2021 List

Effective January 1, 2021

Ambetter.SuperiorHealthPlan.com Formulary Introduction

SUMMARY OF FORMULARY BENEFITS

The information in this document is designed to help you understand the prescription drug benefits offered under this plan and to compare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare both the value and scope of formulary benefits.

HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGS To find the cost of your prescription please visit https://ambetter.superiorhealthplan.com/resources/pharmacy- resources.html. In the Drug Cost Tool please select the plan in which you are participating (planning to participate) and enter thatyou are taking. The toolwill provide you an approximate cost ofyour prescriptions, excluding any deductible or maximumoutofpocketrequirements. The tool uses median cost for generic prescriptions andactual allowed costfor branded products. If the total cost is less than the co-pay that you would pay for that Tier you will be responsible only for the lesser of amount.

FORMULARY BY HEALTH BENEFIT PLAN

Plan Formulary Summary of Benefits and Coverage Ambetter Balanced Care 11 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 12 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 201 Standard https://ambetter.superiorhealthplan.com/2021- HSA (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 203 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 204 Standard https://ambetter.superiorhealthplan.com/2021- HSA (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 205 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 207 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 209 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 25 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 25 Standard https://ambetter.superiorhealthplan.com/2021- HSA (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 27 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 28 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 29 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 5 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=BalancedCare Ambetter Essential Care 1 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 10 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 2 Standard https://ambetter.superiorhealthplan.com/2021- HSA (2021) Formulary brochures.html?plan=EssentialCare Ambetter Secure Care 15 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=SecureCare Ambetter Secure Care 201 Standard https://ambetter.superiorhealthplan.com/2021- HSA (2021) Formulary brochures.html?plan=SecureCare Ambetter Secure Care 202 Standard https://ambetter.superiorhealthplan.com/2021- (2021) Formulary brochures.html?plan=SecureCare Ambetter Secure Care 5 (2021) Standard https://ambetter.superiorhealthplan.com/2021- Formulary brochures.html?plan=SecureCare

DRUG BY COST-SHARING TIER

Tier Percent of drugs in each cost-sharing tier: 0 6% 1 84% 2 2% 3 2% 4 6%

HOW PRESCRIPTION DRUGS ARE COVERED UNDER THE PLAN

A) FORMULARY COMPOSITION: a. Ambetter formulary is guided by the principle of offering widest possible access to drugs at the lowest cost. With that in mind, we start with the Affordable Care Act mandated benchmark. We then review the formulary for addition of other clinically necessary and appropriate drugs. Ambetter’s formulary is considered a closed formulary. This means that any drug not found in the formulary requires prior authorization. To make sure that our membersalwayshaveaccess to appropriatedrugs, we review and update our formulary ona monthly basis. B) RIGHT TO APPEAL a. If we deny your request for Prior Authorization you have 180 days from being denied coverage for a drug to file an appeal, and your appeal will be resolved within 30 days. In the event that your appeal is successful, non-specialty non-formulary drugs will be covered at your Tier 3 cost-share (co-pay or co- ) and specialty non-formulary drugs will be covered at your Tier 4 cost-share (co-pay or co- insurance). Please consult your individual Summary of Benefits and Coverage for additional information on your cost-share. All other provisions of your benefit, such as deductibles and maximum out of pockets, apply to formulary and non-formulary drugs that have been provided through an appeal.

C) CONTINUATION OF COVERAGE a. Ambetter does not make changes to our formulary requiring a continuation of coverage. However, if a formulary change is made requiring a continuation of coverage, you would have the right to continue taking the drug at the coverage level or tier at which the drug was covered at the beginning of the plan year until your plan is renewed.

D) OFF-LABEL DRUG USE a. We provide coverage for off-label drug use. Off-label use indicates medication use that has not been FDA approved for that condition. Coverage of a product under off-label use policy requires that the following must be true: i. Use must be diagnosis specific as defined by ICD-10 code AND ii. Off-label use must be supported by one major multi-site study or three smaller studies published in a reputable medical journal, peer reviewed specialty medical journal, or listed in reputable compendia.

E) COST SHARING a. Cost sharing is your monetary participation in your care. You will need to know few items to determine the cost-share you are responsible for. Knowing the following items will help you estimate the cost you’ll be responsible for at any given time: how much of your deductible you have already paid, how much deductibleremains, what drug you are prescribed, and your maximum out of pocket allowance. All those items, with the exception of the tier, can be obtained from the Summary of Benefits and Coverage (see links above). To obtain the tier for your drug please consult the Formulary. To determine your cost share please follow those steps: i. Determine the tier that the drug/product you are filling is listed under by consulting the Formulary. ii. Once you have determined the tier, utilize the Summary of Benefits and Coverage (SBC) document to determine what cost-share will apply to your selected drug/product. iii. If you have not met your deductible, you will be responsible for the full cost of the drug until you meet your deductible. iv. If you have met your deductible, but not the Maximum Out of Pocket, you will be charged a copay for drugs that are assigned a copay under your SBC and co-insurance for drugs that are assigned a co-insurance under your SBC. Generally, you will pay one (1) co-pay for each 30 day supply of medication. Two co-pays will be charged for 2 month supply and three co-pays for 3 month supply of your medication, respectively. v. To determine the cost for co-insurance drugs/products, please utilize our online drug search tool. Please see section: “HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGS” above.

b. Please be aware that pharmacy claims will only process if you present your prescription to an in- network pharmacy. Out-of-network claims will not be covered. To find an in-network-pharmacy close to you please consult our Find a Provider tool available on our website under Pharmacy Resources.

c. Your cost share for maintenance medications obtained through either Mail Order or at retail pharmacies participating in our Extended Day Supply retail network will be calculated based on the day supply that you obtain. For up to 30 day supply you will be charged one (1) copay or co-insurance, 31 to 60 day supply you will be responsible for two (2) copays or co-insurance and for day supply greater than 60 but less than 91 you will be charged three (3) copays or co-insurance. F) MEDICAL MANAGEMENT REQUIREMENTS a. Prior Authorization (PA) – Drugs that have PA indication on the Formulary require Prior Authorization. You or your provider have to request an authorization from us to use this drug/productprior to be able to fill a prescription for the drug/product. b. Step Therapy(ST) – Drugs thathave ST indication on theFormularyrequirethatyoutry andfailother formulary products before you can obtain the drug/product. When your provider does not feel that trying another product is appropriate your provider or you can submit a regular Prior Authorization request to obtain the Step Therapy drug/product. c. Quantity Limit (QL) – Drugs that have QL indication on the Formulary are limited to the quantity indicated. Those quantity limits are based on the FDA approved maximum doses. If your provider would like to request exception to those limits he/she may submit a Prior Authorization request. All request requested for quantity limit exemptions will be processed under our Off-Label policy. d. Non-Formulary Drugs – Drugs not found on this formulary are considered non-formulary drugs. To obtain non-formulary drugs your provider would have to submit a regular Prior Authorization request. All request for Non-Formulary Drugs will be reviewed under our Non-Formulary Drug Request Policy.

STANDARD FORMULARY

The Ambetterfrom Superior Health PlanFormulary, or PreferredDrugList, is a guide to available brand and generic drugs that are approved by theFood and Drug Administration (FDA) and covered throughyour prescription drug benefit. Generic drugs havethesame active ingredients as their brand namecounterparts and should be considered thefirst line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition.Preferredbrandnamedrugs are listed on Tier2 to helpidentifybranddrugsthat are clinically appropriate,safe,andcost-effectivetreatmentoptions, if ageneric medication on theformulary is not suitable for your condition.

Drug List Key: Brandnamedrugs are listed in CAPS and genericdrugsare lower case. Drugs are covered under different copay tiers depending on your benefit:

Tier0 - No copaymentforthosedrugsthat are usedforpreventionandaremandated by AffordableCare Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered underthis tier. Certain age or genderlimits apply.

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

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

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

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

Abbreviation Term What it means

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

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

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

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

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMIRA PEN-CD/UC/HS PA; QL(0.143 ARCALYST SOLR 4 PA; QL(0.286 STARTER PNKT 40 4 ea daily) ea daily); SP MG/0.8ML Interleukin-1beta Blockers PA; 1 rtl pack PA; QL(0.072 lmt amt,180 rtl ILARIS SOLN 4 ml daily) HUMIRA PEN-CD/UC/HS pack lmt STARTER PNKT 80 4 day(s),1 mail Anti-inflammatory Agents (NSAIDs) pack lmt MG/0.8ML ARTHROTEC 50 TBEC amt,180 mail (Use diclofenac w/ NF pack lmt misoprostol) day(s), ARTHROTEC 75 TBEC PA; 1 rtl pack (Use diclofenac w/ NF lmt amt,180 rtl misoprostol) pack lmt HUMIRA PEN-PEDIATRIC CELEBREX CAPS (Use PA UC STARTER PACK 4 day(s),1 mail NF pack lmt ) PNKT amt,180 mail celecoxib caps 1 PA pack lmt day(s), CHILDRENS ADVIL SUSP NF RX/OTC PA; 1 rtl pack (Use ibuprofen) lmt amt,180 rtl CHILDRENS MOTRIN NF RX/OTC pack lmt SUSP (Use ibuprofen) HUMIRA PEN-PS/UV day(s),1 mail 4 DAYPRO TABS (Use NF STARTER PNKT pack lmt oxaprozin) amt,180 mail pack lmt diclofenac potassium tabs 1 day(s), diclofenac sodium tb24 1 HUMIRA PEN-PS/UV 4 PA; QL(0.143 STARTER PNKT ea daily) diclofenac sodium tbec 1 HUMIRA PSKT 4 PA; QL(0.143 ea daily) diclofenac w/ misoprostol 1 Antirheumatic - Enzyme Inhibitors tbec EC-NAPROSYN TBEC 500 RINVOQ TB24 4 PA; QL(1 ea NF daily) MG (Use naproxen) etodolac caps 200 mg, 300 XELJANZ TABS 10 MG 4 PA; QL(2 ea 1 daily) mg etodolac tabs 400 mg, 500 XELJANZ TABS 5 MG 4 PA; QL(2 ea 1 daily); SP mg FELDENE CAPS (Use XELJANZ XR TB24 4 PA; QL(1 ea NF daily) piroxicam) fenoprofen calcium tabs 1 ST; QL(4 ea Antirheumatic Antimetabolites 600 mg daily) METHOTREXATE TABS 4 PA; QL(1.714 ea daily); SP flurbiprofen tabs 1 Gold Compounds ibuprofen susp 100 mg/5ml 1 RX/OTC RIDAURA CAPS 3 QL(3 ea daily) ibuprofen tabs 400 mg, 600 1 mg, 800 mg Interleukin-1 Blockers Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANADROL-50 TABS 3 hydrocortisone acetate 1 (rectal) supp oxandrolone tabs 1 PROCTOCORT CREA (Use hydrocortisone NF Androgens (rectal)) PROCTOCORT SUPP ANDRODERM PT24 2 PA; QL(1 ea daily) (Use hydrocortisone NF ANDROGEL GEL 25 acetate (rectal)) MG/2.5GM, 50 MG/5GM NF Vasodilating Agents (Use testosterone) RECTIV OINT 3 QL(2 gm daily) danazol caps 1 ANTHELMINTICS - Drugs to Treat Worm DEPO-TESTOSTERONE Infections SOLN (Use testosterone NF cypionate) Anthelmintics PA METHITEST TABS 3 albendazole tabs 1 ALBENZA TABS (Use PA TESTIM GEL (Use NF NF testosterone) albendazole) TESTOSTERONE BILTRICIDE TABS (Use NF PA CYPIONATE SOLN IJ 200 1 praziquantel) MG/ML QL(2 ea daily,6 ea per fill testosterone cypionate soln 1 ij 200 mg/ml retail,6 ea per fill mail)1 rtl testosterone cypionate soln 1 im 100 mg/ml, 200 mg/ml EMVERM CHEW 2 MAX fill,60 rtl day(s) supply,1 testosterone enanthate 1 mail MAX fill,60 soln im mail day(s) VOGELXO GEL (Use NF supply, testosterone) ivermectin tabs or 3 mg 1 VOGELXO PUMP GEL NF (Use testosterone) praziquantel tabs 1 PA ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching STROMECTOL TABS (Use NF ivermectin) Intrarectal Steroids ANTI-INFECTIVE AGENTS - MISC. - Drugs to CORTENEMA ENEM (Use NF Treat Bacterial Infections hydrocortisone (intrarectal)) Anti-infective Agents - Misc. hydrocortisone (intrarectal) 1 enem solr 3 UCERIS FOAM RE 2 4 PA; QL(3.2 gm MG/ACT daily) FLAGYL TABS 500 MG NF (Use ) Rectal Steroids PA; QL(3 ea IMPAVIDO CAPS 3 ANUSOL-HC CREA (Use NF daily) hydrocortisone (rectal)) metronidazole tabs or 250 1 hydrocortisone (rectal) crea 1 mg, 500 mg

Ambetter Formulary Updated September 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tabs 1 CUBICIN RF SOLR (Use NF daptomycin) PA; AL(At least XIFAXAN TABS 3 CUBICIN SOLR (Use NF 12 yrs old) daptomycin) Anti-infective Misc. - Combinations DAPTOMYCIN SOLR 350 NF BACTRIM DS TABS (Use MG (Use daptomycin) - NF daptomycin solr 500 mg 1 trimethoprim) BACTRIM TABS (Use Glycopeptides sulfamethoxazole- NF FIRVANQ SOLR 2 QL(300 ml per trimethoprim) fill retail) sulfamethoxazole- 1 QL(4 ea trimethoprim soln VANCOCIN CAPS (Use NF hcl) daily,40 ea per sulfamethoxazole- 1 fill retail) trimethoprim susp QL(4 ea VANCOCIN HCL CAPS NF sulfamethoxazole- 1 (Use vancomycin hcl) daily,40 ea per trimethoprim tabs fill retail) Antiprotozoal Agents QL(4 ea vancomycin hcl caps or 1 daily,40 ea per ALINIA SUSR 100 PA 125 mg, 250 mg 2 fill retail) MG/5ML vancomycin hcl solr iv 10 ALINIA TABS 500 MG (Use 2 PA 1 nitazoxanide) gm, 500 mg, 1 gm, 1000 mg atovaquone susp 1 VANCOMYCIN QL(300 ml per HYDROCHLORIDE SOLR 2 fill retail) MEPRON SUSP (Use NF OR 250 MG/5ML atovaquone) Leprostatics nitazoxanide tabs or 1 PA tabs 1 Carbapenems Lincosamides ertapenem sodium solr 1 CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use NF imipenem-cilastatin solr 1 clindamycin hcl) INVANZ SOLR (Use NF CLEOCIN PEDIATRIC ertapenem sodium) GRANULES SOLR (Use NF clindamycin palmitate meropenem solr 1 hydrochloride) CLEOCIN PHOSPHATE MERREM SOLR (Use NF meropenem) SOLN IJ 300 MG/2ML, 600 MG/4ML, 900 MG/6ML, 9 NF PRIMAXIN IV SOLR (Use NF imipenem-cilastatin) GM/60ML (Use clindamycin phosphate) Chloramphenicols clindamycin hcl caps 1 sodium 4 PA; SP succinate solr clindamycin palmitate 1 Cyclic Lipopeptides hydrochloride solr

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxazepam caps 10 mg, 30 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety mg, 15 mg Antianxiety Agents - Misc. TRANXENE T TABS (Use NF dipotassium) buspirone hcl tabs 10 mg, 1 30 mg, 7.5 mg, 15 mg VALIUM TABS (Use NF QL(4 ea daily) ) buspirone hcl tabs 5 mg 1 QL(6 ea daily) XANAX TABS (Use NF QL(4 ea daily) alprazolam) hydroxyzine hcl soln im 50 1 mg/ml XANAX XR TB24 (Use NF alprazolam) hydroxyzine hcl syrp or 10 1 mg/5ml ANTIARRHYTHMICS - Drugs to treat abnormal hydroxyzine hcl tabs or 10 1 heart rhythms mg, 25 mg, 50 mg Antiarrhythmics Type I-A hydroxyzine pamoate caps 1 disopyramide phosphate 1 caps meprobamate tabs 1 NORPACE CAPS (Use NF disopyramide phosphate) VISTARIL CAPS (Use NF ) hydroxyzine pamoate procainamide hcl soln 500 1 mg/ml quinidine sulfate tabs 1 alprazolam tabs 0.25 mg, 1 QL(4 ea daily) 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-B alprazolam tb24 0.5 mg, 1 1 mg, 2 mg, 3 mg mexiletine hcl caps 250 1 mg, 150 mg, 200 mg alprazolam tbdp 0.25 mg, 1 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-C ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) flecainide acetate tabs 1 2 MG (Use ) ATIVAN TABS OR 1 MG NF QL(4 ea daily) propafenone hcl cp12 1 (Use lorazepam) chlordiazepoxide hcl caps 1 propafenone hcl tabs 1 RYTHMOL SR CP12 (Use clorazepate dipotassium 1 NF tabs propafenone hcl) diazepam conc or 5 mg/ml 1 Antiarrhythmics Type III amiodarone hcl soln iv 150 1 diazepam soln or 5 mg/5ml 1 mg/3ml, 50 mg/ml amiodarone hcl tabs or 100 1 diazepam tabs or 10 mg, 2 1 QL(4 ea daily) mg, 200 mg, 400 mg mg, 5 mg caps 1 lorazepam conc or 2 mg/ml 1 MULTAQ TABS 3 lorazepam tabs or 0.5 mg, 1 QL(3 ea daily) 2 mg TIKOSYN CAPS (Use NF lorazepam tabs or 1 mg 1 QL(4 ea daily) dofetilide)

Ambetter Formulary Updated September 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIASTHMATIC AND BRONCHODILATOR SINGULAIR TABS 10 MG NF QL(1 ea daily) AGENTS - Drugs to Treat Lung Conditions (Use montelukast sodium) QL(2 ea daily) Anti-Inflammatory Agents zafirlukast tabs 1 QL(8 ml daily) cromolyn sodium nebu 1 zileuton tb12 1 QL(4 ea daily) Antiasthmatic - Monoclonal Antibodies Selective Phosphodiesterase 4 (PDE4) Inhibitors FASENRA PEN SOAJ 4 PA QL(1 ea daily)30 rtl FASENRA SOSY 4 PA MAX day(s) supply,180 rtl PA DALIRESP TABS 250 3 NUCALA SOAJ 4 MCG lmt day(s),30 mail MAX NUCALA SOLR 4 PA day(s) supply,180 mail NUCALA SOSY 4 PA lmt day(s), DALIRESP TABS 500 3 QL(1 ea daily) XOLAIR SOLR 150 MG 4 PA; SP MCG Steroid Inhalants XOLAIR SOSY 150 4 PA MG/ML, 75 MG/0.5ML ARNUITY ELLIPTA AEPB 2 Bronchodilators - Anticholinergics (inhalation) 1 PA; QL(4 ml ATROVENT HFA AERS 3 QL(0.44 gm susp daily) daily) FLOVENT DISKUS AEPB 2 INCRUSE ELLIPTA AEPB 2 QL(1 ea daily) FLOVENT HFA AERO 2 ipratropium soln 1 QL(15 ml daily) PULMICORT FLEXHALER 2 SPIRIVA HANDIHALER 2 QL(1 ea daily) AEPB CAPS PULMICORT SUSP (Use NF PA; QL(4 ml SPIRIVA RESPIMAT 2 QL(0.14 gm budesonide (inhalation)) daily) AERS daily) QVAR REDIHALER AERB 2 Leukotriene Modulators ACCOLATE TABS (Use NF QL(2 ea daily) Sympathomimetics zafirlukast) ADVAIR DISKUS AEPB montelukast sodium chew 1 QL(1 ea daily) (Use fluticasone- NF 4 mg, 5 mg salmeterol) montelukast sodium pack 4 1 PA; QL(1 ea ADVAIR HFA AERO 2 mg daily) AIRDUO RESPICLICK montelukast sodium tabs 1 QL(1 ea daily) 10 mg 113/14 AEPB (Use NF SINGULAIR CHEW 4 MG, QL(1 ea daily) fluticasone-salmeterol) 5 MG (Use montelukast NF AIRDUO RESPICLICK sodium) 232/14 AEPB (Use NF fluticasone-salmeterol) SINGULAIR PACK 4 MG NF PA; QL(1 ea (Use montelukast sodium) daily)

Ambetter Formulary Updated September 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIRDUO RESPICLICK fluticasone-salmeterol aepb 55/14 AEPB (Use NF 50 mcg/dose-500 fluticasone-salmeterol) mcg/dose, 100 mcg/act-50 2 rtl pack lmt mcg/act, 50 mcg/act-250 1 albuterol sulfate aers in 1 amt,30 rtl pack mcg/act, 50 mcg/dose-100 108 mcg/act lmt day(s), mcg/dose, 50 mcg/dose- 250 mcg/dose Limit 2 inhalers per month;1 rtl ipratropium-albuterol soln 1 QL(18 ml daily) albuterol sulfate aers in 1 pack lmt per 108 mcg/act fill,2 rtl MAX levalbuterol hcl nebu 0.31 PA; QL(12 ml fill,30 rtl day(s) mg/3ml, 0.63 mg/3ml, 1.25 1 daily) supply, mg/3ml Limit 2 Inhalers levalbuterol hcl nebu 1.25 1 PA per month;1 rtl mg/0.5ml albuterol sulfate aers in 1 pack lmt per PA; Limit 2 108 mcg/act fill,2 rtl MAX 3 inhalers per fill,30 rtl day(s) levalbuterol tartrate aero month;QL(1 gm supply, daily) albuterol sulfate nebu in 1 PROAIR HFA AERS (Use NF 0.5 %, 2.5 mg/0.5ml albuterol sulfate) albuterol sulfate nebu in QL(15 ml daily) PROVENTIL HFA AERS NF 0.63 mg/3ml, 1.25 mg/3ml, 1 (Use albuterol sulfate) 0.083 % SEREVENT DISKUS 2 albuterol sulfate syrp or 2 1 AEPB mg/5ml STRIVERDI RESPIMAT 2 albuterol sulfate tabs or 2 1 AERS mg, 4 mg SYMBICORT AERO (Use albuterol sulfate tb12 or 4 1 budesonide-formoterol 2 mg, 8 mg fumarate dihydrate) ANORO ELLIPTA AEPB 2 QL(2 ea daily) terbutaline sulfate soln 1

ARCAPTA NEOHALER 2 terbutaline sulfate tabs 1 CAPS PA; QL(4 ml QL(2 ea daily) arformoterol tartrate nebu 1 TRELEGY ELLIPTA AEPB 2 daily) UTIBRON NEOHALER PA; QL(2 ea BEVESPI AEROSPHERE 2 QL(0.36 gm 3 AERO daily) CAPS daily) VENTOLIN HFA AERS NF BREO ELLIPTA AEPB 2 (Use albuterol sulfate) XOPENEX PA BROVANA NEBU (Use 3 PA; QL(4 ml arformoterol tartrate) daily) CONCENTRATE NEBU NF (Use levalbuterol hcl) budesonide-formoterol 1 fumarate dihydrate aero PA; Limit 2 XOPENEX HFA AERO 3 inhalers per (Use levalbuterol tartrate) month;QL(1 gm daily) XOPENEX NEBU (Use NF PA; QL(12 ml levalbuterol hcl) daily) Ambetter Formulary Updated September 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Xanthines QL(3.6 ml per ARIXTRA SOLN 5 180 days aminophylline soln 1 MG/0.4ML (Use NF retail,3.6 ml per fondaparinux sodium) 180 days mail); ELIXOPHYLLIN ELIX 1 SP QL(5.4 ml per theophylline soln 80 1 QL(56 ml daily) mg/15ml ARIXTRA SOLN 7.5 180 days MG/0.6ML (Use NF retail,5.4 ml per theophylline tb12 100 mg, 1 fondaparinux sodium) 180 days mail); 200 mg, 300 mg, 450 mg SP theophylline tb24 400 mg, 1 enoxaparin sodium soln ij 4 QL(6 ml daily) 600 mg 300 mg/3ml ANTICOAGULANTS - Blood Thinners enoxaparin sodium soln sc 4 QL(2 ml daily) 100 mg/ml, 150 mg/ml Coumarin Anticoagulants enoxaparin sodium soln sc 4 QL(1.6 ml COUMADIN TABS (Use 2 120 mg/0.8ml, 80 mg/0.8ml daily) warfarin sodium) enoxaparin sodium soln sc 4 QL(0.6 ml warfarin sodium tabs 1 30 mg/0.3ml daily); SP QL(0.8 ml enoxaparin sodium soln sc 4 daily,30 day(s) Direct Factor Xa Inhibitors 40 mg/0.4ml QL(42 ea per limit); SP 42 days QL(1.2 ml BEVYXXA CAPS 3 enoxaparin sodium soln sc 4 daily,30 day(s) retail,42 ea per 60 mg/0.6ml 42 days mail) limit); SP QL(7.2 ml per ELIQUIS STARTER PACK 2 QL(2.47 ea TBPK daily) 180 days fondaparinux sodium soln 4 retail,7.2 ml per ELIQUIS TABS 2 QL(2.47 ea 10 mg/0.8ml daily) 180 days mail); SP 1 rtl MAX XARELTO STARTER 2 QL(4.5 ml per PACK TBPK fill,365 rtl day(s) supply, 180 days fondaparinux sodium soln 4 retail,4.5 ml per 2.5 mg/0.5ml XARELTO TABS 10 MG, 2 QL(1 ea daily) 180 days mail); 20 MG SP XARELTO TABS 15 MG, 2 QL(2 ea daily) QL(3.6 ml per 2.5 MG 180 days fondaparinux sodium soln 5 4 retail,3.6 ml per Heparins And Heparinoid-Like Agents mg/0.4ml QL(7.2 ml per 180 days mail); ARIXTRA SOLN 10 180 days SP MG/0.8ML (Use NF retail,7.2 ml per QL(5.4 ml per fondaparinux sodium) 180 days mail); 180 days fondaparinux sodium soln 4 retail,5.4 ml per SP 7.5 mg/0.6ml QL(4.5 ml per 180 days mail); ARIXTRA SOLN 2.5 180 days SP MG/0.5ML (Use NF retail,4.5 ml per fondaparinux sodium) 180 days mail); SP

Ambetter Formulary Updated September 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FRAGMIN SOLN 10000 PA; SP tabs 10 mg, 20 1 PA; QL(2 ea UNIT/ML, 12500 mg daily) UNIT/0.5ML, 15000 tabs 0.5 mg, 1 1 UNIT/0.6ML, 18000 4 mg, 2 mg UNT/0.72ML, 2500 UNIT/0.2ML, 5000 DIASTAT ACUDIAL GEL UNIT/0.2ML, 7500 (Use diazepam 3 UNIT/0.3ML ()) HEPARIN LOCK FLUSH DIASTAT PEDIATRIC GEL SOLN (Use heparin sodium NF (Use diazepam 3 (porcine) lock flush) (anticonvulsant)) diazepam (anticonvulsant) heparin sod (porcine) in 1 3 d5w soln 5 %-40 unit/ml gel heparin sodium (porcine) KLONOPIN TABS (Use NF soln 10000 unit/ml, 20000 1 clonazepam) unit/ml, 5000 unit/ml PA; QL(10 ea HEPARIN SODIUM/NACL NAYZILAM SOLN 3 per 30 days 0.45% SOLN 0.45 %- 1 retail) 12500 UNIT/250ML ONFI SUSP 2.5 MG/ML NF PA; QL(16 ml LOVENOX SOLN IJ 300 QL(6 ml daily) (Use clobazam) daily) MG/3ML (Use enoxaparin NF ONFI TABS 10 MG, 20 MG NF PA; QL(2 ea sodium) (Use clobazam) daily) LOVENOX SOLN SC 100 QL(2 ml daily) PA; QL(10 ea MG/ML, 150 MG/ML (Use NF VALTOCO LIQD 4 per 30 days enoxaparin sodium) retail) LOVENOX SOLN SC 120 QL(1.6 ml PA; QL(10 ea MG/0.8ML, 80 MG/0.8ML NF daily) VALTOCO LQPK 4 per 30 days (Use enoxaparin sodium) retail) LOVENOX SOLN SC 30 QL(0.6 ml - Misc. MG/0.3ML (Use NF daily); SP APTIOM TABS 3 ST; QL(2 ea enoxaparin sodium) daily) LOVENOX SOLN SC 40 QL(0.8 ml BANZEL SUSP 40 MG/ML 2 PA; QL(80 ml MG/0.4ML (Use NF daily,30 day(s) (Use ) daily) enoxaparin sodium) limit); SP BANZEL TABS 200 MG 2 PA; QL(2 ea LOVENOX SOLN SC 60 QL(1.2 ml (Use rufinamide) daily) MG/0.6ML (Use NF daily,30 day(s) enoxaparin sodium) limit); SP BANZEL TABS 400 MG 2 PA; QL(8 ea (Use rufinamide) daily) ANTICONVULSANTS - Drugs to Treat Seizures BRIVIACT SOLN OR 10 3 PA MG/ML AMPA Glutamate Receptor Antagonists BRIVIACT TABS OR 10 PA FYCOMPA TABS 10 MG, PA MG, 100 MG, 25 MG, 50 3 12 MG, 2 MG, 4 MG, 6 MG, 3 MG, 75 MG 8 MG chew 100 1 Anticonvulsants - Benzodiazepines mg PA; QL(16 ml clobazam susp 2.5 mg/ml 1 carbamazepine cp12 100 1 daily) mg

Ambetter Formulary Updated September 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbamazepine cp12 200 1 QL(6 ea daily) KEPPRA XR TB24 (Use NF QL(4 ea daily) mg ) carbamazepine cp12 300 1 QL(4 ea daily) LAMICTAL CHEWABLE QL(20 ea daily) mg DISPERSIBLE CHEW 25 NF MG (Use ) carbamazepine susp 100 1 mg/5ml LAMICTAL CHEWABLE QL(100 ea DISPERSIBLE CHEW 5 NF daily) carbamazepine tabs 200 1 mg MG (Use lamotrigine) LAMICTAL ODT TBDP 100 QL(1 ea daily) carbamazepine tb12 100 1 QL(4 ea daily) mg, 400 mg MG, 200 MG, 25 MG, 50 NF MG (Use lamotrigine) carbamazepine tb12 200 1 QL(6 ea daily) mg LAMICTAL TABS (Use NF lamotrigine) CARBATROL CP12 100 NF MG (Use carbamazepine) lamotrigine chew 25 mg 1 QL(20 ea daily) CARBATROL CP12 200 QL(6 ea daily) NF QL(100 ea MG (Use carbamazepine) lamotrigine chew 5 mg 1 daily) CARBATROL CP12 300 NF QL(4 ea daily) MG (Use carbamazepine) lamotrigine tabs 100 mg, 1 150 mg, 200 mg, 25 mg PA; QL(12 ea DIACOMIT CAPS 250 MG 4 daily) lamotrigine tbdp 100 mg, 1 QL(1 ea daily) 200 mg, 25 mg, 50 mg PA; QL(6 ea DIACOMIT CAPS 500 MG 4 daily) levetiracetam soln iv 500 1 QL(30 ml daily) mg/5ml PA; QL(12 ea DIACOMIT PACK 250 MG 4 daily) levetiracetam soln or 100 1 QL(30 ml daily) mg/ml, 500 mg/5ml PA; QL(6 ea DIACOMIT PACK 500 MG 4 daily) levetiracetam tabs or 1000 1 QL(3 ea daily) mg EPIDIOLEX SOLN 3 PA levetiracetam tabs or 250 1 QL(4 ea daily) mg, 750 mg caps 100 mg, 1 300 mg, 400 mg levetiracetam tabs or 500 1 QL(6 ea daily) mg gabapentin soln 250 1 QL(60 ml daily) mg/5ml, 300 mg/6ml levetiracetam tb24 or 500 1 QL(4 ea daily) mg, 750 mg gabapentin tabs 600 mg, 1 800 mg LYRICA CAPS 100 MG, PA; QL(3 ea 150 MG, 200 MG, 25 MG, NF daily) KEPPRA SOLN IV 500 QL(30 ml daily) 50 MG, 75 MG (Use MG/5ML (Use NF ) levetiracetam) LYRICA CAPS 225 MG, NF PA; QL(2 ea KEPPRA SOLN OR 100 NF QL(30 ml daily) 300 MG (Use pregabalin) daily) MG/ML (Use levetiracetam) LYRICA SOLN 20 MG/ML NF PA; QL(30 ml KEPPRA TABS OR 1000 NF QL(3 ea daily) (Use pregabalin) daily) MG (Use levetiracetam) MYSOLINE TABS (Use NF KEPPRA TABS OR 250 QL(4 ea daily) ) MG, 750 MG (Use NF levetiracetam) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use NF KEPPRA TABS OR 500 NF QL(6 ea daily) gabapentin) MG (Use levetiracetam)

Ambetter Formulary Updated September 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN SOLN 250 NF QL(60 ml daily) TOPAMAX TABS 200 MG NF QL(2 ea daily) MG/5ML (Use gabapentin) (Use ) NEURONTIN TABS 600 TOPAMAX TABS 50 MG NF QL(6 ea daily) MG, 800 MG (Use NF (Use topiramate) gabapentin) topiramate cpsp 15 mg 1 QL(6 ea daily) susp 300 1 QL(40 ml daily) mg/5ml, 60 mg/ml topiramate cpsp 25 mg 1 QL(8 ea daily) oxcarbazepine tabs 150 1 QL(3 ea daily) mg, 300 mg topiramate tabs 100 mg, 25 1 QL(4 ea daily) mg oxcarbazepine tabs 600 1 QL(4 ea daily) mg topiramate tabs 200 mg 1 QL(2 ea daily) pregabalin caps 100 mg, PA; QL(3 ea 150 mg, 200 mg, 25 mg, 50 1 daily) topiramate tabs 50 mg 1 QL(6 ea daily) mg, 75 mg TRILEPTAL SUSP 300 QL(40 ml daily) pregabalin caps 225 mg, 1 PA; QL(2 ea 300 mg daily) MG/5ML (Use NF oxcarbazepine) PA; QL(30 ml pregabalin soln 20 mg/ml 1 daily) TRILEPTAL TABS 150 QL(3 ea daily) MG, 300 MG (Use NF primidone tabs 1 oxcarbazepine) TRILEPTAL TABS 600 MG NF QL(4 ea daily) QUDEXY XR CS24 (Use NF (Use oxcarbazepine) topiramate) VIMPAT SOLN IV 200 QL(40 ml daily) PA; QL(80 ml 3 rufinamide susp 40 mg/ml 1 MG/20ML daily) VIMPAT SOLN OR 10 PA; QL(40 ml PA; QL(2 ea 3 rufinamide tabs 200 mg 1 MG/ML daily) daily) VIMPAT TABS OR 100 PA; QL(2 ea PA; QL(8 ea rufinamide tabs 400 mg 1 MG, 150 MG, 200 MG, 50 3 daily) daily) MG TEGRETOL SUSP (Use 2 ZONEGRAN CAPS (Use NF QL(6 ea daily) carbamazepine) ) TEGRETOL TABS (Use 2 QL(6 ea daily) carbamazepine) zonisamide caps 1 TEGRETOL-XR TB12 100 QL(4 ea daily) MG, 400 MG (Use NF carbamazepine) susp 600 mg/5ml 1 QL(30 ml daily) TEGRETOL-XR TB12 200 NF QL(6 ea daily) MG (Use carbamazepine) felbamate tabs 400 mg 1 QL(9 ea daily) TOPAMAX SPRINKLE QL(6 ea daily) QL(6 ea daily) CPSP 15 MG (Use NF felbamate tabs 600 mg 1 topiramate) FELBATOL SUSP 600 NF QL(30 ml daily) TOPAMAX SPRINKLE QL(8 ea daily) MG/5ML (Use felbamate) CPSP 25 MG (Use NF FELBATOL TABS 400 MG NF QL(9 ea daily) topiramate) (Use felbamate) TOPAMAX TABS 100 MG, QL(4 ea daily) NF FELBATOL TABS 600 MG NF QL(6 ea daily) 25 MG (Use topiramate) (Use felbamate) GABA Modulators Ambetter Formulary Updated September 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GABITRIL TABS 2 MG, 4 NF ZARONTIN CAPS 250 MG 2 QL(6 ea daily) MG (Use hcl) (Use ) SABRIL PACK (Use NF PA; QL(6 ea ZARONTIN SOLN 250 QL(30 ml daily) ) daily); SP MG/5ML (Use NF ethosuximide) SABRIL TABS (Use NF PA; QL(6 ea vigabatrin) daily); SP Valproic Acid tiagabine hcl tabs 2 mg, 4 1 DEPACON SOLN (Use NF mg sodium) PA; QL(6 ea vigabatrin pack 4 DEPAKENE CAPS (Use NF daily); SP valproic acid) PA; QL(6 ea vigabatrin tabs 4 DEPAKOTE ER TB24 (Use NF daily); SP divalproex sodium) DEPAKOTE TBEC (Use NF divalproex sodium) CEREBYX SOLN (Use NF sodium) divalproex sodium tb24 250 1 DILANTIN CAPS 100 MG mg, 500 mg (Use sodium 2 divalproex sodium tbec 125 1 extended) mg, 250 mg, 500 mg DILANTIN CAPS 30 MG 2 valproate sodium soln 1

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

Ambetter Formulary Updated September 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REMERON TABS 30 MG NF QL(1.5 ea N-Methyl-D-aspartic acid (NMDA) Receptor (Use mirtazapine) daily) SPRAVATO 56MG DOSE 4 PA Antidepressants - Misc. SOPK bupropion hcl tabs 100 mg, 1 QL(3 ea daily) SPRAVATO 84MG DOSE 4 PA 75 mg SOPK bupropion hcl tb12 100 mg 1 QL(4 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG QL(4 ea daily) bupropion hcl tb12 150 mg 1 QL(3 ea daily) (Use citalopram NF hydrobromide) QL(2 ea daily) bupropion hcl tb12 200 mg 1 CELEXA TABS 20 MG QL(2 ea daily) QL(3 ea daily) (Use citalopram NF bupropion hcl tb24 150 mg 1 hydrobromide) QL(1 ea daily) CELEXA TABS 40 MG QL(1 ea daily) bupropion hcl tb24 300 mg 1 (Use citalopram NF hydrobromide) FORFIVO XL TB24 (Use NF bupropion hcl) citalopram hydrobromide 1 QL(20 ml daily) soln 10 mg/5ml maprotiline hcl tabs 1 citalopram hydrobromide 1 QL(4 ea daily) WELLBUTRIN SR TB12 QL(4 ea daily) tabs 10 mg 100 MG (Use bupropion NF citalopram hydrobromide 1 QL(2 ea daily) hcl) tabs 20 mg WELLBUTRIN SR TB12 QL(3 ea daily) citalopram hydrobromide 1 QL(1 ea daily) 150 MG (Use bupropion NF tabs 40 mg hcl) escitalopram oxalate soln 5 1 QL(20 ml daily) WELLBUTRIN SR TB12 QL(2 ea daily) mg/5ml 200 MG (Use bupropion NF escitalopram oxalate tabs 1 QL(2 ea daily) hcl) 10 mg WELLBUTRIN XL TB24 QL(3 ea daily) escitalopram oxalate tabs 1 QL(1 ea daily) 150 MG (Use bupropion NF 20 mg hcl) escitalopram oxalate tabs 5 1 QL(4 ea daily) WELLBUTRIN XL TB24 QL(1 ea daily) mg 300 MG (Use bupropion NF hcl) fluoxetine hcl caps 10 mg 1 QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl caps 20 mg 1 QL(3 ea daily) EMSAM PT24 3 QL(1 ea daily) fluoxetine hcl caps 40 mg 1 QL(2 ea daily) MARPLAN TABS 2 QL(6 ea daily) fluoxetine hcl cpdr 90 mg 1 NARDIL TABS (Use NF phenelzine sulfate) fluoxetine hcl soln 20 1 QL(20 ml daily) mg/5ml PARNATE TABS (Use NF tranylcypromine sulfate) fluoxetine hcl tabs 10 mg, 1 QL(1 ea daily) 60 mg phenelzine sulfate tabs 1 fluoxetine hcl tabs 20 mg 1 QL(3 ea daily) tranylcypromine sulfate 1 tabs

Ambetter Formulary Updated September 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUOXETINE QL(1 ea daily) sertraline hcl tabs 100 mg 1 QL(2 ea daily) HYDROCHLORIDE TABS NF (Use fluoxetine hcl) sertraline hcl tabs 25 mg, 1 QL(4 ea daily) 50 mg fluvoxamine maleate tabs 1 QL(3 ea daily) 100 mg ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) (Use sertraline hcl) fluvoxamine maleate tabs 1 QL(2 ea daily) 25 mg, 50 mg ZOLOFT TABS 100 MG NF QL(2 ea daily) (Use sertraline hcl) LEXAPRO TABS 10 MG NF QL(2 ea daily) (Use escitalopram oxalate) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) MG (Use sertraline hcl) LEXAPRO TABS 20 MG NF QL(1 ea daily) (Use escitalopram oxalate) Serotonin Modulators LEXAPRO TABS 5 MG NF QL(4 ea daily) (Use escitalopram oxalate) nefazodone hcl tabs 1 QL(6 ea daily) paroxetine hcl tabs 10 mg 1 trazodone hcl tabs 1 QL(3 ea daily) PA; QL(1 ea paroxetine hcl tabs 20 mg 1 TRINTELLIX TABS 3 daily) paroxetine hcl tabs 30 mg 1 QL(2 ea daily) PA; 1 rtl pack VIIBRYD STARTER PACK 3 lmt amt,180 rtl paroxetine hcl tabs 40 mg 1 QL(1 ea daily) KIT pack lmt day(s), paroxetine hcl tb24 12.5 QL(1 ea daily) 1 VIIBRYD TABS 3 PA; QL(1 ea mg daily) paroxetine hcl tb24 37.5 1 QL(2 ea daily) mg, 25 mg Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use QL(2 ea daily) PAXIL CR TB24 12.5 MG NF QL(1 ea daily) NF (Use paroxetine hcl) duloxetine hcl) desvenlafaxine succinate QL(4 ea daily) PAXIL CR TB24 37.5 MG, NF QL(2 ea daily) 1 25 MG (Use paroxetine hcl) tb24 100 mg QL(30 ml daily) desvenlafaxine succinate 1 QL(1 ea daily) PAXIL SUSP 10 MG/5ML 3 tb24 25 mg, 50 mg duloxetine hcl cpep or 20 QL(2 ea daily) PAXIL TABS 10 MG (Use NF QL(6 ea daily) 1 paroxetine hcl) mg, 60 mg, 30 mg duloxetine hcl cpep or 40 PAXIL TABS 20 MG (Use NF QL(3 ea daily) 1 paroxetine hcl) mg EFFEXOR XR CP24 150 QL(2 ea daily) PAXIL TABS 30 MG (Use NF QL(2 ea daily) NF paroxetine hcl) MG (Use venlafaxine hcl) EFFEXOR XR CP24 37.5 QL(4 ea daily) PAXIL TABS 40 MG (Use NF QL(1 ea daily) NF paroxetine hcl) MG (Use venlafaxine hcl) EFFEXOR XR CP24 75 QL(5 ea daily) PROZAC CAPS 10 MG NF QL(1 ea daily) NF (Use fluoxetine hcl) MG (Use venlafaxine hcl) PA PROZAC CAPS 20 MG NF QL(3 ea daily) FETZIMA CP24 3 (Use fluoxetine hcl) FETZIMA TITRATION PA PROZAC CAPS 40 MG NF QL(2 ea daily) 3 (Use fluoxetine hcl) PACK C4PK KHEDEZLA TB24 (Use sertraline hcl conc 20 1 QL(10 ml daily) NF mg/ml desvenlafaxine) Ambetter Formulary Updated September 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRISTIQ TB24 100 MG QL(4 ea daily) protriptyline hcl tabs 1 (Use desvenlafaxine NF succinate) TOFRANIL TABS (Use NF PRISTIQ TB24 25 MG, 50 QL(1 ea daily) imipramine hcl) NF MG (Use desvenlafaxine trimipramine maleate caps 1 succinate) venlafaxine hcl cp24 150 1 QL(2 ea daily) ANTIDIABETICS - Drugs to Regulate Blood mg Sugar venlafaxine hcl cp24 37.5 1 QL(4 ea daily) Alpha-Glucosidase Inhibitors mg acarbose tabs 1 QL(3 ea daily) venlafaxine hcl cp24 75 mg 1 QL(5 ea daily) GLYSET TABS (Use NF venlafaxine hcl tabs 100 QL(3 ea daily) miglitol) mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg miglitol tabs 1 venlafaxine hcl tb24 150 QL(2 ea daily) 1 PRECOSE TABS (Use NF QL(3 ea daily) mg acarbose) venlafaxine hcl tb24 225 1 ST; QL(1 ea mg daily) Antidiabetic - Amylin Analogs PA; QL(0.36 ml venlafaxine hcl tb24 75 mg, 1 QL(1 ea daily) SYMLINPEN 120 SOPN 2 37.5 mg daily) SYMLINPEN 60 SOPN 2 PA; QL(0.2 ml Tricyclic Agents daily) amitriptyline hcl tabs 1 Antidiabetic Combinations ACTOPLUS MET TABS QL(2 ea daily) amoxapine tabs 3 (Use pioglitazone hcl- NF hcl) ANAFRANIL CAPS (Use NF clomipramine hcl) DUETACT TABS (Use QL(1 ea daily) pioglitazone hcl- NF clomipramine hcl caps 1 ) desipramine hcl tabs 1 -metformin hcl tabs QL(2 ea daily) 2.5 mg-250 mg, 250 mg- 1 2.5 mg, 2.5 mg-500 mg, 1 doxepin hcl caps 500 mg-2.5 mg doxepin hcl conc 1 glipizide-metformin hcl tabs 1 QL(4 ea daily) 5 mg-500 mg imipramine hcl tabs 1 glyburide-metformin tabs QL(2 ea daily) 1.25 mg-250 mg, 250 mg- 1 imipramine pamoate caps 1 1.25 mg glyburide-metformin tabs 5 QL(4 ea daily) NORPRAMIN TABS (Use NF mg-500 mg, 2.5 mg-500 1 desipramine hcl) mg, 500 mg-2.5 mg nortriptyline hcl caps 1 GLYXAMBI TABS 2 nortriptyline hcl soln 1 JANUMET TABS 2 QL(2 ea daily) PAMELOR CAPS (Use NF nortriptyline hcl) Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APIDRA SOLOSTAR 3 PA TRESIBA SOLN 3 PA SOPN BASAGLAR KWIKPEN 2 Meglitinide Analogues SOPN nateglinide tabs 1 QL(3 ea daily) FIASP FLEXTOUCH 2 SOPN PRANDIN TABS 1 MG NF QL(4 ea daily) (Use repaglinide) FIASP PENFILL SOCT 2 PRANDIN TABS 2 MG NF QL(8 ea daily) FIASP SOLN 2 (Use repaglinide) repaglinide tabs 0.5 mg, 1 1 QL(4 ea daily) HUMULIN R U-500 2 mg (CONCENTRATED) SOLN repaglinide tabs 2 mg 1 QL(8 ea daily) HUMULIN R U-500 2 KWIKPEN SOPN STARLIX TABS (Use NF QL(3 ea daily) LEVEMIR FLEXTOUCH 2 nateglinide) SOPN Sodium-Glucose Co-Transporter 2 (SGLT2) LEVEMIR SOLN 2 PA; QL(1 ea FARXIGA TABS 3 daily) NOVOLIN 70/30 FLEXPEN 2 RELION SUPN JARDIANCE TABS 2 QL(1 ea daily) NOVOLIN 70/30 FLEXPEN 2 SUPN STEGLATRO TABS 2 QL(1 ea daily) NOVOLIN 70/30 RELION 2 SUSP Sulfonylureas AMARYL TABS 1 MG, 2 NF QL(4 ea daily) NOVOLIN 70/30 SUSP 2 MG (Use glimepiride) AMARYL TABS 4 MG (Use QL(2 ea daily) NOVOLIN N RELION 2 NF SUSP glimepiride) QL(4 ea daily) NOVOLIN N SUSP 2 glimepiride tabs 1 mg, 2 mg 1 QL(2 ea daily) NOVOLIN R RELION 2 glimepiride tabs 4 mg 1 SOLN QL(4 ea daily) NOVOLIN R SOLN 2 glipizide tabs 10 mg, 5 mg 1 glipizide tb24 10 mg, 2.5 QL(2 ea daily) NOVOLOG FLEXPEN 2 1 SOPN mg, 5 mg NOVOLOG MIX 70/30 GLUCOTROL TABS (Use NF QL(4 ea daily) PREFILLED FLEXPEN 2 glipizide) SUPN GLUCOTROL XL TB24 NF QL(2 ea daily) (Use glipizide) NOVOLOG MIX 70/30 2 SUSP glyburide micronized tabs 1 QL(4 ea daily) NOVOLOG PENFILL 2 SOCT glyburide tabs 1 QL(4 ea daily) NOVOLOG SOLN 2 GLYNASE TABS (Use NF QL(4 ea daily) glyburide micronized) TRESIBA FLEXTOUCH 3 PA SOPN tabs 1 QL(6 ea daily)

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.34 ea scopolamine pt72 1 EMEND CAPS OR 80 MG NF PA; QL(0.134 daily) (Use aprepitant) ea daily) TIGAN CAPS OR 300 MG EMEND SOLR IV 150 MG (Use trimethobenzamide NF (Use fosaprepitant NF hcl) dimeglumine) TRANSDERM SCOP PT72 2 QL(0.34 ea EMEND TRIPACK CAPS NF PA (Use scopolamine) daily) (Use aprepitant) TRANSDERM-SCOP PT72 2 QL(0.34 ea VARUBI TBPK 3 PA (Use scopolamine) daily) trimethobenzamide hcl 1 ANTIFUNGALS - Drugs to Treat Fungal Infections caps Antiemetics - Miscellaneous Antifungal - Glucan Synthesis Inhibitors CANCIDAS SOLR (Use AKYNZEO CAPS OR 0.5 3 PA NF MG-300 MG caspofungin acetate) caspofungin acetate solr 50 1 CESAMET CAPS 3 mg, 70 mg PA; QL(4 ea ERAXIS SOLR 3 daily)3 rtl MAX fill,365 rtl micafungin sodium solr 100 1 DICLEGIS TBEC (Use NF mg, 50 mg doxylamine-pyridoxine) day(s) supply,3 mail MAX fill,365 mail MYCAMINE SOLR 3 day(s) supply, Antifungals PA; QL(4 ea daily)3 rtl MAX ABELCET SUSP 3 fill,365 rtl doxylamine-pyridoxine tbec 1 day(s) supply,3 AMBISOME SUSR 3 mail MAX fill,365 mail solr 3 day(s) supply, ANCOBON CAPS (Use NF dronabinol caps 1 flucytosine)

MARINOL CAPS (Use NF flucytosine caps 1 dronabinol) griseofulvin microsize susp 1 AL(At least 2 Substance P/Neurokinin 1 (NK1) Receptor 125 mg/5ml yrs old) PA aprepitant caps 1 griseofulvin microsize tabs 1 500 mg aprepitant caps 125 mg, 40 PA; QL(0.067 1 griseofulvin ultramicrosize 1 mg ea daily) tabs PA; QL(0.134 aprepitant caps 80 mg 1 ea daily) tabs 1 PA aprepitant misc 1 terbinafine hcl tabs 1 QL(1 ea daily) EMEND CAPS OR 125 PA; QL(0.067 -Related Antifungals MG, 40 MG (Use NF ea daily) aprepitant) CRESEMBA CAPS OR 3 PA 186 MG

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLARITIN TABS (Use 1 promethazine hcl soln 1 loratadine) desloratadine tabs 5 mg 1 QL(1 ea daily) promethazine hcl supp 1 desloratadine tbdp 2.5 mg 1 QL(1 ea daily) promethazine hcl syrp 1 fexofenadine hcl susp 30 1 QL(30 ml daily) promethazine hcl tabs 1 mg/5ml Antihistamines - Piperidines fexofenadine hcl tabs 180 1 QL(1 ea daily) mg cyproheptadine hcl syrp 1 fexofenadine hcl tabs 60 1 QL(2 ea daily) mg cyproheptadine hcl tabs 1 levocetirizine QL(10 ml dihydrochloride soln 2.5 1 daily); RX/OTC ANTIHYPERLIPIDEMICS - Drugs to Treat High mg/5ml Cholesterol levocetirizine 1 QL(1 ea daily); Antihyperlipidemics - Combinations dihydrochloride tabs 5 mg RX/OTC ezetimibe-simvastatin tabs 1 QL(1 ea daily) loratadine caps 1 VYTORIN TABS (Use NF QL(1 ea daily) loratadine chew 1 ezetimibe-simvastatin) Antihyperlipidemics - Misc. loratadine soln 1 PA; QL(4 ea icosapent ethyl caps 1 daily) loratadine syrp 1 LOVAZA CAPS (Use NF QL(4 ea daily) loratadine tabs 1 omega-3-acid ethyl esters) omega-3-acid ethyl esters 1 QL(4 ea daily) loratadine tbdp 1 caps PA XYZAL ALLERGY 24HR QL(10 ml VASCEPA CAPS 0.5 GM 3 CHILDRENS SOLN (Use daily); RX/OTC NF VASCEPA CAPS 1 GM 3 PA; QL(4 ea levocetirizine daily) dihydrochloride) XYZAL ALLERGY 24HR QL(1 ea daily); Bile Acid Sequestrants TABS (Use levocetirizine NF RX/OTC cholestyramine light pack 4 1 QL(6 ea daily) dihydrochloride) gm cholestyramine light powd QL(24 gm ZYRTEC ALLERGY CAPS 1 QL(1 ea daily) 1 (Use cetirizine hcl) 4 gm/dose daily) QL(6 ea daily) ZYRTEC ALLERGY TABS 1 QL(1 ea daily) cholestyramine pack 4 gm 1 (Use cetirizine hcl) ZYRTEC CHILDRENS QL(10 ml cholestyramine powd 4 1 QL(25.2 gm ALLERGY SOLN (Use 1 daily); RX/OTC gm/dose daily) cetirizine hcl) colesevelam hcl pack 3.75 1 PA; QL(1 ea Antihistamines - Phenothiazines gm daily) colesevelam hcl tabs 625 QL(7 ea daily) PHENERGAN SOLN (Use NF 1 promethazine hcl) mg

Ambetter Formulary Updated September 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COLESTID FLAVORED QL(6 gm daily) ALTOPREV TB24 3 ST; QL(1 ea GRAN 5 GM (Use NF daily) colestipol hcl) atorvastatin calcium tabs 1 QL(1 ea daily) COLESTID FLAVORED QL(6 ea daily) PACK 5 GM/7.5GM (Use NF CRESTOR TABS (Use NF QL(1 ea daily) colestipol hcl) rosuvastatin calcium) COLESTID GRAN 5 GM QL(6 gm daily) NF fluvastatin sodium caps 20 1 QL(1 ea daily) (Use colestipol hcl) mg COLESTID PACK 5 GM QL(6 ea daily) NF fluvastatin sodium caps 40 1 QL(2 ea daily) (Use colestipol hcl) mg COLESTID TABS 1 GM QL(16 ea daily) NF LIPITOR TABS (Use NF QL(1 ea daily) (Use colestipol hcl) atorvastatin calcium) QL(6 gm daily) colestipol hcl gran 5 gm 1 LIVALO TABS 3 ST; QL(1 ea daily) colestipol hcl pack 5 gm 1 QL(6 ea daily) $0 copay for generic only, lovastatin tabs 10 mg, 20 colestipol hcl tabs 1 gm 1 QL(16 ea daily) 1 age 40 to mg 76;QL(1 ea QUESTRAN LIGHT POWD NF QL(24 gm daily); PV (Use cholestyramine light) daily) $0 copay for QUESTRAN PACK 4 GM NF QL(6 ea daily) generic only, (Use cholestyramine) lovastatin tabs 40 mg 1 age 40 to QUESTRAN POWD 4 QL(25.2 gm 76;QL(2 ea GM/DOSE (Use NF daily) daily); PV cholestyramine) PRAVACHOL TABS (Use NF QL(1 ea daily) pravastatin sodium) WELCHOL PACK 3.75 GM NF PA; QL(1 ea (Use colesevelam hcl) daily) pravastatin sodium tabs 1 QL(1 ea daily) WELCHOL TABS 625 MG NF QL(7 ea daily) (Use colesevelam hcl) rosuvastatin calcium tabs 3 QL(1 ea daily) Fibric Acid Derivatives simvastatin tabs 5 mg, 80 1 QL(1 ea daily) fenofibrate micronized caps 1 QL(1 ea daily) mg, 10 mg, 20 mg, 40 mg 134 mg, 200 mg, 67 mg ZOCOR TABS (Use NF QL(1 ea daily) fenofibrate tabs 145 mg, 48 1 QL(1 ea daily) simvastatin) mg, 54 mg, 160 mg Intestinal Cholesterol Absorption Inhibitors FIBRICOR TABS (Use NF fenofibric acid) ezetimibe tabs 1 QL(1 ea daily) gemfibrozil tabs 1 QL(2 ea daily) ZETIA TABS (Use NF QL(1 ea daily) ezetimibe) LIPOFEN CAPS (Use NF fenofibrate) Nicotinic Acid Derivatives niacin (antihyperlipidemic) QL(2 ea daily) LOPID TABS (Use NF QL(2 ea daily) gemfibrozil) tbcr 1000 mg, 500 mg, 750 1 mg TRICOR TABS (Use NF QL(1 ea daily) fenofibrate) NIASPAN TBCR (Use NF QL(2 ea daily) niacin (antihyperlipidemic)) HMG CoA Reductase Inhibitors Proprotein Convertase Subtilisin/Kexin Type 9

Ambetter Formulary Updated September 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REPATHA PUSHTRONEX 4 PA; QL(0.25 ml Angiotensin II Receptor Antagonists SYSTEM SOCT daily) ATACAND TABS (Use NF QL(1 ea daily) REPATHA SOSY 4 PA; QL(0.0714 candesartan cilexetil) ml daily) AVAPRO TABS (Use NF QL(1 ea daily) REPATHA SURECLICK 4 PA; QL(0.0714 irbesartan) SOAJ ml daily) BENICAR TABS (Use NF QL(1 ea daily) ANTIHYPERTENSIVES - Drugs to Treat High olmesartan medoxomil) Blood Pressure candesartan cilexetil tabs 1 QL(1 ea daily) ACE Inhibitors COZAAR TABS (Use QL(1 ea daily) ACCUPRIL TABS (Use NF NF quinapril hcl) losartan potassium) DIOVAN TABS (Use QL(1 ea daily) ALTACE CAPS (Use NF NF ramipril) valsartan) EDARBI TABS 3 ST; QL(1 ea benazepril hcl tabs 1 daily) QL(1 ea daily) captopril tabs 1 eprosartan mesylate tabs 1 QL(1 ea daily) enalapril maleate tabs 10 1 irbesartan tabs 1 mg, 2.5 mg, 20 mg, 5 mg losartan potassium tabs or 1 QL(1 ea daily) fosinopril sodium tabs 1 100 mg, 25 mg, 50 mg MICARDIS TABS (Use NF QL(1 ea daily) lisinopril tabs 1 telmisartan) QL(1 ea daily) LOTENSIN TABS (Use NF olmesartan medoxomil tabs 1 benazepril hcl) QL(1 ea daily) moexipril hcl tabs 1 telmisartan tabs 1 QL(1 ea daily) perindopril erbumine tabs 1 valsartan tabs 1

PRINIVIL TABS (Use NF Antiadrenergic Antihypertensives lisinopril) CARDURA TABS (Use NF quinapril hcl tabs 1 mesylate) CATAPRES TABS (Use NF QL(8 ea daily) ramipril caps 1 clonidine hcl) CATAPRES-TTS-1 PTWK NF QL(0.15 ea trandolapril tabs 1 (Use clonidine) daily) CATAPRES-TTS-2 PTWK QL(0.15 ea VASOTEC TABS (Use NF NF enalapril maleate) (Use clonidine) daily) CATAPRES-TTS-3 PTWK QL(0.15 ea ZESTRIL TABS (Use NF NF lisinopril) (Use clonidine) daily) QL(8 ea daily) Agents for Pheochromocytoma clonidine hcl tabs 1 DIBENZYLINE CAPS (Use PA QL(0.15 ea NF clonidine ptwk 3 phenoxybenzamine hcl) daily) phenoxybenzamine hcl 3 PA caps doxazosin mesylate tabs 1

Ambetter Formulary Updated September 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits guanfacine hcl tabs 1 candesartan cilexetil- 1 tabs tabs 1 QL(6 ea daily) DIOVAN HCT TABS (Use valsartan- NF MINIPRESS CAPS (Use NF QL(4 ea daily) hydrochlorothiazide) hcl) enalapril maleate & 1 prazosin hcl caps 1 QL(4 ea daily) hydrochlorothiazide tabs EXFORGE HCT TABS 2 terazosin hcl caps 1 EXFORGE TABS (Use Antihypertensive Combinations amlodipine besylate- NF ACCURETIC TABS 12.5 QL(3 ea daily) valsartan) MG-10 MG (Use quinapril- NF fosinopril sodium & 1 hydrochlorothiazide) hydrochlorothiazide tabs ACCURETIC TABS 12.5 QL(4 ea daily) HYZAAR TABS 12.5 MG- QL(2 ea daily) MG-20 MG (Use quinapril- NF 50 MG (Use losartan NF hydrochlorothiazide) potassium & ACCURETIC TABS 20 QL(2 ea daily) hydrochlorothiazide) MG-25 MG (Use quinapril- NF HYZAAR TABS 25 MG-100 QL(1 ea daily) hydrochlorothiazide) MG, 100 MG-12.5 MG, 12.5 MG-100 MG (Use NF amlodipine besylate- 1 benazepril hcl caps losartan potassium & hydrochlorothiazide) amlodipine besylate- 1 ST olmesartan medoxomil tabs irbesartan- 1 hydrochlorothiazide tabs amlodipine besylate- 1 valsartan tabs lisinopril & 1 hydrochlorothiazide tabs amlodipine-valsartan- 1 hydrochlorothiazide tabs LOPRESSOR HCT TABS ATACAND HCT TABS (Use metoprolol & NF (Use candesartan cilexetil- NF hydrochlorothiazide) hydrochlorothiazide) losartan potassium & QL(2 ea daily) hydrochlorothiazide tabs atenolol & chlorthalidone 1 1 tabs 12.5 mg-50 mg, 50 mg- 12.5 mg AVALIDE TABS (Use irbesartan- NF losartan potassium & QL(1 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 25 1 mg-100 mg, 100 mg-12.5 AZOR TABS (Use ST mg, 12.5 mg-100 mg amlodipine besylate- NF olmesartan medoxomil) LOTENSIN HCT TABS (Use benazepril & NF benazepril & 1 hydrochlorothiazide) hydrochlorothiazide tabs LOTREL CAPS (Use BENICAR HCT TABS (Use amlodipine besylate- NF olmesartan medoxomil- NF benazepril hcl) hydrochlorothiazide) metoprolol & 1 bisoprolol & 1 QL(2 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs

Ambetter Formulary Updated September 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICARDIS HCT TABS ZIAC TABS (Use bisoprolol NF QL(2 ea daily) (Use telmisartan- NF & hydrochlorothiazide) hydrochlorothiazide) Antihypertensives - Misc. olmesartan medoxomil- ST amlodipine- 1 VECAMYL TABS 3 PA hydrochlorothiazide tabs Direct Renin Inhibitors olmesartan medoxomil- 1 hydrochlorothiazide tabs aliskiren fumarate tabs 1 QL(1 ea daily) quinapril- QL(3 ea daily) TEKTURNA TABS (Use QL(1 ea daily) hydrochlorothiazide tabs 10 1 NF mg-12.5 mg, 12.5 mg-10 aliskiren fumarate) mg Selective Aldosterone Receptor Antagonists quinapril- QL(4 ea daily) hydrochlorothiazide tabs 1 tabs 1 12.5 mg-20 mg INSPRA TABS (Use NF quinapril- QL(2 ea daily) eplerenone) hydrochlorothiazide tabs 20 1 Vasodilators mg-25 mg hydralazine hcl soln 1 TARKA TBCR (Use NF trandolapril-verapamil hcl) hydralazine hcl tabs 1 telmisartan-amlodipine tabs 1 minoxidil tabs 1 telmisartan- 1 hydrochlorothiazide tabs ANTIMALARIALS - Drugs to Treat Malaria TENORETIC 100 TABS (Parasitic Infections) (Use atenolol & NF chlorthalidone) Antimalarial Combinations TENORETIC 50 TABS Covered for (Use atenolol & NF malaria chlorthalidone) treatment only. Limit 1 fill every trandolapril-verapamil hcl 1 tbcr 180 days;QL(12 ea TRIBENZOR TABS (Use ST atovaquone-proguanil hcl 1 per fill retail,12 olmesartan medoxomil- NF tabs ea per fill amlodipine- mail)1 rtl MAX hydrochlorothiazide) fill,180 rtl day(s) supply,1 TWYNSTA TABS (Use NF telmisartan-amlodipine) mail MAX fill,180 mail valsartan- 1 hydrochlorothiazide tabs day(s) supply, VASERETIC TABS (Use enalapril maleate & NF hydrochlorothiazide) ZESTORETIC TABS (Use lisinopril & NF hydrochlorothiazide)

Ambetter Formulary Updated September 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Covered for PLAQUENIL TABS (Use NF malaria hydroxychloroquine sulfate) treatment only. Limit 1 fill every primaquine phosphate tabs 3 180 PRIMAQUINE days;QL(24 ea PHOSPHATE TABS (Use NF 2 per fill retail,24 primaquine phosphate) COARTEM TABS ea per fill PA; QL(3 ea mail)1 rtl MAX tabs 1 fill,180 rtl daily) day(s) supply,1 QUALAQUIN CAPS (Use NF PA; mail MAX quinine sulfate) fill,180 mail PA; day(s) supply, quinine sulfate caps 1 Covered for malaria ANTIMYASTHENIC/CHOLINERGIC AGENTS treatment only. Antimyasthenic/Cholinergic Agents Limit 1 fill every 180 FIRDAPSE TABS 4 PA days;QL(12 ea MALARONE TABS (Use NF per fill retail,12 GUANIDINE HCL TABS 2 atovaquone-proguanil hcl) ea per fill mail)1 rtl MAX MESTINON SOLN (Use NF fill,180 rtl pyridostigmine bromide) day(s) supply,1 MESTINON TABS (Use NF mail MAX pyridostigmine bromide) fill,180 mail MESTINON TIMESPAN day(s) supply, TBCR (Use pyridostigmine NF Antimalarials bromide) NEOSTIGMINE PA chloroquine phosphate 1 tabs METHYLSULFATE SOSY 3 PA; QL(3 ea 3 MG/3ML DARAPRIM TABS 3 daily) pyridostigmine bromide 1 soln 60 mg/5ml hydroxychloroquine sulfate 1 tabs pyridostigmine bromide 1 QL(2 ea per 30 tabs 60 mg KRINTAFEL TABS 3 days retail) pyridostigmine bromide tbcr 1 180 mg Covered for PA; QL(10 ea malaria RUZURGI TABS 4 treatment only. daily) Limit 1 fill every ANTIMYCOBACTERIAL AGENTS - Drugs to 180 days;QL(5 Treat Tuberculosis (Bacterial Infections) mefloquine hcl tabs 1 ea daily)1 rtl MAX fill,180 rtl Anti TB Combinations day(s) supply,1 RIFAMATE CAPS 3 mail MAX fill,180 mail QL(6 ea daily) day(s) supply, RIFATER TABS 3 Antimycobacterial Agents

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZANOSAR SOLR 4 PA; SP TREXALL TABS 4 PA; SP

Antimetabolites VIDAZA SUSR (Use NF PA; SP azacitidine) ALIMTA SOLR 500 MG 4 PA; SP XELODA TABS (Use NF PA; SP capecitabine) ARRANON SOLN 4 PA; SP Antineoplastic - Angiogenesis Inhibitors PA; SP azacitidine susr 4 INLYTA TABS 4 PA; QL(2 ea daily); SP capecitabine tabs 4 PA; SP LENVIMA 10 MG DAILY 4 PA; QL(1 ea DOSE CPPK daily) clofarabine soln 4 PA; SP LENVIMA 12MG DAILY 4 PA; QL(3 ea DOSE CPPK daily) CLOLAR SOLN (Use NF PA; SP clofarabine) LENVIMA 14 MG DAILY 4 PA; QL(2 ea DOSE CPPK daily) cytarabine soln 100 mg/ml, 4 PA; SP 20 mg/ml LENVIMA 18 MG DAILY 4 PA; QL(3 ea DOSE CPPK daily) DACOGEN SOLR (Use NF PA; SP decitabine) LENVIMA 20 MG DAILY 4 PA; QL(2 ea DOSE CPPK daily) decitabine solr 4 PA; SP LENVIMA 24 MG DAILY 4 PA; QL(3 ea DOSE CPPK daily) floxuridine solr 4 PA; SP LENVIMA 4 MG DAILY 4 PA; QL(1 ea fludarabine phosphate soln 4 PA; SP DOSE CPPK daily) LENVIMA 8 MG DAILY 4 PA; QL(2 ea fludarabine phosphate solr 4 PA; SP DOSE CPPK daily) MVASI SOLN 4 PA fluorouracil soln 500 4 PA; SP mg/10ml ZALTRAP SOLN 100 4 PA; SP FOLOTYN SOLN 20 4 PA; SP MG/4ML MG/ML ZIRABEV SOLN 4 PA gemcitabine hcl solr 2 gm, 4 PA; SP 200 mg Antineoplastic - Anti-HER2 Agents GEMCITABINE HYDROCHLORIDE SOLN HERCEPTIN SOLR 4 PA; SP 1 GM/10ML, 2 GM/20ML, NF 200 MG/2ML (Use PERJETA SOLN 4 PA; SP gemcitabine hcl) TUKYSA TABS 4 PA mercaptopurine tabs 1 Antineoplastic - Antibodies methotrexate sodium soln ij 1 250 mg/10ml, 50 mg/2ml ADCETRIS SOLR 4 PA; SP methotrexate sodium solr ij 1 SP 1 gm ARZERRA CONC 4 PA; SP methotrexate sodium tabs 1 SP or 2.5 mg RITUXAN SOLN 4 PA; SP TABLOID TABS 4 PA; SP

Ambetter Formulary Updated September 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RUXIENCE SOLN 4 PA ELIGARD KIT 7.5 MG 4 PA; QL(0.0089 ea daily); SP PA; SP YERVOY SOLN 4 EMCYT CAPS 4 PA; SP QL(1 ea daily); Antineoplastic - EGFR Inhibitors exemestane tabs 4 SP ERBITUX SOLN 4 PA; SP FARESTON TABS (Use NF PA; QL(1 ea toremifene citrate) erlotinib hcl tabs 4 daily); SP FASLODEX SOLN (Use NF PA; QL(0.357 fulvestrant) ml daily); SP GILOTRIF TABS 4 PA; QL(1 ea daily) FEMARA TABS (Use NF letrozole) TARCEVA TABS (Use NF PA; QL(1 ea erlotinib hcl) daily); SP FIRMAGON SOLR 4 PA; QL(0.143 ea daily); SP VECTIBIX SOLN 100 4 PA; SP MG/5ML PA; QL(6 ea flutamide caps 4 daily); SP VIZIMPRO TABS 4 PA PA; QL(0.357 fulvestrant soln 4 Antineoplastic - Hedgehog Pathway Inhibitors ml daily); SP DAURISMO TABS 4 PA letrozole tabs 1 PA; QL(1 ea PA; SP ERIVEDGE CAPS 4 leuprolide acetate kit 4 daily); SP LUPRON DEPOT (1- PA; QL(0.0357 ODOMZO CAPS 4 PA; QL(1 ea 4 daily) MONTH) KIT ea daily); SP LUPRON DEPOT (3- 4 PA; SP Antineoplastic - Hormonal and Related Agents MONTH) KIT abiraterone acetate tabs PA; QL(4 ea 4 LUPRON DEPOT (4- 4 PA; QL(0.1339 250 mg daily); SP MONTH) KIT ea daily); SP abiraterone acetate tabs PA; QL(2 ea 4 LUPRON DEPOT (6- 4 PA; QL(0.0089 500 mg daily) MONTH) KIT ea daily); SP QL(1 ea daily) anastrozole tabs 1 LYSODREN TABS 4 PA; SP ARIMIDEX TABS (Use NF QL(1 ea daily) anastrozole) megestrol acetate susp 1 AROMASIN TABS (Use NF QL(1 ea daily); exemestane) SP megestrol acetate tabs 1 PA; QL(1 ea bicalutamide tabs 4 NILANDRON TABS (Use NF QL(2 ea daily) daily); SP nilutamide) CASODEX TABS (Use NF PA; QL(1 ea nilutamide tabs 1 QL(2 ea daily) bicalutamide) daily); SP PA ELIGARD KIT 22.5 MG 4 PA; SP NUBEQA TABS 4

ELIGARD KIT 30 MG 4 PA; SP tamoxifen citrate tabs 0

ELIGARD KIT 45 MG 4 PA; SP toremifene citrate tabs 1

Ambetter Formulary Updated September 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRELSTAR MIXJECT 4 PA; SP doxorubicin hcl soln 2 4 PA; SP SUSR mg/ml, 200 mg/100ml doxorubicin hcl solr 50 mg, PA; SP XTANDI CAPS 40 MG 4 PA; QL(4 ea 4 daily); SP 10 mg YONSA TABS 4 PA ELLENCE SOLN 50 PA; SP MG/25ML (Use epirubicin NF hcl) ZOLADEX IMPL 10.8 MG 4 PA; QL(0.0119 ea daily); SP epirubicin hcl soln 50 4 PA; SP PA; QL(0.0357 mg/25ml ZOLADEX IMPL 3.6 MG 4 ea daily); SP IDAMYCIN PFS SOLN 10 PA; SP MG/10ML, 5 MG/5ML (Use NF ZYTIGA TABS 250 MG NF PA; QL(4 ea (Use abiraterone acetate) daily); SP idarubicin hcl) IDAMYCIN PFS SOLN 20 PA ZYTIGA TABS 500 MG 4 PA; QL(2 ea (Use abiraterone acetate) daily) MG/20ML (Use idarubicin NF hcl) Antineoplastic - Immunomodulators idarubicin hcl soln 10 4 PA; SP POMALYST CAPS 4 PA; QL(1 ea mg/10ml, 5 mg/5ml daily) idarubicin hcl soln 20 4 PA Antineoplastic - PDGFR-alpha Inhibitors mg/20ml AYVAKIT TABS 100 MG, 4 PA; SL(1 ea PA; SP 200 MG, 300 MG daily) mitomycin solr iv 20 mg 4 Antineoplastic - XPO1 Inhibitors mitoxantrone hcl conc 4 PA; SP XPOVIO 100 MG ONCE 4 PA WEEKLY TBPK valrubicin soln 4 PA; SP XPOVIO 60 MG ONCE PA 4 VALSTAR SOLN (Use NF PA; SP WEEKLY TBPK valrubicin) XPOVIO 80 MG ONCE 4 PA WEEKLY TBPK Antineoplastic Enzyme Inhibitors AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea XPOVIO 80 MG TWICE 4 PA WEEKLY TBPK MG, 7.5 MG (Use NF daily); SP everolimus) Antineoplastic PA; QL(4 ea ALECENSA CAPS 4 bleomycin sulfate solr 15 4 PA; SP daily) unit PA; QL(1 ea ALUNBRIG TABS 4 COSMEGEN SOLR (Use NF PA; SP daily) dactinomycin) PA; QL(1 ea ALUNBRIG TBPK 4 dactinomycin solr 4 PA; SP daily) PA DAUNORUBICIN BALVERSA TABS 4 HYDROCHLORIDE SOLN NF PA; 20 MG/4ML (Use BORTEZOMIB SOLR 4 daunorubicin hcl) BOSULIF TABS 100 MG, 4 PA; QL(1 ea DOXIL INJ (Use NF PA; SP 500 MG daily); SP doxorubicin hcl liposomal) BOSULIF TABS 400 MG 4 PA; doxorubicin hcl liposomal 4 PA; SP inj BRAFTOVI CAPS 4 PA; SP

Ambetter Formulary Updated September 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA PA; QL(6 ea BRUKINSA CAPS 4 lapatinib ditosylate tabs 4 daily); SP CAPRELSA TABS 4 PA; QL(1 ea PA daily); SP LORBRENA TABS 4 PA; QL(2 ea PA; QL(16 ea COMETRIQ KIT 4 LYNPARZA TABS 4 daily); SP daily) PA; QL(4 ea PA; QL(3 ea COMETRIQ KIT 4 MEKINIST TABS 0.5 MG 4 daily); SP daily) PA; QL(3 ea PA; QL(1 ea COMETRIQ KIT 4 MEKINIST TABS 2 MG 4 daily); SP daily) COPIKTRA CAPS 4 PA MEKTOVI TABS 4 PA; SP PA; QL(1 ea PA; QL(4 ea everolimus tabs 4 NEXAVAR TABS 4 daily); SP daily); SP GLEEVEC TABS (Use PA; QL(2 ea PA; QL(0.143 NF NINLARO CAPS 4 imatinib mesylate) daily); SP ea daily) IBRANCE CAPS 3 PA PEMAZYRE TABS 4 PA; QL(1 ea daily) PA IBRANCE TABS 3 PIQRAY 200MG DAILY 4 PA DOSE TBPK ICLUSIG TABS 10 MG, 30 PA; QL(1 ea 4 PIQRAY 250MG DAILY 4 PA MG, 45 MG daily) DOSE TBPK PA; QL(2 ea ICLUSIG TABS 15 MG 4 PIQRAY 300MG DAILY 4 PA daily) DOSE TBPK PA; QL(2 ea imatinib mesylate tabs 4 PA daily); SP QINLOCK TABS 4 IMBRUVICA CAPS 140 4 PA; QL(3 ea PA MG daily) RETEVMO CAPS 4 ROMIDEPSIN SOLR 10 PA; SP IMBRUVICA CAPS 70 MG 4 PA; QL(1 ea 4 daily) MG IMBRUVICA TABS 140 PA; QL(1 ea ROZLYTREK CAPS 4 PA MG, 280 MG, 420 MG, 560 4 daily) MG RUBRACA TABS 4 PA; QL(4 ea daily) INREBIC CAPS 4 PA PA; QL(1 ea SPRYCEL TABS 4 ISTODAX (OVERFILL) 4 PA; SP daily); SP SOLR PA; QL(4 ea STIVARGA TABS 4 JAKAFI TABS 10 MG, 20 4 PA; SP daily); SP MG sunitinib malate caps 12.5 4 PA; QL(1 ea JAKAFI TABS 15 MG, 25 4 PA; QL(2 ea mg, 25 mg, 50 mg daily); SP MG, 5 MG daily); SP SUTENT CAPS 12.5 MG, PA; QL(1 ea KISQALI TBPK 3 PA 25 MG, 50 MG (Use 4 daily); SP sunitinib malate) PA KOSELUGO CAPS 4 TABRECTA TABS 4 PA PA KYPROLIS SOLR 4 TAFINLAR CAPS 4 PA; QL(4 ea daily) Ambetter Formulary Updated September 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TALZENNA CAPS 4 PA ONCASPAR SOLN 4 PA; SP

TASIGNA CAPS 150 MG, 4 PA; QL(4 ea Antineoplastics Misc. 200 MG daily); SP ACTIMMUNE SOLN 4 PA; SP TASIGNA CAPS 50 MG 4 PA; QL(4 ea daily) arsenic trioxide soln 10 4 PA; SP TAZVERIK TABS 4 PA mg/10ml PA; SP PA; QL(0.143 bexarotene caps 4 temsirolimus soln 4 ml daily); SP dacarbazine solr 200 mg 4 PA; SP TIBSOVO TABS 4 PA HYDREA CAPS (Use NF TORISEL SOLN (Use NF PA; QL(0.143 hydroxyurea) temsirolimus) ml daily); SP hydroxyurea caps 1 TURALIO CAPS 4 PA INTRON A SOLR 18 MU 4 PA; SP TYKERB TABS (Use 4 PA; QL(6 ea lapatinib ditosylate) daily); SP MATULANE CAPS 4 PA; SP VELCADE SOLR 4 PA; SP NIPENT SOLR 4 PA; SP VERZENIO TABS 4 PA PHOTOFRIN SOLR 4 PA; SP VITRAKVI CAPS 4 PA PROLEUKIN SOLR 4 PA; SP VITRAKVI SOLN 4 PA SYLATRON KIT 4 PA; SP PA; QL(4 ea VOTRIENT TABS 4 daily); SP SYNRIBO SOLR 4 PA; SP PA; QL(2 ea XALKORI CAPS 4 daily); SP TARGRETIN CAPS OR 75 NF PA; SP MG (Use bexarotene) XOSPATA TABS 4 PA tretinoin () 1 PA; QL(3 ea caps ZEJULA CAPS 4 daily) UVADEX SOLN 4 PA; SP ZELBORAF TABS 4 PA; SP Chemotherapy Adjuncts ZOLINZA CAPS 4 PA; QL(4 ea PA; SP daily); SP KEPIVANCE SOLR 4 PA; QL(2 ea ZYDELIG TABS 4 Chemotherapy Rescue/Antidote/Protective Agents daily) leucovorin calcium solr ij PA; QL(5 ea ZYKADIA CAPS 4 500 mg, 100 mg, 200 mg, 1 daily) 350 mg, 50 mg Antineoplastic Enzymes leucovorin calcium tabs or 1 25 mg, 5 mg, 10 mg, 15 mg ERWINASE SOLR 4 PA; SP VORAXAZE SOLR 4 PA; SP ERWINAZE SOLR 4 PA; SP Mitotic Inhibitors

Ambetter Formulary Updated September 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ABRAXANE SUSR 4 PA; SP HYCAMTIN SOLR IV 4 MG NF PA; SP (Use topotecan hcl) PA; SP docetaxel conc 20 mg/ml 4 irinotecan hcl soln 100 4 PA; SP mg/5ml, 40 mg/2ml DOCETAXEL CONC 20 NF PA; SP PA; SP MG/ML (Use docetaxel) topotecan hcl solr 4 mg 4 DOCETAXEL CONC 80 NF ANTIPARKINSON AND RELATED THERAPY MG/4ML (Use docetaxel) AGENTS - Drugs to Treat Parkinson's Disease DOCETAXEL SOLN 20 4 PA; SP MG/2ML Antiparkinson Adjunctive Therapy docetaxel soln 20 mg/2ml 4 PA; SP carbidopa tabs 1 LODOSYN TABS (Use DOCETAXEL SOLN 20 4 PA; SP NF MG/2ML (Use docetaxel) carbidopa) ETOPOPHOS SOLR 4 PA; SP Antiparkinson Anticholinergics benztropine mesylate soln 1 etoposide caps 4 PA; SP benztropine mesylate tabs 1 etoposide soln 4 PA; SP COGENTIN SOLN (Use NF HALAVEN SOLN 4 PA; SP benztropine mesylate) trihexyphenidyl hcl soln 1 IXEMPRA KIT SOLR 15 4 PA; SP MG trihexyphenidyl hcl tabs 1 JEVTANA SOLN 4 PA; SP Antiparkinson COMT Inhibitors NAVELBINE SOLN 10 PA; SP MG/ML (Use vinorelbine NF COMTAN TABS (Use NF QL(8 ea daily) tartrate) entacapone) paclitaxel conc 150 PA; SP entacapone tabs 1 QL(8 ea daily) mg/25ml, 100 mg/16.7ml, 6 4 mg/ml TASMAR TABS (Use NF tolcapone) TAXOTERE CONC (Use NF PA; SP docetaxel) tolcapone tabs 1 PA; SP TENIPOSIDE SOLN 4 Antiparkinson Dopaminergics vincristine sulfate soln 4 PA; SP amantadine hcl caps 1 vinorelbine tartrate soln 10 4 PA; SP amantadine hcl syrp 1 mg/ml Topoisomerase I Inhibitors amantadine hcl tabs 1 CAMPTOSAR SOLN 100 PA; SP PA; MG/5ML, 40 MG/2ML (Use NF APOKYN SOCT 4 irinotecan hcl) bromocriptine mesylate 1 HYCAMTIN CAPS OR 0.25 4 PA; SP caps MG, 1 MG bromocriptine mesylate 1 tabs

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FAZACLO TBDP 100 MG NF QL(9 ea daily) SEROQUEL XR TB24 150 PA; QL(1 ea (Use clozapine) MG, 200 MG, 50 MG (Use NF daily) quetiapine fumarate) FAZACLO TBDP 12.5 MG NF QL(6 ea daily) (Use clozapine) SEROQUEL XR TB24 300 PA; QL(2 ea MG, 400 MG (Use NF daily) FAZACLO TBDP 150 MG 1 QL(6 ea daily) (Use clozapine) quetiapine fumarate) ZYPREXA SOLR IM 10 QL(0.215 ea FAZACLO TBDP 200 MG 1 QL(4 ea daily) NF (Use clozapine) MG (Use olanzapine) daily) ZYPREXA TABS OR 10 QL(2 ea daily) FAZACLO TBDP 25 MG NF QL(3 ea daily) (Use clozapine) MG, 15 MG, 20 MG, 7.5 NF MG (Use olanzapine) loxapine succinate caps 1 ZYPREXA TABS OR 2.5 QL(4 ea daily) QL(0.215 ea MG, 5 MG (Use NF olanzapine solr im 10 mg 1 daily) olanzapine) ZYPREXA ZYDIS TBDP 10 QL(2 ea daily) olanzapine tabs or 10 mg, 1 QL(2 ea daily) 15 mg, 20 mg, 7.5 mg MG, 15 MG, 5 MG (Use NF olanzapine) olanzapine tabs or 2.5 mg, 1 QL(4 ea daily) 5 mg ZYPREXA ZYDIS TBDP 20 NF QL(1 ea daily) MG (Use olanzapine) olanzapine tbdp or 10 mg, 1 QL(2 ea daily) 15 mg, 5 mg Phenothiazines QL(1 ea daily) chlorpromazine hcl soln ij 3 olanzapine tbdp or 20 mg 1 25 mg/ml, 50 mg/2ml quetiapine fumarate tabs QL(4 ea daily); chlorpromazine hcl tabs or 100 mg, 200 mg, 25 mg, 50 1 AL(At least 10 10 mg, 100 mg, 200 mg, 25 1 mg yrs old) mg, 50 mg QL(2 ea daily); fluphenazine hcl conc or 5 quetiapine fumarate tabs 1 AL(At least 10 1 300 mg, 400 mg mg/ml yrs old) fluphenazine hcl elix or 2.5 1 quetiapine fumarate tb24 1 PA; QL(1 ea mg/5ml 150 mg, 200 mg, 50 mg daily) fluphenazine hcl soln ij 2.5 1 quetiapine fumarate tb24 1 PA; QL(2 ea mg/ml 300 mg, 400 mg daily) fluphenazine hcl tabs or 1 1 SAPHRIS SUBL 10 MG, 5 PA; QL(2 ea mg, 10 mg, 2.5 mg, 5 mg MG (Use asenapine 3 daily) maleate) perphenazine tabs 1 SAPHRIS SUBL 2.5 MG PA; QL(4 ea 3 prochlorperazine maleate 1 (Use asenapine maleate) daily) tabs SAPHRIS SUBL 5 MG 3 PA; QL(2 ea daily) prochlorperazine supp 1 SEROQUEL TABS 100 QL(4 ea daily); thioridazine hcl tabs 1 MG, 200 MG, 25 MG, 50 NF AL(At least 10 MG (Use quetiapine yrs old) trifluoperazine hcl tabs 1 fumarate) SEROQUEL TABS 300 QL(2 ea daily); Quinolinone Derivatives MG, 400 MG (Use NF AL(At least 10 QL(1 ea daily); quetiapine fumarate) yrs old) ABILIFY TABS (Use NF aripiprazole) AL(At least 6 yrs old) Ambetter Formulary Updated September 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml DELSTRIGO TABS 3 QL(1 ea daily) aripiprazole soln 1 mg/ml 3 daily); AL(At least 6 yrs old) PA; QL(1 ea DESCOVY TABS 2 aripiprazole tabs 10 mg, 15 QL(1 ea daily); daily) 1 mg, 2 mg, 20 mg, 30 mg, 5 AL(At least 6 didanosine cpdr 200 mg 1 QL(2 ea daily) mg yrs old) didanosine cpdr 250 mg, QL(1 ea daily) 3 PA 1 REXULTI TABS 400 mg Thioxanthenes DOVATO TABS 2 QL(1 ea daily) thiothixene caps 1 EDURANT TABS 2 QL(1 ea daily) ANTIVIRALS - Drugs to Treat Viral Infections efavirenz caps 200 mg 1 QL(2 ea daily) Antiretrovirals efavirenz caps 50 mg 1 QL(3 ea daily) abacavir sulfate soln 20 1 QL(32 ml daily) mg/ml efavirenz tabs 600 mg 1 QL(1 ea daily) abacavir sulfate tabs 300 1 QL(2 ea daily) mg efavirenz-emtricitabine- QL(1 ea daily) tenofovir disoproxil 1 abacavir sulfate-lamivudine 1 QL(1 ea daily) tabs fumarate tabs efavirenz-lamivudine- QL(1 ea daily) abacavir sulfate- 1 QL(2 ea daily) lamivudine-zidovudine tabs tenofovir disoproxil 1 fumarate tabs APTIVUS CAPS 250 MG 2 QL(4 ea daily) emtricitabine caps 1 QL(1 ea daily) APTIVUS SOLN 100 2 QL(10 ml daily) MG/ML emtricitabine-tenofovir QL(1 ea disoproxil fumarate tabs daily,30 day(s) atazanavir sulfate caps 150 1 QL(1 ea daily) 1 mg, 300 mg 133 mg-200 mg, 150 mg- limit) 100 mg, 167 mg-250 mg atazanavir sulfate caps 200 1 QL(2 ea daily) mg emtricitabine-tenofovir QL(1 ea daily) disoproxil fumarate tabs 0 ATRIPLA TABS (Use QL(1 ea daily) 200 mg-300 mg, 300 mg- efavirenz-emtricitabine- 3 200 mg tenofovir disoproxil fumarate) emtricitabine-tenofovir QL(1 ea disoproxil fumarate tabs 0 daily,30 day(s) BIKTARVY TABS 2 QL(1 ea daily) 300 mg-200 mg limit) EMTRIVA CAPS 200 MG 2 QL(1 ea daily) CIMDUO TABS 2 ST; QL(1 ea (Use emtricitabine) daily) EMTRIVA SOLN 10 2 QL(24 ml daily) COMBIVIR TABS (Use NF QL(2 ea daily) MG/ML lamivudine-zidovudine) EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) COMPLERA TABS 3 QL(1 ea daily) (Use lamivudine) QL(9 ea daily) EPIVIR TABS 150 MG NF QL(2 ea daily) CRIXIVAN CAPS 200 MG 2 (Use lamivudine) QL(6 ea daily) EPIVIR TABS 300 MG NF QL(1 ea daily) CRIXIVAN CAPS 400 MG 2 (Use lamivudine)

Ambetter Formulary Updated September 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPZICOM TABS (Use QL(1 ea daily) lopinavir-ritonavir soln 100 1 QL(12.5 ml abacavir sulfate- NF mg/5ml-400 mg/5ml daily) lamivudine) lopinavir-ritonavir tabs 100 1 QL(4 ea daily) etravirine tabs 100 mg 1 QL(4 ea daily) mg-25 mg, 50 mg-200 mg nevirapine susp 50 mg/5ml 1 QL(40 ml daily) etravirine tabs 200 mg 1 QL(2 ea daily) nevirapine tabs 200 mg 1 QL(2 ea daily) calcium tabs 1 QL(4 ea daily) nevirapine tb24 100 mg 1 QL(3 ea daily) FUZEON SOLR 4 PA; SP nevirapine tb24 400 mg 1 QL(1 ea daily) GENVOYA TABS 2 QL(1 ea daily) QL(12 ea INTELENCE TABS 100 QL(4 ea daily) 2 2 daily)30 rtl lmt MG (Use etravirine) NORVIR PACK 100 MG day(s),30 mail lmt day(s), INTELENCE TABS 200 2 QL(2 ea daily) MG (Use etravirine) NORVIR SOLN 80 MG/ML 2 QL(15 ml daily) INTELENCE TABS 25 MG 2 QL(8 ea daily) NORVIR TABS 100 MG NF QL(12 ea daily) INVIRASE TABS 2 QL(4 ea daily) (Use ritonavir) ODEFSEY TABS 2 QL(1 ea daily) ISENTRESS CHEW 100 2 QL(6 ea daily) MG, 25 MG PIFELTRO TABS 2 QL(1 ea daily) ISENTRESS HD TABS 2 QL(2 ea daily) PREZCOBIX TABS 2 QL(1 ea daily) ISENTRESS TABS 400 2 QL(2 ea daily) MG PREZISTA SUSP 100 2 QL(12 ml daily) MG/ML JULUCA TABS 3 QL(1 ea daily) PREZISTA TABS 150 MG, 2 QL(2 ea daily) KALETRA SOLN 400 QL(12.5 ml 600 MG, 75 MG MG/5ML-100 MG/5ML NF daily) QL(1 ea daily) (Use lopinavir-ritonavir) PREZISTA TABS 800 MG 2 KALETRA TABS 200 MG- QL(4 ea daily) RESCRIPTOR TABS 2 QL(6 ea daily) 50 MG, 25 MG-100 MG, 50 2 MG-200 MG (Use lopinavir- RETROVIR CAPS 100 MG NF QL(6 ea daily) ritonavir) (Use zidovudine) QL(30 ml daily) lamivudine soln 10 mg/ml 1 RETROVIR IV INFUSION 1 SOLN QL(2 ea daily) lamivudine tabs 150 mg 1 RETROVIR SYRP 50 NF QL(60 ml daily) MG/5ML (Use zidovudine) lamivudine tabs 300 mg 1 QL(1 ea daily) REYATAZ CAPS 150 MG, QL(1 ea daily) 300 MG (Use atazanavir NF lamivudine-zidovudine tabs 1 QL(2 ea daily) sulfate) QL(56 ml daily) REYATAZ CAPS 200 MG NF QL(2 ea daily) LEXIVA SUSP 50 MG/ML 2 (Use atazanavir sulfate) LEXIVA TABS 700 MG QL(4 ea daily) ritonavir tabs 1 QL(12 ea daily) (Use fosamprenavir NF calcium) Ambetter Formulary Updated September 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RUKOBIA TB12 4 PA TYBOST TABS 2 QL(1 ea daily)

SELZENTRY SOLN 20 2 QL(30 ml daily) VIDEX EC CPDR 125 MG 2 QL(2 ea daily) MG/ML VIDEX EC CPDR 200 MG QL(2 ea daily) SELZENTRY TABS 150 2 QL(2 ea daily) NF MG, 25 MG, 75 MG (Use didanosine) VIDEX EC CPDR 250 MG, QL(1 ea daily) SELZENTRY TABS 300 2 QL(4 ea daily) NF MG 400 MG (Use didanosine) stavudine caps 15 mg, 20 1 QL(2 ea daily) VIDEXPEDIATRIC SOLR 2 mg, 30 mg, 40 mg QL(10 ea daily) STAVUDINE CAPS 15 MG, 2 QL(2 ea daily) VIRACEPT TABS 250 MG 2 30 MG VIRACEPT TABS 625 MG 2 QL(4 ea daily) STAVUDINE CAPS 20 MG, 1 QL(2 ea daily) 40 MG VIRAMUNE SUSP 50 NF QL(40 ml daily) STRIBILD TABS 3 QL(1 ea daily) MG/5ML (Use nevirapine) VIRAMUNE TABS 200 MG NF QL(2 ea daily) SUSTIVA CAPS 200 MG NF QL(2 ea daily) (Use nevirapine) (Use efavirenz) VIRAMUNE XR TB24 (Use NF QL(1 ea daily) SUSTIVA CAPS 50 MG NF QL(3 ea daily) nevirapine) (Use efavirenz) VIREAD POWD 40 MG/GM 2 SUSTIVA TABS 600 MG NF QL(1 ea daily) (Use efavirenz) VIREAD TABS 150 MG, 2 QL(1 ea daily) SYMFI LO TABS (Use QL(1 ea daily) 200 MG, 250 MG efavirenz-lamivudine- 2 tenofovir disoproxil VIREAD TABS 300 MG fumarate) (Use tenofovir disoproxil NF fumarate) SYMFI TABS (Use QL(1 ea daily) ZIAGEN SOLN 20 MG/ML QL(32 ml daily) efavirenz-lamivudine- 2 NF tenofovir disoproxil (Use abacavir sulfate) fumarate) ZIAGEN TABS 300 MG NF QL(2 ea daily) ST; QL(1 ea (Use abacavir sulfate) SYMTUZA TABS 3 daily) zidovudine caps 100 mg 1 QL(6 ea daily) ST; QL(1 ea TEMIXYS TABS 2 daily) zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) tenofovir disoproxil 1 QL(2 ea daily) fumarate tabs zidovudine tabs 300 mg 1 TIVICAY TABS 3 QL(2 ea daily) CMV Agents

TRIUMEQ TABS 2 QL(1 ea daily) cidofovir soln 3 TRIZIVIR TABS (Use QL(2 ea daily) CYTOVENE SOLR (Use NF abacavir sulfate- NF ganciclovir sodium) lamivudine-zidovudine) ganciclovir sodium solr 1 TRUVADA TABS (Use QL(1 ea emtricitabine-tenofovir 2 daily,30 day(s) VALCYTE TABS 450 MG NF PA; QL(4 ea disoproxil fumarate) limit) (Use valganciclovir hcl) daily)

Ambetter Formulary Updated September 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits valganciclovir hcl tabs 450 1 PA; QL(4 ea ZEPATIER TABS 4 PA mg daily) Hepatitis Agents Herpes Agents PA; QL(1 ea QL(5 ea adefovir dipivoxil tabs 4 daily,50 ea per daily); SP acyclovir caps 200 mg 1 fill retail,50 ea BARACLUDE SOLN 0.05 4 PA; QL(20 ml MG/ML daily); SP per fill mail) QL(13.34 ml BARACLUDE TABS 0.5 NF PA; QL(1 ea acyclovir susp 200 mg/5ml 1 MG, 1 MG (Use entecavir) daily); SP daily) PA; QL(1 ea acyclovir tabs 400 mg, 800 QL(5 ea daily) entecavir tabs 4 1 daily); SP mg famciclovir tabs 125 mg, QL(3 ea daily) EPCLUSA TABS 400 MG- 4 PA; QL(1 ea 1 100 MG daily) 250 mg famciclovir tabs 500 mg 1 QL(4 ea daily) EPIVIR HBV SOLN 5 4 PA; QL(60 ml MG/ML daily); SP valacyclovir hcl tabs 1 gm, 1 QL(4 ea daily) EPIVIR HBV TABS 100 NF QL(3 ea daily); 1000 mg MG (Use lamivudine (hbv)) SP valacyclovir hcl tabs 500 1 QL(2 ea daily) HEPSERA TABS (Use NF PA; QL(1 ea mg adefovir dipivoxil) daily); SP VALTREX TABS 1 GM QL(4 ea daily) QL(3 ea daily); NF lamivudine (hbv) tabs 1 (Use valacyclovir hcl) SP VALTREX TABS 500 MG NF QL(2 ea daily) MAVYRET TABS 4 PA; QL(3 ea (Use valacyclovir hcl) daily) QL(5 ea PEGASYS PROCLICK PA; QL(0.0714 4 ZOVIRAX CAPS OR 200 NF daily,50 ea per SOLN ml daily); SP MG (Use acyclovir) fill retail,50 ea PA; QL(0.0714 PEGASYS SOLN 4 per fill mail) ml daily); SP ZOVIRAX SUSP OR 200 QL(13.34 ml PA; QL(0.143 NF PEGINTRON KIT 4 MG/5ML (Use acyclovir) daily) ea daily); SP ZOVIRAX TABS OR 400 QL(5 ea daily) RIBASPHERE RIBAPAK 4 PA MG, 800 MG (Use NF TBPK 400 MG, 600 MG acyclovir) RIBASPHERE TABS 4 PA Influenza Agents FLUMADINE TABS (Use NF QL(2 ea daily) ribavirin (hepatitis c) caps 1 QL(7 ea daily) rimantadine hydrochloride) 200 mg Limit 1 fill every ribavirin (hepatitis c) tabs 1 PA; QL(7 ea 90 days.;QL(10 200 mg daily) ea per fill ribavirin (hepatitis c) tabs 4 PA retail,10 ea per 600 mg oseltamivir phosphate caps 1 fill mail)1 rtl or 30 mg, 45 mg, 75 mg MAX fill,90 rtl SOFOSBUVIR/VELPATAS 4 PA; QL(1 ea VIR TABS daily) day(s) supply,1 mail MAX fill,90 VEMLIDY TABS 4 PA; QL(1 ea daily); SP mail day(s) supply, VOSEVI TABS 4 PA; QL(1 ea daily)

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANOXIN TABS OR 250 VENTAVIS SOLN 4 PA; SP MCG, 125 MCG (Use 2 digoxin) - Endothelin Receptor LANOXIN TABS OR 62.5 PA; QL(1 ea 2 tabs 4 MCG daily); SP CARDIOVASCULAR AGENTS - MISC. - Drugs to PA; QL(2 ea tabs 125 mg 4 Treat Heart and Circulation Conditions daily); SP PA; QL(2 ea Cardioplegic Solutions bosentan tabs 62.5 mg 4 daily) PLEGISOL SOLN (Use NF cardioplegic soln) LETAIRIS TABS (Use NF PA; QL(1 ea ambrisentan) daily); SP Cardiovascular Agents Misc. - Combinations PA; QL(1 ea OPSUMIT TABS 4 amlodipine besylate- 1 QL(1 ea daily) daily) atorvastatin calcium tabs TRACLEER TABS 125 MG NF PA; QL(2 ea BIDIL TABS 2 (Use bosentan) daily); SP CADUET TABS (Use QL(1 ea daily) TRACLEER TABS 62.5 NF PA; QL(2 ea amlodipine besylate- NF MG (Use bosentan) daily) atorvastatin calcium) TRACLEER TBSO 32 MG 4 PA; QL(2 ea daily); SP ENTRESTO TABS 3 PA Pulmonary Hypertension - Phosphodiesterase Impotence Agents ADCIRCA TABS (Use PA; QL(2 ea PA; BPH tadalafil (pulmonary NF daily); SP CIALIS TABS 5 MG (Use NF hypertension)) tadalafil) Only;QL(1 ea daily) REVATIO SOLN IV 10 PA; QL(37.5 ml PA; QL(0.1334 MG/12.5ML (Use sildenafil daily); SP sildenafil citrate tabs 1 NF ea daily) citrate (pulmonary hypertension)) STENDRA TABS 3 QL(0.134 ea daily) REVATIO SUSR OR 10 PA; QL(6 ml MG/ML (Use sildenafil NF daily) PA; BPH citrate (pulmonary tadalafil tabs 5 mg 1 Only;QL(1 ea hypertension)) daily) REVATIO TABS OR 20 PA; QL(3 ea VIAGRA TABS (Use NF PA; QL(0.1334 MG (Use sildenafil citrate NF daily); SP sildenafil citrate) ea daily) (pulmonary hypertension)) Prostaglandin Vasodilators sildenafil citrate (pulmonary PA; QL(37.5 ml epoprostenol sodium solr 4 PA hypertension) soln iv 10 4 daily); SP mg/12.5ml FLOLAN SOLR (Use NF PA sildenafil citrate (pulmonary PA; QL(6 ml epoprostenol sodium) hypertension) susr or 10 4 daily) ORENITRAM TBCR 0.125 PA mg/ml MG, 0.25 MG, 1 MG, 2.5 3 sildenafil citrate (pulmonary PA; QL(3 ea MG hypertension) tabs or 20 4 daily); SP mg treprostinil soln 4 PA; SP tadalafil (pulmonary 4 PA; QL(2 ea VELETRI SOLR (Use NF PA hypertension) tabs daily); SP epoprostenol sodium) Pulmonary Hypertension - Sol Guanylate Cyclase

Ambetter Formulary Updated September 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADEMPAS TABS 0.5 MG, 4 PA; QL(3 ea cefprozil susr 1 1.5 MG, 2 MG, 2.5 MG daily) Sinus Node Inhibitors cefprozil tabs 1 CORLANOR SOLN 5 3 PA; QL(15 ml MG/5ML daily) cefuroxime axetil tabs 1 CORLANOR TABS 5 MG, PA; QL(2 ea 3 cefuroxime sodium solr ij 1 7.5 MG daily) 750 mg Transthyretin Stabilizers Cephalosporins - 3rd Generation VYNDAMAX CAPS 4 PA; QL(1 ea daily) cefdinir caps 1 PA; QL(4 ea VYNDAQEL CAPS 4 cefdinir susr 1 daily) CEPHALOSPORINS - Drugs to Treat Bacterial cefditoren pivoxil tabs 200 3 Infections mg cefditoren pivoxil tabs 400 1 Cephalosporins - 1st Generation mg cefadroxil caps 1 cefixime susr 100 mg/5ml, 1 ST 200 mg/5ml cefadroxil susr 1 cefotaxime sodium solr 1 cefadroxil tabs 1 cefpodoxime proxetil susr 1 cefazolin sodium solr ij 20 1 gm, 500 mg, 1 gm, 10 gm cefpodoxime proxetil tabs 1 cephalexin caps 1 ceftazidime solr ij 2 gm, 1 1 gm, 6 gm cephalexin susr 1 ceftriaxone sodium solr ij 1 1 gm, 2 gm, 250 mg, 500 mg cephalexin tabs 1 FORTAZ SOLR IJ 1 GM NF (Use ceftazidime) KEFLEX CAPS (Use NF cephalexin) SUPRAX SUSR 100 ST MG/5ML, 200 MG/5ML NF Cephalosporins - 2nd Generation (Use cefixime) cefaclor caps 1 Cephalosporins - 4th Generation cefaclor susr 1 cefepime hcl solr 1 MAXIPIME SOLR IJ 1 GM, CEFOTAN SOLR (Use NF NF cefotetan disodium) 2 GM (Use cefepime hcl) cefotetan disodium solr 1 1 Cephalosporins - 5th Generation gm, 2 gm TEFLARO SOLR 3 cefotetan disodium solr 10 3 gm CONTRACEPTIVES - Drugs to Prevent cefoxitin sodium solr ij 10 1 Pregnancy gm Combination Contraceptives - Oral cefoxitin sodium solr iv 2 1 gm, 1 gm Ambetter Formulary Updated September 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BALCOLTRA TABS 0 NATAZIA TABS 0

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

Ambetter Formulary Updated September 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YASMIN 28 TABS (Use DEPO-PROVERA QL(1 ml per 90 drospirenone-ethinyl NF CONTRACEPTIVE SUSP NF days retail) estradiol) (Use medroxyprogesterone YAZ TABS (Use acetate (contraceptive)) drospirenone-ethinyl NF DEPO-PROVERA QL(90 day(s) estradiol) CONTRACEPTIVE SUSY NF limit,1 ml per (Use medroxyprogesterone 90 days retail) Combination Contraceptives - Transdermal acetate (contraceptive)) norelgestromin-ethinyl 0 DEPO-SUBQ PROVERA estradiol ptwk 0 104 SUSY 0 QL(3 ea per 28 QL(1 ml per 90 TWIRLA PTWK days retail) medroxyprogesterone acetate (contraceptive) 0 days retail) Combination Contraceptives - Vaginal susp ANNOVERA RING 0 PA medroxyprogesterone QL(90 day(s) acetate (contraceptive) 0 limit,1 ml per susy 90 days retail) etonogestrel-ethinyl 0 estradiol ring Progestin Contraceptives - Oral NUVARING RING (Use norethindrone 0 etonogestrel-ethinyl NF (contraceptive) tabs estradiol) ORTHO MICRONOR Copper Contraceptives - IUD TABS (Use norethindrone NF PARAGARD (contraceptive)) INTRAUTERINE COPPER 0 QL(1 ea daily) CONTRACEPTIVE T380A SLYND TABS 0 IUD - Steroid Hormone Drugs to Emergency Contraceptives Treat Systemic Swelling Conditions ELLA TABS 0 Glucocorticosteroids budesonide cpep 3 mg 1 QL(3 ea daily) levonorgestrel (emergency 0 oc) tabs CELESTONE SOLUSPAN PLAN B ONE-STEP TABS SUSP (Use NF (Use levonorgestrel NF sod phosphate & acetate) (emergency oc)) CELESTONE-SOLUSPAN Progestin Contraceptives - IUD SUSP (Use betamethasone NF sod phosphate & acetate) KYLEENA IUD 0 CORTEF TABS (Use NF LILETTA IUD 0 hydrocortisone) cortisone acetate tabs 1 MIRENA IUD 0 DEPO-MEDROL SUSP 20 3 SKYLA IUD 0 MG/ML DEPO-MEDROL SUSP 80 Progestin Contraceptives - Implants MG/ML, 40 MG/ML (Use NF methylprednisolone NEXPLANON IMPL 0 acetate) Progestin Contraceptives - Injectable dexamethasone elix 0.5 1 mg/5ml Ambetter Formulary Updated September 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXAMETHASONE 1 sodium INTENSOL CONC phosphate soln or 10 dexamethasone sodium mg/5ml, 15 mg/5ml, 20 1 mg/5ml, 25 mg/5ml, 5 phosphate soln ij 120 1 mg/30ml, 20 mg/5ml, 4 mg/5ml, 6.7 mg/5ml mg/ml prednisolone sodium phosphate tbdp or 10 mg, 3 dexamethasone soln 0.5 1 mg/5ml 15 mg, 30 mg dexamethasone tabs 1 mg, prednisolone soln 1 1.5 mg, 2 mg, 4 mg, 0.5 1 mg, 0.75 mg, 6 mg soln 1 EMFLAZA SUSP 4 PA prednisone tabs 1 EMFLAZA TABS 4 PA prednisone tbpk 1 ENTOCORT EC CPEP NF QL(3 ea daily) (Use budesonide) 2 rtl MAX fill,30 SOLU-CORTEF SOLR 100 3 rtl day(s) MG, 1000 MG, 500 MG hydrocortisone tabs 1 supply, SOLU-CORTEF SOLR 250 KENALOG-40 SUSP (Use NF 3 triamcinolone acetonide) MG SOLU-MEDROL SOLR 2 MEDROL DOSEPAK TBPK NF 3 (Use methylprednisolone) GM MEDROL TABS 16 MG, 32 SOLU-MEDROL SOLR 500 MG, 8 MG, 4 MG (Use NF MG, 1000 MG, 125 MG, 40 methylprednisolone) MG (Use NF methylprednisolone sod MEDROL TABS 2 MG 3 succ) triamcinolone acetonide 1 methylprednisolone acetate 1 susp 40 mg/ml susp 80 mg/ml, 40 mg/ml Mineralocorticoids methylprednisolone sod 1 succ solr fludrocortisone acetate tabs 1 methylprednisolone tabs 1 COUGH/COLD/ALLERGY - Drugs to Treat methylprednisolone tbpk 1 Cough, Cold and Allergy Symptoms Antitussives MILLIPRED DP TBPK 3 benzonatate caps 100 mg 1 QL(6 ea daily) MILLIPRED TABS 3 benzonatate caps 150 mg 1 QL(4 ea daily) ORAPRED ODT TBDP (Use prednisolone sodium NF benzonatate caps 200 mg 1 QL(3 ea daily) phosphate) TESSALON PERLES NF QL(6 ea daily) PEDIAPRED SOLN (Use CAPS (Use benzonatate) prednisolone sodium NF phosphate) Cough/Cold/Allergy Combinations

Ambetter Formulary Updated September 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALLEGRA-D 12 HOUR QL(2 ea daily) NEBUSAL NEBU 1 ALLERGY & CONGESTION TB12 (Use NF sodium chloride (inhalant) 1 fexofenadine- nebu 7 % pseudoephedrine) Mucolytics ALLEGRA-D 24 HOUR QL(1 ea daily) ALLERGY & acetylcysteine soln 1 CONGESTION TB24 (Use NF fexofenadine- DERMATOLOGICALS - Drugs to Treat Skin pseudoephedrine) Conditions cetirizine-pseudoephedrine 1 QL(2 ea daily) Acne Products tb12 ABSORICA CAPS 30 MG, PA; AL(At least CLARITIN-D 12 HOUR QL(2 ea daily) 10 MG, 20 MG, 40 MG NF 12 yrs old) TB12 (Use loratadine & 1 (Use isotretinoin) pseudoephedrine) PA; AL(At least adapalene crea 0.1 % 1 CLARITIN-D 24 HOUR QL(1 ea daily) 12 yrs old) TB24 (Use loratadine & 1 PA; AL(At least pseudoephedrine) adapalene gel 0.1 % 1 12 yrs old); fexofenadine- QL(2 ea daily) RX/OTC pseudoephedrine tb12 120 1 ST; AL(At least adapalene gel 0.3 % 1 mg-60 mg, 60 mg-120 mg 12 yrs old) fexofenadine- QL(1 ea daily) ST; AL(At least adapalene lotn 0.1 % 1 pseudoephedrine tb24 180 1 12 yrs old) mg-240 mg adapalene-benzoyl 1 ST; AL(At least hydrocodone polistirex- peroxide gel 12 yrs old) chlorpheniramine polistirex 1 suer AZELEX CREA 3 ST; AL(At least 12 yrs old) loratadine & QL(2 ea daily) pseudoephedrine tb12 120 1 BENZACLIN GEL (Use PA; AL(At least mg-5 mg, 5 mg-120 mg clindamycin phosphate- NF 12 yrs old) benzoyl peroxide) loratadine & QL(1 ea daily) BENZACLIN WITH PUMP PA; AL(At least pseudoephedrine tb24 10 1 mg-10 mg-240 mg-240 mg, GEL (Use clindamycin NF 12 yrs old) 240 mg-10 mg phosphate-benzoyl peroxide) PA TUZISTRA XR SUER 2 BENZAMYCIN GEL (Use PA; AL(At least ZYRTEC-D QL(2 ea daily) benzoyl peroxide- NF 12 yrs old) erythromycin) ALLERGY/CONGESTION 1 TB12 (Use cetirizine- BENZOYL PEROXIDE 2 AL(At least 12 pseudoephedrine) CLEANSER LIQD yrs old) Misc. Respiratory Inhalants AL(At least 12 benzoyl peroxide foam 5.3 1 yrs old); % HYPER-SAL NEBU (Use NF RX/OTC sodium chloride (inhalant)) benzoyl peroxide foam 9.8 1 AL(At least 12 HYPERSAL NEBU 3.5 % 1 % yrs old) HYPERSAL NEBU 7 % benzoyl peroxide gel 5 %, 1 AL(At least 12 (Use sodium chloride NF 10 % yrs old) (inhalant)) Ambetter Formulary Updated September 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzoyl peroxide liqd 4 %, 1 AL(At least 12 EPIDUO GEL (Use ST; AL(At least 7 %, 10 % yrs old) adapalene-benzoyl NF 12 yrs old) peroxide) benzoyl peroxide- 1 PA; AL(At least erythromycin gel 12 yrs old) erythromycin (acne aid) 1 AL(At least 12 CLEOCIN-T GEL (Use AL(At least 12 pads yrs old) clindamycin phosphate NF yrs old) erythromycin (acne aid) 1 AL(At least 12 (topical)) soln yrs old) CLEOCIN-T LOTN (Use AL(At least 12 EVOCLIN FOAM (Use PA; AL(At least clindamycin phosphate NF yrs old) clindamycin phosphate NF 12 yrs old) (topical)) (topical)) CLINDAGEL GEL (Use AL(At least 12 isotretinoin caps 30 mg, 10 3 PA; AL(At least clindamycin phosphate NF yrs old) mg, 20 mg, 40 mg 12 yrs old) (topical)) KLARON LOTN (Use AL(At least 12 clindamycin phosphate 1 PA; AL(At least sodium NF yrs old) (topical) foam 12 yrs old) (acne)) clindamycin phosphate 1 AL(At least 12 AL(At least 12 yrs old) RETIN-A CREA (Use NF yrs old - Up to (topical) gel tretinoin) 30 yrs old) clindamycin phosphate 1 AL(At least 12 (topical) lotn yrs old) AL(At least 12 RETIN-A GEL (Use NF QL(4 ml daily); tretinoin) yrs old - Up to clindamycin phosphate 1 AL(At least 12 30 yrs old) (topical) soln yrs old) RETIN-A MICRO GEL 0.1 PA; AL(At least % (Use tretinoin NF 12 yrs old - Up clindamycin phosphate 1 AL(At least 12 (topical) swab yrs old) microsphere) to 30 yrs old) clindamycin phosphate- PA; AL(At least RETIN-A MICRO PUMP PA; AL(At least benzoyl peroxide 1 12 yrs old) GEL 0.1 % (Use tretinoin NF 12 yrs old - Up (refrigerate) gel microsphere) to 30 yrs old) clindamycin phosphate- PA; AL(At least sulfacetamide sodium 1 AL(At least 12 benzoyl peroxide gel 1 %-5 1 12 yrs old) (acne) lotn yrs old) %, 5 %-1 % sulfacetamide sodium w/ 1 AL(At least 12 sulfur crea 5 %-10 % yrs old) clindamycin phosphate- 1 ST; AL(At least tretinoin gel 12 yrs old) sulfacetamide sodium w/ AL(At least 12 sulfur emul 10 %-5 %, 5 %- 1 yrs old) DIFFERIN CREA 0.1 % NF PA; AL(At least (Use adapalene) 12 yrs old) 10 % PA; AL(At least sulfacetamide sodium w/ ST; AL(At least DIFFERIN GEL 0.1 % (Use NF 12 yrs old); sulfur liqd 4.5 %-9 %, 9 %- 1 12 yrs old) adapalene) RX/OTC 4.5 % sulfacetamide sodium- AL(At least 12 DIFFERIN GEL 0.3 % (Use NF ST; AL(At least 1 adapalene) 12 yrs old) sulfur in vehicle emul yrs old) SUMADAN WASH LIQD ST; AL(At least DIFFERIN LOTN 0.1 % 1 ST; AL(At least 12 yrs old) (Use sulfacetamide sodium NF 12 yrs old) w/ sulfur) DUAC GEL (Use PA; AL(At least clindamycin phosphate- 12 yrs old) AL(At least 12 NF tretinoin crea 0.05 %, 0.1 1 yrs old - Up to benzoyl peroxide %, 0.025 % (refrigerate)) 30 yrs old)

Ambetter Formulary Updated September 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 12 ciclopirox olamine susp 1 tretinoin gel 0.01 %, 0.025 1 yrs old - Up to % 30 yrs old) ciclopirox sham ex 1 % 1 PA; AL(At least tretinoin microsphere gel 1 12 yrs old - Up 0.1 % ciclopirox soln ex 8 % 1 to 30 yrs old) VELTIN GEL (Use ST; AL(At least clotrimazole (topical) crea 1 RX/OTC clindamycin phosphate- NF 12 yrs old) tretinoin) clotrimazole (topical) soln 1 RX/OTC ZIANA GEL (Use ST; AL(At least clindamycin phosphate- NF 12 yrs old) clotrimazole w/ 1 tretinoin) betamethasone crea clotrimazole w/ 1 Agents for External Genital and Perianal Warts betamethasone lotn VEREGEN OINT 3 QL(85 gm per econazole nitrate crea 1 fill retail,85 gm Anti-inflammatory Agents - Topical per fill mail) PA; QL(2 ea diclofenac epolamine ptch 1 ERTACZO CREA 3 daily) EXELDERM CREA (Use diclofenac sodium (topical) 1 QL(3.34 gm 3 gel 1 % daily); RX/OTC sulconazole nitrate) FLECTOR PTCH (Use 3 PA; QL(2 ea EXELDERM SOLN 3 diclofenac epolamine) daily) EXELDERM SOLN (Use VOLTAREN GEL (Use NF QL(3.34 gm 3 diclofenac sodium (topical)) daily); RX/OTC sulconazole nitrate) PA Antibiotics - Topical JUBLIA SOLN 3

ALTABAX OINT 2 KERYDIN SOLN (Use 3 PA tavaborole) gentamicin sulfate (topical) QL(1 gm daily) 1 ketoconazole (topical) crea 1 crea 2 % gentamicin sulfate (topical) 1 ketoconazole (topical) 1 oint sham 2 % oint 1 QL(90 gm per LOPROX CREA (Use NF fill retail)1 rtl NEO-SYNALAR CREA 3 PA ciclopirox olamine) MAX fill,30 rtl day(s) supply, Antifungals - Topical LOPROX SHAMPOO NF butenafine hcl crea 1 RX/OTC SHAM (Use ciclopirox) LOPROX SUSP (Use NF CICLODAN SOLUTION NF ciclopirox olamine) KIT KIT (Use ciclopirox) LOTRIMIN AF CREA (Use NF RX/OTC ciclopirox gel ex 0.77 % 1 clotrimazole (topical)) LOTRIMIN AF JOCK ITCH RX/OTC QL(90 gm per CREA (Use clotrimazole NF fill retail)1 rtl ciclopirox olamine crea 1 (topical)) MAX fill,30 rtl day(s) supply, LOTRIMIN ULTRA CREA 1 RX/OTC (Use butenafine hcl) Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARAC CREA (Use NF PA; Limit 1 fill fluorouracil (topical)) every 180 days;QL(45 gm diclofenac sodium (actinic 1 PA; QL(3.34 keratoses) gel gm daily) per fill retail,45 gm per fill EFUDEX CREA (Use PRUDOXIN CREA (Use 3 NF doxepin hcl (antipruritic)) mail)1 rtl MAX fluorouracil (topical)) fill,180 rtl fluorouracil (topical) crea 5 1 day(s) supply,1 % mail MAX fill,180 mail fluorouracil (topical) soln 2 1 %, 5 % day(s) supply, PANRETIN GEL 3 PA; Limit 1 fill every 180 QL(3 ea per fill days;QL(45 gm retail,3 ea per per fill retail,45 fill mail)1 rtl gm per fill ZONALON CREA (Use 3 mail)1 rtl MAX 2 MAX fill,60 rtl doxepin hcl (antipruritic)) PICATO GEL 0.015 % day(s) supply,1 fill,180 rtl mail MAX fill,60 day(s) supply,1 mail day(s) mail MAX supply, fill,180 mail QL(2 ea per fill day(s) supply, retail,2 ea per Antipsoriatics fill mail)1 rtl acitretin caps 17.5 mg, 10 1 QL(1 ea daily) 2 MAX fill,60 rtl mg PICATO GEL 0.05 % day(s) supply,1 mail MAX fill,60 acitretin caps 25 mg 1 QL(2 ea daily) mail day(s) PA; QL(4 gm supply, calcipotriene crea 1 daily) PA; SP TARGRETIN GEL EX 1 % 4 PA; QL(4 gm calcipotriene oint 1 daily) Antipruritics - Topical PA; QL(4 ml calcipotriene soln 1 PA; Limit 1 fill daily) every 180 QL(3.34 gm days;QL(45 gm calcitriol (topical) oint 1 per fill retail,45 daily) gm per fill COSENTYX 4 PA; QL(0.072 doxepin hcl (antipruritic) 3 mail)1 rtl MAX SENSOREADY PEN SOAJ ml daily) crea fill,180 rtl COSENTYX SOSY 150 4 PA; QL(0.036 day(s) supply,1 MG/ML ml daily) mail MAX COSENTYX SOSY 150 4 PA; QL(0.072 fill,180 mail MG/ML ml daily) day(s) supply, DOVONEX CREA (Use NF PA; QL(4 gm calcipotriene) daily) methoxsalen rapid caps 1 QL(4 ea daily) OXSORALEN ULTRA QL(4 ea daily) CAPS (Use methoxsalen NF rapid)

Ambetter Formulary Updated September 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SKYRIZI PSKT 75 4 PA; QL(0.025 silver crea 1 MG/0.83ML ea daily) SULFAMYLON CREA 85 SORIATANE CAPS 10 MG NF QL(1 ea daily) 3 (Use acitretin) MG/GM SULFAMYLON PACK 5 % SORIATANE CAPS 25 MG NF QL(2 ea daily) NF (Use acitretin) (Use acetate) STELARA SOLN SC 45 4 PA; QL(0.012 Corticosteroids - Topical MG/0.5ML ml daily) alclometasone dipropionate 1 STELARA SOSY SC 45 4 PA; QL(0.012 crea MG/0.5ML ml daily) alclometasone dipropionate 1 STELARA SOSY SC 90 4 PA; QL(0.018 oint MG/ML ml daily); SP QL(60 gm per tazarotene crea 1 PA fill retail,60 gm per fill mail)1 rtl TAZORAC CREA 0.05 % 2 1 MAX fill,30 rtl amcinonide crea day(s) supply,1 mail MAX fill,30 TAZORAC CREA 0.1 % NF PA (Use tazarotene) mail day(s) supply, TAZORAC GEL 0.05 %, 2 0.1 % amcinonide lotn 3 PA; QL(0.018 TREMFYA SOPN 4 ml daily) AMCINONIDE OINT 3 4 PA; QL(0.018 betamethasone TREMFYA SOSY ml daily) 1 dipropionate (topical) crea VECTICAL OINT (Use 1 QL(3.34 gm betamethasone calcitriol (topical)) daily) 1 dipropionate (topical) lotn Antiseborrheic Products betamethasone 1 selenium sulfide lotn 1 dipropionate (topical) oint betamethasone Antivirals - Topical dipropionate augmented 1 crea acyclovir topical crea 1 betamethasone dipropionate augmented 1 acyclovir topical oint 1 lotn QL(0.18 gm DENAVIR CREA 3 betamethasone daily) dipropionate augmented 1 oint ZOVIRAX CREA EX 5 % NF (Use acyclovir topical) betamethasone valerate 1 crea 0.1 % ZOVIRAX OINT EX 5 % NF (Use acyclovir topical) betamethasone valerate 1 QL(1.67 gm Burn Products foam 0.12 % daily) betamethasone valerate 1 mafenide acetate pack 3 lotn 0.1 % betamethasone valerate SILVADENE CREA (Use NF 1 ) oint 0.1 %

Ambetter Formulary Updated September 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcipotriene- ST desoximetasone crea 0.25 1 betamethasone 1 % dipropionate oint 0.005 %- 0.064 %, 0.064 %-0.005 % desoximetasone gel 0.05 % 1 calcipotriene- ST desoximetasone oint 0.25 1 betamethasone 1 % dipropionate susp 0.005 %- PA 0.064 % diflorasone diacetate crea 1 PA; QL(3 gm clobetasol propionate crea 1 PA daily) diflorasone diacetate oint 1 DIPROLENE AF CREA clobetasol propionate 1 PA; QL(1 gm emollient base crea daily) (Use betamethasone NF ST; QL(3 gm dipropionate augmented) clobetasol propionate foam 1 daily) DIPROLENE OINT (Use ST; QL(2 gm betamethasone NF clobetasol propionate gel 1 daily) dipropionate augmented) PA; QL(1 gm ELOCON CREA (Use clobetasol propionate oint 1 NF daily) mometasone furoate) PA; QL(3.34 ml fluocinolone acetonide crea clobetasol propionate soln 1 1 daily) 0.01 %, 0.025 % QL(118.28 ml clocortolone pivalate crea 3 fluocinolone acetonide oil 1 per fill retail)1 0.01 % rtl MAX fill,30 rtl CLODERM CREA (Use 3 clocortolone pivalate) day(s) supply, fluocinolone acetonide oil CORDRAN CREA 0.05 % NF 1 (Use flurandrenolide) 0.01 % fluocinolone acetonide oint CORDRAN LOTN 0.05 % NF 1 (Use flurandrenolide) 0.025 % fluocinolone acetonide soln CORDRAN TAPE 4 3 1 MCG/SQCM 0.01 % QL(2 gm daily) CUTIVATE LOTN (Use NF QL(6 ml daily) fluocinonide crea 0.05 % 1 fluticasone propionate) fluocinonide emulsified 1 QL(2 gm daily) QL(118.28 ml base crea DERMA-SMOOTHE/FS per fill retail)1 BODY OIL (Use NF fluocinolone acetonide) rtl MAX fill,30 rtl fluocinonide gel 0.05 % 1 day(s) supply, DERMA-SMOOTHE/FS fluocinonide oint 0.05 % 1 QL(2 gm daily) SCALP OIL (Use NF fluocinolone acetonide) fluocinonide soln 0.05 % 1 QL(2 ml daily) QL(4 gm daily) desonide crea 1 flurandrenolide crea 2 QL(2 gm daily) QL(4 ml daily) desonide lotn 1 flurandrenolide lotn 2 QL(2 ml daily) desonide oint 1 QL(3 gm daily) fluticasone propionate crea 1 0.05 % DESOWEN CREA (Use NF QL(4 gm daily) desonide) fluticasone propionate lotn 1 QL(6 ml daily) 0.05 % Ambetter Formulary Updated September 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluticasone propionate oint 1 MONISTAT SOOTHING RX/OTC 0.005 % CARE ITCH RELIEF CREA NF PA (Use hydrocortisone halcinonide crea 1 (topical)) OLUX FOAM (Use ST; QL(3 gm halobetasol propionate 1 NF crea clobetasol propionate) daily) halobetasol propionate oint 1 prednicarbate crea 1

HALOG CREA (Use NF PA prednicarbate oint 1 halcinonide) PA HALOG OINT 3 PA PSORCON CREA 2 SYNALAR CREA (Use hydrocortisone (topical) 1 RX/OTC NF crea 1 % fluocinolone acetonide) SYNALAR OINT (Use hydrocortisone (topical) 1 NF crea 2.5 % fluocinolone acetonide) SYNALAR SOLN (Use hydrocortisone (topical) 1 NF lotn 2.5 % fluocinolone acetonide) TACLONEX OINT (Use ST hydrocortisone (topical) 1 RX/OTC oint 1 % calcipotriene- NF betamethasone hydrocortisone (topical) 1 dipropionate) oint 2.5 % TACLONEX SUSP (Use ST hydrocortisone butyrate 1 calcipotriene- 3 crea betamethasone hydrocortisone butyrate 1 dipropionate) oint TEMOVATE CREA (Use NF PA; QL(3 gm hydrocortisone butyrate 1 clobetasol propionate) daily) soln TEMOVATE OINT (Use NF PA; QL(1 gm hydrocortisone valerate 1 clobetasol propionate) daily) crea TOPICORT CREA 0.25 % NF hydrocortisone valerate 1 (Use desoximetasone) oint TOPICORT GEL 0.05 % NF LOCOID CREA (Use NF (Use desoximetasone) hydrocortisone butyrate) TOPICORT OINT 0.25 % NF LOCOID SOLN (Use NF (Use desoximetasone) hydrocortisone butyrate) triamcinolone acetonide LUXIQ FOAM (Use NF QL(1.67 gm (topical) crea 0.025 %, 0.5 1 betamethasone valerate) daily) % mometasone furoate crea 1 triamcinolone acetonide 1 QL(3.34 gm (topical) crea 0.1 % daily) mometasone furoate oint 1 triamcinolone acetonide (topical) lotn 0.025 %, 0.1 1 mometasone furoate soln 1 % triamcinolone acetonide (topical) oint 0.025 %, 0.1 1 %, 0.5 %

Ambetter Formulary Updated September 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA PA; AL(At least triamcinolone acetonide- 1 tacrolimus (topical) oint 1 dimethicone-silicone kit 2 yrs old) TRIDESILON CREA (Use NF QL(4 gm daily) Keratolytic/Antimitotic Agents desonide) podofilox soln 1 Eczema Agents DUPIXENT SOPN 300 4 PA Local Anesthetics - Topical MG/2ML lidocaine hcl gel ex 2 % 1 QL(4 ml daily) DUPIXENT SOSY 200 4 PA MG/1.14ML, 300 MG/2ML QL(4 ml daily); lidocaine hcl gel ex 2 % 1 Emollient/Keratolytic Agents RX/OTC QL(4 ml daily) HYDRO 35 FOAM (Use NF lidocaine hcl prsy ex 2 % 1 urea in lactic acid vehicle) Emollients lidocaine hcl soln ex 4 % 1 LAC-HYDRIN CREA (Use RX/OTC lidocaine ptch ex 5 % 1 PA lactic acid ( NF lactate)) lidocaine-prilocaine crea 1 QL(1 gm daily) LAC-HYDRIN TWELVE RX/OTC LOTN (Use lactic acid NF LIDODERM PTCH (Use NF PA (ammonium lactate)) lidocaine) QL(10 ea per lactic acid (ammonium 1 RX/OTC lactate) crea fill retail,10 ea per fill mail)1 rtl lactic acid (ammonium 1 RX/OTC lactate) lotn 3 MAX fill,30 rtl SYNERA PTCH day(s) supply,1 Enzymes - Topical mail MAX fill,30 PA mail day(s) SANTYL OINT 3 supply, Immunomodulating Agents - Topical Phosphodiesterase 4 (PDE4) Inhibitors - Topical QL(12 ea per PA; QL(2 gm ALDARA CREA (Use NF EUCRISA OINT 3 ) fill retail,12 ea daily) per fill mail) Rosacea Agents QL(12 ea per imiquimod crea 5 % 1 fill retail,12 ea azelaic acid gel 1 PA per fill mail) FINACEA GEL (Use NF PA ZYCLARA CREA (Use NF azelaic acid) imiquimod) METROCREAM CREA ZYCLARA PUMP CREA NF (Use metronidazole NF 3.75 % (Use imiquimod) (topical)) Immunosuppressive Agents - Topical METROGEL GEL (Use NF metronidazole (topical)) ELIDEL CREA (Use NF PA; AL(At least pimecrolimus) 2 yrs old) METROLOTION LOTN PA; AL(At least (Use metronidazole NF pimecrolimus crea 1 2 yrs old) (topical)) metronidazole (topical) PROTOPIC OINT (Use NF PA; AL(At least 1 tacrolimus (topical)) 2 yrs old) crea

Ambetter Formulary Updated September 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metronidazole (topical) gel 1 DIAGNOSTIC PRODUCTS metronidazole (topical) lotn 1 Diagnostic Drugs GLUCAGEN DIAGNOSTIC 3 QL(0.035 ea MIRVASO GEL 3 PA; QL(1 gm SOLR daily) daily) PA; 1 rtl MAX ORACEA CPDR (Use NF fill,365 rtl doxycycline (rosacea)) day(s) supply,1 THYROGEN SOLR 3 SOOLANTRA CREA (Use NF mail MAX ivermectin (rosacea)) fill,365 mail Scabicides & Pediculicides day(s) supply, Diagnostic Tests crotamiton lotn 1 PA CHEMSTRIP-K STRP 1 ELIMITE CREA (Use NF permethrin) FORA GTEL BLOOD KETONE TEST STRIPS 1 EURAX CREA 3 STRP EURAX LOTN (Use PA NF GOJJI BLOOD KETONE 1 crotamiton) TEST STRIPS STRP ivermectin (pediculicide) 1 PA; RX/OTC KETONE STRP 1 lotn KETONE TEST STRIPS IVERMECTIN LOTN EX 3 PA; RX/OTC 1 0.5 % STRP lindane sham 1 KETOSTIX STRP 1 NOVA MAX PLUS malathion lotn 1 KETONE TESTSTRIPS 1 STRP NATROBA SUSP (Use 1 PA spinosad) PRECISION XTRA STRP 1 VI NIX CREME RINSE LIQD NF (Use permethrin) PTS PANELS KETONE 1 TEST STRP OVIDE LOTN (Use NF malathion) RELION KETONE TEST 1 STRIPS STRP permethrin crea 1 RELION TRUE METRIX QL(3.34 ea permethrin liqd 1 BLOODGLUCOSE TEST 1 daily); RX/OTC STRIPS STRP SKLICE LOTN (Use 3 PA; RX/OTC Limit 100 per ivermectin (pediculicide)) TRUE METRIX BLOOD 1 month;QL(3.34 GLUCOSETEST STRIPS ea daily); 1 PA STRP spinosad susp RX/OTC ULESFIA LOTN 3 Limit 100 per month;QL(3.34 TRUETRACK TEST STRP 1 Wound Care Products ea daily); RX/OTC REGRANEX GEL 3 DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes Ambetter Formulary Updated September 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Digestive Enzymes soln ij 0.25 1 mg/ml CREON CPEP 2 bumetanide tabs or 0.5 mg, 1 QL(5 ea daily) 1 mg, 2 mg SUCRAID SOLN 3 BUMEX TABS (Use NF QL(5 ea daily) bumetanide) ZENPEP CPEP 2 EDECRIN TABS (Use NF QL(16 ea daily) - Drugs to Treat Heart, Circulation ethacrynic acid) Conditions and Blood Pressure ethacrynic acid tabs 1 QL(16 ea daily) Carbonic Anhydrase Inhibitors soln 1 cp12 500 1 QL(2 ea daily) mg furosemide tabs 1 acetazolamide sodium solr 1 LASIX TABS (Use NF acetazolamide tabs 125 mg 1 QL(8 ea daily) furosemide) torsemide tabs 1 acetazolamide tabs 250 mg 1 QL(4 ea daily) PA; QL(4 ea Potassium Sparing Diuretics KEVEYIS TABS 4 daily) ALDACTONE TABS (Use NF ) tabs 1 QL(6 ea daily) hcl tabs 1 Combinations DYRENIUM CAPS (Use NF QL(3 ea daily) ALDACTAZIDE TABS 25 ) MG-25 MG (Use NF spironolactone & spironolactone tabs 1 hydrochlorothiazide) triamterene caps 1 QL(3 ea daily) amiloride & 1 hydrochlorothiazide tabs DYAZIDE CAPS (Use and -Like Diuretics triamterene & NF tabs 1 hydrochlorothiazide) MAXZIDE TABS (Use chlorthalidone tabs 1 triamterene & NF hydrochlorothiazide) DIURIL SUSP 2 QL(20 ml daily) MAXZIDE-25 TABS (Use QL(2 ea daily) triamterene & NF hydrochlorothiazide caps 1 hydrochlorothiazide) hydrochlorothiazide tabs 1 QL(2 ea daily) spironolactone & 1 hydrochlorothiazide tabs tabs 1.25 mg 1 QL(1 ea daily) triamterene & 1 hydrochlorothiazide caps indapamide tabs 2.5 mg 1 QL(2 ea daily) triamterene & 1 hydrochlorothiazide tabs tabs 1 QL(2 ea daily) Loop Diuretics

Ambetter Formulary Updated September 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENDOCRINE AND METABOLIC AGENTS - risedronate sodium tabs 1 PA; QL(0.036 MISC. - Drugs to Treat Bone Disease and 150 mg ea daily) Regulate Hormones risedronate sodium tabs 30 1 PA; QL(1 ea mg, 5 mg daily) Bone Density Regulators risedronate sodium tabs 35 PA; QL(0.143 ACTONEL TABS 150 MG NF PA; QL(0.036 1 (Use risedronate sodium) ea daily) mg ea daily) risedronate sodium tbec 35 PA ACTONEL TABS 35 MG NF PA; QL(0.143 1 (Use risedronate sodium) ea daily) mg TYMLOS SOPN 4 PA; ACTONEL TABS 5 MG NF PA; QL(1 ea (Use risedronate sodium) daily) XGEVA SOLN 4 PA; SP alendronate sodium tabs 1 QL(0.143 ea 35 mg, 70 mg daily) zoledronic acid conc 4 4 PA; SP alendronate sodium tabs 1 QL(1 ea daily) mg/5ml 40 mg, 5 mg, 10 mg ZOLEDRONIC ACID SOLN 4 PA; SP ATELVIA TBEC (Use NF PA 4 MG/100ML risedronate sodium) zoledronic acid soln 4 4 PA; SP BONIVA SOLN IV 3 PA; SP mg/100ml, 5 mg/100ml MG/3ML (Use ibandronate NF ZOLEDRONIC ACID SOLR 4 PA; SP sodium) 4 MG BONIVA TABS OR 150 MG NF QL(0.036 ea (Use ibandronate sodium) daily) Corticotropin PA calcitonin (salmon) soln na 1 ACTHAR GEL 4 200 unit/act Fertility Regulators etidronate disodium tabs 1 CHORIONIC 4 PA; SP GONADOTROPIN SOLR FOSAMAX PLUS D TABS 3 PA; QL(0.143 ea daily) NOVAREL SOLR 10000 4 PA; SP UNIT FOSAMAX TABS (Use NF QL(0.143 ea alendronate sodium) daily) PREGNYL W/DILUENT PA; SP BENZYLALCOHOL/NACL 4 ibandronate sodium soln iv 4 PA; SP 3 mg/3ml SOLR ibandronate sodium tabs or 1 QL(0.036 ea GnRH/LHRH Antagonists 150 mg daily) CETROTIDE KIT 4 PA pamidronate disodium soln 4 PA; SP 30 mg/10ml, 90 mg/10ml ganirelix acetate sosy 4 PA PAMIDRONATE PA; SP DISODIUM SOLN 6 4 GANIRELIX ACETATE PA MG/ML SOSY (Use ganirelix NF acetate) pamidronate disodium solr 4 PA; SP 30 mg, 90 mg Growth Hormone Receptor Antagonists PA; 1 rtl MAX SOMAVERT SOLR 10 MG, 4 PA; SP 4 fill,180 rtl 15 MG, 20 MG PROLIA SOSY day(s) supply,; SP Growth Hormone Releasing Hormones (GHRH) PA RECLAST SOLN (Use NF PA; SP EGRIFTA SOLR 4 zoledronic acid)

Ambetter Formulary Updated September 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EGRIFTA SV SOLR 4 PA LUPRON DEPOT-PED (1- 4 PA; SP MONTH) KIT Growth Hormones LUPRON DEPOT-PED (3- 4 PA; SP MONTH) KIT 30 MG GENOTROPIN MINIQUICK 4 PA; SP SOLR 0.2 MG SYNAREL SOLN 4 PA; SP GENOTROPIN SOLR 5 4 PA; SP MG Metabolic Modifiers HUMATROPE COMBO 4 PA; SP ALDURAZYME SOLN 4 PA; SP PACK SOLR PA; SP BUPHENYL POWD (Use NF PA HUMATROPE SOLR 4 sodium phenylbutyrate) NORDITROPIN FLEXPRO PA; SP BUPHENYL TABS (Use NF PA SOPN 10 MG/1.5ML, 15 4 sodium phenylbutyrate) MG/1.5ML, 5 MG/1.5ML calcitriol caps 1 NORDITROPIN FLEXPRO 4 PA SOPN 30 MG/3ML calcitriol soln 1 NUTROPIN AQ NUSPIN 4 PA; SP 10 SOPN CARBAGLU TABS 4 PA; SP OMNITROPE SOCT 10 PA; SP 4 PA; QL(4 ea MG/1.5ML, 5 MG/1.5ML cinacalcet hcl tabs 4 daily); SP SAIZEN SOLR 4 PA; SP CYSTADANE POWD 4 PA; SP SAIZENPREP PA; SP RECONSTITUTIONKIT 4 doxercalciferol caps 1 SOLR SEROSTIM SOLR 4 PA; SP doxercalciferol soln 1 PA; SP ZOMACTON SOLR 4 PA; SP ELAPRASE SOLN 4 PA; SP FABRAZYME SOLR 35 4 PA; SP ZORBTIVE SOLR 4 MG GALAFOLD CAPS 4 PA; QL(0.5 ea Hormone Receptor Modulators daily) EVISTA TABS (Use NF QL(1 ea daily) HECTOROL SOLN 4 raloxifene hcl) MCG/2ML (Use NF OSPHENA TABS 3 PA doxercalciferol) KUVAN PACK (Use PA raloxifene hcl tabs 0 QL(1 ea daily) sapropterin NF dihydrochloride) Insulin-Like Growth Factors (Somatomedins) KUVAN TABS (Use PA INCRELEX SOLN 4 PA; SP sapropterin NF dihydrochloride) LHRH/GnRH Agonist Analog Pituitary LUMIZYME SOLR 4 PA; SP FENSOLVI KIT 4 PA; SP MYALEPT SOLR 4 PA LUPANETA PACK KIT 4 PA NAGLAZYME SOLN 4 PA; SP

Ambetter Formulary Updated September 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitisinone caps 4 PA; SP desmopressin acetate 1 spray refrigerated soln ORFADIN CAPS 10 MG, 2 PA; SP NF desmopressin acetate 1 MG, 5 MG (Use nitisinone) spray soln PA PALYNZIQ SOSY 4 desmopressin acetate tabs 1 QL(6 ea daily) or 0.1 mg paricalcitol caps 1 desmopressin acetate tabs 1 QL(8 ea daily) or 0.2 mg paricalcitol soln 1 STIMATE SOLN 4 PA; SP ROCALTROL CAPS (Use NF calcitriol) Prolactin Inhibitors ROCALTROL SOLN (Use NF cabergoline tabs 1 calcitriol) Somatostatic Agents sapropterin dihydrochloride 4 PA pack acetate soln 4 PA; SP sapropterin dihydrochloride 4 PA tabs SANDOSTATIN SOLN NF PA; SP (Use octreotide acetate) SENSIPAR TABS (Use NF PA; QL(4 ea cinacalcet hcl) daily); SP SIGNIFOR SOLN 4 PA sodium phenylbutyrate 1 PA powd SOMATULINE DEPOT 4 PA; QL(0.0179 SOLN 120 MG/0.5ML ml daily); SP sodium phenylbutyrate tabs 1 PA SOMATULINE DEPOT 4 PA; QL(0.0075 SOLN 60 MG/0.2ML ml daily); SP ZEMPLAR CAPS (Use NF paricalcitol) SOMATULINE DEPOT 4 PA; QL(0.011 SOLN 90 MG/0.3ML ml daily); SP ZEMPLAR SOLN (Use NF paricalcitol) Vasopressin Receptor Antagonists Posterior Pituitary Hormones JYNARQUE TABS 15 MG, 4 PA; QL(2 ea DDAVP SOLN IJ 4 PA 30 MG daily); SP MCG/ML (Use NF JYNARQUE TBPK 4 PA; SP desmopressin acetate) DDAVP SOLN NA 0.01 % SAMSCA TABS (Use 4 PA; QL(2 ea (Use desmopressin acetate NF ) daily); SP spray) PA; QL(2 ea tolvaptan tabs 4 DDAVP TABS OR 0.1 MG QL(6 ea daily) daily); SP (Use desmopressin NF ESTROGENS - Hormone Replacement/Modifying acetate) Drugs QL(8 ea daily) DDAVP TABS OR 0.2 MG Estrogen Combinations (Use desmopressin NF acetate) CLIMARA PRO PTWK 3 desmopressin acetate soln 1 PA ij 4 mcg/ml DUAVEE TABS 3 PA DESMOPRESSIN PA; SP FEMHRT TABS (Use ACETATE SOLN NA 1.5 4 norethindrone acetate- NF MG/ML ethinyl estradiol)

Ambetter Formulary Updated September 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone acetate- 1 PREMARIN TABS 2 ethinyl estradiol tabs VIVELLE-DOT PTTW (Use NF QL(0.286 ea PREMPHASE TABS 2 estradiol) daily) PREMPRO TABS 2 FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Estrogens Fluoroquinolones CLIMARA PTWK (Use NF AVELOX SOLN (Use estradiol) hcl in sodium 1 DELESTROGEN OIL 10 1 chloride) MG/ML PA DELESTROGEN OIL 20 BAXDELA SOLR 3 MG/ML, 40 MG/ML (Use NF PA estradiol valerate) BAXDELA TABS 3 DEPO-ESTRADIOL OIL 3 2 rtl MAX fill,30 CIPRO SUSR 5 2 rtl day(s) GM/100ML, 500 MG/5ML DIVIGEL GEL 0.25 supply, MG/0.25GM, 0.5 3 CIPRO TABS 250 MG, 500 NF MG/0.5GM, 1 MG/GM MG (Use hcl) ELESTRIN GEL 3 ciprofloxacin hcl tabs 1 ESTRACE TABS (Use NF ciprofloxacin in d5w soln estradiol) 200 mg/100ml-5 %, 5 %- 3 estradiol pttw td 0.025 QL(0.286 ea 200 mg/100ml mg/24hr, 0.0375 mg/24hr, 1 daily) 2 rtl MAX fill,30 0.05 mg/24hr, 0.075 ciprofloxacin susr 1 rtl day(s) mg/24hr, 0.1 mg/24hr supply, estradiol ptwk td 0.025 LEVAQUIN TABS (Use NF mg/24hr, 0.075 mg/24hr, ) 0.1 mg/24hr, 0.05 mg/24hr, 1 0.06 mg/24hr, 37.5 levofloxacin in d5w soln 5 mcg/24hr %-500 mg/100ml, 500 1 mg/100ml-5 % estradiol tabs or 0.5 mg, 1 1 mg, 2 mg levofloxacin soln 1 estradiol valerate oil 1 levofloxacin tabs 1

ESTROGEL GEL 3 moxifloxacin hcl in sodium 1 chloride soln EVAMIST SOLN 3 moxifloxacin hcl tabs 1 MENEST TABS 3 tabs 1 MENOSTAR PTWK 3 GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs MINIVELLE PTTW (Use NF QL(0.286 ea estradiol) daily) Bile Acid Synthesis Disorder Agents PREMARIN SOLR 2 CHOLBAM CAPS 4 PA; SP

Ambetter Formulary Updated September 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Gallstone Solubilizing Agents DIPENTUM CAPS 2 ACTIGALL CAPS (Use NF ursodiol) PA; 30 rtl lmt INFLECTRA SOLR 4 day(s),30 mail URSO 250 TABS (Use NF lmt day(s), ursodiol) LIALDA TBEC (Use NF URSO FORTE TABS (Use NF mesalamine) ursodiol) mesalamine cp24 or 0.375 1 ursodiol caps 300 mg 1 gm mesalamine cpdr or 400 1 ursodiol tabs 250 mg, 500 1 mg mg Gastrointestinal Chloride Channel Activators mesalamine enem re 4 gm 1 AMITIZA CAPS (Use PA; QL(2 ea 2 mesalamine supp re 1000 1 lubiprostone) daily) mg PA; QL(2 ea lubiprostone caps 1 mesalamine tbec or 1.2 gm 1 daily) Gastrointestinal Stimulants mesalamine tbec or 800 1 QL(6 ea daily) mg metoclopramide hcl soln ij 1 5 mg/ml PA; 30 rtl lmt RENFLEXIS SOLR 4 day(s),30 mail metoclopramide hcl soln or 1 QL(60 ml daily) lmt day(s), 10 mg/10ml, 5 mg/5ml STELARA SOLN IV 130 4 PA metoclopramide hcl tabs or 1 QL(6 ea daily) MG/26ML 10 mg, 5 mg tabs 1 REGLAN TABS (Use NF QL(6 ea daily) metoclopramide hcl) sulfasalazine tbec 1 Inflammatory Bowel Agents APRISO CP24 (Use NF Intestinal Acidifiers mesalamine) lactulose (encephalopathy) 1 ASACOL HD TBEC (Use NF QL(6 ea daily) soln mesalamine) Irritable Bowel Syndrome (IBS) Agents AVSOLA SOLR 4 PA alosetron hcl tabs 1 QL(2 ea daily) AZULFIDINE EN-TABS NF PA; QL(1 ea TBEC (Use sulfasalazine) LINZESS CAPS 2 daily) AZULFIDINE TABS (Use NF sulfasalazine) LOTRONEX TABS (Use NF QL(2 ea daily) alosetron hcl) disodium caps 1 Peripheral Opioid Receptor Antagonists CANASA SUPP (Use NF alvimopan caps 1 mesalamine) ENTEREG CAPS (Use COLAZAL CAPS (Use NF 3 balsalazide disodium) alvimopan) RELISTOR SOLN SC 12 PA DELZICOL CPDR (Use NF 3 mesalamine) MG/0.6ML, 8 MG/0.4ML Phosphate Binder Agents Ambetter Formulary Updated September 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium acetate (phosphate 1 SORBITOL- 1 binder) caps SOLN calcium acetate (phosphate 1 RX/OTC SORBITOL/MANNITOL 1 binder) tabs IRRIGATION SOLN FOSRENOL CHEW 1000 Interstitial Cystitis Agents MG, 500 MG, 750 MG (Use NF lanthanum carbonate) ELMIRON CAPS 2 lanthanum carbonate chew 1 Prostatic Hypertrophy Agents QL(1 ea daily) PHOSLYRA SOLN 2 alfuzosin hcl tb24 1 AVODART CAPS (Use QL(1 ea daily) RENVELA PACK (Use NF NF sevelamer carbonate) dutasteride) QL(1 ea daily) RENVELA TABS (Use NF dutasteride caps 1 sevelamer carbonate) 5 mg only sevelamer carbonate pack 1 finasteride tabs 1 FLOMAX CAPS (Use NF sevelamer carbonate tabs 1 tamsulosin hcl) PA PROSCAR TABS (Use NF 5 mg only VELPHORO CHEW 3 finasteride) GENITOURINARY AGENTS - MISCELLANEOUS RAPAFLO CAPS (Use NF - Miscellaneous Drugs to Treat Reproductive silodosin) Organs and Urinary System silodosin caps 8 mg, 4 mg 1 Alkalinizers potassium citrate tamsulosin hcl caps 1 (alkalinizer) tbcr 10 meq, 1 UROXATRAL TB24 (Use NF QL(1 ea daily) 1080 mg alfuzosin hcl) sodium citrate & citric acid 1 RX/OTC soln Urinary Analgesics UROCIT-K 10 TBCR (Use phenazopyridine hcl tabs 1 potassium citrate NF (alkalinizer)) PYRIDIUM TABS (Use NF phenazopyridine hcl) Cystinosis Agents GOUT AGENTS - Drugs to Treat Gout CYSTAGON CAPS 3 PA Gout Agent Combinations Genitourinary Irrigants colchicine w/ 1 acetic acid soln 1 tabs Gout Agents glycine (gu irrigant) soln 1 allopurinol tabs 1 RESECTISOL SOLN 1 colchicine tabs 1 QL(1 ea daily) sodium chloride (gu 1 irrigant) soln COLCRYS TABS (Use NF QL(1 ea daily) colchicine) SORBITOL SOLN 1

Ambetter Formulary Updated September 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea febuxostat tabs 1 BRILINTA TABS 2 daily) PA KRYSTEXXA SOLN 4 PA CABLIVI KIT 4

MITIGARE CAPS (Use NF cilostazol tabs 1 colchicine) clopidogrel bisulfate tabs ULORIC TABS (Use NF PA; QL(1 ea 1 febuxostat) daily) 300 mg clopidogrel bisulfate tabs QL(1 ea daily) ZYLOPRIM TABS (Use NF 1 allopurinol) 75 mg dipyridamole tabs 1 probenecid tabs 1 EFFIENT TABS (Use NF QL(1 ea daily) prasugrel hcl) HEMATOLOGICAL AGENTS - MISC. - Drugs to PLAVIX TABS (Use NF QL(1 ea daily) Treat Blood Disorders clopidogrel bisulfate) Bradykinin B2 Receptor Antagonists prasugrel hcl tabs 1 QL(1 ea daily) FIRAZYR SOLN (Use NF PA; QL(9 ml icatibant acetate) daily) REOPRO SOLN 3 PA; QL(9 ml icatibant acetate soln 4 daily) ZONTIVITY TABS 3 PA Complement Inhibitors HEMATOPOIETIC AGENTS - Drugs to Treat CINRYZE SOLR 4 PA Blood Disorders PA Agents for Gaucher Disease HAEGARDA SOLR 4 PA; QL(2 ea CERDELGA CAPS 4 PA; QL(0.143 daily) RUCONEST SOLR 4 ea daily) CEREZYME SOLR 4 PA; SP SOLIRIS SOLN 4 PA ELELYSO SOLR 4 PA; SP Hematorheologic Agents PA; QL(3 ea miglustat caps 4 pentoxifylline tbcr 1 QL(3 ea daily) daily); SP PA; SP Plasma Kallikrein Inhibitors VPRIV SOLR 4 PA; TAKHZYRO SOLN 4 ZAVESCA CAPS (Use NF PA; QL(3 ea miglustat) daily); SP Platelet Aggregation Inhibitors Agents for Sickle Cell Disease AGGRENOX CP12 (Use NF PA; QL(2 ea aspirin-dipyridamole) daily) DROXIA CAPS 3 AGRYLIN CAPS (Use NF OXBRYTA TABS 4 PA anagrelide hcl) anagrelide hcl caps 1 Cobalamins cyanocobalamin soln ij QL(1 ml daily) PA; QL(2 ea 1 aspirin-dipyridamole cp12 1 1000 mcg/ml daily) Folic Acid/Folates

Ambetter Formulary Updated September 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits folic acid tabs or 1 mg 0 RX/OTC PROMACTA TABS 12.5 4 PA; SP MG, 25 MG, 50 MG, 75 MG folic acid tabs or 400 mcg 0 RETACRIT SOLN 10000 PA UNIT/ML, 2000 UNIT/ML, Hematopoietic Growth Factors 20000 UNIT/2ML, 3000 4 ARANESP ALBUMIN PA; SP UNIT/ML, 4000 UNIT/ML, FREE SOLN 100 MCG/ML, 4 40000 UNIT/ML 40 MCG/ML, 60 MCG/ML UDENYCA SOSY 4 PA ARANESP ALBUMIN 4 SP FREE SOLN 25 MCG/ML PA; 30 rtl lmt ZARXIO SOSY 4 day(s),30 mail ARANESP ALBUMIN PA; SP lmt day(s), FREE SOSY 150 MCG/0.3ML, 200 4 ZIEXTENZO SOSY 4 PA; MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML Hematopoietic Mixtures DOPTELET TABS 4 PA ferrous fumarate-folic acid 1 QL(1 ea daily) tabs EPOGEN SOLN 3 PA; SP Iron PA; FER-IN-SOL SOLN (Use 0 AL(Up to 1 yrs FULPHILA SOSY 4 ferrous sulfate) old ) PA; SP ferrous sulfate soln or 15 0 AL(Up to 1 yrs LEUKINE SOLR 4 mg/ml old ) MIRCERA SOSY 4 PA ferrous sulfate tabs or 325 0 mg, 65 mg PA MULPLETA TABS 4 ferrous sulfate tbec or 325 0 mg NEULASTA ONPRO KIT 4 PA; SP PSKT Stem Cell Mobilizers PA; SP NEULASTA SOSY 4 PA; SP MOZOBIL SOLN 4 PA; SP HEMOSTATICS - Drugs to Stop Bleeding/Treat NEUPOGEN SOLN 4 Blood Disorders NEUPOGEN SOSY 4 PA; SP Hemostatics - Systemic AMICAR TABS 1000 MG, PA NIVESTYM SOSY 300 PA 500 MG (Use aminocaproic NF MCG/0.5ML, 480 4 acid) MCG/0.8ML aminocaproic acid tabs or 1 PA NPLATE SOLR 250 MCG, 4 PA; SP 1000 mg, 500 mg 500 MCG CYKLOKAPRON SOLN NF PROCRIT SOLN 10000 PA; SP (Use tranexamic acid) UNIT/ML, 2000 UNIT/ML, 3 20000 UNIT/ML, 3000 LYSTEDA TABS (Use NF UNIT/ML, 4000 UNIT/ML tranexamic acid) PROCRIT SOLN 40000 4 PA; SP tranexamic acid soln 1 UNIT/ML tranexamic acid tabs 1 PROMACTA PACK 12.5 4 PA; QL(1 ea MG daily)

Ambetter Formulary Updated September 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYPNOTICS/SEDATIVES/SLEEP DISORDER QL(2 ea daily); AGENTS zaleplon caps 10 mg 1 AL(At least 18 yrs old) Hypnotics QL(1 ea daily); elix 20 1 zaleplon caps 5 mg 1 AL(At least 18 mg/5ml yrs old) phenobarbital soln 20 1 QL(1 ea daily); mg/5ml zolpidem tartrate tabs or 10 1 AL(At least 18 mg, 5 mg phenobarbital tabs 100 mg, yrs old) 64.8 mg, 97.2 mg, 15 mg, 1 ST; Must try 16.2 mg, 30 mg, 32.4 mg immediate zolpidem tartrate tbcr or Hypnotics - Tricyclic Agents 1 release 6.25 mg, 12.5 mg zolpidem.;QL(1 PA; QL(1 ea doxepin hcl (sleep) tabs 1 ea daily) daily) Orexin Receptor Antagonists SILENOR TABS (Use NF PA; QL(1 ea doxepin hcl (sleep)) daily) BELSOMRA TABS 3 PA Non-Barbiturate Hypnotics ST; Must try Selective Melatonin Receptor Agonists PA; QL(1 ea immediate HETLIOZ CAPS 3 AMBIEN CR TBCR (Use NF daily) zolpidem tartrate) release zolpidem.;QL(1 ST; QL(1 ea ea daily) daily); AL(At ramelteon tabs 1 QL(1 ea daily); least 18 yrs AMBIEN TABS (Use NF old) zolpidem tartrate) AL(At least 18 yrs old) ST; QL(1 ea ROZEREM TABS (Use daily); AL(At DORAL TABS (Use NF NF quazepam) ramelteon) least 18 yrs old) estazolam tabs 1 LAXATIVES - Bowel Treatment Drugs ST; QL(1 ea 1 daily); AL(At Bulk Laxatives eszopiclone tabs least 18 yrs old) calcium polycarbophil tabs 1 HALCION TABS (Use NF FIBERCON TABS (Use NF triazolam) calcium polycarbophil) ST; QL(1 ea Laxative Combinations LUNESTA TABS (Use NF daily); AL(At eszopiclone) least 18 yrs CLENPIQ SOLN 3 PA old) COLYTE-FLAVOR PACKS RESTORIL CAPS (Use QL(1 ea daily) NF SOLR (Use peg 3350-kcl- NF ) sod bicarb-sod chloride-sod temazepam caps 1 QL(1 ea daily) sulfate) GOLYTELY SOLR 2.97 triazolam tabs 1 GM-5.86 GM-6.74 GM- 22.74 GM-236 GM (Use 0 peg 3350-kcl-sod bicarb- sod chloride-sod sulfate)

Ambetter Formulary Updated September 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOVIPREP SOLR (Use PA XYLOCAINE-MPF SOLN peg 3350-kcl-nacl-na 2 0.5 %, 1 %, 2 % (Use NF sulfate-na ascorbate- lidocaine hcl (local ascorbic acid) anesth.)) peg 3350-kcl-nacl-na PA MACROLIDES - Drugs to Treat Bacterial sulfate-na ascorbate- 1 Infections ascorbic acid solr peg 3350-kcl-sod bicarb- Azithromycin sod chloride-sod sulfate 0 azithromycin pack or 1 gm 1 solr 2.97 gm-5.86 gm-6.74 gm-22.74 gm-236 gm azithromycin solr iv 500 mg 1 PREPOPIK PACK 3 PA azithromycin susr or 100 1 mg/5ml, 200 mg/5ml SUPREP BOWEL PREP 0 KIT SOLN QL(6 ea per fill azithromycin tabs or 250 1 retail,6 ea per mg Laxatives - Miscellaneous fill mail) lactulose soln 10 gm/15ml, 1 QL(4 ea per fill 20 gm/30ml azithromycin tabs or 500 1 retail,4 ea per mg Saline Laxatives fill mail) PA azithromycin tabs or 600 1 QL(0.286 ea OSMOPREP TABS 3 mg daily) Stimulant Laxatives ZITHROMAX PACK OR 1 NF GM (Use azithromycin) bisacodyl tbec 1 ZITHROMAX SOLR IV 500 NF MG (Use azithromycin) DULCOLAX TBEC (Use NF bisacodyl) ZITHROMAX SUSR OR 100 MG/5ML, 200 MG/5ML NF Surfactant Laxatives (Use azithromycin) COLACE CAPS (Use NF QL(6 ea per fill docusate sodium) ZITHROMAX TABS OR NF 250 MG (Use azithromycin) retail,6 ea per docusate calcium caps 1 fill mail) QL(4 ea per fill ZITHROMAX TABS OR NF docusate sodium caps 1 500 MG (Use azithromycin) retail,4 ea per fill mail) LOCAL ANESTHETICS-Parenteral - Drugs for ZITHROMAX TABS OR NF QL(0.286 ea Numbing 600 MG (Use azithromycin) daily) Local Anesthetics - Amides QL(4 ea per fill ZITHROMAX TRI-PAK NF retail,4 ea per lidocaine hcl (local anesth.) 1 TABS (Use azithromycin) soln 0.5 %, 1 %, 2 % fill mail) MARCAINE SOLN 0.5 % QL(6 ea per fill NF ZITHROMAX Z-PAK TABS NF retail,6 ea per (Use bupivacaine hcl) (Use azithromycin) NAROPIN SOLN 5 MG/ML, fill mail) 2 MG/ML (Use ropivacaine NF Clarithromycin hcl) clarithromycin susr 1 XYLOCAINE SOLN 0.5 %, 1 % (Use lidocaine hcl NF (local anesth.)) clarithromycin tabs 1 Ambetter Formulary Updated September 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin tb24 1 K-Y ME & YOU INTENSE 0 QL(2 ea daily) DEVI Erythromycins KAMELEON LUBRICATED 0 QL(2 ea daily) E.E.S. GRANULES SUSR MISC (Use erythromycin NF KIMONO COLORS DEVI 0 QL(2 ea daily) ethylsuccinate) ERYPED 200 SUSR (Use KIMONO LUBRICATED 0 QL(2 ea daily) erythromycin NF MISC ethylsuccinate) KIMONO MICRO THIN QL(2 ea daily) ERYPED 400 SUSR (Use PLUS SPERMICIDE 0 erythromycin 3 LUBRICATED MISC ethylsuccinate) KIMONO PLUS QL(2 ea daily) SPERMICIDE 0 erythromycin base cpep 3 250 mg LUBRICATED MISC KIMONO PLUS QL(2 ea daily) erythromycin base tabs 3 250 mg, 500 mg SPERMICIDE/LUBRICATE 0 D MISC erythromycin base tbec 1 250 mg, 333 mg, 500 mg KIMONO PS LUBRICATED 0 QL(2 ea daily) erythromycin MISC ethylsuccinate susr 200 1 KIMONO PS PLUS QL(2 ea daily) mg/5ml, 400 mg/5ml SPERMICIDE/LUBRICATE 0 D MISC erythromycin 3 ethylsuccinate tabs 400 mg KIMONO SENSATION 0 QL(2 ea daily) LUBRICATED MISC KIMONO SENSATION QL(2 ea daily) DIFICID TABS 200 MG 2 PLUS SPERMICIDE 0 LUBRICATED MISC MEDICAL DEVICES AND SUPPLIES KIMONO SPECIAL DEVI 0 QL(2 ea daily) Contraceptives MAXX LUBRICATED MISC 0 QL(2 ea daily) AIMSCO LUBRICATED 0 QL(2 ea daily) MISC MAXX PLUS SPERMICIDE 0 QL(2 ea daily) LUBRICATED MISC CAYA DPRH 0 OMNIFLEX DIAPHRAGM 0 DPRH DUREX EXTRA 0 QL(2 ea daily) SENSITIVE DEVI PREMIUM CONDOMS 0 QL(2 ea daily) LUBRICATED MISC FANTASY LUBRICATED 0 QL(2 ea daily) MISC REALITY LATEX QL(2 ea daily) FANTASY QL(2 ea daily) CONDOMS/LUBRICATED 0 LUBRICATED/SPERMICID 0 MISC E MISC REALITY LATEX/ULTRA 0 QL(2 ea daily) TEXTURED DEVI FC FEMALE CONDOM 0 QL(1 ea daily) MISC REALITY LATEX/ULTRA 0 QL(2 ea daily) FEMCAP DEVI 0 THIN DEVI TRUSTEX COLOR 0 QL(2 ea daily) K-Y ME & YOU EXTRA 0 QL(2 ea daily) CONDOMS + LUBE MISC LUBRICATED DEVI

Ambetter Formulary Updated September 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX LUBRICATED 0 QL(2 ea daily) WIDE-SEAL SILICONE EXTRALARGE MISC DIAPHRAGM KIT 80 0 DPRH TRUSTEX LUBRICATED 0 QL(2 ea daily) EXTRASTRENGTH MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 85 0 TRUSTEX LUBRICATED 0 QL(2 ea daily) MISC DPRH TRUSTEX QL(2 ea daily) WIDE-SEAL SILICONE LUBRICATED/RIBBED/ST 0 DIAPHRAGM KIT 90 0 UDDED MISC DPRH TRUSTEX QL(2 ea daily) WIDE-SEAL SILICONE LUBRICATED/SPERMICID 0 DIAPHRAGM KIT 95 0 E EXTRA LARGE MISC DPRH TRUSTEX QL(2 ea daily) Diabetic Supplies LUBRICATED/SPERMICID 0 1ST TIER UNILET QL(6.6667 ea E EXTRA STRENGTH COMFORTOUCH 1 daily) MISC LANCETS 28G MISC TRUSTEX QL(2 ea daily) 1ST TIER UNILET QL(6.6667 ea LUBRICATED/SPERMICID 0 COMFORTOUCH 1 daily) E MISC LANCETS 30G MISC TRUSTEX NATURAL QL(2 ea daily) ACCU-CHEK FASTCLIX 1 QL(6.6667 ea CONDOMS 0 LANCETS MISC daily) +LUBE/LUBRICATED ACCU-CHEK MULTICLIX QL(6.6667 ea MISC 1 LANCETS MISC daily) TRUSTEX WITH QL(2 ea daily) ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea NONOXYNOL- 0 LANCETS MISC daily) 9/RIBBED/STUDDED MISC ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea PLUSLANCETS MISC daily) TRUSTEX/RIA 0 QL(2 ea daily) LUBRICATED MISC ACCU-CHEK SOFTCLIX 1 QL(6.6667 ea LANCETS MISC daily) TRUSTEX/RIA QL(2 ea daily) LUBRICATED 0 ACTI-LANCE LANCETS 1 QL(6.6667 ea SPERMICIDE MISC 28G MISC daily) TRUSTEX/RIA QL(2 ea daily) ACTI-LANCE LITE QL(6.6667 ea LUBRICATED/SPERMICID 0 SAFETY LANCETS 28G 1 daily) E MISC MISC WIDE-SEAL SILICONE ACTI-LANCE SPECIAL QL(6.6667 ea DIAPHRAGM KIT 60 0 SAFETY LANCETS 17G 1 daily) DPRH MISC WIDE-SEAL SILICONE ACTI-LANCE SPECIAL QL(6.6667 ea DIAPHRAGM KIT 65 0 SAFETYLANCETS 17G 1 daily) DPRH MISC WIDE-SEAL SILICONE ACTI-LANCE UNIVERSAL QL(6.6667 ea DIAPHRAGM KIT 70 0 SAFETY LANCETS 23G 1 daily) DPRH MISC WIDE-SEAL SILICONE ADJUSTABLE LANCING 1 DIAPHRAGM KIT 75 0 DEVICE MISC DPRH ADVANCED MOBILE 1 QL(6.6667 ea LANCET 30G MISC daily) Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea 23G/PRESSURE 1 daily) LANCETS26G/PRESSURE 1 daily) ACTIVATED MISC ACTIVATED MISC EASY TOUCH LANCETS QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea 26G/PRESSURE 1 daily) LANCETS28G/BUTTON 1 daily) ACTIVATED MISC ACTIVATED MISC EASY TOUCH LANCETS 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea 26G/PULL-TOP MISC daily) LANCETS28G/PRESSURE 1 daily) EASY TOUCH LANCETS QL(6.6667 ea ACTIVATED MISC 1 28G/PRESSURE daily) EASY TWIST & CAP 1 QL(6.6667 ea ACTIVATED MISC LANCETS MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EMBRACE LANCETS 1 QL(6.6667 ea 28G/PULL-TOP MISC daily) ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EMBRACE LANCING 28G/TWIST MISC daily) DEVICE WITH EJECTOR 1 EASY TOUCH LANCETS QL(6.6667 ea MISC 30G/BUTTON-ACTIVATED 1 daily) EQL COLOR LANCETS 1 QL(6.6667 ea MISC 21G MISC daily) EASY TOUCH LANCETS QL(6.6667 ea EQL COLOR LANCETS 1 QL(6.6667 ea 30G/PRESSURE 1 daily) MICRO THIN 33G MISC daily) ACTIVATED MISC EQL SUPER THIN 1 QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea LANCETS 30G MISC daily) 30G/PULL-TOP MISC daily) EQL THIN LANCETS 26G 1 QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea MISC daily) 30G/TWIST MISC daily) EZ-LETS LANCETS 21G 1 QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea MISC daily) 32G/PRESSURE 1 daily) EZ-LETS LANCETS 26G 1 QL(6.6667 ea ACTIVATED MISC SUPER-SOFT MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 EZ-LETS LANCETS 28G 1 QL(6.6667 ea 32G/PULL-TOP MISC daily) ULTRA-SOFT MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 EZ-LETS LANCETS 30G 1 QL(6.6667 ea 32G/TWIST MISC daily) MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 1 FIFTY50 SAFETY SEAL 1 QL(6.6667 ea 33G/TWIST MISC daily) LANCETS 30G MISC daily) EASY TOUCH LANCING 1 FIFTY50 SAFETY SEAL 1 QL(6.6667 ea DEVICE/EJECTOR MISC LANCETS 32G MISC daily) EASY TOUCH SAFETY QL(6.6667 ea FIFTY50 UNILET 1 QL(6.6667 ea LANCETS21G/PRESSURE 1 daily) LANCETS 33G MISC daily) ACTIVATED MISC FINE 30 MISC 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea daily) LANCETS23G/PRESSURE 1 daily) ACTIVATED MISC FINGERSTIX LANCETS 1 QL(6.6667 ea MISC daily) EASY TOUCH SAFETY QL(6.6667 ea QL(6.6667 ea LANCETS26G/BUTTON 1 daily) FORA LANCETS MISC 1 ACTIVATED MISC daily) FORA LANCING DEVICE 1 MISC

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS SAFETY SEAL 1 QL(6.6667 ea LIVE BETTER LANCET 1 QL(6.6667 ea 21G MISC daily) SUPERTHIN 30G MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea LIVE BETTER LANCET 1 QL(6.6667 ea 26G MISC daily) ULTRATHIN 28G MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea LONGS LANCETS 1 QL(6.6667 ea 28G MISC daily) STANDARD MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea LONGS LANCETS THIN 1 QL(6.6667 ea 30G MISC daily) MISC daily) LANCETS SUPER THIN 1 QL(6.6667 ea LONGS LANCETS ULTRA 1 QL(6.6667 ea 28G MISC daily) THIN MISC daily) LANCETS THIN MISC 1 QL(6.6667 ea MEDICHOICE PRE-SET QL(6.6667 ea daily) SAFETY LANCET DUAL 1 daily) USE MISC LANCETS TWIST TOP 1 QL(6.6667 ea MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET LOW 1 daily) LANCETS ULTRA THIN 1 QL(6.6667 ea 30G MISC daily) FLOW MISC MEDICHOICE PRE-SET QL(6.6667 ea LANCETS ULTRA THIN 1 QL(6.6667 ea MISC daily) SAFETY LANCET 1 daily) MEDIUM FLOW MISC LANCETSBULLSEYE 1 QL(6.6667 ea SAFETY MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET 1 daily) LANCING DEVICE 1 MODERATE FLOW MISC ADJUSTABLE MISC MEDICHOICE SAFETY 1 QL(6.6667 ea LANCING DEVICE MISC 1 LANCETEXTRA MISC daily) MEDICHOICE SAFETY 1 QL(6.6667 ea LANZO MISC 1 LANCETNORMAL MISC daily) MEDISENSE THIN QL(6.6667 ea LEADER ADVANCED 1 1 LANCING DEVICE MISC LANCETS MISC daily) MEDLANCE PLUS EXTRA QL(6.6667 ea LIBERTY MEDICAL 1 QL(6.6667 ea 1 LANCETS 30G MISC daily) LANCETS 21G MISC daily) MEDLANCE PLUS QL(6.6667 ea LIBERTY MINI LANCING 1 1 DEVICE MISC LANCETS LITE 25G MISC daily) LIFESCAN UNISTIK 2 QL(6.6667 ea MEDLANCE PLUS 1 QL(6.6667 ea DEEP PENETRATION 1 daily) LANCETS MISC daily) MISC MEDLANCE PLUS LITE 1 QL(6.6667 ea LANCETS 25G MISC daily) LIFESCAN UNISTIK II 1 QL(6.6667 ea LANCETS MISC daily) MEDLANCE PLUS QL(6.6667 ea SPECIAL LANCETS 1 daily) LITE TOUCH LANCETS 1 QL(6.6667 ea MISC daily) 0.8MM MISC MEDLANCE PLUS QL(6.6667 ea LITE TOUCH LANCING 1 1 PEN MISC SUPERLITE 30G MISC daily) MEDLANCE PLUS QL(6.6667 ea LITETOUCH LANCETS 1 QL(6.6667 ea MICRO THIN 33G MISC daily) SUPERLITE 1 daily) 30G/COMFORT MAX LIVE BETTER ADVANCED 1 LANCING DEVICE MISC MISC

Ambetter Formulary Updated September 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDLANCE PLUS QL(6.6667 ea MPD SAFETY LANCET 1 QL(6.6667 ea UNIVERSAL LANCETS 1 daily) 30G/1.8MM MISC daily) 21G MISC MPD SAFETY LANCETS 1 QL(6.6667 ea MEDLANCE PLUS/LITE 1 QL(6.6667 ea 23G/1.8MM MISC daily) 25G MISC daily) MULTI-LANCET DEVICE 1 QL(6.6667 ea MISC MEDLANCE/EXTRA MISC 1 daily) MYGLUCOHEALTH MGH QL(6.6667 ea SOFTLANCE LANCETS 1 daily) MEDLANCE/LITE MISC 1 QL(6.6667 ea daily) 30G MISC MEDLANCE/UNIVERSAL 1 QL(6.6667 ea NOVA SAFETY LANCETS 1 QL(6.6667 ea MISC daily) 23G MISC daily) MEIJER COLOR QL(6.6667 ea NOVA SAFETY LANCETS 1 QL(6.6667 ea LANCETS UNIVERSAL 1 daily) 28G MISC daily) 33G MISC NOVA SUREFLEX 1 QL(6.6667 ea LANCETS MISC daily) MEIJER LANCETS MISC 1 QL(6.6667 ea daily) NOVA SUREFLEX 1 MEIJER LANCETS THIN 1 QL(6.6667 ea LANCING DEVICE MISC MISC daily) ON CALL LANCING 1 MEIJER LANCETS 1 QL(6.6667 ea DEVICE MISC UNIVERSAL21G MISC daily) ON CALL PLUS LANCING 1 MEIJER LANCETS 1 QL(6.6667 ea DEVICE MISC UNIVERSAL30G MISC daily) ONETOUCH CLUB QL(6.6667 ea 1 MEIJER LANCETS 1 QL(6.6667 ea LANCETS FINE POINT daily) UNIVERSAL33G MISC daily) MISC MEIJER SUPER THIN 1 QL(6.6667 ea ONETOUCH DELICA QL(6.6667 ea LANCETS MISC daily) LANCETS EXTRA FINE 1 daily) 33G MISC MICROLET LANCETS 1 QL(6.6667 ea MISC daily) ONETOUCH DELICA 1 QL(6.6667 ea LANCETS FINE 30G MISC daily) MICROLET NEXT MISC 1 ONETOUCH DELICA 1 LANCING DEVICE MISC MINI LANCING DEVICE 1 MISC ONETOUCH DELICA QL(6.6667 ea PLUS LANCETS EXTRA 1 daily) MM LANCING DEVICE 1 MISC FINE 33G MISC ONETOUCH DELICA QL(6.6667 ea MM TWIST LANCETS 1 QL(6.6667 ea MISC daily) PLUS LANCETS FINE 30G 1 daily) MISC MONOLET LANCETS 1 QL(6.6667 ea MISC daily) ONETOUCH DELICA PLUS LANCING DEVICE 1 MONOLET OPD LANCETS 1 QL(6.6667 ea MISC daily) MISC ONETOUCH DELICA MONOLETTOR SAFETY 1 QL(6.6667 ea LANCETS MISC daily) SAFETY LACING DEVICE 1 MISC MPD SAFETY LANCET 1 QL(6.6667 ea 21G/1.8MM MISC daily) ONETOUCH FINEPOINT 1 QL(6.6667 ea LANCETS MISC daily) MPD SAFETY LANCET 1 QL(6.6667 ea 28G/1.8MM MISC daily) ONETOUCH ULTRASOFT 1 QL(6.6667 ea LANCETS MISC daily) Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION 2-IN-1 LANCING 1 SAFETY LANCET QL(6.6667 ea DEVICE 25G MISC 28G/PRESSURE 1 daily) ACTIVATED MISC RELION 2-IN-1 LANCING 1 DEVICE 30G MISC SAFETY LANCETS 21G 1 QL(6.6667 ea MISC daily) RELION LANCETS 1 QL(6.6667 ea MICRO-THIN33G MISC daily) SAFETY LANCETS 28G 1 QL(6.6667 ea MISC daily) RELION LANCETS THIN 1 QL(6.6667 ea 26G MISC daily) SAFETY LET LANCETS 1 QL(6.6667 ea MISC daily) RELION LANCETS 1 QL(6.6667 ea ULTRA-THIN30G MISC daily) QL(6.6667 ea SB LANCETS THIN MISC 1 daily) RELION LANCING 1 DEVICE MISC SB LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS/30G MISC daily) SELECT-LITE LANCING 1 DEVICE MISC RELION ULTRA THIN 1 QL(6.6667 ea LANCETS30G MISC daily) SHOPKO AUTOLET 1 RELION ULTRA THIN QL(6.6667 ea LANCING DEVICE MISC PLUS LANCETS 32G 1 daily) SHOPKO ON-THE-GO QL(6.6667 ea MISC COMFORTLANCETS 30G 1 daily) RELION ULTRA THIN QL(6.6667 ea MISC PLUS LANCETS 33G 1 daily) SHOPKO UNILET QL(6.6667 ea MISC LANCETS SUPER THIN 1 daily) 30G MISC REXALL LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) SHOPKO UNILET QL(6.6667 ea LANCETS ULTRA THIN 1 daily) RIGHTEST GD500 1 LANCING DEVICE MISC 28G MISC SIDE BUTTON SAFETY QL(6.6667 ea RIGHTEST GL300 1 QL(6.6667 ea 1 LANCETS MISC daily) LANCET21G MISC daily) SIMPLE DIAGNOSTICS SAFE-T-LANCE LOW 1 QL(6.6667 ea 1 FLOW 25G MISC daily) LANCING DEVICE MISC QL(6.6667 ea SAFE-T-LANCE NORMAL 1 QL(6.6667 ea SINGLE-LET MISC 1 FLOW21G MISC daily) daily) SAFE-T-LANCE PLUS QL(6.6667 ea SM MICRO THIN 1 QL(6.6667 ea SAFETYLANCET HIGH 1 daily) LANCETS 33G MISC daily) FLOW MISC SM TRUEDRAW LANCING 1 SAFE-T-LANCE PLUS QL(6.6667 ea DEVICE MISC SAFETYLANCET LOW 1 daily) SMART DIABETES FLOW MISC VANTAGE LANCING 1 SAFE-T-LANCE PLUS QL(6.6667 ea DEVICE MISC SAFETYLANCET 1 daily) SMART SENSE COLOR QL(6.6667 ea NORMAL FLOW MISC LANCETS UNIVERSAL 1 daily) SAFETY LANCET QL(6.6667 ea 33G MISC 21G/PRESSURE 1 daily) SMART SENSE QL(6.6667 ea ACTIVATED MISC STANDARD LANCETS 1 daily) SAFETY LANCET QL(6.6667 ea UNIVERSAL 21G MISC 23G/PRESSURE 1 daily) ACTIVATED MISC Ambetter Formulary Updated September 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SMART SENSE SUPER QL(6.6667 ea TECHLITE AST LANCETS 1 QL(6.6667 ea THIN LANCETS 1 daily) MISC daily) UNIVERSAL 30G MISC TECHLITE LANCETS 30G 1 QL(6.6667 ea SMART SENSE THIN QL(6.6667 ea MISC daily) LANCETSUNIVERSAL 1 daily) TECHLITE LANCETS 1 QL(6.6667 ea 26G MISC MISC daily) SMARTEST LANCETS QL(6.6667 ea 1 TGT LANCET MICRO 1 QL(6.6667 ea 28G MISC daily) THIN 33G MISC daily) SOLUS V2 LANCING 1 TGT LANCET THIN 26G 1 QL(6.6667 ea DEVICE MISC MISC daily) SOLUS V2 PRESSURE QL(6.6667 ea TGT LANCET ULTRA 1 QL(6.6667 ea ACTIVATED SAFETY 1 daily) THIN 30G MISC daily) LANCETS 28G MISC TGT LANCING DEVICE 1 SOLUS V2 TWIST 1 QL(6.6667 ea MISC LANCETS 30G MISC daily) THINLETS GP LANCETS 1 QL(6.6667 ea STERILANCE TL MISC 1 QL(6.6667 ea MISC daily) daily) TODAYS HEALTH SUPER THIN LANCETS 1 QL(6.6667 ea ADVANCED LANCING 1 MISC daily) DEVICE MISC SURE COMFORT QL(6.6667 ea 1 TODAYS HEALTH SUPER 1 QL(6.6667 ea LANCETS 18G MISC daily) THINLANCETS 30G MISC daily) SURE COMFORT QL(6.6667 ea 1 TODAYS HEALTH ULTRA 1 QL(6.6667 ea LANCETS 21G MISC daily) THINLANCETS 28G MISC daily) SURE COMFORT QL(6.6667 ea 1 TOPCARE LANCETS 1 QL(6.6667 ea LANCETS 23G MISC daily) MICRO-THIN 33G MISC daily) SURE COMFORT QL(6.6667 ea 1 TRAVEL LANCETS 30G 1 QL(6.6667 ea LANCETS 28G MISC daily) MISC daily) SURE COMFORT QL(6.6667 ea 1 TRAVEL LANCETS 1 QL(6.6667 ea LANCETS 30G MISC daily) ADVANCED 28G MISC daily) SURE COMFORT 1 TRUE METRIX CONTROL LANCING PEN MISC SOLUTION LEVEL 3 1 SURE-LANCE FLAT 1 QL(6.6667 ea SOLN LANCETS MISC daily) TRUEDRAW LANCING 1 SURE-LANCE LANCETS 1 QL(6.6667 ea DEVICE MISC 26G MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-LANCE THIN 1 QL(6.6667 ea 26G MISC daily) LANCETS 28G MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-LANCE ULTRA 1 QL(6.6667 ea 28G MISC daily) THIN LANCETS MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-PEN MISC 1 28G SUPER THIN MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-TOUCH LANCETS 1 QL(6.6667 ea 30G MISC daily) UNIVERSAL MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea SURELITE LANCETS 1 QL(6.6667 ea 30G ULTRA THIN MISC daily) MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea 33G MICRO THIN MISC daily)

Ambetter Formulary Updated September 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS LANCETS 1 QL(6.6667 ea UNILET SUPERLITE 1 QL(6.6667 ea 33G MISC daily) LANCET MISC daily) TRUEPLUS SAFETY QL(6.6667 ea 1 UNISTIK 3 GENTLE MISC 1 QL(6.6667 ea LANCETS 28G MISC daily) daily) ULTI-LANCE AUTOMATIC/ 1 UNISTIK PRO SAFETY 1 QL(6.6667 ea CLEAR TIP MISC LANCET 21G MISC daily) ULTILET CLASSIC 1 QL(6.6667 ea UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCETS MISC daily) LANCET 25G MISC daily) ULTILET LANCETS 33G QL(6.6667 ea 1 UNISTIK PRO SAFETY 1 QL(6.6667 ea MISC daily) LANCET 28G MISC daily) QL(6.6667 ea UNISTIK SAFETY QL(6.6667 ea ULTILET LANCETS MISC 1 1 daily) LANCETS 28G MISC daily) ULTILET SAFETY QL(6.6667 ea UNISTIK SAFETY 1 QL(6.6667 ea LANCETS 21G X 2.2MM 1 daily) LANCETS 30G MISC daily) MISC UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTILET SAFETY 1 QL(6.6667 ea LANCETS 21G MISC daily) LANCETS 23G MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA THIN LANCETS 1 QL(6.6667 ea LANCETS 23G MISC daily) 31G MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA-THIN II AUTO 1 QL(6.6667 ea LANCETS 28G MISC daily) LANCET MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA-THIN II LANCETS 1 QL(6.6667 ea LANCETS 30G MISC daily) 28G MISC daily) UNIVERSAL 1 LANCETS 1 QL(6.6667 ea ULTRA-THIN II LANCETS 1 QL(6.6667 ea THIN26G MISC daily) 30G MISC daily) UNIVERSAL 1 LANCETS 1 QL(6.6667 ea UNILET COMFORTOUCH 1 QL(6.6667 ea ULTRA THIN 30G MISC daily) LANCET MISC daily) UNIVERSAL 1 QL(6.6667 ea QL(6.6667 ea LANCETS/33G/MICRO- 1 daily) UNILET EXCELITE II MISC 1 daily) THIN MISC QL(6.6667 ea VALUE PLUS LANCETS QL(6.6667 ea UNILET EXCELITE MISC 1 1 daily) STANDARD 21G MISC daily) UNILET G.P. LANCET 1 QL(6.6667 ea VALUE PLUS LANCETS 1 QL(6.6667 ea MISC daily) SUPERTHIN 30G MISC daily) UNILET G.P. SUPERLITE 1 QL(6.6667 ea VALUE PLUS LANCETS 1 QL(6.6667 ea LANCET MISC daily) THIN 26G MISC daily) UNILET GP 28 ULTRA 1 QL(6.6667 ea VALUE PLUS LANCING 1 THIN MISC daily) DEVICE MISC VALUMARK LANCET QL(6.6667 ea UNILET LANCET MISC 1 QL(6.6667 ea 1 daily) SUPER THIN 30G MISC daily) UNILET LANCETS 1 QL(6.6667 ea VALUMARK LANCET 1 QL(6.6667 ea MICRO-THIN33G MISC daily) ULTRA THIN 28G MISC daily) UNILET LANCETS 1 QL(6.6667 ea VIDA MIA AUTOLET 1 SUPER-THIN30G MISC daily) LANCINGDEVICE MISC UNILET LANCETS 1 QL(6.6667 ea VIDA MIA UNILET QL(6.6667 ea ULTRA-THIN 28G MISC daily) LANCETS SUPER THIN 1 daily) 30G MISC

Ambetter Formulary Updated September 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNILET QL(6.6667 ea ADVOCATE INSULIN QL(5 ea daily); LANCETS ULTRA THIN 1 daily) SYRINGE/U- 1 RX/OTC 28G MISC 100/1ML/29GX1/2" MISC VIVAGUARD LANCETS 1 QL(6.6667 ea ADVOCATE INSULIN QL(5 ea daily); MISC daily) SYRINGE/U- 1 RX/OTC 100/1ML/30GX5/16" MISC VIVAGUARD LANCING 1 DEVICE MISC ADVOCATE INSULIN QL(5 ea daily) WALGREENS ADVANCED QL(6.6667 ea SYRINGE/U- 1 TRAVELLANCETS 28G 1 daily) 100/1ML/31GX5/16" MISC MISC ASSURE ID INSULIN QL(5 ea daily); WALGREENS COMFORT QL(6.6667 ea SAFETYSYRINGE/U- 1 RX/OTC ASSUREDLANCETS 1 daily) 100/0.5ML/29G X 1/2" MICRO THIN/33G MISC MISC WALGREENS COMFORT QL(6.6667 ea ASSURE ID INSULIN QL(5 ea daily); ASSUREDLANCETS 1 daily) SAFETYSYRINGE/U- 1 RX/OTC SUPER THIN/28G MISC 100/1ML/29G X 1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) WALGREENS LANCETS 1 QL(6.6667 ea MISC daily) ULTRAFINE II/0.3ML/31G 1 X 5/16" MISC WALGREENS THIN 1 QL(6.6667 ea LANCETS MISC daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.5ML/31G 1 WALGREENS ULTRA 1 QL(6.6667 ea X 5/16" MISC THIN LANCETS MISC daily) B-D INSULIN SYRINGE QL(5 ea daily) Parenteral Therapy Supplies ULTRAFINE II/1ML/31G X 1 ADVOCATE INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 1 RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) 100/0.3ML/29GX1/2" MISC ULTRAFINE/0.3ML/30G X 1 ADVOCATE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 1 RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) 100/0.3ML/30GX5/16" ULTRAFINE/0.5ML/30G X 1 MISC 1/2" MISC ADVOCATE INSULIN QL(5 ea daily) BD LO-DOSE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE MICROFINE 1 RX/OTC 100/0.3ML/31GX5/16" IV/0.5ML/28G X 1/2" MISC MISC BD AUTOSHIELD 29G X 1 QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); 3/16" MISC SYRINGE/U- 1 RX/OTC BD AUTOSHIELD 29G X QL(5 ea daily) 100/0.5ML/29GX1/2" MISC 1 5/16" MISC ADVOCATE INSULIN QL(5 ea daily); BD AUTOSHIELD DUO QL(5 ea daily) SYRINGE/U- 1 RX/OTC 1 100/0.5ML/30GX5/16" 30G X 5MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily); LUER-LOK/U-100/1ML 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 100/0.5ML/31GX5/16" BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE IV/U- 1 RX/OTC 100/0.5ML/28G X 1/2" MISC

Ambetter Formulary Updated September 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 1 ULTRAFINE/0.3ML/30G X 1 100/1ML/27G X 5/8" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 1 RX/OTC ULTRAFINE/0.3ML/31G X 1 100/1ML/28G X 1/2" MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE/U- 1 RX/OTC ULTRAFINE/0.5ML/30G X 1 100/0.5ML/28G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/31G X 1 MICROFINE/U- 1 5/16" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/1ML/30G X 1 MICROFINE/U- 1 RX/OTC 1/2" MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- 1 RX/OTC SAFETYGLIDE/1ML/29G X 1 RX/OTC 100/0.3ML/29G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE 1 QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); SLIP TIP/U-100/1ML MISC RX/OTC ULTRAFINE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/29G X 1/2" ULTRA-FINE/0.3ML/30G X 1 MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- 1 RX/OTC ULTRA-FINE/0.3ML/31G X 1 100/1ML/29G X 1/2" MISC 8MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- 1 ULTRA-FINE/0.5ML/30G X 1 100/1ML/31G X 5/16" 12.7MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); ULTRA-FINE/0.5ML/31G X 1 SYRINGE/0.3ML/29G X 1 RX/OTC 8MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC ULTRA-FINE/1/2 1 UNIT/0.3ML/31G X 8MM 12.7MM MISC MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/27G X 1 RX/OTC ULTRA-FINE/1ML/30G X 1 12.7MM MISC 12.7MM MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/29G X 1 RX/OTC ULTRA-FINE/1ML/31G X 1 12.7MM MISC 8MM MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G ULTRAFINE HALF- 1 UNIT/0.3ML/31G X 5/16" X 1" MISC MISC

Ambetter Formulary Updated September 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily) SYRINGE/DETACHABLE 1 INSULIN 1 NEEDLE/U-100/1ML/25G SYRINGE/1ML/31G X X 5/8" MISC 15/64" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily); SYRINGE/DETACHABLE 1 INSULIN 1 RX/OTC NEEDLE/U-100/1ML/26G SYSYRINGE/0.5ML/30G X X 1/2" MISC 5/16" MISC BD INSULIN SYRINGE/U- 1 QL(5 ea daily); BD VEO INSULIN QL(5 ea daily) 100/1ML/27G X 1/2" MISC RX/OTC SYRINGE ULTRA- 1 BD PEN QL(5 ea daily) FINE/1ML/31G X 6MM NEEDLE/MICRO/ULTRA- 1 MISC FINE/32G X 6MM MISC BD VEO INSULIN QL(5 ea daily) BD PEN QL(5 ea daily); SYRINGE ULTRA-FINE/U- 1 NEEDLE/MINI/ULTRA- 1 RX/OTC 100/1ML/31G X 15/64" FINE/31G X 5MM MISC MISC BD PEN NEEDLE/NANO QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) 2ND GEN/32G X 5/32" 1 RX/OTC SYRINGES/0.3ML/30G X 1 MISC 1/2" MISC BD PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLE/NANO/ULTRA- 1 RX/OTC SYRINGES/0.3ML/31G X 1 FINE/32G X 4MM MISC 5/16" MISC BD PEN QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) SYRINGES/0.5ML/30G X 1 NEEDLE/ORIGINAL/ULTR 1 A-FINE/29G X 12.7MM 1/2" MISC MISC CAREONE INSULIN QL(5 ea daily) BD PEN QL(5 ea daily); SYRINGES/0.5ML/31G X 1 NEEDLE/SHORT/ULTRA- 1 RX/OTC 5/16" MISC FINE/31G X 8MM MISC CAREONE INSULIN QL(5 ea daily) BD SAFETY-GLIDE QL(5 ea daily); SYRINGES/1ML/30G X 1 1/2" MISC INSULIN 1 RX/OTC SYRINGE/0.5ML/29G X CAREONE INSULIN QL(5 ea daily) 1/2" MISC SYRINGES/1ML/31GX5/16 1 BD SAFETY-LOK INSULIN QL(5 ea daily); " MISC SYRINGE/PERM 1 RX/OTC CLEVER CHOICE QL(5 ea daily); NEEDLE/UF/1ML/29G X COMFORT EZINSULIN 1 RX/OTC 1/2" MISC SYRINGE/0.3ML/29G X BD SAFETYGLIDE QL(5 ea daily); 1/2" MISC INSULIN 1 RX/OTC CLEVER CHOICE QL(5 ea daily) SYRINGE/0.3ML/29G X COMFORT EZINSULIN 1 1/2" MISC SYRINGE/0.3ML/30G X BD SAFETYGLIDE QL(5 ea daily) 1/2" MISC INSULIN 1 CLEVER CHOICE QL(5 ea daily); SYRINGE/0.3ML/31G X COMFORT EZINSULIN 1 RX/OTC 5/16" MISC SYRINGE/0.3ML/30G X 5/16" MISC

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGE/1ML/31G X 1 100/0.5ML/30G X 5/16" 5/16" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN 1 RX/OTC SYRINGE/U- 1 SYRINGE/0.3ML/29G X 100/0.5ML/31G X 5/16" 1/2" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN 1 RX/OTC SYRINGE/U-100/1ML/30G 1 SYRINGE/0.3ML/30G X X 1/2" MISC 5/16" SHORT MISC GLUCOPRO INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC INSULIN 1 RX/OTC X 5/16" MISC SYRINGE/0.5ML/28G X GLUCOPRO INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U-100/1ML/31G 1 GNP ULTRA COMFORT QL(5 ea daily); X 5/16" MISC INSULIN 1 RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X SYRINGE/0.3ML/29G X 1 RX/OTC 1/2" MISC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC SYRINGE/1ML/28G X 1/2" 5/16" MISC MISC GNP INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.3ML/31G X 1 INSULIN 1 RX/OTC 5/16" MISC SYRINGE/1ML/29G X 1/2" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X 1 RX/OTC HEALTHWISE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/U- 1 GNP INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" SYRINGE/0.5ML/30G X 1 RX/OTC MISC 5/16" MISC HEALTHWISE INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGE/0.5ML/31G X 1 100/0.5ML/30G X 5/16" 5/16" MISC MISC GNP INSULIN QL(5 ea daily); HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/1ML/28G X 1/2" 1 RX/OTC SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 1 RX/OTC GNP INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC

Ambetter Formulary Updated September 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/NEEDLE 1 RX/OTC X 5/16" MISC 0.3ML/30G X 5/16" MISC HM ULTICARE INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 1 SYRINGE/NEEDLE 1 MISC 0.3ML/31G X 5/16" MISC HM ULTICARE INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/NEEDLE 1 RX/OTC 100/0.3ML/31G X 5/16" 0.5ML/29G X 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC SYRINGE/0.3ML/29G X 1" 1 0.5ML/30G X 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 SYRINGE/0.3ML/29G X 1 RX/OTC 0.5ML/31G X 5/16" MISC 1/2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC 1ML/29G X 1/2" MISC 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC SYRINGE/0.3ML/31G X 1 1ML/30G X 5/16" MISC 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 SYRINGE/0.5ML/27G X 1 1ML/31G X 5/16" MISC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily); 100/0.3ML/29G X 1/2" 1 RX/OTC SYRINGE/0.5ML/28G X 1 RX/OTC MISC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" 1 RX/OTC SYRINGE/0.5ML/30G X 1 MISC 1/2" MISC INSULIN SYRINGE/U- 1 QL(5 ea daily); INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC INSULIN SYRINGE/U- QL(5 ea daily); 5/16" MISC 100/1ML/30G X 5/16" 1 RX/OTC INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 INSULIN SYRINGE/U- QL(5 ea daily) 5/16" MISC 100/1ML/30G X 5/16" 1 INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/27GX1/ 1 INSULIN QL(5 ea daily); 2" MISC SYRINGE/1ML/30G X 1 RX/OTC INSULIN QL(5 ea daily); 5/16" MISC SYRINGES/0.5ML/28GX1/ 1 RX/OTC 2" MISC

Ambetter Formulary Updated September 1, 2021

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

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

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

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

Ambetter Formulary Updated September 1, 2021

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

Ambetter Formulary Updated September 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IONOSOL-MB/DEXTROSE POTASSIUM 5% SOLN 3 MEQ/L-3 CHLORIDE/DEXTROSE/L MEQ/L-5 %-20 MEQ/L-22 ACTATED RINGERS MEQ/L-23 MEQ/L-25 1 SOLN 2.7 MEQ/L-5 %-24 MEQ/L, 3 MEQ/L-3 MEQ/L-28 MEQ/L-129 1 MMOLE/L-5 %-20 MEQ/L- MEQ/L-130 MEQ/L, 3 22 MEQ/L-23 MEQ/L-25 MEQ/L-5 %-24 MEQ/L-28 MEQ/L MEQ/L-130 MEQ/L-149 MEQ/L ISOLYTE-P/DEXTROSE 1 5% SOLN POTASSIUM CHLORIDE/SODIUM ISOLYTE-S SOLN 1 CHLORIDE SOLN 0.45 %- 1 20 MEQ/L (Use potassium KCL 0.3%/D5W/NACL 1 0.9% SOLN chloride in nacl) lactated ringer's soln 109 ringer's soln 1 meq/l-3 meq/l-4 meq/l-28 meq/l-130 meq/l, 20 Fluoride mg/100ml-30 mg/100ml- sodium fluoride chew 0.25 0 QL(1 ea daily) 310 mg/100ml-600 1 mg, 0.5 mg, 1 mg, 2.2 mg mg/100ml, 3 meq/l-130 meq/l-4 meq/l-28 meq/l-109 Magnesium meq/l, 3 meq/l-4 meq/l-28 magnesium sulfate soln ij 1 meq/l-109 meq/l-130 meq/l 50 % NORMOSOL-M IN D5W 1 Phosphate SOLN potassium phosphates soln 1 NORMOSOL-M/D5W 1 224 mg/ml-236 mg/ml SOLN Potassium NORMOSOL-R SOLN 1 K-TAB TBCR 10 MEQ (Use NF potassium chloride) parenteral electrolytes conc 1 K-TAB TBCR 8 MEQ (Use 1 potassium chloride) PLASMA-LYTE A SOLN 1 potassium acetate soln 1 PLASMA-LYTE-148 SOLN 1 potassium bicarbonate tbef 1 potassium chloride in dextrose & sodium chloride 1 potassium chloride cpcr or 1 soln 10 meq, 8 meq potassium chloride in 1 potassium chloride dextrose soln microencapsulated crystals 1 potassium chloride in nacl er tbcr 15 meq, 20 meq, 10 soln 0.45 %-20 meq/l, 0.9 meq %-40 meq/l, 0.15 %-0.9 %, 1 potassium chloride pack or 1 PA 0.9 %-20 meq/l, 20 meq/l- 20 meq 0.9 % POTASSIUM CHLORIDE SOLN IV 10 MEQ/100ML, 1 10 MEQ/50ML

Ambetter Formulary Updated September 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride soln iv CELLCEPT CAPS 250 MG 10 meq/50ml, 20 1 (Use mycophenolate NF meq/50ml, 2 meq/ml mofetil) potassium chloride soln or 1 CELLCEPT TABS 500 MG 10 % (Use mycophenolate NF mofetil) potassium chloride tbcr or 1 10 meq, 8 meq cyclosporine caps 1 Sodium cyclosporine modified (for 1 sodium chloride soln ij 2.5 1 microemulsion) caps meq/ml cyclosporine modified (for 1 sodium chloride soln iv 3 microemulsion) soln %, 5 %, 0.9 %, 4 meq/ml, 1 0.45 % cyclosporine soln 1

MISCELLANEOUS THERAPEUTIC CLASSES everolimus 4 PA; QL(20 ea (immunosuppressant) tabs daily); SP Chelating Agents IMURAN TABS (Use NF CUPRIMINE CAPS (Use NF PA azathioprine) penicillamine) mycophenolate mofetil 1 DEPEN TITRATABS TABS NF QL(8 ea daily) caps or 250 mg (Use penicillamine) mycophenolate mofetil tabs 1 penicillamine caps 1 PA or 500 mg mycophenolate sodium 1 penicillamine tabs 1 QL(8 ea daily) tbec MYFORTIC TBEC (Use NF SYPRINE CAPS (Use NF PA; QL(8 ea mycophenolate sodium) trientine hcl) daily); SP NEORAL CAPS (Use PA; QL(8 ea trientine hcl caps 4 cyclosporine modified (for NF daily); SP microemulsion)) Immunomodulators NEORAL SOLN (Use REVLIMID CAPS 10 MG, PA; QL(1 ea cyclosporine modified (for NF 15 MG, 2.5 MG, 25 MG, 5 4 daily); SP microemulsion)) MG NULOJIX SOLR 4 PA; SP REVLIMID CAPS 20 MG 4 PA; PROGRAF CAPS OR 0.5 PA; QL(3 ea MG, 1 MG, 5 MG (Use NF THALOMID CAPS 4 daily); SP tacrolimus) Immunosuppressive Agents PROGRAF PACK OR 0.2 2 PA MG, 1 MG ATGAM INJ 4 PA; SP PROGRAF SOLN IV 5 2 MG/ML AZASAN TABS 3 RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use NF AZATHIOPRINE SOLR IJ 1 100 MG sirolimus) SANDIMMUNE CAPS OR azathioprine tabs or 50 mg 1 100 MG, 25 MG (Use NF cyclosporine)

Ambetter Formulary Updated September 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SANDIMMUNE SOLN IV PERIDEX SOLN (Use 50 MG/ML (Use NF chlorhexidine gluconate NF cyclosporine) (mouth-throat)) SIMULECT SOLR 3 Dental Products stannous fluoride conc 0 RX/OTC sirolimus tabs 0.5 mg, 1 1 mg, 2 mg Steroids - Mouth/Throat/Dental tacrolimus caps 1 triamcinolone acetonide 1 (mouth) pste THYMOGLOBULIN SOLR 4 PA; SP Throat Products - Misc. ZORTRESS TABS 0.25 PA; QL(20 ea cevimeline hcl caps 1 MG, 0.5 MG, 0.75 MG (Use NF daily); SP everolimus EVOXAC CAPS (Use NF (immunosuppressant)) cevimeline hcl) Irrigation Solutions pilocarpine hcl (oral) tabs 1 irrigation solutions, 1 physiological soln SALAGEN TABS (Use NF pilocarpine hcl (oral)) lactated ringer's (irrigation) 1 soln MULTIVITAMINS ringer's irrigation soln 1 Prenatal Vitamins water for irrigation, sterile 1 CLASSIC PRENATAL 2 QL(1 ea daily) soln TABS Potassium Removing Agents CVS PRENATAL TABS 2 QL(1 ea daily) sodium polystyrene 1 sulfonate powd EQL PRENATAL 2 QL(1 ea daily) FORMULA TABS sodium polystyrene 1 sulfonate susp GNP PRENATAL TABS 2 QL(1 ea daily) MOUTH/THROAT/DENTAL AGENTS GOODSENSE PRENATAL 2 QL(1 ea daily) VITAMINS TABS Anesthetics Topical Oral HM PRENATAL TABS 2 QL(1 ea daily) lidocaine hcl (mouth-throat) 1 QL(4 ml daily) soln 2 % KP PRENATAL 2 QL(1 ea daily) lidocaine hcl (mouth-throat) 1 MULTIVITAMINS TABS soln 4 % QL(1 ea daily); M-NATAL PLUS TABS 2 Anti-infectives - Throat RX/OTC QL(1 ea daily) clotrimazole troc 1 MULTI PRENATAL TABS 2 NEONATAL COMPLETE QL(1 ea daily); nystatin (mouth-throat) 1 susp TABS 0.2 MG-1.84 MG-2 RX/OTC MG-2 MG-3 MG-5 MG-9.2 Antiseptics - Mouth/Throat MG-10 MCG-10 MG-12 2 chlorhexidine gluconate 1 MCG-20 MG-25 MG-27 (mouth-throat) soln MG-120 MG-200 MG-1000 MCG-1200 MCG DEBACTEROL SOLN 2

Ambetter Formulary Updated September 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PRENATAL TABS 0.8 MG- QL(1 ea daily) NEONATAL PLUS TABS 2 RX/OTC 1.5 MG-1.7 MG-2.6 MG-4 MCG-11 UNIT-18 MG-25 NEONATAL VITAMIN 2 QL(1 ea daily) TABS MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT, QL(1 ea daily); NIVA-PLUS TABS 2 0.8 MG-1.5 MG-1.7 MG-2.6 RX/OTC MG-4 MCG-18 MG-27 MG- QL(1 ea daily); O-CAL FA TABS 2 100 MG-263 MG-400 RX/OTC UNIT-4000 UNIT-25 MG-11 ONE VITE WOMENS QL(1 ea daily); UNIT, 0.8 MG-1.7 MG-1.8 PRENATALVITAMIN PLUS 2 RX/OTC MG-2.6 MG-8 MCG-20 TABS MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 ONE VITE WOMENS 2 QL(1 ea daily) PRENATALVITAMIN TABS UNIT-4000 UNIT, 1.5 MG- 1.7 MG-2.6 MG-4 MCG-5 PRENATAL LOW IRON QL(1 ea daily) 2 MG-10 MCG-18 MG-25 2 TABS MG-27 MG-100 MG-200 PRENATAL 2 QL(1 ea daily) MG-800 MCG-1200 MCG, MULTIVITAMIN TABS 1.7 MG-1.8 MG-2.6 MG-8 MCG-20 MG-25 MG-28 PRENATAL ONE DAILY 2 QL(1 ea daily) TABS MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG- 4000 UNIT, 1.7 MG-1.8 MG-2.6 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-800 MCG- 4000 UNIT-400 UNIT-200 MG, 1.7 MG-1.84 MG-2.6 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-160 MG-200 MG-400 UNIT-800 MCG-4000 UNIT PRENATAL TABS 1 MG- QL(1 ea daily); 1.84 MG-2 MG-3 MG-10 RX/OTC MCG-10 MG-10 MG-12 2 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1200 MCG PRENATAL VITAMIN & 2 QL(1 ea daily) MINERAL TABS PRENATAL VITAMIN 2 QL(1 ea daily) TABS PRENATAL 2 QL(1 ea daily) VITAMIN/IRON TABS PRENATAL VITAMINS 2 QL(1 ea daily); PLUS LOW IRON TABS RX/OTC PRENATAL VITAMINS 2 QL(1 ea daily) TABS PRENATRIX TABS 2 QL(1 ea daily); RX/OTC Ambetter Formulary Updated September 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Use QL(4 ea daily) PRENATRYL TABS 2 QL(1 ea daily); SKELAXIN TABS ( NF RX/OTC metaxalone) SOMA TABS (Use PREPLUS TABS 2 QL(1 ea daily); NF RX/OTC carisoprodol) PX PRENATAL 2 QL(1 ea daily) tizanidine hcl caps 1 MULTIVITAMINS TABS QC PRENATAL TABS 2 QL(1 ea daily) tizanidine hcl tabs 1 RA PRENATAL QL(1 ea daily) ZANAFLEX CAPS (Use NF FORMULA/FOLICACID 2 tizanidine hcl) TABS ZANAFLEX TABS (Use NF tizanidine hcl) RA PRENATAL TABS 2 QL(1 ea daily) Direct Muscle Relaxants RIGHT STEP PRENATAL QL(1 ea daily) 2 DANTRIUM CAPS (Use NF QL(4 ea daily) TABS dantrolene sodium) SM PRENATAL VITAMINS 2 QL(1 ea daily) dantrolene sodium caps or QL(4 ea daily) TABS 1 100 mg, 25 mg, 50 mg THERANATAL CORE 2 QL(1 ea daily); NUTRITION TABS RX/OTC NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus TRICARE TABS 2 QL(1 ea daily); RX/OTC Nasal Antiallergy VITATHELY/GINGER 2 QL(1 ea daily); azelastine hcl soln 1 TABS RX/OTC VOL-PLUS TABS 2 QL(1 ea daily); olopatadine hcl (nasal) soln 1 RX/OTC PATANASE SOLN (Use WESTAB PLUS TABS 2 QL(1 ea daily); NF RX/OTC olopatadine hcl (nasal)) MUSCULOSKELETAL THERAPY AGENTS - Nasal Anticholinergics Drugs to Treat Spasms ipratropium bromide (nasal) 1 QL(1 ml daily) soln 0.03 % Central Muscle Relaxants ipratropium bromide (nasal) 1 baclofen tabs or 10 mg, 20 1 soln 0.06 % mg Nasal Steroids carisoprodol tabs 1 budesonide (nasal) susp 1 QL(6 ea daily) chlorzoxazone tabs 500 mg 1 Limit 2 inhalers FLONASE ALLERGY per cyclobenzaprine hcl tabs 1 QL(3 ea daily) RELIEF CHILDRENS 10 mg, 5 mg NF month;QL(32 SUSP (Use fluticasone ml per 30 days QL(4 ea daily) propionate (nasal)) metaxalone tabs 800 mg 1 retail); RX/OTC Limit 2 inhalers methocarbamol tabs or 500 1 FLONASE ALLERGY mg, 750 mg per RELIEF SUSP (Use NF month;QL(32 orphenadrine citrate tb12 QL(2 ea daily) fluticasone propionate 1 (nasal)) ml per 30 days or 100 mg retail); RX/OTC ROBAXIN-750 TABS (Use 1 rtl pack lmt NF flunisolide (nasal) soln 1 methocarbamol) per fill, Ambetter Formulary Updated September 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers CLINIMIX 5%/DEXTROSE 3 per 25% SOLN fluticasone propionate 1 month;QL(32 (nasal) susp CLINIMIX E ml per 30 days 5%/DEXTROSE 20% 3 retail); RX/OTC SOLN mometasone furoate 1 PA; QL(1.14 (nasal) susp gm daily) OPHTHALMIC AGENTS - Drugs to Treat the Eye NASACORT ALLERGY Artificial Tears and Lubricants 24HR AERO (Use NF triamcinolone acetonide LACRISERT INST 3 (nasal)) NASACORT ALLERGY Beta-blockers - Ophthalmic 24HR CHILDRENS AERO NF betaxolol hcl (ophth) soln 1 (Use triamcinolone acetonide (nasal)) carteolol hcl (ophth) soln 1 NASONEX SUSP (Use PA; QL(1.14 mometasone furoate NF gm daily) COMBIGAN SOLN 2 (nasal)) COSOPT SOLN (Use triamcinolone acetonide 1 (nasal) aero hcl-timolol NF maleate) NEUROMUSCULAR AGENTS - Drugs to dorzolamide hcl-timolol Relax/Paralyze Muscles maleate soln 0.5 %-2 %, 20 ALS Agents mg/ml-5 mg/ml, 22.3 1 mg/ml-6.8 mg/ml, 6.8 RILUTEK TABS (Use NF riluzole) mg/ml-22.3 mg/ml riluzole tabs 3 levobunolol hcl soln 1 timolol maleate (ophth) solg 1 Neuromuscular Blocking Agent - Neurotoxins 0.25 %, 0.5 % PA BOTOX SOLR 3 timolol maleate (ophth) soln 1 0.25 %, 0.5 % DYSPORT SOLR 3 PA TIMOPTIC SOLN (Use NF timolol maleate (ophth)) XEOMIN SOLR 3 PA TIMOPTIC-XE SOLG (Use NF timolol maleate (ophth)) NUTRIENTS Cycloplegic Mydriatics MYDRIACYL SOLN (Use NF CLINIMIX tropicamide) 4.25%/DEXTROSE 10% 3 1 SOLN tropicamide soln CLINIMIX Miotics 4.25%/DEXTROSE 25% 3 ISOPTO CARPINE SOLN NF SOLN (Use pilocarpine hcl) CLINIMIX PHOSPHOLINE IODIDE 3 4.25%/DEXTROSE 5% 3 SOLR SOLN

Ambetter Formulary Updated September 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pilocarpine hcl soln 1 ofloxacin (ophth) soln 1

Ophthalmic Adrenergic Agents polymyxin b-trimethoprim 1 soln ALPHAGAN P SOLN 0.15 % (Use brimonidine NF POLYTRIM SOLN (Use NF tartrate) polymyxin b-trimethoprim) sulfacetamide sodium 1 apraclonidine hcl soln 1 (ophth) soln brimonidine tartrate soln 1 tobramycin (ophth) soln 1

IOPIDINE SOLN 3 TOBREX SOLN (Use NF tobramycin (ophth)) PA SIMBRINZA SUSP 3 trifluridine soln 1

Ophthalmic Anti-infectives VIGAMOX SOLN (Use NF moxifloxacin hcl (ophth)) AZASITE SOLN 3 ZIRGAN GEL 2 bacitracin (ophthalmic) oint 3 ZYMAXID SOLN (Use NF BLEPH-10 SOLN (Use (ophth)) sulfacetamide sodium NF Ophthalmic Immunomodulators (ophth)) RESTASIS EMUL 2 PA CILOXAN SOLN (Use NF ciprofloxacin hcl (ophth)) RESTASIS MULTIDOSE 2 PA ciprofloxacin hcl (ophth) 1 EMUL soln Ophthalmic Local Anesthetics erythromycin (ophth) oint 1 ALCAINE SOLN (Use NF proparacaine hcl) gatifloxacin (ophth) soln 1 proparacaine hcl soln 1 gentamicin sulfate (ophth) 1 oint Ophthalmic Nerve Growth Factors gentamicin sulfate (ophth) 1 OXERVATE SOLN 4 PA soln KLARITY-A SOLN 3 Ophthalmic Steroids ALREX SUSP 3 PA levofloxacin (ophth) soln 1 dexamethasone sodium 1 moxifloxacin hcl (ophth) 1 phosphate (ophth) soln soln DUREZOL EMUL 3 PA NATACYN SUSP 2 fluorometholone (ophth) 1 neomycin-bacitracin zn- 1 susp polymyxin oint FML FORTE SUSP 3 PA OCUFLOX SOLN (Use NF ofloxacin (ophth))

Ambetter Formulary Updated September 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FML LIQUIFILM SUSP ACULAR LS SOLN (Use (Use fluorometholone NF ketorolac tromethamine NF (ophth)) (ophth)) FML OINT 3 PA ACULAR SOLN (Use ketorolac tromethamine NF (ophth)) LOTEMAX GEL (Use 3 PA loteprednol etabonate) ALOCRIL SOLN 3 PA LOTEMAX OINT 3 PA ALOMIDE SOLN 3 PA LOTEMAX SUSP (Use NF PA loteprednol etabonate) azelastine hcl (ophth) soln 1 loteprednol etabonate gel 1 PA bepotastine besilate soln 3 PA loteprednol etabonate susp 1 PA BEPREVE SOLN (Use 3 PA bepotastine besilate) MAXIDEX SUSP 3 PA bromfenac sodium (ophth) 1 MAXITROL OINT (Use soln neomycin-polymy- NF cromolyn sodium (ophth) 1 dexameth) soln MAXITROL SUSP (Use CYSTARAN SOLN 2 PA; QL(2.143 neomycin-polymy- NF ml daily) dexameth) diclofenac sodium (ophth) 1 neomycin-polymy- 1 soln dexameth oint dorzolamide hcl soln 1 neomycin-polymy- 1 dexameth susp epinastine hcl (ophth) soln 1 neomycin-polymyxin-hc 1 (ophth) susp flurbiprofen sodium soln 1 PRED FORTE SUSP (Use ST; QL(0.2 ml prednisolone acetate NF ILEVRO SUSP 3 (ophth)) daily) ketorolac tromethamine 3 PA 1 PRED MILD SUSP (ophth) soln prednisolone acetate 1 ketotifen fumarate (ophth) 1 (ophth) susp soln PREDNISOLONE 1 LASTACAFT SOLN 3 PA ACETATE P-F SUSP ST; QL(0.2 ml PREDNISOLONE SODIUM NEVANAC SUSP 3 PHOSPHATE SOLN OP 1 3 daily) % olopatadine hcl soln 1 RX/OTC TOBRADEX SUSP (Use tobramycin- NF PATADAY SOLN (Use NF RX/OTC dexamethasone) olopatadine hcl) PATANOL SOLN (Use RX/OTC tobramycin- 1 NF dexamethasone susp olopatadine hcl) Ophthalmics - Misc.

Ambetter Formulary Updated September 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSOPT SOLN (Use NF CORTISPORIN-TC SUSP 3 dorzolamide hcl) neomycin-polymyxin-hc ZADITOR SOLN (Use NF 1 ketotifen fumarate (ophth)) (otic) soln PA neomycin-polymyxin-hc 1 ZERVIATE SOLN 3 (otic) susp Prostaglandins - Ophthalmic OTOVEL SOLN (Use PA; QL(0.5 ea ciprofloxacin-fluocinolone 3 daily) bimatoprost soln 3 acetonide) latanoprost soln 1 Otic Steroids DERMOTIC OIL (Use LUMIGAN SOLN 3 ST fluocinolone acetonide NF (otic)) TRAVATAN Z SOLN (Use NF fluocinolone acetonide 1 travoprost) (otic) oil travoprost soln 1 hydrocortisone w/acetic 1 acid soln XALATAN SOLN (Use NF latanoprost) PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune ZIOPTAN SOLN 2 System Immune Serums OTIC AGENTS - Drugs to Treat the Ear CUVITRU SOLN 1 PA; SP Otic Agents - Miscellaneous GM/5ML, 10 GM/50ML, 2 4 GM/10ML, 4 GM/20ML acetic acid (otic) soln 1 GAMMAGARD LIQUID PA; SP Otic Anti-infectives SOLN 1 GM/10ML, 10 4 GM/100ML, 2.5 GM/25ML, CETRAXAL SOLN (Use 1 20 GM/200ML, 5 GM/50ML ciprofloxacin hcl (otic)) GAMMAGARD LIQUID 4 PA ciprofloxacin hcl (otic) soln 1 SOLN 30 GM/300ML GAMMAGARD S/D IGA PA; SP FLOXIN OTIC SOLN (Use NF LESS THAN 1MCG/ML 4 ofloxacin (otic)) SOLR ofloxacin (otic) soln 1 GAMMAKED SOLN 4 PA; SP Otic Combinations GAMUNEX-C SOLN 4 PA; SP CIPRO HC SUSP 3 HIZENTRA SOLN 1 PA; SP CIPRODEX SUSP (Use PA GM/5ML, 10 GM/50ML, 2 4 ciprofloxacin- NF GM/10ML, 4 GM/20ML dexamethasone) Passive Immunizing Agents - Combinations ciprofloxacin- 1 PA PA dexamethasone susp HYQVIA KIT 4 ciprofloxacin-fluocinolone 1 PA; QL(0.5 ea acetonide soln daily) PENICILLINS - Drugs to Treat Bacterial Infections COLY-MYCIN S SUSP 3 Aminopenicillins

Ambetter Formulary Updated September 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amoxicillin caps 1 AUGMENTIN ES-600 SUSR (Use amoxicillin & NF amoxicillin chew 1 pot clavulanate) AUGMENTIN SUSR 62.5 amoxicillin susr 1 MG/5ML-250 MG/5ML NF (Use amoxicillin & pot amoxicillin tabs 1 clavulanate) AUGMENTIN TABS 125 ampicillin caps 1 MG-500 MG (Use NF amoxicillin & pot ampicillin sodium solr ij 1 1 clavulanate) gm piperacillin sodium- 1 ampicillin sodium solr iv 10 1 tazobactam sodium solr gm UNASYN BULK PACK Natural Penicillins SOLR (Use ampicillin & NF PENICILLIN G sulbactam sodium) POTASSIUM IN ISO- UNASYN SOLR (Use OSMOTIC DEXTROSE 1 ampicillin & sulbactam NF SOLN 40000 UNIT/ML, sodium) 60000 UNIT/ML ZOSYN SOLR 0.25 GM-2 GM, 0.375 GM-3 GM, 0.5 penicillin g potassium solr 1 5000000 unit GM-4 GM, 2 GM-0.25 GM, 3 GM-0.375 GM, 4 GM-0.5 NF PENICILLIN G PROCAINE 3 SUSP GM, 4.5 GM-36 GM (Use piperacillin sodium- penicillin g sodium solr 3 tazobactam sodium) Penicillinase-Resistant Penicillins penicillin v potassium solr 1 dicloxacillin sodium caps 1 penicillin v potassium tabs 1 nafcillin sodium solr ij 1 gm 1 Penicillin Combinations nafcillin sodium solr iv 10 amoxicillin & pot 1 1 clavulanate chew gm oxacillin sodium solr ij 1 gm 1 amoxicillin & pot 1 clavulanate susr oxacillin sodium solr iv 10 1 amoxicillin & pot 1 gm clavulanate tabs PROGESTINS - Hormone Replacement/Modifying amoxicillin & pot 1 clavulanate tb12 Drugs ampicillin & sulbactam Progestins sodium solr ij 0.5 gm-1 gm, 1 AYGESTIN TABS (Use NF 1 gm-0.5 gm, 1 gm-2 gm, 2 norethindrone acetate) gm-1 gm medroxyprogesterone 1 ampicillin & sulbactam acetate tabs sodium solr iv 10 gm-5 gm, 1 MEGACE ES SUSP (Use PA 5 gm-10 gm megestrol acetate NF (appetite))

Ambetter Formulary Updated September 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits megestrol acetate 1 PA galantamine hydrobromide 1 QL(2 ea daily) (appetite) susp tabs 12 mg, 4 mg, 8 mg norethindrone acetate tabs 0 memantine hcl tabs 1 progesterone caps or 100 1 memantine hcl tabs 10 mg 1 QL(2 ea daily) mg, 200 mg QL(1 ea daily) PROMETRIUM CAPS (Use NF memantine hcl tabs 5 mg 1 progesterone) PROVERA TABS (Use NAMENDA TABS 10 MG NF QL(2 ea daily) medroxyprogesterone NF (Use memantine hcl) acetate) NAMENDA TABS 5 MG NF QL(1 ea daily) (Use memantine hcl) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and NAMENDA TITRATION Emotional Conditions PAK TABS (Use NF memantine hcl) Agents for Chemical Dependency RAZADYNE ER CP24 (Use NF QL(1 ea daily) acamprosate calcium tbec 1 galantamine hydrobromide) RAZADYNE TABS (Use NF QL(2 ea daily) ANTABUSE TABS (Use NF galantamine hydrobromide) disulfiram) rivastigmine tartrate caps 1 disulfiram tabs 1 PA; QL(224 ea Combination Psychotherapeutics LUCEMYRA TABS 3 per 14 days perphenazine-amitriptyline 1 QL(4 ea daily) retail) tabs Anti-Cataplectic Agents Fibromyalgia Agents PA; QL(2 ea XYREM SOLN 4 PA; QL(18 ml SAVELLA TABS 2 daily); SP daily) Antidementia Agents SAVELLA TITRATION 2 PA PACK MISC ARICEPT TABS 10 MG QL(2 ea daily) (Use donepezil NF Movement Disorder Drug Therapy hydrochloride) PA; QL(4 ea AUSTEDO TABS 4 ARICEPT TABS 5 MG QL(1 ea daily) daily) (Use donepezil NF PA; QL(3 ea tetrabenazine tabs 4 hydrochloride) daily); SP donepezil hydrochloride QL(2 ea daily) 1 XENAZINE TABS (Use NF PA; QL(3 ea tabs 10 mg tetrabenazine) daily); SP donepezil hydrochloride 1 QL(1 ea daily) Multiple Sclerosis Agents tabs 5 mg AMPYRA TB12 (Use NF PA; QL(2 ea donepezil hydrochloride 1 QL(2 ea daily) dalfampridine) daily); SP tbdp 10 mg AUBAGIO TABS 4 PA donepezil hydrochloride 1 QL(1 ea daily) tbdp 5 mg PA; QL(0.0714 AVONEX PEN AJKT 4 galantamine hydrobromide 1 QL(1 ea daily) ml daily); SP cp24 16 mg, 24 mg, 8 mg PA; QL(0.0714 AVONEX PSKT 4 galantamine hydrobromide 1 QL(6 ml daily) ml daily); SP soln 4 mg/ml Ambetter Formulary Updated September 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECFIDERA CPDR (Use PA BETASERON KIT 4 PA; QL(0.5 ea NF daily); SP dimethyl fumarate) COPAXONE SOSY 20 PA; QL(1 ml TECFIDERA STARTER PA MG/ML (Use glatiramer 3 daily); SP PACK MISC (Use dimethyl NF acetate) fumarate) PA; QL(0.429 COPAXONE SOSY 40 TYSABRI CONC 4 PA; QL(0.536 MG/ML (Use glatiramer 3 ml daily); SP ml daily); SP acetate) Postherpetic Neuralgia (PHN)/Neuropathic Pain PA; QL(2 ea dalfampridine tb12 4 LYRICA CR TB24 165 MG, PA; QL(1 ea daily); SP 82.5 MG (Use pregabalin 3 daily) dimethyl fumarate cpdr 4 PA (once-daily)) LYRICA CR TB24 330 MG PA; QL(2 ea dimethyl fumarate misc 4 PA (Use pregabalin (once- 3 daily) daily)) PA; QL(0.5 ea EXTAVIA KIT 4 daily); SP pregabalin (once-daily) 3 PA; QL(1 ea tb24 165 mg, 82.5 mg daily) GILENYA CAPS 4 PA pregabalin (once-daily) 3 PA; QL(2 ea tb24 330 mg daily) glatiramer acetate sosy 20 3 PA; QL(1 ml mg/ml daily); SP Premenstrual Dysphoric Disorder (PMDD) Agents glatiramer acetate sosy 40 PA; QL(0.429 3 fluoxetine hcl (pmdd) caps 1 QL(1 ea daily) mg/ml ml daily); SP 10 mg PA MAVENCLAD TBPK 4 fluoxetine hcl (pmdd) caps 1 QL(3 ea daily) 20 mg MAYZENT STARTER 4 PA Pseudobulbar Affect (PBA) Agents PACK TBPK NUEDEXTA CAPS 3 PA MAYZENT TABS 4 PA Psychotherapeutic and Neurological Agents - OCREVUS SOLN 4 PA ergoloid mesylates tabs 1 PA; QL(0.0357 PLEGRIDY SOPN SC 4 ml daily) pimozide tabs 1 PLEGRIDY SOSY SC 4 PA Restless Leg Syndrome (RLS) Agents PLEGRIDY STARTER PA 4 HORIZANT TBCR 3 PA; QL(2 ea PACK SOPN daily) PLEGRIDY STARTER 4 PA; QL(0.0357 Smoking Deterrents PACK SOSY ml daily) APO-VARENICLINE TABS 0 QL(2 ea daily) REBIF REBIDOSE SOAJ 4 PA; QL(0.214 ml daily); SP bupropion hcl (smoking 0 QL(2 ea daily) REBIF REBIDOSE 4 PA; SP deterrent) tb12 TITRATIONPACK SOAJ CHANTIX CONTINUING 0 QL(2 ea daily) REBIF SOSY 4 PA; QL(0.214 MONTHPAK TABS ml daily); SP CHANTIX STARTING 0 REBIF TITRATION PACK 4 PA; SP MONTH PAK TABS SOSY CHANTIX TABS 0 QL(2 ea daily)

Ambetter Formulary Updated September 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICODERM CQ PT24 (Use NF QL(1 ea daily) ORKAMBI TABS 100 MG- 4 PA; QL(4 ea nicotine) 125 MG, 125 MG-200 MG daily) NICORETTE GUM (Use NF PULMOZYME SOLN 4 PA; QL(2.5 ml nicotine polacrilex) daily); SP NICORETTE LOZG (Use NF TRIKAFTA TBPK 50 MG- 4 PA; QL(3 ea nicotine polacrilex) 100 MG daily) NICORETTE MINI LOZG NF Pulmonary Fibrosis Agents (Use nicotine polacrilex) OFEV CAPS 4 PA; QL(2 ea NICORETTE STARTER daily) KIT GUM (Use nicotine NF polacrilex) SULFONAMIDES - Drugs to Treat Bacterial Infections nicotine polacrilex gum 0 Sulfonamides nicotine polacrilex lozg 0 SULFADIAZINE TABS 1 nicotine pt24 0 QL(1 ea daily) - Drugs to Treat Bacterial Infections NICOTINE TRANSDERMAL SYSTEM 0 Glycylcyclines KIT tigecycline solr 1 NICOTROL INHALER 0 INHA TYGACIL SOLR (Use NF tigecycline) NICOTROL NS SOLN 0 Tetracyclines Transthyretin Amyloidosis Agents hcl tabs 1 TEGSEDI SOSY 4 PA doxycycline (monohydrate) 1 QL(2 ea daily) RESPIRATORY AGENTS - MISC. - Drugs to caps 50 mg, 100 mg Treat Lung Conditions doxycycline (monohydrate) 1 caps 75 mg Alpha-Proteinase Inhibitor (Human) doxycycline (monohydrate) 1 QL(2 ea daily) ARALAST NP SOLR 1000 4 PA; SP tabs 100 mg MG doxycycline (monohydrate) 1 ARALAST NP SOLR 500 4 PA tabs 50 mg MG doxycycline hyclate caps or 1 QL(2 ea daily) PROLASTIN-C SOLN 1000 4 PA; 50 mg, 100 mg MG/20ML doxycycline hyclate solr iv 1 PROLASTIN-C SOLR 1000 4 PA; SP 100 mg MG doxycycline hyclate tabs or 1 QL(2 ea daily) ZEMAIRA SOLR 4 PA; SP 100 mg, 20 mg MINOCIN CAPS OR 50 NF QL(3 ea daily) Cystic Fibrosis Agents MG (Use minocycline hcl) PA; QL(2 ea KALYDECO TABS 150 MG 4 minocycline hcl caps 100 1 QL(3 ea daily) daily); SP mg, 50 mg, 75 mg ORKAMBI PACK 100 MG- PA; QL(2 ea 4 minocycline hcl tabs 100 1 QL(3 ea daily) 125 MG, 150 MG-188 MG daily) mg, 50 mg, 75 mg

Ambetter Formulary Updated September 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TARGADOX TABS (Use NF TRIOSTAT SOLN (Use NF doxycycline hyclate) liothyronine sodium) hcl caps 1 QL(8 ea daily) WESTHROID TABS 2

VIBRAMYCIN CAPS 100 QL(2 ea daily) WP THYROID TABS 2 MG (Use doxycycline NF hyclate) TOXOIDS XIMINO CP24 135 MG, 45 MG, 90 MG (Use NF Toxoid Combinations minocycline hcl) ADACEL SUSP 0 THYROID AGENTS - Drugs to Regulate Thyroid Hormones BOOSTRIX SUSP 0 Antithyroid Agents DAPTACEL SUSP 0 methimazole tabs 1 DIPHTHERIA/TETANUS propylthiouracil tabs 1 TOXOIDS ADSORBED 0 PEDIATRIC SUSP TAPAZOLE TABS (Use NF methimazole) INFANRIX SUSP 0 Thyroid Hormones KINRIX SUSP 0 ARMOUR THYROID TABS QL(1 ea daily) 120 MG, 15 MG, 30 MG, 2 PEDIARIX SUSP 0 60 MG, 90 MG (Use thyroid) PENTACEL SUSR 0 ARMOUR THYROID TABS 2 QL(1 ea daily) 180 MG, 240 MG, 300 MG QUADRACEL SUSP 0 CYTOMEL TABS (Use NF liothyronine sodium) TDVAX SUSP 0 levothyroxine sodium tabs or 300 mcg, 100 mcg, 112 TENIVAC INJ 0 mcg, 125 mcg, 137 mcg, 1 TETANUS/DIPHTHERIA 150 mcg, 175 mcg, 200 TOXOIDS-ADSORBED 0 mcg, 25 mcg, 50 mcg, 75 ADULT SUSP mcg, 88 mcg ULCER DRUGS - Drugs to Treat Bowel, Intestine liothyronine sodium soln 1 and Stomach Conditions liothyronine sodium tabs 1 Antispasmodics atropine sulfate soln ij 0.4 1 NATURE-THROID NT-2.5 2 mg/ml, 1 mg/ml TABS atropine sulfate sosy ij 0.25 1 NATURE-THROID TABS 2 mg/5ml chlordiazepoxide hcl- 1 SYNTHROID TABS (Use 2 clidinium bromide caps levothyroxine sodium) dicyclomine hcl caps or 10 QL(1 ea daily) 1 thyroid tabs 1 mg

Ambetter Formulary Updated September 1, 2021

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dicyclomine hcl soln or 10 1 ranitidine hcl soln ij 150 1 mg/5ml mg/6ml dicyclomine hcl tabs or 20 1 ranitidine hcl syrp or 15 QL(40 ml daily) mg mg/ml, 150 mg/10ml, 75 1 mg/5ml glycopyrrolate soln ij 4 1 mg/20ml ranitidine hcl tabs or 150 1 RX/OTC mg glycopyrrolate tabs or 1 1 mg, 2 mg ranitidine hcl tabs or 300 1 LIBRAX CAPS (Use mg chlordiazepoxide hcl- NF TAGAMET HB TABS (Use NF RX/OTC clidinium bromide) ) methscopolamine bromide 1 ZANTAC 150 MAXIMUM RX/OTC tabs STRENGTH TABS (Use NF ranitidine hcl) H-2 Antagonists cimetidine hcl soln 300 QL(20 ml daily) ZANTAC SOLN 25 MG/ML NF 1 (Use ranitidine hcl) mg/5ml Misc. Anti-Ulcer cimetidine tabs 200 mg 1 RX/OTC CARAFATE SUSP 1 NF QL(40 ml daily) GM/10ML (Use sucralfate) cimetidine tabs 300 mg, 1 400 mg, 800 mg CARAFATE TABS 1 GM NF QL(4 ea daily) famotidine in nacl soln 1 (Use sucralfate) 1 QL(40 ml daily) famotidine soln iv 20 sucralfate susp 1 gm/10ml mg/2ml, 200 mg/20ml, 40 1 QL(4 ea daily) mg/4ml sucralfate tabs 1 gm 1 famotidine susr or 40 1 QL(10 ml daily) Proton Pump Inhibitors mg/5ml ACIPHEX TBEC (Use NF QL(1 ea daily) famotidine tabs or 20 mg 1 RX/OTC rabeprazole sodium) DEXILANT CPDR 3 PA; QL(1 ea famotidine tabs or 40 mg 1 daily) esomeprazole magnesium QL(2 ea daily); nizatidine caps 150 mg, 1 1 300 mg cpdr 20 mg RX/OTC QL(20 ml daily) esomeprazole magnesium 3 QL(1 ea daily) nizatidine soln 15 mg/ml 1 cpdr 40 mg QL(2 ea daily); PEPCID AC MAXIMUM RX/OTC lansoprazole cpdr 15 mg 1 STRENGTH TABS (Use NF RX/OTC famotidine) lansoprazole cpdr 30 mg 1 PEPCID AC TABS (Use NF RX/OTC famotidine) NEXIUM 24HR TBEC 1 QL(2 ea daily) PEPCID TABS 20 MG (Use NF RX/OTC famotidine) NEXIUM CPDR 20 MG QL(2 ea daily); (Use esomeprazole NF RX/OTC PEPCID TABS 40 MG (Use NF magnesium) famotidine) NEXIUM CPDR 40 MG QL(1 ea daily) ranitidine hcl caps or 150 1 (Use esomeprazole NF mg, 300 mg magnesium)

Ambetter Formulary Updated September 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omeprazole cpdr 10 mg, 40 1 QL(2 ea daily) Urinary Antispasmodic - Antimuscarinics mg darifenacin hydrobromide QL(1 ea daily) QL(2 ea daily); 1 omeprazole cpdr 20 mg 1 tb24 RX/OTC DETROL LA CP24 (Use NF QL(1 ea daily) omeprazole magnesium 1 QL(4 ea daily) tolterodine tartrate) cpdr DETROL TABS (Use NF omeprazole magnesium 1 QL(4 ea daily) tolterodine tartrate) tbec DITROPAN XL TB24 (Use NF omeprazole tbec 20 mg 1 QL(2 ea daily) oxybutynin chloride) ENABLEX TB24 (Use NF QL(1 ea daily) pantoprazole sodium tbec 1 QL(1 ea daily) darifenacin hydrobromide) or 20 mg oxybutynin chloride syrp 1 pantoprazole sodium tbec 1 or 40 mg oxybutynin chloride tabs 1 PREVACID 24HR CPDR NF QL(2 ea daily); (Use lansoprazole) RX/OTC oxybutynin chloride tb24 1 PREVACID CPDR 15 MG NF QL(2 ea daily); (Use lansoprazole) RX/OTC PA; QL(1 ea solifenacin succinate tabs 1 daily) PREVACID CPDR 30 MG NF (Use lansoprazole) tolterodine tartrate cp24 2 1 QL(1 ea daily) PRILOSEC OTC TBEC QL(4 ea daily) mg, 4 mg (Use omeprazole 1 tolterodine tartrate tabs 1 1 magnesium) mg, 2 mg PROTONIX TBEC OR 20 QL(1 ea daily) TOVIAZ TB24 3 PA; QL(1 ea MG (Use pantoprazole NF daily) sodium) trospium chloride cp24 60 1 QL(1 ea daily) PROTONIX TBEC OR 40 mg MG (Use pantoprazole NF trospium chloride tabs 20 1 sodium) mg QL(1 ea daily) rabeprazole sodium tbec 1 VESICARE TABS (Use NF PA; QL(1 ea solifenacin succinate) daily) Ulcer Drugs - Prostaglandins Urinary Antispasmodics - Beta-3 Adrenergic CYTOTEC TABS (Use NF QL(4 ea daily) misoprostol) MYRBETRIQ TB24 25 MG, 3 PA 50 MG QL(4 ea daily) misoprostol tabs 1 Urinary Antispasmodics - Cholinergic Agonists Ulcer Therapy Combinations bethanechol chloride tabs 1 QL(4 ea daily) omeprazole-sodium QL(1 ea daily); 10 mg, 5 mg, 50 mg bicarbonate caps 20 mg- 1 RX/OTC bethanechol chloride tabs 1 1100 mg 25 mg ZEGERID CAPS 20 MG- RX/OTC URECHOLINE TABS 10 QL(4 ea daily) MG, 5 MG, 50 MG (Use NF 1100 MG (Use NF omeprazole-sodium bethanechol chloride) bicarbonate) URECHOLINE TABS 25 URINARY ANTISPASMODICS - Drugs to Treat MG (Use bethanechol NF Miscellaneous Bladder Spasms chloride)

Ambetter Formulary Updated September 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Urinary Antispasmodics - Direct Muscle Relaxants Limit 1 dose AFLURIA QUADRIVALENT 0 per season;1 rtl flavoxate hcl tabs 1 2021-2022 SUSP MAX fill,180 rtl day(s) supply, VACCINES Limit 1 dose AFLURIA QUADRIVALENT 0 per season;1 rtl Bacterial Vaccines 2021-2022 SUSY MAX fill,180 rtl ACTHIB SOLR 0 day(s) supply, 3 rtl MAX BEXSERO SUSY 0 fill,365 rtl day(s) supply,3 ENGERIX-B INJ 0 HIBERIX SOLR 0 mail MAX fill,365 mail MENACTRA INJ 0 day(s) supply, 3 rtl MAX MENQUADFI INJ 0 fill,365 rtl day(s) supply,3 ENGERIX-B SUSP 0 MENVEO SOLR 0 mail MAX fill,365 mail PEDVAX HIB SUSP 0 day(s) supply, Limit 1 dose per season;1 rtl PNEUMOVAX 23 INJ 0 FLUAD 2019-2020 SUSY 0 MAX fill,180 rtl PNEUMOVAX 23/1 DOSE 0 day(s) supply, INJ Limit 1 dose PREVNAR 13 SUSP 0 FLUAD 2020-2021 SUSY 0 per season;1 rtl MAX fill,180 rtl TRUMENBA SUSY 0 day(s) supply, 1 rtl MAX Viral Vaccines FLUAD QUADRIVALENT 0 fill,180 rtl 2021-2022 PRSY Limit 1 dose day(s) supply, AFLURIA QUADRIVALENT 0 per season;1 rtl FLUAD QUADRIVALENT 1 rtl MAX 2019-2020 SUSP MAX fill,180 rtl INFLUENZA VACCINE 0 fill,180 rtl day(s) supply, FOR ADULTS PRSY day(s) supply, Limit 1 dose Limit 1 dose AFLURIA QUADRIVALENT per season;1 rtl 0 FLUARIX QUADRIVALENT 0 per season;1 rtl 2019-2020 SUSY MAX fill,180 rtl 2019-2020 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose AFLURIA QUADRIVALENT per season;1 rtl 0 FLUARIX QUADRIVALENT 0 per season;1 rtl 2020-2021 SUSP MAX fill,180 rtl 2020-2021 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose AFLURIA QUADRIVALENT per season;1 rtl 0 FLUARIX QUADRIVALENT 0 per season;1 rtl 2020-2021 SUSY MAX fill,180 rtl 2021-2022 SUSY MAX fill,180 rtl day(s) supply, day(s) supply,

Ambetter Formulary Updated September 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose Limit 1 dose FLUBLOK FLULAVAL QUADRIVALENT 2019- 0 per season;1 rtl 0 per season;1 rtl MAX fill,180 rtl QUADRIVALENT 2021- MAX fill,180 rtl 2020 SOSY 2022 SUSY day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK QUADRIVALENT 2020- 0 per season;1 rtl FLUMIST 0 per season;1 rtl MAX fill,180 rtl QUADRIVALENT SUSP MAX fill,180 rtl 2021 SOSY day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK QUADRIVALENT 2021- 0 per season;1 rtl FLUZONE HIGH-DOSE PF 0 per season;1 rtl MAX fill,180 rtl 2019-2020 SUSY MAX fill,180 rtl 2022 SOSY day(s) supply, day(s) supply, FLUCELVAX Limit 1 dose 1 rtl MAX per season;1 rtl FLUZONE HIGH-DOSE PF 0 fill,180 rtl QUADRIVALENT 2019- 0 2020-2021 SUSY 2020 SUSP MAX fill,180 rtl day(s) supply, day(s) supply, FLUZONE HIGH-DOSE PF 1 rtl MAX Limit 1 dose 0 fill,180 rtl FLUCELVAX 2021-2022 SUSY QUADRIVALENT 2019- 0 per season;1 rtl day(s) supply, 2020 SUSY MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2019- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLUCELVAX 2020 SUSP QUADRIVALENT 2020- 0 per season;1 rtl day(s) supply, 2021 SUSP MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2019- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLUCELVAX 2020 SUSY QUADRIVALENT 2020- 0 per season;1 rtl day(s) supply, 2021 SUSY MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2020- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLUCELVAX 2021 SUSP QUADRIVALENT 2021- 0 per season;1 rtl day(s) supply, 2022 SUSP MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2020- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLUCELVAX 2021 SUSY QUADRIVALENT 2021- 0 per season;1 rtl day(s) supply, 2022 SUSY MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2021- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLULAVAL 2022 SUSP QUADRIVALENT 2019- 0 per season;1 rtl day(s) supply, 2020 SUSP MAX fill,180 rtl Limit 1 dose day(s) supply, FLUZONE QUADRIVALENT 2021- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLULAVAL 2022 SUSY 0 per season;1 rtl day(s) supply, QUADRIVALENT 2019- MAX fill,180 rtl 2020 SUSY 3 rtl MAX day(s) supply, GARDASIL 9 SUSP 0 fill,365 rtl Limit 1 dose day(s) supply, FLULAVAL 0 per season;1 rtl 3 rtl MAX QUADRIVALENT 2020- MAX fill,180 rtl 2021 SUSY GARDASIL 9 SUSY 0 fill,365 rtl day(s) supply, day(s) supply,

Ambetter Formulary Updated September 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HAVRIX SUSP 0 CLEOCIN CREA VA 2 % (Use clindamycin NF HEPLISAV-B SOLN 0 phosphate vaginal) clindamycin phosphate 1 HEPLISAV-B SOSY 0 vaginal crea clotrimazole vaginal crea 1 IPOL INACTIVATED IPV 0 INJ 3 1 rtl MAX GYNAZOLE-1 CREA M-M-R II SOLR 0 fill,365 rtl GYNE-LOTRIMIN CREA NF day(s) supply, (Use clotrimazole vaginal) RECOMBIVAX HB SUSP 0 METROGEL-VAGINAL GEL (Use metronidazole NF ROTARIX SUSR 0 vaginal) metronidazole vaginal gel 1 ROTATEQ SOLN 0 miconazole nitrate vaginal 1 2 rtl pack lmt supp amt,999 rtl terconazole vaginal crea 1 0 pack lmt SHINGRIX SUSR day(s),; AL(At least 50 yrs terconazole vaginal supp 1 old) Vaginal Contraceptive - pH Modulators TWINRIX SUSY 0 PHEXXI GEL 0 PV VAQTA SUSP 0 Vaginal Estrogens 2 rtl MAX ESTRACE CREA (Use NF VARIVAX INJ 0 fill,365 rtl estradiol vaginal) day(s) supply, 1 rtl pack lmt estradiol vaginal crea 1 amt,999 rtl estradiol vaginal tabs 1 0 pack lmt ZOSTAVAX SUSR day(s),; AL(At least 50 yrs FEMRING RING 3 old) PREMARIN CREA 2 VAGINAL AND RELATED PRODUCTS VAGIFEM TABS (Use NF Miscellaneous Vaginal Products estradiol vaginal) INTRAROSA INST 3 PA VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions Spermicides Anaphylaxis Therapy Agents SHUR-SEAL GEL 0 ADRENALIN SOLN IJ 30 MG/30ML (Use epinephrine NF TODAY SPONGE MISC 0 (anaphylaxis)) Vaginal Anti-infectives

Ambetter Formulary Updated September 1, 2021

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea per fill Water Soluble Vitamins retail,2 ea per fill mail)2 rtl niacin cpcr or 500 mg, 250 1 mg epinephrine (anaphylaxis) 1 MAX fill,365 rtl soaj 0.15 mg/0.3ml day(s) supply,2 niacin tabs or 250 mg, 50 1 mail MAX mg, 100 mg, 500 mg fill,365 mail niacin tbcr or 750 mg, 250 1 day(s) supply, mg, 500 mg QL(2 ea per fill NIACIN TR TBCR 1 epinephrine (anaphylaxis) 2 retail)2 rtl MAX soaj 0.3 mg/0.3ml fill,365 rtl niacinamide tabs or 100 1 day(s) supply, mg, 500 mg QL(2 ea per fill SLO-NIACIN TBCR (Use 1 retail,2 ea per niacin) fill mail)2 rtl epinephrine (anaphylaxis) 2 MAX fill,365 rtl soaj 0.3 mg/0.3ml day(s) supply,2 mail MAX fill,365 mail day(s) supply, EPIPEN 2-PAK SOAJ (Use NF epinephrine (anaphylaxis)) QL(2 ea per fill retail,2 ea per fill mail)2 rtl EPIPEN-JR 2-PAK SOAJ (Use epinephrine 2 MAX fill,365 rtl (anaphylaxis)) day(s) supply,2 mail MAX fill,365 mail day(s) supply, Vasopressors midodrine hcl tabs 1

VITAMINS Oil Soluble Vitamins cholecalciferol caps 1.25 1 mg, 50000 unit cholecalciferol tabs 400 0 unit DRISDOL CAPS (Use 0 ergocalciferol) ergocalciferol caps or 1.25 0 mg, 50000 unit ergocalciferol soln or 200 1 mcg/ml, 8000 unit/ml VITAMIN D2 TABS 0 AL(At least 65 yrs old) Ambetter Formulary Updated September 1, 2021

133 Index 1ST TIER UNILET ACTIGALL 71 ADVOCATE INSULIN COMFORTOUCH LANCETS ACTIMMUNE 40 SYRINGE/U-100/1ML/31GX5/16" 28G 78 90 1ST TIER UNILET ACTIQ 6 ADVOCATE LANCETS 79 COMFORTOUCH LANCETS ACTONEL 67 ADVOCATE LANCETS 30G 79 30G 78 ACTOPLUS MET 23 ADVOCATE LANCING abacavir sulfate 45 ACTOS 24 DEVICE 79 abacavir sulfate-lamivudine 45 ACULAR 121 ADVOCATE RAPID-SAFE abacavir sulfate-lamivudine- LANCING DEVICE 79 zidovudine 45 ACULAR LS 121 ADVOCATE SAFETY ABELCET 27 acyclovir 48 LANCETS 79 ABILIFY 44 acyclovir topical 61 ADVOCATE SAFETY LANCETS ADACEL 127 26G 79 abiraterone acetate 37 ADZENYS ER 1 ADALAT CC 50 ABRAXANE 41 AFINITOR 38 adapalene 56 ABSORICA 56 AFLURIA QUADRIVALENT acamprosate calcium 124 adapalene-benzoyl 2019-2020 130 peroxide 56 acarbose 23 AFLURIA QUADRIVALENT ADCETRIS 36 2020-2021 130 ACCOLATE 14 ADCIRCA 51 AFLURIA QUADRIVALENT ACCU-CHEK FASTCLIX ADDERALL 1 2021-2022 130 LANCETS 78 AGAMATRIX ULTRA-THIN ACCU-CHEK MULTICLIX ADDERALL XR 1 LANCETS 33G 79 LANCETS 78 adefovir dipivoxil 48 AGGRENOX 73 ACCU-CHEK SAFE-T-PRO ADEMPAS 52 LANCETS 78 AGRYLIN 73 ACCU-CHEK SAFE-T-PRO ADIPEX-P 1 AIMOVIG 111 PLUSLANCETS 78 ADJUSTABLE LANCING AIMSCO LUBRICATED 77 DEVICE 78 ACCU-CHEK SOFTCLIX AIMSCO TWIST LANCETS LANCETS 78 ADRENALIN 132 32G 79 ACCUPRIL 31 ADVAIR DISKUS 14 AIMSCO TWIST LANCETS ACCURETIC 32 ADVAIR HFA 14 33G 79 acebutolol hcl 49 ADVANCED MOBILE LANCET AIRDUO RESPICLICK 113/14 14 acetaminophen w/ codeine 8 30G 78 ADVOCATE INSULIN AIRDUO RESPICLICK acetaminophen-caff- 232/14 14 dihydrocod 8 SYRINGE/U- 100/0.3ML/29GX1/2" 90 AIRDUO RESPICLICK 55/1415 acetazolamide 66 ADVOCATE INSULIN AKYNZEO 27 acetazolamide sodium 66 SYRINGE/U- albendazole 10 acetic acid 72 100/0.3ML/30GX5/16" 90 ALBENZA 10 acetic acid (otic) 122 ADVOCATE INSULIN SYRINGE/U- albuterol sulfate 15 acetylcysteine 56 100/0.3ML/31GX5/16" 90 ALCAINE 120 ACIPHEX 128 ADVOCATE INSULIN alclometasone dipropionate 61 acitretin 60 SYRINGE/U- ALDACTAZIDE 66 ACTHAR 67 100/0.5ML/29GX1/2" 90 ADVOCATE INSULIN ALDACTONE 66 ACTHIB 130 SYRINGE/U- ALDARA 64 ACTI-LANCE LANCETS 100/0.5ML/30GX5/16" 90 28G 78 ADVOCATE INSULIN ALDURAZYME 68 ACTI-LANCE LITE SAFETY SYRINGE/U- ALECENSA 38 LANCETS 28G 78 100/0.5ML/31GX5/16" 90 alendronate sodium 67 ACTI-LANCE SPECIAL SAFETY ADVOCATE INSULIN alfuzosin hcl 72 LANCETS 17G 78 SYRINGE/U- ACTI-LANCE SPECIAL 100/1ML/29GX1/2" 90 ALIMTA 36 SAFETYLANCETS 17G 78 ADVOCATE INSULIN ALINIA 11 ACTI-LANCE UNIVERSAL SYRINGE/U- aliskiren fumarate 33 SAFETY LANCETS 23G 78 100/1ML/30GX5/16" 90

Index 1 ALKERAN 35 amlodipine besylate-olmesartan ARIMIDEX 37 ALLEGRA ALLERGY 28 medoxomil 32 aripiprazole 45 amlodipine besylate- ALLEGRA ALLERGY valsartan 32 ARIXTRA 16 CHILDRENS 28 amlodipine-valsartan- armodafinil 2 ALLEGRA-D 12 HOUR hydrochlorothiazide 32 ALLERGY & CONGESTION 56 ARMOUR THYROID 127 ALLEGRA-D 24 HOUR amoxapine 23 ARNUITY ELLIPTA 14 ALLERGY & CONGESTION 56 amoxicillin 123 AROMASIN 37 amoxicillin & pot allopurinol 72 ARRANON 36 almotriptan malate 112 clavulanate 123 amphetamine- arsenic trioxide 40 ALOCRIL 121 dextroamphetamine 1 ARTHROTEC 50 4 alogliptin benzoate 24 amphotericin b 27 ARTHROTEC 75 4 ALOMIDE 121 ampicillin 123 ARZERRA 36 alosetron hcl 71 ampicillin & sulbactam ASACOL HD 71 ALOXI 26 sodium 123 ampicillin sodium 123 asenapine maleate 43 ALPHAGAN P 120 aspirin 6 alprazolam 13 AMPYRA 124 ANADROL-50 10 aspirin-dipyridamole 73 ALREX 120 ASSURE HAEMOLANCE PLUS ALTABAX 58 ANAFRANIL 23 HIGH FLOW 18G 79 ALTACE 31 anagrelide hcl 73 ASSURE HAEMOLANCE PLUS ALTERNATE SITE LANCING anastrozole 37 LOW FLOW 25G 79 DEVICE 79 ANCOBON 27 ASSURE HAEMOLANCE PLUS MICRO FLOW 28G 79 ALTOPREV 30 ANDRODERM 10 ASSURE HAEMOLANCE PLUS ALUNBRIG 38 ANDROGEL 10 NORMAL FLOW 21G 79 alvimopan 71 ANNOVERA 54 ASSURE HAEMOLANCE PLUS amantadine hcl 41 PEDIATRIC BLADE 79 ANORO ELLIPTA 15 ASSURE ID INSULIN AMARYL 25 ANTABUSE 124 SAFETYSYRINGE/U- AMBIEN 75 ANUSOL-HC 10 100/0.5ML/29G X 1/2" 90 AMBIEN CR 75 ANZEMET 26 ASSURE ID INSULIN SAFETYSYRINGE/U- AMBISOME 27 APIDRA 24 100/1ML/29G X 1/2" 90 ambrisentan 51 APIDRA SOLOSTAR 25 ASSURE LANCE LANCETS 79 amcinonide 61 APO-VARENICLINE 125 ASSURE LANCE LANCETS AMCINONIDE 61 APOKYN 41 21G 79 AMERGE 112 ASSURE LANCE PLUS apraclonidine hcl 120 SAFETYLANCETS 25G 79 AMICAR 74 aprepitant 27 ASSURE LANCE PLUS amikacin sulfate 3 APRISO 71 SAFETYLANCETS 30G 79 amiloride & APTIOM 17 ASSURE LANCE SAFETY hydrochlorothiazide 66 LANCET 28G 79 APTIVUS 45 amiloride hcl 66 ASSURE LANCETS 79 AQUA LANCE ADJUSTABLE aminocaproic acid 74 LANCING DEVICE 79 ATACAND 31 aminophylline 16 ARALAST NP 126 ATACAND HCT 32 amiodarone hcl 13 ARANESP ALBUMIN atazanavir sulfate 45 AMITIZA 71 FREE 74 ATELVIA 67 amitriptyline hcl 23 ARAVA 5 atenolol 49 amlodipine besylate 50 ARCALYST 4 atenolol & chlorthalidone 32 amlodipine besylate-atorvastatin ARCAPTA NEOHALER 15 ATGAM 115 calcium 51 arformoterol tartrate 15 ATIVAN 13 amlodipine besylate-benazepril ARICEPT 124 hcl 32 atomoxetine hcl 2 ARIKAYCE 3

Index 2 atorvastatin calcium 30 B-D INSULIN SYRINGE BD INSULIN SYRINGE atovaquone 11 ULTRAFINE II/0.3ML/31G X MICROFINE/U-100/1ML/28G X 5/16" 90 1/2" 91 atovaquone-proguanil hcl 33 B-D INSULIN SYRINGE BD INSULIN SYRINGE ATRIPLA 45 ULTRAFINE II/0.5ML/31G X SAFETYGLIDE/1ML/29G X atropine sulfate 127 5/16" 90 1/2" 91 B-D INSULIN SYRINGE BD INSULIN SYRINGE SLIP ATROVENT HFA 14 ULTRAFINE II/1ML/31G X TIP/U-100/1ML 91 AUBAGIO 124 5/16" 90 BD INSULIN SYRINGE ULTRA- AUGMENTIN 123 B-D INSULIN SYRINGE FINE/0.3ML/30G X 12.7MM 91 AUGMENTIN ES-600 123 ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE ULTRA- 1/2" 90 FINE/0.3ML/31G X 8MM 91 AURORA LANCET SUPER BD INSULIN SYRINGE ULTRA- THIN30G 79 B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X FINE/0.5ML/30G X 12.7MM 91 AURORA LANCET THIN BD INSULIN SYRINGE ULTRA- 23G 79 1/2" 90 bacitracin 10 FINE/0.5ML/31G X 8MM 91 AUSTEDO 124 BD INSULIN SYRINGE ULTRA- AUTO-LANCET 79 bacitracin (ophthalmic) 120 FINE/1/2 UNIT/0.3ML/31G X AUTO-LANCET MINI 79 baclofen 118 8MM 91 AUTOLET IMPRESSION BACTRIM 11 BD INSULIN SYRINGE ULTRA- LANCING DEVICE 79 BACTRIM DS 11 FINE/1ML/30G X 12.7MM 91 BD INSULIN SYRINGE ULTRA- AUTOLET LANCING BALCOLTRA 53 DEVICE 79 FINE/1ML/31G X 8MM 91 balsalazide disodium 71 BD INSULIN SYRINGE AUTOLET MINI 79 BALVERSA 38 ULTRAFINE HALF- AUTOLET PLUS 79 BANZEL 17 UNIT/0.3ML/31G X 5/16" 91 AVALIDE 32 BD INSULIN SYRINGE BAQSIMI ONE PACK 24 AVANDIA 24 ULTRAFINE/0.3ML/30G X BAQSIMI TWO PACK 24 1/2" 91 AVAPRO 31 BARACLUDE 48 BD INSULIN SYRINGE AVELOX 70 ULTRAFINE/0.3ML/31G X BASAGLAR KWIKPEN 25 AVODART 72 5/16" 91 BAXDELA 70 AVONEX 124 BD INSULIN SYRINGE BD LO-DOSE INSULIN ULTRAFINE/0.5ML/30G X AVONEX PEN 124 SYRINGE MICROFINE 1/2" 91 AVSOLA 71 IV/0.5ML/28G X 1/2" 90 BD INSULIN SYRINGE AYGESTIN 123 BD AUTOSHIELD 29G X ULTRAFINE/0.5ML/31G X 3/16" 90 5/16" 91 AYVAKIT 38 BD AUTOSHIELD 29G X BD INSULIN SYRINGE azacitidine 36 5/16" 90 ULTRAFINE/1ML/30G X AZACTAM 12 BD AUTOSHIELD DUO 30G X 1/2" 91 AZASAN 115 5MM 90 BD INSULIN SYRINGE BD INSULIN SYRINGE LUER- ULTRAFINE/U-100/0.3ML/29G X AZASITE 120 LOK/U-100/1ML 90 1/2" 91 AZATHIOPRINE 115 BD INSULIN SYRINGE BD INSULIN SYRINGE azathioprine 115 MICROFINE IV/U- ULTRAFINE/U-100/0.5ML/29G X 100/0.5ML/28G X 1/2" 90 1/2" 91 azelaic acid 64 BD INSULIN SYRINGE BD INSULIN SYRINGE azelastine hcl 118 MICROFINE IV/U- ULTRAFINE/U-100/1ML/29G X azelastine hcl (ophth) 121 100/1ML/27G X 5/8" 91 1/2" 91 AZELEX 56 BD INSULIN SYRINGE BD INSULIN SYRINGE MICROFINE IV/U- ULTRAFINE/U-100/1ML/31G X AZILECT 42 100/1ML/28G X 1/2" 91 5/16" 91 azithromycin 76 BD INSULIN SYRINGE BD INSULIN AZOR 32 MICROFINE/U-100/0.5ML/28G SYRINGE/0.3ML/29G X aztreonam 12 X 1/2" 91 12.7MM 91 BD INSULIN SYRINGE BD INSULIN AZULFIDINE 71 MICROFINE/U-100/1ML/27G X SYRINGE/0.5ML/29G X AZULFIDINE EN-TABS 71 5/8" 91 12.7MM 91

Index 3 BD INSULIN SYRINGE/1ML/27G BD VEO INSULIN SYRINGE bisoprolol fumarate 49 X 12.7MM 91 ULTRA-FINE/1ML/31G X bleomycin sulfate 38 BD INSULIN SYRINGE/1ML/29G 6MM 92 X 12.7MM 91 BD VEO INSULIN SYRINGE BLEPH-10 120 BD INSULIN ULTRA-FINE/U-100/1ML/31G BONIVA 67 SYRINGE/DETACHABLE X 15/64" 92 BOOSTRIX 127 NEEDLE/U-100/1ML/25G X BELSOMRA 75 BORTEZOMIB 38 1" 91 BELVIQ 2 BD INSULIN bosentan 51 SYRINGE/DETACHABLE benazepril & hydrochlorothiazide 32 BOSULIF 38 NEEDLE/U-100/1ML/25G X BOTOX 119 5/8" 92 benazepril hcl 31 BD INSULIN BENICAR 31 BRAFTOVI 38 SYRINGE/DETACHABLE BENICAR HCT 32 BREO ELLIPTA 15 NEEDLE/U-100/1ML/26G X BENZACLIN 56 BRILINTA 73 1/2" 92 brimonidine tartrate 120 BD INSULIN SYRINGE/U- BENZACLIN WITH PUMP 56 100/1ML/27G X 1/2" 92 BENZAMYCIN 56 BRIVIACT 17 BD LANCET ULTRAFINE benzonatate 55 bromfenac sodium (ophth) 121 30G 79 bromocriptine mesylate 41 BD LANCET ULTRAFINE benzoyl peroxide 56,57 33G 79 BENZOYL PEROXIDE BROVANA 15 BD MICROTAINER CLEANSER 56 BRUKINSA 39 LANCETS 79 benzoyl peroxide- budesonide 54 erythromycin 57 BD PEN budesonide (inhalation) 14 NEEDLE/MICRO/ULTRA- benztropine mesylate 41 FINE/32G X 6MM 92 bepotastine besilate 121 budesonide (nasal) 118 budesonide-formoterol fumarate BD PEN NEEDLE/MINI/ULTRA- BEPREVE 121 FINE/31G X 5MM 92 dihydrate 15 BD PEN NEEDLE/NANO 2ND betamethasone dipropionate BULLSEYE MINI SAFETY GEN/32G X 5/32" 92 (topical) 61 LANCETS 79 BD PEN betamethasone dipropionate BULLSEYE SAFETY NEEDLE/NANO/ULTRA- augmented 61 LANCETS 79 FINE/32G X 4MM 92 betamethasone valerate 61 bumetanide 66 BD PEN BETAPACE 49 BUMEX 66 NEEDLE/ORIGINAL/ULTRA- BETAPACE AF 49 FINE/29G X 12.7MM 92 BUNAVAIL 9 BD PEN BETASERON 125 BUPHENYL 68 NEEDLE/SHORT/ULTRA- betaxolol hcl 49 BUPRENEX 9 FINE/31G X 8MM 92 betaxolol hcl (ophth) 119 buprenorphine 9 BD SAFETY-GLIDE INSULIN bethanechol chloride 129 SYRINGE/0.5ML/29G X 1/2" 92 buprenorphine hcl 9 BD SAFETY-LOK INSULIN BEVESPI AEROSPHERE 15 buprenorphine hcl-naloxone hcl SYRINGE/PERM BEVYXXA 16 dihydrate 9 NEEDLE/UF/1ML/29G X bexarotene 40 bupropion hcl 21 1/2" 92 BEXSERO 130 bupropion hcl (smoking BD SAFETYGLIDE INSULIN deterrent) 125 SYRINGE/0.3ML/29G X 1/2" 92 BEYAZ 53 buspirone hcl 13 BD SAFETYGLIDE INSULIN bicalutamide 37 busulfan 35 SYRINGE/0.3ML/31G X BICNU 35 5/16" 92 BUSULFEX 35 BD SAFETYGLIDE INSULIN BIDIL 51 butalbital-acetaminophen 5 SYRINGE/1ML/31G X BIKTARVY 45 butalbital-acetaminophen- 15/64" 92 BILTRICIDE 10 caffeine 5 BD SAFETYGLIDE INSULIN bimatoprost 122 butalbital-acetaminophen- SYSYRINGE/0.5ML/30G X caffeine w/ codeine 8 bisacodyl 76 5/16" 92 butalbital-aspirin-caffeine 5 bisoprolol & butalbital-aspirin-caffeine hydrochlorothiazide 32 w/cod 8

Index 4 BUTALBITAL/ACETAMINOPHEN CARDIZEM LA 50 cefazolin sodium 52 5 CARDURA 31 cefdinir 52 butenafine hcl 58 CAREONE ADVANCED cefditoren pivoxil 52 butorphanol tartrate 9 LANCINGDEVICE 79 cefepime hcl 52 BUTRANS 9 CAREONE INSULIN cefixime 52 BYSTOLIC 49 SYRINGES/0.3ML/30G X 1/2" 92 CEFOTAN 52 cabergoline 69 CAREONE INSULIN cefotaxime sodium 52 CABLIVI 73 SYRINGES/0.3ML/31G X cefotetan disodium 52 CADUET 51 5/16" 92 CAREONE INSULIN cefoxitin sodium 52 CAFERGOT 112 SYRINGES/0.5ML/30G X cefpodoxime proxetil 52 CALAN 50 1/2" 92 cefprozil 52 CALAN SR 50 CAREONE INSULIN ceftazidime 52 calcipotriene 60 SYRINGES/0.5ML/31G X ceftriaxone sodium 52 calcipotriene-betamethasone 5/16" 92 CAREONE INSULIN dipropionate 62 cefuroxime axetil 52 SYRINGES/1ML/30G X cefuroxime sodium 52 calcitonin (salmon) 67 1/2" 92 calcitriol 68 CAREONE INSULIN CELEBREX 4 calcitriol (topical) 60 SYRINGES/1ML/31GX5/16" celecoxib 4 calcium acetate (phosphate 92 CELESTONE SOLUSPAN 54 CAREONE LANCET SUPER binder) 72 CELESTONE-SOLUSPAN 54 calcium chloride (dihydrate)113 THIN/30G 79 CAREONE LANCET THIN 79 CELEXA 21 CALCIUM GLUCONATE 113 CARESENS LANCETS 79 CELLCEPT 115 calcium gluconate 113 CARETOUCH LANCING CELONTIN 20 calcium polycarbophil 75 DEVICEWITH EJECTOR 79 cephalexin 52 CAMPTOSAR 41 CARETOUCH SAFETY CERDELGA 73 CANASA 71 LANCETS/26G 80 CARETOUCH SAFETY CEREBYX 20 CANCIDAS 27 LANCETS/28G 80 CEREZYME 73 candesartan cilexetil 31 CARETOUCH SAFETY CESAMET 27 candesartan cilexetil- LANCETS/30G 80 hydrochlorothiazide 32 CARETOUCH TWIST cetirizine hcl 28 CAPASTAT SULFATE 35 LANCETS 28G 80 cetirizine-pseudoephedrine 56 capecitabine 36 CARETOUCH TWIST CETRAXAL 122 LANCETS 30G 80 CAPRELSA 39 CARETOUCH TWIST CETROTIDE 67 captopril 31 LANCETS 33G 80 cevimeline hcl 116 CARAC 60 carisoprodol 118 CHANTIX 125 CARAFATE 128 carmustine 35 CHANTIX CONTINUING MONTHPAK 125 CARBAGLU 68 carteolol hcl (ophth) 119 CHANTIX STARTING MONTH carbamazepine 17,18 carvedilol 49 PAK 125 CARBATROL 18 CASODEX 37 CHEMET 26 carbidopa 41 caspofungin acetate 27 CHEMSTRIP-K 65 carbidopa-levodopa 42 CATAPRES 31 CHILDRENS ADVIL 4 carbidopa-levodopa-entacapone CATAPRES-TTS-1 31 CHILDRENS MOTRIN 4 42 CATAPRES-TTS-2 31 chloramphenicol sodium carbinoxamine maleate 28 CATAPRES-TTS-3 31 succinate 11 chlordiazepoxide hcl 13 carboplatin 35 CAYA 77 CARDIOCOM LANCING chlordiazepoxide hcl-clidinium DEVICE 79 CAYSTON 12 bromide 127 CARDIZEM 50 cefaclor 52 chlorhexidine gluconate (mouth- throat) 116 CARDIZEM CD 50 cefadroxil 52

Index 5 chloroquine phosphate 34 CLEMASTINE CLEVER CHOICE COMFORT chlorothiazide 66 FUMARATE 28 EZINSULIN SYRINGE/1ML/30G clemastine fumarate 28 X 5/16" 93 chlorpromazine hcl 44 CLENPIQ 75 CLEVER CHOICE COMFORT chlorthalidone 66 EZINSULIN SYRINGE/U- CLEOCIN 11,132 chlorzoxazone 118 100/1ML/31GX5/16" 93 CLEOCIN PEDIATRIC CLIMARA 70 CHOLBAM 70 GRANULES 11 CLIMARA PRO 69 cholecalciferol 133 CLEOCIN PHOSPHATE 11 CLINDAGEL 57 cholestyramine 29 CLEOCIN-T 57 cholestyramine light 29 CLEVER CHOICE COMFORT clindamycin hcl 11 CHORIONIC EZINSULIN clindamycin palmitate GONADOTROPIN 67 SYRINGE/0.3ML/29G X hydrochloride 11 CIALIS 51 1/2" 92 clindamycin phosphate 12 CLEVER CHOICE COMFORT clindamycin phosphate CICLODAN SOLUTION KIT 58 EZINSULIN (topical) 57 ciclopirox 58 SYRINGE/0.3ML/30G X clindamycin phosphate ciclopirox olamine 58 1/2" 92 vaginal 132 cidofovir 47 CLEVER CHOICE COMFORT clindamycin phosphate-benzoyl EZINSULIN peroxide 57 cilostazol 73 SYRINGE/0.3ML/30G X clindamycin phosphate-benzoyl CILOXAN 120 5/16" 92 peroxide (refrigerate) 57 CIMDUO 45 CLEVER CHOICE COMFORT clindamycin phosphate- tretinoin 57 cimetidine 128 EZINSULIN SYRINGE/0.3ML/31G X CLINIMIX 4.25%/DEXTROSE cimetidine hcl 128 5/16" 93 10% 119 cinacalcet hcl 68 CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE CINRYZE 73 EZINSULIN 25% 119 CLINIMIX 4.25%/DEXTROSE CIPRO 70 SYRINGE/0.5ML/28G X 1/2" 93 5% 119 CIPRO HC 122 CLEVER CHOICE COMFORT CLINIMIX 5%/DEXTROSE CIPRODEX 122 EZINSULIN 25% 119 CLINIMIX E 5%/DEXTROSE ciprofloxacin 70 SYRINGE/0.5ML/29G X 1/2" 93 20% 119 ciprofloxacin hcl 70 CLEVER CHOICE COMFORT clobazam 17 ciprofloxacin hcl (ophth) 120 EZINSULIN clobetasol propionate 62 ciprofloxacin hcl (otic) 122 SYRINGE/0.5ML/30G X clobetasol propionate emollient ciprofloxacin in d5w 70 1/2" 93 base 62 ciprofloxacin-dexamethasone CLEVER CHOICE COMFORT clocortolone pivalate 62 122 EZINSULIN SYRINGE/0.5ML/30G X CLODERM 62 ciprofloxacin-fluocinolone clofarabine 36 acetonide 122 5/16" 93 CLEVER CHOICE COMFORT cisplatin 35 CLOLAR 36 EZINSULIN clomipramine hcl 23 citalopram hydrobromide 21 SYRINGE/0.5ML/31G X CLARINEX 28 5/16" 93 clonazepam 17 clarithromycin 76 CLEVER CHOICE COMFORT clonidine 31 EZINSULIN CLARITIN 28 clonidine hcl 31 SYRINGE/1.0ML/30G X clonidine hcl (adhd) 2 CLARITIN ALLERGY 1/2" 93 CHILDRENS 28 CLEVER CHOICE COMFORT clopidogrel bisulfate 73 CLARITIN CHILDRENS 28 EZINSULIN clorazepate dipotassium 13 CLARITIN REDITABS 28 SYRINGE/1ML/28G X 1/2" 93 clotrimazole 116 CLARITIN-D 12 HOUR 56 CLEVER CHOICE COMFORT EZINSULIN clotrimazole (topical) 58 CLARITIN-D 24 HOUR 56 SYRINGE/1ML/29G X 1/2" 93 clotrimazole vaginal 132 CLASSIC PRENATAL 116 clotrimazole w/ CLEANLET LANCETS 28G 80 betamethasone 58

Index 6 clozapine 43 COMFORT EZ INSULIN CVS LANCING DEVICE 80 CLOZARIL 43 SYRINGE/U-100/1ML/31G X CVS PRENATAL 116 5/16" 93 CVS ULTRA THIN COAGUCHEK LANCETS 80 COMFORT LANCETS 80 COARTEM 34 LANCETS 80 COMPLERA 45 cyanocobalamin 73 CODEINE SULFATE 6 COMTAN 41 cyclobenzaprine hcl 118 codeine sulfate 6 CONCERTA 2 cyclophosphamide 35 COGENTIN 41 CONTRAVE 2 cycloserine 35 COLACE 76 CONZIP 6 CYCLOSET 24 COLAZAL 71 COPAXONE 125 cyclosporine 115 colchicine 72 COPIKTRA 39 cyclosporine modified (for colchicine w/ probenecid 72 CORDRAN 62 microemulsion) 115 COLCRYS 72 COREG 49 CYKLOKAPRON 74 colesevelam hcl 29 CORGARD 49 CYMBALTA 22 COLESTID 30 CORLANOR 52 cyproheptadine hcl 29 COLESTID FLAVORED 30 CORTEF 54 CYSTADANE 68 colestipol hcl 30 CORTENEMA 10 CYSTAGON 72 COLY-MYCIN S 122 cortisone acetate 54 CYSTARAN 121 COLYTE-FLAVOR PACKS 75 CORTISPORIN-TC 122 cytarabine 36 COMBIGAN 119 COSENTYX 60 CYTOMEL 127 COMBIVIR 45 COSENTYX SENSOREADY CYTOTEC 129 COMETRIQ 39 PEN 60 CYTOVENE 47 COMFORT ASSIST INSULIN COSMEGEN 38 D.H.E. 45 112 SYRINGE 0.3ML/29G X 1/2" 93 COSOPT 119 COMFORT ASSIST INSULIN dacarbazine 40 SYRINGE/0.3ML/30G X COUMADIN 16 DACOGEN 36 5/16" 93 COZAAR 31 dactinomycin 38 COMFORT ASSIST INSULIN CREON 66 dalfampridine 125 SYRINGE/0.3ML/31G X CRESEMBA 27 5/16" 93 DALIRESP 14 COMFORT ASSIST INSULIN CRESTOR 30 danazol 10 SYRINGE/0.5ML/29G X 1/2" 93 CRIXIVAN 45 DANTRIUM 118 COMFORT ASSIST INSULIN cromolyn sodium 14 SYRINGE/0.5ML/30G X dantrolene sodium 118 5/16" 93 cromolyn sodium (ophth) 121 dapsone 11 COMFORT ASSIST INSULIN crotamiton 65 DAPTACEL 127 SYRINGE/0.5ML/31G X CUBICIN 11 DAPTOMYCIN 11 5/16" 93 CUBICIN RF 11 COMFORT ASSIST INSULIN daptomycin 11 SYRINGE/1ML/29G X 1/2" 93 CUPRIMINE 115 DARAPRIM 34 COMFORT ASSIST INSULIN CUTIVATE 62 darifenacin hydrobromide 129 SYRINGE/1ML/30G X 5/16" 93 CUVITRU 122 DAUNORUBICIN COMFORT ASSIST INSULIN HYDROCHLORIDE 38 SYRINGE/1ML/31G X 5/16" 93 CVS LANCETS 21G 80 COMFORT ASSURED CVS LANCETS MICRO THIN DAURISMO 37 LANCETS MICRO THIN 33G 80 DAYPRO 4 33G 80 CVS LANCETS MICRO-THIN DAYTRANA 2 33G 80 COMFORT ASSURED DDAVP 69 LANCETS SUPER THIN CVS LANCETS ORIGINAL80 28G 80 CVS LANCETS THIN 26G 80 DEBACTEROL 116 COMFORT EZ INSULIN CVS LANCETS ULTRA THIN decitabine 36 SYRINGE/U-100/0.5ML/31G X 30G 80 deferasirox 26 5/16" 93 CVS LANCETS ULTRA-THIN deferiprone 26 30G 80

Index 7 DELESTROGEN 70 dexamethasone sodium diltiazem hcl 50 DELSTRIGO 45 phosphate (ophth) 120 DILTIAZEM HCL 50 dexchlorpheniramine DELZICOL 71 maleate 28 diltiazem hcl 50 demeclocycline hcl 126 DEXEDRINE 1 diltiazem hcl coated beads 50 DEMEROL 6 DEXILANT 128 diltiazem hcl extended release beads 50 DENAVIR 61 dexmethylphenidate hcl 2 dimethyl fumarate 125 DEPACON 20 dextroamphetamine sulfate 1 DIOVAN 31 DEPAKENE 20 DEXTROSE 5%/NACL DIOVAN HCT 32 DEPAKOTE 20 0.3% 113 dextrose in lactated DIPENTUM 71 DEPAKOTE ER 20 ringers 113 diphenhydramine hcl 28 DEPEN TITRATABS 115 DEXTROSE/SODIUM diphenoxylate w/ atropine 26 DEPO-ESTRADIOL 70 CHLORIDE 113 DIACOMIT 18 DIPHTHERIA/TETANUS DEPO-MEDROL 54 TOXOIDS ADSORBED DEPO-PROVERA DIASTAT ACUDIAL 17 PEDIATRIC 127 CONTRACEPTIVE 54 DIASTAT PEDIATRIC 17 DIPROLENE 62 DEPO-SUBQ PROVERA DIATHRIVE LANCETS 80 104 54 DIPROLENE AF 62 DIATHRIVE LANCETS ULTRA dipyridamole 73 DEPO-TESTOSTERONE 10 THIN 30G 80 DERMA-SMOOTHE/FS DIATHRIVE LANCING disopyramide phosphate 13 BODY 62 DEVICE 80 disulfiram 124 DERMA-SMOOTHE/FS diazepam 13 DITROPAN XL 129 SCALP 62 DERMOTIC 122 diazepam (anticonvulsant) 17 DIURIL 66 DESCOVY 45 diazoxide 24 divalproex sodium 20 desipramine hcl 23 DIBENZYLINE 31 DIVIGEL 70 desloratadine 29 DICLEGIS 27 docetaxel 41 desmopressin acetate 69 diclofenac epolamine 58 DOCETAXEL 41 DESMOPRESSIN diclofenac potassium 4 docetaxel 41 ACETATE 69 diclofenac sodium 4 docusate calcium 76 desmopressin acetate 69 diclofenac sodium (actinic docusate sodium 76 desmopressin acetate spray 69 keratoses) 60 dofetilide 13 diclofenac sodium (ophth)121 desmopressin acetate spray DOLOPHINE 6 refrigerated 69 diclofenac sodium (topical) 58 donepezil hydrochloride 124 desogestrel & ethinyl diclofenac w/ misoprostol 4 estradiol 53 DOPTELET 74 dicloxacillin sodium 123 desogestrel-ethinyl estradiol DORAL 75 (biphasic) 53 dicyclomine hcl 127,128 desogestrel-ethinyl estradiol dorzolamide hcl 121 didanosine 45 dorzolamide hcl-timolol (triphasic) 53 DIFFERIN 57 desonide 62 maleate 119 DIFICID 77 DOVATO 45 DESOWEN 62 diflorasone diacetate 62 DOVONEX 60 desoximetasone 62 DIFLUCAN 28 doxazosin mesylate 31 DESOXYN 1 diflunisal 6 doxepin hcl 23 desvenlafaxine succinate 22 digoxin 50 doxepin hcl (antipruritic) 60 DETROL 129 dihydroergotamine doxepin hcl (sleep) 75 DETROL LA 129 mesylate 112 doxercalciferol 68 dexamethasone 54,55 DILANTIN 20 DOXIL 38 DEXAMETHASONE DILANTIN INFATABS 20 doxorubicin hcl 38 INTENSOL 55 DILANTIN-125 20 dexamethasone sodium doxorubicin hcl liposomal 38 DILAUDID 6 phosphate 55 doxycycline (monohydrate) 126

Index 8 doxycycline hyclate 126 drospirenone-ethinyl estradiol- EASY COMFORT INSULIN doxylamine-pyridoxine 27 levomefolate calcium 53 SYRINGE/U-100/0.5ML/30G X DROXIA 73 1/2" 94 DRISDOL 133 DRUG MART ADJUSTABLE EASY COMFORT INSULIN dronabinol 27 LANCING DEVICE 80 SYRINGE/U-100/1ML/30G X DROPLET GENTEEL LANCING DRUG MART LANCETS 1/2" 94 DEVICE 80 THIN 80 EASY MINI EJECT LANCING DROPLET INSULIN SYRINGE DRUG MART ON-THE-GO DEVICE 80 0.3ML/29G X 1/2" 93 LANCETS GENTLE 30G 80 EASY MINI LANCING DROPLET INSULIN SYRINGE DRUG MART UNILET DEVICE 80 0.5ML/29G X 1/2" 93 LANCETSSUPER THIN EASY TOUCH FLIPLOCK DROPLET INSULIN SYRINGE 30G 80 SAFETY INSULIN SYRINGE 1ML/29G X 1/2" 93 DRUG MART UNILET 1ML/29GX1/2" 94 DROPLET INSULIN SYRINGE LANCETSULTRA THIN EASY TOUCH FLIPLOCK U-100/0.3/31G X 5/16" 94 28G 80 SAFETY INSULIN SYRINGE DROPLET INSULIN SYRINGE DRUG MART UNILET MICRO 1ML/30GX1/2" 94 U-100/0.3ML/30G X 1/2" 94 THIN LANCETS 33G 80 EASY TOUCH FLIPLOCK DROPLET INSULIN SYRINGE DUAC 57 SAFETY INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 94 1ML/30GX5/16" 94 DROPLET INSULIN SYRINGE DUAVEE 69 EASY TOUCH FLIPLOCK U-100/0.5ML/30G X 1/2" 94 DUETACT 23 SAFETY INSULIN SYRINGE DROPLET INSULIN SYRINGE DULCOLAX 76 1ML/31GX5/16" 94 U-100/0.5ML/30G X 5/16" 94 duloxetine hcl 22 EASY TOUCH INSULIN DROPLET INSULIN SYRINGE SYRINGE/0.3ML/30G X U-100/0.5ML/31G X 5/16" 94 DUPIXENT 64 5/16" 94 DROPLET INSULIN SYRINGE DURAGESIC 6 EASY TOUCH INSULIN U-100/1ML/30G X 1/2" 94 DUREX EXTRA SYRINGE/0.3ML/31G X DROPLET INSULIN SYRINGE SENSITIVE 77 5/16" 95 U-100/1ML/30G X 5/16" 94 DUREZOL 120 EASY TOUCH INSULIN DROPLET INSULIN SYRINGE SYRINGE/0.5ML/29G X 1/2" 95 U-100/1ML/31G X 15/64" 94 dutasteride 72 EASY TOUCH INSULIN DROPLET INSULIN SYRINGE DYAZIDE 66 SYRINGE/0.5ML/30G X U-100/1ML/31G X 5/16" 94 DYRENIUM 66 5/16" 95 DROPLET INSULIN DYSPORT 119 EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/31G X SYRINGE/1ML/30G X 5/16" 95 5/16" 94 E-Z JECT LANCETS 80 EASY TOUCH INSULIN DROPLET INSULIN E-Z JECT LANCETS 21G 80 SYRINGE/SAFETY/U- SYRINGE/U-100/0.5ML/30G X E-Z JECT LANCETS 100/0.5ML/29G X 1/2" 95 1/2" 94 COLOR 80 EASY TOUCH INSULIN DROPLET INSULIN E-Z JECT LANCETS SUPER SYRINGE/SAFETY/U- SYRINGE/U-100/0.5ML/31G X THIN 30G 80 100/0.5ML/30G X 5/16" 95 5/16" 94 E-Z JECT LANCETS THIN EASY TOUCH INSULIN DROPLET INSULIN 26G 80 SYRINGE/SAFETY/U- SYRINGE/U-100/1ML/30G X E-ZJECT LANCETS MICRO- 100/1ML/29G X 1/2" 95 1/2" 94 THIN 33G 80 EASY TOUCH INSULIN DROPLET INSULIN E.E.S. GRANULES 77 SYRINGE/SAFETY/U- SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN 100/1ML/30G X 1/2" 95 15/64" 94 SYRINGE/0.5ML/30G X EASY TOUCH INSULIN DROPLET INSULIN 5/16" 94 SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN 1/2" 95 5/16" 94 SYRINGE/0.5ML/31G X EASY TOUCH INSULIN DROPLET LANCETS ULTRA 5/16" 94 SYRINGE/U-100/0.5ML/27G X THIN 30G 80 EASY COMFORT INSULIN 1/2" 95 DROPLET LANCING SYRINGE/1ML/30G X EASY TOUCH INSULIN DEVICE 80 5/16" 94 SYRINGE/U-100/0.5ML/28G X DROPLET PERSONAL EASY COMFORT INSULIN 1/2" 95 LANCETS30G 80 SYRINGE/1ML/31G X EASY TOUCH INSULIN drospirenone-ethinyl 5/16" 94 SYRINGE/U-100/0.5ML/29G X estradiol 53 1/2" 95

Index 9 EASY TOUCH INSULIN EASY TOUCH SAFETY ELIMITE 65 SYRINGE/U-100/0.5ML/30G X LANCETS21G/PRESSURE ELIQUIS 16 1/2" 95 ACTIVATED 81 EASY TOUCH INSULIN EASY TOUCH SAFETY ELIQUIS STARTER PACK 16 SYRINGE/U-100/0.5ML/31G X LANCETS23G/PRESSURE ELITE-THIN INSULIN 5/16" 95 ACTIVATED 81 SYRINGE/0.3ML/31G X EASY TOUCH INSULIN EASY TOUCH SAFETY 5/16" 95 SYRINGE/U-100/1ML/27G X LANCETS26G/BUTTON ELITE-THIN INSULIN 1/2" 95 ACTIVATED 81 SYRINGE/0.5ML/29G X 1/2" 95 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X LANCETS26G/PRESSURE SYRINGE/0.5ML/30G X 1/2" 95 ACTIVATED 81 5/16" 95 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X LANCETS28G/BUTTON SYRINGE/1ML/30G X 5/16" 95 1/2" 95 ACTIVATED 81 ELITE-THIN INSULIN EASY TOUCH INSULIN EASY TOUCH SAFETY SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/1ML/30G X LANCETS28G/PRESSURE 1/2" 96 1/2" 95 ACTIVATED 81 ELITE-THIN INSULIN EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/31G X SAFETY INSULIN SYRINGE 5/16" 96 5/16" 95 1ML/29GX1/2" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/28G X 21G/PRESSURE SAFETY INSULIN SYRINGE 1/2" 96 ACTIVATED 80 1ML/30GX5/16" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/29G X 23G/PRESSURE SAFETY INSULIN SYRINGE 1/2" 96 ACTIVATED 81 1ML/31GX5/16" 95 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/31G X 26G/PRESSURE SAFETY SYRINGE 5/16" 96 ACTIVATED 81 1ML/30GX1/2" 95 ELIXOPHYLLIN 16 EASY TOUCH LANCETS EASY TWIST & CAP ELLA 54 26G/PULL-TOP 81 LANCETS 81 ELLENCE 38 EASY TOUCH LANCETS EC-NAPROSYN 4 ELMIRON 72 28G/PRESSURE econazole nitrate 58 ACTIVATED 81 ELOCON 62 EDARBI 31 EASY TOUCH LANCETS EMBEDA 6 28G/PULL-TOP 81 EDECRIN 66 EMBRACE LANCETS ULTRA EASY TOUCH LANCETS EDURANT 45 THIN 30G 81 28G/TWIST 81 efavirenz 45 EMBRACE LANCING DEVICE EASY TOUCH LANCETS WITH EJECTOR 81 30G/BUTTON-ACTIVATED 81 efavirenz-emtricitabine- EASY TOUCH LANCETS tenofovir disoproxil EMCYT 37 30G/PRESSURE fumarate 45 EMEND 27 ACTIVATED 81 efavirenz-lamivudine-tenofovir EMEND TRIPACK 27 disoproxil fumarate 45 EASY TOUCH LANCETS EMFLAZA 55 30G/PULL-TOP 81 EFFEXOR XR 22 EASY TOUCH LANCETS EFFIENT 73 EMGALITY 111,112 30G/TWIST 81 EFUDEX 60 EMSAM 21 EASY TOUCH LANCETS EGRIFTA 67 emtricitabine 45 32G/PRESSURE emtricitabine-tenofovir disoproxil ACTIVATED 81 EGRIFTA SV 68 fumarate 45 EASY TOUCH LANCETS ELAPRASE 68 32G/PULL-TOP 81 EMTRIVA 45 EASY TOUCH LANCETS ELELYSO 73 EMVERM 10 32G/TWIST 81 ELESTRIN 70 ENABLEX 129 EASY TOUCH LANCETS eletriptan hydrobromide 112 enalapril maleate 31 33G/TWIST 81 ELIDEL 64 EASY TOUCH LANCING enalapril maleate & DEVICE/EJECTOR 81 ELIGARD 37 hydrochlorothiazide 32

Index 10 ENBREL 5 EQL SUPER THIN LANCETS EURAX 65 ENBREL MINI 5 30G 81 EVAMIST 70 EQL THIN LANCETS 26G 81 ENBREL SURECLICK 5 everolimus 39 EQUETRO 43 ENGERIX-B 130 everolimus ERAXIS 27 enoxaparin sodium 16 (immunosuppressant) 115 ERBITUX 37 EVISTA 68 entacapone 41 ergocalciferol 133 EVOCLIN 57 entecavir 48 ergoloid mesylates 125 EVOXAC 116 ENTEREG 71 ERGOMAR 112 EXEL COMFORT POINT ENTOCORT EC 55 ergotamine w/ caffeine 112 INSULIN SYRINGE/0.3ML/29G X ENTRESTO 51 1/2" 96 ERIVEDGE 37 EPCLUSA 48 EXEL COMFORT POINT erlotinib hcl 37 INSULIN SYRINGE/0.3ML/30G X EPIDIOLEX 18 ERTACZO 58 5/16" 96 EPIDUO 57 EXEL COMFORT POINT ertapenem sodium 11 epinastine hcl (ophth) 121 INSULIN SYRINGE/0.5ML/28G X ERWINASE 40 epinephrine (anaphylaxis) 133 1/2" 96 ERWINAZE 40 EXEL COMFORT POINT EPIPEN 2-PAK 133 ERYPED 200 77 INSULIN SYRINGE/0.5ML/29G X EPIPEN-JR 2-PAK 133 1/2" 96 ERYPED 400 77 epirubicin hcl 38 EXEL COMFORT POINT erythromycin (acne aid) 57 EPIVIR 45 INSULIN SYRINGE/0.5ML/30G X erythromycin (ophth) 120 5/16" 96 EPIVIR HBV 48 erythromycin base 77 EXEL COMFORT POINT eplerenone 33 INSULIN SYRINGE/1ML/28G X erythromycin EPOGEN 74 1/2" 96 ethylsuccinate 77 EXEL COMFORT POINT epoprostenol sodium 51 escitalopram oxalate 21 INSULIN SYRINGE/1ML/29G X eprosartan mesylate 31 ESGIC 5 1/2" 96 EPZICOM 46 esomeprazole EXEL COMFORT POINT EQL COLOR LANCETS 21G81 magnesium 128 INSULIN SYRINGE/1ML/30G X 96 EQL COLOR LANCETS MICRO estazolam 75 5/16" THIN 33G 81 ESTRACE 70 EXELDERM 58 EQL INSULIN estradiol 70 exemestane 37 SYRINGE/0.3ML/29G X 1/2" 96 estradiol vaginal 132 EXFORGE 32 EQL INSULIN EXFORGE HCT 32 SYRINGE/0.3ML/30G X estradiol valerate 70 5/16" 96 ESTROGEL 70 EXJADE 26 EQL INSULIN ESTROSTEP FE 53 EXTAVIA 125 SYRINGE/0.3ML/31G X eszopiclone 75 EZ-LETS LANCETS 21G 81 5/16" 96 EZ-LETS LANCETS 26G EQL INSULIN ethacrynic acid 66 SUPER-SOFT 81 SYRINGE/0.5ML/29G X 1/2" 96 ethambutol hcl 35 EZ-LETS LANCETS 28G EQL INSULIN ULTRA-SOFT 81 SYRINGE/0.5ML/30G X ethosuximide 20 5/16" 96 ethynodiol diacet & eth EZ-LETS LANCETS 30G 81 EQL INSULIN estrad 53 ezetimibe 30 SYRINGE/0.5ML/31G X etidronate disodium 67 ezetimibe-simvastatin 29 5/16" 96 etodolac 4 FABRAZYME 68 EQL INSULIN etonogestrel-ethinyl FALESSA 53 SYRINGE/1ML/29G X 1/2" 96 estradiol 54 EQL INSULIN ETOPOPHOS 41 famciclovir 48 SYRINGE/1ML/30G X 5/16" 96 famotidine 128 EQL INSULIN etoposide 41 SYRINGE/1ML/31G X 5/16" 96 etravirine 46 famotidine in nacl 128 EQL PRENATAL EUCRISA 64 FANAPT 43 FORMULA 116 FANAPT TITRATION PACK 43

Index 11 FANTASY LUBRICATED 77 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FANTASY COMFORTINSULIN 2020-2021 131 LUBRICATED/SPERMICIDE SYRINGE/0.5ML/31G X FLUBLOK QUADRIVALENT 77 5/16" 96 2021-2022 131 FARESTON 37 FIFTY50 SUPERIOR FLUCELVAX QUADRIVALENT COMFORTINSULIN 2019-2020 131 FARXIGA 25 SYRINGE/1ML/31G X FLUCELVAX QUADRIVALENT FASENRA 14 5/16" 96 2020-2021 131 FASENRA PEN 14 FIFTY50 UNILET LANCETS FLUCELVAX QUADRIVALENT 2021-2022 131 FASLODEX 37 33G 81 FINACEA 64 fluconazole 28 FAZACLO 44 finasteride 72 flucytosine 27 FC FEMALE CONDOM 77 FINE 30 81 fludarabine phosphate 36 febuxostat 73 FINGERSTIX LANCETS 81 fludrocortisone acetate 55 felbamate 19 FIORICET 6 FLULAVAL QUADRIVALENT FELBATOL 19 2019-2020 131 FIORICET/CODEINE 8 FELDENE 4 FLULAVAL QUADRIVALENT FIORINAL 6 felodipine 50 2020-2021 131 FIORINAL/CODEINE #3 8 FLULAVAL QUADRIVALENT FEMARA 37 FIRAZYR 73 2021-2022 131 FEMCAP 77 FLUMADINE 48 FIRDAPSE 34 FEMHRT 69 FLUMIST QUADRIVALENT131 FIRMAGON 37 FEMRING 132 flunisolide (nasal) 118 FIRVANQ 11 fenofibrate 30 fluocinolone acetonide 62 FLAGYL 10 fenofibrate micronized 30 fluocinolone acetonide flavoxate hcl 130 fenoprofen calcium 4 (otic) 122 flecainide acetate 13 62 FENSOLVI 68 fluocinonide FLECTOR 58 62 fentanyl 6 fluocinonide emulsified base FLOLAN 51 120 fentanyl citrate 6 fluorometholone (ophth) FLOMAX 72 36 FENTORA 6 fluorouracil FLONASE ALLERGY fluorouracil (topical) 60 FER-IN-SOL 74 RELIEF 118 21 FERRIPROX 26 FLONASE ALLERGY RELIEF fluoxetine hcl 125 ferrous fumarate-folic acid 74 CHILDRENS 118 fluoxetine hcl (pmdd) FLOVENT DISKUS 14 FLUOXETINE ferrous sulfate 74 FLOVENT HFA 14 HYDROCHLORIDE 22 FETZIMA 22 fluphenazine hcl 44 FLOXIN OTIC 122 FETZIMA TITRATION PACK22 flurandrenolide 62 floxuridine 36 fexofenadine hcl 29 flurbiprofen 4 FLUAD 2019-2020 130 fexofenadine-pseudoephedrine flurbiprofen sodium 121 56 FLUAD 2020-2021 130 37 FIASP 25 FLUAD QUADRIVALENT 2021- flutamide 62,63 FIASP FLEXTOUCH 25 2022 130 fluticasone propionate FLUAD QUADRIVALENT fluticasone propionate FIASP PENFILL 25 INFLUENZA VACCINE FOR (nasal) 119 FIBERCON 75 ADULTS 130 fluticasone-salmeterol 15 FIBRICOR 30 FLUARIX QUADRIVALENT fluvastatin sodium 30 2019-2020 130 FIFTY50 SAFETY SEAL fluvoxamine maleate 22 LANCETS 30G 81 FLUARIX QUADRIVALENT FIFTY50 SAFETY SEAL 2020-2021 130 FLUZONE HIGH-DOSE PF 2019- 2020 131 LANCETS 32G 81 FLUARIX QUADRIVALENT FIFTY50 SUPERIOR 2021-2022 130 FLUZONE HIGH-DOSE PF 2020- 131 COMFORTINSULIN FLUBLOK QUADRIVALENT 2021 2019-2020 131 FLUZONE HIGH-DOSE PF 2021- SYRINGE/0.3ML/31G X 2022 131 5/16" 96

Index 12 FLUZONE QUADRIVALENT FREESTYLE UNISTICK II GENTEEL PLUS LANCING 2019-2020 131 LANCETS 82 DEVICE/BUTTERFLY BLUE 82 FLUZONE QUADRIVALENT FROVA 112 GENTEEL PLUS LANCING 2020-2021 131 frovatriptan succinate 112 DEVICE/PLAYFUL PURPLE 82 FLUZONE QUADRIVALENT GENTEEL PLUS LANCING 2021-2022 131 FULPHILA 74 DEVICE/PRINCESS PINK 82 FML 121 fulvestrant 37 GENTEEL PLUS LANCING FML FORTE 120 FURADANTIN 12 DEVICE/WILLOWY WHITE 82 GENTLE-LET GP LANCETS 82 FML LIQUIFILM 121 furosemide 66 GENTLE-LET LANCETS FOCALIN 2 FUZEON 46 GENERAL PURPOSE FOCALIN XR 2 FYCOMPA 17 STYLE/FINE POINT 82 folic acid 74 gabapentin 18 GENTLE-LET LANCETS GABITRIL 20 GENERAL PURPOSE FOLOTYN 36 STYLE/MEDIUM POINT 82 fondaparinux sodium 16 GALAFOLD 68 GENTLE-LET LANCETS FORA GTEL BLOOD KETONE galantamine SAFETY STYLE/FINE TEST STRIPS 65 hydrobromide 124 POINT 82 FORA LANCETS 81 GAMMAGARD LIQUID 122 GENTLE-LET LANCETS FORA LANCING DEVICE 81 GAMMAGARD S/D IGA LESS SAFETY STYLE/MEDIUM FORA LANCING THAN 1MCG/ML 122 POINT 82 DEVICE/CLEARCAP 82 GAMMAKED 122 GENVOYA 46 FORFIVO XL 21 GAMUNEX-C 122 GEODON 43 FORTAZ 52 ganciclovir sodium 47 GILENYA 125 FOSAMAX 67 ganirelix acetate 67 GILOTRIF 37 FOSAMAX PLUS D 67 GANIRELIX ACETATE 67 glatiramer acetate 125 fosamprenavir calcium 46 GARDASIL 9 131 GLEEVEC 39 fosfomycin tromethamine 12 gatifloxacin (ophth) 120 GLEOSTINE 35 fosinopril sodium 31 gemcitabine hcl 36 glimepiride 25 fosinopril sodium & GEMCITABINE glipizide 25 hydrochlorothiazide 32 HYDROCHLORIDE 36 glipizide-metformin hcl 23 fosphenytoin sodium 20 gemfibrozil 30 GLOBAL EASY GLIDE INSULIN FOSRENOL 72 GENERESS FE 53 SYRINGE/1ML/31G X FRAGMIN 17 GENOTROPIN 68 15/64" 97 FREDS PHARMACY AUTOLET GENOTROPIN GLOBAL EASY GLIDE LANCING DEVICE 82 MINIQUICK 68 INSULINSYRINGE/U- FREDS PHARMACY UNILET gentamicin in saline 3 100/0.3ML/31G X 5/16" 97 GLOBAL INJECT EASE INSULIN LANCETS SUPER THIN gentamicin sulfate 3 30G 82 SYRINGE/U-100/0.3ML/29G X gentamicin sulfate 1/2" 97 FREDS PHARMACY UNILET (ophth) 120 LANCETS ULTRA THIN GLOBAL INJECT EASE INSULIN 28G 82 gentamicin sulfate (topical) 58 SYRINGE/U-100/0.3ML/30G X 1/2" 97 FREESTYLE LANCETS 82 GENTEEL BUTTERFLY TOUCH LANCETS 82 GLOBAL INJECT EASE INSULIN FREESTYLE PRECISION GENTEEL LANCING SYRINGE/U-100/0.3ML/30G X INSULIN SYRINGE/U- DEVICE/GLORIOUS 5/16" 97 100/0.5ML/30G X 5/16" 96 GOLD 82 GLOBAL INJECT EASE INSULIN FREESTYLE PRECISION GENTEEL LANCING SYRINGE/U-100/0.3ML/31G X INSULIN SYRINGE/U- DEVICE/PRECIOUS 5/16" 97 100/0.5ML/31G X 5/16" 96 PLATINUM 82 GLOBAL INJECT EASE INSULIN FREESTYLE PRECISION GENTEEL LANCING SYRINGE/U-100/0.5ML/28G X INSULIN SYRINGE/U- DEVICE/STATELY 1/2" 97 100/1ML/31G X 5/16" 97 SILVER 82 GLOBAL INJECT EASE INSULIN FREESTYLE PRECISION GENTEEL PLUS LANCING SYRINGE/U-100/0.5ML/29G X INSULIN SYRINGES/U- DEVICE/BUFF BLACK 82 1/2" 97 100/1ML/30G X 5/16" 97

Index 13 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP LANCETS THIN 26G 82 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X GNP PRENATAL 116 1/2" 97 1/2" 98 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X INSULIN SYRINGE/0.3ML/29G X 5/16" 97 5/16" 98 1/2" 98 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/31G X INSULIN SYRINGE/0.3ML/30G X 5/16" 97 5/16" 98 5/16" SHORT 98 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT GLUCOTROL 25 INSULIN SYRINGE/0.5ML/28G X SYRINGE/U-100/1ML/28G X GLUCOTROL XL 25 1/2" 97 1/2" 98 GLOBAL INJECT EASE INSULIN glyburide 25 GNP ULTRA COMFORT SYRINGE/U-100/1ML/29G X glyburide micronized 25 INSULIN SYRINGE/0.5ML/29G X 1/2" 98 1/2" 97 glyburide-metformin 23 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X glycine (gu irrigant) 72 INSULIN SYRINGE/1ML/28G X 1/2" 97 glycopyrrolate 128 1/2" 98 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT GLYNASE 25 INSULIN SYRINGE/1ML/29G X SYRINGE/U-100/1ML/30G X GLYSET 23 5/16" 97 1/2" 98 GLOBAL INJECT EASE INSULIN GLYXAMBI 23 GOJJI BLOOD KETONE TEST SYRINGE/U-100/1ML/31G X GNP INSULIN STRIPS 65 GOJJI LANCING 5/16" 97 SYRINGE/0.3ML/29G X GLOBAL INSULIN SYRINGE/U- 1/2" 98 DEVICE/CLEAR CAP 82 GOJJI STERILE LANCETS 100/0.3ML/30G X 1/2" 97 GNP INSULIN GLOBAL INSULIN SYRINGES/U- SYRINGE/0.3ML/30G X 30G 82 100/0.3ML/30GX5/16" 97 5/16" 98 GOLYTELY 75 GLOBAL LANCING DEVICE 82 GNP INSULIN GOODSENSE COLOR SYRINGE/0.3ML/31G X LANCETS MICRO-THIN 33G GLUCAGEN DIAGNOSTIC 65 5/16" 98 UNIVERSAL 82 GLUCAGEN HYPOKIT 24 GNP INSULIN GOODSENSE LANCETS glucagon (rdna) 24 SYRINGE/0.5ML/28G X MICRO-THIN 33G 82 GLUCAGON EMERGENCY 1/2" 98 GOODSENSE LANCETS KIT 24 GNP INSULIN MICRO-THIN 33G GLUCOCOM LANCETS SYRINGE/0.5ML/29G X UNIVERSAL 82 28G 82 1/2" 98 GOODSENSE LANCETS GLUCOCOM LANCETS GNP INSULIN ULTRA-THIN 26G 30G 82 SYRINGE/0.5ML/30G X UNIVERSAL 82 GLUCOCOM LANCETS 5/16" 98 GOODSENSE LANCETS 33G 82 GNP INSULIN ULTRA-THIN 30G 82 GLUCOPRO INSULIN SYRINGE/0.5ML/31G X GOODSENSE LANCETS SYRINGE/U-100/0.3ML/30G X 5/16" 98 ULTRA-THIN 30G 1/2" 97 GNP INSULIN UNIVERSAL 83 GLUCOPRO INSULIN SYRINGE/1ML/28G X 1/2" 98 GOODSENSE LANCING SYRINGE/U-100/0.3ML/30G X GNP INSULIN DEVICE 83 5/16" 97 SYRINGE/1ML/29G X 1/2" 98 GOODSENSE PRENATAL GLUCOPRO INSULIN GNP INSULIN VITAMINS 116 SYRINGE/U-100/0.3ML/31G X SYRINGE/1ML/30G X granisetron hcl 26 5/16" 97 5/16" 98 GRASTEK 3 GNP INSULIN GLUCOPRO INSULIN griseofulvin microsize 27 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/31G X 1/2" 97 5/16" 98 griseofulvin ultramicrosize 27 GLUCOPRO INSULIN GNP LANCETS 21G 82 guanfacine hcl 32 SYRINGE/U-100/0.5ML/30G X GNP LANCETS MICRO THIN guanfacine hcl (adhd) 2 5/16" 98 33G 82 GLUCOPRO INSULIN GNP LANCETS SUPER THIN GUANIDINE HCL 34 SYRINGE/U-100/0.5ML/31G X 30G 82 GVOKE PFS 24 5/16" 98 GNP LANCETS THIN 82 GYNAZOLE-1 132

Index 14 GYNE-LOTRIMIN 132 HEALTHY ACCENTS hydrochlorothiazide 66 H-E-B INCONTROL AUTOLET IMPRESSION hydrocodone bitartrate 6 ADVANCEDLANCING LANCING DEVICE 83 hydrocodone polistirex- DEVICE 83 HEALTHY ACCENTS UNILET LANCETS SUPER THIN chlorpheniramine polistirex 56 H-E-B INCONTROL LANCETS hydrocodone-acetaminophen 8 MICRO THIN 33G 83 30G 83 H-E-B INCONTROL LANCETS HECTOROL 68 hydrocodone-ibuprofen 8 SUPER THIN 30G 83 HEMANGEOL 49 hydrocortisone 55 H-E-B INCONTROL LANCETS HEPARIN LOCK FLUSH 17 hydrocortisone (intrarectal) 10 ULTRA THIN 28G 83 heparin sod (porcine) in hydrocortisone (rectal) 10 HAEGARDA 73 d5w 17 hydrocortisone (topical) 63 HAEMOLANCE 83 heparin sodium (porcine) 17 hydrocortisone acetate HAEMOLANCE LOW FLOW HEPARIN SODIUM/NACL (rectal) 10 LANCETS 83 0.45% 17 hydrocortisone butyrate 63 HAEMOLANCE PLUS 83 HEPLISAV-B 132 hydrocortisone valerate 63 HAEMOLANCE PLUS HIGH HEPSERA 48 FLOW 83 hydrocortisone w/acetic HAEMOLANCE PLUS LOW HERCEPTIN 36 acid 122 FLOW 83 HETLIOZ 75 hydromorphone hcl 6 HAEMOLANCE PLUS MAX HIBERIX 130 HYDROMORPHONE FLOW 83 HYDROCHLORIDE 6 HIPREX 12 HAEMOLANCE PLUS hydroxychloroquine sulfate 34 HIZENTRA 122 PEDIATRIC FLOW 83 hydroxyurea 40 HALAVEN 41 HM PRENATAL 116 hydroxyzine hcl 13 halcinonide 63 HM ULTICARE INSULIN hydroxyzine pamoate 13 HALCION 75 SYRINGE/1ML/30G X 1/2" 99 HM ULTICARE INSULIN HYPER-SAL 56 HALDOL 43 SYRINGE/U-100/0.3ML/31G X HYPERSAL 56 HALDOL DECANOATE 100 43 5/16" 99 HYQVIA 122 HALDOL DECANOATE 50 43 HORIZANT 125 HYZAAR 32 halobetasol propionate 63 HUMATIN 3 ibandronate sodium 67 HALOG 63 HUMATROPE 68 IBRANCE 39 haloperidol 43 HUMATROPE COMBO ibuprofen 4 haloperidol decanoate 43 PACK 68 HUMIRA 4 icatibant acetate 73 haloperidol lactate 43 HUMIRA PEDIATRIC CROHNS ICLUSIG 39 HAVRIX 132 DISEASE STARTER PACK 3 icosapent ethyl 29 HEALTH CARE LANCING HUMIRA PEN 3 IDAMYCIN PFS 38 DEVICE 83 HUMIRA PEN-CD/UC/HS HEALTHWISE INSULIN STARTER 4 idarubicin hcl 38 SYRINGE/U-100/0.3ML/30G X HUMIRA PEN-PEDIATRIC UC IFEX 35 5/16" 98 STARTER PACK 4 ifosfamide 35 HEALTHWISE INSULIN HUMIRA PEN-PS/UV SYRINGE/U-100/0.3ML/31G X STARTER 4 ILARIS 4 5/16" 98 HUMULIN R U-500 ILEVRO 121 HEALTHWISE INSULIN (CONCENTRATED) 25 imatinib mesylate 39 SYRINGE/U-100/0.5ML/30G X HUMULIN R U-500 IMBRUVICA 39 5/16" 98 KWIKPEN 25 HEALTHWISE INSULIN HY-VEE LANCETS 83 imipenem-cilastatin 11 SYRINGE/U-100/0.5ML/31G X imipramine hcl 23 5/16" 98 HY-VEE THIN LANCETS 83 HEALTHWISE INSULIN HYCAMTIN 41 imipramine pamoate 23 SYRINGE/U-100/1ML/30G X hydralazine hcl 33 imiquimod 64 5/16" 98 HYDREA 40 IMITREX 112 HEALTHWISE INSULIN IMITREX STATDOSE SYRINGE/U-100/1ML/31G X HYDRO 35 64 REFILL 112 5/16" 99

Index 15 IMITREX STATDOSE INSULIN SYRINGE/NEEDLE IONOSOL-MB/DEXTROSE SYSTEM 112 1ML/30G X 5/16" 99 5% 114 IMODIUM A-D 26 INSULIN SYRINGE/NEEDLE IOPIDINE 120 IMPAVIDO 10 1ML/31G X 5/16" 99 IPOL INACTIVATED IPV 132 INSULIN SYRINGE/U- IMURAN 115 100/0.3ML/29G X 1/2" 99 ipratropium bromide 14 IN TOUCH LANCING INSULIN SYRINGE/U- ipratropium bromide (nasal)118 DEVICE 83 100/0.5ML/29G X 1/2" 99 ipratropium-albuterol 15 IN TOUCH STERILE INSULIN SYRINGE/U- LANCETS30G 83 100/1ML/29G X 1/2" 99 irbesartan 31 INCRELEX 68 INSULIN SYRINGE/U- irbesartan-hydrochlorothiazide 32 INCRUSE ELLIPTA 14 100/1ML/30G X 5/16" 99 INSULIN SYRINGE/U- irinotecan hcl 41 indapamide 66 100/1ML/31G X 5/16" 99 irrigation solutions, INDERAL LA 49 INSULIN physiological 116 indomethacin 5 SYRINGES/0.5ML/27GX1/2" ISENTRESS 46 INFANRIX 127 99 ISENTRESS HD 46 INSULIN INFLECTRA 71 SYRINGES/0.5ML/28GX1/2" ISOLYTE-P/DEXTROSE INLYTA 36 99 5% 114 ISOLYTE-S 114 INREBIC 39 INSULIN SYRINGES/0.5ML/29GX1/2" isoniazid 35 INSPRA 33 100 ISOPTO CARPINE 119 INSULIN SYRINGE/0.3ML/29G X INSULIN 1" 99 SYRINGES/0.5ML/30GX5/16" ISORDIL TITRADOSE 12 INSULIN SYRINGE/0.3ML/29G X 100 isosorbide dinitrate 12 1/2" 99 INSULIN isosorbide mononitrate 12 INSULIN SYRINGE/0.3ML/30G X SYRINGES/0.5ML/31GX isotretinoin 57 5/16" 99 5/16" 100 INSULIN SYRINGE/0.3ML/31G X INSULIN isradipine 50 5/16" 99 SYRINGES/0.5ML/31GX5/16" ISTODAX (OVERFILL) 39 INSULIN SYRINGE/0.5ML/27G X 100 1/2" 99 itraconazole 28 INSULIN ivermectin 10 INSULIN SYRINGE/0.5ML/28G X SYRINGES/1ML/27GX/1/2" 1/2" 99 100 IVERMECTIN 65 INSULIN SYRINGE/0.5ML/30G X INSULIN ivermectin (pediculicide) 65 1/2" 99 INSULIN SYRINGE/0.5ML/30G X SYRINGES/1ML/27GX1/2" IXEMPRA KIT 41 100 5/16" 99 JADENU 26 INSULIN SYRINGE/0.5ML/31G X INSULIN SYRINGES/1ML/28GX1/2" JADENU SPRINKLE 26 5/16" 99 INSULIN SYRINGE/1ML/28G X 100 JAKAFI 39 1/2" 99 INSULIN JANUMET 23 SYRINGES/1ML/29GX1/2" INSULIN SYRINGE/1ML/29G X JANUMET XR 24 1/2" 99 100 INSULIN SYRINGE/1ML/30G X INSULIN JANUVIA 24 5/16" 99 SYRINGES/1ML/30GX1/2" JARDIANCE 25 INSULIN SYRINGE/NEEDLE 100 INSULIN JEVTANA 41 0.3ML/30G X 5/16" 99 JUBLIA 58 INSULIN SYRINGE/NEEDLE SYRINGES/1ML/31GX5/16" 0.3ML/31G X 5/16" 99 100 JULUCA 46 INSULIN SYRINGE/NEEDLE INTELENCE 46 JYNARQUE 69 0.5ML/29G X 1/2" 99 INTRAROSA 132 K-TAB 114 INSULIN SYRINGE/NEEDLE INTRON A 40 K-Y ME & YOU EXTRA 0.5ML/30G X 5/16" 99 LUBRICATED 77 INSULIN SYRINGE/NEEDLE INTUNIV 2 0.5ML/31G X 5/16" 99 INVANZ 11 K-Y ME & YOU INTENSE 77 INSULIN SYRINGE/NEEDLE INVEGA 43 KADIAN 6 1ML/29G X 1/2" 99 INVIRASE 46 KALETRA 46

Index 16 KALYDECO 126 KINRAY INSULIN SYRINGE KROGER LANCETS SUPER KAMELEON LUBRICATED 77 PREFERRED PLUS/1ML/31G THIN 83 X 5/16" 100 KROGER LANCETS THIN 83 KAPVAY 2 KINRAY INSULIN KROGER LANCETS THIN KAZANO 24 SYRINGE/0.5ML/29G X 26G 83 KCL 0.3%/D5W/NACL 1/2" 100 KROGER LANCETS 0.9% 114 KINRIX 127 ULTRATHIN30G 83 KEFLEX 52 KISQALI 39 KROGER LANCING KENALOG-40 55 KITABIS PAK 3 DEVICE 83 KRYSTEXXA 73 KEPIVANCE 40 KLARITY-A 120 KUVAN 68 KEPPRA 18 KLARON 57 KYLEENA 54 KEPPRA XR 18 KLONOPIN 17 KERYDIN 58 KMART VALU PLUS INSULIN KYPROLIS 39 ketoconazole 28 SYRINGE/1ML/29G 100 labetalol hcl 49 KMART VALU PLUS INSULIN ketoconazole (topical) 58 LAC-HYDRIN 64 SYRINGE/1ML/30G 100 LAC-HYDRIN TWELVE 64 KETONE 65 KOSELUGO 39 LACRISERT 119 KETONE TEST STRIPS 65 KP PRENATAL ketoprofen 5 MULTIVITAMINS 116 lactated ringer's 114 ketorolac tromethamine 5 KRINTAFEL 34 lactated ringer's (irrigation) 116 ketorolac tromethamine KROGER AUTOLET LANCING lactic acid (ammonium (ophth) 121 DEVICE 83 lactate) 64 KETOSTIX 65 KROGER HEALTHPRO TWIST lactulose 76 LANCETS/26G 83 lactulose (encephalopathy) 71 ketotifen fumarate (ophth) 121 KROGER INSULIN KEVEYIS 66 SYRINGE/0.3ML/29G X LAMICTAL 18 LAMICTAL CHEWABLE KHEDEZLA 22 1/2" 100 KROGER INSULIN DISPERSIBLE 18 KIMONO COLORS 77 SYRINGE/0.3ML/30G X LAMICTAL ODT 18 KIMONO LUBRICATED 77 5/16" 100 lamivudine 46 KIMONO MICRO THIN PLUS KROGER INSULIN lamivudine (hbv) 48 SPERMICIDE LUBRICATED77 SYRINGE/0.3ML/31G X KIMONO PLUS SPERMICIDE 5/16" 100 lamivudine-zidovudine 46 LUBRICATED 77 KROGER INSULIN lamotrigine 18 KIMONO PLUS SYRINGE/0.5ML/29G X LANCET DEVICE SPERMICIDE/LUBRICATED 1/2" 100 ADJUSTABLE 83 77 KROGER INSULIN LANCET DEVICE WITH KIMONO PS LUBRICATED 77 SYRINGE/0.5ML/30G X EJECTOR 83 KIMONO PS PLUS 5/16" 100 LANCETS 83 SPERMICIDE/LUBRICATED KROGER INSULIN LANCETS 26G TWIST TOP 83 77 SYRINGE/0.5ML/31G X KIMONO SENSATION 5/16" 100 LANCETS 30G 83 LUBRICATED 77 KROGER INSULIN LANCETS 30G TWIST TOP 83 KIMONO SENSATION PLUS SYRINGE/1ML/29G X LANCETS 30G/TWIST TOP 83 SPERMICIDE LUBRICATED77 1/2" 100 LANCETS 31G TWIST TOP 83 KIMONO SPECIAL 77 KROGER INSULIN SYRINGE/1ML/30G X LANCETS 33G EXTRA KINNEY LANCETS 83 5/16" 100 FINE 83 KINNEY THIN LANCETS 83 KROGER INSULIN LANCETS MICRO THIN KINRAY INSULIN SYRINGE SYRINGE/1ML/31G X 33G 83 PREFERRED PLUS/0.3ML/31G 5/16" 100 LANCETS SAFETY SEAL X 5/16" 100 21G 84 KROGER LANCETS 83 LANCETS SAFETY SEAL KINRAY INSULIN SYRINGE KROGER LANCETS 21G 83 PREFERRED PLUS/0.5ML/31G 26G 84 X 5/16" 100 KROGER LANCETS MICRO LANCETS SAFETY SEAL THIN33G 83 28G 84

Index 17 LANCETS SAFETY SEAL LEADER INSULIN LIBERTY MEDICAL LANCETS 30G 84 SYRINGE/1ML/31G X 30G 84 LANCETS SUPER THIN 5/16" 101 LIBERTY MINI LANCING 28G 84 leflunomide 5 DEVICE 84 LANCETS THIN 84 LENVIMA 10 MG DAILY LIBRAX 128 LANCETS TWIST TOP 84 DOSE 36 lidocaine 64 LANCETS ULTRA THIN 84 LENVIMA 12MG DAILY lidocaine hcl 64 DOSE 36 LANCETS ULTRA THIN LENVIMA 14 MG DAILY lidocaine hcl (local anesth.) 76 30G 84 DOSE 36 lidocaine hcl (mouth-throat) 116 LANCETSBULLSEYE LENVIMA 18 MG DAILY lidocaine-prilocaine 64 SAFETY 84 DOSE 36 LANCING DEVICE 84 LENVIMA 20 MG DAILY LIDODERM 64 LANCING DEVICE DOSE 36 LIFESCAN UNISTIK 2 DEEP ADJUSTABLE 84 LENVIMA 24 MG DAILY PENETRATION 84 LANOXIN 50,51 DOSE 36 LIFESCAN UNISTIK II LANCETS 84 lansoprazole 128 LENVIMA 4 MG DAILY DOSE 36 LILETTA 54 lanthanum carbonate 72 LENVIMA 8 MG DAILY LINCOCIN 12 LANZO 84 DOSE 36 lincomycin hcl 12 lapatinib ditosylate 39 LETAIRIS 51 lindane 65 LASIX 66 letrozole 37 linezolid 12 LASTACAFT 121 leucovorin calcium 40 LINZESS 71 latanoprost 122 LEUKERAN 35 liothyronine sodium 127 LATUDA 43 LEUKINE 74 LIPITOR 30 LEADER ADVANCED LANCING leuprolide acetate 37 LIPOFEN 30 DEVICE 84 levalbuterol hcl 15 LEADER INSULIN lisinopril 31 SYRINGE/0.3ML/29G X levalbuterol tartrate 15 lisinopril & 1/2" 100 LEVAQUIN 70 hydrochlorothiazide 32 LEADER INSULIN LEVEMIR 25 LITE TOUCH LANCETS 84 SYRINGE/0.3ML/30G X LITE TOUCH LANCING 5/16" 100 LEVEMIR FLEXTOUCH 25 levetiracetam 18 PEN 84 LEADER INSULIN LITETOUCH INSULIN SYRINGE/0.3ML/31G X levobunolol hcl 119 SYRINGE/0.3ML/29G X 5/16" 100 levocetirizine 1/2" 101 LEADER INSULIN dihydrochloride 29 LITETOUCH INSULIN SYRINGE/0.5ML/28G X levofloxacin 70 SYRINGE/0.3ML/30G X 1/2" 100 levofloxacin (ophth) 120 5/16" 101 LEADER INSULIN LITETOUCH INSULIN SYRINGE/0.5ML/29G X levofloxacin in d5w 70 SYRINGE/0.3ML/31G X 1/2" 100 levonorgestrel & eth 5/16" 101 LEADER INSULIN estradiol 53 LITETOUCH INSULIN SYRINGE/0.5ML/30G X levonorgestrel (emergency SYRINGE/0.5ML/30G X 5/16" 100 oc) 54 5/16" 101 LEADER INSULIN levonorgestrel-eth estradiol LITETOUCH INSULIN SYRINGE/0.5ML/31G X (triphasic) 53 SYRINGE/0.5ML/31G X 5/16" 101 levonorgestrel-ethinyl estradiol 5/16" 101 LEADER INSULIN (91-day) 53 LITETOUCH INSULIN SYRINGE/1ML/28G X 1/2" 101 levonorgestrel-ethinyl estradiol SYRINGE/1ML/30G X LEADER INSULIN (continuous) 53 5/16" 101 SYRINGE/1ML/29G X 1/2" 101 levorphanol tartrate 6 LITETOUCH INSULIN LEADER INSULIN levothyroxine sodium 127 SYRINGE/U-100/0.3ML/30G X SYRINGE/1ML/30G X LEXAPRO 22 5/16" 101 5/16" 101 LITETOUCH INSULIN LEXIVA 46 SYRINGE/U-100/0.3ML/31G X LIALDA 71 5/16" 101

Index 18 LITETOUCH INSULIN LOPROX SHAMPOO 58 LYSTEDA 74 SYRINGE/U-100/0.5ML/28G X loratadine 29 M-M-R II 132 1/2" 101 LITETOUCH INSULIN loratadine & M-NATAL PLUS 116 SYRINGE/U-100/0.5ML/29G X pseudoephedrine 56 MACROBID 12 lorazepam 13 1/2" 101 MACRODANTIN 12 LITETOUCH INSULIN LORBRENA 39 mafenide acetate 61 SYRINGE/U-100/0.5ML/30G X LORTAB 9 5/16" 101 MAGELLAN INSULIN SAFETY LITETOUCH INSULIN losartan potassium 31 SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/0.5ML/31G X losartan potassium & 1/2" 101 5/16" 101 hydrochlorothiazide 32 MAGELLAN INSULIN SAFETY LITETOUCH INSULIN LOSEASONIQUE 53 SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/1ML/28G X LOTEMAX 121 5/16" 101 MAGELLAN INSULIN SAFETY 1/2" 101 LOTENSIN 31 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/1ML/29G X LOTENSIN HCT 32 1/2" 101 1/2" 101 loteprednol etabonate 121 MAGELLAN INSULIN SAFETY LITETOUCH INSULIN LOTREL 32 SYRINGE/U-100/0.5ML/30G X 5/16" 101 SYRINGE/U-100/1ML/30G X LOTRIMIN AF 58 5/16" 101 MAGELLAN INSULIN SAFETY LITETOUCH INSULIN LOTRIMIN AF JOCK ITCH 58 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/1ML/31G X LOTRIMIN ULTRA 58 1/2" 101 MAGELLAN INSULIN SAFETY 5/16" 101 LOTRISONE 59 LITETOUCH LANCETS MICRO SYRINGE/U-100/1ML/30G X THIN 33G 84 LOTRONEX 71 5/16" 102 LITHIUM 43 lovastatin 30 magnesium sulfate 114 lithium carbonate 43 LOVAZA 29 MALARONE 34 LITHOBID 43 LOVENOX 17 malathion 65 LIVALO 30 loxapine succinate 44 maprotiline hcl 21 LIVE BETTER ADVANCED lubiprostone 71 MARCAINE 76 LANCING DEVICE 84 LUCEMYRA 124 MARINOL 27 LIVE BETTER LANCET luliconazole 59 MARPLAN 21 SUPERTHIN 30G 84 LIVE BETTER LANCET LUMIGAN 122 MATULANE 40 ULTRATHIN 28G 84 LUMIZYME 68 MAVENCLAD 125 LO LOESTRIN FE 53 LUNESTA 75 MAVYRET 48 LOCOID 63 LUPANETA PACK 68 MAXALT 112 LODINE 5 LUPRON DEPOT (1- MAXALT-MLT 112 LODOSYN 41 MONTH) 37 MAXI-COMFORT INSULIN LUPRON DEPOT (3- SYRINGE/U- LOMOTIL 26 MONTH) 37 LONGS INSULIN 100/0.5ML/28GX1/2" 102 LUPRON DEPOT (4- MAXI-COMFORT INSULIN SYRINGE/0.5ML/31G X MONTH) 37 5/16" 101 SYRINGE/U-100/1ML/28GX1/2" LUPRON DEPOT (6- 102 LONGS LANCETS MONTH) 37 STANDARD 84 MAXICOMFORT INSULIN LUPRON DEPOT-PED (1- SYRINGES 27G X 1/2" 102 LONGS LANCETS THIN 84 MONTH) 68 MAXIDEX 121 LONGS LANCETS ULTRA LUPRON DEPOT-PED (3- THIN 84 MONTH) 68 MAXIPIME 52 loperamide hcl 26 LUXIQ 63 MAXITROL 121 LOPID 30 LUZU 59 MAXX LUBRICATED 77 lopinavir-ritonavir 46 LYNPARZA 39 MAXX PLUS SPERMICIDE LUBRICATED 77 LOPRESSOR 49 LYRICA 18 MAXZIDE 66 LOPRESSOR HCT 32 LYRICA CR 125 MAXZIDE-25 66 LOPROX 58 LYSODREN 37

Index 19 MAYZENT 125 mefloquine hcl 34 METHITEST 10 MAYZENT STARTER MEGACE ES 123 methocarbamol 118 PACK 125 megestrol acetate 37 METHOTREXATE 4 meclizine hcl 26 megestrol acetate methotrexate sodium 36 meclofenamate sodium 5 (appetite) 124 methoxsalen rapid 60 MEDIC INSULIN MEIJER COLOR LANCETS SYRINGE/0.3ML/30G X UNIVERSAL 33G 85 methscopolamine bromide 128 5/16" 102 MEIJER LANCETS 85 methyldopa 32 MEDIC INSULIN MEIJER LANCETS THIN 85 METHYLIN 2 SYRINGE/0.5ML/30G X MEIJER LANCETS 5/16" 102 methylphenidate hcl 2 UNIVERSAL21G 85 methylprednisolone 55 MEDICHOICE PRE-SET MEIJER LANCETS SAFETY LANCET DUAL UNIVERSAL30G 85 methylprednisolone acetate 55 USE 84 MEIJER LANCETS methylprednisolone sod MEDICHOICE PRE-SET UNIVERSAL33G 85 succ 55 SAFETY LANCET LOW MEIJER SUPER THIN metoclopramide hcl 71 FLOW 84 LANCETS 85 MEDICHOICE PRE-SET metolazone 66 SAFETY LANCET MEDIUM MEKINIST 39 metoprolol & FLOW 84 MEKTOVI 39 hydrochlorothiazide 32 MEDICHOICE PRE-SET meloxicam 5 metoprolol succinate 49 SAFETY LANCET MODERATE melphalan 35 metoprolol tartrate 49 FLOW 84 METROCREAM 64 MEDICHOICE SAFETY melphalan hcl 35 LANCETEXTRA 84 memantine hcl 124 METROGEL 64 MEDICHOICE SAFETY MENACTRA 130 METROGEL-VAGINAL 132 LANCETNORMAL 84 METROLOTION 64 MEDISENSE THIN MENEST 70 LANCETS 84 MENOSTAR 70 metronidazole 10 MEDLANCE PLUS EXTRA MENQUADFI 130 metronidazole (topical) 64 LANCETS 21G 84 MENVEO 130 metronidazole vaginal 132 MEDLANCE PLUS mexiletine hcl 13 LANCETS 84 meperidine hcl 7 MEDLANCE PLUS LANCETS meprobamate 13 micafungin sodium 27 LITE 25G 84 MEPRON 11 MICARDIS 31 MEDLANCE PLUS LITE MICARDIS HCT 33 LANCETS 25G 84 mercaptopurine 36 MEDLANCE PLUS SPECIAL meropenem 11 miconazole nitrate vaginal 132 LANCETS 0.8MM 84 MERREM 11 MICROLET LANCETS 85 MEDLANCE PLUS SUPERLITE mesalamine 71 MICROLET NEXT 85 30G 84 MEDLANCE PLUS SUPERLITE MESTINON 34 midodrine hcl 133 30G/COMFORT MAX 84 MESTINON TIMESPAN 34 miglitol 23 MEDLANCE PLUS UNIVERSAL metaxalone 118 miglustat 73 LANCETS 21G 85 MIGRANAL 112 MEDLANCE PLUS/LITE metformin hcl 24 25G 85 methadone hcl 7 MILLIPRED 55 MEDLANCE/EXTRA 85 METHADONE HCL 7 MILLIPRED DP 55 MEDLANCE/LITE 85 methadone hcl 7 MINASTRIN 24 FE 53 MEDLANCE/UNIVERSAL 85 METHADOSE 7 MINI LANCING DEVICE 85 MEDROL 55 METHADOSE SUGAR- MINIPRESS 32 MEDROL DOSEPAK 55 FREE 7 MINIVELLE 70 medroxyprogesterone methamphetamine hcl 1 MINOCIN 126 acetate 123 methazolamide 66 minocycline hcl 126 medroxyprogesterone acetate methenamine hippurate 12 minoxidil 33 (contraceptive) 54 methimazole 127 mefenamic acid 5 MIRAPEX 42

Index 20 MIRCERA 74 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIRCETTE 53 SYRINGE/SAFETY/PERM INSULIN SYRINGE/1ML/28G X NEEDLE/0.5ML/29G X 1/2" 103 MIRENA 54 1/2" 102 MONOJECT ULTRA COMFORT mirtazapine 20 MONOJECT INSULIN INSULIN SYRINGE/1ML/29G X MIRVASO 65 SYRINGE/SAFETY/PERM 1/2" 103 misoprostol 129 NEEDLE/1ML/29G X 1/2" 102 MONOLET LANCETS 85 MONOJECT INSULIN MONOLET OPD LANCETS 85 MITIGARE 73 SYRINGE/SOFTPACK/1ML/27 G X 1/2" 102 MONOLETTOR SAFETY mitomycin 38 LANCETS 85 mitoxantrone hcl 38 MONOJECT INSULIN SYRINGE/SOFTPACK/U- montelukast sodium 14 MM INSULIN SYRINGE/U- MONUROL 12 100/0.3ML/30G X 5/16" 102 100/0.5ML/28G X 1/2" 102 MM INSULIN SYRINGE/U- MONOJECT INSULIN MORPHABOND ER 7 100/0.3ML/31G X 5/16" 102 SYRINGE/U-100/0.3ML/30G X morphine sulfate 7 5/16" 102 MM INSULIN SYRINGE/U- MORPHINE SULFATE 7 100/1/2ML/30G X 5/16" 102 MONOJECT INSULIN MM INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X morphine sulfate 7 100/1/2ML/31G X 5/16" 102 5/16" 102 MOTOFEN 26 MONOJECT INSULIN MM INSULIN SYRINGE/U- MOVIPREP 76 100/1ML/30G X 5/16" 102 SYRINGE/U-100/1ML/28G X MM INSULIN SYRINGE/U- 1/2" 103 moxifloxacin hcl 70 100/1ML/31G X 5/16" 102 MONOJECT INSULIN moxifloxacin hcl (ophth) 120 MM LANCING DEVICE 85 SYRINGE/U-100/1ML/30G X moxifloxacin hcl in sodium 5/16" 103 MM TWIST LANCETS 85 chloride 70 MONOJECT INSULIN MOZOBIL 74 SYRINGEREGULAR LUER MOBIC 5 MPD SAFETY LANCET modafinil 2,3 TIP/SOFTPACK/1ML 103 MONOJECT ULTRA 21G/1.8MM 85 moexipril hcl 31 MPD SAFETY LANCET COMFORT INSULIN 28G/1.8MM 85 mometasone furoate 63 SYRINGE/0.3ML/29G X mometasone furoate MPD SAFETY LANCET 1/2" 103 30G/1.8MM 85 (nasal) 119 MONOJECT ULTRA MONISTAT SOOTHING CARE MPD SAFETY LANCETS COMFORT INSULIN 23G/1.8MM 85 ITCH RELIEF 63 SYRINGE/0.3ML/30G X MONOJECT INSULIN 5/16" 103 MS CONTIN 7 SYRINGE/1ML 102 MONOJECT ULTRA MS INSULIN MONOJECT INSULIN COMFORT INSULIN SYRINGE/0.3ML/31G X SYRINGE/1ML/31G X SYRINGE/0.3ML/31G X 5/16" 103 5/16" 102 5/16" 103 MS INSULIN MONOJECT INSULIN MONOJECT ULTRA SYRINGE/0.5ML/31G X SYRINGE/DETACH COMFORT INSULIN 5/16" 103 NEEDLE/1ML/25G X 5/8" 102 SYRINGE/0.5ML/28G X MS INSULIN SYRINGE/1ML/31G MONOJECT INSULIN 1/2" 103 X 5/16" 103 SYRINGE/DETACH MONOJECT ULTRA MULPLETA 74 NEEDLE/1ML/27G X 1/2" 102 COMFORT INSULIN MULTAQ 13 MONOJECT INSULIN SYRINGE/0.5ML/29G X MULTI PRENATAL 116 SYRINGE/PERM 1/2" 103 NEEDLE/1ML/28G X 1/2" 102 MONOJECT ULTRA MULTI-LANCET DEVICE 85 MONOJECT INSULIN COMFORT INSULIN mupirocin 58 SYRINGE/PERM NEEDLE/U- SYRINGE/0.5ML/30G X MVASI 36 100/0.5ML/28G X 1/2" 102 5/16" 103 MYALEPT 68 MONOJECT INSULIN MONOJECT ULTRA SYRINGE/SAFETY/PERM COMFORT INSULIN MYAMBUTOL 35 NEEDLE/0.3ML/29G X 1/2" 102 SYRINGE/0.5ML/31G X MYCAMINE 27 MONOJECT INSULIN 5/16" 103 MYCOBUTIN 35 SYRINGE/SAFETY/PERM NEEDLE/0.3ML/29GX1/2" 102 mycophenolate mofetil 115 mycophenolate sodium 115

Index 21 MYDRIACYL 119 neomycin-polymy- nitisinone 69 MYFORTIC 115 dexameth 121 NITRO-BID 12 neomycin-polymyxin-hc MYGLUCOHEALTH MGH (ophth) 121 NITRO-DUR 12 SOFTLANCE LANCETS neomycin-polymyxin-hc nitrofurantoin 12 30G 85 (otic) 122 MYLERAN 35 nitrofurantoin macrocrystal 12 NEONATAL COMPLETE 116 nitrofurantoin monohyd MYRBETRIQ 129 NEONATAL PLUS 117 macro 12 MYSOLINE 18 NEONATAL VITAMIN 117 nitroglycerin 12 nabumetone 5 NEORAL 115 NITROGLYCERIN 12 nadolol 49 NEOSTIGMINE nitroglycerin 12 nafcillin sodium 123 METHYLSULFATE 34 NITROSTAT 12 naftifine hcl 59 NESINA 24 NIVA-PLUS 117 NAFTIFINE NEULASTA 74 NIVESTYM 74 HYDROCHLORIDE 59 NEULASTA ONPRO KIT 74 NAFTIN 59 NIX CREME RINSE 65 NEUPOGEN 74 nizatidine 128 NAGLAZYME 68 NEUPRO 42 nalbuphine hcl 9 NIZORAL 59 NEURONTIN 18,19 NORCO 9 NALFON 5 NEVANAC 121 naloxone hcl 26 NORDITROPIN FLEXPRO 68 nevirapine 46 norelgestromin-ethinyl naltrexone hcl 26 NEXAVAR 39 estradiol 54 NAMENDA 124 NEXIUM 128 norethin acet & estrad-fe 53 NAMENDA TITRATION norethindrone & eth estradiol53 PAK 124 NEXIUM 24HR 128 NEXPLANON 54 norethindrone & ethinyl estradiol- NAPROSYN 5 fe 53 naproxen 5 niacin 133 norethindrone naproxen sodium 5 niacin (antihyperlipidemic) 30 (contraceptive) 54 naratriptan hcl 112 NIACIN TR 133 norethindrone acet & eth niacinamide 133 estra 53 NARCAN 26 norethindrone acetate 124 NIASPAN 30 NARDIL 21 norethindrone acetate-ethinyl NAROPIN 76 nicardipine hcl 50 estradiol 70 NASACORT ALLERGY NICODERM CQ 126 norethindrone acetate-ethinyl 24HR 119 NICORETTE 126 estradiol-fe 53 norethindrone-eth estradiol NASACORT ALLERGY 24HR NICORETTE MINI 126 CHILDRENS 119 (triphasic) 53 NICORETTE STARTER NASONEX 119 norgestimate-ethinyl KIT 126 estradiol 53 NATACYN 120 nicotine 126 norgestimate-ethinyl estradiol NATAZIA 53 nicotine polacrilex 126 (triphasic) 53 nateglinide 25 NICOTINE TRANSDERMAL norgestrel & ethinyl estradiol 53 NATROBA 65 SYSTEM 126 NORMOSOL-M IN D5W 114 NATURE-THROID 127 NICOTROL INHALER 126 NORMOSOL-M/D5W 114 NATURE-THROID NT-2.5 127 NICOTROL NS 126 NORMOSOL-R 114 NAVELBINE 41 nifedipine 50 NORPACE 13 NAYZILAM 17 NILANDRON 37 NORPRAMIN 23 NEBUSAL 56 nilutamide 37 nortriptyline hcl 23 nefazodone hcl 22 nimodipine 50 NORVASC 50 NEO-SYNALAR 58 NINLARO 39 NORVIR 46 neomycin sulfate 3 NIPENT 40 NOVA MAX PLUS KETONE neomycin-bacitracin zn- nisoldipine 50 TESTSTRIPS 65 polymyxin 120 nitazoxanide 11

Index 22 NOVA SAFETY LANCETS olanzapine 44 ORACEA 65 23G 85 olmesartan medoxomil 31 ORAPRED ODT 55 NOVA SAFETY LANCETS 28G 85 olmesartan medoxomil- ORENITRAM 51 NOVA SUREFLEX amlodipine-hydrochlorothiazide ORFADIN 69 33 LANCETS 85 ORKAMBI 126 NOVA SUREFLEX LANCING olmesartan medoxomil- DEVICE 85 hydrochlorothiazide 33 orphenadrine citrate 118 NOVAREL 67 olopatadine hcl 121 ORTHO MICRONOR 54 NOVOLIN 70/30 25 olopatadine hcl (nasal) 118 ORTHO TRI-CYCLEN LO 53 NOVOLIN 70/30 FLEXPEN 25 OLUX 63 ORTHO-NOVUM 1/35 53 NOVOLIN 70/30 FLEXPEN omega-3-acid ethyl esters 29 ORTHO-NOVUM 7/7/7 53 RELION 25 omeprazole 129 oseltamivir phosphate 48,49 NOVOLIN 70/30 RELION 25 omeprazole magnesium 129 OSENI 24 NOVOLIN N 25 omeprazole-sodium OSMOPREP 76 bicarbonate 129 NOVOLIN N RELION 25 OSPHENA 68 OMNIFLEX DIAPHRAGM 77 NOVOLIN R 25 OTEZLA 5 NOVOLIN R RELION 25 OMNITROPE 68 ON CALL LANCING OTOVEL 122 NOVOLOG 25 DEVICE 85 OVIDE 65 NOVOLOG FLEXPEN 25 ON CALL PLUS LANCING oxacillin sodium 123 NOVOLOG MIX 70/30 25 DEVICE 85 oxaliplatin 35 ONCASPAR 40 NOVOLOG MIX 70/30 oxandrolone 10 PREFILLED FLEXPEN 25 ondansetron 26 oxaprozin 5 NOVOLOG PENFILL 25 ondansetron hcl 26 OXAYDO 7 NOXAFIL 28 ONE VITE WOMENS NPLATE 74 PRENATALVITAMIN 117 oxazepam 13 NUBEQA 37 ONE VITE WOMENS OXBRYTA 73 PRENATALVITAMIN oxcarbazepine 19 NUCALA 14 PLUS 117 NUCYNTA 7 ONETOUCH CLUB LANCETS OXERVATE 120 NUCYNTA ER 7 FINE POINT 85 oxiconazole nitrate 59 ONETOUCH DELICA NUEDEXTA 125 OXISTAT 59 LANCETS EXTRA FINE OXSORALEN ULTRA 60 NULOJIX 115 33G 85 NUTROPIN AQ NUSPIN 10 68 ONETOUCH DELICA oxybutynin chloride 129 NUVARING 54 LANCETS FINE 30G 85 oxycodone hcl 7 ONETOUCH DELICA oxycodone w/ acetaminophen 9 NUVIGIL 3 LANCING DEVICE 85 nystatin 27 ONETOUCH DELICA PLUS oxycodone-ibuprofen 9 nystatin (mouth-throat) 116 LANCETS EXTRA FINE OXYCONTIN 7 nystatin (topical) 59 33G 85 oxymorphone hcl 7 ONETOUCH DELICA PLUS OZEMPIC 24 nystatin-triamcinolone 59 LANCETS FINE 30G 85 O-CAL FA 117 ONETOUCH DELICA PLUS paclitaxel 41 OCREVUS 125 LANCING DEVICE 85 paliperidone 43 ONETOUCH DELICA SAFETY palonosetron hcl 26 octreotide acetate 69 LACING DEVICE 85 OCUFLOX 120 ONETOUCH FINEPOINT PALYNZIQ 69 ODEFSEY 46 LANCETS 85 PAMELOR 23 ONETOUCH ULTRASOFT ODOMZO 37 pamidronate disodium 67 LANCETS 85 PAMIDRONATE DISODIUM 67 OFEV 126 ONFI 17 pamidronate disodium 67 ofloxacin 70 OPANA 7 PANRETIN 60 ofloxacin (ophth) 120 OPSUMIT 51 ofloxacin (otic) 122 pantoprazole sodium 129

Index 23 PARAGARD INTRAUTERINE PERIDEX 116 PLAQUENIL 34 COPPER CONTRACEPTIVE perindopril erbumine 31 PLASMA-LYTE A 114 T380A 54 parenteral electrolytes 114 PERJETA 36 PLASMA-LYTE-148 114 paricalcitol 69 permethrin 65 PLAVIX 73 PARLODEL 42 perphenazine 44 PLEGISOL 51 perphenazine-amitriptyline PARNATE 21 PLEGRIDY 125 124 PLEGRIDY STARTER paromomycin sulfate 3 PERSERIS 43 PACK 125 paroxetine hcl 22 PHARMACY COUNTER PNEUMOVAX 23 130 PASER 35 LANCETS 86 PNEUMOVAX 23/1 DOSE 130 phenazopyridine hcl 72 PATADAY 121 podofilox 64 phendimetrazine tartrate 1 PATANASE 118 polymyxin b sulfate 12 phenelzine sulfate 21 PATANOL 121 polymyxin b-trimethoprim 120 PHENERGAN 29 PAXIL 22 POLYTRIM 120 phenobarbital 75 PAXIL CR 22 POMALYST 38 phenoxybenzamine hcl 31 PC LANCETS SUPER THIN potassium acetate 114 30G 86 phentermine hcl 2 potassium bicarbonate 114 PEDIAPRED 55 PHENYTEK 20 potassium chloride 114 PEDIARIX 127 phenytoin 20 POTASSIUM CHLORIDE 114 PEDVAX HIB 130 phenytoin sodium 20 potassium chloride 115 peg 3350-kcl-nacl-na sulfate-na phenytoin sodium ascorbate-ascorbic acid 76 extended 20 potassium chloride in dextrose 114 peg 3350-kcl-sod bicarb-sod PHEXXI 132 chloride-sod sulfate 76 potassium chloride in dextrose & PEGANONE 20 PHOSLYRA 72 sodium chloride 114 PEGASYS 48 PHOSPHOLINE IODIDE 119 potassium chloride in nacl 114 potassium chloride PEGASYS PROCLICK 48 PHOTOFRIN 40 PICATO 60 microencapsulated crystals PEGINTRON 48 er 114 PEMAZYRE 39 PIFELTRO 46 POTASSIUM penicillamine 115 pilocarpine hcl 120 CHLORIDE/DEXTROSE/LACTA pilocarpine hcl (oral) 116 TED RINGERS 114 penicillin g potassium 123 POTASSIUM PENICILLIN G POTASSIUM IN pimecrolimus 64 CHLORIDE/SODIUM ISO-OSMOTIC pimozide 125 CHLORIDE 114 DEXTROSE 123 pindolol 49 potassium citrate PENICILLIN G PROCAINE 123 pioglitazone hcl 24 (alkalinizer) 72 penicillin g sodium 123 pioglitazone hcl- potassium phosphates 114 penicillin v potassium 123 glimepiride 24 pramipexole dihydrochloride 42 PENLAC NAIL LACQUER 59 pioglitazone hcl-metformin PRANDIN 25 hcl 24 PENTACEL 127 prasugrel hcl 73 PIP LANCETS/28G 86 pentazocine w/ naloxone 9 PRAVACHOL 30 PIP LANCETS/30G 86 pentoxifylline 73 piperacillin sodium-tazobactam pravastatin sodium 30 PEPCID 128 sodium 123 praziquantel 10 PEPCID AC 128 PIQRAY 200MG DAILY prazosin hcl 32 PEPCID AC MAXIMUM DOSE 39 PRECISION SURE-DOSE STRENGTH 128 PIQRAY 250MG DAILY INSULIN SYRINGE/0.3ML/30G X PERCOCET 9 DOSE 39 5/16" 103 PIQRAY 300MG DAILY PRECISION SURE-DOSE PERFECT LANCETS 30G 86 DOSE 39 INSULIN SYRINGE/0.5ML/28G X PERFECT PRESSURE piroxicam 5 1/2" 103 ACTIVATED SAFETY LANCETS PLAN B ONE-STEP 54 28G 86

Index 24 PRECISION SURE-DOSE PREFERRED PLUS LANCETS PRO COMFORT INSULIN INSULIN SYRINGE/0.5ML/29G X COLORED 21G 86 SYRINGES/0.5ML/30G X 1/2" 103 PREFERRED PLUS LANCETS 5/16" 104 PRECISION SURE-DOSE SUPER THIN 30G 86 PRO COMFORT INSULIN INSULIN SYRINGE/0.5ML/30G X PREFERRED PLUS LANCETS SYRINGES/0.5ML/31G X 3/8" 103 THIN 26G 86 5/16" 104 PRECISION SURE-DOSE pregabalin 19 PRO COMFORT INSULIN INSULIN SYRINGE/1ML/28G X pregabalin (once-daily) 125 SYRINGES/1ML/30G X 1/2" 103 PREGNYL W/DILUENT 1/2" 104 PRECISION SURE-DOSE PRO COMFORT INSULIN BENZYLALCOHOL/NACL 67 PLUSINSULIN SYRINGES/1ML/30G X SYRINGE/0.3ML/29G X PREMARIN 70 5/16" 104 1/2" 103 PREMIUM CONDOMS PRO COMFORT INSULIN PRECISION SURE-DOSE LUBRICATED 77 SYRINGES/1ML/31G X PLUSINSULIN PREMPHASE 70 5/16" 104 SYRINGE/1ML/29G X 1/2" 103 PREMPRO 70 PROAIR HFA 15 PRECISION THINS GP PRENATAL 117 probenecid 73 LANCET 86 PRECISION XTRA 65 PRENATAL LOW IRON 117 procainamide hcl 13 PRENATAL PRECOSE 23 PROCARDIA 50 MULTIVITAMIN 117 PROCARDIA XL 50 PRED FORTE 121 PRENATAL ONE DAILY 117 prochlorperazine 44 PRED MILD 121 PRENATAL VITAMIN 117 prochlorperazine maleate 44 prednicarbate 63 PRENATAL VITAMIN & prednisolone 55 MINERAL 117 PROCRIT 74 prednisolone acetate PRENATAL PROCTOCORT 10 (ophth) 121 VITAMIN/IRON 117 PRODIGY INSULIN SYRING/U- PREDNISOLONE ACETATE P- PRENATAL VITAMINS 117 100/0.3ML/31G X 5/16" 104 F 121 PRENATAL VITAMINS PLUS PRODIGY INSULIN prednisolone sodium LOW IRON 117 SYRINGE/1/2ML/31G X phosphate 55 PRENATRIX 117 5/16" 104 PRODIGY INSULIN PREDNISOLONE SODIUM PRENATRYL 118 PHOSPHATE 121 SYRINGE/1ML/28G X 1/2" 104 prednisone 55 PREPLUS 118 PRODIGY LANCING PREFERRED PLUS INSULIN PREPOPIK 76 DEVICE 86 SYRINGE/U-100/0.3ML/29G X PRESSURE ACTIVATED PRODIGY PRESSURE 1/2" 103 SAFETYLANCET 21G 86 ACTIVATED SAFETY PREFERRED PLUS INSULIN PREVACID 129 LANCETS 86 PRODIGY SAFETY SYRINGE/U-100/0.3ML/30G X PREVACID 24HR 129 5/16" 103 LANCETS 86 PREFERRED PLUS INSULIN PREVNAR 13 130 PRODIGY TWIST TOP SYRINGE/U-100/0.5ML/28G X PREZCOBIX 46 LANCETS 86 1/2" 103 PREZISTA 46 progesterone 124 PREFERRED PLUS INSULIN PRIFTIN 35 PROGLYCEM 24 SYRINGE/U-100/0.5ML/29G X PROGRAF 115 1/2" 104 PRILOSEC OTC 129 PREFERRED PLUS INSULIN primaquine phosphate 34 PROLASTIN-C 126 SYRINGE/U-100/0.5ML/30G X PRIMAQUINE PROLEUKIN 40 5/16" 104 PHOSPHATE 34 PROLIA 67 PREFERRED PLUS INSULIN PRIMAXIN IV 11 PROMACTA 74 SYRINGE/U-100/1ML/28G X primidone 19 1/2" 104 promethazine hcl 29 PREFERRED PLUS INSULIN PRINIVIL 31 PROMETRIUM 124 SYRINGE/U-100/1ML/29G X PRISTIQ 23 propafenone hcl 13 1/2" 104 PRO COMFORT INSULIN proparacaine hcl 120 PREFERRED PLUS INSULIN SYRINGES/0.5ML/30G X SYRINGE/U-100/1ML/30G X 1/2" 104 propranolol hcl 49 5/16" 104 propylthiouracil 127

Index 25 PROSCAR 72 QUESTRAN 30 REALITY INSULIN SYRINGE/U- PROTONIX 129 QUESTRAN LIGHT 30 100/0.5ML/28G X 1/2" 104 REALITY INSULIN SYRINGE/U- PROTOPIC 64 quetiapine fumarate 44 100/0.5ML/29G X 1/2" 104 protriptyline hcl 23 quinapril hcl 31 REALITY INSULIN SYRINGE/U- PROVENTIL HFA 15 quinapril-hydrochlorothiazide 100/1ML/28G X 1/2" 104 REALITY INSULIN SYRINGE/U- PROVERA 124 33 quinidine sulfate 13 100/1ML/29G X 1/2" 104 PROVIGIL 3 quinine sulfate 34 REALITY LANCETS 86 PROZAC 22 REALITY LATEX QVAR REDIHALER 14 PRUDOXIN 60 CONDOMS/LUBRICATED 77 RA E-ZJECT LANCETS PSORCON 63 REALITY LATEX/ULTRA 28G 86 TEXTURED 77 PSS SELECT GP LANCETS 86 RA E-ZJECT LANCETS THIN REALITY LATEX/ULTRA PSS SELECT SAFETY 26G 86 THIN 77 LANCETS 86 RA E-ZJECT LANCETS THIN REALITY TRIGGER PTS PANELS KETONE 28G 86 LANCETS 86 TEST 65 RA E-ZJECT LANCETS REBIF 125 PULMICORT 14 ULTRATHIN 30G 86 RA INSULIN REBIF REBIDOSE 125 PULMICORT FLEXHALER 14 SYRINGE/0.5ML/29G X REBIF REBIDOSE PULMOZYME 126 1/2" 104 TITRATIONPACK 125 PUSH BUTTON SAFETY RA INSULIN REBIF TITRATION PACK 125 LANCETS 21G 86 SYRINGE/1ML/29G X RECLAST 67 PUSH BUTTON SAFETY 1/2" 104 LANCETS 28G 86 RA INSULIN SYRINGE/U- RECOMBIVAX HB 132 PX ADVANCED LANCING 100/0.5ML/30G X 5/16" 104 RECTIV 10 DEVICE 86 RA INSULIN SYRINGE/U- REGLAN 71 PX INSULIN SYRINGE/U- 100/1 ML/30G X 5/16" 104 REGRANEX 65 100/0.5ML/30G X 1/2" 104 RA PRENATAL 118 PX LANCET AUTO RELENZA DISKHALER 49 RA PRENATAL RELION 2-IN-1 LANCET INJECTOR 86 FORMULA/FOLICACID 118 PX LANCETS ULTRA THIN 86 DEVICES 30G 86 rabeprazole sodium 129 RELION 2-IN-1 LANCING PX LANCETS ULTRA THIN raloxifene hcl 68 28G 86 DEVICE 25G 87 PX PRENATAL ramelteon 75 RELION 2-IN-1 LANCING MULTIVITAMINS 118 DEVICE 30G 87 ramipril 31 RELION INSULIN SYRINGE pyrazinamide 35 RANEXA 12 1ML/31GX15/64" 104 PYRIDIUM 72 ranitidine hcl 128 RELION INSULIN SYRINGE/U- pyridostigmine bromide 34 ranolazine 12 100/0.3ML/31G X 5/16" 104 pyrimethamine 34 RELION INSULIN SYRINGE/U- RAPAFLO 72 100/0.5ML/29G X 1/2" 104 QC ADVANCED LANCING RAPAMUNE 115 RELION INSULIN SYRINGE/U- DEVICE 86 rasagiline mesylate 42 100/0.5ML/31G X 5/16" 104 QC LANCETS SUPER THIN 86 RELION INSULIN SYRINGE/U- RAZADYNE 124 QC LANCETS ULTRA THIN 86 100/1ML/31G X 15/64" 104 RAZADYNE ER 124 QC PRENATAL 118 RELION INSULIN SYRINGE/U- READYLANCE SAFETY 100/1ML/31G X 5/16" 104 QC UNILET LANCETS LANCETS/21G/2.2MM 86 28G/ULTRA THIN 86 RELION KETONE TEST READYLANCE SAFETY STRIPS 65 QC UNILET LANCETS LANCETS/23G/1.8MM 86 33G/MICRO THIN 86 RELION LANCETS MICRO- READYLANCE SAFETY THIN33G 87 QINLOCK 39 LANCETS/26G/1.8MM 86 RELION LANCETS THIN QUADRACEL 127 READYLANCE SAFETY 26G 87 QUALAQUIN 34 LANCETS/28G/1.8MM 86 RELION LANCETS ULTRA- READYLANCE SAFETY QUARTETTE 53 THIN30G 87 LANCETS/30G/1.6MM 86 RELION LANCING DEVICE 87 QUDEXY XR 19

Index 26 RELION TRUE METRIX RIFAMATE 34 SAFE-T-LANCE PLUS BLOODGLUCOSE TEST rifampin 35 SAFETYLANCET HIGH STRIPS 65 FLOW 87 RELION ULTRA THIN RIFATER 34 SAFE-T-LANCE PLUS LANCETS/30G 87 RIGHT STEP SAFETYLANCET LOW RELION ULTRA THIN PRENATAL 118 FLOW 87 LANCETS30G 87 RIGHTEST GD500 LANCING SAFE-T-LANCE PLUS RELION ULTRA THIN PLUS DEVICE 87 SAFETYLANCET NORMAL LANCETS 32G 87 RIGHTEST GL300 FLOW 87 RELION ULTRA THIN PLUS LANCETS 87 SAFESNAP INSULIN LANCETS 33G 87 RILUTEK 119 SYRINGE/0.3ML/30G X RELISTOR 71 riluzole 119 5/16" 105 RELPAX 113 rimantadine hydrochloride 49 SAFESNAP INSULIN SYRINGE/0.5ML/29G X REMERON 20,21 ringer's 114 1/2" 105 REMERON SOLTAB 20 ringer's irrigation 116 SAFESNAP INSULIN RENFLEXIS 71 RINVOQ 4 SYRINGE/0.5ML/30G X RENVELA 72 5/16" 105 risedronate sodium 67 SAFESNAP INSULIN REOPRO 73 RISPERDAL 43 SYRINGE/1ML/28G X 1/2" 105 repaglinide 25 RISPERDAL CONSTA 43 SAFESNAP INSULIN repaglinide-metformin hcl 24 risperidone 43 SYRINGE/1ML/29G X 1/2" 105 SAFETY INSULIN SYRINGES REPATHA 31 RITALIN 3 0.5ML/29GX1/2" 105 REPATHA PUSHTRONEX RITALIN LA 3 SAFETY INSULIN SYRINGES SYSTEM 31 ritonavir 46 0.5ML/30GX5/16" 105 REPATHA SURECLICK 31 SAFETY INSULIN SYRINGES RITUXAN 36 REQUIP XL 42 1ML/27GX1/2" 105 rivastigmine tartrate 124 RESCRIPTOR 46 SAFETY INSULIN SYRINGES rizatriptan benzoate 113 1ML/29GX1/2" 105 RESECTISOL 72 ROBAXIN-750 118 SAFETY INSULIN SYRINGES RESTASIS 120 1ML/30GX1/2" 105 ROCALTROL 69 RESTASIS MULTIDOSE 120 SAFETY LANCET ROMIDEPSIN 39 21G/PRESSURE RESTORIL 75 ropinirole hydrochloride 42 ACTIVATED 87 RETACRIT 74 SAFETY LANCET rosuvastatin calcium 30 RETEVMO 39 23G/PRESSURE ROTARIX 132 RETIN-A 57 ACTIVATED 87 ROTATEQ 132 SAFETY LANCET RETIN-A MICRO 57 ROXICODONE 8 28G/PRESSURE RETIN-A MICRO PUMP 57 ACTIVATED 87 ROZEREM 75 RETROVIR 46 SAFETY LANCETS 21G 87 ROZLYTREK 39 RETROVIR IV INFUSION 46 SAFETY LANCETS 28G 87 RUBRACA 39 REVATIO 51 SAFETY LET LANCETS 87 RUCONEST 73 REVLIMID 115 SAFYRAL 53 REXALL LANCETS ULTRA rufinamide 19 SAIZEN 68 THIN 87 RUKOBIA 47 SAIZENPREP REXULTI 45 RUXIENCE 37 RECONSTITUTIONKIT 68 REYATAZ 46 RUZURGI 34 SALAGEN 116 RIBASPHERE 48 RYTHMOL SR 13 salsalate 6 RIBASPHERE RIBAPAK 48 SABRIL 20 SAMSCA 69 ribavirin (hepatitis c) 48 SAFE-T-LANCE LOW FLOW SANDIMMUNE 115,116 RIDAURA 4 25G 87 SANDOSTATIN 69 SAFE-T-LANCE NORMAL rifabutin 35 FLOW21G 87 SANTYL 64 RIFADIN 35 SAPHRIS 44

Index 27 sapropterin dihydrochloride 69 SILENOR 75 sodium phenylbutyrate 69 SAVELLA 124 silodosin 72 sodium polystyrene SAVELLA TITRATION SILVADENE 61 sulfonate 116 SOFOSBUVIR/VELPATASVIR PACK 124 silver sulfadiazine 61 SB INSULIN SYRINGE/U- 48 100/0.5ML/29G X 1/2" 105 SIMBRINZA 120 solifenacin succinate 129 SB INSULIN SYRINGE/U- SIMPLE DIAGNOSTICS SOLIRIS 73 LANCING DEVICE 87 100/0.5ML/30G X 5/16" 105 SOLOSEC 3 SB INSULIN SYRINGE/U- SIMULECT 116 SOLU-CORTEF 55 100/1ML/29G X 1/2" 105 simvastatin 30 SB INSULIN SYRINGE/U- SOLU-MEDROL 55 SINEMET 42 100/1ML/30G X 5/16" 105 SOLUS V2 LANCING SB INSULIN SYRINGE/U- SINEMET CR 42 DEVICE 88 100/1ML/31G X 5/16" 105 SINGLE-LET 87 SOLUS V2 PRESSURE SB LANCETS THIN 87 SINGULAIR 14 ACTIVATED SAFETY LANCETS SB LANCETS ULTRA THIN 87 28G 88 sirolimus 116 SOLUS V2 TWIST LANCETS scopolamine 27 SIRTURO 35 30G 88 SEASONIQUE 53 SIVEXTRO 12 SOMA 118 SECURESAFE SAFETY SKELAXIN 118 SOMATULINE DEPOT 69 INSULIN SYRINGES/U- 100/0.5ML/29GX1/2" 105 SKLICE 65 SOMAVERT 67 SECURESAFE SAFETY SKYLA 54 SOOLANTRA 65 INSULIN SYRINGES/U- SKYRIZI 61 SORBITOL 72 100/1ML/29GX1/2" 105 SLO-NIACIN 133 SORBITOL-MANNITOL 72 SEGLUROMET 24 SLYND 54 SORBITOL/MANNITOL SELECT-LITE LANCING IRRIGATION 72 DEVICE 87 SM MICRO THIN LANCETS SORIATANE 61 selegiline hcl 42 33G 87 SM PRENATAL sotalol hcl 49 selenium sulfide 61 VITAMINS 118 sotalol hcl (afib/afl) 49 SELZENTRY 47 SM TRUEDRAW LANCING spinosad 65 SENSIPAR 69 DEVICE 87 SMART DIABETES VANTAGE SPIRIVA HANDIHALER 14 SEREVENT DISKUS 15 LANCING DEVICE 87 SPIRIVA RESPIMAT 14 SEROQUEL 44 SMART SENSE COLOR spironolactone 66 SEROQUEL XR 44 LANCETS UNIVERSAL spironolactone & SEROSTIM 68 33G 87 SMART SENSE STANDARD hydrochlorothiazide 66 sertraline hcl 22 LANCETS UNIVERSAL SPORANOX 28 sevelamer carbonate 72 21G 87 SPORANOX PULSEPAK 28 SHINGRIX 132 SMART SENSE SUPER THIN SPRAVATO 56MG DOSE 21 LANCETS UNIVERSAL SHOPKO AUTOLET LANCING SPRAVATO 84MG DOSE 21 DEVICE 87 30G 88 SHOPKO ON-THE-GO SMART SENSE THIN SPRYCEL 39 COMFORTLANCETS 30G 87 LANCETSUNIVERSAL STALEVO 100 42 SHOPKO UNILET LANCETS 26G 88 SMARTEST LANCETS STALEVO 125 42 SUPER THIN 30G 87 STALEVO 150 42 SHOPKO UNILET LANCETS 28G 88 ULTRA THIN 28G 87 SODIUM ACETATE 113 STALEVO 200 42 SHUR-SEAL 132 sodium acetate 113 STALEVO 50 42 SIDE BUTTON SAFETY sodium chloride 115 STALEVO 75 42 LANCET21G 87 sodium chloride (gu stannous fluoride 116 SIGNIFOR 69 irrigant) 72 STARLIX 25 sodium chloride (inhalant) 56 sildenafil citrate 51 stavudine 47 sildenafil citrate (pulmonary sodium citrate & citric acid 72 STAVUDINE 47 hypertension) 51 sodium fluoride 114

Index 28 STEGLATRO 25 SURE COMFORT INSULIN SURE-JECT INSULIN STELARA 61,71 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.5ML/28G X 5/16 105 1/2" 106 STENDRA 51 SURE COMFORT INSULIN SURE-JECT INSULIN STERILANCE TL 88 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.5ML/29G X STIMATE 69 5/16" 105 1/2" 106 SURE COMFORT INSULIN SURE-JECT INSULIN STIVARGA 39 SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.5ML/30G X STRATTERA 2 1/2" 105 5/16" 106 streptomycin sulfate 3 SURE COMFORT INSULIN SURE-JECT INSULIN STRIBILD 47 SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.5ML/31G X 1/2" 105 5/16" 106 STRIVERDI RESPIMAT 15 SURE COMFORT INSULIN SURE-JECT INSULIN STROMECTOL 10 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/28G X SUBOXONE 9 1/2" 105 1/2" 106 SUBSYS 8 SURE COMFORT INSULIN SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/29G X SUCRAID 66 5/16" 105 1/2" 106 sucralfate 128 SURE COMFORT INSULIN SURE-JECT INSULIN SULAR 50 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/30G X 5/16 105 5/16" 106 sulconazole nitrate 59 SURE COMFORT INSULIN SURE-JECT INSULIN sulfacetamide sodium (acne)57 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/1ML/31G X sulfacetamide sodium 1/2" 105 5/16" 106 (ophth) 120 SURE COMFORT INSULIN SURE-LANCE FLAT sulfacetamide sodium w/ SYRINGE/U-100/1ML/29G X LANCETS 88 sulfur 57 1/2" 106 SURE-LANCE LANCETS sulfacetamide sodium-sulfur in SURE COMFORT INSULIN 26G 88 urea vehicle 57 SYRINGE/U-100/1ML/30G X SURE-LANCE THIN LANCETS SULFADIAZINE 126 1/2" 106 28G 88 sulfamethoxazole-trimethoprim SURE COMFORT INSULIN SURE-LANCE ULTRA THIN 11 SYRINGE/U-100/1ML/30G X LANCETS 88 SULFAMYLON 61 5/16" 106 SURE-PEN 88 SURE COMFORT INSULIN sulfasalazine 71 SURE-TOUCH LANCETS SYRINGE/U-100/1ML/31G X UNIVERSAL 88 sulindac 5 5/16" 106 SURELITE LANCETS 88 SURE COMFORT LANCETS SUMADAN WASH 57 SUSTIVA 47 sumatriptan 113 18G 88 SURE COMFORT LANCETS SUTENT 39 sumatriptan succinate 113 21G 88 SYLATRON 40 sumatriptan-naproxen SURE COMFORT LANCETS SYMBICORT 15 sodium 112 23G 88 sunitinib malate 39 SURE COMFORT LANCETS SYMFI 47 SUNOSI 2 28G 88 SYMFI LO 47 SURE COMFORT LANCETS SYMLINPEN 120 23 SUPER THIN LANCETS 88 30G 88 SUPRAX 52 SURE COMFORT LANCING SYMLINPEN 60 23 SUPREP BOWEL PREP KIT76 PEN 88 SYMTUZA 47 SURE COMFORT INSULIN SURE-JECT INSULIN SYNALAR 63 SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/0.3ML/29G X SYNAREL 68 1/2" 106 1/2" 105 SYNERA 64 SURE COMFORT INSULIN SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/30G X SYNJARDY 24 1/2" 105 5/16" 106 SYNJARDY XR 24 SURE-JECT INSULIN SURE COMFORT INSULIN SYNRIBO 40 SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/31G X 5/16" 105 5/16" 106 SYNTHROID 127 SYPRINE 115

Index 29 TABLOID 36 TECHLITE INSULIN tetracycline hcl 127 TABRECTA 39 SYRINGEU-100/1ML/30G X TGT LANCET MICRO THIN 1/2" 106 TACLONEX 63 33G 88 TECHLITE INSULIN TGT LANCET THIN 26G 88 tacrolimus 116 SYRINGEU-100/1ML/30G X TGT LANCET ULTRA THIN tacrolimus (topical) 64 5/16" 106 TECHLITE INSULIN 30G 88 tadalafil 51 SYRINGEU-100/1ML/31G X TGT LANCING DEVICE 88 tadalafil (pulmonary 15/64" 107 THALOMID 115 hypertension) 51 TECHLITE INSULIN theophylline 16 TAFINLAR 39 SYRINGEU-100/1ML/31G X THERANATAL CORE TAGAMET HB 128 5/16" 107 NUTRITION 118 TAKHZYRO 73 TECHLITE LANCETS 88 THINLETS GP LANCETS 88 TALZENNA 40 TECHLITE LANCETS 30G 88 thioridazine hcl 44 TAMIFLU 49 TEFLARO 52 thiotepa 35 tamoxifen citrate 37 TEGRETOL 19 thiothixene 45 tamsulosin hcl 72 TEGRETOL-XR 19 THYMOGLOBULIN 116 TAPAZOLE 127 TEGSEDI 126 THYROGEN 65 TARCEVA 37 TEKTURNA 33 thyroid 127 TARGADOX 127 telmisartan 31 tiagabine hcl 20 TARGRETIN 40,60 telmisartan-amlodipine 33 TIAZAC 50 TARKA 33 telmisartan-hydrochlorothiazide TIBSOVO 40 33 TASIGNA 40 temazepam 75 TIGAN 27 TASMAR 41 TEMIXYS 47 tigecycline 126 tavaborole 59 TEMODAR 35 TIKOSYN 13 TAXOTERE 41 TEMOVATE 63 timolol maleate 49 TAYTULLA 53 temozolomide 35 timolol maleate (ophth) 119 tazarotene 61 temsirolimus 40 TIMOPTIC 119 TAZORAC 61 TENIPOSIDE 41 TIMOPTIC-XE 119 TAZVERIK 40 TENIVAC 127 TIVICAY 47 TDVAX 127 tenofovir disoproxil tizanidine hcl 118 TECFIDERA 125 fumarate 47 TOBI 3 TECFIDERA STARTER TENORETIC 100 33 TOBRADEX 121 PACK 125 TENORETIC 50 33 tobramycin 3 TECHLITE AST LANCETS 88 TENORMIN 49 TECHLITE INSULIN SYRINGEU- tobramycin (ophth) 120 100/0.3ML/29G X 1/2" 106 TEPADINA 35 tobramycin sulfate 3 TECHLITE INSULIN SYRINGEU- terazosin hcl 32 tobramycin- 100/0.3ML/30G X 1/2" 106 terbinafine hcl 27 dexamethasone 121 TECHLITE INSULIN SYRINGEU- terbutaline sulfate 15 TOBREX 120 100/0.3ML/30G X 5/16" 106 TODAY SPONGE 132 TECHLITE INSULIN SYRINGEU- terconazole vaginal 132 100/0.3ML/31G X 5/16" 106 TODAYS HEALTH ADVANCED TESSALON PERLES 55 LANCING DEVICE 88 TECHLITE INSULIN SYRINGEU- TESTIM 10 100/0.5ML/29G X 1/2" 106 TODAYS HEALTH SUPER TECHLITE INSULIN SYRINGEU- TESTOSTERONE THINLANCETS 30G 88 100/0.5ML/30G X 1/2" 106 CYPIONATE 10 TODAYS HEALTH ULTRA TECHLITE INSULIN SYRINGEU- testosterone cypionate 10 THINLANCETS 28G 88 100/0.5ML/30G X 5/16" 106 testosterone enanthate 10 TOFRANIL 23 TECHLITE INSULIN SYRINGEU- TETANUS/DIPHTHERIA tolbutamide 25 100/0.5ML/31G X 5/16" 106 TOXOIDS-ADSORBED tolcapone 41 TECHLITE INSULIN SYRINGEU- ADULT 127 tolmetin sodium 5 100/1ML/29G X 1/2" 106 tetrabenazine 124

Index 30 TOLSURA 28 TRAVATAN Z 122 TRIZIVIR 47 tolterodine tartrate 129 TRAVEL LANCETS 30G 88 tropicamide 119 tolvaptan 69 TRAVEL LANCETS trospium chloride 129 TOPAMAX 19 ADVANCED 28G 88 TRUE COMFORT INSULIN travoprost 122 TOPAMAX SPRINKLE 19 SYRINGE/0.5ML/31G X trazodone hcl 22 5/16" 107 TOPCARE LANCETS MICRO- TRUE COMFORT INSULIN THIN 33G 88 TREANDA 35 TOPCARE ULTRA COMFORT SYRINGE/1ML/31G X TRECATOR 35 5/16" 107 INSULIN SYRINGE/0.3ML/30G X TRELEGY ELLIPTA 15 TRUE COMFORT PRO 5/16" 107 TOPCARE ULTRA COMFORT TRELSTAR MIXJECT 38 INSULINSYRINGE/0.5ML/30G X 5/16" 107 INSULIN SYRINGE/0.3ML/31G X TREMFYA 61 TRUE COMFORT PRO 5/16" 107 treprostinil 51 INSULINSYRINGE/0.5ML/31G X TOPCARE ULTRA COMFORT TRESIBA 25 5/16" 107 INSULIN SYRINGE/0.5ML/30G X TRUE COMFORT PRO 5/16" 107 TRESIBA FLEXTOUCH 25 TOPCARE ULTRA COMFORT INSULINSYRINGE/1ML/30G X tretinoin 57,58 5/16" 107 INSULIN SYRINGE/0.5ML/31G X tretinoin (chemotherapy) 40 TRUE COMFORT PRO 5/16" 107 INSULINSYRINGE/1ML/31G X TOPCARE ULTRA COMFORT tretinoin microsphere 58 TREXALL 36 5/16" 107 INSULIN SYRINGE/1ML/30G X TRUE COMFORT PRO 5/16" 107 TREXIMET 112 TOPCARE ULTRA COMFORT INSULINSYRINGE/U- triamcinolone acetonide 55 100/0.5ML/30G X 1/2" 107 INSULIN SYRINGE/1ML/31G X TRUE COMFORT PRO 5/16" 107 triamcinolone acetonide (mouth) 116 INSULINSYRINGE/U- TOPCARE ULTRA COMFORT 107 INSULIN SYRINGE/U- triamcinolone acetonide 100/1ML/30G X 1/2" (nasal) 119 TRUE METRIX BLOOD 100/0.3ML/29G X 1/2" 107 GLUCOSETEST STRIPS 65 TOPCARE ULTRA COMFORT triamcinolone acetonide (topical) 63 TRUE METRIX CONTROL INSULIN SYRINGE/U- triamcinolone acetonide- SOLUTION LEVEL 3 88 100/0.5ML/29G X 1/2" 107 dimethicone-silicone 64 TRUEDRAW LANCING TOPCARE ULTRA COMFORT DEVICE 88 INSULIN SYRINGE/U- triamterene 66 triamterene & TRUEPLUS INSULIN 100/1ML/29G X 1/2" 107 SYRINGE/U-100/0.3ML/29G X TOPICORT 63 hydrochlorothiazide 66 triazolam 75 1/2" 107 topiramate 19 TRUEPLUS INSULIN TRIBENZOR 33 topotecan hcl 41 SYRINGE/U-100/0.3ML/30G X TRICARE 118 5/16" 107 TOPROL XL 49 TRICOR 30 TRUEPLUS INSULIN toremifene citrate 37 SYRINGE/U-100/0.3ML/31G X TRIDESILON 64 TORISEL 40 5/16" 107 trientine hcl 115 torsemide 66 TRUEPLUS INSULIN trifluoperazine hcl 44 SYRINGE/U-100/0.5ML/28G X TOVIAZ 129 trifluridine 120 1/2" 107 TRACLEER 51 TRUEPLUS INSULIN trihexyphenidyl hcl 41 tramadol hcl 8 SYRINGE/U-100/0.5ML/29G X TRIJARDY XR 24 tramadol-acetaminophen 9 1/2" 107 TRIKAFTA 126 TRUEPLUS INSULIN trandolapril 31 SYRINGE/U-100/0.5ML/30G X TRILEPTAL 19 trandolapril-verapamil hcl 33 5/16" 107 trimethobenzamide hcl 27 tranexamic acid 74 TRUEPLUS INSULIN trimethoprim 11 SYRINGE/U-100/0.5ML/31G X TRANSDERM SCOP 27 trimipramine maleate 23 5/16" 108 TRANSDERM-SCOP 27 TRUEPLUS INSULIN TRINTELLIX 22 TRANXENE T 13 SYRINGE/U-100/1ML/28G X TRIOSTAT 127 tranylcypromine sulfate 21 1/2" 108 TRIUMEQ 47

Index 31 TRUEPLUS INSULIN TRUVADA 47 ULTICARE INSULIN SYRINGE/U-100/1ML/29G X TUKYSA 36 SYRINGE/1ML/30G X 1/2" 108 1/2" 108 ULTICARE INSULIN TRUEPLUS INSULIN TURALIO 40 SYRINGE/1ML/30G X SYRINGE/U-100/1ML/30G X TUZISTRA XR 56 5/16" 108 5/16" 108 TWINRIX 132 ULTICARE INSULIN TRUEPLUS INSULIN SYRINGE/SHORT/0.3ML/30G X SYRINGE/U-100/1ML/31G X TWIRLA 54 5/16" 108 5/16" 108 TWYNSTA 33 ULTICARE INSULIN TRUEPLUS LANCETS 26G 88 TYBLUME 53 SYRINGE/SHORT/0.3ML/31G X TRUEPLUS LANCETS 28G 88 TYBOST 47 5/16" 108 ULTICARE INSULIN TRUEPLUS LANCETS 28G TYGACIL 126 SYRINGE/SHORT/0.5ML/30G X SUPER THIN 88 TYKERB 40 5/16" 108 88 TRUEPLUS LANCETS 30G TYLENOL/CODEINE #3 9 ULTICARE INSULIN TRUEPLUS LANCETS 30G TYLENOL/CODEINE #4 9 SYRINGE/SHORT/0.5ML/31G X ULTRA THIN 88 5/16" 108 TRUEPLUS LANCETS 33G 89 TYMLOS 67 ULTICARE INSULIN TRUEPLUS LANCETS 33G TYSABRI 125 SYRINGE/SHORT/1ML/30G X MICRO THIN 88 UCERIS 10 5/16" 108 TRUEPLUS SAFETY LANCETS ULTICARE INSULIN 28G 89 UDENYCA 74 SYRINGE/SHORT/1ML/31G X TRUETRACK TEST 65 ULESFIA 65 5/16" 108 TRULICITY 24 ULORIC 73 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X TRUMENBA 130 ULTI-LANCE AUTOMATIC/ CLEAR TIP 89 1/2" 108 TRUSOPT 122 ULTICARE INSULIN SAFETY ULTICARE INSULIN TRUSTEX COLOR CONDOMS + SYRINGE/0.5ML/29G X SYRINGE/U-100/0.3ML/31G X LUBE 77 1/2" 108 5/16" 108 TRUSTEX LUBRICATED 78 ULTICARE INSULIN SAFETY ULTICARE INSULIN TRUSTEX LUBRICATED SYRINGE/1ML/29G X SYRINGE/U-100/0.5ML/30G X EXTRALARGE 78 1/2" 108 1/2" 108 TRUSTEX LUBRICATED ULTICARE INSULIN ULTICARE INSULIN EXTRASTRENGTH 78 SYRINGE/0.3ML/29G X SYRINGE/U-100/0.5ML/31G X TRUSTEX 1/2" 108 5/16" 108 LUBRICATED/RIBBED/STUDDE ULTICARE INSULIN ULTICARE INSULIN D 78 SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/30G X TRUSTEX 1/2" 108 1/2" 108 LUBRICATED/SPERMICIDE ULTICARE INSULIN ULTICARE INSULIN 78 SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G X TRUSTEX 5/16" 108 5/16" 109 LUBRICATED/SPERMICIDE ULTICARE INSULIN ULTICARE INSULIN EXTRA LARGE 78 SYRINGE/0.5ML/28G X SYRINGEULTRAFINE U- TRUSTEX 1/2" 108 100/0.3ML/31G X 5/16" 109 LUBRICATED/SPERMICIDE ULTICARE INSULIN ULTICARE INSULIN EXTRA STRENGTH 78 SYRINGE/0.5ML/29G X SYRINGEULTRAFINE U- TRUSTEX NATURAL 1/2" 108 100/0.5ML/31G X 5/16" 109 CONDOMS ULTICARE INSULIN ULTICARE INSULIN +LUBE/LUBRICATED 78 SYRINGE/0.5ML/30G X SYRINGEULTRAFINE U- TRUSTEX WITH NONOXYNOL- 1/2" 108 100/1ML/31G X 5/16" 109 9/RIBBED/STUDDED 78 ULTICARE INSULIN ULTIGUARD SAFEPACK TRUSTEX/RIA SYRINGE/0.5ML/30G X INSULIN SYRINGE 0.3ML/30G X LUBRICATED 78 5/16" 108 1/2"/SHARPS C 109 TRUSTEX/RIA LUBRICATED ULTICARE INSULIN ULTIGUARD SAFEPACK SPERMICIDE 78 SYRINGE/1ML/28G X INSULIN SYRINGE 1/2ML 30G X TRUSTEX/RIA 1/2" 108 1/2"/SHARPS C 109 LUBRICATED/SPERMICIDE ULTICARE INSULIN ULTIGUARD SAFEPACK 78 SYRINGE/1ML/29G X INSULIN SYRINGE 1ML 30G X 1/2" 108 1/2"/SHARPS CON 109

Index 32 ULTIGUARD SAFEPACK ULTILET SAFETY LANCETS ULTRA-COMFORT INSULIN INSULIN SYRINGE 1ML 31G X 21G X 2.2MM 89 SYRINGE/U-100/0.3ML/31G X 5/16"/SHARPS CO 109 ULTILET SAFETY LANCETS 5/16" 110 ULTIGUARD SAFEPACK 23G 89 ULTRA-COMFORT INSULIN INSULIN SYRINGE/0.3ML/30G X ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"/SHARPS C 109 SYRINGE/U-100/0.3ML/30G X 1/2" 110 ULTIGUARD SAFEPACK 5/16" 109 ULTRA-COMFORT INSULIN INSULIN SYRINGE/0.3ML/31G X ULTRA FLO INSULIN SYRINGE/U-100/0.5ML/29G X 5/16"/SHARPS 109 SYRINGE 0.3ML/29G X 1/2" 110 ULTIGUARD SAFEPACK 1/2" 110 ULTRA-COMFORT INSULIN INSULIN SYRINGE/0.5ML/30G X ULTRA FLO INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"/SHARPS C 109 SYRINGE 5/16" 110 ULTIGUARD 0.3ML/30GX1/2" 110 ULTRA-COMFORT INSULIN SAFEPACK/SYRINGE/NEEDLE/ ULTRA FLO INSULIN SYRINGE/U-100/0.5ML/31G X 31G X 5/16"/SHARPS SYRINGE 5/16" 110 CONTAIN 109 0.3ML/30GX5/16" 110 ULTRA-COMFORT INSULIN ULTILET CLASSIC ULTRA FLO INSULIN SYRINGE/U-100/1ML/28G X LANCETS 89 SYRINGE 1/2" 110 ULTILET INSULIN 0.3ML/31GX5/16" 110 ULTRA-COMFORT INSULIN SYRINGE/0.3ML/30G X ULTRA FLO INSULIN SYRINGE/U-100/1ML/29G X 8MM 109 SYRINGE 1/2" 110 ULTILET INSULIN 0.5ML/29GX1/2" 110 ULTRA-COMFORT INSULIN SYRINGE/0.3ML/31G X ULTRA FLO INSULIN SYRINGE/U-100/1ML/30G X 8MM 109 SYRINGE 5/16" 110 ULTILET INSULIN 0.5ML/30GX1/2" 110 ULTRA-COMFORT INSULIN SYRINGE/0.5ML/30G X ULTRA FLO INSULIN SYRINGE/U-100/1ML/31G X 8MM 109 SYRINGE 5/16" 110 ULTILET INSULIN 0.5ML/30GX5/16" 110 ULTRA-THIN II AUTO SYRINGE/1ML/30G X 8MM109 ULTRA FLO INSULIN LANCET 89 ULTILET INSULIN SYRINGE ULTRA-THIN II INSULIN SYRINGE/1ML/31G X 8MM109 0.5ML/31GX5/16" 110 SYRINGE SHORT/U- ULTILET INSULIN ULTRA FLO INSULIN 100/0.3ML/30GX5/16" 110 SYRINGE/SHORT/0.3ML/30G X SYRINGE 1/2 ULTRA-THIN II INSULIN 12.7MM 109 UNIT/0.3ML/30GX1/2" 110 SYRINGE SHORT/U- ULTILET INSULIN ULTRA FLO INSULIN 100/0.3ML/31GX5/16" 111 SYRINGE/SHORT/0.3ML/30G X SYRINGE 1/2 ULTRA-THIN II INSULIN 5/16" 109 UNIT/0.3ML/30GX5/16" 110 SYRINGE SHORT/U- ULTILET INSULIN ULTRA FLO INSULIN 100/0.5ML/30GX5/16" 111 SYRINGE/SHORT/0.3ML/31G X SYRINGE 1/2 ULTRA-THIN II INSULIN 5/16" 109 UNIT/0.3ML/31GX5/16" 110 SYRINGE SHORT/U- ULTILET INSULIN ULTRA FLO INSULIN 100/0.5ML/31GX5/16" 111 SYRINGE/SHORT/0.5ML/30G X SYRINGE 1M/29GX1/2" 110 ULTRA-THIN II INSULIN 5/16" 109 ULTRA FLO INSULIN SYRINGE SHORT/U- ULTILET INSULIN SYRINGE 1ML/30GX1/2" 110 100/1ML/30GX5/16" 111 SYRINGE/SHORT/0.5ML/31G X ULTRA FLO INSULIN ULTRA-THIN II INSULIN 5/16" 109 SYRINGE SYRINGE SHORT/U- ULTILET INSULIN 1ML/30GX5/16" 110 100/1ML/31GX5/16" 111 SYRINGE/SHORT/1ML/30G X ULTRA FLO INSULIN ULTRA-THIN II INSULIN 5/16" 109 SYRINGE SYRINGE/U- ULTILET INSULIN 1ML/31GX5/16" 110 100/0.5ML/29GX1/2" 111 SYRINGE/SHORT/1ML/31G X ULTRA THIN LANCETS ULTRA-THIN II INSULIN 5/16" 109 31G 89 SYRINGE/U-100/1ML/29GX1/2" ULTILET INSULIN SYRINGE/U- ULTRA-COMFORT INSULIN 111 100/0.5ML/30G X 1/2" 109 SYRINGE/U-100/0.3ML/29G X ULTRA-THIN II LANCETS ULTILET INSULIN SYRINGE/U- 1/2" 110 28G 89 100/1ML/30G X 1/2" 109 ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS ULTILET LANCETS 89 SYRINGE/U-100/0.3ML/30G X 30G 89 ULTILET LANCETS 33G 89 5/16" 110

Index 33 ULTRACARE INSULIN UNISTIK TOUCH SAFETY VALUMARK LANCET ULTRA SYRINGE/U-100/0.3ML/30G X LANCETS 21G 89 THIN 28G 89 5/16" 111 UNISTIK TOUCH SAFETY VANCOCIN 11 ULTRACARE INSULIN LANCETS 23G 89 VANCOCIN HCL 11 SYRINGE/U-100/0.3ML/31G X UNISTIK TOUCH SAFETY 5/16" 111 LANCETS 28G 89 vancomycin hcl 11 ULTRACARE INSULIN UNISTIK TOUCH SAFETY VANCOMYCIN SYRINGE/U-100/0.5ML/30G X LANCETS 30G 89 HYDROCHLORIDE 11 1/2" 111 UNIVERSAL 1 LANCETS VANISHPOINT INSULIN ULTRACARE INSULIN THIN26G 89 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/30G X UNIVERSAL 1 LANCETS 1/2" 111 5/16" 111 ULTRA THIN 30G 89 VANISHPOINT INSULIN ULTRACARE INSULIN UNIVERSAL 1 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/31G X LANCETS/33G/MICRO-THIN 5/16" 111 5/16" 111 89 VANISHPOINT INSULIN ULTRACARE INSULIN URECHOLINE 129 SYRINGE/1ML/29G X 1/2" 111 VANISHPOINT INSULIN SYRINGE/U-100/1ML/30G X UROCIT-K 10 72 1/2" 111 SYRINGE/1ML/30G X ULTRACARE INSULIN UROXATRAL 72 5/16" 111 SYRINGE/U-100/1ML/30G X URSO 250 71 VAQTA 132 5/16" 111 URSO FORTE 71 VARIVAX 132 ULTRACARE INSULIN ursodiol 71 VARUBI 27 SYRINGE/U-100/1ML/31G X 5/16" 111 UTIBRON NEOHALER 15 VASCEPA 29 ULTRACET 9 UVADEX 40 VASERETIC 33 ULTRAM 8 VAGIFEM 132 VASOTEC 31 UNASYN 123 valacyclovir hcl 48 VECAMYL 33 UNASYN BULK PACK 123 VALCYTE 47 VECTIBIX 37 UNILET COMFORTOUCH valganciclovir hcl 48 VECTICAL 61 LANCET 89 VALIUM 13 VELCADE 40 UNILET EXCELITE 89 valproate sodium 20 VELETRI 51 UNILET EXCELITE II 89 valproic acid 20 VELPHORO 72 UNILET G.P. LANCET 89 valrubicin 38 VELTIN 58 UNILET G.P. SUPERLITE LANCET 89 valsartan 31 VEMLIDY 48 UNILET GP 28 ULTRA THIN89 valsartan-hydrochlorothiazide venlafaxine hcl 23 33 VENTAVIS 51 UNILET LANCET 89 VALSTAR 38 UNILET LANCETS MICRO- VENTOLIN HFA 15 VALTOCO 17 THIN33G 89 verapamil hcl 50 VALTREX 48 UNILET LANCETS SUPER- VEREGEN 58 THIN30G 89 VALUE HEALTH INSULIN UNILET LANCETS ULTRA-THIN SYRINGE/U-100/0.5ML/29G X VERELAN 50 28G 89 1/2" 111 VERELAN PM 50 UNILET SUPERLITE VALUE HEALTH INSULIN VERZENIO 40 LANCET 89 SYRINGE/U-100/1ML/29G X VESICARE 129 UNISTIK 3 GENTLE 89 1/2" 111 UNISTIK PRO SAFETY LANCET VALUE PLUS LANCETS VFEND 28 21G 89 STANDARD 21G 89 VIAGRA 51 UNISTIK PRO SAFETY LANCET VALUE PLUS LANCETS VIBRAMYCIN 127 25G 89 SUPERTHIN 30G 89 UNISTIK PRO SAFETY LANCET VALUE PLUS LANCETS THIN VICTOZA 24 28G 89 26G 89 VIDA MIA AUTOLET UNISTIK SAFETY LANCETS VALUE PLUS LANCING LANCINGDEVICE 89 28G 89 DEVICE 89 VIDA MIA UNILET LANCETS UNISTIK SAFETY LANCETS VALUMARK LANCET SUPER SUPER THIN 30G 89 30G 89 THIN 30G 89 VIDA MIA UNILET LANCETS ULTRA THIN 28G 90

Index 34 VIDAZA 36 WALGREENS THIN XPOVIO 60 MG ONCE VIDEX EC 47 LANCETS 90 WEEKLY 38 WALGREENS ULTRA THIN XPOVIO 80 MG ONCE VIDEXPEDIATRIC 47 LANCETS 90 WEEKLY 38 vigabatrin 20 warfarin sodium 16 XPOVIO 80 MG TWICE VIGAMOX 120 water for irrigation, sterile 116 WEEKLY 38 XTAMPZA ER 8 VIIBRYD 22 WELCHOL 30 XTANDI 38 VIIBRYD STARTER PACK 22 WELLBUTRIN SR 21 XULTOPHY 100/3.6 24 VIMPAT 19 WELLBUTRIN XL 21 XYLOCAINE 76 vincristine sulfate 41 WESTAB PLUS 118 XYLOCAINE-MPF 76 vinorelbine tartrate 41 WESTHROID 127 VIRACEPT 47 WIDE-SEAL SILICONE XYREM 124 VIRAMUNE 47 DIAPHRAGM KIT 60 78 XYZAL ALLERGY 24HR 29 WIDE-SEAL SILICONE XYZAL ALLERGY 24HR VIRAMUNE XR 47 DIAPHRAGM KIT 65 78 CHILDRENS 29 VIREAD 47 WIDE-SEAL SILICONE YASMIN 28 54 VISTARIL 13 DIAPHRAGM KIT 70 78 YAZ 54 VISTOGARD 26 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 78 YERVOY 37 VITAMIN D2 133 WIDE-SEAL SILICONE YONSA 38 VITATHELY/GINGER 118 DIAPHRAGM KIT 80 78 ZADITOR 122 VITRAKVI 40 WIDE-SEAL SILICONE DIAPHRAGM KIT 85 78 zafirlukast 14 VIVAGUARD LANCETS 90 WIDE-SEAL SILICONE zaleplon 75 VIVAGUARD LANCING DIAPHRAGM KIT 90 78 ZALTRAP 36 DEVICE 90 WIDE-SEAL SILICONE ZANAFLEX 118 VIVELLE-DOT 70 DIAPHRAGM KIT 95 78 VIZIMPRO 37 WP THYROID 127 ZANOSAR 36 VOGELXO 10 XALATAN 122 ZANTAC 128 ZANTAC 150 MAXIMUM VOGELXO PUMP 10 XALKORI 40 STRENGTH 128 VOL-PLUS 118 XANAX 13 ZARONTIN 20 VOLTAREN 58 XANAX XR 13 ZARXIO 74 VORAXAZE 40 XARELTO 16 ZAVESCA 73 voriconazole 28 XARELTO STARTER ZEGERID 129 VOSEVI 48 PACK 16 XELJANZ 4 ZEJULA 40 VOTRIENT 40 XELJANZ XR 4 ZELBORAF 40 VP INSULIN SYRINGE/U- ZEMAIRA 126 100/0.3ML/29G X 1/2" 111 XELODA 36 VPRIV 73 XENAZINE 124 ZEMPLAR 69 VUSION 59 XEOMIN 119 ZENPEP 66 VYNDAMAX 52 XGEVA 67 ZEPATIER 48 VYNDAQEL 52 XIFAXAN 11 ZERVIATE 122 VYTORIN 29 XIGDUO XR 24 ZESTORETIC 33 VYVANSE 1 XIMINO 127 ZESTRIL 31 WALGREENS ADVANCED XOLAIR 14 ZETIA 30 ZEVRX INSULIN TRAVELLANCETS 28G 90 XOPENEX 15 WALGREENS COMFORT SYRINGE/0.5ML/30G X ASSUREDLANCETS MICRO XOPENEX 1/2" 111 15 THIN/33G 90 CONCENTRATE ZEVRX INSULIN WALGREENS COMFORT XOPENEX HFA 15 SYRINGE/0.5ML/30G X ASSUREDLANCETS SUPER XOSPATA 40 5/16" 111 THIN/28G 90 XPOVIO 100 MG ONCE ZEVRX INSULIN WALGREENS LANCETS 90 WEEKLY 38 SYRINGE/1ML/30G X 1/2" 111

Index 35 ZEVRX INSULIN ZYPREXA ZYDIS 44 SYRINGE/1ML/30G X ZYRTEC ALLERGY 29 5/16" 111 ZYRTEC CHILDRENS ZIAC 33 ALLERGY 29 ZIAGEN 47 ZYRTEC-D ZIANA 58 ALLERGY/CONGESTION 56 zidovudine 47 ZYTIGA 38 ZIEXTENZO 74 ZYVOX 12 zileuton 14 ZIOPTAN 122 ziprasidone hcl 43 ZIRABEV 36 ZIRGAN 120 ZITHROMAX 76 ZITHROMAX TRI-PAK 76 ZITHROMAX Z-PAK 76 ZOCOR 30 ZOFRAN 26 ZOHYDRO ER 8 ZOLADEX 38 zoledronic acid 67 ZOLEDRONIC ACID 67 zoledronic acid 67 ZOLEDRONIC ACID 67 ZOLINZA 40 zolmitriptan 113 ZOLOFT 22 zolpidem tartrate 75 ZOMACTON 68 ZOMIG 113 ZOMIG ZMT 113 ZONALON 60 ZONEGRAN 19 zonisamide 19 ZONTIVITY 73 ZORBTIVE 68 ZORTRESS 116 ZOSTAVAX 132 ZOSYN 123 ZOVIRAX 48,61 ZYCLARA 64 ZYCLARA PUMP 64 ZYDELIG 40 ZYKADIA 40 ZYLOPRIM 73 ZYMAXID 120 ZYPREXA 44

Index 36 superior~ - FROM I healthplan.

© 2020 Celtic Insurance Company. All rights reserved. AMB19-TX-C-00236 Statement of Non-Discrimination Ambetter from Superior HealthPlan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from Superior HealthPlan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Ambetter from Superior HealthPlan: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Ambetter from Superior HealthPlan at 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989). If you believe that Ambetter from Superior HealthPlan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a complaint with: Superior HealthPlan Complaints Department 5900 E Ben White Blvd., Austin, TX 78741 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989) Fax 1-866-683-5369 You can file a complaint by mail, fax, or email. If you need help filing a complaint, Ambetter from Superior HealthPlan is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Declaracin de no discriminacin Ambetter de Superior HealthPlan cumple con las leyes de derechos civiles federales aplicables y no discrimina basándose en la raza, color, origen nacional, edad, discapacidad, o sexo. Ambetter de Superior HealthPlan no excluye personas o las trata de manera diferente debido a su raza, color, origen nacional, edad, discapacidad, o sexo. Ambetter de Superior HealthPlan: • Proporciona ayuda y servicios gratuitos a las personas con discapacidad para que se comuniquen eficazmente con nosotros, tales como: o Intérpretes calificados de lenguaje por seas o Informacin escrita en otros formatos (letra grande, audio, formatos electrnicos accesibles, otros formatos) • Proporciona servicios de idiomas a las personas cuyo lenguaje primario no es el inglés, tales como: o Intérpretes calificados o Informacin escrita en otros idiomas Si necesita estos servicios, comuníquese con Ambetter de Superior HealthPlan a 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989). Si considera que Ambetter de Superior HealthPlan no le ha proporcionado estos servicios, o en cierto modo le ha discriminado debido a su raza, color, origen nacional, edad, discapacidad o sexo, puede presentar una queja ante: Superior HealthPlan Complaints Department 5900 E Ben White Blvd., Austin, TX 78741 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989) Fax 1-866-683-5369 Usted puede presentar una queja por correo, fax, o correo electrnico. Si necesita ayuda para presentar una queja, Ambetter de Superior HealthPlan está disponible para brindarle ayuda. También puede presentar una queja de violacin a sus derechos civiles ante la Oficina de derechos civiles del Departamento de Salud y Servicios Humanos de Estados Unidos (U.S. Department of Health and Human Services), en forma electrnica a través del portal de quejas de la Oficina de derechos civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o vía telefnica llamando al: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Los formularios de queja están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

SHP_20163873A-AMBETTER 2020 AMB19-TX-C-00016 © 2019 Celtic Insurance Company. All rights reserved. © 2019 Celtic Insurance Company. Todos los derechos reservados. Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter de Superior HealthPlan, tiene derecho a obtener Spanish: ayuda e informacin en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

Nếu qu vị, hay người mà qu vị đang giúp đỡ, c câu hỏi về Ambetter from Superior HealthPlan, qu vị sẽ c quyền được gip và Vietnamese: c thêm thng tin bằng ngn ngữ của mình miễn phí. Để ni chuyện với một thng dịch viên, xin gọi 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

如果您，或是您正在協助的對象，有關於 Ambetter from Superior HealthPlan 方面的問題，您有權利免費以您的母語得到幫助和訊 Chinese: 息。如果要與一位翻譯員講話，請撥電話 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989)。

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from Superior HealthPlan 에 관해서 질문이 있다면 귀하는 그러한 도움과 Korean: 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 로 전화하십시오 . ذإ ا كا دلن يك أ و لدى شخص عتسا ده ئأس لة حول Ambetter from Superior HealthPlan ، دل يك حلا ق في حلا صول على عساملا دة ولعملاو ما ت رورضلا ية تكغلب Arabic: من دون ةيأ كت لفة . دحتلل ث مع مجرتم تا صل ـب Relay Texas/TTY 1-800-735-2989) 1-877-687-1196).

گا ر Ambetter from Superior HealthPlan کے راب ے یم ں پآ ، جی ا ن یک آپ دم د ہررک ے یہ ں ا ن ےک الاوس ت وہ ں وت ، آ پ کو ب ضواعمال ہ نپا ی ابز ن یم ں دم د

او لوعمر تما حاصل کرنے کا ہےح سیک۔ق مجرتم سے تبا کرنے کے لیے، Relay Texas/TTY 1-800-735-2989 )، 1-877-687-1196) پر ک لا ۔ںیکر :Urdu

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Ambetter from Superior HealthPlan, may karapatan ka Tagalog: na makakuha nang tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

Si vous-même ou une personne que vous aidez avez des questions à propos d’Ambetter from Superior HealthPlan, vous avez le French: droit de bénéficier gratuitement d’aide et d’informations dans votre langue. Pour parler à un interprète, appelez le 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

आप या जिसकी आप मदद कर रहे हℂ उनके , Ambetter from Superior HealthPlan के बारे मᴂ कोई सवाल हⴂ, तो आपको बबना ककसी ख셍च के Hindi: अपनी भाषा मᴂ मदद और िानकारी प्राꥍत करने का अधिकार है। ककसी दभु ाषषये से बात करने के ललए 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) पर कॉल करᴂ। گرا ش ما، يا کسي که به او مکک يم کنيد يلاسؤ رد درمو Ambetter from Superior HealthPlan يد،راد زا ينا حق ريداردوخرب که مکک تعاطالاو را تروبص ر نايگا به انزب دخو تفرياد دکني ۔ ايرب تحبص دنرک اب جمرتم اب مارهش Relay Texas/TTY 1-800-735-2989) 1-877-687-1196) سمات :Persian ب گي ريد۔

Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter from Superior HealthPlan hat, haben Sie das Recht, kostenlose Hilfe German: und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) an.

狇 તમને અથવા તમે 狇મની મદદ કરી રહ્યા હોય તેમને, Ambetter from Superior HealthPlan વવશે કોઈ પ્રશ્ન હોય તો તમને, કોઈ ખ싍ચ વવના Gujarati: તમારી ભાષામા廒 મદદ અને માહહતી પ્રા꫍ત કરવાનો અવિકાર છે. દુ ભાવષયા સાથે વાત કરવા માટે 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) ઉપર કૉલ કરો. В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter Russian: from Superior HealthPlan вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы поговорить с переводчиком, позвоните по телефону 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

Ambetter from Superior HealthPlan について何かご質問がございましたらご連絡ください。 ご希望の言語によるサポートや情報を無料でご提供い Japanese: たします。 通訳が必要な場合は、1- 877-687-1196 (Relay Texas/TTY 1-800-735-2989) までお電話ください。

ຖ້າທານ່ ຫ ຄົນທ ່ທ່ ານກາລໍັງຊ ່ ວຍເຫ ອມຄ ໍາຖາມກ ່ຽວກັບ Ambetter from Superior HealthPlan, ທ່ ານ ມສດທິ ່ ຈະໄດ້ຮັບການຊ ່ ວຍເຫ ອແລະຂໍ້ມູ ນ

Laotian: ຂ່າວສານ ່ທເປັນພາສາຂອງທ່ານ ໂດຍບ ໍ່ ມຄ ່າໃຊ ້ຈ່າຍ. ເພ່ ອຈະເວົ້າກ ັບນາຍພາສາ, ໃຫ້ໂທຫາ 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

SHP_20163873C-AMBETTER AMB16-TX-C-00076AMB16-TX-C- 00076 © 2016 Celtic Insurance © 2016 Celtic Company. Insurance Company. All rights All rights reserved. reserved.