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 6/19/2018. 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. 13 M-106CY 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 6/19/2018. 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 prior authorization, quantity limits and/or step therapy 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 6/19/2018. 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 changes to our formulary, we will update the formulary with any CMS approved changes. We will notify you of any non-maintenance changes to your printed formulary 60 days prior to the effective date of the changes. The updated formulary will be available on our Web site. A printed copy can be requested by calling us. See the contact information that appears on the front and back cover pages. I M-106CY18

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 88. 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: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. 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. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. 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. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask 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-106CY18 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-106CY18

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 require prior authorization or step therapy, or that 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-106CY18 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 88. 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) PRIOR AUTHORIZATION (PA) STEP THERAPY (ST) 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. Certain medications require prior authorization. This means that you need approval before you fill your prescription. If you don t get approval, the drug may not be covered. In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 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. V M-106CY18

8 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. M-106CY18 VI

9 NAME ANALGESICS OPIOID ANALGESICS, LONG-ACTING BELBUCA Tier 3 buprenorphine 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 PA OPIOID ANALGESICS, SHORT-ACTING ABSTRAL Tier 3 PA 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 PA asa-butalb-caffeine-codeine Tier 3 ASCOMP WITH CODEINE Tier 3 aspirin-caffeine-dihydrocodein Tier 1 BUPRENEX Tier 3 buprenorphine hcl (0.3 mg/ml syring, 0.3 Tier 1 mg/ml 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 Tier , butalb-acetamin-caff , 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 PA citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FENTORA Tier 3 PA hydrocodone-acetaminophen (hydrocodoneacetamin Tier , hydrocodone-acetamin /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 via) INFUMORPH Tier 3 LAZANDA Tier 3 PA levorphanol tartrate Tier 2 LORCET Tier 1 LORCET HD Tier 1 LORCET PLUS Tier 1 MARGESIC Tier 3 2

11 NAME ANALGESICS (CONTINUED) 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 (100 MCG SPRAY, 200 MCG Tier 3 SPRAY, 400 MCG SPRAY, 600 MCG SPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY) TALWIN Tier 3 TENCON Tier 3 PA 3

12 NAME ANALGESICS (CONTINUED) 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 PA, 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 PA, 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 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 Tier 3 SMOKING CESSATION AGENTS BUPROBAN Tier 1 bupropion hcl sr 150 mg tablet Tier 1 CHANTIX Tier 2 QL (336 per 365 days) 4

13 NAME ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS (CONTINUED) 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 PA, 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 (50 mg capsule, 75 mg capsule) Tier 1 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, Tier mg tablet, dr 375 mg tablet, dr 500 mg tablet, 500 mg kit, 500 mg tablet) naproxen sodium (275 mg tab, 550 mg tab) Tier 1 naproxen sodium ds Tier 1 oxaprozin Tier 1 piroxicam Tier 1 sulindac Tier 1 5

14 NAME ANTI-INFLAMMATORY AGENTS (CONTINUED) 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 drops, 3 mg/ml eye drops, 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 drops 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 clindamycin hcl Tier 1 clindamycin palmitate hcl Tier 1 clindamycin pediatric Tier 1 clindamycin phosphate (ph 1% solution, ph 1% gel, 2% vaginal cream, ph 9 g/60 ml vial, ph 300 mg/2 ml vl, 300 mg/2 ml addvan, ph 600 mg/4 ml vl, 600 mg/4 ml addvan, ph 900 mg/6 ml vl, phos 1% pledget, phosp 1% lotion, 900 mg/6 ml addvan) Tier 1 6

15 NAME ANTIBACTERIALS (CONTINUED) clindamycin phosphate 1% foam Tier 3 clindamycin phosphate-d5w Tier 1 CLINDESSE Tier 3 colistimethate Tier 3 CORTISPORIN CREAM Tier 3 DALVANCE Tier 3 daptomycin 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 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 PA, QL (6 per 6 days) 7

16 NAME ANTIBACTERIALS (CONTINUED) 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, Tier 1 1 gm add-van vial, hcl 5 gm vial, hcl 10 gm vial, hcl 100 gm smartpak, 500 mg vial, 500 mg a-v vial, hcl 750 mg vial) 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) 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 8

17 NAME ANTIBACTERIALS (CONTINUED) 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 imipenem-cilastatin sodium Tier 1 INVANZ Tier 3 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) 9

18 NAME ANTIBACTERIALS (CONTINUED) ampicillin-sulbactam (1.5 gm vl, 3 gm vial, 15 gm vl) Tier 3 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) 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) Tier 3 MACROLIDES 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) 10

19 NAME ANTIBACTERIALS (CONTINUED) erythromycin (250 mg filmtab, dr 250 mg cap, 500 mg filmtab) Tier 2 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 ciprofloxacin-d5w Tier 1 FLOXIN Tier 1 gatifloxacin Tier 1 levofloxacin (0.5% eye drops, 25 mg/ml 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) Tier 1 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 11

20 NAME ANTIBACTERIALS (CONTINUED) 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, Tier mg tablet) minocycline hcl er (er 45 mg tablet, er 65 mg Tier 3 tablet, er 90 mg tablet, er 115 mg tablet, er 135 mg tablet) 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 Tier 3 QL (60 per 30 days) TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET) 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, Tier mg/5 ml soln, 500 mg/5 ml vial, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) levetiracetam er 500 mg tablet Tier 1 QL (180 per 30 days) 12

21 NAME ANTICONVULSANTS (CONTINUED) levetiracetam er 750 mg tablet Tier 1 QL (120 per 30 days) levetiracetam-nacl Tier 3 phenobarbital (15 mg tablet, 16.2 mg tablet, Tier 1 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) 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 PA, QL (60 per 30 days) TABLET, 1,000 MG TABLET) SPRITAM 750 MG TABLET Tier 3 PA, QL (120 per 30 days) VIMPAT (10 MG/ML SOLUTION, 200 Tier 3 MG/20 ML VIAL) VIMPAT (50 MG TABLET, 100 MG Tier 3 QL (60 per 30 days) TABLET, 150 MG TABLET, 200 MG TABLET) 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 MG TABLET) Tier 3 PA, QL (180 per 30 days) 13

22 NAME ANTICONVULSANTS (CONTINUED) tiagabine hcl (2 mg tablet, 4 mg tablet, 12 mg tablet, 16 mg tablet) Tier 1 valproate sodium Tier 1 valproic acid (250 mg/5 ml soln, 250 mg Tier 1 capsule, 500 mg/10 ml sol) vigabatrin Tier 3 PA, QL (180 per 30 days) GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) Tier 3 FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) Tier 3 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 Tier 2 tab) 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 PA, QL (60 per 30 days) MG CAPSULE) QUDEXY XR (50 MG CAPSULE, 100 MG Tier 3 PA, QL (30 per 30 days) CAPSULE) QUDEXY XR 25 MG CAPSULE Tier 3 PA topiramate Tier 1 topiramate er Tier 3 PA TROKENDI XR Tier 3 PA, 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 INFATAB, 100 MG CAPSULE) Tier 3 14

23 NAME ANTICONVULSANTS (CONTINUED) DILANTIN-125 Tier 3 EPITOL Tier 1 fosphenytoin sodium Tier 1 GRALISE 30-DAY STARTER PACK Tier 3 PA GRALISE ER 300 MG TABLET Tier 3 PA, QL (60 per 30 days) GRALISE ER 600 MG TABLET Tier 3 PA, QL (90 per 30 days) HORIZANT ER 300 MG TABLET Tier 3 PA, QL (90 per 30 days) HORIZANT ER 600 MG TABLET Tier 3 PA, QL (60 per 30 days) oxcarbazepine (150 mg tablet, 300 mg tablet, Tier mg/5 ml susp, 600 mg tablet) OXTELLAR XR Tier 3 PA PEGANONE Tier 3 PHENYTEK Tier 3 phenytoin (50 mg infatab, 50 mg tablet chew, Tier mg/4 ml susp, 125 mg/5 ml susp) 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) 15

24 NAME ANTIDEMENTIA AGENTS (CONTINUED) NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK) NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG Tier 3 Tier 3 ST, QL (30 per 30 days) PA, QL (30 per 30 days) CAPSULE, 28 MG-10 MG CAPSULE) NAMZARIC TITRATION PACK Tier 3 PA, QL (28 per 28 days) ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN Tier 3 QL (30 per 30 days) bupropion hcl Tier 1 bupropion hcl sr (100 mg tablet, 200 mg Tier 1 tablet) bupropion xl Tier 1 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 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) Tier 3 QL (30 per 30 days) FETZIMA MG TITRATION PAK Tier 3 QL (28 per 28 days) fluoxetine dr 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 capsule, 20 mg/5 ml solution, hcl 40 mg capsule) Tier 1 16

25 NAME ANTIDEPRESSANTS (CONTINUED) 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 Tier 1 oral conc, hcl 25 mg tablet, hcl 50 mg tablet, hcl 100 mg tablet) 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 17

26 NAME ANTIEMETICS (CONTINUED) promethazine hcl (6.25 mg/5 ml soln, 6.25 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) Tier 3 PROMETHEGAN Tier 3 scopolamine Tier 2 TRANSDERM-SCOP Tier 3 trimethobenzamide hcl Tier 2 B/D PA 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 PA, QL (120 per 30 days) CINVANTI Tier 3 QL (36 per 30 days) dronabinol Tier 3 PA 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 ST, QL (4 per 28 days) SYNDROS Tier 3 PA VARUBI MG/92.5 ML VIAL Tier 3 VARUBI 90 MG TABLET Tier 3 B/D PA, QL (4 per 28 days) ZUPLENZ (4 MG FILM, 8 MG FILM) Tier 3 B/D PA, ST, QL (90 per 30 days) 18

27 NAME 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% Tier 3 ST SOLUTION) ciclopirox (0.77% topical susp, 0.77% cream, Tier % gel, 1% shampoo, 8% solution) clotrimazole (1% cream, 1% solution, 10 mg Tier 1 troche) clotrimazole-betamethasone (crm, lot) Tier 1 CRESEMBA Tier 3 econazole nitrate Tier 1 ERAXIS (WATER DILUENT) Tier 3 ERTACZO Tier 3 ST EXELDERM (1% SOLUTION, 1% Tier 3 ST CREAM) fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 Tier 1 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) 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 Tier 2 JUBLIA Tier 3 PA KERYDIN Tier 3 PA ketoconazole (2% cream, 2% shampoo, 200 Tier 1 mg tablet) ketoconazole 2% foam Tier 3 KETODAN 2% FOAM Tier 3 ST LUZU Tier 3 ST MENTAX Tier 3 ST miconazole mg vag supp Tier 1 MYCAMINE Tier 3 naftifine hcl Tier 3 NAFTIN (1% GEL, 2% GEL) Tier 3 ST 19

28 NAME ANTIFUNGALS (CONTINUED) NATACYN Tier 3 NOXAFIL (40 MG/ML SUSPENSION, DR Tier MG TABLET, 300 MG/16.7 ML VIAL) NYAMYC Tier 1 NYATA 100,000 UNIT/GM POWDER Tier 1 nystatin (100,000 units/gm oint, 100,000 Tier 1 unit/gm powd, 100,000 unit/gm cream, 100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus) nystatin-triamcinolone Tier 1 NYSTOP Tier 1 ONMEL Tier 3 ST oxiconazole nitrate Tier 3 OXISTAT 1% LOTION Tier 3 ST SPORANOX (10 MG/ML SOLUTION, 100 Tier 3 ST 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 PA, QL (30 per 30 days) MITIGARE Tier 3 QL (60 per 30 days) probenecid Tier 1 probenecid-colchicine Tier 1 ULORIC (40 MG TABLET, 80 MG Tier 2 ST, QL (30 per 30 days) TABLET) ZURAMPIC Tier 3 PA, 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 20

29 NAME ANTIMIGRAINE AGENTS (CONTINUED) propranolol hcl er Tier 1 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) Tier 1 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 ST, QL (16 per 30 days) RELPAX (20 MG TABLET, 40 MG Tier 3 ST, QL (12 per 30 days) TABLET) 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 (4 MG/0.5 ML, 6 Tier 3 ST, QL (5 per 30 days) MG/0.5 ML) TREXIMET MG TABLET Tier 3 ST, QL (16 per 30 days) TREXIMET MG TABLET Tier 3 ST, QL (10 per 30 days) ZEMBRACE SYMTOUCH Tier 3 ST, 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 21

30 NAME 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, Tier mg/ml vial, 300 mg tablet) 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 PA 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 PA VIAL, 100 MG VIAL, 180 MG/2 ML VIAL) VALCHLOR Tier 3 PA, QL (60 per 30 days) YONDELIS Tier 3 PA 22

31 NAME ANTINEOPLASTICS (CONTINUED) ZANOSAR Tier 3 ANTIANDROGENS bicalutamide Tier 1 ERLEADA Tier 3 PA, QL (120 per 30 days) flutamide Tier 1 nilutamide Tier 3 XTANDI Tier 3 PA, QL (120 per 30 days) ANTIANGIOGENIC AGENTS POMALYST Tier 3 PA, QL (21 per 28 days) REVLIMID Tier 3 QL (30 per 30 days) THALOMID (50 MG CAPSULE, 100 MG Tier 3 PA, QL (30 per 30 days) CAPSULE, 150 MG CAPSULE) THALOMID 200 MG CAPSULE Tier 3 PA, QL (60 per 30 days) VOTRIENT Tier 3 PA, 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 Tier 1 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 23

32 NAME ANTINEOPLASTICS (CONTINUED) ALIQOPA Tier 3 PA ALUNBRIG (90 MG-180 MG TAB PACK, Tier 3 PA, QL (30 per 30 days) 90 MG TABLET, 180 MG TABLET) ALUNBRIG 30 MG TABLET Tier 3 PA, QL (180 per 30 days) ARRANON Tier 3 BESPONSA Tier 3 PA BICNU Tier 3 BLEO 15K Tier 1 bleomycin sulfate (15 vial, 30 vial) Tier 1 B/D PA BLINCYTO 35MCG VIAL+STABILIZER Tier 3 PA bortezomib Tier 3 PA BUSULFEX Tier 3 CAPRELSA 100 MG TABLET Tier 3 PA, QL (60 per 30 days) CAPRELSA 300 MG TABLET Tier 3 PA, 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 PA, QL (30 per 30 days) ERWINAZE Tier 3 PA 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 20 MG/ML VIAL Tier 3 PA FOLOTYN 40 MG/2 ML VIAL Tier 3 PA FUSILEV Tier 3 HALAVEN Tier 3 PA 24

33 NAME ANTINEOPLASTICS (CONTINUED) IDAMYCIN PFS Tier 3 idarubicin hcl Tier 3 IDHIFA Tier 3 PA, QL (30 per 30 days) irinotecan hcl Tier 1 ISTODAX Tier 3 PA IXEMPRA Tier 3 PA JAKAFI Tier 3 PA KADCYLA (100 MG VIAL, 160 MG VIAL) Tier 3 PA KEYTRUDA (50 MG VIAL, 100 MG/4 ML Tier 3 PA VIAL) KISQALI Tier 3 PA, QL (63 per 28 days) KISQALI FEMARA 200 MG CO-PACK Tier 3 PA, QL (49 per 28 days) KISQALI FEMARA 400 MG CO-PACK Tier 3 PA, QL (70 per 28 days) KISQALI FEMARA 600 MG CO-PACK Tier 3 PA, QL (91 per 28 days) KYPROLIS Tier 3 PA 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 PA, QL (100 per 28 days) LONSURF 20 MG-8.19 MG TABLET Tier 3 PA, QL (80 per 28 days) MARQIBO Tier 3 PA MEKINIST 0.5 MG TABLET Tier 3 PA, QL (90 per 30 days) MEKINIST 2 MG TABLET Tier 3 PA, QL (30 per 30 days) mitomycin Tier 3 mitoxantrone hcl Tier 1 NINLARO Tier 3 PA, 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 PA RUBRACA Tier 3 PA, QL (120 per 30 days) SYLATRON Tier 3 PA SYNRIBO Tier 3 PA TAFINLAR Tier 3 PA, QL (120 per 30 days) TORISEL Tier 3 PA TRISENOX Tier 3 UNITUXIN Tier 3 VELCADE Tier 3 PA VERZENIO Tier 3 PA, QL (60 per 30 days) vinblastine sulfate Tier 1 B/D PA VINCASAR PFS (1 MG/ML VIAL, 2 MG/2 ML VIAL) Tier 1 B/D PA 25

34 NAME ANTINEOPLASTICS (CONTINUED) vincristine sulfate (1 mg/ml vial, 2 mg/2 ml vial) Tier 1 B/D PA vinorelbine tartrate Tier 1 VYXEOS Tier 3 PA XALKORI Tier 3 PA YERVOY 200 MG/40 ML VIAL Tier 3 PA YERVOY 50 MG/10 ML VIAL Tier 3 PA ZEJULA Tier 3 PA, QL (90per 30 days) ZELBORAF Tier 3 PA ZINECARD Tier 3 ZOLINZA Tier 3 PA, 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 PA, QL (30 per 30 days) AFINITOR (7.5 MG TABLET, 10 MG Tier 3 PA, QL (60 per 30 days) TABLET) AFINITOR DISPERZ (2 MG TABLET, 3 Tier 3 PA MG TABLET) AFINITOR DISPERZ 5 MG TABLET Tier 3 PA, QL (112 per 28 days) ALECENSA Tier 3 PA, QL (240 per 30 days) BELEODAQ Tier 3 PA BOSULIF (400 MG TABLET, 500 MG Tier 3 PA, QL (30 per 30 days) TABLET) BOSULIF 100 MG TABLET Tier 3 PA, QL (120 per 30 days) CABOMETYX Tier 3 PA, QL (30 per 30 days) CALQUENCE Tier 3 PA, QL (60 per 30 days) COMETRIQ Tier 3 PA COTELLIC Tier 3 PA, QL (63 per 28 days) CYRAMZA Tier 3 PA FARYDAK Tier 3 PA, QL (6 per 21 days) 26

35 NAME ANTINEOPLASTICS (CONTINUED) GILOTRIF Tier 3 PA, QL (30 per 30 days) IBRANCE Tier 3 PA, QL (21 per 28 days) ICLUSIG Tier 3 PA imatinib mesylate 100 mg tab Tier 3 PA, QL (120 per 30 days) imatinib mesylate 400 mg tab Tier 3 PA, QL (60 per 30 days) IMBRUVICA (70 MG CAPSULE, 140 MG Tier 3 PA, QL (30 per 30 days) TABLET, 280 MG TABLET, 420 MG TABLET, 560 MG TABLET) IMBRUVICA 140 MG CAPSULE Tier 3 PA, QL (120 per 30 days) INLYTA 1 MG TABLET Tier 3 PA, QL (180 per 30 days) INLYTA 5 MG TABLET Tier 3 PA, QL (120 per 30 days) IRESSA Tier 3 PA, QL (30 per 30 days) JEVTANA Tier 3 PA LENVIMA (18 MG DAILY, 24 MG Tier 3 PA, QL (90 per 30 days) DAILY) LENVIMA (8 MG DAILY, 14 MG DAILY, Tier 3 PA, QL (60 per 30 days) 20 MG DAILY) LENVIMA 10 MG DAILY DOSE Tier 3 PA, QL (30 per 30 days) LYNPARZA (100 MG TABLET, 150 MG Tier 3 PA, QL (120 per 30 days) TABLET) LYNPARZA 50 MG CAPSULE Tier 3 PA, QL (480 per 30 days) NERLYNX Tier 3 PA, QL (180 per 30 days) NEXAVAR Tier 3 PA, QL (120 per 30 days) ODOMZO Tier 3 PA, QL (30 per 30 days) RYDAPT Tier 3 PA, QL (240 per 30 days) SPRYCEL (20 MG TABLET, 50 MG Tier 3 PA, QL (60 per 30 days) TABLET, 70 MG TABLET) SPRYCEL (80 MG TABLET, 100 MG Tier 3 PA, QL (30 per 30 days) TABLET, 140 MG TABLET) STIVARGA Tier 3 PA SUTENT Tier 3 PA, QL (30 per 30 days) TAGRISSO Tier 3 PA, QL (30 per 30 days) TARCEVA Tier 3 QL (30 per 30 days) TASIGNA Tier 3 PA, QL (120 per 30 days) TYKERB Tier 3 PA, QL (150 per 30 days) VECTIBIX Tier 3 VENCLEXTA 10 MG TABLET Tier 3 PA, QL (42 per 28 days) VENCLEXTA 100 MG TABLET Tier 3 PA, QL (112 per 28 days) VENCLEXTA 50 MG TABLET Tier 3 PA, QL (224 per 28 days) VENCLEXTA STARTING PACK Tier 3 PA, QL (42 per 28 days) ZALTRAP 100 MG/4 ML VIAL Tier 3 PA ZALTRAP 200 MG/8 ML VIAL Tier 3 PA 27

36 NAME ANTINEOPLASTICS (CONTINUED) ZYDELIG Tier 3 PA, QL (60 per 30 days) ZYKADIA Tier 3 PA MONOCLONAL ANTIBODY/ANTIBODY- CONJUGATE ARZERRA Tier 3 PA AVASTIN Tier 3 PA BAVENCIO Tier 3 PA DARZALEX Tier 3 PA EMPLICITI Tier 3 PA ERBITUX 100 MG/50 ML VIAL Tier 3 PA ERBITUX 200 MG/100 ML VIAL Tier 3 PA GAZYVA Tier 3 PA HERCEPTIN Tier 3 IMFINZI Tier 3 PA LARTRUVO Tier 3 PA MYLOTARG Tier 3 PA OPDIVO (40 MG/4 ML VIAL, 100 MG/10 Tier 3 PA ML VIAL, 240 MG/24 ML VIAL) PERJETA Tier 3 PA PORTRAZZA Tier 3 PA RITUXAN Tier 3 PA RITUXAN HYCELA Tier 3 PA TECENTRIQ Tier 3 PA 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 ANTIPARASITICS ANTHELMINTICS ALBENZA Tier 3 BILTRICIDE Tier 3 EMVERM Tier 3 ivermectin Tier 1 praziquantel Tier 2 SOOLANTRA Tier 3 ST ANTIPROTOZOALS ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) Tier 3 28

37 NAME ANTIPARASITICS (CONTINUED) 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 PA quinine sulfate Tier 2 PA SOLOSEC Tier 3 tinidazole Tier 1 PEDICULICIDES/ SCABICIDES 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 PA, QL (60 per 30 days) GOCOVRI ER 68.5 MG CAPSULE Tier 3 PA, 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, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) Tier 1 QL (90 per 30 days) 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 29

38 NAME ANTIPARKINSON AGENTS (CONTINUED) carbidopa-levodopa ( mg odt, mg odt, mg odt) carbidopa-levodopa ( tab, tab, Tier 2 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 ST, QL (30 per 30 days) XADAGO 50 MG TABLET Tier 3 ST, QL (46 per 30 days) ZELAPAR Tier 3 ST ANTIPSYCHOTICS 1ST GENERATION/TYPICAL ADASUVE Tier 3 chlorpromazine hcl (10 mg tablet, 25 mg/ml amp, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) Tier 2 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 (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 5 mg/ml ampul, 10 mg tablet, 20 mg tablet) Tier 1 haloperidol decanoate Tier 1 haloperidol decanoate 100 Tier 1 haloperidol lactate Tier 1 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 tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) Tier 1 aripiprazole 1 mg/ml solution Tier 2 30

39 NAME ANTIPSYCHOTICS (CONTINUED) aripiprazole odt Tier 2 ARISTADA Tier 3 FANAPT Tier 3 PA, QL (60 per 30 days) GEODON 20 MG/ML VIAL Tier 3 INVEGA SUSTENNA (39 MG/0.25 ML, 78 Tier 3 ST MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML) INVEGA TRINZA (273 MG/0.875 ML, 410 Tier 3 ST MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML) LATUDA Tier 3 PA, QL (30 per 30 days) NUPLAZID Tier 3 PA, 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) 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 Tier 2 QL (30 per 30 days) mg tablet, er 200 mg tablet) REXULTI (0.25 MG TABLET, 2 MG Tier 3 PA, QL (30 per 30 days) TABLET, 3 MG TABLET, 4 MG TABLET) REXULTI (0.5 MG TABLET, 1 MG Tier 3 PA, QL (120 per 30 days) TABLET) 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) risperidone odt Tier 2 SAPHRIS Tier 3 PA, QL (60 per 30 days) VRAYLAR (1.5 MG CAPSULE, 3 MG Tier 3 PA, QL (30 per 30 days) CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) VRAYLAR 1.5 MG-3 MG PACK Tier 3 PA ziprasidone hcl Tier 1 ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT, 300 MG VL KIT, 405 MG VL KIT) Tier 3 31

40 NAME ANTIPSYCHOTICS (CONTINUED) TREATMENT-RESISTANT clozapine Tier 1 clozapine odt Tier 1 VERSACLOZ Tier 3 QL (540 per 30 days) ANTISPASTICITY AGENTS ANTISPASTICITY AGENTS baclofen (10 mg tablet, 20 mg tablet) 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) 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 PA, QL (30 per 30 days) EPCLUSA Tier 3 PA, QL (30 per 30 days) HARVONI Tier 3 PA, QL (30 per 30 days) MAVYRET Tier 3 PA, QL (90per 30 days) OLYSIO Tier 3 PA, QL (30 per 30 days) SOVALDI Tier 3 PA, QL (30 per 30 days) TECHNIVIE Tier 3 PA, QL (60 per 30 days) VIEKIRA PAK Tier 3 PA, QL (112 per 28 days) VIEKIRA XR Tier 3 PA, QL (90 per 30 days) 32

41 NAME ANTIVIRALS (CONTINUED) VOSEVI Tier 3 PA, QL (30 per 30 days) ZEPA Tier 3 PA, 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 PA, QL (4 per 28 days) PEGINTRON REDIPEN Tier 3 PA, QL (4 per 28 days) REBETOL 40 MG/ML SOLUTION Tier 3 PA RIBASPHERE (200 MG TABLET, 200 MG Tier 1 PA CAPSULE, 400 MG TABLET) RIBASPHERE 600 MG TABLET Tier 3 PA RIBASPHERE RIBAPAK Tier 3 PA ribavirin (200 mg capsule, 200 mg tablet) Tier 1 PA ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA Tier 3 QL (30 per 30 days) 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 PA 33

42 NAME ANTIVIRALS (CONTINUED) 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) 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 zidovudine (50 mg/5 ml syrup, 100 mg capsule, Tier mg tablet) ANTI-HIV AGENTS, OTHER 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, MG TABLET) Tier 3 34

43 NAME ANTIVIRALS (CONTINUED) LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) Tier 3 lopinavir-ritonavir Tier 3 NORVIR (80 MG/ML SOLUTION, 100 Tier 2 MG SOFTGEL CAP, 100 MG TABLET) 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, Tier 3 QL (60 per 30 days) 400 MG TABLET) 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 mg/10 ml vial, 1,000 mg/20 ml vial) Tier 1 B/D PA 35

44 NAME ANTIVIRALS (CONTINUED) 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 diazepam (2 mg tablet, 5 mg/ml vial, 5 mg Tier 1 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 Tier 1 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 2 mg tablet, 4 mg/ml vial, 4 mg/ml 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 (6.25 mg tablet, 12.5 mg tablet, 25 Tier 3 ST, QL (30 per 30 days) mg tablet) alogliptin-metformin ( , ) Tier 3 ST, QL (60 per 30 days) alogliptin-pioglitazone ( mg, Tier 3 ST, QL (30 per 30 days) mg, mg, mg tb, mg tb, mg tb) AVANDIA (2 MG TABLET, 4 MG TABLET) Tier 3 QL (60 per 30 days) 36

45 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) 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 PA, QL (90 per 30 days) CYCLOSET Tier 3 DIABETA 1.25 MG TABLET Tier 3 PA, QL (60 per 30 days) DIABETA 2.5 MG TABLET Tier 3 PA, QL (90 per 30 days) DIABETA 5 MG TABLET Tier 3 PA, 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) 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 PA, QL (120 per 30 days) GLUMETZA ER 1,000 MG TABLET Tier 3 PA, QL (60 per 30 days) GLUMETZA ER 500 MG TABLET Tier 3 PA, QL (120 per 30 days) glyburid-metformin mg Tier 2 PA, QL (60 per 30 days) glyburide 1.25 mg tablet Tier 2 PA, QL (60 per 30 days) glyburide 2.5 mg tablet Tier 2 PA, QL (90 per 30 days) glyburide 5 mg tablet Tier 2 PA, QL (120 per 30 days) glyburide micronized Tier 2 PA, QL (60 per 30 days) glyburide-metformin hcl ( mg, Tier 2 PA, QL (120 per 30 days) mg) GLYNASE Tier 3 PA, 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) 37

46 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) 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 (12.5-1,000 MG TABLET, Tier 3 ST, QL (60 per 30 days) 500 MG TABLET) 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) metformin hcl er 1000 mg tablet (generic for Tier 3 PA, 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 PA, 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 (6.25 MG TABLET, 12.5 MG Tier 3 ST, QL (30 per 30 days) TABLET, 25 MG TABLET) ONGLYZA Tier 2 QL (30 per 30 days) OSENI ( MG TABLET, MG Tier 3 ST, QL (30 per 30 days) TABLET, MG TABLET, MG TABLET, MG TABLET, MG TABLET) 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) 38

47 NAME BLOOD GLUCOSE REGULATORS (CONTINUED) 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 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 39

48 NAME 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 Tier 1 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) 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 PA, QL (30 per 30 days) BLOOD FORMATION MODIFIERS anagrelide hcl Tier 1 ARANESP Tier 3 PA azacitidine Tier 1 EPOGEN Tier 3 PA GRANIX Tier 3 LEUKINE Tier 3 MIRCERA Tier 3 MOZOBIL Tier 3 PA NEULASTA Tier 3 QL (2 per 30 days) NEUPOGEN Tier 3 PROCRIT Tier 3 PA PROMACTA (12.5 MG TABLET, 50 MG TABLET, 75 MG TABLET) Tier 3 PA, QL (30 per 30 days) 40

49 NAME BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (CONTINUED) PROMACTA 25 MG TABLET Tier 3 PA, 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) 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 mg tablet) Tier 1 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 PA, 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 (40 MG TABLET, 80 MG TABLET) EDARBYCLOR ( MG TABLET, MG TABLET) Tier 3 Tier 3 ST, QL (30 per 30 days) ST, QL (30 per 30 days) 41

50 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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) valsartan (40 mg tablet, 80 mg tablet, 160 mg Tier 1 QL (60 per 30 days) tablet) 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 42

51 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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 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 (CR 10 MG CAPSULE, CR 20 Tier 3 ST, QL (30 per 30 days) MG CAPSULE, CR 40 MG CAPSULE, CR 80 MG CAPSULE) 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 43

52 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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) CARDENE I.V. (CARDENE-DEX 20 Tier 3 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) 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 Tier 1 mg cap, 24hr 240 mg cap, 24hr 180 mg cap, 24hr 120 mg cap) diltiazem 24hr er (24hr er 240 mg tab, 24hr er Tier 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) 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, er 90 mg tablet) Tier 1 44

53 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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 Tier 1 ampul, 5 mg/2 ml vial, 40 mg tablet, 80 mg tablet, 120 mg tablet, 360 mg cap pellet) verapamil sr Tier 1 CARDIOVASCULAR AGENTS, OTHER CORLANOR Tier 3 QL (60 per 30 days) 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 45

54 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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 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 (20 MG TABLET, 40 MG Tier 3 ST, QL (30 per 30 days) TABLET, 60 MG TABLET) 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 46

55 NAME CARDIOVASCULAR AGENTS (CONTINUED) DYSLIPIDEMICS, OTHER cholestyramine (packet, powder) Tier 1 cholestyramine light (packet, powder) Tier 1 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 PA, QL (30 per 30 days) KYNAMRO Tier 3 PA, QL (4 per 28 days) niacin er (er 750 mg tablet, er 1,000 mg Tier 1 QL (60 per 30 days) tablet) 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 PA, QL (2 per 28 days) PRALUENT SYRINGE (75 MG/ML Tier 3 PA, QL (2 per 28 days) SYRINGE, 150 MG/ML SYRINGE) PREVALITE (PACKET, POWDER) Tier 1 REPATHA PUSHTRONEX Tier 3 PA, QL (4 per 30 days) REPATHA SURECLICK Tier 3 PA, QL (2 per 28 days) REPATHA SYRINGE Tier 3 PA, 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 47

56 NAME CARDIOVASCULAR AGENTS (CONTINUED) 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 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 PA 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 tablet, 5 mg chew tab, 10 mg chew tab, 10 mg tablet, 20 mg tablet) Tier 2 48

57 NAME CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) 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) methylphenidate la 30 mg cap Tier 2 QL (60 per 30 days) RITALIN LA 10 MG CAPSULE Tier 3 CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO (9 MG TABLET, 12 MG Tier 3 PA, QL (120 per 30 days) TABLET) AUSTEDO 6 MG TABLET Tier 3 PA, QL (60 per 30 days) INGREZZA 40 MG CAPSULE Tier 3 PA, QL (60 per 30 days) INGREZZA 80 MG CAPSULE Tier 3 PA, QL (30 per 30 days) NUEDEXTA Tier 3 PA, 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 PA, QL (240 per 30 days) tetrabenazine 25 mg tablet Tier 3 PA, 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 ST, QL (60 per 30 days) SAVELLA TITRATION PACK Tier 3 ST MULTIPLE SCLEROSIS AGENTS AMPYRA Tier 3 PA, 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 PA, QL (14 per 28 days) COPAXONE 20 MG/ML SYRINGE Tier 3 PA, QL (30 per 30 days) 49

58 NAME CENTRAL NERVOUS SYSTEM AGENTS (CONTINUED) COPAXONE 40 MG/ML SYRINGE Tier 3 QL (12 per 28 days) EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) Tier 3 PA, QL (15 per 30 days) GILENYA 0.5 MG CAPSULE Tier 3 QL (30 per 30 days) 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 PA OCREVUS Tier 3 PA 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 PA ZINBRYTA Tier 3 PA 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 PA adapalene (0.1% cream, 0.1% gel, 0.3% gel, Tier 3 PA 0.3% gel pump) adapalene-benzoyl peroxide Tier 2 ammonium lactate Tier 1 AMNESTEEM Tier 2 ATRALIN Tier 3 PA 50

59 NAME DERMATOLOGICAL AGENTS (CONTINUED) AVITA Tier 3 PA 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 perox 1.2-5% Tier 2 clinda-benzoyl perox 1-5% pump Tier 2 clindamycin phos-benzoyl perox Tier 2 clindamycin phos-tretinoin Tier 3 clindamycin-benzoyl perox 1-5% Tier 2 CONDYLOX (0.5% TOPICAL SOLN, 0.5% Tier 3 GEL) COSENTYX (2 SYRINGES) Tier 3 PA, QL (10 per 28 days) COSENTYX PEN Tier 3 PA, QL (10 per 28 days) COSENTYX PEN (2 PENS) Tier 3 PA, QL (10 per 28 days) COSENTYX SYRINGE Tier 3 PA, QL (10 per 28 days) dapsone 5% gel Tier 2 PA diclofenac sodium 3% gel Tier 3 DIFFERIN (0.1% CREAM, 0.1% LOTION, Tier 3 PA 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 ST EPIDUO ( % GEL, % GEL Tier 3 PUMP) EPIDUO FORTE Tier 3 erythromycin-benzoyl peroxide Tier 2 FABIOR Tier 3 PA FINACEA Tier 3 fluorouracil (2% topical soln, 5% cream, 5% Tier 1 topical soln) fluorouracil 0.5% cream Tier 3 imiquimod Tier 2 isotretinoin Tier 2 methoxsalen Tier 3 MYORISAN Tier 2 ONEXTON GEL PUMP Tier 3 PICATO Tier 3 51

60 NAME DERMATOLOGICAL AGENTS (CONTINUED) podofilox Tier 1 PRUDOXIN Tier 3 REGRANEX Tier 3 RETIN-A Tier 3 PA RETIN-A MICRO Tier 3 PA RETIN-A MICRO PUMP (PUMP 0.04% Tier 3 PA 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 ST tacrolimus (0.03% ointment, 0.1% ointment) Tier 1 QL (100 per 30 days) TALTZ AUTOINJECTOR Tier 3 PA, QL (4 per 28 days) TALTZ AUTOINJECTOR (2 PACK) Tier 3 PA, QL (4 per 28 days) TALTZ AUTOINJECTOR (3 PACK) Tier 3 PA, QL (4 per 28 days) TALTZ SYRINGE Tier 3 PA, QL (4 per 28 days) TALTZ SYRINGE (2 PACK) Tier 3 PA, QL (4 per 28 days) TALTZ SYRINGE (3 PACK) Tier 3 PA, QL (4 per 28 days) tazarotene Tier 2 PA TAZORAC (0.05% CREAM, 0.05% GEL, Tier 3 PA 0.1% CREAM, 0.1% GEL) TOLAK Tier 3 TRETIN-X (0.0375% CREAM, 0.075% Tier 3 PA CREAM) tretinoin (0.01% gel, 0.025% gel, 0.025% Tier 2 PA cream, 0.05% cream, 0.05% gel, 0.1% cream) tretinoin microsphere Tier 3 PA 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 52

61 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 PA 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 dextrose 5%-potassium chloride Tier 1 FREAMINE HBC Tier 3 B/D PA 53

62 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) 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% (40 meq/30 ml, 10 meq/100 ml sol, er 10 meq capsule, er 10 meq tablet, 10% (20 meq/15 ml, 20 meq/100 ml sol, 20 meq/50 ml sol, 20% (40 meq/15 ml, 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 54

63 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) potassium citrate er Tier 1 potassium cl 20 meq packet (qualitest and Tier 3 virtus manufacturers only) potassium cl 20 meq-0.45% nacl Tier 3 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 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 ST DEPEN Tier 3 EXJADE Tier 3 FERRIPROX (100 MG/ML SOLUTION, Tier MG TABLET) JADENU Tier 3 JADENU SPRINKLE Tier 3 55

64 NAME ELECTROLYTES/MINERALS/METALS/VITAMINS (CONTINUED) JYNARQUE Tier 3 PA, QL (56 per 28 days) KIONEX (15 GM/60 ML SUSPENSION, Tier 1 POWDER) SAMSCA Tier 3 PA 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 ST trientine hcl Tier 3 ST VELTASSA Tier 3 QL (30 per 30 days) PHOSPHATE BINDERS AURYXIA Tier 3 ST calcium acetate (667 mg capsule, 667 mg Tier 1 tablet, 667 mg gelcap) ELIPHOS Tier 1 FOSRENOL (500 MG TABLET CHEW, Tier 3 ST 750 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 QL (270 per 30 days) VITAMINS cyanocobalamin injection Tier 1 EX folic acid 1 mg tablet Tier 1 EX MEPHYTON 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 Tier 1 mg/ml syringe, 0.1 mg/ml abboject) 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 glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1 mg/5 ml vial, 1 mg tablet, 2 mg tablet, 4 mg/20 ml vial) Tier 1 56

65 NAME GASTROINTESTINAL AGENTS (CONTINUED) 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 PA loperamide 2 mg capsule Tier 1 MOVANTIK Tier 2 QL (30 per 30 days) MYTESI Tier 3 PA 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 PA, QL (30 per 30 days) RELISTOR 150 MG TABLET Tier 3 PA, QL (90 per 30 days) SUPREP Tier 3 SYMPROIC Tier 3 PA, 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 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 57

66 NAME GASTROINTESTINAL AGENTS (CONTINUED) 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 Tier 1 MOVIPREP Tier 3 peg 3350 electrolyte soln Tier 1 peg-3350 and electrolytes Tier 1 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, Tier 3 QL (60 per 30 days) 20-1,100 cap, 40-1,100 cap, 40-1,680 pkt) pantoprazole sodium (dr 20 mg tab, dr 40 mg Tier 1 QL (60 per 30 days) tab) pantoprazole sodium 40 mg vial Tier 2 PRILOSEC DR SUSPENSION Tier 3 rabeprazole sodium Tier 1 QL (60 per 30 days) 58

67 NAME GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ADAGEN Tier 3 ALDURAZYME Tier 3 PA ARALAST NP (500 MG VIAL, 1,000 MG Tier 3 PA VIAL) BUPHENYL 500 MG TABLET Tier 3 CERDELGA Tier 3 PA, QL (56 per 28 days) CEREZYME Tier 3 PA CHOLBAM Tier 3 PA CREON Tier 2 CYSTADANE Tier 3 CYSTAGON Tier 3 ELAPRASE Tier 3 PA ELELYSO Tier 3 PA EXONDYS 51 Tier 3 PA FABRAZYME (5 MG VIAL, 35 MG VIAL) Tier 3 PA GLASSIA Tier 3 PA KANUMA Tier 3 PA KRYSTEXXA Tier 3 PA KUVAN Tier 3 PA LUMIZYME Tier 3 miglustat Tier 3 PA NAGLAZYME Tier 3 PA OCALIVA Tier 3 PA, QL (30 per 30 days) ORFADIN (2 MG CAPSULE, 4 MG/ML Tier 3 PA SUSPENSION, 5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) PANCREAZE Tier 2 PROCYSBI Tier 3 PA PROLASTIN C (1,000 MG/20 ML VL, Tier 3 PA 1,000 MG VIAL) RAVICTI Tier 3 PA sodium phenylbutyrate (500mg tb, powder) Tier 3 STRENSIQ (18 MG/0.45 ML VIAL, 28 Tier 3 PA MG/0.7 ML VIAL, 40 MG/ML VIAL) STRENSIQ 80 MG/0.8 ML VIAL Tier 3 PA, QL (38.4 per 28 days) SUCRAID Tier 3 VIMIZIM Tier 3 PA VPRIV Tier 3 PA ZAVESCA Tier 3 PA ZEMAIRA Tier 3 PA ZENPEP Tier 3 59

68 NAME GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin er Tier 1 QL (30 per 30 days) flavoxate hcl Tier 1 GELNIQUE (10% GEL SACHETS, 10% Tier 3 QL (30 per 30 days) 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 Tier 2 PA, QL (30 per 30 days) CIALIS 5 MG TABLET Tier 2 PA, QL (30 per 30 days) ELMIRON Tier 3 LEVITRA Tier 3 QL (6 per 30 days), (capped benefit)ex 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 THIOLA Tier 3 VIAGRA Tier 3 QL (6 per 30 days), (capped benefit)ex 60

69 NAME 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 ST 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 Tier % spray, 0.05% gel, 0.05% shampoo) clocortolone pivalate Tier 1 CORDRAN (4 CM TAPE LARGE, 4 CM Tier 3 ST 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 ST desonide (0.05% ointment, 0.05% lotion, Tier % cream) desoximetasone Tier 2 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 INTENSOL Tier 1 61

70 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) 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 PA 30 MG TABLET, 36 MG TABLET) EMFLAZA 18 MG TABLET Tier 3 PA, QL (30 per 30 days) EMFLAZA 6 MG TABLET Tier 3 PA, 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 fluticasone propionate (0.005% oint, 0.05% Tier 1 cream) H.P. ACTHAR Tier 3 PA halobetasol propionate Tier 1 HALOG (0.1% CREAM, 0.1% Tier 3 ST OINTMENT) 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 ST KENALOG-10 Tier 3 KENALOG-40 Tier 3 LOCOID 0.1% LOTION Tier 3 ST LOCORT Tier 3 B/D PA 62

71 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) 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 ST 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 Tier 3 B/D PA soln, 20 mg/5 ml soln) 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 ST SOLU-CORTEF (100 MG VIAL, 250 MG Tier 3 B/D PA VIAL, 500 MG VIAL, 1,000 MG VIAL) SOLU-MEDROL (1 GM VIAL, 40 MG Tier 3 B/D PA VIAL, 125 MG VIAL, 500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) TAPERDEX Tier 3 B/D PA TOPICORT 0.25% SPRAY Tier 3 ST triamcinolone mg/g spray Tier 2 triamcinolone mg/g topical spray Tier 2 63

72 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) (CONTINUED) 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 Tier 3 B/D PA ZONACORT Tier 3 B/D PA HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) chorionic gonadotropin Tier 3 PA 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) desmopressin acetate (0.1 mg tb, 0.2 mg tb) Tier 1 EGRIFTA 1 MG VIAL Tier 3 PA EGRIFTA 2 MG VIAL Tier 3 PA GENOTROPIN (MINIQUICK 0.4 MG, Tier 3 PA 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 PA HUMATROPE Tier 3 PA INCRELEX Tier 3 PA NOCTIVA Tier 3 NORDITROPIN FLEXPRO Tier 3 PA NOVAREL (5,000 UNIT VIAL, 10,000 Tier 3 PA UNITS VIAL) NUTROPIN AQ Tier 3 PA NUTROPIN AQ NUSPIN Tier 3 PA OMNITROPE (5 MG/1.5 ML CRTG, 5.8 Tier 3 PA MG VIAL, 10 MG/1.5 ML CRTG) PREGNYL Tier 3 PA SAIZEN Tier 3 PA SAIZEN-SAIZENPREP Tier 3 PA 64

73 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) (CONTINUED) SEROSTIM Tier 3 PA STIMATE Tier 3 ZOMACTON Tier 3 PA ZORBTIVE Tier 3 PA 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 PA, QL (30 per 30 days) ANDROGEL (1%(2.5G) GEL PACKET, Tier 2 PA, QL (300 per 30 days) 1%(5G) GEL PACKET) ANDROGEL (1.62% GEL PUMP, Tier 2 PA, QL (150 per 30 days) 1.62%(2.5G) GEL PCKT) ANDROGEL 1.62%(1.25G) GEL PCKT Tier 2 PA, QL (38 per 30 days) ANDROXY Tier 1 AXIRON Tier 3 PA, QL (180 per 30 days) danazol Tier 1 FORTESTA Tier 3 PA, QL (120 per 30 days) METHITEST Tier 3 methyltestosterone Tier 2 NATESTO Tier 3 PA STRIANT Tier 3 PA, QL (60 per 30 days) TESTIM Tier 3 PA, QL (300 per 30 days) testosterone (12.5 mg/1.25 gram, 25 mg/2.5 Tier 3 PA, QL (300 per 30 days) gm pkt, 50 mg/5 gram pkt) testosterone 10 mg gel pump Tier 3 PA, QL (120 per 30 days) testosterone 30 mg/1.5 ml pump Tier 3 PA, QL (180 per 30 days) testosterone 50 mg/5 gram gel Tier 3 PA, QL (300 per 30 days) testosterone cypionate Tier 1 testosterone enanthate Tier 1 VOGELXO Tier 3 PA, 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 65

74 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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 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 66

75 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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 FYAVOLV Tier 1 GIANVI Tier 1 GILDAGIA Tier 1 GILDESS (1 MG-20 MCG TABLET, 1.5 Tier 1 MG-30 MCG TABLET) GILDESS 24 FE Tier 1 GILDESS FE (1-20 TABLET, Tier 1 TABLET) 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, TABLET) Tier 1 67

76 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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 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) 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 68

77 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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 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-PREVIFEM Tier 1 TRI-SPRINTEC Tier 1 TRI-VYLIBRA Tier 1 TRINESSA Tier 1 TRIVORA-28 Tier 1 TYDEMY Tier 3 VELIVET Tier 1 69

78 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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 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 caproate Tier 3 JENCYCLA Tier 1 JOLIVETTE Tier 1 KYLEENA Tier 3 LILETTA Tier 3 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 capsule) Tier 1 70

79 NAME HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) (CONTINUED) 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) 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 PA leuprolide acetate (2wk 1 mg/0.2 ml kit, 2wk Tier 1 PA 14 mg/2.8 ml kt) LUPRON DEPOT (DEPOT 3.75 MG KIT, Tier 3 PA DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, DEPOT MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 MG 6MO KIT) LUPRON DEPOT (LUPANETA) (DEPO Tier 3 PA 11.25MG (LUPANETA), DEPOT 3.75MG (LUPANETA)) LUPRON DEPOT-PED (7.5 MG KIT, MG KIT, MG 3MO, 15 MG KIT, 30 MG 3MO KIT) Tier 3 PA 71

80 NAME HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (CONTINUED) 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) SANDOSTATIN LAR Tier 3 SANDOSTATIN LAR DEPOT Tier 3 SIGNIFOR LAR Tier 3 PA, QL (1 per 28 days) SOMATULINE DEPOT (60 MG/0.2 ML, Tier 3 PA 90 MG/0.3 ML) SOMATULINE DEPOT 120 MG/0.5 ML Tier 3 PA SOMAVERT Tier 3 PA SYNAREL Tier 3 TRELSTAR (3.75 MG SYRINGE, Tier 3 PA MG SYRINGE, 22.5 MG VIAL, 22.5 MG SYRINGE) TRELSTAR (3.75 MG VIAL, MG Tier 3 PA VIAL) TRIPTODUR Tier 3 PA HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole Tier 1 propylthiouracil Tier 1 IMMUNOLOGICAL AGENTS ANGIOEDEMA AGENTS BERINERT 500 UNIT KIT Tier 3 PA CINRYZE Tier 3 PA FIRAZYR Tier 3 PA HAEGARDA Tier 3 PA, QL (16 per 28 days) RUCONEST Tier 3 PA IMMUNE SUPPRESSANTS ACTEMRA (162 MG/0.9 ML SYRINGE, Tier 3 PA 200 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 PA VIAL) BENLYSTA (200 MG/ML SYRINGE, 200 MG/ML AUTOINJECT) Tier 3 PA, QL (4 per 28 days) 72

81 NAME IMMUNOLOGICAL AGENTS (CONTINUED) CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET, 500 MG VIAL) CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT, 200 MG VIAL KIT) cyclosporine (25 mg capsule, 50 mg/ml ampul, 100 mg capsule) cyclosporine modified (25 mg, 50 mg, 100mg/ml, 100 mg) ENBREL (25 MG/0.5 ML SYRINGE, 50 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 B/D PA PA, QL (6 per 28 days) B/D PA B/D PA PA, QL (8 per 28 days) MG/ML SYRINGE) ENBREL 25 MG KIT Tier 3 PA, QL (16 per 28 days) ENBREL MINI Tier 3 PA, QL (8 per 28 days) ENBREL SURECLICK Tier 3 PA, 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) HUMIRA (10 MG/0.2 ML SYRINGE, 10 MG/0.1 ML SYRINGE) HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) Tier 1 Tier 3 Tier 3 B/D PA PA, QL (2 per 28 days) PA, QL (6 per 28 days) HUMIRA PED CROHNS 40 MG/0.8 ML Tier 3 PA, QL (6 per 28 days) HUMIRA PED CROHNS 80 MG/0.8 ML Tier 3 PA, QL (3 per 28 days) HUMIRA PEDIATR CROHN'S 80-40MG Tier 3 QL (6 per 28 days) HUMIRA PEN Tier 3 PA, QL (6 per 28 days) HUMIRA PEN CROHN-UC-HS Tier 3 PA, QL (6 per 28 days) STARTER HUMIRA PEN PSORIASIS-UVEITIS Tier 3 PA, QL (6 per 28 days) INFLECTRA Tier 3 PA 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 73

82 NAME IMMUNOLOGICAL AGENTS (CONTINUED) NULOJIX Tier 3 PA ORENCIA (125 MG/ML SYRINGE, 250 Tier 3 PA MG VIAL) ORENCIA 50 MG/0.4 ML SYRINGE Tier 3 PA, QL (1.6 per 28 days) ORENCIA 87.5 MG/0.7 ML SYRINGE Tier 3 PA, QL (2.8 per 28 days) ORENCIA CLICKJECT Tier 3 PA, QL (4 per 28 days) PROGRAF (0.5 MG CAPSULE, 1 MG Tier 3 B/D PA CAPSULE, 5 MG CAPSULE, 5 MG/ML AMPULE) PROLIA Tier 3 PA RAPAMUNE (0.5 MG TABLET, 1 Tier 3 B/D PA MG/ML ORAL SOLN, 1 MG TABLET, 2 MG TABLET) REMICADE Tier 3 PA RENFLEXIS Tier 3 PA SANDIMMUNE (25 MG CAPSULE, 50 Tier 3 B/D PA MG/ML AMPUL, 100 MG CAPSULE, 100 MG/ML SOLN) SIMPONI Tier 3 PA, QL (1 per 28 days) SIMPONI ARIA Tier 3 PA sirolimus Tier 1 B/D PA SOLIRIS Tier 3 PA STELARA (45 MG/0.5 ML SYRINGE, 45 Tier 3 PA MG/0.5 ML VIAL, 90 MG/ML SYRINGE, 130 MG/26 ML VIAL) tacrolimus (0.5 mg capsule, 1 mg capsule, 5 Tier 1 B/D PA mg capsule) TREMFYA Tier 3 PA XATMEP Tier 3 B/D PA XELJANZ Tier 3 PA, QL (60 per 30 days) XELJANZ XR Tier 3 PA, QL (30 per 30 days) ZORTRESS Tier 3 B/D PA IMMUNIZING AGENTS, PASSIVE ATGAM Tier 3 PA BIVIGAM Tier 3 PA CARIMUNE NF NANOFILTERED (6 Tier 3 PA GM VIAL, 12 GM VIAL) CUVITRU Tier 3 PA FLEBOGAMMA DIF Tier 3 PA GAMMAGARD LIQUID Tier 3 PA GAMMAGARD S-D Tier 3 PA GAMMAKED (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL) Tier 3 PA 74

83 NAME IMMUNOLOGICAL AGENTS (CONTINUED) GAMMAPLEX Tier 3 PA GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 Tier 3 PA GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL) HIZENTRA Tier 3 PA HYQVIA Tier 3 PA OCTAGAM Tier 3 PA PRIVIGEN Tier 3 PA THYMOGLOBULIN Tier 3 PA IMMUNOMODULATORS ACTIMMUNE Tier 3 PA ARCALYST Tier 3 PA DUPIXENT Tier 3 PA, QL (8 per 28 days) ILARIS (150 MG/ML VIAL, 180 MG Tier 3 PA VIAL) KINERET Tier 3 PA leflunomide Tier 1 OTEZLA (28 DAY STARTER PACK, 30 Tier 3 PA, QL (60 per 30 days) MG TABLET, STARTER PACK) RIDAURA Tier 3 SIMULECT Tier 3 SYLVANT Tier 3 PA XOLAIR Tier 3 PA 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 CERVARIX 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 75

84 NAME IMMUNOLOGICAL AGENTS (CONTINUED) 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 Tier 3 B/D PA MCG/0.5 ML SYR, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL) ROTARIX Tier 3 ROTATEQ Tier 3 SHINGRIX Tier 2 PA STAMARIL Tier 3 TENIVAC Tier 3 tetanus diphtheria toxoids Tier 3 THERACYS 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 PA 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 76

85 NAME INFLAMMATORY BOWEL DISEASE AGENTS (CONTINUED) 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 COLOCORT Tier 1 CORTENEMA Tier 3 hydrocortisone 100 mg/60 ml Tier 1 UCERIS 2 MG RECTAL FOAM Tier 3 PA UCERIS 9 MG ER TABLET Tier 3 PA, QL (30 per 30 days) SULFONAMIDES sulfasalazine Tier 1 sulfasalazine dr Tier 1 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 PA, 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 PA, 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 mcg capsule) Tier 1 77

86 NAME METABOLIC BONE DISEASE AGENTS (CONTINUED) 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 PA, QL (2 per 30 days) XGEVA Tier 3 PA 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 70% prep pads Tier 3 alcohol pads Tier 3 amifostine Tier 3 aminocaproic acid (500 mg tab, 1,000 mg tab) Tier 3 autopen Tier 3 BOTOX Tier 3 PA CARNITOR 1 GM/5 ML VIAL Tier 3 CHENODAL Tier 3 clomiphene citrate Tier 3 PA 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 PA, QL (180 per 30 days) fomepizole Tier 3 78

87 NAME MISCELLANEOUS THERAPEUTIC AGENTS (CONTINUED) 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 PA KEVEYIS Tier 3 PA, QL (120 per 30 days) KORLYM Tier 3 PA, QL (120 per 30 days) levocarnitine (1 g/10 ml soln, 200 mg/ml vial, Tier mg tablet) methylergonovine 0.2 mg tablet Tier 3 METOPIRONE Tier 3 PA MYALEPT Tier 3 PA novopen echo Tier 3 NUTRILIPID Tier 3 B/D PA ORALAIR (300 IR SUBLINGUAL TAB, Tier IR ADULT SAMPLE KT, 300 IR STARTER PACK) RADICAVA Tier 3 PA RAGWITEK Tier 3 SIGNIFOR Tier 3 PA 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 PA, QL (90 per 30 days) OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER atropine 1% eye drops Tier 1 CYSTARAN Tier 3 EYLEA Tier 3 PA JETREA 1.25 MG/ML VIAL Tier 3 PA LACRISERT Tier 3 LUCENTIS Tier 3 PA 79

88 NAME OPHTHALMIC AGENTS (CONTINUED) MACUGEN Tier 3 PA 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 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 80

89 NAME OPHTHALMIC AGENTS (CONTINUED) PRED-G (1% DROPS, S.O.P. OINTMENT) Tier 3 prednisolone acetate 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 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 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) 81

90 NAME OPHTHALMIC AGENTS (CONTINUED) 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 hydrocortisone-acetic acid Tier 2 neomycin-polymyxin-hc ear susp Tier 1 neomycin-polymyxin-hydrocort Tier 1 OTOVEL Tier 3 RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ADVAIR DISKUS Tier 2 QL (60 per 30 days) ADVAIR HFA Tier 2 QL (12 per 30 days) ARNUITY ELLIPTA (100 MCG, 200 Tier 2 QL (30 per 30 days) MCG) ASMANEX Tier 2 QL (1 per 30 days) ASMANEX HFA Tier 2 QL (13 per 30 days) BREO ELLIPTA Tier 2 QL (60 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) DULERA Tier 2 QL (13 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) SYMBICORT Tier 2 QL (11 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 82

91 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) 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) diphenhydramine 50 mg/ml syrng Tier 1 diphenhydramine 50 mg/ml vial Tier 1 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 ST, QL (120 per 30 days) ZYFLO Tier 3 ST ZYFLO CR Tier 3 ST, 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 83

92 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) 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 Tier 1 B/D PA 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) 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 Tier 3 B/D PA XOPENEX CONCENTRATE Tier 3 B/D PA CYSTIC FIBROSIS KALYDECO Tier 3 PA, QL (60 per 30 days) ORKAMBI Tier 3 PA, QL (120 per 30 days) SYMDEKO Tier 3 PA, 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 PA, QL (60 per 30 days) 84

93 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) ADEMPAS Tier 3 PA, QL (90 per 30 days) epoprostenol sodium Tier 1 PA FLOLAN Tier 3 PA LETAIRIS Tier 3 PA, QL (30 per 30 days) OPSUMIT Tier 3 PA, QL (30 per 30 days) ORENITRAM ER (ER MG Tier 3 PA, QL (90 per 30 days) TABLET, ER 0.25 MG TABLET, ER 1 MG TABLET) ORENITRAM ER 2.5 MG TABLET Tier 3 PA ORENITRAM ER 5 MG TABLET Tier 3 PA, QL (90per 30 days) REMODULIN Tier 3 PA REVATIO 10 MG/12.5 ML VIAL Tier 3 PA REVATIO 10 MG/ML ORAL SUSP Tier 3 PA, QL (180 per 30 days) REVATIO 20 MG TABLET Tier 3 PA, QL (90 per 30 days) sildenafil 10 mg/12.5 ml vial Tier 3 PA sildenafil 20 mg tablet Tier 2 PA, QL (90 per 30 days) TRACLEER (32 MG TABLET FOR SUSP, Tier 3 PA, QL (60 per 30 days) 62.5 MG TABLET, 125 MG TABLET) TYVASO Tier 3 PA, QL (87 per 30 days) TYVASO INSTITUTIONAL START KIT Tier 3 PA, QL (87 per 30 days) TYVASO REFILL KIT Tier 3 PA, QL (87 per 30 days) TYVASO STARTER KIT Tier 3 PA, QL (87 per 30 days) UPTRAVI (400 MCG TABLET, 600 MCG Tier 3 PA, 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 PA, QL (140 per 28 days) UPTRAVI TITRATION PACK Tier 3 PA, QL (200 per 30 days) VELETRI Tier 3 PA VENTAVIS Tier 3 PA PULMONARY FIBROSIS AGENTS ESBRIET (267 MG TABLET, 267 MG Tier 3 PA, QL (270 per 30 days) CAPSULE) ESBRIET 801 MG TABLET Tier 3 PA, QL (90 per 30 days) OFEV Tier 3 PA, 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 PA DALIRESP 250 MCG TABLET Tier 3 QL (28 per 28 days) 85

94 NAME RESPIRATORY TRACT/PULMONARY AGENTS (CONTINUED) DALIRESP 500 MCG TABLET Tier 3 FASENRA Tier 3 PA, QL (1 per 28 days) hydrocodone-homatropine mbr (5-1.5, syrup) Tier 1 EX HYDROMET Tier 1 EX NUCALA Tier 3 PA PULMOZYME Tier 3 PA 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) SLEEP DISORDERS, OTHERS armodafinil Tier 2 PA, QL (30 per 30 days) BELSOMRA Tier 3 QL (30 per 30 days) HETLIOZ Tier 3 PA, QL (30 per 30 days) modafinil Tier 2 PA, QL (60 per 30 days) NUVIGIL Tier 3 PA, QL (30 per 30 days) 86

95 NAME SLEEP DISORDER AGENTS (CONTINUED) PROVIGIL Tier 3 PA, QL (60 per 30 days) 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 PA, QL (540 per 30 days) 87

96 Index of Drugs 8 8-MOP 50 A A-HYDROCORT 61 abacavir 33 abacavir-lamivudine 33 abacavir-lamivudine-zidovudine 33 ABELCET 19 ABILIFY MAINTENA 30 ABRAXANE 23 ABSORICA 50 ABSTRAL 1 acamprosate calcium 4 ACANYA 50 acarbose 36 acebutolol hcl 43 acetaminophen-codeine 1 ACETASOL HC 82 acetazolamide 81 acetazolamide sodium 45 acetic acid 6,82 acetic acid-aluminum 82 acetylcysteine 85 acitretin 50 ACTEMRA 72 ACTHIB 75 ACTIMMUNE 75 ACTIQ 1 ACUVAIL 80 acyclovir 35 acyclovir sodium 35 ACZONE 50 ADACEL TDAP 75 ADAGEN 59 adapalene 50 adapalene-benzoyl peroxide 50 ADASUVE 30 ADCIRCA 84 adefovir dipivoxil 32 ADEMPAS 85 ADRIAMYCIN 23 ADRUCIL 23 ADVAIR DISKUS 82 ADVAIR HFA 82 AFEDITAB CR 44 AFINITOR 26 AFINITOR DISPERZ 26 AGGRENOX 41 AKYNZEO 18 ALA-CORT 61 ALBENZA 28 albuterol sulfate 84 alclometasone dipropionate 61 alcohol pads 78 alcohol prep pads 78 ALDURAZYME 59 ALECENSA 26 alendronate sodium 77 alfuzosin hcl er 60 ALIMTA 23 ALINIA 28 ALIQOPA 24 ALKERAN 22 allopurinol 20 almotriptan malate 21 ALOCRIL 80 alogliptin 36 alogliptin-metformin 36 alogliptin-pioglitazone 36 ALOMIDE 80 ALORA 65 alosetron hcl 57 ALOXI 18 ALPHAGAN P 81 alprazolam 36 alprazolam er 36 alprazolam odt 36 alprazolam xr 36 ALREX 80 ALTAVERA ALTOPREV 46 ALUNBRIG 24 ALYACEN 65 AMABELZ 65 amantadine 35 AMBIEN 86 AMBIEN CR 86 AMBISOME 19 amcinonide 61 AMETHIA 65 AMETHIA LO 65 amifostine 78 amikacin sulfate 6 amiloride hcl 46 amiloride-hydrochlorothiazide 46 aminocaproic acid 78 aminophylline 83 AMINOSYN 53 AMINOSYN II 53 AMINOSYN II WITH ELECTROLYTES 53 AMINOSYN M 53 AMINOSYN WITH ELECTROLYTES 53 AMINOSYN-HBC 53 AMINOSYN-PF 53 AMINOSYN-RF 53 amiodarone hcl 42 amitriptyline hcl 17 amlodipine besylate 44 amlodipine besylate-benazepril 44 amlodipine-atorvastatin 44 amlodipine-olmesartan 44 amlodipine-valsartan 44 amlodipine-valsartan-hctz 44 ammonium lactate 50 AMNESTEEM 50 amoxapine 17 amoxicillin 9 amoxicillin-clavulanate pot er 9 amoxicillin-clavulanate potass 9

97 amphotericin b 19 ampicillin sodium 9 ampicillin trihydrate 9 ampicillin-sulbactam 10 AMPYRA 49 ANADROL anagrelide hcl 40 ANALPRAM HC 61 anastrozole 26 ANDRODERM 65 ANDROGEL 65 ANDROXY 65 ANGELIQ 66 ANORO ELLIPTA 85 ANZEMET 18 APEXICON E 61 APLENZIN 16 APOKYN 29 apraclonidine hcl 81 aprepitant 18 APRI 66 APTIOM 14 APTIVUS 34 ARALAST NP 59 ARANELLE 66 ARANESP 40 ARBINOXA 82 ARCALYST 75 aripiprazole 30 aripiprazole odt 31 ARISTADA 31 ARISTOSPAN 61 armodafinil 86 ARNUITY ELLIPTA 82 ARRANON 24 ARZERRA 28 asa-butalb-caffeine-codeine 1 ASACOL HD 76 ASCOMP WITH CODEINE 1 ASHLYNA 66 ASMANEX 82 ASMANEX HFA 82 aspirin-caffeine-dihydrocodein 1 aspirin-dipyridamole er 41 ASTAGRAF XL 72 atazanavir sulfate 34 atenolol 43 atenolol-chlorthalidone 43 ATGAM 74 atomoxetine hcl 48 atorvastatin calcium 46 atovaquone 29 atovaquone-proguanil hcl 29 ATRALIN 50 ATRIPLA 33 atropine sulfate 56,79 ATROVENT HFA 83 AUBAGIO 49 AUBRA 66 AURYXIA 56 AUSTEDO 49 autopen 78 AVANDIA 36,37 AVASTIN 28 AVELOX IV 11 AVIANE 66 AVITA 51 AVONEX 49 AVONEX PEN 49 AXIRON 65 azacitidine 40 AZACTAM 9 AZACTAM-ISO-OSMOTIC DEXTROSE 9 AZASAN 72 AZASITE 10 azathioprine 72 azathioprine sodium 72 azelastine hcl 80,83 AZELEX 51 azithromycin 10 AZOPT aztreonam 9 AZURETTE 66 B BACIIM 6 bacitracin 6 bacitracin-polymyxin 6 baclofen 32 balsalazide disodium 76 BALZIVA 66 BANZEL 12 BARACLUDE 32 BAVENCIO 28 BAXDELA 11 bcg (tice strain) 75 bcg vaccine (tice strain) 75 BEKYREE 66 BELBUCA 1 BELEODAQ 26 BELSOMRA 86 benazepril hcl 42 benazepril-hydrochlorothiazide 42 BENDEKA 22 BENLYSTA 72 BENTYL 56 benzonatate 85 benztropine mesylate 29 BEPREVE 80 BERINERT 72 BESIVANCE 11 BESPONSA 24 betamethasone diprop augmented 61 betamethasone dipropionate 61 betamethasone valerate 61 BETASERON 49 betaxolol hcl 43,81 bethanechol chloride 60 BETHKIS 6 BETIMOL 81 BETOPTIC S 81

98 bexarotene 28 BEXSERO 75 bicalutamide 23 BICILLIN C-R 10 BICILLIN L-A 10 BICNU 24 BIDIL 47 BIKTARVY 35 BILTRICIDE 28 bimatoprost 81 bisoprolol fumarate 43 bisoprolol-hydrochlorothiazide 43 BIVIGAM 74 BLEO 15K 24 bleomycin sulfate 24 BLEPHAMIDE 80 BLEPHAMIDE S.O.P. 80 BLINCYTO 24 BLISOVI 24 FE 66 BLISOVI FE 66 BOOSTRIX TDAP 75 bortezomib 24 BOSULIF 26 BOTOX 78 BREO ELLIPTA 82 BRIELLYN 66 BRILINTA 40 brimonidine tartrate 81 BRIVIACT 12 bromfenac sodium 80 bromocriptine mesylate 71 BROVANA 84 budesonide 82 budesonide ec 77 bumetanide 45 BUPHENYL 59 BUPRENEX 1 buprenorphine 1 buprenorphine hcl 1 buprenorphine-naloxone 4 BUPROBAN 4 bupropion hcl 16 bupropion hcl sr 4,16 bupropion xl 16 buspirone hcl 36 busulfan 22 BUSULFEX 24 butalb-acetaminoph-caff-codein 1 butalb-caff-acetaminoph-codein 2 butalbital compound-codeine 2 carbamazepine 14 butalbital-acetaminophen 2 carbamazepine er 14 butalbital-acetaminophen-caffe 2 carbidopa 29 butalbital-aspirin-caffeine 2 butorphanol tartrate 2 BUTRANS 1 BYDUREON 37 BYDUREON BCISE 37 BYDUREON PEN 37 BYETTA 37 BYSTOLIC 43 BYVALSON 43 C cabergoline 71 CABOMETYX 26 calcipotriene 51 calcipotriene-betamethasone dp 51 calcitonin-salmon 77 CALCITRENE 51 calcitriol 51,77 calcium acetate 56 calcium gluconate 53 CALQUENCE 26 CAMBIA 5 CAMILA 70 CAMRESE 66 CAMRESE LO 66 CANASA 76 CANCIDAS 19 candesartan cilexetil 41 candesartan-hydrochlorothiazid41 CAPACET 2 90 CAPASTAT SULFATE 22 CAPEX SHAMPOO 61 CAPRELSA 24 captopril 42 captopril-hydrochlorothiazide 42 CARAC 51 CARAFATE 58 CARBAGLU 53 carbidopa-levodopa 30 carbidopa-levodopa er 30 carbidopa-levodopaentacapone 30 carbinoxamine maleate 83 carboplatin 24 CARDENE I.V. 44 CARDURA XL 41 CARIMUNE NF NANOFILTERED 74 carisoprodol 86 carisoprodol compound 86 carisoprodol compoundcodeine 86 carisoprodol-aspirin 86 carisoprodol-aspirin-codeine 86 CARNITOR 78 carteolol hcl 81 CARTIA XT 44 carvedilol 43 carvedilol er 43 caspofungin acetate 19 CAYSTON 9 CAZIANT 66 cefaclor 8 cefaclor er 8 cefadroxil 8 cefazolin sodium 8 cefazolin sodium-dextrose 8 cefdinir 8

99 cefepime 8 cefepime hcl 8 cefepime-dextrose 8 cefixime 8 CEFOTAN 8 cefotaxime sodium 8 cefotetan 8 cefotetan & dextrose 8 cefoxitin 8 cefoxitin sodium 8 cefpodoxime proxetil 8 cefprozil 8 ceftazidime 8 ceftibuten 9 CEFTIN 9 ceftriaxone 9 cefuroxime 9 cefuroxime sodium 9 celecoxib 5 CELESTONE 61 CELLCEPT 73 CELONTIN 13 cephalexin 9 CERDELGA 59 CEREZYME 59 CERVARIX 75 CESAMET 18 cevimeline hcl 50 CHANTIX 4 CHATEAL 66 CHEMET 55 CHENODAL 78 chloramphenicol sod succinate 6 chlordiazepoxide hcl 36 chlordiazepoxide-amitriptyline 36 chlordiazepoxide/clidinium (select manufacturers only) 57 chlorhexidine gluconate 50 chloroquine phosphate 29 chlorothiazide 46 chlorothiazide sodium 46 chlorpromazine hcl 30 chlorpropamide 37 chlorthalidone 46 chlorzoxazone 86 CHOLBAM 59 ciclopirox 19 cidofovir 32 cilostazol 41 CILOXAN 11 CIMDUO 34 cimetidine 57 CIMZIA 73 CINQAIR 85 CINRYZE 72 CINVANTI 18 CIPRO HC 82 CIPRODEX 82 ciprofloxacin 11 ciprofloxacin er 11 ciprofloxacin hcl 11 ciprofloxacin-d5w 11 cisplatin 24 citalopram hbr 16 cladribine 23 CLARAVIS 51 clonidine patch 41 clarithromycin 10 clopidogrel 41 clarithromycin er 10 clemastine fumarate 83 CLENPIQ 57 CLEOCIN 6 CLEVIPREX 44 CLIMARA 66 CLIMARA PRO 66 clind ph-benzoyl perox 1.2-5% 51 CLINDACIN ETZ 6 CLINDACIN P 6 CLINDAGEL 6 clindamycin hcl 6 clindamycin palmitate hcl 6 cholestyramine 47 clindamycin pediatric 6 cholestyramine light 47 clindamycin phos-benzoyl chorionic gonadotropin 64 perox 51 CIALIS 60 clindamycin phos-tretinoin 51 CIALIS 2.5 MG TABLET 60 clindamycin phosphate 6,7 CIALIS 5 MG TABLET 60 clindamycin phosphate-d5w 7 CICLODAN 19 clindamycin-benzoyl perox % 51 clindamycin-benzoyl peroxide 51 CLINDESSE 7 CLINIMIX 53 CLINIMIX E 53 CLINIMIX N14G30E 53 CLINIMIX N9G15E 53 CLINIMIX N9G20E 53 CLINISOL 53 clobetasol emollient 61 clobetasol emulsion 61 clobetasol propionate 61 clocortolone pivalate 61 clofarabine 23 clomiphene citrate 78 clomipramine hcl 17 clonazepam 13 clonidine hcl 41 clonidine hcl er 48 clorazepate dipotassium 13 CLORPRES 41 clotrimazole 19 clotrimazole-betamethasone 19 clozapine 32 clozapine odt 32 COARTEM 29 codeine sulfate 2

100 colchicine 20 COLCRYS 20 colestipol hcl 47 colistimethate 7 COLOCORT 77 COLY-MYCIN S 82 COMBIGAN 81 COMBIPATCH 66 COMBIVENT RESPIMAT 83 COMETRIQ 26 COMPLERA 33 COMPRO 17 CONDYLOX 51 CONSTULOSE 57 COPAXONE 49,50 CORDRAN 61 COREG CR 43 CORLANOR 45 CORTENEMA 77 CORTIFOAM 61 cortisone acetate 61 CORTISPORIN 7,80 COSENTYX (2 SYRINGES) 51 COSENTYX PEN 51 COSENTYX PEN (2 PENS) 51 COSENTYX SYRINGE 51 COSMEGEN 24 COSOPT PF 81 COTELLIC 26 COUMADIN 40 CREON 59 CRESEMBA 19 CRIXIVAN 34 cromolyn sodium 80,84 CRYSELLE 66 CUPRIMINE 55 CUROSURF 78 CUVITRU 74 cyanocobalamin injection 56 CYCLAFEM 66 cyclobenzaprine hcl 86 cyclophosphamide 22 cycloserine 22 CYCLOSET 37 cyclosporine 73 cyclosporine modified 73 cyproheptadine hcl 83 CYRAMZA 26 CYRED 66 CYSTADANE 59 CYSTAGON 59 CYSTARAN 79 cytarabine 23 CYTOGAM 78 CYTOMEL 71 D dacarbazine 22 dactinomycin 24 DAKLINZA 32 DALIRESP 85,86 DALVANCE 7 danazol 65 dantrolene sodium 32 dapsone 22,51 DAPTACEL DTAP 75 daptomycin 7 DARAPRIM 29 darifenacin er 60 DARZALEX 28 DASETTA 66 daunorubicin hcl 24 DAXBIA 9 DAYSEE 66 DAYTRANA 48 DEBLITANE 70 DECADRON 61 decitabine 24 deferoxamine mesylate 78 DELESTROGEN 66 DELTASONE 61 DELYLA DELZICOL 76 demeclocycline hcl 11 DEMSER 45 DENAVIR 36 DENTA 5000 PLUS 53 DENTAGEL 53 DEPEN 55 DEPO-ESTRADIOL 66 DEPO-MEDROL 61 DEPO-SUBQ PROVERA DESCOVY 34 DESFERAL 78 DESFERAL MESYLATE 78 desipramine hcl 17 desloratadine 83 desmopressin acetate 64 desogestr-eth estrad eth estra 66 desogestrel-ethinyl estradiol 66 DESONATE 61 desonide 61 desoximetasone 61 desvenlafaxine er 16 desvenlafaxine fumarate er 16 desvenlafaxine succinate er 16 dexamethasone 61 DEXAMETHASONE INTENSOL 61 dexamethasone sodium phosphate 62,80 DEXILANT 58 dexmethylphenidate hcl 48 dexmethylphenidate hcl er 48 dexrazoxane 24 dextroamphetamine sulfate 48 dextroamphetamine sulfate er 48 dextroamphetamine-amphet er 48 dextroamphetamineamphetamine 48 dextrose 10%-0.2% nacl 53 dextrose 10%-0.45% nacl 53

101 dextrose 2.5%-0.45% nacl 53 dextrose 5%-0.2% nacl 53 dextrose 5%-0.2% nacl-kcl 53 dextrose 5%-0.225% nacl 53 dextrose 5%-0.225% nacl-kcl 53 dextrose 5%-0.3% nacl 53 dextrose 5%-0.3% nacl-kcl 53 dextrose 5%-0.33% nacl 53 dextrose 5%-0.33% nacl-kcl 53 dextrose 5%-0.45% nacl 53 dextrose 5%-0.45% nacl-kcl 53 dextrose 5%-0.9% nacl 53 dextrose 5%-1/2ns-kcl 53 dextrose 5%-1/4ns-kcl 53 dextrose 5%-electrolyte #48 53 dextrose 5%-ns-kcl 53 dextrose 5%-potassium chloride53 dextrose in lactated ringers 78 dextrose in water 78 DIABETA 37 DIASTAT 13 DIASTAT ACUDIAL 13 diazepam 13,36 diclofenac potassium 5 diclofenac sodium 5,51,80 diclofenac sodium er 5 diclofenac sodium-misoprostol 5 dicloxacillin sodium 10 dicyclomine hcl 56 didanosine 34 DIFFERIN 51 DIFICID 10 diflorasone diacetate 62 diflunisal 5 DIGITEK 45 DIGOX 45 digoxin 45 dihydroergotamine mesylate 20 DILANTIN 14 DILANTIN DILATRATE-SR 47 DILT-XR 44 DUPIXENT 75 diltiazem 12hr er 44 DURAMORPH 2 diltiazem 24hr cd 44 DUREZOL 80 diltiazem 24hr er 44 dutasteride 60 diltiazem er 44 dutasteride-tamsulosin 60 diltiazem hcl 44 DUZALLO 20 DIPENTUM 76 DYRENIUM 46 diphenhydramine 50 mg/ml vial 83 diphenhydramine hcl 83 diphenoxylate-atropine 57 diphtheria-tetanus toxoids-ped 75 dipyridamole 41 DISKETS 2 disulfiram 4 divalproex sodium 13 divalproex sodium er 13 DIVIGEL 66 docetaxel 24 dofetilide 43 donepezil hcl 15 donepezil hcl odt 15 DORIBAX 9 doripenem 9 dorzolamide hcl 81 dorzolamide-timolol 81 doxazosin mesylate 60 doxepin hcl 17,51 doxercalciferol 77 doxorubicin hcl 24 doxorubicin hcl liposome 24 DOXY doxycycline hyclate 12 doxycycline ir-dr 12 doxycycline monohydrate 12 dronabinol 18 drospirenone-eth estra-levomef 66 drospirenone-ethinyl estradiol 66 DROXIA 23 DUAVEE 66 DULERA 82 duloxetine hcl E E.E.S econazole nitrate 19 EDARBI 41 EDARBYCLOR 41 EDLUAR 86 EDURANT 33 efavirenz 33 EFFIENT 41 EGRIFTA 64 ELAPRASE 59 ELELYSO 59 ELESTRIN 66 eletriptan hbr 21 ELIDEL 51 ELIGARD 71 ELINEST 66 ELIPHOS 56 ELIQUIS 40 ELITEK 28 ELIXOPHYLLIN 83 ELLA 70 ELLENCE 24 ELMIRON 60 EMADINE 80 EMBEDA 1 EMCYT 23 EMEND 18 EMFLAZA 62 EMOQUETTE 66 EMPLICITI 28 EMSAM 16 EMTRIVA 34

102 EMVERM 28 enalapril maleate 42 enalapril-hydrochlorothiazide 42 ENBREL 73 ENBREL MINI 73 ENBREL SURECLICK 73 ENDARI 78 ENDOCET 2 ENGERIX-B ADULT 75 ENGERIX-B PEDIATRIC- ADOLESCENT 75 enoxaparin sodium 40 ENPRESSE 66 ENSKYCE 66 ENSTILAR 51 entacapone 29 entecavir 32 ENTRESTO 45 ENULOSE 57 ENVARSUS XR 73 EPCLUSA 32 EPIDUO 51 EPIDUO FORTE 51 epinastine hcl 80 epinephrine 84 EPIPEN 84 EPIPEN 2-PAK 84 EPIPEN JR 2-PAK 84 epirubicin hcl 24 EPITOL 15 EPIVIR HBV 32 eplerenone 46 EPOGEN 40 epoprostenol sodium 85 eprosartan mesylate 42 EQUETRO 36 ERAXIS (WATER DILUENT) 19 ERBITUX 28 ergoloid mesylates 15 ERGOMAR 20 ergotamine-caffeine 20 ERIVEDGE 24 ERLEADA 23 ERRIN 70 ERTACZO 19 ERWINAZE 24 ERY 2% PADS 10 ERY-TAB 10 ERYPED ERYPED ERYTHROCIN LACTOBIONATE 10 ERYTHROCIN STEARATE 10 erythromycin 10,11 erythromycin ethylsuccinate 11 erythromycin-benzoyl peroxide 51 ESBRIET 85 escitalopram oxalate 16 esomeprazole magnesium 58 esomeprazole sodium 58 ESTARYLLA 66 ESTRACE 67 estradiol 67 estradiol twice weekly 67 estradiol valerate 67 estradiol weekly 67 estradiol-norethindrone acetat 67 ESTRING 67 estropipate 67 eszopiclone 86 ethacrynate sodium 45 ethacrynic acid 45 ethambutol hcl 22 ethosuximide 13 ethynodiol-ethinyl estradiol 67 etidronate disodium 77 etodolac 5 etodolac er 5 ETOPOPHOS 26 etoposide 26 EURAX EVAMIST 67 EVOMELA 22 EVOTAZ 34 EVZIO 4 EXELDERM 19 exemestane 26 EXJADE 55 EXONDYS EXTAVIA 50 EYLEA 79 ezetimibe 47 ezetimibe-simvastatin 46 F FABIOR 51 FABRAZYME 59 FALMINA 67 famciclovir 36 famotidine 57 FANAPT 31 FARESTON 23 FARYDAK 26 FASENRA 86 FASLODEX 23 FAYOSIM 67 felbamate 14 felodipine er 44 FEMRING 67 FEMYNOR 67 fenofibrate 46 fenofibric acid 46 FENOGLIDE 46 fenoprofen calcium 5 fentanyl 1 fentanyl citrate 2 FENTORA 2 FERRIPROX 55 FETZIMA 16 FINACEA 51 finasteride 5 mg tablet 60 FIRAZYR 72

103 FIRMAGON 24 FLAREX 80 flavoxate hcl 60 FLEBOGAMMA DIF 74 flecainide acetate 43 FLECTOR 5 FLOLAN 85 FLOVENT DISKUS 82 FLOVENT HFA 82 FLOXIN 11 fluconazole 19 fluconazole in dextrose 19 fluconazole in saline 19 fluconazole-nacl 19 flucytosine 19 fludarabine phosphate 23 fludrocortisone acetate 62 flunisolide 82 fluocinolone acetonide 62 fluocinolone acetonide oil 82 fluocinonide 62 fluocinonide-e 62 fluorometholone 80 fluorouracil 24,51 fluoxetine dr 16 fluoxetine hcl 16 fluphenazine decanoate 30 fluphenazine hcl 30 flurandrenolide 62 flurbiprofen 5 flurbiprofen sodium 80 flutamide 23 fluticasone propionate 62,82 fluvastatin er 46 fluvastatin sodium 46 fluvoxamine maleate 17 fluvoxamine maleate er 17 FML FORTE 80 FML S.O.P. 80 folic acid 56 FOLOTYN 24 fomepizole 78 fondaparinux sodium 40 FORTEO 77 FORTESTA 65 FORTICAL 77 fosamprenavir calcium 34 foscarnet sodium 32 fosinopril sodium 42 fosinopril-hydrochlorothiazide 42 fosphenytoin sodium 15 FOSRENOL 56 FRAGMIN 40 FREAMINE HBC 53 FREAMINE III 54 frovatriptan succinate 21 furosemide 45 FUSILEV 24 FUZEON 34 FYAVOLV 67 FYCOMPA 14 G gabapentin 13 GABITRIL 13 galantamine 4 mg/ml oral soln 15 galantamine er 15 galantamine hbr 15 GAMMAGARD LIQUID 74 GAMMAGARD S-D 74 GAMMAKED 74 GAMMAPLEX 75 GAMUNEX-C 75 ganciclovir sodium 32 GARDASIL 75 GARDASIL 9 75 gatifloxacin 11 GATTEX 57 gauze pads 2 x 2 79 GAVILYTE-C 58 GAVILYTE-G GAVILYTE-H AND BISACODYL 58 GAVILYTE-N 58 GAZYVA 28 GELNIQUE 60 gemcitabine hcl 23 gemfibrozil 46 GENERLAC 58 GENGRAF 73 GENOTROPIN 64 GENTAK 6 gentamicin sulfate 6 gentamicin sulfate in ns 6 GENVOYA 35 GEODON 31 GIANVI 67 GIAZO 76 GILDAGIA 67 GILDESS 67 GILDESS 24 FE 67 GILDESS FE 67 GILENYA 50 GILOTRIF 27 GLASSIA 59 glatiramer acetate 50 GLATOPA 50 GLEOSTINE 22 glimepiride 37 glipizide 37 glipizide er 37 glipizide xl 37 glipizide-metformin 37 GLUCAGEN 39 GLUCAGON EMERGENCY KIT 39 glucose in water 79 GLUCOVANCE 37 GLUMETZA 37 glyburide 37 glyburide micronized 37 glyburide-metformin hcl 37

104 glycopyrrolate 56,57 GLYNASE 37 GOCOVRI 29 GONITRO 47 GRALISE 15 granisetron hcl 18 GRANIX 40 GRASTEK 79 griseofulvin 19 griseofulvin ultramicrosize 19 guanfacine hcl 41 guanfacine hcl er 48 guanidine hcl 21 H H.P. ACTHAR 62 HAEGARDA 72 HALAVEN 24 halobetasol propionate 62 HALOG 62 haloperidol 30 haloperidol decanoate 30 haloperidol decanoate haloperidol lactate 30 HARVONI 32 HAVRIX 75 HEATHER 70 HECTOROL 77 heparin sodium 40 heparin sodium in 0.45% nacl 40 heparin sodium-0.45% nacl 40 heparin sodium-0.9% nacl 40 heparin sodium-d5w 40 HEPATAMINE 54 HERCEPTIN 28 HETLIOZ 86 HEXALEN 22 HIBERIX 75 HIZENTRA 75 HORIZANT 15 HUMALOG 39 HUMALOG JUNIOR KWIKPEN 39 HUMALOG KWIKPEN U HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 39 HUMALOG MIX HUMALOG MIX KWIKPEN 39 humapen luxura hd 79 HUMATROPE 64 HUMIRA 73 HUMIRA PEDIATRIC CROHN'S 73 HUMIRA PEN 73 HUMIRA PEN CROHN-UC- HS STARTER 73 HUMIRA PEN PSORIASIS- UVEITIS 73 HUMULIN HUMULIN 70/30 KWIKPEN 39 HUMULIN N 39 HUMULIN N KWIKPEN 39 HUMULIN R 39 HUMULIN R U HUMULIN R U-500 KWIKPEN 39 hydralazine hcl 47 hydrochlorothiazide 46 hydrocodone-acetaminophen 2 hydrocodone-homatropine mbr 86 hydrocodone-ibuprofen 2 hydrocortisone 62,77 hydrocortisone butyrate 62 hydrocortisone valerate 62 hydrocortisone-acetic acid 82 hydrocortisone-pramoxine HYDROMET 86 hydromorphone er 1 hydromorphone hcl 2 hydroxychloroquine sulfate 29 hydroxyprogesterone caproate 70 hydroxyurea 23 hydroxyzine hcl 83 hydroxyzine pamoate 36 HYQVIA 75 HYSINGLA ER 1 I ibandronate sodium 77 IBRANCE 27 IBU 5 ibuprofen 5 ICLUSIG 27 IDAMYCIN PFS 25 idarubicin hcl 25 IDHIFA 25 ifosfamide 22 ILARIS 75 ILEVRO 80 imatinib mesylate 27 IMBRUVICA 27 IMFINZI 28 imipenem-cilastatin sodium 9 imipramine hcl 17 imipramine pamoate 17 imiquimod 51 IMOVAX RABIES VACCINE 76 IMPOYZ 62 INCRELEX 64 indapamide 46 indomethacin 5 indomethacin er 5 INFANRIX DTAP 76 INFLECTRA 73 INFUMORPH 2 INGREZZA 49

105 INLYTA 27 INNOPRAN XL 20 inpen (for humalog) 79 inpen (for novolog) 79 insulin pen needle 79 insulin pen needle, safety 79 insulin syringe 79 insulin syringe u INTELENCE 33 INTERMEZZO 86 INTRALIPID 79 INTRON A 33 INTROVALE 67 INVANZ 9 INVEGA SUSTENNA 31 INVEGA TRINZA 31 INVIRASE 34 INVOKAMET 37 INVOKAMET XR 37 INVOKANA 37 IONOSOL B WITH DEXTROSE 5% 54 IONOSOL MB-DEXTROSE 5% 54 IOPIDINE 81 IPOL 76 ipratropium bromide 83 ipratropium-albuterol 83 irbesartan 42 irbesartan-hydrochlorothiazide 42 IRESSA 27 irinotecan hcl 25 ISENTRESS 35 ISENTRESS HD 35 ISIBLOOM 67 ISOLYTE P WITH DEXTROSE 54 ISOLYTE S 54 isoniazid 22 isosorbide dinitrate 47 isosorbide dinitrate er 47 isosorbide mononitrate 47 isosorbide mononitrate er 47 isotretinoin 51 isradipine 44 ISTALOL 81 ISTODAX 25 ISUPREL 84 itraconazole 19 ivermectin 28 IXEMPRA 25 IXIARO 76 J JADENU 55 JADENU SPRINKLE 55 JAKAFI 25 JANTOVEN 40 JANUMET 37 JANUMET XR 37 JANUVIA 37 JARDIANCE 37 JENCYCLA 70 JENTADUETO 38 JENTADUETO XR 38 JETREA 79 JEVANTIQUE LO 67 JEVTANA 27 JINTELI 67 JOLESSA 67 JOLIVETTE 70 JUBLIA 19 JULEBER 67 JULUCA 35 JUNEL 67 JUNEL FE 67 JUNEL FE JUXTAPID 47 JYNARQUE 56 K KABIVEN KADCYLA 25 KAITLIB FE 67 KALBITOR 79 KALETRA 34 KALYDECO 84 KANUMA 59 KARIVA 67 KAZANO 38 kcl 20 meq in d5w-lact ringer 54 kcl-ns 1,000 ml iv soln 54 KELNOR KELNOR KENALOG KENALOG KEPIVANCE 50 KERYDIN 19 KETEK 11 ketoconazole 19 KETODAN 19 ketoprofen 5 ketorolac tromethamine 5,80 KEVEYIS 79 KEYTRUDA 25 KIMIDESS 67 KINERET 75 KINRIX 76 KIONEX 56 KISQALI 25 KISQALI FEMARA CO- PACK 25 KITABIS PAK 6 KLOFENSAID II 5 KLOR-CON KLOR-CON 20 MEQ PACKET (SELECT MANUFACTURERS ONLY) 54 KLOR-CON 8 54 KLOR-CON M10 54 KLOR-CON M15 54 KLOR-CON M20 54

106 KLOR-CON SPRINKLE 54 KOMBIGLYZE XR 38 KORLYM 79 KRISTALOSE 58 KRYSTEXXA 59 KURVELO 67 KUVAN 59 KYLEENA 70 KYNAMRO 47 KYPROLIS 25 L labetalol hcl 43 LACRISERT 79 lactated ringers 54 lactulose 58 lamivudine 32,34 lamivudine hbv 32 lamivudine-zidovudine 34 lamotrigine 14 lamotrigine (blue) 14 lamotrigine (green) 14 lamotrigine (orange) 14 lamotrigine er 14 lamotrigine odt 14 lamotrigine odt (blue) 14 lamotrigine odt (green) 14 lamotrigine odt (orange) 14 LANOXIN 45 lansoprazol-amoxicil-clarithro 7 lansoprazole 58 lanthanum carbonate 56 LANTUS 39 LANTUS SOLOSTAR 39 LARIN 67 LARIN 24 FE 68 LARIN FE 68 LARISSIA 68 LARTRUVO 28 latanoprost 81 LATUDA 31 LAZANDA 2 LEENA 68 leflunomide 75 LEMTRADA 50 LENVIMA 27 LESSINA 68 LETAIRIS 85 letrozole 26 leucovorin calcium 25 LEUKERAN 22 LEUKINE 40 leuprolide acetate 71 levalbuterol concentrate hcl vialneb 84 levalbuterol hcl vial-neb 84 levalbuterol tar hfa 45mcg inhaler 84 LEVEMIR 39 LEVEMIR FLEXTOUCH 39 levetiracetam 12 levetiracetam er 12,13 levetiracetam-nacl 13 LEVITRA 60 levobunolol hcl 81 loperamide 57 levocarnitine 79 lopinavir-ritonavir 35 levocetirizine dihydrochloride 83 LOPREEZA 68 levofloxacin 11 levofloxacin-d5w 11 levoleucovorin calcium 25 LEVONEST 68 levonorg-eth estrad eth estrad 68 levonorgestrel-eth estradiol 68 LEVORA levorphanol tartrate 2 levothyroxine sodium 71 LEVOXYL 71 LEXIVA 35 LIALDA 77 lidocaine 4 lidocaine hcl 4,43 lidocaine hcl viscous 4 98 lidocaine-prilocaine 4 LIDODERM 4 LILETTA 70 LINCOCIN 7 lincomycin hcl 7 lindane 29 linezolid 7 linezolid-0.9% nacl 7 linezolid-d5w 7 LINZESS 57 liothyronine sodium 71 lisinopril 42 lisinopril-hydrochlorothiazide 42 lithium 36 lithium carbonate 36 lithium carbonate er 36 LITHOSTAT 60 LIVALO 46 LO LOESTRIN FE 68 LOCOID 62 LOCORT 62 LOMEDIA 24 FE 68 LONSURF 25 lorazepam 36 LORCET 2 LORCET HD 2 LORCET PLUS 2 LORYNA 68 losartan potassium 42 losartan-hydrochlorothiazide 42 LOTEMAX 80 lovastatin 46 LOW-OGESTREL 68 loxapine 30 LUCENTIS 79 LUMIGAN 81 LUMIZYME 59 LUNESTA 86

107 LUPRON DEPOT 71 LUPRON DEPOT (LUPANETA) 71 LUPRON DEPOT-PED 71 LUTERA 68 LUZU 19 LYNPARZA 27 LYRICA 13,49 LYSODREN 71 M M-M-R II VACCINE 76 MACUGEN 80 magnesium chloride 54 magnesium sulfate 54 magnesium sulfate-d5w 54 malathion 29 maprotiline hcl 16 MARGESIC 2 MARLISSA 68 MARPLAN 16 MARQIBO 25 MARTEN-TAB 3 MATULANE 22 MATZIM LA 44 MAVYRET 32 MAXIDEX 80 meclizine hcl 17 meclofenamate sodium 5 MEDROL 63 medroxyprogesterone acetate 70 mefloquine hcl 29 megestrol acetate 70 MEKINIST 25 MELODETTA 24 FE 68 meloxicam 5 melphalan 2mg tablet 22 melphalan hcl 22 memantine hcl 15 memantine hcl er 15 MENACTRA 76 MENEST 68 MENHIBRIX 76 MENOMUNE-A-C-Y-W MENTAX 19 MENVEO A-C-Y-W-135-DIP76 MEPHYTON 56 mercaptopurine 23 meropenem 9 meropenem-0.9% nacl 9 mesalamine 77 mesna 28 MESNEX 28 MESTINON 21 METADATE ER 48 metaproterenol sulfate 84 METAXALL 86 metaxalone 86 metformin er 1000 mg osmotic tablet (generic for fortamet) 38 metformin er 500 mg osmotic tablet (generic for fortamet) 38 metformin hcl 1000mg tablet (immediate-release) 38 metformin hcl 500 mg tablet (immediate-release) 38 metformin hcl 850 mg tablet (immediate-release) 38 metformin hcl er 1000 mg tablet (generic for glumetza) 38 metformin hcl er 500mg (generic for glucophage xr) 38 metformin hcl er 500mg (generic for glumetza) 38 metformin hcl er 750 mg (generic for glucophage xr) 38 methadone hcl 3 METHADONE INTENSOL 3 METHADOSE 3 methamphetamine hcl 48 methazolamide 45 methenamine hippurate 7 99 methimazole 72 METHITEST 65 methocarbamol 86 methotrexate 73 methotrexate sodium 73 methoxsalen 51 methscopolamine bromide 57 methyclothiazide 46 methyldopa 41 methyldopahydrochlorothiazide 41 methyldopate hcl 41 methylergonovine maleate 79 METHYLIN 48 methylphenidate er 48 methylphenidate hcl 48 methylphenidate hcl cd 48,49 methylphenidate hcl er 49 methylphenidate la 49 methylprednisolone 63 methylprednisolone acetate 63 methylprednisolone sodium succ 63 methyltestosterone 65 metipranolol 81 metoclopramide hcl 17 metoclopramide hcl odt 17 metolazone 46 METOPIRONE 79 metoprolol succinate er 43 metoprolol tartrate 43 metoprololhydrochlorothiazide 43 METRO IV 7 metronidazole 7 mexiletine hcl 43 MIACALCIN 77 MIBELAS 24 FE 68 miconazole 3 19 MICORT-HC 63 MICROGESTIN 68

108 MICROGESTIN FE 68 midodrine hcl 41 MIGERGOT 20 miglitol 38 miglustat 59 MIMVEY LO 68 MINASTRIN 24 FE 68 MINITRAN 47 minocycline hcl 12 minocycline hcl er 12 minoxidil 47 MIRCERA 40 MIRENA 70 mirtazapine 16 misoprostol 58 MITIGARE 20 mitomycin 25 mitoxantrone hcl 25 modafinil 86 MODERIBA 33 moexipril hcl 42 moexipril-hydrochlorothiazide 42 molindone hcl 30 mometasone furoate 63,82 MONDOXYNE NL 12 MONO-LINYAH 68 MONONESSA 68 montelukast sodium 83 MONUROL 7 MORGIDOX 12 morphine sulfate 3 morphine sulfate er 1 MOVANTIK 57 MOVIPREP 58 MOXEZA 11 moxifloxacin 11 moxifloxacin hcl 11 MOZOBIL 40 MULTAQ 43 mupirocin 7 MUSTARGEN 22 MYALEPT 79 MYCAMINE 19 mycophenolate mofetil 73 mycophenolic acid 73 MYFORTIC 73 MYLOTARG 28 MYORISAN 51 MYRBETRIQ 60 MYTESI 57 MYZILRA 68 N nabumetone 5 nadolol 43 nadolol-bendroflumethiazide 44 nafcillin 10 nafcillin sodium 10 naftifine hcl 19 NAFTIN 19 NAGLAZYME 59 nalbuphine hcl 3 naloxone hcl 4 naltrexone hcl 4 NAMENDA XR 16 NAMZARIC 16 naproxen 5 naproxen sodium 5 naproxen sodium ds 5 naratriptan 21 naratriptan hcl 21 NARCAN 4 NATACYN 20 NATAZIA 68 nateglinide 38 NATESTO 65 NATPARA 77 NEBUPENT 29 NECON 68 nefazodone hcl 16 NEO-POLYCIN 7 NEO-POLYCIN HC NEO-SYNALAR 7 neomycin sulfate 6 neomycin-bacitracin-poly-hc 7 neomycin-bacitracin-polymyxin 7 neomycin-polymyxin b 7 neomycin-polymyxin-dexameth80 neomycin-polymyxin-gramicidin 7 neomycin-polymyxin-hc 7,82 neomycin-polymyxin-hydrocort82 NEORAL 73 NEPHRAMINE 54 NERLYNX 27 NESINA 38 NEULASTA 40 NEUPOGEN 40 NEUPRO 29 NEVANAC 80 nevirapine 33 nevirapine er 33 NEXAVAR 27 NEXIUM 58 niacin er 47 NIACOR 47 nicardipine hcl 44 NICOTROL 5 NICOTROL NS 5 NIFEDICAL XL 44 nifedipine er 44 NIKKI 68 nilutamide 23 nimodipine 45 NINLARO 25 NIPENT 23 nisoldipine 45 NITRO-BID 47 NITRO-DUR 47 nitrofurantoin 7 nitrofurantoin mono-macro 7 nitroglycerin 47,48 nitroglycerin 400 mcg lingual spray 47

109 nitroglycerin patch 48 NITROLINGUAL 48 NITROMIST 48 nizatidine 57 NOCTIVA 64 NOLIX 63 NORA-BE 70 NORDITROPIN FLEXPRO 64 noreth-estrad-fe (24) norethin-eth estra-ferrous fum 68 norethindron-ethinyl estradiol 68 norethindrone 70 norethindrone ac (lupaneta) 70 norethindrone acetate 70 norgestimate-ethinyl estradiol 68 NORITATE 7 NORLYROC 70 NORMOSOL-M AND DEXTROSE 54 NORMOSOL-R 54 NORMOSOL-R AND DEXTROSE 54 NORMOSOL-R PH NORTHERA 41 NORTREL 68 nortriptyline hcl 17 NORVIR 35 NOVAREL 64 novopen echo 79 NOXAFIL 20 NUCALA 86 NUCYNTA 3 NUCYNTA ER 1 NUEDEXTA 49 NULOJIX 74 NUPLAZID 31 NUTRILIPID 79 NUTROPIN AQ 64 NUTROPIN AQ NUSPIN 64 NUVARING 68 NUVESSA 7 NUVIGIL 86 NYAMYC 20 NYATA 20 nystatin 20 nystatin-triamcinolone 20 NYSTOP 20 O OCALIVA 59 OCELLA 69 OCREVUS 50 OCTAGAM 75 octreotide acetate 72 ODEFSEY 33 ODOMZO 27 OFEV 85 ofloxacin 11 OGESTREL 69 olanzapine 31 olanzapine odt 31 olanzapine-fluoxetine hcl 31 olmesartan medoxomil 42 olmesartan-amlodipine-hctz 42 olmesartan-hydrochlorothiazide42 olopatadine hcl 80,83 OLYSIO 32 omega-3 acid ethyl esters 47 omeprazole 58 omeprazole-sodium bicarbonate58 OMNITROPE 64 ondansetron hcl 18 ondansetron odt 18 ONEXTON 51 ONFI 13 ONGLYZA 38 ONMEL 20 ONZETRA XSAIL 21 OPDIVO 28 OPSUMIT 85 ORACEA 12 ORALAIR ORALONE 50 ORENCIA 74 ORENCIA CLICKJECT 74 ORENITRAM ER 85 ORFADIN 59 ORKAMBI 84 orphenadrine citrate 86 ORSYTHIA 69 oseltamivir phosphate 35 OSENI 38 OSMOPREP 57 OTEZLA 75 OTOVEL 82 oxacillin 10 oxacillin sodium 10 oxaliplatin 25 oxandrolone 65 oxaprozin 5 oxazepam 36 oxcarbazepine 15 oxiconazole nitrate 20 OXISTAT 20 OXTELLAR XR 15 oxybutynin chloride 60 oxybutynin chloride er 60 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 P PACERONE 43 paclitaxel 25 paliperidone er 31 palonosetron hcl 18 pamidronate disodium 77 PANCREAZE 59

110 PANDEL 63 PANRETIN 28 pantoprazole sodium 58 paricalcitol 77,78 PAROEX 50 paromomycin sulfate 6 paroxetine cr 17 paroxetine er 17 paroxetine hcl 17 PARSABIV 78 PASER 22 PAXIL 17 PCE 11 PEDIARIX 76 PEDVAXHIB 76 peg 3350-electrolyte 57,58 peg-3350 and electrolytes 58 PEGANONE 15 PEGASYS 33 PEGASYS PROCLICK 33 PEGINTRON 33 PEGINTRON REDIPEN 33 penicillin g potassium 10 penicillin g procaine 10 penicillin g sodium 10 penicillin gk-iso-osm dextrose 10 penicillin v potassium 10 PENTACEL 76 PENTACEL ACTHIB COMPONENT 76 PENTAM PENTASA 77 pentazocine-naloxone hcl 3 pentoxifylline 45 PERFOROMIST 84 PERIKABIVEN 54 perindopril erbumine 42 PERIOGARD 50 PERJETA 28 permethrin 29 perphenazine 30 perphenazine-amitriptyline 30 PEXEVA 17 PFIZERPEN 10 PHENADOZ 17 phenelzine sulfate 16 PHENERGAN 17 phenobarbital 13 phenoxybenzamine hcl 41 phentermine hcl 49 PHENYTEK 15 phenytoin 15 phenytoin sodium 15 phenytoin sodium extended 15 PHILITH 69 PHOSLYRA 56 PHOSPHOLINE IODIDE 81 PHRENILIN FORTE 3 PHYSIOLYTE 54 PHYSIOSOL 54 PICATO 51 pilocarpine hcl 50,81 pimozide 30 PIMTREA 69 pindolol 44 pioglitazone hcl 38 pioglitazone-glimepiride 38 pioglitazone-metformin 38 piperacillin-tazobactam 10 PIRMELLA 69 piroxicam 5 PLASMA-LYTE PLASMA-LYTE 56 IN DEXTROSE 54 PLASMA-LYTE A PH PLEGRIDY 50 PLEGRIDY PEN 50 PLIAGLIS 4 podofilox 52 POLYCIN 7 polyethylene glycol polymyxin b sul-trimethoprim polymyxin b sulfate 7 POMALYST 23 PORTIA 69 PORTRAZZA 28 potassium chloride 54 potassium chloride in d5lr 54 potassium citrate er 55 potassium cl 20 meq packet (qualitest and virtus manufacturers only) 55 potassium cl 20 meq-0.45% nacl 55 POTIGA 13 PRADAXA 41 PRALUENT PEN 47 PRALUENT SYRINGE 47 pramipexole dihydrochloride 29 pramipexole er 29 PRAMOSONE 63 prasugrel hcl 41 pravastatin sodium 46 praziquantel 28 prazosin hcl 41 PRED MILD 80 PRED-G 81 prednicarbate 63 prednisolone 63 prednisolone acetate 81 prednisolone sodium phos odt 63 prednisolone sodium phosphate 63,81 prednisone 63 PREDNISONE INTENSOL 63 PREFEST 69 PREGNYL 64 PREMARIN 69 PREMASOL 55 PREMPHASE 69 PREMPRO 69 PRENATAL VITAMIN ORAL TABLET 56

111 PREVALITE 47 PREVIDENT % DRY MOUTH 55 PREVIDENT 5000 ENAMEL PROTECT 55 PREVIDENT 5000 SENSITIVE 55 PREVIFEM 69 PREVYMIS 32 PREZCOBIX 35 PREZISTA 35 PRIFTIN 22 PRILOSEC DR SUSPENSION 58 primaquine 29 primidone 13 PRIMSOL 7 PRISTIQ 17 PRIVIGEN 75 PROAIR HFA 84 PROAIR RESPICLICK 84 probenecid 20 probenecid-colchicine 20 procainamide hcl 43 PROCALAMINE 55 prochlorperazine 17 prochlorperazine edisylate 30 prochlorperazine maleate 17 PROCRIT 40 PROCTO-MED HC 63 PROCTO-PAK 63 PROCTOFOAM-HC 63 PROCTOSOL-HC 63 PROCTOZONE-HC 63 PROCYSBI 59 progesterone 70 PROGLYCEM 39 PROGRAF 74 PROLASTIN C 59 PROLEUKIN 25 PROLIA 74 PROMACTA 40,41 promethazine hcl 18 promethazine vc 83 PROMETHEGAN 18 propafenone hcl 43 propafenone hcl er 43 proparacaine hcl 80 propranolol hcl 44 propranolol hcl er 21 propranolol-hydrochlorothiazid 44 propylthiouracil 72 PROQUAD 76 PROSOL 55 protamine sulfate 41 protriptyline hcl 17 PROVIGIL 87 PRUDOXIN 52 PULMICORT RESPULE 82 PULMOZYME 86 PURIXAN 23 PYLERA 57 pyrazinamide 22 pyridostigmine bromide 21 pyridostigmine bromide er 21 Q QUADRACEL DTAP-IPV 76 QUALAQUIN 29 QUARTETTE 69 QUASENSE 69 QUDEXY XR 14 quetiapine fumarate 31 quetiapine fumarate er 31 quinapril hcl 42 quinapril-hydrochlorothiazide 42 quinidine gluconate 43 quinidine sulfate 43 quinine sulfate 29 QVAR 82 QVAR REDIHALER R RABAVERT 76 rabeprazole sodium 58 RADICAVA 79 RAGWITEK 79 RAJANI 69 raloxifene hcl 71 ramipril 42 RANEXA 45 ranitidine hcl 57 RAPAFLO 60 RAPAMUNE 74 rasagiline mesylate 30 RAVICTI 59 RAYALDEE 78 RAYOS 63 REBETOL 33 REBIF 50 REBIF REBIDOSE 50 RECLIPSEN 69 RECOMBIVAX HB 76 REGRANEX 52 RELENZA 35 RELISTOR 57 RELPAX 21 REMICADE 74 REMODULIN 85 RENACIDIN 55 RENFLEXIS 74 RENVELA 56 repaglinide 38 repaglinide-metformin hcl 38 REPATHA PUSHTRONEX 47 REPATHA SURECLICK 47 REPATHA SYRINGE 47 RESCRIPTOR 33 reserpine 41 RESTASIS 80 RESTASIS MULTIDOSE 80 RETIN-A 52

112 RETIN-A MICRO 52 RETIN-A MICRO PUMP 52 RETROVIR 34 REVATIO 85 REVLIMID 23 REXULTI 31 REYATAZ 35 RIBASPHERE 33 RIBASPHERE RIBAPAK 33 ribavirin 33 RIDAURA 75 rifabutin 22 RIFAMATE 22 rifampin 22 RIFATER 22 riluzole 49 rimantadine hcl 35 ringers injection 55 ringers irrigation 55 RIOMET 38 risedronate sodium 78 risedronate sodium dr 78 RISPERDAL CONSTA 31 risperidone 31 risperidone odt 31 RITALIN LA 49 ritonavir 35 RITUXAN 28 RITUXAN HYCELA 28 rivastigmine 15 RIVELSA 69 rizatriptan 21 ROCALTROL 78 romidepsin 25 ropinirole er 29 ropinirole hcl 29 ROSADAN 7 rosuvastatin calcium 46 ROTARIX 76 ROTATEQ 76 ROWEEPRA 13 ROWEEPRA XR 13 ROZEREM 87 RUBRACA 25 RUCONEST 72 RYDAPT 27 S SABRIL 13 SAFYRAL 69 SAIZEN 64 SAIZEN-SAIZENPREP 64 SAMSCA 56 SANCUSO 18 SANDIMMUNE 74 SANDOSTATIN LAR 72 SANDOSTATIN LAR DEPOT 72 SANTYL 52 SAPHRIS 31 SAVELLA 49 scopolamine 18 selegiline hcl 30 selenium sulfide 52 SELZENTRY 34 SEMPREX-D 83 SENSIPAR 78 SEREVENT DISKUS 84 SERNIVO 63 SEROSTIM 65 sertraline hcl 17 SETLAKIN 69 sevelamer carbonate 56 SF 1.1% GEL 55 SF 5000 PLUS 55 SHAROBEL 71 SHINGRIX 76 SIGNIFOR 79 SIGNIFOR LAR 72 sildenafil 10 mg/12.5 ml vial 85 sildenafil 20 mg tablet 85 sildenafil citrate SILENOR 87 silver sulfadiazine 7 SIMBRINZA 81 SIMPONI 74 SIMPONI ARIA 74 SIMULECT 75 simvastatin 46 sirolimus 74 SIRTURO 22 SIVEXTRO 7 SKYLA 71 SMOFLIPID 79 sodium chloride 55 sodium chloride-water 55 SODIUM FLUORIDE ORAL TABLET 55 sodium lactate 55 sodium phenylbutyrate 59 sodium polystyrene sulfonate 56 sodium sulfacetamide 52 SOLIRIS 74 SOLODYN 12 SOLOSEC 29 SOLTAMOX 23 SOLU-CORTEF 63 SOLU-MEDROL 63 SOMATULINE DEPOT 72 SOMAVERT 72 SONATA 86 SOOLANTRA 28 SORILUX 52 SORINE 43 sotalol 43 sotalol af 43 SOTYLIZE 43 SOVALDI 32 SPIRIVA 83 SPIRIVA RESPIMAT 83 spironolactone 46 spironolactone-hctz 46 SPORANOX 20

113 SPRINTEC 69 SPRITAM 13 SPRYCEL 27 SPS 56 SRONYX 69 SSD 8 STAMARIL 76 stavudine 34 STAXYN 60 STELARA 74 STENDRA 60 sterile water for irrigation 79 STIMATE 65 STIOLTO RESPIMAT 83 STIVARGA 27 STRENSIQ 59 streptomycin sulfate 6 STRIANT 65 STRIBILD 35 STRIVERDI RESPIMAT 84 SUBOXONE 4 SUBSYS 3 SUCRAID 59 sucralfate 58 sulfacetamide sodium 11,52,80 sulfacetamide-prednisolone 81 sulfadiazine 11 sulfamethoxazole-trimethoprim 11 SULFAMYLON 8 sulfasalazine 77 sulfasalazine dr 77 SULFATRIM 11 sulindac 5 sumatriptan 21 sumatriptan succ-naproxen sod 21 sumatriptan succinate 21 SUMAVEL DOSEPRO 21 SUPRAX 9 SUPREP 57 SUSTIVA 33 SUTENT 27 SYEDA 69 SYLATRON 25 SYLVANT 75 SYMBICORT 82 SYMDEKO 84 SYMFI 33 SYMFI LO 33 SYMLINPEN SYMLINPEN SYMPROIC 57 SYNAGIS 79 SYNAREL 72 SYNDROS 18 SYNERA 4 SYNERCID 8 SYNJARDY 39 SYNJARDY XR 39 SYNRIBO 25 SYNTHROID 71 SYPRINE 56 T TABLOID 23 TACLONEX 52 tacrolimus 52,74 TAFINLAR 25 TAGRISSO 27 TALTZ AUTOINJECTOR 52 TALTZ AUTOINJECTOR (2 PACK) 52 TALTZ AUTOINJECTOR (3 PACK) 52 TALTZ SYRINGE 52 TALTZ SYRINGE (2 PACK)52 TALTZ SYRINGE (3 PACK)52 TALWIN 3 TAMIFLU 35 tamoxifen citrate 23 tamsulosin hcl 60 TAPERDEX 63 TARCEVA TARGRETIN 28 TARINA FE 69 TASIGNA 27 TAYTULLA 69 tazarotene 52 TAZORAC 52 TAZTIA XT 45 TECENTRIQ 28 TECFIDERA 50 TECHNIVIE 32 TEFLARO 9 TEGRETOL 15 TEGRETOL XR 15 TEKTURNA 45 TEKTURNA HCT 45 telmisartan 42 telmisartan-amlodipine 42 telmisartan-hydrochlorothiazid 42 temazepam 87 TENCON 3 TENIVAC 76 tenofovir disoproxil fumarate 34 terazosin hcl 41 terbinafine hcl 20 terbutaline sulfate 84 terconazole 20 TESTIM 65 testosterone 65 testosterone cypionate 65 testosterone enanthate 65 tetanus diphtheria toxoids 76 tetrabenazine 49 tetracycline hcl 12 THALOMID 23 THEO theophylline 84 theophylline anhydrous 84 THERACYS 76 THERMAZENE 8 THIOLA 60 thioridazine hcl 30

114 thiotepa 22 thiothixene 30 THYMOGLOBULIN 75 THYROLAR-1 71 THYROLAR-1/2 71 THYROLAR-1/4 71 THYROLAR-2 71 THYROLAR-3 71 tiagabine hcl 14 ticlopidine hcl 41 tigecycline 8 TILIA FE 69 timolol 0.25% eye drops 81 timolol 0.25% gel-solution 81 timolol 0.5% eye drops (generic for istalol) 81 timolol 0.5% eye drops (generic for timoptic) 81 timolol 0.5% gel-solution 81 timolol maleate 21 TIMOPTIC OCUDOSE 81 tinidazole 29 TIS-U-SOL PENTALYTE 55 TIVICAY 35 tizanidine hcl 32 TOBI 6 TOBI PODHALER 6 TOBRADEX 81 TOBRADEX ST 81 tobramycin 6 tobramycin sulfate 6 tobramycin-dexamethasone 81 TOBREX 6 TOLAK 52 tolazamide 39 tolbutamide 39 tolcapone 29 tolmetin sodium 6 tolterodine tartrate 60 tolterodine tartrate er 60 TOPICORT 63 topiramate 14 topiramate er 14 TOPOSAR 26 topotecan hcl 26 TORISEL 25 torsemide 45 TOUJEO MAX SOLOSTAR 39 TOUJEO SOLOSTAR 39 TOVIAZ 60 TPN ELECTROLYTES 55 TRACLEER 85 TRADJENTA 39 tramadol hcl 4 tramadol hcl er 1 tramadol hcl-acetaminophen 4 trandolapril 42 trandolapril-verapamil er 42 tranexamic acid 41 TRANSDERM-SCOP 18 tranylcypromine sulfate 16 TRAVASOL 55 TRAVATAN Z 81 trazodone hcl 16 TREANDA 22 TRECATOR 22 TRELSTAR 72 TREMFYA 74 TRETIN-X 52 tretinoin 28,52 tretinoin microsphere 52 TREXIMET 21 TRI-ESTARYLLA 69 TRI-LEGEST FE 69 TRI-LINYAH 69 TRI-LO-ESTARYLLA 69 TRI-LO-MARZIA 69 TRI-LO-SPRINTEC 69 TRI-PREVIFEM 69 TRI-SPRINTEC 69 TRI-VYLIBRA triamcinolone mg/g topical spray 63 triamcinolone acetonide 50,63,64,82 triamterene-hydrochlorothiazid46 TRIANEX 64 TRIDERM 64 trientine hcl 56 trifluoperazine hcl 30 trifluridine 36 TRIGLIDE 46 trihexyphenidyl hcl 29 TRILYTE WITH FLAVOR PACKETS 57 trimethobenzamide hcl 18 trimethoprim 8 trimipramine maleate 17 TRINESSA 69 TRINTELLIX 17 TRIPTODUR 72 TRISENOX 25 TRIUMEQ 34 TRIVORA TROGARZO 34 TROKENDI XR 14 TROPHAMINE 55 trospium chloride 60 trospium chloride er 60 TRULICITY 39 TRUMENBA 76 TRUVADA 34 TUDORZA PRESSAIR 83 TUSSIGON 86 TWINRIX 76 TYBOST 34 TYDEMY 69 TYGACIL 8 TYKERB 27 TYMLOS 78 TYPHIM VI 76 TYSABRI 50

115 TYVASO 85 TYVASO INSTITUTIONAL START KIT 85 TYVASO REFILL KIT 85 TYVASO STARTER KIT 85 TYZEKA 32 U U-CORT 64 UCERIS 77 ULORIC 20 UNITHROID 71 UNITUXIN 25 UPTRAVI 85 ursodiol 57 UTIBRON NEOHALER 84 UVADEX 52 V VABOMERE 9 valacyclovir 36 VALCHLOR 22 valganciclovir hcl 32 valproate sodium 14 valproic acid 14 valsartan 42 valsartan-hydrochlorothiazide 42 VANATOL LQ 4 vancomycin 8 vancomycin hcl 8 vancomycin hcl-d5w 8 vancomycin in 0.9 % sodium chloride 8 VAQTA 76 VARIVAX VACCINE 76 VARUBI 18 VASCEPA 47 VECAMYL 45 VECTIBIX 27 VELCADE 25 VELETRI 85 VELIVET 69 VELTASSA 56 VEMLIDY 32 VENCLEXTA 27 VENCLEXTA STARTING PACK 27 venlafaxine hcl 17 venlafaxine hcl er 17 VENTAVIS 85 VENTOLIN HFA 84 verapamil er 45 verapamil er pm 45 verapamil hcl 45 verapamil sr 45 VEREGEN 52 VERSACLOZ 32 VERZENIO 25 VESICARE 60 VESTURA 70 vgo vgo vgo VIAGRA 60 VIBERZI 57 VIBRAMYCIN 12 VICODIN 4 VICODIN ES 4 VICODIN HP 4 VICTOZA 2-PAK 39 VICTOZA 3-PAK 39 VIDEX 2 GM PEDIATRIC SOLN 34 VIDEX 4 GM PEDIATRIC SOLN 34 VIDEX EC 34 VIEKIRA PAK 32 VIEKIRA XR 32 VIENVA 70 vigabatrin 14 VIGAMOX 11 VIIBRYD VIMIZIM 59 VIMOVO 6 VIMPAT 13 vinblastine sulfate 25 VINCASAR PFS 25 vincristine sulfate 26 vinorelbine tartrate 26 VIORELE 70 VIRACEPT 35 VIRAMUNE 33 VIREAD 34 VISTIDE 32 vitamin d2 56 VITEKTA 35 VIVELLE-DOT 70 VIVITROL 4 VOGELXO 65 voriconazole 20 VOSEVI 33 VOTRIENT 23 VPRIV 59 VRAYLAR 31 VYFEMLA 70 VYLIBRA 70 VYXEOS 26 W warfarin sodium 40 WELCHOL 47 WERA 70 WYMZYA FE 70 X XADAGO 30 XALKORI 26 XARELTO 40 XARTEMIS XR 1 XATMEP 74 XELJANZ 74 XELJANZ XR 74 XERESE 52

116 XERMELO 79 XGEVA 78 XIFAXAN 57 XOLAIR 75 XOPENEX 84 XOPENEX CONCENTRATE 84 XTAMPZA ER 1 XTANDI 23 XULANE 70 XYLOCAINE 4 XYLOCAINE-MPF 4 XYREM 87 Y YERVOY 26 YF-VAX 76 YONDELIS 22 YUVAFEM 70 Z zafirlukast 83 zaleplon 86 ZALTRAP 27 ZANOSAR 23 ZARAH 70 ZARXIO 41 ZAVESCA 59 ZEBUTAL 4 ZEJULA 26 ZELAPAR 30 ZELBORAF 26 ZEMAIRA 59 ZEMBRACE SYMTOUCH 21 ZEMPLAR 78 ZENATANE 52 ZENCHENT 70 ZENCHENT FE 70 ZENPEP 59 ZEPA 33 ZERBAXA 9 ZERIT 34 ZIAGEN 34 zidovudine 34 zileuton er 83 ZINBRYTA 50 ZINECARD 26 ZIOPTAN 82 ziprasidone hcl 31 ZIRGAN 32 ZMAX 11 ZODEX 64 ZOHYDRO ER 1 zoledronic acid 78 ZOLINZA 26 zolmitriptan 21 zolmitriptan odt 21 zolpidem tartrate 86 zolpidem tartrate er 86 ZOMACTON 65 ZOMETA 78 ZONACORT 64 zonisamide 13 ZONTIVITY 40 ZORBTIVE 65 ZORTRESS 74 ZOSTAVAX 76 ZOSYN 10 ZOVIA 1-35E 70 ZOVIA 1-50E 70 ZOVIRAX 36 ZUPLENZ 18 ZURAMPIC 20 ZYCLARA 52 ZYDELIG 28 ZYFLO 83 ZYFLO CR 83 ZYKADIA 28 ZYLET 81 ZYPREXA RELPREVV 31 ZYTIGA

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