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2021 List

Effective January 1, 2021 Formulary Introduction

FORMULARY

The Ambetter from NH Healthy Families Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost- effective treatment options, if a generic medication on the formulary is not suitable for your condition.

Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug.

Specific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs.

Drug List Key: Brand name drugs are listed in CAPS and generic drugs are lower case. Drugs are covered under different copay tiers depending on your benefit:

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) , and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for “specialty” drugs. Specialty drugs are used to treat complex, chronic conditions and may require special handling, storage, or clinical management. Prescription drugs covered under the specialty tier require fulfillment at a pharmacy that participates in Ambetter’s “specialty” or “hemophilia” networks. For additional information on which pharmacies are within our “specialty” or “hemophilia” networks, please consult Ambetter website’s pharmacy information section.

Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests, and within 72 hours for non-urgent requests, unless state law requires faster response. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request. Formulary Abbreviations:

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages.

QL Quantity Limit Some drugs are only covered for a certain amount.

Your doctor must ask for approval from Ambetter before PA Prior Authorization some drugs will be covered.

In some cases, you must first try certain drugs before Ambetter covers another drug for your medical condition. ST Step Therapy For example, if Drug A and Drug B both treat your medical condition, Ambetter may not cover Drug B unless you try Drug A first. This product is not covered unless you or your provider NF Non-formulary request an exception. Alternative medications are listed next to non-covered product

These drugs are made in both prescription form and RX/OTC Prescription and OTC Over-the-counter (OTC) form. Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(2 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine cp24 5 ADHD, Sleep and Eating Disorders mg-5 mg-5 mg-5 mg, 6.25 1 mg-6.25 mg-6.25 mg-6.25 Amphetamines mg, 7.5 mg-7.5 mg-7.5 mg- TABS 1.25 QL(3 ea daily) 7.5 mg MG-1.25 MG-1.25 MG-1.25 amphetamine- QL(3 ea daily) MG, 1.875 MG-1.875 MG- dextroamphetamine tabs 1.875 MG-1.875 MG, 2.5 1.25 mg-1.25 mg-1.25 mg- MG-2.5 MG-2.5 MG-2.5 1.25 mg, 1.875 mg-1.875 MG, 3.125 MG-3.125 MG- NF mg-1.875 mg-1.875 mg, 1 3.125 MG-3.125 MG, 3.75 2.5 mg-2.5 mg-2.5 mg-2.5 MG-3.75 MG-3.75 MG-3.75 mg, 3.125 mg-3.125 mg- MG, 5 MG-5 MG-5 MG-5 3.125 mg-3.125 mg, 3.75 MG (Use amphetamine- mg-3.75 mg-3.75 mg-3.75 dextroamphetamine) mg, 5 mg-5 mg-5 mg-5 mg ADDERALL TABS 7.5 MG- QL(2 ea daily) amphetamine- QL(2 ea daily) 7.5 MG-7.5 MG-7.5 MG NF dextroamphetamine tabs 1 (Use amphetamine- 7.5 mg-7.5 mg-7.5 mg-7.5 dextroamphetamine) mg ADDERALL XR CP24 1.25 QL(1 ea daily) QL(5 ea daily); MG-1.25 MG-1.25 MG-1.25 DESOXYN TABS (Use NF hcl) AL(At least 6 MG, 2.5 MG-2.5 MG-2.5 NF yrs old) MG-2.5 MG (Use amphetamine- DEXEDRINE CP24 10 MG, QL(4 ea daily) dextroamphetamine) 15 MG (Use NF dextroamphetamine ADDERALL XR CP24 3.75 sulfate) MG-3.75 MG-3.75 MG-3.75 NF MG (Use amphetamine- DEXEDRINE CP24 5 MG dextroamphetamine) (Use dextroamphetamine NF sulfate) ADDERALL XR CP24 5 QL(2 ea daily) MG-5 MG-5 MG-5 MG, dextroamphetamine sulfate 1 QL(4 ea daily) 6.25 MG-6.25 MG-6.25 cp24 10 mg, 15 mg MG-6.25 MG, 7.5 MG-7.5 NF dextroamphetamine sulfate 1 MG-7.5 MG-7.5 MG (Use cp24 5 mg amphetamine- dextroamphetamine sulfate 1 QL(4 ea daily) dextroamphetamine) tabs 10 mg, 5 mg ADZENYS ER SUER (Use NF QL(5 ea daily); amphetamine) methamphetamine hcl tabs 3 AL(At least 6 amphetamine- QL(1 ea daily) yrs old) dextroamphetamine cp24 VYVANSE CAPS 10 MG, ST; QL(1 ea 1.25 mg-1.25 mg-1.25 mg- 1 20 MG, 30 MG, 40 MG, 50 3 daily) 1.25 mg, 2.5 mg-2.5 mg- MG, 60 MG, 70 MG 2.5 mg-2.5 mg Anorexiants Non-Amphetamine amphetamine- ADIPEX-P CAPS (Use PA dextroamphetamine cp24 1 NF 3.75 mg-3.75 mg-3.75 mg- phentermine hcl) 3.75 mg tartrate 1 PA tabs

Ambetter NH Formulary Updated October 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phentermine hcl caps 1 PA hcl QL(1 ea daily) cp24 35 mg, 10 mg, 15 mg, 1 Anti-Obesity Agents 20 mg, 25 mg, 30 mg, 40 mg, 5 mg BELVIQ TABS 3 PA; QL(2 ea daily) QL(2 ea daily); dexmethylphenidate hcl 1 AL(At least 6 tabs 2.5 mg, 10 mg, 5 mg CONTRAVE TB12 3 PA; QL(4 ea yrs old) daily) QL(2 ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) FOCALIN TABS (Use NF dexmethylphenidate hcl) AL(At least 6 QL(2 ea daily); yrs old) hcl caps 10 1 AL(At least 6 mg, 18 mg, 25 mg, 40 mg FOCALIN XR CP24 (Use NF QL(1 ea daily) yrs old) dexmethylphenidate hcl) QL(1 ea daily); atomoxetine hcl caps 100 QL(30 ml 1 AL(At least 6 METHYLIN SOLN (Use NF mg, 60 mg, 80 mg hcl) daily); AL(At yrs old) least 6 yrs old) clonidine hcl (adhd) tb12 1 methylphenidate hcl cp24 1 AL(At least 6 20 mg, 40 mg yrs old) QL(1 ea daily); QL(3 ea daily); guanfacine hcl (adhd) tb24 1 AL(At least 6 methylphenidate hcl cp24 1 AL(At least 6 30 mg yrs old) yrs old) QL(1 ea daily); methylphenidate hcl cpcr QL(1 ea daily); INTUNIV TB24 (Use NF guanfacine hcl (adhd)) AL(At least 6 40 mg, 60 mg, 10 mg, 20 1 AL(At least 6 yrs old) mg, 30 mg, 50 mg yrs old) KAPVAY TB12 (Use NF QL(30 ml clonidine hcl (adhd)) methylphenidate hcl soln 1 daily); AL(At 10 mg/5ml, 5 mg/5ml STRATTERA CAPS 10 QL(2 ea daily); least 6 yrs old) MG, 18 MG, 25 MG, 40 MG NF AL(At least 6 QL(5 ea daily); (Use atomoxetine hcl) yrs old) methylphenidate hcl tabs 1 AL(At least 6 10 mg, 20 mg STRATTERA CAPS 100 QL(1 ea daily); yrs old) MG, 60 MG, 80 MG (Use NF AL(At least 6 QL(6 ea daily); atomoxetine hcl) yrs old) methylphenidate hcl tabs 5 1 AL(At least 6 mg and Norepinephrine Reuptake yrs old) PA QL(3 ea daily); SUNOSI TABS 3 methylphenidate hcl tbcr 10 1 AL(At least 6 mg, 20 mg - Misc. yrs old) PA; QL(1 ea QL(1 ea daily); methylphenidate hcl tbcr 18 1 AL(At least 6 1 daily); AL(At mg, 27 mg tabs least 17 yrs yrs old) old) QL(2 ea daily); methylphenidate hcl tbcr 36 1 AL(At least 6 CONCERTA TBCR 18 MG, QL(1 ea daily); mg, 54 mg 27 MG (Use NF AL(At least 6 yrs old) methylphenidate hcl) yrs old) PA; QL(1 ea daily); AL(At CONCERTA TBCR 36 MG, QL(2 ea daily); tabs 100 mg 1 54 MG (Use NF AL(At least 6 least 16 yrs methylphenidate hcl) yrs old) old) DAYTRANA PTCH 3 PA; QL(1 ea daily)

Ambetter NH Formulary Updated October 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea gentamicin in saline soln 1 daily); AL(At 0.8 mg/ml-0.9 %, 0.9 %-1 1 modafinil tabs 200 mg least 16 yrs mg/ml, 0.9 %-1.2 mg/ml, old) 0.9 %-1.6 mg/ml PA; QL(1 ea gentamicin sulfate soln 40 1 NUVIGIL TABS (Use NF daily); AL(At mg/ml armodafinil) least 17 yrs HUMATIN CAPS (Use NF old) paromomycin sulfate) PA; QL(1 ea KITABIS PAK NEBU (Use NF PA PROVIGIL TABS 100 MG NF daily); AL(At tobramycin) (Use modafinil) least 16 yrs old) sulfate tabs 1 PA; QL(2 ea paromomycin sulfate caps 1 PROVIGIL TABS 200 MG NF daily); AL(At (Use modafinil) least 16 yrs old) streptomycin sulfate solr 3 RITALIN LA CP24 20 MG, AL(At least 6 TOBI NEBU (Use NF PA 40 MG (Use NF yrs old) tobramycin) methylphenidate hcl) tobramycin nebu 300 4 PA QL(3 ea daily); mg/5ml RITALIN LA CP24 30 MG NF AL(At least 6 (Use methylphenidate hcl) yrs old) tobramycin sulfate soln 10 mg/ml, 40 mg/ml, 80 1 RITALIN TABS 10 MG, 20 QL(5 ea daily); mg/2ml MG (Use methylphenidate NF AL(At least 6 hcl) yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs QL(6 ea daily); to Treat Pain, Swelling, Muscle and Joint RITALIN TABS 5 MG (Use NF Conditions methylphenidate hcl) AL(At least 6 yrs old) Anti-TNF-alpha - Monoclonal Antibodies PA; 1 rtl pack ALLERGENIC EXTRACTS/BIOLOGICALS MISC lmt amt,180 rtl pack lmt Allergenic Extracts HUMIRA PEDIATRIC 4 day(s),1 mail GRASTEK SUBL 3 PA CROHNS DISEASE STARTER PACK PSKT pack lmt amt,180 mail AMEBICIDES pack lmt day(s), Amebicides HUMIRA PEN PNKT 40 4 PA; QL(0.143 SOLOSEC PACK 3 PA MG/0.4ML, 40 MG/0.8ML ea daily) PA; 1 rtl pack AMINOGLYCOSIDES - Drugs to Treat Bacterial lmt amt,180 rtl Infections pack lmt HUMIRA PEN PNKT 80 4 day(s),1 mail Aminoglycosides MG/0.8ML pack lmt amikacin sulfate soln 1 amt,180 mail pack lmt ARIKAYCE SUSP 4 PA day(s), HUMIRA PEN-CD/UC/HS PA; QL(0.143 STARTER PNKT 40 4 ea daily) MG/0.8ML Ambetter NH Formulary Updated October 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; 1 rtl pack Interleukin-1beta Blockers lmt amt,180 rtl pack lmt ILARIS SOLN 4 PA; QL(0.072 HUMIRA PEN-CD/UC/HS ml daily) 4 day(s),1 mail STARTER PNKT 80 pack lmt MG/0.8ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) amt,180 mail ARTHROTEC 50 TBEC pack lmt (Use diclofenac w/ NF day(s), misoprostol) PA; 1 rtl pack ARTHROTEC 75 TBEC lmt amt,180 rtl (Use diclofenac w/ NF pack lmt HUMIRA PEN-PEDIATRIC misoprostol) UC STARTER PACK 4 day(s),1 mail pack lmt CELEBREX CAPS 100 PA; QL(2 ea PNKT amt,180 mail MG, 200 MG, 50 MG (Use NF daily) pack lmt celecoxib) day(s), CELEBREX CAPS 400 MG NF PA; QL(1 ea PA; 1 rtl pack (Use celecoxib) daily) lmt amt,180 rtl celecoxib caps 100 mg, 1 PA; QL(2 ea pack lmt 200 mg, 50 mg daily) HUMIRA PEN-PS/UV day(s),1 mail PA; QL(1 ea 4 celecoxib caps 400 mg 1 STARTER PNKT pack lmt daily) amt,180 mail CHILDRENS ADVIL SUSP NF RX/OTC pack lmt (Use ibuprofen) day(s), CHILDRENS MOTRIN NF RX/OTC HUMIRA PEN-PS/UV 4 PA; QL(0.143 SUSP (Use ibuprofen) STARTER PNKT ea daily) DAYPRO TABS (Use PA; QL(0.143 NF HUMIRA PSKT 4 oxaprozin) ea daily) Antirheumatic - Enzyme Inhibitors diclofenac potassium tabs 1 RINVOQ TB24 4 PA; QL(1 ea diclofenac sodium tb24 1 daily) XELJANZ TABS 10 MG 4 PA; QL(2 ea diclofenac sodium tbec 1 daily) diclofenac w/ misoprostol XELJANZ TABS 5 MG 4 PA; QL(2 ea 1 daily); SP tbec EC-NAPROSYN TBEC 500 XELJANZ XR TB24 4 PA; QL(1 ea NF daily) MG (Use naproxen) etodolac caps 200 mg, 300 1 Antirheumatic Antimetabolites mg PA; QL(1.714 METHOTREXATE TABS 4 etodolac tabs 400 mg, 500 1 ea daily); SP mg Gold Compounds FELDENE CAPS (Use NF piroxicam) RIDAURA CAPS 3 QL(3 ea daily) fenoprofen calcium tabs 1 ST; QL(4 ea Interleukin-1 Blockers 600 mg daily) ARCALYST SOLR 4 PA; QL(0.286 flurbiprofen tabs 1 ea daily); SP

Ambetter NH Formulary Updated October 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ibuprofen susp 100 mg/5ml 1 RX/OTC tolmetin sodium tabs 1 ibuprofen tabs 400 mg, 600 1 Phosphodiesterase 4 (PDE4) Inhibitors mg, 800 mg PA; QL(2 ea OTEZLA TABS 4 indomethacin caps 25 mg, 1 daily) 50 mg PA; 1 rtl pack indomethacin cpcr 75 mg 1 4 lmt amt,180 rtl OTEZLA TBPK pack lmt ketoprofen caps 50 mg, 75 1 day(s), mg Pyrimidine Synthesis Inhibitors ketorolac tromethamine 1 QL(0.667 ea tabs or 10 mg daily) ARAVA TABS (Use NF QL(1 ea daily) leflunomide) LODINE TABS (Use NF etodolac) leflunomide tabs 1 QL(1 ea daily) meclofenamate sodium 1 caps Soluble Tumor Necrosis Factor Receptor Agents PA; QL(0.15 ml ST; Must try ENBREL MINI SOCT 4 mefenamic acid caps 1 ibuprofen. daily) ;QL(5 ea daily) ENBREL SOLN 25 4 PA; QL(0.146 MG/0.5ML ml daily) meloxicam tabs 15 mg, 7.5 1 QL(1 ea daily) mg ENBREL SOLR 25 MG 4 PA; QL(0.286 ea daily); SP MOBIC TABS (Use NF QL(1 ea daily) meloxicam) ENBREL SOSY 25 4 PA; QL(0.146 MG/0.5ML ml daily); SP nabumetone tabs 1 ENBREL SOSY 50 MG/ML 4 PA; QL(0.28 ml daily); SP NALFON TABS 600 MG NF ST; QL(4 ea (Use fenoprofen calcium) daily) ENBREL SURECLICK 4 PA; QL(0.143 SOAJ ml daily); SP NAPROSYN SUSP 125 NF PA MG/5ML (Use naproxen) ANALGESICS - NonNarcotic - Drugs to Treat NAPROSYN TABS 500 NF Pain, Muscle and Joint Conditions MG (Use naproxen) Analgesic Combinations naproxen sodium tabs 550 1 mg butalbital-acetaminophen 1 tabs 50 mg-325 mg PA naproxen susp 125 mg/5ml 1 butalbital-acetaminophen- caps 40 mg-50 naproxen tabs 250 mg, 375 1 1 mg, 500 mg mg-300 mg, 40 mg-50 mg- 325 mg naproxen tbec 500 mg 1 butalbital-acetaminophen- caffeine tabs 40 mg-50 mg- 1 oxaprozin tabs 1 325 mg butalbital-aspirin-caffeine 1 piroxicam caps 1 caps BUTALBITAL/ACETAMINO sulindac tabs 1 PHEN CAPS (Use NF butalbital-acetaminophen) tolmetin sodium caps 1

Ambetter NH Formulary Updated October 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESGIC TABS (Use New starts DILAUDID TABS OR 2 butalbital-acetaminophen- NF NF limited to 7 day ) MG, 4 MG, 8 MG (Use caffeine hydromorphone hcl) supply;QL(8 ea FIORICET CAPS (Use daily) butalbital-acetaminophen- NF DURAGESIC PT72 (Use NF QL(0.34 ea caffeine) fentanyl) daily) FIORINAL CAPS (Use NF EMBEDA CPCR 3 PA; QL(2 ea butalbital-aspirin-caffeine) daily) Salicylates fentanyl citrate lpop bu PA; QL(4 ea AL(At least 45 1200 mcg, 1600 mcg, 200 1 daily) 0 yrs old - Up to mcg, 400 mcg, 600 mcg, aspirin chew 800 mcg 79 yrs old) AL(At least 45 fentanyl pt72 td 100 QL(0.34 ea 0 yrs old - Up to mcg/hr, 12 mcg/hr, 25 1 daily) aspirin tabs mcg/hr, 50 mcg/hr, 75 79 yrs old) mcg/hr AL(At least 45 0 yrs old - Up to FENTORA TABS (Use NF aspirin tbec fentanyl citrate) 79 yrs old) hydrocodone bitartrate PA; QL(2 ea diflunisal tabs 1 cp12 10 mg, 15 mg, 30 mg, 1 daily) 40 mg, 50 mg salsalate tabs 1 HYDROCODONE 3 PA; QL(2 ea BITARTRATE ER CP12 daily) ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions New starts hydromorphone hcl liqd or 1 limited to 7 day 1 mg/ml Opioid Agonists supply ACTIQ LPOP (Use fentanyl NF PA; QL(4 ea hydromorphone hcl soln ij citrate) daily) 10 mg/ml, 50 mg/5ml, 500 1 New starts mg/50ml CODEINE SULFATE TABS 1 15 MG, 60 MG limited to 7 day New starts supply hydromorphone hcl tabs or 1 limited to 7 day New starts 2 mg, 4 mg, 8 mg supply;QL(8 ea codeine sulfate tabs 30 mg 1 limited to 7 day daily) supply hydromorphone hcl tb24 or 1 PA; QL(2 ea 12 mg, 16 mg, 8 mg daily) CONZIP CP24 (Use NF hcl) hydromorphone hcl tb24 or 1 PA; QL(1 ea DEMEROL SOLN 100 32 mg daily) MG/ML, 25 MG/ML, 50 NF HYDROMORPHONE MG/ML (Use meperidine HYDROCHLORIDE SOLN NF hcl) IJ 10 MG/ML (Use DILAUDID LIQD OR 1 New starts hydromorphone hcl) MG/ML (Use NF limited to 7 day KADIAN CP24 100 MG, 20 PA; QL(2 ea hydromorphone hcl) supply MG, 30 MG, 50 MG, 60 NF daily) DILAUDID SOLN IJ 1 MG, 80 MG (Use morphine MG/ML, 2 MG/ML (Use NF sulfate) hydromorphone hcl) New starts tartrate tabs 2 1 limited to 7 day mg supply Ambetter NH Formulary Updated October 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits meperidine hcl soln ij 100 1 New starts mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate soln or 10 1 limited to 7 day New starts mg/5ml supply;QL(100 ml daily) meperidine hcl soln or 50 1 limited to 7 day mg/5ml supply;QL(500 New starts ml per fill retail) morphine sulfate soln or 20 1 limited to 7 day New starts mg/5ml supply;QL(50 ml daily) meperidine hcl tabs or 50 1 limited to 7 day mg supply;QL(6 ea morphine sulfate tabs or 15 1 daily) mg hcl conc or 10 1 QL(10 ml daily) New starts mg/ml morphine sulfate tabs or 15 1 limited to 7 day mg, 30 mg supply;QL(6 ea methadone hcl soln ij 10 1 mg/ml daily) METHADONE HCL SOLN morphine sulfate tbcr or QL(2 ea daily) IJ 10 MG/ML (Use 1 100 mg, 15 mg, 200 mg, 30 1 methadone hcl) mg, 60 mg MS CONTIN TBCR (Use QL(2 ea daily) methadone hcl soln or 10 1 QL(50 ml daily) NF mg/5ml morphine sulfate) PA; QL(2 ea methadone hcl soln or 5 1 QL(100 ml NUCYNTA ER TB12 2 mg/5ml daily) daily) PA; QL(6 ea methadone hcl tabs or 10 1 QL(10 ea daily) NUCYNTA TABS 2 mg daily) OPANA TABS (Use PA; QL(12 ea methadone hcl tabs or 5 1 QL(4 ea daily) NF mg oxymorphone hcl) daily) New starts methadone hcl tbso or 40 1 QL(2 ea daily) mg 2 limited to 7 day OXAYDO TABS 5 MG supply;QL(12 METHADOSE CONC (Use NF QL(10 ml daily) ea daily) methadone hcl) oxycodone hcl t12a 15 mg, PA; QL(2 ea METHADOSE SUGAR- QL(10 ml daily) 30 mg, 60 mg, 80 mg, 10 3 daily) FREE CONC (Use NF mg, 20 mg, 40 mg methadone hcl) New starts MORPHABOND ER T12A PA; QL(1 ea 3 oxycodone hcl tabs 10 mg, 1 limited to 7 day 100 MG, 30 MG, 60 MG daily) 20 mg, 15 mg, 30 mg, 5 mg supply;QL(12 MORPHABOND ER T12A 3 PA; QL(3 ea ea daily) 15 MG daily) OXYCONTIN T12A 3 PA; QL(2 ea morphine sulfate cp24 or PA; QL(2 ea daily) 100 mg, 20 mg, 30 mg, 50 1 daily) oxymorphone hcl tabs 10 1 PA; QL(12 ea mg, 60 mg, 80 mg mg, 5 mg daily) morphine sulfate soln ij 0.5 1 oxymorphone hcl tb12 10 PA; QL(2 ea mg/ml, 1 mg/ml mg, 15 mg, 20 mg, 30 mg, 1 daily) MORPHINE SULFATE 5 mg, 7.5 mg SOLN IV 10 MG/ML (Use NF oxymorphone hcl tb12 40 1 PA; QL(4 ea morphine sulfate) mg daily)

Ambetter NH Formulary Updated October 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits New starts acetaminophen-caff- PA; New starts 3 ROXICODONE TABS (Use NF limited to 7 day dihydrocod caps 16 mg-30 limited to 7 day oxycodone hcl) supply;QL(12 mg-320.5 mg supply ea daily) butalbital-acetaminophen- New starts caffeine w/ codeine caps limited to 7 day SUBSYS LIQD 100 MCG 3 PA; QL(3 ea 1 daily) 30 mg-40 mg-50 mg-300 supply SUBSYS LIQD 1200 MCG, PA; QL(4 ea mg 1600 MCG, 200 MCG, 400 3 daily) butalbital-acetaminophen- New starts MCG, 600 MCG caffeine w/ codeine caps 1 limited to 7 day 30 mg-40 mg-50 mg-325 supply;QL(6 ea SUBSYS LIQD 800 MCG 3 PA; QL(8 ea daily) mg daily) New starts New starts butalbital-aspirin-caffeine limited to 7 day 1 limited to 7 day 1 tramadol hcl tabs 50 mg supply;QL(8 ea w/cod caps supply;QL(6 ea daily) daily) FIORICET/CODEINE New starts tramadol hcl tb24 100 mg, 1 QL(1 ea daily) 200 mg, 300 mg CAPS (Use butalbital- NF limited to 7 day acetaminophen-caffeine w/ supply New starts codeine) ULTRAM TABS (Use NF limited to 7 day tramadol hcl) supply;QL(8 ea New starts FIORINAL/CODEINE #3 limited to 7 day daily) CAPS (Use butalbital- NF aspirin-caffeine w/cod) supply;QL(6 ea XTAMPZA ER C12A 2 PA; QL(2 ea daily) daily) hydrocodone- New starts PA; QL(2 ea ZOHYDRO ER CP12 3 acetaminophen soln 10 1 limited to 7 day daily) mg/15ml-325 mg/15ml supply Opioid Combinations hydrocodone- New starts New starts acetaminophen soln 2.5 limited to 7 day acetaminophen w/ codeine mg/5ml-108 mg/5ml, 5 1 supply;QL(180 1 limited to 7 day soln 12 mg/5ml-120 supply;QL(75 mg/10ml-217 mg/10ml, 7.5 ml daily) mg/5ml ml daily) mg/15ml-325 mg/15ml New starts hydrocodone- New starts acetaminophen tabs 10 limited to 7 day acetaminophen w/ codeine 1 limited to 7 day 1 tabs 15 mg-300 mg supply;QL(13 mg-300 mg, 5 mg-300 mg, supply;QL(13 ea daily) 7.5 mg-300 mg ea daily) New starts hydrocodone- New starts acetaminophen tabs 10 limited to 7 day acetaminophen w/ codeine 1 limited to 7 day 1 tabs 30 mg-300 mg supply;QL(12 mg-325 mg, 5 mg-325 mg, supply;QL(12 ea daily) 7.5 mg-325 mg ea daily) New starts hydrocodone-ibuprofen PA tabs 10 mg-200 mg, 5 mg- 1 acetaminophen w/ codeine 1 limited to 7 day tabs 60 mg-300 mg supply;QL(6 ea 200 mg daily) New starts acetaminophen-caff- New starts hydrocodone-ibuprofen 1 limited to 7 day dihydrocod caps 16 mg-30 1 limited to 7 day tabs 7.5 mg-200 mg supply;QL(5 ea mg-320.5 mg supply daily)

Ambetter NH Formulary Updated October 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits New starts buprenorphine hcl subl sl 2 1 QL(3 ea daily) limited to 7 day mg, 8 mg LORTAB ELIX 2 supply;QL(60 buprenorphine hcl- QL(3 ea daily) ml daily) naloxone hcl dihydrate film 1 New starts 0.5 mg-2 mg, 1 mg-4 mg NORCO TABS (Use hydrocodone- NF limited to 7 day buprenorphine hcl- QL(2 ea daily) acetaminophen) supply;QL(12 naloxone hcl dihydrate film 1 ea daily) 2 mg-8 mg, 3 mg-12 mg oxycodone w/ New starts buprenorphine hcl- QL(3 ea daily) acetaminophen tabs 10 1 limited to 7 day naloxone hcl dihydrate subl 1 mg-325 mg, 5 mg-325 mg, supply;QL(12 0.5 mg-2 mg, 2 mg-8 mg 7.5 mg-325 mg ea daily) buprenorphine ptwk td 10 PA; QL(0.143 New starts mcg/hr, 15 mcg/hr, 20 ea daily) limited to 7 day 1 oxycodone-ibuprofen tabs 1 mcg/hr, 5 mcg/hr, 7.5 supply;QL(1 ea mcg/hr daily) butorphanol tartrate soln ij 1 PERCOCET TABS 10 MG- New starts 1 mg/ml, 2 mg/ml 325 MG, 5 MG-325 MG, limited to 7 day 7.5 MG-325 MG (Use NF supply;QL(12 butorphanol tartrate soln na 1 PA oxycodone w/ ea daily) 10 mg/ml acetaminophen) BUTRANS PTWK 10 PA; QL(0.143 New starts MCG/HR, 15 MCG/HR, 20 NF ea daily) MCG/HR, 5 MCG/HR (Use tramadol-acetaminophen 1 limited to 7 day tabs supply;QL(8 ea buprenorphine) daily) BUTRANS PTWK 7.5 PA; QL(0.143 New starts MCG/HR (Use 3 ea daily) TYLENOL/CODEINE #3 limited to 7 day buprenorphine) TABS (Use acetaminophen NF QL(8 ml daily) w/ codeine) supply;QL(12 nalbuphine hcl soln 1 ea daily) New starts New starts TYLENOL/CODEINE #4 pentazocine w/ naloxone 1 limited to 7 day limited to 7 day tabs TABS (Use acetaminophen NF supply w/ codeine) supply;QL(6 ea daily) SUBOXONE FILM 0.5 MG- QL(3 ea daily) New starts 2 MG, 1 MG-4 MG (Use NF buprenorphine hcl- ULTRACET TABS (Use NF limited to 7 day tramadol-acetaminophen) supply;QL(8 ea naloxone hcl dihydrate) daily) SUBOXONE FILM 2 MG-8 QL(2 ea daily) MG, 3 MG-12 MG (Use NF Opioid Partial Agonists buprenorphine hcl- BUNAVAIL FILM 0.3 MG- 3 PA; QL(4 ea naloxone hcl dihydrate) 2.1 MG daily) ANDROGENS-ANABOLIC - Drugs to Regulate BUNAVAIL FILM 0.7 MG- 3 PA; QL(2 ea Hormones 4.2 MG daily) Anabolic Steroids BUNAVAIL FILM 1 MG-6.3 3 PA; QL(1 ea MG daily) ANADROL-50 TABS 3 BUPRENEX SOLN (Use NF buprenorphine hcl) oxandrolone tabs 1 buprenorphine hcl soln ij 1 0.3 mg/ml Androgens Ambetter NH Formulary Updated October 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANDRODERM PT24 2 PA; QL(1 ea PROCTOCORT SUPP daily) (Use hydrocortisone NF ANDROGEL GEL 25 acetate (rectal)) MG/2.5GM, 50 MG/5GM NF Vasodilating Agents (Use testosterone) RECTIV OINT 3 QL(2 gm daily) danazol caps 1 ANTHELMINTICS - Drugs to Treat Worm DEPO-TESTOSTERONE Infections SOLN (Use testosterone NF cypionate) Anthelmintics METHITEST TABS 3 albendazole tabs 1 PA ALBENZA TABS (Use PA TESTIM GEL (Use NF NF testosterone) albendazole) TESTOSTERONE BILTRICIDE TABS (Use NF PA CYPIONATE SOLN IJ 200 1 praziquantel) MG/ML QL(2 ea daily,6 ea per fill testosterone cypionate soln 1 ij 200 mg/ml retail,6 ea per fill mail)1 rtl testosterone cypionate soln 1 im 100 mg/ml, 200 mg/ml EMVERM CHEW 2 MAX fill,60 rtl day(s) supply,1 testosterone enanthate 1 mail MAX fill,60 soln im mail day(s) VOGELXO GEL (Use NF supply, testosterone) ivermectin tabs or 3 mg 1 VOGELXO PUMP GEL NF (Use testosterone) praziquantel tabs 1 PA ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching STROMECTOL TABS (Use NF ivermectin) Intrarectal Steroids ANTI-INFECTIVE AGENTS - MISC. - Drugs to CORTENEMA ENEM (Use NF hydrocortisone (intrarectal)) Treat Bacterial Infections Anti-infective Agents - Misc. hydrocortisone (intrarectal) 1 enem bacitracin solr 3 UCERIS FOAM RE 2 4 PA MG/ACT FLAGYL TABS 500 MG NF (Use metronidazole) Rectal Steroids PA; QL(3 ea IMPAVIDO CAPS 3 ANUSOL-HC CREA (Use NF daily) hydrocortisone (rectal)) metronidazole tabs or 250 1 hydrocortisone (rectal) crea 1 mg, 500 mg trimethoprim tabs 1 hydrocortisone acetate 1 (rectal) supp XIFAXAN TABS 3 PA; AL(At least PROCTOCORT CREA 12 yrs old) (Use hydrocortisone NF (rectal)) Anti-infective Misc. - Combinations Ambetter NH Formulary Updated October 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACTRIM DS TABS (Use DAPTOMYCIN SOLR 350 NF sulfamethoxazole- NF MG (Use daptomycin) trimethoprim) daptomycin solr 500 mg 1 BACTRIM TABS (Use sulfamethoxazole- NF Glycopeptides trimethoprim) QL(300 ml per FIRVANQ SOLR 2 sulfamethoxazole- 1 fill retail) trimethoprim soln QL(4 ea sulfamethoxazole- VANCOCIN CAPS (Use NF 1 vancomycin hcl) daily,40 ea per trimethoprim susp fill retail) sulfamethoxazole- 1 QL(4 ea trimethoprim tabs VANCOCIN HCL CAPS NF daily,40 ea per (Use vancomycin hcl) Antiprotozoal Agents fill retail) ALINIA SUSR 100 PA QL(4 ea 2 vancomycin hcl caps or 1 daily,40 ea per MG/5ML 125 mg, 250 mg fill retail) ALINIA TABS 500 MG (Use 2 PA nitazoxanide) vancomycin hcl solr iv 10 gm, 500 mg, 1 gm, 1000 1 atovaquone susp 1 mg VANCOMYCIN QL(300 ml per MEPRON SUSP (Use NF atovaquone) HYDROCHLORIDE SOLR 2 fill retail) OR 250 MG/5ML nitazoxanide tabs or 1 PA Leprostatics Carbapenems dapsone tabs 1 ertapenem sodium solr 1 Lincosamides imipenem-cilastatin solr 1 CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use NF INVANZ SOLR (Use NF clindamycin hcl) ertapenem sodium) CLEOCIN PEDIATRIC meropenem solr 1 GRANULES SOLR (Use NF clindamycin palmitate hydrochloride) MERREM SOLR (Use NF meropenem) CLEOCIN PHOSPHATE SOLN IJ 300 MG/2ML, 600 PRIMAXIN IV SOLR (Use NF imipenem-cilastatin) MG/4ML, 900 MG/6ML, 9 NF GM/60ML (Use clindamycin Chloramphenicols phosphate) chloramphenicol sodium 4 PA; SP succinate solr clindamycin hcl caps 1 Cyclic Lipopeptides clindamycin palmitate 1 hydrochloride solr CUBICIN RF SOLR (Use NF daptomycin) clindamycin phosphate soln 1 CUBICIN SOLR (Use NF daptomycin) LINCOCIN SOLN (Use NF lincomycin hcl)

Ambetter NH Formulary Updated October 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lincomycin hcl soln 1 RANEXA TB12 1000 MG NF QL(2 ea daily) (Use ranolazine) Monobactams RANEXA TB12 500 MG NF QL(3 ea daily) PA; QL(3 ml (Use ranolazine) CAYSTON SOLR 4 daily) ranolazine tb12 1000 mg 1 QL(2 ea daily) Oxazolidinones ranolazine tb12 500 mg 1 QL(3 ea daily) linezolid susr or 100 1 mg/5ml Nitrates PA; QL(2 ea linezolid tabs or 600 mg 1 daily) ISORDIL TITRADOSE TABS 5 MG (Use NF SIVEXTRO TABS OR 3 PA isosorbide dinitrate) isosorbide dinitrate tabs 30 1 ZYVOX SUSR OR 100 NF MG/5ML (Use linezolid) mg, 10 mg, 20 mg, 5 mg isosorbide dinitrate tbcr 40 1 ZYVOX TABS OR 600 MG NF PA; QL(2 ea mg (Use linezolid) daily) Polymyxins isosorbide mononitrate tabs 1 polymyxin b sulfate solr 1 isosorbide mononitrate 1 tb24 Urinary Anti-infectives NITRO-BID OINT 3 fosfomycin tromethamine 1 pack NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4 FURADANTIN SUSP (Use NF NF nitrofurantoin) MG/HR, 0.6 MG/HR (Use nitroglycerin) HIPREX TABS (Use NF methenamine hippurate) nitroglycerin cpcr or 6.5 1 QL(4 ea daily) mg, 9 mg, 2.5 mg MACROBID CAPS (Use nitrofurantoin monohyd NF nitroglycerin pt24 td 0.1 macro) mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr MACRODANTIN CAPS 50 MG, 100 MG (Use NF NITROGLYCERIN SOLN 1 nitrofurantoin macrocrystal) IV 5 MG/ML nitroglycerin subl sl 0.3 mg, methenamine hippurate 1 1 tabs 0.4 mg, 0.6 mg NITROSTAT SUBL (Use MONUROL PACK (Use 3 NF fosfomycin tromethamine) nitroglycerin) nitrofurantoin macrocrystal 1 ANTIANXIETY AGENTS - Drugs to Treat caps 50 mg, 100 mg Antianxiety Agents - Misc. nitrofurantoin monohyd 1 macro caps hcl tabs 10 mg, 1 30 mg, 7.5 mg, 15 mg nitrofurantoin susp 1 buspirone hcl tabs 5 mg 1 QL(6 ea daily) ANTIANGINAL AGENTS - Drugs to Treat Chest Pain hcl soln im 50 1 mg/ml Antianginals-Other Ambetter NH Formulary Updated October 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydroxyzine hcl syrp or 10 1 ANTIARRHYTHMICS - Drugs to treat abnormal mg/5ml heart rhythms hydroxyzine hcl tabs or 10 1 Antiarrhythmics Type I-A mg, 25 mg, 50 mg disopyramide phosphate 1 hydroxyzine pamoate caps 1 caps NORPACE CAPS (Use NF tabs 1 disopyramide phosphate) procainamide hcl soln 500 VISTARIL CAPS (Use NF 1 hydroxyzine pamoate) mg/ml Benzodiazepines quinidine sulfate tabs 1 alprazolam tabs 0.25 mg, 1 QL(4 ea daily) 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-B mexiletine hcl caps 150 alprazolam tb24 0.5 mg, 1 1 1 mg, 2 mg, 3 mg mg, 200 mg, 250 mg Antiarrhythmics Type I-C alprazolam tbdp 0.25 mg, 1 0.5 mg, 1 mg, 2 mg flecainide acetate tabs 1 ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) 2 MG (Use lorazepam) propafenone hcl cp12 1 ATIVAN TABS OR 1 MG NF QL(4 ea daily) (Use lorazepam) propafenone hcl tabs 1 chlordiazepoxide hcl caps 1 RYTHMOL SR CP12 (Use NF propafenone hcl) clorazepate dipotassium 1 tabs Antiarrhythmics Type III diazepam conc or 5 mg/ml 1 amiodarone hcl soln iv 150 1 mg/3ml, 50 mg/ml diazepam soln or 5 mg/5ml 1 amiodarone hcl tabs or 100 1 mg, 200 mg, 400 mg diazepam tabs or 10 mg, 2 1 QL(4 ea daily) mg, 5 mg dofetilide caps 1 lorazepam conc or 2 mg/ml 1 MULTAQ TABS 3 lorazepam tabs or 0.5 mg, QL(3 ea daily) 1 TIKOSYN CAPS (Use NF 2 mg dofetilide) lorazepam tabs or 1 mg 1 QL(4 ea daily) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions oxazepam caps 10 mg, 15 1 mg, 30 mg Anti-Inflammatory Agents QL(8 ml daily) TRANXENE T TABS (Use NF cromolyn sodium nebu 1 clorazepate dipotassium) Antiasthmatic - Monoclonal Antibodies VALIUM TABS (Use NF QL(4 ea daily) diazepam) FASENRA PEN SOAJ 4 PA XANAX TABS (Use NF QL(4 ea daily) alprazolam) FASENRA SOSY 4 PA XANAX XR TB24 (Use NF alprazolam) Ambetter NH Formulary Updated October 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUCALA SOAJ 4 PA QL(1 ea daily)30 rtl NUCALA SOLR 4 PA MAX day(s) supply,180 rtl DALIRESP TABS 250 3 PA MCG lmt day(s),30 NUCALA SOSY 4 mail MAX PA; SP day(s) XOLAIR SOLR 150 MG 4 supply,180 mail lmt day(s), XOLAIR SOSY 150 4 PA MG/ML, 75 MG/0.5ML DALIRESP TABS 500 3 QL(1 ea daily) MCG Bronchodilators - QL(0.44 gm Steroid Inhalants ATROVENT HFA AERS 3 daily) ARNUITY ELLIPTA AEPB 2 INCRUSE ELLIPTA AEPB 2 QL(1 ea daily) budesonide (inhalation) 1 PA; QL(4 ml susp daily) ipratropium bromide soln 1 QL(15 ml daily) FLOVENT DISKUS AEPB 2 SPIRIVA HANDIHALER 2 QL(1 ea daily) CAPS FLOVENT HFA AERO 2 SPIRIVA RESPIMAT 2 QL(0.14 gm AERS daily) PULMICORT FLEXHALER 2 AEPB Leukotriene Modulators PULMICORT SUSP (Use NF PA; QL(4 ml ACCOLATE TABS (Use NF QL(2 ea daily) budesonide (inhalation)) daily) zafirlukast) QVAR REDIHALER AERB 2 montelukast sodium chew 1 QL(1 ea daily) 4 mg, 5 mg Sympathomimetics montelukast sodium pack 4 1 PA; QL(1 ea mg daily) ADVAIR DISKUS AEPB (Use fluticasone- NF montelukast sodium tabs 1 QL(1 ea daily) salmeterol) 10 mg SINGULAIR CHEW 4 MG, QL(1 ea daily) ADVAIR HFA AERO 2 5 MG (Use montelukast NF AIRDUO RESPICLICK sodium) 113/14 AEPB (Use NF SINGULAIR PACK 4 MG NF PA; QL(1 ea fluticasone-salmeterol) (Use montelukast sodium) daily) AIRDUO RESPICLICK SINGULAIR TABS 10 MG NF QL(1 ea daily) 232/14 AEPB (Use NF (Use montelukast sodium) fluticasone-salmeterol) zafirlukast tabs 1 QL(2 ea daily) AIRDUO RESPICLICK 55/14 AEPB (Use NF zileuton tb12 1 QL(4 ea daily) fluticasone-salmeterol) 1 rtl pack lmt Selective Phosphodiesterase 4 (PDE4) Inhibitors albuterol sulfate aers in 108 1 per fill,2 rtl mcg/act MAX fill,30 rtl day(s) supply,

Ambetter NH Formulary Updated October 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers levalbuterol hcl nebu 0.31 PA; QL(12 ml per month;1 rtl mg/3ml, 0.63 mg/3ml, 1.25 1 daily) albuterol sulfate aers in 1 pack lmt per mg/3ml 108 mcg/act fill,2 rtl MAX levalbuterol hcl nebu 1.25 1 PA fill,30 rtl day(s) mg/0.5ml supply, PA; Limit 2 Limit 2 Inhalers 3 inhalers per per month;1 rtl levalbuterol tartrate aero month;QL(1 gm albuterol sulfate aers in 1 pack lmt per daily) 108 mcg/act fill,2 rtl MAX fill,30 rtl day(s) PROAIR HFA AERS (Use NF supply, albuterol sulfate) PROVENTIL HFA AERS albuterol sulfate nebu in 1 NF 0.5 %, 2.5 mg/0.5ml (Use albuterol sulfate) albuterol sulfate nebu in QL(15 ml daily) SEREVENT DISKUS 2 0.63 mg/3ml, 1.25 mg/3ml, 1 AEPB 0.083 % STRIVERDI RESPIMAT 2 AERS albuterol sulfate syrp or 2 1 mg/5ml SYMBICORT AERO (Use budesonide-formoterol 2 albuterol sulfate tabs or 2 1 mg, 4 mg fumarate dihydrate) terbutaline sulfate soln 1 albuterol sulfate tb12 or 4 1 mg, 8 mg terbutaline sulfate tabs 1 ANORO ELLIPTA AEPB 2 QL(2 ea daily) TRELEGY ELLIPTA AEPB 2 QL(2 ea daily) ARCAPTA NEOHALER 2 CAPS UTIBRON NEOHALER PA PA; QL(4 ml 3 arformoterol tartrate nebu 1 CAPS daily) VENTOLIN HFA AERS NF BEVESPI AEROSPHERE 2 QL(0.36 gm (Use albuterol sulfate) AERO daily) XOPENEX PA BREO ELLIPTA AEPB 2 CONCENTRATE NEBU NF (Use levalbuterol hcl) BROVANA NEBU (Use 3 PA; QL(4 ml PA; Limit 2 arformoterol tartrate) daily) XOPENEX HFA AERO 3 inhalers per budesonide-formoterol 1 (Use levalbuterol tartrate) month;QL(1 gm fumarate dihydrate aero daily) fluticasone-salmeterol aepb XOPENEX NEBU (Use NF PA; QL(12 ml 50 mcg/dose-500 levalbuterol hcl) daily) mcg/dose, 50 mcg/act-100 mcg/act, 50 mcg/act-250 1 mcg/act, 50 mcg/dose-100 aminophylline soln 1 mcg/dose, 50 mcg/dose- 250 mcg/dose ELIXOPHYLLIN ELIX 1 ipratropium-albuterol soln 1 QL(18 ml daily) soln 80 1 QL(56 ml daily) mg/15ml

Ambetter NH Formulary Updated October 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits theophylline tb12 300 mg, 1 QL(5.4 ml per 450 mg ARIXTRA SOLN 7.5 180 days MG/0.6ML (Use NF retail,5.4 ml per theophylline tb24 400 mg, 1 600 mg fondaparinux sodium) 180 days mail); SP ANTICOAGULANTS - Blood Thinners enoxaparin sodium soln ij 4 QL(6 ml daily) 300 mg/3ml Coumarin Anticoagulants enoxaparin sodium soln sc 4 QL(2 ml daily) COUMADIN TABS (Use 2 100 mg/ml, 150 mg/ml warfarin sodium) enoxaparin sodium soln sc 4 QL(1.6 ml warfarin sodium tabs 1 120 mg/0.8ml, 80 mg/0.8ml daily) enoxaparin sodium soln sc 4 QL(0.6 ml Direct Factor Xa Inhibitors 30 mg/0.3ml daily); SP QL(42 ea per QL(0.8 ml 42 days enoxaparin sodium soln sc 4 daily,30 day(s) BEVYXXA CAPS 3 40 mg/0.4ml retail,42 ea per limit); SP 42 days mail) QL(1.2 ml ELIQUIS STARTER PACK QL(2.47 ea enoxaparin sodium soln sc 4 daily,30 day(s) 2 60 mg/0.6ml TBPK daily) limit); SP QL(2.47 ea ELIQUIS TABS 2 QL(7.2 ml per daily) 180 days 1 rtl MAX fondaparinux sodium soln 4 retail,7.2 ml per XARELTO STARTER 2 fill,365 rtl 10 mg/0.8ml PACK TBPK 180 days mail); day(s) supply, SP XARELTO TABS 10 MG, 2 QL(1 ea daily) QL(4.5 ml per 20 MG 180 days fondaparinux sodium soln 4 retail,4.5 ml per XARELTO TABS 15 MG, 2 QL(2 ea daily) 2.5 mg/0.5ml 2.5 MG 180 days mail); SP Heparins And Heparinoid-Like Agents QL(3.6 ml per QL(7.2 ml per 180 days ARIXTRA SOLN 10 180 days fondaparinux sodium soln 5 4 retail,3.6 ml per MG/0.8ML (Use NF retail,7.2 ml per mg/0.4ml 180 days mail); fondaparinux sodium) 180 days mail); SP SP QL(5.4 ml per QL(4.5 ml per 180 days ARIXTRA SOLN 2.5 180 days fondaparinux sodium soln 4 retail,5.4 ml per MG/0.5ML (Use NF retail,4.5 ml per 7.5 mg/0.6ml 180 days mail); fondaparinux sodium) 180 days mail); SP SP FRAGMIN SOLN 10000 PA; SP QL(3.6 ml per UNIT/ML, 12500 ARIXTRA SOLN 5 180 days UNIT/0.5ML, 15000 MG/0.4ML (Use NF retail,3.6 ml per UNIT/0.6ML, 18000 4 fondaparinux sodium) 180 days mail); UNT/0.72ML, 2500 SP UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

Ambetter NH Formulary Updated October 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEPARIN LOCK FLUSH DIASTAT PEDIATRIC GEL SOLN (Use heparin sodium NF (Use diazepam 3 (porcine) lock flush) (anticonvulsant)) heparin sod (porcine) in 1 diazepam (anticonvulsant) 3 d5w soln 5 %-40 unit/ml gel heparin sodium (porcine) KLONOPIN TABS (Use NF soln 10000 unit/ml, 20000 1 clonazepam) unit/ml, 5000 unit/ml PA; QL(10 ea HEPARIN SODIUM/NACL NAYZILAM SOLN 3 per 30 days 0.45% SOLN 0.45 %- 1 retail) 12500 UNIT/250ML ONFI SUSP 2.5 MG/ML NF PA; QL(16 ml LOVENOX SOLN IJ 300 QL(6 ml daily) (Use clobazam) daily) MG/3ML (Use enoxaparin NF ONFI TABS 10 MG, 20 MG NF PA; QL(2 ea sodium) (Use clobazam) daily) LOVENOX SOLN SC 100 QL(2 ml daily) PA; QL(10 ea MG/ML, 150 MG/ML (Use NF VALTOCO LIQD 4 per 30 days enoxaparin sodium) retail) LOVENOX SOLN SC 120 QL(1.6 ml PA; QL(10 ea MG/0.8ML, 80 MG/0.8ML NF daily) VALTOCO LQPK 4 per 30 days (Use enoxaparin sodium) retail) LOVENOX SOLN SC 30 QL(0.6 ml MG/0.3ML (Use NF daily); SP Anticonvulsants - Misc. enoxaparin sodium) 3 ST; QL(2 ea APTIOM TABS daily) LOVENOX SOLN SC 40 QL(0.8 ml MG/0.4ML (Use NF daily,30 day(s) BANZEL SUSP 40 MG/ML 2 PA; QL(80 ml enoxaparin sodium) limit); SP (Use rufinamide) daily) LOVENOX SOLN SC 60 QL(1.2 ml BANZEL TABS 200 MG 2 PA; QL(2 ea MG/0.6ML (Use NF daily,30 day(s) (Use rufinamide) daily) enoxaparin sodium) limit); SP BANZEL TABS 400 MG 2 PA; QL(8 ea (Use rufinamide) daily) ANTICONVULSANTS - Drugs to Treat Seizures BRIVIACT SOLN OR 10 3 PA AMPA Antagonists MG/ML FYCOMPA TABS 10 MG, PA BRIVIACT TABS OR 10 PA 12 MG, 2 MG, 4 MG, 6 MG, 3 MG, 100 MG, 25 MG, 50 3 8 MG MG, 75 MG carbamazepine chew 100 1 Anticonvulsants - Benzodiazepines mg PA; QL(16 ml clobazam susp 2.5 mg/ml 1 carbamazepine cp12 100 daily) 1 mg clobazam tabs 10 mg, 20 PA; QL(2 ea 1 carbamazepine cp12 200 QL(6 ea daily) mg daily) 1 mg clonazepam tabs 0.5 mg, 1 1 carbamazepine cp12 300 QL(4 ea daily) mg, 2 mg 1 mg DIASTAT ACUDIAL GEL (Use diazepam 3 carbamazepine susp 100 1 (anticonvulsant)) mg/5ml carbamazepine tabs 200 1 mg

Ambetter NH Formulary Updated October 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbamazepine tb12 100 1 QL(4 ea daily) LAMICTAL ODT TBDP 100 QL(1 ea daily) mg, 400 mg MG, 200 MG, 25 MG, 50 NF MG (Use lamotrigine) carbamazepine tb12 200 1 QL(6 ea daily) mg LAMICTAL TABS (Use NF lamotrigine) CARBATROL CP12 100 NF MG (Use carbamazepine) lamotrigine chew 25 mg 1 QL(20 ea daily) CARBATROL CP12 200 QL(6 ea daily) NF QL(100 ea MG (Use carbamazepine) lamotrigine chew 5 mg 1 daily) CARBATROL CP12 300 NF QL(4 ea daily) MG (Use carbamazepine) lamotrigine tabs 100 mg, 1 PA; QL(12 ea 150 mg, 200 mg, 25 mg DIACOMIT CAPS 250 MG 4 daily) lamotrigine tbdp 100 mg, 1 QL(1 ea daily) PA; QL(6 ea 200 mg, 25 mg, 50 mg DIACOMIT CAPS 500 MG 4 daily) levetiracetam soln iv 500 1 QL(30 ml daily) PA; QL(12 ea mg/5ml DIACOMIT PACK 250 MG 4 daily) levetiracetam soln or 100 1 QL(30 ml daily) PA; QL(6 ea mg/ml, 500 mg/5ml DIACOMIT PACK 500 MG 4 daily) levetiracetam tabs or 1000 1 QL(3 ea daily) mg EPIDIOLEX SOLN 3 PA levetiracetam tabs or 250 1 QL(4 ea daily) mg, 750 mg gabapentin caps 100 mg, 1 300 mg, 400 mg levetiracetam tabs or 500 1 QL(6 ea daily) mg gabapentin soln 250 1 QL(60 ml daily) mg/5ml, 300 mg/6ml levetiracetam tb24 or 500 1 QL(4 ea daily) mg, 750 mg gabapentin tabs 600 mg, 1 800 mg LYRICA CAPS 100 MG, PA; QL(3 ea KEPPRA SOLN IV 500 QL(30 ml daily) 150 MG, 200 MG, 25 MG, NF daily) MG/5ML (Use NF 50 MG, 75 MG (Use levetiracetam) pregabalin) LYRICA CAPS 225 MG, PA; QL(2 ea KEPPRA SOLN OR 100 NF QL(30 ml daily) NF MG/ML (Use levetiracetam) 300 MG (Use pregabalin) daily) LYRICA SOLN 20 MG/ML PA; QL(30 ml KEPPRA TABS OR 1000 NF QL(3 ea daily) NF MG (Use levetiracetam) (Use pregabalin) daily) KEPPRA TABS OR 250 QL(4 ea daily) MYSOLINE TABS (Use NF MG, 750 MG (Use NF primidone) levetiracetam) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use NF KEPPRA TABS OR 500 NF QL(6 ea daily) MG (Use levetiracetam) gabapentin) NEURONTIN SOLN 250 QL(60 ml daily) KEPPRA XR TB24 (Use NF QL(4 ea daily) NF levetiracetam) MG/5ML (Use gabapentin) LAMICTAL CHEWABLE QL(20 ea daily) NEURONTIN TABS 600 DISPERSIBLE CHEW 25 NF MG, 800 MG (Use NF MG (Use lamotrigine) gabapentin) LAMICTAL CHEWABLE QL(100 ea oxcarbazepine susp 300 1 QL(40 ml daily) DISPERSIBLE CHEW 5 NF daily) mg/5ml, 60 mg/ml MG (Use lamotrigine)

Ambetter NH Formulary Updated October 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxcarbazepine tabs 150 1 QL(3 ea daily) tabs 100 mg, 25 1 QL(4 ea daily) mg, 300 mg mg oxcarbazepine tabs 600 1 QL(4 ea daily) topiramate tabs 200 mg 1 QL(2 ea daily) mg pregabalin caps 100 mg, PA; QL(3 ea topiramate tabs 50 mg 1 QL(6 ea daily) 150 mg, 200 mg, 25 mg, 50 1 daily) mg, 75 mg TRILEPTAL SUSP 300 QL(40 ml daily) MG/5ML (Use NF pregabalin caps 225 mg, 1 PA; QL(2 ea 300 mg daily) oxcarbazepine) PA; QL(30 ml TRILEPTAL TABS 150 QL(3 ea daily) pregabalin soln 20 mg/ml 1 daily) MG, 300 MG (Use NF oxcarbazepine) primidone tabs 1 TRILEPTAL TABS 600 MG NF QL(4 ea daily) (Use oxcarbazepine) QUDEXY XR CS24 (Use NF topiramate) VIMPAT SOLN IV 200 3 QL(40 ml daily) PA; QL(80 ml MG/20ML rufinamide susp 40 mg/ml 1 daily) VIMPAT SOLN OR 10 3 PA; QL(40 ml PA; QL(2 ea MG/ML daily) rufinamide tabs 200 mg 1 daily) VIMPAT TABS OR 100 PA; QL(2 ea PA; QL(8 ea MG, 150 MG, 200 MG, 50 3 daily) rufinamide tabs 400 mg 1 daily) MG ZONEGRAN CAPS (Use QL(6 ea daily) TEGRETOL SUSP (Use 2 NF carbamazepine) zonisamide) zonisamide caps 1 QL(6 ea daily) TEGRETOL TABS (Use 2 carbamazepine) TEGRETOL-XR TB12 100 QL(4 ea daily) Carbamates MG, 400 MG (Use NF susp 600 mg/5ml 1 QL(30 ml daily) carbamazepine) QL(9 ea daily) TEGRETOL-XR TB12 200 NF QL(6 ea daily) felbamate tabs 400 mg 1 MG (Use carbamazepine) QL(6 ea daily) TOPAMAX SPRINKLE QL(6 ea daily) felbamate tabs 600 mg 1 CPSP 15 MG (Use NF topiramate) FELBATOL SUSP 600 NF QL(30 ml daily) MG/5ML (Use felbamate) TOPAMAX SPRINKLE QL(8 ea daily) CPSP 25 MG (Use NF FELBATOL TABS 400 MG NF QL(9 ea daily) topiramate) (Use felbamate) FELBATOL TABS 600 MG QL(6 ea daily) TOPAMAX TABS 100 MG, NF QL(4 ea daily) NF 25 MG (Use topiramate) (Use felbamate) GABA Modulators TOPAMAX TABS 200 MG NF QL(2 ea daily) (Use topiramate) GABITRIL TABS 2 MG, 4 NF MG (Use tiagabine hcl) TOPAMAX TABS 50 MG NF QL(6 ea daily) (Use topiramate) SABRIL PACK (Use NF PA; QL(6 ea vigabatrin) daily); SP topiramate cpsp 15 mg 1 QL(6 ea daily) SABRIL TABS (Use NF PA; QL(6 ea topiramate cpsp 25 mg 1 QL(8 ea daily) vigabatrin) daily); SP

Ambetter NH Formulary Updated October 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tiagabine hcl tabs 2 mg, 4 1 DEPACON SOLN (Use NF mg valproate sodium) PA; QL(6 ea vigabatrin pack 4 DEPAKENE CAPS (Use NF daily); SP valproic acid) PA; QL(6 ea vigabatrin tabs 4 DEPAKOTE ER TB24 (Use NF daily); SP divalproex sodium) Hydantoins DEPAKOTE TBEC (Use NF divalproex sodium) CEREBYX SOLN (Use NF fosphenytoin sodium) divalproex sodium tb24 250 1 mg, 500 mg DILANTIN CAPS 100 MG (Use phenytoin sodium 2 divalproex sodium tbec 125 1 extended) mg, 250 mg, 500 mg DILANTIN CAPS 30 MG 2 valproate sodium soln 1

DILANTIN INFATABS 2 valproic acid caps or 1 CHEW (Use phenytoin) ANTIDEPRESSANTS - Drugs to Treat DILANTIN-125 SUSP (Use 2 phenytoin) Depression fosphenytoin sodium soln 1 Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg 1 QL(3 ea daily) PEGANONE TABS 3 QL(1.5 ea mirtazapine tabs 30 mg 1 PHENYTEK CAPS (Use daily) phenytoin sodium 2 extended) mirtazapine tabs 45 mg, 1 QL(1 ea daily) 7.5 mg phenytoin chew 1 mirtazapine tbdp 15 mg 1 QL(3 ea daily) phenytoin sodium extended 1 QL(1.5 ea caps mirtazapine tbdp 30 mg 1 daily) phenytoin sodium soln 1 mirtazapine tbdp 45 mg 1 QL(1 ea daily) phenytoin susp 1 REMERON SOLTAB TBDP NF QL(3 ea daily) 15 MG (Use mirtazapine) Succinimides REMERON SOLTAB TBDP NF QL(1.5 ea CELONTIN CAPS 3 QL(4 ea daily) 30 MG (Use mirtazapine) daily) REMERON SOLTAB TBDP NF QL(1 ea daily) ethosuximide caps 250 mg 1 QL(6 ea daily) 45 MG (Use mirtazapine) REMERON TABS 15 MG QL(3 ea daily) ethosuximide soln 250 1 QL(30 ml daily) NF mg/5ml (Use mirtazapine) REMERON TABS 30 MG QL(1.5 ea ZARONTIN CAPS 250 MG 2 QL(6 ea daily) NF (Use ethosuximide) (Use mirtazapine) daily) ZARONTIN SOLN 250 QL(30 ml daily) Antidepressants - Misc. MG/5ML (Use NF bupropion hcl tabs 100 mg, 1 QL(3 ea daily) ethosuximide) 75 mg Valproic Acid bupropion hcl tb12 100 mg 1 QL(4 ea daily)

Ambetter NH Formulary Updated October 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bupropion hcl tb12 150 mg 1 QL(3 ea daily) CELEXA TABS 10 MG QL(4 ea daily) (Use citalopram NF bupropion hcl tb12 200 mg 1 QL(2 ea daily) hydrobromide) CELEXA TABS 20 MG QL(2 ea daily) bupropion hcl tb24 150 mg 1 QL(3 ea daily) (Use citalopram NF hydrobromide) bupropion hcl tb24 300 mg 1 QL(1 ea daily) CELEXA TABS 40 MG QL(1 ea daily) (Use citalopram NF FORFIVO XL TB24 (Use NF hydrobromide) bupropion hcl) citalopram hydrobromide 1 QL(20 ml daily) maprotiline hcl tabs 1 soln 10 mg/5ml citalopram hydrobromide 1 QL(4 ea daily) WELLBUTRIN SR TB12 QL(4 ea daily) tabs 10 mg 100 MG (Use bupropion NF hcl) citalopram hydrobromide 1 QL(2 ea daily) tabs 20 mg WELLBUTRIN SR TB12 QL(3 ea daily) 150 MG (Use bupropion NF citalopram hydrobromide 1 QL(1 ea daily) hcl) tabs 40 mg WELLBUTRIN SR TB12 QL(2 ea daily) escitalopram oxalate soln 5 1 QL(20 ml daily) 200 MG (Use bupropion NF mg/5ml hcl) escitalopram oxalate tabs 1 QL(2 ea daily) WELLBUTRIN XL TB24 QL(3 ea daily) 10 mg 150 MG (Use bupropion NF escitalopram oxalate tabs 1 QL(1 ea daily) hcl) 20 mg WELLBUTRIN XL TB24 QL(1 ea daily) escitalopram oxalate tabs 5 1 QL(4 ea daily) 300 MG (Use bupropion NF mg hcl) fluoxetine hcl caps 10 mg 1 QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) QL(3 ea daily) EMSAM PT24 3 QL(1 ea daily) fluoxetine hcl caps 20 mg 1 QL(2 ea daily) MARPLAN TABS 2 QL(6 ea daily) fluoxetine hcl caps 40 mg 1 fluoxetine hcl cpdr 90 mg 1 NARDIL TABS (Use NF phenelzine sulfate) fluoxetine hcl soln 20 1 QL(20 ml daily) PARNATE TABS (Use NF mg/5ml tranylcypromine sulfate) fluoxetine hcl tabs 10 mg, 1 QL(1 ea daily) phenelzine sulfate tabs 1 60 mg fluoxetine hcl tabs 20 mg 1 QL(3 ea daily) tranylcypromine sulfate 1 tabs FLUOXETINE QL(1 ea daily) N-Methyl-D- (NMDA) Receptor HYDROCHLORIDE TABS NF (Use fluoxetine hcl) SPRAVATO 56MG DOSE 4 PA SOPK fluvoxamine maleate tabs 1 QL(3 ea daily) 100 mg SPRAVATO 84MG DOSE 4 PA SOPK fluvoxamine maleate tabs 1 QL(2 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs) 25 mg, 50 mg

Ambetter NH Formulary Updated October 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXAPRO TABS 10 MG NF QL(2 ea daily) ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) (Use escitalopram oxalate) (Use sertraline hcl) LEXAPRO TABS 20 MG NF QL(1 ea daily) ZOLOFT TABS 100 MG NF QL(2 ea daily) (Use escitalopram oxalate) (Use sertraline hcl) LEXAPRO TABS 5 MG NF QL(4 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) (Use escitalopram oxalate) MG (Use sertraline hcl) paroxetine hcl susp 10 3 QL(30 ml daily) Serotonin Modulators mg/5ml hcl tabs 1 paroxetine hcl tabs 10 mg 1 QL(6 ea daily) trazodone hcl tabs 1 paroxetine hcl tabs 20 mg 1 QL(3 ea daily) PA; QL(1 ea TRINTELLIX TABS 3 paroxetine hcl tabs 30 mg 1 QL(2 ea daily) daily) PA; 1 rtl pack paroxetine hcl tabs 40 mg 1 QL(1 ea daily) VIIBRYD STARTER PACK 3 lmt amt,180 rtl KIT pack lmt paroxetine hcl tb24 12.5 1 QL(1 ea daily) day(s), mg PA; QL(1 ea VIIBRYD TABS 3 paroxetine hcl tb24 37.5 1 QL(2 ea daily) daily) mg, 25 mg Serotonin-Norepinephrine Reuptake Inhibitors PAXIL CR TB24 12.5 MG NF QL(1 ea daily) (Use paroxetine hcl) CYMBALTA CPEP (Use NF QL(2 ea daily) duloxetine hcl) PAXIL CR TB24 37.5 MG, NF QL(2 ea daily) 25 MG (Use paroxetine hcl) desvenlafaxine succinate 1 QL(4 ea daily) tb24 100 mg PAXIL SUSP 10 MG/5ML 3 QL(30 ml daily) (Use paroxetine hcl) desvenlafaxine succinate 1 QL(1 ea daily) tb24 25 mg, 50 mg PAXIL TABS 10 MG (Use NF QL(6 ea daily) paroxetine hcl) duloxetine hcl cpep or 20 1 QL(2 ea daily) mg, 60 mg, 30 mg PAXIL TABS 20 MG (Use NF QL(3 ea daily) paroxetine hcl) duloxetine hcl cpep or 40 1 mg PAXIL TABS 30 MG (Use NF QL(2 ea daily) paroxetine hcl) EFFEXOR XR CP24 150 NF QL(2 ea daily) MG (Use venlafaxine hcl) PAXIL TABS 40 MG (Use NF QL(1 ea daily) paroxetine hcl) EFFEXOR XR CP24 37.5 NF QL(4 ea daily) MG (Use venlafaxine hcl) PROZAC CAPS 10 MG NF QL(1 ea daily) (Use fluoxetine hcl) EFFEXOR XR CP24 75 NF QL(5 ea daily) MG (Use venlafaxine hcl) PROZAC CAPS 20 MG NF QL(3 ea daily) (Use fluoxetine hcl) FETZIMA CP24 3 PA PROZAC CAPS 40 MG NF QL(2 ea daily) (Use fluoxetine hcl) FETZIMA TITRATION 3 PA PACK C4PK sertraline hcl conc 20 1 QL(10 ml daily) mg/ml KHEDEZLA TB24 (Use NF desvenlafaxine) QL(2 ea daily) sertraline hcl tabs 100 mg 1 PRISTIQ TB24 100 MG QL(4 ea daily) (Use desvenlafaxine NF sertraline hcl tabs 25 mg, 1 QL(4 ea daily) 50 mg succinate)

Ambetter NH Formulary Updated October 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRISTIQ TB24 25 MG, 50 QL(1 ea daily) TOFRANIL TABS (Use NF MG (Use desvenlafaxine NF hcl) succinate) maleate caps 1 venlafaxine hcl cp24 150 1 QL(2 ea daily) mg ANTIDIABETICS - Drugs to Regulate Blood venlafaxine hcl cp24 37.5 1 QL(4 ea daily) Sugar mg Alpha-Glucosidase Inhibitors venlafaxine hcl cp24 75 mg 1 QL(5 ea daily) acarbose tabs 1 QL(3 ea daily) venlafaxine hcl tabs 100 QL(3 ea daily) mg, 25 mg, 37.5 mg, 50 1 GLYSET TABS (Use NF mg, 75 mg miglitol) miglitol tabs 1 venlafaxine hcl tb24 150 1 QL(2 ea daily) mg PRECOSE TABS (Use NF QL(3 ea daily) venlafaxine hcl tb24 225 1 ST; QL(1 ea acarbose) mg daily) venlafaxine hcl tb24 75 mg, QL(1 ea daily) Antidiabetic - Amylin Analogs 1 PA; QL(0.36 ml 37.5 mg SYMLINPEN 120 SOPN 2 daily) Tricyclic Agents PA; QL(0.2 ml SYMLINPEN 60 SOPN 2 hcl tabs 1 daily) Antidiabetic Combinations tabs 3 ACTOPLUS MET TABS QL(2 ea daily) (Use pioglitazone hcl- NF ANAFRANIL CAPS (Use NF hcl) metformin hcl) clomipramine hcl caps 1 DUETACT TABS (Use QL(1 ea daily) pioglitazone hcl- NF glimepiride) hcl tabs 1 glipizide-metformin hcl tabs QL(2 ea daily) hcl caps 1 2.5 mg-250 mg, 2.5 mg- 1 500 mg doxepin hcl conc 1 glipizide-metformin hcl tabs 1 QL(4 ea daily) 5 mg-500 mg imipramine hcl tabs 1 glyburide-metformin tabs 1 QL(2 ea daily) 1.25 mg-250 mg imipramine pamoate caps 1 glyburide-metformin tabs QL(4 ea daily) 2.5 mg-500 mg, 5 mg-500 1 NORPRAMIN TABS (Use NF desipramine hcl) mg nortriptyline hcl caps 1 GLYXAMBI TABS 2 QL(2 ea daily) nortriptyline hcl soln 1 JANUMET TABS 2 JANUMET XR TB24 2 QL(1 ea daily) PAMELOR CAPS (Use NF nortriptyline hcl) KAZANO TABS (Use NF protriptyline hcl tabs 1 alogliptin-metformin hcl)

Ambetter NH Formulary Updated October 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OSENI TABS (Use NF GLUCAGEN HYPOKIT 3 QL(0.035 ea alogliptin-pioglitazone) SOLR daily) QL(1 ea daily) QL(0.035 ea pioglitazone hcl-glimepiride 1 glucagon (rdna) kit 1 tabs daily) pioglitazone hcl-metformin 1 QL(2 ea daily) GLUCAGON QL(0.035 ea hcl tabs EMERGENCY KIT KIT 3 daily) (Use glucagon (rdna)) repaglinide-metformin hcl 1 QL(2 ea daily) tabs GVOKE PFS SOSY 3 QL(0.02 ml daily) SEGLUROMET TABS 2 QL(2 ea daily) PROGLYCEM SUSP (Use NF SYNJARDY TABS 2 QL(2 ea daily) ) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors SYNJARDY XR TB24 10 QL(2 ea daily) MG-1000 MG, 12.5 MG- 2 alogliptin benzoate tabs 1 QL(1 ea daily) 1000 MG, 5 MG-1000 MG JANUVIA TABS 2 QL(1 ea daily) SYNJARDY XR TB24 25 2 QL(1 ea daily) MG-1000 MG NESINA TABS (Use NF TRIJARDY XR TB24 2 alogliptin benzoate) XIGDUO XR TB24 10 MG- PA; QL(1 ea Agonists - Antidiabetic 1000 MG, 10 MG-500 MG, 3 daily) CYCLOSET TABS 3 QL(6 ea daily) 5 MG-500 MG Incretin Mimetic Agents (GLP-1 Receptor XIGDUO XR TB24 2.5 MG- 3 QL(2 ea daily) 1000 MG OZEMPIC SOPN 2 2 PA; QL(0.054 MG/1.5ML ml daily) XIGDUO XR TB24 5 MG- 3 PA; QL(2 ea 1000 MG daily) OZEMPIC SOPN 2 2 PA; QL(0.108 PA; QL(0.5 ml MG/1.5ML, 4 MG/3ML ml daily) XULTOPHY 100/3.6 SOPN 2 daily) PA; QL(0.143 TRULICITY SOPN 2 Biguanides ml daily) PA; QL(0.3 ml metformin hcl tabs 1000 1 QL(2.5 ea VICTOZA SOPN 2 mg daily) daily) metformin hcl tabs 500 mg 1 QL(5 ea daily) Insulin Sensitizing Agents ACTOS TABS (Use NF QL(1 ea daily) metformin hcl tabs 850 mg 1 QL(3 ea daily) pioglitazone hcl) AVANDIA TABS 3 QL(1 ea daily) metformin hcl tb24 500 mg 1 QL(4 ea daily) pioglitazone hcl tabs 1 QL(1 ea daily) metformin hcl tb24 750 mg 1 QL(3 ea daily) Insulin Diabetic Other APIDRA SOLN 3 PA BAQSIMI ONE PACK 3 QL(0.069 ea POWD daily) APIDRA SOLOSTAR 3 PA BAQSIMI TWO PACK 3 QL(0.069 ea SOPN POWD daily) BASAGLAR KWIKPEN 2 diazoxide susp 1 SOPN

Ambetter NH Formulary Updated October 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIASP FLEXTOUCH 2 nateglinide tabs 1 QL(3 ea daily) SOPN repaglinide tabs 0.5 mg, 1 1 QL(4 ea daily) FIASP PENFILL SOCT 2 mg FIASP SOLN 2 repaglinide tabs 2 mg 1 QL(8 ea daily)

HUMULIN R U-500 2 STARLIX TABS (Use NF QL(3 ea daily) (CONCENTRATED) SOLN nateglinide) HUMULIN R U-500 2 Sodium-Glucose Co-Transporter 2 (SGLT2) KWIKPEN SOPN PA; QL(1 ea FARXIGA TABS 3 LEVEMIR FLEXTOUCH 2 daily) SOPN JARDIANCE TABS 2 QL(1 ea daily) LEVEMIR SOLN 2 STEGLATRO TABS 2 QL(1 ea daily) NOVOLIN 70/30 FLEXPEN 2 RELION SUPN Sulfonylureas NOVOLIN 70/30 FLEXPEN 2 SUPN AMARYL TABS 1 MG, 2 NF QL(4 ea daily) MG (Use glimepiride) NOVOLIN 70/30 RELION 2 SUSP AMARYL TABS 4 MG (Use NF QL(2 ea daily) glimepiride) NOVOLIN 70/30 SUSP 2 glimepiride tabs 1 mg, 2 mg 1 QL(4 ea daily) NOVOLIN N RELION 2 SUSP glimepiride tabs 4 mg 1 QL(2 ea daily)

NOVOLIN N SUSP 2 glipizide tabs 10 mg, 5 mg 1 QL(4 ea daily) NOVOLIN R RELION 2 glipizide tb24 10 mg, 2.5 1 QL(2 ea daily) SOLN mg, 5 mg NOVOLIN R SOLN 2 GLUCOTROL TABS (Use NF QL(4 ea daily) glipizide) NOVOLOG FLEXPEN 2 SOPN GLUCOTROL XL TB24 NF QL(2 ea daily) (Use glipizide) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 glyburide micronized tabs 1 QL(4 ea daily) SUPN glyburide tabs 1 QL(4 ea daily) NOVOLOG MIX 70/30 2 SUSP GLYNASE TABS (Use NF QL(4 ea daily) NOVOLOG PENFILL 2 glyburide micronized) SOCT tolbutamide tabs 1 QL(6 ea daily) NOVOLOG SOLN 2 ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs TRESIBA FLEXTOUCH 3 PA to Treat Diarrhea SOPN Antiperistaltic Agents TRESIBA SOLN 3 PA diphenoxylate w/ atropine 1 Meglitinide Analogues liqd

Ambetter NH Formulary Updated October 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diphenoxylate w/ atropine 1 ALOXI SOLN (Use NF tabs palonosetron hcl) IMODIUM A-D CAPS (Use NF RX/OTC ANZEMET TABS 3 PA; QL(0.167 hcl) ea daily) LOMOTIL TABS (Use NF granisetron hcl soln iv 1 1 diphenoxylate w/ atropine) mg/ml loperamide hcl caps 2 mg 1 RX/OTC granisetron hcl tabs or 1 1 QL(0.34 ea mg daily) MOTOFEN TABS 3 ondansetron hcl soln ij 4 1 mg/2ml ANTIDOTES AND SPECIFIC ANTAGONISTS ondansetron hcl soln or 4 1 QL(3.34 ml mg/5ml daily) Antidotes - Chelating Agents ondansetron hcl tabs or 24 1 QL(0.143 ea CHEMET CAPS 3 mg daily) QL(4 ea deferasirox pack 180 mg, PA 4 ondansetron hcl tabs or 4 1 daily,60 ea per 360 mg, 90 mg mg fill retail,60 ea per fill mail) deferasirox tabs 180 mg, 4 PA; SP 360 mg, 90 mg QL(3 ea ondansetron hcl tabs or 8 daily,45 ea per deferasirox tbso 125 mg, 4 PA; SP 1 250 mg, 500 mg mg fill retail,45 ea per fill mail) deferiprone tabs 1 ondansetron tbdp 4 mg 1 QL(1 ea daily) EXJADE TBSO (Use NF PA; SP deferasirox) ondansetron tbdp 8 mg 1 FERRIPROX TABS 500 3 MG (Use deferiprone) palonosetron hcl soln 1 JADENU SPRINKLE PACK NF PA (Use deferasirox) QL(4 ea ZOFRAN TABS 4 MG (Use NF daily,60 ea per JADENU TABS (Use NF PA; SP ondansetron hcl) fill retail,60 ea deferasirox) per fill mail) Antidotes and Specific Antagonists QL(3 ea PA ZOFRAN TABS 8 MG (Use NF daily,45 ea per VISTOGARD PACK 4 ondansetron hcl) fill retail,45 ea per fill mail) Opioid Antagonists Antiemetics - naloxone hcl soln 0.4 1 mg/ml, 4 mg/10ml meclizine hcl tabs 1 RX/OTC naltrexone hcl tabs 1 QL(0.34 ea scopolamine pt72 1 QL(2 ea per fill daily) retail)2 rtl MAX NARCAN LIQD 3 TIGAN CAPS OR 300 MG fill,30 rtl day(s) (Use NF supply, hcl) ANTIEMETICS - Drugs to Treat and TRANSDERM SCOP PT72 2 QL(0.34 ea Vomiting (Use scopolamine) daily) 5-HT3 Receptor Antagonists Ambetter NH Formulary Updated October 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRANSDERM-SCOP PT72 2 QL(0.34 ea (Use scopolamine) daily) ANTIFUNGALS - Drugs to Treat Fungal Infections trimethobenzamide hcl 1 Antifungal - Glucan Synthesis Inhibitors caps CANCIDAS SOLR (Use NF Antiemetics - Miscellaneous caspofungin acetate) caspofungin acetate solr 50 AKYNZEO CAPS OR 0.5 3 PA 1 MG-300 MG mg, 70 mg PA; QL(4 ea ERAXIS SOLR 3 daily)3 rtl MAX fill,365 rtl micafungin sodium solr 100 1 DICLEGIS TBEC (Use NF mg, 50 mg doxylamine-pyridoxine) day(s) supply,3 mail MAX fill,365 mail MYCAMINE SOLR 3 day(s) supply, Antifungals PA; QL(4 ea daily)3 rtl MAX ABELCET SUSP 3 fill,365 rtl doxylamine-pyridoxine tbec 1 day(s) supply,3 AMBISOME SUSR 3 mail MAX fill,365 mail amphotericin b solr 3 day(s) supply, ANCOBON CAPS (Use NF dronabinol caps 1 flucytosine)

MARINOL CAPS (Use NF flucytosine caps 1 dronabinol) griseofulvin microsize susp 1 AL(At least 2 Substance P/Neurokinin 1 (NK1) Receptor 125 mg/5ml yrs old) PA aprepitant caps 1 griseofulvin microsize tabs 1 500 mg aprepitant caps 125 mg, 40 QL(0.067 ea 1 griseofulvin ultramicrosize 1 mg daily) tabs QL(0.134 ea aprepitant caps 80 mg 1 daily) nystatin tabs 1 PA aprepitant misc 1 terbinafine hcl tabs 1 QL(1 ea daily) EMEND CAPS OR 125 QL(0.067 ea Imidazole-Related Antifungals MG, 40 MG (Use NF daily) aprepitant) CRESEMBA CAPS OR 3 PA 186 MG EMEND CAPS OR 80 MG NF QL(0.134 ea (Use aprepitant) daily) DIFLUCAN SUSR (Use NF fluconazole) EMEND SOLR IV 150 MG (Use fosaprepitant NF DIFLUCAN TABS (Use NF dimeglumine) fluconazole) EMEND TRIPACK CAPS NF PA fluconazole susr 1 (Use aprepitant) VARUBI TBPK 3 PA fluconazole tabs 1 PA; QL(4 ea itraconazole caps 100 mg 1 daily) Ambetter NH Formulary Updated October 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(20 ml ALLEGRA ALLERGY QL(2 ea daily) itraconazole soln 10 mg/ml 1 1 daily) CHILDRENS TBDP 30 MG ketoconazole tabs 1 ALLEGRA ALLERGY QL(1 ea daily) TABS 180 MG (Use 1 fexofenadine hcl) NOXAFIL SUSP OR 40 3 QL(20 ml daily) MG/ML ALLEGRA ALLERGY QL(2 ea daily) TABS 60 MG (Use 1 SPORANOX CAPS 100 NF PA; QL(4 ea MG (Use itraconazole) daily) fexofenadine hcl) QL(1 ea daily) SPORANOX PULSEPAK NF PA; QL(4 ea cetirizine hcl caps 10 mg 1 CAPS (Use itraconazole) daily) cetirizine hcl chew 5 mg, 10 QL(1 ea daily) SPORANOX SOLN 10 NF PA; QL(20 ml 1 MG/ML (Use itraconazole) daily) mg PA cetirizine hcl soln 1 mg/ml, 1 QL(10 ml TOLSURA CAPS 4 5 mg/5ml daily); RX/OTC cetirizine hcl syrp 1 mg/ml, QL(10 ml VFEND TABS 200 MG, 50 NF QL(4 ea daily) 1 MG (Use voriconazole) 5 mg/5ml daily); RX/OTC cetirizine hcl tabs 5 mg, 10 QL(1 ea daily) voriconazole tabs or 200 1 QL(4 ea daily) 1 mg, 50 mg mg CLARINEX TABS (Use NF QL(1 ea daily) ANTIHISTAMINES - Drugs to Treat Allergies desloratadine) Antihistamines - Alkylamines CLARITIN ALLERGY CHILDRENS SYRP (Use 1 dexchlorpheniramine 1 maleate soln loratadine) CLARITIN CAPS (Use 1 Antihistamines - Ethanolamines loratadine) carbinoxamine maleate 1 CLARITIN CHEW (Use 1 soln 4 mg/5ml loratadine) carbinoxamine maleate 1 CLARITIN CHILDRENS 1 tabs 4 mg CHEW (Use loratadine) CLEMASTINE FUMARATE 1 CLARITIN REDITABS SYRP 0.67 MG/5ML TBDP 10 MG (Use 1 clemastine fumarate tabs 1 loratadine) 2.68 mg CLARITIN REDITABS 1 hcl caps 1 TBDP 5 MG or 50 mg CLARITIN SYRP (Use 1 diphenhydramine hcl elix or 1 loratadine) 12.5 mg/5ml CLARITIN TABS (Use 1 diphenhydramine hcl liqd or 1 loratadine) 12.5 mg/5ml desloratadine tabs 5 mg 1 QL(1 ea daily) diphenhydramine hcl soln ij 1 50 mg/ml desloratadine tbdp 2.5 mg 1 QL(1 ea daily) Antihistamines - Non-Sedating QL(30 ml daily) ALLEGRA ALLERGY QL(30 ml daily) fexofenadine hcl susp 30 1 mg/5ml CHILDRENS SUSP 30 1 MG/5ML (Use fexofenadine fexofenadine hcl tabs 180 1 QL(1 ea daily) hcl) mg

Ambetter NH Formulary Updated October 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fexofenadine hcl tabs 60 1 QL(2 ea daily) hcl tabs 1 mg levocetirizine QL(10 ml ANTIHYPERLIPIDEMICS - Drugs to Treat High dihydrochloride soln 2.5 1 daily); RX/OTC Cholesterol mg/5ml Antihyperlipidemics - Combinations levocetirizine 1 QL(1 ea daily); dihydrochloride tabs 5 mg RX/OTC ezetimibe-simvastatin tabs 1 QL(1 ea daily) loratadine caps 1 VYTORIN TABS (Use NF QL(1 ea daily) ezetimibe-simvastatin) loratadine chew 1 Antihyperlipidemics - Misc. PA; QL(4 ea loratadine soln 1 icosapent ethyl caps 1 daily) loratadine syrp 1 LOVAZA CAPS (Use NF QL(4 ea daily) omega-3-acid ethyl esters) loratadine tabs 1 omega-3-acid ethyl esters 1 QL(4 ea daily) caps loratadine tbdp 1 VASCEPA CAPS 0.5 GM 3 PA XYZAL ALLERGY 24HR QL(10 ml PA; QL(4 ea CHILDRENS SOLN (Use NF daily); RX/OTC VASCEPA CAPS 1 GM 3 levocetirizine daily) dihydrochloride) Bile Acid Sequestrants XYZAL ALLERGY 24HR QL(1 ea daily); cholestyramine light pack 4 1 QL(6 ea daily) TABS (Use levocetirizine NF RX/OTC gm dihydrochloride) cholestyramine light powd 1 QL(24 gm ZYRTEC ALLERGY CAPS 1 QL(1 ea daily) 4 gm/dose daily) (Use cetirizine hcl) cholestyramine pack 4 gm 1 QL(6 ea daily) ZYRTEC ALLERGY TABS 1 QL(1 ea daily) (Use cetirizine hcl) cholestyramine powd 4 1 QL(25.2 gm ZYRTEC CHILDRENS QL(10 ml gm/dose daily) ALLERGY SOLN (Use 1 daily); RX/OTC colesevelam hcl pack 3.75 1 PA; QL(1 ea cetirizine hcl) gm daily) Antihistamines - colesevelam hcl tabs 625 1 QL(7 ea daily) mg PHENERGAN SOLN (Use NF hcl) COLESTID FLAVORED QL(6 gm daily) GRAN 5 GM (Use NF promethazine hcl soln 1 colestipol hcl) COLESTID FLAVORED QL(6 ea daily) promethazine hcl supp 1 PACK 5 GM/7.5GM (Use NF colestipol hcl) promethazine hcl syrp 1 COLESTID GRAN 5 GM NF QL(6 gm daily) promethazine hcl tabs 1 (Use colestipol hcl) COLESTID PACK 5 GM NF QL(6 ea daily) Antihistamines - Piperidines (Use colestipol hcl) COLESTID TABS 1 GM NF QL(16 ea daily) cyproheptadine hcl syrp 1 (Use colestipol hcl)

Ambetter NH Formulary Updated October 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 gm daily) colestipol hcl gran 5 gm 1 LIVALO TABS 3 ST; QL(1 ea daily) colestipol hcl pack 5 gm 1 QL(6 ea daily) $0 copay for generic only, lovastatin tabs 10 mg, 20 colestipol hcl tabs 1 gm 1 QL(16 ea daily) 1 age 40 to mg 76;QL(1 ea QUESTRAN LIGHT POWD NF QL(24 gm daily); PV (Use cholestyramine light) daily) $0 copay for QUESTRAN PACK 4 GM NF QL(6 ea daily) generic only, (Use cholestyramine) lovastatin tabs 40 mg 1 age 40 to QUESTRAN POWD 4 QL(25.2 gm 76;QL(2 ea GM/DOSE (Use NF daily) daily); PV cholestyramine) PRAVACHOL TABS (Use NF QL(1 ea daily) pravastatin sodium) WELCHOL PACK 3.75 GM NF PA; QL(1 ea (Use colesevelam hcl) daily) pravastatin sodium tabs 1 QL(1 ea daily) WELCHOL TABS 625 MG NF QL(7 ea daily) (Use colesevelam hcl) rosuvastatin calcium tabs 3 QL(1 ea daily) Fibric Acid Derivatives simvastatin tabs 5 mg, 80 1 QL(1 ea daily) fenofibrate micronized caps 1 QL(1 ea daily) mg, 10 mg, 20 mg, 40 mg 134 mg, 200 mg, 67 mg ZOCOR TABS (Use NF QL(1 ea daily) fenofibrate tabs 145 mg, 48 1 QL(1 ea daily) simvastatin) mg, 54 mg, 160 mg Intestinal Cholesterol Absorption Inhibitors FIBRICOR TABS (Use NF fenofibric acid) ezetimibe tabs 1 QL(1 ea daily) gemfibrozil tabs 1 QL(2 ea daily) ZETIA TABS (Use NF QL(1 ea daily) ezetimibe) LIPOFEN CAPS (Use NF fenofibrate) Nicotinic Acid Derivatives niacin (antihyperlipidemic) QL(2 ea daily) LOPID TABS (Use NF QL(2 ea daily) gemfibrozil) tbcr 1000 mg, 500 mg, 750 1 mg TRICOR TABS (Use NF QL(1 ea daily) fenofibrate) NIASPAN TBCR (Use NF QL(2 ea daily) niacin (antihyperlipidemic)) HMG CoA Reductase Inhibitors ST; QL(1 ea Proprotein Convertase Subtilisin/Kexin Type 9 ALTOPREV TB24 3 daily) REPATHA PUSHTRONEX 4 PA; QL(0.25 ml SYSTEM SOCT daily) atorvastatin calcium tabs 1 QL(1 ea daily) REPATHA SOSY 4 PA; QL(0.0714 ml daily) CRESTOR TABS (Use NF QL(1 ea daily) rosuvastatin calcium) REPATHA SURECLICK 4 PA; QL(0.0714 SOAJ ml daily) fluvastatin sodium caps 20 1 QL(1 ea daily) mg ANTIHYPERTENSIVES - Drugs to Treat High fluvastatin sodium caps 40 1 QL(2 ea daily) Blood Pressure mg ACE Inhibitors LIPITOR TABS (Use NF QL(1 ea daily) atorvastatin calcium) ACCUPRIL TABS (Use NF quinapril hcl)

Ambetter NH Formulary Updated October 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALTACE CAPS (Use NF DIOVAN TABS (Use NF QL(1 ea daily) ramipril) valsartan) benazepril hcl tabs 1 EDARBI TABS 3 ST; QL(1 ea daily) captopril tabs 1 eprosartan mesylate tabs 1 QL(1 ea daily) enalapril maleate tabs 10 1 QL(1 ea daily) mg, 2.5 mg, 20 mg, 5 mg irbesartan tabs 1 fosinopril sodium tabs 1 losartan potassium tabs or 1 QL(1 ea daily) 100 mg, 25 mg, 50 mg lisinopril tabs 1 MICARDIS TABS (Use NF QL(1 ea daily) telmisartan) LOTENSIN TABS (Use NF QL(1 ea daily) benazepril hcl) olmesartan medoxomil tabs 1 moexipril hcl tabs 1 telmisartan tabs 1 QL(1 ea daily) perindopril erbumine tabs 1 valsartan tabs 1 QL(1 ea daily) PRINIVIL TABS (Use NF Antiadrenergic Antihypertensives lisinopril) CARDURA TABS (Use NF quinapril hcl tabs 1 doxazosin mesylate) CATAPRES TABS (Use NF QL(8 ea daily) ramipril caps 1 clonidine hcl) CATAPRES-TTS-1 PTWK NF QL(0.15 ea trandolapril tabs 1 (Use clonidine) daily) CATAPRES-TTS-2 PTWK QL(0.15 ea VASOTEC TABS (Use NF NF enalapril maleate) (Use clonidine) daily) CATAPRES-TTS-3 PTWK QL(0.15 ea ZESTRIL TABS (Use NF NF lisinopril) (Use clonidine) daily) Agents for Pheochromocytoma clonidine hcl tabs 1 QL(8 ea daily) DIBENZYLINE CAPS (Use PA NF QL(0.15 ea phenoxybenzamine hcl) clonidine ptwk 3 daily) phenoxybenzamine hcl 3 PA caps doxazosin mesylate tabs 1 Angiotensin II Receptor Antagonists guanfacine hcl tabs 1 ATACAND TABS (Use NF QL(1 ea daily) candesartan cilexetil) MINIPRESS CAPS (Use NF QL(4 ea daily) prazosin hcl) AVAPRO TABS (Use NF QL(1 ea daily) irbesartan) prazosin hcl caps 1 QL(4 ea daily) BENICAR TABS (Use NF QL(1 ea daily) olmesartan medoxomil) terazosin hcl caps 1 QL(1 ea daily) candesartan cilexetil tabs 1 Antihypertensive Combinations COZAAR TABS (Use NF QL(1 ea daily) losartan potassium)

Ambetter NH Formulary Updated October 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCURETIC TABS 10 QL(3 ea daily) EXFORGE TABS (Use MG-12.5 MG (Use NF amlodipine besylate- NF quinapril- valsartan) ) fosinopril sodium & 1 ACCURETIC TABS 12.5 QL(4 ea daily) hydrochlorothiazide tabs MG-20 MG (Use quinapril- NF HYZAAR TABS 12.5 MG- QL(1 ea daily) hydrochlorothiazide) 100 MG, 25 MG-100 MG NF ACCURETIC TABS 20 QL(2 ea daily) (Use losartan potassium & MG-25 MG (Use quinapril- NF hydrochlorothiazide) hydrochlorothiazide) HYZAAR TABS 12.5 MG- QL(2 ea daily) amlodipine besylate- 1 50 MG (Use losartan NF benazepril hcl caps potassium & hydrochlorothiazide) amlodipine besylate- 1 ST olmesartan medoxomil tabs irbesartan- 1 hydrochlorothiazide tabs amlodipine besylate- 1 valsartan tabs lisinopril & 1 hydrochlorothiazide tabs amlodipine-valsartan- 1 hydrochlorothiazide tabs LOPRESSOR HCT TABS ATACAND HCT TABS (Use metoprolol & NF (Use candesartan cilexetil- NF hydrochlorothiazide) hydrochlorothiazide) losartan potassium & QL(1 ea daily) hydrochlorothiazide tabs atenolol & chlorthalidone 1 1 tabs 12.5 mg-100 mg, 25 mg- 100 mg AVALIDE TABS (Use irbesartan- NF losartan potassium & QL(2 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 1 12.5 mg-50 mg AZOR TABS (Use ST amlodipine besylate- NF LOTENSIN HCT TABS olmesartan medoxomil) (Use benazepril & NF hydrochlorothiazide) benazepril & 1 hydrochlorothiazide tabs LOTREL CAPS (Use amlodipine besylate- NF BENICAR HCT TABS (Use benazepril hcl) olmesartan medoxomil- NF hydrochlorothiazide) metoprolol & 1 hydrochlorothiazide tabs bisoprolol & 1 QL(2 ea daily) hydrochlorothiazide tabs MICARDIS HCT TABS (Use telmisartan- NF candesartan cilexetil- 1 hydrochlorothiazide) hydrochlorothiazide tabs olmesartan medoxomil- ST DIOVAN HCT TABS (Use amlodipine- 1 valsartan- NF hydrochlorothiazide tabs hydrochlorothiazide) olmesartan medoxomil- 1 enalapril maleate & 1 hydrochlorothiazide tabs hydrochlorothiazide tabs quinapril- QL(3 ea daily) EXFORGE HCT TABS 2 hydrochlorothiazide tabs 10 1 mg-12.5 mg

Ambetter NH Formulary Updated October 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits quinapril- QL(4 ea daily) Selective Aldosterone Receptor Antagonists hydrochlorothiazide tabs 1 12.5 mg-20 mg eplerenone tabs 1 quinapril- QL(2 ea daily) INSPRA TABS (Use NF hydrochlorothiazide tabs 20 1 eplerenone) mg-25 mg Vasodilators TARKA TBCR (Use NF trandolapril-verapamil hcl) hydralazine hcl soln 1 telmisartan-amlodipine tabs 1 hydralazine hcl tabs 1 telmisartan- 1 hydrochlorothiazide tabs minoxidil tabs 1 TENORETIC 100 TABS (Use atenolol & NF ANTIMALARIALS - Drugs to Treat Malaria chlorthalidone) (Parasitic Infections) TENORETIC 50 TABS Antimalarial Combinations (Use atenolol & NF Covered for chlorthalidone) malaria treatment only. trandolapril-verapamil hcl 1 tbcr Limit 1 fill every 180 TRANDOLAPRIL/VERAPA 2 MIL HCL ER TBCR days;QL(12 ea atovaquone-proguanil hcl 1 per fill retail,12 TRIBENZOR TABS (Use ST tabs ea per fill olmesartan medoxomil- NF mail)1 rtl MAX amlodipine- fill,180 rtl hydrochlorothiazide) day(s) supply,1 TWYNSTA TABS (Use NF mail MAX telmisartan-amlodipine) fill,180 mail day(s) supply, valsartan- 1 hydrochlorothiazide tabs Covered for VASERETIC TABS (Use malaria enalapril maleate & NF treatment only. hydrochlorothiazide) Limit 1 fill every ZESTORETIC TABS (Use 180 lisinopril & NF days;QL(24 ea hydrochlorothiazide) 2 per fill retail,24 COARTEM TABS ea per fill ZIAC TABS (Use bisoprolol NF QL(2 ea daily) mail)1 rtl MAX & hydrochlorothiazide) fill,180 rtl Antihypertensives - Misc. day(s) supply,1 PA mail MAX VECAMYL TABS 3 fill,180 mail day(s) supply, Direct Renin Inhibitors aliskiren fumarate tabs 1 QL(1 ea daily)

TEKTURNA TABS (Use NF QL(1 ea daily) aliskiren fumarate)

Ambetter NH Formulary Updated October 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Covered for Antimyasthenic/Cholinergic Agents malaria treatment only. FIRDAPSE TABS 4 PA Limit 1 fill every 180 GUANIDINE HCL TABS 2 days;QL(12 ea MESTINON SOLN (Use MALARONE TABS (Use NF per fill retail,12 NF atovaquone-proguanil hcl) ea per fill pyridostigmine bromide) mail)1 rtl MAX MESTINON TABS (Use NF fill,180 rtl pyridostigmine bromide) day(s) supply,1 MESTINON TIMESPAN mail MAX TBCR (Use pyridostigmine NF fill,180 mail bromide) day(s) supply, NEOSTIGMINE PA Antimalarials METHYLSULFATE SOSY 3 3 MG/3ML chloroquine phosphate 1 tabs pyridostigmine bromide 1 PA; QL(3 ea soln 60 mg/5ml DARAPRIM TABS 3 daily) pyridostigmine bromide 1 tabs 60 mg hydroxychloroquine sulfate 1 tabs 200 mg pyridostigmine bromide tbcr 1 QL(2 ea per 30 180 mg KRINTAFEL TABS 3 PA; QL(10 ea days retail) RUZURGI TABS 4 Covered for daily) malaria ANTIMYCOBACTERIAL AGENTS - Drugs to treatment only. Treat Tuberculosis (Bacterial Infections) Limit 1 fill every 180 days;QL(5 Anti TB Combinations mefloquine hcl tabs 1 ea daily)1 rtl RIFAMATE CAPS 3 MAX fill,180 rtl day(s) supply,1 RIFATER TABS 3 QL(6 ea daily) mail MAX fill,180 mail Antimycobacterial Agents day(s) supply, CAPASTAT SULFATE 3 PLAQUENIL TABS (Use NF SOLR hydroxychloroquine sulfate) caps 1 QL(4 ea daily) primaquine phosphate tabs 3 PRIMAQUINE ethambutol hcl tabs 1 PHOSPHATE TABS (Use NF primaquine phosphate) isoniazid soln 1 PA; QL(3 ea pyrimethamine tabs 1 daily) isoniazid syrp 1 QUALAQUIN CAPS (Use NF PA; quinine sulfate) isoniazid tabs 1 quinine sulfate caps 1 PA; MYAMBUTOL TABS (Use NF ethambutol hcl) ANTIMYASTHENIC/CHOLINERGIC AGENTS Ambetter NH Formulary Updated October 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYCOBUTIN CAPS (Use NF PA GLEOSTINE CAPS 100 4 PA rifabutin) MG, 40 MG PASER PACK 3 QL(3 ea daily) IFEX SOLR 1 GM (Use NF PA; SP ifosfamide) PRIFTIN TABS 3 ifosfamide soln 1 gm/20ml 4 PA; SP pyrazinamide tabs 1 ifosfamide solr 1 gm 4 PA; SP PA rifabutin caps 1 LEUKERAN TABS 4 PA; SP RIFADIN CAPS (Use NF rifampin) melphalan hcl solr 1 RIFADIN SOLR (Use NF melphalan tabs 1 rifampin) PA; SP rifampin caps 1 MYLERAN TABS 4 oxaliplatin soln 100 4 PA; SP rifampin solr 1 mg/20ml, 50 mg/10ml SIRTURO TABS 100 MG 3 PA TEMODAR CAPS OR 100 PA; SP MG, 140 MG, 180 MG, 20 NF TRECATOR TABS 3 QL(4 ea daily) MG, 250 MG, 5 MG (Use temozolomide) ANTINEOPLASTICS AND ADJUNCTIVE TEMODAR SOLR IV 100 4 PA; SP THERAPIES - Drugs to Treat Cancer MG Alkylating Agents temozolomide caps 4 PA; SP ALKERAN SOLR (Use NF TEPADINA SOLR 100 MG NF SP melphalan hcl) (Use thiotepa) ALKERAN TABS (Use NF TEPADINA SOLR 15 MG NF PA; SP melphalan) (Use thiotepa) BICNU SOLR (Use NF PA; SP PA; SP carmustine) thiotepa solr 15 mg 4 PA; SP busulfan soln 4 TREANDA SOLR 4 PA; SP BUSULFEX SOLN (Use NF PA; SP PA; SP busulfan) ZANOSAR SOLR 4 carboplatin soln 50 mg/5ml 4 PA; SP Antimetabolites ALIMTA SOLR 500 MG 4 PA; SP carmustine solr 4 PA; SP ARRANON SOLN 4 PA; SP cisplatin soln 100 4 PA; SP mg/100ml azacitidine susr 4 PA; SP cyclophosphamide caps or 1 PA 25 mg, 50 mg capecitabine tabs 4 PA; SP cyclophosphamide solr ij 1 4 PA; SP gm, 2 gm, 500 mg clofarabine soln 4 PA; SP GLEOSTINE CAPS 10 MG 4 PA; SP

Ambetter NH Formulary Updated October 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLOLAR SOLN (Use NF PA; SP LENVIMA 12MG DAILY 4 PA; QL(3 ea clofarabine) DOSE CPPK daily) cytarabine soln 100 mg/ml, 4 PA; SP LENVIMA 14 MG DAILY 4 PA; QL(2 ea 20 mg/ml DOSE CPPK daily) DACOGEN SOLR (Use NF PA; SP LENVIMA 18 MG DAILY 4 PA; QL(3 ea decitabine) DOSE CPPK daily) decitabine solr 4 PA; SP LENVIMA 20 MG DAILY 4 PA; QL(2 ea DOSE CPPK daily) PA; SP floxuridine solr 4 LENVIMA 24 MG DAILY 4 PA; QL(3 ea DOSE CPPK daily) PA; SP fludarabine phosphate soln 4 LENVIMA 4 MG DAILY 4 PA; QL(1 ea DOSE CPPK daily) fludarabine phosphate solr 4 PA; SP LENVIMA 8 MG DAILY 4 PA; QL(2 ea DOSE CPPK daily) fluorouracil soln 500 4 PA; SP mg/10ml MVASI SOLN 4 PA FOLOTYN SOLN 20 4 PA; SP MG/ML ZALTRAP SOLN 100 4 PA; SP MG/4ML gemcitabine hcl solr 2 gm, 4 PA; SP 200 mg ZIRABEV SOLN 4 PA GEMCITABINE HYDROCHLORIDE SOLN Antineoplastic - Anti-HER2 Agents 1 GM/10ML, 2 GM/20ML, NF HERCEPTIN SOLR 4 PA; SP 200 MG/2ML (Use gemcitabine hcl) PERJETA SOLN 4 PA; SP mercaptopurine tabs 1 TUKYSA TABS 4 PA methotrexate sodium soln ij 1 250 mg/10ml, 50 mg/2ml Antineoplastic - Antibodies methotrexate sodium solr ij 1 SP ADCETRIS SOLR 4 PA; SP 1 gm PA; SP methotrexate sodium tabs 1 SP ARZERRA CONC 4 or 2.5 mg PA; SP TABLOID TABS 4 PA; SP RITUXAN SOLN 4 PA TREXALL TABS 4 PA; SP RUXIENCE SOLN 4 PA; SP VIDAZA SUSR (Use NF PA; SP YERVOY SOLN 4 azacitidine) Antineoplastic - EGFR Inhibitors XELODA TABS (Use NF PA; SP capecitabine) ERBITUX SOLN 4 PA; SP Antineoplastic - Angiogenesis Inhibitors PA; QL(1 ea erlotinib hcl tabs 4 INLYTA TABS 4 PA; QL(2 ea daily); SP daily); SP PA; QL(1 ea GILOTRIF TABS 4 LENVIMA 10 MG DAILY 4 PA; QL(1 ea daily) DOSE CPPK daily) TARCEVA TABS (Use NF PA; QL(1 ea erlotinib hcl) daily); SP Ambetter NH Formulary Updated October 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VECTIBIX SOLN 100 PA; SP PA; QL(6 ea 4 flutamide caps 4 MG/5ML daily); SP PA; QL(0.357 VIZIMPRO TABS 4 PA fulvestrant soln 4 ml daily) Antineoplastic - Hedgehog Pathway Inhibitors letrozole tabs 1 DAURISMO TABS 4 PA leuprolide acetate kit 4 PA; SP PA; QL(1 ea ERIVEDGE CAPS 4 daily); SP LUPRON DEPOT (1- 4 PA; QL(0.0357 MONTH) KIT ea daily); SP PA; QL(1 ea ODOMZO CAPS 4 daily) LUPRON DEPOT (3- 4 PA; SP MONTH) KIT Antineoplastic - Hormonal and Related Agents LUPRON DEPOT (4- 4 PA; QL(0.1339 abiraterone acetate tabs 4 PA; QL(4 ea MONTH) KIT ea daily); SP 250 mg daily); SP LUPRON DEPOT (6- 4 PA; QL(0.0089 abiraterone acetate tabs 4 PA; SP MONTH) KIT ea daily); SP 500 mg LYSODREN TABS 4 PA; SP anastrozole tabs 1 QL(1 ea daily) megestrol acetate susp 1 ARIMIDEX TABS (Use NF QL(1 ea daily) anastrozole) megestrol acetate tabs 1 AROMASIN TABS (Use NF QL(1 ea daily); exemestane) SP NILANDRON TABS (Use NF QL(2 ea daily) PA; QL(1 ea nilutamide) bicalutamide tabs 4 daily); SP nilutamide tabs 1 QL(2 ea daily) CASODEX TABS (Use NF PA; QL(1 ea bicalutamide) daily); SP NUBEQA TABS 4 PA ELIGARD KIT 22.5 MG 4 PA; SP tamoxifen citrate tabs 0 ELIGARD KIT 30 MG 4 PA; SP toremifene citrate tabs 1 ELIGARD KIT 45 MG 4 PA; SP TRELSTAR MIXJECT 4 PA; SP PA; QL(0.0089 SUSR ELIGARD KIT 7.5 MG 4 ea daily); SP XTANDI CAPS 40 MG 4 PA; QL(4 ea daily); SP EMCYT CAPS 4 PA; SP YONSA TABS 4 PA QL(1 ea daily); exemestane tabs 4 SP ZOLADEX IMPL 10.8 MG 4 PA; QL(0.0119 ea daily); SP FARESTON TABS (Use NF toremifene citrate) ZOLADEX IMPL 3.6 MG 4 PA; QL(0.0357 ea daily); SP FASLODEX SOLN (Use NF PA; QL(0.357 fulvestrant) ml daily) ZYTIGA TABS 250 MG NF PA; QL(4 ea (Use abiraterone acetate) daily); SP FEMARA TABS (Use NF letrozole) ZYTIGA TABS 500 MG 4 PA; SP PA; QL(0.143 (Use abiraterone acetate) FIRMAGON SOLR 4 ea daily); SP Antineoplastic - Immunomodulators

Ambetter NH Formulary Updated October 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits idarubicin hcl soln 20 PA POMALYST CAPS 4 PA; QL(1 ea 4 daily) mg/20ml Antineoplastic - PDGFR-alpha Inhibitors mitomycin solr iv 20 mg 4 PA; SP AYVAKIT TABS 4 PA; SL(1 ea daily) mitoxantrone hcl conc 4 PA; SP Antineoplastic - XPO1 Inhibitors valrubicin soln 4 PA; SP XPOVIO 100 MG ONCE 4 PA WEEKLY TBPK VALSTAR SOLN (Use NF PA; SP valrubicin) XPOVIO 60 MG ONCE 4 PA WEEKLY TBPK Antineoplastic Enzyme Inhibitors XPOVIO 80 MG ONCE 4 PA AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea WEEKLY TBPK MG, 7.5 MG (Use NF daily); SP everolimus) XPOVIO 80 MG TWICE 4 PA WEEKLY TBPK PA; QL(4 ea ALECENSA CAPS 4 Antineoplastic Antibiotics daily) PA; QL(1 ea bleomycin sulfate solr 15 4 PA; SP ALUNBRIG TABS 4 unit daily) PA; QL(1 ea COSMEGEN SOLR (Use NF PA; SP ALUNBRIG TBPK 4 dactinomycin) daily) PA dactinomycin solr 4 PA; SP BALVERSA TABS 4 DAUNORUBICIN BORTEZOMIB SOLR 4 PA; SP HYDROCHLORIDE SOLN NF 20 MG/4ML (Use BOSULIF TABS 100 MG, 4 PA; QL(1 ea daunorubicin hcl) 500 MG daily); SP PA; DOXIL INJ (Use NF PA; SP BOSULIF TABS 400 MG 4 doxorubicin hcl liposomal) PA; SP doxorubicin hcl liposomal 4 PA; SP BRAFTOVI CAPS 4 inj BRUKINSA CAPS 4 PA doxorubicin hcl soln 4 PA; SP CAPRELSA TABS 4 PA; QL(1 ea doxorubicin hcl solr 4 PA; SP daily); SP PA; QL(2 ea ELLENCE SOLN 50 PA; SP COMETRIQ KIT 4 MG/25ML (Use epirubicin NF daily); SP PA; QL(4 ea hcl) COMETRIQ KIT 4 epirubicin hcl soln 50 PA; SP daily); SP 4 PA; QL(3 ea mg/25ml COMETRIQ KIT 4 IDAMYCIN PFS SOLN 10 PA; SP daily); SP MG/10ML, 5 MG/5ML (Use NF COPIKTRA CAPS 4 PA idarubicin hcl) PA; QL(1 ea IDAMYCIN PFS SOLN 20 PA everolimus tabs 4 MG/20ML (Use idarubicin NF daily); SP hcl) GLEEVEC TABS (Use NF PA; QL(2 ea imatinib mesylate) daily); SP idarubicin hcl soln 10 4 PA; SP mg/10ml, 5 mg/5ml Ambetter NH Formulary Updated October 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IBRANCE CAPS 3 PA PEMAZYRE TABS 4 PA; QL(1 ea daily) PA IBRANCE TABS 3 PIQRAY 200MG DAILY 4 PA DOSE TBPK ICLUSIG TABS 10 MG, 30 PA; QL(1 ea 4 PIQRAY 250MG DAILY 4 PA MG, 45 MG daily) DOSE TBPK PA; QL(2 ea ICLUSIG TABS 15 MG 4 PIQRAY 300MG DAILY 4 PA daily) DOSE TBPK PA; QL(2 ea imatinib mesylate tabs 4 PA daily); SP QINLOCK TABS 4 IMBRUVICA CAPS 140 4 PA; QL(3 ea PA MG daily) RETEVMO CAPS 4 PA; QL(1 ea ROMIDEPSIN SOLR 10 PA; SP IMBRUVICA CAPS 70 MG 4 4 daily) MG IMBRUVICA TABS 140 PA; QL(1 ea ROZLYTREK CAPS 4 PA MG, 280 MG, 420 MG, 560 4 daily) MG RUBRACA TABS 4 PA; QL(4 ea daily) INREBIC CAPS 4 PA PA; QL(1 ea SPRYCEL TABS 4 ISTODAX (OVERFILL) 4 PA; SP daily); SP SOLR PA; QL(4 ea STIVARGA TABS 4 JAKAFI TABS 10 MG, 20 4 PA; SP daily); SP MG sunitinib malate caps 12.5 4 PA; QL(1 ea JAKAFI TABS 15 MG, 25 4 PA; QL(2 ea mg, 25 mg, 50 mg daily); SP MG, 5 MG daily); SP SUTENT CAPS 12.5 MG, PA; QL(1 ea KISQALI TBPK 3 PA 25 MG, 50 MG (Use 4 daily); SP sunitinib malate) PA KOSELUGO CAPS 4 TABRECTA TABS 4 PA PA KYPROLIS SOLR 4 TAFINLAR CAPS 4 PA; QL(4 ea daily) PA; QL(6 ea lapatinib ditosylate tabs 4 PA daily); SP TALZENNA CAPS 4 PA LORBRENA TABS 4 TASIGNA CAPS 150 MG, 4 PA; QL(4 ea 200 MG daily); SP PA; QL(16 ea LYNPARZA TABS 4 TASIGNA CAPS 50 MG 4 PA; QL(4 ea daily) daily) MEKINIST TABS 0.5 MG 4 PA; QL(3 ea PA daily) TAZVERIK TABS 4 PA; QL(1 ea MEKINIST TABS 2 MG 4 temsirolimus soln 4 PA; QL(0.143 daily) ml daily); SP PA; SP MEKTOVI TABS 4 TIBSOVO TABS 4 PA PA; QL(4 ea NEXAVAR TABS 4 TORISEL SOLN (Use NF PA; QL(0.143 daily); SP temsirolimus) ml daily); SP NINLARO CAPS 4 PA; QL(0.143 PA; AC ea daily) TURALIO CAPS 4

Ambetter NH Formulary Updated October 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYKERB TABS (Use 4 PA; QL(6 ea INTRON A SOLR 18 MU 4 PA; SP lapatinib ditosylate) daily); SP PA; SP VELCADE SOLR 4 PA; SP MATULANE CAPS 4 PA; SP VERZENIO TABS 4 PA NIPENT SOLR 4 PA; SP VITRAKVI CAPS 4 PA PHOTOFRIN SOLR 4 PA; SP VITRAKVI SOLN 4 PA PROLEUKIN SOLR 4 PA; SP VOTRIENT TABS 4 PA; QL(4 ea SYLATRON KIT 4 daily); SP PA; SP XALKORI CAPS 4 PA; QL(2 ea SYNRIBO SOLR 4 daily); SP TARGRETIN CAPS OR 75 NF PA; SP XOSPATA TABS 4 PA MG (Use bexarotene) tretinoin (chemotherapy) ZEJULA CAPS 4 PA; QL(3 ea 1 daily) caps PA; SP ZELBORAF TABS 4 PA; SP UVADEX SOLN 4 PA; QL(4 ea Chemotherapy Adjuncts ZOLINZA CAPS 4 daily); SP KEPIVANCE SOLR 4 PA; SP PA; QL(2 ea ZYDELIG TABS 4 daily) Chemotherapy Rescue/Antidote/Protective Agents PA; QL(5 ea ZYKADIA CAPS 4 leucovorin calcium solr ij daily) 500 mg, 100 mg, 200 mg, 1 Antineoplastic Enzymes 350 mg, 50 mg PA; SP leucovorin calcium tabs or 1 ERWINASE SOLR 4 25 mg, 5 mg, 10 mg, 15 mg PA; SP ERWINAZE SOLR 4 PA; SP VORAXAZE SOLR 4

ONCASPAR SOLN 4 PA; SP Mitotic Inhibitors ABRAXANE SUSR 4 PA; SP Antineoplastics Misc. PA; SP ACTIMMUNE SOLN 4 PA; SP docetaxel conc 20 mg/ml 4 DOCETAXEL CONC 20 PA; SP arsenic trioxide soln 10 4 PA; SP NF mg/10ml MG/ML (Use docetaxel) PA; SP DOCETAXEL CONC 80 NF bexarotene caps 4 MG/4ML (Use docetaxel) PA; SP dacarbazine solr 200 mg 4 DOCETAXEL SOLN 20 4 PA; SP MG/2ML HYDREA CAPS (Use NF PA; SP hydroxyurea) docetaxel soln 20 mg/2ml 4 hydroxyurea caps 1 DOCETAXEL SOLN 20 4 PA; SP MG/2ML (Use docetaxel)

Ambetter NH Formulary Updated October 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ETOPOPHOS SOLR 4 PA; SP benztropine mesylate soln 1 etoposide caps 4 PA; SP benztropine mesylate tabs 1 etoposide soln 4 PA; SP COGENTIN SOLN (Use NF benztropine mesylate) PA; SP HALAVEN SOLN 4 hcl soln 1 IXEMPRA KIT SOLR 15 4 PA; SP MG trihexyphenidyl hcl tabs 1 JEVTANA SOLN 4 PA; SP Antiparkinson COMT Inhibitors COMTAN TABS (Use NF QL(8 ea daily) NAVELBINE SOLN 10 PA; SP ) MG/ML (Use vinorelbine NF tartrate) entacapone tabs 1 QL(8 ea daily) paclitaxel conc 150 PA; SP 4 TASMAR TABS (Use NF mg/25ml, 100 mg/16.7ml, 6 ) mg/ml tolcapone tabs 1 TAXOTERE CONC (Use NF PA; SP docetaxel) Antiparkinson TENIPOSIDE SOLN 4 PA; SP hcl caps 1 vincristine sulfate soln 4 PA; SP amantadine hcl syrp 1 vinorelbine tartrate soln 10 4 PA; SP mg/ml amantadine hcl tabs 1 Topoisomerase I Inhibitors PA; CAMPTOSAR SOLN 100 PA; SP APOKYN SOCT 4 MG/5ML, 40 MG/2ML (Use NF mesylate 1 irinotecan hcl) caps HYCAMTIN CAPS OR 0.25 PA; SP 4 bromocriptine mesylate 1 MG, 1 MG tabs HYCAMTIN SOLR IV 4 MG NF PA; SP (Use topotecan hcl) -levodopa tabs 1 irinotecan hcl soln 100 4 PA; SP carbidopa-levodopa tbcr 1 mg/5ml, 40 mg/2ml topotecan hcl solr 4 mg 4 PA; SP carbidopa-levodopa tbdp 1 ANTIPARKINSON AND RELATED THERAPY carbidopa-levodopa- 1 AGENTS - Drugs to Treat Parkinson's Disease entacapone tabs MIRAPEX TABS 0.125 MG QL(4 ea daily) Antiparkinson Adjunctive Therapy (Use NF carbidopa tabs 1 dihydrochloride) MIRAPEX TABS 0.25 MG, LODOSYN TABS (Use NF 0.5 MG, 0.75 MG, 1 MG, NF carbidopa) 1.5 MG (Use pramipexole Antiparkinson Anticholinergics dihydrochloride)

Ambetter NH Formulary Updated October 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUPRO PT24 2 STALEVO 150 TABS (Use carbidopa-levodopa- NF entacapone) PARLODEL CAPS (Use NF bromocriptine mesylate) STALEVO 200 TABS (Use carbidopa-levodopa- 1 PARLODEL TABS (Use NF bromocriptine mesylate) entacapone) pramipexole QL(4 ea daily) STALEVO 200 TABS (Use dihydrochloride tabs 0.125 1 carbidopa-levodopa- NF mg entacapone) pramipexole STALEVO 50 TABS (Use carbidopa-levodopa- 1 dihydrochloride tabs 0.25 1 mg, 0.5 mg, 0.75 mg, 1 mg, entacapone) 1.5 mg STALEVO 75 TABS (Use REQUIP XL TB24 12 MG, ST; QL(2 ea carbidopa-levodopa- 1 8 MG (Use NF daily) entacapone) hydrochloride) STALEVO 75 TABS (Use REQUIP XL TB24 4 MG, 6 ST; QL(1 ea carbidopa-levodopa- NF MG (Use ropinirole NF daily) entacapone) hydrochloride) Antiparkinson Monoamine Oxidase Inhibitors ropinirole hydrochloride AZILECT TABS (Use NF PA; QL(1 ea tabs 0.25 mg, 3 mg, 1 mg, 1 mesylate) daily) 2 mg, 4 mg, 5 mg, 0.5 mg PA; QL(1 ea rasagiline mesylate tabs 1 ropinirole hydrochloride 1 ST; QL(2 ea daily) tb24 12 mg, 8 mg daily) hcl caps 1 ropinirole hydrochloride 1 ST; QL(1 ea tb24 2 mg, 4 mg, 6 mg daily) selegiline hcl tabs 1 SINEMET CR TBCR (Use NF carbidopa-levodopa) /ANTIMANIC AGENTS - SINEMET TABS (Use NF Drugs to Treat Mood Disorders carbidopa-levodopa) STALEVO 100 TABS (Use Antimanic Agents carbidopa-levodopa- 1 lithium carbonate caps 1 entacapone) STALEVO 100 TABS (Use lithium carbonate tabs 1 carbidopa-levodopa- NF entacapone) lithium carbonate tbcr 1 STALEVO 125 TABS (Use carbidopa-levodopa- 1 LITHIUM SOLN 1 entacapone) LITHOBID TBCR (Use NF STALEVO 125 TABS (Use lithium carbonate) carbidopa-levodopa- NF entacapone) Antipsychotics - Misc. ST; QL(2 ea STALEVO 150 TABS (Use EQUETRO CP12 100 MG 3 carbidopa-levodopa- 1 daily) entacapone) EQUETRO CP12 200 MG 3 ST; QL(8 ea daily)

Ambetter NH Formulary Updated October 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALDOL DECANOATE 50 QL(0.036 ml EQUETRO CP12 300 MG 3 ST; QL(4 ea daily) SOLN (Use NF daily) GEODON CAPS OR 20 QL(2 ea daily); decanoate) MG, 40 MG, 60 MG, 80 MG NF AL(At least 18 HALDOL SOLN (Use NF (Use hcl) yrs old) haloperidol lactate) PA; QL(1 ea QL(0.036 ml LATUDA TABS 3 soln 1 daily) daily) QL(2 ea daily); haloperidol lactate conc 1 ziprasidone hcl caps 1 AL(At least 18 yrs old) haloperidol lactate soln 1 Benzisoxazoles PA; QL(2 ea haloperidol tabs 1 FANAPT TABS 2 daily) Dibenzapines FANAPT TITRATION 2 PA PACK TABS maleate subl 10 1 PA; QL(2 ea mg, 5 mg daily) INVEGA TB24 1.5 MG, 3 QL(1 ea daily) MG, 9 MG (Use NF asenapine maleate subl 2.5 1 PA; QL(4 ea ) mg daily) tabs 200 mg, 50 INVEGA TB24 6 MG (Use NF QL(2 ea daily) 1 paliperidone) mg, 100 mg, 25 mg QL(9 ea daily) paliperidone tb24 1.5 mg, 3 1 QL(1 ea daily) clozapine tbdp 100 mg 1 mg, 9 mg QL(2 ea daily) clozapine tbdp 12.5 mg, 1 QL(6 ea daily) paliperidone tb24 6 mg 1 150 mg QL(4 ea daily) PERSERIS PRSY 2 PA; QL(0.072 clozapine tbdp 200 mg 1 ea daily) clozapine tbdp 25 mg 1 QL(3 ea daily) RISPERDAL CONSTA 2 PA; QL(0.072 SRER ea daily) CLOZARIL TABS (Use NF RISPERDAL SOLN 1 NF QL(8 ml daily) clozapine) MG/ML (Use ) FAZACLO TBDP 100 MG NF QL(9 ea daily) RISPERDAL TABS 0.25 QL(4 ea daily) (Use clozapine) MG, 0.5 MG, 1 MG, 2 MG, NF 3 MG, 4 MG (Use FAZACLO TBDP 12.5 MG NF QL(6 ea daily) risperidone) (Use clozapine) QL(8 ml daily) FAZACLO TBDP 150 MG 1 QL(6 ea daily) risperidone soln 1 mg/ml 1 (Use clozapine) risperidone tabs 0.25 mg, QL(4 ea daily) FAZACLO TBDP 200 MG 1 QL(4 ea daily) 0.5 mg, 1 mg, 2 mg, 3 mg, 1 (Use clozapine) 4 mg FAZACLO TBDP 25 MG NF QL(3 ea daily) risperidone tbdp 0.25 mg, QL(2 ea daily) (Use clozapine) 0.5 mg, 1 mg, 2 mg, 3 mg, 1 succinate caps 1 4 mg QL(0.215 ea Butyrophenones solr im 10 mg 1 daily) HALDOL DECANOATE QL(0.036 ml 100 SOLN (Use haloperidol NF daily) olanzapine tabs or 10 mg, 1 QL(2 ea daily) decanoate) 15 mg, 20 mg, 7.5 mg

Ambetter NH Formulary Updated October 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine tabs or 2.5 mg, 1 QL(4 ea daily) ZYPREXA TABS OR 2.5 QL(4 ea daily) 5 mg MG, 5 MG (Use NF olanzapine) olanzapine tbdp or 10 mg, 1 QL(2 ea daily) 15 mg, 5 mg ZYPREXA ZYDIS TBDP 10 QL(2 ea daily) QL(1 ea daily) MG, 15 MG, 5 MG (Use NF olanzapine tbdp or 20 mg 1 olanzapine) fumarate tabs QL(4 ea daily); ZYPREXA ZYDIS TBDP 20 NF QL(1 ea daily) 100 mg, 200 mg, 25 mg, 50 1 AL(At least 10 MG (Use olanzapine) mg yrs old) Phenothiazines QL(2 ea daily); hcl soln ij quetiapine fumarate tabs 1 AL(At least 10 3 300 mg, 400 mg 25 mg/ml, 50 mg/2ml yrs old) chlorpromazine hcl tabs or PA; QL(1 ea 10 mg, 100 mg, 200 mg, 25 1 quetiapine fumarate tb24 1 daily); AL(At mg, 50 mg 150 mg, 200 mg, 50 mg least 10 yrs old) hcl conc or 5 1 mg/ml PA; QL(2 ea fluphenazine hcl elix or 2.5 quetiapine fumarate tb24 1 daily); AL(At 1 300 mg, 400 mg least 10 yrs mg/5ml old) fluphenazine hcl soln ij 2.5 1 SAPHRIS SUBL 10 MG, 5 PA; QL(2 ea mg/ml MG (Use asenapine 3 daily) fluphenazine hcl tabs or 1 1 maleate) mg, 10 mg, 2.5 mg, 5 mg SAPHRIS SUBL 2.5 MG 3 PA; QL(4 ea tabs 1 (Use asenapine maleate) daily) maleate SAPHRIS SUBL 5 MG 3 PA; QL(2 ea 1 daily) tabs SEROQUEL TABS 100 QL(4 ea daily); prochlorperazine supp 1 MG, 200 MG, 25 MG, 50 NF AL(At least 10 MG (Use quetiapine yrs old) hcl tabs 1 fumarate) SEROQUEL TABS 300 QL(2 ea daily); hcl tabs 1 MG, 400 MG (Use NF AL(At least 10 quetiapine fumarate) yrs old) Quinolinone Derivatives PA; QL(1 ea QL(1 ea daily); SEROQUEL XR TB24 150 ABILIFY TABS (Use NF daily); AL(At ) AL(At least 6 MG, 200 MG, 50 MG (Use NF yrs old) quetiapine fumarate) least 10 yrs old) QL(30 ml PA; QL(2 ea aripiprazole soln 1 mg/ml 3 daily); AL(At SEROQUEL XR TB24 300 daily); AL(At least 6 yrs old) MG, 400 MG (Use NF quetiapine fumarate) least 10 yrs aripiprazole tabs 10 mg, 15 QL(1 ea daily); old) mg, 2 mg, 20 mg, 30 mg, 5 1 AL(At least 6 mg yrs old) ZYPREXA SOLR IM 10 NF QL(0.215 ea MG (Use olanzapine) daily) REXULTI TABS 3 PA ZYPREXA TABS OR 10 QL(2 ea daily) MG, 15 MG, 20 MG, 7.5 NF MG (Use olanzapine)

Ambetter NH Formulary Updated October 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits thiothixene caps 1 EDURANT TABS 2 QL(1 ea daily) QL(2 ea daily) ANTIVIRALS - Drugs to Treat Viral Infections efavirenz caps 200 mg 1 Antiretrovirals efavirenz caps 50 mg 1 QL(3 ea daily) abacavir sulfate soln 20 1 QL(32 ml daily) mg/ml efavirenz tabs 600 mg 1 QL(1 ea daily) abacavir sulfate tabs 300 1 QL(2 ea daily) efavirenz-emtricitabine- QL(1 ea daily) mg tenofovir disoproxil 1 abacavir sulfate-lamivudine 1 QL(1 ea daily) fumarate tabs tabs efavirenz-lamivudine- QL(1 ea daily) abacavir sulfate- 1 QL(2 ea daily) tenofovir disoproxil 1 lamivudine-zidovudine tabs fumarate tabs QL(4 ea daily) APTIVUS CAPS 250 MG 2 emtricitabine caps 1 QL(1 ea daily)

APTIVUS SOLN 100 2 QL(10 ml daily) emtricitabine-tenofovir QL(1 ea MG/ML disoproxil fumarate tabs 1 daily,30 day(s) 100 mg-150 mg, 133 mg- limit) atazanavir sulfate caps 150 1 QL(1 ea daily) mg, 300 mg 200 mg, 167 mg-250 mg emtricitabine-tenofovir QL(1 ea daily) atazanavir sulfate caps 200 1 QL(2 ea daily) mg disoproxil fumarate tabs 0 ATRIPLA TABS (Use QL(1 ea daily) 200 mg-300 mg emtricitabine-tenofovir QL(1 ea efavirenz-emtricitabine- 3 tenofovir disoproxil disoproxil fumarate tabs 0 daily,30 day(s) fumarate) 200 mg-300 mg limit) QL(1 ea daily) EMTRIVA CAPS 200 MG 2 QL(1 ea daily) BIKTARVY TABS 2 (Use emtricitabine) ST; QL(1 ea CIMDUO TABS 2 EMTRIVA SOLN 10 2 QL(24 ml daily) daily) MG/ML COMBIVIR TABS (Use QL(2 ea daily) NF EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) lamivudine-zidovudine) (Use lamivudine) QL(1 ea daily) COMPLERA TABS 3 EPIVIR TABS 150 MG NF QL(2 ea daily) (Use lamivudine) QL(9 ea daily) CRIXIVAN CAPS 200 MG 2 EPIVIR TABS 300 MG NF QL(1 ea daily) (Use lamivudine) CRIXIVAN CAPS 400 MG 2 QL(6 ea daily) EPZICOM TABS (Use QL(1 ea daily) abacavir sulfate- NF DELSTRIGO TABS 3 QL(1 ea daily) lamivudine) etravirine tabs 100 mg 1 QL(4 ea daily) DESCOVY TABS 2 PA; QL(1 ea daily) etravirine tabs 200 mg 1 QL(2 ea daily) didanosine cpdr 200 mg 1 QL(2 ea daily) fosamprenavir calcium tabs 1 QL(4 ea daily) didanosine cpdr 250 mg, 1 QL(1 ea daily) 400 mg FUZEON SOLR 4 PA; SP DOVATO TABS 2 QL(1 ea daily)

Ambetter NH Formulary Updated October 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENVOYA TABS 2 QL(1 ea daily) nevirapine tb24 400 mg 1 QL(1 ea daily)

INTELENCE TABS 100 2 QL(4 ea daily) QL(12 ea MG (Use etravirine) 2 daily)30 rtl lmt NORVIR PACK 100 MG day(s),30 mail INTELENCE TABS 200 2 QL(2 ea daily) MG (Use etravirine) lmt day(s), QL(15 ml daily) INTELENCE TABS 25 MG 2 QL(8 ea daily) NORVIR SOLN 80 MG/ML 2 QL(4 ea daily) NORVIR TABS 100 MG NF QL(12 ea daily) INVIRASE TABS 2 (Use ) QL(1 ea daily) ISENTRESS CHEW 100 2 QL(6 ea daily) ODEFSEY TABS 2 MG, 25 MG QL(1 ea daily) ISENTRESS HD TABS 2 QL(2 ea daily) PIFELTRO TABS 2 QL(1 ea daily) ISENTRESS TABS 400 2 QL(2 ea daily) PREZCOBIX TABS 2 MG QL(1 ea daily) PREZISTA SUSP 100 2 QL(12 ml daily) JULUCA TABS 3 MG/ML KALETRA SOLN 100 QL(12.5 ml PREZISTA TABS 150 MG, 2 QL(2 ea daily) MG/5ML-400 MG/5ML NF daily) 600 MG, 75 MG (Use lopinavir-ritonavir) PREZISTA TABS 800 MG 2 QL(1 ea daily) KALETRA TABS 25 MG- QL(4 ea daily) 100 MG, 50 MG-200 MG 2 RESCRIPTOR TABS 2 QL(6 ea daily) (Use lopinavir-ritonavir) QL(30 ml daily) RETROVIR CAPS 100 MG NF QL(6 ea daily) lamivudine soln 10 mg/ml 1 (Use zidovudine) QL(2 ea daily) RETROVIR IV INFUSION 1 lamivudine tabs 150 mg 1 SOLN lamivudine tabs 300 mg 1 QL(1 ea daily) RETROVIR SYRP 50 NF QL(60 ml daily) MG/5ML (Use zidovudine) lamivudine-zidovudine tabs 1 QL(2 ea daily) REYATAZ CAPS 150 MG, QL(1 ea daily) 300 MG (Use atazanavir NF LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily) sulfate) REYATAZ CAPS 200 MG NF QL(2 ea daily) LEXIVA TABS 700 MG QL(4 ea daily) (Use atazanavir sulfate) (Use fosamprenavir NF calcium) ritonavir tabs 1 QL(12 ea daily) lopinavir-ritonavir soln 100 1 QL(12.5 ml PA mg/5ml-400 mg/5ml daily) RUKOBIA TB12 4 lopinavir-ritonavir tabs 25 QL(4 ea daily) 1 SELZENTRY SOLN 20 2 QL(30 ml daily) mg-100 mg, 50 mg-200 mg MG/ML QL(40 ml daily) nevirapine susp 50 mg/5ml 1 SELZENTRY TABS 150 2 QL(2 ea daily) MG, 25 MG, 75 MG QL(2 ea daily) nevirapine tabs 200 mg 1 SELZENTRY TABS 300 2 QL(4 ea daily) MG nevirapine tb24 100 mg 1 QL(3 ea daily) stavudine caps 15 mg, 20 1 QL(2 ea daily) mg, 30 mg, 40 mg

Ambetter NH Formulary Updated October 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STAVUDINE CAPS 15 MG, 2 QL(2 ea daily) VIRACEPT TABS 625 MG 2 QL(4 ea daily) 30 MG VIRAMUNE SUSP 50 QL(40 ml daily) STAVUDINE CAPS 20 MG, 1 QL(2 ea daily) NF 40 MG MG/5ML (Use nevirapine) QL(1 ea daily) VIRAMUNE TABS 200 MG NF QL(2 ea daily) STRIBILD TABS 3 (Use nevirapine) SUSTIVA CAPS 200 MG NF QL(2 ea daily) VIRAMUNE XR TB24 (Use 2 QL(1 ea daily) (Use efavirenz) nevirapine) SUSTIVA CAPS 50 MG NF QL(3 ea daily) VIREAD POWD 40 MG/GM 2 (Use efavirenz) VIREAD TABS 150 MG, QL(1 ea daily) SUSTIVA TABS 600 MG NF QL(1 ea daily) 2 (Use efavirenz) 200 MG, 250 MG SYMFI LO TABS (Use QL(1 ea daily) VIREAD TABS 300 MG (Use tenofovir disoproxil NF efavirenz-lamivudine- 2 tenofovir disoproxil fumarate) fumarate) ZIAGEN SOLN 20 MG/ML NF QL(32 ml daily) SYMFI TABS (Use QL(1 ea daily) (Use abacavir sulfate) efavirenz-lamivudine- 2 ZIAGEN TABS 300 MG NF QL(2 ea daily) tenofovir disoproxil (Use abacavir sulfate) fumarate) zidovudine caps 100 mg 1 QL(6 ea daily) SYMTUZA TABS 3 ST; QL(1 ea daily) zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) ST; QL(1 ea TEMIXYS TABS 2 daily) zidovudine tabs 300 mg 1 QL(2 ea daily) tenofovir disoproxil 1 fumarate tabs CMV Agents TIVICAY TABS 3 QL(2 ea daily) cidofovir soln 3 QL(1 ea daily) TRIUMEQ TABS 2 CYTOVENE SOLR (Use NF ganciclovir sodium) TRIZIVIR TABS (Use QL(2 ea daily) abacavir sulfate- NF ganciclovir sodium solr 1 lamivudine-zidovudine) VALCYTE TABS 450 MG NF PA; QL(4 ea TRUVADA TABS (Use QL(1 ea (Use valganciclovir hcl) daily) emtricitabine-tenofovir 2 daily,30 day(s) valganciclovir hcl tabs 450 1 PA; QL(4 ea disoproxil fumarate) limit) mg daily) QL(1 ea daily) TYBOST TABS 2 Hepatitis Agents PA; QL(1 ea QL(2 ea daily) adefovir dipivoxil tabs 4 VIDEX EC CPDR 125 MG 2 daily); SP BARACLUDE SOLN 0.05 PA; QL(20 ml VIDEX EC CPDR 200 MG NF QL(2 ea daily) 4 (Use didanosine) MG/ML daily); SP BARACLUDE TABS 0.5 PA; QL(1 ea VIDEX EC CPDR 250 MG, NF QL(1 ea daily) NF 400 MG (Use didanosine) MG, 1 MG (Use entecavir) daily); SP PA; QL(1 ea 2 entecavir tabs 4 VIDEXPEDIATRIC SOLR daily); SP VIRACEPT TABS 250 MG 2 QL(10 ea daily)

Ambetter NH Formulary Updated October 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPCLUSA TABS 100 MG- 4 PA; QL(1 ea famciclovir tabs 125 mg, 1 QL(3 ea daily) 400 MG daily) 250 mg EPIVIR HBV SOLN 5 4 PA; QL(60 ml famciclovir tabs 500 mg 1 QL(4 ea daily) MG/ML daily); SP valacyclovir hcl tabs 1 gm, QL(4 ea daily) EPIVIR HBV TABS 100 NF QL(3 ea daily); 1 MG (Use lamivudine (hbv)) SP 1000 mg valacyclovir hcl tabs 500 QL(2 ea daily) HEPSERA TABS (Use NF PA; QL(1 ea 1 adefovir dipivoxil) daily); SP mg QL(3 ea daily); VALTREX TABS 1 GM QL(4 ea daily) lamivudine (hbv) tabs 1 NF SP (Use valacyclovir hcl) VALTREX TABS 500 MG QL(2 ea daily) MAVYRET TABS 4 PA; QL(3 ea NF daily) (Use valacyclovir hcl) QL(5 ea PEGASYS PROCLICK 4 PA; QL(0.0714 SOLN ml daily); SP ZOVIRAX CAPS OR 200 NF daily,50 ea per MG (Use acyclovir) fill retail,50 ea PEGASYS SOLN 4 PA; QL(0.0714 ml daily); SP per fill mail) ZOVIRAX SUSP OR 200 QL(13.34 ml PEGINTRON KIT 4 PA; QL(0.143 NF ea daily); SP MG/5ML (Use acyclovir) daily) ZOVIRAX TABS OR 400 QL(5 ea daily) RIBASPHERE RIBAPAK 4 PA TBPK 400 MG, 600 MG MG, 800 MG (Use NF acyclovir) PA RIBASPHERE TABS 4 Agents FLUMADINE TABS (Use QL(2 ea daily) () caps 1 PA; QL(7 ea NF 200 mg daily) hydrochloride) Limit 1 fill every ribavirin (hepatitis c) tabs 1 PA; QL(7 ea 200 mg daily) 90 days. ;QL(10 ea per ribavirin (hepatitis c) tabs 4 PA 600 mg fill retail,10 ea phosphate caps 1 per fill mail)1 rtl /VELPATAS 4 PA; QL(1 ea or 30 mg, 45 mg, 75 mg MAX fill,90 rtl VIR TABS daily) day(s) supply,1 PA; QL(1 ea VEMLIDY TABS 4 mail MAX fill,90 daily); SP mail day(s) PA; QL(1 ea supply, VOSEVI TABS 4 daily) Limit 1 fill every PA 90 ZEPATIER TABS 4 days.;QL(125 oseltamivir phosphate susr Herpes Agents 1 ml per fill or 6 mg/ml retail)1 rtl MAX QL(5 ea fill,90 rtl day(s) daily,50 ea per acyclovir caps 200 mg 1 supply, fill retail,50 ea per fill mail) 1 rtl pack lmt RELENZA DISKHALER 2 amt,30 rtl pack QL(13.34 ml AEPB acyclovir susp 200 mg/5ml 1 lmt day(s), daily) rimantadine hydrochloride 1 QL(2 ea daily) acyclovir tabs 400 mg, 800 1 QL(5 ea daily) tabs mg

Ambetter NH Formulary Updated October 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 fill every metoprolol tartrate tabs or 1 90 days. 100 mg, 25 mg, 50 mg ;QL(10 ea per nebivolol hcl tabs 10 mg, 1 PA; QL(1 ea fill retail,10 ea 2.5 mg, 5 mg daily) TAMIFLU CAPS 30 MG, 45 per fill mail)1 rtl MG, 75 MG (Use NF PA; QL(2 ea ) MAX fill,90 rtl nebivolol hcl tabs 20 mg 1 oseltamivir phosphate day(s) supply,1 daily) mail MAX fill,90 TENORMIN TABS (Use NF mail day(s) atenolol) supply, TOPROL XL TB24 (Use NF Limit 1 fill every metoprolol succinate) 90 Beta Blockers Non-Selective TAMIFLU SUSR 6 MG/ML days.;QL(125 (Use oseltamivir NF ml per fill BETAPACE AF TABS (Use NF phosphate) retail)1 rtl MAX sotalol hcl (afib/afl)) fill,90 rtl day(s) BETAPACE TABS (Use NF QL(2 ea daily) supply, sotalol hcl) BETA BLOCKERS - Drugs to Treat High Blood CORGARD TABS (Use NF Pressure nadolol) HEMANGEOL SOLN 4 PA; QL(75 ml Alpha-Beta Blockers daily) carvedilol tabs 1 INDERAL LA CP24 (Use NF propranolol hcl) COREG TABS (Use NF carvedilol) nadolol tabs 1 labetalol hcl soln iv 5 mg/ml 1 pindolol tabs 1 labetalol hcl tabs or 100 1 mg, 200 mg, 300 mg propranolol hcl cp24 1 Beta Blockers Cardio-Selective propranolol hcl soln 1 acebutolol hcl caps 1 propranolol hcl tabs 1 atenolol tabs 1 sotalol hcl (afib/afl) tabs 1 betaxolol hcl tabs 1 sotalol hcl tabs 120 mg, 1 QL(2 ea daily) 160 mg, 80 mg bisoprolol fumarate tabs or 1 10 mg, 5 mg sotalol hcl tabs 240 mg 1 BYSTOLIC TABS 10 MG, PA; QL(1 ea 2.5 MG, 5 MG (Use 2 daily) timolol maleate tabs 1 nebivolol hcl) CALCIUM CHANNEL BLOCKERS - Drugs to BYSTOLIC TABS 20 MG 2 PA; QL(2 ea (Use nebivolol hcl) daily) Treat High Blood Pressure LOPRESSOR TABS (Use NF Calcium Channel Blockers metoprolol tartrate) ADALAT CC TB24 (Use NF metoprolol succinate tb24 1 nifedipine) amlodipine besylate tabs 1 metoprolol tartrate soln iv 5 1 mg/5ml Ambetter NH Formulary Updated October 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALAN SR TBCR (Use NF NORVASC TABS (Use NF verapamil hcl) amlodipine besylate) CALAN TABS (Use NF PROCARDIA CAPS (Use NF verapamil hcl) nifedipine) CARDIZEM CD CP24 (Use NF PROCARDIA XL TB24 NF diltiazem hcl coated beads) (Use nifedipine) CARDIZEM LA TB24 180 SULAR TB24 (Use NF MG, 240 MG, 300 MG, 360 NF nisoldipine) MG, 420 MG (Use TIAZAC CP24 120 MG, diltiazem hcl coated beads) 180 MG, 240 MG, 300 MG, NF CARDIZEM TABS (Use NF 360 MG (Use diltiazem hcl diltiazem hcl) extended release beads) diltiazem hcl coated beads 1 verapamil hcl cp24 1 cp24 diltiazem hcl coated beads 1 verapamil hcl soln 1 tb24 diltiazem hcl cp12 or 120 1 verapamil hcl tabs 1 mg, 60 mg, 90 mg verapamil hcl tbcr 1 diltiazem hcl cp24 or 120 1 mg, 180 mg, 240 mg VERELAN CP24 120 MG, diltiazem hcl extended 180 MG, 240 MG (Use NF release beads cp24 120 1 verapamil hcl) mg, 180 mg, 240 mg, 300 mg, 360 mg VERELAN CP24 360 MG 1 (Use verapamil hcl) diltiazem hcl soln iv 50 1 mg/10ml VERELAN PM CP24 100 MG, 200 MG (Use NF DILTIAZEM HCL SOLR IV 1 verapamil hcl) 100 MG VERELAN PM CP24 300 1 diltiazem hcl tabs or 120 1 MG (Use verapamil hcl) mg, 30 mg, 60 mg, 90 mg CARDIOTONICS - Drugs to Treat Heart Failure felodipine tb24 1 and Abnormal Heart Rhythm isradipine caps 1 Cardiac Glycosides digoxin soln 1 nicardipine hcl caps 1 digoxin tabs 1 nicardipine hcl soln 1 LANOXIN SOLN IJ 0.25 2 nifedipine caps 1 MG/ML (Use digoxin) LANOXIN TABS OR 250 nifedipine tb24 1 MCG, 125 MCG (Use 2 digoxin) nimodipine caps 1 LANOXIN TABS OR 62.5 2 MCG nisoldipine tb24 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 1 CARDIOVASCULAR AGENTS - MISC. - Drugs to 8.5 mg Treat Heart and Circulation Conditions

Ambetter NH Formulary Updated October 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea Cardioplegic Solutions bosentan tabs 62.5 mg 4 daily) PLEGISOL SOLN (Use NF cardioplegic soln) LETAIRIS TABS (Use NF PA; QL(1 ea ambrisentan) daily); SP Cardiovascular Agents Misc. - Combinations PA; QL(1 ea OPSUMIT TABS 4 amlodipine besylate- 1 QL(1 ea daily) daily) atorvastatin calcium tabs TRACLEER TABS 125 MG NF PA; QL(2 ea BIDIL TABS 2 (Use bosentan) daily); SP TRACLEER TABS 62.5 NF PA; QL(2 ea CADUET TABS (Use QL(1 ea daily) MG (Use bosentan) daily) amlodipine besylate- NF atorvastatin calcium) TRACLEER TBSO 32 MG 4 PA; QL(2 ea daily); SP ENTRESTO TABS 3 PA Pulmonary Hypertension - Phosphodiesterase Impotence Agents ADCIRCA TABS (Use PA; QL(2 ea PA; BPH tadalafil (pulmonary NF daily); SP CIALIS TABS 5 MG (Use NF hypertension)) tadalafil) Only;QL(1 ea daily) REVATIO SOLN IV 10 PA; QL(37.5 ml PA; QL(0.1334 MG/12.5ML (Use sildenafil daily); SP sildenafil citrate tabs 1 NF ea daily) citrate (pulmonary hypertension)) STENDRA TABS 3 QL(0.134 ea daily) REVATIO SUSR OR 10 PA; QL(6 ml MG/ML (Use sildenafil NF daily) PA; BPH citrate (pulmonary tadalafil tabs 5 mg 1 Only;QL(1 ea hypertension)) daily) REVATIO TABS OR 20 PA; QL(3 ea VIAGRA TABS (Use NF PA; QL(0.1334 MG (Use sildenafil citrate NF daily); SP sildenafil citrate) ea daily) (pulmonary hypertension)) Prostaglandin Vasodilators sildenafil citrate (pulmonary PA; QL(37.5 ml PA hypertension) soln iv 10 4 daily); SP epoprostenol sodium solr 4 mg/12.5ml FLOLAN SOLR (Use NF PA sildenafil citrate (pulmonary PA; QL(6 ml epoprostenol sodium) hypertension) susr or 10 4 daily) ORENITRAM TBCR 0.125 PA mg/ml MG, 0.25 MG, 1 MG, 2.5 3 sildenafil citrate (pulmonary PA; QL(3 ea MG hypertension) tabs or 20 4 daily); SP mg treprostinil soln 4 PA; SP tadalafil (pulmonary 4 PA; QL(2 ea hypertension) tabs daily); SP VELETRI SOLR (Use NF PA epoprostenol sodium) Pulmonary Hypertension - Sol Guanylate Cyclase VENTAVIS SOLN 4 PA; SP ADEMPAS TABS 0.5 MG, 4 PA; QL(3 ea 1.5 MG, 2 MG, 2.5 MG daily) Pulmonary Hypertension - Endothelin Receptor Sinus Node Inhibitors PA; QL(1 ea ambrisentan tabs 4 daily); SP CORLANOR SOLN 5 3 PA; QL(15 ml MG/5ML daily) PA; QL(2 ea bosentan tabs 125 mg 4 daily); SP CORLANOR TABS 5 MG, 3 PA; QL(2 ea 7.5 MG daily) Ambetter NH Formulary Updated October 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Transthyretin Stabilizers cefdinir caps 1 VYNDAMAX CAPS 4 PA; QL(1 ea daily) cefdinir susr 1 PA; QL(4 ea VYNDAQEL CAPS 4 cefditoren pivoxil tabs 200 3 daily) mg CEPHALOSPORINS - Drugs to Treat Bacterial cefditoren pivoxil tabs 400 1 Infections mg Cephalosporins - 1st Generation cefixime susr 100 mg/5ml, 1 ST 200 mg/5ml cefadroxil caps 1 cefotaxime sodium solr 1 cefadroxil susr 1 cefpodoxime proxetil susr 1 cefadroxil tabs 1 cefpodoxime proxetil tabs 1 cefazolin sodium solr ij 500 1 mg, 1 gm, 10 gm ceftazidime solr ij 2 gm, 1 1 gm, 6 gm cephalexin caps 1 ceftriaxone sodium solr ij 1 1 gm, 2 gm, 250 mg, 500 mg cephalexin susr 1 FORTAZ SOLR IJ 1 GM NF cephalexin tabs 1 (Use ceftazidime) FORTAZ SOLR IV 2 GM NF KEFLEX CAPS (Use NF (Use ceftazidime) cephalexin) SUPRAX SUSR 100 ST Cephalosporins - 2nd Generation MG/5ML, 200 MG/5ML NF (Use cefixime) cefaclor caps 1 Cephalosporins - 4th Generation cefaclor susr 1 cefepime hcl solr 1 CEFOTAN SOLR (Use NF MAXIPIME SOLR IJ 1 GM, NF cefotetan disodium) 2 GM (Use cefepime hcl) cefotetan disodium solr 1 Cephalosporins - 5th Generation cefoxitin sodium solr ij 10 1 TEFLARO SOLR 3 gm CONTRACEPTIVES - Drugs to Prevent cefoxitin sodium solr iv 2 1 gm, 1 gm Pregnancy cefprozil susr 1 Combination Contraceptives - Oral BALCOLTRA TABS 0 cefprozil tabs 1 BEYAZ TABS (Use cefuroxime axetil tabs 1 drospirenone-ethinyl NF estradiol-levomefolate cefuroxime sodium solr ij 1 calcium) 750 mg desogestrel & ethinyl 0 Cephalosporins - 3rd Generation estradiol tabs

Ambetter NH Formulary Updated October 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desogestrel-ethinyl 0 norethindrone & eth 0 estradiol (biphasic) tabs estradiol tabs desogestrel-ethinyl 0 norethindrone & ethinyl 0 estradiol (triphasic) tabs estradiol-fe chew drospirenone-ethinyl 0 norethindrone acet & eth 0 estradiol tabs estra tabs drospirenone-ethinyl norethindrone acetate- 0 estradiol-levomefolate 0 ethinyl estradiol-fe tabs calcium tabs norethindrone-eth estradiol 0 ESTROSTEP FE TABS (triphasic) tabs (Use norethindrone NF norgestimate-ethinyl 0 acetate-ethinyl estradiol-fe) estradiol (triphasic) tabs ethynodiol diacet & eth 0 norgestimate-ethinyl 0 estrad tabs estradiol tabs FALESSA KIT 0 norgestrel & ethinyl 0 estradiol tabs GENERESS FE CHEW ORTHO TRI-CYCLEN LO (Use norethindrone & NF TABS (Use norgestimate- NF ethinyl estradiol-fe) ethinyl estradiol (triphasic)) levonorgestrel & eth 0 ORTHO-NOVUM 1/35 estradiol tabs TABS (Use norethindrone NF levonorgestrel-eth estradiol 0 & eth estradiol) (triphasic) tabs ORTHO-NOVUM 7/7/7 levonorgestrel-ethinyl 0 TABS (Use norethindrone- NF estradiol (91-day) tabs eth estradiol (triphasic)) levonorgestrel-ethinyl 0 QUARTETTE TABS (Use estradiol (continuous) tabs levonorgestrel-ethinyl NF LO LOESTRIN FE TABS 0 estradiol (91-day)) SAFYRAL TABS (Use LOSEASONIQUE TABS drospirenone-ethinyl NF (Use levonorgestrel-ethinyl NF estradiol-levomefolate estradiol (91-day)) calcium) MINASTRIN 24 FE CHEW SEASONIQUE TABS (Use (Use norethin acet & NF levonorgestrel-ethinyl NF estrad-fe) estradiol (91-day)) MIRCETTE TABS (Use TAYTULLA CAPS (Use 0 desogestrel-ethinyl NF norethin acet & estrad-fe) estradiol (biphasic)) TYBLUME CHEW 0 NATAZIA TABS 0 YASMIN 28 TABS (Use norethin acet & estrad-fe 0 drospirenone-ethinyl NF caps estradiol) norethin acet & estrad-fe 0 YAZ TABS (Use chew drospirenone-ethinyl NF estradiol) norethin acet & estrad-fe 0 tabs Combination Contraceptives - Transdermal

Ambetter NH Formulary Updated October 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norelgestromin-ethinyl 0 DEPO-SUBQ PROVERA 0 estradiol ptwk 104 SUSY QL(1 ml per 90 TWIRLA PTWK 0 QL(3 ea per 28 medroxyprogesterone days retail) acetate (contraceptive) 0 days retail) susp Combination Contraceptives - Vaginal medroxyprogesterone QL(1 ml per 90 PA ANNOVERA RING 0 acetate (contraceptive) 0 days retail) susy etonogestrel-ethinyl 0 estradiol ring Progestin Contraceptives - Oral NUVARING RING (Use norethindrone 0 etonogestrel-ethinyl NF (contraceptive) tabs estradiol) ORTHO MICRONOR Copper Contraceptives - IUD TABS (Use norethindrone NF (contraceptive)) PARAGARD QL(1 ea daily) INTRAUTERINE COPPER 0 SLYND TABS 0 CONTRACEPTIVE T380A IUD CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions Emergency Contraceptives Glucocorticosteroids ELLA TABS 0 budesonide cpep 3 mg 1 QL(3 ea daily) levonorgestrel (emergency 0 oc) tabs CELESTONE SOLUSPAN PLAN B ONE-STEP TABS SUSP (Use betamethasone NF (Use levonorgestrel NF sod phosphate & acetate) (emergency oc)) CELESTONE-SOLUSPAN SUSP (Use betamethasone NF Progestin Contraceptives - IUD sod phosphate & acetate) KYLEENA IUD 0 CORTEF TABS (Use NF hydrocortisone) LILETTA IUD 0 cortisone acetate tabs 1 MIRENA IUD 0 DEPO-MEDROL SUSP 20 3 MG/ML SKYLA IUD 0 DEPO-MEDROL SUSP 80 Progestin Contraceptives - Implants MG/ML, 40 MG/ML (Use NF methylprednisolone NEXPLANON IMPL 0 acetate) dexamethasone elix 0.5 1 Progestin Contraceptives - Injectable mg/5ml DEPO-PROVERA QL(1 ml per 90 DEXAMETHASONE 1 CONTRACEPTIVE SUSP NF days retail) INTENSOL CONC (Use medroxyprogesterone acetate (contraceptive)) dexamethasone sodium phosphate soln ij 120 1 DEPO-PROVERA QL(1 ml per 90 mg/30ml, 20 mg/5ml, 4 CONTRACEPTIVE SUSY NF days retail) mg/ml (Use medroxyprogesterone acetate (contraceptive))

Ambetter NH Formulary Updated October 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dexamethasone soln 0.5 1 prednisolone soln 1 mg/5ml dexamethasone tabs 1 mg, prednisone soln 1 1.5 mg, 2 mg, 4 mg, 0.5 1 mg, 0.75 mg, 6 mg prednisone tabs 1 EMFLAZA SUSP 4 PA prednisone tbpk 1 PA EMFLAZA TABS 4 2 rtl MAX fill,30 SOLU-CORTEF SOLR 100 3 rtl day(s) ENTOCORT EC CPEP NF QL(3 ea daily) MG, 1000 MG, 500 MG (Use budesonide) supply, SOLU-CORTEF SOLR 250 3 hydrocortisone tabs 1 MG SOLU-MEDROL SOLR 2 KENALOG-40 SUSP (Use NF 3 triamcinolone acetonide) GM SOLU-MEDROL SOLR 500 MEDROL DOSEPAK TBPK NF (Use methylprednisolone) MG, 1000 MG, 125 MG, 40 MEDROL TABS 16 MG, 32 MG (Use NF MG, 8 MG, 4 MG (Use NF methylprednisolone sod methylprednisolone) succ) triamcinolone acetonide 1 MEDROL TABS 2 MG 3 susp 40 mg/ml Mineralocorticoids methylprednisolone acetate 1 susp 80 mg/ml, 40 mg/ml fludrocortisone acetate tabs 1 methylprednisolone sod 1 succ solr COUGH/COLD/ALLERGY - Drugs to Treat methylprednisolone tabs 1 Cough, Cold and Allergy Symptoms Antitussives methylprednisolone tbpk 1 benzonatate caps 100 mg 1 QL(6 ea daily) MILLIPRED DP TBPK 3 benzonatate caps 150 mg 1 QL(4 ea daily) MILLIPRED TABS 3 benzonatate caps 200 mg 1 QL(3 ea daily) ORAPRED ODT TBDP (Use prednisolone sodium NF TESSALON PERLES NF QL(6 ea daily) phosphate) CAPS (Use benzonatate) PEDIAPRED SOLN (Use Cough/Cold/Allergy Combinations prednisolone sodium NF ALLEGRA-D 12 HOUR QL(2 ea daily) phosphate) ALLERGY & prednisolone sodium CONGESTION TB12 (Use NF phosphate soln or 10 fexofenadine- mg/5ml, 15 mg/5ml, 25 1 pseudoephedrine) mg/5ml, 20 mg/5ml, 5 ALLEGRA-D 24 HOUR QL(1 ea daily) mg/5ml, 6.7 mg/5ml ALLERGY & prednisolone sodium CONGESTION TB24 (Use NF phosphate tbdp or 10 mg, 3 fexofenadine- 15 mg, 30 mg pseudoephedrine)

Ambetter NH Formulary Updated October 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cetirizine-pseudoephedrine 1 QL(2 ea daily) Acne Products tb12 ABSORICA CAPS 30 MG, PA; AL(At least CLARITIN-D 12 HOUR QL(2 ea daily) 10 MG, 20 MG, 40 MG NF 12 yrs old) TB12 (Use loratadine & 1 (Use isotretinoin) ) pseudoephedrine PA; AL(At least adapalene crea 0.1 % 1 CLARITIN-D 24 HOUR QL(1 ea daily) 12 yrs old) 1 TB24 (Use loratadine & PA; AL(At least pseudoephedrine) adapalene gel 0.1 % 1 12 yrs old); fexofenadine- QL(2 ea daily) RX/OTC 1 pseudoephedrine tb12 60 ST; AL(At least mg-120 mg adapalene gel 0.3 % 1 12 yrs old) fexofenadine- QL(1 ea daily) ST; AL(At least pseudoephedrine tb24 180 1 adapalene lotn 0.1 % 1 12 yrs old) mg-240 mg ST; AL(At least hydrocodone polistirex- adapalene-benzoyl 1 peroxide gel 12 yrs old) chlorpheniramine polistirex 1 suer AZELEX CREA 3 ST; AL(At least 12 yrs old) loratadine & QL(2 ea daily) pseudoephedrine tb12 5 1 BENZACLIN GEL (Use PA; AL(At least mg-120 mg clindamycin phosphate- NF 12 yrs old) benzoyl peroxide) loratadine & QL(1 ea daily) pseudoephedrine tb24 10 1 BENZACLIN WITH PUMP PA; AL(At least mg-10 mg-240 mg-240 mg GEL (Use clindamycin NF 12 yrs old) phosphate-benzoyl TUZISTRA XR SUER 2 PA peroxide) ZYRTEC-D QL(2 ea daily) BENZAMYCIN GEL (Use PA; AL(At least benzoyl peroxide- NF 12 yrs old) ALLERGY/CONGESTION 1 TB12 (Use cetirizine- erythromycin) pseudoephedrine) BENZOYL PEROXIDE 2 AL(At least 12 CLEANSER LIQD yrs old) Misc. Respiratory Inhalants AL(At least 12 HYPER-SAL NEBU (Use benzoyl peroxide foam 5.3 1 yrs old); NF % sodium chloride (inhalant)) RX/OTC HYPERSAL NEBU 3.5 % 1 benzoyl peroxide foam 9.8 1 AL(At least 12 % yrs old) HYPERSAL NEBU 7 % (Use sodium chloride NF benzoyl peroxide gel 5 %, 1 AL(At least 12 (inhalant)) 10 % yrs old) benzoyl peroxide liqd 4 %, 1 AL(At least 12 NEBUSAL NEBU 1 7 %, 10 % yrs old) benzoyl peroxide- PA; AL(At least sodium chloride (inhalant) 1 1 nebu 7 % erythromycin gel 12 yrs old) Mucolytics CLEOCIN-T GEL (Use AL(At least 12 clindamycin phosphate NF yrs old) soln 1 (topical)) CLEOCIN-T LOTN (Use AL(At least 12 DERMATOLOGICALS - Drugs to Treat Skin clindamycin phosphate NF yrs old) Conditions (topical))

Ambetter NH Formulary Updated October 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDAGEL GEL (Use AL(At least 12 KLARON LOTN (Use AL(At least 12 clindamycin phosphate NF yrs old) sulfacetamide sodium NF yrs old) (topical)) (acne)) clindamycin phosphate 1 PA; AL(At least AL(At least 12 12 yrs old) RETIN-A CREA (Use NF (topical) foam tretinoin) yrs old - Up to 30 yrs old) clindamycin phosphate 1 AL(At least 12 (topical) gel yrs old) AL(At least 12 RETIN-A GEL (Use NF yrs old - Up to clindamycin phosphate 1 AL(At least 12 tretinoin) (topical) lotn yrs old) 30 yrs old) QL(4 ml daily); RETIN-A MICRO GEL 0.1 PA; AL(At least clindamycin phosphate 1 AL(At least 12 % (Use tretinoin NF 12 yrs old - Up (topical) soln yrs old) microsphere) to 30 yrs old) RETIN-A MICRO PUMP PA; AL(At least clindamycin phosphate 1 AL(At least 12 (topical) swab yrs old) GEL 0.1 % (Use tretinoin NF 12 yrs old - Up microsphere) to 30 yrs old) clindamycin phosphate- PA; AL(At least benzoyl peroxide 1 12 yrs old) sulfacetamide sodium 1 AL(At least 12 (refrigerate) gel (acne) lotn yrs old) clindamycin phosphate- PA; AL(At least sulfacetamide sodium w/ 1 AL(At least 12 benzoyl peroxide gel 1 %-5 1 12 yrs old) sulfur crea 5 %-10 % yrs old) % sulfacetamide sodium w/ 1 AL(At least 12 sulfur emul 5 %-10 % yrs old) clindamycin phosphate- 1 ST; AL(At least tretinoin gel 12 yrs old) sulfacetamide sodium w/ 1 ST; AL(At least sulfur liqd 4.5 %-9 % 12 yrs old) DIFFERIN CREA 0.1 % NF PA; AL(At least (Use adapalene) 12 yrs old) sulfacetamide sodium- 1 AL(At least 12 PA; AL(At least sulfur in urea vehicle emul yrs old) DIFFERIN GEL 0.1 % (Use NF SUMADAN WASH LIQD adapalene) 12 yrs old); ST; AL(At least RX/OTC (Use sulfacetamide sodium NF 12 yrs old) w/ sulfur) DIFFERIN GEL 0.3 % (Use NF ST; AL(At least adapalene) 12 yrs old) AL(At least 12 tretinoin crea 0.05 %, 0.1 1 yrs old - Up to DIFFERIN LOTN 0.1 % 1 ST; AL(At least %, 0.025 % 12 yrs old) 30 yrs old) DUAC GEL (Use PA; AL(At least AL(At least 12 tretinoin gel 0.01 %, 0.025 1 yrs old - Up to clindamycin phosphate- NF 12 yrs old) % benzoyl peroxide 30 yrs old) (refrigerate)) PA; AL(At least tretinoin microsphere gel 1 12 yrs old - Up EPIDUO GEL (Use ST; AL(At least 0.1 % adapalene-benzoyl NF 12 yrs old) to 30 yrs old) peroxide) VELTIN GEL (Use ST; AL(At least clindamycin phosphate- NF 12 yrs old) erythromycin (acne aid) 1 AL(At least 12 pads yrs old) tretinoin) ZIANA GEL (Use ST; AL(At least erythromycin (acne aid) 1 AL(At least 12 soln yrs old) clindamycin phosphate- NF 12 yrs old) tretinoin) EVOCLIN FOAM (Use PA; AL(At least clindamycin phosphate NF 12 yrs old) Agents for External Genital and Perianal Warts (topical)) VEREGEN OINT 3 isotretinoin caps 30 mg, 10 3 PA; AL(At least mg, 20 mg, 40 mg 12 yrs old) Anti-inflammatory Agents - Topical Ambetter NH Formulary Updated October 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea diclofenac epolamine ptch 1 ERTACZO CREA 3 daily) EXELDERM CREA (Use diclofenac sodium (topical) 1 QL(3.34 gm 3 gel 1 % daily); RX/OTC sulconazole nitrate) FLECTOR PTCH (Use 3 PA; QL(2 ea EXELDERM SOLN 3 diclofenac epolamine) daily) EXELDERM SOLN (Use VOLTAREN GEL (Use NF QL(3.34 gm 3 diclofenac sodium (topical)) daily); RX/OTC sulconazole nitrate) PA Antibiotics - Topical JUBLIA SOLN 3 ALTABAX OINT 2 KERYDIN SOLN (Use 3 PA tavaborole) gentamicin sulfate (topical) QL(1 gm daily) 1 ketoconazole (topical) crea 1 crea 2 % gentamicin sulfate (topical) 1 ketoconazole (topical) 1 oint sham 2 % mupirocin oint 1 QL(90 gm per LOPROX CREA (Use NF fill retail)1 rtl NEO-SYNALAR CREA 3 PA ciclopirox olamine) MAX fill,30 rtl day(s) supply, Antifungals - Topical LOPROX SHAMPOO NF butenafine hcl crea 1 RX/OTC SHAM (Use ciclopirox) LOPROX SUSP (Use NF CICLODAN SOLUTION NF ciclopirox olamine) KIT KIT (Use ciclopirox) LOTRIMIN AF CREA (Use NF RX/OTC ciclopirox gel ex 0.77 % 1 clotrimazole (topical)) LOTRIMIN AF JOCK ITCH RX/OTC QL(90 gm per CREA (Use clotrimazole NF fill retail)1 rtl ciclopirox olamine crea 1 (topical)) MAX fill,30 rtl day(s) supply, LOTRIMIN ULTRA CREA 1 RX/OTC (Use butenafine hcl) ciclopirox olamine susp 1 LOTRISONE CREA (Use clotrimazole w/ NF ciclopirox sham ex 1 % 1 betamethasone) PA ciclopirox soln ex 8 % 1 luliconazole crea 1 RX/OTC LUZU CREA (Use 3 PA clotrimazole (topical) crea 1 luliconazole) clotrimazole (topical) soln 1 RX/OTC QL(3 gm daily)1 rtl MAX fill,180 rtl clotrimazole w/ 1 betamethasone crea naftifine hcl crea 1 % 1 day(s) supply,1 mail MAX clotrimazole w/ 1 betamethasone lotn fill,180 mail day(s) supply, QL(85 gm per econazole nitrate crea 1 fill retail,85 gm per fill mail)

Ambetter NH Formulary Updated October 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 gm Limit 1 Fill per daily)1 rtl MAX 180 days;QL(3 fill,180 rtl gm daily)1 rtl 1 day(s) supply,1 MAX fill,180 rtl naftifine hcl crea 2 % oxiconazole nitrate crea 1 mail MAX day(s) supply,1 fill,180 mail mail MAX day(s) supply, fill,180 mail QL(3 gm day(s) supply, daily)1 rtl MAX Limit 1 Fill per fill,180 rtl 180 days;QL(3 naftifine hcl gel 1 % 1 day(s) supply,1 gm daily)1 rtl mail MAX OXISTAT CREA (Use NF MAX fill,180 rtl fill,180 mail oxiconazole nitrate) day(s) supply,1 day(s) supply, mail MAX QL(2 gm fill,180 mail daily)1 rtl MAX day(s) supply, NAFTIFINE fill,180 rtl Limit 1 Fill per HYDROCHLORIDE CREA NF day(s) supply,1 180 days;QL(2 (Use naftifine hcl) mail MAX ml daily)1 rtl fill,180 mail OXISTAT LOTN 2 MAX fill,180 rtl day(s) supply, day(s) supply,1 QL(2 gm mail MAX daily)1 rtl MAX fill,180 mail fill,180 rtl day(s) supply, NAFTIN CREA 2 % (Use NF naftifine hcl) day(s) supply,1 PENLAC NAIL LACQUER NF mail MAX SOLN (Use ciclopirox) fill,180 mail day(s) supply, sulconazole nitrate crea 1 QL(3 gm sulconazole nitrate soln 1 daily)1 rtl MAX fill,180 rtl PA NAFTIN GEL 1 % (Use NF tavaborole soln 1 naftifine hcl) day(s) supply,1 mail MAX VUSION OINT (Use fill,180 mail miconazole- oxide- NF day(s) supply, white petrolatum) NIZORAL SHAM (Use NF ketoconazole (topical)) Antineoplastic or Premalignant Lesion Agents - CARAC CREA (Use NF nystatin (topical) crea 1 fluorouracil (topical)) diclofenac sodium (actinic 1 PA; QL(3.34 nystatin (topical) oint 1 keratoses) gel gm daily) EFUDEX CREA (Use NF nystatin (topical) powd 1 fluorouracil (topical)) nystatin-triamcinolone crea 1 fluorouracil (topical) crea 5 1 % nystatin-triamcinolone oint 1 fluorouracil (topical) soln 2 1 %, 5 % PANRETIN GEL 3

Ambetter NH Formulary Updated October 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea per fill PA; Limit 1 fill retail,3 ea per every 180 fill mail)1 rtl days;QL(45 gm 2 MAX fill,60 rtl per fill retail,45 PICATO GEL 0.015 % day(s) supply,1 gm per fill ZONALON CREA (Use 3 mail MAX fill,60 doxepin hcl (antipruritic)) mail)1 rtl MAX mail day(s) fill,180 rtl supply, day(s) supply,1 QL(2 ea per fill mail MAX retail,2 ea per fill,180 mail fill mail)1 rtl day(s) supply, PICATO GEL 0.05 % 2 MAX fill,60 rtl Antipsoriatics day(s) supply,1 acitretin caps 17.5 mg, 10 1 QL(1 ea daily) mail MAX fill,60 mg mail day(s) supply, acitretin caps 25 mg 1 QL(2 ea daily) PA; SP TARGRETIN GEL EX 1 % 4 PA; QL(4 gm calcipotriene crea 1 daily) Antipruritics - Topical PA; QL(4 gm calcipotriene oint 1 PA; Limit 1 fill daily) every 180 PA; QL(4 ml days;QL(45 gm calcipotriene soln 1 per fill retail,45 daily) QL(3.34 gm gm per fill calcitriol (topical) oint 1 doxepin hcl (antipruritic) 3 mail)1 rtl MAX daily) crea fill,180 rtl COSENTYX 4 PA day(s) supply,1 SENSOREADY PEN SOAJ mail MAX COSENTYX 4 PA; QL(0.072 fill,180 mail SENSOREADY PEN SOAJ ml daily) day(s) supply, COSENTYX SOSY 150 4 PA PA; Limit 1 fill MG/ML every 180 days;QL(45 gm DOVONEX CREA (Use NF PA; QL(4 gm per fill retail,45 calcipotriene) daily) gm per fill methoxsalen rapid caps 1 QL(4 ea daily) PRUDOXIN CREA (Use 3 doxepin hcl (antipruritic)) mail)1 rtl MAX fill,180 rtl OXSORALEN ULTRA QL(4 ea daily) day(s) supply,1 CAPS (Use methoxsalen NF mail MAX rapid) fill,180 mail SKYRIZI PEN SOAJ 4 PA; QL(0.25 ml day(s) supply, daily) SKYRIZI PSKT 75 4 PA; QL(0.025 MG/0.83ML ea daily) SKYRIZI SOSY 150 4 PA; QL(0.25 ml MG/ML daily) SORIATANE CAPS 10 MG NF QL(1 ea daily) (Use acitretin) SORIATANE CAPS 25 MG NF QL(2 ea daily) (Use acitretin)

Ambetter NH Formulary Updated October 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STELARA SOLN SC 45 4 PA; QL(0.012 alclometasone dipropionate 1 MG/0.5ML ml daily) crea STELARA SOSY SC 45 4 PA; QL(0.012 alclometasone dipropionate 1 MG/0.5ML ml daily) oint STELARA SOSY SC 90 4 PA; QL(0.018 QL(60 gm per MG/ML ml daily); SP fill retail,60 gm per fill mail)1 rtl tazarotene crea 1 PA 1 MAX fill,30 rtl amcinonide crea day(s) supply,1 TAZORAC CREA 0.05 % 2 mail MAX fill,30 mail day(s) TAZORAC CREA 0.1 % NF PA (Use tazarotene) supply, amcinonide lotn 3 TAZORAC GEL 0.05 %, 2 0.1 % AMCINONIDE OINT 3 TREMFYA SOPN 4 PA; QL(0.018 ml daily) betamethasone 1 TREMFYA SOSY 4 PA; QL(0.018 dipropionate (topical) crea ml daily) betamethasone 1 VECTICAL OINT (Use 1 QL(3.34 gm dipropionate (topical) lotn calcitriol (topical)) daily) betamethasone 1 Antiseborrheic Products dipropionate (topical) oint selenium sulfide lotn 1 betamethasone dipropionate augmented 1 Antivirals - Topical crea betamethasone acyclovir topical crea 1 dipropionate augmented 1 lotn acyclovir topical oint 1 betamethasone dipropionate augmented 1 DENAVIR CREA 3 QL(0.18 gm daily) oint betamethasone valerate ZOVIRAX CREA EX 5 % NF 1 (Use acyclovir topical) crea 0.1 % betamethasone valerate QL(1.67 gm ZOVIRAX OINT EX 5 % NF 1 (Use acyclovir topical) foam 0.12 % daily) Burn Products betamethasone valerate 1 lotn 0.1 % mafenide acetate pack 3 betamethasone valerate 1 oint 0.1 % SILVADENE CREA (Use NF silver sulfadiazine) calcipotriene- ST betamethasone 1 silver sulfadiazine crea 1 dipropionate oint calcipotriene- ST SULFAMYLON CREA 85 3 MG/GM betamethasone 1 dipropionate susp SULFAMYLON PACK 5 % NF PA; QL(3 gm (Use mafenide acetate) clobetasol propionate crea 1 daily) Corticosteroids - Topical Ambetter NH Formulary Updated October 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clobetasol propionate 1 PA; QL(1 gm DIPROLENE AF CREA emollient base crea daily) (Use betamethasone NF ST; QL(3 gm dipropionate augmented) clobetasol propionate foam 1 daily) DIPROLENE OINT (Use ST; QL(2 gm betamethasone NF clobetasol propionate gel 1 daily) dipropionate augmented) PA; QL(1 gm ELOCON CREA (Use clobetasol propionate oint 1 NF daily) mometasone furoate) PA; QL(3.34 ml fluocinolone acetonide crea clobetasol propionate soln 1 1 daily) 0.01 %, 0.025 % QL(118.28 ml clocortolone pivalate crea 3 fluocinolone acetonide oil 1 per fill retail)1 0.01 % rtl MAX fill,30 rtl CLODERM CREA (Use 3 clocortolone pivalate) day(s) supply, fluocinolone acetonide oil CORDRAN CREA 0.05 % NF 1 (Use flurandrenolide) 0.01 % fluocinolone acetonide oint CORDRAN LOTN 0.05 % NF 1 (Use flurandrenolide) 0.025 % fluocinolone acetonide soln CORDRAN TAPE 4 3 1 MCG/SQCM 0.01 % QL(2 gm daily) CUTIVATE LOTN (Use NF QL(6 ml daily) fluocinonide crea 0.05 % 1 fluticasone propionate) fluocinonide emulsified 1 QL(2 gm daily) QL(118.28 ml base crea DERMA-SMOOTHE/FS per fill retail)1 BODY OIL (Use NF fluocinolone acetonide) rtl MAX fill,30 rtl fluocinonide gel 0.05 % 1 day(s) supply, DERMA-SMOOTHE/FS fluocinonide oint 0.05 % 1 QL(2 gm daily) SCALP OIL (Use NF fluocinolone acetonide) fluocinonide soln 0.05 % 1 QL(2 ml daily) QL(4 gm daily) desonide crea 1 flurandrenolide crea 2 QL(2 gm daily) QL(4 ml daily) desonide lotn 1 flurandrenolide lotn 2 QL(2 ml daily) desonide oint 1 QL(3 gm daily) fluticasone propionate crea 1 0.05 % DESOWEN CREA (Use NF QL(4 gm daily) desonide) fluticasone propionate lotn 1 QL(6 ml daily) 0.05 % desoximetasone crea 0.25 1 % fluticasone propionate oint 1 0.005 % desoximetasone gel 0.05 1 % halcinonide crea 1 PA desoximetasone oint 0.25 1 halobetasol propionate 1 % crea PA diflorasone diacetate crea 1 halobetasol propionate oint 1 diflorasone diacetate oint 1 PA HALOG CREA (Use NF PA halcinonide) Ambetter NH Formulary Updated October 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALOG OINT 3 PA SYNALAR CREA (Use NF fluocinolone acetonide) hydrocortisone (topical) RX/OTC 1 SYNALAR OINT (Use NF crea 1 % fluocinolone acetonide) hydrocortisone (topical) 1 SYNALAR SOLN (Use NF crea 2.5 % fluocinolone acetonide) hydrocortisone (topical) 1 TACLONEX OINT (Use ST lotn 2.5 % calcipotriene- NF betamethasone hydrocortisone (topical) 1 RX/OTC oint 1 % dipropionate) TACLONEX SUSP (Use ST hydrocortisone (topical) 1 oint 2.5 % calcipotriene- 3 betamethasone hydrocortisone butyrate 1 crea dipropionate) TEMOVATE CREA (Use PA; QL(3 gm hydrocortisone butyrate 1 NF oint clobetasol propionate) daily) TEMOVATE OINT (Use PA; QL(1 gm hydrocortisone butyrate 1 NF soln clobetasol propionate) daily) TOPICORT CREA 0.25 % hydrocortisone valerate 1 NF crea (Use desoximetasone) TOPICORT GEL 0.05 % hydrocortisone valerate 1 NF oint (Use desoximetasone) TOPICORT OINT 0.25 % LOCOID CREA (Use NF NF hydrocortisone butyrate) (Use desoximetasone) triamcinolone acetonide LOCOID SOLN (Use NF hydrocortisone butyrate) (topical) crea 0.025 %, 0.5 1 % LUXIQ FOAM (Use NF QL(1.67 gm betamethasone valerate) daily) triamcinolone acetonide 1 QL(3.34 gm (topical) crea 0.1 % daily) mometasone furoate crea 1 triamcinolone acetonide (topical) lotn 0.025 %, 0.1 1 mometasone furoate oint 1 % triamcinolone acetonide mometasone furoate soln 1 (topical) oint 0.025 %, 0.1 1 MONISTAT SOOTHING RX/OTC %, 0.5 % triamcinolone acetonide- PA CARE ITCH RELIEF CREA NF 1 (Use hydrocortisone dimethicone-silicone kit (topical)) TRIDESILON CREA (Use NF QL(4 gm daily) desonide) OLUX FOAM (Use NF ST; QL(3 gm clobetasol propionate) daily) Eczema Agents prednicarbate crea 1 DUPIXENT SOPN 300 4 PA MG/2ML prednicarbate oint 1 DUPIXENT SOSY 200 4 PA MG/1.14ML, 300 MG/2ML PSORCON CREA 2 PA Emollient/Keratolytic Agents

Ambetter NH Formulary Updated October 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDRO 35 FOAM (Use NF lidocaine hcl prsy ex 2 % 1 QL(4 ml daily) urea in lactic acid vehicle) Emollients lidocaine hcl soln ex 4 % 1 LAC-HYDRIN CREA (Use RX/OTC PA lactic acid (ammonium NF lidocaine ptch ex 5 % 1 lactate)) QL(1 gm daily) LAC-HYDRIN TWELVE RX/OTC lidocaine-prilocaine crea 1 LOTN (Use lactic acid NF LIDODERM PTCH (Use NF PA (ammonium lactate)) lidocaine) lactic acid (ammonium 1 RX/OTC QL(10 ea per lactate) crea fill retail,10 ea lactic acid (ammonium 1 RX/OTC per fill mail)1 rtl lactate) lotn SYNERA PTCH 3 MAX fill,30 rtl day(s) supply,1 Enzymes - Topical mail MAX fill,30 SANTYL OINT 3 PA mail day(s) supply, Immunomodulating Agents - Topical Phosphodiesterase 4 (PDE4) Inhibitors - Topical QL(12 ea per PA; QL(2 gm ALDARA CREA (Use NF EUCRISA OINT 3 imiquimod) fill retail,12 ea daily) per fill mail) QL(12 ea per Rosacea Agents imiquimod crea 5 % 1 fill retail,12 ea azelaic acid gel 1 PA per fill mail) FINACEA GEL (Use PA ZYCLARA CREA (Use NF NF imiquimod) azelaic acid) METROCREAM CREA ZYCLARA PUMP CREA NF 3.75 % (Use imiquimod) (Use metronidazole NF (topical)) Immunosuppressive Agents - Topical METROGEL GEL (Use NF ELIDEL CREA (Use NF PA; AL(At least metronidazole (topical)) pimecrolimus) 2 yrs old) METROLOTION LOTN PA; AL(At least pimecrolimus crea 1 (Use metronidazole NF 2 yrs old) (topical)) PROTOPIC OINT (Use PA; AL(At least NF metronidazole (topical) 1 tacrolimus (topical)) 2 yrs old) crea PA; AL(At least tacrolimus (topical) oint 1 2 yrs old) metronidazole (topical) gel 1 Keratolytic/Antimitotic Agents metronidazole (topical) lotn 1 podofilox soln 1 MIRVASO GEL 3 PA; QL(1 gm daily) Local Anesthetics - Topical ORACEA CPDR (Use NF lidocaine hcl gel ex 2 % 1 QL(4 ml daily) doxycycline (rosacea)) QL(4 ml daily); SOOLANTRA CREA (Use lidocaine hcl gel ex 2 % 1 NF RX/OTC ivermectin (rosacea)) Scabicides & Pediculicides Ambetter NH Formulary Updated October 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits crotamiton lotn 1 PA CHEMSTRIP-K STRP 1

ELIMITE CREA (Use NF FORA GTEL BLOOD permethrin) KETONE TEST STRIPS 1 STRP EURAX CREA 3 GOJJI BLOOD KETONE 1 TEST STRIPS STRP EURAX LOTN (Use NF PA crotamiton) KETONE STRP 1 ivermectin (pediculicide) 1 PA; RX/OTC lotn KETONE TEST STRIPS 1 STRP IVERMECTIN LOTN EX 3 PA; RX/OTC 0.5 % KETOSTIX STRP 1 lindane sham 3 NOVA MAX PLUS KETONE TESTSTRIPS 1 malathion lotn 1 STRP PRECISION XTRA STRP NATROBA SUSP (Use 1 PA 1 spinosad) VI PTS PANELS KETONE NIX CREME RINSE LIQD NF 1 (Use permethrin) TEST STRP RELION KETONE TEST OVIDE LOTN (Use NF 1 malathion) STRIPS STRP permethrin crea 1 RELION TRUE METRIX QL(3.34 ea BLOODGLUCOSE TEST 1 daily); RX/OTC STRIPS STRP permethrin liqd 1 Limit 100 per TRUE METRIX BLOOD SKLICE LOTN (Use 3 PA; RX/OTC month;QL(3.34 ivermectin (pediculicide)) GLUCOSETEST STRIPS 1 STRP ea daily); RX/OTC spinosad susp 1 PA Limit 100 per ULESFIA LOTN 3 1 month;QL(3.34 TRUETRACK TEST STRP ea daily); Wound Care Products RX/OTC DIGESTIVE AIDS - Drugs to Treat Low Digestive REGRANEX GEL 3 Enzymes DIAGNOSTIC PRODUCTS Digestive Enzymes Diagnostic Drugs CREON CPEP 2 GLUCAGEN DIAGNOSTIC 3 QL(0.035 ea SUCRAID SOLN 3 SOLR daily) PA; 1 rtl MAX ZENPEP CPEP 2 fill,365 rtl day(s) supply,1 THYROGEN SOLR 3 DIURETICS - Drugs to Treat Heart, Circulation mail MAX Conditions and Blood Pressure fill,365 mail day(s) supply, Carbonic Anhydrase Inhibitors Diagnostic Tests

Ambetter NH Formulary Updated October 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acetazolamide cp12 500 1 QL(2 ea daily) tabs 1 mg LASIX TABS (Use NF acetazolamide sodium solr 1 furosemide) acetazolamide tabs 125 mg 1 QL(8 ea daily) torsemide tabs 1 acetazolamide tabs 250 mg 1 QL(4 ea daily) Potassium Sparing Diuretics ALDACTONE TABS (Use NF KEVEYIS TABS 4 PA; QL(4 ea spironolactone) daily) amiloride hcl tabs 1 methazolamide tabs 1 QL(6 ea daily) DYRENIUM CAPS (Use NF QL(3 ea daily) Diuretic Combinations triamterene) ALDACTAZIDE TABS 25 spironolactone tabs 1 MG-25 MG (Use NF spironolactone & QL(3 ea daily) hydrochlorothiazide) triamterene caps 1 amiloride & 1 Thiazides and Thiazide-Like Diuretics hydrochlorothiazide tabs DYAZIDE CAPS (Use chlorthalidone tabs 1 triamterene & NF QL(2 ea daily) hydrochlorothiazide) hydrochlorothiazide caps 1 MAXZIDE TABS (Use QL(2 ea daily) triamterene & NF hydrochlorothiazide tabs 1 hydrochlorothiazide) indapamide tabs 1.25 mg 1 QL(1 ea daily) MAXZIDE-25 TABS (Use triamterene & NF QL(2 ea daily) hydrochlorothiazide) indapamide tabs 2.5 mg 1 QL(2 ea daily) spironolactone & 1 metolazone tabs 1 hydrochlorothiazide tabs ENDOCRINE AND METABOLIC AGENTS - triamterene & 1 hydrochlorothiazide caps MISC. - Drugs to Treat Bone Disease and Regulate Hormones triamterene & 1 hydrochlorothiazide tabs Bone Density Regulators Loop Diuretics ACTONEL TABS 150 MG NF PA; QL(0.036 (Use risedronate sodium) ea daily) soln ij 0.25 1 mg/ml ACTONEL TABS 35 MG NF PA; QL(0.143 (Use risedronate sodium) ea daily) bumetanide tabs or 0.5 mg, 1 QL(5 ea daily) 1 mg, 2 mg ACTONEL TABS 5 MG NF PA; QL(1 ea (Use risedronate sodium) daily) BUMEX TABS (Use NF QL(5 ea daily) bumetanide) alendronate sodium tabs 1 QL(0.143 ea 35 mg, 70 mg daily) EDECRIN TABS (Use NF QL(16 ea daily) ethacrynic acid) alendronate sodium tabs 1 QL(1 ea daily) 40 mg, 5 mg, 10 mg ethacrynic acid tabs 1 QL(16 ea daily) ATELVIA TBEC (Use NF PA risedronate sodium) furosemide soln 1

Ambetter NH Formulary Updated October 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BONIVA SOLN IV 3 PA; SP zoledronic acid soln 4 4 PA; SP MG/3ML (Use ibandronate NF mg/100ml, 5 mg/100ml sodium) ZOLEDRONIC ACID SOLR 4 PA; SP BONIVA TABS OR 150 MG NF QL(0.036 ea 4 MG (Use ibandronate sodium) daily) Corticotropin calcitonin (salmon) soln na 1 PA 200 unit/act ACTHAR GEL 4 etidronate disodium tabs 1 Fertility Regulators CHORIONIC PA; SP FOSAMAX PLUS D TABS 3 PA; QL(0.143 4 ea daily) GONADOTROPIN SOLR NOVAREL SOLR 10000 PA; SP FOSAMAX TABS (Use NF QL(0.143 ea 4 alendronate sodium) daily) UNIT PREGNYL W/DILUENT PA; SP ibandronate sodium soln iv 4 PA; SP 3 mg/3ml BENZYLALCOHOL/NACL 4 SOLR ibandronate sodium tabs or 1 QL(0.036 ea 150 mg daily) GnRH/LHRH Antagonists PA pamidronate disodium soln 4 PA; SP CETROTIDE KIT 4 30 mg/10ml, 90 mg/10ml PAMIDRONATE PA; SP ganirelix acetate sosy 4 PA DISODIUM SOLN 6 4 MG/ML GANIRELIX ACETATE PA SOSY (Use ganirelix NF pamidronate disodium solr 4 PA; SP 30 mg, 90 mg acetate) PA; 1 rtl MAX Growth Hormone Receptor Antagonists fill,180 rtl PROLIA SOSY 4 SOMAVERT SOLR 10 MG, 4 PA; SP day(s) supply,; 15 MG, 20 MG SP Growth Hormone Releasing Hormones (GHRH) RECLAST SOLN (Use NF PA; SP zoledronic acid) EGRIFTA SOLR 4 PA risedronate sodium tabs 1 PA; QL(0.036 PA 150 mg ea daily) EGRIFTA SV SOLR 4 risedronate sodium tabs 30 1 PA; QL(1 ea Growth Hormones mg, 5 mg daily) GENOTROPIN MINIQUICK 4 PA; SP risedronate sodium tabs 35 1 PA; QL(0.143 SOLR 0.2 MG mg ea daily) GENOTROPIN SOLR 5 4 PA; SP risedronate sodium tbec 35 1 PA MG mg HUMATROPE COMBO 4 PA; SP TYMLOS SOPN 4 PA; PACK SOLR PA; SP XGEVA SOLN 4 PA; SP HUMATROPE SOLR 4 NORDITROPIN FLEXPRO PA; SP zoledronic acid conc 4 4 PA; SP mg/5ml SOPN 10 MG/1.5ML, 15 4 MG/1.5ML, 5 MG/1.5ML ZOLEDRONIC ACID SOLN 4 PA; SP 4 MG/100ML NORDITROPIN FLEXPRO 4 PA SOPN 30 MG/3ML

Ambetter NH Formulary Updated October 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUTROPIN AQ NUSPIN 4 PA; SP CARBAGLU TABS 4 PA; SP 10 SOPN PA; QL(4 ea OMNITROPE SOCT 10 4 PA; SP cinacalcet hcl tabs 4 MG/1.5ML, 5 MG/1.5ML daily); SP PA; SP SAIZEN SOLR 4 PA; SP CYSTADANE POWD 4 SAIZENPREP PA; SP doxercalciferol caps 1 RECONSTITUTIONKIT 4 SOLR doxercalciferol soln 1 SEROSTIM SOLR 4 PA; SP ELAPRASE SOLN 4 PA; SP ZOMACTON SOLR 4 PA; SP FABRAZYME SOLR 35 4 PA; SP PA; SP MG ZORBTIVE SOLR 4 PA; QL(0.5 ea GALAFOLD CAPS 4 Hormone Receptor Modulators daily) HECTOROL SOLN 4 EVISTA TABS (Use NF QL(1 ea daily) raloxifene hcl) MCG/2ML (Use NF doxercalciferol) PA OSPHENA TABS 3 KUVAN PACK (Use PA NF QL(1 ea daily) sapropterin raloxifene hcl tabs 0 dihydrochloride) KUVAN TABS (Use PA Insulin-Like Growth Factors (Somatomedins) sapropterin NF INCRELEX SOLN 4 PA; SP dihydrochloride) PA; SP LHRH/GnRH Agonist Analog Pituitary LUMIZYME SOLR 4 FENSOLVI KIT 4 PA; SP MYALEPT SOLR 4 PA

LUPANETA PACK KIT 4 PA NAGLAZYME SOLN 4 PA; SP PA; SP LUPRON DEPOT-PED (1- 4 PA; SP nitisinone caps 4 MONTH) KIT ORFADIN CAPS 10 MG, 2 PA; SP LUPRON DEPOT-PED (3- 4 PA; SP NF MONTH) KIT 30 MG MG, 5 MG (Use nitisinone) PA SYNAREL SOLN 4 PA; SP PALYNZIQ SOSY 4 Metabolic Modifiers paricalcitol caps 1 PA; SP ALDURAZYME SOLN 4 paricalcitol soln 1 BUPHENYL POWD (Use PA NF ROCALTROL CAPS (Use NF sodium phenylbutyrate) calcitriol) BUPHENYL TABS (Use PA NF ROCALTROL SOLN (Use NF sodium phenylbutyrate) calcitriol) calcitriol caps 1 sapropterin dihydrochloride 4 PA pack calcitriol soln 1

Ambetter NH Formulary Updated October 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sapropterin dihydrochloride 4 PA SANDOSTATIN SOLN NF PA; SP tabs (Use octreotide acetate) SENSIPAR TABS (Use NF PA; QL(4 ea SIGNIFOR SOLN 4 PA cinacalcet hcl) daily); SP SOMATULINE DEPOT PA; QL(0.0179 sodium phenylbutyrate 1 PA 4 powd SOLN 120 MG/0.5ML ml daily); SP PA SOMATULINE DEPOT 4 PA; QL(0.0075 sodium phenylbutyrate tabs 1 SOLN 60 MG/0.2ML ml daily); SP ZEMPLAR CAPS (Use NF SOMATULINE DEPOT 4 PA; QL(0.011 paricalcitol) SOLN 90 MG/0.3ML ml daily); SP ZEMPLAR SOLN (Use NF Vasopressin Receptor Antagonists paricalcitol) JYNARQUE TABS 15 MG, 4 PA; QL(2 ea Posterior Pituitary Hormones 30 MG daily); SP DDAVP SOLN IJ 4 PA JYNARQUE TBPK 4 PA; SP MCG/ML (Use NF desmopressin acetate) SAMSCA TABS (Use 4 PA; QL(2 ea DDAVP SOLN NA 0.01 % tolvaptan) daily); SP (Use desmopressin acetate NF PA; QL(2 ea tolvaptan tabs 4 spray) daily); SP DDAVP TABS OR 0.1 MG QL(6 ea daily) ESTROGENS - Hormone Replacement/Modifying (Use desmopressin NF Drugs acetate) DDAVP TABS OR 0.2 MG QL(8 ea daily) Estrogen Combinations (Use desmopressin NF CLIMARA PRO PTWK 3 acetate) PA desmopressin acetate soln 1 PA DUAVEE TABS 3 ij 4 mcg/ml FEMHRT TABS (Use DESMOPRESSIN PA; SP norethindrone acetate- NF ACETATE SOLN NA 1.5 4 ethinyl estradiol) MG/ML norethindrone acetate- 1 desmopressin acetate 1 ethinyl estradiol tabs spray refrigerated soln PREMPHASE TABS 2 desmopressin acetate 1 spray soln PREMPRO TABS 2 desmopressin acetate tabs 1 QL(6 ea daily) or 0.1 mg Estrogens desmopressin acetate tabs 1 QL(8 ea daily) or 0.2 mg CLIMARA PTWK (Use NF estradiol) STIMATE SOLN 4 PA; SP DELESTROGEN OIL 10 1 MG/ML Prolactin Inhibitors DELESTROGEN OIL 20 tabs 1 MG/ML, 40 MG/ML (Use NF estradiol valerate) Somatostatic Agents DEPO-ESTRADIOL OIL 3 octreotide acetate soln 4 PA; SP

Ambetter NH Formulary Updated October 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIVIGEL GEL 0.25 CIPRO SUSR 5 2 rtl MAX fill,30 MG/0.25GM, 0.5 3 2 rtl day(s) GM/100ML, 500 MG/5ML MG/0.5GM, 1 MG/GM supply, ELESTRIN GEL 3 CIPRO TABS 250 MG, 500 NF MG (Use ciprofloxacin hcl) ESTRACE TABS (Use NF estradiol) ciprofloxacin hcl tabs 1 estradiol pttw td 0.025 QL(0.286 ea ciprofloxacin in d5w soln 5 3 mg/24hr, 0.0375 mg/24hr, 1 daily) %-200 mg/100ml 0.05 mg/24hr, 0.075 2 rtl MAX fill,30 mg/24hr, 0.1 mg/24hr ciprofloxacin susr 1 rtl day(s) estradiol ptwk td 0.025 supply, mg/24hr, 0.075 mg/24hr, LEVAQUIN TABS (Use NF 0.1 mg/24hr, 0.05 mg/24hr, 1 levofloxacin) 0.06 mg/24hr, 37.5 mcg/24hr levofloxacin in d5w soln 5 1 %-500 mg/100ml estradiol tabs or 0.5 mg, 1 1 mg, 2 mg levofloxacin soln 1 estradiol valerate oil 1 levofloxacin tabs 1

ESTROGEL GEL 3 moxifloxacin hcl in sodium 1 chloride soln EVAMIST SOLN 3 moxifloxacin hcl tabs 1 MENEST TABS 3 ofloxacin tabs 1 MENOSTAR PTWK 3 GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs MINIVELLE PTTW (Use NF QL(0.286 ea estradiol) daily) Bile Acid Synthesis Disorder Agents PREMARIN SOLR 2 CHOLBAM CAPS 4 PA; SP PREMARIN TABS 2 Gallstone Solubilizing Agents ACTIGALL CAPS (Use VIVELLE-DOT PTTW (Use NF QL(0.286 ea NF estradiol) daily) ursodiol) URSO 250 TABS (Use NF FLUOROQUINOLONES - Drugs to Treat Bacterial ursodiol) Infections URSO FORTE TABS (Use NF Fluoroquinolones ursodiol) AVELOX SOLN (Use moxifloxacin hcl in sodium 1 ursodiol caps 300 mg 1 chloride) ursodiol tabs 250 mg, 500 1 BAXDELA SOLR 3 PA mg Gastrointestinal Chloride Channel Activators BAXDELA TABS 3 PA AMITIZA CAPS (Use 2 PA; QL(2 ea lubiprostone) daily)

Ambetter NH Formulary Updated October 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea QL(6 ea daily) lubiprostone caps 1 mesalamine tbec or 800 1 daily) mg Gastrointestinal Stimulants PA; 30 rtl lmt RENFLEXIS SOLR 4 day(s),30 mail hcl soln ij 1 lmt day(s), 5 mg/ml metoclopramide hcl soln or QL(60 ml daily) STELARA SOLN IV 130 4 PA 1 MG/26ML 10 mg/10ml, 5 mg/5ml sulfasalazine tabs 1 metoclopramide hcl tabs or 1 QL(6 ea daily) 10 mg, 5 mg sulfasalazine tbec 1 REGLAN TABS (Use NF QL(6 ea daily) metoclopramide hcl) Intestinal Acidifiers Inflammatory Bowel Agents lactulose (encephalopathy) 1 APRISO CP24 (Use NF soln mesalamine) Irritable Bowel Syndrome (IBS) Agents ASACOL HD TBEC (Use NF QL(6 ea daily) mesalamine) alosetron hcl tabs 1 QL(2 ea daily) AZULFIDINE EN-TABS PA; QL(1 ea NF LINZESS CAPS 2 TBEC (Use sulfasalazine) daily) AZULFIDINE TABS (Use NF LOTRONEX TABS (Use NF QL(2 ea daily) sulfasalazine) alosetron hcl) balsalazide disodium caps 1 Peripheral Opioid Receptor Antagonists CANASA SUPP (Use NF alvimopan caps 1 mesalamine) ENTEREG CAPS (Use COLAZAL CAPS (Use NF 3 balsalazide disodium) alvimopan) RELISTOR SOLN SC 12 PA DELZICOL CPDR (Use NF 3 mesalamine) MG/0.6ML, 8 MG/0.4ML DIPENTUM CAPS 2 Phosphate Binder Agents calcium acetate (phosphate 1 PA; 30 rtl lmt binder) caps INFLECTRA SOLR 4 day(s),30 mail calcium acetate (phosphate 1 RX/OTC lmt day(s), binder) tabs LIALDA TBEC (Use NF FOSRENOL CHEW 1000 mesalamine) MG, 500 MG, 750 MG (Use NF mesalamine cp24 or 0.375 1 lanthanum carbonate) gm lanthanum carbonate chew 1 mesalamine cpdr or 400 1 mg PHOSLYRA SOLN 2 mesalamine enem re 4 gm 1 RENVELA PACK (Use NF sevelamer carbonate) mesalamine supp re 1000 1 mg RENVELA TABS (Use NF sevelamer carbonate) mesalamine tbec or 1.2 gm 1 sevelamer carbonate pack 1

Ambetter NH Formulary Updated October 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sevelamer carbonate tabs 1 FLOMAX CAPS (Use NF tamsulosin hcl) PA VELPHORO CHEW 3 PROSCAR TABS (Use NF 5 mg only finasteride) GENITOURINARY AGENTS - MISCELLANEOUS RAPAFLO CAPS (Use NF - Miscellaneous Drugs to Treat Reproductive silodosin) Organs and Urinary System silodosin caps 8 mg, 4 mg 1 Alkalinizers potassium citrate tamsulosin hcl caps 1 (alkalinizer) tbcr 10 meq, 1 1080 mg UROXATRAL TB24 (Use NF QL(1 ea daily) alfuzosin hcl) sodium citrate & citric acid 1 RX/OTC soln Urinary Analgesics UROCIT-K 10 TBCR (Use phenazopyridine hcl tabs 1 potassium citrate NF (alkalinizer)) PYRIDIUM TABS (Use NF Cystinosis Agents phenazopyridine hcl) CYSTAGON CAPS 3 PA GOUT AGENTS - Drugs to Treat Gout Genitourinary Irrigants Gout Agent Combinations colchicine w/ probenecid 1 acetic acid soln 1 tabs (gu irrigant) soln 1 Gout Agents allopurinol tabs 1 RESECTISOL SOLN 1 colchicine tabs 1 QL(1 ea daily) sodium chloride (gu 1 irrigant) soln COLCRYS TABS (Use NF QL(1 ea daily) SORBITOL SOLN 1 colchicine) PA; QL(1 ea febuxostat tabs 1 SORBITOL-MANNITOL 1 daily) SOLN KRYSTEXXA SOLN 4 PA SORBITOL/MANNITOL 1 IRRIGATION SOLN MITIGARE CAPS (Use NF Interstitial Cystitis Agents colchicine) ULORIC TABS (Use NF PA; QL(1 ea ELMIRON CAPS 2 febuxostat) daily) Prostatic Hypertrophy Agents ZYLOPRIM TABS (Use NF allopurinol) alfuzosin hcl tb24 1 QL(1 ea daily) Uricosurics AVODART CAPS (Use NF QL(1 ea daily) dutasteride) probenecid tabs 1 dutasteride caps 1 QL(1 ea daily) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders 5 mg only finasteride tabs 1 Bradykinin B2 Receptor Antagonists

Ambetter NH Formulary Updated October 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRAZYR SOLN (Use NF PA; QL(9 ml REOPRO SOLN 3 icatibant acetate) daily) PA; QL(9 ml PA icatibant acetate soln 4 ZONTIVITY TABS 3 daily) Complement Inhibitors HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders 4 PA CINRYZE SOLR Agents for Gaucher Disease PA HAEGARDA SOLR 4 CERDELGA CAPS 4 PA; QL(2 ea daily) RUCONEST SOLR 4 PA; QL(0.143 PA; SP ea daily) CEREZYME SOLR 4 SOLIRIS SOLN 4 PA ELELYSO SOLR 4 PA; SP PA; QL(3 ea Hematorheologic Agents miglustat caps 4 daily); SP pentoxifylline tbcr 1 QL(3 ea daily) VPRIV SOLR 4 PA; SP Plasma Kallikrein Inhibitors ZAVESCA CAPS (Use NF PA; QL(3 ea TAKHZYRO SOLN 4 PA; miglustat) daily); SP Platelet Aggregation Inhibitors Agents for Sickle Cell Disease DROXIA CAPS 3 AGGRENOX CP12 (Use NF PA; QL(2 ea aspirin-dipyridamole) daily) OXBRYTA TABS 4 PA AGRYLIN CAPS (Use NF anagrelide hcl) Cobalamins anagrelide hcl caps 1 cyanocobalamin soln ij 1 QL(1 ml daily) PA; QL(2 ea 1000 mcg/ml aspirin-dipyridamole cp12 1 daily) Folic Acid/Folates BRILINTA TABS 2 folic acid tabs or 1 mg 0 RX/OTC

CABLIVI KIT 4 PA folic acid tabs or 400 mcg 0 cilostazol tabs 1 Hematopoietic Growth Factors ARANESP ALBUMIN PA; SP clopidogrel bisulfate tabs 1 FREE SOLN 100 MCG/ML, 4 300 mg 40 MCG/ML, 60 MCG/ML clopidogrel bisulfate tabs QL(1 ea daily) 1 ARANESP ALBUMIN 4 SP 75 mg FREE SOLN 25 MCG/ML dipyridamole tabs 1 ARANESP ALBUMIN PA; SP FREE SOSY 150 EFFIENT TABS (Use NF QL(1 ea daily) MCG/0.3ML, 200 4 prasugrel hcl) MCG/0.4ML, 300 PLAVIX TABS (Use NF QL(1 ea daily) MCG/0.6ML, 500 MCG/ML clopidogrel bisulfate) DOPTELET TABS 4 PA prasugrel hcl tabs 1 QL(1 ea daily)

Ambetter NH Formulary Updated October 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPOGEN SOLN 3 PA; SP Iron FER-IN-SOL SOLN (Use 0 AL(Up to 1 yrs FULPHILA SOSY 4 PA; ferrous sulfate) old ) PA; SP ferrous sulfate soln or 15 0 AL(Up to 1 yrs LEUKINE SOLR 4 mg/ml old ) PA ferrous sulfate tabs or 325 0 MIRCERA SOSY 4 mg, 65 mg MULPLETA TABS 4 PA ferrous sulfate tbec or 325 0 mg NEULASTA ONPRO KIT 4 PA; SP Stem Cell Mobilizers PSKT MOZOBIL SOLN 4 PA; SP NEULASTA SOSY 4 PA; SP PA; SP HEMOSTATICS - Drugs to Stop Bleeding/Treat NEUPOGEN SOLN 4 Blood Disorders NEUPOGEN SOSY 4 PA; SP Hemostatics - Systemic AMICAR TABS 1000 MG, PA NIVESTYM SOSY 300 PA 500 MG (Use aminocaproic NF MCG/0.5ML, 480 4 acid) MCG/0.8ML aminocaproic acid tabs or 1 PA NPLATE SOLR 250 MCG, 4 PA; SP 1000 mg, 500 mg 500 MCG CYKLOKAPRON SOLN NF PROCRIT SOLN 10000 PA; SP (Use tranexamic acid) UNIT/ML, 2000 UNIT/ML, 3 20000 UNIT/ML, 3000 LYSTEDA TABS (Use NF UNIT/ML, 4000 UNIT/ML tranexamic acid) tranexamic acid soln 1 PROCRIT SOLN 40000 4 PA; SP UNIT/ML tranexamic acid tabs 1 PROMACTA PACK 12.5 4 PA; QL(1 ea MG daily) HYPNOTICS/SEDATIVES/SLEEP DISORDER PROMACTA TABS 12.5 4 PA; SP AGENTS MG, 25 MG, 50 MG, 75 MG RETACRIT SOLN 10000 PA Hypnotics UNIT/ML, 2000 UNIT/ML, elix 20 1 20000 UNIT/2ML, 3000 4 mg/5ml UNIT/ML, 4000 UNIT/ML, phenobarbital soln 20 1 40000 UNIT/ML mg/5ml UDENYCA SOSY 4 PA phenobarbital tabs 100 mg, 16.2 mg, 32.4 mg, 64.8 mg, 1 PA; 30 rtl lmt 97.2 mg, 15 mg, 30 mg ZARXIO SOSY 4 day(s),30 mail lmt day(s), Hypnotics - Tricyclic Agents PA; QL(1 ea PA; doxepin hcl (sleep) tabs 1 ZIEXTENZO SOSY 4 daily) Hematopoietic Mixtures SILENOR TABS (Use NF PA; QL(1 ea doxepin hcl (sleep)) daily) ferrous fumarate-folic acid 1 QL(1 ea daily) tabs Non-Barbiturate Hypnotics

Ambetter NH Formulary Updated October 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Must try HETLIOZ CAPS 3 PA; QL(1 ea immediate daily) AMBIEN CR TBCR (Use NF ) release ST; QL(1 ea zolpidem tartrate zolpidem.;QL(1 1 daily); AL(At ea daily) ramelteon tabs least 18 yrs QL(1 ea daily); old) AMBIEN TABS (Use NF zolpidem tartrate) AL(At least 18 ST; QL(1 ea yrs old) ROZEREM TABS (Use NF daily); AL(At DORAL TABS (Use NF ramelteon) least 18 yrs quazepam) old) estazolam tabs 1 LAXATIVES - Bowel Treatment Drugs ST; QL(1 ea Bulk Laxatives 1 daily); AL(At eszopiclone tabs least 18 yrs calcium polycarbophil tabs 1 old) FIBERCON TABS (Use NF HALCION TABS (Use NF calcium polycarbophil) triazolam) ST; QL(1 ea Laxative Combinations PA LUNESTA TABS (Use NF daily); AL(At CLENPIQ SOLN 3 eszopiclone) least 18 yrs old) COLYTE-FLAVOR PACKS SOLR (Use peg 3350-kcl- RESTORIL CAPS (Use NF QL(1 ea daily) NF temazepam) sod bicarb-sod chloride-sod sulfate) QL(1 ea daily) temazepam caps 1 GOLYTELY SOLR 2.97 GM-5.86 GM-6.74 GM- triazolam tabs 1 22.74 GM-236 GM (Use 0 peg 3350-kcl-sod bicarb- QL(2 ea daily); sod chloride-sod sulfate) zaleplon caps 10 mg 1 AL(At least 18 yrs old) MOVIPREP SOLR (Use PA peg 3350-kcl-nacl-na 2 QL(1 ea daily); sulfate-na ascorbate- zaleplon caps 5 mg 1 AL(At least 18 ascorbic acid) yrs old) peg 3350-kcl-nacl-na PA QL(1 ea daily); sulfate-na ascorbate- 1 zolpidem tartrate tabs or 10 1 AL(At least 18 mg, 5 mg ascorbic acid solr yrs old) peg 3350-kcl-sod bicarb- ST; Must try sod chloride-sod sulfate immediate 0 zolpidem tartrate tbcr or solr 2.97 gm-5.86 gm-6.74 1 release gm-22.74 gm-236 gm 6.25 mg, 12.5 mg zolpidem.;QL(1 ea daily) PREPOPIK PACK 3 PA Orexin Receptor Antagonists SUPREP BOWEL PREP 0 BELSOMRA TABS 3 PA KIT SOLN Laxatives - Miscellaneous Selective Melatonin Receptor Agonists lactulose soln 10 gm/15ml, 1 20 gm/30ml

Ambetter NH Formulary Updated October 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Saline Laxatives QL(4 ea per fill azithromycin tabs or 500 1 retail,4 ea per PA mg OSMOPREP TABS 3 fill mail) azithromycin tabs or 600 1 QL(0.286 ea Laxatives mg daily) bisacodyl tbec 1 ZITHROMAX PACK OR 1 NF GM (Use azithromycin) DULCOLAX TBEC (Use NF bisacodyl) ZITHROMAX SOLR IV 500 NF MG (Use azithromycin) Surfactant Laxatives ZITHROMAX SUSR OR COLACE CAPS (Use NF 100 MG/5ML, 200 MG/5ML NF docusate sodium) (Use azithromycin) docusate calcium caps 1 QL(6 ea per fill ZITHROMAX TABS OR NF 250 MG (Use azithromycin) retail,6 ea per docusate sodium caps 1 fill mail) QL(4 ea per fill LOCAL ANESTHETICS-Parenteral - Drugs for ZITHROMAX TABS OR NF retail,4 ea per 500 MG (Use azithromycin) Numbing fill mail) Local Anesthetics - Amides ZITHROMAX TABS OR NF QL(0.286 ea 600 MG (Use azithromycin) daily) lidocaine hcl (local anesth.) 1 soln 0.5 %, 1 %, 2 % QL(4 ea per fill ZITHROMAX TRI-PAK NF retail,4 ea per MARCAINE SOLN 0.5 % NF TABS (Use azithromycin) (Use bupivacaine hcl) fill mail) NAROPIN SOLN 5 MG/ML, QL(6 ea per fill ZITHROMAX Z-PAK TABS NF retail,6 ea per 2 MG/ML (Use ropivacaine NF (Use azithromycin) hcl) fill mail) XYLOCAINE SOLN 0.5 %, Clarithromycin 1 % (Use lidocaine hcl NF clarithromycin susr 1 (local anesth.)) XYLOCAINE-MPF SOLN clarithromycin tabs 1 0.5 %, 1 %, 2 % (Use NF lidocaine hcl (local clarithromycin tb24 1 anesth.)) MACROLIDES - Drugs to Treat Bacterial Erythromycins Infections E.E.S. GRANULES SUSR (Use erythromycin NF Azithromycin ethylsuccinate) azithromycin pack or 1 gm 1 ERYPED 200 SUSR (Use erythromycin NF azithromycin solr iv 500 mg 1 ethylsuccinate) ERYPED 400 SUSR (Use azithromycin susr or 100 1 mg/5ml, 200 mg/5ml erythromycin 3 ethylsuccinate) QL(6 ea per fill azithromycin tabs or 250 1 retail,6 ea per erythromycin base cpep mg 3 fill mail) 250 mg erythromycin base tabs 250 3 mg, 500 mg Ambetter NH Formulary Updated October 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits erythromycin base tbec 1 KIMONO PLUS QL(2 ea daily) 250 mg, 333 mg, 500 mg SPERMICIDE/LUBRICATE 0 erythromycin D MISC 1 ethylsuccinate susr 200 KIMONO PS LUBRICATED 0 QL(2 ea daily) mg/5ml, 400 mg/5ml MISC erythromycin 3 KIMONO PS PLUS QL(2 ea daily) ethylsuccinate tabs 400 mg SPERMICIDE/LUBRICATE 0 D MISC Fidaxomicin KIMONO SENSATION 0 QL(2 ea daily) DIFICID TABS 200 MG 2 LUBRICATED MISC KIMONO SENSATION QL(2 ea daily) MEDICAL DEVICES AND SUPPLIES PLUS SPERMICIDE 0 LUBRICATED MISC Contraceptives KIMONO SPECIAL DEVI 0 QL(2 ea daily) AIMSCO LUBRICATED 0 QL(2 ea daily) MISC MAXX LUBRICATED MISC 0 QL(2 ea daily) CAYA DPRH 0 MAXX PLUS SPERMICIDE 0 QL(2 ea daily) DUREX EXTRA 0 QL(2 ea daily) LUBRICATED MISC SENSITIVE DEVI OMNIFLEX DIAPHRAGM 0 FANTASY LUBRICATED 0 QL(2 ea daily) DPRH MISC PREMIUM CONDOMS 0 QL(2 ea daily) FANTASY QL(2 ea daily) LUBRICATED MISC LUBRICATED/SPERMICID 0 REALITY LATEX QL(2 ea daily) E MISC CONDOMS/LUBRICATED 0 FC FEMALE CONDOM 0 QL(1 ea daily) MISC MISC REALITY LATEX/ULTRA 0 QL(2 ea daily) FEMCAP DEVI 0 TEXTURED DEVI REALITY LATEX/ULTRA 0 QL(2 ea daily) K-Y ME & YOU EXTRA 0 QL(2 ea daily) THIN DEVI LUBRICATED DEVI TRUSTEX COLOR 0 QL(2 ea daily) K-Y ME & YOU INTENSE 0 QL(2 ea daily) CONDOMS + LUBE MISC DEVI TRUSTEX LUBRICATED 0 QL(2 ea daily) KAMELEON LUBRICATED 0 QL(2 ea daily) EXTRALARGE MISC MISC TRUSTEX LUBRICATED 0 QL(2 ea daily) KIMONO COLORS DEVI 0 QL(2 ea daily) EXTRASTRENGTH MISC TRUSTEX LUBRICATED QL(2 ea daily) KIMONO LUBRICATED 0 QL(2 ea daily) 0 MISC MISC KIMONO MICRO THIN QL(2 ea daily) TRUSTEX QL(2 ea daily) PLUS SPERMICIDE 0 LUBRICATED/RIBBED/ST 0 LUBRICATED MISC UDDED MISC KIMONO PLUS QL(2 ea daily) TRUSTEX QL(2 ea daily) SPERMICIDE 0 LUBRICATED/SPERMICID 0 LUBRICATED MISC E EXTRA LARGE MISC

Ambetter NH Formulary Updated October 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX QL(2 ea daily) Diabetic Supplies LUBRICATED/SPERMICID 0 1ST TIER UNILET QL(6.6667 ea E EXTRA STRENGTH 1 MISC COMFORTOUCH daily) LANCETS 28G MISC TRUSTEX QL(2 ea daily) 1ST TIER UNILET QL(6.6667 ea LUBRICATED/SPERMICID 0 1 E MISC COMFORTOUCH daily) LANCETS 30G MISC TRUSTEX NATURAL QL(2 ea daily) ACCU-CHEK FASTCLIX QL(6.6667 ea CONDOMS 0 1 +LUBE/LUBRICATED LANCETS MISC daily) MISC ACCU-CHEK MULTICLIX 1 QL(6.6667 ea LANCETS MISC daily) TRUSTEX WITH QL(2 ea daily) ACCU-CHEK SAFE-T-PRO QL(6.6667 ea NONOXYNOL- 0 1 9/RIBBED/STUDDED LANCETS MISC daily) MISC ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea PLUSLANCETS MISC daily) TRUSTEX/RIA 0 QL(2 ea daily) LUBRICATED MISC ACCU-CHEK SOFTCLIX 1 QL(6.6667 ea TRUSTEX/RIA QL(2 ea daily) LANCETS MISC daily) LUBRICATED 0 ACTI-LANCE LANCETS 1 QL(6.6667 ea SPERMICIDE MISC 28G MISC daily) TRUSTEX/RIA QL(2 ea daily) ACTI-LANCE LITE QL(6.6667 ea LUBRICATED/SPERMICID 0 SAFETY LANCETS 28G 1 daily) E MISC MISC WIDE-SEAL SILICONE ACTI-LANCE SPECIAL QL(6.6667 ea DIAPHRAGM KIT 60 0 SAFETY LANCETS 17G 1 daily) DPRH MISC WIDE-SEAL SILICONE ACTI-LANCE SPECIAL QL(6.6667 ea DIAPHRAGM KIT 65 0 SAFETYLANCETS 17G 1 daily) DPRH MISC WIDE-SEAL SILICONE ACTI-LANCE UNIVERSAL QL(6.6667 ea DIAPHRAGM KIT 70 0 SAFETY LANCETS 23G 1 daily) DPRH MISC WIDE-SEAL SILICONE ADJUSTABLE LANCING 1 DIAPHRAGM KIT 75 0 DEVICE MISC DPRH ADVANCED MOBILE 1 QL(6.6667 ea WIDE-SEAL SILICONE LANCET 30G MISC daily) DIAPHRAGM KIT 80 0 ADVOCATE LANCETS 1 QL(6.6667 ea DPRH 30G MISC daily) WIDE-SEAL SILICONE ADVOCATE LANCETS 1 QL(6.6667 ea DIAPHRAGM KIT 85 0 MISC daily) DPRH ADVOCATE LANCING 1 WIDE-SEAL SILICONE DEVICE MISC DIAPHRAGM KIT 90 0 DPRH ADVOCATE RAPID-SAFE 1 LANCING DEVICE MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 95 0 ADVOCATE SAFETY 1 QL(6.6667 ea DPRH LANCETS 26G MISC daily)

Ambetter NH Formulary Updated October 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE SAFETY 1 QL(6.6667 ea AUTO-LANCET MINI MISC 1 LANCETS MISC daily) AGAMATRIX ULTRA-THIN 1 QL(6.6667 ea AUTO-LANCET MISC 1 LANCETS 33G MISC daily) AUTOLET IMPRESSION AIMSCO TWIST LANCETS 1 QL(6.6667 ea 1 32G MISC daily) LANCING DEVICE MISC AUTOLET LANCING AIMSCO TWIST LANCETS 1 QL(6.6667 ea 1 33G MISC daily) DEVICE MISC ALTERNATE SITE 1 AUTOLET MINI MISC 1 LANCING DEVICE MISC AQUA LANCE AUTOLET PLUS MISC 1 ADJUSTABLE LANCING 1 DEVICE DEVI BD LANCET ULTRAFINE 1 QL(6.6667 ea 30G MISC daily) ASSURE HAEMOLANCE QL(6.6667 ea PLUS HIGH FLOW 18G 1 daily) BD LANCET ULTRAFINE 1 QL(6.6667 ea MISC 33G MISC daily) ASSURE HAEMOLANCE QL(6.6667 ea BD MICROTAINER 1 QL(6.6667 ea PLUS LOW FLOW 25G 1 daily) LANCETS MISC daily) MISC BULLSEYE MINI SAFETY 1 QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea LANCETS MISC daily) PLUS MICRO FLOW 28G 1 daily) BULLSEYE SAFETY 1 QL(6.6667 ea MISC LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.6667 ea CARDIOCOM LANCING 1 PLUS NORMAL FLOW 1 daily) DEVICE MISC 21G MISC CAREONE ADVANCED 1 ASSURE HAEMOLANCE QL(6.6667 ea LANCINGDEVICE MISC PLUS PEDIATRIC BLADE 1 daily) CAREONE LANCET 1 QL(6.6667 ea MISC SUPER THIN/30G MISC daily) ASSURE LANCE QL(6.6667 ea 1 CAREONE LANCET THIN 1 QL(6.6667 ea LANCETS 21G MISC daily) MISC daily) ASSURE LANCE QL(6.6667 ea 1 CARESENS LANCETS 1 QL(6.6667 ea LANCETS MISC daily) MISC daily) ASSURE LANCE PLUS QL(6.6667 ea CARETOUCH LANCING SAFETYLANCETS 25G 1 daily) DEVICEWITH EJECTOR 1 MISC MISC ASSURE LANCE PLUS QL(6.6667 ea CARETOUCH SAFETY 1 QL(6.6667 ea SAFETYLANCETS 30G 1 daily) LANCETS/26G MISC daily) MISC CARETOUCH SAFETY 1 QL(6.6667 ea ASSURE LANCE SAFETY 1 QL(6.6667 ea LANCETS/28G MISC daily) LANCET 28G MISC daily) CARETOUCH SAFETY 1 QL(6.6667 ea ASSURE LANCETS MISC 1 QL(6.6667 ea LANCETS/30G MISC daily) daily) CARETOUCH TWIST 1 QL(6.6667 ea AURORA LANCET SUPER 1 QL(6.6667 ea LANCETS 28G MISC daily) THIN30G MISC daily) CARETOUCH TWIST 1 QL(6.6667 ea AURORA LANCET THIN 1 QL(6.6667 ea LANCETS 30G MISC daily) 23G MISC daily)

Ambetter NH Formulary Updated October 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARETOUCH TWIST 1 QL(6.6667 ea DRUG MART LANCETS 33G MISC daily) ADJUSTABLE LANCING 1 DEVICE MISC CLEANLET LANCETS 28G 1 QL(6.6667 ea MISC daily) DRUG MART LANCETS 1 QL(6.6667 ea THIN MISC daily) COAGUCHEK LANCETS 1 QL(6.6667 ea MISC daily) DRUG MART ON-THE-GO QL(6.6667 ea COMFORT ASSURED QL(6.6667 ea LANCETS GENTLE 30G 1 daily) LANCETS MICRO THIN 1 daily) MISC 33G MISC DRUG MART UNILET QL(6.6667 ea COMFORT ASSURED QL(6.6667 ea LANCETSSUPER THIN 1 daily) LANCETS SUPER THIN 1 daily) 30G MISC 28G MISC DRUG MART UNILET QL(6.6667 ea LANCETSULTRA THIN 1 daily) COMFORT LANCETS 1 QL(6.6667 ea MISC daily) 28G MISC DRUG MART UNILET QL(6.6667 ea CVS LANCETS 21G MISC 1 QL(6.6667 ea daily) MICRO THIN LANCETS 1 daily) 33G MISC CVS LANCETS MICRO 1 QL(6.6667 ea THIN 33G MISC daily) E-Z JECT LANCETS 21G 1 QL(6.6667 ea MISC daily) CVS LANCETS MICRO- 1 QL(6.6667 ea THIN 33G MISC daily) E-Z JECT LANCETS 1 QL(6.6667 ea COLOR MISC daily) CVS LANCETS ORIGINAL 1 QL(6.6667 ea MISC daily) E-Z JECT LANCETS MISC 1 QL(6.6667 ea daily) CVS LANCETS THIN 26G 1 QL(6.6667 ea MISC daily) E-Z JECT LANCETS 1 QL(6.6667 ea SUPER THIN 30G MISC daily) CVS LANCETS ULTRA 1 QL(6.6667 ea THIN 30G MISC daily) E-Z JECT LANCETS THIN 1 QL(6.6667 ea 26G MISC daily) CVS LANCETS ULTRA- 1 QL(6.6667 ea THIN 30G MISC daily) E-ZJECT LANCETS 1 QL(6.6667 ea MICRO-THIN 33G MISC daily) CVS LANCING DEVICE 1 MISC EASY MINI EJECT 1 LANCING DEVICE MISC CVS ULTRA THIN 1 QL(6.6667 ea LANCETS MISC daily) EASY MINI LANCING 1 DEVICE MISC DIATHRIVE LANCETS 1 QL(6.6667 ea MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 21G/PRESSURE 1 daily) DIATHRIVE LANCETS 1 QL(6.6667 ea ACTIVATED MISC ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS QL(6.6667 ea DIATHRIVE LANCING 1 23G/PRESSURE 1 daily) DEVICE MISC ACTIVATED MISC DROPLET GENTEEL 1 EASY TOUCH LANCETS QL(6.6667 ea LANCING DEVICE MISC 26G/PRESSURE 1 daily) DROPLET LANCETS 1 QL(6.6667 ea ACTIVATED MISC ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea DROPLET LANCING 1 26G/PULL-TOP MISC daily) DEVICE MISC EASY TOUCH LANCETS QL(6.6667 ea DROPLET PERSONAL 1 QL(6.6667 ea 28G/PRESSURE 1 daily) LANCETS30G MISC daily) ACTIVATED MISC Ambetter NH Formulary Updated October 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 1 QL(6.6667 ea EMBRACE LANCING 28G/PULL-TOP MISC daily) DEVICE WITH EJECTOR 1 MISC EASY TOUCH LANCETS 1 QL(6.6667 ea 28G/TWIST MISC daily) EQL COLOR LANCETS 1 QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea 21G MISC daily) 30G/BUTTON-ACTIVATED 1 daily) EQL COLOR LANCETS 1 QL(6.6667 ea MISC MICRO THIN 33G MISC daily) EASY TOUCH LANCETS QL(6.6667 ea EQL SUPER THIN 1 QL(6.6667 ea 30G/PRESSURE 1 daily) LANCETS 30G MISC daily) ACTIVATED MISC EQL THIN LANCETS 26G 1 QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea MISC daily) 30G/PULL-TOP MISC daily) EZ-LETS LANCETS 21G 1 QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea MISC daily) 30G/TWIST MISC daily) EZ-LETS LANCETS 26G 1 QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea SUPER-SOFT MISC daily) 32G/PRESSURE 1 daily) EZ-LETS LANCETS 28G 1 QL(6.6667 ea ACTIVATED MISC ULTRA-SOFT MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 EZ-LETS LANCETS 30G 1 QL(6.6667 ea 32G/PULL-TOP MISC daily) MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 FIFTY50 SAFETY SEAL 1 QL(6.6667 ea 32G/TWIST MISC daily) LANCETS 30G MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 FIFTY50 SAFETY SEAL 1 QL(6.6667 ea 33G/TWIST MISC daily) LANCETS 32G MISC daily) EASY TOUCH LANCING 1 FIFTY50 UNILET 1 QL(6.6667 ea DEVICE/EJECTOR MISC LANCETS 33G MISC daily) EASY TOUCH SAFETY QL(6.6667 ea FINE 30 MISC 1 QL(6.6667 ea LANCETS21G/PRESSURE 1 daily) daily) ACTIVATED MISC FINGERSTIX LANCETS 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea MISC daily) LANCETS23G/PRESSURE 1 daily) ACTIVATED MISC FORA LANCETS MISC 1 QL(6.6667 ea daily) EASY TOUCH SAFETY QL(6.6667 ea LANCETS26G/BUTTON 1 daily) FORA LANCING DEVICE 1 ACTIVATED MISC MISC EASY TOUCH SAFETY QL(6.6667 ea FORA LANCING 1 LANCETS26G/PRESSURE 1 daily) DEVICE/CLEARCAP MISC ACTIVATED MISC FREDS PHARMACY EASY TOUCH SAFETY QL(6.6667 ea AUTOLET LANCING 1 LANCETS28G/BUTTON 1 daily) DEVICE MISC ACTIVATED MISC FREDS PHARMACY QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea UNILET LANCETS SUPER 1 daily) LANCETS28G/PRESSURE 1 daily) THIN 30G MISC ACTIVATED MISC FREDS PHARMACY QL(6.6667 ea UNILET LANCETS ULTRA 1 daily) EASY TWIST & CAP 1 QL(6.6667 ea LANCETS MISC daily) THIN 28G MISC FREESTYLE LANCETS QL(6.6667 ea EMBRACE LANCETS 1 QL(6.6667 ea 1 ULTRA THIN 30G MISC daily) MISC daily) Ambetter NH Formulary Updated October 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE UNISTICK II 1 QL(6.6667 ea GLUCOCOM LANCETS 1 QL(6.6667 ea LANCETS MISC daily) 30G MISC daily) GENTEEL BUTTERFLY 1 QL(6.6667 ea GLUCOCOM LANCETS 1 QL(6.6667 ea TOUCH LANCETS MISC daily) 33G MISC daily) GENTEEL LANCING GNP LANCETS 21G MISC 1 QL(6.6667 ea DEVICE/GLORIOUS 1 daily) GOLD MISC GNP LANCETS MICRO 1 QL(6.6667 ea GENTEEL LANCING THIN 33G MISC daily) DEVICE/PRECIOUS 1 GNP LANCETS SUPER 1 QL(6.6667 ea PLATINUM MISC THIN 30G MISC daily) GENTEEL LANCING GNP LANCETS THIN 26G 1 QL(6.6667 ea DEVICE/STATELY SILVER 1 MISC daily) MISC GNP LANCETS THIN 1 QL(6.6667 ea GENTEEL PLUS LANCING MISC daily) DEVICE/BUFF BLACK 1 MISC GOJJI LANCING DEVICE/CLEAR CAP 1 GENTEEL PLUS LANCING MISC DEVICE/BUTTERFLY 1 BLUE MISC GOJJI STERILE LANCETS 1 QL(6.6667 ea 30G MISC daily) GENTEEL PLUS LANCING DEVICE/PLAYFUL 1 GOODSENSE COLOR QL(6.6667 ea PURPLE MISC LANCETS MICRO-THIN 1 daily) 33G UNIVERSAL MISC GENTEEL PLUS LANCING DEVICE/PRINCESS PINK 1 GOODSENSE LANCETS 1 QL(6.6667 ea MISC MICRO-THIN 33G MISC daily) GENTEEL PLUS LANCING GOODSENSE LANCETS QL(6.6667 ea DEVICE/WILLOWY WHITE 1 MICRO-THIN 33G 1 daily) MISC UNIVERSAL MISC GOODSENSE LANCETS QL(6.6667 ea GENTLE-LET GP 1 QL(6.6667 ea LANCETS MISC daily) ULTRA-THIN 26G 1 daily) UNIVERSAL MISC GENTLE-LET LANCETS QL(6.6667 ea GENERAL PURPOSE 1 daily) GOODSENSE LANCETS 1 QL(6.6667 ea STYLE/FINE POINT MISC ULTRA-THIN 30G MISC daily) GENTLE-LET LANCETS QL(6.6667 ea GOODSENSE LANCETS QL(6.6667 ea ULTRA-THIN 30G 1 daily) GENERAL PURPOSE 1 daily) STYLE/MEDIUM POINT UNIVERSAL MISC MISC GOODSENSE LANCING 1 GENTLE-LET LANCETS QL(6.6667 ea DEVICE MISC SAFETY STYLE/FINE 1 daily) H-E-B INCONTROL POINT MISC ADVANCEDLANCING 1 GENTLE-LET LANCETS QL(6.6667 ea DEVICE MISC SAFETY STYLE/MEDIUM 1 daily) H-E-B INCONTROL QL(6.6667 ea POINT MISC LANCETS MICRO THIN 1 daily) 33G MISC GLOBAL LANCING 1 DEVICE MISC H-E-B INCONTROL QL(6.6667 ea LANCETS SUPER THIN 1 daily) GLUCOCOM LANCETS 1 QL(6.6667 ea 28G MISC daily) 30G MISC

Ambetter NH Formulary Updated October 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL QL(6.6667 ea KROGER LANCETS MISC 1 QL(6.6667 ea LANCETS ULTRA THIN 1 daily) daily) 28G MISC KROGER LANCETS 1 QL(6.6667 ea HAEMOLANCE LOW 1 QL(6.6667 ea SUPER THIN MISC daily) FLOW LANCETS MISC daily) KROGER LANCETS THIN 1 QL(6.6667 ea HAEMOLANCE MISC 1 QL(6.6667 ea 26G MISC daily) daily) KROGER LANCETS THIN 1 QL(6.6667 ea HAEMOLANCE PLUS 1 QL(6.6667 ea MISC daily) HIGH FLOW MISC daily) KROGER LANCETS 1 QL(6.6667 ea HAEMOLANCE PLUS 1 QL(6.6667 ea ULTRATHIN30G MISC daily) LOW FLOW MISC daily) KROGER LANCING 1 HAEMOLANCE PLUS 1 QL(6.6667 ea DEVICE MISC MAX FLOW MISC daily) LANCET DEVICE 1 HAEMOLANCE PLUS 1 QL(6.6667 ea ADJUSTABLE MISC MISC daily) LANCET DEVICE WITH 1 HAEMOLANCE PLUS 1 QL(6.6667 ea EJECTOR MISC PEDIATRIC FLOW MISC daily) LANCETS 26G TWIST 1 QL(6.6667 ea HEALTH CARE LANCING 1 TOP MISC daily) DEVICE MISC LANCETS 30G MISC 1 QL(6.6667 ea HEALTHY ACCENTS daily) AUTOLET IMPRESSION 1 LANCETS 30G TWIST 1 QL(6.6667 ea LANCING DEVICE MISC TOP MISC daily) HEALTHY ACCENTS QL(6.6667 ea LANCETS 30G/TWIST 1 QL(6.6667 ea UNILET LANCETS SUPER 1 daily) TOP MISC daily) THIN 30G MISC LANCETS 31G TWIST 1 QL(6.6667 ea HY-VEE LANCETS MISC 1 QL(6.6667 ea TOP MISC daily) daily) LANCETS 33G EXTRA 1 QL(6.6667 ea HY-VEE THIN LANCETS 1 QL(6.6667 ea FINE MISC daily) MISC daily) LANCETS MICRO THIN 1 QL(6.6667 ea IN TOUCH LANCING 1 33G MISC daily) DEVICE MISC QL(6.6667 ea LANCETS MISC 1 IN TOUCH STERILE 1 QL(6.6667 ea daily) LANCETS30G MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea KINNEY LANCETS MISC 1 QL(6.6667 ea 21G MISC daily) daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea KINNEY THIN LANCETS 1 QL(6.6667 ea 26G MISC daily) MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea KROGER AUTOLET 1 28G MISC daily) LANCING DEVICE MISC LANCETS SAFETY SEAL 1 QL(6.6667 ea KROGER HEALTHPRO QL(6.6667 ea 30G MISC daily) TWIST LANCETS/26G 1 daily) MISC LANCETS SUPER THIN 1 QL(6.6667 ea 28G MISC daily) KROGER LANCETS 21G 1 QL(6.6667 ea MISC daily) LANCETS THIN MISC 1 QL(6.6667 ea daily) KROGER LANCETS 1 QL(6.6667 ea MICRO THIN33G MISC daily) LANCETS TWIST TOP 1 QL(6.6667 ea MISC daily) Ambetter NH Formulary Updated October 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS ULTRA THIN 1 QL(6.6667 ea MEDICHOICE PRE-SET QL(6.6667 ea 30G MISC daily) SAFETY LANCET LOW 1 daily) FLOW MISC LANCETS ULTRA THIN 1 QL(6.6667 ea MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET 1 daily) LANCETSBULLSEYE 1 QL(6.6667 ea SAFETY MISC daily) MEDIUM FLOW MISC MEDICHOICE PRE-SET QL(6.6667 ea LANCING DEVICE 1 ADJUSTABLE MISC SAFETY LANCET 1 daily) MODERATE FLOW MISC LANCING DEVICE MISC 1 MEDICHOICE SAFETY 1 QL(6.6667 ea LANCETEXTRA MISC daily) LANZO MISC 1 MEDICHOICE SAFETY 1 QL(6.6667 ea LANCETNORMAL MISC daily) LEADER ADVANCED 1 LANCING DEVICE MISC MEDISENSE THIN 1 QL(6.6667 ea LANCETS MISC daily) LIBERTY MEDICAL 1 QL(6.6667 ea LANCETS 30G MISC daily) MEDLANCE PLUS EXTRA 1 QL(6.6667 ea LANCETS 21G MISC daily) LIBERTY MINI LANCING 1 DEVICE MISC MEDLANCE PLUS 1 QL(6.6667 ea LIFESCAN UNISTIK 2 QL(6.6667 ea LANCETS LITE 25G MISC daily) DEEP PENETRATION 1 daily) MEDLANCE PLUS 1 QL(6.6667 ea MISC LANCETS MISC daily) LIFESCAN UNISTIK II QL(6.6667 ea 1 MEDLANCE PLUS LITE 1 QL(6.6667 ea LANCETS MISC daily) LANCETS 25G MISC daily) LITE TOUCH LANCETS 1 QL(6.6667 ea MEDLANCE PLUS QL(6.6667 ea MISC daily) SPECIAL LANCETS 1 daily) 0.8MM MISC LITE TOUCH LANCING 1 PEN MISC MEDLANCE PLUS 1 QL(6.6667 ea SUPERLITE 30G MISC daily) LITETOUCH LANCETS 1 QL(6.6667 ea MICRO THIN 33G MISC daily) MEDLANCE PLUS QL(6.6667 ea SUPERLITE daily) LIVE BETTER ADVANCED 1 1 LANCING DEVICE MISC 30G/COMFORT MAX MISC LIVE BETTER LANCET 1 QL(6.6667 ea SUPERTHIN 30G MISC daily) MEDLANCE PLUS QL(6.6667 ea UNIVERSAL LANCETS 1 daily) LIVE BETTER LANCET 1 QL(6.6667 ea ULTRATHIN 28G MISC daily) 21G MISC MEDLANCE PLUS/LITE QL(6.6667 ea LONGS LANCETS 1 QL(6.6667 ea 1 STANDARD MISC daily) 25G MISC daily) QL(6.6667 ea LONGS LANCETS THIN 1 QL(6.6667 ea MEDLANCE/EXTRA MISC 1 MISC daily) daily) QL(6.6667 ea LONGS LANCETS ULTRA 1 QL(6.6667 ea MEDLANCE/LITE MISC 1 THIN MISC daily) daily) MEDICHOICE PRE-SET QL(6.6667 ea MEDLANCE/UNIVERSAL 1 QL(6.6667 ea SAFETY LANCET DUAL 1 daily) MISC daily) USE MISC MEIJER COLOR QL(6.6667 ea LANCETS UNIVERSAL 1 daily) 33G MISC

Ambetter NH Formulary Updated October 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.6667 ea NOVA SUREFLEX QL(6.6667 ea MEIJER LANCETS MISC 1 1 daily) LANCETS MISC daily) MEIJER LANCETS THIN 1 QL(6.6667 ea NOVA SUREFLEX 1 MISC daily) LANCING DEVICE MISC MEIJER LANCETS 1 QL(6.6667 ea ON CALL LANCING 1 UNIVERSAL21G MISC daily) DEVICE MISC MEIJER LANCETS 1 QL(6.6667 ea ON CALL PLUS LANCING 1 UNIVERSAL30G MISC daily) DEVICE MISC MEIJER LANCETS 1 QL(6.6667 ea ONETOUCH CLUB QL(6.6667 ea UNIVERSAL33G MISC daily) LANCETS FINE POINT 1 daily) MISC MEIJER SUPER THIN 1 QL(6.6667 ea LANCETS MISC daily) ONETOUCH DELICA QL(6.6667 ea LANCETS EXTRA FINE 1 daily) MICROLET LANCETS 1 QL(6.6667 ea MISC daily) 33G MISC ONETOUCH DELICA 1 QL(6.6667 ea MICROLET NEXT MISC 1 LANCETS FINE 30G MISC daily) ONETOUCH DELICA MINI LANCING DEVICE 1 1 MISC LANCING DEVICE MISC ONETOUCH DELICA QL(6.6667 ea MM LANCING DEVICE 1 MISC PLUS LANCETS EXTRA 1 daily) FINE 33G MISC MM TWIST LANCETS 1 QL(6.6667 ea MISC daily) ONETOUCH DELICA QL(6.6667 ea PLUS LANCETS FINE 30G 1 daily) MONOLET LANCETS 1 QL(6.6667 ea MISC daily) MISC ONETOUCH DELICA MONOLET OPD LANCETS 1 QL(6.6667 ea MISC daily) PLUS LANCING DEVICE 1 MISC MONOLETTOR SAFETY 1 QL(6.6667 ea LANCETS MISC daily) ONETOUCH DELICA SAFETY LACING DEVICE 1 MPD SAFETY LANCET 1 QL(6.6667 ea MISC 21G/1.8MM MISC daily) ONETOUCH FINEPOINT 1 QL(6.6667 ea MPD SAFETY LANCET 1 QL(6.6667 ea LANCETS MISC daily) 28G/1.8MM MISC daily) ONETOUCH ULTRASOFT 1 QL(6.6667 ea MPD SAFETY LANCET 1 QL(6.6667 ea LANCETS MISC daily) 30G/1.8MM MISC daily) PC LANCETS SUPER 1 QL(6.6667 ea MPD SAFETY LANCETS 1 QL(6.6667 ea THIN 30G MISC daily) 23G/1.8MM MISC daily) PERFECT LANCETS 30G 1 QL(6.6667 ea MULTI-LANCET DEVICE 1 MISC daily) MISC PERFECT PRESSURE QL(6.6667 ea MYGLUCOHEALTH MGH QL(6.6667 ea ACTIVATED SAFETY 1 daily) SOFTLANCE LANCETS 1 daily) LANCETS 28G MISC 30G MISC PHARMACY COUNTER 1 QL(6.6667 ea NOVA SAFETY LANCETS 1 QL(6.6667 ea LANCETS MISC daily) 23G MISC daily) QL(6.6667 ea PIP LANCETS/28G MISC 1 NOVA SAFETY LANCETS 1 QL(6.6667 ea daily) 28G MISC daily) PIP LANCETS/30G MISC 1 QL(6.6667 ea daily) Ambetter NH Formulary Updated October 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRECISION THINS GP 1 QL(6.6667 ea QC UNILET LANCETS 1 QL(6.6667 ea LANCET MISC daily) 33G/MICRO THIN MISC daily) PREFERRED PLUS QL(6.6667 ea RA E-ZJECT LANCETS 1 QL(6.6667 ea LANCETS COLORED 21G 1 daily) 28G MISC daily) MISC RA E-ZJECT LANCETS 1 QL(6.6667 ea PREFERRED PLUS QL(6.6667 ea THIN 26G MISC daily) LANCETS SUPER THIN 1 daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea 30G MISC THIN 28G MISC daily) PREFERRED PLUS QL(6.6667 ea 1 RA E-ZJECT LANCETS 1 QL(6.6667 ea LANCETS THIN 26G MISC daily) ULTRATHIN 30G MISC daily) PRESSURE ACTIVATED QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea SAFETYLANCET 21G 1 daily) LANCETS/21G/2.2MM 1 daily) MISC MISC PRODIGY LANCING 1 READYLANCE SAFETY QL(6.6667 ea DEVICE MISC LANCETS/23G/1.8MM 1 daily) PRODIGY PRESSURE QL(6.6667 ea MISC ACTIVATED SAFETY 1 daily) READYLANCE SAFETY QL(6.6667 ea LANCETS MISC LANCETS/26G/1.8MM 1 daily) PRODIGY SAFETY 1 QL(6.6667 ea MISC LANCETS MISC daily) READYLANCE SAFETY QL(6.6667 ea PRODIGY TWIST TOP 1 QL(6.6667 ea LANCETS/28G/1.8MM 1 daily) LANCETS MISC daily) MISC PSS SELECT GP 1 QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea LANCETS MISC daily) LANCETS/30G/1.6MM 1 daily) MISC PSS SELECT SAFETY 1 QL(6.6667 ea LANCETS MISC daily) REALITY LANCETS MISC 1 QL(6.6667 ea daily) PUSH BUTTON SAFETY 1 QL(6.6667 ea LANCETS 21G MISC daily) REALITY TRIGGER 1 QL(6.6667 ea LANCETS MISC daily) PUSH BUTTON SAFETY 1 QL(6.6667 ea LANCETS 28G MISC daily) RELION 2-IN-1 LANCET 1 DEVICES 30G MISC PX ADVANCED LANCING 1 DEVICE MISC RELION 2-IN-1 LANCING 1 DEVICE 25G MISC PX LANCET AUTO 1 INJECTOR MISC RELION 2-IN-1 LANCING 1 DEVICE 30G MISC PX LANCETS ULTRA 1 QL(6.6667 ea THIN 28G MISC daily) RELION LANCETS 1 QL(6.6667 ea MICRO-THIN33G MISC daily) PX LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) RELION LANCETS THIN 1 QL(6.6667 ea 26G MISC daily) QC ADVANCED LANCING 1 DEVICE MISC RELION LANCETS 1 QL(6.6667 ea ULTRA-THIN30G MISC daily) QC LANCETS SUPER 1 QL(6.6667 ea THIN MISC daily) RELION LANCING 1 DEVICE MISC QC LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS/30G MISC daily) QC UNILET LANCETS 1 QL(6.6667 ea 28G/ULTRA THIN MISC daily)

Ambetter NH Formulary Updated October 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION ULTRA THIN 1 QL(6.6667 ea SELECT-LITE LANCING 1 LANCETS30G MISC daily) DEVICE MISC RELION ULTRA THIN QL(6.6667 ea SHOPKO AUTOLET 1 PLUS LANCETS 32G 1 daily) LANCING DEVICE MISC MISC SHOPKO ON-THE-GO QL(6.6667 ea RELION ULTRA THIN QL(6.6667 ea COMFORTLANCETS 30G 1 daily) PLUS LANCETS 33G 1 daily) MISC MISC SHOPKO UNILET QL(6.6667 ea 1 REXALL LANCETS ULTRA 1 QL(6.6667 ea LANCETS SUPER THIN daily) THIN MISC daily) 30G MISC RIGHTEST GD500 1 SHOPKO UNILET QL(6.6667 ea LANCING DEVICE MISC LANCETS ULTRA THIN 1 daily) 28G MISC RIGHTEST GL300 1 QL(6.6667 ea LANCETS MISC daily) SIDE BUTTON SAFETY 1 QL(6.6667 ea LANCET21G MISC daily) SAFE-T-LANCE LOW 1 QL(6.6667 ea FLOW 25G MISC daily) SIMPLE DIAGNOSTICS 1 LANCING DEVICE MISC SAFE-T-LANCE NORMAL 1 QL(6.6667 ea FLOW21G MISC daily) QL(6.6667 ea SINGLE-LET MISC 1 SAFE-T-LANCE PLUS QL(6.6667 ea daily) SAFETYLANCET HIGH 1 daily) SM MICRO THIN 1 QL(6.6667 ea FLOW MISC LANCETS 33G MISC daily) SAFE-T-LANCE PLUS QL(6.6667 ea SM TRUEDRAW LANCING 1 SAFETYLANCET LOW 1 daily) DEVICE MISC FLOW MISC SMART DIABETES SAFE-T-LANCE PLUS QL(6.6667 ea VANTAGE LANCING 1 SAFETYLANCET 1 daily) DEVICE MISC NORMAL FLOW MISC SMART SENSE COLOR QL(6.6667 ea SAFETY LANCET QL(6.6667 ea LANCETS UNIVERSAL 1 daily) 21G/PRESSURE 1 daily) 33G MISC ACTIVATED MISC SMART SENSE QL(6.6667 ea SAFETY LANCET QL(6.6667 ea STANDARD LANCETS 1 daily) 23G/PRESSURE 1 daily) UNIVERSAL 21G MISC ACTIVATED MISC SMART SENSE SUPER QL(6.6667 ea SAFETY LANCET QL(6.6667 ea THIN LANCETS 1 daily) 28G/PRESSURE 1 daily) UNIVERSAL 30G MISC ACTIVATED MISC SMART SENSE THIN QL(6.6667 ea 1 SAFETY LANCETS 21G 1 QL(6.6667 ea LANCETSUNIVERSAL daily) MISC daily) 26G MISC SAFETY LANCETS 28G 1 QL(6.6667 ea SMARTEST LANCETS 1 QL(6.6667 ea MISC daily) 28G MISC daily) SAFETY LET LANCETS 1 QL(6.6667 ea SOLUS V2 LANCING 1 MISC daily) DEVICE MISC SOLUS V2 PRESSURE QL(6.6667 ea SB LANCETS THIN MISC 1 QL(6.6667 ea daily) ACTIVATED SAFETY 1 daily) LANCETS 28G MISC SB LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) SOLUS V2 TWIST 1 QL(6.6667 ea LANCETS 30G MISC daily) Ambetter NH Formulary Updated October 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.6667 ea TODAYS HEALTH STERILANCE TL MISC 1 daily) ADVANCED LANCING 1 DEVICE MISC SUPER THIN LANCETS 1 QL(6.6667 ea MISC daily) TODAYS HEALTH SUPER 1 QL(6.6667 ea THINLANCETS 30G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 18G MISC daily) TODAYS HEALTH ULTRA 1 QL(6.6667 ea THINLANCETS 28G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 21G MISC daily) TOPCARE LANCETS 1 QL(6.6667 ea MICRO-THIN 33G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 23G MISC daily) TRAVEL LANCETS 30G 1 QL(6.6667 ea MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 28G MISC daily) TRAVEL LANCETS 1 QL(6.6667 ea ADVANCED 28G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 30G MISC daily) TRUE METRIX CONTROL SOLUTION LEVEL 3 1 SURE COMFORT 1 LANCING PEN MISC SOLN TRUEDRAW LANCING SURE-LANCE FLAT 1 QL(6.6667 ea 1 LANCETS MISC daily) DEVICE MISC TRUEPLUS LANCETS QL(6.6667 ea SURE-LANCE LANCETS 1 QL(6.6667 ea 1 26G MISC daily) 26G MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURE-LANCE THIN 1 QL(6.6667 ea 1 LANCETS 28G MISC daily) 28G MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURE-LANCE ULTRA 1 QL(6.6667 ea 1 THIN LANCETS MISC daily) 28G SUPER THIN MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-PEN MISC 1 30G MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURE-TOUCH LANCETS 1 QL(6.6667 ea 1 UNIVERSAL MISC daily) 30G ULTRA THIN MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURELITE LANCETS 1 QL(6.6667 ea 1 MISC daily) 33G MICRO THIN MISC daily) TRUEPLUS LANCETS QL(6.6667 ea TECHLITE AST LANCETS 1 QL(6.6667 ea 1 MISC daily) 33G MISC daily) TRUEPLUS SAFETY QL(6.6667 ea TECHLITE LANCETS 30G 1 QL(6.6667 ea 1 MISC daily) LANCETS 28G MISC daily) ULTI-LANCE AUTOMATIC/ TECHLITE LANCETS 1 QL(6.6667 ea 1 MISC daily) CLEAR TIP MISC ULTILET CLASSIC QL(6.6667 ea TGT LANCET MICRO 1 QL(6.6667 ea 1 THIN 33G MISC daily) LANCETS MISC daily) ULTILET LANCETS 33G QL(6.6667 ea TGT LANCET THIN 26G 1 QL(6.6667 ea 1 MISC daily) MISC daily) QL(6.6667 ea TGT LANCET ULTRA 1 QL(6.6667 ea ULTILET LANCETS MISC 1 THIN 30G MISC daily) daily) ULTILET SAFETY QL(6.6667 ea TGT LANCING DEVICE 1 MISC LANCETS 21G X 2.2MM 1 daily) MISC THINLETS GP LANCETS 1 QL(6.6667 ea MISC daily)

Ambetter NH Formulary Updated October 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET SAFETY 1 QL(6.6667 ea UNISTIK TOUCH SAFETY 1 QL(6.6667 ea LANCETS 23G MISC daily) LANCETS 23G MISC daily) ULTRA THIN LANCETS 1 QL(6.6667 ea UNISTIK TOUCH SAFETY 1 QL(6.6667 ea 31G MISC daily) LANCETS 28G MISC daily) ULTRA-THIN II AUTO 1 QL(6.6667 ea UNISTIK TOUCH SAFETY 1 QL(6.6667 ea LANCET MISC daily) LANCETS 30G MISC daily) ULTRA-THIN II LANCETS 1 QL(6.6667 ea UNIVERSAL 1 LANCETS 1 QL(6.6667 ea 28G MISC daily) THIN26G MISC daily) ULTRA-THIN II LANCETS QL(6.6667 ea 1 UNIVERSAL 1 LANCETS 1 QL(6.6667 ea 30G MISC daily) ULTRA THIN 30G MISC daily) UNILET COMFORTOUCH 1 QL(6.6667 ea UNIVERSAL 1 QL(6.6667 ea LANCET MISC daily) LANCETS/33G/MICRO- 1 daily) QL(6.6667 ea THIN MISC UNILET EXCELITE II MISC 1 daily) VALUE PLUS LANCETS 1 QL(6.6667 ea QL(6.6667 ea STANDARD 21G MISC daily) UNILET EXCELITE MISC 1 daily) VALUE PLUS LANCETS 1 QL(6.6667 ea SUPERTHIN 30G MISC daily) UNILET G.P. LANCET 1 QL(6.6667 ea MISC daily) VALUE PLUS LANCETS 1 QL(6.6667 ea THIN 26G MISC daily) UNILET G.P. SUPERLITE 1 QL(6.6667 ea LANCET MISC daily) VALUE PLUS LANCING 1 DEVICE MISC UNILET GP 28 ULTRA 1 QL(6.6667 ea THIN MISC daily) VALUMARK LANCET 1 QL(6.6667 ea QL(6.6667 ea SUPER THIN 30G MISC daily) UNILET LANCET MISC 1 daily) VALUMARK LANCET 1 QL(6.6667 ea ULTRA THIN 28G MISC daily) UNILET LANCETS 1 QL(6.6667 ea MICRO-THIN33G MISC daily) VIDA MIA AUTOLET 1 LANCINGDEVICE MISC UNILET LANCETS 1 QL(6.6667 ea SUPER-THIN30G MISC daily) VIDA MIA UNILET QL(6.6667 ea LANCETS SUPER THIN 1 daily) UNILET LANCETS 1 QL(6.6667 ea ULTRA-THIN 28G MISC daily) 30G MISC VIDA MIA UNILET QL(6.6667 ea UNILET SUPERLITE 1 QL(6.6667 ea LANCET MISC daily) LANCETS ULTRA THIN 1 daily) 28G MISC QL(6.6667 ea UNISTIK 3 GENTLE MISC 1 daily) VIVAGUARD LANCETS 1 QL(6.6667 ea MISC daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 21G MISC daily) VIVAGUARD LANCING 1 DEVICE MISC UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 25G MISC daily) WALGREENS ADVANCED QL(6.6667 ea TRAVELLANCETS 28G 1 daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea MISC LANCET 28G MISC daily) WALGREENS COMFORT QL(6.6667 ea UNISTIK SAFETY 1 QL(6.6667 ea ASSUREDLANCETS 1 daily) LANCETS 28G MISC daily) MICRO THIN/33G MISC UNISTIK SAFETY 1 QL(6.6667 ea WALGREENS COMFORT QL(6.6667 ea LANCETS 30G MISC daily) ASSUREDLANCETS 1 daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea SUPER THIN/28G MISC LANCETS 21G MISC daily) Ambetter NH Formulary Updated October 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WALGREENS LANCETS 1 QL(6.6667 ea B-D INSULIN SYRINGE QL(5 ea daily) MISC daily) ULTRAFINE II/0.3ML/31G 1 X 5/16" MISC WALGREENS THIN 1 QL(6.6667 ea LANCETS MISC daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.5ML/31G 1 WALGREENS ULTRA 1 QL(6.6667 ea THIN LANCETS MISC daily) X 5/16" MISC B-D INSULIN SYRINGE QL(5 ea daily) Parenteral Therapy Supplies ULTRAFINE II/1ML/31G X 1 ADVOCATE INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC 100/0.3ML/29GX1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 1 ADVOCATE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 1 RX/OTC 100/0.3ML/30GX5/16" B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 1 MISC 1/2" MISC ADVOCATE INSULIN QL(5 ea daily) BD LO-DOSE INSULIN QL(5 ea daily); SYRINGE/U- 1 1 100/0.3ML/31GX5/16" SYRINGE MICROFINE RX/OTC IV/0.5ML/28G X 1/2" MISC MISC ADVOCATE INSULIN QL(5 ea daily); BD AUTOSHIELD 29G X 1 QL(5 ea daily) 3/16" MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/29GX1/2" MISC BD AUTOSHIELD 29G X 1 QL(5 ea daily) 5/16" MISC ADVOCATE INSULIN QL(5 ea daily); BD AUTOSHIELD DUO QL(5 ea daily) SYRINGE/U- 1 RX/OTC 1 100/0.5ML/30GX5/16" 30G X 5MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) LUER-LOK/U-100/1ML 1 RX/OTC MISC SYRINGE/U- 1 100/0.5ML/31GX5/16" BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE IV/U- 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/U- 1 RX/OTC MISC 100/1ML/29GX1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); MICROFINE IV/U- 1 SYRINGE/U- 1 RX/OTC 100/1ML/27G X 5/8" MISC 100/1ML/30GX5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) MICROFINE IV/U- 1 RX/OTC SYRINGE/U- 1 100/1ML/28G X 1/2" MISC 100/1ML/31GX5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) ASSURE ID INSULIN QL(5 ea daily); MICROFINE/U- 1 100/1ML/27G X 5/8" MISC SAFETYSYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE/U- 1 RX/OTC ASSURE ID INSULIN QL(5 ea daily); 100/1ML/28G X 1/2" MISC SAFETYSYRINGE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/29G X 1/2" MISC SAFETYGLIDE/1ML/29G X 1 RX/OTC 1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE 1 QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); SLIP TIP/U-100/1ML MISC RX/OTC ULTRAFINE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/29G X 1/2" ULTRA-FINE/0.3ML/30G X 1 MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- 1 RX/OTC ULTRA-FINE/0.3ML/31G X 1 100/1ML/29G X 1/2" MISC 8MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- 1 ULTRA-FINE/0.5ML/30G X 1 100/1ML/31G X 5/16" 12.7MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); ULTRA-FINE/0.5ML/31G X 1 SYRINGE/0.3ML/29G X 1 RX/OTC 8MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC ULTRA-FINE/1/2 1 UNIT/0.3ML/31G X 8MM 12.7MM MISC MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/27G X 1 RX/OTC ULTRA-FINE/1ML/30G X 1 12.7MM MISC 12.7MM MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/29G X 1 RX/OTC ULTRA-FINE/1ML/31G X 1 12.7MM MISC 8MM MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G ULTRAFINE HALF- 1 UNIT/0.3ML/31G X 5/16" X 1" MISC MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1 ULTRAFINE/0.3ML/30G X 1 NEEDLE/U-100/1ML/25G 1/2" MISC X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily) ULTRAFINE/0.3ML/31G X 1 SYRINGE/DETACHABLE 1 5/16" MISC NEEDLE/U-100/1ML/26G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 1 BD INSULIN SYRINGE/U- 1 QL(5 ea daily); 1/2" MISC 100/1ML/27G X 1/2" MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily) ULTRAFINE/0.5ML/31G X 1 NEEDLE/MICRO/ULTRA- 1 5/16" MISC FINE/32G X 6MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily); ULTRAFINE/1ML/30G X 1 NEEDLE/MINI/ULTRA- 1 RX/OTC 1/2" MISC FINE/31G X 5MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD PEN NEEDLE/NANO QL(5 ea daily); 2ND GEN/32G X 5/32" 1 RX/OTC ULTRAFINE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" MISC MISC

Ambetter NH Formulary Updated October 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLE/NANO/ULTRA- 1 RX/OTC SYRINGES/0.5ML/30G X 1 FINE/32G X 4MM MISC 1/2" MISC BD PEN QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) NEEDLE/ORIGINAL/ULTR 1 SYRINGES/0.5ML/31G X 1 A-FINE/29G X 12.7MM 5/16" MISC MISC CAREONE INSULIN QL(5 ea daily) BD PEN QL(5 ea daily); SYRINGES/1ML/30G X 1 NEEDLE/SHORT/ULTRA- 1 RX/OTC 1/2" MISC FINE/31G X 8MM MISC CAREONE INSULIN QL(5 ea daily) BD SAFETY-GLIDE QL(5 ea daily); SYRINGES/1ML/31GX5/16 1 INSULIN 1 RX/OTC " MISC SYRINGE/0.5ML/29G X CARETOUCH INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/0.3ML/31GX5/1 1 BD SAFETY-LOK INSULIN QL(5 ea daily); 6" MISC SYRINGE/PERM 1 RX/OTC CARETOUCH INSULIN QL(5 ea daily) NEEDLE/UF/1ML/29G X SYRINGE/0.5ML/31GX5/1 1 1/2" MISC 6" MISC BD SAFETYGLIDE QL(5 ea daily); CARETOUCH INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/1ML/30GX5/16" 1 RX/OTC SYRINGE/0.3ML/29G X MISC 1/2" MISC CARETOUCH INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily) SYRINGE/1ML/31GX5/16" 1 INSULIN 1 MISC SYRINGE/0.3ML/31G X 5/16" MISC CARETOUCH INSULIN QL(5 ea daily); SYRINGE0.5ML/30GX5/16 1 RX/OTC BD SAFETYGLIDE QL(5 ea daily) " MISC INSULIN 1 SYRINGE/1ML/31G X CLEVER CHOICE QL(5 ea daily); 15/64" MISC COMFORT EZINSULIN 1 RX/OTC SYRINGE/0.3ML/29G X BD SAFETYGLIDE QL(5 ea daily); 1/2" MISC INSULIN 1 RX/OTC SYSYRINGE/0.5ML/30G X CLEVER CHOICE QL(5 ea daily) 5/16" MISC COMFORT EZINSULIN 1 SYRINGE/0.3ML/30G X BD VEO INSULIN QL(5 ea daily) 1/2" MISC SYRINGE ULTRA- 1 FINE/1ML/31G X 6MM CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 RX/OTC SYRINGE/0.3ML/30G X BD VEO INSULIN QL(5 ea daily) 5/16" MISC SYRINGE ULTRA-FINE/U- 1 100/1ML/31G X 15/64" CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 1 SYRINGE/0.3ML/31G X CAREONE INSULIN QL(5 ea daily) 5/16" MISC SYRINGES/0.3ML/30G X 1 1/2" MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC CAREONE INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X SYRINGES/0.3ML/31G X 1 1/2" MISC 5/16" MISC

Ambetter NH Formulary Updated October 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC INSULIN 1 RX/OTC SYRINGE/0.5ML/29G X SYRINGE/0.5ML/29G X 1/2" MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN 1 INSULIN 1 RX/OTC SYRINGE/0.5ML/30G X SYRINGE/0.5ML/30G X 1/2" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC INSULIN 1 SYRINGE/0.5ML/30G X SYRINGE/0.5ML/31G X 5/16" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN 1 INSULIN 1 RX/OTC SYRINGE/0.5ML/31G X SYRINGE/1ML/29G X 1/2" 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN 1 INSULIN 1 RX/OTC SYRINGE/1.0ML/30G X SYRINGE/1ML/30G X 1/2" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC INSULIN 1 SYRINGE/1ML/28G X 1/2" SYRINGE/1ML/31G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZ INSULIN QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC SYRINGE/U- 1 SYRINGE/1ML/29G X 1/2" 100/0.5ML/31G X 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZ INSULIN QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC SYRINGE/U-100/1ML/31G 1 SYRINGE/1ML/30G X X 5/16" MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) SYRINGE 0.3ML/29G X 1 RX/OTC COMFORT EZINSULIN 1 1/2" MISC SYRINGE/U- DROPLET INSULIN QL(5 ea daily); 100/1ML/31GX5/16" MISC SYRINGE 0.5ML/29G X 1 RX/OTC COMFORT ASSIST QL(5 ea daily); 1/2" MISC INSULIN SYRINGE 1 RX/OTC DROPLET INSULIN QL(5 ea daily); 0.3ML/29G X 1/2" MISC SYRINGE 1ML/29G X 1/2" 1 RX/OTC COMFORT ASSIST QL(5 ea daily); MISC INSULIN 1 RX/OTC DROPLET INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X SYRINGE U-100/0.3/31G X 1 5/16" MISC 5/16" MISC COMFORT ASSIST QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) INSULIN 1 SYRINGE U- 1 SYRINGE/0.3ML/31G X 100/0.3ML/30G X 1/2" 5/16" MISC MISC

Ambetter NH Formulary Updated October 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE U- 1 RX/OTC SYRINGE/U-100/1ML/31G 1 100/0.3ML/30G X 5/16" X 5/16" MISC MISC EASY COMFORT INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE U- 1 5/16" MISC 100/0.5ML/30G X 1/2" EASY COMFORT INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE U- 1 RX/OTC EASY COMFORT INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily) EASY COMFORT INSULIN QL(5 ea daily) SYRINGE U- 1 SYRINGE/1ML/31G X 1 100/0.5ML/31G X 5/16" 5/16" MISC MISC EASY COMFORT INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) SYRINGE/U- 1 SYRINGE U-100/1ML/30G 1 100/0.5ML/30G X 1/2" X 1/2" MISC MISC DROPLET INSULIN QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily) SYRINGE U-100/1ML/30G 1 RX/OTC SYRINGE/U-100/1ML/30G 1 X 5/16" MISC X 1/2" MISC DROPLET INSULIN QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily); SYRINGE U-100/1ML/31G 1 SAFETY INSULIN 1 RX/OTC X 15/64" MISC SYRINGE 1ML/29GX1/2" DROPLET INSULIN QL(5 ea daily) MISC SYRINGE U-100/1ML/31G 1 EASY TOUCH FLIPLOCK QL(5 ea daily) X 5/16" MISC SAFETY INSULIN 1 DROPLET INSULIN QL(5 ea daily) SYRINGE 1ML/30GX1/2" SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN 1 RX/OTC DROPLET INSULIN QL(5 ea daily) SYRINGE 1ML/30GX5/16" SYRINGE/U- 1 MISC 100/0.5ML/30G X 1/2" EASY TOUCH FLIPLOCK QL(5 ea daily) MISC SAFETY INSULIN 1 DROPLET INSULIN QL(5 ea daily) SYRINGE 1ML/31GX5/16" SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 1 RX/OTC DROPLET INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/30G 1 EASY TOUCH INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/0.3ML/31G X 1 DROPLET INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 1 EASY TOUCH INSULIN QL(5 ea daily); X 15/64" MISC SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/28G 1 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- 1 RX/OTC SYRINGE/U-100/1ML/30G 1 100/0.5ML/29G X 1/2" X 1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/SAFETY/U- 1 RX/OTC X 5/16" MISC 100/0.5ML/30G X 5/16" EASY TOUCH QL(5 ea daily); MISC SHEATHLOCK SAFETY 1 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); INSULIN SYRINGE SYRINGE/SAFETY/U- 1 RX/OTC 1ML/29GX1/2" MISC 100/1ML/29G X 1/2" MISC EASY TOUCH QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SHEATHLOCK SAFETY 1 RX/OTC SYRINGE/SAFETY/U- 1 INSULIN SYRINGE 100/1ML/30G X 1/2" MISC 1ML/30GX5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily) SYRINGE/U- 1 SHEATHLOCK SAFETY 1 100/0.3ML/30G X 1/2" INSULIN SYRINGE MISC 1ML/31GX5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily) SYRINGE/U- 1 SHEATHLOCK SAFETY 1 100/0.5ML/27G X 1/2" SYRINGE 1ML/30GX1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGE/0.3ML/31G X 1 100/0.5ML/28G X 1/2" 5/16" MISC MISC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.5ML/29G X 1/2" ELITE-THIN INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 ELITE-THIN INSULIN QL(5 ea daily); 100/0.5ML/30G X 1/2" SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/U- 1 RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/27G 1 RX/OTC SYRINGE/U- 1 X 1/2" MISC 100/0.5ML/31G X 5/16" MISC

Ambetter NH Formulary Updated October 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC INSULIN 1 RX/OTC X 1/2" MISC SYRINGE/0.5ML/29G X ELITE-THIN INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/29G 1 RX/OTC EXEL COMFORT POINT QL(5 ea daily); X 1/2" MISC INSULIN 1 RX/OTC ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/31G 1 5/16" MISC X 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC SYRINGE/1ML/28G X 1/2" 1/2" MISC MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC INSULIN 1 RX/OTC 5/16" MISC SYRINGE/1ML/29G X 1/2" MISC EQL INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC SYRINGE/1ML/30G X EQL INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC FIFTY50 SUPERIOR QL(5 ea daily) COMFORTINSULIN 1 EQL INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC FIFTY50 SUPERIOR QL(5 ea daily) EQL INSULIN QL(5 ea daily) COMFORTINSULIN 1 SYRINGE/0.5ML/31G X 1 SYRINGE/0.5ML/31G X 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC COMFORTINSULIN 1 MISC SYRINGE/1ML/31G X EQL INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X 1 RX/OTC FREESTYLE PRECISION QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC EQL INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X 1 MISC 5/16" MISC FREESTYLE PRECISION QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); INSULIN SYRINGE/U- 1 INSULIN 1 RX/OTC 100/0.5ML/31G X 5/16" SYRINGE/0.3ML/29G X MISC 1/2" MISC FREESTYLE PRECISION QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); INSULIN SYRINGE/U- 1 INSULIN 1 RX/OTC 100/1ML/31G X 5/16" SYRINGE/0.3ML/30G X MISC 5/16" MISC FREESTYLE PRECISION QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); INSULIN SYRINGES/U- 1 RX/OTC INSULIN 1 RX/OTC 100/1ML/30G X 5/16" SYRINGE/0.5ML/28G X MISC 1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL EASY GLIDE QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily); INSULIN 1 INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/1ML/31G X 100/1ML/29G X 1/2" MISC 15/64" MISC GLOBAL INJECT EASE QL(5 ea daily) GLOBAL EASY GLIDE QL(5 ea daily) INSULIN SYRINGE/U- 1 INSULINSYRINGE/U- 1 100/1ML/30G X 1/2" MISC 100/0.3ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/1ML/30G X 5/16" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/29G X 1/2" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily) 100/1ML/31G X 5/16" INSULIN SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" GLOBAL INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/30G X 5/16" GLOBAL INSULIN QL(5 ea daily); MISC SYRINGES/U- 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/30GX5/16" INSULIN SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 5/16" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/29G X 1/2" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/31G X 5/16" INSULIN SYRINGE/U- 1 MISC 100/0.5ML/30G X 1/2" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily); 100/0.5ML/30G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/30G X 5/16" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.5ML/30G X 5/16" INSULIN SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/1ML/28G X 1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 SYRINGES/1ML/28GX1/2" 1 RX/OTC X 1/2" MISC MISC GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGES/1ML/29GX1/2" 1 RX/OTC X 5/16" MISC MISC GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 SYRINGES/3ML/31GX5/16 1 X 5/16" MISC " MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC INSULIN 1 RX/OTC 1/2" MISC SYRINGE/0.3ML/29G X GNP INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/30G X 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC GNP INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X SYRINGE/0.3ML/31G X 1 5/16" SHORT MISC 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/0.5ML/28G X 1 RX/OTC SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC INSULIN 1 RX/OTC 1/2" MISC SYRINGE/0.5ML/29G X 1/2" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC SYRINGE/1ML/28G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); INSULIN 1 RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC MISC HEALTHWISE INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC GNP INSULIN QL(5 ea daily); HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/U- 1 5/16" MISC 100/0.3ML/31G X 5/16" GNP INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X 1 HEALTHWISE INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC GNP INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGES/0.3ML/30GX5/ 1 RX/OTC MISC 16" MISC GNP INSULIN QL(5 ea daily); SYRINGES/1/2ML/29GX1/ 1 RX/OTC 2" MISC Ambetter NH Formulary Updated October 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC 100/0.5ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); HEALTHWISE INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC 5/16" MISC X 5/16" MISC INSULIN QL(5 ea daily); HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC SYRINGE/U-100/1ML/31G 1 0.3ML/30G X 5/16" MISC X 5/16" MISC INSULIN QL(5 ea daily) HM ULTICARE INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 SYRINGE/1ML/30G X 1/2" 1 0.3ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); HM ULTICARE INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC SYRINGE/U- 1 0.5ML/29G X 1/2" MISC 100/0.3ML/31G X 5/16" INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 1 RX/OTC INSULIN QL(5 ea daily) 0.5ML/30G X 5/16" MISC SYRINGE/0.3ML/29G X 1" 1 INSULIN QL(5 ea daily) MISC SYRINGE/NEEDLE 1 INSULIN QL(5 ea daily); 0.5ML/31G X 5/16" MISC SYRINGE/0.3ML/29G X 1 RX/OTC INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/NEEDLE 1 RX/OTC INSULIN QL(5 ea daily); 1ML/29G X 1/2" MISC SYRINGE/0.3ML/30G X 1 RX/OTC INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/NEEDLE 1 RX/OTC INSULIN QL(5 ea daily) 1ML/30G X 5/16" MISC SYRINGE/0.3ML/31G X 1 INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/NEEDLE 1 INSULIN QL(5 ea daily) 1ML/31G X 5/16" MISC SYRINGE/0.5ML/27G X 1 INSULIN SYRINGE/U- QL(5 ea daily); 1/2" MISC 100/0.3ML/29G X 1/2" 1 RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/28G X 1 RX/OTC INSULIN SYRINGE/U- QL(5 ea daily); 1/2" MISC 100/0.5ML/29G X 1/2" 1 RX/OTC INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/30G X 1 INSULIN SYRINGE/U- 1 QL(5 ea daily); 1/2" MISC 100/1ML/29G X 1/2" MISC RX/OTC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC 100/1ML/30G X 5/16" 1 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/31G X 1 100/1ML/30G X 5/16" 1 RX/OTC 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/1ML/28G X 1/2" 1 RX/OTC 100/1ML/31G X 5/16" 1 MISC MISC

Ambetter NH Formulary Updated October 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) KINRAY INSULIN QL(5 ea daily); SYRINGES/0.5ML/27GX1/ 1 SYRINGE/0.5ML/29G X 1 RX/OTC 2" MISC 1/2" MISC INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGES/0.5ML/28GX1/ 1 RX/OTC INSULIN 1 RX/OTC 2" MISC SYRINGE/1ML/29G MISC INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGES/0.5ML/29GX1/ 1 RX/OTC INSULIN 1 RX/OTC 2" MISC SYRINGE/1ML/30G MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/0.5ML/30GX5/ 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC 16" MISC 1/2" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/0.5ML/31GX 1 SYRINGE/0.3ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily) SYRINGES/0.5ML/31GX5/ 1 SYRINGE/0.3ML/31G X 1 16" MISC 5/16" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/27GX/1/2" 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC MISC 1/2" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/27GX1/2" 1 RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC MISC 5/16" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily) SYRINGES/1ML/28GX1/2" 1 RX/OTC SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/29GX1/2" 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/30GX1/2" 1 SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily) SYRINGES/1ML/31GX5/16 1 SYRINGE/1ML/31G X 1 " MISC 5/16" MISC KINRAY INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE PREFERRED 1 SYRINGE/0.3ML/29G X 1 RX/OTC PLUS/0.3ML/31G X 5/16" 1/2" MISC MISC LEADER INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC SYRINGE PREFERRED 1 5/16" MISC PLUS/0.5ML/31G X 5/16" LEADER INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 1 KINRAY INSULIN QL(5 ea daily) 5/16" MISC SYRINGE PREFERRED 1 LEADER INSULIN QL(5 ea daily); PLUS/1ML/31G X 5/16" SYRINGE/0.5ML/28G X 1 RX/OTC MISC 1/2" MISC Ambetter NH Formulary Updated October 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.5ML/28G X 1/2" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC LEADER INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SYRINGE/1ML/28G X 1/2" 1 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16" MISC LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/28G 1 RX/OTC X 1/2" MISC LEADER INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/29G 1 RX/OTC X 1/2" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/30G 1 RX/OTC X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 1 X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 LONGS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X 1 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC MAGELLAN INSULIN QL(5 ea daily); 5/16" MISC SAFETY SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" LITETOUCH INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 5/16" MISC MAGELLAN INSULIN QL(5 ea daily); SAFETY SYRINGE/U- 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC MAGELLAN INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SAFETY SYRINGE/U- 1 RX/OTC SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC MAGELLAN INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SAFETY SYRINGE/U- 1 RX/OTC SYRINGE/U- 1 100/0.5ML/30G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC

Ambetter NH Formulary Updated October 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGELLAN INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily) SAFETY SYRINGE/U- 1 RX/OTC SYRINGE/DETACH 1 100/1ML/29G X 1/2" MISC NEEDLE/1ML/25G X 5/8" MAGELLAN INSULIN QL(5 ea daily); MISC SAFETY SYRINGE/U- 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" SYRINGE/DETACH 1 RX/OTC MISC NEEDLE/1ML/27G X 1/2" MAXI-COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); 100/0.5ML/28GX1/2" MISC SYRINGE/PERM 1 RX/OTC MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLE/1ML/28G X 1/2" SYRINGE/U- 1 RX/OTC MISC 100/1ML/28GX1/2" MISC MONOJECT INSULIN QL(5 ea daily); MAXICOMFORT INSULIN QL(5 ea daily) SYRINGE/PERM 1 RX/OTC SYRINGES 27G X 1/2" 1 NEEDLE/U-100/0.5ML/28G MISC X 1/2" MISC MAXICOMFORT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGES 27G X 1/2" 1 RX/OTC SYRINGE/SAFETY/PERM 1 RX/OTC MISC NEEDLE/0.3ML/29G X 1/2" MISC MEDIC INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SAFETY/PERM 1 RX/OTC NEEDLE/0.3ML/29GX1/2" MEDIC INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); SYRINGE/SAFETY/PERM 1 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily); NEEDLE/0.5ML/29G X 1/2" 100/0.3ML/30G X 5/16" 1 RX/OTC MISC MISC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/SAFETY/PERM 1 RX/OTC 100/0.3ML/31G X 5/16" 1 NEEDLE/1ML/29G X 1/2" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 100/1/2ML/30G X 5/16" 1 RX/OTC SYRINGE/SOFTPACK/1M 1 RX/OTC MISC L/27G X 1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/1/2ML/31G X 5/16" 1 SYRINGE/SOFTPACK/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/1ML/30G X 5/16" 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/0.3ML/30G X 5/16" 100/1ML/31G X 5/16" 1 MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 1 SYRINGE/U- 1 RX/OTC SYRINGE/1ML MISC RX/OTC 100/0.5ML/30G X 5/16" MONOJECT INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X 1 5/16" MISC Ambetter NH Formulary Updated October 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT INSULIN QL(5 ea daily); MS INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/28G 1 RX/OTC SYRINGE/0.5ML/31G X 1 X 1/2" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MS INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE/1ML/31G X 1 X 5/16" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); 1 SYRINGEREGULAR LUER RX/OTC INSULIN 1 RX/OTC TIP/SOFTPACK/1ML MISC SYRINGE/0.3ML/30G X MONOJECT ULTRA QL(5 ea daily); 5/16" MISC COMFORT INSULIN 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); SYRINGE/0.3ML/29G X INSULIN 1 RX/OTC 1/2" MISC SYRINGE/0.5ML/28G X MONOJECT ULTRA QL(5 ea daily); 1/2" MISC COMFORT INSULIN 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); SYRINGE/0.3ML/30G X INSULIN 1 RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X MONOJECT ULTRA QL(5 ea daily) 1/2" MISC COMFORT INSULIN 1 PRECISION SURE-DOSE QL(5 ea daily) SYRINGE/0.3ML/31G X INSULIN 1 5/16" MISC SYRINGE/0.5ML/30G X MONOJECT ULTRA QL(5 ea daily); 3/8" MISC COMFORT INSULIN 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); SYRINGE/0.5ML/28G X INSULIN 1 RX/OTC 1/2" MISC SYRINGE/1ML/28G X 1/2" MONOJECT ULTRA QL(5 ea daily); MISC COMFORT INSULIN 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); SYRINGE/0.5ML/29G X PLUSINSULIN 1 RX/OTC 1/2" MISC SYRINGE/0.3ML/29G X MONOJECT ULTRA QL(5 ea daily); 1/2" MISC COMFORT INSULIN 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); SYRINGE/0.5ML/30G X PLUSINSULIN 1 RX/OTC 5/16" MISC SYRINGE/1ML/29G X 1/2" MONOJECT ULTRA QL(5 ea daily) MISC COMFORT INSULIN 1 PREFERRED PLUS QL(5 ea daily); SYRINGE/0.5ML/31G X INSULIN SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.3ML/29G X 1/2" MONOJECT ULTRA QL(5 ea daily); MISC COMFORT INSULIN 1 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/1ML/28G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/30G X 5/16" MONOJECT ULTRA QL(5 ea daily); MISC COMFORT INSULIN 1 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/1ML/29G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" MS INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 1 5/16" MISC

Ambetter NH Formulary Updated October 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(5 ea daily); RA INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC 100/0.5ML/29G X 1/2" 1/2" MISC MISC RA INSULIN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/30G X 5/16" RA INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.5ML/30G X 5/16" 1 RX/OTC PREFERRED PLUS QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC RA INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/28G X 1/2" MISC 100/1 ML/30G X 5/16" 1 RX/OTC PREFERRED PLUS QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC REALITY INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U- 1 RX/OTC PREFERRED PLUS QL(5 ea daily); 100/0.5ML/28G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/1ML/30G X 5/16" REALITY INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC PRO COMFORT INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGES/0.5ML/30G X 1 MISC 1/2" MISC REALITY INSULIN QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC SYRINGES/0.5ML/30G X 1 RX/OTC X 1/2" MISC 5/16" MISC REALITY INSULIN QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/29G 1 RX/OTC SYRINGES/0.5ML/31G X 1 X 1/2" MISC 5/16" MISC RELION INSULIN QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily) SYRINGE 1 SYRINGES/1ML/30G X 1 1ML/31GX15/64" MISC 1/2" MISC RELION INSULIN QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGES/1ML/30G X 1 RX/OTC 100/0.3ML/31G X 5/16" 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) RELION INSULIN QL(5 ea daily); 1 SYRINGES/1ML/31G X SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.5ML/29G X 1/2" PRODIGY INSULIN QL(5 ea daily) MISC SYRING/U-100/0.3ML/31G 1 RELION INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- 1 PRODIGY INSULIN QL(5 ea daily) 100/0.5ML/31G X 5/16" SYRINGE/1/2ML/31G X 1 MISC 5/16" MISC RELION INSULIN QL(5 ea daily) PRODIGY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/1ML/28G X 1/2" 1 RX/OTC X 15/64" MISC MISC RELION INSULIN QL(5 ea daily) PX INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 100/0.5ML/30G X 1/2" 1 X 5/16" MISC MISC

Ambetter NH Formulary Updated October 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFESNAP INSULIN QL(5 ea daily); SECURESAFE SAFETY QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC INSULIN SYRINGES/U- 1 RX/OTC 5/16" MISC 100/1ML/29GX1/2" MISC SAFESNAP INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.3ML/29G X 1/2" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC SURE COMFORT QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 1 SAFESNAP INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC MISC SURE COMFORT QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC SAFETY INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily) SYRINGES 1 RX/OTC INSULIN SYRINGE/U- 1 0.5ML/29GX1/2" MISC 100/0.3ML/31G X 5/16 MISC SAFETY INSULIN QL(5 ea daily); SYRINGES 1 RX/OTC SURE COMFORT QL(5 ea daily) 0.5ML/30GX5/16" MISC INSULIN SYRINGE/U- 1 100/0.3ML/31G X 5/16" SAFETY INSULIN QL(5 ea daily); MISC SYRINGES 1ML/27GX1/2" 1 RX/OTC MISC SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SAFETY INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGES 1ML/29GX1/2" 1 RX/OTC MISC MISC SURE COMFORT QL(5 ea daily); SAFETY INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC SYRINGES 1ML/30GX1/2" 1 100/0.5ML/29G X 1/2" MISC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily) 100/0.5ML/29G X 1/2" 1 RX/OTC INSULIN SYRINGE/U- 1 MISC 100/0.5ML/30G X 1/2" SB INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.5ML/30G X 5/16" 1 RX/OTC SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC SB INSULIN SYRINGE/U- 1 QL(5 ea daily); 100/0.5ML/30G X 5/16" 100/1ML/29G X 1/2" MISC RX/OTC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily) 100/1ML/30G X 5/16" 1 RX/OTC INSULIN SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16 SB INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC SECURESAFE SAFETY QL(5 ea daily); 100/1ML/28G X 1/2" MISC INSULIN SYRINGES/U- 1 RX/OTC 100/0.5ML/29GX1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC 100/1ML/29G X 1/2" MISC X 5/16" MISC SURE COMFORT QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 SYRINGE/U-100/1ML/31G 1 100/1ML/30G X 1/2" MISC X 5/16" MISC SURE COMFORT QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGEU- 1 RX/OTC 100/1ML/30G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 SYRINGEU- 1 100/1ML/31G X 5/16" 100/0.3ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC 1 SYRINGEU- 1 RX/OTC 100/0.3ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGEU- 1 100/0.3ML/30G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGEU- 1 RX/OTC 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGEU- 1 100/0.5ML/28G X 1/2" 100/0.5ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SYRINGEU- 1 RX/OTC 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGEU- 1 100/0.5ML/30G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGEU-100/1ML/29G 1 RX/OTC 100/0.5ML/31G X 5/16" X 1/2" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1 SYRINGE/U-100/1ML/28G 1 RX/OTC X 1/2" MISC X 1/2" MISC TECHLITE INSULIN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC X 5/16" MISC X 1/2" MISC

Ambetter NH Formulary Updated October 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN QL(5 ea daily) TRUE COMFORT INSULIN QL(5 ea daily) SYRINGEU-100/1ML/31G 1 SYRINGE/1ML/31G X 1 X 15/64" MISC 5/16" MISC TECHLITE INSULIN QL(5 ea daily) TRUE COMFORT PRO QL(5 ea daily); SYRINGEU-100/1ML/31G 1 INSULINSYRINGE/0.5ML/ 1 RX/OTC X 5/16" MISC 30G X 5/16" MISC TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily) COMFORT INSULIN 1 RX/OTC INSULINSYRINGE/0.5ML/ 1 SYRINGE/0.3ML/30G X 31G X 5/16" MISC 5/16" MISC TRUE COMFORT PRO QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) INSULINSYRINGE/1ML/30 1 RX/OTC COMFORT INSULIN 1 G X 5/16" MISC SYRINGE/0.3ML/31G X TRUE COMFORT PRO QL(5 ea daily) 5/16" MISC INSULINSYRINGE/1ML/31 1 TOPCARE ULTRA QL(5 ea daily); G X 5/16" MISC COMFORT INSULIN 1 RX/OTC TRUE COMFORT PRO QL(5 ea daily) SYRINGE/0.5ML/30G X INSULINSYRINGE/U- 1 5/16" MISC 100/0.5ML/30G X 1/2" TOPCARE ULTRA QL(5 ea daily) MISC COMFORT INSULIN 1 TRUE COMFORT PRO QL(5 ea daily) SYRINGE/0.5ML/31G X INSULINSYRINGE/U- 1 5/16" MISC 100/1ML/30G X 1/2" MISC TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); COMFORT INSULIN RX/OTC 1 SYRINGE/U- 1 RX/OTC SYRINGE/1ML/30G X 100/0.3ML/29G X 1/2" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); COMFORT INSULIN 1 SYRINGE/U- 1 RX/OTC SYRINGE/1ML/31G X 100/0.3ML/30G X 5/16" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) COMFORT INSULIN RX/OTC SYRINGE/U- 1 SYRINGE/U- 1 100/0.3ML/31G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- 1 RX/OTC COMFORT INSULIN RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/U- 1 MISC 100/0.5ML/29G X 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC TOPCARE ULTRA QL(5 ea daily); 100/0.5ML/29G X 1/2" COMFORT INSULIN 1 RX/OTC MISC SYRINGE/U-100/1ML/29G X 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC TRUE COMFORT INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC

Ambetter NH Formulary Updated October 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC 100/0.5ML/31G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1/2" 1 SYRINGE/U-100/1ML/28G 1 RX/OTC MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC 5/16" MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 1 RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC 0G X 5/16" MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 1 SYRINGE/U-100/1ML/31G 1 1G X 5/16" MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 RX/OTC SAFETY 1 RX/OTC 0G X 5/16" MISC SYRINGE/0.5ML/29G X ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/SHORT/0.5ML/3 1 ULTICARE INSULIN QL(5 ea daily); 1G X 5/16" MISC SAFETY 1 RX/OTC ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" SYRINGE/SHORT/1ML/30 1 RX/OTC MISC G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1 RX/OTC SYRINGE/SHORT/1ML/31 1 1/2" MISC G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 SYRINGE/U- 1 1/2" MISC 100/0.3ML/30G X 1/2" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 1 RX/OTC ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 ULTICARE INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" SYRINGE/0.5ML/28G X 1 RX/OTC MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.5ML/29G X 1 RX/OTC 100/0.5ML/30G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) 1 SYRINGE/0.5ML/30G X SYRINGE/U- 1 1/2" MISC 100/0.5ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/30G 1 ULTICARE INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC

Ambetter NH Formulary Updated October 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/0.3ML/30G X 1 RX/OTC X 5/16" MISC 8MM MISC ULTICARE INSULIN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SYRINGEULTRAFINE U- 1 SYRINGE/0.3ML/31G X 1 100/0.3ML/31G X 5/16" 8MM MISC MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGEULTRAFINE U- 1 8MM MISC 100/0.5ML/31G X 5/16" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC ULTICARE INSULIN QL(5 ea daily) 8MM MISC SYRINGEULTRAFINE U- 1 ULTILET INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" SYRINGE/1ML/31G X 1 MISC 8MM MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE 1 SYRINGE/SHORT/0.3ML/3 1 0.3ML/30G X 0G X 12.7MM MISC 1/2"/SHARPS C MISC ULTILET INSULIN QL(5 ea daily); ULTIGUARD SAFEPACK QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 1 RX/OTC INSULIN SYRINGE 1/2ML 1 0G X 5/16" MISC 30G X 1/2"/SHARPS C MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 1 ULTIGUARD SAFEPACK QL(5 ea daily) 1G X 5/16" MISC INSULIN SYRINGE 1ML 1 30G X 1/2"/SHARPS CON ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 1 RX/OTC 0G X 5/16" MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE 1ML 1 31G X 5/16"/SHARPS CO SYRINGE/SHORT/0.5ML/3 1 MISC 1G X 5/16" MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 1 RX/OTC INSULIN 1 SYRINGE/0.3ML/30G X G X 5/16" MISC 1/2"/SHARPS C MISC ULTILET INSULIN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily) SYRINGE/SHORT/1ML/31 1 G X 5/16" MISC INSULIN 1 SYRINGE/0.3ML/31G X ULTILET INSULIN QL(5 ea daily) 5/16"/SHARPS MISC SYRINGE/U- 1 ULTIGUARD SAFEPACK QL(5 ea daily) 100/0.5ML/30G X 1/2" MISC INSULIN 1 SYRINGE/0.5ML/30G X ULTILET INSULIN QL(5 ea daily) 1/2"/SHARPS C MISC SYRINGE/U-100/1ML/30G 1 ULTIGUARD QL(5 ea daily) X 1/2" MISC SAFEPACK/SYRINGE/NE ULTRA COMFORT QL(5 ea daily); EDLE/31G X 1 INSULIN SYRINGE/U- 1 RX/OTC 5/16"/SHARPS CONTAIN 100/0.3ML/30G X 5/16" MISC MISC

Ambetter NH Formulary Updated October 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE 0.3ML/29G X 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.3ML/29G X 1/2" ULTRA FLO INSULIN QL(5 ea daily) MISC SYRINGE 0.3ML/30GX1/2" 1 ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC ULTRA FLO INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGE 1 RX/OTC MISC 0.3ML/30GX5/16" MISC ULTRA-COMFORT QL(5 ea daily) ULTRA FLO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 SYRINGE 1 100/0.3ML/31G X 5/16" 0.3ML/31GX5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE 0.5ML/29GX1/2" 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" MISC ULTRA FLO INSULIN QL(5 ea daily) SYRINGE 0.5ML/30GX1/2" 1 ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" ULTRA FLO INSULIN QL(5 ea daily); MISC SYRINGE 1 RX/OTC 0.5ML/30GX5/16" MISC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC ULTRA FLO INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE 1 MISC 0.5ML/31GX5/16" MISC ULTRA-COMFORT QL(5 ea daily) ULTRA FLO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 SYRINGE 1/2 1 100/0.5ML/31G X 5/16" UNIT/0.3ML/30GX1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGE 1/2 1 RX/OTC 100/1ML/28G X 1/2" MISC UNIT/0.3ML/30GX5/16" MISC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC ULTRA FLO INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC SYRINGE 1/2 1 UNIT/0.3ML/31GX5/16" ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/30G X 5/16" ULTRA FLO INSULIN QL(5 ea daily); MISC SYRINGE 1M/29GX1/2" 1 RX/OTC MISC ULTRA-COMFORT QL(5 ea daily) INSULIN SYRINGE/U- 1 ULTRA FLO INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" SYRINGE 1ML/30GX1/2" 1 MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC SYRINGE 1ML/30GX5/16" 1 RX/OTC 100/0.3ML/30GX5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) SYRINGE 1ML/31GX5/16" 1 MISC

Ambetter NH Formulary Updated October 1, 2021

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 SYRINGE/U-100/1ML/30G 1 RX/OTC 100/0.3ML/31GX5/16" X 5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE SHORT/U- 1 RX/OTC X 5/16" MISC 100/0.5ML/30GX5/16" VALUE HEALTH INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE SHORT/U- 1 MISC 100/0.5ML/31GX5/16" VALUE HEALTH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE SHORT/U- 1 RX/OTC VANISHPOINT INSULIN QL(5 ea daily) 100/1ML/30GX5/16" MISC SYRINGE/0.5ML/30G X 1 ULTRA-THIN II INSULIN QL(5 ea daily) 1/2" MISC SYRINGE SHORT/U- 1 VANISHPOINT INSULIN QL(5 ea daily); 100/1ML/31GX5/16" MISC SYRINGE/0.5ML/30G X 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC VANISHPOINT INSULIN QL(5 ea daily); 100/0.5ML/29GX1/2" MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC VANISHPOINT INSULIN QL(5 ea daily); 100/1ML/29GX1/2" MISC SYRINGE/1ML/30G X 1 RX/OTC ULTRACARE INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC VP INSULIN SYRINGE/U- QL(5 ea daily); 100/0.3ML/30G X 5/16" 100/0.3ML/29G X 1/2" 1 RX/OTC MISC MISC ULTRACARE INSULIN QL(5 ea daily) ZEVRX INSULIN QL(5 ea daily) SYRINGE/U- 1 SYRINGE/0.5ML/30G X 1 100/0.3ML/31G X 5/16" 1/2" MISC MISC ZEVRX INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/U- 1 5/16" MISC 100/0.5ML/30G X 1/2" MISC ZEVRX INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 1 ULTRACARE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/30G X 5/16" ZEVRX INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC ULTRACARE INSULIN QL(5 ea daily) MIGRAINE PRODUCTS - Drugs to Treat Migraine SYRINGE/U- 1 100/0.5ML/31G X 5/16" Headaches MISC Calcitonin -Related Peptide (CGRP) ULTRACARE INSULIN QL(5 ea daily) AIMOVIG SOAJ 2 PA; QL(0.04 ml SYRINGE/U-100/1ML/30G 1 daily) X 1/2" MISC EMGALITY SOAJ 120 2 PA; QL(0.07 ml MG/ML daily) Ambetter NH Formulary Updated October 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMGALITY SOSY 100 3 PA; QL(0.1 ml ST; QL(0.2 ea MG/ML daily) eletriptan hydrobromide 1 daily); AL(At tabs least 18 yrs EMGALITY SOSY 120 2 PA; QL(0.07 ml MG/ML daily) old) ST; QL(0.4 ea Migraine Combinations FROVA TABS (Use NF daily); AL(At CAFERGOT TABS (Use NF frovatriptan succinate) least 18 yrs w/ caffeine) old) ergotamine w/ caffeine tabs 1 ST; QL(0.4 ea or 1 mg-100 mg daily); AL(At frovatriptan succinate tabs 1 QL(10 ea per least 18 yrs old) sumatriptan-naproxen 3 30 days sodium tabs retail,10 ea per QL(0.2 ea 30 days mail) IMITREX SOLN NA 20 daily); AL(At MG/ACT, 5 MG/ACT (Use NF QL(10 ea per sumatriptan) least 18 yrs TREXIMET TABS (Use old) sumatriptan-naproxen NF 30 days sodium) retail,10 ea per QL(0.134 ml 30 days mail) IMITREX SOLN SC 6 NF daily); AL(At MG/0.5ML (Use least 18 yrs Migraine Products sumatriptan succinate) old) D.H.E. 45 SOLN (Use NF IMITREX STATDOSE QL(0.134 ml daily); AL(At mesylate) REFILL SOCT (Use NF sumatriptan succinate) least 18 yrs dihydroergotamine 1 old) mesylate soln ij 1 mg/ml QL(0.134 ml IMITREX STATDOSE dihydroergotamine 1 PA; QL(0.267 daily); AL(At mesylate soln na 4 mg/ml ml daily) SYSTEM SOAJ (Use NF sumatriptan succinate) least 18 yrs dihydroergotamine 1 QL(0.267 ml old) mesylate soln na 4 mg/ml daily) QL(0.3 ea IMITREX TABS OR 50 MG, ERGOMAR SUBL 3 QL(0.667 ea daily); AL(At daily) 100 MG, 25 MG (Use NF sumatriptan succinate) least 18 yrs MIGRANAL SOLN (Use QL(0.267 ml old) dihydroergotamine NF daily) QL(0.6 ea mesylate) MAXALT TABS (Use NF rizatriptan benzoate) daily); AL(At Serotonin Agonists least 6 yrs old) ST; QL(0.4 ea QL(0.6 ea MAXALT-MLT TBDP (Use NF daily); AL(At almotriptan malate tabs 1 daily); AL(At rizatriptan benzoate) 12.5 mg least 12 yrs least 6 yrs old) old) QL(0.3 ea ST; QL(0.3 ea 1 daily); AL(At naratriptan hcl tabs least 18 yrs almotriptan malate tabs 1 daily); AL(At 6.25 mg least 12 yrs old) old) ST; QL(0.2 ea QL(0.3 ea RELPAX TABS (Use NF daily); AL(At eletriptan hydrobromide) least 18 yrs AMERGE TABS (Use NF daily); AL(At naratriptan hcl) least 18 yrs old) old)

Ambetter NH Formulary Updated October 1, 2021

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.6 ea ST; QL(0.2 ea rizatriptan benzoate tabs 1 daily); AL(At 10 mg ZOMIG SOLN NA 2.5 MG, 3 daily); AL(At least 6 yrs old) 5 MG (Use zolmitriptan) least 12 yrs QL(0.4 ea old) rizatriptan benzoate tabs 5 1 daily); AL(At ST; QL(0.3 ea mg least 6 yrs old) ZOMIG TABS OR 2.5 MG, NF daily); AL(At QL(0.6 ea 5 MG (Use zolmitriptan) least 12 yrs rizatriptan benzoate tbdp 1 daily); AL(At old) 10 mg least 6 yrs old) ST; QL(0.3 ea QL(0.4 ea ZOMIG ZMT TBDP (Use NF daily); AL(At rizatriptan benzoate tbdp 5 1 daily); AL(At zolmitriptan) least 12 yrs mg least 6 yrs old) old) QL(0.2 ea MINERALS & ELECTROLYTES daily); AL(At sumatriptan soln 1 least 18 yrs Bicarbonates old) SODIUM ACETATE SOLN 1 QL(0.134 ml 2 MEQ/ML sumatriptan succinate soaj 1 daily); AL(At SODIUM ACETATE SOLN sc 4 mg/0.5ml, 6 mg/0.5ml least 18 yrs 2 MEQ/ML (Use sodium 1 old) acetate) QL(0.134 ml sodium acetate soln 2 1 sumatriptan succinate soct 1 daily); AL(At meq/ml, 4 meq/ml sc 4 mg/0.5ml, 6 mg/0.5ml least 18 yrs old) Calcium QL(0.134 ml calcium chloride (dihydrate) 1 soln sumatriptan succinate soln 1 daily); AL(At sc 6 mg/0.5ml least 18 yrs CALCIUM GLUCONATE 1 old) SOLN QL(0.134 ml calcium gluconate soln 1 sumatriptan succinate sosy 1 daily); AL(At sc 6 mg/0.5ml least 18 yrs Electrolyte Mixtures old) DEXTROSE 5%/NACL QL(0.3 ea 0.3% SOLN (Use dextrose NF sumatriptan succinate tabs 1 daily); AL(At w/ sodium chloride) or 50 mg, 100 mg, 25 mg least 18 yrs old) dextrose in lactated ringers 1 soln ST; QL(0.2 ea DEXTROSE/SODIUM zolmitriptan soln na 2.5 mg, 1 daily); AL(At 5 mg least 12 yrs CHLORIDE SOLN (Use NF old) dextrose w/ sodium chloride) ST; QL(0.3 ea IONOSOL-MB/DEXTROSE zolmitriptan tabs or 2.5 mg, 1 daily); AL(At 5 mg least 12 yrs 5% SOLN 3 MEQ/L-3 old) MEQ/L-5 %-20 MEQ/L-22 MEQ/L-23 MEQ/L-25 1 ST; QL(0.3 ea MEQ/L, 3 MEQ/L-3 zolmitriptan tbdp or 2.5 mg, 1 daily); AL(At MMOLE/L-5 %-20 MEQ/L- 5 mg least 12 yrs 22 MEQ/L-23 MEQ/L-25 old) MEQ/L

Ambetter NH Formulary Updated October 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOLYTE-P/DEXTROSE 1 Fluoride 5% SOLN sodium fluoride chew 0.25 0 QL(1 ea daily) ISOLYTE-S SOLN 1 mg, 0.5 mg, 1 mg, 2.2 mg KCL 0.3%/D5W/NACL 1 0.9% SOLN magnesium sulfate soln ij 1 lactated ringer's soln 20 50 % mg/100ml-30 mg/100ml- Phosphate 310 mg/100ml-600 1 potassium phosphates soln 1 mg/100ml, 3 meq/l-4 meq/l- 224 mg/ml-236 mg/ml 28 meq/l-109 meq/l-130 meq/l Potassium K-TAB TBCR 10 MEQ (Use NORMOSOL-M IN D5W 1 NF SOLN potassium chloride) K-TAB TBCR 8 MEQ (Use NORMOSOL-M/D5W 1 1 SOLN potassium chloride) NORMOSOL-R SOLN 1 potassium acetate soln 1 parenteral electrolytes conc 1 potassium bicarbonate tbef 1

PLASMA-LYTE A SOLN 1 potassium chloride cpcr or 1 10 meq, 8 meq PLASMA-LYTE-148 SOLN 1 potassium chloride microencapsulated crystals 1 potassium chloride in er tbcr dextrose & sodium chloride 1 potassium chloride pack or 1 PA soln 20 meq potassium chloride in 1 POTASSIUM CHLORIDE 1 dextrose soln SOLN IV 10 MEQ/50ML potassium chloride in nacl potassium chloride soln iv soln 0.15 %-0.9 %, 0.45 %- 1 10 meq/50ml, 20 1 20 meq/l, 0.9 %-40 meq/l meq/50ml, 2 meq/ml POTASSIUM potassium chloride soln or 1 CHLORIDE/DEXTROSE/L 10 % ACTATED RINGERS SOLN 2.7 MEQ/L-5 %-24 potassium chloride tbcr or 1 MEQ/L-28 MEQ/L-129 1 10 meq, 8 meq MEQ/L-130 MEQ/L, 3 Sodium MEQ/L-5 %-24 MEQ/L-28 sodium chloride soln ij 2.5 1 MEQ/L-130 MEQ/L-149 meq/ml MEQ/L sodium chloride soln iv 3 POTASSIUM %, 5 %, 4 meq/ml, 0.9 %, 1 CHLORIDE/SODIUM 0.45 % CHLORIDE SOLN 0.45 %- 1 20 MEQ/L (Use potassium MISCELLANEOUS THERAPEUTIC CLASSES chloride in nacl) Chelating Agents ringer's soln 1 CUPRIMINE CAPS (Use NF PA penicillamine) Ambetter NH Formulary Updated October 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPEN TITRATABS TABS NF QL(8 ea daily) mycophenolate mofetil tabs 1 (Use penicillamine) or 500 mg penicillamine caps 1 PA mycophenolate sodium 1 tbec QL(8 ea daily) penicillamine tabs 1 MYFORTIC TBEC (Use NF mycophenolate sodium) SYPRINE CAPS (Use NF PA; QL(8 ea NEORAL CAPS (Use trientine hcl) daily); SP cyclosporine modified (for NF PA; QL(8 ea trientine hcl caps 4 microemulsion)) daily); SP NEORAL SOLN (Use Immunomodulators cyclosporine modified (for NF REVLIMID CAPS 10 MG, PA; QL(1 ea microemulsion)) 15 MG, 2.5 MG, 25 MG, 5 4 daily); SP NULOJIX SOLR 4 PA; SP MG PA; PROGRAF CAPS OR 0.5 REVLIMID CAPS 20 MG 4 MG, 1 MG, 5 MG (Use NF PA; QL(3 ea tacrolimus) THALOMID CAPS 4 daily); SP PROGRAF PACK OR 0.2 2 PA MG, 1 MG Immunosuppressive Agents PROGRAF SOLN IV 5 2 ATGAM INJ 4 PA; SP MG/ML RAPAMUNE TABS 0.5 AZASAN TABS 3 MG, 1 MG, 2 MG (Use NF sirolimus) AZATHIOPRINE SOLR IJ 1 100 MG SANDIMMUNE CAPS OR 100 MG, 25 MG (Use NF azathioprine tabs or 50 mg 1 cyclosporine) CELLCEPT CAPS 250 MG SANDIMMUNE SOLN IV (Use mycophenolate NF 50 MG/ML (Use NF mofetil) cyclosporine) CELLCEPT TABS 500 MG SIMULECT SOLR 3 (Use mycophenolate NF mofetil) sirolimus tabs 0.5 mg, 1 1 mg, 2 mg cyclosporine caps 1 tacrolimus caps 1 cyclosporine modified (for 1 microemulsion) caps THYMOGLOBULIN SOLR 4 PA; SP cyclosporine modified (for 1 microemulsion) soln ZORTRESS TABS 0.25 PA; QL(20 ea MG, 0.5 MG, 0.75 MG (Use NF daily); SP cyclosporine soln 1 everolimus (immunosuppressant)) everolimus 4 PA; QL(20 ea (immunosuppressant) tabs daily); SP Irrigation Solutions irrigation solutions, IMURAN TABS (Use NF 1 azathioprine) physiological soln lactated ringer's (irrigation) mycophenolate mofetil 1 1 caps or 250 mg soln Ambetter NH Formulary Updated October 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ringer's irrigation soln 1 MULTIVITAMINS water for irrigation, sterile 1 Prenatal Vitamins soln CLASSIC PRENATAL 2 QL(1 ea daily) Potassium Removing Agents TABS sodium polystyrene 1 CVS PRENATAL TABS 2 QL(1 ea daily) sulfonate powd EQL PRENATAL QL(1 ea daily) sodium polystyrene 1 2 sulfonate susp FORMULA TABS QL(1 ea daily) MOUTH/THROAT/DENTAL AGENTS GNP PRENATAL TABS 2 Anesthetics Topical Oral GOODSENSE PRENATAL 2 QL(1 ea daily) VITAMINS TABS lidocaine hcl (mouth-throat) 1 QL(4 ml daily) soln 2 % HM PRENATAL TABS 2 QL(1 ea daily) lidocaine hcl (mouth-throat) 1 KP PRENATAL 2 QL(1 ea daily) soln 4 % MULTIVITAMINS TABS Anti-infectives - Throat QL(1 ea daily); M-NATAL PLUS TABS 2 RX/OTC clotrimazole troc 1 MULTI PRENATAL TABS 2 QL(1 ea daily) nystatin (mouth-throat) 1 susp NEONATAL COMPLETE QL(1 ea daily); Antiseptics - Mouth/Throat TABS 0.2 MG-1.84 MG-2 RX/OTC MG-2 MG-3 MG-5 MG-9.2 chlorhexidine gluconate 1 MG-10 MCG-10 MG-12 2 (mouth-throat) soln MCG-20 MG-25 MG-27 DEBACTEROL SOLN 2 MG-120 MG-200 MG-1000 MCG-1200 MCG PERIDEX SOLN (Use NEONATAL PLUS TABS 2 QL(1 ea daily); chlorhexidine gluconate NF RX/OTC (mouth-throat)) NEONATAL VITAMIN 2 QL(1 ea daily) Dental Products TABS RX/OTC stannous fluoride conc 0 NIVA-PLUS TABS 2 QL(1 ea daily); RX/OTC Steroids - Mouth/Throat/Dental O-CAL FA TABS 2 QL(1 ea daily); RX/OTC triamcinolone acetonide 1 (mouth) pste ONE VITE WOMENS QL(1 ea daily); Throat Products - Misc. PRENATALVITAMIN PLUS 2 RX/OTC TABS cevimeline hcl caps 1 ONE VITE WOMENS 2 QL(1 ea daily) PRENATALVITAMIN TABS EVOXAC CAPS (Use NF cevimeline hcl) PRENATAL LOW IRON 2 QL(1 ea daily) TABS pilocarpine hcl (oral) tabs 1 PRENATAL 2 QL(1 ea daily) MULTIVITAMIN TABS SALAGEN TABS (Use NF pilocarpine hcl (oral)) PRENATAL ONE DAILY 2 QL(1 ea daily) TABS

Ambetter NH Formulary Updated October 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 0.8 MG- QL(1 ea daily) RA PRENATAL QL(1 ea daily) 1.5 MG-1.7 MG-2.6 MG-4 FORMULA/FOLICACID 2 MCG-11 UNIT-18 MG-25 TABS MG-27 MG-100 MG-263 QL(1 ea daily) MG-400 UNIT-4000 UNIT, RA PRENATAL TABS 2 0.8 MG-1.7 MG-1.8 MG-2.6 RIGHT STEP PRENATAL 2 QL(1 ea daily) MG-8 MCG-20 MG-25 MG- TABS 28 MG-30 UNIT-120 MG- 200 MG-400 UNIT-4000 SM PRENATAL VITAMINS 2 QL(1 ea daily) UNIT, 1.5 MG-1.7 MG-2.6 TABS MG-4 MCG-5 MG-10 THERANATAL CORE 2 QL(1 ea daily); MCG-18 MG-25 MG-27 2 NUTRITION TABS RX/OTC MG-100 MG-200 MG-800 QL(1 ea daily); TRICARE TABS 2 MCG-1200 MCG, 1.7 MG- RX/OTC 1.8 MG-2.6 MG-8 MCG-20 VITATHELY/GINGER 2 QL(1 ea daily); MG-25 MG-28 MG-30 TABS RX/OTC UNIT-120 MG-200 MG-400 QL(1 ea daily); UNIT-800 MCG-4000 VOL-PLUS TABS 2 UNIT, 1.7 MG-1.84 MG-2.6 RX/OTC QL(1 ea daily); MG-4 MCG-11 UNIT-18 WESTAB PLUS TABS 2 MG-25 MG-27 MG-100 RX/OTC MG-160 MG-200 MG-400 UNIT-800 MCG-4000 UNIT MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms PRENATAL TABS 1 MG- QL(1 ea daily); 1.84 MG-2 MG-3 MG-10 RX/OTC Central Muscle Relaxants MCG-10 MG-10 MG-12 2 baclofen tabs or 10 mg, 20 1 MCG-20 MG-25 MG-27 mg MG-120 MG-200 MG-1200 MCG tabs 1 PRENATAL VITAMIN & QL(1 ea daily) 2 chlorzoxazone tabs 500 mg 1 QL(6 ea daily) MINERAL TABS cyclobenzaprine hcl tabs QL(3 ea daily) PRENATAL VITAMIN 2 QL(1 ea daily) 1 TABS 10 mg, 5 mg QL(4 ea daily) PRENATAL 2 QL(1 ea daily) metaxalone tabs 800 mg 1 VITAMIN/IRON TABS methocarbamol tabs or 500 PRENATAL VITAMINS 2 QL(1 ea daily); 1 PLUS LOW IRON TABS RX/OTC mg, 750 mg citrate tb12 or QL(2 ea daily) PRENATAL VITAMINS 2 QL(1 ea daily) 1 TABS 100 mg ROBAXIN-750 TABS (Use PRENATRIX TABS 2 QL(1 ea daily); NF RX/OTC methocarbamol) SKELAXIN TABS (Use QL(4 ea daily) PRENATRYL TABS 2 QL(1 ea daily); NF RX/OTC metaxalone) SOMA TABS (Use PREPLUS TABS 2 QL(1 ea daily); NF RX/OTC carisoprodol) PX PRENATAL 2 QL(1 ea daily) tizanidine hcl caps 1 MULTIVITAMINS TABS QC PRENATAL TABS 2 QL(1 ea daily) tizanidine hcl tabs 1

Ambetter NH Formulary Updated October 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZANAFLEX CAPS (Use NF NASACORT ALLERGY tizanidine hcl) 24HR AERO (Use NF triamcinolone acetonide ZANAFLEX TABS (Use NF tizanidine hcl) (nasal)) NASACORT ALLERGY Direct Muscle Relaxants 24HR CHILDRENS AERO NF DANTRIUM CAPS (Use NF QL(4 ea daily) (Use triamcinolone dantrolene sodium) acetonide (nasal)) dantrolene sodium caps or 1 QL(4 ea daily) NASONEX SUSP (Use PA; QL(1.14 100 mg, 25 mg, 50 mg mometasone furoate NF gm daily) NASAL AGENTS - SYSTEMIC AND TOPICAL - (nasal)) Drugs to treat the Nose or Sinus triamcinolone acetonide 1 (nasal) aero Nasal Antiallergy NEUROMUSCULAR AGENTS - Drugs to azelastine hcl soln 1 Relax/Paralyze Muscles olopatadine hcl (nasal) soln 1 ALS Agents RILUTEK TABS (Use NF PATANASE SOLN (Use NF riluzole) olopatadine hcl (nasal)) riluzole tabs 3 Nasal Anticholinergics ipratropium bromide (nasal) 1 QL(1 ml daily) Neuromuscular Blocking Agent - Neurotoxins soln 0.03 % BOTOX SOLR 3 PA ipratropium bromide (nasal) 1 soln 0.06 % DYSPORT SOLR 3 PA Nasal Steroids PA budesonide (nasal) susp 1 XEOMIN SOLR 3 Limit 2 inhalers NUTRIENTS FLONASE ALLERGY per RELIEF CHILDRENS NF month;QL(32 Proteins SUSP (Use fluticasone propionate (nasal)) ml per 30 days CLINIMIX retail); RX/OTC 4.25%/DEXTROSE 10% 3 Limit 2 inhalers SOLN FLONASE ALLERGY per CLINIMIX RELIEF SUSP (Use NF fluticasone propionate month;QL(32 4.25%/DEXTROSE 25% 3 (nasal)) ml per 30 days SOLN retail); RX/OTC CLINIMIX 1 rtl pack lmt flunisolide (nasal) soln 1 4.25%/DEXTROSE 5% 3 per fill, SOLN Limit 2 inhalers CLINIMIX 5%/DEXTROSE 3 per 25% SOLN fluticasone propionate 1 month;QL(32 (nasal) susp CLINIMIX E ml per 30 days 5%/DEXTROSE 20% 3 retail); RX/OTC SOLN mometasone furoate 1 PA; QL(1.14 (nasal) susp gm daily) OPHTHALMIC AGENTS - Drugs to Treat the Eye

Ambetter NH Formulary Updated October 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Artificial Tears and Lubricants brimonidine tartrate soln 1 LACRISERT INST 3 IOPIDINE SOLN 3 Beta-blockers - Ophthalmic SIMBRINZA SUSP 3 PA betaxolol hcl (ophth) soln 1 Ophthalmic Anti-infectives carteolol hcl (ophth) soln 1 AZASITE SOLN 3 COMBIGAN SOLN 2 bacitracin (ophthalmic) oint 3 COSOPT SOLN (Use dorzolamide hcl-timolol NF BLEPH-10 SOLN (Use maleate) sulfacetamide sodium NF (ophth)) dorzolamide hcl-timolol CILOXAN SOLN (Use maleate soln 0.5 %-2 %, 5 1 NF mg/ml-20 mg/ml, 6.8 ciprofloxacin hcl (ophth)) mg/ml-22.3 mg/ml ciprofloxacin hcl (ophth) 1 soln levobunolol hcl soln 1 erythromycin (ophth) oint 1 timolol maleate (ophth) 1 solg 0.25 %, 0.5 % gatifloxacin (ophth) soln 1 timolol maleate (ophth) 1 soln 0.25 %, 0.5 % gentamicin sulfate (ophth) 1 oint TIMOPTIC SOLN (Use NF timolol maleate (ophth)) gentamicin sulfate (ophth) 1 soln TIMOPTIC-XE SOLG (Use NF timolol maleate (ophth)) KLARITY-A SOLN 3 Cycloplegic Mydriatics levofloxacin (ophth) soln 1 MYDRIACYL SOLN (Use NF tropicamide) moxifloxacin hcl (ophth) 1 soln tropicamide soln 1 NATACYN SUSP 2 Miotics neomycin-bacitracin zn- ISOPTO CARPINE SOLN NF 1 (Use pilocarpine hcl) polymyxin oint OCUFLOX SOLN (Use PHOSPHOLINE IODIDE 3 NF SOLR ofloxacin (ophth)) pilocarpine hcl soln 1 ofloxacin (ophth) soln 1 polymyxin b-trimethoprim 1 Ophthalmic Adrenergic Agents soln ALPHAGAN P SOLN 0.15 POLYTRIM SOLN (Use NF % (Use brimonidine NF polymyxin b-trimethoprim) tartrate) sulfacetamide sodium 1 apraclonidine hcl soln 1 (ophth) soln

Ambetter NH Formulary Updated October 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tobramycin (ophth) soln 1 LOTEMAX OINT 3 PA

TOBREX SOLN (Use NF LOTEMAX SUSP (Use NF PA tobramycin (ophth)) loteprednol etabonate) trifluridine soln 1 loteprednol etabonate gel 1 PA

VIGAMOX SOLN (Use NF loteprednol etabonate susp 1 PA moxifloxacin hcl (ophth)) PA ZIRGAN GEL 2 MAXIDEX SUSP 3 MAXITROL OINT (Use ZYMAXID SOLN (Use NF gatifloxacin (ophth)) neomycin-polymy- NF dexameth) Ophthalmic Immunomodulators MAXITROL SUSP (Use RESTASIS EMUL 2 PA neomycin-polymy- NF dexameth) RESTASIS MULTIDOSE PA 2 neomycin-polymy- EMUL 1 dexameth oint Ophthalmic Local Anesthetics neomycin-polymy- 1 ALCAINE SOLN (Use NF dexameth susp proparacaine hcl) neomycin-polymyxin-hc 1 proparacaine hcl soln 1 (ophth) susp PRED FORTE SUSP (Use Ophthalmic Nerve Growth Factors prednisolone acetate NF (ophth)) OXERVATE SOLN 4 PA PRED MILD SUSP 3 PA Ophthalmic Steroids prednisolone acetate 1 ALREX SUSP 3 PA (ophth) susp PREDNISOLONE SODIUM dexamethasone sodium 1 phosphate (ophth) soln PHOSPHATE SOLN OP 1 3 % PA difluprednate emul 1 TOBRADEX SUSP (Use tobramycin- NF DUREZOL EMUL (Use 3 PA difluprednate) dexamethasone) tobramycin- fluorometholone (ophth) 1 1 susp dexamethasone susp Ophthalmics - Misc. FML FORTE SUSP 3 PA ACULAR LS SOLN (Use FML LIQUIFILM SUSP ketorolac tromethamine NF (Use fluorometholone NF (ophth)) (ophth)) ACULAR SOLN (Use FML OINT 3 PA ketorolac tromethamine NF (ophth)) LOTEMAX GEL (Use 3 PA PA loteprednol etabonate) ALOCRIL SOLN 3

Ambetter NH Formulary Updated October 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALOMIDE SOLN 3 PA latanoprost soln 1 azelastine hcl (ophth) soln 1 LUMIGAN SOLN 3 ST bepotastine besilate soln 3 PA TRAVATAN Z SOLN (Use NF travoprost) BEPREVE SOLN (Use 3 PA bepotastine besilate) travoprost soln 1 bromfenac sodium (ophth) 1 XALATAN SOLN (Use NF soln latanoprost) cromolyn sodium (ophth) 1 ZIOPTAN SOLN 2 soln CYSTARAN SOLN 2 PA; QL(2.143 OTIC AGENTS - Drugs to Treat the Ear ml daily) Otic Agents - Miscellaneous diclofenac sodium (ophth) 1 soln acetic acid (otic) soln 1 dorzolamide hcl soln 1 Otic Anti-infectives epinastine hcl (ophth) soln 1 CETRAXAL SOLN (Use 1 ciprofloxacin hcl (otic)) flurbiprofen sodium soln 1 ciprofloxacin hcl (otic) soln 1 ST; QL(0.2 ml ILEVRO SUSP 3 daily) FLOXIN OTIC SOLN (Use NF ofloxacin (otic)) ketorolac tromethamine 1 (ophth) soln ofloxacin (otic) soln 1 ketotifen fumarate (ophth) 1 soln Otic Combinations LASTACAFT SOLN 3 PA CIPRO HC SUSP 3 CIPRODEX SUSP (Use PA NEVANAC SUSP 3 ST; QL(0.2 ml daily) ciprofloxacin- NF dexamethasone) olopatadine hcl soln 1 RX/OTC ciprofloxacin- 1 PA dexamethasone susp PATADAY SOLN (Use NF RX/OTC olopatadine hcl) ciprofloxacin-fluocinolone 1 PA; QL(0.5 ea acetonide soln daily) PATANOL SOLN (Use NF RX/OTC olopatadine hcl) COLY-MYCIN S SUSP 3 TRUSOPT SOLN (Use NF dorzolamide hcl) CORTISPORIN-TC SUSP 3 ZADITOR SOLN (Use NF neomycin-polymyxin-hc 1 ketotifen fumarate (ophth)) (otic) soln PA ZERVIATE SOLN 3 neomycin-polymyxin-hc 1 (otic) susp Prostaglandins - Ophthalmic OTOVEL SOLN (Use PA; QL(0.5 ea bimatoprost soln 3 ciprofloxacin-fluocinolone 3 daily) acetonide) Ambetter NH Formulary Updated October 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Otic Steroids ampicillin sodium solr ij 1 1 gm DERMOTIC OIL (Use fluocinolone acetonide NF ampicillin sodium solr iv 10 1 (otic)) gm fluocinolone acetonide 1 Natural Penicillins (otic) oil PENICILLIN G hydrocortisone w/acetic 1 POTASSIUM IN ISO- acid soln OSMOTIC DEXTROSE 1 SOLN 40000 UNIT/ML, PASSIVE IMMUNIZING AND TREATMENT 60000 UNIT/ML AGENTS - Antibody Drugs to Treat Low Immune System penicillin g potassium solr 1 5000000 unit Immune Serums PENICILLIN G PROCAINE 3 CUVITRU SOLN 1 PA; SP SUSP GM/5ML, 10 GM/50ML, 2 4 GM/10ML, 4 GM/20ML penicillin g sodium solr 3 GAMMAGARD LIQUID PA; SP penicillin v potassium solr 1 SOLN 1 GM/10ML, 10 4 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML penicillin v potassium tabs 1 GAMMAGARD LIQUID 4 PA Penicillin Combinations SOLN 30 GM/300ML amoxicillin & pot 1 GAMMAGARD S/D IGA PA; SP clavulanate chew LESS THAN 1MCG/ML 4 SOLR amoxicillin & pot 1 clavulanate susr GAMMAKED SOLN 4 PA; SP amoxicillin & pot 1 clavulanate tabs GAMUNEX-C SOLN 4 PA; SP amoxicillin & pot 1 HIZENTRA SOLN 1 PA; SP clavulanate tb12 GM/5ML, 10 GM/50ML, 2 4 ampicillin & sulbactam GM/10ML, 4 GM/20ML sodium solr ij 0.5 gm-1 gm, 1 Passive Immunizing Agents - Combinations 1 gm-2 gm PA ampicillin & sulbactam 1 HYQVIA KIT 4 sodium solr iv 5 gm-10 gm AUGMENTIN ES-600 PENICILLINS - Drugs to Treat Bacterial Infections SUSR (Use amoxicillin & NF pot clavulanate) Aminopenicillins AUGMENTIN SUSR 62.5 amoxicillin caps 1 MG/5ML-250 MG/5ML NF (Use amoxicillin & pot amoxicillin chew 1 clavulanate) AUGMENTIN TABS 125 amoxicillin susr 1 MG-500 MG (Use NF amoxicillin & pot amoxicillin tabs 1 clavulanate) piperacillin sodium- 1 ampicillin caps 1 tazobactam sodium solr Ambetter NH Formulary Updated October 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNASYN BULK PACK Agents for Chemical Dependency SOLR (Use ampicillin & NF sulbactam sodium) acamprosate calcium tbec 1 UNASYN SOLR (Use ANTABUSE TABS (Use NF ampicillin & sulbactam NF disulfiram) sodium) ZOSYN SOLR 0.25 GM-2 disulfiram tabs 1 GM, 0.375 GM-3 GM, 0.5 PA; QL(224 ea GM-4 GM, 4.5 GM-36 GM NF LUCEMYRA TABS 3 per 14 days (Use piperacillin sodium- retail) tazobactam sodium) Anti-Cataplectic Agents Penicillinase-Resistant Penicillins PA; QL(18 ml XYREM SOLN 4 dicloxacillin sodium caps 1 daily); SP Antidementia Agents nafcillin sodium solr ij 1 gm 1 ARICEPT TABS 10 MG QL(2 ea daily) nafcillin sodium solr iv 10 1 (Use donepezil NF gm hydrochloride) oxacillin sodium solr ij 1 gm 1 ARICEPT TABS 5 MG QL(1 ea daily) (Use donepezil NF hydrochloride) oxacillin sodium solr iv 10 1 gm donepezil hydrochloride 1 QL(2 ea daily) PROGESTINS - Hormone Replacement/Modifying tabs 10 mg Drugs donepezil hydrochloride 1 QL(1 ea daily) tabs 5 mg Progestins donepezil hydrochloride 1 QL(2 ea daily) AYGESTIN TABS (Use NF tbdp 10 mg norethindrone acetate) donepezil hydrochloride 1 QL(1 ea daily) medroxyprogesterone 1 tbdp 5 mg acetate tabs galantamine hydrobromide 1 QL(1 ea daily) MEGACE ES SUSP (Use PA cp24 16 mg, 24 mg, 8 mg megestrol acetate NF (appetite)) galantamine hydrobromide 1 QL(6 ml daily) soln 4 mg/ml megestrol acetate 1 PA (appetite) susp galantamine hydrobromide 1 QL(2 ea daily) tabs 12 mg, 4 mg, 8 mg norethindrone acetate tabs 0 hcl tabs 1 progesterone caps or 100 1 mg, 200 mg memantine hcl tabs 10 mg 1 QL(2 ea daily) PROMETRIUM CAPS (Use NF progesterone) memantine hcl tabs 5 mg 1 QL(1 ea daily) PROVERA TABS (Use NAMENDA TABS 10 MG NF QL(2 ea daily) medroxyprogesterone NF (Use memantine hcl) acetate) NAMENDA TABS 5 MG NF QL(1 ea daily) PSYCHOTHERAPEUTIC AND NEUROLOGICAL (Use memantine hcl) AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions

Ambetter NH Formulary Updated October 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAMENDA TITRATION dimethyl fumarate misc 4 PA PAK TABS (Use NF memantine hcl) EXTAVIA KIT 4 PA; QL(0.5 ea daily); SP RAZADYNE ER CP24 (Use NF QL(1 ea daily) galantamine hydrobromide) GILENYA CAPS 4 PA RAZADYNE TABS (Use NF QL(2 ea daily) galantamine hydrobromide) glatiramer acetate sosy 20 3 PA; QL(1 ml mg/ml daily); SP rivastigmine tartrate caps 1 glatiramer acetate sosy 40 3 PA; QL(0.429 Combination Psychotherapeutics mg/ml ml daily); SP MAVENCLAD TBPK 4 PA perphenazine-amitriptyline 1 QL(4 ea daily) tabs MAYZENT STARTER 4 PA Fibromyalgia Agents PACK TBPK PA; QL(2 ea SAVELLA TABS 2 PA daily) MAYZENT TABS 4 PA SAVELLA TITRATION 2 PA OCREVUS SOLN 4 PACK MISC PA; QL(0.036 Movement Disorder Drug Therapy PLEGRIDY SOPN SC 4 ml daily) PA; QL(4 ea AUSTEDO TABS 4 daily) PLEGRIDY SOSY IM 4 PA; QL(0.036 ml daily) PA; QL(3 ea tetrabenazine tabs 4 daily); SP PLEGRIDY SOSY SC 4 PA XENAZINE TABS (Use PA; QL(3 ea NF PLEGRIDY STARTER 4 PA tetrabenazine) daily); SP PACK SOPN Multiple Sclerosis Agents PLEGRIDY STARTER 4 PA; QL(0.036 PACK SOSY ml daily) AMPYRA TB12 (Use NF PA; QL(2 ea dalfampridine) daily); SP REBIF REBIDOSE SOAJ 4 PA; QL(0.214 ml daily); SP AUBAGIO TABS 4 PA REBIF REBIDOSE PA; SP PA; QL(0.0714 4 AVONEX PEN AJKT 4 TITRATIONPACK SOAJ ml daily); SP PA; QL(0.214 REBIF SOSY 4 AVONEX PSKT 4 PA; QL(0.0714 ml daily); SP ml daily); SP REBIF TITRATION PACK 4 PA; SP BETASERON KIT 4 PA; QL(0.5 ea SOSY daily); SP TECFIDERA CPDR (Use NF PA COPAXONE SOSY 20 PA; QL(1 ml dimethyl fumarate) MG/ML (Use glatiramer 3 daily); SP TECFIDERA STARTER PA acetate) PACK MISC (Use dimethyl NF COPAXONE SOSY 40 PA; QL(0.429 fumarate) MG/ML (Use glatiramer 3 ml daily); SP TYSABRI CONC 4 PA; QL(0.536 acetate) ml daily); SP PA; QL(2 ea dalfampridine tb12 4 daily); SP Postherpetic Neuralgia (PHN)/Neuropathic Pain PA LYRICA CR TB24 165 MG, PA; QL(1 ea dimethyl fumarate cpdr 4 82.5 MG (Use pregabalin 3 daily) (once-daily)) Ambetter NH Formulary Updated October 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LYRICA CR TB24 330 MG PA; QL(2 ea nicotine polacrilex gum 0 (Use pregabalin (once- 3 daily) daily)) nicotine polacrilex lozg 0 pregabalin (once-daily) 3 PA; QL(1 ea tb24 165 mg, 82.5 mg daily) nicotine pt24 0 QL(1 ea daily) pregabalin (once-daily) 3 PA; QL(2 ea tb24 330 mg daily) NICOTINE TRANSDERMAL SYSTEM 0 Premenstrual Dysphoric Disorder (PMDD) Agents KIT fluoxetine hcl (pmdd) caps QL(1 ea daily) 1 NICOTROL INHALER 0 10 mg INHA fluoxetine hcl (pmdd) caps 1 QL(3 ea daily) 20 mg NICOTROL NS SOLN 0 Pseudobulbar Affect (PBA) Agents tartrate tabs 0 QL(2 ea daily) PA NUEDEXTA CAPS 3 Transthyretin Amyloidosis Agents Psychotherapeutic and Neurological Agents - TEGSEDI SOSY 4 PA mesylates tabs 1 RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions tabs 1 Alpha-Proteinase Inhibitor (Human) Restless Leg Syndrome (RLS) Agents ARALAST NP SOLR 1000 4 PA; SP MG HORIZANT TBCR 3 PA; QL(2 ea daily) ARALAST NP SOLR 500 4 PA Smoking Deterrents MG QL(2 ea daily) PROLASTIN-C SOLN 1000 4 PA; APO-VARENICLINE TABS 0 MG/20ML PROLASTIN-C SOLR 1000 PA; SP bupropion hcl (smoking 0 QL(2 ea daily) 4 deterrent) tb12 MG PA; SP CHANTIX CONTINUING 0 QL(2 ea daily) ZEMAIRA SOLR 4 MONTHPAK TABS Cystic Fibrosis Agents CHANTIX STARTING 0 MONTH PAK TABS PA; QL(2 ea KALYDECO TABS 150 MG 4 CHANTIX TABS 0 QL(2 ea daily) daily); SP ORKAMBI PACK 100 MG- 4 PA; QL(2 ea NICODERM CQ PT24 (Use NF QL(1 ea daily) 125 MG, 150 MG-188 MG daily) nicotine) ORKAMBI TABS 100 MG- 4 PA; QL(4 ea NICORETTE GUM (Use NF 125 MG, 125 MG-200 MG daily) nicotine polacrilex) PA; QL(2.5 ml PULMOZYME SOLN 4 NICORETTE LOZG (Use NF daily); SP nicotine polacrilex) PA; QL(3 ea TRIKAFTA TBPK 4 NICORETTE MINI LOZG NF daily) (Use nicotine polacrilex) Pulmonary Fibrosis Agents NICORETTE STARTER PA; QL(2 ea KIT GUM (Use nicotine NF OFEV CAPS 4 polacrilex) daily)

Ambetter NH Formulary Updated October 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFONAMIDES - Drugs to Treat Bacterial THYROID AGENTS - Drugs to Regulate Thyroid Infections Hormones Sulfonamides Antithyroid Agents SULFADIAZINE TABS 1 methimazole tabs 1

TETRACYCLINES - Drugs to Treat Bacterial propylthiouracil tabs 1 Infections TAPAZOLE TABS (Use NF Glycylcyclines methimazole) tigecycline solr 1 Thyroid Hormones ARMOUR THYROID TABS QL(1 ea daily) TYGACIL SOLR (Use NF tigecycline) 120 MG, 15 MG, 30 MG, 2 60 MG, 90 MG (Use Tetracyclines thyroid) demeclocycline hcl tabs 1 ARMOUR THYROID TABS 2 QL(1 ea daily) 180 MG, 240 MG, 300 MG doxycycline (monohydrate) QL(2 ea daily) 1 CYTOMEL TABS (Use NF caps 50 mg, 100 mg liothyronine sodium) doxycycline (monohydrate) 1 levothyroxine sodium tabs caps 75 mg or 300 mcg, 100 mcg, 112 doxycycline (monohydrate) QL(2 ea daily) 1 mcg, 125 mcg, 137 mcg, 1 tabs 100 mg 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 doxycycline (monohydrate) 1 tabs 50 mg mcg, 88 mcg doxycycline hyclate caps or 1 QL(2 ea daily) liothyronine sodium soln 1 50 mg, 100 mg doxycycline hyclate solr iv 1 liothyronine sodium tabs 1 100 mg NATURE-THROID NT-2.5 doxycycline hyclate tabs or 1 QL(2 ea daily) 2 100 mg, 20 mg TABS NATURE-THROID TABS 2 MINOCIN CAPS OR 50 NF QL(3 ea daily) MG (Use hcl) SYNTHROID TABS (Use 2 minocycline hcl caps 100 1 QL(3 ea daily) levothyroxine sodium) mg, 50 mg, 75 mg thyroid tabs 1 QL(1 ea daily) minocycline hcl tabs 100 1 QL(3 ea daily) mg, 50 mg, 75 mg TRIOSTAT SOLN (Use NF TARGADOX TABS (Use NF liothyronine sodium) doxycycline hyclate) WESTHROID TABS 2 tetracycline hcl caps 1 QL(8 ea daily) VIBRAMYCIN CAPS 100 QL(2 ea daily) WP THYROID TABS 2 MG (Use doxycycline NF hyclate) TOXOIDS XIMINO CP24 135 MG, 45 Toxoid Combinations MG, 90 MG (Use NF minocycline hcl) ADACEL SUSP 0

Ambetter NH Formulary Updated October 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BOOSTRIX SUSP 0 methscopolamine bromide 1 tabs DAPTACEL SUSP 0 H-2 Antagonists DIPHTHERIA/TETANUS hcl soln 300 1 QL(20 ml daily) TOXOIDS ADSORBED 0 mg/5ml PEDIATRIC SUSP cimetidine tabs 200 mg 1 RX/OTC INFANRIX SUSP 0 cimetidine tabs 300 mg, 1 400 mg, 800 mg KINRIX SUSP 0 famotidine in nacl soln 1 PEDIARIX SUSP 0 famotidine soln iv 20 mg/2ml, 200 mg/20ml, 40 1 PENTACEL SUSR 0 mg/4ml QUADRACEL SUSP 0 famotidine susr or 40 1 QL(10 ml daily) mg/5ml TDVAX SUSP 0 famotidine tabs or 20 mg 1 RX/OTC

TENIVAC INJ 0 famotidine tabs or 40 mg 1 TETANUS/DIPHTHERIA nizatidine caps 150 mg, 1 TOXOIDS-ADSORBED 0 300 mg ADULT SUSP nizatidine soln 15 mg/ml 1 QL(20 ml daily) ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions PEPCID AC MAXIMUM RX/OTC STRENGTH TABS (Use NF Antispasmodics famotidine) atropine sulfate soln ij 0.4 1 mg/ml, 1 mg/ml PEPCID AC TABS (Use NF RX/OTC famotidine) atropine sulfate sosy ij 0.25 1 mg/5ml PEPCID TABS 20 MG (Use NF RX/OTC famotidine) chlordiazepoxide hcl- 1 clidinium bromide caps PEPCID TABS 40 MG (Use NF famotidine) dicyclomine hcl caps or 10 1 ranitidine hcl caps or 150 mg 1 mg, 300 mg dicyclomine hcl soln or 10 1 ranitidine hcl soln ij 150 mg/5ml 1 mg/6ml dicyclomine hcl tabs or 20 1 mg ranitidine hcl syrp or 15 QL(40 ml daily) mg/ml, 150 mg/10ml, 75 1 glycopyrrolate soln ij 4 1 mg/5ml mg/20ml ranitidine hcl tabs or 150 1 RX/OTC glycopyrrolate tabs or 1 1 mg mg, 2 mg ranitidine hcl tabs or 300 1 LIBRAX CAPS (Use mg chlordiazepoxide hcl- NF clidinium bromide) TAGAMET HB TABS (Use NF RX/OTC cimetidine)

Ambetter NH Formulary Updated October 1, 2021

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZANTAC 150 MAXIMUM RX/OTC pantoprazole sodium tbec 1 STRENGTH TABS (Use NF or 40 mg ranitidine hcl) PREVACID 24HR CPDR NF QL(2 ea daily); Misc. Anti-Ulcer (Use lansoprazole) RX/OTC PREVACID CPDR 15 MG QL(2 ea daily); CARAFATE SUSP 1 NF QL(40 ml daily) NF GM/10ML (Use sucralfate) (Use lansoprazole) RX/OTC PREVACID CPDR 30 MG CARAFATE TABS 1 GM NF QL(4 ea daily) NF (Use sucralfate) (Use lansoprazole) QL(40 ml daily) PRILOSEC OTC TBEC QL(4 ea daily) sucralfate susp 1 gm/10ml 1 (Use omeprazole 1 magnesium) sucralfate tabs 1 gm 1 QL(4 ea daily) PROTONIX TBEC OR 20 QL(1 ea daily) Proton Pump Inhibitors MG (Use pantoprazole NF sodium) ACIPHEX TBEC (Use NF QL(1 ea daily) rabeprazole sodium) PROTONIX TBEC OR 40 MG (Use pantoprazole NF PA; QL(1 ea DEXILANT CPDR 3 sodium) daily) rabeprazole sodium tbec 1 QL(1 ea daily) esomeprazole magnesium 1 QL(2 ea daily); cpdr 20 mg RX/OTC Ulcer Drugs - Prostaglandins esomeprazole magnesium 3 QL(1 ea daily) cpdr 40 mg CYTOTEC TABS (Use NF QL(4 ea daily) misoprostol) QL(2 ea daily); lansoprazole cpdr 15 mg 1 RX/OTC misoprostol tabs 1 QL(4 ea daily) lansoprazole cpdr 30 mg 1 Ulcer Therapy Combinations NEXIUM 24HR TBEC 1 QL(2 ea daily) omeprazole-sodium QL(1 ea daily); bicarbonate caps 20 mg- 1 RX/OTC NEXIUM CPDR 20 MG QL(2 ea daily); 1100 mg (Use esomeprazole NF RX/OTC ZEGERID CAPS 20 MG- RX/OTC magnesium) 1100 MG (Use NF NEXIUM CPDR 40 MG QL(1 ea daily) omeprazole-sodium (Use esomeprazole NF bicarbonate) magnesium) URINARY ANTISPASMODICS - Drugs to Treat omeprazole cpdr 10 mg, 40 1 QL(2 ea daily) Miscellaneous Bladder Spasms mg Urinary Antispasmodic - Antimuscarinics QL(2 ea daily); omeprazole cpdr 20 mg 1 RX/OTC darifenacin hydrobromide 1 QL(1 ea daily) tb24 omeprazole magnesium 1 QL(4 ea daily) cpdr DETROL LA CP24 (Use NF QL(1 ea daily) tolterodine tartrate) omeprazole magnesium 1 QL(4 ea daily) tbec DETROL TABS (Use NF tolterodine tartrate) omeprazole tbec 20 mg 1 QL(2 ea daily) DITROPAN XL TB24 (Use NF oxybutynin chloride) pantoprazole sodium tbec 1 QL(1 ea daily) or 20 mg ENABLEX TB24 (Use NF QL(1 ea daily) darifenacin hydrobromide)

Ambetter NH Formulary Updated October 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxybutynin chloride syrp 1 MENACTRA INJ 0 oxybutynin chloride tabs 1 MENQUADFI INJ 0 oxybutynin chloride tb24 1 MENVEO SOLR 0 PA; QL(1 ea solifenacin succinate tabs 1 PEDVAX HIB SUSP 0 daily) tolterodine tartrate cp24 2 1 QL(1 ea daily) PNEUMOVAX 23 INJ 0 mg, 4 mg PNEUMOVAX 23/1 DOSE tolterodine tartrate tabs 1 1 0 mg, 2 mg INJ TOVIAZ TB24 3 PA; QL(1 ea PREVNAR 13 SUSP 0 daily) TRUMENBA SUSY 0 trospium chloride cp24 60 1 QL(1 ea daily) mg Viral Vaccines trospium chloride tabs 20 1 mg Limit 1 dose AFLURIA QUADRIVALENT 0 per season;1 rtl VESICARE TABS (Use NF PA; QL(1 ea 2019-2020 SUSP MAX fill,180 rtl solifenacin succinate) daily) day(s) supply, Urinary Antispasmodics - Beta-3 Adrenergic Limit 1 dose AFLURIA QUADRIVALENT per season;1 rtl MYRBETRIQ TB24 25 MG, 3 PA 0 50 MG 2019-2020 SUSY MAX fill,180 rtl day(s) supply, Urinary Antispasmodics - Cholinergic Agonists Limit 1 dose bethanechol chloride tabs QL(4 ea daily) 1 AFLURIA QUADRIVALENT 0 per season;1 rtl 10 mg, 5 mg, 50 mg 2020-2021 SUSP MAX fill,180 rtl bethanechol chloride tabs 1 day(s) supply, 25 mg Limit 1 dose URECHOLINE TABS 10 QL(4 ea daily) AFLURIA QUADRIVALENT 0 per season;1 rtl MG, 5 MG, 50 MG (Use NF 2020-2021 SUSY MAX fill,180 rtl bethanechol chloride) day(s) supply, URECHOLINE TABS 25 Limit 1 dose MG (Use bethanechol NF AFLURIA QUADRIVALENT 0 per season;1 rtl chloride) 2021-2022 SUSP MAX fill,180 rtl Urinary Antispasmodics - Direct Muscle Relaxants day(s) supply, Limit 1 dose flavoxate hcl tabs 1 AFLURIA QUADRIVALENT 0 per season;1 rtl 2021-2022 SUSY MAX fill,180 rtl VACCINES day(s) supply, Bacterial Vaccines 3 rtl MAX fill,365 rtl ACTHIB SOLR 0 ENGERIX-B INJ 0 day(s) supply,3 mail MAX BEXSERO SUSY 0 fill,365 mail day(s) supply, HIBERIX SOLR 0

Ambetter NH Formulary Updated October 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3 rtl MAX Limit 1 dose FLUCELVAX fill,365 rtl 0 per season;1 rtl day(s) supply,3 QUADRIVALENT 2019- MAX fill,180 rtl ENGERIX-B SUSP 0 2020 SUSY mail MAX day(s) supply, fill,365 mail Limit 1 dose day(s) supply, FLUCELVAX QUADRIVALENT 2020- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl per season;1 rtl 2021 SUSP day(s) supply, FLUAD 2019-2020 SUSY 0 MAX fill,180 rtl Limit 1 dose day(s) supply, FLUCELVAX QUADRIVALENT 2020- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl per season;1 rtl 2021 SUSY day(s) supply, FLUAD 2020-2021 SUSY 0 MAX fill,180 rtl Limit 1 dose day(s) supply, FLUCELVAX QUADRIVALENT 2021- 0 per season;1 rtl FLUAD QUADRIVALENT 1 rtl MAX MAX fill,180 rtl 0 fill,180 rtl 2022 SUSP day(s) supply, 2021-2022 PRSY day(s) supply, Limit 1 dose FLUCELVAX FLUAD QUADRIVALENT 1 rtl MAX 0 per season;1 rtl 0 fill,180 rtl QUADRIVALENT 2021- 2022 SUSY MAX fill,180 rtl FOR ADULTS PRSY day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLULAVAL FLUARIX QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2019-2020 SUSY MAX fill,180 rtl QUADRIVALENT 2019- 2020 SUSP MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLULAVAL FLUARIX QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2020-2021 SUSY MAX fill,180 rtl QUADRIVALENT 2019- 2020 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLULAVAL FLUARIX QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2021-2022 SUSY MAX fill,180 rtl QUADRIVALENT 2020- 2021 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK FLULAVAL QUADRIVALENT 2019- 0 per season;1 rtl 0 per season;1 rtl MAX fill,180 rtl QUADRIVALENT 2021- MAX fill,180 rtl 2020 SOSY 2022 SUSY day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK QUADRIVALENT 2020- 0 per season;1 rtl FLUMIST 0 per season;1 rtl MAX fill,180 rtl QUADRIVALENT SUSP MAX fill,180 rtl 2021 SOSY day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK QUADRIVALENT 2021- 0 per season;1 rtl FLUZONE HIGH-DOSE PF 0 per season;1 rtl MAX fill,180 rtl 2019-2020 SUSY MAX fill,180 rtl 2022 SOSY day(s) supply, day(s) supply, FLUCELVAX Limit 1 dose 1 rtl MAX per season;1 rtl FLUZONE HIGH-DOSE PF 0 fill,180 rtl QUADRIVALENT 2019- 0 2020-2021 SUSY 2020 SUSP MAX fill,180 rtl day(s) supply, day(s) supply,

Ambetter NH Formulary Updated October 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl MAX 1 rtl MAX FLUZONE HIGH-DOSE PF 0 0 2021-2022 SUSY fill,180 rtl RECOMBIVAX HB SUSP fill,365 rtl day(s) supply, day(s) supply, Limit 1 dose 1 rtl MAX FLUZONE 0 per season;1 rtl ROTARIX SUSR 0 fill,365 rtl QUADRIVALENT 2019- MAX fill,180 rtl day(s) supply, 2020 SUSP day(s) supply, 1 rtl MAX Limit 1 dose ROTATEQ SOLN 0 fill,365 rtl FLUZONE 0 per season;1 rtl day(s) supply, QUADRIVALENT 2019- MAX fill,180 rtl 2020 SUSY 2 rtl pack lmt day(s) supply, amt,999 rtl Limit 1 dose pack lmt FLUZONE SHINGRIX SUSR 0 QUADRIVALENT 2020- 0 per season;1 rtl day(s),; AL(At MAX fill,180 rtl least 50 yrs 2021 SUSP day(s) supply, old) Limit 1 dose 1 rtl MAX FLUZONE 0 fill,365 rtl QUADRIVALENT 2020- 0 per season;1 rtl TWINRIX SUSY MAX fill,180 rtl day(s) supply, 2021 SUSY day(s) supply, 1 rtl MAX Limit 1 dose VAQTA SUSP 0 fill,365 rtl FLUZONE 0 per season;1 rtl day(s) supply, QUADRIVALENT 2021- MAX fill,180 rtl 2022 SUSP 2 rtl MAX day(s) supply, VARIVAX INJ 0 fill,365 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2021- 0 per season;1 rtl 1 rtl pack lmt 2022 SUSY MAX fill,180 rtl amt,999 rtl day(s) supply, ZOSTAVAX SUSR 0 pack lmt 3 rtl MAX day(s),; AL(At GARDASIL 9 SUSP 0 fill,365 rtl least 50 yrs day(s) supply, old) 3 rtl MAX GARDASIL 9 SUSY 0 fill,365 rtl VAGINAL AND RELATED PRODUCTS day(s) supply, Miscellaneous Vaginal Products 1 rtl MAX PA HAVRIX SUSP 0 fill,365 rtl INTRAROSA INST 3 day(s) supply, Spermicides 1 rtl MAX HEPLISAV-B SOLN 0 fill,365 rtl SHUR-SEAL GEL 0 day(s) supply, 1 rtl MAX TODAY SPONGE MISC 0 HEPLISAV-B SOSY 0 fill,365 rtl day(s) supply, Vaginal Anti-infectives 1 rtl MAX CLEOCIN CREA VA 2 % IPOL INACTIVATED IPV 0 (Use clindamycin NF INJ fill,365 rtl day(s) supply, phosphate vaginal) clindamycin phosphate 1 M-M-R II SOLR 0 vaginal crea

Ambetter NH Formulary Updated October 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clotrimazole vaginal crea 1 QL(2 ea per fill epinephrine (anaphylaxis) 2 retail)2 rtl MAX GYNAZOLE-1 CREA 3 soaj 0.3 mg/0.3ml fill,365 rtl day(s) supply, GYNE-LOTRIMIN CREA NF QL(2 ea per fill (Use clotrimazole vaginal) retail,2 ea per METROGEL-VAGINAL fill mail)2 rtl GEL (Use metronidazole NF epinephrine (anaphylaxis) 2 MAX fill,365 rtl vaginal) soaj 0.3 mg/0.3ml day(s) supply,2 mail MAX metronidazole vaginal gel 1 fill,365 mail day(s) supply, miconazole nitrate vaginal 1 supp EPIPEN 2-PAK SOAJ (Use NF epinephrine (anaphylaxis)) terconazole vaginal crea 1 QL(2 ea per fill retail,2 ea per terconazole vaginal supp 1 EPIPEN-JR 2-PAK SOAJ fill mail)2 rtl MAX fill,365 rtl Vaginal Contraceptive - pH Modulators (Use epinephrine 2 (anaphylaxis)) day(s) supply,2 PHEXXI GEL 0 PV mail MAX fill,365 mail Vaginal Estrogens day(s) supply, ESTRACE CREA (Use NF Vasopressors estradiol vaginal) midodrine hcl tabs 1 estradiol vaginal crea 1 VITAMINS estradiol vaginal tabs 1 Oil Soluble Vitamins FEMRING RING 3 cholecalciferol caps 1.25 1 mg, 50000 unit PREMARIN CREA 2 cholecalciferol tabs 400 0 unit VAGIFEM TABS (Use NF estradiol vaginal) DRISDOL CAPS (Use 0 ergocalciferol) VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions ergocalciferol caps or 1.25 0 mg, 50000 unit Anaphylaxis Therapy Agents ergocalciferol soln or 200 1 ADRENALIN SOLN IJ 30 mcg/ml, 8000 unit/ml MG/30ML (Use NF VITAMIN D2 TABS 0 AL(At least 65 epinephrine (anaphylaxis)) yrs old) QL(2 ea per fill retail,2 ea per Water Soluble Vitamins fill mail)2 rtl niacin cpcr or 500 mg, 250 1 mg epinephrine (anaphylaxis) 1 MAX fill,365 rtl soaj 0.15 mg/0.3ml day(s) supply,2 niacin tabs or 250 mg, 50 1 mail MAX mg, 100 mg, 500 mg fill,365 mail niacin tbcr or 750 mg, 250 1 day(s) supply, mg, 500 mg Ambetter NH Formulary Updated October 1, 2021

132 Drug Requirements/ Drug Name Tier Limits NIACIN TR TBCR 1 niacinamide tabs or 100 1 mg, 500 mg SLO-NIACIN TBCR (Use 1 niacin)

Ambetter NH Formulary Updated October 1, 2021

133 Index 1ST TIER UNILET ACTIGALL 70 ADVOCATE INSULIN COMFORTOUCH LANCETS ACTIMMUNE 40 SYRINGE/U-100/1ML/31GX5/16" 28G 78 90 1ST TIER UNILET ACTIQ 6 ADVOCATE LANCETS 78 COMFORTOUCH LANCETS ACTONEL 66 ADVOCATE LANCETS 30G 78 30G 78 ACTOPLUS MET 23 ADVOCATE LANCING abacavir sulfate 45 ACTOS 24 DEVICE 78 abacavir sulfate-lamivudine 45 ACULAR 120 ADVOCATE RAPID-SAFE abacavir sulfate-lamivudine- LANCING DEVICE 78 zidovudine 45 ACULAR LS 120 ADVOCATE SAFETY ABELCET 27 acyclovir 48 LANCETS 79 ABILIFY 44 acyclovir topical 61 ADVOCATE SAFETY LANCETS ADACEL 126 26G 78 abiraterone acetate 37 ADZENYS ER 1 ADALAT CC 49 ABRAXANE 40 AFINITOR 38 adapalene 56 ABSORICA 56 AFLURIA QUADRIVALENT acamprosate calcium 123 adapalene-benzoyl 2019-2020 129 peroxide 56 acarbose 23 AFLURIA QUADRIVALENT ADCETRIS 36 2020-2021 129 ACCOLATE 14 ADCIRCA 51 AFLURIA QUADRIVALENT ACCU-CHEK FASTCLIX ADDERALL 1 2021-2022 129 LANCETS 78 AGAMATRIX ULTRA-THIN ACCU-CHEK MULTICLIX ADDERALL XR 1 LANCETS 33G 79 LANCETS 78 adefovir dipivoxil 47 AGGRENOX 73 ACCU-CHEK SAFE-T-PRO ADEMPAS 51 LANCETS 78 AGRYLIN 73 ACCU-CHEK SAFE-T-PRO ADIPEX-P 1 AIMOVIG 111 PLUSLANCETS 78 ADJUSTABLE LANCING AIMSCO LUBRICATED 77 DEVICE 78 ACCU-CHEK SOFTCLIX AIMSCO TWIST LANCETS LANCETS 78 ADRENALIN 132 32G 79 ACCUPRIL 30 ADVAIR DISKUS 14 AIMSCO TWIST LANCETS ACCURETIC 32 ADVAIR HFA 14 33G 79 acebutolol hcl 49 ADVANCED MOBILE LANCET AIRDUO RESPICLICK 113/14 14 acetaminophen w/ codeine 8 30G 78 ADVOCATE INSULIN AIRDUO RESPICLICK acetaminophen-caff- 232/14 14 dihydrocod 8 SYRINGE/U- 100/0.3ML/29GX1/2" 90 AIRDUO RESPICLICK 55/1414 acetazolamide 66 ADVOCATE INSULIN AKYNZEO 27 acetazolamide sodium 66 SYRINGE/U- albendazole 10 acetic acid 72 100/0.3ML/30GX5/16" 90 ALBENZA 10 acetic acid (otic) 121 ADVOCATE INSULIN SYRINGE/U- albuterol sulfate 14,15 acetylcysteine 56 100/0.3ML/31GX5/16" 90 ALCAINE 120 ACIPHEX 128 ADVOCATE INSULIN alclometasone dipropionate 61 acitretin 60 SYRINGE/U- ALDACTAZIDE 66 ACTHAR 67 100/0.5ML/29GX1/2" 90 ADVOCATE INSULIN ALDACTONE 66 ACTHIB 129 SYRINGE/U- ALDARA 64 ACTI-LANCE LANCETS 100/0.5ML/30GX5/16" 90 28G 78 ADVOCATE INSULIN ALDURAZYME 68 ACTI-LANCE LITE SAFETY SYRINGE/U- ALECENSA 38 LANCETS 28G 78 100/0.5ML/31GX5/16" 90 alendronate sodium 66 ACTI-LANCE SPECIAL SAFETY ADVOCATE INSULIN alfuzosin hcl 72 LANCETS 17G 78 SYRINGE/U- ACTI-LANCE SPECIAL 100/1ML/29GX1/2" 90 ALIMTA 35 SAFETYLANCETS 17G 78 ADVOCATE INSULIN ALINIA 11 ACTI-LANCE UNIVERSAL SYRINGE/U- aliskiren fumarate 33 SAFETY LANCETS 23G 78 100/1ML/30GX5/16" 90

Index 1 ALKERAN 35 amlodipine besylate-olmesartan ARIMIDEX 37 ALLEGRA ALLERGY 28 medoxomil 32 aripiprazole 44 amlodipine besylate- ALLEGRA ALLERGY valsartan 32 ARIXTRA 16 CHILDRENS 28 amlodipine-valsartan- armodafinil 2 ALLEGRA-D 12 HOUR hydrochlorothiazide 32 ALLERGY & CONGESTION 55 ARMOUR THYROID 126 ALLEGRA-D 24 HOUR amoxapine 23 ARNUITY ELLIPTA 14 ALLERGY & CONGESTION 55 amoxicillin 122 AROMASIN 37 amoxicillin & pot allopurinol 72 ARRANON 35 almotriptan malate 112 clavulanate 122 amphetamine- arsenic trioxide 40 ALOCRIL 120 dextroamphetamine 1 ARTHROTEC 50 4 alogliptin benzoate 24 amphotericin b 27 ARTHROTEC 75 4 ALOMIDE 121 ampicillin 122 ARZERRA 36 alosetron hcl 71 ampicillin & sulbactam ASACOL HD 71 ALOXI 26 sodium 122 ampicillin sodium 122 asenapine maleate 43 ALPHAGAN P 119 aspirin 6 alprazolam 13 AMPYRA 124 ANADROL-50 9 aspirin-dipyridamole 73 ALREX 120 ASSURE HAEMOLANCE PLUS ALTABAX 58 ANAFRANIL 23 HIGH FLOW 18G 79 ALTACE 31 anagrelide hcl 73 ASSURE HAEMOLANCE PLUS ALTERNATE SITE LANCING anastrozole 37 LOW FLOW 25G 79 DEVICE 79 ANCOBON 27 ASSURE HAEMOLANCE PLUS MICRO FLOW 28G 79 ALTOPREV 30 ANDRODERM 10 ASSURE HAEMOLANCE PLUS ALUNBRIG 38 ANDROGEL 10 NORMAL FLOW 21G 79 alvimopan 71 ANNOVERA 54 ASSURE HAEMOLANCE PLUS amantadine hcl 41 PEDIATRIC BLADE 79 ANORO ELLIPTA 15 ASSURE ID INSULIN AMARYL 25 ANTABUSE 123 SAFETYSYRINGE/U- AMBIEN 75 ANUSOL-HC 10 100/0.5ML/29G X 1/2" 90 AMBIEN CR 75 ANZEMET 26 ASSURE ID INSULIN SAFETYSYRINGE/U- AMBISOME 27 APIDRA 24 100/1ML/29G X 1/2" 90 ambrisentan 51 APIDRA SOLOSTAR 24 ASSURE LANCE LANCETS 79 amcinonide 61 APO-VARENICLINE 125 ASSURE LANCE LANCETS AMCINONIDE 61 APOKYN 41 21G 79 AMERGE 112 ASSURE LANCE PLUS apraclonidine hcl 119 SAFETYLANCETS 25G 79 AMICAR 74 aprepitant 27 ASSURE LANCE PLUS amikacin sulfate 3 APRISO 71 SAFETYLANCETS 30G 79 amiloride & APTIOM 17 ASSURE LANCE SAFETY hydrochlorothiazide 66 LANCET 28G 79 APTIVUS 45 amiloride hcl 66 ASSURE LANCETS 79 AQUA LANCE ADJUSTABLE aminocaproic acid 74 LANCING DEVICE 79 ATACAND 31 aminophylline 15 ARALAST NP 125 ATACAND HCT 32 amiodarone hcl 13 ARANESP ALBUMIN atazanavir sulfate 45 AMITIZA 70 FREE 73 ATELVIA 66 amitriptyline hcl 23 ARAVA 5 atenolol 49 amlodipine besylate 49 ARCALYST 4 atenolol & chlorthalidone 32 amlodipine besylate-atorvastatin ARCAPTA NEOHALER 15 ATGAM 115 calcium 51 arformoterol tartrate 15 ATIVAN 13 amlodipine besylate-benazepril ARICEPT 123 hcl 32 atomoxetine hcl 2 ARIKAYCE 3

Index 2 atorvastatin calcium 30 B-D INSULIN SYRINGE BD INSULIN SYRINGE SLIP atovaquone 11 ULTRAFINE II/0.5ML/31G X TIP/U-100/1ML 91 5/16" 90 BD INSULIN SYRINGE ULTRA- atovaquone-proguanil hcl 33 B-D INSULIN SYRINGE FINE/0.3ML/30G X 12.7MM 91 ATRIPLA 45 ULTRAFINE II/1ML/31G X BD INSULIN SYRINGE ULTRA- atropine sulfate 127 5/16" 90 FINE/0.3ML/31G X 8MM 91 B-D INSULIN SYRINGE BD INSULIN SYRINGE ULTRA- ATROVENT HFA 14 ULTRAFINE/0.3ML/30G X FINE/0.5ML/30G X 12.7MM 91 AUBAGIO 124 1/2" 90 BD INSULIN SYRINGE ULTRA- AUGMENTIN 122 B-D INSULIN SYRINGE FINE/0.5ML/31G X 8MM 91 AUGMENTIN ES-600 122 ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE ULTRA- FINE/1/2 UNIT/0.3ML/31G X AURORA LANCET SUPER 1/2" 90 bacitracin 10 8MM 91 THIN30G 79 BD INSULIN SYRINGE ULTRA- AURORA LANCET THIN bacitracin (ophthalmic) 119 FINE/1ML/30G X 12.7MM 91 23G 79 baclofen 117 BD INSULIN SYRINGE ULTRA- AUSTEDO 124 BACTRIM 11 FINE/1ML/31G X 8MM 91 AUTO-LANCET 79 BACTRIM DS 11 BD INSULIN SYRINGE ULTRAFINE HALF- AUTO-LANCET MINI 79 BALCOLTRA 52 AUTOLET IMPRESSION UNIT/0.3ML/31G X 5/16" 91 LANCING DEVICE 79 balsalazide disodium 71 BD INSULIN SYRINGE AUTOLET LANCING BALVERSA 38 ULTRAFINE/0.3ML/30G X DEVICE 79 1/2" 91 BANZEL 17 BD INSULIN SYRINGE AUTOLET MINI 79 BAQSIMI ONE PACK 24 ULTRAFINE/0.3ML/31G X AUTOLET PLUS 79 BAQSIMI TWO PACK 24 5/16" 91 AVALIDE 32 BARACLUDE 47 BD INSULIN SYRINGE AVANDIA 24 ULTRAFINE/0.5ML/30G X BASAGLAR KWIKPEN 24 1/2" 91 AVAPRO 31 BAXDELA 70 BD INSULIN SYRINGE AVELOX 70 BD LO-DOSE INSULIN ULTRAFINE/0.5ML/31G X AVODART 72 SYRINGE MICROFINE 5/16" 91 AVONEX 124 IV/0.5ML/28G X 1/2" 90 BD INSULIN SYRINGE BD AUTOSHIELD 29G X ULTRAFINE/1ML/30G X AVONEX PEN 124 3/16" 90 1/2" 91 AYGESTIN 123 BD AUTOSHIELD 29G X BD INSULIN SYRINGE AYVAKIT 38 5/16" 90 ULTRAFINE/U-100/0.3ML/29G X BD AUTOSHIELD DUO 30G X 1/2" 91 azacitidine 35 5MM 90 BD INSULIN SYRINGE AZASAN 115 BD INSULIN SYRINGE LUER- ULTRAFINE/U-100/0.5ML/29G X AZASITE 119 LOK/U-100/1ML 90 1/2" 91 AZATHIOPRINE 115 BD INSULIN SYRINGE BD INSULIN SYRINGE MICROFINE IV/U- ULTRAFINE/U-100/1ML/29G X azathioprine 115 100/0.5ML/28G X 1/2" 90 1/2" 91 azelaic acid 64 BD INSULIN SYRINGE BD INSULIN SYRINGE azelastine hcl 118 MICROFINE IV/U- ULTRAFINE/U-100/1ML/31G X 100/1ML/27G X 5/8" 90 5/16" 91 azelastine hcl (ophth) 121 BD INSULIN SYRINGE BD INSULIN AZELEX 56 MICROFINE IV/U- SYRINGE/0.3ML/29G X AZILECT 42 100/1ML/28G X 1/2" 90 12.7MM 91 azithromycin 76 BD INSULIN SYRINGE BD INSULIN MICROFINE/U-100/1ML/27G X SYRINGE/0.5ML/29G X AZOR 32 5/8" 90 12.7MM 91 AZULFIDINE 71 BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/27G AZULFIDINE EN-TABS 71 MICROFINE/U-100/1ML/28G X X 12.7MM 91 B-D INSULIN SYRINGE 1/2" 90 BD INSULIN SYRINGE/1ML/29G ULTRAFINE II/0.3ML/31G X BD INSULIN SYRINGE X 12.7MM 91 5/16" 90 SAFETYGLIDE/1ML/29G X 1/2" 90

Index 3 BD INSULIN BELSOMRA 75 BORTEZOMIB 38 SYRINGE/DETACHABLE BELVIQ 2 bosentan 51 NEEDLE/U-100/1ML/25G X benazepril & 1" 91 BOSULIF 38 BD INSULIN hydrochlorothiazide 32 BOTOX 118 benazepril hcl 31 SYRINGE/DETACHABLE BRAFTOVI 38 BENICAR 31 NEEDLE/U-100/1ML/25G X BREO ELLIPTA 15 5/8" 91 BENICAR HCT 32 BRILINTA 73 BD INSULIN BENZACLIN 56 SYRINGE/DETACHABLE brimonidine tartrate 119 BENZACLIN WITH PUMP 56 NEEDLE/U-100/1ML/26G X BRIVIACT 17 1/2" 91 BENZAMYCIN 56 bromfenac sodium (ophth) 121 BD INSULIN SYRINGE/U- benzonatate 55 100/1ML/27G X 1/2" 91 bromocriptine mesylate 41 benzoyl peroxide 56 BD LANCET ULTRAFINE BROVANA 15 BENZOYL PEROXIDE 30G 79 BRUKINSA 38 BD LANCET ULTRAFINE CLEANSER 56 33G 79 benzoyl peroxide- budesonide 54 BD MICROTAINER erythromycin 56 budesonide (inhalation) 14 LANCETS 79 benztropine mesylate 41 budesonide (nasal) 118 BD PEN bepotastine besilate 121 budesonide-formoterol fumarate NEEDLE/MICRO/ULTRA- BEPREVE 121 dihydrate 15 FINE/32G X 6MM 91 BULLSEYE MINI SAFETY BD PEN NEEDLE/MINI/ULTRA- betamethasone dipropionate (topical) 61 LANCETS 79 FINE/31G X 5MM 91 betamethasone dipropionate BULLSEYE SAFETY BD PEN NEEDLE/NANO 2ND LANCETS 79 GEN/32G X 5/32" 91 augmented 61 BD PEN betamethasone valerate 61 bumetanide 66 NEEDLE/NANO/ULTRA- BETAPACE 49 BUMEX 66 FINE/32G X 4MM 92 BETAPACE AF 49 BUNAVAIL 9 BD PEN BUPHENYL 68 NEEDLE/ORIGINAL/ULTRA- BETASERON 124 FINE/29G X 12.7MM 92 betaxolol hcl 49 BUPRENEX 9 BD PEN betaxolol hcl (ophth) 119 buprenorphine 9 NEEDLE/SHORT/ULTRA- bethanechol chloride 129 buprenorphine hcl 9 FINE/31G X 8MM 92 BEVESPI AEROSPHERE 15 buprenorphine hcl-naloxone hcl BD SAFETY-GLIDE INSULIN dihydrate 9 SYRINGE/0.5ML/29G X 1/2" 92 BEVYXXA 16 BD SAFETY-LOK INSULIN bupropion hcl 20,21 bexarotene 40 bupropion hcl (smoking SYRINGE/PERM BEXSERO 129 NEEDLE/UF/1ML/29G X deterrent) 125 1/2" 92 BEYAZ 52 buspirone hcl 12 BD SAFETYGLIDE INSULIN bicalutamide 37 busulfan 35 SYRINGE/0.3ML/29G X 1/2" 92 BICNU 35 BUSULFEX 35 BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G X BIDIL 51 butalbital-acetaminophen 5 5/16" 92 BIKTARVY 45 butalbital-acetaminophen- BD SAFETYGLIDE INSULIN BILTRICIDE 10 caffeine 5 butalbital-acetaminophen- SYRINGE/1ML/31G X bimatoprost 121 15/64" 92 caffeine w/ codeine 8 BD SAFETYGLIDE INSULIN bisacodyl 76 butalbital-aspirin-caffeine 5 SYSYRINGE/0.5ML/30G X bisoprolol & butalbital-aspirin-caffeine 5/16" 92 hydrochlorothiazide 32 w/cod 8 BD VEO INSULIN SYRINGE bisoprolol fumarate 49 BUTALBITAL/ACETAMINOPHEN ULTRA-FINE/1ML/31G X bleomycin sulfate 38 5 6MM 92 BLEPH-10 119 butenafine hcl 58 BD VEO INSULIN SYRINGE butorphanol tartrate 9 ULTRA-FINE/U-100/1ML/31G X BONIVA 67 15/64" 92 BOOSTRIX 127 BUTRANS 9

Index 4 BYSTOLIC 49 CAREONE INSULIN CATAPRES 31 cabergoline 69 SYRINGES/0.3ML/30G X CATAPRES-TTS-1 31 1/2" 92 CABLIVI 73 CAREONE INSULIN CATAPRES-TTS-2 31 CADUET 51 SYRINGES/0.3ML/31G X CATAPRES-TTS-3 31 CAFERGOT 112 5/16" 92 CAYA 77 CAREONE INSULIN CALAN 50 SYRINGES/0.5ML/30G X CAYSTON 12 CALAN SR 50 1/2" 92 cefaclor 52 calcipotriene 60 CAREONE INSULIN cefadroxil 52 calcipotriene-betamethasone SYRINGES/0.5ML/31G X cefazolin sodium 52 5/16" 92 dipropionate 61 cefdinir 52 calcitonin (salmon) 67 CAREONE INSULIN SYRINGES/1ML/30G X cefditoren pivoxil 52 calcitriol 68 1/2" 92 cefepime hcl 52 calcitriol (topical) 60 CAREONE INSULIN cefixime 52 calcium acetate (phosphate SYRINGES/1ML/31GX5/16" binder) 71 92 CEFOTAN 52 calcium chloride (dihydrate)113 CAREONE LANCET SUPER cefotaxime sodium 52 CALCIUM GLUCONATE 113 THIN/30G 79 cefotetan disodium 52 CAREONE LANCET THIN 79 calcium gluconate 113 cefoxitin sodium 52 CARESENS LANCETS 79 calcium polycarbophil 75 cefpodoxime proxetil 52 CARETOUCH INSULIN CAMPTOSAR 41 SYRINGE/0.3ML/31GX5/16" cefprozil 52 CANASA 71 92 ceftazidime 52 CANCIDAS 27 CARETOUCH INSULIN ceftriaxone sodium 52 SYRINGE/0.5ML/31GX5/16" cefuroxime axetil 52 candesartan cilexetil 31 92 candesartan cilexetil- CARETOUCH INSULIN cefuroxime sodium 52 hydrochlorothiazide 32 SYRINGE/1ML/30GX5/16" CELEBREX 4 CAPASTAT SULFATE 34 92 celecoxib 4 CARETOUCH INSULIN capecitabine 35 CELESTONE SOLUSPAN 54 CAPRELSA 38 SYRINGE/1ML/31GX5/16" 92 CELESTONE-SOLUSPAN 54 captopril 31 CARETOUCH INSULIN CELEXA 21 CARAC 59 SYRINGE0.5ML/30GX5/16" CELLCEPT 115 92 CARAFATE 128 CELONTIN 20 CARBAGLU 68 CARETOUCH LANCING DEVICEWITH EJECTOR 79 cephalexin 52 carbamazepine 17,18 CARETOUCH SAFETY CERDELGA 73 CARBATROL 18 LANCETS/26G 79 CEREBYX 20 carbidopa 41 CARETOUCH SAFETY LANCETS/28G 79 CEREZYME 73 carbidopa-levodopa 41 CARETOUCH SAFETY cetirizine hcl 28 carbidopa-levodopa-entacapone LANCETS/30G 79 cetirizine-pseudoephedrine 56 41 CARETOUCH TWIST carbinoxamine maleate 28 LANCETS 28G 79 CETRAXAL 121 carboplatin 35 CARETOUCH TWIST CETROTIDE 67 CARDIOCOM LANCING LANCETS 30G 79 cevimeline hcl 116 CARETOUCH TWIST DEVICE 79 CHANTIX 125 CARDIZEM 50 LANCETS 33G 80 carisoprodol 117 CHANTIX CONTINUING CARDIZEM CD 50 MONTHPAK 125 carmustine 35 CARDIZEM LA 50 CHANTIX STARTING MONTH carteolol hcl (ophth) 119 PAK 125 CARDURA 31 CHEMET 26 CAREONE ADVANCED carvedilol 49 LANCINGDEVICE 79 CASODEX 37 CHEMSTRIP-K 65 caspofungin acetate 27 CHILDRENS ADVIL 4

Index 5 CHILDRENS MOTRIN 4 CLARITIN CHILDRENS 28 CLEVER CHOICE COMFORT chloramphenicol sodium CLARITIN REDITABS 28 EZINSULIN SYRINGE/1ML/28G X 1/2" 93 succinate 11 CLARITIN-D 12 HOUR 56 chlordiazepoxide hcl 13 CLEVER CHOICE COMFORT CLARITIN-D 24 HOUR 56 EZINSULIN SYRINGE/1ML/29G chlordiazepoxide hcl-clidinium X 1/2" 93 bromide 127 CLASSIC PRENATAL 116 chlorhexidine gluconate (mouth- CLEANLET LANCETS CLEVER CHOICE COMFORT throat) 116 28G 80 EZINSULIN SYRINGE/1ML/30G X 5/16" 93 chloroquine phosphate 34 CLEMASTINE FUMARATE 28 CLEVER CHOICE COMFORT chlorpromazine hcl 44 clemastine fumarate 28 EZINSULIN SYRINGE/U- chlorthalidone 66 100/1ML/31GX5/16" 93 CLENPIQ 75 chlorzoxazone 117 CLIMARA 69 CLEOCIN 11,131 CLIMARA PRO 69 CHOLBAM 70 CLEOCIN PEDIATRIC cholecalciferol 132 GRANULES 11 CLINDAGEL 57 cholestyramine 29 CLEOCIN PHOSPHATE 11 clindamycin hcl 11 cholestyramine light 29 CLEOCIN-T 56 clindamycin palmitate hydrochloride 11 CHORIONIC CLEVER CHOICE COMFORT GONADOTROPIN 67 EZINSULIN clindamycin phosphate 11 CIALIS 51 SYRINGE/0.3ML/29G X clindamycin phosphate (topical) 57 CICLODAN SOLUTION KIT 58 1/2" 92 CLEVER CHOICE COMFORT clindamycin phosphate ciclopirox 58 EZINSULIN vaginal 131 ciclopirox olamine 58 SYRINGE/0.3ML/30G X clindamycin phosphate-benzoyl 1/2" 92 peroxide 57 cidofovir 47 clindamycin phosphate-benzoyl cilostazol 73 CLEVER CHOICE COMFORT EZINSULIN peroxide (refrigerate) 57 CILOXAN 119 SYRINGE/0.3ML/30G X clindamycin phosphate- tretinoin 57 CIMDUO 45 5/16" 92 CLINIMIX 4.25%/DEXTROSE CLEVER CHOICE COMFORT cimetidine 127 10% 118 EZINSULIN CLINIMIX 4.25%/DEXTROSE cimetidine hcl 127 SYRINGE/0.3ML/31G X cinacalcet hcl 68 25% 118 5/16" 92 CLINIMIX 4.25%/DEXTROSE CINRYZE 73 CLEVER CHOICE COMFORT 5% 118 CIPRO 70 EZINSULIN CLINIMIX 5%/DEXTROSE SYRINGE/0.5ML/28G X CIPRO HC 121 25% 118 1/2" 92 CLINIMIX E 5%/DEXTROSE CIPRODEX 121 CLEVER CHOICE COMFORT 20% 118 ciprofloxacin 70 EZINSULIN clobazam 17 ciprofloxacin hcl 70 SYRINGE/0.5ML/29G X 1/2" 93 clobetasol propionate 61 ciprofloxacin hcl (ophth) 119 CLEVER CHOICE COMFORT clobetasol propionate emollient ciprofloxacin hcl (otic) 121 EZINSULIN base 62 ciprofloxacin in d5w 70 SYRINGE/0.5ML/30G X clocortolone pivalate 62 ciprofloxacin-dexamethasone 1/2" 93 CLODERM 62 121 CLEVER CHOICE COMFORT EZINSULIN clofarabine 35 ciprofloxacin-fluocinolone CLOLAR 36 acetonide 121 SYRINGE/0.5ML/30G X cisplatin 35 5/16" 93 clomipramine hcl 23 CLEVER CHOICE COMFORT clonazepam 17 citalopram hydrobromide 21 EZINSULIN CLARINEX 28 SYRINGE/0.5ML/31G X clonidine 31 clarithromycin 76 5/16" 93 clonidine hcl 31 CLEVER CHOICE COMFORT CLARITIN 28 clonidine hcl (adhd) 2 EZINSULIN clopidogrel bisulfate 73 CLARITIN ALLERGY SYRINGE/1.0ML/30G X CHILDRENS 28 1/2" 93 clorazepate dipotassium 13

Index 6 clotrimazole 116 COMFORT ASSURED CVS LANCETS ORIGINAL 80 clotrimazole (topical) 58 LANCETS SUPER THIN CVS LANCETS THIN 26G 80 28G 80 clotrimazole vaginal 132 COMFORT EZ INSULIN CVS LANCETS ULTRA THIN clotrimazole w/ 30G 80 SYRINGE/U-100/0.5ML/31G X CVS LANCETS ULTRA-THIN betamethasone 58 5/16" 93 clozapine 43 COMFORT EZ INSULIN 30G 80 CVS LANCING DEVICE 80 CLOZARIL 43 SYRINGE/U-100/1ML/31G X CVS PRENATAL 116 COAGUCHEK LANCETS 80 5/16" 93 COMFORT LANCETS 80 CVS ULTRA THIN COARTEM 33 COMPLERA 45 LANCETS 80 CODEINE SULFATE 6 cyanocobalamin 73 COMTAN 41 codeine sulfate 6 cyclobenzaprine hcl 117 CONCERTA 2 COGENTIN 41 cyclophosphamide 35 CONTRAVE 2 COLACE 76 cycloserine 34 CONZIP 6 COLAZAL 71 CYCLOSET 24 COPAXONE 124 colchicine 72 cyclosporine 115 COPIKTRA 38 colchicine w/ probenecid 72 cyclosporine modified (for CORDRAN 62 COLCRYS 72 microemulsion) 115 COREG 49 colesevelam hcl 29 CYKLOKAPRON 74 CORGARD 49 COLESTID 29 CYMBALTA 22 CORLANOR 51 COLESTID FLAVORED 29 cyproheptadine hcl 29 CORTEF 54 colestipol hcl 30 CYSTADANE 68 CORTENEMA 10 COLY-MYCIN S 121 CYSTAGON 72 cortisone acetate 54 COLYTE-FLAVOR PACKS 75 CYSTARAN 121 CORTISPORIN-TC 121 COMBIGAN 119 cytarabine 36 COSENTYX 60 COMBIVIR 45 CYTOMEL 126 COSENTYX SENSOREADY CYTOTEC 128 COMETRIQ 38 PEN 60 CYTOVENE 47 COMFORT ASSIST INSULIN COSMEGEN 38 D.H.E. 45 112 SYRINGE 0.3ML/29G X 1/2" 93 COSOPT 119 COMFORT ASSIST INSULIN dacarbazine 40 SYRINGE/0.3ML/30G X COUMADIN 16 DACOGEN 36 5/16" 93 COZAAR 31 dactinomycin 38 COMFORT ASSIST INSULIN CREON 65 SYRINGE/0.3ML/31G X dalfampridine 124 CRESEMBA 27 5/16" 93 DALIRESP 14 COMFORT ASSIST INSULIN CRESTOR 30 danazol 10 SYRINGE/0.5ML/29G X 1/2" 93 CRIXIVAN 45 DANTRIUM 118 COMFORT ASSIST INSULIN cromolyn sodium 13 SYRINGE/0.5ML/30G X dantrolene sodium 118 cromolyn sodium (ophth) 121 5/16" 93 dapsone 11 COMFORT ASSIST INSULIN crotamiton 65 DAPTACEL 127 SYRINGE/0.5ML/31G X CUBICIN 11 5/16" 93 DAPTOMYCIN 11 CUBICIN RF 11 COMFORT ASSIST INSULIN daptomycin 11 SYRINGE/1ML/29G X 1/2" 93 CUPRIMINE 114 DARAPRIM 34 COMFORT ASSIST INSULIN CUTIVATE 62 darifenacin hydrobromide 128 SYRINGE/1ML/30G X 5/16" 93 CUVITRU 122 COMFORT ASSIST INSULIN DAUNORUBICIN SYRINGE/1ML/31G X 5/16" 93 CVS LANCETS 21G 80 HYDROCHLORIDE 38 COMFORT ASSURED CVS LANCETS MICRO THIN DAURISMO 37 33G 80 LANCETS MICRO THIN DAYPRO 4 33G 80 CVS LANCETS MICRO-THIN 33G 80 DAYTRANA 2

Index 7 DDAVP 69 DETROL LA 128 digoxin 50 DEBACTEROL 116 dexamethasone 54,55 dihydroergotamine decitabine 36 DEXAMETHASONE mesylate 112 DILANTIN 20 deferasirox 26 INTENSOL 54 dexamethasone sodium DILANTIN INFATABS 20 deferiprone 26 phosphate 54 DILANTIN-125 20 DELESTROGEN 69 dexamethasone sodium DILAUDID 6 DELSTRIGO 45 phosphate (ophth) 120 dexchlorpheniramine diltiazem hcl 50 DELZICOL 71 maleate 28 DILTIAZEM HCL 50 demeclocycline hcl 126 DEXEDRINE 1 diltiazem hcl 50 DEMEROL 6 DEXILANT 128 diltiazem hcl coated beads 50 DENAVIR 61 dexmethylphenidate hcl 2 diltiazem hcl extended release DEPACON 20 dextroamphetamine sulfate 1 beads 50 DEPAKENE 20 DEXTROSE 5%/NACL dimethyl fumarate 124 DEPAKOTE 20 0.3% 113 DIOVAN 31 DEPAKOTE ER 20 dextrose in lactated ringers 113 DIOVAN HCT 32 DEPEN TITRATABS 115 DEXTROSE/SODIUM DIPENTUM 71 DEPO-ESTRADIOL 69 CHLORIDE 113 diphenhydramine hcl 28 DEPO-MEDROL 54 DIACOMIT 18 diphenoxylate w/ atropine 25 DEPO-PROVERA DIASTAT ACUDIAL 17 DIPHTHERIA/TETANUS CONTRACEPTIVE 54 DIASTAT PEDIATRIC 17 TOXOIDS ADSORBED DEPO-SUBQ PROVERA DIATHRIVE LANCETS 80 PEDIATRIC 127 104 54 DIPROLENE 62 DEPO-TESTOSTERONE 10 DIATHRIVE LANCETS ULTRA THIN 30G 80 DIPROLENE AF 62 DERMA-SMOOTHE/FS DIATHRIVE LANCING dipyridamole 73 BODY 62 DEVICE 80 DERMA-SMOOTHE/FS disopyramide phosphate 13 diazepam 13 SCALP 62 disulfiram 123 diazepam (anticonvulsant) 17 DERMOTIC 122 DITROPAN XL 128 diazoxide 24 DESCOVY 45 divalproex sodium 20 DIBENZYLINE 31 desipramine hcl 23 DIVIGEL 70 DICLEGIS 27 desloratadine 28 docetaxel 40 diclofenac epolamine 58 desmopressin acetate 69 DOCETAXEL 40 diclofenac potassium 4 DESMOPRESSIN docetaxel 40 ACETATE 69 diclofenac sodium 4 desmopressin acetate 69 diclofenac sodium (actinic docusate calcium 76 desmopressin acetate spray 69 keratoses) 59 docusate sodium 76 desmopressin acetate spray diclofenac sodium (ophth)121 dofetilide 13 refrigerated 69 diclofenac sodium (topical) 58 donepezil hydrochloride 123 desogestrel & ethinyl diclofenac w/ misoprostol 4 DOPTELET 73 estradiol 52 desogestrel-ethinyl estradiol dicloxacillin sodium 123 DORAL 75 (biphasic) 53 dicyclomine hcl 127 dorzolamide hcl 121 desogestrel-ethinyl estradiol didanosine 45 dorzolamide hcl-timolol (triphasic) 53 DIFFERIN 57 maleate 119 desonide 62 DOVATO 45 DIFICID 77 DESOWEN 62 DOVONEX 60 diflorasone diacetate 62 desoximetasone 62 doxazosin mesylate 31 DIFLUCAN 27 DESOXYN 1 doxepin hcl 23 diflunisal 6 desvenlafaxine succinate 22 doxepin hcl (antipruritic) 60 difluprednate 120 DETROL 128 doxepin hcl (sleep) 74

Index 8 doxercalciferol 68 DROPLET LANCING EASY COMFORT INSULIN DOXIL 38 DEVICE 80 SYRINGE/1ML/30G X 5/16" 94 DROPLET PERSONAL EASY COMFORT INSULIN doxorubicin hcl 38 LANCETS30G 80 SYRINGE/1ML/31G X 5/16" 94 doxorubicin hcl liposomal 38 drospirenone-ethinyl EASY COMFORT INSULIN doxycycline (monohydrate) 126 estradiol 53 SYRINGE/U-100/0.5ML/30G X drospirenone-ethinyl estradiol- 1/2" 94 doxycycline hyclate 126 levomefolate calcium 53 EASY COMFORT INSULIN doxylamine-pyridoxine 27 DROXIA 73 SYRINGE/U-100/1ML/30G X DRISDOL 132 DRUG MART ADJUSTABLE 1/2" 94 dronabinol 27 LANCING DEVICE 80 EASY MINI EJECT LANCING DRUG MART LANCETS DEVICE 80 DROPLET GENTEEL LANCING EASY MINI LANCING DEVICE 80 THIN 80 DRUG MART ON-THE-GO DEVICE 80 DROPLET INSULIN SYRINGE EASY TOUCH FLIPLOCK 0.3ML/29G X 1/2" 93 LANCETS GENTLE 30G 80 DRUG MART UNILET SAFETY INSULIN SYRINGE DROPLET INSULIN SYRINGE 1ML/29GX1/2" 94 0.5ML/29G X 1/2" 93 LANCETSSUPER THIN 30G 80 EASY TOUCH FLIPLOCK DROPLET INSULIN SYRINGE SAFETY INSULIN SYRINGE 1ML/29G X 1/2" 93 DRUG MART UNILET LANCETSULTRA THIN 1ML/30GX1/2" 94 DROPLET INSULIN SYRINGE EASY TOUCH FLIPLOCK U-100/0.3/31G X 5/16" 93 28G 80 DROPLET INSULIN SYRINGE DRUG MART UNILET MICRO SAFETY INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 93 THIN LANCETS 33G 80 1ML/30GX5/16" 94 DROPLET INSULIN SYRINGE DUAC 57 EASY TOUCH FLIPLOCK U-100/0.3ML/30G X 5/16" 94 SAFETY INSULIN SYRINGE DUAVEE 69 1ML/31GX5/16" 94 DROPLET INSULIN SYRINGE DUETACT 23 U-100/0.5ML/30G X 1/2" 94 EASY TOUCH INSULIN DROPLET INSULIN SYRINGE DULCOLAX 76 SYRINGE/0.3ML/30G X U-100/0.5ML/30G X 5/16" 94 duloxetine hcl 22 5/16" 94 EASY TOUCH INSULIN DROPLET INSULIN SYRINGE DUPIXENT 63 U-100/0.5ML/31G X 5/16" 94 SYRINGE/0.3ML/31G X DROPLET INSULIN SYRINGE DURAGESIC 6 5/16" 94 U-100/1ML/30G X 1/2" 94 DUREX EXTRA EASY TOUCH INSULIN DROPLET INSULIN SYRINGE SENSITIVE 77 SYRINGE/0.5ML/29G X 1/2" 94 U-100/1ML/30G X 5/16" 94 DUREZOL 120 EASY TOUCH INSULIN SYRINGE/0.5ML/30G X DROPLET INSULIN SYRINGE dutasteride 72 U-100/1ML/31G X 15/64" 94 5/16" 95 DROPLET INSULIN SYRINGE DYAZIDE 66 EASY TOUCH INSULIN U-100/1ML/31G X 5/16" 94 DYRENIUM 66 SYRINGE/1ML/30G X 5/16" 95 DROPLET INSULIN DYSPORT 118 EASY TOUCH INSULIN SYRINGE/SAFETY/U- SYRINGE/U-100/0.3ML/31G X E-Z JECT LANCETS 80 5/16" 94 100/0.5ML/29G X 1/2" 95 DROPLET INSULIN E-Z JECT LANCETS 21G 80 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X E-Z JECT LANCETS SYRINGE/SAFETY/U- 1/2" 94 COLOR 80 100/0.5ML/30G X 5/16" 95 DROPLET INSULIN E-Z JECT LANCETS SUPER EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X THIN 30G 80 SYRINGE/SAFETY/U- 5/16" 94 E-Z JECT LANCETS THIN 100/1ML/29G X 1/2" 95 DROPLET INSULIN 26G 80 EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X E-ZJECT LANCETS MICRO- SYRINGE/SAFETY/U- 1/2" 94 THIN 33G 80 100/1ML/30G X 1/2" 95 DROPLET INSULIN E.E.S. GRANULES 76 EASY TOUCH INSULIN SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 15/64" 94 SYRINGE/0.5ML/30G X 1/2" 95 DROPLET INSULIN 5/16" 94 EASY TOUCH INSULIN SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/27G X 5/16" 94 SYRINGE/0.5ML/31G X 1/2" 95 DROPLET LANCETS ULTRA 5/16" 94 THIN 30G 80

Index 9 EASY TOUCH INSULIN EASY TOUCH LANCETS ELELYSO 73 SYRINGE/U-100/0.5ML/28G X 32G/TWIST 81 ELESTRIN 70 1/2" 95 EASY TOUCH LANCETS EASY TOUCH INSULIN 33G/TWIST 81 eletriptan hydrobromide 112 SYRINGE/U-100/0.5ML/29G X EASY TOUCH LANCING ELIDEL 64 1/2" 95 DEVICE/EJECTOR 81 ELIGARD 37 EASY TOUCH INSULIN EASY TOUCH SAFETY SYRINGE/U-100/0.5ML/30G X LANCETS21G/PRESSURE ELIMITE 65 1/2" 95 ACTIVATED 81 ELIQUIS 16 EASY TOUCH INSULIN EASY TOUCH SAFETY ELIQUIS STARTER PACK 16 SYRINGE/U-100/0.5ML/31G X LANCETS23G/PRESSURE ELITE-THIN INSULIN 5/16" 95 ACTIVATED 81 SYRINGE/0.3ML/31G X EASY TOUCH INSULIN EASY TOUCH SAFETY 5/16" 95 SYRINGE/U-100/1ML/27G X LANCETS26G/BUTTON ELITE-THIN INSULIN 1/2" 95 ACTIVATED 81 SYRINGE/0.5ML/29G X 1/2" 95 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X LANCETS26G/PRESSURE SYRINGE/0.5ML/30G X 1/2" 95 ACTIVATED 81 5/16" 95 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X LANCETS28G/BUTTON SYRINGE/1ML/30G X 5/16" 95 1/2" 95 ACTIVATED 81 ELITE-THIN INSULIN EASY TOUCH INSULIN EASY TOUCH SAFETY SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/1ML/30G X LANCETS28G/PRESSURE 1/2" 95 1/2" 95 ACTIVATED 81 ELITE-THIN INSULIN EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/31G X SAFETY INSULIN SYRINGE 5/16" 95 5/16" 95 1ML/29GX1/2" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/28G X 21G/PRESSURE SAFETY INSULIN SYRINGE 1/2" 96 ACTIVATED 80 1ML/30GX5/16" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/29G X 23G/PRESSURE SAFETY INSULIN SYRINGE 1/2" 96 ACTIVATED 80 1ML/31GX5/16" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/31G X 26G/PRESSURE SAFETY SYRINGE 5/16" 96 ACTIVATED 80 1ML/30GX1/2" 95 ELIXOPHYLLIN 15 EASY TOUCH LANCETS EASY TWIST & CAP 26G/PULL-TOP 80 LANCETS 81 ELLA 54 EASY TOUCH LANCETS EC-NAPROSYN 4 ELLENCE 38 28G/PRESSURE econazole nitrate 58 ELMIRON 72 ACTIVATED 80 ELOCON 62 EASY TOUCH LANCETS EDARBI 31 28G/PULL-TOP 81 EDECRIN 66 EMBEDA 6 EASY TOUCH LANCETS EDURANT 45 EMBRACE LANCETS ULTRA 28G/TWIST 81 THIN 30G 81 EASY TOUCH LANCETS efavirenz 45 EMBRACE LANCING DEVICE 30G/BUTTON-ACTIVATED 81 efavirenz-emtricitabine- WITH EJECTOR 81 EASY TOUCH LANCETS tenofovir disoproxil EMCYT 37 fumarate 45 30G/PRESSURE EMEND 27 ACTIVATED 81 efavirenz-lamivudine-tenofovir EASY TOUCH LANCETS disoproxil fumarate 45 EMEND TRIPACK 27 30G/PULL-TOP 81 EFFEXOR XR 22 EMFLAZA 55 EASY TOUCH LANCETS EFFIENT 73 EMGALITY 111,112 30G/TWIST 81 EFUDEX 59 EMSAM 21 EASY TOUCH LANCETS 32G/PRESSURE EGRIFTA 67 emtricitabine 45 ACTIVATED 81 EGRIFTA SV 67 emtricitabine-tenofovir disoproxil EASY TOUCH LANCETS ELAPRASE 68 fumarate 45 32G/PULL-TOP 81 EMTRIVA 45

Index 10 EMVERM 10 EQL INSULIN etonogestrel-ethinyl estradiol54 ENABLEX 128 SYRINGE/1ML/30G X ETOPOPHOS 41 5/16" 96 enalapril maleate 31 EQL INSULIN etoposide 41 enalapril maleate & SYRINGE/1ML/31G X etravirine 45 hydrochlorothiazide 32 5/16" 96 EUCRISA 64 ENBREL 5 EQL PRENATAL EURAX 65 ENBREL MINI 5 FORMULA 116 EQL SUPER THIN LANCETS EVAMIST 70 ENBREL SURECLICK 5 30G 81 everolimus 38 ENGERIX-B 129 EQL THIN LANCETS 26G 81 everolimus enoxaparin sodium 16 EQUETRO 42,43 (immunosuppressant) 115 entacapone 41 ERAXIS 27 EVISTA 68 entecavir 47 ERBITUX 36 EVOCLIN 57 ENTEREG 71 ergocalciferol 132 EVOXAC 116 ENTOCORT EC 55 ergoloid mesylates 125 EXEL COMFORT POINT ENTRESTO 51 INSULIN SYRINGE/0.3ML/29G X ERGOMAR 112 1/2" 96 EPCLUSA 48 ergotamine w/ caffeine 112 EXEL COMFORT POINT EPIDIOLEX 18 ERIVEDGE 37 INSULIN SYRINGE/0.3ML/30G X EPIDUO 57 5/16" 96 erlotinib hcl 36 EXEL COMFORT POINT epinastine hcl (ophth) 121 ERTACZO 58 INSULIN SYRINGE/0.5ML/28G X epinephrine (anaphylaxis) 132 ertapenem sodium 11 1/2" 96 EPIPEN 2-PAK 132 ERWINASE 40 EXEL COMFORT POINT EPIPEN-JR 2-PAK 132 INSULIN SYRINGE/0.5ML/29G X ERWINAZE 40 1/2" 96 epirubicin hcl 38 ERYPED 200 76 EXEL COMFORT POINT EPIVIR 45 ERYPED 400 76 INSULIN SYRINGE/0.5ML/30G X EPIVIR HBV 48 erythromycin (acne aid) 57 5/16" 96 eplerenone 33 EXEL COMFORT POINT erythromycin (ophth) 119 INSULIN SYRINGE/1ML/28G X EPOGEN 74 erythromycin base 76,77 1/2" 96 epoprostenol sodium 51 erythromycin EXEL COMFORT POINT eprosartan mesylate 31 ethylsuccinate 77 INSULIN SYRINGE/1ML/29G X escitalopram oxalate 21 1/2" 96 EPZICOM 45 EXEL COMFORT POINT EQL COLOR LANCETS 21G81 ESGIC 6 INSULIN SYRINGE/1ML/30G X EQL COLOR LANCETS MICRO esomeprazole 5/16" 96 THIN 33G 81 magnesium 128 EXELDERM 58 estazolam 75 EQL INSULIN exemestane 37 SYRINGE/0.3ML/29G X 1/2" 96 ESTRACE 70 EXFORGE 32 EQL INSULIN estradiol 70 SYRINGE/0.3ML/30G X EXFORGE HCT 32 estradiol vaginal 132 5/16" 96 EXJADE 26 EQL INSULIN estradiol valerate 70 EXTAVIA 124 SYRINGE/0.3ML/31G X ESTROGEL 70 5/16" 96 EZ-LETS LANCETS 21G 81 EQL INSULIN ESTROSTEP FE 53 EZ-LETS LANCETS 26G SYRINGE/0.5ML/29G X 1/2" 96 eszopiclone 75 SUPER-SOFT 81 EQL INSULIN ethacrynic acid 66 EZ-LETS LANCETS 28G SYRINGE/0.5ML/30G X ethambutol hcl 34 ULTRA-SOFT 81 5/16" 96 EZ-LETS LANCETS 30G 81 ethosuximide 20 EQL INSULIN ezetimibe 30 SYRINGE/0.5ML/31G X ethynodiol diacet & eth 5/16" 96 estrad 53 ezetimibe-simvastatin 29 EQL INSULIN etidronate disodium 67 FABRAZYME 68 SYRINGE/1ML/29G X 1/2" 96 etodolac 4 FALESSA 53

Index 11 famciclovir 48 FIFTY50 SAFETY SEAL FLUARIX QUADRIVALENT famotidine 127 LANCETS 32G 81 2020-2021 130 FIFTY50 SUPERIOR FLUARIX QUADRIVALENT famotidine in nacl 127 COMFORTINSULIN 2021-2022 130 FANAPT 43 SYRINGE/0.3ML/31G X FLUBLOK QUADRIVALENT FANAPT TITRATION PACK 43 5/16" 96 2019-2020 130 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FANTASY LUBRICATED 77 COMFORTINSULIN 2020-2021 130 FANTASY SYRINGE/0.5ML/31G X FLUBLOK QUADRIVALENT LUBRICATED/SPERMICIDE 5/16" 96 2021-2022 130 77 FIFTY50 SUPERIOR FLUCELVAX QUADRIVALENT FARESTON 37 COMFORTINSULIN 2019-2020 130 FARXIGA 25 SYRINGE/1ML/31G X FLUCELVAX QUADRIVALENT FASENRA 13 5/16" 96 2020-2021 130 FIFTY50 UNILET LANCETS FLUCELVAX QUADRIVALENT FASENRA PEN 13 33G 81 2021-2022 130 FASLODEX 37 FINACEA 64 fluconazole 27 FAZACLO 43 finasteride 72 flucytosine 27 FC FEMALE CONDOM 77 FINE 30 81 fludarabine phosphate 36 febuxostat 72 FINGERSTIX LANCETS 81 fludrocortisone acetate 55 felbamate 19 FIORICET 6 FLULAVAL QUADRIVALENT FELBATOL 19 2019-2020 130 FIORICET/CODEINE 8 FLULAVAL QUADRIVALENT FELDENE 4 FIORINAL 6 2020-2021 130 felodipine 50 FIORINAL/CODEINE #3 8 FLULAVAL QUADRIVALENT FEMARA 37 FIRAZYR 73 2021-2022 130 FLUMADINE 48 FEMCAP 77 FIRDAPSE 34 FLUMIST QUADRIVALENT130 FEMHRT 69 FIRMAGON 37 flunisolide (nasal) 118 FEMRING 132 FIRVANQ 11 fenofibrate 30 fluocinolone acetonide 62 FLAGYL 10 fluocinolone acetonide fenofibrate micronized 30 flavoxate hcl 129 (otic) 122 fenoprofen calcium 4 flecainide acetate 13 fluocinonide 62 FENSOLVI 68 FLECTOR 58 fluocinonide emulsified base 62 fentanyl 6 FLOLAN 51 fluorometholone (ophth) 120 fentanyl citrate 6 FLOMAX 72 fluorouracil 36 FENTORA 6 FLONASE ALLERGY fluorouracil (topical) 59 FER-IN-SOL 74 RELIEF 118 fluoxetine hcl 21 FERRIPROX 26 FLONASE ALLERGY RELIEF CHILDRENS 118 fluoxetine hcl (pmdd) 125 ferrous fumarate-folic acid 74 FLOVENT DISKUS 14 FLUOXETINE ferrous sulfate 74 FLOVENT HFA 14 HYDROCHLORIDE 21 fluphenazine hcl 44 FETZIMA 22 FLOXIN OTIC 121 flurandrenolide 62 FETZIMA TITRATION PACK22 floxuridine 36 flurbiprofen 4 fexofenadine hcl 28,29 FLUAD 2019-2020 130 fexofenadine-pseudoephedrine flurbiprofen sodium 121 FLUAD 2020-2021 130 56 flutamide 37 FIASP 25 FLUAD QUADRIVALENT 2021- 2022 130 fluticasone propionate 62 FIASP FLEXTOUCH 25 FLUAD QUADRIVALENT fluticasone propionate FIASP PENFILL 25 INFLUENZA VACCINE FOR (nasal) 118 FIBERCON 75 ADULTS 130 fluticasone-salmeterol 15 FLUARIX QUADRIVALENT fluvastatin sodium 30 FIBRICOR 30 2019-2020 130 FIFTY50 SAFETY SEAL fluvoxamine maleate 21 LANCETS 30G 81

Index 12 FLUZONE HIGH-DOSE PF 2019- FREESTYLE PRECISION GENTEEL LANCING 2020 130 INSULIN SYRINGE/U- DEVICE/STATELY SILVER 82 FLUZONE HIGH-DOSE PF 2020- 100/1ML/31G X 5/16" 96 GENTEEL PLUS LANCING 2021 130 FREESTYLE PRECISION DEVICE/BUFF BLACK 82 FLUZONE HIGH-DOSE PF 2021- INSULIN SYRINGES/U- GENTEEL PLUS LANCING 2022 131 100/1ML/30G X 5/16" 96 DEVICE/BUTTERFLY BLUE 82 FLUZONE QUADRIVALENT FREESTYLE UNISTICK II GENTEEL PLUS LANCING 2019-2020 131 LANCETS 82 DEVICE/PLAYFUL PURPLE 82 FLUZONE QUADRIVALENT FROVA 112 GENTEEL PLUS LANCING 2020-2021 131 DEVICE/PRINCESS PINK 82 FLUZONE QUADRIVALENT frovatriptan succinate 112 GENTEEL PLUS LANCING 2021-2022 131 FULPHILA 74 DEVICE/WILLOWY WHITE 82 FML 120 fulvestrant 37 GENTLE-LET GP LANCETS 82 FML FORTE 120 FURADANTIN 12 GENTLE-LET LANCETS FML LIQUIFILM 120 furosemide 66 GENERAL PURPOSE STYLE/FINE POINT 82 FOCALIN 2 FUZEON 45 GENTLE-LET LANCETS FOCALIN XR 2 FYCOMPA 17 GENERAL PURPOSE folic acid 73 gabapentin 18 STYLE/MEDIUM POINT 82 GABITRIL 19 GENTLE-LET LANCETS FOLOTYN 36 SAFETY STYLE/FINE fondaparinux sodium 16 GALAFOLD 68 POINT 82 FORA GTEL BLOOD KETONE galantamine GENTLE-LET LANCETS TEST STRIPS 65 hydrobromide 123 SAFETY STYLE/MEDIUM FORA LANCETS 81 GAMMAGARD LIQUID 122 POINT 82 FORA LANCING DEVICE 81 GAMMAGARD S/D IGA LESS GENVOYA 46 FORA LANCING THAN 1MCG/ML 122 GEODON 43 DEVICE/CLEARCAP 81 GAMMAKED 122 GILENYA 124 FORFIVO XL 21 GAMUNEX-C 122 GILOTRIF 36 FORTAZ 52 ganciclovir sodium 47 glatiramer acetate 124 FOSAMAX 67 ganirelix acetate 67 GLEEVEC 38 FOSAMAX PLUS D 67 GANIRELIX ACETATE 67 GLEOSTINE 35 fosamprenavir calcium 45 GARDASIL 9 131 glimepiride 25 fosfomycin tromethamine 12 gatifloxacin (ophth) 119 glipizide 25 fosinopril sodium 31 gemcitabine hcl 36 glipizide-metformin hcl 23 fosinopril sodium & GEMCITABINE GLOBAL EASY GLIDE INSULIN hydrochlorothiazide 32 HYDROCHLORIDE 36 SYRINGE/1ML/31G X fosphenytoin sodium 20 gemfibrozil 30 15/64" 97 FOSRENOL 71 GENERESS FE 53 GLOBAL EASY GLIDE FRAGMIN 16 GENOTROPIN 67 INSULINSYRINGE/U- FREDS PHARMACY AUTOLET GENOTROPIN 100/0.3ML/31G X 5/16" 97 LANCING DEVICE 81 MINIQUICK 67 GLOBAL INJECT EASE INSULIN FREDS PHARMACY UNILET gentamicin in saline 3 SYRINGE/U-100/0.3ML/29G X 1/2" 97 LANCETS SUPER THIN gentamicin sulfate 3 30G 81 GLOBAL INJECT EASE INSULIN gentamicin sulfate SYRINGE/U-100/0.3ML/30G X FREDS PHARMACY UNILET (ophth) 119 LANCETS ULTRA THIN 1/2" 97 28G 81 gentamicin sulfate (topical) 58 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X FREESTYLE LANCETS 81 GENTEEL BUTTERFLY TOUCH LANCETS 82 5/16" 97 FREESTYLE PRECISION GENTEEL LANCING GLOBAL INJECT EASE INSULIN INSULIN SYRINGE/U- DEVICE/GLORIOUS SYRINGE/U-100/0.3ML/31G X 100/0.5ML/30G X 5/16" 96 GOLD 82 5/16" 97 FREESTYLE PRECISION GENTEEL LANCING GLOBAL INJECT EASE INSULIN INSULIN SYRINGE/U- DEVICE/PRECIOUS SYRINGE/U-100/0.5ML/28G X 100/0.5ML/31G X 5/16" 96 PLATINUM 82 1/2" 97

Index 13 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.5ML/31G X SYRINGES/1/2ML/29GX1/2" 1/2" 97 5/16" 97 98 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X SYRINGES/1ML/28GX1/2" 98 1/2" 97 1/2" 98 GNP INSULIN GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN SYRINGES/1ML/29GX1/2" 98 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X GNP INSULIN 5/16" 97 5/16" 98 SYRINGES/3ML/31GX5/16" 98 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP LANCETS 21G 82 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/31G X GNP LANCETS MICRO THIN 5/16" 97 5/16" 98 33G 82 GLOBAL INJECT EASE INSULIN GLUCOTROL 25 GNP LANCETS SUPER THIN SYRINGE/U-100/1ML/28G X GLUCOTROL XL 25 30G 82 1/2" 97 GNP LANCETS THIN 82 GLOBAL INJECT EASE INSULIN glyburide 25 SYRINGE/U-100/1ML/29G X glyburide micronized 25 GNP LANCETS THIN 26G 82 1/2" 97 glyburide-metformin 23 GNP PRENATAL 116 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X glycine (gu irrigant) 72 INSULIN SYRINGE/0.3ML/29G X 1/2" 97 glycopyrrolate 127 1/2" 98 GLOBAL INJECT EASE INSULIN GLYNASE 25 GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X GLYSET 23 INSULIN SYRINGE/0.3ML/30G X 5/16" 97 5/16" SHORT 98 GLOBAL INJECT EASE INSULIN GLYXAMBI 23 GNP ULTRA COMFORT SYRINGE/U-100/1ML/31G X GNP INSULIN INSULIN SYRINGE/0.5ML/28G X 5/16" 97 SYRINGE/0.3ML/29G X 1/2" 98 GLOBAL INSULIN SYRINGE/U- 1/2" 98 GNP ULTRA COMFORT 100/0.3ML/30G X 1/2" 97 GNP INSULIN INSULIN SYRINGE/0.5ML/29G X GLOBAL INSULIN SYRINGES/U- SYRINGE/0.3ML/30G X 1/2" 98 100/0.3ML/30GX5/16" 97 5/16" 98 GNP ULTRA COMFORT GLOBAL LANCING DEVICE 82 GNP INSULIN INSULIN SYRINGE/1ML/28G X SYRINGE/0.3ML/31G X GLUCAGEN DIAGNOSTIC 65 1/2" 98 5/16" 98 GNP ULTRA COMFORT GLUCAGEN HYPOKIT 24 GNP INSULIN INSULIN SYRINGE/1ML/29G X glucagon (rdna) 24 SYRINGE/0.5ML/28G X 1/2" 98 GLUCAGON EMERGENCY 1/2" 98 GOJJI BLOOD KETONE TEST KIT 24 GNP INSULIN STRIPS 65 GLUCOCOM LANCETS SYRINGE/0.5ML/29G X GOJJI LANCING 28G 82 1/2" 98 DEVICE/CLEAR CAP 82 GLUCOCOM LANCETS GNP INSULIN GOJJI STERILE LANCETS 30G 82 SYRINGE/0.5ML/30G X 30G 82 GLUCOCOM LANCETS 5/16" 98 GOLYTELY 75 33G 82 GNP INSULIN GOODSENSE COLOR GLUCOPRO INSULIN SYRINGE/0.5ML/31G X LANCETS MICRO-THIN 33G SYRINGE/U-100/0.3ML/30G X 5/16" 98 UNIVERSAL 82 1/2" 97 GNP INSULIN GOODSENSE LANCETS GLUCOPRO INSULIN SYRINGE/1ML/28G X 1/2" 98 MICRO-THIN 33G 82 SYRINGE/U-100/0.3ML/30G X GNP INSULIN GOODSENSE LANCETS 5/16" 97 SYRINGE/1ML/29G X 1/2" 98 MICRO-THIN 33G GNP INSULIN GLUCOPRO INSULIN UNIVERSAL 82 SYRINGE/U-100/0.3ML/31G X SYRINGE/1ML/30G X GOODSENSE LANCETS 5/16" 97 5/16" 98 ULTRA-THIN 26G GNP INSULIN GLUCOPRO INSULIN UNIVERSAL 82 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/31G X GOODSENSE LANCETS 1/2" 97 5/16" 98 ULTRA-THIN 30G 82 GLUCOPRO INSULIN GNP INSULIN GOODSENSE LANCETS SYRINGE/U-100/0.5ML/30G X SYRINGES/0.3ML/30GX5/16" ULTRA-THIN 30G 5/16" 97 98 UNIVERSAL 82

Index 14 GOODSENSE LANCING HEALTHWISE INSULIN HUMIRA PEN-CD/UC/HS DEVICE 82 SYRINGE/U-100/0.3ML/30G X STARTER 3,4 GOODSENSE PRENATAL 5/16" 98 HUMIRA PEN-PEDIATRIC UC VITAMINS 116 HEALTHWISE INSULIN STARTER PACK 4 granisetron hcl 26 SYRINGE/U-100/0.3ML/31G X HUMIRA PEN-PS/UV GRASTEK 3 5/16" 98 STARTER 4 HEALTHWISE INSULIN HUMULIN R U-500 griseofulvin microsize 27 SYRINGE/U-100/0.5ML/30G X (CONCENTRATED) 25 griseofulvin ultramicrosize 27 5/16" 98 HUMULIN R U-500 guanfacine hcl 31 HEALTHWISE INSULIN KWIKPEN 25 guanfacine hcl (adhd) 2 SYRINGE/U-100/0.5ML/31G X HY-VEE LANCETS 83 5/16" 99 HY-VEE THIN LANCETS 83 GUANIDINE HCL 34 HEALTHWISE INSULIN GVOKE PFS 24 SYRINGE/U-100/1ML/30G X HYCAMTIN 41 GYNAZOLE-1 132 5/16" 99 hydralazine hcl 33 HEALTHWISE INSULIN GYNE-LOTRIMIN 132 HYDREA 40 SYRINGE/U-100/1ML/31G X HYDRO 35 64 H-E-B INCONTROL 5/16" 99 ADVANCEDLANCING HEALTHY ACCENTS hydrochlorothiazide 66 DEVICE 82 AUTOLET IMPRESSION hydrocodone bitartrate 6 H-E-B INCONTROL LANCETS LANCING DEVICE 83 HYDROCODONE BITARTRATE MICRO THIN 33G 82 HEALTHY ACCENTS UNILET ER 6 H-E-B INCONTROL LANCETS LANCETS SUPER THIN hydrocodone polistirex- SUPER THIN 30G 82 30G 83 chlorpheniramine polistirex 56 H-E-B INCONTROL LANCETS HECTOROL 68 ULTRA THIN 28G 83 hydrocodone-acetaminophen 8 HAEGARDA 73 HEMANGEOL 49 hydrocodone-ibuprofen 8 HAEMOLANCE 83 HEPARIN LOCK FLUSH 17 hydrocortisone 55 HAEMOLANCE LOW FLOW heparin sod (porcine) in hydrocortisone (intrarectal) 10 LANCETS 83 d5w 17 hydrocortisone (rectal) 10 HAEMOLANCE PLUS 83 heparin sodium (porcine) 17 HEPARIN SODIUM/NACL hydrocortisone (topical) 63 HAEMOLANCE PLUS HIGH hydrocortisone acetate FLOW 83 0.45% 17 HEPLISAV-B 131 (rectal) 10 HAEMOLANCE PLUS LOW hydrocortisone butyrate 63 FLOW 83 HEPSERA 48 hydrocortisone valerate 63 HAEMOLANCE PLUS MAX HERCEPTIN 36 FLOW 83 hydrocortisone w/acetic HAEMOLANCE PLUS HETLIOZ 75 acid 122 PEDIATRIC FLOW 83 HIBERIX 129 hydromorphone hcl 6 HALAVEN 41 HIPREX 12 HYDROMORPHONE halcinonide 62 HIZENTRA 122 HYDROCHLORIDE 6 hydroxychloroquine sulfate 34 HALCION 75 HM PRENATAL 116 HALDOL 43 HM ULTICARE INSULIN hydroxyurea 40 HALDOL DECANOATE 100 43 SYRINGE/1ML/30G X 1/2" 99 hydroxyzine hcl 12,13 HM ULTICARE INSULIN HALDOL DECANOATE 50 43 hydroxyzine pamoate 13 SYRINGE/U-100/0.3ML/31G X HYPER-SAL 56 halobetasol propionate 62 5/16" 99 HALOG 62 HORIZANT 125 HYPERSAL 56 haloperidol 43 HUMATIN 3 HYQVIA 122 haloperidol decanoate 43 HUMATROPE 67 HYZAAR 32 haloperidol lactate 43 HUMATROPE COMBO ibandronate sodium 67 HAVRIX 131 PACK 67 IBRANCE 39 HEALTH CARE LANCING HUMIRA 4 ibuprofen 5 DEVICE 83 HUMIRA PEDIATRIC CROHNS icatibant acetate 73 DISEASE STARTER PACK 3 ICLUSIG 39 HUMIRA PEN 3

Index 15 icosapent ethyl 29 INSULIN SYRINGE/0.5ML/31G INSULIN IDAMYCIN PFS 38 X 5/16" 99 SYRINGES/1ML/28GX1/2" 100 INSULIN SYRINGE/1ML/28G X INSULIN idarubicin hcl 38 1/2" 99 SYRINGES/1ML/29GX1/2" 100 IFEX 35 INSULIN SYRINGE/1ML/29G X INSULIN ifosfamide 35 1/2" 99 SYRINGES/1ML/30GX1/2" 100 INSULIN SYRINGE/1ML/30G X INSULIN ILARIS 4 5/16" 99 SYRINGES/1ML/31GX5/16" ILEVRO 121 INSULIN SYRINGE/NEEDLE 100 imatinib mesylate 39 0.3ML/30G X 5/16" 99 INTELENCE 46 IMBRUVICA 39 INSULIN SYRINGE/NEEDLE INTRAROSA 131 0.3ML/31G X 5/16" 99 imipenem-cilastatin 11 INSULIN SYRINGE/NEEDLE INTRON A 40 imipramine hcl 23 0.5ML/29G X 1/2" 99 INTUNIV 2 imipramine pamoate 23 INSULIN SYRINGE/NEEDLE INVANZ 11 0.5ML/30G X 5/16" 99 imiquimod 64 INSULIN SYRINGE/NEEDLE INVEGA 43 IMITREX 112 0.5ML/31G X 5/16" 99 INVIRASE 46 IMITREX STATDOSE INSULIN SYRINGE/NEEDLE IONOSOL-MB/DEXTROSE REFILL 112 1ML/29G X 1/2" 99 5% 113 IMITREX STATDOSE INSULIN SYRINGE/NEEDLE IOPIDINE 119 SYSTEM 112 1ML/30G X 5/16" 99 IPOL INACTIVATED IPV 131 IMODIUM A-D 26 INSULIN SYRINGE/NEEDLE ipratropium bromide 14 IMPAVIDO 10 1ML/31G X 5/16" 99 INSULIN SYRINGE/U- ipratropium bromide (nasal)118 IMURAN 115 100/0.3ML/29G X 1/2" 99 ipratropium-albuterol 15 IN TOUCH LANCING INSULIN SYRINGE/U- DEVICE 83 100/0.5ML/29G X 1/2" 99 irbesartan 31 IN TOUCH STERILE INSULIN SYRINGE/U- irbesartan-hydrochlorothiazide LANCETS30G 83 100/1ML/29G X 1/2" 99 32 INCRELEX 68 INSULIN SYRINGE/U- irinotecan hcl 41 INCRUSE ELLIPTA 14 100/1ML/30G X 5/16" 99 irrigation solutions, INSULIN SYRINGE/U- physiological 115 indapamide 66 100/1ML/31G X 5/16" 99 ISENTRESS 46 INDERAL LA 49 INSULIN ISENTRESS HD 46 indomethacin 5 SYRINGES/0.5ML/27GX1/2" 100 ISOLYTE-P/DEXTROSE INFANRIX 127 INSULIN 5% 114 INFLECTRA 71 SYRINGES/0.5ML/28GX1/2" ISOLYTE-S 114 INLYTA 36 100 isoniazid 34 INREBIC 39 INSULIN ISOPTO CARPINE 119 SYRINGES/0.5ML/29GX1/2" INSPRA 33 100 ISORDIL TITRADOSE 12 INSULIN SYRINGE/0.3ML/29G X INSULIN isosorbide dinitrate 12 1" 99 SYRINGES/0.5ML/30GX5/16" isosorbide mononitrate 12 INSULIN SYRINGE/0.3ML/29G X 100 isotretinoin 57 1/2" 99 INSULIN INSULIN SYRINGE/0.3ML/30G X SYRINGES/0.5ML/31GX isradipine 50 5/16" 99 5/16" 100 ISTODAX (OVERFILL) 39 INSULIN SYRINGE/0.3ML/31G X INSULIN itraconazole 27,28 5/16" 99 SYRINGES/0.5ML/31GX5/16" INSULIN SYRINGE/0.5ML/27G X 100 ivermectin 10 1/2" 99 INSULIN IVERMECTIN 65 INSULIN SYRINGE/0.5ML/28G X SYRINGES/1ML/27GX/1/2" ivermectin (pediculicide) 65 1/2" 99 100 IXEMPRA KIT 41 INSULIN SYRINGE/0.5ML/30G X INSULIN 1/2" 99 SYRINGES/1ML/27GX1/2" JADENU 26 INSULIN SYRINGE/0.5ML/30G X 100 JADENU SPRINKLE 26 5/16" 99 JAKAFI 39

Index 16 JANUMET 23 KIMONO PS PLUS KROGER INSULIN JANUMET XR 23 SPERMICIDE/LUBRICATED SYRINGE/0.5ML/31G X 77 5/16" 100 JANUVIA 24 KIMONO SENSATION KROGER INSULIN JARDIANCE 25 LUBRICATED 77 SYRINGE/1ML/29G X 1/2" 100 JEVTANA 41 KIMONO SENSATION PLUS KROGER INSULIN SPERMICIDE SYRINGE/1ML/30G X JUBLIA 58 LUBRICATED 77 5/16" 100 JULUCA 46 KIMONO SPECIAL 77 KROGER INSULIN JYNARQUE 69 KINNEY LANCETS 83 SYRINGE/1ML/31G X K-TAB 114 5/16" 100 KINNEY THIN LANCETS 83 KROGER LANCETS 83 K-Y ME & YOU EXTRA KINRAY INSULIN SYRINGE LUBRICATED 77 PREFERRED KROGER LANCETS 21G 83 K-Y ME & YOU INTENSE 77 PLUS/0.3ML/31G X 5/16" 100 KROGER LANCETS MICRO KADIAN 6 KINRAY INSULIN SYRINGE THIN33G 83 KROGER LANCETS SUPER KALETRA 46 PREFERRED PLUS/0.5ML/31G X 5/16" 100 THIN 83 KALYDECO 125 KINRAY INSULIN SYRINGE KROGER LANCETS THIN 83 KAMELEON LUBRICATED 77 PREFERRED PLUS/1ML/31G KROGER LANCETS THIN KAPVAY 2 X 5/16" 100 26G 83 KROGER LANCETS KAZANO 23 KINRAY INSULIN SYRINGE/0.5ML/29G X ULTRATHIN30G 83 KCL 0.3%/D5W/NACL 1/2" 100 KROGER LANCING 0.9% 114 KINRIX 127 DEVICE 83 KEFLEX 52 KISQALI 39 KRYSTEXXA 72 KENALOG-40 55 KITABIS PAK 3 KUVAN 68 KEPIVANCE 40 KLARITY-A 119 KYLEENA 54 KEPPRA 18 KLARON 57 KYPROLIS 39 KEPPRA XR 18 KLONOPIN 17 labetalol hcl 49 KERYDIN 58 KMART VALU PLUS INSULIN LAC-HYDRIN 64 ketoconazole 28 SYRINGE/1ML/29G 100 LAC-HYDRIN TWELVE 64 ketoconazole (topical) 58 KMART VALU PLUS INSULIN LACRISERT 119 SYRINGE/1ML/30G 100 KETONE 65 lactated ringer's 114 KETONE TEST STRIPS 65 KOSELUGO 39 KP PRENATAL lactated ringer's (irrigation) 115 ketoprofen 5 MULTIVITAMINS 116 lactic acid (ammonium ketorolac tromethamine 5 KRINTAFEL 34 lactate) 64 ketorolac tromethamine KROGER AUTOLET LANCING lactulose 75 (ophth) 121 DEVICE 83 lactulose (encephalopathy) 71 KETOSTIX 65 KROGER HEALTHPRO TWIST LAMICTAL 18 ketotifen fumarate (ophth) 121 LANCETS/26G 83 LAMICTAL CHEWABLE KEVEYIS 66 KROGER INSULIN DISPERSIBLE 18 SYRINGE/0.3ML/29G X LAMICTAL ODT 18 KHEDEZLA 22 1/2" 100 KIMONO COLORS 77 KROGER INSULIN lamivudine 46 KIMONO LUBRICATED 77 SYRINGE/0.3ML/30G X lamivudine (hbv) 48 KIMONO MICRO THIN PLUS 5/16" 100 lamivudine-zidovudine 46 KROGER INSULIN SPERMICIDE LUBRICATED77 lamotrigine 18 KIMONO PLUS SPERMICIDE SYRINGE/0.3ML/31G X 5/16" 100 LANCET DEVICE LUBRICATED 77 ADJUSTABLE 83 KIMONO PLUS KROGER INSULIN SYRINGE/0.5ML/29G X LANCET DEVICE WITH SPERMICIDE/LUBRICATED EJECTOR 83 77 1/2" 100 KROGER INSULIN LANCETS 83 KIMONO PS LUBRICATED 77 SYRINGE/0.5ML/30G X LANCETS 26G TWIST TOP 83 5/16" 100

Index 17 LANCETS 30G 83 LEADER INSULIN levonorgestrel & eth LANCETS 30G TWIST TOP 83 SYRINGE/0.5ML/30G X estradiol 53 5/16" 101 levonorgestrel (emergency LANCETS 30G/TWIST TOP 83 LEADER INSULIN oc) 54 LANCETS 31G TWIST TOP 83 SYRINGE/0.5ML/31G X levonorgestrel-eth estradiol LANCETS 33G EXTRA 5/16" 101 (triphasic) 53 FINE 83 LEADER INSULIN levonorgestrel-ethinyl estradiol LANCETS MICRO THIN SYRINGE/1ML/28G X (91-day) 53 33G 83 1/2" 101 levonorgestrel-ethinyl estradiol LANCETS SAFETY SEAL LEADER INSULIN (continuous) 53 21G 83 SYRINGE/1ML/29G X levorphanol tartrate 6 LANCETS SAFETY SEAL 1/2" 101 levothyroxine sodium 126 26G 83 LEADER INSULIN LANCETS SAFETY SEAL SYRINGE/1ML/30G X LEXAPRO 22 28G 83 5/16" 101 LEXIVA 46 LANCETS SAFETY SEAL LEADER INSULIN LIALDA 71 30G 83 SYRINGE/1ML/31G X LIBERTY MEDICAL LANCETS LANCETS SUPER THIN 5/16" 101 30G 84 28G 83 leflunomide 5 LIBERTY MINI LANCING LANCETS THIN 83 LENVIMA 10 MG DAILY DEVICE 84 LANCETS TWIST TOP 83 DOSE 36 LIBRAX 127 LANCETS ULTRA THIN 84 LENVIMA 12MG DAILY lidocaine 64 DOSE 36 LANCETS ULTRA THIN LENVIMA 14 MG DAILY lidocaine hcl 64 30G 84 DOSE 36 lidocaine hcl (local anesth.) 76 LANCETSBULLSEYE LENVIMA 18 MG DAILY lidocaine hcl (mouth-throat) 116 SAFETY 84 DOSE 36 LANCING DEVICE 84 LENVIMA 20 MG DAILY lidocaine-prilocaine 64 LANCING DEVICE DOSE 36 LIDODERM 64 ADJUSTABLE 84 LENVIMA 24 MG DAILY LIFESCAN UNISTIK 2 DEEP LANOXIN 50 DOSE 36 PENETRATION 84 lansoprazole 128 LENVIMA 4 MG DAILY LIFESCAN UNISTIK II DOSE 36 LANCETS 84 lanthanum carbonate 71 LENVIMA 8 MG DAILY LILETTA 54 LANZO 84 DOSE 36 LINCOCIN 11 lapatinib ditosylate 39 LETAIRIS 51 lincomycin hcl 12 LASIX 66 letrozole 37 lindane 65 LASTACAFT 121 leucovorin calcium 40 linezolid 12 latanoprost 121 LEUKERAN 35 LINZESS 71 LATUDA 43 LEUKINE 74 liothyronine sodium 126 LEADER ADVANCED LANCING leuprolide acetate 37 LIPITOR 30 DEVICE 84 levalbuterol hcl 15 LEADER INSULIN LIPOFEN 30 levalbuterol tartrate 15 SYRINGE/0.3ML/29G X lisinopril 31 1/2" 100 LEVAQUIN 70 lisinopril & LEADER INSULIN LEVEMIR 25 hydrochlorothiazide 32 SYRINGE/0.3ML/30G X 5/16" 100 LEVEMIR FLEXTOUCH 25 LITE TOUCH LANCETS 84 LEADER INSULIN levetiracetam 18 LITE TOUCH LANCING SYRINGE/0.3ML/31G X levobunolol hcl 119 PEN 84 LITETOUCH INSULIN 5/16" 100 levocetirizine LEADER INSULIN SYRINGE/0.3ML/29G X dihydrochloride 29 1/2" 101 SYRINGE/0.5ML/28G X levofloxacin 70 1/2" 100 LITETOUCH INSULIN LEADER INSULIN levofloxacin (ophth) 119 SYRINGE/0.3ML/30G X SYRINGE/0.5ML/29G X levofloxacin in d5w 70 5/16" 101 1/2" 101

Index 18 LITETOUCH INSULIN LODOSYN 41 LUPRON DEPOT (1- SYRINGE/0.3ML/31G X LOMOTIL 26 MONTH) 37 5/16" 101 LUPRON DEPOT (3- LITETOUCH INSULIN LONGS INSULIN MONTH) 37 SYRINGE/0.5ML/30G X SYRINGE/0.5ML/31G X LUPRON DEPOT (4- 5/16" 101 5/16" 101 MONTH) 37 LITETOUCH INSULIN LONGS LANCETS LUPRON DEPOT (6- SYRINGE/0.5ML/31G X STANDARD 84 MONTH) 37 5/16" 101 LONGS LANCETS THIN 84 LUPRON DEPOT-PED (1- LITETOUCH INSULIN LONGS LANCETS ULTRA MONTH) 68 SYRINGE/1ML/30G X THIN 84 LUPRON DEPOT-PED (3- 5/16" 101 loperamide hcl 26 MONTH) 68 LITETOUCH INSULIN LOPID 30 LUXIQ 63 SYRINGE/U-100/0.3ML/30G X lopinavir-ritonavir 46 LUZU 58 5/16" 101 LITETOUCH INSULIN LOPRESSOR 49 LYNPARZA 39 SYRINGE/U-100/0.3ML/31G X LOPRESSOR HCT 32 LYRICA 18 5/16" 101 LOPROX 58 LYRICA CR 124,125 LITETOUCH INSULIN LYSODREN 37 SYRINGE/U-100/0.5ML/28G X LOPROX SHAMPOO 58 1/2" 101 loratadine 29 LYSTEDA 74 LITETOUCH INSULIN loratadine & M-M-R II 131 SYRINGE/U-100/0.5ML/29G X pseudoephedrine 56 M-NATAL PLUS 116 1/2" 101 lorazepam 13 MACROBID 12 LITETOUCH INSULIN LORBRENA 39 SYRINGE/U-100/0.5ML/30G X MACRODANTIN 12 5/16" 101 LORTAB 9 mafenide acetate 61 LITETOUCH INSULIN losartan potassium 31 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/31G X losartan potassium & SYRINGE/U-100/0.3ML/29G X 5/16" 101 hydrochlorothiazide 32 1/2" 101 LITETOUCH INSULIN LOSEASONIQUE 53 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/28G X LOTEMAX 120 SYRINGE/U-100/0.3ML/30G X 1/2" 101 5/16" 101 LITETOUCH INSULIN LOTENSIN 31 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X LOTENSIN HCT 32 SYRINGE/U-100/0.5ML/29G X 1/2" 101 loteprednol etabonate 120 1/2" 101 LITETOUCH INSULIN LOTREL 32 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.5ML/30G X 5/16" 101 LOTRIMIN AF 58 5/16" 101 LITETOUCH INSULIN LOTRIMIN AF JOCK ITCH 58 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/31G X LOTRIMIN ULTRA 58 SYRINGE/U-100/1ML/29G X 5/16" 101 1/2" 102 LITETOUCH LANCETS MICRO LOTRISONE 58 MAGELLAN INSULIN SAFETY THIN 33G 84 LOTRONEX 71 SYRINGE/U-100/1ML/30G X LITHIUM 42 lovastatin 30 5/16" 102 lithium carbonate 42 LOVAZA 29 magnesium sulfate 114 LITHOBID 42 LOVENOX 17 MALARONE 34 LIVALO 30 loxapine succinate 43 malathion 65 LIVE BETTER ADVANCED lubiprostone 71 maprotiline hcl 21 LANCING DEVICE 84 MARCAINE 76 LIVE BETTER LANCET LUCEMYRA 123 SUPERTHIN 30G 84 luliconazole 58 MARINOL 27 LIVE BETTER LANCET LUMIGAN 121 MARPLAN 21 ULTRATHIN 28G 84 LUMIZYME 68 MATULANE 40 LO LOESTRIN FE 53 LUNESTA 75 MAVENCLAD 124 LOCOID 63 LUPANETA PACK 68 MAVYRET 48 LODINE 5 MAXALT 112

Index 19 MAXALT-MLT 112 MEDLANCE PLUS meropenem 11 MAXI-COMFORT INSULIN SUPERLITE 30G 84 MERREM 11 MEDLANCE PLUS SYRINGE/U- mesalamine 71 100/0.5ML/28GX1/2" 102 SUPERLITE 30G/COMFORT MAXI-COMFORT INSULIN MAX 84 MESTINON 34 SYRINGE/U-100/1ML/28GX1/2" MEDLANCE PLUS MESTINON TIMESPAN 34 UNIVERSAL LANCETS 102 metaxalone 117 MAXICOMFORT INSULIN 21G 84 SYRINGES 27G X 1/2" 102 MEDLANCE PLUS/LITE metformin hcl 24 MAXIDEX 120 25G 84 methadone hcl 7 MEDLANCE/EXTRA 84 MAXIPIME 52 METHADONE HCL 7 MEDLANCE/LITE 84 MAXITROL 120 methadone hcl 7 MEDLANCE/UNIVERSAL 84 MAXX LUBRICATED 77 METHADOSE 7 MAXX PLUS SPERMICIDE MEDROL 55 METHADOSE SUGAR-FREE 7 LUBRICATED 77 MEDROL DOSEPAK 55 methamphetamine hcl 1 MAXZIDE 66 medroxyprogesterone methazolamide 66 MAXZIDE-25 66 acetate 123 medroxyprogesterone acetate methenamine hippurate 12 MAYZENT 124 (contraceptive) 54 methimazole 126 MAYZENT STARTER mefenamic acid 5 METHITEST 10 PACK 124 mefloquine hcl 34 meclizine hcl 26 methocarbamol 117 MEGACE ES 123 meclofenamate sodium 5 METHOTREXATE 4 MEDIC INSULIN megestrol acetate 37 methotrexate sodium 36 SYRINGE/0.3ML/30G X megestrol acetate methoxsalen rapid 60 (appetite) 123 5/16" 102 methscopolamine bromide 127 MEDIC INSULIN MEIJER COLOR LANCETS SYRINGE/0.5ML/30G X UNIVERSAL 33G 84 METHYLIN 2 5/16" 102 MEIJER LANCETS 85 methylphenidate hcl 2 MEDICHOICE PRE-SET MEIJER LANCETS THIN 85 methylprednisolone 55 SAFETY LANCET DUAL MEIJER LANCETS methylprednisolone acetate 55 USE 84 UNIVERSAL21G 85 methylprednisolone sod MEDICHOICE PRE-SET MEIJER LANCETS succ 55 SAFETY LANCET LOW UNIVERSAL30G 85 metoclopramide hcl 71 FLOW 84 MEIJER LANCETS MEDICHOICE PRE-SET UNIVERSAL33G 85 metolazone 66 SAFETY LANCET MEDIUM MEIJER SUPER THIN metoprolol & FLOW 84 LANCETS 85 hydrochlorothiazide 32 MEDICHOICE PRE-SET MEKINIST 39 metoprolol succinate 49 SAFETY LANCET MODERATE metoprolol tartrate 49 FLOW 84 MEKTOVI 39 MEDICHOICE SAFETY meloxicam 5 METROCREAM 64 LANCETEXTRA 84 melphalan 35 METROGEL 64 MEDICHOICE SAFETY melphalan hcl 35 METROGEL-VAGINAL 132 LANCETNORMAL 84 MEDISENSE THIN memantine hcl 123 METROLOTION 64 LANCETS 84 MENACTRA 129 metronidazole 10 MEDLANCE PLUS EXTRA MENEST 70 metronidazole (topical) 64 LANCETS 21G 84 metronidazole vaginal 132 MEDLANCE PLUS MENOSTAR 70 LANCETS 84 MENQUADFI 129 mexiletine hcl 13 MEDLANCE PLUS LANCETS MENVEO 129 micafungin sodium 27 LITE 25G 84 meperidine hcl 7 MICARDIS 31 MEDLANCE PLUS LITE LANCETS 25G 84 meprobamate 13 MICARDIS HCT 32 MEDLANCE PLUS SPECIAL MEPRON 11 miconazole nitrate vaginal 132 LANCETS 0.8MM 84 mercaptopurine 36 MICROLET LANCETS 85

Index 20 MICROLET NEXT 85 MONOJECT INSULIN MONOJECT ULTRA COMFORT midodrine hcl 132 SYRINGE/DETACH INSULIN SYRINGE/0.3ML/31G X NEEDLE/1ML/25G X 5/8" 102 5/16" 103 miglitol 23 MONOJECT INSULIN MONOJECT ULTRA COMFORT miglustat 73 SYRINGE/DETACH INSULIN SYRINGE/0.5ML/28G X MIGRANAL 112 NEEDLE/1ML/27G X 1/2" 102 1/2" 103 MONOJECT INSULIN MONOJECT ULTRA COMFORT MILLIPRED 55 SYRINGE/PERM INSULIN SYRINGE/0.5ML/29G X MILLIPRED DP 55 NEEDLE/1ML/28G X 1/2" 102 1/2" 103 MINASTRIN 24 FE 53 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINI LANCING DEVICE 85 SYRINGE/PERM NEEDLE/U- INSULIN SYRINGE/0.5ML/30G X 100/0.5ML/28G X 1/2" 102 5/16" 103 MINIPRESS 31 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINIVELLE 70 SYRINGE/SAFETY/PERM INSULIN SYRINGE/0.5ML/31G X MINOCIN 126 NEEDLE/0.3ML/29G X 5/16" 103 minocycline hcl 126 1/2" 102 MONOJECT ULTRA COMFORT MONOJECT INSULIN INSULIN SYRINGE/1ML/28G X minoxidil 33 SYRINGE/SAFETY/PERM 1/2" 103 MIRAPEX 41 NEEDLE/0.3ML/29GX1/2" MONOJECT ULTRA COMFORT MIRCERA 74 102 INSULIN SYRINGE/1ML/29G X MONOJECT INSULIN 1/2" 103 MIRCETTE 53 SYRINGE/SAFETY/PERM MONOLET LANCETS 85 MIRENA 54 NEEDLE/0.5ML/29G X MONOLET OPD LANCETS 85 mirtazapine 20 1/2" 102 MONOLETTOR SAFETY MIRVASO 64 MONOJECT INSULIN LANCETS 85 SYRINGE/SAFETY/PERM misoprostol 128 NEEDLE/1ML/29G X 1/2" 102 montelukast sodium 14 MITIGARE 72 MONOJECT INSULIN MONUROL 12 mitomycin 38 SYRINGE/SOFTPACK/1ML/27 MORPHABOND ER 7 mitoxantrone hcl 38 G X 1/2" 102 morphine sulfate 7 MONOJECT INSULIN MM INSULIN SYRINGE/U- SYRINGE/SOFTPACK/U- MORPHINE SULFATE 7 100/0.3ML/30G X 5/16" 102 100/0.5ML/28G X 1/2" 102 morphine sulfate 7 MM INSULIN SYRINGE/U- MONOJECT INSULIN 100/0.3ML/31G X 5/16" 102 MOTOFEN 26 MM INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/30G X 5/16" 102 MOVIPREP 75 100/1/2ML/30G X 5/16" 102 moxifloxacin hcl 70 MM INSULIN SYRINGE/U- MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X 100/1/2ML/31G X 5/16" 102 moxifloxacin hcl (ophth) 119 MM INSULIN SYRINGE/U- 5/16" 102 moxifloxacin hcl in sodium MONOJECT INSULIN 100/1ML/30G X 5/16" 102 chloride 70 MM INSULIN SYRINGE/U- SYRINGE/U-100/1ML/28G X MOZOBIL 74 100/1ML/31G X 5/16" 102 1/2" 103 MPD SAFETY LANCET MONOJECT INSULIN 21G/1.8MM 85 MM LANCING DEVICE 85 SYRINGE/U-100/1ML/30G X MM TWIST LANCETS 85 MPD SAFETY LANCET 5/16" 103 28G/1.8MM 85 MOBIC 5 MONOJECT INSULIN MPD SAFETY LANCET modafinil 2,3 SYRINGEREGULAR LUER 30G/1.8MM 85 TIP/SOFTPACK/1ML 103 moexipril hcl 31 MPD SAFETY LANCETS MONOJECT ULTRA 23G/1.8MM 85 mometasone furoate 63 COMFORT INSULIN MS CONTIN 7 mometasone furoate SYRINGE/0.3ML/29G X (nasal) 118 1/2" 103 MS INSULIN MONISTAT SOOTHING CARE MONOJECT ULTRA SYRINGE/0.3ML/31G X ITCH RELIEF 63 COMFORT INSULIN 5/16" 103 MONOJECT INSULIN SYRINGE/0.3ML/30G X MS INSULIN SYRINGE/1ML 102 5/16" 103 SYRINGE/0.5ML/31G X MONOJECT INSULIN 5/16" 103 SYRINGE/1ML/31G X MS INSULIN SYRINGE/1ML/31G 5/16" 102 X 5/16" 103

Index 21 MULPLETA 74 NATAZIA 53 NICORETTE STARTER MULTAQ 13 nateglinide 25 KIT 125 nicotine 125 MULTI PRENATAL 116 NATROBA 65 nicotine polacrilex 125 MULTI-LANCET DEVICE 85 NATURE-THROID 126 NICOTINE TRANSDERMAL mupirocin 58 NATURE-THROID NT- SYSTEM 125 2.5 126 MVASI 36 NICOTROL INHALER 125 NAVELBINE 41 MYALEPT 68 NICOTROL NS 125 NAYZILAM 17 MYAMBUTOL 34 nifedipine 50 nebivolol hcl 49 MYCAMINE 27 NILANDRON 37 NEBUSAL 56 MYCOBUTIN 35 nilutamide 37 nefazodone hcl 22 mycophenolate mofetil 115 nimodipine 50 NEO-SYNALAR 58 mycophenolate sodium 115 NINLARO 39 neomycin sulfate 3 MYDRIACYL 119 neomycin-bacitracin zn- NIPENT 40 MYFORTIC 115 polymyxin 119 nisoldipine 50 MYGLUCOHEALTH MGH neomycin-polymy- nitazoxanide 11 SOFTLANCE LANCETS dexameth 120 nitisinone 68 30G 85 neomycin-polymyxin-hc MYLERAN 35 (ophth) 120 NITRO-BID 12 MYRBETRIQ 129 neomycin-polymyxin-hc NITRO-DUR 12 (otic) 121 MYSOLINE 18 nitrofurantoin 12 NEONATAL COMPLETE 116 nabumetone 5 nitrofurantoin macrocrystal 12 NEONATAL PLUS 116 nadolol 49 nitrofurantoin monohyd NEONATAL VITAMIN 116 macro 12 nafcillin sodium 123 NEORAL 115 nitroglycerin 12 naftifine hcl 58,59 NEOSTIGMINE NITROGLYCERIN 12 NAFTIFINE METHYLSULFATE 34 nitroglycerin 12 HYDROCHLORIDE 59 NESINA 24 NAFTIN 59 NITROSTAT 12 NEULASTA 74 NAGLAZYME 68 NIVA-PLUS 116 NEULASTA ONPRO KIT 74 nalbuphine hcl 9 NIVESTYM 74 NEUPOGEN 74 NALFON 5 NIX CREME RINSE 65 NEUPRO 42 naloxone hcl 26 nizatidine 127 NEURONTIN 18 naltrexone hcl 26 NIZORAL 59 NEVANAC 121 NAMENDA 123 NORCO 9 nevirapine 46 NAMENDA TITRATION NORDITROPIN FLEXPRO 67 PAK 124 NEXAVAR 39 norelgestromin-ethinyl NAPROSYN 5 NEXIUM 128 estradiol 54 naproxen 5 NEXIUM 24HR 128 norethin acet & estrad-fe 53 naproxen sodium 5 NEXPLANON 54 norethindrone & eth estradiol53 naratriptan hcl 112 niacin 132 norethindrone & ethinyl estradiol- fe 53 NARCAN 26 niacin (antihyperlipidemic) 30 norethindrone NARDIL 21 NIACIN TR 133 (contraceptive) 54 NAROPIN 76 niacinamide 133 norethindrone acet & eth NASACORT ALLERGY NIASPAN 30 estra 53 norethindrone acetate 123 24HR 118 nicardipine hcl 50 NASACORT ALLERGY 24HR norethindrone acetate-ethinyl CHILDRENS 118 NICODERM CQ 125 estradiol 69 NASONEX 118 NICORETTE 125 norethindrone acetate-ethinyl estradiol-fe 53 NATACYN 119 NICORETTE MINI 125

Index 22 norethindrone-eth estradiol NUVARING 54 ONETOUCH DELICA LANCETS (triphasic) 53 NUVIGIL 3 FINE 30G 85 norgestimate-ethinyl ONETOUCH DELICA LANCING estradiol 53 nystatin 27 DEVICE 85 norgestimate-ethinyl estradiol nystatin (mouth-throat) 116 ONETOUCH DELICA PLUS (triphasic) 53 nystatin (topical) 59 LANCETS EXTRA FINE 33G 85 norgestrel & ethinyl estradiol 53 nystatin-triamcinolone 59 NORMOSOL-M IN D5W 114 ONETOUCH DELICA PLUS O-CAL FA 116 LANCETS FINE 30G 85 NORMOSOL-M/D5W 114 OCREVUS 124 ONETOUCH DELICA PLUS NORMOSOL-R 114 octreotide acetate 69 LANCING DEVICE 85 NORPACE 13 ONETOUCH DELICA SAFETY OCUFLOX 119 LACING DEVICE 85 NORPRAMIN 23 ODEFSEY 46 ONETOUCH FINEPOINT nortriptyline hcl 23 ODOMZO 37 LANCETS 85 NORVASC 50 ONETOUCH ULTRASOFT OFEV 125 LANCETS 85 NORVIR 46 ofloxacin 70 NOVA MAX PLUS KETONE ONFI 17 TESTSTRIPS 65 ofloxacin (ophth) 119 OPANA 7 NOVA SAFETY LANCETS ofloxacin (otic) 121 OPSUMIT 51 23G 85 olanzapine 43,44 ORACEA 64 NOVA SAFETY LANCETS olmesartan medoxomil 31 28G 85 ORAPRED ODT 55 NOVA SUREFLEX olmesartan medoxomil- ORENITRAM 51 amlodipine-hydrochlorothiazide LANCETS 85 ORFADIN 68 NOVA SUREFLEX LANCING 32 DEVICE 85 olmesartan medoxomil- ORKAMBI 125 NOVAREL 67 hydrochlorothiazide 32 orphenadrine citrate 117 olopatadine hcl 121 NOVOLIN 70/30 25 ORTHO MICRONOR 54 olopatadine hcl (nasal) 118 NOVOLIN 70/30 FLEXPEN 25 ORTHO TRI-CYCLEN LO 53 NOVOLIN 70/30 FLEXPEN OLUX 63 ORTHO-NOVUM 1/35 53 RELION 25 omega-3-acid ethyl esters 29 ORTHO-NOVUM 7/7/7 53 NOVOLIN 70/30 RELION 25 omeprazole 128 oseltamivir phosphate 48 NOVOLIN N 25 omeprazole magnesium 128 OSENI 24 omeprazole-sodium NOVOLIN N RELION 25 OSMOPREP 76 NOVOLIN R 25 bicarbonate 128 OMNIFLEX DIAPHRAGM 77 OSPHENA 68 NOVOLIN R RELION 25 OMNITROPE 68 OTEZLA 5 NOVOLOG 25 ON CALL LANCING OTOVEL 121 NOVOLOG FLEXPEN 25 DEVICE 85 OVIDE 65 NOVOLOG MIX 70/30 25 ON CALL PLUS LANCING oxacillin sodium 123 DEVICE 85 NOVOLOG MIX 70/30 oxaliplatin 35 PREFILLED FLEXPEN 25 ONCASPAR 40 NOVOLOG PENFILL 25 ondansetron 26 oxandrolone 9 NOXAFIL 28 ondansetron hcl 26 oxaprozin 5 NPLATE 74 ONE VITE WOMENS OXAYDO 7 NUBEQA 37 PRENATALVITAMIN 116 oxazepam 13 ONE VITE WOMENS OXBRYTA 73 NUCALA 14 PRENATALVITAMIN NUCYNTA 7 PLUS 116 oxcarbazepine 18,19 NUCYNTA ER 7 ONETOUCH CLUB LANCETS OXERVATE 120 NUEDEXTA 125 FINE POINT 85 oxiconazole nitrate 59 ONETOUCH DELICA OXISTAT 59 NULOJIX 115 LANCETS EXTRA FINE NUTROPIN AQ NUSPIN 10 68 33G 85 OXSORALEN ULTRA 60 oxybutynin chloride 129

Index 23 oxycodone hcl 7 PENICILLIN G POTASSIUM IN pimecrolimus 64 oxycodone w/ acetaminophen 9 ISO-OSMOTIC pimozide 125 DEXTROSE 122 oxycodone-ibuprofen 9 PENICILLIN G pindolol 49 OXYCONTIN 7 PROCAINE 122 pioglitazone hcl 24 oxymorphone hcl 7 penicillin g sodium 122 pioglitazone hcl-glimepiride 24 OZEMPIC 24 penicillin v potassium 122 pioglitazone hcl-metformin paclitaxel 41 PENLAC NAIL LACQUER 59 hcl 24 PIP LANCETS/28G 85 paliperidone 43 PENTACEL 127 PIP LANCETS/30G 85 palonosetron hcl 26 pentazocine w/ naloxone 9 piperacillin sodium-tazobactam PALYNZIQ 68 pentoxifylline 73 sodium 122 PAMELOR 23 PEPCID 127 PIQRAY 200MG DAILY pamidronate disodium 67 PEPCID AC 127 DOSE 39 PIQRAY 250MG DAILY PAMIDRONATE DISODIUM 67 PEPCID AC MAXIMUM STRENGTH 127 DOSE 39 pamidronate disodium 67 PERCOCET 9 PIQRAY 300MG DAILY PANRETIN 59 DOSE 39 PERFECT LANCETS 30G 85 piroxicam 5 pantoprazole sodium 128 PERFECT PRESSURE PARAGARD INTRAUTERINE ACTIVATED SAFETY PLAN B ONE-STEP 54 COPPER CONTRACEPTIVE LANCETS 28G 85 PLAQUENIL 34 T380A 54 PERIDEX 116 PLASMA-LYTE A 114 parenteral electrolytes 114 perindopril erbumine 31 PLASMA-LYTE-148 114 paricalcitol 68 PERJETA 36 PLAVIX 73 PARLODEL 42 permethrin 65 PLEGISOL 51 PARNATE 21 perphenazine 44 PLEGRIDY 124 paromomycin sulfate 3 perphenazine-amitriptyline PLEGRIDY STARTER paroxetine hcl 22 124 PACK 124 PASER 35 PERSERIS 43 PNEUMOVAX 23 129 PATADAY 121 PHARMACY COUNTER PNEUMOVAX 23/1 DOSE 129 PATANASE 118 LANCETS 85 podofilox 64 phenazopyridine hcl 72 PATANOL 121 polymyxin b sulfate 12 phendimetrazine tartrate 1 PAXIL 22 polymyxin b-trimethoprim 119 phenelzine sulfate 21 PAXIL CR 22 POLYTRIM 119 PHENERGAN 29 PC LANCETS SUPER THIN POMALYST 38 phenobarbital 74 30G 85 potassium acetate 114 PEDIAPRED 55 phenoxybenzamine hcl 31 potassium bicarbonate 114 PEDIARIX 127 phentermine hcl 2 potassium chloride 114 PEDVAX HIB 129 PHENYTEK 20 POTASSIUM CHLORIDE 114 peg 3350-kcl-nacl-na sulfate-na phenytoin 20 potassium chloride 114 ascorbate-ascorbic acid 75 phenytoin sodium 20 peg 3350-kcl-sod bicarb-sod potassium chloride in chloride-sod sulfate 75 phenytoin sodium dextrose 114 extended 20 PEGANONE 20 potassium chloride in dextrose & PHEXXI 132 sodium chloride 114 PEGASYS 48 PHOSLYRA 71 potassium chloride in nacl 114 PEGASYS PROCLICK 48 PHOSPHOLINE IODIDE 119 potassium chloride PEGINTRON 48 PHOTOFRIN 40 microencapsulated crystals PEMAZYRE 39 er 114 PICATO 60 penicillamine 115 POTASSIUM PIFELTRO 46 CHLORIDE/DEXTROSE/LACTA penicillin g potassium 122 pilocarpine hcl 119 TED RINGERS 114 pilocarpine hcl (oral) 116

Index 24 POTASSIUM PREFERRED PLUS INSULIN PREVNAR 13 129 CHLORIDE/SODIUM SYRINGE/U-100/0.5ML/28G X PREZCOBIX 46 CHLORIDE 114 1/2" 103 potassium citrate PREFERRED PLUS INSULIN PREZISTA 46 (alkalinizer) 72 SYRINGE/U-100/0.5ML/29G X PRIFTIN 35 potassium phosphates 114 1/2" 104 PRILOSEC OTC 128 pramipexole dihydrochloride 42 PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/30G X primaquine phosphate 34 prasugrel hcl 73 5/16" 104 PRIMAQUINE PHOSPHATE 34 PRAVACHOL 30 PREFERRED PLUS INSULIN PRIMAXIN IV 11 pravastatin sodium 30 SYRINGE/U-100/1ML/28G X primidone 19 1/2" 104 praziquantel 10 PREFERRED PLUS INSULIN PRINIVIL 31 prazosin hcl 31 SYRINGE/U-100/1ML/29G X PRISTIQ 22,23 PRECISION SURE-DOSE 1/2" 104 PRO COMFORT INSULIN INSULIN SYRINGE/0.3ML/30G X PREFERRED PLUS INSULIN SYRINGES/0.5ML/30G X 5/16" 103 SYRINGE/U-100/1ML/30G X 1/2" 104 PRECISION SURE-DOSE 5/16" 104 PRO COMFORT INSULIN INSULIN SYRINGE/0.5ML/28G X PREFERRED PLUS LANCETS SYRINGES/0.5ML/30G X 1/2" 103 COLORED 21G 86 5/16" 104 PRECISION SURE-DOSE PREFERRED PLUS LANCETS PRO COMFORT INSULIN INSULIN SYRINGE/0.5ML/29G X SUPER THIN 30G 86 SYRINGES/0.5ML/31G X 1/2" 103 PREFERRED PLUS LANCETS 5/16" 104 PRECISION SURE-DOSE THIN 26G 86 PRO COMFORT INSULIN INSULIN SYRINGE/0.5ML/30G X pregabalin 19 SYRINGES/1ML/30G X 3/8" 103 pregabalin (once-daily) 125 1/2" 104 PRECISION SURE-DOSE PRO COMFORT INSULIN INSULIN SYRINGE/1ML/28G X PREGNYL W/DILUENT BENZYLALCOHOL/NACL 67 SYRINGES/1ML/30G X 1/2" 103 5/16" 104 PRECISION SURE-DOSE PREMARIN 70 PRO COMFORT INSULIN PLUSINSULIN PREMIUM CONDOMS SYRINGES/1ML/31G X SYRINGE/0.3ML/29G X LUBRICATED 77 5/16" 104 1/2" 103 PREMPHASE 69 PROAIR HFA 15 PRECISION SURE-DOSE PREMPRO 69 probenecid 72 PLUSINSULIN PRENATAL 117 SYRINGE/1ML/29G X 1/2" 103 procainamide hcl 13 PRECISION THINS GP PRENATAL LOW IRON 116 PROCARDIA 50 LANCET 86 PRENATAL PROCARDIA XL 50 PRECISION XTRA 65 MULTIVITAMIN 116 prochlorperazine 44 PRECOSE 23 PRENATAL ONE DAILY 116 prochlorperazine maleate 44 PRED FORTE 120 PRENATAL VITAMIN 117 PRENATAL VITAMIN & PROCRIT 74 PRED MILD 120 MINERAL 117 PROCTOCORT 10 prednicarbate 63 PRENATAL PRODIGY INSULIN SYRING/U- prednisolone 55 VITAMIN/IRON 117 100/0.3ML/31G X 5/16" 104 prednisolone acetate PRENATAL VITAMINS 117 PRODIGY INSULIN (ophth) 120 PRENATAL VITAMINS PLUS SYRINGE/1/2ML/31G X prednisolone sodium LOW IRON 117 5/16" 104 phosphate 55 PRENATRIX 117 PRODIGY INSULIN PREDNISOLONE SODIUM PRENATRYL 117 SYRINGE/1ML/28G X 1/2" 104 PHOSPHATE 120 PRODIGY LANCING prednisone 55 PREPLUS 117 DEVICE 86 PREFERRED PLUS INSULIN PREPOPIK 75 PRODIGY PRESSURE SYRINGE/U-100/0.3ML/29G X PRESSURE ACTIVATED ACTIVATED SAFETY 1/2" 103 SAFETYLANCET 21G 86 LANCETS 86 PREFERRED PLUS INSULIN PREVACID 128 PRODIGY SAFETY LANCETS 86 SYRINGE/U-100/0.3ML/30G X PREVACID 24HR 128 5/16" 103

Index 25 PRODIGY TWIST TOP pyridostigmine bromide 34 ranitidine hcl 127 LANCETS 86 pyrimethamine 34 ranolazine 12 progesterone 123 QC ADVANCED LANCING RAPAFLO 72 PROGLYCEM 24 DEVICE 86 RAPAMUNE 115 PROGRAF 115 QC LANCETS SUPER rasagiline mesylate 42 PROLASTIN-C 125 THIN 86 QC LANCETS ULTRA RAZADYNE 124 PROLEUKIN 40 THIN 86 RAZADYNE ER 124 PROLIA 67 QC PRENATAL 117 READYLANCE SAFETY PROMACTA 74 QC UNILET LANCETS LANCETS/21G/2.2MM 86 promethazine hcl 29 28G/ULTRA THIN 86 READYLANCE SAFETY QC UNILET LANCETS PROMETRIUM 123 LANCETS/23G/1.8MM 86 33G/MICRO THIN 86 READYLANCE SAFETY propafenone hcl 13 QINLOCK 39 LANCETS/26G/1.8MM 86 proparacaine hcl 120 QUADRACEL 127 READYLANCE SAFETY propranolol hcl 49 LANCETS/28G/1.8MM 86 QUALAQUIN 34 READYLANCE SAFETY propylthiouracil 126 QUARTETTE 53 LANCETS/30G/1.6MM 86 PROSCAR 72 QUDEXY XR 19 REALITY INSULIN SYRINGE/U- PROTONIX 128 QUESTRAN 30 100/0.5ML/28G X 1/2" 104 PROTOPIC 64 REALITY INSULIN SYRINGE/U- QUESTRAN LIGHT 30 100/0.5ML/29G X 1/2" 104 protriptyline hcl 23 quetiapine fumarate 44 REALITY INSULIN SYRINGE/U- PROVENTIL HFA 15 quinapril hcl 31 100/1ML/28G X 1/2" 104 PROVERA 123 quinapril-hydrochlorothiazide REALITY INSULIN SYRINGE/U- 100/1ML/29G X 1/2" 104 PROVIGIL 3 32,33 quinidine sulfate 13 REALITY LANCETS 86 PROZAC 22 REALITY LATEX PRUDOXIN 60 quinine sulfate 34 CONDOMS/LUBRICATED 77 PSORCON 63 QVAR REDIHALER 14 REALITY LATEX/ULTRA PSS SELECT GP LANCETS 86 RA E-ZJECT LANCETS TEXTURED 77 28G 86 REALITY LATEX/ULTRA PSS SELECT SAFETY RA E-ZJECT LANCETS THIN THIN 77 LANCETS 86 26G 86 REALITY TRIGGER PTS PANELS KETONE RA E-ZJECT LANCETS THIN LANCETS 86 TEST 65 28G 86 REBIF 124 PULMICORT 14 RA E-ZJECT LANCETS REBIF REBIDOSE 124 ULTRATHIN 30G 86 PULMICORT FLEXHALER 14 REBIF REBIDOSE PULMOZYME 125 RA INSULIN SYRINGE/0.5ML/29G X TITRATIONPACK 124 PUSH BUTTON SAFETY REBIF TITRATION PACK 124 LANCETS 21G 86 1/2" 104 PUSH BUTTON SAFETY RA INSULIN RECLAST 67 LANCETS 28G 86 SYRINGE/1ML/29G X RECOMBIVAX HB 131 PX ADVANCED LANCING 1/2" 104 RA INSULIN SYRINGE/U- RECTIV 10 DEVICE 86 REGLAN 71 PX INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 104 100/0.5ML/30G X 1/2" 104 RA INSULIN SYRINGE/U- REGRANEX 65 PX LANCET AUTO 100/1 ML/30G X 5/16" 104 RELENZA DISKHALER 48 INJECTOR 86 RA PRENATAL 117 RELION 2-IN-1 LANCET PX LANCETS ULTRA THIN 86 RA PRENATAL DEVICES 30G 86 PX LANCETS ULTRA THIN FORMULA/FOLICACID 117 RELION 2-IN-1 LANCING 28G 86 rabeprazole sodium 128 DEVICE 25G 86 PX PRENATAL raloxifene hcl 68 RELION 2-IN-1 LANCING MULTIVITAMINS 117 ramelteon 75 DEVICE 30G 86 pyrazinamide 35 RELION INSULIN SYRINGE ramipril 31 1ML/31GX15/64" 104 PYRIDIUM 72 RANEXA 12 RELION INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 104

Index 26 RELION INSULIN SYRINGE/U- RETROVIR 46 ROZLYTREK 39 100/0.5ML/29G X 1/2" 104 RETROVIR IV INFUSION 46 RUBRACA 39 RELION INSULIN SYRINGE/U- 100/0.5ML/31G X 5/16" 104 REVATIO 51 RUCONEST 73 RELION INSULIN SYRINGE/U- REVLIMID 115 rufinamide 19 100/1ML/31G X 15/64" 104 REXALL LANCETS ULTRA RUKOBIA 46 RELION INSULIN SYRINGE/U- THIN 87 RUXIENCE 36 100/1ML/31G X 5/16" 104 REXULTI 44 RELION KETONE TEST RUZURGI 34 REYATAZ 46 STRIPS 65 RYTHMOL SR 13 RIBASPHERE 48 RELION LANCETS MICRO- SABRIL 19 THIN33G 86 RIBASPHERE RIBAPAK 48 SAFE-T-LANCE LOW FLOW RELION LANCETS THIN ribavirin (hepatitis c) 48 26G 86 25G 87 RELION LANCETS ULTRA- RIDAURA 4 SAFE-T-LANCE NORMAL THIN30G 86 rifabutin 35 FLOW21G 87 SAFE-T-LANCE PLUS RELION LANCING DEVICE 86 RIFADIN 35 SAFETYLANCET HIGH RELION TRUE METRIX RIFAMATE 34 FLOW 87 BLOODGLUCOSE TEST rifampin 35 SAFE-T-LANCE PLUS STRIPS 65 SAFETYLANCET LOW RELION ULTRA THIN RIFATER 34 FLOW 87 LANCETS/30G 86 RIGHT STEP SAFE-T-LANCE PLUS RELION ULTRA THIN PRENATAL 117 SAFETYLANCET NORMAL LANCETS30G 87 RIGHTEST GD500 LANCING FLOW 87 RELION ULTRA THIN PLUS DEVICE 87 SAFESNAP INSULIN LANCETS 32G 87 RIGHTEST GL300 SYRINGE/0.3ML/30G X RELION ULTRA THIN PLUS LANCETS 87 5/16" 105 LANCETS 33G 87 RILUTEK 118 SAFESNAP INSULIN RELISTOR 71 riluzole 118 SYRINGE/0.5ML/29G X RELPAX 112 rimantadine hydrochloride 48 1/2" 105 REMERON 20 SAFESNAP INSULIN ringer's 114 SYRINGE/0.5ML/30G X REMERON SOLTAB 20 ringer's irrigation 116 5/16" 105 RENFLEXIS 71 RINVOQ 4 SAFESNAP INSULIN RENVELA 71 risedronate sodium 67 SYRINGE/1ML/28G X 1/2" 105 REOPRO 73 SAFESNAP INSULIN RISPERDAL 43 SYRINGE/1ML/29G X 1/2" 105 repaglinide 25 RISPERDAL CONSTA 43 SAFETY INSULIN SYRINGES repaglinide-metformin hcl 24 risperidone 43 0.5ML/29GX1/2" 105 REPATHA 30 SAFETY INSULIN SYRINGES RITALIN 3 0.5ML/30GX5/16" 105 REPATHA PUSHTRONEX RITALIN LA 3 SYSTEM 30 SAFETY INSULIN SYRINGES 1ML/27GX1/2" 105 REPATHA SURECLICK 30 ritonavir 46 RITUXAN 36 SAFETY INSULIN SYRINGES REQUIP XL 42 1ML/29GX1/2" 105 RESCRIPTOR 46 rivastigmine tartrate 124 SAFETY INSULIN SYRINGES RESECTISOL 72 rizatriptan benzoate 113 1ML/30GX1/2" 105 ROBAXIN-750 117 SAFETY LANCET RESTASIS 120 21G/PRESSURE RESTASIS MULTIDOSE 120 ROCALTROL 68 ACTIVATED 87 RESTORIL 75 ROMIDEPSIN 39 SAFETY LANCET 23G/PRESSURE RETACRIT 74 ropinirole hydrochloride 42 rosuvastatin calcium 30 ACTIVATED 87 RETEVMO 39 SAFETY LANCET RETIN-A 57 ROTARIX 131 28G/PRESSURE RETIN-A MICRO 57 ROTATEQ 131 ACTIVATED 87 SAFETY LANCETS 21G 87 RETIN-A MICRO PUMP 57 ROXICODONE 8 ROZEREM 75 SAFETY LANCETS 28G 87

Index 27 SAFETY LET LANCETS 87 SHOPKO AUTOLET LANCING SMART SENSE SUPER THIN SAFYRAL 53 DEVICE 87 LANCETS UNIVERSAL 30G 87 SHOPKO ON-THE-GO SMART SENSE THIN SAIZEN 68 COMFORTLANCETS 30G 87 LANCETSUNIVERSAL 26G 87 SAIZENPREP SHOPKO UNILET LANCETS SMARTEST LANCETS 28G 87 RECONSTITUTIONKIT 68 SUPER THIN 30G 87 SODIUM ACETATE 113 SALAGEN 116 SHOPKO UNILET LANCETS sodium acetate 113 salsalate 6 ULTRA THIN 28G 87 sodium chloride 114 SAMSCA 69 SHUR-SEAL 131 SIDE BUTTON SAFETY sodium chloride (gu irrigant) 72 SANDIMMUNE 115 LANCET21G 87 sodium chloride (inhalant) 56 SANDOSTATIN 69 SIGNIFOR 69 sodium citrate & citric acid 72 SANTYL 64 sildenafil citrate 51 sodium fluoride 114 SAPHRIS 44 sildenafil citrate (pulmonary sodium phenylbutyrate 69 sapropterin dihydrochloride 68 hypertension) 51 SILENOR 74 sodium polystyrene SAVELLA 124 sulfonate 116 SAVELLA TITRATION silodosin 72 SOFOSBUVIR/ PACK 124 SILVADENE 61 48 SB INSULIN SYRINGE/U- silver sulfadiazine 61 solifenacin succinate 129 100/0.5ML/29G X 1/2" 105 SB INSULIN SYRINGE/U- SIMBRINZA 119 SOLIRIS 73 100/0.5ML/30G X 5/16" 105 SIMPLE DIAGNOSTICS SOLOSEC 3 SB INSULIN SYRINGE/U- LANCING DEVICE 87 SOLU-CORTEF 55 100/1ML/29G X 1/2" 105 SIMULECT 115 SOLU-MEDROL 55 SB INSULIN SYRINGE/U- simvastatin 30 100/1ML/30G X 5/16" 105 SOLUS V2 LANCING SB INSULIN SYRINGE/U- SINEMET 42 DEVICE 87 100/1ML/31G X 5/16" 105 SINEMET CR 42 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS SB LANCETS THIN 87 SINGLE-LET 87 28G 87 SB LANCETS ULTRA THIN 87 SINGULAIR 14 SOLUS V2 TWIST LANCETS scopolamine 26 sirolimus 115 30G 87 SEASONIQUE 53 SIRTURO 35 SOMA 117 SECURESAFE SAFETY SIVEXTRO 12 SOMATULINE DEPOT 69 INSULIN SYRINGES/U- SKELAXIN 117 SOMAVERT 67 100/0.5ML/29GX1/2" 105 SOOLANTRA 64 SECURESAFE SAFETY SKLICE 65 INSULIN SYRINGES/U- SKYLA 54 SORBITOL 72 100/1ML/29GX1/2" 105 SKYRIZI 60 SORBITOL-MANNITOL 72 SEGLUROMET 24 SKYRIZI PEN 60 SORBITOL/MANNITOL SELECT-LITE LANCING IRRIGATION 72 DEVICE 87 SLO-NIACIN 133 SORIATANE 60 selegiline hcl 42 SLYND 54 sotalol hcl 49 selenium sulfide 61 SM MICRO THIN LANCETS 33G 87 sotalol hcl (afib/afl) 49 SELZENTRY 46 SM PRENATAL spinosad 65 SENSIPAR 69 VITAMINS 117 SPIRIVA HANDIHALER 14 SEREVENT DISKUS 15 SM TRUEDRAW LANCING SPIRIVA RESPIMAT 14 DEVICE 87 SEROQUEL 44 SMART DIABETES VANTAGE spironolactone 66 SEROQUEL XR 44 LANCING DEVICE 87 spironolactone & SEROSTIM 68 SMART SENSE COLOR hydrochlorothiazide 66 sertraline hcl 22 LANCETS UNIVERSAL SPORANOX 28 33G 87 SPORANOX PULSEPAK 28 sevelamer carbonate 71 SMART SENSE STANDARD SHINGRIX 131 LANCETS UNIVERSAL SPRAVATO 56MG DOSE 21 21G 87 SPRAVATO 84MG DOSE 21

Index 28 SPRYCEL 39 SUPER THIN LANCETS 88 SURE COMFORT LANCETS STALEVO 100 42 SUPRAX 52 30G 88 SURE COMFORT LANCING STALEVO 125 42 SUPREP BOWEL PREP PEN 88 STALEVO 150 42 KIT 75 SURE-JECT INSULIN SURE COMFORT INSULIN STALEVO 200 42 SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/0.3ML/29G X 1/2" 106 STALEVO 50 42 1/2" 105 SURE-JECT INSULIN STALEVO 75 42 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/30G X 5/16" 106 stannous fluoride 116 1/2" 105 STARLIX 25 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X stavudine 46 SYRINGE/U-100/0.3ML/30G X 5/16" 106 STAVUDINE 47 5/16" 105 SURE-JECT INSULIN SURE COMFORT INSULIN STEGLATRO 25 SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.3ML/31G X 1/2" 106 STELARA 61,71 5/16 105 SURE-JECT INSULIN STENDRA 51 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X STERILANCE TL 88 SYRINGE/U-100/0.3ML/31G X 1/2" 106 5/16" 105 STIMATE 69 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X STIVARGA 39 SYRINGE/U-100/0.5ML/28G X 5/16" 106 STRATTERA 2 1/2" 105 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X streptomycin sulfate 3 SYRINGE/U-100/0.5ML/29G X STRIBILD 47 5/16" 106 1/2" 105 SURE-JECT INSULIN STRIVERDI RESPIMAT 15 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X STROMECTOL 10 SYRINGE/U-100/0.5ML/30G X 1/2" 106 1/2" 105 SUBOXONE 9 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X SUBSYS 8 SYRINGE/U-100/0.5ML/30G X 1/2" 106 SUCRAID 65 5/16" 105 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X sucralfate 128 SYRINGE/U-100/0.5ML/31G X SULAR 50 5/16" 106 5/16 105 SURE-JECT INSULIN sulconazole nitrate 59 SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X sulfacetamide sodium (acne)57 SYRINGE/U-100/1ML/28G X 5/16" 106 sulfacetamide sodium 1/2" 105 SURE-LANCE FLAT (ophth) 119 SURE COMFORT INSULIN LANCETS 88 sulfacetamide sodium w/ SYRINGE/U-100/1ML/29G X SURE-LANCE LANCETS sulfur 57 1/2" 106 26G 88 sulfacetamide sodium-sulfur in SURE COMFORT INSULIN SURE-LANCE THIN LANCETS urea vehicle 57 SYRINGE/U-100/1ML/30G X 28G 88 1/2" 106 SURE-LANCE ULTRA THIN SULFADIAZINE 126 SURE COMFORT INSULIN sulfamethoxazole-trimethoprim LANCETS 88 SYRINGE/U-100/1ML/30G X SURE-PEN 88 11 5/16" 106 SULFAMYLON 61 SURE COMFORT INSULIN SURE-TOUCH LANCETS sulfasalazine 71 SYRINGE/U-100/1ML/31G X UNIVERSAL 88 SURELITE LANCETS 88 sulindac 5 5/16" 106 SURE COMFORT LANCETS SUSTIVA 47 SUMADAN WASH 57 18G 88 SUTENT 39 sumatriptan 113 SURE COMFORT LANCETS SYLATRON 40 sumatriptan succinate 113 21G 88 sumatriptan-naproxen SURE COMFORT LANCETS SYMBICORT 15 sodium 112 23G 88 SYMFI 47 SURE COMFORT LANCETS SYMFI LO 47 sunitinib malate 39 28G 88 SUNOSI 2 SYMLINPEN 120 23

Index 29 SYMLINPEN 60 23 TECHLITE INSULIN TENORETIC 100 33 SYMTUZA 47 SYRINGEU-100/0.3ML/30G X TENORETIC 50 33 5/16" 106 SYNALAR 63 TECHLITE INSULIN TENORMIN 49 SYNAREL 68 SYRINGEU-100/0.3ML/31G X TEPADINA 35 SYNERA 64 5/16" 106 terazosin hcl 31 TECHLITE INSULIN SYNJARDY 24 SYRINGEU-100/0.5ML/29G X terbinafine hcl 27 SYNJARDY XR 24 1/2" 106 terbutaline sulfate 15 SYNRIBO 40 TECHLITE INSULIN terconazole vaginal 132 SYNTHROID 126 SYRINGEU-100/0.5ML/30G X TESSALON PERLES 55 1/2" 106 SYPRINE 115 TECHLITE INSULIN TESTIM 10 TABLOID 36 SYRINGEU-100/0.5ML/30G X TESTOSTERONE TABRECTA 39 5/16" 106 CYPIONATE 10 testosterone cypionate 10 TACLONEX 63 TECHLITE INSULIN SYRINGEU-100/0.5ML/31G X testosterone enanthate 10 tacrolimus 115 5/16" 106 TETANUS/DIPHTHERIA tacrolimus (topical) 64 TECHLITE INSULIN TOXOIDS-ADSORBED tadalafil 51 SYRINGEU-100/1ML/29G X ADULT 127 tadalafil (pulmonary 1/2" 106 tetrabenazine 124 hypertension) 51 TECHLITE INSULIN SYRINGEU-100/1ML/30G X tetracycline hcl 126 TAFINLAR 39 1/2" 106 TGT LANCET MICRO THIN TAGAMET HB 127 TECHLITE INSULIN 33G 88 TAKHZYRO 73 SYRINGEU-100/1ML/30G X TGT LANCET THIN 26G 88 TALZENNA 39 5/16" 106 TGT LANCET ULTRA THIN TECHLITE INSULIN 30G 88 TAMIFLU 49 SYRINGEU-100/1ML/31G X TGT LANCING DEVICE 88 tamoxifen citrate 37 15/64" 107 THALOMID 115 tamsulosin hcl 72 TECHLITE INSULIN theophylline 15,16 TAPAZOLE 126 SYRINGEU-100/1ML/31G X 5/16" 107 THERANATAL CORE TARCEVA 36 TECHLITE LANCETS 88 NUTRITION 117 TARGADOX 126 TECHLITE LANCETS 30G 88 THINLETS GP LANCETS 88 TARGRETIN 40,60 TEFLARO 52 thioridazine hcl 44 TARKA 33 TEGRETOL 19 thiotepa 35 TASIGNA 39 TEGRETOL-XR 19 thiothixene 45 TASMAR 41 TEGSEDI 125 THYMOGLOBULIN 115 tavaborole 59 TEKTURNA 33 THYROGEN 65 TAXOTERE 41 telmisartan 31 thyroid 126 TAYTULLA 53 telmisartan-amlodipine 33 tiagabine hcl 20 tazarotene 61 telmisartan-hydrochlorothiazide TIAZAC 50 TAZORAC 61 33 TIBSOVO 39 TAZVERIK 39 temazepam 75 TIGAN 26 TDVAX 127 TEMIXYS 47 tigecycline 126 TECFIDERA 124 TEMODAR 35 TIKOSYN 13 TECFIDERA STARTER TEMOVATE 63 timolol maleate 49 PACK 124 temozolomide 35 timolol maleate (ophth) 119 TECHLITE AST LANCETS 88 temsirolimus 39 TIMOPTIC 119 TECHLITE INSULIN SYRINGEU- 100/0.3ML/29G X 1/2" 106 TENIPOSIDE 41 TIMOPTIC-XE 119 TECHLITE INSULIN SYRINGEU- TENIVAC 127 TIVICAY 47 100/0.3ML/30G X 1/2" 106 tenofovir disoproxil tizanidine hcl 117 fumarate 47

Index 30 TOBI 3 topiramate 19 triamterene & TOBRADEX 120 topotecan hcl 41 hydrochlorothiazide 66 triazolam 75 tobramycin 3 TOPROL XL 49 TRIBENZOR 33 tobramycin (ophth) 120 toremifene citrate 37 TRICARE 117 tobramycin sulfate 3 TORISEL 39 TRICOR 30 tobramycin- torsemide 66 TRIDESILON 63 dexamethasone 120 TOVIAZ 129 TOBREX 120 trientine hcl 115 TRACLEER 51 TODAY SPONGE 131 trifluoperazine hcl 44 tramadol hcl 8 TODAYS HEALTH ADVANCED trifluridine 120 tramadol-acetaminophen 9 LANCING DEVICE 88 trihexyphenidyl hcl 41 TODAYS HEALTH SUPER trandolapril 31 TRIJARDY XR 24 THINLANCETS 30G 88 trandolapril-verapamil hcl 33 TODAYS HEALTH ULTRA TRANDOLAPRIL/VERAPAMIL TRIKAFTA 125 THINLANCETS 28G 88 HCL ER 33 TRILEPTAL 19 TOFRANIL 23 tranexamic acid 74 trimethobenzamide hcl 27 tolbutamide 25 TRANSDERM SCOP 26 trimethoprim 10 tolcapone 41 TRANSDERM-SCOP 27 trimipramine maleate 23 tolmetin sodium 5 TRANXENE T 13 TRINTELLIX 22 TOLSURA 28 tranylcypromine sulfate 21 TRIOSTAT 126 tolterodine tartrate 129 TRAVATAN Z 121 TRIUMEQ 47 tolvaptan 69 TRAVEL LANCETS 30G 88 TRIZIVIR 47 TOPAMAX 19 TRAVEL LANCETS tropicamide 119 TOPAMAX SPRINKLE 19 ADVANCED 28G 88 trospium chloride 129 TOPCARE LANCETS MICRO- travoprost 121 TRUE COMFORT INSULIN THIN 33G 88 trazodone hcl 22 SYRINGE/0.5ML/31G X TOPCARE ULTRA COMFORT 5/16" 107 INSULIN SYRINGE/0.3ML/30G X TREANDA 35 TRECATOR 35 TRUE COMFORT INSULIN 5/16" 107 SYRINGE/1ML/31G X TOPCARE ULTRA COMFORT TRELEGY ELLIPTA 15 5/16" 107 INSULIN SYRINGE/0.3ML/31G X TRELSTAR MIXJECT 37 TRUE COMFORT PRO 5/16" 107 INSULINSYRINGE/0.5ML/30G X TOPCARE ULTRA COMFORT TREMFYA 61 5/16" 107 INSULIN SYRINGE/0.5ML/30G X treprostinil 51 TRUE COMFORT PRO 5/16" 107 TRESIBA 25 INSULINSYRINGE/0.5ML/31G X TOPCARE ULTRA COMFORT 5/16" 107 INSULIN SYRINGE/0.5ML/31G X TRESIBA FLEXTOUCH 25 tretinoin 57 TRUE COMFORT PRO 5/16" 107 INSULINSYRINGE/1ML/30G X TOPCARE ULTRA COMFORT tretinoin (chemotherapy) 40 5/16" 107 INSULIN SYRINGE/1ML/30G X tretinoin microsphere 57 TRUE COMFORT PRO 5/16" 107 INSULINSYRINGE/1ML/31G X TOPCARE ULTRA COMFORT TREXALL 36 TREXIMET 112 5/16" 107 INSULIN SYRINGE/1ML/31G X TRUE COMFORT PRO 5/16" 107 triamcinolone acetonide 55 INSULINSYRINGE/U- TOPCARE ULTRA COMFORT triamcinolone acetonide 100/0.5ML/30G X 1/2" 107 INSULIN SYRINGE/U- (mouth) 116 TRUE COMFORT PRO 100/0.3ML/29G X 1/2" 107 triamcinolone acetonide INSULINSYRINGE/U- TOPCARE ULTRA COMFORT (nasal) 118 100/1ML/30G X 1/2" 107 INSULIN SYRINGE/U- triamcinolone acetonide TRUE METRIX BLOOD 100/0.5ML/29G X 1/2" 107 (topical) 63 GLUCOSETEST STRIPS 65 TOPCARE ULTRA COMFORT triamcinolone acetonide- TRUE METRIX CONTROL INSULIN SYRINGE/U- dimethicone-silicone 63 SOLUTION LEVEL 3 88 100/1ML/29G X 1/2" 107 triamterene 66 TRUEDRAW LANCING TOPICORT 63 DEVICE 88

Index 31 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X LUBRICATED/RIBBED/STUDD SYRINGE/0.3ML/29G X 1/2" 107 ED 77 1/2" 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X LUBRICATED/SPERMICIDE SYRINGE/0.3ML/30G X 5/16" 107 78 1/2" 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X LUBRICATED/SPERMICIDE SYRINGE/0.3ML/30G X 5/16" 107 EXTRA LARGE 77 5/16" 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.5ML/28G X LUBRICATED/SPERMICIDE SYRINGE/0.5ML/28G X 1/2" 107 EXTRA STRENGTH 78 1/2" 108 TRUEPLUS INSULIN TRUSTEX NATURAL ULTICARE INSULIN SYRINGE/U-100/0.5ML/29G X CONDOMS SYRINGE/0.5ML/29G X 1/2" 107 +LUBE/LUBRICATED 78 1/2" 108 TRUEPLUS INSULIN TRUSTEX WITH ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X NONOXYNOL- SYRINGE/0.5ML/30G X 5/16" 107 9/RIBBED/STUDDED 78 1/2" 108 TRUEPLUS INSULIN TRUSTEX/RIA ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X LUBRICATED 78 SYRINGE/0.5ML/30G X 5/16" 108 TRUSTEX/RIA LUBRICATED 5/16" 108 TRUEPLUS INSULIN SPERMICIDE 78 ULTICARE INSULIN SYRINGE/U-100/1ML/28G X TRUSTEX/RIA SYRINGE/1ML/28G X 1/2" 108 1/2" 108 LUBRICATED/SPERMICIDE ULTICARE INSULIN TRUEPLUS INSULIN 78 SYRINGE/1ML/29G X 1/2" 108 SYRINGE/U-100/1ML/29G X TRUVADA 47 ULTICARE INSULIN 1/2" 108 TUKYSA 36 SYRINGE/1ML/30G X 1/2" 108 TRUEPLUS INSULIN ULTICARE INSULIN SYRINGE/U-100/1ML/30G X TURALIO 39 SYRINGE/1ML/30G X 5/16" 108 TUZISTRA XR 56 5/16" 108 TRUEPLUS INSULIN TWINRIX 131 ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X SYRINGE/U-100/1ML/31G X TWIRLA 54 5/16" 108 5/16" 108 TRUEPLUS LANCETS 26G 88 TWYNSTA 33 ULTICARE INSULIN TRUEPLUS LANCETS 28G 88 TYBLUME 53 SYRINGE/SHORT/0.3ML/31G X TYBOST 47 5/16" 108 TRUEPLUS LANCETS 28G ULTICARE INSULIN SUPER THIN 88 TYGACIL 126 SYRINGE/SHORT/0.5ML/30G X TRUEPLUS LANCETS 30G 88 TYKERB 40 5/16" 108 TRUEPLUS LANCETS 30G TYLENOL/CODEINE #3 9 ULTICARE INSULIN ULTRA THIN 88 TYLENOL/CODEINE #4 9 SYRINGE/SHORT/0.5ML/31G X TRUEPLUS LANCETS 33G 88 5/16" 108 TRUEPLUS LANCETS 33G TYMLOS 67 ULTICARE INSULIN MICRO THIN 88 TYSABRI 124 SYRINGE/SHORT/1ML/30G X TRUEPLUS SAFETY LANCETS UCERIS 10 5/16" 108 ULTICARE INSULIN 28G 88 UDENYCA 74 TRUETRACK TEST 65 SYRINGE/SHORT/1ML/31G X ULESFIA 65 TRULICITY 24 5/16" 108 ULORIC 72 ULTICARE INSULIN TRUMENBA 129 ULTI-LANCE AUTOMATIC/ SYRINGE/U-100/0.3ML/30G X TRUSOPT 121 CLEAR TIP 88 1/2" 108 TRUSTEX COLOR CONDOMS + ULTICARE INSULIN SAFETY ULTICARE INSULIN LUBE 77 SYRINGE/0.5ML/29G X SYRINGE/U-100/0.3ML/31G X TRUSTEX LUBRICATED 77 1/2" 108 5/16" 108 TRUSTEX LUBRICATED ULTICARE INSULIN SAFETY ULTICARE INSULIN EXTRALARGE 77 SYRINGE/1ML/29G X SYRINGE/U-100/0.5ML/30G X TRUSTEX LUBRICATED 1/2" 108 1/2" 108 EXTRASTRENGTH 77

Index 32 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/0.5ML/31G X SYRINGE/SHORT/0.3ML/30G 0.5ML/31GX5/16" 110 5/16" 108 X 12.7MM 109 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 1/2 UNIT/0.3ML/30GX1/2" 110 SYRINGE/U-100/1ML/30G X SYRINGE/SHORT/0.3ML/30G ULTRA FLO INSULIN SYRINGE 1/2" 108 X 5/16" 109 1/2 UNIT/0.3ML/30GX5/16" ULTICARE INSULIN ULTILET INSULIN 110 SYRINGE/U-100/1ML/31G X SYRINGE/SHORT/0.3ML/31G ULTRA FLO INSULIN SYRINGE 5/16" 109 X 5/16" 109 1/2 UNIT/0.3ML/31GX5/16" ULTICARE INSULIN ULTILET INSULIN 110 SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/30G ULTRA FLO INSULIN SYRINGE 100/0.3ML/31G X 5/16" 109 X 5/16" 109 1M/29GX1/2" 110 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/31G 1ML/30GX1/2" 110 100/0.5ML/31G X 5/16" 109 X 5/16" 109 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 1ML/30GX5/16" 110 SYRINGEULTRAFINE U- SYRINGE/SHORT/1ML/30G X ULTRA FLO INSULIN SYRINGE 100/1ML/31G X 5/16" 109 5/16" 109 1ML/31GX5/16" 110 ULTIGUARD SAFEPACK ULTILET INSULIN ULTRA THIN LANCETS INSULIN SYRINGE 0.3ML/30G X SYRINGE/SHORT/1ML/31G X 31G 89 1/2"/SHARPS C 109 5/16" 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/U-100/0.3ML/29G X INSULIN SYRINGE 1/2ML 30G X SYRINGE/U-100/0.5ML/30G X 1/2" 110 1/2"/SHARPS C 109 1/2" 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/U-100/0.3ML/30G X INSULIN SYRINGE 1ML 30G X SYRINGE/U-100/1ML/30G X 5/16" 110 1/2"/SHARPS CON 109 1/2" 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK ULTILET LANCETS 88 SYRINGE/U-100/0.3ML/31G X 5/16" 110 INSULIN SYRINGE 1ML 31G X ULTILET LANCETS 33G 88 5/16"/SHARPS CO 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK ULTILET SAFETY LANCETS SYRINGE/U-100/0.5ML/28G X INSULIN SYRINGE/0.3ML/30G X 21G X 2.2MM 88 1/2" 110 ULTILET SAFETY LANCETS 1/2"/SHARPS C 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK 23G 89 SYRINGE/U-100/0.5ML/29G X ULTRA COMFORT INSULIN 1/2" 110 INSULIN SYRINGE/0.3ML/31G X SYRINGE/U-100/0.3ML/30G X 5/16"/SHARPS 109 ULTRA-COMFORT INSULIN ULTIGUARD SAFEPACK 5/16" 109 SYRINGE/U-100/0.5ML/30G X ULTRA FLO INSULIN 5/16" 110 INSULIN SYRINGE/0.5ML/30G X SYRINGE 0.3ML/29G X 1/2"/SHARPS C 109 ULTRA-COMFORT INSULIN ULTIGUARD 1/2" 110 SYRINGE/U-100/0.5ML/31G X ULTRA FLO INSULIN 5/16" 110 SAFEPACK/SYRINGE/NEEDLE/ SYRINGE 31G X 5/16"/SHARPS ULTRA-COMFORT INSULIN 0.3ML/30GX1/2" 110 SYRINGE/U-100/1ML/28G X CONTAIN 109 ULTRA FLO INSULIN ULTILET CLASSIC 1/2" 110 SYRINGE LANCETS 88 ULTRA-COMFORT INSULIN 0.3ML/30GX5/16" 110 SYRINGE/U-100/1ML/29G X ULTILET INSULIN ULTRA FLO INSULIN SYRINGE/0.3ML/30G X 1/2" 110 SYRINGE 8MM 109 ULTRA-COMFORT INSULIN 0.3ML/31GX5/16" 110 SYRINGE/U-100/1ML/30G X ULTILET INSULIN ULTRA FLO INSULIN SYRINGE/0.3ML/31G X 5/16" 110 SYRINGE 8MM 109 ULTRA-COMFORT INSULIN 0.5ML/29GX1/2" 110 SYRINGE/U-100/1ML/31G X ULTILET INSULIN ULTRA FLO INSULIN SYRINGE/0.5ML/30G X 5/16" 110 SYRINGE 8MM 109 ULTRA-THIN II AUTO 0.5ML/30GX1/2" 110 LANCET 89 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE/1ML/30G X 8MM109 ULTRA-THIN II INSULIN ULTILET INSULIN SYRINGE SYRINGE SHORT/U- SYRINGE/1ML/31G X 8MM109 0.5ML/30GX5/16" 110 100/0.3ML/30GX5/16" 110

Index 33 ULTRA-THIN II INSULIN UNILET G.P. LANCET 89 valproic acid 20 SYRINGE SHORT/U- UNILET G.P. SUPERLITE valrubicin 38 100/0.3ML/31GX5/16" 111 LANCET 89 valsartan 31 ULTRA-THIN II INSULIN UNILET GP 28 ULTRA SYRINGE SHORT/U- THIN 89 valsartan-hydrochlorothiazide 33 100/0.5ML/30GX5/16" 111 UNILET LANCET 89 VALSTAR 38 ULTRA-THIN II INSULIN UNILET LANCETS MICRO- SYRINGE SHORT/U- THIN33G 89 VALTOCO 17 100/0.5ML/31GX5/16" 111 UNILET LANCETS SUPER- VALTREX 48 ULTRA-THIN II INSULIN THIN30G 89 SYRINGE SHORT/U- VALUE HEALTH INSULIN UNILET LANCETS ULTRA- SYRINGE/U-100/0.5ML/29G X 100/1ML/30GX5/16" 111 THIN 28G 89 ULTRA-THIN II INSULIN 1/2" 111 UNILET SUPERLITE VALUE HEALTH INSULIN SYRINGE SHORT/U- LANCET 89 100/1ML/31GX5/16" 111 SYRINGE/U-100/1ML/29G X ULTRA-THIN II INSULIN UNISTIK 3 GENTLE 89 1/2" 111 SYRINGE/U- UNISTIK PRO SAFETY VALUE PLUS LANCETS 100/0.5ML/29GX1/2" 111 LANCET 21G 89 STANDARD 21G 89 ULTRA-THIN II INSULIN UNISTIK PRO SAFETY VALUE PLUS LANCETS SYRINGE/U-100/1ML/29GX1/2" LANCET 25G 89 SUPERTHIN 30G 89 111 UNISTIK PRO SAFETY VALUE PLUS LANCETS THIN ULTRA-THIN II LANCETS LANCET 28G 89 26G 89 28G 89 UNISTIK SAFETY LANCETS VALUE PLUS LANCING ULTRA-THIN II LANCETS 28G 89 DEVICE 89 30G 89 UNISTIK SAFETY LANCETS VALUMARK LANCET SUPER ULTRACARE INSULIN 30G 89 THIN 30G 89 SYRINGE/U-100/0.3ML/30G X UNISTIK TOUCH SAFETY VALUMARK LANCET ULTRA 5/16" 111 LANCETS 21G 89 THIN 28G 89 ULTRACARE INSULIN UNISTIK TOUCH SAFETY VANCOCIN 11 SYRINGE/U-100/0.3ML/31G X LANCETS 23G 89 VANCOCIN HCL 11 UNISTIK TOUCH SAFETY 5/16" 111 vancomycin hcl 11 ULTRACARE INSULIN LANCETS 28G 89 UNISTIK TOUCH SAFETY VANCOMYCIN SYRINGE/U-100/0.5ML/30G X HYDROCHLORIDE 11 1/2" 111 LANCETS 30G 89 UNIVERSAL 1 LANCETS VANISHPOINT INSULIN ULTRACARE INSULIN SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/30G X THIN26G 89 UNIVERSAL 1 LANCETS 1/2" 111 5/16" 111 VANISHPOINT INSULIN ULTRACARE INSULIN ULTRA THIN 30G 89 UNIVERSAL 1 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/31G X LANCETS/33G/MICRO-THIN 5/16" 111 5/16" 111 VANISHPOINT INSULIN ULTRACARE INSULIN 89 URECHOLINE 129 SYRINGE/1ML/29G X 1/2" 111 SYRINGE/U-100/1ML/30G X VANISHPOINT INSULIN 1/2" 111 UROCIT-K 10 72 SYRINGE/1ML/30G X ULTRACARE INSULIN UROXATRAL 72 5/16" 111 SYRINGE/U-100/1ML/30G X URSO 250 70 VAQTA 131 5/16" 111 ULTRACARE INSULIN URSO FORTE 70 varenicline tartrate 125 SYRINGE/U-100/1ML/31G X ursodiol 70 VARIVAX 131 5/16" 111 UTIBRON NEOHALER 15 VARUBI 27 ULTRACET 9 UVADEX 40 VASCEPA 29 ULTRAM 8 VAGIFEM 132 VASERETIC 33 UNASYN 123 valacyclovir hcl 48 VASOTEC 31 UNASYN BULK PACK 123 VALCYTE 47 VECAMYL 33 UNILET COMFORTOUCH LANCET 89 valganciclovir hcl 47 VECTIBIX 37 UNILET EXCELITE 89 VALIUM 13 VECTICAL 61 UNILET EXCELITE II 89 valproate sodium 20 VELCADE 40

Index 34 VELETRI 51 VOGELXO PUMP 10 XALKORI 40 VELPHORO 72 VOL-PLUS 117 XANAX 13 VELTIN 57 VOLTAREN 58 XANAX XR 13 VEMLIDY 48 VORAXAZE 40 XARELTO 16 venlafaxine hcl 23 voriconazole 28 XARELTO STARTER PACK 16 VENTAVIS 51 VOSEVI 48 XELJANZ 4 VENTOLIN HFA 15 VOTRIENT 40 XELJANZ XR 4 verapamil hcl 50 VP INSULIN SYRINGE/U- XELODA 36 VEREGEN 57 100/0.3ML/29G X 1/2" 111 XENAZINE 124 VPRIV 73 VERELAN 50 XEOMIN 118 VUSION 59 VERELAN PM 50 XGEVA 67 VYNDAMAX 52 VERZENIO 40 XIFAXAN 10 VYNDAQEL 52 VESICARE 129 XIGDUO XR 24 VYTORIN 29 VFEND 28 XIMINO 126 VYVANSE 1 VIAGRA 51 XOLAIR 14 WALGREENS ADVANCED VIBRAMYCIN 126 TRAVELLANCETS 28G 89 XOPENEX 15 VICTOZA 24 WALGREENS COMFORT XOPENEX CONCENTRATE 15 VIDA MIA AUTOLET ASSUREDLANCETS MICRO XOPENEX HFA 15 THIN/33G 89 LANCINGDEVICE 89 XOSPATA 40 VIDA MIA UNILET LANCETS WALGREENS COMFORT SUPER THIN 30G 89 ASSUREDLANCETS SUPER XPOVIO 100 MG ONCE VIDA MIA UNILET LANCETS THIN/28G 89 WEEKLY 38 ULTRA THIN 28G 89 WALGREENS LANCETS 90 XPOVIO 60 MG ONCE WEEKLY 38 VIDAZA 36 WALGREENS THIN XPOVIO 80 MG ONCE VIDEX EC 47 LANCETS 90 WEEKLY 38 WALGREENS ULTRA THIN XPOVIO 80 MG TWICE VIDEXPEDIATRIC 47 LANCETS 90 vigabatrin 20 WEEKLY 38 warfarin sodium 16 XTAMPZA ER 8 VIGAMOX 120 water for irrigation, sterile 116 XTANDI 37 VIIBRYD 22 WELCHOL 30 XULTOPHY 100/3.6 24 VIIBRYD STARTER PACK 22 WELLBUTRIN SR 21 XYLOCAINE 76 VIMPAT 19 WELLBUTRIN XL 21 XYLOCAINE-MPF 76 vincristine sulfate 41 WESTAB PLUS 117 XYREM 123 vinorelbine tartrate 41 WESTHROID 126 XYZAL ALLERGY 24HR 29 VIRACEPT 47 WIDE-SEAL SILICONE XYZAL ALLERGY 24HR VIRAMUNE 47 DIAPHRAGM KIT 60 78 CHILDRENS 29 VIRAMUNE XR 47 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 78 YASMIN 28 53 VIREAD 47 WIDE-SEAL SILICONE YAZ 53 VISTARIL 13 DIAPHRAGM KIT 70 78 YERVOY 36 VISTOGARD 26 WIDE-SEAL SILICONE YONSA 37 DIAPHRAGM KIT 75 78 VITAMIN D2 132 WIDE-SEAL SILICONE ZADITOR 121 VITATHELY/GINGER 117 DIAPHRAGM KIT 80 78 zafirlukast 14 VITRAKVI 40 WIDE-SEAL SILICONE zaleplon 75 VIVAGUARD LANCETS 89 DIAPHRAGM KIT 85 78 WIDE-SEAL SILICONE ZALTRAP 36 VIVAGUARD LANCING DIAPHRAGM KIT 90 78 ZANAFLEX 118 DEVICE 89 WIDE-SEAL SILICONE ZANOSAR 35 VIVELLE-DOT 70 DIAPHRAGM KIT 95 78 ZANTAC 150 MAXIMUM VIZIMPRO 37 WP THYROID 126 STRENGTH 128 VOGELXO 10 XALATAN 121 ZARONTIN 20

Index 35 ZARXIO 74 zolpidem tartrate 75 ZAVESCA 73 ZOMACTON 68 ZEGERID 128 ZOMIG 113 ZEJULA 40 ZOMIG ZMT 113 ZELBORAF 40 ZONALON 60 ZEMAIRA 125 ZONEGRAN 19 ZEMPLAR 69 zonisamide 19 ZENPEP 65 ZONTIVITY 73 ZEPATIER 48 ZORBTIVE 68 ZERVIATE 121 ZORTRESS 115 ZESTORETIC 33 ZOSTAVAX 131 ZESTRIL 31 ZOSYN 123 ZETIA 30 ZOVIRAX 48,61 ZEVRX INSULIN ZYCLARA 64 SYRINGE/0.5ML/30G X ZYCLARA PUMP 64 1/2" 111 ZEVRX INSULIN ZYDELIG 40 SYRINGE/0.5ML/30G X ZYKADIA 40 5/16" 111 ZYLOPRIM 72 ZEVRX INSULIN SYRINGE/1ML/30G X 1/2" 111 ZYMAXID 120 ZEVRX INSULIN ZYPREXA 44 SYRINGE/1ML/30G X ZYPREXA ZYDIS 44 5/16" 111 ZYRTEC ALLERGY 29 ZIAC 33 ZYRTEC CHILDRENS ZIAGEN 47 ALLERGY 29 ZIANA 57 ZYRTEC-D zidovudine 47 ALLERGY/CONGESTION 56 ZYTIGA 37 ZIEXTENZO 74 ZYVOX 12 zileuton 14 ZIOPTAN 121 ziprasidone hcl 43 ZIRABEV 36 ZIRGAN 120 ZITHROMAX 76 ZITHROMAX TRI-PAK 76 ZITHROMAX Z-PAK 76 ZOCOR 30 ZOFRAN 26 ZOHYDRO ER 8 ZOLADEX 37 zoledronic acid 67 ZOLEDRONIC ACID 67 zoledronic acid 67 ZOLEDRONIC ACID 67 ZOLINZA 40 zolmitriptan 113 ZOLOFT 22

Index 36 FROM/ ~ nh ~~althy fam1l1es™

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Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Ambetter from NH Healthy Families, você tem o direito de Portuguese: obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-265-1278 (TTY/TDD 1-855-742-0123).

Εάν εσείς ή κάποιος που βοηθάτε, έχετε ερωτήσεις σχετικά με την Ambetter from NH Healthy Families, έχετε το δικαίωμα να ζητήσετε Greek: βοήθεια και πληροφορίες στη γλώσσα σας, χωρίς χρέωση. Για να μιλήσετε με διερμηνέα, καλέστε το 1-844-265-1278 (TTY/TDD 1-855- 742-0123).

إ ذا ناك كيدل أو ىدل صخش عاست ده ئلةسأ ولح Ambetter from NH Healthy Families ل، اكيد حقل ف اي صولحل ودةعاسمالىعل اتاملوعمال يةرورضل أندونمكتغبل ةفكلتية . Arabic: ثدحتلل مع مجرتم ا صلت ـب TTY/TDD 1-855-742-0123) 1-844-265-1278) .

Serbo- Ako Vi, ili neko kome pomažete, imate pitanja u vezi Ambetter from NH Healthy Families, imate pravo na besplatnu pomoć i informaciju Croatian: na sopstvenom jeziku. Ukoliko želite da pričate sa prevodiocem, pozovite broj 1-844-265-1278 (TTY/TDD 1-855-742-0123).

Jika Anda, atau orang yang Anda bantu, memiliki pertanyaan tentang Ambetter from NH Healthy Families, Anda berhak mendapatkan Indonesian: bantuan dan informasi dalam bahasa Anda tanpa dikenakan biaya. Untuk berbicara dengan juru bicara, hubungi 1-844-265-1278 (TTY/TDD 1-855-742-0123).

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from NH Healthy Families 에 관해서 질문이 있다면 귀하는 그러한 도움과 Korean: 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 그렇게 통역사와 얘기하기 위해서는 1-844-265-1278 (TTY/TDD 1-855-742-0123) 로 전화하십시오 . В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter Russian: from NH Healthy Families вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы поговорить с переводчиком, позвоните по телефону 1-844-265-1278 (TTY/TDD 1-855-742-0123). Si oumenm, oubyen yon moun w ap ede, gen kesyon nou ta renmen poze sou Ambetter from NH Healthy Families, ou gen tout dwa French pou w jwenn èd ak enfmasyon nan lang manman w san sa pa koute w anyen. Pou w pale avèk yon entèprèt, sonnen nimewo Creole: 1-844-265-1278 (TTY/TDD 1-855-742-0123). Niba wowe cyangwa undi muntu wese uri gufasha yaba afite ikibazo kijyanye na Ambetter from NH Healthy Families, ufite Bantu: uburenganzira bwo guhabwa amakuru mu rurimi wunva utishyuye. Kugira ngo uvugane n'umusobanuzi, Hamagara 1-844-265-1278 (TTY/TDD 1-855-742-0123).

Jeżeli ty lub osoba, której pomagasz, macie pytania na temat planów oferowanych za pośrednictwem Ambetter from NH Healthy Polish: Families, macie prawo poprosić o bezpłatną pomoc i informacje w języku ojczystym. Aby skorzystać z pomocy tłumacza, zadzwoń pod numer 1-844-265-1278 (TTY/TDD 1-855-742-0123).

AMB16-NH-C-00076 Ambetter from NH Healthy Families is underwritten by Celtic Insurance Company. © 2016 NH Healthy Families. All rights reserved.