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Pharmacy | PDL | California

2021 California Access Large Group 4-Tier HMO and PPO List

Please note: This Prescription Drug List (PDL) is accurate as of September 1, 2021 and is subject to change after this date. All previous versions of this PDL are no longer in effect. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

This PDL can also be accessed online at myuhc.com > Pharmacy Information > Prescription Drug Lists > California plans > Large Group - Access. Plan-specific coverage documents may be accessed online at uhc.com/statedruglists > Large Group Plans > California. If you are a UnitedHealthcare member, please register or log on to myuhc.com, or call the toll-free number on your health plan ID card to find pharmacy information specific to your benefit plan. This PDL is applicable to the following health insurance products offered by UnitedHealthcare: • Navigate • Navigate Plus • Choice • Choice Plus • Select • Select Plus • Core • Core Essential • Options PPO • Non-Differential PPO • SignatureValue • SignatureValue Advantage • SignatureValue Alliance • SignatureValue Focus • SignatureValue Harmony

Please refer to your ID card for plan type (HMO or PPO).

Updated 7/13/2021

7/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. WF4335930-G Contents

At UnitedHealthcare, we want to help you better understand your options...... 3

How do I use my PDL? ...... 4

What are tiers? ...... 5

When does the PDL change? ...... 5

Utilization Management Programs ...... 6

Your Right to Request Access to a Non-formulary Drug ...... 6

Requesting a Prior Authorization or Step Therapy Exception ...... 7

How do I locate and fill a prescription through a retail network pharmacy? ...... 7

How do I locate and fill a prescription through the mail order pharmacy? ...... 7

How do I locate and fill a prescription at a specialty pharmacy? ...... 8

How do I get updated information about my pharmacy benefit? ...... 8

Nondiscrimination notice and access to communication services ...... 9

Prescription Drug List ...... 13

2 At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly used terms and their definitions as well as frequently asked questions: Brand-name drug means a Prescription Drug Product (1) which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that we identify as a brand-name product, based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “brand-name” by the manufacturer, pharmacy, or your Physician will be classified as brand-name by us. A brand- name drug is listed in this PDL in all CAPITAL letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either 1 deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug. Enrollee is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this formulary template shall also include subscribers as defined in this section below. Exception request means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or Prescription Drug List (PDL) means a list that categorizes into tiers or products that have been approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and modification (generally quarterly, but no more than 6 times per calendar year). means a Prescription Drug Product: (1) that is chemically equivalent to a brand-name drug; or (2) that we identify as a generic product based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “generic” by the manufacturer, pharmacy or your Physician will be classified as a generic by us. A generic drug is listed in this PDL in bold and italicized lowercase letters. Non-formulary drug means a Prescription Drug Product that is not listed on this PDL. Out-of-pocket costs means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered. Prescribing provider means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription means an oral, written, or electronic order from a prescribing provider authorizing a Prescription Drug Product to be provided to a specific individual. Prescription Drug Product means a medication or product that has been approved by the U.S. Food and Drug Administration (FDA) and that can, under federal or state law, be dispensed only according to a Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. We will provide coverage for a Prescription Drug Product which includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. This definition includes: Inhalers (with spacers);

3 ; the following diabetic supplies: standard insulin syringes with needles; blood-testing strips - glucose; -testing strips - glucose; ketone-testing strips and tablets; lancets and lancet devices; and glucose meters (including continuous glucose monitors [applies to PPO plans only]); disposable devices which are medically necessary for the administration of a covered outpatient Prescription Drug Product. Benefits also include FDA-approved contraceptive drugs, devices and products available over-the-counter when prescribed by a Network provider. Prior Authorization means a process by your health insurer to determine that a health care benefit is medically necessary for you. If a Prescription Drug Product is subject to prior authorization in this PDL, your prescribing provider must request approval from your health insurer to cover the drug. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy means a specific sequence in which Prescription Drug Products for a particular medical condition must be tried. If a drug is subject to step therapy in this PDL, you may have to try 1 or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug. Subscriber means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan. How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if special programs apply. Bring this list with you when you see your doctor. It is organized by therapeutic category and class. The therapeutic category and class are based on the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification. You may also find a drug by its brand or generic name in the alphabetical index. If a generic equivalent for a brand-name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name. This is the way Prescription Drug Products appear in the PDL: 1. A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs; 2. The generic name for a brand-name drug is included after the brand-name in parentheses and all lowercase bold and italicized letters; 3. If a generic equivalent for a brand-name drug is both available and covered, the generic drug will be listed separately from the brand-name drug in all lowercase bold and italicized letters; and 4. If a generic drug is marketed under a proprietary, trademark-protected brand-name, the brand-name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Example:

Prescription Drug Name Drug Tier Coverage Requirements & Limits AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG (irbesartan) 4 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on your health plan ID card. Below is a list of drug tier numbers, abbreviations and designations used in the PDL as well as an explanation for each.

Drug Tier 1 Your lowest cost medications H-N May be part of health care reform preventive when used for appropriate Drug Tier 2 Your mid-range cost medications preventive purposes Drug Tier 3 Your mid-range cost medications SP Specialty medication Drug Tier 4 Your highest cost medications CM Orally administered anti-cancer medication PA Prior authorization required M May be covered under the medical benefit SL Supply Limit with prior authorization for HMO plans ST Step Therapy SMCS Specialty medication cost share may apply (for HMO plans, does not apply to injectables H May be part of health care reform preventive covered under the medical benefit)

4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see if there is a Tier 1 option available. Discuss these options with your doctor. For orally administered anti-cancer medications on any Tier, the total amount of copayments and/or coinsurance shall not exceed $250 for an individual prescription of up to a 30-day supply. For high deductible health plans, the $250 maximum only applies once the deductible has been met. Check your benefit plan documents to find out your specific pharmacy plan costs, including any maximum dollar amount of cost sharing that may apply to a drug. Preferred medications are found in Tier 1, Tier 2 or Tier 3 and may vary depending on the medication and the condition it treats.

$ Drug Tier Includes Helpful Tips Tier 1 Medications that provide the highest Use Tier 1 drugs for the lowest $ Your lowest cost overall value. Mostly generic drugs. Some out-of-pocket costs. brand-name drugs may also be included.

Tier 2 and 3 Medications that provide good overall Use Tier 2 or Tier 3 drugs instead $$ Your mid-range cost value. A mix of brand-name and of Tier 4 to help reduce your generic drugs. out-of-pocket costs.

Tier 4 Medications that provide the lowest Many Tier 4 drugs have lower-cost $$$ Your highest cost overall value. Mostly brand-name drugs, options in Tier 1, 2 or 3. Ask your as well as some generics. doctor if they could work for you.

Please note: If you have a high deductible plan, the tier cost levels may apply once you reach your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan. For HMO plans, please reference your Schedule of Benefits for costs associated with medications covered under the medical benefit. For information related to specialty medication cost share, please refer to the Specialty Medication Cost Share (SMCS) section below.

When does the PDL change? This PDL is required to be updated on a monthly basis. • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or become non-formulary most often on Jan. 1, May 1, or Sept. 1. • Medications may become subject to new or revised utilization management procedures, such as prior authorization, step therapy or supply limits, at any time but most often upon FDA approval of the medication or its generic, Jan. 1, May 1, or Sept. 1. When a medication changes tiers, you may have to pay a different amount for that medication. The presence of a Prescription Drug Product on the PDL does not guarantee that you will be prescribed that Prescription Drug Product by your provider for a particular medical condition.

5 Utilization Management Programs

Prior authorization required—Your doctor is required to provide additional information to us to determine coverage. For specific prior authorization requirements, please refer to your Evidence of Coverage. Supply limit—Amount of medication covered per copayment or in a specific time period. Step therapy—Requires you to try 1 or more other medications before the medication you are requesting may be covered. For specific step therapy requirements, please refer to your Evidence of Coverage. Health Care Reform Preventive when used for appropriate preventive purposes—This medication is part of a health care reform preventive benefit and may be available at no cost to you when used for appropriate preventive purposes. For more information, please refer to the California Traditional, Access, and Enhanced HMO and PPO Prescription Drug List (PDL) PPACA $0 Cost-Share Preventive Care Medications list. Designated specialty program —For certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products, which are identified in the Coverage Requirements and Limits column of the Prescription Drug List (PDL). If you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program by contacting us at myuhc.com or the telephone number on your ID card. Specialty Medication Cost Share (SMCS) — Specialty medication cost share may apply. Please refer to the Pharmacy Schedule of Benefits for specific cost share. For HMO plans, does not apply to injectable medications covered under the medical benefit.

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on your health plan ID card. If you are a pre-enrollee and you would like to learn more about your specific pharmacy benefit, please contact your employer. Drugs administered by a health care professional are generally covered under the medical benefit while drugs that are self- administered are covered under the pharmacy benefit. In order to obtain medical benefits for drugs that are administered by a health care professional, your provider may also be required to obtain a prior authorization. The provider may contact UnitedHealthcare for more information or uhcprovider.com. Your Right to Request Access to a Non-formulary Drug This plan must cover all Medically Necessary Prescription Drug Products. When a Prescription Drug Product is not on our PDL, you or your representative may request an exception to gain access to that Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. If approved, we will cover the Prescription Drug Product for the duration of the prescription, including refills.

Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. If approved, we will cover the Prescription Drug Product for the duration of the exigency.

External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of its determination within 72 hours.

Expedited External Review If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. If we deny your exception request, you may appeal. Please refer to your Evidence of Coverage for details. The complaint and appeals process, including independent review, is described under Section 6: Questions, Complaints and Appeals. You may also call the telephone number listed on your identification (ID) card.

6 Requesting a Prior Authorization or Step Therapy Exception Before certain Prescription Drug Products are dispensed to you, your prescribing provider or your pharmacist is required to obtain prior authorization or step therapy exception from us. Your prescribing provider can submit a request by phone to OptumRx or electronically by contacting us at uhcprovider.com. The Prior Authorization staff of qualified pharmacists and technicians is available Monday – Friday from 5 a.m. – 10 p.m. PST and Saturday from 6 a.m. – 3 p.m. PST to assist licensed physicians. Most authorizations are completed within 24 hours. The most common reason for delay in the authorization process is insufficient information. Your licensed physician may need to provide information on diagnosis and medication history and/or evidence in the form of documents, records or lab tests which establish that the use of the requested Prescription Drug Product meets plan criteria. You may determine whether a particular Prescription Drug Product is subject to prior authorization or step therapy requirements by going online at myuhc.com or by calling at the toll-free phone number on the back of your health plan ID card. If you are changing policies, we will not require you to repeat step therapy when you are already being treated for a medical condition by a Prescription Drug Product provided the Prescription Drug Product is appropriately prescribed and considered safe and effective for your medical condition. However, we may impose a prior authorization requirement for the continued coverage of a Prescription Drug Product prescribed pursuant to step therapy requirements imposed by the former policy. Your prescribing provider may also prescribe another Prescription Drug Product covered under your policy that is medically appropriate for your medical condition. If you are currently taking a Prescription Drug Product which was approved by UnitedHealthcare for a specific medical condition and that drug is removed from the Prescription Drug List (PDL) and the prescribing provider continues to prescribe the Prescription Drug Product for your medical condition, we will continue to cover the Prescription Drug Product provided that the drug is appropriately prescribed and is considered safe and effective for treating your medical condition. In the case of a standard prior authorization or step therapy exception request, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 72 hours following receipt of the request. In the case of an expedited prior authorization or step therapy exception request based on exigent circumstances, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 24 hours following receipt of the request. If we fail to respond to you, your designee, or your prescribing provider within the prescribed time limits, the request is deemed approved and we may not deny the request thereafter. If you disagree with a determination, you can request an appeal. The complaint and appeals process, including independent medical review, is described in the Evidence of Coverage under Section 6: Questions, Complaints and Appeals. You may also call at the telephone number on your ID card.

How do I locate and fill a prescription through a retail network pharmacy? UnitedHealthcare has a well-established network of pharmacies including most major pharmacy and supermarket chains as well as many independent pharmacies. For a listing of network pharmacies, call the toll-free phone number on your health plan ID card to help locate a network pharmacy near you or visit our website at myuhc.com for an up-to-date list.

How do I locate and fill a prescription through the mail order pharmacy? UnitedHealthcare offers a Mail Order Pharmacy Program through OptumRx®. Here’s how to fill prescriptions through the Mail Order Pharmacy Program. 1. Call your prescribing provider to obtain a new prescription for each medication. When you call, ask the Physician to write the prescription for a 90-day supply which represents 3 prescription units with up to 3 additional refills. The doctor will tell you when to pick up the written prescription. (Note: OptumRx must have a new prescription to process any new Mail Order request.)

7 2. After picking up the prescription, complete the Mail Order Form included in your enrollment materials. (To obtain additional forms or for assistance in completing the form, contact UnitedHealthcare’s Customer Service Department by calling the telephone number on the back of your ID card. You can also find the form atoptumrx.com .) 3. Enclose the prescription and appropriate copayment via check, money order, or credit card. Your Pharmacy Schedule of Benefits will have the applicable copayment for the Mail Order Pharmacy Program. Make the check or money order payable to OptumRx. No cash please. Important Tip: If you are starting a new Prescription Drug Product, please request 2 prescriptions from your physician. Have 1 filled immediately at a network pharmacy while mailing the second prescription to UnitedHealthcare’s Mail Order Pharmacy. Once you receive your medication through the Mail Order Pharmacy Program, you should stop filling the prescription at the network pharmacy.

How do I locate and fill a prescription at a specialty pharmacy? Call the phone number on the back of your health plan ID card or visit specialty.optumrx.com to locate a designated specialty pharmacy for your medication.

Designated Pharmacies If you require certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Specialty Prescription Drug Products. There are both retail and mail pharmacies in the Designated Pharmacy network. Note that not all contracted retail pharmacies are in the Designated Pharmacy network. Only retail pharmacies that are in the Designated Pharmacy network will provide access to these Specialty Prescription Drug Products. If you choose not to obtain your Specialty Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program through the Internet at myuhc.com or by calling the telephone number on your ID card. If you want to opt-out of the program and fill your Specialty Prescription Drug Product at a non-Designated Pharmacy but do not inform us, you will be responsible for the entire cost of the Specialty Prescription Drug Product and no Benefits will be paid. In urgent or emergent circumstances, you may contact Customer Service by calling the telephone number on the back of your ID card. This will allow you access to the retail network override process and allow the urgent or emergent prescription claim to pay at your local pharmacy for same day access if they have the Prescription Drug Product available.

How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log in to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by ZIP code • Your prescription history

And, if mail order services are included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set up reminders for refills • Manage your account

Learn more Call the toll-free member phone number on your health plan ID card, or visit myuhc.com.

8 Nondiscrimination notice and access to communication services UnitedHealthcare Services, Inc. on behalf of itself and its affiliates does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. If you think you were treated unfairly for any of these reasons, you can send a complaint to: Online: [email protected] Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll- free phone number listed on your ID card. If you think you were treated unfairly because of your race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can also send a complaint to the California Department of Managed Health Care DMHC California Help Center 980 9th Street, Suite 500 Sacramento, CA 95814-2725 1-888-HMO-2219 (1-888-466-2219) 1-800-735-2929 or 1-888-877-5378 (TTY) Internet Website: www.hmohelp.ca.gov If you think you were treated unfairly because of your sex, age, race, color, national origin, or disability, you can also file a complaint with the U.S. Dept. of Health and Human Services: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

9 English IMPORTANT LANGUAGE INFORMATION: You may be entitled to the rights and services below. You can get an interpreter or services at no charge. Written information may also be available in some languages at no charge. To get help in your language, please call your health plan at: UnitedHealthcare of California 1-800-624-8822 / TTY: 711. If you need more help, call HMO Help Line at 1-888-466-2219.

Spanish INFORMACIÓN IMPORTANTE SOBRE IDIOMAS: Es probable que usted disponga de los derechos y servicios a continuación. Puede pedir un intérprete o servicios de traducción sin cargo. Es posible que tenga disponible documentación impresa en algunos idiomas sin cargo. Para recibir ayuda en su idioma, llame a su plan de salud de UnitedHealthcare of California al 1-800- 624-8822 / TTY: 711. Si necesita más ayuda, llame a la línea de ayuda de la HMO al 1-888-466-2219.

Chinese 重要語言資訊: 您可能有資格享有下列權利並取得下列服務。您可以免費獲取口譯員或翻譯服務。部分語言亦備 有免費書面資訊。如需取得您語言的協助,請撥打下列電話與您的健保計畫聯絡: UnitedHealthcare of California 1-800-624-8822 / 聽力語言殘障服務專線 (TTY):711。若您需要 更多協助,請撥打 HMO 協助專線 1-888-466-2219。

Armenian ԿԱՐԵՎՈՐ ԼԵԶՎԱԿԱՆ ՏԵՂԵԿՈՒԹՅՈՒՆ՝ Հավանական է, որ Ձեզ հասանելի լինեն հետևյալ իրավունքներն ու ծառայությունները: Կարող եք ստանալ բանավոր թարգմանչի կամ թարգմանության անվճար ծառայություններ: Հնարավոր է, որ մի շարք լեզուներով նաև առկա լինի անվճար գրավոր տեղեկություն: Ձեր լեզվով օգնություն ստանալու համար խնդրում ենք զանգահարել Ձեր առողջապահական ծրագիր՝ UnitedHealthcare of California 1-800-624-8822 / TTY 711 համարով: Հավելյալ օգնության կարիքի դեպքում, զանգահարեք HMO-ի Օգնության հեռախոսագիծ 1-888-466-2219 համարով:

10 Hmong COV NTAUB NTAWV LUS TSEEM CEEB: Tej zaum koj yuav muaj cai rau cov cai pab cuam hauv qab no. Koj tuaj yeem tau txais ib tug kws txhais lus los sis txhais ntawv pub dawb. Cov ntaub ntawv sau no muaj sau ua qee yam ntaub ntawv pub dawb rau sawd daws. Yuav tau txais kev cov ntaub ntawv sau ua koj lus, thov hu rau qhov chaw npaj kho mob rau ntawm: UnitedHealthcare of California 1-800-624-8822 / TTY: 711. Yog koj xav tau kev pab ntxiv, hu rau HMO Help Line ntawm tus xov tooj 1-888-466-2219.

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11 Russian :

12 Table of Contents of Prescription Drug List Informational Section...... 1 ANTIHISTAMINE DRUGS - Drugs for Allergy...... 13 ANTI-INFECTIVE AGENTS - Drugs for ...... 15 ANTINEOPLASTIC AGENTS - Drugs for Cancer ...... 37 ANTITOXINS,IMMUNE GLOB,TOXOIDS, - DRUGS FOR THE IMMUNE SYSTEM...... 46 AUTONOMIC DRUGS - Drugs for the Nervous System ...... 50 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ...... 61 CARDIOVASCULAR DRUGS - Drugs for the Heart...... 71 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ...... 94 DENTAL AGENTS - Oral Care ...... 137 DEVICES - Medical Supplies and Durable Medical Equipment...... 137 DIAGNOSTIC AGENTS...... 141 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants ...... 141 ELECTROLYTIC, CALORIC, AND WATER BALANCE ...... 142 ENZYMES...... 150 EYE, EAR, NOSE AND THROAT (EENT) PREPS...... 151 GASTROINTESTINAL DRUGS ...... 162 GASTROINTESTINAL DRUGS - Drugs for the Stomach ...... 162 GOLD COMPOUNDS...... 171 HEAVY METAL ANTAGONISTS - Drugs to Reduce ...... 171 AND SYNTHETIC SUBSTITUTES - Hormones ...... 171 LOCAL (PARENTERAL) - Drugs for Numbing ...... 211 MISCELLANEOUS THERAPEUTIC AGENTS ...... 212 NONHORMONAL CONTRACEPTIVES - Drugs for Women ...... 232 OXYTOCICS - Drugs for Women...... 233 PHARMACEUTICAL AIDS...... 233 RESPIRATORY TRACT AGENTS - Drugs for the Lungs ...... 233 AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ...... 242 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ...... 268 VITAMINS...... 269

TOC-1 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINE DRUGS - Drugs for Allergy ANTIHISTAMINE DRUGS - Drugs for Allergy promethazine hcl oral tablet 25 mg 1 ETHANOLAMINE DERIVATIVES - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML ( hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 FIRST- BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 4 MG/5ML (carbinoxamine maleate) FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - Drugs for Allergy cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 FIRST GENERATION ANTIHISTAMINES - Drugs for Allergy ANTIVERT ORAL TABLET 50 MG ( hcl) 2 carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 13 Coverage Requirements & Prescription Drug Name Drug Tier Limits di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 4 MG/5ML (carbinoxamine maleate) promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 4 pamoate) OTHER ANTIHISTAMINES - Drugs for Allergy cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 famotidine oral suspension reconstituted 40 mg/5ml 1 hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 nizatidine oral solution 15 mg/ml 1 olopatadine hcl nasal solution 0.6 % 1 olopatadine hcl solution 0.1 % ophthalmic (rx) 0.1 % 1 PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 4 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 4 pamoate) PHENOTHIAZINE DERIVATIVES - Drugs for Allergy promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 14 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA promethazine-codeine oral solution 6.25-10 mg/5ml 1 PA promethazine-codeine oral syrup 6.25-10 mg/5ml 1 PA promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 PROPYLAMINE DERIVATIVES - Drugs for Allergy dexchlorpheniramine maleate oral solution 2 mg/5ml 1 hydrocodone polst-chlorphen polst er susp oral 1 PA suspension extended release 10-8 mg/5ml pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 4 PA 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) SECOND GENERATION ANTIHISTAMINES - Drugs for Allergy ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) desloratadine oral tablet 5 mg 1 desloratadine oral tablet dispersible 5 mg 1 levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 levocetirizine dihydrochloride oral tablet 5 mg 1 ANTI-INFECTIVE AGENTS - Drugs for Infections 1ST GENERATION CEPHALOSPORIN - Antibiotics cefadroxil oral capsule 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 15 Coverage Requirements & Prescription Drug Name Drug Tier Limits cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml 1 cefadroxil oral tablet 1 gm 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cephalexin oral tablet 250 mg, 500 mg 1 KEFLEX ORAL CAPSULE 750 MG (cephalexin) 4 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefaclor er oral tablet extended release 12 hour 500 mg 1 cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml 1 cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefixime oral capsule 400 mg 1 cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1 cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml 1 cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 SUPRAX ORAL CAPSULE 400 MG (cefixime) 4 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 4 MG/5ML, 200 MG/5ML, 500 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 4 (cefixime)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 16 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADAMANTANE ANTIVIRALS - Drugs for Viral Infections hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1 hcl oral tablet 100 mg 1 ALLYLAMINE - Drugs for Fungus terbinafine hcl oral tablet 250 mg 1 SL (90 tablets per 365 days) AMEBICIDES - Drugs for the Mouth and Throat FIRST- ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate) FLAGYL ORAL CAPSULE 375 MG (metronidazole) 4 FLAGYL ORAL TABLET 500 MG (metronidazole) 4 METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate) metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole vaginal gel 0.75 % 1 NUVESSA VAGINAL GEL 1.3 % (metronidazole) 4 sulfate oral capsule 250 mg 1 vandazole vaginal gel 0.75 % 1 ANTIBIOTICS - Antibiotics ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML PA; SL (8.4 ml per day.); 4 ( sulfate liposome) SMCS; SP sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 TOBI PODHALER INHALATION CAPSULE 28 MG PA; SL (224 capsules per 56 3 () days.); SMCS; SP PA; SL (224 ml per 56 tobramycin inhalation nebulization solution 300 mg/4ml 1 days.); SMCS; SP AMINOMETHYLCYCLINES - Antibiotics NUZYRA ORAL TABLET 150 MG ( tosylate) 4 AMINOPENICILLIN ANTIBIOTICS - Antibiotics SL (112 capsules and tablets amoxicill-clarithro-lansopraz oral 1 (1 Package) per 180 days.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 17 Coverage Requirements & Prescription Drug Name Drug Tier Limits amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1 amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 amoxicillin-potassium clavulanate er oral tablet extended 1 release 12 hour 1000-62.5 mg amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 1 mg/5ml, 600-42.9 mg/5ml amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg 1 amoxicillin-potassium clavulanate oral tablet chewable 200- 28.5 mg, 400-57 mg 1 ampicillin oral capsule 500 mg 1 AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125- 4 31.25 MG/5ML (amoxicillin-pot clavulanate) SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 administrative cards, 80 clarithro-) tablets) per 6 months.) ANTHELMINTICS - Drugs for Parasites oral tablet 200 mg 1 SL (124 tablets per month.) ALBENZA ORAL TABLET 200 MG ( albendazole) 4 SL (124 tablets per month.) BILTRICIDE ORAL TABLET 600 MG (praziquantel) 4 EGATEN ORAL TABLET 250 MG (triclabendazole) 3 EMVERM ORAL TABLET CHEWABLE 100 MG 4 SL (6 tablets per 3 days.) (mebendazole) ivermectin oral tablet 3 mg 1 praziquantel oral tablet 600 mg 1 STROMECTOL ORAL TABLET 3 MG ( ivermectin) 4 ANTIFUNGALS, MISCELLANEOUS - Drugs for Fungus microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 18 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTI-INFECTIVES (SYSTEMIC), MISC. - Drugs for Infections PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) ANTIMALARIALS - Drugs for the Mouth and Throat ARAKODA ORAL TABLET 100 MG ( succinate) 4 SL (16 tablets per month.) - hcl oral tablet 250-100 mg, 62.5-25 mg 1 avidoxy oral tablet 100 mg 1 phosphate oral tablet 250 mg, 500 mg 1 COARTEM ORAL TABLET 20-120 MG (- 2 ) DARAPRIM ORAL TABLET 25 MG () 4 PA; SMCS; SP DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG 4 ( hyclate) DORYX ORAL TABLET DELAYED RELEASE 80 MG 4 (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 75 mg 1 doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg 1 DOXYCYCLINE HYCLATE ORAL TABLET DELAYED 4 RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg 1 doxycycline monohydrate oral suspension reconstituted 25 mg/5ml 1 doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1 sulfate oral tablet 200 mg 1 KRINTAFEL ORAL TABLET 150 MG ( tafenoquine succinate) 1 MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG 4 (atovaquone-proguanil hcl) hcl oral tablet 250 mg 1 hcl oral capsule 100 mg, 50 mg, 75 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 19 Coverage Requirements & Prescription Drug Name Drug Tier Limits minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 mondoxyne nl oral capsule 100 mg, 75 mg 1 morgidox oral capsule 100 mg 1 phosphate oral tablet 26.3 (15 base) mg 1 pyrimethamine oral tablet 25 mg 1 PA; SMCS; SP QUALAQUIN ORAL CAPSULE 324 MG ( sulfate) 4 gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 quinine sulfate oral capsule 324 mg 1 hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 4 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 4 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 calcium) ANTIMYCOBACTERIALS, MISCELLANEOUS - Antibiotics oral tablet 100 mg, 25 mg 1 , MISCELLANEOUS - Drugs for the Mouth and Throat ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 2 () ALINIA ORAL TABLET 500 MG (nitazoxanide) 4 atovaquone oral suspension 750 mg/5ml 1 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 4 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 4 trimethoprim) PA; SL (248 tablets per 720 ORAL TABLET 100 MG 2 days) PA; SL (720 tablets per 720 BENZNIDAZOLE ORAL TABLET 12.5 MG 2 days.) dapsone oral tablet 100 mg, 25 mg 1 FIRST-METRONIDAZOLE ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 20 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLAGYL ORAL CAPSULE 375 MG (metronidazole) 4 FLAGYL ORAL TABLET 500 MG (metronidazole) 4 IMPAVIDO ORAL CAPSULE 50 MG () 2 PA; SL (3 capsules per day.) LAMPIT ORAL TABLET 120 MG () 4 PA; SL (7.5 tablets per day.) LAMPIT ORAL TABLET 30 MG (nifurtimox) 4 PA; SL (9 tablets per day.) METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate) metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 4 MG ( isethionate) nitazoxanide oral tablet 500 mg 1 pentamidine isethionate inhalation solution reconstituted 300 mg 1 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) SOLOSEC ORAL PACKET 2 GM (secnidazole) 4 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 oral tablet 250 mg, 500 mg 1 ANTITUBERCULOSIS AGENTS - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) () CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 4 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1 cycloserine oral capsule 250 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 21 Coverage Requirements & Prescription Drug Name Drug Tier Limits ethambutol hcl oral tablet 100 mg, 400 mg 1 oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 1 MYAMBUTOL ORAL TABLET 400 MG ( ethambutol hcl) 4 MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 4 PASER ORAL PACKET 4 GM (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 200 MG 4 PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 RIFAMPIN+SYRSPEND SF ORAL SUSPENSION 25 MG/ML 3 PA (rifampin) SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline 2 fumarate) TRECATOR ORAL TABLET 250 MG ( ethionamide) 2 ANTIVIRALS, MISCELLANEOUS - Drugs for Viral Infections FAVIPIRAVIR ORAL TABLET 200 MG 3 PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) 2 PA XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per month.) X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per month.) X 40 MG (baloxavir marboxil) AZOLE ANTIFUNGALS - Drugs for Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium 3 sulfate) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 4 MG/ML, 40 MG/ML () DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG 4 (fluconazole) DIFLUCAN ORAL TABLET 50 MG (fluconazole) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 22 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 1 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 SL (180 capsules per 365 itraconazole oral capsule 100 mg 1 days) itraconazole oral solution 10 mg/ml 1 SL (1800 ml per 365 days) oral tablet 200 mg 1 NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) 2 SL (20 ml per day.) posaconazole oral tablet delayed release 100 mg 1 SL (180 capsules per 365 SPORANOX ORAL CAPSULE 100 MG (itraconazole) 4 days) SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) 4 SL (1800 ml per 365 days) SPORANOX PULSEPAK ORAL CAPSULE 100 MG SL (180 capsules per 365 4 (itraconazole) days) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML 4 (voriconazole) VFEND ORAL TABLET 200 MG (voriconazole) 4 VFEND ORAL TABLET 50 MG (voriconazole) 3 voriconazole oral suspension reconstituted 40 mg/ml 1 voriconazole oral tablet 200 mg, 50 mg 1 ANTIBIOTICS - Antibiotics E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 4 MG/5ML (erythromycin ethylsuccinate) ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 4 MG, 500 MG (erythromycin base) ERYTHROCIN STEARATE ORAL TABLET 250 MG 2 (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg 1 erythromycin base oral tablet 250 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 23 Coverage Requirements & Prescription Drug Name Drug Tier Limits erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg 1 erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml 1 erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg 1 GLYCOPEPTIDE ANTIBIOTICS - Antibiotics FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 1 MG/ML (vancomycin hcl) VANCOCIN HCL ORAL CAPSULE 125 MG (vancomycin hcl) 4 SL (56 capsules per 11 days) SL (112 capsules per 11 VANCOCIN ORAL CAPSULE 250 MG (vancomycin hcl) 4 days) vancomycin hcl oral capsule 125 mg 1 SL (56 capsules per 11 days) SL (112 capsules per 11 vancomycin hcl oral capsule 250 mg 1 days) vancomycin hcl oral solution reconstituted 250 mg/5ml 1 VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 3 PA MG/ML (vancomycin hcl) HCV POLYMERASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir- PA; SL (1 tablet per day.); 2 velpatasvir) SMCS EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir- PA; SL (84 tablets per 720 2 velpatasvir) days.); SMCS HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG SL (1 pellet per day and 84 2 (ledipasvir-sofosbuvir) pellets per 720 days.); SMCS PA; ST; SL (84 tablets per HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 2 720 days.); SMCS PA; ST; SL (56 tablets per HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 720 days.); SMCS PA; ST; SL (56 tablets per LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 720 days.); SMCS PA; SL (84 tablets per 720 SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 days.); SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 24 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; SL (1 pellet per day SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) 4 and 84 pellets per 720 days.); SMCS PA; ST; SL (84 tablets per SOVALDI ORAL TABLET 200 MG (sofosbuvir) 4 720 days.); SMCS PA; ST; SL (84 tablets per SOVALDI ORAL TABLET 400 MG (sofosbuvir) 4 720 days.); SMCS; SP VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 4 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SMCS; SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SL (84 tablets per 720 2 velpatasv-voxilaprev) days); SMCS; SP HCV PROTEASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SL (168 tablets per 720 2 pibrentasvir) days); SMCS; SP VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 4 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SMCS; SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SL (84 tablets per 720 2 velpatasv-voxilaprev) days); SMCS; SP PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks).); SMCS; SP HCV REPLICATION COMPLEX INHIBITORS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir- PA; SL (1 tablet per day.); 2 velpatasvir) SMCS EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir- PA; SL (84 tablets per 720 2 velpatasvir) days.); SMCS HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG SL (1 pellet per day and 84 2 (ledipasvir-sofosbuvir) pellets per 720 days.); SMCS PA; ST; SL (84 tablets per HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 2 720 days.); SMCS PA; ST; SL (56 tablets per HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 720 days.); SMCS PA; ST; SL (56 tablets per LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 720 days.); SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 25 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SL (168 tablets per 720 2 pibrentasvir) days); SMCS; SP PA; SL (84 tablets per 720 SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 days.); SMCS VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 4 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SMCS; SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SL (84 tablets per 720 2 velpatasv-voxilaprev) days); SMCS; SP PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks).); SMCS; SP HIV ENTRY AND FUSION INHIBITORS - Drugs for Viral Infections FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 2 M MG () RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 4 PA 600 MG ( tromethamine) SELZENTRY ORAL SOLUTION 20 MG/ML () 2 PA SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 2 PA (maraviroc) HIV ANTIRETROVIRALS - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (- 3 SL (1 tablet per day.) emtricitab-tenofov) DOVATO ORAL TABLET 50-300 MG (- 2 SL (1 tablet per day.) ) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) ISENTRESS HD ORAL TABLET 600 MG ( 2 potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET 400 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 2 (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir-) 2 SL (1 tablet per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 26 Coverage Requirements & Prescription Drug Name Drug Tier Limits STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 SL (1 tablet per day.) cobic-emtricit-tenofdf) TIVICAY ORAL TABLET 50 MG (dolutegravir sodium) 3 TIVICAY PD ORAL TABLET SOLUBLE 5 MG (dolutegravir 3 sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (- 2 SL (1 tablet per day.) dolutegravir-lamivud) HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 3 SL (1 tablet per day.) emtricitab-tenofov) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 3 SL (1 tablet per day.) rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 SL (1 tablet per day.) lamivudin-tenofov df) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) 2 oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 SL (1 tablet per day.) efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg 1 SL (1 tablet per day.) oral tablet 100 mg, 200 mg 1 INTELENCE ORAL TABLET 100 MG, 200 MG ( etravirine) 4 INTELENCE ORAL TABLET 25 MG ( etravirine) 2 JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 SL (1 tablet per day.) er oral tablet extended release 24 hour 100 mg, 400 mg 1 nevirapine oral suspension 50 mg/5ml 1 nevirapine oral tablet 200 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 3 SL (1 tablet per day.) tenofov af) PIFELTRO ORAL TABLET 100 MG () 3 SUSTIVA ORAL TABLET 600 MG (efavirenz) 4 SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 27 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir) VIRAMUNE ORAL SUSPENSION 50 MG/5ML (nevirapine) 4 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS - Drugs for Viral Infections abacavir sulfate oral solution 20 mg/ml 1 abacavir sulfate oral tablet 300 mg 1 abacavir sulfate-lamivudine oral tablet 600-300 mg 1 SL (1 tablet per day.) abacavir-lamivudine- oral tablet 300-150-300 mg 1 BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 3 SL (1 tablet per day.) emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 SL (1 tablet per day.) COMBIVIR ORAL TABLET 150-300 MG (lamivudine- 4 zidovudine) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 3 SL (1 tablet per day.) rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 SL (1 tablet per day.) lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (- 3 SL (1 tablet per day.); H-N tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- 2 SL (1 tablet per day.) lamivudine) efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 SL (1 tablet per day.) efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg 1 SL (1 tablet per day.) emtricitabine oral capsule 200 mg 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg 1 SL (1 tablet per day.) emtricitabine-tenofovir df oral tablet 200-300 mg 1 SL (1 tablet per day.); H EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) 4 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) 2 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) 2 SMCS EPIVIR HBV ORAL TABLET 100 MG (lamivudine) 4 SMCS EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) 4 EPIVIR ORAL TABLET 150 MG, 300 MG (lamivudine) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 28 Coverage Requirements & Prescription Drug Name Drug Tier Limits GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 100 mg 1 SMCS lamivudine oral tablet 150 mg, 300 mg 1 lamivudine-zidovudine oral tablet 150-300 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 3 SL (1 tablet per day.) tenofov af) RETROVIR ORAL CAPSULE 100 MG (zidovudine) 4 RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) 3 oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 SL (1 tablet per day.) cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 3 SL (1 tablet per day.) emtricit-tenofaf) fumarate oral tablet 300 mg 1 H-N TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 SL (1 tablet per day.) dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 4 SL (1 tablet per day.) MG (emtricitabine-tenofovir df) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil 3 fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir 2 disoproxil fumarate) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) 4 ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) 4 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 29 Coverage Requirements & Prescription Drug Name Drug Tier Limits HIV PROTEASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG () 2 sulfate oral capsule 150 mg, 200 mg, 300 mg 1 CRIXIVAN ORAL CAPSULE 400 MG ( sulfate) 2 EVOTAZ ORAL TABLET 300-150 MG (atazanavir-) 2 calcium oral tablet 700 mg 1 INVIRASE ORAL TABLET 500 MG ( mesylate) 2 KALETRA ORAL SOLUTION 400-100 MG/5ML (- 4 ) KALETRA ORAL TABLET 100-25 MG, 200-50 MG (lopinavir- 4 ritonavir) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir 2 calcium) lopinavir-ritonavir oral solution 400-100 mg/5ml 1 lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 1 NORVIR ORAL PACKET 100 MG (ritonavir) 2 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) 2 PREZCOBIX ORAL TABLET 800-150 MG (- 2 cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir 2 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 (darunavir ethanolate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) 2 ritonavir oral tablet 100 mg 1 SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 3 SL (1 tablet per day.) emtricit-tenofaf) VIRACEPT ORAL TABLET 250 MG, 625 MG ( 2 mesylate) INTERFERON ANTIVIRALS - Drugs for Viral Infections ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 M (interferon alfa-n3) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 4 PA; M; SMCS; SP 6000000 UNIT/ML (interferon alfa-2b)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 30 Coverage Requirements & Prescription Drug Name Drug Tier Limits INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 4 PA; M; SMCS; SP alfa-2b) PA; M; SL (4 prefilled PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML 2 syringes per month.); SMCS; (peginterferon alfa-2a) SP PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PA; M; SL (4 auto-injectors 2 (peginterferon alfa-2a) per month); SMCS; SP ANTIBIOTICS - Antibiotics CLEOCIN ORAL CAPSULE 150 MG, 300 MG ( 4 hcl) CLEOCIN ORAL CAPSULE 75 MG (clindamycin hcl) 2 CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML 4 (clindamycin palmitate hcl) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml 1 MONOBACTAM ANTIBIOTICS - Antibiotics CAYSTON INHALATION SOLUTION RECONSTITUTED 75 PA; ST; SL (84 vials per 56 2 MG (aztreonam ) days.); SMCS; SP NATURAL PENICILLIN ANTIBIOTICS - Antibiotics penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml 1 penicillin v potassium oral tablet 250 mg, 500 mg 1 NEURAMINIDASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg 1 oseltamivir phosphate oral suspension reconstituted 6 mg/ml 1 SL (180 ml per month) RELENZA DISKHALER INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 5 MG/BLISTER (zanamivir) NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS - Drugs for Viral Infections acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 400 mg, 800 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 31 Coverage Requirements & Prescription Drug Name Drug Tier Limits adefovir dipivoxil oral tablet 10 mg 1 SMCS BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) 2 SMCS BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) 4 SMCS entecavir oral tablet 0.5 mg, 1 mg 1 SMCS famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 ribavirin inhalation solution reconstituted 6 gm 1 ribavirin oral capsule 200 mg 1 ribavirin oral tablet 200 mg 1 valacyclovir hcl oral tablet 1 gm, 500 mg 1 valganciclovir hcl oral solution reconstituted 50 mg/ml 1 valganciclovir hcl oral tablet 450 mg 1 SL (2 tablets per day) VEMLIDY ORAL TABLET 25 MG ( 4 ST; SMCS fumarate) VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM 4 (ribavirin) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) 4 OTHER ANTIBIOTICS - Antibiotics SL (112 capsules and tablets amoxicill-clarithro-lansopraz oral 1 (1 Package) per 180 days.) oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1 azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 SL (136 mL per 10 days.) (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) 3 SL (20 tablets per 7 days) SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 administrative cards, 80 clarithro-omeprazole) tablets) per 6 months.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 32 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZITHROMAX ORAL PACKET 1 GM (azithromycin) 4 ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 4 MG/5ML, 200 MG/5ML (azithromycin) ZITHROMAX ORAL TABLET 250 MG, 500 MG (azithromycin) 4 ZITHROMAX TRI-PAK ORAL TABLET 500 MG (azithromycin) 4 ZITHROMAX Z-PAK ORAL TABLET 250 MG (azithromycin) 4 OXAZOLIDINONE ANTIBIOTICS - Antibiotics oral suspension reconstituted 100 mg/5ml 1 SL (900 ml per 11 days) linezolid oral tablet 600 mg 1 SL (28 tablets per 11 days) SIVEXTRO ORAL TABLET 200 MG ( phosphate) 3 ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 4 SL (900 ml per 11 days) (linezolid) PENICILLINASE-RESISTANT PENICILLINS - Antibiotics sodium oral capsule 250 mg, 500 mg 1 - Antibiotics XENLETA ORAL TABLET 600 MG ( acetate) 3 POLYENE ANTIFUNGALS - Drugs for Fungus nystatin mouth/throat suspension 100000 unit/ml 1 nystatin oral tablet 500000 unit 1 POLYMYXIN ANTIBIOTICS - Antibiotics colistimethate sodium (cba) injection solution reconstituted 150 mg 1 M COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 4 M 150 MG (colistimethate sodium) PYRIMIDINE ANTIFUNGALS - Drugs for Fungus ANCOBON ORAL CAPSULE 250 MG (flucytosine) 4 ANCOBON ORAL CAPSULE 500 MG (flucytosine) 3 flucytosine oral capsule 250 mg, 500 mg 1 QUINOLONE ANTIBIOTICS - Antibiotics BAXDELA ORAL TABLET 450 MG (delafloxacin meglumine) 3 CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 33 Coverage Requirements & Prescription Drug Name Drug Tier Limits ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 1 oral tablet 300 mg, 400 mg 1 ANTIBIOTICS - Antibiotics AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG 3 (rifamycin sodium) MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 4 PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 RIFAMPIN+SYRSPEND SF ORAL SUSPENSION 25 MG/ML 3 PA (rifampin) XIFAXAN ORAL TABLET 200 MG () 3 XIFAXAN ORAL TABLET 550 MG (rifaximin) 3 SL (62 tablets per month.) ANTIBIOTICS (SYSTEMIC) - Antibiotics AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 4 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 4 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 4 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 4 trimethoprim) oral tablet 500 mg 1 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 34 Coverage Requirements & Prescription Drug Name Drug Tier Limits - Antibiotics AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) avidoxy oral tablet 100 mg 1 hcl oral tablet 150 mg, 300 mg 1 DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG 4 (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 80 MG 4 (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg 1 doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg 1 DOXYCYCLINE HYCLATE ORAL TABLET DELAYED 4 RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg 1 doxycycline monohydrate oral suspension reconstituted 25 mg/5ml 1 doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1 doxycycline oral capsule delayed release 40 mg 4 minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 mondoxyne nl oral capsule 100 mg, 75 mg 1 MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 4 (doxycycline hyclate-cleanser) morgidox oral capsule 100 mg 1 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 35 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 4 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 calcium) URINARY ANTI-INFECTIVES - Drugs for the Urinary System BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 4 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 4 trimethoprim) fosfomycin tromethamine oral packet 3 gm 1 HIPREX ORAL TABLET 1 GM (methenamine hippurate) 4 HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) MACROBID ORAL CAPSULE 100 MG (nitrofurantoin 4 monohyd macro) MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG 4 (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methenamine hippurate oral tablet 1 gm 1 methenamine mandelate oral tablet 0.5 gm, 1 gm 1 MONUROL ORAL PACKET 3 GM (fosfomycin tromethamine) 4 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 nitrofurantoin monohydrate macrocrystals oral capsule 100 mg 1 nitrofurantoin oral suspension 25 mg/5ml 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim hcl) 3 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 trimethoprim oral tablet 100 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 36 Coverage Requirements & Prescription Drug Name Drug Tier Limits URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 2 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 4 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) ANTINEOPLASTIC AGENTS - Drugs for Cancer ANTINEOPLASTIC AGENTS - Drugs for Cancer PA; SL (4 tablets per day.); abiraterone acetate oral tablet 250 mg 1 SMCS; SP; CM AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 PA; SL (1 tablet per day.); 2 MG (everolimus) SMCS; SP; CM PA; SL (1 tablet per day.); AFINITOR ORAL TABLET 10 MG (everolimus) 2 SMCS; SP; CM PA; SL (8 capsules per day.); ALECENSA ORAL CAPSULE 150 MG ( hcl) 2 SMCS; SP; CM ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 M (interferon alfa-n3) ALKERAN ORAL TABLET 2 MG (melphalan) 4 SMCS; CM PA; SL (1 tablet per day); ALUNBRIG ORAL TABLET 180 MG, 90 MG () 2 SMCS; SP; CM PA; SL (6 tablets per day); ALUNBRIG ORAL TABLET 30 MG (brigatinib) 2 SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 37 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG PA; SL (30 packs per year); 2 (brigatinib) SMCS; SP; CM anastrozole oral tablet 1 mg 1 AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG PA; SL (1 tablet per day.); 4 () SMCS; SP; CM AYVAKIT ORAL TABLET 25 MG, 50 MG (avapritinib) 4 PA; SMCS; SP; CM PA; SL (3 tablets per day.); BALVERSA ORAL TABLET 3 MG (erdafitinib) 2 SMCS; SP; CM PA; SL (2 tablets per day.); BALVERSA ORAL TABLET 4 MG (erdafitinib) 2 SMCS; SP; CM PA; SL (1 tablet per day.); BALVERSA ORAL TABLET 5 MG (erdafitinib) 2 SMCS; SP; CM oral tablet 50 mg 1 PA; ST; SL (4 tablets per BOSULIF ORAL TABLET 100 MG () 2 day.); SMCS; SP; CM PA; ST; SL (1 tablet per BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) 2 day.); SMCS; SP; CM PA; ST; SL (6 capsules per BRAFTOVI ORAL CAPSULE 75 MG () 4 day); SMCS; SP; CM PA; SL (4 capsules per day.); BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) 2 SMCS; SP; CM CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; SL (1 tablet per day.); 2 ( s-malate) SMCS; SP; CM PA; SL (2 capsules per day); CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) 2 SMCS; SP; CM capecitabine oral tablet 150 mg, 500 mg 1 SMCS; SP; CM PA; SL (2 tablets per day.); CAPRELSA ORAL TABLET 100 MG () 2 SMCS; SP; CM PA; SL (1 tablet per day.); CAPRELSA ORAL TABLET 300 MG (vandetanib) 2 SMCS; SP; CM CASODEX ORAL TABLET 50 MG (bicalutamide) 4 PA; SL (93 capsules per COMETRIQ ORAL KIT 20 MG (cabozantinib s-malate) 2 month.); SMCS; SP; CM COMETRIQ ORAL KIT 3 X 20 MG & 80 MG (cabozantinib s- PA; SL (124 capsules per 2 malate) month.); SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 38 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (62 capsules per COMETRIQ ORAL KIT 80 & 20 MG (cabozantinib s-malate) 2 month.); SMCS; SP; CM PA; SL (2 capsules per day.); COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) 4 SMCS; SP; CM COTELLIC ORAL TABLET 20 MG ( fumarate) 2 PA; SMCS; SP; CM oral capsule 25 mg, 50 mg 1 CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM PA; SL (1 tablet per day.); DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 2 SMCS; SP; CM PA; SL (2 tablets per day.); DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 2 SMCS; SP; CM DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 2 (hydroxyurea) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 PA; M; SMCS (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 PA; M; SMCS month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 PA; M; SMCS month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA; M; SMCS EMCYT ORAL CAPSULE 140 MG (estramustine phosphate 2 sodium) PA; SL (1 capsule per day.); ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) 2 SMCS; SP; CM PA; SL (4 tablets per day.); ERLEADA ORAL TABLET 60 MG (apalutamide) 2 SMCS; SP; CM PA; SL (1 tablet per day.); hcl oral tablet 100 mg, 150 mg, 25 mg 1 SMCS; SP; CM etoposide oral capsule 50 mg 1 SMCS; SP; CM PA; SL (1 tablet per day.); everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 SMCS; SP; CM exemestane oral tablet 25 mg 1 FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 2 PA; SMCS; SP; CM (panobinostat lactate) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 M; SMCS; SP RECONSTITUTED 120 MG/VIAL (degarelix acetate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 39 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 M; SMCS; SP 80 MG (degarelix acetate) oral capsule 125 mg 1 PA; SL (4 capsules per day.); GAVRETO ORAL CAPSULE 100 MG () 4 SMCS; SP; CM GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ( PA; SL (1 tablet per day.); 3 dimaleate) SMCS; SP; CM GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 2 SMCS; SP (lomustine) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan hcl) 2 PA; SMCS; SP; CM HYDREA ORAL CAPSULE 500 MG (hydroxyurea) 4 hydroxyurea oral capsule 500 mg 1 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; SL (21 capsules per 2 (palbociclib) month.); SMCS; SP; CM IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; SL (0.75 tablets per 2 (palbociclib) day.); SMCS; SP; CM PA; SL (2 tablets per day.); ICLUSIG ORAL TABLET 15 MG ( hcl) 3 SMCS; SP; CM PA; SL (1 tablet per day.); ICLUSIG ORAL TABLET 45 MG (ponatinib hcl) 3 SMCS; SP; CM IDHIFA ORAL TABLET 100 MG, 50 MG ( PA; SL (1 tablet per day); 2 mesylate) SMCS; SP; CM PA; SL (6 tablets per day.); mesylate oral tablet 100 mg 1 SMCS; SP; CM PA; SL (1 tablet per day.); imatinib mesylate oral tablet 400 mg 1 SMCS; SP; CM PA; SL (3 capsules per day.); IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) 2 SMCS; SP; CM PA; SL (1 capsule per day.); IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) 2 SMCS; SP; CM IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 PA; SL (1 tablet per day.); 2 MG (ibrutinib) SMCS; SP; CM PA; SL (4 tablets per day.); INLYTA ORAL TABLET 1 MG () 3 SMCS; SP; CM PA; SL (124 tablets per 30 INLYTA ORAL TABLET 5 MG (axitinib) 3 days.); SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 40 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (5 tablets per INQOVI ORAL TABLET 35-100 MG (decitabine-cedazuridine) 4 month.); SMCS; SP; CM PA; ST; SL (4 capsules per INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) 4 day.); SMCS; SP INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 4 PA; M; SMCS; SP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 4 PA; M; SMCS; SP alfa-2b) PA; SL (1 tablet per day.); IRESSA ORAL TABLET 250 MG () 3 SMCS; SP; CM JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; SL (2 tablets per day.); 2 (ruxolitinib phosphate) SMCS; SP; CM KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG 4 PA; SMCS; SP; CM ORAL 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG PA; SL (42 tablets per 4 ORAL 200 MG (ribociclib succinate) month); SMCS; SP; CM KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG 4 PA; SMCS; SP; CM ORAL 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG PA; SL (63 tablets per 4 ORAL 200 MG (ribociclib succinate) month); SMCS; SP; CM KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 4 PA; SMCS; CM MG (ribociclib-letrozole) KISQALI ORAL TABLET THERAPY PACK 200 MG (ribociclib PA; SL (21 tablets per 4 succinate) month); SMCS; SP; CM PA; SL (8 capsules per day.); KOSELUGO ORAL CAPSULE 10 MG ( sulfate) 3 SMCS; SP; CM PA; SL (4 capsules per day.); KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 3 SMCS; SP; CM ditosylate oral tablet 250 mg 1 PA; SMCS; SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 2 X PA; SL (2 capsules per day.); 3 10 MG, 2 X 4 MG ( mesylate) SMCS; SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 PA; SL (3 capsules per day.); 3 MG, 2 X 10 MG & 4 MG, 3 X 4 MG (lenvatinib mesylate) SMCS; SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 MG, 4 MG PA; SL (1 capsule per day.); 3 (lenvatinib mesylate) SMCS; SP; CM letrozole oral tablet 2.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 41 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEUKERAN ORAL TABLET 2 MG (chlorambucil) 2 leuprolide acetate injection 1 mg/0.2ml 1 PA; M; SMCS LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PA; SL (100 tablets per 2 (trifluridine-tipiracil) month.); SMCS; SP; CM LORBRENA ORAL TABLET 100 MG, 25 MG ( ) 3 PA; SMCS; SP; CM LUMAKRAS ORAL TABLET 120 MG (sotorasib) 4 PA; SMCS; SP; CM PA; SL (4 tablets per day); LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) 2 SMCS; SP; CM LYSODREN ORAL TABLET 500 MG (mitotane) 2 MATULANE ORAL CAPSULE 50 MG ( hcl) 2 SMCS; SP; CM megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 MEKINIST ORAL TABLET 0.5 MG ( dimethyl PA; SL (2 tablets per day.); 3 sulfoxide) SMCS; SP; CM MEKINIST ORAL TABLET 2 MG (trametinib dimethyl PA; SL (1 tablet per day.); 3 sulfoxide) SMCS; SP; CM PA; ST; SL (6 tablets per MEKTOVI ORAL TABLET 15 MG () 4 day); SMCS; SP; CM melphalan oral tablet 2 mg 1 SMCS; CM mercaptopurine oral tablet 50 mg 1 oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution reconstituted 1 gm 1 M methotrexate sodium oral tablet 2.5 mg 1 MYLERAN ORAL TABLET 2 MG (busulfan) 2 PA; SL (6 tablets per day.); NERLYNX ORAL TABLET 40 MG ( maleate) 2 SMCS; SP; CM PA; SL (4 tablets per day.); NEXAVAR ORAL TABLET 200 MG ( tosylate) 2 SMCS; SP; CM NILANDRON ORAL TABLET 150 MG ( nilutamide) 4 SMCS; SP nilutamide oral tablet 150 mg 1 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 42 Coverage Requirements & Prescription Drug Name Drug Tier Limits NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG (ixazomib 2 PA; SMCS; SP; CM citrate) PA; SL (4 tablets per day.); NUBEQA ORAL TABLET 300 MG (darolutamide) 2 SMCS; SP; CM PA; SL (1 capsule per day.); ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) 2 SMCS; SP; CM PA; SL (1 tablet per day.); ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) 2 SMCS; SP; CM PA; SL (1 tablet per day); ORGOVYX ORAL TABLET 120 MG (relugolix) 3 SMCS; SP; CM PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG PA; SL (14 tablets per 21 4 () days.); SMCS; SP; CM PIQRAY ORAL TABLET THERAPY PACK 2 X 150 MG, 200 & PA; SL (2 tablets per day.); 2 50 MG (alpelisib) SMCS; SP; CM PA; SL (1 tablet per day.); PIQRAY ORAL TABLET THERAPY PACK 200 MG (alpelisib) 2 SMCS; SP; CM POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 3 PA; SMCS; SP; CM (pomalidomide) PURIXAN ORAL SUSPENSION 2000 MG/100ML 4 PA; SMCS; SP (mercaptopurine) PA; SL (3 tablets per day.); QINLOCK ORAL TABLET 50 MG () 4 SMCS; SP; CM PA; SL (6 capsules per day.); RETEVMO ORAL CAPSULE 40 MG () 4 SMCS; SP; CM RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 4 PA; SMCS; SP; CM REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 2 PA; SMCS; SP; CM 25 MG, 5 MG (lenalidomide) PA; SL (1 capsule per day.); ROZLYTREK ORAL CAPSULE 100 MG () 2 SMCS; SP; CM PA; SL (3 capsules per day.); ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 2 SMCS; SP; CM PA; ST; SL (2 tablets per RUBRACA ORAL TABLET 200 MG (rucaparib camsylate) 3 day.); SMCS; SP; CM RUBRACA ORAL TABLET 250 MG, 300 MG (rucaparib PA; ST; SL (4 tablets per 3 camsylate) day.); SMCS; SP; CM PA; SL (8 capsules per day); RYDAPT ORAL CAPSULE 25 MG (midostaurin) 2 SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 43 Coverage Requirements & Prescription Drug Name Drug Tier Limits SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, PA; ST; SL (1 tablet per 4 80 MG () day.); SMCS; SP; CM PA; ST; SL (2 tablets per SPRYCEL ORAL TABLET 20 MG (dasatinib) 4 day.); SMCS; SP; CM STIVARGA ORAL TABLET 40 MG () 2 PA; SMCS; SP; CM SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA; SL (1 capsule per day.); 2 ( malate) SMCS; SP; CM SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (28 vials per 2 3.5 MG (omacetaxine mepesuccinate) month); SMCS; SP TABLOID ORAL TABLET 40 MG (thioguanine) 2 SMCS; SP PA; SL (4 tablets per day.); TABRECTA ORAL TABLET 150 MG, 200 MG ( hcl) 4 SMCS; SP; CM TAFINLAR ORAL CAPSULE 50 MG, 75 MG ( PA; SL (4 capsules per day.); 3 mesylate) SMCS; SP; CM TAGRISSO ORAL TABLET 40 MG, 80 MG ( PA; SL (1 tablet per day.); 3 mesylate) SMCS; SP; CM PA; ST; SL (3 capsules per TALZENNA ORAL CAPSULE 0.25 MG (talazoparib tosylate) 4 day.); SMCS; SP; CM PA; ST; SL (1 capsule per TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 4 day.); SMCS; SP; CM tamoxifen citrate oral tablet 10 mg 1 tamoxifen citrate oral tablet 20 mg 1 H-N TARGRETIN ORAL CAPSULE 75 MG (bexarotene) 1 SMCS; CM TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG ( PA; ST; SL (4 capsules per 2 hcl) day.); SMCS; SP; CM PA; SL (8 tablets per day.); TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) 4 SMCS; SP; CM temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg 1 PA; SMCS; SP; CM PA; SL (2 tablets per day.); TEPMETKO ORAL TABLET 225 MG ( hcl) 4 SMCS; SP; CM PA; SL (2 tablets per day.); TIBSOVO ORAL TABLET 250 MG (ivosidenib) 2 SMCS; SP; CM toremifene citrate oral tablet 60 mg 1 oral capsule 10 mg 1 SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 44 Coverage Requirements & Prescription Drug Name Drug Tier Limits TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) PA; SL (4 tablets per day.); TUKYSA ORAL TABLET 150 MG () 2 SMCS; SP; CM PA; SL (10 tablets per day.); TUKYSA ORAL TABLET 50 MG (tucatinib) 2 SMCS; SP; CM PA; SL (4 capsules per day.); TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) 2 SMCS; SP; CM TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) 4 PA; SMCS; SP; CM PA; SL (4 tablets per day.); UKONIQ ORAL TABLET 200 MG (umbralisib tosylate) 4 SMCS; SP; CM PA; SL (4 tablets per day.); VENCLEXTA ORAL TABLET 10 MG, 100 MG (venetoclax) 2 SMCS; SP; CM PA; SL (1 tablet per day.); VENCLEXTA ORAL TABLET 50 MG ( venetoclax) 2 SMCS; SP; CM VENCLEXTA STARTING PACK ORAL TABLET THERAPY PA; SL (42 tablets per year.); 2 PACK 10 & 50 & 100 MG (venetoclax) SMCS; SP; CM VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; SL (2 tablets per day); 2 (abemaciclib) SMCS; SP; CM PA; SL (2 capsules per day.); VITRAKVI ORAL CAPSULE 100 MG ( sulfate) 2 SMCS; SP; CM PA; SL (6 capsules per day.); VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 2 SMCS; SP; CM PA; SL (10 mL per day.); VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib sulfate) 2 SMCS; SP; CM VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG PA; SL (1 tablet per day.); 3 () SMCS; SP; CM PA; SL (4 tablets per day.); VOTRIENT ORAL TABLET 200 MG ( hcl) 2 SMCS; SP; CM PA; SL (2 capsules per day.); XALKORI ORAL CAPSULE 200 MG, 250 MG () 2 SMCS; SP; CM XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 4 SL (4 ml per day) PA; SL (3 tablets per day.); XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) 3 SMCS; SP; CM XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.26 tablet per day.); 4 PACK 50 MG (selinexor) SMCS; SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 45 Coverage Requirements & Prescription Drug Name Drug Tier Limits XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.26 tablet per day.); 4 PACK 40 MG (selinexor) SMCS; SP; CM XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 4 PACK 40 MG (selinexor) SMCS; SP; CM XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 4 PACK 60 MG (selinexor) SMCS; SP; CM XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (0.86 tablets per 4 PACK 20 MG (selinexor) day.); SMCS; SP; CM XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 4 PACK 40 MG (selinexor) SMCS; SP; CM XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (1.15 tablets per 4 PACK 20 MG (selinexor) day.); SMCS; SP; CM PA; ST; SL (4 capsules per XTANDI ORAL CAPSULE 40 MG (enzalutamide) 4 day.); SMCS; SP; CM PA; ST; SL (4 tablets per XTANDI ORAL TABLET 40 MG (enzalutamide) 4 day.); SMCS; CM PA; ST; SL (2 tablets per XTANDI ORAL TABLET 80 MG (enzalutamide) 4 day.); SMCS; CM PA; SL (3 capsules per day); ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) 2 SMCS; SP; CM PA; SL (8 tablets per day.); ZELBORAF ORAL TABLET 240 MG () 2 SMCS; SP; CM ZOLINZA ORAL CAPSULE 100 MG (vorinostat) 2 PA; SMCS; SP; CM PA; SL (60 tablets per ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) 4 month.); SMCS; SP; CM PA; SL (3 tablets per day.); ZYKADIA ORAL TABLET 150 MG () 2 SMCS; SP; CM ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ALLERGENIC EXTRACTS (THERAPEUTIC) - DRUGS FOR THE IMMUNE SYSTEM GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 4 PA; SL (1 tablet per day.) (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 4 PA; SL (1 tablet per day.) (dust mite mixed allergen ext) ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET 4 PA; SL (1 tablet per day.) SUBLINGUAL 300 IR (grass mix pollens allergen ext)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 46 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 100 IR (grass mix pollens allergen 4 PA; SL (3 tablets per year.) ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR (grass 4 PA; SL (1 tablet per day.) mix pollens allergen ext) PALFORZIA ORAL 0.5 & 1 & 1.5 & 3 & 6 MG (peanut powder- PA; SL (13 capsules per 3 dnfp) year.); SMCS; SP PALFORZIA ORAL 2 X 1 MG & 10 MG, 3 X 1 MG (peanut PA; SL (45 capsules per 13 3 powder-dnfp) days.); SMCS; SP PALFORZIA ORAL 2 X 100 MG, 2 X 20 MG, 20 MG & 100 MG PA; SL (30 capsules per 13 3 (peanut powder-dnfp) days.); SMCS; SP PALFORZIA ORAL 2 X 20 MG & 2 X 100 MG, 4 X 20 MG PA; SL (60 capsules per 13 3 (peanut powder-dnfp) days.); SMCS; SP PA; SL (15 capsules per 13 PALFORZIA ORAL 20 MG (peanut powder-dnfp) 3 days.); SMCS; SP PALFORZIA ORAL 3 X 20 MG & 100 MG (peanut powder- PA; SL (60 capsule per 13 3 dnfp) days.); SMCS; SP PA; SL (90 capsules per 13 PALFORZIA ORAL 6 X 1 MG (peanut powder-dnfp) 3 days.); SMCS; SP PA; SL (1 capsule per day.); PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 SMCS; SP PA; SL (15 capsules per 13 PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 days.); SMCS; SP RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 4 PA; SL (1 tablet per day.) 1-U (short ragweed pollen ext) TOXOIDS - Vaccines ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- 3 H MCG/0.5 (tetanus-diphth-acell pertussis) BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- 2 H MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 2 H (diphth-acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 2 H 10 (diphth-acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 3 H 10 (diphth-acell pertussis-tetanus)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 47 Coverage Requirements & Prescription Drug Name Drug Tier Limits TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU (tetanus- 3 H diphtheria toxoids td) VACCINES - Vaccines ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 2 H (haemophilus b polysac conj vac) ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- 3 H MCG/0.5 (tetanus-diphth-acell pertussis) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 3 H (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML (influenza vac split 3 H quad) ASTRAZENECA COVID-19 INTRAMUSCULAR 3 H SUSPENSION 0.5 ML BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (meningococcal b recomb omv adj) BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- 2 H MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 2 H (diphth-acell pertussis-tetanus) ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 2 H MCG/ML ( b vac recombinant) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED 3 H SYRINGE 0.5 ML (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 3 H PREFILLED SYRINGE 0.5 ML (influenza vac split quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR 3 H SUSPENSION (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H split quad) FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML (influenza vac 3 H high-dose quad)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 48 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLUZONE QUADRIVALENT INTRAMUSCULAR 3 H SUSPENSION , 0.5 ML (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent 3 H recomb vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 3 H EL U/0.5ML (hepatitis a vaccine) HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED 3 H SYRINGE 20 MCG/0.5ML (hepatitis b vac recomb adj) HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG 3 H (haemophilus b polysac conj vac) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 2 H 10 (diphth-acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 3 H 10 (diphth-acell pertussis-tetanus) IPOL INJECTION INJECTABLE (poliovirus vaccine 2 H inactivated) JANSSEN COVID-19 VACCINE INTRAMUSCULAR 3 H SUSPENSION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE 3 H (meningococcal a c y&w-135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE 3 H (meningococcal a c y&w-135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 3 H (meningococcal a c y&w-135 olig) M-M-R II INJECTION SOLUTION RECONSTITUTED 2 H (measles, mumps & rubella vac) MODERNA COVID-19 VACCINE INTRAMUSCULAR 3 H SUSPENSION 100 MCG/0.5ML PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 2 H MCG/0.5ML (haemophilus b polysac conj vac) -BIONTECH COVID-19 VACC INTRAMUSCULAR 3 H SUSPENSION 30 MCG/0.3ML

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 49 Coverage Requirements & Prescription Drug Name Drug Tier Limits PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML 2 H (pneumococcal vac polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION 3 H (pneumococcal 13-val conj vacc) RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 2 H MCG/ML, 5 MCG/0.5ML (hepatitis b vac recombinant) SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML (zoster vac recomb 3 H adjuvanted) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (meningococcal b vac (recomb)) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML (hepatitis a-hep b recomb 3 H vac) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 2 H UNIT/ML (hepatitis a vaccine) VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML 3 H (varicella virus vaccine live) AUTONOMIC DRUGS - Drugs for the Nervous System ALPHA- AND BETA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) PA; SL (90 tablets per oral capsule 100 mg 1 month.); SMCS; SP PA; SL (180 tablets per droxidopa oral capsule 200 mg, 300 mg 1 month.); SMCS; SP epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml 1 epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml 1 lets kit 1 PA pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 2 MG/0.3ML, 0.3 MG/0.3ML (epinephrine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 50 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALPHA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 1 GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) 4 SL (192 tablets per year.) oral tablet 250 mg, 500 mg 1 midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 ANTIMUSCARINICS/ANTISPASMODICS - Drugs for Parkinson ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG 2 (hyoscyamine sulfate) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day.) vilanterol) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 2 SL (0.87 grams per day.) MCG/ACT (ipratropium bromide hfa) belladonna -opium rectal suppository 16.2-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-60 mg 2 BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 2 SL (0.36 grams per day.) MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 51 Coverage Requirements & Prescription Drug Name Drug Tier Limits CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) 3 dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 ED-SPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 glycopyrrolate oral tablet 1 mg, 2 mg 1 hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 PA hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA hydromet oral syrup 5-1.5 mg/5ml 1 PA HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg 1 hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg 1 hyoscyamine sulfate sublingual tablet sublingual 0.125 mg 1 hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 4 0.375 MG (hyoscyamine sulfate) LEVSIN ORAL TABLET 0.125 MG (hyoscyamine sulfate) 4 LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 4 (hyoscyamine sulfate) LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 4 atropine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 52 Coverage Requirements & Prescription Drug Name Drug Tier Limits me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methscopolamine bromide oral tablet 2.5 mg, 5 mg 1 MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-atropine) 4 NULEV ORAL TABLET DISPERSIBLE 0.125 MG 4 (hyoscyamine sulfate) oscimin oral tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hour 0.375 mg 1 oscimin sublingual tablet sublingual 0.125 mg 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) scopolamine transdermal patch 72 hour 1 mg/3days 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 2 SL (0.15 grams per day.) MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 3 MG (hyoscyamine sulfate) SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 4 (hyoscyamine sulfate) SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 4 0.375 MG (hyoscyamine sulfate) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day.) umeclidin-vilant) URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 2 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 53 Coverage Requirements & Prescription Drug Name Drug Tier Limits UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 4 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) YUPELRI INHALATION SOLUTION 175 MCG/3ML 4 SL (3 ml per day.) (revefenacin) ANTIPARKINSONIAN AGENTS - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 AUTONOMIC DRUGS, MISCELLANEOUS - Drugs for the Nervous System CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 2 H (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline tartrate) 2 H CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 2 H 11 & 1 MG X 42 (varenicline tartrate) goodsense mouth/throat lozenge 4 mg 1 H habitrol transdermal patch 24 hour 21 mg/24hr 1 H NICORETTE MOUTH/THROAT GUM 2 MG (nicotine 4 H polacrilex)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits nicotine polacrilex mini mouth/throat lozenge 2 mg 1 H nicotine polacrilex mouth/throat gum 2 mg, 4 mg 1 H nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg 1 H nicotine step 1 transdermal patch 24 hour 21 mg/24hr 1 H nicotine step 2 transdermal patch 24 hour 14 mg/24hr 1 H nicotine step 3 transdermal patch 24 hour 7 mg/24hr 1 H NICOTROL INHALATION INHALER 10 MG (nicotine) 4 H NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) 4 H CENTRALLY ACTING SKELETAL MUSCLE RELAXNT - Drugs for Relaxing Muscles aif #2 drug preparation kit external cream 1 PA AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA carisoprodol oral tablet 250 mg, 350 mg 1 carisoprodol--codeine oral tablet 200-325-16 mg 1 chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg 1 cyclobenzaprine hcl oral tablet 10 mg, 5 mg 1 CYCLOPHENE RAPIDPAQ TRANSDERMAL CREAM 5 % 3 PA (cyclobenzaprine hcl) DUAL COMPLEX FORMULA 1 KIT EXTERNAL CREAM 3 PA enovarx-cyclobenzaprine hcl transdermal cream 20 mg/gm 1 PA LORZONE ORAL TABLET 375 MG, 750 MG (chlorzoxazone) 4 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol oral tablet 500 mg, 750 mg 1 TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML 3 PA (cyclobenzaprine hcl-msm) TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML 3 PA (cyclobenzaprine hcl-msm) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine hcl oral tablet 2 mg, 4 mg 1 VP FC KIT EXTERNAL CREAM 3 PA ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG (tizanidine 4 hcl) ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIRECT-ACTING SKELETAL MUSCLE RELAXANTS - Drugs for Relaxing Muscles DANTRIUM ORAL CAPSULE 25 MG, 50 MG (dantrolene 4 sodium) dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT - Drugs for Relaxing Muscles AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA BACLOFEN EXTERNAL CREAM 2 % 3 PA baclofen oral tablet 10 mg, 20 mg, 5 mg 1 enovarx-baclofen external cream 1 % 1 PA FBL KIT EXTERNAL CREAM 15-4-5 % 3 PA FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 MG/ML 3 PA (baclofen) K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % 3 PA (ketoprofen-baclofen-gabap-lido ) OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) 4 NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 4 (sotalol hcl af) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 4 (nebivolol hcl) oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 4 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 56 Coverage Requirements & Prescription Drug Name Drug Tier Limits propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 4 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS - Drugs for the Heart CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 4 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 4 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart CAFERGOT ORAL TABLET 1-100 MG (ergotamine-) 4 dihydroergotamine mesylate injection solution 1 mg/ml 1 M dihydroergotamine mesylate nasal solution 4 mg/ml 1 ergoloid mesylates oral tablet 1 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 4 (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) phenoxybenzamine hcl oral capsule 10 mg 1 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) - Drugs for Bladder Incontinence bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 cevimeline hcl oral capsule 30 mg 1 donepezil hcl oral tablet 10 mg, 23 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 57 Coverage Requirements & Prescription Drug Name Drug Tier Limits donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 galantamine hydrobromide er oral capsule extended 1 release 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 1 MESTINON ORAL SOLUTION 60 MG/5ML (pyridostigmine 4 bromide) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 4 & 14 & 21 &28 -10 MG ( hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 4 donepezil hcl) pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 pyridostigmine bromide er oral tablet extended release 180 mg 1 pyridostigmine bromide oral solution 60 mg/5ml 1 pyridostigmine bromide oral tablet 60 mg 1 RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 16 MG, 24 MG, 8 MG (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1 rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr 1 SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) 4 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT - Drugs for the Heart alfuzosin hcl er oral tablet extended release 24 hour 10 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg -tamsulosin hcl oral capsule 0.5-0.4 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 silodosin oral capsule 4 mg, 8 mg 1 tamsulosin hcl oral capsule 0.4 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 58 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECTIVE BETA-2-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 1 SL (2 blisters per day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 SL (0.4 grams per day.) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act 1 albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml 1 albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% 1 albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day.) vilanterol) arformoterol tartrate inhalation nebulization solution 15 mcg/2ml 1 SL (2 nebules per day) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 2 SL (0.36 grams per day.) MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 inhalers per day.) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 blisters per day.) ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION 15 4 SL (2 nebules per day) MCG/2ML (arformoterol tartrate) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 4 ST; SL (0.44 grams per day.) MCG/ACT (mometasone furo-formoterol fum) DULERA INHALATION AEROSOL 50-5 MCG/ACT 4 ST; SL (0.44 mcg per day.) (mometasone furo-formoterol fum )

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 59 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 1 SL (0.04 mcg per day.) MCG/ACT, 55-14 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml 1 LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 4 SL (2 vials per day) MCG/2ML (formoterol fumarate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (2 blisters per day.) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.14 grams per day.) 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 2 SL (0.34 grams per day.) 4.5 MCG/ACT (budesonide-formoterol fumarate) terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day.) umeclidin-vilant) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) SELECTIVE BETA-ADRENERGIC BLOCKING AGENT - Drugs for the Heart acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 MG/ML 3 PA (atenolol) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 4 succinate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 60 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 4 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS - Drugs for Relaxing Muscles citrate er oral tablet extended release 12 hour 100 mg 1 orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ANTIANEMIA DRUGS - Vitamins and Minerals ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 M; SL (2 syringes per 2 MCG/ML, 300 MCG/ML (darbepoetin alfa) month); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION 200 M; SL (4 syringes per MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ( darbepoetin 2 month); SMCS; SP alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (1.6 ml per month.); 2 PREFILLED SYRINGE 10 MCG/0.4ML (darbepoetin alfa) SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (1 prefill syringe per 2 PREFILLED SYRINGE 100 MCG/0.5ML (darbepoetin alfa) month); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 vials per month); PREFILLED SYRINGE 150 MCG/0.3ML, 60 MCG/0.3ML 2 SMCS; SP (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (4 vials per month); PREFILLED SYRINGE 200 MCG/0.4ML, 25 MCG/0.42ML, 40 2 SMCS; SP MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 vials per 2 PREFILLED SYRINGE 300 MCG/0.6ML (darbepoetin alfa) prescription); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 syringes per 2 PREFILLED SYRINGE 500 MCG/ML (darbepoetin alfa) month); SMCS; SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML (epoetin M; SL (8 ml per 21 days.); 2 alfa-epbx) SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 61 Coverage Requirements & Prescription Drug Name Drug Tier Limits RETACRIT INJECTION SOLUTION 2000 UNIT/ML, 3000 M; SL (12 ml per 21 days.); 2 UNIT/ML, 4000 UNIT/ML (epoetin alfa-epbx) SMCS; SP RETACRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin 2 M; SMCS alfa-epbx) RETACRIT INJECTION SOLUTION 40000 UNIT/ML (epoetin M; SL (4 ml per 21 days.); 2 alfa-epbx) SMCS; SP ANTICOAGULANTS, MISCELLANEOUS - Drugs to Prevent Blood Clots ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 3 GM/100ML (anticoagulant cit dext soln a) ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 %, 4 GM/100ML fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml 1 M TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 (anticoagulant sodium citrate) ANTITHROMBOTIC AGENTS, MISCELLANEOUS - Drugs to Prevent Blood Clots PA; M; SL (1 vial per day and CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) 2 58 vials per 120 days.); SMCS; SP BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. - Drugs to Prevent Bleeding PA; SL (3 tablets per day.); OXBRYTA ORAL TABLET 500 MG (voxelotor) 4 SMCS; SP TAVALISSE ORAL TABLET 100 MG, 150 MG (fostamatinib PA; ST; SL (2 tablets per 4 disodium) day); SMCS; SP COUMARIN DERIVATIVES - Drugs to Prevent Blood Clots jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 DIRECT FACTOR XA INHIBITORS - Drugs to Prevent Blood Clots ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY 2 SL (2.5 tablets per day.) PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 SL (2 tablets per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 62 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELIQUIS ORAL TABLET 5 MG (apixaban) 2 SL (2.5 tablets per day.) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG (edoxaban 4 SL (1 tablet per day.) tosylate) XARELTO ORAL TABLET 10 MG (rivaroxaban) 2 SL (1 tablet per day.) SL (52 tablets per month XARELTO ORAL TABLET 15 MG (rivaroxaban) 2 initial 1 tablet per day for maintenance.) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) 2 SL (2 tablets per day.) XARELTO ORAL TABLET 20 MG (rivaroxaban) 2 SL (31 tablets per 31 days.) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 SL (51 tablets per year.) 15 & 20 MG (rivaroxaban) DIRECT THROMBIN INHIBITORS - Drugs to Prevent Blood Clots PRADAXA ORAL CAPSULE 110 MG (dabigatran etexilate 2 SL (2 tablets per day.) mesylate) PRADAXA ORAL CAPSULE 150 MG, 75 MG (dabigatran SL (62 capsules per 31 2 etexilate mesylate) days.) HEMATOPOIETIC AGENTS - Drugs for Anemia ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 M; SL (2 syringes per 2 MCG/ML, 300 MCG/ML (darbepoetin alfa) month); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION 200 M; SL (4 syringes per MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ( darbepoetin 2 month); SMCS; SP alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (1.6 ml per month.); 2 PREFILLED SYRINGE 10 MCG/0.4ML (darbepoetin alfa) SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (1 prefill syringe per 2 PREFILLED SYRINGE 100 MCG/0.5ML (darbepoetin alfa) month); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 vials per month); PREFILLED SYRINGE 150 MCG/0.3ML, 60 MCG/0.3ML 2 SMCS; SP (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (4 vials per month); PREFILLED SYRINGE 200 MCG/0.4ML, 25 MCG/0.42ML, 40 2 SMCS; SP MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 vials per 2 PREFILLED SYRINGE 300 MCG/0.6ML (darbepoetin alfa) prescription); SMCS; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION M; SL (2 syringes per 2 PREFILLED SYRINGE 500 MCG/ML (darbepoetin alfa) month); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 63 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; SL (15 tablets per DOPTELET ORAL TABLET 20 MG ( avatrombopag maleate) 4 month.); SMCS; SP LEUKINE INJECTION SOLUTION RECONSTITUTED 250 2 M; SMCS MCG () MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML 2 M; SMCS; SP (plerixafor) MULPLETA ORAL TABLET 3 MG ( lusutrombopag) 2 PA; SMCS; SP NEULASTA SUBCUTANEOUS SOLUTION PREFILLED 3 M; SMCS SYRINGE 6 MG/0.6ML () PROMACTA ORAL PACKET 12.5 MG (eltrombopag olamine) 4 PA; SMCS; SP PROMACTA ORAL PACKET 25 MG (eltrombopag olamine) 4 PA; SMCS PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 4 PA; SMCS; SP (eltrombopag olamine) RETACRIT INJECTION SOLUTION 10000 UNIT/ML (epoetin M; SL (8 ml per 21 days.); 2 alfa-epbx) SMCS; SP RETACRIT INJECTION SOLUTION 2000 UNIT/ML, 3000 M; SL (12 ml per 21 days.); 2 UNIT/ML, 4000 UNIT/ML (epoetin alfa-epbx) SMCS; SP RETACRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin 2 M; SMCS alfa-epbx) RETACRIT INJECTION SOLUTION 40000 UNIT/ML (epoetin M; SL (4 ml per 21 days.); 2 alfa-epbx) SMCS; SP ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 2 M; SMCS; SP MCG/0.5ML, 480 MCG/0.8ML (-sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED 3 M; SMCS; SP SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMORRHEOLOGIC AGENTS - Drugs for Blood Flow pentoxifylline er oral tablet extended release 400 mg 1 HEMOSTATICS - Drugs to Prevent Bleeding ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 2 M; SMCS; SP UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 4 PA; M; SMCS; SP UNIT, 750 UNIT

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 64 Coverage Requirements & Prescription Drug Name Drug Tier Limits AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT 4 PA; M; SMCS; SP (antihemophil fact single chain) ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT 2 M; SMCS; SP (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION 2 M; SMCS RECONSTITUTED 1000 UNIT (coagulation factor ix) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT, 500 UNIT (coagulation factor 2 M; SMCS; SP ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 3 M; SMCS; SP UNIT (coagulation factor ix (rfixfc)) aminocaproic acid oral solution 0.25 gm/ml 1 aminocaproic acid oral tablet 1000 mg, 500 mg 1 ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 2 M; SMCS; SP UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS; SP 250 UNIT, 500 UNIT (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor xiii 2 M; SMCS; SP concentrate human) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 M desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 M desmopressin acetate spray nasal solution 0.01 % 1 ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4 PA; M; SMCS; SP 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 M; SMCS; SP UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant cmplx) GELFILM OPHTHALMIC FILM (gelatin adsorbable) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 65 Coverage Requirements & Prescription Drug Name Drug Tier Limits GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) 3 GELFOAM-JMI POWDER EXTERNAL KIT (gelatin absorb- 3 thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin absorb- 3 thrombin) HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 2 PA; M; SMCS; SP MG/ML, 30 MG/ML, 60 MG/0.4ML (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS 1000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS; SP 1700 UNIT (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT 2 M; SMCS; SP (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT 4 M; SMCS; SP (coagulation factor ix (rix-fp)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd-rfviii peg- 4 PA; M; SMCS; SP aucl)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 M; SMCS UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS 1000 UNIT, 500 UNIT (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor recomb 2 M; SMCS (rfviii)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 M; SMCS; SP (antihemophil factor (rahf-pfm)) LYSTEDA ORAL TABLET 650 MG (tranexamic acid) 3 SL (30 tablets per 5 days.) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS 1000 UNIT (coagulation factor ix) monsels ferric subsulfate external solution 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 SL (1 tablet per day.) 55.3 MCG (desmopressin acetate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 66 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 M; SMCS (antihemophil fact bd truncated) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS; SP 1500 UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation 2 M; SMCS; SP factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact 2 M; SMCS; SP (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 2 M; SMCS; SP UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS; SP 1000 UNIT, 1500 UNIT, 500 UNIT (factor ix complex) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 2 M; SMCS; SP UNIT, 401-800 UNIT, 801-1240 UNIT (antihem factor recomb (rfviii)) RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 3 20000 UNIT, 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION 3 RECONSTITUTED 20000 UNIT (thrombin (recombinant)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 M; SMCS UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT 3 (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT 3 (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 1000 UNIT, 10000 UNIT (thrombin) tranexamic acid oral tablet 650 mg 1 SL (30 tablets per 5 days.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 67 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 3 M; SMCS; SP 2000-3125 UNIT (coagulation factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 2 M; SMCS; SP 1300 UNIT, 650 UNIT (von willebrand factor (recomb)) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT 2 M; SMCS; SP (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 4 PA; ST; M; SMCS UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 4 PA; ST; M; SMCS UNIT, 250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 3000 UNIT 4 PA; ST; M; SMCS; SP (antihem fact (bdd-rfviii,mor)) HEPARINS - Drugs to Prevent Blood Clots enoxaparin sodium injection solution 300 mg/3ml 1 M enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 1 M mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 4 M 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin lock flush intravenous solution 10 unit/ml 1 M heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml 1 M heparin sodium (porcine) injection solution prefilled 1 M syringe 5000 unit/0.5ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml, 5000 unit/ml 1 M heparin sodium lock flush intravenous solution 100 unit/ml 1 M IRON PREPARATIONS - Vitamins and Minerals ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 3 fa) CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 68 Coverage Requirements & Prescription Drug Name Drug Tier Limits CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 vit a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 69 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 4 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 70 Coverage Requirements & Prescription Drug Name Drug Tier Limits WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 AND STOMACH PREPARATIONS - Vitamins and Minerals cyanocobalamin injection solution 1000 mcg/ml 1 M CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 M NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 M (cyanocobalamin) PLATELET-AGGREGATION INHIBITORS - Drugs to Prevent Blood Clots aspirin-dipyridamole er oral capsule extended release 12 1 hour 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG ( ticagrelor) 2 SL (2 tablets per day.) cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 prasugrel hcl oral tablet 10 mg, 5 mg 1 SL (31 tablets per 31 days.) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) 4 SL (1 tablet per day.) PLATELET-REDUCING AGENTS - Drugs to Prevent Blood Clots AGRYLIN ORAL CAPSULE 0.5 MG (anagrelide hcl) 4 anagrelide hcl oral capsule 0.5 mg, 1 mg 1 CARDIOVASCULAR DRUGS - Drugs for the Heart ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for High Blood Pressure CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 4 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 4 hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 71 Coverage Requirements & Prescription Drug Name Drug Tier Limits prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 4 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 4 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN) - Drugs for High Blood Pressure & Angina candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan 2 medoxomil) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 oral tablet 20 mg, 40 mg, 80 mg 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs for the Heart besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg 1 amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 72 Coverage Requirements & Prescription Drug Name Drug Tier Limits candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg 1 EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan 2 medoxomil) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 2 (azilsartan-chlorthalidone) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 4 PA; SL (2 tablets per day.) (sacubitril-valsartan) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 12.5 mg 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg 1 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg 1 olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg 1 telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg 1 ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) - Drugs for High Blood Pressure & Angina ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 4 (quinapril hcl) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 4 fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 4 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRINIVIL ORAL TABLET 20 MG (lisinopril) 4 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS - Drugs for the Heart ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 4 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 4 MG (quinapril-hydrochlorothiazide) amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg, 5-6.25 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 4 fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 4 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 4 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRINIVIL ORAL TABLET 20 MG (lisinopril) 4 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) 4 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 4 240 MG, 4-240 MG (trandolapril-verapamil hcl) trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 trandolapril-verapamil hcl er oral tablet extended release 1- 240 mg, 2-180 mg, 2-240 mg, 4-240 mg 1 ANTIARRHYTHMICS, MISCELLANEOUS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) ANTILIPEMIC AGENTS, MISCELLANEOUS - Drugs for Cholesterol JUXTAPID ORAL CAPSULE 10 MG, 5 MG (lomitapide PA; ST; SL (1 tablet per 4 mesylate) day.); SMCS; SP JUXTAPID ORAL CAPSULE 20 MG, 30 MG (lomitapide PA; ST; SL (1 capsule per 4 mesylate) day.); SMCS; SP NEXLETOL ORAL TABLET 180 MG ( bempedoic acid) 2 SL (1 tablet per day.) NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 SL (1 tablet per day.) ezetimibe) niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 75 Coverage Requirements & Prescription Drug Name Drug Tier Limits NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 4 500 MG, 750 MG (niacin (antihyperlipidemic)) omega-3-acid ethyl esters oral capsule 1 gm 1 BETA-ADRENERGIC BLOCKING AGENTS - Drugs for Abnormal Heart Rhythms acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 MG/ML 3 PA (atenolol) atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 4 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 6.25 mg, 5-6.25 mg 1 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 4 (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 4 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 4 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 4 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 50 mg, 50-25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 76 Coverage Requirements & Prescription Drug Name Drug Tier Limits nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 4 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG (bisoprolol- 3 hydrochlorothiazide) ZIAC ORAL TABLET 5-6.25 MG (bisoprolol- 4 hydrochlorothiazide) BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 MG/ML 3 PA (atenolol) BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 4 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 4 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 77 Coverage Requirements & Prescription Drug Name Drug Tier Limits KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 4 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 4 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 4 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) SEQUESTRANTS - Drugs for Cholesterol cholestyramine oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 CLINOIN EXTERNAL CREAM 1.25-0.025-1 % (clindamycin- 3 PA tretinoin-cholesty) COLESTID FLAVORED ORAL GRANULES 5 GM ( 3 hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol hcl) 4 COLESTID ORAL GRANULES 5 GM (colestipol hcl) 3 COLESTID ORAL PACKET 5 GM (colestipol hcl) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 78 Coverage Requirements & Prescription Drug Name Drug Tier Limits COLESTID ORAL TABLET 1 GM (colestipol hcl) 4 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 prevalite oral packet 4 gm 1 prevalite oral powder 4 gm/dose 1 QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE 4 (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) 4 QUESTRAN ORAL POWDER 4 GM/DOSE (cholestyramine) 4 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 1 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 1 CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 4 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 79 Coverage Requirements & Prescription Drug Name Drug Tier Limits tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 4 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS, MISC. - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 4 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 4 240 MG, 4-240 MG (trandolapril-verapamil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 80 Coverage Requirements & Prescription Drug Name Drug Tier Limits taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 4 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1- 240 mg, 2-180 mg, 2-240 mg, 4-240 mg 1 verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CARBONIC ANHYDRASE INHIBITORS(HYPOTEN) - Drugs for High Blood Pressure & Angina acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 methazolamide oral tablet 25 mg, 50 mg 1 CARDIAC DRUGS, MISCELLANEOUS - Drugs for Angina CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 ml per day.) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day.) ranolazine er oral tablet extended release 12 hour 1000 mg, 500 mg 1 PA; SL (1 capsule per day.); VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 SMCS; SP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis meglumine PA; SL (4 capsules per day.); 2 (cardiac)) SMCS; SP CARDIOTONIC AGENTS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 81 Coverage Requirements & Prescription Drug Name Drug Tier Limits digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) CENTRAL ALPHA-AGONISTS - Drugs for High Blood Pressure & Angina clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 1 guanfacine hcl oral tablet 1 mg, 2 mg 1 methyldopa oral tablet 250 mg, 500 mg 1 NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA CHOLESTEROL ABSORPTION INHIBITORS - Drugs for Cholesterol ezetimibe oral tablet 10 mg 1 ezetimibe- oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg 1 NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 SL (1 tablet per day.) ezetimibe) VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 4 80 MG (ezetimibe-simvastatin) CLASS IA ANTIARRHYTHMICS - Drugs for Angina disopyramide phosphate oral capsule 100 mg, 150 mg 1 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 2 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG (disopyramide 4 phosphate) quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 CLASS IB ANTIARRHYTHMICS - Drugs for Angina DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 () DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin 3 sodium extended)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 82 Coverage Requirements & Prescription Drug Name Drug Tier Limits DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 4 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg 1 CLASS IC ANTIARRHYTHMICS - Drugs for Angina flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1 propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg 1 propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 CLASS II ANTIARRHYTHMICS - Drugs for Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 MG/ML 3 PA (atenolol) BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 4 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 4 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 4 tartrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 83 Coverage Requirements & Prescription Drug Name Drug Tier Limits metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 4 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) CLASS III ANTIARRHYTHMICS - Drugs for Angina hcl oral tablet 100 mg, 200 mg, 400 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 4 (sotalol hcl af) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) 4 PA PACERONE ORAL TABLET 100 MG, 400 MG (amiodarone 3 hcl) PACERONE ORAL TABLET 200 MG (amiodarone hcl) 4 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 4 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 4 (dofetilide) CLASS IV ANTIARRHYTHMICS - Drugs for Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 4 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 84 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 4 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIHYDROPYRIDINES - Drugs for High Blood Pressure & Angina AMLODIPINE BES+SYRSPEND SF ORAL SUSPENSION 1 3 PA MG/ML (amlodipine besylate) amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 85 Coverage Requirements & Prescription Drug Name Drug Tier Limits amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg 1 amlodipine- oral tablet 10-10 mg, 10-20 mg, 10- 40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg 1 amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg 1 SL (1 tablet per day) amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg 1 er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 4 benzoate) hcl oral capsule 20 mg, 30 mg 1 er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1 nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 1 NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2 olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg 1 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 4 MG, 34 MG, 8.5 MG (nisoldipine) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 86 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIHYDROPYRIDINES (ANTIHYPERTENSIVE) - Drugs for High Blood Pressure & Angina AMLODIPINE BES+SYRSPEND SF ORAL SUSPENSION 1 3 PA MG/ML (amlodipine besylate) amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 4 benzoate) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1 nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 1 NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 4 MG, 34 MG, 8.5 MG (nisoldipine) DIRECT VASODILATORS - Drugs for High Blood Pressure & Angina BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 2 ) hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 oral tablet 10 mg, 2.5 mg 1 DIURETICS, MISCELLANEOUS (HYPOTENSIVE) - Drugs for High Blood Pressure & Angina ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 87 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 FIBRIC ACID DERIVATIVES - Drugs for Cholesterol ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate 4 micronized) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 1 fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg 1 fenofibrate oral tablet 120 mg, 145 mg, 160 mg, 40 mg, 48 mg, 54 mg 1 fenofibric acid oral capsule delayed release 135 mg, 45 mg 1 fenofibric acid oral tablet 105 mg, 35 mg 1 FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric acid) 4 gemfibrozil oral tablet 600 mg 1 LIPOFEN ORAL CAPSULE 150 MG, 50 MG (fenofibrate) 4 LOPID ORAL TABLET 600 MG (gemfibrozil) 4 HMG-COA REDUCTASE INHIBITORS - Drugs for Cholesterol ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 4 20 MG, 40 MG, 60 MG () amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10- 40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg 1 amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg 1 SL (1 tablet per day) atorvastatin calcium oral tablet 10 mg, 20 mg 1 SL (3 tablets per day.); H-N atorvastatin calcium oral tablet 40 mg, 80 mg 1 SL (31 tablets per 31 days.) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 3 MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg 1 FLOLIPID ORAL SUSPENSION 20 MG/5ML, 40 MG/5ML 4 fluvastatin sodium er oral tablet extended release 24 hour 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 88 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluvastatin sodium oral capsule 20 mg, 40 mg 1 LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin 4 SL (1 tablet per day) calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 H pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 rosuvastatin calcium oral tablet 10 mg 1 SL (3 tablets per day) rosuvastatin calcium oral tablet 20 mg, 40 mg, 5 mg 1 SL (1 tablet per day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 H-N simvastatin oral tablet 80 mg 1 VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 4 80 MG (ezetimibe-simvastatin) ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin 4 SL (1 tablet per day.) magnesium) HYPOTENSIVE AGENTS, MISCELLANEOUS - Drugs for High Blood Pressure & Angina phenoxybenzamine hcl oral capsule 10 mg 1 VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) 4 LOOP DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 4 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 4 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS - Drugs for the Heart ALDACTAZIDE ORAL TABLET 25-25 MG (- 4 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 89 Coverage Requirements & Prescription Drug Name Drug Tier Limits CAROSPIR ORAL SUSPENSION 25 MG/5ML 4 (spironolactone) eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT) - Drugs for High Blood Pressure & Angina CAROSPIR ORAL SUSPENSION 25 MG/5ML 4 (spironolactone) eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 NITRATES AND NITRITES - Drugs for the Heart BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 2 hydralazine) DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 3 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG (nitroglycerin) 4 ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG 4 (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 isosorbide mononitrate er oral tablet extended release 24 1 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr 1 NITRO-BID TRANSDERMAL OINTMENT 2 % ( nitroglycerin) 2 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR 3 (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr 1 nitroglycerin translingual solution 0.4 mg/spray 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 90 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 4 MCG/SPRAY (nitroglycerin) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 4 0.4 MG, 0.6 MG (nitroglycerin) NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 3 6.5 MG, 9 MG (nitroglycerin) PCSK9 INHIBITORS - Drugs for Cholesterol REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS PA; ST; M; SL (3.5 ml (1 2 SOLUTION CARTRIDGE 420 MG/3.5ML () cartridge) per month.) REPATHA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (2 syringes 2 SYRINGE 140 MG/ML (evolocumab) per 28 days.) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (2 ml per 2 INJECTOR 140 MG/ML (evolocumab) month.) PHOSPHODIESTERASE TYPE 5 INHIBITORS - Drugs for the Heart PA; SL (2 tablets per day); alyq oral tablet 20 mg 1 SMCS; SP cilostazol oral tablet 100 mg, 50 mg 1 PA; SL (186 ml per month.); sildenafil citrate oral suspension reconstituted 10 mg/ml 1 SMCS; SP sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 SL (6 tablets per month) SL (0.5 tablet per day.); sildenafil citrate oral tablet 20 mg 1 SMCS STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG ( avanafil) 2 SL (6 tablets per month) PA; SL (2 tablets per day); tadalafil (pah) oral tablet 20 mg 1 SMCS; SP tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 SL (6 tablets per month) vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 SL (6 tablets per month) vardenafil hcl oral tablet dispersible 10 mg 1 SL (6 tablets per month) POTASSIUM-SPARING DIURETICS (HYPOTEN) - Drugs for High Blood Pressure & Angina amiloride hcl oral tablet 5 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 4 (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 91 Coverage Requirements & Prescription Drug Name Drug Tier Limits eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 RENIN INHIBITORS - Drugs for the Heart aliskiren fumarate oral tablet 150 mg, 300 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG ( aliskiren 3 fumarate) RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC - Drugs for the Heart ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 4 PA; SL (2 tablets per day.) (sacubitril-valsartan) THIAZIDE DIURETICS(HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT) - Drugs for High Blood Pressure & Angina chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 VASODILATING AGENTS, MISCELLANEOUS - Drugs for the Heart AMLODIPINE BES+SYRSPEND SF ORAL SUSPENSION 1 3 PA MG/ML (amlodipine besylate) amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 4 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 3 M; SL (6 units per month) MCG (alprostadil (vasodilator))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 92 Coverage Requirements & Prescription Drug Name Drug Tier Limits CAVERJECT INTRACAVERNOSAL SOLUTION 3 M; SL (6 units per month) RECONSTITUTED 40 MCG (alprostadil (vasodilator)) CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 ml per day.) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day.) diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG 3 M; SL (6 units per month) (alprostadil (vasodilator)) isoxsuprine hcl oral tablet 10 mg, 20 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 4 benzoate) matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 MUSE URETHRAL PELLET 1000 MCG, 250 MCG, 500 MCG 3 SL (6 units per month) (alprostadil (vasodilator)) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1 nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 93 Coverage Requirements & Prescription Drug Name Drug Tier Limits taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 4 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ADAMANTANES (CNS) - Drugs for Parkinson amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1 AMPHETAMINE DERIVATIVES - Drugs for the Nervous System ADIPEX-P ORAL CAPSULE 37.5 MG (phentermine hcl) 4 PA ADIPEX-P ORAL TABLET 37.5 MG (phentermine hcl) 4 PA diethylpropion hcl er oral tablet extended release 24 hour 75 mg 1 PA diethylpropion hcl oral tablet 25 mg 1 PA LOMAIRA ORAL TABLET 8 MG (phentermine hcl) 3 PA phendimetrazine tartrate er oral capsule extended release 1 PA 24 hour 105 mg phendimetrazine tartrate oral tablet 35 mg 1 PA phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg 1 PA phentermine hcl oral tablet 37.5 mg 1 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 94 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMPHETAMINES - Drugs for the Nervous System ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG 1 SL (1 capsule per day.) (amphetamine-dextroamphetamine) ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 4 SL (15 ml per day.) 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 4 PA; SL (1 tablet per day.) 9.4 MG (amphetamine) AMPHETAMINE ER ORAL SUSPENSION EXTENDED 4 SL (15 ml per day.) RELEASE 1.25 MG/ML amphetamine sulfate oral tablet 10 mg, 5 mg 1 amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 1 benzphetamine hcl oral tablet 25 mg, 50 mg 1 PA dextroamphetamine sulfate er oral capsule extended 1 SL (4 capsules per day.) release 24 hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended 1 SL (10 capsules per day.) release 24 hour 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml 1 dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1 DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 4 SL (15 mL per day.) 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 4 PA; SL (2 tablets per day.) 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine sulfate) 4 methamphetamine hcl oral tablet 5 mg 1 MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- 2 SL (1 capsule per day) dextroamphetamine) PROCENTRA ORAL SOLUTION 5 MG/5ML 3 (dextroamphetamine sulfate) VYVANSE ORAL CAPSULE 10 MG, 30 MG, 40 MG, 50 MG, 60 2 SL (1 capsule per day) MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL CAPSULE 20 MG (lisdexamfetamine 2 SL (1 capsule per day.) dimesylate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 2 SL (1 tablet per day) 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) AND ANTIPYRETICS, MISC. - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg 1 ALLZITAL ORAL TABLET 25-325 MG ( butalbital- 4 acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG BUPAP ORAL TABLET 50-300 MG (butalbital- 4 acetaminophen) butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 4 SL (6 tablets per day) caffeine) FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML 3 PA; ST (gabapentin) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 4 SL (6 capsules per day.) caffeine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml 1 hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg 1 HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 4 acetaminophen) NEURAPTINE EXTERNAL CREAM 10 % (gabapentin) 3 PA NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 4 ST (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 4 ST NEURONTIN ORAL TABLET 600 MG, 800 MG ( gabapentin) 4 ST NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 OXYCODONE-ACETAMINOPHEN ORAL TABLET 5-300 MG 4 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) pregabalin er oral tablet extended release 24 hour 165 mg, 330 mg, 82.5 mg 1 SL (1 tablet per day.) PROLATE ORAL TABLET 5-300 MG, 7.5-300 MG 4 (oxycodone-acetaminophen) TENCON ORAL TABLET 50-325 MG ( butalbital- 3 acetaminophen) tramadol-acetaminophen oral tablet 37.5-325 mg 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 1 dihydrocodeine) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 4 acetaminophen)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 2 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 4 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) ANOREXIGENIC AGENTS AND STIMULANTS, MISC - Drugs for the Nervous System QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 3 PA (phentermine-topiramate) ANOREXIGENIC AGENTS, MISCELLANEOUS - Drugs for the Nervous System CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA 8-90 MG (naltrexone-bupropion hcl) IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML 3 PA; M; SMCS; SP (setmelanotide acetate) AGENTS (CNS) - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 98 Coverage Requirements & Prescription Drug Name Drug Tier Limits DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 orphenadrine citrate er oral tablet extended release 12 hour 100 mg 1 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 ANTICONVULSANTS, MISCELLANEOUS - Drugs for Seizures acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 aif #2 drug preparation kit external cream 1 PA APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 3 PA (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) 4 BANZEL ORAL TABLET 200 MG, 400 MG ( rufinamide) 4 PA BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) 4 PA BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 3 PA MG (brivaracetam) er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg 1 carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg 1 carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 4 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 4 ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 4 MG, 500 MG (divalproex sodium)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 99 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 4 RELEASE SPRINKLE 125 MG (divalproex sodium) DIACOMIT ORAL CAPSULE 250 MG, 500 MG (stiripentol) 3 PA; SMCS; SP DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) 3 PA; SMCS; SP divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 1 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) 3 PA; SMCS; SP epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML 3 PA; ST (gabapentin) felbamate oral suspension 600 mg/5ml 1 felbamate oral tablet 400 mg, 600 mg 1 FELBATOL ORAL SUSPENSION 600 MG/5ML (felbamate) 4 FELBATOL ORAL TABLET 400 MG, 600 MG ( felbamate) 4 FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine hcl) 4 PA; SMCS FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) 4 PA FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 3 PA 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 4 (tiagabine hcl) GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) 4 ST KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG 4 ST (levetiracetam)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 100 Coverage Requirements & Prescription Drug Name Drug Tier Limits KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 ST 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 42 X 50 3 ST MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG (lamotrigine) 4 ST LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 4 ST MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 4 ST (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 4 ST (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 4 ST X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 ST 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 ST (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg 1 ST lamotrigine oral kit 25 & 50 & 100 mg 1 lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg 1 ST lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, SL (93 capsules per 31 4 50 MG, 75 MG (pregabalin) days.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 101 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (62 capsules per 31 LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 4 days.) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 4 SL (30.52 ml per day.) NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 4 ST (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 4 ST NEURONTIN ORAL TABLET 600 MG, 800 MG ( gabapentin) 4 ST oxcarbazepine oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 SL (93 capsules per 31 1 mg, 75 mg days.) SL (62 capsules per 31 pregabalin oral capsule 225 mg, 300 mg 1 days.) pregabalin oral solution 20 mg/ml 1 SL (30.52 ml per day.) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 4 ST MG, 150 MG, 200 MG, 25 MG, 50 MG (topiramate) roweepra oral tablet 500 mg 1 rufinamide oral suspension 40 mg/ml 1 rufinamide oral tablet 200 mg, 400 mg 1 PA PA; ST; SL (6 tablets per SABRIL ORAL TABLET 500 MG (vigabatrin) 4 day.); SMCS; SP SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 4 ST MG, 250 MG, 500 MG, 750 MG (levetiracetam) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 4 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 102 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 4 ST (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 4 ST MG (topiramate) topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg 1 ST topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TRILEPTAL ORAL SUSPENSION 300 MG/5ML 4 ST (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG 4 ST (oxcarbazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 PA; ST; SL (6 packets per vigabatrin oral packet 500 mg 1 day.); SMCS PA; ST; SL (6 tablets per vigabatrin oral tablet 500 mg 1 day.); SMCS; SP PA; ST; SL (6 packets per vigadrone oral packet 500 mg 1 day.); SMCS VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) 2 PA VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 2 PA (lacosamide) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 100 & 150 MG, 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 3 PA MG & 14 X100 MG, 150 & 200 MG, 50 & 200 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG (zonisamide) 4 ST zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 ANTIDEPRESSANTS, MISCELLANEOUS - Drugs for Depression & Psychosis APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 4 SL (1 tablet per day) 174 MG, 348 MG, 522 MG (bupropion hbr)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 103 Coverage Requirements & Prescription Drug Name Drug Tier Limits bupropion hcl er (smoking det) oral tablet extended release 1 H 12 hour 150 mg bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg 1 bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg 1 BUPROPION HCL ER (XL) ORAL TABLET EXTENDED 4 SL (1 tablet per day.) RELEASE 24 HOUR 450 MG bupropion hcl oral tablet 100 mg, 75 mg 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 SL (1 tablet per day.) 450 MG (bupropion hcl) mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 REMERON ORAL TABLET 15 MG, 30 MG (mirtazapine) 4 REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 4 MG, 45 MG (mirtazapine) SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PA; SL (8 devices (4 kits) per 4 PACK 28 MG/DEVICE (esketamine hcl) month.); SMCS SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PA; SL (12 devices (4 kits) 4 PACK 28 MG/DEVICE (esketamine hcl) per month.); SMCS ANTIMANIC AGENTS - Drugs for Personality Disorder aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 SL (1 tablet per day) aripiprazole oral tablet 2 mg 1 SL (2 tablets per day.) aripiprazole oral tablet 5 mg 1 SL (1.5 tablets per day.) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (1 tablet per day.) carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg 1 carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg 1 carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 4 HOUR 100 MG, 200 MG, 300 MG (carbamazepine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 104 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 4 ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 4 MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 4 RELEASE SPRINKLE 125 MG (divalproex sodium) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 1 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 42 X 50 3 ST MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG (lamotrigine) 4 ST LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 4 ST MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 4 ST (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 4 ST (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 4 ST X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 ST 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 ST (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg 1 ST lamotrigine oral kit 25 & 50 & 100 mg 1 lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 105 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg 1 ST lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 lithium carbonate er oral tablet extended release 300 mg, 450 mg 1 lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 lithium carbonate oral tablet 300 mg 1 LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG 4 (lithium carbonate) olanzapine oral tablet 10 mg, 15 mg, 20 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet 2.5 mg 1 SL (2 tablets per day.) olanzapine oral tablet 5 mg 1 SL (3 tablets per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 mg 1 SL (31 tablets per 31 days.) quetiapine fumarate er oral tablet extended release 24 hour 200 mg 1 SL (1 tablet per day.) quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg 1 SL (62 tablets per 31 days.) quetiapine fumarate er oral tablet extended release 24 hour SL (13 tablets per year for 50 mg 1 initial fill 3 tablets per day for maintenance fill.) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg 1 risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 1 SL (2 tablets per day) (asenapine maleate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 106 Coverage Requirements & Prescription Drug Name Drug Tier Limits SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG 1 SL (2 tablets per day.) (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (31 tablets per 31 days.) HOUR 150 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (1 tablet per day.) HOUR 200 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (62 tablets per 31 days.) HOUR 300 MG, 400 MG (quetiapine fumarate) SL (13 tablets per year for SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 initial fill 3 tablets per day for HOUR 50 MG (quetiapine fumarate) maintenance fill.) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 4 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 SL (62 capsules per 31 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 days.) ANTIMIGRAINE AGENTS, MISCELLANEOUS - Migraine Treatment butorphanol tartrate nasal solution 10 mg/ml 1 CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 4 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CAMBIA ORAL PACKET 50 MG (diclofenac 4 potassium(migraine)) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 4 ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 4 MG, 500 MG (divalproex sodium)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 107 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 4 RELEASE SPRINKLE 125 MG (divalproex sodium) dihydroergotamine mesylate injection solution 1 mg/ml 1 M dihydroergotamine mesylate nasal solution 4 mg/ml 1 divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 1 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG 3 (naproxen) EC-NAPROSYN ORAL TABLET DELAYED RELEASE 500 MG 4 (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 4 (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 1 oral tablet 400 mg, 600 mg, 800 mg 1 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 1 naproxen sodium oral tablet 275 mg, 550 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 108 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 4 ST (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 4 ST MG (topiramate) topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 ANTIPSYCHOTICS, MISCELLANEOUS - Drugs for Depression & Psychosis ADASUVE INHALATION AEROSOL POWDER BREATH 3 ACTIVATED 10 MG (loxapine) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 molindone hcl oral tablet 10 mg, 25 mg, 5 mg 1 pimozide oral tablet 1 mg, 2 mg 1 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC - Drugs for Anxiety & Sleep Disorder BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 4 SL (1 tablet per day.) (suvorexant) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) 4 SL (1 tablet per day.) DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG SL (1 sublingual tablet per 3 (zolpidem tartrate) day) eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 SL (1 tablet per day) PA; SL (1 capsule per day.); HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) 4 SMCS; SP hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 109 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 meprobamate oral tablet 200 mg, 400 mg 1 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 ramelteon oral tablet 8 mg 1 SL (1 tablet per day) VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 4 pamoate) zaleplon oral capsule 10 mg, 5 mg 1 SL (1 tablet per day) zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg 1 SL (31 tablets per month) zolpidem tartrate oral tablet 10 mg, 5 mg 1 SL (1 tablet per day) zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 SL (1 sublingual tablet per 1 mg day) SL (8 ml (1 canister) per ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem tartrate) 4 month) ATYPICAL ANTIPSYCHOTICS - Drugs for Depression & Psychosis aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 SL (1 tablet per day) aripiprazole oral tablet 2 mg 1 SL (2 tablets per day.) aripiprazole oral tablet 5 mg 1 SL (1.5 tablets per day.) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (1 tablet per day.) CAPLYTA ORAL CAPSULE 42 MG (lumateperone tosylate) 4 PA; SL (1 capsule per day.) clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg 1 CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 4 (clozapine) FANAPT ORAL TABLET 1 MG ( iloperidone) 4 SL (86 tablets per year.) FANAPT ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG, 8 MG 4 SL (2 tablets per day) (iloperidone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 110 Coverage Requirements & Prescription Drug Name Drug Tier Limits FANAPT ORAL TABLET 2 MG ( iloperidone) 4 SL (56 tablets per year.) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG SL (8 tablets (1 pack) per 3 (iloperidone) 365 days.) LATUDA ORAL TABLET 120 MG, 20 MG, 60 MG (lurasidone 2 SL (1 tablet per day.) hcl) LATUDA ORAL TABLET 40 MG (lurasidone hcl) 2 SL (1 tablet per day) LATUDA ORAL TABLET 80 MG (lurasidone hcl) 2 SL (2 tablets per day.) NUPLAZID ORAL CAPSULE 34 MG (pimavanserin tartrate) 4 PA NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 4 PA olanzapine oral tablet 10 mg, 15 mg, 20 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet 2.5 mg 1 SL (2 tablets per day.) olanzapine oral tablet 5 mg 1 SL (3 tablets per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg 1 SL (1 capsule per day) paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg 1 SL (1 tablet per day) paliperidone er oral tablet extended release 24 hour 6 mg 1 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 mg 1 SL (31 tablets per 31 days.) quetiapine fumarate er oral tablet extended release 24 hour 200 mg 1 SL (1 tablet per day.) quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg 1 SL (62 tablets per 31 days.) quetiapine fumarate er oral tablet extended release 24 hour SL (13 tablets per year for 50 mg 1 initial fill 3 tablets per day for maintenance fill.) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg 1 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 4 ST; SL (1 tablet per day.) MG, 4 MG (brexpiprazole) risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 111 Coverage Requirements & Prescription Drug Name Drug Tier Limits risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 1 SL (2 tablets per day) (asenapine maleate) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG 1 SL (2 tablets per day.) (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (31 tablets per 31 days.) HOUR 150 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (1 tablet per day.) HOUR 200 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 SL (62 tablets per 31 days.) HOUR 300 MG, 400 MG (quetiapine fumarate) SL (13 tablets per year for SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 4 initial fill 3 tablets per day for HOUR 50 MG (quetiapine fumarate) maintenance fill.) SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 4 SL (1 capsule per day) fluoxetine hcl) VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) 4 VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 4 SL (1 capsule per day.) (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG 4 SL (7 capsules per year.) (cariprazine hcl) SL (62 capsules per 31 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 days.) BARBITURATES (ANTICONVULSANTS) - Drugs for Seizures MYSOLINE ORAL TABLET 250 MG, 50 MG (primidone) 2 ST oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 primidone oral tablet 250 mg, 50 mg 1 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) - Drugs for Anxiety & Sleep Disorder ALLZITAL ORAL TABLET 25-325 MG ( butalbital- 4 acetaminophen) ascomp-codeine oral capsule 50-325-40-30 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 112 Coverage Requirements & Prescription Drug Name Drug Tier Limits bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) BUPAP ORAL TABLET 50-300 MG (butalbital- 4 acetaminophen) butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 4 SL (6 tablets per day) caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 4 SL (6 capsules per day.) caffeine) phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 TENCON ORAL TABLET 50-325 MG ( butalbital- 3 acetaminophen) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) BENZODIAZEPINES (ANTICONVULSANTS) - Drugs for Seizures clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 113 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 4 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 diazepam intensol oral concentrate 5 mg/ml 1 diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam 3 PA (anticonvulsant)) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 4 ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 4 TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 4 dipotassium) VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML 3 PA (diazepam) VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 3 PA MG/0.1ML (diazepam) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) - Drugs for Anxiety & Sleep Disorder alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg 1 alprazolam intensol oral concentrate 1 mg/ml 1 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg 1 chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1 chlordiazepoxide- oral tablet 10-25 mg, 5-12.5 mg 1 chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 114 Coverage Requirements & Prescription Drug Name Drug Tier Limits clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 4 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 diazepam intensol oral concentrate 5 mg/ml 1 diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 estazolam oral tablet 1 mg, 2 mg 1 flurazepam hcl oral capsule 15 mg, 30 mg 1 HALCION ORAL TABLET 0.25 MG (triazolam) 4 lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 midazolam hcl oral syrup 2 mg/ml 1 MIDAZOLAM+SYRSPEND SF ORAL SUSPENSION 1 MG/ML 3 PA (midazolam) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 4 ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 4 oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG 4 (temazepam) temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 4 dipotassium) triazolam oral tablet 0.125 mg, 0.25 mg 1 BUTYROPHENONES - Drugs for Depression & Psychosis haloperidol lactate oral concentrate 2 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 115 Coverage Requirements & Prescription Drug Name Drug Tier Limits haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1 CALCITONIN -RELATED PEPTIDE ANTAG. - Migraine Treatment AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 PA; M 140 MG/ML, 70 MG/ML (-aooe) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION 2 PA; M; SL (0.1 mL per day.) PREFILLED SYRINGE 100 MG/ML (-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 PA; M; SL (0.04 ml per day.) 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED 2 PA; M; SL (0.04 ml per day.) SYRINGE 120 MG/ML (galcanezumab-gnlm) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) 2 PA; ST CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. - Drugs for Parkinson -levodopa- oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg COMTAN ORAL TABLET 200 MG ( entacapone) 4 entacapone oral tablet 200 mg 1 STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 4 levodopa-entacapone) oral tablet 100 mg 1 PA CENTRAL NERVOUS SYSTEM AGENTS, MISC. - Drugs for Attention Deficit Disorder acamprosate calcium oral tablet delayed release 333 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 116 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADDYI ORAL TABLET 100 MG (flibanserin) 4 SL (1 tablet per day.) atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 SL (2 capsules per day) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 1 SL (1 capsule per day) guanfacine hcl er oral tablet extended release 24 hour 1 mg 1 SL (1 tablet per day) guanfacine hcl er oral tablet extended release 24 hour 2 mg, 4 mg 1 SL (1 tablet per day.) guanfacine hcl er oral tablet extended release 24 hour 3 mg 1 SL (2 tablets per day.) guanfacine hcl oral tablet 1 mg, 2 mg 1 memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg 1 memantine hcl oral solution 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg 1 NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 4 10 MG (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 4 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 4 donepezil hcl) NOURIANZ ORAL TABLET 20 MG, 40 MG () 3 SL (1 tablet per day.) NUEDEXTA ORAL CAPSULE 20-10 MG (dextromethorphan- 2 PA quinidine) RILUTEK ORAL TABLET 50 MG (riluzole) 4 SMCS riluzole oral tablet 50 mg 1 SMCS STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG 4 SL (2 capsules per day) (atomoxetine hcl) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 4 SL (1 capsule per day) (atomoxetine hcl) TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) 4 PA; SMCS; SP VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR M; SL (4 autoinjector pens 4 1.75 MG/0.3ML (bremelanotide acetate) (1.2mls) per month.) PA; SL (1 capsule per day.); VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 117 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (18 ml per day.); XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) 4 SMCS; SP XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na PA; SL (18 mL per day.); 4 oxybates) SMCS; SP CYCLOOXYGENASE-2 (COX-2) INHIBITORS - Drugs for Pain celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 SL (2 capsules per day) SL (31 capsules per 31 celecoxib oral capsule 400 mg 1 days.) PRECURSORS - Drugs for Parkinson carbidopa oral tablet 25 mg 1 carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg 1 carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25- 250 mg 1 carbidopa-levodopa oral tablet dispersible 10-100 mg, 25- 100 mg, 25-250 mg 1 carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML (carbidopa- 4 levodopa) PA; SL (10 tablets per day.); INBRIJA INHALATION CAPSULE 42 MG (levodopa) 3 SMCS; SP SINEMET ORAL TABLET 10-100 MG, 25-100 MG (carbidopa- 4 levodopa) STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 4 levodopa-entacapone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 118 Coverage Requirements & Prescription Drug Name Drug Tier Limits STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 4 levodopa-entacapone) ERGOT-DERIV. AGONISTS - Drugs for Parkinson mesylate oral capsule 5 mg 1 bromocriptine mesylate oral tablet 2.5 mg 1 oral tablet 0.5 mg 1 FIBROMYALGIA AGENTS - Drugs for Nerve Pain duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg 1 SL (2 capsules per day.) duloxetine hcl oral capsule delayed release particles 30 mg 1 SL (1 capsule per day.) duloxetine hcl oral capsule delayed release particles 40 mg 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, SL (93 capsules per 31 4 50 MG, 75 MG (pregabalin) days.) SL (62 capsules per 31 LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 4 days.) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 4 SL (30.52 ml per day.) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 SL (93 capsules per 31 1 mg, 75 mg days.) SL (62 capsules per 31 pregabalin oral capsule 225 mg, 300 mg 1 days.) pregabalin oral solution 20 mg/ml 1 SL (30.52 ml per day.) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 4 SL (2 tablets per day) (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 4 SL (1 pack per 365 days.) (milnacipran hcl) HYDANTOINS - Drugs for Seizures DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin 3 sodium extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 4 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 119 Coverage Requirements & Prescription Drug Name Drug Tier Limits phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg 1 INHALATION ANESTHETICS - Anesthetics FORANE INHALATION SOLUTION (isoflurane) 2 isoflurane inhalation solution 1 sevoflurane inhalation solution 1 terrell inhalation solution 1 ULTANE INHALATION SOLUTION (sevoflurane) 3 B INHIBITORS - Drugs for Parkinson AZILECT ORAL TABLET 0.5 MG, 1 MG ( mesylate) 4 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR () rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) MONOAMINE OXIDASE INHIBITORS - Drugs for Depression & Psychosis AZILECT ORAL TABLET 0.5 MG, 1 MG (rasagiline mesylate) 4 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) MARPLAN ORAL TABLET 10 MG ( ) 3 NARDIL ORAL TABLET 15 MG ( sulfate) 4 PARNATE ORAL TABLET 10 MG ( sulfate) 4 phenelzine sulfate oral tablet 15 mg 1 rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 tranylcypromine sulfate oral tablet 10 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 120 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST - Drugs for Parkinson APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 PA; M; SL (3 ml per day.); 2 MG/3ML ( hcl) SMCS; SP KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, PA; SL (5 films per day.); 3 30 MG (apomorphine hcl) SMCS; SP KYNMOBI TITRATION KIT SUBLINGUAL KIT 10/15/20/25/30 3 PA; SMCS; SP MG (apomorphine hcl) MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG 4 ( dihydrochloride) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 () pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1 hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg 1 ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1 OPIATE AGONISTS - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg 1 apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 ascomp-codeine oral capsule 50-325-40-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-60 mg 2 BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 325-40-30 mg 1 SL (6 capsules per day.) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 SL (1 capsule per day) 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) 4 DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG 4 (hydromorphone hcl) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg 1 citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg 1 PA; SL (4 lozenges per day) FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, PA; SL (4 buccal tablets per 4 400 MCG, 600 MCG, 800 MCG day) fentanyl transdermal patch 72 hour 100 mcg/hr, 37.5 PA; SL (0.34 patches per 1 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr day) PA; SL (15 patches per 31 fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr 1 days) FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, PA; SL (4 buccal tablets per 4 600 MCG, 800 MCG (fentanyl citrate) day) hydrocodone bitartrate er oral capsule extended release 12 1 PA; SL (2 capsules per day) hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml 1 hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 1 hydromorphone hcl er oral tablet extended release 24 hour PA; ST; SL (2 tablets per 1 12 mg day) hydromorphone hcl er oral tablet extended release 24 hour 16 mg, 8 mg 1 PA; ST; SL (1 tablet per day) hydromorphone hcl er oral tablet extended release 24 hour PA; ST; SL (0 tablet per 0 1 32 mg days)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydromorphone hcl oral liquid 1 mg/ml 1 hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 hydromorphone hcl rectal suppository 3 mg 1 LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT 4 PA; SL (0.5 bottle per day) (fentanyl citrate) levorphanol tartrate oral tablet 2 mg 1 ST; SL (4 tablets per day) levorphanol tartrate oral tablet 3 mg 1 ST; SL (4 tablets per day.) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 4 acetaminophen) meperidine hcl oral solution 50 mg/5ml 1 meperidine hcl oral tablet 50 mg 1 hcl intensol oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadone hcl oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadone hcl oral solution 10 mg/5ml 1 PA; SL (11.3 mL per day) methadone hcl oral solution 5 mg/5ml 1 PA; SL (22.6 mL per day) methadone hcl oral tablet 10 mg 1 PA; SL (2 tablets per day) methadone hcl oral tablet 5 mg 1 PA; SL (4 tablets per day) methadone hcl oral tablet soluble 40 mg 1 SL (1.5 tablets per day.) methadose oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadose oral tablet soluble 40 mg 1 SL (1.5 tablets per day.) methadose sugar-free oral concentrate 10 mg/ml 1 SL (6 ml per day.) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml 1 morphine sulfate er beads oral capsule extended release 24 PA; ST; SL (0 capsule per 1 hour 120 mg 100 days) morphine sulfate er beads oral capsule extended release 24 PA; ST; SL (1 capsule per 1 hour 30 mg, 45 mg, 60 mg, 75 mg, 90 mg day) morphine sulfate er oral capsule extended release 24 hour PA; ST; SL (62 capsules per 1 10 mg, 20 mg, 30 mg 31 days) morphine sulfate er oral capsule extended release 24 hour PA; ST; SL (0 capsule per 1 100 mg 100 days) morphine sulfate er oral capsule extended release 24 hour PA; ST; SL (2 capsules per 1 40 mg day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits morphine sulfate er oral capsule extended release 24 hour PA; ST; SL (1 capsule per 1 50 mg, 60 mg, 80 mg day) morphine sulfate er oral tablet extended release 100 mg, PA; SL (0 capsule per 100 1 200 mg, 60 mg days) morphine sulfate er oral tablet extended release 15 mg, 30 PA; SL (93 tablets per 31 1 mg days) morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg 1 morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg 1 MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, PA; ST; SL (0 capsule per 3 200 MG, 60 MG (morphine sulfate) 100 days) MS CONTIN ORAL TABLET EXTENDED RELEASE 15 MG, 30 PA; ST; SL (93 tablets per 31 3 MG (morphine sulfate) days) NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 3 PA; SL (2 tablets per day) HOUR 100 MG, 50 MG (tapentadol hcl) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 PA; SL (0 capsule per 100 3 HOUR 150 MG, 200 MG, 250 MG (tapentadol hcl) days) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG 2 SL (6 tablets per day) (tapentadol hcl) oxycodone hcl oral capsule 5 mg 1 oxycodone hcl oral concentrate 100 mg/5ml 1 oxycodone hcl oral solution 5 mg/5ml 1 oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 oxycodone hcl oral tablet 5 mg 1 SL (12 tablets per day) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 OXYCODONE-ACETAMINOPHEN ORAL TABLET 5-300 MG 4 oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg 1 PA oxymorphone hcl er oral tablet extended release 12 hour 30 PA; SL (0 capsule per 100 1 mg, 40 mg days) oxymorphone hcl oral tablet 10 mg, 5 mg 1 SL (6 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 124 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROLATE ORAL TABLET 5-300 MG, 7.5-300 MG 4 (oxycodone-acetaminophen) SYNAPRYN FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 10 MG/ML (tramadol hcl) tramadol hcl er (biphasic) oral tablet extended release 24 1 SL (1 tablet per day) hour 100 mg, 200 mg, 300 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 4 SL (1 capsule per day) 24 HOUR 100 MG, 200 MG, 300 MG tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg 1 SL (1 tablet per day) tramadol hcl oral tablet 50 mg 1 tramadol-acetaminophen oral tablet 37.5-325 mg 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 1 dihydrocodeine) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 4 acetaminophen) XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- 2 PA; SL (2 tablets per day) DETERRENT 13.5 MG, 18 MG, 27 MG, 9 MG (oxycodone) XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- PA; SL (0 capsule per 100 2 DETERRENT 36 MG (oxycodone) days) OPIATE ANTAGONISTS - Drugs for Overdose or Poisoning BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG PA; ST; SL (2 buccal films 4 (buprenorphine hcl-naloxone hcl) per day.) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 SL (2 films per day.) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 SL (1 film per day.) buprenorphine hcl-naloxone hcl sublingual film 4-1 mg 1 SL (1 sublingual film per day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day.) buprenorphine hcl-naloxone hcl sublingual tablet SL (3 sublingual tablets per 1 sublingual 2-0.5 mg day) buprenorphine hcl-naloxone hcl sublingual tablet 1 SL (3 tablets per day.) sublingual 8-2 mg naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 naltrexone hcl oral tablet 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 125 Coverage Requirements & Prescription Drug Name Drug Tier Limits NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 2 pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML 4 M; SL (0.6 ml per day.) (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML 4 M; SL (0.4 ml per day.) (methylnaltrexone bromide) SUBOXONE SUBLINGUAL FILM 12-3 MG (buprenorphine 4 PA; ST; SL (2 films per day.) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG (buprenorphine 4 PA; ST; SL (1 film per day.) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 4-1 MG (buprenorphine hcl- PA; ST; SL (1 sublingual film 4 naloxone hcl) per day) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 4 PA; ST; SL (3 films per day.) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG 1 SL (1 tablet per day.) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 1 SL (3 tablets per day.) 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (2 tablets per day.) 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG 1 SL (1 tablet per day) (buprenorphine hcl-naloxone hcl) OPIATE PARTIAL AGONISTS - Drugs for Pain BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 3 PA; SL (2 films per day) MCG, 75 MCG, 750 MCG, 900 MCG (buprenorphine hcl) BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG PA; ST; SL (2 buccal films 4 (buprenorphine hcl-naloxone hcl) per day.) SL (3 sublingual tablets per buprenorphine hcl sublingual tablet sublingual 2 mg 1 day) buprenorphine hcl sublingual tablet sublingual 8 mg 1 SL (3 tablets per day) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 SL (2 films per day.) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 SL (1 film per day.) buprenorphine hcl-naloxone hcl sublingual film 4-1 mg 1 SL (1 sublingual film per day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day.) buprenorphine hcl-naloxone hcl sublingual tablet SL (3 sublingual tablets per 1 sublingual 2-0.5 mg day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits buprenorphine hcl-naloxone hcl sublingual tablet 1 SL (3 tablets per day.) sublingual 8-2 mg butorphanol tartrate nasal solution 10 mg/ml 1 pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 SUBOXONE SUBLINGUAL FILM 12-3 MG (buprenorphine 4 PA; ST; SL (2 films per day.) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG (buprenorphine 4 PA; ST; SL (1 film per day.) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 4-1 MG (buprenorphine hcl- PA; ST; SL (1 sublingual film 4 naloxone hcl) per day) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 4 PA; ST; SL (3 films per day.) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG 1 SL (1 tablet per day.) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 1 SL (3 tablets per day.) 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (2 tablets per day.) 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG 1 SL (1 tablet per day) (buprenorphine hcl-naloxone hcl) OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Pain aif #2 drug preparation kit external cream 1 PA AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA CAMBIA ORAL PACKET 50 MG (diclofenac 4 potassium(migraine)) DAYPRO ORAL TABLET 600 MG (oxaprozin) 4 DICLOFENAC CAP ORAL CAPSULE 35 MG 4 diclofenac potassium oral tablet 50 mg 1 diclofenac sodium er oral tablet extended release 24 hour 100 mg 1 diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg 1 diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg 1 diflunisal oral tablet 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG 3 (naproxen) EC-NAPROSYN ORAL TABLET DELAYED RELEASE 500 MG 4 (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg 1 etodolac oral capsule 200 mg, 300 mg 1 etodolac oral tablet 400 mg, 500 mg 1 FELDENE ORAL CAPSULE 10 MG, 20 MG (piroxicam) 4 flurbiprofen oral tablet 100 mg, 50 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3 indomethacin er oral capsule extended release 75 mg 1 INDOMETHACIN ORAL CAPSULE 20 MG 4 indomethacin oral capsule 25 mg, 50 mg 1 K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % 3 PA (ketoprofen-baclofen-gabap-lido ) KETOROLAC TROMETHAMINE NASAL SOLUTION 15.75 4 ST MG/SPRAY ketorolac tromethamine oral tablet 10 mg 1 meclofenamate sodium oral capsule 100 mg, 50 mg 1 mefenamic acid oral capsule 250 mg 1 meloxicam oral tablet 15 mg, 7.5 mg 1 MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) 4 nabumetone oral tablet 500 mg, 750 mg 1 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits naproxen sodium oral tablet 275 mg, 550 mg 1 NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA oxaprozin oral tablet 600 mg 1 piroxicam oral capsule 10 mg, 20 mg 1 QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 MG 4 (meloxicam) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac 4 ST tromethamine) sulindac oral tablet 150 mg, 200 mg 1 TIVORBEX ORAL CAPSULE 20 MG (indomethacin) 4 ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) 4 ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) 4 PHENOTHIAZINES - Drugs for Depression & Psychosis hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg 1 compro rectal suppository 25 mg 1 fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 10 mg, 4-25 mg, 4-50 mg 1 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 RESPIRATORY AND CNS STIMULANTS - Drugs for the Nervous System ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG 4 SL (1 capsule per day.) (methylphenidate hcl) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 129 Coverage Requirements & Prescription Drug Name Drug Tier Limits APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG 4 SL (1 capsule per day.) (methylphenidate hcl) ascomp-codeine oral capsule 50-325-40-30 mg 1 bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 4 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 1 SL (1 tablet per day.) MG, 54 MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG 1 SL (2 tablets per day.) (methylphenidate hcl) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 4 SL (1 tablet per day) DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 4 SL (1 patch per day) MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release SL (31 capsules per 31 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 1 5 mg days.) dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 ergotamine-caffeine oral tablet 1-100 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 4 SL (6 tablets per day) caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 4 SL (6 capsules per day.) caffeine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 130 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG 4 (dexmethylphenidate hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG 4 PA; SL (1 capsule per day.) (methylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML 4 (methylphenidate hcl) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg 1 SL (31 tablets per 31 days.) methylphenidate hcl er (cd) oral capsule extended release SL (31 capsules per 31 1 40 mg, 50 mg, 60 mg days.) methylphenidate hcl er (la) oral capsule extended release 1 SL (1 capsule per day) 24 hour 10 mg, 20 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 1 SL (2 capsules per day.) 24 hour 30 mg methylphenidate hcl er (la) oral capsule extended release 1 24 hour 60 mg methylphenidate hcl er (xr) oral capsule extended release 1 SL (1 capsule per day.) 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg 1 SL (6 tablets per day.) methylphenidate hcl er oral tablet extended release 20 mg 1 SL (3 tablets per day.) methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 4 SL (1 tablet per day.) RELEASE 20 MG, 30 MG, 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 4 SL (360 mL per month.) 25 MG/5ML (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG 4 (methylphenidate hcl) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 131 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 1 dihydrocodeine) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) SALICYLATES - Drugs for Pain ascomp-codeine oral capsule 50-325-40-30 mg 1 aspirin-dipyridamole er oral capsule extended release 12 1 hour 25-200 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 salsalate oral tablet 500 mg, 750 mg 1 SEL.,NOREPI REUPTAKE INHIBITOR - Drugs for Depression & Psychosis DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 4 24 HOUR 100 MG, 50 MG desvenlafaxine succinate er oral tablet extended release 24 1 SL (1 tablet per day) hour 100 mg, 50 mg desvenlafaxine succinate er oral tablet extended release 24 1 SL (1 tablet per day.) hour 25 mg DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 4 SL (2 capsules per day.) SPRINKLE 20 MG, 30 MG, 60 MG (duloxetine hcl) DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 4 SL (1 capsule per day.) SPRINKLE 40 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg 1 SL (2 capsules per day.) duloxetine hcl oral capsule delayed release particles 30 mg 1 SL (1 capsule per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 132 Coverage Requirements & Prescription Drug Name Drug Tier Limits duloxetine hcl oral capsule delayed release particles 40 mg 1 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 ST; SL (1 capsule per day.) 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR ST; SL (28 capsules per 4 THERAPY PACK 20 & 40 MG (levomilnacipran hcl) year.) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 4 SL (2 tablets per day) (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 4 SL (1 pack per 365 days.) (milnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg 1 venlafaxine hcl er oral tablet extended release 24 hour 150 mg 1 SL (2 tablets per day) venlafaxine hcl er oral tablet extended release 24 hour 225 mg, 37.5 mg, 75 mg 1 SL (1 tablet per day) venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 SELECTIVE SEROTONIN AGONISTS - Migraine Treatment almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 eletriptan hydrobromide oral tablet 20 mg, 40 mg 1 frovatriptan succinate oral tablet 2.5 mg 1 IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT 4 (sumatriptan) naratriptan hcl oral tablet 1 mg, 2.5 mg 1 ONZETRA XSAIL NASAL EXHALER POWDER 11 4 MG/NOSEPC (sumatriptan succinate) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan 2 PA succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg 1 rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 1 sumatriptan nasal solution 20 mg/act, 5 mg/act 1 sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 sumatriptan succinate refill subcutaneous solution 1 M cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml 1 M

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 133 Coverage Requirements & Prescription Drug Name Drug Tier Limits sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml 1 M TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) 4 ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION 4 M AUTO-INJECTOR 3 MG/0.5ML (sumatriptan succinate) zolmitriptan oral tablet 2.5 mg, 5 mg 1 zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) 2 SELECTIVE-SEROTONIN REUPTAKE INHIBITORS - Drugs for Depression & Psychosis citalopram hydrobromide oral solution 10 mg/5ml 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg 1 escitalopram oxalate oral solution 5 mg/5ml 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg 1 fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 fluoxetine hcl oral capsule delayed release 90 mg 1 SL (4 capsules per 28 days.) fluoxetine hcl oral solution 20 mg/5ml 1 fluoxetine hcl oral tablet 10 mg 1 SL (1 tablet per day.) fluoxetine hcl oral tablet 20 mg, 60 mg 1 fluvoxamine maleate er oral capsule extended release 24 1 SL (2 capsules per day) hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg 1 SL (1 capsule per day) paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 SL (1 tablet per day) paroxetine hcl er oral tablet extended release 24 hour 25 mg, 37.5 mg 1 SL (2 tablets per day) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 paroxetine mesylate oral capsule 7.5 mg 1 SL (1 capsule per day.) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) 3 PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG (paroxetine 4 SL (1 tablet per day) mesylate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 134 Coverage Requirements & Prescription Drug Name Drug Tier Limits PEXEVA ORAL TABLET 30 MG (paroxetine mesylate) 4 SL (2 tablets per day) sertraline hcl oral concentrate 20 mg/ml 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 4 SL (1 capsule per day) fluoxetine hcl) SEROTONIN MODULATORS - Drugs for Depression & Psychosis hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 1 trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4 ST; SL (1 tablet per day.) (vortioxetine hbr) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (vilazodone 2 SL (1 tablet per day) hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG (vilazodone 2 hcl) SUCCINIMIDES - Drugs for Seizures CELONTIN ORAL CAPSULE 300 MG (methsuximide) 2 ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 ZARONTIN ORAL CAPSULE 250 MG (ethosuximide) 4 ZARONTIN ORAL SOLUTION 250 MG/5ML (ethosuximide) 4 THIOXANTHENES - Drugs for Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 TRICYCLICS, OTHER NOREPI-RU INHIBITORS - Drugs for Depression & Psychosis amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg 1 clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 1 desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 135 Coverage Requirements & Prescription Drug Name Drug Tier Limits doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 doxepin hcl oral concentrate 10 mg/ml 1 doxepin hcl oral tablet 3 mg, 6 mg 1 SL (1 tablet per day) enovarx-amitriptyline external kit 2 % 1 PA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg 1 NORPRAMIN ORAL TABLET 10 MG, 25 MG (desipramine 4 hcl) nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 nortriptyline hcl oral solution 10 mg/5ml 1 NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 10 mg, 4-25 mg, 4-50 mg 1 protriptyline hcl oral tablet 10 mg, 5 mg 1 SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) 4 SL (1 tablet per day) trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg 1 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR - Drugs for the Nervous System PA; SL (4 tablets per day); AUSTEDO ORAL TABLET 12 MG, 9 MG (deutetrabenazine) 2 SMCS; SP PA; SL (2 tablets per day); AUSTEDO ORAL TABLET 6 MG (deutetrabenazine) 2 SMCS; SP tetrabenazine oral tablet 12.5 mg 1 PA; SMCS tetrabenazine oral tablet 25 mg 1 PA; SMCS; SP WAKEFULNESS-PROMOTING AGENTS - Drugs for the Nervous System armodafinil oral tablet 150 mg, 250 mg 1 PA; SL (1 tablet per day) armodafinil oral tablet 200 mg, 50 mg 1 PA; SL (1 tablet per day.) modafinil oral tablet 100 mg, 200 mg 1 PA; SL (1 tablet per day) SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) 3 PA; SL (1 tablet per day.) PA; SL (2 tablets per day.); WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) 4 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 136 Coverage Requirements & Prescription Drug Name Drug Tier Limits DENTAL AGENTS - Oral Care DENTAL AGENTS - Oral Care FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (- 2 phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 DEVICES - Medical Supplies and Durable Medical Equipment DEVICES - Medical Supplies and Durable Medical Equipment ACCU-CHEK AVIVA IN VITRO SOLUTION (blood glucose 1 calibration) ACCU-CHEK COMPACT PLUS CONTROL IN VITRO 1 SOLUTION (blood glucose calibration) ACCU-CHEK FASTCLIX LANCET KIT KIT (lancets misc.) 1 ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID (blood 1 glucose calibration) ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose 3 M monitoring suppl) ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID 1 (blood glucose calibration) ACCU-CHEK SOFTCLIX LANCET DEVICE KIT KIT (lancets 1 misc.) ALCOHOL PREP PADS SHEET 70 % 3 AUTOLET LANCING DEVICE (lancet devices) 3 CARETOUCH CONTROL SOL LEVEL 2 IN VITRO LIQUID 3 (blood glucose calibration) CARETOUCH LANCING/EJECTOR (lancet devices) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 137 Coverage Requirements & Prescription Drug Name Drug Tier Limits CONTOUR CONTROL IN VITRO LIQUID HIGH (blood 3 glucose calibration) CONTOUR CONTROL IN VITRO LIQUID LOW , NORMAL 2 (blood glucose calibration) CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , 2 NORMAL (blood glucose calibration) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose 2 M monitoring suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose 4 M monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood glucose 2 M monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring 2 M suppl) DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR PA; M; SL (1 kit per 999 (INCLUDING PLATINUM, PLATINUM PEDIATRIC) 3 days.) (continuous blood gluc transmit) DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR PA; M; SL (4 sensors per (INCLUDING PLATINUM, PLATINUM PEDIATRIC) 3 month.) (continuous blood gluc sensor) PA; M; SL (1 transmitter per DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR 6 months for Dexcom G4 (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE 3 Transmitter. 2 transmitter per (continuous blood gluc receiver) 6 months for Dexcom G5 Transmitter.) EASIVENT (spacer/aero-holding chambers) 2 EASYMAX 15 LEVEL 2-3 CONTROL IN VITRO LIQUID (blood 3 glucose calibration) EASYMAX CONTROL IN VITRO SOLUTION NORMAL (blood 3 glucose calibration) EASYMAX CONTROL NORMAL/HIGH IN VITRO LIQUID 3 (blood glucose calibration) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) 3 PA; M FLEXICHAMBER ADULT MASK/SMALL (spacer/aero-hold 2 chamber mask) FLEXICHAMBER CHILD MASK/LARGE (spacer/aero-hold 2 chamber mask)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 138 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLEXICHAMBER CHILD MASK/SMALL (spacer/aero-hold 2 chamber mask) FORTISCARE CONTROL IN VITRO SOLUTION HIGH , LOW , 2 NORMAL (blood glucose calibration) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous 3 PA; M blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood 3 PA; M gluc sensor) FREESTYLE LIBRE 2 READER DEVICE (continuous blood 3 PA; M gluc receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc 3 PA; M sensor) FREESTYLE LIBRE READER DEVICE (continuous blood PA; M; SL (1 kit per 999 3 gluc receiver) days.) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood 3 PA; M gluc sensor) GUARDIAN SENSOR (3) (continuous blood gluc sensor) 3 PA; M INSPIREASE RESERVOIR BAGS (spacer/aero-hold chamber 2 bags) INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 32G X 2 4 MM (insulin pen needle) INSULIN PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 2 MM INSULIN PEN NEEDLES 29G X 5MM , 29G X 8MM , 33G X 4 3 MM , 33G X 5 MM , 33G X 6 MM (insulin pen needle) INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 2 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MICROLET NEXT LANCING DEVICE (lancet devices) 3 NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM (insulin 2 pen needle) NOVOFINE PEN NEEDLE 32G X 6 MM (insulin pen needle) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 139 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOFINE PLUS PEN NEEDLE 32G X 4 MM (insulin pen 2 needle) NOVOPEN ECHO DEVICE (injection device for insulin) 3 NOVOTWIST PEN NEEDLE 32G X 5 MM (insulin pen needle) 2 ONETOUCH DELICA LANCING DEVICE (lancet devices) 1 ONETOUCH DELICA PLUS LANCING DEVICE (lancet 1 devices) ONETOUCH ULTRA 2 KIT W/DEVICE (blood glucose 1 M monitoring suppl) ONETOUCH ULTRA MINI KIT W/DEVICE (blood glucose 1 M monitoring suppl) ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE KIT 1 M W/DEVICE (blood glucose monitoring suppl) ONETOUCH VERIO IN VITRO SOLUTION HIGH (blood 1 glucose calibration) ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE (blood 1 M glucose monitoring suppl) ONETOUCH VERIO KIT W/DEVICE (blood glucose 1 M monitoring suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood glucose 1 M monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE KIT 1 M W/DEVICE (blood glucose monitoring suppl) SHARPS CONTAINER 3 SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID 3 (blood glucose calibration) TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW (blood 2 glucose calibration) TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL 2 (blood glucose calibration) TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH (blood 2 glucose calibration)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 140 Coverage Requirements & Prescription Drug Name Drug Tier Limits UNISTRIP CONTROL IN VITRO SOLUTION LOW (blood 3 glucose calibration) DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY PA; ST; M; SL (20 ml per 24 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 4 days.); SMCS; SP CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 4 M MG (cosyntropin) cosyntropin injection solution reconstituted 0.25 mg 1 M DIABETES MELLITUS SL (51 strips per prescription ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 3 without history 204 strips per prescription with history.) SL (51 strips per prescription CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) 2 without history 204 strips per prescription with history.) SL (51 strips per prescription ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 1 without history 204 strips per prescription with history.) SL (51 strips per prescription ONETOUCH VERIO IN VITRO STRIP (glucose blood) 1 without history 204 strips per prescription with history.) KETONES KETONE TEST IN VITRO STRIP 2 KETOSTIX IN VITRO STRIP (acetone (urine) test) 2 PANCREATIC FUNCTION tolbutamide oral tablet 500 mg 1 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants formaldehyde external solution 10 % 1 FORMALDEHYDE EXTERNAL SOLUTION 37 % 3 GLUTARALDEHYDE EXTERNAL SOLUTION 25 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 141 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac 2 phosphates) ALKALINIZING AGENTS cytra k crystals oral packet 3300-1002 mg 1 ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- 2 citric acid) potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg) 1 potassium citrate-citric acid oral solution 1100-334 mg/5ml 1 sod citrate-citric acid oral solution 500-334 mg/5ml 1 tricitrates oral solution 550-500-334 mg/5ml 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 4 (1080 MG) (potassium citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ 4 (1620 MG) (potassium citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ 4 (540 MG) (potassium citrate) AMMONIA DETOXICANTS BUPHENYL ORAL POWDER 3 GM/TSP (sodium 4 PA; SMCS phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium phenylbutyrate) 4 PA; SMCS CARBAGLU ORAL TABLET 200 MG (carglumic acid) 2 PA; SMCS; SP constulose oral solution 10 gm/15ml 1 enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) 3 lactulose encephalopathy oral solution 10 gm/15ml 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 LITHOSTAT ORAL TABLET 250 MG ( acetohydroxamic acid) 3 PA; ST; SL (17.5 ml per RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol phenylbutyrate) 4 day.); SMCS; SP sodium phenylbutyrate oral powder 3 gm/tsp 1 PA; SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 142 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium phenylbutyrate oral tablet 500 mg 1 PA; SMCS CALORIC AGENTS - Drugs for Nutrition aminoamrms oral capsule 1 aminoreliefrms oral capsule 1 DOJOLVI ORAL LIQUID 100 % (triheptanoin) 4 PA; SMCS; SP L-CYSTINE POWDER 3 L-ISOLEUCINE POWDER 3 PA CARBONIC ANHYDRASE INHIBITORS - Drugs for Water Balance acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 DIURETICS, MISCELLANEOUS - Drugs for Water Balance ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 LOOP DIURETICS - Drugs for Water Balance bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 4 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 4 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 OTHER -REMOVING AGENTS RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 143 Coverage Requirements & Prescription Drug Name Drug Tier Limits PHOSPHATE-REMOVING AGENTS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric citrate) 3 calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg 1 PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 4 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 4 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 VELPHORO ORAL TABLET CHEWABLE 500 MG (sucroferric 2 oxyhydroxide) POTASSIUM-REMOVING AGENTS LOKELMA ORAL PACKET 10 GM (sodium zirconium 3 SL (3 packets per day.) cyclosilicate) LOKELMA ORAL PACKET 5 GM (sodium zirconium 3 SL (1 packet per day.) cyclosilicate) sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM 3 SL (1 Packet per day.) (patiromer sorbitex calcium) POTASSIUM-SPARING DIURETICS - Drugs for Water Balance amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 4 (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 144 Coverage Requirements & Prescription Drug Name Drug Tier Limits eplerenone oral tablet 25 mg, 50 mg 1 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 4 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 4 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 REPLACEMENT PREPARATIONS CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 calcium-folic acid plus d oral wafer 1342-1 mg 1 CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ 2 (potassium bicarb-citric acid) effer-k oral tablet effervescent 25 meq 1 GALZIN ORAL CAPSULE 25 MG, 50 MG ( acetate (oral)) 3 klor-con 10 oral tablet extended release 10 meq 1 klor-con m10 oral tablet extended release 10 meq 1 klor-con m15 oral tablet extended release 15 meq 3 klor-con m20 oral tablet extended release 20 meq 1 klor-con oral packet 20 meq 1 klor-con oral tablet extended release 8 meq 1 klor-con/ef oral tablet effervescent 25 meq 1 K-PHOS ORAL TABLET 500 MG (potassium phosphate 2 monobasic) K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k phos 2 mono-sod phos di & mono) k-prime oral tablet effervescent 25 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 3 MEQ, 8 MEQ (potassium chloride)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 145 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEONATAL + DHA ORAL 29-1 & 200 MG 3 ONEVITE ORAL TABLET 1 MG 3 PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- 4 metoclop) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG (k 2 phos mono-sod phos di & mono ) phosphorous oral tablet 155-852-130 mg 1 phospho-trin 250 neutral oral tablet 155-852-130 mg 1 potassium chloride crys er oral tablet extended release 10 meq, 20 meq 1 potassium chloride crys er oral tablet extended release 15 meq 3 potassium chloride er oral capsule extended release 10 meq, 8 meq 1 potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq 1 potassium chloride oral packet 20 meq 1 potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) 1 PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat 3 mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 146 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) virt-phos 250 neutral oral tablet 155-852-130 mg 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 WILZIN ORAL CAPSULE 25 MG (zinc acetate (oral)) 3 THIAZIDE DIURETICS - Drugs for Water Balance ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 4 MG (quinapril-hydrochlorothiazide) ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone- 4 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz) amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg, 5-6.25 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 6.25 mg, 5-6.25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 147 Coverage Requirements & Prescription Drug Name Drug Tier Limits candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg 1 DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 2 (azilsartan-chlorthalidone) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 12.5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg 1 LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 4 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 4 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 4 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 50 mg, 50-25 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg 1 olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 148 Coverage Requirements & Prescription Drug Name Drug Tier Limits valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg 1 ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG (bisoprolol- 3 hydrochlorothiazide) ZIAC ORAL TABLET 5-6.25 MG (bisoprolol- 4 hydrochlorothiazide) THIAZIDE-LIKE DIURETICS - Drugs for Water Balance atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 URICOSURIC AGENTS colchicine-probenecid oral tablet 0.5-500 mg 1 probenecid oral tablet 500 mg 1 VASOPRESSIN ANTAGONISTS - Drugs for Water Balance PA; SL (2 tablets per day.); JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) 2 SMCS; SP JYNARQUE ORAL TABLET THERAPY PACK 15 MG PA; SL (2 tablets per day.); 2 (tolvaptan) SMCS; SP JYNARQUE ORAL TABLET THERAPY PACK 30 & 15 MG PA; SL (2 tablets per day.); 2 (tolvaptan) SMCS JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 PA; SL (2 tablets per day); 2 & 30 MG, 90 & 30 MG (tolvaptan) SMCS; SP PA; SL (90 tablets per 365 SAMSCA ORAL TABLET 15 MG (tolvaptan) 2 days.); SMCS; SP PA; SL (60 tablets per 365 SAMSCA ORAL TABLET 30 MG (tolvaptan) 4 days.); SMCS; SP TOLVAPTAN ORAL TABLET 15 MG 2 PA; SMCS; SP PA; SL (2 tablets per day.); tolvaptan oral tablet 30 mg 1 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 149 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENZYMES ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (7 mL per 3 SYRINGE 10 MG/0.5ML (pegvaliase-pqpz) year.); SMCS; SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (3 ml per 3 SYRINGE 2.5 MG/0.5ML (pegvaliase-pqpz) year.); SMCS; SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (1 ml per 3 SYRINGE 20 MG/ML (pegvaliase-pqpz) day.); SMCS; SP PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 4 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase PA; SL (5 ml per day.); 2 alfa) SMCS; SP SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML PA; M; SL (5.4 ml per 2 (asfotase alfa) month.); SMCS; SP STRENSIQ SUBCUTANEOUS SOLUTION 28 MG/0.7ML PA; M; SL (8.4 ml per 2 (asfotase alfa) month.); SMCS; SP STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML PA; M; SL (12 ml tablets per 2 (asfotase alfa) month.); SMCS; SP STRENSIQ SUBCUTANEOUS SOLUTION 80 MG/0.8ML PA; M; SL (9.6 ml (12 vials) 2 (asfotase alfa) per month.); SMCS; SP SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) 2 PA; SMCS; SP VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 4 ST UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 150 Coverage Requirements & Prescription Drug Name Drug Tier Limits EYE, EAR, NOSE AND THROAT (EENT) PREPS. ALPHA-ADRENERGIC AGONISTS (EENT) - Drugs for the Eye ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % ( 2 tartrate) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine 4 tartrate) brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 2 (brimonidine tartrate-timolol) SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 4 (brinzolamide-brimonidine) ANTIALLERGIC AGENTS - Drugs for Allergy ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 azelastine-fluticasone nasal suspension 137-50 mcg/act 1 bepotastine besilate ophthalmic solution 1.5 % 1 cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 (azelastine-fluticasone) epinastine hcl ophthalmic solution 0.05 % 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 olopatadine hcl nasal solution 0.6 % 1 olopatadine hcl solution 0.1 % ophthalmic (rx) 0.1 % 1 PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 4 ANTIBACTERIALS (EENT) - Drugs for Infections ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 151 Coverage Requirements & Prescription Drug Name Drug Tier Limits ophthalmic ointment 500 unit/gm 1 bacitracin- ophthalmic ointment 500-10000 unit/gm 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 3 (besifloxacin hcl) BLEPH-10 OPHTHALMIC SOLUTION 10 % ( 3 sodium) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 2 (sulfacetamide-prednisolone) CETRAXAL OTIC SOLUTION 0.2 % (ciprofloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT 0.3 % (ciprofloxacin 3 hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % (ciprofloxacin hcl) 4 CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 ) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 1 ) ciprofloxacin hcl ophthalmic solution 0.3 % 1 ciprofloxacin hcl otic solution 0.2 % 1 CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 4 0.025 % CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium ) DOUBLE PM OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5 % erythromycin ophthalmic ointment 5 mg/gm 1 H-N gatifloxacin ophthalmic solution 0.5 % 1 gentak ophthalmic ointment 0.3 % 1 sulfate ophthalmic solution 0.3 % 1 levofloxacin ophthalmic solution 0.5 % 1 MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 4 (neomycin-polymyxin-dexameth)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 152 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 4 (neomycin-polymyxin-dexameth) MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin hcl) 4 moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1 moxifloxacin hcl ophthalmic solution 0.5 % 1 neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5- 400-10000 , 5-400-10000 1 neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 10000-0.1 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 10000-0.1 1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- 10000-.025 1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 neo-polycin ophthalmic ointment 3.5-400-10000 1 OCUFLOX OPHTHALMIC SOLUTION 0.3 % (ofloxacin) 4 ofloxacin ophthalmic solution 0.3 % 1 ofloxacin otic solution 0.3 % 1 OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 4 fluocinolone) polycin ophthalmic ointment 500-10000 unit/gm 1 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% 1 POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-% 4 (polymyxin b-trimethoprim) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) sulfacetamide sodium ophthalmic ointment 10 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 153 Coverage Requirements & Prescription Drug Name Drug Tier Limits sulfacetamide sodium ophthalmic solution 10 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 4 (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 4 (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % 1 tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 TOBREX OPHTHALMIC OINTMENT 0.3 % ( tobramycin) 3 TOBREX OPHTHALMIC SOLUTION 0.3 % (tobramycin) 4 TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.09 % TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.5 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % (moxifloxacin 4 hcl) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % (gatifloxacin) 4 ANTIFUNGALS (EENT) - Drugs for Infections NATACYN OPHTHALMIC SUSPENSION 5 % () 3 ANTIVIRALS (EENT) - Drugs for Infections trifluridine ophthalmic solution 1 % 1 ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) 3 BETA-ADRENERGIC BLOCKING AGENTS (EENT) - Drugs for the Eye betaxolol hcl ophthalmic solution 0.5 % 1 BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 2 hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % (betaxolol 3 hcl) carteolol hcl ophthalmic solution 1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 154 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 2 (brimonidine tartrate-timolol) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 4 (dorzolamide hcl-timolol mal) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 4 levobunolol hcl ophthalmic solution 0.5 % 1 timolol maleate ocudose ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 1 timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) 1 timolol maleate pf ophthalmic solution 0.5 % 1 TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % 2 (timolol maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % 4 (timolol maleate) TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 4 maleate) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 4 %, 0.5 % (timolol maleate) CARBONIC ANHYDRASE INHIBITORS (EENT) - Drugs for the Eye acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) 4 brinzolamide ophthalmic suspension 1 % 1 COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 4 (dorzolamide hcl-timolol mal) DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 % 4 dorzolamide hcl solution 2 % ophthalmic 2 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 155 Coverage Requirements & Prescription Drug Name Drug Tier Limits dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 methazolamide oral tablet 25 mg, 50 mg 1 SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 4 (brinzolamide-brimonidine) TRUSOPT OPHTHALMIC SOLUTION 2 % (dorzolamide hcl) 4 (EENT) - Drugs for Inflammation ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol 4 etabonate) azelastine-fluticasone nasal suspension 137-50 mcg/act 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 4 (beclomethasone diprop monohyd) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 2 (sulfacetamide-prednisolone) CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 1 dexamethasone) CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 4 0.025 % cortic-nd otic solution 10-10-1 mg/ml 1 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium ) DERMOTIC OTIC OIL 0.01 % () 4 dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 DEXTENZA OPHTHALMIC INSERT 0.4 MG (dexamethasone) 3 DOUBLE PM OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5 % DUREZOL OPHTHALMIC EMULSION 0.05 % (difluprednate) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 156 Coverage Requirements & Prescription Drug Name Drug Tier Limits DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 (azelastine-fluticasone) flac otic oil 0.01 % 1 FLAREX OPHTHALMIC SUSPENSION 0.1 % 2 ( acetate) flunisolide nasal solution 25 mcg/act (0.025%) 1 fluocinolone acetonide otic oil 0.01 % 1 fluorometholone ophthalmic suspension 0.1 % 1 fluticasone propionate nasal suspension 50 mcg/act 1 FML FORTE OPHTHALMIC SUSPENSION 0.25 % 3 (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % 4 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % ( fluorometholone) 3 hydrocortisone- otic solution 1-2 % 1 INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol 3 etabonate) LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol etabonate) 4 LOTEMAX OPHTHALMIC OINTMENT 0.5 % ( loteprednol 3 etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol 3 etabonate) loteprednol etabonate ophthalmic gel 0.5 % 1 loteprednol etabonate ophthalmic suspension 0.5 % 1 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 2 (dexamethasone) MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 4 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 4 (neomycin-polymyxin-dexameth) mometasone furoate nasal suspension 50 mcg/act 1 neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 10000-0.1 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 10000-0.1 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 157 Coverage Requirements & Prescription Drug Name Drug Tier Limits neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 OMNARIS NASAL SUSPENSION 50 MCG/ACT (ciclesonide) 4 OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 4 fluocinolone) PRED MILD OPHTHALMIC SUSPENSION 0.12 % 3 (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) prednisolone acetate ophthalmic suspension 1 % 1 prednisolone sodium phosphate ophthalmic solution 1 % 1 QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 4 MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 4 (beclomethasone diprop (nasal)) sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 4 (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 4 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.09 % TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.5 % ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT 3 (ciclesonide)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 158 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) EENT ANTI-INFECTIVES, MISCELLANEOUS - Drugs for Infections ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % 1 (silver nitrate-pot nitrate) BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 3 % (povidone-iodine) gluconate mouth/throat solution 0.12 % 1 cortic-nd otic solution 10-10-1 mg/ml 1 PERIDEX MOUTH/THROAT SOLUTION 0.12 % 4 (chlorhexidine gluconate) periogard mouth/throat solution 0.12 % 1 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % 1 EENT ANTI-INFLAMMATORY AGENTS, MISC. - Drugs for Inflammation RESTASIS MULTIDOSE EMULSION 0.05 % OPHTHALMIC 4 PA; SL (5.5 ml per month.) 0.05 % (cyclosporine) RESTASIS MULTIDOSE EMULSION 0.05 % OPHTHALMIC 4 PA 0.05 % (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % (cyclosporine) 2 PA XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) 2 PA EENT DRUGS, MISCELLANEOUS acetic acid otic solution 2 % 1 apraclonidine hcl ophthalmic solution 0.5 % 1 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % PA; SL (20 mL per 21 days); 4 (cysteamine hcl) SMCS CYSTARAN OPHTHALMIC SOLUTION 0.44 % (cysteamine PA; SL (60 ml (4 bottles) per 2 hcl) month.); SMCS; SP DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 2 (sulfuric acid-sulf phenolics) hydrocortisone-acetic acid otic solution 1-2 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 159 Coverage Requirements & Prescription Drug Name Drug Tier Limits IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine hcl) 3 LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear 2 insert) MUCOSITISRX MOUTH/THROAT PACKET (artificial saliva) 3 OXERVATE OPHTHALMIC SOLUTION 0.002 % (cenegermin- PA; SL (1 ml per day and 56 4 bkbj) ml per 365 days.); SMCS; SP SALIVAMAX MOUTH/THROAT PACKET (artificial saliva) 4 EENT NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Inflammation ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac 4 tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac 4 tromethamine) ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac 4 tromethamine) bromfenac sodium (once-daily) ophthalmic solution 0.09 % 1 BROMSITE OPHTHALMIC SOLUTION 0.075 % (bromfenac 4 sodium) diclofenac sodium ophthalmic solution 0.1 % 1 flurbiprofen sodium ophthalmic solution 0.03 % 1 ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) 4 ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NEVANAC OPHTHALMIC SUSPENSION 0.1 % (nepafenac) 4 PROLENSA OPHTHALMIC SOLUTION 0.07 % (bromfenac 4 sodium) TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.09 % TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1- 3 PA 0.5-0.5 % LOCAL ANESTHETICS (EENT) - Drugs for Numbing AKTEN OPHTHALMIC GEL 3.5 % ( hcl) 3 ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine hcl) 3 ALTACAINE OPHTHALMIC SOLUTION 0.5 % (tetracaine hcl) 3 cortic-nd otic solution 10-10-1 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 160 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) lidocaine hcl mouth/throat solution 4 % 1 lidocaine viscous hcl mouth/throat solution 2 % 1 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 proparacaine hcl ophthalmic solution 0.5 % 1 tetracaine hcl ophthalmic solution 0.5 % 1 MIOTICS - Drugs for the Eye ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 % 4 (pilocarpine hcl) ISOPTO CARPINE OPHTHALMIC SOLUTION 4 % 3 (pilocarpine hcl) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 MYDRIATICS - Drugs for the Eye altafrin ophthalmic solution 10 %, 2.5 % 1 atropine sulfate ophthalmic ointment 1 % 1 atropine sulfate ophthalmic solution 1 % 1 CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 % 4 (cyclopentolate hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1 homatropaire ophthalmic solution 5 % 1 ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % (atropine 3 sulfate) phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 PROSTAGLANDIN ANALOGS - Drugs for the Eye bimatoprost ophthalmic solution 0.03 % 1 latanoprost ophthalmic solution 0.005 % 1 LUMIGAN OPHTHALMIC SOLUTION 0.01 % (bimatoprost) 2 ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 (netarsudil-latanoprost) travoprost (bak free) ophthalmic solution 0.004 % 1 XELPROS OPHTHALMIC EMULSION 0.005 % (latanoprost) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 161 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % (tafluprost) 3 ST RHO KINASE INHIBITORS - Drugs for the Eye RHOPRESSA OPHTHALMIC SOLUTION 0.02 % (netarsudil 3 dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 (netarsudil-latanoprost) VASOCONSTRICTORS ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) altafrin ophthalmic solution 10 %, 2.5 % 1 CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 UPNEEQ OPHTHALMIC SOLUTION 0.1 % (oxymetazoline 4 PA hcl) GASTROINTESTINAL DRUGS AND ADSORBENTS FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) SODIUM BICARBONATE ORAL POWDER 3 GASTROINTESTINAL DRUGS - Drugs for the Stomach 5-HT3 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 4 palonosetron) granisetron hcl oral tablet 1 mg 1 ondansetron hcl oral solution 4 mg/5ml 1 ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 ondansetron odt oral tablet dispersible 4 mg, 8 mg 1 ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) 4 ANTIDIARRHEA AGENTS - Drugs for diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 162 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 4 atropine) MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-atropine) 4 MYTESI ORAL TABLET DELAYED RELEASE 125 MG 4 PA; SL (2 tablets per day.) (crofelemer) opium oral tincture 10 mg/ml (1%) 1 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) PA; SL (3 tablets per day); XERMELO ORAL TABLET 250 MG (telotristat etiprate) 3 SMCS; SP ANTIEMETICS, MISCELLANEOUS - Drugs for Vomiting and Nausea oral capsule 10 mg, 2.5 mg, 5 mg 1 MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG 4 (dronabinol) promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 scopolamine transdermal patch 72 hour 1 mg/3days 1 SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) 4 SL (4 ml per day) ANTIFLATULENTS - Drugs for Gas FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) ANTIHISTAMINES (GI DRUGS) - Drugs for Vomiting and Nausea ANTIVERT ORAL TABLET 50 MG ( meclizine hcl) 2 compro rectal suppository 25 mg 1 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 trimethobenzamide hcl oral capsule 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 163 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTI-INFLAMMATORY AGENTS (GI DRUGS) - Drugs for Inflammation alosetron hcl oral tablet 0.5 mg, 1 mg 1 PA; SL (2 tablets per day) APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 1 0.375 GM (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 4 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 4 balsalazide disodium oral capsule 750 mg 1 DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) 3 LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 1 (mesalamine) mesalamine rectal enema 4 gm 1 mesalamine rectal suppository 1000 mg 1 SL (1 suppository per day.) mesalamine-cleanser rectal kit 4 gm 1 SL (4 grams per month.) ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) 4 SL (4 grams per month.) SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) 4 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 ANTIULCER AGENTS AND ACID SUPPRESS.,MISC - Drugs for Ulcers and Stomach Acid PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) ANTIULCER AGENTS AND ACID SUPPRESSANTS - Drugs for Ulcers and Stomach Acid amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1 amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 164 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIRST-METRONIDAZOLE ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate) FLAGYL ORAL CAPSULE 375 MG (metronidazole) 4 FLAGYL ORAL TABLET 500 MG (metronidazole) 4 METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION 3 PA RECONSTITUTED 50 MG/ML (metronidazole benzoate) metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 SODIUM BICARBONATE ORAL POWDER 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 CATHARTICS AND LAXATIVES - Drugs for cascara sagrada oral fluid extract 1 gm/ml 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML 2 (sod picosulfate-mag ox-cit acd) FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) gavilyte-c oral solution reconstituted 240 gm 1 H gavilyte-g oral solution reconstituted 236 gm 1 H gavilyte-n with flavor pack oral solution reconstituted 420 gm 1 H GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM 4 (peg 3350-kcl-nabcb-nacl-nasulf) mineral oil heavy oral oil 1 MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 2 (peg-kcl-nacl-nasulf-na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION 4 RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos 3 mono-sod phos dibasic) PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- 4 metoclop) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 165 Coverage Requirements & Prescription Drug Name Drug Tier Limits peg-3350/electrolytes oral solution reconstituted 236 gm 1 H peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm 1 peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 1 peg-prep oral kit 5-210 mg-gm 1 PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- 2 kcl-nacl-nasulf-na asc-c) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 2 GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate- 2 mag sulfate-kcl) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) CHOLELITHOLYTIC AGENTS - Drugs for the Stomach CHENODAL ORAL TABLET 250 MG (chenodiol) 3 SMCS; SP URSO 250 ORAL TABLET 250 MG (ursodiol) 4 URSO FORTE ORAL TABLET 500 MG (ursodiol) 4 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 URSODIOL+SYRSPEND SF ORAL SUSPENSION 30 MG/ML 3 PA (ursodiol) DIGESTANTS - Drugs for the Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 4 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 4 ST UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) GI DRUGS, MISCELLANEOUS - Drugs for the Stomach alvimopan oral capsule 12 mg 1 AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) 4 PA; ST BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE 200 MCG, 3 600 MCG (odevixibat) BYLVAY ORAL CAPSULE 1200 MCG, 400 MCG (odevixibat) 3 PA; SL (4 capsules per day.); CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) 2 SMCS; SP CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; M; SL (1 kit per 21 2 MG/ML (certolizumab pegol) days.); SMCS; SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; M; SL (6 mL per 365 2 (certolizumab pegol) days.); SMCS; SP ENTEREG ORAL CAPSULE 12 MG (alvimopan) 4 PA; M; SL (1 vial per day.); GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide (rdna)) 2 SMCS; SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year); SMCS; SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (2 kits per year); PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 pens per 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) month.); SMCS; SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; M; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; M; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; M; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; M; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SMCS; SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG 2 PA; SL (1 capsule per day.) (linaclotide) LUBIPROSTONE ORAL CAPSULE 24 MCG, 8 MCG 4 PA; ST MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride 3 PA; SL (1 tablet per day.) succinate) PA; ST; SL (1 tablet per OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) 4 day.); SMCS; SP octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml 1 PA; M; SMCS RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML 4 M; SL (0.6 ml per day.) (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML 4 M; SL (0.4 ml per day.) (methylnaltrexone bromide) SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 4 PA; M; SMCS MCG/ML, 500 MCG/ML (octreotide acetate) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; M; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; M; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SMCS; SP SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) 2 PA; SL (1 tablet per day) TRULANCE ORAL TABLET 3 MG (plecanatide) 4 PA; ST; SL (1 tablet per day) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) 4 SL (2 tablets per day.) XENICAL ORAL CAPSULE 120 MG () 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 168 Coverage Requirements & Prescription Drug Name Drug Tier Limits H2-ANTAGONISTS - Drugs for Ulcers and Stomach Acid cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 famotidine oral suspension reconstituted 40 mg/5ml 1 nizatidine oral solution 15 mg/ml 1 NEUROKININ-1 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 4 palonosetron) aprepitant oral 80 & 125 mg 1 aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg 1 EMEND ORAL CAPSULE 80 MG (aprepitant) 4 EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML 2 (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG 4 (aprepitant) PROKINETIC AGENTS - Drugs for the Stomach metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet dispersible 10 mg, 5 mg 1 PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- 4 metoclop) REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide hcl) 4 ZELNORM ORAL TABLET 6 MG ( tegaserod maleate) 3 PA; SL (2 tablets per day.) PROSTAGLANDINS - Drugs for Ulcers and Stomach Acid CYTOTEC ORAL TABLET 100 MCG, 200 MCG (misoprostol) 4 diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg 1 misoprostol oral tablet 100 mcg, 200 mcg 1 PROTECTANTS - Drugs for Ulcers and Stomach Acid sucralfate oral suspension 1 gm/10ml 1 sucralfate oral tablet 1 gm 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 169 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROTON-PUMP INHIBITORS - Drugs for Ulcers and Stomach Acid ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 4 SL (1 capsule per day.) MG (rabeprazole sodium) SL (112 capsules and tablets amoxicill-clarithro-lansopraz oral 1 (1 Package) per 180 days.) DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 2 SL (1 capsule per day) MG (dexlansoprazole) esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg 1 SL (1 packet per day) FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML 3 PA (lansoprazole) FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML 3 PA (omeprazole) lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg 1 SL (1 tablet per day.) NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG 4 SL (1 packet per day) (esomeprazole magnesium) NEXIUM ORAL PACKET 2.5 MG, 5 MG (esomeprazole 4 SL (1 packet per day.) magnesium) SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 administrative cards, 80 clarithro-omeprazole) tablets) per 6 months.) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg 1 OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 3 PA MG/ML (omeprazole) pantoprazole sodium oral packet 40 mg 1 pantoprazole sodium oral tablet delayed release 20 mg, 40 mg 1 PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole 4 magnesium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) 4 RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG 4 SL (1 capsule per day.) rabeprazole sodium oral tablet delayed release 20 mg 1 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 170 Coverage Requirements & Prescription Drug Name Drug Tier Limits GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SMCS; SP HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron CHEMET ORAL CAPSULE 100 MG (succimer) 2 clovique oral capsule 250 mg 1 PA; SMCS; SP deferasirox granules oral packet 180 mg, 360 mg, 90 mg 1 SMCS; SP deferasirox oral packet 180 mg, 360 mg, 90 mg 1 SMCS; SP deferasirox oral tablet 180 mg, 360 mg, 90 mg 1 PA; SMCS; SP deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg 1 PA; SMCS; SP deferiprone oral tablet 500 mg 1 PA; SMCS; SP DEPEN TITRATABS ORAL TABLET 250 MG ( penicillamine) 2 SMCS; SP FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) 2 PA; SMCS; SP FERRIPROX ORAL TABLET 1000 MG (deferiprone) 4 SMCS FERRIPROX ORAL TABLET 500 MG (deferiprone) 4 PA; SMCS; SP penicillamine oral capsule 250 mg 1 SMCS; SP penicillamine oral tablet 250 mg 1 SMCS; SP trientine hcl oral capsule 250 mg 1 PA; SMCS; SP HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ADRENALS - Hormones ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 1 SL (2 blisters per day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 SL (0.4 grams per day.) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) aif #2 drug preparation kit external cream 1 PA ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 1 SL (1 blister per day.) (fluticasone furoate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER 1 SL (1 packet per day.) BREATH ACTIVATED 50 MCG/ACT (fluticasone furoate) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 inhalers per day.) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 171 Coverage Requirements & Prescription Drug Name Drug Tier Limits BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 blisters per day.) ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) SL (120 ml (2 boxes) per 30 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 days.) SL (60 ml (1 box) per 30 budesonide inhalation suspension 1 mg/2ml 1 days.) budesonide oral capsule delayed release particles 3 mg 1 CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 4 (hydrocortisone) dexamethasone intensol oral concentrate 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1 dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51) 1 DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 4 ST; SL (0.44 grams per day.) MCG/ACT (mometasone furo-formoterol fum) DULERA INHALATION AEROSOL 50-5 MCG/ACT 4 ST; SL (0.44 mcg per day.) (mometasone furo-formoterol fum ) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (2 packages per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 1 SL (4 packages per day) propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 1 SL (1 inhaler per month) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT 1 SL (2 inhalers per month) (fluticasone propionate hfa) fludrocortisone acetate oral tablet 0.1 mg 1 flunisolide nasal solution 25 mcg/act (0.025%) 1 fluticasone propionate nasal suspension 50 mcg/act 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 172 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 1 SL (0.04 mcg per day.) MCG/ACT, 55-14 MCG/ACT hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 INTRAROSA VAGINAL INSERT 6.5 MG () 2 SL (1 insert per day) MEDROL ORAL TABLET 16 MG, 4 MG, 8 MG 4 () MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET 32 MG (methylprednisolone) 3 MEDROL ORAL TABLET THERAPY PACK 4 MG 4 (methylprednisolone) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 methylprednisolone oral tablet therapy pack 4 mg 1 MILLIPRED ORAL TABLET 5 MG (prednisolone) 2 mometasone furoate nasal suspension 50 mcg/act 1 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 4 30 MG (prednisolone sodium phosphate) PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML 2 (prednisolone sodium phosphate) prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml 1 prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg 1 prednisone intensol oral concentrate 5 mg/ml 1 prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 1 prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) 1 PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 2 SL (0.34 grams per day.) 4.5 MCG/ACT (budesonide-formoterol fumarate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 173 Coverage Requirements & Prescription Drug Name Drug Tier Limits TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (49) (dexamethasone) TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG 4 (dexamethasone) TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (21) (dexamethasone) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (27) (dexamethasone) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 3 SL (2 blisters per day.) umeclidin-vilant) UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 1 MG (budesonide) ALPHA-GLUCOSIDASE INHIBITORS - Drugs for Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg 1 miglitol oral tablet 100 mg, 25 mg, 50 mg 1 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG (acarbose) 4 AMYLINOMIMETICS - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- SL (4 pens (10.8 ml) per 3 INJECTOR 2700 MCG/2.7ML (pramlintide acetate) month.) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- 3 SL (4 pens (6 ml) per month.) INJECTOR 1500 MCG/1.5ML (pramlintide acetate) - Hormones ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 2 SL (1 patch per day) MG/24HR, 4 MG/24HR () COVARYX HS ORAL TABLET 0.625-1.25 MG (est - 3 methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 3 M MG/ML (testosterone cypionate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 174 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 4 M MG/ML (testosterone cypionate) EC-RX TESTOSTERONE TRANSDERMAL CREAM 0.2 %, 0.4 3 PA %, 10 %, 20 % EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 METHITEST ORAL TABLET 10 MG 2 methyltestosterone oral capsule 10 mg 1 oxandrolone oral tablet 10 mg, 2.5 mg 1 SL (100 mg Testosterone (2 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) 1 X 5 grams tubes = 10 grams) (testosterone) per day) testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml 1 M testosterone enanthate intramuscular solution 200 mg/ml 1 M XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML (testosterone 4 M enanthate) ANTIDIABETIC AGENTS, MISCELLANEOUS - Drugs for Diabetes CYCLOSET ORAL TABLET 0.8 MG (bromocriptine mesylate) 3 KORLYM ORAL TABLET 300 MG () 3 PA; SMCS; SP WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 1 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 1 ANTIESTROGENS - Drugs for Women anastrozole oral tablet 1 mg 1 exemestane oral tablet 25 mg 1 KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 4 PA; SMCS; CM MG (ribociclib-letrozole)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 175 Coverage Requirements & Prescription Drug Name Drug Tier Limits letrozole oral tablet 2.5 mg 1 ANTIGONADTROPINS - Hormones FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 M; SMCS; SP RECONSTITUTED 120 MG/VIAL (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 M; SMCS; SP 80 MG (degarelix acetate) PA; SL (1 tablet per day); ORGOVYX ORAL TABLET 120 MG (relugolix) 3 SMCS; SP; CM ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 4 PA; SL (2 capsules per day.) MG (elagolix--norethind) ORILISSA ORAL TABLET 150 MG (elagolix sodium) 4 SL (1 tablet per day.) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 4 SL (2 tablets per day.) ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS - Hormones diazoxide oral suspension 50 mg/ml 1 ANTIPARATHYROID AGENTS - Drugs for Bones calcitonin (salmon) injection solution 200 unit/ml 1 M calcitonin (salmon) nasal solution 200 unit/act 1 cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 PA MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 M (salmon)) ANTITHYROID AGENTS - Drugs for the Thyroid methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 TAPAZOLE ORAL TABLET 10 MG, 5 MG (methimazole) 4 - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 4 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg 1 glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 500 mg 1 JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day.) 850 MG (linagliptin-metformin hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 176 Coverage Requirements & Prescription Drug Name Drug Tier Limits JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day.) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (62 tablets per month.) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (31 tablets per month.) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg 1 metformin hcl oral solution 500 mg/5ml 1 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1 pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day.) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin 2 SL (1 tablet per day) hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin 2 SL (2 tablets per day) hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform) CONTRACEPTIVES - Drugs for Women afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amethia oral tablet 0.15-0.03 &0.01 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 177 Coverage Requirements & Prescription Drug Name Drug Tier Limits amethyst oral tablet 90-20 mcg 1 H ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 4 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 4 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 178 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 4 SL (5 ml per year.) MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone 4 acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 ml per year.); H (medroxyprogesterone acetate) -ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 1 H -ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per 21 days.); H emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 4 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg 1 H falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 179 Coverage Requirements & Prescription Drug Name Drug Tier Limits femynor oral tablet 0.25-35 mg-mcg 1 H gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H iclevia oral tablet 0.15-0.03 mg 1 H incassia oral tablet 0.35 mg 1 H introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 180 Coverage Requirements & Prescription Drug Name Drug Tier Limits larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg 1 H levonorgestrel oral tablet 1.5 mg 1 H levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg 1 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 4 (norethin ace-eth estrad-fe) lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 4 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 181 Coverage Requirements & Prescription Drug Name Drug Tier Limits medroxyprogesterone acetate intramuscular suspension 150 mg/ml 1 SL (5 ml per year.); H medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 4 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 4 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 1 H norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone oral tablet 0.35 mg 1 H norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 1 H norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 182 Coverage Requirements & Prescription Drug Name Drug Tier Limits norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H previfem oral tablet 0.25-35 mg-mcg 1 H reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H SLYND ORAL TABLET 4 MG (drospirenone) 4 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 183 Coverage Requirements & Prescription Drug Name Drug Tier Limits tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 4 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 184 Coverage Requirements & Prescription Drug Name Drug Tier Limits YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day.) linagliptin) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day.) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day.) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (62 tablets per month.) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (31 tablets per month.) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG (alogliptin 2 SL (1 tablet per day.) benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) 2 SL (1 tablet per day) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day.) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) TRADJENTA ORAL TABLET 5 MG ( linagliptin) 2 SL (1 tablet per day) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 185 Coverage Requirements & Prescription Drug Name Drug Tier Limits AGONIST-ANTAGONISTS - Drugs for Women DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 SL (1 tablet per day) bazedoxifene) OSPHENA ORAL TABLET 60 MG (ospemifene) 2 PA; SL (1 tablet per day.) raloxifene hcl oral tablet 60 mg 1 H SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 4 tamoxifen citrate oral tablet 10 mg 1 tamoxifen citrate oral tablet 20 mg 1 H-N toremifene citrate oral tablet 60 mg 1 ESTROGENS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 4 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 SL (8 patches (1 box) per 28 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 days.) (estradiol) altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 H amethyst oral tablet 90-20 mcg 1 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 4 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 186 Coverage Requirements & Prescription Drug Name Drug Tier Limits aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 4 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 2 SL (4 patches per month.) 0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 2 SL (8 patches per 28 days.) norethindrone acet) COVARYX HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 187 Coverage Requirements & Prescription Drug Name Drug Tier Limits dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 4 M MG/ML, 40 MG/ML (estradiol valerate) delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML 3 M (estradiol cypionate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 2 (estradiol) dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 1 H drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 SL (1 tablet per day) bazedoxifene) EC-RX ESTRADIOL TRANSDERMAL CREAM 0.4 %, 0.6 % 3 PA EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) elinest oral tablet 0.3-30 mg-mcg 1 H emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 estarylla oral tablet 0.25-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 188 Coverage Requirements & Prescription Drug Name Drug Tier Limits estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, SL (8 patches (1 box) per 28 1 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr days.) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 carton) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 mg/24hr 28 days.) estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 M estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ESTRING VAGINAL RING 2 MG (estradiol) 2 SL (1 ring per 90 days.) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 grams (1 box) per 3 (estradiol) month.) ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 4 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg 1 H EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 2 (estradiol) falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months.) (estradiol acetate) femynor oral tablet 0.25-35 mg-mcg 1 H fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H iclevia oral tablet 0.15-0.03 mg 1 H IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 3 4 MCG (estradiol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 189 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG, 4 3 MCG (estradiol) introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 190 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg 1 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 4 (norethin ace-eth estrad-fe) lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 4 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 SL (4 patches (1 carton) per 3 MCG/24HR (estradiol) 28 days.) merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 191 Coverage Requirements & Prescription Drug Name Drug Tier Limits mimvey oral tablet 1-0.5 mg 1 MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 4 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 4 H estetrol) nikki oral tablet 3-0.02 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 1 H norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 1 H norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 4 PA; SL (2 capsules per day.) MG (elagolix-estradiol-norethind)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 192 Coverage Requirements & Prescription Drug Name Drug Tier Limits orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 3 conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 193 Coverage Requirements & Prescription Drug Name Drug Tier Limits tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 4 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 28 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 1 days.) MG/24HR, 0.1 MG/24HR (estradiol) volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) yuvafem vaginal tablet 10 mcg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 194 Coverage Requirements & Prescription Drug Name Drug Tier Limits zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H GLYCOGENOLYTIC AGENTS - Hormones BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) GLUCAGEN HYPOKIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency kit 1 mg injection 1 mg 1 GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 M AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 M AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GONADOTROPINS - Hormones ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 PA; M; SMCS (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 PA; M; SMCS month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 PA; M; SMCS month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA; M; SMCS leuprolide acetate injection kit 1 mg/0.2ml 1 PA; M; SMCS SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 INCRETIN MIMETICS - Drugs for Diabetes ADLYXIN STARTER PACK SUBCUTANEOUS PEN- 4 PA; ST; SL (6 ml per year.) INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 195 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 4 PA; ST; SL (6 ml per month.) MCG/0.2ML (lixisenatide) BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS PA; ST; SL (3.4 mL per 2 AUTO-INJECTOR 2 MG/0.85ML (exenatide) month) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; ST; SL (2.4 mL (one 2 INJECTOR 10 MCG/0.04ML (exenatide) pen) per prescription) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; ST; SL (1.2 mL (one 2 INJECTOR 5 MCG/0.02ML (exenatide) pen) per prescription) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (1.5 mL per 21 2 MG/1.5ML (semaglutide) days.) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (9 ml per 3 2 MG/1.5ML, 4 MG/3ML (semaglutide) months.) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG 2 PA; ST; SL (1 tablet per day.) (semaglutide) SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 3 PA; M; SL (0.5 mL per day.) MG/3ML (liraglutide -weight management) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 SL (18 ml per month.) 33 UNT-MCG/ML (insulin glargine-lixisenatide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (2 ml per month.) 0.75 MG/0.5ML, 1.5 MG/0.5ML (dulaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 PA; ST; SL (2 mL per 21 2 MG/0.5ML, 4.5 MG/0.5ML (dulaglutide) days) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML PA; ST; SL (6 ml (2 pens) 2 SUBCUTANEOUS 18 MG/3ML (liraglutide) per month.) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML PA; ST; SL (6 ml (2 pens) 3 SUBCUTANEOUS 18 MG/3ML (liraglutide) per month.) WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA 2.4 MG/0.75ML (semaglutide-weight management) INTERMEDIATE-ACTING - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph human 2 (isophane))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 196 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 1 UNIT/ML (insulin nph human (isophane)) LEPTINS - Hormones MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 vial per day.); 3 11.3 MG (metreleptin) SMCS; SP LONG-ACTING INSULINS - Drugs for Diabetes LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 1 INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 1 UNIT/ML (insulin glargine) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 SL (18 ml per month.) 33 UNT-MCG/ML (insulin glargine-lixisenatide) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 300 UNIT/ML (insulin glargine) MEGLITINIDES - Drugs for Diabetes nateglinide oral tablet 120 mg, 60 mg 1 SL (3 tablets per day) oral tablet 0.5 mg, 1 mg 1 SL (4 tablets per day) repaglinide oral tablet 2 mg 1 SL (8 tablets per day) PARATHYROID AGENTS - Drugs for Bones NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; M; SL (2 cartridges per 4 MCG, 50 MCG, 75 MCG (parathyroid (recomb)) month.); SMCS; SP TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS 3 PA; M; SMCS; SP SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 PA; M; SMCS; SP MCG/1.56ML (abaloparatide) PITUITARY - Hormones PA; ST; M; SL (20 ml per 24 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 4 days.); SMCS; SP desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 M desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 M desmopressin acetate spray nasal solution 0.01 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 197 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 SL (1 tablet per day.) 55.3 MCG (desmopressin acetate) PA; M; SL (18 ml (9 NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 10 MG/2ML (somatropin) SMCS; SP PA; M; SL (10 ml (5 NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 20 MG/2ML (somatropin) SMCS; SP PA; M; SL (36 ml (18 NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 5 MG/2ML (somatropin) SMCS; SP SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 tablet per day); 4 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) SMCS; SP STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 tablet per day); 3 8.8 MG (somatropin (non-refrigerated)) SMCS; SP PROGESTINS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 4 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 H amethyst oral tablet 90-20 mcg 1 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 4 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 198 Coverage Requirements & Prescription Drug Name Drug Tier Limits aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) 4 ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 4 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 2 SL (4 patches per month.) 0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 2 SL (8 patches per 28 days.) norethindrone acet) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) 4 ST cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 199 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 4 SL (5 ml per year.) MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone 4 acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 ml per year.); H (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 1 H drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H EC-RX PROGESTERONE TRANSDERMAL CREAM 10 %, 20 3 PA % elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per 21 days.); H emoquette oral tablet 0.15-30 mg-mcg 1 H ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) 2 enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 200 Coverage Requirements & Prescription Drug Name Drug Tier Limits ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 4 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg 1 H falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) femynor oral tablet 0.25-35 mg-mcg 1 H FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 3 PA MG, 200 MG (progesterone) fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H iclevia oral tablet 0.15-0.03 mg 1 H incassia oral tablet 0.35 mg 1 H introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 201 Coverage Requirements & Prescription Drug Name Drug Tier Limits kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg 1 H levonorgestrel oral tablet 1.5 mg 1 H levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg 1 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 4 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 4 (norethin ace-eth estrad-fe)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 202 Coverage Requirements & Prescription Drug Name Drug Tier Limits lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 4 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H medroxyprogesterone acetate intramuscular suspension 150 mg/ml 1 SL (5 ml per year.); H medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1 megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H mimvey oral tablet 1-0.5 mg 1 MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 4 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 203 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 4 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 1 H norethindrone acetate oral tablet 5 mg 1 norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone oral tablet 0.35 mg 1 H norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 1 H norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg 1 H norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 4 PA; SL (2 capsules per day.) MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 204 Coverage Requirements & Prescription Drug Name Drug Tier Limits philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H progesterone intramuscular oil 50 mg/ml 1 M PROGESTERONE MICRONIZED TRANSDERMAL CREAM 10 3 PA % progesterone oral capsule 100 mg, 200 mg 1 PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG 4 (medroxyprogesterone acetate) reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H SLYND ORAL TABLET 4 MG (drospirenone) 4 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 205 Coverage Requirements & Prescription Drug Name Drug Tier Limits tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 4 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 206 Coverage Requirements & Prescription Drug Name Drug Tier Limits YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H RAPID-ACTING INSULINS - Drugs for Diabetes AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 4 90X12 UNIT (insulin regular human) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 1 (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 1 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 2 UNIT/ML (insulin lispro) HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 1 lispro-aabc)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 207 Coverage Requirements & Prescription Drug Name Drug Tier Limits SHORT-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 1 UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 1 (insulin regular human) SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day.) linagliptin) ST; SL (30 tablets per JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) 2 month.) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day.) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin 2 SL (1 tablet per day) hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin 2 SL (2 tablets per day) hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform) SOMATOSTATIN AGONISTS - Hormones octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml 1 PA; M; SMCS SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 4 PA; M; SMCS MCG/ML, 500 MCG/ML (octreotide acetate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 208 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 PA; M; SL (2 ampules per 2 MG/ML, 0.9 MG/ML (pasireotide diaspartate) day.); SMCS; SP SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 4 M; SMCS; SP MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide acetate) SOMATOTROPIN AGONISTS - Hormones EGRIFTA SV SUBCUTANEOUS SOLUTION 4 PA; M; SMCS RECONSTITUTED 2 MG (tesamorelin acetate) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA; M; SL (52 vials per 2 () month.); SMCS; SP PA; M; SL (18 ml (9 NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 10 MG/2ML (somatropin) SMCS; SP PA; M; SL (10 ml (5 NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 20 MG/2ML (somatropin) SMCS; SP PA; M; SL (36 ml (18 NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 2 cartridges) per month.); PEN-INJECTOR 5 MG/2ML (somatropin) SMCS; SP SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 tablet per day); 4 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) SMCS; SP ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 tablet per day); 3 8.8 MG (somatropin (non-refrigerated)) SMCS; SP SOMATOTROPIN ANTAGONISTS - Hormones SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (1 vial per day.); 3 10 MG, 15 MG, 20 MG, 25 MG, 30 MG (pegvisomant) SMCS; SP SULFONYLUREAS - Drugs for Diabetes AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG (glimepiride) 4 DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 SL (1 tablet per day) hcl-glimepiride) glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 glipizide oral tablet 10 mg, 5 mg 1 glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 209 Coverage Requirements & Prescription Drug Name Drug Tier Limits glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg 1 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 4 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 500 mg 1 GLYNASE ORAL TABLET 1.5 MG (glyburide micronized) 3 GLYNASE ORAL TABLET 3 MG, 6 MG (glyburide 4 micronized) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) tolbutamide oral tablet 500 mg 1 THIAZOLIDINEDIONES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 4 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 SL (1 tablet per day) hcl-glimepiride) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day.) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 SL (1 tablet per day) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) THYROID AGENTS - Drugs for the Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 2 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 1 88 mcg SODIUM ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 4 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 210 Coverage Requirements & Prescription Drug Name Drug Tier Limits levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 1 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 2 MG, 48.75 MG, 81.25 MG (thyroid) NATURE-THROID TABLET 65 MG ORAL 65 MG (thyroid) 3 NATURE-THROID TABLET 65 MG ORAL 65 MG (thyroid) 2 NATURE-THROID TABLET 97.5 MG ORAL 97.5 MG (thyroid) 3 NATURE-THROID TABLET 97.5 MG ORAL 97.5 MG (thyroid) 2 np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg 1 TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 4 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 MCG/ML, 44 2 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 1 mcg, 88 mcg WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 3 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 3 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing lets kit 1 PA ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) 4 PA; SL (3 patches per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 211 Coverage Requirements & Prescription Drug Name Drug Tier Limits MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS dutasteride oral capsule 0.5 mg 1 dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1 oral tablet 5 mg 1 PROSCAR ORAL TABLET 5 MG (finasteride) 4 ALCOHOL DETERRENTS - Drugs for Alcohol Dependence oral tablet 250 mg, 500 mg 1 naltrexone hcl oral tablet 50 mg 1 ANTIDOTES - Drugs for Overdose or Poisoning acetylcysteine inhalation solution 10 %, 20 % 1 BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) CHEMET ORAL CAPSULE 100 MG (succimer) 2 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) GLUCAGEN HYPOKIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency kit 1 mg injection 1 mg 1 GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 M AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 M AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg 1 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 MEPHYTON ORAL TABLET 5 MG ( phytonadione) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 212 Coverage Requirements & Prescription Drug Name Drug Tier Limits naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 naltrexone hcl oral tablet 50 mg 1 phytonadione oral tablet 5 mg 1 RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 4 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 4 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VISTOGARD ORAL PACKET 10 GM (uridine triacetate) 2 PA ANTIGOUT AGENTS - Drugs for Gout allopurinol oral tablet 100 mg, 300 mg 1 colchicine-probenecid oral tablet 0.5-500 mg 1 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG 3 (naproxen) EC-NAPROSYN ORAL TABLET DELAYED RELEASE 500 MG 4 (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 febuxostat oral tablet 40 mg, 80 mg 1 SL (1 tablet per day) GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) 4 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3 indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 MITIGARE ORAL CAPSULE 0.6 MG (colchicine) 2 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 213 Coverage Requirements & Prescription Drug Name Drug Tier Limits naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 1 naproxen sodium oral tablet 275 mg, 550 mg 1 probenecid oral tablet 500 mg 1 ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) 4 ANTISENSE OLIGONUCLEOTIDES TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.22 ml per day.); 2 SYRINGE 284 MG/1.5ML (inotersen sodium) SMCS; SP BONE ANABOLIC AGENTS NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; M; SL (2 cartridges per 4 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) month.); SMCS; SP TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS 3 PA; M; SMCS; SP SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 PA; M; SMCS; SP MCG/1.56ML (abaloparatide) BONE RESORPTION INHIBITORS - Drugs for Bone Loss alendronate sodium oral solution 70 mg/75ml 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 SL (8 patches (1 box) per 28 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 days.) (estradiol) BINOSTO ORAL TABLET EFFERVESCENT 70 MG 4 SL (4 tablets per month.) (alendronate sodium) BONIVA ORAL TABLET 150 MG (ibandronate sodium) 4 calcitonin (salmon) injection solution 200 unit/ml 1 M calcitonin (salmon) nasal solution 200 unit/act 1 DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 4 M MG/ML, 40 MG/ML (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML 3 M (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 2 (estradiol) EC-RX ESTRADIOL TRANSDERMAL CREAM 0.4 %, 0.6 % 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 214 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, SL (8 patches (1 box) per 28 1 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr days.) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 carton) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 mg/24hr 28 days.) estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 M ESTRING VAGINAL RING 2 MG (estradiol) 2 SL (1 ring per 90 days.) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 grams (1 box) per 3 (estradiol) month.) EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 2 (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months.) (estradiol acetate) FOSAMAX ORAL TABLET 70 MG (alendronate sodium) 4 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg 1 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 SL (4 patches (1 carton) per 3 MCG/24HR (estradiol) 28 days.) MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 M (salmon)) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 3 conjugated) raloxifene hcl oral tablet 60 mg 1 H risedronate sodium oral tablet 150 mg 1 SL (1 tablet per month) risedronate sodium oral tablet 30 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 215 Coverage Requirements & Prescription Drug Name Drug Tier Limits risedronate sodium oral tablet 35 mg 1 SL (4 tablets per 28 days.) risedronate sodium oral tablet delayed release 35 mg 1 SL (4 tablets per month) VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 28 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 1 days.) MG/24HR, 0.1 MG/24HR (estradiol) yuvafem vaginal tablet 10 mcg 1 CARBONIC ANHYDRASE INHIBITORS (MISC.) PA; SL (4 tablets per day.); KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) 2 SMCS; SP CARIOSTATIC AGENTS - Vitamins and Fluoride adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 cavarest dental gel 1.1 % 1 CLINPRO 5000 DENTAL PASTE 1.1 % (sodium fluoride) 3 DENTA 5000 PLUS DENTAL CREAM 1.1 % (sodium fluoride) 4 DENTAGEL DENTAL GEL 1.1 % (sodium fluoride) 4 easygel dental gel 0.4 % 1 FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) fluoridex daily renewal mouth/throat concentrate 0.63 % 1 FLUORIDEX DENTAL PASTE 1.1 % (sodium fluoride) 3 FLUORIDEX ENHANCED WHITENING DENTAL PASTE 1.1 % 3 (sodium fluoride) FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) fluoritab oral solution 0.275 (0.125 f) mg/drop 1 H multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 216 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium fluoride- 2 phosphoric acd) NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 2 RECONSTITUTED 0.05 % (sodium fluoride) nafrinse drops oral solution 0.275 (0.125 f) mg/drop 1 H nafrinse oral tablet chewable 2.2 (1 f) mg 1 H NAFRINSE WEEKLY MOUTH/THROAT SOLUTION 4 RECONSTITUTED 0.2 % (sodium fluoride) POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % (sodium 4 fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium 4 fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) 4 PREVIDENT MOUTH/THROAT SOLUTION 0.2 % (sodium 3 fluoride) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 217 Coverage Requirements & Prescription Drug Name Drug Tier Limits sf 5000 plus dental cream 1.1 % 1 sf dental gel 1.1 % 1 sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 plus dental cream 1.1 % 1 sodium fluoride 5000 ppm dental cream 1.1 % 1 sodium fluoride 5000 ppm dental paste 1.1 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 sodium fluoride dental cream 1.1 % 1 sodium fluoride dental gel 1.1 % 1 sodium fluoride mouth/throat solution 0.2 % 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 H sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg 1 sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg 1 H TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 COMPLEMENT INHIBITORS BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase PA; ST; M; SL (0.34 boxes 4 inhibitor (human)) per day.); SMCS; SP FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML PA; M; SL (0.6 ml per day.); 1 (icatibant acetate) SMCS; SP HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (11 vials per 2 2000 UNIT, 3000 UNIT (c1 esterase inhibitor (human)) month); SMCS; SP RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED PA; M; SL (0.27 vials per 4 2100 UNIT (c1 esterase inhibitor (recomb)) day.); SMCS; SP TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML PA; M; SL (0.075 ml per 2 (lanadelumab-flyo) day.); SMCS; SP DISEASE-MODIFYING ANTIRHEUMATIC AGENTS - Drugs for Arthritis ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (3.6 ml per 21 3 INJECTOR 162 MG/0.9ML (tocilizumab) days.); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 218 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; M; SL (4 syringes ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED 3 (36 mL) per month); SMCS; SYRINGE 162 MG/0.9ML (tocilizumab) SP ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 4 AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 4 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 4 CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; M; SL (1 kit per 21 2 MG/ML (certolizumab pegol) days.); SMCS; SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; M; SL (6 mL per 365 2 (certolizumab pegol) days.); SMCS; SP cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 SMCS cyclosporine modified oral solution 100 mg/ml 1 SMCS cyclosporine oral capsule 100 mg, 25 mg 1 SMCS DEPEN TITRATABS ORAL TABLET 250 MG ( penicillamine) 2 SMCS; SP ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; ST; M; SL (0.15mg/ml 4 MG/ML (etanercept) per day.); SMCS; SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML ST; M; SL (0.15 ml per day.); 4 (etanercept) SMCS ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (0.15mg/ml 4 SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) per day.); SMCS; SP ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; ST; M; SL (0.29mg per 4 MG (etanercept) day.); SMCS; SP ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (0.15mg/ml 4 INJECTOR 50 MG/ML (etanercept) per day.); SMCS; SP gengraf oral capsule 100 mg, 25 mg 1 SMCS gengraf oral solution 100 mg/ml 1 SMCS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year); SMCS; SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (2 kits per year); PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 pens per 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) month.); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 219 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; M; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; M; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; M; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; M; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SMCS; SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS hydroxychloroquine sulfate oral tablet 200 mg 1 KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; ST; M; SL (2.28 ml per 4 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) month.); SMCS; SP KEVZARA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (2.28 mL per 4 SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) month); SMCS; SP PA; M; SL (0.67 ml (1 KINERET SUBCUTANEOUS SOLUTION PREFILLED 3 syringe) per day.); SMCS; SYRINGE 100 MG/0.67ML (anakinra) SP leflunomide oral tablet 10 mg, 20 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution reconstituted 1 gm 1 M methotrexate sodium oral tablet 2.5 mg 1 PA; ST; SL (1 tablet per OLUMIANT ORAL TABLET 1 MG (baricitinib) 2 day.); SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 220 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; SL (1 tablet per OLUMIANT ORAL TABLET 2 MG (baricitinib) 2 day.); SMCS; SP PA; ST; M; SL (4 auto- ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- 3 injectors per month.); SMCS; INJECTOR 125 MG/ML (abatacept) SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (4 syringes 3 SYRINGE 125 MG/ML (abatacept) per month); SMCS; SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.06 ml per day.); 3 SYRINGE 50 MG/0.4ML (abatacept) SMCS; SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.1 ml per day.); 3 SYRINGE 87.5 MG/0.7ML (abatacept) SMCS; SP PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SMCS; SP PA; SL (55 tablets (one OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 starter pack) per year.); (apremilast) SMCS; SP penicillamine oral capsule 250 mg 1 SMCS; SP penicillamine oral tablet 250 mg 1 SMCS; SP RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 M; SL (0.8 ml (4 auto- 2 MG/0.2ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR M; SL (1 ml (4 auto-injectors) 2 12.5 MG/0.25ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 15 M; SL (1.2 ml (4 auto- 2 MG/0.3ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR M; SL (1.4 ml (4 auto- 2 17.5 MG/0.35ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 M; SL (1.6 ml (4 auto- 2 MG/0.4ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR M; SL (1.8 ml (4 auto- 2 22.5 MG/0.45ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 25 M; SL (2 ml (4 auto-injectors) 2 MG/0.5ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 M; SL (2.4 ml (4 auto- 2 MG/0.6ML (methotrexate (anti-rheumatic)) injectors) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 7.5 M; SL (0.6 ml (4 auto- 2 MG/0.15ML (methotrexate (anti-rheumatic)) injectors) per month.) RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 221 Coverage Requirements & Prescription Drug Name Drug Tier Limits RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 PA; SL (1 tablet per day.); 2 MG (upadacitinib) SMCS; SP SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 4 SMCS SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; M; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; M; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SMCS; SP sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 4 SL (4 ml per day) PA; ST; SL (8 mL per day.); XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 2 SMCS; SP PA; ST; SL (2 tablets per XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) 2 day); SMCS; SP PA; ST; SL (2 tablets per XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) 2 day.); SMCS; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; ST; SL (1 tablet per 2 11 MG (tofacitinib citrate) day.); SMCS; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; ST; SL (1 tablet per 2 22 MG (tofacitinib citrate) day.); SMCS IMMUNOMODULATORY AGENTS - DRUGS FOR THE IMMUNE SYSTEM ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (3.6 ml per 21 3 INJECTOR 162 MG/0.9ML (tocilizumab) days.); SMCS; SP PA; ST; M; SL (4 syringes ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED 3 (36 mL) per month); SMCS; SYRINGE 162 MG/0.9ML (tocilizumab) SP ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 PA; M; SL (6.5 ml (13 vials) 2 UNIT/0.5ML (interferon gamma-1b) per month.); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 222 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 M (interferon alfa-n3) ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 4 PA; SL (1 tablet per day.); AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) 3 SMCS AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 PA; M; SL (4 pens (1 box) 2 MCG/0.5ML (interferon beta-1a) per month.); SMCS; SP AVONEX PREFILLED INTRAMUSCULAR PREFILLED PA; M; SL (4 syringes (1 box) 2 SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) per month.); SMCS; SP AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 4 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 4 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG PA; SL (4 capsules per day.); 2 (monomethyl fumarate) SMCS; SP BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon beta- PA; M; SL (15 vials per 2 1b) month); SMCS CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; M; SL (1 kit per 21 2 MG/ML (certolizumab pegol) days.); SMCS; SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; M; SL (6 mL per 365 2 (certolizumab pegol) days.); SMCS; SP cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 SMCS cyclosporine modified oral solution 100 mg/ml 1 SMCS cyclosporine oral capsule 100 mg, 25 mg 1 SMCS PA; SL (56 capsules per dimethyl fumarate oral capsule delayed release 120 mg 1 year.); SMCS PA; SL (2 capsules per day.); dimethyl fumarate oral capsule delayed release 240 mg 1 SMCS ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; ST; M; SL (0.15mg/ml 4 MG/ML (etanercept) per day.); SMCS; SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML ST; M; SL (0.15 ml per day.); 4 (etanercept) SMCS ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (0.15mg/ml 4 SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) per day.); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 223 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; ST; M; SL (0.29mg per 4 MG (etanercept) day.); SMCS; SP ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (0.15mg/ml 4 INJECTOR 50 MG/ML (etanercept) per day.); SMCS; SP ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.04 ml per day.); 4 SYRINGE 120 MG/ML (satralizumab-mwge) SMCS; SP gengraf oral capsule 100 mg, 25 mg 1 SMCS gengraf oral solution 100 mg/ml 1 SMCS PA; SL (1 capsule per day.); GILENYA ORAL CAPSULE 0.25 MG (fingolimod hcl) 3 SMCS PA; SL (1 capsule per day); GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) 3 SMCS glatiramer acetate subcutaneous solution prefilled syringe PA; M; SL (30 ml per 1 20 mg/ml month.); SMCS glatiramer acetate subcutaneous solution prefilled syringe PA; M; SL (12 ml per 21 1 40 mg/ml days.); SMCS PA; M; SL (30 ml per glatopa subcutaneous solution prefilled syringe 20 mg/ml 1 month.); SMCS PA; M; SL (12 ml per 21 glatopa subcutaneous solution prefilled syringe 40 mg/ml 1 days.); SMCS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year); SMCS; SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; M; SL (2 kits per year); PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 pens per 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) month.); SMCS; SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; M; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; M; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SMCS; SP HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; M; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 224 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; M; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SMCS; SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; M; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SMCS; SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; M; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SMCS hydroxychloroquine sulfate oral tablet 200 mg 1 INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 4 PA; M; SMCS; SP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 4 PA; M; SMCS; SP alfa-2b) KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; M; SL (0.02 ml per day.); 2 20 MG/0.4ML (ofatumumab) SMCS; SP PA; M; SL (0.67 ml (1 KINERET SUBCUTANEOUS SOLUTION PREFILLED 3 syringe) per day.); SMCS; SYRINGE 100 MG/0.67ML (anakinra) SP leflunomide oral tablet 10 mg, 20 mg 1 PA; SL (4 tablets per day.); MAYZENT ORAL TABLET 0.25 MG ( siponimod fumarate) 3 SMCS PA; SL (1 tablet per day.); MAYZENT ORAL TABLET 2 MG ( siponimod fumarate) 3 SMCS methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution reconstituted 1 gm 1 M methotrexate sodium oral tablet 2.5 mg 1 PA; ST; M; SL (4 auto- ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- 3 injectors per month.); SMCS; INJECTOR 125 MG/ML (abatacept) SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; M; SL (4 syringes 3 SYRINGE 125 MG/ML (abatacept) per month); SMCS; SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.06 ml per day.); 3 SYRINGE 50 MG/0.4ML (abatacept) SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 225 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.1 ml per day.); 3 SYRINGE 87.5 MG/0.7ML (abatacept) SMCS; SP PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SMCS; SP PA; SL (55 tablets (one OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 starter pack) per year.); (apremilast) SMCS; SP PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED PA; SL (1 ml per month.); 3 SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) SMCS PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PA; M; SL (1 ml per year.); 3 PEN-INJECTOR 63 & 94 MCG/0.5ML (peginterferon beta-1a) SMCS; SP PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PA; M; SL (1 ml per year.); PREFILLED SYRINGE 63 & 94 MCG/0.5ML (peginterferon 3 SMCS; SP beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; M; SL (1 ml per month.); 3 125 MCG/0.5ML (peginterferon beta-1a) SMCS; SP PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (1 ml per month.); 3 SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) SMCS; SP POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 3 PA; SMCS; SP; CM (pomalidomide) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- PA; ST; M; SL (6 ml (12 INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- 4 syringes) per month); SMCS; 1a) SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS PA; ST; M; SL (4.2 mL (1 SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG (interferon 4 pack) per year); SMCS; SP beta-1a) PA; ST; M; SL (6 ml (12 REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 syringes) per month); SMCS; 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PA; ST; M; SL (4.2 ml (1 PREFILLED SYRINGE 6X8.8 & 6X22 MCG (interferon beta- 4 pack) per year); SMCS; SP 1a) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 2 PA; SMCS; SP; CM 25 MG, 5 MG (lenalidomide) RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SMCS; SP SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 4 SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 226 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; M; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; M; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SMCS; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SMCS; SP sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 2 PA; SMCS; SP; CM MG (thalidomide) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 4 SL (4 ml per day) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE PA; SL (7 capsules per 3 THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod hcl) year.); SMCS PA; SL (1 capsule per day.); ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) 3 SMCS ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; SL (37 capsules per 3 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) year.); SMCS IMMUNOSUPPRESSIVE AGENTS - Drugs for Transplant ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 4 AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; M; SL (4 ml per month.); 2 200 MG/ML (belimumab) SMCS; SP BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (4 ml per month.); 2 SYRINGE 200 MG/ML (belimumab) SMCS; SP cyclophosphamide oral capsule 25 mg, 50 mg 1 CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 SMCS cyclosporine modified oral solution 100 mg/ml 1 SMCS cyclosporine oral capsule 100 mg, 25 mg 1 SMCS everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 227 Coverage Requirements & Prescription Drug Name Drug Tier Limits gengraf oral capsule 100 mg, 25 mg 1 SMCS gengraf oral solution 100 mg/ml 1 SMCS leflunomide oral tablet 10 mg, 20 mg 1 PA; SL (6 capsules per day.); LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 4 SMCS MAVENCLAD ORAL TABLET THERAPY PACK 10 MG PA; ST; SL (40 tablets per 3 (cladribine) 720 days.); SMCS mercaptopurine oral tablet 50 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 M methotrexate sodium injection solution reconstituted 1 gm 1 M methotrexate sodium oral tablet 2.5 mg 1 mycophenolate mofetil oral capsule 250 mg 1 SMCS mycophenolate mofetil oral suspension reconstituted 200 mg/ml 1 SMCS mycophenolate mofetil oral tablet 500 mg 1 SMCS mycophenolate sodium oral tablet delayed release 180 mg, 360 mg 1 SMCS external cream 1 % 1 ST PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG 4 SMCS () PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) 4 SMCS PURIXAN ORAL SUSPENSION 2000 MG/100ML 4 PA; SMCS; SP (mercaptopurine) RAPAMUNE ORAL SOLUTION 1 MG/ML () 4 SMCS SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 4 SMCS sirolimus oral solution 1 mg/ml 1 SMCS sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 SMCS tacrolimus external ointment 0.03 %, 0.1 % 1 ST tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 SMCS

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 228 Coverage Requirements & Prescription Drug Name Drug Tier Limits TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 4 SL (4 ml per day) OTHER MISCELLANEOUS THERAPEUTIC AGENTS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; M; SL (4 syringes per 2 220 MG (rilonacept) month); SMCS; SP CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) 4 CARNITOR ORAL TABLET 330 MG (levocarnitine) 4 CARNITOR SF ORAL SOLUTION 1 GM/10ML (levocarnitine) 4 CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) 2 PA; SMCS; SP CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) CYSTADANE ORAL POWDER (betaine) 2 SMCS; SP CYSTAGON ORAL CAPSULE 150 MG, 50 MG (cysteamine 2 SMCS; SP bitartrate) PA; SL (2 tablets per day); dalfampridine er oral tablet extended release 12 hour 10 mg 1 SMCS DEMSER ORAL CAPSULE 250 MG (metyrosine) 3 EC-RX DHEA EXTERNAL CREAM 10 %, 4 % (prasterone 3 (dhea)) ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate 2 ST sodium) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) 4 SL (6 packets per day) EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML PA; SL (6.7 ml per day, 1280 2 (risdiplam) ml per 180 days.); SMCS; SP PA; SL (14 capsules per 21 GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) 4 days.); SMCS; SP PA; SL (8 tablets per day.); ISTURISA ORAL TABLET 1 MG (osilodrostat phosphate) 4 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 229 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (6 tablets per day.); ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 4 SMCS; SP PA; SL (2 tablets per day.); ISTURISA ORAL TABLET 5 MG (osilodrostat phosphate) 4 SMCS; SP levocarnitine oral solution 1 gm/10ml 1 levocarnitine oral tablet 330 mg 1 levocarnitine sf oral solution 1 gm/10ml 1 me/naphos/mb/hyo1 oral tablet 81.6 mg 1 metyrosine oral capsule 250 mg 1 miglustat oral capsule 100 mg 1 SMCS NEONATAL + DHA ORAL 29-1 & 200 MG 3 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG 1 PA; SMCS; SP (nitisinone) PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PREZCOBIX ORAL TABLET 800-150 MG (darunavir- 2 cobicistat) PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 230 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 4 PA; ST; SMCS; SP MG (cysteamine bitartrate) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine 4 SMCS; SP bitartrate) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 REZUROCK ORAL TABLET 200 MG (belumosudil mesylate) 3 PA; SL (10 tablets per day.); RUZURGI ORAL TABLET 10 MG (amifampridine) 2 SMCS; SP PA; SL (16 packets per day.); sapropterin dihydrochloride oral packet 100 mg 1 SMCS; SP PA; SL (4 packets per day.); sapropterin dihydrochloride oral packet 500 mg 1 SMCS; SP PA; SL (16 tablets per day); sapropterin dihydrochloride oral tablet 100 mg 1 SMCS; SP SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 SL (1 tablet per day.) cobic-emtricit-tenofdf) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 3 SL (1 tablet per day.) emtricit-tenofaf) THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 3 SMCS; SP MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) 4 SMCS; SP tiopronin oral tablet 100 mg 1 SMCS; SP TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRI-CHLOR EXTERNAL LIQUID 80 % (trichloroacetic acid) 2 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TYBOST ORAL TABLET 150 MG ( cobicistat) 2 URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 231 Coverage Requirements & Prescription Drug Name Drug Tier Limits URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 2 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 4 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 XURIDEN ORAL PACKET 2 GM (uridine triacetate) 2 PA; SMCS; SP PA; SL (4 capsules per day.); ZOKINVY ORAL CAPSULE 50 MG (lonafarnib) 2 SMCS; SP PA; SL (1 tablet per day.); ZOKINVY ORAL CAPSULE 75 MG (lonafarnib) 2 SMCS; SP PROTECTIVE AGENTS MESNEX ORAL TABLET 400 MG (mesna) 3 SMCS; SP; CM NONHORMONAL CONTRACEPTIVES - Drugs for Women NONHORMONAL CONTRACEPTIVES - Drugs for Women CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 3 H PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot 4 H bitart)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 232 Coverage Requirements & Prescription Drug Name Drug Tier Limits WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) OXYTOCICS - Drugs for Women OXYTOCICS - Drugs for Women CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) 3 methergine oral tablet 0.2 mg 1 SL (28 tablets per year.) methylergonovine maleate oral tablet 0.2 mg 1 SL (28 tablets per year.) PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY 20 MG 3 (dinoprostone) PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET 3 (wound dressings) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 RESPIRATORY TRACT AGENTS - Drugs for the Lungs ALPHA AND BETA ADRENERGIC AGONIST(RESPR) - Drugs for Asthma/COPD ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 233 Coverage Requirements & Prescription Drug Name Drug Tier Limits epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml 1 epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml 1 SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 2 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTICHOLINERGIC AGENTS (RESPIR.TRACT) - Drugs for Asthma/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION 17 2 SL (0.87 grams per day.) MCG/ACT (ipratropium bromide hfa) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol) ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 2 SL (0.15 grams per day.) MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) ANTIFIBROTIC AGENTS - Drugs for the Lungs PA; SL (9 capsules per day.); ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 2 SMCS; SP PA; SL (9 tablets per day.); ESBRIET ORAL TABLET 267 MG (pirfenidone) 2 SMCS; SP PA; SL (3 tablets per day.); ESBRIET ORAL TABLET 801 MG (pirfenidone) 2 SMCS; SP PA; SL (2 capsules per day.); OFEV ORAL CAPSULE 100 MG, 150 MG ( esylate) 4 SMCS; SP ANTI-INFLAMMATORY AGENTS (RESPIRATORY) - Drugs for Inflammation NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 PA; M; SL (0.04 mL per 4 MG/ML (mepolizumab) day.); SMCS; SP NUCALA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (0.04 mL per 4 SYRINGE 100 MG/ML (mepolizumab) day.); SMCS; SP ANTITUSSIVES - Drugs for Cough and Cold benzonatate oral capsule 100 mg, 150 mg, 200 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 234 Coverage Requirements & Prescription Drug Name Drug Tier Limits codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 hydrocodone polst-chlorphen polst er susp oral 1 PA suspension extended release 10-8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 PA hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA hydromet oral syrup 5-1.5 mg/5ml 1 PA maxi-tuss ac oral solution 100-10 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA promethazine-codeine oral solution 6.25-10 mg/5ml 1 PA promethazine-codeine oral syrup 6.25-10 mg/5ml 1 PA promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 TESSALON PERLES ORAL CAPSULE 100 MG (benzonatate) 4 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 4 PA 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin ac w/alc oral liquid 100-10 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 235 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYSTIC FIBROSIS (CFTR) CORRECTORS - Drugs for the Lungs ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SL (728 packets per 356 2 (lumacaftor-ivacaftor) days.); SMCS; SP ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SL (1456 tablets per 356 2 (lumacaftor-ivacaftor) days.); SMCS; SP SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SL (728 tablets per 356 2 MG (tezacaftor-ivacaftor) days.); SMCS; SP SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG PA; SL (728 tablets per 356 2 (tezacaftor-ivacaftor) days.); SMCS TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SL (1092 tablets per 356 2 MG (elexacaftor-tezacaftor-ivacaft) days.); SMCS; SP TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 & 75 2 PA; SMCS; SP MG (elexacaftor-tezacaftor-ivacaft) CYSTIC FIBROSIS (CFTR) POTENTIATORS - Drugs for the Lungs PA; SL (728 packets per 356 KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG (ivacaftor) 2 days.); SMCS; SP PA; SL (780 tablets per 356 KALYDECO ORAL TABLET 150 MG (ivacaftor) 2 days.); SMCS; SP ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SL (728 packets per 356 2 (lumacaftor-ivacaftor) days.); SMCS; SP ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SL (1456 tablets per 356 2 (lumacaftor-ivacaftor) days.); SMCS; SP SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SL (728 tablets per 356 2 MG (tezacaftor-ivacaftor) days.); SMCS; SP SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG PA; SL (728 tablets per 356 2 (tezacaftor-ivacaftor) days.); SMCS TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SL (1092 tablets per 356 2 MG (elexacaftor-tezacaftor-ivacaft) days.); SMCS; SP TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 & 75 2 PA; SMCS; SP MG (elexacaftor-tezacaftor-ivacaft) EXPECTORANTS - Drugs for the Lungs GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 236 Coverage Requirements & Prescription Drug Name Drug Tier Limits guaifenesin ac oral syrup 100-10 mg/5ml 1 IODINE STRONG ORAL SOLUTION 5 % 2 maxi-tuss ac oral solution 100-10 mg/5ml 1 SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 FIRST GENERATION ANTIHIST.(RESPIR TRACT) - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) DICOPANOL RAPIDPAQ ORAL SUSPENSION 3 PA RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 4 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 4 MG/5ML (carbinoxamine maleate) promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 ANTAGONISTS - Drugs for Inflammation DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED 4 PA; ST; M; SMCS; SP SYRINGE 200 MG/1.14ML (dupilumab) FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PA; M; SL (1 pen per 56 4 INJECTOR 30 MG/ML (benralizumab) days.); SMCS LEUKOTRIENE MODIFIERS - Drugs for Inflammation ACCOLATE ORAL TABLET 10 MG, 20 MG () 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 237 Coverage Requirements & Prescription Drug Name Drug Tier Limits montelukast sodium oral packet 4 mg 1 montelukast sodium oral tablet 10 mg 1 montelukast sodium oral tablet chewable 4 mg, 5 mg 1 SINGULAIR ORAL PACKET 4 MG (montelukast sodium) 3 zafirlukast oral tablet 10 mg, 20 mg 1 zileuton er oral tablet extended release 12 hour 600 mg 1 ST ZYFLO ORAL TABLET 600 MG (zileuton) 4 ST MAST-CELL STABILIZERS - Drugs for Inflammation ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 MUCOLYTIC AGENTS - Drugs for the Lungs acetylcysteine inhalation solution 10 %, 20 % 1 HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 2 7 % (sodium chloride) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase PA; SL (5 ml per day.); 2 alfa) SMCS; SP sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 % 1 NASAL PREPARATIONS () - Drugs for Inflammation azelastine-fluticasone nasal suspension 137-50 mcg/act 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 4 (beclomethasone diprop monohyd) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 (azelastine-fluticasone) flunisolide nasal solution 25 mcg/act (0.025%) 1 fluticasone propionate nasal suspension 50 mcg/act 1 mometasone furoate nasal suspension 50 mcg/act 1 QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 4 MCG/ACT (beclomethasone diprop (nasal))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 238 Coverage Requirements & Prescription Drug Name Drug Tier Limits QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 4 (beclomethasone diprop (nasal)) ORALLY INHALED PREPARATIONS (STEROIDS) - Drugs for Inflammation ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 1 SL (1 blister per day.) (fluticasone furoate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER 1 SL (1 packet per day.) BREATH ACTIVATED 50 MCG/ACT (fluticasone furoate) SL (120 ml (2 boxes) per 30 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 days.) SL (60 ml (1 box) per 30 budesonide inhalation suspension 1 mg/2ml 1 days.) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (2 packages per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 1 SL (4 packages per day) propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 1 SL (1 inhaler per month) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT 1 SL (2 inhalers per month) (fluticasone propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) PHOSPHODIESTERASE TYPE 4 INHIBITORS - Drugs for the Lungs DALIRESP ORAL TABLET 250 MCG (roflumilast) 3 PA; SL (31 tablets per year.) DALIRESP ORAL TABLET 500 MCG (roflumilast) 3 PA; SL (1 tablet per day) SECOND GENERATION ANTIHIST(RESPIR TRACT) - Drugs for Allergy azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 azelastine-fluticasone nasal suspension 137-50 mcg/act 1 desloratadine oral tablet 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 239 Coverage Requirements & Prescription Drug Name Drug Tier Limits desloratadine oral tablet dispersible 5 mg 1 DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 (azelastine-fluticasone) SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) - Drugs for Asthma/COPD albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act 1 albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml 1 albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% 1 albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml 1 LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 4 SL (2 vials per day) MCG/2ML (formoterol fumarate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (2 blisters per day.) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.14 grams per day.) 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) VASODILATING AGENTS (RESPIRATORY TRACT) - Drugs for the Lungs ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 PA; SL (3 tablets per day.); 2 MG (riociguat) SMCS; SP PA; SL (2 tablets per day); alyq oral tablet 20 mg 1 SMCS; SP PA; SL (1 tablet per day.); oral tablet 10 mg, 5 mg 1 SMCS; SP PA; SL (2 tablets per day.); oral tablet 125 mg, 62.5 mg 1 SMCS; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 240 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (1 tablet per day.); OPSUMIT ORAL TABLET 10 MG (macitentan) 2 SMCS; SP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 PA; SL (6 tablets per day.); 4 MG, 5 MG (treprostinil diolamine) SMCS; SP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, PA; SL (6 tablets per day); 4 1 MG, 2.5 MG (treprostinil diolamine) SMCS; SP PA; SL (186 ml per month.); sildenafil citrate oral suspension reconstituted 10 mg/ml 1 SMCS; SP sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 SL (6 tablets per month) SL (0.5 tablet per day.); sildenafil citrate oral tablet 20 mg 1 SMCS PA; SL (2 tablets per day); tadalafil (pah) oral tablet 20 mg 1 SMCS; SP PA; SL (2 tablets per day.); TRACLEER ORAL TABLET 125 MG, 62.5 MG ( bosentan) 2 SMCS; SP PA; SL (4 tablets per day.); TRACLEER ORAL TABLET SOLUBLE 32 MG ( bosentan) 2 SMCS; SP TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 2 PA; SMCS TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML 2 PA; SMCS (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML 2 PA; SMCS (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, PA; SL (2 tablets per day.); 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 4 SMCS; SP (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PA; SL (200 tablets per 4 (selexipag) year.); SMCS; SP VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 2 PA; SMCS; SP (iloprost) DERIVATIVES - Drugs for Asthma/COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 241 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin naftifine hcl external cream 1 %, 2 % 1 naftifine hcl external gel 1 % 1 NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) 4 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- 4 benzoyl perox) ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 2 ALTABAX EXTERNAL OINTMENT 1 % ( ) 3 AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl 4 micronized) AVAR CLEANSER EXTERNAL EMULSION 10-5 % 4 (sulfacetamide sodium-) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) BENZAMYCIN EXTERNAL GEL 5-3 % (- 2 erythromycin) benzoyl peroxide-erythromycin external gel 5-3 % 1 bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 CENTANY AT EXTERNAL KIT 2 % ( ) 4 CENTANY EXTERNAL OINTMENT 2 % ( mupirocin) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 242 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLEOCIN VAGINAL CREAM 2 % (clindamycin phosphate) 4 CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin 2 phosphate) CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin 4 phosphate) CLINDACIN ETZ EXTERNAL KIT 1 % (clindamycin phos & 4 cleanser) clindacin etz external swab 1 % 1 CLINDACIN PAC EXTERNAL KIT 1 % (clindamycin phos & 4 cleanser) clindacin-p external swab 1 % 1 CLINDAGEL EXTERNAL GEL 1 % (clindamycin phosphate) 4 SL (1 bottle (45 grams) per clindamycin phos-benzoyl perox external gel 1.2-5 % 1 month.) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 clindamycin phosphate external foam 1 % 1 clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 clindamycin phosphate external swab 1 % 1 CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL 1 % 4 clindamycin phosphate gel 1 % external 1 % 1 clindamycin phosphate vaginal cream 2 % 1 clindamycin-tretinoin external gel 1.2-0.025 % 1 CLINDESSE VAGINAL CREAM 2 % (clindamycin phosphate 2 (1 dose)) CLINOIN EXTERNAL CREAM 1.25-0.025-1 % (clindamycin- 3 PA tretinoin-cholesty) ery external pad 2 % 1 ERYGEL EXTERNAL GEL 2 % (erythromycin) 3 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1 EVOCLIN EXTERNAL FOAM 1 % (clindamycin phosphate) 4 gentamicin sulfate external cream 0.1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 243 Coverage Requirements & Prescription Drug Name Drug Tier Limits gentamicin sulfate external ointment 0.1 % 1 KLARON EXTERNAL LOTION 10 % (sulfacetamide sodium 4 ()) METROCREAM EXTERNAL CREAM 0.75 % (metronidazole) 4 METROLOTION EXTERNAL LOTION 0.75 % ( metronidazole) 4 metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 %, 1 % 1 metronidazole external lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium external cream 2 % 1 mupirocin external ointment 2 % 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 4 fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- 4 fluocinolone & emollient) SL (1 bottle (45 grams) per neuac external gel 1.2-5 % 1 month.) NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 4 moist) NUVESSA VAGINAL GEL 1.3 % (metronidazole) 4 ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 4 benzoyl perox) OVACE PLUS EXTERNAL CREAM 10 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL LOTION 9.8 % (sulfacetamide 4 sodium) OVACE PLUS EXTERNAL SHAMPOO 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL GEL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL LIQUID 10 % 4 (sulfacetamide sodium) OVACE WASH EXTERNAL LIQUID 10 % (sulfacetamide 4 sodium)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 244 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 4 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 4 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 4 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 4 sodium-sulfur) rosadan external cream 0.75 % 1 rosadan external gel 0.75 % 1 ROSADAN EXTERNAL KIT 0.75 % (CREAM), 0.75 % (GEL) 4 (metronidazole-cleanser) sodium sulfacetamide external shampoo 10 % 1 sodium sulfacetamide wash external liquid 10 % 1 SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium (acne) external lotion 10 % 1 sulfacetamide sodium external gel 10 % (cleans) 1 sulfacetamide sodium external liquid 10 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in external emulsion 10-5 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 245 Coverage Requirements & Prescription Drug Name Drug Tier Limits SULFACLEANSE 8/4 EXTERNAL SUSPENSION 8-4 % 3 (sulfacetamide sodium-sulfur) sulfamez wash external emulsion 10-1 % 1 SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 4 sulfur-sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 4 cleanser) SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 4 sulfur) vandazole vaginal gel 0.75 % 1 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 4 XEPI EXTERNAL CREAM 1 % (ozenoxacin) 3 ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl micronized) 4 PA; ST ANTI-INFLAMMATORY AGENTS, MISC (SKIN) - Drugs for the Skin EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 ST ANTIPRURITICS AND LOCAL ANESTHETICS - Drugs for the Skin 7T LIDO EXTERNAL GEL 2 % (lidocaine hcl) 4 aif #2 drug preparation kit external cream 1 PA AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 4 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 4 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 4 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % 3 (hydrocortisone ace-pramoxine) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 4 pramoxine-chloroxylenol) doxepin hcl external cream 5 % 1 PA enovarx-lidocaine hcl external cream 10 %, 5 % 1 PA EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 2 FBL KIT EXTERNAL CREAM 15-4-5 % 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 246 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 PA (dph-lido-alhydr-mghydr-simeth) glydo external prefilled syringe 2 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % 3 PA (ketoprofen-baclofen-gabap-lido ) lidocaine external ointment 5 % 1 SL (1.19 grams per day.) lidocaine external patch 5 % 1 PA; SL (3 patches per day) lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 lidocaine hcl urethral/mucosal external prefilled syringe 2 % 1 lidocaine-prilocaine external cream 2.5-2.5 % 1 LIDTOPIC MAX EXTERNAL CREAM 10 % (lidocaine hcl) 3 PA NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA phenazo oral tablet 200 mg 1 phenazopyridine hcl oral tablet 100 mg, 200 mg 1 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 % ( pramoxine-hc) 2 PRAMOSONE EXTERNAL OINTMENT 1-2.5 % (pramoxine- 4 hc) pramox external gel 1 % 1 premium lidocaine external ointment 5 % 1 SL (1.19 grams per day.) PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 4 ace-pramoxine) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) PYRIDIUM ORAL TABLET 100 MG, 200 MG 3 (phenazopyridine hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 247 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRIPLE COMPLEX FORMULA 3 KIT EXTERNAL CREAM 20- 3 2-10 % VP GKL KIT EXTERNAL CREAM 20-2-10 % 3 PA ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin acyclovir external cream 5 % 1 acyclovir external ointment 5 % 1 DENAVIR EXTERNAL CREAM 1 % () 4 ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) 4 ASTRINGENTS - Drugs for the Skin DRYSOL EXTERNAL SOLUTION 20 % (aluminum chloride) 2 -ZINC OXIDE-PETROLAT EXTERNAL 4 OINTMENT 0.25-15-81.35 % VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 4 (miconazole-zinc oxide-petrolat) AZOLES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin mouth/throat troche 10 mg 1 clotrimazole- external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 econazole nitrate external cream 1 % 1 ECOZA EXTERNAL FOAM 1 % (econazole nitrate) 4 EXELDERM EXTERNAL CREAM 1 % (sulconazole nitrate) 3 EXELDERM EXTERNAL SOLUTION 1 % (sulconazole 3 nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) 4 GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole nitrate (1 3 dose)) JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) 4 SL (4 ml per month.) ketoconazole external cream 2 % 1 ketoconazole external foam 2 % 1 ketoconazole external shampoo 2 % 1 ketodan external foam 2 % 1 LULICONAZOLE EXTERNAL CREAM 1 % 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 248 Coverage Requirements & Prescription Drug Name Drug Tier Limits LUZU EXTERNAL CREAM 1 % (luliconazole) 4 miconazole 3 vaginal suppository 200 mg 1 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 4 OINTMENT 0.25-15-81.35 % ORAVIG BUCCAL TABLET 50 MG (miconazole) 3 oxiconazole nitrate external cream 1 % 1 OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) 4 OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) 4 SULCONAZOLE NITRATE EXTERNAL CREAM 1 % 3 SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 % 3 vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 4 (miconazole-zinc oxide-petrolat) XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) 3 BASIC LOTIONS AND LINIMENTS - Drugs for the Skin GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 2 acid-) methyl salicylate external liquid 1 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (- 3 urea in lactac) TURPENTINE EXTERNAL SPIRIT 3 ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) BASIC OINTMENTS AND PROTECTANTS - Drugs for the Skin NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- 4 fluocinolone & emollient)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 249 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 4 moist) SYNALAR (CREAM) EXTERNAL KIT 0.025 % (fluocinolone- 4 emollient) SYNALAR (OINTMENT) EXTERNAL KIT 0.025 % 4 (fluocinolone-emollient) BASIC POWDERS AND DEMULCENTS - Drugs for the Skin benzoin compound external tincture 1 BENZOIN EXTERNAL TINCTURE 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin MENTAX EXTERNAL CREAM 1 % (butenafine hcl) 3 CELL STIMULANTS AND PROLIFERANTS - Drugs for the Skin ALTRENO EXTERNAL LOTION 0.05 % ( tretinoin) 4 PA AVITA EXTERNAL GEL 0.025 % (tretinoin) 4 PA clindamycin-tretinoin external gel 1.2-0.025 % 1 CLINOIN EXTERNAL CREAM 1.25-0.025-1 % (clindamycin- 3 PA tretinoin-cholesty) RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 % 4 PA (tretinoin microsphere) tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1 tretinoin external gel 0.01 % 1 tretinoin external gel 0.05 % 1 PA tretinoin microsphere external gel 0.04 %, 0.1 % 1 PA tretinoin microsphere pump external gel 0.04 %, 0.1 % 1 PA VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 4 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) 4 ala-cort external cream 2.5 % 1 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 external cream 0.1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 250 Coverage Requirements & Prescription Drug Name Drug Tier Limits amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 4 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 4 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 4 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % 3 (hydrocortisone ace-pramoxine) anucort-hc rectal suppository 25 mg 1 ANUSOL-HC EXTERNAL CREAM 2.5 % (hydrocortisone) 4 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet 2 emoll base) beser external lotion 0.05 % 1 betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 BRYHALI EXTERNAL LOTION 0.01 % (halobetasol 4 ST propionate) calcipotriene-betameth diprop external ointment 0.005- 0.064 % 1 CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 2 acetonide) clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 251 Coverage Requirements & Prescription Drug Name Drug Tier Limits clobetasol propionate emulsion external foam 0.05 % 1 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 1 clobetasol propionate external gel 0.05 % 1 clobetasol propionate external liquid 0.05 % 1 clobetasol propionate external lotion 0.05 % 1 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1 clobetasol propionate external solution 0.05 % 1 CLOBETAVIX EXTERNAL KIT 0.05 % 3 clocortolone pivalate external cream 0.1 % 1 CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & 4 cleanser) clodan external shampoo 0.05 % 1 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) 4 CORDRAN EXTERNAL LOTION 0.05 % (flurandrenolide) 4 CORDRAN EXTERNAL OINTMENT 0.05 % ( flurandrenolide) 4 CORDRAN EXTERNAL TAPE 4 MCG/SQCM 3 (flurandrenolide) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 4 pramoxine-chloroxylenol) CORTENEMA RECTAL ENEMA 100 MG/60ML 4 (hydrocortisone) CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone 2 acetate) CORTI-SAV EXTERNAL CREAM 1-1 % 3 CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone 3 propionate) DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % 4 (fluocinolone acetonide) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % 4 (fluocinolone acetonide)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 252 Coverage Requirements & Prescription Drug Name Drug Tier Limits DESONATE EXTERNAL GEL 0.05 % (desonide) 4 desonide external cream 0.05 % 1 desonide external gel 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 DESOWEN EXTERNAL CREAM 0.05 % (desonide) 3 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 desrx external gel 0.05 % 1 diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1 DIPROLENE AF EXTERNAL CREAM 0.05 % (betamethasone 4 dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % ( betamethasone 4 dipropionate aug) ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 4 betameth diprop) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 2 fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 % 1 fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 253 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 halcinonide external cream 0.1 % 1 halobetasol propionate external cream 0.05 % 1 halobetasol propionate external ointment 0.05 % 1 HALOG EXTERNAL OINTMENT 0.1 % ( halcinonide) 3 hydrocortisone (perianal) external cream 1 %, 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocortisone acetate rectal suppository 25 mg, 30 mg 1 hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 hydrocortisone-iodoquinol external cream 1-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 4 fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- 4 fluocinolone & emollient) nolix external cream 0.05 % 1 nolix external lotion 0.05 % 1 NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 254 Coverage Requirements & Prescription Drug Name Drug Tier Limits nystatin- external cream 100000-0.1 unit/gm- % 1 nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% 1 oralone mouth/throat paste 0.1 % 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone 3 probutate) pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 % ( pramoxine-hc) 2 PRAMOSONE EXTERNAL OINTMENT 1-2.5 % (pramoxine- 4 hc) prednicarbate external ointment 0.1 % 1 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 4 ace-pramoxine) PROCTOCORT RECTAL SUPPOSITORY 30 MG 4 (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) procto-med hc external cream 2.5 % 1 procto-pak external cream 1 % 1 proctozone-hc external cream 2.5 % 1 PSORCON EXTERNAL CREAM 0.05 % 3 SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone 4 dipropionate) SYNALAR (CREAM) EXTERNAL KIT 0.025 % (fluocinolone- 4 emollient) SYNALAR (OINTMENT) EXTERNAL KIT 0.025 % 4 (fluocinolone-emollient) SYNALAR EXTERNAL CREAM 0.025 % (fluocinolone 4 acetonide)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 255 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYNALAR EXTERNAL OINTMENT 0.025 % ( fluocinolone 4 acetonide) SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone 4 acetonide) SYNALAR TS EXTERNAL KIT 0.01 % (fluocinolone & 4 cleanser) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol 4 propionate) TEMOVATE EXTERNAL OINTMENT 0.05 % ( clobetasol 4 propionate) TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 2 TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % 4 (desoximetasone) TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) 4 TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % 4 (desoximetasone) tovet external foam 0.05 % 1 triamcinolone acetonide external aerosol solution 0.147 mg/gm 1 triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % 1 triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % 1 triamcinolone acetonide mouth/throat paste 0.1 % 1 triderm external cream 0.1 %, 0.5 % 1 TRIDESILON EXTERNAL CREAM 0.05 % (desonide) 1 UCERIS RECTAL FOAM 2 MG/ACT (budesonide) 2 VERDESO EXTERNAL FOAM 0.05 % (desonide) 4 XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 256 Coverage Requirements & Prescription Drug Name Drug Tier Limits DETERGENTS - Drugs for the Skin CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & 4 cleanser) EMOLLIENTS, DEMULCENTS, AND PROTECTANTS - Drugs for the Skin INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 4 OINTMENT 0.25-15-81.35 % PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- 4 metoclop) VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 4 (miconazole-zinc oxide-petrolat) HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ciclodan external solution 8 % 1 external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 ciclopirox treatment external kit 8 % 1 LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine- 4 cleanser) AGENTS - Drugs for the Skin AVAR CLEANSER EXTERNAL EMULSION 10-5 % 4 (sulfacetamide sodium-sulfur) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 257 Coverage Requirements & Prescription Drug Name Drug Tier Limits AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 cerovel external lotion 40 % 1 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 2 acid-lactic acid) HYDRO 40 EXTERNAL FOAM 40 % (urea) 3 INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) KERALYT SCALP EXTERNAL KIT 6 % (salicylic acid) 4 NUTRASEB EXTERNAL CREAM (antiseborrheic products, 4 misc.) PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 4 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 4 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 4 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 4 sodium-sulfur) PROMISEB EXTERNAL CREAM (antiseborrheic products, 4 misc.) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 salicylic acid external solution 26 % 1 salimez external cream 6 % 1 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (salicylic acid- 3 urea in lactac) SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 258 Coverage Requirements & Prescription Drug Name Drug Tier Limits selenium sulfide external shampoo 2.25 % 1 sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in urea external emulsion 10-5 % 1 SULFACLEANSE 8/4 EXTERNAL SUSPENSION 8-4 % 3 (sulfacetamide sodium-sulfur) sulfamez wash external emulsion 10-1 % 1 SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 4 sulfur-sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 4 cleanser) SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 4 sulfur) UMECTA MOUSSE EXTERNAL FOAM 40 % (urea) 3 URAMAXIN EXTERNAL GEL 45 % (urea) 4 urea external cream 40 %, 41 %, 45 % 1 urea external lotion 40 % 1 urea nail external gel 45 % 1 UREMEZ-40 EXTERNAL CREAM 40 % 3 UTOPIC EXTERNAL CREAM 41 % (urea) 4 KERATOPLASTIC AGENTS - Drugs for the Skin EXTERNAL SOLUTION 20 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 259 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOCAL ANTI-INFECTIVES, MISCELLANEOUS - Drugs for the Skin ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- 4 benzoyl perox) -benzoyl peroxide external gel 0.1-2.5 % 1 BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 2 benzalkonium chloride external solution 50 % 1 BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 2 erythromycin) benzoyl peroxide-erythromycin external gel 5-3 % 1 chlorhexidine gluconate mouth/throat solution 0.12 % 1 SL (1 bottle (45 grams) per clindamycin phos-benzoyl perox external gel 1.2-5 % 1 month.) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 4 pramoxine-chloroxylenol) CORTI-SAV EXTERNAL CREAM 1-1 % 3 DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 2 (sulfuric acid-sulf phenolics) EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl 4 peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- 4 benzoyl peroxide) FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 4 oxyquinoline) hydrocortisone-iodoquinol external cream 1-1 % 1 INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) iodine tincture external tincture 2 % 1 LUGOLS STRONG IODINE EXTERNAL SOLUTION 5-10 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 260 Coverage Requirements & Prescription Drug Name Drug Tier Limits acetate external packet 5 % 1 SL (1 bottle (45 grams) per neuac external gel 1.2-5 % 1 month.) NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 4 moist) ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 4 benzoyl perox) PERIDEX MOUTH/THROAT SOLUTION 0.12 % 4 (chlorhexidine gluconate) periogard mouth/throat solution 0.12 % 1 selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.25 % 1 SILVADENE EXTERNAL CREAM 1 % () 4 silver sulfadiazine external cream 1 % 1 ssd external cream 1 % 1 SULFAMYLON EXTERNAL CREAM 85 MG/GM (mafenide 3 acetate) SULFAMYLON EXTERNAL PACKET 5 % (mafenide acetate) 4 XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) zaclir cleansing external lotion 8 % 1 NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) - Drugs for the Skin aif #2 drug preparation kit external cream 1 PA AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA diclofenac sodium external gel 3 % 1 PA DUAL COMPLEX FORMULA 1 KIT EXTERNAL CREAM 3 PA enovarx-ibuprofen external cream 10 % 1 PA enovarx-naproxen external cream 10 % 1 PA FBL KIT EXTERNAL CREAM 15-4-5 % 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 261 Coverage Requirements & Prescription Drug Name Drug Tier Limits FROTEK EXTERNAL CREAM 10 % (ketoprofen) 3 PA K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % 3 PA (ketoprofen-baclofen-gabap-lido ) KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % 3 PA (ketoprofen) KETOROLAC TROMETHAMINE EXTERNAL GEL 2 % 3 PA NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA TRIPLE COMPLEX FORMULA 3 KIT EXTERNAL CREAM 20- 3 2-10 % VP FC KIT EXTERNAL CREAM 3 PA VP GKL KIT EXTERNAL CREAM 20-2-10 % 3 PA OXABOROLES - Drugs for the Skin KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) 4 SL (4 ml per month.) tavaborole external solution 5 % 1 SL (4 ml per month.) PIGMENTING AGENTS - Drugs for the Skin methoxsalen rapid oral capsule 10 mg 1 POLYENES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin nyamyc external powder 100000 unit/gm 1 nystatin external cream 100000 unit/gm 1 nystatin external ointment 100000 unit/gm 1 nystatin external powder 100000 unit/gm 1 nystatin-triamcinolone external cream 100000-0.1 unit/gm- % 1 nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% 1 nystop external powder 100000 unit/gm 1 SCABICIDES AND PEDICULICIDES - Drugs for the Skin crotan external lotion 10 % 1 ivermectin external lotion 0.5 % 1 lindane external shampoo 1 % 1 malathion external lotion 0.5 % 1 OVIDE EXTERNAL LOTION 0.5 % (malathion) 4 external cream 5 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 262 Coverage Requirements & Prescription Drug Name Drug Tier Limits SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) 1 spinosad external suspension 0.9 % 1 SULFURATED LIME EXTERNAL SOLUTION 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. - Drugs for the Skin A.A.G.C. KIT IN TERODERM EXTERNAL CREAM 8-4-10-4 % 3 PA (amantad-amitrip-gabap-cycloben) accutane oral capsule 20 mg, 30 mg, 40 mg 1 acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 2 adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 aif #2 drug preparation kit external cream 1 PA AIF #3 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA ALDARA EXTERNAL CREAM 5 % () 4 ALEVAMAX EXTERNAL CREAM 4 AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) 3 amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 ATOPADERM EXTERNAL CREAM 4 external gel 15 % 1 AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 balsam peru-castor oil external ointment 1 calcipotriene external cream 0.005 % 1 CALCIPOTRIENE EXTERNAL FOAM 0.005 % 4 calcipotriene external ointment 0.005 % 1 calcipotriene external solution 0.005 % 1 calcipotriene-betameth diprop external ointment 0.005- 0.064 % 1 CALCITRENE EXTERNAL OINTMENT 0.005 % 3 (calcipotriene) calcitriol external ointment 3 mcg/gm 1 CARAC EXTERNAL CREAM 0.5 % (fluorouracil) 2 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 263 Coverage Requirements & Prescription Drug Name Drug Tier Limits clindamycin-tretinoin external gel 1.2-0.025 % 1 CLINOIN EXTERNAL CREAM 1.25-0.025-1 % (clindamycin- 3 PA tretinoin-cholesty) CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 3 COPASIL EXTERNAL GEL (scar treatment products) 3 PA COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PA; ST; M; SL (2 ml (2 Pens) 3 PREFILLED SYRINGE 150 MG/ML (secukinumab) per month.); SMCS; SP COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PA; ST; M; SL (2 ml (2 Pens) 3 PREFILLED SYRINGE 150 MG/ML (secukinumab) per month.); SMCS; SP COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION 3 PA; ST; SMCS PREFILLED SYRINGE 75 MG/0.5ML (secukinumab) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS PA; ST; M; SL (2 ml (2 Pens) 3 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per month.); SMCS; SP COSENTYX SENSOREADY PEN SUBCUTANEOUS PA; ST; M; SL (2 ml (2 Pens) 3 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per month.); SMCS; SP DOVONEX EXTERNAL CREAM 0.005 % (calcipotriene) 4 doxycycline oral capsule delayed release 40 mg 4 DUAL COMPLEX FORMULA 1 KIT EXTERNAL CREAM 3 PA DUPIXENT SOLUTION PEN-INJECTOR 200 MG/1.14ML 4 PA; ST; M; SMCS; SP SUBCUTANEOUS 200 MG/1.14ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; ST; M; SL (4 ml (2 pens) 4 300 MG/2ML (dupilumab) per 23 days.); SMCS; SP DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED 4 PA; ST; M; SMCS; SP SYRINGE 300 MG/2ML (dupilumab) EFUDEX EXTERNAL CREAM 5 % (fluorouracil) 4 enovarx-tramadol external cream 5 % 1 PA ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 4 betameth diprop) EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl 4 peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- 4 benzoyl peroxide) FABIOR EXTERNAL FOAM 0.1 % () 4 FBL KIT EXTERNAL CREAM 15-4-5 % 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 264 Coverage Requirements & Prescription Drug Name Drug Tier Limits FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 4 oxyquinoline) FINACEA EXTERNAL FOAM 15 % (azelaic acid) 2 FINACEA EXTERNAL GEL 15 % (azelaic acid) 4 FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 4 FLUOROURACIL EXTERNAL CREAM 0.5 % 2 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 HALUCORT EXTERNAL GEL (dermatological products, 3 misc.) hpr plus external foam 4 HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) 3 ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; ST; M; SL (1 ml per 63 4 100 MG/ML (tildrakizumab-asmn) days.); SMCS; SP imiquimod external cream 5 % 1 capsule 10 mg oral 10 mg 1 isotretinoin capsule 20 mg oral 20 mg 1 isotretinoin capsule 30 mg oral 30 mg 1 isotretinoin capsule 40 mg oral 40 mg 1 K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % 3 PA (ketoprofen-baclofen-gabap-lido ) LEVULAN KERASTICK EXTERNAL SOLUTION 3 RECONSTITUTED 20 % (aminolevulinic acid hcl) LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine- 4 cleanser) MEDERMA SPF 30 EXTERNAL CREAM (scar treatment 3 PA products) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) 4 PA MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 4 (doxycycline hyclate-cleanser) myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 NP #2 DRUG PREPARATION KIT EXTERNAL CREAM 3 PA NUVAIL EXTERNAL SOLUTION (dermatological products, 3 misc.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 265 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SMCS; SP PA; SL (55 tablets (one OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 starter pack) per year.); (apremilast) SMCS; SP PANRETIN EXTERNAL GEL 0.1 % () 3 pimecrolimus external cream 1 % 1 ST podocon external solution 25 % 1 podofilox external solution 0.5 % 1 PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) 3 SL (30 grams per month.) REGRANEX EXTERNAL GEL 0.01 % () 2 PA REMIGEN EXTERNAL CREAM 4 RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) 4 PA SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 SCARCIN EXTERNAL CREAM 3 PA SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED PA; M; SL (1 box per 3 2 SYRINGE KIT 75 MG/0.83ML (risankizumab-rzaa) months.); SMCS; SP SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- 2 PA INJECTOR 150 MG/ML (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 2 PA 150 MG/ML (risankizumab-rzaa) SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) 4 STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 2 PA; M; SMCS; SP (ustekinumab) PA; M; SL (0.5 ml (1 prefilled STELARA SUBCUTANEOUS SOLUTION PREFILLED 2 syringe) per 3 months.); SYRINGE 45 MG/0.5ML (ustekinumab) SMCS; SP PA; M; SL (1 ml (1 prefilled STELARA SUBCUTANEOUS SOLUTION PREFILLED 2 syringe) per 3 months.); SYRINGE 90 MG/ML (ustekinumab) SMCS; SP STRATA CTX EXTERNAL GEL (dermatological products, 3 misc.) STRATA XRT EXTERNAL GEL (dermatological products, 3 misc.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 266 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYNALAR TS EXTERNAL KIT 0.01 % (fluocinolone & 4 cleanser) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) tacrolimus external ointment 0.03 %, 0.1 % 1 ST TARGRETIN EXTERNAL GEL 1 % (bexarotene) 3 SMCS; SP tazarotene external cream 0.1 % 1 PA TAZAROTENE EXTERNAL FOAM 0.1 % 4 TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) 4 PA TAZORAC EXTERNAL GEL 0.05 % (tazarotene) 2 PA TAZORAC EXTERNAL GEL 0.1 % (tazarotene) 4 PA TETRIX EXTERNAL CREAM (dermatological products, 4 misc.) TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML ( fibrin sealant 3 component) TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 PA; M; SL (1 ml per 42 2 MG/ML (guselkumab) days.); SMCS; SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED PA; M; SL (2 ml per 2 2 SYRINGE 100 MG/ML (guselkumab) months); SMCS; SP TRIPLE COMPLEX FORMULA 3 KIT EXTERNAL CREAM 20- 3 2-10 % VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl 2 PA; SMCS; SP (topical)) VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 4 VENELEX EXTERNAL OINTMENT ( balsam peru-castor oil) 3 VEREGEN EXTERNAL OINTMENT 15 % ( sinecatechins) 3 ST VP FC KIT EXTERNAL CREAM 3 PA VP GKL KIT EXTERNAL CREAM 20-2-10 % 3 PA zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 SUNSCREEN AGENTS - Drugs for the Skin AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 4 sulfur-sunscreen)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 267 Coverage Requirements & Prescription Drug Name Drug Tier Limits SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ANTIMUSCARINICS - Drugs for the Urinary System darifenacin hydrobromide er oral tablet extended release 24 1 hour 15 mg, 7.5 mg DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 5 MG (oxybutynin chloride) flavoxate hcl oral tablet 100 mg 1 GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin chloride) 4 oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg 1 oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 solifenacin succinate oral tablet 10 mg, 5 mg 1 tolterodine tartrate er oral capsule extended release 24 1 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 2 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 mg 1 trospium chloride oral tablet 20 mg 1 VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin 4 succinate) RESPIRATORY SMOOTH MUSCLE RELAXANTS - Drugs for Lungs ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 PA; SL (186 ml per month.); sildenafil citrate oral suspension reconstituted 10 mg/ml 1 SMCS; SP SL (0.5 tablet per day.); sildenafil citrate oral tablet 20 mg 1 SMCS THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 268 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 SELECTIVE BETA-3-ADRENERGIC AGONISTS - Drugs for the Urinary System MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 25 MG, 50 MG (mirabegron) VITAMINS MULTIVITAMIN PREPARATIONS adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 3 fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) M-NATAL PLUS ORAL TABLET 27-1 MG 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL 19 ORAL TABLET 1 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 269 Coverage Requirements & Prescription Drug Name Drug Tier Limits NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 vit a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 ONEVITE ORAL TABLET 1 MG 3 POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat 3 mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 270 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 4 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3-folic 3 acid) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 271 Coverage Requirements & Prescription Drug Name Drug Tier Limits VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 VITAMIN A adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITAMIN B COMPLEX ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 3 fa) CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium-folic acid plus d oral wafer 1342-1 mg 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) cyanocobalamin injection solution 1000 mcg/ml 1 M CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 M drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 1 H ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) folic acid oral tablet 1 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 272 Coverage Requirements & Prescription Drug Name Drug Tier Limits hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 3 NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 M (cyanocobalamin) NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 vit a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 ONEVITE ORAL TABLET 1 MG 3 POTABA ORAL CAPSULE 500 MG (potassium 4 aminobenzoate) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat 3 mv-min-methylfolate-fa)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 273 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 4 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tydemy oral tablet 3-0.03-0.451 mg 1 H UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 3 minerals-fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 274 Coverage Requirements & Prescription Drug Name Drug Tier Limits VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 VITAMIN C adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 2 (peg-kcl-nacl-nasulf-na asc-c) peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm 1 peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 1 PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- 2 kcl-nacl-nasulf-na asc-c) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITAMIN D adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 calcium-folic acid plus d oral wafer 1342-1 mg 1 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) 4 (ergocalciferol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 275 Coverage Requirements & Prescription Drug Name Drug Tier Limits ERGOCAL ORAL CAPSULE 62.5 MCG (2500 UT) 3 ergocalciferol oral capsule 1.25 mg (50000 ut) 1 FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG 4 (calcitriol) ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) 4 TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) 4 VITAMIN E NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) WHEAT GERM OIL ORAL OIL 3 VITAMIN K ACTIVITY MEPHYTON ORAL TABLET 5 MG ( phytonadione) 4 phytonadione oral tablet 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication; M: May be covered under the medical benefit with prior authorization for HMO plans; SMCS: Specialty medication cost share may apply (for HMO plans, does not apply to injectables covered under the medical benefit). 276 Index of Drugs 7T LIDO ...... 246 acyclovir...... 31, 248 ALEVAMAX...... 263 A.A.G.C. KIT IN TERODERM. 263 ACZONE...... 242, 263 ALFERON N...... 30, 37, 223 abacavir sulfate...... 28 ADACEL...... 47, 48 alfuzosin hcl er...... 58 abacavir sulfate-lamivudine ...28 adapalene-benzoyl peroxide ALINIA...... 20 abacavir-lamivudine- ...... 260, 263 aliskiren fumarate...... 92 zidovudine ...... 28 ADASUVE...... 109 ALKERAN...... 37 abiraterone acetate...... 37 adc/f (0.5mg/ml) allopurinol...... 213 acamprosate calcium...... 116 ...... 216, 269, 272, 275 ALLZITAL...... 96, 112 ACANYA...... 242, 260 ADDERALL XR...... 95 almotriptan malate ...... 133 acarbose...... 174 ADDYI...... 117 ALOCRIL...... 151, 238 ACCOLATE...... 237 adefovir dipivoxil...... 32 ALOMIDE...... 15, 151 ACCU-CHEK AVIVA...... 137 ADEMPAS...... 240 ALORA...... 186, 214 ACCU-CHEK COMPACT ADHANSIA XR...... 129 alosetron hcl...... 164 PLUS CONTROL...... 137 ADIPEX-P...... 94 ALPHAGAN P...... 151 ACCU-CHEK FASTCLIX ADLYXIN...... 196 ALPHANATE ...... 65 LANCET KIT...... 137 ADLYXIN STARTER PACK.... 195 ALPHANINE SD...... 65 ACCU-CHEK GUIDE...... 137, 141 ADRENALIN...... 50, 162, 233 alprazolam...... 114 ACCU-CHEK GUIDE ADVAIR DISKUS...... 59, 171 alprazolam er...... 114 CONTROL ...... 137 ADVAIR HFA...... 59, 171 alprazolam intensol ...... 114 ACCU-CHEK SMARTVIEW ADVATE...... 64 alprazolam xr...... 114 CONTROL ...... 137 ADYNOVATE...... 64 ALPROLIX...... 65 ACCU-CHEK SOFTCLIX ADZENYS ER...... 95 ALREX...... 156 LANCET DEVICE KIT...... 137 ADZENYS XR-ODT...... 95 ALTABAX ...... 242 ACCUPRIL...... 73, 74 AEMCOLO...... 34 ALTACAINE ...... 160 ACCURETIC...... 74, 147 AFINITOR...... 37 altafrin...... 161, 162 accutane...... 263 AFINITOR DISPERZ...... 37 altavera...... 177, 186, 198 ACD-A NOCLOT-50...... 62 afirmelle...... 177, 186, 198 ALTOPREV...... 88 acebutolol hcl ...... 60, 76, 77, 83 AFLURIA QUADRIVALENT...... 48 ALTRENO ...... 250 acetaminophen-codeine .96, 121 AFREZZA...... 207 ALUNBRIG...... 37, 38 acetaminophen-codeine #2 AFSTYLA ...... 65 alvimopan...... 167 ...... 96, 121 AGRYLIN...... 71 alyacen 1/35...... 177, 186, 198 acetaminophen-codeine #3 aif #2 drug preparation kit alyacen 7/7/7...... 177, 186, 198 ...... 96, 121 .... 55, 99, 127, 171, 246, 261, 263 alyq...... 91, 240 acetaminophen-codeine #4 AIF #3 DRUG PREPARATION amabelz...... 186, 198 ...... 96, 121 KIT...... 55, 56, 127, 246, 261, 263 amantadine hcl...... 17, 94 acetazolamide ... 81, 99, 143, 155 AIMOVIG...... 116 AMARYL...... 209 acetazolamide er ak-poly-bac ...... 151 ambrisentan...... 240 ...... 81, 99, 143, 155 AKTEN...... 160 amcinonide ...... 250, 251 acetic acid...... 159 AKYNZEO...... 162, 169 AMELUZ...... 263 acetylcysteine...... 212, 238 ALA SCALP...... 250 amethia...... 177, 186, 198 ACIPHEX SPRINKLE...... 170 ala-cort...... 250 amethyst...... 178, 186, 198 acitretin...... 263 albendazole ...... 18 amiloride hcl...... 91, 144 ACTEMRA ...... 219, 222 ALBENZA ...... 18 amiloride- ACTEMRA ACTPEN ...... 218, 222 albuterol sulfate...... 59, 240 hydrochlorothiazide ...... 144, 147 ACTHAR...... 141, 197 albuterol sulfate hfa ...... 59, 240 aminoamrms...... 143 ACTHIB...... 48 ALCAINE...... 160 aminocaproic acid...... 65 ACTIMMUNE ...... 222 alclometasone dipropionate 250 aminoreliefrms...... 143 ACTIVELLA...... 186, 198 ALCOHOL PREP PADS...... 137 amiodarone hcl ...... 84 ACTOPLUS MET...... 176, 210 ALDACTAZIDE...... 89, 147 AMITIZA...... 167 ACULAR...... 160 ALDARA...... 263 amitriptyline hcl...... 135 ACULAR LS...... 160 ALECENSA...... 37 AMLODIPINE ACUVAIL...... 160 alendronate sodium ...... 214 BES+SYRSPEND SF... 85, 87, 92

277 amlodipine besylate ....85, 87, 92 APTIVUS...... 30 aviane...... 178, 187, 199 amlodipine besylate- ARAKODA...... 19 avidoxy...... 19, 35 benazepril hcl...... 74, 86 aranelle...... 178, 186, 198 AVIDOXY DK...... 35, 258, 267 amlodipine besylate- ARANESP (ALBUMIN FREE) AVITA...... 250 valsartan...... 72, 86 ...... 61, 63 AVONEX PEN...... 223 amlodipine-atorvastatin ... 86, 88 ARAVA...... 219, 223, 227 AVONEX PREFILLED...... 223 amlodipine-olmesartan .....72, 86 ARCALYST...... 229 AYGESTIN...... 199 amlodipine-valsartan-hctz arformoterol tartrate...... 59 ayuna...... 178, 187, 199 ...... 72, 86, 147 ARIKAYCE...... 17 AYVAKIT...... 38 amnesteem...... 263 aripiprazole...... 104, 110 AZASAN...... 219, 223, 227 amoxapine...... 135 armodafinil...... 136 AZASITE...... 151 amoxicill-clarithro-lansopraz ARMOUR THYROID...... 210 azathioprine...... 219, 223, 227 ...... 17, 32, 170 ARNUITY ELLIPTA ...... 171, 239 azelaic acid...... 263 amoxicillin...... 18, 164 ARTISS...... 263 azelastine hcl...... 151, 239 amoxicillin-potassium ARZOL SILVER NIT azelastine-fluticasone clavulanate...... 18 APPLICATORS...... 159 ...... 151, 156, 238, 239 amoxicillin-potassium ascomp-codeine AZELEX...... 263 clavulanate er...... 18 ...... 112, 121, 130, 132 AZILECT...... 120 AMPHETAMINE ER...... 95 ashlyna...... 178, 186, 198 azithromycin...... 32 amphetamine sulfate ...... 95 aspirin-dipyridamole er .. 71, 132 AZOPT...... 155 amphetamine- ASTRAZENECA COVID-19 AZULFIDINE..... 34, 164, 219, 223 dextroamphetamine ...... 95 VACCINE...... 48 AZULFIDINE EN-TABS ampicillin...... 18 ASTRINGYN...... 65 ...... 34, 164, 219, 223 AMZEEQ...... 242 ATABEX OB...... 68, 269, 272 azurette...... 178, 187, 199 anagrelide hcl...... 71 atazanavir sulfate ...... 30 bac...... 96, 113, 130 ANALPRAM HC ...... 246, 251 atenolol...... 60, 76, 77, 83 bacitracin...... 152 ANALPRAM HC SINGLES ATENOLOL+SYRSPEND SF bacitracin-polymyxin b ...... 152 ...... 246, 251 ...... 60, 76, 77, 83 bacitra-neomycin- ANALPRAM-HC ...... 246, 251 atenolol-chlorthalidone .. 76, 149 polymyxin-hc...... 152, 156 ANASPAZ...... 51 atomoxetine hcl ...... 117 BACLOFEN...... 56 anastrozole ...... 38, 175 ATOPADERM...... 263 baclofen...... 56 ANCOBON...... 33 atorvastatin calcium ...... 88 BACTRIM...... 20, 34, 36 ANDRODERM...... 174 atovaquone...... 20 BACTRIM DS...... 20, 34, 36 ANGELIQ...... 186, 198 atovaquone-proguanil hcl ...... 19 BAFIERTAM...... 223 ANNOVERA ...... 178, 186, 198 atropine sulfate...... 161 BALCOLTRA ...... 178, 187, 199 ANORO ELLIPTA ...... 51, 59 ATROVENT HFA ...... 51, 234 balsalazide disodium ...... 164 ANTARA ...... 88 AUBAGIO...... 223 balsam peru-castor oil...... 263 ANTICOAGULANT SODIUM aubra...... 178, 186, 199 BALVERSA...... 38 CITRATE ...... 62 aubra eq...... 178, 186, 198 balziva...... 178, 187, 199 ANTIVERT...... 13, 163 AUGMENTIN...... 18 BANZEL...... 99 anucort-hc ...... 251 aurovela 1.5/30...... 178, 186, 199 BAQSIMI ONE PACK..... 195, 212 ANUSOL-HC...... 251 aurovela 1/20...... 178, 186, 199 BAQSIMI TWO PACK.....195, 212 apap-caff-dihydrocodeine aurovela 24 fe...... 178, 186, 199 BARACLUDE...... 32 ...... 96, 121, 129 aurovela fe 1.5/30.. 178, 187, 199 BAXDELA...... 33 APEXICON E...... 251 aurovela fe 1/20..... 178, 187, 199 BECONASE AQ...... 156, 238 APLENZIN...... 103 AURYXIA...... 144 BELBUCA...... 126 APOKYN...... 121 AUSTEDO...... 136 belladonna alkaloids-opium apraclonidine hcl...... 159 AUTOLET LANCING DEVICE 137 ...... 51, 121 aprepitant...... 169 AVAR CLEANSER...... 242, 257 BELSOMRA ...... 109 apri...... 178, 186, 198 AVAR LS CLEANSER.... 242, 257 benazepril hcl...... 73, 74 APRISO...... 164 AVAR-E EMOLLIENT..... 242, 257 benazepril- APTENSIO XR...... 130 AVAR-E GREEN...... 242, 258 hydrochlorothiazide ...... 74, 147 APTIOM...... 99 AVAR-E LS...... 242, 258 BENEFIX...... 65

278 BENLYSTA ...... 227 BOSULIF...... 38 cabergoline...... 119 BENZALKONIUM CHLORIDE 260 bp 10-1...... 242, 258 CABLIVI...... 62 benzalkonium chloride ...... 260 bp cleansing wash...... 242, 258 CABOMETYX...... 38 BENZAMYCIN ...... 242, 260 BRAFTOVI ...... 38 CAFERGOT...... 57, 107, 130 BENZHYDROCODONE- BREO ELLIPTA ...... 59, 171, 172 caffeine citrate...... 107, 130 ACETAMINOPHEN...... 96, 121 BREZTRI AEROSPHERE CALAN SR...... 79, 80, 84, 92 BENZNIDAZOLE ...... 20 ...... 51, 59, 172 CALCIFOL...... 145, 272, 275 BENZOIN...... 250 briellyn...... 178, 187, 199 calcipotriene...... 263 benzoin compound ...... 250 BRILINTA ...... 71 CALCIPOTRIENE...... 263 benzonatate ...... 234 brimonidine tartrate ...... 151 calcipotriene-betameth benzoyl peroxide- brinzolamide...... 155 diprop...... 251, 263 erythromycin...... 242, 260 BRIVIACT...... 99 calcitonin (salmon) ...... 176, 214 benzphetamine hcl ...... 95 bromfenac sodium (once- CALCITRENE ...... 263 benztropine mesylate ...... 54, 98 daily)...... 160 calcitriol...... 263, 275 bepotastine besilate ...... 151 bromocriptine mesylate ...... 119 calcium acetate...... 144, 145 BERINERT...... 218 BROMSITE...... 160 calcium acetate (phos beser...... 251 BROVANA...... 59 binder)...... 144, 145 BESIVANCE...... 152 BRUKINSA...... 38 calcium-folic acid plus d BETADINE OPHTHALMIC BRYHALI...... 251 ...... 145, 272, 275 PREP...... 159 budesonide...... 172, 239 CALQUENCE...... 38 betamethasone dipropionate bumetanide...... 89, 143 CAMBIA...... 107, 127 ...... 251 BUMEX...... 89, 143 camila...... 178, 199 betamethasone dipropionate BUNAVAIL...... 125, 126 camrese...... 178, 187, 199 aug...... 251 BUPAP...... 96, 113 camrese lo...... 178, 187, 199 betamethasone valerate ...... 251 BUPHENYL...... 142 candesartan cilexetil...... 72, 73 BETAPACE AF. 56, 76, 77, 83, 84 buprenorphine hcl ...... 126 candesartan cilexetil-hctz BETASERON...... 223 buprenorphine hcl-naloxone ...... 73, 148 betaxolol hcl.. 60, 76, 77, 83, 154 hcl...... 125, 126, 127 capecitabine...... 38 bethanechol chloride ...... 57 bupropion hcl ...... 104 CAPEX...... 251 BETIMOL...... 154 bupropion hcl er (smoking CAPLYTA...... 110 BETOPTIC-S...... 154 det)...... 104 CAPRELSA...... 38 BEVESPI AEROSPHERE...51, 59 bupropion hcl er (sr) ...... 104 captopril...... 73, 74 BEXSERO...... 48 bupropion hcl er (xl) ...... 104 CARAC...... 263 bicalutamide...... 38 BUPROPION HCL ER (XL).... 104 CARBAGLU...... 142 BIDIL...... 87, 90 buspirone hcl ...... 109 carbamazepine...... 99, 104 BIJUVA...... 187, 199 butalbital-acetaminophen carbamazepine er...... 99, 104 BIKTARVY...... 26, 27, 28 ...... 96, 113 CARBATROL...... 99, 104 BILTRICIDE...... 18 butalbital-apap-caff-cod carbidopa...... 118 bimatoprost...... 161 ...... 96, 113, 122, 130 carbidopa-levodopa ...... 118 BINOSTO...... 214 butalbital-apap-caffeine carbidopa-levodopa er ...... 118 bisoprolol fumarate ...... 96, 113, 130 carbidopa-levodopa- ...... 60, 76, 77, 83 butalbital-asa-caff-codeine entacapone ...... 116, 118 bisoprolol- ...... 113, 122, 130, 132 carbinoxamine maleate.. 13, 237 hydrochlorothiazide ...... 76, 147 butalbital-aspirin-caffeine CARDURA...... 57, 71, 72 BLEPH-10...... 152 ...... 113, 130, 132 CARDURA XL...... 57, 71, 72 BLEPHAMIDE...... 152, 156 butorphanol tartrate ...... 107, 127 CARETOUCH CONTROL SOL BLEPHAMIDE S.O.P...... 152, 156 BYDUREON BCISE LEVEL 2...... 137 blisovi 24 fe...... 178, 187, 199 AUTOINJECTOR...... 196 CARETOUCH blisovi fe 1.5/30..... 178, 187, 199 BYETTA 10 MCG PEN ...... 196 LANCING/EJECTOR...... 137 blisovi fe 1/20...... 178, 187, 199 BYETTA 5 MCG PEN ...... 196 carisoprodol...... 55 BONIVA...... 214 BYLVAY...... 167 carisoprodol-aspirin-codeine BOOSTRIX...... 47, 48 BYLVAY (PELLETS) ...... 167 ...... 55, 122, 132 bosentan...... 240 BYSTOLIC...... 56, 76 CARNITOR...... 229

279 CARNITOR SF...... 229 chlorthalidone ...... 92, 149 clindamycin-tretinoin CAROSPIR...... 90, 91, 144 chlorzoxazone ...... 55 ...... 243, 250, 264 carteolol hcl...... 154 CHOLBAM...... 167 CLINDESSE...... 243 cartia xt...... 79, 80, 84, 92 cholestyramine...... 78 CLINOIN...... 78, 243, 250, 264 carvedilol cholestyramine light...... 78 CLINPRO 5000...... 216 ...... 56, 58, 71, 72, 76, 77, 83 ciclodan...... 257 clobazam...... 113, 115 carvedilol phosphate er ciclopirox...... 257 clobetasol prop emollient ...... 56, 58, 71, 72, 76, 77, 83 ciclopirox olamine...... 257 base...... 251 cascara sagrada...... 165 ciclopirox treatment...... 257 clobetasol propionate ...... 252 CASODEX...... 38 cilostazol...... 71, 91 clobetasol propionate e ...... 251 cavarest...... 216 CILOXAN...... 152 clobetasol propionate CAVERJECT...... 93 CIMDUO...... 28 emulsion...... 252 CAVERJECT IMPULSE...... 92 cimetidine...... 14, 169 CLOBETAVIX...... 252 CAYA...... 232 cimetidine hcl...... 14, 169 clocortolone pivalate ...... 252 CAYSTON...... 31 CIMZIA PREFILLED KIT CLODAN...... 252, 257 caziant...... 178, 187, 199 ...... 167, 219, 223 clodan...... 252 cefaclor...... 16 CIMZIA STARTER KIT clomipramine hcl...... 135 cefaclor er...... 16 ...... 167, 219, 223 clonazepam...... 113, 115 cefadroxil...... 15, 16 cinacalcet hcl...... 176 clonidine...... 51, 82 cefdinir...... 16 CIPRO...... 21, 33 clonidine hcl...... 51, 82 cefixime...... 16 CIPRO HC...... 152, 156 clonidine hcl er...... 51, 82 cefpodoxime proxetil ...... 16 CIPRODEX...... 152, 156 clopidogrel bisulfate ...... 71 cefprozil...... 16 ciprofloxacin hcl...... 21, 34, 152 clorazepate dipotassium cefuroxime axetil...... 16 CIPROFLOXACIN- ...... 113, 115 celecoxib...... 118 FLUOCINOLONE PF...... 152, 156 clotrimazole...... 248 CELONTIN...... 135 citalopram hydrobromide .....134 clotrimazole-betamethasone CENTANY ...... 242 CITRANATAL BLOOM ...... 248, 252 CENTANY AT ...... 242 ...... 68, 165, 272, 275 clovique...... 171 cephalexin...... 16 CITRANATAL ESSENCE clozapine...... 110 CERDELGA...... 229 ...... 68, 145, 229, 269, 272 CLOZARIL...... 110 cerovel...... 258 CITRANATAL MEDLEY COAGADEX...... 65 CERVIDIL...... 233 ...... 69, 229, 269, 272 COAL TAR...... 259 CETRAXAL...... 152 claravis...... 263 COARTEM...... 19 cevimeline hcl...... 57 CLARINEX-D 12 HOUR...... 15, 50 codeine sulfate...... 122, 235 CHANTIX...... 54 clarithromycin...... 21, 32, 164 colchicine-probenecid ..149, 213 CHANTIX CONTINUING clarithromycin er...... 21, 32, 164 COLESTID...... 78, 79 MONTH PAK ...... 54 clemastine fumarate ...... 13, 237 COLESTID FLAVORED...... 78 CHANTIX STARTING MONTH CLENPIQ...... 165 colestipol hcl...... 79 PAK...... 54 CLEOCIN...... 31, 243 colistimethate sodium (cba) .. 33 charlotte 24 fe...... 178, 187, 199 CLEOCIN-T...... 243 COLY-MYCIN M...... 33 chateal...... 178, 187, 199 CLIMARA PRO...... 187, 199 COMBIGAN...... 151, 155 chateal eq...... 178, 187, 199 CLINDACIN ETZ ...... 243 COMBIPATCH...... 187, 199 CHEMET...... 171, 212 clindacin etz...... 243 COMBIVENT RESPIMAT CHENODAL...... 166 CLINDACIN PAC...... 243 ...... 51, 59, 234 chlordiazepoxide hcl ...... 114 clindacin-p...... 243 COMBIVIR...... 28 chlordiazepoxide- CLINDAGEL...... 243 COMETRIQ...... 38, 39 amitriptyline...... 114, 135 clindamycin hcl...... 31 COMPLERA...... 27, 28 chlordiazepoxide-clidinium clindamycin palmitate hcl ...... 31 compro...... 129, 163 ...... 51, 114 clindamycin phos-benzoyl COMTAN...... 116 chlorhexidine gluconate perox...... 243, 260 CONCERTA ...... 130 ...... 159, 260 clindamycin phosphate ...... 243 CONDYLOX...... 264 chloroquine phosphate ...... 19 CLINDAMYCIN PHOSPHATE 243 constulose...... 142 chlorpromazine hcl ...... 129 CONTOUR CONTROL ...... 138

280 CONTOUR NEXT CONTROL .138 CYCLOPHOSPHAMIDE... 39, 227 DEPO-SUBQ PROVERA 104 CONTOUR NEXT EZ ...... 138 cycloserine...... 21 ...... 179, 200 CONTOUR NEXT LINK ...... 138 CYCLOSET...... 175 DEPO-TESTOSTERONE174, 175 CONTOUR NEXT MONITOR . 138 cyclosporine...... 219, 223, 227 DERMA-SMOOTHE/FS BODY CONTOUR NEXT ONE ...... 138 cyclosporine modified ...... 252 CONTOUR NEXT TEST ...... 141 ...... 219, 223, 227 DERMA-SMOOTHE/FS CONTRAVE ...... 98 cyproheptadine hcl ...... 13, 237 SCALP...... 252 CONZIP...... 122 cyred...... 179, 187, 200 DERMOTIC...... 156 COPASIL...... 264 cyred eq...... 179, 187, 200 DESCOVY...... 28 COPIKTRA...... 39 CYSTADANE ...... 229 desipramine hcl...... 135 CORDRAN...... 252 CYSTADROPS...... 159 desloratadine...... 15, 239, 240 CORGARD...... 56, 76, 77 CYSTAGON...... 229 desmopressin ace spray CORIFACT...... 65 CYSTARAN...... 159 refrig...... 65, 197 CORLANOR...... 81, 93 CYTOTEC...... 169 desmopressin acetate.... 65, 197 CORTANE-B ...... 246, 252, 260 cytra k crystals...... 142 desmopressin acetate pf 65, 197 CORTEF...... 172 dalfampridine er...... 229 desmopressin acetate spray CORTENEMA ...... 252 DALIRESP...... 239 ...... 65, 197 cortic-nd...... 156, 159, 160 danazol...... 174 desogestrel-ethinyl estradiol CORTIFOAM...... 252 DANTRIUM...... 56 ...... 179, 188, 200 CORTI-SAV...... 252, 260 dantrolene sodium ...... 56 DESONATE...... 253 CORTISPORIN-TC...... 152, 156 dapsone...... 20 desonide...... 253 CORTROSYN...... 141 DAPTACEL...... 47, 48 DESOWEN...... 253 COSENTYX (300 MG DOSE).264 DARAPRIM...... 19 desoximetasone...... 253 COSENTYX 150 MG/ML ...... 264 darifenacin hydrobromide er268 desrx...... 253 COSENTYX SENSOREADY dasetta 1/35...... 179, 187, 200 DESVENLAFAXINE ER...... 132 (300 MG)...... 264 dasetta 7/7/7...... 179, 188, 200 desvenlafaxine succinate er 132 COSENTYX SENSOREADY DAURISMO...... 39 dexamethasone...... 172 PEN...... 264 DAYPRO...... 127 dexamethasone intensol ...... 172 COSOPT...... 155 daysee...... 179, 188, 200 dexamethasone sodium cosyntropin ...... 141 DAYTRANA ...... 130 phosphate ...... 156 COTELLIC ...... 39 DAYVIGO...... 109 dexchlorpheniramine COTEMPLA XR-ODT...... 130 DEBACTEROL...... 159, 260 maleate...... 15 COVARYX...... 174, 187 deblitane...... 179, 200 DEXCOM G4 / G5 / G6 COVARYX HS...... 174, 187 deferasirox...... 171 RECEIVER, TRANSMITTER, CREON...... 150, 166 deferasirox granules...... 171 SENSOR (INCLUDING CRESEMBA...... 22 deferiprone...... 171 PLATINUM, PLATINUM CRINONE...... 199 DELESTROGEN...... 188, 214 PEDIATRIC)...... 138 CRIXIVAN...... 30 DELSTRIGO...... 27, 28 DEXILANT...... 170 cromolyn sodium .. 151, 159, 238 delyla...... 179, 188, 200 dexmethylphenidate hcl ...... 130 crotan...... 262 demeclocycline hcl...... 35 dexmethylphenidate hcl er ...130 cryselle-28...... 178, 187, 199 DEMSER...... 229 DEXTENZA ...... 156 CUTIVATE...... 252 DENAVIR...... 248 dextroamphetamine sulfate ... 95 CUVPOSA...... 52 DENTA 5000 PLUS...... 216 dextroamphetamine sulfate cyanocobalamin ...... 71, 272 DENTAGEL...... 216 er...... 95 CYANOCOBALAMIN...... 71, 272 DEPAKOTE...... 99, 105, 107 DIACOMIT...... 100 cyclafem 1/35...... 178, 187, 199 DEPAKOTE ER...... 99, 105, 107 DIASTAT ACUDIAL...... 114, 115 cyclafem 7/7/7...... 178, 187, 200 DEPAKOTE SPRINKLES DIASTAT PEDIATRIC.....114, 115 cyclobenzaprine hcl ...... 55 ...... 100, 105, 108 diazepam...... 114, 115 CYCLOGYL...... 161 DEPEN TITRATABS ...... 171, 219 diazepam intensol ...... 114, 115 CYCLOMYDRIL...... 161, 162 DEPO-ESTRADIOL...... 188, 214 diazoxide...... 176 cyclopentolate hcl ...... 161 DEPO-PROVERA...... 179, 200 DICLOFENAC CAP...... 127 CYCLOPHENE RAPIDPAQ...... 55 diclofenac potassium ...... 127 cyclophosphamide ...... 39, 227 diclofenac sodium 127, 160, 261

281 diclofenac sodium er ...... 127 DOPTELET...... 64 ec-naproxen...... 108, 128, 213 diclofenac-misoprostol 127, 169 DORYX...... 19, 35 econazole nitrate ...... 248 dicloxacillin sodium ...... 33 DORYX MPC...... 19, 35 ECOZA...... 248 DICOPANOL FUSEPAQ DORZOLAMIDE HCL...... 155 EC-RX DHEA...... 229 ...... 13, 54, 98, 109, 235, 237 dorzolamide hcl ...... 155 EC-RX ESTRADIOL...... 188, 214 DICOPANOL RAPIDPAQ dorzolamide hcl-timolol mal EC-RX PROGESTERONE..... 200 ...... 13, 54, 99, 109, 235, 237 ...... 155, 156 EC-RX TESTOSTERONE ...... 175 dicyclomine hcl...... 52 dorzolamide hcl-timolol mal EDARBI...... 72, 73 diethylpropion hcl ...... 94 pf...... 155, 156 EDARBYCLOR...... 73, 148 diethylpropion hcl er ...... 94 DOUBLE PM...... 152, 156 EDECRIN...... 89, 143 DIFICID...... 32 DOVATO...... 26, 28 EDEX...... 93 diflorasone diacetate ...... 253 DOVONEX...... 264 EDLUAR...... 109 DIFLUCAN...... 22 doxazosin mesylate .... 57, 71, 72 ED-SPAZ...... 52 diflunisal...... 127 doxepin hcl ...... 136, 246 EDURANT...... 27 digitek...... 75, 81 doxercalciferol...... 275 EEMT...... 175, 188 digox...... 75, 81 doxycycline...... 35, 264 EEMT HS...... 175, 188 digoxin...... 75, 82 doxycycline hyclate...... 19, 35 efavirenz...... 27 dihydroergotamine mesylate DOXYCYCLINE HYCLATE .19, 35 efavirenz-emtricitab- ...... 57, 108 doxycycline monohydrate 19, 35 tenofovir ...... 27, 28 DILANTIN...... 82, 83, 119 DRISDOL...... 275 efavirenz-lamivudine- DILANTIN INFATABS ...... 82, 119 DRIZALMA SPRINKLE...... 132 tenofovir ...... 27, 28 DILATRATE-SR...... 90 dronabinol...... 163 EFFER-K...... 145 DILAUDID...... 122 drospiren-eth estrad- effer-k...... 145 diltiazem hcl ...... 79, 80, 85, 93 levomefol...... 179, 188, 200, 272 EFUDEX...... 264 diltiazem hcl er...... 79, 80, 85, 93 drospirenone-ethinyl EGATEN...... 18 diltiazem hcl er beads estradiol...... 179, 188, 200 EGRIFTA SV...... 209 ...... 79, 80, 85, 93 DROXIA...... 39 ELESTRIN...... 188, 215 diltiazem hcl er coated droxidopa...... 50 eletriptan hydrobromide ...... 133 beads...... 79, 80, 85, 93 DRYSOL...... 248 ELIGARD...... 39, 195 dilt-xr...... 79, 80, 85, 93 DUAL COMPLEX FORMULA 1 elinest...... 179, 188, 200 dimethyl fumarate ...... 223 KIT...... 55, 261, 264 ELIQUIS...... 62, 63 DIPENTUM...... 164 DUAVEE...... 186, 188 ELIQUIS DVT/PE STARTER diphen.. 13, 54, 99, 109, 235, 237 DUETACT...... 209, 210 PACK...... 62 di-phen DULERA...... 59, 172 ELITE-OB...... 69, 269, 272 ...... 13, 14, 54, 99, 109, 235, 237 duloxetine hcl...... 119, 132, 133 ELIXOPHYLLIN diphenhydramine hcl DUOPA...... 118 ...... 87, 130, 143, 241, 268 ...... 13, 14, 54, 99, 109, 235, 237 DUPIXENT...... 237, 264 ELLA...... 179, 200 diphenoxylate-atropine .. 52, 162 DUREZOL...... 156 ELMIRON...... 229 DIPROLENE...... 253 dutasteride...... 212 ELOCTATE ...... 65 DIPROLENE AF...... 253 dutasteride-tamsulosin hcl EMCYT...... 39 dipyridamole...... 71, 93 ...... 58, 212 EMEND...... 169 disopyramide phosphate ...... 82 DYANAVEL XR...... 95 EMEND TRI-PACK...... 169 disulfiram...... 212 DYMISTA...... 151, 157, 238, 240 EMGALITY...... 116 DITROPAN XL...... 268 DYRENIUM...... 91, 144 EMGALITY (300 MG DOSE).. 116 DIURIL...... 92, 148 E.E.S. GRANULES...... 23 emoquette ...... 179, 188, 200 divalproex sodium 100, 105, 108 EASIVENT...... 138 EMSAM...... 120 divalproex sodium er easygel...... 216 emtricitabine...... 28 ...... 100, 105, 108 EASYMAX 15 LEVEL 2-3 emtricitabine-tenofovir df ...... 28 DIVIGEL...... 188, 214 CONTROL...... 138 EMTRIVA...... 28 dofetilide ...... 84 EASYMAX CONTROL...... 138 EMVERM...... 18 DOJOLVI...... 143 EASYMAX CONTROL enalapril maleate...... 73, 74 dolishale...... 179, 188, 200 NORMAL/HIGH...... 138 enalapril- donepezil hcl ...... 57, 58 EC-NAPROSYN...... 108, 128, 213 hydrochlorothiazide ...... 74, 148

282 ENBRACE HR .. 69, 229, 269, 272 ERYTHROCIN STEARATE ...... 23 FANAPT TITRATION PACK ... 111 ENBREL...... 219, 223, 224 erythromycin...... 24, 152, 243 FANATREX FUSEPAQ.....96, 100 ENBREL MINI ...... 219, 223 erythromycin base...... 23, 24 FARYDAK...... 39 ENBREL SURECLICK.... 219, 224 erythromycin ethylsuccinate . 24 FASENRA PEN...... 237 ENDARI...... 229 ESBRIET...... 234 FAVIPIRAVIR...... 22 endocet...... 96, 122 escitalopram oxalate...... 134 fayosim...... 179, 189, 201 ENDOMETRIN ...... 200 ESGIC...... 96, 113, 130 FBL KIT...... 56, 246, 261, 264 ENGERIX-B...... 48 esomeprazole magnesium ... 170 febuxostat...... 213 ENLITE GLUCOSE SENSOR.138 est estrogens-methyltest FEIBA...... 65 enovarx-amitriptyline ...... 136 ...... 175, 188 felbamate...... 100 enovarx-baclofen ...... 56 est estrogens-methyltest ds FELBATOL ...... 100 enovarx-cyclobenzaprine hcl .55 ...... 175, 188 FELDENE...... 128 enovarx-ibuprofen ...... 261 est estrogens-methyltest hs felodipine er...... 86, 87 enovarx-lidocaine hcl ...... 246 ...... 175, 188 FEM PH...... 260, 265 enovarx-naproxen ...... 261 estarylla...... 179, 188, 200 FEMHRT...... 189, 201 enovarx-tramadol ...... 264 estazolam...... 115 FEMRING...... 189, 215 enoxaparin sodium ...... 68 estradiol...... 189, 215 femynor...... 180, 189, 201 enpresse-28...... 179, 188, 200 estradiol valerate...... 189, 215 fenofibrate...... 88 enskyce...... 179, 188, 200 estradiol-norethindrone acet fenofibrate micronized ...... 88 ENSPRYNG ...... 224 ...... 189, 200 fenofibric acid...... 88 ENSTILAR ...... 253, 264 ESTRING...... 189, 215 fentanyl...... 122 entacapone ...... 116 ESTROGEL...... 189, 215 fentanyl citrate...... 122 entecavir...... 32 ESTROSTEP FE.....179, 189, 201 FENTANYL CITRATE ...... 122 ENTEREG ...... 167 eszopiclone ...... 109 FENTORA ...... 122 ENTRESTO ...... 73, 92 ethacrynic acid...... 89, 143 FERRIPROX...... 171 enulose...... 142 ethambutol hcl ...... 22 FETZIMA ...... 133 EPANED...... 74 ethosuximide...... 135 FETZIMA TITRATION ...... 133 EPCLUSA...... 24, 25 ethynodiol diac-eth estradiol FIBRICOR...... 88 EPIDIOLEX...... 100 ...... 179, 189, 201 FINACEA...... 265 EPIDUO...... 260, 264 etodolac...... 128 finasteride...... 212 EPIDUO FORTE...... 260, 264 etodolac er...... 128 FINTEPLA ...... 100 EPIFOAM...... 246, 253 etoposide ...... 39 FIORICET...... 96, 113, 130 epinastine hcl...... 151 etravirine...... 27 FIRAZYR...... 218 epinephrine...... 50, 234 EUCRISA...... 246 FIRMAGON...... 40, 176 epitol...... 100, 105 euthyrox...... 210 FIRMAGON (240 MG DOSE) EPIVIR...... 28 EVAMIST...... 189, 215 ...... 39, 176 EPIVIR HBV...... 28 EVEKEO...... 95 FIRST-BACLOFEN...... 56 eplerenone...... 90, 92, 145 EVEKEO ODT...... 95 FIRST-LANSOPRAZOLE...... 170 EQUETRO...... 100, 105 everolimus...... 39, 227 FIRST-METRONIDAZOLE ERGOCAL...... 276 EVOCLIN...... 243 ...... 17, 20, 165 ergocalciferol...... 276 EVOTAZ...... 30, 229 FIRST-MOUTHWASH BLM ergoloid mesylates...... 57 EVRYSDI...... 229 ...... 13, 161, 162, 163, 165, 247 ERGOMAR...... 57, 108 EXELDERM...... 248 FIRST-OMEPRAZOLE...... 170 ergotamine-caffeine 57, 108, 130 exemestane...... 39, 175 FIRST-PROGESTERONE ERIVEDGE...... 39 EXTINA...... 248 VGS...... 201 ERLEADA...... 39 EZALLOR SPRINKLE ...... 88 FIRVANQ...... 24 erlotinib hcl...... 39 ezetimibe...... 82 flac...... 157 errin...... 179, 200 ezetimibe-simvastatin ...... 82, 88 FLAGYL...... 17, 21, 165 ery...... 243 FABIOR...... 264 FLAREX...... 157 ERYGEL...... 243 falmina...... 179, 189, 201 flavoxate hcl...... 268 ERYPED 200...... 23 famciclovir...... 32 flecainide acetate...... 83 ERYPED 400...... 23 famotidine...... 14, 169 FLEXICHAMBER ADULT ERY-TAB...... 23 FANAPT...... 110, 111 MASK/SMALL...... 138

283 FLEXICHAMBER CHILD FLUZONE HIGH-DOSE GELFILM...... 65 MASK/LARGE...... 138 QUADRIVALENT...... 48 GEL-FLOW...... 66 FLEXICHAMBER CHILD FLUZONE QUADRIVALENT.... 49 GELFOAM-JMI POWDER...... 66 MASK/SMALL...... 139 FML...... 157 GELFOAM-JMI SPONGE...... 66 FLOLIPID...... 88 FML FORTE ...... 157 GELNIQUE...... 268 FLORIVA...... 216, 276 FML LIQUIFILM...... 157 gemfibrozil...... 88 FLORIVA PLUS...... 216, 269 FOCALIN...... 131 gemmily...... 180, 189, 201 FLOVENT DISKUS...... 172, 239 folic acid...... 272 generlac...... 142 FLOVENT HFA ...... 172, 239 fondaparinux sodium ...... 62 gengraf...... 219, 224, 228 FLUAD QUADRIVALENT...... 48 FORANE...... 120 gentak...... 152 FLUARIX QUADRIVALENT...... 48 FORFIVO XL...... 104 gentamicin sulfate 152, 243, 244 FLUCELVAX formaldehyde ...... 141 GENVOYA...... 26, 29 QUADRIVALENT...... 48 FORMALDEHYDE...... 141 GILENYA...... 224 fluconazole ...... 23 FORTISCARE CONTROL ...... 139 GILOTRIF...... 40 flucytosine ...... 33 FOSAMAX...... 215 GILPHEX TR...... 51, 236 fludrocortisone acetate ...... 172 FOSAMAX PLUS D...... 215, 276 glatiramer acetate...... 224 FLULAVAL QUADRIVALENT... 48 fosamprenavir calcium...... 30 glatopa...... 224 flunisolide ...... 157, 172, 238 fosfomycin tromethamine ...... 36 GLEOSTINE...... 40 fluocinolone acetonide .157, 253 fosinopril sodium ...... 74 glimepiride...... 209 fluocinolone acetonide body 253 fosinopril sodium-hctz ... 74, 148 glipizide...... 209 fluocinolone acetonide scalp FOSRENOL...... 144, 212 glipizide er...... 209 ...... 253 FRAGMIN...... 68 glipizide xl...... 209 fluocinonide ...... 253 FREESTYLE LIBRE 14 DAY glipizide-metformin hcl .176, 210 fluocinonide emulsified base READER...... 139 GLOPERBA...... 213 ...... 253 FREESTYLE LIBRE 14 DAY GLUCAGEN HYPOKIT... 195, 212 FLUORIDEX...... 216 SENSOR...... 139 glucagon emergency kit fluoridex daily renewal...... 216 FREESTYLE LIBRE 2 ...... 195, 212 FLUORIDEX ENHANCED READER...... 139 GLUCAGON EMERGENCY WHITENING...... 216 FREESTYLE LIBRE 2 KIT...... 195, 212 FLUORIDEX SENSITIVITY SENSOR...... 139 GLUCOTROL XL...... 210 RELIEF...... 137, 216 FREESTYLE LIBRE READER 139 GLUTARALDEHYDE...... 141 fluoritab...... 216 FREESTYLE LIBRE SENSOR glyburide...... 210 fluorometholone ...... 157 SYSTEM...... 139 glyburide micronized...... 210 FLUOROPLEX...... 265 FROTEK...... 262 glyburide-metformin ..... 176, 210 FLUOROURACIL...... 265 frovatriptan succinate ...... 133 glycopyrrolate...... 52 fluorouracil...... 265 furosemide...... 89, 143 glydo...... 247 fluoxetine hcl ...... 134 FUZEON...... 26 GLYNASE...... 210 fluoxetine hcl (pmdd) ...... 134 fyavolv...... 189, 201 GLYXAMBI...... 185, 208 fluphenazine hcl ...... 129 FYCOMPA...... 100 GOLYTELY ...... 165 flurandrenolide ...... 253 gabapentin...... 97, 100 GONITRO...... 90 flurazepam hcl ...... 115 GABITRIL...... 100 goodsense nicotine ...... 54 flurbiprofen ...... 128 GALAFOLD...... 229 GORDOFILM...... 249, 258 flurbiprofen sodium ...... 160 galantamine hydrobromide ....58 GRALISE...... 97, 100 flutamide ...... 40 galantamine hydrobromide granisetron hcl...... 162 fluticasone propionate er...... 58 GRASTEK...... 46 ...... 157, 172, 238, 254 GALZIN...... 145 griseofulvin microsize ...... 18 FLUTICASONE- GARDASIL 9...... 49 griseofulvin ultramicrosize .... 18 SALMETEROL ...... 60, 173 gatifloxacin...... 152 guaiatussin ac...... 235, 236 fluvastatin sodium ...... 89 GATTEX ...... 167 guaifenesin ac...... 235, 237 fluvastatin sodium er ...... 88 gavilyte-c...... 165 guanfacine hcl...... 82, 117 fluvoxamine maleate ...... 134 gavilyte-g...... 165 guanfacine hcl er ...... 117 fluvoxamine maleate er ...... 134 gavilyte-n with flavor pack... 165 GUARDIAN SENSOR (3)...... 139 GAVRETO...... 40

284 GVOKE HYPOPEN 1-PACK HUMIRA PEN-PEDIATRIC UC hyoscyamine sulfate sl...... 52 ...... 195, 212 START...... 167, 220, 224 hyosyne...... 52 GVOKE HYPOPEN 2-PACK HUMIRA PEN-PS/UV/ADOL HYPERSAL...... 238 ...... 195, 212 HS START...... 168, 220, 224 HYPOCYN...... 265 GVOKE PFS...... 195, 212 HUMIRA PEN-PSOR/UVEIT ibandronate sodium ...... 215 GYNAZOLE-1...... 248 STARTER ...... 168, 220, 225 IBRANCE...... 40 habitrol...... 54 HUMULIN 70/30 KWIKPEN ibuprofen...... 108, 128 HAEGARDA...... 218 ...... 196, 208 iclevia...... 180, 189, 201 hailey 1.5/30...... 180, 189, 201 HUMULIN 70/30 VIAL.....196, 208 ICLUSIG...... 40 hailey 24 fe...... 180, 189, 201 HUMULIN N KWIKPEN...... 196 IDELVION...... 66 hailey fe 1.5/30...... 180, 189, 201 HUMULIN N VIAL...... 197 IDHIFA...... 40 hailey fe 1/20...... 180, 189, 201 HUMULIN R U-500 KWIKPEN208 ILEVRO...... 160 halcinonide ...... 254 HUMULIN R U-500 VIAL...... 208 ILUMYA...... 265 HALCION...... 115 HUMULIN R VIAL...... 208 imatinib mesylate...... 40 halobetasol propionate ...... 254 HYCAMTIN...... 40 IMBRUVICA...... 40 HALOG...... 254 hydralazine hcl...... 87 IMCIVREE...... 98 haloperidol...... 116 HYDREA...... 40 imipramine hcl...... 136 haloperidol lactate ...... 115 HYDRO 40...... 258 imipramine pamoate ...... 136 HALUCORT...... 265 hydrochlorothiazide ...... 92, 148 imiquimod...... 265 HARVONI...... 24, 25 hydrocodone bitartrate er .... 122 IMITREX...... 133 HAVRIX...... 49 hydrocodone polst- IMPAVIDO...... 21 heather...... 180, 201 chlorphen polst er susp . 15, 235 IMVEXXY MAINTENANCE hematinic/folic acid ...... 69, 273 hydrocodone- PACK...... 189 HEMLIBRA...... 66 acetaminophen ...... 97, 122 IMVEXXY STARTER PACK... 190 hemocyte-f ...... 69, 273 hydrocodone-homatropine INBRIJA...... 118 HEMOFIL M...... 66 ...... 52, 235 incassia...... 180, 201 heparin lock flush ...... 68 hydrocodone-ibuprofen 122, 128 INCRELEX...... 209 heparin sodium (porcine) ...... 68 hydrocortisone...... 173, 254 indapamide ...... 92, 149 heparin sodium (porcine) pf .. 68 hydrocortisone (perianal) .....254 INDERAL LA ... 56, 76, 77, 83, 108 heparin sodium lock flush ..... 68 hydrocortisone ace- INDOCIN...... 128, 213 HEPLISAV-B...... 49 pramoxine...... 247, 254 INDOMETHACIN...... 128 HETLIOZ...... 109 hydrocortisone acetate ...... 254 indomethacin ...... 128, 213 HIBERIX...... 49 hydrocortisone butyr lipo indomethacin er ...... 128, 213 HIPREX...... 36 base...... 254 INFANRIX...... 47, 49 homatropaire...... 161 hydrocortisone butyrate ...... 254 INLYTA...... 40 hpr plus...... 265 hydrocortisone valerate ...... 254 INOVA...... 257, 260 HUMALOG...... 207 hydrocortisone-acetic acid INOVA 4/1 ACNE CONTROL HUMALOG KWIKPEN...... 207 ...... 157, 159 THERAPY...... 257, 258, 260 HUMALOG MIX 50/50 hydrocortisone-iodoquinol INOVA 8/2 ACNE CONTROL KWIKPEN...... 207 ...... 254, 260 THERAPY...... 257, 258, 260 HUMALOG MIX 50/50 VIAL....207 hydrocort-pramoxine INQOVI...... 41 HUMALOG MIX 75/25 (perianal)...... 247, 254 INREBIC...... 41 KWIKPEN...... 207 hydromet...... 52, 235 INSPIREASE RESERVOIR HUMALOG MIX 75/25 VIAL....207 hydromorphone hcl ...... 123 BAGS...... 139 HUMALOG U-100 JUNIOR hydromorphone hcl er ...... 122 INSULIN PEN NEEDLES...... 139 KWIKPEN...... 207 hydroxychloroquine sulfate INSULIN SYRINGES...... 139 HUMATE-P...... 66 ...... 19, 220, 225 INTELENCE ...... 27 HUMIRA...... 168, 220, 225 hydroxyurea...... 40 INTRAROSA...... 173 HUMIRA PEDIATRIC hydroxyzine hcl ...... 14, 109 INTRON A ...... 30, 31, 41, 225 CROHNS START....167, 219, 224 hydroxyzine pamoate ..... 14, 110 introvale...... 180, 190, 201 HUMIRA PEN. 167, 219, 220, 224 HYOPHEN...... 36, 52, 97 INVELTYS...... 157 HUMIRA PEN-CD/UC/HS hyoscyamine sulfate...... 52 INVIRASE...... 30 STARTER ...... 167, 220, 224 hyoscyamine sulfate er ...... 52 IODINE STRONG...... 237

285 iodine tincture ...... 260 K.B.G.L IN TERODERM KRINTAFEL...... 19 IOPIDINE...... 160 ...... 56, 128, 247, 262, 265 KRISTALOSE...... 142 IPOL...... 49 kaitlib fe...... 180, 190, 202 K-TAB...... 145 ipratropium bromide ...... 52, 234 KALETRA...... 30 kurvelo...... 180, 190, 202 ipratropium-albuterol 52, 60, 234 kalliga...... 180, 190, 202 KYNMOBI...... 121 irbesartan...... 72, 73 KALYDECO...... 236 KYNMOBI TITRATION KIT .....121 irbesartan- KAPSPARGO SPRINKLE labetalol hcl hydrochlorothiazide ...... 73, 148 ...... 60, 76, 78, 83 ...... 56, 58, 71, 72, 76, 78, 83 IRESSA...... 41 KARBINAL ER...... 13, 14, 237 LACRISERT...... 160 ISENTRESS...... 26 kariva...... 180, 190, 202 lactulose...... 142 ISENTRESS HD...... 26 KATERZIA...... 86, 87, 93 lactulose encephalopathy .... 142 isibloom...... 180, 190, 201 KAZANO...... 177, 185 LAMICTAL...... 101, 105 isoflurane...... 120 KEFLEX...... 16 LAMICTAL ODT ...... 101, 105 isoniazid...... 22 kelnor 1/35...... 180, 190, 202 LAMICTAL STARTER .....101, 105 ISOPTO ATROPINE...... 161 kelnor 1/50...... 180, 190, 202 LAMICTAL XR...... 101, 105 ISOPTO CARPINE...... 161 KEPPRA...... 100 lamivudine...... 29 ISORDIL TITRADOSE...... 90 KEPPRA XR...... 101 lamivudine-zidovudine ...... 29 isosorbide dinitrate ...... 90 KERALYT SCALP ...... 258 lamotrigine...... 101, 105, 106 isosorbide mononitrate ...... 90 KERAMATRIX REPLICINE lamotrigine er...... 101, 105 isosorbide mononitrate er ...... 90 5CMX5CM...... 233 lamotrigine starter kit-blue isotretinoin ...... 265 KERYDIN...... 262 ...... 101, 106 isoxsuprine hcl...... 93 KESIMPTA...... 225 lamotrigine starter kit-green isradipine...... 86, 87 ketoconazole ...... 23, 248 ...... 101, 106 ISTALOL...... 155 ketodan...... 248 lamotrigine starter kit- ISTURISA...... 229, 230 KETONE TEST ...... 141 orange...... 101, 106 itraconazole...... 23 KETOPHENE RAPIDPAQ...... 262 LAMPIT...... 21 ivermectin...... 18, 262 KETOROLAC LANOXIN...... 75, 82 jaimiess...... 180, 190, 201 TROMETHAMINE ...... 128, 262 lansoprazole...... 170 JAKAFI...... 41 ketorolac tromethamine128, 160 lanthanum carbonate ....144, 212 JANSSEN COVID-19 KETOSTIX...... 141 LANTUS SOLOSTAR ...... 197 VACCINE...... 49 KEVEYIS...... 216 LANTUS U-100 VIAL...... 197 jantoven...... 62 KEVZARA...... 220 lapatinib ditosylate ...... 41 JARDIANCE...... 208 KINERET...... 220, 225 larin 1.5/30...... 180, 190, 202 jasmiel...... 180, 190, 201 KISQALI...... 41 larin 1/20...... 180, 190, 202 jencycla...... 180, 201 KISQALI FEMARA...... 41, 175 larin 24 fe...... 180, 190, 202 JENTADUETO ...... 176, 185 KLARON...... 244 larin fe 1.5/30...... 180, 190, 202 JENTADUETO XR...... 177, 185 klor-con...... 145 larin fe 1/20...... 180, 190, 202 jinteli...... 190, 201 klor-con 10...... 145 larissia...... 181, 190, 202 JIVI...... 66 klor-con m10...... 145 LASIX...... 89, 143 jolessa...... 180, 190, 201 klor-con m15...... 145 LASTACAFT...... 14, 151 JORNAY PM...... 131 klor-con m20...... 145 latanoprost...... 161 JUBLIA...... 248 klor-con/ef...... 145 LATUDA...... 111 juleber...... 180, 190, 201 KOATE...... 66 layolis fe...... 181, 190, 202 JULUCA...... 26, 27 KOATE-DVI...... 66 LAZANDA...... 123 junel 1.5/30...... 180, 190, 201 KOGENATE FS...... 66 L-CYSTINE...... 143 junel 1/20...... 180, 190, 201 KOMBIGLYZE XR...... 177, 185 LEDIPASVIR-SOFOSBUVIR junel fe 1.5/30...... 180, 190, 201 KORLYM...... 175 ...... 24, 25 junel fe 1/20...... 180, 190, 201 KOSELUGO...... 41 leena...... 181, 190, 202 junel fe 24...... 180, 190, 201 KOVALTRY...... 66 leflunomide...... 220, 225, 228 JUXTAPID...... 75 K-PHOS...... 145 LENVIMA...... 41 JYNARQUE...... 149 K-PHOS NO 2...... 142 lessina...... 181, 190, 202 K-PHOS-NEUTRAL...... 145 letrozole...... 41, 176 k-prime...... 145 lets...... 50, 211

286 leucovorin calcium...... 212, 273 lithium carbonate ...... 106 LYUMJEV KWIKPEN...... 207 LEUKERAN...... 42 lithium carbonate er ...... 106 LYUMJEV VIAL...... 207 LEUKINE...... 64 LITHOBID...... 106 lyza...... 181, 203 leuprolide acetate...... 42, 195 LITHOSTAT...... 142 MACROBID...... 36 levalbuterol hcl...... 60, 240 LIVALO...... 89 MACRODANTIN...... 36 LEVALBUTEROL HFA ...... 60, 240 LO LOESTRIN FE ...181, 191, 202 mafenide acetate...... 261 LEVBID...... 52 LOESTRIN 1.5/30 (21) MALARONE...... 19 levetiracetam...... 101 ...... 181, 191, 202 malathion...... 262 levetiracetam er...... 101 LOESTRIN 1/20 (21) MARINOL...... 163 levobunolol hcl ...... 155 ...... 181, 191, 202 marlissa...... 181, 191, 203 levocarnitine...... 230 LOESTRIN FE 1.5/30 MARPLAN...... 120 levocarnitine sf...... 230 ...... 181, 191, 202 MATULANE ...... 42 levocetirizine lojaimiess...... 181, 191, 203 matzim la...... 79, 80, 85, 93 dihydrochloride ...... 15 LOKELMA ...... 144 MAVENCLAD ...... 228 levofloxacin...... 22, 34, 152 LOMAIRA...... 94 MAVYRET...... 25, 26 levonest...... 181, 190, 202 LOMOTIL...... 52, 163 MAXIDEX...... 157 levonorgest-eth est & eth est LONSURF...... 42 MAXITROL...... 152, 153, 157 ...... 181, 190, 202 LOPID...... 88 maxi-tuss ac...... 235, 237 levonorgest-eth estrad 91- lopinavir-ritonavir ...... 30 MAXZIDE...... 145, 148 day...... 181, 190, 202 LOPRESSOR...... 61, 76, 78, 83 MAXZIDE-25...... 145, 148 levonorgestrel...... 181, 202 LOPROX...... 257, 265 MAYZENT...... 225 levonorgestrel-ethinyl estrad lorazepam...... 114, 115 me/naphos/mb/hyo1 . 36, 53, 230 ...... 181, 191, 202 lorazepam intensol ...... 114, 115 meclofenamate sodium ...... 128 levonorg-eth estrad triphasic LORBRENA ...... 42 MEDERMA SPF 30...... 265 ...... 181, 191, 202 LORTAB ...... 97, 123 MEDROL...... 173 levora 0.15/30 (28). 181, 191, 202 loryna...... 181, 191, 203 medroxyprogesterone levorphanol tartrate ...... 123 LORZONE...... 55 acetate...... 182, 203 levo-t...... 210 losartan potassium ...... 72, 73 mefenamic acid...... 128 LEVOTHYROXINE SODIUM.. 210 losartan potassium-hctz .73, 148 mefloquine hcl ...... 19 levothyroxine sodium ...... 211 LOSEASONIQUE... 181, 191, 203 megestrol acetate...... 42, 203 levoxyl...... 211 LOTEMAX ...... 157 MEKINIST...... 42 LEVSIN...... 52 LOTEMAX SM ...... 157 MEKTOVI...... 42 LEVSIN/SL...... 52 LOTENSIN...... 74, 75 meloxicam...... 128 LEVULAN KERASTICK...... 265 LOTENSIN HCT ...... 75, 148 melphalan...... 42 LEXIVA...... 30 loteprednol etabonate ...... 157 memantine hcl...... 117 LIALDA...... 164 lovastatin...... 89 memantine hcl er ...... 117 lidocaine...... 247 low-ogestrel...... 181, 191, 203 MENACTRA ...... 49 lidocaine hcl...... 161, 247 loxapine succinate ...... 109 MENEST...... 191, 215 lidocaine hcl lo-zumandimine .....181, 191, 203 MENOSTAR ...... 191, 215 urethral/mucosal...... 247 LUBIPROSTONE...... 168 MENQUADFI...... 49 lidocaine viscous hcl...... 161 LUCEMYRA...... 51 MENTAX ...... 250 lidocaine-prilocaine ...... 247 LUGOLS STRONG IODINE....260 MENVEO...... 49 LIDTOPIC MAX...... 247 LULICONAZOLE...... 248 meperidine hcl...... 123 lillow...... 181, 191, 202 LUMAKRAS...... 42 MEPHYTON...... 212, 276 lindane...... 262 LUMIGAN...... 161 meprobamate...... 110 linezolid...... 33 LUPKYNIS...... 228 mercaptopurine...... 42, 228 LINZESS...... 168 lutera...... 181, 191, 203 merzee...... 182, 191, 203 liothyronine sodium ...... 211 LUZU...... 249 mesalamine...... 164 LIPOFEN...... 88 lyleq...... 181, 203 mesalamine-cleanser...... 164 lisinopril...... 74 LYNPARZA ...... 42 MESNEX...... 232 lisinopril- LYRICA...... 101, 102, 119 MESTINON...... 58 hydrochlorothiazide ...... 74, 148 LYSODREN...... 42 metaxalone...... 55 L-ISOLEUCINE...... 143 LYSTEDA...... 66 metformin hcl ...... 177

287 metformin hcl er ...... 177 microgestin fe 1.5/30 MOXEZA...... 153 methadone hcl ...... 123 ...... 182, 191, 203 moxifloxacin hcl...... 22, 34, 153 methadone hcl intensol ...... 123 microgestin fe 1/20182, 191, 203 moxifloxacin hcl (2x day) ..... 153 methadose ...... 123 MICROLET NEXT LANCING MOZOBIL...... 64 methadose sugar-free ...... 123 DEVICE...... 139 MS CONTIN...... 124 methamphetamine hcl ...... 95 midazolam hcl...... 115 MUCOSITISRX...... 160 methazolamide ...... 81, 156 MIDAZOLAM+SYRSPEND SF MULPLETA ...... 64 methenamine hippurate ...... 36 ...... 115 MULTAQ...... 84 methenamine mandelate ...... 36 midodrine hcl ...... 51 multi-vit/iron/fluoride methergine...... 233 MIGERGOT...... 57, 108, 131 ...... 69, 216, 269 methimazole ...... 176 miglitol...... 174 multivitamin/fluoride .....216, 269 METHITEST ...... 175 miglustat...... 230 multi-vitamin/fluoride ... 216, 269 methocarbamol ...... 55 mili...... 182, 191, 203 multi-vitamin/fluoride/iron methotrexate ... 42, 220, 225, 228 MILLIPRED...... 173 ...... 69, 216, 269 methotrexate sodium mimvey...... 192, 203 mupirocin...... 244 ...... 42, 220, 225, 228 mineral oil heavy...... 165 mupirocin calcium...... 244 methotrexate sodium (pf) MINIPRESS...... 57, 71, 72 MUSE...... 93 ...... 42, 220, 225, 228 minitran...... 90 MYALEPT...... 197 methoxsalen rapid ...... 262 minocycline hcl...... 19, 20, 35 MYAMBUTOL ...... 22 methscopolamine bromide .... 53 minoxidil...... 87 MYCOBUTIN...... 22, 34 methyl salicylate...... 249 MIRAPEX...... 121 mycophenolate mofetil ...... 228 methyldopa ...... 51, 82 MIRCETTE ...... 182, 192, 203 mycophenolate sodium ...... 228 methylergonovine maleate ...233 mirtazapine ...... 104 MYDAYIS...... 95 METHYLIN...... 131 MIRVASO...... 265 MYLERAN...... 42 methylphenidate hcl ...... 131 misoprostol ...... 169 myorisan...... 265 methylphenidate hcl er ...... 131 MITIGARE...... 213 MYRBETRIQ...... 269 methylphenidate hcl er (cd) . 131 MITOSOL...... 153 MYSOLINE...... 112 methylphenidate hcl er (la) .. 131 M-M-R II...... 49 MYTESI...... 163 methylphenidate hcl er (xr) .. 131 M-NATAL PLUS ...... 69, 269, 273 nabumetone ...... 128 methylprednisolone ...... 173 MOBIC...... 128 nadolol...... 56, 77, 78 methyltestosterone ...... 175 modafinil ...... 136 nafrinse...... 217 metoclopramide hcl ...... 169 MODERNA COVID-19 NAFRINSE DAILY metolazone ...... 92, 149 VACCINE...... 49 ACIDULATED...... 137, 217 metoprolol succinate er moexipril hcl...... 74, 75 NAFRINSE DAILY/NEUTRAL.217 ...... 61, 76, 78, 84 molindone hcl ...... 109 nafrinse drops...... 217 metoprolol tartrate 61, 76, 78, 84 mometasone furoate NAFRINSE WEEKLY...... 217 metoprolol- ...... 157, 173, 238, 254 naftifine hcl...... 242 hydrochlorothiazide ...... 76, 148 mondoxyne nl ...... 20, 35 NAFTIN...... 242 METROCREAM...... 244 mono-linyah ...... 182, 192, 203 naloxone hcl...... 125, 213 METROLOTION ...... 244 MONONINE ...... 66 naltrexone hcl...... 125, 212, 213 metronidazole ....17, 21, 165, 244 monsels ferric subsulfate ...... 66 NAMENDA TITRATION PAK ..117 METRONIDAZOLE montelukast sodium ...... 238 NAMZARIC...... 58, 117 BENZO+SYRSPEND ..17, 21, 165 MONUROL...... 36 naproxen...... 108, 128, 213, 214 metyrosine...... 230 morgidox...... 20, 35 naproxen sodium .. 108, 129, 214 mexiletine hcl...... 83 MORGIDOX...... 35, 265 naproxen sodium er MIACALCIN...... 176, 215 morphine sulfate ...... 124 ...... 108, 128, 214 mibelas 24 fe...... 182, 191, 203 morphine sulfate naratriptan hcl...... 133 miconazole 3 ...... 249 (concentrate)...... 123 NARCAN...... 126 MICONAZOLE-ZINC OXIDE- morphine sulfate er ...... 123, 124 NARDIL...... 120 PETROLAT...... 248, 249, 257 morphine sulfate er beads ... 123 NASCOBAL...... 71, 273 microgestin 1.5/30.182, 191, 203 MOTEGRITY...... 168 NATACYN...... 154 microgestin 1/20....182, 191, 203 MOTOFEN...... 53, 163 NATAZIA...... 182, 192, 203 microgestin 24 fe.. 182, 191, 203 MOVIPREP...... 165, 275 nateglinide...... 197

288 NATPARA ...... 197, 214 NICOTROL NS ...... 55 NOVOFINE AUTOCOVER NATURE-THROID...... 211 nifedipine ...... 86, 87, 93 PEN NEEDLE ...... 139 NAYZILAM...... 114 nifedipine er...... 86, 87, 93 NOVOFINE PEN NEEDLE ..... 139 NEBUPENT ...... 21 nifedipine er osmotic release NOVOFINE PLUS PEN necon 0.5/35 (28)... 182, 192, 203 ...... 86, 87, 93 NEEDLE ...... 140 nefazodone hcl ...... 135 nikki...... 182, 192, 204 NOVOPEN ECHO...... 140 neomycin sulfate ...... 17 NILANDRON...... 42 NOVOSEVEN RT...... 67 neomycin-bacitracin zn- nilutamide ...... 42 NOVOTWIST PEN NEEDLE .. 140 polymyx...... 153 nimodipine...... 86, 87, 93 NOXAFIL...... 23 neomycin-polymyxin- NINLARO ...... 43 NP #2 DRUG PREPARATION dexameth...... 153, 157 nisoldipine er...... 86, 87 KIT neomycin-polymyxin- nitazoxanide ...... 21 51, 82, 97, 124, 129, 136, 247, gramicidin...... 153 NITRO-BID...... 90 262, 265 neomycin-polymyxin-hc NITRO-DUR...... 90 np thyroid...... 211 ...... 153, 158 nitrofurantoin ...... 36 NUBEQA...... 43 NEONATAL + DHA nitrofurantoin macrocrystal ... 36 NUCALA...... 234 ...... 69, 146, 230, 269, 273 nitrofurantoin monohydrate NUCORT...... 254 NEONATAL 19 ...... 269 macrocrystals...... 36 NUCYNTA ...... 124 NEONATAL COMPLETE nitroglycerin...... 90 NUCYNTA ER ...... 124 ...... 69, 269, 273 NITROMIST...... 91 NUEDEXTA...... 117 NEONATAL FE ...... 69, 269, 273 NITROSTAT ...... 91 NULEV...... 53 NEONATAL PLUS .... 69, 269, 273 NITRO-TIME ...... 91 NULYTELY LEMON-LIME ...... 165 neo-polycin ...... 153 nizatidine...... 14, 169 NUPLAZID...... 111 neo-polycin hc ...... 153, 158 NOCDURNA...... 66, 198 NUTRASEB...... 258 NEO-SYNALAR...... 244, 249, 254 nolix...... 254 NUTRIDOX...... 35, 230, 276 NERLYNX ...... 42 nora-be...... 182, 204 NUTROPIN AQ NUSPIN 10 NESINA...... 185 norethin ace-eth estrad-fe ...... 198, 209 NESTABS ...... 69, 270, 273 ...... 182, 192, 204 NUTROPIN AQ NUSPIN 20 neuac...... 244, 261 norethindrone ...... 182, 204 ...... 198, 209 NEUAC...... 244, 250, 261 norethindrone acetate ...... 204 NUTROPIN AQ NUSPIN 5 NEULASTA ...... 64 norethindrone acet-ethinyl ...... 198, 209 NEUPRO...... 121 est...... 182, 192, 204 NUVAIL...... 265 NEURAPTINE...... 97 norethindrone-eth estradiol NUVARING...... 183, 192, 204 NEURONTIN...... 97, 102 ...... 192, 204 NUVESSA...... 17, 244 NEVANAC...... 160 norethin-eth estradiol-fe NUWIQ...... 67 nevirapine...... 27 ...... 182, 192, 204 NUZYRA...... 17 nevirapine er...... 27 norgestimate-eth estradiol nyamyc...... 262 NEXAVAR...... 42 ...... 182, 192, 204 nylia 7/7/7...... 183, 192, 204 NEXIUM...... 170 norgestimate-ethinyl NYMALIZE...... 86, 87, 93 NEXLETOL ...... 75 estradiol triphasic. 182, 192, 204 nymyo...... 183, 192, 204 NEXLIZET...... 75, 82 norlyda...... 183, 204 nystatin...... 33, 262 NEXTSTELLIS ...... 182, 192, 204 norlyroc...... 183, 204 nystatin-triamcinolone . 255, 262 niacin er NORPACE...... 82 nystop...... 262 (antihyperlipidemic) ...... 75 NORPACE CR...... 82 OCALIVA...... 168 NIASPAN...... 76 NORPRAMIN...... 136 ocella...... 183, 192, 204 nicardipine hcl...... 86, 87, 93 nortrel 0.5/35 (28).. 183, 192, 204 octreotide acetate...... 168, 208 NICORETTE ...... 54 nortrel 1/35 (21)..... 183, 192, 204 OCUFLOX...... 153 nicotine polacrilex...... 55 nortrel 1/35 (28)..... 183, 192, 204 ODACTRA...... 46 nicotine polacrilex mini...... 55 nortrel 7/7/7...... 183, 192, 204 ODEFSEY...... 27, 29 nicotine step 1 ...... 55 nortriptyline hcl...... 136 ODOMZO...... 43 nicotine step 2 ...... 55 NORVIR...... 30 OFEV...... 234 nicotine step 3 ...... 55 NOURIANZ...... 117 ofloxacin...... 34, 153 NICOTROL...... 55 NOVOEIGHT...... 67 olanzapine...... 106, 111

289 olanzapine-fluoxetine hcl ORENCIA CLICKJECT... 221, 225 paroxetine hcl...... 134 ...... 111, 134 ORENITRAM...... 241 paroxetine hcl er...... 134 olmesartan medoxomil .....72, 73 ORFADIN...... 230 paroxetine mesylate...... 134 olmesartan medoxomil-hctz ORGOVYX...... 43, 176 PASER...... 22 ...... 73, 148 ORIAHNN...... 176, 192, 204 PATANASE...... 14, 151 olmesartan-amlodipine-hctz ORILISSA...... 176 PAXIL...... 134 ...... 73, 86, 148 ORKAMBI...... 236 PCP 100...... 146, 165, 169, 257 olopatadine hcl ...... 14, 151 orphenadrine citrate er .....61, 99 PEDIAPRED...... 173 OLUMIANT...... 220, 221 orphenadrine-asa-caffeine PEDVAX HIB...... 49 OMECLAMOX-PAK.... 18, 32, 170 ...... 61, 131, 132 peg 3350-kcl-na bicarb-nacl .165 omega-3-acid ethyl esters ...... 76 orsythia...... 183, 193, 204 peg-3350/electrolytes...... 166 omeprazole ...... 170 oscimin...... 53 peg- OMEPRAZOLE+SYRSPEND oscimin sr...... 53 3350/electrolytes/ascorbat SF ALKA...... 170 oseltamivir phosphate ...... 31 ...... 166, 275 OMNARIS...... 158 OSENI...... 185, 210 PEGASYS...... 31 ondansetron hcl ...... 162 OSMOPREP...... 165 peg-kcl-nacl-nasulf-na asc-c ondansetron odt ...... 162 OSPHENA...... 186 ...... 166, 275 ONE VITE WOMENS PLUS OTEZLA ...... 221, 226, 266 peg-prep...... 166 ...... 69, 270, 273 OTOVEL...... 153, 158 PEMAZYRE...... 43 ONETOUCH DELICA OVACE PLUS...... 244 penicillamine...... 171, 221 LANCING DEVICE...... 140 OVACE PLUS WASH...... 244 penicillin v potassium ...... 31 ONETOUCH DELICA PLUS OVACE WASH...... 244 pentamidine isethionate ...... 21 LANCING DEVICE...... 140 OVIDE...... 262 pentazocine-naloxone hcl ONETOUCH ULTRA ...... 141 oxandrolone ...... 175 ...... 126, 127 ONETOUCH ULTRA 2...... 140 oxaprozin...... 129 pentoxifylline er ...... 64 ONETOUCH ULTRA MINI ...... 140 oxazepam...... 115 PERFOROMIST...... 60, 240 ONETOUCH VERIO...... 140, 141 OXBRYTA...... 62 PERIDEX...... 159, 261 ONETOUCH VERIO FLEX oxcarbazepine...... 102 perindopril erbumine ...... 74, 75 SYSTEM KIT W/DEVICE...... 140 OXERVATE...... 160 periogard...... 159, 261 ONETOUCH VERIO IQ oxiconazole nitrate ...... 249 permethrin...... 262 SYSTEM...... 140 OXISTAT...... 249 perphenazine...... 129 ONETOUCH VERIO oxybutynin chloride ...... 268 perphenazine-amitriptyline REFLECT...... 140 oxybutynin chloride er ...... 268 ...... 129, 136 ONETOUCH VERIO SYNC oxycodone hcl ...... 124 PERTZYE...... 150, 166 SYSTEM KIT W/DEVICE...... 140 oxycodone-acetaminophen PEXEVA...... 134, 135 ONEVITE...... 146, 270, 273 ...... 97, 124 PFIZER-BIONTECH COVID- ONEXTON...... 244, 261 OXYCODONE- 19 VACC...... 49 ONFI...... 114, 115 ACETAMINOPHEN...... 97, 124 phenazo...... 247 ONGLYZA ...... 185 oxymorphone hcl ...... 124 phenazopyridine hcl ...... 247 ONUREG...... 43 oxymorphone hcl er ...... 124 phendimetrazine tartrate ...... 94 ONZETRA XSAIL...... 133 OZEMPIC...... 196 phendimetrazine tartrate er ....94 opium...... 163 OZOBAX...... 56 phenelzine sulfate ...... 120 OPSUMIT...... 241 PACERONE...... 84 phenobarbital ...... 112, 113 ORACIT...... 142 PALFORZIA...... 47 phenoxybenzamine hcl .... 57, 89 ORALAIR...... 47 paliperidone er...... 111 phentermine hcl...... 94 ORALAIR ADULT STARTER PALYNZIQ...... 150 phenylephrine hcl...... 161, 162 PACK...... 46 PANCREAZE...... 150, 166 PHENYTEK...... 83, 119 ORALAIR CHILDRENS PANDEL...... 255 phenytoin...... 83, 120 STARTER PACK ...... 47 PANRETIN...... 266 phenytoin infatabs ...... 83, 119 oralone...... 255 pantoprazole sodium ...... 170 phenytoin sodium extended ORAPRED ODT...... 173 paricalcitol...... 276 ...... 83, 120 ORAVIG...... 249 PARNATE ...... 120 PHEXXI...... 232 ORENCIA...... 221, 225, 226 paromomycin sulfate ...... 17 philith...... 183, 193, 205

290 PHOSLYRA...... 144, 146 prasugrel hcl...... 71 prevalite...... 79 PHOSPHA 250 NEUTRAL...... 146 pravastatin sodium ...... 89 PREVIDENT...... 217 PHOSPHASAL...... 36, 53, 97, 230 praziquantel...... 18 PREVIDENT 5000 BOOSTER phosphorous ...... 146 prazosin hcl...... 57, 72 PLUS...... 217 phospho-trin 250 neutral ...... 146 PRECOSE...... 174 PREVIDENT 5000 DRY phytonadione ...... 213, 276 PRED MILD...... 158 MOUTH...... 217 PIFELTRO...... 27 PRED-G...... 153, 158 PREVIDENT 5000 ENAMEL pilocarpine hcl...... 58, 161 PRED-G S.O.P...... 153, 158 PROTECT...... 137, 217 pimecrolimus...... 228, 266 prednicarbate...... 255 PREVIDENT 5000 ORTHO pimozide ...... 109 prednisolone ...... 173 DEFENSE...... 217 pimtrea...... 183, 193, 205 prednisolone acetate ...... 158 PREVIDENT 5000 PLUS...... 217 pindolol ...... 56, 77, 78, 84 prednisolone sodium PREVIDENT 5000 SENSITIVE pioglitazone hcl ...... 210 phosphate ...... 158, 173 ...... 137, 217 pioglitazone hcl-glimepiride 210 prednisone...... 173 previfem...... 183, 193, 205 pioglitazone hcl-metformin prednisone intensol ...... 173 PREVNAR 13...... 50 hcl...... 177, 210 PREFEST...... 193, 205 PREVYMIS...... 22 PIQRAY...... 43 pregabalin...... 102, 119 PREZCOBIX...... 30, 230 pirmella 1/35...... 183, 193, 205 pregabalin er...... 97 PREZISTA...... 30 pirmella 7/7/7...... 183, 193, 205 PREMARIN...... 193, 215 PRIFTIN...... 22, 34 piroxicam...... 129 PREMESISRX 146, 230, 270, 273 PRILOSEC...... 170 PLAN B ONE-STEP ...... 183, 205 premium lidocaine...... 247 PRIMACARE.....70, 230, 271, 274 PLEGRIDY...... 226 PREMPHASE...... 193, 205 primaquine phosphate ...... 20 PLEGRIDY STARTER PACK. 226 PREMPRO...... 193, 205 primidone...... 112 PLENVU...... 166, 275 PRENAISSANCE PRIMSOL...... 36 PLEXION...... 245, 258 ...... 69, 166, 230, 270, 273 PRINIVIL...... 74, 75 PLEXION CLEANSER.... 245, 258 prenatal...... 69, 270, 273 probenecid...... 149, 214 PLEXION CLEANSING prenatal plus iron....69, 270, 273 PROCENTRA...... 95 CLOTH ...... 245, 258 prenatal vitamin plus low prochlorperazine...... 129, 163 PNEUMOVAX 23...... 50 iron...... 69, 270, 273 prochlorperazine maleate podocon...... 266 PRENATE ...... 146, 270, 273 ...... 129, 163 podofilox ...... 266 PRENATE DHA PROCORT...... 247, 255 polycin...... 153 ...... 69, 146, 230, 270, 273 PROCTOCORT...... 255 polymyxin b-trimethoprim ....153 PRENATE ELITE ...... 69, 270, 273 PROCTOFOAM HC...... 247, 255 POLYTRIM...... 153 PRENATE ENHANCE procto-med hc ...... 255 POLY-VI-FLOR...... 217, 270 ...... 69, 146, 230, 270, 273 procto-pak...... 255 POLY-VI-FLOR/IRON PRENATE ESSENTIAL proctozone-hc ...... 255 ...... 69, 217, 270 ...... 69, 146, 230, 270, 273 PROCYSBI...... 231 POMALYST...... 43, 226 PRENATE MINI PROFILNINE...... 67 portia-28...... 183, 193, 205 ...... 70, 146, 230, 270, 273 progesterone ...... 205 posaconazole ...... 23 PRENATE PIXIE PROGESTERONE POTABA...... 273 ...... 70, 146, 230, 270, 274 MICRONIZED...... 205 potassium chloride ...... 146 PRENATE RESTORE PROGRAF...... 228 potassium chloride crys er .. 146 ...... 70, 147, 230, 270, 274 PROLATE...... 97, 125 potassium chloride er ...... 146 PRENATVITE COMPLETE PROLENSA...... 160 potassium citrate er ...... 142 ...... 70, 147, 270, 274 PROMACTA...... 64 potassium citrate-citric acid 142 PRENATVITE PLUS promethazine hcl PRADAXA...... 63 ...... 70, 147, 270, 274 ...... 13, 14, 110, 163, 237 pramipexole dihydrochloride PRENATVITE RX promethazine vc ...... 15, 51 ...... 121 ...... 70, 147, 271, 274 promethazine vc/codeine pramosone...... 247, 255 PREPIDIL...... 233 ...... 15, 51, 235 PRAMOSONE...... 247, 255 preplus...... 70, 271, 274 promethazine-codeine ....15, 235 PRAMOTIC...... 159, 161 PRETAB...... 70, 271, 274 promethazine-dm ...... 15, 235 pramox...... 247 PRETOMANID...... 22

291 promethazine-phenyleph- quinidine sulfate ...... 20, 82 RHOFADE...... 266 codeine...... 15, 51, 235 quinine sulfate ...... 20 RHOPRESSA...... 162 promethazine-phenylephrine RABEPRAZOLE SODIUM...... 170 ribavirin...... 32 ...... 15, 51 rabeprazole sodium ...... 170 RIDAURA...... 171, 221, 226 promethegan RADIOGARDASE...... 143, 213 rifabutin...... 22, 34 ...... 14, 15, 110, 163, 237 RAGWITEK...... 47 rifampin...... 22, 34 PROMISEB...... 258 raloxifene hcl...... 186, 215 RIFAMPIN+SYRSPEND SF22, 34 propafenone hcl ...... 83 ramelteon...... 110 RILUTEK...... 117 propafenone hcl er ...... 83 ramipril...... 74, 75 riluzole...... 117 proparacaine hcl...... 161 ranolazine er...... 81 rimantadine hcl ...... 17 propranolol hcl RAPAMUNE...... 228 RINVOQ...... 222 ...... 56, 57, 77, 78, 84, 108 rasagiline mesylate...... 120 risedronate sodium...... 215, 216 propranolol hcl er RASUVO...... 221 risperidone...... 106, 111, 112 ...... 56, 77, 78, 84, 108 RAVICTI...... 142 RITALIN...... 131 propylthiouracil ...... 176 RAZADYNE ER...... 58 ritonavir...... 30 PROSCAR...... 212 REBIF...... 226 rivastigmine...... 58 PROSTIN E2...... 233 REBIF REBIDOSE...... 226 rivastigmine tartrate...... 58 PROTONIX...... 170 REBIF REBIDOSE rivelsa...... 183, 193, 205 protriptyline hcl ...... 136 TITRATION PACK...... 226 RIXUBIS...... 67 PROVERA...... 205 REBIF TITRATION PACK...... 226 rizatriptan benzoate ...... 133 pseudoephedrine- reclipsen...... 183, 193, 205 ROCALTROL...... 276 bromphen-dm ...... 15, 50, 235 RECOMBINATE ...... 67 ROCKLATAN...... 161, 162 PSORCON...... 255 RECOMBIVAX HB...... 50 ropinirole hcl...... 121 PULMICORT FLEXHALER RECOTHROM...... 67 ropinirole hcl er...... 121 ...... 173, 239 RECOTHROM SPRAY KIT...... 67 rosadan...... 245 PULMOZYME...... 150, 238 RECTIV...... 266 ROSADAN...... 245 PURIXAN...... 43, 228 REGLAN...... 169 rosuvastatin calcium...... 89 PYLERA...... 19, 21, 35, 163, 164 REGRANEX...... 266 ROWASA...... 164 pyrazinamide...... 22 RELENZA DISKHALER...... 31 roweepra...... 102 PYRIDIUM...... 247 RELISTOR...... 126, 168 ROZLYTREK...... 43 pyridostigmine bromide ...... 58 RELNATE DHA .70, 231, 271, 274 RUBRACA...... 43 pyridostigmine bromide er .....58 REMERON...... 104 RUCONEST...... 218 pyrimethamine ...... 20 REMERON SOLTAB ...... 104 rufinamide...... 102 PYROGALLIC ACID233, 258, 266 REMIGEN...... 266 RUKOBIA...... 26 QBRELIS...... 75 RENAGEL...... 144, 213 RUZURGI...... 231 QINLOCK...... 43 RENVELA...... 144, 213 RYBELSUS...... 196 QMIIZ ODT...... 129 repaglinide...... 197 RYDAPT...... 43 QNASL...... 158, 239 REPATHA...... 91 SABRIL...... 102 QNASL CHILDRENS ...... 158, 238 REPATHA PUSHTRONEX SALAGEN...... 58 QSYMIA...... 98 SYSTEM...... 91 salicylic acid...... 258 QUALAQUIN...... 20 REPATHA SURECLICK...... 91 salimez...... 258 QUDEXY XR...... 102 RESTASIS...... 159 SALIVAMAX...... 160 QUESTRAN...... 79 RESTASIS MULTIDOSE...... 159 salsalate...... 132 QUESTRAN LIGHT...... 79 RESTORIL...... 115 SALVAX DUO PLUS...... 249, 258 quetiapine fumarate ...... 106, 111 RETACRIT...... 61, 62, 64 SAMSCA...... 149 quetiapine fumarate er . 106, 111 RETEVMO...... 43 SANDIMMUNE...... 222, 226, 228 QUFLORA PEDIATRIC.. 217, 271 RETIN-A MICRO PUMP...... 250 SANDOSTATIN...... 168, 208 QUILLICHEW ER...... 131 RETROVIR...... 29 SANTYL...... 150, 266 QUILLIVANT XR...... 131 REVLIMID...... 43, 226 SAPHRIS...... 106, 107, 112 quinapril hcl...... 74, 75 REXULTI...... 111 sapropterin dihydrochloride 231 quinapril- REYATAZ...... 30 SAVAYSA...... 63 hydrochlorothiazide ...... 75, 148 REYVOW...... 133 SAVELLA...... 119, 133 quinidine gluconate er ...... 20, 82 REZUROCK...... 231

292 SAVELLA TITRATION PACK sodium fluoride 5000 enamel STENDRA ...... 91 ...... 119, 133 ...... 137, 218 STIMATE...... 67, 198 SAXENDA...... 196 sodium fluoride 5000 plus ....218 STIVARGA...... 44 SCALACORT DK...... 255, 258 sodium fluoride 5000 ppm ... 218 STRATA CTX ...... 266 SCARCIN...... 266 sodium fluoride 5000 STRATA XRT ...... 266 scopolamine...... 53, 163 sensitive...... 137, 218 STRATTERA ...... 117 SELECT-OB...... 70, 271, 274 sodium phenylbutyrate 142, 143 STRENSIQ...... 150 selegiline hcl...... 120 sodium polystyrene STRIBILD...... 27, 29, 231 selenium sulfide ...... 259, 261 sulfonate ...... 144, 213 STRIVERDI RESPIMAT... 60, 240 SELZENTRY ...... 26 sodium sulfacetamide ...... 245 STROMECTOL ...... 18 SEREVENT DISKUS...... 60, 240 sodium sulfacetamide wash 245 SUBOXONE...... 126, 127 SERNIVO...... 255 SODIUM SULFACETAMIDE- subvenite...... 102, 107 SEROQUEL XR...... 107, 112 BAKUCHIOL...... 231, 245 subvenite starter kit-blue SEROSTIM...... 198, 209 SOFOSBUVIR-VELPATASVIR ...... 102, 107 sertraline hcl...... 135 ...... 24, 26 subvenite starter kit-green setlakin...... 183, 193, 205 solifenacin succinate...... 268 ...... 102, 107 sevelamer carbonate.... 144, 213 SOLIQUA...... 196, 197 subvenite starter kit-orange sevelamer hcl...... 144, 213 SOLOSEC...... 21 ...... 102, 107 sevoflurane...... 120 SOLTAMOX ...... 44, 186 SUCRAID...... 150 sf...... 218 SOMATULINE DEPOT...... 209 sucralfate...... 169 sf 5000 plus...... 218 SOMAVERT...... 209 SULAR...... 86, 87 SFROWASA...... 164 SOOLANTRA...... 263 SULCONAZOLE NITRATE .....249 sharobel...... 183, 205 SORILUX...... 266 sulfacetamide sodium SHARPS CONTAINER...... 140 sotalol hcl...... 57, 77, 78, 84 ...... 153, 154, 245 SHINGRIX...... 50 sotalol hcl (af)...... 57, 77, 78, 84 sulfacetamide sodium (acne) SIGNIFOR...... 209 SOTYLIZE...... 57, 77, 78, 84 ...... 245 sildenafil citrate...... 91, 241, 268 SOVALDI...... 25 sulfacetamide sodium-sulfur SILENOR...... 136 spinosad...... 263 ...... 245, 259 silodosin...... 58 SPIRIVA HANDIHALER....53, 234 sulfacetamide sod-sulfur SILVADENE...... 261 SPIRIVA RESPIMAT...... 53, 234 wash...... 245, 259 silver nitrate...... 159 spironolactone ...... 90, 92, 145 sulfacetamide-prednisolone silver sulfadiazine...... 261 spironolactone-hctz ...... 90, 148 ...... 154, 158 SIMBRINZA...... 151, 156 SPORANOX...... 23 sulfacetamide-sulfur in urea simliya...... 183, 193, 205 SPORANOX PULSEPAK...... 23 ...... 245, 259 simpesse...... 183, 193, 205 SPRAVATO (56 MG DOSE)... 104 SULFACLEANSE 8/4...... 246, 259 SIMPONI...... 168, 222, 227 SPRAVATO (84 MG DOSE)... 104 sulfadiazine...... 34 simvastatin...... 89 sprintec 28...... 183, 193, 205 sulfamethoxazole- SINEMET...... 118 SPRITAM...... 102 trimethoprim...... 21, 34, 36 SINGULAIR...... 238 SPRIX...... 129 sulfamez wash...... 246, 259 sirolimus...... 228 SPRYCEL...... 44 SULFAMYLON...... 261 SIRTURO...... 22 sps...... 144, 213 sulfasalazine....34, 164, 222, 227 SIVEXTRO...... 33 sronyx...... 183, 193, 205 sulfatrim pediatric...... 21, 34, 36 SKYRIZI...... 266 ssd...... 261 SULFURATED LIME...... 263 SKYRIZI (150 MG DOSE)...... 266 SSKI...... 237 sulindac...... 129 SKYRIZI PEN...... 266 sss 10-5...... 245, 259 SUMADAN XLT...... 246, 259, 267 SLYND ...... 183, 205 STALEVO 100...... 116, 118 sumatriptan...... 133 sod citrate-citric acid...... 142 STALEVO 125...... 116, 118 sumatriptan succinate ..133, 134 SODIUM BICARBONATE STALEVO 150...... 116, 118 sumatriptan succinate refill . 133 ...... 162, 165 STALEVO 200...... 116, 118 SUMAXIN...... 246, 259 sodium chloride ...... 238 STALEVO 50...... 116, 118 SUMAXIN CP...... 246, 259 sodium fluoride ...... 218 STALEVO 75...... 116, 119 SUNOSI...... 136 stavudine...... 29 SUPRAX...... 16 STELARA...... 266 SUPREP BOWEL PREP KIT..166

293 SURESTEP PRO HIGH tarina fe 1/20...... 183, 193, 205 THROMBIN-JMI ...... 67 GLUCOSE...... 140 tarina fe 1/20 eq.....183, 193, 205 THROMBIN-JMI EPISTAXIS.... 67 SURESTEP PRO LOW TARKA...... 75, 80 THROMBOGEN...... 67 GLUCOSE...... 140 TASIGNA...... 44 tiadylt er...... 80, 81, 85, 94 SURESTEP PRO NORMAL tavaborole...... 262 tiagabine hcl...... 102 GLUCOSE...... 140 TAVALISSE...... 62 TIAZAC...... 80, 81, 85, 94 SUSTIVA...... 27 tazarotene ...... 267 TIBSOVO...... 44 SUTAB...... 166 TAZAROTENE ...... 267 TIGLUTIK...... 117 SUTENT...... 44 TAZORAC...... 267 TIKOSYN...... 84 syeda...... 183, 193, 205 taztia xt...... 79, 81, 85, 94 tilia fe...... 184, 193, 205 SYMAX DUOTAB...... 53 TAZVERIK...... 44 timolol maleate SYMAX-SL...... 53 TEGRETOL...... 102, 107 ...... 57, 77, 78, 84, 108, 155 SYMAX-SR...... 53 TEGRETOL-XR...... 102, 107 timolol maleate ocudose ...... 155 SYMBICORT...... 60, 173 TEGSEDI...... 214 timolol maleate pf ...... 155 SYMBYAX...... 112, 135 TEKTURNA ...... 92 TIMOPTIC...... 155 SYMDEKO...... 236 TEKTURNA HCT ...... 92, 148 TIMOPTIC OCUDOSE...... 155 SYMFI...... 28, 29 telmisartan...... 72, 73 TIMOPTIC-XE...... 155 SYMFI LO...... 27, 29 telmisartan-amlodipine .....73, 86 tinidazole...... 21 SYMJEPI...... 50, 234 telmisartan-hctz ...... 73, 148 tiopronin...... 231 SYMLINPEN 120 ...... 174 temazepam ...... 115 TIROSINT...... 211 SYMLINPEN 60 ...... 174 TEMOVATE ...... 256 TIROSINT-SOL...... 211 SYMPROIC...... 168 temozolomide ...... 44 TISSEEL...... 267 SYMTUZA...... 29, 30, 231 TENCON...... 97, 113 TIVICAY...... 27 SYNALAR...... 255, 256 TENIVAC...... 48 TIVICAY PD...... 27 SYNALAR (CREAM) ...... 250, 255 tenofovir disoproxil fumarate 29 TIVORBEX...... 129 SYNALAR (OINTMENT) . 250, 255 TEPMETKO ...... 44 tizanidine hcl ...... 55 SYNALAR TS ...... 256, 267 terazosin hcl...... 57, 72 TOBI PODHALER...... 17 SYNAPRYN FUSEPAQ...... 125 terbinafine hcl ...... 17 TOBRADEX...... 154, 158 SYNAREL...... 195 terbutaline sulfate ...... 60, 240 TOBRADEX ST...... 154, 158 SYNDROS...... 163 terconazole ...... 249 tobramycin...... 17, 154 SYNJARDY...... 177, 208 TERIPARATIDE tobramycin-dexamethasone SYNJARDY XR...... 177, 208 (RECOMBINANT) ...... 197, 214 ...... 154, 158 SYNRIBO...... 44 terrell...... 120 TOBREX...... 154 TABLOID...... 44 TESSALON PERLES...... 235 tolbutamide ...... 141, 210 TABRADOL FUSEPAQ...... 55 TESTIM...... 175 tolcapone...... 116 TABRADOL RAPIDPAQ...... 55 testosterone cypionate ...... 175 tolterodine tartrate ...... 268 TABRECTA ...... 44 testosterone enanthate ...... 175 tolterodine tartrate er ...... 268 TACLONEX ...... 256, 267 tetrabenazine...... 136 TOLVAPTAN ...... 149 tacrolimus...... 228, 267 tetracaine hcl...... 161 tolvaptan...... 149 tadalafil...... 91 tetracycline hcl...... 20, 35, 165 TOPAMAX...... 103, 109 tadalafil (pah) ...... 91, 241 TETRIX...... 267 TOPAMAX SPRINKLE....103, 109 TAFINLAR ...... 44 TEXACORT...... 256 TOPICORT...... 256 TAGRISSO...... 44 THALOMID...... 227 topiramate...... 103, 109 TAKHZYRO...... 218 THEO-24...87, 131, 143, 241, 268 topiramate er...... 103 TALZENNA ...... 44 theophylline TOPROL XL...... 61, 77, 78, 84 tamoxifen citrate ...... 44, 186 ...... 88, 132, 143, 242, 269 toremifene citrate...... 44, 186 tamsulosin hcl ...... 58 theophylline er torsemide...... 89, 143 TAPAZOLE...... 176 87, 88, 132, 143, 241, 242, 268, TOSYMRA...... 134 TAPERDEX 12-DAY...... 174 269 TOUJEO MAX SOLOSTAR.... 197 TAPERDEX 6-DAY...... 174 THIOLA...... 231 TOUJEO SOLOSTAR...... 197 TAPERDEX 7-DAY...... 174 THIOLA EC...... 231 tovet...... 256 TARGRETIN...... 44, 267 thioridazine hcl ...... 129 TOVIAZ...... 268 tarina 24 fe...... 183, 193, 205 thiothixene...... 135 TRACLEER...... 241

294 TRADJENTA ...... 185 TRINATE ...... 70, 271, 274 UCERIS...... 174, 256 tramadol hcl...... 125 TRINTELLIX ...... 135 UDAMIN SP...... 147, 271, 274 TRAMADOL HCL ER ...... 125 tri-nymyo...... 184, 194, 206 UKONIQ...... 45 tramadol hcl er ...... 125 TRIPLE COMPLEX FORMULA ULTANE ...... 120 tramadol hcl er (biphasic) .... 125 3 KIT...... 248, 262, 267 ULTRACET...... 97, 125 tramadol-acetaminophen97, 125 TRIPLE PMB...... 154, 158, 160 UMECTA MOUSSE...... 259 trandolapril...... 74, 75 TRIPLE PMK...... 154, 158, 160 UNISTRIP CONTROL...... 141 trandolapril-verapamil hcl er tri-previfem...... 184, 194, 206 unithroid...... 211 ...... 75, 81 tri-sprintec...... 184, 194, 206 UPNEEQ...... 162 tranexamic acid...... 67 TRISTART DHA UPTRAVI...... 241 TRANXENE-T ...... 114, 115 ...... 70, 147, 231, 271, 274 URAMAXIN...... 259 tranylcypromine sulfate ...... 120 TRISTART FREE urea...... 259 travoprost (bak free)...... 161 ...... 70, 147, 231, 271, 274 urea nail...... 259 trazodone hcl ...... 135 TRISTART ONE URELLE...... 37, 53, 98, 231 TRECATOR ...... 22 ...... 70, 147, 231, 271, 274 UREMEZ-40...... 259 TRELEGY ELLIPTA ....53, 60, 174 TRIUMEQ...... 27, 29 URIBEL...... 37, 53, 98, 232 TREMFYA ...... 267 TRI-VI-FLOR URIMAR-T...... 37, 53, 98, 232 tretinoin...... 44, 250 ...... 218, 271, 272, 274, 275, 276 urin ds...... 37, 53, 98, 232 tretinoin microsphere ...... 250 TRI-VI-FLORO URO-458...... 37, 53, 98, 232 tretinoin microsphere pump 250 ...... 218, 271, 272, 274, 275, 276 UROCIT-K 10...... 142 TRETTEN ...... 68 tri-vite/fluoride UROCIT-K 15...... 142 TREXALL ...... 45, 222, 227, 229 ...... 218, 271, 272, 275, 276 UROCIT-K 5...... 142 TREZIX...... 97, 125, 132 trivora (28)...... 184, 194, 206 UROGESIC-BLUE...... 37, 54, 232 tri femynor...... 184, 193, 206 tri-vylibra...... 184, 194, 206 uro-mp...... 37, 54, 98, 232 triamcinolone acetonide ...... 256 tri-vylibra lo...... 184, 194, 206 URSO 250...... 166 triamterene...... 92, 145 trospium chloride ...... 268 URSO FORTE...... 166 triamterene-hctz ...... 145, 148 trospium chloride er ...... 268 ursodiol...... 166 triazolam...... 115 TRUE METRIX LEVEL 1 ...... 140 URSODIOL+SYRSPEND SF..166 TRICARE PRENATAL DHA TRUE METRIX LEVEL 2 ...... 140 USTELL...... 37, 54, 98, 232 ONE...... 70, 166, 231, 271, 274 TRUE METRIX LEVEL 3 ...... 140 UTIRA-C...... 37, 54, 98, 232 TRI-CHLOR...... 231 TRULANCE ...... 168 UTOPIC...... 259 TRICITRASOL...... 62 TRULICITY...... 196 valacyclovir hcl...... 32 tricitrates...... 142 TRUMENBA ...... 50 VALCHLOR...... 267 triderm...... 256 TRUSOPT...... 156 valganciclovir hcl...... 32 TRIDESILON...... 256 TRUVADA...... 29 valproic acid...... 103, 107, 109 trientine hcl...... 171 TUKYSA...... 45 valsartan...... 72, 73 tri-estarylla...... 184, 193, 206 tulana...... 184, 206 valsartan- trifluoperazine hcl ...... 129 TURALIO...... 45 hydrochlorothiazide ...... 73, 149 trifluridine...... 154 TURPENTINE ...... 249 VALTOCO...... 114 trihexyphenidyl hcl ...... 54, 99 TUSSICAPS...... 15, 235 VANCOCIN...... 24 TRIJARDY XR...... 177, 185, 208 TUXARIN ER...... 15, 235 VANCOCIN HCL...... 24 TRIKAFTA...... 236 TUZISTRA XR...... 15, 235 vancomycin hcl...... 24 tri-legest fe...... 184, 193, 206 TWINRIX...... 50 VANCOMYCIN+SYRSPEND TRILEPTAL ...... 103 TWIRLA...... 184, 194, 206 SF...... 24 tri-linyah...... 184, 193, 206 tyblume...... 184, 194, 206 vandazole...... 17, 246 tri-lo-estarylla...... 184, 194, 206 TYBOST...... 231 VAQTA...... 50 tri-lo-marzia ...... 184, 194, 206 tydemy...... 184, 194, 206, 274 vardenafil hcl...... 91 tri-lo-mili...... 184, 194, 206 TYKERB...... 45 VARIVAX...... 50 tri-lo-sprintec ...... 184, 194, 206 TYMLOS ...... 197, 214 VECAMYL...... 89 trimethobenzamide hcl ...... 163 TYVASO...... 241 velivet...... 184, 194, 206 trimethoprim ...... 36 TYVASO REFILL...... 241 VELPHORO...... 144 tri-mili...... 184, 194, 206 TYVASO STARTER...... 241 VELTASSA...... 144 trimipramine maleate...... 136 UBRELVY...... 116 VELTIN...... 246, 250, 267

295 VEMLIDY...... 32 vitamins acd-fluoride XELPROS...... 161 VENCLEXTA ...... 45 ...... 218, 272, 275, 276 XENICAL...... 168 VENCLEXTA STARTING VITATHELY WITH GINGER XENLETA ...... 33 PACK...... 45 ...... 70, 272, 275 XEPI...... 246 VENELEX...... 267 VITRAKVI...... 45 XERMELO...... 163 venlafaxine hcl...... 133 VIVELLE-DOT...... 194, 216 XIFAXAN...... 34 venlafaxine hcl er...... 133 VIZIMPRO...... 45 XIIDRA...... 159 VENTAVIS...... 241 volnea...... 184, 194, 206 XOFLUZA (40 MG DOSE)...... 22 VENTRIXYL...... 147, 271, 274 VONVENDI...... 68 XOFLUZA (80 MG DOSE)...... 22 verapamil hcl...... 80, 81, 85, 94 voriconazole...... 23 XOLEGEL...... 249 verapamil hcl er.....80, 81, 85, 94 VOSEVI...... 25, 26 XOLEGEL COREPAK.....249, 256 VERDESO...... 256 VOTRIENT...... 45 XOLEGEL DUO/HEAD & VEREGEN...... 267 VP FC KIT...... 55, 262, 267 SHOULDERS...... 249, 261 VERELAN...... 80, 81, 85, 94 VP GKL KIT...... 248, 262, 267 XOLEGEL DUO/XOLEX. 249, 261 VERELAN PM...... 80, 81, 85, 94 vp-pnv-dha ...... 70, 232, 272, 275 XOPENEX HFA...... 60, 240 VERSACLOZ...... 112 VRAYLAR...... 112 XOSPATA...... 45 VERZENIO...... 45 VTOL LQ ...... 98, 113, 132 XPOVIO (100 MG ONCE VESICARE...... 268 VUSION...... 248, 249, 257 WEEKLY)...... 45 vestura...... 184, 194, 206 vyfemla...... 184, 194, 206 XPOVIO (40 MG ONCE VFEND...... 23 VYLEESI...... 117 WEEKLY)...... 46 VIBERZI...... 168 vylibra...... 184, 194, 206 XPOVIO (40 MG TWICE VIBRAMYCIN...... 20, 35, 36 VYNDAMAX...... 81, 117 WEEKLY)...... 46 VICTOZA...... 196 VYNDAQEL...... 81 XPOVIO (60 MG ONCE VIEKIRA PAK...... 25, 26 VYTORIN...... 82, 89 WEEKLY)...... 46 vienva...... 184, 194, 206 VYVANSE...... 95, 96 XPOVIO (60 MG TWICE vigabatrin...... 103 WAKIX...... 136 WEEKLY)...... 46 vigadrone ...... 103 warfarin sodium...... 62 XPOVIO (80 MG ONCE VIGAMOX...... 154 WEGOVY...... 196 WEEKLY)...... 46 VIIBRYD...... 135 WELCHOL...... 79, 175 XPOVIO (80 MG TWICE VIIBRYD STARTER PACK..... 135 wera...... 184, 194, 206 WEEKLY)...... 46 VILAMIT MB...... 37, 54, 98, 232 WESTGEL DHA XTAMPZA ER...... 125 VILEVEV MB...... 37, 54, 98, 232 ...... 71, 147, 232, 272, 275 XTANDI ...... 46 VIMPAT...... 103 WESTHROID...... 211 xulane...... 184, 194, 206 VINATE ONE...... 70, 271, 274 WHEAT GERM OIL...... 276 XURIDEN...... 232 VIOKACE...... 150, 167 WIDE-SEAL DIAPHRAGM 60 233 XYNTHA...... 68 viorele...... 184, 194, 206 WIDE-SEAL DIAPHRAGM 65 233 XYNTHA SOLOFUSE...... 68 VIRACEPT...... 30 WIDE-SEAL DIAPHRAGM 70 233 XYOSTED...... 175 VIRAMUNE...... 28 WIDE-SEAL DIAPHRAGM 75 233 XYREM...... 118 VIRAZOLE...... 32 WIDE-SEAL DIAPHRAGM 80 233 XYWAV...... 118 VIREAD...... 29 WIDE-SEAL DIAPHRAGM 85 233 YASMIN 28...... 184, 194, 206 virt-phos 250 neutral ...... 147 WIDE-SEAL DIAPHRAGM 90 233 YAZ...... 185, 194, 207 virtussin ac w/alc...... 235, 237 WIDE-SEAL DIAPHRAGM 95 233 YUPELRI...... 54 VISTARIL...... 14, 110 WILATE...... 68 yuvafem...... 194, 216 VISTOGARD...... 213 WILZIN...... 147 ZACARE...... 249, 261 VITAFOL FE+ WP THYROID...... 211 zaclir cleansing...... 261 ...... 70, 147, 232, 271, 274 wymzya fe...... 184, 194, 206 zafemy...... 185, 195, 207 VITAFOL STRIPS...... 271 XALKORI...... 45 zafirlukast...... 238 VITAFOL-NANO ...... 70, 271, 275 XARELTO...... 63 zaleplon...... 110 VITAFOL-OB+DHA XARELTO STARTER PACK .....63 ZANAFLEX...... 55 ...... 70, 147, 232, 272, 275 XATMEP...... 45, 222, 227, 229 zarah...... 185, 195, 207 vitamin d (ergocalciferol) ..... 276 XCOPRI...... 103 ZARONTIN...... 135 XELJANZ...... 222 ZARXIO...... 64 XELJANZ XR...... 222 ZEBUTAL...... 98, 113, 132

296 ZEJULA...... 46 ZYVOX...... 33 ZELAPAR...... 120, 121 ZELBORAF...... 46 ZELNORM ...... 169 ZEMBRACE SYMTOUCH ...... 134 ZEMPLAR...... 276 zenatane...... 267 ZENPEP...... 150, 167 ZEPATIER...... 25, 26 ZEPOSIA...... 227 ZEPOSIA 7-DAY STARTER PACK...... 227 ZEPOSIA STARTER KIT...... 227 ZETONNA ...... 158 ZIAC...... 77, 149 ZIAGEN...... 29 zidovudine ...... 29 ZIEXTENZO ...... 64 zileuton er ...... 238 ZILXI...... 246 ZIOPTAN...... 162 ziprasidone hcl ...... 107, 112 ZIPSOR...... 129 ZIRGAN...... 154 ZITHROMAX ...... 33 ZITHROMAX TRI-PAK...... 33 ZITHROMAX Z-PAK...... 33 ZOKINVY...... 232 ZOLINZA...... 46 zolmitriptan ...... 134 zolpidem tartrate ...... 110 zolpidem tartrate er ...... 110 ZOLPIMIST...... 110 ZOMIG...... 134 ZONEGRAN...... 103 zonisamide ...... 103 ZONTIVITY...... 71 ZORBTIVE...... 198, 209 ZORVOLEX...... 129 zovia 1/35 (28)...... 185, 195, 207 zovia 1/35e (28)...... 185, 195, 207 ZOVIRAX...... 32, 248 ZTLIDO...... 211 ZUBSOLV...... 126, 127 zumandimine ...... 185, 195, 207 ZUPLENZ...... 162 ZYDELIG...... 46 ZYFLO ...... 238 ZYKADIA...... 46 ZYLET...... 154, 159 ZYLOPRIM...... 214 ZYMAXID...... 154 ZYPITAMAG...... 89

297