Formulary (List of Covered Drugs)

Plan Year 2021

2021 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THE FOLLOWING PLAN:

$0 Cost Share AI/AN HMO Minimum Coverage HMO Silver 70 HMO Active Choice PPO Silver Opal 25 Gold HMO Silver 70 OFF Exchange HMO Amber 50 HMO Silver Opal 50 Silver HMO Silver 73 HMO Bronze 60 HDHP HMO Platinum 90 HMO Silver 87 HMO Bronze 60 HMO Ruby 10 Platinum HMO Silver 94 HMO Gold 80 HMO Ruby 20 Platinum HMO Jade 15 HMO Ruby 40 Platinum HMO

This formulary was last updated on 4//201. This formulary is subject to change and all previous versions of the formulary no longer apply. For more recent information or other questions, please contact Chinese Community Health Plan Member Services at 1-888-775-7888 or, for TTY users, 1-877-681-8898, seven days a week from 8:00 a.m. to 8:00 p.m., or visit www.cchphealthplan.com/family-member -,-1 -,-1 " &* !# " +

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This formulary was last updated 4/1/2021. This formulary is subject to change and all previous versions of the formulary no longer apply. For more recent information or other questions, please contact Chinese Community Health Plan Member Services at 1-888-775-7888 or, for TTY users, 1-877-681-8898, seven days a week from 8:00 a.m. to 8:00 p.m., or visit www.cchphealthplan.com/family-member !!

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O Table of Contents Informational Section ...... 3 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever ...... 1 Anesthetics - Drugs for Pain and Fever ...... 9 Anorectal Preparations - Rectal Preparations ...... 9 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning ...... 9 Anti-Infective Agents - Drugs for Infections ...... 10 Antineoplastics - Drugs for Cancer ...... 22 Antiseptics and Disinfectants - Antiseptics and Disinfectants ...... 29 Biologicals - Biological Agents ...... 30 Cardiovascular Therapy Agents - Drugs for the Heart ...... 33 Central Nervous System Agents - Drugs for the Nervous System ...... 43 Chemical Dependency, Agents to Treat - Drugs for Addiction ...... 57 Chemicals-Pharmaceutical Adjuvants ...... 59 Cognitive Disorder Therapy - Drugs for the Nervous System ...... 59 Contraceptives - Drugs for Women ...... 60 Dermatological - Drugs for the Skin ...... 71 Diagnostic Agents ...... 82 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System ...... 83 Eating Disorder Therapy - Drugs for Eating Disorders ...... 83 Electrolyte Balance-Nutritional Products - Drugs for Nutrition ...... 83 Endocrine - Hormones ...... 98 Gastrointestinal Therapy Agents - Drugs for the Stomach ...... 109 Genitourinary Therapy - Drugs for the Urinary System ...... 116 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever ...... 119 Hematological Agents - Drugs for the Blood ...... 119 Immunosuppressive Agents - Drugs for Organ Transplants ...... 122 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones ...... 123 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment ...... 124 Medical Supply, FDB Superset ...... 173 Metabolic Modifiers - Drugs that Alter Metabolism ...... 208 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat ...... 208 Multiple Sclerosis Agents - Drugs for the Nervous System ...... 210 Ophthalmic Agents - Drugs for the Eye ...... 212 Otic (Ear) - Drugs for the Ear ...... 218 Respiratory Therapy Agents - Drugs for the Lungs...... 219 TOC-1 Vaginal Products - Drugs for Women ...... 226

TOC-2 Informational Section

Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever Analgesic Opioid Agonists - Arthritis and Pain Drugs codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Tier 1 fentanyl citrate buccal lozenge on a handle 1,200 mcg, PA; QL (120 EA per 30 Tier 1 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 Tier 1 QL (10 EA per 30 days) mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, PA; QL (120 EA per 30 200 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl Tier 2 days) citrate) hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 hydromorphone rectal suppository 3 mg Tier 1 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 Tier 3 QL (1 EA per 1 day) MG (hydrocodone bitartrate) levorphanol tartrate oral tablet 2 mg Tier 2 meperidine oral tablet 50 mg Tier 1 methadone hcl (Methadone Intensol Oral Concentrate 10 Tier 1 Mg/Ml) methadone oral concentrate 10 mg/ml Tier 1 methadone oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 methadone oral tablet 10 mg, 5 mg Tier 1 methadone oral tablet,soluble 40 mg Tier 1 methadone hcl (Methadose Oral Tablet,Soluble 40 Mg) Tier 1 morphine concentrate oral solution 100 mg/5 ml (20 Tier 1 mg/ml) morphine oral capsule,extend.release pellets 10 mg, Tier 1 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 Tier 1 mg/ml) morphine oral tablet extended release 100 mg, 15 mg, Tier 1 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg Tier 1 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Tier 2 QL (2 EA per 1 day) (tapentadol hcl)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 1 Coverage Prescription Drug Name Drug Tier Requirements and Limits oxycodone oral capsule 5 mg Tier 1 oxycodone oral concentrate 20 mg/ml Tier 1 oxycodone oral solution 5 mg/5 ml Tier 1 oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 Tier 1 mg oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 20 Tier 2 QL (4 EA per 1 day) mg, 40 mg, 80 mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR Tier 2 QL (120 EA per 30 days) 15 MG, 30 MG, 60 MG (oxycodone hcl) tramadol oral tablet 100 mg Tier 1 QL (120 EA per 30 days) tramadol oral tablet 50 mg Tier 1 tramadol oral tablet extended release 24 hr 100 mg, 200 Tier 1 mg, 300 mg tramadol oral tablet, er multiphase 24 hr 100 mg, 200 Tier 1 mg, 300 mg Analgesic Opioid Codeine Combinations - Arthritis and Pain Drugs acetaminophen-codeine oral solution 120 mg-12 mg /5 Tier 1 ml (5 ml), 120-12 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg Tier 1 /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 Tier 1 mg, 300-60 mg Analgesic Opioid Hydrocodone Combinations - Arthritis and Pain Drugs hydrocodone-acetaminophen oral solution 7.5-325 Tier 1 mg/15 ml hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5- Tier 1 325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 Tier 1 mg, 7.5-200 mg hydrocodone/ibuprofen (Xylon 10 Oral Tablet 10-200 Mg) Tier 1 Analgesic Opioid Oxycodone and Non-Salicylate Combinations - Arthritis and Pain Drugs oxycodone hcl/acetaminophen (Endocet Oral Tablet 10- Tier 1 325 Mg, 2.5-325 Mg, 7.5-325 Mg) Analgesic Opioid Oxycodone and NSAID Combinations - Arthritis and Pain Drugs PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 2 Coverage Prescription Drug Name Drug Tier Requirements and Limits ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 Analgesic Opioid Oxycodone and Salicylate Combinations - Arthritis and Pain Drugs oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 Analgesic Opioid Oxycodone Combinations - Arthritis and Pain Drugs oxycodone hcl/acetaminophen (Endocet Oral Tablet 10- Tier 1 325 Mg, 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- Tier 1 325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 Analgesic Opioid Partial-Mixed Agonists - Arthritis and Pain Drugs buprenorphine transdermal patch weekly 10 mcg/hour, Tier 3 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butorphanol nasal spray,non-aerosol 10 mg/ml Tier 1 QL (2.5 ML per 1 FILL) pentazocine-naloxone oral tablet 50-0.5 mg Tier 1 Analgesic Opioid Tramadol Combinations - Arthritis and Pain Drugs tramadol-acetaminophen oral tablet 37.5-325 mg Tier 1 Anti-inflammatory Tumor Necrosis Factor Inhibiting Agnts,TNF-alpha Sel - Arthritis and Pain Drugs CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA; SP 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SP 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA; SP (200 MG/ML X 2) (certolizumab pegol) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PA; SP; QL (2 EA per 28 Tier 4 PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) days) HUMIRA PEN PSOR-UVEITS-ADOL HS PA; SP; QL (2 EA per 28 SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL (2 EA per 28 Tier 4 (adalimumab) days) HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (3 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML Tier 4 days) (adalimumab) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 3 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (2 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 Tier 4 days) ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 Tier 4 PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) days) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 days) (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 PA; SP; QL (2 EA per 28 Tier 4 ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) days) DMARD - Anti-inflammatory Tumor Necrosis Factor Inhibiting Agents - Arthritis and Pain Drugs CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA; SP 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SP 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA; SP (200 MG/ML X 2) (certolizumab pegol) ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) PA; SP; QL (8 EA per 28 Tier 4 (etanercept) days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) PA; SP; QL (8 ML per 28 Tier 4 (etanercept) days) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) PA; SP; QL (4 ML per 28 Tier 4 (etanercept) days) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR PA; SP; QL (4 ML per 28 Tier 4 50 MG/ML (1 ML) (etanercept) days) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PA; SP; QL (2 EA per 28 Tier 4 PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) days) HUMIRA PEN PSOR-UVEITS-ADOL HS PA; SP; QL (2 EA per 28 SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL (2 EA per 28 Tier 4 (adalimumab) days) HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (3 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 Tier 4 PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 4 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 days) (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 PA; SP; QL (2 EA per 28 Tier 4 ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) days) DMARD - Antimetabolites - Arthritis and Pain Drugs methotrexate sodium injection solution 25 mg/ml Tier 1 methotrexate sodium oral tablet 2.5 mg Tier 1 OCH TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 OCH (methotrexate sodium) DMARD - Gold Compounds - Arthritis and Pain Drugs RIDAURA ORAL CAPSULE 3 MG (auranofin) Tier 2 DMARD - Immunosuppressives - Arthritis and Pain Drugs cyclosporine oral capsule 100 mg Tier 4 cyclosporine, modified (Gengraf Oral Capsule 100 Mg, 25 Tier 2 Mg) cyclosporine, modified (Gengraf Oral Solution 100 Mg/Ml) Tier 4 SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 4 (cyclosporine) DMARD - Interleukin-1 Receptor Antagonist (IL-1Ra) - Arthritis and Pain Drugs KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML Tier 4 PA; SP (anakinra) DMARD - Janus Kinase (JAK) Inhibitors - Arthritis and Pain Drugs RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 PA; SP; QL (30 EA per 30 Tier 4 MG (upadacitinib) days) XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) Tier 4 PA; SP; QL (2 EA per 1 day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Tier 4 PA; SP; QL (1 EA per 1 day) HR 11 MG (tofacitinib citrate) DMARD - Other - Arthritis and Pain Drugs penicillamine oral tablet 250 mg Tier 3 SP DMARD - Pyrimidine Synthesis Inhibitors - Arthritis and Pain Drugs leflunomide oral tablet 10 mg, 20 mg Tier 1 NSAID Analgesic and Prostaglandin Analog Combinations - Arthritis and Pain Drugs

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 6 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLANAX (NAPROXEN) ORAL TABLET 220 MG (naproxen Tier 1 sodium) flurbiprofen oral tablet 100 mg Tier 1 ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) Tier 1 ibuprofen oral drops,suspension 50 mg/1.25 ml Tier 1 ibuprofen oral suspension 100 mg/5 ml Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 INFANT'S ADVIL ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANT'S IBUPROFEN ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANT'S MOTRIN ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANTS PROFENIB ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) MEDIPROXEN ORAL TABLET 220 MG (naproxen Tier 1 sodium) naproxen oral suspension 125 mg/5 ml Tier 1 naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 Tier 1 mg naproxen sodium oral tablet 220 mg, 275 mg Tier 1 WAL-PROXEN ORAL TABLET 220 MG (naproxen Tier 1 sodium) NSAID Analgesics, (COX Non-specific) - Indole Acetic Acid Derivatives - Arthritis and Pain Drugs etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg, 500 mg Tier 1 etodolac oral tablet extended release 24 hr 400 mg, 500 Tier 1 mg, 600 mg INDOCIN ORAL SUSPENSION 25 MG/5 ML Tier 2 (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG Tier 2 (indomethacin) indomethacin oral capsule 25 mg, 50 mg Tier 1 indomethacin oral capsule, extended release 75 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 7 Coverage Prescription Drug Name Drug Tier Requirements and Limits Salicylate Analgesics - Arthritis and Pain Drugs ADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG EHB; AG: IF MALE, 45-79 $0 (aspirin) YEARS ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE EHB; AG: IF MALE, 45-79 $0 (DR/EC) 81 MG (aspirin) YEARS EHB; AG: IF MALE, 45-79 aspirin oral tablet 325 mg $0 YEARS|IF FEMALE, 55-79 YEARS EHB; AG: IF MALE, 45-79 aspirin oral tablet,chewable 81 mg $0 YEARS EHB; AG: IF MALE, 45-79 aspirin oral tablet,delayed release (dr/ec) 325 mg $0 YEARS|IF FEMALE, 55-79 YEARS EHB; AG: IF MALE, 45-79 aspirin oral tablet,delayed release (dr/ec) 81 mg $0 YEARS EHB; AG: IF MALE, 45-79 aspirin rectal suppository 600 mg $0 YEARS|IF FEMALE, 55-79 YEARS EHB; AG: IF MALE, 45-79 ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) $0 YEARS|IF FEMALE, 55-79 325 MG (aspirin) YEARS CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG EHB; AG: IF MALE, 45-79 $0 (aspirin) YEARS diflunisal oral tablet 500 mg Tier 1 EHB; AG: IF MALE, 45-79 ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) $0 YEARS|IF FEMALE, 55-79 325 MG (aspirin) YEARS EHB; AG: IF MALE, 45-79 LITE COAT ASPIRIN ORAL TABLET 325 MG (aspirin) $0 YEARS|IF FEMALE, 55-79 YEARS LO-DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE EHB; AG: IF MALE, 45-79 $0 (DR/EC) 81 MG (aspirin) YEARS salsalate oral tablet 500 mg, 750 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 8 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST JOSEPH ASPIRIN ORAL TABLET,CHEWABLE 81 MG EHB; AG: IF MALE, 45-79 $0 (aspirin) YEARS ST. JOSEPH ASPIRIN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS Anesthetics - Drugs for Pain and Fever Local Anesthetic - Amides - Drugs for Sedation lidocaine hcl laryngotracheal solution 4 % Tier 1 lidocaine topical ointment 5 % Tier 2 QL (50 GM per 30 days) Anorectal Preparations - Rectal Preparations Anorectal - Glucocorticoids - Rectal Preparations hydrocortisone topical cream with perineal applicator 1 Tier 1 %, 2.5 % hydrocortisone (Procto-Med Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) hydrocortisone (Proctozone-Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb - Rectal Preparations lidocaine hcl-hydrocortison ac rectal cream 3-0.5 % Tier 1 lidocaine hcl-hydrocortison ac rectal kit 3-0.5 % Tier 1 hydrocortisone acetate/pramoxine hcl (Proctofoam Hc Tier 2 Rectal Foam 1-1 %) Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning Antidote Others - Drugs for Overdose or Poisoning GALZIN ORAL CAPSULE 25 MG (ZINC), 50 MG (ZINC) Tier 2 (zinc acetate) WILZIN ORAL CAPSULE 25 MG (ZINC) (zinc acetate) Tier 2 Chelating Agents - Copper - Drugs for Overdose or Poisoning penicillamine oral tablet 250 mg Tier 3 SP Chelating Agents - Iron - Drugs for Overdose or Poisoning

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 18 Coverage Prescription Drug Name Drug Tier Requirements and Limits HARVONI ORAL PELLETS IN PACKET 45-200 MG PA; SP; QL (56 EA per 28 Tier 4 (ledipasvir/sofosbuvir) days) HARVONI ORAL TABLET 45-200 MG PA; SP; QL (60 EA per 30 Tier 4 (ledipasvir/sofosbuvir) days) Hepatitis C - Nucleos(t)ide Analog NS5B Polymerase Inhibitors - Drugs for Viral Infections PA; SP; QL (60 EA per 30 SOVALDI ORAL TABLET 200 MG (sofosbuvir) Tier 4 days) Hepatitis C - Nucleoside Analogs - Drugs for Viral Infections ribavirin oral capsule 200 mg Tier 1 ribavirin oral tablet 200 mg Tier 1 Herpes Antiviral Agent - Purine Analogs - Drugs for Viral Infections acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5 ml Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 valacyclovir oral tablet 1 gram, 500 mg Tier 1 Herpes Antiviral Agent - Thymidine Analogs - Drugs for Viral Infections famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1 Influenza Antiviral Agents - Neuraminidase Inhibitors - Drugs for Viral Infections oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 1 FILL) oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 1 FILL) oseltamivir oral suspension for reconstitution 6 mg/ml Tier 2 QL (250 ML per 1 FILL) RELENZA DISKHALER INHALATION BLISTER WITH Tier 2 QL (20 EA per 1 FILL) DEVICE 5 MG/ACTUATION (zanamivir) Influenza-A Antiviral Agents - Drugs for Viral Infections rimantadine oral tablet 100 mg Tier 1 Lincosamide Antibiotics - Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Tier 1 clindamycin palmitate hcl (Clindamycin Pediatric Oral Tier 1 Recon Soln 75 Mg/5 Ml) Macrolide Antibiotics - Antibiotics azithromycin oral suspension for reconstitution 100 Tier 1 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 19 Coverage Prescription Drug Name Drug Tier Requirements and Limits clarithromycin oral suspension for reconstitution 125 Tier 1 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg Tier 1 clarithromycin oral tablet extended release 24 hr 500 Tier 1 mg ST: Prior prescription for Vancomycin HCL in 120 DIFICID ORAL TABLET 200 MG ( ) Tier 3 fidaxomicin days; QL (20 EA per 30 days) erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet 400 Tier 1 Mg) erythromycin base (Ery-Tab Oral Tablet,Delayed Release Tier 1 (Dr/Ec) 250 Mg, 500 Mg) erythromycin stearate (Erythrocin (As Stearate) Oral Tier 1 Tablet 250 Mg) erythromycin ethylsuccinate oral suspension for Tier 1 reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral suspension for Tier 3 reconstitution 400 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg Tier 1 erythromycin oral capsule,delayed release(dr/ec) 250 Tier 1 mg erythromycin oral tablet 250 mg, 500 mg Tier 3 erythromycin oral tablet,delayed release (dr/ec) 250 mg, Tier 1 333 mg, 500 mg Misc Anti-Infective - Drugs for Infections methenamine hippurate oral tablet 1 gram Tier 1 methenamine mandelate oral tablet 1 gram Tier 1 NEBUPENT INHALATION RECON SOLN 300 MG Tier 2 (pentamidine isethionate) Oxazolidinone Antibiotics - Antibiotics PR: RESTRICTED TO linezolid oral suspension for reconstitution 100 mg/5 ml Tier 4 INFECTIOUS DISEASE SPECIALIST PR: RESTRICTED TO linezolid oral tablet 600 mg Tier 4 INFECTIOUS DISEASE SPECIALIST

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 20 Coverage Prescription Drug Name Drug Tier Requirements and Limits PR: RESTRICTED TO INFECTIOUS DISEASE SIVEXTRO ORAL TABLET 200 MG ( ) Tier 2 tedizolid phosphate SPECIALIST; QL (6 EA per 1 FILL) Penicillin Antibiotic - Natural - Antibiotics penicillin v potassium oral recon soln 125 mg/5 ml, 250 Tier 1 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg Tier 1 Penicillin Antibiotic - Penicillinase-resistant - Antibiotics dicloxacillin oral capsule 250 mg, 500 mg Tier 1 Protease Inhibitors (Non-Peptidic) Antiretroviral - Drugs for Viral Infections APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 Tier 4 MG/ML (tipranavir/vitamin e tpgs) APTIVUS ORAL CAPSULE 250 MG (tipranavir) Tier 4 PREZCOBIX ORAL TABLET 800-150 MG-MG (darunavir Tier 4 ethanolate/cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir Tier 4 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 Tier 4 MG (darunavir ethanolate) Protease Inhibitors (Peptidic) Antiretroviral - Drugs for Viral Infections atazanavir oral capsule 150 mg, 200 mg, 300 mg Tier 4 CRIXIVAN ORAL CAPSULE 200 MG (indinavir sulfate) Tier 4 EVOTAZ ORAL TABLET 300-150 MG (atazanavir Tier 4 sulfate/cobicistat) fosamprenavir oral tablet 700 mg Tier 2 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) Tier 4 LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir Tier 4 calcium) NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) Tier 2 REYATAZ ORAL POWDER IN PACKET 50 MG Tier 4 (atazanavir sulfate) ritonavir oral tablet 100 mg Tier 2 VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir Tier 4 mesylate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 22 Coverage Prescription Drug Name Drug Tier Requirements and Limits IRESSA ORAL TABLET 250 MG (gefitinib) Tier 4 PA; SP; OCH Antineoplastic - 3rd generation EGFR tyrosine kinase inhibitor - Drugs for Cancer TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib PA; SP; OCH; QL (1 EA per Tier 4 mesylate) 1 day) Antineoplastic - Alkylating Agent - Alkyl Sulfonates - Drugs for Cancer MYLERAN ORAL TABLET 2 MG (busulfan) Tier 4 SP; OCH Antineoplastic - Alkylating Agent - Methylhydrazines - Drugs for Cancer MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) Tier 2 SP; OCH Antineoplastic - Alkylating Agent - Nitrogen Mustards - Drugs for Cancer cyclophosphamide oral capsule 25 mg, 50 mg Tier 2 SP; OCH LEUKERAN ORAL TABLET 2 MG (chlorambucil) Tier 2 SP; OCH melphalan oral tablet 2 mg Tier 2 OCH Antineoplastic - Alkylating Agent - Nitrosoureas - Drugs for Cancer GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Tier 3 SP; OCH (lomustine) Antineoplastic - Alkylating Agent - Triazenes - Drugs for Cancer temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 Tier 4 SP; OCH mg, 250 mg, 5 mg Antineoplastic - Anaplastic Lymphoma Kinase (ALK) Inhibitors - Drugs for Cancer PA; SP; OCH; QL (8 EA per ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) Tier 4 1 day) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG PA; SP; OCH; QL (6 EA per Tier 4 (brigatinib) 1 day) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 PA; SP; OCH; QL (6 EA per Tier 4 MG (23) (brigatinib) 1 day) XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) Tier 4 PA; SP; OCH Antineoplastic - Antiandrogens - Drugs for Cancer PA; SP; OCH; QL (4 EA per abiraterone oral tablet 250 mg Tier 3 1 day) bicalutamide oral tablet 50 mg Tier 1 OCH flutamide oral capsule 125 mg Tier 1 OCH nilutamide oral tablet 150 mg Tier 4 SP; OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 23 Coverage Prescription Drug Name Drug Tier Requirements and Limits PA; SP; OCH; QL (120 EA NUBEQA ORAL TABLET 300 MG (darolutamide) Tier 4 per 30 days) PA; SP; OCH; QL (4 EA per XTANDI ORAL CAPSULE 40 MG (enzalutamide) Tier 4 1 day) PA; SP; OCH; QL (2 EA per ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) Tier 3 1 day) Antineoplastic - Antimetabolite - Folic Acid Analogs - Drugs for Cancer methotrexate sodium (pf) injection recon soln 1 gram Tier 1 methotrexate sodium (pf) injection solution 25 mg/ml Tier 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 OCH (methotrexate sodium) Antineoplastic - Antimetabolite - Purine Analogs - Drugs for Cancer mercaptopurine oral tablet 50 mg Tier 1 OCH TABLOID ORAL TABLET 40 MG (thioguanine) Tier 2 SP; OCH Antineoplastic - Antimetabolite - Pyrimidine Analogs - Drugs for Cancer capecitabine oral tablet 150 mg, 500 mg Tier 4 SP; OCH Antineoplastic - Antimetabolite - Urea Derivatives - Drugs for Cancer hydroxyurea oral capsule 500 mg Tier 1 OCH Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations - Drugs for Cancer LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 4 PA; SP; OCH (trifluridine/tipiracil hcl) Antineoplastic - Aromatase Inhibitors - Drugs for Cancer anastrozole oral tablet 1 mg Tier 1 OCH exemestane oral tablet 25 mg Tier 1 OCH letrozole oral tablet 2.5 mg Tier 1 OCH Antineoplastic - B-cell lymphoma-2 (BCL-2) inhibitors - Drugs for Cancer VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG Tier 4 PA; SP; OCH (venetoclax) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE Tier 4 PA; SP; OCH PACK 10 MG-50 MG- 100 MG (venetoclax) Antineoplastic - BRAF Kinase Inhibitors - Drugs for Cancer PA; SP; OCH; QL (4 EA per BRAFTOVI ORAL CAPSULE 50 MG (encorafenib) Tier 4 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 24 Coverage Prescription Drug Name Drug Tier Requirements and Limits TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib PA; SP; OCH; QL (2 EA per Tier 4 mesylate) 1 day) ZELBORAF ORAL TABLET 240 MG (vemurafenib) Tier 4 PA; SP; OCH Antineoplastic - Bruton's tyrosine kinase (BTK) inhibitor - Drugs for Cancer PA; SP; OCH; QL (60 EA CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) Tier 4 per 30 days) PA; SP; OCH; QL (4 EA per IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) Tier 4 1 day) IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, PA; SP; OCH; QL (4 EA per Tier 4 560 MG (ibrutinib) 1 day) Antineoplastic - Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors - Drugs for Cancer IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; SP; OCH; QL (21 EA Tier 4 (palbociclib) per 28 days) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; SP; OCH; QL (21 EA Tier 4 (palbociclib) per 28 days) KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) PA; SP; OCH; QL (21 EA Tier 4 (ribociclib succinate) per 28 days) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) PA; SP; OCH; QL (42 EA Tier 4 (ribociclib succinate) per 28 days) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) PA; SP; OCH; QL (63 EA Tier 4 (ribociclib succinate) per 28 days) Antineoplastic - Epidermal Growth Factor Receptor-2 (HER2) inhibitor - Drugs for Cancer PA; SP; OCH; QL (120 EA TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) Tier 4 per 30 days) Antineoplastic - Epipodophyllotoxins - Drugs for Cancer etoposide oral capsule 50 mg Tier 4 OCH Antineoplastic - Estrogens - Drugs for Cancer EMCYT ORAL CAPSULE 140 MG (estramustine Tier 2 SP; OCH phosphate sodium) Antineoplastic - Hedgehog Pathway Inhibitor - Drugs for Cancer ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) Tier 4 PA; SP; OCH ODOMZO ORAL CAPSULE 200 MG (sonidegib PA; SP; OCH; QL (1 EA per Tier 4 phosphate) 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 29 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY COMFORT ALCOHOL PAD TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) EASY TOUCH ALCOHOL PREP PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) INCONTROL ALCOHOL PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) IV PREP WIPES TOPICAL PADS, MEDICATED (alcohol Tier 1 DD antiseptic pads) PRO COMFORT ALCOHOL PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) PURE COMFORT ALCOHOL PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) SURE COMFORT ALCOHOL PREP PADS TOPICAL Tier 1 DD PADS, MEDICATED (alcohol antiseptic pads) SURE-PREP ALCOHOL PREP PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) TRUE COMFORT ALCOHOL PADS TOPICAL PADS, Tier 1 DD MEDICATED (alcohol antiseptic pads) ULTILET ALCOHOL SWAB TOPICAL PADS, MEDICATED Tier 1 DD (alcohol antiseptic pads) WEBCOL TOPICAL PADS, MEDICATED (alcohol Tier 1 DD antiseptic pads) Disinfectants - Other - Antiseptics and Disinfectants ALCOH-GLOVE TOWELETTE 70 % (isopropyl alcohol) Tier 1 ALCOH-WIPE TOWELETTE 70 % (isopropyl alcohol) Tier 1 Biologicals - Biological Agents Hepatitis B Vaccines - Single Agents - Vaccines ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 Tier 3 QL (3 ML per 365 days) MCG/ML (hepatitis b virus vaccine recombinant/pf) ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 Tier 3 QL (3 ML per 365 days) MCG/ML (hepatitis b virus vaccine recombinant/pf) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML (hepatitis b Tier 3 QL (3 ML per 365 days) virus vaccine recombinant/pf) RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML (hepatitis b virus vaccine Tier 3 QL (3 ML per 365 days) recombinant/pf) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 30 Coverage Prescription Drug Name Drug Tier Requirements and Limits Immune Globulin - gamma globulin (IgG), human - Biological Agents HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 Tier 3 PA; SP GRAM/20 ML (20 %) (immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml) HIZENTRA SUBCUTANEOUS SYRINGE 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) Tier 3 PA; SP (immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml) Toxoid Vaccine Combinations - Vaccines ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)- Tier 3 QL (1 ML per 300 days) 5LF/0.5 ML (diphtheria,pertussis(acellular),tetanus vaccine/pf) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)- Tier 3 QL (1 ML per 300 days) 5LF/0.5 ML (diphtheria,pertussis(acellular),tetanus vaccine/pf) BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5- 8-5 LF-MCG-LF/0.5ML Tier 3 QL (1 ML per 300 days) (diphtheria,pertussis(acellular),tetanus vaccine) BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML Tier 3 QL (1 ML per 300 days) (diphtheria,pertussis(acellular),tetanus vaccine) Vaccine Bacterial - Gram Positive Cocci - Vaccines PNEUMOVAX-23 INJECTION SOLUTION 25 MCG/0.5 ML Tier 3 QL (1 ML per 365 days) (pneumococcal 23-valent polysaccharide vaccine) PNEUMOVAX-23 INJECTION SYRINGE 25 MCG/0.5 ML Tier 3 QL (1 ML per 365 days) (pneumococcal 23-valent polysaccharide vaccine) Vaccine Viral - Influenza A and B - Vaccines AFLURIA QD 2020-21(3YR UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrivalent 2020-21 (36 mos up)/pf) AFLURIA QD 2020-21(6-35MO)(PF) INTRAMUSCULAR EHB; QL (0.25 ML per 180 SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML (influenza $0 days) virus vaccine quadrival 2020-21 (6 mos-35 mos)/pf) AFLURIA QUAD 2020-2021(6MO UP) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrivalent 2020-21 (6 mos and up)) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 31 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLUAD 2020-2021 (65 YR UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 45 MCG (15 MCG X 3)/0.5 ML (influenza $0 days); Age (Min 65 Years) vaccine tvs 2020-21 (65 yr up)/adjuvant mf59c.1/pf) FLUAD QUAD 2020-21(65Y UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days); Age (Min 65 Years) vaccine quadrivalent 2020-21 (65 yr up)/mf59c.1/pf) FLUARIX QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUBLOK QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 180 MCG (45 MCG X 4)/0.5 ML (influenza virus $0 days); Age (Min 18 Years) vaccine qv 2020-21(18 yrs and older)rcmb/pf) FLUCELVAX QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (flu vaccine $0 days) quad 2020-2021(4 years and older)cell derived/pf) FLUCELVAX QUAD 2020-2021 INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (flu vaccine $0 days) quadriv 2020-2021(4 years and older)cell derived) FLULAVAL QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUMIST QUAD 2020-2021 NASAL NASAL SPRAY EHB; QL (1 EA per 180 SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML (influenza $0 days) vaccine quadrivalent live 2020-2021 (2 yrs-49 yrs)) FLUZONE HIGHDOSE QUAD 20-21 PF EHB; QL (0.7 ML per 180 INTRAMUSCULAR SYRINGE 240 MCG/0.7 ML (influenza $0 days); Age (Min 65 Years) virus vaccine quadrival split 2020-21(65 yr up)/pf) FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrival 2020-2021(6 mos and up)/pf) FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUZONE QUAD 2020-2021 INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrivalent 2020-21 (6 mos and up)) Vaccine Viral - Varicella - Vaccines

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 32 Coverage Prescription Drug Name Drug Tier Requirements and Limits SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 RECONSTITUTION 50 MCG/0.5 ML (varicella-zoster $0 days); Age (Min 50 Years) virus glycoprotein e,rec/as01b adjuvant/pf) SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 $0 RECONSTITUTION 50 MCG (varicella-zoster virus days); Age (Min 50 Years) glycoprotein e,rec,component 2 of 2) Cardiovascular Therapy Agents - Drugs for the Heart ACE Inhibitor and Calcium Channel Blocker Combinations - Drugs for High Blood Pressure amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, Tier 1 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg trandolapril-verapamil oral tablet, ir - er, biphasic 24hr Tier 1 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg ACE Inhibitor and Diuretic Combinations - Drugs for High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25- Tier 1 25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5- Tier 1 12.5 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg ACE Inhibitors - Drugs for High Blood Pressure benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Tier 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) Tier 3 PA fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 Tier 1 mg, 5 mg moexipril oral tablet 15 mg, 7.5 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 33 Coverage Prescription Drug Name Drug Tier Requirements and Limits perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Tier 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 Aldosterone Receptor Antagonists - Drugs for High Blood Pressure eplerenone oral tablet 25 mg, 50 mg Tier 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 Alpha-Beta Blockers - Drugs for High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Tier 1 labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1 Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker Comb. - Drugs for High Blood Pressure amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, Tier 1 5-160 mg, 5-320 mg Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker-Diuretic - Drugs for High Blood Pressure amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160- Tier 1 25 mg Angiotensin II Receptor Blocker (ARB)-Diuretic Combinations - Drugs for High Blood Pressure candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, Tier 1 32-12.5 mg, 32-25 mg irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, Tier 1 300-12.5 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, Tier 1 100-25 mg, 50-12.5 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, Tier 1 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin II Receptor Blocker-Neprilysin Inhibitor Comb. (ARNi) - Drugs for High Blood Pressure ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 Tier 2 PA MG (sacubitril/valsartan) Angiotensin II Receptor Blockers (ARBs) - Drugs for High Blood Pressure candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 34 Coverage Prescription Drug Name Drug Tier Requirements and Limits irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Tier 1 Antianginal - Coronary Vasodilators (Nitrates) - Drugs for Angina isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 Tier 1 mg isosorbide dinitrate oral tablet extended release 40 mg Tier 1 isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 isosorbide mononitrate oral tablet extended release 24 Tier 1 hr 120 mg, 30 mg, 60 mg nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Tier 1 Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 Tier 2 MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg Tier 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 Tier 1 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin (Nitro-Time Oral Capsule, Extended Release Tier 1 2.5 Mg, 6.5 Mg, 9 Mg) Antianginal and Anti-ischemic Agents, Non-hemodynamic - Drugs for Angina ranolazine oral tablet extended release 12 hr 1,000 mg, Tier 1 500 mg Antiarrhythmic - Class Ia - Drugs for Abnormal Heart Rhythms disopyramide phosphate oral capsule 100 mg, 150 mg Tier 1 NORPACE CR ORAL CAPSULE, EXTENDED RELEASE Tier 2 100 MG, 150 MG (disopyramide phosphate) quinidine gluconate oral tablet extended release 324 mg Tier 1 quinidine sulfate oral tablet 200 mg, 300 mg Tier 1 Antiarrhythmic - Class Ib - Drugs for Abnormal Heart Rhythms mexiletine oral capsule 150 mg, 200 mg, 250 mg Tier 1 Antiarrhythmic - Class Ic - Drugs for Abnormal Heart Rhythms flecainide oral tablet 100 mg, 150 mg, 50 mg Tier 1 propafenone oral capsule,extended release 12 hr 225 Tier 1 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 35 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiarrhythmic - Class II - Drugs for Abnormal Heart Rhythms sotalol hcl (Sorine Oral Tablet 120 Mg, 160 Mg, 240 Mg, Tier 1 80 Mg) sotalol hcl (Sotalol Af Oral Tablet 120 Mg, 160 Mg, 80 Mg) Tier 1 sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg Tier 1 Antiarrhythmic - Class III - Drugs for Abnormal Heart Rhythms amiodarone oral tablet 100 mg, 200 mg, 400 mg Tier 1 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Tier 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) Tier 2 amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, Tier 1 400 Mg) Antiarrhythmic - Class IV - Drugs for Abnormal Heart Rhythms verapamil oral tablet 120 mg, 40 mg, 80 mg Tier 1 Antihyperlipidemic - Anti-PCSK9 Monoclonal Antibody - Drugs for Cholesterol REPATHA SURECLICK SUBCUTANEOUS PEN Tier 4 PA; QL (3 ML per 28 days) INJECTOR 140 MG/ML (evolocumab) REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 Tier 4 PA; QL (3 ML per 28 days) MG/ML (evolocumab) Antihyperlipidemic - ATP-Citrate Lyase (ACLY) Inhibitor - Drugs for Cholesterol NEXLETOL ORAL TABLET 180 MG (bempedoic acid) Tier 3 PA; QL (30 EA per 30 days) Antihyperlipidemic - Bile Acid Sequestrants - Drugs for Cholesterol cholestyramine (with sugar) oral powder 4 gram Tier 1 cholestyramine (with sugar) oral powder in packet 4 Tier 1 gram cholestyramine/aspartame (Cholestyramine Light Oral Tier 1 Powder 4 Gram) cholestyramine/aspartame (Cholestyramine Light Oral Tier 1 Powder In Packet 4 Gram) colesevelam oral powder in packet 3.75 gram Tier 2 colesevelam oral tablet 625 mg Tier 2 COLESTID FLAVORED ORAL PACKET 7.5 GRAM Tier 3 (colestipol hcl) colestipol oral granules 5 gram Tier 1 colestipol oral packet 5 gram Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 45 Coverage Prescription Drug Name Drug Tier Requirements and Limits EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 Tier 3 MG (carbamazepine) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) Tier 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 1 TEGRETOL ORAL SUSPENSION 100 MG/5 ML Tier 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) Tier 3 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 Tier 3 HR 100 MG, 200 MG, 400 MG (carbamazepine) Anticonvulsant - Monosaccharide Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 Anticonvulsant - Phenyltriazine Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 Tier 3 MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 Tier 3 MG (lamotrigine) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 Tier 3 MG, 5 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 300 MG, 50 MG Tier 3 (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE Tier 4 24HR 250 MG (lamotrigine) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg Tier 1 lamotrigine oral tablet extended release 24hr 100 mg, Tier 2 200 mg, 25 mg, 50 mg lamotrigine oral tablet extended release 24hr 250 mg Tier 4 lamotrigine oral tablet extended release 24hr 300 mg Tier 3 lamotrigine oral tablet, chewable dispersible 25 mg, 5 Tier 1 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, Tier 1 25 mg, 50 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 50 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiparkinson Adjuvant - Peripheral Dopa-decarboxylase Inhibitors - Drugs for Parkinson carbidopa oral tablet 25 mg Tier 1 Antiparkinson Therapy - Anticholinergic Agents - Drugs for Parkinson benztropine oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 trihexyphenidyl oral elixir 0.4 mg/ml Tier 1 trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1 Antiparkinson Therapy - Ergot Alkaloids and Derivatives - Drugs for Parkinson bromocriptine oral capsule 5 mg Tier 2 bromocriptine oral tablet 2.5 mg Tier 2 Antiparkinson Therapy - Monoamine Oxidase Inhibitor(MAO-B) - Drugs for Parkinson rasagiline oral tablet 0.5 mg, 1 mg Tier 2 selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1 Antiparkinson Therapy - Non-ergot Dopamine Agonist Agents - Drugs for Parkinson amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral solution 50 mg/5 ml Tier 1 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, Tier 4 PA 6 MG/24 HOUR, 8 MG/24 HOUR (rotigotine) pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 Tier 1 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr 0.375 Tier 2 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, Tier 1 4 mg, 5 mg ropinirole oral tablet extended release 24 hr 12 mg, 2 Tier 2 mg, 4 mg, 6 mg, 8 mg Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisoxazole Deriv - Drugs for Severe Mental Disorders paliperidone oral tablet extended release 24hr 1.5 mg, 3 Tier 3 QL (30 EA per 30 days) mg, 6 mg, 9 mg risperidone oral solution 1 mg/ml Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 51 Coverage Prescription Drug Name Drug Tier Requirements and Limits risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 Tier 1 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg Tier 1 risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 Tier 1 mg, 3 mg, 4 mg Antipsychotic - Atypical Dopamine-Serotonin Antag-Dibenzodiazepine Der - Drugs for Severe Mental Disorders clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 clozapine oral tablet,disintegrating 100 mg, 25 mg Tier 1 clozapine oral tablet,disintegrating 12.5 mg, 150 mg, Tier 2 200 mg Antipsychotic - Butyrophenone Derivatives - Drugs for Severe Mental Disorders haloperidol lactate oral concentrate 2 mg/ml Tier 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 Tier 1 mg, 5 mg Antipsychotic - Dibenzoxazepine Derivatives - Drugs for Severe Mental Disorders loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 Tier 1 mg Antipsychotic - Diphenylbutylpiperidine Derivatives - Drugs for Severe Mental Disorders pimozide oral tablet 1 mg, 2 mg Tier 1 Antipsychotic - Phenothiazines, Aliphatic - Drugs for Severe Mental Disorders chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 Tier 1 mg, 50 mg Antipsychotic - Phenothiazines, Piperazine - Drugs for Severe Mental Disorders fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg Tier 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 1 prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Antipsychotic - Phenothiazines, Piperidine - Drugs for Severe Mental Disorders thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 Antipsychotic - Thioxanthenes - Drugs for Severe Mental Disorders thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 52 Coverage Prescription Drug Name Drug Tier Requirements and Limits Attention Deficit-Hyperact. Disorder (ADHD)- alpha-2 Receptor Agonist - Drugs for Attention Deficit Disorder guanfacine oral tablet extended release 24 hr 1 mg, 2 Tier 1 mg, 3 mg, 4 mg Attention Deficit-Hyperactivity (ADHD) Therapy, Stimulant-Type - Drugs for Attention Deficit Disorder dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 methylphenidate hcl (Metadate Er Oral Tablet Extended Tier 1 Release 20 Mg) methylphenidate hcl oral capsule, er biphasic 30-70 10 Tier 1 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic 50-50 20 Tier 1 mg, 30 mg, 40 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Tier 1 methylphenidate hcl oral tablet extended release 10 mg, Tier 1 20 mg methylphenidate hcl oral tablet extended release 24hr Tier 1 18 mg, 27 mg, 36 mg, 54 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine Tier 2 dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Tier 1 Mg) Attention Deficit-Hyperactivity Disorder (ADHD) Therapy, NRI-Type - Drugs for Attention Deficit Disorder atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, Tier 2 40 mg, 60 mg, 80 mg Benzodiazepines - Drugs for Seizures /Personality Disorder/Nerve Pain diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 flurazepam oral capsule 15 mg, 30 mg Tier 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 54 Coverage Prescription Drug Name Drug Tier Requirements and Limits lithium carbonate oral capsule 300 mg Tier 1 lithium carbonate oral tablet 300 mg Tier 1 lithium carbonate oral tablet extended release 300 mg, Tier 1 450 mg lithium citrate oral solution 8 meq/5 ml Tier 1 LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG Tier 3 (lithium carbonate) CNS Stimulant - Amphetamine Combinations - Drugs for Attention Deficit Disorder dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 Tier 1 mg, 30 mg, 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, Tier 1 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg CNS Stimulant - Amphetamines - Drugs for Attention Deficit Disorder dextroamphetamine oral capsule, extended release 10 Tier 1 mg, 15 mg, 5 mg dextroamphetamine oral solution 5 mg/5 ml Tier 1 dextroamphetamine oral tablet 10 mg, 5 mg Tier 1 methamphetamine oral tablet 5 mg Tier 1 dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Tier 1 Mg) CNS Stimulant - Analeptics - Drugs for Attention Deficit Disorder caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) Tier 1 Age (Max 1 Years) Fibromyalgia Agents - Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) - Drugs for Seizures /Personality Disorder/Nerve Pain SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 2 QL (2 EA per 1 day) MG (milnacipran hcl) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 Tier 2 MG(8)-50 MG(42) (milnacipran hcl) Hypnotics - Melatonin M1/M2 Receptor Agonists - Drugs for Insomnia ramelteon oral tablet 8 mg Tier 2 PA; QL (1 EA per 1 day) Migraine Therapy - Ergot Alkaloids and Derivatives - Drugs for Migraine Headaches dihydroergotamine injection solution 1 mg/ml Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 55 Coverage Prescription Drug Name Drug Tier Requirements and Limits ERGOMAR SUBLINGUAL TABLET 2 MG (ergotamine Tier 3 tartrate) Migraine Therapy - Ergot Combinations - Drugs for Migraine Headaches MIGERGOT RECTAL SUPPOSITORY 2-100 MG Tier 2 (ergotamine tartrate/caffeine) Migraine Therapy - Selective Serotonin Agonists 5-HT(1) - Drugs for Migraine Headaches naratriptan oral tablet 1 mg, 2.5 mg Tier 1 QL (9 EA per 1 FILL) rizatriptan oral tablet 10 mg, 5 mg Tier 1 QL (12 EA per 1 FILL) rizatriptan oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL (12 EA per 1 FILL) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 Tier 1 QL (6 EA per 1 FILL) mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL (9 EA per 1 FILL) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 Tier 3 QL (2 ML per 1 FILL) ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 Tier 1 QL (2 ML per 1 FILL) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 Tier 1 QL (2.5 ML per 1 FILL) ml zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 QL (9 EA per 1 FILL) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 QL (9 EA per 1 FILL) Migraine Therapy - Selective Serotonin Agonists 5-HT(1F) - Drugs for Migraine Headaches REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan Tier 4 PA; QL (9 EA per 30 days) succinate) Movement Disorder Drug Therapy - Drugs for the Nervous System tetrabenazine oral tablet 12.5 mg, 25 mg Tier 4 PA; SP Narcolepsy Therapy Agents - Non-Sympathomimetic - Drugs for Sleep Disorder modafinil oral tablet 100 mg, 200 mg Tier 1 PA; QL (2 EA per 1 day) Narcolepsy Therapy Agents- Stimulant-Type,Sympathomimetic,Amphetamines - Drugs for Sleep Disorder dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Tier 1 Mg) Pseudobulbar Affect (PBA) Agents, NMDA antagonists type - Drugs for Severe Mental Disorders PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 56 Coverage Prescription Drug Name Drug Tier Requirements and Limits NUEDEXTA ORAL CAPSULE 20-10 MG Tier 2 QL (2 EA per 1 day) (dextromethorphan hbr/quinidine sulfate) Sedative-Hypnotic - Antihistamines - Drugs for Insomnia NIGHTIME SLEEP ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) SLEEP AID MAX STR (DIPHENHYDR) ORAL CAPSULE Tier 1 50 MG (diphenhydramine hcl) SLEEPING ORAL CAPSULE 50 MG (diphenhydramine Tier 1 hcl) UNISOM SLEEPGELS ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) Sedative-Hypnotic - Barbiturates - Drugs for Insomnia phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) Tier 1 phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 Tier 1 mg, 97.2 mg phenobarbital oral tablet 15 mg, 30 mg, 60 mg Tier 1 SECONAL SODIUM ORAL CAPSULE 100 MG Tier 2 (secobarbital sodium) Sedative-Hypnotic - Benzodiazepines - Drugs for Insomnia estazolam oral tablet 1 mg, 2 mg Tier 1 flurazepam oral capsule 15 mg, 30 mg Tier 1 temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg Tier 1 triazolam oral tablet 0.125 mg, 0.25 mg Tier 1 Sedative-Hypnotic - GABA-Receptor Modulators - Drugs for Insomnia eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 2 zaleplon oral capsule 10 mg, 5 mg Tier 1 zolpidem oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) Chemical Dependency, Agents to Treat - Drugs for Addiction Agents for Opioid Withdrawal, Opioid-Type - Drugs for Opioid Addiction PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 57 Coverage Prescription Drug Name Drug Tier Requirements and Limits buprenorphine-naloxone sublingual film 12-3 mg, 2-0.5 Tier 2 mg, 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 Tier 1 mg Alcohol Abstinence Therapy - Glutamate and GABA System Type - Drugs for Alcohol Addiction acamprosate oral tablet,delayed release (dr/ec) 333 mg Tier 1 Alcohol Deterrents - Drugs for Alcohol Addiction disulfiram oral tablet 250 mg, 500 mg Tier 1 Smoking Deterrents - NE and Dopamine Reuptake Inhibitor (NDRI)-Type - Drugs for Smoking Addiction bupropion hcl (smoking deter) oral tablet extended EHB; QL (180 EA per 365 $0 release 12 hr 150 mg days) Smoking Deterrents - Nicotine-Type - Drugs for Smoking Addiction EHB; QL (180 EA per 365 nicotine (polacrilex) buccal gum 2 mg $0 days) nicotine (polacrilex) buccal gum 4 mg $0 EHB nicotine (polacrilex) buccal lozenge 2 mg, 4 mg $0 EHB nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg $0 EHB nicotine transdermal patch 24 hour 14 mg/24 hr, 21 $0 EHB mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, sequential 21-14-7 $0 EHB mg/24 hr NICOTROL INHALATION CARTRIDGE 10 MG (nicotine) $0 EHB NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 $0 EHB MG/ML (nicotine) EHB; QL (180 EA per 365 QUIT 2 BUCCAL GUM 2 MG (nicotine polacrilex) $0 days) QUIT 2 BUCCAL LOZENGE 2 MG (nicotine polacrilex) $0 EHB QUIT 4 BUCCAL GUM 4 MG (nicotine polacrilex) $0 EHB QUIT 4 BUCCAL LOZENGE 4 MG (nicotine polacrilex) $0 EHB STOP SMOKING AID BUCCAL LOZENGE 2 MG, 4 MG $0 EHB (nicotine polacrilex) Smoking Deterrents - Nicotinic Receptor Partial Agonist, alpha4beta2 - Drugs for Smoking Addiction

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 58 Coverage Prescription Drug Name Drug Tier Requirements and Limits CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 $0 EHB MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline $0 EHB tartrate) CHANTIX STARTING MONTH BOX ORAL EHB; QL (180 EA per 365 TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) $0 days) (varenicline tartrate) Chemicals-Pharmaceutical Adjuvants Pharmaceutical Adjuvant - Inhalation Vehicles HYPER-SAL INHALATION SOLUTION FOR Tier 2 NEBULIZATION 3.5 % (sodium chloride for inhalation) NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 1 3 % (sodium chloride for inhalation) NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 2 6 % (sodium chloride for inhalation) sodium chloride inhalation solution for nebulization 0.9 Tier 1 %, 10 %, 3 %, 7 % Cognitive Disorder Therapy - Drugs for the Nervous System Alzheimer's Disease Therapy - Cholinesterase Inhibitors - Drugs for Alzheimer's Disease donepezil oral tablet 10 mg, 5 mg Tier 1 QL (2 EA per 1 day) donepezil oral tablet 23 mg Tier 1 QL (1 EA per 1 day) donepezil oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 Tier 2 mg, 8 mg galantamine oral solution 4 mg/ml Tier 2 galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 2 rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, Tier 1 6 mg ST: Prior prescription for Donepezil HCL, rivastigmine transdermal patch 24 hour 13.3 mg/24 Tier 2 Galantamine HBR, or hour, 4.6 mg/24 hour, 9.5 mg/24 hour Rivastigmine Tartrate in 120 days; QL (1 EA per 1 day) Alzheimer's Disease Therapy - NMDA Receptor Antagonists - Drugs for Alzheimer's Disease

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 69 Coverage Prescription Drug Name Drug Tier Requirements and Limits norgestimate-ethinyl estradiol (Tri-Nymyo Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Previfem (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Sprintec (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) levonorgestrel/ethinyl estradiol (Trivora (28) Oral Tablet $0 CT; EHB 50-30 (6)/75-40 (5)/125-30(10)) norgestimate-ethinyl estradiol (Tri-Vylibra Lo Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Vylibra Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) desogestrel-ethinyl estradiol (Velivet Triphasic Regimen $0 CT; EHB (28) Oral Tablet 0.1/.125/.15-25 Mg-Mcg) Contraceptive Transdermal Combinations - Birth Control Pills XULANE TRANSDERMAL PATCH WEEKLY 150-35 $0 CT; EHB MCG/24 HR (norelgestromin/ethinyl estradiol) Contraceptives - Intravaginal, Systemic - Birth Control Pills etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 $0 CT; EHB mg/24 hr Contraceptives - Intravaginal, Systemic - Estrogen and Progestin Comb. - Birth Control Pills etonogestrel/ethinyl estradiol (Eluryng Vaginal Ring 0.12- $0 CT; EHB 0.015 Mg/24 Hr) Emergency Contraceptives - Birth Control Pills AFTERA ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB ECONTRA ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) ELLA ORAL TABLET 30 MG (ulipristal acetate) $0 CT; EHB levonorgestrel oral tablet 1.5 mg $0 CT; EHB MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB MY WAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB OPCICON ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 70 Coverage Prescription Drug Name Drug Tier Requirements and Limits OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB Emergency Contraceptives - Progestin Type - Birth Control Pills MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB MY WAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB OPCICON ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB Spermicides - Birth Control Pills GYNOL II VAGINAL GEL 3 % (nonoxynol 9) $0 CT; EHB TODAY CONTRACEPTIVE SPONGE VAGINAL $0 CT; EHB CONTRACEPTIVE SPONGE 1,000 MG (nonoxynol 9) VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 % $0 CT; EHB (nonoxynol 9) VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 $0 CT; EHB % (nonoxynol 9) VCF CONTRACEPTIVE FILM VAGINAL FILM 28 % $0 CT; EHB (nonoxynol 9) VCF CONTRACEPTIVE GEL VAGINAL GEL 4 % $0 CT; EHB (nonoxynol 9) Dermatological - Drugs for the Skin Acne Therapy Systemic - Retinoids and Derivatives - Drugs for the Skin isotretinoin (Accutane Oral Capsule 20 Mg, 30 Mg, 40 Mg) Tier 3 QL (60 EA per 30 days) isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Tier 3 QL (60 EA per 30 days) Mg) isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, Tier 3 QL (60 EA per 30 days) 40 Mg) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg Tier 3 QL (60 EA per 30 days) isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, Tier 3 QL (60 EA per 30 days) 40 Mg) isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, Tier 3 QL (60 EA per 30 days) 40 Mg) Acne Therapy Topical - Anti-infective - Drugs for the Skin azelaic acid topical gel 15 % Tier 1 Age (Max 34 Years) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 71 Coverage Prescription Drug Name Drug Tier Requirements and Limits clindamycin phosphate topical foam 1 % Tier 1 clindamycin phosphate topical gel 1 % Tier 1 clindamycin phosphate topical lotion 1 % Tier 1 clindamycin phosphate topical solution 1 % Tier 1 clindamycin phosphate topical swab 1 % Tier 1 ERY PADS TOPICAL SWAB 2 % (erythromycin base in Tier 1 ethanol) erythromycin with ethanol topical gel 2 % Tier 1 erythromycin with ethanol topical solution 2 % Tier 1 metronidazole topical cream 0.75 % Tier 1 metronidazole topical lotion 0.75 % Tier 1 metronidazole (Rosadan Topical Cream 0.75 %) Tier 1 sulfacetamide sodium (acne) topical suspension 10 % Tier 1 Acne Therapy Topical - Anti-infective-Keratolytic Combinations - Drugs for the Skin BP 10-1 TOPICAL CLEANSER 10-1 % (sulfacetamide Tier 1 sodium/sulfur) CLEANSING WASH TOPICAL CLEANSER 10-4-10 % Tier 1 (sulfacetamide sodium/sulfur/urea) clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 Tier 1 % base) -5 % clindamycin-benzoyl peroxide topical gel with pump 1-5 Tier 1 % erythromycin-benzoyl peroxide topical gel 3-5 % Tier 1 clindamycin phosphate/benzoyl peroxide (Neuac Topical Tier 1 Gel 1.2 %(1 % Base) -5 %) ROSANIL TOPICAL CLEANSER 10-5 % (W/W) Tier 1 (sulfacetamide sodium/sulfur) ROSULA CLEANSING CLOTHS TOPICAL PADS, Tier 1 MEDICATED 10-5 % (sulfacetamide sodium/sulfur) SSS 10-5 TOPICAL CREAM 10-5 % (W/W) (sulfacetamide Tier 1 sodium/sulfur) SSS 10-5 TOPICAL FOAM 10-5 % (sulfacetamide Tier 1 sodium/sulfur) sulfacetamide sodium-sulfur topical cleanser 10-2 %, Tier 1 10-5 % (w/w), 9-4 %, 9-4.5 %, 9.8-4.8 % PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 72 Coverage Prescription Drug Name Drug Tier Requirements and Limits sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 Tier 1 % (w/w), 9.8-4.8 % sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), Tier 1 10-5 % (w/w), 9.8-4.8 % sulfacetamide sodium-sulfur topical pads, medicated Tier 1 10-4 % sulfacetamide sodium-sulfur topical suspension 10-5 Tier 1 %, 8-4 % sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 Tier 1 % SULFACLEANSE 8-4 TOPICAL SUSPENSION 8-4 % Tier 1 (sulfacetamide sodium/sulfur) Acne Therapy Topical - Anti-infective-Retinoid Combinations - Drugs for the Skin clindamycin-tretinoin topical gel 1.2-0.025 % Tier 1 Acne Therapy Topical - Keratolytic - Drugs for the Skin ACNE MEDICATION TOPICAL GEL 2.5 % (benzoyl Tier 1 peroxide) benzoyl peroxide topical gel 2.5 % Tier 1 Acne Therapy Topical - Retinoids and Derivatives - Drugs for the Skin adapalene topical cream 0.1 % Tier 1 Age (Max 34 Years) adapalene topical gel 0.1 % Tier 1 Age (Max 34 Years) AVITA TOPICAL CREAM 0.025 % (tretinoin) Tier 1 Age (Max 34 Years) AVITA TOPICAL GEL 0.025 % (tretinoin) Tier 1 Age (Max 34 Years) EFFACLAR ADAPALENE TOPICAL GEL 0.1 % Tier 1 Age (Max 34 Years) (adapalene) tretinoin topical cream 0.025 %, 0.05 %, 0.1 % Tier 1 Age (Max 34 Years) tretinoin topical gel 0.01 %, 0.025 %, 0.05 % Tier 1 Age (Max 34 Years) Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations - Drugs for the Skin calcipotriene-betamethasone topical ointment 0.005- Tier 2 0.064 % Antipsoriatic Agents - Interleukin-23 (IL-23) Antagonist, MC Antibody - Drugs for the Skin SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 ML PA; SP; QL (1.66 ML per 84 Tier 4 (risankizumab-rzaa) days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 76 Coverage Prescription Drug Name Drug Tier Requirements and Limits ANTI-DANDRUFF WITH MENTHOL TOPICAL SHAMPOO Tier 1 1 % (selenium sulfide/menthol) DANDRUFF SHAMPOO (SELEN-ALOE) TOPICAL Tier 1 SHAMPOO 1 % (selenium sulfide/aloe vera) DANDRUFF SHAMPOO-MENTHOL TOPICAL SHAMPOO Tier 1 1 % (selenium sulfide/menthol) SELSUN BLUE MOISTURIZING TOPICAL SHAMPOO 1 % Tier 1 (selenium sulfide/aloe vera) Dermatological - Antiviral, Herpes - Drugs for the Skin ST: Prior prescription for Acyclovir, Famciclovir, Tier 4 acyclovir topical ointment 5 % Sitavig, or Valacyclovir HCL in 120 days DENAVIR TOPICAL CREAM 1 % (penciclovir) Tier 2 Dermatological - Burn Products Anti-infective - Drugs for the Skin silver sulfadiazine topical cream 1 % Tier 1 SSD TOPICAL CREAM 1 % (silver sulfadiazine) Tier 1 SULFAMYLON TOPICAL CREAM 85 MG/G (mafenide Tier 2 acetate) Dermatological - Calcineurin Inhibitors - Drugs for the Skin pimecrolimus topical cream 1 % Tier 1 tacrolimus topical ointment 0.03 %, 0.1 % Tier 1 Dermatological - Emollients - Drugs for the Skin ammonium lactate topical cream 12 % Tier 1 ammonium lactate topical lotion 12 % Tier 1 SKIN TREATMENT TOPICAL LOTION 12 % (ammonium Tier 1 lactate) Dermatological - Enzymes - Drugs for the Skin SANTYL TOPICAL OINTMENT 250 UNIT/GRAM Tier 2 (collagenase clostridium histolyticum) Dermatological - Glucocorticoid - Drugs for the Skin hydrocortisone (Ala-Cort Topical Cream 1 %) Tier 1 hydrocortisone (Ala-Scalp Topical Lotion 2 %) Tier 1 alclometasone topical ointment 0.05 % Tier 1 QL (60 GM per 1 FILL) ANTI-ITCH (HC) TOPICAL CREAM 1 % (hydrocortisone) Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 77 Coverage Prescription Drug Name Drug Tier Requirements and Limits ANTI-ITCH (HC) TOPICAL LOTION 1 % (hydrocortisone) Tier 1 ANTI-ITCH (HC) TOPICAL OINTMENT 1 % Tier 1 (hydrocortisone) AQUANIL HC TOPICAL LOTION 1 % (hydrocortisone) Tier 1 AQUAPHOR ITCH RELIEF TOPICAL OINTMENT 1 % Tier 1 (hydrocortisone) BETA-HC TOPICAL LOTION 1 % (hydrocortisone) Tier 1 betamethasone dipropionate topical cream 0.05 % Tier 1 QL (45 GM per 1 FILL) betamethasone dipropionate topical lotion 0.05 % Tier 1 QL (60 ML per 1 FILL) betamethasone dipropionate topical ointment 0.05 % Tier 1 QL (45 GM per 1 FILL) betamethasone valerate topical cream 0.1 % Tier 1 QL (45 GM per 1 FILL) betamethasone valerate topical lotion 0.1 % Tier 1 QL (60 ML per 1 FILL) betamethasone valerate topical ointment 0.1 % Tier 1 QL (45 GM per 1 FILL) betamethasone, augmented topical cream 0.05 % Tier 1 betamethasone, augmented topical gel 0.05 % Tier 1 betamethasone, augmented topical lotion 0.05 % Tier 1 betamethasone, augmented topical ointment 0.05 % Tier 1 clobetasol scalp solution 0.05 % Tier 2 PA clobetasol topical cream 0.05 % Tier 2 PA; QL (30 GM per 1 FILL) clobetasol topical foam 0.05 % Tier 2 PA clobetasol topical gel 0.05 % Tier 2 PA clobetasol topical lotion 0.05 % Tier 2 PA clobetasol topical ointment 0.05 % Tier 2 PA; QL (30 GM per 1 FILL) clobetasol topical shampoo 0.05 % Tier 2 PA clobetasol-emollient topical cream 0.05 % Tier 2 PA clobetasol-emollient topical foam 0.05 % Tier 2 PA CORTAID TOPICAL CREAM 1 % (hydrocortisone) Tier 1 CORTISONE (HYDROCORTISONE) TOPICAL CREAM 1 Tier 1 % (hydrocortisone) CORTISONE (HYDROCORTISONE) TOPICAL LOTION 1 Tier 1 % (hydrocortisone) CORTIZONE-10 PLUS TOPICAL CREAM 1 % Tier 1 (hydrocortisone) CORTIZONE-10 TOPICAL CREAM 1 % (hydrocortisone) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 81 Coverage Prescription Drug Name Drug Tier Requirements and Limits ASPERCREME (LIDOCAINE) TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) ASPERFLEX TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) BLUE-EMU LIDOCAINE PATCH TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) lidocaine hcl (Glydo Mucous Membrane Jelly In Applicator Tier 1 2 %) LIDO KING TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) lidocaine hcl mucous membrane jelly 2 % Tier 1 lidocaine hcl mucous membrane jelly in applicator 2 % Tier 1 lidocaine hcl topical cream 3 % Tier 1 LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) lidocaine topical adhesive patch,medicated 4 %, 5 % Tier 2 PA; QL (1 EA per 1 day) LIDOCARE TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) REGENECARE HA TOPICAL GEL 2 % (lidocaine Tier 1 hcl/hyaluronic acid/aloe vera/collagen) SALONPAS (LIDOCAINE) TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) Scabicide and Pediculicide Single Agents - Drugs for the Skin EURAX TOPICAL CREAM 10 % (crotamiton) Tier 2 lindane topical shampoo 1 % Tier 1 malathion topical lotion 0.5 % Tier 1 QL (118 ML per 1 FILL) permethrin topical cream 5 % Tier 1 spinosad topical suspension 0.9 % Tier 2 QL (120 ML per 1 FILL) Wound Care - Growth Factor Agents - Drugs for the Skin REGRANEX TOPICAL GEL 0.01 % (becaplermin) Tier 2 DD; QL (30 GM per 1 FILL) Diagnostic Agents Diagnostic - Blood Test Others PRECISION XTRA B-KETONE STRIP (blood ketone test, Tier 2 strips) Diagnostic - Multiple Urine Tests

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 86 Coverage Prescription Drug Name Drug Tier Requirements and Limits BRAINSTRONG PRENATAL ORAL COMBO PACK 33 MG IRON- 800 MCG-350 MG (prenatal vitamins Tier 3 no.139/iron,carbonyl/folic acid/dha) CADEAU DHA ORAL CAPSULE 29 MG IRON- 1 MG-150 MG (prenatal vitamins no.83/iron fumarate/folate combo Tier 3 no.6/dha) CALCIUM PNV ORAL CAPSULE 28-1-250 MG (multivitamin comb no.48/ferrous fumarate/folic Tier 3 acid/dha) CITRANATAL (DUAL-IRON) ORAL TABLET 27 MG IRON- 1 MG -50 MG (prenatal vits no.81/iron Tier 3 carbonyl,gluc/folic acid/docusate) CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK 90 MG IRON-1 MG -50 MG-300 MG (prenatal vit Tier 3 no.72/iron carbony,gluc/folic acid/docusate/dha) CITRANATAL ASSURE ORAL COMBO PACK 35 MG IRON-1 MG -50 MG-300 MG (prenatal vit no.73/iron Tier 3 carbony,gluc/folic acid/docusate/dha) CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK 27 MG IRON-1 MG -50 MG-250 MG (prenatal vit no.76/iron Tier 3 carbony,gluc/folic acid/docusate/dha) CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE 27 MG IRON-1 MG -50 MG-260 MG (prenatal vitamin Tier 3 no.59/iron carb,fum/folic acid/docusate/dha) C-NATE DHA ORAL CAPSULE 28 MG IRON-1 MG -200 MG (prenatal vitamins no.11/ferrous fumarate/folic Tier 3 acid/omega-3) COMPLETE NATAL DHA ORAL COMBO PACK 29-1-250- 200 MG (prenatal vitamin no.52/iron/folic acid/omega- Tier 3 3/dha) COMPLETENATE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG (prenatal vitamins no.14/ferrous Tier 3 fumarate/folic acid) DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG- MCG-MG (prenatal vit with calcium 75/iron/folic Tier 3 acid/omega-3/dha/epa) DERMACINRX PRENATRIX ORAL TABLET 27 MG IRON- 1 MG (prenatal vitamins no.170/ferrous fumarate/folic Tier 3 acid)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 88 Coverage Prescription Drug Name Drug Tier Requirements and Limits MYNATAL PLUS ORAL TABLET 65 MG IRON- 1 MG (prenatal vitamins with calcium/ferrous fumarate/folic Tier 1 acid) MYNATAL-Z ORAL TABLET 65 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium/ferrous fumarate/folic acid) MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE 90 MG IRON-1 MG (prenatal vitamins with Tier 3 calcium/ferrous fum/docusate/folic ac) NATACHEW (FE BIS-GLYCINATE) ORAL TABLET,CHEWABLE 28 MG IRON -1 MG (prenatal Tier 3 vitamin no.55/iron fumarate,bisglycinate/folic acid) NATAVI PNV ORAL CAPSULE 13.5 MG IRON- 0.5 MG- 150 MG (prenatal no.158/iron fum/folic acid/omega- Tier 3 3/dha/epa/fish oil) NATAVI PRIMA ORAL CAPSULE 4 MG IRON- 0.5 MG-150 MG (prenatal no.157/iron fum/folic acid/omega- Tier 3 3/dha/epa/fish oil) NESTABS ABC ORAL COMBO PACK 32 MG IRON-1 MG - 120 MG-180 MG (prenatal vitamin comb no.86/iron ps Tier 3 cmplx/folic acid/dha/epa) NESTABS DHA ORAL COMBO PACK 32 MG IRON- 1,000 MCG-230MG (prenatal vits with calcium no.87/iron Tier 3 bisgly/folic acid/dha) NEWGEN ORAL TABLET 32-1,000 MG-MCG (prenatal Tier 3 vitamin no.86/iron bis-glycinate/folic acid) NEXA PLUS ORAL CAPSULE 29 MG IRON-1.25 MG-55 MG (prenatal vits no.53/iron fum/folic acid/docusate Tier 3 calcium/dha) NIVA-PLUS ORAL TABLET 27 MG IRON- 1 MG (multivitamin-minerals no.60/ferrous fumarate/folic Tier 1 acid) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG (prenatal vits no.83/iron,carbonyl,iron aspart.gly/folic Tier 3 acid) OB COMPLETE WITH DHA ORAL CAPSULE 30 MG IRON-10 MG IRON-1 MG (prenatal vit no.30/iron Tier 3 carbonyl,asp glyc/folic acid/omega-3) OBSTETRIX DHA ORAL COMBO PACK,TABLET AND CAP,DR 29 MG IRON-1 MG -50 MG (prenatal vits Tier 3 no.12/iron,carb/folic acid/docusate/omega-3) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 89 Coverage Prescription Drug Name Drug Tier Requirements and Limits OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC) 29 MG IRON-1 MG -50 MG (prenatal vitamins Tier 3 no.127/iron,carbonyl/folic acid/docusate) OBTREX DHA (WITH QUATREFOLIC) ORAL COMB PACK,TABLET DR,CAPSULE DR 29 MG IRON-1 MG -350 Tier 3 MG (prenatal vitamins no.12/iron carbonyl/methylfolate/dha) O-CAL PRENATAL ORAL TABLET 15 MG IRON- 1,000 MCG (prenatal vit with calcium no.127/ferrous Tier 1 fumarate/folic acid) ONE DAILY PRENATAL ORAL COMBO PACK 28 MG IRON- 800 MCG, 28-800-440 MG-MCG-MG (prenatal vit Tier 3 with calcium 75/iron/folic acid/omega-3/dha/epa) ONE-A-DAY PRENATAL-1 ORAL CAPSULE 27 MG IRON- 800 MCG-235 MG (prenatal vitamins no.168/iron/folic Tier 3 acid/omega-3/dha/epa) PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG (prenatal vits with calcium 36/ferrous fumarate/folic Tier 1 acid) pnv cmb#95-ferrous fumarate-fa oral tablet 28 mg iron- Tier 1 800 mcg PNV-DHA + DOCUSATE ORAL CAPSULE 27-1.25-55-300 MG (prenatal vits,calcium no.66/iron fum/folic Tier 3 acid/docusate/dha) PNV-FERROUS FUMARATE-DOCU-FA ORAL TABLET 29 MG IRON- 1 MG-25 MG (prenatal vits no.115/iron Tier 3 fumarate/folic acid/docusate sod.) PNV-SELECT ORAL TABLET 27-1 MG (prenatal vit with Tier 3 calcium no.40/iron fumarate/folate no.1) PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-400 MG (prenatal vit no.19/iron bg hcl,suc- Tier 3 prot/folic acid/omega-3) PR NATAL 400 ORAL COMBO PACK 29-1-400 MG (prenatal vit with calcium 53/iron bis,s-p/folic Tier 3 acid/omega-3) PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-430 MG (prenatal vit 55/iron bisgly Tier 3 hcl,suc-prot/folic acid/omega-3)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 90 Coverage Prescription Drug Name Drug Tier Requirements and Limits PR NATAL 430 ORAL COMBO PACK 29 MG IRON-1 MG - 430 MG (prenatal vit with calcium 54/iron bis,s-p/folic Tier 3 acid/omega-3) PRENA1 CHEW ORAL TABLET,CHEW,IR - DR,BIPHASE Tier 3 1.4 MG (prenatal vitamins combination no.42/folic acid) PRENA1 PEARL ORAL CAPSULE,IR - DELAY REL,BIPHASE 30-1.4-200 MG (prenatal vit no.71/iron Tier 3 fum-sodium feredetate/folic acid/dha) PRENA1 TRUE ORAL COMBO PACK 30 MG IRON- 1.4 MG-300 MG (prenatal vits no.105/iron amino acid Tier 3 chelate/folic acid/dha) PRENAISSANCE ORAL CAPSULE 29-1.25-55-325 MG (prenatal vits with calcium no.80/iron fum/folic Tier 3 acid/dss/dha) PRENAISSANCE PLUS ORAL CAPSULE 28-1-50-250 MG (prenatal vit with calcium no.69/iron/folic Tier 3 acid/docusate/dha) PRENATA ORAL TABLET,CHEWABLE 29 MG IRON- 1 Tier 3 MG (prenatal vitamins no.37/ferrous fumarate/folic acid) PRENATABS FA ORAL TABLET 29-1 MG (prenatal vits Tier 1 with calcium no.78/ferrous fumarate/folic acid) PRENATABS RX ORAL TABLET 29 MG IRON- 1 MG (prenatal vitamin with calcium no.76/iron,carbonyl/folic Tier 3 acid) PRENATAL + DHA ORAL COMBO PACK 28 MG IRON- 975 MCG-200 MG (prenatal vits, calcium no.91/ferrous Tier 3 fumarate/folic acid/dha) PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG (prenatal vit with calcium 95/ferrous Tier 3 fumarate/folic acid/dha) PRENATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG IRON- 1 MG-25 MG (prenatal vits no.115/iron Tier 3 fumarate/folic acid/docusate sod.) PRENATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG (prenatal vits with calcium no.115/iron Tier 3 fumarate/folic acid) PRENATAL COMPLETE ORAL TABLET 14 MG IRON- 400 MCG (prenatal vits with calcium no.21/ferrous Tier 1 fumarate/folic acid)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 91 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG (prenatal vits with calcium 95/ferrous Tier 1 fumarate/folic acid) PRENATAL FORMULA ORAL TABLET 9 MG IRON- 267 MCG (prenatal vits with calcium no.93/ferrous Tier 3 fumarate/folic acid) PRENATAL FORMULA-DHA ORAL CAPSULE 28 MG-800 MCG- 200 MG (prenatal vitamins no.116/iron Tier 3 fumarate/folic acid/dha) PRENATAL GUMMY ORAL TABLET,CHEWABLE 400 MCG-35 MG -25 MG-5 MG (prenatal vitamins no.62/folic Tier 3 acid/omega-3s/dha/epa/fish oil) PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG (prenatal vits with calcium no.74/ferrous Tier 1 fumarate/folic acid) PRENATAL MULTI ORAL TABLET 27-800 MG-MCG (prenatal vit with calcium no.122/ferrous fumarate/folic Tier 1 acid) PRENATAL MULTI-DHA (ALGAL OIL) ORAL CAPSULE 27MG IRON- 800 MCG-250 MG (prenatal vitamins Tier 3 no.40/ferrous fumarate/folic acid/dha) PRENATAL MULTI-DHA(WITH VIT K) ORAL CAPSULE 27 MG IRON-800 MCG-260 MG (prenatal vits no.151/iron Tier 3 fum/folic acid/omega3/dha/epa/fish) PRENATAL MULTIVITAMINS ORAL TABLET 28 MG IRON- 800 MCG (prenatal vits with calcium 95/ferrous Tier 3 fumarate/folic acid) PRENATAL ONE DAILY ORAL TABLET 27 MG IRON- 800 MCG (prenatal vit with calcium no.129/ferrous Tier 1 fumarate/folic acid) PRENATAL ORAL TABLET 28 MG IRON- 800 MCG (prenatal vits with calcium 95/ferrous fumarate/folic Tier 1 acid) PRENATAL ORAL TABLET 28-800 MG-MCG (prenatal Tier 1 vits with calcium 133/ferrous fumarate/folic acid) PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG (prenatal vits with calcium Tier 1 no.72/ferrous fumarate/folic acid)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 92 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRENATAL PLUS DHA ORAL COMBO PACK 27 MG IRON-1 MG -312 MG-250 MG (pnv no.72/ferrous Tier 3 fumarate/folic acid/omega-3/dha) PRENATAL PLUS ORAL TABLET 29 MG IRON- 1 MG (prenatal vits with calcium no.72/iron,carbonyl/folic Tier 3 acid) PRENATAL TABLET ORAL TABLET 28 MG IRON- 800 MCG (prenatal vitamins with calcium/ferrous Tier 1 fumarate/folic acid) PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG (prenatal vit with calcium no.130/ferrous fumarate/folic Tier 3 acid) PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG (prenatal vits with calcium no.124/ferrous Tier 1 fumarat/folic acid) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG (prenatal vits with calcium Tier 1 no.72/ferrous fumarate/folic acid) PRENATAL VITAMIN WITH MINERALS ORAL TABLET 28 MG IRON- 800 MCG (prenatal vitamins with Tier 1 calcium/ferrous fumarate/folic acid) prenatal vit-iron fum-folic ac oral tablet 28 mg iron- 800 Tier 1 mcg prenatal vits96-iron fum-folic oral tablet 27 mg iron- 800 Tier 1 mcg PRENATAL WITH DHA-FOLIC ACID ORAL TABLET,CHEWABLE 400-32.5 MCG-MG (prenatal Tier 3 vitamin no.103/folic acid/omega-3s/dha/fish oil) PRENATE ELITE ORAL TABLET 26 MG IRON- 1 MG (prenatal vitamins no.36/ferrous fumarate/folate comb. Tier 3 no.6) PREPLUS ORAL TABLET 27 MG IRON- 1 MG (prenatal Tier 1 vits with calcium no.72/ferrous fumarate/folic acid) PRETAB ORAL TABLET 29-1 MG (prenatal vits with Tier 1 calcium no.78/ferrous fumarate/folic acid) PROVIDA OB ORAL CAPSULE 40 MG IRON- 1.25 MG (prenatal vits no.65/iron fumarate,polysac complex/folic Tier 3 acid)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 95 Coverage Prescription Drug Name Drug Tier Requirements and Limits VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-200 MG (prenatal vits Tier 3 no.102/iron polysacch/folate no.1/docusate/dha) VITAFOL GUMMIES ORAL TABLET,CHEWABLE 3.33 MG IRON- 0.33 MG (prenatal vit no.112/iron phosph/folic Tier 3 acid/omega-3s/dha/epa) VITAFOL NANO ORAL TABLET 18 MG IRON- 1 MG (prenatal vitamins no.75/ferrous fumarate/folate comb. Tier 3 no.1) VITAFOL ULTRA ORAL CAPSULE 29 MG IRON- 1 MG- 200 MG (prenatal vit no.67/iron polysaccharides/folate Tier 3 comb.no.1/dha) VITAFOL-OB ORAL TABLET 65-1 MG (prenatal vits with Tier 1 calcium no.10/ferrous fumarate/folic acid) VITAFOL-OB+DHA ORAL COMBO PACK 65-1-250 MG (prenatal vits with calcium no.10/ferrous fum/folic Tier 3 acid/dha) VITAFOL-ONE ORAL CAPSULE 29 MG IRON- 1 MG-200 MG (prenatal vits no.26/iron polysaccharide cplex/folic Tier 3 acid/dha) VITAMED MD ONE RX ORAL CAPSULE 30 MG IRON- 1MG -200 MG (prenatal vits no.25/ferrous Tier 3 fumarate/folate comb. no.6/dha) VIVA DHA ORAL CAPSULE 28 MG IRON-1 MG -200 MG (prenatal vitamins no.11/ferrous fumarate/folic Tier 3 acid/omega-3) VP-CH PLUS ORAL CAPSULE 29 MG IRON-1 MG -50 MG-265 MG (prenatal vits no.59/iron,carb/folic Tier 3 acid/docuate sodium/dha) VP-CH-PNV ORAL CAPSULE 30 MG IRON-1 MG -50 MG- 260 MG (prenatal vits no.34/iron,carb/folic Tier 3 acid/docusate sodium/dha) VP-PNV-DHA ORAL CAPSULE 28 MG IRON- 1 MG-200 MG (prenatal vitamins no.52/ferrous fumarate/folic Tier 3 acid/dha) WESTAB PLUS ORAL TABLET 27 MG IRON- 1 MG (prenatal vits with calcium no.72/ferrous fumarate/folic Tier 1 acid)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 96 Coverage Prescription Drug Name Drug Tier Requirements and Limits WOMEN'S PRENATAL PLUS DHA ORAL COMBO PACK 28 MG-975 MCG- 200 MG (prenatal vit with calcium Tier 3 no.61/iron fumarate/folic acid/dha) Prenatal Vitamins with Low or No Iron (less than 27 mg) - Drugs for Nutrition ALIVE PRENATAL ORAL TABLET,CHEWABLE 400 MCG- 25 MG (prenatal vitamins no.138/folic Tier 3 acid/docosahexaenoic acid) NATAVI PRIMA ORAL CAPSULE 4 MG IRON- 0.5 MG-150 MG (prenatal no.157/iron fum/folic acid/omega- Tier 3 3/dha/epa/fish oil) PRENATAL GUMMIES ORAL TABLET,CHEWABLE 400 MCG-35 MG- 25 MG-5 MG (prenatal vitamins Tier 3 no.153/folic acid/omega3/dha/epa/fish oil) PRENATAL ORAL TABLET,CHEWABLE 400 MCG Tier 3 (prenatal vitamins no.144/folic acid) ZINGIBER ORAL TABLET 1.2 MG-40 MG- 124.1 MG-100 MG (folic acid/pyridoxine hcl/ca phos dibasic & Tier 3 tribasic/ginger) Vitamins - B Preparation Combinations - Drugs for Nutrition VIRT-VITE ORAL TABLET 2.5-25-1 MG Tier 1 (cyanocobalamin/folic acid/pyridoxine) ZINGIBER ORAL TABLET 1.2 MG-40 MG- 124.1 MG-100 MG (folic acid/pyridoxine hcl/ca phos dibasic & Tier 3 tribasic/ginger) Vitamins - B-12, Cyanocobalamin and derivatives - Drugs for Nutrition cyanocobalamin (vitamin b-12) injection solution 1,000 Tier 1 mcg/ml Vitamins - D Derivatives - Drugs for Nutrition calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1 calcitriol oral solution 1 mcg/ml Tier 1 cholecalciferol (vitamin d3) oral capsule 10 mcg (400 $0 EHB; Age (Min 65 Years) unit), 25 mcg (1,000 unit) cholecalciferol (vitamin d3) oral tablet 25 mcg (1,000 $0 EHB; Age (Min 65 Years) unit) ergocalciferol (vitamin d2) oral capsule 1,250 mcg Tier 1 (50,000 unit) ergocalciferol (vitamin d2) oral tablet 10 mcg (400 unit) $0 EHB; Age (Min 65 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 104 Coverage Prescription Drug Name Drug Tier Requirements and Limits methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 Tier 1 mg methylprednisolone oral tablets,dose pack 4 mg Tier 1 prednisolone oral solution 15 mg/5 ml Tier 1 prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 5 mg Tier 1 base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral Tier 1 tablet,disintegrating 10 mg, 15 mg, 30 mg prednisone oral solution 5 mg/5 ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 Tier 1 mg, 50 mg prednisone oral tablets,dose pack 10 mg, 5 mg Tier 2 Gonadotropin Inhibitor Pituitary Suppressants - Drugs for Women danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1 Growth Hormone Receptor Antagonists - Drugs for Growth SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 Tier 4 PA; SP MG, 20 MG, 25 MG, 30 MG (pegvisomant) Growth Hormones - Drugs for Growth NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 Tier 4 PA; SP MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) Human Insulins - Fixed Combinations - Drugs for Diabetes HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) (insulin nph human Tier 3 DD isophane/insulin regular, human) HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin nph human Tier 3 DD isophane/insulin regular, human) NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) (insulin nph human Tier 2 DD isophane/insulin regular, human) NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin nph human Tier 2 DD isophane/insulin regular, human) Human Insulins - Intermediate Acting - Drugs for Diabetes PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 105 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) (insulin nph human Tier 3 DD isophane) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (insulin nph human Tier 3 DD isophane) NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN Tier 2 DD 100 UNIT/ML (3 ML) (insulin nph human isophane) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (insulin nph human Tier 2 DD isophane) Human Insulins - Short Acting - Drugs for Diabetes HUMULIN R REGULAR U-100 INSULN INJECTION Tier 3 DD SOLUTION 100 UNIT/ML (insulin regular, human) HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS Tier 2 DD SOLUTION 500 UNIT/ML (insulin regular, human) HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) (insulin regular, Tier 2 DD human) NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN Tier 2 DD 100 UNIT/ML (3 ML) (insulin regular, human) NOVOLIN R REGULAR U-100 INSULN INJECTION Tier 2 DD SOLUTION 100 UNIT/ML (insulin regular, human) Insulin Analogs - Fixed Combinations - Drugs for Diabetes HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) (insulin lispro Tier 3 DD protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) (insulin lispro Tier 3 DD protamine and insulin lispro) HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) (insulin lispro Tier 3 DD protamine and insulin lispro) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) (insulin lispro Tier 3 DD protamine and insulin lispro) NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) (insulin aspart Tier 2 DD protamine human/insulin aspart) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 106 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin aspart Tier 2 DD protamine human/insulin aspart) Insulin Analogs - Long Acting - Drugs for Diabetes LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) (insulin Tier 2 DD glargine,human recombinant analog) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin glargine,human recombinant Tier 2 DD analog) SEMGLEE U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin glargine,human recombinant Tier 2 DD analog) TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) (insulin Tier 2 DD glargine,human recombinant analog) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) (insulin Tier 2 DD glargine,human recombinant analog) Insulin Analogs - Rapid Acting - Drugs for Diabetes HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS Tier 3 DD INSULIN PEN, HALF-UNIT 100 UNIT/ML (insulin lispro) HUMALOG KWIKPEN INSULIN SUBCUTANEOUS Tier 3 DD INSULIN PEN 200 UNIT/ML (3 ML) (insulin lispro) HUMALOG U-100 INSULIN SUBCUTANEOUS Tier 3 DD CARTRIDGE 100 UNIT/ML (insulin lispro) NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS Tier 2 DD INSULIN PEN 100 UNIT/ML (3 ML) (insulin aspart) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS BRAND COVERED AT Tier 2 CARTRIDGE 100 UNIT/ML (insulin aspart) GENERIC COPAY; DD NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS BRAND COVERED AT Tier 2 SOLUTION 100 UNIT/ML (insulin aspart) GENERIC COPAY; DD Insulin Response Enhancers - Biguanides - Drugs for Diabetes metformin oral tablet 1,000 mg, 500 mg, 850 mg Tier 1 DD metformin oral tablet extended release 24 hr 500 mg, Tier 1 DD 750 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 111 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACID REDUCER (CIMETIDINE) ORAL TABLET 200 MG Tier 1 (cimetidine) ACID REDUCER (FAMOTIDINE) ORAL TABLET 10 MG, Tier 1 20 MG (famotidine) ACID-PEP ORAL TABLET 20 MG (famotidine) Tier 1 cimetidine hcl oral solution 300 mg/5 ml Tier 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg Tier 1 famotidine oral suspension 40 mg/5 ml (8 mg/ml) Tier 1 famotidine oral tablet 10 mg, 20 mg, 40 mg Tier 1 HEARTBURN PREVENTION ORAL TABLET 10 MG, 20 Tier 1 MG (famotidine) HEARTBURN RELIEF (CIMETIDINE) ORAL TABLET 200 Tier 1 MG (cimetidine) HEARTBURN RELIEF (FAMOTIDINE) ORAL TABLET 10 Tier 1 MG, 20 MG (famotidine) nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 150 mg/10 ml Tier 1 Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (PPIs) - Drugs for Ulcers and Stomach Acid lansoprazole oral capsule,delayed release(dr/ec) 15 mg, Tier 1 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 Tier 2 mg omeprazole oral capsule,delayed release(dr/ec) 10 mg, Tier 1 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, Tier 1 40 mg Gastric Mucosa - Cytoprotective Prostaglandin Analogs - Drugs for Ulcers and Stomach Acid misoprostol oral tablet 100 mcg, 200 mcg Tier 1 Gastrointestinal Prokinetic Agents - D2 Antagonist/5-HT4 Agonists - Drugs for the Stomach metoclopramide hcl oral solution 5 mg/5 ml Tier 1 metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 GI Antispasmodic - Belladonna Alkaloids - Drugs for Stomach Cramps

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 112 Coverage Prescription Drug Name Drug Tier Requirements and Limits ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1 hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1 hyoscyamine sulfate oral tablet 0.125 mg Tier 1 hyoscyamine sulfate oral tablet extended release 12 hr Tier 1 0.375 mg hyoscyamine sulfate oral tablet,disintegrating 0.125 mg Tier 1 hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1 HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) methscopolamine oral tablet 2.5 mg, 5 mg Tier 1 OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate) GI Antispasmodic - Quaternary Ammonium Compounds - Drugs for Stomach Cramps glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 GI Antispasmodic - Synthetic Tertiary Amines - Drugs for Stomach Cramps dicyclomine oral capsule 10 mg Tier 1 dicyclomine oral solution 10 mg/5 ml Tier 1 dicyclomine oral tablet 20 mg Tier 1 GI Antispasmodic Combinations Other - Drugs for Stomach Cramps belladonna alkaloids-opium rectal suppository 16.2-30 Tier 2 mg, 16.2-60 mg Inflammatory Bowel Agent - Aminosalicylates and Related Agents - Drugs for Inflammatory Bowel Disease balsalazide oral capsule 750 mg Tier 1 mesalamine oral capsule (with del rel tablets) 400 mg Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 114 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (3 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (2 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 Tier 4 days) ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 Tier 4 PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) days) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 days) (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT PA; SP; QL (2 EA per 28 Tier 4 40 MG/0.4 ML (adalimumab) days) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT PA; SP; QL (3 EA per 28 Tier 4 80 MG/0.8 ML (adalimumab) days) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 PA; SP; QL (2 EA per 28 Tier 4 ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) days) Irritable Bowel Syndrome (IBS) Agents - Drugs for Irritable Bowel Syndrome LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG Tier 2 PA; QL (1 EA per 1 day) (linaclotide) Laxative - Saline and Osmotic - Drugs to Prevent Constipation lactulose (Constulose Oral Solution 10 Gram/15 Ml) Tier 1 lactulose oral solution 10 gram/15 ml Tier 1 lactulose oral solution 20 gram/30 ml Tier 1 Laxative - Saline/Osmotic Mixtures - Drugs to Prevent Constipation GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 $0 COPAY IF AGE 50-75 GRAM (peg 3350/sod sulf/sod bicarb/sod Tier 1 YEARS chloride/potassium chloride) peg 3350/sod sulf/sod bicarb/sod chloride/potassium $0 COPAY IF AGE 50-75 chloride (Gavilyte-G Oral Recon Soln 236-22.74-6.74 -5.86 Tier 1 YEARS Gram) sodium chloride/sodium bicarbonate/potassium $0 COPAY IF AGE 50-75 Tier 1 chloride/peg (Gavilyte-N Oral Recon Soln 420 Gram) YEARS OSMOPREP ORAL TABLET 1.5 GRAM (sodium Tier 3 phosphate,monobasic/sodium phosphate,dibasic) peg 3350-electrolytes oral recon soln 236-22.74-6.74 - $0 COPAY IF AGE 50-75 Tier 1 5.86 gram YEARS

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 117 Coverage Prescription Drug Name Drug Tier Requirements and Limits AZO URINARY PAIN RELIEF ORAL TABLET 95 MG Tier 1 (phenazopyridine hcl) phenazopyridine oral tablet 100 mg, 200 mg Tier 1 URINARY PAIN RELIEF ORAL TABLET 95 MG, 97.5 MG Tier 1 (phenazopyridine hcl) Urinary Antibacterial - Nitrofuran Derivatives - Drugs for Infections nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, Tier 1 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg Tier 1 nitrofurantoin oral suspension 25 mg/5 ml Tier 1 Urinary Antibacterial - Quinolones - Drugs for Infections CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin/ciprofloxacin hcl) Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) - Drugs for the Bladder solifenacin oral tablet 10 mg, 5 mg Tier 2 Urinary Antispasmodic - Anticholinergics, Non-Selective - Drugs for the Bladder ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate) Urinary Antispasmodic - Smooth Muscle Relaxants - Drugs for the Bladder oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 oxybutynin chloride oral tablet extended release 24hr Tier 1 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 Tier 1 mg PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 118 Coverage Prescription Drug Name Drug Tier Requirements and Limits tolterodine oral tablet 1 mg, 2 mg Tier 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 Tier 2 MG, 8 MG (fesoterodine fumarate) trospium oral capsule,extended release 24hr 60 mg Tier 1 trospium oral tablet 20 mg Tier 1 Urinary Retention Therapy - Parasympathomimetic Agents - Drugs for the Bladder bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 Tier 1 mg Gout and Hyperuricemia Therapy - Drugs for Pain and Fever Gout Acute Therapy - Antimitotics - Gout Drugs colchicine oral capsule 0.6 mg Tier 1 Gout and Hyperuricemia - Antimitotic-Uricosuric Combinations - Gout Drugs probenecid-colchicine oral tablet 500-0.5 mg Tier 1 Hyperuricemia Therapy - Uricosurics - Gout Drugs probenecid oral tablet 500 mg Tier 1 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors - Gout Drugs allopurinol oral tablet 100 mg, 300 mg Tier 1 febuxostat oral tablet 40 mg, 80 mg Tier 2 PA; QL (30 EA per 30 days) Hematological Agents - Drugs for the Blood Anticoagulants - Coumarin - Drugs to Prevent Blood Clots warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, Tier 1 2.5 Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 Tier 1 mg, 5 mg, 6 mg, 7.5 mg C1 Esterase Inhibitor Agents - Drugs for the Blood BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) (c1 Tier 4 PA; SP esterase inhibitor) BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 Tier 4 PA; SP ML) (c1 esterase inhibitor) Direct Factor Xa Inhibitors - Drugs to Prevent Blood Clots ELIQUIS DVT-PE TREAT 30D START ORAL Tier 3 TABLETS,DOSE PACK 5 MG (74 TABS) (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 119 Coverage Prescription Drug Name Drug Tier Requirements and Limits XARELTO DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Tier 2 (rivaroxaban) XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG Tier 2 (rivaroxaban) Erythropoietins - Drugs for the Blood ARANESP (IN POLYSORBATE) INJECTION SOLUTION PA; SP; ST: Prior 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 Tier 4 prescription for Retacrit in MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML 120 days (darbepoetin alfa in polysorbate 80) ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 PA; SP; ST: Prior MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 Tier 4 prescription for Retacrit in MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML (darbepoetin 120 days alfa in polysorbate 80) EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 PA; SP; ST: Prior UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 Tier 4 prescription for Retacrit in UNIT/ML, 4,000 UNIT/ML (epoetin alfa) 120 days RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 Tier 3 PA; SP UNIT/ML, 40,000 UNIT/ML (epoetin alfa-epbx) Granulocyte Colony-Stimulating Factor (G-CSF) - Drugs for the Blood NEULASTA ONPRO SUBCUTANEOUS SYRINGE, W/ Tier 4 SP WEARABLE INJECTOR 6 MG/0.6 ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 4 SP (pegfilgrastim) ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 Tier 4 SP MCG/0.8 ML (filgrastim-sndz) Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) - Drugs for the Blood LEUKINE INJECTION RECON SOLN 250 MCG Tier 4 SP (sargramostim) Hematorheologic Agents - Drugs for the Blood pentoxifylline oral tablet extended release 400 mg Tier 1 Hemostatic Systemic - Antifibrinolytic Agents - Drugs to Prevent Bleeding aminocaproic acid oral solution 250 mg/ml (25 %) Tier 1 aminocaproic acid oral tablet 1,000 mg, 500 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 124 Coverage Prescription Drug Name Drug Tier Requirements and Limits CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM $0 CT; EHB (diaphragms, contoured) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 $0 CT; EHB MM (diaphragms, wide seal) Medical Supplies and DME - Equipment Cleaning Agents - Medical Supplies and Durable Medical Equipment ALCOH-GLOVE TOWELETTE 70 % (isopropyl alcohol) Tier 1 ALCOH-WIPE TOWELETTE 70 % (isopropyl alcohol) Tier 1 Medical Supplies and DME - Female Condoms - Medical Supplies and Durable Medical Equipment FC2 FEMALE CONDOM (condoms, female) $0 CT; EHB Medical Supplies and DME - Glucose Monitoring Test Supplies - Medical Supplies and Durable Medical Equipment 1ST TIER UNILET COMFORTOUCH 28 GAUGE, 30 Tier 1 DD GAUGE (lancets) 2TEK CONTROL (HIGH-NORMAL) SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) Tier 1 DD ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing Tier 1 DD device/lancets)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 125 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK MULTICLIX LANCET (lancets) Tier 1 DD ACCU-CHEK MULTICLIX LANCET KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SAFE-T-PRO 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SOFTCLIX LANCETS (lancets) Tier 1 DD ACCUTREND GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACTI-LANCE LANCETS 17 GAUGE, 23 GAUGE, 28 Tier 1 DD GAUGE (lancets) ADJUSTABLE LANCING DEVICE (lancing device) Tier 1 DD ADVANCED LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) ADVANCED TRAVEL LANCETS 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) ADVOCATE CONTROL SOLUTION HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ADVOCATE LANCET 26 GAUGE, 30 GAUGE (lancets) Tier 1 DD ADVOCATE LANCING DEVICE (lancing device) Tier 1 DD ADVOCATE LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) ADVOCATE RAPID-SAFE LANCING (lancing device) Tier 1 DD ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) ADVOCATE REDI-CODE+ CTRL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) AGAMATRIX CONTROL HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) AGAMATRIX CONTROL NORM-HI SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 126 Coverage Prescription Drug Name Drug Tier Requirements and Limits AGAMATRIX CONTROL SOLN-LEVEL 2 SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) AGAMATRIX CONTROL SOLN-LEVEL 4 SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ALTERNATE SITE LANCET 26 GAUGE (lancets) Tier 1 DD ALTERNATE SITE LANCING DEVICE (lancing device) Tier 1 DD AQUA LANCE LANCING DEVICE (lancing device) Tier 1 DD ASSURE 4 CONTROL SOLUTION COMBO PACK (blood- Tier 1 DD glucose calib. control) ASSURE DOSE NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ASSURE DOSE NORM-HI CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) ASSURE HAEMOLANCE PLUS 1.2 MM (blade lancet, Tier 1 DD safety) ASSURE HAEMOLANCE PLUS 18 GAUGE, 21 GAUGE, Tier 1 DD 25 GAUGE, 28 GAUGE (lancets) ASSURE LANCE 25 GAUGE, 28 GAUGE (lancets) Tier 1 DD ASSURE LANCE PLUS 21 GAUGE, 25 GAUGE, 30 Tier 1 DD GAUGE (lancets) ASSURE PRISM CONTROL 1-2 SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) AUTO-LANCET MINI (lancing device) Tier 1 DD AUTOLET IMPRESSION LANC DEV KIT (lancing Tier 1 DD device/lancets) AUTOLET LANCING DEVICE (lancing device) Tier 1 DD AUTOLET PLUS LANCING DEVICE (lancing device) Tier 1 DD BD MICROTAINER LANCET 1.5 X 2 MM (blade lancet, Tier 1 DD safety) BD MICROTAINER LANCET 21 GAUGE, 30 GAUGE Tier 1 DD (lancets) BD ULTRA FINE LANCETS 33 GAUGE (lancets) Tier 1 DD BD ULTRA-FINE II LANCETS 30 GAUGE (lancets) Tier 1 DD blood glucose contrl hi,normal solution Tier 1 DD blood glucose control, normal solution Tier 1 DD blood glucose ctl high,nml,low solution Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 127 Coverage Prescription Drug Name Drug Tier Requirements and Limits BREEZE 2 CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) BREEZE 2 CONTROL SOLUTION, NML SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) BREEZE 2 CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) BULLSEYE MINI SAFETY LANCETS 21 GAUGE, 25 Tier 1 DD GAUGE, 28 GAUGE (lancets) BUTTERFLY TOUCH LANCET 30 GAUGE (lancets) Tier 1 DD CAREONE LANCING DEVICE (lancing device) Tier 1 DD CAREONE THIN LANCET (lancets) Tier 1 DD CAREONE ULTRA THIN LANCET (lancets) Tier 1 DD CARESENS CONTROL A AND B SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) CARESENS CONTROL A NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) CARESENS LANCETS 30 GAUGE (lancets) Tier 1 DD CARETOUCH LANCING DEVICE (lancing device) Tier 1 DD CARETOUCH SAFETY LANCETS 26 GAUGE, 28 GAUGE Tier 1 DD (lancets) CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) CHOICE DM CLARUS NORM CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) CLEVER CHEK LANCETS 30 GAUGE (lancets) Tier 1 DD CLEVER CHOICE LEVEL 1 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, low) CLEVER CHOICE LEVEL 2 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) CLEVER CHOICE LEVEL 3 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) COAGUCHEK LANCETS (lancets) Tier 1 DD COLOR LANCETS 21 GAUGE (lancets) Tier 1 DD COMFORT EZ LANCETS 21 GAUGE, 23 GAUGE, 28 Tier 1 DD GAUGE (lancets) COMFORT LANCETS (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 128 Coverage Prescription Drug Name Drug Tier Requirements and Limits CONTOUR CONTROL SOLUTION, HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) CONTOUR CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) CONTOUR CONTROL SOLUTION, NML SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) CONTOUR NEXT LEV 1 CONTROL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, low) CONTOUR NEXT LEV 2 CONTROL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) COOL CONTROL A SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) COOL CONTROL B SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, high) DIATRUE CONTROL SOLN NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) DIATRUE CONTROL SOLUTION HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) DIATRUE CONTROL SOLUTION LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) DROPLET LANCETS 30 GAUGE (lancets) Tier 1 DD DROPLET LANCING DEVICE (lancing device) Tier 1 DD EASY COMFORT LANCETS 30 GAUGE (lancets) Tier 1 DD EASY MINI EJECT LANCING DEVICE (lancing device) Tier 1 DD EASY PLUS II HIGH CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) EASY PLUS II LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EASY STEP HIGH CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, high) EASY STEP LOW CONTROL SOLUTION SOLUTION Tier 1 DD (blood glucose calibration control solution, low) EASY STEP NORMAL CONTROL SOLN SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) EASY TALK HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 129 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TALK LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASY TOUCH HIGH-LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) EASY TOUCH LANCETS 26 GAUGE, 28 GAUGE, 30 Tier 1 DD GAUGE, 32 GAUGE (lancets) EASY TOUCH LANCING DEVICE (lancing device) Tier 1 DD EASY TOUCH SAFETY LANCETS 21 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE Tier 1 DD (lancets) EASY TOUCH TWIST LANCETS 26 GAUGE, 28 GAUGE, Tier 1 DD 30 GAUGE, 32 GAUGE, 33 GAUGE (lancets) EASY TRAK HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) EASY TRAK II CTRL SOLN-NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EASY TRAK LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASY TWIST AND CAP LANCETS 28 GAUGE (lancets) Tier 1 DD EASYGLUCO PLUS NORMAL CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) EASYMAX 15 LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASYMAX 15 LEVEL 2 SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) EASYMAX LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASYMAX NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ELEMENT COMPACT HIGH CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ELEMENT COMPACT NORMAL CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ELEMENT HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) ELEMENT LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 130 Coverage Prescription Drug Name Drug Tier Requirements and Limits ELEMENT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EMBRACE EVO LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EMBRACE GLUCOSE CONTROL HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) EMBRACE GLUCOSE CONTROL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EMBRACE LANCETS 30 GAUGE (lancets) Tier 1 DD EMBRACE PRO SOLUTION (blood glucose calibration Tier 1 DD control solution, high and normal) EMBRACE TALK CONTROL-HIGH (L2) SOLUTION (blood Tier 1 DD glucose calibration control solution, high) EMBRACE TALK CONTROL-LOW (L1) SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EVENCARE G2 SOLUTION (blood glucose calibration Tier 1 DD control high and low) EVENCARE G3 CONTROL SOLUTION (blood glucose Tier 1 DD calibration control high and low) EVENCARE MINI GLUCOSE CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) EVENCARE PROVIEW CONTROL-L2,L3 SOLUTION Tier 1 DD (blood glucose calibration control high and low) EVENCARE SOLUTION (blood glucose calibration Tier 1 DD control high and low) EVOLUTION NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) E-Z JECT LANCETS , 26 GAUGE, 30 GAUGE, 32 Tier 1 DD GAUGE, 33 GAUGE (lancets) E-Z JECT THIN LANCETS 28 GAUGE (lancets) Tier 1 DD EZ SMART CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EZ SMART LANCETS 28 GAUGE (lancets) Tier 1 DD EZ-LETS 26 GAUGE (lancets) Tier 1 DD FIFTY50 SAFETY SEAL LANCETS 30 GAUGE, 32 GAUGE Tier 1 DD (lancets) FINE 30 UNIVERSAL LANCETS 30 GAUGE (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 131 Coverage Prescription Drug Name Drug Tier Requirements and Limits FINGERSTIX LANCETS (lancets) Tier 1 DD FORA HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) FORA LANCING DEVICE (lancing device) Tier 1 DD FORA LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) FORA NORMAL CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) FORACARE GDH HIGH CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) FORACARE GDH LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, low) FORACARE GDH NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) FORACARE LANCETS 30 GAUGE (lancets) Tier 1 DD FORTISCARE HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) FORTISCARE LOW SOLUTION (blood glucose Tier 1 DD calibration control solution, low) FORTISCARE NORMAL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) FREESTYLE CONTROL SOLUTION (blood glucose Tier 1 DD calibration control high and low) FREESTYLE FREEDOM LITE KIT (blood-glucose meter) $0 DD; EHB FREESTYLE INSULINX (blood-glucose meter) $0 DD; EHB FREESTYLE LANCETS 28 GAUGE (lancets) Tier 1 DD FREESTYLE LITE METER KIT (blood-glucose meter) $0 DD; EHB FREESTYLE UNISTIK 2 (lancets) Tier 1 DD GE100 CONTROL SOLUTION NORMAL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) GLUCOCARD 01 HI-NORMAL CONTROL SOLUTION (blood glucose calibration control solution, high and Tier 1 DD normal) GLUCOCARD 01 NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) GLUCOCARD EXPRESSION SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 132 Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCOCARD SHINE SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) GLUCOCOM CONTROL HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) GLUCOCOM CONTROL NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) GLUCOCOM LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) GLUCOSE CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) GLUCOSE KETONE CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) GOJJI GLUCOSE CNTRL SOL-NORMAL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) GOJJI LANCETS 30 GAUGE (lancets) Tier 1 DD HARMONY CONTROL L1,L3 SOLUTION (blood glucose Tier 1 DD calibration control high and low) HEALTHPRO HIGH-LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) HEALTHY ACCENTS AUTOLET (lancing device) Tier 1 DD HEALTHY ACCENTS UNILET LANCET 30 GAUGE Tier 1 DD (lancets) HYPOLANCE AST LANCING KIT (lancing device/lancets) Tier 1 DD INCONTROL LANCING DEVICE (lancing device) Tier 1 DD INCONTROL SUPER THIN LANCETS 30 GAUGE Tier 1 DD (lancets) INCONTROL ULTRA THIN LANCETS 28 GAUGE (lancets) Tier 1 DD INFINITY CONTROL SOLUTION HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) INFINITY CONTROL SOLUTION LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) INFINITY CONTROL SOLUTION NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) INFINITY VOICE CTRL SOLN-LVL 2 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) INJECT EASE LANCETS 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD INVACARE LANCETS 30 GAUGE (lancets) Tier 1 DD PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 133 Coverage Prescription Drug Name Drug Tier Requirements and Limits lancets , 21 gauge, 26 gauge, 28 gauge, 30 gauge, 33 Tier 1 DD gauge LANCETS, SUPER THIN (lancets) Tier 1 DD LANCETS,THIN , 23 GAUGE, 28 GAUGE (lancets) Tier 1 DD LANCETS,ULTRA THIN , 26 GAUGE (lancets) Tier 1 DD lancing device Tier 1 DD LANCING DEVICE WITH LANCETS (lancing device) Tier 1 DD lancing device with lancets kit Tier 1 DD LANCING SYSTEM (lancing device) Tier 1 DD LANZO LANCING DEVICE KIT (lancing device/lancets) Tier 1 DD LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) LITE TOUCH LANCING DEVICE (lancing device) Tier 1 DD MEDISENSE COMBO PACK (blood-glucose calib. Tier 1 DD control) MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK Tier 1 DD (blood-glucose calib. control) MEDISENSE GLUCOSE KETONE COMBO PACK (blood- Tier 1 DD glucose calib. control) MEDISENSE MID CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) MEDISENSE THIN LANCETS 28 GAUGE (lancets) Tier 1 DD MEDLANCE PLUS LANCETS 21 GAUGE, 25 GAUGE, 30 Tier 1 DD GAUGE (lancets) MEDLANCE PLUS SPECIAL BLADE 0.8 X 2 MM (blade Tier 1 DD lancet, safety) MEDPOINT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) METER-CHECK SOLUTION (blood glucose calibration Tier 1 DD control solution, normal) MICRO THIN LANCETS 33 GAUGE (lancets) Tier 1 DD MICRODOT HIGH-LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) MICRODOT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 134 Coverage Prescription Drug Name Drug Tier Requirements and Limits MICROLET 2 LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) MICROLET LANCET (lancets) Tier 1 DD MICROLET NEXT LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) MINI LANCING DEVICE (lancing device) Tier 1 DD MONOLET LANCETS 21 GAUGE (lancets) Tier 1 DD MONOLET THIN LANCETS 28 GAUGE (lancets) Tier 1 DD MULTI-LANCET DEVICE 2 KIT (lancing device/lancets) Tier 1 DD MYGLUCOHEALTH CONTROL SOLUTION SOLUTION (blood glucose calibration control solutions Tier 1 DD high,normal,low) MYGLUCOHEALTH LANCETS 30 GAUGE (lancets) Tier 1 DD NOVA MAX GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) NOVA SAFETY LANCETS 23 GAUGE, 28 GAUGE Tier 1 DD (lancets) NOVA SUREFLEX LANCETS (lancets) Tier 1 DD NOVAMAX PLUS GLU-KET SOLUTION (blood glucose Tier 1 DD and ketone control, normal) ON CALL EXPRESS CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solutions high,normal,low) ON CALL LANCET 30 GAUGE (lancets) Tier 1 DD ON CALL LANCING DEVICE (lancing device) Tier 1 DD ON CALL PLUS CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high and normal) ON CALL PLUS LANCET 30 GAUGE (lancets) Tier 1 DD ON CALL PLUS LANCING DEVICE (lancing device) Tier 1 DD ON CALL VIVID CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high and normal) ONETOUCH DELICA LANC DEVICE KIT (lancing Tier 1 DD device/lancets) ONETOUCH DELICA LANCETS 30 GAUGE, 33 GAUGE Tier 1 DD (lancets) ONETOUCH DELICA PLUS LANCET 30 GAUGE, 33 Tier 1 DD GAUGE (lancets)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 135 Coverage Prescription Drug Name Drug Tier Requirements and Limits ONETOUCH SURESOFT LANCING DEV 18 GAUGE, 21 Tier 1 DD GAUGE, 28 GAUGE (lancets) ONETOUCH ULTRA CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ONETOUCH ULTRASOFT LANCETS (lancets) Tier 1 DD ONETOUCH VERIO HIGH CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) ONETOUCH VERIO MID CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ON-THE-GO LANCETS 30 GAUGE (lancets) Tier 1 DD OPTUMRX SOLUTION (blood glucose calibration Tier 1 DD control solution, high and normal) PIP LANCET 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD PRECISION GLUCOSE CONTROL SOLN COMBO PACK Tier 1 DD (blood-glucose calib. control) PRECISION GLUCOSE/KETONE CONTR COMBO PACK Tier 1 DD (blood-glucose calib. control) PRECISION XTRA MONITOR (blood-glucose meter) $0 DD; EHB PRESSURE ACTIVATED LANCETS 21 GAUGE, 28 Tier 1 DD GAUGE (lancets) PRO COMFORT LANCET 30 GAUGE, 31 GAUGE Tier 1 DD (lancets) PRODIGY CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) PRODIGY CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) PRODIGY LANCETS 26 GAUGE, 28 GAUGE (lancets) Tier 1 DD PRODIGY LANCING DEVICE (lancing device) Tier 1 DD PRODIGY TWIST TOP LANCET 28 GAUGE (lancets) Tier 1 DD PURE COMFORT LANCETS 30 GAUGE (lancets) Tier 1 DD PURE COMFORT SAFETY LANCETS 30 GAUGE Tier 1 DD (lancets) PUSH BUTTON SAFETY LANCETS 21 GAUGE, 28 Tier 1 DD GAUGE (lancets) READYLANCE SAFETY LANCETS 21 GAUGE, 23 Tier 1 DD GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE (lancets)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 136 Coverage Prescription Drug Name Drug Tier Requirements and Limits REFUAH PLUS GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) RELIAMED LANCET 23 GAUGE, 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) RELIAMED MINI LANCING DEVICE (lancing device) Tier 1 DD RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 Tier 1 DD GAUGE (lancets) RELIAMED TWIST AND CAP LANCET 28 GAUGE Tier 1 DD (lancets) RELION THIN LANCETS 26 GAUGE (lancets) Tier 1 DD RELION ULTRA THIN PLUS LANCETS (lancets) Tier 1 DD RIGHTEST CONTROL SOLUTION HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) RIGHTEST CONTROL SOLUTION NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) RIGHTEST GC250S CNTRL SOL NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) RIGHTEST GD500 LANCING DEVICE (lancing device) Tier 1 DD RIGHTEST GL300 LANCETS 30 GAUGE (lancets) Tier 1 DD RIGHTEST GT333 LEV 2 CTRL SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) SAFETY LANCETS 21 GAUGE, 26 GAUGE, 28 GAUGE Tier 1 DD (lancets) SAFETY SEAL LANCETS 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) SAFETY-LET LANCETS 30 GAUGE (lancets) Tier 1 DD SINGLE-LET (lancets) Tier 1 DD SMART SENSE LANCETS 21 GAUGE, 26 GAUGE, 33 Tier 1 DD GAUGE (lancets) SMARTDIABETES VANTAGE (lancing device) Tier 1 DD SMARTEST CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) SMARTEST LANCET (lancets) Tier 1 DD SOFT TOUCH LANCETS (lancets) Tier 1 DD SOLUS V2 CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 137 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOLUS V2 CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) SOLUS V2 LANCETS 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD SOLUS V2 LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) STERILANCE TL 30 GAUGE, 32 GAUGE (lancets) Tier 1 DD SUPER THIN LANCETS , 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) SURE COMFORT LANCETS 18 GAUGE, 21 GAUGE, 23 Tier 1 DD GAUGE, 28 GAUGE, 30 GAUGE (lancets) SURE COMFORT LANCING PEN (lancing device) Tier 1 DD SUREFLEX DEVICE WITH LANCETS KIT (lancing Tier 1 DD device/lancets) SUREFLEX LANCING DEVICE (lancing device) Tier 1 DD SURE-LANCE , 26 GAUGE, 28 GAUGE (lancets) Tier 1 DD SURE-LANCE ULTRA THIN 30 GAUGE (lancets) Tier 1 DD SURE-TEST EASYPLUS MINI SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) SURE-TOUCH LANCET (lancets) Tier 1 DD TD GOLD LEVEL 1 CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) TD GOLD LEVEL 2 CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) TD GOLD LEVEL 3 CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) TECHLITE LANCETS 25 GAUGE, 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) TELCARE CONTROL SOLUTION (blood glucose Tier 1 DD calibration control high and low) TELCARE LANCETS 30 GAUGE (lancets) Tier 1 DD THIN LANCETS 26 GAUGE (lancets) Tier 1 DD TOPCARE UNIVERSAL1 LANCET , 33 GAUGE (lancets) Tier 1 DD TRUE COMFORT LANCET 30 GAUGE (lancets) Tier 1 DD TRUE METRIX LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 138 Coverage Prescription Drug Name Drug Tier Requirements and Limits TRUE METRIX LEVEL 2 SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) TRUE METRIX LEVEL 3 SOLUTION (blood glucose Tier 1 DD calibration control solution, high) TRUECONTROL LEVEL 0 SOLUTION (blood glucose Tier 1 DD calibration control solution, high) TRUECONTROL LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) TRUEDRAW LANCING DEVICE (lancing device) Tier 1 DD TRUEPLUS LANCETS 26 GAUGE, 28 GAUGE, 30 Tier 1 DD GAUGE, 33 GAUGE (lancets) TWIST LANCETS 30 GAUGE, 32 GAUGE (lancets) Tier 1 DD ULTI-LANCE (lancing device) Tier 1 DD ULTI-LANCE KIT (lancing device/lancets) Tier 1 DD ULTILET BASIC LANCETS 30 GAUGE (lancets) Tier 1 DD ULTILET CLASSIC LANCETS , 28 GAUGE, 30 GAUGE, Tier 1 DD 33 GAUGE (lancets) ULTILET LANCETS 28 GAUGE, 30 GAUGE, 33 GAUGE Tier 1 DD (lancets) ULTILET SAFETY LANCETS 23 GAUGE (lancets) Tier 1 DD ULTRA FINE LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRA THIN II LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRA THIN LANCETS , 28 GAUGE, 30 GAUGE, 31 Tier 1 DD GAUGE, 33 GAUGE (lancets) ULTRA THIN PLUS LANCETS 33 GAUGE (lancets) Tier 1 DD ULTRA TLC LANCETS (lancets) Tier 1 DD ULTRA-CARE LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE Tier 1 DD (lancets) ULTRA-THIN II LANCETS 28 GAUGE (lancets) Tier 1 DD ULTRATRAK HIGH-LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ULTRATRAK NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ULTRATRAK ULTIMATE SOLUTION (blood glucose Tier 1 DD calibration control high and low)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 139 Coverage Prescription Drug Name Drug Tier Requirements and Limits UNILET COMFORTOUCH LANCET , 26 GAUGE (lancets) Tier 1 DD UNILET EXCELITE II LANCET (lancets) Tier 1 DD UNILET EXCELITE LANCET (lancets) Tier 1 DD UNILET GP LANCET (lancets) Tier 1 DD UNILET LANCET 28 GAUGE, 33 GAUGE (lancets) Tier 1 DD UNILET LANCETS 30 GAUGE (lancets) Tier 1 DD UNILET SUPER THIN LANCETS 30 GAUGE (lancets) Tier 1 DD UNISTIK 2 NORMAL LANCET,DEVICE KIT (lancing Tier 1 DD device/lancets) UNISTIK 3 COMFORT LANCET (lancets) Tier 1 DD UNISTIK 3 EXTRA LANCET 21 GAUGE (lancets) Tier 1 DD UNISTIK 3 GENTLE 30 GAUGE (lancets) Tier 1 DD UNISTIK 3 LANCETS 21 GAUGE (lancets) Tier 1 DD UNISTIK 3 NORMAL LANCET 23 GAUGE (lancets) Tier 1 DD UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE (lancets) Tier 1 DD UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 Tier 1 DD GAUGE (lancets) UNISTIK SAFETY 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD UNISTIK TOUCH LANCETS 21 GAUGE, 23 GAUGE, 28 Tier 1 DD GAUGE, 30 GAUGE (lancets) UNISTRIP HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) UNISTRIP LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) UNIVERSAL 1 LANCETS 21 GAUGE, 26 GAUGE, 30 Tier 1 DD GAUGE, 33 GAUGE (lancets) VERASENS CONTROL SOLN-LEVEL 1 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) VIVAGUARD INO CTRL SOLN-L1,2,3 SOLUTION (blood Tier 1 DD glucose calibration control solutions high,normal,low) VIVAGUARD INO CTRL SOLN-L1,L3 SOLUTION (blood Tier 1 DD glucose calibration control high and low) VIVAGUARD INO CTRL SOLN-L2 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) VIVAGUARD LANCET 30 GAUGE (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 140 Coverage Prescription Drug Name Drug Tier Requirements and Limits WAVESENSE CONTROL SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) Medical Supplies and DME - Humidifiers - Medical Supplies and Durable Medical Equipment COOL MIST HUMIDIFIER (humidifier) Tier 2 HEALTHMIST (humidifier) Tier 2 humidifiers Tier 2 PROCARE HUMIDIFIER (humidifier) Tier 2 PURE COMFORT HUMIDIFIER (humidifier) Tier 2 Medical Supplies and DME - Incontinence Supplies - Medical Supplies and Durable Medical Equipment CATH-SECURE TUBE HOLDER (catheter Tier 2 accessories,external) Medical Supplies and DME - Insulin Needles-Syringes and Admin Supplies - Medical Supplies and Durable Medical Equipment 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 2 DD 32 GAUGE X 5/32" (pen needle, diabetic) 1ST TIER UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) ABOUTTIME PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) ADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.3 ml) ADVOCATE SYRINGES SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.5 ml) ADVOCATE SYRINGES SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 141 Coverage Prescription Drug Name Drug Tier Requirements and Limits ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 GAUGE X 15/64" (syringe with Tier 2 DD needle, insulin, safety, 0.5 ml) ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64" (syringe with needle, Tier 2 DD insulin, safety, 1 ml) ASSURE ID PEN NEEDLE NEEDLE 30 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16" (pen needle, Tier 2 DD diabetic, safety) BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 Tier 2 DD GAUGE X 3/16" (pen needle, diabetic disposable, safety) BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X Tier 2 DD 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin 0.3 ml (half Tier 2 DD unit mark)) BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML (syringe Tier 2 DD without needle,insulin disposible, 1 ml) BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.3 ml) BD INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.5 ml) BD INSULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 Tier 2 DD ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64" (syringe, insulin u-500 with needle, Tier 2 DD disposable, 0.5 ml) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 142 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE Tier 2 DD X 1/2" (syringe with needle,insulin,0.5 ml) BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML Tier 2 DD 30 GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE Tier 2 DD X 5/8" (syringe with needle,disposable,insulin 1 ml) BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 Tier 2 DD GAUGE X 1/4" (pen needle, diabetic) BD ULTRA-FINE MINI PEN NEEDLE NEEDLE 31 GAUGE Tier 2 DD X 3/16" (pen needle, diabetic) BD ULTRA-FINE NANO PEN NEEDLE NEEDLE 32 Tier 2 DD GAUGE X 5/32" (pen needle, diabetic) BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE 29 GAUGE Tier 2 DD X 1/2" (pen needle, diabetic) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 143 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD ULTRA-FINE SHORT PEN NEEDLE NEEDLE 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 15/64" (syringe with needle,insulin 0.3 ml (half Tier 2 DD unit mark)) BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 15/64" (syringe with needle,insulin,0.3 ml) BD VEO INSULIN SYRINGE UF SYRINGE 1 ML 31 GAUGE X 15/64" (syringe with needle,disposable,insulin Tier 2 DD 1 ml) BD VEO INSULIN SYRINGE UF SYRINGE 1/2 ML 31 Tier 2 DD GAUGE X 15/64" (syringe with needle,insulin,0.5 ml) CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) CARETOUCH INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) CARETOUCH INSULIN SYRINGE SYRINGE 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) CARETOUCH PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CLICKFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 Tier 2 DD GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 144 Coverage Prescription Drug Name Drug Tier Requirements and Limits COMFORT EZ INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/16", 33 GAUGE X 5/32" (pen needle, diabetic) COMFORT TOUCH PEN NEEDLE NEEDLE 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64" (syringe with needle,insulin 0.5 ml (half unit mark)) DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) DROPLET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML Tier 2 DD 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) DROPLET MICRON PEN NEEDLE NEEDLE 34 GAUGE X Tier 2 DD 9/64" (pen needle, diabetic) DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 Tier 2 DD GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic, safety) EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 146 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML Tier 2 DD (syringe without needle,insulin disposible, 1 ml) EASY TOUCH NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16" Tier 2 DD (pen needle, diabetic) EASY TOUCH SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 30 GAUGE X 3/16" (pen needle, diabetic, Tier 2 DD safety) EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety, 1 ml) EASY TOUCH UNI-SLIP SYRINGE 1 ML (syringe without Tier 2 DD needle,insulin disposible, 1 ml) EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,insulin,0.3 ml) EXEL INSULIN SYRINGE 0.5 ML 30 GAUGE X 5/16", 1/2 Tier 2 DD ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) EXEL INSULIN SYRINGE 1 ML 30 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) FREESTYLE PRECISION SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 147 Coverage Prescription Drug Name Drug Tier Requirements and Limits HEALTHWISE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 Tier 2 DD GAUGE X 1/2" (pen needle, diabetic, safety) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 5/32" (pen needle, diabetic) INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 2 DD 32 GAUGE X 5/32" (pen needle, diabetic) insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 2 DD 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) INSULIN SYRINGE MICROFINE SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) insulin syringe needleless syringe 1 ml Tier 2 DD INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,insulin,0.5 ml) INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 0.3 ml 29 gauge x 1/2", 0.3 ml 30, 0.3 ml 30 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 1/4", 0.3 ml 31 gauge x 15/64", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 27 gauge x 1/2", 1 ml 28 gauge, 1 ml 28 gauge x 1/2", 1 ml 29 gauge x 1/2", 1 Tier 2 DD ml 29 gauge x 7/16", 1 ml 30 gauge x 1/2", 1 ml 30 gauge x 3/8", 1 ml 30 gauge x 5/16, 1 ml 30 gauge x 7/16", 1 ml 31 gauge x 1/4", 1 ml 31 gauge x 15/64", 1 ml 31 gauge x 5/16, 1/2 ml 27 gauge x 1/2", 1/2 ml 28 gauge, 1/2 ml 28 gauge x 1/2", 1/2 ml 29 , 1/2 ml 30 gauge, 1/2 ml 31 gauge x 1/4", 1/2 ml 31 gauge x 15/64"

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 148 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSUPEN NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 2 DD 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) LITE TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) LITE TOUCH INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X Tier 2 DD 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) LITE TOUCH INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML Tier 2 DD 29 X 1/2" (syringe with needle, insulin, safety, 0.3 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.5 ML 29 GAUGE X 1/2" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16" (syringe with Tier 2 DD needle, insulin, safety, 1 ml) MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16" Tier 2 DD (syringe with needle, insulin, safety, 0.3 ml) MAGELLAN SYRINGE SYRINGE 0.5 ML 30 GAUGE X Tier 2 DD 5/16" (syringe with needle, insulin, safety, 0.5 ml) MAXICOMFORT II PEN NEEDLE NEEDLE 31 GAUGE X Tier 2 DD 1/4" (pen needle, diabetic) MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 149 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAXICOMFORT INSULIN SYRINGE SYRINGE 1/2 ML 27 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) MAXI-COMFORT INSULIN SYRINGE SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) MAXICOMFORT SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 29 GAUGE X 5/16" (pen needle, diabetic, Tier 2 DD safety) MICRODOT INSULIN PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen Tier 2 DD needle, diabetic) MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16" (pen Tier 2 DD needle, diabetic) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.3 ml) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.5 ml) MONOJECT INSULIN SAFETY SYRING SYRINGE 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) MONOJECT INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) MONOJECT INSULIN SYRINGE SYRINGE 1 ML , 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE Tier 2 DD (syringe with needle,insulin,0.5 ml) MONOJECT ULTRA COMFORT INSULIN SYRINGE 1/2 Tier 2 DD ML 28 GAUGE (syringe with needle,insulin,0.5 ml) NOVOFINE 32 NEEDLE 32 GAUGE X 1/4" (pen needle, Tier 2 DD diabetic)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 150 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVOFINE AUTOCOVER NEEDLE 30 GAUGE X 1/3" Tier 2 DD (pen needle, diabetic, safety) NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6" (pen Tier 2 DD needle, diabetic) NOVOTWIST NEEDLE 32 GAUGE X 1/5" (pen needle, Tier 2 DD diabetic) PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) pen needle, diabetic needle 29 gauge x 1/2", 30 gauge x 5/16", 31 gauge x 1/4", 31 gauge x 3/16", 31 gauge x Tier 2 DD 5/16", 32 gauge x 1/4", 32 gauge x 3/16", 32 gauge x 5/32", 33 gauge x 5/32" pen needle, diabetic needle 31 gauge x 1/3", 31 gauge x Tier 2 DD 1/6" PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16" (pen needle, diabetic, Tier 2 DD safety) PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) PRO COMFORT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) PRODIGY INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) PRODIGY INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE Tier 2 DD X 1/2" (syringe with needle,disposable,insulin 1 ml) PURE COMFORT PEN NEEDLE NEEDLE 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 151 Coverage Prescription Drug Name Drug Tier Requirements and Limits RELION NEEDLES NEEDLE 31 GAUGE X 1/4" (pen Tier 2 DD needle, diabetic) RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32" (pen Tier 2 DD needle, diabetic) SAFESNAP INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16" (syringe w-needle 0.3 ml,insulin,safety Tier 2 DD w-self-cont.dis.unit) SAFESNAP INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" (insulin Tier 2 DD syringe-needle,safety,disposal unit,0.5 ml) SAFESNAP INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with Tier 2 DD needle 1 ml,insulin,safety w-self-con.disp.unit) SAFETY PEN NEEDLE NEEDLE 31 GAUGE X 3/16" (pen Tier 2 DD needle, diabetic, safety) SECURESAFE PEN NEEDLE NEEDLE 30 GAUGE X 5/16" Tier 2 DD (pen needle, diabetic, safety) SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4" (syringe with needle,insulin,0.5 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16" (pen needle, Tier 2 DD diabetic)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 152 Coverage Prescription Drug Name Drug Tier Requirements and Limits SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) SURE-JECT INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) SURE-JECT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) TECHLITE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin 0.3 ml (half unit mark)) TECHLITE INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin 0.5 ml (half unit mark)) TECHLITE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 2 DD GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8" Tier 2 DD (syringe with needle,insulin,0.3 ml) TERUMO INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 Tier 2 DD GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin,0.5 ml) TERUMO INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8" Tier 2 DD (syringe with needle,insulin,0.3 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 153 Coverage Prescription Drug Name Drug Tier Requirements and Limits THINPRO INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1/2 ML 28 GAUGE X Tier 2 DD 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin,0.5 ml) THINPRO INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 Tier 2 DD ML 31 X 3/8" (syringe with needle,disposable,insulin 1 ml) TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) TOPCARE ULTRA COMFORT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TOPCARE ULTRA COMFORT SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TRUE COMFORT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) TRUEPLUS INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.3 ml) TRUEPLUS INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 Tier 2 DD ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) TRUEPLUS INSULIN SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 Tier 2 DD GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) TRUEPLUS PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 5/32" (pen needle, diabetic)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 154 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTICARE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 1/4" (syringe with needle,insulin 0.3 ml (half Tier 2 DD unit mark)) ULTICARE INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 1/4" (syringe with needle,insulin,0.3 ml) ULTICARE INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE Tier 2 DD X 1/4" (syringe with needle,disposable,insulin 1 ml) ULTICARE INSULIN SYRINGE SYRINGE 1/2 ML 31 Tier 2 DD GAUGE X 1/4" (syringe with needle,insulin,0.5 ml) ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) ULTICARE SAFETY PEN NEEDLE NEEDLE 30 GAUGE X Tier 2 DD 3/16", 30 GAUGE X 5/16" (pen needle, diabetic, safety) ULTICARE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTICARE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) ULTICARE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) ULTIGUARD SAFEPACK-PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic, remover and disposal unit) ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X Tier 2 DD 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTILET INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 2 DD 5/16", 1/2 ML 29 (syringe with needle,insulin,0.5 ml) ULTILET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 Tier 2 DD GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE Tier 2 DD X 5/32" (pen needle, diabetic)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 155 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin 0.3 ml (half unit mark)) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", Tier 2 DD 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X Tier 2 DD 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) ULTRA COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.3 ml) ULTRA FLO PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 Tier 2 DD GAUGE X 3/16" (pen needle, diabetic) ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRACARE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) ULTRACARE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", Tier 2 DD 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 156 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X Tier 2 DD 5/16" (pen needle, diabetic) ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X Tier 2 DD 1/2" (pen needle, diabetic) ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) UNIFINE PENTIPS MAXFLOW NEEDLE 30 GAUGE X Tier 2 DD 3/16" (pen needle, diabetic) UNIFINE PENTIPS NEEDLE 29 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) UNIFINE PENTIPS PLUS MAXFLOW NEEDLE 30 GAUGE Tier 2 DD X 3/16" (pen needle, diabetic) UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) VANISHPOINT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 3/16" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.5 ml) VANISHPOINT SYRINGE SYRINGE 1 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,disposable,insulin 1 ml) VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) Medical Supplies and DME - IV Sets-Tubing - Medical Supplies and Durable Medical Equipment PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 157 Coverage Prescription Drug Name Drug Tier Requirements and Limits ANGIOCATH AUTOGUARD IV CATH INFUSION SET 20 Tier 2 GAUGE X 1" (intravenous catheter) BD ANGIOCATH IV CATHETER INFUSION SET 24 Tier 2 GAUGE X 3/4" (intravenous catheter) BD INSYTE AUTOGUARD INFUSION SET 18 X 1.16 ", 20 GAUGE X 1", 22 GAUGE X 1", 24 GAUGE X 3/4" Tier 2 (intravenous catheter) BD SAF-T-INTIMA INFUSION SET 18 GAUGE X 1", 22 Tier 2 GAUGE X 3/4" (intravenous catheter kit) BD SAF-T-INTIMA INFUSION SET 20 GAUGE X 1", 24 Tier 2 GAUGE X 3/4" (intravenous catheter) INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 2 1.16 " (intravenous catheter) INTROSYTE AUTOGUARD INFUSION SET 16 GAUGE X 5 FR, 18 GAUGE X 4 FR, 20 GAUGE X 3 FR (intravenous Tier 2 catheter kit/intravenous catheter kit accessory) NEXIVA INFUSION SET 18 X 1 1/4 ", 18 X 1 3/4 ", 20 GAUGE X 1", 20 X 1 1/4 ", 20 X 1 3/4 ", 22 GAUGE X 1", 24 Tier 2 GAUGE X 3/4", 24 X 0.56 " (intravenous catheter) SAFELET IV CATHETER INFUSION SET (intravenous Tier 2 catheter) Medical Supplies and DME - Miscellaneous Other - Medical Supplies and Durable Medical Equipment AIRZONE AND MINIWRIGHT AFS (medical supply, Tier 2 miscellaneous) AMIELLE VAGINAL TRAINER KIT (medical supply, Tier 2 miscellaneous) ANTI-EMBOLISM STOCKINGS (medical supply, Tier 2 miscellaneous) AUTODROP (medical supply, miscellaneous) Tier 2 AUTOSQUEEZE (medical supply, miscellaneous) Tier 2 BARD CATHETER STRAP (medical supply, Tier 2 miscellaneous) DISPOSABLE PAPER MOUTHPIECE (medical supply, Tier 2 miscellaneous) FACE SPLASH SHIELD, FULL (medical supply, Tier 2 miscellaneous)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 160 Coverage Prescription Drug Name Drug Tier Requirements and Limits TRUZONE PEAK FLOW METER DEVICE (peak flow Tier 1 meter) Medical Supplies and DME - Respiratory Therapy Supplies - Medical Supplies and Durable Medical Equipment A.I.R.S NEBULIZER REPLACEMENT KIT (nebulizer Tier 2 accessories) ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 2 assist devices) ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ADULT DISPOSABLE MOUTHPIECE (nebulizer Tier 2 accessories) AEROCHAMBER MINI SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER MV SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER PLUS FLOW-VU SPACER (inhaler, Tier 2 assist devices) AEROCHAMBER PLUS FLOW-VU,L MSK SPACER Tier 2 (inhaler,assist device with large mask) AEROCHAMBER PLUS FLOW-VU,M MSK SPACER Tier 2 (inhaler,assist device with medium mask) AEROCHAMBER PLUS FLOW-VU,S MSK SPACER Tier 2 (inhaler,assist device with small mask) AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 2 (inhaler,assist device with large mask) AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 2 (inhaler,assist device with medium mask) AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 2 (inhaler,assist device with small mask) AEROCHAMBER PLUS Z STAT SPACER (inhaler, assist Tier 2 devices) AEROCHAMBER WITH FLOWSIGNAL SPACER (inhaler, Tier 2 assist devices) AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 2 (inhaler, assist devices) AERONEB GO (nebulizer accessories) Tier 2 AEROTRACH PLUS SPACER (inhaler, assist devices) Tier 2 AEROVENT PLUS SPACER (inhaler, assist devices) Tier 2 AIR TUBE WITH AIR PLUGS (nebulizer accessories) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 161 Coverage Prescription Drug Name Drug Tier Requirements and Limits AIRS ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ALL FLOW 1000 KIT (nebulizer accessories) Tier 2 ALL FLOW 1000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 3000 KIT (nebulizer accessories) Tier 2 ALL FLOW 3000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 4000 KIT (nebulizer accessories) Tier 2 ALL FLOW 4000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 5000 KIT (nebulizer accessories) Tier 2 ALL FLOW 5000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 6000 PFT FILTER (nebulizer accessories) Tier 2 BREATHERITE MDI SPACER SPACER (inhaler, assist Tier 2 devices) BREATHERITE SPACER-MASK, NEO. SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE SPACER-MASK,ADULT SPACER Tier 2 (inhaler,assist device with large mask) BREATHERITE SPACER-MASK,CHILD SPACER Tier 2 (inhaler,assist device with medium mask) BREATHERITE SPACER-MASK,INFANT SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE SPACER-MASK,S.CHLD SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE VALVED MDI CHAMBER SPACER Tier 2 (inhaler, assist devices) BREATHERITE VALVED MDI SPACER SPACER (inhaler, Tier 2 assist devices) BUBBLES THE FISH PEDI MASK (nebulizer accessories) Tier 2 CLEVER CHOICE CHAMBER-LRG MASK SPACER Tier 2 (inhaler,assist device with large mask) CLEVER CHOICE CHAMBER-MED MASK SPACER Tier 2 (inhaler,assist device with medium mask) CLEVER CHOICE CHAMBER-SM MASK SPACER Tier 2 (inhaler,assist device with small mask) CLEVER CHOICE NEBULIZER DEVICE (nebulizer and Tier 2 compressor)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 162 Coverage Prescription Drug Name Drug Tier Requirements and Limits CLEVER CHOICE WHISPER AIRE PED DEVICE Tier 2 (nebulizer and compressor) COMPACT SPACE CHAMBER PLUS SPACER (inhaler, Tier 2 assist devices) COMPACT SPACE CHAMBER SPACER (inhaler, assist Tier 2 devices) COMPACT SPACE CHAMBER-LRG MASK SPACER Tier 2 (inhaler,assist device with large mask) COMPACT SPACE CHAMBER-MED MASK SPACER Tier 2 (inhaler,assist device with medium mask) COMPACT SPACE CHAMBER-SM MASK SPACER Tier 2 (inhaler,assist device with small mask) COMP-AIR NEBULIZER COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) DEVILBISS PULMO-AIDE COMPRESSR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMOMATE COMPRESSOR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMONEB LT COMP-NEB DEVICE Tier 2 (nebulizer and compressor) DEVILBISS TRAVELER COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) EASIVENT HOLDING CHAMBER SPACER (inhaler, Tier 2 assist devices) EASIVENT MASK LARGE DEVICE (inhaler, assist Tier 2 devices, accessories) EASIVENT MASK MEDIUM DEVICE (inhaler, assist Tier 2 devices, accessories) EASIVENT MASK SMALL DEVICE (inhaler, assist Tier 2 devices, accessories) EASY NEB COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) EASYAIR COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) EBASE CONTROLLER DEVICE (compressor, for Tier 2 nebulizer) EXPIRATORY MOUTHPIECE (nebulizer accessories) Tier 2 FLEXICHAMBER SPACER (inhaler, assist devices) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 163 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLEXICHAMBER-LG CHILD MASK DEVICE (inhaler, Tier 2 assist devices, accessories) FLEXICHAMBER-SM ADULT MASK DEVICE (inhaler, Tier 2 assist devices, accessories) FLEXICHAMBER-SM CHILD MASK DEVICE (inhaler, Tier 2 assist devices, accessories) HOME NEBULIZER PLUS SIDESTREAM DEVICE Tier 2 (nebulizer and compressor) HYPERSONIQ NEBULIZER CARTRIDGE (nebulizer Tier 2 accessories) IN-CHECK DIAL TRAINING DEVICE DEVICE Tier 2 (spirometers and accessories) INNOSPIRE DELUXE DEVICE (nebulizer and Tier 2 compressor) INNOSPIRE ELEGANCE DEVICE (nebulizer and Tier 2 compressor) INNOSPIRE ESSENCE DEVICE (nebulizer and Tier 2 compressor) INNOSPIRE MINI DEVICE (nebulizer and compressor) Tier 2 INNOSPIRE REPLACEMENT FILTER (nebulizer Tier 2 accessories) INSPIRACHAMBER SPACER (inhaler, assist devices) Tier 2 INSPIRACHAMBER WITH MASK-LARGE SPACER Tier 2 (inhaler,assist device with large mask) INSPIRACHAMBER WITH MASK-MED SPACER Tier 2 (inhaler,assist device with medium mask) INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 2 (inhaler,assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 2 LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 2 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 2 devices, accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 164 Coverage Prescription Drug Name Drug Tier Requirements and Limits MICRO ELITE REPLACEMENT FILTER (nebulizer Tier 2 accessories) MICROCHAMBER SPACER (inhaler, assist devices) Tier 2 MICROSPACER SPACER (inhaler, assist devices) Tier 2 MINI ELITE FILTER REPLACEMENT (nebulizer Tier 2 accessories) MISTASSIST DEVICE (spirometers and accessories) Tier 2 MISTASSIST KIT DEVICE (spirometer with drug delivery Tier 2 adapters) MOUTHPIECE DEVICE (inhaler, assist devices, Tier 2 accessories) MY MDI PORTABLE NEBULISER DEVICE (nebulizer and Tier 2 compressor) nebulizer and compressor device Tier 2 NOSE CLIP (nebulizer accessories) Tier 2 OMBRA COMPRESSOR SYSTEM DEVICE (nebulizer and Tier 2 compressor) ONE WAY VALVED MOUTHPIECE DEVICE (inhaler, Tier 2 assist devices, accessories) OPTICHAMBER ADULT MASK-LARGE DEVICE (inhaler, Tier 2 assist devices, accessories) OPTICHAMBER DIAMOND LG MASK SPACER Tier 2 (inhaler,assist device with large mask) OPTICHAMBER DIAMOND VHC SPACER (inhaler, assist Tier 2 devices) OPTICHAMBER DIAMOND-MED MSK SPACER Tier 2 (inhaler,assist device with medium mask) OPTICHAMBER DIAMOND-SML MASK SPACER Tier 2 (inhaler,assist device with small mask) PANDA MASK DEVICE (inhaler, assist devices, Tier 2 accessories) PARI BABY CONV KIT - SIZE 1 KIT (nebulizer Tier 2 accessories) PARI BABY CONV KIT - SIZE 2 KIT (nebulizer Tier 2 accessories) PARI BABY CONV KIT - SIZE 3 KIT (nebulizer Tier 2 accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 165 Coverage Prescription Drug Name Drug Tier Requirements and Limits PARI SINUS AEROSOL SYSTEM DEVICE (nebulizer and Tier 2 compressor) PARI TREK S COMBO PACK DEVICE (nebulizer and Tier 2 compressor) PARI TREK S COMPACT COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) PARI TREK S PORTABLE PWR KIT (nebulizer Tier 2 accessories) PEDIATRIC AEROSOL MASK (nebulizer accessories) Tier 2 PEDIATRIC BEAR NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC COMP-AIR COMPRES NEB DEVICE Tier 2 (nebulizer and compressor) PEDIATRIC DINOSAUR NEBULIZER DEVICE (nebulizer Tier 2 and compressor) PEDIATRIC DOG NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC FROG NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories) PEDIATRIC PANDA MASK DEVICE (inhaler, assist Tier 2 devices, accessories) PEDIATRIC SMALL MASK DEVICE (inhaler, assist Tier 2 devices, accessories) PFLEX INSPIRATORY TRAINER DEVICE (spirometers Tier 2 and accessories) PILLOW MASK CHILD (nebulizer accessories) Tier 2 PILLOW MASK PEDIATRIC (nebulizer accessories) Tier 2 POCKET CHAMBER SPACER (inhaler, assist devices) Tier 2 PORTABLE NEBULIZER SYSTEM DEVICE (nebulizer Tier 2 and compressor) PRIMEAIRE SPACER (inhaler, assist devices) Tier 2 PRO COMFORT SPACER-ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PRO COMFORT SPACER-CHILD MASK SPACER Tier 2 (inhaler,assist device with small mask)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 166 Coverage Prescription Drug Name Drug Tier Requirements and Limits PROCARE COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) PROCARE PEDIATRIC NEBULIZER DEVICE (nebulizer Tier 2 and compressor) PROCARE SPACER WITH ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PROCARE SPACER WITH CHILD MASK SPACER Tier 2 (inhaler,assist device with medium mask) PROCHAMBER SPACER (inhaler, assist devices) Tier 2 PRONEB ULTRA FILTER SET (nebulizer accessories) Tier 2 PRONEB ULTRA II FILTER ASSEM (nebulizer Tier 2 accessories) PULMO-AIDE COMPRESSOR DEVICE (compressor, for Tier 2 nebulizer) PULMONEB LT COMPRESSOR NEBUL DEVICE Tier 2 (nebulizer and compressor) PUREAIR MINI NEBULIZER DEVICE (nebulizer and Tier 2 compressor) REUSABLE NEBULIZER KIT KIT (nebulizer accessories) Tier 2 RITEFLO AEROCHAMBER SPACER (inhaler, assist Tier 2 devices) RUBBER MOUTHPIECE (nebulizer accessories) Tier 2 SAMI THE SEAL DEVICE (nebulizer and compressor) Tier 2 SAMI THE SEAL FILTER (nebulizer accessories) Tier 2 SAMI THE SEAL MASK (nebulizer accessories) Tier 2 SIDESTREAM ADULT FACE MASK (nebulizer Tier 2 accessories) SIDESTREAM MASK (nebulizer accessories) Tier 2 SIDESTREAM PEDIATRIC FACE MASK DEVICE (inhaler, Tier 2 assist devices, accessories) SILICONE MASK (nebulizer accessories) Tier 2 SILICONE MASK - INFANT DEVICE (inhaler, assist Tier 2 devices, accessories) SILICONE MASK - PEDIATRIC DEVICE (inhaler, assist Tier 2 devices, accessories) SINUSTAR AEROSOL DEVICE (nebulizer and Tier 2 compressor) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 167 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOOTHENEB COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) SOOTHENEB NBL100 ADULT MASK (nebulizer Tier 2 accessories) SOOTHENEB NBL100 CHILD MASK (nebulizer Tier 2 accessories) SOOTHENEB NBL100 MED CUP (nebulizer accessories) Tier 2 SOOTHENEB NBL100 MESH CAP (nebulizer Tier 2 accessories) SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 2 devices) SPACE CHAMBER SPACER (inhaler, assist devices) Tier 2 SPACE CHAMBER WITH LARGE MASK SPACER Tier 2 (inhaler,assist device with large mask) SPACE CHAMBER WITH MEDIUM MASK SPACER Tier 2 (inhaler,assist device with medium mask) SPACE CHAMBER WITH SMALL MASK SPACER Tier 2 (inhaler,assist device with small mask) SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 2 (compressor, for nebulizer) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 2 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 2 accessories) VAPORIZER CLEANING TABLET,SOLUBLE (vaporizer- Tier 2 humidifier supplies) VAPORIZER INHALANT LIQUID (vaporizer-humidifier Tier 2 supplies) VIOS AEROSOL DELIVERY SYSTEM DEVICE (nebulizer Tier 2 and compressor) VORTEX ADULT MASK DEVICE (inhaler, assist devices, Tier 2 accessories) VORTEX HOLDING CHAMBER SPACER (inhaler, assist Tier 2 devices) VORTEX VHC FROG MASK-CHILD SPACER Tier 2 (inhaler,assist device with medium mask) VORTEX VHC LADYBUG MASK-TODDLR SPACER Tier 2 (inhaler,assist device with small mask) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 168 Coverage Prescription Drug Name Drug Tier Requirements and Limits WILLIS THE WHALE COMPRESSR NEB DEVICE Tier 2 (nebulizer and compressor) WINDMILL TRAINER DEVICE (spirometers and Tier 2 accessories) WING TIP TUBING (nebulizer accessories) Tier 2 Medical Supplies and DME - Subcutaneous Insulin Delivery Devices - Medical Supplies and Durable Medical Equipment V-GO 20 DEVICE (sub-q insulin delivery device, 20 Tier 2 DD; QL (1 EA per 1 day) unit,disposable) V-GO 30 DEVICE (sub-q insulin delivery device, 30 unit, Tier 2 DD; QL (1 EA per 1 day) disposable) V-GO 40 DEVICE (sub-q insulin delivery device, 40 unit, Tier 2 DD; QL (1 EA per 1 day) disposable) Medical Supplies and DME - Urinary Catheters and Related Devices - Medical Supplies and Durable Medical Equipment ACTIVE CATH (catheter male,external) Tier 2 ADD-A-FOLEY CATH-MONO-FLO DRNG TRAY Tier 2 (catheterization tray) ADD-A-FOLEY CATH-PRE-FILL SYRN TRAY Tier 2 (catheterization tray) ADD-A-FOLEY TRAY TRAY (catheterization tray) Tier 2 ADVANCE PLUS INTERMITTENT 10 FR, 10-16 FR-", 12 FR, 12-16 FR-", 14-16 FR-", 16-16 FR-", 18-16 FR-", 6-16 Tier 2 FR-", 8-16 FR-" (catheter) APOGEE HC INTERMIT CATHETER 12-16 FR-", 14-16 Tier 2 FR-", 16-16 FR-" (catheter) APOGEE IC INTERMIT CATHETER 14-6 FR-" (catheter) Tier 2 ARGYLE TROCAR 10 FR, 12 FR, 16 FR, 20 FR, 24 FR, 8 Tier 2 FR (catheter) BARD CLEAN-CATH , 8 FR-10 ", 8-16 FR-" (catheter) Tier 2 BARD COUDE TIP CATHETER 10 FR, 12 FR, 14 FR, 16 Tier 2 FR, 18 FR, 20 FR, 22 FR, 8 FR (catheter) BARD FEMALE INTERMITTENT CATH 14-6 FR-" Tier 2 (catheter) BARD INFECT CONT TRAY-NO CATH TRAY Tier 2 (catheterization tray)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 171 Coverage Prescription Drug Name Drug Tier Requirements and Limits FOLEY CATHETER 14 FR, 16 FR, 18 FR, 20 FR, 22 FR, Tier 2 24 FR, 26 FR, 28 FR, 30 FR (catheter) FOLEY CATHETER TRAY TRAY , 16 FR, 18 FR Tier 2 (catheterization tray) FREEDOM CATH (catheter male,external) Tier 2 GENTLECATH 10 FR, 12 FR, 12-16 FR-", 14 FR, 14-16 Tier 2 FR-", 16 FR, 16-16 FR-", 8 FR, 8-16 FR-" (catheter) GIZMO (catheter male,external) Tier 2 INCARE INVIEW CATHETER 25 MM, 29 MM, 32 MM, 36 Tier 2 MM, 41 MM (catheter male,external) KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 2 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 2 tray) KENLINE ADD-A-FOLEY TRAY 30CC TRAY Tier 2 (catheterization tray) LOFRIC 12-16 FR-", 14-16 FR-" (catheter) Tier 2 LOFRIC ORIGO 14-16 FR-" (catheter) Tier 2 LOFRIC PRIMO NELATON CATHETER 16-16 FR-" Tier 2 (catheter) MAGIC3 GO INTERMIT CATHETER 14-16 FR-" (catheter) Tier 2 MAGIC3 INTERMITTENT CATHETER 10-16 FR-", 12-16 Tier 2 FR-", 16-16 FR-", 18-16 FR-" (catheter) PERSONAL CATHETER INTERMITTENT 14-6 FR-" Tier 2 (catheter) RETRACTED PENIS POUCH (catheter) Tier 2 ROBINSON CLEAR VINYL CATHETER 16 FR (catheter) Tier 2 ROB-NEL URETHRAL CATHETER 10-16 FR-", 12-16 FR-", Tier 2 14-16 FR-", 16-16 FR-", 18-16 FR-", 8-16 FR-" (catheter) SELF-CATH (medical supply, miscellaneous) Tier 2 SELF-CATH 10" 10 FR (catheter) Tier 2 SELF-CATH 10-16 FR-", 14-16 FR-", 20-16 FR-", 6-16 FR-" Tier 2 (catheter) SELF-CATHETER, FEMALE 14 FR, 8 FR (catheter) Tier 2 SILASTIC FOLEY CATHETER 20 FR (catheter) Tier 2 SPEEDICATH (FEMALE) 16 FR (catheter) Tier 2 SPEEDICATH (MALE) 12 FR (catheter) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 172 Coverage Prescription Drug Name Drug Tier Requirements and Limits SPIRIT EXT CATHETER TYPE 3 32 MM (catheter Tier 2 male,external) SPIRIT STYLE-3 29 MM (catheter male,external) Tier 2 TOUCH-TROL 10 FR (catheter) Tier 2 URETHRAL CATHETER 14-16 FR-" (catheter) Tier 2 URO-SAN PLUS (medical supply, miscellaneous) Tier 2 VINYL CATHETER 14-16 FR-", 14-6 FR-" (catheter) Tier 2 Medical Supplies and DME - Urine Glucose Tests - Medical Supplies and Durable Medical Equipment DIASTIX STRIP (urine glucose test strip) Tier 1 DD NO-STICK GLUCOSE STRIP (urine glucose test strip) Tier 1 DD Medical Supplies and DME - Urine Glucose-Acetone Combination Tests - Medical Supplies and Durable Medical Equipment KETO-DIASTIX STRIP (urine glucose-acet test strip) Tier 1 DD Medical Supplies and DME - Urine Ketone Tests - Medical Supplies and Durable Medical Equipment CHEK-STIX CONTROL STRIP (urine multiple test strips) Tier 1 KETONE CARE STRIP (urine acetone test,strips) Tier 1 DD Medical Supplies and DME - Vaporizers - Medical Supplies and Durable Medical Equipment vaporizers Tier 2 VICKS WARM STEAM VAPORIZER (vaporizer) Tier 2 WARM STEAM VAPORIZER (vaporizer) Tier 2 Medical Supply, FDB Superset Medical Supply, FDB Superset A.I.R.S NEBULIZER REPLACEMENT KIT (nebulizer Tier 2 accessories) ABOUTTIME PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 173 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK MULTICLIX LANCET KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing Tier 1 DD device/lancets) ACCUTREND GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 2 assist devices) ADD-A-FOLEY CATH-MONO-FLO DRNG TRAY Tier 2 (catheterization tray) ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ADULT DISPOSABLE MOUTHPIECE (nebulizer Tier 2 accessories) ADVANCE PLUS INTERMITTENT 10 FR, 10-16 FR-", 12 Tier 2 FR, 6-16 FR-", 8-16 FR-" (catheter) ADVANCED TRAVEL LANCETS 30 GAUGE (lancets) Tier 1 DD ADVOCATE CONTROL SOLUTION HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ADVOCATE LANCING DEVICE (lancing device) Tier 1 DD ADVOCATE LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) ADVOCATE RAPID-SAFE LANCING (lancing device) Tier 1 DD ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) ADVOCATE REDI-CODE+ CTRL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) ADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 174 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVOCATE SYRINGES SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.5 ml) ADVOCATE SYRINGES SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) AEROCHAMBER MINI SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER MV SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 2 (inhaler,assist device with large mask) AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 2 (inhaler,assist device with medium mask) AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 2 (inhaler,assist device with small mask) AEROCHAMBER PLUS Z STAT SPACER (inhaler, assist Tier 2 devices) AEROCHAMBER WITH FLOWSIGNAL SPACER (inhaler, Tier 2 assist devices) AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 2 (inhaler, assist devices) AEROECLIPSE II NEBULIZER (nebulizer) Tier 2 AEROGEAR ACTION ASTHMA KIT KIT (peak flow Tier 1 meter/inhaler, assist devices) AEROTRACH PLUS SPACER (inhaler, assist devices) Tier 2 AEROVENT PLUS SPACER (inhaler, assist devices) Tier 2 AGAMATRIX CONTROL HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) AGAMATRIX CONTROL NORM-HI SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) AGAMATRIX CONTROL SOLN-LEVEL 2 SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) AGAMATRIX CONTROL SOLN-LEVEL 4 SOLUTION Tier 1 DD (blood glucose calibration control solution, high) AIR TUBE WITH AIR PLUGS (nebulizer accessories) Tier 2 AIRS ADULT AEROSOL MASK (nebulizer accessories) Tier 2 AIRS DISPOSABLE NEBULIZER (nebulizer) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 176 Coverage Prescription Drug Name Drug Tier Requirements and Limits BARD INFECT CONT TRAY-NO CATH TRAY Tier 2 (catheterization tray) BARD LUBRICATH FOLEY TRAY 18FR TRAY 18 FR Tier 2 (catheterization tray) BARD LUBRICATH FOLEY TRAY TRAY 16 FR Tier 2 (catheterization tray) BARD RUBBER UTILITY CATHETER 10 FR, 12 FR, 14 Tier 2 FR, 16 FR, 18 FR, 20 FR, 8 FR (catheter) BARD URETHRAL CATHETER TRAY TRAY 14 FR Tier 2 (catheterization tray) BARDEX ALL-SILICONE FOLEY CATH 14 FR (catheter) Tier 2 BARDEX CLOSED SYSTEM CATH TRAY TRAY Tier 2 (catheterization tray) BARDEX LUBRICATH FOLEY CATH 16 FR, 24 FR Tier 2 (catheter) BARDEX URETHRAL CATHETERTRAY TRAY 16 FR Tier 2 (catheterization tray) BARDIA RED RUBBER CATHETER 14 FR, 16 FR Tier 2 (catheter) BD ANGIOCATH IV CATHETER INFUSION SET 24 Tier 2 GAUGE X 3/4" (intravenous catheter) BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 Tier 2 DD GAUGE X 3/16" (pen needle, diabetic disposable, safety) BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X Tier 2 DD 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML (syringe Tier 2 DD without needle,insulin disposible, 1 ml) BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.3 ml) BD INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.5 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 177 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD INSULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 Tier 2 DD ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64" (syringe, insulin u-500 with needle, Tier 2 DD disposable, 0.5 ml) BD INSYTE AUTOGUARD INFUSION SET 18 X 1.16 ", 22 Tier 2 GAUGE X 1" (intravenous catheter) BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE Tier 2 DD X 1/2" (syringe with needle,insulin,0.5 ml) BD MICROTAINER LANCET 1.5 X 2 MM (blade lancet, Tier 1 DD safety) BD MICROTAINER LANCET 21 GAUGE, 30 GAUGE Tier 1 DD (lancets) BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML Tier 2 DD 30 GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE Tier 2 DD X 5/8" (syringe with needle,disposable,insulin 1 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 178 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD SAF-T-INTIMA INFUSION SET 18 GAUGE X 1" Tier 2 (intravenous catheter kit) BD SAF-T-INTIMA INFUSION SET 20 GAUGE X 1", 24 Tier 2 GAUGE X 3/4" (intravenous catheter) BD ULTRA FINE LANCETS 33 GAUGE (lancets) Tier 1 DD BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 Tier 2 DD GAUGE X 1/4" (pen needle, diabetic) blood glucose contrl hi,normal solution Tier 1 DD blood glucose ctl high,nml,low solution Tier 1 DD BREEZE 2 CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) BREEZE 2 CONTROL SOLUTION, NML SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) BREEZE 2 CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) BUBBLES THE FISH PEDI MASK (nebulizer accessories) Tier 2 BUTTERFLY TOUCH LANCET 30 GAUGE (lancets) Tier 1 DD CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CAREONE LANCING DEVICE (lancing device) Tier 1 DD CAREONE THIN LANCET (lancets) Tier 1 DD CARESENS CONTROL A AND B SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) CARESENS CONTROL A NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) CARESENS LANCETS 30 GAUGE (lancets) Tier 1 DD CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) CARETOUCH INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) CARETOUCH INSULIN SYRINGE SYRINGE 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 180 Coverage Prescription Drug Name Drug Tier Requirements and Limits COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 Tier 2 DD GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 1/2", 1 ML 30 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 32 GAUGE X 5/16", 33 GAUGE X 1/4", 33 GAUGE X Tier 2 DD 3/16", 33 GAUGE X 5/16" (pen needle, diabetic) COMFORT TOUCH PEN NEEDLE NEEDLE 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) COMPACT COMPRESSOR NEBULIZER (nebulizer) Tier 2 COMPACT SPACE CHAMBER PLUS SPACER (inhaler, Tier 2 assist devices) COMPACT SPACE CHAMBER SPACER (inhaler, assist Tier 2 devices) COMPACT ULTRASONIC NEBULIZER (nebulizer) Tier 2 COMP-AIR NEBULIZER COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) CONTOUR CONTROL SOLUTION, HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) CONTOUR CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) CONTOUR CONTROL SOLUTION, NML SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) CONTOUR NEXT LEV 1 CONTROL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, low) CONTOUR NEXT LEV 2 CONTROL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) COOL CONTROL A SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 181 Coverage Prescription Drug Name Drug Tier Requirements and Limits COOL CONTROL B SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, high) CURITY 8000 URINE MTR FLY TRAY TRAY , 16 FR, 18 Tier 2 FR (catheterization tray) CURITY BEDSIDE DRAINAGE SET TRAY Tier 2 (catheterization tray) CURITY BEDSIDE-MONO-FLO DRANGE TRAY Tier 2 (catheterization tray) CURITY STRMLIN CATH - MONO-FLO TRAY 14 FR Tier 2 (catheterization tray) CURITY ULTRAMER 2-W CATH LAT/T 16 FR, 18 FR, 20 Tier 2 FR, 24 FR, 26 FR, 30 FR (catheter) CURITY ULTRAMER 2-W CATH TEFLN 28 FR (catheter) Tier 2 CURITY ULTRAMER 2-WAY CATHETER 12 FR, 14 FR, 16 Tier 2 FR, 18 FR, 20 FR, 24 FR, 26 FR, 28 FR, 30 FR (catheter) CURITY ULTRAMER IRRG 3WAY CATH 26 FR (catheter) Tier 2 CURITY ULTRAMER URETHRAL CATH 12 FR, 14 FR, 16 Tier 2 FR, 18 FR, 20 FR, 22 FR, 24 FR (catheter) CURITY UNIVERSAL - NO DRAINAGE TRAY 16 FR, 18 Tier 2 FR (catheterization tray) CURITY URETHRAL CATHETER 14 FR (catheter) Tier 2 DAVOL C.S. FOLEY CATHETER TRAY TRAY 16 FR, 18 Tier 2 FR (catheterization tray) DAVOL SILICONE FOLEY CATHETER 14 FR (catheter) Tier 2 DAVOL URETHRAL CATHETER TRAY TRAY 15 FR Tier 2 (catheterization tray) DAVOL URETHRAL CATHTRAY (W/O) TRAY Tier 2 (catheterization tray) DEVILBISS DISPOSABLE NEBULIZER (nebulizer) Tier 2 DEVILBISS PULMO-AIDE COMPRESSR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMOMATE COMPRESSOR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMONEB LT COMP-NEB DEVICE Tier 2 (nebulizer and compressor) DIATRUE CONTROL SOLN NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 182 Coverage Prescription Drug Name Drug Tier Requirements and Limits DIATRUE CONTROL SOLUTION HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) DIATRUE CONTROL SOLUTION LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) DOVER CATHETER 10 FR (catheter) Tier 2 DOVER FOLEY CATHETER 10 FR, 24 FR (catheter) Tier 2 DOVER LATEX FOLEY CATHETER 28 FR (catheter) Tier 2 DOVER RED RUBBER ROBINSON CATH 8 FR (catheter) Tier 2 DOVER UNIVERSAL TRAY (catheterization tray) Tier 2 DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5ML 30 Tier 2 DD GAUGE X 15/64" (syringe with needle,insulin 0.5 ml (half unit mark)) DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) DROPLET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) DROPLET LANCING DEVICE (lancing device) Tier 1 DD DROPLET MICRON PEN NEEDLE NEEDLE 34 GAUGE X Tier 2 DD 9/64" (pen needle, diabetic) DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 3/8", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 32 GAUGE X 1/4", 32 Tier 2 DD GAUGE X 3/16", 32 GAUGE X 5/16" (pen needle, diabetic) DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic, safety) EASIVENT MASK LARGE DEVICE (inhaler, assist Tier 2 devices, accessories) EASIVENT MASK MEDIUM DEVICE (inhaler, assist Tier 2 devices, accessories) EASIVENT MASK SMALL DEVICE (inhaler, assist Tier 2 devices, accessories) EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 184 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety, 1 ml) EASY TOUCH INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" (syringe Tier 2 DD with needle, insulin, safety, 0.5 ml) EASY TOUCH INSULIN SAFETY SYR SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2" (syringe with Tier 2 DD needle, insulin, safety, 1 ml) EASY TOUCH LANCETS 26 GAUGE, 28 GAUGE, 30 Tier 1 DD GAUGE, 32 GAUGE (lancets) EASY TOUCH LANCING DEVICE (lancing device) Tier 1 DD EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML Tier 2 DD (syringe without needle,insulin disposible, 1 ml) EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16" Tier 2 DD (pen needle, diabetic) EASY TOUCH SAFETY LANCETS 30 GAUGE, 32 GAUGE Tier 1 DD (lancets) EASY TOUCH SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 30 GAUGE X 3/16" (pen needle, diabetic, Tier 2 DD safety) EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety, 1 ml) EASY TOUCH TWIST LANCETS 26 GAUGE, 28 GAUGE, Tier 1 DD 30 GAUGE, 32 GAUGE, 33 GAUGE (lancets) EASY TRAK HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) EASY TRAK II CTRL SOLN-NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EASY TRAK LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASY TWIST AND CAP LANCETS 28 GAUGE (lancets) Tier 1 DD EASYAIR COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) EASYGLUCO PLUS NORMAL CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 185 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASYMAX 15 LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EASYMAX 15 LEVEL 2 SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) EBASE CONTROLLER DEVICE (compressor, for Tier 2 nebulizer) ELEMENT COMPACT HIGH CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ELEMENT COMPACT NORMAL CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ELEMENT HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) ELEMENT LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) ELEMENT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EMBRACE EVO LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EMBRACE GLUCOSE CONTROL HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) EMBRACE GLUCOSE CONTROL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EMBRACE LANCETS 30 GAUGE (lancets) Tier 1 DD EMBRACE PRO SOLUTION (blood glucose calibration Tier 1 DD control solution, high and normal) EMBRACE TALK CONTROL-HIGH (L2) SOLUTION (blood Tier 1 DD glucose calibration control solution, high) EMBRACE TALK CONTROL-LOW (L1) SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EVENCARE MINI GLUCOSE CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) EVENCARE PROVIEW CONTROL-L2,L3 SOLUTION Tier 1 DD (blood glucose calibration control high and low) EVENCARE SOLUTION (blood glucose calibration Tier 1 DD control high and low) EVOLUTION NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EXPIRATORY MOUTHPIECE (nebulizer accessories) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 186 Coverage Prescription Drug Name Drug Tier Requirements and Limits external catheter, male 22 mm to 25 mm, 26 mm to 30 Tier 2 mm, 31 mm to 35 mm E-Z JECT LANCETS 26 GAUGE, 32 GAUGE (lancets) Tier 1 DD EZ SMART LANCETS 28 GAUGE (lancets) Tier 1 DD EZ-LETS 26 GAUGE (lancets) Tier 1 DD FACE SPLASH SHIELD, FULL (medical supply, Tier 2 miscellaneous) FACE SPLASH SHIELD, SHORT (medical supply, Tier 2 miscellaneous) FC2 FEMALE CONDOM (condoms, female) $0 CT; EHB FEMALE CATHETER 14 FR (catheter) Tier 2 FEMALE SPECIMEN CATHETER 8 FR (catheter) Tier 2 FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM $0 CT; EHB (cervical cap) FILTERED MOUTHPIECE ATTACHMENT (medical Tier 2 supply, miscellaneous) FINGERSTIX LANCETS (lancets) Tier 1 DD FLEXICHAMBER SPACER (inhaler, assist devices) Tier 2 FLEXICHAMBER-LG CHILD MASK DEVICE (inhaler, Tier 2 assist devices, accessories) FLEXICHAMBER-SM ADULT MASK DEVICE (inhaler, Tier 2 assist devices, accessories) FLEXICHAMBER-SM CHILD MASK DEVICE (inhaler, Tier 2 assist devices, accessories) FOLEY CATHETER 14 FR (catheter) Tier 2 FOLEY CATHETER TRAY TRAY (catheterization tray) Tier 2 FORA HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) FORA LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) FORACARE GDH HIGH CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) FORACARE GDH LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, low) FORACARE GDH NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 187 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORACARE LANCETS 30 GAUGE (lancets) Tier 1 DD FORTISCARE HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) FORTISCARE LOW SOLUTION (blood glucose Tier 1 DD calibration control solution, low) FORTISCARE NORMAL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) FREESTYLE FREEDOM LITE KIT (blood-glucose meter) $0 DD; EHB FREESTYLE INSULINX (blood-glucose meter) $0 DD; EHB FREESTYLE INSULINX STRIP (blood sugar diagnostic) $0 DD; EHB FREESTYLE INSULINX TEST STRIPS STRIP (blood $0 DD; EHB sugar diagnostic) FREESTYLE LANCETS 28 GAUGE (lancets) Tier 1 DD FREESTYLE LITE METER KIT (blood-glucose meter) $0 DD; EHB FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) FREESTYLE PRECISION SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) FREESTYLE UNISTIK 2 (lancets) Tier 1 DD GENTLECATH 10 FR, 12 FR, 12-16 FR-", 14 FR, 14-16 Tier 2 FR-", 16 FR, 16-16 FR-", 8 FR, 8-16 FR-" (catheter) GLUCOCOM CONTROL HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) GLUCOCOM CONTROL NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) GLUCOCOM LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) GOJJI GLUCOSE CNTRL SOL-NORMAL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) GOJJI LANCETS 30 GAUGE (lancets) Tier 1 DD HARMONY CONTROL L1,L3 SOLUTION (blood glucose Tier 1 DD calibration control high and low) HEALTHMIST (humidifier) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 188 Coverage Prescription Drug Name Drug Tier Requirements and Limits HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) HEALTHY ACCENTS AUTOLET (lancing device) Tier 1 DD HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 32 Tier 2 DD GAUGE X 5/32" (pen needle, diabetic) HEMA-COMBISTIX STRIP (urine multiple test strips) Tier 1 HYPERSONIQ NEBULIZER CARTRIDGE (nebulizer Tier 2 accessories) HYPOLANCE AST LANCING KIT (lancing device/lancets) Tier 1 DD IN-CHECK DIAL TRAINING DEVICE DEVICE Tier 2 (spirometers and accessories) IN-CHECK NASAL WITH MASK DEVICE (peak flow Tier 1 meter) IN-CHECK ORAL FLOW METER DEVICE (peak flow Tier 1 meter) INCONTROL LANCING DEVICE (lancing device) Tier 1 DD INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 5/16" (pen needle, Tier 2 DD diabetic) INCONTROL SUPER THIN LANCETS 30 GAUGE Tier 1 DD (lancets) INCONTROL ULTRA THIN LANCETS 28 GAUGE (lancets) Tier 1 DD INFINITY CONTROL SOLUTION HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) INFINITY CONTROL SOLUTION LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) INFINITY CONTROL SOLUTION NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 189 Coverage Prescription Drug Name Drug Tier Requirements and Limits INFINITY VOICE CTRL SOLN-LVL 2 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) INJECT EASE LANCETS 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD INNOSPIRE DELUXE DEVICE (nebulizer and Tier 2 compressor) INNOSPIRE GO NEBULIZER (nebulizer) Tier 2 INNOSPIRE REPLACEMENT FILTER (nebulizer Tier 2 accessories) INSPIRACHAMBER SPACER (inhaler, assist devices) Tier 2 INSPIRACHAMBER WITH MASK-LARGE SPACER Tier 2 (inhaler,assist device with large mask) INSPIRACHAMBER WITH MASK-MED SPACER Tier 2 (inhaler,assist device with medium mask) INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 2 (inhaler,assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 2 insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 2 DD 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) INSULIN SYRINGE MICROFINE SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) insulin syringe needleless syringe 1 ml Tier 2 DD INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 28 gauge, 1 ml 29 gauge x 7/16", 1 ml 30 Tier 2 DD gauge x 3/8", 1 ml 30 gauge x 5/16, 1 ml 31 gauge x 1/4", 1/2 ml 28 gauge, 1/2 ml 31 gauge x 1/4" INSUPEN NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", Tier 2 DD 33 GAUGE X 5/32" (pen needle, diabetic) INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 2 1.16 " (intravenous catheter) INTELLIGENT MESH NEBULIZER (nebulizer) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 190 Coverage Prescription Drug Name Drug Tier Requirements and Limits INTROSYTE AUTOGUARD INFUSION SET 16 GAUGE X 5 FR, 18 GAUGE X 4 FR, 20 GAUGE X 3 FR (intravenous Tier 2 catheter kit/intravenous catheter kit accessory) INVACARE LANCETS 30 GAUGE (lancets) Tier 1 DD KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 2 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 2 tray) KENLINE ADD-A-FOLEY TRAY 30CC TRAY Tier 2 (catheterization tray) KETONE CARE STRIP (urine acetone test,strips) Tier 1 DD KETONE URINE TEST STRIP (urine acetone test,strips) Tier 1 DD KETOSTIX STRIP (urine acetone test,strips) Tier 1 DD LABSTIX REAGENT STRIP (urine multiple test strips) Tier 1 LANCETS, SUPER THIN (lancets) Tier 1 DD LANCETS,THIN 28 GAUGE (lancets) Tier 1 DD LANCETS,ULTRA THIN (lancets) Tier 1 DD LANCING SYSTEM (lancing device) Tier 1 DD LANZO LANCING DEVICE KIT (lancing device/lancets) Tier 1 DD LC PLUS NEBULIZER-PED MASK (nebulizer) Tier 2 LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) LITE TOUCH INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1/2 ML 28 Tier 2 DD GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) LITE TOUCH INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) LITE TOUCH LANCING DEVICE (lancing device) Tier 1 DD LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 192 Coverage Prescription Drug Name Drug Tier Requirements and Limits MEDPOINT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) MICRO ELITE REPLACEMENT FILTER (nebulizer Tier 2 accessories) MICRODOT HIGH-LOW CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) MICROLET 2 LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) MICROLET NEXT LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) MICROLIFE PEAK FLOW METER DEVICE (peak flow Tier 1 meter) MINI ELITE FILTER REPLACEMENT (nebulizer Tier 2 accessories) MINI LANCING DEVICE (lancing device) Tier 1 DD MINI PLUS NEBULIZER (nebulizer) Tier 2 MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16" (pen Tier 2 DD needle, diabetic) MISTASSIST DEVICE (spirometers and accessories) Tier 2 MISTASSIST KIT DEVICE (spirometer with drug delivery Tier 2 adapters) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.3 ml) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.5 ml) MONOJECT INSULIN SAFETY SYRING SYRINGE 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) MONOJECT INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) MONOJECT INSULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 29 GAUGE X 1/2" (syringe with Tier 2 DD needle,disposable,insulin 1 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 194 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6" (pen Tier 2 DD needle, diabetic) NOVOTWIST NEEDLE 32 GAUGE X 1/5" (pen needle, Tier 2 DD diabetic) OMBRA COMPRESSOR SYSTEM DEVICE (nebulizer and Tier 2 compressor) ON CALL EXPRESS CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solutions high,normal,low) ON CALL LANCET 30 GAUGE (lancets) Tier 1 DD ON CALL LANCING DEVICE (lancing device) Tier 1 DD ON CALL PLUS CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high and normal) ON CALL PLUS LANCET 30 GAUGE (lancets) Tier 1 DD ON CALL PLUS LANCING DEVICE (lancing device) Tier 1 DD ON CALL VIVID CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high and normal) ONETOUCH DELICA LANC DEVICE KIT (lancing Tier 1 DD device/lancets) ONETOUCH DELICA LANCETS 30 GAUGE (lancets) Tier 1 DD ONETOUCH DELICA PLUS LANCET 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) ONETOUCH SURESOFT LANCING DEV 18 GAUGE, 21 Tier 1 DD GAUGE, 28 GAUGE (lancets) ONETOUCH ULTRASOFT LANCETS (lancets) Tier 1 DD ONETOUCH VERIO HIGH CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) ONETOUCH VERIO MID CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) OPTICHAMBER ADULT MASK-LARGE DEVICE (inhaler, Tier 2 assist devices, accessories) OPTICHAMBER DIAMOND LG MASK SPACER Tier 2 (inhaler,assist device with large mask) OPTICHAMBER DIAMOND VHC SPACER (inhaler, assist Tier 2 devices) OPTICHAMBER DIAMOND-MED MSK SPACER Tier 2 (inhaler,assist device with medium mask)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 195 Coverage Prescription Drug Name Drug Tier Requirements and Limits OPTICHAMBER DIAMOND-SML MASK SPACER Tier 2 (inhaler,assist device with small mask) OPTUMRX SOLUTION (blood glucose calibration Tier 1 DD control solution, high and normal) PARI BABY CONV KIT - SIZE 1 KIT (nebulizer Tier 2 accessories) PARI BABY CONV KIT - SIZE 2 KIT (nebulizer Tier 2 accessories) PARI BABY CONV KIT - SIZE 3 KIT (nebulizer Tier 2 accessories) PARI LC SPRINT NEBULIZER SET (nebulizer) Tier 2 PARI LC SPRINT SINUS (nebulizer) Tier 2 PARI SINUS AEROSOL SYSTEM DEVICE (nebulizer and Tier 2 compressor) PARI TREK S COMBO PACK DEVICE (nebulizer and Tier 2 compressor) PARI TREK S COMPACT COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) PARI TREK S PORTABLE PWR KIT (nebulizer Tier 2 accessories) PEAK AIR PEAK FLOW METER DEVICE (peak flow Tier 1 meter) PEDIATRIC AEROSOL MASK (nebulizer accessories) Tier 2 PEDIATRIC BEAR NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC COMP-AIR COMPRES NEB DEVICE Tier 2 (nebulizer and compressor) PEDIATRIC DINOSAUR NEBULIZER DEVICE (nebulizer Tier 2 and compressor) PEDIATRIC DOG NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC FROG NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PEDIATRIC MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories) PEDIATRIC MOUTHPIECES (medical supply, Tier 2 miscellaneous)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 196 Coverage Prescription Drug Name Drug Tier Requirements and Limits PEDIATRIC PANDA MASK DEVICE (inhaler, assist Tier 2 devices, accessories) PEDIATRIC SMALL MASK DEVICE (inhaler, assist Tier 2 devices, accessories) pen needle, diabetic needle 30 gauge x 5/16", 32 gauge Tier 2 DD x 3/16" PERSONAL BEST FULL RANGE DEVICE (peak flow Tier 1 meter) PERSONAL BEST LOW RANGE DEVICE (peak flow Tier 1 meter) PERSONAL CATHETER INTERMITTENT 14-6 FR-" Tier 2 (catheter) PFLEX INSPIRATORY TRAINER DEVICE (spirometers Tier 2 and accessories) PIKO 1 DEVICE (peak flow meter) Tier 1 PILLOW MASK CHILD (nebulizer accessories) Tier 2 PILLOW MASK PEDIATRIC (nebulizer accessories) Tier 2 PIP LANCET 28 GAUGE (lancets) Tier 1 DD POCKET PEAK FLOW METER DEVICE (peak flow meter) Tier 1 PORTABLE NEBULIZER SYSTEM DEVICE (nebulizer Tier 2 and compressor) PRECISION GLUCOSE CONTROL SOLN COMBO PACK Tier 1 DD (blood-glucose calib. control) PRECISION GLUCOSE/KETONE CONTR COMBO PACK Tier 1 DD (blood-glucose calib. control) PRECISION XTRA B-KETONE STRIP (blood ketone test, Tier 2 strips) PRECISION XTRA MONITOR (blood-glucose meter) $0 DD; EHB PRESSURE ACTIVATED LANCETS 21 GAUGE, 28 Tier 1 DD GAUGE (lancets) PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16" (pen needle, diabetic, Tier 2 DD safety) PRIMEAIRE SPACER (inhaler, assist devices) Tier 2 PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 197 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRO COMFORT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) PRO COMFORT LANCET 30 GAUGE, 31 GAUGE Tier 1 DD (lancets) PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) PRO COMFORT SPACER-ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PRO COMFORT SPACER-CHILD MASK SPACER Tier 2 (inhaler,assist device with small mask) PROCARE COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) PROCARE HUMIDIFIER (humidifier) Tier 2 PROCARE SPACER WITH ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PROCARE SPACER WITH CHILD MASK SPACER Tier 2 (inhaler,assist device with medium mask) PROCHAMBER SPACER (inhaler, assist devices) Tier 2 PRODIGY CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) PRODIGY INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) PRODIGY INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE Tier 2 DD X 1/2" (syringe with needle,disposable,insulin 1 ml) PRODIGY LANCETS 28 GAUGE (lancets) Tier 1 DD PRODIGY LANCING DEVICE (lancing device) Tier 1 DD PRONEB ULTRA FILTER SET (nebulizer accessories) Tier 2 PRONEB ULTRA II FILTER ASSEM (nebulizer Tier 2 accessories) PULMONEB LT COMPRESSOR NEBUL DEVICE Tier 2 (nebulizer and compressor) PURE COMFORT HUMIDIFIER (humidifier) Tier 2 PURE COMFORT LANCETS 30 GAUGE (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 198 Coverage Prescription Drug Name Drug Tier Requirements and Limits PURE COMFORT PEN NEEDLE NEEDLE 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) PURE COMFORT SAFETY LANCETS 30 GAUGE Tier 1 DD (lancets) PUREAIR MINI NEBULIZER DEVICE (nebulizer and Tier 2 compressor) PUSH BUTTON SAFETY LANCETS 21 GAUGE (lancets) Tier 1 DD READYLANCE SAFETY LANCETS 21 GAUGE, 23 Tier 1 DD GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE (lancets) REFUAH PLUS GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high) RELIAMED LANCET 23 GAUGE, 30 GAUGE (lancets) Tier 1 DD RELIAMED MINI LANCING DEVICE (lancing device) Tier 1 DD RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 Tier 1 DD GAUGE (lancets) RELIAMED TWIST AND CAP LANCET 28 GAUGE Tier 1 DD (lancets) RELION NEEDLES NEEDLE 31 GAUGE X 1/4" (pen Tier 2 DD needle, diabetic) RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32" (pen Tier 2 DD needle, diabetic) RELION THIN LANCETS 26 GAUGE (lancets) Tier 1 DD RELION ULTRA THIN PLUS LANCETS (lancets) Tier 1 DD REPLACEMENT J-4 CANNULA (medical supply, Tier 2 miscellaneous) RIGHTEST CONTROL SOLUTION HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) RIGHTEST CONTROL SOLUTION NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) RIGHTEST GC250S CNTRL SOL NORM SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) RIGHTEST GD500 LANCING DEVICE (lancing device) Tier 1 DD RIGHTEST GL300 LANCETS 30 GAUGE (lancets) Tier 1 DD RIGHTEST GT333 LEV 2 CTRL SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 199 Coverage Prescription Drug Name Drug Tier Requirements and Limits RITEFLO AEROCHAMBER SPACER (inhaler, assist Tier 2 devices) ROBINSON CLEAR VINYL CATHETER 16 FR (catheter) Tier 2 ROB-NEL URETHRAL CATHETER 10-16 FR-", 12-16 FR-", Tier 2 14-16 FR-", 16-16 FR-", 18-16 FR-", 8-16 FR-" (catheter) RUBBER MOUTHPIECE (nebulizer accessories) Tier 2 SAFETY LANCETS 26 GAUGE (lancets) Tier 1 DD SAFETY-LET LANCETS 30 GAUGE (lancets) Tier 1 DD SAMI THE SEAL DEVICE (nebulizer and compressor) Tier 2 SAMI THE SEAL FILTER (nebulizer accessories) Tier 2 SAMI THE SEAL MASK (nebulizer accessories) Tier 2 SELF-CATH 20-16 FR-", 6-16 FR-" (catheter) Tier 2 SELF-CATHETER, FEMALE 14 FR (catheter) Tier 2 SIDESTREAM ADULT FACE MASK (nebulizer Tier 2 accessories) SIDESTREAM PLUS (nebulizer) Tier 2 SILASTIC FOLEY CATHETER 20 FR (catheter) Tier 2 SILICONE MASK - INFANT DEVICE (inhaler, assist Tier 2 devices, accessories) SILICONE MASK - PEDIATRIC DEVICE (inhaler, assist Tier 2 devices, accessories) SINGLE-LET (lancets) Tier 1 DD SINUSTAR NEBULIZER (nebulizer) Tier 2 SMART SENSE LANCETS 21 GAUGE, 33 GAUGE Tier 1 DD (lancets) SMARTDIABETES VANTAGE (lancing device) Tier 1 DD SMARTEST CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, normal) SMARTEST LANCET (lancets) Tier 1 DD SOFT TOUCH LANCETS (lancets) Tier 1 DD SOLUS V2 CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) SOLUS V2 CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) SOLUS V2 LANCETS 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 202 Coverage Prescription Drug Name Drug Tier Requirements and Limits TERUMO INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8" Tier 2 DD (syringe with needle,insulin,0.3 ml) THINPRO INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1/2 ML 28 GAUGE X Tier 2 DD 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin,0.5 ml) THINPRO INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 Tier 2 DD ML 31 X 3/8" (syringe with needle,disposable,insulin 1 ml) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 2 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 2 accessories) TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) TOPCARE ULTRA COMFORT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TOPCARE ULTRA COMFORT SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) TOPCARE UNIVERSAL1 LANCET 33 GAUGE (lancets) Tier 1 DD TOUCH-TROL 10 FR (catheter) Tier 2 TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TRUE COMFORT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) TRUE COMFORT LANCET 30 GAUGE (lancets) Tier 1 DD TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 203 Coverage Prescription Drug Name Drug Tier Requirements and Limits TRUECONTROL LEVEL 0 SOLUTION (blood glucose Tier 1 DD calibration control solution, high) TRUECONTROL LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) TRUEDRAW LANCING DEVICE (lancing device) Tier 1 DD TRUEPLUS KETONE STRIP (urine acetone test,strips) Tier 1 DD TRUEPLUS LANCETS 26 GAUGE, 33 GAUGE (lancets) Tier 1 DD TRUNEB NEBULIZER (nebulizer) Tier 2 TRUZONE PEAK FLOW METER DEVICE (peak flow Tier 1 meter) ULTICARE SAFETY PEN NEEDLE NEEDLE 30 GAUGE X Tier 2 DD 3/16", 30 GAUGE X 5/16" (pen needle, diabetic, safety) ULTI-LANCE (lancing device) Tier 1 DD ULTI-LANCE KIT (lancing device/lancets) Tier 1 DD ULTILET BASIC LANCETS 30 GAUGE (lancets) Tier 1 DD ULTILET CLASSIC LANCETS 33 GAUGE (lancets) Tier 1 DD ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X Tier 2 DD 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTILET INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 2 DD 5/16", 1/2 ML 29 (syringe with needle,insulin,0.5 ml) ULTILET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 Tier 2 DD GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTILET LANCETS 30 GAUGE, 33 GAUGE (lancets) Tier 1 DD ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE Tier 2 DD X 5/32" (pen needle, diabetic) ULTILET SAFETY LANCETS 23 GAUGE (lancets) Tier 1 DD ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin 0.3 ml (half unit mark)) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML Tier 2 DD 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 204 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA COMFORT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) ULTRA FINE LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.3 ml) ULTRA FLO PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 Tier 2 DD GAUGE X 3/16" (pen needle, diabetic) ULTRA THIN II LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRA THIN LANCETS 33 GAUGE (lancets) Tier 1 DD ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) ULTRA THIN PLUS LANCETS 33 GAUGE (lancets) Tier 1 DD ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRACARE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) ULTRACARE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRA-CARE LANCETS 30 GAUGE (lancets) Tier 1 DD ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", Tier 2 DD 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE Tier 1 DD (lancets) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 205 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X Tier 2 DD 5/16" (pen needle, diabetic) ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X Tier 2 DD 1/2" (pen needle, diabetic) ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) ULTRA-THIN II LANCETS 28 GAUGE (lancets) Tier 1 DD ULTRATRAK ULTIMATE SOLUTION (blood glucose Tier 1 DD calibration control high and low) UNIFINE PENTIPS NEEDLE 29 GAUGE (pen needle, Tier 2 DD diabetic) UNISTIK 2 NORMAL LANCET,DEVICE KIT (lancing Tier 1 DD device/lancets) UNISTIK 3 COMFORT LANCET (lancets) Tier 1 DD UNISTIK 3 LANCETS 21 GAUGE (lancets) Tier 1 DD UNISTIK 3 NORMAL LANCET 23 GAUGE (lancets) Tier 1 DD UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE (lancets) Tier 1 DD UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 Tier 1 DD GAUGE (lancets) UNISTIK SAFETY 28 GAUGE, 30 GAUGE (lancets) Tier 1 DD UNISTIK TOUCH LANCETS 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) UNISTRIP HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) UNISTRIP LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) URETHRAL CATHETER 14-16 FR-" (catheter) Tier 2 URISTIX 4 STRIP (urine multiple test strips) Tier 1 URISTIX REAGENT STRIP (urine multiple test strips) Tier 1 VANISHPOINT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 3/16" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) VAPORIZER CLEANING TABLET,SOLUBLE (vaporizer- Tier 2 humidifier supplies) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 206 Coverage Prescription Drug Name Drug Tier Requirements and Limits VAPORIZER INHALANT LIQUID (vaporizer-humidifier Tier 2 supplies) VERASENS CONTROL SOLN-LEVEL 1 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" Tier 2 DD (pen needle, diabetic) V-GO 20 DEVICE (sub-q insulin delivery device, 20 Tier 2 DD; QL (1 EA per 1 day) unit,disposable) V-GO 30 DEVICE (sub-q insulin delivery device, 30 unit, Tier 2 DD; QL (1 EA per 1 day) disposable) V-GO 40 DEVICE (sub-q insulin delivery device, 40 unit, Tier 2 DD; QL (1 EA per 1 day) disposable) VICKS WARM STEAM VAPORIZER (vaporizer) Tier 2 VINYL CATHETER 14-16 FR-", 14-6 FR-" (catheter) Tier 2 VIVAGUARD INO CTRL SOLN-L1,2,3 SOLUTION (blood Tier 1 DD glucose calibration control solutions high,normal,low) VIVAGUARD INO CTRL SOLN-L1,L3 SOLUTION (blood Tier 1 DD glucose calibration control high and low) VIVAGUARD INO CTRL SOLN-L2 SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) VIVAGUARD LANCET 30 GAUGE (lancets) Tier 1 DD VIXONE NEBULIZER (nebulizer) Tier 2 VIXONE NEBULIZER-ADULT MASK (nebulizer) Tier 2 VIXONE NEBULIZER-PEDIATRIC MSK (nebulizer) Tier 2 VORTEX ADULT MASK DEVICE (inhaler, assist devices, Tier 2 accessories) VORTEX HOLDING CHAMBER SPACER (inhaler, assist Tier 2 devices) VORTEX VHC FROG MASK-CHILD SPACER Tier 2 (inhaler,assist device with medium mask) VORTEX VHC LADYBUG MASK-TODDLR SPACER Tier 2 (inhaler,assist device with small mask) WARM STEAM VAPORIZER (vaporizer) Tier 2 WAVESENSE CONTROL SOLUTION SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 207 Coverage Prescription Drug Name Drug Tier Requirements and Limits WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 $0 CT; EHB MM (diaphragms, wide seal) WILLIS THE WHALE COMPRESSR NEB DEVICE Tier 2 (nebulizer and compressor) WINDMILL TRAINER DEVICE (spirometers and Tier 2 accessories) WING TIP TUBING (nebulizer accessories) Tier 2 Metabolic Modifiers - Drugs that Alter Metabolism Hyperparathyroid Treatment Agents - Vitamin D Analog-Type - Drugs that Alter Metabolism doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg Tier 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg Tier 1 Metabolic Modifier - Carnitine Replenisher Agents - Drugs that Alter Metabolism levocarnitine (with sugar) oral solution 100 mg/ml Tier 1 levocarnitine oral tablet 330 mg Tier 1 Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating agents - Drugs that Alter Metabolism sodium phenylbutyrate oral powder 0.94 gram/gram Tier 4 PA; SP sodium phenylbutyrate oral tablet 500 mg Tier 4 PA; SP Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat Dental Product - Fluoride Preparations - Drugs for the Mouth and Throat

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 210 Coverage Prescription Drug Name Drug Tier Requirements and Limits REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) (interferon beta- Tier 4 SP 1a/albumin human) Multiple Sclerosis Agent - Others - Drugs for Multiple Sclerosis dimethyl fumarate oral capsule,delayed release(dr/ec) Tier 4 PA; SP 120 mg (14)- 240 mg (46) dimethyl fumarate oral capsule,delayed release(dr/ec) Tier 4 PA; SP; QL (2 EA per 1 day) 120 mg, 240 mg glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml Tier 4 SP glatiramer acetate (Glatopa Subcutaneous Syringe 20 Tier 4 SP Mg/Ml, 40 Mg/Ml) Multiple Sclerosis Agent - Potassium Channel Blocker - Drugs for Multiple Sclerosis dalfampridine oral tablet extended release 12 hr 10 mg Tier 3 PA; SP; QL (2 EA per 1 day) Multiple Sclerosis Agent - Purine Nucleoside Analogs - Drugs for Multiple Sclerosis MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG PA; SP; QL (20 EA per 365 Tier 4 (cladribine) days) Multiple Sclerosis Agent - Pyrimidine Synthesis Inhibitors - Drugs for Multiple Sclerosis AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) Tier 4 PA; SP; QL (1 EA per 1 day) Multiple Sclerosis Agent - Sphingosine 1-phosphate receptor modulator - Drugs for Multiple Sclerosis GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) Tier 4 PA; SP; QL (1 EA per 1 day) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 211 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod) Tier 4 PA; SP; QL (1 EA per 1 day) MAYZENT STARTER PACK ORAL TABLETS,DOSE PACK Tier 4 PA; SP; QL (1 EA per 1 day) 0.25 MG (12 TABS) (siponimod) Ophthalmic Agents - Drugs for the Eye Artificial Tears and Lubricant Combinations - Drugs for the Eye ARTIFICIAL TEARS(GLYCERIN-PEG) OPHTHALMIC $0 EHB (EYE) DROPS 1-0.3 % (glycerin/propylene glycol) GENTEAL TEARS MODERATE (PF) OPHTHALMIC (EYE) $0 EHB DROPPERETTE 0.1-0.3 % (dextran 70/hypromellose/pf) LUBRICANT EYE (CMC-GLYCERIN) OPHTHALMIC (EYE) DROPS 0.5-0.9 % (carboxymethylcellulose $0 EHB sodium/glycerin) LUBRICATING DROPS OPHTHALMIC (EYE) DROPS 0.5- $0 EHB 0.9 % (carboxymethylcellulose sodium/glycerin) REFRESH DIGITAL PF OPHTHALMIC (EYE) DROPPERETTE 0.5-1-0.5 % (carboxymethylcellulose $0 EHB sodium/glycerin/polysorbate 80/pf) REFRESH OPTIVE ADVANCED (PF) OPHTHALMIC (EYE) DROPPERETTE 0.5-1-0.5 % (carboxymethylcellulose $0 EHB sodium/glycerin/polysorbate 80/pf) REFRESH OPTIVE MEGA-3 (PF) OPHTHALMIC (EYE) DROPPERETTE 0.5-1-0.5 % (carboxymethylcellulose $0 EHB sodium/glycerin/polysorbate 80/pf) REFRESH OPTIVE SENSITIVE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.5-0.9 % (carboxymethylcellulose $0 EHB sodium/glycerin/pf) REFRESH RELIEVA OPHTHALMIC (EYE) DROPS 0.5-0.9 $0 EHB % (carboxymethylcellulose sodium/glycerin) Artificial Tears and Lubricant Single Agents - Drugs for the Eye ARTIFICIAL TEARS (POLYVIN ALC) OPHTHALMIC (EYE) $0 EHB DROPS 1.4 % (polyvinyl alcohol) LACRISERT OPHTHALMIC (EYE) INSERT 5 MG Tier 2 (hydroxypropyl cellulose) polyvinyl alcohol ophthalmic (eye) drops 1.4 % $0 EHB Miotics - Cholinesterase Inhibitors - Drugs for Glaucoma PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS Tier 2 0.125 % (echothiophate iodide)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 213 Coverage Prescription Drug Name Drug Tier Requirements and Limits HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % Tier 1 (homatropine hbr) tropicamide ophthalmic (eye) drops 0.5 %, 1 % Tier 1 Ophthalmic - Antihistamines - Drugs for Itchy Eye ALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) EHB; QL (10 ML per 30 $0 (ketotifen fumarate) days) ALLERGY EYE (KETOTIFEN) OPHTHALMIC (EYE) EHB; QL (10 ML per 30 $0 DROPS 0.025 % (0.035 %) (ketotifen fumarate) days) azelastine ophthalmic (eye) drops 0.05 % Tier 1 CHILDREN'S ALAWAY OPHTHALMIC (EYE) DROPS EHB; QL (10 ML per 30 $0 0.025 % (0.035 %) (ketotifen fumarate) days) ST: At least 2 prior prescriptions for Azelastine epinastine ophthalmic (eye) drops 0.05 % Tier 2 HCL, Ketotifen Fumarate or Olopatadine HCL in 120 days EYE ITCH RELIEF OPHTHALMIC (EYE) DROPS 0.025 % EHB; QL (10 ML per 30 $0 (0.035 %) (ketotifen fumarate) days) ITCHY EYE DROPS OPHTHALMIC (EYE) DROPS 0.025 EHB; QL (10 ML per 30 $0 % (0.035 %) (ketotifen fumarate) days) ketotifen fumarate ophthalmic (eye) drops 0.025 % EHB; QL (10 ML per 30 $0 (0.035 %) days) ST: Prior prescription for Azelastine HCL, Ketotifen olopatadine ophthalmic (eye) drops 0.1 % Tier 2 Fumarate, or Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) ST: At least 2 prior prescriptions for Azelastine HCL, Ketotifen Fumarate or Tier 2 olopatadine ophthalmic (eye) drops 0.2 % Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) WAL-ZYR (KETOTIFEN) OPHTHALMIC (EYE) DROPS EHB; QL (10 ML per 30 $0 0.025 % (0.035 %) (ketotifen fumarate) days) Ophthalmic - Anti-Inflammatory, Glucocorticoids - Anti-Infective/Anti- Inflammatories

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 219 Coverage Prescription Drug Name Drug Tier Requirements and Limits NIGHTIME SLEEP ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) promethazine oral tablet 12.5 mg Tier 1 promethazine rectal suppository 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 25 Tier 1 Mg) Antitussives - Non-Opioid - Drugs for Allergies benzonatate oral capsule 100 mg, 200 mg Tier 1 benzonatate oral capsule 150 mg Tier 3 Asthma Therapy - Inhaled Corticosteroids (Glucocorticoids) - Drugs for Asthma/COPD ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 Tier 2 MCG/ACTUATION (fluticasone furoate) budesonide inhalation suspension for nebulization 0.25 Tier 1 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 Tier 2 MCG/ACTUATION (fluticasone propionate) FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 Tier 2 MCG/ACTUATION (fluticasone propionate) Asthma Therapy - Leukotriene Receptor Antagonists - Drugs for Asthma/COPD montelukast oral granules in packet 4 mg Tier 1 montelukast oral tablet 10 mg Tier 1 montelukast oral tablet,chewable 4 mg, 5 mg Tier 1 zafirlukast oral tablet 10 mg, 20 mg Tier 1 Asthma Therapy - Mast Cell Stabilizers - Drugs for Asthma/COPD cromolyn inhalation solution for nebulization 20 mg/2 Tier 1 ml Asthma Therapy - Xanthines - Drugs for Asthma/COPD theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15 Tier 2 Ml) theophylline anhydrous (Theochron Oral Tablet Extended Tier 1 Release 12 Hr 100 Mg, 200 Mg, 300 Mg) theophylline oral elixir 80 mg/15 ml Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 220 Coverage Prescription Drug Name Drug Tier Requirements and Limits theophylline oral solution 80 mg/15 ml Tier 1 theophylline oral tablet extended release 12 hr 300 mg, Tier 1 450 mg theophylline oral tablet extended release 24 hr 400 mg, Tier 1 600 mg Asthma Therapy- Monoclonal Antibody - Interleukin-5 (IL-5) Antagonists - Drugs for Asthma/COPD NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML PA; SP; QL (1 ML per 28 Tier 4 (mepolizumab) days) NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML PA; SP; QL (1 ML per 28 Tier 4 (mepolizumab) days) Asthma/COPD - Anticholinergic Agents, Inhaled Long Acting - Drugs for Asthma/COPD INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE Tier 2 62.5 MCG/ACTUATION (umeclidinium bromide) SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION (tiotropium Tier 2 bromide) SPIRIVA WITH HANDIHALER INHALATION CAPSULE, Tier 2 W/INHALATION DEVICE 18 MCG (tiotropium bromide) Asthma/COPD - Anticholinergic Agents, Inhaled Short Acting - Drugs for Asthma/COPD ATROVENT HFA INHALATION HFA AEROSOL INHALER Tier 2 17 MCG/ACTUATION (ipratropium bromide) ipratropium bromide inhalation solution 0.02 % Tier 1 Asthma/COPD - Beta 2-Adrenergic Agents, Inhaled, Ultra-Long Acting - Drugs for Asthma/COPD STRIVERDI RESPIMAT INHALATION MIST 2.5 Tier 2 QL (4 GM per 30 days) MCG/ACTUATION (olodaterol hcl) Asthma/COPD Therapy - Beta 2-Adrenergic Agents, Inhaled, Long Acting - Drugs for Asthma/COPD SEREVENT DISKUS INHALATION BLISTER WITH Tier 3 DEVICE 50 MCG/DOSE (salmeterol xinafoate) Asthma/COPD Therapy - Beta 2-Adrenergic Agents, Inhaled, Short Acting - Drugs for Asthma/COPD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 223 Coverage Prescription Drug Name Drug Tier Requirements and Limits ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 4 PA; SP; QL (4 EA per 1 day) (lumacaftor/ivacaftor) SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG Tier 4 PA; SP; QL (2 EA per 1 day) (D)/ 150 MG (N) (tezacaftor/ivacaftor) Mucolytics - Drugs for the Lungs acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 Tier 1 %) PULMOZYME INHALATION SOLUTION 1 MG/ML Tier 4 SP (dornase alfa) Nasal Anticholinergics - Allergy ipratropium bromide nasal spray,non-aerosol 21 mcg Tier 1 (0.03 %), 42 mcg (0.06 %) Nasal Antihistamines - Allergy azelastine nasal aerosol,spray 137 mcg (0.1 %) Tier 1 azelastine nasal spray,non-aerosol 205.5 mcg (0.15 %) Tier 1 olopatadine nasal spray,non-aerosol 0.6 % Tier 1 Nasal Corticosteroids - Allergy 24 HOUR ALLERGY RELIEF NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION (fluticasone Tier 1 QL (31.6 ML per 1 FILL) propionate) 24 HOUR NASAL ALLERGY NASAL AEROSOL,SPRAY 55 Tier 1 QL (33.8 ML per 1 FILL) MCG (triamcinolone acetonide) ALLER-CORT NASAL AEROSOL,SPRAY 55 MCG Tier 1 QL (33.8 ML per 1 FILL) (triamcinolone acetonide) ALLER-FLO NASAL SPRAY,SUSPENSION 50 Tier 1 QL (31.6 ML per 1 FILL) MCG/ACTUATION (fluticasone propionate) ALLERGY RELIEF (FLUTICASONE) NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION (fluticasone Tier 1 QL (31.6 ML per 1 FILL) propionate) budesonide nasal spray,non-aerosol 32 mcg/actuation Tier 2 ST: Prior prescription for Children's Nasacort, CHILDREN'S FLONASE SENSIMIST NASAL Flunisolide, Fluticasone SPRAY,SUSPENSION 27.5 MCG/ACTUATION Tier 3 Propionate, Mometasone (fluticasone furoate) Furoate, or Triamcinolone Acetonide in 120 days; QL (31.6 ML per 1 FILL)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 224 Coverage Prescription Drug Name Drug Tier Requirements and Limits CLARISPRAY NASAL SPRAY,SUSPENSION 50 Tier 1 QL (31.6 ML per 1 FILL) MCG/ACTUATION (fluticasone propionate) ST: Prior prescription for Children's Nasacort, Flunisolide, Fluticasone FLONASE SENSIMIST NASAL SPRAY,SUSPENSION 27.5 Tier 3 Propionate, Mometasone MCG/ACTUATION ( ) fluticasone furoate Furoate, or Triamcinolone Acetonide in 120 days; QL (31.6 ML per 1 FILL) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) Tier 1 QL (50 ML per 1 FILL) fluticasone propionate nasal spray,suspension 50 Tier 1 QL: 2 BOTTLES PER FILL mcg/actuation mometasone nasal spray,non-aerosol 50 mcg/actuation Tier 1 QL (34 GM per 1 FILL) NASAL ALLERGY NASAL AEROSOL,SPRAY 55 MCG Tier 1 QL (33.8 ML per 1 FILL) (triamcinolone acetonide) triamcinolone acetonide nasal aerosol,spray 55 mcg Tier 1 QL (33.8 ML per 1 FILL) Nasal Sympathomimetic Decongestants (Intranasal) - Allergy TYZINE NASAL DROPS 0.1 % (tetrahydrozoline hcl) Tier 3 TYZINE NASAL SPRAY,NON-AEROSOL 0.1 % Tier 3 (tetrahydrozoline hcl) Non-Opioid Antitussive-Antihistamine Combinations - Drugs for Cough and Cold promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1 Opioid Antitussive-1st Generation Antihistamine Combinations - Drugs for Cough and Cold hydrocodone-chlorpheniramine oral Tier 1 QL (120 ML per 1 FILL) suspension,extended rel 12 hr 10-8 mg/5 ml promethazine-codeine oral syrup 6.25-10 mg/5 ml Tier 1 Age (Min 18 Years) Opioid Antitussive-1st Generation Antihistamine-Decongestant Comb. - Drugs for Cough and Cold promethazine/phenylephrine hcl/codeine (Promethazine Tier 1 Age (Min 18 Years) Vc-Codeine Oral Syrup 6.25-5-10 Mg/5 Ml) promethazine-phenyleph-codeine oral syrup 6.25-5-10 Tier 1 Age (Min 18 Years) mg/5 ml RYDEX ORAL LIQUID 1.3-10-6.3 MG/5 ML (brompheniramine maleate/pseudoephedrine Tier 1 hcl/codeine phosphat)

1 ACCUTREND GLUCOSE ADVOCATE CONTROL 1ST TIER UNIFINE CONTROL ...... 126, 174 SOLUTION HIGH 126, 174 PENTIPS ...... 141 ACE AEROSOL CLOUD ADVOCATE LANCET ..... 126 1ST TIER UNIFINE ENHANCER ...... 161, 174 ADVOCATE LANCING PENTIPS PLUS ...... 141 acebutolol ...... 38 DEVICE ...... 126, 174 1ST TIER UNILET acetaminophen-codeine ...... 2 ADVOCATE LOW COMFORTOUCH ...... 125 acetazolamide ...... 41 CONTROL ...... 126, 174 2 acetic acid ...... 219 ADVOCATE PEN NEEDLE 24 HOUR ALLERGY RELIEF acetylcysteine ...... 224 ...... 141, 174 ...... 224 ACID CONTROLLER ...... 111 ADVOCATE RAPID-SAFE 24 HOUR NASAL ALLERGY ACID REDUCER LANCING ...... 126, 174 ...... 224 (CIMETIDINE) ...... 112 ADVOCATE REDI-CODE+ 2TEK CONTROL (HIGH- ACID REDUCER CTRL HIGH ...... 126, 174 NORMAL) ...... 125 (FAMOTIDINE) ...... 112 ADVOCATE REDI-CODE+ A ACID-PEP ...... 112 CTRL LOW ...... 126, 174 A.I.R.S NEBULIZER acitretin ...... 76 ADVOCATE SYRINGES 141, REPLACEMENT .. 161, 173 ACNE MEDICATION ...... 73 174, 175 abacavir ...... 14 ACTI-LANCE LANCETS . 126 AEROCHAMBER MINI ... 161, abacavir-lamivudine ...... 16 ACTIVE CATH ...... 169 175 abacavir-lamivudine- acyclovir ...... 19, 77 AEROCHAMBER MV ..... 161, zidovudine ...... 16 ADACEL(TDAP 175 abiraterone ...... 23 ADOLESN/ADULT)(PF) . 31 AEROCHAMBER PLUS ABOUTTIME PEN NEEDLE adapalene ...... 73 FLOW-VU ...... 161 ...... 141, 173 ADD-A-FOLEY CATH- AEROCHAMBER PLUS acamprosate ...... 58 MONO-FLO DRNG ..... 169, FLOW-VU,L MSK ...... 161 acarbose ...... 99 174 AEROCHAMBER PLUS ACCU-CHEK AVIVA ADD-A-FOLEY CATH-PRE- FLOW-VU,M MSK ...... 161 CONTROL SOLN 125, 173 FILL SYRN ...... 169 AEROCHAMBER PLUS ACCU-CHEK FASTCLIX ADD-A-FOLEY TRAY...... 169 FLOW-VU,S MSK ...... 161 LANCET DRUM ... 125, 173 adefovir ...... 18 AEROCHAMBER PLUS Z ACCU-CHEK FASTCLIX ADJUSTABLE LANCING STAT ...... 161, 175 LANCING DEV .... 125, 174 DEVICE ...... 126 AEROCHAMBER PLUS Z ACCU-CHEK GUIDE L1-L2 ADULT AEROSOL MASK STAT LG MSK ..... 161, 175 CTRL SOL ...... 126 ...... 161, 174 AEROCHAMBER PLUS Z ACCU-CHEK MULTICLIX ADULT ASPIRIN REGIMEN 8 STAT MD MSK .... 161, 175 LANCET ...... 126, 174 ADULT DISPOSABLE AEROCHAMBER PLUS Z ACCU-CHEK SAFE-T-PRO MOUTHPIECE ..... 161, 174 STAT SM MSK .... 161, 175 ...... 126 ADULT LOW DOSE AEROCHAMBER WITH ACCU-CHEK SAFE-T-PRO ASPIRIN ...... 8, 121 FLOWSIGNAL ..... 161, 175 PLUS ...... 126, 174 ADVAIR DISKUS ...... 222 AEROCHAMBER Z-STAT ACCU-CHEK SMARTVIEW ADVAIR HFA ...... 223 PLUS-FLW SG .... 161, 175 CONTRL SOL ...... 126, 174 ADVANCE PLUS AEROECLIPSE II ACCU-CHEK SOFT DEV INTERMITTENT .. 169, 174 NEBULIZER...... 159, 175 LANCETS ...... 126, 174 ADVANCED LANCING AEROGEAR ACTION ACCU-CHEK SOFTCLIX DEVICE ...... 126 ASTHMA KIT ...... 160, 175 LANCETS ...... 126 ADVANCED TRAVEL AERONEB GO ...... 161 Accutane ...... 71 LANCETS ...... 126, 174 AERONEB GO NEBULIZER ...... 159

228 AEROTRACH PLUS 161, 175 alfuzosin ...... 117 amiloride-hydrochlorothiazide AEROVENT PLUS .. 161, 175 ALINIA ...... 12 ...... 42 AFINITOR ...... 27 ALIVE PRENATAL ...... 97 aminocaproic acid ...... 120 AFINITOR DISPERZ ...... 27 ALL DAY PAIN RELIEF ...... 6 amiodarone ...... 36 Afirmelle ...... 61 ALL DAY RELIEF ...... 6 amitriptyline ...... 50 AFLURIA QD 2020-21(3YR ALL FLOW 1000 KIT ...... 162 amitriptyline-chlordiazepoxide UP)(PF) ...... 31 ALL FLOW 1000 PFT ...... 49 AFLURIA QD 2020-21(6- FILTER ...... 162 amlodipine ...... 39 35MO)(PF) ...... 31 ALL FLOW 3000 KIT ...... 162 amlodipine-atorvastatin ..... 38 AFLURIA QUAD 2020- ALL FLOW 3000 PFT amlodipine-benazepril ...... 33 2021(6MO UP) ...... 31 FILTER ...... 162 amlodipine-valsartan ...... 34 AFTERA ...... 70 ALL FLOW 4000 KIT ...... 162 amlodipine-valsartan- AGAMATRIX CONTROL ALL FLOW 4000 PFT hcthiazid ...... 34 HIGH ...... 126, 175 FILTER ...... 162 ammonium lactate ...... 77 AGAMATRIX CONTROL ALL FLOW 5000 KIT ...... 162 Amnesteem ...... 71 NORM-HI ...... 126, 175 ALL FLOW 5000 PFT amoxapine ...... 50 AGAMATRIX CONTROL FILTER ...... 162 amoxicil-clarithromy- SOLN-LEVEL 2 ... 127, 175 ALL FLOW 6000 PFT lansopraz ...... 116 AGAMATRIX CONTROL FILTER ...... 162 amoxicillin ...... 10 SOLN-LEVEL 4 ... 127, 175 ALLER-CORT ...... 224 amoxicillin-pot clavulanate 10, AIR TUBE WITH AIR PLUGS ALLER-FLO ...... 224 11 ...... 161, 175 ALLERGY EYE ampicillin ...... 10 AIRS ADULT AEROSOL (KETOTIFEN) ...... 214 anagrelide ...... 121 MASK ...... 162, 175 ALLERGY RELIEF anastrozole ...... 24 AIRS DISPOSABLE (FLUTICASONE) ...... 224 ANGIOCATH AUTOGUARD NEBULIZER ...... 159, 175 allopurinol ...... 119 IV CATH ...... 158, 176 AIRZONE AND ALOCRIL ...... 216 ANORO ELLIPTA ...... 222 MINIWRIGHT AFS ..... 158, ALOMIDE ...... 216 ANTI-DANDRUFF ...... 76 176 ALORA ...... 104 ANTI-DANDRUFF WITH AIRZONE PEAK FLOW ALPHAGAN P ...... 218 MENTHOL ...... 77 METER ...... 160, 176 alprazolam ...... 43 ANTI-EMBOLISM Ak-Poly-Bac ...... 216 Altavera (28) ...... 61 STOCKINGS...... 158, 176 AKYNZEO (NETUPITANT) ALTERA NEBULIZER .... 159, ANTI-ITCH (HC) ...... 77, 78 ...... 111 176 ANTI-ITCH PLUS ...... 80 Ala-Cort ...... 77 ALTERA NEBULIZER ANTI- Ala-Scalp ...... 77 SYSTEM ...... 159, 176 ITCH(HYDROCORTISON ALAWAY ...... 214 ALTERNATE SITE LANCET E)-ALOE ...... 80 albendazole ...... 11 ...... 127, 176 APOGEE HC INTERMIT albuterol sulfate ...... 222 ALTERNATE SITE LANCING CATHETER ...... 169 Alcaine ...... 216 DEVICE ...... 127, 176 APOGEE IC INTERMIT alclometasone ...... 77 ALUNBRIG ...... 23 CATHETER ...... 169, 176 ALCOH-GLOVE ...... 30, 125 Alyacen 1/35 (28) ...... 61 apraclonidine ...... 218 ALCOHOL PADS ...... 29 Alyacen 7/7/7 (28) ...... 68 aprepitant ...... 111 ALCOHOL PREP PADS ... 29 Alyq ...... 43 Apri ...... 61 alcohol swabs ...... 29 Amabelz ...... 103 APTIVUS ...... 21 ALCOHOL WIPES ...... 29 amantadine hcl ...... 51 APTIVUS (WITH VITAMIN E) ALCOH-WIPE ...... 30, 125 Amethia ...... 60 ...... 21 ALECENSA ...... 23 AMIELLE VAGINAL AQUA CARE SODIUM alendronate ...... 103 TRAINER ...... 158 CHLORIDE ...... 84 ALEVE ...... 6 amiloride ...... 41

229 AQUA LANCE LANCING atenolol ...... 38 BAL-CARE DHA ESSENTIAL DEVICE ...... 127, 176 atenolol-chlorthalidone ...... 40 ...... 86 AQUANIL HC ...... 78 atomoxetine ...... 53 balsalazide ...... 113 AQUAPHOR ITCH RELIEF atorvastatin ...... 37 Balziva (28) ...... 62 ...... 78 atovaquone ...... 12 BANOPHEN ...... 219 Aranelle (28)...... 68 atovaquone-proguanil ...... 12 BANZEL ...... 47 ARANESP (IN atropine ...... 213 BAQSIMI ...... 98 POLYSORBATE) ...... 120 ATROVENT HFA ...... 221 BARD CATHETER STRAP ARGYLE TROCAR . 169, 176 AUBAGIO ...... 211 ...... 158, 176 aripiprazole...... 54 Aubra...... 61 BARD CLEAN-CATH ..... 169, ARMOUR THYROID ...... 109 Aubra Eq ...... 61 176 ARNUITY ELLIPTA ...... 220 AURA PORTANEB . 159, 176 BARD COUDE TIP ARTHRITIS PAIN Aurovela 1.5/30 (21) ...... 62 CATHETER ...... 169, 176 (DICLOFENAC) ...... 81 Aurovela 1/20 (21) ...... 62 BARD FEMALE ARTIFICIAL TEARS Aurovela 24 Fe ...... 62 INTERMITTENT CATH (POLYVIN ALC) ...... 212 Aurovela Fe 1.5/30 (28) ..... 62 ...... 169, 176 ARTIFICIAL Aurovela Fe 1-20 (28) ...... 62 BARD INFECT CONT TRAY- TEARS(GLYCERIN-PEG) AURYXIA ...... 84, 116, 117 NO CATH ...... 169, 177 ...... 212 AUTODROP ...... 158, 176 BARD LUBRICATH FOLEY Ashlyna ...... 60 AUTO-LANCET MINI ..... 127, TRAY ...... 170, 177 ASPERCREME 176 BARD LUBRICATH FOLEY (LIDOCAINE) ...... 82 AUTOLET IMPRESSION TRAY 18FR ...... 170, 177 ASPERFLEX ...... 82 LANC DEV ...... 127 BARD RUBBER UTILITY aspirin ...... 8 AUTOLET LANCING CATHETER ...... 170, 177 ASPIRIN CHILDRENS 8, 121 DEVICE ...... 127 BARD UNIVERSAL FOLEY ASPIRIN LOW DOSE ...... 8 AUTOLET PLUS LANCING CATH TRAY ...... 170 aspirin-dipyridamole ...... 121 DEVICE ...... 127 BARD URETHRAL ASPIR-TRIN ...... 8, 121 AUTOSQUEEZE ..... 158, 176 CATHETER TRAY ...... 170, ASSURE 4 CONTROL AVANDIA ...... 108 177 SOLUTION ...... 127 AVASTIN ...... 22 BARDEX ALL-SILICONE ASSURE DOSE NORMAL AVEENO ANTI-ITCH FOLEY CATH ...... 170, 177 CONTROL ...... 127 (HYDROCORTSN) ...... 80 BARDEX CLOSED SYSTEM ASSURE DOSE NORM-HI Aviane ...... 62 CATH TRAY ...... 170, 177 CONTROL ...... 127 AVITA ...... 73 BARDEX LUBRICATH ASSURE HAEMOLANCE AVONEX ...... 210 FOLEY CATH ...... 170, 177 PLUS ...... 127 Ayuna ...... 62 BARDEX URETHRAL ASSURE ID INSULIN AZASITE ...... 217 CATHETERTRAY 170, 177 SAFETY...... 142, 176 azathioprine ...... 123 BARDIA RED RUBBER ASSURE ID PEN NEEDLE azelaic acid ...... 71 CATHETER ...... 170, 177 ...... 142 azelastine ...... 214, 224 BD ALCOHOL SWABS ..... 29 ASSURE LANCE ...... 127 azithromycin ...... 19 BD ANGIOCATH IV ASSURE LANCE PLUS .. 127 AZO URINARY PAIN CATHETER ...... 158, 177 ASSURE PRISM CONTROL RELIEF ...... 118 BD AUTOSHIELD DUO PEN 1-2 SOLN...... 127 Azurette (28) ...... 60 NEEDLE ...... 142, 177 ASTHMA CHECK METER B BD ECLIPSE LUER-LOK 142, ...... 160, 176 bacitracin ...... 217 177 ASTHMAPACK CHILDREN'S bacitracin-polymyxin b ..... 216 BD INSULIN SYRINGE .. 142, ...... 160, 176 baclofen ...... 124 177, 178 ATABEX OB ...... 86 BALANCED B-50 ...... 84 BD INSULIN SYRINGE atazanavir...... 21 BAL-CARE DHA ...... 86 HALF UNIT ...... 142

230 BD INSULIN SYRINGE benzoyl peroxide ...... 73 BREATHERITE VALVED MICRO-FINE ...... 142, 177 benztropine ...... 51 MDI CHAMBER ...... 162 BD INSULIN SYRINGE BERINERT ...... 119 BREATHERITE VALVED SAFETY-LOK ...... 142, 177 BETA-HC ...... 78 MDI SPACER ...... 162 BD INSULIN SYRINGE SLIP betamethasone dipropionate BREEZE 2 CONTROL TIP ...... 142, 177 ...... 78 SOLUTION, LOW 128, 179 BD INSULIN SYRINGE U- betamethasone valerate .... 78 BREEZE 2 CONTROL 500 ...... 142, 178 betamethasone, augmented SOLUTION, NML . 128, 179 BD INSULIN SYRINGE ...... 78 BREEZE 2 CONTROL ULTRA-FINE ...... 142, 143 betaxolol ...... 38, 216 SOLUTION,HIGH 128, 179 BD INSYTE AUTOGUARD bethanechol chloride ...... 119 BREO ELLIPTA ...... 223 ...... 158, 178 bexarotene ...... 29 Briellyn ...... 62 BD LO-DOSE MICRO-FINE bicalutamide ...... 23 BRILINTA ...... 121 IV ...... 143, 178 BIKTARVY ...... 15 brimonidine ...... 218 BD LO-DOSE ULTRA-FINE bimatoprost ...... 218 bromfenac ...... 215 ...... 143, 178 bisoprolol fumarate ...... 38 bromocriptine ...... 51 BD MICROTAINER LANCET bisoprolol- BROMSITE ...... 215 ...... 127, 178 hydrochlorothiazide...... 40 BUBBLES THE FISH PEDI BD NANO 2ND GEN PEN Bleph-10 ...... 217 MASK ...... 162, 179 NEEDLE ...... 143, 178 BLEPHAMIDE ...... 213 budesonide ...... 114, 220, 224 BD SAFETYGLIDE INSULIN Blisovi 24 Fe ...... 62 BULLSEYE MINI SAFETY SYRINGE ...... 143, 178 Blisovi Fe 1.5/30 (28) ...... 62 LANCETS ...... 128 BD SAFETYGLIDE Blisovi Fe 1/20 (28) ...... 62 bumetanide ...... 41 SYRINGE ...... 143, 178 blood glucose contrl buprenorphine ...... 3 BD SAF-T-INTIMA .. 158, 179 hi,normal ...... 127, 179 buprenorphine-naloxone ... 58 BD ULTRA FINE LANCETS blood glucose control, normal bupropion hcl ...... 49 ...... 127, 179 ...... 127 bupropion hcl (smoking BD ULTRA-FINE II blood glucose ctl deter) ...... 58 LANCETS ...... 127 high,nml,low ...... 127, 179 BURN RELIEF WITH ALOE BD ULTRA-FINE MICRO BLUE-EMU LIDOCAINE ...... 81 PEN NEEDLE ...... 143, 179 PATCH ...... 82 buspirone ...... 43 BD ULTRA-FINE MINI PEN BOOSTRIX TDAP ...... 31 butorphanol ...... 3 NEEDLE ...... 143 BOSULIF ...... 28 BUTTERFLY TOUCH BD ULTRA-FINE NANO PEN BP 10-1 ...... 72 LANCET ...... 128, 179 NEEDLE ...... 143 BRAFTOVI ...... 24 BYSTOLIC ...... 38 BD ULTRA-FINE ORIG PEN BRAINSTRONG PRENATAL C NEEDLE ...... 143 ...... 87 cabergoline ...... 108 BD ULTRA-FINE SHORT BREATHERITE MDI CABOMETYX ...... 27 PEN NEEDLE ...... 144 SPACER ...... 162 CADEAU DHA ...... 87 BD VEO INSULIN SYR HALF BREATHERITE SPACER- caffeine citrate ...... 55 UNIT ...... 144 MASK, NEO...... 162 calcipotriene ...... 76 BD VEO INSULIN SYRINGE BREATHERITE SPACER- calcipotriene-betamethasone UF ...... 144 MASK,ADULT ...... 162 ...... 73 Bekyree (28)...... 60 BREATHERITE SPACER- calcitonin (salmon) ...... 103 belladonna alkaloids-opium MASK,CHILD ...... 162 calcitriol ...... 76, 97 ...... 113 BREATHERITE SPACER- calcium acetate ...... 84 benazepril...... 33 MASK,INFANT ...... 162 calcium acetate(phosphat benazepril- BREATHERITE SPACER- bind) ...... 116, 117 hydrochlorothiazide ...... 33 MASK,S.CHLD ...... 162 CALCIUM PNV ...... 86, 87 benzonatate ...... 220 CALPHRON ...... 84, 116, 117

231 CALQUENCE ...... 25, 28 Cartia Xt ...... 39 cholecalciferol (vitamin d3) 97 Camila ...... 68 carvedilol ...... 34 cholestyramine (with sugar) CAMRESE ...... 60 CATH-SECURE TUBE ...... 36 CAMRESE LO ...... 60 HOLDER ...... 141, 180 Cholestyramine Light ...... 36 candesartan ...... 34 CAYA CONTOURED ..... 125, ciclopirox ...... 75 candesartan- 180 cilostazol ...... 121 hydrochlorothiazid ...... 34 CAYSTON ...... 223 cimetidine ...... 112 capecitabine ...... 24 Caziant (28) ...... 68 cimetidine hcl ...... 112 CAPRELSA ...... 28 cefaclor ...... 17 CIMZIA ...... 3, 4, 114 captopril ...... 33 cefadroxil ...... 16 CIMZIA POWDER FOR captopril-hydrochlorothiazide cefdinir ...... 17 RECONST ...... 3, 4, 114 ...... 33 cefixime ...... 17 CIMZIA STARTER KIT ... 3, 4, carbamazepine ...... 45 cefpodoxime ...... 17 114 CARBATROL ...... 45, 54 cefprozil ...... 17 cinacalcet ...... 103 carbidopa ...... 51 cefuroxime axetil ...... 17 CIPRO ...... 17 carbidopa-levodopa ...... 50 celecoxib ...... 6 CIPRO XR ...... 17, 118 carbidopa-levodopa- CELONTIN ...... 47 ciprofloxacin ...... 17 entacapone ...... 50 cephalexin ...... 16, 17 ciprofloxacin hcl . 17, 217, 219 carbinoxamine maleate ... 219 CERTAIN DRI ...... 76 ciprofloxacin-dexamethasone CAREFINE PEN NEEDLE cevimeline ...... 210 ...... 218 ...... 144, 179 CHANTIX ...... 59 citalopram ...... 48 CAREONE LANCING CHANTIX CONTINUING CITRANATAL (DUAL-IRON) DEVICE ...... 128, 179 MONTH BOX ...... 59 ...... 87 CAREONE THIN LANCET CHANTIX STARTING CITRANATAL 90 DHA ...... 128, 179 MONTH BOX ...... 59 (ALGAL OIL) ...... 87 CAREONE ULTRA THIN Chateal (28) ...... 62 CITRANATAL ASSURE .... 87 LANCET ...... 128 Chateal Eq (28) ...... 62 CITRANATAL DHA (ALGAL CARESENS CONTROL A CHEK-STIX CONTROL.... 83, OIL) ...... 87 AND B ...... 128, 179 173, 180 CITRANATAL HARMONY CARESENS CONTROL A CHEMET ...... 10 (IRON FUM)...... 87 NORMAL ...... 128, 179 CHEMSTRIP 10 MD.. 83, 180 Claravis ...... 71 CARESENS LANCETS .. 128, CHEMSTRIP 10/SG .. 83, 180 CLARISPRAY ...... 225 179 CHEMSTRIP 2 GP .... 83, 180 clarithromycin ...... 20 CARETOUCH ALCOHOL CHEMSTRIP 50B ...... 83, 180 CLEANSING WASH .... 72, 81 PREP PAD ...... 29 CHEMSTRIP 7 ...... 83, 180 CLEAR ADVANTAGE ..... 170 CARETOUCH INSULIN CHEMSTRIP 9 ...... 83, 180 CLEVER CHEK LANCETS SYRINGE ...... 144, 179 CHILDREN'S ALAWAY ... 214 ...... 128 CARETOUCH LANCING CHILDREN'S ASPIRIN ...... 8 CLEVER CHOICE DEVICE ...... 128, 180 CHILDREN'S FLONASE CHAMBER-LRG MASK162 CARETOUCH PEN NEEDLE SENSIMIST ...... 224 CLEVER CHOICE ...... 144, 180 CHILDREN'S IBUPROFEN . 6 CHAMBER-MED MASK CARETOUCH SAFETY CHILDREN'S IRON ...... 84 ...... 162 LANCETS ...... 128, 180 CHILDREN'S PROFEN IB... 6 CLEVER CHOICE CARETOUCH TWIST chlordiazepoxide hcl ...... 43 CHAMBER-SM MASK . 162 LANCET ...... 128, 180 chlorhexidine gluconate... 209 CLEVER CHOICE LEVEL 1 carisoprodol...... 124 chloroquine phosphate ...... 12 CONTROL ...... 128, 180 carisoprodol-aspirin ...... 123 chlorpromazine ...... 52 CLEVER CHOICE LEVEL 2 carisoprodol-aspirin-codeine chlorthalidone ...... 42 CONTROL ...... 128, 180 ...... 124 CHOICE DM CLARUS CLEVER CHOICE LEVEL 3 carteolol ...... 216 NORM CONTROL 128, 180 CONTROL ...... 128, 180

232 CLEVER CHOICE COMFORT TOUCH PEN CORTIZONE-10 WITH ALOE NEBULIZER ...... 162, 180 NEEDLE ...... 145, 181 ...... 80 CLEVER CHOICE PEAK COMPACT COMPRESSOR COSENTYX ...... 74 FLOW METER ..... 160, 180 NEBULIZER ...... 159, 181 COSENTYX (2 SYRINGES) CLEVER CHOICE WHISPER COMPACT SPACE ...... 74 AIRE PED ...... 163, 180 CHAMBER ...... 163, 181 COSENTYX PEN ...... 74 CLICKFINE PEN NEEDLE COMPACT SPACE COSENTYX PEN (2 PENS) ...... 144 CHAMBER PLUS 163, 181 ...... 74 clindamycin hcl ...... 19 COMPACT SPACE COTELLIC ...... 26 Clindamycin Pediatric ...... 19 CHAMBER-LRG MASK163 CREON ...... 111 clindamycin phosphate ..... 72, COMPACT SPACE CRIXIVAN ...... 21 226 CHAMBER-MED MASK cromolyn ...... 26, 216, 220 clindamycin-benzoyl peroxide ...... 163 Cryselle (28) ...... 62 ...... 72 COMPACT SPACE CURITY 8000 URINE MTR clindamycin-tretinoin ...... 73 CHAMBER-SM MASK . 163 FLY TRAY ...... 170, 182 CLINPRO 5000 ...... 209 COMPACT ULTRASONIC CURITY ALCOHOL SWABS clobazam ...... 44 NEBULIZER ...... 159, 181 ...... 29 clobetasol ...... 78 COMP-AIR NEBULIZER CURITY BEDSIDE clobetasol-emollient ...... 78 COMPRESSOR ... 163, 181 DRAINAGE SET .. 170, 182 clomipramine ...... 50 COMPETE ...... 85 CURITY BEDSIDE-MONO- clonazepam ...... 43 COMPLERA ...... 16 FLO DRANGE ..... 170, 182 clonidine ...... 41 COMPLETE ...... 85 CURITY FOLEY CATHETER clonidine hcl ...... 41 COMPLETE NATAL DHA . 87 KIT ...... 170 clopidogrel ...... 121 COMPLETENATE ...... 87 CURITY PREMIUM clorazepate dipotassium ... 43 Compro ...... 110 CATHETER TRAY ...... 170 clotrimazole ...... 209 Constulose ...... 115 CURITY STRMLIN CATH - clotrimazole-betamethasone CONTOUR CONTROL MONO-FLO ...... 170, 182 ...... 75 SOLUTION, HIGH 129, 181 CURITY ULTRAMER 2-W clozapine ...... 52 CONTOUR CONTROL CATH LAT/T ...... 170, 182 C-NATE DHA ...... 87 SOLUTION, LOW 129, 181 CURITY ULTRAMER 2-W COAGUCHEK LANCETS CONTOUR CONTROL CATH TEFLN...... 170, 182 ...... 128, 180 SOLUTION, NML . 129, 181 CURITY ULTRAMER 2-WAY COARTEM ...... 12 CONTOUR NEXT LEV 1 CATHETER ...... 170, 182 codeine sulfate ...... 1 CONTROL SOL ... 129, 181 CURITY ULTRAMER IRRG codeine-guaifenesin ...... 226 CONTOUR NEXT LEV 2 3WAY CATH ...... 171, 182 colchicine ...... 119 CONTROL SOL ... 129, 181 CURITY ULTRAMER colesevelam ...... 36 COOL CONTROL A URETHRAL CATH ...... 171, COLESTID FLAVORED .... 36 SOLUTION ...... 129, 181 182 colestipol ...... 36, 37 COOL CONTROL B CURITY UNIVERSAL - NO COLOR LANCETS .. 128, 180 SOLUTION ...... 129, 182 DRAINAGE ...... 171, 182 COMBIPATCH ...... 103 COOL MIST HUMIDIFIER CURITY URETH CATH COMBISTIX REAGENT ... 83, ...... 141 CLOSED SYSTM ...... 171 180 CORLANOR ...... 42 CURITY URETH CATH COMBIVENT RESPIMAT 222 CORTAID ...... 78 OPEN SYSTEM ...... 171 COMFORT EZ INSULIN CORTISONE CURITY URETHRAL SYRINGE .... 144, 145, 181 (HYDROCORTISONE) .. 78 CATHETER ...... 171, 182 COMFORT EZ LANCETS 128 CORTISONE WITH ALOE 80 cyanocobalamin (vitamin b- COMFORT EZ PEN CORTISPORIN-TC ...... 218 12) ...... 97 NEEDLES ...... 145, 181 CORTIZONE-10 ...... 78, 79 Cyclafem 1/35 (28) ...... 62 COMFORT LANCETS .... 128 CORTIZONE-10 PLUS ...... 78 Cyclafem 7/7/7 (28) ...... 68

233 cyclobenzaprine ...... 124 DERMACINRX PRENATRIX DIFICID ...... 20 CYCLOMYDRIL ...... 213 ...... 87 diflorasone ...... 79 cyclopentolate ...... 213 DERMACINRX PRENATRYL diflunisal ...... 8 cyclophosphamide ...... 23 ...... 88 Digitek ...... 41 cyclosporine ...... 5, 122 DERMAREST ECZEMA Digox ...... 41 cyclosporine modified ...... 122 (HYDROCORT) ...... 79 digoxin ...... 41 cyproheptadine ...... 219 DESCOVY ...... 14 dihydroergotamine ...... 55 Cyred ...... 63 desipramine ...... 50 DILANTIN ...... 45 Cyred Eq ...... 63 desmopressin ...... 99 Dilantin Extended ...... 45 D desog-e.estradiol/e.estradiol Dilantin Infatabs...... 45 DAILY PRENATAL ...... 87 ...... 60 DILANTIN-125 ...... 45 dalfampridine ...... 211 desogestrel-ethinyl estradiol diltiazem hcl ...... 39 danazol ...... 105 ...... 63 DILT-XR ...... 39 DANDRUFF SHAMPOO desoximetasone ...... 79 dimethyl fumarate ...... 211 (SELEN-ALOE) ...... 77 DEVILBISS DISPOSABLE diphenhydramine hcl ...... 219 DANDRUFF SHAMPOO NEBULIZER ...... 159, 182 diphenoxylate-atropine .... 109 (SELENIUM) ...... 76 DEVILBISS PULMO-AIDE dipyridamole ...... 122 DANDRUFF SHAMPOO- COMPRESSR ..... 163, 182 disopyramide phosphate ... 35 MENTHOL ...... 77 DEVILBISS PULMOMATE DISPOSABLE PAPER dapsone ...... 12 COMPRESSOR ... 163, 182 MOUTHPIECE ...... 158 Dasetta 1/35 (28) ...... 63 DEVILBISS PULMONEB LT disulfiram ...... 58 Dasetta 7/7/7 (28) ...... 68 COMP-NEB ...... 163, 182 DIURIL ...... 42 DAVOL C.S. FOLEY DEVILBISS TRAVELER divalproex ...... 44 CATHETER TRAY ...... 171, COMPRESSOR ...... 163 dofetilide ...... 36 182 dexamethasone ...... 104 donepezil ...... 59 DAVOL COMPLETE FOLEY DEXAMETHASONE dorzolamide ...... 216 ...... 171 INTENSOL ...... 104 dorzolamide-timolol ...... 216 DAVOL FOLEY CATH dexamethasone sodium Dotti ...... 104 INSERT TRAY ...... 171 phosphate ...... 215 DOVATO ...... 14 DAVOL SILICONE FOLEY dexmethylphenidate ...... 53 DOVER CATHETER 171, 183 CATHETER ...... 171, 182 dextroamphetamine ...... 55 DOVER FOLEY CATHETER DAVOL UNIVERSAL CATH dextroamphetamine- ...... 171, 183 TRAY ...... 171 amphetamine ...... 55 DOVER LATEX FOLEY DAVOL URETHRAL DIACOMIT ...... 47 CATHETER ...... 171, 183 CATHETER TRAY ...... 171, DIASTIX ...... 173 DOVER RED RUBBER 182 DIATRUE CONTROL SOLN ROBINSON CATH ...... 171, DAVOL URETHRAL NORMAL ...... 129, 182 183 CATHTRAY (W/O) ...... 171, DIATRUE CONTROL DOVER TEXAS MALE 182 SOLUTION HIGH 129, 183 EXTERNAL CATH ...... 171 Daysee ...... 60 DIATRUE CONTROL DOVER UNIVERSAL ..... 171, DDAVP ...... 99 SOLUTION LOW . 129, 183 183 Deblitane ...... 68 diazepam ...... 43, 53 DOVER URI-DRAIN MALE Decadron ...... 104 Diazepam Intensol ...... 43, 53 EXT CATH ...... 171 deferasirox ...... 10 diclofenac potassium ...... 6 doxazosin ...... 42 demeclocycline ...... 22 diclofenac sodium .. 6, 75, 81, doxepin ...... 50 DENAVIR ...... 77 215 doxercalciferol ...... 208 DENTA 5000 PLUS ...... 209 diclofenac-misoprostol...... 6 doxycycline hyclate ... 22, 210 DENTAGEL ...... 209 dicloxacillin ...... 21 doxycycline monohydrate .. 22 DEPO-SUBQ PROVERA 104 dicyclomine ...... 113 DRAMAMINE LESS ...... 60 didanosine ...... 14 DROWSY ...... 110

234 dronabinol ...... 110 EASY GLIDE INSULIN EASY TOUCH TWIST DROPLET INSULIN SYR SYRINGE ...... 146, 184 LANCETS ...... 130, 185 HALF UNIT ...... 145, 183 EASY GLIDE PEN NEEDLE EASY TOUCH UNI-SLIP . 147 DROPLET INSULIN ...... 146, 184 EASY TRAK HIGH SYRINGE ...... 145, 183 EASY MINI EJECT CONTROL ...... 130, 185 DROPLET LANCETS ...... 129 LANCING DEVICE ..... 129, EASY TRAK II CTRL SOLN- DROPLET LANCING 184 NORMAL ...... 130, 185 DEVICE ...... 129, 183 EASY NEB COMPRESSOR EASY TRAK LOW DROPLET MICRON PEN NEBULIZER ...... 163, 184 CONTROL ...... 130, 185 NEEDLE ...... 145, 183 EASY PLUS II HIGH EASY TWIST AND CAP DROPLET PEN NEEDLE CONTROL ...... 129, 184 LANCETS ...... 130, 185 ...... 145, 183 EASY PLUS II LOW EASYAIR COMPRESSOR DROPSAFE PEN NEEDLE CONTROL ...... 129, 184 NEBULIZER...... 163, 185 ...... 145, 183 EASY STEP HIGH EASYGLUCO PLUS drospirenone-e.estradiol- CONTROL SOLN 129, 184 NORMAL CONTROL .. 130, lm.fa ...... 63 EASY STEP LOW 185 drospirenone-ethinyl estradiol CONTROL SOLUTION EASYMAX 15 LEVEL 1 .. 130, ...... 63 ...... 129, 184 186 DROXIA ...... 122 EASY STEP NORMAL EASYMAX 15 LEVEL 2 .. 130, DRYSOL ...... 76 CONTROL SOLN 129, 184 186 DRYSOL DAB-O-MATIC ... 76 EASY TALK HIGH EASYMAX LOW CONTROL DUAVEE ...... 103 CONTROL ...... 129, 184 ...... 130 DUET DHA BALANCED ... 88 EASY TALK LOW CONTROL EASYMAX NORMAL DUET DHA WITH OMEGA-3 ...... 130, 184 CONTROL ...... 130 ...... 88 EASY TOUCH ...... 147 EBASE CONTROLLER .. 163, duloxetine ...... 49 EASY TOUCH ALCOHOL 186 DUPIXENT PEN ...... 74 PREP PADS ...... 30 EC-NAPROXEN ...... 6 DUPIXENT SYRINGE ...... 74 EASY TOUCH FLIPLOCK econazole ...... 75 dutasteride ...... 117 INSULIN ...... 146, 185 ECONTRA EZ ...... 70 dutasteride-tamsulosin .... 116 EASY TOUCH HIGH-LOW ECONTRA ONE-STEP ..... 70 DUTOPROL ...... 40 CONTROL ...... 130 ECOTRIN ...... 8 E EASY TOUCH INSULIN ED-SPAZ ...... 113, 118 E.E.S. 400 ...... 20 SAFETY SYR ...... 146, 185 EDURANT ...... 14 EASIVENT HOLDING EASY TOUCH INSULIN efavirenz ...... 14 CHAMBER ...... 163 SYRINGE ...... 146, 147 efavirenz-emtricitabin-tenofov EASIVENT MASK LARGE EASY TOUCH LANCETS ...... 16 ...... 163, 183 ...... 130, 185 EFFACLAR ADAPALENE . 73 EASIVENT MASK MEDIUM EASY TOUCH LANCING EFFER-K ...... 85 ...... 163, 183 DEVICE ...... 130, 185 ELEMENT COMPACT HIGH EASIVENT MASK SMALL EASY TOUCH LUER LOCK CONTROL ...... 130, 186 ...... 163, 183 INSULIN ...... 147, 185 ELEMENT COMPACT EASY COMFORT ALCOHOL EASY TOUCH PEN NEEDLE NORMAL CONTROL .. 130, PAD ...... 30 ...... 147, 185 186 EASY COMFORT INSULIN EASY TOUCH SAFETY ELEMENT HIGH CONTROL SYRINGE ... 145, 146, 183, LANCETS ...... 130, 185 ...... 130, 186 184 EASY TOUCH SAFETY PEN ELEMENT LOW CONTROL EASY COMFORT LANCETS NEEDLE ...... 147, 185 ...... 130, 186 ...... 129 EASY TOUCH ELEMENT NORMAL EASY COMFORT PEN SHEATHLOCK INSULIN CONTROL ...... 131, 186 NEEDLES ...... 146, 184 ...... 147, 185 Elinest ...... 63

235 ELIQUIS ...... 119 ergocalciferol (vitamin d2) . 97 exemestane ...... 24 ELIQUIS DVT-PE TREAT ERGOMAR ...... 56 EXPECTA PRENATAL ...... 88 30D START ...... 119 ERIVEDGE ...... 25 EXPIRATORY Elixophyllin ...... 220 erlotinib ...... 22 MOUTHPIECE ..... 163, 186 ELLA ...... 70 Errin...... 68 EXTAVIA ...... 210 ELMIRON ...... 116 ERY PADS ...... 72 external catheter, male ... 171, Eluryng ...... 70 Ery-Tab ...... 20 187 EMBRACE EVO LEVEL 1 Erythrocin (As Stearate) .... 20 EXTRA-VIRT PLUS DHA .. 88 ...... 131, 186 erythromycin ...... 20, 217 EYE ITCH RELIEF ...... 214 EMBRACE GLUCOSE erythromycin ethylsuccinate E-Z JECT LANCETS 131, 187 CONTROL HIGH . 131, 186 ...... 20 E-Z JECT THIN LANCETS EMBRACE GLUCOSE erythromycin with ethanol .. 72 ...... 131 CONTROL LOW .. 131, 186 erythromycin-benzoyl EZ SMART CONTROL .... 131 EMBRACE LANCETS .... 131, peroxide ...... 72 EZ SMART LANCETS .... 131, 186 ESBRIET ...... 226 187 EMBRACE PRO ...... 131, 186 escitalopram oxalate ...... 48 ezetimibe ...... 38 EMBRACE TALK Estarylla ...... 63 EZ-LETS ...... 131, 187 CONTROL-HIGH (L2) 131, estazolam ...... 57 F 186 estradiol ...... 104, 227 FACE SPLASH SHIELD, EMBRACE TALK estradiol-norethindrone acet FULL ...... 158, 187 CONTROL-LOW (L1) . 131, ...... 103 FACE SPLASH SHIELD, 186 ESTRING ...... 227 SHORT ...... 159, 187 EMCYT ...... 25 eszopiclone ...... 57 FACTIVE ...... 18 Emoquette ...... 63 ethacrynic acid ...... 41 Falmina (28) ...... 63 emtricitabine ...... 14 ethambutol ...... 16 famciclovir ...... 19 emtricitabine-tenofovir (tdf) 14 ethosuximide ...... 47 famotidine ...... 112 EMTRIVA ...... 14 ethynodiol diac-eth estradiol FARXIGA ...... 100 enalapril maleate ...... 33 ...... 63 FARYDAK ...... 26 enalapril-hydrochlorothiazide etidronate disodium ...... 103 FC2 FEMALE CONDOM 125, ...... 33 etodolac ...... 7 187 ENBREL ...... 4 etonogestrel-ethinyl estradiol febuxostat ...... 119 ENBREL SURECLICK ...... 4 ...... 70 felbamate ...... 44 Endocet ...... 2, 3 etoposide ...... 25 FELBATOL ...... 44 ENGERIX-B (PF) ...... 30 EURAX ...... 82 felodipine ...... 39 enoxaparin ...... 121 EUTHYROX ...... 109 FEMALE CATHETER ..... 171, Enpresse ...... 69 EVENCARE ...... 131, 186 187 Enskyce ...... 63 EVENCARE G2 ...... 131 FEMALE SPECIMEN entacapone ...... 50 EVENCARE G3 CONTROL CATHETER ...... 171, 187 entecavir ...... 18 ...... 131 FEMCAP ...... 124, 187 ENTRESTO...... 34 EVENCARE MINI GLUCOSE Femynor ...... 63 Enulose ...... 111 CONTROL ...... 131, 186 fenofibrate ...... 37 EPANED ...... 33 EVENCARE PROVIEW fenofibrate micronized ...... 37 EPIFOAM ...... 81 CONTROL-L2,L3 . 131, 186 fenofibrate nanocrystallized epinastine ...... 214 everolimus (antineoplastic) 27 ...... 37 epinephrine ...... 40 everolimus fenofibric acid (choline) ..... 37 Epitol ...... 45, 54 (immunosuppressive) .. 123 fentanyl ...... 1 EPIVIR HBV ...... 18 EVOLUTION NORMAL fentanyl citrate ...... 1 eplerenone ...... 34 CONTROL ...... 131, 186 FENTORA ...... 1 EPOGEN ...... 120 EVOTAZ ...... 15, 21 ferrous sulfate ...... 84, 85 EQUETRO ...... 45, 46, 54 EXEL INSULIN ...... 147 FETZIMA ...... 49

236 FIFTY50 SAFETY SEAL FLUORIDEX DAILY fosinopril-hydrochlorothiazide LANCETS ...... 131 DEFENSE ...... 209 ...... 33 FILTERED MOUTHPIECE fluorometholone ...... 215 FOSRENOL ...... 117 ATTACHMENT .... 159, 187 FLUOROPLEX ...... 75 FREEDOM CATH ...... 172 finasteride...... 117 fluorouracil ...... 75 FREESTYLE CONTROL . 132 FINE 30 UNIVERSAL fluoxetine ...... 48 FREESTYLE FREEDOM LANCETS ...... 131 fluphenazine hcl ...... 52 LITE ...... 132, 188 FINGERSTIX LANCETS 132, flurazepam ...... 53, 57 FREESTYLE INSULINX . 124, 187 flurbiprofen ...... 7 132, 188 FLANAX (NAPROXEN) ...... 7 flurbiprofen sodium ...... 215 FREESTYLE INSULINX flecainide ...... 35 flutamide ...... 23 TEST STRIPS...... 124, 188 FLEXICHAMBER .... 163, 187 fluticasone propionate 79, 225 FREESTYLE LANCETS . 132, FLEXICHAMBER-LG CHILD fluvastatin ...... 37 188 MASK ...... 164, 187 fluvoxamine ...... 48 FREESTYLE LITE METER FLEXICHAMBER-SM ADULT FLUZONE HIGHDOSE ...... 132, 188 MASK ...... 164, 187 QUAD 20-21 PF ...... 32 FREESTYLE LITE STRIPS FLEXICHAMBER-SM CHILD FLUZONE QUAD 2020-2021 ...... 124 MASK ...... 164, 187 ...... 32 FREESTYLE PRECISION FLONASE SENSIMIST ... 225 FLUZONE QUAD 2020-2021 ...... 147, 188 FLOVENT DISKUS ...... 220 (PF) ...... 32 FREESTYLE PRECISION FLOVENT HFA ...... 220 FLYP NEBULIZER ...... 159 NEO STRIPS ...... 124 FLUAD 2020-2021 (65 YR FOLET ONE ...... 86, 88 FREESTYLE TEST ...... 124 UP)(PF) ...... 32 FOLEY CATHETER 172, 187 FREESTYLE UNISTIK 2 132, FLUAD QUAD 2020-21(65Y FOLEY CATHETER TRAY 188 UP)(PF) ...... 32 ...... 172, 187 furosemide ...... 41 FLUARIX QUAD 2020-2021 folic acid ...... 98 FUZEON ...... 13 (PF) ...... 32 fondaparinux ...... 121 Fyavolv ...... 103 FLUBLOK QUAD 2020-2021 FORA HIGH CONTROL . 132, G (PF) ...... 32 187 G TUSSIN AC ...... 226 FLUCELVAX QUAD 2020- FORA LANCING DEVICE 132 gabapentin ...... 44 2021 ...... 32 FORA LOW CONTROL.. 132, GABITRIL ...... 45 FLUCELVAX QUAD 2020- 187 galantamine ...... 59 2021 (PF)...... 32 FORA NORMAL CONTROL GALZIN ...... 9 fluconazole ...... 11 ...... 132 gatifloxacin ...... 217 flucytosine ...... 12 FORACARE GDH HIGH GAVILYTE-C ...... 115 fludrocortisone ...... 108 CONTROL ...... 132, 187 Gavilyte-G ...... 115 FLULAVAL QUAD 2020- FORACARE GDH LOW Gavilyte-N ...... 115 2021 (PF)...... 32 CONTROL ...... 132, 187 GE100 CONTROL FLUMIST QUAD 2020-2021 FORACARE GDH NORMAL SOLUTION NORMAL .. 132 ...... 32 CONTROL ...... 132, 187 gemfibrozil ...... 37 flunisolide ...... 225 FORACARE LANCETS .. 132, Generlac ...... 111 fluocinolone ...... 79 188 Gengraf ...... 5, 122 fluocinolone acetonide oil 219 FORTEO ...... 102 Gentak ...... 217 fluocinolone and shower cap FORTISCARE HIGH 132, 188 gentamicin ...... 74, 217 ...... 79 FORTISCARE LOW 132, 188 GENTEAL TEARS fluocinonide ...... 79 FORTISCARE NORMAL 132, MODERATE (PF) ...... 212 Fluocinonide-E ...... 79 188 GENTLECATH ...... 172, 188 fluocinonide-emollient ...... 79 fosamprenavir ...... 21 GENVOYA ...... 15 fluoride (sodium) ...... 209 fosinopril ...... 33 GILENYA ...... 211 GIZMO ...... 172

237 glatiramer ...... 211 HARMONY CONTROL L1,L3 HUMIRA(CF) ...... 4, 5, 115 Glatopa ...... 211 ...... 133, 188 HUMIRA(CF) PEDI CROHNS GLEOSTINE ...... 23 HARVONI ...... 18, 19 STARTER ...... 3, 4, 115 glimepiride ...... 101 HEALTHMIST ...... 141, 188 HUMIRA(CF) PEN ...... 115 glipizide ...... 101 HEALTHPRO HIGH-LOW HUMIRA(CF) PEN glipizide-metformin ...... 100 CONTROL ...... 133 CROHNS-UC-HS ..... 4, 115 GLUCAGEN HYPOKIT ..... 98 HEALTHWISE INSULIN HUMIRA(CF) PEN PSOR- Glucagon Emergency Kit SYRINGE .... 147, 148, 189 UV-ADOL HS ...... 4, 5, 115 (Human)...... 98 HEALTHWISE PEN NEEDLE HUMULIN 70/30 U-100 GLUCOCARD 01 HI- ...... 148, 189 INSULIN ...... 105 NORMAL CONTROL ... 132 HEALTHY ACCENTS HUMULIN 70/30 U-100 GLUCOCARD 01 NORMAL AUTOLET ...... 133, 189 KWIKPEN ...... 105 CONTROL ...... 132 HEALTHY ACCENTS HUMULIN N NPH INSULIN GLUCOCARD EXPRESSION UNIFINE PENTIP 148, 189 KWIKPEN ...... 106 ...... 132 HEALTHY ACCENTS HUMULIN N NPH U-100 GLUCOCARD SHINE ..... 133 UNILET LANCET ...... 133 INSULIN ...... 106 GLUCOCOM CONTROL HEARTBURN PREVENTION HUMULIN R REGULAR U- HIGH ...... 133, 188 ...... 112 100 INSULN...... 106 GLUCOCOM CONTROL HEARTBURN RELIEF HUMULIN R U-500 (CONC) NORMAL ...... 133, 188 (CIMETIDINE) ...... 112 INSULIN ...... 106 GLUCOCOM LANCETS 133, HEARTBURN RELIEF HUMULIN R U-500 (CONC) 188 (FAMOTIDINE) ...... 112 KWIKPEN ...... 106 GLUCOSE CONTROL .... 133 Heather ...... 68 HYCAMTIN ...... 29 GLUCOSE KETONE HEMA-COMBISTIX ... 83, 189 hydralazine ...... 41 CONTROL SOLN ...... 133 HIZENTRA ...... 31 hydrochlorothiazide ...... 42 glyburide ...... 101 HOMATROPAIRE ...... 214 hydrocodone-acetaminophen glyburide micronized ...... 101 HOME NEBULIZER PLUS ...... 2 glyburide-metformin ...... 101 SIDESTREAM ...... 164 hydrocodone- glycopyrrolate ...... 113 HUMALOG JUNIOR chlorpheniramine ...... 225 Glydo ...... 82 KWIKPEN U-100 ...... 107 hydrocodone-homatropine GOJJI GLUCOSE CNTRL HUMALOG KWIKPEN ...... 226 SOL-NORMAL ..... 133, 188 INSULIN ...... 107 hydrocodone-ibuprofen ...... 2 GOJJI LANCETS .... 133, 188 HUMALOG MIX 50-50 hydrocortisone ...... 9, 79, 104, granisetron hcl ...... 110 INSULN U-100 ...... 106 114 griseofulvin microsize ...... 12 HUMALOG MIX 50-50 hydrocortisone acetate ...... 79 griseofulvin ultramicrosize . 12 KWIKPEN ...... 106 HYDROCORTISONE PLUS GUAIATUSSIN AC ...... 226 HUMALOG MIX 75-25 ...... 79 GUAIFENESIN AC ...... 226 KWIKPEN ...... 106 hydrocortisone-acetic acid guanfacine...... 41, 53 HUMALOG MIX 75-25(U- ...... 219 guanidine ...... 123 100)INSULN ...... 106 hydrocortisone-aloe vera ... 80 GYNOL II...... 71 HUMALOG U-100 INSULIN HYDROCREAM ...... 79 H ...... 107 Hydromet ...... 226 Hailey ...... 63 humidifiers ...... 141 hydromorphone ...... 1 Hailey 24 Fe ...... 63 HUMIRA ...... 3, 4, 114 hydroxychloroquine ...... 12 Hailey Fe 1.5/30 (28) ...... 63 HUMIRA PEN ...... 114 hydroxyurea ...... 24 Hailey Fe 1/20 (28) ...... 63 HUMIRA PEN CROHNS-UC- hydroxyzine hcl...... 43 HAIR,SKIN AND NAILS .... 85 HS START ...... 3, 4, 114 hydroxyzine pamoate ...... 43 halobetasol propionate ...... 79 HUMIRA PEN PSOR- hyoscyamine sulfate ...... 113 haloperidol...... 52 UVEITS-ADOL HS ...... 3, 4, HYOSYNE ...... 113, 118 haloperidol lactate ...... 52 114 HYPER-SAL ...... 59

238 HYPERSONIQ NEBULIZER INFINITY CONTROL Introvale ...... 64 CARTRIDGE ...... 164, 189 SOLUTION HIGH 133, 189 INVACARE LANCETS ... 133, HYPOLANCE AST LANCING INFINITY CONTROL 191 ...... 133, 189 SOLUTION LOW . 133, 189 INVIRASE ...... 21 HYSINGLA ER ...... 1 INFINITY CONTROL ipratropium bromide 221, 224 I SOLUTION NORM ..... 133, ipratropium-albuterol ...... 222 ibandronate ...... 103 189 irbesartan ...... 35 IBRANCE ...... 25 INFINITY VOICE CTRL irbesartan- Ibu ...... 7 SOLN-LVL 2 ...... 133, 190 hydrochlorothiazide ...... 34 ibuprofen ...... 7 INJECT EASE LANCETS IRESSA ...... 23 ibuprofen-oxycodone ...... 3 ...... 133, 190 ISENTRESS ...... 13 Iclevia ...... 63 INLYTA ...... 28 ISENTRESS HD ...... 13 icosapent ethyl ...... 37, 38 INNOPRAN XL ...... 38 Isibloom ...... 64 IDHIFA ...... 27 INNOSPIRE DELUXE .... 164, isoniazid ...... 16 ILEVRO ...... 215 190 isosorbide dinitrate ...... 35 imatinib ...... 28 INNOSPIRE ELEGANCE 164 isosorbide mononitrate ...... 35 IMBRUVICA ...... 25, 28 INNOSPIRE ESSENCE .. 164 isotretinoin ...... 71 imipramine hcl ...... 50 INNOSPIRE GO isradipine ...... 39 imipramine pamoate ...... 50 NEBULIZER ...... 159, 190 ITCHY EYE DROPS ...... 214 imiquimod ...... 81 INNOSPIRE MINI ...... 164 itraconazole ...... 11 INCARE INVIEW INNOSPIRE IV PREP WIPES...... 30 CATHETER ...... 172 REPLACEMENT FILTER ivermectin ...... 11 Incassia ...... 68 ...... 164, 190 J IN-CHECK DIAL TRAINING INSPIRACHAMBER 164, 190 Jaimiess ...... 61 DEVICE ...... 164, 189 INSPIRACHAMBER WITH JAKAFI ...... 26 IN-CHECK NASAL WITH MASK-LARGE ..... 164, 190 Jantoven ...... 119 MASK ...... 160, 189 INSPIRACHAMBER WITH JANUMET ...... 102 IN-CHECK ORAL FLOW MASK-MED ...... 164, 190 JANUMET XR ...... 102 METER ...... 160, 189 INSPIRACHAMBER WITH JANUVIA ...... 99 INCONTROL ALCOHOL MASK-SMALL ..... 164, 190 JARDIANCE ...... 100 PADS ...... 30 INSPIRATION ELITE FILTER Jasmiel (28) ...... 64 INCONTROL LANCING ...... 164, 190 Jencycla ...... 68 DEVICE ...... 133, 189 insulin syr/ndl u100 half mark Jinteli ...... 103 INCONTROL PEN NEEDLE ...... 148, 190 JOLESSA ...... 64 ...... 148, 189 INSULIN SYRINGE . 148, 190 Juleber ...... 64 INCONTROL SUPER THIN INSULIN SYRINGE JULUCA ...... 13 LANCETS ...... 133, 189 MICROFINE ...... 148, 190 Junel 1.5/30 (21) ...... 64 INCONTROL ULTRA THIN insulin syringe needleless Junel 1/20 (21) ...... 64 LANCETS ...... 133, 189 ...... 148, 190 Junel Fe 1.5/30 (28) ...... 64 INCRELEX ...... 108 insulin syringe-needle u-100 Junel Fe 1/20 (28) ...... 64 INCRUSE ELLIPTA ...... 221 ...... 148, 190 Junel Fe 24 ...... 64 indapamide...... 42 INSUPEN ...... 149, 190 K INDERAL XL ...... 38 INSYTE IV CATHETER .. 158, Kaitlib Fe ...... 64 INDOCIN ...... 7 190 KALETRA ...... 15 indomethacin ...... 7 INTELENCE ...... 14 Kalliga ...... 64 INFANT'S ADVIL ...... 7 INTELLIGENT MESH KALYDECO ...... 223 INFANT'S IBUPROFEN ...... 7 NEBULIZER ...... 159, 190 Kariva (28) ...... 61 INFANT'S MOTRIN ...... 7 INTRON A ...... 26 Kelnor 1/35 (28)...... 64 INFANTS PROFENIB ...... 7 INTROSYTE AUTOGUARD Kelnor 1-50 (28) ...... 64 ...... 158, 191

239 KENGUARD FOLEY LANTUS SOLOSTAR U-100 LIDOCARE ...... 82 CATHETER ...... 172, 191 INSULIN ...... 107 Lillow (28) ...... 65 KENLINE ADD-A-FOLEY LANTUS U-100 INSULIN 107 lindane ...... 82 TRAY 30CC ...... 172, 191 LANZO LANCING DEVICE linezolid ...... 20 ketoconazole ...... 11, 75 ...... 134, 191 LINZESS ...... 115 KETO-DIASTIX ...... 173 lapatinib ...... 22 liothyronine ...... 109 KETONE CARE ...... 173, 191 Larin 1.5/30 (21) ...... 64 lisinopril ...... 33 KETONE URINE TEST ... 191 Larin 1/20 (21) ...... 64 lisinopril-hydrochlorothiazide ketorolac ...... 6, 215 Larin 24 Fe ...... 65 ...... 33 KETOSTIX ...... 191 Larin Fe 1.5/30 (28) ...... 65 LITE COAT ASPIRIN ...... 8 ketotifen fumarate ...... 214 Larin Fe 1/20 (28) ...... 65 LITE TOUCH INSULIN PEN KINERET...... 5 Larissia ...... 65 NEEDLES ...... 149, 191 KIONEX (WITH SORBITOL) latanoprost ...... 218 LITE TOUCH INSULIN ...... 84 LAYOLIS FE ...... 65 SYRINGE ...... 149, 191 KISQALI ...... 25 LC PLUS ...... 159 LITE TOUCH LANCETS 134, KISQALI FEMARA CO-PACK LC PLUS NEBULIZER-PED 191 ...... 26 MASK ...... 159, 191 LITE TOUCH LANCING Klor-Con M10 ...... 85 LEENA 28 ...... 69 DEVICE ...... 134, 191 Klor-Con M15 ...... 85 leflunomide ...... 5 LITE TOUCH-MEDIUM Klor-Con M20 ...... 85 LENVIMA ...... 28 MASK ...... 164, 191 K-PHOS ORIGINAL ...... 117 Lessina ...... 65 LITEAIRE MDI CHAMBER KPN ...... 88 letrozole ...... 24 ...... 164, 192 Kurvelo (28)...... 64 leucovorin calcium ...... 29 LITETOUCH-LARGE MASK L LEUKERAN ...... 23 ...... 164, 192 l norgest/e.estradiol-e.estrad LEUKINE ...... 120 LITETOUCH-SMALL MASK ...... 61 levalbuterol hcl ...... 222 ...... 164, 192 labetalol ...... 34 levetiracetam ...... 47 lithium carbonate ...... 54, 55 LABSTIX REAGENT . 83, 191 levobunolol ...... 216 lithium citrate ...... 55 LACRISERT ...... 212 levocarnitine ...... 83, 208 LITHOBID ...... 55 lactulose ...... 111, 115 levocarnitine (with sugar) 208 LO LOESTRIN FE ...... 61 LAMICTAL...... 46 levofloxacin ...... 18, 217 LO-DOSE ASPIRIN ..... 8, 121 LAMICTAL ODT ...... 46, 54 Levonest (28) ...... 69 LOFRIC ...... 172, 192 LAMICTAL XR ...... 46 levonorgestrel ...... 70 LOFRIC ORIGO ...... 172, 192 lamivudine ...... 14, 15, 18 levonorgestrel-ethinyl estrad LOFRIC PRIMO NELATON lamivudine-zidovudine ...... 16 ...... 65 CATHETER ...... 172 lamotrigine...... 46 levonorg-eth estrad triphasic Lojaimiess ...... 61 lancets ...... 134 ...... 69 LONSURF ...... 24 LANCETS, SUPER THIN 134, Levora-28 ...... 65 lopinavir-ritonavir ...... 15 191 levorphanol tartrate ...... 1 lorazepam ...... 43 LANCETS,THIN ...... 134, 191 levothyroxine ...... 109 Lorazepam Intensol ..... 43, 53 LANCETS,ULTRA THIN 134, LEXIVA ...... 21 Loryna (28) ...... 65 191 LIDO KING ...... 82 losartan ...... 35 lancing device ...... 134 lidocaine ...... 9, 82 losartan-hydrochlorothiazide lancing device with lancets lidocaine hcl ...... 9, 82, 210 ...... 34 ...... 134 lidocaine hcl-hydrocortison ac loteprednol etabonate ...... 215 LANCING DEVICE WITH ...... 9, 81 lovastatin ...... 37 LANCETS ...... 134 LIDOCAINE PAIN RELIEF 82 Low-Ogestrel (28) ...... 65 LANCING SYSTEM 134, 191 Lidocaine Viscous ...... 210 loxapine succinate ...... 52 lansoprazole ...... 112 lidocaine-aloe vera ...... 81 Lo-Zumandimine (28) ...... 65 lanthanum ...... 117 lidocaine-prilocaine ...... 81

240 LUBRICANT EYE (CMC- MAXI-COMFORT INSULIN methamphetamine ...... 55 GLYCERIN) ...... 212 SYRINGE ...... 192 methazolamide ...... 41 LUBRICATING DROPS .. 212 MAXICOMFORT SAFETY methenamine hippurate ..... 20 Lutera (28)...... 65 PEN NEEDLE ...... 150 methenamine mandelate ... 20 Lyleq ...... 68 MAXIDEX ...... 215 methimazole ...... 102 Lyllana ...... 104 MAXIMUM DAILY GREEN 85 methocarbamol...... 124 LYNPARZA ...... 28 MAXI-TUSS AC ...... 226 methotrexate sodium ...... 5 Lyza ...... 68 MAYZENT ...... 212 methotrexate sodium (pf) .. 24 M MAYZENT STARTER PACK methoxsalen ...... 76 MAGELLAN INSULIN ...... 212 methscopolamine ...... 113 SAFETY SYRNG . 149, 192 M-CLEAR WC ...... 226 methyldopa ...... 41 MAGELLAN SYRINGE .. 149, meclizine ...... 110 methyldopa- 192 MEDI-MECLIZINE ...... 110 hydrochlorothiazide ...... 40 MAGIC3 GO INTERMIT MEDIPROXEN ...... 7 methylergonovine ...... 108 CATHETER ...... 172, 192 MEDISENSE ...... 134 methylphenidate hcl ...... 53 MAGIC3 INTERMITTENT MEDISENSE CONTROLS 1- methylprednisolone ...... 105 CATHETER ...... 172, 192 HI 1-LO ...... 134, 192 methyltestosterone ...... 98 malathion ...... 82 MEDISENSE GLUCOSE metipranolol ...... 216 maprotiline...... 50 KETONE ...... 134 metoclopramide hcl ...... 112 Marlissa (28) ...... 65 MEDISENSE MID CONTROL metolazone ...... 42 MARNATAL-F ...... 88 ...... 134 metoprolol succinate ...... 38 MARPLAN ...... 48 MEDISENSE THIN metoprolol ta- MATULANE...... 23 LANCETS ...... 134 hydrochlorothiaz ...... 40 Matzim La...... 39 MEDLANCE PLUS metoprolol tartrate ...... 38 MAVENCLAD (10 TABLET LANCETS ...... 134 metronidazole 13, 72, 81, 227 PACK) ...... 211 MEDLANCE PLUS SPECIAL mexiletine ...... 35 MAVENCLAD (4 TABLET BLADE ...... 134 MIACALCIN ...... 103 PACK) ...... 211 MEDPOINT NORMAL MICRO ELITE MAVENCLAD (5 TABLET CONTROL ...... 134, 193 REPLACEMENT FILTER PACK) ...... 211 MEDROL ...... 104 ...... 165, 193 MAVENCLAD (6 TABLET medroxyprogesterone 60, 108 MICRO THIN LANCETS . 134 PACK) ...... 211 mefloquine ...... 12 MICROAIR MESH MAVENCLAD (7 TABLET megestrol ...... 28, 83 NEBULIZER...... 159 PACK) ...... 211 MEKINIST ...... 26 MICROCHAMBER ...... 165 MAVENCLAD (8 TABLET MEKTOVI ...... 26 MICRODOT HIGH-LOW PACK) ...... 211 meloxicam ...... 6 CONTROL ...... 134, 193 MAVENCLAD (9 TABLET melphalan ...... 23 MICRODOT INSULIN PEN PACK) ...... 211 memantine ...... 60 NEEDLE ...... 150 MAVYRET ...... 18 meperidine ...... 1 MICRODOT NORMAL MAXICOMFORT II PEN meprobamate ...... 43 CONTROL ...... 134 NEEDLE ...... 149, 192 mercaptopurine ...... 24 Microgestin 1.5/30 (21) ...... 65 MAXICOMFORT INSULIN mesalamine ...... 113, 114 Microgestin 1/20 (21) ...... 65 SYRINGE .... 149, 150, 192 MESNEX ...... 29 Microgestin 24 Fe ...... 66 MAXI-COMFORT INSULIN Metadate Er ...... 53 Microgestin Fe 1.5/30 (28) 66 SYRINGE ...... 149 metaproterenol ...... 222 Microgestin Fe 1/20 (28) ... 66 MAXI-COMFORT INSULIN METER-CHECK ...... 134 MICROLET 2 LANCING SYRINGE ...... 150 metformin ...... 107 DEVICE ...... 135, 193 MAXI-COMFORT INSULIN methadone ...... 1 MICROLET LANCET ...... 135 SYRINGE ...... 192 Methadone Intensol ...... 1 MICROLET NEXT LANCING Methadose ...... 1 DEVICE ...... 135, 193

241 MICROLIFE PEAK FLOW MOTION SICKNESS nateglinide ...... 99 METER ...... 160, 193 RELIEF(MECLIZ)...... 110 nebulizer and compressor MICROSPACER ...... 165 MOUTHPIECE ...... 165, 194 ...... 165, 194 midodrine ...... 40 moxifloxacin ...... 18, 217 NEBUPENT ...... 20 MIGERGOT ...... 56 MULTAQ ...... 36 NEBUSAL ...... 59 Mili ...... 66 MULTI-LANCET DEVICE 2 Necon 0.5/35 (28)...... 66 Mimvey ...... 103 ...... 135, 194 nefazodone ...... 48 MINI ELITE FILTER MULTISTIX ...... 83, 194 neomycin ...... 10 REPLACEMENT .. 165, 193 MULTISTIX 10 SG .... 83, 194 neomycin-bacitracin-poly-hc MINI LANCING DEVICE 135, MULTISTIX 5 ...... 83, 194 ...... 213 193 MULTISTIX 7 ...... 83, 194 neomycin-bacitracin- MINI PLUS NEBULIZER 159, MULTISTIX 8 SG ...... 83, 194 polymyxin ...... 216 193 MULTISTIX 9 ...... 83, 194 neomycin-polymyxin b- MINI PRENATAL ...... 88 MULTISTIX 9 SG ...... 83, 194 dexameth ...... 213 MINI ULTRA-THIN II 150, 193 MULTI-VIT WITH neomycin-polymyxin- MINI WRIGHT PEAK FLOW FLUORIDE-IRON ...... 86 gramicidin ...... 217 METER ...... 160 mupirocin ...... 74 neomycin-polymyxin-hc .. 213, Minitran ...... 35 mupirocin calcium ...... 74 218 minocycline ...... 22 MY CHOICE ...... 70, 71 Neo-Polycin ...... 217 minoxidil ...... 41 MY MDI PORTABLE Neo-Polycin Hc...... 213 mirtazapine...... 47 NEBULISER ...... 165, 194 NESTABS ABC ...... 89 misoprostol ...... 112 MY WAY ...... 70, 71 NESTABS DHA ...... 89 MISTASSIST ...... 165, 193 mycophenolate mofetil .... 123 Neuac ...... 72 MISTASSIST KIT .... 165, 193 mycophenolate sodium ... 123 NEULASTA ...... 120 M-NATAL PLUS ...... 88 MYGLUCOHEALTH NEULASTA ONPRO ...... 120 modafinil ...... 56 CONTROL SOLUTION NEUPRO ...... 51 moexipril ...... 33 ...... 135, 194 NEVANAC ...... 215 mometasone ...... 79, 80, 225 MYGLUCOHEALTH nevirapine ...... 14 Mondoxyne Nl ...... 22 LANCETS ...... 135, 194 NEW DAY ...... 70, 71 MONOJECT INSULIN MYLERAN ...... 23 NEWGEN ...... 89 SAFETY SYRING 150, 193 MYNATAL ...... 88 NEXA PLUS ...... 89 MONOJECT INSULIN MYNATAL ADVANCE ...... 88 NEXAVAR ...... 27 SYRINGE ...... 150, 193 MYNATAL PLUS ...... 89 NEXIVA ...... 158, 194 MONOJECT SYRINGE .. 150, MYNATAL-Z ...... 89 NEXLETOL ...... 36 194 MYNATE 90 PLUS ...... 89 NEXLIZET ...... 38 MONOJECT ULTRA Myorisan ...... 71 niacin ...... 37 COMFORT INSULIN .. 150, MYSOLINE ...... 44 NIACIN-AZE AC-TURMER- 194 N FA-B6-ZN ...... 84 MONOLET LANCETS ..... 135 nabumetone ...... 6 Niacor ...... 37 MONOLET THIN LANCETS naftifine ...... 74 nicardipine ...... 40 ...... 135, 194 naloxone ...... 10 nicotine ...... 58 Mono-Linyah ...... 66 naltrexone ...... 10 nicotine (polacrilex) ...... 58 montelukast ...... 220 naproxen ...... 7 NICOTROL ...... 58 morphine ...... 1 naproxen sodium ...... 7 NICOTROL NS ...... 58 morphine concentrate ...... 1 naratriptan ...... 56 nifedipine ...... 40 MOTION RELIEF NASAL ALLERGY ...... 225 NIGHTIME SLEEP .... 57, 220 (MECLIZINE) ...... 110 NATACHEW (FE BIS- NIGHTTIME SLEEP AID MOTION SICKNESS GLYCINATE) ...... 89 (DIPHEN) ...... 57 (MECLIZINE) ...... 110 NATAVI PNV ...... 89 Nikki (28) ...... 66 MOTION SICKNESS II .... 110 NATAVI PRIMA ...... 89, 97 nilutamide ...... 23

242 nimodipine ...... 39 NOVOFINE PLUS ... 151, 195 ofloxacin ...... 18, 217, 219 NINLARO ...... 28 NOVOLIN 70/30 U-100 olanzapine ...... 54 nisoldipine ...... 40 INSULIN ...... 105 olanzapine-fluoxetine ...... 54 NITRO-DUR ...... 35 NOVOLIN 70-30 FLEXPEN olopatadine ...... 214, 224 nitrofurantoin ...... 118 U-100 ...... 105 OMBRA COMPRESSOR nitrofurantoin macrocrystal NOVOLIN N FLEXPEN ... 106 SYSTEM ...... 165, 195 ...... 118 NOVOLIN N NPH U-100 omega-3 acid ethyl esters . 38 nitrofurantoin monohyd/m- INSULIN ...... 106 omeprazole ...... 112 cryst ...... 118 NOVOLIN R FLEXPEN ... 106 ON CALL EXPRESS nitroglycerin ...... 35 NOVOLIN R REGULAR U- CONTROL ...... 135, 195 Nitro-Time ...... 35 100 INSULN ...... 106 ON CALL LANCET .. 135, 195 NIVA-PLUS ...... 86, 89 NOVOLOG FLEXPEN U-100 ON CALL LANCING DEVICE nizatidine ...... 112 INSULIN ...... 107 ...... 135, 195 NOBLE FORMULA HC ..... 80 NOVOLOG MIX 70-30 U-100 ON CALL PLUS CONTROL NORA-BE ...... 68 INSULN ...... 106 ...... 135, 195 NORDITROPIN FLEXPRO NOVOLOG MIX 70- ON CALL PLUS LANCET ...... 105 30FLEXPEN U-100...... 107 ...... 135, 195 noreth-ethinyl estradiol-iron NOVOLOG PENFILL U-100 ON CALL PLUS LANCING ...... 66 INSULIN ...... 107 DEVICE ...... 135, 195 norethindrone (contraceptive) NOVOLOG U-100 INSULIN ON CALL VIVID CONTROL ...... 68 ASPART ...... 107 ...... 135, 195 norethindrone acetate ..... 108 NOVOTWIST ...... 151, 195 ondansetron ...... 110 norethindrone ac-eth NOXAFIL ...... 11 ondansetron hcl ...... 110 estradiol ...... 66, 103 NP THYROID ...... 109 ONE DAILY PRENATAL ... 90 norethindrone-e.estradiol-iron NUBEQA ...... 24 ONE WAY VALVED ...... 66 NUCALA ...... 221 MOUTHPIECE ...... 165 norgestimate-ethinyl estradiol NUCYNTA ER ...... 1 ONE-A-DAY PRENATAL-1 90 ...... 66, 69 NUEDEXTA ...... 57 ONETOUCH DELICA LANC Norlyda ...... 68 Nyamyc ...... 75 DEVICE ...... 135, 195 NORPACE CR ...... 35 Nylia 7/7/7 (28) ...... 69 ONETOUCH DELICA Nortrel 0.5/35 (28) ...... 66 Nymyo ...... 66 LANCETS ...... 135, 195 NORTREL 1/35 (21) ...... 66 nystatin ...... 11, 75, 209 ONETOUCH DELICA PLUS Nortrel 1/35 (28) ...... 66 nystatin-triamcinolone ...... 75 LANCET ...... 135, 195 Nortrel 7/7/7 (28) ...... 69 Nystop ...... 75 ONETOUCH SURESOFT nortriptyline...... 50 O LANCING DEV .... 136, 195 NORVIR ...... 21 OB COMPLETE PREMIER ONETOUCH ULTRA NOSE CLIP ...... 165, 194 ...... 85, 89 CONTROL ...... 136 NO-STICK GLUCOSE ... 173, OB COMPLETE WITH DHA ONETOUCH ULTRASOFT 194 ...... 89 LANCETS ...... 136, 195 NOVA MAX GLUCOSE OBSTETRIX DHA ...... 89 ONETOUCH VERIO HIGH CONTROL ...... 135, 194 OBSTETRIX EC ...... 90 CONTROL ...... 136, 195 NOVA SAFETY LANCETS OBSTETRIX ONE ...... 86 ONETOUCH VERIO MID ...... 135 OBTREX DHA (WITH CONTROL ...... 136, 195 NOVA SUREFLEX QUATREFOLIC) ...... 90 ON-THE-GO LANCETS .. 136 LANCETS ...... 135, 194 O-CAL PRENATAL ...... 90 OPCICON ONE-STEP 70, 71 NOVAMAX PLUS GLU-KET OCELLA ...... 66 opium tincture ...... 109 ...... 135, 194 octreotide acetate ...... 108 OPSUMIT ...... 42 NOVOFINE 32 ...... 150, 194 ODEFSEY ...... 16 OPTICHAMBER ADULT NOVOFINE AUTOCOVER ODOMZO ...... 25 MASK-LARGE ..... 165, 195 ...... 151, 194 OFEV ...... 28, 226

243 OPTICHAMBER DIAMOND PARI SINUS AEROSOL Periogard ...... 209 LG MASK...... 165, 195 SYSTEM ...... 166, 196 permethrin ...... 82 OPTICHAMBER DIAMOND PARI TREK S COMBO perphenazine ...... 52 VHC ...... 165, 195 PACK ...... 166, 196 perphenazine-amitriptyline 49 OPTICHAMBER DIAMOND- PARI TREK S COMPACT PERRY PRENATAL ...... 90 MED MSK ...... 165, 195 COMPRESSOR ... 166, 196 PERSONAL BEST FULL OPTICHAMBER DIAMOND- PARI TREK S PORTABLE RANGE ...... 160, 197 SML MASK ...... 165, 196 PWR KIT ...... 166, 196 PERSONAL BEST LOW OPTION-2 ...... 71 paricalcitol ...... 208 RANGE ...... 160, 197 OPTUMRX ...... 136, 196 Paroex Oral Rinse ...... 209 PERSONAL CATHETER ORACIT ...... 117 paromomycin ...... 10 INTERMITTENT .. 172, 197 Oralone ...... 210 paroxetine hcl ...... 48 PFLEX INSPIRATORY ORKAMBI...... 223, 224 PEAK AIR PEAK FLOW TRAINER ...... 166, 197 orphenadrine-asa-caffeine METER ...... 160, 196 PHARBEDRYL ...... 219 ...... 123 PEDIA IRON ...... 85 phenazopyridine ...... 118 Orphengesic Forte ...... 124 PEDIATRIC AEROSOL phenelzine ...... 48 Orsythia ...... 66 MASK ...... 166, 196 phenobarbital ...... 57 OSCIMIN ...... 113, 118 PEDIATRIC BEAR phenoxybenzamine ...... 42 OSCIMIN SL ...... 113, 118 NEBULIZER ...... 166, 196 phenylephrine hcl ...... 216 OSCIMIN SR ...... 113, 118 PEDIATRIC COMP-AIR Phenytek ...... 45 oseltamivir ...... 19 COMPRES NEB .. 166, 196 phenytoin ...... 45 OSMOPREP ...... 115 PEDIATRIC DINOSAUR phenytoin sodium extended OVACE PLUS SHAMPOO 76 NEBULIZER ...... 166, 196 ...... 45 oxandrolone ...... 98 PEDIATRIC DOG Philith ...... 67 oxazepam...... 43 NEBULIZER ...... 166, 196 PHOSLYRA ...... 116, 117 oxcarbazepine ...... 46 PEDIATRIC FE-VITE ...... 85 PHOSPHOLINE IODIDE . 212 oxiconazole ...... 75 PEDIATRIC FROG phytonadione (vitamin k1) . 98 OXISTAT ...... 75 NEBULIZER ...... 166, 196 PIKO 1 ...... 160, 197 oxybutynin chloride ...... 118 PEDIATRIC MEDIUM MASK PILLOW MASK CHILD ... 166, oxycodone ...... 2 ...... 166, 196 197 oxycodone-acetaminophen . 3 PEDIATRIC MOUTHPIECES PILLOW MASK PEDIATRIC oxycodone-aspirin ...... 3 ...... 159, 196 ...... 166, 197 OXYCONTIN ...... 2 PEDIATRIC PANDA MASK pilocarpine hcl ...... 210, 213 P ...... 166, 197 pimecrolimus ...... 77 Pacerone ...... 36 PEDIATRIC SMALL MASK pimozide ...... 52 paliperidone...... 51 ...... 166, 197 Pimtrea (28) ...... 61 PANCREAZE ...... 111 PEDIATRIC-SMALL MOUTH pioglitazone ...... 108 PANDA MASK ...... 165 ADAPTOR ...... 159 pioglitazone-glimepiride ... 101 pantoprazole ...... 112 peg 3350-electrolytes ...... 115 pioglitazone-metformin .... 101 PARI BABY CONV KIT - PEGASYS ...... 18 PIP LANCET ...... 136, 197 SIZE 1 ...... 165, 196 peg-electrolyte soln ...... 116 PIQRAY ...... 27 PARI BABY CONV KIT - PEGINTRON ...... 18 Pirmella ...... 67, 69 SIZE 2 ...... 165, 196 PEN NEEDLE ...... 151 piroxicam ...... 6 PARI BABY CONV KIT - pen needle, diabetic 151, 197 PLEGRIDY ...... 210 SIZE 3 ...... 165, 196 penicillamine ...... 5, 9 PNEUMOVAX-23 ...... 31 PARI LC SPRINT penicillin v potassium ...... 21 pnv cmb#95-ferrous NEBULIZER SET 159, 196 pentazocine-naloxone ...... 3 fumarate-fa ...... 90 PARI LC SPRINT SINUS 159, PENTIPS ...... 151 PNV-DHA + DOCUSATE .. 90 196 pentoxifylline ...... 120 PNV-FERROUS perindopril erbumine ...... 34 FUMARATE-DOCU-FA . 90

244 PNV-SELECT ...... 90 PRENAISSANCE ...... 91 PREVENT DROPSAFE PEN POCKET CHAMBER ...... 166 PRENAISSANCE PLUS .... 91 NEEDLE ...... 151, 197 POCKET PEAK FLOW PRENATA ...... 91 PREVIDENT ...... 209 METER ...... 160, 197 PRENATABS FA ...... 91 Previfem ...... 67 PODOCON...... 81 PRENATABS RX ...... 91 PREVYMIS ...... 17 podofilox ...... 81 PRENATAL ...... 92, 97 PREZCOBIX ...... 15, 21 Polycin ...... 217 PRENATAL + DHA ...... 91 PREZISTA ...... 21 polymyxin b sulf-trimethoprim PRENATAL 19 ...... 91 PRIFTIN ...... 16 ...... 217 PRENATAL 19 (WITH primaquine ...... 12 polyvinyl alcohol ...... 212 DOCUSATE) ...... 91 PRIMEAIRE ...... 166, 197 PORTABLE NEBULIZER PRENATAL COMPLETE ... 91 primidone ...... 44 SYSTEM ...... 166, 197 PRENATAL FORMULA ..... 92 PRO COMFORT ALCOHOL Portia 28 ...... 67 PRENATAL FORMULA-DHA PADS ...... 30 posaconazole ...... 11 ...... 92 PRO COMFORT INSULIN potassium chloride ...... 85 PRENATAL GUMMIES ..... 97 SYRINGE .... 151, 197, 198 potassium citrate ...... 117 PRENATAL GUMMY...... 92 PRO COMFORT LANCET PR NATAL 400 ...... 90 PRENATAL LOW IRON .... 92 ...... 136, 198 PR NATAL 400 EC ...... 90 PRENATAL MULTI ...... 92 PRO COMFORT PEN PR NATAL 430 ...... 91 PRENATAL MULTI-DHA NEEDLE ...... 151, 198 PR NATAL 430 EC ...... 90 (ALGAL OIL) ...... 92 PRO COMFORT SPACER- PRADAXA ...... 122 PRENATAL MULTI- ADULT MASK ...... 166, 198 pramipexole...... 51 DHA(WITH VIT K)...... 92 PRO COMFORT SPACER- PRAMOSONE ...... 81 PRENATAL CHILD MASK ...... 166, 198 prasugrel ...... 121 MULTIVITAMINS ...... 92 probenecid ...... 119 pravastatin...... 37 PRENATAL ONE DAILY ... 92 probenecid-colchicine ...... 119 prazosin ...... 42 PRENATAL PLUS ...... 93 PROCARE COMPRESSOR PRECISION GLUCOSE PRENATAL PLUS NEBULIZER...... 167, 198 CONTROL SOLN 136, 197 (CALCIUM CARB) ...... 92 PROCARE HUMIDIFIER 141, PRECISION PRENATAL PLUS DHA .... 93 198 GLUCOSE/KETONE PRENATAL TABLET ...... 93 PROCARE PEDIATRIC CONTR ...... 136, 197 PRENATAL VITAMIN ...... 93 NEBULIZER...... 167 PRECISION XTRA B- PRENATAL VITAMIN PLUS PROCARE SPACER WITH KETONE ...... 82, 197 LOW IRON ...... 93 ADULT MASK ...... 167, 198 PRECISION XTRA PRENATAL VITAMIN WITH PROCARE SPACER WITH MONITOR ...... 136, 197 MINERALS ...... 93 CHILD MASK ...... 167, 198 PRECISION XTRA TEST 124 prenatal vit-iron fum-folic ac PROCHAMBER...... 167, 198 PRED-G ...... 213 ...... 93 prochlorperazine...... 110 prednicarbate ...... 80 prenatal vits96-iron fum-folic prochlorperazine maleate .. 52 prednisolone...... 105 ...... 93 Proctofoam Hc...... 9 prednisolone acetate ...... 215 PRENATAL WITH DHA- Procto-Med Hc ...... 9, 80 prednisolone sodium FOLIC ACID ...... 93 Procto-Pak ...... 9, 80 phosphate ...... 105, 215 PRENATE ELITE ...... 93 Proctosol Hc ...... 9, 80 prednisone ...... 105 PREPARATION H Proctozone-Hc...... 9 pregabalin ...... 44 HYDROCORTISONE .... 80 PROCYSBI ...... 116 PREMARIN ...... 104, 227 PREPLUS ...... 93 PRODIGY CONTROL PREMPHASE ...... 104 PRESSURE ACTIVATED SOLUTION, LOW ...... 136 PREMPRO ...... 104 LANCETS ...... 136, 197 PRODIGY CONTROL PRENA1 CHEW ...... 91 PRETAB ...... 93 SOLUTION,HIGH 136, 198 PRENA1 PEARL ...... 91 Prevalite ...... 37 PRODIGY INSULIN PRENA1 TRUE ...... 91 SYRINGE ...... 151, 198

245 PRODIGY LANCETS ..... 136, PURE COMFORT SAFETY RELIAMED MINI LANCING 198 LANCETS ...... 136, 199 DEVICE ...... 137, 199 PRODIGY LANCING PUREAIR MINI NEBULIZER RELIAMED SAFETY SEAL DEVICE ...... 136, 198 ...... 167, 199 LANCETS ...... 137, 199 PRODIGY MINI-MIST PURECOMFORT PEAK RELIAMED TWIST AND NEBULIZER ...... 159 FLOW METER ...... 160 CAP LANCET ...... 137, 199 PRODIGY TWIST TOP PUSH BUTTON SAFETY RELION NEEDLES . 152, 199 LANCET ...... 136 LANCETS ...... 136, 199 RELION PEN NEEDLES 152, progesterone micronized . 108 pyrazinamide ...... 16 199 PROGRAF ...... 122 pyridostigmine bromide ... 123 RELION THIN LANCETS137, PROLENSA...... 215 pyrimethamine ...... 12 199 PROLEUKIN ...... 26 Q RELION ULTRA THIN PLUS PROMACTA ...... 122 quetiapine ...... 54 LANCETS ...... 137, 199 promethazine .. 110, 219, 220 quinapril ...... 34 RELISTOR ...... 10 Promethazine Vc ...... 219 quinapril-hydrochlorothiazide repaglinide ...... 99 Promethazine Vc-Codeine ...... 33 REPATHA SURECLICK .... 36 ...... 225 quinidine gluconate ...... 35 REPATHA SYRINGE ...... 36 promethazine-codeine ..... 225 quinidine sulfate ...... 35 REPLACEMENT J-4 promethazine-dm ...... 225 quinine sulfate ...... 12 CANNULA ...... 159, 199 promethazine-phenyleph- QUIT 2 ...... 58 RESTASIS ...... 215 codeine ...... 225 QUIT 4 ...... 58 RESTASIS MULTIDOSE . 215 promethazine-phenylephrine R RETACRIT ...... 120 ...... 219 raloxifene ...... 108 RETRACTED PENIS Promethegan ... 110, 219, 220 ramelteon ...... 55 POUCH ...... 172 PRONEB ULTRA FILTER ramipril ...... 34 REUSABLE NEBULIZER KIT SET ...... 167, 198 ranolazine ...... 35 ...... 167 PRONEB ULTRA II FILTER rasagiline ...... 51 REVLIMID ...... 29 ASSEM ...... 167, 198 READYLANCE SAFETY REYATAZ ...... 21 propafenone ...... 35 LANCETS ...... 136, 199 REYVOW ...... 56 proparacaine ...... 216 REBIF (WITH ALBUMIN) 210 ribavirin ...... 19 propranolol ...... 39 REBIF REBIDOSE ...... 210 RIDAURA ...... 5 propranolol- REBIF TITRATION PACK 211 rifabutin ...... 16, 22 hydrochlorothiazid ...... 42 Reclipsen (28) ...... 67 rifampin ...... 16 propylthiouracil ...... 102 RECOMBIVAX HB (PF) .... 30 RIGHTEST CONTROL protriptyline...... 50 REFRESH DIGITAL PF ... 212 SOLUTION HIGH 137, 199 PROVIDA OB ...... 93 REFRESH OPTIVE RIGHTEST CONTROL PULMO-AIDE ADVANCED (PF) ...... 212 SOLUTION NORM ..... 137, COMPRESSOR ...... 167 REFRESH OPTIVE MEGA-3 199 PULMONEB LT (PF) ...... 212 RIGHTEST GC250S CNTRL COMPRESSOR NEBUL REFRESH OPTIVE SOL NORM...... 137, 199 ...... 167, 198 SENSITIVE (PF) ...... 212 RIGHTEST GD500 PULMOZYME ...... 224 REFRESH RELIEVA ...... 212 LANCING DEVICE ..... 137, PURE COMFORT ALCOHOL REFUAH PLUS GLUCOSE 199 PADS ...... 30 CONTROL ...... 137, 199 RIGHTEST GL300 PURE COMFORT REGENECARE HA ...... 82 LANCETS ...... 137, 199 HUMIDIFIER ...... 141, 198 REGRANEX ...... 82 RIGHTEST GT333 LEV 2 PURE COMFORT LANCETS RELENZA DISKHALER .... 19 CTRL SOLN...... 137, 199 ...... 136, 198 RELIAMED LANCET ...... 137, riluzole ...... 123 PURE COMFORT PEN 199 rimantadine ...... 19 NEEDLE ...... 151, 199 RINVOQ ...... 5

246 risedronate ...... 103 SECONAL SODIUM ...... 57 SILICONE MASK - INFANT risperidone ...... 51, 52 SECURESAFE PEN ...... 167, 200 RITEFLO AEROCHAMBER NEEDLE ...... 152 SILICONE MASK - ...... 167, 200 SELECT-OB ...... 94 PEDIATRIC...... 167, 200 ritonavir ...... 21 SELECT-OB (FOLIC ACID) silver sulfadiazine ...... 77 rivastigmine ...... 59 ...... 94 SIMILAC PRENATAL ...... 94 rivastigmine tartrate ...... 59 SELECT-OB + DHA ...... 94 Simliya (28) ...... 61 rizatriptan ...... 56 selegiline hcl ...... 51 Simpesse ...... 61 R-NATAL OB ...... 94 selenium sulfide ...... 76 simvastatin ...... 37 ROBINSON CLEAR VINYL SELF-CATH ...... 172, 200 SINGLE-LET ...... 137, 200 CATHETER ...... 172, 200 SELF-CATH 10 ...... 172 SINUSTAR AEROSOL .... 167 ROB-NEL URETHRAL SELF-CATHETER, FEMALE SINUSTAR NEBULIZER 160, CATHETER ...... 172, 200 ...... 172, 200 200 ropinirole ...... 51 SELSUN BLUE ...... 76 sirolimus ...... 123 Rosadan ...... 72, 81 SELSUN BLUE SIVEXTRO ...... 21 ROSANIL ...... 72 MOISTURIZING ...... 77 SKIN TREATMENT ...... 77 ROSULA CLEANSING SELZENTRY ...... 13 SKYRIZI ...... 73, 74 CLOTHS ...... 72 SEMGLEE U-100 INSULIN SLEEP AID rosuvastatin ...... 37 ...... 107 (DIPHENHYDRAMINE) . 57 RUBBER MOUTHPIECE 167, SE-NATAL 19 CHEWABLE SLEEP AID MAX STR 200 ...... 94 (DIPHENHYDR) ...... 57 RUBRACA...... 28 SE-NATAL-19 ...... 94 SLEEPING ...... 57 rufinamide ...... 47 SEREVENT DISKUS...... 221 SMART SENSE LANCETS RUKOBIA ...... 13 sertraline ...... 48 ...... 137, 200 RYDEX ...... 225 Setlakin ...... 67 SMARTDIABETES RYTARY ...... 50 sevelamer carbonate ...... 117 VANTAGE ...... 137, 200 S SF ...... 209 SMARTEST CONTROL . 137, SAFELET IV CATHETER 158 SF 5000 PLUS ...... 209 200 SAFESNAP INSULIN Sharobel ...... 68 SMARTEST LANCET ..... 137, SYRINGE ...... 152 SHINGRIX (PF) ...... 33 200 SAFETY LANCETS . 137, 200 SHINGRIX GE ANTIGEN sodium chloride ...... 59, 84 SAFETY PEN NEEDLE .. 152 COMPONENT ...... 33 SODIUM FLUORIDE 5000 SAFETY SEAL LANCETS SHOHL'S MODIFIED ...... 117 DRY MOUTH ...... 209 ...... 137 SIDESTREAM ...... 159 SODIUM FLUORIDE 5000 SAFETY-LET LANCETS 137, SIDESTREAM ADULT FACE PLUS ...... 209 200 MASK ...... 167, 200 sodium phenylbutyrate .... 208 salicylic acid ...... 81 SIDESTREAM MASK ...... 167 SODIUM POLYSTYRENE SALONPAS (LIDOCAINE) 82 SIDESTREAM NEBULIZER (SORB FREE)...... 84 salsalate ...... 8 ...... 159 sodium polystyrene sulfonate SAMI THE SEAL ..... 167, 200 SIDESTREAM PEDIATRIC ...... 84 SAMI THE SEAL FILTER FACE MASK ...... 167 SOFT TOUCH LANCETS ...... 167, 200 SIDESTREAM PLUS...... 160, ...... 137, 200 SAMI THE SEAL MASK . 167, 200 solifenacin ...... 118 200 SIGNIFOR ...... 108 SOLUS V2 CONTROL SANDIMMUNE ...... 5, 123 SILASTIC FOLEY SOLUTION, LOW 137, 200 SANTYL ...... 77 CATHETER ...... 172, 200 SOLUS V2 CONTROL SAVELLA ...... 49, 55 sildenafil (pulm.hypertension) SOLUTION,HIGH 138, 200 scopolamine base ...... 109 ...... 43 SOLUS V2 LANCETS .... 138, SEA-CLENS WOUND SILICONE MASK ...... 167 200 CLEANSER ...... 116

247 SOLUS V2 LANCING Sronyx ...... 67 SURE COMFORT LANCING DEVICE ...... 138, 201 SSD ...... 77 PEN ...... 138, 202 SOMAVERT ...... 105 SSKI ...... 84 SURE COMFORT PEN SOOTHENEB SSS 10-5 ...... 72, 74 NEEDLE ...... 152, 202 COMPRESSOR ST JOSEPH ASPIRIN ...... 9 SURE-FINE PEN NEEDLES NEBULIZER ...... 168, 201 ST. JOSEPH ASPIRIN ...... 9 ...... 152 SOOTHENEB MESH stavudine ...... 15 SUREFLEX DEVICE WITH NEBULIZER ...... 160, 201 STERILANCE TL .... 138, 201 LANCETS ...... 138, 202 SOOTHENEB NBL100 STERILE SALINE ...... 84 SUREFLEX LANCING ADULT MASK ...... 168, 201 STIOLTO RESPIMAT...... 222 DEVICE ...... 138, 202 SOOTHENEB NBL100 STIVARGA ...... 27 SURE-JECT INSULIN CHILD MASK ...... 168, 201 STOP SMOKING AID...... 58 SYRINGE ...... 153, 202 SOOTHENEB NBL100 MED STRIBILD ...... 15 SURE-LANCE ...... 138, 202 CUP ...... 168, 201 STRIVERDI RESPIMAT .. 221 SURE-LANCE ULTRA THIN SOOTHENEB NBL100 STUART ONE ...... 94 ...... 138 MESH CAP ...... 168, 201 Subvenite ...... 47 SURE-PREP ALCOHOL SOOTHING CARE sucralfate ...... 116 PREP PADS ...... 30 (HYDROCORTISONE) .. 80 sulfacetamide sodium 76, 217 SURE-TEST EASYPLUS Sorine ...... 36 sulfacetamide sodium (acne) MINI ...... 138 sotalol ...... 36 ...... 72 SURE-TOUCH LANCET 138, Sotalol Af ...... 36 sulfacetamide sodium-sulfur 202 SOVALDI ...... 19 ...... 72, 73 SUTENT ...... 28 SPACE CHAMBER . 168, 201 sulfacetamide sod-sulfur-urea Syeda ...... 67 SPACE CHAMBER PLUS ...... 73, 81 SYMDEKO ...... 224 ...... 168, 201 sulfacetamide-prednisolone SYMPAZAN ...... 44 SPACE CHAMBER WITH ...... 213 SYNAREL ...... 108 LARGE MASK ..... 168, 201 SULFACLEANSE 8-4 ...... 73 SYNJARDY ...... 99 SPACE CHAMBER WITH sulfadiazine ...... 22 SYNJARDY XR ...... 100 MEDIUM MASK ... 168, 201 sulfamethoxazole- T SPACE CHAMBER WITH trimethoprim ...... 11 TABLOID ...... 24 SMALL MASK ...... 168, 201 SULFAMYLON ...... 77 tacrolimus ...... 77, 123 SPEEDICATH (FEMALE) sulfasalazine ...... 114 tadalafil ...... 83 ...... 172, 201 SULFATRIM ...... 11 tadalafil (pulm. hypertension) SPEEDICATH (MALE) ... 172, sulindac ...... 6 ...... 43 201 sumatriptan ...... 56 TAFINLAR ...... 25 spinosad ...... 82 sumatriptan succinate ...... 56 TAGRISSO ...... 23 SPIRIT EXT CATHETER SUNRISE COMPRESSOR- TAKE ACTION ...... 71 TYPE 3 ...... 173, 201 NEBULIZER ...... 168, 201 tamoxifen ...... 29 SPIRIT STYLE-3 ..... 173, 201 SUPER THIN LANCETS 138, tamsulosin ...... 117 SPIRIVA RESPIMAT ...... 221 201 TARGRETIN ...... 76 SPIRIVA WITH SUPRAX ...... 17 Tarina 24 Fe ...... 67 HANDIHALER ...... 221 SURE COMFORT ALCOHOL Tarina Fe 1/20 (28) ...... 67 spironolactone ...... 34 PREP PADS ...... 30 Tarina Fe 1-20 Eq (28) ...... 67 spironolacton- SURE COMFORT INS. SYR. TARON-PREX PRENATAL- hydrochlorothiaz ...... 42 U-100 ...... 152, 201 DHA ...... 86, 94 SPLASH SHIELD FLEX .. 159 SURE COMFORT INSULIN TASIGNA ...... 28 Sprintec (28)...... 67 SYRINGE .... 152, 201, 202 Taztia Xt ...... 39 SPRYCEL ...... 28 SURE COMFORT LANCETS TD GOLD LEVEL 1 Sps (With Sorbitol) ...... 84 ...... 138, 202 CONTROL ...... 138 SPS (WITH SORBITOL) ... 84

248 TD GOLD LEVEL 2 THRIVITE-19 ...... 86, 95 TRAVEL-EASE (MECLIZINE) CONTROL ...... 138 THYROLAR-1 ...... 109 ...... 110 TD GOLD LEVEL 3 THYROLAR-1/2 ...... 109 travoprost ...... 218 CONTROL ...... 138 THYROLAR-1/4 ...... 109 trazodone ...... 48 TECHLITE INSULIN SYR THYROLAR-2 ...... 109 TRECATOR ...... 16 HALF UNIT ...... 153 THYROLAR-3 ...... 109 tretinoin ...... 73 TECHLITE INSULIN Tiadylt Er ...... 39 tretinoin (antineoplastic) .... 28 SYRINGE ...... 153 tiagabine ...... 45 TREXALL ...... 5, 24 TECHLITE LANCETS ..... 138 TIBSOVO ...... 27 Tri Femynor ...... 69 TECHLITE PEN NEEDLE 153 Tilia Fe ...... 69 triamcinolone acetonide ... 80, TEGRETOL ...... 46, 54 timolol maleate ...... 216 210, 225 TEGRETOL XR ...... 46, 54 tinidazole ...... 13 triamterene ...... 41 TELCARE CONTROL .... 138, TIVICAY ...... 13 triamterene- 202 TIVICAY PD ...... 13 hydrochlorothiazid ...... 42 TELCARE LANCETS ..... 138, tizanidine ...... 124 triazolam ...... 57 202 TOBI PODHALER ...... 223 TRICARE ...... 95 temazepam ...... 57 TOBRADEX ...... 213 Triderm ...... 80 temozolomide ...... 23 tobramycin ...... 217, 223 Tri-Estarylla ...... 69 TENDERA-OB ...... 94 tobramycin in 0.225 % nacl trifluoperazine ...... 52 tenofovir disoproxil fumarate ...... 223 trifluridine ...... 218 ...... 15 tobramycin with nebulizer 223 trihexyphenidyl ...... 51 terazosin ...... 42 tobramycin-dexamethasone Tri-Legest Fe ...... 69 terbinafine hcl ...... 11 ...... 213 Tri-Linyah ...... 69 terbutaline ...... 222 TODAY CONTRACEPTIVE Tri-Lo-Estarylla ...... 69 terconazole...... 226 SPONGE ...... 71 Tri-Lo-Marzia ...... 69 teriparatide ...... 103 TOLAK ...... 75 Tri-Lo-Mili ...... 69 TERUMO INSULIN tolmetin ...... 6 Tri-Lo-Sprintec...... 69 SYRINGE .... 153, 202, 203 tolterodine ...... 118, 119 Trilyte With Flavor Packets testosterone ...... 98, 99 TOPCARE CLICKFINE .. 154, ...... 116 testosterone cypionate ...... 98 203 trimethobenzamide ...... 110 tetrabenazine ...... 56 TOPCARE ULTRA trimethoprim ...... 11 tetracycline ...... 22 COMFORT ...... 154, 203 Tri-Mili ...... 69 THALOMID...... 12 TOPCARE UNIVERSAL1 trimipramine ...... 50 Theochron ...... 220 LANCET ...... 138, 203 TRINATE ...... 95 theophylline ...... 220, 221 topiramate ...... 46 TRINTELLIX ...... 49 THERANATAL ...... 94 toremifene ...... 29 Tri-Nymyo ...... 70 THERANATAL COMPLETE torsemide ...... 41 TRIPLE ANTIBIOTIC PLUS ...... 94 TOUCH-TROL ...... 173, 203 ...... 74 THERANATAL ONE ...... 94 TOUJEO MAX U-300 Tri-Previfem (28) ...... 70 THERANATAL OVAVITE .. 94 SOLOSTAR ...... 107 Tri-Sprintec (28) ...... 70 THERANATAL PLUS ...... 95 TOUJEO SOLOSTAR U-300 TRIUMEQ ...... 15 THIN LANCETS ...... 138 INSULIN ...... 107 TRIVEEN-DUO DHA ...... 95 THINPRO INSULIN TOVIAZ ...... 119 TRIVEEN-PRX RNF ...... 95 SYRINGE .... 153, 154, 203 tramadol ...... 2 Trivora (28) ...... 70 thioridazine ...... 52 tramadol-acetaminophen ..... 3 Tri-Vylibra ...... 70 thiothixene ...... 52 trandolapril ...... 34 Tri-Vylibra Lo ...... 70 THRESHOLD IMT TRAINER trandolapril-verapamil ...... 33 tropicamide ...... 214 ...... 168, 203 tranexamic acid ...... 121 trospium ...... 119 THRESHOLD PEP DEVICE tranylcypromine ...... 48 TRUE COMFORT ALCOHOL ...... 168, 203 PADS ...... 30

249 TRUE COMFORT INSULIN ULTILET CLASSIC ULTRATRAK NORMAL SYRINGE ...... 154, 203 LANCETS ...... 139, 204 CONTROL ...... 139 TRUE COMFORT LANCET ULTILET INSULIN SYRINGE ULTRATRAK ULTIMATE 139, ...... 138, 203 ...... 155, 204 206 TRUE COMFORT PEN ULTILET LANCETS 139, 204 ULTRAVATE ...... 76 NEEDLE ...... 154, 203 ULTILET PEN NEEDLE . 155, UNIFINE PENTIPS .. 157, 206 TRUE METRIX LEVEL 1 . 138 204 UNIFINE PENTIPS TRUE METRIX LEVEL 2 . 139 ULTILET SAFETY LANCETS MAXFLOW ...... 157 TRUE METRIX LEVEL 3 . 139 ...... 139, 204 UNIFINE PENTIPS PLUS 157 TRUECONTROL LEVEL 0 ULTRA CMFT INS SYR UNIFINE PENTIPS PLUS ...... 139, 204 HALF UNIT ...... 156, 204 MAXFLOW ...... 157 TRUECONTROL LEVEL 1 ULTRA COMFORT INSULIN UNILET COMFORTOUCH ...... 139, 204 SYRINGE .... 156, 204, 205 LANCET ...... 140 TRUEDRAW LANCING ULTRA FINE LANCETS . 139, UNILET EXCELITE II DEVICE ...... 139, 204 205 LANCET ...... 140 TRUEPLUS INSULIN ...... 154 ULTRA FLO INSULIN UNILET EXCELITE LANCET TRUEPLUS KETONE ..... 204 SYRINGE ...... 156, 205 ...... 140 TRUEPLUS LANCETS .. 139, ULTRA FLO PEN NEEDLE UNILET GP LANCET ...... 140 204 ...... 156, 205 UNILET LANCET ...... 140 TRUEPLUS PEN NEEDLE ULTRA PRENATAL PLUS UNILET LANCETS ...... 140 ...... 154 DHA ...... 95 UNILET SUPER THIN TRULICITY...... 101 ULTRA THIN II LANCETS LANCETS ...... 140 TRUNEB NEBULIZER ... 160, ...... 139, 205 UNISOM SLEEPGELS ...... 57 204 ULTRA THIN LANCETS . 139, UNISTIK 2 NORMAL TRUVADA ...... 14 205 LANCET,DEVICE 140, 206 TRUZONE PEAK FLOW ULTRA THIN PEN NEEDLE UNISTIK 3 COMFORT METER ...... 161, 204 ...... 156, 205 LANCET ...... 140, 206 TUKYSA ...... 25 ULTRA THIN PLUS UNISTIK 3 EXTRA LANCET Tulana ...... 68 LANCETS ...... 139, 205 ...... 140 TWIST LANCETS ...... 139 ULTRA TLC LANCETS ... 139 UNISTIK 3 GENTLE ...... 140 TYBLUME ...... 67 ULTRACARE INSULIN UNISTIK 3 LANCETS ..... 140, TYZINE ...... 225 SYRINGE ...... 156, 205 206 U ULTRA-CARE LANCETS UNISTIK 3 NORMAL ULTICARE ...... 155 ...... 139, 205 LANCET ...... 140, 206 ULTICARE INSULIN SYR ULTRACARE PEN NEEDLE UNISTIK CZT LANCET .. 140, HALF UNIT ...... 155 ...... 156, 205 206 ULTICARE INSULIN ULTRALANCE LANCETS UNISTIK PRO LANCET . 140, SYRINGE ...... 155 ...... 139, 205 206 ULTICARE PEN NEEDLE ULTRA-THIN II (SHORT) INS UNISTIK SAFETY ... 140, 206 ...... 155 SYR ...... 156, 157, 205 UNISTIK TOUCH LANCETS ULTICARE SAFETY PEN ULTRA-THIN II (SHORT) ...... 140, 206 NEEDLE ...... 155, 204 PEN NDL ...... 157, 206 UNISTRIP HIGH CONTROL ULTIGUARD SAFEPACK- ULTRA-THIN II INS PEN ...... 140, 206 PEN NEEDLE ...... 155 NEEDLES ...... 157, 206 UNISTRIP LOW CONTROL ULTI-LANCE ...... 139, 204 ULTRA-THIN II INSULIN ...... 140, 206 ULTILET ALCOHOL SWAB SYRINGE ...... 157, 206 UNIVERSAL 1 LANCETS 140 ...... 30 ULTRA-THIN II LANCETS URETHRAL CATHETER 173, ULTILET BASIC LANCETS ...... 139, 206 206 ...... 139, 204 ULTRATRAK HIGH-LOW URINARY PAIN RELIEF . 118 CONTROL ...... 139 URISTIX 4 ...... 83, 206

250 URISTIX REAGENT .. 83, 206 VICTOZA 2-PAK ...... 101 VORTEX HOLDING URO-SAN PLUS ...... 173 VICTOZA 3-PAK ...... 102 CHAMBER ...... 168, 207 ursodiol ...... 111 Vienva ...... 67 VORTEX VHC FROG MASK- V VINACAL B ...... 95 CHILD ...... 168, 207 VAGINAL CONTRACEPTIVE VINATE GT ...... 95 VORTEX VHC LADYBUG FILM ...... 71 VINATE II ...... 95 MASK-TODDLR ... 168, 207 VAGINAL CONTRACEPTIVE VINATE M ...... 95 VOTRIENT ...... 28 FOAM ...... 71 VINATE ONE ...... 95 VP-CH PLUS ...... 96 valacyclovir...... 19 VINATE ULTRA ...... 95 VP-CH-PNV ...... 96 valganciclovir ...... 17 VINYL CATHETER . 173, 207 VP-PNV-DHA ...... 96 valproic acid ...... 44 Viorele (28) ...... 61 Vyfemla (28) ...... 67 valsartan ...... 35 VIOS AEROSOL DELIVERY Vylibra ...... 67 valsartan-hydrochlorothiazide SYSTEM ...... 168 VYVANSE ...... 53 ...... 34 VIRACEPT ...... 21 W vancomycin ...... 18 VIREAD ...... 15, 18 WAL-DRAM 2 ...... 110 VANDAZOLE ...... 227 VIRT-NATE DHA ...... 95 WAL-PROXEN ...... 7 VANICREAM HC ...... 80 VIRTUSSIN AC ...... 226 WAL-SOM VANISHPOINT INSULIN VIRT-VITE ...... 97, 98 (DIPHENHYDRAMINE) . 57 SYRINGE ...... 157, 206 VIRT-VITE PLUS ...... 83 WAL-ZYR (KETOTIFEN) . 214 VANISHPOINT SYRINGE VITAFOL FE+ (WITH warfarin ...... 119 ...... 157 DOCUSATE) ...... 96 WARM STEAM VAPORIZER VAPORIZER CLEANING 168, VITAFOL GUMMIES ...... 96 ...... 173, 207 206 VITAFOL NANO ...... 96 WAVESENSE CONTROL VAPORIZER INHALANT 168, VITAFOL ULTRA ...... 96 SOLUTION ...... 141, 207 207 VITAFOL-OB ...... 96 WEBCOL ...... 30 vaporizers...... 173 VITAFOL-OB+DHA ...... 96 Wera (28) ...... 67 VARUBI ...... 111 VITAFOL-ONE ...... 96 WESTAB PLUS ...... 96 VASCEPA ...... 37, 38 VITAMED MD ONE RX ..... 96 WESTHROID ...... 109 VCF CONTRACEPTIVE Vitamin D2 ...... 98 WIDE-SEAL DIAPHRAGM FILM ...... 71 VITAMIN D3 ...... 98 60 ...... 125, 208 VCF CONTRACEPTIVE GEL VIVA DHA ...... 96 WIDE-SEAL DIAPHRAGM ...... 71 VIVAGUARD INO CTRL 65 ...... 125, 208 Velivet Triphasic Regimen SOLN-L1,2,3 ...... 140, 207 WIDE-SEAL DIAPHRAGM (28) ...... 70 VIVAGUARD INO CTRL 70 ...... 125, 208 VENA-BAL DHA ...... 95 SOLN-L1,L3 ...... 140, 207 WIDE-SEAL DIAPHRAGM VENCLEXTA ...... 24 VIVAGUARD INO CTRL 75 ...... 125, 208 VENCLEXTA STARTING SOLN-L2 ...... 140, 207 WIDE-SEAL DIAPHRAGM PACK ...... 24 VIVAGUARD LANCET ... 140, 80 ...... 125, 208 venlafaxine ...... 49 207 WIDE-SEAL DIAPHRAGM verapamil ...... 36, 40 VIXONE NEBULIZER..... 160, 85 ...... 125, 208 VERASENS CONTROL 207 WIDE-SEAL DIAPHRAGM SOLN-LEVEL 1 ... 140, 207 VIXONE NEBULIZER- 90 ...... 125, 208 VERIFINE PEN NEEDLE 157, ADULT MASK ...... 160, 207 WIDE-SEAL DIAPHRAGM 207 VIXONE NEBULIZER- 95 ...... 125, 208 VERTICALM ...... 110 PEDIATRIC MSK . 160, 207 WILLIS THE WHALE V-GO 20 ...... 169, 207 Volnea (28) ...... 61 COMPRESSR NEB .... 169, V-GO 30 ...... 169, 207 voriconazole ...... 11, 12 208 V-GO 40 ...... 169, 207 VORTEX ADULT MASK . 168, WILZIN ...... 9 VICKS WARM STEAM 207 WINDMILL TRAINER ..... 169, VAPORIZER ...... 173, 207 208

251 WING TIP TUBING . 169, 208 Xylon 10 ...... 2 ziprasidone hcl ...... 54 WOMEN'S PRENATAL Z ZIRGAN ...... 218 PLUS DHA ...... 97 zafirlukast ...... 220 ZOLINZA ...... 26 Wymzya Fe ...... 68 zaleplon ...... 57 zolmitriptan ...... 56 X Zarah ...... 68 zolpidem ...... 57 XALKORI ...... 23 Zarontin ...... 47 zonisamide ...... 47 XARELTO ...... 120 ZARONTIN ...... 47 ZONTIVITY ...... 122 XARELTO DVT-PE TREAT ZARXIO ...... 120 Zovia 1/35E (28) ...... 68 30D START ...... 120 ZELBORAF ...... 25 Zovia 1-35 (28) ...... 68 XELJANZ ...... 5, 114 Zenatane ...... 71 Zumandimine (28) ...... 68 XELJANZ XR ...... 5, 114 Zenzedi ...... 53, 55, 56 ZYDELIG ...... 27 XIGDUO XR ...... 100 ZEPATIER ...... 18 ZYLET ...... 213 XTANDI ...... 24 zidovudine ...... 15 ZYTIGA ...... 22, 24 XULANE ...... 70 ZINGIBER ...... 97

252