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Illinois Medicaid Preferred Drug List

Effective January 1, 2020 (Updated January 27, 2020)

▪ The Preferred Drug List (PDL) has products listed in groups by drug class, drug name, dosage form, and PDL status

▪ Multi-source drugs are listed by both brand and generic names when applicable

▪ ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19 years of age and older

▪ Spiriva AER 1.25mcg: Prior authorization NOT required for participants ages 6-17 years

▪ : Prior authorization NOT required for participants age 7 years and under

▪ Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records

▪ Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents

▪ For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com

Page 1 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES ADZENYS ER SUER NON_PREFERRED AMPHETAMINE ER SUER NON_PREFERRED DYANAVEL XR SUER NON_PREFERRED ADZENYS XR-ODT TBED NON_PREFERRED AMPHETAMINE SULFATE TABS NON_PREFERRED EVEKEO TABS NON_PREFERRED EVEKEO ODT TBDP NON_PREFERRED DEXEDRINE CP24 NON_PREFERRED DEXTROAMPHETAMINE SULFATE ER CP24 NON_PREFERRED DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED PROCENTRA SOLN NON_PREFERRED DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED ZENZEDI TABS NON_PREFERRED VYVANSE CAPS PREFERRED VYVANSE CHEW PREFERRED DESOXYN TABS NON_PREFERRED METHAMPHETAMINE HCL TABS NON_PREFERRED ADDERALL XR CP24 NON_PREFERRED AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED MYDAYIS CP24 NON_PREFERRED ADDERALL TABS NON_PREFERRED AMPHETAMINE/DEXTROAMPHETAMINE TABS PREFERRED ADHD / ANTI-NARCOLEPSY AGENTS : MISC CLONIDINE HCL ER TB12 PREFERRED CLONIDINE HYDROCHLORIDE TB12 PREFERRED CLONIDINE HYDROCHLORIDE ER TB12 PREFERRED GUANFACINE ER TB24 PREFERRED GUANFACINE HYDROCHLORIDE TB24 PREFERRED INTUNIV TB24 NON_PREFERRED ATOMOXETINE CAPS NON_PREFERRED ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED STRATTERA CAPS NON_PREFERRED SUNOSI TABS NON_PREFERRED ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS ARMODAFINIL TABS NON_PREFERRED NUVIGIL TABS NON_PREFERRED DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE CP24 NON_PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED FOCALIN XR CP24 PREFERRED DEXMETHYLPHENIDATE HCL TABS PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED FOCALIN TABS NON_PREFERRED DAYTRANA PTCH NON_PREFERRED COTEMPLA XR-ODT TBED NON_PREFERRED QUILLICHEW ER CHER NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE CHEW NON_PREFERRED ADHANSIA XR CP24 NON_PREFERRED APTENSIO XR CP24 NON_PREFERRED Page 2 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM JORNAY PM CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 NON_PREFERRED RITALIN LA CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE CD CPCR NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER CPCR NON_PREFERRED METHYLIN SOLN NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE SOLN NON_PREFERRED QUILLIVANT XR SUSR NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED RITALIN TABS NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER TB24 NON_PREFERRED METHYLPHENID TAB 10MG ER TBCR PREFERRED METHYLPHENID TAB 20MG ER TBCR PREFERRED CONCERTA TBCR PREFERRED METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED METHYLPHENID TAB 27MG ER TBCR NON_PREFERRED METHYLPHENID TAB 36MG ER TBCR NON_PREFERRED METHYLPHENID TAB 54MG ER TBCR NON_PREFERRED METHYLPHENID TAB 72MG ER TBCR NON_PREFERRED METHYLPHENIDATE HYDROCHLO TBCR NON_PREFERRED RELEXXII TBCR NON_PREFERRED MODAFINIL TABS NON_PREFERRED PROVIGIL TABS NON_PREFERRED ANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURA CAPS NON_PREFERRED OTREXUP SOAJ NON_PREFERRED RASUVO SOAJ NON_PREFERRED ARAVA TABS NON_PREFERRED LEFLUNOMIDE TABS PREFERRED ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI- INFLAMMATORY AGENTS (NSAIDs) ZORVOLEX CAPS NON_PREFERRED ZIPSOR CAPS NON_PREFERRED DICLOFENAC POTASSIUM TABS PREFERRED DICLOFENAC SODIUM ER TB24 PREFERRED DICLOFENAC SODIUM DR TBEC PREFERRED ETODOLAC CAPS PREFERRED ETODOLAC TABS PREFERRED ETODOLAC ER TB24 PREFERRED FENOPROFEN CAPS NON_PREFERRED NALFON CAPS NON_PREFERRED FENOPROFEN CALCIUM TABS NON_PREFERRED NALFON TABS NON_PREFERRED FLURBIPROFEN TABS PREFERRED IBUPROFEN SUSP NON_PREFERRED IBU TABS PREFERRED IBUPROFEN TABS PREFERRED INDOMETHACIN CAPS PREFERRED Page 3 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TIVORBEX CAPS NON_PREFERRED INDOMETHACIN ER CPCR PREFERRED INDOCIN SUPP NON_PREFERRED INDOCIN SUSP NON_PREFERRED KETOPROFEN ER CP24 NON_PREFERRED SPRIX SOLN NON_PREFERRED KETOROLAC TROMETHAMINE TABS PREFERRED MECLOFENAMATE SODIUM CAPS NON_PREFERRED MEFENAMIC ACID CAPS NON_PREFERRED VIVLODEX CAPS NON_PREFERRED MELOXICAM TABS PREFERRED MOBIC TABS NON_PREFERRED QMIIZ ODT TBDP NON_PREFERRED NABUMETONE TABS PREFERRED RELAFEN DS TABS NON_PREFERRED NAPROXEN SUSP PREFERRED NAPROXEN TABS PREFERRED EC-NAPROXEN TBEC NON_PREFERRED NAPROXEN DR TBEC PREFERRED NAPROXEN SODIUM TABS PREFERRED NAPRELAN TB24 NON_PREFERRED NAPROXEN SODIUM TB24 NON_PREFERRED NAPROXEN SODIUM CR TB24 NON_PREFERRED NAPROXEN SODIUM ER TB24 NON_PREFERRED DAYPRO TABS NON_PREFERRED OXAPROZIN TABS NON_PREFERRED FELDENE CAPS NON_PREFERRED PIROXICAM CAPS NON_PREFERRED SULINDAC TABS PREFERRED TOLMETIN SODIUM CAPS NON_PREFERRED TOLMETIN SODIUM TABS NON_PREFERRED CELEBREX CAPS NON_PREFERRED CELECOXIB CAPS PREFERRED INFLAMMACIN THPK NON_PREFERRED ARTHROTEC 50 TBEC NON_PREFERRED ARTHROTEC 75 TBEC NON_PREFERRED DICLOFENAC SODIUM/MISOPROSTOL TBEC NON_PREFERRED DUEXIS TABS NON_PREFERRED VIMOVO TBEC NON_PREFERRED ANALGESICS - NONNARCOTIC DIFLUNISAL TABS PREFERRED SALSALATE TABS PREFERRED BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED ALLZITAL TABS NON_PREFERRED BUPAP TABS NON_PREFERRED BUTALBITAL/ACETAMINOPHEN TABS PREFERRED BUTALBITAL/ACETAMINOPHEN/ CAPS PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS PREFERRED Page 4 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ESGIC CAPS PREFERRED FIORICET CAPS NON_PREFERRED ZEBUTAL CAPS PREFERRED VANATOL LQ SOLN NON_PREFERRED VANATOL S SOLN NON_PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS PREFERRED ESGIC TABS NON_PREFERRED BUTALBITAL/ASPIRIN/CAFFEINE CAPS PREFERRED FIORINAL CAPS NON_PREFERRED BUTALBITAL/ASPIRIN/CAFFEINE TABS PREFERRED ANALGESICS : OPIOID CODEINE SULFATE TABS PREFERRED DURAGESIC PT72 NON_PREFERRED FENTANYL PT72 NON_PREFERRED ACTIQ LPOP NON_PREFERRED FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON_PREFERRED LAZANDA SOLN NON_PREFERRED ABSTRAL SUBL NON_PREFERRED FENTANYL CITRATE TABS NON_PREFERRED FENTORA TABS NON_PREFERRED HYDROCODONE BITARTRATE ER C12A NON_PREFERRED ZOHYDRO ER C12A NON_PREFERRED HYSINGLA ER T24A NON_PREFERRED DILAUDID LIQD NON_PREFERRED HYDROMORPHONE HCL LIQD PREFERRED HYDROMORPHONE HCL SUPP PREFERRED HYDROMORPHONE HCL ER T24A NON_PREFERRED HYDROMORPHONE HYDROCHLORIDE ER T24A NON_PREFERRED DILAUDID TABS NON_PREFERRED HYDROMORPHONE HCL TABS PREFERRED LEVORPHANOL TARTRATE TABS NON_PREFERRED MEPERIDINE HCL SOLN NON_PREFERRED MEPERIDINE HCL TABS NON_PREFERRED METHADONE HCL CONC NON_PREFERRED METHADONE HCL INTENSOL CONC NON_PREFERRED METHADOSE CONC NON_PREFERRED METHADOSE SUGAR-FREE CONC NON_PREFERRED METHADONE HCL SOLN NON_PREFERRED DOLOPHINE TABS NON_PREFERRED METHADONE HCL TABS NON_PREFERRED METHADONE HYDROCHLORIDE TABS NON_PREFERRED METHADONE HCL TBSO NON_PREFERRED METHADOSE TBSO NON_PREFERRED KADIAN CP24 NON_PREFERRED MORPHINE SULFATE ER CP24 NON_PREFERRED MORPHINE SULFATE SOLN PREFERRED MORPHINE SULFATE SUPP PREFERRED MORPHABOND ER T12A NON_PREFERRED Page 5 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MORPHINE SULFATE TABS PREFERRED MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA MS CONTIN TBCR NON_PREFERRED ARYMO ER TBEA NON_PREFERRED MORPHINE SULFATE ER CP24 NON_PREFERRED XTAMPZA ER C12A NON_PREFERRED OXYCODONE HCL CAPS PREFERRED OXYCODONE HYDROCHLORIDE CAPS PREFERRED OXYCODONE HCL CONC PREFERRED OXYCODONE HYDROCHLORIDE CONC PREFERRED OXYCODONE HYDROCHLORIDE SOLN PREFERRED OXYCODONE HCL ER T12A NON_PREFERRED OXYCODONE HYDROCHLORIDE ER T12A NON_PREFERRED OXYCONTIN T12A NON_PREFERRED OXAYDO TABA NON_PREFERRED OXYCODONE HCL TABS PREFERRED OXYCODONE HYDROCHLORIDE TABS PREFERRED ROXICODONE TABS NON_PREFERRED OPANA TABS NON_PREFERRED OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED OXYMORPHONE HYDROCHLORIDE ER TB12 NON_PREFERRED OXYMORPHONE HYDROCHLORIDEER TB12 NON_PREFERRED NUCYNTA TABS NON_PREFERRED NUCYNTA ER TB12 NON_PREFERRED CONZIP CP24 NON_PREFERRED TRAMADOL HCL ER CP24 NON_PREFERRED TRAMADOL HCL TABS PREFERRED ULTRAM TABS NON_PREFERRED TRAMADOL HCL ER TB24 NON_PREFERRED BUPRENORPHINE PTWK NON_PREFERRED BUTRANS PTWK NON_PREFERRED BELBUCA FILM NON_PREFERRED BUTORPHANOL TARTRATE SOLN NON_PREFERRED PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED ANALGESICS : OPIOID COMBINATIONS APADAZ TABS NON_PREFERRED BENZHYDROCODONE/ACETAMINOPHEN TABS NON_PREFERRED ENDOCET TABS PREFERRED NALOCET TABS NON_PREFERRED OXYCODONE/ACETAMINOPHEN TABS PREFERRED PERCOCET TABS NON_PREFERRED PRIMLEV TABS NON_PREFERRED OXYCODONE/ASPIRIN TABS NON_PREFERRED OXYCODONE/IBUPROFEN TABS NON_PREFERRED ACETAMINOPHEN/CODEINE SOLN PREFERRED ACETAMINOPHEN/CODEINE TABS PREFERRED ACETAMINOPHEN/CODEINE PHOSPHATE TABS PREFERRED TYLENOL/CODEINE #3 TABS NON_PREFERRED Page 6 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TYLENOL/CODEINE #4 TABS NON_PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS NON_PREFERRED ASCOMP/CODEINE CAPS PREFERRED BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS PREFERRED FIORINAL/CODEINE #3 CAPS NON_PREFERRED ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPS NON_PREFERRED DVORAH TABS NON_PREFERRED LORTAB ELIX NON_PREFERRED HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN PREFERRED HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS PREFERRED HYDROCODONE/ACETAMINOPHEN TABS PREFERRED LORCET TABS PREFERRED LORCET HD TABS PREFERRED LORCET PLUS TABS PREFERRED NORCO TABS NON_PREFERRED VICODIN ES TABS PREFERRED VICODIN HP TABS PREFERRED HYDROCODONE/IBUPROFEN TABS PREFERRED TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN TABS NON_PREFERRED ULTRACET TABS NON_PREFERRED ANAPHYLAXIS THERAPY AGENTS EPINEPHRINE SOAJ PREFERRED EPIPEN 2-PAK SOAJ NON_PREFERRED EPIPEN-JR 2-PAK SOAJ NON_PREFERRED SYMJEPI SOSY NON_PREFERRED ANORECTAL AGENTS ANUSOL-HC CREA NON_PREFERRED CREA PREFERRED PROCTO-MED HC CREA PREFERRED PROCTO-PAK CREA PREFERRED PROCTOSOL HC CREA PREFERRED PROCTOZONE-HC CREA PREFERRED UCERIS FOAM NON_PREFERRED COLOCORT ENEM PREFERRED CORTENEMA ENEM NON_PREFERRED HYDROCORTISONE ENEM PREFERRED CORTIFOAM FOAM PREFERRED RECTIV OINT NON_PREFERRED LIDOCAINE HCL/HYDROCORTISONE ACETATE CREA NON_PREFERRED LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL NON_PREFERRED ANA-LEX KIT NON_PREFERRED LIDOCAINE HCL/HYDROCORTISONE ACETATE KIT NON_PREFERRED PROCTOFOAM HC FOAM NON_PREFERRED ANTIANXIETY AGENTS : BENZODIAZEPINES ALPRAZOLAM INTENSOL CONC PREFERRED ALPRAZOLAM TABS PREFERRED XANAX TABS NON_PREFERRED ALPRAZOLAM ER TB24 NON_PREFERRED ALPRAZOLAM XR TB24 NON_PREFERRED XANAX XR TB24 NON_PREFERRED Page 7 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ALPRAZOLAM ODT TBDP NON_PREFERRED CHLORDIAZEPOXIDE HCL CAPS PREFERRED CHLORDIAZEPOXIDE HYDROCHLORIDE CAPS PREFERRED CLORAZEPATE DIPOTASSIUM TABS PREFERRED TRANXENE T TABS NON_PREFERRED DIAZEPAM CONC PREFERRED DIAZEPAM INTENSOL CONC PREFERRED DIAZEPAM SOLN PREFERRED DIAZEPAM TABS PREFERRED LORAZEPAM CONC PREFERRED LORAZEPAM INTENSOL CONC PREFERRED ATIVAN TABS NON_PREFERRED LORAZEPAM TABS PREFERRED OXAZEPAM CAPS PREFERRED ANTIANXIETY AGENTS : MISC BUSPIRONE HCL TABS PREFERRED BUSPIRONE HYDROCHLORIDE TABS PREFERRED HYDROXYZINE HCL SYRP PREFERRED HYDROXYZINE HCL TABS PREFERRED HYDROXYZINE HYDROCHLORIDE TABS PREFERRED HYDROXYZINE PAMOATE CAPS PREFERRED VISTARIL CAPS NON_PREFERRED MEPROBAMATE TABS NON_PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ADRENERGIC COMBINATIONS COMBIVENT RESPIMAT AERS NON_PREFERRED IPRATROPIUM BROMIDE/ALBUTEROL SULFATE SOLN PREFERRED DUAKLIR PRESSAIR AEPB NON_PREFERRED BUDESONIDE/FORMOTEROL FUM AERO NON_PREFERRED SYMBICORT AERO PREFERRED BEVESPI AEROSPHERE AERO PREFERRED UTIBRON NEOHALER CAPS NON_PREFERRED ADVAIR DISKUS AEPB NON_PREFERRED AIRDUO RESPICLICK 113/14 AEPB NON_PREFERRED AIRDUO RESPICLICK 232/14 AEPB NON_PREFERRED AIRDUO RESPICLICK 55/14 AEPB NON_PREFERRED /SALMETEROL AEPB NON_PREFERRED FLUTICASONE PROPIONATE/SALMETEROL DISKUS AEPB NON_PREFERRED WIXELA INHUB AEPB PREFERRED ADVAIR HFA AERO NON_PREFERRED BREO ELLIPTA AEPB NON_PREFERRED DULERA AERO PREFERRED STIOLTO RESPIMAT AERS NON_PREFERRED ANORO ELLIPTA AEPB NON_PREFERRED TRELEGY ELLIPTA AEPB NON_PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ANTICHOLINERGICS TUDORZA PRESSAIR AEPB NON_PREFERRED SEEBRI NEOHALER CAPS NON_PREFERRED LONHALA MAGNAIR REFILL KIT SOLN NON_PREFERRED Page 8 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LONHALA MAGNAIR STARTER KIT SOLN NON_PREFERRED IPRATROPIUM BROMIDE SOLN PREFERRED ATROVENT HFA AERS PREFERRED YUPELRI SOLN NON_PREFERRED SPIRIVA AER 1.25MCG AERS PREFERRED SPIRIVA SPR 2.5MCG AERS NON_PREFERRED SPIRIVA HANDIHALER CAPS PREFERRED INCRUSE ELLIPTA AEPB NON_PREFERRED CROMOLYN SODIUM NEBU PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : BETA ADRENERGICS PROAIR DIGIHALER AEPB NON_PREFERRED PROAIR RESPICLICK AEPB NON_PREFERRED ALBUTEROL SULFATE HFA AERS NON_PREFERRED PROAIR HFA AERS PREFERRED PROVENTIL HFA AERS PREFERRED VENTOLIN HFA AERS NON_PREFERRED ALBUTEROL SULFATE NEBU PREFERRED ALBUTEROL SULFATE SYRP PREFERRED ALBUTEROL TABS NON_PREFERRED ALBUTEROL SULFATE TABS NON_PREFERRED ALBUTEROL SULFATE ER TB12 NON_PREFERRED BROVANA NEBU NON_PREFERRED PERFOROMIST NEBU NON_PREFERRED ARCAPTA NEOHALER CAPS NON_PREFERRED LEVALBUTEROL NEBU NON_PREFERRED LEVALBUTEROL HCL NEBU NON_PREFERRED LEVALBUTEROL HYDROCHLORIDE NEBU NON_PREFERRED XOPENEX NEBU NON_PREFERRED XOPENEX CONCENTRATE NEBU NON_PREFERRED LEVALBUTEROL TARTRATE HFA AERO NON_PREFERRED XOPENEX HFA AERO NON_PREFERRED METAPROTERENOL SULFATE SYRP NON_PREFERRED STRIVERDI RESPIMAT AERS NON_PREFERRED SEREVENT DISKUS AEPB PREFERRED TERBUTALINE SULFATE TABS PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : LEUKOTRIENE MODULATORS ZYFLO TABS NON_PREFERRED ZILEUTON ER TB12 NON_PREFERRED MONTELUKAST SODIUM CHEW PREFERRED SINGULAIR CHEW NON_PREFERRED MONTELUKAST SODIUM PACK PREFERRED SINGULAIR PACK NON_PREFERRED MONTELUKAST SODIUM TABS PREFERRED SINGULAIR TABS NON_PREFERRED ACCOLATE TABS NON_PREFERRED ZAFIRLUKAST TABS PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MISC THEO-24 CP24 PREFERRED Page 9 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ELIXOPHYLLIN ELIX PREFERRED THEOPHYLLINE SOLN PREFERRED THEOPHYLLINE ER TB12 PREFERRED THEOPHYLLINE ER TB24 PREFERRED DALIRESP TABS NON_PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MONOCLONAL ANTIBODIES XOLAIR SOLR NON_PREFERRED XOLAIR SOSY NON_PREFERRED FASENRA PEN SOAJ NON_PREFERRED FASENRA SOSY NON_PREFERRED NUCALA SOAJ NON_PREFERRED NUCALA SOLR PREFERRED_WITH_PA NUCALA SOSY NON_PREFERRED CINQAIR SOLN NON_PREFERRED DUPIXENT INJ 200/1.14 SOSY PREFERRED_WITH_PA DUPIXENT INJ 300/2ML SOSY NON_PREFERRED ANTIASTHMATIC AND BRONCHODILATOR AGENTS : INHALANTS QVAR REDIHALER AERB NON_PREFERRED PULMICORT FLEXHALER AEPB NON_PREFERRED BUDESONIDE SUSP PREFERRED PULMICORT SUSP NON_PREFERRED ALVESCO AERS NON_PREFERRED ARNUITY ELLIPTA AEPB NON_PREFERRED FLOVENT DISKUS AEPB PREFERRED FLOVENT HFA AERO PREFERRED ASMANEX TWISTHALER 120 METERED DOSES AEPB PREFERRED ASMANEX TWISTHALER 14 METERED DOSES AEPB PREFERRED ASMANEX TWISTHALER 30 METERED DOSES AEPB PREFERRED ASMANEX TWISTHALER 60 METERED DOSES AEPB PREFERRED ASMANEX HFA AERO NON_PREFERRED ANTIBIOITCS : FLUOROQUINOLONES CIPRO SUSR NON_PREFERRED CIPROFLOXACIN SUSR PREFERRED CIPRO TABS NON_PREFERRED CIPROFLOXACIN HCL TABS PREFERRED CIPROFLOXACIN HYDROCHLORIDE TABS PREFERRED BAXDELA TABS NON_PREFERRED LEVOFLOXACIN SOLN PREFERRED LEVAQUIN TABS NON_PREFERRED LEVOFLOXACIN TABS PREFERRED MOXIFLOXACIN HYDROCHLORIDE TABS NON_PREFERRED OFLOXACIN TABS NON_PREFERRED ANTIBIOTICS : AMINOGLYCOSIDES NEOMYCIN SULFATE TABS PREFERRED PAROMOMYCIN SULFATE CAPS PREFERRED ANTIBIOTICS : AMINOGLYCOSIDES - INHALED ARIKAYCE SUSP NON_PREFERRED TOBI PODHALER CAPS NON_PREFERRED BETHKIS NEBU NON_PREFERRED KITABIS PAK NEBU PREFERRED Page 10 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TOBI NEBU NON_PREFERRED TOBRAMYCIN NEBU NON_PREFERRED ANTIBIOTICS : ANTI-INFECTIVE AGENTS SULFADIAZINE TABS PREFERRED SOLOSEC PACK NON_PREFERRED FLAGYL CAPS NON_PREFERRED METRONIDAZOLE CAPS NON_PREFERRED FLAGYL TABS NON_PREFERRED METRONIDAZOLE TABS PREFERRED NEBUPENT SOLR PREFERRED PENTAMIDINE ISETHIONATE SOLR PREFERRED XIFAXAN TABS NON_PREFERRED TINIDAZOLE TABS NON_PREFERRED TRIMETHOPRIM TABS PREFERRED CAYSTON SOLR NON_PREFERRED CLEOCIN CAPS NON_PREFERRED CLINDAMYCIN HCL CAPS PREFERRED CLINDAMYCIN HYDROCHLORIDE CAPS PREFERRED CLEOCIN PEDIATRIC GRANULES SOLR NON_PREFERRED CLINDAMYCIN PALMITATE HCL SOLR PREFERRED CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLR PREFERRED LINEZOLID SUSR NON_PREFERRED ZYVOX SUSR NON_PREFERRED LINEZOLID TABS NON_PREFERRED ZYVOX TABS NON_PREFERRED SIVEXTRO TABS NON_PREFERRED XENLETA TABS NON_PREFERRED VANCOCIN CAPS NON_PREFERRED VANCOCIN HCL CAPS NON_PREFERRED VANCOMYCIN HYDROCHLORIDE CAPS PREFERRED FIRST-VANCOMYCIN 25 SOLN NON_PREFERRED FIRST-VANCOMYCIN 50 SOLN NON_PREFERRED FIRVANQ SOLR NON_PREFERRED VANCOMYCIN HYDROCHLORIDE SOLR PREFERRED DAPSONE TABS PREFERRED ATOVAQUONE SUSP PREFERRED MEPRON SUSP NON_PREFERRED SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP PREFERRED SULFATRIM PEDIATRIC SUSP PREFERRED BACTRIM TABS NON_PREFERRED BACTRIM DS TABS NON_PREFERRED SULFAMETHOXAZOLE/TRIMETHOPRIM TABS PREFERRED SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS PREFERRED ANTIBIOTICS : ANTIMYCOBACTERIAL AGENTS PASER PACK NON_PREFERRED SIRTURO TABS NON_PREFERRED CYCLOSERINE CAPS PREFERRED ETHAMBUTOL HCL TABS PREFERRED ETHAMBUTOL HYDROCHLORIDE TABS PREFERRED Page 11 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MYAMBUTOL TABS NON_PREFERRED TRECATOR TABS PREFERRED ISONIAZID SYRP PREFERRED ISONIAZID TABS PREFERRED PRETOMANID TABS NON_PREFERRED PYRAZINAMIDE TABS PREFERRED MYCOBUTIN CAPS NON_PREFERRED RIFABUTIN CAPS PREFERRED RIFADIN CAPS NON_PREFERRED RIFAMPIN CAPS PREFERRED PRIFTIN TABS NON_PREFERRED RIFAMATE CAPS PREFERRED RIFATER TABS PREFERRED ANTIBIOTICS : CEPHALOSPORINS CEFADROXIL CAPS PREFERRED CEFADROXIL SUSR PREFERRED CEFADROXIL TABS PREFERRED CEPHALEXIN CAPS PREFERRED KEFLEX CAPS NON_PREFERRED CEPHALEXIN SUSR PREFERRED CEPHALEXIN TABS PREFERRED CEFACLOR CAPS PREFERRED CEFACLOR SUSR PREFERRED CEFACLOR ER TB12 NON_PREFERRED CEFPROZIL SUSR PREFERRED CEFPROZIL TABS NON_PREFERRED CEFUROXIME AXETIL TABS PREFERRED CEFDINIR CAPS PREFERRED CEFDINIR SUSR PREFERRED CEFIXIME CAPS PREFERRED SUPRAX CAPS PREFERRED SUPRAX CHEW NON_PREFERRED CEFIXIME SUSR NON_PREFERRED SUPRAX SUSR NON_PREFERRED CEFPODOXIME PROXETIL SUSR NON_PREFERRED CEFPODOXIME PROXETIL TABS NON_PREFERRED ANTIBIOTICS : MACROLIDES ERYTHROMYCIN CPEP PREFERRED ERYTHROMYCIN BASE TABS PREFERRED ERY-TAB TBEC PREFERRED ERYTHROMYCIN DR TBEC PREFERRED ERYTHROCIN STEARATE TABS PREFERRED E.E.S. GRANULES SUSR PREFERRED ERYPED 200 SUSR PREFERRED ERYPED 400 SUSR PREFERRED ERYTHROMYCIN ETHYLSUCCINATE SUSR PREFERRED E.E.S. 400 TABS PREFERRED ERYTHROMYCIN ETHYLSUCCINATE TABS PREFERRED AZITHROMYCIN PACK PREFERRED Page 12 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ZITHROMAX PACK PREFERRED AZITHROMYCIN SUSR PREFERRED ZITHROMAX SUSR NON_PREFERRED AZITHROMYCIN TABS PREFERRED ZITHROMAX TABS NON_PREFERRED ZITHROMAX TRI-PAK TABS NON_PREFERRED ZITHROMAX Z-PAK TABS NON_PREFERRED CLARITHROMYCIN SUSR PREFERRED CLARITHROMYCIN TABS PREFERRED CLARITHROMYCIN ER TB24 PREFERRED DIFICID TABS NON_PREFERRED ANTIBIOTICS : PENICILLINS PENICILLIN V POTASSIUM SOLR PREFERRED PENICILLIN V POTASSIUM TABS PREFERRED AMOXICILLIN CAPS PREFERRED AMOXICILLIN CHEW PREFERRED AMOXICILLIN SUSR PREFERRED AMOXICILLIN TABS PREFERRED AMPICILLIN CAPS PREFERRED DICLOXACILLIN SODIUM CAPS PREFERRED AMOXICILLIN/CLAVULANATE POTASSIUM CHEW PREFERRED AMOXICILLIN/CLAVULANATE POTASSIUM SUSR PREFERRED AUGMENTIN SUSR PREFERRED AMOXICILLIN/CLAVULANATE P TABS PREFERRED AMOXICILLIN/CLAVULANATE POTASSIUM TABS PREFERRED AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 NON_PREFERRED ANTIBIOTICS : TETRACYCLINES HCL TABS PREFERRED DEMECLOCYCLINE HYDROCHLORIDE TABS PREFERRED DOXYCYCLINE MONOHYDRATE CAPS PREFERRED DOXYCYCLINE SUSR PREFERRED VIBRAMYCIN SUSR NON_PREFERRED DOXYCYCLINE TABS PREFERRED DOXYCYCLINE MONOHYDRATE TABS PREFERRED DOXYCYCLINE HYCLATE CAPS PREFERRED MORGIDOX 1X100MG CAPS PREFERRED MORGIDOX 1X50MG CAPS PREFERRED MORGIDOX 2X100MG CAPS PREFERRED VIBRAMYCIN CAPS NON_PREFERRED DOXYCYCLINE HYCLATE TABS PREFERRED DORYX TBEC NON_PREFERRED DORYX MPC TBEC NON_PREFERRED DOXYCYCLINE HYCLATE DR TBEC NON_PREFERRED VIBRAMYCIN SYRP PREFERRED MORGIDOX 1X100MG KIT NON_PREFERRED MORGIDOX 1X50MG KIT KIT NON_PREFERRED MORGIDOX 2X100MG KIT NON_PREFERRED MINOCIN CAPS NON_PREFERRED MINOCYCLINE HCL CAPS PREFERRED Page 13 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MINOCYCLINE HYDROCHLORIDE CAPS PREFERRED XIMINO CP24 NON_PREFERRED MINOCYCLINE HCL TABS PREFERRED MINOCYCLINE HYDROCHLORIDE TABS PREFERRED MINOCYCLINE HCL ER TB24 NON_PREFERRED MINOCYCLINE HYDROCHLORIDE ER TB24 NON_PREFERRED MINOCYCLINE HYDROCHLORIDEER TB24 NON_PREFERRED MINOLIRA TB24 NON_PREFERRED SOLODYN TB24 NON_PREFERRED TETRACYCLINE HYDROCHLORIDE CAPS PREFERRED NUZYRA TABS NON_PREFERRED ANTICOAGULANTS : COUMARIN COUMADIN TABS NON_PREFERRED JANTOVEN TABS PREFERRED WARFARIN SODIUM TABS PREFERRED ANTICOAGULANTS : DIRECT FACTOR XA INHIBITORS & MISC PRADAXA CAPS NON_PREFERRED ELIQUIS TABS PREFERRED_WITH_PA ELIQUIS STARTER PACK TABS PREFERRED_WITH_PA BEVYXXA CAPS NON_PREFERRED SAVAYSA TABS NON_PREFERRED XARELTO TABS PREFERRED_WITH_PA XARELTO STARTER PACK TBPK PREFERRED_WITH_PA ANTICOAGULANTS : HEPARIN AND HEPARINOID-LIKE AGENTS HEPARIN SODIUM SOLN PREFERRED HEPARIN SODIUM DCU SOLN PREFERRED HEPARIN SODIUM SOSY PREFERRED FRAGMIN SOLN PREFERRED ENOXAPARIN SODIUM SOLN PREFERRED LOVENOX SOLN NON_PREFERRED ARIXTRA SOLN NON_PREFERRED FONDAPARINUX SODIUM SOLN PREFERRED ANTICONVULSANTS SYMPAZAN FILM NON_PREFERRED CLOBAZAM SUSP NON_PREFERRED ONFI SUSP NON_PREFERRED CLOBAZAM TABS NON_PREFERRED ONFI TABS NON_PREFERRED CLONAZEPAM TABS PREFERRED KLONOPIN TABS NON_PREFERRED CLONAZEPAM ODT TBDP NON_PREFERRED DIASTAT ACUDIAL GEL PREFERRED DIASTAT PEDIATRIC GEL PREFERRED DIAZEPAM RECTAL GEL GEL PREFERRED NAYZILAM SOLN NON_PREFERRED FELBAMATE SUSP NON_PREFERRED FELBATOL SUSP NON_PREFERRED FELBAMATE TABS NON_PREFERRED FELBATOL TABS NON_PREFERRED GABITRIL TABS NON_PREFERRED TIAGABINE HYDROCHLORIDE TABS NON_PREFERRED Page 14 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SABRIL PACK NON_PREFERRED VIGABATRIN PACK NON_PREFERRED VIGADRONE PACK NON_PREFERRED SABRIL TABS NON_PREFERRED VIGABATRIN TABS NON_PREFERRED PEGANONE TABS NON_PREFERRED DILANTIN INFATABS CHEW NON_PREFERRED CHEW PREFERRED PHENYTOIN INFATABS CHEW PREFERRED DILANTIN-125 SUSP NON_PREFERRED PHENYTOIN SUSP PREFERRED DILANTIN CAPS NON_PREFERRED PHENYTEK CAPS NON_PREFERRED PHENYTOIN SODIUM EXTENDED CAPS PREFERRED ETHOSUXIMIDE CAPS PREFERRED ZARONTIN CAPS NON_PREFERRED ETHOSUXIMIDE SOLN PREFERRED ZARONTIN SOLN NON_PREFERRED CELONTIN CAPS NON_PREFERRED DEPAKOTE SPRINKLES CSDR NON_PREFERRED DIVALPROEX SODIUM CSDR PREFERRED DEPAKOTE ER TB24 NON_PREFERRED DIVALPROEX SODIUM ER TB24 PREFERRED DEPAKOTE TBEC NON_PREFERRED DIVALPROEX SODIUM DR TBEC PREFERRED VALPROIC ACID SOLN PREFERRED VALPROIC ACID CAPS PREFERRED FYCOMPA SUSP NON_PREFERRED FYCOMPA TABS NON_PREFERRED BRIVIACT SOLN NON_PREFERRED BRIVIACT TABS NON_PREFERRED EPIDIOLEX SOLN NON_PREFERRED CARBAMAZEPINE CHEW PREFERRED CARBAMAZEPINE ER CP12 NON_PREFERRED CARBATROL CP12 NON_PREFERRED CARBAMAZEPINE SUSP PREFERRED TEGRETOL SUSP NON_PREFERRED CARBAMAZEPINE TABS PREFERRED EPITOL TABS PREFERRED TEGRETOL TABS NON_PREFERRED CARBAMAZEPINE ER TB12 PREFERRED TEGRETOL-XR TB12 NON_PREFERRED APTIOM TABS NON_PREFERRED GABAPENTIN CAPS PREFERRED NEURONTIN CAPS NON_PREFERRED GABAPENTIN SOLN PREFERRED NEURONTIN SOLN NON_PREFERRED Page 15 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM GABAPENTIN TABS PREFERRED NEURONTIN TABS NON_PREFERRED VIMPAT SOLN NON_PREFERRED VIMPAT TABS NON_PREFERRED LAMICTAL CHEWABLE DISPERSIBLE CHEW NON_PREFERRED LAMOTRIGINE CHEW PREFERRED LAMICTAL ODT KIT NON_PREFERRED LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT NON_PREFERRED LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING KIT NON_PREFERRED LAMICTAL STARTER/TAKING VALPROATE KIT NON_PREFERRED LAMICTAL XR KIT NON_PREFERRED LAMOTRIGINE STARTER KIT/BLUE KIT NON_PREFERRED LAMOTRIGINE STARTER KIT/GREEN KIT NON_PREFERRED LAMOTRIGINE STARTER KIT/ORANGE KIT NON_PREFERRED SUBVENITE STARTER KIT/BLUE KIT NON_PREFERRED SUBVENITE STARTER KIT/GREEN KIT NON_PREFERRED SUBVENITE STARTER KIT/ORANGE KIT NON_PREFERRED LAMICTAL TABS NON_PREFERRED LAMOTRIGINE TABS PREFERRED SUBVENITE TABS PREFERRED LAMICTAL XR TB24 NON_PREFERRED LAMOTRIGINE ER TB24 NON_PREFERRED LAMICTAL ODT TBDP NON_PREFERRED LAMOTRIGINE ODT TBDP NON_PREFERRED KEPPRA SOLN NON_PREFERRED LEVETIRACETAM SOLN PREFERRED KEPPRA TABS NON_PREFERRED LEVETIRACETAM TABS PREFERRED ROWEEPRA TABS PREFERRED KEPPRA XR TB24 NON_PREFERRED LEVETIRACETAM ER TB24 PREFERRED ROWEEPRA XR TB24 PREFERRED SPRITAM TB3D NON_PREFERRED OXCARBAZEPINE SUSP PREFERRED TRILEPTAL SUSP NON_PREFERRED OXCARBAZEPINE TABS PREFERRED TRILEPTAL TABS NON_PREFERRED OXTELLAR XR TB24 NON_PREFERRED LYRICA CAPS NON_PREFERRED PREGABALIN CAPS PREFERRED LYRICA SOLN NON_PREFERRED PREGABALIN SOLN PREFERRED MYSOLINE TABS NON_PREFERRED PRIMIDONE TABS PREFERRED BANZEL SUSP NON_PREFERRED BANZEL TABS NON_PREFERRED DIACOMIT CAPS NON_PREFERRED Page 16 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM DIACOMIT PACK NON_PREFERRED TROKENDI XR CP24 NON_PREFERRED TOPAMAX SPRINKLE CPSP NON_PREFERRED TOPIRAMATE CPSP PREFERRED QUDEXY XR CS24 NON_PREFERRED TOPIRAMATE ER CS24 NON_PREFERRED TOPAMAX TABS NON_PREFERRED TOPIRAMATE TABS PREFERRED ZONISAMIDE CAPS PREFERRED ANTIDEPRESSANTS : MISC MIRTAZAPINE TABS PREFERRED REMERON TABS NON_PREFERRED MIRTAZAPINE ODT TBDP PREFERRED REMERON SOLTAB TBDP NON_PREFERRED MARPLAN TABS NON_PREFERRED NARDIL TABS NON_PREFERRED PHENELZINE SULFATE TABS PREFERRED EMSAM PT24 NON_PREFERRED TRANYLCYPROMINE SULFATE TABS PREFERRED SPRAVATO 56MG DOSE SOPK NON_PREFERRED SPRAVATO 84MG DOSE SOPK NON_PREFERRED NEFAZODONE HCL TABS NON_PREFERRED NEFAZODONE HYDROCHLORIDE TABS NON_PREFERRED TRAZODONE HYDROCHLORIDE TABS PREFERRED VIIBRYD STARTER PACK KIT NON_PREFERRED VIIBRYD TABS NON_PREFERRED TRINTELLIX TABS NON_PREFERRED AMITRIPTYLINE HCL TABS PREFERRED AMITRIPTYLINE HYDROCHLORIDE TABS PREFERRED AMOXAPINE TABS NON_PREFERRED ANAFRANIL CAPS NON_PREFERRED CLOMIPRAMINE HCL CAPS PREFERRED CLOMIPRAMINE HYDROCHLORIDE CAPS PREFERRED DESIPRAMINE HCL TABS PREFERRED DESIPRAMINE HYDROCHLORIDE TABS PREFERRED NORPRAMIN TABS NON_PREFERRED DOXEPIN HCL CAPS PREFERRED DOXEPIN HYDROCHLORIDE CAPS PREFERRED DOXEPIN HCL CONC PREFERRED IMIPRAMINE HCL TABS PREFERRED IMIPRAMINE HYDROCHLORIDE TABS PREFERRED IMIPRAMINE PAMOATE CAPS NON_PREFERRED NORTRIPTYLINE HCL CAPS PREFERRED NORTRIPTYLINE HYDROCHLORIDE CAPS PREFERRED PAMELOR CAPS NON_PREFERRED NORTRIPTYLINE HCL SOLN PREFERRED PROTRIPTYLINE HCL TABS PREFERRED TRIMIPRAMINE MALEATE CAPS NON_PREFERRED Page 17 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MAPROTILINE HCL TABS PREFERRED BUPROPION HCL TABS PREFERRED BUPROPION HYDROCHLORIDE TABS PREFERRED BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED WELLBUTRIN SR TB12 NON_PREFERRED BUPROPION HYDROCHLORIDE ER (XL) TB24 PREFERRED FORFIVO XL TB24 NON_PREFERRED WELLBUTRIN XL TB24 NON_PREFERRED APLENZIN TB24 NON_PREFERRED ANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIs) CITALOPRAM HYDROBROMIDE SOLN PREFERRED CELEXA TABS NON_PREFERRED CITALOPRAM TABS PREFERRED CITALOPRAM HYDROBROMIDE TABS PREFERRED ESCITALOPRAM OXALATE SOLN PREFERRED ESCITALOPRAM OXALATE TABS PREFERRED LEXAPRO TABS NON_PREFERRED FLUOXETINE HCL CAPS PREFERRED FLUOXETINE HYDROCHLORIDE CAPS PREFERRED PROZAC CAPS NON_PREFERRED FLUOXETINE DR CPDR NON_PREFERRED FLUOXETINE HCL SOLN PREFERRED FLUOXETINE HYDROCHLORIDE SOLN PREFERRED FLUOXETINE HYDROCHLORIDE TABS PREFERRED FLUVOXAMINE MALEATE ER CP24 NON_PREFERRED FLUVOXAMINE MALEATE TABS PREFERRED PAXIL SUSP NON_PREFERRED PAROXETINE HCL TABS PREFERRED PAROXETINE HYDROCHLORIDE TABS PREFERRED PAXIL TABS NON_PREFERRED PAROXETINE HCL ER TB24 NON_PREFERRED PAROXETINE HYDROCHLORIDEER TB24 NON_PREFERRED PAXIL CR TB24 NON_PREFERRED PEXEVA TABS NON_PREFERRED SERTRALINE HCL CONC PREFERRED SERTRALINE HYDROCHLORIDE CONC PREFERRED SERTRALINE HCL TABS PREFERRED SERTRALINE HYDROCHLORIDE TABS PREFERRED ZOLOFT TABS NON_PREFERRED DULOXETINE HYDROCHLORIDE CPEP PREFERRED ANTIDEPRESSANTS : SELECTIVE SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITOR (SNRIs) DESVENLAFAXINE ER TB24 NON_PREFERRED KHEDEZLA TB24 NON_PREFERRED DESVENLAFAXINE ER TB24 NON_PREFERRED PRISTIQ TB24 NON_PREFERRED CYMBALTA CPEP NON_PREFERRED DULOXETINE HCL CPEP PREFERRED Page 18 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM DULOXETINE HYDROCHLORIDE CPEP PREFERRED DRIZALMA SPRINKLE CSDR NON_PREFERRED FETZIMA TITRATION PACK C4PK NON_PREFERRED FETZIMA CP24 NON_PREFERRED EFFEXOR XR CP24 NON_PREFERRED VENLAFAXINE HCL ER CP24 PREFERRED VENLAFAXINE HCL TABS PREFERRED VENLAFAXINE HYDROCHLORIDE TABS PREFERRED VENLAFAXINE HCL ER TB24 NON_PREFERRED VENLAFAXINE HYDROCHLORIDE ER TB24 NON_PREFERRED ANTIDIABETICS : COMBINATIONS XULTOPHY 100/3.6 SOPN NON_PREFERRED SOLIQUA 100/33 SOPN NON_PREFERRED ALOGLIPTIN/METFORMIN HCL TABS NON_PREFERRED KAZANO TABS NON_PREFERRED JENTADUETO TABS NON_PREFERRED JENTADUETO XR TB24 NON_PREFERRED KOMBIGLYZE XR TB24 NON_PREFERRED JANUMET TABS NON_PREFERRED JANUMET XR TB24 NON_PREFERRED ALOGLIPTIN/PIOGLITAZONE TABS NON_PREFERRED OSENI TABS NON_PREFERRED REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS NON_PREFERRED INVOKAMET TABS NON_PREFERRED INVOKAMET XR TB24 NON_PREFERRED XIGDUO XR TB24 NON_PREFERRED SYNJARDY TABS NON_PREFERRED SYNJARDY XR TB24 NON_PREFERRED SEGLUROMET TABS NON_PREFERRED QTERN TABS NON_PREFERRED GLYXAMBI TABS NON_PREFERRED STEGLUJAN TABS NON_PREFERRED GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED GLYBURIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED DUETACT TABS NON_PREFERRED PIOGLITAZONE HCL-GLIMEPIRIDE TABS NON_PREFERRED ACTOPLUS MET TABS NON_PREFERRED PIOGLITAZONE HCL/METFORMIN HCL TABS NON_PREFERRED

ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS ALOGLIPTIN TABS NON_PREFERRED NESINA TABS NON_PREFERRED TRADJENTA TABS PREFERRED ONGLYZA TABS NON_PREFERRED JANUVIA TABS PREFERRED ANTIDIABETICS : INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) TRULICITY SOPN NON_PREFERRED BYDUREON BCISE AUIJ NON_PREFERRED BYDUREON PEN PEN NON_PREFERRED Page 19 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM BYETTA SOPN PREFERRED VICTOZA SOPN PREFERRED ADLYXIN STARTER PACK PNKT NON_PREFERRED ADLYXIN SOPN NON_PREFERRED OZEMPIC SOPN NON_PREFERRED RYBELSUS TABS NON_PREFERRED ANTIDIABETICS : INSULIN NOVOLOG PENFILL SOCT NON_PREFERRED NOVOLOG SOLN NON_PREFERRED NOVOLOG FLEXPEN SOPN NON_PREFERRED FIASP PENFILL SOCT NON_PREFERRED FIASP SOLN NON_PREFERRED FIASP FLEXTOUCH SOPN NON_PREFERRED LANTUS SOLN PREFERRED BASAGLAR KWIKPEN SOPN NON_PREFERRED LANTUS SOLOSTAR SOPN PREFERRED TOUJEO MAX SOLOSTAR SOPN NON_PREFERRED TOUJEO SOLOSTAR SOPN NON_PREFERRED APIDRA SOLN NON_PREFERRED APIDRA SOLOSTAR SOPN NON_PREFERRED HUMALOG SOCT PREFERRED ADMELOG SOLN NON_PREFERRED HUMALOG SOLN PREFERRED INSULIN LISPRO SOLN PREFERRED ADMELOG SOLOSTAR SOPN NON_PREFERRED HUMALOG JUNIOR KWIKPEN SOPN PREFERRED HUMALOG KWIKPEN SOPN PREFERRED INSULIN LISPRO KWIKPEN SOPN PREFERRED LEVEMIR SOLN PREFERRED LEVEMIR FLEXTOUCH SOPN PREFERRED TRESIBA SOLN NON_PREFERRED TRESIBA FLEXTOUCH SOPN NON_PREFERRED AFREZZA POWD NON_PREFERRED HUMULIN R SOLN PREFERRED HUMULIN R U-500 (CONCENTRATED) SOLN PREFERRED NOVOLIN R SOLN NON_PREFERRED NOVOLIN R RELION SOLN NON_PREFERRED HUMULIN R U-500 KWIKPEN SOPN PREFERRED HUMULIN N KWIKPEN SUPN PREFERRED HUMULIN N SUSP PREFERRED NOVOLIN N SUSP NON_PREFERRED NOVOLIN N RELION SUSP NON_PREFERRED NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN NON_PREFERRED NOVOLOG MIX 70/30 SUSP NON_PREFERRED HUMALOG MIX 50/50 KWIKPEN SUPN PREFERRED HUMALOG MIX 75/25 KWIKPEN SUPN PREFERRED HUMALOG MIX 50/50 SUSP PREFERRED HUMALOG MIX 75/25 SUSP PREFERRED Page 20 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM HUMULIN 70/30 KWIKPEN SUPN PREFERRED NOVOLIN 70/30 FLEXPEN SUPN NON_PREFERRED NOVOLIN 70/30 FLEXPEN RELION SUPN NON_PREFERRED HUMULIN 70/30 SUSP PREFERRED NOVOLIN 70/30 SUSP NON_PREFERRED NOVOLIN 70/30 RELION SUSP NON_PREFERRED ANTIDIABETICS : MISC SYMLINPEN 120 SOPN NON_PREFERRED SYMLINPEN 60 SOPN NON_PREFERRED AMARYL TABS NON_PREFERRED GLIMEPIRIDE TABS PREFERRED GLIPIZIDE TABS PREFERRED GLUCOTROL TABS NON_PREFERRED GLIPIZIDE ER TB24 PREFERRED GLIPIZIDE XL TB24 PREFERRED GLUCOTROL XL TB24 NON_PREFERRED GLYBURIDE TABS PREFERRED GLYBURIDE TABS PREFERRED GLYBURIDE MICRONIZED TABS PREFERRED GLYNASE TABS NON_PREFERRED TOLBUTAMIDE TABS PREFERRED RIOMET SOLN NON_PREFERRED GLUCOPHAGE TABS NON_PREFERRED METFORMIN HYDROCHLORIDE TABS PREFERRED FORTAMET TB24 NON_PREFERRED GLUCOPHAGE XR TB24 NON_PREFERRED GLUMETZA TB24 NON_PREFERRED METFORMIN HYDROCHLORIDE ER TB24 PREFERRED NATEGLINIDE TABS PREFERRED STARLIX TABS NON_PREFERRED REPAGLINIDE TABS NON_PREFERRED BAQSIMI ONE PACK POWD NON_PREFERRED BAQSIMI TWO PACK POWD NON_PREFERRED GVOKE PFS SOSY NON_PREFERRED GLUCAGON EMERGENCY KIT KIT PREFERRED GLUCAGEN HYPOKIT SOLR PREFERRED GLUCAGON EMERGENCY KIT FO SOLR PREFERRED PROGLYCEM SUSP PREFERRED KORLYM TABS NON_PREFERRED ACARBOSE TABS PREFERRED PRECOSE TABS NON_PREFERRED GLYSET TABS NON_PREFERRED MIGLITOL TABS PREFERRED CYCLOSET TABS NON_PREFERRED ACTOS TABS NON_PREFERRED PIOGLITAZONE HCL TABS PREFERRED PIOGLITAZONE HYDROCHLORIDE TABS PREFERRED AVANDIA TABS PREFERRED Page 21 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ANTIDIABETICS : SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TABS PREFERRED FARXIGA TABS NON_PREFERRED JARDIANCE TABS PREFERRED STEGLATRO TABS NON_PREFERRED ANTIDOTES AND SPECIFIC ANTAGONISTS : ANTIDOTES - CHELATING AGENTS JADENU SPRINKLE PACK NON_PREFERRED DEFERASIROX TABS NON_PREFERRED JADENU TABS NON_PREFERRED DEFERASIROX TBSO NON_PREFERRED EXJADE TBSO NON_PREFERRED FERRIPROX SOLN NON_PREFERRED FERRIPROX TABS NON_PREFERRED CHEMET CAPS PREFERRED CLOVIQUE CAPS PREFERRED SYPRINE CAPS NON_PREFERRED TRIENTINE HYDROCHLORIDE CAPS PREFERRED CUPRIMINE CAPS NON_PREFERRED PENICILLAMINE CAPS PREFERRED D-PENAMINE TABS PREFERRED DEPEN TITRATABS TABS PREFERRED PENICILLAMINE TABS PREFERRED ANTIEMETICS : 5-HT3 RECEPTOR ANTAGONISTS ANZEMET TABS NON_PREFERRED SANCUSO PTCH NON_PREFERRED GRANISETRON HCL TABS NON_PREFERRED ZUPLENZ FILM NON_PREFERRED ONDANSETRON ODT TBDP PREFERRED ONDANSETRON HCL SOLN PREFERRED ONDANSETRON HYDROCHLORIDE SOLN PREFERRED ONDANSETRON HYDROCHLORIDE TABS PREFERRED ZOFRAN TABS NON_PREFERRED ANTIEMETICS : MISC MECLIZINE HCL TABS PREFERRED MECLIZINE HYDROCHLORIDE TABS PREFERRED SCOPOLAMINE PT72 PREFERRED TRANSDERM SCOP PT72 PREFERRED TRANSDERM-SCOP PT72 PREFERRED TIGAN CAPS NON_PREFERRED TRIMETHOBENZAMIDE HYDROCHLORIDE CAPS NON_PREFERRED DRONABINOL CAPS NON_PREFERRED MARINOL CAPS NON_PREFERRED BONJESTA TBCR NON_PREFERRED DICLEGIS TBEC NON_PREFERRED DOXYLAMINE SUCCINATE/PYRI TBEC NON_PREFERRED DOXYLAMINE SUCCINATE/PYRIDOXINE HYDROCHLORIDE TBEC NON_PREFERRED AKYNZEO CAPS NON_PREFERRED ANTIEMETICS : SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS APREPITANT CAPS PREFERRED Page 22 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM EMEND CAPS NON_PREFERRED EMEND TRIPACK CAPS NON_PREFERRED EMEND SUSR NON_PREFERRED VARUBI TABS NON_PREFERRED ANTIFUNGALS ANCOBON CAPS NON_PREFERRED FLUCYTOSINE CAPS NON_PREFERRED GRISEOFULVIN MICROSIZE SUSP PREFERRED GRISEOFULVIN MICROSIZE TABS PREFERRED GRISEOFULVIN ULTRAMICROSIZE TABS PREFERRED NYSTATIN TABS PREFERRED TERBINAFINE HCL TABS PREFERRED TERBINAFINE HYDROCHLORIDE TABS PREFERRED TABS PREFERRED DIFLUCAN SUSR NON_PREFERRED FLUCONAZOLE SUSR PREFERRED DIFLUCAN TABS NON_PREFERRED FLUCONAZOLE TABS PREFERRED CRESEMBA CAPS NON_PREFERRED ITRACONAZOLE CAPS NON_PREFERRED SPORANOX CAPS NON_PREFERRED SPORANOX PULSEPAK CAPS NON_PREFERRED TOLSURA CAPS NON_PREFERRED ITRACONAZOLE SOLN NON_PREFERRED SPORANOX SOLN NON_PREFERRED NOXAFIL SUSP NON_PREFERRED NOXAFIL TBEC NON_PREFERRED POSACONAZOLE DR TBEC NON_PREFERRED VFEND SUSR NON_PREFERRED VORICONAZOLE SUSR NON_PREFERRED VFEND TABS NON_PREFERRED VORICONAZOLE TABS NON_PREFERRED ANTIHYPERLIPIDEMICS CHOLESTYRAMINE PACK PREFERRED QUESTRAN PACK NON_PREFERRED CHOLESTYRAMINE POWD PREFERRED QUESTRAN POWD NON_PREFERRED CHOLESTYRAMINE LIGHT PACK PREFERRED PREVALITE PACK PREFERRED CHOLESTYRAMINE LIGHT POWD PREFERRED PREVALITE POWD PREFERRED QUESTRAN LIGHT POWD NON_PREFERRED COLESEVELAM HYDROCHLORIDE PACK NON_PREFERRED WELCHOL PACK NON_PREFERRED COLESEVELAM HYDROCHLORIDE TABS NON_PREFERRED WELCHOL TABS NON_PREFERRED COLESTID GRAN NON_PREFERRED COLESTID FLAVORED GRAN NON_PREFERRED COLESTIPOL HCL GRAN NON_PREFERRED Page 23 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM COLESTID PACK NON_PREFERRED COLESTID FLAVORED PACK NON_PREFERRED COLESTIPOL HCL PACK NON_PREFERRED COLESTID TABS NON_PREFERRED COLESTIPOL HCL TABS NON_PREFERRED FENOFIBRIC ACID DR CPDR PREFERRED TRILIPIX CPDR NON_PREFERRED FENOFIBRATE CAPS PREFERRED LIPOFEN CAPS NON_PREFERRED FENOFIBRATE TABS PREFERRED FENOGLIDE TABS NON_PREFERRED TRICOR TABS NON_PREFERRED ANTARA CAPS NON_PREFERRED FENOFIBRATE CAPS PREFERRED FENOFIBRATE MICRONIZED CAPS PREFERRED GEMFIBROZIL TABS PREFERRED LOPID TABS NON_PREFERRED EZETIMIBE TABS PREFERRED ZETIA TABS NON_PREFERRED PRALUENT SOAJ NON_PREFERRED REPATHA SURECLICK SOAJ NON_PREFERRED REPATHA PUSHTRONEX SYSTEM SOCT NON_PREFERRED REPATHA SOSY NON_PREFERRED ATORVASTATIN CALCIUM TABS PREFERRED LIPITOR TABS NON_PREFERRED FLUVASTATIN CAPS NON_PREFERRED FLUVASTATIN SODIUM ER TB24 NON_PREFERRED LESCOL XL TB24 NON_PREFERRED LOVASTATIN TABS PREFERRED ALTOPREV TB24 NON_PREFERRED LIVALO TABS NON_PREFERRED ZYPITAMAG TABS NON_PREFERRED EZALLOR SPRINKLE CPSP NON_PREFERRED CRESTOR TABS NON_PREFERRED ROSUVASTATIN CALCIUM TABS PREFERRED PRAVACHOL TABS NON_PREFERRED PRAVASTATIN SODIUM TABS PREFERRED SIMVASTATIN TABS PREFERRED ZOCOR TABS NON_PREFERRED ER TBCR NON_PREFERRED NIASPAN TBCR NON_PREFERRED JUXTAPID CAPS NON_PREFERRED VASCEPA CAPS NON_PREFERRED LOVAZA CAPS NON_PREFERRED OMEGA-3-ACID ETHYL ESTERS CAPS NON_PREFERRED EZETIMIBE/SIMVASTATIN TABS NON_PREFERRED VYTORIN TABS NON_PREFERRED Page 24 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ANTIMYASTHENIC AGENTS RUZURGI TABS NON_PREFERRED FIRDAPSE TABS NON_PREFERRED GUANIDINE HCL TABS NON_PREFERRED MESTINON SOLN NON_PREFERRED PYRIDOSTIGMINE BROMIDE SOLN PREFERRED MESTINON TABS NON_PREFERRED PYRIDOSTIGMINE BROMIDE TABS PREFERRED MESTINON TIMESPAN TBCR NON_PREFERRED PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ALKYLATING AGENTS MYLERAN TABS PREFERRED LEUKERAN TABS PREFERRED CYCLOPHOSPHAMIDE CAPS PREFERRED ALKERAN TABS NON_PREFERRED MELPHALAN TABS PREFERRED GLEOSTINE CAPS PREFERRED TEMODAR CAPS NON_PREFERRED TEMOZOLOMIDE CAPS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTIMETABOLITES CAPECITABINE TABS NON_PREFERRED XELODA TABS NON_PREFERRED PURIXAN SUSP NON_PREFERRED MERCAPTOPURINE TABS PREFERRED XATMEP SOLN NON_PREFERRED METHOTREXATE TABS PREFERRED TREXALL TABS PREFERRED TABLOID TABS PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS LYSODREN TABS PREFERRED ERLEADA TABS NON_PREFERRED TABS PREFERRED CASODEX TABS NON_PREFERRED NUBEQA TABS NON_PREFERRED XTANDI CAPS NON_PREFERRED CAPS PREFERRED TABS PREFERRED SOLTAMOX SOLN PREFERRED CITRATE TABS PREFERRED FARESTON TABS NON_PREFERRED CITRATE TABS PREFERRED TABS PREFERRED ARIMIDEX TABS NON_PREFERRED AROMASIN TABS NON_PREFERRED TABS PREFERRED FEMARA TABS NON_PREFERRED TABS PREFERRED EMCYT CAPS PREFERRED Page 25 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ACETATE SUSP PREFERRED TABS PREFERRED TABS PREFERRED YONSA TABS NON_PREFERRED ZYTIGA TABS NON_PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC ENZYME INHIBITORS VERZENIO TABS NON_PREFERRED IBRANCE CAPS NON_PREFERRED KISQALI TBPK NON_PREFERRED FARYDAK CAPS NON_PREFERRED ZOLINZA CAPS NON_PREFERRED TAFINLAR CAPS NON_PREFERRED BRAFTOVI CAPS NON_PREFERRED ZELBORAF TABS NON_PREFERRED BALVERSA TABS NON_PREFERRED AFINITOR TABS NON_PREFERRED EVEROLIMUS TABS NON_PREFERRED AFINITOR DISPERZ TBSO NON_PREFERRED RYDAPT CAPS NON_PREFERRED STIVARGA TABS NON_PREFERRED NEXAVAR TABS PREFERRED SUTENT CAPS PREFERRED MEKTOVI TABS NON_PREFERRED COTELLIC TABS NON_PREFERRED MEKINIST TABS NON_PREFERRED ROZLYTREK CAPS NON_PREFERRED VITRAKVI CAPS NON_PREFERRED VITRAKVI SOLN NON_PREFERRED CALQUENCE CAPS NON_PREFERRED GILOTRIF TABS NON_PREFERRED ALECENSA CAPS NON_PREFERRED INLYTA TABS NON_PREFERRED ALUNBRIG TABS NON_PREFERRED ALUNBRIG TBPK NON_PREFERRED BOSULIF TABS NON_PREFERRED COMETRIQ KIT NON_PREFERRED CABOMETYX TABS NON_PREFERRED ZYKADIA TABS NON_PREFERRED XALKORI CAPS NON_PREFERRED VIZIMPRO TABS NON_PREFERRED SPRYCEL TABS NON_PREFERRED ERLOTINIB HYDROCHLORIDE TABS PREFERRED TARCEVA TABS NON_PREFERRED IRESSA TABS PREFERRED XOSPATA TABS NON_PREFERRED IMBRUVICA CAPS NON_PREFERRED IMBRUVICA TABS NON_PREFERRED Page 26 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM GLEEVEC TABS NON_PREFERRED IMATINIB MESYLATE TABS NON_PREFERRED TYKERB TABS NON_PREFERRED LENVIMA 10 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 12MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 14 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 18 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 20 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 24 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 4 MG DAILY DOSE CPPK NON_PREFERRED LENVIMA 8 MG DAILY DOSE CPPK NON_PREFERRED LORBRENA TABS NON_PREFERRED NERLYNX TABS NON_PREFERRED TASIGNA CAPS NON_PREFERRED TAGRISSO TABS NON_PREFERRED VOTRIENT TABS PREFERRED TURALIO CAPS NON_PREFERRED ICLUSIG TABS NON_PREFERRED CAPRELSA TABS PREFERRED TIBSOVO TABS NON_PREFERRED IDHIFA TABS NON_PREFERRED ZEJULA CAPS NON_PREFERRED LYNPARZA TABS NON_PREFERRED RUBRACA TABS NON_PREFERRED TALZENNA CAPS NON_PREFERRED NINLARO CAPS NON_PREFERRED INREBIC CAPS NON_PREFERRED JAKAFI TABS PREFERRED PIQRAY 200MG DAILY DOSE TBPK NON_PREFERRED PIQRAY 250MG DAILY DOSE TBPK NON_PREFERRED PIQRAY 300MG DAILY DOSE TBPK NON_PREFERRED COPIKTRA CAPS NON_PREFERRED ZYDELIG TABS NON_PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : CHEMOTHERAPY RESCUE / ANTIDOTE AGENTS LEUCOVORIN CALCIUM TABS PREFERRED MESNEX TABS PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MISC DAURISMO TABS NON_PREFERRED ODOMZO CAPS NON_PREFERRED ERIVEDGE CAPS PREFERRED POMALYST CAPS NON_PREFERRED VENCLEXTA TABS NON_PREFERRED VENCLEXTA STARTING PACK TBPK NON_PREFERRED HYCAMTIN CAPS PREFERRED XPOVIO 100 MG ONCE WEEKLY TBPK NON_PREFERRED XPOVIO 60 MG ONCE WEEKLY TBPK NON_PREFERRED XPOVIO 80 MG ONCE WEEKLY TBPK NON_PREFERRED XPOVIO 80 MG TWICE WEEKLY TBPK NON_PREFERRED Page 27 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM HYDREA CAPS NON_PREFERRED HYDROXYUREA CAPS PREFERRED MATULANE CAPS PREFERRED TRETINOIN CAPS PREFERRED BEXAROTENE CAPS PREFERRED TARGRETIN CAPS NON_PREFERRED KISQALI FEMARA 200 DOSE TBPK NON_PREFERRED KISQALI FEMARA 400 DOSE TBPK NON_PREFERRED KISQALI FEMARA 600 DOSE TBPK NON_PREFERRED LONSURF TABS NON_PREFERRED ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MITOTIC INHIBITORS ETOPOSIDE CAPS PREFERRED ANTIPARASITICS : ANTHELMINTICS ALBENDAZOLE TABS NON_PREFERRED ALBENZA TABS NON_PREFERRED BENZNIDAZOLE TABS NON_PREFERRED IVERMECTIN TABS NON_PREFERRED STROMECTOL TABS NON_PREFERRED EMVERM CHEW NON_PREFERRED BILTRICIDE TABS NON_PREFERRED PRAZIQUANTEL TABS PREFERRED EGATEN TABS NON_PREFERRED ANTIPARASITICS : ANTIMALARIALS CHLOROQUINE PHOSPHATE TABS PREFERRED HYDROXYCHLOROQUINE SULFATE TABS PREFERRED MEFLOQUINE HCL TABS PREFERRED PRIMAQUINE PHOSPHATE TABS PREFERRED DARAPRIM TABS NON_PREFERRED QUALAQUIN CAPS NON_PREFERRED QUININE SULFATE CAPS NON_PREFERRED KRINTAFEL TABS NON_PREFERRED COARTEM TABS NON_PREFERRED ATOVAQUONE/PROGUANIL HCL TABS PREFERRED MALARONE TABS NON_PREFERRED ANTIPARKINSON AND RELATED THERAPY AGENTS BENZTROPINE MESYLATE TABS PREFERRED TRIHEXYPHENIDYL HCL ELIX PREFERRED TRIHEXYPHENIDYL HYDROCHLORIDE TABS PREFERRED TASMAR TABS NON_PREFERRED TOLCAPONE TABS NON_PREFERRED COMTAN TABS NON_PREFERRED ENTACAPONE TABS PREFERRED AMANTADINE HCL CAPS PREFERRED AMANTADINE HYDROCHLORIDE CAPS PREFERRED GOCOVRI CP24 NON_PREFERRED AMANTADINE HCL SYRP PREFERRED AMANTADINE HCL TABS PREFERRED AMANTADINE HYDROCHLORIDE TABS PREFERRED OSMOLEX ER TB24 NON_PREFERRED BROMOCRIPTINE MESYLATE CAPS PREFERRED Page 28 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PARLODEL CAPS NON_PREFERRED BROMOCRIPTINE MESYLATE TABS PREFERRED PARLODEL TABS NON_PREFERRED INBRIJA CAPS NON_PREFERRED APOKYN SOCT NON_PREFERRED MIRAPEX TABS NON_PREFERRED PRAMIPEXOLE DIHYDROCHLORIDE TABS PREFERRED MIRAPEX ER TB24 NON_PREFERRED PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 NON_PREFERRED ROPINIROLE HCL TABS PREFERRED ROPINIROLE HYDROCHLORIDE TABS PREFERRED REQUIP XL TB24 NON_PREFERRED ROPINIROLE ER TB24 NON_PREFERRED NEUPRO PT24 NON_PREFERRED RYTARY CPCR NON_PREFERRED CARBIDOPA/LEVODOPA TABS PREFERRED SINEMET TABS NON_PREFERRED CARBIDOPA/LEVODOPA ER TBCR PREFERRED SINEMET CR TBCR NON_PREFERRED CARBIDOPA/LEVODOPA ODT TBDP NON_PREFERRED CARBIDOPA/LEVODOPA/ENTACAPONE TABS NON_PREFERRED STALEVO 100 TABS NON_PREFERRED STALEVO 125 TABS NON_PREFERRED STALEVO 150 TABS NON_PREFERRED STALEVO 200 TABS NON_PREFERRED STALEVO 50 TABS NON_PREFERRED STALEVO 75 TABS NON_PREFERRED AZILECT TABS NON_PREFERRED RASAGILINE MESYLATE TABS NON_PREFERRED XADAGO TABS NON_PREFERRED SELEGILINE HCL CAPS PREFERRED SELEGILINE HYDROCHLORIDE CAPS PREFERRED SELEGILINE HCL TABS PREFERRED ZELAPAR TBDP NON_PREFERRED NOURIANZ TABS NON_PREFERRED CARBIDOPA TABS PREFERRED LODOSYN TABS NON_PREFERRED ANTIPSYCHOTICS / ANTIMANIC AGENTS : BENZISOXAZOLES FANAPT TABS NON_PREFERRED FANAPT TITRATION PACK TABS NON_PREFERRED INVEGA TB24 NON_PREFERRED PALIPERIDONE ER TB24 NON_PREFERRED INVEGA SUSTENNA SUSY PREFERRED_WITH_PA INVEGA TRINZA SUSY PREFERRED_WITH_PA PERSERIS PRSY NON_PREFERRED RISPERDAL SOLN NON_PREFERRED RISPERIDONE SOLN PREFERRED RISPERDAL TABS NON_PREFERRED Page 29 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM RISPERIDONE TABS PREFERRED RISPERIDONE ODT TBDP NON_PREFERRED RISPERDAL CONSTA SRER NON_PREFERRED ANTIPSYCHOTICS / ANTIMANIC AGENTS : DIBENZAPINES VERSACLOZ SUSP NON_PREFERRED CLOZAPINE TABS PREFERRED CLOZARIL TABS NON_PREFERRED CLOZAPINE ODT TBDP NON_PREFERRED FAZACLO TBDP NON_PREFERRED QUETIAPINE FUMARATE TABS PREFERRED SEROQUEL TABS NON_PREFERRED QUETIAPINE FUMARATE ER TB24 PREFERRED SEROQUEL XR TB24 NON_PREFERRED ADASUVE AEPB NON_PREFERRED LOXAPINE CAPS PREFERRED LOXAPINE SUCCINATE CAPS PREFERRED SECUADO PT24 NON_PREFERRED SAPHRIS SUBL NON_PREFERRED OLANZAPINE SOLR NON_PREFERRED ZYPREXA SOLR NON_PREFERRED OLANZAPINE TABS PREFERRED ZYPREXA TABS NON_PREFERRED OLANZAPINE ODT TBDP PREFERRED ZYPREXA ZYDIS TBDP NON_PREFERRED ZYPREXA RELPREVV SUSR NON_PREFERRED ANTIPSYCHOTICS / ANTIMANIC AGENTS : MISC HALOPERIDOL TABS PREFERRED HALOPERIDOL CONC PREFERRED MOLINDONE HYDROCHLORIDE TABS NON_PREFERRED CHLORPROMAZINE HCL TABS PREFERRED CHLORPROMAZINE HYDROCHLORIDE TABS PREFERRED FLUPHENAZINE HCL CONC PREFERRED FLUPHENAZINE HYDROCHLORIDE ELIX PREFERRED FLUPHENAZINE HCL TABS PREFERRED PERPHENAZINE TABS PREFERRED COMPRO SUPP PREFERRED PROCHLORPERAZINE SUPP PREFERRED PROCHLORPERAZINE MALEATE TABS PREFERRED THIORIDAZINE HCL TABS PREFERRED TRIFLUOPERAZINE HCL TABS PREFERRED TRIFLUOPERAZINE HYDROCHLORIDE TABS PREFERRED THIOTHIXENE CAPS PREFERRED EQUETRO CP12 NON_PREFERRED VRAYLAR CAPS NON_PREFERRED VRAYLAR CPPK NON_PREFERRED LATUDA TABS NON_PREFERRED NUPLAZID CAPS NON_PREFERRED NUPLAZID TABS NON_PREFERRED GEODON CAPS NON_PREFERRED Page 30 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ZIPRASIDONE HCL CAPS PREFERRED ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED GEODON SOLR NON_PREFERRED LITHIUM SOLN PREFERRED LITHIUM CARBONATE CAPS PREFERRED LITHIUM CARBONATE TABS PREFERRED LITHIUM CARBONATE ER TBCR PREFERRED LITHOBID TBCR NON_PREFERRED ANTIPSYCHOTICS / ANTIMANIC AGENTS : QUINOLINONE DERIVATIVES ABILIFY MAINTENA PRSY PREFERRED_WITH_PA ARIPIPRAZOLE SOLN NON_PREFERRED ABILIFY MAINTENA SRER PREFERRED_WITH_PA ABILIFY TABS NON_PREFERRED ABILIFY MYCITE TABS NON_PREFERRED ARIPIPRAZOLE TABS PREFERRED ARIPIPRAZOLE ODT TBDP NON_PREFERRED ARISTADA PRSY PREFERRED_WITH_PA ARISTADA INITIO PRSY PREFERRED_WITH_PA REXULTI TABS NON_PREFERRED ANTIVIRALS : ANTIRETROVIRALS (HIV) SELZENTRY SOLN NON_PREFERRED SELZENTRY TABS NON_PREFERRED TROGARZO SOLN PREFERRED_WITH_PA FUZEON SOLR NON_PREFERRED TIVICAY TABS PREFERRED ISENTRESS CHEW PREFERRED ISENTRESS PACK PREFERRED ISENTRESS TABS PREFERRED ISENTRESS HD TABS PREFERRED ATAZANAVIR CAPS PREFERRED ATAZANAVIR SULFATE CAPS PREFERRED REYATAZ CAPS PREFERRED REYATAZ PACK PREFERRED PREZISTA SUSP PREFERRED PREZISTA TABS PREFERRED LEXIVA SUSP PREFERRED FOSAMPRENAVIR CALCIUM TABS PREFERRED LEXIVA TABS PREFERRED CRIXIVAN CAPS PREFERRED VIRACEPT TABS PREFERRED NORVIR PACK PREFERRED NORVIR SOLN PREFERRED NORVIR TABS PREFERRED RITONAVIR TABS PREFERRED INVIRASE TABS PREFERRED APTIVUS CAPS PREFERRED APTIVUS SOLN PREFERRED ABACAVIR SOLN PREFERRED Page 31 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ZIAGEN SOLN PREFERRED ABACAVIR TABS PREFERRED ABACAVIR SULFATE TABS PREFERRED ZIAGEN TABS NON_PREFERRED DIDANOSINE CPDR PREFERRED VIDEX EC CPDR NON_PREFERRED VIDEXPEDIATRIC SOLR PREFERRED EMTRIVA CAPS PREFERRED EMTRIVA SOLN PREFERRED EPIVIR SOLN NON_PREFERRED LAMIVUDINE SOLN PREFERRED EPIVIR TABS NON_PREFERRED LAMIVUDINE TABS PREFERRED STAVUDINE CAPS PREFERRED RETROVIR CAPS NON_PREFERRED ZIDOVUDINE CAPS PREFERRED RETROVIR SYRP NON_PREFERRED ZIDOVUDINE SYRP PREFERRED ZIDOVUDINE TABS PREFERRED VIREAD POWD PREFERRED TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED VIREAD TABS PREFERRED RESCRIPTOR TABS PREFERRED PIFELTRO TABS NON_PREFERRED CAPS PREFERRED SUSTIVA CAPS PREFERRED EFAVIRENZ TABS PREFERRED SUSTIVA TABS PREFERRED INTELENCE TABS PREFERRED NEVIRAPINE SUSP PREFERRED VIRAMUNE SUSP PREFERRED NEVIRAPINE TABS PREFERRED VIRAMUNE TABS NON_PREFERRED NEVIRAPINE ER TB24 PREFERRED VIRAMUNE XR TB24 NON_PREFERRED EDURANT TABS PREFERRED TYBOST TABS NON_PREFERRED ABACAVIR SULFATE/LAMIVUDINE TABS PREFERRED EPZICOM TABS NON_PREFERRED EVOTAZ TABS NON_PREFERRED DOVATO TABS PREFERRED PREZCOBIX TABS NON_PREFERRED JULUCA TABS NON_PREFERRED DESCOVY TABS PREFERRED TRUVADA TABS PREFERRED CIMDUO TABS NON_PREFERRED TEMIXYS TABS NON_PREFERRED Page 32 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM COMBIVIR TABS NON_PREFERRED LAMIVUDINE/ZIDOVUDINE TABS PREFERRED KALETRA SOLN NON_PREFERRED LOPINAVIR/RITONAVIR SOLN PREFERRED KALETRA TABS PREFERRED TRIUMEQ TABS PREFERRED ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS PREFERRED TRIZIVIR TABS NON_PREFERRED BIKTARVY TABS PREFERRED DELSTRIGO TABS PREFERRED ATRIPLA TABS PREFERRED SYMFI TABS PREFERRED SYMFI LO TABS PREFERRED ODEFSEY TABS PREFERRED COMPLERA TABS PREFERRED SYMTUZA TABS NON_PREFERRED GENVOYA TABS PREFERRED STRIBILD TABS NON_PREFERRED ANTIVIRALS : HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL TABS NON_PREFERRED HEPSERA TABS NON_PREFERRED BARACLUDE SOLN NON_PREFERRED BARACLUDE TABS NON_PREFERRED ENTECAVIR TABS PREFERRED EPIVIR HBV SOLN NON_PREFERRED EPIVIR HBV TABS NON_PREFERRED LAMIVUDINE TABS NON_PREFERRED VEMLIDY TABS NON_PREFERRED ANTIVIRALS : HEPATITIS C AGENTS PEGASYS SOLN NON_PREFERRED PEGASYS PROCLICK SOLN NON_PREFERRED PEGINTRON KIT PREFERRED_WITH_PA RIBAVIRIN CAPS PREFERRED RIBAVIRIN TABS PREFERRED SOVALDI TABS NON_PREFERRED ZEPATIER TABS NON_PREFERRED MAVYRET TABS PREFERRED_WITH_PA HARVONI TABS NON_PREFERRED LEDIPASVIR/SOFOSBUVIR TABS NON_PREFERRED EPCLUSA TABS NON_PREFERRED SOFOSBUVIR/VELPATASVIR TABS PREFERRED_WITH_PA VOSEVI TABS NON_PREFERRED VIEKIRA PAK TBPK NON_PREFERRED ANTIVIRALS : MISC PREVYMIS TABS NON_PREFERRED VALCYTE SOLR NON_PREFERRED VALGANCICLOVIR HYDROCHLORDE SOLR NON_PREFERRED VALCYTE TABS NON_PREFERRED VALGANCICLOVIR TABS PREFERRED ACYCLOVIR CAPS PREFERRED Page 33 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ZOVIRAX CAPS NON_PREFERRED ACYCLOVIR SUSP PREFERRED ZOVIRAX SUSP NON_PREFERRED ACYCLOVIR TABS PREFERRED SITAVIG TABS NON_PREFERRED ZOVIRAX TABS NON_PREFERRED VALACYCLOVIR HCL TABS PREFERRED VALACYCLOVIR HYDROCHLORIDE TABS PREFERRED VALTREX TABS NON_PREFERRED FAMCICLOVIR TABS NON_PREFERRED FLUMADINE TABS NON_PREFERRED RIMANTADINE HCL TABS NON_PREFERRED XOFLUZA TBPK NON_PREFERRED OSELTAMIVIR PHOSPHATE CAPS PREFERRED TAMIFLU CAPS NON_PREFERRED OSELTAMIVIR PHOSPHATE SUSR PREFERRED TAMIFLU SUSR NON_PREFERRED RELENZA DISKHALER AEPB PREFERRED RIBAVIRIN SOLR PREFERRED VIRAZOLE SOLR NON_PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITOR COMBINATIONS BESYLATE/BENAZEPRIL HCL CAPS PREFERRED AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE CAPS PREFERRED LOTREL CAPS NON_PREFERRED TARKA TBCR NON_PREFERRED TRANDOLAPRIL/VERAPAMIL HCL ER TBCR PREFERRED BENAZEPRIL HCL/ TABS PREFERRED BENAZEPRIL HYDROCHLORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED LOTENSIN HCT TABS NON_PREFERRED CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE TABS PREFERRED VASERETIC TABS NON_PREFERRED FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED LISINOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED ZESTORETIC TABS NON_PREFERRED ACCURETIC TABS NON_PREFERRED QUINAPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITORS BENAZEPRIL HCL TABS PREFERRED BENAZEPRIL HYDROCHLORIDE TABS PREFERRED LOTENSIN TABS NON_PREFERRED CAPTOPRIL TABS PREFERRED EPANED SOLN NON_PREFERRED ENALAPRIL MALEATE TABS PREFERRED VASOTEC TABS NON_PREFERRED FOSINOPRIL SODIUM TABS PREFERRED QBRELIS SOLN NON_PREFERRED Page 34 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LISINOPRIL TABS PREFERRED PRINIVIL TABS NON_PREFERRED ZESTRIL TABS NON_PREFERRED MOEXIPRIL HCL TABS PREFERRED PERINDOPRIL ERBUMINE TABS NON_PREFERRED ACCUPRIL TABS NON_PREFERRED QUINAPRIL HCL TABS PREFERRED QUINAPRIL HYDROCHLORIDE TABS PREFERRED ALTACE CAPS NON_PREFERRED RAMIPRIL CAPS PREFERRED TRANDOLAPRIL TABS PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS AMLODIPINE/OLMESARTAN MEDOXOMIL TABS NON_PREFERRED AZOR TABS NON_PREFERRED AMLODIPINE BESYLATE/VALSARTAN TABS NON_PREFERRED EXFORGE TABS NON_PREFERRED TELMISARTAN/AMLODIPINE TABS NON_PREFERRED TWYNSTA TABS NON_PREFERRED EDARBYCLOR TABS NON_PREFERRED ATACAND HCT TABS NON_PREFERRED CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED AVALIDE TABS NON_PREFERRED IRBESARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED HYZAAR TABS NON_PREFERRED LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED BENICAR HCT TABS NON_PREFERRED OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED MICARDIS HCT TABS NON_PREFERRED TELMISARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED DIOVAN HCT TABS NON_PREFERRED VALSARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED AMLODIPINE/VALSARTAN/HCTZ TABS NON_PREFERRED AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED EXFORGE HCT TABS NON_PREFERRED OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED TRIBENZOR TABS NON_PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II RECEPTOR BLOCKERS EDARBI TABS NON_PREFERRED ATACAND TABS NON_PREFERRED CANDESARTAN CILEXETIL TABS NON_PREFERRED EPROSARTAN MESYLATE TABS NON_PREFERRED AVAPRO TABS NON_PREFERRED IRBESARTAN TABS PREFERRED COZAAR TABS NON_PREFERRED LOSARTAN POTASSIUM TABS PREFERRED BENICAR TABS NON_PREFERRED OLMESARTAN MEDOXOMIL TABS NON_PREFERRED Page 35 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MICARDIS TABS NON_PREFERRED TELMISARTAN TABS NON_PREFERRED DIOVAN TABS NON_PREFERRED VALSARTAN TABS PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANTIADRENERGICS CATAPRES-TTS-1 PTWK NON_PREFERRED CATAPRES-TTS-2 PTWK NON_PREFERRED CATAPRES-TTS-3 PTWK NON_PREFERRED CLONIDINE HCL PTWK PREFERRED CATAPRES TABS NON_PREFERRED CLONIDINE HCL TABS PREFERRED CLONIDINE HYDROCHLORIDE TABS PREFERRED GUANFACINE HCL TABS PREFERRED GUANFACINE HYDROCHLORIDE TABS PREFERRED METHYLDOPA TABS PREFERRED CARDURA TABS NON_PREFERRED DOXAZOSIN TABS PREFERRED DOXAZOSIN MESYLATE TABS PREFERRED MINIPRESS CAPS NON_PREFERRED PRAZOSIN HCL CAPS PREFERRED PRAZOSIN HYDROCHLORIDE CAPS PREFERRED TERAZOSIN HCL CAPS PREFERRED TERAZOSIN HYDROCHLORIDE CAPS PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKER COMBINATIONS ATENOLOL/CHLORTHALIDONE TABS PREFERRED TENORETIC 100 TABS NON_PREFERRED TENORETIC 50 TABS NON_PREFERRED BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TABS PREFERRED ZIAC TABS NON_PREFERRED METOPROLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKERS CORGARD TABS NON_PREFERRED NADOLOL TABS PREFERRED PINDOLOL TABS PREFERRED INDERAL LA CP24 NON_PREFERRED PROPRANOLOL HCL ER CP24 PREFERRED PROPRANOLOL HYDROCHLORIDE ER CP24 PREFERRED HEMANGEOL SOLN PREFERRED_WITH_PA PROPRANOLOL HCL SOLN PREFERRED PROPRANOLOL HCL TABS PREFERRED PROPRANOLOL HYDROCHLORIDE TABS PREFERRED INDERAL XL CP24 NON_PREFERRED INNOPRAN XL CP24 NON_PREFERRED SOTYLIZE SOLN NON_PREFERRED BETAPACE TABS NON_PREFERRED SORINE TABS PREFERRED Page 36 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SOTALOL HCL TABS PREFERRED SOTALOL HYDROCHLORIDE TABS PREFERRED SOTALOL HYDROCHOLRIDE TABS PREFERRED BETAPACE AF TABS NON_PREFERRED SOTALOL HCL (AF) TABS NON_PREFERRED SOTALOL HCL AF TABS NON_PREFERRED SOTALOL HYDROCHLORIDE (AF) TABS NON_PREFERRED SOTALOL HYDROCHLORIDE AF TABS NON_PREFERRED TIMOLOL MALEATE TABS PREFERRED ACEBUTOLOL HCL CAPS PREFERRED ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED FIRST-ATENOLOL SOLN NON_PREFERRED ATENOLOL TABS PREFERRED TENORMIN TABS NON_PREFERRED BETAXOLOL HCL TABS PREFERRED BISOPROLOL FUMARATE TABS PREFERRED KAPSPARGO SPRINKLE CS24 NON_PREFERRED METOPROLOL SUCCINATE ER TB24 PREFERRED TOPROL XL TB24 NON_PREFERRED FIRST - METOPROLOL SOLN NON_PREFERRED LOPRESSOR TABS NON_PREFERRED METOPROLOL TARTRATE TABS PREFERRED BYSTOLIC TABS NON_PREFERRED CARVEDILOL TABS PREFERRED COREG TABS NON_PREFERRED CARVEDILOL PHOSPHATE CP24 NON_PREFERRED COREG CR CP24 NON_PREFERRED LABETALOL HYDROCHLORIDE TABS PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS KATERZIA SUSP NON_PREFERRED AMLODIPINE BESYLATE TABS PREFERRED NORVASC TABS NON_PREFERRED DILTIAZEM HCL ER CP12 PREFERRED DILT-XR CP24 NON_PREFERRED CARDIZEM TABS NON_PREFERRED DILTIAZEM HCL TABS PREFERRED DILTIAZEM HCL ER CP24 PREFERRED DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED TAZTIA XT CP24 PREFERRED TIADYLT ER CP24 PREFERRED TIAZAC CP24 NON_PREFERRED CARDIZEM CD CP24 NON_PREFERRED CARTIA XT CP24 PREFERRED DILTIAZEM HCL CD CP24 PREFERRED DILTIAZEM HCL ER CP24 PREFERRED DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED CARDIZEM LA TB24 NON_PREFERRED Page 37 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM DILTIAZEM HCL ER TB24 PREFERRED MATZIM LA TB24 PREFERRED ER TB24 PREFERRED ISRADIPINE CAPS NON_PREFERRED NICARDIPINE HCL CAPS NON_PREFERRED CAPS PREFERRED PROCARDIA CAPS NON_PREFERRED ADALAT CC TB24 NON_PREFERRED NIFEDIPINE ER TB24 PREFERRED PROCARDIA XL TB24 NON_PREFERRED CAPS PREFERRED NYMALIZE SOLN NON_PREFERRED NISOLDIPINE ER TB24 NON_PREFERRED SULAR TB24 NON_PREFERRED VERAPAMIL HCL ER CP24 PREFERRED VERAPAMIL HCL SR CP24 PREFERRED VERELAN CP24 NON_PREFERRED VERELAN PM CP24 NON_PREFERRED CALAN TABS NON_PREFERRED VERAPAMIL HCL TABS PREFERRED VERAPAMIL HYDROCHLORIDE TABS PREFERRED CALAN SR TBCR NON_PREFERRED VERAPAMIL HCL ER TBCR PREFERRED VERAPAMIL HYDROCHLORIDE ER TBCR PREFERRED CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : MISC ALISKIREN TABS NON_PREFERRED TEKTURNA TABS NON_PREFERRED TABS NON_PREFERRED INSPRA TABS NON_PREFERRED PHENOXYBENZAMINE HYDROCHLORIDE CAPS NON_PREFERRED DEMSER CAPS PREFERRED HYDRALAZINE HCL TABS PREFERRED HYDRALAZINE HYDROCHLORIDE TABS PREFERRED MINOXIDIL TABS PREFERRED VECAMYL TABS NON_PREFERRED METHYLDOPA/HYDROCHLOROTHIAZIDE TABS PREFERRED TEKTURNA HCT TABS NON_PREFERRED

CARDIOVASCULAR AGENTS - CARDIOTONICS : CARDIAC GLYCOSIDES DIGOXIN SOLN PREFERRED DIGITEK TABS PREFERRED DIGOX TABS PREFERRED DIGOXIN TABS PREFERRED CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS DILATRATE SR CPCR PREFERRED ISORDIL TITRADOSE TABS NON_PREFERRED ISOSORBIDE DINITRATE TABS PREFERRED ISOSORBIDE MONONITRATE TABS PREFERRED ISOSORBIDE MONONITRATE ER TB24 PREFERRED NITROMIST AERS NON_PREFERRED Page 38 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM NITRO-BID OINT PREFERRED GONITRO PACK NON_PREFERRED MINITRAN PT24 PREFERRED NITRO-DUR PT24 NON_PREFERRED NITROGLYCERIN TRANSDERMAL PT24 PREFERRED NITROGLYCERIN LINGUAL SOLN NON_PREFERRED NITROLINGUAL PUMPSPRAY SOLN NON_PREFERRED NITROGLYCERIN SUBL PREFERRED NITROSTAT SUBL NON_PREFERRED RANEXA TB12 NON_PREFERRED RANOLAZINE ER TB12 NON_PREFERRED CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAPS PREFERRED NORPACE CAPS NON_PREFERRED NORPACE CR CP12 PREFERRED QUINIDINE GLUCONATE CR TBCR PREFERRED QUINIDINE SULFATE TABS PREFERRED MEXILETINE HCL CAPS PREFERRED FLECAINIDE ACETATE TABS PREFERRED PROPAFENONE HYDROCHLORIDE ER CP12 NON_PREFERRED RYTHMOL SR CP12 NON_PREFERRED PROPAFENONE HCL TABS PREFERRED AMIODARONE HCL TABS PREFERRED AMIODARONE HYDROCHLORIDE TABS PREFERRED PACERONE TABS PREFERRED DOFETILIDE CAPS PREFERRED TIKOSYN CAPS NON_PREFERRED MULTAQ TABS NON_PREFERRED CARDIOVASCULAR AGENTS : ER CP12 PREFERRED ACETAZOLAMIDE TABS PREFERRED KEVEYIS TABS NON_PREFERRED METHAZOLAMIDE TABS PREFERRED TABS PREFERRED BUMEX TABS NON_PREFERRED EDECRIN TABS NON_PREFERRED ETHACRYNIC ACID TABS PREFERRED SOLN PREFERRED FUROSEMIDE TABS PREFERRED LASIX TABS NON_PREFERRED TORSEMIDE TABS PREFERRED HCL TABS PREFERRED CAROSPIR SUSP NON_PREFERRED ALDACTONE TABS NON_PREFERRED TABS PREFERRED CAPS PREFERRED DIURIL SUSP PREFERRED TABS PREFERRED CHLORTHALIDONE TABS PREFERRED Page 39 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM HYDROCHLOROTHIAZIDE CAPS PREFERRED HYDROCHLOROTHIAZIDE TABS PREFERRED TABS PREFERRED TABS PREFERRED AMILORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED ALDACTAZIDE TABS NON_PREFERRED SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS PREFERRED DYAZIDE CAPS NON_PREFERRED TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS PREFERRED MAXZIDE TABS NON_PREFERRED MAXZIDE-25 TABS NON_PREFERRED TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS PREFERRED CARDIOVASCULAR AGENTS : MISC MIDODRINE HCL TABS PREFERRED MIDODRINE HYDROCHLORIDE TABS PREFERRED NORTHERA CAPS NON_PREFERRED CIALIS TABS NON_PREFERRED TADALAFIL TABS NON_PREFERRED VYNDAMAX CAPS NON_PREFERRED VYNDAQEL CAPS NON_PREFERRED CORLANOR SOLN NON_PREFERRED CORLANOR TABS NON_PREFERRED ENTRESTO TABS NON_PREFERRED AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS NON_PREFERRED CADUET TABS NON_PREFERRED BIDIL TABS PREFERRED CARDIOVASCULAR AGENTS : PULMONARY HYPERTENSION UPTRAVI TABS NON_PREFERRED UPTRAVI TBPK NON_PREFERRED ADEMPAS TABS NON_PREFERRED REVATIO SOLN NON_PREFERRED SILDENAFIL SOLN NON_PREFERRED REVATIO SUSR PREFERRED_WITH_PA SILDENAFIL CITRATE SUSR NON_PREFERRED REVATIO TABS NON_PREFERRED SILDENAFIL CITRATE TABS PREFERRED_WITH_PA ADCIRCA TABS PREFERRED_WITH_PA ALYQ TABS PREFERRED_WITH_PA TADALAFIL TABS PREFERRED_WITH_PA AMBRISENTAN TABS NON_PREFERRED LETAIRIS TABS PREFERRED_WITH_PA BOSENTAN TABS NON_PREFERRED TRACLEER TABS PREFERRED_WITH_PA TRACLEER TBSO PREFERRED_WITH_PA OPSUMIT TABS NON_PREFERRED EPOPROSTENOL SODIUM SOLR PREFERRED_WITH_PA FLOLAN SOLR PREFERRED_WITH_PA VELETRI SOLR NON_PREFERRED VENTAVIS SOLN NON_PREFERRED Page 40 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM REMODULIN SOLN NON_PREFERRED TREPROSTINIL SOLN NON_PREFERRED TYVASO SOLN NON_PREFERRED TYVASO REFILL SOLN NON_PREFERRED TYVASO STARTER SOLN NON_PREFERRED ORENITRAM TBCR NON_PREFERRED CONTRACEPTIVES : COMBINATION CONTRACEPTIVES XULANE PTWK PREFERRED ELURYNG RING PREFERRED /ETHINYL ESTR RING PREFERRED NUVARING RING PREFERRED APRI TABS PREFERRED CYRED TABS PREFERRED CYRED EQ TABS PREFERRED /ETHINYL TABS PREFERRED EMOQUETTE TABS PREFERRED ENSKYCE TABS PREFERRED ISIBLOOM TABS PREFERRED JULEBER TABS PREFERRED KALLIGA TABS PREFERRED RECLIPSEN TABS PREFERRED /ETHINYL ESTRADIOL TABS PREFERRED GIANVI TABS PREFERRED JASMIEL TABS PREFERRED LO-ZUMANDIMINE TABS PREFERRED LORYNA TABS PREFERRED NIKKI TABS PREFERRED OCELLA TABS PREFERRED SYEDA TABS PREFERRED YASMIN 28 TABS PREFERRED YAZ TABS PREFERRED ZARAH TABS PREFERRED ZUMANDIMINE TABS PREFERRED ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL TABS PREFERRED KELNOR 1/35 TABS PREFERRED KELNOR 1/50 TABS PREFERRED ZOVIA 1/35E TABS PREFERRED AFIRMELLE TABS PREFERRED ALTAVERA TABS PREFERRED AUBRA TABS PREFERRED AUBRA EQ TABS PREFERRED AVIANE TABS PREFERRED AYUNA TABS PREFERRED CHATEAL TABS PREFERRED CHATEAL EQ TABS PREFERRED FALMINA TABS PREFERRED KURVELO TABS PREFERRED LARISSIA TABS PREFERRED Page 41 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LESSINA TABS PREFERRED /ETHINYL ESTRADIOL TABS PREFERRED LEVORA 0.15/30-28 TABS PREFERRED LILLOW TABS PREFERRED LUTERA TABS PREFERRED MARLISSA TABS PREFERRED ORSYTHIA TABS PREFERRED PORTIA-28 TABS PREFERRED SRONYX TABS PREFERRED VIENVA TABS PREFERRED ALYACEN 1/35 TABS PREFERRED BALZIVA TABS PREFERRED BRIELLYN TABS PREFERRED CYCLAFEM 1/35 TABS PREFERRED DASETTA 1/35 TABS PREFERRED NECON 0.5/35-28 TABS PREFERRED NORTREL 0.5/35 (28) TABS PREFERRED NORTREL 1/35 TABS PREFERRED ORTHO-NOVUM 1/35 TABS PREFERRED PHILITH TABS PREFERRED PIRMELLA 1/35 TABS PREFERRED VYFEMLA TABS PREFERRED WERA TABS PREFERRED AUROVELA 1.5/30 TABS PREFERRED AUROVELA 1/20 TABS PREFERRED HAILEY 1.5/30 TABS PREFERRED JUNEL 1.5/30 TABS PREFERRED JUNEL 1/20 TABS PREFERRED LARIN 1.5/30 TABS PREFERRED LARIN 1/20 TABS PREFERRED LOESTRIN 1.5/30-21 TABS PREFERRED LOESTRIN 1/20-21 TABS PREFERRED MICROGESTIN 1.5/30 TABS PREFERRED MICROGESTIN 1/20 TABS PREFERRED NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS PREFERRED CRYSELLE-28 TABS PREFERRED ELINEST TABS PREFERRED LOW-OGESTREL TABS PREFERRED OGESTREL TABS PREFERRED ESTARYLLA TABS PREFERRED FEMYNOR TABS PREFERRED MILI TABS PREFERRED MONO-LINYAH TABS PREFERRED /ETHINYL ESTRADIOL TABS PREFERRED PREVIFEM TABS PREFERRED SPRINTEC 28 TABS PREFERRED VYLIBRA TABS PREFERRED Page 42 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM BEYAZ TABS PREFERRED DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS PREFERRED SAFYRAL TABS PREFERRED TYDEMY TABS PREFERRED BALCOLTRA TABS PREFERRED FALESSA KIT PREFERRED GENERESS FE CHEW PREFERRED KAITLIB FE CHEW PREFERRED LAYOLIS FE CHEW PREFERRED NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE CHEW PREFERRED NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED WYMZYA FE CHEW PREFERRED TAYTULLA CAPS PREFERRED MELODETTA 24 FE CHEW PREFERRED MIBELAS 24 FE CHEW PREFERRED MINASTRIN 24 FE CHEW PREFERRED NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED AUROVELA 24 FE TABS PREFERRED AUROVELA FE 1.5/30 TABS PREFERRED AUROVELA FE 1/20 TABS PREFERRED BLISOVI 24 FE TABS PREFERRED BLISOVI FE 1.5/30 TABS PREFERRED BLISOVI FE 1/20 TABS PREFERRED HAILEY 24 FE TABS PREFERRED JUNEL FE 1.5/30 TABS PREFERRED JUNEL FE 1/20 TABS PREFERRED JUNEL FE 24 TABS PREFERRED LARIN 24 FE TABS PREFERRED LARIN FE 1.5/30 TABS PREFERRED LARIN FE 1/20 TABS PREFERRED LOESTRIN FE 1.5/30 TABS PREFERRED LOESTRIN FE 1/20 TABS PREFERRED MICROGESTIN FE TABS PREFERRED MICROGESTIN FE 1.5/30 TABS PREFERRED NORETHINDRONE ACETATE/ETH TABS PREFERRED NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS PREFERRED TARINA 24 FE TABS PREFERRED TARINA FE 1/20 TABS PREFERRED TARINA FE 1/20 EQ TABS PREFERRED AZURETTE TABS PREFERRED BEKYREE TABS PREFERRED DESOGESTREL/ETHINYL ESTRADIOL TABS PREFERRED KARIVA TABS PREFERRED MIRCETTE TABS PREFERRED PIMTREA TABS PREFERRED SIMLIYA TABS PREFERRED VIORELE TABS PREFERRED Page 43 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LO LOESTRIN FE TABS PREFERRED CAZIANT TABS PREFERRED VELIVET TABS PREFERRED ENPRESSE-28 TABS PREFERRED LEVONEST TABS PREFERRED LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED TRIVORA-28 TABS PREFERRED ALYACEN 7/7/7 TABS PREFERRED ARANELLE TABS PREFERRED CYCLAFEM 7/7/7 TABS PREFERRED DASETTA 7/7/7 TABS PREFERRED LEENA TABS PREFERRED NORTREL 7/7/7 TABS PREFERRED ORTHO-NOVUM 7/7/7 TABS PREFERRED PIRMELLA 7/7/7 TABS PREFERRED NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED ORTHO TRI-CYCLEN LO TABS PREFERRED TRI FEMYNOR TABS PREFERRED TRI-ESTARYLLA TABS PREFERRED TRI-LINYAH TABS PREFERRED TRI-LO-ESTARYLLA TABS PREFERRED TRI-LO-MARZIA TABS PREFERRED TRI-LO-MILI TABS PREFERRED TRI-LO-SPRINTEC TABS PREFERRED TRI-MILI TABS PREFERRED TRI-PREVIFEM TABS PREFERRED TRI-SPRINTEC TABS PREFERRED TRI-VYLIBRA TABS PREFERRED TRI-VYLIBRA LO TABS PREFERRED ESTROSTEP FE TABS PREFERRED TILIA FE TABS PREFERRED TRI-LEGEST FE TABS PREFERRED NATAZIA TABS PREFERRED AMETHIA TABS PREFERRED AMETHIA LO TABS PREFERRED ASHLYNA TABS PREFERRED CAMRESE TABS PREFERRED CAMRESE LO TABS PREFERRED DAYSEE TABS PREFERRED FAYOSIM TABS PREFERRED INTROVALE TABS PREFERRED JOLESSA TABS PREFERRED LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED LOSEASONIQUE TABS PREFERRED QUARTETTE TABS PREFERRED RIVELSA TABS PREFERRED Page 44 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SEASONIQUE TABS PREFERRED SETLAKIN TABS PREFERRED SIMPESSE TABS PREFERRED AMETHYST TABS PREFERRED LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED CONTRACEPTIVES : EMERGENCY CONTRACEPTIVES AFTERA TABS PREFERRED ECONTRA EZ TABS PREFERRED ECONTRA ONE-STEP TABS PREFERRED LEVONORGESTREL TABS PREFERRED MY CHOICE TABS PREFERRED MY WAY TABS PREFERRED NEW DAY TABS PREFERRED OPCICON ONE-STEP TABS PREFERRED OPTION 2 TABS PREFERRED PLAN B ONE-STEP TABS PREFERRED TAKE ACTION TABS PREFERRED ELLA TABS PREFERRED CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES CAMILA TABS PREFERRED DEBLITANE TABS PREFERRED ERRIN TABS PREFERRED HEATHER TABS PREFERRED INCASSIA TABS PREFERRED JENCYCLA TABS PREFERRED LYZA TABS PREFERRED NORA-BE TABS PREFERRED NORETHINDRONE TABS PREFERRED NORLYDA TABS PREFERRED ORTHO MICRONOR TABS PREFERRED SHAROBEL TABS PREFERRED TULANA TABS PREFERRED SLYND TABS PREFERRED DEPO-PROVERA CONTRACEPTIVE SUSP PREFERRED ACETATE SUSP PREFERRED DEPO-PROVERA CONTRACEPTIVE SUSY PREFERRED DEPO-SUBQ PROVERA 104 SUSY PREFERRED MEDROXYPROGESTERONE ACETATE SUSY PREFERRED BUDESONIDE CPEP NON_PREFERRED ENTOCORT EC CPEP NON_PREFERRED BUDESONIDE ER TB24 NON_PREFERRED UCERIS TB24 NON_PREFERRED ACETATE TABS NON_PREFERRED EMFLAZA SUSP NON_PREFERRED EMFLAZA TABS NON_PREFERRED INTENSOL CONC PREFERRED DEXAMETHASONE ELIX PREFERRED DEXAMETHASONE SOLN PREFERRED DECADRON TABS PREFERRED Page 45 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM DEXAMETHASONE TABS PREFERRED DEXAMETHASONE 10-DAY DOSE PACK TBPK PREFERRED DEXAMETHASONE 13-DAY DOSE PACK TBPK PREFERRED DEXAMETHASONE 6-DAY DOSEPACK TBPK PREFERRED DEXPAK 10 DAY TBPK NON_PREFERRED DEXPAK 13 DAY TBPK NON_PREFERRED DEXPAK 6 DAY TBPK NON_PREFERRED DXEVO 11-DAY TBPK NON_PREFERRED TAPERDEX 12-DAY TBPK NON_PREFERRED TAPERDEX 6-DAY TBPK NON_PREFERRED TAPERDEX 7-DAY TBPK NON_PREFERRED CORTEF TABS NON_PREFERRED HYDROCORTISONE TABS PREFERRED MEDROL TABS NON_PREFERRED TABS PREFERRED MEDROL DOSEPAK TBPK NON_PREFERRED METHYLPREDNISOLONE DOSE PACK TBPK PREFERRED SOLN PREFERRED MILLIPRED TABS PREFERRED MILLIPRED DP TBPK PREFERRED PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED PREDNISOLONE SODIUM PHOSPHATE ODT TBDP NON_PREFERRED INTENSOL CONC PREFERRED PREDNISONE SOLN PREFERRED PREDNISONE TABS PREFERRED RAYOS TBEC NON_PREFERRED PREDNISONE TBPK PREFERRED ACETATE TABS PREFERRED DERMATOLOGICALS : ACNE PRODUCTS ADAPALENE CREA NON_PREFERRED DIFFERIN CREA NON_PREFERRED ADAPALENE GEL NON_PREFERRED ADAPALENE PUMP GEL NON_PREFERRED DIFFERIN GEL NON_PREFERRED DIFFERIN LOTN NON_PREFERRED ADAPALENE SOLN NON_PREFERRED AZELEX CREA NON_PREFERRED BPO GEL NON_PREFERRED ABSORICA CAPS NON_PREFERRED AMNESTEEM CAPS NON_PREFERRED CLARAVIS CAPS NON_PREFERRED ISOTRETINOIN CAPS NON_PREFERRED MYORISAN CAPS NON_PREFERRED ZENATANE CAPS NON_PREFERRED ABSORICA LD CAPS NON_PREFERRED FABIOR FOAM NON_PREFERRED AVITA CREA PREFERRED RETIN-A CREA NON_PREFERRED Page 46 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TRETINOIN CREA PREFERRED ATRALIN GEL NON_PREFERRED AVITA GEL PREFERRED RETIN-A GEL NON_PREFERRED TRETINOIN GEL PREFERRED ALTRENO LOTN NON_PREFERRED RETIN-A MICRO GEL NON_PREFERRED RETIN-A MICRO PUMP GEL NON_PREFERRED TRETINOIN MICROSPHERE GEL NON_PREFERRED TRETINOIN MICROSPHERE PUMP GEL NON_PREFERRED AKLIEF CREA NON_PREFERRED CLINDAMYCIN PHOSPHATE FOAM NON_PREFERRED EVOCLIN FOAM NON_PREFERRED CLEOCIN-T GEL NON_PREFERRED CLINDAGEL GEL NON_PREFERRED CLINDAMYCIN PHOSPHATE GEL PREFERRED CLEOCIN-T LOTN NON_PREFERRED CLINDAMYCIN PHOSPHATE LOTN PREFERRED CLINDAMYCIN PHOSPHATE SOLN PREFERRED CLINDACIN ETZ PLEDGETS SWAB PREFERRED CLINDACIN-P SWAB PREFERRED CLINDAMYCIN PHOSPHATE SWAB PREFERRED ACZONE GEL NON_PREFERRED DAPSONE GEL NON_PREFERRED ERYGEL GEL NON_PREFERRED ERYTHROMYCIN GEL PREFERRED ERY PADS NON_PREFERRED ERYTHROMYCIN SOLN PREFERRED KLARON LOTN NON_PREFERRED SODIUM SULFACETAMIDE LOTN NON_PREFERRED SULFACETAMIDE SODIUM LOTN NON_PREFERRED ADAPALENE/BENZOYL PEROXIDE GEL NON_PREFERRED EPIDUO GEL NON_PREFERRED EPIDUO FORTE GEL NON_PREFERRED BENZAMYCIN GEL NON_PREFERRED ERYTHROMYCIN/BENZOYL PEROXIDE GEL PREFERRED ACANYA GEL NON_PREFERRED BENZACLIN GEL NON_PREFERRED BENZACLIN WITH PUMP GEL NON_PREFERRED CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED CLINDAMYCIN/BENZOYL PEROXIDE GEL NON_PREFERRED ONEXTON GEL NON_PREFERRED CLINDAMYCIN PHOSPHATE/BEN GEL NON_PREFERRED CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED DUAC GEL NON_PREFERRED NEUAC GEL NON_PREFERRED CLINDACIN ETZ KIT NON_PREFERRED Page 47 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CLINDACIN PAC KIT NON_PREFERRED CLINDAMYCIN PHOSPHATE/TRETINOIN GEL NON_PREFERRED ZIANA GEL NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR CREA NON_PREFERRED SSS 10%-5% CREA NON_PREFERRED BP 10-1 EMUL NON_PREFERRED SULFACETAMIDE SODIUM/SULFUR CLEANSER EMUL NON_PREFERRED SSS 10-5 FOAM NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR LIQD NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR CLEANSER LIQD NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR WASH LIQD NON_PREFERRED SUMADAN WASH LIQD NON_PREFERRED SUMAXIN WASH LIQD NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR PADS NON_PREFERRED SUMAXIN PADS NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR SUSP NON_PREFERRED BP CLEANSING WASH EMUL NON_PREFERRED SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL NON_PREFERRED SUMADAN KIT KIT NON_PREFERRED SUMAXIN CP KIT KIT NON_PREFERRED SUMADAN XLT KIT NON_PREFERRED NEUAC KIT KIT NON_PREFERRED DERMATOLOGICALS : ANTIBIOTICS GENTAMICIN SULFATE CREA PREFERRED GENTAMICIN SULFATE OINT PREFERRED CENTANY AT KIT NON_PREFERRED CENTANY OINT NON_PREFERRED MUPIROCIN OINT PREFERRED MUPIROCIN CREA NON_PREFERRED NEO-SYNALAR CREA NON_PREFERRED CORTISPORIN CREA NON_PREFERRED NEO-SYNALAR KIT KIT NON_PREFERRED CORTISPORIN OINT PREFERRED DERMATOLOGICALS : ANTIFUNGALS MENTAX CREA NON_PREFERRED CICLOPIROX GEL NON_PREFERRED CICLODAN SOLUTION KIT KIT NON_PREFERRED CICLOPIROX TREATMENT KIT NON_PREFERRED CICLOPIROX SHAM NON_PREFERRED LOPROX SHAMPOO SHAM NON_PREFERRED CICLODAN SOLN NON_PREFERRED CICLOPIROX NAIL LACQUER SOLN NON_PREFERRED PENLAC NAIL LACQUER SOLN NON_PREFERRED CICLOPIROX OLAMINE CREA NON_PREFERRED LOPROX CREA NON_PREFERRED CICLOPIROX SUSP NON_PREFERRED LOPROX SUSP NON_PREFERRED LOPROX KIT NON_PREFERRED LOPROX KIT KIT NON_PREFERRED Page 48 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM NAFTIFINE HCL CREA NON_PREFERRED NAFTIFINE HYDROCHLORIDE CREA NON_PREFERRED NAFTIN CREA NON_PREFERRED NAFTIFINE HYDROCHLORIDE GEL NON_PREFERRED NAFTIN GEL NON_PREFERRED NYSTATIN CREA PREFERRED NYSTATIN OINT PREFERRED NYAMYC POWD PREFERRED NYSTATIN POWD PREFERRED NYSTOP POWD PREFERRED CLOTRIMAZOLE CREA PREFERRED CLOTRIMAZOLE SOLN NON_PREFERRED ECONAZOLE NITRATE CREA PREFERRED JUBLIA SOLN NON_PREFERRED KETOCONAZOLE CREA PREFERRED EXTINA FOAM NON_PREFERRED KETOCONAZOLE FOAM NON_PREFERRED KETOCONAZOLE SHAM PREFERRED NIZORAL SHAM NON_PREFERRED LULICONAZOLE CREA NON_PREFERRED LUZU CREA NON_PREFERRED OXICONAZOLE NITRATE CREA NON_PREFERRED OXISTAT CREA NON_PREFERRED OXISTAT LOTN NON_PREFERRED ERTACZO CREA NON_PREFERRED EXELDERM CREA NON_PREFERRED EXELDERM SOLN NON_PREFERRED KERYDIN SOLN NON_PREFERRED CLOTRIMAZOLE/ DIPROPIONATE CREA NON_PREFERRED LOTRISONE CREA NON_PREFERRED CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED NYSTATIN/ CREA NON_PREFERRED NYSTATIN/ CREA NON_PREFERRED NYSTATIN/TRIAMCINOLONE OINT NON_PREFERRED NYSTATIN/TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED DERMACINRX THERAZOLE PAK THPK NON_PREFERRED NITRATE/ OXIDE/WHITE PETROLATUM OINT NON_PREFERRED VUSION OINT NON_PREFERRED DERMATOLOGICALS : ANTIPSORIATICS CALCIPOTRIENE CREA PREFERRED DOVONEX CREA NON_PREFERRED SORILUX FOAM NON_PREFERRED CALCIPOTRIENE OINT PREFERRED CALCIPOTRIENE SOLN PREFERRED CALCITRIOL OINT NON_PREFERRED VECTICAL OINT NON_PREFERRED TAZAROTENE CREA NON_PREFERRED TAZORAC CREA NON_PREFERRED Page 49 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TAZORAC GEL NON_PREFERRED ACITRETIN CAPS NON_PREFERRED SORIATANE CAPS NON_PREFERRED SILIQ SOSY NON_PREFERRED TREMFYA SOPN NON_PREFERRED TREMFYA SOSY NON_PREFERRED TALTZ SOAJ NON_PREFERRED TALTZ SOSY NON_PREFERRED METHOXSALEN CAPS NON_PREFERRED OXSORALEN ULTRA CAPS NON_PREFERRED SKYRIZI PSKT NON_PREFERRED COSENTYX SENSOREADY PEN SOAJ NON_PREFERRED COSENTYX SOSY NON_PREFERRED ILUMYA SOSY NON_PREFERRED STELARA SOLN NON_PREFERRED STELARA SOSY NON_PREFERRED DERMATOLOGICALS : CORTICOSTEROIDS - TOPICAL DIPROPIONATE CREA PREFERRED ALCLOMETASONE DIPROPIONATE OINT PREFERRED CREA NON_PREFERRED AMCINONIDE LOTN NON_PREFERRED BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED SERNIVO EMUL NON_PREFERRED BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED AUGMENTED BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED AUGMENTED BETAMETHASONE DIPROPIONATE GEL NON_PREFERRED AUGMENTED BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED AUGMENTED BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED DIPROLENE OINT NON_PREFERRED BETAMETHASONE VALERATE CREA PREFERRED BETAMETHASONE VALERATE FOAM NON_PREFERRED LUXIQ FOAM NON_PREFERRED BETAMETHASONE VALERATE LOTN PREFERRED BETAMETHASONE VALERATE OINT PREFERRED PROPIONATE CREA PREFERRED TEMOVATE CREA NON_PREFERRED FOAM NON_PREFERRED OLUX FOAM NON_PREFERRED CLOBETASOL PROPIONATE GEL PREFERRED CLOBETASOL PROPIONATE LIQD NON_PREFERRED CLOBEX LIQD NON_PREFERRED CLOBETASOL PROPIONATE LOTN NON_PREFERRED CLOBEX LOTN NON_PREFERRED CLOBETASOL PROPIONATE OINT PREFERRED TEMOVATE OINT NON_PREFERRED CLOBETASOL PROPIONATE SHAM NON_PREFERRED CLOBEX SHAM NON_PREFERRED Page 50 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CLODAN SHAM NON_PREFERRED CLOBETASOL PROPIONATE SOLN PREFERRED CLOBETASOL PROPIONATE E CREA PREFERRED CLOBETASOL PROPIONATE EMOLLIENT CREA PREFERRED CLOBETASOL PROPIONATE FOAM NON_PREFERRED CLOBETASOL PROPIONATE EMOLLIENT FOAM NON_PREFERRED OLUX-E FOAM NON_PREFERRED TOVET FOAM NON_PREFERRED TOVET KIT KIT NON_PREFERRED PIVALATE CREA NON_PREFERRED CLODERM CREA NON_PREFERRED CREA PREFERRED DESOWEN CREA NON_PREFERRED DESONATE GEL NON_PREFERRED DESONIDE LOTN NON_PREFERRED DESONIDE OINT PREFERRED CREA NON_PREFERRED TOPICORT CREA NON_PREFERRED DESOXIMETASONE GEL NON_PREFERRED TOPICORT GEL NON_PREFERRED DESOXIMETASONE LIQD NON_PREFERRED TOPICORT LIQD NON_PREFERRED DESOXIMETASONE OINT NON_PREFERRED TOPICORT OINT NON_PREFERRED DIACETATE CREA PREFERRED PSORCON CREA NON_PREFERRED OINT PREFERRED APEXICON E CREA NON_PREFERRED ACETONIDE CREA PREFERRED SYNALAR CREA NON_PREFERRED DERMA-SMOOTHE/FS BODY OIL NON_PREFERRED DERMA-SMOOTHE/FS SCALP OIL NON_PREFERRED BODY OIL PREFERRED FLUOCINOLONE ACETONIDE SCALP OIL PREFERRED FLUOCINOLONE ACETONIDE OINT PREFERRED SYNALAR OINT NON_PREFERRED CAPEX SHAM NON_PREFERRED FLUOCINOLONE ACETONIDE SOLN PREFERRED SYNALAR SOLN NON_PREFERRED CREA PREFERRED VANOS CREA NON_PREFERRED FLUOCINONIDE GEL PREFERRED FLUOCINONIDE OINT PREFERRED FLUOCINONIDE SOLN PREFERRED FLUOCINONIDE EMULSIFIED BASE CREA PREFERRED FLUOCINONIDE EMULSIFIEDBASE CREA PREFERRED FLURANDRENOLIDE CREA NON_PREFERRED Page 51 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM FLURANDRENOLIDE LOTN NON_PREFERRED FLURANDRENOLIDE OINT NON_PREFERRED CORDRAN TAPE NON_PREFERRED FLUTICASONE PROPIONATE CREA PREFERRED BESER LOTN NON_PREFERRED CUTIVATE LOTN NON_PREFERRED FLUTICASONE PROPIONATE LOTN NON_PREFERRED FLUTICASONE PROPIONATE OINT PREFERRED CREA NON_PREFERRED HALOG CREA NON_PREFERRED HALOG OINT NON_PREFERRED HALOBETASOL PROPIONATE CREA PREFERRED HALOBETASOL PROPIONATE FOAM NON_PREFERRED LEXETTE FOAM NON_PREFERRED BRYHALI LOTN NON_PREFERRED ULTRAVATE LOTN NON_PREFERRED HALOBETASOL PROPIONATE OINT PREFERRED ALA-CORT CREA PREFERRED HYDROCORTISONE CREA PREFERRED ALA SCALP LOTN NON_PREFERRED HYDROCORTISONE LOTN PREFERRED HYDROCORTISONE OINT PREFERRED TEXACORT SOLN NON_PREFERRED MICORT-HC CREA NON_PREFERRED HYDROCORTISONE OINT PREFERRED HYDROCORTISONE VALERATE CREA PREFERRED HYDROCORTISONE VALERATE OINT PREFERRED PANDEL CREA NON_PREFERRED HYDROCORTISONE BUTYRATE CREA NON_PREFERRED LOCOID CREA NON_PREFERRED HYDROCORTISONE BUTYRATE LOTN NON_PREFERRED LOCOID LOTN NON_PREFERRED HYDROCORTISONE BUTYRATE OINT NON_PREFERRED HYDROCORTISONE BUTYRATE SOLN NON_PREFERRED LOCOID SOLN NON_PREFERRED HYDROCORTISONE BUTYRATE (LIPID) CREA NON_PREFERRED HYDROCORTISONE BUTYRATE (LIPOPHILIC) CREA NON_PREFERRED LOCOID LIPOCREAM CREA NON_PREFERRED ELOCON CREA NON_PREFERRED FUROATE CREA PREFERRED MOMETASONE FUROATE OINT PREFERRED MOMETASONE FUROATE SOLN PREFERRED CREA NON_PREFERRED PREDNICARBATE OINT NON_PREFERRED KENALOG AERS NON_PREFERRED TRIAMCINOLONE ACETONIDE AERS NON_PREFERRED TRIAMCINOLONE ACETONIDE CREA PREFERRED Page 52 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TRIDERM CREA PREFERRED TRIAMCINOLONE ACETONIDE LOTN PREFERRED TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED TRIAMCINOLONE ACETONIDE OINT PREFERRED TRIANEX OINT NON_PREFERRED EPIFOAM FOAM NON_PREFERRED ENSTILAR FOAM NON_PREFERRED CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED TACLONEX OINT NON_PREFERRED TACLONEX SUSP NON_PREFERRED CLODAN KIT KIT NON_PREFERRED SYNALAR TS KIT NON_PREFERRED SYNALAR CREAM KIT KIT NON_PREFERRED SYNALAR OINTMENT KIT KIT NON_PREFERRED BESER KIT NON_PREFERRED DUOBRII LOTN NON_PREFERRED ELLZIA PAK THPK NON_PREFERRED SILA III THPK NON_PREFERRED DERMATOLOGICALS : MISC FINACEA FOAM NON_PREFERRED AZELAIC ACID GEL NON_PREFERRED FINACEA GEL NON_PREFERRED MIRVASO GEL NON_PREFERRED DOXYCYCLINE CPDR NON_PREFERRED ORACEA CPDR NON_PREFERRED IVERMECTIN CREA NON_PREFERRED SOOLANTRA CREA NON_PREFERRED METROCREAM CREA NON_PREFERRED METRONIDAZOLE CREA PREFERRED NORITATE CREA NON_PREFERRED ROSADAN CREA PREFERRED METROGEL GEL NON_PREFERRED METRONIDAZOLE GEL PREFERRED ROSADAN GEL PREFERRED METROLOTION LOTN NON_PREFERRED METRONIDAZOLE LOTN PREFERRED ROSADAN KIT KIT NON_PREFERRED RHOFADE CREA NON_PREFERRED DICLOFENAC EPOLAMINE PTCH NON_PREFERRED FLECTOR PTCH NON_PREFERRED DICLOFENAC SODIUM GEL NON_PREFERRED VOLTAREN GEL NON_PREFERRED DICLOFENAC SODIUM SOLN NON_PREFERRED PENNSAID SOLN NON_PREFERRED DYNABAC 5.0 THPK NON_PREFERRED DICLOFEX DC THPK NON_PREFERRED DOXEPIN HYDROCHLORIDE CREA NON_PREFERRED PRUDOXIN CREA NON_PREFERRED Page 53 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ZONALON CREA NON_PREFERRED EUCRISA OINT PREFERRED_WITH_PA SELENIUM SULFIDE LOTN PREFERRED SELENIUM SULFIDE SHAM NON_PREFERRED SELENIUM SULFIDE SHAMPOO SHAM NON_PREFERRED SODIUM SULFACETAMIDE GEL NON_PREFERRED SODIUM SULFACETAMIDE WASH LIQD NON_PREFERRED ACYCLOVIR CREA NON_PREFERRED ZOVIRAX CREA NON_PREFERRED ACYCLOVIR OINT NON_PREFERRED ZOVIRAX OINT NON_PREFERRED DENAVIR CREA NON_PREFERRED XERESE CREA NON_PREFERRED VALCHLOR GEL NON_PREFERRED CARAC CREA NON_PREFERRED EFUDEX CREA NON_PREFERRED FLUOROURACIL CREA NON_PREFERRED TOLAK CREA NON_PREFERRED FLUOROURACIL SOLN NON_PREFERRED DICLOFENAC SODIUM GEL NON_PREFERRED AMELUZ GEL NON_PREFERRED LEVULAN KERASTICK SOLR PREFERRED PANRETIN GEL PREFERRED TARGRETIN GEL PREFERRED PICATO GEL NON_PREFERRED ORMECA KIT NON_PREFERRED SULFAMYLON CREA PREFERRED MAFENIDE ACETATE PACK PREFERRED SULFAMYLON PACK NON_PREFERRED SILVADENE CREA NON_PREFERRED SILVER SULFADIAZINE CREA PREFERRED SSD CREA PREFERRED SILVER NITRATE SOLN NON_PREFERRED ARZOL SILVER NITRATE APPLICATORS MISC NON_PREFERRED GRAFCO SILVER NITRATE APPLICATOR MISC NON_PREFERRED AMMONIUM LACTATE CREA NON_PREFERRED AMMONIUM LACTATE LOTN PREFERRED UREA CREA PREFERRED UMECTA MOUSSE FOAM NON_PREFERRED UREA LOTN PREFERRED UREA HYDRATING FOAM NON_PREFERRED SANTYL OINT NON_PREFERRED CONDYLOX GEL PREFERRED PODOFILOX SOLN PREFERRED PODOCON 25 IN BENZOIN TINCTURE SOLN NON_PREFERRED SALICYLIC ACID FOAM NON_PREFERRED SALICYLIC ACID GEL PREFERRED Page 54 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SALICYLIC ACID WART REMOVER LIQD PREFERRED SALEX SHAM NON_PREFERRED SALEX CREAM KIT NON_PREFERRED SALEX LOTION KIT NON_PREFERRED BENSAL HP OINT NON_PREFERRED VEREGEN OINT NON_PREFERRED ALDARA CREA NON_PREFERRED IMIQUIMOD CREA PREFERRED IMIQUIMOD PUMP CREA NON_PREFERRED ZYCLARA CREA NON_PREFERRED ZYCLARA PUMP CREA NON_PREFERRED ELIDEL CREA PREFERRED_WITH_PA PIMECROLIMUS CREA PREFERRED_WITH_PA PROTOPIC OINT PREFERRED_WITH_PA TACROLIMUS OINT PREFERRED_WITH_PA QUTENZA KIT NON_PREFERRED LIDOCAINE OINT PREFERRED LIDOCAINE PTCH NON_PREFERRED LIDOCAINE PAIN RELIEF PATCH PTCH NON_PREFERRED LIDODERM PTCH NON_PREFERRED ZTLIDO PTCH NON_PREFERRED LIDOCAINE CREA PREFERRED LIDOCAINE HYDROCHLORIDE CREA PREFERRED LIDOTRAL CREA NON_PREFERRED LIDOCAINE HCL JELLY GEL PREFERRED LIDOZION LOTN NON_PREFERRED GLYDO PRSY PREFERRED LIDOCAINE HCL PRSY PREFERRED LIDOCAINE HCL JELLY PRSY PREFERRED LIDOCAINE HCL SOLN PREFERRED LIDOCAINE HYDROCHLORIDE SOLN PREFERRED LIDOPURE PATCH KIT NON_PREFERRED ZILACAINE PATCH THPK NON_PREFERRED PLIAGLIS CREA NON_PREFERRED SYNERA PTCH NON_PREFERRED LIDOCAINE/PRILOCAINE CREA NON_PREFERRED DERMACINRX EMPRICAINE KIT NON_PREFERRED LIDOCAINE/PRILOCAINE KIT NON_PREFERRED NUVAKAAN KIT NON_PREFERRED PRILO PATCH KIT NON_PREFERRED PRILOXX LP KIT NON_PREFERRED PRIZOTRAL KIT NON_PREFERRED DERMACINRX NEUROTRAL PHARMAPAK THPK NON_PREFERRED APRIZIO PAK KIT NON_PREFERRED DERMACINRX DUOPATCH PHARMAPAK THPK NON_PREFERRED REGRANEX GEL NON_PREFERRED QBREXZA PADS NON_PREFERRED Page 55 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM XERAC AC SOLN NON_PREFERRED HYCLODEX SOLN NON_PREFERRED HYPOCYN SOLN NON_PREFERRED DERMACINRX CLORHEXACIN KIT NON_PREFERRED NUVAIL SOLN NON_PREFERRED DERMATOLOGICALS : SCABICIDES & PEDICULICIDES EURAX CREA PREFERRED CROTAN LOTN PREFERRED EURAX LOTN NON_PREFERRED SKLICE LOTN NON_PREFERRED LINDANE SHAM NON_PREFERRED MALATHION LOTN NON_PREFERRED OVIDE LOTN NON_PREFERRED ELIMITE CREA NON_PREFERRED PERMETHRIN CREA PREFERRED GNP LICE TREATMENT LIQD PREFERRED HM LICE TREATMENT LIQD PREFERRED LICE TREATMENT LOTN PREFERRED SM LICE TREATMENT LOTN PREFERRED NATROBA SUSP PREFERRED SPINOSAD SUSP NON_PREFERRED GNP LICE TREATMENT SHAM PREFERRED HM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED LICE KILLING SHAMPOO SHAM PREFERRED SM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED SM LICE SOLUTION KIT KIT PREFERRED DIGESTIVE ENZYMES CREON CPEP PREFERRED PANCREAZE CPEP PREFERRED PERTZYE CPEP NON_PREFERRED ZENPEP CPEP PREFERRED VIOKACE TABS NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS ALENDRONATE SODIUM SOLN PREFERRED ALENDRONATE SODIUM TABS PREFERRED FOSAMAX TABS NON_PREFERRED BINOSTO TBEF NON_PREFERRED FOSAMAX PLUS D TABS NON_PREFERRED ETIDRONATE DISODIUM TABS NON_PREFERRED BONIVA TABS NON_PREFERRED IBANDRONATE SODIUM TABS NON_PREFERRED ACTONEL TABS NON_PREFERRED RISEDRONATE SODIUM TABS NON_PREFERRED ATELVIA TBEC NON_PREFERRED RISEDRONATE SODIUM DR TBEC NON_PREFERRED CALCITONIN SALMON SOLN PREFERRED CALCITONIN-SALMON SOLN PREFERRED ENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES NORDITROPIN FLEXPRO SOLN NON_PREFERRED Page 56 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM NUTROPIN AQ NUSPIN 10 SOLN NON_PREFERRED NUTROPIN AQ NUSPIN 20 SOLN NON_PREFERRED NUTROPIN AQ NUSPIN 5 SOLN NON_PREFERRED OMNITROPE SOLN NON_PREFERRED GENOTROPIN SOLR PREFERRED_WITH_PA GENOTROPIN MINIQUICK SOLR PREFERRED_WITH_PA HUMATROPE SOLR NON_PREFERRED HUMATROPE COMBO PACK SOLR NON_PREFERRED OMNITROPE SOLR NON_PREFERRED ZOMACTON SOLR NON_PREFERRED SAIZEN SOLR NON_PREFERRED SAIZENPREP RECONSTITUTIONKIT SOLR NON_PREFERRED SEROSTIM SOLR NON_PREFERRED ZORBTIVE SOLR NON_PREFERRED ENDOCRINE AND METABOLIC AGENTS : MISC OSPHENA TABS NON_PREFERRED EVISTA TABS NON_PREFERRED HYDROCHLORIDE TABS NON_PREFERRED SYNAREL SOLN NON_PREFERRED ORILISSA TABS PREFERRED_WITH_PA EGRIFTA SOLR NON_PREFERRED EGRIFTA SV SOLR NON_PREFERRED INCRELEX SOLN NON_PREFERRED SOMATULINE DEPOT SOLN NON_PREFERRED SANDOSTATIN LAR DEPOT KIT NON_PREFERRED OCTREOTIDE ACETATE SOLN NON_PREFERRED SANDOSTATIN SOLN NON_PREFERRED SIGNIFOR SOLN NON_PREFERRED SIGNIFOR LAR SRER NON_PREFERRED NOCTIVA EMUL NON_PREFERRED STIMATE SOLN PREFERRED NOCDURNA SUBL NON_PREFERRED DDAVP TABS NON_PREFERRED DESMOPRESSIN ACETATE TABS PREFERRED DDAVP SOLN NON_PREFERRED DESMOPRESSIN ACETATE SOLN PREFERRED DDAVP SOLN NON_PREFERRED DESMOPRESSIN ACETATE SOLN PREFERRED CABERGOLINE TABS PREFERRED JYNARQUE TABS NON_PREFERRED SAMSCA TABS NON_PREFERRED JYNARQUE TBPK NON_PREFERRED MIFEPREX TABS NON_PREFERRED TABS NON_PREFERRED CARNITOR SOLN NON_PREFERRED CARNITOR SF SOLN NON_PREFERRED LEVOCARNITINE SOLN NON_PREFERRED LEVOCARNITINE SF SOLN NON_PREFERRED Page 57 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CARNITOR TABS NON_PREFERRED LEVOCARNITINE TABS NON_PREFERRED GALAFOLD CAPS NON_PREFERRED NITISINONE CAPS PREFERRED ORFADIN CAPS PREFERRED ORFADIN SUSP NON_PREFERRED NITYR TABS NON_PREFERRED CYSTADANE POWD NON_PREFERRED CINACALCET HYDROCHLORIDE TABS NON_PREFERRED SENSIPAR TABS NON_PREFERRED RAVICTI LIQD NON_PREFERRED BUPHENYL POWD NON_PREFERRED SODIUM PHENYLBUTYRATE POWD NON_PREFERRED BUPHENYL TABS NON_PREFERRED SODIUM PHENYLBUTYRATE TABS NON_PREFERRED CARBAGLU TABS NON_PREFERRED KUVAN PACK NON_PREFERRED KUVAN TBSO NON_PREFERRED ENDOCRINE AND METABOLIC AGENTS : VITAMIN D ANALOGS RAYALDEE CPCR NON_PREFERRED CALCITRIOL CAPS PREFERRED ROCALTROL CAPS NON_PREFERRED CALCITRIOL SOLN PREFERRED ROCALTROL SOLN NON_PREFERRED DOXERCALCIFEROL CAPS PREFERRED PARICALCITOL CAPS NON_PREFERRED ZEMPLAR CAPS NON_PREFERRED PREMARIN TABS PREFERRED MENEST TABS PREFERRED DIVIGEL GEL NON_PREFERRED ELESTRIN GEL NON_PREFERRED ALORA PTTW NON_PREFERRED DOTTI PTTW PREFERRED ESTRADIOL PTTW PREFERRED MINIVELLE PTTW NON_PREFERRED VIVELLE-DOT PTTW NON_PREFERRED CLIMARA PTWK NON_PREFERRED ESTRADIOL PTWK PREFERRED MENOSTAR PTWK NON_PREFERRED EVAMIST SOLN NON_PREFERRED ESTRACE TABS NON_PREFERRED ESTRADIOL TABS PREFERRED PREMPHASE TABS PREFERRED PREMPRO TABS PREFERRED COMBIPATCH PTTW PREFERRED ACTIVELLA TABS NON_PREFERRED AMABELZ TABS PREFERRED ESTRADIOL/NORETHINDRONE ACETATE TABS PREFERRED Page 58 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LOPREEZA TABS PREFERRED MIMVEY TABS PREFERRED FEMHRT LOW DOSE TABS NON_PREFERRED FYAVOLV TABS NON_PREFERRED JINTELI TABS NON_PREFERRED NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS NON_PREFERRED ANGELIQ TABS NON_PREFERRED CLIMARA PRO PTWK NON_PREFERRED PREFEST TABS NON_PREFERRED DUAVEE TABS NON_PREFERRED GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS BALSALAZIDE DISODIUM CAPS PREFERRED COLAZAL CAPS NON_PREFERRED APRISO CP24 NON_PREFERRED MESALAMINE ER CP24 NON_PREFERRED PENTASA CPCR PREFERRED DELZICOL CPDR NON_PREFERRED MESALAMINE DR CPDR NON_PREFERRED MESALAMINE ENEM PREFERRED SFROWASA ENEM PREFERRED CANASA SUPP NON_PREFERRED MESALAMINE SUPP PREFERRED ASACOL HD TBEC NON_PREFERRED LIALDA TBEC NON_PREFERRED MESALAMINE DR TBEC NON_PREFERRED MESALAMINE KIT NON_PREFERRED ROWASA KIT NON_PREFERRED DIPENTUM CAPS NON_PREFERRED AZULFIDINE TABS NON_PREFERRED SULFASALAZINE TABS PREFERRED AZULFIDINE EN-TABS TBEC NON_PREFERRED SULFASALAZINE TBEC PREFERRED GASTROINTESTINAL AGENTS : MISC CHENODAL TABS NON_PREFERRED ACTIGALL CAPS NON_PREFERRED URSODIOL CAPS PREFERRED URSO 250 TABS NON_PREFERRED URSO FORTE TABS NON_PREFERRED URSODIOL TABS NON_PREFERRED CROMOLYN SODIUM CONC PREFERRED GASTROCROM CONC NON_PREFERRED METOCLOPRAMIDE HCL SOLN PREFERRED METOCLOPRAMIDE HCL TABS PREFERRED METOCLOPRAMIDE HYDROCHLORIDE TABS PREFERRED REGLAN TABS NON_PREFERRED METOCLOPRAMIDE ODT TBDP NON_PREFERRED ENULOSE SOLN PREFERRED GENERLAC SOLN PREFERRED LACTULOSE SOLN PREFERRED Page 59 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM AMITIZA CAPS NON_PREFERRED GATTEX KIT NON_PREFERRED TRULANCE TABS NON_PREFERRED ALOSETRON HYDROCHLORIDE TABS NON_PREFERRED LOTRONEX TABS NON_PREFERRED ZELNORM TABS NON_PREFERRED LINZESS CAPS NON_PREFERRED VIBERZI TABS NON_PREFERRED MOTEGRITY TABS NON_PREFERRED XERMELO TABS NON_PREFERRED ENTEREG CAPS NON_PREFERRED RELISTOR SOLN NON_PREFERRED RELISTOR TABS NON_PREFERRED SYMPROIC TABS NON_PREFERRED MOVANTIK TABS NON_PREFERRED CHOLBAM CAPS NON_PREFERRED OCALIVA TABS NON_PREFERRED GASTROINTESTINAL AGENTS : PHOSPHATE BINDER AGENTS CALCIUM ACETATE CAPS PREFERRED PHOSLYRA SOLN NON_PREFERRED CALCIUM ACETATE TABS PREFERRED AURYXIA TABS NON_PREFERRED FOSRENOL CHEW NON_PREFERRED LANTHANUM CARBONATE CHEW PREFERRED FOSRENOL PACK PREFERRED RENVELA PACK NON_PREFERRED SEVELAMER CARBONATE PACK NON_PREFERRED RENVELA TABS NON_PREFERRED SEVELAMER CARBONATE TABS NON_PREFERRED SEVELAMER CARBONATE TABS PREFERRED RENAGEL TABS NON_PREFERRED SEVELAMER HYDROCHLORIDE TABS PREFERRED VELPHORO CHEW NON_PREFERRED GENITOURINARY AGENTS : MISC K-PHOS NO 2 TABS NON_PREFERRED POTASSIUM CITRATE ER TBCR NON_PREFERRED UROCIT-K 10 TBCR NON_PREFERRED UROCIT-K 15 TBCR NON_PREFERRED UROCIT-K 5 TBCR NON_PREFERRED ORACIT SOLN PREFERRED SODIUM CITRATE/CITRIC ACID SOLN PREFERRED CYTRA K CRYSTALS PACK NON_PREFERRED TARON-CRYSTALS PACK NON_PREFERRED POTASSIUM CITRATE/CITRICACID SOLN NON_PREFERRED POTASSIUM CITRATE/SODIUMCITRATE/CITRIC ACID SOLN NON_PREFERRED TRICITRATES SOLN NON_PREFERRED PHENAZOPYRIDINE HCL TABS PREFERRED PHENAZOPYRIDINE HYDROCHLORIDE TABS PREFERRED PYRIDIUM TABS NON_PREFERRED Page 60 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CYSTAGON CAPS PREFERRED PROCYSBI CPDR NON_PREFERRED ELMIRON CAPS NON_PREFERRED LITHOSTAT TABS NON_PREFERRED THIOLA TABS NON_PREFERRED THIOLA EC TBEC NON_PREFERRED GENITOURINARY AGENTS : PROSTATIC HYPERTROPHY AGENTS AVODART CAPS NON_PREFERRED DUTASTERIDE CAPS NON_PREFERRED FINASTERIDE TABS PREFERRED PROSCAR TABS NON_PREFERRED ALFUZOSIN HCL ER TB24 PREFERRED CARDURA XL TB24 NON_PREFERRED RAPAFLO CAPS NON_PREFERRED SILODOSIN CAPS NON_PREFERRED FLOMAX CAPS NON_PREFERRED TAMSULOSIN HYDROCHLORIDE CAPS PREFERRED DUTASTERIDE/TAMSULOSIN HCL CAPS NON_PREFERRED DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS NON_PREFERRED JALYN CAPS NON_PREFERRED GLUCOSE MONITORING SUPPLIES : CGMs GUARDIAN REAL-TIME STARTER KIT KIT NON_PREFERRED GUARDIAN REAL-TIME SYSTEM KIT NON_PREFERRED GUARDIAN REAL-TIME SYSTEMPEDIATRIC KIT NON_PREFERRED GUARDIAN RT STARTER KIT KIT NON_PREFERRED GUARDIAN RT SYSTEM KIT NON_PREFERRED PARADIGM REAL-TIME STARTER KIT KIT NON_PREFERRED DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT DEVI NON_PREFERRED DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT/SHARE DEVI NON_PREFERRED DEXCOM G4 PLATINUM RECEIVER KIT DEVI NON_PREFERRED DEXCOM G4 PLATINUM RECEIVER KIT/SHARE DEVI NON_PREFERRED DEXCOM G5 MOBILE RECEIVERKIT DEVI NON_PREFERRED DEXCOM G6 RECEIVER DEVI PREFERRED_WITH_PA DEXCOM RECEIVER KIT DEVI NON_PREFERRED FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED GUARDIAN REAL-TIME REPLACEMENT MONITOR DEVI NON_PREFERRED GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI NON_PREFERRED DEXCOM G4 SENSOR KIT MISC NON_PREFERRED DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT MISC NON_PREFERRED DEXCOM G6 SENSOR MISC PREFERRED_WITH_PA ENLITE GLUCOSE SENSOR MISC NON_PREFERRED EVERSENSE SENSOR/HOLDER MISC NON_PREFERRED FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED GUARDIAN SENSOR (3) MISC NON_PREFERRED MINIMED GUARDIAN SENSOR 3 MISC NON_PREFERRED SOF-SENSOR MISC NON_PREFERRED DEXCOM G4 PLATINUM TRANSMITTER KIT MISC NON_PREFERRED Page 61 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM DEXCOM G5 MOBILE TRANSMITTER KIT MISC NON_PREFERRED DEXCOM G6 TRANSMITTER MISC PREFERRED_WITH_PA EVERSENSE SMART TRANSMITTER MISC NON_PREFERRED GUARDIAN CONNECT TRANSMITTER MISC NON_PREFERRED GUARDIAN LINK 3 MISC NON_PREFERRED GUARDIAN TRANSMITTER MISC NON_PREFERRED GLUCOSE MONITORING SUPPLIES : DEVICES AND KITS ACCU-CHEK AVIVA DEVI NON_PREFERRED ADVANCE INTUITION BLOOD GLUCOSE METER DEVI NON_PREFERRED ADVANCE MICRO-DRAW METER DEVI NON_PREFERRED ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ADVOCATE REDI-CODE DEVI NON_PREFERRED ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING DEVISYST NON_PREFERRED AGAMATRIX PRESTO PRO METER DEVI NON_PREFERRED ASSURE 4 BLOOD GLUCOSE METER DEVI NON_PREFERRED ASSURE PLATINUM BLOOD GLUCOSE METER DEVI NON_PREFERRED ASSURE PRISM MULTI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ASSURE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED CARESENS N GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING SYSTEMDEVI NON_PREFERRED CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING SYSTEMDEVI NON_PREFERRED CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING SYSTEMDEVI NON_PREFERRED CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED COOL BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED DIATHRIVE BLOOD GLUCOSE METER DEVI NON_PREFERRED DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED EASY PLUS II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED EASY STEP BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED EASYMAX L BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED EASYMAX N BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED EASYMAX V BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED ELEMENT COMPACT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ELEMENT COMPACT V BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ELEMENT PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED EMBRACE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED EMBRACE BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED Page 62 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM EVENCARE G2 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED EVENCARE G3 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED EVENCARE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED EVOLUTION AUTOCODE DEVI NON_PREFERRED EZ SMART DIABETES MONITORING SYSTEM DEVI NON_PREFERRED EZ SMART PLUS DIABETES MONITORING SYSTEM DEVI NON_PREFERRED FORA G30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-FUNCTIONALDEVI NON_PREFERRED FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODING DEVI NON_PREFERRED FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED FORA V20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORA V30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED GE100 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED GLUCO PERFECT 3 BLOOD GLUCOSE METER DEVI NON_PREFERRED GLUCO PERFECT 3 BLOOD GLUCOSE MONITORING SYSTEM/VOICE DEVI NON_PREFERRED GLUCOCARD 01 BLOOD GLUCOSE METER DEVI NON_PREFERRED GLUCOCARD SHINE DEVI NON_PREFERRED GLUCOCARD SHINE XL DEVI NON_PREFERRED GLUCOCOM BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED GNP EASY TOUCH GLUCOSE MONITORING SYSTEM/NO CODING DEVI NON_PREFERRED HW EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED IN TOUCH DEVI NON_PREFERRED LIBERTY BLOOD GLUCOSE METER DEVI NON_PREFERRED LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ON CALL EXPRESS BLOOD GLUCOSE METER DEVI NON_PREFERRED ON CALL PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED ON CALL VIVID BLOOD GLUCOSE METER DEVI NON_PREFERRED ON CALL VIVID PAL BLOOD GLUCOSE METER DEVI NON_PREFERRED OPTIUM BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED PRECISION QID MONITOR DEVI NON_PREFERRED PRECISION SOF-TACT MONITOR DEVI NON_PREFERRED PRECISION XTRA DEVI NON_PREFERRED PRECISION XTRA MONITOR DEVI NON_PREFERRED PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED Page 63 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED QUINTET AC BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED QUINTET BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED RA BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED RELION PREMIER BLU BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM DEVI NON_PREFERRED SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE METER DEVI NON_PREFERRED SURECHEK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED TRUE FOCUS BLOOD GLUCOSESELF MONITORING METER DEVI NON_PREFERRED TRUE METRIX DEVI NON_PREFERRED TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH DEVI NON_PREFERRED TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED ULTRATRAK ACTIVE DEVI NON_PREFERRED ULTRATRAK PRO DEVI NON_PREFERRED ULTRATRAK ULTIMATE MONITOR DEVI NON_PREFERRED VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT DEVI NON_PREFERRED VICTORY BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED VIVAGUARD INO BLOOD GLUCOSE METER DEVI NON_PREFERRED VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED WAVESENSE KEYNOTE PRO METER DEVI NON_PREFERRED ACCU-CHEK AVIVA CONNECT KIT NON_PREFERRED ACCU-CHEK AVIVA PLUS KIT NON_PREFERRED ACCU-CHEK COMPACT PLUS CARE KIT KIT NON_PREFERRED ACCU-CHEK GUIDE KIT NON_PREFERRED ACCU-CHEK GUIDE ME KIT NON_PREFERRED ACCU-CHEK NANO SMARTVIEW KIT NON_PREFERRED ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED ADVOCATE REDI-CODE+/ TALKING KIT NON_PREFERRED ADVOCATE REDI-CODE/TALKING KIT NON_PREFERRED AGAMATRIX JAZZ WIRELESS 2 KIT NON_PREFERRED AGAMATRIX PRESTO KIT NON_PREFERRED ASSURE 3 METER KIT NON_PREFERRED BAYER CONTOUR LINK 2.4 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED BD LATITUDE DIABETES MANAGEMENT SYSTEM KIT NON_PREFERRED BD LOGIC BLOOD GLUCOSE MONITOR KIT NON_PREFERRED BIOTEL CARE CONNECTED BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED BLOOD GLUCOSE MONITORINGSYSTEM KIT NON_PREFERRED BLOOD GLUCOSE MONITORINGSYSTEM PREMIUM KIT NON_PREFERRED BLOOD GLUCOSE SYSTEM PAK KIT NON_PREFERRED Page 64 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM KIT NON_PREFERRED CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE KIT NON_PREFERRED CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CHOICE DM DIABETES RISK IN-HOME TEST KIT KIT NON_PREFERRED CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CONTOUR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CONTOUR NEXT EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CONTOUR NEXT LINK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED CONTOUR NEXT LINK WIRELESS BLOOD GLUCOSE MONITORING SY KIT NON_PREFERRED CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED COOL BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED CVS ADVANCED GLUCOSE METER KIT NON_PREFERRED D-CARE GLUCOMETER KIT/GLUCOSE TEST STRIPS KIT NON_PREFERRED EASY TOUCH GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED EASY TOUCH HEALTHPRO GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED EASYGLUCO KIT NON_PREFERRED EASYGLUCO STARTER KIT KIT NON_PREFERRED EASYMAX L BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED EASYMAX N BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED EASYMAX V BLOOD GLUCOSE SYSTEM/TALKING KIT NON_PREFERRED EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED EASYPLUS R13N SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED EASYPLUS V SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED EASYPRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED EASYPRO PLUS KIT NON_PREFERRED ELEMENT AUTOCODE SYSTEM KIT NON_PREFERRED EMBRACE EVO BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED EVENCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FIFTY50 GLUCOSE METER 2.0 KIT NON_PREFERRED FORA G20 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FORA V10/V12/D10/D20 BLOOD GLUCOSE TEST STRIPS/LANCETS 30G KIT NON_PREFERRED FORA V30A BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED FREESTYLE FLASH SYSTEM KIT NON_PREFERRED FREESTYLE FREEDOM KIT NON_PREFERRED FREESTYLE FREEDOM LITE KIT NON_PREFERRED FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED FREESTYLE SIDEKICK II VALUEPACK KIT NON_PREFERRED FREESTYLE SYSTEM KIT KIT NON_PREFERRED GE100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GHT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED Page 65 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE MONITORINGKIT NON_PREFERRED GLUCOCARD SHINE KIT NON_PREFERRED GLUCOCARD SHINE CONNEX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCARD SHINE EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLACK KIT NON_PREFERRED GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLUE KIT NON_PREFERRED GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM PINK KIT NON_PREFERRED GLUCOCARD X-METER KIT NON_PREFERRED GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM VALUE KIT KIT NON_PREFERRED GLUCONAVII BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED GOODSENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED IBG STAR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM KIT NON_PREFERRED INFINITY BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KIT KIT NON_PREFERRED INFINITY VOICE KIT NON_PREFERRED KROGER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED KROGER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED LDR BLOOD GLUCOSE TRUETEST KIT KIT NON_PREFERRED MEIJER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED MEIJER ESSENTIAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED MEIJER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED MEIJER TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED MEIJER TRUERESULT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED MEIJER TRUETRACK BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED MM EASY TOUCH BLOOD GLUCOSE METER KIT NON_PREFERRED MYGLUCOHEALTH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ON CALL EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ON CALL PLUS BLOOD GLUCOSE METER KIT NON_PREFERRED ON CALL PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ON CALL VIVID BLOOD GLUCOSE METER KIT NON_PREFERRED ON CALL VIVID BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ON CALL VIVID PAL BLOOD GLUCOSE METER KIT NON_PREFERRED ONE DROP BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED ONETOUCH ULTRA 2 KIT PREFERRED ONETOUCH ULTRA MINI KIT PREFERRED ONETOUCH ULTRALINK SYSTEM (DEC) KIT NON_PREFERRED ONETOUCH ULTRALINK SYSTEM (HEX) KIT NON_PREFERRED ONETOUCH VERIO KIT PREFERRED ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED Page 66 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED ONETOUCH VERIO SYNC BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED OPTIUM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED OPTUMRX BLOOD GLUCOSE METER KIT NON_PREFERRED OPTUMRX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED PARADIGM LINK BLOOD GLUCOSE MONITOR KIT NON_PREFERRED PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING SYSTEMKIT NON_PREFERRED POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED PRECISION LINK KIT NON_PREFERRED PRECISION XTRA KIT NON_PREFERRED PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKING KIT NON_PREFERRED PRODIGY NO CODING BLOOD GLUCOSE KIT NON_PREFERRED PRODIGY POCKET BLOOD GLUCOSE METER KIT KIT NON_PREFERRED PRODIGY VOICE BLOOD GLUCOSE METER KIT KIT NON_PREFERRED QUICKTEK KIT NON_PREFERRED RA TRUE2GO BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED RA TRUERESULT BLOOD GLUCOSE MONITOR KIT NON_PREFERRED REFUAH PLUS BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RELION MICRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED REVEAL BLOOD GLUCOSE MONITOR KIT NON_PREFERRED REXALL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RIGHTEST GM300 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED RIGHTEST GM550 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED SMARTEST EJECT STARTER KIT KIT NON_PREFERRED SMARTEST PERSONA STARTERKIT KIT NON_PREFERRED SMARTEST PRONTO STARTERKIT KIT NON_PREFERRED SMARTEST PROTEGE STARTERKIT KIT NON_PREFERRED SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM KIT NON_PREFERRED SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED TELCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED TGT BLOOD GLUCOSE METER MONITORING SYSTEM KIT NON_PREFERRED TGT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED TGT BLOOD GLUCOSE MONITORING SYSTEM PREMIUM KIT NON_PREFERRED TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH SMART KIT NON_PREFERRED TRUE METRIX AIR W/BLUETOOTH SMART KIT NON_PREFERRED TRUE METRIX BLOOD GLUCOSEMETER KIT NON_PREFERRED TRUE METRIX GO BLOOD GLUCOSE METER KIT NON_PREFERRED TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING KIT NON_PREFERRED TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED TRUETRACK SMART SYSTEM KIT NON_PREFERRED Page 67 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ULTIMA KIT NON_PREFERRED ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED VERASENS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED WAVESENSE AMP KIT NON_PREFERRED WAVESENSE KEYNOTE KIT NON_PREFERRED RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM DEVI NON_PREFERRED SIDEKICK BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED GLUCOSE MONITORING SUPPLIES : INSULIN INFUSION DISPOSABLE PUMP OMNIPOD DASH SYSTEM KIT PREFERRED_WITH_PA OMNIPOD STARTER KIT KIT PREFERRED_WITH_PA V-GO 20 KIT NON_PREFERRED V-GO 30 KIT NON_PREFERRED V-GO 40 KIT NON_PREFERRED OMNIPOD 5 PACK MISC PREFERRED_WITH_PA OMNIPOD DASH 5 PACK MISC PREFERRED_WITH_PA GLUCOSE MONITORING SUPPLIES : TEST STRIPS ACCU-CHEK AVIVA PLUS STRP NON_PREFERRED ACCU-CHEK COMPACT PLUS STRP NON_PREFERRED ACCU-CHEK GUIDE STRP NON_PREFERRED ACCU-CHEK SMARTVIEW STRIPS STRP NON_PREFERRED ACCUTREND GLUCOSE STRP NON_PREFERRED ADVANCE INTUITION TEST STRIPS STRP NON_PREFERRED ADVANCE MICRO-DRAW TEST STRIPS STRP NON_PREFERRED ADVOCATE REDI-CODE STRP NON_PREFERRED ADVOCATE REDI-CODE+ TESTSTRIPS STRP NON_PREFERRED ADVOCATE TEST STRIPS STRP NON_PREFERRED AGAMATRIX AMP NO CODE TEST STRIPS STRP NON_PREFERRED AGAMATRIX JAZZ TEST STRIPS STRP NON_PREFERRED AGAMATRIX KEYNOTE TEST STRIPS STRP NON_PREFERRED AGAMATRIX PRESTO TEST STRIPS STRP NON_PREFERRED ASSURE 3 TEST STRIPS STRP NON_PREFERRED ASSURE 4 TEST STRIPS STRP NON_PREFERRED ASSURE II STRP NON_PREFERRED ASSURE II CHECK STRIP STRP NON_PREFERRED ASSURE II TEST STRIPS STRP NON_PREFERRED ASSURE PLATINUM TEST STRIPS STRP NON_PREFERRED ASSURE PRISM MULTI TEST STRIPS STRP NON_PREFERRED ASSURE PRO TEST STRIPS STRP NON_PREFERRED BIOSCANNER GLUCOSE TEST STRIPS STRP NON_PREFERRED BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP NON_PREFERRED CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP NON_PREFERRED CARESENS N BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED CARETOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED CLEVER CHEK AUTO-CODE TEST STRIPS STRP NON_PREFERRED CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP NON_PREFERRED CLEVER CHEK TEST STRIPS STRP NON_PREFERRED Page 68 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP NON_PREFERRED CLEVER CHOICE MICRO TESTSTRIPS STRP NON_PREFERRED CLEVER CHOICE NO CODING TEST STRIPS STRP NON_PREFERRED CLEVER CHOICE TALK NO CODING TEST STRIPS STRP NON_PREFERRED CONTOUR BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED CONTOUR NEXT BLOOD GLUCOSE TEST STRP NON_PREFERRED COOL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED CVS ADVANCED GLUCOSE METER TEST STRIPS STRP NON_PREFERRED D-CARE BLOOD GLUCOSE STRP NON_PREFERRED DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED DUO-CARE TEST STRIPS STRP NON_PREFERRED EASY PLUS II BLOOD GLUCOSE TEST STRP NON_PREFERRED EASY STEP TEST STRIPS STRP NON_PREFERRED EASY TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED EASY TOUCH HEALTHPRO GLUCOSE TEST STRIPS STRP NON_PREFERRED EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EASYGLUCO STRP NON_PREFERRED EASYGLUCO PLUS STRP NON_PREFERRED EASYMAX 15 TEST STRIPS STRP NON_PREFERRED EASYMAX TEST STRIPS STRP NON_PREFERRED EASYPLUS BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED EASYPRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EASYPRO PLUS STRP NON_PREFERRED ELEMENT COMPACT TEST STRIPS STRP NON_PREFERRED ELEMENT TEST STRIPS STRP NON_PREFERRED EMBRACE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EQ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EVENCARE + BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED EVENCARE BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED EVENCARE G2 TEST STRIPS STRP NON_PREFERRED EVENCARE G3 TEST STRIPS STRP NON_PREFERRED EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EVOLUTION AUTOCODE STRP NON_PREFERRED EXACTECH R-S-G TEST STRIPS STRP NON_PREFERRED EXACTECH TEST STRIPS STRP NON_PREFERRED EZ SMART BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NON_PREFERRED FORA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA D15G BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA D20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA D40/G31 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED Page 69 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM FORA G20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA GD20 TEST STRIPS STRP NON_PREFERRED FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA GTEL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA V12 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA V20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORA V30A BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FORACARE GD40 STRP NON_PREFERRED FORACARE PREMIUM V10 TESTSTRIPS STRP NON_PREFERRED FORACARE TEST N GO TEST STRIPS STRP NON_PREFERRED FORTISCARE BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED FREESTYLE INSULINX BLOODGLUCOSE TEST STRP NON_PREFERRED FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP NON_PREFERRED FREESTYLE LITE TEST STRIPS STRP NON_PREFERRED FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED FREESTYLE TEST STRIPS STRP NON_PREFERRED GE100 BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED GENSTRIP 50 STRP NON_PREFERRED GENULTIMATE TEST STRIPS STRP NON_PREFERRED GHT TEST STRIPS STRP NON_PREFERRED GLUCO PERFECT 3 TEST STRIPS STRP NON_PREFERRED GLUCOCARD 01 SENSOR PLUS STRP NON_PREFERRED GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NON_PREFERRED GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED GLUCOCARD SHINE TEST STRIPS STRP NON_PREFERRED GLUCOCARD VITAL TEST STRIPS STRP NON_PREFERRED GLUCOCARD X-SENSOR STRP NON_PREFERRED GLUCOCOM TEST STRIPS STRP NON_PREFERRED GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED GLUCOSE METER TEST STRIPS ADVANCED STRP NON_PREFERRED GNP EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED GOJJI BLOOD GLUCOSE TEST STRP NON_PREFERRED GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED IGLUCOSE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED INFINITY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED INFINITY VOICE STRP NON_PREFERRED KROGER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED KROGER HEALTHPRO GLUCOSE STRP NON_PREFERRED KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED KROGER TEST STRIPS STRP NON_PREFERRED LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED Page 70 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM LIBERTY TEST STRIPS STRP NON_PREFERRED MEIJER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED MICRODOT TEST STRIPS STRP NON_PREFERRED MM EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP NON_PREFERRED NEUTEK 2TEK TEST STRIPS STRP NON_PREFERRED NOVA MAX GLUCOSE TEST STRIPS STRP NON_PREFERRED ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED ON CALL PLUS BLOOD GLUCOSE TEST STRP NON_PREFERRED ON CALL VIVID BLOOD GLUCOSE TEST STRP NON_PREFERRED ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED ONE DROP BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED ONETOUCH ULTRA BLUE STRP PREFERRED ONETOUCH VERIO TEST STRIPS STRP PREFERRED OPTIUM TEST STRIPS STRP NON_PREFERRED OPTIUMEZ TEST STRIPS STRP NON_PREFERRED OPTUMRX BLOOD GLUCOSE TEST STRP NON_PREFERRED PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PRECISION PCX STRP NON_PREFERRED PRECISION PCX PLUS TEST STRIPS STRP NON_PREFERRED PRECISION POINT OF CARE TEST STRIPS STRP NON_PREFERRED PRECISION QID TEST STRIPS STRP NON_PREFERRED PRECISION SOF-TACT TEST STRIPS STRP NON_PREFERRED PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED PTS PANELS GLUCOSE TEST STRP NON_PREFERRED QUICKTEK TEST STRIPS STRP NON_PREFERRED QUINTET AC BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED QUINTET BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RA TRUETEST STRIPS STRP NON_PREFERRED REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED RELION BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED RELION CONFIRM/MICRO TEST STRIPS STRP NON_PREFERRED RELION PREMIER BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RELION ULTIMA TEST STRIPS STRP NON_PREFERRED REVEAL BLOOD GLUCOSE TEST STRP NON_PREFERRED REXALL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED Page 71 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP NON_PREFERRED SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP NON_PREFERRED SMARTEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED SOLUS V2 AUDIBLE TEST STRP NON_PREFERRED SUPREME TEST STRIPS STRP NON_PREFERRED SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED SURECHEK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED TELCARE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED TGT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED TRUE METRIX PRO GLUCOSE T STRP NON_PREFERRED TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP NON_PREFERRED TRUETEST STRIPS STRP NON_PREFERRED TRUETRACK BLOOD GLUCOSE TEST STRP NON_PREFERRED TRUETRACK TEST STRP NON_PREFERRED ULTIMA TEST STRIPS STRP NON_PREFERRED ULTRATRAK PRO TEST STRIPS STRP NON_PREFERRED ULTRATRAK ULTIMATE TEST STRIPS STRP NON_PREFERRED UNISTRIP1 GENERIC STRP NON_PREFERRED VERASENS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED VICTORY AGM-4000 TEST STRIPS STRP NON_PREFERRED VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED WAVESENSE PRESTO TEST STRIPS STRP NON_PREFERRED GOUT AGENTS ALLOPURINOL TABS PREFERRED ZYLOPRIM TABS NON_PREFERRED COLCHICINE CAPS NON_PREFERRED MITIGARE CAPS NON_PREFERRED GLOPERBA SOLN NON_PREFERRED COLCHICINE TABS NON_PREFERRED COLCRYS TABS NON_PREFERRED FEBUXOSTAT TABS NON_PREFERRED ULORIC TABS NON_PREFERRED PROBENECID TABS PREFERRED PROBENECID/COLCHICINE TABS PREFERRED HEMATOLOGICAL AGENTS : ANTIHEMOPHILIC PRODUCTS HEMOFIL M SOLR PREFERRED_WITH_PA KOATE SOLR PREFERRED_WITH_PA KOATE-DVI SOLR PREFERRED_WITH_PA KOGENATE FS KIT PREFERRED_WITH_PA KOVALTRY SOLR PREFERRED_WITH_PA NOVOEIGHT SOLR PREFERRED_WITH_PA Page 72 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM RECOMBINATE SOLR PREFERRED_WITH_PA NUWIQ KIT PREFERRED_WITH_PA NUWIQ SOLR PREFERRED_WITH_PA ADVATE SOLR PREFERRED_WITH_PA XYNTHA KIT PREFERRED_WITH_PA XYNTHA SOLOFUSE KIT PREFERRED_WITH_PA ELOCTATE SOLR PREFERRED_WITH_PA ADYNOVATE SOLR PREFERRED_WITH_PA JIVI SOLR PREFERRED_WITH_PA OBIZUR SOLR PREFERRED_WITH_PA AFSTYLA KIT PREFERRED_WITH_PA WILATE KIT PREFERRED_WITH_PA ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN SOLR PREFERRED_WITH_PA HUMATE-P SOLR PREFERRED_WITH_PA FEIBA SOLR PREFERRED_WITH_PA NOVOSEVEN RT SOLR PREFERRED_WITH_PA ALPHANINE SD SOLR PREFERRED_WITH_PA MONONINE SOLR PREFERRED_WITH_PA BENEFIX KIT PREFERRED_WITH_PA IXINITY SOLR PREFERRED_WITH_PA RIXUBIS SOLR PREFERRED_WITH_PA IDELVION SOLR PREFERRED_WITH_PA ALPROLIX SOLR PREFERRED_WITH_PA REBINYN SOLR PREFERRED_WITH_PA PROFILNINE SOLR PREFERRED_WITH_PA PROFILNINE SD SOLR PREFERRED_WITH_PA COAGADEX SOLR PREFERRED_WITH_PA TRETTEN SOLR PREFERRED_WITH_PA CORIFACT KIT PREFERRED_WITH_PA VONVENDI SOLR PREFERRED_WITH_PA HEMLIBRA SOLN PREFERRED_WITH_PA HEMATOLOGICAL AGENTS : MISC PENTOXIFYLLINE ER TBCR PREFERRED TAVALISSE TABS NON_PREFERRED HAEGARDA SOLR NON_PREFERRED FIRAZYR SOLN NON_PREFERRED ICATIBANT ACETATE SOLN NON_PREFERRED KALBITOR SOLN NON_PREFERRED TAKHZYRO SOLN NON_PREFERRED

HEMATOLOGICAL AGENTS : PLATELET AGGREGATION INHIBITORS DIPYRIDAMOLE TABS PREFERRED CILOSTAZOL TABS NON_PREFERRED ZONTIVITY TABS NON_PREFERRED AGRYLIN CAPS NON_PREFERRED ANAGRELIDE HYDROCHLORIDE CAPS PREFERRED CLOPIDOGREL TABS PREFERRED PLAVIX TABS NON_PREFERRED EFFIENT TABS NON_PREFERRED Page 73 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PRASUGREL TABS NON_PREFERRED BRILINTA TABS PREFERRED AGGRENOX CP12 NON_PREFERRED ASPIRIN/DIPYRIDAMOLE CP12 PREFERRED ASPIRIN/DIPYRIDAMOLE ER CP12 PREFERRED HEMATOPOIETIC AGENTS : HEMATOPOIETIC GROWTH FACTORS REBLOZYL SOLR NON_PREFERRED ARANESP ALBUMIN FREE SOLN NON_PREFERRED ARANESP ALBUMIN FREE SOSY NON_PREFERRED EPOGEN SOLN PREFERRED_WITH_PA PROCRIT SOLN PREFERRED_WITH_PA RETACRIT SOLN NON_PREFERRED MIRCERA SOSY NON_PREFERRED NEUPOGEN SOLN PREFERRED NEUPOGEN SOSY PREFERRED NIVESTYM SOLN NON_PREFERRED NIVESTYM SOSY NON_PREFERRED ZARXIO SOSY NON_PREFERRED GRANIX SOLN NON_PREFERRED GRANIX SOSY NON_PREFERRED NEULASTA ONPRO KIT PSKT NON_PREFERRED NEULASTA SOSY NON_PREFERRED ZIEXTENZO SOSY NON_PREFERRED UDENYCA SOSY NON_PREFERRED FULPHILA SOSY NON_PREFERRED LEUKINE SOLR PREFERRED DOPTELET TABS NON_PREFERRED PROMACTA PACK NON_PREFERRED PROMACTA TABS NON_PREFERRED MULPLETA TABS NON_PREFERRED NPLATE SOLR NON_PREFERRED HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : BENZODIAZEPINE HYPNOTICS ESTAZOLAM TABS PREFERRED FLURAZEPAM HCL CAPS NON_PREFERRED MIDAZOLAM HCL SYRP NON_PREFERRED RESTORIL CAPS NON_PREFERRED TEMAZEPAM CAPS PREFERRED HALCION TABS NON_PREFERRED TRIAZOLAM TABS PREFERRED HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : MISC BUTISOL SODIUM TABS NON_PREFERRED PHENOBARBITAL ELIX PREFERRED PHENOBARBITAL SOLN PREFERRED PHENOBARBITAL TABS PREFERRED SECONAL SODIUM CAPS NON_PREFERRED RAMELTEON TABS NON_PREFERRED ROZEREM TABS NON_PREFERRED HETLIOZ CAPS NON_PREFERRED DOXEPIN HYDROCHLORIDE TABS NON_PREFERRED Page 74 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SILENOR TABS NON_PREFERRED BELSOMRA TABS NON_PREFERRED HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : NON - BENZODIAZEPINE HYPNOTICS ESZOPICLONE TABS NON_PREFERRED LUNESTA TABS NON_PREFERRED ZALEPLON CAPS NON_PREFERRED ZOLPIMIST SOLN NON_PREFERRED EDLUAR SUBL NON_PREFERRED INTERMEZZO SUBL NON_PREFERRED ZOLPIDEM TARTRATE SUBL NON_PREFERRED AMBIEN TABS NON_PREFERRED ZOLPIDEM TARTRATE TABS PREFERRED AMBIEN CR TBCR NON_PREFERRED ZOLPIDEM TARTRATE ER TBCR NON_PREFERRED IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAPS PREFERRED SANDIMMUNE CAPS NON_PREFERRED SANDIMMUNE SOLN PREFERRED CYCLOSPORINE MODIFIED CAPS PREFERRED GENGRAF CAPS PREFERRED NEORAL CAPS NON_PREFERRED CYCLOSPORINE MODIFIED SOLN PREFERRED GENGRAF SOLN PREFERRED NEORAL SOLN NON_PREFERRED CELLCEPT CAPS NON_PREFERRED MYCOPHENOLATE MOFETIL CAPS PREFERRED CELLCEPT SUSR NON_PREFERRED MYCOPHENOLATE MOFETIL SUSR PREFERRED CELLCEPT TABS NON_PREFERRED MYCOPHENOLATE MOFETIL TABS PREFERRED MYCOPHENOLIC ACID DR TBEC PREFERRED MYFORTIC TBEC NON_PREFERRED ZORTRESS TABS NON_PREFERRED RAPAMUNE SOLN NON_PREFERRED SIROLIMUS SOLN PREFERRED RAPAMUNE TABS NON_PREFERRED SIROLIMUS TABS PREFERRED PROGRAF CAPS NON_PREFERRED TACROLIMUS CAPS PREFERRED ASTAGRAF XL CP24 NON_PREFERRED PROGRAF PACK NON_PREFERRED ENVARSUS XR TB24 NON_PREFERRED AZASAN TABS NON_PREFERRED AZATHIOPRINE TABS PREFERRED IMURAN TABS NON_PREFERRED MIGRAINE PRODUCTS : MISC ERGOMAR SUBL NON_PREFERRED DIHYDROERGOTAMINE MESYLATE SOLN NON_PREFERRED MIGRANAL SOLN NON_PREFERRED Page 75 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CAMBIA PACK NON_PREFERRED MIGRANOW THPK NON_PREFERRED CAFERGOT TABS NON_PREFERRED SUMATRIPTAN/NAPROXEN SODIUM TABS NON_PREFERRED TREXIMET TABS NON_PREFERRED MIGRAINE PRODUCTS : MONOCLONAL ANTIBODIES AIMOVIG SOAJ PREFERRED_WITH_PA AJOVY SOSY NON_PREFERRED EMGALITY INJ 120MG/ML SOAJ PREFERRED_WITH_PA EMGALITY INJ 100MG/ML SOSY NON_PREFERRED EMGALITY INJ 120MG/ML SOSY PREFERRED_WITH_PA

MIGRAINE PRODUCTS : SELECTIVE SEROTONIN AGONISTS 5-HT(1) ALMOTRIPTAN TABS NON_PREFERRED ALMOTRIPTAN MALATE TABS NON_PREFERRED ELETRIPTAN HYDROBROMIDE TABS NON_PREFERRED RELPAX TABS NON_PREFERRED FROVA TABS NON_PREFERRED FROVATRIPTAN SUCCINATE TABS NON_PREFERRED AMERGE TABS NON_PREFERRED NARATRIPTAN HCL TABS NON_PREFERRED MAXALT TABS NON_PREFERRED RIZATRIPTAN BENZOATE TABS PREFERRED MAXALT-MLT TBDP NON_PREFERRED RIZATRIPTAN BENZOATE ODT TBDP PREFERRED IMITREX SOLN NON_PREFERRED SUMATRIPTAN SOLN PREFERRED TOSYMRA SOLN NON_PREFERRED ONZETRA XSAIL EXHP NON_PREFERRED IMITREX STATDOSE SYSTEM SOAJ NON_PREFERRED SUMATRIPTAN SUCCINATE SOAJ PREFERRED ZEMBRACE SYMTOUCH SOAJ NON_PREFERRED IMITREX STATDOSE REFILL SOCT NON_PREFERRED SUMATRIPTAN SUCCINATE REFILL SOCT PREFERRED IMITREX SOLN NON_PREFERRED SUMATRIPTAN SUCCINATE SOLN PREFERRED SUMATRIPTAN SUCCINATE SOSY PREFERRED IMITREX TABS NON_PREFERRED SUMATRIPTAN SUCCINATE TABS PREFERRED ZOMIG SOLN NON_PREFERRED ZOLMITRIPTAN TABS NON_PREFERRED ZOMIG TABS NON_PREFERRED ZOLMITRIPTAN ODT TBDP NON_PREFERRED ZOMIG ZMT TBDP NON_PREFERRED MISCELLANEOUS THERAPEUTIC CLASSES THALOMID CAPS NON_PREFERRED REVLIMID CAPS NON_PREFERRED BENLYSTA SOAJ NON_PREFERRED BENLYSTA SOSY NON_PREFERRED SODIUM POLYSTYRENE SULFONATE POWD PREFERRED Page 76 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM KIONEX SUSP PREFERRED SODIUM POLYSTYRENE SULFONATE SUSP PREFERRED SPS SUSP PREFERRED LOKELMA PACK NON_PREFERRED VELTASSA PACK NON_PREFERRED MOUTH / THROAT / DENTAL AGENTS NYSTATIN SUSP PREFERRED CLOTRIMAZOLE LOZG PREFERRED CLOTRIMAZOLE TROC PREFERRED ORAVIG TABS NON_PREFERRED CHLORHEXIDINE GLUCONATE SOLN PREFERRED PAROEX SOLN PREFERRED ORALONE DENTAL PASTE PSTE PREFERRED TRIAMCINOLONE ACETONIDE DENTAL PASTE PSTE PREFERRED LIDOCAINE HCL SOLN PREFERRED LIDOCAINE VISCOUS SOLN PREFERRED DENTA 5000 PLUS CREA NON_PREFERRED SF 5000 PLUS CREA NON_PREFERRED SODIUM FLUORIDE 5000 PLUS CREA NON_PREFERRED DENTAGEL GEL NON_PREFERRED SF GEL NON_PREFERRED SODIUM FLUORIDE GEL NON_PREFERRED AQUORAL SOLN NON_PREFERRED CEVIMELINE HCL CAPS NON_PREFERRED CEVIMELINE HYDROCHLORIDE CAPS NON_PREFERRED EVOXAC CAPS NON_PREFERRED PILOCARPINE HCL TABS PREFERRED PILOCARPINE HYDROCHLORIDE TABS PREFERRED SALAGEN TABS NON_PREFERRED MULTIVITAMINS : PRENATAL VITAMINS VITAFOL STRIPS FILM NON_PREFERRED PREMESISRX TABS NON_PREFERRED PRENATE AM TABS NON_PREFERRED PRENATE CHEW NON_PREFERRED VITAFOL GUMMIES CHEW NON_PREFERRED ENBRACE HR CAPS NON_PREFERRED ELITE-OB TABS PREFERRED OB COMPLETE TABS PREFERRED PNV TABS 29-1 TABS PREFERRED THRIVITE RX TABS PREFERRED PRENATE ELITE TABS NON_PREFERRED OB COMPLETE/DHA CAPS NON_PREFERRED OB COMPLETE PREMIER TABS NON_PREFERRED COMPLETENATE CHEW PREFERRED SE-NATAL 19 CHEW PREFERRED M-NATAL PLUS TABS PREFERRED NIVA-PLUS TABS PREFERRED PRENATAL TABS PREFERRED PRENATAL VITAMINS PLUS LOW IRON TABS PREFERRED Page 77 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PREPLUS TABS PREFERRED PRETAB TABS PREFERRED TRICARE TABS PREFERRED TRINATAL RX 1 TABS PREFERRED VITAFOL-OB TABS PREFERRED VOL-PLUS TABS PREFERRED C-NATE DHA CAPS NON_PREFERRED RELNATE DHA CAPS NON_PREFERRED VIRT-NATE DHA CAPS NON_PREFERRED VP-PNV-DHA CAPS NON_PREFERRED PNV-SELECT TABS NON_PREFERRED SELECT-OB CHEW NON_PREFERRED SELECT-OB CHEW NON_PREFERRED VITAFOL-NANO TABS NON_PREFERRED CITRANATAL RX TABS NON_PREFERRED CONCEPT OB CAPS NON_PREFERRED FOLIVANE-OB CAPS NON_PREFERRED PROVIDA OB CAPS NON_PREFERRED PNV-OMEGA CAPS NON_PREFERRED VIRT-PN PLUS CAPS NON_PREFERRED ZATEAN-PN PLUS CAPS NON_PREFERRED NESTABS TABS NON_PREFERRED NESTABS DHA MISC NON_PREFERRED TRI-TABS DHA MISC NON_PREFERRED SE-NATAL 19 TABS PREFERRED THRIVITE 19 TABS PREFERRED CITRANATAL B-CALM MISC NON_PREFERRED OB COMPLETE ONE CAPS NON_PREFERRED OB COMPLETE PETITE CAPS NON_PREFERRED VINATE DHA RF CAPS NON_PREFERRED PRIMACARE CAPS NON_PREFERRED CITRANATAL BLOOM TABS NON_PREFERRED CONCEPT DHA CAPS NON_PREFERRED TARON-C DHA CAPS NON_PREFERRED VIRT-C DHA CAPS NON_PREFERRED TRICARE PRENATAL DHA ONE CAPS NON_PREFERRED COMPLETE NATAL DHA MISC NON_PREFERRED TRIVEEN-DUO DHA MISC NON_PREFERRED PRENATAL + DHA THPK NON_PREFERRED VITAFOL-OB+DHA MISC NON_PREFERRED TRISTART DHA CAPS NON_PREFERRED TRISTART ONE CAPS NON_PREFERRED PNV-DHA CAPS NON_PREFERRED PRENATE ENHANCE CAPS NON_PREFERRED PRENATE RESTORE CAPS NON_PREFERRED VIRT-PN DHA CAPS NON_PREFERRED ZATEAN-PN DHA CAPS NON_PREFERRED Page 78 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PRENATE DHA CAPS NON_PREFERRED PRENATE ESSENTIAL CAPS NON_PREFERRED PRENATE PIXIE CAPS NON_PREFERRED VITAFOL-ONE CAPS NON_PREFERRED SELECT-OB+DHA MISC NON_PREFERRED PRENAISSANCE PLUS CAPS NON_PREFERRED PNV-DHA+DOCUSATE CAPS NON_PREFERRED PRENAISSANCE CAPS NON_PREFERRED TARON-PREX CAPS NON_PREFERRED CITRANATAL 90 DHA MISC NON_PREFERRED CITRANATAL ASSURE MISC NON_PREFERRED CITRANATAL BLOOM DHA MISC NON_PREFERRED CITRANATAL DHA MISC NON_PREFERRED PRENATE MINI CAPS NON_PREFERRED CITRANATAL HARMONY CAPS NON_PREFERRED CITRANATAL MEDLEY CAPS NON_PREFERRED VITAFOL FE+ CAPS NON_PREFERRED VITAFOL ULTRA CAPS NON_PREFERRED NESTABS ONE CAPS NON_PREFERRED VITAFOL FE+ CPPK NON_PREFERRED MUSCULOSKELETAL THERAPY AGENTS BACLOFEN TABS PREFERRED CARISOPRODOL TABS NON_PREFERRED SOMA TABS NON_PREFERRED CHLORZOXAZONE TABS PREFERRED LORZONE TABS PREFERRED AMRIX CP24 NON_PREFERRED CYCLOBENZAPRINE HYDROCHLORIDE ER CP24 NON_PREFERRED CYCLOBENZAPRINE HYDROCHLORIDE TABS PREFERRED FEXMID TABS NON_PREFERRED METAXALONE TABS NON_PREFERRED SKELAXIN TABS NON_PREFERRED METHOCARBAMOL TABS PREFERRED ROBAXIN-750 TABS NON_PREFERRED ORPHENADRINE CITRATE ER TB12 PREFERRED TIZANIDINE HCL CAPS NON_PREFERRED TIZANIDINE HYDROCHLORIDE CAPS NON_PREFERRED ZANAFLEX CAPS NON_PREFERRED TIZANIDINE HCL TABS PREFERRED TIZANIDINE HYDROCHLORIDE TABS PREFERRED ZANAFLEX TABS NON_PREFERRED DANTRIUM CAPS NON_PREFERRED DANTROLENE SODIUM CAPS PREFERRED METAXALL CP KIT NON_PREFERRED CARISOPRODOL/ASPIRIN/CODEINE TABS NON_PREFERRED NORGESIC FORTE TABS NON_PREFERRED NASAL AGENTS - SYSTEMIC AND TOPICAL : MISC QNASL AERS NON_PREFERRED QNASL CHILDRENS AERS NON_PREFERRED Page 79 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM BECONASE AQ SUSP NON_PREFERRED ZETONNA AERS NON_PREFERRED OMNARIS SUSP NON_PREFERRED SOLN PREFERRED XHANCE EXHU NON_PREFERRED FLUTICASONE PROPIONATE SUSP PREFERRED SINUVA IMPL NON_PREFERRED MOMETASONE FUROATE SUSP NON_PREFERRED NASONEX SUSP NON_PREFERRED COCAINE HYDROCHLORIDE SOLN NON_PREFERRED GOPRELTO SOLN NON_PREFERRED IPRATROPIUM BROMIDE SOLN NON_PREFERRED ASTEPRO SOLN NON_PREFERRED AZELASTINE HCL SOLN PREFERRED AZELASTINE HYDROCHLORIDE SOLN PREFERRED OLOPATADINE HCL SOLN PREFERRED PATANASE SOLN NON_PREFERRED DERMACINRX TICANASE PAK THPK NON_PREFERRED DYMISTA SUSP NON_PREFERRED DERMACINRX AZENASE PAK THPK NON_PREFERRED NEUROMUSCULAR AGENTS TIGLUTIK SUSP NON_PREFERRED RILUTEK TABS NON_PREFERRED RILUZOLE TABS PREFERRED OPHTHALMIC AGENTS : BETA-BLOCKERS - OPHTHALMIC BETAXOLOL HCL SOLN PREFERRED BETOPTIC-S SUSP NON_PREFERRED CARTEOLOL HCL SOLN PREFERRED LEVOBUNOLOL HCL SOLN PREFERRED TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG PREFERRED TIMOPTIC-XE SOLG NON_PREFERRED ISTALOL SOLN NON_PREFERRED TIMOLOL MALEATE SOLN PREFERRED TIMOPTIC SOLN NON_PREFERRED TIMOPTIC OCUDOSE SOLN NON_PREFERRED COMBIGAN SOLN NON_PREFERRED COSOPT SOLN NON_PREFERRED COSOPT PF SOLN NON_PREFERRED DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN PREFERRED DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF SOLN NON_PREFERRED OPHTHALMIC AGENTS : MISC LACRISERT INST PREFERRED BIMATOPROST SOLN NON_PREFERRED LUMIGAN SOLN NON_PREFERRED XELPROS EMUL NON_PREFERRED LATANOPROST SOLN PREFERRED XALATAN SOLN NON_PREFERRED VYZULTA SOLN NON_PREFERRED ZIOPTAN SOLN NON_PREFERRED TRAVATAN Z SOLN NON_PREFERRED Page 80 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TRAVOPROST SOLN NON_PREFERRED ATROPINE SULFATE OINT PREFERRED ATROPINE SULFATE SOLN PREFERRED ISOPTO ATROPINE SOLN NON_PREFERRED CYCLOGYL SOLN NON_PREFERRED CYCLOPENTOLATE HCL SOLN PREFERRED CYCLOPENTOLATE HYDROCHLORIDE SOLN PREFERRED PHENYLEPHRINE HCL SOLN NON_PREFERRED MYDRIACYL SOLN NON_PREFERRED TROPICAMIDE SOLN PREFERRED CYCLOMYDRIL SOLN PREFERRED ISOPTO CARPINE SOLN NON_PREFERRED PILOCARPINE HCL SOLN PREFERRED PILOCARPINE HYDROCHLORIDE SOLN PREFERRED PHOSPHOLINE IODIDE SOLR PREFERRED RHOPRESSA SOLN NON_PREFERRED ROCKLATAN SOLN NON_PREFERRED APRACLONIDINE SOLN NON_PREFERRED IOPIDINE SOLN NON_PREFERRED ALPHAGAN P SOLN PREFERRED BRIMONIDINE TARTRATE SOLN PREFERRED SIMBRINZA SUSP NON_PREFERRED RESTASIS EMUL NON_PREFERRED RESTASIS MULTIDOSE EMUL NON_PREFERRED CEQUA SOLN NON_PREFERRED XIIDRA SOLN NON_PREFERRED AKTEN GEL NON_PREFERRED ALCAINE SOLN NON_PREFERRED PROPARACAINE HCL SOLN NON_PREFERRED TETRACAINE HYDROCHLORIDE SOLN NON_PREFERRED OXERVATE SOLN NON_PREFERRED AZOPT SUSP NON_PREFERRED DORZOLAMIDE HCL SOLN PREFERRED DORZOLAMIDE HYDROCHLORIDE SOLN PREFERRED TRUSOPT SOLN NON_PREFERRED BROMFENAC SOLN NON_PREFERRED BROMSITE SOLN NON_PREFERRED PROLENSA SOLN NON_PREFERRED DICLOFENAC SODIUM SOLN PREFERRED FLURBIPROFEN SODIUM SOLN PREFERRED ACULAR SOLN NON_PREFERRED ACULAR LS SOLN NON_PREFERRED ACUVAIL SOLN NON_PREFERRED KETOROLAC TROMETHAMINE SOLN PREFERRED ILEVRO SUSP NON_PREFERRED NEVANAC SUSP NON_PREFERRED CYSTARAN SOLN NON_PREFERRED Page 81 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM GLOSTRIPS STRP NON_PREFERRED OPHTHALMIC AGENTS : OPHTHALMIC ANTI-INFECTIVES AZASITE SOLN NON_PREFERRED BACITRACIN OINT PREFERRED BESIVANCE SUSP NON_PREFERRED CILOXAN OINT PREFERRED CILOXAN SOLN NON_PREFERRED CIPROFLOXACIN HYDROCHLORIDE SOLN PREFERRED ERYTHROMYCIN OINT PREFERRED GATIFLOXACIN SOLN NON_PREFERRED ZYMAXID SOLN NON_PREFERRED GENTAK OINT PREFERRED GENTAMICIN SULFATE SOLN PREFERRED LEVOFLOXACIN SOLN PREFERRED MOXEZA SOLN NON_PREFERRED MOXIFLOXACIN HYDROCHLORIDE SOLN NON_PREFERRED VIGAMOX SOLN NON_PREFERRED OCUFLOX SOLN NON_PREFERRED OFLOXACIN SOLN PREFERRED TOBREX OINT PREFERRED TOBRAMYCIN SOLN PREFERRED TOBRAMYCIN SULFATE SOLN PREFERRED TOBREX SOLN NON_PREFERRED SULFACETAMIDE SODIUM OINT PREFERRED BLEPH-10 SOLN NON_PREFERRED SODIUM SULFACETAMIDE SOLN PREFERRED SULFACETAMIDE SODIUM SOLN PREFERRED ZIRGAN GEL PREFERRED TRIFLURIDINE SOLN PREFERRED NATACYN SUSP PREFERRED BETADINE OPHTHALMIC PREP SOLN NON_PREFERRED AK-POLY-BAC OINT PREFERRED BACITRACIN/POLYMYXIN B OINT PREFERRED POLYCIN OINT PREFERRED POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN PREFERRED POLYTRIM SOLN NON_PREFERRED TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE SOLN PREFERRED NEO-POLYCIN OINT PREFERRED NEOMYCIN/BACITRACIN/POLYMYXIN OINT PREFERRED NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN PREFERRED OPHTHALMIC AGENTS : OPHTHALMIC ANTIALLERGIC LASTACAFT SOLN NON_PREFERRED AZELASTINE HCL SOLN PREFERRED AZELASTINE HYDROCHLORIDE SOLN PREFERRED BEPREVE SOLN NON_PREFERRED CROMOLYN SODIUM SOLN PREFERRED EPINASTINE HCL SOLN NON_PREFERRED ALOMIDE SOLN NON_PREFERRED ALOCRIL SOLN NON_PREFERRED Page 82 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM OLOPATADINE HCL SOLN NON_PREFERRED OLOPATADINE HYDROCHLORIDE SOLN NON_PREFERRED PATADAY SOLN NON_PREFERRED PATANOL SOLN NON_PREFERRED PAZEO SOLN PREFERRED OPHTHALMIC AGENTS : OPHTHALMIC DEXTENZA INST NON_PREFERRED MAXIDEX SUSP PREFERRED DEXAMETHASONE SODIUM PHOSPHATE SOLN PREFERRED DUREZOL EMUL NON_PREFERRED FML OINT PREFERRED SUSP PREFERRED FML FORTE SUSP PREFERRED FML LIQUIFILM SUSP NON_PREFERRED FLAREX SUSP PREFERRED LOTEMAX GEL NON_PREFERRED LOTEMAX SM GEL NON_PREFERRED LOTEMAX OINT NON_PREFERRED ALREX SUSP PREFERRED INVELTYS SUSP NON_PREFERRED LOTEMAX SUSP NON_PREFERRED ETABONATE SUSP PREFERRED PRED FORTE SUSP NON_PREFERRED PRED MILD SUSP PREFERRED PREDNISOLONE ACETATE SUSP PREFERRED PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED PRED-G S.O.P. OINT NON_PREFERRED PRED-G SUSP NON_PREFERRED ZYLET SUSP NON_PREFERRED BLEPHAMIDE S.O.P. OINT NON_PREFERRED SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN NON_PREFERRED BLEPHAMIDE SUSP NON_PREFERRED TOBRADEX OINT NON_PREFERRED TOBRADEX SUSP NON_PREFERRED TOBRADEX ST SUSP NON_PREFERRED TOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED MAXITROL OINT NON_PREFERRED NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT PREFERRED MAXITROL SUSP NON_PREFERRED NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP PREFERRED NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED NEO-POLYCIN HC OINT PREFERRED NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT PREFERRED OTIC AGENTS CIPROFLOXACIN SOLN NON_PREFERRED FLOXIN OTIC SOLN NON_PREFERRED OFLOXACIN SOLN PREFERRED DERMOTIC OIL NON_PREFERRED FLAC OIL NON_PREFERRED Page 83 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM FLUOCINOLONE ACETONIDE OIL NON_PREFERRED HYDROCORTISONE/ACETIC ACID SOLN NON_PREFERRED ACETIC ACID SOLN PREFERRED OTIC AGENTS : OTIC COMBINATIONS CIPRODEX SUSP PREFERRED CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF SOLN NON_PREFERRED OTOVEL SOLN NON_PREFERRED CIPRO HC SUSP NON_PREFERRED NEOMYCIN/POLYMYXIN/HC SOLN PREFERRED NEOMYCIN/POLYMYXIN/HYDROCORTISONE SOLN PREFERRED NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED COLY-MYCIN S SUSP NON_PREFERRED CORTISPORIN-TC SUSP NON_PREFERRED PROGESTINS HYDROXYPROGESTERONE CAPROATE OIL NON_PREFERRED MAKENA OIL PREFERRED_WITH_PA MAKENA SOAJ PREFERRED_WITH_PA MEDROXYPROGESTERONE ACETATE TABS PREFERRED PROVERA TABS NON_PREFERRED MEGACE ES SUSP NON_PREFERRED MEGESTROL ACETATE SUSP NON_PREFERRED AYGESTIN TABS NON_PREFERRED NORETHINDRONE ACETATE TABS NON_PREFERRED OIL PREFERRED PROGESTERONE CAPS PREFERRED PROMETRIUM CAPS NON_PREFERRED PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : ANTIDEMENTIA AGENTS ARICEPT TABS NON_PREFERRED DONEPEZIL HCL TABS PREFERRED DONEPEZIL HYDROCHLORIDE TABS PREFERRED DONEPEZIL HCL TBDP PREFERRED DONEPEZIL HYDROCHLORIDE ODT TBDP PREFERRED GALANTAMINE HYDROBROMIDEER CP24 NON_PREFERRED RAZADYNE ER CP24 NON_PREFERRED GALANTAMINE HYDROBROMIDE SOLN NON_PREFERRED GALANTAMINE HYDROBROMIDE TABS NON_PREFERRED RAZADYNE TABS NON_PREFERRED EXELON PT24 NON_PREFERRED RIVASTIGMINE TRANSDERMALSYSTEM PT24 NON_PREFERRED RIVASTIGMINE TARTRATE CAPS NON_PREFERRED MEMANTINE HYDROCHLORIDE ER CP24 NON_PREFERRED NAMENDA XR CP24 NON_PREFERRED NAMENDA XR TITRATION PACK CP24 NON_PREFERRED MEMANTINE HYDROCHLORIDE SOLN NON_PREFERRED MEMANTINE HCL TABS PREFERRED MEMANTINE HCL TITRATION PAK TABS NON_PREFERRED MEMANTINE HYDROCHLORIDE TABS PREFERRED NAMENDA TABS NON_PREFERRED NAMENDA TITRATION PAK TABS NON_PREFERRED Page 84 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM NAMZARIC C4PK NON_PREFERRED NAMZARIC CP24 NON_PREFERRED PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MISC ERGOLOID MESYLATES TABS PREFERRED PIMOZIDE TABS PREFERRED VYLEESI SOAJ NON_PREFERRED FLUOXETINE HYDROCHLORIDE TABS NON_PREFERRED SARAFEM TABS NON_PREFERRED BRISDELLE CAPS NON_PREFERRED PAROXETINE CAPS NON_PREFERRED AUSTEDO TABS NON_PREFERRED TETRABENAZINE TABS NON_PREFERRED XENAZINE TABS NON_PREFERRED INGREZZA CAPS NON_PREFERRED INGREZZA CPPK NON_PREFERRED XYREM SOLN NON_PREFERRED SAVELLA TITRATION PACK MISC NON_PREFERRED SAVELLA TABS NON_PREFERRED GRALISE TABS NON_PREFERRED LYRICA CR TB24 NON_PREFERRED GABACAINE THPK NON_PREFERRED GPL PAK THPK NON_PREFERRED LIDO GB-300 THPK NON_PREFERRED PRILOPENTIN THPK NON_PREFERRED HORIZANT TBCR NON_PREFERRED NUEDEXTA CAPS NON_PREFERRED TEGSEDI SOSY NON_PREFERRED CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS PREFERRED PERPHENAZINE/AMITRIPTYLINE TABS PREFERRED OLANZAPINE/FLUOXETINE CAPS NON_PREFERRED SYMBYAX CAPS NON_PREFERRED PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MULTIPLE SCLEROSIS AGENTS COPAXONE INJ 20MG/ML SOSY PREFERRED COPAXONE INJ 40MG/ML SOSY NON_PREFERRED GLATIRAMER ACETATE SOSY NON_PREFERRED GLATOPA SOSY NON_PREFERRED MAVENCLAD TBPK NON_PREFERRED AVONEX PEN AJKT NON_PREFERRED AVONEX PSKT NON_PREFERRED REBIF REBIDOSE SOAJ PREFERRED REBIF REBIDOSE TITRATIONPACK SOAJ PREFERRED REBIF SOSY PREFERRED REBIF TITRATION PACK SOSY PREFERRED BETASERON KIT PREFERRED EXTAVIA KIT NON_PREFERRED PLEGRIDY SOPN NON_PREFERRED PLEGRIDY STARTER PACK SOPN NON_PREFERRED PLEGRIDY SOSY NON_PREFERRED Page 85 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PLEGRIDY STARTER PACK SOSY NON_PREFERRED AUBAGIO TABS NON_PREFERRED LEMTRADA SOLN NON_PREFERRED TYSABRI CONC NON_PREFERRED OCREVUS SOLN NON_PREFERRED TECFIDERA CPDR PREFERRED_WITH_PA TECFIDERA STARTER PACK MISC PREFERRED_WITH_PA VUMERITY CPDR NON_PREFERRED AMPYRA TB12 NON_PREFERRED DALFAMPRIDINE ER TB12 NON_PREFERRED GILENYA CAPS NON_PREFERRED MAYZENT TABS NON_PREFERRED MAYZENT STARTER PACK TBPK NON_PREFERRED PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : SMOKING DETERRENTS BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED NICOTROL INHALER INHA PREFERRED NICOTINE TRANSDERMAL SYSTEM KIT PREFERRED GNP NICOTINE TRANSDERMALSYSTEM PT24 PREFERRED GNP NICOTINE TRANSDERMALSYSTEM STEP 2 PT24 PREFERRED HM NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED HM NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED HM NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED HM NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED HM NICOTINE TRANSDERMALSYSTEM PT24 PREFERRED NICODERM CQ PT24 PREFERRED NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED SM NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED SM NICOTINE TRANSDERMAL SYSTEM/STEP 1/CLEAR PT24 PREFERRED SM NICOTINE TRANSDERMAL SYSTEM/STEP 2/CLEAR PT24 PREFERRED SM NICOTINE TRANSDERMAL SYSTEM/STEP 3/CLEAR PT24 PREFERRED NICOTROL NS SOLN PREFERRED GNP NICOTINE POLACRILEX GUM PREFERRED GOODSENSE NICOTINE GUM GUM PREFERRED HM NICOTINE POLACRILEX GUM PREFERRED NICORELIEF GUM PREFERRED NICORETTE GUM PREFERRED NICORETTE STARTER KIT GUM PREFERRED NICOTINE POLACRILEX GUM PREFERRED SM NICOTINE GUM PREFERRED SM NICOTINE POLACRILEX GUM PREFERRED GNP NICOTINE MINI LOZENGE LOZG PREFERRED GNP NICOTINE POLACRILEX LOZG PREFERRED GNP NICOTINE POLACRILEX MINI LOZG PREFERRED GOODSENSE NICOTINE LOZG PREFERRED Page 86 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM GOODSENSE NICOTINE POLACRILEX LOZG PREFERRED HM NICOTINE POLACRILEX LOZG PREFERRED NICORETTE LOZG PREFERRED NICORETTE MINI LOZG PREFERRED NICOTINE LOZG PREFERRED NICOTINE POLACRILEX LOZG PREFERRED SM NICOTINE LOZG PREFERRED SM NICOTINE POLACRILEX LOZG PREFERRED CHANTIX TABS PREFERRED CHANTIX CONTINUING MONTHPAK TABS PREFERRED CHANTIX STARTING MONTH PAK TABS PREFERRED RESPIRATORY AGENTS : CYSTIC FIBROSIS AGENTS KALYDECO PACK NON_PREFERRED KALYDECO TABS NON_PREFERRED PULMOZYME SOLN PREFERRED ORKAMBI PACK NON_PREFERRED ORKAMBI TABS NON_PREFERRED SYMDEKO TBPK NON_PREFERRED TRIKAFTA TBPK NON_PREFERRED RESPIRATORY AGENTS : MISC ESBRIET CAPS NON_PREFERRED ESBRIET TABS NON_PREFERRED OFEV CAPS NON_PREFERRED SUBSTANCE USE DISORDER AGENTS ACAMPROSATE CALCIUM DR TBEC PREFERRED ANTABUSE TABS PREFERRED DISULFIRAM TABS PREFERRED LUCEMYRA TABS PREFERRED SUBLOCADE SOSY PREFERRED PROBUPHINE IMPLANT KIT IMPL PREFERRED BUPRENORPHINE HCL SUBL PREFERRED BUNAVAIL FILM PREFERRED BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE FILM PREFERRED SUBOXONE FILM PREFERRED BUPRENORPHINE HCL/NALOXONE HCL SUBL PREFERRED BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE SUBL PREFERRED ZUBSOLV SUBL PREFERRED NARCAN LIQD PREFERRED NALOXONE HCL SOCT PREFERRED NALOXONE HCL SOLN PREFERRED NALOXONE HYDROCHLORIDE SOLN PREFERRED NALOXONE HCL SOSY PREFERRED VIVITROL SUSR PREFERRED NALTREXONE HCL TABS PREFERRED THYROID AGENTS TIROSINT CAPS NON_PREFERRED TIROSINT-SOL SOLN NON_PREFERRED EUTHYROX TABS PREFERRED LEVO-T TABS PREFERRED LEVOTHYROXINE SODIUM TABS PREFERRED LEVOXYL TABS PREFERRED Page 87 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM SYNTHROID TABS NON_PREFERRED UNITHROID TABS PREFERRED CYTOMEL TABS NON_PREFERRED LIOTHYRONINE SODIUM TABS PREFERRED ARMOUR THYROID TABS PREFERRED LEVOTHYROXINE/LIOTHYRONINE TABS PREFERRED NP THYROID 120 TABS PREFERRED NP THYROID 15 TABS PREFERRED NP THYROID 30 TABS PREFERRED NP THYROID 60 TABS PREFERRED NP THYROID 90 TABS PREFERRED METHIMAZOLE TABS PREFERRED TAPAZOLE TABS NON_PREFERRED PROPYLTHIOURACIL TABS PREFERRED TUMOR NECROSIS FACTOR ALPHA INHIBITORS AND MISC IMMUNOSUPPRESSIVES ENTYVIO SOLR NON_PREFERRED STELARA SOLN NON_PREFERRED CIMZIA KIT KIT NON_PREFERRED CIMZIA PREFL KIT 200MG/ML KIT PREFERRED_WITH_PA CIMZIA STARTER KIT KIT PREFERRED_WITH_PA REMICADE SOLR NON_PREFERRED RENFLEXIS SOLR NON_PREFERRED INFLECTRA SOLR NON_PREFERRED KINERET SOSY NON_PREFERRED HUMIRA PEN PNKT PREFERRED_WITH_PA HUMIRA PEN-CD/UC/HS STARTER PNKT PREFERRED_WITH_PA HUMIRA PEN-PS/UV STARTER PNKT PREFERRED_WITH_PA HUMIRA PSKT PREFERRED_WITH_PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT PREFERRED_WITH_PA SIMPONI SOAJ NON_PREFERRED SIMPONI ARIA SOLN NON_PREFERRED SIMPONI SOSY NON_PREFERRED ENBREL SURECLICK SOAJ PREFERRED_WITH_PA ENBREL MINI SOCT PREFERRED_WITH_PA ENBREL SOLR PREFERRED_WITH_PA ENBREL SOSY PREFERRED_WITH_PA ORENCIA CLICKJECT SOAJ NON_PREFERRED ORENCIA SOLR NON_PREFERRED ORENCIA SOSY NON_PREFERRED ARCALYST SOLR NON_PREFERRED ILARIS SOLN NON_PREFERRED KEVZARA SOAJ NON_PREFERRED KEVZARA SOSY NON_PREFERRED ACTEMRA ACTPEN SOAJ NON_PREFERRED ACTEMRA SOLN NON_PREFERRED ACTEMRA SOSY NON_PREFERRED OLUMIANT TABS NON_PREFERRED Page 88 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM XELJANZ TABS PREFERRED_WITH_PA XELJANZ XR TB24 PREFERRED_WITH_PA RINVOQ TB24 NON_PREFERRED OTEZLA TABS NON_PREFERRED OTEZLA TBPK NON_PREFERRED ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : H-2 ANTAGONISTS TABS PREFERRED CIMETIDINE HCL SOLN PREFERRED RANITIDINE HYDROCHLORIDE CAPS PREFERRED RANITIDINE HCL SYRP PREFERRED RANITIDINE HYDROCHLORIDE SYRP PREFERRED RANITIDINE HCL TABS PREFERRED RANITIDINE HYDROCHLORIDE TABS PREFERRED FAMOTIDINE SUSR PREFERRED FAMOTIDINE TABS PREFERRED PEPCID TABS NON_PREFERRED NIZATIDINE CAPS PREFERRED NIZATIDINE SOLN PREFERRED ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : MISC HYOSCYAMINE SULFATE ELIX PREFERRED HYOSCYAMINE SULFATE SOLN PREFERRED HYOSCYAMINE SULFATE SUBL PREFERRED LEVSIN/SL SUBL NON_PREFERRED OSCIMIN SUBL PREFERRED HYOSCYAMINE SULFATE TABS PREFERRED LEVSIN TABS NON_PREFERRED OSCIMIN TABS PREFERRED OSCIMIN SR TB12 PREFERRED ANASPAZ TBDP NON_PREFERRED ED-SPAZ TBDP PREFERRED HYOSCYAMINE SULFATE TBDP PREFERRED NULEV TBDP PREFERRED OSCIMIN TBDP PREFERRED CUVPOSA SOLN NON_PREFERRED GLYCATE TABS NON_PREFERRED GLYCOPYRROLATE TABS PREFERRED METHSCOPOLAMINE BROMIDE TABS NON_PREFERRED PROPANTHELINE BROMIDE TABS PREFERRED DICYCLOMINE HYDROCHLORIDE CAPS PREFERRED DICYCLOMINE HCL SOLN PREFERRED DICYCLOMINE HYDROCHLORIDE TABS PREFERRED BELLADONNA/OPIUM SUPP PREFERRED CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS NON_PREFERRED LIBRAX CAPS NON_PREFERRED CYTOTEC TABS NON_PREFERRED MISOPROSTOL TABS PREFERRED CARAFATE SUSP PREFERRED SUCRALFATE SUSP PREFERRED Page 89 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM CARAFATE TABS NON_PREFERRED SUCRALFATE TABS PREFERRED PYLERA CAPS NON_PREFERRED LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN MISC NON_PREFERRED OMECLAMOX-PAK MISC NON_PREFERRED OMEPRAZOLE/SODIUM BICARBONATE CAPS NON_PREFERRED ZEGERID CAPS NON_PREFERRED OMEPRAZOLE/SODIUM BICARBONATE PACK NON_PREFERRED ZEGERID PACK NON_PREFERRED ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : PROTON PUMP INHIBITORS DEXILANT CPDR NON_PREFERRED ESOMEPRAZOLE CPDR NON_PREFERRED NEXIUM CPDR NON_PREFERRED ESOMEP-EZS KIT NON_PREFERRED NEXIUM PACK NON_PREFERRED LANSOPRAZOLE CPDR NON_PREFERRED PREVACID CPDR NON_PREFERRED LANSOPRAZOLE TBDD PREFERRED LANSOPRAZOLE ODT TBDD PREFERRED PREVACID SOLUTAB TBDD NON_PREFERRED OMEPRAZOLE CPDR PREFERRED OMEPRAZOLE DR CPDR PREFERRED PRILOSEC PACK NON_PREFERRED PROTONIX PACK NON_PREFERRED PANTOPRAZOLE SODIUM TBEC PREFERRED PANTOPRAZOLE SODIUM DR TBEC PREFERRED PROTONIX TBEC NON_PREFERRED ACIPHEX SPRINKLE CPSP NON_PREFERRED ACIPHEX TBEC NON_PREFERRED RABEPRAZOLE SODIUM TBEC NON_PREFERRED URINARY ANTI-INFECTIVES MONUROL PACK PREFERRED METHENAMINE MANDELATE TABS PREFERRED HIPREX TABS NON_PREFERRED METHENAMINE HIPPURATE TABS PREFERRED NITROFURANTOIN SUSP PREFERRED MACRODANTIN CAPS NON_PREFERRED NITROFURANTOIN MACROCRYST CAPS PREFERRED NITROFURANTOIN MACROCRYSTALS CAPS PREFERRED MACROBID CAPS NON_PREFERRED NITROFURANTOIN MONOHYDRAT CAPS PREFERRED NITROFURANTOIN MONOHYDRATE CAPS PREFERRED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS CAPS PREFERRED ME/NAPHOS/MB/HYO 1 TABS NON_PREFERRED UROGESIC-BLUE TABS NON_PREFERRED HYOPHEN TABS NON_PREFERRED URIBEL CAPS NON_PREFERRED USTELL CAPS NON_PREFERRED Page 90 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM PHOSPHASAL TABS NON_PREFERRED URIMAR-T TABS NON_PREFERRED URIN D/S TABS NON_PREFERRED URO-458 TABS NON_PREFERRED URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDEER TB24 NON_PREFERRED ENABLEX TB24 NON_PREFERRED TOVIAZ TB24 NON_PREFERRED OXYTROL PTTW NON_PREFERRED GELNIQUE GEL NON_PREFERRED GELNIQUE PUMP GEL NON_PREFERRED OXYBUTYNIN CHLORIDE SYRP PREFERRED OXYBUTYNIN CHLORIDE TABS PREFERRED DITROPAN XL TB24 NON_PREFERRED OXYBUTYNIN CHLORIDE ER TB24 PREFERRED SOLIFENACIN SUCCINATE TABS PREFERRED VESICARE TABS NON_PREFERRED DETROL LA CP24 NON_PREFERRED TOLTERODINE TARTRATE ER CP24 NON_PREFERRED DETROL TABS NON_PREFERRED TOLTERODINE TARTRATE TABS NON_PREFERRED TROSPIUM CHLORIDE ER CP24 NON_PREFERRED TROSPIUM CHLORIDE TABS NON_PREFERRED MYRBETRIQ TB24 NON_PREFERRED BETHANECHOL CHLORIDE TABS PREFERRED URECHOLINE TABS NON_PREFERRED FLAVOXATE HCL TABS NON_PREFERRED VAGINAL PRODUCTS CLEOCIN CREA NON_PREFERRED CLINDAMYCIN PHOSPHATE CREA PREFERRED CLEOCIN SUPP PREFERRED CLINDESSE CREA NON_PREFERRED METRONIDAZOLE VAGINAL GEL PREFERRED NUVESSA GEL NON_PREFERRED VANDAZOLE GEL PREFERRED AVC CREA PREFERRED GYNAZOLE-1 CREA NON_PREFERRED MICONAZOLE 3 SUPP PREFERRED TERCONAZOLE CREA PREFERRED TERCONAZOLE SUPP PREFERRED ESTRACE CREA NON_PREFERRED ESTRADIOL CREA PREFERRED ESTRING RING NON_PREFERRED ESTRADIOL TABS NON_PREFERRED VAGIFEM TABS NON_PREFERRED YUVAFEM TABS NON_PREFERRED FEMRING RING NON_PREFERRED PREMARIN CREA PREFERRED CRINONE GEL NON_PREFERRED Page 91 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ENDOMETRIN INST PREFERRED INTRAROSA INST NON_PREFERRED TRIMO-SAN GEL NON_PREFERRED

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