproterenol sulfate METAPROTERENOL SULFATE 10 MG TAB Non-Preferred QL 4 / 1 days metaproterenol sulfate

metaproterenol sulfate 10 mg/5ml syrup Non-Preferred QL 40 / 1 days

PERFOROMIST Non-Preferred QL 120 / 30 days formoterol fumarate PROAIR DIGIHALER Non-Preferred albuterol sulfate PROAIR HFA Preferred QLC 2 inhalers/month albuterol sulfate PROAIR RESPICLICK Preferred albuterol sulfate PROVENTIL HFA Preferred QLC 2 inhalers/month albuterol sulfate

SEREVENT DISKUS QL 60 / 30 days Preferred salmeterol xinafoate PA

STRIVERDI RESPIMAT Non-Preferred QL 4 / 30 days olodaterol hcl

terbutaline sulfate 5 mg tab Non-Preferred QL 3 / 1 days

terbutaline sulfate 2.5 mg tab Non-Preferred QL 3 / 1 days

VENTOLIN HFA Preferred QLC 2 inhalers/month albuterol sulfate

PAGE 282 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XOPENEX Non-Preferred levalbuterol hcl XOPENEX CONCENTRATE Non-Preferred levalbuterol hcl XOPENEX HFA Preferred QL 30 / 30 days levalbuterol tartrate CYSTIC FIBROSIS AGENTS

BETHKIS Non-Preferred tobramycin CAYSTON Non-Preferred aztreonam lysine TOBI PODHALER Non-Preferred tobramycin tobramycin 300 mg/4ml nebu soln Non-Preferred MAST CELL STABILIZERS

cromolyn sodium 20 mg/2ml nebu soln Preferred QL 8 / 1 days

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate Preferred DALIRESP Non-Preferred roflumilast THEO-24 Preferred theophylline THEOCHRON 200 MG TAB ER 12H Preferred QL 3 / 1 days theophylline THEOCHRON 100 MG TAB ER 12H Preferred QL 4 / 1 days theophylline

theophylline Preferred QL 75 / 1 days

theophylline er 600 mg tab er 24h Preferred QL 1 / 1 days

theophylline er 100 mg tab er 12h Preferred QL 4 / 1 days

theophylline er 400 mg tab er 24h Preferred QL 1 / 1 days

theophylline er 300 mg tab er 12h Preferred QL 2 / 1 days

theophylline er 450 mg tab er 12h Preferred QL 1 / 1 days

theophylline er 200 mg tab er 12h Preferred QL 3 / 1 days

PAGE 283 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PULMONARY ANTIHYPERTENSIVES

ADCIRCA QL 60 / 30 days Non-Preferred tadalafil (pulmonary hypertension) PA

ADEMPAS Non-Preferred riociguat

QL 60 / 30 days alyq Non-Preferred PA

ambrisentan Preferred PA

bosentan Non-Preferred LETAIRIS Non-Preferred ambrisentan OPSUMIT Non-Preferred macitentan ORENITRAM Non-Preferred treprostinil diolamine REVATIO 20 MG TAB sildenafil citrate (pulmonary Non-Preferred QL 90 / 30 days hypertension) REVATIO 10 MG/ML RECON SUSP sildenafil citrate (pulmonary Preferred PA hypertension)

QL 90 / 30 days sildenafil citrate 20 mg tab Preferred PA

sildenafil citrate 10 mg/ml recon susp Non-Preferred

QL 60 / 30 days tadalafil (pah) Preferred PA

TRACLEER 62.5 MG TAB Preferred PA bosentan TRACLEER 32 MG TAB SOL Non-Preferred bosentan TRACLEER 125 MG TAB Preferred PA bosentan TYVASO Preferred PA treprostinil TYVASO REFILL Preferred PA treprostinil

PAGE 284 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TYVASO STARTER Preferred PA treprostinil UPTRAVI Non-Preferred selexipag VENTAVIS Preferred PA iloprost PULMONARY FIBROSIS AGENTS

ESBRIET Preferred PA pirfenidone OFEV Preferred PA nintedanib esylate RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine 10 % solution Preferred acetylcysteine 20 % solution Preferred ADVAIR DISKUS Non-Preferred QL 60 / 30 days fluticasone-salmeterol ADVAIR HFA Preferred QL 12 / 30 days fluticasone-salmeterol AIRDUO DIGIHALER Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 113/14 Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 232/14 Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 55/14 Non-Preferred fluticasone-salmeterol ANORO ELLIPTA Preferred QL 60 / 30 days umeclidinium-vilanterol azelastine-fluticasone Non-Preferred

benzonatate 200 mg cap Preferred QL 3 / 1 days

benzonatate 100 mg cap Preferred QL 3 / 1 days

BEVESPI AEROSPHERE Preferred glycopyrrolate-formoterol fumarate BREO ELLIPTA Non-Preferred QL 60 / 30 days fluticasone furoate-vilanterol BREZTRI AEROSPHERE budesonide-glycopyrrolate-formoterol Non-Preferred QL 10.7 / 30 days fumarate

PAGE 285 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS bromfed dm Preferred

budesonide-formoterol fumarate Non-Preferred QL 10.2 / 30 days

CLARINEX-D 12 HOUR Non-Preferred desloratadine-pseudoephedrine COMBIVENT RESPIMAT Preferred QL 4 / 20 days ipratropium-albuterol DUAKLIR PRESSAIR Non-Preferred aclidinium bromide-formoterol fumarate DULERA mometasone furoate-formoterol Preferred QL 13 / 30 days fumarate dihydrate DYMISTA Non-Preferred azelastine hcl-fluticasone propionate FASENRA Preferred PA benralizumab FASENRA PEN Preferred PA benralizumab fluticasone-salmeterol 500-50 mcg/dose Preferred QL 60 / 30 days aer pow ba fluticasone-salmeterol 113-14 mcg/act Preferred QL 1 / 30 days aer pow ba fluticasone-salmeterol 55-14 mcg/act aer Preferred QL 1 / 30 days pow ba fluticasone-salmeterol 250-50 mcg/dose Preferred QL 60 / 30 days aer pow ba fluticasone-salmeterol 100-50 mcg/dose Preferred QL 60 / 30 days aer pow ba fluticasone-salmeterol 232-14 mcg/act Preferred QL 1 / 30 days aer pow ba ipratropium-albuterol Preferred KITABIS PAK Preferred tobramycin NUCALA Preferred PA mepolizumab

promethazine vc plain Preferred QL 6 / 1 days

PROMETHAZINE-DM 6.25-15 MG/5ML SOLUTION Preferred promethazine-dm

PAGE 286 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS promethazine-dm 6.25-15 mg/5ml syrup Preferred

promethazine-phenylephrine Preferred QL 6 / 1 days

pseudoeph-bromphen-dm Preferred SEMPREX-D Non-Preferred acrivastine & pseudoephedrine sodium chloride 3 % nebu soln Preferred

sodium chloride 7 % nebu soln Preferred QL 480 / 30 days

STIOLTO RESPIMAT Non-Preferred QL 4 / 30 days tiotropium bromide-olodaterol hcl SYMBICORT budesonide-formoterol fumarate Preferred QL 10.2 / 30 days dihydrate TOBI Non-Preferred tobramycin tobramycin 300 mg/5ml nebu soln Preferred TOBRAMYCIN 300 MG/5ML NEBU SOLN Non-Preferred tobramycin TRELEGY ELLIPTA Non-Preferred QL 60 / 30 days fluticasone-umeclidinium-vilanterol UTIBRON NEOHALER Non-Preferred indacaterol maleate-glycopyrrolate

wixela inhub Non-Preferred QL 60 / 30 days

XOLAIR 150 MG RECON SOLN Preferred PA omalizumab XOLAIR 75 MG/0.5ML SOLN PRSYR Non-Preferred omalizumab XOLAIR 150 MG/ML SOLN PRSYR Non-Preferred omalizumab SKELETAL MUSCLE RELAXANTS

AMRIX Non-Preferred cyclobenzaprine hcl

carisoprodol 350 mg tab Non-Preferred QL 4 / 1 days

carisoprodol 250 mg tab Non-Preferred CARISOPRODOL-ASPIRIN Non-Preferred QL 3 / 1 days carisoprodol w/ aspirin

PAGE 287 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS chlorzoxazone 750 mg tab Non-Preferred chlorzoxazone 375 mg tab Non-Preferred

chlorzoxazone 500 mg tab Non-Preferred QL 6 / 1 days

cyclobenzaprine hcl 10 mg tab Preferred QL 3 / 1 days

cyclobenzaprine hcl 7.5 mg tab Preferred

cyclobenzaprine hcl 5 mg tab Preferred QL 6 / 1 days

cyclobenzaprine hcl er Non-Preferred DYSPORT Preferred PA abobotulinumtoxina FEXMID Non-Preferred cyclobenzaprine hcl lorzone Non-Preferred metaxall Non-Preferred metaxalone Non-Preferred

methocarbamol 500 mg tab Preferred QL 16 / 1 days

methocarbamol 750 mg tab Preferred QL 10 / 1 days

MYOBLOC Non-Preferred rimabotulinumtoxinb NORGESIC FORTE Non-Preferred orphenadrine w/ aspirin & caff

orphenadrine citrate er Non-Preferred QL 2 / 1 days

orphenadrine-asa-caffeine Non-Preferred orphengesic forte 50-770-60 mg tab Non-Preferred ROBAXIN-750 Non-Preferred methocarbamol SKELAXIN Non-Preferred metaxalone SOMA Non-Preferred carisoprodol vanadom Non-Preferred

PAGE 288 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

AMBIEN Non-Preferred QL 30 / 30 days zolpidem tartrate AMBIEN CR Non-Preferred QL 30 / 30 days zolpidem tartrate DORAL Non-Preferred quazepam EDLUAR Non-Preferred QL 30 / 30 days zolpidem tartrate

estazolam Non-Preferred QL 30 / 30 days

eszopiclone Preferred QL 1 / 1 days

FLURAZEPAM HCL Non-Preferred QL 1 / 1 days flurazepam hcl HALCION Non-Preferred triazolam INTERMEZZO Non-Preferred QL 30 / 30 days zolpidem tartrate LUNESTA Non-Preferred QL 1 / 1 days eszopiclone QUAZEPAM Non-Preferred quazepam RESTORIL Non-Preferred QL 30 / 30 days temazepam

QL 30 / 30 days

temazepam 15 mg cap Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

temazepam 22.5 mg cap Non-Preferred QL 30 / 30 days

QL 30 / 30 days

temazepam 30 mg cap Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

temazepam 7.5 mg cap Non-Preferred QL 30 / 30 days

triazolam 0.125 mg tab Non-Preferred QL 60 / 30 days

PAGE 289 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

triazolam 0.25 mg tab Non-Preferred QL 1 / 1 days

zaleplon Preferred QL 2 / 1 days

zolpidem tartrate 1.75 mg sl tab Non-Preferred QL 30 / 30 days

zolpidem tartrate 10 mg tab Preferred QL 30 / 30 days

zolpidem tartrate 5 mg tab Preferred QL 30 / 30 days

zolpidem tartrate 3.5 mg sl tab Non-Preferred QL 30 / 30 days

zolpidem tartrate er Non-Preferred QL 30 / 30 days

ZOLPIMIST Non-Preferred zolpidem tartrate SLEEP DISORDERS, OTHER

armodafinil Preferred PA

BELSOMRA Non-Preferred QL 1 / 1 days suvorexant BUTISOL SODIUM Non-Preferred butabarbital sodium DAYVIGO Non-Preferred lemborexant doxepin hcl 6 mg tab Non-Preferred doxepin hcl 3 mg tab Non-Preferred HETLIOZ Non-Preferred QL 30 / 30 days tasimelteon HETLIOZ LQ Non-Preferred tasimelteon

modafinil Preferred PA

NUVIGIL Non-Preferred armodafinil PROVIGIL Non-Preferred modafinil ramelteon Non-Preferred ROZEREM Non-Preferred ramelteon SECONAL Non-Preferred secobarbital sodium

PAGE 290 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SILENOR Non-Preferred doxepin hcl (sleep) SUNOSI Non-Preferred solriamfetol hcl WAKIX Non-Preferred pitolisant hcl

PAGE 291 LAST UPDATED 07/2021 Category Listing ANALGESICS5 ANESTHETICS23 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS25 ANTIBACTERIALS27 ANTICONVULSANTS41 ANTIDEMENTIA AGENTS50 ANTIDEPRESSANTS51 ANTIEMETICS59 ANTIFUNGALS64 ANTIGOUT AGENTS68 ANTIMIGRAINE AGENTS69 ANTIMYASTHENIC AGENTS72 ANTIMYCOBACTERIALS72 ANTINEOPLASTICS73 ANTIPARASITICS82 ANTIPARKINSON AGENTS84 ANTIPSYCHOTICS88 ANTISPASTICITY AGENTS107 ANTIVIRALS108 ANXIOLYTICS119 BIPOLAR AGENTS124 BLOOD GLUCOSE REGULATORS125 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS134 CARDIOVASCULAR AGENTS142 CENTRAL NERVOUS SYSTEM AGENTS165 DENTAL AND ORAL AGENTS185 DERMATOLOGICAL AGENTS186 ELECTROLYTES/MINERALS/METALS/VITAMINS195 GASTROINTESTINAL AGENTS209 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT216 GENITOURINARY AGENTS217 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)220 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)230 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)231 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)248 HORMONAL AGENTS, SUPPRESSANT (PITUITARY)251 HORMONAL AGENTS, SUPPRESSANT (THYROID)252 IMMUNOLOGICAL AGENTS253 INFLAMMATORY BOWEL DISEASE AGENTS261 METABOLIC BONE DISEASE AGENTS263 MISCELLANEOUS THERAPEUTIC AGENTS266 OPHTHALMIC AGENTS269 OTIC AGENTS275

PAGE 292 LAST UPDATED 07/2021 RESPIRATORY TRACT/PULMONARY AGENTS276 SKELETAL MUSCLE RELAXANTS287 SLEEP DISORDER AGENTS289

PAGE 293 LAST UPDATED 07/2021 Class Listing 1ST GENERATION/TYPICAL88 2ND GENERATION/ATYPICAL92 ALCOHOL DETERRENTS/ANTI-CRAVING25 ALKYLATING AGENTS73 ALPHA-ADRENERGIC AGONISTS142 ALPHA-ADRENERGIC BLOCKING AGENTS142 AMINOGLYCOSIDES27 AMINOSALICYLATES261 ANABOLIC STEROIDS231 ANDROGENS231 ANGIOEDEMA AGENTS253 ANGIOTENSIN II RECEPTOR ANTAGONISTS143 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS144 ANTI-CYTOMEGALOVIRUS (CMV) AGENTS108 ANTI-HEPATITIS B (HBV) AGENTS108 ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS109 ANTI-HEPATITIS C (HCV) AGENTS, OTHER109 ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)110 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)111 ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)112 ANTI-HIV AGENTS, OTHER115 ANTI-HIV AGENTS, PROTEASE INHIBITORS115 ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS276 ANTI-INFLUENZA AGENTS117 ANTIANDROGENS73 ANTIANGIOGENIC AGENTS74 ANTIARRHYTHMICS146 ANTIBACTERIALS, OTHER28 ANTICHOLINERGICS84 ANTICOAGULANTS134 ANTICONVULSANTS, OTHER41 ANTIDEPRESSANTS, OTHER51 ANTIDIABETIC AGENTS125 ANTIEMETICS, OTHER59 ANTIESTROGENS/MODIFIERS74 ANTIHELMINTHICS82 ANTIHERPETIC AGENTS118 ANTIHISTAMINES278 ANTILEUKOTRIENES280 ANTIMETABOLITES74 ANTIMIGRAINE AGENTS, OTHER69 ANTIMYCOBACTERIALS, OTHER72 ANTINEOPLASTICS, OTHER75

PAGE 294 LAST UPDATED 07/2021 ANTIPARKINSON AGENTS, OTHER84 ANTIPROTOZOALS82 ANTISPASMODICS, GASTROINTESTINAL209 ANTISPASMODICS, URINARY217 ANTITHYROID AGENTS252 ANTITUBERCULARS72 ANXIOLYTICS, OTHER119 AROMATASE INHIBITORS, 3RD GENERATION78 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES165 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES171 BENIGN PROSTATIC HYPERTROPHY AGENTS218 BENZODIAZEPINES119 BETA-ADRENERGIC BLOCKING AGENTS147 BETA-LACTAM, CEPHALOSPORINS31 BETA-LACTAM, PENICILLINS33 BLOOD FORMATION MODIFIERS137 BRONCHODILATORS, ANTICHOLINERGIC280 BRONCHODILATORS, SYMPATHOMIMETIC281 CALCIUM CHANNEL BLOCKING AGENTS149 CALCIUM CHANNEL MODIFYING AGENTS43 CARDIOVASCULAR AGENTS, OTHER154 CENTRAL NERVOUS SYSTEM, OTHER180 CHOLINESTERASE INHIBITORS50 CYSTIC FIBROSIS AGENTS283 DIURETICS, CARBONIC ANHYDRASE INHIBITORS158 DIURETICS, LOOP158 DIURETICS, POTASSIUM-SPARING159 DIURETICS, THIAZIDE159 DOPAMINE AGONISTS85 DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS86 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES159 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS161 DYSLIPIDEMICS, OTHER162 ELECTROLYTE/MINERAL REPLACEMENT195 ELECTROLYTE/MINERAL/METAL MODIFIERS199 EMETOGENIC THERAPY ADJUNCTS62 ENZYME INHIBITORS78 ERGOT ALKALOIDS69 ESTROGENS233 FIBROMYALGIA AGENTS182 GABA RECEPTOR MODULATORS289 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS43 GASTROINTESTINAL AGENTS, OTHER209 GENITOURINARY AGENTS, OTHER219 GLUCOCORTICOIDS262

PAGE 295 LAST UPDATED 07/2021 GLUTAMATE REDUCING AGENTS46 GLYCEMIC AGENTS131 HEMOSTASIS AGENTS138 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS210 IMMUNE SUPPRESSANTS253 IMMUNIZING AGENTS, PASSIVE259 IMMUNOMODULATORS259 INSULINS131 IRRITABLE BOWEL SYNDROME AGENTS211 LAXATIVES212 LOCAL ANESTHETICS23 MACROLIDES35 MAST CELL STABILIZERS283 MOLECULAR TARGET INHIBITORS78 MONOAMINE OXIDASE B (MAO-B) INHIBITORS87 MONOAMINE OXIDASE INHIBITORS53 MOOD STABILIZERS124 MULTIPLE SCLEROSIS AGENTS183 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST51 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS5 OPHTHALMIC AGENTS, OTHER269 OPHTHALMIC ANTI-ALLERGY AGENTS270 OPHTHALMIC ANTI-INFLAMMATORIES271 OPHTHALMIC ANTIGLAUCOMA AGENTS273 OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS275 OPIOID ANALGESICS, LONG-ACTING9 OPIOID ANALGESICS, SHORT-ACTING14 OPIOID DEPENDENCE TREATMENTS26 OPIOID REVERSAL AGENTS26 PARASYMPATHOMIMETICS72 PEDICULICIDES/SCABICIDES83 PHOSPHATE BINDERS199 PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE283 PLATELET MODIFYING AGENTS141 PROGESTERONE AGONISTS/ANTAGONISTS246 PROGESTINS246 PROPHYLACTIC70 PROTECTANTS213 PROTON PUMP INHIBITORS213 PULMONARY ANTIHYPERTENSIVES284 PULMONARY FIBROSIS AGENTS285 QUINOLONES37 RESPIRATORY TRACT AGENTS, OTHER285 RETINOIDS82 SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS248

PAGE 296 LAST UPDATED 07/2021 SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS70 SLEEP DISORDERS, OTHER290 SMOKING CESSATION AGENTS27 SODIUM CHANNEL AGENTS48 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)54 SULFONAMIDES38 TETRACYCLINES39 TREATMENT-RESISTANT105 TRICYCLICS57 VACCINES260 VASODILATORS, DIRECT-ACTING ARTERIAL164 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS164 VITAMINS200

PAGE 297 LAST UPDATED 07/2021 Index of covered drugs Actemra ACTPen259 A Actigall209 ABACAVIR SULFATE112,114 Actiq15 ABACAVIR SULFATE-LAMIVUDINE112,113 ACTIQ15 ABACAVIR SULFATE-LAMIVUDINE- Active FE195 ZIDOVUDINE112,113 Activella233 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE115 Actonel263 ABALOPARATIDE265 Actoplus Met125 ABATACEPT256 Actoplus met XR125 ABEMACICLIB82 Actos125 Abilify92 Acular271 Abilify Maintena92 Acular LS271 Abilify MyCite92 Acuvail271 Abilify MyCite Maintenance Kit92 ACYCLOVIR118,119 Abilify MyCite Starter Kit93 ACYCLOVIR TOPICAL118,119 ABIRATERONE ACETATE73,74 ACYCLOVIR-HYDROCORTISONE118 ABOBOTULINUMTOXINA288 Aczone186 Absorica186 Adacel260 Absorica LD186 Adakveo141 Abstral14 Adalat CC149 ACALABRUTINIB78 ADALIMUMAB254,255 ACAMPROSATE CALCIUM25 ADAPALENE186,189 Acanya186 Adapalene186 ACARBOSE125,129 ADAPALENE-BENZOYL PEROXIDE186,190 Accolate280 Adasuve88 Accupril144 Adcirca284 Accuretic154 Adderall165,166 ACEBUTOLOL HCL147 Adderall XR166 ACETAMINOPHEN W/ CODEINE14,15,22,23 ADEFOVIR DIPIVOXIL108 ACETAMINOPHEN-CAFF-DIHYDROCOD15,16 Adempas284 ACETAZOLAMIDE158 Adhansia XR171 ACETIC ACID (OTIC)275 Adlyxin125 ACETYLCYSTEINE285 Adlyxin Starter Pack125 Aciphex213 Admelog131 AcipHex Sprinkle213 Admelog SoloStar131 ACITRETIN186,192 Advair Diskus285 ACLIDINIUM BROMIDE281 Advair HFA285 ACLIDINIUM BROMIDE-FORMOTEROL Advate138 FUMARATE286 Adynovate138 ACRIVASTINE & PSEUDOEPHEDRINE287 Adzenys ER166 Actemra259 Adzenys XR-ODT166

PAGE 298 LAST UPDATED 07/2021 AeroChamber MV266 ALIROCUMAB163 AeroChamber Plus Flo-Vu266 ALISKIREN FUMARATE154,157 AeroChamber Plus Flo-Vu Large266 ALISKIREN-HYDROCHLOROTHIAZIDE157 AeroChamber Plus Flo-Vu Medium266 Alkindi Sprinkle220 AeroChamber Plus Flo-Vu Small266 ALLOPURINOL68,69 AeroChamber Plus Flo-Vu w/Mask266 Allzital180 AeroChamber Plus Flow VU266 ALMOTRIPTAN MALATE70 AFATINIB DIMALEATE79 Alocril270 Afinitor78 ALOGLIPTIN BENZOATE125,129 Afinitor Disperz78 ALOGLIPTIN-METFORMIN HCL125,128 AFLIBERCEPT269 ALOGLIPTIN-PIOGLITAZONE125,129 Afluria260 Alomide271 Afluria Preservative Free260 Alora233 Afluria Quadrivalent260 ALOSETRON HCL211,212 Afrezza131,132 Aloxi62 Afstyla138 ALPELISIB81 Aggrenox141 Alphagan P273 Aimovig69 Alphanate138 AirDuo Digihaler285 Alphanate/VWF Complex/Human138 AirDuo RespiClick 113/14285 AlphaNine SD138 AirDuo RespiClick 232/14285 ALPRAZOLAM119,120,124 AirDuo RespiClick 55/14285 ALPRAZolam Intensol120 Ajovy69 Alprolix138 Aklief186 Alrex271 Akynzeo62 Altace144 Ala Scalp220 Altoprev161 ALBIGLUTIDE130 Altreno187 ALBUTEROL SULFATE281,282 ALUMINUM CHLORIDE189 Albuterol Sulfate281 Alunbrig75 ALCAFTADINE271 Alvesco276 ALCLOMETASONE DIPROPIONATE220 AMANTADINE HCL84 Alcortin A187 Amaryl125 Aldactazide154 Ambien289 Aldara187 Ambien CR289 Alecensa78 AMBRISENTAN284 ALECTINIB HCL78 AMCINONIDE220 ALEMTUZUMAB (MS)184 Amerge70 ALENDRONATE SODIUM263,264 AMIKACIN SULFATE LIPOSOME27 ALENDRONATE SODIUM-CHOLECALCIFEROL264 AMILORIDE & HYDROCHLOROTHIAZIDE154 ALFUZOSIN HCL218 AMILORIDE HCL159 Alinia82 AMINOCAPROIC ACID138,139

PAGE 299 LAST UPDATED 07/2021 AMIODARONE HCL146 Annovera233 AMISULPRIDE (ANTIEMETIC)59 Anoro Ellipta285 Amitiza211 Antara159 AMITRIPTYLINE HCL57,58 ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL AMLODIPINE BENZOATE151 (BDD-RFVIII PEG-AUCL)139 AMLODIPINE BESYLATE149,152 ANTIHEMOPHILIC FACTOR (HUMAN)139,140 AMLODIPINE BESYLATE-ATORVASTATIN ANTIHEMOPHILIC FACTOR (RCMB) BD CALCIUM154,155 TRUNCATED (BD TRUNC-RFVIII)140 AMLODIPINE BESYLATE-BENAZEPRIL HCL154,156 ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION AMLODIPINE BESYLATE-OLMESARTAN PROTEIN(BDD-RFVIIIFC)139 MEDOXOMIL154 ANTIHEMOPHILIC FACTOR (RCMB) AMLODIPINE BESYLATE-VALSARTAN154,155 MOROCTOCOG ALFA(BDD-RFVIII,MOR)141 AMLODIPINE-VALSARTAN- ANTIHEMOPHILIC FACTOR (RCMB) HYDROCHLOROTHIAZIDE154,156 PLASMA/ALBUMIN FREE (RAHF-PFM)138,140 AMOXAPINE58 ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG AMOXICILLIN33,34 ALFA(BDD-RFVIII,SIM)140 AMOXICILLIN & POT CLAVULANATE33,34 ANTIHEMOPHILIC FACTOR (RECOMBINANT AMOXICILLIN-CLARITHROMYCIN W/ PORCINE) (RPFVIII)140 LANSOPRAZOLE209 ANTIHEMOPHILIC FACTOR AMOXICILLIN-CLARITHROMYCIN W/ (RECOMBINANT)139,140 OMEPRAZOLE209 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMOXICILLIN-RIFABUTIN-OMEPRAZOLE210 GLYCOPEGYLATED-EXEI139 AMPHETAMINE166,168 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Amphetamine ER166 PEGYLATED138 AMPHETAMINE SULFATE166,168 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMPHETAMINE- SINGLE CHAIN138 DEXTROAMPHETAMINE165,166,167,169 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND AMPICILLIN34 FACTOR COMPLEX (HUMAN)138,139,141 Ampyra183 ANTIINHIBITOR COAGULANT COMPLEX139 Amrix287 Anzemet62 Amzeeq39 Apadaz15 Anadrol-50231 APALUTAMIDE73 Anafranil58 APAP-Caff-Dihydrocodeine15 ANAKINRA256 ApexiCon E220 ANASTROZOLE78 Apidra132 Ancobon64 Apidra SoloStar132 Androderm231 APIXABAN134 AndroGel231 Aplenzin51 AndroGel Pump232 APOMORPHINE HYDROCHLORIDE85 Android232 APRACLONIDINE HCL273,274 Angeliq233 APREMILAST259,260

PAGE 300 LAST UPDATED 07/2021 APREPITANT62,63 Aspirin-Omeprazole141 Apriso261 Astagraf XL253 Aprizio Pak23 Astepro278 Aprizio Pak II23 Atacand143 Aptensio XR171 Atacand HCT154 Aptiom48 ATAZANAVIR SULFATE115,116,117 Aptivus115 ATAZANAVIR SULFATE-COBICISTAT116 Arakoda83 Atelvia263 Aranesp (Albumin Free)137 ATENOLOL147,149 Arazlo187 ATENOLOL & CHLORTHALIDONE154,157 Arcalyst259 Ativan120 Arcapta Neohaler281 ATOMOXETINE HCL171,172,179,180 ARFORMOTEROL TARTRATE281 ATORVASTATIN CALCIUM161 Aricept50 ATOVAQUONE-PROGUANIL HCL83 Arikayce27 Atralin187 Arimidex78 Atripla111 ARIPIPRAZOLE92,93 Atropine Sulfate269 ARIPIPRAZOLE LAUROXIL94 ATROPINE SULFATE (OPHTHALMIC)269 Aristada94 Atrovent HFA280 Aristada Initio94 Aubagio183 Arixtra134 Augmentin34 ARMODAFINIL290 Augmentin XR34 ArmonAir Digihaler276 Auryxia199 ArmonAir RespiClick 232276 Austedo180 ArmonAir RespiClick 55276 Avalide154 Armour Thyroid248 Avandia125 Arnuity Ellipta276 AVAPRITINIB75 Aromasin78 Avapro143 ARTEMETHER-LUMEFANTRINE83 AVATROMBOPAG MALEATE141 Arthrotec5 AVC Vaginal38 Arymo ER9 Aveed232 Asacol HD261 Avelox37 ASENAPINE102 Avodart218 ASENAPINE MALEATE94,102 Avonex183 Asmanex (120 Metered Doses)276 Avonex Pen183 Asmanex (14 Metered Doses)276 Avonex Prefilled183 Asmanex (30 Metered Doses)276 Avsola253 Asmanex (60 Metered Doses)276 AXITINIB79 Asmanex HFA276 Aygestin246 ASPIRIN-DIPYRIDAMOLE141 Ayvakit75 ASPIRIN-OMEPRAZOLE141,142 Azasan253

PAGE 301 LAST UPDATED 07/2021 AzaSite35 BD Luer-Lok Syringe266 AZATHIOPRINE253,255 BECLOMETHASONE DIPROP MONOHYD277 AZELAIC ACID (ACNE)187 BECLOMETHASONE DIPROPIONATE278 AZELASTINE HCL278 BECLOMETHASONE DIPROPIONATE AZELASTINE HCL (OPHTH)271 (NASAL)277,278 AZELASTINE HCL-FLUTICASONE BECLOMETHASONE DIPROPIONATE HFA278 PROPIONATE285,286 Beconase AQ277 Azelex187 Belbuca9 AzesChew Prenatal/Postnatal200 Belsomra290 Azilect87 BEMPEDOIC ACID156 AZILSARTAN MEDOXOMIL143 BEMPEDOIC ACID-EZETIMIBE163 AZILSARTAN MEDOXOMIL-CHLORTHALIDONE155 BENAZEPRIL & HYDROCHLOROTHIAZIDE154,156 AZITHROMYCIN35,36 BENAZEPRIL HCL144,145 AZITHROMYCIN (OPHTH)35 Benazepril-Hydrochlorothiazide154 Azopt273 BeneFIX139 Azor154 Benicar143 AZTREONAM LYSINE283 Benicar HCT154 Azulfidine261 BENRALIZUMAB286 Azulfidine EN-tabs261 Bensal HP187 BenzaClin187 B BenzaClin with Pump187 B-COMPLEX W/ C & FOLIC Benzamycin28 ACID203,205,206,207,208 BenzePrO187 BACITRACIN (OPHTHALMIC)28 BENZHYDROCODONE HCL-ACETAMINOPHEN15 BACITRACIN-POLY-NEOMYCIN-HC269 Benzhydrocodone-Acetaminophen15 BACITRACIN-POLYMYXIN B (OPHTH)269,270 BENZONATATE285 BACITRACIN-POLYMYXIN-NEOMYCIN HC188 BENZOYL PEROXIDE187,188 BACLOFEN107 BENZOYL PEROXIDE-ERYTHROMYCIN28 Bafiertam183 BENZTROPINE MESYLATE84 Balcoltra234 Beovu269 BALOXAVIR MARBOXIL118 BEPOTASTINE BESILATE271 BALSALAZIDE DISODIUM261,262 Bepreve271 Balversa75 Berinert253 Banzel48 BEROTRALSTAT HCL253 Baqsimi One Pack131 Beser220 Baqsimi Two Pack131 BESIFLOXACIN HCL37 Baraclude108 Besivance37 Barhemsys59 BETAMETHASONE DIPROPIONATE BARICITINIB256 (TOPICAL)192,220 Basaglar KwikPen132 BETAMETHASONE DIPROPIONATE Baxdela37 AUGMENTED189,220

PAGE 302 LAST UPDATED 07/2021 BETAMETHASONE VALERATE191,220,221 Braftovi78 Betapace146 Breo Ellipta285 Betapace AF146 BREXPIPRAZOLE99,100 Betaseron183 Breztri Aerosphere285 BETAXOLOL HCL147 BRIGATINIB75 BETAXOLOL HCL (OPHTH)273 Brilinta141 BETHANECHOL CHLORIDE219 BRIMONIDINE TARTRATE273 Bethkis283 BRIMONIDINE TARTRATE-TIMOLOL MALEATE274 Betoptic-S273 BRINZOLAMIDE273 BETRIXABAN MALEATE134 BRINZOLAMIDE-BRIMONIDINE TARTRATE274 Bevespi Aerosphere285 Brisdelle54 Bevyxxa134 BRIVARACETAM41,42 Beyaz234 Briviact41,42 BEZLOTOXUMAB31 BRODALUMAB258 BICALUTAMIDE73 BROLUCIZUMAB-DBLL269 Bicillin L-A34 BROMFENAC SODIUM (OPHTH)271,273 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR BROMOCRIPTINE MESYLATE85 ALAFENAMIDE FUMARATE110 BromSite271 BiDil154 BROVANA281 Bijuva234 Brukinsa75 Biktarvy110 Bryhali221 BIMATOPROST275 BUDESONIDE262 BINIMETINIB80 BUDESONIDE (INHALATION)277 Binosto263 BUDESONIDE (INTRARECTAL)262 BISMUTH SUBCITRATE POTASSIUM- BUDESONIDE-FORMOTEROL FUMARATE METRONIDAZOLE-TETRACYCLINE210 DIHYDRATE286,287 BISOPROLOL & HYDROCHLOROTHIAZIDE154,158 BUDESONIDE-GLYCOPYRROLATE-FORMOTEROL BISOPROLOL FUMARATE147 FUMARATE285 Bleph-1038 BUMETANIDE158 Blephamide269 Bunavail26 Blephamide S.O.P.269 Buphenyl216 Boniva263 BUPRENORPHINE9,10,26 Bonjesta59 BUPRENORPHINE HCL9,26 Boostrix260 BUPRENORPHINE HCL-NALOXONE HCL BOSENTAN284 DIHYDRATE26 Bosulif78 BUPROPION HCL51,52,53 BOSUTINIB78 BUPROPION HCL (SMOKING DETERRENT)27 Botox107 BUPROPION HYDROBROMIDE51 BP Cleansing Wash188 BUSPIRONE HCL119 BP Vit 3200 BUSULFAN73 BPO188 BUTABARBITAL SODIUM290

PAGE 303 LAST UPDATED 07/2021 BUTALBITAL-ACETAMINOPHEN180,181 CALCITRIOL263,265 Butalbital-Acetaminophen181 CALCITRIOL (TOPICAL)188,195 BUTALBITAL-ACETAMINOPHEN- CALCIUM ACETATE (PHOSPHATE BINDER)199,200 CAFFEINE180,181,182 Calquence78 BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ Cambia5 CODEINE16 CANAGLIFLOZIN127 BUTALBITAL-ASPIRIN-CAFFEINE5,18 CANAGLIFLOZIN-METFORMIN HCL127 Butalbital-Aspirin-Caffeine5 CANAKINUMAB255,259 BUTALBITAL-ASPIRIN-CAFFEINE W/COD15,16,18 Canasa261 BUTENAFINE HCL66 CANDESARTAN CILEXETIL143 Butisol Sodium290 CANDESARTAN CILEXETIL- BUTOCONAZOLE NITRATE (ONE DOSE)65 HYDROCHLOROTHIAZIDE154,155 BUTORPHANOL TARTRATE16 CANNABIDIOL42 Butrans10 CAPECITABINE74,75 Bydureon125 Capex221 Bydureon BCise125 Caplyta94 Byetta 10 MCG Pen125 CAPMATINIB HCL76 Byetta 5 MCG Pen125 Caprelsa78 Bystolic147 CAPSAICIN & CLEANSING GEL25 CAPTOPRIL145 C CAPTOPRIL & HYDROCHLOROTHIAZIDE155 C-Nate DHA200 CARBAMAZEPINE48,49 C1 ESTERASE INHIBITOR (HUMAN)253 CARBAMAZEPINE (ANTIPSYCHOTIC)124 C1 ESTERASE INHIBITOR (RECOMBINANT)253 Carbatrol48 Cabenuva115 CARBIDOPA86,87 CABERGOLINE251 CARBIDOPA-LEVODOPA86,87 Cabometyx78 Carbidopa-Levodopa86,87 CABOTEGRAVIR & RILPIVIRINE115 CARBIDOPA-LEVODOPA-ENTACAPONE84,85 CABOTEGRAVIR SODIUM111 Cardizem149 CABOZANTINIB S-MALATE78,79 Cardizem CD149,150 Caduet155 Cardizem LA150 Cafergot69 Cardura142 CAFFEINE CITRATE283 Cardura XL218 Calan149 CARIPRAZINE HCL103,104 Calan SR149 CARISOPRODOL287,288 CALCIFEDIOL264 CARISOPRODOL W/ ASPIRIN287 CALCIPOTRIENE188,189,192 CARISOPRODOL W/ ASPIRIN & CODEINE16 Calcipotriene188 Carisoprodol-Aspirin287 CALCIPOTRIENE-BETAMETHASONE Carisoprodol-Aspirin-Codeine16 DIPROPIONATE188,190,194,195 CARTEOLOL HCL (OPHTH)274 CALCITONIN (SALMON)263,264 CARVEDILOL147

PAGE 304 LAST UPDATED 07/2021 CARVEDILOL PHOSPHATE147,148 Chantix Starting Month Pak27 Casodex73 Chemet199 Catapres142 Chenodal209 Catapres-TTS-1142 CHENODIOL209 Catapres-TTS-2142 CHLORAMBUCIL73 Catapres-TTS-3142 CHLORDIAZEPOXIDE HCL120 Cayston283 CHLORDIAZEPOXIDE-AMITRIPTYLINE52 CEFACLOR31 CHLORHEXIDINE GLUCONATE (MOUTH- Cefaclor31 THROAT)185 Cefaclor ER31 CHLOROQUINE PHOSPHATE83 CEFACLOR MONOHYDRATE31 CHLOROTHIAZIDE159 CEFADROXIL31,32 CHLORPROMAZINE HCL88 Cefadroxil31 CHLORPROPAMIDE125,126 CEFDINIR32 ChlorproPAMIDE125,126 CEFIXIME32,33 CHLORTHALIDONE159 CEFPODOXIME PROXETIL32 CHLORZOXAZONE288 CEFPROZIL32 Cholbam216 Ceftin32 CHOLESTYRAMINE162,163 CEFTRIAXONE SODIUM32 CHOLESTYRAMINE LIGHT162,163 CEFUROXIME AXETIL32 CHOLIC ACID216 CeleBREX5 CHOLINE FENOFIBRATE160 CELECOXIB5 Cialis218,219 CeleXA54 CICLESONIDE276 CellCept253 CICLESONIDE (NASAL)277,278 Celontin43 Ciclodan Cream64 CENOBAMATE48 Ciclodan Solution64 Centany28 CICLOPIROX64,66,67 Centany AT28 CICLOPIROX OLAMINE64,66 Centratex200 CICLOPIROX OLAMINE & CLEANSER64,66 CEPHALEXIN32,33 Ciclopirox Treatment64 Cephalexin32,33 CILOSTAZOL141 Cequa269 Ciloxan37 Cerdelga216 Cimduo112 Cerezyme216 CIMETIDINE210 CERITINIB82 CIMETIDINE HCL210 CERTOLIZUMAB PEGOL253,254 Cimzia253 Cesamet62 Cimzia Prefilled254 CETIRIZINE HCL278 Cimzia Starter Kit254 CETIRIZINE HCL (OPHTH)271 CINACALCET HCL263 Chantix27 Cinqair259 Chantix Continuing Month Pak27 Cinryze253

PAGE 305 LAST UPDATED 07/2021 Cinvanti62 CLINDAMYCIN PHOSPHATE Cipro37 (TOPICAL)28,29,188,190 Cipro HC275 CLINDAMYCIN PHOSPHATE VAGINAL28,29 Ciprodex276 CLINDAMYCIN PHOSPHATE-BENZOYL CIPROFLOXACIN37 PEROXIDE186,187,188,191 CIPROFLOXACIN (OTIC)38 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE CIPROFLOXACIN HCL37 & MOISTURIZER191 CIPROFLOXACIN HCL (OPHTH)37 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE CIPROFLOXACIN HCL (OTIC)37 (REFRIGERATE)188,189,191 Ciprofloxacin-Ciproflox HCl ER37 CLINDAMYCIN PHOSPHATE-TRETINOIN188,195 CIPROFLOXACIN-CIPROFLOXACIN HCL37 Clindesse29 CIPROFLOXACIN-DEXAMETHASONE276 CLOBAZAM43,45 CIPROFLOXACIN-FLUOCINOLONE ACETONIDE276 CLOBETASOL PROPIONATE221,225,226,229 Ciprofloxacin-Fluocinolone PF276 CLOBETASOL PROPIONATE & CLEANSER221 CIPROFLOXACIN-HYDROCORTISONE275 CLOBETASOL PROPIONATE EMOLLIENT BASE221 CITALOPRAM HYDROBROMIDE54 CLOBETASOL PROPIONATE CitraNatal 90 DHA201 EMULSION221,226,229 CitraNatal Assure201 CLOBETASOL PROPIONATE EMULSION FOAM W/ CitraNatal B-Calm201 MOISTURIZING CREAM194 CitraNatal Bloom201 Clobetex188 CitraNatal DHA201 Clobex221 CitraNatal Harmony201 Clobex Spray221 CitraNatal Rx201 CLOCORTOLONE PIVALATE221 CLADRIBINE (MULTIPLE SCLEROSIS)184 Clocortolone Pivalate221 Clarinex278 Clocortolone Pivalate Pump221 Clarinex-D 12 Hour286 Clodan221 CLARITHROMYCIN35 Cloderm221 CLASCOTERONE195 Cloderm Pump221 Clenia Plus188 CLOMIPRAMINE HCL58 Cleocin28 CLONAZEPAM121,123 Cleocin-T28 CLONIDINE142 Climara235 CLONIDINE HCL142 Climara Pro235 CLONIDINE HCL (ADHD)172,175 Clindacin ETZ28 CLOPIDOGREL BISULFATE141,142 Clindacin Pac28 CLORAZEPATE DIPOTASSIUM121,122,124 Clindagel28 CLOTRIMAZOLE64 CLINDAMYCIN HCL28 CLOTRIMAZOLE (TOPICAL)64 CLINDAMYCIN PALMITATE HYDROCHLORIDE28 CLOTRIMAZOLE W/ BETAMETHASONE188,191 CLINDAMYCIN PHOSPHATE & CLEANSER28 CLOZAPINE105,106,107 CLINDAMYCIN PHOSPHATE (ONE DOSE)29 Clozaril106 COAGULATION FACTOR IX138,140

PAGE 306 LAST UPDATED 07/2021 COAGULATION FACTOR IX (RECOMB) FC FUSION Concept OB201 PROTEIN (RFIXFC)138 Concerta172 COAGULATION FACTOR IX CONJUGATED ESTROGENS-BAZEDOXIFENE248 (RECOMBINANT)139,140 CONJUGATED ESTROGENS- COAGULATION FACTOR IX (RECOMBINANT) MEDROXYPROGESTERONE ACETATE243 GLYCOPEGYLATED140 Conjupri150 COAGULATION FACTOR IX RECOMB ALBUMIN CONTINUOUS BLOOD GLUCOSE SYSTEM FUSION PROTEIN (RIX-FP)139 RECEIVER266,267 COAGULATION FACTOR VIIA (RECOMBINANT)140 CONTINUOUS BLOOD GLUCOSE SYSTEM COAGULATION FACTOR VIIA (RECOMBINANT)- SENSOR267 JNCW140 ConZip10 Coartem83 Copaxone183 COBALAMIN COMBINATIONS202 Copiktra75 COBICISTAT115 COPPER (IUD)219 COBIMETINIB FUMARATE79 Cordran222 CODEINE SULFATE16 Coreg147 Codeine Sulfate16 Coreg CR148 Colazal261 Corgard148 COLCHICINE68 Cortef222 COLCHICINE W/ PROBENECID68 CORTISONE ACETATE222 Colcrys68 Cortisporin188,189 COLESEVELAM HCL162,163 Cortisporin-TC276 Colestid162 Corvite 150201 Colestid Flavored162 Corvite Fe201 COLESTIPOL HCL162 Corzide155 COLLAGENASE192 Cosentyx189 Coly-Mycin S276 Cosentyx (300 MG Dose)189 Combigan274 Cosentyx Sensoready (300 MG)189 CombiPatch235 Cosentyx Sensoready Pen189 Combivent Respimat286 Cosopt274 Combivir112 Cosopt PF274 Cometriq (100 mg Daily Dose)78 Cotellic79 Cometriq (140 mg Daily Dose)78 Cotempla XR-ODT172 Cometriq (60 mg Daily Dose)79 Coumadin134 Comp Air Compressor Nebulizer266 Cozaar143 Compact Space Chamber/Lg Mask266 Creon216 Complera111 Cresemba65 Complete Natal DHA201 Crestor161 CompleteNate201 Crinone246 Comtan84 CRISABOROLE190 Concept DHA201 Crixivan116

PAGE 307 LAST UPDATED 07/2021 CRIZANLIZUMAB-TMCA141 DAROLUTAMIDE73 CRIZOTINIB82 DARUNAVIR ETHANOLATE116,117 CROMOLYN SODIUM283 DARUNAVIR-COBICISTAT116 CROMOLYN SODIUM (OPHTH)271 DARUNAVIR-COBICISTAT-EMTRICITABINE- CROSS-LINKED HYALURONATE267 TENOFOVIR ALAFENAMIDE117 CROTAMITON83 DASATINIB81 Crotan83 DASIGLUCAGON HCL131 Cutivate222 Daurismo79 CYANOCOBALAMIN201 Daypro5 Cyclessa235 Daytrana172 CYCLOBENZAPRINE HCL287,288 DayVigo290 CYCLOPENTOLATE HCL269 DECITABINE-CEDAZURIDINE76 CYCLOPHOSPHAMIDE73 DEFERASIROX199 CYCLOSPORINE254,258 DEFERIPRONE199 CYCLOSPORINE (OPHTH)269,270 DEFLAZACORT223 CYCLOSPORINE MODIFIED (FOR DELAFLOXACIN MEGLUMINE37 MICROEMULSION)254,256 DELAVIRDINE MESYLATE111 Cymbalta182 Delestrogen235 CYPROHEPTADINE HCL278 Delstrigo111 Cytomel248 Delzicol261 DEMECLOCYCLINE HCL39 D Demerol16 D.H.E. 4569 Denavir118 DABIGATRAN ETEXILATE MESYLATE136 DENOSUMAB264,265 DABRAFENIB MESYLATE81 Depakene43 DACLATASVIR DIHYDROCHLORIDE109 Depakote43 DACOMITINIB77 Depakote ER43 Daklinza109 Depakote Sprinkles43 DALFAMPRIDINE183,184 Depo-Estradiol235 Daliresp283 DEPO-Medrol222 DALTEPARIN SODIUM135 Depo-Provera246 Dantrium107 Depo-SubQ Provera 104246 DANTROLENE SODIUM107 Depo-Testosterone232 DAPAGLIFLOZIN PROPANEDIOL126 Derma-Smoothe/FS Body222 DAPAGLIFLOZIN-METFORMIN HCL131 Derma-Smoothe/FS Scalp222 DAPAGLIFLOZIN-SAXAGLIPTIN129 Dermalid23 DAPSONE72 Dermatop222 Dapsone189 Descovy115 DAPSONE (TOPICAL)186,189 DESIPRAMINE HCL58,59 DARBEPOETIN ALFA137 DESLORATADINE278 DARIFENACIN HYDROBROMIDE217 DESLORATADINE-CLOBETASOL PROPIONATE188

PAGE 308 LAST UPDATED 07/2021 DESLORATADINE-PSEUDOEPHEDRINE286 DIAZEPAM122,123 DESMOPRESSIN ACETATE230,231 DiazePAM122 DESMOPRESSIN ACETATE SPRAY230 DIAZEPAM (ANTICONVULSANT)43,44,45,46 DESMOPRESSIN ACETATE SPRAY Diclegis60 REFRIGERATED230 DICLOFENAC5,9 DESOGESTREL & ETHINYL Diclofenac5 ESTRADIOL234,235,236,238,239,243 DICLOFENAC EPOLAMINE5,6,7 DESOGESTREL-ETHINYL ESTRADIOL Diclofenac Epolamine5 (BIPHASIC)234,235,239,241,243,244,245 DICLOFENAC POTASSIUM5,9 DESOGESTREL-ETHINYL ESTRADIOL DICLOFENAC POTASSIUM (MIGRAINE)5 (TRIPHASIC)234,235,245 DICLOFENAC SODIUM6 Desonate222 DICLOFENAC SODIUM (OPHTH)272 DESONIDE222 DICLOFENAC SODIUM (TOPICAL)5,8,9,189 DesOwen222 DICLOFENAC SODIUM-CAPSAICIN (TOPICAL)189 DESOXIMETASONE222,229 DICLOFENAC W/ MISOPROSTOL5,6 Desoxyn167 DICLOXACILLIN SODIUM34 DESVENLAFAXINE54,55 DICYCLOMINE HCL209 Desvenlafaxine ER54 DIDANOSINE112,114 DESVENLAFAXINE SUCCINATE54,56 Differin189 Detrol217 Dificid35 Detrol LA217 DIFLORASONE DIACETATE223,228 DEUTETRABENAZINE180 DIFLORASONE DIACETATE EMOLLIENT BASE220 Dexabliss222 Diflucan65 DEXAMETHASONE222,223,224,228,229,230 DIFLUNISAL6 Dexamethasone223 DIFLUPREDNATE272 DEXAMETHASONE (OPHTH)271,272,273 DIGOXIN155 Dexamethasone Intensol223 DIHYDROERGOTAMINE MESYLATE69 DEXAMETHASONE SODIUM PHOSPHATE223 Dilantin48,49 DEXAMETHASONE SODIUM PHOSPHATE Dilantin Infatabs49 (OPHTH)271 Dilatrate-SR164 Dexedrine167,168 Dilaudid16 Dexilant213 DILTIAZEM HCL149,150 DEXLANSOPRAZOLE213 DILTIAZEM HCL COATED BEADS149,150,151 DEXMETHYLPHENIDATE HCL172,173,174 DILTIAZEM HCL EXTENDED RELEASE Dextenza271 BEADS150,151,152,153 DEXTROAMPHETAMINE DIMENHYDRINATE60 SULFATE167,168,169,170,171 DimenhyDRINATE60 Dexycu272 DIMETHYL FUMARATE184,185 Diacomit42 Diovan143 Diastat AcuDial43 Diovan HCT155 Diastat Pediatric43 Dipentum262

PAGE 309 LAST UPDATED 07/2021 DIPHENHYDRAMINE HCL278 Drizalma Sprinkle182 DIPHENOXYLATE W/ ATROPINE209 DRONABINOL62,63,64 Diprolene189 DROSPIRENONE248 DIPYRIDAMOLE141 DROSPIRENONE-ESTETROL241 DIROXIMEL FUMARATE185 DROSPIRENONE-ESTRADIOL233 DISOPYRAMIDE PHOSPHATE146 DROSPIRENONE-ETHINYL DISULFIRAM25 ESTRADIOL236,238,240,241,242,244,245 Ditropan XL217 DROSPIRENONE-ETHINYL ESTRADIOL- Diuril159 LEVOMEFOLATE CALCIUM234,236,243,245 DIVALPROEX SODIUM43,44 Droxia74 Divigel235 Drysol189 DOLASETRON MESYLATE62 Dsuvia16 Dolophine10 Duac189 DOLUTEGRAVIR SODIUM110 Duaklir Pressair286 DOLUTEGRAVIR SODIUM-LAMIVUDINE115 Duavee248 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL115 Duetact126 DONEPEZIL HYDROCHLORIDE50 Duexis6 Doptelet141 DULAGLUTIDE130 Doral289 Dulera286 DORAVIRINE111 DULOXETINE HCL182 DORAVIRINE-LAMIVUDINE-TENOFOVIR Duobrii189 DISOPROXIL FUMARATE111 Duopa87 Doryx39 DUPILUMAB190 Doryx MPC39 Dupixent190 DORZOLAMIDE HCL274,275 Duragesic-10010 DORZOLAMIDE HCL-TIMOLOL MALEATE274 Duragesic-1210 Dovato115 Duragesic-2510 Dovonex189 Duragesic-5010 DOXAZOSIN MESYLATE142 Duragesic-7510 DOXAZOSIN MESYLATE (BPH)218 Durezol272 DOXEPIN HCL58 Durolane190 DOXEPIN HCL (SLEEP)290,291 Durysta275 DOXERCALCIFEROL263,264 DUTASTERIDE218 Doxycycline39 DUTASTERIDE-TAMSULOSIN HCL218,219 DOXYCYCLINE (MONOHYDRATE)40,41 DUVELISIB75 DOXYCYCLINE (ROSACEA)39,41 Duzallo68 DOXYCYCLINE CALCIUM41 Dxevo 11-Day223 DOXYCYCLINE HYCLATE39,41 Dyanavel XR168 Doxycycline Hyclate39 Dymista286 DOXYCYCLINE HYCLATE W/ CLEANSER41 Dysport288 DOXYLAMINE-PYRIDOXINE59,60

PAGE 310 LAST UPDATED 07/2021 ELTROMBOPAG OLAMINE138 E ELUXADOLINE212 E.E.S. Granules35 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- EasiVent266 TENOFOVIR ALAFENAMIDE110 EasiVent Mask Large266 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- EasiVent Mask Medium266 TENOFOVIR DF110 EasiVent Mask Small266 Emcyt74 ECALLANTIDE253 Emend62,63 ECHOTHIOPHATE IODIDE274 Emend Tri-Pack63 ECONAZOLE NITRATE65 Emflaza223 Edarbi143 Emgality69 Edarbyclor155 Emgality (300 MG Dose)69 Edluar289 EMICIZUMAB-KXWH139 EDOXABAN TOSYLATE136 EMPAGLIFLOZIN128 Edurant111 EMPAGLIFLOZIN-LINAGLIPTIN127 EFAVIRENZ111,112 EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN130 EFAVIRENZ-EMTRICITABINE-TENOFOVIR EMPAGLIFLOZIN-METFORMIN HCL130 DISOPROXIL FUMARATE111 Empricaine-II23 EFAVIRENZ-LAMIVUDINE-TENOFOVIR Emsam53 DISOPROXIL FUMARATE111,112 EMTRICITABINE112 Effexor XR54 EMTRICITABINE-RILPIVIRINE-TENOFOVIR Effient141 ALAFENAMIDE FUMARATE111 EFINACONAZOLE66 EMTRICITABINE-RILPIVIRINE-TENOFOVIR ELAGOLIX SODIUM252 DISOPROXIL FUMARATE111 ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONE EMTRICITABINE-TENOFOVIR ALAFENAMIDE ACETATE231 FUMARATE115 ELBASVIR-GRAZOPREVIR109 EMTRICITABINE-TENOFOVIR DISOPROXIL Elelyso216 FUMARATE112,113 Elepsia XR42 Emtriva112 Elestrin236 Enablex217 ELETRIPTAN HYDROBROMIDE70 ENALAPRIL MALEATE145,146 Elidel190 ENALAPRIL MALEATE & Eligard251 HYDROCHLOROTHIAZIDE155,158 ELIGLUSTAT TARTRATE216 ENASIDENIB MESYLATE76 Elimite83 EnBrace HR202 Eliquis134 Enbrel254 Eliquis DVT/PE Starter Pack134 Enbrel Mini254 Ella246 Enbrel SureClick254 Elmiron219 ENCORAFENIB78 Elocon223 Endari196 Eloctate139 ENFUVIRTIDE115

PAGE 311 LAST UPDATED 07/2021 Engerix-B260 ERTUGLIFLOZIN L-PYROGLUTAMIC ACID130 ENOXAPARIN SODIUM134,135,136 ERTUGLIFLOZIN-METFORMIN HCL129 Enstilar190 ERTUGLIFLOZIN-SITAGLIPTIN130 ENTACAPONE84 Erygel35 ENTECAVIR108 EryPed 20035 Entocort EC262 EryPed 40035 ENTRECTINIB76 Erythrocin Stearate35 Entresto155 ERYTHROMYCIN (ACNE AID)35,36 Entyvio254 ERYTHROMYCIN (OPHTH)36 Envarsus XR254 ERYTHROMYCIN BASE35,36 ENZALUTAMIDE74 ERYTHROMYCIN ETHYLSUCCINATE35,36 Epaned145 ERYTHROMYCIN STEARATE35 Epclusa109 Esbriet285 Epidiolex42 ESCITALOPRAM OXALATE54,55 Epiduo190 Esgic181 Epiduo Forte190 ESKETAMINE HCL53 EPINASTINE HCL (OPHTH)271 ESLICARBAZEPINE ACETATE48 EPINEPHrine281 ESOMEPRAZOLE MAGNESIUM213,214 EPINEPHRINE (ANAPHYLAXIS)281,282 ESOMEPRAZOLE STRONTIUM213 EpiPen 2-Pak282 Esomeprazole Strontium213 EpiPen Jr 2-Pak282 Esperoct139 Epivir113 ESTAZOLAM289 Epivir HBV108 ESTERIFIED ESTROGENS240 EPOETIN ALFA137,138 ESTERIFIED ESTROGENS & EPOETIN ALFA-EPBX138 METHYLTESTOSTERONE235,236 Epogen137 Estrace236 EPROSARTAN MESYLATE143 ESTRADIOL233,235,236,237,240,241,245 Eprosartan Mesylate143 ESTRADIOL & NORETHINDRONE EPTINEZUMAB-JJMR70 ACETATE233,235,237,240,241 Epzicom113 ESTRADIOL ACETATE VAGINAL238 Equetro124 ESTRADIOL CYPIONATE235 ERDAFITINIB75 ESTRADIOL VAGINAL236,237,245 ERENUMAB-AOOE69 ESTRADIOL VALERATE235,237 ERGOCALCIFEROL263,265 ESTRADIOL VALERATE-DIENOGEST241 Ergomar69 ESTRADIOL-LEVONORGESTREL235 ERGOTAMINE TARTRATE69 ESTRADIOL-NORGESTIMATE243 ERGOTAMINE W/ CAFFEINE69 ESTRADIOL-PROGESTERONE234 Erivedge79 ESTRAMUSTINE PHOSPHATE SODIUM74 Erleada73 Estring237 ERLOTINIB HCL79,81 Estrogel237 Ertaczo65 ESTROGENS, CONJUGATED243

PAGE 312 LAST UPDATED 07/2021 ESTROGENS, CONJUGATED VAGINAL243 Extavia184 ESTROPIPATE237 Extina65 Estropipate237 Eylea269 Estrostep Fe237 Eysuvis272 ESZOPICLONE289 Ezallor Sprinkle161 ETANERCEPT254 EZETIMIBE162,164 ETHAMBUTOL HCL72 EZETIMIBE-ROSUVASTATIN CALCIUM163 ETHOSUXIMIDE43 EZETIMIBE-SIMVASTATIN162,163 ETHOTOIN49 ETHYNODIOL DIACET & ETH ESTRAD237,239,245 F ETIDRONATE DISODIUM263 Fabior190 Etidronate Disodium263 FACTOR IX COMPLEX140 ETODOLAC6 FAMCICLOVIR118 ETONOGESTREL247 FAMOTIDINE210,211 ETONOGESTREL-ETHINYL ESTRADIOL236,237,242 FAMOTIDINE IN NACL211 ETOPOSIDE78 Famotidine Premixed211 Etoposide78 Fanapt94 ETRAVIRINE111 Fanapt Titration Pack94 Eucrisa190 Fareston74 Euflexxa266 Farxiga126 Eurax83 Farydak79 Evamist237 Fasenra286 Evekeo168 Fasenra Pen286 Evekeo ODT168 FazaClo106,107 Evenity264 FE ASPARTO GLY-FE FUMARATE-SUCC ACD-C- EVEROLIMUS78,79 THREONIC ACD-B12-FA197 EVEROLIMUS (IMMUNOSUPPRESSANT)254,259 FE ASPARTO GLY-SUCCIN AC-C-THREONIC AC- EVINACUMAB-DGNB162 B12-DES STOM SUBST197 Evista248 FE ASPARTO GLY-SUCCINIC ACD-VIT C- Evkeeza162 THREONIC ACD-VIT B12-FA197 Evoclin190 FE ASPARTO GLY-VIT B12-FA-VIT C-DSS- EVOLOCUMAB163 SUCCINIC ACID-ZINC196 Evotaz116 FE BISGLYC-FE POLYSACCHARIDE-SUCC ACD-B Exalgo10 COMPLEX-C-CA-FA197 Exelderm65 FE BISGLYCINATE-FE POLYSACCHARIDE-VIT C- Exelon50 VIT B12-FOLIC ACID198 EXEMESTANE78 FE CARBONYL-FA-B COMPLEX-A-C-D-E-MIN195 EXENATIDE125 FE CARBONYL-FE GLUCONATE-FA-VIT B12-VIT C- Exforge155 DOCUSATE SODIUM196 Exforge HCT156 FE FUM-IRON POLYSACCH COMPLEX-FA-B Exjade199 CMPLX-C-BIOTIN-PROBIOTIC196

PAGE 313 LAST UPDATED 07/2021 FE FUM-IRON POLYSACCH COMPLEX-FA-B FERROUS FUMARATE W/ B12-VIT C-FA-IFC202,206 COMPLEX-C-BIOTIN202,207 FERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT FE FUM-IRON POLYSACCH COMPLEX-FA-B C198 COMPLEX-C-ZN-MN-CU198 FERROUS FUMARATE-FA-B COMPLEX-C-ZN-MG- FE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC MN-CU196,200,202 ACID196,198 FERROUS FUMARATE-FOLIC ACID196 FEBUXOSTAT68 FERROUS FUMARATE-IRON POLYSACCHARIDE FEDRATINIB HCL76 COMPLEX-FA-C-PROBIOTIC196 Feiba139 FERROUS FUMARATE-IRON POLYSACCHARIDE FELBAMATE46 COMPLEX-FOLIC ACID-C-B3196,197 Felbatol46 FERUMOXYTOL196 Feldene6 FESOTERODINE FUMARATE218 FELODIPINE151 Fetzima54 Femara78 Fetzima Titration54 Femhrt238 Fexmid288 Femring238 Fiasp132 FENFLURAMINE HCL (ANTICONVULSANT)42 Fiasp FlexTouch132 FENOFIBRATE159,160 Fiasp PenFill132 FENOFIBRATE MICRONIZED159,160 Fibricor160 FENOFIBRIC ACID160 FIDAXOMICIN35 Fenofibric Acid160 FILGRASTIM137 Fenoglide160 FILGRASTIM-AAFI137 FENOPROFEN CALCIUM6,8 FILGRASTIM-SNDZ138 Fensolvi (6 Month)251 FINASTERIDE219 FENTANYL10,11,22 FINGOLIMOD HCL184 FENTANYL CITRATE14,15,17,19 Fintepla42 fentaNYL Citrate17 Fioricet181 FENTORA17 Fiorinal18 Fentora17 Fiorinal/Codeine #318 Feraheme196 Firazyr253 FeRiva 21/7196 Firvanq29 FeRivaFA196 Flagyl29 Ferralet 90196 Flarex272 FerraPlus 90196 FLAVOXATE HCL217 FERRIC CARBOXYMALTOSE197 FLECAINIDE ACETATE146 FERRIC CITRATE199 Flector6 FERRIC DERISOMALTOSE197 Flomax219 FERRIC PYROPHOSPHATE CITRATE199 Flovent Diskus277 Ferriprox199 Flovent HFA277 Ferriprox Twice-A-Day199 Fluad260 Ferrlecit196 Fluarix Quadrivalent260

PAGE 314 LAST UPDATED 07/2021 Flublok Quadrivalent260 Fluzone Quadrivalent260,261 Flucelvax Quadrivalent260 FML272 FLUCONAZOLE65 FML Forte272 FLUCYTOSINE64,65 FML Liquifilm272 FLUDROCORTISONE ACETATE223 Focalin173 Flulaval Quadrivalent260 Focalin XR173,174 Flumadine117 FOLIC ACID202 FLUNISOLIDE (NASAL)277 FOLIC ACID-PYRIDOXINE- FLUOCINOLONE ACETONIDE221,222,224,228 CYANOCOBALAMIN203,207 FLUOCINOLONE ACETONIDE & CLEANSER228 FOLIC ACID-VITAMIN B6-VITAMIN FLUOCINOLONE ACETONIDE (OPHTH)272,273 B12202,206,207,208 FLUOCINOLONE-EMOLLIENT228 FOLIC ACID-VITAMIN B6-VITAMIN B12-OMEGA 3 FLUOCINONIDE224,230 ACIDS-PHYTOSTEROLS200 FLUOCINONIDE EMULSIFIED BASE224 FOLIC ACID-VITAMIN D3-MAG CIT- FLUOROMETHOLONE (OPHTH)272 ACETYLCYSTEINE-CA CIT202 FLUOROMETHOLONE ACETATE272 Folite202 FLUOROURACIL (TOPICAL)74,75 Folivane-F196 FLUOXETINE HCL54,55,56 Folivane-OB202 FLUoxetine HCl54 Folivane-Plus202 FLUOXETINE HCL (PMDD)55,56 Foltrate202 FLUoxetine HCl (PMDD)55 FONDAPARINUX SODIUM134,135 FLUPHENAZINE DECANOATE88 Forfivo XL52 FLUPHENAZINE HCL88,89 FORMOTEROL FUMARATE282 FLURANDRENOLIDE222,224 Fortamet126 FLURAZEPAM HCL289 Forteo264 Flurazepam HCl289 Fortesta232 FLURBIPROFEN6 Fosamax264 FLURBIPROFEN SODIUM272 Fosamax Plus D264 FLUTAMIDE73 FOSAMPRENAVIR CALCIUM116 FLUTICASONE FUROATE (INHALATION)276 FOSAPREPITANT DIMEGLUMINE62,63 FLUTICASONE FUROATE-VILANTEROL285 Fosaprepitant Dimeglumine63 FLUTICASONE PROPIONATE220,222,224 FOSFOMYCIN TROMETHAMINE29,30 FLUTICASONE PROPIONATE (INHALATION)276,277 FOSINOPRIL SODIUM145 FLUTICASONE PROPIONATE (NASAL)277,278 FOSINOPRIL SODIUM & FLUTICASONE PROPIONATE HFA277 HYDROCHLOROTHIAZIDE156 FLUTICASONE-EMOLLIENT220 FOSNETUPITANT CHORIDE-PALONOSETRON FLUTICASONE-SALMETEROL285,286,287 HCL62 FLUTICASONE-UMECLIDINIUM-VILANTEROL287 Fosrenol199 FLUVASTATIN SODIUM161 FOSTAMATINIB DISODIUM138 FLUVOXAMINE MALEATE55 FOSTEMSAVIR TROMETHAMINE115 Fluzone High-Dose260 Fotivda75

PAGE 315 LAST UPDATED 07/2021 Fragmin135 Genotropin230 FreeStyle Libre 14 Day Reader266 Genotropin MiniQuick230 FreeStyle Libre 14 Day Sensor267 GENTAMICIN SULFATE (OPHTH)27 FreeStyle Libre 2 Reader267 GENTAMICIN SULFATE (TOPICAL)27 FreeStyle Libre 2 Sensor267 GENTAMICIN-PREDNISOLONE ACETATE270 FreeStyle Libre Reader267 GenVisc 850267 FreeStyle Libre Sensor System267 Genvoya110 FREMANEZUMAB-VFRM69 Geodon94,95 Frova70 Giazo262 FROVATRIPTAN SUCCINATE70 Gilenya184 Fulphila137 Gilotrif79 Furadantin29 GILTERITINIB FUMARATE77 FUROSEMIDE158 Gimoti60 Fusion Plus196 GLASDEGIB MALEATE79 Fusion Sprinkles196 GLATIRAMER ACETATE183,184 Fuzeon115 GLECAPREVIR-PIBRENTASVIR109 Fycompa46 Gleevec79 GLIMEPIRIDE125,126 G GLIPIZIDE126,127 Gabapal44 GLIPIZIDE-METFORMIN HCL126 GABAPENTIN44,45 Gloperba68 GABAPENTIN & LIDOCAINE45 GlucaGen Diagnostic131 GABAPENTIN & LIDOCAINE-PRILOCAINE & GlucaGen HypoKit131 TRANSPARENT DRESSING44 GLUCAGON131 GABAPENTIN (ONCE-DAILY)44 GLUCAGON (RDNA)131 GABAPENTIN ENACARBIL181 Glucagon Emergency131 GABAPENTIN-LIDOCAINE-SILICONE44 GLUCAGON HCL (RDNA)131 Gabitril44 GLUCAGON HCL RDNA (DIAGNOSTIC)131 GALANTAMINE HYDROBROMIDE50 Glucophage126 GALCANEZUMAB-GNLM69 Glucophage XR126,127 GATIFLOXACIN (OPHTH)37,38 Glucotrol127 Gavreto79 Glucotrol XL127 GEFITINIB79 Glumetza127 Gel-One267 GLUTAMINE (SICKLE CELL)196 Gelnique217 GLYBURIDE127 Gelnique Pump217 GLYBURIDE MICRONIZED127 Gelsyn-3267 GLYBURIDE-METFORMIN127 GEMFIBROZIL160 GLYCEROL PHENYLBUTYRATE217 Gemtesa217 GLYCOPYRROLATE209 GEN7T PLUS23 GLYCOPYRROLATE (INHALATION)280,281 Generess FE238 GLYCOPYRROLATE-FORMOTEROL FUMARATE285

PAGE 316 LAST UPDATED 07/2021 Glynase127 Hemady224 Glyset127 Hemangeol76 Glyxambi127 Hematogen FA196 Gocovri84 HemeTab196 GOLIMUMAB258 Hemlibra139 Golytely212 Hemocyte Plus202 GoNitro164 Hemofil M139 GOSERELIN ACETATE77 HEPARIN SODIUM (PORCINE)135 Gralise44 HEPARIN SODIUM (PORCINE) LOCK FLUSH135 GRANISETRON63,64 HEPATITIS A (INACTIVATED)-HEPATITIS B GRANISETRON HCL63 (RECOMBINANT) VACCINES261 Granix137 HEPATITIS A VACCINE261 GRISEOFULVIN MICROSIZE65 HEPATITIS B VACCINE (RECOMB)260,261 GRISEOFULVIN ULTRAMICROSIZE65 Hepsera108 GUANFACINE HCL142 Hetlioz290 GUANFACINE HCL (ADHD)174,175 Hetlioz LQ290 GUSELKUMAB258 Hiprex29 Gvoke HypoPen 1-Pack131 HISTRELIN ACETATE252 Gvoke HypoPen 2-Pack131 HISTRELIN ACETATE (CPP)252 Gvoke PFS131 Horizant181 Gynazole-165 HumaLOG132 HumaLOG Junior KwikPen132 H HumaLOG KwikPen132 Haegarda253 HumaLOG Mix 50/50132 HALCINONIDE224 HumaLOG Mix 50/50 KwikPen132 Halcion289 HumaLOG Mix 75/25132 Haldol89 HumaLOG Mix 75/25 KwikPen132 Haldol Decanoate89 Humate-P139 HALOBETASOL PROPIONATE221,224,225,229,230 Humatin27 Halobetasol Propionate224 Humatrope230 HALOBETASOL PROPIONATE & LACTIC ACID230 Humira254,255 HALOBETASOL PROPIONATE-TAZAROTENE189 Humira Pediatric Crohns Start255 Halog224 Humira Pen255 HALOPERIDOL89,90 Humira Pen-CD/UC/HS Starter255 HALOPERIDOL DECANOATE89,90 Humira Pen-Pediatric UC Start255 HALOPERIDOL LACTATE89,90 Humira Pen-Ps/UV/Adol HS Start255 Harvoni109 Humira Pen-Psor/Uveit Starter255 Havrix261 HumuLIN R U-500 (CONCENTRATED)132 Hectorol264 HumuLIN R U-500 KwikPen132 Helidac Therapy209 Hyalgan267 Helixate FS139 HYALURONAN267,268

PAGE 317 LAST UPDATED 07/2021 HYDRALAZINE HCL164 IBANDRONATE SODIUM263,264 Hydrea75 Ibrance79 HYDROCHLOROTHIAZIDE159 IBRUTINIB79 HYDROCODONE BITARTRATE11,14 Ibudone19 HYDROCODONE-ACETAMINOPHEN18,19,20,23 IBUPROFEN6,7 HYDROCODONE-IBUPROFEN18,19 IBUPROFEN-FAMOTIDINE6 Hydrocodone-Ibuprofen18 ICATIBANT ACETATE253 HYDROCORTISONE220,222,224,225 Iclusig79 HYDROCORTISONE (INTRARECTAL)262 ICOSAPENT ETHYL162,163 HYDROCORTISONE (RECTAL)190,191,225,228 IDELALISIB82 HYDROCORTISONE (TOPICAL)220,224,225,229 Idelvion139 HYDROCORTISONE ACETATE (TOPICAL)191 IDHIFA76 HYDROCORTISONE ACETATE W/ PRAMOXINE191 Ilaris255,259 HYDROCORTISONE BUTYRATE225 Ilevro272 Hydrocortisone Butyrate225 ILOPERIDONE94 HYDROCORTISONE BUTYRATE HYDROPHILIC ILOPROST285 LIPO BASE225 Ilumya190 HYDROCORTISONE PROBUTATE226 Iluvien272 HYDROCORTISONE SOD SUCCINATE228 IMATINIB MESYLATE79 HYDROCORTISONE VALERATE225 Imbruvica79 HYDROCORTISONE W/ACETIC ACID275,276 IMIGLUCERASE216 HYDROMORPHONE HCL10,11,16,19 IMIPRAMINE HCL58,59 HYDROmorphone HCl19 IMIPRAMINE PAMOATE59 HYDROXYCHLOROQUINE SULFATE83 IMIQUIMOD187,190,195 HYDROXYPROGESTERONE CAPROATE246,247 Imitrex70 HYDROXYprogesterone Caproate246 Imitrex STATdose Refill70 HYDROXYPROGESTERONE CAPROATE Imitrex STATdose System70 (ANTINEOPLASTIC)246 Impeklo225 HYDROXYUREA75 Imuran255 HYDROXYUREA (SICKLE CELL ANEMIA)74,75 Inbrija87 HYDROXYZINE HCL278 INCOBOTULINUMTOXINA108 HYDROXYZINE PAMOATE278,279 Incruse Ellipta280 HYLAN268 INDACATEROL MALEATE281 Hymovis267 INDACATEROL MALEATE-GLYCOPYRROLATE287 Hyophen29 INDAPAMIDE159 HyperRHO S/D259 Inderal LA148 Hysingla ER11 Inderal XL148 Hyzaar156 INDINAVIR SULFATE116 Indocin7 I INDOMETHACIN7,9 IBALIZUMAB-UIYK115 Indomethacin7

PAGE 318 LAST UPDATED 07/2021 Infed197 INSULIN GLULISINE132 INFIGRATINIB PHOSPHATE77 INSULIN LISPRO131,132,133 Inflectra256 Insulin Lispro133 INFLIXIMAB258 Insulin Lispro (1 Unit Dial)133 INFLIXIMAB-ABDA258 Insulin Lispro Junior KwikPen133 INFLIXIMAB-AXXQ253 Insulin Lispro Prot & Lispro133 INFLIXIMAB-DYYB256 INSULIN LISPRO PROTAMINE & LISPRO132,133 INFLUENZA VIRUS VAC RECOMB INSULIN LISPRO-AABC133 HEMAGGLUTININ (HA) QUADRIVALENT260 INSULIN REGULAR (HUMAN)131,132 INFLUENZA VIRUS VACCINE SPLIT260 Integra F197 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE Integra Plus202 PRESERVATIVE FREE260 Intelence111 INFLUENZA VIRUS VACCINE SPLIT INTERFERON BETA-1A183,185 PRESERVATIVE FREE260 INTERFERON BETA-1B183,184 INFLUENZA VIRUS VACCINE SPLIT Intermezzo289 QUADRIVALENT260,261 Intuniv174,175 INFLUENZA VIRUS VACCINE TISSUE-CULTURED Invega95 SUBUNIT QUADRIVALENT260 Invega Sustenna95,96 INFLUENZA VIRUS VACCINE TYPES A & B Invega Trinza96 SURFACE ANTIGEN ADJUVANT260 Inveltys272 Ingrezza181 Invirase116 Injectafer197 Invokamet127 Inlyta79 Invokamet XR127 InnoPran XL148 Invokana127 InnoSpire Essence Nebulizer267 IODOQUINOL-HC189,190 Inqovi76 IODOQUINOL-HYDROCORTISONE-ALOE Inrebic76 POLYSACCHARIDE187,190 Insulin Asp Prot & Asp FlexPen132 Iopidine274 INSULIN ASPART133,134 IPRATROPIUM BROMIDE280 Insulin Aspart133 IPRATROPIUM BROMIDE (NASAL)280 INSULIN ASPART (WITH NIACINAMIDE)132 IPRATROPIUM BROMIDE HFA280 Insulin Aspart FlexPen133 IPRATROPIUM-ALBUTEROL286 Insulin Aspart PenFill133 IRBESARTAN143,144 Insulin Aspart Prot & Aspart133 IRBESARTAN-HYDROCHLOROTHIAZIDE154,156 INSULIN ASPART PROTAMINE & ASPART Iressa79 (HUMAN)132,133 IRON COMBINATIONS201,202,203 INSULIN DEGLUDEC134 IRON DEXTRAN197 INSULIN DEGLUDEC-LIRAGLUTIDE134 IRON POLYSACCHARIDE COMPLEX-VIT B12-FOLIC INSULIN DETEMIR133 ACID197,198 INSULIN GLARGINE132,133,134 IRON SUCROSE198 INSULIN GLARGINE-LIXISENATIDE134 IRON W/ VITAMINS207

PAGE 319 LAST UPDATED 07/2021 IRON-DOCUSATE-B12-FOLIC ACID-VIT C-VIT E- Januvia128 COPPER-BIOTIN198 Jardiance128 IRON-FOLIC ACID-VITAMIN B12-VITAMIN C- Jatenzo232 DOCUSATE SODIUM196 Jentadueto128 IRON-FOLIC ACID-VITAMIN C-VITAMIN B6-VITAMIN Jentadueto XR128 B12-ZINC195 Jivi139 IRON-VIT C-FA-B12-BIOTIN-COPPER- Jornay PM175 DOCUSATE196 Jublia66 Irospan 24/6197 Juluca115 ISAVUCONAZONIUM SULFATE65 Juxtapid162 Isentress110 Isentress HD110 K ISOCARBOXAZID53 Kadian11,12 ISONIAZID72 Kalbitor253 Isopto Atropine269 Kaletra116 Isopto Carpine274 Kapspargo Sprinkle148 Isordil Titradose164 Kapvay175 ISOSORBIDE DINITRATE164 Katerzia151 ISOSORBIDE DINITRATE-HYDRALAZINE HCL154 Kazano128 ISOSORBIDE MONONITRATE164 Keflex33 ISOTRETINOIN186,187,188,190,191,195 Kenalog225 ISOTRETINOIN MICRONIZED186 Keppra42 ISRADIPINE151 Keppra XR42 Istalol274 Kerydin66 ISTRADEFYLLINE84 Kesimpta184 ITRACONAZOLE66,67,68 KETOCONAZOLE66 IVERMECTIN82 KETOCONAZOLE (TOPICAL)65,66 Ivermectin82 KETOPROFEN7 IVERMECTIN (PEDICULICIDE)82 Ketoprofen7 IVOSIDENIB77 KETOROLAC TROMETHAMINE7,9 IXAZOMIB CITRATE76 Ketorolac Tromethamine7 IXEKIZUMAB194 KETOROLAC TROMETHAMINE (OPHTH)271,272 Ixinity139 Kevzara256 Khedezla55 J Kineret256 Jadenu199 Kisqali (200 MG Dose)79 Jadenu Sprinkle199 Kisqali (400 MG Dose)80 Jakafi79 Kisqali (600 MG Dose)80 Jalyn219 Kisqali Femara (400 MG Dose)80 Janumet127 Kisqali Femara (600 MG Dose)80 Janumet XR127,128 Kisqali Femara(200 MG Dose)80

PAGE 320 LAST UPDATED 07/2021 Kitabis Pak286 LATANOPROSTENE BUNOD275 Klaron38 Latuda96,97 KlonoPIN123 Lazanda19 Koate139 LEDIPASVIR-SOFOSBUVIR109 Koate-DVI140 Ledipasvir-Sofosbuvir109 Kogenate FS140 LEFLUNOMIDE259 Kogenate FS Bio-Set140 LEMBOREXANT290 Kombiglyze XR128 Lemtrada184 Koselugo80 LENALIDOMIDE74 Kovaltry140 LENVATINIB MESYLATE80 Krintafel83 Lenvima (10 MG Daily Dose)80 Krystexxa68 Lenvima (12 MG Daily Dose)80 Kyleena246 Lenvima (14 MG Daily Dose)80 Kynmobi85 Lenvima (18 MG Daily Dose)80 Lenvima (20 MG Daily Dose)80 L Lenvima (24 MG Daily Dose)80 LABETALOL HCL148 Lenvima (4 MG Daily Dose)80 LACOSAMIDE49,50 Lenvima (8 MG Daily Dose)80 LACTIC ACID (AMMONIUM LACTATE)187 Lescol XL161 LACTULOSE212 LESINURAD68 LACTULOSE (ENCEPHALOPATHY)212 LESINURAD-ALLOPURINOL68 LaMICtal46 Letairis284 LaMICtal ODT46 LETERMOVIR108 LaMICtal Starter46 LETROZOLE78 LaMICtal XR46 LEUCOVORIN CALCIUM76 LAMIVUDINE113 Leukeran73 LAMIVUDINE (HBV)108 Leukine137 LAMIVUDINE-TENOFOVIR DISOPROXIL LEUPROLIDE ACETATE251 FUMARATE112,113 LEUPROLIDE ACETATE & NORETHINDRONE LAMIVUDINE-ZIDOVUDINE112,113 ACETATE251 LAMOTRIGINE46,47 LEUPROLIDE ACETATE (3 MONTH)251 LANADELUMAB-FLYO253 LEUPROLIDE ACETATE (4 MONTH)251 LANSOPRAZOLE214,215 LEUPROLIDE ACETATE (6 MONTH)251,252 LANTHANUM CARBONATE199,200 LEUPROLIDE ACETATE (CPP)252 Lantus133 LEUPROLIDE ACETATE (CPP) (3 MONTH)252 Lantus SoloStar133 LEUPROLIDE ACETATE (CPP) (6 MONTH)251 LAPATINIB DITOSYLATE80,82 LEVALBUTEROL HCL282,283 LAROTRECTINIB SULFATE77 LEVALBUTEROL TARTRATE282,283 LASMIDITAN SUCCINATE70,71 LEVAMLODIPINE MALEATE150 Lastacaft271 Levaquin37 LATANOPROST275 Levemir133

PAGE 321 LAST UPDATED 07/2021 Levemir FlexTouch133 Lidocaine-Tetracaine24 LEVETIRACETAM42,43 Lidoderm24 LEVOBUNOLOL HCL274 Lidotin44 LEVOCARNITINE (METABOLIC MODIFIERS)197 Lidotral24 LEVOCETIRIZINE DIHYDROCHLORIDE279 LifEMS Naloxone26 LEVODOPA87 LIFITEGRAST270 LEVOFLOXACIN37,38 Liletta (52 MG)247 LEVOFLOXACIN (OPHTH)38 LINACLOTIDE211,212 LEVOMILNACIPRAN HCL54 LINAGLIPTIN130 LEVONORGESTREL & ETH LINAGLIPTIN-METFORMIN HCL128 ESTRADIOL233,234,235,237,239,240,242,243,244,24 LINDANE83 5 Linzess211,212 LEVONORGESTREL (IUD)246,247,248 LIOTHYRONINE SODIUM248,250,251 LEVONORGESTREL-ETH ESTRADIOL Lipitor161 (TRIPHASIC)236,239,241,245 Lipofen160 LEVONORGESTREL-ETHINYL ESTRADIOL245 Lipritin44 LEVONORGESTREL-ETHINYL ESTRADIOL (91- LIRAGLUTIDE130 DAY)233,234,235,238,239,240,243,244 LISDEXAMFETAMINE DIMESYLATE169,170 LEVONORGESTREL-ETHINYL ESTRADIOL LISINOPRIL145,146 (CONTINUOUS)233,235,239 LISINOPRIL & HYDROCHLOROTHIAZIDE156,158 LEVONORGESTREL-ETHINYL ESTRADIOL- LITHIUM CARBONATE124 FERROUS BISGLYCINATE234 Livalo161 LEVORPHANOL TARTRATE19 LIXISENATIDE125 LEVOTHYROXINE SODIUM248,249,250,251 Lo Loestrin Fe240 Levothyroxine Sodium249 Locoid225 Lexapro55 Locoid Lipocream225 Lexette225 Lodosyn87 Lexiva116 LODOXAMIDE TROMETHAMINE271 Lialda262 LOFEXIDINE HCL26 Licart7 Lokelma267 LIDOCAINE23,24,25 LOMITAPIDE MESYLATE162 LIDOCAINE HCL23,24,25 Lonhala Magnair Refill Kit280 Lidocaine HCl24 Lonhala Magnair Starter Kit280 LIDOCAINE HCL (LOCAL ANESTH.)24 Lonsurf76 LIDOCAINE HCL (MOUTH-THROAT)24 LOPERAMIDE HCL209 LIDOCAINE-LATEX ADHESIVE WRAP23 Lopid160 LIDOCAINE-MENTHOL23 LOPINAVIR-RITONAVIR116 LIDOCAINE-PRILOCAINE23,24,25 Lopressor148 LIDOCAINE-PRILOCAINE-TRANSPARENT Loprox66 DRESSING23,25 LORAZEPAM120,123 LIDOCAINE-TETRACAINE24,25 Lorbrena80

PAGE 322 LAST UPDATED 07/2021 LORLATINIB80 Lynparza80 Lortab19 Lyrica182 LOSARTAN POTASSIUM143,144 Lyrica CR182 LOSARTAN POTASSIUM & Lysodren76 HYDROCHLOROTHIAZIDE156 Lyumjev133 LoSeasonique240 Lyumjev KwikPen133 Lotemax272 Lotemax SM272 M Lotensin145 M-Natal Plus202 Lotensin HCT156 MACITENTAN284 LOTEPREDNOL ETABONATE271,272 Macrobid29 LOTEPREDNOL ETABONATE-TOBRAMYCIN270 Macrodantin29 Lotrel156 Macugen269 Lotrisone191 Makena247 Lotronex212 Malarone83 LOVASTATIN161 MALATHION84 Lovaza162 MAPROTILINE HCL55 Lovenox135,136 MARAVIROC115 LOXAPINE88 Marinol63 LOXAPINE SUCCINATE90,91 Marplan53 LUBIPROSTONE211,212 Mavenclad (10 Tabs)184 Lucemyra26 Mavenclad (4 Tabs)184 Lucentis269 Mavenclad (5 Tabs)184 LULICONAZOLE66 Mavenclad (6 Tabs)184 Luliconazole66 Mavenclad (7 Tabs)184 Lumakras76 Mavenclad (8 Tabs)184 LUMATEPERONE TOSYLATE94 Mavenclad (9 Tabs)184 Lumigan275 Mavyret109 Lunesta289 Maxalt70 Lupaneta Pack251 Maxalt-MLT70 Lupkynis256 Maxidex272 Lupron Depot (1-Month)251 Maxitrol269 Lupron Depot (3-Month)251 Mayzent184,185 Lupron Depot (4-Month)251 Mayzent Starter Pack185 Lupron Depot (6-Month)252 MECLIZINE HCL60 Lupron Depot-Ped (1-Month)252 MECLOFENAMATE SODIUM7 Lupron Depot-Ped (3-Month)252 Medrol225,226 LURASIDONE HCL96,97 MEDROXYPROGESTERONE ACETATE247,248 LUSUTROMBOPAG141 MEDROXYPROGESTERONE ACETATE Luxiq191 (ANTINEOPLASTIC)246 Luzu66

PAGE 323 LAST UPDATED 07/2021 MEDROXYPROGESTERONE ACETATE METHOTREXATE258 (CONTRACEPTIVE)246,247 METHOTREXATE (ANTIRHEUMATIC)257,258 MEFENAMIC ACID7 METHOTREXATE SODIUM256,258 MEFLOQUINE HCL83 METHOXSALEN RAPID191 MEGESTROL ACETATE247 Methoxsalen Rapid191 Mekinist80 METHOXY POLYETHYLENE GLYCOL-EPOETIN Mektovi80 BETA137 MELOXICAM7,8,9 METHSUXIMIDE43 MELPHALAN73 METHYCLOTHIAZIDE159 MEMANTINE HCL51 METHYLDOPA142 MEMANTINE HCL-DONEPEZIL HCL50 Methyldopa142 Menest240 METHYLDOPA & HYDROCHLOROTHIAZIDE156 Menostar240 Methylin175 Mentax66 METHYLNALTREXONE BROMIDE210 MEPERIDINE HCL16,19,20 METHYLPHENIDATE172 Meperidine HCl19,20 METHYLPHENIDATE MEPOLIZUMAB286 HCL171,172,175,176,177,178,179 MEPROBAMATE119 Methylphenidate HCl ER177 MERCAPTOPURINE75 METHYLPREDNISOLONE225,226 MESALAMINE261,262 METHYLPREDNISOLONE ACETATE222,226 MESALAMINE W/ CLEANSER262 METHYLPREDNISOLONE SOD SUCC226,228 METAPROTERENOL SULFATE282 METHYLTESTOSTERONE232,233 Metaproterenol Sulfate282 METOCLOPRAMIDE HCL60,61 METAXALONE288 Metoclopramide HCl60 METFORMIN HCL126,127,128,129 METOLAZONE159 METHADONE HCL10,12 METOPROLOL & HYDROCHLOROTHIAZIDE156 Methadose12 METOPROLOL SUCCINATE148,149 Methadose Sugar-Free12 METOPROLOL TARTRATE148 METHAMPHETAMINE HCL167,169 MetroGel-Vaginal29 METHAZOLAMIDE274 METRONIDAZOLE29,30 METHENAMINE HIPPURATE29 METRONIDAZOLE (TOPICAL)191,192 METHENAMINE MANDELATE29 METRONIDAZOLE VAGINAL29,30,31 METHENAMINE-HYOSC-METHYLENE BLUE- METRONIDAZOLE-TETRACYCLINE W/ BISMUTH BENZOIC ACID-PHENYL SAL29 SUBSALICYLATE209 METHENAMINE-HYOSC-METHYLENE BLUE-SOD MEXILETINE HCL146 PHOS-PHENYL SAL30,31 Miacalcin264 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- Micardis144 SODIUM PHOSPHATE29,30 Micardis HCT156 METHIMAZOLE252 MICONAZOLE (MOUTH-THROAT)67 Methitest232 Miconazole 366 METHOCARBAMOL288 MICONAZOLE NITRATE VAGINAL66

PAGE 324 LAST UPDATED 07/2021 Miconazole-Zinc Oxide-Petrolat66 MOMETASONE FUROATE (INHALATION)276 MICONAZOLE-ZINC OXIDE-WHITE MOMETASONE FUROATE (NASAL)277,278 PETROLATUM66,68 MOMETASONE FUROATE-FORMOTEROL MiCort-HC191 FUMARATE DIHYDRATE286 MIDAZOLAM (ANTICONVULSANT)43 Monoclate-P140 MIDAZOLAM HCL24 Monoferric197 MIDODRINE HCL142 Monoject Hypodermic Needle267 MIDOSTAURIN76 Monoject Magellan Safety Ndl267 Migergot69 Monoject Magellan Syringe267 MIGLITOL127,128 Monoject Syringe267 MIGLUSTAT216,217 MONOMETHYL FUMARATE183 Migranal69 Mononine140 Millipred226 Monovisc267 Millipred DP226 MONTELUKAST SODIUM280 MILNACIPRAN HCL183 Monurol30 Minastrin 24 Fe241 Morgidox41 Minipress143 MorphaBond ER12 Minivelle241 MORPHINE SULFATE9,11,12,13,20 Minocin40 Morphine Sulfate20 MINOCYCLINE HCL40,41 MORPHINE SULFATE BEADS13 Minocycline HCl ER40,41 Morphine Sulfate ER Beads13 MINOCYCLINE HCL MICRONIZED (ACNE)39 Motegrity209 Minolira41 Movantik209 MINOXIDIL164 MoviPrep212 MIRABEGRON218 Moxatag34 Mirapex85 Moxeza38 Mirapex ER85 MOXIFLOXACIN HCL37,38 Mircera137 MOXIFLOXACIN HCL (OPHTH)38 Mircette241 MS Contin13 Mirena (52 MG)247 Mulpleta141 MIRTAZAPINE52,53 Multigen197 MISOPROSTOL213 Multigen Folic197 Mitigare68 Multigen Plus197 MITOTANE76 MULTIPLE VITAMINS W/ MINERALS201,203,207,208 Mobic7 MULTIPLE VITAMINS W/ MINERALS & FOLIC MODAFINIL290 ACID206 Moderiba (1200 MG Pack)109 Multivitamin/Fluoride202,203 MOEXIPRIL HCL145 MUPIROCIN28,30 MOEXIPRIL-HYDROCHLOROTHIAZIDE156 MUPIROCIN CALCIUM (TOPICAL)30 MOLINDONE HCL91 MYCOPHENOLATE MOFETIL253,256 MOMETASONE FUROATE223,226 MYCOPHENOLATE SODIUM256

PAGE 325 LAST UPDATED 07/2021 Mydayis169 NATAMYCIN66 Myfembree230 Natazia241 Myfortic256 NATEGLINIDE128,130 Myleran73 Natesto232 Myobloc288 Natroba82 Myrbetriq218 Nayzilam43 Mysoline44 NEBIVOLOL HCL147 NEBULIZERS266,267,268 N NEDOCROMIL SODIUM (OPHTH)270 NABILONE62 NEEDLE (DISP) 18 G267 NABUMETONE7,8 NEFAZODONE HCL55,56 NADOLOL148 NELFINAVIR MESYLATE117 NADOLOL & BENDROFLUMETHIAZIDE155,156 Neo-Synalar191 Nadolol-Bendroflumethiazide156 NEOMYCIN SULFATE27 NAFARELIN ACETATE252 NEOMYCIN SULFATE-FLUOCINOLONE NAFTIFINE HCL66 ACETONIDE191 Naftin66 NEOMYCIN-BACITRACIN ZN-POLYMYXIN269 NALDEMEDINE TOSYLATE210 NEOMYCIN-COLISTIN-HC-THONZONIUM276 Nalfon8 NEOMYCIN-FLUOCINOLONE & EMOLLIENT191 Nalocet20 NEOMYCIN-POLYMY-DEXAMETH269 NALOXEGOL OXALATE209 NEOMYCIN-POLYMYXIN-GRAMICIDIN270 NALOXONE HCL26,27 NEOMYCIN-POLYMYXIN-HC189 Naloxone HCl26 NEOMYCIN-POLYMYXIN-HC (OPHTH)270 NALTREXONE25 NEOMYCIN-POLYMYXIN-HC (OTIC)276 NALTREXONE HCL25 Neoral256 Namenda51 NEPAFENAC272,273 Namenda Titration Pak51 Nephron FA198 Namenda XR51 NERATINIB MALEATE80 Namenda XR Titration Pack51 Nerlynx80 Namzaric50 Nesina129 Naprelan8 Nestabs203 NAPROXEN6,8 Nestabs DHA203 NAPROXEN SODIUM8 Nestabs One203 Naproxen Sodium ER8 NETARSUDIL DIMESYLATE274 NAPROXEN-ESOMEPRAZOLE MAGNESIUM8,9 NETARSUDIL DIMESYLATE-LATANOPROST274 NARATRIPTAN HCL70 NETUPITANT-PALONOSETRON62 Narcan27 Neuac191 Nardil53 Neulasta137 Nasonex277 Neulasta Onpro137 Natacyn66 Neupogen137 NATALIZUMAB185 Neupro85

PAGE 326 LAST UPDATED 07/2021 Neurontin45 NORELGESTROMIN-ETHINYL ESTRADIOL245 Nevanac273 NORETHIN ACET & ESTRAD- NEVIRAPINE111,112 FE234,235,238,239,240,241,242,244 NexAVAR81 NORETHINDRONE & ETH NexIUM214 ESTRADIOL233,234,235,241,242,243,245 Nexletol156 NORETHINDRONE & ETHINYL ESTRADIOL- Nexlizet163 FE238,239,241,242,245 Nexplanon247 NORETHINDRONE (CONTRACEPTIVE)246,247,248 Nextstellis241 NORETHINDRONE ACET & ETH NIACIN (ANTIHYPERLIPIDEMIC)163 ESTRA234,238,239,240,242 Niacor163 NORETHINDRONE ACETATE246,247 Niaspan163 NORETHINDRONE ACETATE-ETHINYL NICARDIPINE HCL151 ESTRADIOL238,242 NICOTINE27 NORETHINDRONE ACETATE-ETHINYL Nicotrol27 ESTRADIOL-FE237,244 Nicotrol NS27 NORETHINDRONE ACETATE-ETHINYL NIFEDIPINE149,152 ESTRADIOL-FE FUM (BIPHASIC)240 Niferex203 NORETHINDRONE-ETH ESTRADIOL NILOTINIB HCL81 (TRIPHASIC)233,234,235,239,241,242,243 NIMODIPINE152 Norgesic Forte288 Ninlaro76 NORGESTIMATE-ETHINYL NINTEDANIB ESYLATE285 ESTRADIOL236,238,241,242,243,244,245 NIRAPARIB TOSYLATE82 NORGESTIMATE-ETHINYL ESTRADIOL NISOLDIPINE152 (TRIPHASIC)242,244 NITAZOXANIDE82,83 NORGESTREL & ETHINYL Nitro-Bid164 ESTRADIOL235,236,240,242 Nitro-Dur165 Norpramin59 NITROFURANTOIN29,30 NORTRIPTYLINE HCL59 NITROFURANTOIN MACROCRYSTAL29,30 Norvasc152 NITROFURANTOIN MONOHYD MACRO29,30 Norvir116 NITROGLYCERIN164,165 Nourianz84 Nitrolingual165 Novoeight140 NitroMist165 NovoLOG133 Nitrostat165 NovoLOG FlexPen133 Niva-Plus203 NovoLOG Mix 70/30133 Nivestym137 NovoLOG Mix 70/30 FlexPen133 NIZATIDINE211 NovoLOG PenFill134 Nizatidine211 NovoSeven RT140 Nizoral66 Noxafil67 Norco20 Nplate137 Norditropin FlexPro230 Nubeqa73

PAGE 327 LAST UPDATED 07/2021 Nucala286 OLANZAPINE97,98,104,105 Nucynta20 OLANZAPINE PAMOATE105 Nucynta ER13 OLANZAPINE-FLUOXETINE HCL52,53 NuFera203 OLAPARIB80 Nuplazid97 OLMESARTAN MEDOXOMIL143,144 Nurtec69 OLMESARTAN MEDOXOMIL-AMLODIPINE- Nutropin AQ NuSpin 10230 HYDROCHLOROTHIAZIDE157 Nutropin AQ NuSpin 20230 OLMESARTAN MEDOXOMIL- Nutropin AQ NuSpin 5230 HYDROCHLOROTHIAZIDE154,157 NuvaRing242 OLODATEROL HCL282 Nuvessa30 OLOPATADINE HCL271 Nuvigil290 OLOPATADINE HCL (NASAL)279 Nuwiq140 OLSALAZINE SODIUM262 Nuzyra41 Olumiant256 Nymalize152 Olux226 NYSTATIN67 Olux-E226 NYSTATIN (MOUTH-THROAT)67 OMADACYCLINE TOSYLATE41 NYSTATIN (TOPICAL)67 OMALIZUMAB287 NYSTATIN-TRIAMCINOLONE67 OMBITASVIR-PARITAPREVIR-RITONAVIR- Nyvepria138 DASABUVIR109 Omeclamox-Pak209 O OMEGA-3-ACID ETHYL ESTERS162,163 O-Cal FA203 OMEPRAZOLE215 O-Cal Prenatal203 OMEPRAZOLE MAGNESIUM215 OB Complete203 OMEPRAZOLE-SODIUM BICARBONATE215,216 OB Complete One203 Omnaris277 OB Complete Petite203 Omnipred273 OB Complete Premier203 Omnitrope230 OB Complete/DHA203 ONABOTULINUMTOXINA107 OBETICHOLIC ACID216 ONDANSETRON63,64 Obizur140 ONDANSETRON HCL63,64 Ocaliva216 Onexton191 OCRELIZUMAB185 Onfi45 Ocrevus185 Ongentys84 Ocuflox38 Onglyza129 Odefsey111 Onmel67 Odomzo81 Onzetra Xsail70 OFATUMUMAB (MS)184 Opana20 Ofev285 Opana ER13 OFLOXACIN38 OPICAPONE84 OFLOXACIN (OPHTH)38 Opsumit284

PAGE 328 LAST UPDATED 07/2021 OptiChamber Diamond268 Oxistat67 OptiChamber Diamond-Lg Mask268 Oxsoralen Ultra191 OptiChamber Diamond-Md Mask268 Oxtellar XR49 OptiChamber Diamond-Sm Mask268 OXYBUTYNIN218 Oracea41 OXYBUTYNIN CHLORIDE217,218 Oracit219 OXYCODONE14 Orapred ODT226 OXYCODONE HCL13,20,21,22 Oravig67 oxyCODONE HCl ER13 Orencia256 OXYCODONE W/ ACETAMINOPHEN17,20,21,22 Orencia ClickJect256 oxyCODONE-Acetaminophen21 Orenitram284 OXYCODONE-ASPIRIN21 Orgovyx252 OXYCODONE-IBUPROFEN21 Oriahnn231 OxyCONTIN13 Orilissa252 OXYMETHOLONE231 Orladeyo253 OXYMORPHONE HCL13,20,21 ORPHENADRINE CITRATE288 Oxytrol218 ORPHENADRINE W/ ASPIRIN & CAFF288 OZANIMOD HCL185 Ortho Micronor247 Ozempic (0.25 or 0.5 MG/DOSE)129 Ortho Tri-Cyclen (28)242 Ozempic (1 MG/DOSE)129 Ortho Tri-Cyclen Lo242 OZENOXACIN195 Ortho-Cyclen (28)242 Ozobax107 Ortho-Novum 1/35 (28)242 Ozurdex273 Ortho-Novum 7/7/7 (28)242 OrthoVisc268 P Ortikos262 PALBOCICLIB79 OSELTAMIVIR PHOSPHATE117,118 PALIPERIDONE95,98 Oseni129 PALIPERIDONE PALMITATE95,96 OSIMERTINIB MESYLATE81 PALONOSETRON HCL62,63 Osmolex ER84 Palonosetron HCl63 Otezla259,260 Pamelor59 Otiprio38 PAMIDRONATE DISODIUM264 Otovel276 Pamidronate Disodium264 Otrexup257 Pancreaze216,217 Ovide84 PANCRELIPASE (LIPASE-PROTEASE- OXANDROLONE231 AMYLASE)216,217 OXAPROZIN5,8 Pandel226 Oxaydo20 PANOBINOSTAT LACTATE79 OXAZEPAM123,124 PANTOPRAZOLE SODIUM215,216 Oxbryta141 Paragard Intrauterine Copper219 OXCARBAZEPINE49 PARICALCITOL264,265 OXICONAZOLE NITRATE67 Parlodel85

PAGE 329 LAST UPDATED 07/2021 PAROMOMYCIN SULFATE27 PENICILLIN V POTASSIUM34 PAROXETINE HCL56 Penlac67 PAROXETINE MESYLATE56 Pennsaid8 PAROXETINE MESYLATE (VASOMOTOR)54,56 Pentasa262 Pataday271 PENTAZOCINE W/ NALOXONE21 Patanase279 Pentican45 Patanol271 PENTOSAN POLYSULFATE SODIUM219 PATIROMER SORBITEX CALCIUM200 PENTOXIFYLLINE157 Paxil56 Pepcid211 Paxil CR56 PERAMIVIR117 Pazeo271 PERAMPANEL46 PAZOPANIB HCL82 Percocet21,22 PED MULTIVITAMINS W/FL & IRON202 Perforomist282 Pediapred227 PERINDOPRIL ERBUMINE145 PEDIATRIC MULTIVITAMINS W/FL202,203 PERMETHRIN83,84 PEG 3350-KCL-NACL-NA SULFATE-NA PERPHENAZINE60 ASCORBATE-ASCORBIC ACID212,213 PERPHENAZINE-AMITRIPTYLINE52 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Perseris98 SULFATE212 Pertzye217 PEG 3350-POTASSIUM CHLORIDE-SOD Pexeva56 BICARBONATE-SOD CHLORIDE212,213 PEXIDARTINIB HCL77 Peganone49 PHENAZOPYRIDINE HCL219 PEGAPTANIB SODIUM269 PHENELZINE SULFATE53,54 Pegasys109 Phenergan279 Pegasys ProClick109 PHENOBARBITAL45 PEGFILGRASTIM137 PHENYLEPHRINE HCL (MYDRIATIC)270 PEGFILGRASTIM-APGF138 Phenytek49 PEGFILGRASTIM-BMEZ138 PHENYTOIN48,49 PEGFILGRASTIM-CBQV138 PHENYTOIN SODIUM EXTENDED48,49 PEGFILGRASTIM-JMDB137 Phoslyra200 PEGINTERFERON ALFA-2A109 Phospholine Iodide274 PEGINTERFERON ALFA-2B109 PHYTONADIONE140 PEGINTERFERON BETA-1A185 Pifeltro111 PegIntron109 PILOCARPINE HCL274 PEGLOTICASE68 PILOCARPINE HCL (ORAL)186 Pemazyre76 PIMAVANSERIN TARTRATE97 PEMIGATINIB76 PIMECROLIMUS190,191 PENCICLOVIR118 PIMOZIDE91 PENICILLIN G BENZATHINE34 PINDOLOL148 PENICILLIN G POTASSIUM34 PIOGLITAZONE HCL125,129 PENICILLIN G SODIUM34 PIOGLITAZONE HCL-GLIMEPIRIDE126,129

PAGE 330 LAST UPDATED 07/2021 PIOGLITAZONE HCL-METFORMIN HCL125,129 POTASSIUM CHLORIDE197,198 Piqray (200 MG Daily Dose)81 POTASSIUM CHLORIDE MICROENCAPSULATED Piqray (250 MG Daily Dose)81 CRYSTALS ER197,198 Piqray (300 MG Daily Dose)81 POTASSIUM CITRATE (ALKALINIZER)219,220 PIRFENIDONE285 Pradaxa136 PIROXICAM6,8 PRALSETINIB79 PITAVASTATIN CALCIUM161 Praluent163 PITAVASTATIN MAGNESIUM162 PRAMIPEXOLE DIHYDROCHLORIDE85,86 PITOLISANT HCL291 PRAMLINTIDE ACETATE130 Plaquenil83 Prandin129 Plavix142 PRASUGREL HCL141,142 PLECANATIDE213 Pravachol161 Plegridy185 PRAVASTATIN SODIUM161 Plegridy Starter Pack185 PRAZOSIN HCL143 Pliaglis24 Precose129 PNEUMOCOCCAL 13-VALENT CONJUGATE Pred Forte273 VACCINE261 Pred Mild273 PNEUMOCOCCAL VAC POLYVALENT261 Pred-G270 Pneumovax 23261 Pred-G S.O.P.270 PNV Prenatal Plus Multivitamin204 PREDNICARBATE222,227 PNV Tabs 20-1204 Prednicarbate227 PNV Tabs 29-1204 PREDNISOLONE226,227 PNV-DHA+Docusate204 PREDNISOLONE ACETATE (OPHTH)273 PNV-Omega204 PREDNISOLONE SODIUM PHOSPHATE226,227 PNV-Select204 PrednisoLONE Sodium Phosphate227,273 PODOFILOX191 PREDNISOLONE SODIUM PHOSPHATE POLYETHYLENE GLYCOL 3350213 (OPHTH)273 POLYMYXIN B-TRIMETHOPRIM270 PREDNISONE227,228 POLYSACCHARIDE FE COMPLEX-FE HEME PredniSONE Intensol228 POLYPEPTIDE-FA-VIT B12196 Prefest243 Polytrim270 PREGABALIN182,183 POMALIDOMIDE74 PREGABALIN (ONCE-DAILY)182,183 Pomalyst74 PreGen DHA204 PONATINIB HCL79 Premarin243 PONESIMOD185 Premphase243 Ponvory185 Prempro243 Ponvory Starter Pack185 Prenaissance204 POSACONAZOLE67 Prenaissance Plus204 POT PHOSPHATE MONOBASIC W/ SOD PRENAT VIT W/ IRON CARBONYL-FE ASP GLYC- PHOSPHATE DIBASIC & MONOBASIC200 FA-OMEGA FATTY ACID203 POTASSIUM BICARBONATE196,197 Prenatal204

PAGE 331 LAST UPDATED 07/2021 Prenatal 19204 PRENATAL VIT W/ SELENIUM-FE FUMARATE- PRENATAL MULTIVIT-MIN W/FE-FA206 FOLIC ACID207 PRENATAL MULTIVITAMINS & MINERALS W/ L- PRENATAL VIT WITHOUT VIT A W/ FE METHYLFOLATE-FA204 BISGLYCINATE-FA-OMEG 3203 PRENATAL MV & MIN W/FE BISGLYC-FE PROT PRENATAL VIT WITHOUT VIT A W/ FE SUCC-FA-CA-OMEGA 3201,206 BISGLYCINATE-FOLIC ACID203 PRENATAL MV & MIN W/FE CARBONYL-FA-DHA204 Prenatal Vitamin Plus Low Iron204 PRENATAL MV & MIN W/FE FUMARATE-FA-DHA208 PRENATAL W/ CALCIUM-VIT B6-VIT B12-FOLIC PRENATAL MV & MIN W/FE POLYSACCHARIDE ACID-GINGER204 COMPLEX-FA-DHA206,208 PRENATAL W/ FE ASPARTO GLYCINATE-L PRENATAL VIT W/ DOCUSATE-FE CARBONYL-FE METHYLFOLATE-FOLIC ACID205 GLUCONATE-FOLIC ACID201 PRENATAL W/O A VIT W/ FE FUMARATE-L PRENATAL VIT W/ DOCUSATE-FE FUMARATE- METHYLFOLATE-FOLIC ACID208 FOLIC ACID206 PRENATAL W/O A W/ FE ASPARTO GLYC-L PRENATAL VIT W/ FE BISGLYCINATE CHELATE- METHYLFOLATE-FA-DHA204,205 FOLIC ACID204 PRENATAL W/O A W/FE CARBONYL-FE BISGLYC-L PRENATAL VIT W/ FE FUM-IRON POLYSACCH METHYLFOL-DHA203 COMPLEX -FA-OMEGA 3201,206,207 PRENATAL W/O VIT A W/ FE CARBONYL-DSS-FA- PRENATAL VIT W/ FE GLYCINE CYSTEINATE-FA- DHA204 OMEGA 3 FATTY ACIDS202 PRENATAL W/O VIT A W/ FE CARBONYL-FE ASP PRENATAL VIT W/ FE POLYSACCH COMPLEX-L GLYC-METHFOL-FA-DHA205 METHYLFOL-FA-DHA-DSS208 PRENATAL W/O VIT A W/ FE CARBONYL-FE PRENATAL VIT W/ FE POLYSACCH COMPLEX-L ASPART GLYC-FA-FISH OIL203 METHYLFOLATE-FA-DHA208 PRENATAL W/O VIT A W/ FE CARBONYL-FE PRENATAL VIT W/ FERRIC PHOSPHATE-FA- ASPART GLYC-FA-OMEGA 3203 OMEGA 3 FATTY ACIDS208 PRENATAL W/O VIT A W/ FE CARBONYL-FE PRENATAL VIT W/ FERROUS FUMARATE-FA- GLUCONATE-DSS-FA-DHA201 OMEGA 3 FATTY ACIDS200,207,208 PRENATAL W/O VIT A W/ FE CARBONYL-FE PRENATAL VIT W/ FERROUS FUMARATE-FOLIC GLUCONATE-FA & VIT B6201 ACID201,202,203,204,205,206,207,208 PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA- PRENATAL VIT W/ FERROUS FUMARATE-L DHA204,206,207 METHYLFOLATE-FOLIC ACID204,207 PRENATAL W/O VIT A W/ FE FUMARATE-FE PRENATAL VIT W/ IRON CARBONYL-FE ASPART CARBONYL-DSS-FA-DHA201 GLYCINATE-FA203 PRENATAL WITHOUT A VIT W/ FE FUM-IRON PRENATAL VIT W/ IRON CARBONYL-FOLIC POLYSACCH COMPLEX -FA201,202,205 ACID201,203,204,206 PRENATAL WITHOUT A VIT W/ FE FUMARATE- PRENATAL VIT W/ IRON POLYSACCHARIDE FOLIC ACID200,204 CMPLX-L METHYLFOLATE-FA206 PRENATAL WITHOUT A W/ FE ASP GLYC-L PRENATAL VIT W/ IRON POLYSACCHARIDE METHYLFOLATE-FA-OMEGA 3205 COMPLEX-FOLIC ACID206 PRENATAL WITHOUT A W/ FE CARBONYL-L METHYLFOLATE-FA-DHA206,209

PAGE 332 LAST UPDATED 07/2021 PRENATAL WITHOUT A W/ FE FUMARATE-L ProAir Digihaler282 METHYLFOLATE-FA-DHA204,205,207,209 ProAir HFA282 PRENATAL WITHOUT A W/ FE FUMARATE-L ProAir RespiClick282 METHYLFOLATE-FA-OMEGA 3204,207,209 PROBENECID68 PRENATAL WITHOUT A W/FE FUM-FE POLYSACCH Probuphine Implant Kit26 COMPLEX-FA-DHA205 Procardia152 PRENATAL WITHOUT VIT A W/ FE CARBONYL-FE Procardia XL152 GLUC-DOCUSATE-FA201 PROCHLORPERAZINE59,61 PRENATAL WITHOUT VIT A W/ FE FUMARATE-L PROCHLORPERAZINE EDISYLATE61 METHYLFOLATE-OMEGAS207 PROCHLORPERAZINE MALEATE61 Prenatal-U204 Procrit138 Prenate204 Proctocort191 Prenate AM204 Proctofoam HC191 Prenate DHA204 Profilnine140 Prenate Elite205 Profilnine SD140 Prenate Enhance205 PROGESTERONE247,248 Prenate Essential205 PROGESTERONE (VAGINAL)246 Prenate Mini205 Progesterone Micronized268 Prenate Pixie205 PROGESTERONE MICRONIZED (BULK)268 Prenate Restore205 Progesterone Ultra Micronized268 Prenatrix205 Prograf257 Prenatryl205 Prolate22 PrePLUS205 Prolensa273 PreTAB205 Prolia264 Prevacid215 Promacta138 Prevacid SoluTab215 PROMETHAZINE & PHENYLEPHRINE286,287 Prevnar 13261 PROMETHAZINE HCL61,279 Prevymis108 PROMETHAZINE-DM286,287 Prezcobix116 Promethazine-DM286 Prezista116,117 Prometrium248 Prilo Patch II24 PROPAFENONE HCL146 PriLOSEC215 PROPANTHELINE BROMIDE209 Prilovixil25 PROPRANOLOL & HYDROCHLOROTHIAZIDE157 PrimaCare205 PROPRANOLOL HCL76,148,149 PRIMAQUINE PHOSPHATE83 PROPRANOLOL HCL SUSTAINED-RELEASE Primaquine Phosphate83 BEADS148 PRIMIDONE44,45 PROPYLTHIOURACIL253 Primlev22 Proscar219 Prinivil145 Protonix215,216 Pristiq56 Protopic192 Prizopak II25 PROTRIPTYLINE HCL59

PAGE 333 LAST UPDATED 07/2021 Proventil HFA282 Qutenza (2 Patch)25 Provera248 Qutenza (4 Patch)25 Provida DHA205 Qvar278 Provida OB205 Qvar RediHaler278 Provigil290 PROzac56 R PRUCALOPRIDE SUCCINATE209 RABEPRAZOLE SODIUM213,216 PSEUDOEPHED-BROMPHEN-DM286,287 RALOXIFENE HCL248 Psorcon228 RALTEGRAVIR POTASSIUM110 Pulmicort277 RAMELTEON290 Pulmicort Flexhaler277 RAMIPRIL144,146 PureFe OB Plus205 Ranexa157 Pylera210 RANIBIZUMAB269 PYRAZINAMIDE72 RANITIDINE HCL211 Pyrazinamide72 raNITIdine HCl211 PYRIDOSTIGMINE BROMIDE72 RANOLAZINE157 Rapaflo219 Q Rapamune257 Qbrelis145 Rapivab117 Qdolo22 RASAGILINE MESYLATE87 Qelbree178 Rasuvo257,258 Qinlock76 Ravicti217 Qmiiz ODT8 Rayaldee264 Qnasl277 Rayos228 Qnasl Childrens278 Razadyne50 Qtern129 Razadyne ER50 Qualaquin83 Rebetol110 Quartette243 Rebif185 QUAZEPAM289 Rebif Rebidose185 Quazepam289 Rebif Rebidose Titration Pack185 Qudexy XR47 Rebif Titration Pack185 Questran163 Rebinyn140 Questran Light163 Reclast265 QUETIAPINE FUMARATE98,99,102,103 Recombinate140 QuilliChew ER179 Recombivax HB261 Quillivant XR179 RediTrex258 QUINAPRIL HCL144,145 Reglan61 QUINAPRIL-HYDROCHLOROTHIAZIDE154,157 REGORAFENIB81 QUINIDINE SULFATE146 Relafen DS8 QUININE SULFATE83 Relenza Diskhaler117 Qutenza25 Relexxii179

PAGE 334 LAST UPDATED 07/2021 Relistor210 Ribasphere Ribapak (1200 Pack)110 Relpax70 RIBAVIRIN (HEPATITIS C)109,110 RELUGOLIX252 RIBOCICLIB SUCCINATE79,80 RELUGOLIX-ESTRADIOL-NORETHINDRONE RIBOCICLIB SUCCINATE-LETROZOLE80 ACETATE230 RIFABUTIN72 Remeron53 RIFAMPIN73 Remeron SolTab53 RIFAXIMIN31 Remicade258 RILONACEPT259 Renagel200 RILPIVIRINE HCL111 Renflexis258 RIMABOTULINUMTOXINB288 Renvela200 RIMANTADINE HYDROCHLORIDE117 REPAGLINIDE129 RIMEGEPANT SULFATE69 REPAGLINIDE-METFORMIN HCL129 Rinvoq258 Repatha163 RIOCIGUAT284 Repatha Pushtronex System163 Riomet129 Repatha SureClick163 Riomet ER129 Requip86 RIPRETINIB76 Requip XL86 RISANKIZUMAB-RZAA192 Rescriptor111 RISEDRONATE SODIUM263,265 RESLIZUMAB259 RisperDAL100,101 Restasis270 RisperDAL Consta101 Restasis Multidose270 RISPERIDONE98,100,101,102 Restoril289 RISPERIDONE MICROSPHERES101 Retacrit138 Ritalin179 Retevmo76 Ritalin LA179 Retin-A192 RITONAVIR116,117 Retin-A Micro192 RIVAROXABAN136,137 Retin-A Micro Pump192 RIVASTIGMINE50,51 Retisert273 RIVASTIGMINE TARTRATE51 Retrovir113 Rixubis140 Revatio284 RIZATRIPTAN BENZOATE70,71 REVEFENACIN281 Robaxin-750288 Revlimid74 Rocaltrol265 Rexulti99,100 rocklatan274 Reyataz117 ROFLUMILAST283 Reyvow70,71 ROLAPITANT HCL64 RHO D IMMUNE GLOBULIN (HUMAN)259 ROMIPLOSTIM137 RhoGAM Ultra-Filtered Plus259 ROMOSOZUMAB-AQQG264 Rhopressa274 ROPINIROLE HYDROCHLORIDE86 Ribasphere110 ROSIGLITAZONE MALEATE125 Ribasphere RibaPak (1000 Pack)110 ROSUVASTATIN CALCIUM161

PAGE 335 LAST UPDATED 07/2021 Roszet163 Se-Natal 19206 ROTIGOTINE85 Seasonique243 Rowasa262 SECNIDAZOLE30 Roxicodone22 SECOBARBITAL SODIUM290 Rozerem290 Seconal290 Rozlytrek76 Secuado102 Rubraca76 SECUKINUMAB189 RUCAPARIB CAMSYLATE76 Seebri Neohaler281 Ruconest253 SEGESTERONE ACETATE-ETHINYL RUFINAMIDE48,49 ESTRADIOL233 Rukobia115 Segluromet129 RUXOLITINIB PHOSPHATE79 Select-OB206 Rybelsus129 Select-OB+DHA206 Rydapt76 SELEGILINE53 Rytary87 SELEGILINE HCL87 SELENIUM SULFIDE192 S SELEXIPAG285 Sabril45 SELINEXOR77 SACUBITRIL-VALSARTAN155 SELPERCATINIB76 SAFINAMIDE MESYLATE87 SELUMETINIB SULFATE80 Safyral243 Selzentry115 Saizen231 SEMAGLUTIDE129 Saizen Click.Easy231 Semglee134 Saizenprep231 Semprex-D287 SALICYLIC ACID187 Serevent Diskus282 SALMETEROL XINAFOATE282 Sernivo192 SALSALATE8 SEROquel102,103 Sancuso63 SEROquel XR103 SandIMMUNE258 Serostim231 Santyl192 SERTACONAZOLE NITRATE65 Saphris102 SERTRALINE HCL56,57 SAQUINAVIR MESYLATE116 SEVELAMER CARBONATE200 Sarafem56 SEVELAMER HCL200 SARGRAMOSTIM137 Sevelamer HCl200 SARILUMAB256 Sevenfact140 Savaysa136 SfRowasa262 Savella183 Shingrix261 Savella Titration Pack183 Siklos75 SAXAGLIPTIN HCL129 Sila III228 SAXAGLIPTIN-METFORMIN HCL128 SILDENAFIL CITRATE (PULMONARY SCOPOLAMINE61,62 HYPERTENSION)284

PAGE 336 LAST UPDATED 07/2021 Silenor291 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR109 Siliq258 SOLIFENACIN SUCCINATE218 SILODOSIN219 Soliqua134 SILVER SULFADIAZINE38 Solodyn41 Simbrinza274 Solosec30 Simponi258 SOLRIAMFETOL HCL291 Simponi Aria258 Soltamox74 SIMVASTATIN161,162 Solu-CORTEF228 Simvastatin161 SOLU-medrol228 Sinemet87 Soma288 Sinemet CR87 SOMATROPIN230,231 Singulair280 SOMATROPIN (NON-REFRIGERATED)231 Sinuva278 SONIDEGIB PHOSPHATE81 SIPONIMOD FUMARATE184,185 SORAFENIB TOSYLATE81 SIROLIMUS257,258 Soriatane192 SITAGLIPTIN PHOSPHATE128 Sorilux192 SITAGLIPTIN-METFORMIN HCL127,128 SOTALOL HCL146,147 Sitavig118 SOTALOL HCL (AFIB/AFL)146,147 Skelaxin288 SOTORASIB76 Sklice82 Sotylize147 SkyaDerm-LP25 Sovaldi109 Skyla248 SPACER/AEROSOL-HOLDING CHAMBERS266,268 Skyrizi192 SPINOSAD82 Skyrizi (150 MG Dose)192 Spiriva HandiHaler281 Slynd248 Spiriva Respimat281 SODIUM BICARBONATE198 SPIRONOLACTONE159 SODIUM CHLORIDE (GU IRRIGANT)198 SPIRONOLACTONE & SODIUM CHLORIDE (INHALANT)287 HYDROCHLOROTHIAZIDE154,157 SODIUM CITRATE & CITRIC ACID219,220 Sporanox67 SODIUM FERRIC GLUCONATE COMPLEX IN Sporanox Pulsepak67 SUCROSE196,197 Spravato (56 MG Dose)53 SODIUM FLUORIDE198 Spravato (84 MG Dose)53 Sodium Hyaluronate268 Spritam43 SODIUM HYALURONATE Sprix9 (VISCOSUPPLEMENT)190,266,267,268 Sprycel81 SODIUM PHENYLBUTYRATE216,217 SSS 10-5192 SODIUM POLYSTYRENE SULFONATE199 Stalevo 10084 SODIUM ZIRCONIUM CYCLOSILICATE267 Stalevo 12584 SOFOSBUVIR109 Stalevo 15085 SOFOSBUVIR-VELPATASVIR109 Stalevo 20085 Sofosbuvir-Velpatasvir109 Stalevo 5085

PAGE 337 LAST UPDATED 07/2021 Stalevo 7585 SULFASALAZINE261,262 Starlix130 SULINDAC9 STAVUDINE113,114 Sumadan193 Stavudine113 Sumadan Wash193 Steglatro130 Sumadan XLT193 Steglujan130 SUMATRIPTAN70,71 Stelara192,193 SUMATRIPTAN SUCCINATE70,71 Stimate231 SUMATRIPTAN-NAPROXEN SODIUM71 Stiolto Respimat287 Sumavel DosePro71 STIRIPENTOL42 Sumaxin193 Stivarga81 Sumaxin CP193 Strattera179,180 Sumaxin TS193 Striant232 Sumaxin Wash194 Stribild110 SUNITINIB MALATE81 Striverdi Respimat282 Sunosi291 Sublocade26 Supartz FX268 Suboxone26 Supprelin LA252 Subsys22 Suprax33 SUCCIMER199 Surmontil59 SUCRALFATE213 Sustiva112 SUCROFERRIC OXYHYDROXIDE200 Sustol64 SUFENTANIL CITRATE16 Sutent81 Sular152 SUVOREXANT290 SULCONAZOLE NITRATE65,67 Symbicort287 Sulconazole Nitrate67 Symbyax53 SULFACETAMIDE SOD-PREDNISOLONE269,270 Symfi112 SULFACETAMIDE SODIUM192,193 Symfi Lo112 SULFACETAMIDE SODIUM (ACNE)38,39 SymlinPen 120130 SULFACETAMIDE SODIUM (OPHTH)38 SymlinPen 60130 SULFACETAMIDE SODIUM W/ Sympazan45 SULFUR187,188,192,193,194 Symproic210 SULFACETAMIDE SODIUM-SULFUR IN UREA Symtuza117 VEHICLE188 Synalar228 SULFACETAMIDE SODIUM-SULFUR W/ SKIN Synalar (Cream)228 CLEANSER193 Synalar (Ointment)228 SULFACETAMIDE SODIUM-SULFUR- Synalar TS228 SUNSCREEN193 Synarel252 SULFADIAZINE39 Syndros64 SulfADIAZINE39 Synera25 SULFAMETHOXAZOLE-TRIMETHOPRIM39 Synjardy130 SULFANILAMIDE VAGINAL38 Synjardy XR130

PAGE 338 LAST UPDATED 07/2021 Synthroid250 Taytulla244 Synvisc268 Tazarotene194 Synvisc One268 TAZAROTENE194 SYRINGE/NEEDLE (DISP) 3 ML266,267 TAZAROTENE (ACNE)187,190,194 TAZEMETOSTAT HBR77 T Tazorac194 Tabloid75 Tazverik77 Tabrecta76 TBO-FILGRASTIM137 Taclonex194 Tecfidera185 TACROLIMUS253,254,257,258 TEGASEROD MALEATE212 TACROLIMUS (TOPICAL)192,194 TEGretol49 TADALAFIL218,219 TEGretol-XR49 TADALAFIL (PULMONARY HYPERTENSION)284 Tekturna157 TAFENOQUINE SUCCINATE83 Tekturna HCT157 Tafinlar81 TELMISARTAN144 TAFLUPROST275 TELMISARTAN-AMLODIPINE157 Tagrisso81 TELMISARTAN-HYDROCHLOROTHIAZIDE156,157 Takhzyro253 TEMAZEPAM289 TALAZOPARIB TOSYLATE81 Temixys113 Talicia210 Temodar73 TALIGLUCERASE ALFA216 Temovate229 Taltz194 TEMOZOLOMIDE73 Talzenna81 TENOFOVIR ALAFENAMIDE FUMARATE109 Tamiflu118 TENOFOVIR DISOPROXIL FUMARATE113,114 TAMOXIFEN CITRATE74 Tenoretic 100157 TAMSULOSIN HCL219 Tenoretic 50157 Tandem Plus198 Tenormin149 Tanzeum130 Tepmetko81 TAPENTADOL HCL13,20 TEPOTINIB HCL81 TaperDex 12-Day228 TERAZOSIN HCL143 TaperDex 7-Day229 TERBINAFINE HCL67 Tarceva81 TERBUTALINE SULFATE282 Tarka157 TERCONAZOLE VAGINAL67,68 Taron Forte198 TERIFLUNOMIDE183 Taron-C DHA206 TERIPARATIDE (RECOMBINANT)264,265 Taron-Prex206 Teriparatide (Recombinant)265 Tasigna81 Testim232 TASIMELTEON290 Testopel232 Tasmar85 TESTOSTERONE231,232,233 TAVABOROLE66,67 Testosterone232 Tavalisse138 TESTOSTERONE CYPIONATE232,233

PAGE 339 LAST UPDATED 07/2021 TESTOSTERONE ENANTHATE233 TIVOZANIB HCL75 TESTOSTERONE UNDECANOATE232 TIZANIDINE HCL107,108 Testred233 Tobi287 TETANUS TOXOID-DIPHTHERIA-ACELLULAR Tobi Podhaler283 PERTUSSIS ADSORB (TDAP)260 TobraDex270 TETRABENAZINE181,182 TobraDex ST270 TETRACYCLINE HCL41 TOBRAMYCIN283,286,287 Texacort229 Tobramycin287 THALIDOMIDE74 TOBRAMYCIN (OPHTH)27,28 Thalomid74 TOBRAMYCIN-DEXAMETHASONE270 Theo-24283 Tobrex27,28 Theochron283 TOCILIZUMAB259 THEOPHYLLINE283 TOFACITINIB CITRATE259 THIOGUANINE75 Tofranil59 THIORIDAZINE HCL91 TOLAZAMIDE130 THIOTHIXENE91 TOLAZamide130 Thrivite 19206 TOLBUTAMIDE130 Thrivite Rx206 TOLCAPONE85 Thyquidity250 TOLMETIN SODIUM9 THYROID248,250 Tolmetin Sodium9 TIAGABINE HCL44,45 Tolsura68 Tiazac152,153 TOLTERODINE TARTRATE217,218 Tibsovo77 Topamax47 TICAGRELOR141 Topamax Sprinkle47 Tigan61 Topicort229 TILDRAKIZUMAB-ASMN190 Topicort Spray229 TIMOLOL MALEATE149 TOPIRAMATE47,48 TIMOLOL MALEATE (OPHTH)274,275 Toprol XL149 Timoptic275 TOREMIFENE CITRATE74 Timoptic Ocudose275 TORSEMIDE158 Timoptic-XE275 Tosymra71 Tindamax30 Toujeo Max SoloStar134 TINIDAZOLE30 Toujeo SoloStar134 TIOTROPIUM BROMIDE MONOHYDRATE281 Tovet194 TIOTROPIUM BROMIDE-OLODATEROL HCL287 Toviaz218 TIPRANAVIR115 Tracleer284 Tirosint251 Tradjenta130 Tirosint-SOL251 TRAMADOL HCL10,13,14,22,23 Tivicay110 TRAMADOL-ACETAMINOPHEN22,23 Tivicay PD110 TRAMETINIB DIMETHYL SULFOXIDE80 Tivorbex9 TRANDOLAPRIL146

PAGE 340 LAST UPDATED 07/2021 TRANDOLAPRIL-VERAPAMIL HCL157 Trijardy XR130 TRANEXAMIC ACID140 Trileptal49 Transderm Scop (1.5 MG)62 Trilipix160 Transderm-Scop (1.5 MG)62 Trilociclo268 Tranxene-T124 Triluron268 TRANYLCYPROMINE SULFATE54 TRIMETHOBENZAMIDE HCL61,62 Travatan Z275 TRIMIPRAMINE MALEATE59 TRAVOPROST275 Trinatal Rx 1206 TRAZODONE HCL57 Trintellix57 Trelegy Ellipta287 Triostat251 Trelstar Mixject252 Triptodur252 Tremfya258 TRIPTORELIN PAMOATE252 TREPROSTINIL284,285 TRIPTORELIN PAMOATE (CPP)252 TREPROSTINIL DIOLAMINE284 TriStart DHA206 Tresiba134 Triumeq115 Tresiba FlexTouch134 Triveen-Duo DHA206 TRETINOIN187,192,194,195 TriVisc268 TRETINOIN (CHEMOTHERAPY)82 Trizivir113 TRETINOIN MICROSPHERE192,195 Trogarzo115 Trexall258 Trokendi XR48 Treximet71 TROPICAMIDE270 TRIAMCINOLONE ACETONIDE225,229 TROSPIUM CHLORIDE218 TRIAMCINOLONE ACETONIDE (MOUTH)186 Trulance213 TRIAMCINOLONE ACETONIDE (OPHTH)273 Trulicity130 TRIAMCINOLONE ACETONIDE (TOPICAL)225,229 Truseltiq (100MG Daily Dose)77 TRIAMCINOLONE ACETONIDE-CICLOPIROX268 Truseltiq (125MG Daily Dose)77 TRIAMCINOLONE ACETONIDE-SILICONE228 Truseltiq (50MG Daily Dose)77 TRIAMTERENE & HYDROCHLOROTHIAZIDE157 Truseltiq (75MG Daily Dose)77 TRIAZOLAM289,290 Trusopt275 Tribenzor157 Truvada113 TriCare206 TUCATINIB81 TriCare Prenatal DHA ONE206 Tudorza Pressair281 Tricor160 Tukysa81 Triesence273 Turalio77 TRIFAROTENE186 Twinrix261 Triferic199 Twirla245 TRIFLUOPERAZINE HCL91 Twynsta157 TRIFLURIDINE118 Tyblume245 TRIFLURIDINE-TIPIRACIL76 Tybost115 Triglide160 Tykerb82 TRIHEXYPHENIDYL HCL84 Tylenol with Codeine #322

PAGE 341 LAST UPDATED 07/2021 Tylenol with Codeine #423 VALGANCICLOVIR HCL108 Tymlos265 VALPROATE SODIUM43,45 Tysabri185 VALPROIC ACID43,45 Tyvaso284 VALSARTAN143,144 Tyvaso Refill284 VALSARTAN-HYDROCHLOROTHIAZIDE155,157,158 Tyvaso Starter285 Valtoco 10 MG Dose45 Valtoco 15 MG Dose46 U Valtoco 20 MG Dose46 Ubrelvy69 Valtoco 5 MG Dose46 UBROGEPANT69 Valtrex118 Uceris262 Valved Holding Chamber268 Udenyca138 Vancocin31 Ukoniq82 Vancocin HCl31 ULIPRISTAL ACETATE246 VANCOMYCIN HCL29,31 Uloric68 Vancomycin HCl31 Ultracet23 VANDETANIB78 Ultram23 Vanos230 Ultravate229,230 Vantas252 Ultravate X (Cream)230 Vaqta261 Ultravate X (Ointment)230 VARENICLINE TARTRATE27 UMBRALISIB TOSYLATE82 Varubi (180 MG Dose)64 UMECLIDINIUM BROMIDE280 Vascepa163 UMECLIDINIUM-VILANTEROL285 Vaseretic158 UPADACITINIB258 Vasotec146 Uptravi285 Vectical195 UREA195 VEDOLIZUMAB254 Urimar-T30 VELAGLUCERASE ALFA217 Urogesic-Blue30 Velphoro200 Urso 250210 Veltassa200 Urso Forte210 Vemlidy109 URSODIOL209,210 VEMURAFENIB82 USTEKINUMAB192,193 Venclexta82 USTEKINUMAB (IV)193 Venclexta Starting Pack82 Ustell30 VENETOCLAX82 Utibron Neohaler287 Venexa Fe207 VENLAFAXINE HCL54,57 V Venofer198 Vagifem245 Ventavis285 VALACYCLOVIR HCL118 Ventolin HFA282 VALBENAZINE TOSYLATE181 VERAPAMIL HCL149,153 Valcyte108 Verelan153

PAGE 342 LAST UPDATED 07/2021 Verelan PM153 Vistaril279 Versacloz107 Visudyne270 VERTEPORFIN270 Vitafol FE+208 Verzenio82 Vitafol Gummies208 VESIcare218 Vitafol Ultra208 VESIcare LS218 Vitafol-Nano208 Vfend68 Vitafol-OB208 VIBEGRON217 Vitafol-OB+DHA208 Viberzi212 Vitafol-One208 Vibramycin41 Vitrakvi77 Victoza130 Vitranol FE208 Videx114 Vitrexate FE208 Videx EC114 Vitrexyl + Iron208 Viekira Pak109 Vivelle-Dot245 VIGABATRIN45,46 Vivitrol25 Vigamox38 Vivlodex9 Viibryd57 Vizimpro77 Viibryd Starter Pack57 Vocabria111 VILAZODONE HCL57 VOCLOSPORIN256 VILOXAZINE HCL (ADHD)178 Vogelxo233 Vimovo9 Vogelxo Pump233 Vimpat49,50 Vol-Plus208 Vinate DHA RF207 Voltaren9 Vinate M207 VON WILLEBRAND FACTOR (RECOMBINANT)141 Viokace217 Vonvendi141 Vios Aerosol Delivery System268 VORAPAXAR SULFATE137 Viracept117 VORICONAZOLE68 Viramune112 VORINOSTAT78 Viramune XR112 VORTIOXETINE HBR57 Viread114 Vosevi109 Virt Nate207 Votrient82 Virt-C DHA207 VOXELOTOR141 Virt-FeFA Plus207 VP-PNV-DHA208 Virt-Nate DHA207 Vpriv217 Virt-PN207 Vraylar103,104 Virt-PN DHA207 Vtol LQ181 Virt-PN Plus207 Vumerity185 Virt-Select207 Vumerity (Starter)185 VirtPrex207 Vusion68 Visco-3268 Vyepti70 VISMODEGIB79 Vytorin163

PAGE 343 LAST UPDATED 07/2021 Vyvanse169,170 Ximino41 Vyzulta275 Xofluza (40 MG Dose)118 Xofluza (80 MG Dose)118 W Xolair287 Wakix291 Xopenex283 WARFARIN SODIUM134,135,136 Xopenex Concentrate283 WATER FOR IRRIGATION, STERILE268 Xopenex HFA283 Welchol163 Xospata77 Wellbutrin SR53 Xpovio (100 MG Once Weekly)77 Wellbutrin XL53 Xpovio (40 MG Once Weekly)77 WesTab Plus208 Xpovio (40 MG Twice Weekly)77 WestGel DHA209 Xpovio (60 MG Once Weekly)77 Wilate141 Xpovio (60 MG Twice Weekly)77 Winlevi195 Xpovio (80 MG Once Weekly)77 Wynzora195 Xpovio (80 MG Twice Weekly)77 Xtampza ER14 X Xtandi74 Xadago87 Xultophy134 Xalatan275 Xyntha141 Xalkori82 Xyntha Solofuse141 Xanax124 Xyosted233 Xanax XR124 Xarelto136,137 Y Xarelto Starter Pack137 Yasmin 28245 Xatmep258 YAZ245 Xcopri48 Yonsa74 Xcopri (250 MG Daily Dose)48 Yosprala142 Xcopri (350 MG Daily Dose)48 Yupelri281 Xeljanz259 Yutiq273 Xeljanz XR259 Xeloda75 Z Xelpros275 ZAFIRLUKAST280 Xenazine182 ZALEPLON290 Xeomin108 Zanaflex108 Xepi195 ZANAMIVIR117 Xerese118 Zantac211 Xgeva265 ZANUBRUTINIB75 Xhance278 Zarontin43 Xifaxan31 Zarxio138 Xigduo XR131 Zatean-Pn DHA209 Xiidra270 Zatean-Pn Plus209

PAGE 344 LAST UPDATED 07/2021 Zavesca217 ZOLEDRONIC ACID265 ZCORT 7-Day230 Zoledronic Acid265 Zegalogue131 Zolinza78 Zegerid216 ZOLMITRIPTAN71,72 Zejula82 ZOLMitriptan71 Zelapar87 Zoloft57 Zelboraf82 ZOLPIDEM TARTRATE289,290 Zelnorm212 Zolpimist290 Zembrace SymTouch71 Zomacton231 Zemplar265 Zomacton (for Zoma-Jet 10)231 Zenpep217 Zometa265 Zenzedi170,171 Zomig72 Zepatier109 Zomig ZMT72 Zeposia185 ZONISAMIDE43 Zeposia 7-Day Starter Pack185 Zontivity137 Zeposia Starter Kit185 Zorbtive231 Zerit114 Zortress259 Zerviate271 Zorvolex9 Zestoretic158 ZOSTER VACCINE RECOMBINANT Zestril146 ADJUVANTED261 Zetia164 Zovirax118,119 Zetonna278 ZTlido25 Ziac158 Zubsolv26 Ziagen114 Zuplenz64 Ziana195 Zurampic68 ZIDOVUDINE113,114 Zyban27 Ziextenzo138 Zyclara195 ZILEUTON280 Zyclara Pump195 Zinplava31 Zydelig82 Zioptan275 Zyflo280 ZIPRASIDONE HCL94,95,104 Zyflo CR280 ZIPRASIDONE MESYLATE95,104 Zykadia82 Zipsor9 Zylet270 Zithromax36 Zyloprim69 Zithromax Tri-Pak36 Zymaxid38 Zithromax Z-Pak36 Zypitamag162 Zocor162 ZyPREXA104,105 Zofran64 ZyPREXA Relprevv105 Zofran ODT64 ZyPREXA Zydis105 Zohydro ER14 Zytiga74 Zoladex77

PAGE 345 LAST UPDATED 07/2021