2021 Bright Formulary (List of Covered Drugs)

Bright Health Individual and Family Plans

Alabama

PLEASE READ: This document contains information about the drugs Bright Health covers in their Individual and Family plans.

This formulary was updated on 09/01/2021. For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the i counter Welcome to Bright

Enclosed you will find a list of the drugs included in our Bright Health Individual and Family plans from January 1, 2021 - December 31, 2021. As you review, be sure to have your medications on hand so you can confirm your prescriptions are covered and compare dosage and pricing of the drugs you take.

Keep in mind, this document includes a comprehensive list of drugs (formulary) included in our Individual and Family plans. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

As a Bright Health member, you must generally use in-network pharmacies to fill your prescriptions. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the 2021 calendar year.

Sincerely, Your Bright Health team

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the ii counter Frequently Asked Questions:

What is a Formulary (drug list)? A formulary is a list of covered drugs selected by Bright Health in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Bright Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, and the prescription is filled at a Bright Health network pharmacy.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. These types of changes may occur without notice to you. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money, or we can ensure your safety. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by Bright Health, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find the drugs you take in the formulary:

1. Medical Condition The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug.

2. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index at the end of the formulary. The Index provides an alphabetical list of all the drugs included in

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the iii counter this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Bright Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Bright Health requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Bright Health before you fill your prescriptions. If you don’t get approval, Bright Health may not cover the drug.

• Quantity Limits: For certain drugs, Bright Health limits the amount of the drug that we will cover. For example, Bright Health provides 15 tablets every 25 days per prescription for Zolpidem Tartrate 5mg. This may be in addition to a standard one-month or three- month supply.

• Step Therapy: In some cases, Bright Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Bright Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Bright Health will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website, www.brighthealthplan.com. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Bright Health to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Bright Health Formulary?” for information about how to request an exception.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the iv counter What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Bright Health does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Bright Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Bright Health.

• You can ask Bright Health to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Bright Health Formulary? You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Bright Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Bright Health will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.

For more information If you have questions about Bright Health please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the v counter Our Formulary (drug list) The formulary below provides coverage information about the drugs covered by our Bright Individual and Family plans. If you have trouble finding your drug in the list, turn to the Index at the end of the formulary. The first column of the chart lists the drug name. Brand name drugs are capitalized and generic drugs are listed in lower-case italics. The second column of the chart, Drug Tier, tells you which tier the drug falls under. Drug tiers are how we divide prescription drugs into different levels of cost. How much you will pay will depend on your individual plan, however, here’s what the drug tier tells you. • Tier 1: Preventative drugs with no member cost share under the Affordable Care Act • Tier 2: Preferred Generic Drugs • Tier 3: Non-Preferred Generic Drugs; Preferred Brand Drugs • Tier 4: Non-Preferred Generic Drugs; Non-Preferred Brand Drugs • Tier 5: Specialty Drugs

The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug.

This formulary was updated on 09/01/2021. For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the vi counter Bright Health Alabama

CURRENT AS OF 9/1/2021

Drug Name Drug Tier Requirements/Limits *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended 4 release 24 hour 1 mg, 2 mg, 3 mg, 4 mg *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 2 QL (30 EA per 30 days) mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 2 QL (30 EA per 30 days) 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 2 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 2 mg dextroamphetamine sulfate oral tablet 10 2 mg, 5 mg methamphetamine hcl oral tablet 5 mg 2 VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 3 QL (30 EA per 30 days) MG *Analeptics*** caffeine citrate intravenous solution 60 2 mg/3ml caffeine citrate oral solution 20 mg/ml 2 caffeine-sodium benzoate injection solution 2 125-125 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

1 Drug Name Drug Tier Requirements/Limits *Stimulants - Misc.*** armodafinil oral tablet 150 mg, 200 mg, 3 PA 250 mg, 50 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 3 QL (30 EA per 30 days) 40 mg dexmethylphenidate hcl oral tablet 10 mg, 2 2.5 mg, 5 mg methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 3 QL (30 EA per 30 days) 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 3 QL (30 EA per 30 days) 40 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 3 QL (30 EA per 30 days) 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 4 QL (30 EA per 30 days) 36 mg, 54 mg methylphenidate hcl oral solution 10 2 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 20 2 mg, 5 mg methylphenidate hcl oral tablet chewable 2 QL (180 EA per 30 days) 10 mg, 2.5 mg, 5 mg modafinil oral tablet 100 mg, 200 mg 2 PA *AMINOGLYCOSIDES* *Aminoglycosides*** amikacin sulfate injection solution 1 2 gm/4ml, 500 mg/2ml gentamicin in saline intravenous solution 2 0.8-0.9 mg/ml-% gentamicin sulfate injection solution 10 2 mg/ml, 40 mg/ml neomycin sulfate oral tablet 500 mg 2 streptomycin sulfate intramuscular solution 2 reconstituted 1 gm tobramycin inhalation nebulization solution 5 PA; SP 300 mg/5ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

2 Drug Name Drug Tier Requirements/Limits tobramycin sulfate injection solution 10 2 mg/ml, 80 mg/2ml *ANALGESICS - ANTI- INFLAMMATORY* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** RINVOQ ORAL TABLET EXTENDED PA; SP; QL (30 EA per 30 5 RELEASE 24 HOUR 15 MG days) *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE 5 PA; SP; QL (3 EA per 28 days) KIT 80 MG/0.8ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE 5 PA; SP; QL (2 EA per 28 days) KIT 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (2 EA per 28 days) INJECTOR KIT 40 MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (6 EA per 28 days) INJECTOR KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- 5 PA; SP; QL (3 EA per 28 days) INJECTOR KIT 80 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (3 EA per 28 days) 80 MG/0.8ML HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (3 EA per 28 days) 80 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (6 EA per 28 days) 40 MG/0.8ML HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 5 PA; SP; QL (3 EA per 28 days) 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 5 PA; SP; QL (2 EA per 28 days) MG/0.2ML, 20 MG/0.2ML, 40 MG/0.4ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

3 Drug Name Drug Tier Requirements/Limits HUMIRA SUBCUTANEOUS PREFILLED 5 PA; SP; QL (6 EA per 28 days) SYRINGE KIT 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 50 3 QL (60 EA per 30 days) mg celecoxib oral capsule 400 mg 3 QL (30 EA per 30 days) *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG 5 PA *Interleukin-1 Blockers*** ARCALYST SUBCUTANEOUS SOLUTION 5 PA; SP RECONSTITUTED 220 MG *Interleukin-6 Receptor Inhibitors*** KEVZARA SUBCUTANEOUS SOLUTION PA; SP; QL (2.28 ML per 28 AUTO-INJECTOR 150 MG/1.14ML, 200 5 days) MG/1.14ML KEVZARA SUBCUTANEOUS SOLUTION PA; SP; QL (2.28 ML per 28 PREFILLED SYRINGE 150 MG/1.14ML, 5 days) 200 MG/1.14ML *Nonsteroidal Anti- Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed 2 release 50-0.2 mg, 75-0.2 mg *Nonsteroidal Anti- Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg 2 diclofenac sodium er oral tablet extended 2 release 24 hour 100 mg diclofenac sodium oral tablet delayed 2 release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 4 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg 2 etodolac oral tablet 400 mg, 500 mg 2 fenoprofen calcium oral tablet 600 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

4 Drug Name Drug Tier Requirements/Limits flurbiprofen oral tablet 100 mg, 50 mg 2 ibuprofen oral suspension 100 mg/5ml 2 ibuprofen oral tablet 400 mg, 600 mg, 800 2 mg indomethacin oral capsule 25 mg, 50 mg 2 ketoprofen oral capsule 50 mg 2 QL (180 EA per 30 days) ketoprofen oral capsule 75 mg 2 QL (120 EA per 30 days) ketorolac tromethamine oral tablet 10 mg 2 QL (20 EA per 5 days) meclofenamate sodium oral capsule 100 3 mg, 50 mg mefenamic acid oral capsule 250 mg 3 meloxicam oral tablet 15 mg, 7.5 mg 2 nabumetone oral tablet 500 mg 2 QL (120 EA per 30 days) nabumetone oral tablet 750 mg 2 QL (60 EA per 30 days) naproxen dr oral tablet delayed release 2 375 mg, 500 mg naproxen oral tablet 250 mg, 375 mg, 500 2 mg naproxen sodium oral tablet 275 mg, 550 2 mg oxaprozin oral tablet 600 mg 2 QL (60 EA per 30 days) piroxicam oral capsule 10 mg, 20 mg 2 sulindac oral tablet 150 mg, 200 mg 2 tolmetin sodium oral capsule 400 mg 3 tolmetin sodium oral tablet 600 mg 3 *Phosphodiesterase 4 (Pde4) Inhibitors*** PA; SP; QL (60 EA per 30 OTEZLA ORAL TABLET 30 MG 5 days) OTEZLA ORAL TABLET THERAPY PACK PA; SP; QL (55 EA per 28 5 10 & 20 & 30 MG days) *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg 3 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS PA; SP; QL (4 ML per 28 5 SOLUTION CARTRIDGE 50 MG/ML days) PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

5 Drug Name Drug Tier Requirements/Limits ENBREL SUBCUTANEOUS SOLUTION 25 PA; SP; QL (8 ML per 28 5 MG/0.5ML days) ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL (8 ML per 28 5 PREFILLED SYRINGE 25 MG/0.5ML days) ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL (4 ML per 28 5 PREFILLED SYRINGE 50 MG/ML days) ENBREL SUBCUTANEOUS SOLUTION 5 PA; SP; QL (8 EA per 28 days) RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS PA; SP; QL (4 ML per 28 5 SOLUTION AUTO-INJECTOR 50 MG/ML days) *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule 50- 3 QL (48 EA per 25 days) 300-40 mg, 50-325-40 mg butalbital-apap-caffeine oral tablet 50-325- 3 QL (180 EA per 30 days) 40 mg butalbital-aspirin-caffeine oral capsule 50- 3 QL (48 EA per 25 days) 325-40 mg TENCON ORAL TABLET 50-325 MG 4 *Salicylates*** aspirin adult low strength oral tablet 1 OTC; QL (100 EA per 30 days) delayed release 81 mg aspirin oral tablet 325 mg 1 OTC; QL (30 EA per 30 days) aspirin oral tablet delayed release 325 mg 1 OTC; QL (30 EA per 30 days) goodsense aspirin oral tablet chewable 81 1 OTC; QL (100 EA per 30 days) mg salsalate oral tablet 500 mg 2 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300- 2 QL (390 EA per 30 days) 15 mg acetaminophen-codeine #3 oral tablet 300- 2 QL (390 EA per 30 days) 30 mg acetaminophen-codeine #4 oral tablet 300- 2 QL (180 EA per 30 days) 60 mg acetaminophen-codeine oral solution 120- 2 12 mg/5ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

6 Drug Name Drug Tier Requirements/Limits butalbital-apap-caff-cod oral capsule 50- 3 QL (48 EA per 25 days) 300-40-30 mg *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 2 10-325 mg/15ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 2 QL (180 EA per 30 days) 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 5-200 2 QL (180 EA per 30 days) mg, 7.5-200 mg *Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg 2 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 3 PA; QL (10 EA per 30 days) 75 mcg/hr hydrocodone bitartrate er oral capsule extended release 12 hour 10 mg, 15 mg, 4 PA; QL (60 EA per 30 days) 20 mg, 30 mg, 40 mg, 50 mg hydromorphone hcl er oral tablet extended release 24 hour 12 mg, 16 mg, 32 mg, 8 4 PA mg hydromorphone hcl oral liquid 1 mg/ml 2 hydromorphone hcl oral tablet 2 mg, 4 mg, 2 QL (240 EA per 30 days) 8 mg hydromorphone hcl rectal suppository 3 4 mg levorphanol tartrate oral tablet 2 mg 2 methadone hcl injection solution 10 mg/ml 2 METHADONE HCL INTENSOL ORAL 2 CONCENTRATE 10 MG/ML methadone hcl oral solution 10 mg/5ml, 5 2 mg/5ml methadone hcl oral tablet 10 mg 2 QL (240 EA per 30 days) methadone hcl oral tablet 5 mg 2 methadone hcl oral tablet soluble 40 mg 2 QL (9 EA per 30 days) METHADOSE ORAL TABLET SOLUBLE 2 QL (9 EA per 30 days) 40 MG morphine sulfate (concentrate) oral 2 solution 100 mg/5ml

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7 Drug Name Drug Tier Requirements/Limits morphine sulfate (pf) injection solution 0.5 2 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous solution 2 10 mg/ml, 4 mg/ml morphine sulfate (pf) intravenous solution 4 2 mg/ml morphine sulfate er oral tablet extended 2 QL (90 EA per 30 days) release 100 mg, 15 mg, 30 mg, 60 mg morphine sulfate intravenous solution 1 2 mg/ml morphine sulfate oral solution 10 mg/5ml, 2 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg 2 QL (180 EA per 30 days) morphine sulfate rectal suppository 10 mg, 4 20 mg, 5 mg morphine sulfate rectal suppository 30 mg 3 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 4 PA 200 MG, 250 MG, 50 MG oxycodone hcl oral concentrate 100 2 mg/5ml oxycodone hcl oral solution 5 mg/5ml 2 oxycodone hcl oral tablet 10 mg, 15 mg, 2 QL (180 EA per 30 days) 20 mg, 30 mg, 5 mg oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 4 PA mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg 2 tramadol hcl er (biphasic) oral tablet 2 QL (30 EA per 30 days) extended release 24 hour 300 mg tramadol hcl er oral tablet extended 2 QL (30 EA per 30 days) release 24 hour 100 mg, 200 mg tramadol hcl oral tablet 50 mg 2 QL (240 EA per 30 days) *Opioid Combinations*** ENDOCET ORAL TABLET 2.5-325 MG 2 ENDOCET ORAL TABLET 5-325 MG 2 QL (360 EA per 30 days) oxycodone-acetaminophen oral tablet 10- 2 QL (180 EA per 30 days) 325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 2.5- 2 325 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

8 Drug Name Drug Tier Requirements/Limits oxycodone-acetaminophen oral tablet 5- 2 QL (360 EA per 30 days) 325 mg oxycodone-aspirin oral tablet 4.8355-325 2 QL (240 EA per 30 days) mg oxycodone-ibuprofen oral tablet 5-400 mg 2 QL (240 EA per 30 days) *Opioid Partial Agonists*** buprenorphine hcl injection solution 0.3 2 PA; SP mg/ml buprenorphine hcl-naloxone hcl sublingual 2 QL (60 EA per 30 days) film 12-3 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual 2 QL (90 EA per 30 days) film 2-0.5 mg, 4-1 mg buprenorphine hcl-naloxone hcl sublingual 1 QL (90 EA per 30 days) tablet sublingual 2-0.5 mg, 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 3 PA; QL (4 EA per 28 days) mcg/hr, 7.5 mcg/hr nalbuphine hcl injection solution 10 mg/ml, 3 20 mg/ml *ANDROGENS-ANABOLIC* *Anabolic Steroids*** ANADROL-50 ORAL TABLET 50 MG 5 PA oxandrolone oral tablet 10 mg, 2.5 mg 4 PA; QL (60 EA per 30 days) *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 2 PA mg methyltestosterone oral capsule 10 mg 2 PA testosterone cypionate intramuscular 2 solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular 2 PA solution 200 mg/ml testosterone transdermal gel 1.62 %, 20.25 mg/1.25gm (1.62%), 20.25 mg/act 3 PA (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%) *ANORECTAL AND RELATED PRODUCTS* *Intrarectal Steroids***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

9 Drug Name Drug Tier Requirements/Limits COLOCORT RECTAL ENEMA 100 2 MG/60ML *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % 4 *Rectal Steroids*** hydrocortisone acetate rectal suppository 2 QL (12 EA per 30 days) 30 mg PROCTO-PAK RECTAL CREAM 1 % 2 PROCTOZONE-HC RECTAL CREAM 2.5 2 % *ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet 200 mg 4 PA EMVERM ORAL TABLET CHEWABLE 100 4 QL (12 EA per 365 days) MG ivermectin oral tablet 3 mg 2 QL (10 EA per 30 days) *ANTIANGINAL AGENTS* *Antianginals-Other*** ranolazine er oral tablet extended release 4 PA; QL (60 EA per 30 days) 12 hour 1000 mg, 500 mg *Nitrates*** isosorbide dinitrate oral tablet 10 mg, 20 2 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 2 60 mg isosorbide mononitrate oral tablet 10 mg, 2 20 mg MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 2 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 4 2 % NITRO-DUR TRANSDERMAL PATCH 24 4 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended 2 release 9 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

10 Drug Name Drug Tier Requirements/Limits nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 2 mcg/ml-% nitroglycerin sublingual tablet sublingual 2 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 2 mg/hr nitroglycerin translingual solution 0.4 2 mg/spray *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 30 2 mg, 5 mg, 7.5 mg hydroxyzine hcl intramuscular solution 25 2 AGE (Max 64 Years) mg/ml, 50 mg/ml hydroxyzine hcl oral syrup 10 mg/5ml 2 AGE (Max 64 Years) hydroxyzine hcl oral tablet 10 mg, 25 mg, 2 AGE (Max 64 Years) 50 mg hydroxyzine pamoate oral capsule 100 mg, 2 AGE (Max 64 Years) 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg 4 *Benzodiazepines*** alprazolam oral tablet 0.25 mg, 0.5 mg, 1 2 QL (150 EA per 30 days) mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, 2 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 2 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml 2 diazepam oral solution 5 mg/5ml 2 diazepam oral tablet 10 mg, 2 mg, 5 mg 2 lorazepam oral concentrate 2 mg/ml 2 QL (150 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 oxazepam oral capsule 10 mg, 15 mg, 30 2 mg *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

11 Drug Name Drug Tier Requirements/Limits disopyramide phosphate oral capsule 100 3 mg, 150 mg NORPACE CR ORAL CAPSULE 4 EXTENDED RELEASE 12 HOUR 100 MG procainamide hcl injection solution 100 2 mg/ml quinidine gluconate er oral tablet extended 4 release 324 mg quinidine sulfate oral tablet 200 mg, 300 2 mg *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) pf intravenous 2 solution 100 mg/5ml mexiletine hcl oral capsule 150 mg, 200 2 mg, 250 mg *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 2 mg, 50 mg propafenone hcl er oral capsule extended 3 release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 2 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200 mg, 400 mg 2 dofetilide oral capsule 125 mcg, 250 mcg, 4 500 mcg *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 12 5 PA hour 600 mg *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 100-50 MCG/DOSE, 250- 50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 3 QL (12 GM per 30 days) 45-21 MCG/ACT PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

12 Drug Name Drug Tier Requirements/Limits ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 62.5-25 MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 3 QL (60 EA per 30 days) MCG/INH, 200-25 MCG/INH budesonide-formoterol fumarate inhalation 3 QL (10.2 GM per 30 days) aerosol 160-4.5 mcg/act, 80-4.5 mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act, 2 QL (1 EA per 30 days) 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 2 0.5-2.5 (3) mg/3ml TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 100-62.5-25 MCG/INH TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 200-62.5-25 MCG/INH *Beta Adrenergics*** albuterol sulfate er oral tablet extended 2 release 12 hour 4 mg, 8 mg albuterol sulfate hfa inhalation aerosol 2 QL (36 GM per 30 days) solution 108 (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 2 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml 2 ARCAPTA NEOHALER INHALATION 4 PA; QL (30 EA per 30 days) CAPSULE 75 MCG arformoterol tartrate inhalation 4 PA; QL (120 ML per 30 days) nebulization solution 15 mcg/2ml levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 2 ST mg/0.5ml, 1.25 mg/3ml metaproterenol sulfate oral syrup 10 2 mg/5ml SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 2 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

13 Drug Name Drug Tier Requirements/Limits terbutaline sulfate oral tablet 2.5 mg, 5 mg 2 VENTOLIN HFA INHALATION AEROSOL 2 QL (36 GM per 30 days) SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL 3 QL (12.9 GM per 30 days) SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 2 0.02 % SPIRIVA HANDIHALER INHALATION 3 QL (30 EA per 30 days) CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 3 QL (4 GM per 30 days) 2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg 2 montelukast sodium oral tablet 10 mg 2 montelukast sodium oral tablet chewable 4 2 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg 2 *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET 250 MCG, 500 4 QL (30 EA per 30 days) MCG *Steroid Inhalants*** ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH 3 QL (30 EA per 30 days) ACTIVATED 100 MCG/ACT, 200 MCG/ACT ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH 3 QL (30 EA per 30 days) ACTIVATED 50 MCG/ACT ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

14 Drug Name Drug Tier Requirements/Limits ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER 3 QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 3 QL (13 GM per 30 days) 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 3 QL (120 ML per 30 days) mg/2ml, 0.5 mg/2ml, 1 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) ACTIVATED 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 3 QL (12 GM per 30 days) 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 3 QL (10.6 GM per 30 days) 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH 4 QL (1 EA per 30 days) ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 3 QL (10.6 GM per 30 days) MCG/ACT, 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 2 12 hour 450 mg theophylline er oral tablet extended release 2 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml 2 *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 2 mg *Direct Factor Xa Inhibitors*** ELIQUIS DVT/PE STARTER PACK ORAL 3 QL (74 EA per 30 days) TABLET THERAPY PACK 5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3 QL (60 EA per 30 days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

15 Drug Name Drug Tier Requirements/Limits XARELTO ORAL TABLET 10 MG, 15 MG, 3 QL (60 EA per 30 days) 2.5 MG, 20 MG XARELTO STARTER PACK ORAL TABLET 3 QL (51 EA per 30 days) THERAPY PACK 15 & 20 MG *Heparins And Heparinoid- Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 2 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection 2 solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 4 mg/3ml enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 4 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 5 PA UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 5 PA mg/0.4ml, 7.5 mg/0.6ml *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 110 MG, 150 4 PA; QL (60 EA per 30 days) MG, 75 MG *ANTICONVULSANTS* *Ampa Glutamate Receptor Antagonists*** FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 PA 2 MG, 4 MG, 6 MG, 8 MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

16 Drug Name Drug Tier Requirements/Limits *Anticonvulsants - Benzodiazepines*** clobazam oral suspension 2.5 mg/ml 4 PA clobazam oral tablet 10 mg, 20 mg 4 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 NAYZILAM NASAL SOLUTION 5 5 QL (10 EA per 30 days) MG/0.1ML *Anticonvulsants - Misc.*** APTIOM ORAL TABLET 200 MG, 400 4 PA MG, 600 MG, 800 MG carbamazepine er oral capsule extended 2 release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended 2 release 12 hour 100 mg, 200 mg, 400 mg carbamazepine oral suspension 100 2 mg/5ml carbamazepine oral tablet 200 mg 2 carbamazepine oral tablet chewable 100 2 mg gabapentin oral capsule 100 mg, 300 mg 2 QL (360 EA per 30 days) gabapentin oral capsule 400 mg 2 QL (270 EA per 30 days) gabapentin oral solution 250 mg/5ml 2 QL (2160 ML per 30 days) gabapentin oral tablet 600 mg 2 QL (180 EA per 30 days) gabapentin oral tablet 800 mg 2 QL (120 EA per 30 days) LAMICTAL ODT ORAL KIT 21 X 25 MG 2 & 7 X 50 MG, 42 X 50 MG & 14X100 MG lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 3 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg 3 lamotrigine oral tablet 100 mg, 150 mg, 2 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 2 mg levetiracetam er oral tablet extended 2 release 24 hour 500 mg, 750 mg levetiracetam intravenous solution 500 2 mg/5ml levetiracetam oral solution 100 mg/ml 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

17 Drug Name Drug Tier Requirements/Limits levetiracetam oral tablet 1000 mg, 250 2 mg, 500 mg, 750 mg oxcarbazepine oral suspension 300 mg/5ml 2 oxcarbazepine oral tablet 150 mg, 300 mg, 2 600 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 3 PA 75 mg pregabalin oral solution 20 mg/ml 3 PA primidone oral tablet 250 mg, 50 mg 2 rufinamide oral suspension 40 mg/ml 4 rufinamide oral tablet 200 mg, 400 mg 4 topiramate oral capsule sprinkle 15 mg, 25 2 mg topiramate oral tablet 100 mg, 200 mg, 25 2 mg, 50 mg VIMPAT ORAL SOLUTION 10 MG/ML 4 PA VIMPAT ORAL TABLET 100 MG, 150 4 PA MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 2 50 mg *Carbamates*** felbamate oral suspension 600 mg/5ml 5 felbamate oral tablet 400 mg, 600 mg 4 *Gaba Modulators*** tiagabine hcl oral tablet 12 mg, 16 mg, 2 4 mg, 4 mg vigabatrin oral packet 500 mg 5 PA; SP *Hydantoins*** DILANTIN ORAL CAPSULE 100 MG, 30 4 MG PEGANONE ORAL TABLET 250 MG 4 phenytoin oral suspension 125 mg/5ml 2 phenytoin oral tablet chewable 50 mg 2 phenytoin sodium extended oral capsule 2 100 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 2 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

18 Drug Name Drug Tier Requirements/Limits *Succinimides*** CELONTIN ORAL CAPSULE 300 MG 3 ethosuximide oral capsule 250 mg 2 ethosuximide oral solution 250 mg/5ml 2 *Valproic Acid*** divalproex sodium er oral tablet extended 2 release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed 2 release sprinkle 125 mg divalproex sodium oral tablet delayed 2 release 125 mg, 250 mg, 500 mg valproic acid oral capsule 250 mg 2 valproic acid oral solution 250 mg/5ml 2 *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 2 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 2 30 mg, 45 mg *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended 2 release 12 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended 2 release 24 hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg 2 maprotiline hcl oral tablet 25 mg, 50 mg, 2 75 mg *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 4 QL (30 EA per 30 days) MG/24HR MARPLAN ORAL TABLET 10 MG 4 phenelzine sulfate oral tablet 15 mg 2 tranylcypromine sulfate oral tablet 10 mg 4

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

19 Drug Name Drug Tier Requirements/Limits *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 2 mg/5ml citalopram hydrobromide oral tablet 10 2 mg, 20 mg citalopram hydrobromide oral tablet 40 mg 2 QL (30 EA per 30 days) escitalopram oxalate oral solution 5 2 QL (600 ML per 30 days) mg/5ml escitalopram oxalate oral tablet 10 mg, 5 2 QL (45 EA per 30 days) mg escitalopram oxalate oral tablet 20 mg 2 QL (30 EA per 30 days) fluoxetine hcl oral capsule 10 mg, 20 mg, 2 40 mg fluoxetine hcl oral capsule delayed release 3 QL (4 EA per 28 days) 90 mg fluoxetine hcl oral solution 20 mg/5ml 2 fluvoxamine maleate oral tablet 100 mg, 2 25 mg, 50 mg paroxetine hcl er oral tablet extended 3 release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 2 30 mg, 40 mg PAXIL ORAL SUSPENSION 10 MG/5ML 3 PA sertraline hcl oral concentrate 20 mg/ml 2 sertraline hcl oral tablet 100 mg, 25 mg, 2 50 mg *Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 4 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 2 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 4 PA MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 4 PA 40 MG VIIBRYD STARTER PACK ORAL KIT 10 4 PA & 20 MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

20 Drug Name Drug Tier Requirements/Limits *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 2 QL (30 EA per 30 days) 50 mg duloxetine hcl oral capsule delayed release 2 QL (60 EA per 30 days) particles 20 mg, 30 mg, 60 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 4 PA MG, 80 MG venlafaxine hcl er oral capsule extended 2 release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 2 37.5 mg, 50 mg, 75 mg *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 25 mg, 2 50 mg amitriptyline hcl oral tablet 100 mg, 150 2 AGE (Max 64 Years) mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 2 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 4 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 3 QL (60 EA per 30 days) 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 2 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml 2 imipramine hcl oral tablet 10 mg, 25 mg, 2 50 mg nortriptyline hcl oral capsule 10 mg, 25 2 mg, 50 mg nortriptyline hcl oral capsule 75 mg 2 AGE (Max 64 Years) nortriptyline hcl oral solution 10 mg/5ml 2 protriptyline hcl oral tablet 10 mg, 5 mg 2 trimipramine maleate oral capsule 100 mg, 4 25 mg, 50 mg *ANTIDIABETICS*

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

21 Drug Name Drug Tier Requirements/Limits *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 2 mg miglitol oral tablet 25 mg, 50 mg 2 *Biguanides*** metformin hcl er oral tablet extended 2 release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 2 mg, 850 mg *Diabetic Other*** glucagon emergency injection kit 1 mg 1 *Dipeptidyl Peptidase-4 (Dpp- 4) Inhibitors*** alogliptin benzoate oral tablet 12.5 mg, 25 2 ST; QL (30 EA per 30 days) mg, 6.25 mg JANUVIA ORAL TABLET 100 MG, 25 3 QL (30 EA per 30 days) MG, 50 MG ONGLYZA ORAL TABLET 2.5 MG, 5 MG 4 ST; QL (30 EA per 30 days) TRADJENTA ORAL TABLET 5 MG 4 ST; QL (30 EA per 30 days) *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 3 QL (60 EA per 30 days) 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50- 3 QL (30 EA per 30 days) 1000 MG, 50-500 MG *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET 0.8 MG 4 *Human Insulin*** APIDRA INJECTION SOLUTION 100 4 PA UNIT/ML APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 4 PA UNIT/ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

22 Drug Name Drug Tier Requirements/Limits FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML FIASP PENFILL SUBCUTANEOUS 3 SOLUTION CARTRIDGE 100 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 3 UNIT/ML insulin asp prot & asp flexpen subcutaneous suspension pen-injector (70- 3 30) 100 unit/ml insulin aspart flexpen subcutaneous 3 solution pen-injector 100 unit/ml insulin aspart penfill subcutaneous solution 3 cartridge 100 unit/ml insulin aspart prot & aspart subcutaneous 3 suspension (70-30) 100 unit/ml insulin aspart subcutaneous solution 100 3 unit/ml LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 3 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 3 100 UNIT/ML NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN- 3 OTC INJECTOR (70-30) 100 UNIT/ML NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- 3 OTC INJECTOR (70-30) 100 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 3 OTC 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS 3 OTC SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN- 3 OTC INJECTOR 100 UNIT/ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

23 Drug Name Drug Tier Requirements/Limits NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 3 OTC UNIT/ML NOVOLIN N RELION SUBCUTANEOUS 3 OTC SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS 3 OTC SUSPENSION 100 UNIT/ML NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-INJECTOR 100 3 OTC UNIT/ML NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 3 OTC 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 3 OTC UNIT/ML NOVOLIN R RELION INJECTION 3 OTC SOLUTION 100 UNIT/ML NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN- 3 INJECTOR (70-30) 100 UNIT/ML NOVOLOG FLEXPEN RELION SUBCUTANEOUS SOLUTION PEN- 3 INJECTOR 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- 3 INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 3 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS 3 SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS 3 SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG RELION SUBCUTANEOUS 3 SOLUTION 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 3 100 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 3 INJECTOR 300 UNIT/ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

24 Drug Name Drug Tier Requirements/Limits TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 3 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 3 UNIT/ML, 200 UNIT/ML TRESIBA SUBCUTANEOUS SOLUTION 3 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 3 QL (1.5 ML per 28 days) INJECTOR 2 MG/1.5ML OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 3 QL (3 ML per 28 days) INJECTOR 2 MG/1.5ML, 4 MG/3ML RYBELSUS ORAL TABLET 14 MG, 3 MG, 3 QL (30 EA per 30 days) 7 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 3 QL (2 ML per 28 days) MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION 3 QL (9 ML per 30 days) PEN-INJECTOR 18 MG/3ML *Insulin-Incretin Mimetic Combinations*** XULTOPHY SUBCUTANEOUS SOLUTION 4 PA PEN-INJECTOR 100-3.6 UNIT-MG/ML *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg 2 repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2 *Sodium-Glucose Co- Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 3 QL (30 EA per 30 days) MG JARDIANCE ORAL TABLET 10 MG, 25 3 QL (30 EA per 30 days) MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

25 Drug Name Drug Tier Requirements/Limits *Sodium-Glucose Co- Transporter 2 Inhibitor- Biguanide Comb*** INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 3 QL (60 EA per 30 days) MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150- 3 QL (60 EA per 30 days) 1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 3 QL (60 EA per 30 days) MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 3 QL (30 EA per 30 days) MG, 12.5-1000 MG, 25-1000 MG, 5- 1000 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 2 mg, 2.5-500 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 2 AGE (Max 64 Years) mg, 2.5-500 mg, 5-500 mg *Sulfonylureas*** glimepiride oral tablet 1 mg, 2 mg, 4 mg 2 glipizide er oral tablet extended release 24 2 QL (60 EA per 30 days) hour 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg 2 glyburide micronized oral tablet 1.5 mg, 3 2 AGE (Max 64 Years) mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 2 AGE (Max 64 Years) mg *Sulfonylurea- Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30- 2 2 mg, 30-4 mg *Thiazolidinedione-Biguanide Combinations***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

26 Drug Name Drug Tier Requirements/Limits pioglitazone hcl-metformin hcl oral tablet 2 15-500 mg, 15-850 mg *Thiazolidinediones*** pioglitazone hcl oral tablet 15 mg, 30 mg, 2 QL (30 EA per 30 days) 45 mg *ANTIDIARRHEAL/PROBIOTI C AGENTS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5- 2 0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5- 2 0.025 mg loperamide hcl oral capsule 2 mg 2 loperamide hcl oral liquid 1 mg/5ml 2 OTC MOTOFEN ORAL TABLET 1-0.025 MG 4 PA *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG 4 deferiprone oral tablet 500 mg 5 PA; SP FERRIPROX ORAL SOLUTION 100 5 PA; SP MG/ML *Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml, 2 4 mg/10ml naloxone hcl injection solution cartridge 2 0.4 mg/ml naloxone hcl injection solution prefilled 3 syringe 2 mg/2ml naltrexone hcl oral tablet 50 mg 2 NARCAN NASAL LIQUID 4 MG/0.1ML 3 VIVITROL INTRAMUSCULAR 5 PA; SP SUSPENSION RECONSTITUTED 380 MG *ANTIEMETICS* *5-Ht3 Receptor Antagonists***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

27 Drug Name Drug Tier Requirements/Limits ANZEMET ORAL TABLET 100 MG, 50 4 ST MG granisetron hcl oral tablet 1 mg 4 QL (60 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml 2 QL (200 ML per 21 days) ondansetron hcl oral tablet 24 mg 2 QL (2 EA per 21 days) ondansetron hcl oral tablet 4 mg, 8 mg 2 QL (18 EA per 21 days) ondansetron oral tablet dispersible 4 mg, 8 2 QL (18 EA per 21 days) mg *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg 2 scopolamine transdermal patch 72 hour 1 3 QL (10 EA per 30 days) mg/3days trimethobenzamide hcl oral capsule 300 2 AGE (Max 64 Years) mg *Antiemetics - Miscellaneous*** dronabinol oral capsule 10 mg, 2.5 mg, 5 3 QL (60 EA per 30 days) mg *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg, 40 mg, 80 4 ST mg *ANTIFUNGALS* *Antifungals*** flucytosine oral capsule 250 mg, 500 mg 5 PA griseofulvin microsize oral suspension 125 2 mg/5ml griseofulvin microsize oral tablet 500 mg 3 griseofulvin ultramicrosize oral tablet 125 3 mg, 250 mg nystatin oral tablet 500000 unit 2 terbinafine hcl oral tablet 250 mg 2 *Imidazoles*** ketoconazole oral tablet 200 mg 2 *Triazoles***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

28 Drug Name Drug Tier Requirements/Limits CRESEMBA ORAL CAPSULE 186 MG 5 PA fluconazole oral suspension reconstituted 2 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 2 200 mg, 50 mg itraconazole oral capsule 100 mg 5 PA itraconazole oral solution 10 mg/ml 5 PA posaconazole oral tablet delayed release 4 PA 100 mg voriconazole oral suspension reconstituted 5 PA 40 mg/ml voriconazole oral tablet 200 mg, 50 mg 5 PA *ANTIHISTAMINES* *Antihistamines - Ethanolamines*** allergy childrens oral liquid 12.5 mg/5ml 2 OTC allergy relief childrens oral liquid 12.5 2 OTC mg/5ml BENADRYL ALLERGY CHILDRENS ORAL 2 OTC LIQUID 12.5 MG/5ML carbinoxamine maleate oral solution 4 2 mg/5ml carbinoxamine maleate oral tablet 4 mg 2 clemastine fumarate oral tablet 2.68 mg 2 AGE (Max 64 Years) diphenhydramine hcl injection solution 50 2 mg/ml diphenhydramine hcl oral elixir 12.5 2 mg/5ml *Antihistamines - Non- Sedating*** cetirizine hcl oral solution 1 mg/ml 2 QL (300 ML per 30 days) cetirizine hcl oral tablet 10 mg, 5 mg 2 OTC; QL (30 EA per 30 days) desloratadine oral tablet 5 mg 2 eq allergy relief oral tablet 10 mg 2 OTC; QL (30 EA per 30 days) fexofenadine hcl oral tablet 180 mg 2 OTC; QL (30 EA per 30 days) fexofenadine hcl oral tablet 60 mg 2 OTC; QL (60 EA per 30 days) levocetirizine dihydrochloride oral tablet 5 2 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

29 Drug Name Drug Tier Requirements/Limits *Antihistamines - Phenothiazines*** promethazine hcl injection solution 25 2 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml 2 AGE (Max 64 Years) promethazine hcl oral tablet 12.5 mg, 25 2 AGE (Max 64 Years) mg, 50 mg PROMETHEGAN RECTAL SUPPOSITORY 2 QL (12 EA per 30 days) 12.5 MG, 25 MG, 50 MG *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml 2 cyproheptadine hcl oral tablet 4 mg 2 *ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** icosapent ethyl oral capsule 1 gm 4 ST; QL (120 EA per 30 days) omega-3-acid ethyl esters oral capsule 1 3 QL (120 EA per 30 days) gm *Bile Acid Sequestrants*** cholestyramine light oral powder 4 2 gm/dose cholestyramine oral powder 4 gm/dose 2 QL (378 GM per 30 days) colestipol hcl oral granules 5 gm 2 colestipol hcl oral tablet 1 gm 2 WELCHOL ORAL PACKET 3.75 GM 2 WELCHOL ORAL TABLET 625 MG 2 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 130 2 mg, 134 mg, 200 mg, 43 mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg 2 fenofibrate oral tablet 145 mg, 160 mg, 48 2 mg, 54 mg fenofibric acid oral capsule delayed release 2 135 mg, 45 mg fenofibric acid oral tablet 105 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

30 Drug Name Drug Tier Requirements/Limits FIBRICOR ORAL TABLET 105 MG, 35 2 MG gemfibrozil oral tablet 600 mg 2 *Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 $0 copay for members age 40 2 mg through 75 atorvastatin calcium oral tablet 40 mg 2 atorvastatin calcium oral tablet 80 mg 2 QL (30 EA per 30 days) fluvastatin sodium oral capsule 20 mg, 40 $0 copay for members age 40 2 mg through 75 LIVALO ORAL TABLET 1 MG, 2 MG, 4 4 ST; QL (30 EA per 30 days) MG $0 copay for members age 40 lovastatin oral tablet 10 mg, 20 mg, 40 mg 2 through 75 pravastatin sodium oral tablet 10 mg, 20 $0 copay for members age 40 2 mg, 40 mg, 80 mg through 75 rosuvastatin calcium oral tablet 10 mg, 5 $0 copay for members age 40 2 mg through 75 rosuvastatin calcium oral tablet 20 mg, 40 2 mg simvastatin oral tablet 10 mg, 20 mg, 40 $0 copay for members age 40 2 mg, 5 mg through 75 simvastatin oral tablet 80 mg 2 *Intest Cholest Absorp Inhib- Hmg Coa Reductase Inhib Comb*** ezetimibe-simvastatin oral tablet 10-10 3 ST mg, 10-20 mg, 10-40 mg, 10-80 mg *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 mg 2 QL (30 EA per 30 days) *Pcsk9 Inhibitors*** PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 5 PA; QL (2 ML per 28 days) MG/ML REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION 5 PA; QL (3.5 ML per 30 days) CARTRIDGE 420 MG/3.5ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

31 Drug Name Drug Tier Requirements/Limits REPATHA SUBCUTANEOUS SOLUTION 5 PA; QL (2 ML per 28 days) PREFILLED SYRINGE 140 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 5 PA; QL (2 ML per 28 days) MG/ML *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 2 mg, 5-20 mg, 5-40 mg trandolapril-verapamil hcl er oral tablet 2 QL (30 EA per 30 days) extended release 1-240 mg trandolapril-verapamil hcl er oral tablet extended release 2-180 mg, 2-240 mg, 4- 3 QL (30 EA per 30 days) 240 mg *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5- 2 6.25 mg captopril-hydrochlorothiazide oral tablet 2 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 2 10-25 mg, 5-12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 2 mg, 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 2 10-12.5 mg, 20-12.5 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 2 10-12.5 mg, 20-12.5 mg, 20-25 mg *Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 2 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 2 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 2 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 2 40 mg PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

32 Drug Name Drug Tier Requirements/Limits lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 2 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg 2 perindopril erbumine oral tablet 2 mg, 4 2 mg, 8 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 2 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 2 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg 2 *Agents For Pheochromocytoma*** phenoxybenzamine hcl oral capsule 10 mg 2 PA; SP *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 2 mg amlodipine-olmesartan oral tablet 10-20 2 ST mg, 10-40 mg, 5-20 mg, 5-40 mg *Angiotensin Ii Receptor Antag & Thiazide/Thiazide- Like*** candesartan cilexetil-hctz oral tablet 16- 2 QL (30 EA per 30 days) 12.5 mg, 32-12.5 mg, 32-25 mg irbesartan-hydrochlorothiazide oral tablet 2 150-12.5 mg, 300-12.5 mg losartan potassium-hctz oral tablet 100- 2 12.5 mg, 100-25 mg, 50-12.5 mg olmesartan medoxomil-hctz oral tablet 20- 3 QL (30 EA per 30 days) 12.5 mg, 40-12.5 mg, 40-25 mg telmisartan-hctz oral tablet 40-12.5 mg, 2 QL (30 EA per 30 days) 80-12.5 mg, 80-25 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 2 320-25 mg, 80-12.5 mg *Angiotensin Ii Receptor Antagonists***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

33 Drug Name Drug Tier Requirements/Limits candesartan cilexetil oral tablet 16 mg, 32 2 QL (30 EA per 30 days) mg, 4 mg, 8 mg eprosartan mesylate oral tablet 600 mg 2 QL (30 EA per 30 days) irbesartan oral tablet 150 mg, 300 mg, 75 2 QL (30 EA per 30 days) mg losartan potassium oral tablet 100 mg 2 QL (30 EA per 30 days) losartan potassium oral tablet 25 mg, 50 2 QL (60 EA per 30 days) mg olmesartan medoxomil oral tablet 20 mg, 3 QL (30 EA per 30 days) 40 mg, 5 mg telmisartan oral tablet 20 mg, 40 mg, 80 2 QL (30 EA per 30 days) mg valsartan oral tablet 160 mg, 40 mg, 80 2 QL (60 EA per 30 days) mg valsartan oral tablet 320 mg 2 QL (30 EA per 30 days) *Angiotensin Ii Receptor Ant- Ca Channel Blocker- Thiazides*** amlodipine-valsartan-hctz oral tablet 10- 160-12.5 mg, 10-160-25 mg, 10-320-25 2 mg, 5-160-12.5 mg, 5-160-25 mg olmesartan-amlodipine-hctz oral tablet 20- 5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 3 40-5-12.5 mg, 40-5-25 mg *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 2 0.3 mg clonidine transdermal patch weekly 0.1 3 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet 1 mg, 2 mg 2 methyldopa oral tablet 250 mg, 500 mg 2 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 2 4 mg, 8 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 2 terazosin hcl oral capsule 1 mg, 10 mg, 2 2 mg, 5 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

34 Drug Name Drug Tier Requirements/Limits *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 2 mg, 50-25 mg bisoprolol-hydrochlorothiazide oral tablet 2 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg metoprolol-hydrochlorothiazide oral tablet 2 100-25 mg, 100-50 mg, 50-25 mg propranolol-hctz oral tablet 40-25 mg, 80- 2 25 mg *Direct Renin Inhibitors*** aliskiren fumarate oral tablet 150 mg, 300 2 QL (30 EA per 30 days) mg *Dopamine D1 Receptor Agonists*** CORLOPAM INTRAVENOUS SOLUTION 5 10 MG/ML *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet 25 mg, 50 mg 2 *Vasodilators*** hydralazine hcl injection solution 20 mg/ml 2 hydralazine hcl oral tablet 10 mg, 100 mg, 2 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg 2 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole in nacl intravenous solution 2 5-0.79 mg/ml-% metronidazole oral capsule 375 mg 2 metronidazole oral tablet 250 mg, 500 mg 2 pentamidine isethionate inhalation solution 2 reconstituted 300 mg pentamidine isethionate injection solution 4 reconstituted 300 mg PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

35 Drug Name Drug Tier Requirements/Limits tinidazole oral tablet 250 mg, 500 mg 2 trimethoprim oral tablet 100 mg 2 XIFAXAN ORAL TABLET 200 MG 4 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG 4 QL (90 EA per 30 days) *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral 2 suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 2 400-80 mg, 800-160 mg *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION 5 PA RECONSTITUTED 100 MG/5ML atovaquone oral suspension 750 mg/5ml 4 nitazoxanide oral tablet 500 mg 5 PA *Carbapenem Combinations*** imipenem-cilastatin intravenous solution 4 reconstituted 250 mg, 500 mg *Carbapenems*** meropenem intravenous solution 4 reconstituted 1 gm, 500 mg *Glycopeptides*** vancomycin hcl intravenous solution 2 reconstituted 1 gm, 500 mg, 750 mg vancomycin hcl intravenous solution 3 reconstituted 10 gm vancomycin hcl oral capsule 125 mg, 250 3 QL (40 EA per 10 days) mg *Leprostatics*** dapsone oral tablet 100 mg, 25 mg 3 *Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 2 mg, 75 mg clindamycin palmitate hcl oral solution 2 reconstituted 75 mg/5ml *Oxazolidinones***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

36 Drug Name Drug Tier Requirements/Limits linezolid intravenous solution 600 4 mg/300ml linezolid oral suspension reconstituted 100 4 mg/5ml linezolid oral tablet 600 mg 3 QL (28 EA per 14 days) SIVEXTRO ORAL TABLET 200 MG 4 PA; SP *Polymyxins*** polymyxin b sulfate injection solution 2 reconstituted 500000 unit *Urinary Anti-Infectives*** fosfomycin tromethamine oral packet 3 gm 4 methenamine hippurate oral tablet 1 gm 2 nitrofurantoin macrocrystal oral capsule 2 AGE (Max 64 Years) 100 mg, 50 mg nitrofurantoin macrocrystal oral capsule 25 2 mg nitrofurantoin monohyd macro oral capsule 2 AGE (Max 64 Years) 100 mg nitrofurantoin oral suspension 25 mg/5ml 2 AGE (Max 64 Years) *ANTIMALARIALS* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250- 3 100 mg atovaquone-proguanil hcl oral tablet 62.5- 3 QL (30 EA per 30 days) 25 mg COARTEM ORAL TABLET 20-120 MG 4 *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 2 500 mg hydroxychloroquine sulfate oral tablet 200 2 mg mefloquine hcl oral tablet 250 mg 2 primaquine phosphate oral tablet 26.3 (15 4 base) mg, 26.3 mg pyrimethamine oral tablet 25 mg 4 PA; SP quinine sulfate oral capsule 324 mg 4

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

37 Drug Name Drug Tier Requirements/Limits *ANTIMYASTHENIC/CHOLINE RGIC AGENTS* *Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet 125 mg 2 pyridostigmine bromide er oral tablet 5 extended release 180 mg pyridostigmine bromide oral solution 60 2 PA mg/5ml pyridostigmine bromide oral tablet 60 mg 2 REGONOL INTRAVENOUS SOLUTION 4 10 MG/2ML *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE 150-300 MG 4 RIFATER ORAL TABLET 50-120-300 MG 4 *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg 2 isoniazid oral syrup 50 mg/5ml 3 isoniazid oral tablet 100 mg, 300 mg 2 PASER ORAL PACKET 4 GM 4 PRIFTIN ORAL TABLET 150 MG 4 pyrazinamide oral tablet 500 mg 2 rifabutin oral capsule 150 mg 2 PA rifampin intravenous solution reconstituted 2 600 mg rifampin oral capsule 150 mg, 300 mg 2 SIRTURO ORAL TABLET 100 MG 4 PA; SP TRECATOR ORAL TABLET 250 MG 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** busulfan intravenous solution 6 mg/ml 4 PA carboplatin intravenous solution 50 2 mg/5ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

38 Drug Name Drug Tier Requirements/Limits cisplatin intravenous solution 50 mg/50ml 2 oxaliplatin intravenous solution 100 2 mg/20ml, 50 mg/10ml oxaliplatin intravenous solution 2 reconstituted 100 mg, 50 mg *Androgen Biosynthesis Inhibitors*** PA; SP; QL (120 EA per 30 abiraterone acetate oral tablet 250 mg 5 days) abiraterone acetate oral tablet 500 mg 5 PA; SP *Antiadrenals*** LYSODREN ORAL TABLET 500 MG 3 PA; SP *Antiandrogens*** bicalutamide oral tablet 50 mg 2 flutamide oral capsule 125 mg 2 nilutamide oral tablet 150 mg 2 SP *Antiestrogens*** tamoxifen citrate oral tablet 10 mg, 20 mg 1 toremifene citrate oral tablet 60 mg 5 PA; SP *Antimetabolites*** ADRUCIL INTRAVENOUS SOLUTION 2 500 MG/10ML ALIMTA INTRAVENOUS SOLUTION 5 PA RECONSTITUTED 100 MG, 500 MG PA; SP; QL (120 EA per 30 capecitabine oral tablet 150 mg 5 days) PA; SP; QL (300 EA per 30 capecitabine oral tablet 500 mg 5 days) cytarabine (pf) injection solution 100 2 mg/ml, 20 mg/ml fluorouracil intravenous solution 1 2 gm/20ml, 2.5 gm/50ml, 500 mg/10ml gemcitabine hcl intravenous solution 1 4 PA gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml gemcitabine hcl intravenous solution 4 PA reconstituted 1 gm, 2 gm mercaptopurine oral tablet 50 mg 2 methotrexate oral tablet 2.5 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

39 Drug Name Drug Tier Requirements/Limits methotrexate sodium (pf) injection solution 2 50 mg/2ml methotrexate sodium injection solution 50 2 mg/2ml methotrexate sodium injection solution 2 reconstituted 1 gm TABLOID ORAL TABLET 40 MG 5 PA; SP *Antineoplastic - Alk Inhibitors*** XALKORI ORAL CAPSULE 200 MG, 250 PA; SP; QL (60 EA per 30 5 MG days) ZYKADIA ORAL TABLET 150 MG 5 PA; SP *Antineoplastic - Anti-Her2 Agents*** HERCEPTIN INTRAVENOUS SOLUTION 5 PA RECONSTITUTED 150 MG *Antineoplastic - Bcr-Abl Kinase Inhibitors*** PA; SP; QL (90 EA per 30 BOSULIF ORAL TABLET 100 MG 5 days) BOSULIF ORAL TABLET 400 MG, 500 PA; SP; QL (30 EA per 30 5 MG days) PA; SP; QL (60 EA per 30 ICLUSIG ORAL TABLET 15 MG 5 days) PA; SP; QL (30 EA per 30 ICLUSIG ORAL TABLET 45 MG 5 days) PA; SP; QL (90 EA per 30 imatinib mesylate oral tablet 100 mg 5 days) PA; SP; QL (60 EA per 30 imatinib mesylate oral tablet 400 mg 5 days) SPRYCEL ORAL TABLET 100 MG, 140 5 PA; SP MG, 20 MG, 50 MG, 70 MG, 80 MG TASIGNA ORAL CAPSULE 150 MG, 200 5 PA; SP MG, 50 MG *Antineoplastic - Braf Kinase Inhibitors*** TAFINLAR ORAL CAPSULE 50 MG, 75 PA; SP; QL (120 EA per 30 5 MG days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

40 Drug Name Drug Tier Requirements/Limits *Antineoplastic - Btk Inhibitors*** PA; SP; QL (120 EA per 30 IMBRUVICA ORAL CAPSULE 140 MG 5 days) IMBRUVICA ORAL TABLET 420 MG, PA; SP; QL (30 EA per 30 5 560 MG days) *Antineoplastic - Egfr Inhibitors*** PA; SP; QL (30 EA per 30 erlotinib hcl oral tablet 100 mg, 150 mg 5 days) PA; SP; QL (60 EA per 30 erlotinib hcl oral tablet 25 mg 5 days) GILOTRIF ORAL TABLET 20 MG, 30 MG, 5 PA; SP 40 MG *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 10 MG, 15 5 PA; SP MG, 20 MG ZOLINZA ORAL CAPSULE 100 MG 5 PA; SP *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 1 MG, 2 MG, PA; SP; QL (21 EA per 21 5 3 MG, 4 MG days) *Antineoplastic - Mek Inhibitors*** PA; SP; QL (90 EA per 30 MEKINIST ORAL TABLET 0.5 MG 5 days) PA; SP; QL (30 EA per 30 MEKINIST ORAL TABLET 2 MG 5 days) *Antineoplastic - Mtor Kinase Inhibitors*** PA; SP; QL (30 EA per 30 AFINITOR ORAL TABLET 10 MG 5 days) everolimus oral tablet 2.5 mg, 5 mg, 7.5 PA; SP; QL (30 EA per 30 5 mg days) *Antineoplastic - Multikinase Inhibitors***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

41 Drug Name Drug Tier Requirements/Limits PA; SP; QL (60 EA per 30 CAPRELSA ORAL TABLET 100 MG 5 days) PA; SP; QL (30 EA per 30 CAPRELSA ORAL TABLET 300 MG 5 days) COMETRIQ (100 MG DAILY DOSE) 5 PA; SP ORAL KIT 80 & 20 MG COMETRIQ (140 MG DAILY DOSE) 5 PA; SP ORAL KIT 3 X 20 MG & 80 MG COMETRIQ (60 MG DAILY DOSE) ORAL 5 PA; SP KIT 20 MG lapatinib ditosylate oral tablet 250 mg 5 PA; SP PA; SP; QL (120 EA per 30 NEXAVAR ORAL TABLET 200 MG 5 days) PA; SP; QL (84 EA per 28 STIVARGA ORAL TABLET 40 MG 5 days) SUTENT ORAL CAPSULE 12.5 MG, 25 PA; SP; QL (30 EA per 30 5 MG, 37.5 MG, 50 MG days) PA; SP; QL (120 EA per 30 VOTRIENT ORAL TABLET 200 MG 5 days) *Antineoplastic Antibiotics*** adriamycin intravenous solution 2 reconstituted 10 mg ADRIAMYCIN INTRAVENOUS 2 SOLUTION RECONSTITUTED 50 MG bleomycin sulfate injection solution 2 reconstituted 15 unit, 30 unit doxorubicin hcl intravenous solution 2 2 mg/ml doxorubicin hcl liposomal intravenous 2 injectable 2 mg/ml epirubicin hcl intravenous solution 200 2 mg/100ml, 50 mg/25ml idarubicin hcl intravenous solution 10 2 mg/10ml, 20 mg/20ml, 5 mg/5ml *Antineoplastics Misc.*** ACTIMMUNE SUBCUTANEOUS 5 PA; SP SOLUTION 2000000 UNIT/0.5ML dacarbazine intravenous solution 4 PA reconstituted 100 mg, 200 mg hydroxyurea oral capsule 500 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

42 Drug Name Drug Tier Requirements/Limits INTRON A INJECTION SOLUTION 5 PA; SP 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 5 PA; SP 18000000 UNIT, 50000000 UNIT MATULANE ORAL CAPSULE 50 MG 5 PA; SP *Aromatase Inhibitors*** anastrozole oral tablet 1 mg 2 exemestane oral tablet 25 mg 2 letrozole oral tablet 2.5 mg 2 QL (30 EA per 30 days) *Cyclin-Dependent Kinases (Cdk) Inhibitors*** IBRANCE ORAL CAPSULE 100 MG, 125 PA; SP; QL (21 EA per 28 5 MG, 75 MG days) IBRANCE ORAL TABLET 100 MG, 125 PA; SP; QL (21 EA per 28 5 MG, 75 MG days) *Estrogen Receptor Antagonist*** fulvestrant intramuscular solution 250 5 PA; SP mg/5ml *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG 4 SP *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 2 mg, 25 mg, 5 mg *Imidazotetrazines*** TEMODAR INTRAVENOUS SOLUTION 5 PA RECONSTITUTED 100 MG temozolomide oral capsule 100 mg, 140 5 PA; SP mg, 180 mg, 20 mg, 250 mg, 5 mg *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, PA; SP; QL (60 EA per 30 5 20 MG, 25 MG, 5 MG days) *Lhrh Analogs*** ELIGARD SUBCUTANEOUS KIT 22.5 5 PA; SP MG, 30 MG, 45 MG, 7.5 MG PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

43 Drug Name Drug Tier Requirements/Limits leuprolide acetate injection kit 1 mg/0.2ml 5 PA; SP LUPRON DEPOT (1-MONTH) 5 PA; SP INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 5 PA; SP MG LUPRON DEPOT (4-MONTH) 5 PA; SP INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) 5 PA; SP INTRAMUSCULAR KIT 45 MG *Mitotic Inhibitors*** ABRAXANE INTRAVENOUS 3 SUSPENSION RECONSTITUTED 100 MG docetaxel intravenous concentrate 20 2 mg/ml, 80 mg/4ml docetaxel intravenous solution 20 mg/2ml, 2 80 mg/8ml etoposide intravenous solution 100 mg/5ml 2 teniposide intravenous solution 10 mg/ml 3 vinblastine sulfate intravenous solution 1 2 mg/ml vincristine sulfate intravenous solution 1 2 mg/ml vinorelbine tartrate intravenous solution 10 2 mg/ml, 50 mg/5ml *Nitrogen Mustards*** cyclophosphamide injection solution 4 SP reconstituted 1 gm, 2 gm, 500 mg cyclophosphamide oral capsule 25 mg, 50 2 mg ifosfamide intravenous solution 1 gm/20ml, 2 3 gm/60ml ifosfamide intravenous solution 2 reconstituted 1 gm LEUKERAN ORAL TABLET 2 MG 5 PA; SP melphalan hcl intravenous solution 2 reconstituted 50 mg melphalan oral tablet 2 mg 2 SP *Nitrosoureas***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

44 Drug Name Drug Tier Requirements/Limits carmustine intravenous solution 2 reconstituted 100 mg GLEOSTINE ORAL CAPSULE 10 MG, 100 5 PA; SP MG, 40 MG GLIADEL WAFER IMPLANT WAFER 7.7 3 MG *Phosphatidylinositol 3- Kinase (Pi3k) Inhibitors*** ZYDELIG ORAL TABLET 100 MG, 150 5 PA; SP MG *Progestins- Antineoplastic*** megestrol acetate oral suspension 40 2 mg/ml megestrol acetate oral tablet 20 mg, 40 2 mg *Retinoids*** tretinoin oral capsule 10 mg 5 PA; SP *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 mg 5 PA; SP *Topoisomerase I Inhibitors*** topotecan hcl intravenous solution 4 5 mg/4ml *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG 5 PA; SP *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** INLYTA ORAL TABLET 1 MG, 5 MG 5 PA; SP LENVIMA (10 MG DAILY DOSE) ORAL PA; SP; QL (30 EA per 30 5 CAPSULE THERAPY PACK 10 MG days) LENVIMA (12 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 5 CAPSULE THERAPY PACK 3 X 4 MG days) LENVIMA (14 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 5 CAPSULE THERAPY PACK 10 & 4 MG days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

45 Drug Name Drug Tier Requirements/Limits LENVIMA (18 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 CAPSULE THERAPY PACK 10 MG & 2 X 5 days) 4 MG LENVIMA (20 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 5 CAPSULE THERAPY PACK 2 X 10 MG days) LENVIMA (24 MG DAILY DOSE) ORAL PA; SP; QL (90 EA per 30 CAPSULE THERAPY PACK 2 X 10 MG & 5 days) 4 MG LENVIMA (4 MG DAILY DOSE) ORAL PA; SP; QL (30 EA per 30 5 CAPSULE THERAPY PACK 4 MG days) LENVIMA (8 MG DAILY DOSE) ORAL PA; SP; QL (60 EA per 30 5 CAPSULE THERAPY PACK 2 X 4 MG days) *ANTIPARKINSON AND RELATED THERAPY AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate injection solution 1 2 mg/ml benztropine mesylate oral tablet 0.5 mg, 1 2 mg, 2 mg trihexyphenidyl hcl oral solution 0.4 mg/ml 2 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 2 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg 2 amantadine hcl oral syrup 50 mg/5ml 2 amantadine hcl oral tablet 100 mg 2 bromocriptine mesylate oral capsule 5 mg 2 bromocriptine mesylate oral tablet 2.5 mg 2 *Antiparkinson Monoamine Oxidase Inhibitors*** rasagiline mesylate oral tablet 0.5 mg, 1 4 mg selegiline hcl oral capsule 5 mg 2 selegiline hcl oral tablet 5 mg 2 *Central/Peripheral Comt Inhibitors*** tolcapone oral tablet 100 mg 5 PA; SP

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

46 Drug Name Drug Tier Requirements/Limits *Decarboxylase Inhibitors*** carbidopa oral tablet 25 mg 4 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended 2 release 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 2 25-100 mg, 25-250 mg carbidopa-levodopa oral tablet dispersible 2 10-100 mg, 25-100 mg, 25-250 mg *Nonergoline Dopamine Receptor Agonists*** APOKYN SUBCUTANEOUS SOLUTION 5 PA; SP CARTRIDGE 30 MG/3ML NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 3 MG/24HR, 6 4 PA MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 4 ST; QL (30 EA per 30 days) mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 2 mg, 1.5 mg ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 2 ST; QL (30 EA per 30 days) 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 2 1 mg, 2 mg, 3 mg, 4 mg, 5 mg *Peripheral Comt Inhibitors*** entacapone oral tablet 200 mg 3 *ANTIPSYCHOTICS/ANTIMAN IC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended 2 release 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 2 300 mg, 600 mg lithium carbonate oral tablet 300 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

47 Drug Name Drug Tier Requirements/Limits lithium oral solution 8 meq/5ml 2 *Antipsychotics - Misc.*** LATUDA ORAL TABLET 120 MG, 20 MG, 4 PA 40 MG, 60 MG, 80 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 2 60 mg, 80 mg *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 5 PA MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML paliperidone er oral tablet extended release 2 PA 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg risperidone oral solution 1 mg/ml 2 risperidone oral tablet 0.25 mg, 0.5 mg, 1 2 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 2 1 mg, 2 mg, 3 mg, 4 mg *Butyrophenones*** haloperidol decanoate intramuscular 2 solution 100 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 2 mg/ml haloperidol lactate oral concentrate 2 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 2 mg, 2 mg, 20 mg, 5 mg *Dibenzodiazepines*** clozapine oral tablet 100 mg, 200 mg, 25 2 mg, 50 mg clozapine oral tablet dispersible 100 mg, 2 12.5 mg, 150 mg, 200 mg, 25 mg *Dibenzo-Oxepino Pyrroles*** asenapine maleate sublingual tablet 4 PA sublingual 10 mg, 2.5 mg, 5 mg *Dibenzothiazepines*** quetiapine fumarate oral tablet 100 mg, 2 200 mg, 25 mg, 300 mg, 400 mg, 50 mg PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

48 Drug Name Drug Tier Requirements/Limits *Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 25 2 mg, 5 mg, 50 mg *Phenothiazines*** chlorpromazine hcl oral tablet 10 mg, 25 2 mg chlorpromazine hcl oral tablet 100 mg 4 chlorpromazine hcl oral tablet 200 mg 5 chlorpromazine hcl oral tablet 50 mg 3 fluphenazine decanoate injection solution 2 25 mg/ml fluphenazine hcl injection solution 2.5 2 mg/ml fluphenazine hcl oral concentrate 5 mg/ml 2 fluphenazine hcl oral elixir 2.5 mg/5ml 2 fluphenazine hcl oral tablet 1 mg, 10 mg, 2 2.5 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 2 mg, 8 mg prochlorperazine edisylate injection 2 solution 10 mg/2ml prochlorperazine maleate oral tablet 10 2 mg, 5 mg prochlorperazine rectal suppository 25 mg 2 thioridazine hcl oral tablet 10 mg, 100 mg, 2 25 mg, 50 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 2 mg, 5 mg *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR 5 PA PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 5 PA MG, 400 MG aripiprazole oral solution 1 mg/ml 2 PA aripiprazole oral tablet 10 mg, 15 mg, 2 2 QL (30 EA per 30 days) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet dispersible 10 mg, 5 PA 15 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

49 Drug Name Drug Tier Requirements/Limits REXULTI ORAL TABLET 0.25 MG, 0.5 4 PA MG, 1 MG, 2 MG, 3 MG, 4 MG *Thienbenzodiazepines*** olanzapine intramuscular solution 2 reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 2 mg, 20 mg, 5 mg, 7.5 mg *Thioxanthenes*** thiothixene oral capsule 1 mg, 10 mg, 2 2 mg, 5 mg *ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 5 QL (30 EA per 30 days) 600-300 mg abacavir-lamivudine-zidovudine oral tablet 5 QL (60 EA per 30 days) 300-150-300 mg BIKTARVY ORAL TABLET 50-200-25 5 QL (30 EA per 30 days) MG COMPLERA ORAL TABLET 200-25-300 5 QL (30 EA per 30 days) MG efavirenz-emtricitab-tenofovir oral tablet 5 QL (30 EA per 30 days) 600-200-300 mg emtricitabine-tenofovir df oral tablet 100- 5 QL (30 EA per 30 days) 150 mg, 133-200 mg, 167-250 mg emtricitabine-tenofovir df oral tablet 200- $ 0 Copay for HIV Prevention; 5 300 mg QL (30 EA per 30 days) GENVOYA ORAL TABLET 150-150-200- 5 QL (30 EA per 30 days) 10 MG lamivudine-zidovudine oral tablet 150-300 2 QL (60 EA per 30 days) mg lopinavir-ritonavir oral solution 400-100 5 QL (450 ML per 30 days) mg/5ml lopinavir-ritonavir oral tablet 100-25 mg 5 QL (360 EA per 30 days) lopinavir-ritonavir oral tablet 200-50 mg 5 QL (180 EA per 30 days) PREZCOBIX ORAL TABLET 800-150 MG 5 QL (30 EA per 30 days) STRIBILD ORAL TABLET 150-150-200- 5 QL (30 EA per 30 days) 300 MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

50 Drug Name Drug Tier Requirements/Limits *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL SOLUTION 20 5 QL (1840 ML per 30 days) MG/ML SELZENTRY ORAL TABLET 150 MG, 300 5 QL (120 EA per 30 days) MG SELZENTRY ORAL TABLET 25 MG 5 QL (240 EA per 30 days) SELZENTRY ORAL TABLET 75 MG 5 QL (60 EA per 30 days) *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION 5 SP; QL (60 EA per 30 days) RECONSTITUTED 90 MG *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 MG 5 QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 5 QL (60 EA per 30 days) 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG 5 QL (60 EA per 30 days) TIVICAY ORAL TABLET 50 MG 5 QL (30 EA per 30 days) *Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG 5 QL (120 EA per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML 5 QL (300 ML per 30 days) atazanavir sulfate oral capsule 150 mg, 5 QL (60 EA per 30 days) 200 mg atazanavir sulfate oral capsule 300 mg 5 QL (30 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG 5 QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG 5 QL (180 EA per 30 days) fosamprenavir calcium oral tablet 700 mg 5 QL (120 EA per 30 days) INVIRASE ORAL TABLET 500 MG 5 QL (120 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML 5 QL (1575 ML per 28 days) NORVIR ORAL SOLUTION 80 MG/ML 5 QL (450 ML per 30 days) PREZISTA ORAL SUSPENSION 100 5 QL (480 ML per 30 days) MG/ML PREZISTA ORAL TABLET 150 MG 5 QL (240 EA per 30 days) PREZISTA ORAL TABLET 600 MG 5 QL (60 EA per 30 days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

51 Drug Name Drug Tier Requirements/Limits PREZISTA ORAL TABLET 75 MG 5 QL (480 EA per 30 days) PREZISTA ORAL TABLET 800 MG 5 QL (30 EA per 30 days) ritonavir oral tablet 100 mg 5 QL (360 EA per 30 days) VIRACEPT ORAL TABLET 250 MG 5 QL (300 EA per 30 days) VIRACEPT ORAL TABLET 625 MG 5 QL (120 EA per 30 days) *Antiretrovirals - Rti-Non- Nucleoside Analogues*** EDURANT ORAL TABLET 25 MG 5 QL (60 EA per 30 days) efavirenz oral capsule 200 mg 5 QL (90 EA per 30 days) efavirenz oral capsule 50 mg 5 QL (360 EA per 30 days) efavirenz oral tablet 600 mg 5 QL (30 EA per 30 days) etravirine oral tablet 100 mg 5 QL (120 EA per 30 days) etravirine oral tablet 200 mg 5 QL (60 EA per 30 days) INTELENCE ORAL TABLET 25 MG 5 QL (480 EA per 30 days) nevirapine er oral tablet extended release 2 24 hour 100 mg nevirapine er oral tablet extended release 2 QL (30 EA per 30 days) 24 hour 400 mg nevirapine oral suspension 50 mg/5ml 2 nevirapine oral tablet 200 mg 2 QL (60 EA per 30 days) *Antiretrovirals - Rti- Nucleoside Analogues- Purines*** abacavir sulfate oral solution 20 mg/ml 5 QL (900 ML per 30 days) abacavir sulfate oral tablet 300 mg 4 QL (60 EA per 30 days) didanosine oral capsule delayed release 2 200 mg, 250 mg, 400 mg VIDEX ORAL SOLUTION 5 QL (603 ML per 30 days) RECONSTITUTED 2 GM *Antiretrovirals - Rti- Nucleoside Analogues- Pyrimidines*** emtricitabine oral capsule 200 mg 5 QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML 5 lamivudine oral solution 10 mg/ml 2 QL (900 ML per 30 days) lamivudine oral tablet 150 mg, 300 mg 5 QL (60 EA per 30 days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

52 Drug Name Drug Tier Requirements/Limits *Antiretrovirals - Rti- Nucleoside Analogues- Thymidines*** stavudine oral capsule 15 mg, 20 mg, 30 2 QL (60 EA per 30 days) mg, 40 mg zidovudine oral capsule 100 mg 2 QL (180 EA per 30 days) zidovudine oral syrup 50 mg/5ml 2 QL (1800 ML per 30 days) zidovudine oral tablet 300 mg 2 QL (60 EA per 30 days) *Antiretrovirals - Rti- Nucleotide Analogues*** tenofovir disoproxil fumarate oral tablet 2 QL (30 EA per 30 days) 300 mg VIREAD ORAL TABLET 150 MG, 200 5 QL (30 EA per 30 days) MG, 250 MG *Cmv Agents*** valganciclovir hcl oral solution 5 PA reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg 5 PA *Hepatitis B Agents*** adefovir dipivoxil oral tablet 10 mg 5 PA; SP BARACLUDE ORAL SOLUTION 0.05 5 PA; SP MG/ML entecavir oral tablet 0.5 mg, 1 mg 5 PA; SP EPIVIR HBV ORAL SOLUTION 5 MG/ML 4 SP; QL (1800 ML per 30 days) lamivudine oral tablet 100 mg 5 SP; QL (90 EA per 30 days) VEMLIDY ORAL TABLET 25 MG 4 *Hepatitis C Agent - Combinations*** PA; SP; QL (84 EA per 28 MAVYRET ORAL TABLET 100-40 MG 5 days) sofosbuvir-velpatasvir oral tablet 400-100 PA; SP; QL (28 EA per 28 5 mg days) VOSEVI ORAL TABLET 400-100-100 PA; SP; QL (28 EA per 28 5 MG days) *Hepatitis C Agents*** PEGASYS SUBCUTANEOUS SOLUTION 5 PA; SP 180 MCG/ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

53 Drug Name Drug Tier Requirements/Limits PEGINTRON SUBCUTANEOUS KIT 50 5 PA; SP MCG/0.5ML ribavirin oral capsule 200 mg 5 PA; SP *Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg 2 acyclovir oral suspension 200 mg/5ml 2 acyclovir oral tablet 400 mg, 800 mg 2 valacyclovir hcl oral tablet 1 gm, 500 mg 2 *Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125 mg, 250 mg, 2 500 mg *Influenza Agents*** rimantadine hcl oral tablet 100 mg 2 *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 mg, 2 QL (10 EA per 5 days) 45 mg, 75 mg oseltamivir phosphate oral suspension 2 QL (120 ML per 5 days) reconstituted 6 mg/ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH 3 QL (20 EA per 5 days) ACTIVATED 5 MG/BLISTER *BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 2 3.125 mg, 6.25 mg labetalol hcl oral tablet 100 mg, 200 mg, 2 300 mg *Beta Blockers Cardio- Selective*** acebutolol hcl oral capsule 200 mg, 400 2 mg atenolol oral tablet 100 mg, 25 mg, 50 mg 2 betaxolol hcl oral tablet 10 mg, 20 mg 2 bisoprolol fumarate oral tablet 10 mg, 5 2 mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

54 Drug Name Drug Tier Requirements/Limits BYSTOLIC ORAL TABLET 10 MG, 2.5 4 MG, 20 MG, 5 MG metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 2 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 2 mg/5ml metoprolol tartrate oral tablet 100 mg, 25 2 mg, 50 mg *Beta Blockers Non- Selective*** nadolol oral tablet 20 mg, 40 mg, 80 mg 2 pindolol oral tablet 10 mg, 5 mg 2 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 2 80 mg propranolol hcl oral solution 20 mg/5ml, 40 2 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 2 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 120 MG, 160 2 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120 mg, 160 mg, 2 80 mg sotalol hcl oral tablet 120 mg, 160 mg, 240 2 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 2 5 mg *CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** AFEDITAB CR ORAL TABLET EXTENDED 2 RELEASE 24 HOUR 30 MG, 60 MG amlodipine besylate oral tablet 10 mg, 2.5 2 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 2 240 MG, 300 MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

55 Drug Name Drug Tier Requirements/Limits diltiazem hcl er beads oral capsule 2 extended release 24 hour 300 mg, 420 mg diltiazem hcl er coated beads oral capsule 2 extended release 24 hour 360 mg diltiazem hcl er oral capsule extended 2 release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended 2 release 24 hour 120 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 2 mg, 90 mg dilt-xr oral capsule extended release 24 2 hour 180 mg, 240 mg felodipine er oral tablet extended release 2 24 hour 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 2 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 2 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20 mg, 30 mg 4 NIFEDICAL XL ORAL TABLET 2 EXTENDED RELEASE 24 HOUR 60 MG nifedipine er oral tablet extended release 2 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 2 90 mg nimodipine oral capsule 30 mg 5 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 3 34 mg, 40 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 2 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 2 200 mg, 240 mg, 300 mg verapamil hcl er oral capsule extended 2 QL (30 EA per 30 days) release 24 hour 360 mg verapamil hcl er oral tablet extended 2 release 120 mg, 180 mg, 240 mg verapamil hcl intravenous solution 2.5 2 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

56 Drug Name Drug Tier Requirements/Limits verapamil hcl oral tablet 120 mg, 40 mg, 2 80 mg *CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution 0.05 mg/ml 2 digoxin oral tablet 125 mcg, 250 mcg 2 *CARDIOVASCULAR AGENTS - MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5- 3 10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg *Neprilysin Inhib (Arni)- Angiotensin Ii Recept Antag Comb*** ENTRESTO ORAL TABLET 24-26 MG, 3 PA; QL (60 EA per 30 days) 49-51 MG, 97-103 MG *Prostaglandin Vasodilators*** ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 5 PA; SP MG, 5 MG VENTAVIS INHALATION SOLUTION 10 5 PA; SP MCG/ML, 20 MCG/ML *Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 5 PA; SP 1.5 MG, 2 MG, 2.5 MG *Pulmonary Hypertension - Endothelin Receptor Antagonists*** ambrisentan oral tablet 10 mg, 5 mg 5 PA; SP bosentan oral tablet 125 mg, 62.5 mg 5 PA; SP OPSUMIT ORAL TABLET 10 MG 5 PA; SP PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

57 Drug Name Drug Tier Requirements/Limits *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** ALYQ ORAL TABLET 20 MG 5 PA; SP sildenafil citrate oral tablet 20 mg 5 PA; SP tadalafil (pah) oral tablet 20 mg 5 PA; SP *Pulmonary Hypertension - Prostacyclin Receptor Agonist*** UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 5 PA; SP MCG, 400 MCG, 600 MCG, 800 MCG *Selective Cgmp Phosphodiesterase Type 5 Inhibitors*** tadalafil oral tablet 2.5 mg, 5 mg 2 PA; QL (30 EA per 30 days) *Sinus Node Inhibitors** CORLANOR ORAL TABLET 5 MG, 7.5 MG 4 PA; QL (60 EA per 30 days) *CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg 2 cefadroxil oral suspension reconstituted 2 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm 2 cephalexin oral capsule 250 mg, 500 mg 2 cephalexin oral suspension reconstituted 2 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg 2 *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250 mg, 500 mg 2 cefaclor oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

58 Drug Name Drug Tier Requirements/Limits cefuroxime axetil oral tablet 250 mg, 500 2 mg *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg 2 cefdinir oral suspension reconstituted 125 2 mg/5ml, 250 mg/5ml cefditoren pivoxil oral tablet 400 mg 3 cefixime oral capsule 400 mg 3 cefixime oral suspension reconstituted 100 3 mg/5ml, 200 mg/5ml cefpodoxime proxetil oral suspension 2 reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 2 200 mg ceftriaxone sodium injection solution 4 reconstituted 1 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution 4 reconstituted 10 gm SUPRAX ORAL SUSPENSION 4 RECONSTITUTED 500 MG/5ML *CHEMICALS* *Bulk Chemicals - Ce's*** ceftriaxone sodium powder 4 *CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** AZURETTE ORAL TABLET 0.15- 1 0.02/0.01 MG (21/5) *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG- 1 MCG alyacen 1/35 oral tablet 1-35 mg-mcg 1 APRI ORAL TABLET 0.15-30 MG-MCG 1 AUROVELA FE 1.5/30 ORAL TABLET 1 1.5-30 MG-MCG AVIANE ORAL TABLET 0.1-20 MG-MCG 1

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

59 Drug Name Drug Tier Requirements/Limits BLISOVI FE 1.5/30 ORAL TABLET 1.5- 1 30 MG-MCG CHATEAL ORAL TABLET 0.15-30 MG- 1 MCG CYCLAFEM 1/35 ORAL TABLET 1-35 1 MG-MCG DASETTA 1/35 ORAL TABLET 1-35 MG- 1 MCG DELYLA ORAL TABLET 0.1-20 MG-MCG 1 drospiren-eth estrad-levomefol oral tablet 1 3-0.02-0.451 mg drospirenone-ethinyl estradiol oral tablet 1 3-0.03 mg EMOQUETTE ORAL TABLET 0.15-30 1 MG-MCG ENSKYCE ORAL TABLET 0.15-30 MG- 1 MCG FALMINA ORAL TABLET 0.1-20 MG- 1 MCG GIANVI ORAL TABLET 3-0.02 MG 1 HAILEY 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG HAILEY FE 1.5/30 ORAL TABLET 1.5- 1 30 MG-MCG JUNEL 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG- 1 MCG JUNEL FE 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG- 1 MCG KURVELO ORAL TABLET 0.15-30 MG- 1 MCG LARIN 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG LARIN FE 1.5/30 ORAL TABLET 1.5-30 1 MG-MCG LESSINA ORAL TABLET 0.1-20 MG-MCG 1 levonorgestrel-ethinyl estrad oral tablet 1 0.15-30 mg-mcg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

60 Drug Name Drug Tier Requirements/Limits LEVORA 0.15/30 (28) ORAL TABLET 1 0.15-30 MG-MCG LOW-OGESTREL ORAL TABLET 0.3-30 1 MG-MCG LUTERA ORAL TABLET 0.1-20 MG-MCG 1 marlissa oral tablet 0.15-30 mg-mcg 1 MICROGESTIN FE 1.5/30 ORAL TABLET 1 1.5-30 MG-MCG MONO-LINYAH ORAL TABLET 0.25-35 1 MG-MCG NECON 0.5/35 (28) ORAL TABLET 0.5- 1 35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 1 MG-MCG norethin ace-eth estrad-fe oral tablet 1-20 1 mg-mcg(24), 1.5-30 mg-mcg norethin-eth estradiol-fe oral tablet 1 chewable 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25- 1 35 mg-mcg NORTREL 0.5/35 (28) ORAL TABLET 1 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1- 1 35 MG-MCG ORSYTHIA ORAL TABLET 0.1-20 MG- 1 MCG PIRMELLA 1/35 ORAL TABLET 1-35 1 MG-MCG PORTIA-28 ORAL TABLET 0.15-30 MG- 1 MCG RECLIPSEN ORAL TABLET 0.15-30 MG- 1 MCG SPRINTEC 28 ORAL TABLET 0.25-35 1 MG-MCG SRONYX ORAL TABLET 0.1-20 MG-MCG 1 SYEDA ORAL TABLET 3-0.03 MG 1 ZARAH ORAL TABLET 3-0.03 MG 1 ZOVIA 1/35E (28) ORAL TABLET 1-35 1 MG-MCG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

61 Drug Name Drug Tier Requirements/Limits *Combination Contraceptives - Transdermal*** XULANE TRANSDERMAL PATCH 1 WEEKLY 150-35 MCG/24HR *Combination Contraceptives - Vaginal*** ELURYNG VAGINAL RING 0.12-0.015 1 MG/24HR etonogestrel-ethinyl estradiol vaginal ring 1 0.12-0.015 mg/24hr *Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE 1 QL (1 EA per 300 days) DEVICE *Emergency Contraceptives*** ELLA ORAL TABLET 30 MG 1 levonorgestrel oral tablet 1.5 mg 1 OTC TAKE ACTION ORAL TABLET 1.5 MG 1 OTC *Extended-Cycle Contraceptives - Oral*** ASHLYNA ORAL TABLET 0.15-0.03 1 &0.01 MG JOLESSA ORAL TABLET 0.15-0.03 MG 1 levonorgest-eth estrad 91-day oral tablet 1 0.1-0.02 & 0.01 mg, 0.15-0.03 mg *Progestin Contraceptives - Implants*** NEXPLANON SUBCUTANEOUS 1 QL (1 EA per 300 days) IMPLANT 68 MG *Progestin Contraceptives - Injectable*** medroxyprogesterone acetate 1 QL (1 ML per 90 days) intramuscular suspension 150 mg/ml *Progestin Contraceptives - Iud***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

62 Drug Name Drug Tier Requirements/Limits KYLEENA INTRAUTERINE 1 QL (1 EA per 300 days) INTRAUTERINE DEVICE 19.5 MG LILETTA (52 MG) INTRAUTERINE 1 QL (1 EA per 300 days) INTRAUTERINE DEVICE 19.5 MCG/DAY SKYLA INTRAUTERINE INTRAUTERINE 1 QL (1 EA per 300 days) DEVICE 13.5 MG *Progestin Contraceptives - Oral*** ERRIN ORAL TABLET 0.35 MG 1 HEATHER ORAL TABLET 0.35 MG 1 NORA-BE ORAL TABLET 0.35 MG 1 *Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 1 mg-mcg CYCLAFEM 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG DASETTA 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG ENPRESSE-28 ORAL TABLET 50-30/75- 1 40/ 125-30 MCG norgestim-eth estrad triphasic oral tablet 1 0.18/0.215/0.25 mg-35 mcg NORTREL 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG PIRMELLA 7/7/7 ORAL TABLET 1 0.5/0.75/1-35 MG-MCG TRI-SPRINTEC ORAL TABLET 1 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET 50- 1 30/75-40/ 125-30 MCG VELIVET ORAL TABLET 0.1/0.125/0.15 1 -0.025 MG *CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release 5 particles 3 mg cortisone acetate oral tablet 25 mg 3

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

63 Drug Name Drug Tier Requirements/Limits DEPO-MEDROL INJECTION 4 SUSPENSION 20 MG/ML DEXAMETHASONE INTENSOL ORAL 2 CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml 2 dexamethasone oral solution 0.5 mg/5ml 2 dexamethasone oral tablet 0.5 mg, 0.75 2 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate 2 injection solution 10 mg/ml dexamethasone sodium phosphate 3 injection solution 120 mg/30ml hydrocortisone oral tablet 10 mg, 20 mg, 5 2 mg methylprednisolone oral tablet 16 mg, 32 2 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy 2 pack 4 mg prednisolone oral solution 15 mg/5ml 2 prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 2 base) mg/5ml PREDNISONE INTENSOL ORAL 4 CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5ml 2 prednisone oral tablet 1 mg, 10 mg, 2.5 2 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 mg 2 (21), 10 mg (48), 5 mg (21), 5 mg (48) *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg 2 *COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg 2 *Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 2 mg/5ml *Antitussive-Expectorant*** cheratussin ac oral syrup 100-10 mg/5ml 2 OTC PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

64 Drug Name Drug Tier Requirements/Limits *Decongestant & Antihistamine*** promethazine vc oral syrup 6.25-5 mg/5ml 2 promethazine vc plain oral solution 6.25-5 2 mg/5ml promethazine-phenylephrine oral syrup 2 6.25-5 mg/5ml *Iodine Expectorants*** SSKI ORAL SOLUTION 1 GM/ML 3 *Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization 2 solution 0.9 %, 10 %, 3 %, 7 % *Mucolytics*** acetylcysteine inhalation solution 10 %, 20 2 % *Non-Narc Antitussive- Antihistamine*** promethazine-dm oral syrup 6.25-15 2 mg/5ml *Non-Narc Antitussive- Decongestant- Antihistamine*** pseudoeph-bromphen-dm oral syrup 30-2- 2 10 mg/5ml *Opioid Antitussive- Antihistamine*** promethazine-codeine oral solution 6.25- 2 10 mg/5ml TUZISTRA XR ORAL SUSPENSION 4 EXTENDED RELEASE 14.7-2.8 MG/5ML *Opioid Antitussive- Decongestant- Antihistamine*** promethazine vc/codeine oral syrup 6.25- 2 5-10 mg/5ml *DERMATOLOGICALS*

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

65 Drug Name Drug Tier Requirements/Limits *Acne Antibiotics*** clindamycin phosphate external foam 1 % 4 clindamycin phosphate external gel 1 % 2 clindamycin phosphate external lotion 1 % 2 clindamycin phosphate external solution 1 2 % clindamycin phosphate external swab 1 % 2 ery external pad 2 % 2 erythromycin external gel 2 % 2 erythromycin external solution 2 % 2 *Acne Combinations*** adapalene-benzoyl peroxide external gel 2 ST 0.1-2.5 % benzoyl peroxide-erythromycin external gel 2 5-3 % clindamycin phos-benzoyl perox external 3 gel 1-5 % *Acne Products*** adapalene external cream 0.1 % 2 AGE (Max 34 Years) adapalene external gel 0.1 %, 0.3 % 2 AGE (Max 34 Years) AMNESTEEM ORAL CAPSULE 10 MG, 20 3 PA MG, 40 MG QL (45 GM per 30 days); AGE AVITA EXTERNAL GEL 0.025 % 3 (Max 34 Years) CLARAVIS ORAL CAPSULE 10 MG, 20 3 PA MG, 30 MG, 40 MG DIFFERIN EXTERNAL LOTION 0.1 % 2 isotretinoin oral capsule 10 mg, 20 mg, 30 3 PA mg, 40 mg MYORISAN ORAL CAPSULE 10 MG, 20 3 PA MG, 30 MG, 40 MG tretinoin external cream 0.025 %, 0.05 %, QL (45 GM per 30 days); AGE 3 0.1 % (Max 34 Years) QL (45 GM per 30 days); AGE tretinoin external gel 0.01 %, 0.025 % 3 (Max 34 Years) ZENATANE ORAL CAPSULE 10 MG, 20 3 PA MG, 30 MG, 40 MG *Antibiotic Steroid Combinations - Topical*** PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

66 Drug Name Drug Tier Requirements/Limits CORTISPORIN EXTERNAL OINTMENT 1 4 % *Antibiotics - Topical*** ALTABAX EXTERNAL OINTMENT 1 % 4 ST gentamicin sulfate external cream 0.1 % 2 gentamicin sulfate external ointment 0.1 % 2 mupirocin external ointment 2 % 2 *Antifungals - Topical Combinations*** clotrimazole-betamethasone external 2 QL (90 GM per 30 days) cream 1-0.05 % clotrimazole-betamethasone external lotion 2 QL (60 ML per 30 days) 1-0.05 % nystatin-triamcinolone external cream 2 100000-0.1 unit/gm-% nystatin-triamcinolone external ointment 2 100000-0.1 unit/gm-% *Antifungals - Topical*** ciclopirox external gel 0.77 % 2 ciclopirox external shampoo 1 % 3 ciclopirox olamine external suspension 2 0.77 % MENTAX EXTERNAL CREAM 1 % 4 naftifine hcl external gel 1 % 4 PA; QL (60 GM per 30 days) NYAMYC EXTERNAL POWDER 100000 2 UNIT/GM nystatin external cream 100000 unit/gm 2 nystatin external ointment 100000 unit/gm 2 nystatin external powder 100000 unit/gm 2 NYSTOP EXTERNAL POWDER 100000 2 UNIT/GM *Anti-Inflammatory Agents - Topical*** diclofenac sodium transdermal gel 1 % 2 *Antineoplastic Antimetabolites - Topical*** fluorouracil external cream 5 % 3

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

67 Drug Name Drug Tier Requirements/Limits fluorouracil external solution 2 %, 5 % 3 *Antipruritics - Topical*** doxepin hcl external cream 5 % 4 *Antipsoriatics - Systemic*** acitretin oral capsule 10 mg, 17.5 mg, 25 5 PA mg COSENTYX (300 MG DOSE) PA; SP; QL (2 ML per 28 SUBCUTANEOUS SOLUTION PREFILLED 5 days) SYRINGE 150 MG/ML COSENTYX SENSOREADY (300 MG) PA; SP; QL (2 ML per 28 SUBCUTANEOUS SOLUTION AUTO- 5 days) INJECTOR 150 MG/ML COSENTYX SENSOREADY PEN PA; SP; QL (1 ML per 28 SUBCUTANEOUS SOLUTION AUTO- 5 days) INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SOLUTION PA; SP; QL (2 ML per 28 5 PREFILLED SYRINGE 150 MG/ML days) COSENTYX SUBCUTANEOUS SOLUTION 5 PA; QL (2 ML per 28 days) PREFILLED SYRINGE 75 MG/0.5ML methoxsalen rapid oral capsule 10 mg 4 PA; SP SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE 5 PA; SP; QL (1 EA per 28 days) KIT 75 MG/0.83ML SKYRIZI PEN SUBCUTANEOUS PA; SP; QL (1 ML per 28 SOLUTION AUTO-INJECTOR 150 5 days) MG/ML SKYRIZI SUBCUTANEOUS SOLUTION PA; SP; QL (1 ML per 28 5 PREFILLED SYRINGE 150 MG/ML days) STELARA SUBCUTANEOUS SOLUTION PA; SP; QL (1 ML per 28 PREFILLED SYRINGE 45 MG/0.5ML, 90 5 days) MG/ML *Antipsoriatics*** calcipotriene external cream 0.005 % 4 calcipotriene external ointment 0.005 % 3 calcipotriene external solution 0.005 % 3 calcitriol external ointment 3 mcg/gm 3 PA TAZORAC EXTERNAL GEL 0.05 %, 0.1 5 PA; AGE (Max 34 Years) % *Antiseborrheic Products*** selenium sulfide external lotion 2.5 % 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

68 Drug Name Drug Tier Requirements/Limits selenium sulfide external shampoo 2.25 % 2 *Antivirals - Topical*** acyclovir external ointment 5 % 3 PA DENAVIR EXTERNAL CREAM 1 % 5 PA *Atopic Dermatitis - Monoclonal Antibodies*** DUPIXENT SUBCUTANEOUS SOLUTION 5 PA PEN-INJECTOR 200 MG/1.14ML DUPIXENT SUBCUTANEOUS SOLUTION 5 PA; SP PEN-INJECTOR 300 MG/2ML DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 5 PA; SP 300 MG/2ML *Burn Products*** silver sulfadiazine external cream 1 % 2 SSD EXTERNAL CREAM 1 % 2 SULFAMYLON EXTERNAL CREAM 85 3 QL (56.7 GM per 30 days) MG/GM *Corticosteroids - Topical*** alclometasone dipropionate external cream 2 0.05 % alclometasone dipropionate external 2 ointment 0.05 % amcinonide external cream 0.1 % 4 amcinonide external lotion 0.1 % 4 amcinonide external ointment 0.1 % 4 betamethasone dipropionate aug external 2 QL (100 GM per 30 days) cream 0.05 % betamethasone dipropionate aug external 2 QL (120 ML per 30 days) lotion 0.05 % betamethasone dipropionate aug external 2 QL (100 GM per 30 days) ointment 0.05 % betamethasone dipropionate external 2 QL (90 GM per 30 days) cream 0.05 % betamethasone dipropionate external 2 QL (120 ML per 30 days) lotion 0.05 % betamethasone dipropionate external 2 QL (90 GM per 30 days) ointment 0.05 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

69 Drug Name Drug Tier Requirements/Limits betamethasone valerate external cream 2 QL (90 GM per 30 days) 0.1 % betamethasone valerate external foam 3 0.12 % betamethasone valerate external lotion 0.1 2 QL (120 ML per 30 days) % betamethasone valerate external ointment 2 QL (90 GM per 30 days) 0.1 % clobetasol propionate external shampoo 3 0.05 % clocortolone pivalate external cream 0.1 % 4 desonide external cream 0.05 % 3 QL (120 GM per 30 days) desonide external lotion 0.05 % 3 desonide external ointment 0.05 % 3 QL (120 GM per 30 days) desoximetasone external cream 0.05 %, 3 QL (200 GM per 30 days) 0.25 % desoximetasone external gel 0.05 % 3 QL (120 GM per 30 days) desoximetasone external ointment 0.05 % 3 QL (120 GM per 30 days) desoximetasone external ointment 0.25 % 3 QL (200 GM per 30 days) fluocinolone acetonide external cream 0.01 2 QL (120 GM per 30 days) %, 0.025 % fluocinolone acetonide external ointment 2 QL (120 GM per 30 days) 0.025 % fluocinolone acetonide external solution 2 0.01 % fluocinolone acetonide scalp external oil 2 0.01 % fluocinonide external gel 0.05 % 2 QL (120 GM per 30 days) fluocinonide external ointment 0.05 % 2 QL (120 GM per 30 days) fluocinonide external solution 0.05 % 2 QL (120 ML per 30 days) fluticasone propionate external cream 0.05 2 QL (120 GM per 30 days) % fluticasone propionate external lotion 0.05 5 % fluticasone propionate external ointment 2 QL (120 GM per 30 days) 0.005 % halcinonide external cream 0.1 % 4 QL (100 GM per 30 days) halobetasol propionate external cream 3 QL (100 GM per 30 days) 0.05 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

70 Drug Name Drug Tier Requirements/Limits halobetasol propionate external ointment 3 QL (100 GM per 30 days) 0.05 % HALOG EXTERNAL OINTMENT 0.1 % 4 QL (100 GM per 30 days) hydrocortisone butyr lipo base external 2 cream 0.1 % hydrocortisone butyrate external ointment 2 0.1 % hydrocortisone butyrate external solution 2 0.1 % hydrocortisone external cream 1 % 2 QL (120 GM per 30 days) hydrocortisone external cream 2.5 % 2 hydrocortisone external lotion 2.5 % 2 QL (120 ML per 30 days) hydrocortisone external ointment 2.5 % 2 QL (90 GM per 30 days) hydrocortisone valerate external cream 0.2 2 QL (120 GM per 30 days) % hydrocortisone valerate external ointment 2 QL (120 GM per 30 days) 0.2 % mometasone furoate external cream 0.1 % 2 mometasone furoate external ointment 0.1 2 % mometasone furoate external solution 0.1 2 % prednicarbate external cream 0.1 % 2 QL (120 GM per 30 days) prednicarbate external ointment 0.1 % 2 QL (120 GM per 30 days) triamcinolone acetonide external aerosol 3 PA solution 0.147 mg/gm triamcinolone acetonide external cream 2 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 2 0.025 %, 0.1 % triamcinolone acetonide external ointment 2 0.025 %, 0.1 %, 0.5 % *Emollients*** ammonium lactate external cream 12 % 2 ammonium lactate external lotion 12 % 2 *Enzymes - Topical*** SANTYL EXTERNAL OINTMENT 250 4 UNIT/GM

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

71 Drug Name Drug Tier Requirements/Limits *Imidazole-Related Antifungals - Topical*** clotrimazole external cream 1 % 2 clotrimazole external solution 1 % 2 econazole nitrate external cream 1 % 2 QL (85 GM per 30 days) ERTACZO EXTERNAL CREAM 2 % 4 EXELDERM EXTERNAL CREAM 1 % 4 QL (60 GM per 30 days) EXELDERM EXTERNAL SOLUTION 1 % 4 QL (30 ML per 30 days) ketoconazole external cream 2 % 2 QL (60 GM per 28 days) ketoconazole external shampoo 2 % 2 QL (120 ML per 30 days) oxiconazole nitrate external cream 1 % 4 OXISTAT EXTERNAL LOTION 1 % 4 *Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external cream 5 % 2 QL (12 EA per 28 days) *Keratolytic/Antimitotic Agents*** podofilox external solution 0.5 % 2 *Local Anesthetics - Topical*** lidocaine external ointment 5 % 2 QL (50 GM per 30 days) lidocaine external patch 5 % 2 PA lidocaine hcl external cream 3 % 2 QL (85 GM per 30 days) lidocaine hcl external lotion 3 % 2 QL (100 ML per 30 days) lidocaine hcl external solution 4 % 2 QL (100 ML per 30 days) lidocaine hcl urethral/mucosal external gel 2 QL (90 ML per 30 days) 2 % lidocaine hcl urethral/mucosal external 2 QL (90 ML per 30 days) prefilled syringe 2 % *Macrolide Immunosuppressants - Topical*** pimecrolimus external cream 1 % 4 PA; QL (100 GM per 30 days) tacrolimus external ointment 0.03 %, 0.1 3 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

72 Drug Name Drug Tier Requirements/Limits *Rosacea Agents*** azelaic acid external gel 15 % 4 PA metronidazole external cream 0.75 % 2 metronidazole external gel 0.75 % 3 metronidazole external lotion 0.75 % 3 MIRVASO EXTERNAL GEL 0.33 % 4 PA *Scabicides & Pediculicides*** CROTAN EXTERNAL LOTION 10 % 2 ST ivermectin external lotion 0.5 % 4 PA lindane external shampoo 1 % 2 malathion external lotion 0.5 % 2 NATROBA EXTERNAL SUSPENSION 0.9 3 ST; QL (120 ML per 30 days) % permethrin external cream 5 % 2 spinosad external suspension 0.9 % 3 ST; QL (120 ML per 30 days) ULESFIA EXTERNAL LOTION 5 % 4 ST; QL (454 GM per 30 days) *Topical Anesthetic Combinations*** lidocaine-prilocaine external cream 2.5-2.5 2 QL (30 GM per 30 days) % *Topical Steroid Combinations*** calcipotriene-betameth diprop external 4 ST; QL (120 GM per 30 days) ointment 0.005-0.064 % *Wound Care - Growth Factor Agents*** REGRANEX EXTERNAL GEL 0.01 % 5 PA *DIAGNOSTIC PRODUCTS* *Diagnostic Drugs*** GLUCAGEN DIAGNOSTIC INJECTION 4 SOLUTION RECONSTITUTED 1 MG *Diagnostic Tests*** DIASTIX IN VITRO STRIP 2 OTC

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

73 Drug Name Drug Tier Requirements/Limits Non Insulin QL (100 per 30 ONETOUCH ULTRA IN VITRO STRIP 3 days); Insulin QL (150 per 30 days); OTC Non Insulin QL (100 per 30 ONETOUCH VERIO IN VITRO STRIP 3 days); Insulin QL (150 per 30 days); OTC *Multiple Urine Tests*** CHEMSTRIP 9 IN VITRO STRIP 3 OTC KETO-DIASTIX IN VITRO STRIP 3 OTC *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* *Dietary Management Product Combinations*** FOLBIC ORAL TABLET 2.5-25-2 MG 2 *DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 3 UNIT, 36000-114000 UNIT, 6000- 19000 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 3 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended 2 QL (60 EA per 30 days) release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg 2 methazolamide oral tablet 25 mg, 50 mg 3 *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5- 2 50 mg spironolactone-hctz oral tablet 25-25 mg 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

74 Drug Name Drug Tier Requirements/Limits triamterene-hctz oral capsule 37.5-25 mg 2 triamterene-hctz oral tablet 37.5-25 mg, 2 75-50 mg *Loop Diuretics*** bumetanide injection solution 0.25 mg/ml 2 bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 2 ethacrynic acid oral tablet 25 mg 2 furosemide injection solution 10 mg/ml 2 furosemide oral solution 10 mg/ml, 8 2 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 2 mg torsemide oral tablet 10 mg, 100 mg, 20 2 mg, 5 mg *Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg 2 spironolactone oral tablet 100 mg, 25 mg, 2 50 mg triamterene oral capsule 100 mg 2 *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg 2 chlorthalidone oral tablet 25 mg, 50 mg 2 hydrochlorothiazide oral capsule 12.5 mg 2 hydrochlorothiazide oral tablet 12.5 mg, 25 2 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg 2 metolazone oral tablet 10 mg, 2.5 mg, 5 2 mg *ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral tablet 10 mg, 5 2 QL (30 EA per 30 days) mg alendronate sodium oral tablet 35 mg, 70 2 QL (4 EA per 28 days) mg

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

75 Drug Name Drug Tier Requirements/Limits FOSAMAX PLUS D ORAL TABLET 70- 4 PA 2800 MG-UNIT, 70-5600 MG-UNIT ibandronate sodium oral tablet 150 mg 2 QL (1 EA per 28 days) pamidronate disodium intravenous solution 3 SP 30 mg/10ml, 90 mg/10ml pamidronate disodium intravenous solution 3 SP reconstituted 30 mg, 90 mg risedronate sodium oral tablet 150 mg 2 QL (1 EA per 28 days) risedronate sodium oral tablet 30 mg, 5 2 QL (30 EA per 30 days) mg risedronate sodium tablet 35 mg oral 35 2 mg *Calcimimetic Agents*** cinacalcet hcl oral tablet 30 mg, 60 mg, 90 5 PA mg *Calcitonins*** calcitonin (salmon) nasal solution 200 2 unit/act MIACALCIN INJECTION SOLUTION 200 5 PA UNIT/ML *Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg 3 *Growth Hormone Receptor Antagonists*** SOMAVERT SUBCUTANEOUS SOLUTION 5 PA; SP RECONSTITUTED 10 MG, 15 MG, 20 MG *Growth Hormones*** OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 MG/1.5ML, 5 PA; SP 5 MG/1.5ML OMNITROPE SUBCUTANEOUS 5 PA; SP SOLUTION RECONSTITUTED 5.8 MG *Homocystinuria Treatment - Agents*** CYSTADANE ORAL POWDER 5 PA *Hyperparathyroid Treatment - Vitamin D Analogs***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

76 Drug Name Drug Tier Requirements/Limits calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 calcitriol oral solution 1 mcg/ml 2 doxercalciferol oral capsule 0.5 mcg, 1 3 PA mcg, 2.5 mcg paricalcitol oral capsule 1 mcg, 2 mcg 3 PA paricalcitol oral capsule 4 mcg 2 PA *Insulin-Like Growth Factors (Somatomedins)*** INCRELEX SUBCUTANEOUS SOLUTION 5 PA; SP 40 MG/4ML *Lhrh/Gnrh Agonist Analog Pituitary Suppressants*** SYNAREL NASAL SOLUTION 2 MG/ML 4 *Rank Ligand (Rankl) Inhibitors*** PROLIA SUBCUTANEOUS SOLUTION 5 PA; SP PREFILLED SYRINGE 60 MG/ML *Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl oral tablet 60 mg 1 PA *Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 5 PA; SP mcg/ml, 500 mcg/ml SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 20 5 PA; SP MG, 40 MG, 60 MG SIGNIFOR SUBCUTANEOUS SOLUTION 5 PA; SP 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 5 PA; SP MG/0.2ML, 90 MG/0.3ML *Vasopressin*** DDAVP RHINAL TUBE NASAL 3 SOLUTION 0.01 % desmopressin ace spray refrig nasal 3 solution 0.01 % desmopressin acetate injection solution 4 5 PA; SP mcg/ml PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

77 Drug Name Drug Tier Requirements/Limits desmopressin acetate oral tablet 0.1 mg, 2 0.2 mg desmopressin acetate pf injection solution 5 PA; SP 4 mcg/ml *ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 2 0.5-0.1 mg, 1-0.5 mg JINTELI ORAL TABLET 1-5 MG-MCG 1 QL (28 EA per 28 days) norethindrone-eth estradiol oral tablet 0.5- 1 QL (28 EA per 28 days) 2.5 mg-mcg, 1-5 mg-mcg *Estrogens*** DOTTI TRANSDERMAL PATCH TWICE QL (8 EA per 28 days); AGE 2 WEEKLY 0.1 MG/24HR (Max 64 Years) estradiol oral tablet 0.5 mg, 1 mg, 2 mg 2 AGE (Max 64 Years) estradiol transdermal patch twice weekly QL (8 EA per 28 days); AGE 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 2 (Max 64 Years) mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, QL (4 EA per 28 days); AGE 2 0.06 mg/24hr, 0.075 mg/24hr, 0.1 (Max 64 Years) mg/24hr estradiol valerate intramuscular oil 20 2 mg/ml, 40 mg/ml LYLLANA TRANSDERMAL PATCH QL (8 EA per 28 days); AGE 2 TWICE WEEKLY 0.1 MG/24HR (Max 64 Years) MENEST ORAL TABLET 0.3 MG, 0.625 4 AGE (Max 64 Years) MG, 1.25 MG *FLUOROQUINOLONES* *Fluoroquinolones*** CIPRO ORAL SUSPENSION 4 RECONSTITUTED 250 MG/5ML (5%) CIPRO ORAL SUSPENSION 2 RECONSTITUTED 500 MG/5ML (10%) ciprofloxacin hcl oral tablet 100 mg, 250 2 mg, 500 mg, 750 mg levofloxacin oral tablet 250 mg, 500 mg, 2 750 mg moxifloxacin hcl oral tablet 400 mg 3 ofloxacin oral tablet 400 mg 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

78 Drug Name Drug Tier Requirements/Limits *GASTROINTESTINAL AGENTS - MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule 300 mg 4 ursodiol oral tablet 250 mg, 500 mg 3 *Gastrointestinal Antiallergy Agents*** cromolyn sodium oral concentrate 100 2 mg/5ml *Gastrointestinal Chloride Channel Activators*** lubiprostone oral capsule 24 mcg, 8 mcg 4 QL (60 EA per 30 days) *Gastrointestinal Stimulants*** metoclopramide hcl oral solution 5 mg/5ml 2 metoclopramide hcl oral tablet 10 mg, 5 2 mg *Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS ORAL CAPSULE 145 MCG, 290 3 QL (30 EA per 30 days) MCG, 72 MCG *Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** alosetron hcl oral tablet 0.5 mg, 1 mg 5 PA *Inflammatory Bowel Agents*** balsalazide disodium oral capsule 750 mg 2 DIPENTUM ORAL CAPSULE 250 MG 4 PA mesalamine er oral capsule extended 4 QL (120 EA per 30 days) release 24 hour 0.375 gm mesalamine oral tablet delayed release 1.2 4 QL (120 EA per 30 days) gm mesalamine oral tablet delayed release 4 QL (180 EA per 30 days) 800 mg mesalamine rectal enema 4 gm 3 QL (1680 ML per 28 days) mesalamine rectal suppository 1000 mg 5 PA PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

79 Drug Name Drug Tier Requirements/Limits sulfasalazine oral tablet 500 mg 2 sulfasalazine oral tablet delayed release 2 500 mg *Intestinal Acidifiers*** enulose oral solution 10 gm/15ml 2 generlac oral solution 10 gm/15ml 2 *Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule 2 667 mg calcium acetate (phos binder) oral tablet 2 667 mg PHOSLYRA ORAL SOLUTION 667 3 PA MG/5ML sevelamer carbonate oral packet 0.8 gm, 5 PA 2.4 gm sevelamer carbonate oral tablet 800 mg 2 PA sevelamer hcl oral tablet 400 mg, 800 mg 4 PA *Tumor Necrosis Factor Alpha Blockers*** CIMZIA PREFILLED SUBCUTANEOUS 5 PA; SP; QL (1 EA per 28 days) KIT 2 X 200 MG/ML CIMZIA STARTER KIT SUBCUTANEOUS PA; SP; QL (3 EA per 180 5 KIT 6 X 200 MG/ML days) CIMZIA SUBCUTANEOUS KIT 2 X 200 5 PA; SP; QL (1 EA per 28 days) MG *GENITOURINARY AGENTS - MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** dutasteride oral capsule 0.5 mg 2 finasteride oral tablet 5 mg 2 *Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended 2 release 24 hour 10 mg silodosin oral capsule 4 mg, 8 mg 3 PA tamsulosin hcl oral capsule 0.4 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

80 Drug Name Drug Tier Requirements/Limits *Anti-Infective Genitourinary Irrigants*** neomycin-polymyxin b gu irrigation 2 solution 40-200000 *Citrates*** CYTRA-3 ORAL SYRUP 550-500-334 2 OTC MG/5ML potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 2 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 2 1100-334 mg/5ml sod citrate-citric acid oral solution 500-334 2 mg/5ml *Cystinosis Agents*** CYSTAGON ORAL CAPSULE 150 MG, 50 5 PA MG *Genitourinary Irrigants*** acetic acid irrigation solution 0.25 % 2 RENACIDIN IRRIGATION SOLUTION 4 sorbitol irrigation solution 3 %, 3.3 % 2 sorbitol-mannitol irrigation solution 2.7- 2 0.54 gm/100ml *Interstitial Cystitis Agents*** ELMIRON ORAL CAPSULE 100 MG 5 PA *Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 2 200 mg *GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 2 mg *Gout Agents*** allopurinol oral tablet 100 mg, 300 mg 2 colchicine oral capsule 0.6 mg 3 ST colchicine oral tablet 0.6 mg 3 ST

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

81 Drug Name Drug Tier Requirements/Limits febuxostat oral tablet 40 mg, 80 mg 3 ST MITIGARE ORAL CAPSULE 0.6 MG 2 *Uricosurics*** probenecid oral tablet 500 mg 2 *HEMATOLOGICAL AGENTS - MISC.* *Bradykinin B2 Receptor Antagonists*** icatibant acetate subcutaneous solution 30 5 PA; SP mg/3ml *Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (60 EA per 30 days) *Hematorheologic Agents*** pentoxifylline er oral tablet extended 2 QL (90 EA per 30 days) release 400 mg *Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100 mg, 50 mg 2 *Platelet Aggregation Inhibitor Combinations*** aspirin-dipyridamole er oral capsule 2 QL (60 EA per 30 days) extended release 12 hour 25-200 mg *Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25 mg, 50 mg, 75 2 AGE (Max 64 Years) mg *Protease-Activated Receptor-1 (Par-1) Antagonists*** ZONTIVITY ORAL TABLET 2.08 MG 4 QL (30 EA per 30 days) *Quinazoline Agents*** anagrelide hcl oral capsule 0.5 mg, 1 mg 2 *Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 300 mg 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

82 Drug Name Drug Tier Requirements/Limits clopidogrel bisulfate oral tablet 75 mg 2 QL (30 EA per 30 days) prasugrel hcl oral tablet 10 mg, 5 mg 3 QL (30 EA per 30 days) *HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution 1000 2 mcg/ml *Erythropoiesis-Stimulating Agents (Esas)*** PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 5 PA; SP UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 40000 5 PA; SP UNIT/ML *Folic Acid/Folates*** folic acid oral tablet 1 mg 1 QL (30 EA per 30 days) folic acid oral tablet 400 mcg, 800 mcg 1 OTC; QL (30 EA per 30 days) *Granulocyte Colony- Stimulating Factors (G- Csf)*** ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 5 PA; SP 480 MCG/0.8ML ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 5 PA; SP MG/0.6ML *Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE INJECTION SOLUTION 5 PA; SP RECONSTITUTED 250 MCG *Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA ORAL TABLET 12.5 MG, 25 4 PA; SP MG, 50 MG, 75 MG *HEMOSTATICS* *Hemostatics - Systemic***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

83 Drug Name Drug Tier Requirements/Limits aminocaproic acid oral tablet 1000 mg, 500 4 PA mg tranexamic acid oral tablet 650 mg 2 *HYPNOTICS/SEDATIVES/SLE EP DISORDER AGENTS* *Barbiturate Hypnotics*** phenobarbital oral elixir 20 mg/5ml 2 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 2 mg, 97.2 mg *Benzodiazepine Hypnotics*** estazolam oral tablet 1 mg, 2 mg 2 flurazepam hcl oral capsule 15 mg, 30 mg 2 QL (30 EA per 30 days) temazepam oral capsule 15 mg, 22.5 mg, 2 QL (30 EA per 30 days) 30 mg, 7.5 mg triazolam oral tablet 0.125 mg, 0.25 mg 2 QL (30 EA per 30 days) *Hypnotics - Tricyclic Agents*** doxepin hcl oral tablet 3 mg, 6 mg 4 QL (30 EA per 30 days) *Non-Benzodiazepine - Gaba- Receptor Modulators*** eszopiclone oral tablet 1 mg, 2 mg, 3 mg 2 QL (30 EA per 30 days) zaleplon oral capsule 10 mg, 5 mg 2 QL (30 EA per 30 days) zolpidem tartrate er oral tablet extended 2 QL (30 EA per 30 days) release 12.5 mg, 6.25 mg zolpidem tartrate oral tablet 10 mg, 5 mg 2 QL (30 EA per 30 days) *Selective Melatonin Receptor Agonists*** ramelteon oral tablet 8 mg 4 ST; QL (30 EA per 30 days) *LAXATIVES* *Bowel Evacuant Combinations*** GAVILYTE-C ORAL SOLUTION 1 RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION 1 RECONSTITUTED 236 GM PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

84 Drug Name Drug Tier Requirements/Limits GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 2 GM GOLYTELY ORAL SOLUTION 2 RECONSTITUTED 227.1 GM peg-3350/electrolytes oral solution 1 reconstituted 236 gm peg-3350/electrolytes/ascorbat oral $0 copay for members age 50 3 solution reconstituted 100 gm through 74 peg-kcl-nacl-nasulf-na asc-c oral solution $0 copay for members age 50 3 reconstituted 100 gm through 74 SUPREP BOWEL PREP KIT ORAL $0 copay for members age 50 3 SOLUTION 17.5-3.13-1.6 GM/177ML through 74 *Laxatives - Miscellaneous*** KRISTALOSE ORAL PACKET 10 GM, 20 4 PA GM lactulose oral solution 10 gm/15ml 2 polyethylene glycol 3350 oral powder 17 2 gm/scoop *Saline Laxative Mixtures*** OSMOPREP ORAL TABLET 1.102-0.398 4 GM *MACROLIDES* *Azithromycin*** azithromycin intravenous solution 2 reconstituted 500 mg azithromycin oral packet 1 gm 2 azithromycin oral suspension reconstituted 2 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg 2 azithromycin oral tablet 600 mg 2 *Clarithromycin*** clarithromycin er oral tablet extended 2 release 24 hour 500 mg clarithromycin oral suspension 2 reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 2 *Erythromycins***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

85 Drug Name Drug Tier Requirements/Limits ERY-TAB ORAL TABLET DELAYED 4 RELEASE 333 MG ERYTHROCIN STEARATE ORAL TABLET 4 250 MG erythromycin base oral capsule delayed 4 release particles 250 mg erythromycin base oral tablet 250 mg, 500 4 mg erythromycin ethylsuccinate oral tablet 400 4 mg *Fidaxomicin*** DIFICID ORAL TABLET 200 MG 4 PA *MEDICAL DEVICES AND SUPPLIES* *Applicators,Cotton Balls,Etc*** BD SWAB SINGLE USE REGULAR PAD 3 OTC BD SWABS SINGLE USE BUTTERFLY 3 OTC PAD *Cervical Caps*** FEMCAP VAGINAL DEVICE 22 MM, 26 1 QL (1 EA per 300 days) MM, 30 MM *Condoms - Female*** FC2 FEMALE CONDOM 1 OTC *Diaphragms*** CAYA VAGINAL DIAPHRAGM 1 QL (1 EA per 300 days) OMNIFLEX DIAPHRAGM VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

86 Drug Name Drug Tier Requirements/Limits WIDE-SEAL DIAPHRAGM 85 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL 1 QL (1 EA per 300 days) DIAPHRAGM 2 % *Glucose Monitoring Test Supplies*** DEXCOM G4 PLAT PED RCV/SHARE 3 QL (1 EA per 365 days) DEVICE DEXCOM G4 PLAT PED RECEIVER 3 QL (1 EA per 365 days) DEVICE DEXCOM G4 PLATINUM RCV/SHARE 3 QL (1 EA per 365 days) DEVICE DEXCOM G4 PLATINUM RECEIVER 3 QL (1 EA per 365 days) DEVICE DEXCOM G4 PLATINUM TRANSMITTER 3 QL (1 EA per 84 days) DEXCOM G4 SENSOR 3 QL (12 EA per 84 days) DEXCOM G5 MOB/G4 PLAT SENSOR 3 QL (12 EA per 84 days) DEXCOM G5 MOBILE RECEIVER DEVICE 3 QL (1 EA per 365 days) DEXCOM G5 MOBILE TRANSMITTER 3 QL (1 EA per 84 days) DEXCOM G5 RECEIVER KIT DEVICE 3 QL (1 EA per 365 days) DEXCOM G6 RECEIVER DEVICE 3 QL (1 EA per 365 days) DEXCOM G6 SENSOR 3 QL (9 EA per 90 days) DEXCOM G6 TRANSMITTER 3 QL (1 EA per 90 days) DIASCREEN 10 2 OTC FREESTYLE LIBRE 14 DAY READER 3 QL (1 EA per 365 days) DEVICE FREESTYLE LIBRE 14 DAY SENSOR 3 QL (2 EA per 28 days) FREESTYLE LIBRE 2 READER DEVICE 3 QL (1 EA per 365 days) FREESTYLE LIBRE 2 SENSOR 3 QL (2 EA per 28 days) FREESTYLE LIBRE READER DEVICE 3 QL (1 EA per 365 days) FREESTYLE LIBRE SENSOR SYSTEM 3 QL (2 EA per 28 days) ONETOUCH DELICA LANCETS 30G 3 OTC ONETOUCH DELICA LANCETS 33G 3 OTC ONETOUCH DELICA LANCING DEV 3 OTC ONETOUCH DELICA PLUS LANCET30G 3 OTC ONETOUCH DELICA PLUS LANCET33G 3 OTC

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

87 Drug Name Drug Tier Requirements/Limits ONETOUCH DELICA PLUS LANCING 3 OTC ONETOUCH SURESOFT LANCING DEV 3 OTC ONETOUCH ULTRA 2 KIT W/DEVICE 3 OTC; QL (1 EA per 365 days) ONETOUCH ULTRA CONTROL IN VITRO 3 OTC SOLUTION ONETOUCH ULTRA MINI KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH ULTRASOFT LANCETS 3 OTC ONETOUCH VERIO FLEX SYSTEM KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH VERIO IN VITRO 3 OTC SOLUTION ONETOUCH VERIO IQ SYSTEM KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE ONETOUCH VERIO KIT W/DEVICE 3 OTC; QL (1 EA per 365 days) ONETOUCH VERIO REFLECT KIT 3 OTC; QL (1 EA per 365 days) W/DEVICE *Iv Sets/Tubing*** BD SAFETY-LOK SET 2 *Needles & Syringes*** BD AUTOSHIELD 29G X 5MM , 29G X 2 OTC 8MM BD AUTOSHIELD DUO 30G X 5 MM 2 OTC BD DISP NEEDLE 23G X 1" 2 OTC BD DISP NEEDLES 16G X 1-1/2" , 18G X 1-1/2" , 19G X 1" , 20G X 1" , 20G X 1-1/2" , 21G X 1-1/2" , 22G X 1-1/2" , 2 OTC 25G X 5/8" , 25G X 7/8" , 27G X 1/2" , 30G X 1/2" BD HYPODERMIC NEEDLE 16G X 1" , 18G X 1" , 18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 21G X 1" , 21G X 2" , 2 OTC 22G X 1-1/2" , 23G X 3/4" , 25G X 1- 1/2" , 26G X 1/2" , 26G X 3/8" BD INSULIN SYR ULTRAFINE II 31G X 2 OTC 5/16" 0.3 ML, 31G X 5/16" 0.5 ML BD INSULIN SYRINGE 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 2 OTC ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, U-100 1 ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

88 Drug Name Drug Tier Requirements/Limits BD INSULIN SYRINGE HALF-UNIT 31G 2 OTC X 5/16" 0.3 ML BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.3 ML, 28G X 2 OTC 1/2" 0.5 ML, 28G X 1/2" 1 ML BD INSULIN SYRINGE U/F 1/2UNIT 2 OTC 31G X 5/16" 0.3 ML BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 2 OTC 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML BD INSULIN SYRINGE U-40 25G X 2 OTC 5/8" 1 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G 2 OTC X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML BD INTEGRA SYRINGE 25G X 1" 1 ML 2 OTC BD PEN 2 OTC BD PEN MINI 2 OTC BD PEN NEEDLE MICRO U/F 32G X 6 2 OTC MM BD PEN NEEDLE MINI U/F 31G X 5 MM 2 OTC BD PEN NEEDLE NANO 2ND GEN 32G X 2 OTC 4 MM BD PEN NEEDLE NANO U/F 32G X 4 2 MM BD PEN NEEDLE ORIGINAL U/F 29G X 2 OTC 12.7MM BD PEN NEEDLE SHORT U/F 31G X 8 2 OTC MM BD PRECISIONGLIDE NEEDLE 27G X 1- 2 OTC 1/2" BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 31G X 15/64" 0.5 2 OTC ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML BD SAFETYGLIDE NEEDLE 25G X 5/8" 2 OTC BD SAFETY-LOK INSULIN SYRINGE 2 OTC 29G X 1/2" 1 ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

89 Drug Name Drug Tier Requirements/Limits BD VEO INSULIN SYR U/F 1/2UNIT 2 OTC 31G X 15/64" 0.3 ML BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 2 OTC 31G X 15/64" 1 ML BD YALE LNR REUSABLE NEEDLE 26G X 2 OTC 1/2" YALE DISP NEEDLES 21G X 1-1/4" 2 OTC *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER PLUS FLO-VU 3 FLEXICHAMBER CHILD MASK/SMALL 3 OPTICHAMBER FACE MASK-SMALL 3 OTC PEDIATRIC PANDA MASK 3 OTC *MIGRAINE PRODUCTS* *Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)*** NURTEC ORAL TABLET DISPERSIBLE 3 ST; QL (16 EA per 30 days) 75 MG UBRELVY ORAL TABLET 100 MG, 50 MG 3 ST; QL (16 EA per 30 days) *Cgrp Receptor Antagonists - Monocolonal Antibodies*** AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 3 PA MG/ML EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED 3 PA SYRINGE 100 MG/ML EMGALITY SUBCUTANEOUS SOLUTION 3 PA AUTO-INJECTOR 120 MG/ML EMGALITY SUBCUTANEOUS SOLUTION 3 PA PREFILLED SYRINGE 120 MG/ML *Ergot Combinations*** ergotamine-caffeine oral tablet 1-100 mg 2 QL (40 EA per 28 days) *Migraine Products*** dihydroergotamine mesylate nasal solution 4 QL (8 ML per 30 days) 4 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

90 Drug Name Drug Tier Requirements/Limits *Selective Serotonin Agonists 5-Ht(1)*** almotriptan malate oral tablet 12.5 mg, 4 ST; QL (9 EA per 30 days) 6.25 mg eletriptan hydrobromide oral tablet 20 mg, 2 ST 40 mg frovatriptan succinate oral tablet 2.5 mg 4 ST; QL (9 EA per 30 days) naratriptan hcl oral tablet 1 mg, 2.5 mg 3 QL (9 EA per 30 days) rizatriptan benzoate oral tablet 10 mg, 5 4 QL (12 EA per 30 days) mg rizatriptan benzoate oral tablet dispersible 4 QL (12 EA per 30 days) 10 mg, 5 mg sumatriptan nasal solution 20 mg/act 2 PA; QL (12 EA per 28 days) sumatriptan nasal solution 5 mg/act 2 PA; QL (24 EA per 28 days) sumatriptan succinate oral tablet 100 mg, 2 QL (9 EA per 30 days) 25 mg, 50 mg sumatriptan succinate subcutaneous 3 PA; QL (12 ML per 28 days) solution 6 mg/0.5ml sumatriptan succinate subcutaneous 3 PA; QL (12 ML per 28 days) solution auto-injector 6 mg/0.5ml zolmitriptan oral tablet 2.5 mg, 5 mg 3 QL (6 EA per 30 days) zolmitriptan oral tablet dispersible 2.5 mg, 5 QL (6 EA per 30 days) 5 mg *MINERALS & ELECTROLYTES* *Fluoride*** fluoritab oral tablet chewable 1.1 (0.5 f) $0 copay for 5 yrs of age and 1 mg younger sodium fluoride oral solution 1.1 (0.5 f) 1 mg/ml sodium fluoride oral tablet chewable 0.55 $0 copay for 5 yrs of age and 1 (0.25 f) mg, 1.1 (0.5 f) mg younger sodium fluoride oral tablet chewable 2.2 (1 1 f) mg *Magnesium*** magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 40 2 gm/1000ml *Potassium***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

91 Drug Name Drug Tier Requirements/Limits KLOR-CON M15 ORAL TABLET 2 EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET 2 EXTENDED RELEASE 20 MEQ potassium chloride crys er oral tablet 2 extended release 10 meq, 15 meq, 20 meq potassium chloride er oral capsule 2 extended release 10 meq, 8 meq potassium chloride er oral tablet extended 2 release 10 meq, 20 meq, 8 meq potassium chloride intravenous solution 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 2 meq/50ml, 40 meq/100ml potassium chloride oral packet 20 meq 3 potassium chloride oral solution 20 2 meq/15ml (10%), 40 meq/15ml (20%) *Sodium*** sodium chloride intravenous solution 0.9 % 2 *MISCELLANEOUS THERAPEUTIC CLASSES* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 5 PA; SP 150 MG, 200 MG, 50 MG *Chelating Agents*** penicillamine oral tablet 250 mg 5 SP *Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 2 25 mg cyclosporine modified oral solution 100 3 mg/ml cyclosporine oral capsule 100 mg, 25 mg 2 SANDIMMUNE ORAL SOLUTION 100 5 PA MG/ML *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 PA; SP; QL (28 EA per 28 5 MG, 2.5 MG, 5 MG days)

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

92 Drug Name Drug Tier Requirements/Limits REVLIMID ORAL CAPSULE 20 MG, 25 PA; SP; QL (21 EA per 28 5 MG days) *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 2 mg mycophenolate mofetil oral suspension 5 reconstituted 200 mg/ml mycophenolate mofetil oral tablet 500 mg 2 mycophenolate sodium oral tablet delayed 3 PA release 180 mg, 360 mg *Irrigation Solutions*** TIS-U-SOL IRRIGATION SOLUTION 2 *Macrolide Immunosuppressants*** everolimus oral tablet 0.25 mg, 0.5 mg, 5 PA 0.75 mg sirolimus oral solution 1 mg/ml 5 PA sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 5 PA tacrolimus oral capsule 0.5 mg, 1 mg, 5 2 mg *Potassium Removing Agents*** KIONEX ORAL SUSPENSION 15 2 GM/60ML sodium polystyrene sulfonate rectal 2 suspension 30 gm/120ml *Purine Analogs*** AZASAN ORAL TABLET 100 MG, 75 MG 4 PA azathioprine oral tablet 50 mg 2 *MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine viscous hcl mouth/throat solution 2 2 % *Anti-Infectives - Throat*** clotrimazole mouth/throat troche 10 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

93 Drug Name Drug Tier Requirements/Limits nystatin mouth/throat suspension 100000 2 unit/ml *Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat 2 solution 0.12 % *Saliva Stimulants*** cevimeline hcl oral capsule 30 mg 2 PA pilocarpine hcl oral tablet 5 mg, 7.5 mg 2 *Steroids - Mouth/Throat/Dental*** triamcinolone acetonide mouth/throat 2 paste 0.1 % *MULTIVITAMINS* *Ped Multi Vitamins W/Fl & Fe*** multi-vitamin/fluoride/iron oral solution 2 0.25-10 mg/ml *Ped Mv W/ Fluoride*** multivitamin/fluoride oral solution 0.5 2 mg/ml multi-vitamin/fluoride oral solution 0.5 2 mg/ml multivitamin/fluoride oral tablet chewable 2 0.25 mg, 0.5 mg, 1 mg MVC-FLUORIDE ORAL TABLET 2 CHEWABLE 1 MG poly-vitamin/fluoride oral solution 0.5 2 mg/ml *Ped Vitamins Acd W/ Fluoride*** adc/f (0.5mg/ml) oral solution 0.5 mg/ml 2 tri-vitamin/fluoride oral solution 0.5 mg/ml 2 tri-vite/fluoride oral solution 0.5 mg/ml 2 vitamins acd-fluoride oral solution 0.25 2 mg/ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

94 Drug Name Drug Tier Requirements/Limits *Prenatal Mv & Min W/Fe- Fa*** CITRANATAL B-CALM ORAL 20-1 MG & 3 2 X 25 MG CITRANATAL RX ORAL TABLET 27-1 3 MG PRENATABS RX ORAL TABLET 29-1 MG 2 *MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg 2 carisoprodol oral tablet 350 mg 2 AGE (Max 64 Years) chlorzoxazone oral tablet 500 mg 2 cyclobenzaprine hcl oral tablet 10 mg, 5 2 AGE (Max 64 Years) mg metaxalone oral tablet 400 mg 2 AGE (Max 64 Years) metaxalone oral tablet 800 mg 3 PA; AGE (Max 64 Years) methocarbamol oral tablet 500 mg, 750 2 AGE (Max 64 Years) mg orphenadrine citrate er oral tablet 2 AGE (Max 64 Years) extended release 12 hour 100 mg tizanidine hcl oral tablet 2 mg, 4 mg 2 QL (90 EA per 30 days) *Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg, 25 3 mg, 50 mg *NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 % 2 QL (30 ML per 30 days) ipratropium bromide nasal solution 0.06 % 2 QL (15 ML per 30 days) *Nasal Antihistamines*** azelastine hcl nasal solution 0.1 %, 0.15 % 2 olopatadine hcl nasal solution 0.6 % 2 QL (31 GM per 30 days) *Nasal Steroids*** BECONASE AQ NASAL SUSPENSION 42 4 ST MCG/SPRAY budesonide nasal suspension 32 mcg/act 2 QL (8.43 GM per 30 days) PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

95 Drug Name Drug Tier Requirements/Limits flunisolide nasal solution 25 mcg/act 2 QL (50 ML per 30 days) (0.025%) fluticasone propionate nasal suspension 50 2 QL (16 GM per 30 days) mcg/act mometasone furoate nasal suspension 50 3 ST mcg/act OMNARIS NASAL SUSPENSION 50 4 ST MCG/ACT triamcinolone acetonide nasal aerosol 55 2 mcg/act *NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet 50 mg 5 SP *Neuromuscular Blocking Agent - Neurotoxins*** DYSPORT INTRAMUSCULAR SOLUTION 5 PA; SP RECONSTITUTED 300 UNIT *OPHTHALMIC AGENTS* *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** SIMBRINZA OPHTHALMIC 4 QL (8 ML per 30 days) SUSPENSION 1-0.2 % *Beta-Blockers - Ophthalmic Combinations*** COMBIGAN OPHTHALMIC SOLUTION 4 0.2-0.5 % dorzolamide hcl-timolol mal ophthalmic 2 solution 22.3-6.8 mg/ml *Beta-Blockers - Ophthalmic*** betaxolol hcl ophthalmic solution 0.5 % 2 BETOPTIC-S OPHTHALMIC 4 PA SUSPENSION 0.25 % carteolol hcl ophthalmic solution 1 % 2 levobunolol hcl ophthalmic solution 0.5 % 2 timolol maleate ophthalmic gel forming 4 solution 0.5 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

96 Drug Name Drug Tier Requirements/Limits timolol maleate ophthalmic solution 0.25 2 %, 0.5 % *Cycloplegic Mydriatics*** atropine sulfate ophthalmic solution 1 % 2 cyclopentolate hcl ophthalmic solution 1 %, 2 2 % HOMATROPAIRE OPHTHALMIC 2 SOLUTION 5 % tropicamide ophthalmic solution 0.5 %, 1 2 % *Miotics - Cholinesterase Inhibitors*** PHOSPHOLINE IODIDE OPHTHALMIC 3 SOLUTION RECONSTITUTED 0.125 % *Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 2 %, 4 % *Ophthalmic Antiallergic*** ALOCRIL OPHTHALMIC SOLUTION 2 % 4 PA ALOMIDE OPHTHALMIC SOLUTION 0.1 4 PA % azelastine hcl ophthalmic solution 0.05 % 2 QL (6 ML per 30 days) BEPREVE OPHTHALMIC SOLUTION 1.5 4 PA % cromolyn sodium ophthalmic solution 4 % 2 epinastine hcl ophthalmic solution 0.05 % 2 LASTACAFT OPHTHALMIC SOLUTION 4 PA 0.25 % ZERVIATE OPHTHALMIC SOLUTION 4 PA 0.24 % *Ophthalmic Antibiotics*** AZASITE OPHTHALMIC SOLUTION 1 % 4 PA bacitracin ophthalmic ointment 500 2 unit/gm BESIVANCE OPHTHALMIC 4 PA SUSPENSION 0.6 % CILOXAN OPHTHALMIC OINTMENT 0.3 4 % ciprofloxacin hcl ophthalmic solution 0.3 % 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

97 Drug Name Drug Tier Requirements/Limits erythromycin ophthalmic ointment 5 2 mg/gm gatifloxacin ophthalmic solution 0.5 % 2 GENTAK OPHTHALMIC OINTMENT 0.3 2 % gentamicin sulfate ophthalmic solution 0.3 2 % levofloxacin ophthalmic solution 0.5 % 2 PA moxifloxacin hcl ophthalmic solution 0.5 % 2 ofloxacin ophthalmic solution 0.3 % 2 tobramycin ophthalmic solution 0.3 % 2 *Ophthalmic Antifungal*** NATACYN OPHTHALMIC SUSPENSION 4 PA 5 % *Ophthalmic Anti-Infective Combinations*** bacitracin-polymyxin b ophthalmic 2 ointment 500-10000 unit/gm neomycin-polymyxin-gramicidin 2 ophthalmic solution 1.75-10000-.025 polymyxin b-trimethoprim ophthalmic 2 solution 10000-0.1 unit/ml-% *Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 % 3 ZIRGAN OPHTHALMIC GEL 0.15 % 4 *Ophthalmic Carbonic Anhydrase Inhibitors*** AZOPT OPHTHALMIC SUSPENSION 1 4 QL (15 ML per 30 days) % dorzolamide hcl ophthalmic solution 2 % 2 *Ophthalmic Immunomodulators*** RESTASIS OPHTHALMIC EMULSION 3 QL (60 EA per 30 days) 0.05 % *Ophthalmic Local Anesthetics*** ALTACAINE OPHTHALMIC SOLUTION 2 0.5 % PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

98 Drug Name Drug Tier Requirements/Limits proparacaine hcl ophthalmic solution 0.5 % 2 *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** bromfenac sodium (once-daily) ophthalmic 4 solution 0.09 % diclofenac sodium ophthalmic solution 0.1 2 % flurbiprofen sodium ophthalmic solution 2 0.03 % ketorolac tromethamine ophthalmic 2 solution 0.4 %, 0.5 % NEVANAC OPHTHALMIC SUSPENSION 4 0.1 % *Ophthalmic Selective Alpha Adrenergic Agonists*** apraclonidine hcl ophthalmic solution 0.5 2 % brimonidine tartrate ophthalmic solution 3 0.15 % brimonidine tartrate ophthalmic solution 2 0.2 % IOPIDINE OPHTHALMIC SOLUTION 1 4 % *Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic 2 ointment 1 % BLEPHAMIDE S.O.P. OPHTHALMIC 3 OINTMENT 10-0.2 % neomycin-polymyxin-dexameth ophthalmic 2 ointment 3.5-10000-0.1 neomycin-polymyxin-dexameth ophthalmic 2 suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic 2 suspension 3.5-10000-1 sulfacetamide-prednisolone ophthalmic 2 solution 10-0.23 % TOBRADEX OPHTHALMIC OINTMENT 4 QL (3.5 GM per 30 days) 0.3-0.1 %

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

99 Drug Name Drug Tier Requirements/Limits tobramycin-dexamethasone ophthalmic 2 QL (5 ML per 30 days) suspension 0.3-0.1 % *Ophthalmic Steroids*** dexamethasone sodium phosphate 2 ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 4 0.05 % fluorometholone ophthalmic suspension 0.1 2 % FML OPHTHALMIC OINTMENT 0.1 % 3 LOTEMAX OPHTHALMIC OINTMENT 0.5 4 % loteprednol etabonate ophthalmic 3 suspension 0.5 % PRED MILD OPHTHALMIC 3 SUSPENSION 0.12 % prednisolone acetate ophthalmic 2 suspension 1 % prednisolone sodium phosphate ophthalmic 2 solution 1 % *Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic solution 2 10 % *Prostaglandins - Ophthalmic*** bimatoprost ophthalmic solution 0.03 % 3 QL (5 ML per 30 days) latanoprost ophthalmic solution 0.005 % 2 QL (5 ML per 30 days) LUMIGAN OPHTHALMIC SOLUTION 4 ST; QL (7.5 ML per 30 days) 0.01 % travoprost (bak free) ophthalmic solution 3 QL (5 ML per 30 days) 0.004 % ZIOPTAN OPHTHALMIC SOLUTION 4 ST; QL (30 EA per 30 days) 0.0015 % *OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % 2 *Otic Anti-Infectives*** ofloxacin otic solution 0.3 % 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

100 Drug Name Drug Tier Requirements/Limits *Otic Steroid-Anti-Infective Combinations*** CIPRO HC OTIC SUSPENSION 0.2-1 % 4 PA ciprofloxacin-dexamethasone otic 2 suspension 0.3-0.1 % CORTISPORIN-TC OTIC SUSPENSION 4 3.3-3-10-0.5 MG/ML neomycin-polymyxin-hc otic solution 3.5- 2 10000-1 neomycin-polymyxin-hc otic suspension 2 3.5-10000-1 *Otic Steroids*** fluocinolone acetonide otic oil 0.01 % 2 hydrocortisone-acetic acid otic solution 1-2 2 % *OXYTOCICS* *Oxytocics*** METHERGINE ORAL TABLET 0.2 MG 2 oxytocin injection solution 10 unit/ml 4 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* *Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR SOLUTION 5 PA; SP 100 MG/ML, 50 MG/0.5ML *Passive Immunizing Agents - Combinations*** HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 5 PA; SP GM/200ML, 30 GM/300ML, 5 GM/50ML *PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg 2 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 2 400 mg/5ml

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

101 Drug Name Drug Tier Requirements/Limits amoxicillin oral tablet 500 mg, 875 mg 2 amoxicillin oral tablet chewable 125 mg, 2 250 mg ampicillin oral capsule 500 mg 2 *Natural Penicillins*** penicillin v potassium oral solution 2 reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 2 500 mg *Penicillin Combinations*** amoxicillin-pot clavulanate er oral tablet 3 extended release 12 hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 2 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250- 2 125 mg, 500-125 mg amoxicillin-pot clavulanate oral tablet 875- 2 QL (28 EA per 14 days) 125 mg amoxicillin-pot clavulanate oral tablet 2 chewable 200-28.5 mg, 400-57 mg AUGMENTIN ORAL SUSPENSION 3 PA RECONSTITUTED 125-31.25 MG/5ML *Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 2 500 mg *PROGESTINS* *Progestins*** norethindrone acetate oral tablet 5 mg 2 progesterone micronized oral capsule 100 2 mg, 200 mg progesterone oral capsule 100 mg, 200 mg 2 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *Alcohol Deterrents***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

102 Drug Name Drug Tier Requirements/Limits acamprosate calcium oral tablet delayed 2 release 333 mg disulfiram oral tablet 250 mg, 500 mg 2 *Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 3 10-25 mg, 5-12.5 mg *Cholinomimetics - Ache Inhibitors*** donepezil hcl oral tablet 10 mg, 23 mg, 5 2 mg donepezil hcl oral tablet dispersible 10 mg, 2 5 mg galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 3 QL (30 EA per 30 days) mg galantamine hydrobromide oral tablet 12 2 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 3 mg, 4.5 mg, 6 mg *Fibromyalgia Agent - Snris*** SAVELLA ORAL TABLET 100 MG, 12.5 4 PA MG, 25 MG, 50 MG *Movement Disorder Drug Therapy*** tetrabenazine oral tablet 12.5 mg, 25 mg 5 PA; SP *Ms Agents - Pyrimidine Synthesis Inhibitors*** AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; SP *Multiple Sclerosis Agents - Interferons*** AVONEX PEN INTRAMUSCULAR AUTO- 5 PA; SP INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 5 PA; SP MCG/0.5ML BETASERON SUBCUTANEOUS KIT 0.3 5 PA; SP MG PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

103 Drug Name Drug Tier Requirements/Limits *Multiple Sclerosis Agents - Nrf2 Pathway Activators*** dimethyl fumarate oral capsule delayed 5 PA; SP release 120 mg, 240 mg dimethyl fumarate starter pack oral 120 & 5 PA; SP 240 mg *Multiple Sclerosis Agents - Potassium Channel Blockers*** dalfampridine er oral tablet extended 5 PA; SP release 12 hour 10 mg *Multiple Sclerosis Agents*** glatiramer acetate subcutaneous solution 5 PA; SP prefilled syringe 20 mg/ml, 40 mg/ml GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 5 PA; SP MG/ML *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution 2 mg/ml 4 PA; QL (300 ML per 30 days) memantine hcl oral tablet 10 mg, 5 mg 2 QL (60 EA per 30 days) memantine hcl oral tablet 28 x 5 mg & 21 2 QL (49 EA per 365 days) x 10 mg *Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 2 mg, 2-25 mg, 4-10 mg, 4-25 mg *Psychotherapeutic And Neurological Agents - Misc.*** ergoloid mesylates oral tablet 1 mg 4 PA pimozide oral tablet 1 mg, 2 mg 2 *Smoking Deterrents*** apo-varenicline oral tablet 0.5 mg, 1 mg 1 QL (60 EA per 30 days) bupropion hcl er (smoking det) oral tablet $0 limited to 2 treatment 1 extended release 12 hour 150 mg cycles/year

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

104 Drug Name Drug Tier Requirements/Limits $0 limited to 2 treatment CHANTIX CONTINUING MONTH PAK 1 cycles/year; QL (60 EA per 30 ORAL TABLET 1 MG days) $0 limited to 2 treatment CHANTIX ORAL TABLET 0.5 MG, 1 MG 1 cycles/year; QL (60 EA per 30 days) CHANTIX STARTING MONTH PAK ORAL $0 limited to 2 treatment 1 TABLET 0.5 MG X 11 & 1 MG X 42 cycles/year goodsense nicotine mouth/throat lozenge 4 OTC; $0 limited to 2 1 mg treatment cycles/year; OTC OTC; QL (810 EA per 365 nicotine polacrilex mouth/throat gum 2 mg 1 days) OTC; $0 limited to 2 nicotine polacrilex mouth/throat gum 4 mg 1 treatment cycles/year; OTC; QL (810 EA per 365 days) nicotine polacrilex mouth/throat lozenge 2 OTC; $0 limited to 2 1 mg treatment cycles/year; OTC nicotine step 3 transdermal patch 24 hour 1 OTC 7 mg/24hr nicotine transdermal patch 24 hour 14 OTC; $0 limited to 2 1 mg/24hr treatment cycles/year; OTC OTC; $0 limited to 2 nicotine transdermal patch 24 hour 21 1 treatment cycles/year; OTC; mg/24hr QL (90 EA per 365 days) NICOTROL INHALATION INHALER 10 $0 limited to 2 treatment 1 MG cycles/year NICOTROL NS NASAL SOLUTION 10 $0 limited to 2 treatment 1 MG/ML cycles/year *Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE 0.5 MG 5 PA; SP *RESPIRATORY AGENTS - MISC.* *Cystic Fibrosis Agent - Combinations*** ORKAMBI ORAL TABLET 100-125 MG, PA; SP; QL (112 EA per 28 5 200-125 MG days) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 5 PA; SP MG PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

105 Drug Name Drug Tier Requirements/Limits *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 5 PA; SP 1 MG/ML *Pulmonary Fibrosis Agents*** ESBRIET ORAL CAPSULE 267 MG 5 PA; SP ESBRIET ORAL TABLET 267 MG, 801 5 PA; SP MG *SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet 500 mg 4 *TETRACYCLINES* *Tetracyclines*** demeclocycline hcl oral tablet 150 mg, 300 3 mg doxycycline hyclate oral capsule 100 mg, 2 50 mg doxycycline hyclate oral tablet 100 mg, 20 2 mg doxycycline monohydrate oral capsule 100 2 mg, 150 mg, 50 mg doxycycline monohydrate oral suspension 2 reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 150 2 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 2 mg, 75 mg tetracycline hcl oral capsule 250 mg, 500 3 mg *THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg 2 propylthiouracil oral tablet 50 mg 2 *Thyroid Hormones*** ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 3 300 MG, 60 MG, 90 MG EUTHYROX ORAL TABLET 25 MCG 2 PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

106 Drug Name Drug Tier Requirements/Limits LEVO-T ORAL TABLET 25 MCG 2 levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 2 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 2 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 2 mcg, 50 mcg NATURE-THROID ORAL TABLET 130 2 MG, 16.25 MG, 195 MG, 32.5 MG np thyroid oral tablet 15 mg, 30 mg, 60 2 mg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 3 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG thyroid oral tablet 30 mg, 60 mg 2 THYROLAR-1/4 ORAL TABLET 15 (3.1- 4 12.5) MG (MCG) UNITHROID ORAL TABLET 100 MCG 2 WESTHROID ORAL TABLET 65 MG 2 *TOXOIDS* *Toxoid Combinations*** ADACEL INTRAMUSCULAR 1 SUSPENSION 5-2-15.5 LF-MCG/0.5 BOOSTRIX INTRAMUSCULAR 1 SUSPENSION 5-2.5-18.5 LF-MCG/0.5 DAPTACEL INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 23-15-5 and younger diphtheria-tetanus toxoids dt intramuscular $0 copay for 18 years of age 1 suspension 25-5 lfu/0.5ml and younger INFANRIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 25-58-10 and younger KINRIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION and younger PEDIARIX INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION and younger

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

107 Drug Name Drug Tier Requirements/Limits PENTACEL INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION RECONSTITUTED and younger TDVAX INTRAMUSCULAR SUSPENSION $0 copay for 19 years of age 1 2-2 LF/0.5ML and older TENIVAC INTRAMUSCULAR $0 copay for 19 years of age 1 INJECTABLE 5-2 LFU and older *ULCER DRUGS/ANTISPASMODICS/A NTICHOLINERGICS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg 2 dicyclomine hcl oral solution 10 mg/5ml 2 dicyclomine hcl oral tablet 20 mg 2 *Belladonna Alkaloids*** hyoscyamine sulfate oral tablet 0.125 mg 2 hyoscyamine sulfate oral tablet dispersible 2 0.125 mg hyoscyamine sulfate sublingual tablet 2 sublingual 0.125 mg *H-2 Antagonists*** cimetidine hcl oral solution 300 mg/5ml 2 cimetidine oral tablet 200 mg, 300 mg, 2 400 mg, 800 mg famotidine intravenous solution 20 mg/2ml 2 famotidine oral suspension reconstituted 2 40 mg/5ml famotidine oral tablet 20 mg, 40 mg 2 nizatidine oral capsule 150 mg, 300 mg 2 nizatidine oral solution 15 mg/ml 2 ranitidine hcl oral capsule 150 mg, 300 mg 2 ranitidine hcl oral syrup 75 mg/5ml 2 ranitidine hcl oral tablet 150 mg, 300 mg 2 *Misc. Anti-Ulcer*** sucralfate oral suspension 1 gm/10ml 3 PA sucralfate oral tablet 1 gm 2 *Proton Pump Inhibitors***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

108 Drug Name Drug Tier Requirements/Limits DEXILANT ORAL CAPSULE DELAYED 4 ST; QL (30 EA per 30 days) RELEASE 30 MG, 60 MG esomeprazole magnesium oral capsule 2 QL (30 EA per 30 days) delayed release 40 mg lansoprazole oral capsule delayed release 2 QL (30 EA per 30 days) 30 mg omeprazole oral capsule delayed release 2 QL (60 EA per 30 days) 10 mg, 20 mg, 40 mg pantoprazole sodium oral tablet delayed 2 QL (60 EA per 30 days) release 20 mg, 40 mg rabeprazole sodium oral tablet delayed 2 QL (30 EA per 30 days) release 20 mg *Quaternary Anticholinergics*** glycopyrrolate oral tablet 1 mg, 2 mg 2 methscopolamine bromide oral tablet 2.5 2 mg, 5 mg *Ulcer Drugs - Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg 2 *URINARY ANTISPASMODICS* *Urinary Antispasmodic - Antimuscarinic (Anticholinergic)*** darifenacin hydrobromide er oral tablet 3 ST extended release 24 hour 15 mg, 7.5 mg oxybutynin chloride er oral tablet extended 2 release 24 hour 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 2 oxybutynin chloride oral tablet 5 mg 2 solifenacin succinate oral tablet 10 mg, 5 3 ST mg tolterodine tartrate er oral capsule 3 ST extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 3 ST TOVIAZ ORAL TABLET EXTENDED 3 ST RELEASE 24 HOUR 4 MG, 8 MG

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

109 Drug Name Drug Tier Requirements/Limits trospium chloride er oral capsule extended 3 ST release 24 hour 60 mg trospium chloride oral tablet 20 mg 3 ST *Urinary Antispasmodics - Cholinergic Agonists*** bethanechol chloride oral tablet 10 mg, 25 2 mg, 5 mg, 50 mg *Urinary Antispasmodics - Direct Muscle Relaxants*** flavoxate hcl oral tablet 100 mg 2 *VACCINES* *Bacterial Vaccines*** ACTHIB INTRAMUSCULAR SOLUTION $0 copay for 18 years of age 1 RECONSTITUTED and younger BEXSERO INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE HIBERIX INJECTION SOLUTION $0 copay for 18 years of age 1 RECONSTITUTED 10 MCG and younger MENACTRA INTRAMUSCULAR 1 INJECTABLE MENVEO INTRAMUSCULAR SOLUTION 1 RECONSTITUTED PEDVAX HIB INTRAMUSCULAR $0 copay for 18 years of age 1 SUSPENSION 7.5 MCG/0.5ML and younger PNEUMOVAX 23 INJECTION 1 INJECTABLE 25 MCG/0.5ML PREVNAR 13 INTRAMUSCULAR 1 QL (5 ML per 365 days) SUSPENSION TRUMENBA INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE *Viral Vaccine Combinations*** PROQUAD SUBCUTANEOUS $0 copay for 18 years of age 1 SUSPENSION RECONSTITUTED and younger TWINRIX INTRAMUSCULAR $0 copay for 19 years of age SUSPENSION PREFILLED SYRINGE 1 and older 720-20 ELU-MCG/ML *Viral Vaccines***

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

110 Drug Name Drug Tier Requirements/Limits ENGERIX-B INJECTION SUSPENSION 1 10 MCG/0.5ML, 20 MCG/ML FLUAD INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 1 0.5 ML FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION 1 PREFILLED SYRINGE 0.5 ML FLUCELVAX QUADRIVALENT 1 INTRAMUSCULAR SUSPENSION FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLULAVAL QUADRIVALENT 1 INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.7 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 1 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 1 PREFILLED SYRINGE 0.25 ML GARDASIL 9 INTRAMUSCULAR 1 SUSPENSION GARDASIL 9 INTRAMUSCULAR 1 SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL 1 U/0.5ML

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

111 Drug Name Drug Tier Requirements/Limits $0 copay for 18 years of age IPOL INJECTION INJECTABLE 1 and younger janssen covid-19 vaccine intramuscular 1 QL (1 ML per 365 days) suspension 0.5 ml moderna covid-19 vaccine intramuscular 1 QL (2 ML per 180 days) suspension 100 mcg/0.5ml pfizer-biontech covid-19 vacc 1 QL (2 ML per 180 days) intramuscular suspension 30 mcg/0.3ml RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 1 5 MCG/0.5ML ROTARIX ORAL SUSPENSION $0 copay for 18 years of age 1 RECONSTITUTED and younger $0 copay for 18 years of age ROTATEQ ORAL SOLUTION 1 and younger SHINGRIX INTRAMUSCULAR $0 copay for 19 years of age SUSPENSION RECONSTITUTED 50 1 and older; QL (1 EA per 1 MCG/0.5ML day) VAQTA INTRAMUSCULAR SUSPENSION 1 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1 1350 PFU/0.5ML ZOSTAVAX SUBCUTANEOUS $0 copay for 19 years of age SUSPENSION RECONSTITUTED 19400 1 and older UNT/0.65ML *VAGINAL AND RELATED PRODUCTS* *Imidazole-Related Antifungals*** GYNAZOLE-1 VAGINAL CREAM 2 % 4 terconazole vaginal cream 0.4 %, 0.8 % 2 terconazole vaginal suppository 80 mg 2 *Miscellaneous Vaginal Products*** INTRAROSA VAGINAL INSERT 6.5 MG 4 PA *Spermicides*** OPTIONS CONCEPTROL VAGINAL GEL 1 OTC 4 % TODAY SPONGE VAGINAL 1000 MG 1 OTC

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

112 Drug Name Drug Tier Requirements/Limits VCF VAGINAL CONTRACEPTIVE 1 OTC VAGINAL GEL 4 % *Vaginal Anti-Infectives*** CLEOCIN VAGINAL SUPPOSITORY 100 4 MG clindamycin phosphate vaginal cream 2 % 2 metronidazole vaginal gel 0.75 % 2 *Vaginal Estrogens*** estradiol vaginal cream 0.1 mg/gm 3 ESTRING VAGINAL RING 2 MG 4 *Vaginal Progestins*** CRINONE VAGINAL GEL 4 %, 8 % 5 PA *VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 2 QL (4 EA per 30 days) mg/0.3ml EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 4 QL (4 EA per 30 days) MG/0.3ML *Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 2 mg *VITAMINS* *Vitamin B-3*** niacin oral tablet 500 mg 2 OTC *Vitamin B-6*** pyridoxine hcl oral tablet 25 mg, 50 mg 2 OTC *Vitamin D*** vitamin d (ergocalciferol) oral capsule 1.25 2 mg (50000 ut) vitamin d3 oral capsule 1.25 mg (50000 2 OTC ut) *Vitamin K*** phytonadione oral tablet 5 mg 2

PA-Prior Authorization ST- Step Therapy QL- Quantity Limit SP- Specialty Pharmacy

113 Index

A alclometasone dipropionate amphetamine-dextroamphet abacavir sulfate ...... 52 ...... 69 er ...... 1 abacavir sulfate-lamivudine alendronate sodium ...... 75 amphetamine- ...... 50 alfuzosin hcl er ...... 80 dextroamphetamine ...... 1 abacavir-lamivudine- ALIMTA ...... 39 ampicillin...... 102 zidovudine ...... 50 ALINIA ...... 36 ANADROL-50 ...... 9 ABILIFY MAINTENA ...... 49 aliskiren fumarate ...... 35 anagrelide hcl ...... 82 abiraterone acetate ...... 39 allergy childrens ...... 29 anastrozole ...... 43 ABRAXANE ...... 44 allergy relief childrens .... 29 ANORO ELLIPTA ...... 13 acamprosate calcium .... 103 allopurinol ...... 81 ANZEMET ...... 28 acarbose ...... 22 almotriptan malate ...... 91 APIDRA ...... 22 acebutolol hcl ...... 54 ALOCRIL ...... 97 APIDRA SOLOSTAR ...... 22 acetaminophen-codeine ... 6 alogliptin benzoate ...... 22 APOKYN ...... 47 acetaminophen-codeine #2 ALOMIDE ...... 97 apo-varenicline ...... 104 ...... 6 alosetron hcl ...... 79 apraclonidine hcl ...... 99 acetaminophen-codeine #3 alprazolam ...... 11 aprepitant ...... 28 ...... 6 ALTABAX ...... 67 APRI ...... 59 acetaminophen-codeine #4 ALTACAINE...... 98 APTIOM ...... 17 ...... 6 ALTAVERA ...... 59 APTIVUS ...... 51 acetazolamide ...... 74 alyacen 1/35 ...... 59 ARCALYST ...... 4 acetazolamide er ...... 74 alyacen 7/7/7 ...... 63 ARCAPTA NEOHALER ...... 13 acetic acid ...... 81, 100 ALYQ ...... 58 arformoterol tartrate ...... 13 acetylcysteine...... 65 amantadine hcl ...... 46 aripiprazole ...... 49 acitretin ...... 68 ambrisentan ...... 57 armodafinil ...... 2 ACTHIB ...... 110 amcinonide ...... 69 ARMOUR THYROID ...... 106 ACTIMMUNE ...... 42 amikacin sulfate ...... 2 ARNUITY ELLIPTA ...... 14 acyclovir ...... 54, 69 amiloride hcl ...... 75 asenapine maleate ...... 48 ADACEL ...... 107 amiloride- ASHLYNA...... 62 adapalene ...... 66 hydrochlorothiazide .... 74 ASMANEX (120 METERED adapalene-benzoyl peroxide aminocaproic acid ...... 84 DOSES) ...... 14 ...... 66 amiodarone hcl ...... 12 ASMANEX (30 METERED adc/f (0.5mg/ml) ...... 94 amitriptyline hcl ...... 21 DOSES) ...... 14 adefovir dipivoxil ...... 53 amlodipine besy-benazepril ASMANEX (60 METERED ADEMPAS ...... 57 hcl ...... 32 DOSES) ...... 15 adriamycin ...... 42 amlodipine besylate ...... 55 ASMANEX HFA...... 15 ADRIAMYCIN ...... 42 amlodipine besylate- aspirin ...... 6 ADRUCIL ...... 39 valsartan ...... 33 aspirin adult low strength .. 6 ADVAIR DISKUS ...... 12 amlodipine-atorvastatin .. 57 aspirin-dipyridamole er ... 82 ADVAIR HFA ...... 12 amlodipine-olmesartan ... 33 atazanavir sulfate ...... 51 AEROCHAMBER PLUS FLO- amlodipine-valsartan-hctz34 atenolol...... 54 VU ...... 90 ammonium lactate ...... 71 atenolol-chlorthalidone ... 35 AFEDITAB CR ...... 55 AMNESTEEM ...... 66 atomoxetine hcl ...... 1 AFINITOR ...... 41 amoxapine ...... 21 atorvastatin calcium ...... 31 AIMOVIG ...... 90 amoxicillin ...... 101, 102 atovaquone ...... 36 albendazole ...... 10 amoxicillin-pot clavulanate atovaquone-proguanil hcl 37 albuterol sulfate ...... 13 ...... 102 atropine sulfate ...... 97 albuterol sulfate er ...... 13 amoxicillin-pot clavulanate ATROVENT HFA ...... 14 albuterol sulfate hfa ...... 13 er ...... 102 AUBAGIO ...... 103 AUGMENTIN ...... 102

114 AUROVELA FE 1.5/30 ...... 59 BD PEN NEEDLE ORIGINAL BLEPHAMIDE S.O.P...... 99 AVIANE ...... 59 U/F ...... 89 BLISOVI FE 1.5/30 ...... 60 AVITA ...... 66 BD PEN NEEDLE SHORT U/F BOOSTRIX ...... 107 AVONEX PEN ...... 103 ...... 89 bosentan ...... 57 AVONEX PREFILLED ...... 103 BD PRECISIONGLIDE BOSULIF ...... 40 AZASAN ...... 93 NEEDLE ...... 89 BREO ELLIPTA ...... 13 AZASITE ...... 97 BD SAFETYGLIDE INSULIN BRILINTA ...... 82 azathioprine ...... 93 SYRINGE ...... 89 brimonidine tartrate ...... 99 azelaic acid ...... 73 BD SAFETYGLIDE NEEDLE89 bromfenac sodium (once- azelastine hcl ...... 95, 97 BD SAFETY-LOK INSULIN daily) ...... 99 azithromycin ...... 85 SYRINGE ...... 89 bromocriptine mesylate .. 46 AZOPT ...... 98 BD SAFETY-LOK SET ...... 88 budesonide ...... 15, 63, 95 AZURETTE ...... 59 BD SWAB SINGLE USE budesonide-formoterol B REGULAR ...... 86 fumarate ...... 13 bacitracin ...... 97 BD SWABS SINGLE USE bumetanide ...... 75 bacitracin-polymyxin b .... 98 BUTTERFLY ...... 86 buprenorphine ...... 9 bacitra-neomycin- BD VEO INSULIN SYR U/F buprenorphine hcl ...... 9 polymyxin-hc ...... 99 1/2UNIT ...... 90 buprenorphine hcl-naloxone baclofen ...... 95 BD VEO INSULIN SYRINGE hcl ...... 9 balsalazide disodium ...... 79 U/F ...... 90 bupropion hcl ...... 19 BARACLUDE ...... 53 BD YALE LNR REUSABLE bupropion hcl er (smoking BD AUTOSHIELD ...... 88 NEEDLE ...... 90 det) ...... 104 BD AUTOSHIELD DUO ..... 88 BECONASE AQ ...... 95 bupropion hcl er (sr) ...... 19 BD DISP NEEDLE ...... 88 BENADRYL ALLERGY bupropion hcl er (xl) ...... 19 BD DISP NEEDLES ...... 88 CHILDRENS ...... 29 buspirone hcl ...... 11 BD HYPODERMIC NEEDLE 88 benazepril hcl ...... 32 busulfan ...... 38 BD INSULIN SYR benazepril- butalbital-apap-caff-cod .... 7 ULTRAFINE II ...... 88 hydrochlorothiazide .... 32 butalbital-apap-caffeine .... 6 BD INSULIN SYRINGE ..... 88 benzonatate ...... 64 butalbital-aspirin-caffeine .. 6 BD INSULIN SYRINGE HALF- benzoyl peroxide- BYSTOLIC ...... 55 UNIT ...... 89 erythromycin ...... 66 C BD INSULIN SYRINGE benztropine mesylate ..... 46 cabergoline ...... 76 MICROFINE ...... 89 BEPREVE ...... 97 caffeine citrate ...... 1 BD INSULIN SYRINGE U/F BESIVANCE ...... 97 caffeine-sodium benzoate . 1 ...... 89 betamethasone dipropionate calcipotriene ...... 68 BD INSULIN SYRINGE U/F ...... 69 calcipotriene-betameth 1/2UNIT ...... 89 betamethasone dipropionate diprop ...... 73 BD INSULIN SYRINGE U-40 aug ...... 69 calcitonin (salmon) ...... 76 ...... 89 betamethasone valerate . 70 calcitriol ...... 68, 77 BD INSULIN SYRINGE BETASERON ...... 103 calcium acetate (phos ULTRAFINE ...... 89 betaxolol hcl ...... 54, 96 binder)...... 80 BD INTEGRA SYRINGE .... 89 bethanechol chloride ..... 110 candesartan cilexetil ...... 34 BD PEN ...... 89 BETOPTIC-S ...... 96 candesartan cilexetil-hctz 33 BD PEN MINI ...... 89 bexarotene ...... 45 capecitabine ...... 39 BD PEN NEEDLE MICRO U/F BEXSERO ...... 110 CAPRELSA ...... 42 ...... 89 bicalutamide ...... 39 captopril ...... 32 BD PEN NEEDLE MINI U/F 89 BIKTARVY ...... 50 captopril- BD PEN NEEDLE NANO 2ND bimatoprost ...... 100 hydrochlorothiazide ..... 32 GEN ...... 89 bisoprolol fumarate ...... 54 carbamazepine ...... 17 BD PEN NEEDLE NANO U/F bisoprolol- carbamazepine er ...... 17 ...... 89 hydrochlorothiazide .... 35 carbidopa ...... 47 bleomycin sulfate ...... 42 carbidopa-levodopa ...... 47

115 carbidopa-levodopa er .... 47 cinacalcet hcl ...... 76 CORTISPORIN-TC ...... 101 carbinoxamine maleate ... 29 CIPRO ...... 78 COSENTYX...... 68 carboplatin ...... 38 CIPRO HC ...... 101 COSENTYX (300 MG DOSE) carisoprodol ...... 95 ciprofloxacin hcl ...... 78, 97 ...... 68 carmustine ...... 45 ciprofloxacin- COSENTYX SENSOREADY carteolol hcl ...... 96 dexamethasone ...... 101 (300 MG) ...... 68 CARTIA XT ...... 55 cisplatin ...... 39 COSENTYX SENSOREADY carvedilol ...... 54 citalopram hydrobromide 20 PEN ...... 68 CAYA ...... 86 CITRANATAL B-CALM ..... 95 CREON ...... 74 cefaclor ...... 58 CITRANATAL RX ...... 95 CRESEMBA ...... 29 cefadroxil ...... 58 CLARAVIS ...... 66 CRINONE ...... 113 cefdinir ...... 59 clarithromycin ...... 85 CRIXIVAN ...... 51 cefditoren pivoxil ...... 59 clarithromycin er ...... 85 cromolyn sodium ...... 79, 97 cefixime ...... 59 clemastine fumarate ...... 29 CROTAN ...... 73 cefpodoxime proxetil ...... 59 CLEOCIN ...... 113 cyanocobalamin...... 83 cefprozil ...... 58 clindamycin hcl ...... 36 CYCLAFEM 1/35 ...... 60 ceftriaxone sodium ...... 59 clindamycin palmitate hcl 36 CYCLAFEM 7/7/7 ...... 63 cefuroxime axetil ...... 59 clindamycin phos-benzoyl cyclobenzaprine hcl ...... 95 celecoxib ...... 4 perox ...... 66 cyclopentolate hcl ...... 97 CELONTIN ...... 19 clindamycin phosphate .. 66, cyclophosphamide ...... 44 cephalexin ...... 58 113 CYCLOSET ...... 22 cetirizine hcl ...... 29 clobazam ...... 17 cyclosporine ...... 92 cevimeline hcl ...... 94 clobetasol propionate ..... 70 cyclosporine modified ..... 92 CHANTIX ...... 105 clocortolone pivalate ...... 70 cyproheptadine hcl ...... 30 CHANTIX CONTINUING clomipramine hcl ...... 21 CYSTADANE ...... 76 MONTH PAK ...... 105 clonazepam ...... 17 CYSTAGON ...... 81 CHANTIX STARTING MONTH clonidine ...... 34 cytarabine (pf) ...... 39 PAK ...... 105 clonidine hcl ...... 34 CYTRA-3 ...... 81 CHATEAL ...... 60 clopidogrel bisulfate .. 82, 83 D CHEMET ...... 27 clorazepate dipotassium . 11 dacarbazine ...... 42 CHEMSTRIP 9 ...... 74 clotrimazole ...... 72, 93 dalfampridine er ...... 104 cheratussin ac ...... 64 clotrimazole-betamethasone DALIRESP ...... 14 chlordiazepoxide hcl ...... 11 ...... 67 danazol ...... 9 chlordiazepoxide- clozapine ...... 48 dantrolene sodium ...... 95 amitriptyline ...... 103 COARTEM ...... 37 dapsone ...... 36 chlorhexidine gluconate... 94 codeine sulfate ...... 7 DAPTACEL ...... 107 chloroquine phosphate .... 37 colchicine ...... 81 darifenacin hydrobromide er chlorothiazide ...... 75 colchicine-probenecid ..... 81 ...... 109 chlorpromazine hcl ...... 49 colestipol hcl...... 30 DASETTA 1/35 ...... 60 chlorthalidone...... 75 COLOCORT ...... 10 DASETTA 7/7/7 ...... 63 chlorzoxazone ...... 95 COMBIGAN ...... 96 DDAVP RHINAL TUBE ..... 77 cholestyramine ...... 30 COMETRIQ (100 MG DAILY deferiprone ...... 27 cholestyramine light ...... 30 DOSE) ...... 42 DELYLA ...... 60 ciclopirox ...... 67 COMETRIQ (140 MG DAILY demeclocycline hcl ...... 106 ciclopirox olamine ...... 67 DOSE) ...... 42 DENAVIR ...... 69 cilostazol ...... 82 COMETRIQ (60 MG DAILY DEPO-MEDROL ...... 64 CILOXAN ...... 97 DOSE) ...... 42 desipramine hcl ...... 21 cimetidine ...... 108 COMPLERA ...... 50 desloratadine ...... 29 cimetidine hcl ...... 108 CORLANOR ...... 58 desmopressin ace spray CIMZIA ...... 80 CORLOPAM ...... 35 refrig ...... 77 CIMZIA PREFILLED ...... 80 cortisone acetate ...... 63 desmopressin acetate 77, 78 CIMZIA STARTER KIT...... 80 CORTISPORIN ...... 67 desmopressin acetate pf . 78

116 desonide ...... 70 dihydroergotamine mesylate efavirenz-emtricitab- desoximetasone ...... 70 ...... 90 tenofovir ...... 50 desvenlafaxine succinate er DILANTIN ...... 18 eletriptan hydrobromide . 91 ...... 21 diltiazem hcl ...... 56 ELIGARD ...... 43 dexamethasone ...... 64 diltiazem hcl er ...... 56 ELIQUIS ...... 15 DEXAMETHASONE diltiazem hcl er beads .... 56 ELIQUIS DVT/PE STARTER INTENSOL ...... 64 diltiazem hcl er coated PACK ...... 15 dexamethasone sodium beads ...... 56 ELLA ...... 62 phosphate ...... 64, 100 dilt-xr ...... 56 ELMIRON ...... 81 DEXCOM G4 PLAT PED dimethyl fumarate ...... 104 ELURYNG ...... 62 RCV/SHARE ...... 87 dimethyl fumarate starter EMCYT ...... 43 DEXCOM G4 PLAT PED pack ...... 104 EMGALITY ...... 90 RECEIVER ...... 87 DIPENTUM ...... 79 EMGALITY (300 MG DOSE) DEXCOM G4 PLATINUM diphenhydramine hcl ...... 29 ...... 90 RCV/SHARE ...... 87 diphenoxylate-atropine ... 27 EMOQUETTE ...... 60 DEXCOM G4 PLATINUM diphtheria-tetanus toxoids EMSAM ...... 19 RECEIVER ...... 87 dt ...... 107 emtricitabine...... 52 DEXCOM G4 PLATINUM dipyridamole ...... 82 emtricitabine-tenofovir df 50 TRANSMITTER ...... 87 disopyramide phosphate . 12 EMTRIVA ...... 52 DEXCOM G4 SENSOR ...... 87 disulfiram ...... 103 EMVERM ...... 10 DEXCOM G5 MOB/G4 PLAT divalproex sodium ...... 19 enalapril maleate ...... 32 SENSOR ...... 87 divalproex sodium er ..... 19 enalapril- DEXCOM G5 MOBILE docetaxel ...... 44 hydrochlorothiazide ..... 32 RECEIVER ...... 87 dofetilide...... 12 ENBREL ...... 6 DEXCOM G5 MOBILE donepezil hcl ...... 103 ENBREL MINI ...... 5 TRANSMITTER ...... 87 dorzolamide hcl ...... 98 ENBREL SURECLICK ...... 6 DEXCOM G5 RECEIVER KIT dorzolamide hcl-timolol mal ENDOCET ...... 8 ...... 87 ...... 96 ENGERIX-B ...... 111 DEXCOM G6 RECEIVER ... 87 DOTTI ...... 78 enoxaparin sodium ...... 16 DEXCOM G6 SENSOR ...... 87 doxazosin mesylate ...... 34 ENPRESSE-28 ...... 63 DEXCOM G6 TRANSMITTER doxepin hcl...... 21, 68, 84 ENSKYCE ...... 60 ...... 87 doxercalciferol ...... 77 entacapone ...... 47 DEXILANT ...... 109 doxorubicin hcl ...... 42 entecavir ...... 53 dexmethylphenidate hcl ... 2 doxorubicin hcl liposomal 42 ENTRESTO ...... 57 dexmethylphenidate hcl er 2 doxycycline hyclate ...... 106 enulose ...... 80 dextroamphetamine sulfate doxycycline monohydrate epinastine hcl ...... 97 ...... 1 ...... 106 epinephrine ...... 113 dextroamphetamine sulfate dronabinol ...... 28 EPIPEN JR 2-PAK ...... 113 er ...... 1 drospiren-eth estrad- epirubicin hcl ...... 42 DIASCREEN 10 ...... 87 levomefol ...... 60 EPIVIR HBV ...... 53 DIASTIX ...... 73 drospirenone-ethinyl eplerenone ...... 35 diazepam ...... 11 estradiol ...... 60 eprosartan mesylate ...... 34 diclofenac potassium ...... 4 duloxetine hcl ...... 21 eq allergy relief ...... 29 diclofenac sodium . 4, 67, 99 DUPIXENT ...... 69 ergoloid mesylates ...... 104 diclofenac sodium er ...... 4 DUREZOL ...... 100 ergotamine-caffeine ...... 90 diclofenac-misoprostol ..... 4 dutasteride ...... 80 erlotinib hcl ...... 41 dicloxacillin sodium ...... 102 DYSPORT ...... 96 ERRIN ...... 63 dicyclomine hcl ...... 108 E ERTACZO ...... 72 didanosine ...... 52 econazole nitrate ...... 72 ery ...... 66 DIFFERIN ...... 66 EDURANT ...... 52 ERY-TAB ...... 86 DIFICID ...... 86 efavirenz ...... 52 ERYTHROCIN STEARATE . 86 digoxin ...... 57 erythromycin ...... 66, 98

117 erythromycin base ...... 86 flavoxate hcl ...... 110 fosinopril sodium-hctz .... 32 erythromycin ethylsuccinate flecainide acetate ...... 12 FRAGMIN ...... 16 ...... 86 FLEXICHAMBER CHILD FREESTYLE LIBRE 14 DAY ESBRIET ...... 106 MASK/SMALL ...... 90 READER ...... 87 escitalopram oxalate ...... 20 FLOVENT DISKUS ...... 15 FREESTYLE LIBRE 14 DAY esomeprazole magnesium FLOVENT HFA ...... 15 SENSOR ...... 87 ...... 109 FLUAD ...... 111 FREESTYLE LIBRE 2 estazolam ...... 84 FLUAD QUADRIVALENT . 111 READER ...... 87 estradiol ...... 78, 113 FLUARIX QUADRIVALENT FREESTYLE LIBRE 2 estradiol valerate ...... 78 ...... 111 SENSOR ...... 87 estradiol-norethindrone acet FLUBLOK QUADRIVALENT FREESTYLE LIBRE READER ...... 78 ...... 111 ...... 87 ESTRING ...... 113 FLUCELVAX QUADRIVALENT FREESTYLE LIBRE SENSOR eszopiclone ...... 84 ...... 111 SYSTEM ...... 87 ethacrynic acid ...... 75 fluconazole ...... 29 frovatriptan succinate ..... 91 ethambutol hcl ...... 38 flucytosine ...... 28 fulvestrant ...... 43 ethosuximide ...... 19 fludrocortisone acetate ... 64 furosemide ...... 75 etodolac ...... 4 FLULAVAL QUADRIVALENT FUZEON ...... 51 etodolac er ...... 4 ...... 111 FYCOMPA ...... 16 etonogestrel-ethinyl flunisolide ...... 96 G estradiol ...... 62 fluocinolone acetonide ... 70, gabapentin ...... 17 etoposide ...... 44 101 galantamine hydrobromide etravirine ...... 52 fluocinolone acetonide scalp ...... 103 EUTHYROX ...... 106 ...... 70 galantamine hydrobromide everolimus ...... 41, 93 fluocinonide ...... 70 er ...... 103 EXELDERM ...... 72 fluoritab ...... 91 GARDASIL 9 ...... 111 exemestane ...... 43 fluorometholone ...... 100 gatifloxacin ...... 98 ezetimibe ...... 31 fluorouracil ...... 39, 67, 68 GAVILYTE-C ...... 84 ezetimibe-simvastatin ..... 31 fluoxetine hcl ...... 20 GAVILYTE-G ...... 84 F fluphenazine decanoate .. 49 GAVILYTE-N WITH FLAVOR FALMINA...... 60 fluphenazine hcl ...... 49 PACK ...... 85 famciclovir ...... 54 flurazepam hcl ...... 84 gemcitabine hcl ...... 39 famotidine ...... 108 flurbiprofen ...... 5 gemfibrozil ...... 31 FARYDAK ...... 41 flurbiprofen sodium...... 99 generlac ...... 80 FC2 FEMALE CONDOM ..... 86 flutamide ...... 39 GENTAK ...... 98 febuxostat ...... 82 fluticasone propionate70, 96 gentamicin in saline ...... 2 felbamate ...... 18 fluticasone-salmeterol .... 13 gentamicin sulfate 2, 67, 98 felodipine er ...... 56 fluvastatin sodium ...... 31 GENVOYA ...... 50 FEMCAP ...... 86 fluvoxamine maleate ...... 20 GIANVI ...... 60 fenofibrate ...... 30 FLUZONE HIGH-DOSE ... 111 GILENYA ...... 105 fenofibrate micronized .... 30 FLUZONE HIGH-DOSE GILOTRIF ...... 41 fenofibric acid ...... 30 QUADRIVALENT ...... 111 glatiramer acetate ...... 104 fenoprofen calcium ...... 4 FLUZONE QUADRIVALENT GLATOPA ...... 104 fentanyl ...... 7 ...... 111 GLEOSTINE ...... 45 FERRIPROX ...... 27 FML ...... 100 GLIADEL WAFER ...... 45 FETZIMA ...... 21 FOLBIC ...... 74 glimepiride ...... 26 fexofenadine hcl ...... 29 folic acid ...... 83 glipizide ...... 26 FIASP ...... 23 fondaparinux sodium ..... 16 glipizide er...... 26 FIASP FLEXTOUCH ...... 23 FOSAMAX PLUS D ...... 76 glipizide-metformin hcl ... 26 FIASP PENFILL ...... 23 fosamprenavir calcium ... 51 GLUCAGEN DIAGNOSTIC 73 FIBRICOR ...... 31 fosfomycin tromethamine 37 glucagon emergency ...... 22 finasteride ...... 80 fosinopril sodium ...... 32 glyburide ...... 26

118 glyburide micronized ...... 26 hydrocortisone ...... 64, 71 IPOL ...... 112 glyburide-metformin ...... 26 hydrocortisone acetate ... 10 ipratropium bromide . 14, 95 glycopyrrolate ...... 109 hydrocortisone butyr lipo ipratropium-albuterol ..... 13 GOLYTELY ...... 85 base ...... 71 irbesartan...... 34 goodsense aspirin ...... 6 hydrocortisone butyrate . 71 irbesartan- goodsense nicotine ...... 105 hydrocortisone valerate .. 71 hydrochlorothiazide ..... 33 granisetron hcl ...... 28 hydrocortisone-acetic acid ISENTRESS ...... 51 griseofulvin microsize ..... 28 ...... 101 isoniazid ...... 38 griseofulvin ultramicrosize hydromorphone hcl ...... 7 isosorbide dinitrate ...... 10 ...... 28 hydromorphone hcl er ...... 7 isosorbide mononitrate ... 10 guanfacine hcl ...... 34 hydroxychloroquine sulfate isosorbide mononitrate er 10 guanfacine hcl er ...... 1 ...... 37 isotretinoin ...... 66 guanidine hcl ...... 38 hydroxyurea ...... 42 isradipine ...... 56 GYNAZOLE-1 ...... 112 hydroxyzine hcl ...... 11 itraconazole ...... 29 H hydroxyzine pamoate ..... 11 ivermectin ...... 10, 73 HAILEY 1.5/30 ...... 60 hyoscyamine sulfate ..... 108 J HAILEY FE 1.5/30 ...... 60 HYQVIA ...... 101 JAKAFI ...... 43 halcinonide ...... 70 I janssen covid-19 vaccine halobetasol propionate ... 70, ibandronate sodium ...... 76 ...... 112 71 IBRANCE ...... 43 JANUMET ...... 22 HALOG ...... 71 ibuprofen ...... 5 JANUMET XR ...... 22 haloperidol ...... 48 icatibant acetate ...... 82 JANUVIA ...... 22 haloperidol decanoate ..... 48 ICLUSIG ...... 40 JARDIANCE ...... 25 haloperidol lactate ...... 48 icosapent ethyl ...... 30 JINTELI ...... 78 HAVRIX ...... 111 idarubicin hcl ...... 42 JOLESSA ...... 62 HEATHER ...... 63 ifosfamide ...... 44 JUNEL 1.5/30 ...... 60 heparin sodium (porcine) 16 imatinib mesylate ...... 40 JUNEL 1/20...... 60 heparin sodium (porcine) pf IMBRUVICA ...... 41 JUNEL FE 1.5/30 ...... 60 ...... 16 imipenem-cilastatin ...... 36 JUNEL FE 1/20 ...... 60 HERCEPTIN ...... 40 imipramine hcl ...... 21 K HIBERIX ...... 110 imiquimod ...... 72 ketoconazole ...... 28, 72 HOMATROPAIRE ...... 97 INCRELEX ...... 77 KETO-DIASTIX ...... 74 HUMIRA ...... 3, 4 indapamide ...... 75 ketoprofen ...... 5 HUMIRA PEDIATRIC indomethacin ...... 5 ketorolac tromethamine ... 5, CROHNS START ...... 3 INFANRIX ...... 107 99 HUMIRA PEN ...... 3 INLYTA ...... 45 KEVZARA ...... 4 HUMIRA PEN-CD/UC/HS insulin asp prot & asp KINRIX ...... 107 STARTER ...... 3 flexpen ...... 23 KIONEX ...... 93 HUMIRA PEN-PEDIATRIC UC insulin aspart ...... 23 KLOR-CON M15 ...... 92 START ...... 3 insulin aspart flexpen ..... 23 KLOR-CON M20 ...... 92 HUMIRA PEN-PS/UV/ADOL insulin aspart penfill ...... 23 KRISTALOSE ...... 85 HS START ...... 3 insulin aspart prot & aspart KURVELO ...... 60 HUMIRA PEN-PSOR/UVEIT ...... 23 KYLEENA ...... 63 STARTER ...... 3 INTELENCE ...... 52 L hydralazine hcl ...... 35 INTRAROSA ...... 112 labetalol hcl ...... 54 hydrochlorothiazide ...... 75 INTRON A ...... 43 lactulose ...... 85 hydrocodone bitartrate er . 7 INVEGA SUSTENNA ...... 48 LAMICTAL ODT ...... 17 hydrocodone- INVIRASE ...... 51 lamivudine ...... 52, 53 acetaminophen ...... 7 INVOKAMET ...... 26 lamivudine-zidovudine .... 50 hydrocodone-homatropine INVOKAMET XR ...... 26 lamotrigine ...... 17 ...... 64 INVOKANA ...... 25 lamotrigine er ...... 17 hydrocodone-ibuprofen .... 7 IOPIDINE ...... 99 lansoprazole ...... 109

119 LANTUS ...... 23 lidocaine hcl ...... 72 medroxyprogesterone LANTUS SOLOSTAR ...... 23 lidocaine hcl (cardiac) pf . 12 acetate ...... 62 lapatinib ditosylate ...... 42 lidocaine hcl mefenamic acid ...... 5 LARIN 1.5/30 ...... 60 urethral/mucosal ...... 72 mefloquine hcl ...... 37 LARIN FE 1.5/30 ...... 60 lidocaine viscous hcl ...... 93 megestrol acetate ...... 45 LASTACAFT ...... 97 lidocaine-prilocaine ...... 73 MEKINIST ...... 41 latanoprost ...... 100 LILETTA (52 MG) ...... 63 meloxicam ...... 5 LATUDA ...... 48 lindane ...... 73 melphalan ...... 44 leflunomide ...... 5 linezolid ...... 37 melphalan hcl ...... 44 LENVIMA (10 MG DAILY LINZESS ...... 79 memantine hcl ...... 104 DOSE) ...... 45 liothyronine sodium ...... 107 MENACTRA ...... 110 LENVIMA (12 MG DAILY lisinopril ...... 33 MENEST ...... 78 DOSE) ...... 45 lisinopril- MENTAX ...... 67 LENVIMA (14 MG DAILY hydrochlorothiazide .... 32 MENVEO ...... 110 DOSE) ...... 45 lithium ...... 48 meprobamate ...... 11 LENVIMA (18 MG DAILY lithium carbonate ...... 47 mercaptopurine ...... 39 DOSE) ...... 46 lithium carbonate er...... 47 meropenem ...... 36 LENVIMA (20 MG DAILY LIVALO ...... 31 mesalamine ...... 79 DOSE) ...... 46 loperamide hcl ...... 27 mesalamine er ...... 79 LENVIMA (24 MG DAILY lopinavir-ritonavir ...... 50 MESNEX ...... 45 DOSE) ...... 46 lorazepam ...... 11 metaproterenol sulfate ... 13 LENVIMA (4 MG DAILY losartan potassium ...... 34 metaxalone ...... 95 DOSE) ...... 46 losartan potassium-hctz . 33 metformin hcl ...... 22 LENVIMA (8 MG DAILY LOTEMAX ...... 100 metformin hcl er ...... 22 DOSE) ...... 46 loteprednol etabonate ... 100 methadone hcl ...... 7 LESSINA ...... 60 lovastatin ...... 31 METHADONE HCL INTENSOL letrozole ...... 43 LOW-OGESTREL ...... 61 ...... 7 leucovorin calcium ...... 43 loxapine succinate ...... 49 METHADOSE ...... 7 LEUKERAN ...... 44 lubiprostone ...... 79 methamphetamine hcl ...... 1 LEUKINE ...... 83 LUMIGAN ...... 100 methazolamide ...... 74 leuprolide acetate ...... 44 LUPRON DEPOT (1-MONTH) methenamine hippurate .. 37 levalbuterol hcl ...... 13 ...... 44 METHERGINE ...... 101 LEVEMIR ...... 23 LUPRON DEPOT (3-MONTH) methimazole ...... 106 LEVEMIR FLEXTOUCH ..... 23 ...... 44 methocarbamol ...... 95 levetiracetam ...... 17, 18 LUPRON DEPOT (4-MONTH) methotrexate ...... 39 levetiracetam er...... 17 ...... 44 methotrexate sodium ..... 40 levobunolol hcl ...... 96 LUPRON DEPOT (6-MONTH) methotrexate sodium (pf) 40 levocetirizine ...... 44 methoxsalen rapid ...... 68 dihydrochloride ...... 29 LUTERA ...... 61 methscopolamine bromide levofloxacin ...... 78, 98 LYLLANA ...... 78 ...... 109 levonorgest-eth estrad 91- LYSODREN ...... 39 methyldopa ...... 34 day ...... 62 M methylphenidate hcl ...... 2 levonorgestrel ...... 62 magnesium sulfate ...... 91 methylphenidate hcl er ..... 2 levonorgestrel-ethinyl malathion...... 73 methylphenidate hcl er (cd) estrad ...... 60 maprotiline hcl ...... 19 ...... 2 LEVORA 0.15/30 (28) ..... 61 marlissa ...... 61 methylphenidate hcl er (la) 2 levorphanol tartrate ...... 7 MARPLAN ...... 19 methylprednisolone ...... 64 LEVO-T ...... 107 MATULANE ...... 43 methyltestosterone ...... 9 levothyroxine sodium .... 107 MATZIM LA ...... 56 metoclopramide hcl ...... 79 LEVOXYL ...... 107 MAVYRET ...... 53 metolazone ...... 75 LEXIVA ...... 51 meclizine hcl ...... 28 metoprolol succinate er .. 55 lidocaine ...... 72 meclofenamate sodium .... 5 metoprolol tartrate ...... 55

120 metoprolol- nateglinide ...... 25 norethindrone-eth estradiol hydrochlorothiazide ..... 35 NATROBA ...... 73 ...... 78 metronidazole .. 35, 73, 113 NATURE-THROID ...... 107 norethin-eth estradiol-fe . 61 metronidazole in nacl ...... 35 NAYZILAM ...... 17 norgestimate-eth estradiol mexiletine hcl ...... 12 NECON 0.5/35 (28) ...... 61 ...... 61 MIACALCIN ...... 76 NECON 1/35 (28) ...... 61 norgestim-eth estrad MICROGESTIN FE 1.5/30 . 61 nefazodone hcl ...... 20 triphasic ...... 63 midodrine hcl ...... 113 neomycin sulfate ...... 2 NORPACE CR ...... 12 miglitol ...... 22 neomycin-polymyxin b gu 81 NORTREL 0.5/35 (28) ..... 61 MINITRAN ...... 10 neomycin-polymyxin- NORTREL 1/35 (21) ...... 61 minocycline hcl ...... 106 dexameth...... 99 NORTREL 7/7/7 ...... 63 minoxidil ...... 35 neomycin-polymyxin- nortriptyline hcl ...... 21 mirtazapine ...... 19 gramicidin ...... 98 NORVIR ...... 51 MIRVASO ...... 73 neomycin-polymyxin-hc 99, NOVOLIN 70/30 ...... 23 misoprostol ...... 109 101 NOVOLIN 70/30 FLEXPEN 23 MITIGARE ...... 82 NEUPRO ...... 47 NOVOLIN 70/30 FLEXPEN modafinil ...... 2 NEVANAC ...... 99 RELION ...... 23 moderna covid-19 vaccine nevirapine ...... 52 NOVOLIN 70/30 RELION . 23 ...... 112 nevirapine er ...... 52 NOVOLIN N...... 24 moexipril hcl ...... 33 NEXAVAR ...... 42 NOVOLIN N FLEXPEN ...... 24 mometasone furoate 71, 96 NEXPLANON ...... 62 NOVOLIN N FLEXPEN MONO-LINYAH ...... 61 niacin ...... 113 RELION ...... 23 montelukast sodium ...... 14 nicardipine hcl ...... 56 NOVOLIN N RELION ...... 24 morphine sulfate ...... 8 nicotine ...... 105 NOVOLIN R ...... 24 morphine sulfate nicotine polacrilex ...... 105 NOVOLIN R FLEXPEN ...... 24 (concentrate) ...... 7 nicotine step 3 ...... 105 NOVOLIN R FLEXPEN morphine sulfate (pf) ...... 8 NICOTROL ...... 105 RELION ...... 24 morphine sulfate er ...... 8 NICOTROL NS ...... 105 NOVOLIN R RELION ...... 24 MOTOFEN ...... 27 NIFEDICAL XL ...... 56 NOVOLOG ...... 24 moxifloxacin hcl ...... 78, 98 nifedipine er ...... 56 NOVOLOG 70/30 FLEXPEN multivitamin/fluoride ...... 94 nifedipine er osmotic RELION ...... 24 multi-vitamin/fluoride ..... 94 release ...... 56 NOVOLOG FLEXPEN ...... 24 multi-vitamin/fluoride/iron nilutamide ...... 39 NOVOLOG FLEXPEN RELION ...... 94 nimodipine ...... 56 ...... 24 mupirocin ...... 67 nisoldipine er ...... 56 NOVOLOG MIX 70/30 ..... 24 MVC-FLUORIDE...... 94 nitazoxanide ...... 36 NOVOLOG MIX 70/30 mycophenolate mofetil .... 93 NITRO-BID ...... 10 FLEXPEN ...... 24 mycophenolate sodium ... 93 NITRO-DUR ...... 10 NOVOLOG MIX 70/30 MYORISAN ...... 66 nitrofurantoin ...... 37 RELION ...... 24 N nitrofurantoin macrocrystal NOVOLOG PENFILL ...... 24 nabumetone ...... 5 ...... 37 NOVOLOG RELION ...... 24 nadolol ...... 55 nitrofurantoin monohyd np thyroid ...... 107 naftifine hcl ...... 67 macro ...... 37 NUCYNTA ER ...... 8 nalbuphine hcl ...... 9 nitroglycerin ...... 11 NURTEC ...... 90 naloxone hcl ...... 27 nitroglycerin er ...... 10 NYAMYC ...... 67 naltrexone hcl ...... 27 nitroglycerin in d5w ...... 11 nystatin ...... 28, 67, 94 naproxen ...... 5 nizatidine ...... 108 nystatin-triamcinolone .... 67 naproxen dr ...... 5 NORA-BE ...... 63 NYSTOP ...... 67 naproxen sodium ...... 5 norethin ace-eth estrad-fe O naratriptan hcl ...... 91 ...... 61 octreotide acetate ...... 77 NARCAN ...... 27 norethindrone acetate ... 102 ofloxacin ...... 78, 98, 100 NATACYN ...... 98 olanzapine ...... 50

121 olmesartan medoxomil .... 34 OSMOPREP ...... 85 perphenazine ...... 49 olmesartan medoxomil-hctz OTEZLA ...... 5 perphenazine-amitriptyline ...... 33 oxaliplatin ...... 39 ...... 104 olmesartan-amlodipine-hctz oxandrolone ...... 9 pfizer-biontech covid-19 ...... 34 oxaprozin ...... 5 vacc ...... 112 olopatadine hcl ...... 95 oxazepam ...... 11 phenazopyridine hcl ...... 81 omega-3-acid ethyl esters oxcarbazepine ...... 18 phenelzine sulfate ...... 19 ...... 30 oxiconazole nitrate ...... 72 phenobarbital ...... 84 omeprazole ...... 109 OXISTAT ...... 72 phenoxybenzamine hcl ... 33 OMNARIS ...... 96 oxybutynin chloride ...... 109 phenytoin ...... 18 OMNIFLEX DIAPHRAGM ... 86 oxybutynin chloride er ... 109 phenytoin sodium ...... 18 OMNITROPE ...... 76 oxycodone hcl ...... 8 phenytoin sodium extended ondansetron ...... 28 oxycodone-acetaminophen ...... 18 ondansetron hcl ...... 28 ...... 8, 9 PHOSLYRA ...... 80 ONETOUCH DELICA oxycodone-aspirin ...... 9 PHOSPHOLINE IODIDE ... 97 LANCETS 30G ...... 87 oxycodone-ibuprofen ...... 9 phytonadione ...... 113 ONETOUCH DELICA oxymorphone hcl ...... 8 pilocarpine hcl ...... 94, 97 LANCETS 33G ...... 87 oxymorphone hcl er ...... 8 pimecrolimus ...... 72 ONETOUCH DELICA oxytocin ...... 101 pimozide ...... 104 LANCING DEV ...... 87 OZEMPIC (0.25 OR 0.5 pindolol ...... 55 ONETOUCH DELICA PLUS MG/DOSE) ...... 25 pioglitazone hcl ...... 27 LANCET30G ...... 87 OZEMPIC (1 MG/DOSE) .. 25 pioglitazone hcl-glimepiride ONETOUCH DELICA PLUS P ...... 26 LANCET33G ...... 87 paliperidone er ...... 48 pioglitazone hcl-metformin ONETOUCH DELICA PLUS pamidronate disodium .... 76 hcl ...... 27 LANCING ...... 88 pantoprazole sodium ..... 109 PIRMELLA 1/35 ...... 61 ONETOUCH SURESOFT PARAGARD INTRAUTERINE PIRMELLA 7/7/7 ...... 63 LANCING DEV ...... 88 COPPER ...... 62 piroxicam ...... 5 ONETOUCH ULTRA ...... 74 paricalcitol ...... 77 PNEUMOVAX 23 ...... 110 ONETOUCH ULTRA 2 ...... 88 paroxetine hcl ...... 20 podofilox ...... 72 ONETOUCH ULTRA paroxetine hcl er ...... 20 polyethylene glycol 3350 85 CONTROL ...... 88 PASER ...... 38 polymyxin b sulfate ...... 37 ONETOUCH ULTRA MINI .. 88 PAXIL ...... 20 polymyxin b-trimethoprim ONETOUCH ULTRASOFT PEDIARIX ...... 107 ...... 98 LANCETS ...... 88 PEDIATRIC PANDA MASK 90 poly-vitamin/fluoride ...... 94 ONETOUCH VERIO.... 74, 88 PEDVAX HIB ...... 110 POMALYST ...... 41 ONETOUCH VERIO FLEX peg-3350/electrolytes .... 85 PORTIA-28 ...... 61 SYSTEM ...... 88 peg- posaconazole ...... 29 ONETOUCH VERIO IQ 3350/electrolytes/ascorba potassium chloride ...... 92 SYSTEM ...... 88 t ...... 85 potassium chloride crys er ONETOUCH VERIO REFLECT PEGANONE ...... 18 ...... 92 ...... 88 PEGASYS ...... 53 potassium chloride er ..... 92 ONGLYZA ...... 22 PEGINTRON ...... 54 potassium citrate er ...... 81 OPSUMIT ...... 57 peg-kcl-nacl-nasulf-na asc-c potassium citrate-citric acid OPTICHAMBER FACE MASK- ...... 85 ...... 81 SMALL ...... 90 penicillamine ...... 92 PRADAXA ...... 16 OPTIONS CONCEPTROL . 112 penicillin v potassium .... 102 PRALUENT ...... 31 ORENITRAM ...... 57 PENTACEL ...... 108 pramipexole dihydrochloride ORKAMBI ...... 105 pentamidine isethionate . 35 ...... 47 orphenadrine citrate er ... 95 pentoxifylline er ...... 82 pramipexole dihydrochloride ORSYTHIA ...... 61 perindopril erbumine ...... 33 er ...... 47 oseltamivir phosphate ..... 54 permethrin ...... 73 prasugrel hcl ...... 83

122 pravastatin sodium ...... 31 pyrazinamide ...... 38 ropinirole hcl ...... 47 prazosin hcl...... 34 pyridostigmine bromide .. 38 ropinirole hcl er ...... 47 PRED MILD ...... 100 pyridostigmine bromide er rosuvastatin calcium ...... 31 prednicarbate ...... 71 ...... 38 ROTARIX ...... 112 prednisolone ...... 64 pyridoxine hcl ...... 113 ROTATEQ ...... 112 prednisolone acetate .... 100 pyrimethamine ...... 37 rufinamide ...... 18 prednisolone sodium Q RYBELSUS ...... 25 phosphate ...... 64, 100 quetiapine fumarate...... 48 S prednisone ...... 64 quinapril hcl ...... 33 salsalate ...... 6 PREDNISONE INTENSOL .. 64 quinapril- SANDIMMUNE ...... 92 pregabalin ...... 18 hydrochlorothiazide .... 32 SANTYL ...... 71 PRENATABS RX ...... 95 quinidine gluconate er .... 12 SAVELLA ...... 103 PREVNAR 13...... 110 quinidine sulfate ...... 12 scopolamine ...... 28 PREZCOBIX ...... 50 quinine sulfate ...... 37 selegiline hcl ...... 46 PREZISTA ...... 51, 52 QVAR REDIHALER ...... 15 selenium sulfide ...... 68, 69 PRIFTIN ...... 38 R SELZENTRY ...... 51 primaquine phosphate .... 37 rabeprazole sodium ...... 109 SEREVENT DISKUS ...... 13 primidone ...... 18 raloxifene hcl ...... 77 sertraline hcl ...... 20 probenecid ...... 82 ramelteon ...... 84 sevelamer carbonate ...... 80 procainamide hcl ...... 12 ramipril...... 33 sevelamer hcl ...... 80 prochlorperazine ...... 49 ranitidine hcl ...... 108 SHINGRIX ...... 112 prochlorperazine edisylate ranolazine er ...... 10 SIGNIFOR ...... 77 ...... 49 rasagiline mesylate ...... 46 SIGNIFOR LAR ...... 77 prochlorperazine maleate 49 RECLIPSEN ...... 61 sildenafil citrate ...... 58 PROCRIT ...... 83 RECOMBIVAX HB ...... 112 silodosin ...... 80 PROCTO-PAK ...... 10 RECTIV ...... 10 silver sulfadiazine ...... 69 PROCTOZONE-HC ...... 10 REGONOL...... 38 SIMBRINZA ...... 96 progesterone ...... 102 REGRANEX ...... 73 simvastatin ...... 31 progesterone micronized 102 RELENZA DISKHALER ..... 54 sirolimus ...... 93 PROLIA ...... 77 RENACIDIN ...... 81 SIRTURO ...... 38 PROMACTA ...... 83 repaglinide ...... 25 SIVEXTRO ...... 37 promethazine hcl ...... 30 REPATHA ...... 32 SKYLA ...... 63 promethazine vc ...... 65 REPATHA PUSHTRONEX SKYRIZI ...... 68 promethazine vc plain ..... 65 SYSTEM ...... 31 SKYRIZI (150 MG DOSE) 68 promethazine vc/codeine . 65 REPATHA SURECLICK ..... 32 SKYRIZI PEN ...... 68 promethazine-codeine .... 65 RESTASIS ...... 98 sod citrate-citric acid ...... 81 promethazine-dm ...... 65 REVLIMID ...... 92, 93 sodium chloride ...... 65, 92 promethazine- REXULTI ...... 50 sodium fluoride ...... 91 phenylephrine ...... 65 ribavirin ...... 54 sodium polystyrene PROMETHEGAN ...... 30 RIDAURA ...... 4 sulfonate ...... 93 propafenone hcl ...... 12 rifabutin ...... 38 sofosbuvir-velpatasvir .... 53 propafenone hcl er ...... 12 RIFAMATE ...... 38 solifenacin succinate .... 109 proparacaine hcl ...... 99 rifampin ...... 38 SOMATULINE DEPOT ...... 77 propranolol hcl ...... 55 RIFATER ...... 38 SOMAVERT ...... 76 propranolol hcl er ...... 55 riluzole ...... 96 sorbitol ...... 81 propranolol-hctz ...... 35 rimantadine hcl ...... 54 sorbitol-mannitol ...... 81 propylthiouracil ...... 106 RINVOQ ...... 3 SORINE ...... 55 PROQUAD ...... 110 risedronate sodium ...... 76 sotalol hcl ...... 55 protriptyline hcl ...... 21 risperidone ...... 48 sotalol hcl (af) ...... 55 pseudoeph-bromphen-dm 65 ritonavir ...... 52 spinosad ...... 73 PULMICORT FLEXHALER .. 15 rivastigmine tartrate ..... 103 SPIRIVA HANDIHALER .... 14 PULMOZYME ...... 106 rizatriptan benzoate ...... 91 SPIRIVA RESPIMAT ...... 14

123 spironolactone ...... 75 TENCON ...... 6 tranylcypromine sulfate .. 19 spironolactone-hctz ...... 74 teniposide ...... 44 travoprost (bak free) .... 100 SPRINTEC 28 ...... 61 TENIVAC ...... 108 trazodone hcl ...... 20 SPRYCEL ...... 40 tenofovir disoproxil TRECATOR ...... 38 SRONYX ...... 61 fumarate ...... 53 TRELEGY ELLIPTA ...... 13 SSD ...... 69 terazosin hcl ...... 34 TRESIBA ...... 25 SSKI ...... 65 terbinafine hcl ...... 28 TRESIBA FLEXTOUCH ..... 25 stavudine ...... 53 terbutaline sulfate .... 13, 14 tretinoin ...... 45, 66 STELARA ...... 68 terconazole ...... 112 triamcinolone acetonide . 71, STIVARGA...... 42 testosterone ...... 9 94, 96 streptomycin sulfate ...... 2 testosterone cypionate ..... 9 triamterene ...... 75 STRIBILD ...... 50 testosterone enanthate .... 9 triamterene-hctz...... 75 sucralfate ...... 108 tetrabenazine ...... 103 triazolam ...... 84 sulfacetamide sodium ... 100 tetracycline hcl ...... 106 trifluoperazine hcl ...... 49 sulfacetamide-prednisolone THALOMID ...... 92 trifluridine ...... 98 ...... 99 theophylline ...... 15 trihexyphenidyl hcl ...... 46 sulfadiazine ...... 106 theophylline er ...... 15 trimethobenzamide hcl ... 28 sulfamethoxazole- thioridazine hcl ...... 49 trimethoprim ...... 36 trimethoprim ...... 36 thiothixene ...... 50 trimipramine maleate ..... 21 SULFAMYLON ...... 69 thyroid ...... 107 TRINTELLIX ...... 20 sulfasalazine ...... 80 THYROLAR-1/4...... 107 TRI-SPRINTEC ...... 63 sulindac ...... 5 tiagabine hcl ...... 18 tri-vitamin/fluoride ...... 94 sumatriptan ...... 91 timolol maleate ... 55, 96, 97 tri-vite/fluoride ...... 94 sumatriptan succinate ..... 91 tinidazole ...... 36 TRIVORA (28) ...... 63 SUPRAX ...... 59 TIS-U-SOL ...... 93 tropicamide ...... 97 SUPREP BOWEL PREP KIT 85 TIVICAY ...... 51 trospium chloride ...... 110 SUTENT ...... 42 tizanidine hcl ...... 95 trospium chloride er ..... 110 SYEDA ...... 61 TOBRADEX ...... 99 TRULICITY ...... 25 SYMDEKO ...... 105 tobramycin ...... 2, 98 TRUMENBA ...... 110 SYNAGIS ...... 101 tobramycin sulfate ...... 3 TUZISTRA XR ...... 65 SYNAREL ...... 77 tobramycin-dexamethasone TWINRIX ...... 110 SYNJARDY ...... 26 ...... 100 U SYNJARDY XR ...... 26 TODAY SPONGE ...... 112 UBRELVY ...... 90 SYNTHROID ...... 107 tolcapone ...... 46 ULESFIA ...... 73 T tolmetin sodium ...... 5 UNITHROID ...... 107 TABLOID ...... 40 tolterodine tartrate ...... 109 UPTRAVI ...... 58 tacrolimus ...... 72, 93 tolterodine tartrate er ... 109 ursodiol ...... 79 tadalafil ...... 58 topiramate ...... 18 V tadalafil (pah) ...... 58 topotecan hcl ...... 45 valacyclovir hcl ...... 54 TAFINLAR ...... 40 toremifene citrate ...... 39 valganciclovir hcl ...... 53 TAKE ACTION ...... 62 torsemide ...... 75 valproic acid ...... 19 tamoxifen citrate ...... 39 TOUJEO MAX SOLOSTAR 24 valsartan ...... 34 tamsulosin hcl ...... 80 TOUJEO SOLOSTAR ...... 25 valsartan- TASIGNA ...... 40 TOVIAZ...... 109 hydrochlorothiazide ..... 33 TAZORAC ...... 68 TRADJENTA ...... 22 vancomycin hcl ...... 36 TAZTIA XT ...... 56 tramadol hcl ...... 8 VAQTA ...... 112 TDVAX ...... 108 tramadol hcl er ...... 8 VARIVAX ...... 112 telmisartan ...... 34 tramadol hcl er (biphasic) . 8 VCF VAGINAL telmisartan-hctz...... 33 trandolapril ...... 33 CONTRACEPTIVE ...... 113 temazepam ...... 84 trandolapril-verapamil hcl er VELIVET ...... 63 TEMODAR ...... 43 ...... 32 VEMLIDY ...... 53 temozolomide ...... 43 tranexamic acid ...... 84 venlafaxine hcl ...... 21

124 venlafaxine hcl er ...... 21 WELCHOL ...... 30 Z VENTAVIS ...... 57 WESTHROID ...... 107 zafirlukast ...... 14 VENTOLIN HFA ...... 14 WIDE-SEAL DIAPHRAGM 60 zaleplon ...... 84 verapamil hcl ...... 56, 57 ...... 86 ZARAH ...... 61 verapamil hcl er ...... 56 WIDE-SEAL DIAPHRAGM 65 ZARXIO ...... 83 VICTOZA ...... 25 ...... 86 ZENATANE ...... 66 VIDEX ...... 52 WIDE-SEAL DIAPHRAGM 70 ZENPEP ...... 74 vigabatrin ...... 18 ...... 86 ZERVIATE ...... 97 VIIBRYD ...... 20 WIDE-SEAL DIAPHRAGM 75 zidovudine ...... 53 VIIBRYD STARTER PACK . 20 ...... 86 ZIEXTENZO ...... 83 VIMPAT ...... 18 WIDE-SEAL DIAPHRAGM 80 zileuton er ...... 12 vinblastine sulfate ...... 44 ...... 86 ZIOPTAN ...... 100 vincristine sulfate ...... 44 WIDE-SEAL DIAPHRAGM 85 ziprasidone hcl ...... 48 vinorelbine tartrate ...... 44 ...... 87 ZIRGAN ...... 98 VIRACEPT ...... 52 WIDE-SEAL DIAPHRAGM 90 ZOLINZA ...... 41 VIREAD ...... 53 ...... 87 zolmitriptan ...... 91 vitamin d (ergocalciferol) WIDE-SEAL DIAPHRAGM 95 zolpidem tartrate ...... 84 ...... 113 ...... 87 zolpidem tartrate er ...... 84 vitamin d3 ...... 113 X zonisamide ...... 18 vitamins acd-fluoride ...... 94 XALKORI ...... 40 ZONTIVITY ...... 82 VIVITROL ...... 27 XARELTO ...... 16 ZOSTAVAX ...... 112 voriconazole ...... 29 XARELTO STARTER PACK 16 ZOVIA 1/35E (28) ...... 61 VOSEVI ...... 53 XIFAXAN ...... 36 ZYDELIG ...... 45 VOTRIENT ...... 42 XULANE ...... 62 ZYKADIA ...... 40 VYVANSE ...... 1 XULTOPHY ...... 25 W Y warfarin sodium ...... 15 YALE DISP NEEDLES ...... 90

125