Excellus BlueCross BlueShield Medicare Employer Group Plans

Transcription

1 A nonprofit independent licensee of the Blue Cross Blue Shield Association Excellus BlueCross BlueShield Medicare Employer Group Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN This formulary was updated on 10/23/2018. For more recent information or other questions, please contact Excellus BlueCross BlueShield at or, for TTY users, , Monday Friday, 8:00 a.m. 8:00 p.m.; From October 1 to February 14, representatives are available to assist you seven days a week from 8:00 a.m. 8:00 p.m., or visit ExcellusMedicare.com. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. H3351, H3335 Formulary ID: Ver. 17 M-109CY Comp Group

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3 When this drug list (formulary) refers to we, us, or our, it means Excellus BlueCross BlueShield. When it refers to plan or our plan, it means Excellus BlueCross BlueShield. This document includes a list of the drugs (formulary) for our plan which is current as of 10/23/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year. What is the Excellus BlueCross BlueShield Medicare Employer Group Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add quantity limits and/or restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/23/2018. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance chang-es to our formulary, we will update the formulary with any CMS approved changes. We will notify you of any nonmaintenance changes to your printed formulary 60 days prior to the effective date of the changes. A printed copy can be requested by calling us. See the contact information that appears on the front and back cover pages. I M-109CY18

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 91. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for XARELTO. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Excellus BlueCross BlueShield Medicare Employer Group Formulary? on page III for information about how to request an exception. M-109CY18 II

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Excellus BlueCross BlueShield Medicare Employer Group Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When you request a formulary, tier or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. III M-109CY18

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Any member experiencing a level of care change, such as a change in their treatment setting, will be provided a one time, up to 31-day supply of medication. This includes emergency supplies of non-formulary drugs and most Part D drugs which have an approved quantity limit lower than the beneficiary s current dose. For more information For more detailed information about your Excellus BlueCross BlueShield prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7days a week. TTY users should call Or, visit M-109CY18 IV

7 Excellus BlueCross BlueShield s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 91. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., XARELTO) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. EXPLANATION OF REQUIREMENTS/LIMITS QUANTITY LIMITS (QL) VERIFICATION FOR PART B OR PART D (B/D PA) EXCLUDED PART D S (EX) For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 tablets per prescription for XARELTO. These medications require prior authorization only to determine whether they qualify for payment under Part B or Part D. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. DESCRIPTION OF S 1 Most generic drugs on our formulary. 2 3 Preferred brand-name drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class. Certain generic drugs may appear in Tier 2 due to the high cost of the drug or the potential safety concerns for our Part D members. Non-preferred or higher cost specialty brand-name drugs. Certain generic drugs may appear in Tier 3 due to the high cost of the drug or the potential safety concerns for our Part D members. V M-109CY18

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9 NAME ANALGESICS OPIOID ANALGESICS, LONG-ACTING BELBUCA Tier 3 buprenorphine patch Tier 3 BUTRANS Tier 3 EMBEDA Tier 3 fentanyl (12 patch, 25 patch, 50 patch, 75 Tier 1 patch, 100 patch) fentanyl (37.5 patch, 62.5 patch, 87.5 patch) Tier 3 hydromorphone er Tier 2 HYSINGLA ER Tier 3 morphine sulfate er (er 10 mg cap, er 20 mg Tier 2 cap, er 30 mg cap, er 45 mg cap, er 50 mg cap, er 60 mg cap, er 75 mg cap, er 80 mg cap, er 90 mg cap, er 100 mg cap, er 120 mg cap) morphine sulfate er (er 15 mg tablet, er 30 mg Tier 1 tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg tablet) NUCYNTA ER Tier 3 oxycodone hcl er Tier 3 OXYCONTIN Tier 3 oxymorphone hcl er Tier 2 tramadol hcl er (er 100 mg tablet, er 200 mg Tier 2 tablet, er 300 mg tablet, hcl er 100 mg capsule, hcl er 100 mg tablet, hcl er 200 mg tablet, hcl er 200 mg capsule, hcl er 300 mg capsule, hcl er 300 mg tablet) XARTEMIS XR Tier 3 XTAMPZA ER Tier 3 ZOHYDRO ER Tier 3 OPIOID ANALGESICS, SHORT-ACTING ABSTRAL Tier 3 acetaminophen-codeine (acetamin-codein 300- Tier 1 30 mg/12.5, acetaminop-codeine mg/5, acetaminophen-cod #2 tablet, acetaminophencod #3 tablet, acetaminophen-cod #4 tablet) ACTIQ Tier 3 ASCOMP WITH CODEINE Tier 3 aspirin-caffeine-dihydrocodein Tier 1 BUPRENEX Tier 3 buprenorphine hcl (0.3 mg/ml crpjct, 0.3 mg/ml Tier 1 vial, 2 mg tablet sl, 8 mg tablet sl) butalb-acetaminoph-caff-codein Tier 3 1

10 NAME ANALGESICS (CONTINUED) butalb-caff-acetaminoph-codein Tier 3 butalbital compound-codeine Tier 3 butalbital-acetaminophen (50-325, ) Tier 3 butalbital-acetaminophen-caffe (butalbacetamin-caff , butalb-acetamin-caff Tier , butalbit-acetaminophen-caff cp) butalbital-aspirin-caffeine Tier 3 butorphanol tartrate Tier 3 CAPACET Tier 3 codeine sulfate Tier 1 DISKETS Tier 1 DURAMORPH Tier 1 ENDOCET Tier 1 fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, Tier 3 citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FENTORA Tier 3 hydrocodone-acetaminophen (hydrocodoneacetamin , hydrocodone-acetamin 2.5- Tier 1 108/5, hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamin 5-217/10, hydrocodoneacetamin 5-163/7.5, hydrocodone-acetamin , hydrocodone-acetamin , hydrocodone-acetamin /15, hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamn /15) hydrocodone-ibuprofen Tier 1 hydromorphone hcl (0.5 mg/0.5 ml, hcl 1 Tier 1 mg/ml amp, 1 mg/ml carpujct, 1 mg/ml syringe, 1 mg/ml solution, 2 mg/ml carpujct, 2 mg/ml vial, hcl 2 mg/ml amp, 2 mg tablet, 2 mg/ml isecure, hcl 4 mg/ml amp, 4 mg/ml carpujct, 4 mg tablet, 5 mg/5 ml soln, 8 mg tablet, hcl 10 mg/ml vl, 10 mg/ml vial, hcl 10 mg/ml amp, 50 mg/5 ml vial, 500 mg/50 ml vl, 500 mg/50 ml via) INFUMORPH Tier 3 LAZANDA Tier 3 levorphanol tartrate Tier 2 LORCET Tier 1 LORCET HD Tier 1 2

11 NAME ANALGESICS (CONTINUED) LORCET PLUS Tier 1 MARGESIC Tier 3 MARTEN-TAB Tier 3 methadone hcl (5 mg/5 ml solution, hcl 5 mg Tier 1 tablet, hcl 10 mg/ml vial, 10 mg/ml oral conc, 10 mg/5 ml solution, hcl 10 mg tablet, hcl 200 mg/20 ml vl) METHADONE INTENSOL Tier 1 METHADOSE (10 MG/ML ORAL CONC, Tier 1 40 MG TABLET DISPR) morphine sulfate (0.5 mg/ml vial, 1 mg/ml vial Tier 2 p-f, sulfate 1 mg/ml vial, 2 mg/ml isecure syr, 2 mg/ml carpuject, 4 mg/ml carpuject, 4 mg/ml isecure syr, sulfate 4 mg/ml vial, 5 mg/ml syringe, 5 mg/ml vial, sulfate 8 mg/ml vial, 8 mg/ml isecure syrng, 8 mg/ml carpuject, sulfate 10 mg/ml vial, 10 mg/ml isecure syrg, 10 mg/ml carpuject) morphine sulfate (sulf 10 mg/5 ml soln, sulf 20 Tier 1 mg/5 ml soln, sulf 100 mg/5 ml soln, sulfate ir 15 mg tab, sulfate ir 30 mg tab) nalbuphine hcl Tier 1 NUCYNTA Tier 3 oxycodone hcl (oxycodon 10 mg/0.5 ml oral Tier 1 syr, oxycodone hcl 5 mg/5 ml soln, oxycodone hcl 5 mg capsule, oxycodone hcl 5 mg tablet, oxycodone hcl 10 mg tablet, oxycodone hcl 15 mg tablet, oxycodone hcl 20 mg tablet, oxycodone hcl 30 mg tablet, oxycodone hcl 100 mg/5 ml soln) oxycodone hcl-aspirin Tier 1 oxycodone hcl-ibuprofen Tier 1 oxycodone-acetaminophen (oxycodonacetaminophen , oxycodon- Tier 1 acetaminophen , oxycodoneacetaminophen 5-325, oxycodoneacetaminophen , oxycodoneacetaminophn 5-325/5) oxymorphone hcl Tier 2 pentazocine-naloxone hcl Tier 2 PHRENILIN FORTE Tier 3 SUBSYS Tier 3 TALWIN Tier 3 3

12 NAME ANALGESICS (CONTINUED) TENCON Tier 3 tramadol hcl Tier 1 tramadol hcl-acetaminophen Tier 1 VANATOL LQ Tier 3 VICODIN Tier 1 VICODIN ES Tier 1 VICODIN HP Tier 1 ZEBUTAL Tier 3 ANESTHETICS LOCAL ANESTHETICS lidocaine 5% ointment Tier 2 lidocaine 5% patch Tier 2 QL (90 per 30 days) lidocaine hcl (0.5% vial, 1% 50 mg/5 ml vl, 1% Tier 1 ampul, 1% vial, 1% 20 mg/2 ml vl, 1% 300 mg/30 ml, 1% 20 mg/2 ml, 1% 50 mg/5 ml, 1.5% ampul, 2% 40 mg/2 ml vl, 2% ampul, 2% jelly, 2% 40 mg/2 ml, 2% vial, 2% 100 mg/5 ml, 4% solution, 4% ampul) lidocaine hcl viscous Tier 1 lidocaine-prilocaine Tier 1 LIDODERM Tier 3 QL (90 per 30 days) PLIAGLIS Tier 3 SYNERA Tier 3 XYLOCAINE (0.5% VIAL, 1% VIAL) Tier 3 XYLOCAINE-MPF (0.5% VIAL, 1% VIAL, 1% AMPUL, 1.5% AMPUL, 2% VIAL, 2% AMPUL) Tier 3 ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS ALCOHOL DETERRENTS, ANTI-CRAVING acamprosate calcium Tier 2 disulfiram Tier 2 VIVITROL Tier 3 OPIOID ANTAGONISTS buprenorphine-naloxone (buprenorp-nalox 8-2 mg sl film, buprenorphin-naloxon 8-2 mg sl, buprenorphn-naloxn mg sl) Tier 1 EVZIO Tier 3 QL (1 per 30 days) naloxone hcl Tier 1 naltrexone hcl Tier 1 NARCAN 4 MG NASAL SPRAY Tier 2 QL (2 per 30 days) SUBOXONE (2 MG-0.5 MG SL FILM, 4 MG-1 MG SL FILM, 8 MG-2 MG SL FILM, 12 MG-3 MG SL FILM) Tier 3 4

13 NAME ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS (CONTINUED) SMOKING CESSATION AGENTS BUPROBAN Tier 1 bupropion hcl sr 150 mg tablet Tier 1 CHANTIX Tier 2 QL (336 per 365 days) NICOTROL Tier 3 NICOTROL NS Tier 3 ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY S CAMBIA Tier 3 QL (9 per 30 days) celecoxib Tier 1 QL (60 per 30 days) diclofenac 1.5% topical soln Tier 2 diclofenac potassium Tier 1 diclofenac sodium (sod dr 25 mg tab, sod dr 50 Tier 1 mg tab, sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sod ec 75 mg tab, sodium 1% gel) diclofenac sodium er Tier 1 diclofenac sodium-misoprostol Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac er Tier 1 fenoprofen 600 mg tablet Tier 1 FLECTOR Tier 3 QL (60 per 30 days) flurbiprofen Tier 1 IBU Tier 1 ibuprofen (100 mg/5 ml susp, 400 mg tablet, Tier mg tablet, 800 mg tablet) indomethacin (25 mg capsule, 50 mg capsule) Tier 1 indomethacin er Tier 1 ketoprofen (25 mg capsule, 50 mg capsule, 75 Tier 1 mg capsule) ketoprofen er 200 mg capsule Tier 1 QL (30 per 30 days) ketorolac 10 mg tablet Tier 1 QL (20 per 30 days) KLOFENSAID II Tier 2 meclofenamate sodium Tier 1 meloxicam 15 mg tablet Tier 1 QL (30 per 30 days) meloxicam 7.5 mg tablet Tier 1 QL (60 per 30 days) meloxicam 7.5 mg/5 ml susp Tier 3 QL (300 per 30 days) nabumetone Tier 1 naproxen (125 mg/5 ml suspen, 250 mg tablet, 375 mg tablet, dr 375 mg tablet, dr 500 mg tablet, 500 mg kit, 500 mg tablet) Tier 1 5

14 NAME ANTI-INFLAMMATORY AGENTS (CONTINUED) naproxen sodium (275 mg tab, 550 mg tab) Tier 1 naproxen sodium ds Tier 1 oxaprozin Tier 1 piroxicam Tier 1 sulindac Tier 1 tolmetin sodium Tier 1 VIMOVO Tier 3 QL (60 per 30 days) ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate Tier 1 BETHKIS Tier 3 B/D PA GENTAK Tier 1 gentamicin sulfate (0.1% cream, 0.1% Tier 1 ointment, 0.3% eye ointment, 0.3% eye drop, 3 mg/ml eye drop, 10 mg/ml vial, 20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) gentamicin sulfate in ns Tier 1 KITABIS PAK Tier 3 neomycin sulfate Tier 1 paromomycin sulfate Tier 1 streptomycin sulfate Tier 1 TOBI Tier 3 B/D PA TOBI PODHALER Tier 3 tobramycin 0.3% eye drop Tier 1 tobramycin 300 mg/5 ml ampule Tier 3 B/D PA tobramycin sulfate (1.2 gram/30 ml vial, 1.2 Tier 1 gm vial, 10 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30 ml vial) TOBREX 0.3% EYE OINTMENT Tier 3 ANTIBACTERIALS, OTHER acetic acid 0.25% irrig soln Tier 3 BACIIM Tier 1 bacitracin (500 unit/gm ophth, 50,000 unit Tier 1 vial) bacitracin-polymyxin eye oint Tier 1 chloramphenicol sod succinate Tier 1 CLEOCIN 100 MG VAGINAL OVULE Tier 3 CLINDACIN ETZ 1% PLEDGET Tier 3 CLINDACIN P Tier 3 CLINDAGEL Tier 3 6

15 NAME ANTIBACTERIALS (CONTINUED) clindamycin hcl Tier 1 clindamycin palmitate hcl Tier 1 clindamycin pediatric Tier 1 clindamycin phosphate (ph 1% solution, ph 9 Tier 1 g/60 ml vial, ph 900 mg/6 ml vl, phos 1% pledget, phosp 1% lotion, 2% vaginal cream, ph 300 mg/2 ml vl, 300 mg/2 ml addvan, ph 600 mg/4 ml vl, 600 mg/4 ml addvan, 900 mg/6 ml addvan) clindamycin phosphate 1% foam Tier 3 clindamycin phosphate 1% gel (alternative to Tier 3 clindagel) clindamycin phosphate 1% gel (generic for Tier 1 cleocin t) clindamycin phosphate-d5w Tier 1 CLINDESSE Tier 3 colistimethate Tier 3 CORTISPORIN CREAM Tier 3 DALVANCE Tier 3 daptomycin 500 mg vial Tier 3 lansoprazol-amoxicil-clarithro Tier 3 QL (112 per 30 days) LINCOCIN Tier 3 lincomycin hcl Tier 2 linezolid 100 mg/5 ml susp Tier 3 linezolid 600 mg tablet Tier 3 QL (60 per 30 days) linezolid-0.9% nacl Tier 3 linezolid-d5w Tier 3 methenamine hippurate Tier 1 METRO IV Tier 1 metronidazole (0.75% lotion, top 1% gel pump, Tier 1 topical 0.75% gl, 0.75% cream, topical 1% gel, vaginal 0.75% gl, 250 mg tablet, 375 mg capsule, 500 mg tablet, 500 mg/100 ml) MONUROL Tier 3 mupirocin Tier 1 NEO-POLYCIN Tier 1 NEO-POLYCIN HC Tier 1 NEO-SYNALAR 0.5%-0.025% CREAM Tier 3 neomycin-bacitracin-poly-hc Tier 1 neomycin-bacitracin-polymyxin Tier 1 neomycin-poly-hc eye drops Tier 1 7

16 NAME ANTIBACTERIALS (CONTINUED) neomycin-polymyxin b Tier 1 neomycin-polymyxin-gramicidin Tier 1 nitrofurantoin (25 mg cap, 50 mg cap, 100 mg Tier 1 cap) nitrofurantoin 25 mg/5 ml susp Tier 2 nitrofurantoin mono-macro Tier 1 NORITATE Tier 3 NUVESSA Tier 3 POLYCIN Tier 1 polymyxin b sulfate Tier 1 PRIMSOL Tier 3 ROSADAN (0.75% CREAM, 0.75% GEL) Tier 1 silver sulfadiazine Tier 1 SIVEXTRO Tier 3 QL (6 per 6 days) SSD Tier 1 SULFAMYLON 8.5% CREAM Tier 3 SYNERCID Tier 3 THERMAZENE Tier 1 tigecycline Tier 3 trimethoprim Tier 1 TYGACIL Tier 3 vancomycin Tier 1 vancomycin hcl (125 mg capsule, 250 mg Tier 2 capsule) vancomycin hcl (hcl 1g/200 ml bag, 1 gm vial, 1 gm add-van vial, hcl 5 gm vial, hcl 10 gm vial, hcl 100 gm smartpak, hcl 250 mg vial, 500 mg vial, 500 mg a-v vial, hcl 750 mg vial) Tier 1 vancomycin in 0.9 % sodium chloride Tier 1 vancomycin-d5w 500 mg/100 ml Tier 1 BETA-LACTAM, CEPHALOSPORINS cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) Tier 1 cefaclor er Tier 1 cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 Tier 1 mg/5 ml susp, 500 mg capsule) cefazolin sodium Tier 1 cefazolin sodium-dextrose (1 g/50, 2 g/100, 2 Tier 1 g/50) cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, Tier mg capsule) 8

17 NAME ANTIBACTERIALS (CONTINUED) cefepime Tier 3 cefepime hcl Tier 3 cefepime-dextrose Tier 3 cefixime Tier 1 CEFOTAN 2 GM VIAL Tier 1 cefotaxime sodium Tier 1 cefotetan & dextrose Tier 1 cefotetan (1 gm vial, 2 gm vial, 10 gm vial) Tier 1 cefoxitin Tier 1 cefoxitin sodium Tier 1 cefpodoxime proxetil (50 mg/5 ml susp, 100 Tier 1 mg/5 ml susp, 100 mg tablet, 200 mg tablet) cefprozil (125 mg/5 ml susp, 250 mg tablet, Tier mg/5 ml susp, 500 mg tablet) ceftazidime Tier 1 ceftibuten (180 mg/5 ml susp, 400 mg capsule) Tier 1 CEFTIN (125 MG/5 ML ORAL SUSP, 250 Tier 3 MG/5 ML ORAL SUSP) ceftriaxone (1 gm-d5w bag, 1 gm vial, 1 gm Tier 1 piggyback, 2 gm-d5w bag, 2 gm vial, 2 gm piggyback, 2 gm add vial, 10 gm vial, 100 gram bulk bag, 250 mg vial, 500 mg vial) cefuroxime Tier 1 cefuroxime sodium Tier 1 cephalexin (125 mg/5 ml susp, 250 mg/5 ml Tier 1 susp, 250 mg capsule, 250 mg tablet, 500 mg tablet, 500 mg capsule, 750 mg capsule) DAXBIA Tier 3 SUPRAX (100 MG TABLET CHEWABLE, Tier MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) TEFLARO Tier 3 ZERBAXA Tier 3 BETA-LACTAM, OTHER AZACTAM 2 GM VIAL Tier 3 AZACTAM-ISO-OSMOTIC DEXTROSE Tier 3 aztreonam (1 gm vial, 2 gm vial) Tier 1 CAYSTON Tier 3 DORIBAX Tier 3 doripenem Tier 3 ertapenem Tier 3 9

18 NAME ANTIBACTERIALS (CONTINUED) imipenem-cilastatin sodium Tier 1 INVANZ (1 GM VIAL, 1 GM ADD- Tier 3 VANTAGE VIAL) meropenem Tier 2 meropenem-0.9% nacl Tier 2 VABOMERE Tier 3 BETA-LACTAM, PENICILLINS amoxicillin (125 mg/5 ml susp, 125 mg tab Tier 1 chew, 200 mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin-clavulanate pot er Tier 1 amoxicillin-clavulanate potass ( mg/5 Tier 1 ml sus, mg tab chew, mg/5 ml sus, mg tablet, mg/5 ml susp, mg tab chew, mg tablet, mg/5 ml sus, mg tablet) ampicillin sodium Tier 1 ampicillin trihydrate (125 mg/5 ml susp, 250 Tier 1 mg capsule, 250 mg/5 ml susp, 500 mg capsule) ampicillin-sulbactam (1.5 gm vl, 3 gm vial, 15 Tier 3 gm vl) BICILLIN C-R Tier 3 BICILLIN L-A Tier 3 dicloxacillin sodium Tier 1 nafcillin Tier 3 nafcillin sodium Tier 3 oxacillin Tier 3 oxacillin sodium Tier 3 penicillin g potassium Tier 1 penicillin g procaine Tier 1 penicillin g sodium Tier 1 penicillin gk-iso-osm dextrose Tier 3 penicillin v potassium (125 mg/5 ml soln, 250 Tier 1 mg tablet, 250 mg/5 ml soln, 500 mg tablet) PFIZERPEN Tier 3 piperacillin-tazobactam (piperacil-tazo 2.25 Tier 1 gm add vl, piperacil-tazobact 2.25 gm vl, piperacil-tazobact gm vl, piperaciltazobact 4.5 gm vial, piperacil-tazobact 13.5 gm vl, piperacil-tazobact 40.5 gram) 10

19 NAME ANTIBACTERIALS (CONTINUED) ZOSYN (2.25 GRAM VIAL, 2.25 GM/50 ML GALAXY BAG, GRAM VIAL, GM/50 ML GALAXY, 4.5 GM/100 ML GALAXY BAG) MACROLIDES Tier 3 AZASITE Tier 3 azithromycin (1 gm pwd packet, 100 mg/5 ml Tier 1 susp, 200 mg/5 ml susp, 250 mg tablet, 500 mg tablet, 600 mg tablet, i.v. 500 mg vial) clarithromycin (125 mg/5 ml sus, 250 mg Tier 1 tablet, 250 mg/5 ml sus, 500 mg tablet) clarithromycin er Tier 1 DIFICID Tier 3 QL (20 per 10 days) E.E.S. 400 Tier 1 ERY 2% PADS Tier 1 ERY-TAB Tier 2 ERYPED 200 Tier 3 ERYPED 400 Tier 3 ERYTHROCIN LACTOBIONATE (500 Tier 3 MG VIAL, 500 MG ADDVNT VL) ERYTHROCIN STEARATE Tier 3 erythromycin (0.5% eye ointment, 2% Tier 1 solution, 2% pledgets, 2% gel) erythromycin (250 mg filmtab, dr 250 mg cap, Tier mg filmtab) erythromycin 200 mg/5 ml gran Tier 3 erythromycin es 400 mg tab Tier 2 KETEK Tier 3 PCE Tier 3 ZMAX Tier 3 QUINOLONES AVELOX IV Tier 3 BAXDELA Tier 3 QL (28 per 14 days) BESIVANCE Tier 3 CILOXAN 0.3% OINTMENT Tier 3 ciprofloxacin Tier 1 ciprofloxacin er Tier 1 QL (30 per 30 days) ciprofloxacin hcl (0.2% otic soln, 0.3% eye drop, hcl 250 mg tab, hcl 500 mg tab, hcl 750 mg tab) Tier 1 ciprofloxacin hcl 100 mg tab Tier 3 11

20 NAME ANTIBACTERIALS (CONTINUED) ciprofloxacin-d5w Tier 1 FLOXIN Tier 1 gatifloxacin Tier 1 levofloxacin (0.5% eye drops, 25 mg/ml Tier 1 solution, 250 mg/10 ml soln, 250 mg tablet, 500 mg tablet, 500 mg/20 ml vial, 500 mg/20 ml soln, 750 mg/30 ml vial, 750 mg tablet) levofloxacin-d5w (250 mg/50 ml-d5w, 500 Tier 1 mg/100 ml-d5w) MOXEZA Tier 3 moxifloxacin 0.5% eye drops Tier 2 moxifloxacin 400 mg/250 ml bag Tier 3 moxifloxacin hcl 400 mg tablet Tier 1 ofloxacin (0.3% ear drops, 0.3% eye drops, Tier mg tablet, 400 mg tablet) VIGAMOX Tier 3 SULFONAMIDES polymyxin b sul-trimethoprim Tier 1 sulfacetamide 10% eye drops Tier 1 sulfadiazine Tier 1 sulfamethoxazole-trimethoprim (ds tablet, inj Tier 1 vial, ss tablet, susp) SULFATRIM Tier 1 TETRACYCLINES demeclocycline hcl Tier 1 DOXY 100 Tier 1 doxycycline hyclate (75 mg tab, 150 mg tab) Tier 3 QL (30 per 30 days) doxycycline hyclate (hyc 100 mg vial, hyclate Tier 1 20 mg tab, hyclate 50 mg cap, hyclate 100 mg tab, hyclate 100 mg vl, hyclate 100 mg cap) doxycycline hyclate (hyc dr 50 mg tab, 50 mg Tier 2 tablet, hyc dr 75 mg tab, hyc dr 100 mg tab, hyc dr 150 mg tab, hyc dr 200 mg tab) doxycycline ir-dr Tier 3 doxycycline mono 75 mg capsule Tier 3 doxycycline monohydrate (25 mg/5 ml susp, Tier 1 mono 50 mg cap, mono 50 mg tablet, mono 75 mg tablet, mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet) minocycline hcl (50 mg capsule, 75 mg Tier 1 capsule, 100 mg capsule) minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg tablet) Tier 2 12

21 NAME ANTIBACTERIALS (CONTINUED) minocycline hcl er (er 45 mg tablet, er 65 mg tablet, er 90 mg tablet, er 115 mg tablet, er 135 mg tablet) Tier 3 MONDOXYNE NL Tier 1 MORGIDOX (50 MG CAPSULE, 100 MG Tier 1 CAPSULE) ORACEA Tier 3 SOLODYN (ER 55 MG TABLET, ER 65 Tier 3 MG TABLET, ER 80 MG TABLET, ER 105 MG TABLET, ER 115 MG TABLET) tetracycline hcl Tier 1 VIBRAMYCIN 50 MG/5 ML SYRUP Tier 3 ANTICONVULSANTS ANTICONVULSANTS, OTHER BANZEL 200 MG TABLET Tier 3 QL (480 per 30 days) BANZEL 40 MG/ML SUSPENSION Tier 3 QL (2400 per 30 days) BANZEL 400 MG TABLET Tier 3 QL (240 per 30 days) BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET) Tier 3 QL (60 per 30 days) BRIVIACT 10 MG/ML ORAL SOLN Tier 3 QL (600 per 30 days) BRIVIACT 50 MG/5 ML VIAL Tier 3 levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg/5 ml soln, 500 mg/5 ml vial, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) Tier 1 levetiracetam er 500 mg tablet Tier 1 QL (180 per 30 days) levetiracetam er 750 mg tablet Tier 1 QL (120 per 30 days) levetiracetam-nacl Tier 3 phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml soln, 20 mg/5 ml elix, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) Tier 1 POTIGA Tier 3 QL (90 per 30 days) ROWEEPRA Tier 1 ROWEEPRA XR 500 MG TABLET Tier 1 QL (180 per 30 days) ROWEEPRA XR 750 MG TABLET Tier 1 QL (120 per 30 days) SPRITAM (250 MG TABLET, 500 MG Tier 3 QL (60 per 30 days) TABLET, 1,000 MG TABLET) SPRITAM 750 MG TABLET Tier 3 QL (120 per 30 days) VIMPAT (10 MG/ML SOLUTION, 200 Tier 3 MG/20 ML VIAL) VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) Tier 3 QL (60 per 30 days) 13

22 NAME ANTICONVULSANTS (CONTINUED) BENZODIAZEPINES clonazepam Tier 1 clorazepate dipotassium Tier 1 ONFI (2.5 MG/ML SUSPENSION, 10 MG Tier 3 TABLET, 20 MG TABLET) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN Tier 3 ethosuximide (250 mg capsule, 250 mg/5 ml Tier 1 soln) LYRICA 20 MG/ML ORAL SOLUTION Tier 2 zonisamide Tier 1 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT Tier 3 DIASTAT ACUDIAL Tier 3 diazepam (2.5 mg rectal gel sys, 10 mg rectal Tier 3 gel syst, 20 mg rectal gel syst) divalproex sodium Tier 1 divalproex sodium er Tier 1 gabapentin (100 mg capsule, 250 mg/5 ml soln, Tier mg capsule, 300 mg/6 ml soln, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG Tier 3 TABLET) primidone Tier 1 SABRIL (500 MG POWDER PACKET, 500 Tier 3 QL (180 per 30 days) MG TABLET) tiagabine hcl (2 mg tablet, 4 mg tablet, 12 mg Tier 1 tablet, 16 mg tablet) valproate sodium Tier 1 valproic acid (250 mg/5 ml soln, 250 mg Tier 1 capsule, 500 mg/10 ml sol) vigabatrin Tier 3 QL (180 per 30 days) GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet, 600 Tier 3 mg/5 ml susp) FYCOMPA (0.5 MG/ML ORAL SUSP, 2 Tier 3 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) lamotrigine (25 mg tablet, 25 mg tb start kit, Tier mg tablet, 150 mg tablet, 200 mg tablet) lamotrigine (5 mg disper tablet, 25 mg disper tab) Tier 2 14

23 NAME ANTICONVULSANTS (CONTINUED) lamotrigine (blue) Tier 1 lamotrigine (green) Tier 1 lamotrigine (orange) Tier 1 lamotrigine er Tier 2 lamotrigine odt Tier 2 lamotrigine odt (blue) Tier 2 lamotrigine odt (green) Tier 2 lamotrigine odt (orange) Tier 2 QUDEXY XR (150 MG CAPSULE, 200 Tier 3 MG CAPSULE) QUDEXY XR (50 MG CAPSULE, 100 MG Tier 3 QL (60 per 30 days) QL (30 per 30 days) CAPSULE) QUDEXY XR 25 MG CAPSULE Tier 3 topiramate Tier 1 topiramate er Tier 3 TROKENDI XR Tier 3 QL (90 per 30 days) SODIUM CHANNEL AGENTS APTIOM (200 MG TABLET, 400 MG TABLET, 800 MG TABLET) Tier 3 QL (30 per 30 days) APTIOM 600 MG TABLET Tier 3 QL (60 per 30 days) carbamazepine (100 mg/5 ml susp, 100 mg tab Tier 1 chew, 200 mg tablet) carbamazepine er (er 100 mg cap, er 100 mg tablet, er 200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mg tablet) Tier 1 DILANTIN (30 MG CAPSULE, 50 MG Tier 3 INFATAB, 100 MG CAPSULE) DILANTIN-125 Tier 3 EPITOL Tier 1 fosphenytoin sodium Tier 1 GRALISE 30-DAY STARTER PACK Tier 3 GRALISE ER 300 MG TABLET Tier 3 QL (60 per 30 days) GRALISE ER 600 MG TABLET Tier 3 QL (90 per 30 days) HORIZANT ER 300 MG TABLET Tier 3 QL (90 per 30 days) HORIZANT ER 600 MG TABLET Tier 3 QL (60 per 30 days) oxcarbazepine (150 mg tablet, 300 mg tablet, Tier mg/5 ml susp, 600 mg tablet) OXTELLAR XR Tier 3 PEGANONE Tier 3 PHENYTEK Tier 3 phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4 ml susp, 125 mg/5 ml susp) Tier 1 15

24 NAME ANTICONVULSANTS (CONTINUED) phenytoin sodium Tier 1 phenytoin sodium extended Tier 1 TEGRETOL (100 MG/5 ML SUSP, 200 MG Tier 3 TABLET) TEGRETOL XR Tier 3 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates Tier 2 CHOLINESTERASE INHIBITORS donepezil hcl (5 mg tablet, 10 mg tablet) Tier 1 donepezil hcl 23 mg tablet Tier 2 QL (30 per 30 days) donepezil hcl odt Tier 1 galantamine 4 mg/ml oral soln Tier 1 galantamine er Tier 1 QL (30 per 30 days) galantamine hbr Tier 1 QL (60 per 30 days) rivastigmine (1.5 mg capsule, 3 mg capsule, Tier 1 QL (60 per 30 days) 4.5 mg capsule, 6 mg capsule) rivastigmine (9.5 mg/24hr patch, 13.3 mg/24hr Tier 2 ptch) rivastigmine 4.6 mg/24hr patch Tier 2 QL (30 per 30 days) N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine 5-10 mg titration pk Tier 1 QL (49 per 28 days) memantine hcl (5 mg tablet, 10 mg tablet) Tier 1 QL (60 per 30 days) memantine hcl 2 mg/ml solution Tier 1 QL (300 per 30 days) memantine hcl er (er 14 mg capsule, er 21 mg Tier 1 QL (30 per 30 days) capsule, er 28 mg capsule) memantine hcl er 7 mg capsule Tier 1 QL (120 per 30 days) NAMENDA XR (7 MG CAPSULE, 14 MG Tier 3 QL (30 per 30 days) CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK) NAMZARIC (7 MG-10 MG CAPSULE, 14 Tier 3 QL (30 per 30 days) MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE) NAMZARIC TITRATION PACK Tier 3 QL (28 per 28 days) ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN Tier 3 QL (30 per 30 days) bupropion hcl Tier 1 bupropion hcl sr (sr 100 mg tablet, sr 200 mg Tier 1 tablet) bupropion xl (150 mg tablet, 300 mg tablet) Tier 1 16

25 NAME ANTIDEPRESSANTS (CONTINUED) maprotiline hcl Tier 1 mirtazapine Tier 1 nefazodone hcl Tier 1 trazodone hcl Tier 1 MONOAMINE OXIDASE INHIBITORS EMSAM Tier 3 QL (30 per 30 days) MARPLAN Tier 3 phenelzine sulfate Tier 1 tranylcypromine sulfate Tier 1 SEROTONIN/ NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hbr (10 mg tablet, 10 mg/5 ml soln, Tier 1 20 mg tablet, 40 mg tablet) desvenlafaxine er Tier 3 QL (30 per 30 days) desvenlafaxine fumarate er Tier 3 QL (30 per 30 days) desvenlafaxine succinate er Tier 1 QL (30 per 30 days) duloxetine hcl (dr 20 mg cap, dr 40 mg cap, dr Tier 1 QL (60 per 30 days) 60 mg cap) duloxetine hcl dr 30 mg cap Tier 1 QL (90 per 30 days) escitalopram oxalate (5 mg tablet, 10 mg Tier 1 tablet, 20 mg tablet) escitalopram oxalate 5 mg/5 ml Tier 3 FETZIMA (ER 20 MG CAPSULE, ER 40 Tier 3 QL (30 per 30 days) MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) FETZIMA MG TITRATION PAK Tier 3 QL (28 per 28 days) fluoxetine dr 90 mg capsule (weekly) Tier 2 QL (8 per 28 days) fluoxetine hcl (10 mg tablet, 20 mg tablet, 60 Tier 2 mg tablet) fluoxetine hcl (hcl 10 mg capsule, hcl 20 mg Tier 1 capsule, 20 mg/5 ml solution, hcl 40 mg capsule) fluvoxamine maleate Tier 1 fluvoxamine maleate er Tier 1 paroxetine cr Tier 2 paroxetine er Tier 2 paroxetine hcl Tier 1 PAXIL 10 MG/5 ML SUSPENSION Tier 3 PEXEVA Tier 3 PRISTIQ Tier 3 QL (30 per 30 days) sertraline hcl (20 mg/ml oral soln, 20 mg/ml oral conc, hcl 25 mg tablet, hcl 50 mg tablet, hcl 100 mg tablet) Tier 1 17

26 NAME ANTIDEPRESSANTS (CONTINUED) TRINTELLIX Tier 3 QL (30 per 30 days) venlafaxine hcl Tier 1 venlafaxine hcl er (er 37.5 mg cap, er 75 mg Tier 1 QL (90 per 30 days) cap, er 150 mg cap) VIIBRYD Tier 3 QL (30 per 30 days) TRICYCLICS amitriptyline hcl Tier 2 amoxapine Tier 2 clomipramine hcl Tier 2 desipramine hcl Tier 2 doxepin hcl (10 mg capsule, 10 mg/ml oral Tier 1 conc, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl Tier 2 imipramine pamoate Tier 3 nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg Tier 2 cap, 20 mg/10 ml soln, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) protriptyline hcl Tier 2 trimipramine maleate Tier 2 ANTIEMETICS ANTIEMETICS, OTHER COMPRO Tier 1 meclizine hcl (12.5 mg tablet, 25 mg tablet) Tier 1 metoclopramide hcl (5 mg tablet, 5 mg/5 ml Tier 1 soln, 10 mg/2 ml vial, 10 mg/10 ml sol, 10 mg/2 ml syr, 10 mg tablet) metoclopramide hcl odt Tier 3 PHENADOZ Tier 3 PHENERGAN (12.5 MG, 25 MG, 50 MG) Tier 3 prochlorperazine Tier 1 prochlorperazine maleate Tier 1 promethazine hcl (6.25 mg/5 ml soln, 6.25 Tier 3 mg/5 ml syrp, 12.5 mg tablet, 12.5 mg suppos, 25 mg tablet, 25 mg/ml ampul, 25 mg/ml vial, 25 mg suppository, 50 mg/ml ampul, 50 mg/ml vial, 50 mg tablet, 50 mg suppository) PROMETHEGAN Tier 3 scopolamine Tier 2 TRANSDERM-SCOP Tier 3 trimethobenzamide hcl Tier 2 B/D PA 18

27 NAME ANTIEMETICS (CONTINUED) EMETOGENIC THERAPY ADJUNCTS AKYNZEO MG CAPSULE Tier 3 B/D PA, QL (2 per 28 days) ALOXI Tier 3 ANZEMET (50 MG TABLET, 100 MG Tier 3 B/D PA, QL (4 per 28 days) TABLET) aprepitant (40 mg capsule, 80 mg capsule) Tier 2 B/D PA, QL (4 per 30 days) aprepitant 125 mg capsule Tier 2 B/D PA, QL (2 per 30 days) aprepitant mg pack Tier 2 B/D PA, QL (6 per 30 days) CESAMET Tier 3 QL (120 per 30 days) CINVANTI Tier 3 QL (36 per 30 days) dronabinol Tier 3 EMEND (125 MG POWDER PACKET, Tier 3 B/D PA, QL (6 per 30 days) TRIPACK) EMEND (40 MG CAPSULE, 80 MG Tier 3 B/D PA, QL (4 per 30 days) CAPSULE) EMEND 125 MG CAPSULE Tier 3 B/D PA, QL (2 per 30 days) EMEND 150 MG VIAL Tier 3 QL (2 per 30 days) granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 Tier 1 mg/4 ml vial) granisetron hcl 1 mg tablet Tier 1 B/D PA, QL (60 per 30 days) ondansetron 4 mg/5 ml solution Tier 2 B/D PA ondansetron hcl (4 mg tablet, 8 mg tablet) Tier 1 B/D PA, QL (90 per 30 days) ondansetron hcl (hcl 4 mg/2 ml amp, hcl 4 Tier 1 mg/2 ml vial, 40 mg/20 ml vial) ondansetron hcl 24 mg tablet Tier 1 B/D PA, QL (30 per 30 days) ondansetron odt Tier 1 B/D PA, QL (90 per 30 days) palonosetron hcl (0.25 mg/5 ml vial, 0.25 mg/2 Tier 3 ml vial) SANCUSO Tier 3 QL (4 per 28 days) SYNDROS Tier 3 VARUBI MG/92.5 ML VIAL Tier 3 VARUBI 90 MG TABLET Tier 3 B/D PA, QL (4 per 28 days) ZUPLENZ Tier 3 B/D PA, QL (90 per 30 days) ANTIFUNGALS ANTIFUNGALS ABELCET Tier 3 B/D PA AMBISOME Tier 3 B/D PA amphotericin b Tier 1 B/D PA CANCIDAS Tier 3 caspofungin acetate Tier 3 CICLODAN (0.77% CREAM, 8% SOLUTION) Tier 3 19

28 NAME ANTIFUNGALS (CONTINUED) ciclopirox (0.77% topical susp, 0.77% cream, 0.77% gel, 1% shampoo, 8% solution) clotrimazole (1% cream, 1% solution, 10 mg Tier 1 Tier 1 troche) clotrimazole-betamethasone (crm, lot) Tier 1 CRESEMBA Tier 3 econazole nitrate Tier 1 ERAXIS (WATER DILUENT) Tier 3 ERTACZO Tier 3 EXELDERM (1% SOLUTION, 1% CREAM) fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) Tier 3 Tier 1 fluconazole in dextrose Tier 1 fluconazole in saline (200 mg/100 ml, 400 Tier 1 mg/200 ml) fluconazole-nacl Tier 1 flucytosine Tier 3 griseofulvin (125 mg/5 ml susp, micro 500 mg Tier 2 tab) griseofulvin ultramicrosize Tier 2 itraconazole 100 mg capsule Tier 2 JUBLIA Tier 3 KERYDIN Tier 3 ketoconazole (2% cream, 2% shampoo, 200 Tier 1 mg tablet) ketoconazole 2% foam Tier 3 KETODAN 2% FOAM Tier 3 luliconazole Tier 3 LUZU Tier 3 MENTAX Tier 3 miconazole mg vag supp Tier 1 MYCAMINE Tier 3 naftifine hcl Tier 3 NAFTIN (1% GEL, 2% GEL) Tier 3 NATACYN Tier 3 NOXAFIL (40 MG/ML SUSPENSION, DR Tier MG TABLET, 300 MG/16.7 ML VIAL) NYAMYC Tier 1 NYATA Tier 1 20

29 NAME ANTIFUNGALS (CONTINUED) nystatin (100,000 unit/gm powd, 100,000 unit/gm cream, 100,000 unit/gm oint, 100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus) Tier 1 nystatin-triamcinolone Tier 1 NYSTOP Tier 1 ONMEL Tier 3 oxiconazole nitrate Tier 3 OXISTAT 1% LOTION Tier 3 SPORANOX (10 MG/ML SOLUTION, 100 Tier 3 MG CAPSULE) terbinafine hcl Tier 1 terconazole (0.4% cream, 0.8% cream, 80 mg Tier 1 suppository) voriconazole (40 mg/ml susp, 50 mg tablet, 200 Tier 3 mg vial, 200 mg tablet) ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol Tier 1 colchicine 0.6 mg capsule Tier 3 QL (60 per 30 days) colchicine 0.6 mg tablet Tier 3 QL (120 per 30 days) COLCRYS Tier 2 QL (120 per 30 days) DUZALLO Tier 3 QL (30 per 30 days) MITIGARE Tier 3 QL (60 per 30 days) probenecid Tier 1 probenecid-colchicine Tier 1 ULORIC Tier 2 QL (30 per 30 days) ZURAMPIC Tier 3 QL (30 per 30 days) ANTIMIGRAINE AGENTS ERGOT ALKALOIDS dihydroergotamine 4 mg/ml spry Tier 3 QL (8 per 28 days) dihydroergotamine mesylate (1 mg/ml vl, 1 Tier 3 mg/ml amp) ERGOMAR Tier 3 QL (20 per 28 days) ergotamine-caffeine Tier 2 QL (40 per 30 days) MIGERGOT Tier 3 QL (20 per 28 days) PROPHYLACTIC INNOPRAN XL Tier 3 propranolol hcl er Tier 1 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) Tier 1 21

30 NAME ANTIMIGRAINE AGENTS (CONTINUED) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate Tier 1 QL (12 per 30 days) eletriptan hbr Tier 1 QL (12 per 30 days) frovatriptan succinate Tier 1 QL (18 per 30 days) naratriptan Tier 1 QL (18 per 30 days) naratriptan hcl Tier 1 QL (18 per 30 days) ONZETRA XSAIL Tier 3 QL (16 per 30 days) RELPAX Tier 3 QL (12 per 30 days) rizatriptan Tier 1 QL (24 per 30 days) sumatriptan 20 mg nasal spray Tier 2 QL (12 per 30 days) sumatriptan 5 mg nasal spray Tier 2 QL (18 per 30 days) sumatriptan succ 100 mg tablet Tier 1 QL (9 per 30 days) sumatriptan succ-naproxen sod Tier 2 QL (10 per 30 days) sumatriptan succinate (25 mg tablet, 50 mg Tier 1 QL (18 per 30 days) tablet) sumatriptan succinate (4 mg/0.5 ml inject, 4 Tier 2 QL (10 per 30 days) mg/0.5 ml cart, 6 mg/0.5 ml refill, 6 mg/0.5 ml syrng, 6 mg/0.5 ml vial, 6 mg/0.5 ml inject) SUMAVEL DOSEPRO Tier 3 QL (5 per 30 days) TREXIMET MG TABLET Tier 3 QL (16 per 30 days) TREXIMET MG TABLET Tier 3 QL (10 per 30 days) ZEMBRACE SYMTOUCH Tier 3 QL (8 per 30 days) zolmitriptan Tier 1 QL (12 per 30 days) zolmitriptan odt Tier 1 QL (12 per 30 days) ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl Tier 3 MESTINON 60 MG/5 ML SYRUP Tier 3 pyridostigmine bromide Tier 1 pyridostigmine bromide er Tier 1 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone (25 mg tablet, 100 mg tablet) Tier 1 rifabutin Tier 3 ANTITUBERCULARS CAPASTAT SULFATE Tier 3 cycloserine Tier 3 ethambutol hcl Tier 1 isoniazid (50 mg/5 ml solution, 100 mg tablet, 100 mg/ml vial, 300 mg tablet) Tier 1 22

31 NAME ANTIMYCOBACTERIALS (CONTINUED) PASER Tier 3 PRIFTIN Tier 3 pyrazinamide Tier 1 RIFAMATE Tier 3 rifampin Tier 1 RIFATER Tier 3 SIRTURO Tier 3 QL (68 per 28 days) TRECATOR Tier 3 ANTINEOPLASTICS ALKYLATING AGENTS ALKERAN 2 MG TABLET Tier 3 B/D PA BENDEKA Tier 3 busulfan Tier 3 cyclophosphamide (1 gm vial, 2 gm vial, 500 Tier 1 mg vial) cyclophosphamide (25 mg capsule, 50 mg Tier 3 B/D PA capsule) dacarbazine Tier 1 EVOMELA Tier 3 GLEOSTINE Tier 3 HEXALEN Tier 3 ifosfamide (1 gm/20 ml vial, 1 gm vial, 3 gm Tier 1 vial, 3 gm/60 ml vial) LEUKERAN Tier 2 MATULANE Tier 3 melphalan 2mg tablet Tier 1 B/D PA melphalan hcl Tier 3 MUSTARGEN Tier 3 thiotepa Tier 1 TREANDA (25 MG VIAL, 45 MG/0.5 ML Tier 3 VIAL, 100 MG VIAL, 180 MG/2 ML VIAL) VALCHLOR Tier 3 QL (60 per 30 days) YONDELIS Tier 3 ZANOSAR Tier 3 ANTIANDROGENS bicalutamide Tier 1 ERLEADA Tier 3 QL (120 per 30 days) flutamide Tier 1 nilutamide Tier 3 XTANDI Tier 3 QL (120 per 30 days) 23

32 NAME ANTINEOPLASTICS (CONTINUED) YONSA Tier 3 QL (240 per 30 days) ANTIANGIOGENIC AGENTS POMALYST Tier 3 QL (21 per 28 days) REVLIMID Tier 3 QL (30 per 30 days) THALOMID (50 MG CAPSULE, 100 MG Tier 3 QL (30 per 30 days) CAPSULE, 150 MG CAPSULE) THALOMID 200 MG CAPSULE Tier 3 QL (60 per 30 days) VOTRIENT Tier 3 QL (120 per 30 days) ANTIESTROGENS/MODIFIERS EMCYT Tier 3 FARESTON Tier 3 FASLODEX Tier 3 SOLTAMOX Tier 3 tamoxifen citrate Tier 1 ANTIMETABOLITES cladribine Tier 3 B/D PA clofarabine Tier 3 cytarabine (2 g/20 ml vial, 20 mg/ml vial, 100 Tier 1 B/D PA mg/5 ml vial, 1000 mg/50 ml vial) DROXIA Tier 3 fludarabine phosphate (50 mg vial, 50 mg/2 ml Tier 1 vial) gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram Tier 3 vial, 2 gram/52.6 ml vl, hcl 2 gram vial, 200 mg/5.26 ml vl, hcl 200 mg vial) hydroxyurea Tier 1 mercaptopurine Tier 1 NIPENT Tier 3 PURIXAN Tier 3 TABLOID Tier 3 ANTINEOPLASTICS, OTHER ABRAXANE Tier 3 ADRIAMYCIN (10 MG VIAL, 10 MG/5 Tier 1 ML VIAL, 20 MG/10 ML VIAL, 50 MG VIAL, 50 MG/25 ML VIAL, 200 MG/100 ML VIAL) ADRUCIL (5 GRAM/100 ML VIAL, 500 Tier 1 B/D PA MG/10 ML VIAL, 2,500 MG/50 ML VIAL) ALIMTA Tier 3 ALIQOPA Tier 3 ALUNBRIG (90 MG-180 MG TAB PACK, 90 MG TABLET, 180 MG TABLET) Tier 3 QL (30 per 30 days) 24

33 NAME ANTINEOPLASTICS (CONTINUED) ALUNBRIG 30 MG TABLET Tier 3 QL (180 per 30 days) ARRANON Tier 3 BESPONSA Tier 3 BICNU Tier 3 BLEO 15K Tier 1 bleomycin sulfate (15 vial, 30 vial) Tier 1 B/D PA BLINCYTO 35MCG VIAL+STABILIZER Tier 3 bortezomib Tier 3 BRAFTOVI 50 MG CAPSULE Tier 3 QL (120 per 30 days) BRAFTOVI 75 MG CAPSULE Tier 3 QL (150 per 30 days) BUSULFEX Tier 3 CAPRELSA 100 MG TABLET Tier 3 QL (60 per 30 days) CAPRELSA 300 MG TABLET Tier 3 QL (30 per 30 days) carboplatin (50 mg/5 ml vial, 150 mg/15 ml Tier 1 vial, 450 mg/45 ml vial, 600 mg/60 ml vial) cisplatin Tier 1 COSMEGEN Tier 3 dactinomycin Tier 3 daunorubicin hcl (20 mg/4 ml vial, 50 mg/10 Tier 1 ml vial) decitabine Tier 1 dexrazoxane Tier 3 docetaxel Tier 3 doxorubicin hcl (10 mg/5 ml vial, 10 mg vial, Tier 1 20 mg/10 ml vial, 50 mg/25 ml vial, 50 mg vial, 150 mg/75 ml vial, 200 mg/100 ml vial) doxorubicin hcl liposome Tier 1 ELLENCE Tier 3 epirubicin hcl (50 mg/25 ml vial, 200 mg/100 Tier 1 ml vial) ERIVEDGE Tier 3 QL (30 per 30 days) ERWINAZE Tier 3 FIRMAGON (2 X 120 MG KIT, 80 MG Tier 3 KIT) fluorouracil (2.5 gm/50 ml btl, 2.5 gm/50 ml Tier 1 B/D PA vial, 5 gm/100 ml vial, 5 gm/100 ml btl, 500 mg/10 ml vial, 1,000 mg/20 ml vl, 2,500 mg/50 ml vl, 5,000 mg/100 ml) FOLOTYN Tier 3 FUSILEV Tier 3 HALAVEN Tier 3 25

34 NAME ANTINEOPLASTICS (CONTINUED) IDAMYCIN PFS Tier 3 idarubicin hcl Tier 3 IDHIFA Tier 3 QL (30 per 30 days) irinotecan hcl Tier 1 ISTODAX Tier 3 IXEMPRA Tier 3 JAKAFI Tier 3 KADCYLA Tier 3 KEYTRUDA (50 MG VIAL, 100 MG/4 ML Tier 3 VIAL) KISQALI Tier 3 QL (63 per 28 days) KISQALI FEMARA 200 MG CO-PACK Tier 3 QL (49 per 28 days) KISQALI FEMARA 400 MG CO-PACK Tier 3 QL (70 per 28 days) KISQALI FEMARA 600 MG CO-PACK Tier 3 QL (91 per 28 days) KYPROLIS Tier 3 leucovorin calcium Tier 1 levoleucovorin calcium (50 mg vial, 175 Tier 3 mg/17.5 ml, 175 mg vial, 250 mg/25 ml vl) LONSURF 15 MG-6.14 MG TABLET Tier 3 QL (100 per 28 days) LONSURF 20 MG-8.19 MG TABLET Tier 3 QL (80 per 28 days) MARQIBO Tier 3 MEKINIST 0.5 MG TABLET Tier 3 QL (90 per 30 days) MEKINIST 2 MG TABLET Tier 3 QL (30 per 30 days) mitomycin Tier 3 mitoxantrone hcl Tier 1 NINLARO Tier 3 QL (3 per 28 days) oxaliplatin (50 mg vial, 50 mg/10 ml vial, 100 Tier 3 mg/20 ml vial, 100 mg vial) paclitaxel Tier 1 PROLEUKIN Tier 3 romidepsin Tier 3 RUBRACA Tier 3 QL (120 per 30 days) SYLATRON Tier 3 SYNRIBO Tier 3 TAFINLAR Tier 3 QL (120 per 30 days) temsirolimus Tier 3 THERACYS Tier 3 TORISEL Tier 3 TRISENOX Tier 3 UNITUXIN Tier 3 26

35 NAME ANTINEOPLASTICS (CONTINUED) VELCADE Tier 3 VERZENIO Tier 3 QL (60 per 30 days) vinblastine sulfate Tier 1 B/D PA VINCASAR PFS (1 MG/ML VIAL, 2 MG/2 Tier 1 B/D PA ML VIAL) vincristine sulfate (1 mg/ml vial, 2 mg/2 ml Tier 1 B/D PA vial) vinorelbine tartrate Tier 1 VYXEOS Tier 3 XALKORI Tier 3 YERVOY Tier 3 ZEJULA Tier 3 QL (90per 30 days) ZELBORAF Tier 3 ZINECARD Tier 3 ZOLINZA Tier 3 QL (120 per 30 days) ZYTIGA 250 MG TABLET Tier 3 QL (120 per 30 days) ZYTIGA 500 MG TABLET Tier 3 QL (60 per 30 days) AROMATASE INHIBITORS, 3RD GENERATION anastrozole Tier 1 exemestane Tier 2 letrozole Tier 1 ENYZME INHIBITORS ETOPOPHOS Tier 3 etoposide (100 mg/5 ml vial, 500 mg/25 ml Tier 1 vial, 1,000 mg/50 ml vial) TOPOSAR Tier 1 topotecan hcl (4 mg/4 ml vial, 4 mg vial) Tier 3 MOLECULAR TARGET INHIBITORS AFINITOR (2.5 MG TABLET, 5 MG TABLET) Tier 3 QL (30 per 30 days) AFINITOR (7.5 MG TABLET, 10 MG Tier 3 QL (60 per 30 days) TABLET) AFINITOR DISPERZ (2 MG TABLET, 3 Tier 3 MG TABLET) AFINITOR DISPERZ 5 MG TABLET Tier 3 QL (112 per 28 days) ALECENSA Tier 3 QL (240 per 30 days) BELEODAQ Tier 3 BOSULIF (400 MG TABLET, 500 MG Tier 3 QL (30 per 30 days) TABLET) BOSULIF 100 MG TABLET Tier 3 QL (120 per 30 days) CABOMETYX Tier 3 QL (30 per 30 days) 27

36 NAME ANTINEOPLASTICS (CONTINUED) CALQUENCE Tier 3 QL (60 per 30 days) COMETRIQ Tier 3 COTELLIC Tier 3 QL (63 per 28 days) CYRAMZA Tier 3 FARYDAK Tier 3 QL (6 per 21 days) GILOTRIF Tier 3 QL (30 per 30 days) IBRANCE Tier 3 QL (21 per 28 days) ICLUSIG Tier 3 imatinib mesylate 100 mg tab Tier 3 QL (120 per 30 days) imatinib mesylate 400 mg tab Tier 3 QL (60 per 30 days) IMBRUVICA (70 MG CAPSULE, 140 MG Tier 3 QL (30 per 30 days) TABLET, 280 MG TABLET, 420 MG TABLET, 560 MG TABLET) IMBRUVICA 140 MG CAPSULE Tier 3 QL (120 per 30 days) INLYTA 1 MG TABLET Tier 3 QL (180 per 30 days) INLYTA 5 MG TABLET Tier 3 QL (120 per 30 days) IRESSA Tier 3 QL (30 per 30 days) JEVTANA Tier 3 LENVIMA (18 MG DAILY, 24 MG Tier 3 QL (90 per 30 days) DAILY) LENVIMA (4 MG CAPSULE, 10 MG Tier 3 QL (30 per 30 days) DAILY DOSE) LENVIMA (8 MG DAILY, 14 MG DAILY, Tier 3 QL (60 per 30 days) 20 MG DAILY) LENVIMA 12 MG DAILY DOSE Tier 3 QL (90per 30 days) LYNPARZA (100 MG TABLET, 150 MG Tier 3 QL (120 per 30 days) TABLET) LYNPARZA 50 MG CAPSULE Tier 3 QL (480 per 30 days) MEKTOVI Tier 3 QL (180 per 30 days) NERLYNX Tier 3 QL (180 per 30 days) NEXAVAR Tier 3 QL (120 per 30 days) ODOMZO Tier 3 QL (30 per 30 days) RYDAPT Tier 3 QL (240 per 30 days) SPRYCEL (20 MG TABLET, 50 MG Tier 3 QL (60 per 30 days) TABLET, 70 MG TABLET) SPRYCEL (80 MG TABLET, 100 MG Tier 3 QL (30 per 30 days) TABLET, 140 MG TABLET) STIVARGA Tier 3 SUTENT Tier 3 QL (30 per 30 days) TAGRISSO Tier 3 QL (30 per 30 days) TARCEVA Tier 3 QL (30 per 30 days) 28

37 NAME ANTINEOPLASTICS (CONTINUED) TASIGNA Tier 3 QL (120 per 30 days) TIBSOVO Tier 3 QL (60 per 30 days) TYKERB Tier 3 QL (150 per 30 days) VECTIBIX Tier 3 VENCLEXTA 10 MG TABLET Tier 3 QL (42 per 28 days) VENCLEXTA 100 MG TABLET Tier 3 QL (112 per 28 days) VENCLEXTA 50 MG TABLET Tier 3 QL (224 per 28 days) VENCLEXTA STARTING PACK Tier 3 QL (42 per 28 days) ZALTRAP Tier 3 ZYDELIG Tier 3 QL (60 per 30 days) ZYKADIA Tier 3 MONOCLONAL ANTIBODY/ANTIBODY- CONJUGATE ARZERRA Tier 3 AVASTIN Tier 3 BAVENCIO Tier 3 DARZALEX Tier 3 EMPLICITI Tier 3 ERBITUX Tier 3 GAZYVA Tier 3 HERCEPTIN Tier 3 IMFINZI Tier 3 LARTRUVO Tier 3 MYLOTARG Tier 3 OPDIVO Tier 3 PERJETA Tier 3 PORTRAZZA Tier 3 RITUXAN Tier 3 RITUXAN HYCELA Tier 3 TECENTRIQ Tier 3 RETINOIDS bexarotene Tier 3 PANRETIN Tier 3 TARGRETIN 1% GEL Tier 3 tretinoin 10 mg capsule Tier 3 TREATMENT ADJUNCTS ELITEK Tier 3 mesna Tier 1 MESNEX 400 MG TABLET Tier 3 29

38 NAME ANTIPARASITICS ANTHELMINTICS ALBENZA Tier 3 BILTRICIDE Tier 3 EMVERM Tier 3 ivermectin Tier 1 praziquantel Tier 2 SOOLANTRA Tier 3 ANTIPROTOZOALS ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) Tier 3 atovaquone Tier 3 atovaquone-proguanil hcl Tier 3 chloroquine phosphate Tier 1 COARTEM Tier 3 DARAPRIM Tier 3 hydroxychloroquine sulfate Tier 1 mefloquine hcl Tier 1 NEBUPENT Tier 3 B/D PA PENTAM 300 Tier 3 primaquine Tier 3 QUALAQUIN Tier 3 quinine sulfate Tier 2 SOLOSEC Tier 3 tinidazole Tier 1 PEDICULICIDES/ SCABICIDES CROTAN Tier 3 EURAX Tier 3 lindane 1% shampoo Tier 2 malathion Tier 2 permethrin 5% cream Tier 2 ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate (mes 0.5 mg tab, mes 1 mg tablet, 2 mg/2 ml ampule, mes 2 mg tablet, 2 mg/2 ml vial) Tier 1 trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml Tier 1 elx, 5 mg tablet) ANTIPARKINSON AGENTS, OTHER entacapone Tier 1 QL (240 per 30 days) GOCOVRI ER 137 MG CAPSULE Tier 3 QL (60 per 30 days) 30

39 NAME ANTIPARKINSON AGENTS (CONTINUED) GOCOVRI ER 68.5 MG CAPSULE Tier 3 QL (30 per 30 days) OSMOLEX ER Tier 3 QL (30 per 30 days) tolcapone Tier 3 DOPAMINE AGONISTS APOKYN Tier 3 NEUPRO Tier 3 QL (30 per 30 days) pramipexole mg tablet Tier 1 pramipexole dihydrochloride (0.25 mg tablet, Tier 1 QL (90 per 30 days) 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) pramipexole er Tier 2 QL (30 per 30 days) ropinirole er Tier 2 QL (60 per 30 days) ropinirole hcl Tier 1 DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa Tier 3 carbidopa-levodopa ( mg odt, Tier 2 mg odt, mg odt) carbidopa-levodopa ( tab, tab, Tier tab) carbidopa-levodopa er Tier 1 carbidopa-levodopa-entacapone Tier 1 MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline mesylate Tier 1 QL (30 per 30 days) selegiline hcl Tier 1 XADAGO 100 MG TABLET Tier 3 QL (30 per 30 days) XADAGO 50 MG TABLET Tier 3 QL (46 per 30 days) ZELAPAR Tier 3 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL ADASUVE Tier 3 chlorpromazine hcl (10 mg tablet, 25 mg/ml Tier 2 amp, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) fluphenazine decanoate Tier 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, Tier mg/5 ml elix, 2.5 mg/ml vial, 5 mg/ml conc, 5 mg tablet, 10 mg tablet) haloperidol Tier 1 haloperidol decanoate Tier 1 haloperidol decanoate 100 Tier 1 haloperidol lactate Tier 1 31

40 NAME ANTIPSYCHOTICS (CONTINUED) loxapine Tier 1 molindone hcl Tier 3 perphenazine Tier 1 perphenazine-amitriptyline Tier 2 pimozide Tier 2 prochlorperazine 10 mg/2 ml vl Tier 1 thioridazine hcl Tier 1 thiothixene Tier 1 trifluoperazine hcl Tier 1 2ND GENERATION/ATYPICAL ABILIFY MAINTENA Tier 3 aripiprazole (2 mg tablet, 5 mg tablet, 10 mg Tier 1 tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) aripiprazole 1 mg/ml solution Tier 2 aripiprazole odt Tier 2 ARISTADA Tier 3 ARISTADA INITIO Tier 3 QL (2.4 per 180 days) FANAPT Tier 3 QL (60 per 30 days) GEODON 20 MG/ML VIAL Tier 3 INVEGA SUSTENNA Tier 3 INVEGA TRINZA Tier 3 LATUDA Tier 3 QL (30 per 30 days) NUPLAZID (10 MG TABLET, 34 MG Tier 3 QL (30 per 30 days) CAPSULE) NUPLAZID 17 MG TABLET Tier 3 QL (60 per 30 days) olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg Tier 1 tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) olanzapine 10 mg vial Tier 3 olanzapine odt Tier 2 olanzapine-fluoxetine hcl Tier 3 paliperidone er (er 1.5 mg tablet, er 3 mg Tier 3 QL (30 per 30 days) tablet, er 9 mg tablet) paliperidone er 6 mg tablet Tier 3 QL (60 per 30 days) PERSERIS Tier 3 quetiapine fumarate Tier 1 quetiapine fumarate er (er 300 mg tablet, er Tier 2 QL (60 per 30 days) 400 mg tablet) quetiapine fumarate er (er 50 mg tablet, er 150 mg tablet, er 200 mg tablet) Tier 2 QL (30 per 30 days) 32

41 NAME ANTIPSYCHOTICS (CONTINUED) REXULTI (0.25 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) REXULTI (0.5 MG TABLET, 1 MG TABLET) Tier 3 Tier 3 RISPERDAL CONSTA Tier 3 risperidone (0.25 mg tablet, 0.5 mg tablet, 1 Tier 1 mg tablet, 1 mg/ml solution, 2 mg tablet, 3 mg tablet, 4 mg tablet) QL (30 per 30 days) QL (120 per 30 days) risperidone odt Tier 2 SAPHRIS Tier 3 QL (60 per 30 days) VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) Tier 3 QL (30 per 30 days) VRAYLAR 1.5 MG-3 MG PACK Tier 3 ziprasidone hcl Tier 1 ZYPREXA RELPREVV (210 MG VIAL, Tier MG VL KIT, 300 MG VL KIT, 405 MG VL KIT) TREATMENT-RESISTANT clozapine Tier 1 clozapine odt Tier 1 VERSACLOZ Tier 3 QL (540 per 30 days) ANTISPASTICITY AGENTS ANTISPASTICITY AGENTS baclofen Tier 1 dantrolene sodium Tier 1 tizanidine hcl Tier 1 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS cidofovir Tier 3 foscarnet sodium Tier 1 B/D PA ganciclovir sodium (500 mg vial, 500 mg/10 ml Tier 2 B/D PA vial) PREVYMIS (240 MG TABLET, 480 MG Tier 3 QL (30 per 30 days) TABLET) PREVYMIS (240 MG/12 ML VIAL, 480 Tier 3 B/D PA MG/24 ML VIAL) valganciclovir hcl (hcl 50 mg/ml, 450 mg Tier 3 tablet) VISTIDE Tier 3 ZIRGAN Tier 3 ANTI-HEPATITIS B (HBV) AGENTS adefovir dipivoxil Tier 1 QL (30 per 30 days) 33

42 NAME ANTIVIRALS (CONTINUED) BARACLUDE 0.05 MG/ML SOLUTION Tier 3 QL (600 per 30 days) entecavir Tier 3 QL (30 per 30 days) EPIVIR HBV 25 MG/5 ML SOLN Tier 3 lamivudine 100 mg tablet Tier 1 lamivudine hbv Tier 1 TYZEKA Tier 3 QL (30 per 30 days) VEMLIDY Tier 3 ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING DAKLINZA Tier 3 QL (30 per 30 days) EPCLUSA Tier 3 QL (30 per 30 days) HARVONI Tier 3 QL (30 per 30 days) MAVYRET Tier 3 QL (90per 30 days) OLYSIO Tier 3 QL (30 per 30 days) SOVALDI Tier 3 QL (30 per 30 days) TECHNIVIE Tier 3 QL (60 per 30 days) VIEKIRA PAK Tier 3 QL (112 per 28 days) VIEKIRA XR Tier 3 QL (90 per 30 days) VOSEVI Tier 3 QL (30 per 30 days) ZEPA Tier 3 QL (28 per 28 days) ANTI-HEPATITIS C (HCV) AGENTS, OTHER INTRON A (10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL) MODERIBA ( MG DOSEPACK, 200 MG TABLET, MG DOSEPACK, MG DOSEPACK, MG DOSEPACK) Tier 3 Tier 3 PEGASYS 180 MCG/0.5 ML SYRINGE Tier 3 QL (2 per 28 days) PEGASYS 180 MCG/ML VIAL Tier 3 PEGASYS PROCLICK 135 MCG/0.5 Tier 3 PEGASYS PROCLICK 180 MCG/0.5 Tier 3 QL (2 per 28 days) PEGINTRON Tier 3 QL (4 per 28 days) PEGINTRON REDIPEN Tier 3 QL (4 per 28 days) REBETOL 40 MG/ML SOLUTION Tier 3 RIBASPHERE (200 MG TABLET, 200 MG Tier 1 CAPSULE, 400 MG TABLET) RIBASPHERE 600 MG TABLET Tier 3 RIBASPHERE RIBAPAK Tier 3 ribavirin (200 mg capsule, 200 mg tablet) Tier 1 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA Tier 3 QL (30 per 30 days) 34

43 NAME ANTIVIRALS (CONTINUED) COMPLERA Tier 3 EDURANT Tier 3 efavirenz Tier 3 INTELENCE Tier 3 QL (120 per 30 days) nevirapine (50 mg/5 ml susp, 200 mg tablet) Tier 1 nevirapine er Tier 1 QL (30 per 30 days) ODEFSEY Tier 3 QL (30 per 30 days) RESCRIPTOR Tier 3 SUSTIVA Tier 3 SYMFI Tier 3 QL (30 per 30 days) SYMFI LO Tier 3 QL (30 per 30 days) VIRAMUNE 50 MG/5 ML SUSP Tier 3 ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir (20 mg/ml solution, 300 mg tablet) Tier 1 abacavir-lamivudine Tier 3 abacavir-lamivudine-zidovudine Tier 3 CIMDUO Tier 3 QL (30 per 30 days) DESCOVY Tier 3 QL (30 per 30 days) didanosine (dr 125 mg capsule, dr 200 mg Tier 1 capsule, dr 250 mg capsule, dr 400 mg capsule) EMTRIVA (10 MG/ML SOLUTION, 200 Tier 3 MG CAPSULE) lamivudine (10 mg/ml oral soln, 150 mg tablet, Tier mg tablet) lamivudine-zidovudine Tier 3 RETROVIR 200 MG/20 ML VIAL Tier 3 stavudine (1 mg/ml solution, 15 mg capsule, 20 Tier 1 mg capsule, 30 mg capsule, 40 mg capsule) SYMTUZA Tier 3 QL (30 per 30 days) tenofovir disoproxil fumarate Tier 3 TRIUMEQ Tier 3 QL (30 per 30 days) TRUVADA Tier 3 VIDEX 2 GM PEDIATRIC SOLN Tier 3 VIDEX 4 GM PEDIATRIC SOLN Tier 3 VIDEX EC 125 MG CAPSULE Tier 3 VIREAD (150 MG TABLET, 200 MG Tier 3 TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZERIT 1 MG/ML SOLUTION Tier 3 ZIAGEN 20 MG/ML SOLUTION Tier 3 35

44 NAME ANTIVIRALS (CONTINUED) zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) ANTI-HIV AGENTS, OTHER Tier 1 FUZEON Tier 3 SELZENTRY (75 MG TABLET, 150 MG Tier 3 QL (60 per 30 days) TABLET) SELZENTRY 20 MG/ML ORAL SOLN Tier 3 SELZENTRY 25 MG TABLET Tier 3 QL (240 per 30 days) SELZENTRY 300 MG TABLET Tier 3 QL (120 per 30 days) TROGARZO Tier 3 TYBOST Tier 2 ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) Tier 3 atazanavir sulfate Tier 3 CRIXIVAN Tier 3 EVOTAZ Tier 3 QL (30 per 30 days) fosamprenavir calcium Tier 3 INVIRASE Tier 3 KALETRA ( MG TABLET, Tier 3 MG TABLET) LEXIVA (50 MG/ML SUSPENSION, 700 Tier 3 MG TABLET) lopinavir-ritonavir Tier 3 NORVIR (80 MG/ML SOLUTION, 100 Tier 2 MG SOFTGEL CAP, 100 MG TABLET) NORVIR 100 MG POWDER PACKET Tier 3 PREZCOBIX Tier 3 QL (30 per 30 days) PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 600 MG TABLET, 800 MG TABLET) Tier 3 REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) Tier 3 ritonavir Tier 1 VIRACEPT Tier 3 ANTI-HIV, INTEGRASE INHIBITORS BIKTARVY Tier 3 QL (30 per 30 days) GENVOYA Tier 3 QL (30 per 30 days) ISENTRESS (100 MG TABLET CHEW, 400 MG TABLET) Tier 3 QL (60 per 30 days) 36

45 NAME ANTIVIRALS (CONTINUED) ISENTRESS 100 MG POWDER PACKET Tier 3 ISENTRESS 25 MG TABLET CHEW Tier 2 ISENTRESS HD Tier 3 QL (60 per 30 days) JULUCA Tier 3 QL (30 per 30 days) STRIBILD Tier 3 TIVICAY (10 MG TABLET, 25 MG Tier 3 QL (30 per 30 days) TABLET) TIVICAY 50 MG TABLET Tier 3 VITEKTA Tier 3 QL (30 per 30 days) ANTI-INFLUENZA AGENTS amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet, 100 mg/10 ml soln) Tier 1 oseltamivir 6 mg/ml suspension Tier 2 oseltamivir phosphate (30 mg capsule, 45 mg Tier 1 capsule, 75 mg capsule) RELENZA Tier 3 QL (56 per 30 days) rimantadine hcl Tier 1 TAMIFLU 6 MG/ML SUSPENSION Tier 3 ANTIHERPETIC AGENTS acyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) Tier 1 acyclovir 200 mg/5 ml susp Tier 3 acyclovir 5% ointment Tier 3 QL (30 per 30 days) acyclovir sodium (sodium 500 mg vial, 500 Tier 1 B/D PA mg/10 ml vial, 1,000 mg/20 ml vial) DENAVIR Tier 3 QL (5 per 30 days) famciclovir Tier 1 QL (90 per 30 days) trifluridine Tier 1 valacyclovir Tier 1 ZOVIRAX 5% CREAM Tier 3 QL (15 per 30 days) ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl Tier 1 chlordiazepoxide-amitriptyline Tier 3 hydroxyzine pamoate Tier 2 BENZODIAZEPINES alprazolam Tier 1 alprazolam er Tier 1 alprazolam odt Tier 1 alprazolam xr Tier 1 chlordiazepoxide hcl Tier 1 37

46 NAME ANXIOLYTICS (CONTINUED) diazepam (2 mg tablet, 5 mg/ml vial, 5 mg tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 10 mg/2 ml carpuject, 10 mg tablet, 50 mg/10 ml vial) lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 2 mg tablet, 4 mg/ml vial, 4 mg/ml Tier 1 Tier 1 carpuject, 20 mg/10 ml vial, 40 mg/10 ml vial) oxazepam Tier 1 BIPOLAR AGENTS MOOD STABILIZERS EQUETRO Tier 3 lithium Tier 1 lithium carbonate (150 mg cap, 300 mg cap) Tier 1 lithium carbonate (300 mg tab, 600 mg cap) Tier 3 lithium carbonate er Tier 1 BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose Tier 1 alogliptin Tier 3 QL (30 per 30 days) alogliptin-metformin Tier 3 QL (60 per 30 days) alogliptin-pioglitazone Tier 3 QL (30 per 30 days) AVANDIA (2 MG TABLET, 4 MG Tier 3 QL (60 per 30 days) TABLET) AVANDIA 8 MG TABLET Tier 3 QL (30 per 30 days) BYDUREON Tier 3 QL (4 per 28 days) BYDUREON BCISE Tier 3 QL (4 per 28 days) BYDUREON PEN Tier 3 QL (4 per 28 days) BYETTA 10 MCG DOSE PEN INJ Tier 3 QL (2.4 per 30 days) BYETTA 5 MCG DOSE PEN INJ Tier 3 QL (1.2 per 30 days) chlorpropamide Tier 2 QL (90 per 30 days) CYCLOSET Tier 3 DIABETA 1.25 MG TABLET Tier 3 QL (60 per 30 days) DIABETA 2.5 MG TABLET Tier 3 QL (90 per 30 days) DIABETA 5 MG TABLET Tier 3 QL (120 per 30 days) glimepiride 1 mg tablet Tier 1 QL (180 per 30 days) glimepiride 2 mg tablet Tier 1 QL (90 per 30 days) glimepiride 4 mg tablet Tier 1 QL (60 per 30 days) glipizide Tier 1 QL (120 per 30 days) glipizide er (er 2.5 mg tablet, er 5 mg tablet) Tier 1 QL (90 per 30 days) glipizide er 10 mg tablet Tier 1 QL (60 per 30 days) 38

47 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) glipizide xl (2.5 mg tablet, 5 mg tablet) Tier 1 QL (90 per 30 days) glipizide xl 10 mg tablet Tier 1 QL (60 per 30 days) glipizide-metformin ( mg, mg) Tier 1 QL (120 per 30 days) glipizide-metformin mg Tier 1 QL (240 per 30 days) GLUCOVANCE Tier 3 QL (120 per 30 days) GLUMETZA ER 1,000 MG TABLET Tier 3 QL (60 per 30 days) GLUMETZA ER 500 MG TABLET Tier 3 QL (120 per 30 days) glyburid-metformin mg Tier 2 QL (60 per 30 days) glyburide 1.25 mg tablet Tier 2 QL (60 per 30 days) glyburide 2.5 mg tablet Tier 2 QL (90 per 30 days) glyburide 5 mg tablet Tier 2 QL (120 per 30 days) glyburide micronized Tier 2 QL (60 per 30 days) glyburide-metformin hcl ( mg, Tier 2 QL (120 per 30 days) mg) GLYNASE Tier 3 QL (60 per 30 days) INVOKAMET Tier 2 QL (60 per 30 days) INVOKAMET XR Tier 2 QL (60 per 30 days) INVOKANA 100 MG TABLET Tier 2 QL (60 per 30 days) INVOKANA 300 MG TABLET Tier 2 QL (30 per 30 days) JANUMET Tier 2 QL (60 per 30 days) JANUMET XR ( MG TABLET, 100- Tier 2 QL (30 per 30 days) 1,000 MG TABLET) JANUMET XR 50-1,000 MG TABLET Tier 2 QL (60 per 30 days) JANUVIA Tier 2 QL (30 per 30 days) JARDIANCE Tier 2 QL (30 per 30 days) JENTADUETO Tier 3 QL (60 per 30 days) JENTADUETO XR 2.5 MG-1,000 MG Tier 3 QL (60 per 30 days) JENTADUETO XR 5 MG-1,000 MG TB Tier 3 QL (30 per 30 days) KAZANO Tier 3 QL (60 per 30 days) KOMBIGLYZE XR (5-500 MG TABLET, Tier 2 QL (30 per 30 days) 5-1,000 MG TAB) KOMBIGLYZE XR 2.5-1,000 MG TAB Tier 2 QL (60 per 30 days) metformin er 1000 mg osmotic tablet (generic Tier 3 QL (60 per 30 days) for fortamet) metformin er 500 mg osmotic tablet (generic Tier 3 QL (150 per 30 days) for fortamet) metformin hcl 1000mg tablet (immediaterelease) Tier 1 QL (60 per 30 days) metformin hcl 500 mg tablet (immediaterelease) Tier 1 QL (150 per 30 days) metformin hcl 850 mg tablet (immediaterelease) Tier 1 QL (90 per 30 days) 39

48 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) metformin hcl er 1000 mg tablet (generic for Tier 3 QL (60 per 30 days) glumetza) metformin hcl er 500mg (generic for Tier 1 QL (120 per 30 days) glucophage xr) metformin hcl er 500mg (generic for Tier 3 QL (120 per 30 days) glumetza) metformin hcl er 750 mg (generic for Tier 1 QL (90 per 30 days) glucophage xr) miglitol Tier 1 nateglinide Tier 1 NESINA Tier 3 QL (30 per 30 days) ONGLYZA Tier 2 QL (30 per 30 days) OSENI Tier 3 QL (30 per 30 days) OZEMPIC MG DOSE PEN Tier 2 QL (1.5 per 28 days) OZEMPIC 1 MG DOSE PEN Tier 2 QL (3 per 28 days) pioglitazone hcl Tier 1 QL (30 per 30 days) pioglitazone-glimepiride Tier 1 QL (30 per 30 days) pioglitazone-metformin Tier 2 QL (90 per 30 days) repaglinide Tier 1 QL (240 per 30 days) repaglinide-metformin hcl Tier 2 QL (150 per 30 days) RIOMET Tier 3 QL (765 per 30 days) SYMLINPEN 120 Tier 2 QL (12 per 28 days) SYMLINPEN 60 Tier 2 QL (12 per 28 days) SYNJARDY Tier 2 QL (60 per 30 days) SYNJARDY XR (10-1,000 MG TABLET, Tier 2 QL (30 per 30 days) 25-1,000 MG TABLET) SYNJARDY XR (5-1,000 MG TABLET, Tier 2 QL (60 per 30 days) ,000 MG TAB) tolazamide Tier 1 QL (60 per 30 days) tolbutamide Tier 1 QL (180 per 30 days) TRADJENTA Tier 3 QL (30 per 30 days) TRULICITY Tier 2 QL (2 per 28 days) VICTOZA 2-PAK Tier 2 QL (9 per 30 days) VICTOZA 3-PAK Tier 2 QL (9 per 30 days) GLYCEMIC AGENTS GLUCAGEN 1 MG HYPOKIT Tier 2 GLUCAGON EMERGENCY KIT Tier 2 PROGLYCEM Tier 3 INSULINS HUMALOG Tier 2 HUMALOG JUNIOR KWIKPEN Tier 2 40

49 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) HUMALOG KWIKPEN U-100 Tier 2 HUMALOG KWIKPEN U-200 Tier 2 HUMALOG MIX Tier 2 HUMALOG MIX KWIKPEN Tier 2 HUMALOG MIX Tier 2 HUMALOG MIX KWIKPEN Tier 2 HUMULIN Tier 2 HUMULIN 70/30 KWIKPEN Tier 2 HUMULIN N Tier 2 HUMULIN N KWIKPEN Tier 2 HUMULIN R Tier 2 HUMULIN R U-500 Tier 2 HUMULIN R U-500 KWIKPEN Tier 2 LANTUS Tier 2 LANTUS SOLOSTAR Tier 2 LEVEMIR Tier 2 LEVEMIR FLEXTOUCH Tier 2 TOUJEO MAX SOLOSTAR Tier 2 TOUJEO SOLOSTAR Tier 2 TRESIBA FLEXTOUCH U-100 Tier 2 TRESIBA FLEXTOUCH U-200 Tier 2 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS BRILINTA Tier 2 QL (60 per 30 days) COUMADIN Tier 3 ELIQUIS (5 MG STARTER PACK, 5 MG Tier 2 QL (74 per 30 days) TABLET) ELIQUIS 2.5 MG TABLET Tier 2 QL (60 per 30 days) enoxaparin sodium Tier 2 fondaparinux sodium Tier 3 FRAGMIN (7,500 UNITS/0.3 ML SYR, Tier 3 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 ML VL) heparin 25,000 unit/500-1/2 ns Tier 1 heparin sodium Tier 1 heparin sodium in 0.45% nacl (heparin-1/2ns Tier 1 25,000 units/500, heparin-1/2ns 12,500 units/250, heparin 25,000 unit/250-1/2 ns) heparin sodium-0.9% nacl (heparin 1,000 unit/500 ml-ns, heparin 2,000 unit/1,000 ml-ns, heparin-ns 1,000 units/500 ml, heparin-ns 2,000 unit/1,000 ml) Tier 1 41

50 NAME BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (CONTINUED) heparin sodium-d5w Tier 1 JANTOVEN Tier 1 warfarin sodium Tier 1 XARELTO (10 MG TABLET, 20 MG Tier 2 QL (30 per 30 days) TABLET) XARELTO 15 MG TABLET Tier 2 QL (60 per 30 days) XARELTO STARTER PACK Tier 2 QL (51 per 30 days) ZONTIVITY Tier 3 QL (30 per 30 days) BLOOD FORMATION MODIFIERS anagrelide hcl Tier 1 ARANESP Tier 3 azacitidine Tier 1 DOPTELET Tier 3 QL (15 per 30 days) EPOGEN Tier 3 GRANIX Tier 3 LEUKINE Tier 3 MIRCERA Tier 3 MOZOBIL Tier 3 MULPLETA Tier 3 QL (7 per 30 days) NEULASTA Tier 3 QL (2 per 30 days) NEUPOGEN Tier 3 PROCRIT Tier 3 PROMACTA (12.5 MG TABLET, 50 MG Tier 3 QL (30 per 30 days) TABLET, 75 MG TABLET) PROMACTA 25 MG TABLET Tier 3 QL (90 per 30 days) protamine sulfate Tier 3 ZARXIO Tier 3 HEMOSTASIS AGENTS tranexamic acid (650 mg tablet, 1,000 mg/10 Tier 1 ml) PLATELET MODIFYING AGENTS AGGRENOX Tier 3 QL (60 per 30 days) aspirin-dipyridamole er Tier 3 QL (60 per 30 days) cilostazol Tier 1 clopidogrel 300 mg tablet Tier 1 QL (1 per 30 days) clopidogrel 75 mg tablet Tier 1 QL (60 per 30 days) dipyridamole (25 mg tablet, 50 mg tablet, 75 Tier 1 mg tablet) EFFIENT Tier 2 QL (30 per 30 days) PRADAXA Tier 3 QL (60 per 30 days) 42

51 NAME BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (CONTINUED) prasugrel hcl Tier 1 QL (30 per 30 days) ticlopidine hcl Tier 1 CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 Tier 1 mg tablet) clonidine patch Tier 2 QL (8 per 28 days) CLORPRES Tier 3 guanfacine hcl Tier 1 methyldopa Tier 1 methyldopa-hydrochlorothiazide Tier 1 methyldopate hcl Tier 1 midodrine hcl Tier 1 NORTHERA Tier 3 QL (180 per 30 days) ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA XL Tier 3 phenoxybenzamine hcl Tier 3 prazosin hcl Tier 1 reserpine Tier 1 terazosin hcl Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil Tier 1 QL (30 per 30 days) candesartan-hydrochlorothiazid Tier 1 QL (30 per 30 days) EDARBI Tier 3 QL (30 per 30 days) EDARBYCLOR Tier 3 QL (30 per 30 days) eprosartan mesylate Tier 1 QL (30 per 30 days) irbesartan (75 mg tablet, 150 mg tablet) Tier 1 QL (60 per 30 days) irbesartan 300 mg tablet Tier 1 QL (30 per 30 days) irbesartan-hydrochlorothiazide Tier 1 QL (30 per 30 days) losartan potassium (50 mg tab, 100 mg tab) Tier 1 QL (60 per 30 days) losartan potassium 25 mg tab Tier 1 QL (120 per 30 days) losartan-hctz mg tab Tier 1 QL (60 per 30 days) losartan-hydrochlorothiazide ( mg Tier 1 QL (30 per 30 days) tab, mg tab) olmesartan medoxomil Tier 1 olmesartan-amlodipine-hctz Tier 1 QL (30 per 30 days) olmesartan-hydrochlorothiazide Tier 1 telmisartan Tier 1 QL (30 per 30 days) telmisartan-amlodipine Tier 2 QL (30 per 30 days) telmisartan-hydrochlorothiazid Tier 2 QL (30 per 30 days) 43

52 NAME CARDIOVASCULAR AGENTS (CONTINUED) valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) Tier 1 QL (60 per 30 days) valsartan 320 mg tablet Tier 1 QL (30 per 30 days) valsartan-hydrochlorothiazide Tier 1 QL (30 per 30 days) ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl Tier 1 benazepril-hydrochlorothiazide Tier 1 captopril Tier 1 captopril-hydrochlorothiazide Tier 1 enalapril maleate Tier 1 enalapril-hydrochlorothiazide Tier 1 fosinopril sodium Tier 1 fosinopril-hydrochlorothiazide Tier 1 lisinopril Tier 1 lisinopril-hydrochlorothiazide Tier 1 moexipril hcl Tier 1 moexipril-hydrochlorothiazide Tier 1 perindopril erbumine Tier 1 quinapril hcl Tier 1 quinapril-hydrochlorothiazide Tier 1 ramipril Tier 1 trandolapril Tier 1 trandolapril-verapamil er Tier 2 QL (30 per 30 days) ANTIARRHYTHMICS amiodarone hcl (hcl 100 mg tablet, 150 mg/3 ml vial, 150 mg/3 ml syringe, hcl 200 mg tablet, hcl 400 mg tablet, 450 mg/9 ml vial, 900 mg/18 ml vial) Tier 1 dofetilide Tier 1 flecainide acetate Tier 1 lidocaine hcl (1% syringe, 1% abboject, 2% Tier 1 luer-jet, 2% syringe, 2% abboject) mexiletine hcl Tier 1 MULTAQ Tier 2 QL (60 per 30 days) PACERONE Tier 1 procainamide hcl Tier 1 propafenone hcl Tier 1 propafenone hcl er Tier 1 quinidine gluc 80 mg/ml vial Tier 1 quinidine gluc er 324 mg tab Tier 2 quinidine sulfate (200 mg tab, 300 mg tab) Tier 1 44

53 NAME CARDIOVASCULAR AGENTS (CONTINUED) SORINE Tier 1 sotalol Tier 1 sotalol af Tier 1 SOTYLIZE Tier 3 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl Tier 1 atenolol Tier 1 atenolol-chlorthalidone Tier 1 betaxolol hcl (10 mg tablet, 20 mg tablet) Tier 1 bisoprolol fumarate Tier 1 bisoprolol-hydrochlorothiazide Tier 1 BYSTOLIC (2.5 MG TABLET, 5 MG Tier 2 QL (30 per 30 days) TABLET, 10 MG TABLET) BYSTOLIC 20 MG TABLET Tier 2 QL (60 per 30 days) BYVALSON Tier 2 QL (120 per 30 days) carvedilol Tier 1 carvedilol er Tier 2 QL (30 per 30 days) COREG CR Tier 3 QL (30 per 30 days) labetalol hcl (100 mg tablet, 100 mg/20 ml vl, Tier mg/40 ml vl, 200 mg tablet, 300 mg tablet) metoprolol succinate er Tier 1 metoprolol tartrate (1 mg/ml carpuject, tart 5 Tier 1 mg/5 ml amp, tart 5 mg/5 ml vial, tartrate 25 mg tab, tartrate 37.5 mg tb, tartrate 50 mg tab, tartrate 75 mg tab, tartrate 100 mg tab) metoprolol-hydrochlorothiazide Tier 1 nadolol Tier 1 nadolol-bendroflumethiazide Tier 1 pindolol Tier 1 propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 Tier 1 mg tablet, 20 mg/5 ml soln, 40 mg/5 ml soln, 40 mg tablet, 60 mg tablet, 80 mg tablet) propranolol-hydrochlorothiazid Tier 1 CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR Tier 1 amlodipine besylate Tier 1 amlodipine besylate-benazepril Tier 1 amlodipine-atorvastatin Tier 3 QL (30 per 30 days) amlodipine-olmesartan Tier 1 QL (30 per 30 days) amlodipine-valsartan Tier 2 QL (30 per 30 days) amlodipine-valsartan-hctz Tier 2 QL (30 per 30 days) 45

54 NAME CARDIOVASCULAR AGENTS (CONTINUED) CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN, CARDENE-DEX 40 MG/200 ML IV, CARDENE-NACL 20 MG/200 ML SOLN, CARDENE-NACL 40 MG/200 ML IV) Tier 3 CARTIA XT Tier 1 CLEVIPREX Tier 3 DILT-XR Tier 1 diltiazem 12hr er Tier 1 diltiazem 24hr cd (24hr 360 mg cap, 24hr 300 mg cap, 24hr 240 mg cap, 24hr 180 mg cap, 24hr 120 mg cap) diltiazem 24hr er (24hr er 240 mg tab, 24hr er 300 mg cap, 24hr er 420 mg cap, 24hr er 420 mg tab, 24hr er 360 mg tab, 24hr er 240 mg cap, 24hr er 180 mg tab, 24hr er 360 mg cap, 24hr er 300 mg tab, 24hr er 180 mg cap, 24hr er 120 mg cap) Tier 1 Tier 1 diltiazem er Tier 1 diltiazem hcl (25 mg/5 ml vial, 30 mg tablet, Tier 1 50 mg/10 ml vial, 60 mg tablet, 90 mg tablet, hcl 100 mg vial, 120 mg tablet, 125 mg/25 ml vial) felodipine er Tier 1 isradipine Tier 1 MATZIM LA Tier 1 nicardipine hcl (20 mg capsule, 25 mg/10 ml Tier 1 vial, 25 mg/10 ml ampule, 30 mg capsule) NIFEDICAL XL Tier 1 nifedipine er (er 30 mg tablet, er 60 mg tablet, Tier 1 er 90 mg tablet) nimodipine Tier 1 nisoldipine Tier 1 TAZTIA XT Tier 1 verapamil er Tier 1 verapamil er pm Tier 1 verapamil hcl (2.5 mg/ml vial, 2.5 mg/ml ampul, 5 mg/2 ml vial, 10 mg/4 ml vial, 40 mg tablet, 80 mg tablet, 120 mg tablet, 360 mg cap pellet) Tier 1 verapamil sr Tier 1 CARDIOVASCULAR AGENTS, OTHER CORLANOR Tier 3 QL (60 per 30 days) 46

55 NAME CARDIOVASCULAR AGENTS (CONTINUED) DEMSER Tier 3 DIGITEK Tier 1 DIGOX Tier 1 digoxin (0.125 mg tablet, 0.25 mg tablet, 125 Tier 1 mcg tablet, 250 mcg tablet, 500 mcg/2 ml ampule) digoxin 0.05 mg/ml solution Tier 3 ENTRESTO Tier 2 QL (60 per 30 days) LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, MCG TABLET, 250 MCG TABLET, 500 MCG/2 ML AMPULE) Tier 3 pentoxifylline Tier 1 RANEXA ER 1,000 MG TABLET Tier 2 QL (60 per 30 days) RANEXA ER 500 MG TABLET Tier 2 QL (120 per 30 days) TEKTURNA Tier 2 QL (30 per 30 days) TEKTURNA HCT Tier 2 QL (30 per 30 days) VECAMYL Tier 3 DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide sodium Tier 1 methazolamide Tier 1 DIURETICS, LOOP bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg/4 ml vial, 1 mg tablet, 2 mg tablet, 2.5 mg/10 ml vial) Tier 1 ethacrynate sodium Tier 3 ethacrynic acid Tier 2 furosemide (10 mg/ml solution, 20 mg/2 ml Tier 1 vial, 20 mg tablet, 40 mg/4 ml syringe, 40 mg/5 ml soln, 40 mg/4 ml vial, 40 mg tablet, 80 mg tablet, 100 mg/10 ml vial, 100 mg/10 ml syring) torsemide Tier 1 DIURETICS, POTASSIUM-SPARING amiloride hcl Tier 1 amiloride-hydrochlorothiazide Tier 1 DYRENIUM Tier 3 eplerenone Tier 1 spironolactone Tier 1 spironolactone-hctz Tier 1 triamterene-hydrochlorothiazid Tier 1 DIURETICS, THIAZIDE chlorothiazide Tier 1 47

56 NAME CARDIOVASCULAR AGENTS (CONTINUED) chlorothiazide sodium Tier 1 chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 methyclothiazide Tier 1 metolazone Tier 1 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate (40 mg tablet, 120 mg tablet) Tier 3 QL (30 per 30 days) fenofibrate (43 mg capsule, 48 mg tablet, 54 Tier 1 QL (30 per 30 days) mg tablet, 67 mg capsule, 130 mg capsule, 134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mg capsule) fenofibric acid (35 mg tablet, 105 mg tablet) Tier 1 fenofibric acid (dr 45 mg cap, dr 135 mg cap) Tier 1 QL (30 per 30 days) FENOGLIDE Tier 3 gemfibrozil Tier 1 TRIGLIDE Tier 3 QL (30 per 30 days) DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS ALTOPREV Tier 3 QL (30 per 30 days) atorvastatin calcium Tier 1 ezetimibe-simvastatin Tier 1 QL (30 per 30 days) fluvastatin er Tier 1 QL (30 per 30 days) fluvastatin sodium 20 mg cap Tier 1 QL (30 per 30 days) fluvastatin sodium 40 mg cap Tier 1 QL (60 per 30 days) LIVALO Tier 3 QL (30 per 30 days) lovastatin Tier 1 pravastatin sodium Tier 1 rosuvastatin calcium (5 mg tab, 10 mg tab, 20 Tier 1 QL (45 per 30 days) mg tab) rosuvastatin calcium 40 mg tab Tier 1 QL (30 per 30 days) simvastatin Tier 1 DYSLIPIDEMICS, OTHER cholestyramine (packet, powder) Tier 1 cholestyramine light (packet, powder) Tier 1 colesevelam hcl Tier 2 colestipol hcl (hcl 1 gm tablet, hcl granules, hcl Tier 1 granules packet, micronized 1 gm tab) ezetimibe Tier 1 QL (30 per 30 days) JUXTAPID Tier 3 QL (30 per 30 days) KYNAMRO Tier 3 QL (4 per 28 days) niacin er (er 750 mg tablet, er 1,000 mg tablet) Tier 1 QL (60 per 30 days) 48

57 NAME CARDIOVASCULAR AGENTS (CONTINUED) niacin er 500 mg tablet Tier 1 QL (90 per 30 days) NIACOR Tier 1 omega-3 acid ethyl esters Tier 1 QL (120 per 30 days) PRALUENT PEN Tier 3 QL (2 per 28 days) PRALUENT SYRINGE Tier 3 QL (2 per 28 days) PREVALITE (PACKET, POWDER) Tier 1 REPATHA PUSHTRONEX Tier 3 QL (4 per 30 days) REPATHA SURECLICK Tier 3 QL (2 per 28 days) REPATHA SYRINGE Tier 3 QL (2 per 28 days) VASCEPA Tier 2 QL (120 per 30 days) WELCHOL Tier 3 VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet) Tier 1 minoxidil (2.5 mg tablet, 10 mg tablet) Tier 1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS BIDIL Tier 3 QL (180 per 30 days) DILATRATE-SR Tier 3 GONITRO Tier 3 isosorbide dinitrate Tier 1 isosorbide dinitrate er Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate er Tier 1 MINITRAN Tier 1 NITRO-BID Tier 3 NITRO-DUR (0.1 PATCH, 0.2 PATCH, 0.3 PATCH, 0.4 PATCH, 0.6 PATCH, 0.8 PATCH) Tier 3 nitroglycerin (0.3 mg tablet sl, 0.4 mg tablet sl, Tier mg tablet sl) nitroglycerin 400 mcg lingual spray Tier 3 nitroglycerin 5 mg/ml vial Tier 3 nitroglycerin patch Tier 1 NITROLINGUAL Tier 3 NITROMIST Tier 3 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES dextroamp-amphet er 30 mg cap Tier 2 QL (60 per 30 days) dextroamphetamine sulfate (5 mg tab, 5 mg/5 Tier 3 ml, 10 mg tab) dextroamphetamine sulfate er Tier 3 49

58 NAME CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) dextroamphetamine-amphet er (er 5 mg cap, Tier 2 QL (90 per 30 days) er 10 mg cap, er 15 mg cap, er 20 mg cap, er 25 mg cap) dextroamphetamine-amphetamine Tier 2 methamphetamine hcl Tier 3 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES atomoxetine hcl Tier 2 clonidine hcl er Tier 2 QL (120 per 30 days) DAYTRANA Tier 3 QL (30 per 30 days) dexmethylphenidate hcl Tier 2 dexmethylphenidate hcl er (er 15 mg cp, er 20 Tier 2 QL (30 per 30 days) mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) dexmethylphenidate hcl er (er 5 mg cap, er 10 Tier 2 QL (60 per 30 days) mg cp) guanfacine hcl er (er 1 mg tablet, er 2 mg Tier 2 QL (60 per 30 days) tablet) guanfacine hcl er (er 3 mg tablet, er 4 mg Tier 2 QL (30 per 30 days) tablet) METADATE ER Tier 1 METHYLIN (2.5 MG TAB, 5 MG Tier 3 TABLET, 10 MG TABLET) methylphenidate cd 30 mg cap Tier 2 QL (60 per 30 days) methylphenidate er (er 10 mg cap, er 18 mg Tier 2 QL (90 per 30 days) tab, er 20 mg cap, er 27 mg tab) methylphenidate er (er 10 mg tab, er 20 mg Tier 2 tab) methylphenidate er (er 30 mg cap, er 36 mg Tier 2 QL (60 per 30 days) tab, er 54 mg tab) methylphenidate er (er 40 mg cap, er 72 mg Tier 2 QL (30 per 30 days) tab) methylphenidate hcl (2.5 mg chew tb, 5 mg Tier 2 tablet, 5 mg chew tab, 10 mg chew tab, 10 mg tablet, 20 mg tablet) methylphenidate hcl cd (10 mg cap, 20 mg Tier 2 QL (90 per 30 days) cap) methylphenidate hcl cd (40 mg cap, 50 mg cap, Tier 2 QL (30 per 30 days) 60 mg cap) methylphenidate hcl er (er 50 mg cap, er 60 mg Tier 2 QL (30 per 30 days) cap) methylphenidate la (10 mg cap, 20 mg cap) Tier 2 QL (90per 30 days) methylphenidate la (40 mg cap, 60 mg cap) Tier 2 QL (30 per 30 days) 50

59 NAME CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) methylphenidate la 30 mg cap Tier 2 QL (60 per 30 days) RELEXXII Tier 3 QL (30 per 30 days) RITALIN LA 10 MG CAPSULE Tier 3 CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO (9 MG TABLET, 12 MG Tier 3 QL (120 per 30 days) TABLET) AUSTEDO 6 MG TABLET Tier 3 QL (60 per 30 days) INGREZZA 40 MG CAPSULE Tier 3 QL (60 per 30 days) INGREZZA 80 MG CAPSULE Tier 3 QL (30 per 30 days) LUCEMYRA Tier 3 NUEDEXTA Tier 3 QL (60 per 30 days) phentermine hcl Tier 1 QL (84 per 365 days), (capped benefit)ex riluzole Tier 1 tetrabenazine 12.5 mg tablet Tier 3 QL (240 per 30 days) tetrabenazine 25 mg tablet Tier 3 QL (120 per 30 days) FIBROMYALGIA AGENTS LYRICA (200 MG CAPSULE, 225 MG CAPSULE) Tier 2 QL (90 per 30 days) LYRICA 100 MG CAPSULE Tier 2 QL (180 per 30 days) LYRICA 150 MG CAPSULE Tier 2 QL (120 per 30 days) LYRICA 25 MG CAPSULE Tier 2 QL (720 per 30 days) LYRICA 300 MG CAPSULE Tier 2 QL (60 per 30 days) LYRICA 50 MG CAPSULE Tier 2 QL (360 per 30 days) LYRICA 75 MG CAPSULE Tier 2 QL (240 per 30 days) SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) Tier 3 QL (60 per 30 days) SAVELLA TITRATION PACK Tier 3 MULTIPLE SCLEROSIS AGENTS AMPYRA Tier 3 QL (60 per 30 days) AUBAGIO Tier 3 QL (30 per 30 days) AVONEX (30 MCG VIAL KIT, Tier 3 QL (4 per 30 days) PREFILLED SYR 30 MCG KT) AVONEX PEN Tier 3 QL (4 per 30 days) BETASERON Tier 3 QL (14 per 28 days) COPAXONE 20 MG/ML SYRINGE Tier 3 QL (30 per 30 days) COPAXONE 40 MG/ML SYRINGE Tier 3 QL (12 per 28 days) dalfampridine er Tier 3 QL (60 per 30 days) EXTAVIA Tier 3 QL (15 per 30 days) GILENYA 0.5 MG CAPSULE Tier 3 QL (30 per 30 days) 51

60 NAME CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) glatiramer 20 mg/ml syringe Tier 3 QL (30 per 30 days) glatiramer 40 mg/ml syringe Tier 3 QL (12 per 28 days) GLATOPA 20 MG/ML SYRINGE Tier 3 QL (30 per 30 days) GLATOPA 40 MG/ML SYRINGE Tier 3 QL (12 per 28 days) LEMTRADA Tier 3 OCREVUS Tier 3 PLEGRIDY Tier 3 QL (1 per 28 days) PLEGRIDY PEN Tier 3 QL (1 per 28 days) REBIF Tier 3 QL (12 per 28 days) REBIF REBIDOSE Tier 3 QL (12 per 28 days) TECFIDERA Tier 3 QL (60 per 30 days) TYSABRI Tier 3 ZINBRYTA Tier 3 DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS cevimeline hcl Tier 2 chlorhexidine 0.12% rinse Tier 1 KEPIVANCE Tier 3 ORALONE Tier 1 PAROEX Tier 1 PERIOGARD Tier 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) Tier 2 triamcinolone 0.1% paste Tier 1 DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS 8-MOP Tier 3 ABSORICA (10 MG CAPSULE, 20 MG Tier 3 CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG CAPSULE) ACANYA Tier 3 acitretin Tier 3 ACZONE (5% GEL, 7.5% GEL PUMP) Tier 3 adapalene (0.1% cream, 0.1% gel, 0.1% Tier 3 solution, 0.3% gel, 0.3% gel pump) adapalene-benzoyl peroxide Tier 2 ammonium lactate Tier 1 AMNESTEEM Tier 2 ATRALIN Tier 3 AVITA Tier 3 52

61 NAME DERMATOLOGICAL AGENTS (CONTINUED) AZELEX Tier 3 calcipotriene (0.005% solution, 0.005% Tier 2 ointment, 0.005% cream) calcipotriene-betamethasone dp Tier 3 CALCITRENE Tier 2 calcitriol 3 mcg/g ointment Tier 3 CARAC Tier 3 CLARAVIS Tier 2 clind ph-benzoyl pero % Tier 3 clind ph-benzoyl perox 1.2-5% Tier 2 clindamycin phos-tretinoin Tier 3 clindamycin-benzoyl perox 1-5% Tier 2 clindamycin-benzoyl peroxide Tier 2 CONDYLOX (0.5% TOPICAL SOLN, 0.5% Tier 3 GEL) COSENTYX (2 SYRINGES) Tier 3 QL (10 per 28 days) COSENTYX PEN Tier 3 QL (10 per 28 days) COSENTYX PEN (2 PENS) Tier 3 QL (10 per 28 days) COSENTYX SYRINGE Tier 3 QL (10 per 28 days) dapsone 5% gel Tier 2 diclofenac sodium 3% gel Tier 3 DIFFERIN (0.1% CREAM, 0.1% LOTION, Tier 3 0.1% GEL, 0.3% GEL PUMP, 0.3% GEL) doxepin 5% cream Tier 3 ELIDEL Tier 3 QL (100 per 30 days) ENSTILAR Tier 3 EPIDUO ( % GEL, % GEL Tier 3 PUMP) EPIDUO FORTE Tier 3 erythromycin-benzoyl peroxide Tier 2 FABIOR Tier 3 FINACEA Tier 3 fluorouracil (2% topical soln, 5% cream, 5% Tier 1 topical soln) fluorouracil 0.5% cream Tier 3 imiquimod 3.75% cream pump Tier 3 imiquimod 5% cream packet Tier 2 isotretinoin Tier 2 methoxsalen Tier 3 MYORISAN Tier 2 ONEXTON GEL PUMP Tier 3 53

62 NAME DERMATOLOGICAL AGENTS (CONTINUED) PICATO Tier 3 PLIXDA Tier 3 podofilox Tier 1 PRUDOXIN Tier 3 REGRANEX Tier 3 RETIN-A Tier 3 RETIN-A MICRO Tier 3 RETIN-A MICRO PUMP (PUMP 0.04% Tier 3 GEL, PUMP 0.06% GEL, PUMP 0.08% GEL, PUMP 0.1% GEL) SANTYL Tier 3 selenium sulfide 2.5% lotion Tier 1 sodium sulfacetamide 10% lot Tier 1 SORILUX Tier 3 sulfacetamide sodium (sod 10% top susp, Tier 1 sodium 10% lotn) TACLONEX 0.005%-0.064% SUSPENS Tier 3 tacrolimus (0.03% ointment, 0.1% ointment) Tier 1 QL (100 per 30 days) TALTZ AUTOINJECTOR Tier 3 QL (4 per 28 days) TALTZ AUTOINJECTOR (2 PACK) Tier 3 QL (4 per 28 days) TALTZ AUTOINJECTOR (3 PACK) Tier 3 QL (4 per 28 days) TALTZ SYRINGE Tier 3 QL (4 per 28 days) TALTZ SYRINGE (2 PACK) Tier 3 QL (4 per 28 days) TALTZ SYRINGE (3 PACK) Tier 3 QL (4 per 28 days) tazarotene Tier 2 TAZORAC (0.05% CREAM, 0.05% GEL, Tier 3 0.1% CREAM, 0.1% GEL) TOLAK Tier 3 TRETIN-X (0.0375% CREAM, 0.075% Tier 3 CREAM) tretinoin (0.01% gel, 0.025% gel, 0.025% Tier 2 cream, 0.05% cream, 0.05% gel, 0.1% cream) tretinoin microsphere Tier 3 UVADEX Tier 3 VEREGEN Tier 3 XERESE Tier 3 ZENATANE Tier 2 ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM PUMP, 3.75% CREAM) Tier 3 54

63 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT AMINOSYN Tier 3 B/D PA AMINOSYN II Tier 3 B/D PA AMINOSYN II WITH ELECTROLYTES Tier 3 B/D PA AMINOSYN M Tier 3 B/D PA AMINOSYN WITH ELECTROLYTES Tier 3 B/D PA AMINOSYN-HBC Tier 3 B/D PA AMINOSYN-PF Tier 3 B/D PA AMINOSYN-RF Tier 3 B/D PA calcium gluconate (gluc 1,000 mg/10 ml vl, Tier 1 gluc 5,000 mg/50 ml vl, gluc 10,000 mg/100 ml, gluconate 10% vial) CARBAGLU Tier 3 CLINIMIX Tier 3 B/D PA CLINIMIX E Tier 3 B/D PA CLINIMIX N14G30E Tier 3 B/D PA CLINIMIX N9G15E Tier 3 B/D PA CLINIMIX N9G20E Tier 3 B/D PA CLINISOL Tier 3 B/D PA DENTA 5000 PLUS Tier 1 DENTAGEL Tier 1 dextrose 10%-0.2% nacl Tier 1 dextrose 10%-0.45% nacl Tier 1 dextrose 2.5%-0.45% nacl Tier 1 dextrose 5%-0.2% nacl Tier 1 dextrose 5%-0.2% nacl-kcl Tier 1 dextrose 5%-0.225% nacl Tier 1 dextrose 5%-0.225% nacl-kcl Tier 1 dextrose 5%-0.3% nacl Tier 1 dextrose 5%-0.3% nacl-kcl Tier 1 dextrose 5%-0.33% nacl Tier 1 dextrose 5%-0.33% nacl-kcl Tier 1 dextrose 5%-0.45% nacl Tier 1 dextrose 5%-0.45% nacl-kcl Tier 1 dextrose 5%-0.9% nacl Tier 1 dextrose 5%-1/2ns-kcl Tier 1 dextrose 5%-1/4ns-kcl (d5%-1/4ns-kcl 40 iv Tier 1 sol, d5%-1/4ns-kcl 30 iv sol) dextrose 5%-electrolyte #48 Tier 1 dextrose 5%-ns-kcl Tier 1 55

64 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) dextrose 5%-potassium chloride Tier 1 FREAMINE HBC Tier 3 B/D PA FREAMINE III Tier 3 B/D PA HEPATAMINE Tier 1 B/D PA IONOSOL B WITH DEXTROSE 5% Tier 3 IONOSOL MB-DEXTROSE 5% Tier 3 ISOLYTE P WITH DEXTROSE Tier 3 ISOLYTE S Tier 3 KABIVEN Tier 3 B/D PA kcl 20 meq in d5w-lact ringer Tier 3 kcl 40 meq in d5w-lact ringer Tier 3 kcl-ns 1,000 ml iv soln Tier 1 KLOR-CON 10 Tier 1 KLOR-CON 20 MEQ PACKET (SELECT Tier 3 MANUFACTURERS ONLY) KLOR-CON 8 Tier 1 KLOR-CON M10 Tier 1 KLOR-CON M15 Tier 1 KLOR-CON M20 Tier 1 KLOR-CON SPRINKLE Tier 1 lactated ringers Tier 1 magnesium chl 200 mg/ml vial Tier 3 magnesium sulf 1 g/100 ml-d5w Tier 3 magnesium sulfate (2 g/50 ml bag, 4 g/50 ml Tier 3 bag, 4 g/100 ml bag, 20 g/500 ml bag, 40 g/1,000 ml) magnesium sulfate (50% syringe, 50% vial) Tier 1 NEPHRAMINE Tier 3 B/D PA NORMOSOL-M AND DEXTROSE Tier 3 NORMOSOL-R Tier 3 NORMOSOL-R AND DEXTROSE Tier 3 NORMOSOL-R PH 7.4 Tier 3 PERIKABIVEN Tier 3 B/D PA PHYSIOLYTE Tier 1 PHYSIOSOL Tier 1 PLASMA-LYTE 148 Tier 3 PLASMA-LYTE 56 IN DEXTROSE Tier 3 PLASMA-LYTE A PH 7.4 Tier 3 potassium chloride (2 meq/ml vial, er 8 meq tablet, er 8 meq capsule, 10 meq/50 ml sol, 10 meq/5 ml conc, 10% (20 meq/15ml), 10% (40 meq/30ml), 10 meq/100 ml sol, er 10 meq capsule, er 10 meq tablet, 20 meq/100 ml sol, 20% (40 meq/15ml), 20 meq/50 ml sol, 20 meq/10 ml conc, er 20 meq tablet, 30 meq/100 ml sol, 40 meq/100 ml sol, 40 meq/20 ml conc) Tier 1 56

65 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) potassium chloride proamp Tier 1 potassium citrate er Tier 1 potassium cl 20 meq packet (select Tier 3 manufacturers only) potassium cl 20 meq-0.45% nacl Tier 3 potassium cl 20meq/100ml-water Tier 1 PREMASOL Tier 3 B/D PA PREVIDENT % DRY MOUTH Tier 3 PREVIDENT 5000 ENAMEL PROTECT Tier 3 PREVIDENT 5000 SENSITIVE Tier 3 PROCALAMINE Tier 3 B/D PA PROSOL Tier 3 B/D PA RENACIDIN Tier 3 ringers injection Tier 1 ringers irrigation Tier 1 SF 1.1% GEL Tier 1 SF 5000 PLUS Tier 1 sodium chloride (saline 0.45% soln-excel con, Tier 1 saline 0.9% soln-excel cont, sodium chloride 0.45% soln, sodium chloride 0.45% solution, sodium chloride 0.9% 50 ml, sodium chloride 0.9% solution, sodium chloride 0.9% soln, sodium chloride 0.9% 1,000 ml, sodium chloride 0.9% irrig., sodium chloride 0.9% 100 ml, sodium chloride 0.9% 250 ml, sodium chloride 0.9% 500 ml, sodium chloride 3% iv soln, sodium chloride 4 meq/ml vl, sodium chloride 5% iv soln, sodium chloride 50 meq/20 ml, sodium chloride 100 meq/40 ml) sodium chloride-water Tier 1 sodium fluoride 1 mg oral tablet Tier 1 sodium lactate Tier 1 TIS-U-SOL PENTALYTE Tier 1 TPN ELECTROLYTES Tier 1 TRAVASOL Tier 3 B/D PA TROPHAMINE Tier 3 B/D PA ELECTROLYTE/MINERAL/METAL MODIFIERS CHEMET Tier 3 CUPRIMINE Tier 3 DEPEN Tier 3 EXJADE Tier 3 FERRIPROX (100 MG/ML SOLUTION, Tier MG TABLET) 57

66 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) JADENU Tier 3 JADENU SPRINKLE Tier 3 JYNARQUE Tier 3 QL (56 per 28 days) KIONEX (15 GM/60 ML SUSPENSION, Tier 1 POWDER) SAMSCA Tier 3 sodium polystyrene sulfonate (sod polystyren Tier 1 sulf 15 g/60 ml, sodium polystyrene sulf powder, sps 15 gm/60 ml suspension, sps 30 gm/120 ml enema, sps 50 gm/200 ml enema) SPS Tier 1 SYPRINE Tier 3 trientine hcl Tier 3 VELTASSA Tier 3 QL (30 per 30 days) PHOSPHATE BINDERS AURYXIA Tier 3 calcium acetate (667 mg capsule, 667 mg Tier 1 tablet, 667 mg gelcap) ELIPHOS Tier 1 FOSRENOL (500 MG TABLET CHEW, Tier MG TABLET CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER PACK, 1,000 MG TABLET CHEW) lanthanum carbonate Tier 3 PHOSLYRA Tier 3 RENVELA (0.8 GM POWDER PACKET, Tier GM POWDER PACKET) RENVELA 800 MG TABLET Tier 2 QL (270 per 30 days) sevelamer 0.8 gm powder packet Tier 3 QL (180 per 30 days) sevelamer 2.4 gm powder packet Tier 3 sevelamer carbonate 800 mg tab Tier 2 VITAMINS cyanocobalamin injection Tier 1 EX folic acid 1 mg tablet Tier 1 EX MEPHYTON Tier 3 EX phytonadione 5 mg tablet Tier 3 EX PRENATAL VITAMIN ORAL TABLET Tier 3 vit d mg (50,000 unit) Tier 1 EX GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml syringe, 0.5 mg/5 ml abboject, 1 mg/10 ml abboject) Tier 1 58

67 NAME GASTROINTESTINAL AGENTS (CONTINUED) BENTYL 10 MG/ML AMPUL Tier 3 dicyclomine 10 mg/5 ml soln Tier 2 dicyclomine hcl (10 mg capsule, 20 mg tablet) Tier 1 GLYCATE Tier 3 glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, Tier 1 1 mg/5 ml vial, 1 mg tablet, 2 mg tablet, 4 mg/20 ml vial) glycopyrrolate 1.5 mg tablet Tier 3 methscopolamine bromide Tier 1 GASTROINTESTINAL AGENTS, OTHER chlordiazepoxide/clidinium (select manufacturers only) Tier 3 diphenoxylate-atropine (diphenoxylat-atrop Tier /5, diphenoxylate-atrop ) GATTEX Tier 3 loperamide 2 mg capsule Tier 1 MOVANTIK Tier 2 QL (30 per 30 days) MYTESI Tier 3 OSMOPREP Tier 3 peg 3350-electrolyte solution Tier 1 PYLERA Tier 2 RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML VIAL, 12 MG/0.6 ML SYRINGE) Tier 3 QL (30 per 30 days) RELISTOR 150 MG TABLET Tier 3 QL (90 per 30 days) SUPREP Tier 3 SYMPROIC Tier 3 QL (30 per 30 days) TRILYTE WITH FLAVOR PACKETS Tier 1 ursodiol Tier 1 XIFAXAN Tier 3 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine (200 mg tablet, 300 mg/5 ml soln, 300 mg tablet, 400 mg tablet, 800 mg tablet) famotidine (20 mg tablet, 20 mg/2 ml vial, 20 mg piggyback, 40 mg/4 ml vial, 40 mg tablet, 200 mg/20 ml vial) nizatidine (15 mg/ml solution, 150 mg capsule, 300 mg capsule) ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 ml vial, 150 mg/10 ml syrup, 150 mg capsule, hcl 150 mg/6 ml vl, 300 mg capsule) Tier 1 Tier 1 Tier 1 Tier 2 ranitidine hcl (150 mg tablet, 300 mg tablet) Tier 1 59

68 NAME GASTROINTESTINAL AGENTS (CONTINUED) IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl Tier 3 QL (60 per 30 days) LINZESS Tier 2 QL (30 per 30 days) VIBERZI Tier 3 QL (60 per 30 days) LAXATIVES CLENPIQ Tier 3 CONSTULOSE Tier 1 ENULOSE Tier 1 GAVILYTE-C Tier 1 GAVILYTE-G Tier 1 GAVILYTE-H AND BISACODYL Tier 1 GAVILYTE-N Tier 1 GENERLAC Tier 1 KRISTALOSE Tier 3 lactulose (10 gm/15 ml solution, 20 gm/30 ml Tier 1 solution) MOVIPREP Tier 3 peg 3350 electrolyte soln Tier 1 peg-3350 and electrolytes Tier 1 PLENVU Tier 3 polyethylene glycol 3350 Tier 1 PROTECTANTS CARAFATE 1 GM/10 ML SUSP Tier 3 misoprostol Tier 1 sucralfate Tier 1 PROTON PUMP INHIBITORS DEXILANT Tier 3 esomeprazole magnesium (dr 20 mg cap, dr 40 Tier 1 QL (60 per 30 days) mg cap) esomeprazole sodium Tier 2 lansoprazole (dr 15 mg capsule, dr 30 mg Tier 1 QL (60 per 30 days) capsule) lansoprazole (odt 15 mg tablet, odt 30 mg Tier 3 QL (60 per 30 days) tablet) NEXIUM (DR 2.5 MG PACKET, DR 5 Tier 3 QL (60 per 30 days) MG PACKET, DR 10 MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET) omeprazole (dr 10 mg capsule, dr 40 mg Tier 1 QL (60 per 30 days) capsule) omeprazole dr 20 mg capsule Tier 1 QL (120 per 30 days) omeprazole-sodium bicarbonate (20-1,680 pkt, 20-1,100 cap, 40-1,100 cap, 40-1,680 pkt) Tier 3 QL (60 per 30 days) 60

69 NAME GASTROINTESTINAL AGENTS (CONTINUED) pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) Tier 1 QL (60 per 30 days) pantoprazole sodium 40 mg vial Tier 2 PRILOSEC DR SUSPENSION Tier 3 rabeprazole sodium Tier 1 QL (60 per 30 days) GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ADAGEN Tier 3 ALDURAZYME Tier 3 ARALAST NP Tier 3 BUPHENYL 500 MG TABLET Tier 3 CERDELGA Tier 3 QL (56 per 28 days) CEREZYME Tier 3 CHOLBAM Tier 3 CREON Tier 2 CYSTADANE Tier 3 CYSTAGON Tier 3 ELAPRASE Tier 3 ELELYSO Tier 3 EXONDYS 51 Tier 3 FABRAZYME Tier 3 GALAFOLD Tier 3 QL (14 per 28 days) GLASSIA Tier 3 KANUMA Tier 3 KRYSTEXXA Tier 3 KUVAN Tier 3 LUMIZYME Tier 3 miglustat Tier 3 NAGLAZYME Tier 3 OCALIVA Tier 3 QL (30 per 30 days) ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) Tier 3 PALYNZIQ Tier 3 PANCREAZE Tier 2 PROCYSBI Tier 3 PROLASTIN C Tier 3 RAVICTI Tier 3 sodium phenylbutyrate (500mg tb, powder) Tier 3 STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL) Tier 3 61

70 NAME GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (CONTINUED) STRENSIQ 80 MG/0.8 ML VIAL Tier 3 QL (38.4 per 28 days) SUCRAID Tier 3 VIMIZIM Tier 3 VPRIV Tier 3 ZAVESCA Tier 3 ZEMAIRA Tier 3 ZENPEP Tier 3 GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin er Tier 1 QL (30 per 30 days) flavoxate hcl Tier 1 GELNIQUE (10% GEL SACHET, 10% Tier 3 QL (30 per 30 days) GEL SACHETS, 10% GEL PUMP) GELNIQUE 3% GEL Tier 3 QL (276 per 30 days) MYRBETRIQ Tier 2 QL (30 per 30 days) oxybutynin chloride (5 mg tablet, 5 mg/5 ml Tier 1 syrup) oxybutynin chloride er Tier 1 QL (60 per 30 days) tolterodine tartrate Tier 1 tolterodine tartrate er Tier 1 QL (30 per 30 days) TOVIAZ Tier 3 QL (30 per 30 days) trospium chloride Tier 1 trospium chloride er Tier 1 QL (30 per 30 days) VESICARE Tier 2 QL (30 per 30 days) BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er Tier 1 QL (60 per 30 days) doxazosin mesylate Tier 1 dutasteride Tier 1 QL (30 per 30 days) dutasteride-tamsulosin Tier 1 QL (30 per 30 days) finasteride 5 mg tablet Tier 1 RAPAFLO Tier 2 tamsulosin hcl Tier 1 QL (60 per 30 days) GENITOURINARY AGENTS, OTHER bethanechol chloride Tier 1 CIALIS (10 MG TABLET, 20 MG TABLET) Tier 2 QL (6 per 30 days), (capped benefit)ex CIALIS (2.5 MG TABLET, 5 MG Tier 2 QL (30 per 30 days) TABLET) ELMIRON Tier 3 LEVITRA Tier 3 QL (6 per 30 days), (capped benefit)ex 62

71 NAME GENITOURINARY AGENTS (CONTINUED) LITHOSTAT Tier 3 sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) Tier 2 QL (6 per 30 days), (capped benefit)ex STAXYN Tier 3 QL (6 per 30 days), (capped benefit)ex STENDRA Tier 3 QL (6 per 30 days), (capped benefit)ex tadalafil 10 mg tablet (generic for cialis) Tier 2 QL (6 per 30 days), (capped benefit)ex tadalafil 2.5 mg tablet (generic for cialis) Tier 2 QL (30 per 30 days) tadalafil 20 mg tablet (generic for cialis) Tier 2 QL (6 per 30 days), (capped benefit)ex tadalafil 5 mg tablet (generic for cialis) Tier 2 QL (30 per 30 days) THIOLA Tier 3 VIAGRA Tier 3 QL (6 per 30 days), (capped benefit)ex HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/ MINERALOCORTICOIDS A-HYDROCORT Tier 1 B/D PA ALA-CORT Tier 1 alclometasone dipropionate Tier 1 amcinonide (0.1% ointment, 0.1% lotion, 0.1% Tier 2 cream) ANALPRAM HC (1% CREAM, 2.5%-1% Tier 1 LOTION) APEXICON E Tier 3 ARISTOSPAN Tier 3 B/D PA betamethasone diprop augmented (0.05% lot, Tier % oin, 0.05% crm, 0.05% gel) betamethasone dipropionate (0.05% oint, Tier % crm, 0.05% lot) betamethasone valer 0.12% foam Tier 2 betamethasone valerate (va 0.1% cream, va Tier 1 0.1% lotion, valer 0.1% ointm) CAPEX SHAMPOO Tier 3 CELESTONE Tier 3 clobetasol emollient 0.05% crm Tier 1 clobetasol emollnt 0.05% foam Tier 3 clobetasol emulsion Tier 3 clobetasol propionate (0.05% ointment, 0.05% Tier 1 cream, 0.05% topical lotn, 0.05% solution) clobetasol propionate (prop 0.05% foam, prop 0.05% spray, 0.05% gel, 0.05% shampoo) Tier 3 63

72 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) clocortolone pivalate Tier 1 CORDRAN (4 CM TAPE LARGE, 4 CM Tier 3 TAPE SMALL) CORTIFOAM Tier 3 cortisone acetate Tier 1 B/D PA DECADRON 0.5 MG/5 ML ELIXIR Tier 1 B/D PA DELTASONE Tier 1 B/D PA DEPO-MEDROL 20 MG/ML VIAL Tier 3 B/D PA DESONATE Tier 3 desonide (0.05% ointment, 0.05% lotion, Tier % cream) desoximetasone (0.05% gel, 0.05% cream, Tier % ointment, 0.25% cream, 0.25% ointment) desoximetasone 0.25% spray Tier 3 dexamethasone (0.5 mg/5 ml elx, 0.5 mg/5 ml Tier 1 B/D PA liq, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) dexamethasone (6 1.5 mg tab, mg tb, 13 Tier mg tb) DEXAMETHASONE INTENSOL Tier 1 dexamethasone sodium phosphate (4 mg/ml Tier 1 B/D PA vial, 4 mg/ml syringe, 10 mg/ml vial, 20 mg/5 ml vial, 100 mg/10 ml vl, 120 mg/30 ml vl) diflorasone diacetate Tier 3 EMFLAZA (22.75 MG/ML ORAL SUSP, Tier 3 30 MG TABLET, 36 MG TABLET) EMFLAZA 18 MG TABLET Tier 3 QL (30 per 30 days) EMFLAZA 6 MG TABLET Tier 3 QL (60 per 30 days) fludrocortisone acetate Tier 1 fluocinolone acetonide (0.01% solution, 0.01% Tier 1 scalp oil, 0.01% body oil, 0.01% cream, 0.025% ointment, 0.025% cream) fluocinonide (0.05% solution, 0.05% gel, Tier % cream, 0.05% ointment) fluocinonide 0.1% cream Tier 2 fluocinonide-e Tier 1 flurandrenolide (0.05% lotion, 0.05% cream, Tier % ointment) fluticasone prop 0.05% lotion Tier 2 64

73 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) fluticasone propionate (0.005% oint, 0.05% Tier 1 cream) H.P. ACTHAR Tier 3 halobetasol propionate Tier 1 HALOG Tier 3 hydrocort-pramoxine 1%-1% crm Tier 1 hydrocortisone (1% ointment, 1% cream, 1% Tier 1 absorbase, 2.5% ointment, 2.5% lotion, 2.5% cream) hydrocortisone (5 mg tablet, 10 mg tablet, 20 Tier 1 B/D PA mg tablet) hydrocortisone butyr 0.1% lotn Tier 3 hydrocortisone butyrate (hydrocort buty 0.1% Tier 1 lipid crm, hydrocort buty 0.1% lipo cream, hydrocortisone buty 0.1% cream, hydrocortisone butyr 0.1% oint, hydrocortisone butyr 0.1% soln) hydrocortisone valerate Tier 1 IMPOYZ Tier 3 KENALOG-10 Tier 3 KENALOG-40 Tier 3 LOCOID 0.1% LOTION Tier 3 LOCORT Tier 3 B/D PA MEDROL 2 MG TABLET Tier 3 B/D PA methylprednisolone Tier 1 B/D PA methylprednisolone acetate (40 mg/ml vl, 80 Tier 1 B/D PA mg/ml vl) methylprednisolone sodium succ (1 gm vl, 40 Tier 1 B/D PA mg vl, 125 mg) MICORT-HC Tier 3 mometasone furoate (0.1% soln, 0.1% oint, Tier 1 0.1% cream) NOLIX (0.05% CREAM, 0.05% LOTION) Tier 2 PANDEL Tier 3 PRAMOSONE (1% LOTION, 1%-1% Tier 1 CREAM, 2.5%-1% LOTION) prednicarbate Tier 1 prednisolone Tier 1 B/D PA prednisolone sodium phos odt Tier 1 prednisolone sodium phosphate (10 mg/5 ml soln, 20 mg/5 ml soln) Tier 3 B/D PA 65

74 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) prednisolone sodium phosphate (5 mg/5 ml Tier 1 B/D PA soln, 15 mg/5 ml soln, sod ph 25 mg/5 ml) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg/5 Tier 1 B/D PA ml solution, 5 mg tablet, 5 mg tab dose pack, 10 mg tab dose pack, 10 mg tablet, 20 mg tablet, 50 mg tablet) PREDNISONE INTENSOL Tier 1 B/D PA PROCTO-MED HC Tier 1 PROCTO-PAK Tier 1 PROCTOFOAM-HC Tier 3 PROCTOSOL-HC Tier 1 PROCTOZONE-HC Tier 1 RAYOS (DR 1 MG TABLET, DR 2 MG Tier 3 B/D PA TABLET, DR 5 MG TABLET) SERNIVO Tier 3 SOLU-CORTEF (100 MG VIAL, 250 MG Tier 3 B/D PA VIAL, 500 MG VIAL, 1,000 MG VIAL) SOLU-MEDROL (1 GRAM VIAL, 40 MG Tier 3 B/D PA VIAL, 125 MG VIAL, 500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) TAPERDEX (6 1.5 MG TABLET, Tier 3 B/D PA MG TABLET) TOPICORT 0.25% SPRAY Tier 3 triamcinolone mg/g topical spray Tier 2 triamcinolone acetonide (0.025% oint, 0.025% Tier 1 cream, 0.025% lotion, 0.1% cream, 0.1% ointment, 0.1% lotion, 0.5% ointment, 0.5% cream) triamcinolone acetonide (acet 40mg/ml vl, acet Tier 1 B/D PA 40 mg/ml vl, acet 50mg/5ml vl, 200 mg/5 ml vial, 400 mg/10 ml vl) TRIANEX Tier 1 TRIDERM Tier 1 U-CORT Tier 1 ZODEX (6 1.5 MG TABLET, MG Tier 3 B/D PA TABLET) ZONACORT Tier 3 B/D PA HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) chorionic gonadotropin Tier 3 desmopressin acetate (0.01% spray, 0.01% Tier 2 solution, 0.1 mg/ml sol, ac 4 mcg/ml ampul, ac 4 mcg/ml vial, 10 mcg/0.1 ml spr, 40 mcg/10 ml vial) 66

75 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) (CONTINUED) desmopressin acetate (0.1 mg tb, 0.2 mg tb) Tier 1 EGRIFTA Tier 3 GENOTROPIN (MINIQUICK 0.4 MG, Tier 3 MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE) GENOTROPIN MINIQUICK 0.2 MG Tier 2 HUMATROPE Tier 3 INCRELEX Tier 3 NOCTIVA Tier 3 NORDITROPIN FLEXPRO Tier 3 NOVAREL (5,000 UNIT VIAL, 10,000 Tier 3 UNITS VIAL) NUTROPIN AQ Tier 3 NUTROPIN AQ NUSPIN Tier 3 OMNITROPE (5 MG/1.5 ML CRTG, 5.8 Tier 3 MG VIAL, 10 MG/1.5 ML CRTG) PREGNYL Tier 3 SAIZEN Tier 3 SAIZEN-SAIZENPREP Tier 3 SEROSTIM Tier 3 STIMATE Tier 3 ZOMACTON Tier 3 ZORBTIVE Tier 3 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 Tier 3 oxandrolone 10 mg tablet Tier 3 oxandrolone 2.5 mg tablet Tier 2 ANDROGENS ANDRODERM Tier 2 QL (30 per 30 days) ANDROGEL (1%(2.5G) GEL PACKET, Tier 2 QL (300 per 30 days) 1%(5G) GEL PACKET) ANDROGEL (1.62% GEL PUMP, Tier 2 QL (150 per 30 days) 1.62%(2.5G) GEL PCKT) ANDROGEL 1.62%(1.25G) GEL PCKT Tier 2 QL (38 per 30 days) ANDROXY Tier 1 67

76 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) AXIRON Tier 3 QL (180 per 30 days) danazol Tier 1 FORTESTA Tier 3 QL (120 per 30 days) METHITEST Tier 3 methyltestosterone Tier 2 NATESTO Tier 3 STRIANT Tier 3 QL (60 per 30 days) TESTIM Tier 3 QL (300 per 30 days) testosterone (12.5 mg/1.25 gram, 25 mg/2.5 Tier 3 QL (300 per 30 days) gm pkt, 50 mg/5 gram gel, 50 mg/5 gram pkt) testosterone 10 mg gel pump Tier 3 QL (120 per 30 days) testosterone 30 mg/1.5 ml pump Tier 3 QL (180 per 30 days) testosterone cypionate Tier 1 testosterone enanthate Tier 1 VOGELXO Tier 3 QL (300 per 30 days) ESTROGENS ALORA Tier 3 QL (8 per 28 days) ALTAVERA Tier 1 ALYACEN Tier 1 AMABELZ Tier 1 AMETHIA Tier 1 AMETHIA LO Tier 1 ANGELIQ Tier 3 APRI Tier 1 ARANELLE Tier 1 ASHLYNA Tier 1 AUBRA Tier 1 AVIANE Tier 1 AZURETTE Tier 1 BALZIVA Tier 1 BEKYREE Tier 1 BLISOVI 24 FE Tier 1 BLISOVI FE (1-20 TABLET, Tier 1 TABLET) BRIELLYN Tier 1 CAMRESE Tier 1 CAMRESE LO Tier 1 CAZIANT Tier 1 CHATEAL Tier 1 68

77 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) CLIMARA Tier 3 QL (4 per 28 days) CLIMARA PRO Tier 3 QL (4 per 28 days) COMBIPATCH Tier 3 QL (8 per 28 days) CRYSELLE Tier 1 CYCLAFEM Tier 1 CYRED Tier 1 DASETTA Tier 1 DAYSEE Tier 1 DELESTROGEN 10 MG/ML VIAL Tier 3 DELYLA Tier 1 DEPO-ESTRADIOL Tier 3 desogestr-eth estrad eth estra Tier 1 desogestrel-ethinyl estradiol Tier 1 DIVIGEL (0.25 MG GEL PACKET, 0.5 Tier 3 MG GEL PACKET, 1 MG GEL PACKET) drospirenone-eth estra-levomef Tier 3 drospirenone-ethinyl estradiol Tier 1 DUAVEE Tier 3 ELESTRIN Tier 3 ELINEST Tier 1 EMOQUETTE Tier 1 ENPRESSE Tier 1 ENSKYCE Tier 1 ESTARYLLA Tier 1 ESTRACE 0.01% CREAM Tier 3 estradiol (0.01% cream, 0.5 mg tablet, 1 mg Tier 1 tablet, 2 mg tablet, 10 mcg vaginal insrt) estradiol twice weekly Tier 1 QL (8 per 28 days) estradiol valerate Tier 1 estradiol weekly Tier 1 QL (4 per 28 days) estradiol-norethindrone acetat Tier 1 ESTRING Tier 3 QL (1 per 90 days) estropipate Tier 1 ethynodiol-ethinyl estradiol Tier 1 EVAMIST Tier 3 FALMINA Tier 1 FAYOSIM Tier 3 FEMRING Tier 3 QL (1 per 90 days) FEMYNOR Tier 1 69

78 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) FYAVOLV Tier 1 GIANVI Tier 1 GILDAGIA Tier 1 GILDESS 24 FE Tier 1 INTROVALE Tier 1 ISIBLOOM Tier 1 JEVANTIQUE LO Tier 1 JINTELI Tier 1 JOLESSA Tier 1 JULEBER Tier 1 JUNEL (1 MG-20 MCG TABLET, 1.5 MG- Tier 1 30 MCG TABLET) JUNEL FE (1 MG-20 MCG TABLET, 1.5 Tier 1 MG-30 MCG TABLET) JUNEL FE 24 Tier 1 KAITLIB FE Tier 1 KARIVA Tier 1 KELNOR 1-35 Tier 1 KELNOR 1-50 Tier 1 KIMIDESS Tier 1 KURVELO Tier 1 LARIN (1.5 MG-30 MCG TABLET, Tier 1 TABLET) LARIN 24 FE Tier 1 LARIN FE (1-20 TABLET, Tier 1 TABLET) LARISSIA Tier 1 LEENA Tier 1 LESSINA Tier 1 LEVONEST Tier 1 levonorg 0.15mg-ee mcg Tier 3 levonorg-eth estrad eth estrad ( , Tier ) levonorgestrel-eth estradiol (estra Tier 1 mg, estrad mg, estrad ) LEVORA-28 Tier 1 LO LOESTRIN FE Tier 3 LOMEDIA 24 FE Tier 1 LOPREEZA Tier 3 LORYNA Tier 1 70

79 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) LOW-OGESTREL Tier 1 LUTERA Tier 1 MARLISSA Tier 1 MELODETTA 24 FE Tier 1 MENEST Tier 3 MIBELAS 24 FE Tier 1 MICROGESTIN ( TABLET, Tier 1 30 TAB) MICROGESTIN FE (1-20 TABLET, Tier 1 TAB) MILI Tier 1 MIMVEY LO Tier 1 MINASTRIN 24 FE Tier 3 MONO-LINYAH Tier 1 MONONESSA Tier 1 MYZILRA Tier 1 NATAZIA Tier 3 NECON Tier 1 NIKKI Tier 1 noreth-estrad-fe (24)-75 Tier 3 norethin-eth estra-ferrous fum Tier 1 norethindron-ethinyl estradiol Tier 1 norgestimate-ethinyl estradiol Tier 1 NORTREL Tier 1 NUVARING Tier 3 OCELLA Tier 1 OGESTREL Tier 1 ORSYTHIA Tier 1 PHILITH Tier 1 PIMTREA Tier 1 PIRMELLA Tier 1 PORTIA Tier 1 PREFEST Tier 3 PREMARIN (0.3 MG TABLET, 0.45 MG Tier 2 TABLET, MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, 25 MG VIAL, VAGINAL CREAM-APPL) PREMPHASE Tier 2 PREMPRO Tier 2 PREVIFEM Tier 1 71

80 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) QUARTETTE Tier 3 QUASENSE Tier 1 RAJANI Tier 1 RECLIPSEN Tier 1 RIVELSA Tier 3 SAFYRAL Tier 3 SETLAKIN Tier 1 SPRINTEC Tier 1 SRONYX Tier 1 SYEDA Tier 3 TARINA FE Tier 1 TAYTULLA Tier 3 TILIA FE Tier 1 TRI-ESTARYLLA Tier 1 TRI-LEGEST FE Tier 1 TRI-LINYAH Tier 1 TRI-LO-ESTARYLLA Tier 1 TRI-LO-MARZIA Tier 1 TRI-LO-SPRINTEC Tier 1 TRI-MILI Tier 1 TRI-PREVIFEM Tier 1 TRI-SPRINTEC Tier 1 TRI-VYLIBRA Tier 1 TRINESSA Tier 1 TRIVORA-28 Tier 1 TYDEMY Tier 3 VELIVET Tier 1 VESTURA Tier 1 VIENVA Tier 1 VIORELE Tier 1 VIVELLE-DOT Tier 3 QL (8 per 28 days) VYFEMLA Tier 1 VYLIBRA Tier 1 WERA Tier 1 WYMZYA FE Tier 1 XULANE Tier 1 YUVAFEM Tier 1 ZARAH Tier 1 ZENCHENT Tier 1 72

81 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) ZENCHENT FE Tier 1 ZOVIA 1-35E Tier 1 ZOVIA 1-50E Tier 1 PROGESTERONE AGONISTS/ANTAGONISTS ELLA Tier 2 PROGESTINS CAMILA Tier 1 DEBLITANE Tier 1 DEPO-SUBQ PROVERA 104 Tier 3 ERRIN Tier 1 HEATHER Tier 1 hydroxyprogesterone 1.25 g/5ml Tier 3 INCASSIA Tier 1 JENCYCLA Tier 1 JOLIVETTE Tier 1 KYLEENA Tier 3 LILETTA Tier 3 LYZA Tier 1 medroxyprogesterone acetate (2.5 mg tab, 5 Tier 1 mg tab, 10 mg tab, 150 mg/ml) megestrol 625 mg/5 ml susp Tier 2 megestrol acetate (20 mg tablet, 40 mg tablet, Tier 1 acet 40 mg/ml susp, acet 400 mg/10 ml) MIRENA Tier 3 NORA-BE Tier 1 norethindrone Tier 1 norethindrone ac (lupaneta) Tier 1 norethindrone acetate Tier 1 NORLYROC Tier 1 progesterone (100 mg capsule, 200 mg Tier 1 capsule) SHAROBEL Tier 1 SKYLA Tier 3 SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS raloxifene hcl Tier 2 QL (30 per 30 days) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) CYTOMEL Tier 3 levothyroxine sodium (25 mcg tablet, 50 mcg Tier 1 tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 100 mcg vial, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) 73

82 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) (CONTINUED) LEVOXYL Tier 1 liothyronine sodium (5 mcg tab, 10 mcg/ml vl, Tier 1 25 mcg tab, 50 mcg tab) SYNTHROID Tier 2 THYROLAR-1 Tier 3 THYROLAR-1/2 Tier 3 THYROLAR-1/4 Tier 3 THYROLAR-2 Tier 3 THYROLAR-3 Tier 3 UNITHROID Tier 1 HORMONAL AGENTS, SUPPRESSANT (ADRENAL) HORMONAL AGENTS, SUPPRESSANT (ADRENAL) LYSODREN Tier 2 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) bromocriptine mesylate Tier 1 cabergoline Tier 1 ELIGARD Tier 3 leuprolide acetate (2wk 1 mg/0.2 ml kit, 2wk Tier 1 14 mg/2.8 ml kt) LUPRON DEPOT Tier 3 LUPRON DEPOT (LUPANETA) Tier 3 LUPRON DEPOT-PED Tier 3 octreotide acetate (acet 0.05 mg/ml vl, acet 50 Tier 2 mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml vl, acet 100 mcg/ml syr, acet 200 mcg/ml vl, 1,000 mcg/5 ml vial) octreotide acetate (acet 500 mcg/ml amp, acet Tier mcg/ml syr, acet 500 mcg/ml vl, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial) ORILISSA 150 MG TABLET Tier 3 QL (28 per 28 days) ORILISSA 200 MG TABLET Tier 3 QL (56 per 28 days) SANDOSTATIN LAR Tier 3 SANDOSTATIN LAR DEPOT Tier 3 SIGNIFOR LAR Tier 3 QL (1 per 28 days) SOMATULINE DEPOT Tier 3 SOMAVERT Tier 3 SYNAREL Tier 3 TRELSTAR Tier 3 74

83 NAME HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (CONTINUED) TRIPTODUR Tier 3 HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole Tier 1 propylthiouracil Tier 1 IMMUNOLOGICAL AGENTS ANGIOEDEMA AGENTS BERINERT 500 UNIT KIT Tier 3 CINRYZE Tier 3 FIRAZYR Tier 3 HAEGARDA Tier 3 QL (16 per 28 days) RUCONEST Tier 3 TAKHZYRO Tier 3 QL (4 per 28 days) IMMUNE SUPPRESSANTS ACTEMRA (162 MG/0.9 ML SYRINGE, Tier MG/10 ML VIAL) ASTAGRAF XL Tier 3 B/D PA AZASAN Tier 3 B/D PA azathioprine Tier 1 B/D PA azathioprine sodium Tier 3 B/D PA BENLYSTA (120 MG VIAL, 400 MG Tier 3 VIAL) BENLYSTA (200 MG/ML SYRINGE, 200 Tier 3 QL (4 per 28 days) MG/ML AUTOINJECT) CELLCEPT (200 MG/ML ORAL SUSP, 250 Tier 3 B/D PA MG CAPSULE, 500 MG TABLET, 500 MG VIAL) CIMZIA Tier 3 QL (6 per 28 days) cyclosporine (25 mg capsule, 50 mg/ml ampul, Tier 1 B/D PA 100 mg capsule) cyclosporine modified (25 mg, 50 mg, Tier 1 B/D PA 100mg/ml, 100 mg) ENBREL (25 MG/0.5 ML SYRINGE, 50 Tier 3 QL (8 per 28 days) MG/ML SYRINGE) ENBREL 25 MG KIT Tier 3 QL (16 per 28 days) ENBREL MINI Tier 3 QL (8 per 28 days) ENBREL SURECLICK Tier 3 QL (8 per 28 days) ENVARSUS XR Tier 3 B/D PA GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG/ML SOLUTION, 100 MG CAPSULE) Tier 1 B/D PA 75

84 NAME IMMUNOLOGICAL AGENTS (CONTINUED) HUMIRA (10 MG/0.2 ML SYRINGE, 10 MG/0.1 ML SYRINGE) HUMIRA (20 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) Tier 3 Tier 3 QL (2 per 28 days) QL (6 per 28 days) HUMIRA PED CROHNS 80 MG/0.8 ML Tier 3 QL (3 per 28 days) HUMIRA PEDIATRIC CROHN'S (PED CROHNS 40 MG/0.8 ML, PEDIATR CROHN'S 80-40MG) Tier 3 QL (6 per 28 days) HUMIRA PEN Tier 3 QL (6 per 28 days) HUMIRA PEN CROHN-UC-HS 40 MG Tier 3 QL (6 per 28 days) HUMIRA PEN CROHN-UC-HS 80 MG Tier 3 QL (3 per 28 days) HUMIRA PEN PSOR-UVEI 80MG-40MG Tier 3 QL (3 per 28 days) HUMIRA PEN PSORIA-UVEITIS 40MG Tier 3 QL (6 per 28 days) INFLECTRA Tier 3 methotrexate (1 gm vial, 2.5 mg tablet, 50 Tier 1 B/D PA mg/2 ml vial, 250 mg/10 ml vial) methotrexate sodium Tier 1 B/D PA mycophenolate 200 mg/ml susp Tier 2 B/D PA mycophenolate 500 mg vial Tier 3 B/D PA mycophenolate mofetil (250 mg capsule, 500 Tier 1 B/D PA mg tablet) mycophenolic acid Tier 3 B/D PA MYFORTIC Tier 3 B/D PA NEORAL (25 MG GELATIN CAPSULE, 100 MG/ML SOLUTION, 100 MG GELATIN CAPSULE) Tier 3 B/D PA NULOJIX Tier 3 ORENCIA (125 MG/ML SYRINGE, 250 Tier 3 MG VIAL) ORENCIA 50 MG/0.4 ML SYRINGE Tier 3 QL (1.6 per 28 days) ORENCIA 87.5 MG/0.7 ML SYRINGE Tier 3 QL (2.8 per 28 days) ORENCIA CLICKJECT Tier 3 QL (4 per 28 days) POTELIGEO Tier 3 PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE, 5 MG/ML AMPULE) Tier 3 PROLIA Tier 3 RAPAMUNE (0.5 MG TABLET, 1 Tier 3 MG/ML ORAL SOLN, 1 MG TABLET, 2 MG TABLET) REMICADE Tier 3 B/D PA B/D PA 76

85 NAME IMMUNOLOGICAL AGENTS (CONTINUED) RENFLEXIS Tier 3 SANDIMMUNE (25 MG CAPSULE, 50 Tier 3 B/D PA MG/ML AMPUL, 100 MG CAPSULE, 100 MG/ML SOLN) SIMPONI Tier 3 QL (1 per 28 days) SIMPONI ARIA Tier 3 sirolimus Tier 1 B/D PA SOLIRIS Tier 3 STELARA Tier 3 tacrolimus (0.5 mg capsule, 1 mg capsule, 5 Tier 1 B/D PA mg capsule) TREMFYA Tier 3 XATMEP Tier 3 B/D PA XELJANZ Tier 3 QL (60 per 30 days) XELJANZ XR Tier 3 QL (30 per 30 days) ZORTRESS (0.25 MG TABLET, 0.5 MG Tier 3 B/D PA TABLET, 0.75 MG TABLET) IMMUNIZING AGENTS, PASSIVE ATGAM Tier 3 BIVIGAM Tier 3 CARIMUNE NF NANOFILTERED Tier 3 CUVITRU Tier 3 FLEBOGAMMA DIF Tier 3 GAMMAGARD LIQUID Tier 3 GAMMAGARD S-D Tier 3 GAMMAKED Tier 3 GAMMAPLEX Tier 3 GAMUNEX-C Tier 3 HIZENTRA Tier 3 HYQVIA Tier 3 OCTAGAM Tier 3 PRIVIGEN Tier 3 THYMOGLOBULIN Tier 3 IMMUNOMODULATORS ACTIMMUNE Tier 3 ARCALYST Tier 3 DUPIXENT 300 MG/2 ML SAFE SYRG Tier 3 QL (8 per 28 days) ILARIS Tier 3 KINERET Tier 3 leflunomide Tier 1 77

86 NAME IMMUNOLOGICAL AGENTS (CONTINUED) OTEZLA Tier 3 QL (60 per 30 days) RIDAURA Tier 3 SIMULECT Tier 3 SYLVANT Tier 3 TAVALISSE Tier 3 QL (60 per 30 days) XOLAIR Tier 3 VACCINES ACTHIB Tier 3 ADACEL TDAP Tier 3 bcg (tice strain) Tier 3 bcg vaccine (tice strain) Tier 3 BEXSERO Tier 3 BOOSTRIX TDAP Tier 3 DAPTACEL DTAP Tier 3 diphtheria-tetanus toxoids-ped Tier 3 ENGERIX-B ADULT (20 MCG/ML Tier 3 B/D PA SYRN, 20 MCG/ML VIAL) ENGERIX-B PEDIATRIC-ADOLESCENT Tier 3 B/D PA GARDASIL Tier 3 GARDASIL 9 Tier 3 HAVRIX Tier 3 HIBERIX Tier 3 IMOVAX RABIES VACCINE Tier 3 B/D PA INFANRIX DTAP Tier 3 IPOL Tier 3 IXIARO Tier 3 KINRIX Tier 3 M-M-R II VACCINE Tier 3 MENACTRA Tier 3 MENHIBRIX Tier 3 MENOMUNE-A-C-Y-W-135 Tier 3 MENVEO A-C-Y-W-135-DIP Tier 3 PEDIARIX Tier 3 PEDVAXHIB Tier 3 PENTACEL Tier 3 PENTACEL ACTHIB COMPONENT Tier 3 PROQUAD Tier 3 QUADRACEL DTAP-IPV Tier 3 RABAVERT Tier 3 B/D PA RECOMBIVAX HB (5 MCG/0.5 ML VL, 5 MCG/0.5 ML SYR, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL) Tier 3 B/D PA 78

87 NAME IMMUNOLOGICAL AGENTS (CONTINUED) ROTARIX Tier 3 ROTATEQ Tier 3 SHINGRIX Tier 2 STAMARIL Tier 3 TENIVAC Tier 3 tetanus diphtheria toxoids Tier 3 TRUMENBA Tier 3 TWINRIX Tier 3 TYPHIM VI Tier 3 VAQTA Tier 3 VARIVAX VACCINE Tier 3 YF-VAX Tier 3 ZOSTAVAX Tier 2 INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES ASACOL HD Tier 2 balsalazide disodium Tier 1 CANASA Tier 3 DELZICOL Tier 2 DIPENTUM Tier 3 GIAZO Tier 3 LIALDA Tier 2 QL (120 per 30 days) mesalamine (4 gm/60 ml enema, 4 gm/60 ml Tier 1 kit) mesalamine 800 mg dr tablet Tier 3 mesalamine dr 1.2 gm tablet Tier 1 QL (120 per 30 days) PENTASA Tier 2 GLUCOCORTICOIDS budesonide ec Tier 3 budesonide er Tier 3 QL (30 per 30 days) COLOCORT Tier 1 CORTENEMA Tier 3 hydrocortisone 100 mg/60 ml Tier 1 UCERIS 2 MG RECTAL FOAM Tier 3 UCERIS 9 MG ER TABLET Tier 3 QL (30 per 30 days) SULFONAMIDES sulfasalazine Tier 1 sulfasalazine dr Tier 1 79

88 NAME METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS alendronate sod 70 mg/75 ml Tier 1 QL (300 per 28 days) alendronate sodium (35 mg tab, 70 mg tab) Tier 1 QL (4 per 28 days) alendronate sodium (5 mg tablet, 10 mg tab, Tier 1 QL (30 per 30 days) 40 mg tab) calcitonin-salmon Tier 1 calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 Tier 1 mcg/ml ampul, 1 mcg/ml solution) doxercalciferol (0.5 mcg cap, 1 mcg capsule, Tier mcg cap, 4 mcg/2 ml vl, 4 mcg/2 ml amp) etidronate disodium Tier 1 FORTEO Tier 3 QL (3 per 28 days) FORTICAL Tier 1 HECTOROL (0.5 MCG CAPSULE, 1 MCG Tier 3 CAPSULE, 2 MCG/ML VIAL, 2.5 MCG CAPSULE, 4 MCG/2 ML VIAL) ibandronate sodium (3 mg/3 ml vial, 3 mg/3 ml Tier 1 syringe, sodium 150 mg tab) MIACALCIN (200 UNIT/ML VIAL, 400 Tier 3 UNIT/2 ML VIAL) NATPARA Tier 3 QL (30 per 30 days) pamidronate disodium (disod 30 mg vial, 30 Tier 1 mg/10 ml vial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90 mg vial) paricalcitol (1 mcg capsule, 2 mcg capsule, 4 Tier 1 mcg capsule) paricalcitol (2 mcg/ml vial, 5 mcg/ml vial, 10 Tier 3 mcg/2 ml vial) PARSABIV Tier 3 RAYALDEE Tier 3 QL (60 per 30 days) risedronate sodium (5 mg tablet, 30 mg tab) Tier 1 QL (30 per 30 days) risedronate sodium 150 mg tab Tier 1 QL (1 per 28 days) risedronate sodium 35 mg tab Tier 1 QL (4 per 28 days) risedronate sodium dr Tier 1 QL (4 per 28 days) ROCALTROL (0.25 MCG CAPSULE, 0.5 Tier 3 MCG CAPSULE, 1 MCG/ML ORAL SOLN) SENSIPAR (60 MG TABLET, 90 MG Tier 3 TABLET) SENSIPAR 30 MG TABLET Tier 2 TYMLOS Tier 3 QL (2 per 30 days) XGEVA Tier 3 80

89 NAME METABOLIC BONE DISEASE AGENTS (CONTINUED) ZEMPLAR (1 MCG CAPSULE, 2 MCG Tier 3 CAPSULE, 2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL) zoledronic acid (4 mg/5 ml vial, 4 mg vial, 5 Tier 3 mg/100 ml) ZOMETA 4 MG/100 ML INJECTION Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS alcohol pads Tier 3 amifostine Tier 3 aminocaproic acid (500 mg tab, 1,000 mg tab) Tier 3 autopen Tier 3 BOTOX Tier 3 CARNITOR 1 GM/5 ML VIAL Tier 3 CHENODAL Tier 3 clomiphene citrate Tier 3 CUROSURF Tier 3 CYTOGAM Tier 3 deferoxamine mesylate Tier 1 DESFERAL Tier 3 DESFERAL MESYLATE Tier 3 dextrose in lactated ringers Tier 1 dextrose in water Tier 1 ENDARI Tier 3 QL (180 per 30 days) fomepizole Tier 3 gauze pads 2 x 2 Tier 3 glucose in water Tier 1 GRASTEK Tier 3 humapen luxura hd Tier 3 inpen (for humalog) Tier 3 inpen (for novolog) Tier 3 insulin pen needle Tier 3 insulin pen needle, safety Tier 3 insulin syringe (bd syringe 1 ml, syringe) Tier 3 insulin syringe u-500 Tier 3 INTRALIPID Tier 3 B/D PA KALBITOR Tier 3 KEVEYIS Tier 3 QL (120 per 30 days) KORLYM Tier 3 QL (120 per 30 days) levocarnitine (1 g/10 ml soln, 200 mg/ml vial, 330 mg tablet) Tier 1 81

90 NAME MISCELLANEOUS THERAPEUTIC AGENTS (CONTINUED) methylergonovine 0.2 mg tablet Tier 3 METOPIRONE Tier 3 MYALEPT Tier 3 novopen echo Tier 3 NUTRILIPID Tier 3 B/D PA ONPATTRO Tier 3 ORALAIR (300 IR SUBLINGUAL TAB, Tier IR ADULT SAMPLE KT, 300 IR STARTER PACK) RADICAVA Tier 3 RAGWITEK Tier 3 SIGNIFOR Tier 3 SMOFLIPID Tier 3 B/D PA sterile water for irrigation Tier 1 SYNAGIS Tier 3 vgo 20 Tier 3 vgo 30 Tier 3 vgo 40 Tier 3 XERMELO Tier 3 QL (90 per 30 days) OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER atropine 1% eye drops Tier 1 CYSTARAN Tier 3 EYLEA Tier 3 JETREA 1.25 MG/ML VIAL Tier 3 LACRISERT Tier 3 LUCENTIS Tier 3 MACUGEN Tier 3 proparacaine hcl Tier 1 RESTASIS Tier 2 RESTASIS MULTIDOSE Tier 2 sulfacetamide 10% eye ointment Tier 1 OPHTHALMIC ANTI-ALLERGY AGENTS ALOCRIL Tier 3 ALOMIDE Tier 3 azelastine hcl 0.05% drops Tier 1 BEPREVE Tier 3 cromolyn 4% eye drops Tier 1 EMADINE Tier 3 epinastine hcl Tier 1 82

91 NAME OPHTHALMIC AGENTS (CONTINUED) olopatadine hcl 0.1% eye drops Tier 1 olopatadine hcl 0.2% eye drop Tier 2 OPHTHALMIC ANTI-INFLAMMATORIES ACUVAIL Tier 3 ALREX Tier 3 BLEPHAMIDE Tier 3 BLEPHAMIDE S.O.P. Tier 3 bromfenac sodium Tier 1 CORTISPORIN OINTMENT Tier 3 dexamethasone 0.1% eye drop Tier 1 diclofenac 0.1% eye drops Tier 1 DUREZOL Tier 2 FLAREX Tier 3 fluorometholone Tier 1 flurbiprofen sodium Tier 1 FML FORTE Tier 3 FML S.O.P. Tier 3 ILEVRO Tier 2 ketorolac tromethamine (0.4% solution, 0.5% Tier 1 solution) LOTEMAX (0.5% OPHTHALMIC GEL, Tier 2 0.5% EYE OINTMENT, 0.5% EYE DROPS) MAXIDEX Tier 3 neomycin-polymyxin-dexameth (neomycpolym-dexamet Tier 1 ointm, neomyc-polym- dexameth drop) NEVANAC Tier 2 PRED MILD Tier 3 PRED-G (1% DROPS, S.O.P. OINTMENT) Tier 3 prednisolone ac 1% eye drop Tier 1 prednisolone sod 1% eye drop Tier 1 sulfacetamide-prednisolone Tier 1 TOBRADEX EYE OINTMENT Tier 3 TOBRADEX ST Tier 3 tobramycin-dexamethasone Tier 1 ZYLET Tier 3 OPHTHALMIC ANTIGLAUCOMA AGENTS acetazolamide Tier 1 ALPHAGAN P 0.1% DROPS Tier 3 apraclonidine hcl Tier 1 83

92 NAME OPHTHALMIC AGENTS (CONTINUED) AZOPT Tier 3 betaxolol hcl 0.5% eye drop Tier 1 BETIMOL Tier 3 BETOPTIC S Tier 3 brimonidine tartrate Tier 1 carteolol hcl Tier 1 COMBIGAN Tier 3 COSOPT PF Tier 3 QL (60 per 30 days) dorzolamide hcl Tier 1 QL (10 per 25 days) dorzolamide-timolol 2%-0.5% Tier 1 dorzolamide-timolol eye drops Tier 1 QL (10 per 25 days) IOPIDINE 1% EYE DROPS Tier 3 ISTALOL Tier 3 levobunolol hcl Tier 1 metipranolol Tier 1 PHOSPHOLINE IODIDE Tier 3 pilocarpine hcl (1% drops, 2% drops, 4% Tier 1 drops) SIMBRINZA Tier 3 timolol 0.25% eye drops Tier 1 timolol 0.25% gel-solution Tier 1 timolol 0.5% eye drops (generic for istalol) Tier 3 timolol 0.5% eye drops (generic for timoptic) Tier 1 timolol 0.5% gel-solution Tier 1 TIMOPTIC OCUDOSE Tier 3 OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost 0.03% eye drops Tier 1 QL (7.5 per 25 days) latanoprost 0.005% eye drops Tier 1 LUMIGAN Tier 2 QL (7.5 per 25 days) TRAVATAN Z Tier 2 QL (5 per 25 days) ZIOPTAN Tier 3 QL (30 per 30 days) OTIC AGENTS OTIC AGENTS ACETASOL HC Tier 1 acetic acid 2% ear solution Tier 1 acetic acid-aluminum Tier 1 CIPRO HC Tier 3 CIPRODEX Tier 3 COLY-MYCIN S Tier 3 fluocinolone acetonide oil Tier 1 84

93 NAME OTIC AGENTS (CONTINUED) hydrocortisone-acetic acid Tier 2 neomycin-polymyxin-hc ear susp Tier 1 neomycin-polymyxin-hydrocort Tier 1 OTOVEL Tier 3 RESPIRATORY TRACT AGENTS RESPIRATORY TRACT AGENTS, OTHER ADVAIR DISKUS Tier 2 QL (60 per 30 days) ADVAIR HFA Tier 2 QL (12 per 30 days) BREO ELLIPTA Tier 2 QL (60 per 30 days) DULERA Tier 2 QL (13 per 30 days) SYMBICORT Tier 2 QL (11 per 30 days) RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA Tier 2 QL (30 per 30 days) ASMANEX Tier 2 QL (1 per 30 days) ASMANEX HFA Tier 2 QL (13 per 30 days) budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml Tier 2 B/D PA, QL (120 per 30 days) susp, 1 mg/2 ml inh susp) budesonide 32 mcg nasal spray Tier 1 QL (17.2 per 30 days) FLOVENT 250 MCG DISKUS Tier 2 QL (240 per 30 days) FLOVENT DISKUS (50 MCG, 100 MCG) Tier 2 QL (60 per 30 days) FLOVENT HFA Tier 2 QL (24 per 30 days) flunisolide Tier 1 QL (50 per 30 days) fluticasone prop 50 mcg spray Tier 1 QL (16 per 30 days) mometasone furoate 50 mcg spry Tier 1 QL (34 per 30 days) PULMICORT RESPULE Tier 3 B/D PA, QL (120 per 30 days) QVAR Tier 2 QL (17.4 per 30 days) QVAR REDIHALER 40 MCG Tier 2 QL (10.6 per 30 days) QVAR REDIHALER 80 MCG Tier 2 QL (21.2 per 30 days) triamcinolone 55 mcg nasal spr Tier 1 QL (16.5 per 25 days) ANTIHISTAMINES ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) Tier 1 azelastine hcl (0.1% (137 mcg) spry, 0.15% Tier 1 QL (30 per 25 days) nasal spray) carbinoxamine maleate 4 mg tab Tier 1 clemastine fum 2.68 mg tab Tier 1 cyproheptadine hcl (2 mg/5 ml syrup, 4 mg Tier 1 tablet, 4 mg/10 ml syrp) desloratadine Tier 1 QL (30 per 30 days) 85

94 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) diphenhydramine hcl (50 mg/ml syrng, 50 Tier 1 mg/ml vial) hydroxyzine hcl (hcl 10 mg tablet, 10 mg/5 ml Tier 2 soln, 10 mg/5 ml syrup, hcl 25 mg tablet, 25 mg/ml vial, 50 mg/ml vial, hcl 50 mg tablet, 50 mg/25 ml syrup, 100 mg/2 ml vial, 500 mg/10 ml vial) levocetirizine 2.5 mg/5 ml sol Tier 1 QL (300 per 30 days) levocetirizine 5 mg tablet Tier 1 QL (60 per 30 days) olopatadine 665 mcg nasal spry Tier 2 QL (31 per 30 days) promethazine vc Tier 1 SEMPREX-D Tier 3 ANTILEUKOTRIENES montelukast sod 4 mg granules Tier 1 montelukast sodium (4 mg tab chew, 5 mg tab Tier 1 QL (30 per 30 days) chew, 10 mg tablet) zafirlukast Tier 1 QL (60 per 30 days) zileuton er Tier 3 QL (120 per 30 days) ZYFLO Tier 3 ZYFLO CR Tier 3 QL (120 per 30 days) BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA Tier 3 QL (25.8 per 30 days) COMBIVENT RESPIMAT Tier 3 QL (8 per 30 days) ipratropium br 0.02% soln Tier 1 B/D PA ipratropium bromide (0.03% spray, 0.06% Tier 1 spray) ipratropium-albuterol Tier 1 B/D PA SPIRIVA Tier 2 QL (30 per 30 days) SPIRIVA RESPIMAT Tier 2 QL (4 per 30 days) STIOLTO RESPIMAT Tier 2 QL (4 per 30 days) TUDORZA PRESSAIR Tier 2 QL (1 per 30 days) BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) aminophylline Tier 1 ELIXOPHYLLIN Tier 3 THEO-24 Tier 3 theophylline (er 400 mg tablet, er 600 mg Tier 1 tablet) theophylline anhydrous Tier 1 BRONCHODILATORS, SYMPATHOMIMETIC albuterol sulfate (er 4 mg tab, er 8 mg tab) Tier 1 albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, 5 mg/ml solution, 15 mg/3 ml solution, 20 mg/4 ml solution) Tier 1 B/D PA 86

95 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate Tier 3 2 mg tab, sulfate 4 mg tab) BROVANA Tier 3 B/D PA, QL (120 per 30 days) epinephrine (0.15 mg auto-injct, 0.3 mg autoinject) Tier 2 QL (2 per 30 days) EPIPEN Tier 2 QL (2 per 30 days) EPIPEN 2-PAK Tier 2 QL (2 per 30 days) EPIPEN JR 2-PAK Tier 2 QL (2 per 30 days) ISUPREL Tier 3 levalbuterol concentrate hcl vial-neb Tier 2 B/D PA levalbuterol hcl vial-neb Tier 2 B/D PA levalbuterol tar hfa 45mcg inhaler Tier 3 QL (30 per 30 days) metaproterenol sulfate (10 mg/5 ml syr, 10 mg Tier 1 tablet, 20 mg tablet) PERFOROMIST Tier 3 B/D PA, QL (120 per 30 days) PROAIR HFA Tier 2 QL (17 per 30 days) PROAIR RESPICLICK Tier 2 QL (2 per 30 days) SEREVENT DISKUS Tier 2 QL (60 per 30 days) STRIVERDI RESPIMAT Tier 3 QL (5 per 30 days) terbutaline sulfate (sulf 1 mg/ml vial, sulfate Tier mg tab, sulfate 5 mg tab) UTIBRON NEOHALER Tier 3 QL (60 per 30 days) VENTOLIN HFA Tier 2 QL (36 per 30 days) XOPENEX CONCENTRATE-NEB Tier 3 B/D PA XOPENEX SOLUTION-NEB Tier 3 B/D PA CYSTIC FIBROSIS KALYDECO Tier 3 QL (60 per 30 days) ORKAMBI (100 MG-125 MG TABLET, Tier 3 QL (120 per 30 days) 200 MG-125 MG TABLET) ORKAMBI ( MG GRANULE PKT, Tier 3 QL (56 per 28 days) MG GRANULE PKT) SYMDEKO Tier 3 QL (56 per 28 days) MAST CELL STABILIZERS cromolyn 100 mg/5 ml oral conc Tier 3 cromolyn 20 mg/2 ml neb soln Tier 1 B/D PA PULMONARY ANTIHYPERTENSIVES ADCIRCA Tier 3 QL (60 per 30 days) ADEMPAS Tier 3 QL (90 per 30 days) epoprostenol sodium Tier 1 FLOLAN Tier 3 LETAIRIS Tier 3 QL (30 per 30 days) 87

96 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) OPSUMIT Tier 3 QL (30 per 30 days) ORENITRAM ER (ER MG Tier 3 QL (90 per 30 days) TABLET, ER 0.25 MG TABLET, ER 1 MG TABLET) ORENITRAM ER 2.5 MG TABLET Tier 3 ORENITRAM ER 5 MG TABLET Tier 3 QL (90per 30 days) REMODULIN Tier 3 REVATIO 10 MG/12.5 ML VIAL Tier 3 REVATIO 10 MG/ML ORAL SUSP Tier 3 QL (180 per 30 days) REVATIO 20 MG TABLET Tier 3 QL (90 per 30 days) sildenafil 10 mg/12.5 ml vial Tier 3 sildenafil 20 mg tablet Tier 2 QL (90 per 30 days) tadalafil 20mg tablet (generic for adcirca) Tier 3 QL (60 per 30 days) TRACLEER Tier 3 QL (60 per 30 days) TYVASO Tier 3 QL (87 per 30 days) TYVASO INSTITUTIONAL START KIT Tier 3 QL (87 per 30 days) TYVASO REFILL KIT Tier 3 QL (87 per 30 days) TYVASO STARTER KIT Tier 3 QL (87 per 30 days) UPTRAVI (400 MCG TABLET, 600 MCG Tier 3 QL (60 per 30 days) TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) UPTRAVI 200 MCG TABLET Tier 3 QL (140 per 28 days) UPTRAVI TITRATION PACK Tier 3 QL (200 per 30 days) VELETRI Tier 3 VENTAVIS Tier 3 PULMONARY FIBROSIS AGENTS ESBRIET (267 MG TABLET, 267 MG Tier 3 QL (270 per 30 days) CAPSULE) ESBRIET 801 MG TABLET Tier 3 QL (90 per 30 days) OFEV Tier 3 QL (60 per 30 days) RESPIRATORY TRACT AGENTS, OTHER acetylcysteine (6 gram/30 ml vl, 10% vial, 20% vial) Tier 1 B/D PA ANORO ELLIPTA Tier 2 QL (60 per 30 days) benzonatate Tier 1 EX CINQAIR Tier 3 DALIRESP 250 MCG TABLET Tier 3 QL (28 per 28 days) DALIRESP 500 MCG TABLET Tier 3 QL (30 per 30 days) FASENRA Tier 3 QL (1 per 28 days) hydrocodone-homatropine mbr (5-1.5, syrup) Tier 1 EX 88

97 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) HYDROMET Tier 1 EX NUCALA Tier 3 PULMOZYME Tier 3 TUSSIGON Tier 1 EX SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS carisoprodol Tier 3 QL (120 per 30 days) carisoprodol compound Tier 3 carisoprodol compound-codeine Tier 3 carisoprodol-aspirin Tier 3 carisoprodol-aspirin-codeine Tier 3 chlorzoxazone 250 mg tablet Tier 3 chlorzoxazone 500 mg tablet Tier 1 cyclobenzaprine hcl Tier 1 METAXALL Tier 3 metaxalone (400 mg tablet, 800 mg tablet) Tier 3 methocarbamol (500 mg tablet, 750 mg tablet) Tier 1 orphenadrine er 100 mg tablet Tier 1 SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS AMBIEN Tier 3 QL (30 per 30 days) AMBIEN CR Tier 3 QL (30 per 30 days) EDLUAR Tier 3 QL (30 per 30 days) eszopiclone Tier 1 QL (30 per 30 days) INTERMEZZO Tier 3 QL (30 per 30 days) LUNESTA Tier 3 QL (30 per 30 days) SONATA Tier 3 QL (30 per 30 days) zaleplon Tier 1 QL (30 per 30 days) zolpidem tartrate (1.75 mg tab sl, 3.5 mg Tier 2 QL (30 per 30 days) tablet sl) zolpidem tartrate (5 mg tablet, 10 mg tablet) Tier 1 QL (30 per 30 days) zolpidem tartrate er Tier 1 QL (30 per 30 days) ZOLPIMIST Tier 3 QL (8 per 30 days) SLEEP DISORDERS, OTHERS armodafinil Tier 2 QL (30 per 30 days) BELSOMRA Tier 3 QL (30 per 30 days) HETLIOZ Tier 3 QL (30 per 30 days) modafinil Tier 2 QL (60 per 30 days) NUVIGIL Tier 3 QL (30 per 30 days) PROVIGIL Tier 3 QL (60 per 30 days) 89

98 NAME SLEEP DISORDER AGENTS (CONTINUED) ROZEREM Tier 3 SILENOR Tier 3 temazepam (15 mg capsule, 30 mg capsule) Tier 1 temazepam (7.5 mg capsule, 22.5 mg capsule) Tier 2 XYREM Tier 3 QL (540 per 30 days) 90

99 Index of Drugs 8 8-MOP 52 A A-HYDROCORT 63 abacavir 35 abacavir-lamivudine 35 abacavir-lamivudine-zidovudine 35 ABELCET 19 ABILIFY MAINTENA 32 ABRAXANE 24 ABSORICA 52 ABSTRAL 1 acamprosate calcium 4 ACANYA 52 acarbose 38 acebutolol hcl 45 acetaminophen-codeine 1 ACETASOL HC 84 acetazolamide 83 acetazolamide sodium 47 acetic acid 6,84 acetic acid-aluminum 84 acetylcysteine 88 acitretin 52 ACTEMRA 75 ACTHIB 78 ACTIMMUNE 77 ACTIQ 1 ACUVAIL 83 acyclovir 37 acyclovir sodium 37 ACZONE 52 ADACEL TDAP 78 ADAGEN 61 adapalene 52 adapalene-benzoyl peroxide 52 ADASUVE 31 ADCIRCA 87 adefovir dipivoxil 33 ADEMPAS 87 ADRIAMYCIN 24 ADRUCIL 24 ADVAIR DISKUS 85 ADVAIR HFA 85 AFEDITAB CR 45 AFINITOR 27 AFINITOR DISPERZ 27 AGGRENOX 42 AKYNZEO 19 ALA-CORT 63 ALBENZA 30 albuterol sulfate 86,87 alclometasone dipropionate 63 alcohol pads 81 ALDURAZYME 61 ALECENSA 27 alendronate sodium 80 alfuzosin hcl er 62 ALIMTA 24 ALINIA 30 ALIQOPA 24 ALKERAN 23 allopurinol 21 almotriptan malate 22 ALOCRIL 82 alogliptin 38 alogliptin-metformin 38 alogliptin-pioglitazone 38 ALOMIDE 82 ALORA 68 alosetron hcl 60 ALOXI 19 ALPHAGAN P 83 alprazolam 37 alprazolam er 37 alprazolam odt 37 alprazolam xr 37 ALREX 83 ALTAVERA 68 ALTOPREV ALUNBRIG 24,25 ALYACEN 68 AMABELZ 68 amantadine 37 AMBIEN 89 AMBIEN CR 89 AMBISOME 19 amcinonide 63 AMETHIA 68 AMETHIA LO 68 amifostine 81 amikacin sulfate 6 amiloride hcl 47 amiloride-hydrochlorothiazide 47 aminocaproic acid 81 aminophylline 86 AMINOSYN 55 AMINOSYN II 55 AMINOSYN II WITH ELECTROLYTES 55 AMINOSYN M 55 AMINOSYN WITH ELECTROLYTES 55 AMINOSYN-HBC 55 AMINOSYN-PF 55 AMINOSYN-RF 55 amiodarone hcl 44 amitriptyline hcl 18 amlodipine besylate 45 amlodipine besylate-benazepril 45 amlodipine-atorvastatin 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hctz 45 ammonium lactate 52 AMNESTEEM 52 amoxapine 18 amoxicillin 10 amoxicillin-clavulanate pot er 10 amoxicillin-clavulanate potass 10 amphotericin b 19

100 ampicillin sodium 10 ampicillin trihydrate 10 ampicillin-sulbactam 10 AMPYRA 51 ANADROL anagrelide hcl 42 ANALPRAM HC 63 anastrozole 27 ANDRODERM 67 ANDROGEL 67 ANDROXY 67 ANGELIQ 68 ANORO ELLIPTA 88 ANZEMET 19 APEXICON E 63 APLENZIN 16 APOKYN 31 apraclonidine hcl 83 aprepitant 19 APRI 68 APTIOM 15 APTIVUS 36 ARALAST NP 61 ARANELLE 68 ARANESP 42 ARBINOXA 85 ARCALYST 77 aripiprazole 32 aripiprazole odt 32 ARISTADA 32 ARISTADA INITIO 32 ARISTOSPAN 63 armodafinil 89 ARNUITY ELLIPTA 85 ARRANON 25 ARZERRA 29 ASACOL HD 79 ASCOMP WITH CODEINE 1 ASHLYNA 68 ASMANEX 85 ASMANEX HFA 85 aspirin-caffeine-dihydrocodein 1 AZURETTE 68 aspirin-dipyridamole er 42 ASTAGRAF XL 75 B atazanavir sulfate 36 BACIIM 6 atenolol 45 atenolol-chlorthalidone 45 ATGAM 77 atomoxetine hcl 50 atorvastatin calcium 48 atovaquone 30 atovaquone-proguanil hcl 30 ATRALIN 52 ATRIPLA 34 atropine sulfate 58,82 ATROVENT HFA 86 AUBAGIO 51 AUBRA 68 AURYXIA 58 AUSTEDO 51 autopen 81 AVANDIA 38 AVASTIN 29 AVELOX IV 11 AVIANE 68 AVITA 52 AVONEX 51 AVONEX PEN 51 AXIRON 68 azacitidine 42 AZACTAM 9 AZACTAM-ISO-OSMOTIC DEXTROSE 9 AZASAN 75 AZASITE 11 azathioprine 75 azathioprine sodium 75 azelastine hcl 82,85 AZELEX 53 azithromycin 11 AZOPT 84 aztreonam 9 92 bacitracin 6 bacitracin-polymyxin 6 baclofen 33 balsalazide disodium 79 BALZIVA 68 BANZEL 13 BARACLUDE 34 BAVENCIO 29 BAXDELA 11 bcg (tice strain) 78 bcg vaccine (tice strain) 78 BEKYREE 68 BELBUCA 1 BELEODAQ 27 BELSOMRA 89 benazepril hcl 44 benazepril-hydrochlorothiazide 44 BENDEKA 23 BENLYSTA 75 BENTYL 59 benzonatate 88 benztropine mesylate 30 BEPREVE 82 BERINERT 75 BESIVANCE 11 BESPONSA 25 betamethasone diprop augmented 63 betamethasone dipropionate 63 betamethasone valerate 63 BETASERON 51 betaxolol hcl 45,84 bethanechol chloride 62 BETHKIS 6 BETIMOL 84 BETOPTIC S 84 bexarotene 29

101 BEXSERO 78 bicalutamide 23 BICILLIN C-R 10 BICILLIN L-A 10 BICNU 25 BIDIL 49 BIKTARVY 36 BILTRICIDE 30 bimatoprost 84 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide 45 BIVIGAM 77 BLEO 15K 25 bleomycin sulfate 25 BLEPHAMIDE 83 BLEPHAMIDE S.O.P. 83 BLINCYTO 25 BLISOVI 24 FE 68 BLISOVI FE 68 BOOSTRIX TDAP 78 bortezomib 25 BOSULIF 27 BOTOX 81 BRAFTOVI 25 BREO ELLIPTA 85 BRIELLYN 68 BRILINTA 41 brimonidine tartrate 84 BRIVIACT 13 bromfenac sodium 83 bromocriptine mesylate 74 BROVANA 87 budesonide 85 budesonide ec 79 budesonide er 79 bumetanide 47 BUPHENYL 61 BUPRENEX 1 buprenorphine hcl 1 buprenorphine patch 1 buprenorphine-naloxone 4 BUPROBAN 5 bupropion hcl 16 bupropion hcl sr 5,16 bupropion xl 16 buspirone hcl 37 busulfan 23 BUSULFEX 25 butalb-acetaminoph-caff-codein 1 butalb-caff-acetaminoph-codein 2 butalbital compound-codeine 2 butalbital-acetaminophen 2 butalbital-acetaminophen-caffe 2 butalbital-aspirin-caffeine 2 butorphanol tartrate 2 BUTRANS 1 BYDUREON 38 BYDUREON BCISE 38 BYDUREON PEN 38 BYETTA 38 BYSTOLIC 45 BYVALSON 45 C cabergoline 74 CABOMETYX 27 calcipotriene 53 calcipotriene-betamethasone dp 53 calcitonin-salmon 80 CALCITRENE 53 calcitriol 53,80 calcium acetate 58 calcium gluconate 55 CALQUENCE 28 CAMBIA 5 CAMILA 73 CAMRESE 68 CAMRESE LO 68 CANASA 79 CANCIDAS 19 candesartan cilexetil 43 candesartan-hydrochlorothiazid43 93 CAPACET 2 CAPASTAT SULFATE 22 CAPEX SHAMPOO 63 CAPRELSA 25 captopril 44 captopril-hydrochlorothiazide 44 CARAC 53 CARAFATE 60 CARBAGLU 55 carbamazepine 15 carbamazepine er 15 carbidopa 31 carbidopa-levodopa 31 carbidopa-levodopa er 31 carbidopa-levodopaentacapone 31 carbinoxamine maleate 85 carboplatin 25 CARDENE I.V. 46 CARDURA XL 43 CARIMUNE NF NANOFILTERED 77 carisoprodol 89 carisoprodol compound 89 carisoprodol compoundcodeine 89 carisoprodol-aspirin 89 carisoprodol-aspirin-codeine 89 CARNITOR 81 carteolol hcl 84 CARTIA XT 46 carvedilol 45 carvedilol er 45 caspofungin acetate 19 CAYSTON 9 CAZIANT 68 cefaclor 8 cefaclor er 8 cefadroxil 8 cefazolin sodium 8 cefazolin sodium-dextrose 8

102 cefdinir 8 cefepime 9 cefepime hcl 9 cefepime-dextrose 9 cefixime 9 CEFOTAN 9 cefotaxime sodium 9 cefotetan 9 cefotetan & dextrose 9 cefoxitin 9 cefoxitin sodium 9 cefpodoxime proxetil 9 cefprozil 9 ceftazidime 9 ceftibuten 9 CEFTIN 9 ceftriaxone 9 cefuroxime 9 cefuroxime sodium 9 celecoxib 5 CELESTONE 63 CELLCEPT 75 CELONTIN 14 cephalexin 9 CERDELGA 61 CEREZYME 61 CESAMET 19 cevimeline hcl 52 CHANTIX 5 CHATEAL 68 CHEMET 57 CHENODAL 81 chloramphenicol sod succinate 6 chlordiazepoxide hcl 37 chlordiazepoxide-amitriptyline 37 chlordiazepoxide/clidinium (select manufacturers only) 59 chlorhexidine gluconate 52 chloroquine phosphate 30 chlorothiazide 47 chlorothiazide sodium 48 chlorpromazine hcl 31 CLINDAGEL 6 chlorpropamide 38 clindamycin hcl 7 chlorthalidone 48 clindamycin palmitate hcl 7 chlorzoxazone 89 clindamycin pediatric 7 CHOLBAM 61 clindamycin phos-benzoyl cholestyramine 48 perox 53 cholestyramine light 48 chorionic gonadotropin 66 CIALIS 62 CICLODAN 19 ciclopirox 20 (alternative to clindagel) 7 clindamycin phosphate 1% gel cidofovir 33 (generic for cleocin t) 7 cilostazol 42 clindamycin phosphate-d5w 7 CILOXAN 11 clindamycin-benzoyl perox 1- CIMDUO 35 cimetidine 59 CIMZIA 75 CINQAIR 88 CINRYZE 75 CINVANTI 19 CIPRO HC 84 CIPRODEX 84 ciprofloxacin 11 ciprofloxacin er 11 ciprofloxacin hcl 11 ciprofloxacin-d5w 12 cisplatin 25 citalopram hbr 17 cladribine 24 CLARAVIS 53 clarithromycin 11 clarithromycin er 11 clemastine fumarate 85 CLENPIQ 60 CLEOCIN 6 CLEVIPREX 46 CLIMARA 69 CLIMARA PRO 69 clind ph-benzoyl perox 1.2-5% 53 CLINDACIN ETZ 6 CLINDACIN P 6 94 clindamycin phos-tretinoin 53 clindamycin phosphate 7 clindamycin phosphate 1% gel 5% 53 clindamycin-benzoyl peroxide 53 CLINDESSE 7 CLINIMIX 55 CLINIMIX E 55 CLINIMIX N14G30E 55 CLINIMIX N9G15E 55 CLINIMIX N9G20E 55 CLINISOL 55 clobetasol emollient 63 clobetasol emulsion 63 clobetasol propionate 63 clocortolone pivalate 64 clofarabine 24 clomiphene citrate 81 clomipramine hcl 18 clonazepam 14 clonidine hcl 43 clonidine hcl er 50 clonidine patch 43 clopidogrel 42 clorazepate dipotassium 14 CLORPRES 43 clotrimazole 20 clotrimazole-betamethasone 20 clozapine 33 clozapine odt 33

103 COARTEM 30 codeine sulfate 2 colchicine 21 COLCRYS 21 colesevelam hcl 48 colestipol hcl 48 colistimethate 7 COLOCORT 79 COLY-MYCIN S 84 COMBIGAN 84 COMBIPATCH 69 COMBIVENT RESPIMAT 86 COMETRIQ 28 COMPLERA 35 COMPRO 18 CONDYLOX 53 CONSTULOSE 60 COPAXONE 51 CORDRAN 64 COREG CR 45 CORLANOR 46 CORTENEMA 79 CORTIFOAM 64 cortisone acetate 64 CORTISPORIN 7,83 COSENTYX (2 SYRINGES) 53 COSENTYX PEN 53 COSENTYX PEN (2 PENS) 53 COSENTYX SYRINGE 53 COSMEGEN 25 COSOPT PF 84 COTELLIC 28 COUMADIN 41 CREON 61 CRESEMBA 20 CRIXIVAN 36 cromolyn sodium 82,87 CROTAN 30 CRYSELLE 69 CUPRIMINE 57 CUROSURF 81 CUVITRU 77 cyanocobalamin injection 58 CYCLAFEM 69 cyclobenzaprine hcl 89 cyclophosphamide 23 cycloserine 22 CYCLOSET 38 cyclosporine 75 cyclosporine modified 75 cyproheptadine hcl 85 CYRAMZA 28 CYRED 69 CYSTADANE 61 CYSTAGON 61 CYSTARAN 82 cytarabine 24 CYTOGAM 81 CYTOMEL 73 D dacarbazine 23 dactinomycin 25 DAKLINZA 34 dalfampridine er 51 DALIRESP 88 DALVANCE 7 danazol 68 dantrolene sodium 33 dapsone 22,53 DAPTACEL DTAP 78 daptomycin 7 DARAPRIM 30 darifenacin er 62 DARZALEX 29 DASETTA 69 daunorubicin hcl 25 DAXBIA 9 DAYSEE 69 DAYTRANA 50 DEBLITANE 73 DECADRON decitabine 25 deferoxamine mesylate 81 DELESTROGEN 69 DELTASONE 64 DELYLA 69 DELZICOL 79 demeclocycline hcl 12 DEMSER 47 DENAVIR 37 DENTA 5000 PLUS 55 DENTAGEL 55 DEPEN 57 DEPO-ESTRADIOL 69 DEPO-MEDROL 64 DEPO-SUBQ PROVERA DESCOVY 35 DESFERAL 81 DESFERAL MESYLATE 81 desipramine hcl 18 desloratadine 85 desmopressin acetate 66,67 desogestr-eth estrad eth estra 69 desogestrel-ethinyl estradiol 69 DESONATE 64 desonide 64 desoximetasone 64 desvenlafaxine er 17 desvenlafaxine fumarate er 17 desvenlafaxine succinate er 17 dexamethasone 64 DEXAMETHASONE INTENSOL 64 dexamethasone sodium phosphate 64,83 DEXILANT 60 dexmethylphenidate hcl 50 dexmethylphenidate hcl er 50 dexrazoxane 25 dextroamphetamine sulfate 49 dextroamphetamine sulfate er 49

104 dextroamphetamine-amphet er 49,50 dextroamphetamineamphetamine 50 dextrose 10%-0.2% nacl 55 dextrose 10%-0.45% nacl 55 dextrose 2.5%-0.45% nacl 55 dextrose 5%-0.2% nacl 55 dextrose 5%-0.2% nacl-kcl 55 dextrose 5%-0.225% nacl 55 dextrose 5%-0.225% nacl-kcl 55 dextrose 5%-0.3% nacl 55 dextrose 5%-0.3% nacl-kcl 55 dextrose 5%-0.33% nacl 55 dextrose 5%-0.33% nacl-kcl 55 dextrose 5%-0.45% nacl 55 dextrose 5%-0.45% nacl-kcl 55 dextrose 5%-0.9% nacl 55 dextrose 5%-1/2ns-kcl 55 dextrose 5%-1/4ns-kcl 55 dextrose 5%-electrolyte #48 55 dextrose 5%-ns-kcl 55 dextrose 5%-potassium chloride56 dextrose in lactated ringers 81 dextrose in water 81 DIABETA 38 DIASTAT 14 DIASTAT ACUDIAL 14 diazepam 14,38 diclofenac potassium 5 diclofenac sodium 5,53,83 diclofenac sodium er 5 diclofenac sodium-misoprostol 5 dicloxacillin sodium 10 dicyclomine hcl 59 didanosine 35 DIFFERIN 53 DIFICID 11 diflorasone diacetate 64 diflunisal 5 DIGITEK 47 DIGOX 47 digoxin 47 dihydroergotamine mesylate 21 DILANTIN 15 DILANTIN DILATRATE-SR 49 DILT-XR 46 diltiazem 12hr er 46 diltiazem 24hr cd 46 diltiazem 24hr er 46 dutasteride 62 diltiazem er 46 dutasteride-tamsulosin 62 diltiazem hcl 46 DUZALLO 21 DIPENTUM 79 DYRENIUM 47 diphenhydramine hcl 86 diphenoxylate-atropine 59 diphtheria-tetanus toxoids-ped 78 dipyridamole 42 DISKETS 2 disulfiram 4 divalproex sodium 14 divalproex sodium er 14 DIVIGEL 69 docetaxel 25 dofetilide 44 donepezil hcl 16 donepezil hcl odt 16 DOPTELET 42 DORIBAX 9 doripenem 9 dorzolamide hcl 84 dorzolamide-timolol 84 doxazosin mesylate 62 doxepin hcl 18,53 doxercalciferol 80 doxorubicin hcl 25 doxorubicin hcl liposome 25 DOXY doxycycline hyclate 12 doxycycline ir-dr 12 doxycycline monohydrate 12 dronabinol drospirenone-eth estra-levomef 69 drospirenone-ethinyl estradiol 69 DROXIA 24 DUAVEE 69 DULERA 85 duloxetine hcl 17 DUPIXENT 77 DURAMORPH 2 DUREZOL 83 E E.E.S econazole nitrate 20 EDARBI 43 EDARBYCLOR 43 EDLUAR 89 EDURANT 35 efavirenz 35 EFFIENT 42 EGRIFTA 67 ELAPRASE 61 ELELYSO 61 ELESTRIN 69 eletriptan hbr 22 ELIDEL 53 ELIGARD 74 ELINEST 69 ELIPHOS 58 ELIQUIS 41 ELITEK 29 ELIXOPHYLLIN 86 ELLA 73 ELLENCE 25 ELMIRON 62 EMADINE 82 EMBEDA 1 EMCYT 24

105 EMEND 19 EMFLAZA 64 EMOQUETTE 69 EMPLICITI 29 EMSAM 17 EMTRIVA 35 EMVERM 30 enalapril maleate 44 enalapril-hydrochlorothiazide 44 ENBREL 75 ENBREL MINI 75 ENBREL SURECLICK 75 ENDARI 81 ENDOCET 2 ENGERIX-B ADULT 78 ENGERIX-B PEDIATRIC- ADOLESCENT 78 enoxaparin sodium 41 ENPRESSE 69 ENSKYCE 69 ENSTILAR 53 entacapone 30 entecavir 34 ENTRESTO 47 ENULOSE 60 ENVARSUS XR 75 EPCLUSA 34 EPIDUO 53 EPIDUO FORTE 53 epinastine hcl 82 epinephrine 87 EPIPEN 87 EPIPEN 2-PAK 87 EPIPEN JR 2-PAK 87 epirubicin hcl 25 EPITOL 15 EPIVIR HBV 34 eplerenone 47 EPOGEN 42 epoprostenol sodium 87 eprosartan mesylate 43 EQUETRO 38 ERAXIS (WATER DILUENT) 20 ERBITUX 29 ergoloid mesylates 16 ERGOMAR 21 ergotamine-caffeine 21 ERIVEDGE 25 ERLEADA 23 ERRIN 73 ERTACZO 20 ertapenem 9 ERWINAZE 25 ERY 2% PADS 11 ERY-TAB 11 ERYPED ERYPED ERYTHROCIN LACTOBIONATE 11 ERYTHROCIN STEARATE 11 erythromycin 11 erythromycin ethylsuccinate 11 erythromycin-benzoyl peroxide 53 ESBRIET 88 escitalopram oxalate 17 esomeprazole magnesium 60 esomeprazole sodium 60 ESTARYLLA 69 ESTRACE 69 estradiol 69 estradiol twice weekly 69 estradiol valerate 69 estradiol weekly 69 estradiol-norethindrone acetat 69 ESTRING 69 estropipate 69 eszopiclone 89 ethacrynate sodium 47 ethacrynic acid 47 ethambutol hcl 22 ethosuximide ethynodiol-ethinyl estradiol 69 etidronate disodium 80 etodolac 5 etodolac er 5 ETOPOPHOS 27 etoposide 27 EURAX 30 EVAMIST 69 EVOMELA 23 EVOTAZ 36 EVZIO 4 EXELDERM 20 exemestane 27 EXJADE 57 EXONDYS EXTAVIA 51 EYLEA 82 ezetimibe 48 ezetimibe-simvastatin 48 F FABIOR 53 FABRAZYME 61 FALMINA 69 famciclovir 37 famotidine 59 FANAPT 32 FARESTON 24 FARYDAK 28 FASENRA 88 FASLODEX 24 FAYOSIM 69 felbamate 14 felodipine er 46 FEMRING 69 FEMYNOR 69 fenofibrate 48 fenofibric acid 48 FENOGLIDE 48 fenoprofen calcium 5 fentanyl 1

106 fentanyl citrate 2 FENTORA 2 FERRIPROX 57 FETZIMA 17 FINACEA 53 finasteride 5 mg tablet 62 FIRAZYR 75 FIRMAGON 25 FLAREX 83 flavoxate hcl 62 FLEBOGAMMA DIF 77 flecainide acetate 44 FLECTOR 5 FLOLAN 87 FLOVENT DISKUS 85 FLOVENT HFA 85 FLOXIN 12 fluconazole 20 fluconazole in dextrose 20 fluconazole in saline 20 fluconazole-nacl 20 flucytosine 20 fludarabine phosphate 24 fludrocortisone acetate 64 flunisolide 85 fluocinolone acetonide 64 fluocinolone acetonide oil 84 fluocinonide 64 fluocinonide-e 64 fluorometholone 83 fluorouracil 25,53 fluoxetine dr 90 mg capsule (weekly) 17 fluoxetine hcl 17 fluphenazine decanoate 31 fluphenazine hcl 31 flurandrenolide 64 flurbiprofen 5 flurbiprofen sodium 83 flutamide 23 fluticasone propionate 64,65,85 fluvastatin er 48 fluvastatin sodium 48 fluvoxamine maleate 17 fluvoxamine maleate er 17 FML FORTE 83 FML S.O.P. 83 folic acid 58 FOLOTYN 25 fomepizole 81 fondaparinux sodium 41 FORTEO 80 FORTESTA 68 FORTICAL 80 fosamprenavir calcium 36 foscarnet sodium 33 fosinopril sodium 44 fosinopril-hydrochlorothiazide 44 fosphenytoin sodium 15 FOSRENOL 58 FRAGMIN 41 FREAMINE HBC 56 FREAMINE III 56 frovatriptan succinate 22 furosemide 47 FUSILEV 25 FUZEON 36 FYAVOLV 70 FYCOMPA 14 G gabapentin 14 GABITRIL 14 GALAFOLD 61 galantamine 4 mg/ml oral soln 16 ganciclovir sodium 33 GARDASIL 78 GARDASIL 9 78 gatifloxacin 12 GATTEX 59 gauze pads 2 x 2 81 GAVILYTE-C 60 GAVILYTE-G 60 GAVILYTE-H AND BISACODYL 60 GAVILYTE-N 60 GAZYVA 29 GELNIQUE 62 gemcitabine hcl 24 gemfibrozil 48 GENERLAC 60 GENGRAF 75 GENOTROPIN 67 GENTAK 6 gentamicin sulfate 6 gentamicin sulfate in ns 6 GENVOYA 36 GEODON 32 GIANVI 70 GIAZO 79 GILDAGIA 70 GILDESS 24 FE 70 GILENYA 51 GILOTRIF 28 GLASSIA 61 glatiramer acetate 52 GLATOPA 52 GLEOSTINE 23 glimepiride 38 galantamine er 16 glipizide 38 galantamine hbr 16 glipizide er 38 GAMMAGARD LIQUID 77 glipizide xl 39 GAMMAGARD S-D 77 glipizide-metformin 39 GAMMAKED 77 GLUCAGEN 40 GAMMAPLEX 77 GLUCAGON EMERGENCY GAMUNEX-C 77 KIT 40 98

107 glucose in water 81 GLUCOVANCE 39 GLUMETZA 39 glyburide 39 glyburide micronized 39 glyburide-metformin hcl 39 GLYCATE 59 glycopyrrolate 59 GLYNASE 39 GOCOVRI 30,31 GONITRO 49 GRALISE 15 granisetron hcl 19 GRANIX 42 GRASTEK 81 griseofulvin 20 griseofulvin ultramicrosize 20 guanfacine hcl 43 guanfacine hcl er 50 guanidine hcl 22 H H.P. ACTHAR 65 HAEGARDA 75 HALAVEN 25 halobetasol propionate 65 HALOG 65 haloperidol 31 haloperidol decanoate 31 haloperidol decanoate haloperidol lactate 31 HARVONI 34 HAVRIX 78 HEATHER 73 HECTOROL 80 heparin sodium 41 heparin sodium in 0.45% nacl 41 heparin sodium-0.45% nacl 41 heparin sodium-0.9% nacl 41 heparin sodium-d5w 42 HEPATAMINE 56 HERCEPTIN 29 HETLIOZ 89 HEXALEN 23 HIBERIX 78 HIZENTRA 77 HORIZANT 15 HUMALOG 40 HUMALOG JUNIOR KWIKPEN 40 HUMALOG KWIKPEN U HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 41 HUMALOG MIX HUMALOG MIX KWIKPEN 41 humapen luxura hd 81 HUMATROPE 67 HUMIRA 76 HUMIRA PEDIATRIC CROHN'S 76 HUMIRA PEN 76 HUMIRA PEN CROHN-UC- HS STARTER 76 HUMIRA PEN PSORIASIS- UVEITIS 76 HUMULIN HUMULIN 70/30 KWIKPEN 41 HUMULIN N 41 HUMULIN N KWIKPEN 41 HUMULIN R 41 HUMULIN R U HUMULIN R U-500 KWIKPEN 41 hydralazine hcl 49 hydrochlorothiazide 48 hydrocodone-acetaminophen 2 99 hydrocodone-homatropine mbr 88 hydrocodone-ibuprofen 2 hydrocortisone 65,79 hydrocortisone butyrate 65 hydrocortisone valerate 65 hydrocortisone-acetic acid 85 hydrocortisone-pramoxine 65 HYDROMET 89 hydromorphone er 1 hydromorphone hcl 2 hydroxychloroquine sulfate 30 hydroxyprogesterone caproate 73 hydroxyurea 24 hydroxyzine hcl 86 hydroxyzine pamoate 37 HYQVIA 77 HYSINGLA ER 1 I ibandronate sodium 80 IBRANCE 28 IBU 5 ibuprofen 5 ICLUSIG 28 IDAMYCIN PFS 26 idarubicin hcl 26 IDHIFA 26 ifosfamide 23 ILARIS 77 ILEVRO 83 imatinib mesylate 28 IMBRUVICA 28 IMFINZI 29 imipenem-cilastatin sodium 10 imipramine hcl 18 imipramine pamoate 18 imiquimod 53 IMOVAX RABIES VACCINE 78 IMPOYZ 65 INCASSIA 73

108 INCRELEX 67 indapamide 48 indomethacin 5 indomethacin er 5 INFANRIX DTAP 78 INFLECTRA 76 INFUMORPH 2 INGREZZA 51 INLYTA 28 INNOPRAN XL 21 inpen (for humalog) 81 inpen (for novolog) 81 insulin pen needle 81 insulin pen needle, safety 81 insulin syringe 81 insulin syringe u INTELENCE 35 INTERMEZZO 89 INTRALIPID 81 INTRON A 34 INTROVALE 70 INVANZ 10 INVEGA SUSTENNA 32 INVEGA TRINZA 32 INVIRASE 36 INVOKAMET 39 INVOKAMET XR 39 INVOKANA 39 IONOSOL B WITH DEXTROSE 5% 56 IONOSOL MB-DEXTROSE 5% 56 IOPIDINE 84 IPOL 78 ipratropium bromide 86 ipratropium-albuterol 86 irbesartan 43 irbesartan-hydrochlorothiazide 43 IRESSA 28 irinotecan hcl 26 ISENTRESS 36,37 ISENTRESS HD 37 ISIBLOOM 70 ISOLYTE P WITH DEXTROSE 56 ISOLYTE S 56 isoniazid 22 isosorbide dinitrate 49 isosorbide dinitrate er 49 isosorbide mononitrate 49 isosorbide mononitrate er 49 isotretinoin 53 isradipine 46 ISTALOL 84 ISTODAX 26 ISUPREL 87 itraconazole 20 ivermectin 30 IXEMPRA 26 IXIARO 78 J JADENU 58 JADENU SPRINKLE 58 JAKAFI 26 JANTOVEN 42 JANUMET 39 JANUMET XR 39 JANUVIA 39 JARDIANCE 39 JENCYCLA 73 JENTADUETO 39 JENTADUETO XR 39 JETREA 82 JEVANTIQUE LO 70 JEVTANA 28 JINTELI 70 JOLESSA 70 JOLIVETTE 73 JUBLIA 20 JULEBER 70 JULUCA JUNEL 70 JUNEL FE 70 JUNEL FE JUXTAPID 48 JYNARQUE 58 K KABIVEN 56 KADCYLA 26 KAITLIB FE 70 KALBITOR 81 KALETRA 36 KALYDECO 87 KANUMA 61 KARIVA 70 KAZANO 39 kcl 20 meq in d5w-lact ringer 56 kcl-ns 1,000 ml iv soln 56 KELNOR KELNOR KENALOG KENALOG KEPIVANCE 52 KERYDIN 20 KETEK 11 ketoconazole 20 KETODAN 20 ketoprofen 5 ketorolac tromethamine 5,83 KEVEYIS 81 KEYTRUDA 26 KIMIDESS 70 KINERET 77 KINRIX 78 KIONEX 58 KISQALI 26 KISQALI FEMARA CO- PACK 26 KITABIS PAK 6 KLOFENSAID II 5 KLOR-CON 10 56

109 KLOR-CON 20 MEQ PACKET (SELECT MANUFACTURERS ONLY) 56 KLOR-CON 8 56 KLOR-CON M10 56 KLOR-CON M15 56 KLOR-CON M20 56 KLOR-CON SPRINKLE 56 KOMBIGLYZE XR 39 KORLYM 81 KRISTALOSE 60 KRYSTEXXA 61 KURVELO 70 KUVAN 61 KYLEENA 73 KYNAMRO 48 KYPROLIS 26 L labetalol hcl 45 LACRISERT 82 lactated ringers 56 lactulose 60 lamivudine 34,35 lamivudine hbv 34 lamivudine-zidovudine 35 lamotrigine 14 lamotrigine (blue) 15 lamotrigine (green) 15 lamotrigine (orange) 15 lamotrigine er 15 lamotrigine odt 15 lamotrigine odt (blue) 15 lamotrigine odt (green) 15 lamotrigine odt (orange) 15 LANOXIN 47 lansoprazol-amoxicil-clarithro 7 lansoprazole 60 lanthanum carbonate 58 LANTUS 41 LANTUS SOLOSTAR 41 LARIN 70 LARIN 24 FE 70 LARIN FE 70 LARISSIA 70 LARTRUVO 29 latanoprost 84 LATUDA 32 LAZANDA 2 LEENA 70 leflunomide 77 LEMTRADA 52 LENVIMA 28 LESSINA 70 LETAIRIS 87 letrozole 27 leucovorin calcium 26 LEUKERAN 23 LEUKINE 42 leuprolide acetate 74 levalbuterol concentrate hcl vialneb 87 levalbuterol hcl vial-neb 87 levalbuterol tar hfa 45mcg inhaler 87 LEVEMIR 41 LEVEMIR FLEXTOUCH 41 levetiracetam 13 levetiracetam er 13 levetiracetam-nacl 13 LEVITRA 62 levobunolol hcl 84 loperamide 59 levocarnitine 81 lopinavir-ritonavir 36 levocetirizine dihydrochloride 86 LOPREEZA 70 levofloxacin 12 levofloxacin-d5w 12 levoleucovorin calcium 26 LEVONEST 70 levonorg-eth estrad eth estrad 70 levonorgestrel-eth estradiol 70 LEVORA levorphanol tartrate 2 levothyroxine sodium 73 LEVOXYL 74 LEXIVA 36 LIALDA 79 lidocaine 4 lidocaine hcl 4,44 lidocaine hcl viscous 4 lidocaine-prilocaine 4 LIDODERM 4 LILETTA 73 LINCOCIN 7 lincomycin hcl 7 lindane 30 linezolid 7 linezolid-0.9% nacl 7 linezolid-d5w 7 LINZESS 60 liothyronine sodium 74 lisinopril 44 lisinopril-hydrochlorothiazide 44 lithium 38 lithium carbonate 38 lithium carbonate er 38 LITHOSTAT 63 LIVALO 48 LO LOESTRIN FE 70 LOCOID 65 LOCORT 65 LOMEDIA 24 FE 70 LONSURF 26 lorazepam 38 LORCET 2 LORCET HD 2 LORCET PLUS 3 LORYNA 70 losartan potassium 43 losartan-hydrochlorothiazide 43

110 LOTEMAX 83 lovastatin 48 LOW-OGESTREL 71 loxapine 32 LUCEMYRA 51 LUCENTIS 82 luliconazole 20 LUMIGAN 84 LUMIZYME 61 LUNESTA 89 LUPRON DEPOT 74 LUPRON DEPOT (LUPANETA) 74 LUPRON DEPOT-PED 74 LUTERA 71 LUZU 20 LYNPARZA 28 LYRICA 14,51 LYSODREN 74 LYZA 73 M M-M-R II VACCINE 78 MACUGEN 82 magnesium chloride 56 magnesium sulfate 56 magnesium sulfate-d5w 56 malathion 30 maprotiline hcl 17 MARGESIC 3 MARLISSA 71 MARPLAN 17 MARQIBO 26 MARTEN-TAB 3 MATULANE 23 MATZIM LA 46 MAVYRET 34 MAXIDEX 83 meclizine hcl 18 meclofenamate sodium 5 MEDROL 65 medroxyprogesterone acetate 73 mefloquine hcl 30 megestrol acetate 73 MEKINIST 26 MEKTOVI 28 MELODETTA 24 FE 71 meloxicam 5 melphalan 2mg tablet 23 melphalan hcl 23 memantine hcl 16 memantine hcl er 16 MENACTRA 78 MENEST 71 MENHIBRIX 78 MENOMUNE-A-C-Y-W MENTAX 20 MENVEO A-C-Y-W-135-DIP78 MEPHYTON 58 mercaptopurine 24 meropenem 10 meropenem-0.9% nacl 10 mesalamine 79 mesna 29 MESNEX 29 MESTINON 22 METADATE ER 50 metaproterenol sulfate 87 METAXALL 89 metaxalone 89 metformin er 1000 mg osmotic tablet (generic for fortamet) 39 metformin er 500 mg osmotic tablet (generic for fortamet) 39 metformin hcl 1000mg tablet (immediate-release) 39 metformin hcl 500 mg tablet (immediate-release) 39 metformin hcl 850 mg tablet (immediate-release) 39 metformin hcl er 1000 mg tablet (generic for glumetza) metformin hcl er 500mg (generic for glucophage xr) 40 metformin hcl er 500mg (generic for glumetza) 40 metformin hcl er 750 mg (generic for glucophage xr) 40 methadone hcl 3 METHADONE INTENSOL 3 METHADOSE 3 methamphetamine hcl 50 methazolamide 47 methenamine hippurate 7 methimazole 75 METHITEST 68 methocarbamol 89 methotrexate 76 methotrexate sodium 76 methoxsalen 53 methscopolamine bromide 59 methyclothiazide 48 methyldopa 43 methyldopahydrochlorothiazide 43 methyldopate hcl 43 methylergonovine maleate 82 METHYLIN 50 methylphenidate er 50 methylphenidate hcl 50 methylphenidate hcl cd 50 methylphenidate hcl er 50 methylphenidate la 50,51 methylprednisolone 65 methylprednisolone acetate 65 methylprednisolone sodium succ 65 methyltestosterone 68 metipranolol 84 metoclopramide hcl 18 metoclopramide hcl odt 18 metolazone 48 METOPIRONE 82

111 metoprolol succinate er 45 metoprolol tartrate 45 metoprolol-hydrochlorothiazide 45 METRO IV 7 metronidazole 7 mexiletine hcl 44 MIACALCIN 80 MIBELAS 24 FE 71 miconazole 3 20 MICORT-HC 65 MICROGESTIN 71 MICROGESTIN FE 71 midodrine hcl 43 MIGERGOT 21 miglitol 40 miglustat 61 MILI 71 MIMVEY LO 71 MINASTRIN 24 FE 71 MINITRAN 49 minocycline hcl 12 minocycline hcl er 13 minoxidil 49 MIRCERA 42 MIRENA 73 mirtazapine 17 misoprostol 60 MITIGARE 21 mitomycin 26 mitoxantrone hcl 26 modafinil 89 MODERIBA 34 moexipril hcl 44 moexipril-hydrochlorothiazide 44 molindone hcl 32 mometasone furoate 65,85 MONDOXYNE NL 13 MONO-LINYAH 71 MONONESSA 71 montelukast sodium 86 MONUROL 7 MORGIDOX 13 morphine sulfate 3 morphine sulfate er 1 MOVANTIK 59 MOVIPREP 60 MOXEZA 12 moxifloxacin 12 moxifloxacin hcl 12 MOZOBIL 42 MULPLETA 42 MULTAQ 44 mupirocin 7 MUSTARGEN 23 MYALEPT 82 MYCAMINE 20 mycophenolate mofetil 76 mycophenolic acid 76 MYFORTIC 76 MYLOTARG 29 MYORISAN 53 MYRBETRIQ 62 MYTESI 59 MYZILRA 71 N nabumetone 5 nadolol 45 nadolol-bendroflumethiazide 45 nafcillin 10 nafcillin sodium 10 naftifine hcl 20 NAFTIN 20 NAGLAZYME 61 nalbuphine hcl 3 naloxone hcl 4 naltrexone hcl 4 NAMENDA XR 16 NAMZARIC 16 naproxen 5 naproxen sodium 6 naproxen sodium ds naratriptan 22 naratriptan hcl 22 NARCAN 4 NATACYN 20 NATAZIA 71 nateglinide 40 NATESTO 68 NATPARA 80 NEBUPENT 30 NECON 71 nefazodone hcl 17 NEO-POLYCIN 7 NEO-POLYCIN HC 7 NEO-SYNALAR 7 neomycin sulfate 6 neomycin-bacitracin-poly-hc 7 neomycin-bacitracin-polymyxin 7 neomycin-polymyxin b 8 neomycin-polymyxin-dexameth83 neomycin-polymyxin-gramicidin 8 neomycin-polymyxin-hc 7,85 neomycin-polymyxin-hydrocort85 NEORAL 76 NEPHRAMINE 56 NERLYNX 28 NESINA 40 NEULASTA 42 NEUPOGEN 42 NEUPRO 31 NEVANAC 83 nevirapine 35 nevirapine er 35 NEXAVAR 28 NEXIUM 60 niacin er 48,49 NIACOR 49 nicardipine hcl 46 NICOTROL 5 NICOTROL NS 5 NIFEDICAL XL 46 nifedipine er 46

112 NIKKI 71 nilutamide 23 nimodipine 46 NINLARO 26 NIPENT 24 nisoldipine 46 NITRO-BID 49 NITRO-DUR 49 nitrofurantoin 8 nitrofurantoin mono-macro 8 nitroglycerin 49 nitroglycerin 400 mcg lingual spray 49 nitroglycerin patch 49 NITROLINGUAL 49 NITROMIST 49 nizatidine 59 NOCTIVA 67 NOLIX 65 NORA-BE 73 NORDITROPIN FLEXPRO 67 noreth-estrad-fe (24) norethin-eth estra-ferrous fum 71 norethindron-ethinyl estradiol 71 norethindrone 73 norethindrone ac (lupaneta) 73 norethindrone acetate 73 norgestimate-ethinyl estradiol 71 NORITATE 8 NORLYROC 73 NORMOSOL-M AND DEXTROSE 56 NORMOSOL-R 56 NORMOSOL-R AND DEXTROSE 56 NORMOSOL-R PH NORTHERA 43 NORTREL 71 nortriptyline hcl 18 NORVIR 36 NOVAREL 67 novopen echo 82 NOXAFIL 20 NUCALA 89 NUCYNTA 3 NUCYNTA ER 1 NUEDEXTA 51 NULOJIX 76 NUPLAZID 32 NUTRILIPID 82 NUTROPIN AQ 67 NUTROPIN AQ NUSPIN 67 NUVARING 71 NUVESSA 8 NUVIGIL 89 NYAMYC 20 NYATA 20 nystatin 21 nystatin-triamcinolone 21 NYSTOP 21 O OCALIVA 61 OCELLA 71 OCREVUS 52 OCTAGAM 77 octreotide acetate 74 ODEFSEY 35 ODOMZO 28 OFEV 88 ofloxacin 12 OGESTREL 71 olanzapine 32 olanzapine odt 32 olanzapine-fluoxetine hcl 32 olmesartan medoxomil 43 olmesartan-amlodipine-hctz 43 olmesartan-hydrochlorothiazide43 olopatadine hcl 83,86 OLYSIO 34 omega-3 acid ethyl esters 49 omeprazole omeprazole-sodium bicarbonate 60 OMNITROPE 67 ondansetron hcl 19 ondansetron odt 19 ONEXTON 53 ONFI 14 ONGLYZA 40 ONMEL 21 ONPATTRO 82 ONZETRA XSAIL 22 OPDIVO 29 OPSUMIT 88 ORACEA 13 ORALAIR 82 ORALONE 52 ORENCIA 76 ORENCIA CLICKJECT 76 ORENITRAM ER 88 ORFADIN 61 ORILISSA 74 ORKAMBI 87 orphenadrine citrate 89 ORSYTHIA 71 oseltamivir phosphate 37 OSENI 40 OSMOLEX ER 31 OSMOPREP 59 OTEZLA 78 OTOVEL 85 oxacillin 10 oxacillin sodium 10 oxaliplatin 26 oxandrolone 67 oxaprozin 6 oxazepam 38 oxcarbazepine 15 oxiconazole nitrate 21 OXISTAT 21 OXTELLAR XR 15 oxybutynin chloride 62

113 oxybutynin chloride er 62 oxycodone hcl 3 oxycodone hcl er 1 oxycodone hcl-aspirin 3 oxycodone hcl-ibuprofen 3 oxycodone-acetaminophen 3 OXYCONTIN 1 oxymorphone hcl 3 oxymorphone hcl er 1 OZEMPIC 40 P PACERONE 44 paclitaxel 26 paliperidone er 32 palonosetron hcl 19 PALYNZIQ 61 pamidronate disodium 80 PANCREAZE 61 PANDEL 65 PANRETIN 29 pantoprazole sodium 61 paricalcitol 80 PAROEX 52 paromomycin sulfate 6 paroxetine cr 17 paroxetine er 17 paroxetine hcl 17 PARSABIV 80 PASER 23 PAXIL 17 PCE 11 PEDIARIX 78 PEDVAXHIB 78 peg 3350-electrolyte 59,60 peg-3350 and electrolytes 60 PEGANONE 15 PEGASYS 34 PEGASYS PROCLICK 34 PEGINTRON 34 PEGINTRON REDIPEN 34 penicillin g potassium 10 pilocarpine hcl 52,84 penicillin g procaine 10 pimozide 32 penicillin g sodium 10 PIMTREA 71 penicillin gk-iso-osm dextrose 10 pindolol 45 penicillin v potassium 10 pioglitazone hcl 40 PENTACEL 78 pioglitazone-glimepiride 40 PENTACEL ACTHIB COMPONENT 78 pioglitazone-metformin piperacillin-tazobactam PENTAM PIRMELLA 71 PENTASA 79 pentazocine-naloxone hcl 3 pentoxifylline 47 PERFOROMIST 87 PERIKABIVEN 56 perindopril erbumine 44 PERIOGARD 52 PERJETA 29 permethrin 30 perphenazine 32 perphenazine-amitriptyline 32 PERSERIS 32 PEXEVA 17 PFIZERPEN 10 PHENADOZ 18 phenelzine sulfate 17 PHENERGAN 18 phenobarbital 13 phenoxybenzamine hcl 43 phentermine hcl 51 PHENYTEK 15 phenytoin 15 phenytoin sodium 16 phenytoin sodium extended 16 PHILITH 71 PHOSLYRA 58 PHOSPHOLINE IODIDE 84 PHRENILIN FORTE 3 PHYSIOLYTE 56 PHYSIOSOL 56 phytonadione 58 PICATO piroxicam 6 PLASMA-LYTE PLASMA-LYTE 56 IN DEXTROSE 56 PLASMA-LYTE A PH PLEGRIDY 52 PLEGRIDY PEN 52 PLENVU 60 PLIAGLIS 4 PLIXDA 54 podofilox 54 POLYCIN 8 polyethylene glycol polymyxin b sul-trimethoprim 12 polymyxin b sulfate 8 POMALYST 24 PORTIA 71 PORTRAZZA 29 potassium chloride 56 potassium chloride in d5lr 56 potassium chloride proamp 57 potassium chloride-water 57 potassium citrate er 57 potassium cl 20 meq packet (select manufacturers only) 57 potassium cl 20 meq-0.45% nacl 57 POTELIGEO 76 POTIGA 13 PRADAXA 42 PRALUENT PEN 49 PRALUENT SYRINGE 49

114 pramipexole dihydrochloride 31 pramipexole er 31 PRAMOSONE 65 prasugrel hcl 43 pravastatin sodium 48 praziquantel 30 prazosin hcl 43 PRED MILD 83 PRED-G 83 prednicarbate 65 prednisolone 65 prednisolone acetate 83 prednisolone sodium phos odt 65 prednisolone sodium phosphate 65,66,83 prednisone 66 PREDNISONE INTENSOL 66 PREFEST 71 PREGNYL 67 PREMARIN 71 PREMASOL 57 PREMPHASE 71 PREMPRO 71 PRENATAL VITAMIN ORAL TABLET 58 PREVALITE 49 PREVIDENT % DRY MOUTH 57 PREVIDENT 5000 ENAMEL PROTECT 57 PREVIDENT 5000 SENSITIVE 57 PREVIFEM 71 PREVYMIS 33 PREZCOBIX 36 PREZISTA 36 PRIFTIN 23 PRILOSEC DR SUSPENSION 61 primaquine 30 primidone 14 PRIMSOL 8 PRISTIQ 17 PRIVIGEN 77 PROAIR HFA 87 PROAIR RESPICLICK 87 probenecid 21 probenecid-colchicine 21 procainamide hcl 44 PROCALAMINE 57 prochlorperazine 18 prochlorperazine edisylate 32 prochlorperazine maleate 18 PROCRIT 42 PROCTO-MED HC 66 PROCTO-PAK 66 PROCTOFOAM-HC 66 PROCTOSOL-HC 66 PROCTOZONE-HC 66 PROCYSBI 61 progesterone 73 PROGLYCEM 40 PROGRAF 76 PROLASTIN C 61 PROLEUKIN 26 PROLIA 76 PROMACTA 42 promethazine hcl 18 promethazine vc 86 PROMETHEGAN 18 propafenone hcl 44 propafenone hcl er 44 proparacaine hcl 82 propranolol hcl 45 propranolol hcl er 21 propranolol-hydrochlorothiazid 45 propylthiouracil 75 PROQUAD 78 PROSOL 57 protamine sulfate 42 protriptyline hcl 18 PROVIGIL PRUDOXIN 54 PULMICORT RESPULE 85 PULMOZYME 89 PURIXAN 24 PYLERA 59 pyrazinamide 23 pyridostigmine bromide 22 pyridostigmine bromide er 22 Q QUADRACEL DTAP-IPV 78 QUALAQUIN 30 QUARTETTE 72 QUASENSE 72 QUDEXY XR 15 quetiapine fumarate 32 quetiapine fumarate er 32 quinapril hcl 44 quinapril-hydrochlorothiazide 44 quinidine gluconate 44 quinidine sulfate 44 quinine sulfate 30 QVAR 85 QVAR REDIHALER 85 R RABAVERT 78 rabeprazole sodium 61 RADICAVA 82 RAGWITEK 82 RAJANI 72 raloxifene hcl 73 ramipril 44 RANEXA 47 ranitidine hcl 59 RAPAFLO 62 RAPAMUNE 76 rasagiline mesylate 31 RAVICTI 61 RAYALDEE 80 RAYOS 66

115 REBETOL 34 REBIF 52 REBIF REBIDOSE 52 RECLIPSEN 72 RECOMBIVAX HB 78 REGRANEX 54 RELENZA 37 RELEXXII 51 RELISTOR 59 RELPAX 22 REMICADE 76 REMODULIN 88 RENACIDIN 57 RENFLEXIS 77 RENVELA 58 repaglinide 40 repaglinide-metformin hcl 40 REPATHA PUSHTRONEX 49 REPATHA SURECLICK 49 REPATHA SYRINGE 49 RESCRIPTOR 35 reserpine 43 RESTASIS 82 RESTASIS MULTIDOSE 82 RETIN-A 54 RETIN-A MICRO 54 RETIN-A MICRO PUMP 54 RETROVIR 35 REVATIO 88 REVLIMID 24 REXULTI 33 REYATAZ 36 RIBASPHERE 34 RIBASPHERE RIBAPAK 34 ribavirin 34 RIDAURA 78 rifabutin 22 RIFAMATE 23 rifampin 23 RIFATER 23 riluzole 51 rimantadine hcl 37 ringers injection 57 ringers irrigation 57 RIOMET 40 risedronate sodium 80 risedronate sodium dr 80 RISPERDAL CONSTA 33 risperidone 33 risperidone odt 33 RITALIN LA 51 ritonavir 36 RITUXAN 29 RITUXAN HYCELA 29 rivastigmine 16 RIVELSA 72 rizatriptan 22 ROCALTROL 80 romidepsin 26 ropinirole er 31 ropinirole hcl 31 ROSADAN 8 rosuvastatin calcium 48 ROTARIX 79 ROTATEQ 79 ROWEEPRA 13 ROWEEPRA XR 13 ROZEREM 90 RUBRACA 26 RUCONEST 75 RYDAPT 28 S SABRIL 14 SAFYRAL 72 SAIZEN 67 SAIZEN-SAIZENPREP 67 SAMSCA 58 SANCUSO 19 SANDIMMUNE 77 SANDOSTATIN LAR SANDOSTATIN LAR DEPOT 74 SANTYL 54 SAPHRIS 33 SAVELLA 51 scopolamine 18 selegiline hcl 31 selenium sulfide 54 SELZENTRY 36 SEMPREX-D 86 SENSIPAR 80 SEREVENT DISKUS 87 SERNIVO 66 SEROSTIM 67 sertraline hcl 17 SETLAKIN 72 sevelamer carbonate 58 SF 1.1% GEL 57 SF 5000 PLUS 57 SHAROBEL 73 SHINGRIX 79 SIGNIFOR 82 SIGNIFOR LAR 74 sildenafil 10 mg/12.5 ml vial 88 sildenafil 20 mg tablet 88 sildenafil citrate 63 SILENOR 90 silver sulfadiazine 8 SIMBRINZA 84 SIMPONI 77 SIMPONI ARIA 77 SIMULECT 78 simvastatin 48 sirolimus 77 SIRTURO 23 SIVEXTRO 8 SKYLA 73 SMOFLIPID 82 sodium chloride 57 sodium chloride-water 57

116 sodium fluoride 1 mg oral tablet 57 sodium lactate 57 sodium phenylbutyrate 61 sodium polystyrene sulfonate 58 sodium sulfacetamide 54 SOLIRIS 77 SOLODYN 13 SOLOSEC 30 SOLTAMOX 24 SOLU-CORTEF 66 SOLU-MEDROL 66 SOMATULINE DEPOT 74 SOMAVERT 74 SONATA 89 SOOLANTRA 30 SORILUX 54 SORINE 45 sotalol 45 sotalol af 45 SOTYLIZE 45 SOVALDI 34 SPIRIVA 86 SPIRIVA RESPIMAT 86 spironolactone 47 spironolactone-hctz 47 SPORANOX 21 SPRINTEC 72 SPRITAM 13 SPRYCEL 28 SPS 58 SRONYX 72 SSD 8 STAMARIL 79 stavudine 35 STAXYN 63 STELARA 77 STENDRA 63 sterile water for irrigation 82 STIMATE 67 STIOLTO RESPIMAT 86 STIVARGA 28 STRENSIQ 61,62 streptomycin sulfate 6 STRIANT 68 STRIBILD 37 STRIVERDI RESPIMAT 87 SUBOXONE 4 SUBSYS 3 SUCRAID 62 sucralfate 60 sulfacetamide sodium 12,54,82 sulfacetamide-prednisolone 83 sulfadiazine 12 sulfamethoxazole-trimethoprim 12 SULFAMYLON 8 sulfasalazine 79 sulfasalazine dr 79 SULFATRIM 12 sulindac 6 sumatriptan 22 sumatriptan succ-naproxen sod 22 sumatriptan succinate 22 SUMAVEL DOSEPRO 22 SUPRAX 9 SUPREP 59 SUSTIVA 35 SUTENT 28 SYEDA 72 SYLATRON 26 SYLVANT 78 SYMBICORT 85 SYMDEKO 87 SYMFI 35 SYMFI LO 35 SYMLINPEN SYMLINPEN SYMPROIC 59 SYMTUZA 35 SYNAGIS 82 SYNAREL 74 SYNDROS SYNERA 4 SYNERCID 8 SYNJARDY 40 SYNJARDY XR 40 SYNRIBO 26 SYNTHROID 74 SYPRINE 58 T TABLOID 24 TACLONEX 54 tacrolimus 54,77 tadalafil 10 mg tablet (generic for cialis) 63 tadalafil 2.5 mg tablet (generic for cialis) 63 tadalafil 20 mg tablet (generic for cialis) 63 tadalafil 20mg tablet (generic for adcirca) 88 tadalafil 5 mg tablet (generic for cialis) 63 TAFINLAR 26 TAGRISSO 28 TAKHZYRO 75 TALTZ AUTOINJECTOR 54 TALTZ AUTOINJECTOR (2 PACK) 54 TALTZ AUTOINJECTOR (3 PACK) 54 TALTZ SYRINGE 54 TALTZ SYRINGE (2 PACK) 54 TALTZ SYRINGE (3 PACK) 54 TALWIN 3 TAMIFLU 37 tamoxifen citrate 24 tamsulosin hcl 62 TAPERDEX 66 TARCEVA 28

117 TARGRETIN 29 TARINA FE 72 TASIGNA 29 TAVALISSE 78 TAYTULLA 72 tazarotene 54 TAZORAC 54 TAZTIA XT 46 TECENTRIQ 29 TECFIDERA 52 TECHNIVIE 34 TEFLARO 9 TEGRETOL 16 TEGRETOL XR 16 TEKTURNA 47 TEKTURNA HCT 47 telmisartan 43 telmisartan-amlodipine 43 telmisartan-hydrochlorothiazid 43 temazepam 90 temsirolimus 26 TENCON 4 TENIVAC 79 tenofovir disoproxil fumarate 35 terazosin hcl 43 terbinafine hcl 21 terbutaline sulfate 87 terconazole 21 TESTIM 68 testosterone 68 testosterone cypionate 68 testosterone enanthate 68 tetanus diphtheria toxoids 79 tetrabenazine 51 tetracycline hcl 13 THALOMID 24 THEO theophylline 86 theophylline anhydrous 86 THERACYS 26 THERMAZENE 8 THIOLA 63 thioridazine hcl 32 thiotepa 23 thiothixene 32 THYMOGLOBULIN 77 THYROLAR-1 74 THYROLAR-1/2 74 THYROLAR-1/4 74 THYROLAR-2 74 THYROLAR-3 74 tiagabine hcl 14 TIBSOVO 29 ticlopidine hcl 43 tigecycline 8 TILIA FE 72 timolol 0.25% eye drops 84 timolol 0.25% gel-solution 84 timolol 0.5% eye drops (generic for istalol) 84 timolol 0.5% eye drops (generic for timoptic) 84 timolol 0.5% gel-solution 84 timolol maleate 21 TIMOPTIC OCUDOSE 84 tinidazole 30 TIS-U-SOL PENTALYTE 57 TIVICAY 37 tizanidine hcl 33 TOBI 6 TOBI PODHALER 6 TOBRADEX 83 TOBRADEX ST 83 tobramycin 6 tobramycin sulfate 6 tobramycin-dexamethasone 83 TOBREX 6 TOLAK 54 tolazamide 40 tolbutamide 40 tolcapone 31 tolmetin sodium tolterodine tartrate 62 tolterodine tartrate er 62 TOPICORT 66 topiramate 15 topiramate er 15 TOPOSAR 27 topotecan hcl 27 TORISEL 26 torsemide 47 TOUJEO MAX SOLOSTAR 41 TOUJEO SOLOSTAR 41 TOVIAZ 62 TPN ELECTROLYTES 57 TRACLEER 88 TRADJENTA 40 tramadol hcl 4 tramadol hcl er 1 tramadol hcl-acetaminophen 4 trandolapril 44 trandolapril-verapamil er 44 tranexamic acid 42 TRANSDERM-SCOP 18 tranylcypromine sulfate 17 TRAVASOL 57 TRAVATAN Z 84 trazodone hcl 17 TREANDA 23 TRECATOR 23 TRELSTAR 74 TREMFYA 77 TRESIBA FLEXTOUCH U TRESIBA FLEXTOUCH U TRETIN-X 54 tretinoin 29,54 tretinoin microsphere 54 TREXIMET 22 TRI-ESTARYLLA 72 TRI-LEGEST FE 72 TRI-LINYAH 72

118 TRI-LO-ESTARYLLA 72 TRI-LO-MARZIA 72 TRI-LO-SPRINTEC 72 TRI-MILI 72 TRI-PREVIFEM 72 TRI-SPRINTEC 72 TRI-VYLIBRA 72 triamcinolone mg/g topical spray 66 triamcinolone acetonide 52,66,85 triamterene-hydrochlorothiazid 47 TRIANEX 66 TRIDERM 66 trientine hcl 58 trifluoperazine hcl 32 trifluridine 37 TRIGLIDE 48 trihexyphenidyl hcl 30 TRILYTE WITH FLAVOR PACKETS 59 trimethobenzamide hcl 18 trimethoprim 8 trimipramine maleate 18 TRINESSA 72 TRINTELLIX 18 TRIPTODUR 75 TRISENOX 26 TRIUMEQ 35 TRIVORA TROGARZO 36 TROKENDI XR 15 TROPHAMINE 57 trospium chloride 62 trospium chloride er 62 TRULICITY 40 TRUMENBA 79 TRUVADA 35 TUDORZA PRESSAIR 86 TUSSIGON 89 TWINRIX 79 TYBOST 36 TYDEMY 72 TYGACIL 8 TYKERB 29 TYMLOS 80 TYPHIM VI 79 TYSABRI 52 TYVASO 88 TYVASO INSTITUTIONAL START KIT 88 TYVASO REFILL KIT 88 TYVASO STARTER KIT 88 TYZEKA 34 U U-CORT 66 UCERIS 79 ULORIC 21 UNITHROID 74 UNITUXIN 26 UPTRAVI 88 ursodiol 59 UTIBRON NEOHALER 87 UVADEX 54 V VABOMERE 10 valacyclovir 37 VALCHLOR 23 valganciclovir hcl 33 valproate sodium 14 valproic acid 14 valsartan 44 valsartan-hydrochlorothiazide 44 VANATOL LQ 4 vancomycin 8 vancomycin hcl 8 vancomycin hcl-d5w 8 vancomycin in 0.9 % sodium chloride 8 VAQTA 79 VARIVAX VACCINE VARUBI 19 VASCEPA 49 VECAMYL 47 VECTIBIX 29 VELCADE 27 VELETRI 88 VELIVET 72 VELTASSA 58 VEMLIDY 34 VENCLEXTA 29 VENCLEXTA STARTING PACK 29 venlafaxine hcl 18 venlafaxine hcl er 18 VENTAVIS 88 VENTOLIN HFA 87 verapamil er 46 verapamil er pm 46 verapamil hcl 46 verapamil sr 46 VEREGEN 54 VERSACLOZ 33 VERZENIO 27 VESICARE 62 VESTURA 72 vgo vgo vgo VIAGRA 63 VIBERZI 60 VIBRAMYCIN 13 VICODIN 4 VICODIN ES 4 VICODIN HP 4 VICTOZA 2-PAK 40 VICTOZA 3-PAK 40 VIDEX 2 GM PEDIATRIC SOLN 35 VIDEX 4 GM PEDIATRIC SOLN 35 VIDEX EC 35

119 VIEKIRA PAK 34 VIEKIRA XR 34 VIENVA 72 vigabatrin 14 VIGAMOX 12 VIIBRYD 18 VIMIZIM 62 VIMOVO 6 VIMPAT 13 vinblastine sulfate 27 VINCASAR PFS 27 vincristine sulfate 27 vinorelbine tartrate 27 VIORELE 72 VIRACEPT 36 VIRAMUNE 35 VIREAD 35 VISTIDE 33 vitamin d2 58 VITEKTA 37 VIVELLE-DOT 72 VIVITROL 4 VOGELXO 68 voriconazole 21 VOSEVI 34 VOTRIENT 24 VPRIV 62 VRAYLAR 33 VYFEMLA 72 VYLIBRA 72 VYXEOS 27 W warfarin sodium 42 WELCHOL 49 WERA 72 WYMZYA FE 72 X XADAGO 31 XALKORI 27 XARELTO 42 XARTEMIS XR 1 XATMEP 77 XELJANZ 77 XELJANZ XR 77 XERESE 54 XERMELO 82 XGEVA 80 XIFAXAN 59 XOLAIR 78 XOPENEX CONCENTRATE- NEB 87 XOPENEX SOLUTION- NEB 87 XTAMPZA ER 1 XTANDI 23 XULANE 72 XYLOCAINE 4 XYLOCAINE-MPF 4 XYREM 90 Y YERVOY 27 YF-VAX 79 YONDELIS 23 YONSA 24 YUVAFEM 72 Z zafirlukast 86 zaleplon 89 ZALTRAP 29 ZANOSAR 23 ZARAH 72 ZARXIO 42 ZAVESCA 62 ZEBUTAL 4 ZEJULA 27 ZELAPAR 31 ZELBORAF 27 ZEMAIRA ZEMBRACE SYMTOUCH 22 ZEMPLAR 81 ZENATANE 54 ZENCHENT 72 ZENCHENT FE 73 ZENPEP 62 ZEPA 34 ZERBAXA 9 ZERIT 35 ZIAGEN 35 zidovudine 36 zileuton er 86 ZINBRYTA 52 ZINECARD 27 ZIOPTAN 84 ziprasidone hcl 33 ZIRGAN 33 ZMAX 11 ZODEX 66 ZOHYDRO ER 1 zoledronic acid 81 ZOLINZA 27 zolmitriptan 22 zolmitriptan odt 22 zolpidem tartrate 89 zolpidem tartrate er 89 ZOLPIMIST 89 ZOMACTON 67 ZOMETA 81 ZONACORT 66 zonisamide 14 ZONTIVITY 42 ZORBTIVE 67 ZORTRESS 77 ZOSTAVAX 79 ZOSYN 11 ZOVIA 1-35E 73 ZOVIA 1-50E 73 ZOVIRAX 37 ZUPLENZ 19 ZURAMPIC 21

120 ZYCLARA 54 ZYDELIG 29 ZYFLO 86 ZYFLO CR 86 ZYKADIA 29 ZYLET 83 ZYPREXA RELPREVV 33 ZYTIGA

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