Preferred Drug List (PDL)

New York – Medicaid Effective Date: 7/1/2021

NOTICE OF NON-DISCRIMINATION

UnitedHealthcare Community Plan complies with Federal civil rights laws. UnitedHealthcare Community Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

UnitedHealthcare Community Plan provides the following: • Free aids and services to people with disabilities to help you communicate with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Free language services to people whose first language is not English, such as: – Qualified interpreters – Information written in other languages

If you need these services, please call the toll-free member phone number listed on your member ID card.

If you believe that UnitedHealthcare Community Plan has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with Civil Rights Coordinator by: • Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

• Email: [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C. 20201

Phone: Toll-free 1-800-868-1019, 1-800-537-7697 (TDD) We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call Member Services at 1-800-493-4647, TTY 711, Monday – Friday 8:00 a.m. to 6:00 p.m.

CSNY15MC3978405_000 - Medicaid NOTIFICACIÓN DE LA NO-DISCRIMINACIÓN

UnitedHealthcare Community Plan cumple con los requisitos fijados por las leyes Federales de los derechos civiles. UnitedHealthcare Community Plan no excluye a las personas o las trata de manera diferente debido a su raza, color, nacionalidad, edad, discapacidad o sexo.

UnitedHealthcare Community Plan provee lo siguiente: • Asistencia y servicios gratuitos de ayuda para las personas con discapacidades en su comunicación con nosotros, con: – Interpretes calificados en el lenguaje de señas – Información por escrito en diferentes formatos (letras de mayor tamaño, audición, formatos electrónicos accesibles, otros formatos) • Servicios gratuitos con diversos idiomas para personas para quienes el inglés no es su lengua materna, como: – Interpretes calificados – Información impresa en diversos idiomas

Si usted necesita estos servicios, por favor llame gratuitamente al número anotado en su tarjeta de identificación como miembro.

Si usted piensa que UnitedHealthcare Community Plan no le ha brindado estos servicios o le han tratado a usted de manera diferente debido a su raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja ante el Coordinador de los Derechos Civiles (Civil Rights Coordinator) haciéndolo por: • Correo: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

• Correo electrónico: [email protected]

Usted también puede presentar una queja acerca de sus derechos civiles ante el Departamento de Salud y Servicios Humanos de los Estados Unidos, Oficina de Derechos Civiles, haciendo por: Internet: Sitio en Imternet para la Oficina de Derechos Civiles en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Correo: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C. 20201

Teléfono: Gratuitamente al 1-800-868-1019, 1-800-537-7697 (TDD)

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame a Servicios para Miembros al 1-800-493-4647, TTY 711, de lunes a viernes, 8:00 a.m. a 6:00 p.m.

UnitedHealthcare Community Plan List of Preferred Drugs

Frequently Asked Questions (FAQ) Find answers here to questions you have about this UnitedHealthcare Community Plan List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1 What drugs are on the Preferred Drug List? (We call the Preferred Drug List the “Drug List” for short.) The drugs on Preferred Drug List that starts on page <3> are the drugs covered by UnitedHealthcare Community Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

UnitedHealthcare will cover all medically necessary drugs if: · your doctor or other prescriber says you need them to get better or stay healthy, and · you fill the prescription at a UnitedHealthcare Community Plan network pharmacy. UnitedHealthcare may have additional steps to access certain drugs (see question <#5> below). You can also see an up-to-date drug list on our website at or call Member Services at <1-888-617-8979> TTY 711.

2 Does the Drug List ever change? Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: · a cheaper drug comes along that works as well as a drug on the Drug List now, or · we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: · Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Community Plan before you can get a drug.) · Add or change the amount of a drug you can get (called “quantity limits”).

9/28/2016 · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see pages <4, 5 and 9>. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check the up-to-date Drug List online at You can also call Member Services to check the current Drug List at <1-888-617-8979, TTY 711>.

3 What happens when another drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because another drug that works just as well is available, we will tell you. You will get a letter letting you know about the change. We will also tell you what alternate drugs are available to you. Contact your doctor or other prescriber to make sure another drug will work for you.

4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases your doctor must do something before you can get the drug. For example: · Prior approval (or prior authorization): For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. · Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug you can get. · Step therapy: Sometimes UnitedHealthcare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If

9/28/2016 your doctor thinks the first drug doesn’t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages <3-106>. You can also get more information by visiting our website at . We have posted online documents that explain our prior authorization and step therapy restrictions. You may also call Member Services and ask us to send you information about our prior authorization and step therapy restrictions.

6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The Preferred Drug List on pages <3-106> has a column labeled “Requirements and Limits.”

7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you before the restriction is added.. This gives you time to talk to your doctor or other prescriber about what to do next.

8 How can you find a drug on the Drug List? There are two ways to find a drug: · You can search by medical condition. To search by medical condition, find the section labeled “List of drugs by medical condition” on pages <3-106>. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. · You can also search for drugs alphabetically. To search alphabetically, go to the starting on page <107> Find the name of your drug. The page number where you can find the drug will be next to it.

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9 What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services and ask about it. If you learn that UnitedHealthcare does not prefer the drug, you can do one of these things: · Ask Member Services for a list of drugs that are similar to the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or · You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

10 What if you just joined UnitedHealthcare Community Plan and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to request an exception.

11Can you ask for an exception to cover your drug? Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to cover a drug that is not on the Drug List. Your doctor can also ask us to change the rules on your drug. · For example, we may limit the amount of a drug we will cover. If your drug has a limit, your doctor can ask us to change the limit and cover more. · Other examples: Your doctor can ask us to drop step therapy restrictions or prior approval requirements.

12 How long does it take to get an exception? First, we must receive some information from your doctor supporting your request for an exception. After we receive the information, we will give you a decision on your exception request within the timeframes required by the state, generally within 24 hours.

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13 How can you ask for an exception? To ask for an exception, you can do one of two things: - Call Member Services. A Member Services representative will work with you and your doctor to help ask for an exception. - Call your doctor and ask them to request an exception by calling the Prior Notification Service at <1-800-310-6826<, or they can fax a request to<866-940- 7328>.

14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). In most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand name drug is medically necessary, you will need to ask your doctor to submit for prior approval.

15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs are preferred.

16 Does UnitedHealthcare cover OTC non-drug products? UnitedHealthcare covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC non- drug products are covered.

17 What is a Specialty Pharmacy Medication? A specialty pharmacy medication is a drug that generally has one or more of the following characteristics:  It’s used by a small number of people

9/28/2016  It treats rare, chronic, and/or potentially life-threatening diseases  It has special storage or handling requirements such as needing to be refrigerated  It may need close monitoring, ongoing clinical support and management, and complete patient education and engagement  It’s a high cost medication  It may not be available at retail pharmacies  It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network. If you have questions, call Member Services at <1-888-617-8979, TTY 711>.

List of Preferred Drugs The List of Preferred Drugs that begins gives you information about the drugs covered by UnitedHealthcare Community Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page <107> . The first column of the chart lists the generic name of the drug. The second column of the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR). The third column in the list tells you if the preferred drug covered is the brand or generic version. The information in the “Requirements & Limits” column tells you if UnitedHealthcare has any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization) For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare Community Plan before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Community Plan limits the amount of a drug you can get.

9/28/2016 ST - Step therapy Sometimes UnitedHealthcare Community Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then your doctor can ask for approval to cover the second.

Other special requirements for coverage

SP – Specialty Pharmacy Drug needs to be accessed through a network Specialty Pharmacy. Specialty Pharmacy Drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.

Drug Tiers

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

[ABBREVIATIONS]

OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy

[You can find information on what the symbols and abbreviations in this table mean by going to page <3-106 in the footnotes>]

9/28/2016 Table of Contents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 3 Anesthetics - Drugs for Numbing...... 12 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence...... 13 Antibacterials...... 15 Antibacterials - Drugs to Treat Bacterial Infections...... 15 Anticonvulsants - Drugs to Treat Seizures...... 19 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia...... 21 Antidepressants - Drugs to Treat Depression...... 22 Antiemetics - Drugs to Treat Nausea and Vomiting...... 24 Antifungals - Drugs to Treat Fungal Infections...... 25 Antigout Agents - Drugs to Treat Gout...... 27 Antimigraine Agents - Drugs to Treat Migraines...... 28 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis...... 28 Antimycobacterials - Drugs to Treat Infections...... 29 Antineoplastics - Drugs to Treat Cancer...... 29 Antiparasitics - Drugs to Treat Parasitic Infections...... 34 Antiparkinson Agents - Drugs to Treat Parkinson's Disease...... 35 Antipsychotics - Drugs to Treat Mood Disorders...... 36 Antivirals - Drugs to Treat Viral Infections...... 38 Anxiolytics - Drugs to Treat Anxiety...... 42 Bipolar Agents - Drugs to Treat Mood Disorders...... 43 Blood Glucose Regulators - Drugs to Regulate Blood Sugar...... 43 Blood Products and Modifiers...... 46 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders...... 47 Cardiovascular Agents...... 48 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions...... 48 Central Nervous System Agents...... 54 Central Nervous System Agents - Drugs to Treat Nerve Conditions...... 55 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions...... 57 Dermatological Agents - Drugs to Treat Skin Conditions...... 58 Electrolytes/Minerals/Metals/Vitamins...... 64 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions...... 74 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 90 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...... 91 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones...... 92 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones...... 93 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones...... 94 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones...... 94 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones...... 101 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones...... 101 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones...... 101 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones...... 102 Immunological Agents - Drugs that Stimulate or Suppress the Immune System...... 102 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease...... 105 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions...... 105 Metabolic Bone Disease Agents - Other...... 106 Miscellaneous Therapeutic Agents...... 106 Ophthalmic Agents - Drugs to Treat Eye Conditions...... 108 Otic Agents - Drugs to Treat Ear Conditions...... 114 Regulators - Drugs to Regulate Blood Sugar...... 115 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 116 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm...... 134 Sleep Disorder Agents - Drugs for Sedation and Sleep...... 135 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies...... 135

2 Preferred Agents Non-Preferred Agents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen childrens - Tier 1; QL acetaminophen childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 3 Preferred Agents Non-Preferred Agents acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml - Tier 1; QL acetaminophen oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1; QL arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL bac (generic for BAC) - Tier 1; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1; QL butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1; QL butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL butalbital-aspirin-caffeine - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents capsaicin cream 0.025 % external (generic for DERMACINRX PENETRAL) - Tier 1; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1; QL childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for gnp headache relief extra str) - Tier 2 EXCEDRIN MIGRAINE (brand for gnp headache relief extra str) - Tier 2 fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1; QL fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL FEVERALL INFANTS - Tier 2; QL FEVERALL JUNIOR STRENGTH - Tier 2; QL headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL mapap oral capsule - Tier 1; QL migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1; QL non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever (generic for PHARBETOL) - Tier 1; QL pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain reliever extra strength oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 PANADOL CHILDRENS (brand for childrens acetaminophen) - Tier 2; QL PANADOL EXTRA STRENGTH (brand for ra pain relief acetaminophen) - Tier 2; QL PANADOL INFANTS (brand for childrens acetaminophen) - Tier 2; QL PHARBETOL EXTRA STRENGTH (brand for ra pain relief acetaminophen) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 7 Preferred Agents Non-Preferred Agents PHARBETOL ORAL TABLET 325 MG (brand for eql acetaminophen) - Tier 2; QL sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1; QL TENCON (brand for butalbital-acetaminophen) - Tier 2; QL TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for childrens acetaminophen) - Tier 2; QL TYLENOL ORAL TABLET 325 MG (brand for eql acetaminophen) - Tier 2; QL TYLENOL ORAL TABLET 500 MG (brand for ra pain relief acetaminophen) - Tier 2; QL TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for acetaminophen childrens) - Tier 2; QL TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for qc acetaminophen 8 hours) - Tier 2; QL Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs addaprin (generic for ADDAPRIN) - Tier 1; QL ADVIL JUNIOR STRENGTH ORAL TABLET CHEWABLE (brand for gnp ibuprofen childrens) - Tier 2; QL ADVIL ORAL TABLET (brand for qc ibuprofen) - Tier 2; QL ALEVE ORAL TABLET (brand for qc naproxen sodium) - Tier 2; QL all day pain relief (generic for MEDIPROXEN) - Tier 1; QL all day relief (generic for MEDIPROXEN) - Tier 1; QL aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL aspirin ec (generic for BAYER ASPIRIN) - Tier 1; QL aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1; QL aspirin oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents aspirin oral tablet chewable 81 mg (generic for ST JOSEPH LOW DOSE) - Tier 1; QL aspirin oral tablet delayed release 325 mg (generic for BAYER ASPIRIN) - Tier 1; QL aspirin oral tablet delayed release 81 mg (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for aspirin ec) - Tier 2; QL aspirin rectal suppository 300 mg, 600 mg - Tier 1 BAYER ASPIRIN (brand for hm aspirin) - Tier 2; QL celecoxib oral (generic for CELEBREX) - Tier 1; PA; QL childrens aspirin oral tablet chewable 81 mg (generic for ST JOSEPH LOW DOSE) - Tier 1; QL diclofenac potassium (generic for CATAFLAM) - Tier 1; QL diclofenac sodium er - Tier 1; QL diclofenac sodium external gel 1 % (generic for ASPERCREME ARTHRITIS PAIN) - Tier 1; PA; Brand OTC and Generic; QL diclofenac sodium oral - Tier 1; QL ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL etodolac - Tier 1; QL h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ibu (generic for IBU) - Tier 1; QL ibu-200 (generic for ADDAPRIN) - Tier 1; QL ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS ADVIL) - Tier 1; QL ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS ADVIL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1; QL indomethacin oral capsule 25 mg, 50 mg - Tier 1; QL INFANTS ADVIL (brand for ibuprofen infants) - Tier 2; QL infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL ketoprofen oral - Tier 1; QL ketorolac tromethamine oral - Tier 1; QL mediproxen (generic for MEDIPROXEN) - Tier 1; QL meloxicam oral tablet (generic for MOBIC) - Tier 1; QL MOTRIN CHILDRENS (brand for gnp ibuprofen childrens) - Tier 2; QL MOTRIN IB ORAL TABLET (brand for qc ibuprofen) - Tier 2; QL MOTRIN INFANTS DROPS (brand for ibuprofen infants) - Tier 2; QL nabumetone oral (generic for RELAFEN) - Tier 1; QL naproxen oral - Tier 1; QL naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier 1; QL naproxen sodium tablet 220 mg oral 220 mg (generic for MEDIPROXEN) - Tier 1; QL oxaprozin (generic for DAYPRO) - Tier 1; QL piroxicam oral (generic for FELDENE) - Tier 1; QL salsalate oral - Tier 1; QL sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ST JOSEPH LOW DOSE (brand for childrens aspirin) - Tier 2; QL sulindac oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents Opioid Analgesics, Long-acting - Opioid Pain Relievers buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 100 mcg/hr (generic for NUCYNTA ER - Tier 2; PA; QL DURAGESIC-100) - Tier 1; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr (generic for ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL DURAGESIC-12) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr (generic for DURAGESIC-25) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr (generic for DURAGESIC-50) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 75 mcg/hr (generic for DURAGESIC-75) - Tier 1; PA; QL morphine sulfate er oral tablet extended release (generic for MS CONTIN) - Tier 1; PA; QL oxymorphone hcl er - Tier 1; PA; QL Opioid Analgesics, Short-acting - Opioid Pain Relievers acetaminophen-codeine - Tier 1; QL; ARL apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA; acetaminophen-codeine #2 - Tier 1; QL; ARL QL; ARL acetaminophen-codeine #3 - Tier 1; QL; ARL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL; ARL acetaminophen-codeine #4 - Tier 1; QL; ARL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butorphanol tartrate nasal - Tier 1; QL codeine sulfate - Tier 1; QL; ARL endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL; ARL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QL; ARL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg - Tier 1; QL; ARL hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL; ARL hydromorphone hcl rectal - Tier 1; QL; ARL morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier 1; QL; ARL morphine sulfate oral - Tier 1; QL; ARL OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL; ARL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL; ARL oxycodone hcl oral solution - Tier 1; QL; ARL oxycodone hcl oral tablet - Tier 1; QL; ARL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL; ARL oxycodone-aspirin - Tier 1; QL; ARL pentazocine-naloxone hcl - Tier 1; QL; ARL tramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL; ARL Anesthetics - Drugs for Numbing Local Anesthetics 7T LIDO - Tier 2; QL anecream external cream (generic for ANECREAM) - Tier 1; QL blue tube/ aloe (generic for ANECREAM) - Tier 1; QL glydo (generic for GLYDO) - Tier 1; QL lidocaine cream 4 % external (generic for ANECREAM) - Tier 1; QL lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; DX2RX; QL lidocaine hcl external cream 3 % - Tier 1; QL lidocaine hcl urethral/mucosal - Tier 1; QL lidocaine viscous hcl - Tier 1; QL lidocaine-prilocaine external cream - Tier 1; QL lidopin external cream 3 % - Tier 1; QL LMX 4 (brand for blue tube/ aloe) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 12 Preferred Agents Non-Preferred Agents Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium - Tier 1; QL disulfiram oral tablet 250 mg - Tier 1; QL disulfiram oral tablet 500 mg - Tier 1 naltrexone hcl oral - Tier 1 VIVITROL - Tier 2; QL

Opioid Dependence Treatments - Upcoming changes to formulary - Single statewide formulary for Opioid Dependence Agents and Opioid Antagonists for both Antidotes/Deterrents/Protectants Medicaid Managed Care Plans and Fee-For-Service effective October 1, 2021 (https://newyork.fhsc.com/providers/mat.asp) buprenorphine hcl sublingual - Tier 1; DX2RX; QL BUNAVAIL - Tier 2; PA; QL buprenorphine hcl-naloxone hcl - Tier 1; DX2RX; QL SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; DX2RX; QL ZUBSOLV - Tier 2; PA; QL Opioid Reversal Agents - Antidotes/Deterrents/Protectants naloxone hcl injection solution - Tier 1; QL naloxone hcl injection solution cartridge - Tier 1; QL NARCAN - Tier 2; QL Smoking Cessation Agents - Deterrents bupropion hcl er (smoking det) - Tier 1 CHANTIX - Tier 2; QL CHANTIX CONTINUING MONTH PAK - Tier 2; QL CHANTIX STARTING MONTH PAK - Tier 2; QL habitrol (generic for HABITROL) - Tier 1; QL mini nicotine (generic for KLS QUIT2) - Tier 1; QL NICODERM CQ (brand for gnp nicotine) - Tier 2; QL NICORETTE (brand for px stop smoking aid) - Tier 2; QL NICORETTE MINI (brand for goodsense nicotine) - Tier 2; QL NICORETTE STARTER KIT (brand for px stop smoking aid) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 13 Preferred Agents Non-Preferred Agents nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mini (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine polacrilex mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine step 1 (generic for HABITROL) - Tier 1; QL nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; QL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; QL NICOTROL - Tier 2; QL NICOTROL NS - Tier 2; QL quit2 (generic for KLS QUIT2) - Tier 1; QL quit4 (generic for KLS QUIT4) - Tier 1; QL THRIVE (brand for px stop smoking aid) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents Antibacterials Antibacterials, Other methenamine hippurate (generic for HIPREX) - Tier 1; QL nitrofurantoin - Tier 1; Members >= 8 years of age will require PA; QL; AL nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - Tier 1; QL Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics gentamicin sulfate external - Tier 1; QL neomycin sulfate oral - Tier 1; QL paromomycin sulfate oral (generic for HUMATIN) - Tier 1; QL Antibacterials, Other - Antibiotics antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL CLEOCIN VAGINAL SUPPOSITORY - Tier 2; PA; QL antiseptic (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 CLINDESSE - Tier 2; PA; QL bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; QL FLAGYL (brand for metronidazole) - Tier 2; PA; QL bacitracin zinc external - Tier 1; QL METROGEL (brand for metronidazole) - Tier 2; PA; QL bacitracin zinc first aid - Tier 1; QL NORITATE - Tier 2; PA CENTANY (brand for mupirocin) - Tier 2; QL VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) - XENLETA ORAL - Tier 2; PA; QL Tier 1; QL clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL double antibiotic external ointment 500-10000 unit/gm (generic for POLYSPORIN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg- unit (generic for NEOSPORIN ORIGINAL) - Tier 1; QL first aid antiseptic external solution 10 % (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 FIRVANQ (brand for vancomycin hcl) - Tier 2; DX2RX; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA; QL linezolid oral tablet (generic for ZYVOX) - Tier 1; PA medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL metronidazole external (generic for ROSADAN) - Tier 1; QL metronidazole oral tablet - Tier 1; QL metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL mupirocin external (generic for CENTANY) - Tier 1; QL NEOSPORIN ORIGINAL (brand for cvs antibiotic) - Tier 2; QL poly bacitracin (generic for POLYSPORIN) - Tier 1 POLYSPORIN (brand for bacitracin-polymyxin b) - Tier 2 povidone-iodine external solution (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 rosadan external cream (generic for ROSADAN) - Tier 1; QL rosadan external gel (generic for ROSADAN) - Tier 1; QL SCRUB CARE POVIDONE-IODINE (brand for cvs povidone-iodine) - Tier 2 trimethoprim oral - Tier 1; QL triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1; QL vandazole (generic for VANDAZOLE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents Beta-Lactam, Cephalosporins - Antibiotics cefaclor - Tier 1; QL cefadroxil - Tier 1; QL cefdinir - Tier 1; QL cefixime oral capsule (generic for SUPRAX) - Tier 1; QL cefprozil - Tier 1; QL cefuroxime axetil - Tier 1; QL cephalexin oral capsule - Tier 1; QL cephalexin oral suspension reconstituted - Tier 1; QL Beta-Lactam, Penicillins - Antibiotics amoxicillin oral capsule - Tier 1; QL amoxicillin oral suspension reconstituted - Tier 1; QL amoxicillin oral tablet 875 mg - Tier 1; QL amoxicillin oral tablet chewable - Tier 1; QL amoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier 1; QL ampicillin - Tier 1; QL dicloxacillin sodium - Tier 1; QL penicillin v potassium - Tier 1; QL Macrolides - Antibiotics azithromycin oral suspension reconstituted (generic for ZITHROMAX) - Tier 1; QL azithromycin oral tablet - Tier 1; QL clarithromycin er - Tier 1; QL clarithromycin oral - Tier 1; QL DIFICID - Tier 2; PA; QL E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; QL erythromycin base - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QL erythromycin oral (generic for ERY-TAB) - Tier 1; QL Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QL ciprofloxacin hcl oral - Tier 1; QL VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QL XEPI - Tier 2; PA; QL ofloxacin oral - Tier 1; QL Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1; QL ssd (generic for SSD) - Tier 1; QL sulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1; QL sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1; QL sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL Tetracyclines - Antibiotics doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; QL ORACEA (brand for doxycycline) - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL SOLODYN (brand for minocycline hcl er) - Tier 2; PA doxycycline monohydrate oral capsule 100 mg (generic for XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL MONDOXYNE NL) - Tier 1; QL doxycycline monohydrate oral capsule 50 mg - Tier 1; QL minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1; QL minocycline hcl oral capsule 50 mg - Tier 1; QL mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL morgidox oral (generic for MORGIDOX) - Tier 1; QL NUZYRA ORAL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 18 Preferred Agents Non-Preferred Agents Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other - Seizure Control Drugs levetiracetam oral solution (generic for KEPPRA) - Tier 1; Maximum BRIVIACT ORAL - Tier 2; PA; QL age of 9 years for solution; QL; AL XCOPRI - Tier 2; PA; QL levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & NAYZILAM - Tier 2; PA; QL 200 MG - Tier 2; PA; QL phenobarbital oral tablet - Tier 1; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL roweepra (generic for ROWEEPRA) - Tier 1; QL Calcium Channel Modifying Agents - Seizure Control Drugs CELONTIN - Tier 2; QL ethosuximide oral (generic for ZARONTIN) - Tier 1; QL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs clobazam (generic for ONFI) - Tier 1; DX2RX; QL SYMPAZAN - Tier 2; PA; QL diazepam rectal (generic for DIASTAT PEDIATRIC) - Tier 1; QL VALTOCO 10 MG DOSE - Tier 2; PA; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL VALTOCO 15 MG DOSE - Tier 2; PA; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL VALTOCO 20 MG DOSE - Tier 2; PA; QL phenobarbital oral elixir - Tier 1; QL VALTOCO 5 MG DOSE - Tier 2; PA; QL primidone oral (generic for MYSOLINE) - Tier 1; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; AL valproic acid oral - Tier 1; QL vigabatrin oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 19 Preferred Agents Non-Preferred Agents Glutamate Reducing Agents - Seizure Control Drugs felbamate oral suspension (generic for FELBATOL) - Tier 1; Members FYCOMPA - Tier 2; PA; QL >= 8 years of age will require PA; QL; AL felbamate oral tablet (generic for FELBATOL) - Tier 1; QL lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; Members >= 8 years of age will require PA; QL; AL lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL subvenite (generic for SUBVENITE) - Tier 1; QL subvenite starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL subvenite starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier 1; Members >= 8 years of age will require PA; QL; AL topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 20 Preferred Agents Non-Preferred Agents Sodium Channel Agents - Seizure Control Drugs carbamazepine er (generic for CARBATROL) - Tier 1; QL APTIOM - Tier 2; PA; QL carbamazepine oral - Tier 1; QL VIMPAT ORAL - Tier 2; PA; QL; AL DILANTIN ORAL CAPSULE 30 MG - Tier 2 epitol (generic for EPITOL) - Tier 1; QL oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; Maximum age of 9 years for solution; QL; AL oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; QL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL rufinamide (generic for BANZEL) - Tier 1; DX2RX; QL TEGRETOL ORAL SUSPENSION (brand for carbamazepine) - Tier 2; QL Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST; Members <18 years of age will require PA; QL; AL donepezil hcl oral tablet 5 mg (generic for ARICEPT) - Tier 1; Members <18 years of age will require PA; QL; AL donepezil hcl tablet 10 mg oral (generic for ARICEPT) - Tier 1; Members <18 years of age will require PA; QL; AL galantamine hydrobromide oral solution - Tier 1; QL; AL galantamine hydrobromide oral tablet 12 mg, 8 mg - Tier 1; QL; AL galantamine hydrobromide oral tablet 4 mg - Tier 1; Members <18 years of age will require PA; QL; AL rivastigmine (generic for EXELON) - Tier 1; Members <18 years of age will require PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents rivastigmine tartrate - Tier 1; QL; AL N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl oral solution 2 mg/ml - Tier 1; QL memantine hcl oral tablet (generic for NAMENDA) - Tier 1; Members <18 years of age will require PA; QL; AL Antidepressants - Drugs to Treat Depression Antidepressants, Other - Antidepressants bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg (generic for WELLBUTRIN XL) - Tier 1; QL bupropion hcl oral - Tier 1; QL mirtazapine oral tablet 15 mg, 30 mg (generic for REMERON) - Tier 1; Tabs (not soltabs); QL mirtazapine oral tablet 45 mg, 7.5 mg - Tier 1; QL perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50 mg - Tier 1 perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; QL Monoamine Oxidase Inhibitors - Antidepressants tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 22 Preferred Agents Non-Preferred Agents SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide (generic for CELEXA) - Tier 1; QL CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 FETZIMA - Tier 2; PA; QL mg (generic for CYMBALTA) - Tier 1; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL trazodone hcl oral tablet 300 mg - Tier 1; PA; QL fluoxetine hcl oral capsule 10 mg, 20 mg (generic for PROZAC) - Tier TRINTELLIX - Tier 2; PA; QL 1; QL VIIBRYD - Tier 2; PA; QL fluoxetine hcl oral solution - Tier 1; QL fluvoxamine maleate - Tier 1; QL maprotiline hcl oral tablet 25 mg - Tier 1 maprotiline hcl oral tablet 50 mg, 75 mg - Tier 1; QL paroxetine hcl (generic for PAXIL) - Tier 1; QL sertraline hcl oral (generic for ZOLOFT) - Tier 1; QL trazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QL venlafaxine hcl - Tier 1; QL venlafaxine hcl er oral capsule extended release 24 hour (generic for EFFEXOR XR) - Tier 1; QL Tricyclics - Antidepressants amitriptyline hcl oral - Tier 1; QL amoxapine - Tier 1; QL desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL doxepin hcl oral capsule - Tier 1; QL doxepin hcl oral concentrate - Tier 1; QL imipramine hcl oral - Tier 1; QL nortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea - Tier 1 BONINE (brand for cvs motion sickness relief) - Tier 2 compro (generic for COMPRO) - Tier 1; QL driminate (generic for DRIMINATE) - Tier 1 meclizine hcl oral tablet 12.5 mg - Tier 1; QL meclizine hcl oral tablet 25 mg (generic for TRAVEL-EASE) - Tier 1; QL meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 metoclopramide hcl oral solution - Tier 1; QL motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet chewable 25 mg (generic for BONINE) - Tier 1 nausea control - Tier 1 nausea relief oral liquid 1.87-1.87-21.5 - Tier 1 perphenazine oral - Tier 1; DX2RX; QL prochlorperazine (generic for COMPRO) - Tier 1; QL trimethobenzamide hcl oral (generic for TIGAN) - Tier 1; QL Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs aprepitant (generic for EMEND) - Tier 1; QL AKYNZEO ORAL - Tier 2; PA; QL dronabinol (generic for MARINOL) - Tier 1; PA; QL EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL ondansetron hcl oral tablet (generic for ZOFRAN) - Tier 1; QL ondansetron odt - Tier 1; QL VARUBI (180 MG DOSE) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day (generic for MONISTAT 3) - Tier 1 DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL af spray powder (generic for ODOR EATERS FOOT/SNEAKER GYNAZOLE-1 - Tier 2; PA; QL SPRAY) - Tier 1 ALOE VESTA CLEAR ANTIFUNGAL - Tier 2 antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; QL antifungal external cream 1 % (generic for TINACTIN) - Tier 1; QL antifungal external cream 2 % (generic for CAVILON) - Tier 1 antifungal foot care (generic for LAMISIL AT) - Tier 1; QL antifungal miconazole (generic for CAVILON) - Tier 1 antifungal tolnaftate (generic for TINACTIN) - Tier 1; QL atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) - Tier 1; QL athletes foot external aerosol powder 2 % (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1; QL athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) - Tier 1 CAVILON (brand for sm antifungal miconazole) - Tier 2 ciclodan (generic for CICLODAN) - Tier 1; QL ciclopirox external solution (generic for CICLODAN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 25 Preferred Agents Non-Preferred Agents clotrimazole 3 vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - Tier 1 clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole external (generic for DESENEX) - Tier 1; QL clotrimazole mouth/throat - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL CRUEX PRESCRIPTION STRENGTH (brand for ra atheletes foot) - Tier 2 DESENEX JOCK ITCH (brand for ra atheletes foot) - Tier 2 fluconazole oral (generic for DIFLUCAN) - Tier 1; QL foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL fungi-guard (generic for TINACTIN) - Tier 1; QL griseofulvin microsize oral - Tier 1; QL griseofulvin ultramicrosize - Tier 1; QL GYNE-LOTRIMIN (brand for clotrimazole-7) - Tier 2; QL GYNE-LOTRIMIN 3 (brand for clotrimazole 3) - Tier 2 itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; QL jock itch max st (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 ketoconazole external cream - Tier 1; QL ketoconazole external shampoo - Tier 1; QL ketoconazole oral - Tier 1; QL LAMISIL AT EXTERNAL CREAM (brand for cvs jock itch) - Tier 2; QL LAMISIL AT JOCK ITCH (brand for cvs jock itch) - Tier 2; QL micaderm (generic for CAVILON) - Tier 1 miconazole 3 - Tier 1; QL miconazole 3 combo pack app (generic for MONISTAT 3 COMBO PACK APP) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 26 Preferred Agents Non-Preferred Agents miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBINATION PACK) - Tier 1; QL miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal suppository 100 mg - Tier 1 miconazole antifungal (generic for CAVILON) - Tier 1 miconazole nitrate external (generic for CAVILON) - Tier 1 miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL nyamyc (generic for NYAMYC) - Tier 1; QL nystatin external - Tier 1; QL nystatin mouth/throat - Tier 1; QL nystatin oral - Tier 1; QL nystop (generic for NYAMYC) - Tier 1; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1; QL terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1; QL terconazole vaginal cream - Tier 1; QL TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2 TINACTIN EXTERNAL CREAM (brand for cvs antifungal) - Tier 2; QL tinaspore (generic for BLIS-TO-SOL) - Tier 1 tolnaftate antifungal (generic for TINACTIN) - Tier 1; QL tolnaftate external cream (generic for TINACTIN) - Tier 1; QL voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL COLCHICINE ORAL CAPSULE - Tier 2; PA; QL febuxostat (generic for ULORIC) - Tier 1; ST; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL MITIGARE (brand for colchicine) - Tier 2; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL probenecid - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 27 Preferred Agents Non-Preferred Agents Antimigraine Agents - Drugs to Treat Migraines Ergot Alkaloids - Migraine Drugs dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; QL ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL MIGERGOT - Tier 2; QL Prophylactic - Migraine Drugs AIMOVIG - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; EMGALITY - Tier 2; PA; QL QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL REYVOW - Tier 2; PA; QL NURTEC - Tier 2; PA; QL UBRELVY - Tier 2; PA; QL Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs naratriptan hcl (generic for AMERGE) - Tier 1; ST; QL rizatriptan benzoate - Tier 1; QL sumatriptan nasal (generic for IMITREX) - Tier 1; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - Tier 1; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 28 Preferred Agents Non-Preferred Agents Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1; QL rifabutin (generic for MYCOBUTIN) - Tier 1; QL Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL ethambutol hcl oral tablet 100 mg - Tier 1 ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QL isoniazid oral - Tier 1; QL PASER - Tier 2; QL PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1; QL rifampin oral - Tier 1; QL SIRTURO - Tier 2; QL TRECATOR - Tier 2; QL Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide oral capsule - Tier 1 CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 GLEOSTINE - Tier 2 LEUKERAN - Tier 2 MATULANE - Tier 2; SP melphalan (generic for ALKERAN) - Tier 1 temozolomide oral capsule 100 mg, 140 mg (generic for TEMODAR) - Tier 1; PA; SP temozolomide oral capsule 180 mg, 250 mg (generic for TEMODAR) - Tier 1; PA; SP; QL temozolomide oral capsule 20 mg, 5 mg - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 29 Preferred Agents Non-Preferred Agents Antiandrogens - Hormone Suppressants abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL XTANDI ORAL CAPSULE - Tier 2; PA; SP; QL bicalutamide (generic for CASODEX) - Tier 1; QL YONSA - Tier 2; PA; SP; QL ERLEADA - Tier 2; PA; SP; QL ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL flutamide - Tier 1; QL NUBEQA - Tier 2; PA; SP; QL Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL Antiestrogens/Modifiers - Chemotherapy Agents tamoxifen citrate oral - Tier 1 toremifene citrate (generic for FARESTON) - Tier 1; QL Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; SP XELODA (brand for capecitabine) - Tier 2; PA; SP DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2 DROXIA ORAL CAPSULE 400 MG - Tier 2; QL hydroxyurea oral (generic for HYDREA) - Tier 1; QL mercaptopurine oral - Tier 1; QL TABLOID - Tier 2; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 30 Preferred Agents Non-Preferred Agents Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral tablet 10 mg - Tier 1 KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; QL KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL LONSURF - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL NINLARO - Tier 2; PA; SP; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL ROZLYTREK - Tier 2; PA; SP; QL VERZENIO - Tier 2; PA; SP; QL ZOLINZA - Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1; QL exemestane (generic for AROMASIN) - Tier 1; QL letrozole oral (generic for FEMARA) - Tier 1 Enzyme Inhibitors - Chemotherapy Agents BALVERSA - Tier 2; PA; SP; QL etoposide oral - Tier 1 HYCAMTIN ORAL - Tier 2; PA; SP RUBRACA - Tier 2; PA; SP; QL ZEJULA - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL AFINITOR ORAL TABLET 10 MG - Tier 2; PA; SP; QL ALECENSA - Tier 2; PA; SP; QL ALUNBRIG - Tier 2; PA; SP; QL BOSULIF - Tier 2; PA; SP; QL BRUKINSA - Tier 2; PA; SP; QL CABOMETYX - Tier 2; PA; SP; QL CALQUENCE - Tier 2; PA; SP; QL CAPRELSA - Tier 2; PA; SP; QL COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL COTELLIC - Tier 2; PA; SP; QL DAURISMO - Tier 2; PA; SP; QL ERIVEDGE - Tier 2; PA; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg (generic for AFINITOR) - Tier 1; PA; SP; QL everolimus oral tablet 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP FARYDAK - Tier 2; PA; SP; QL GILOTRIF - Tier 2; PA; SP; QL IBRANCE - Tier 2; PA; SP; QL ICLUSIG - Tier 2; PA; SP; QL IDHIFA ORAL TABLET 50 MG - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 32 Preferred Agents Non-Preferred Agents imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL IMBRUVICA - Tier 2; PA; SP; QL INLYTA - Tier 2; PA; SP; QL IRESSA - Tier 2; PA; SP; QL JAKAFI - Tier 2; PA; SP; QL lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL LYNPARZA - Tier 2; PA; SP; QL MEKINIST - Tier 2; PA; SP; QL NEXAVAR - Tier 2; PA; SP; QL ODOMZO - Tier 2; PA; SP; QL RYDAPT - Tier 2; PA; SP; QL SPRYCEL - Tier 2; PA; SP; QL STIVARGA - Tier 2; PA; SP; QL SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG - Tier 2; PA; SP; QL SUTENT ORAL CAPSULE 37.5 MG - Tier 2; PA; SP TAFINLAR - Tier 2; PA; SP; QL TASIGNA - Tier 2; PA; SP; QL TIBSOVO - Tier 2; PA; SP; QL TURALIO - Tier 2; PA; SP; QL VENCLEXTA - Tier 2; PA; SP; QL VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL VITRAKVI - Tier 2; PA; SP; QL VOTRIENT - Tier 2; PA; SP; QL XALKORI - Tier 2; PA; SP; QL ZELBORAF - Tier 2; PA; SP; QL ZYDELIG - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP PANRETIN - Tier 2; PA TARGRETIN EXTERNAL - Tier 2; PA; SP tretinoin oral - Tier 1; SP Treatment Adjuncts - Supportive Chemotherapy Drugs MESNEX ORAL - Tier 2; SP Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; DX2RX; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; Members ARAKODA - Tier 2; PA; QL >= 8 years of age will require PA; QL; AL atovaquone oral (generic for MEPRON) - Tier 1; PA; QL BENZNIDAZOLE - Tier 2; DX2RX; QL chloroquine phosphate oral - Tier 1; DX2RX; QL hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; DX2RX; QL IMPAVIDO - Tier 2; PA; QL KRINTAFEL - Tier 2; QL mefloquine hcl - Tier 1; QL nitazoxanide (generic for ALINIA) - Tier 1; DX2RX; QL pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1 primaquine phosphate - Tier 1 pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents Pediculicides/Scabicides - Scabies and Lice Drugs crotan - Tier 1; QL lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice treatment - Tier 1 lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1 lice treatment external shampoo 0.33-4 % (generic for RID LICE KILLING SHAMPOO) - Tier 1 malathion (generic for OVIDE) - Tier 1; QL permethrin external (generic for ELIMITE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for lice killing maximum strength) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 spinosad (generic for NATROBA) - Tier 1; QL Antiparkinson Agents - Drugs to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease Drugs benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral capsule - Tier 1; QL amantadine hcl oral syrup - Tier 1; QL entacapone (generic for COMTAN) - Tier 1; QL tolcapone (generic for TASMAR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 35 Preferred Agents Non-Preferred Agents Dopamine Agonists - Parkinson's Disease Drugs bromocriptine mesylate oral tablet (generic for PARLODEL) - Tier 1 pramipexole dihydrochloride oral tablet 0.125 mg, 0.5 mg, 1 mg (generic for MIRAPEX) - Tier 1; QL pramipexole dihydrochloride oral tablet 0.25 mg, 1.5 mg - Tier 1; QL pramipexole dihydrochloride oral tablet 0.75 mg (generic for MIRAPEX) - Tier 1 ropinirole hcl - Tier 1; QL Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa er - Tier 1; QL carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs selegiline hcl oral - Tier 1; QL Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs chlorpromazine hcl oral - Tier 1; DX2RX; QL fluphenazine decanoate injection - Tier 1; DX2RX; QL fluphenazine hcl injection - Tier 1; DX2RX fluphenazine hcl oral concentrate - Tier 1; DX2RX fluphenazine hcl oral elixir - Tier 1; DX2RX fluphenazine hcl oral tablet - Tier 1; DX2RX; QL haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; DX2RX; QL haloperidol oral - Tier 1; DX2RX; QL loxapine succinate - Tier 1; DX2RX; QL pimozide - Tier 1; QL; AL prochlorperazine maleate oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 36 Preferred Agents Non-Preferred Agents thioridazine hcl oral - Tier 1; DX2RX; QL thiothixene - Tier 1; DX2RX; QL trifluoperazine hcl - Tier 1; DX2RX; QL 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY MAINTENA - Tier 2; PA; QL; AL ABILIFY (brand for aripiprazole) - Tier 2; DX2RX; QL; AL aripiprazole oral tablet (generic for ABILIFY) - Tier 1; DX2RX; QL; AL aripiprazole oral solution - Tier 1; PA; QL; AL ARISTADA - Tier 2; PA; QL; AL aripiprazole oral tablet dispersible - Tier 1; PA; QL; AL INVEGA SUSTENNA - Tier 2; PA; QL; AL ARISTADA INITIO - Tier 2; PA; QL; AL INVEGA TRINZA - Tier 2; DX2RX; QL; AL FANAPT - Tier 2; PA; QL; AL olanzapine oral tablet (generic for ZYPREXA) - Tier 1; DX2RX; QL; AL GEODON ORAL (brand for ziprasidone hcl) - Tier 2; DX2RX; QL; AL PERSERIS - Tier 2; PA; QL; AL INVEGA (brand for paliperidone er) - Tier 2; PA; QL; AL quetiapine fumarate (generic for SEROQUEL) - Tier 1; DX2RX; QL; AL LATUDA - Tier 2; PA; QL; AL RISPERDAL CONSTA - Tier 2; PA; QL; AL olanzapine oral tablet dispersible (generic for ZYPREXA ZYDIS) - Tier 1; risperidone oral solution (generic for RISPERDAL) - Tier 1; DX2RX; PA; QL; AL Members >= 8 years of age will require PA; QL; AL paliperidone er (generic for INVEGA) - Tier 1; PA; QL; AL quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA; QL; AL risperidone oral tablet (generic for RISPERDAL) - Tier 1; DX2RX; QL; REXULTI - Tier 2; PA; QL; AL AL RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; DX2RX; ziprasidone hcl (generic for GEODON) - Tier 1; DX2RX; QL; AL Members >= 8 years of age will require PA; QL; AL RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; DX2RX; QL; AL risperidone oral tablet dispersible - Tier 1; PA; QL; AL SAPHRIS (brand for asenapine maleate) - Tier 2; PA; QL; AL SEROQUEL (brand for quetiapine fumarate) - Tier 2; DX2RX; QL; AL SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL; AL VRAYLAR - Tier 2; PA; QL; AL ZYPREXA ORAL (brand for olanzapine) - Tier 2; DX2RX; QL; AL ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents Treatment-Resistant - Mood Disorder Drugs clozapine oral tablet 100 mg, 25 mg, 50 mg (generic for CLOZARIL) - CLOZARIL ORAL TABLET 100 MG, 25 MG (brand for clozapine) - Tier 2; Tier 1; DX2RX; QL; AL DX2RX; QL; AL CLOZARIL ORAL TABLET 200 MG (brand for clozapine) - Tier 2; PA; QL; AL CLOZARIL ORAL TABLET 50 MG (brand for clozapine) - Tier 2; DX2RX; QL; AL Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs BARACLUDE ORAL SOLUTION - Tier 2; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; QL Anti-hepatitis C (HCV) Agents, Direct Acting Agents - Hepatitis C Drugs MAVYRET - Tier 2; DX2RX; Preferred for Genotypes 1, 2, 3, 4, 5,& 6; EPCLUSA ORAL TABLET 200-50 MG - Tier 2; PA; SP; QL SP; QL EPCLUSA ORAL TABLET 400-100 MG (brand for sofosbuvir-velpatasvir) SOFOSBUVIR-VELPATASVIR - Tier 2; DX2RX; SP; QL - Tier 2; DX2RX; SP; QL ZEPATIER - Tier 2; DX2RX; SP; QL HARVONI (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL LEDIPASVIR-SOFOSBUVIR - Tier 2; PA; SP; QL SOVALDI - Tier 2; PA; SP; QL VIEKIRA PAK - Tier 2; PA; SP; QL VOSEVI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP PEGASYS - Tier 2; PA; SP; QL ribavirin oral - Tier 1; QL Antiherpetic Agents - Herpes Drugs ABREVA (brand for hm docosanol) - Tier 2; QL acyclovir oral - Tier 1; QL docosanol external (generic for ABREVA) - Tier 1; QL trifluridine - Tier 1; QL valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs DOVATO - Tier 2; DX2RX; QL GENVOYA - Tier 2; PA; SP; QL ISENTRESS HD - Tier 2; DX2RX; SP; QL ISENTRESS ORAL PACKET - Tier 2; DX2RX; Members >= 2 years of age will require PA; SP; QL; AL ISENTRESS ORAL TABLET - Tier 2; DX2RX; SP; QL ISENTRESS ORAL TABLET CHEWABLE - Tier 2; DX2RX; SP; QL STRIBILD - Tier 2; PA; SP; QL TIVICAY - Tier 2; DX2RX; SP; QL TIVICAY PD - Tier 2; DX2RX; SP; QL; AL TRIUMEQ - Tier 2; DX2RX; SP; QL TYBOST - Tier 2; DX2RX; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 39 Preferred Agents Non-Preferred Agents Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs COMPLERA - Tier 2; PA; SP; QL ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; PA; SP; QL DELSTRIGO - Tier 2; DX2RX; SP; QL SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; SP; QL EDURANT - Tier 2; DX2RX; SP; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; SP; efavirenz (generic for SUSTIVA) - Tier 1; DX2RX; SP; QL QL efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; DX2RX; SP; QL INTELENCE - Tier 2; DX2RX; SP; QL JULUCA - Tier 2; DX2RX; SP; QL nevirapine - Tier 1; DX2RX; SP; QL nevirapine er (generic for VIRAMUNE XR) - Tier 1; DX2RX; SP; QL ODEFSEY - Tier 2; DX2RX; SP; QL VIRAMUNE (brand for nevirapine) - Tier 2; DX2RX; SP; QL Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs abacavir sulfate (generic for ZIAGEN) - Tier 1; DX2RX; SP; QL CIMDUO - Tier 2; PA; SP; QL abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; DX2RX; SP; QL abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; DX2RX; SP; QL BIKTARVY - Tier 2; DX2RX; SP; QL DESCOVY - Tier 2; DX2RX; SP; QL emtricitabine (generic for EMTRIVA) - Tier 1; DX2RX; SP; QL emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; DX2RX; SP; QL EMTRIVA ORAL SOLUTION - Tier 2; DX2RX; SP; QL lamivudine oral solution (generic for EPIVIR) - Tier 1; DX2RX; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; DX2RX; SP; QL lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; DX2RX; SP; QL stavudine - Tier 1; DX2RX; SP; QL TEMIXYS - Tier 2; DX2RX; SP; QL tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; DX2RX; SP; QL TRUVADA ORAL TABLET 100-150 MG, 167-250 MG (brand for emtricitabine-tenofovir df) - Tier 2; DX2RX; SP; QL VIREAD ORAL POWDER - Tier 2; DX2RX; SP; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; DX2RX; SP; QL zidovudine (generic for RETROVIR) - Tier 1; DX2RX; SP; QL Anti-HIV Agents, Other - HIV Drugs FUZEON - Tier 2; DX2RX; SP; QL SELZENTRY - Tier 2; DX2RX; SP; QL Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS - Tier 2; DX2RX; SP; QL KALETRA (brand for lopinavir-ritonavir) - Tier 2; DX2RX; SP; QL atazanavir sulfate (generic for REYATAZ) - Tier 1; DX2RX; SP; QL REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; CRIXIVAN - Tier 2; DX2RX; SP; QL DX2RX; SP; QL EVOTAZ - Tier 2; DX2RX; SP; QL SYMTUZA - Tier 2; PA; SP; QL fosamprenavir calcium (generic for LEXIVA) - Tier 1; DX2RX; SP; QL INVIRASE - Tier 2; DX2RX; SP; QL LEXIVA ORAL SUSPENSION - Tier 2; DX2RX; SP; QL lopinavir-ritonavir (generic for KALETRA) - Tier 1; DX2RX; SP; QL NORVIR ORAL PACKET - Tier 2; DX2RX; SP; QL NORVIR ORAL SOLUTION - Tier 2; DX2RX; SP; QL PREZCOBIX - Tier 2; DX2RX; SP; QL PREZISTA - Tier 2; DX2RX; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents REYATAZ ORAL PACKET - Tier 2; DX2RX; Members >= 8 years of age will require PA; SP; QL; AL ritonavir (generic for NORVIR) - Tier 1; DX2RX; SP; QL VIRACEPT - Tier 2; DX2RX; SP; QL Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA; oseltamivir phosphate oral suspension reconstituted (generic for QL TAMIFLU) - Tier 1; QL; AL TAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir RELENZA DISKHALER - Tier 2; QL phosphate) - Tier 2; PA; QL; AL XOFLUZA (40 MG DOSE) - Tier 2; PA; QL XOFLUZA (80 MG DOSE) - Tier 2; PA; QL Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs buspirone hcl oral - Tier 1; QL hydroxyzine hcl oral - Tier 1; QL Benzodiazepines - Anxiety Drugs alprazolam oral tablet (generic for XANAX) - Tier 1; QL chlordiazepoxide hcl - Tier 1; QL clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL clorazepate dipotassium - Tier 1; QL diazepam oral solution - Tier 1; QL diazepam oral tablet (generic for VALIUM) - Tier 1; QL lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL oxazepam - Tier 1; QL triazolam - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs divalproex sodium oral capsule delayed release sprinkle (generic for DEPAKOTE SPRINKLES) - Tier 1; Members >= 8 years of age will require PA; QL; AL divalproex sodium oral tablet delayed release (generic for DEPAKOTE) - Tier 1; Minimum age of 2 years; QL lithium - Tier 1; QL lithium carbonate er (generic for LITHOBID) - Tier 1; QL lithium carbonate oral - Tier 1; QL Blood Glucose Regulators - Drugs to Regulate Blood Sugar Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL ADLYXIN - Tier 2; ST; QL BYETTA 10 MCG PEN - Tier 2; PA; QL ADLYXIN STARTER PACK - Tier 2; ST; QL BYETTA 5 MCG PEN - Tier 2; PA; QL ALOGLIPTIN BENZOATE - Tier 2; ST; QL GLYXAMBI - Tier 2; PA ALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QL INVOKAMET - Tier 2; PA; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QL INVOKAMET XR - Tier 2; PA; QL FARXIGA - Tier 2; PA; QL INVOKANA - Tier 2; PA; QL glimepiride (generic for AMARYL) - Tier 1; QL JANUMET - Tier 2; PA; QL glipizide er (generic for GLUCOTROL XL) - Tier 1; QL JANUMET XR - Tier 2; PA; QL glipizide ir (generic for GLUCOTROL) - Tier 1; QL JANUVIA - Tier 2; PA; QL glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL JARDIANCE - Tier 2; PA; QL glyburide micronized (generic for GLYNASE) - Tier 1; QL JENTADUETO - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 43 Preferred Agents Non-Preferred Agents glyburide oral - Tier 1; QL JENTADUETO XR - Tier 2; PA; QL glyburide-metformin - Tier 1; QL KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; ST; QL metformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA; QL KOMBIGLYZE XR - Tier 2; PA; QL metformin hcl er oral tablet extended release 24 hour 500 mg - Tier 1; NESINA (brand for alogliptin benzoate) - Tier 2; PA; ST; QL QL ONGLYZA - Tier 2; PA; QL metformin hcl er oral tablet extended release 24 hour 750 mg - Tier 1 OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; ST; QL metformin hcl oral tablet - Tier 1; QL OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML - nateglinide - Tier 1; QL Tier 2; PA; QL pioglitazone hcl (generic for ACTOS) - Tier 1; QL QTERN - Tier 2; PA; QL repaglinide - Tier 1; QL RYBELSUS - Tier 2; PA; QL SEGLUROMET - Tier 2; ST; QL STEGLUJAN - Tier 2; PA; QL SOLIQUA - Tier 2; ST; QL SYNJARDY - Tier 2; PA; QL STEGLATRO - Tier 2; ST; QL SYNJARDY XR - Tier 2; PA; QL SYMLINPEN 120 - Tier 2; PA; QL TRADJENTA - Tier 2; PA; QL SYMLINPEN 60 - Tier 2; PA; QL TRIJARDY XR - Tier 2; PA; QL TRULICITY - Tier 2; ST; QL VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS - VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML Tier 2; PA; QL SUBCUTANEOUS - Tier 2; ST; QL XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG - Tier 2; PA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG - Tier 2; PA; QL XULTOPHY - Tier 2; PA; QL Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; PA; QL BAQSIMI TWO PACK - Tier 2; QL GLUCAGEN HYPOKIT - Tier 2; QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - Tier 2; QL glucagon emergency kit 1 mg injection - Tier 1; QL glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL GVOKE PFS - Tier 2; QL glucose tablet chewable 4 gm oral 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 44 Preferred Agents Non-Preferred Agents soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL Insulins - Diabetic Drugs ADMELOG (brand for insulin lispro) - Tier 2; QL AFREZZA - Tier 2; PA; QL ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML APIDRA SOLOSTAR - Tier 2; PA; QL SUBCUTANEOUS (brand for insulin lispro (1 unit dial)) - Tier 2; QL APIDRA VIAL - Tier 2; PA; QL ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP - Tier 2; PA; QL SUBCUTANEOUS (brand for insulin lispro (1 unit dial)) - Tier 2; PA; FIASP FLEXTOUCH - Tier 2; PA; QL QL HUMALOG (brand for insulin lispro) - Tier 2; PA; QL BASAGLAR KWIKPEN - Tier 2; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - HUMALOG MIX 50/50 - Tier 2; QL Tier 2; PA; QL HUMALOG MIX 75/25 - Tier 2; QL HUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; PA; HUMULIN 70/30 VIAL - Tier 2; QL QL HUMULIN N VIAL - Tier 2; QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL HUMULIN R VIAL - Tier 2; QL INSULIN ASPART PROT & ASPART - Tier 2; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - NOVOLIN 70/30 RELION - Tier 2; QL Tier 2; PA; QL NOVOLIN 70/30 VIAL - Tier 2; QL HUMULIN 70/30 KWIKPEN - Tier 2; PA; QL NOVOLIN N RELION - Tier 2; QL HUMULIN N KWIKPEN - Tier 2; PA; QL NOVOLIN N VIAL - Tier 2; QL HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL NOVOLIN R RELION - Tier 2; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL NOVOLIN R VIAL - Tier 2; QL INSULIN ASP PROT & ASP FLEXPEN - Tier 2; PA; QL SEMGLEE - Tier 2; QL INSULIN ASPART - Tier 2; PA; QL INSULIN LISPRO - Tier 2; PA; QL INSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QL LANTUS SOLOSTAR - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents LEVEMIR U-100 FLEXTOUCH - Tier 2; PA; QL LEVEMIR U-100 VIAL - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL NOVOLIN N FLEXPEN - Tier 2; PA; QL NOVOLIN R FLEXPEN - Tier 2; PA; QL NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; PA; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL TOUJEO SOLOSTAR - Tier 2; PA; QL TRESIBA - Tier 2; PA; QL TRESIBA FLEXTOUCH - Tier 2; PA; QL

Blood Products and Modifiers Blood Products and Modifiers, Other NYVEPRIA - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 46 Preferred Agents Non-Preferred Agents Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2; QL PRADAXA - Tier 2; PA; QL ELIQUIS DVT/PE STARTER PACK - Tier 2; QL XARELTO - Tier 2; PA; QL enoxaparin sodium (generic for LOVENOX) - Tier 1; QL XARELTO STARTER PACK - Tier 2; PA; QL heparin sodium (porcine) - Tier 1 heparin sodium (porcine) pf - Tier 1 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1 SAVAYSA - Tier 2; QL warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1 Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 DOPTELET - Tier 2; PA; SP; QL ARANESP (ALBUMIN FREE) INJECTION SOLUTION - Tier 2; PA; SP EPOGEN - Tier 2; PA; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED FULPHILA - Tier 2; PA; SP SYRINGE 10 MCG/0.4ML - Tier 2; PA; SP; QL GRANIX - Tier 2; PA; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2; MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 PA; SP; QL MCG/0.3ML - Tier 2; PA; SP NEUPOGEN INJECTION SOLUTION 300 MCG/ML - Tier 2; PA; SP LEUKINE - Tier 2; PA; SP NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML - Tier 2; PA; SP; MULPLETA - Tier 2; PA; SP; QL QL NEULASTA - Tier 2; PA; SP NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE - Tier 2; PA; PROMACTA ORAL PACKET 25 MG - Tier 2; PA; SP; QL SP PROMACTA ORAL TABLET - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP RETACRIT - Tier 2; PA; SP PROCRIT - Tier 2; PA; SP ZARXIO - Tier 2; PA; SP UDENYCA - Tier 2; PA; SP ZIEXTENZO - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 47 Preferred Agents Non-Preferred Agents Hemostasis Agents - Drugs to Stop Bleeding aminocaproic acid oral (generic for AMICAR) - Tier 1; QL HEMLIBRA - Tier 2; PA; SP; QL tranexamic acid oral (generic for LYSTEDA) - Tier 1; DX2RX; QL Platelet Modifying Agents - Platelet Modifying Drugs BRILINTA - Tier 2; DX2RX; QL CABLIVI - Tier 2; PA; SP; QL cilostazol - Tier 1; QL clopidogrel bisulfate oral - Tier 1; QL dipyridamole oral - Tier 1; QL prasugrel hcl (generic for EFFIENT) - Tier 1; DX2RX; QL Cardiovascular Agents Cardiovascular Agents, Other NEXLIZET - Tier 2; PA; QL Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs clonidine hcl oral - Tier 1; QL guanfacine hcl - Tier 1; QL methyldopa - Tier 1; QL midodrine hcl - Tier 1; QL Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL Angiotensin II Receptor Antagonists - Blood Pressure Drugs losartan potassium oral (generic for COZAAR) - Tier 1; QL EDARBI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 48 Preferred Agents Non-Preferred Agents Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL captopril oral - Tier 1; QL enalapril maleate oral (generic for VASOTEC) - Tier 1; QL EPANED - Tier 2; Members >= 8 years of age will require PA; QL; AL fosinopril sodium - Tier 1; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL ramipril (generic for ALTACE) - Tier 1; QL trandolapril - Tier 1; QL Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL disopyramide phosphate (generic for NORPACE) - Tier 1; QL MULTAQ - Tier 2; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL flecainide acetate - Tier 1; QL NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 150 mexiletine hcl oral - Tier 1; QL MG - Tier 2; PA NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL 100 MG - Tier 2 RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 propafenone hcl - Tier 1; QL MG, 325 MG (brand for propafenone hcl er) - Tier 2; PA; QL quinidine gluconate er - Tier 1; QL RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 425 quinidine sulfate - Tier 1; QL MG (brand for propafenone hcl er) - Tier 2; PA sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

Beta-adrenergic Blocking Agents - Blood Pressure Drugs acebutolol hcl oral - Tier 1; QL HEMANGEOL - Tier 2; PA; QL atenolol oral (generic for TENORMIN) - Tier 1; QL betaxolol hcl oral - Tier 1; QL bisoprolol fumarate oral - Tier 1; QL carvedilol (generic for COREG) - Tier 1; QL labetalol hcl oral - Tier 1; QL metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL metoprolol tartrate oral tablet 100 mg, 50 mg (generic for LOPRESSOR) - Tier 1; QL metoprolol tartrate oral tablet 25 mg - Tier 1; QL propranolol hcl er (generic for INDERAL LA) - Tier 1; DX2RX; QL propranolol hcl oral solution 20 mg/5ml - Tier 1; QL propranolol hcl oral solution 40 mg/5ml - Tier 1 propranolol hcl oral tablet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 50 Preferred Agents Non-Preferred Agents Calcium Channel Blocking Agents - Blood Pressure Drugs amlodipine besylate oral (generic for NORVASC) - Tier 1; QL cartia xt (generic for CARTIA XT) - Tier 1; QL diltiazem hcl er - Tier 1; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL diltiazem hcl er coated beads oral capsule extended release 24 hour (generic for CARTIA XT) - Tier 1; QL diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL dilt-xr - Tier 1; QL felodipine er - Tier 1; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; QL nifedipine oral (generic for PROCARDIA) - Tier 1; QL nimodipine oral - Tier 1; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QL verapamil hcl er oral tablet extended release (generic for CALAN SR) - Tier 1; QL verapamil hcl oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL BIDIL - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL CORLANOR - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL captopril-hydrochlorothiazide - Tier 1; QL digitek (generic for DIGITEK) - Tier 1; QL digox (generic for DIGITEK) - Tier 1; QL digoxin oral solution - Tier 1 digoxin oral tablet (generic for DIGITEK) - Tier 1; QL enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL ENTRESTO - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL methyldopa-hydrochlorothiazide - Tier 1; QL pentoxifylline er - Tier 1; QL propranolol-hctz - Tier 1; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL ranolazine er (generic for RANEXA) - Tier 1; ST; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL VYNDAMAX - Tier 2; PA; SP; QL VYNDAQEL - Tier 2; PA; SP; QL Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral - Tier 1; QL Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1; QL furosemide oral solution 10 mg/ml - Tier 1; QL furosemide oral tablet (generic for LASIX) - Tier 1; QL torsemide - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL Diuretics, Thiazide - Cardiac Drugs chlorthalidone - Tier 1; QL DIURIL - Tier 2; QL hydrochlorothiazide oral capsule - Tier 1; QL hydrochlorothiazide oral tablet 12.5 mg - Tier 1 hydrochlorothiazide oral tablet 25 mg, 50 mg - Tier 1; QL indapamide - Tier 1; QL metolazone - Tier 1; QL Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral tablet 160 mg, 54 mg - Tier 1; PA; ST; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL lovastatin oral - Tier 1; QL; AL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL simvastatin oral (generic for ZOCOR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light oral powder (generic for PREVALITE) - Tier 1 NEXLETOL - Tier 2; PA; QL cholestyramine oral powder (generic for QUESTRAN) - Tier 1; Only PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL the bulk products are covered (cans) Individual packets are not covered; QL ezetimibe (generic for ZETIA) - Tier 1; PA; QL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QL niacor (generic for NIACOR) - Tier 1; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL prevalite oral powder (generic for PREVALITE) - Tier 1 REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/PA; SP; QL Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate - Tier 1; QL isosorbide mononitrate - Tier 1; QL isosorbide mononitrate er - Tier 1; QL minitran (generic for MINITRAN) - Tier 1; QL NITRO-BID - Tier 2; QL NITRO-DUR (brand for nitroglycerin) - Tier 2; QL nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL RECTIV - Tier 2; DX2RX; QL Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA; SP; QL KESIMPTA - Tier 2; PA; SP; QL Central Nervous System Agents - Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; ADZENYS XR-ODT - Tier 2; PA; QL; AL DX2RX; QL; AL DYANAVEL XR - Tier 2; PA; QL; AL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL; AL Tier 1; DX2RX; QL; AL EVEKEO ODT - Tier 2; PA; QL; AL MYDAYIS - Tier 2; PA; QL; AL VYVANSE ORAL CAPSULE - Tier 2; PA; QL; AL VYVANSE ORAL TABLET CHEWABLE - Tier 2; PA; QL ZENZEDI - Tier 2; PA; QL; AL Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; QL; AL APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; PA; QL; AL guanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; QL; AL CONCERTA (brand for methylphenidate hcl er) - Tier 2; DX2RX; QL; AL methylphenidate hcl er (cd) - Tier 1; DX2RX; QL; AL COTEMPLA XR-ODT - Tier 2; PA; QL; AL methylphenidate hcl er (la) oral capsule extended release 24 hour 20 DAYTRANA - Tier 2; PA; QL; AL mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX; QL; AL FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 10 mg, 20 mg - JORNAY PM - Tier 2; PA; QL; AL Tier 1; DX2RX; QL; AL KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 METHYLIN (brand for methylphenidate hcl) - Tier 2; PA; QL; AL mg, 54 mg (generic for CONCERTA) - Tier 1; DX2RX; QL; AL RITALIN (brand for methylphenidate hcl) - Tier 2; DX2RX; QL; AL methylphenidate hcl er oral tablet extended release 24 hour - Tier 1; STRATTERA (brand for atomoxetine hcl) - Tier 2; DX2RX; QL; AL DX2RX; Mallinckrodt and Kremers Urban labelers; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX; QL; AL

Central Nervous System, Other - Miscellaneous Central Nervous System Drugs AUSTEDO - Tier 2; PA; SP; QL caffeine citrate oral - Tier 1; QL; AL INGREZZA - Tier 2; PA; SP; QL NUEDEXTA - Tier 2; DX2RX; QL riluzole (generic for RILUTEK) - Tier 1; QL tetrabenazine (generic for XENAZINE) - Tier 1; PA; SP; QL Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain pregabalin oral (generic for LYRICA) - Tier 1; QL Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO - Tier 2; PA; SP; QL AVONEX PEN - Tier 2; PA; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; PA; SP; QL AVONEX PREFILLED - Tier 2; PA; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; PA; BETASERON - Tier 2; PA; SP SP; QL COPAXONE (brand for glatiramer acetate) - Tier 2; PA; SP; QL GILENYA - Tier 2; PA; SP; QL EXTAVIA - Tier 2; PA; SP glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP; QL MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL glatopa (generic for GLATOPA) - Tier 1; PA; SP; QL MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; PA; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL PLEGRIDY SUBCUTANEOUS - Tier 2; PA; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents REBIF - Tier 2; PA; SP; QL REBIF REBIDOSE - Tier 2; PA; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; PA; SP; QL TECFIDERA (brand for dimethyl fumarate) - Tier 2; PA; SP; QL VUMERITY - Tier 2; PA; SP; QL

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier 1; QL DENTA 5000 PLUS (brand for sodium fluoride) - Tier 2; QL DENTAGEL (brand for sodium fluoride) - Tier 2 easygel - Tier 1 fluoridex daily renewal - Tier 1 oralone (generic for ORALONE) - Tier 1; QL periogard (generic for PERIOGARD) - Tier 1; QL pilocarpine hcl oral tablet 5 mg (generic for SALAGEN) - Tier 1; QL pilocarpine hcl oral tablet 7.5 mg (generic for SALAGEN) - Tier 1 PREVIDENT 5000 DRY MOUTH (brand for sodium fluoride) - Tier 2 PREVIDENT 5000 PLUS (brand for sodium fluoride) - Tier 2; QL PREVIDENT DENTAL (brand for sodium fluoride) - Tier 2 sf (generic for CAVAREST) - Tier 1 sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental gel (generic for CAVAREST) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL Dermatological Agents - Drugs to Treat Skin Conditions accutane (generic for ACCUTANE) - Tier 1; PA; QL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL acitretin (generic for SORIATANE) - Tier 1; PA; QL ABSORICA LD - Tier 2; PA; QL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL WASH) - Tier 1 ACZONE EXTERNAL GEL 7.5 % (brand for dapsone) - Tier 2; PA; QL advanced acne spot treat (generic for CLEAN & CLEAR ACNE ALDARA (brand for imiquimod) - Tier 2; PA; QL SCRUB) - Tier 1 AMZEEQ - Tier 2; PA; QL advanced healing external ointment (generic for AQUAPHILIC) - Tier ATRALIN (brand for tretinoin) - Tier 2; PA; QL; AL 1 BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - alclometasone dipropionate external ointment - Tier 1; QL Tier 2; PA; QL alum sulfate-ca acetate (generic for DOMEBORO) - Tier 1 BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL amcinonide external ointment - Tier 1 CARAC (brand for fluorouracil) - Tier 2; PA; QL ammonium lactate external (generic for AL12) - Tier 1; QL CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL arthritis pain relieving - Tier 1; QL DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL astringent solution (generic for DOMEBORO) - Tier 1 DIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QL AVAR-E EMOLLIENT (brand for sulfacetamide sodium-sulfur) - Tier 2 DIFFERIN EXTERNAL LOTION - Tier 2; PA; QL AVAR-E GREEN (brand for sulfacetamide sodium-sulfur) - Tier 2 DOVONEX (brand for calcipotriene) - Tier 2; PA; ST; QL AVITA EXTERNAL CREAM (brand for tretinoin) - Tier 2; ST; QL; AL DUPIXENT - Tier 2; PA; SP; QL azelaic acid external (generic for FINACEA) - Tier 1; QL EFUDEX (brand for fluorouracil) - Tier 2; PA; QL baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - ELIDEL (brand for pimecrolimus) - Tier 2; PA; ST; Minimum age of 2 Tier 1; QL years; QL; AL beauty 360 pure glycerin - Tier 1 ENSTILAR - Tier 2; PA; QL BENZAC AC WASH (brand for bp wash) - Tier 2; QL EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 58 Preferred Agents Non-Preferred Agents betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier EPIDUO FORTE - Tier 2; PA; QL 1; QL FABIOR (brand for tazarotene) - Tier 2; PA; QL betamethasone dipropionate external lotion - Tier 1 FINACEA (brand for azelaic acid) - Tier 2; PA; QL betamethasone dipropionate external ointment - Tier 1; QL LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL betamethasone valerate external cream - Tier 1; QL MIRVASO - Tier 2; PA; QL betamethasone valerate external lotion - Tier 1 OLUX (brand for clobetasol propionate) - Tier 2; PA; QL betamethasone valerate external ointment - Tier 1; QL OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL boro-packs (generic for DOMEBORO) - Tier 1 ONEXTON - Tier 2; PA; QL BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % (brand PROTOPIC EXTERNAL OINTMENT 0.03 % (brand for tacrolimus) - Tier for eql baby basics diaper rash) - Tier 2; QL 2; PA; ST; Minimum age of 2 years; QL; AL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 PROTOPIC EXTERNAL OINTMENT 0.1 % (brand for tacrolimus) - Tier 2; calamine external lotion 8-8 % - Tier 1 PA; ST; Minimum age of 16 years; QL; AL calamine-zinc oxide external lotion - Tier 1 QBREXZA - Tier 2; PA; QL calcipotriene external cream (generic for DOVONEX) - Tier 1; ST; QL RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL; calcipotriene external ointment (generic for CALCITRENE) - Tier 1; AL ST; QL RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL; AL calcipotriene external solution - Tier 1; QL RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere calcitriol external (generic for VECTICAL) - Tier 1; ST; QL pump) - Tier 2; PA; QL; AL capsaicin cream 0.1 % external (generic for CAPZASIN-HP) - Tier 1; RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; AL QL RHOFADE - Tier 2; PA; QL cerovel - Tier 1; QL SERNIVO - Tier 2; PA; QL claravis (generic for AMNESTEEM) - Tier 1; PA; QL SILIQ - Tier 2; PA; SP; QL clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL SOOLANTRA - Tier 2; PA; QL clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL SORILUX (brand for calcipotriene) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1; TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL QL TALTZ - Tier 2; PA; SP; QL clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier TAZORAC EXTERNAL CREAM - Tier 2; PA; QL 1; QL TAZORAC EXTERNAL GEL 0.1 % - Tier 2; PA; QL clindamycin phosphate external solution - Tier 1; QL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL clindamycin phosphate external swab (generic for CLINDACIN ETZ) - TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL Tier 1; QL TREMFYA - Tier 2; PA; SP; QL clobetasol prop emollient base - Tier 1; QL VANOS (brand for fluocinonide) - Tier 2; PA; QL clobetasol propionate e - Tier 1; QL VECTICAL (brand for calcitriol) - Tier 2; PA; ST; QL clobetasol propionate external solution - Tier 1; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL clotrimazole-betamethasone - Tier 1; QL ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL ZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML - Tier 2; PA; SP; QL COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML - Tier 2; PA; SP; QL daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1 diaper rash external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene treatment) - Tier 2; QL DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL DR SMITHS DIAPER - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents erythromycin external (generic for ERYGEL) - Tier 1; QL EUCRISA - Tier 2; ST; QL fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; QL fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; QL fluocinonide emulsified base - Tier 1; QL fluocinonide external solution - Tier 1; QL fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL fluorouracil external solution - Tier 1 fluticasone propionate external cream - Tier 1; QL fluticasone propionate external ointment - Tier 1; QL glycerin external - Tier 1 glycerin external liquid 99.5 % - Tier 1 halobetasol propionate external cream - Tier 1; QL hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL hydrocortisone butyrate external ointment - Tier 1; QL hydrocortisone butyrate external solution - Tier 1; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL hydrocortisone external lotion 2.5 % - Tier 1; QL hydrocortisone external ointment 0.5 % - Tier 1 hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH RELIEF MAX STR) - Tier 1; QL hydrocortisone external ointment 2.5 % - Tier 1; QL hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone-aloe - Tier 1 hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 ILUMYA - Tier 2; PA; SP; QL imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL instacort 5 - Tier 1; QL isotretinoin oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; QL isotretinoin oral capsule 20 mg, 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; PA; QL lactic acid external - Tier 1 medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1 methoxsalen rapid - Tier 1 mometasone furoate external - Tier 1; QL myorisan (generic for AMNESTEEM) - Tier 1; PA; QL NEUTROGENA OIL-FREE ACNE WASH (brand for eql acne scrub pink grapefruit) - Tier 2 NUTRAPLUS EXTERNAL CREAM (brand for urea 10 hydrating) - Tier 2; QL OVACE PLUS WASH EXTERNAL LIQUID (brand for sodium sulfacetamide wash) - Tier 2 OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2 PANOXYL (brand for bp wash) - Tier 2 pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2 years; QL; AL podofilox external - Tier 1; QL prednicarbate external cream - Tier 1; QL REGRANEX - Tier 2; DX2RX; QL SANTYL - Tier 2; QL sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1 sulfacetamide sodium external liquid (generic for OVACE PLUS WASH) - Tier 1 sulfacetamide sodium-sulfur cream 10-5 % external (generic for AVAR-E EMOLLIENT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1 sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; QL sulfacetamide sodium-sulfur liquid 9-4.5 % external (generic for SUMADAN WASH) - Tier 1; QL sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfamez wash - Tier 1 tacrolimus external ointment 0.03 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 2 years; QL; AL tacrolimus external ointment 0.1 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 16 years; QL; AL tretinoin external cream (generic for AVITA) - Tier 1; ST; QL; AL triamcinolone acetonide external cream - Tier 1; QL triamcinolone acetonide external lotion 0.025 % - Tier 1 triamcinolone acetonide external lotion 0.1 % - Tier 1; QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier 1; QL triderm (generic for TRIDERM) - Tier 1; QL wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1 zaclir cleansing - Tier 1 zenatane (generic for AMNESTEEM) - Tier 1; PA; QL zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL Dermatological Agents - Skin Agents ZILXI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs BPROTECTED PEDIA IRON (brand for pc pediatric iron drops) - Tier 2; QL calcium 500/d oral tablet (generic for RA HI CAL) - Tier 1; QL calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL calcium 600/vitamin d - Tier 1 calcium 600/vitamin d-3 - Tier 1; QL calcium 600+d oral tablet 600-400 mg-unit - Tier 1; QL calcium 600+d tablet 600-400 mg-unit oral 600-400 mg-unit - Tier 1 calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1; QL calcium carbonate-vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium carbonate-vitamin d3 - Tier 1; QL calcium fast dissolution - Tier 1; QL calcium high potency - Tier 1; QL calcium oral tablet 1500 (600 ca) mg - Tier 1; QL calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; QL calcium plus vitamin d oral tablet 500-5 mg-mcg (generic for OYSCO 500+D) - Tier 1; QL calcium plus vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium plus vitamin d3 - Tier 1; QL calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier 1 calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 64 Preferred Agents Non-Preferred Agents calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL CARBAGLU - Tier 2; PA; SP effer-k oral tablet effervescent 25 meq - Tier 1; QL electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL ENFAMIL ENFALYTE (brand for ra pediatric electrolyte) - Tier 2; QL ferate (generic for FERATE) - Tier 1 FER-IN-SOL (brand for pc pediatric iron drops) - Tier 2; QL ferocon (generic for TRICON) - Tier 1 ferosul (generic for FEROSUL) - Tier 1; QL ferotrinsic (generic for TRICON) - Tier 1 ferrex 150 (generic for FERREX 150) - Tier 1 ferric x-150 (generic for FERREX 150) - Tier 1 ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1 ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL ferrous sulfate oral elixir - Tier 1 ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for BPROTECTED PEDIA IRON) - Tier 1; QL ferrous sulfate oral tablet delayed release - Tier 1; QL ferrous sulfate tablet 325 (65 fe) mg oral (generic for FEROSUL) - Tier 1; QL fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL fluoritab (generic for NAFRINSE DROPS) - Tier 1; QL folic acid oral tablet 1 mg - Tier 1; QL folic acid oral tablet 400 mcg - Tier 1 foltrin (generic for TRICON) - Tier 1 hi cal (generic for RA HI CAL) - Tier 1; QL iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL iron supplement childrens (generic for BPROTECTED PEDIA IRON) - Tier 1; QL klor-con (generic for KLOR-CON) - Tier 1; QL klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL klor-con/ef - Tier 1; QL K-PHOS-NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL k-prime - Tier 1; QL magnesium oral tablet 500 mg - Tier 1; AL magnesium oxide oral tablet 500 mg - Tier 1; AL magnesium oxide tablet 400 (241.3 mg) mg oral (generic for MAGNESIUM-OXIDE) - Tier 1; AL magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1; AL myferon 150 (generic for FERREX 150) - Tier 1 myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 nafrinse (generic for NAFRINSE) - Tier 1; QL nafrinse drops (generic for NAFRINSE DROPS) - Tier 1; QL NU-IRON (brand for ferric x-150) - Tier 2 oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL OS-CAL CALCIUM + D3 (brand for calcium 500 + d) - Tier 2; QL oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium plus d tablet 500-200 mg-unit oral (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium tablet 500 mg oral (generic for OYSTERCAL) - Tier 1; QL oyster shell calcium/d oral tablet 250-250 mg-unit - Tier 1 oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1; QL oyster shell calcium/vitamin d tablet 500-200 mg-unit oral (generic for OYSCO 500+D) - Tier 1; QL ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - Tier 1; QL ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL PEDIALYTE FREEZER POPS (brand for ra pediatric electrolyte) - Tier 2; QL PEDIALYTE ORAL SOLUTION (brand for ra pediatric electrolyte) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 66 Preferred Agents Non-Preferred Agents PEDIALYTE SINGLES (brand for ra pediatric electrolyte) - Tier 2; QL pediatric electrolyte oral solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL PHOSPHA 250 NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL poly-iron 150 (generic for FERREX 150) - Tier 1 poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide-iron complex (generic for FERREX 150) - Tier 1 potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL potassium chloride er oral capsule extended release 10 meq - Tier 1; QL potassium chloride er oral tablet extended release (generic for KLOR- CON 10) - Tier 1; QL potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) - Tier 1; QL potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL potassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1 potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 potassium citrate-citric acid - Tier 1 PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2 REHYDRALYTE (brand for ra pediatric electrolyte) - Tier 2; QL sod citrate-citric acid - Tier 1 sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1 sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1 sodium fluoride oral tablet chewable - Tier 1; QL TRICON (brand for foltrin) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 67 Preferred Agents Non-Preferred Agents virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL deferasirox oral packet (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL deferasirox oral tablet (generic for JADENU) - Tier 1; PA; SP; QL deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; PA; SP LOKELMA - Tier 2; PA; QL sps - Tier 1; QL VELTASSA - Tier 2; PA; QL Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) oral tablet (generic for CALPHRON) - AURYXIA - Tier 2; PA; QL Tier 1; QL VELPHORO - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; QL sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; ST; QL Vitamins a-25 - Tier 1; QL animal shapes/iron (generic for CEROVITE JR) - Tier 1; QL; AL AQUADEKS - Tier 2; DX2RX; QL; AL aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL ascorbic acid tablet 500 mg oral (generic for PUREWAY-C) - Tier 1; QL ATABEX OB - Tier 2; QL b complex oral capsule - Tier 1; QL b complex vitamins - Tier 1; QL b-1 - Tier 1; QL b6 - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents b-complex oral tablet - Tier 1 b-complex with b-12 - Tier 1 b-complex/b-12 oral - Tier 1 biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL BPROTECTED PEDIA D-VITE (brand for d-vite pediatric) - Tier 2; QL BPROTECTED VITAMIN C (brand for ascorbic acid) - Tier 2; QL c 250 oral tablet - Tier 1; QL c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL calcidol (generic for CALCIDOL) - Tier 1; QL CENTRUM FLAVOR BURST KIDS (brand for disney princess gummies) - Tier 2; QL; AL chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; QL childrens chewable vitamins (generic for BOUNTY BEARS/C) - Tier 1; QL childrens vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL; AL classic prenatal - Tier 1; QL CO-NATAL FA (brand for neonatal complete) - Tier 2; QL cyanocobalamin injection solution 1000 mcg/ml - Tier 1; QL CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML - Tier 2; QL d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1; AL d3 super strength - Tier 1; QL; AL d3-50 (generic for D3-50) - Tier 1; QL daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for cvs vitamin d3) - Tier 2 D-VI-SOL (brand for d-vite pediatric) - Tier 2; QL d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL ENFAMIL EXPECTA - Tier 2; QL ergocalciferol oral (generic for DRISDOL) - Tier 1; QL essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 fruity c - Tier 1; QL gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL; AL INATAL GT - Tier 2; QL kp vitamin d3 capsule 50 mcg (2000 ut) oral 50 mcg (2000 ut) - Tier 1; QL; AL lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL M-NATAL PLUS - Tier 2; QL multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins essential (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL MULTIPRO - Tier 2 multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multivitamin/fluoride tablet chewable 0.25 mg oral (generic for QUFLORA PEDIATRIC) - Tier 1; QL multivitamin/fluoride tablet chewable 0.5 mg oral (generic for QUFLORA PEDIATRIC) - Tier 1; QL multivitamin/fluoride tablet chewable 1 mg oral (generic for QUFLORA PEDIATRIC) - Tier 1; QL multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents mynephrocaps (generic for MYNEPHRON) - Tier 1 MYNEPHRON (brand for mynephrocaps) - Tier 2 NEONATAL COMPLETE - Tier 2; QL NEONATAL PLUS (brand for prenatal plus) - Tier 2; QL NEONATAL VITAMIN (brand for prenatal) - Tier 2; QL niacin er capsule extended release 250 mg oral - Tier 1; QL niacin er oral capsule extended release 500 mg - Tier 1 niacin er oral tablet extended release 500 mg (generic for SLO- NIACIN) - Tier 1 NIVA-PLUS (brand for prenatal plus) - Tier 2; QL nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL O-CAL PRENATAL - Tier 2; QL one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 ONE VITE WOMENS - Tier 2; QL ONE VITE WOMENS PLUS - Tier 2; QL one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONEVITE - Tier 2; QL phytonadione oral (generic for MEPHYTON) - Tier 1; QL POLY-VI-SOL (brand for pc pediatric poly-vitamin drop) - Tier 2; QL POLY-VITE PEDIATRIC - Tier 2; QL PRENATABS RX (brand for thrivite rx) - Tier 2; QL prenatal formula oral tablet 28-0.8 mg - Tier 1; QL prenatal multi+dha - Tier 1; QL prenatal multivitamins - Tier 1; QL prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier 1; QL prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; QL prenatal oral tablet 28-0.8 mg - Tier 1; QL prenatal plus iron (generic for PRENATABS RX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; QL prenatal vitamins oral tablet 28-0.8 mg - Tier 1; QL prenatal/iron - Tier 1; QL PRENATAL-U - Tier 2; QL PRENATVITE RX - Tier 2; QL preplus (generic for NEONATAL PLUS) - Tier 1; QL PRETAB - Tier 2; QL pyridoxine hcl oral - Tier 1; QL SLO-NIACIN ORAL TABLET EXTENDED RELEASE 500 MG (brand for niacin er) - Tier 2 tab-a-vite (generic for LYSIPLEX PLUS) - Tier 1 tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thiamine hcl oral - Tier 1; QL thiamine mononitrate oral - Tier 1; QL TRINATE - Tier 2; QL UDAMIN SP (brand for onevite) - Tier 2; QL v-c forte (generic for VIC-FORTE) - Tier 1 vic-forte (generic for VIC-FORTE) - Tier 1 VINATE II - Tier 2; QL VINATE ONE - Tier 2; QL vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL vitamin a oral capsule 3 mg (10000 ut) - Tier 1; QL vitamin b-1 oral tablet 100 mg - Tier 1; QL vitamin b-12 er tablet extended release 1000 mcg oral - Tier 1 vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1 vitamin b-6 - Tier 1; QL vitamin c er oral tablet extended release 1500 mg - Tier 1; QL vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN C) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents vitamin c oral tablet 250 mg - Tier 1; QL vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c oral tablet chewable 250 mg - Tier 1; QL vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c tablet 250 mg oral 250 mg - Tier 1; QL vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c-rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1; AL vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QL vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1; AL vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL; AL vitamin d3 capsule 1.25 mg (50000 ut) oral 1.25 mg (50000 ut) (generic for D3-50) - Tier 1; QL vitamin d3 capsule 250 mcg (10000 ut) oral 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL; AL vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL; AL vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1; AL vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents vitamin d3 oral tablet chewable 25 mcg (generic for KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1 vitamin d3 tablet 25 mcg (1000 ut) oral 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1; AL vitamin-b complex - Tier 1 VITATHELY WITH GINGER (brand for prenatal plus) - Tier 2; QL WESTAB PLUS - Tier 2; QL womens prenatal+dha - Tier 1; QL ZYVANA - Tier 2 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; QL dicyclomine hcl oral capsule - Tier 1; QL dicyclomine hcl oral solution - Tier 1 dicyclomine hcl oral tablet - Tier 1; QL ED-SPAZ - Tier 2; QL glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL hyoscyamine sulfate oral tablet (generic for LEVSIN) - Tier 1; QL hyoscyamine sulfate oral tablet dispersible (generic for ANASPAZ) - Tier 1; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL NULEV (brand for hyoscyamine sulfate) - Tier 2; QL oscimin oral (generic for LEVSIN) - Tier 1; QL oscimin sr (generic for LEVBID) - Tier 1; QL SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex (generic for ABATINEX) - Tier 1 OMECLAMOX-PAK - Tier 2; PA acid gone oral suspension - Tier 1 PYLERA - Tier 2; PA acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1 RELISTOR - Tier 2; PA; QL acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1 SYMPROIC - Tier 2; PA; QL acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier 1 acidophilus probiotic oral tablet 0.5 mg (generic for FLORANEX) - Tier 1 acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1 adult 50+ probiotic (generic for RESTORA) - Tier 1; QL adult probiotic (generic for RESTORA) - Tier 1; QL advanced antacid max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL almacone double strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid & gas relief (generic for MINTOX) - Tier 1; QL antacid advanced (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 75 Preferred Agents Non-Preferred Agents antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas (generic for MINTOX) - Tier 1; QL antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas max strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid extra strength oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid extra strength oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid extra strength tablet chewable 750 mg oral 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid fast relief (generic for MINTOX) - Tier 1; QL antacid i (generic for MINTOX) - Tier 1; QL antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid liquid (generic for MINTOX) - Tier 1; QL antacid m (generic for MINTOX) - Tier 1; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid maximum strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1; QL antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid regular strength oral suspension (generic for MINTOX) - Tier 1; QL antacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 antacid supreme - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1 anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1 anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 biotinex (generic for ABATINEX) - Tier 1 bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL bismuth (generic for SOOTHE) - Tier 1; QL bismuth subsalicylate oral suspension (generic for SOOTHE) - Tier 1 bismuth subsalicylate oral tablet chewable (generic for SOOTHE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 77 Preferred Agents Non-Preferred Agents calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium carbonate antacid oral suspension - Tier 1; QL calcium carbonate antacid oral tablet chewable (generic for CAL- GEST ANTACID) - Tier 1 calcium carbonate oral tablet chewable 500 mg (generic for CAL- GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 childrens soothe - Tier 1 comfort gel (generic for MINTOX) - Tier 1; QL comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL digestive probiotic capsule oral (generic for RESTORA) - Tier 1; QL diamode (generic for IMODIUM A-D) - Tier 1 diarrhea (generic for SOOTHE) - Tier 1 diarrhea relief (generic for SOOTHE) - Tier 1 digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 diotame instydose (generic for SOOTHE) - Tier 1 diphenoxylate-atropine - Tier 1; QL floranex tablet oral (generic for FLORANEX) - Tier 1 FLORANEX TABLET ORAL (brand for acidophilus probiotic) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1 gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief extra strength oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extra strength oral tablet chewable 125 mg (generic for GAS- X EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension 20 mg/0.3ml (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral tablet chewable 80 mg - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for hm gas relief extra strength) - Tier 2 GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for simethicone) - Tier 2 GAS-X ULTRA STRENGTH (brand for simethicone ultra strength) - Tier 2 GATTEX - Tier 2; PA; SP; QL GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for antacid extra strength) - Tier 2 GAVISCON ORAL SUSPENSION - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1; QL geri-lanta supreme - Tier 1 geri-mox (generic for MINTOX) - Tier 1; QL geri-pectate (generic for SOOTHE) - Tier 1 antacid extra strength tablet chewable 750 mg oral 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 heartburn antacid (generic for GAVISCON EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents heartburn antacid ex st (generic for GAVISCON EXTRA STRENGTH) - Tier 1 heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1 heartburn relief oral tablet chewable 160-105 mg (generic for GAVISCON EXTRA STRENGTH) - Tier 1 high potency probiotic (generic for RESTORA) - Tier 1; QL IMODIUM A-D ORAL TABLET (brand for eq anti-diarrheal) - Tier 2 IMODIUM MULTI-SYMPTOM RELIEF (brand for goodsense anti- diarr/ant-gas) - Tier 2 infant gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants simethicone (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 lactobacillus oral tablet (generic for FLORANEX) - Tier 1 lacto-pectin (generic for RESTORA) - Tier 1; QL long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1 MAALOX - Tier 2 MAALOX CHILDRENS (brand for childrens pepto) - Tier 2 MAALOX MAX ORAL SUSPENSION (brand for cvs antacid/anti-gas) - Tier 2; QL MAALOX MULTI SYMPTOM MAX ST (brand for cvs antacid/anti-gas) - Tier 2; QL mag-al plus (generic for MINTOX) - Tier 1; QL mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL magnesium oxide oral tablet 400 mg - Tier 1; AL magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1; AL MAOX (brand for magnesium oxide) - Tier 2; AL mega probiotic (generic for RESTORA) - Tier 1; QL meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL mi-acid gas relief - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mood support probiotic (generic for RESTORA) - Tier 1; QL MOTEGRITY - Tier 2; DX2RX; ST; QL MOVANTIK - Tier 2; DX2RX; ST; QL MYTESI - Tier 2; DX2RX; QL peptic relief (generic for SOOTHE) - Tier 1; QL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for gnp stomach relief) - Tier 2 PHAZYME (brand for simethicone) - Tier 2 PHAZYME ULTRA STRENGTH (brand for simethicone ultra strength) - Tier 2 pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1 pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL pink-bismuth (generic for SOOTHE) - Tier 1; QL pro-biotic blend (generic for RESTORA) - Tier 1; QL probiotic colon care (generic for RESTORA) - Tier 1; QL probiotic complex (generic for RESTORA) - Tier 1; QL probiotic maximum strength (generic for RESTORA) - Tier 1; QL probiotic oral capsule (generic for RESTORA) - Tier 1; QL probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 probiotic pearls ex st (generic for RESTORA) - Tier 1; QL RESTORA (brand for cvs probiotic maximum strength) - Tier 2; QL RESTORA RX - Tier 2 RISAQUAD (brand for cvs probiotic maximum strength) - Tier 2; QL RISAQUAD-2 (brand for cvs probiotic maximum strength) - Tier 2; QL senior probiotic (generic for RESTORA) - Tier 1; QL simeped (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 simethicone oral (generic for GAS-X EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 81 Preferred Agents Non-Preferred Agents simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 smooth antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sodium bicarbonate oral tablet - Tier 1 soothe maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 soothe oral suspension (generic for SOOTHE) - Tier 1 soothe oral tablet (generic for SOOTHE) - Tier 1 soothe oral tablet chewable (generic for SOOTHE) - Tier 1; QL stomach relief extra strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max st oral suspension 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527 mg/30ml (generic for SOOTHE) - Tier 1 stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1 stomach relief oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 TRULANCE - Tier 2; DX2RX; ST; QL TUMS (brand for calcium carbonate antacid) - Tier 2 TUMS CHEWY BITES (brand for cvs antacid extra strength) - Tier 2 TUMS E-X 750 (brand for cvs antacid extra strength) - Tier 2 TUMS EXTRA STRENGTH 750 (brand for cvs antacid extra strength) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents TUMS LASTING EFFECTS (brand for calcium carbonate antacid) - Tier 2 TUMS SMOOTHIES (brand for cvs antacid extra strength) - Tier 2 TUMS ULTRA 1000 (brand for gnp antacid ultra strength) - Tier 2 ursodiol oral capsule - Tier 1; QL ursodiol oral tablet (generic for URSO 250) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs probiotic maximum strength) - Tier 2; QL ZELAC - Tier 2; QL Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1 cimetidine hcl - Tier 1 cimetidine oral tablet 200 mg (generic for TAGAMET HB) - Tier 1 cimetidine oral tablet 300 mg, 400 mg, 800 mg - Tier 1; QL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL famotidine oral tablet 20 mg (generic for MM ACID-PEP MAXIMUM STRENGTH) - Tier 1; QL famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL famotidine orig st (generic for PEPCID AC) - Tier 1; QL heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1 Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LUBIPROSTONE - Tier 2; DX2RX; ST; QL AMITIZA (brand for lubiprostone) - Tier 2; DX2RX; ST; QL LINZESS - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents Laxatives - Drugs to treat Constipation bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1; QL bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1; QL bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL citrate of magnesia (generic for CITROMA) - Tier 1; QL citroma (generic for CITROMA) - Tier 1; QL CITRUCEL - Tier 2 c-lax laxative (generic for EX-LAX ULTRA) - Tier 1; QL clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL COLACE (brand for stool softener laxative) - Tier 2; QL col-rite oral capsule 250 mg - Tier 1; QL constulose - Tier 1; QL daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 docu (generic for DOCU LIQUID) - Tier 1; QL docusate calcium (generic for SURFAK) - Tier 1 docusate mini (generic for ENEMEEZ MINI) - Tier 1; QL docusate sodium oral capsule (generic for DOK) - Tier 1; QL docusate sodium oral liquid 50 mg/5ml (generic for DOCU LIQUID) - Tier 1; QL docusate sodium oral syrup - Tier 1 docuzen (generic for SENEXON-S) - Tier 1 dok oral capsule (generic for DOK) - Tier 1; QL dss (generic for DOK) - Tier 1; QL easy-lax plus (generic for SENEXON-S) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL enulose - Tier 1; QL EVAC (brand for natural psyllium seed) - Tier 2 EX-LAX ULTRA (brand for qc gentle laxative) - Tier 2; QL fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL fiber laxative (generic for FIBERCON) - Tier 1 fiber laxative + calcium (generic for FIBERCON) - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber oral powder 30.9 % - Tier 1 fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber-caps (generic for FIBERCON) - Tier 1 FIBERCON (brand for gnp fiber-caps) - Tier 2 fiber-lax (generic for FIBERCON) - Tier 1 FLEET BISACODYL - Tier 2; QL FLEET ENEMA (brand for qc enema) - Tier 2 FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents gavilyte-c - Tier 1; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL generlac - Tier 1; QL gentle laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) - Tier 1; QL gentle laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1; QL gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1; QL gentlelax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL geri-kot (generic for SENOKOT) - Tier 1 glycerin (adult) suppository 2 gm rectal - Tier 1 glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin adult rectal suppository 2 gm - Tier 1 glycerin child rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin child rectal suppository 1.2 gm - Tier 1 glycerin childrens (generic for PEDIA-LAX) - Tier 1 glycerin pediatric rectal suppository 1.2 gm - Tier 1 glycolax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL lactulose encephalopathy - Tier 1; QL lactulose oral solution - Tier 1; QL laxacin (generic for SENEXON-S) - Tier 1 laxaclear (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL laxative max str - Tier 1 laxative maximum strength oral tablet 25 mg - Tier 1 laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 86 Preferred Agents Non-Preferred Agents laxative pills (generic for SENNA SMOOTH) - Tier 1 laxative pills max st - Tier 1 laxative pills oral tablet 25 mg - Tier 1 laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1; QL magnesium citrate oral solution (generic for CITROMA) - Tier 1; QL milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for sb polyethylene glycol 3350) - Tier 2; ONLY powder bottle; QL mm clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL mm stool softener laxative (generic for DOK) - Tier 1; QL natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber supplement oral powder (generic for EVAC) - Tier 1 natural laxative (generic for SENOKOT) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENOKOT) - Tier 1 natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natural vegetable laxative (generic for SENOKOT) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL p col-rite (generic for SENEXON-S) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for glycerin (infants & children)) - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for sm milk of magnesia) - Tier 2 polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL psyldex - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 saline enema (generic for FLEET ENEMA) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENOKOT) - Tier 1 senna laxative (generic for SENOKOT) - Tier 1 senna oral tablet (generic for SENOKOT) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna syrup 8.8 mg/5ml oral (otc) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-lax (generic for SENOKOT) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENOKOT) - Tier 1 senna-time (generic for SENOKOT) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 SENOKOT (brand for gnp senna lax) - Tier 2 SENOKOT S (brand for sm natural laxative/stool soft) - Tier 2 silace oral liquid (generic for DOCU LIQUID) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 88 Preferred Agents Non-Preferred Agents smooth lax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL soluble fiber therapy (generic for CITRUCEL) - Tier 1 stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener laxative oral capsule (generic for DOK) - Tier 1; QL stool softener oral capsule 100 mg (generic for DOK) - Tier 1; QL stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral capsule 250 mg - Tier 1; QL stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 womans laxative (generic for EX-LAX ULTRA) - Tier 1; QL womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1; QL womens laxative (generic for EX-LAX ULTRA) - Tier 1; QL Protectants - Ulcer and Stomach Acid Drugs misoprostol oral (generic for CYTOTEC) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members 10 years of age up to 65 years of age will require PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 89 Preferred Agents Non-Preferred Agents Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL Members >= 2 years of age will require PA; QL; AL DEXILANT - Tier 2; PA; QL lansoprazole oral capsule delayed release 15 mg (generic for esomeprazole magnesium oral capsule delayed release (generic for PREVACID) - Tier 1; QL NEXIUM) - Tier 1; PA; QL lansoprazole oral capsule delayed release 30 mg (generic for NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for ra PREVACID) - Tier 1; QL esomeprazole magnesium) - Tier 2; PA; QL lansoprazole oral tablet delayed release dispersible 15 mg (generic for NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG (brand for esomeprazole PREVACID SOLUTAB) - Tier 1; QL; AL magnesium) - Tier 2; PA; Members >= 2 years of age will require PA; QL; lansoprazole oral tablet delayed release dispersible 30 mg (generic for AL PREVACID SOLUTAB) - Tier 1; Members >= 2 years of age will omeprazole magnesium oral tablet delayed release (generic for require PA; QL; AL PRILOSEC OTC) - Tier 1; PA; QL omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members >= 2 years pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA; of age will require PA; QL; AL QL omeprazole magnesium oral capsule delayed release - Tier 1; QL PREVACID (brand for eql lansoprazole) - Tier 2; PA; QL omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20 PRILOSEC - Tier 2; PA; QL base) mg, 40 mg - Tier 1; QL ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL pantoprazole sodium oral tablet delayed release (generic for PROTONIX) - Tier 1; QL PREVACID 24HR (brand for eql lansoprazole) - Tier 2; QL Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CHOLBAM - Tier 2; PA; SP; QL CERDELGA - Tier 2; PA; SP; QL CREON - Tier 2 ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL CYSTAGON - Tier 2; SP; QL PANCREAZE - Tier 2; PA NITYR - Tier 2; DX2RX; SP; QL VIOKACE ORAL TABLET 10440-39150 UNIT - Tier 2; PA RAVICTI - Tier 2; PA; SP; QL ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL sapropterin dihydrochloride (generic for KUVAN) - Tier 1; PA; SP; QL ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000- sodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1; 32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 3000-10000 UNIT, PA; SP 40000-126000 UNIT, 5000-24000 UNIT - Tier 2; PA STRENSIQ - Tier 2; PA; SP TEGSEDI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 90 Preferred Agents Non-Preferred Agents Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QL oxybutynin chloride oral - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL OXYTROL FOR WOMEN - Tier 2; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL tolterodine tartrate (generic for DETROL) - Tier 1; ST; QL ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG trospium chloride - Tier 1; ST; QL (brand for darifenacin hydrobromide er) - Tier 2; PA; QL MYRBETRIQ - Tier 2; PA; QL TOVIAZ - Tier 2; PA; QL VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL tamsulosin hcl (generic for FLOMAX) - Tier 1; QL terazosin hcl - Tier 1; QL Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP azo tabs (generic for PHENAZO) - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL bethanechol chloride oral - Tier 1 ELMIRON - Tier 2; DX2RX; QL penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1; PA; SP; QL phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1; QL phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 91 Preferred Agents Non-Preferred Agents PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL SHUR-SEAL CONTRACEPTIVE - Tier 2; GE urin ds (generic for UTIRA-C) - Tier 1; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 urinary pain relief tablet 95 mg oral (generic for PHENAZO) - Tier 1 UTIRA-C (brand for urin ds) - Tier 2; QL Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs DECADRON ORAL TABLET 0.5 MG, 0.75 MG (brand for dexamethasone) - Tier 2 DECADRON ORAL TABLET 4 MG, 6 MG (brand for dexamethasone) - Tier 2; QL dexamethasone intensol - Tier 1 dexamethasone oral elixir - Tier 1; QL dexamethasone oral solution - Tier 1; QL dexamethasone oral tablet 0.5 mg, 0.75 mg (generic for DECADRON) - Tier 1 dexamethasone oral tablet 1 mg, 2 mg - Tier 1 dexamethasone oral tablet 1.5 mg - Tier 1; QL dexamethasone oral tablet 4 mg, 6 mg (generic for DECADRON) - Tier 1; QL fludrocortisone acetate oral - Tier 1; QL hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - Tier 1; QL MEDROL ORAL TABLET 2 MG - Tier 2 methylprednisolone oral (generic for MEDROL) - Tier 1; QL prednisolone oral solution - Tier 1; QL prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml (generic for PEDIAPRED) - Tier 1; QL prednisone oral solution - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 92 Preferred Agents Non-Preferred Agents prednisone oral tablet - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) - Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; GENOTROPIN - Tier 2; PA; SP DX2RX HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 DDAVP RHINAL TUBE - Tier 2; QL MG, 6 MG - Tier 2; PA; SP desmopressin ace spray refrig - Tier 1; QL NORDITROPIN FLEXPRO - Tier 2; PA; SP desmopressin acetate oral (generic for DDAVP) - Tier 1; QL NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP desmopressin acetate spray - Tier 1; QL NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP INCRELEX - Tier 2; PA; SP NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP NOCDURNA - Tier 2; PA; QL OMNITROPE - Tier 2; PA; SP novarel intramuscular solution reconstituted 10000 unit (generic for SAIZEN - Tier 2; PA; SP NOVAREL) - Tier 1; DX2RX pregnyl (generic for NOVAREL) - Tier 1; DX2RX ZOMACTON - Tier 2; PA; SP ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 93 Preferred Agents Non-Preferred Agents Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs danazol oral - Tier 1; QL testosterone cypionate intramuscular (generic for DEPO- TESTOSTERONE) - Tier 1; QL testosterone enanthate intramuscular - Tier 1; QL testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; QL testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; QL Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL; GE ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE ANGELIQ - Tier 2; PA alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE CLIMARA (brand for estradiol) - Tier 2; PA; QL apri (generic for APRI) - Tier 1; QL; GE CLIMARA PRO - Tier 2; PA aranelle - Tier 1; QL; GE COMBIPATCH - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1; QL; GE DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25 aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE MG/1.25GM - Tier 2; PA; QL aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM - Tier 2; PA aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE ELESTRIN - Tier 2; PA aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE ESTRACE (brand for estradiol) - Tier 2; PA; QL aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 94 Preferred Agents Non-Preferred Agents aviane (generic for AFIRMELLE) - Tier 1; QL; GE estradiol transdermal patch twice weekly (generic for ALORA) - Tier 1; ayuna (generic for ALTAVERA) - Tier 1; QL; GE PA; QL azurette (generic for AZURETTE) - Tier 1; QL; GE estradiol-norethindrone acet oral tablet 1-0.5 mg (generic for MIMVEY) - balziva (generic for BALZIVA) - Tier 1; QL; GE Tier 1; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL; GE ESTRING - Tier 2; PA; QL blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE ESTROGEL - Tier 2; PA blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE EVAMIST - Tier 2; PA briellyn (generic for BALZIVA) - Tier 1; QL; GE FEMRING - Tier 2; PA; QL caziant - Tier 1; QL fyavolv oral tablet 0.5-2.5 mg-mcg - Tier 1; PA chateal (generic for ALTAVERA) - Tier 1; QL; GE fyavolv oral tablet 1-5 mg-mcg - Tier 1; PA; QL chateal eq (generic for ALTAVERA) - Tier 1; QL; GE jinteli - Tier 1; PA; QL cryselle-28 - Tier 1; QL; GE MENEST - Tier 2; PA; QL cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE MENOSTAR - Tier 2; PA; QL cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE mimvey (generic for MIMVEY) - Tier 1; PA; QL cyred (generic for APRI) - Tier 1; QL; GE MINIVELLE (brand for estradiol) - Tier 2; PA; QL cyred eq (generic for APRI) - Tier 1; QL; GE PREFEST - Tier 2; PA; QL dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE PREMARIN VAGINAL - Tier 2; PA; QL dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE VAGIFEM (brand for estradiol) - Tier 2; PA; QL delyla (generic for AFIRMELLE) - Tier 1; QL; GE VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL DEPO-ESTRADIOL - Tier 2; QL desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GE DUAVEE - Tier 2; QL elinest - Tier 1; QL; GE eluryng (generic for ELURYNG) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 95 Preferred Agents Non-Preferred Agents emoquette (generic for APRI) - Tier 1; QL; GE enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GE enskyce (generic for APRI) - Tier 1; QL; GE estarylla (generic for ESTARYLLA) - Tier 1; QL; GE estradiol oral (generic for ESTRACE) - Tier 1; QL estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL estradiol vaginal (generic for ESTRACE) - Tier 1; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL; GE etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE falmina (generic for AFIRMELLE) - Tier 1; QL; GE femynor (generic for ESTARYLLA) - Tier 1; QL; GE hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE iclevia (generic for ICLEVIA) - Tier 1; QL introvale (generic for ICLEVIA) - Tier 1; QL isibloom (generic for APRI) - Tier 1; QL; GE jolessa (generic for ICLEVIA) - Tier 1; QL juleber (generic for APRI) - Tier 1; QL; GE junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) - Tier 1; QL; GE kalliga (generic for APRI) - Tier 1; QL; GE kariva (generic for AZURETTE) - Tier 1; QL; GE kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GE kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GE kurvelo (generic for ALTAVERA) - Tier 1; QL; GE larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE larissia (generic for AFIRMELLE) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 96 Preferred Agents Non-Preferred Agents leena - Tier 1; QL; GE lessina (generic for AFIRMELLE) - Tier 1; QL; GE levonest (generic for ENPRESSE-28) - Tier 1; QL; GE levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg (generic for ICLEVIA) - Tier 1; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1; QL; GE levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1; QL; GE levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL; GE levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GE lillow (generic for ALTAVERA) - Tier 1; QL; GE low-ogestrel - Tier 1; QL; GE lutera (generic for AFIRMELLE) - Tier 1; QL; GE marlissa (generic for ALTAVERA) - Tier 1; QL; GE microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE mili (generic for ESTARYLLA) - Tier 1; QL; GE mono-linyah (generic for ESTARYLLA) - Tier 1; QL; GE necon 0.5/35 (28) - Tier 1; QL; GE norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL; GE norethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL; GE norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GE norgestimate-ethinyl estradiol triphasic (generic for TRI-LO- ESTARYLLA) - Tier 1; QL; GE nortrel 0.5/35 (28) - Tier 1; QL; GE nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nylia 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 97 Preferred Agents Non-Preferred Agents nymyo (generic for ESTARYLLA) - Tier 1; QL; GE orsythia (generic for AFIRMELLE) - Tier 1; QL; GE philith (generic for BALZIVA) - Tier 1; QL; GE pimtrea (generic for AZURETTE) - Tier 1; QL; GE pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE portia-28 (generic for ALTAVERA) - Tier 1; QL; GE PREMARIN ORAL - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1; QL; GE reclipsen (generic for APRI) - Tier 1; QL; GE setlakin (generic for ICLEVIA) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1; QL; GE sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GE sronyx (generic for AFIRMELLE) - Tier 1; QL; GE tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tilia fe - Tier 1; QL; GE tri femynor (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-legest fe - Tier 1; QL; GE tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-mili (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-nymyo (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-previfem (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL; GE trivora (28) (generic for ENPRESSE-28) - Tier 1; QL; GE tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tyblume - Tier 1; QL; GE velivet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents vienva (generic for AFIRMELLE) - Tier 1; QL; GE viorele (generic for AZURETTE) - Tier 1; QL; GE volnea (generic for AZURETTE) - Tier 1; QL; GE vyfemla (generic for BALZIVA) - Tier 1; QL; GE vylibra (generic for ESTARYLLA) - Tier 1; QL; GE wera - Tier 1; QL; GE xulane - Tier 1; QL; GE yuvafem (generic for YUVAFEM) - Tier 1; QL zafemy - Tier 1; QL; GE zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL; GE zovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL; GE Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL; GE camila (generic for CAMILA) - Tier 1; QL; GE deblitane (generic for CAMILA) - Tier 1; QL; GE DEPO-SUBQ PROVERA 104 - Tier 2; QL econtra ez (generic for AFTERA) - Tier 1; QL; GE econtra one-step (generic for AFTERA) - Tier 1; QL; GE errin (generic for CAMILA) - Tier 1; QL; GE heather (generic for CAMILA) - Tier 1; QL; GE incassia (generic for CAMILA) - Tier 1; QL; GE jencycla (generic for CAMILA) - Tier 1; QL; GE levonorgestrel (generic for AFTERA) - Tier 1; QL; GE lyleq (generic for CAMILA) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents lyza (generic for CAMILA) - Tier 1; QL; GE medroxyprogesterone acetate intramuscular (generic for DEPO- PROVERA) - Tier 1; QL; GE medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QL megestrol acetate oral suspension 40 mg/ml - Tier 1; QL megestrol acetate oral tablet 20 mg - Tier 1 megestrol acetate oral tablet 40 mg - Tier 1; QL my choice (generic for AFTERA) - Tier 1; QL; GE my way (generic for AFTERA) - Tier 1; QL; GE new day (generic for AFTERA) - Tier 1; QL; GE nora-be (generic for CAMILA) - Tier 1; QL; GE norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1; QL; GE norlyda (generic for CAMILA) - Tier 1; QL; GE norlyroc (generic for CAMILA) - Tier 1; QL; GE opcicon one-step (generic for AFTERA) - Tier 1; QL; GE option 2 (generic for AFTERA) - Tier 1; QL; GE PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GE progesterone oral (generic for PROMETRIUM) - Tier 1; DX2RX; QL react (generic for AFTERA) - Tier 1; QL; GE sharobel (generic for CAMILA) - Tier 1; QL; GE take action (generic for AFTERA) - Tier 1; QL; GE tulana (generic for CAMILA) - Tier 1; QL; GE Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs clomiphene citrate oral - Tier 1; PA OSPHENA - Tier 2; PA; QL; GE raloxifene hcl (generic for EVISTA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs euthyrox (generic for EUTHYROX) - Tier 1; QL levo-t (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL levoxyl (generic for EUTHYROX) - Tier 1; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL unithroid (generic for EUTHYROX) - Tier 1; QL Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2; QL Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL leuprolide acetate injection - Tier 1; PA; SP LUPANETA PACK - Tier 2; PA; SP LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL ORIAHNN - Tier 2; PA; QL LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL SYNAREL - Tier 2; PA LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; TRIPTODUR - Tier 2; PA; SP; QL PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml (generic for SANDOSTATIN) - Tier 1; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents octreotide acetate injection solution 1000 mcg/ml - Tier 1; SP; QL octreotide acetate injection solution 200 mcg/ml - Tier 1; SP octreotide acetate injection solution 500 mcg/ml (generic for SANDOSTATIN) - Tier 1; SP; QL ORILISSA - Tier 2; PA; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1; QL propylthiouracil oral - Tier 1; QL Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin HAEGARDA - Tier 2; PA; SP; QL BERINERT - Tier 2; PA; SP icatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL RUCONEST - Tier 2; PA; SP; QL Immune Suppressants - Immune System Drugs azathioprine oral (generic for IMURAN) - Tier 1; QL ORENCIA CLICKJECT - Tier 2; PA; SP; QL CIMZIA - Tier 2; PA; SP; QL ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL cyclosporine modified oral capsule 100 mg (generic for GENGRAF) - OTREXUP - Tier 2; PA; QL Tier 1; SP; QL RASUVO - Tier 2; PA; QL cyclosporine modified oral capsule 25 mg (generic for GENGRAF) - REDITREX - Tier 2; PA; QL Tier 1; SP SIMPONI - Tier 2; PA; SP; QL cyclosporine modified oral capsule 50 mg - Tier 1; SP; QL SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL cyclosporine modified oral solution (generic for GENGRAF) - Tier 1; STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL SP XELJANZ ORAL TABLET - Tier 2; PA; SP; QL cyclosporine oral (generic for SANDIMMUNE) - Tier 1; SP; QL XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG - ENBREL - Tier 2; PA; SP; QL Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 MG - ZORTRESS) - Tier 1; SP Tier 2; PA; QL gengraf oral capsule 100 mg (generic for GENGRAF) - Tier 1; SP; QL gengraf oral capsule 25 mg (generic for GENGRAF) - Tier 1; SP HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL KINERET - Tier 2; PA; SP; QL methotrexate oral - Tier 1 methotrexate sodium - Tier 1 methotrexate sodium (pf) - Tier 1 mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; SP; QL mycophenolate sodium (generic for MYFORTIC) - Tier 1; SP; QL OLUMIANT - Tier 2; PA; SP; QL sirolimus oral solution (generic for RAPAMUNE) - Tier 1; SP; QL sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; SP; QL sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1; SP tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1; SP tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; SP; QL ZORTRESS ORAL TABLET 1 MG - Tier 2 Immunomodulators - Immune System Drugs ACTIMMUNE - Tier 2; PA; SP ACTEMRA ACTPEN - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL leflunomide oral (generic for ARAVA) - Tier 1; QL RINVOQ - Tier 2; PA; SP; QL OTEZLA - Tier 2; PA; SP; QL SYNAGIS - Tier 2; PA; SP; QL XOLAIR - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 103 Preferred Agents Non-Preferred Agents Vaccines ADACEL - Tier 2; QL ASTRAZENECA COVID-19 VACCINE - Tier 2; QL BEXSERO - Tier 2; QL BOOSTRIX - Tier 2; QL DAPTACEL - Tier 2; QL DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QL ENGERIX-B - Tier 2; QL GARDASIL 9 - Tier 2; QL HAVRIX - Tier 2; QL HEPLISAV-B - Tier 2; QL; AL HYPERTET S/D - Tier 2; QL INFANRIX - Tier 2; QL JANSSEN COVID-19 VACCINE - Tier 2; QL MENACTRA - Tier 2; QL MENQUADFI - Tier 2; QL MENVEO - Tier 2; QL M-M-R II - Tier 2; QL MODERNA COVID-19 VACCINE - Tier 2; QL PFIZER-BIONTECH COVID-19 VACC - Tier 2; QL PNEUMOVAX 23 - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL; AL TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL TENIVAC - Tier 2; QL TETANUS-DIPHTHERIA TOXOIDS TD - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs balsalazide disodium (generic for COLAZAL) - Tier 1; QL APRISO (brand for mesalamine er) - Tier 2; PA; QL mesalamine oral capsule delayed release 400 mg (generic for ASACOL HD (brand for mesalamine) - Tier 2; PA; QL DELZICOL) - Tier 1; QL COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL mesalamine rectal - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL SFROWASA - Tier 2; QL DIPENTUM - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; PA; QL PENTASA - Tier 2; PA; QL Glucocorticoids - Drugs to Treat Inflammation budesonide oral (generic for ENTOCORT EC) - Tier 1; DX2RX; QL CORTIFOAM - Tier 2; PA; QL hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO- PROCTOFOAM HC - Tier 2; PA MED HC) - Tier 1; QL hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) - Tier 1; QL procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL Sulfonamides - Antibiotics sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium - Tier 1; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL TYMLOS - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents Metabolic Bone Disease Agents - Other calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members >= 8 years of age will require PA; AL Miscellaneous Therapeutic Agents ALCOHOL PREP PADS PAD 70 % - Tier 2; QL ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for easy plus ii glucose anti-fungal external powder (generic for ODOR EATERS test) - Tier 2; PA; QL ANTIFUNGAL) - Tier 1 ACCU-CHEK COMPACT PLUS (brand for easy plus ii glucose test) - Tier athletes foot external powder 2 % (generic for DESENEX) - Tier 1; QL 2; PA; QL BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite 2; QL device/lancets) - Tier 2; PA; QL BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL ACCU-CHEK GUIDE TEST STRIPS (brand for goodsense blood glucose) BD ULTRA-FINE PEN NEEDLES (brand for sure comfort pen needles) - Tier 2; PA; QL - Tier 2; QL ACCU-CHEK SMARTVIEW (brand for easy plus ii glucose test) - Tier 2; DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2; QL PA; QL LANCETS (brand for comfort lancets) - Tier 2; QL ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite device/lancets) - Tier 2; PA; QL LOTRIMIN AF EXTERNAL POWDER (brand for antifungal) - Tier 2; AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; QL PA; QL methergine (generic for METHERGINE) - Tier 1; QL CONTOUR NEXT TEST STRIPS (brand for easy plus ii glucose test) - methylergonovine maleate oral (generic for METHERGINE) - Tier 1; Tier 2; PA; QL QL CONTOUR TEST STRIPS (brand for easy plus ii glucose test) - Tier 2; MYCOZYL AP (brand for antifungal) - Tier 2; QL PA; QL NEODOT THERMOMETER - Tier 2; QL FREESTYLE PRECISION NEO TEST (brand for easy plus ii glucose test) ONETOUCH ULTRA (brand for easy plus ii glucose test) - Tier 2; QL - Tier 2; PA; QL for non-insulin dependent members: allow twice daily testing; QL INSULIN PEN NEEDLES 32G X 6 MM (brand for sure comfort pen ONETOUCH ULTRA 2 KIT W/DEVICE (brand for goodsense blood needles) - Tier 2; PA; QL glucose) - Tier 2; QL LANCETS (brand for comfort lancets) - Tier 2; PA; QL NOVOTWIST PEN NEEDLE (brand for pen needles) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents ONETOUCH ULTRA CONTROL (brand for element compact control ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for 3) - Tier 2; QL goodsense blood glucose) - Tier 2; PA; QL ONETOUCH ULTRA MINI KIT W/DEVICE (brand for goodsense blood ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for goodsense glucose) - Tier 2; QL blood glucose) - Tier 2; PA; QL ONETOUCH VERIO KIT W/DEVICE (brand for goodsense blood PRECISION LINK (brand for goodsense blood glucose) - Tier 2; PA; QL glucose) - Tier 2; QL PRECISION PCX PLUS TEST (brand for easy plus ii glucose test) - Tier ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for 2; PA; QL goodsense blood glucose) - Tier 2; QL PRECISION POINT OF CARE TEST (brand for easy plus ii glucose test) - ONETOUCH VERIO IN VITRO SOLUTION (brand for element Tier 2; PA; QL compact control 3) - Tier 2; QL PRECISION QID MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL ONETOUCH VERIO TEST STRIPS (brand for easy plus ii glucose PRECISION QID TEST (brand for easy plus ii glucose test) - Tier 2; PA; test) - Tier 2; QL for non-insulin dependent members: allow twice daily QL testing; QL PRECISION SOF-TACT MONITOR (brand for verasens blood glucose ONETOUCH VERIO IQ SYSTEM (brand for goodsense blood meter) - Tier 2; PA; QL glucose) - Tier 2; QL PRECISION XTRA BLOOD GLUCOSE (brand for easy plus ii glucose ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for goodsense test) - Tier 2; PA; QL blood glucose) - Tier 2; QL PRECISION XTRA DEVICE (brand for verasens blood glucose meter) - ONETOUCH VERIO SYNC SYSTEM (brand for goodsense blood Tier 2; PA; QL glucose) - Tier 2; QL PRECISION XTRA MONITOR (brand for verasens blood glucose meter) - RUZURGI - Tier 2; PA; SP; QL Tier 2; PA; QL tolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) TRUETRACK TEST (brand for easy plus ii glucose test) - Tier 2; PA; QL - Tier 1 VISTOGARD - Tier 2; QL ZEASORB-AF (brand for antifungal) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 107 Preferred Agents Non-Preferred Agents Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1; QL CEQUA - Tier 2; PA; QL altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 RESTASIS - Tier 2; PA; QL altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL RESTASIS MULTIDOSE - Tier 2; PA; QL altafrin (generic for ALTAFRIN) - Tier 1 TOBRADEX ST - Tier 2; PA; QL altalube (generic for ALTALUBE) - Tier 1; QL ZYLET - Tier 2; PA; QL artificial eye (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic solution (generic for SYSTANE CONTACTS) - Tier 1 artificial tears ophthalmic solution 1.4 % - Tier 1 astringent eye drops (generic for VISINE-AC) - Tier 1; QL atropine sulfate ophthalmic ointment - Tier 1 atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE) - Tier 1; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1; QL bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; QL BIOLLE TEARS (brand for lubricating plus eye drops) - Tier 2 carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) - Tier 1; QL cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - Tier 1; QL CYSTARAN - Tier 2; PA; SP; QL dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL eye drops long lasting (generic for SYSTANE) - Tier 1; QL eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye lubricant (generic for ALTALUBE) - Tier 1; QL for sty relief (generic for ALTALUBE) - Tier 1; QL GENTEAL SEVERE - Tier 2; QL GENTEAL TEARS MODERATE PF (brand for artificial tears pf) - Tier 2 GENTEAL TEARS NIGHT-TIME (brand for lubricant pm) - Tier 2; QL GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.3 % (brand for natural balance tears) - Tier 2 GENTEAL TEARS PF (brand for artificial tears pf) - Tier 2 GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL HYPOTEARS (brand for lubricant pm) - Tier 2; QL ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL lubricant drops fast act (generic for SYSTANE) - Tier 1; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for SYSTANE HYDRATION PF) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - Tier 1; QL lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye pm (generic for ALTALUBE) - Tier 1; QL lubricant pm (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 109 Preferred Agents Non-Preferred Agents lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 MURO 128 OPHTHALMIC OINTMENT (brand for sodium chloride (hypertonic)) - Tier 2 MURO 128 OPHTHALMIC SOLUTION 5 % (brand for cvs sodium chloride) - Tier 2; QL natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-gramicidin - Tier 1; QL neo-polycin (generic for NEO-POLYCIN) - Tier 1 neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1 polycin (generic for POLYCIN) - Tier 1; QL polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QL polyvinyl alcohol ophthalmic - Tier 1 PRED-G S.O.P. - Tier 2 PURALUBE (brand for lubricant pm) - Tier 2; QL REFRESH LACRI-LUBE (brand for lubricant pm) - Tier 2; QL REFRESH P.M. (brand for lubricant pm) - Tier 2; QL REFRESH PLUS (brand for lubricating plus eye drops) - Tier 2 REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2; QL relief eye drops (generic for VISINE-AC) - Tier 1; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 110 Preferred Agents Non-Preferred Agents restore pm (generic for ALTALUBE) - Tier 1; QL sodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1 sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) - Tier 1 sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - Tier 1; QL sulfacetamide-prednisolone ophthalmic solution - Tier 1 SYSTANE COMPLETE (brand for lubricant eye drops) - Tier 2; QL SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2 SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE OPHTHALMIC SOLUTION (brand for cvs lubricant drops fast act) - Tier 2; QL SYSTANE OVERNIGHT THERAPY - Tier 2; QL SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE ULTRA (brand for cvs lubricant drops fast act) - Tier 2; QL SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL TEARS AGAIN (brand for lubricant pm) - Tier 2; QL TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for sm artificial tears) - Tier 2 tears pure (generic for GENTEAL TEARS) - Tier 1 TOBRADEX OPHTHALMIC OINTMENT - Tier 2; QL tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; QL ultra fresh (generic for ULTRA FRESH) - Tier 1; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL VISINE ADVANCED RELIEF (brand for gnp eye drops) - Tier 2; QL VISTA GEL DRY EYE RELIEF - Tier 2; QL VISTA MEIBO TEARS (brand for lubricant eye drops) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents VISTA TEARS (brand for cvs lubricant drops fast act) - Tier 2; QL XIIDRA - Tier 2; PA; QL

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs azelastine hcl ophthalmic - Tier 1; ST cromolyn sodium ophthalmic - Tier 1; QL eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1 olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL PATADAY OPHTHALMIC SOLUTION 0.1 % (brand for eye allergy itch/redness rel) - Tier 2; QL PATADAY OPHTHALMIC SOLUTION 0.2 % (brand for eye allergy itch relief) - Tier 2; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; QL VASOCLEAR-A - Tier 2; QL VISINE (brand for allergy eye) - Tier 2 Ophthalmic Antibiotics - Drugs to treat Eye Infections bacitracin ophthalmic - Tier 1; QL AZASITE - Tier 2; PA; QL ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QL BESIVANCE - Tier 2; PA; QL erythromycin ophthalmic - Tier 1; QL CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA; QL gentak - Tier 1; QL ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL gentamicin sulfate ophthalmic - Tier 1; QL ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL acetazolamide oral - Tier 1; QL AZOPT (brand for brinzolamide) - Tier 2; PA apraclonidine hcl - Tier 1; QL BETIMOL - Tier 2; PA; QL betaxolol hcl ophthalmic - Tier 1; QL BETOPTIC-S - Tier 2; PA; QL brimonidine tartrate ophthalmic - Tier 1; QL COMBIGAN - Tier 2; PA; QL carteolol hcl - Tier 1 COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISTALOL (brand for timolol maleate) - Tier 2; PA; QL 1; QL SIMBRINZA - Tier 2; PA; QL dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL levobunolol hcl - Tier 1; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1 TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for TIMOPTIC) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 113 Preferred Agents Non-Preferred Agents Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALAWAY (brand for ra eye itch relief) - Tier 2; QL ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA ALAWAY CHILDRENS ALLERGY (brand for ra eye itch relief) - Tier 2; ACUVAIL - Tier 2; PA; QL QL ILEVRO - Tier 2; PA; QL allergy eye drops (generic for ALAWAY) - Tier 1; QL NEVANAC - Tier 2; PA; QL CLARITIN EYE (brand for ra eye itch relief) - Tier 2; QL PROLENSA - Tier 2; PA; QL dexamethasone sodium phosphate ophthalmic - Tier 1 diclofenac sodium ophthalmic - Tier 1; QL eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - Tier 1; QL fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL flurbiprofen sodium - Tier 1; QL ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1 ketorolac tromethamine ophthalmic solution 0.5 % (generic for ACULAR) - Tier 1; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; QL prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL prednisolone sodium phosphate ophthalmic - Tier 1 ZADITOR (brand for ra eye itch relief) - Tier 2; QL Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL ZIOPTAN - Tier 2; PA; QL Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 115 Preferred Agents Non-Preferred Agents Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1; QL CHLOR-TRIMETON ALLERGY (brand for cvs allergy relief) - Tier 2; QL CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2; QL Antihistamines - Drugs to Treat Allergies ALAVERT (brand for cvs allergy relief) - Tier 2; QL all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1; QL allergy antihistamine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy childrens oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy medication (generic for BANOPHEN) - Tier 1; QL allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL allergy rel child (loratadine) (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL anti-hist allergy (generic for BANOPHEN) - Tier 1; QL aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL azelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1; QL banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL banophen oral tablet (generic for BANOPHEN) - Tier 1; QL BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for sm allergy relief) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 117 Preferred Agents Non-Preferred Agents BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE (brand for gnp allergy relief) - Tier 2; QL BENADRYL ALLERGY ORAL TABLET (brand for eql allergy relief) - Tier 2; QL cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) - Tier 1; QL cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; QL childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL CLARITIN ALLERGY CHILDRENS (brand for sm loratadine) - Tier 2; QL CLARITIN ORAL TABLET (brand for goodsense allergy relief) - Tier 2; QL CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for cvs allergy relief) - Tier 2; QL clemastine fumarate oral syrup - Tier 1; QL clemastine fumarate oral tablet 2.68 mg - Tier 1; QL complete allergy (generic for BANOPHEN) - Tier 1; QL complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1; QL complete allergy relief (generic for BANOPHEN) - Tier 1; QL cyproheptadine hcl oral - Tier 1; QL DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2; QL diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphen - Tier 1; QL di-phen - Tier 1; QL diphenhist (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral elixir - Tier 1; QL diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 118 Preferred Agents Non-Preferred Agents diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral tablet chewable (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL dye-free allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL geri-dryl (generic for BANOPHEN) - Tier 1; QL h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL hydroxyzine pamoate oral - Tier 1; QL indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1; QL liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL loradamed (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1; QL NARAMIN (brand for sm allergy relief) - Tier 2; QL pharbedryl (generic for BANOPHEN) - Tier 1; QL promethazine hcl oral - Tier 1; QL promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents promethegan - Tier 1; QL px allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief tablet 25 mg oral 25 mg (generic for BANOPHEN) - Tier 1; QL sb allergy medicine oral tablet (generic for BANOPHEN) - Tier 1; QL siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL total allergy (generic for BANOPHEN) - Tier 1; QL total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2; QL ZYRTEC ALLERGY ORAL TABLET (brand for hm all day allergy) - Tier 2; QL Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL ALVESCO - Tier 2; PA allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - ASMANEX (120 METERED DOSES) - Tier 2; PA; QL Tier 1; QL ASMANEX (14 METERED DOSES) - Tier 2; PA; QL ARNUITY ELLIPTA - Tier 2; QL ASMANEX (30 METERED DOSES) - Tier 2; PA; QL ASMANEX HFA - Tier 2; Members >= 8 years of age will require PA; ASMANEX (60 METERED DOSES) - Tier 2; PA; QL QL; AL ASMANEX (7 METERED DOSES) - Tier 2; PA; QL budesonide inhalation (generic for PULMICORT) - Tier 1; Members >= FLOVENT DISKUS - Tier 2; PA; QL 5 years of age will require PA; QL; AL FLOVENT HFA - Tier 2; PA; QL fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL OMNARIS - Tier 2; PA; QL NASACORT ALLERGY 24HR (brand for triamcinolone acetonide) - PULMICORT FLEXHALER - Tier 2; PA; QL Tier 2; QL ZETONNA - Tier 2; PA; QL NASACORT ALLERGY 24HR CHILDREN (brand for triamcinolone acetonide) - Tier 2; QL nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER- CORT) - Tier 1; QL nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; QL QVAR REDIHALER - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 120 Preferred Agents Non-Preferred Agents Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL SEEBRI NEOHALER - Tier 2; PA; QL INCRUSE ELLIPTA - Tier 2; QL SPIRIVA HANDIHALER - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL SPIRIVA RESPIMAT - Tier 2; PA; QL ipratropium bromide nasal - Tier 1; QL TUDORZA PRESSAIR - Tier 2; PA; QL Bronchodilators, Sympathomimetic - Asthma/Lung Drugs albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation AUVI-Q (brand for epinephrine) - Tier 2; PA; QL (generic for PROAIR HFA) - Tier 1; QL BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL MCG/ACT INHALATION - Tier 2; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, PERFOROMIST - Tier 2; PA; QL 2.5 mg/0.5ml - Tier 1; QL PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL mg/3ml - Tier 1; Members >= 8 years of age will require PA; QL; AL SEREVENT DISKUS - Tier 2; PA; QL ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL INHALATION - Tier 2; QL XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier 1; QL albuterol sulfate oral syrup - Tier 1; QL epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier 1; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; ST; QL STRIVERDI RESPIMAT - Tier 2; QL SYMJEPI - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis CAYSTON - Tier 2; PA; SP; QL BETHKIS (brand for tobramycin) - Tier 2; PA; SP; QL KALYDECO - Tier 2; PA; SP; QL KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL ORKAMBI - Tier 2; PA; SP; QL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL SYMDEKO - Tier 2; PA; SP; QL TOBI PODHALER - Tier 2; PA; SP; QL tobramycin inhalation nebulization solution 300 mg/4ml (generic for tobramycin nebulization solution 300 mg/5ml inhalation (generic for BETHKIS) - Tier 1; PA; SP; QL KITABIS PAK) - Tier 1; PA; SP; QL TRIKAFTA - Tier 2; PA; SP; QL TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP; QL Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1; QL cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL NASALCROM (brand for cromolyn sodium) - Tier 2; QL Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN - Tier 2; QL THEO-24 - Tier 2 theophylline - Tier 1; QL theophylline er oral tablet extended release 12 hour 300 mg - Tier 1; QL theophylline er oral tablet extended release 12 hour 450 mg - Tier 1 theophylline er oral tablet extended release 24 hour 400 mg - Tier 1; QL theophylline er oral tablet extended release 24 hour 600 mg - Tier 1 Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS - Tier 2; PA; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP; QL TRACLEER (brand for bosentan) - Tier 2; PA; SP; QL bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL OPSUMIT - Tier 2; PA; SP; QL sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis ESBRIET - Tier 2; PA; SP; QL OFEV - Tier 2; PA; SP; QL Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL 12 hour decongestant nasal (generic for GILTUSS SEVERE SINUS) - ADVAIR HFA - Tier 2; PA; QL Tier 1 AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour mucus relief oral tablet extended release 12 hour 1200 mg PA; QL (generic for EQ MUCUS ER) - Tier 1; QL; AL AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal decongestant (generic for SUDAFED SINUS PA; QL CONGESTION 12HR) - Tier 1 AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal decongestant nasal (generic for GILTUSS SEVERE PA; QL SINUS) - Tier 1 ANORO ELLIPTA - Tier 2; PA; QL 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - BEVESPI AEROSPHERE - Tier 2; PA; QL Tier 1 BREO ELLIPTA - Tier 2; PA; QL 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 DULERA - Tier 2; PA; QL 4-WAY FAST ACTING (brand for hm nose drops) - Tier 2 SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA; 4-WAY MENTHOL (brand for hm nose drops) - Tier 2 ST; QL; AL acetylcysteine inhalation solution 10 % - Tier 1; QL TRELEGY ELLIPTA - Tier 2; PA; QL acetylcysteine inhalation solution 20 % - Tier 1 ADVIL COLD/SINUS (brand for cvs cold & sinus relief) - Tier 2; AL AFRIN NODRIP ORIGINAL (brand for nasal spray max strength) - Tier 2 AFRIN SINUS (brand for nasal spray max strength) - Tier 2 ALAVERT ALLERGY/SINUS (brand for ra allergy/congestion relief) - Tier 2; AL all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy & congestion oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief/nasal decongest oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decongest oral tablet extended release 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy/congestion relief (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL altamist spray (generic for AYR) - Tier 1 altarussin (generic for DIABETIC TUSSIN EX) - Tier 1; AL altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL altarussin-pe - Tier 1; AL anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents aprodine - Tier 1; AL AYR (brand for deep sea nasal spray) - Tier 2 AYR NASAL MIST ALLERGY/SINUS - Tier 2 benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; AL benzonatate oral capsule 200 mg - Tier 1; QL; AL cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; QL; AL chest congest/cough child (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 chest congestion relief dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL chest congestion relief oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL chest congestion relief oral tablet (generic for XPECT) - Tier 1 childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL childrens cough (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 childrens mucus relief cough (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 CLARITIN-D 12 HOUR (brand for ra allergy/congestion relief) - Tier 2; AL CLARITIN-D 24 HOUR (brand for hm allergy relief/nasal decong) - Tier 2; AL cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & sinus relief oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 125 Preferred Agents Non-Preferred Agents cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL COMBIVENT RESPIMAT - Tier 2; QL CORICIDIN HBP COUGH/COLD (brand for cvs cough & cold hbp) - Tier 2; AL cough & chest congestion (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough childrens (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 cough dm (generic for DELSYM) - Tier 1; QL; AL cough dm childrens (generic for DELSYM) - Tier 1; QL; AL cough dm er (generic for DELSYM) - Tier 1; QL; AL cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH) - Tier 1; AL cough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL cough/chest dm childrens oral liquid (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 deep sea nasal spray (generic for AYR) - Tier 1 DELSYM (brand for cvs cough dm childrens) - Tier 2; QL; AL DELSYM COUGH CHILDRENS (brand for cvs cough dm childrens) - Tier 2; QL; AL DELSYM COUGH/CHEST CONGEST DM (brand for cvs chest congest/cough child) - Tier 2 desgen dm oral liquid (generic for DESGEN DM) - Tier 1; AL dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL DIABETIC TUSSIN MAX ST (brand for ra tussin cough/chest dm max) - Tier 2; AL dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL DIMETAPP COLD RELIEF CHILDRENS (brand for px dibromm dm cold/cough child) - Tier 2; QL; AL DIMETAPP COLD/ALLERGY (brand for childrens cold & allergy) - Tier 2; AL DIMETAPP DM COLD/COUGH (brand for px dibromm dm cold/cough child) - Tier 2; QL; AL dm maximum adult (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 DRISTAN SPRAY (brand for nasal spray max strength) - Tier 2 ENDACOF-DM (brand for px dibromm dm cold/cough child) - Tier 2; QL; AL ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 FASENRA PEN - Tier 2; PA; SP; QL fluticasone-salmeterol inhalation aerosol powder breath activated 100- 50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; QL g tussin ac - Tier 1; QL; AL genaphed (generic for SUDOGEST) - Tier 1; QL geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL guaifenesin ac - Tier 1; QL; AL guaifenesin er (generic for EQ MUCUS ER) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 127 Preferred Agents Non-Preferred Agents guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1 guaifenesin-codeine - Tier 1; QL; AL guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL hydrocodone-homatropine oral syrup (generic for HYCODAN) - Tier 1; QL; AL ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ipratropium-albuterol - Tier 1; QL liquibid (generic for XPECT) - Tier 1 long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL medifin 400 (generic for XPECT) - Tier 1 meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for cvs chest congest/cough child) - Tier 2 MUCINEX CHILDRENS STUFFY NOSE (brand for nasal spray max strength) - Tier 2 MUCINEX COUGH CHILDRENS (brand for cvs chest congest/cough child) - Tier 2 MUCINEX D (brand for ra mucus relief d) - Tier 2; AL MUCINEX D MAX STRENGTH (brand for mucus relief d) - Tier 2; AL MUCINEX DM (brand for eq mucus relief dm) - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 128 Preferred Agents Non-Preferred Agents MUCINEX FAST-MAX DM MAX (brand for cvs chest congest/cough child) - Tier 2 MUCINEX MAXIMUM STRENGTH (brand for qc mucus relief er) - Tier 2; QL; AL MUCINEX SINUS-MAX CLEAR & COOL (brand for nasal spray max strength) - Tier 2 MUCINEX SINUS-MAX SINUS/ALLRGY (brand for nasal spray max strength) - Tier 2 mucus & cough relief childrens (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 mucus d (generic for MUCINEX D) - Tier 1; AL mucus d extended release (generic for MUCINEX D) - Tier 1; AL mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1 mucus relief cough children (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 mucus relief cough childrens (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; AL mucus relief dm max oral liquid (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 mucus relief dm oral liquid (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; QL; AL mucus relief er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief max strength oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief oral tablet (generic for XPECT) - Tier 1 mucus-d (generic for MUCINEX D) - Tier 1; AL mucus-dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for deep sea nasal spray) - Tier 2 nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray anti-drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray fast acting nasal solution 1 % (generic for 4-WAY FAST ACTING) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 130 Preferred Agents Non-Preferred Agents nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray saline (generic for AYR) - Tier 1 nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 non-pseudo sinus decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1 NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; SP; QL NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP; QL OCEAN FOR KIDS (brand for deep sea nasal spray) - Tier 2 OCEAN NASAL SPRAY (brand for deep sea nasal spray) - Tier 2 pharbinex (generic for XPECT) - Tier 1 phenylephrine hcl oral (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 promethazine vc - Tier 1; QL; AL promethazine vc/codeine - Tier 1; QL; AL promethazine-codeine - Tier 1; QL; AL promethazine-dm - Tier 1; QL; AL pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL pseudoephedrine-bromphen-dm - Tier 1; QL; AL pseudoephedrine-guaifenesin er oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; AL PULMOZYME - Tier 2; PA; SP; QL refenesen 400 (generic for XPECT) - Tier 1 robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL ROBITUSSIN 12 HOUR COUGH (brand for cvs cough dm childrens) - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 131 Preferred Agents Non-Preferred Agents ROBITUSSIN 12 HOUR COUGH CHILD (brand for cvs cough dm childrens) - Tier 2; QL; AL ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; AL ROBITUSSIN CHILDRENS COUGH LA - Tier 2; AL ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for cvs chest congest/cough child) - Tier 2 ROBITUSSIN NIGHTTIME COUGH - Tier 2; AL ROBITUSSIN PEAK COLD MULTI-SYM (brand for tussin multi- symptom cold cf) - Tier 2; AL rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL saline mist spray (generic for AYR) - Tier 1 saline nasal spray (generic for AYR) - Tier 1 sb mucus relief (generic for XPECT) - Tier 1 siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1; AL siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 sinus pe decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1 sinus/congestion relief pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sodium chloride inhalation nebulization solution 0.9 %, 3 % - Tier 1 STIOLTO RESPIMAT - Tier 2; QL SUDAFED (brand for sm nasal decongestant max st) - Tier 2; QL SUDAFED CHILDRENS - Tier 2; QL SUDAFED CONGESTION (brand for sm nasal decongestant max st) - Tier 2; QL SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for hm nasal decongestant pe) - Tier 2 SUDAFED PE SINUS CONGESTION (brand for hm nasal decongestant pe) - Tier 2 SUDAFED SINUS CONGESTION (brand for sm nasal decongestant max st) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 132 Preferred Agents Non-Preferred Agents SUDAFED SINUS CONGESTION 12HR (brand for sudogest 12 hour) - Tier 2 sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 tab tussin (generic for XPECT) - Tier 1 tussin adult dm oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin adult multi-symptom (generic for DESGEN DM) - Tier 1; AL tussin cf cough & cold oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL tussin cf oral liquid 30-10-100 mg/5ml - Tier 1 tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin chest congestion oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin cough dm sugar free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm cough/chest cong (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm max adult (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 tussin dm max daytime (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 133 Preferred Agents Non-Preferred Agents tussin dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm max oral liquid 20-400 mg/20ml (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 tussin dm max st (generic for DELSYM COUGH/CHEST CONGEST DM) - Tier 1 tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin maximum strength oral syrup 15 mg/5ml (generic for WAL- TUSSIN COUGH) - Tier 1; AL tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; AL tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL XPECT (brand for pharbinex) - Tier 2 ZYRTEC-D ALLERGY & CONGESTION (brand for 12 hour allergy-d) - Tier 2; QL; AL Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1; QL chlorzoxazone oral tablet 500 mg - Tier 1; QL cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL dantrolene sodium oral - Tier 1; QL methocarbamol oral - Tier 1; QL orphenadrine citrate er - Tier 1; QL tizanidine hcl oral tablet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 134 Preferred Agents Non-Preferred Agents Sleep Disorder Agents - Drugs for Sedation and Sleep GABA Receptor Modulators - Drugs for Sleeping temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL 1; QL AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA zaleplon - Tier 1; QL LUNESTA ORAL TABLET 1 MG (brand for eszopiclone) - Tier 2; PA; QL zolpidem tartrate oral (generic for AMBIEN) - Tier 1; QL LUNESTA ORAL TABLET 2 MG, 3 MG (brand for eszopiclone) - Tier 2; PA zolpidem tartrate sublingual - Tier 1; PA; QL Sleep Disorders, Other - Drugs for Sleeping armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QL SILENOR (brand for doxepin hcl) - Tier 2; PA; QL Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs prenatal gummy oral tablet chewable 0.4-25 mg (generic for ALIVE PRENATAL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; ARL: Quantity limits may vary depending on age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 136 Index of Drugs 12 hour allergy-d...... 123 ACCU-CHEK SMARTVIEW...... 106 acetic acid otic...... 115 12 hour decongestant nasal...... 123 ACCU-CHEK SOFTCLIX LANCET acetylcysteine inhalation solution 10 %...... 123 12 hour mucus relief oral tablet extended DEVICE KIT...... 106 acetylcysteine inhalation solution 20 %...... 123 release 12 hour 1200 mg...... 123 accutane...... 58 acid controller...... 83 12 hour nasal decongestant...... 123 acebutolol hcl oral...... 50 acid gone oral suspension...... 75 12 hour nasal decongestant nasal...... 123 acetaminophen 8 hour...... 3 acid reducer oral tablet 10 mg...... 83 12 hour nasal relief spray...... 123 acetaminophen 8 hours...... 3 acid reducer oral tablet 200 mg...... 83 12 hour nasal spray...... 123 acetaminophen 8hr arth pain...... 3 acidophilus lactobacillus oral...... 75 3 day...... 25 acetaminophen 8hr musc ache...... 3 acidophilus oral capsule , 10 mg...... 75 4-WAY FAST ACTING...... 123 acetaminophen childrens...... 3 acidophilus probiotic oral capsule 10 mg..... 75 4-WAY MENTHOL...... 123 acetaminophen childrens oral suspension acidophilus probiotic oral tablet 0.5 mg...... 75 7T LIDO...... 12 160 mg/5ml...... 3 acidophilus/l-sporogenes...... 75 8 hour arthritis pain reliever...... 3 acetaminophen childrens oral tablet ACIPHEX...... 90 8 hour arthritis relief...... 3 chewable 160 mg...... 3 acitretin...... 58 8 hour pain relief oral tablet extended acetaminophen er...... 3 ACTEMRA ACTPEN...... 103 release 650 mg...... 3 acetaminophen ex st oral liquid 500 ACTEMRA SUBCUTANEOUS...... 103 8 hour pain reliever...... 3 mg/15ml...... 3 ACTIMMUNE...... 103 8 hr arthritis pain relief...... 3 acetaminophen ex st oral tablet 500 mg...... 3 ACTIVELLA...... 94 8hr arthritis pain relief...... 3 acetaminophen extra strength...... 4 ACULAR LS...... 114 8hr muscle aches & pain...... 3 acetaminophen infants oral suspension ACUVAIL...... 114 a-25...... 68 160 mg/5ml...... 4 acyclovir oral...... 39 abacavir sulfate...... 40 acetaminophen oral liquid 500 mg/15ml...... 4 ACZONE EXTERNAL GEL 7.5 %...... 58 abacavir sulfate-lamivudine...... 40 acetaminophen oral solution 160 mg/5ml, ADACEL...... 104 abacavir-lamivudine-zidovudine...... 40 325 mg/10.15ml, 650 mg/20.3ml...... 4 addaprin...... 8 abatinex...... 75 acetaminophen oral suspension 160 ADEMPAS...... 122 ABILIFY...... 37 mg/5ml...... 4 ADLYXIN...... 43 ABILIFY MAINTENA...... 37 acetaminophen oral tablet 325 mg...... 4 ADLYXIN STARTER PACK...... 43 abiraterone acetate...... 30 acetaminophen oral tablet 500 mg...... 4 ADMELOG...... 45 ABREVA...... 39 acetaminophen oral tablet chewable 160 ADMELOG SOLOSTAR SOLUTION PEN- ABSORICA...... 58 mg...... 4 INJECTOR 100 UNIT/ML ABSORICA LD...... 58 acetaminophen rectal suppository 120 mg.... 4 SUBCUTANEOUS...... 45 acamprosate calcium...... 13 acetaminophen rectal suppository 650 mg.... 4 adult 50+ probiotic...... 75 ACANYA...... 58 acetaminophen-codeine...... 11 adult probiotic...... 75 acarbose oral...... 43 acetaminophen-codeine #2...... 11 adv acne spot treatment...... 58 ACCU-CHEK AVIVA PLUS TEST STRIPS 106 acetaminophen-codeine #3...... 11 ADVAIR DISKUS...... 123 ACCU-CHEK COMPACT PLUS...... 106 acetaminophen-codeine #4...... 11 ADVAIR HFA...... 123 ACCU-CHEK FASTCLIX LANCET KIT...... 106 acetazolamide er...... 113 advanced acne spot treat...... 58 ACCU-CHEK GUIDE TEST STRIPS...... 106 acetazolamide oral...... 113 advanced antacid max st...... 75

137 advanced healing external ointment ...... 58 albuterol sulfate inhalation nebulization allergy oral tablet extended release 12 mg 116 ADVIL COLD/SINUS...... 123 solution 0.63 mg/3ml, 1.25 mg/3ml...... 121 allergy rel child (loratadine)...... 117 ADVIL JUNIOR STRENGTH ORAL ALBUTEROL SULFATE NEBULIZATION allergy relief (cetirizine) oral tablet 10 mg.. 117 TABLET CHEWABLE...... 8 SOLUTION (5 MG/ML) 0.5% INHALATION allergy relief adult...... 117 ADVIL ORAL TABLET...... 8 ...... 121 allergy relief cetirizine...... 117 ADZENYS XR-ODT...... 55 albuterol sulfate nebulization solution (5 allergy relief child...... 117 af spray powder...... 25 mg/ml) 0.5% inhalation...... 121 allergy relief childrens oral liquid 12.5 AFINITOR DISPERZ...... 32 albuterol sulfate oral syrup...... 121 mg/5ml...... 117 AFINITOR ORAL TABLET 10 MG...... 32 alclometasone dipropionate external allergy relief childrens oral syrup 5 mg/5ml 117 afirmelle...... 94 ointment...... 58 allergy relief d oral tablet extended release AFREZZA...... 45 ALCOHOL PREP PADS PAD 70 %...... 106 12 hour...... 124 AFRIN NODRIP ORIGINAL...... 123 ALDARA...... 58 allergy relief d-12...... 124 AFRIN SINUS...... 123 ALECENSA...... 32 allergy relief d-24...... 124 aftera...... 99 alendronate sodium...... 105 allergy relief oral capsule 25 mg...... 117 AIMOVIG...... 28 ALEVE ORAL TABLET...... 8 allergy relief oral liquid 12.5 mg/5ml, 25 AIRDUO RESPICLICK 113/14...... 123 alfuzosin hcl er...... 91 mg/10ml...... 117 AIRDUO RESPICLICK 232/14...... 123 ALINIA ORAL SUSPENSION allergy relief oral tablet 10 mg...... 117 AIRDUO RESPICLICK 55/14...... 123 RECONSTITUTED...... 34 allergy relief oral tablet 25 mg...... 117 AJOVY SUBCUTANEOUS SOLUTION all day allergy d...... 123 allergy relief oral tablet dispersible 10 mg..117 AUTO-INJECTOR...... 28 all day allergy d-12...... 123 allergy relief oral tablet extended release AJOVY SUBCUTANEOUS SOLUTION all day allergy oral tablet 10 mg...... 116 12 hour 5-120 mg...... 124 PREFILLED SYRINGE...... 106 all day allergy-d...... 123 allergy relief oral tablet extended release ak-poly-bac...... 108 all day pain relief...... 8 12 mg...... 116 AKYNZEO ORAL...... 24 all day relief...... 8 allergy relief tablet 25 mg oral 25 mg...... 120 ala-cort...... 58 allerclear...... 116 allergy relief(cetirizine)...... 117 ALAVERT...... 116 allerclear d-12hr...... 124 allergy relief/indoor/outdoor oral tablet 10 ALAVERT ALLERGY/SINUS...... 123 allerclear d-24hr...... 124 mg...... 117 ALAWAY...... 114 aller-cort...... 120 allergy relief/nasal decong...... 124 ALAWAY CHILDRENS ALLERGY...... 114 allergy & congestion oral tablet extended allergy relief/nasal decongest oral tablet albendazole oral...... 34 release 24 hour 10-240 mg...... 124 extended release 12 hour...... 124 albuterol sulfate hfa aerosol solution 108 allergy 24hour indoor/outdoor...... 116 allergy relief/nasal decongest oral tablet (90 base) mcg/act inhalation...... 121 allergy antihistamine...... 116 extended release 24 hour...... 124 ALBUTEROL SULFATE HFA AEROSOL allergy childrens oral liquid 12.5 mg/5ml.... 116 allergy relief-d oral tablet extended release SOLUTION 108 (90 BASE) MCG/ACT allergy complete-d...... 124 12 hour 5-120 mg...... 124 INHALATION...... 121 allergy eye drops...... 114 allergy relief-d oral tablet extended release albuterol sulfate inhalation nebulization allergy medication...... 116 24 hour 10-240 mg...... 124 solution (2.5 mg/3ml) 0.083%, 2.5 allergy oral capsule 25 mg...... 116 allergy relief-d12...... 124 mg/0.5ml...... 121 allergy oral liquid 12.5 mg/5ml...... 116 allergy spray 24 hour nasal aerosol...... 120 allergy oral tablet 25 mg...... 117 allergy/congestion relief...... 124

138 aller-tec...... 117 amlodipine besylate oral...... 51 antacid extra strength oral tablet chewable aller-tec d...... 124 ammonium lactate external...... 58 750 mg...... 76 allopurinol oral...... 27 amnesteem...... 58 antacid extra strength tablet chewable 750 almacone double strength...... 75 amoxapine...... 23 mg oral 750 mg...... 76 ALOE VESTA CLEAR ANTIFUNGAL...... 25 amoxicillin oral capsule...... 17 antacid extra strength tablet chewable 750 ALOGLIPTIN BENZOATE...... 43 amoxicillin oral suspension reconstituted.....17 mg oral 750 mg...... 79 ALOGLIPTIN-METFORMIN HCL...... 43 amoxicillin oral tablet 875 mg...... 17 antacid fast relief...... 76 ALOGLIPTIN-PIOGLITAZONE...... 43 amoxicillin oral tablet chewable...... 17 antacid i...... 76 ALORA...... 94 amoxicillin-potassium clavulanate oral...... 17 antacid iii...... 76 ALPHAGAN P...... 113 amphetamine-dextroamphetamine...... 55 antacid kids...... 76 alprazolam oral tablet...... 42 amphetamine-dextroamphetamine er...... 55 antacid liquid...... 76 altachlore ophthalmic ointment...... 108 ampicillin...... 17 antacid m...... 76 altachlore ophthalmic solution...... 108 AMZEEQ...... 58 antacid maximum...... 76 altafrin...... 108 anagrelide hcl...... 47 antacid maximum strength...... 76 altalube...... 108 ANASPAZ...... 74 antacid maximum strength oral tablet altamist spray...... 124 anastrozole oral...... 31 chewable 1000 mg...... 76 altarussin...... 124 anecream external cream...... 12 antacid oral suspension 200-200-20 altarussin dm...... 124 anefrin spray...... 124 mg/5ml, 400-400-40 mg/10ml...... 76 altarussin-pe...... 124 ANGELIQ...... 94 antacid oral tablet chewable 1000 mg...... 76 altavera...... 94 animal shapes/iron...... 68 antacid oral tablet chewable 500 mg...... 76 alum & mag hydroxide-simeth...... 75 ANORO ELLIPTA...... 124 antacid oral tablet chewable 750 mg...... 76 alum sulfate-ca acetate...... 58 antacid & anti-gas oral suspension 200- antacid plus antigas...... 77 alumina-magnesia-simethicone...... 75 200-20 mg/5ml...... 75 antacid plus anti-gas relief...... 77 ALUNBRIG...... 32 antacid & anti-gas oral suspension 400- antacid regular strength oral suspension..... 77 ALVESCO...... 120 400-40 mg/5ml...... 75 antacid regular strength oral tablet alyacen 1/35...... 94 antacid & gas relief...... 75 chewable...... 77 alyacen 7/7/7...... 94 antacid advanced...... 75 antacid supreme...... 77 amantadine hcl oral capsule...... 35 antacid advanced max st...... 75 antacid ultra strength oral tablet chewable amantadine hcl oral syrup...... 35 antacid anti-gas...... 76 1000 mg...... 77 AMBIEN...... 135 antacid anti-gas ex st oral suspension 400- antacid/anti-gas...... 77 AMBIEN CR...... 135 400-40 mg/5ml...... 76 antacid/anti-gas max st...... 77 ambrisentan...... 122 antacid anti-gas max strength...... 76 antacid/antigas oral suspension 200-200- amcinonide external ointment...... 58 antacid anti-gas reg strength...... 76 20 mg/5ml...... 77 amiloride hcl oral...... 53 antacid calcium...... 76 antacid/gas relief max st...... 77 amiloride-hydrochlorothiazide...... 52 antacid calcium rich...... 76 antibiotic...... 15 aminocaproic acid oral...... 48 antacid extra...... 76 anti-diarr/ant-gas...... 77 amiodarone hcl oral tablet 200 mg, 400 mg.49 antacid extra strength oral suspension 400- anti-diarrheal oral liquid 1 mg/5ml...... 77 AMITIZA...... 83 400-40 mg/5ml...... 76 anti-diarrheal oral suspension 262 mg/15ml 77 amitriptyline hcl oral...... 23 anti-diarrheal oral tablet 2 mg...... 77

139 antifungal (tolnaftate)...... 25 aripiprazole oral tablet dispersible...... 37 atenolol-chlorthalidone...... 52 antifungal external cream 1 %...... 25 ARISTADA...... 37 atheletes foot...... 25 antifungal external cream 2 %...... 25 ARISTADA INITIO...... 37 athletes foot (terbinafine)...... 25 anti-fungal external powder...... 106 armodafinil...... 135 athletes foot (tolnaftate) external cream 1 antifungal foot care...... 25 ARNUITY ELLIPTA...... 120 %...... 25 antifungal miconazole...... 25 arthritis pain oral tablet extended release athletes foot external aerosol powder 2 %... 25 antifungal tolnaftate...... 25 650 mg...... 4 athletes foot external cream 1 %...... 25 anti-gas oral capsule 180 mg...... 77 arthritis pain relief oral tablet extended athletes foot external powder 2 %...... 106 anti-hist allergy...... 117 release 650 mg...... 4 athletes foot spray external aerosol 2 %...... 25 anti-nausea...... 24 arthritis pain reliever oral...... 4 atomoxetine hcl...... 55 antiseptic...... 15 arthritis pain relieving...... 58 atorvastatin calcium oral...... 53 apap-caff-dihydrocodeine oral capsule...... 11 artificial eye...... 108 atovaquone oral...... 34 APIDRA SOLOSTAR...... 45 artificial tears ophthalmic solution ...... 108 ATRALIN...... 58 APIDRA VIAL...... 45 artificial tears ophthalmic solution 1.4 %.... 108 ATRIPLA...... 40 apraclonidine hcl...... 113 ASACOL HD...... 105 atropine sulfate ophthalmic ointment...... 108 aprepitant...... 24 ascomp-codeine...... 11 atropine sulfate ophthalmic solution 1 %....108 apri...... 94 ascorbic acid tablet 500 mg oral...... 68 ATROVENT HFA...... 121 APRISO...... 105 ASMANEX (120 METERED DOSES)...... 120 AUBAGIO...... 56 aprodine...... 124 ASMANEX (14 METERED DOSES)...... 120 aubra...... 94 APTENSIO XR...... 55 ASMANEX (30 METERED DOSES)...... 120 aubra eq...... 94 APTIOM...... 21 ASMANEX (60 METERED DOSES)...... 120 aurodryl allergy childrens...... 117 APTIVUS...... 41 ASMANEX (7 METERED DOSES)...... 120 aurophen childrens...... 4 AQUADEKS...... 68 ASMANEX HFA...... 120 aurovela 1.5/30...... 94 aqueous vitamin d...... 68 aspirin childrens...... 8 aurovela 1/20...... 94 ARAKODA...... 34 aspirin ec...... 8 aurovela fe 1.5/30...... 94 aranelle...... 94 aspirin ec oral tablet 325 mg...... 8 aurovela fe 1/20...... 94 ARANESP (ALBUMIN FREE) INJECTION aspirin oral tablet 325 mg...... 8 AURYXIA...... 68 SOLUTION...... 47 aspirin oral tablet chewable 81 mg...... 8 AUSTEDO...... 56 ARANESP (ALBUMIN FREE) INJECTION aspirin oral tablet delayed release 325 mg.... 9 AUVI-Q...... 121 SOLUTION PREFILLED SYRINGE 10 aspirin oral tablet delayed release 81 mg...... 9 AVAR-E EMOLLIENT...... 58 MCG/0.4ML...... 47 ASPIRIN ORAL TABLET DELAYED AVAR-E GREEN...... 58 ARANESP (ALBUMIN FREE) INJECTION RELEASE 81 MG...... 9 aviane...... 94 SOLUTION PREFILLED SYRINGE 100 aspirin rectal suppository 300 mg, 600 mg.... 9 AVITA EXTERNAL CREAM...... 58 MCG/0.5ML, 150 MCG/0.3ML, 200 ASTRAZENECA COVID-19 VACCINE...... 104 AVONEX PEN...... 56 MCG/0.4ML, 25 MCG/0.42ML, 300 astringent eye drops...... 108 AVONEX PREFILLED...... 56 MCG/0.6ML, 40 MCG/0.4ML, 500 astringent solution...... 58 AYR...... 125 MCG/ML, 60 MCG/0.3ML...... 47 ATABEX OB...... 68 AYR NASAL MIST ALLERGY/SINUS...... 125 aripiprazole oral solution...... 37 atazanavir sulfate...... 41 ayuna...... 95 aripiprazole oral tablet...... 37 atenolol oral...... 50 AZASITE...... 112

140 azathioprine oral...... 102 BD ULTRA-FINE INSULIN SYRINGES..... 106 bexarotene...... 34 azelaic acid external...... 58 BD ULTRA-FINE PEN NEEDLES...... 106 BEXSERO...... 104 azelastine hcl nasal solution 0.1 %, 137 beauty 360 pure glycerin...... 58 bicalutamide...... 30 mcg/spray...... 117 bekyree...... 95 BIDIL...... 52 azelastine hcl ophthalmic...... 112 BENADRYL ALLERGY CHILDRENS BIKTARVY...... 40 azithromycin oral suspension reconstituted. 17 ORAL LIQUID...... 117 biocel...... 69 azithromycin oral tablet...... 17 BENADRYL ALLERGY CHILDRENS BIOLLE TEARS...... 108 azo...... 91 ORAL TABLET CHEWABLE...... 117 biotinex...... 77 azo tabs...... 91 BENADRYL ALLERGY ORAL TABLET.....118 bisacodyl ec...... 84 AZOPT...... 113 benazepril hcl oral...... 49 bisacodyl laxative...... 84 azurette...... 95 benazepril-hydrochlorothiazide...... 52 bisacodyl rectal...... 84 b complex oral capsule...... 68 BENZAC AC WASH...... 58 bismatrol oral tablet chewable...... 77 b complex vitamins...... 68 BENZACLIN...... 58 bismuth...... 77 b-1...... 68 BENZACLIN WITH PUMP...... 58 bismuth subsalicylate oral suspension...... 77 b6...... 68 BENZAMYCIN...... 58 bismuth subsalicylate oral tablet chewable.. 77 baby basics diaper rash...... 58 BENZNIDAZOLE...... 34 bisoprolol fumarate oral...... 50 bac...... 4 benzonatate oral capsule 100 mg...... 125 bisoprolol-hydrochlorothiazide...... 52 bacitracin external...... 15 benzonatate oral capsule 200 mg...... 125 blisovi fe 1.5/30...... 95 bacitracin ophthalmic...... 112 benztropine mesylate oral...... 35 blisovi fe 1/20...... 95 bacitracin zinc external...... 15 BERINERT...... 102 blue tube/ aloe...... 12 bacitracin zinc first aid...... 15 BESIVANCE...... 112 BONINE...... 24 bacitracin-polymyxin b ophthalmic...... 108 betamethasone dipropionate aug...... 58 BOOSTRIX...... 104 bacitra-neomycin-polymyxin-hc...... 108 betamethasone dipropionate external lotion 59 boro-packs...... 59 baclofen oral...... 134 betamethasone dipropionate external bosentan...... 122 BAFIERTAM...... 55 ointment...... 59 BOSULIF...... 32 balsalazide disodium...... 105 betamethasone valerate external cream...... 59 BOUDREAUXS BUTT PASTE EXTERNAL BALVERSA...... 31 betamethasone valerate external lotion...... 59 OINTMENT 40 %...... 59 balziva...... 95 betamethasone valerate external ointment.. 59 bp wash external liquid 2.5 %...... 59 banophen oral capsule 25 mg...... 117 BETAPACE...... 49 b-plex plus...... 69 banophen oral tablet...... 117 BETAPACE AF...... 49 BPROTECTED PEDIA D-VITE...... 69 BAQSIMI ONE PACK...... 44 BETASERON...... 56 BPROTECTED PEDIA IRON...... 64 BAQSIMI TWO PACK...... 44 betatemp childrens...... 4 BPROTECTED VITAMIN C...... 69 BARACLUDE ORAL SOLUTION...... 38 betaxolol hcl ophthalmic...... 113 BREO ELLIPTA...... 125 BASAGLAR KWIKPEN...... 45 betaxolol hcl oral...... 50 briellyn...... 95 BAYER ASPIRIN...... 9 bethanechol chloride oral...... 91 BRILINTA...... 48 b-complex oral tablet ...... 68 BETHKIS...... 122 brimonidine tartrate ophthalmic...... 113 b-complex with b-12...... 69 BETIMOL...... 113 BRIVIACT ORAL...... 19 b-complex/b-12 oral...... 69 BETOPTIC-S...... 113 bromocriptine mesylate oral tablet...... 36 BD AUTOSHIELD DUO PEN NEEDLES... 106 BEVESPI AEROSPHERE...... 125 BROVANA...... 121

141 BRUKINSA...... 32 calcitonin (salmon) nasal...... 105 calcium plus vitamin d oral tablet 600-400 budesonide inhalation...... 120 calcitriol external...... 59 mg-unit...... 64 budesonide oral...... 105 calcitriol oral capsule...... 106 calcium plus vitamin d3...... 64 bumetanide oral...... 52 calcitriol oral solution...... 106 calcium soft chews oral tablet chewable BUNAVAIL...... 13 calcium 500/d oral tablet...... 64 500-200-40 mg-unt-mcg...... 64 buprenorphine hcl sublingual...... 13 calcium 600 oral tablet 1500 (600 ca) mg.... 64 calcium-vitamin d oral tablet 600-400 mg- buprenorphine hcl-naloxone hcl...... 13 calcium 600/vitamin d...... 64 unit...... 64 buprenorphine transdermal...... 11 calcium 600/vitamin d-3...... 64 calcium-vitamin d3 oral tablet 600-400 mg- bupropion hcl er (smoking det)...... 13 calcium 600+d oral tablet 600-400 mg-unit..64 unit...... 64 bupropion hcl er (sr)...... 22 calcium 600+d tablet 600-400 mg-unit oral cal-gest antacid...... 78 bupropion hcl er (xl) oral tablet extended 600-400 mg-unit...... 64 CALQUENCE...... 32 release 24 hour 150 mg, 300 mg...... 22 calcium acetate (phos binder) oral tablet..... 68 camila...... 99 bupropion hcl oral...... 22 calcium acetate oral tablet 667 mg...... 68 capecitabine...... 30 buspirone hcl oral...... 42 calcium antacid...... 77 CAPRELSA...... 32 butalbital-acetaminophen oral tablet 50- calcium antacid ex st oral tablet chewable capsaicin cream 0.025 % external...... 4 325 mg...... 4 750 mg...... 78 capsaicin cream 0.1 % external...... 59 butalbital-apap-caff-cod oral capsule 50- calcium antacid extra strength...... 78 captopril oral...... 49 325-40-30 mg...... 11 calcium carb-cholecalciferol oral tablet captopril-hydrochlorothiazide...... 52 butalbital-apap-caffeine oral capsule 50- 600-400 mg-unit...... 64 CARAC...... 59 325-40 mg...... 4 calcium carbonate antacid oral suspension. 78 CARBAGLU...... 65 butalbital-apap-caffeine oral tablet...... 4 calcium carbonate antacid oral tablet carbamazepine er...... 21 butalbital-asa-caff-codeine...... 11 chewable...... 78 carbamazepine oral...... 21 butalbital-aspirin-caffeine...... 4 calcium carbonate oral tablet 1500 (600 carbidopa-levodopa er...... 36 butorphanol tartrate nasal...... 11 ca) mg...... 64 carbidopa-levodopa oral tablet...... 36 BYDUREON BCISE AUTOINJECTOR...... 43 calcium carbonate oral tablet chewable carboxymethylcellulose sodium ophthalmic BYETTA 10 MCG PEN...... 43 1250 (500 ca) mg...... 64 ...... 108 BYETTA 5 MCG PEN...... 43 calcium carbonate oral tablet chewable carteolol hcl...... 113 c 250 oral tablet...... 69 500 mg...... 78 cartia xt...... 51 c 500/rose hips...... 69 calcium carbonate-vitamin d oral tablet carvedilol...... 50 cabergoline...... 101 600-400 mg-unit...... 64 cavarest...... 57 CABLIVI...... 48 calcium carbonate-vitamin d3...... 64 CAVILON...... 25 CABOMETYX...... 32 calcium fast dissolution...... 64 CAYSTON...... 122 caffeine citrate oral...... 56 calcium high potency...... 64 caziant...... 95 calamine external lotion 8-8 %...... 59 calcium oral tablet 1500 (600 ca) mg...... 64 cefaclor...... 17 calamine-zinc oxide external lotion...... 59 calcium oyster shell oral tablet 1250 (500 cefadroxil...... 17 calcidol...... 69 ca) mg...... 64 cefdinir...... 17 calcipotriene external cream...... 59 calcium plus vitamin d oral tablet 500-5 cefixime oral capsule...... 17 calcipotriene external ointment...... 59 mg-mcg...... 64 cefprozil...... 17 calcipotriene external solution...... 59 cefuroxime axetil...... 17

142 celecoxib oral...... 9 childrens vitamins/iron...... 69 CLARITIN EYE...... 114 CELONTIN...... 19 childs non-aspirin...... 5 CLARITIN ORAL TABLET...... 118 CENTANY...... 15 chlordiazepoxide hcl...... 42 CLARITIN REDITABS ORAL TABLET CENTRUM FLAVOR BURST KIDS...... 69 chlorhexidine gluconate mouth/throat...... 57 DISPERSIBLE 10 MG...... 118 cephalexin oral capsule...... 17 chloroquine phosphate oral...... 34 CLARITIN-D 12 HOUR...... 125 cephalexin oral suspension reconstituted.... 17 chlorpheniramine maleate er...... 116 CLARITIN-D 24 HOUR...... 125 CEQUA...... 108 chlorpromazine hcl oral...... 36 classic prenatal...... 69 CERDELGA...... 90 chlorthalidone...... 53 c-lax laxative...... 84 cerovel...... 59 CHLOR-TRIMETON ALLERGY...... 116 CLEARCANAL EARWAX SOFTENER...... 115 cetiri-d...... 125 CHLOR-TRIMETON ORAL SYRUP...... 116 clearlax oral powder 17 gm/scoop...... 84 cetirizine hcl oral solution...... 118 chlorzoxazone oral tablet 500 mg...... 134 clemastine fumarate oral syrup...... 118 cetirizine hcl oral tablet...... 118 CHOLBAM...... 90 clemastine fumarate oral tablet 2.68 mg.... 118 cetirizine-pseudoephedrine er...... 125 cholestyramine light oral powder...... 54 CLEOCIN VAGINAL SUPPOSITORY...... 15 CHANTIX...... 13 cholestyramine oral powder...... 54 CLIMARA...... 95 CHANTIX CONTINUING MONTH PAK...... 13 chorionic gonadotropin intramuscular...... 93 CLIMARA PRO...... 95 CHANTIX STARTING MONTH PAK...... 13 ciclodan...... 25 clindacin etz external swab...... 59 chateal...... 95 ciclopirox external solution...... 25 clindacin-p...... 59 chateal eq...... 95 cilostazol...... 48 clindamycin hcl oral capsule 150 mg, 300 CHEMET...... 68 CILOXAN...... 112 mg...... 15 chest congest/cough child...... 125 CIMDUO...... 40 clindamycin palmitate hcl...... 15 chest congestion relief dm...... 125 cimetidine hcl...... 83 clindamycin phosphate external gel...... 59 chest congestion relief oral syrup...... 125 cimetidine oral tablet 200 mg...... 83 clindamycin phosphate external lotion...... 60 chest congestion relief oral tablet...... 125 cimetidine oral tablet 300 mg, 400 mg, 800 clindamycin phosphate external solution..... 60 chewable c...... 69 mg...... 83 clindamycin phosphate external swab...... 60 chewable c with rose hips...... 69 CIMZIA...... 102 clindamycin phosphate vaginal...... 15 chewy not chalky flavor...... 78 cinacalcet hcl...... 105 CLINDESSE...... 15 childrens acetaminophen...... 5 CIPRO ORAL SUSPENSION clobazam...... 19 childrens allergy oral liquid 12.5 mg/5ml.... 118 RECONSTITUTED...... 18 clobetasol prop emollient base...... 60 childrens apap...... 5 ciprofloxacin hcl ophthalmic...... 112 clobetasol propionate e...... 60 childrens aspirin oral tablet chewable 81 ciprofloxacin hcl oral...... 18 clobetasol propionate external solution...... 60 mg...... 9 ciprofloxacin-dexamethasone...... 115 CLOBEX...... 60 childrens chewable vitamins...... 69 citalopram hydrobromide...... 23 CLOBEX SPRAY...... 60 childrens cold & allergy...... 125 citrate of magnesia...... 84 clomiphene citrate oral...... 100 childrens cough...... 125 citroma...... 84 clonazepam oral tablet...... 42 childrens loratadine...... 118 CITRUCEL...... 84 clonidine hcl oral...... 48 childrens mucus relief cough...... 125 claravis...... 59 clopidogrel bisulfate oral...... 48 childrens non-aspirin...... 5 clarithromycin er...... 17 clorazepate dipotassium...... 42 childrens silapap...... 5 clarithromycin oral...... 17 clotrimazole 3 vaginal cream 2 %...... 25 childrens soothe...... 78 CLARITIN ALLERGY CHILDRENS...... 118 clotrimazole 7...... 26

143 clotrimazole external...... 26 complete allergy...... 118 CUPRIMINE...... 91 clotrimazole mouth/throat...... 26 complete allergy medicine oral capsule..... 118 cyanocobalamin injection solution 1000 clotrimazole vaginal...... 26 complete allergy relief...... 118 mcg/ml...... 69 clotrimazole-betamethasone...... 60 compro...... 24 CYANOCOBALAMIN INJECTION clozapine oral tablet 100 mg, 25 mg, 50 mg 38 CO-NATAL FA...... 69 SOLUTION 2000 MCG/ML...... 69 CLOZARIL ORAL TABLET 100 MG, 25 CONCERTA...... 55 cyclafem 1/35...... 95 MG...... 38 constulose...... 84 cyclafem 7/7/7...... 95 CLOZARIL ORAL TABLET 200 MG...... 38 CONTOUR NEXT TEST STRIPS...... 106 cyclobenzaprine hcl oral tablet 10 mg, 5 CLOZARIL ORAL TABLET 50 MG...... 38 CONTOUR TEST STRIPS...... 106 mg...... 134 codeine sulfate...... 11 COPAXONE...... 56 cyclopentolate hcl ophthalmic solution 1 %108 COLACE...... 84 CORICIDIN HBP COUGH/COLD...... 126 cyclophosphamide oral capsule...... 29 COLAZAL...... 105 CORLANOR...... 52 CYCLOPHOSPHAMIDE ORAL TABLET.....29 COLCHICINE ORAL CAPSULE...... 27 CORTIFOAM...... 105 cycloserine oral...... 29 colchicine oral tablet...... 27 COSENTYX SUBCUTANEOUS cyclosporine modified oral capsule 100 mg102 COLCRYS...... 27 SOLUTION AUTO-INJECTOR 150 MG/ML.60 cyclosporine modified oral capsule 25 mg. 102 cold & allergy...... 125 COSENTYX SUBCUTANEOUS cyclosporine modified oral capsule 50 mg. 102 cold & allergy childrens oral elixir 1-15 SOLUTION PREFILLED SYRINGE 150 cyclosporine modified oral solution...... 102 mg/5ml...... 125 MG/ML...... 60 cyclosporine oral...... 102 cold & cough childrens oral liquid 2.5-1-5 COSOPT...... 113 CYMBALTA...... 23 mg/5ml...... 125 COSOPT PF...... 113 cyproheptadine hcl oral...... 118 cold & cough dm childrens oral liquid 2.5-1- COTELLIC...... 32 cyred...... 95 5 mg/5ml...... 125 COTEMPLA XR-ODT...... 55 cyred eq...... 95 cold & sinus relief oral tablet 30-200 mg.... 125 cough & chest congestion...... 126 CYSTAGON...... 90 cold/cough...... 125 cough & cold hbp...... 126 CYSTARAN...... 108 cold/cough childrens...... 126 cough childrens...... 126 d 1000 oral tablet...... 69 cold/cough dm childrens oral liquid 2.5-1-5 cough dm...... 126 d3 super strength...... 69 mg/5ml...... 126 cough dm childrens...... 126 d3-50...... 69 cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 126 cough dm er...... 126 daily acne wash...... 60 col-rite oral capsule 250 mg...... 84 cough relief oral syrup 15 mg/5ml...... 126 daily fiber oral capsule 0.52 gm...... 84 COMBIGAN...... 113 cough/chest congestion dm...... 126 daily multiple vitamins...... 69 COMBIPATCH...... 95 cough/chest dm childrens oral liquid...... 126 daily multivitamins/iron...... 69 COMBIVENT RESPIMAT...... 126 CREON...... 90 daily vitamin formula+iron...... 69 COMETRIQ (100 MG DAILY DOSE)...... 32 CRIXIVAN...... 41 daily vitamins...... 69 COMETRIQ (140 MG DAILY DOSE)...... 32 cromolyn sodium inhalation...... 122 daily vite...... 69 COMETRIQ (60 MG DAILY DOSE)...... 32 cromolyn sodium nasal...... 122 daily vites...... 69 comfort gel...... 78 cromolyn sodium ophthalmic...... 112 daily-vite...... 69 comfort gel antacid anti-gas oral crotan...... 35 danazol oral...... 94 suspension 400-400-40 mg/5ml...... 78 CRUEX PRESCRIPTION STRENGTH...... 26 dantrolene sodium oral...... 134 COMPLERA...... 40 cryselle-28...... 95 dapsone oral...... 29

144 DAPTACEL...... 104 DETROL LA...... 91 digitek...... 52 dasetta 1/35...... 95 dexamethasone intensol...... 92 digox...... 52 dasetta 7/7/7...... 95 dexamethasone oral elixir...... 92 digoxin oral solution...... 52 DAURISMO...... 32 dexamethasone oral solution...... 92 digoxin oral tablet...... 52 DAYHIST ALLERGY 12 HOUR RELIEF....118 dexamethasone oral tablet 0.5 mg, 0.75 dihydroergotamine mesylate injection...... 28 DAYTRANA...... 55 mg...... 92 DILANTIN ORAL CAPSULE 30 MG...... 21 DDAVP RHINAL TUBE...... 93 dexamethasone oral tablet 1 mg, 2 mg...... 92 diltiazem hcl er...... 51 deblitane...... 99 dexamethasone oral tablet 1.5 mg...... 92 diltiazem hcl er beads...... 51 DECADRON ORAL TABLET 0.5 MG, 0.75 dexamethasone oral tablet 4 mg, 6 mg...... 92 diltiazem hcl er coated beads oral capsule MG...... 92 dexamethasone sodium phosphate extended release 24 hour...... 51 DECADRON ORAL TABLET 4 MG, 6 MG...92 ophthalmic...... 114 diltiazem hcl oral...... 51 DECARA ORAL CAPSULE 250 MCG DEXILANT...... 90 dilt-xr...... 51 (10000 UT)...... 70 dextromethorphan polistirex er...... 126 dimaphen dm cold/cough...... 127 deep sea nasal spray...... 126 dextromethorphan-guaifenesin oral syrup..126 DIMETAPP COLD RELIEF CHILDRENS.. 127 deferasirox granules...... 68 DIABETIC TUSSIN MAX ST...... 127 DIMETAPP COLD/ALLERGY...... 127 deferasirox oral packet...... 68 diamode...... 78 DIMETAPP DM COLD/COUGH...... 127 deferasirox oral tablet...... 68 diaper rash external ointment 40 %...... 60 dimethyl fumarate oral...... 56 deferasirox oral tablet soluble...... 68 diarrhea...... 78 dimethyl fumarate starter pack...... 56 DELSTRIGO...... 40 diarrhea relief...... 78 diotame instydose...... 78 DELSYM...... 126 diazepam oral solution...... 42 DIPENTUM...... 105 DELSYM COUGH CHILDRENS...... 126 diazepam oral tablet...... 42 diphedryl allergy...... 118 DELSYM COUGH/CHEST CONGEST DM126 diazepam rectal...... 19 diphen...... 118 delyla...... 95 diclofenac potassium...... 9 di-phen...... 118 DELZICOL...... 105 diclofenac sodium er...... 9 diphenhist...... 118 DENTA 5000 PLUS...... 57 diclofenac sodium external gel 1 %...... 9 diphenhydramine hcl oral capsule...... 118 DENTAGEL...... 57 diclofenac sodium ophthalmic...... 114 diphenhydramine hcl oral elixir...... 118 DEPEN TITRATABS...... 91 diclofenac sodium oral...... 9 diphenhydramine hcl oral liquid 12.5 DEPO-ESTRADIOL...... 95 dicloxacillin sodium...... 17 mg/5ml...... 118 DEPO-SUBQ PROVERA 104...... 99 dicyclomine hcl oral capsule...... 74 diphenhydramine hcl oral tablet...... 118 DESCOVY...... 40 dicyclomine hcl oral solution...... 74 diphenhydramine hcl oral tablet chewable. 119 DESENEX EXTERNAL POWDER...... 106 dicyclomine hcl oral tablet...... 74 diphenoxylate-atropine...... 78 DESENEX JOCK ITCH...... 26 DIFFERIN EXTERNAL CREAM...... 60 DIPHTHERIA-TETANUS TOXOIDS DT.... 104 desgen dm oral liquid...... 126 DIFFERIN EXTERNAL GEL 0.1 %...... 60 dipyridamole oral...... 48 desipramine hcl oral...... 23 DIFFERIN EXTERNAL GEL 0.3 %...... 60 disopyramide phosphate...... 49 desmopressin ace spray refrig...... 93 DIFFERIN EXTERNAL LOTION...... 60 disulfiram oral tablet 250 mg...... 13 desmopressin acetate oral...... 93 DIFICID...... 17 disulfiram oral tablet 500 mg...... 13 desmopressin acetate spray...... 93 DIFLUCAN...... 26 DITROPAN XL...... 91 desogestrel-ethinyl estradiol...... 95 digestive probiotic capsule oral...... 78 DIURIL...... 53 DETROL...... 91 digestive probiotic oral capsule 250 mg...... 78

145 divalproex sodium oral capsule delayed doxycycline monohydrate oral capsule 50 EDARBI...... 48 release sprinkle...... 43 mg...... 18 EDARBYCLOR...... 52 divalproex sodium oral tablet delayed DR SMITHS ADULT BARRIER ED-SPAZ...... 74 release...... 43 EXTERNAL OINTMENT...... 60 EDURANT...... 40 DIVIGEL TRANSDERMAL GEL 0.25 DR SMITHS DIAPER...... 60 efavirenz...... 40 MG/0.25GM, 0.75 MG/0.75GM, 1.25 driminate...... 24 efavirenz-lamivudine-tenofovir...... 40 MG/1.25GM...... 95 DRISTAN SPRAY...... 127 effer-k oral tablet effervescent 25 meq...... 65 DIVIGEL TRANSDERMAL GEL 0.5 dronabinol...... 24 EFUDEX...... 60 MG/0.5GM, 1 MG/GM...... 95 DROXIA ORAL CAPSULE 200 MG, 300 electrolyte solution...... 65 dm maximum adult...... 127 MG...... 30 ELESTRIN...... 95 docosanol external...... 39 DROXIA ORAL CAPSULE 400 MG...... 30 ELIDEL...... 60 docu...... 84 dry-eye relief nighttime...... 108 elinest...... 95 docusate calcium...... 84 dss...... 84 ELIQUIS...... 47 docusate mini...... 84 DUAVEE...... 95 ELIQUIS DVT/PE STARTER PACK...... 47 docusate sodium oral capsule...... 84 DULERA...... 127 ELIXOPHYLLIN...... 122 docusate sodium oral liquid 50 mg/5ml...... 84 duloxetine hcl oral capsule delayed release ELMIRON...... 91 docusate sodium oral syrup...... 84 particles 20 mg, 30 mg, 60 mg...... 23 eluryng...... 95 docuzen...... 84 DUPIXENT...... 60 EMEND ORAL...... 24 dofetilide...... 49 D-VI-SOL...... 70 EMGALITY...... 28 dok oral capsule...... 84 d-vite pediatric...... 70 EMGALITY (300 MG DOSE)...... 28 donepezil hcl oral tablet 23 mg...... 21 DYANAVEL XR...... 55 emoquette...... 95 donepezil hcl oral tablet 5 mg...... 21 dye-free allergy relief...... 119 emtricitabine...... 40 donepezil hcl tablet 10 mg oral...... 21 E.E.S. GRANULES...... 17 emtricitabine-tenofovir df...... 40 DOPTELET...... 47 ear drops earwax aid...... 115 EMTRIVA ORAL SOLUTION...... 40 DORZOLAMIDE HCL SOLUTION 2 % ear drops otic solution 6.5 %...... 115 ENABLEX ORAL TABLET EXTENDED OPHTHALMIC...... 113 ear wax kit...... 115 RELEASE 24 HOUR 7.5 MG...... 91 dorzolamide hcl solution 2 % ophthalmic... 113 ear wax removal...... 115 enalapril maleate oral...... 49 dorzolamide hcl-timolol mal...... 113 ear wax removal drops...... 115 enalapril-hydrochlorothiazide...... 52 double antibiotic external ointment 500- ear wax removal kit...... 115 ENBREL...... 102 10000 unit/gm...... 15 ear wax removal system...... 115 ENDACOF-DM...... 127 DOVATO...... 39 earwax removal...... 115 endocet oral tablet 10-325 mg, 5-325 mg, DOVONEX...... 60 earwax removal drops...... 115 7.5-325 mg...... 11 doxazosin mesylate oral...... 48 earwax removal kit otic solution 6.5 %...... 115 enema...... 84 doxepin hcl oral capsule...... 23 easygel...... 57 enema disposable...... 85 doxepin hcl oral concentrate...... 23 easy-lax plus...... 84 enema mineral oil...... 85 doxycycline hyclate oral capsule...... 18 ec-naproxen...... 9 enema ready-to-use...... 85 doxycycline hyclate oral tablet 100 mg...... 18 econtra ez...... 99 enema rectal enema 16-6 gm/133ml, 19-7 doxycycline monohydrate oral capsule 100 econtra one-step...... 99 gm/118ml...... 85 mg...... 18 ed-apap...... 5 ENEMEEZ MINI...... 85

146 ENFAMIL ENFALYTE...... 65 esomeprazole magnesium oral capsule eye drops ophthalmic solution 0.05 %...... 112 ENFAMIL EXPECTA...... 70 delayed release...... 90 eye drops ophthalmic solution 0.05-0.1-1-1 ENGERIX-B...... 104 esomeprazole magnesium oral packet...... 90 %...... 109 enoxaparin sodium...... 47 essential one daily...... 70 eye itch relief ophthalmic solution 0.025 % 114 enpresse-28...... 96 estarylla...... 96 eye lubricant...... 109 enskyce...... 96 ESTRACE...... 96 ezetimibe...... 54 ENSTILAR...... 60 estradiol oral...... 96 FABIOR...... 61 entacapone...... 35 estradiol transdermal patch twice weekly.....96 falmina...... 96 entecavir...... 38 estradiol transdermal patch weekly...... 96 famotidine oral suspension reconstituted enteric aspirin...... 9 estradiol vaginal...... 96 40 mg/5ml...... 83 ENTRESTO...... 52 estradiol-norethindrone acet oral tablet 1- famotidine oral tablet 10 mg...... 83 enulose...... 85 0.5 mg...... 96 famotidine oral tablet 20 mg...... 83 EPANED...... 49 ESTRING...... 96 famotidine oral tablet 40 mg...... 83 EPCLUSA ORAL TABLET 200-50 MG...... 38 ESTROGEL...... 96 famotidine orig st...... 83 EPCLUSA ORAL TABLET 400-100 MG...... 38 ethambutol hcl oral tablet 100 mg...... 29 FANAPT...... 37 ephrine nose drops...... 127 ethambutol hcl oral tablet 400 mg...... 29 FARXIGA...... 43 EPIDUO...... 60 ethosuximide oral...... 19 FARYDAK...... 32 EPIDUO FORTE...... 60 ethynodiol diac-eth estradiol...... 96 FASENRA PEN...... 127 epinephrine injection solution auto-injector 121 etodolac...... 9 fast relief laxative...... 85 EPIPEN 2-PAK...... 121 etonogestrel-ethinyl estradiol...... 96 febuxostat...... 27 EPIPEN JR 2-PAK...... 121 etoposide oral...... 31 felbamate oral suspension...... 20 epitol...... 21 EUCRISA...... 61 felbamate oral tablet...... 20 EPIVIR HBV ORAL SOLUTION...... 38 euthyrox...... 101 felodipine er...... 51 EPOGEN...... 47 EVAC...... 85 FEMRING...... 96 ergocalciferol oral...... 70 EVAMIST...... 96 femynor...... 96 ergotamine-caffeine...... 28 EVEKEO...... 55 fenofibrate micronized oral capsule 134 ERIVEDGE...... 32 EVEKEO ODT...... 55 mg, 200 mg, 67 mg...... 53 ERLEADA...... 30 everolimus oral tablet 0.25 mg, 0.5 mg, fenofibrate oral capsule 134 mg, 200 mg, erlotinib hcl...... 32 0.75 mg...... 102 67 mg...... 53 errin...... 99 everolimus oral tablet 2.5 mg, 5 mg...... 32 fenofibrate oral tablet 160 mg, 54 mg...... 53 ERYPED 200...... 17 everolimus oral tablet 7.5 mg...... 32 FENSOLVI (6 MONTH)...... 101 ERYTHROCIN STEARATE...... 17 EVOTAZ...... 41 fentanyl transdermal patch 72 hour 100 erythromycin base...... 17 EXCEDRIN EXTRA STRENGTH...... 5 mcg/hr...... 11 erythromycin ethylsuccinate oral...... 17 EXCEDRIN MIGRAINE...... 5 fentanyl transdermal patch 72 hour 12 erythromycin external...... 60 exemestane...... 31 mcg/hr...... 11 erythromycin ophthalmic...... 112 EX-LAX ULTRA...... 85 fentanyl transdermal patch 72 hour 25 erythromycin oral...... 18 EXTAVIA...... 56 mcg/hr...... 11 ESBRIET...... 123 eye drops allergy relief...... 108 fentanyl transdermal patch 72 hour 50 escitalopram oxalate oral tablet...... 23 eye drops long lasting...... 109 mcg/hr...... 11

147 fentanyl transdermal patch 72 hour 75 fiber therapy oral capsule 0.52 gm...... 85 fluoxetine hcl oral solution...... 23 mcg/hr...... 11 fiber therapy oral powder 28.3 %...... 85 fluphenazine decanoate injection...... 36 ferate...... 65 fiber therapy oral tablet 500 mg...... 85 fluphenazine hcl injection...... 36 FER-IN-SOL...... 65 fiber therapy oral tablet 625 mg...... 85 fluphenazine hcl oral concentrate...... 36 ferocon...... 65 fiber-caps...... 85 fluphenazine hcl oral elixir...... 36 ferosul...... 65 FIBERCON...... 85 fluphenazine hcl oral tablet...... 36 ferotrinsic...... 65 fiber-lax...... 85 flurbiprofen sodium...... 114 ferrex 150...... 65 FINACEA...... 61 flutamide...... 30 ferric x-150...... 65 finasteride oral tablet 5 mg...... 91 fluticasone propionate external cream...... 61 ferrous gluconate oral tablet 240 (27 fe) mg 65 FIRAZYR...... 102 fluticasone propionate external ointment..... 61 ferrous gluconate oral tablet 324 (37.5 fe) first aid antibiotic external ointment 3.5- fluticasone propionate nasal...... 120 mg...... 65 400-5000 , 3.5-400-5000 mg-unit...... 15 fluticasone-salmeterol inhalation aerosol ferrous gluconate oral tablet 324 (38 fe) mg 65 first aid antiseptic external solution 10 %..... 16 powder breath activated 100-50 mcg/dose, ferrous sulfate oral elixir...... 65 FIRVANQ...... 16 250-50 mcg/dose, 500-50 mcg/dose...... 127 ferrous sulfate oral solution 75 (15 fe) FLAGYL...... 16 FLUTICASONE-SALMETEROL mg/ml...... 65 flecainide acetate...... 49 INHALATION AEROSOL POWDER ferrous sulfate oral tablet delayed release... 65 FLEET BISACODYL...... 85 BREATH ACTIVATED 113-14 MCG/ACT, ferrous sulfate tablet 325 (65 fe) mg oral..... 65 FLEET ENEMA...... 85 232-14 MCG/ACT, 55-14 MCG/ACT...... 127 FETZIMA...... 23 FLEET PEDIATRIC...... 85 fluvoxamine maleate...... 23 fever reducer/pain reliever...... 5 floranex tablet oral...... 78 foaming antacid oral tablet chewable 80-20 fever reducing childrens...... 5 FLORANEX TABLET ORAL...... 78 mg...... 78 feverall adults...... 5 FLOVENT DISKUS...... 120 FOCALIN...... 55 feverall childrens...... 5 FLOVENT HFA...... 120 folic acid oral tablet 1 mg...... 65 FEVERALL INFANTS...... 5 fluconazole oral...... 26 folic acid oral tablet 400 mcg...... 65 FEVERALL JUNIOR STRENGTH...... 5 fludrocortisone acetate oral...... 92 foltrin...... 65 fe-vite iron...... 65 fluocinolone acetonide body...... 61 foot & sneaker...... 26 FIASP...... 45 fluocinolone acetonide external cream foot care (terbinafine)...... 26 FIASP FLEXTOUCH...... 45 0.025 %...... 61 for sty relief...... 109 fiber laxative...... 85 fluocinolone acetonide external ointment.....61 fosamprenavir calcium...... 41 fiber laxative + calcium...... 85 fluocinolone acetonide external solution...... 61 fosinopril sodium...... 49 fiber laxative oral capsule 0.52 gm...... 85 fluocinolone acetonide scalp...... 61 fosinopril sodium-hctz...... 52 fiber laxative oral tablet 500 mg...... 85 fluocinonide emulsified base...... 61 FREESTYLE PRECISION NEO TEST...... 106 fiber oral capsule 0.52 gm...... 85 fluocinonide external solution...... 61 freeze dried acidophilus...... 78 fiber oral powder 28.3 %...... 85 fluoridex daily renewal...... 57 fruity c...... 70 fiber oral powder 30.9 %...... 85 fluoritab...... 65 FULPHILA...... 47 fiber oral powder 48.57 %...... 85 fluorometholone...... 114 fungi-guard...... 26 fiber oral powder 58.6 %...... 85 fluorouracil external cream 5 %...... 61 furosemide oral solution 10 mg/ml...... 52 fiber oral tablet 500 mg...... 85 fluorouracil external solution...... 61 furosemide oral tablet...... 52 fiber oral tablet 625 mg...... 85 fluoxetine hcl oral capsule 10 mg, 20 mg.....23 FUZEON...... 41

148 fyavolv oral tablet 0.5-2.5 mg-mcg...... 96 genaphed...... 127 GLUCAGEN HYPOKIT...... 44 fyavolv oral tablet 1-5 mg-mcg...... 96 generlac...... 86 GLUCAGON EMERGENCY INJECTION FYCOMPA...... 20 gengraf oral capsule 100 mg...... 103 SOLUTION RECONSTITUTED...... 44 g tussin ac...... 127 gengraf oral capsule 25 mg...... 103 glucagon emergency kit 1 mg injection...... 44 gabapentin oral capsule...... 19 GENOTROPIN...... 93 GLUCAGON EMERGENCY KIT 1 MG gabapentin oral tablet...... 19 gentak...... 112 INJECTION...... 44 galantamine hydrobromide oral solution...... 21 gentamicin sulfate external...... 15 glucose oral tablet chewable 4 gm...... 44 galantamine hydrobromide oral tablet 12 gentamicin sulfate ophthalmic...... 112 glucose tablet chewable 4 gm oral 4 gm...... 44 mg, 8 mg...... 21 GENTEAL SEVERE...... 109 glyburide micronized...... 43 galantamine hydrobromide oral tablet 4 mg.21 GENTEAL TEARS MODERATE PF...... 109 glyburide oral...... 43 GARDASIL 9...... 104 GENTEAL TEARS NIGHT-TIME...... 109 glyburide-metformin...... 44 gas relief drops infants...... 78 GENTEAL TEARS OPHTHALMIC glycerin (adult) suppository 2 gm rectal...... 86 gas relief extra strength oral capsule 125 SOLUTION 0.1-0.3 %...... 109 glycerin (infants & children) rectal mg...... 78 GENTEAL TEARS PF...... 109 suppository 1 gm...... 86 gas relief extra strength oral tablet GENTEAL TEARS SEVERE DAY/NIGHT. 109 glycerin (pediatric) rectal suppository 1 gm..86 chewable 125 mg...... 78 gentle laxative oral tablet delayed release glycerin adult rectal suppository 2 gm...... 86 gas relief extstrength...... 78 5 mg...... 86 glycerin child rectal suppository 1 gm...... 86 gas relief infants...... 79 gentle laxative rectal suppository 10 mg...... 86 glycerin child rectal suppository 1.2 gm...... 86 gas relief infants drops...... 79 gentle laxative womens...... 86 glycerin childrens...... 86 gas relief oral capsule 125 mg...... 79 gentlelax...... 86 glycerin external...... 61 gas relief oral suspension 20 mg/0.3ml...... 79 GENVOYA...... 39 glycerin external liquid 99.5 %...... 61 gas relief oral tablet chewable 125 mg...... 79 GEODON ORAL...... 37 glycerin pediatric rectal suppository 1.2 gm. 86 gas relief oral tablet chewable 80 mg...... 79 geri-dryl...... 119 glycolax...... 86 gas relief ultra strength...... 79 geri-kot...... 86 glycopyrrolate oral tablet 1 mg, 2 mg...... 74 gas relief ultstrength...... 79 geri-lanta...... 79 glydo...... 12 GAS-X EXTRA STRENGTH ORAL geri-lanta supreme...... 79 GLYXAMBI...... 44 CAPSULE...... 79 geri-mox...... 79 GRANIX...... 47 GAS-X EXTRA STRENGTH ORAL geri-pectate...... 79 griseofulvin microsize oral...... 26 TABLET CHEWABLE...... 79 geri-tussin dm...... 127 griseofulvin ultramicrosize...... 26 GAS-X ULTRA STRENGTH...... 79 GILENYA...... 56 guaicon dms...... 127 GATTEX...... 79 GILOTRIF...... 32 guaifenesin ac...... 127 gavilax oral powder...... 85 giltuss severe sinus...... 127 guaifenesin er...... 127 gavilyte-c...... 85 glatiramer acetate...... 56 guaifenesin oral tablet 400 mg...... 127 gavilyte-n with flavor pack...... 86 glatopa...... 56 guaifenesin-codeine...... 128 GAVISCON EXTRA RELIEF FORMULA..... 79 GLEOSTINE...... 29 guaifenesin-dm oral syrup...... 128 GAVISCON EXTRA STRENGTH...... 79 glimepiride...... 43 guanfacine hcl...... 48 GAVISCON ORAL SUSPENSION...... 79 glipizide er...... 43 guanfacine hcl er...... 55 GELUSIL...... 79 glipizide ir...... 43 gummy dinos...... 70 gemfibrozil oral...... 53 glipizide xl...... 43 GVOKE PFS...... 44

149 GYNAZOLE-1...... 26 HUMALOG MIX 50/50...... 45 hydrocortisone butyrate external ointment... 61 GYNE-LOTRIMIN...... 26 HUMALOG MIX 50/50 KWIKPEN...... 45 hydrocortisone butyrate external solution.... 61 GYNE-LOTRIMIN 3...... 26 HUMALOG MIX 75/25...... 45 hydrocortisone external cream 0.5 %, 2.5 habitrol...... 13 HUMALOG MIX 75/25 KWIKPEN...... 45 %...... 61 HAEGARDA...... 102 HUMATROPE INJECTION SOLUTION hydrocortisone external cream 1 %...... 61 hailey 1.5/30...... 96 RECONSTITUTED 12 MG, 24 MG, 6 MG... 93 hydrocortisone external lotion 2.5 %...... 61 hailey fe 1.5/30...... 96 HUMIRA PEN-PEDIATRIC UC START..... 103 hydrocortisone external ointment 0.5 %...... 61 hailey fe 1/20...... 96 HUMIRA PEN-PSOR/UVEIT STARTER....103 hydrocortisone external ointment 1 %...... 61 halobetasol propionate external cream...... 61 HUMIRA SUBCUTANEOUS PEN- hydrocortisone external ointment 2.5 %...... 61 haloperidol decanoate intramuscular...... 36 INJECTOR KIT 40 MG/0.4ML, 40 hydrocortisone oral tablet 10 mg, 20 mg, 5 haloperidol oral...... 36 MG/0.8ML, 80 MG/0.8ML...... 103 mg...... 92 HARVONI...... 38 HUMIRA SUBCUTANEOUS PREFILLED hydrocortisone plus external cream 1 %...... 61 HAVRIX...... 104 SYRINGE KIT 10 MG/0.1ML, 20 hydrocortisone rectal enema 100 mg/60ml 105 headache formula...... 5 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, hydrocortisone/aloe max str...... 61 headache relief extra str...... 5 80 MG/0.8ML, 80 MG/0.8ML & hydrocortisone-acetic acid...... 115 headache relief oral tablet 250-250-65 mg.... 5 40MG/0.4ML...... 103 hydrocortisone-aloe...... 62 heartburn antacid...... 79 HUMULIN 70/30 KWIKPEN...... 45 hydrocortisone-aloe max st...... 62 heartburn antacid ex st...... 79 HUMULIN 70/30 VIAL...... 45 hydromorphone hcl oral...... 12 heartburn prevention oral tablet 10 mg...... 83 HUMULIN N KWIKPEN...... 45 hydromorphone hcl rectal...... 12 heartburn relief ex st...... 80 HUMULIN N VIAL...... 45 hydroxychloroquine sulfate oral...... 34 heartburn relief oral tablet 10 mg...... 83 HUMULIN R U-500 KWIKPEN...... 45 hydroxyurea oral...... 30 heartburn relief oral tablet 200 mg...... 83 HUMULIN R U-500 VIAL hydroxyzine hcl oral...... 42 heartburn relief oral tablet chewable 160- (CONCENTRATED)...... 45 hydroxyzine pamoate oral...... 119 105 mg...... 80 HUMULIN R VIAL...... 45 hyoscyamine sulfate er...... 74 heather...... 99 HYCAMTIN ORAL...... 31 hyoscyamine sulfate oral tablet...... 74 h-e-b aspirin...... 9 hydralazine hcl oral...... 54 hyoscyamine sulfate oral tablet dispersible..74 h-e-b childrens allergy...... 119 hydrochlorothiazide oral capsule...... 53 hyoscyamine sulfate sl...... 74 HEMANGEOL...... 50 hydrochlorothiazide oral tablet 12.5 mg...... 53 hyoscyamine sulfate sublingual...... 74 HEMLIBRA...... 48 hydrochlorothiazide oral tablet 25 mg, 50 HYPERTET S/D...... 104 hemorrhoidal rectal suppository 0.25-3- mg...... 53 HYPOTEARS...... 109 85.5 %...... 61 hydrocodone-acetaminophen oral solution HYSINGLA ER...... 11 heparin sodium (porcine)...... 47 7.5-325 mg/15ml...... 11 IBRANCE...... 32 heparin sodium (porcine) pf...... 47 hydrocodone-acetaminophen oral tablet ibu...... 9 HEPLISAV-B...... 104 10-325 mg, 5-325 mg, 7.5-325 mg...... 12 ibu-200...... 9 hi cal...... 65 hydrocodone-homatropine oral syrup...... 128 ibuprofen cold/sinus oral tablet 30-200 mg 128 high potency probiotic...... 80 hydrocortisone (perianal) external cream ibu-profen cold/sinus oral tablet 30-200 mg HUMALOG...... 45 2.5 %...... 105 ...... 128 HUMALOG JUNIOR KWIKPEN...... 45 hydrocortisone anti-itch external cream 0.5 ibuprofen ib childrens...... 9 HUMALOG KWIKPEN...... 45 %...... 61 ibuprofen ib oral tablet 200 mg...... 9

150 ibuprofen infants oral suspension 50 instacort 5...... 62 ivermectin oral...... 34 mg/1.25ml...... 9 INSULIN ASP PROT & ASP FLEXPEN...... 45 JAKAFI...... 33 ibuprofen junior...... 9 INSULIN ASPART...... 45 JANSSEN COVID-19 VACCINE...... 104 ibuprofen junior strength...... 9 INSULIN ASPART PROT & ASPART...... 45 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 ibuprofen oral suspension 100 mg/5ml...... 9 INSULIN LISPRO...... 45 mg, 3 mg, 4 mg, 5 mg, 7.5 mg...... 47 ibuprofen oral tablet 200 mg...... 9 INSULIN LISPRO (1 UNIT DIAL)...... 45 jantoven oral tablet 6 mg...... 47 ibuprofen oral tablet 400 mg, 600 mg, 800 INSULIN PEN NEEDLES 32G X 6 MM...... 106 JANUMET...... 44 mg...... 10 INTELENCE...... 40 JANUMET XR...... 44 icatibant acetate...... 102 INTRON A...... 39 JANUVIA...... 44 iclevia...... 96 introvale...... 96 JARDIANCE...... 44 ICLUSIG...... 32 INVEGA...... 37 jencycla...... 99 IDHIFA ORAL TABLET 50 MG...... 32 INVEGA SUSTENNA...... 37 JENTADUETO...... 44 ILEVRO...... 114 INVEGA TRINZA...... 37 JENTADUETO XR...... 44 ILUMYA...... 62 INVIRASE...... 41 jinteli...... 96 imatinib mesylate...... 32 INVOKAMET...... 44 jock itch external cream 1 %...... 26 IMBRUVICA...... 33 INVOKAMET XR...... 44 jock itch max st...... 26 imipramine hcl oral...... 23 INVOKANA...... 44 jock itch spray powder...... 26 imiquimod external cream 5 %...... 62 ipratropium bromide inhalation...... 121 jolessa...... 96 IMODIUM A-D ORAL TABLET...... 80 ipratropium bromide nasal...... 121 JORNAY PM...... 55 IMODIUM MULTI-SYMPTOM RELIEF...... 80 ipratropium-albuterol...... 128 juleber...... 96 IMPAVIDO...... 34 IRESSA...... 33 JULUCA...... 40 INATAL GT...... 70 iron oral tablet 240 (27 fe) mg...... 65 junel 1.5/30...... 96 incassia...... 99 iron oral tablet 325 (65 fe) mg...... 65 junel 1/20...... 96 INCRELEX...... 93 iron supplement childrens...... 65 junel fe oral tablet 1.5-30 mg-mcg...... 96 INCRUSE ELLIPTA...... 121 ISENTRESS HD...... 39 junel fe oral tablet 1-20 mg-mcg...... 96 indapamide...... 53 ISENTRESS ORAL PACKET...... 39 KALETRA...... 41 indomethacin oral capsule 25 mg, 50 mg.... 10 ISENTRESS ORAL TABLET...... 39 kalliga...... 96 indoor/outdoor allergy rlf...... 119 ISENTRESS ORAL TABLET CHEWABLE.. 39 KALYDECO...... 122 INFANRIX...... 104 isibloom...... 96 KAPVAY...... 55 infant gas relief...... 80 isoniazid oral...... 29 kariva...... 96 INFANTS ADVIL...... 10 ISOPTO ATROPINE...... 109 KAZANO...... 44 infants gas relief...... 80 isosorbide dinitrate...... 54 kelnor 1/35...... 96 infants ibuprofen...... 10 isosorbide mononitrate...... 54 kelnor 1/50...... 96 infants pain & fever...... 5 isosorbide mononitrate er...... 54 KESIMPTA...... 55 infants pain relief drops...... 5 isotretinoin oral capsule 10 mg...... 62 ketoconazole external cream...... 26 infants pain/fever...... 5 isotretinoin oral capsule 20 mg, 30 mg, 40 ketoconazole external shampoo...... 26 infants simethicone...... 80 mg...... 62 ketoconazole oral...... 26 INGREZZA...... 56 ISTALOL...... 113 ketoprofen oral...... 10 INLYTA...... 33 itraconazole oral...... 26

151 ketorolac tromethamine ophthalmic lamivudine-zidovudine...... 41 LENVIMA (10 MG DAILY DOSE)...... 33 solution 0.4 %...... 114 lamotrigine oral tablet...... 20 LENVIMA (12 MG DAILY DOSE)...... 33 ketorolac tromethamine ophthalmic lamotrigine oral tablet chewable...... 20 LENVIMA (14 MG DAILY DOSE)...... 33 solution 0.5 %...... 114 lamotrigine starter kit-blue...... 20 LENVIMA (18 MG DAILY DOSE)...... 33 ketorolac tromethamine oral...... 10 lamotrigine starter kit-green...... 20 LENVIMA (20 MG DAILY DOSE)...... 33 ketotifen fumarate ophthalmic...... 114 lamotrigine starter kit-orange...... 20 LENVIMA (24 MG DAILY DOSE)...... 33 KEVZARA...... 103 LANCETS...... 106 LENVIMA (4 MG DAILY DOSE)...... 33 KINERET...... 103 lansoprazole oral capsule delayed release LENVIMA (8 MG DAILY DOSE)...... 33 KISQALI (200 MG DOSE)...... 31 15 mg...... 90 lessina...... 97 KISQALI (400 MG DOSE)...... 31 lansoprazole oral capsule delayed release LETAIRIS...... 122 KISQALI (600 MG DOSE)...... 31 30 mg...... 90 letrozole oral...... 31 KITABIS PAK...... 122 lansoprazole oral tablet delayed release leucovorin calcium oral tablet 10 mg...... 31 klor-con...... 65 dispersible 15 mg...... 90 leucovorin calcium oral tablet 15 mg, 25 klor-con 10...... 65 lansoprazole oral tablet delayed release mg, 5 mg...... 31 klor-con m10...... 65 dispersible 30 mg...... 90 LEUKERAN...... 29 klor-con m20...... 65 LANTUS SOLOSTAR...... 45 LEUKINE...... 47 klor-con/ef...... 66 LANTUS U-100 VIAL...... 45 leuprolide acetate injection...... 101 KOMBIGLYZE XR...... 44 lapatinib ditosylate...... 33 levalbuterol hcl inhalation...... 121 KONSYL DAILY FIBER ORAL POWDER larin 1.5/30...... 96 LEVBID...... 74 100 %...... 86 larin 1/20...... 96 LEVEMIR U-100 FLEXTOUCH...... 45 konsyl daily fiber oral powder 28.3 %...... 86 larin fe 1.5/30...... 96 LEVEMIR U-100 VIAL...... 46 KORLYM...... 94 larin fe 1/20...... 96 levetiracetam oral solution...... 19 kp vitamin d3 capsule 50 mcg (2000 ut) larissia...... 96 levetiracetam oral tablet...... 19 oral 50 mcg (2000 ut)...... 70 latanoprost ophthalmic...... 114 levobunolol hcl...... 113 K-PHOS-NEUTRAL...... 66 LATUDA...... 37 levocetirizine dihydrochloride oral tablet.... 119 k-prime...... 66 laxacin...... 86 levofloxacin oral tablet...... 18 KRINTAFEL...... 34 laxaclear...... 86 levonest...... 97 kurvelo...... 96 laxative max str...... 86 levonorgest-eth estrad 91-day oral tablet labetalol hcl oral...... 50 laxative maximum strength oral tablet 25 0.15-0.03 mg...... 97 lactic acid external...... 62 mg...... 86 levonorgestrel...... 99 lactobacillus oral tablet...... 80 laxative oral powder 17 gm/scoop...... 86 levonorgestrel-ethinyl estrad oral tablet lacto-pectin...... 80 laxative oral tablet delayed release 5 mg.....86 0.1-20 mg-mcg...... 97 lactulose encephalopathy...... 86 laxative pills...... 86 levonorgestrel-ethinyl estrad oral tablet lactulose oral solution...... 86 laxative pills max st...... 87 0.15-30 mg-mcg...... 97 LAMISIL AT EXTERNAL CREAM...... 26 laxative pills oral tablet 25 mg...... 87 levonorg-eth estrad triphasic...... 97 LAMISIL AT JOCK ITCH...... 26 laxative rectal suppository 10 mg...... 87 levora 0.15/30 (28)...... 97 lamivudine oral solution...... 40 LEDIPASVIR-SOFOSBUVIR...... 38 levo-t...... 101 lamivudine oral tablet 100 mg...... 38 leena...... 96 levothyroxine sodium oral tablet...... 101 lamivudine oral tablet 150 mg, 300 mg...... 40 leflunomide oral...... 103 levoxyl...... 101

152 LEXIVA ORAL SUSPENSION...... 41 loradamed...... 119 lubricant eye ophthalmic solution 0.4-0.3 % LIALDA...... 105 lorata-d...... 128 ...... 109 lice killing...... 35 loratadine allergy relief oral tablet 10 mg... 119 lubricant eye pm...... 109 lice killing max st...... 35 loratadine allergy relief oral tablet lubricant pm...... 109 lice killing max strength...... 35 dispersible 10 mg...... 119 lubricating eye drop...... 109 lice killing maximum strength...... 35 loratadine childrens oral solution 5 mg/5ml 119 lubricating eye drops ophthalmic solution lice maximum strength...... 35 loratadine childrens oral syrup 5 mg/5ml... 119 0.4-0.3 %...... 110 lice treatment...... 35 lorata-dine d...... 128 lubricating eye/overnight...... 110 lice treatment creme rinse...... 35 loratadine d 12hr...... 128 lubricating plus...... 110 lice treatment external shampoo 0.33-4 %...35 loratadine oral syrup 5 mg/5ml...... 119 lubricating plus eye drops...... 110 lidocaine cream 4 % external...... 12 loratadine oral tablet 10 mg...... 119 lubricating tears...... 110 lidocaine external patch 5 %...... 12 loratadine oral tablet dispersible 10 mg..... 119 lubricating tears eye drops...... 110 lidocaine hcl external cream 3 %...... 12 loratadine-d...... 128 LUMIGAN...... 114 lidocaine hcl urethral/mucosal...... 12 loratadine-d 12hr...... 128 LUNESTA ORAL TABLET 1 MG...... 135 lidocaine viscous hcl...... 12 loratadine-d 24hr...... 128 LUNESTA ORAL TABLET 2 MG, 3 MG.....135 lidocaine-prilocaine external cream...... 12 lorazepam oral tablet...... 42 LUPANETA PACK...... 101 lidopin external cream 3 %...... 12 LORBRENA...... 33 LUPRON DEPOT (1-MONTH)...... 101 lillow...... 97 losartan potassium oral...... 48 LUPRON DEPOT (3-MONTH)...... 101 linezolid oral suspension reconstituted...... 16 losartan potassium-hctz...... 52 LUPRON DEPOT (4-MONTH) linezolid oral tablet...... 16 LOTRIMIN AF EXTERNAL POWDER...... 106 INTRAMUSCULAR KIT 30MG...... 101 LINZESS...... 83 lovastatin oral...... 53 LUPRON DEPOT (6-MONTH) liothyronine sodium oral...... 101 low-ogestrel...... 97 INTRAMUSCULAR KIT 45MG...... 101 liquibid...... 128 loxapine succinate...... 36 LUPRON DEPOT-PED (1-MONTH)...... 101 liquid acetaminophen...... 5 LUBIPROSTONE...... 83 LUPRON DEPOT-PED (3-MONTH)...... 101 liquid allergy relief...... 119 lubricant drops fast act...... 109 lutera...... 97 liquid pain relief...... 5 lubricant drops long last...... 109 LUXIQ...... 62 lisinopril oral...... 49 lubricant drops ophthalmic solution...... 109 lyleq...... 99 lisinopril-hydrochlorothiazide...... 52 lubricant eye drops (pf) ophthalmic solution LYNPARZA...... 33 lithium...... 43 0.4-0.3 %...... 109 lysiplex plus oral tablet...... 70 lithium carbonate er...... 43 lubricant eye drops (pf) ophthalmic solution LYSODREN...... 101 lithium carbonate oral...... 43 0.5 %...... 109 LYUMJEV...... 115 LMX 4...... 12 lubricant eye drops ophthalmic solution lyza...... 99 LOKELMA...... 68 0.4-0.3 %...... 109 MAALOX...... 80 long acting nasal spray...... 128 lubricant eye drops ophthalmic solution 0.5 MAALOX CHILDRENS...... 80 long lasting antacid...... 80 %...... 109 MAALOX MAX ORAL SUSPENSION...... 80 long lasting nasal spray...... 128 lubricant eye drops ophthalmic solution 0.6 MAALOX MULTI SYMPTOM MAX ST...... 80 LONSURF...... 31 %...... 109 mag-al plus...... 80 loperamide hcl oral tablet...... 80 lubricant eye drops pf...... 109 mag-al plus xs...... 80 lopinavir-ritonavir...... 41 lubricant eye nighttime...... 109 magnesium citrate oral solution...... 87

153 magnesium oral tablet 500 mg...... 66 mega probiotic...... 80 methyldopa-hydrochlorothiazide...... 52 magnesium oxide oral tablet 400 mg...... 80 megestrol acetate oral suspension 40 methylergonovine maleate oral...... 106 magnesium oxide oral tablet 420 mg...... 80 mg/ml...... 100 METHYLIN...... 55 magnesium oxide oral tablet 500 mg...... 66 megestrol acetate oral tablet 20 mg...... 100 methylphenidate hcl er (cd)...... 55 magnesium oxide tablet 400 (241.3 mg) megestrol acetate oral tablet 40 mg...... 100 methylphenidate hcl er (la) oral capsule mg oral...... 66 meijer allergy relief-d...... 128 extended release 24 hour 20 mg, 30 mg, magnesium-oxide...... 66 meijer antacid...... 80 40 mg...... 55 malathion...... 35 meijer anti-diarrheal...... 80 methylphenidate hcl er oral tablet extended MAOX...... 80 MEKINIST...... 33 release 10 mg, 20 mg...... 55 mapap arthritis pain...... 5 meloxicam oral tablet...... 10 methylphenidate hcl er oral tablet extended mapap childrens...... 6 melphalan...... 29 release 18 mg, 27 mg, 36 mg, 54 mg...... 55 mapap oral capsule...... 6 memantine hcl oral solution 2 mg/ml...... 22 methylphenidate hcl er oral tablet extended maprotiline hcl oral tablet 25 mg...... 23 memantine hcl oral tablet...... 22 release 24 hour...... 55 maprotiline hcl oral tablet 50 mg, 75 mg...... 23 MENACTRA...... 104 methylphenidate hcl oral tablet...... 55 marlissa...... 97 MENEST...... 97 methylprednisolone oral...... 92 MATULANE...... 29 MENOSTAR...... 97 metoclopramide hcl oral solution...... 24 MAVENCLAD (10 TABS)...... 56 MENQUADFI...... 104 metoclopramide hcl oral tablet...... 80 MAVENCLAD (4 TABS)...... 56 MENVEO...... 104 metolazone...... 53 MAVENCLAD (5 TABS)...... 56 mercaptopurine oral...... 30 metoprolol succinate er...... 50 MAVENCLAD (6 TABS)...... 56 mesalamine oral capsule delayed release metoprolol tartrate oral tablet 100 mg, 50 MAVENCLAD (7 TABS)...... 56 400 mg...... 105 mg...... 50 MAVENCLAD (8 TABS)...... 56 mesalamine rectal...... 105 metoprolol tartrate oral tablet 25 mg...... 50 MAVENCLAD (9 TABS)...... 56 MESNEX ORAL...... 34 METROGEL...... 16 MAVYRET...... 38 metformin hcl er (osm)...... 44 metronidazole external...... 16 maxi-tuss gmx...... 128 metformin hcl er oral tablet extended metronidazole oral tablet...... 16 MAYZENT...... 56 release 24 hour 500 mg...... 44 metronidazole vaginal...... 16 m-dryl...... 119 metformin hcl er oral tablet extended mexiletine hcl oral...... 49 meclizine hcl oral tablet 12.5 mg...... 24 release 24 hour 750 mg...... 44 mi-acid gas relief...... 81 meclizine hcl oral tablet 25 mg...... 24 metformin hcl oral tablet...... 44 micaderm...... 26 meclizine hcl oral tablet chewable...... 24 methazolamide oral...... 52 miconazole 3...... 26 medicated spot...... 62 methenamine hippurate...... 15 miconazole 3 combo pack app...... 26 medifin 400...... 128 methergine...... 106 miconazole 3 combo pack vaginal kit 200 & medi-first triple antibiotic...... 16 methimazole oral...... 102 2 mg-% (9gm)...... 26 mediproxen...... 10 methocarbamol oral...... 134 miconazole 7 day treatment...... 27 MEDROL ORAL TABLET 2 MG...... 92 methotrexate oral...... 103 miconazole 7 vaginal cream 2 %...... 27 medroxyprogesterone acetate methotrexate sodium...... 103 miconazole 7 vaginal suppository 100 mg... 27 intramuscular...... 100 methotrexate sodium (pf)...... 103 miconazole antifungal...... 27 medroxyprogesterone acetate oral...... 100 methoxsalen rapid...... 62 miconazole nitrate external...... 27 mefloquine hcl...... 34 methyldopa...... 48 miconazole nitrate vaginal...... 27

154 microgestin 1.5/30...... 97 MODERNA COVID-19 VACCINE...... 104 mucus er oral tablet extended release 12 microgestin 1/20...... 97 mometasone furoate external...... 62 hour 1200 mg...... 129 microgestin fe 1.5/30...... 97 mondoxyne nl oral capsule 100 mg...... 18 mucus extended release oral tablet microgestin fe 1/20...... 97 mono-linyah...... 97 extended release 12 hour 1200 mg...... 129 midodrine hcl...... 48 montelukast sodium oral...... 121 mucus relief chest oral tablet 400 mg...... 129 MIGERGOT...... 28 mood support probiotic...... 81 mucus relief cough children...... 129 migraine formula...... 6 morgidox oral...... 18 mucus relief cough childrens...... 129 migraine relief...... 6 morphine sulfate (concentrate) oral mucus relief d max strength...... 129 mili...... 97 solution 100 mg/5ml, 20 mg/ml...... 12 mucus relief d oral tablet extended release milk of magnesia...... 87 morphine sulfate er oral tablet extended 12 hour 60-600 mg...... 129 mimvey...... 97 release...... 11 mucus relief dm max oral liquid...... 129 mineral oil enema...... 87 morphine sulfate oral...... 12 mucus relief dm oral liquid...... 129 mineral oil heavy oral...... 87 MOTEGRITY...... 81 mucus relief dm oral tablet extended MINERAL OIL ORAL OIL...... 87 motion sickness oral tablet 50 mg...... 24 release 12 hour 30-600 mg...... 129 mineral oil oral oil ...... 87 motion sickness relief oral tablet 50 mg...... 24 mucus relief er oral tablet extended release mineral oil rectal enema ...... 87 motion sickness relief oral tablet chewable 12 hour 1200 mg...... 129 mini nicotine...... 13 25 mg...... 24 mucus relief max st...... 129 minitran...... 54 MOTRIN CHILDRENS...... 10 mucus relief max strength oral tablet MINIVELLE...... 97 MOTRIN IB ORAL TABLET...... 10 extended release 12 hour 1200 mg...... 130 minocycline hcl oral capsule 100 mg...... 18 MOTRIN INFANTS DROPS...... 10 mucus relief oral tablet...... 130 minocycline hcl oral capsule 50 mg...... 18 MOVANTIK...... 81 mucus-d...... 130 minoxidil oral...... 54 MOXEZA...... 18 mucus-dm...... 130 mintox maximum strength...... 81 m-pap...... 6 mucus-er oral tablet extended release 12 MIRALAX ORAL POWDER...... 87 MUCINEX CHILDRENS FREEFROM hour 1200 mg...... 130 MIRCERA INJECTION SOLUTION ORAL LIQUID 5-100 MG/5ML...... 128 MULPLETA...... 47 PREFILLED SYRINGE 100 MCG/0.3ML, MUCINEX CHILDRENS STUFFY NOSE...128 MULTAQ...... 49 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MUCINEX COUGH CHILDRENS...... 128 multi vitamin...... 70 MCG/0.3ML...... 47 MUCINEX D...... 128 multi vitamin w/d-3...... 70 mirtazapine oral tablet 15 mg, 30 mg...... 22 MUCINEX D MAX STRENGTH...... 128 multiple vitamins essential...... 70 mirtazapine oral tablet 45 mg, 7.5 mg...... 22 MUCINEX DM...... 128 multiple vitamins/iron...... 70 MIRVASO...... 62 MUCINEX FAST-MAX DM MAX...... 128 MULTIPRO...... 70 misoprostol oral...... 89 MUCINEX MAXIMUM STRENGTH...... 129 multi-vitamin...... 70 MITIGARE...... 27 MUCINEX SINUS-MAX CLEAR & COOL.. 129 multivitamin/fluoride tablet chewable 0.25 mm arthritis pain...... 6 MUCINEX SINUS-MAX SINUS/ALLRGY.. 129 mg oral...... 70 mm cetirizine hcl...... 119 mucus & cough relief childrens...... 129 multivitamin/fluoride tablet chewable 0.5 mm clearlax...... 87 mucus d...... 129 mg oral...... 70 mm stool softener laxative...... 87 mucus d extended release...... 129 multivitamin/fluoride tablet chewable 1 mg M-M-R II...... 104 mucus d max st er...... 129 oral...... 70 M-NATAL PLUS...... 70 mucus dm...... 129 multi-vitamin/iron...... 70

155 mupirocin external...... 16 nasal decongestant pe oral tablet 10 mg... 130 neomycin-polymyxin-dexameth ophthalmic MURO 128 OPHTHALMIC OINTMENT.....110 nasal decongestant spray...... 130 ointment...... 110 MURO 128 OPHTHALMIC SOLUTION 5 nasal mist nasal solution...... 130 neomycin-polymyxin-dexameth ophthalmic %...... 110 NASAL MOIST NASAL SOLUTION...... 130 suspension 3.5-10000-0.1 ...... 110 my choice...... 100 nasal relief...... 130 neomycin-polymyxin-gramicidin...... 110 my way...... 100 nasal relief moisturizing...... 130 neomycin-polymyxin-hc otic...... 115 mycophenolate mofetil oral...... 103 nasal spray...... 130 NEONATAL COMPLETE...... 71 mycophenolate sodium...... 103 nasal spray 12 hour...... 130 NEONATAL PLUS...... 71 MYCOZYL AP...... 106 nasal spray anti-drip...... 130 NEONATAL VITAMIN...... 71 MYDAYIS...... 55 nasal spray extra moist...... 130 neo-polycin...... 110 myferon 150...... 66 nasal spray extra moisturizing...... 130 neo-polycin hc...... 110 myferon 150 forte...... 66 nasal spray fast acting nasal solution 1 %. 130 NEOSPORIN ORIGINAL...... 16 mynephrocaps...... 70 nasal spray moisturizing...... 130 NESINA...... 44 MYNEPHRON...... 71 nasal spray no drip...... 131 NEULASTA...... 47 myorisan...... 62 nasal spray saline...... 131 NEUPOGEN INJECTION SOLUTION 300 MYRBETRIQ...... 91 nasal spray sinus...... 131 MCG/ML...... 47 MYTESI...... 81 NASALCROM...... 122 NEUPOGEN INJECTION SOLUTION 480 nabumetone oral...... 10 nateglinide...... 44 MCG/1.6ML...... 47 nafrinse...... 66 natural daily fiber...... 87 NEUPOGEN INJECTION SOLUTION nafrinse drops...... 66 natural fiber laxative oral powder 58.6 %..... 87 PREFILLED SYRINGE...... 47 naloxone hcl injection solution...... 13 natural fiber oral capsule 0.52 gm...... 87 NEUTROGENA OIL-FREE ACNE WASH... 62 naloxone hcl injection solution cartridge...... 13 natural fiber oral powder 28.3 %...... 87 NEVANAC...... 114 naltrexone hcl oral...... 13 natural fiber oral powder 58.6 %...... 87 nevirapine...... 40 naproxen oral...... 10 natural fiber supplement oral powder...... 87 nevirapine er...... 40 naproxen sodium oral tablet 220 mg...... 10 natural laxative...... 87 new day...... 100 naproxen sodium tablet 220 mg oral 220 natural laxative/stool soft...... 87 NEXAVAR...... 33 mg...... 10 natural senna laxative...... 87 NEXIUM ORAL CAPSULE DELAYED NARAMIN...... 119 natural tears pf...... 110 RELEASE...... 90 naratriptan hcl...... 28 natural vegetable...... 87 NEXIUM ORAL PACKET 10 MG, 20 MG, NARCAN...... 13 natural vegetable fiber...... 87 40 MG...... 90 NASACORT ALLERGY 24HR...... 120 natural vegetable laxative...... 87 NEXIUM ORAL PACKET 2.5 MG, 5 MG..... 90 NASACORT ALLERGY 24HR CHILDREN 120 natura-lax...... 87 NEXLETOL...... 54 nasal allergy 24 hour...... 120 nausea control...... 24 NEXLIZET...... 48 nasal allergy nasal aerosol 55 mcg/act...... 120 nausea relief oral liquid 1.87-1.87-21.5 ...... 24 niacin (antihyperlipidemic)...... 54 nasal allergy spray...... 120 NAYZILAM...... 19 niacin er (antihyperlipidemic)...... 54 nasal decongestant 12hr...... 130 necon 0.5/35 (28)...... 97 niacin er capsule extended release 250 mg nasal decongestant max st...... 130 NEODOT THERMOMETER...... 106 oral...... 71 nasal decongestant oral tablet 30 mg...... 130 neomycin sulfate oral...... 15 niacin er oral capsule extended release nasal decongestant pe max st...... 130 neomycin-bacitracin zn-polymyx...... 110 500 mg...... 71

156 niacin er oral tablet extended release 500 nitazoxanide...... 34 nortrel 1/35 (21)...... 97 mg...... 71 NITRO-BID...... 54 nortrel 1/35 (28)...... 97 niacor...... 54 NITRO-DUR...... 54 nortrel 7/7/7...... 97 NICODERM CQ...... 13 nitrofurantoin...... 15 nortriptyline hcl oral...... 23 NICORETTE...... 13 nitrofurantoin macrocrystal...... 15 NORVIR ORAL PACKET...... 41 NICORETTE MINI...... 13 nitrofurantoin monohydrate macrocrystals... 15 NORVIR ORAL SOLUTION...... 41 NICORETTE STARTER KIT...... 13 nitroglycerin sublingual...... 54 nose drops extstrength...... 131 nicotine gum mouth/throat gum 2 mg...... 13 nitroglycerin transdermal...... 54 novarel intramuscular solution nicotine gum mouth/throat gum 4 mg...... 14 nitroglycerin translingual...... 54 reconstituted 10000 unit...... 93 nicotine gum mouth/throat lozenge 2 mg..... 14 NITYR...... 90 NOVOLIN 70/30 FLEXPEN...... 46 nicotine gum mouth/throat lozenge 4 mg..... 14 NIVA-PLUS...... 71 NOVOLIN 70/30 RELION...... 46 nicotine mini...... 14 NIVESTYM...... 47 NOVOLIN 70/30 VIAL...... 46 nicotine mouth/throat gum 2 mg...... 14 no drip nasal relief...... 131 NOVOLIN N FLEXPEN...... 46 nicotine mouth/throat gum 4 mg...... 14 no drip nasal spray...... 131 NOVOLIN N RELION...... 46 nicotine mouth/throat lozenge 2 mg...... 14 NOCDURNA...... 93 NOVOLIN N VIAL...... 46 nicotine mouth/throat lozenge 4 mg...... 14 non-aspirin...... 6 NOVOLIN R FLEXPEN...... 46 nicotine polacrilex mini...... 14 non-aspirin 8 hour...... 6 NOVOLIN R RELION...... 46 nicotine polacrilex mouth/throat...... 14 non-aspirin childrens...... 6 NOVOLIN R VIAL...... 46 nicotine polacrilex mouth/throat gum 4 mg.. 14 non-aspirin extra strength...... 6 NOVOLOG FLEXPEN...... 46 nicotine polacrilex mouth/throat lozenge 2 non-aspirin jr strength...... 6 NOVOLOG MIX 70/30 FLEXPEN...... 46 mg...... 14 non-aspirin pain relief...... 6 NOVOLOG MIX 70/30 VIAL...... 46 nicotine polacrilex mouth/throat lozenge 4 non-pseudo sinus decongestant...... 131 NOVOLOG PENFILL...... 46 mg...... 14 nora-be...... 100 NOVOLOG U-100 VIAL...... 46 nicotine step 1...... 14 NORDITROPIN FLEXPRO...... 93 NOVOTWIST PEN NEEDLE...... 106 nicotine step 2...... 14 norethin ace-eth estrad-fe oral tablet...... 97 NUBEQA...... 30 nicotine step 3...... 14 norethindrone acetate oral...... 100 NUCALA SUBCUTANEOUS SOLUTION nicotine transdermal patch 24 hour 14 norethindrone acet-ethinyl est...... 97 AUTO-INJECTOR...... 131 mg/24hr, 7 mg/24hr...... 14 norethindrone oral...... 100 NUCALA SUBCUTANEOUS SOLUTION nicotine transdermal patch 24 hour 21 norgestimate-eth estradiol...... 97 PREFILLED SYRINGE...... 131 mg/24hr...... 14 norgestimate-ethinyl estradiol triphasic...... 97 NUCYNTA ER...... 11 nicotine transdermal system...... 14 NORITATE...... 16 NUEDEXTA...... 56 NICOTROL...... 14 norlyda...... 100 NU-IRON...... 66 NICOTROL NS...... 14 norlyroc...... 100 NULEV...... 74 nifedipine er...... 51 NORPACE...... 49 NURTEC...... 28 nifedipine er osmotic release...... 51 NORPACE CR ORAL CAPSULE NUTRAPLUS EXTERNAL CREAM...... 62 nifedipine oral...... 51 EXTENDED RELEASE 12 HOUR 100 MG..49 nutrifac zx...... 71 nighttime dry-eye relief...... 110 NORPACE CR ORAL CAPSULE NUTROPIN AQ NUSPIN 10...... 93 nimodipine oral...... 51 EXTENDED RELEASE 12 HOUR 150 MG..49 NUTROPIN AQ NUSPIN 20...... 93 NINLARO...... 31 nortrel 0.5/35 (28)...... 97 NUTROPIN AQ NUSPIN 5...... 93

157 NUZYRA ORAL...... 18 omeprazole oral capsule delayed release ORFADIN...... 90 nyamyc...... 27 10 mg, 20 mg, 20.6 (20 base) mg, 40 mg.... 90 ORIAHNN...... 102 nylia 7/7/7...... 97 omeprazole oral tablet delayed release 20 ORILISSA...... 102 nymyo...... 97 mg...... 90 ORKAMBI...... 122 nystatin external...... 27 OMNARIS...... 120 orphenadrine citrate er...... 134 nystatin mouth/throat...... 27 OMNITROPE...... 93 orsythia...... 98 nystatin oral...... 27 ondansetron hcl oral tablet...... 24 OS-CAL CALCIUM + D3...... 66 nystop...... 27 ondansetron odt...... 24 oscimin oral...... 74 NYVEPRIA...... 46 one daily...... 71 oscimin sr...... 74 O-CAL PRENATAL...... 71 ONE VITE WOMENS...... 71 oseltamivir phosphate oral capsule...... 42 OCEAN FOR KIDS...... 131 ONE VITE WOMENS PLUS...... 71 oseltamivir phosphate oral suspension OCEAN NASAL SPRAY...... 131 one-daily multi vitamins...... 71 reconstituted...... 42 octreotide acetate injection solution 100 one-daily multi-vitamin oral tablet...... 71 OSENI...... 44 mcg/ml, 50 mcg/ml...... 101 one-daily multi-vitamin/iron...... 71 OSPHENA...... 100 octreotide acetate injection solution 1000 ONETOUCH ULTRA...... 106 OTEZLA...... 103 mcg/ml...... 101 ONETOUCH ULTRA 2 KIT W/DEVICE..... 106 OTREXUP...... 103 octreotide acetate injection solution 200 ONETOUCH ULTRA CONTROL...... 106 OVACE PLUS WASH EXTERNAL LIQUID. 62 mcg/ml...... 102 ONETOUCH ULTRA MINI KIT W/DEVICE 107 OVACE WASH...... 62 octreotide acetate injection solution 500 ONETOUCH VERIO FLEX SYSTEM KIT oxaprozin...... 10 mcg/ml...... 102 W/DEVICE...... 107 OXAYDO ORAL TABLET 5 MG...... 12 ODEFSEY...... 40 ONETOUCH VERIO IN VITRO SOLUTION oxazepam...... 42 ODOMZO...... 33 ...... 107 oxcarbazepine oral suspension...... 21 OFEV...... 123 ONETOUCH VERIO IQ SYSTEM...... 107 oxcarbazepine oral tablet...... 21 ofloxacin ophthalmic...... 112 ONETOUCH VERIO KIT W/DEVICE...... 107 oxybutynin chloride er...... 91 ofloxacin oral...... 18 ONETOUCH VERIO REFLECT KIT oxybutynin chloride oral...... 91 ofloxacin otic...... 114 W/DEVICE...... 107 oxycodone hcl oral concentrate 100 olanzapine oral tablet...... 37 ONETOUCH VERIO SYNC SYSTEM...... 107 mg/5ml...... 12 olanzapine oral tablet dispersible...... 37 ONETOUCH VERIO TEST STRIPS...... 107 oxycodone hcl oral solution...... 12 olopatadine hcl ophthalmic...... 112 ONEVITE...... 71 oxycodone hcl oral tablet...... 12 OLUMIANT...... 103 ONEXTON...... 62 oxycodone-acetaminophen oral tablet 10- OLUX...... 62 ONGLYZA...... 44 325 mg, 5-325 mg, 7.5-325 mg...... 12 OLUX-E...... 62 opcicon one-step...... 100 oxycodone-aspirin...... 12 OMECLAMOX-PAK...... 81 OPSUMIT...... 122 OXYCONTIN...... 11 omega-3-acid ethyl esters...... 54 option 2...... 100 oxymorphone hcl er...... 11 omeprazole magnesium oral capsule ORACEA...... 18 OXYTROL FOR WOMEN...... 91 delayed release...... 90 oralone...... 57 oysco 500+d...... 66 omeprazole magnesium oral tablet delayed oralyte freezer pops...... 66 oyster shell calcium plus d tablet 500-200 release...... 90 ORENCIA CLICKJECT...... 103 mg-unit oral...... 66 ORENCIA SUBCUTANEOUS...... 103 oyster shell calcium tablet 500 mg oral...... 66

158 oyster shell calcium/d oral tablet 250-250 pain reliever ex st oral tablet extended penicillin v potassium...... 17 mg-unit...... 66 release 650 mg...... 7 pentamidine isethionate inhalation...... 34 oyster shell calcium/d oral tablet 500-200 pain reliever extra strength oral tablet 250- PENTASA...... 105 mg-unit...... 66 250-65 mg...... 7 pentazocine-naloxone hcl...... 12 oyster shell calcium/vitamin d tablet 500- pain reliever extra strength oral tablet 500 pentoxifylline er...... 52 200 mg-unit oral...... 66 mg...... 7 peptic relief...... 81 OZEMPIC SUBCUTANEOUS SOLUTION pain reliever infants oral suspension 160 PEPTO-BISMOL ORAL SUSPENSION PEN-INJECTOR 2 MG/1.5ML...... 44 mg/5ml...... 7 524 MG/30ML...... 81 p col-rite...... 87 pain reliever plus...... 7 PERDIEM OVERNIGHT RELIEF...... 88 PACERONE...... 49 pain-off...... 7 PERFOROMIST...... 121 pain & fever child...... 6 paliperidone er...... 37 periogard...... 57 pain & fever childrens oral suspension 160 PANADOL CHILDRENS...... 7 permethrin external...... 35 mg/5ml...... 6 PANADOL EXTRA STRENGTH...... 7 perphenazine oral...... 24 pain & fever childrens oral tablet chewable PANADOL INFANTS...... 7 perphenazine-amitriptyline oral tablet 2-10 160 mg...... 6 PANCREAZE...... 90 mg, 4-10 mg, 4-25 mg, 4-50 mg...... 22 pain & fever infants...... 6 PANOXYL...... 62 perphenazine-amitriptyline oral tablet 2-25 pain relief childrens oral suspension 160 PANRETIN...... 34 mg...... 22 mg/5ml...... 6 pantoprazole sodium oral packet...... 90 PERSERIS...... 37 pain relief childrens oral tablet chewable pantoprazole sodium oral tablet delayed PFIZER-BIONTECH COVID-19 VACC...... 104 160 mg...... 6 release...... 90 pharbedryl...... 119 pain relief extra st...... 6 paromomycin sulfate oral...... 15 PHARBETOL EXTRA STRENGTH...... 7 pain relief extra strength...... 6 paroxetine hcl...... 23 PHARBETOL ORAL TABLET 325 MG...... 7 pain relief infants oral suspension 160 PASER...... 29 pharbinex...... 131 mg/5ml...... 6 PATADAY OPHTHALMIC SOLUTION 0.1 PHAZYME...... 81 pain relief oral liquid 500 mg/15ml...... 6 %...... 112 PHAZYME ULTRA STRENGTH...... 81 pain relief oral tablet 325 mg...... 6 PATADAY OPHTHALMIC SOLUTION 0.2 phenazo oral tablet 200 mg...... 91 pain relief oral tablet 500 mg...... 6 %...... 112 phenazo oral tablet 95 mg...... 91 pain relief oral tablet extended release 650 ped electrolyte freeze pop...... 66 phenazopyridine hcl oral tablet 100 mg...... 91 mg...... 7 ped electrolyte freezer pops...... 66 phenazopyridine hcl oral tablet 200 mg...... 91 pain relief regular st...... 7 PEDIA-LAX RECTAL SUPPOSITORY 1 phenobarbital oral elixir...... 19 pain relief regular strength...... 7 GM...... 87 phenobarbital oral tablet...... 19 pain relief/rapid burst...... 7 PEDIALYTE FREEZER POPS...... 66 phenylephrine hcl ophthalmic...... 110 pain relieve child dye-free...... 7 PEDIALYTE ORAL SOLUTION...... 66 phenylephrine hcl oral...... 131 pain reliever...... 7 PEDIALYTE SINGLES...... 66 phenytoin infatabs...... 21 pain reliever childrens oral suspension 160 pediatric electrolyte oral solution...... 67 phenytoin oral suspension 125 mg/5ml...... 21 mg/5ml...... 7 peg 3350 oral powder...... 88 phenytoin oral tablet chewable...... 21 pain reliever ex st oral liquid 500 mg/15ml.....7 peg 3350-kcl-na bicarb-nacl...... 88 phenytoin sodium extended...... 21 pain reliever ex st oral tablet 500 mg...... 7 PEGASYS...... 39 philith...... 98 penicillamine oral tablet...... 91

159 PHILLIPS MILK OF MAGNESIA ORAL polyvinyl alcohol ophthalmic...... 110 PRECISION XTRA DEVICE...... 107 SUSPENSION 400 MG/5ML...... 88 POLY-VI-SOL...... 71 PRECISION XTRA MONITOR...... 107 PHOSPHA 250 NEUTRAL...... 67 POLY-VITE PEDIATRIC...... 71 PRED-G S.O.P...... 110 phosphorous...... 67 POMALYST...... 30 prednicarbate external cream...... 62 phospho-trin 250 neutral...... 67 portia-28...... 98 prednisolone acetate ophthalmic...... 114 phytonadione oral...... 71 potassium chloride crys er...... 67 prednisolone acetate p-f...... 114 pilocarpine hcl ophthalmic...... 113 potassium chloride er oral capsule prednisolone oral solution...... 92 pilocarpine hcl oral tablet 5 mg...... 57 extended release 10 meq...... 67 prednisolone sodium phosphate pilocarpine hcl oral tablet 7.5 mg...... 57 potassium chloride er oral tablet extended ophthalmic...... 114 pimecrolimus...... 62 release...... 67 prednisolone sodium phosphate oral pimozide...... 36 potassium chloride oral packet...... 67 solution 15 mg/5ml...... 92 pimtrea...... 98 potassium chloride oral solution 20 prednisolone sodium phosphate oral pink bismuth maximum strength...... 81 meq/15ml (10%), 40 meq/15ml (20%)...... 67 solution 6.7 (5 base) mg/5ml...... 92 pink bismuth oral suspension 262 mg/15ml. 81 potassium citrate er oral tablet extended prednisone oral solution...... 92 pink bismuth oral tablet 262 mg...... 81 release 10 meq (1080 mg)...... 67 prednisone oral tablet...... 92 pink bismuth oral tablet chewable 262 mg... 81 potassium citrate er oral tablet extended prednisone oral tablet therapy pack 10 mg pink-bismuth...... 81 release 15 meq (1620 mg)...... 67 (21)...... 93 pioglitazone hcl...... 44 potassium citrate er oral tablet extended prednisone oral tablet therapy pack 10 mg PIQRAY (200 MG DAILY DOSE)...... 31 release 5 meq (540 mg)...... 67 (48), 5 mg (21), 5 mg (48)...... 93 PIQRAY (250 MG DAILY DOSE)...... 31 potassium citrate-citric acid...... 67 PREFEST...... 98 PIQRAY (300 MG DAILY DOSE)...... 31 povidone-iodine external solution...... 16 pregabalin oral...... 56 pirmella 1/35...... 98 PRADAXA...... 47 pregnyl...... 93 pirmella 7/7/7...... 98 PRALUENT...... 54 PREMARIN ORAL...... 98 piroxicam oral...... 10 pramipexole dihydrochloride oral tablet PREMARIN VAGINAL...... 98 PLAN B ONE-STEP...... 100 0.125 mg, 0.5 mg, 1 mg...... 36 PREMPHASE...... 98 PLEGRIDY STARTER PACK...... 56 pramipexole dihydrochloride oral tablet PREMPRO...... 98 PLEGRIDY SUBCUTANEOUS...... 56 0.25 mg, 1.5 mg...... 36 PRENATABS RX...... 71 PNEUMOVAX 23...... 104 pramipexole dihydrochloride oral tablet prenatal formula oral tablet 28-0.8 mg...... 71 podofilox external...... 62 0.75 mg...... 36 prenatal gummy oral tablet chewable 0.4- poly bacitracin...... 16 prasugrel hcl...... 48 25 mg...... 135 polycin...... 110 praziquantel oral...... 34 prenatal multi+dha...... 71 polyethylene glycol 3350 oral powder...... 88 prazosin hcl oral...... 48 prenatal multivitamins...... 71 poly-iron 150...... 67 PRECISION LINK...... 107 prenatal oral tablet 27-0.8 mg...... 71 poly-iron 150 forte...... 67 PRECISION PCX PLUS TEST...... 107 prenatal oral tablet 27-1 mg...... 71 polymyxin b-trimethoprim...... 110 PRECISION POINT OF CARE TEST...... 107 prenatal oral tablet 28-0.8 mg...... 71 polysaccharide iron complex...... 67 PRECISION QID MONITOR...... 107 prenatal plus iron...... 71 polysaccharide iron forte...... 67 PRECISION QID TEST...... 107 prenatal vitamin plus low iron...... 71 polysaccharide-iron complex...... 67 PRECISION SOF-TACT MONITOR...... 107 prenatal vitamins oral tablet 28-0.8 mg...... 72 POLYSPORIN...... 16 PRECISION XTRA BLOOD GLUCOSE.....107 prenatal/iron...... 72

160 PRENATAL-U...... 72 promethazine hcl oral...... 119 quetiapine fumarate...... 37 PRENATVITE RX...... 72 promethazine hcl rectal...... 119 quetiapine fumarate er...... 37 preplus...... 72 promethazine vc...... 131 quinapril hcl...... 49 PRETAB...... 72 promethazine vc/codeine...... 131 quinapril-hydrochlorothiazide...... 52 PREVACID...... 90 promethazine-codeine...... 131 quinidine gluconate er...... 49 PREVACID 24HR...... 90 promethazine-dm...... 131 quinidine sulfate...... 49 prevalite oral powder...... 54 promethegan...... 119 quit2...... 14 PREVIDENT 5000 DRY MOUTH...... 57 propafenone hcl...... 49 quit4...... 14 PREVIDENT 5000 PLUS...... 57 propranolol hcl er...... 50 QVAR REDIHALER...... 120 PREVIDENT DENTAL...... 57 propranolol hcl oral solution 20 mg/5ml...... 50 raloxifene hcl...... 100 PREVIDENT MOUTH/THROAT...... 67 propranolol hcl oral solution 40 mg/5ml...... 50 ramipril...... 49 previfem...... 98 propranolol hcl oral tablet...... 50 ranolazine er...... 52 PREVNAR 13...... 104 propranolol-hctz...... 52 RASUVO...... 103 PREZCOBIX...... 41 propylthiouracil oral...... 102 RAVICTI...... 90 PREZISTA...... 41 PROTOPIC EXTERNAL OINTMENT 0.03 react...... 100 PRIFTIN...... 29 %...... 62 ready-to-use enema rectal enema ...... 88 PRILOSEC...... 90 PROTOPIC EXTERNAL OINTMENT 0.1 % 62 REBIF...... 56 primaquine phosphate...... 34 PROVENTIL HFA...... 121 REBIF REBIDOSE...... 57 primidone oral...... 19 pseudoephedrine hcl er...... 131 REBIF REBIDOSE TITRATION PACK...... 57 PRISTIQ...... 23 pseudoephedrine hcl oral tablet 30 mg...... 131 REBIF TITRATION PACK...... 57 PROAIR HFA...... 121 pseudoephedrine-bromphen-dm...... 131 reclipsen...... 98 probenecid...... 27 pseudoephedrine-guaifenesin er oral tablet RECOMBIVAX HB...... 104 pro-biotic blend...... 81 extended release 12 hour 60-600 mg...... 131 RECTIV...... 54 probiotic colon care...... 81 psyldex...... 88 REDITREX...... 103 probiotic complex...... 81 PULMICORT FLEXHALER...... 120 redness relief ophthalmic solution 0.012- probiotic maximum strength...... 81 PULMOZYME...... 131 0.2 %...... 112 probiotic oral capsule ...... 81 PURALUBE...... 110 refenesen 400...... 131 probiotic oral capsule 250 mg...... 81 purelax oral powder...... 88 REFRESH LACRI-LUBE...... 110 probiotic pearls ex st...... 81 px allergy relief cetirizine...... 120 REFRESH P.M...... 110 prochlorperazine...... 24 PYLERA...... 81 REFRESH PLUS...... 110 prochlorperazine maleate oral...... 36 pyrazinamide oral...... 29 REFRESH TEARS...... 110 PROCRIT...... 47 PYRIDIUM...... 91 REGRANEX...... 62 PROCTOFOAM HC...... 105 pyridostigmine bromide er...... 28 REHYDRALYTE...... 67 procto-med hc...... 105 pyridostigmine bromide oral solution...... 28 RELENZA DISKHALER...... 42 proctozone-hc...... 105 pyridostigmine bromide oral tablet 60 mg.... 28 relief eye drops...... 110 progesterone oral...... 100 pyridoxine hcl oral...... 72 RELISTOR...... 81 PROLENSA...... 114 pyrimethamine oral...... 34 repaglinide...... 44 PROMACTA ORAL PACKET 25 MG...... 47 QBREXZA...... 62 REPATHA...... 54 PROMACTA ORAL TABLET...... 47 QTERN...... 44 RESTASIS...... 110

161 RESTASIS MULTIDOSE...... 110 ROBITUSSIN CHILD COUGH/COLD LA...132 sb lice killing max st...... 35 RESTORA...... 81 ROBITUSSIN CHILDRENS COUGH LA....132 sb mucus relief...... 132 RESTORA RX...... 81 ROBITUSSIN COUGH+CHEST CONG sb pain reliever childrens...... 8 restore plus lubricant eye...... 110 DM ORAL LIQUID 20-400 MG/20ML...... 132 sb pain reliever ex st...... 8 restore pm...... 110 ROBITUSSIN NIGHTTIME COUGH...... 132 SCRUB CARE POVIDONE-IODINE...... 16 RETACRIT...... 47 ROBITUSSIN PEAK COLD MULTI-SYM...132 SEEBRI NEOHALER...... 121 RETIN-A EXTERNAL CREAM...... 62 ropinirole hcl...... 36 SEGLUROMET...... 44 RETIN-A EXTERNAL GEL...... 62 rosadan external cream...... 16 selegiline hcl oral...... 36 RETIN-A MICRO GEL 0.04 %, 0.1 %...... 62 rosadan external gel...... 16 SELZENTRY...... 41 RETIN-A MICRO PUMP EXTERNAL GEL rosuvastatin calcium...... 53 SEMGLEE...... 46 0.06 %...... 62 roweepra...... 19 senexon-s...... 88 REVLIMID...... 30 ROZEREM...... 135 senior probiotic...... 81 REXULTI...... 37 ROZLYTREK...... 31 senna lax...... 88 REYATAZ ORAL CAPSULE...... 41 RUBRACA...... 31 senna laxative...... 88 REYATAZ ORAL PACKET...... 41 RUCONEST...... 102 senna oral tablet...... 88 REYVOW...... 28 rufinamide...... 21 senna plus oral tablet...... 88 RHOFADE...... 62 RUZURGI...... 107 senna s...... 88 ribavirin oral...... 39 RYBELSUS...... 44 senna smooth...... 88 RID LICE KILLING SHAMPOO...... 35 RYDAPT...... 33 senna syrup 8.8 mg/5ml oral (otc)...... 88 rifabutin...... 29 rynex dm...... 132 senna-docusate sodium...... 88 rifampin oral...... 29 rynex pe...... 132 senna-lax...... 88 riluzole...... 56 RYTHMOL SR ORAL CAPSULE senna-plus...... 88 RINVOQ...... 103 EXTENDED RELEASE 12 HOUR 225 MG, senna-s...... 88 RISAQUAD...... 81 325 MG...... 49 senna-tabs...... 88 RISAQUAD-2...... 81 RYTHMOL SR ORAL CAPSULE senna-time...... 88 RISPERDAL CONSTA...... 37 EXTENDED RELEASE 12 HOUR 425 MG..49 senna-time s...... 88 RISPERDAL ORAL SOLUTION...... 37 SAIZEN...... 93 SENOKOT...... 88 RISPERDAL ORAL TABLET...... 37 saline enema...... 88 SENOKOT S...... 88 risperidone oral solution...... 37 saline mist spray...... 132 SEREVENT DISKUS...... 121 risperidone oral tablet...... 37 saline nasal spray...... 132 SERNIVO...... 62 risperidone oral tablet dispersible...... 37 salsalate oral...... 10 SEROQUEL...... 37 RITALIN...... 56 SANTYL...... 62 SEROQUEL XR...... 37 ritonavir...... 42 SAPHRIS...... 37 sertraline hcl oral...... 23 rivastigmine...... 21 sapropterin dihydrochloride...... 90 setlakin...... 98 rivastigmine tartrate...... 21 SAVAYSA...... 47 sevelamer carbonate oral tablet...... 68 rizatriptan benzoate...... 28 sb allergy medicine oral tablet...... 120 sf...... 57 robafen cf multi-symptom cold...... 131 sb arthritis pain relief...... 8 sf 5000 plus...... 57 ROBITUSSIN 12 HOUR COUGH...... 131 sb aspirin oral tablet delayed release...... 10 SFROWASA...... 105 ROBITUSSIN 12 HOUR COUGH CHILD.. 131 sb docusate sodium/senna...... 88 sharobel...... 100

162 SHINGRIX...... 104 sodium chloride (hypertonic) ophthalmic ssd...... 18 SHUR-SEAL CONTRACEPTIVE...... 92 solution...... 111 ST JOSEPH LOW DOSE...... 10 SIGNIFOR...... 102 sodium chloride inhalation nebulization stavudine...... 41 silace oral liquid...... 88 solution 0.9 %, 3 %...... 132 STEGLATRO...... 44 siladryl allergy...... 120 sodium chloride ophthalmic ointment 5 %..111 STEGLUJAN...... 44 sildenafil citrate oral tablet 20 mg...... 122 sodium chloride ophthalmic solution 5 %... 111 STELARA SUBCUTANEOUS...... 103 SILENOR...... 135 sodium fluoride 5000 plus...... 57 stimulant laxative oral tablet 8.6-50 mg...... 89 SILIQ...... 62 sodium fluoride 5000 ppm dental cream...... 57 STIOLTO RESPIMAT...... 132 siltussin sa...... 132 sodium fluoride dental cream...... 57 STIVARGA...... 33 siltussin-dm alcohol free...... 132 sodium fluoride dental gel...... 57 stomach relief extra strength...... 82 silver sulfadiazine external...... 18 sodium fluoride mouth/throat...... 67 stomach relief max st oral suspension 525 SIMBRINZA...... 113 sodium fluoride oral tablet 1.1 (0.5 f) mg...... 67 mg/15ml...... 82 simeped...... 81 sodium fluoride oral tablet chewable...... 67 stomach relief max strength...... 82 simethicone oral...... 81 sodium phenylbutyrate oral powder...... 90 stomach relief oral suspension 1050 simethicone ultra strength...... 81 sodium sulfacetamide wash...... 62 mg/30ml, 525 mg/15ml...... 82 simliya...... 98 SOFOSBUVIR-VELPATASVIR...... 38 stomach relief oral suspension 262 SIMPONI...... 103 soft glucose...... 44 mg/15ml, 525 mg/30ml, 527 mg/30ml...... 82 simvastatin oral...... 53 SOLIQUA...... 44 stomach relief oral tablet 262 mg...... 82 sinus congestion max strength...... 132 SOLODYN...... 18 stomach relief oral tablet chewable 262 mg.82 sinus nasal spray...... 132 soluble fiber therapy...... 89 stomach relief plus...... 82 sinus pe decongestant...... 132 SOMAVERT...... 102 stomach relief ultra...... 82 sinus relief ext st...... 132 SOOLANTRA...... 62 stool softener laxative oral capsule...... 89 sinus/congestion relief pe...... 132 soothe maximum strength...... 82 stool softener oral capsule 100 mg...... 89 sirolimus oral solution...... 103 soothe oral suspension...... 82 stool softener oral capsule 240 mg...... 89 sirolimus oral tablet 0.5 mg, 1 mg...... 103 soothe oral tablet...... 82 stool softener oral capsule 250 mg...... 89 sirolimus oral tablet 2 mg...... 103 soothe oral tablet chewable...... 82 stool softener oral capsule 50 mg...... 89 SIRTURO...... 29 SORILUX...... 62 stool softener oral tablet 8.6-50 mg...... 89 SKYRIZI (150 MG DOSE)...... 103 sotalol hcl (af)...... 49 stool softener pls laxative...... 89 SLO-NIACIN ORAL TABLET EXTENDED sotalol hcl oral...... 49 stool softener plus laxative...... 89 RELEASE 500 MG...... 72 SOVALDI...... 38 stool softener/laxative...... 89 smooth antacid ex st oral tablet chewable spinosad...... 35 stool softener/stimulant...... 89 750 mg...... 82 SPIRIVA HANDIHALER...... 121 STRATTERA...... 56 smooth antacid extra st...... 82 SPIRIVA RESPIMAT...... 121 STRENSIQ...... 90 smooth lax oral powder...... 88 spironolactone oral...... 53 STRIBILD...... 39 sod citrate-citric acid...... 67 spironolactone-hctz...... 52 STRIVERDI RESPIMAT...... 121 sodium bicarbonate oral tablet...... 82 sprintec 28...... 98 SUBOXONE...... 13 sodium chloride (hypertonic) ophthalmic SPRYCEL...... 33 subvenite...... 20 ointment...... 111 sps...... 68 subvenite starter kit-blue...... 20 sronyx...... 98 subvenite starter kit-green...... 20

163 subvenite starter kit-orange...... 20 sure result sr relief...... 8 TALTZ...... 63 sucralfate oral suspension...... 89 SUTENT ORAL CAPSULE 12.5 MG, 25 TAMIFLU ORAL CAPSULE...... 42 sucralfate oral tablet...... 89 MG, 50 MG...... 33 TAMIFLU ORAL SUSPENSION SUDAFED...... 132 SUTENT ORAL CAPSULE 37.5 MG...... 33 RECONSTITUTED...... 42 SUDAFED CHILDRENS...... 132 SYMAX-SR...... 74 tamoxifen citrate oral...... 30 SUDAFED CONGESTION...... 132 SYMBICORT...... 133 tamsulosin hcl...... 91 SUDAFED PE CONGESTION ORAL SYMDEKO...... 122 TARGRETIN EXTERNAL...... 34 TABLET 10 MG...... 132 SYMFI...... 40 tarina fe 1/20...... 98 SUDAFED PE SINUS CONGESTION...... 132 SYMFI LO...... 40 tarina fe 1/20 eq...... 98 SUDAFED SINUS CONGESTION...... 132 SYMJEPI...... 121 TASIGNA...... 33 SUDAFED SINUS CONGESTION 12HR...132 SYMLINPEN 120...... 44 TAZORAC EXTERNAL CREAM...... 63 sudogest maximum strength...... 133 SYMLINPEN 60...... 44 TAZORAC EXTERNAL GEL 0.1 %...... 63 sudogest oral tablet 30 mg...... 133 SYMPAZAN...... 19 taztia xt...... 51 sulfacetamide sodium external liquid...... 62 SYMPROIC...... 82 TDVAX...... 104 sulfacetamide sodium ophthalmic...... 18 SYMTUZA...... 42 TEARS AGAIN...... 111 sulfacetamide sodium-sulfur cream 10-5 % SYNAGIS...... 103 TEARS AGAIN ADVANCED EYELID external...... 62 SYNAREL...... 102 OPHTHALMIC...... 111 sulfacetamide sodium-sulfur external lotion SYNJARDY...... 44 tears pure...... 111 10-5 %...... 62 SYNJARDY XR...... 44 TECFIDERA...... 57 sulfacetamide sodium-sulfur external SYSTANE COMPLETE...... 111 TEGRETOL ORAL SUSPENSION...... 21 suspension 10-5 %...... 63 SYSTANE CONTACTS...... 111 TEGSEDI...... 90 sulfacetamide sodium-sulfur liquid 9-4.5 % SYSTANE HYDRATION PF...... 111 temazepam oral capsule 15 mg, 30 mg..... 135 external...... 63 SYSTANE OPHTHALMIC SOLUTION...... 111 TEMIXYS...... 41 sulfacetamide sod-sulfur wash external SYSTANE OVERNIGHT THERAPY...... 111 TEMOVATE...... 63 liquid 9-4.5 %...... 63 SYSTANE PRESERVATIVE FREE...... 111 temozolomide oral capsule 100 mg, 140 sulfacetamide-prednisolone ophthalmic SYSTANE ULTRA...... 111 mg...... 29 solution...... 111 SYSTANE ULTRA PF...... 111 temozolomide oral capsule 180 mg, 250 sulfamethoxazole-trimethoprim oral...... 18 tab tussin...... 133 mg...... 29 sulfamez wash...... 63 tab-a-vite...... 72 temozolomide oral capsule 20 mg, 5 mg..... 29 sulfasalazine oral...... 105 tab-a-vite/beta carotene...... 72 TENCON...... 8 sulfatrim pediatric...... 18 tab-a-vite/iron...... 72 TENIVAC...... 104 sulindac oral...... 10 TABLOID...... 30 tenofovir disoproxil fumarate...... 41 sumatriptan nasal...... 28 TACLONEX...... 63 terazosin hcl...... 91 sumatriptan succinate oral...... 28 tacrolimus external ointment 0.03 %...... 63 terbinafine hcl external...... 27 sumatriptan succinate refill...... 28 tacrolimus external ointment 0.1 %...... 63 terbinafine hcl oral...... 27 sumatriptan succinate subcutaneous...... 28 tacrolimus oral capsule 0.5 mg, 5 mg...... 103 terbinafine hydrochloride external cream 1 suphedrine oral tablet 30 mg...... 133 tacrolimus oral capsule 1 mg...... 103 %...... 27 suphedrine oral tablet extended release 12 TAFINLAR...... 33 terconazole vaginal cream...... 27 hour 120 mg...... 133 take action...... 100 TERIPARATIDE (RECOMBINANT)...... 105

164 testosterone cypionate intramuscular...... 94 TIVICAY...... 39 trazodone hcl oral tablet 300 mg...... 23 testosterone enanthate intramuscular...... 94 TIVICAY PD...... 39 TRECATOR...... 29 testosterone transdermal gel 12.5 mg/act tizanidine hcl oral tablet...... 134 TRELEGY ELLIPTA...... 133 (1%)...... 94 TOBI NEBULIZER...... 122 TREMFYA...... 63 testosterone transdermal gel 25 mg/2.5gm TOBI PODHALER...... 122 TRESIBA...... 46 (1%), 50 mg/5gm (1%)...... 94 TOBRADEX OPHTHALMIC OINTMENT... 111 TRESIBA FLEXTOUCH...... 46 TETANUS-DIPHTHERIA TOXOIDS TD.... 104 TOBRADEX ST...... 111 tretinoin external cream...... 63 tetrabenazine...... 56 tobramycin inhalation nebulization solution tretinoin oral...... 34 THALOMID...... 30 300 mg/4ml...... 122 TREZIX...... 12 the magic bullet...... 89 tobramycin nebulization solution 300 tri femynor...... 98 THEO-24...... 122 mg/5ml inhalation...... 122 triamcinolone acetonide external cream...... 63 theophylline...... 122 TOBRAMYCIN NEBULIZATION triamcinolone acetonide external lotion theophylline er oral tablet extended release SOLUTION 300 MG/5ML INHALATION.... 122 0.025 %...... 63 12 hour 300 mg...... 122 tobramycin ophthalmic...... 112 triamcinolone acetonide external lotion 0.1 theophylline er oral tablet extended release tobramycin-dexamethasone...... 111 %...... 63 12 hour 450 mg...... 122 tolcapone...... 35 triamcinolone acetonide external ointment theophylline er oral tablet extended release tolnaftate antifungal...... 27 0.025 %, 0.1 %, 0.5 %...... 63 24 hour 400 mg...... 122 tolnaftate external cream...... 27 triamcinolone acetonide mouth/throat...... 57 theophylline er oral tablet extended release tolnaftate external powder...... 107 TRIAMINIC ALLERCHEWS...... 120 24 hour 600 mg...... 122 tolterodine tartrate...... 91 triamterene-hctz...... 52 thera...... 72 TOPICORT SPRAY...... 63 triazolam...... 42 thera-tabs...... 72 topiramate oral capsule sprinkle...... 20 TRICON...... 67 thiamine hcl oral...... 72 topiramate oral tablet...... 20 triderm...... 63 thiamine mononitrate oral...... 72 toremifene citrate...... 30 tri-estarylla...... 98 thioridazine hcl oral...... 36 torsemide...... 52 trifluoperazine hcl...... 37 thiothixene...... 37 total allergy...... 120 trifluridine...... 39 THRIVE...... 14 total allergy medicine...... 120 trihexyphenidyl hcl...... 35 tiadylt er...... 51 TOUJEO MAX SOLOSTAR...... 46 TRIJARDY XR...... 44 tiagabine hcl...... 19 TOUJEO SOLOSTAR...... 46 TRIKAFTA...... 122 TIBSOVO...... 33 TOVIAZ...... 91 tri-legest fe...... 98 TIKOSYN...... 50 TRACLEER...... 122 tri-linyah...... 98 tilia fe...... 98 TRADJENTA...... 44 tri-lo-estarylla...... 98 timolol maleate ophthalmic solution 0.25 tramadol hcl oral tablet 50 mg...... 12 tri-lo-marzia...... 98 %, 0.5 %...... 113 trandolapril...... 49 tri-lo-mili...... 98 TIMOPTIC...... 113 tranexamic acid oral...... 48 tri-lo-sprintec...... 98 TIMOPTIC-XE...... 113 tranylcypromine sulfate...... 22 trimethobenzamide hcl oral...... 24 TINACTIN EXTERNAL AEROSOL...... 27 TRAVATAN Z...... 114 trimethoprim oral...... 16 TINACTIN EXTERNAL CREAM...... 27 trazodone hcl oral tablet 100 mg, 150 mg, tri-mili...... 98 tinaspore...... 27 50 mg...... 23 TRINATE...... 72

165 TRINTELLIX...... 23 tussin cough long-acting...... 133 urin ds...... 92 tri-nymyo...... 98 tussin cough/chest congest oral syrup 100- urinary pain relief oral tablet 95 mg...... 92 triple antibiotic...... 16 10 mg/5ml...... 133 urinary pain relief tablet 95 mg oral...... 92 triple antibiotic original...... 16 tussin cough/chest dm max oral liquid 10- ursodiol oral capsule...... 83 tri-previfem...... 98 200 mg/5ml...... 133 ursodiol oral tablet...... 83 TRIPTODUR...... 102 tussin dm cough/chest cong...... 133 UTIRA-C...... 92 tri-sprintec...... 98 tussin dm cough/chest oral syrup 10-100 VAGIFEM...... 98 TRIUMEQ...... 39 mg/5ml...... 133 valacyclovir hcl oral...... 39 trivora (28)...... 98 tussin dm max adult...... 133 valganciclovir hcl oral tablet...... 38 tri-vylibra...... 98 tussin dm max daytime...... 133 valproic acid oral...... 19 tri-vylibra lo...... 98 tussin dm max oral liquid 10-200 mg/5ml...133 VALTOCO 10 MG DOSE...... 19 trospium chloride...... 91 tussin dm max oral liquid 20-400 mg/20ml.134 VALTOCO 15 MG DOSE...... 19 TRUETRACK TEST...... 107 tussin dm max st...... 134 VALTOCO 20 MG DOSE...... 19 TRULANCE...... 82 tussin dm oral syrup 100-10 mg/5ml...... 134 VALTOCO 5 MG DOSE...... 19 TRULICITY...... 44 tussin maximum strength oral syrup 15 VANCOCIN...... 16 TRUMENBA...... 104 mg/5ml...... 134 vandazole...... 16 TRUSOPT...... 113 tussin mucus+chest congestion oral syrup 134 VANOS...... 63 TRUVADA ORAL TABLET 100-150 MG, tussin multi-symptom cold cf...... 134 VAQTA...... 104 167-250 MG...... 41 tussin oral syrup 100 mg/5ml...... 134 VARIVAX...... 104 TUDORZA PRESSAIR...... 121 TWINRIX...... 104 VARUBI (180 MG DOSE)...... 24 tulana...... 100 tyblume...... 98 VASOCLEAR-A...... 112 TUMS...... 82 TYBOST...... 39 v-c forte...... 72 TUMS CHEWY BITES...... 82 TYLENOL ORAL SUSPENSION 160 VECTICAL...... 63 TUMS E-X 750...... 82 MG/5ML...... 8 vegetable lax+stool softener...... 89 TUMS EXTRA STRENGTH 750...... 82 TYLENOL ORAL TABLET 325 MG...... 8 velivet...... 98 TUMS LASTING EFFECTS...... 82 TYLENOL ORAL TABLET 500 MG...... 8 VELPHORO...... 68 TUMS SMOOTHIES...... 83 TYLENOL ORAL TABLET CHEWABLE VELTASSA...... 68 TUMS ULTRA 1000...... 83 160 MG...... 8 VELTIN...... 63 TURALIO...... 33 TYLENOL ORAL TABLET EXTENDED VENCLEXTA...... 33 tussin adult dm oral liquid 10-200 mg/5ml..133 RELEASE 650 MG...... 8 VENCLEXTA STARTING PACK...... 33 tussin adult multi-symptom...... 133 TYMLOS...... 105 venlafaxine hcl...... 23 tussin cf cough & cold oral liquid 5-10-100 UBRELVY...... 28 venlafaxine hcl er oral capsule extended mg/5ml...... 133 UDAMIN SP...... 72 release 24 hour...... 23 tussin cf multi-symptom cold...... 133 UDENYCA...... 47 VENTOLIN HFA...... 121 tussin cf oral liquid 30-10-100 mg/5ml...... 133 ultra fresh...... 111 verapamil hcl er oral capsule extended tussin cf oral liquid 5-10-100 mg/5ml...... 133 ultra fresh pm...... 111 release 24 hour 120 mg, 180 mg, 240 mg, tussin chest congestion oral syrup 100 ultra lubricant drop...... 111 360 mg...... 51 mg/5ml...... 133 ultra lubricating eye drops...... 111 verapamil hcl er oral tablet extended tussin cough dm sugar free...... 133 unithroid...... 101 release...... 51

166 verapamil hcl oral...... 51 vitamin b-12 tr oral tablet extended release volnea...... 99 VERZENIO...... 31 1000 mcg...... 72 voriconazole oral tablet...... 27 VESICARE...... 91 vitamin b-6...... 72 VOSEVI...... 38 vic-forte...... 72 vitamin c er oral tablet extended release VOTRIENT...... 33 VICTOZA SOLUTION PEN-INJECTOR 18 1500 mg...... 72 VRAYLAR...... 37 MG/3ML SUBCUTANEOUS...... 44 vitamin c oral liquid 500 mg/5ml...... 72 VUMERITY...... 57 VIEKIRA PAK...... 38 vitamin c oral tablet 250 mg...... 72 vyfemla...... 99 vienva...... 98 vitamin c oral tablet 500 mg...... 73 vylibra...... 99 vigabatrin oral packet...... 19 vitamin c oral tablet chewable 250 mg...... 73 VYNDAMAX...... 52 vigadrone...... 19 vitamin c oral tablet chewable 500 mg...... 73 VYNDAQEL...... 52 VIGAMOX...... 18 vitamin c tablet 250 mg oral 250 mg...... 73 VYVANSE ORAL CAPSULE...... 55 VIIBRYD...... 23 vitamin c/acerola...... 73 VYVANSE ORAL TABLET CHEWABLE...... 55 VIMPAT ORAL...... 21 vitamin c/rose hips oral tablet 500 mg...... 73 warfarin sodium oral tablet 1 mg, 10 mg, 2 VINATE II...... 72 vitamin c-rose hips oral tablet 500 mg...... 73 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg...... 47 VINATE ONE...... 72 vitamin d (cholecalciferol) oral tablet 25 warfarin sodium oral tablet 6 mg...... 47 VIOKACE ORAL TABLET 10440-39150 mcg (1000 ut)...... 73 wart remover external liquid 17 %...... 63 UNIT...... 90 vitamin d (ergocalciferol) oral capsule 1.25 wera...... 99 viorele...... 99 mg (50000 ut)...... 73 WESTAB PLUS...... 74 VIRACEPT...... 42 vitamin d oral liquid...... 73 wixela inhub...... 134 VIRAMUNE...... 40 vitamin d oral tablet 25 mcg (1000 ut)...... 73 womans laxative...... 89 VIREAD ORAL POWDER...... 41 vitamin d oral tablet 50 mcg (2000 ut)...... 73 womens gentle laxative...... 89 VIREAD ORAL TABLET 150 MG, 200 MG, vitamin d3 capsule 1.25 mg (50000 ut) oral womens laxative...... 89 250 MG...... 41 1.25 mg (50000 ut)...... 73 womens prenatal+dha...... 74 virt-phos 250 neutral...... 67 vitamin d3 capsule 250 mcg (10000 ut) oral XALATAN...... 114 VISBIOME HIGH POTENCY ORAL 250 mcg (10000 ut)...... 73 XALKORI...... 33 CAPSULE...... 83 vitamin d3 oral capsule 250 mcg (10000 ut) 73 XARELTO...... 47 VISINE...... 112 vitamin d3 oral capsule 50 mcg (2000 ut).... 73 XARELTO STARTER PACK...... 47 VISINE ADVANCED RELIEF...... 111 vitamin d-3 oral capsule 50 mcg (2000 ut)... 73 XCOPRI...... 19 VISTA GEL DRY EYE RELIEF...... 111 vitamin d3 oral liquid 10 mcg/ml...... 73 XCOPRI (250 MG DAILY DOSE) ORAL VISTA MEIBO TEARS...... 111 vitamin d3 oral tablet 25 mcg (1000 ut)...... 73 TABLET THERAPY PACK 50 & 200 MG.....19 VISTA TEARS...... 111 vitamin d3 oral tablet 50 mcg (2000 ut)...... 73 XCOPRI (350 MG DAILY DOSE)...... 19 VISTOGARD...... 107 vitamin d3 oral tablet chewable 25 mcg...... 73 XELJANZ ORAL TABLET...... 103 vita s forte...... 72 vitamin d3 tablet 25 mcg (1000 ut) oral 25 XELJANZ XR ORAL TABLET EXTENDED vitacel...... 72 mcg (1000 ut)...... 74 RELEASE 24 HOUR 11 MG...... 103 vitamin a oral capsule 3 mg (10000 ut)...... 72 vitamin-b complex...... 74 XELJANZ XR ORAL TABLET EXTENDED vitamin b-1 oral tablet 100 mg...... 72 VITATHELY WITH GINGER...... 74 RELEASE 24 HOUR 22 MG...... 103 vitamin b-12 er tablet extended release VITRAKVI...... 33 XELODA...... 30 1000 mcg oral...... 72 VIVELLE-DOT...... 99 XENLETA ORAL...... 16 VIVITROL...... 13 XEPI...... 18

167 XIGDUO XR ORAL TABLET EXTENDED ZIANA...... 63 RELEASE 24 HOUR 10-1000 MG, 10-500 zidovudine...... 41 MG...... 44 ZIEXTENZO...... 47 XIGDUO XR ORAL TABLET EXTENDED ZILXI...... 63 RELEASE 24 HOUR 2.5-1000 MG, 5-1000 zinc oxide external ointment 40 %...... 63 MG, 5-500 MG...... 44 ZIOPTAN...... 114 XIIDRA...... 112 ziprasidone hcl...... 37 XIMINO...... 18 ZOHYDRO ER...... 11 XOFLUZA (40 MG DOSE)...... 42 ZOLINZA...... 31 XOFLUZA (80 MG DOSE)...... 42 zolpidem tartrate oral...... 135 XOLAIR...... 103 zolpidem tartrate sublingual...... 135 XOPENEX HFA...... 121 ZOMACTON...... 93 XPECT...... 134 ZOMACTON (FOR ZOMA-JET 10)...... 93 XTANDI ORAL CAPSULE...... 30 zonisamide oral...... 19 xulane...... 99 ZORTRESS ORAL TABLET 1 MG...... 103 XULTOPHY...... 44 zovia 1/35 (28)...... 99 YONSA...... 30 zovia 1/35e (28)...... 99 yuvafem...... 99 ZUBSOLV...... 13 zaclir cleansing...... 63 ZYCLARA...... 63 ZADITOR...... 114 ZYDELIG...... 33 zafemy...... 99 ZYKADIA...... 31 zaleplon...... 135 ZYLET...... 112 ZARXIO...... 47 ZYMAXID...... 112 ZAVESCA...... 90 ZYPREXA ORAL...... 37 ZEASORB-AF...... 107 ZYPREXA ZYDIS...... 37 ZEGERID...... 90 ZYRTEC ALLERGY ORAL TABLET...... 120 ZEJULA...... 31 ZYRTEC-D ALLERGY & CONGESTION...134 ZELAC...... 83 ZYTIGA...... 30 ZELBORAF...... 33 ZYVANA...... 74 zenatane...... 63 ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT...... 90 ZENZEDI...... 55 ZEPATIER...... 38 ZEPOSIA...... 54 ZETONNA...... 120

168