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2018 Prime Drug Formulary By Therapeutic Class Name Prime Drug Formulary … · not include all...

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Page 1 of 48 GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Insurance Agency, LLC in California and New York) an independent licensee of the BlueCross and Blue Shield Association made available in cooperation with Blue Cross and Blue Shield companies in select service areas. Coverage is provided under insurance policies underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois. NAIC #80985. Universal Rx is an independent Prescription Benefit Management company that does not provide Blue Cross or Blue Shield services. Universal Rx is solely responsible for the services they provide 2018 Prime Drug Formulary By Therapeutic Class Name Effective Date: July 1, 2018 Date Last Updated: June 30, 2018 Next Revision Date: October 1, 2018 The Universal Rx Outcomes Drug Formulary defines the copayment tier status of the medicines most commonly prescribed. It may not include all drugs covered by your prescription drug benefit and it may include some drugs that are excluded under your particular coverage. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised from time to time as new drugs and new prescribing information becomes available. The coverage tier for each medication has been indicated. Tier 1 medicines require the lowest member copayment. Higher tier medicines require greater member copayment. If a brand name drug does not appear on the list it is assigned the highest copay. It is recommended that you have this list of medications available when you are with your physician, and a prescription drug is going to be part of the treatment for a clinical condition. Definitions: Generic Prescription Drug (Generic) is a pharmaceutical equivalent of one or more Brand Name Drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the Brand Name Drug. Generally Generic Prescription Drugs are covered under as a Tier 1 drug. Preferred Brand Name Prescription Drug (Brand Name) is a Prescription Drug that has been patented and is only produced by one manufacturer. These drugs are generally covered as a Tier 2 drug. A Non-preferred Brand Name Prescription Drug is one not included on the Plan’s formulary or list of preferred prescriptions. Non- preferred Brand Name Prescription Drugs have a higher coinsurance than Preferred Brand Name Prescription Drugs. You pay more if You use non-preferred drugs than if You opt for Generics and Brand Name Prescription Drugs. These drugs are generally covered as a Tier 3 drug. Specialty Drugs are “bioengineered” oral or injectable medicines that target and treat complex medical conditions including: blood disorders, cancers, Infertility, hormone or enzyme deficiencies, multiple sclerosis, rheumatoid arthritis, and a growing list of obscure or “orphan” diagnoses. Specialty drugs are complex compounds and some have unique “handling” requirements. The FDA in selected situations has required dispensing from a single Pharmacy or a limited set of “approved” pharmacies. Some “specialty” drugs are oral tablets or capsules while others require injection Mail Order Prescription Drug Program Prescription drugs are available through GeoBlue both for delivery inside the United States as well as outside the United States. If you reside within the United States, the prescription mail order program is available through DrugSource, Inc. If you reside outside of the United States, the prescription drug mail order program is through Expatriate Prescription Services. Both services require the completion of a prescription mail order form, which is located in the GeoBlue Member Hub under the Coverage & Benefits tab, prescription drugs. The forms are also available through our customer service department available toll-free at 1.855.282.3517 or by email to [email protected],
Transcript
Page 1: 2018 Prime Drug Formulary By Therapeutic Class Name Prime Drug Formulary … · not include all drugs covered by your prescription drug benefit and it may include some drugs that

Page 1 of 48

GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Insurance Agency, LLC in California and New York) an independent licensee of the BlueCross and Blue Shield Association made available in cooperation with Blue Cross and Blue Shield companies in select service areas. Coverage is provided under insurance policies underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois. NAIC #80985. Universal Rx is an independent Prescription Benefit Management company that does not provide Blue Cross or Blue Shield services. Universal Rx is solely responsible for the services they provide

2018 Prime Drug Formulary By Therapeutic Class Name

Effective Date: July 1, 2018 Date Last Updated: June 30, 2018 Next Revision Date: October 1, 2018

The Universal Rx Outcomes Drug Formulary defines the copayment tier status of the medicines most commonly prescribed. It may not include all drugs covered by your prescription drug benefit and it may include some drugs that are excluded under your particular coverage. For benefit coverage or restrictions please check your benefit plan document(s).

This listing is revised from time to time as new drugs and new prescribing information becomes available.

The coverage tier for each medication has been indicated. Tier 1 medicines require the lowest member copayment. Higher tier medicines require greater member copayment. If a brand name drug does not appear on the list it is assigned the highest copay.

It is recommended that you have this list of medications available when you are with your physician, and a prescription drug is going to be part of the treatment for a clinical condition.

Definitions:

Generic Prescription Drug (Generic) is a pharmaceutical equivalent of one or more Brand Name Drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the Brand Name Drug. Generally Generic Prescription Drugs are covered under as a Tier 1 drug.

Preferred Brand Name Prescription Drug (Brand Name) is a Prescription Drug that has been patented and is only produced by one manufacturer. These drugs are generally covered as a Tier 2 drug.

A Non-preferred Brand Name Prescription Drug is one not included on the Plan’s formulary or list of preferred prescriptions. Non-preferred Brand Name Prescription Drugs have a higher coinsurance than Preferred Brand Name Prescription Drugs. You pay more if You use non-preferred drugs than if You opt for Generics and Brand Name Prescription Drugs. These drugs are generally covered as a Tier 3 drug.

Specialty Drugs are “bioengineered” oral or injectable medicines that target and treat complex medical conditions including: blood disorders, cancers, Infertility, hormone or enzyme deficiencies, multiple sclerosis, rheumatoid arthritis, and a growing list of obscure or “orphan” diagnoses. Specialty drugs are complex compounds and some have unique “handling” requirements. The FDA in selected situations has required dispensing from a single Pharmacy or a limited set of “approved” pharmacies. Some “specialty” drugs are oral tablets or capsules while others require injection

Mail Order Prescription Drug Program

Prescription drugs are available through GeoBlue both for delivery inside the United States as well as outside the United States. If you reside within the United States, the prescription mail order program is available through DrugSource, Inc. If you reside outside of the United States, the prescription drug mail order program is through Expatriate Prescription Services. Both services require the completion of a prescription mail order form, which is located in the GeoBlue Member Hub under the Coverage & Benefits tab, prescription drugs. The forms are also available through our customer service department available toll-free at 1.855.282.3517 or by email to [email protected],

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Key to Notations/Special Instructions Found in the Formulary List: PA: Your plan may require authorization or documentation of previous therapy with other similar medications before this medication is covered. If your plan does require prior authorization before dispensing of the drug, you and your prescribing physician will be asked to complete a Pharmacy Services Review Form. This form is located in the GeoBlue Member Hub under the Coverage & Benefits tab, prescription drugs. The form is also available through our customer service department available toll-free at 1.855.282.3517 or by email to [email protected], ST: A step therapy protocol may be in place for this medication. Claims for this medication may be covered based on previous medication history. If prior medication history does not meet clinical guidelines, prior authorization may be required. QL: Quantity limitations (maximum number of tablets/capsules, etc. per month or year) may be in place for this medication.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

5-HT3 Receptor Antagonists ONDANSETRON HCL 1 5-HT3 Receptor Antagonists ONDANSETRON ODT 1 5-HT3 Receptor Antagonists SANCUSO 2 A ACE Inhibitors BENAZEPRIL HCL 1 ACE Inhibitors CAPTOPRIL 1 ACE Inhibitors ENALAPRIL MALEATE 1 ACE Inhibitors EPANED 3 ACE Inhibitors FOSINOPRIL SODIUM 1 ACE Inhibitors LISINOPRIL 1 ACE Inhibitors MOEXIPRIL HCL 1 ACE Inhibitors PERINDOPRIL ERBUMINE 1 ACE Inhibitors QUINAPRIL HCL 1 ACE Inhibitors RAMIPRIL 1 ACE Inhibitors TRANDOLAPRIL 1 Acne Products ABSORICA 2 Acne Products ACANYA 2 Acne Products ACZONE 3 Acne Products ADAPALENE 1 Acne Products ADAPALENE AND BENZOYL PER 1 Acne Products ADAPALENE PUMP 1 Acne Products AKTIPAK 3 Acne Products AMNESTEEM 1 Acne Products ATRALIN 3 Acne Products AVAR CLEANSER 1 Acne Products AVAR LS 3 Acne Products AVAR LS CLEANSER 3 Acne Products AVAR-E GREEN 1 Acne Products AVAR-E LS 3 Acne Products AZELEX 3 Acne Products BENZACLIN WITH PUMP 3 Acne Products BENZEFOAM ULTRA 3 Acne Products BENZEPRO CREAMY WASH 1 Acne Products BENZEPRO FOAMING CLOTHS 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Acne Products BP 10-1 1 Acne Products BP CLEANSING WASH 2 Acne Products BP WASH 1 Acne Products CLARAVIS 1 Acne Products CLINDACIN ETZ 3 Acne Products CLINDACIN PAC 3 Acne Products CLINDAGEL 3 Acne Products CLINDAMYCIN PHOSPHATE 1 Acne Products CLINDAMYCIN PHOSPHATE/TRE 1 Acne Products CLINDAMYCIN/BENZOYL PEROX 1 Acne Products DAPSONE 1 Acne Products DIFFERIN 3 Acne Products DUAC 3 Acne Products EPIDUO 2 Acne Products EPIDUO FORTE 2 Acne Products ERY 1 Acne Products ERYTHROMYCIN 1 Acne Products ERYTHROMYCIN/BENZOYL PERO 1 Acne Products FABIOR 3 Acne Products ISOTRETINOIN 1 Acne Products MYORISAN 1 Acne Products NEUAC KIT 3 Acne Products ONEXTON 2 Acne Products PLEXION 3 Acne Products PLEXION CLEANSER 3 Acne Products RETIN-A MICRO 3 Acne Products RETIN-A MICRO PUMP 3 Acne Products RIAX 3 Acne Products SODIUM SULFACETAMIDE 1 Acne Products SODIUM SULFACETAMIDE/SULF 1 Acne Products SSS 10%-5% 1 Acne Products SULFACETAMIDE SODIUM 1 Acne Products SULFACETAMIDE SODIUM/SULF 1 Acne Products SULFACLEANSE 8/4 1 Acne Products TRETINOIN 1 Acne Products TRETINOIN MICROSPHERE 1 Acne Products TRETINOIN MICROSPHERE PUM 1 Acne Products VELTIN 3 Acne Products ZENATANE 1 Acne Products ZIANA 3 Agents for Chemical Dependency DISULFIRAM 1 Agents for External Genital and Perianal Warts VEREGEN 3 Alkalinizers POTASSIUM CITRATE ER 1 Alkalinizers SODIUM CITRATE/CITRIC ACI 1 Alkalinizers TRICITRATES 1 Alkylating Agents CYCLOPHOSPHAMIDE 2 Alkylating Agents TEMODAR 3 Alkylating Agents TEMOZOLOMIDE 1 Alpha-2 Receptor Antagonists (Tetracyclics) MIRTAZAPINE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Alpha-2 Receptor Antagonists (Tetracyclics) MIRTAZAPINE ODT 1 Alpha-Beta Blockers CARVEDILOL 1 Alpha-Beta Blockers CARVEDILOL PHOSPHATE 1 Alpha-Beta Blockers COREG CR 3 ST

Alpha-Beta Blockers LABETALOL HCL 1 Alpha-Glucosidase Inhibitors ACARBOSE 1 ALS Agents RILUZOLE 1 Aminoglycosides GENTAMICIN SULFATE 1 Aminoglycosides NEOMYCIN SULFATE 1 Aminoglycosides PAROMOMYCIN SULFATE 1 Aminoglycosides TOBRAMYCIN 1 Aminopenicillins AMOXICILLIN 1 Aminopenicillins AMPICILLIN 1 Amphetamines ADDERALL 3 Amphetamines ADDERALL XR 3 Amphetamines ADZENYS XR-ODT 3 Amphetamines AMPHETAMINE/DEXTROAMPHETA 1 Amphetamines DEXTROAMPHETAMINE SULFATE 1 Amphetamines EVEKEO 2 Amphetamines MYDAYIS 2 Amphetamines VYVANSE 2 Amphetamines ZENZEDI 3 Anabolic Steroids OXANDROLONE 1 Analgesic Combinations BUTALBITAL/ACETAMINOPHEN/ 1 Analgesic Combinations BUTALBITAL/ASPIRIN/CAFFEI 1 Anaphylaxis Therapy Agents AUVI-Q 3 Anaphylaxis Therapy Agents EPINEPHRINE 3 Anaphylaxis Therapy Agents EPINEPHRINE 2 Anaphylaxis Therapy Agents EPIPEN 2-PAK 2 Anaphylaxis Therapy Agents EPIPEN-JR 2-PAK 2 Androgens ANDRODERM 2 Androgens ANDROGEL 2 Androgens ANDROGEL 3 Androgens ANDROGEL PUMP 2 Androgens DANAZOL 1 Androgens DEPO-TESTOSTERONE 3 Androgens TESTIM 3 Androgens TESTOSTERONE 1 Androgens TESTOSTERONE 3 Androgens TESTOSTERONE 2 Androgens TESTOSTERONE CYPIONATE 1 Androgens TESTOSTERONE ENANTHATE 1 Androgens TESTOSTERONE PUMP 1 Androgens TESTOSTERONE TOPICAL SOLU 1 Anesthetics Topical Oral FIRST-MOUTHWASH BLM 2 Anesthetics Topical Oral LIDOCAINE VISCOUS 1 Angiotensin II Receptor Antagonists ATACAND 3 Angiotensin II Receptor Antagonists BENICAR 3 Angiotensin II Receptor Antagonists CANDESARTAN CILEXETIL 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Angiotensin II Receptor Antagonists DIOVAN 3 Angiotensin II Receptor Antagonists EDARBI 2 ST

Angiotensin II Receptor Antagonists IRBESARTAN 1 Angiotensin II Receptor Antagonists LOSARTAN POTASSIUM 1 Angiotensin II Receptor Antagonists MICARDIS 3 Angiotensin II Receptor Antagonists OLMESARTAN MEDOXOMIL 1 Angiotensin II Receptor Antagonists TELMISARTAN 1 Angiotensin II Receptor Antagonists VALSARTAN 1 Anorexiants Non-Amphetamine DIETHYLPROPION HCL ER 1 Anorexiants Non-Amphetamine PHENTERMINE HCL 1 Anorexiants Non-Amphetamine QSYMIA 3 Anthelmintics ALBENZA 2 Anthelmintics BILTRICIDE 2 Anthelmintics EMVERM 2 Anthelmintics IVERMECTIN 1 Anthelmintics STROMECTOL 3 Antiadrenergic Antihypertensives CARDURA 3 Antiadrenergic Antihypertensives CATAPRES-TTS-3 3 Antiadrenergic Antihypertensives CLONIDINE HCL 1 Antiadrenergic Antihypertensives DOXAZOSIN 1 Antiadrenergic Antihypertensives DOXAZOSIN MESYLATE 1 Antiadrenergic Antihypertensives GUANFACINE HCL 1 Antiadrenergic Antihypertensives METHYLDOPA 1 Antiadrenergic Antihypertensives PRAZOSIN HCL 1 Antiadrenergic Antihypertensives TERAZOSIN HCL 1 Antianginals-Other RANEXA 2 Antianxiety Agents - Misc. BUSPIRONE HCL 1 Antianxiety Agents - Misc. HYDROXYZINE HCL 1 Antianxiety Agents - Misc. HYDROXYZINE PAMOATE 1 Antiarrhythmics Type I-C FLECAINIDE ACETATE 1 Antiarrhythmics Type I-C PROPAFENONE HCL 1 Antiarrhythmics Type I-C PROPAFENONE HCL ER 1 Antiarrhythmics Type I-C PROPAFENONE HYDROCHLORIDE 1 Antiarrhythmics Type III AMIODARONE HCL 1 Antiarrhythmics Type III DOFETILIDE 1 Antiarrhythmics Type III MULTAQ 3 Antiasthmatic - Monoclonal Antibodies XOLAIR 2 Antibiotics - Topical ALTABAX 3 Antibiotics - Topical CORTISPORIN 3 Antibiotics - Topical GENTAMICIN SULFATE 1 Antibiotics - Topical MUPIROCIN 1 Antibiotics - Topical NEOMYCIN SULFATE 3 Antibiotics - Topical NEO-SYNALAR 3 Antibiotics - Topical NEO-SYNALAR KIT 3 Anti-Cataplectic Agents XYREM 2 Anticonvulsants - Benzodiazepines CLONAZEPAM 1 Anticonvulsants - Benzodiazepines CLONAZEPAM ODT 1 Anticonvulsants - Benzodiazepines DIASTAT ACUDIAL 3 Anticonvulsants - Benzodiazepines DIAZEPAM RECTAL GEL 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Anticonvulsants - Benzodiazepines KLONOPIN 3 Anticonvulsants - Benzodiazepines ONFI 2 Anticonvulsants - Misc. APTIOM 3 Anticonvulsants - Misc. CARBAMAZEPINE 1 Anticonvulsants - Misc. CARBAMAZEPINE ER 1 Anticonvulsants - Misc. GABAPENTIN 1 Anticonvulsants - Misc. KEPPRA 3 Anticonvulsants - Misc. LAMICTAL 3 Anticonvulsants - Misc. LAMICTAL XR 3 Anticonvulsants - Misc. LAMOTRIGINE 1 Anticonvulsants - Misc. LAMOTRIGINE ER 1 Anticonvulsants - Misc. LAMOTRIGINE ODT 1 Anticonvulsants - Misc. LAMOTRIGINE STARTER KIT/O 1 Anticonvulsants - Misc. LAMOTRIGINE TITRATION 1 Anticonvulsants - Misc. LEVETIRACETAM 1 Anticonvulsants - Misc. LEVETIRACETAM ER 1 Anticonvulsants - Misc. LYRICA 2 Anticonvulsants - Misc. NEURONTIN 3 Anticonvulsants - Misc. OXCARBAZEPINE 1 Anticonvulsants - Misc. OXTELLAR XR 3 Anticonvulsants - Misc. PRIMIDONE 1 Anticonvulsants - Misc. TEGRETOL 3 Anticonvulsants - Misc. TEGRETOL-XR 3 Anticonvulsants - Misc. TOPAMAX 3 Anticonvulsants - Misc. TOPIRAMATE 1 Anticonvulsants - Misc. TOPIRAMATE ER 3 Anticonvulsants - Misc. TROKENDI XR 3 ST

Anticonvulsants - Misc. VIMPAT 2 Anticonvulsants - Misc. ZONEGRAN 3 Anticonvulsants - Misc. ZONISAMIDE 1 Antidementia Agents DONEPEZIL HCL 1 Antidementia Agents EXELON 3 Antidementia Agents GALANTAMINE HYDROBROMIDE 1 Antidementia Agents MEMANTINE HCL 1 Antidementia Agents MEMANTINE HCL TITRATION P 1 Antidementia Agents MEMANTINE HYDROCHLORIDE E 1 Antidementia Agents NAMENDA 3 Antidementia Agents NAMENDA XR 2 Antidementia Agents NAMZARIC 2 Antidementia Agents RIVASTIGMINE TARTRATE 1 Antidementia Agents RIVASTIGMINE TRANSDERMAL 1 Antidepressants - Misc. APLENZIN 3 Antidepressants - Misc. BUPROPION HCL 1 Antidepressants - Misc. BUPROPION HCL ER 1 Antidepressants - Misc. BUPROPION HCL SR 1 Antidepressants - Misc. BUPROPION HCL XL 1 Antidepressants - Misc. FORFIVO XL 3 Antidepressants - Misc. WELLBUTRIN SR 3 Antidepressants - Misc. WELLBUTRIN XL 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antidiabetic Combinations GLIPIZIDE/METFORMIN HCL 1 Antidiabetic Combinations GLYBURIDE/METFORMIN HCL 1 Antidiabetic Combinations GLYXAMBI 2 Antidiabetic Combinations INVOKAMET 2 Antidiabetic Combinations INVOKAMET XR 2 Antidiabetic Combinations JANUMET 2 Antidiabetic Combinations JANUMET XR 2 Antidiabetic Combinations JENTADUETO 2 Antidiabetic Combinations KAZANO 3 ST

Antidiabetic Combinations KOMBIGLYZE XR 3 ST

Antidiabetic Combinations PIOGLITAZONE HCL/METFORMI 1 Antidiabetic Combinations PIOGLITAZONE HCL-GLIMEPIR 1 Antidiabetic Combinations SOLIQUA 100/33 2 Antidiabetic Combinations SYNJARDY 2 Antidiabetic Combinations SYNJARDY XR 2 Antidiabetic Combinations XIGDUO XR 2 Antidiabetic Combinations XULTOPHY 100/3.6 2 Antidiarrheal/Probiotic Agents - Misc. VSL#3 DS 3 Antidiarrheal/Probiotic Combinations RESTORA RX 3 Antidotes - Chelating Agents JADENU 2 Antiemetics - Anticholinergic MECLIZINE HCL 1 Antiemetics - Anticholinergic SCOPOLAMINE 1 Antiemetics - Anticholinergic TRANSDERM-SCOP 3 Antiemetics - Anticholinergic TRIMETHOBENZAMIDE HCL 1 Antiemetics - Miscellaneous DICLEGIS 3 Antiemetics - Miscellaneous DRONABINOL 1 Antifungals GRISEOFULVIN MICROSIZE 1 Antifungals GRISEOFULVIN ULTRAMICROSI 1 Antifungals NYSTATIN 1 Antifungals TERBINAFINE HCL 1 Antifungals - Topical ALA-QUIN 3 Antifungals - Topical ALCORTIN A 3 Antifungals - Topical CICLOPIROX 1 Antifungals - Topical CICLOPIROX NAIL LACQUER 1 Antifungals - Topical CICLOPIROX OLAMINE 1 Antifungals - Topical CICLOPIROX TREATMENT 1 Antifungals - Topical CLOTRIMAZOLE 1 Antifungals - Topical CLOTRIMAZOLE/BETAMETHASON 1 Antifungals - Topical DERMAZENE 1 Antifungals - Topical ECONAZOLE NITRATE 1 Antifungals - Topical ECOZA 3 Antifungals - Topical ERTACZO 3 Antifungals - Topical HYDROCORTISONE/IODOQUINOL 1 Antifungals - Topical JUBLIA 3 ST

Antifungals - Topical KERYDIN 3 ST

Antifungals - Topical KETOCONAZOLE 1 Antifungals - Topical LUZU 3 ST

Antifungals - Topical MENTAX 3 ST

Antifungals - Topical NAFTIFINE HYDROCHLORIDE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antifungals - Topical NAFTIN 3 ST

Antifungals - Topical NYAMYC 1 Antifungals - Topical NYSTATIN 1 Antifungals - Topical NYSTATIN/TRIAMCINOLONE 1 Antifungals - Topical NYSTOP 1 Antifungals - Topical OXICONAZOLE NITRATE 1 Antifungals - Topical OXISTAT 3 ST

Antifungals - Topical VYTONE 3 Antifungals - Topical XOLEGEL 3 ST

Antihemophilic Products ELOCTATE 3 Antihistamines - Ethanolamines CLEMASTINE FUMARATE 1 Antihistamines - Ethanolamines DIPHENHYDRAMINE HCL 1 Antihistamines - Ethanolamines KARBINAL ER 3 Antihistamines - Non-Sedating ALL DAY ALLERGY 1 Antihistamines - Non-Sedating ALLERGY 1 Antihistamines - Non-Sedating CETIRIZINE HCL 1 Antihistamines - Non-Sedating CETIRIZINE HCL ALLERGY CH 1 Antihistamines - Non-Sedating CHILDRENS LORATADINE 1 Antihistamines - Non-Sedating DESLORATADINE 1 Antihistamines - Non-Sedating FEXOFENADINE HCL 1 Antihistamines - Non-Sedating LEVOCETIRIZINE DIHYDROCHL 1 Antihistamines - Non-Sedating LORATADINE 1 Antihistamines - Non-Sedating LORATADINE CHILDRENS 1 Antihistamines - Non-Sedating RA ALLERGY RELIEF 1 Antihistamines - Non-Sedating RA LORATADINE 1 Antihistamines - Phenothiazines PHENADOZ 1 Antihistamines - Phenothiazines PROMETHAZINE HCL 1 Antihistamines - Phenothiazines PROMETHAZINE HCL PLAIN 1 Antihistamines - Phenothiazines PROMETHEGAN 1 Antihistamines - Piperidines CYPROHEPTADINE HCL 1 ANTIHYPERLIPIDEMICS PRALUENT 2 ANTIHYPERLIPIDEMICS REPATHA 2 ANTIHYPERLIPIDEMICS REPATHA SURECLICK 2 Antihyperlipidemics - Combinations EZETIMIBE/SIMVASTATIN 1 Antihyperlipidemics - Combinations VYTORIN 3 ST

Antihyperlipidemics - Misc. LOVAZA 3 Antihyperlipidemics - Misc. OMEGA-3-ACID ETHYL ESTERS 1 Antihyperlipidemics - Misc. VASCEPA 2 Antihypertensive Combinations AMLODIPINE BESYLATE/BENAZ 1 Antihypertensive Combinations AMLODIPINE BESYLATE/VALSA 1 Antihypertensive Combinations AMLODIPINE/OLMESARTAN MED 1 Antihypertensive Combinations AMLODIPINE/VALSARTAN/HCTZ 1 Antihypertensive Combinations ATACAND HCT 3 Antihypertensive Combinations ATENOLOL/CHLORTHALIDONE 1 Antihypertensive Combinations AVALIDE 3 Antihypertensive Combinations BENAZEPRIL HCL/HYDROCHLOR 1 Antihypertensive Combinations BENICAR HCT 3 Antihypertensive Combinations BISOPROLOL FUMARATE/HYDRO 1 Antihypertensive Combinations CANDESARTAN CILEXETIL/HYD 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antihypertensive Combinations EDARBYCLOR 2 Antihypertensive Combinations ENALAPRIL MALEATE/HYDROCH 1 Antihypertensive Combinations EXFORGE 3 Antihypertensive Combinations IRBESARTAN/HYDROCHLOROTHI 1 Antihypertensive Combinations LISINOPRIL/HYDROCHLOROTHI 1 Antihypertensive Combinations LOSARTAN POTASSIUM/HYDROC 1 Antihypertensive Combinations METOPROLOL/HYDROCHLOROTHI 1 Antihypertensive Combinations MICARDIS HCT 3 Antihypertensive Combinations OLMESARTAN MEDOXOMIL/AMLO 1 Antihypertensive Combinations OLMESARTAN MEDOXOMIL/HYDR 1 Antihypertensive Combinations QUINAPRIL/HYDROCHLOROTHIA 1 Antihypertensive Combinations TELMISARTAN/AMLODIPINE 1 Antihypertensive Combinations TELMISARTAN/HYDROCHLOROTH 1 Antihypertensive Combinations VALSARTAN/HYDROCHLOROTHIA 1 Anti-infective Agents - Misc. FIRST-METRONIDAZOLE 100 3 Anti-infective Agents - Misc. METRONIDAZOLE 1 Anti-infective Agents - Misc. TINIDAZOLE 1 Anti-infective Agents - Misc. TRIMETHOPRIM 1 Anti-infective Agents - Misc. VANCOMYCIN HCL 1 Anti-infective Agents - Misc. XIFAXAN 2 Anti-infective Misc. - Combinations SULFAMETHOXAZOLE/TRIMETHO 1 Anti-infective Misc. - Combinations SULFATRIM PEDIATRIC 1 Anti-infectives - Throat CLOTRIMAZOLE 1 Anti-infectives - Throat NYSTATIN 1 Anti-Inflammatory Agents CROMOLYN SODIUM 1 Anti-Inflammatory Agents CROMOLYN SODIUM 3 Anti-inflammatory Agents - Topical DERMACINRX LEXITRAL PHARM 3 Anti-inflammatory Agents - Topical DICLOFENAC SODIUM 1 Anti-inflammatory Agents - Topical DICLOFEX DC 1 Anti-inflammatory Agents - Topical FLECTOR 2 Anti-inflammatory Agents - Topical PENNSAID 3 Anti-inflammatory Agents - Topical VOLTAREN 3 Anti-inflammatory Agents - Topical XRYLIX 3 Antimalarial Combinations ATOVAQUONE/PROGUANIL HCL 1 Antimalarial Combinations COARTEM 2 Antimalarial Combinations MALARONE 3 Antimalarials CHLOROQUINE PHOSPHATE 1 Antimalarials HYDROXYCHLOROQUINE SULFAT 1 Antimalarials MEFLOQUINE HCL 1 Antimalarials PLAQUENIL 3 Antimalarials PRIMAQUINE PHOSPHATE 1 Antimalarials PRIMAQUINE PHOSPHATE 2 Antimanic Agents LITHIUM CARBONATE 1 Antimanic Agents LITHIUM CARBONATE ER 1 Antimetabolites CAPECITABINE 1 Antimetabolites MERCAPTOPURINE 1 Antimetabolites METHOTREXATE 1 Antimetabolites METHOTREXATE SODIUM 1 Antimetabolites TABLOID 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antimyasthenic/Cholinergic Agents PYRIDOSTIGMINE BROMIDE 1 Antimycobacterial Agents ETHAMBUTOL HCL 1 Antimycobacterial Agents ISONIAZID 1 Antimycobacterial Agents PYRAZINAMIDE 1 Antimycobacterial Agents RIFABUTIN 1 Antimycobacterial Agents RIFAMPIN 1 Antineoplastic - Antibodies RITUXAN 2 Antineoplastic - Hormonal and Related Agents ANASTROZOLE 1 Antineoplastic - Hormonal and Related Agents BICALUTAMIDE 1 Antineoplastic - Hormonal and Related Agents EXEMESTANE 1 Antineoplastic - Hormonal and Related Agents LETROZOLE 1 Antineoplastic - Hormonal and Related Agents LEUPROLIDE ACETATE 1 Antineoplastic - Hormonal and Related Agents LUPRON DEPOT (1-MONTH) 2 Antineoplastic - Hormonal and Related Agents LUPRON DEPOT (3-MONTH) 2 Antineoplastic - Hormonal and Related Agents MEGESTROL ACETATE 1 Antineoplastic - Hormonal and Related Agents TAMOXIFEN CITRATE 1 Antineoplastic - Hormonal and Related Agents XTANDI 2 Antineoplastic - Immunomodulators POMALYST 2 Antineoplastic Enzyme Inhibitors AFINITOR 2 Antineoplastic Enzyme Inhibitors BOSULIF 2 Antineoplastic Enzyme Inhibitors CABOMETYX 3 Antineoplastic Enzyme Inhibitors GLEEVEC 3 Antineoplastic Enzyme Inhibitors IBRANCE 2 Antineoplastic Enzyme Inhibitors ICLUSIG 2 Antineoplastic Enzyme Inhibitors IMATINIB MESYLATE 1 Antineoplastic Enzyme Inhibitors JAKAFI 2 Antineoplastic Enzyme Inhibitors MEKINIST 2 Antineoplastic Enzyme Inhibitors NEXAVAR 2 Antineoplastic Enzyme Inhibitors NINLARO 2 Antineoplastic Enzyme Inhibitors SPRYCEL 2 Antineoplastic Enzyme Inhibitors STIVARGA 2 Antineoplastic Enzyme Inhibitors SUTENT 2 Antineoplastic Enzyme Inhibitors TAFINLAR 2 Antineoplastic Enzyme Inhibitors TASIGNA 2 Antineoplastic Enzyme Inhibitors TYKERB 2 Antineoplastic Enzyme Inhibitors VOTRIENT 2 Antineoplastic or Premalignant Lesion Agents - Topical DICLOFENAC SODIUM 1 Antineoplastic or Premalignant Lesion Agents - Topical EFUDEX 3 Antineoplastic or Premalignant Lesion Agents - Topical FLUOROPLEX 3 Antineoplastic or Premalignant Lesion Agents - Topical FLUOROURACIL 1 Antineoplastic or Premalignant Lesion Agents - Topical FLUOROURACIL 3 Antineoplastic or Premalignant Lesion Agents - Topical LEVULAN KERASTICK 3 Antineoplastic or Premalignant Lesion Agents - Topical PICATO 2 Antineoplastic or Premalignant Lesion Agents - Topical TOLAK 3 Antineoplastics Misc. HYDROXYUREA 1 Antineoplastics Misc. INTRON A 2 Antineoplastics Misc. TRETINOIN 1 Anti-Obesity Agents CONTRAVE 3 Antiparkinson Anticholinergics BENZTROPINE MESYLATE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antiparkinson Anticholinergics TRIHEXYPHENIDYL HCL 1 Antiparkinson COMT Inhibitors ENTACAPONE 1 Antiparkinson Dopaminergics AMANTADINE HCL 1 Antiparkinson Dopaminergics BROMOCRIPTINE MESYLATE 1 Antiparkinson Dopaminergics CARBIDOPA/LEVODOPA 1 Antiparkinson Dopaminergics CARBIDOPA/LEVODOPA ER 1 Antiparkinson Dopaminergics CARBIDOPA/LEVODOPA ODT 1 Antiparkinson Dopaminergics CARBIDOPA/LEVODOPA/ENTACA 2 Antiparkinson Dopaminergics CARBIDOPA/LEVODOPA/ENTACA 1 Antiparkinson Dopaminergics GOCOVRI 3 Antiparkinson Dopaminergics NEUPRO 3 Antiparkinson Dopaminergics PRAMIPEXOLE DIHYDROCHLORI 1 Antiparkinson Dopaminergics REQUIP 3 Antiparkinson Dopaminergics REQUIP XL 3 Antiparkinson Dopaminergics ROPINIROLE ER 1 Antiparkinson Dopaminergics ROPINIROLE HCL 1 Antiparkinson Dopaminergics RYTARY 3 Antiparkinson Dopaminergics SINEMET 3 Antiparkinson Monoamine Oxidase Inhibitors AZILECT 3 Antiparkinson Monoamine Oxidase Inhibitors RASAGILINE MESYLATE 1 Antiparkinson Monoamine Oxidase Inhibitors SELEGILINE HCL 1 Antiperistaltic Agents DIPHENOXYLATE/ATROPINE 1 Antiperistaltic Agents LOPERAMIDE HCL 1 Antiprotozoal Agents ALINIA 2 Antiprotozoal Agents ATOVAQUONE 1 Antipruritics - Topical DOXEPIN HYDROCHLORIDE 1 Antipruritics - Topical ZONALON 3 Antipsoriatics ACITRETIN 1 Antipsoriatics CALCIPOTRIENE 1 Antipsoriatics CALCITRENE 1 Antipsoriatics SORILUX 3 Antipsoriatics STELARA 2 Antipsoriatics TALTZ 3 Antipsoriatics TAZAROTENE 1 Antipsoriatics TAZORAC 2 Antipsoriatics TAZORAC 3 Antipsychotics - Misc. GEODON 3 Antipsychotics - Misc. LATUDA 2 Antipsychotics - Misc. VRAYLAR 3 Antipsychotics - Misc. ZIPRASIDONE HCL 1 Antiretrovirals ABACAVIR 1 Antiretrovirals ABACAVIR/LAMIVUDINE 1 Antiretrovirals ATAZANAVIR SULFATE 1 Antiretrovirals ATRIPLA 2 Antiretrovirals COMPLERA 2 Antiretrovirals DESCOVY 2 Antiretrovirals GENVOYA 2 Antiretrovirals ISENTRESS 2 Antiretrovirals LAMIVUDINE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antiretrovirals LEXIVA 3 Antiretrovirals NEVIRAPINE 1 Antiretrovirals NORVIR 2 Antiretrovirals ODEFSEY 2 Antiretrovirals PREZCOBIX 3 Antiretrovirals REYATAZ 3 Antiretrovirals STRIBILD 2 Antiretrovirals SUSTIVA 3 Antiretrovirals TENOFOVIR DISOPROXIL FUMA 1 Antiretrovirals TIVICAY 2 Antiretrovirals TRIUMEQ 2 Antiretrovirals TRUVADA 2 Antiretrovirals VIREAD 3 Antirheumatic - Enzyme Inhibitors XELJANZ 2 Antirheumatic - Enzyme Inhibitors XELJANZ XR 2 Antiseborrheic Products PROMISEB 3 Antiseborrheic Products PROMISEB COMPLETE 3 Antiseborrheic Products SEB-PREV WASH 1 Antiseborrheic Products SELENIUM SULFIDE 1 Antiseborrheic Products SODIUM SULFACETAMIDE 1 Antiseborrheic Products SODIUM SULFACETAMIDE WASH 1 Antiseptics - Mouth/Throat CHLORHEXIDINE GLUCONATE 1 Antiseptics - Mouth/Throat DEBACTEROL 3 Antiseptics & Disinfectants HYDROGEN PEROXIDE 2 Antispasmodics ANASPAZ 2 Antispasmodics ATROPINE SULFATE 1 Antispasmodics CHLORDIAZEPOXIDE HCL/CLID 1 Antispasmodics DICYCLOMINE HCL 1 Antispasmodics DONNATAL 3 Antispasmodics GLYCOPYRROLATE 1 Antispasmodics HYOSCYAMINE SULFATE 1 Antispasmodics HYOSCYAMINE SULFATE ER 1 Antispasmodics HYOSCYAMINE SULFATE ODT 1 Antispasmodics HYOSYNE 1 Antispasmodics METHSCOPOLAMINE BROMIDE 1 Antispasmodics NULEV 1 Antispasmodics OSCIMIN 1 Antispasmodics PHENOHYTRO 1 Antithyroid Agents METHIMAZOLE 1 Antithyroid Agents PROPYLTHIOURACIL 1 Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA 2 Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA PEN 2 Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA PEN-CROHNS DISEASE 2 Anti-TNF-alpha - Monoclonoal Antibodies SIMPONI 3 Antitussives BENZONATATE 1 Antitussives HYDROCODONE BITARTRATE/HO 1 Antitussives HYDROCODONE/HOMATROPINE 1 Antitussives HYDROMET 1 Antivirals - Topical ACYCLOVIR 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Antivirals - Topical DENAVIR 3 Antivirals - Topical XERESE 3 Antivirals - Topical ZOVIRAX 2 Artificial Tears and Lubricants TEARS NATURALE PM 3 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents ATOMOXETINE 1 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents CLONIDINE HCL ER 1 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents GUANFACINE ER 1 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents STRATTERA 3 Azithromycin AZITHROMYCIN 1 Azithromycin AZITHROMYCIN 2 Azithromycin ZITHROMAX Z-PAK 3 B Bacterial Vaccines BEXSERO 2 Bacterial Vaccines HIBERIX 2 Bacterial Vaccines MENACTRA 2 Bacterial Vaccines MENVEO 3 Bacterial Vaccines PNEUMOVAX 23 2 Bacterial Vaccines PNEUMOVAX 23/1 DOSE 2 Bacterial Vaccines PREVNAR 13 2 Bacterial Vaccines TRUMENBA 2 Bacterial Vaccines TYPHIM VI 2 Bacterial Vaccines VIVOTIF 2 Barbiturate Hypnotics PHENOBARBITAL 1 B-Complex w/ Folic Acid Cap NEPHRO-VITE RX 2 Benzisoxazoles FANAPT 3 Benzisoxazoles INVEGA SUSTENNA 3 Benzisoxazoles PALIPERIDONE ER 1 Benzisoxazoles RISPERIDONE 1 Benzisoxazoles RISPERIDONE ODT 1 Benzodiazepines ALPRAZOLAM 1 Benzodiazepines ALPRAZOLAM ER 1 Benzodiazepines ALPRAZOLAM XR 1 Benzodiazepines ATIVAN 3 Benzodiazepines CHLORDIAZEPOXIDE HCL 1 Benzodiazepines CLORAZEPATE DIPOTASSIUM 1 Benzodiazepines DIAZEPAM 1 Benzodiazepines DIAZEPAM INTENSOL 1 Benzodiazepines LORAZEPAM 1 Benzodiazepines LORAZEPAM INTENSOL 1 Benzodiazepines XANAX 3 Beta Blockers Cardio-Selective ACEBUTOLOL HCL 1 Beta Blockers Cardio-Selective ATENOLOL 1 Beta Blockers Cardio-Selective BISOPROLOL FUMARATE 1 Beta Blockers Cardio-Selective BYSTOLIC 2 Beta Blockers Cardio-Selective METOPROLOL SUCCINATE ER 1 Beta Blockers Cardio-Selective METOPROLOL TARTRATE 1 Beta Blockers Cardio-Selective METOPROLOL TARTRATE 2 Beta Blockers Cardio-Selective TOPROL XL 3 Beta Blockers Non-Selective INNOPRAN XL 3 ST

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Beta Blockers Non-Selective NADOLOL 1 Beta Blockers Non-Selective PINDOLOL 1 Beta Blockers Non-Selective PROPRANOLOL HCL 1 Beta Blockers Non-Selective PROPRANOLOL HCL ER 1 Beta Blockers Non-Selective PROPRANOLOL HYDROCHLORIDE 1 Beta Blockers Non-Selective SOTALOL HCL 1 Beta Blockers Non-Selective SOTALOL HCL (AF) 1 Beta Blockers Non-Selective SOTALOL HYDROCHOLRIDE 1 Beta-blockers - Ophthalmic BETIMOL 3 Beta-blockers - Ophthalmic CARTEOLOL HCL 1 Beta-blockers - Ophthalmic COMBIGAN 2 Beta-blockers - Ophthalmic COSOPT 3 Beta-blockers - Ophthalmic COSOPT PF 3 Beta-blockers - Ophthalmic DORZOLAMIDE HCL/TIMOLOL M 1 Beta-blockers - Ophthalmic ISTALOL 3 Beta-blockers - Ophthalmic TIMOLOL MALEATE 1 Beta-blockers - Ophthalmic TIMOLOL MALEATE OPHTHALMI 1 Beta-blockers - Ophthalmic TIMOPTIC OCUDOSE 3 Bicarbonates SODIUM BICARBONATE 1 Biguanides GLUCOPHAGE 3 Biguanides GLUCOPHAGE XR 3 Biguanides GLUMETZA 3 Biguanides METFORMIN HCL 1 Biguanides METFORMIN HCL ER 1 Biguanides METFORMIN HYDROCHLORIDE 1 Bile Acid Sequestrants CHOLESTYRAMINE 1 Bile Acid Sequestrants CHOLESTYRAMINE LIGHT 1 Bile Acid Sequestrants COLESTIPOL HCL 1 Bile Acid Sequestrants WELCHOL 2 Bone Density Regulators ACTONEL 3 ST

Bone Density Regulators ALENDRONATE SODIUM 1 Bone Density Regulators BONIVA 3 Bone Density Regulators CALCITONIN SALMON 1 Bone Density Regulators CALCITONIN-SALMON 1 Bone Density Regulators FORTEO 2 Bone Density Regulators FOSAMAX PLUS D 3 Bone Density Regulators IBANDRONATE SODIUM 1 Bone Density Regulators PROLIA 3 Bone Density Regulators RISEDRONATE SODIUM 1 Bone Density Regulators RISEDRONATE SODIUM DR 1 Bone Density Regulators XGEVA 2 Bronchodilators - Anticholinergics ATROVENT HFA 2 Bronchodilators - Anticholinergics INCRUSE ELLIPTA 2 Bronchodilators - Anticholinergics IPRATROPIUM BROMIDE 1 Bronchodilators - Anticholinergics SPIRIVA HANDIHALER 2 Bronchodilators - Anticholinergics SPIRIVA RESPIMAT 2 Bulk Chemicals - A's ASCORBIC ACID 3 Bulk Chemicals - C's CELLULOSE MICROCRYSTALLIN 2 Bulk Chemicals - C's ETHOXY DIGLYCOL 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Bulk Chemicals - D's DIAZEPAM 3 Bulk Chemicals - D's DILTIAZEM HCL 3 Bulk Chemicals - D's DULOXETINE HCL 3 Bulk Chemicals - E's ESTRADIOL 3 Bulk Chemicals - E's ESTRIOL 3 Bulk Chemicals - E's ETHYL OLEATE 3 Bulk Chemicals - F's FLUOROURACIL 3 Bulk Chemicals - F's FLUTICASONE PROPIONATE 3 Bulk Chemicals - G's GABAPENTIN 3 Bulk Chemicals - H's HYDROXYPROPYL METHYLCELLU 2 Bulk Chemicals - K's KETAMINE HCL 3 Bulk Chemicals - L's LEUPROLIDE ACETATE 3 Bulk Chemicals - L's LEVOTHYROXINE SODIUM 3 Bulk Chemicals - L's PCCA T4 SODIUM DILUTION 3 Bulk Chemicals - M's MUPIROCIN 3 Bulk Chemicals - N's NALTREXONE HCL 3 Bulk Chemicals - P's PROGESTERONE MICRONIZED 3 Bulk Chemicals - P's PROMETHAZINE HCL 3 Bulk Chemicals - T's TESTOSTERONE 3 Bulk Chemicals - T's TESTOSTERONE MICRONIZED S 3 Burn Products SILVADENE 3 Burn Products SILVER SULFADIAZINE 1 Burn Products SSD 1 Butyrophenones HALOPERIDOL 1 C Calcium Channel Blockers AMLODIPINE BESYLATE 1 Calcium Channel Blockers CARTIA XT 1 Calcium Channel Blockers DILTIAZEM HCL 1 Calcium Channel Blockers DILTIAZEM HCL CD 1 Calcium Channel Blockers DILTIAZEM HCL ER 1 Calcium Channel Blockers DILT-XR 1 Calcium Channel Blockers FELODIPINE ER 1 Calcium Channel Blockers MATZIM LA 1 Calcium Channel Blockers NIFEDIPINE 1 Calcium Channel Blockers NIFEDIPINE 3 Calcium Channel Blockers NIFEDIPINE ER 1 Calcium Channel Blockers NISOLDIPINE ER 1 Calcium Channel Blockers NORVASC 3 Calcium Channel Blockers PROCARDIA XL 3 Calcium Channel Blockers TAZTIA XT 1 Calcium Channel Blockers VERAPAMIL HCL 1 Calcium Channel Blockers VERAPAMIL HCL ER 1 Calcium Channel Blockers VERAPAMIL HCL SR 1 Carbamates FELBAMATE 1 Carbonic Anhydrase Inhibitors ACETAZOLAMIDE 1 Carbonic Anhydrase Inhibitors ACETAZOLAMIDE ER 1 Carbonic Anhydrase Inhibitors METHAZOLAMIDE 1 Cardiac Glycosides DIGOX 1 Cardiac Glycosides DIGOXIN 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

CARDIOVASCULAR AGENTS - MISC. ADCIRCA 2 CARDIOVASCULAR AGENTS - MISC. CORLANOR 2 CARDIOVASCULAR AGENTS - MISC. SILDENAFIL 1 Cardiovascular Agents Misc. - Combinations AMLODIPINE BESYLATE/ATORV 1 Cardiovascular Agents Misc. - Combinations CADUET 3 Cardiovascular Agents Misc. - Combinations ENTRESTO 2 Cauterizing Agents ARZOL SILVER NITRATE APP 2 Central Muscle Relaxants AMRIX 3 QL

Central Muscle Relaxants BACLOFEN 1 Central Muscle Relaxants CARISOPRODOL 1 Central Muscle Relaxants CHLORZOXAZONE 1 Central Muscle Relaxants CYCLOBENZAPRINE HCL 1 Central Muscle Relaxants GABLOFEN 2 Central Muscle Relaxants LORZONE 3 Central Muscle Relaxants METAXALONE 1 Central Muscle Relaxants METHOCARBAMOL 1 Central Muscle Relaxants ORPHENADRINE CITRATE ER 1 Central Muscle Relaxants TIZANIDINE HCL 1 Cephalosporins - 1st Generation CEFADROXIL 1 Cephalosporins - 1st Generation CEPHALEXIN 1 Cephalosporins - 1st Generation DAXBIA 3 Cephalosporins - 2nd Generation CEFACLOR 1 Cephalosporins - 2nd Generation CEFPROZIL 1 Cephalosporins - 2nd Generation CEFTIN 3 Cephalosporins - 2nd Generation CEFUROXIME AXETIL 1 Cephalosporins - 3rd Generation CEFDINIR 1 Cephalosporins - 3rd Generation CEFIXIME 1 Cephalosporins - 3rd Generation CEFPODOXIME PROXETIL 1 Cephalosporins - 3rd Generation CEFTRIAXONE SODIUM 1 Cephalosporins - 3rd Generation SUPRAX 3 Chemotherapy Rescue/Antidote Agents LEUCOVORIN CALCIUM 1 Clarithromycin CLARITHROMYCIN 1 Clarithromycin CLARITHROMYCIN ER 1 CMV Agents VALGANCICLOVIR 1 Cobalamins CYANOCOBALAMIN 1 Cobalamins NASCOBAL 2 Combination Contraceptives - Oral ALTAVERA 1 Combination Contraceptives - Oral ALYACEN 1/35 1 Combination Contraceptives - Oral ALYACEN 7/7/7 1 Combination Contraceptives - Oral AMETHIA 1 Combination Contraceptives - Oral AMETHIA LO 1 Combination Contraceptives - Oral APRI 1 Combination Contraceptives - Oral ARANELLE 1 Combination Contraceptives - Oral ASHLYNA 1 Combination Contraceptives - Oral AUBRA 1 Combination Contraceptives - Oral AVIANE 1 Combination Contraceptives - Oral AZURETTE 1 Combination Contraceptives - Oral BALZIVA 1 Combination Contraceptives - Oral BEKYREE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Combination Contraceptives - Oral BEYAZ 3 Combination Contraceptives - Oral BLISOVI 24 FE 1 Combination Contraceptives - Oral BLISOVI FE 1.5/30 1 Combination Contraceptives - Oral BLISOVI FE 1/20 1 Combination Contraceptives - Oral CAMRESE 1 Combination Contraceptives - Oral CAMRESE LO 1 Combination Contraceptives - Oral CAZIANT 1 Combination Contraceptives - Oral CHATEAL 1 Combination Contraceptives - Oral CRYSELLE-28 1 Combination Contraceptives - Oral CYCLAFEM 1/35 1 Combination Contraceptives - Oral CYRED 1 Combination Contraceptives - Oral DASETTA 1/35 1 Combination Contraceptives - Oral DASETTA 7/7/7 1 Combination Contraceptives - Oral DAYSEE 1 Combination Contraceptives - Oral DESOGESTREL/ETHINYL ESTRA 1 Combination Contraceptives - Oral DROSPIRENONE/ETHINYL ESTR 1 Combination Contraceptives - Oral ELINEST 1 Combination Contraceptives - Oral EMOQUETTE 1 Combination Contraceptives - Oral ENPRESSE-28 1 Combination Contraceptives - Oral ENSKYCE 1 Combination Contraceptives - Oral ESTARYLLA 1 Combination Contraceptives - Oral ETHYNODIOL DIACETATE/ETHI 1 Combination Contraceptives - Oral FALMINA 1 Combination Contraceptives - Oral FEMYNOR 1 Combination Contraceptives - Oral GENERESS FE 3 Combination Contraceptives - Oral GIANVI 1 Combination Contraceptives - Oral INTROVALE 1 Combination Contraceptives - Oral ISIBLOOM 1 Combination Contraceptives - Oral JOLESSA 1 Combination Contraceptives - Oral JULEBER 1 Combination Contraceptives - Oral JUNEL 1.5/30 1 Combination Contraceptives - Oral JUNEL 1/20 1 Combination Contraceptives - Oral JUNEL FE 1.5/30 1 Combination Contraceptives - Oral JUNEL FE 1/20 1 Combination Contraceptives - Oral JUNEL FE 24 1 Combination Contraceptives - Oral KAITLIB FE 1 Combination Contraceptives - Oral KARIVA 1 Combination Contraceptives - Oral KELNOR 1/35 1 Combination Contraceptives - Oral KURVELO 1 Combination Contraceptives - Oral LARIN 1/20 1 Combination Contraceptives - Oral LARIN 24 FE 1 Combination Contraceptives - Oral LARIN FE 1.5/30 1 Combination Contraceptives - Oral LARIN FE 1/20 1 Combination Contraceptives - Oral LARISSIA 1 Combination Contraceptives - Oral LAYOLIS FE 1 Combination Contraceptives - Oral LEENA 1 Combination Contraceptives - Oral LESSINA 1 Combination Contraceptives - Oral LEVONEST 1 Combination Contraceptives - Oral LEVONORGESTREL AND ETHINY 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Combination Contraceptives - Oral LEVONORGESTREL/ETHINYL ES 1 Combination Contraceptives - Oral LEVORA 0.15/30-28 1 Combination Contraceptives - Oral LILLOW 1 Combination Contraceptives - Oral LO LOESTRIN FE 2 Combination Contraceptives - Oral LORYNA 1 Combination Contraceptives - Oral LOW-OGESTREL 1 Combination Contraceptives - Oral LUTERA 1 Combination Contraceptives - Oral MARLISSA 1 Combination Contraceptives - Oral MELODETTA 24 FE 1 Combination Contraceptives - Oral MIBELAS 24 FE 1 Combination Contraceptives - Oral MICROGESTIN 1.5/30 1 Combination Contraceptives - Oral MICROGESTIN 1/20 1 Combination Contraceptives - Oral MICROGESTIN FE 1 Combination Contraceptives - Oral MICROGESTIN FE 1.5/30 1 Combination Contraceptives - Oral MINASTRIN 24 FE 3 Combination Contraceptives - Oral MIRCETTE 3 Combination Contraceptives - Oral MONO-LINYAH 1 Combination Contraceptives - Oral MONONESSA 1 Combination Contraceptives - Oral MYZILRA 1 Combination Contraceptives - Oral NATAZIA 2 Combination Contraceptives - Oral NECON 0.5/35-28 1 Combination Contraceptives - Oral NECON 7/7/7 1 Combination Contraceptives - Oral NIKKI 1 Combination Contraceptives - Oral NORETHINDRONE & ETHINYL E 1 Combination Contraceptives - Oral NORETHINDRONE ACETATE/ETH 1 Combination Contraceptives - Oral NORETHINDRONE/ETHINYL EST 1 Combination Contraceptives - Oral NORGESTIMATE/ETHINYL ESTR 1 Combination Contraceptives - Oral NORTREL 0.5/35 (28) 1 Combination Contraceptives - Oral NORTREL 1/35 1 Combination Contraceptives - Oral NORTREL 7/7/7 1 Combination Contraceptives - Oral OCELLA 1 Combination Contraceptives - Oral ORSYTHIA 1 Combination Contraceptives - Oral ORTHO TRI-CYCLEN 3 Combination Contraceptives - Oral ORTHO TRI-CYCLEN LO 3 Combination Contraceptives - Oral ORTHO-CYCLEN 3 Combination Contraceptives - Oral PIMTREA 1 Combination Contraceptives - Oral PIRMELLA 1/35 1 Combination Contraceptives - Oral PIRMELLA 7/7/7 1 Combination Contraceptives - Oral PORTIA-28 1 Combination Contraceptives - Oral PREVIFEM 1 Combination Contraceptives - Oral QUASENSE 1 Combination Contraceptives - Oral RAJANI 1 Combination Contraceptives - Oral RECLIPSEN 1 Combination Contraceptives - Oral SAFYRAL 2 Combination Contraceptives - Oral SEASONIQUE 3 Combination Contraceptives - Oral SOLIA 1 Combination Contraceptives - Oral SPRINTEC 28 1 Combination Contraceptives - Oral SRONYX 1 Combination Contraceptives - Oral SYEDA 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Combination Contraceptives - Oral TARINA FE 1/20 1 Combination Contraceptives - Oral TAYTULLA 2 Combination Contraceptives - Oral TILIA FE 1 Combination Contraceptives - Oral TRI FEMYNOR 1 Combination Contraceptives - Oral TRI-ESTARYLLA 1 Combination Contraceptives - Oral TRI-LEGEST FE 1 Combination Contraceptives - Oral TRI-LINYAH 1 Combination Contraceptives - Oral TRI-LO-ESTARYLLA 1 Combination Contraceptives - Oral TRI-LO-MARZIA 1 Combination Contraceptives - Oral TRI-LO-SPRINTEC 1 Combination Contraceptives - Oral TRINESSA 1 Combination Contraceptives - Oral TRINESSA LO 1 Combination Contraceptives - Oral TRI-SPRINTEC 1 Combination Contraceptives - Oral TRIVORA-28 1 Combination Contraceptives - Oral VELIVET 1 Combination Contraceptives - Oral VESTURA 1 Combination Contraceptives - Oral VIENVA 1 Combination Contraceptives - Oral VIORELE 1 Combination Contraceptives - Oral VYFEMLA 1 Combination Contraceptives - Oral WYMZYA FE 1 Combination Contraceptives - Oral YASMIN 28 3 Combination Contraceptives - Oral YAZ 3 Combination Contraceptives - Oral ZARAH 1 Combination Contraceptives - Oral ZENCHENT 1 Combination Contraceptives - Oral ZOVIA 1/35E 1 Combination Contraceptives - Oral ZOVIA 1/50E 1 Combination Contraceptives - Transdermal XULANE 2 Combination Contraceptives - Vaginal NUVARING 2 Combination Psychotherapeutics CHLORDIAZEPOXIDE/AMITRIPT 1 Copper Contraceptives - IUD PARAGARD INTRAUTERINE COP 3 Corticosteroids - Topical ALA SCALP 3 Corticosteroids - Topical ALCLOMETASONE DIPROPIONAT 1 Corticosteroids - Topical AMCINONIDE 1 Corticosteroids - Topical APEXICON E 2 Corticosteroids - Topical AUGMENTED BETAMETHASONE D 1 Corticosteroids - Topical BETAMETHASONE DIPROPIONAT 1 Corticosteroids - Topical BETAMETHASONE VALERATE 1 Corticosteroids - Topical CALCIPOTRIENE/BETAMETHASO 1 Corticosteroids - Topical CLOBETASOL PROPIONATE 1 Corticosteroids - Topical CLOBETASOL PROPIONATE E 1 Corticosteroids - Topical CLOBETASOL PROPIONATE EMO 1 Corticosteroids - Topical CLOBEX 3 Corticosteroids - Topical CLOCORTOLONE PIVALATE 3 Corticosteroids - Topical CLOCORTOLONE PIVALATE PUM 3 Corticosteroids - Topical CLODERM 3 Corticosteroids - Topical CORDRAN 3 Corticosteroids - Topical DERMASORB TA 3 Corticosteroids - Topical DESONATE 3 Corticosteroids - Topical DESONIDE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Corticosteroids - Topical DESOXIMETASONE 1 Corticosteroids - Topical DIFLORASONE DIACETATE 1 Corticosteroids - Topical ENSTILAR 2 Corticosteroids - Topical EPIFOAM 3 Corticosteroids - Topical FLUOCINOLONE ACETONIDE 1 Corticosteroids - Topical FLUOCINOLONE ACETONIDE BO 1 Corticosteroids - Topical FLUOCINOLONE ACETONIDE SC 1 Corticosteroids - Topical FLUOCINONIDE 1 Corticosteroids - Topical FLUOCINONIDE EMULSIFIED B 1 Corticosteroids - Topical FLURANDRENOLIDE 1 Corticosteroids - Topical FLUTICASONE PROPIONATE 1 Corticosteroids - Topical HALOBETASOL PROPIONATE 1 Corticosteroids - Topical HALOG 3 Corticosteroids - Topical HYDROCORTISONE 1 Corticosteroids - Topical HYDROCORTISONE 3 Corticosteroids - Topical HYDROCORTISONE ACETATE/PR 1 Corticosteroids - Topical HYDROCORTISONE BUTYRATE 1 Corticosteroids - Topical HYDROCORTISONE BUTYRATE ( 1 Corticosteroids - Topical HYDROCORTISONE VALERATE 1 Corticosteroids - Topical LOCOID 3 Corticosteroids - Topical MOMETASONE FUROATE 1 Corticosteroids - Topical NOVACORT 3 Corticosteroids - Topical PRAMOSONE 3 Corticosteroids - Topical PSORCON 3 Corticosteroids - Topical SERNIVO 3 Corticosteroids - Topical SYNALAR 3 Corticosteroids - Topical TACLONEX 2 Corticosteroids - Topical TEXACORT 3 Corticosteroids - Topical TOPICORT 3 Corticosteroids - Topical TRIAMCINOLONE ACETONIDE 1 Corticosteroids - Topical TRIANEX 2 Corticosteroids - Topical ULTRAVATE 3 Corticosteroids - Topical VERDESO 3 Corticotropin H.P. ACTHAR 2 Cough/Cold/Allergy Combinations ALAVERT ALLERGY/SINUS 1 Cough/Cold/Allergy Combinations BROMFED DM 1 Cough/Cold/Allergy Combinations BROMPHEN/PSEUDOEPHEDRINE 1 Cough/Cold/Allergy Combinations CETIRIZINE HCL/PSEUDOEPHE 1 Cough/Cold/Allergy Combinations CLARINEX-D 12 HOUR 3 Cough/Cold/Allergy Combinations CLARITIN-D 24 HOUR 2 Cough/Cold/Allergy Combinations GNP ALL DAY ALLERGY-D 1 Cough/Cold/Allergy Combinations GUAIFENESIN/CODEINE 1 Cough/Cold/Allergy Combinations HYCOFENIX 3 Cough/Cold/Allergy Combinations HYDROCODONE POLISTIREX/CH 1 Cough/Cold/Allergy Combinations LORATADINE-D 24HR 1 Cough/Cold/Allergy Combinations PROMETHAZINE VC PLAIN 1 Cough/Cold/Allergy Combinations PROMETHAZINE VC/CODEINE 1 Cough/Cold/Allergy Combinations PROMETHAZINE/CODEINE 1 Cough/Cold/Allergy Combinations PROMETHAZINE/DEXTROMETHOR 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Cough/Cold/Allergy Combinations PROMETHAZINE/PHENYLEPHRIN 1 Cough/Cold/Allergy Combinations PROMETHAZINE-DM 1 Cough/Cold/Allergy Combinations RA LORATA-D 1 Cough/Cold/Allergy Combinations TUZISTRA XR 3 Cough/Cold/Allergy Combinations VANACOF DM 3 Cough/Cold/Allergy Combinations VIRTUSSIN A/C 1 Cough/Cold/Allergy Combinations ZYRTEC-D ALLERGY/CONGESTI 2 Coumarin Anticoagulants COUMADIN 3 Coumarin Anticoagulants JANTOVEN 1 Coumarin Anticoagulants WARFARIN SODIUM 1 Cycloplegic Mydriatics ATROPINE SULFATE 1 Cycloplegic Mydriatics CYCLOPENTOLATE HCL 1 Cycloplegic Mydriatics HOMATROPAIRE 1 Cycloplegic Mydriatics HOMATROPINE HBR 1 Cystic Fibrosis Agents ORKAMBI 2 D Dental Products - Rinse DENTA 5000 PLUS 1 Dental Products - Rinse DENTAGEL 1 Dental Products - Rinse PREVIDENT 5000 BOOSTER PL 3 Dental Products - Rinse PREVIDENT 5000 DRY MOUTH 3 Dental Products - Rinse PREVIDENT 5000 ENAMEL PRO 3 Dental Products - Rinse PREVIDENT 5000 PLUS 3 Dental Products - Rinse PREVIDENT 5000 SENSITIVE 3 Dental Products - Rinse PREVIDENT FLUORIDE 3 Dental Products - Rinse PREVIDENT RINSE 1 Dental Products - Rinse SF 1 Dental Products - Rinse SF 5000 PLUS 1 Dermatological Products Misc - Gel ALEVICYN ANTIPRURITIC SG 3 Dermatological Products Misc - Gel CERACADE 3 Dermatological Products Misc - Gel EPICERAM 3 Dermatological Products Misc - Gel GENADUR 3 Dermatological Products Misc - Gel HPR PLUS 2 Dermatological Products Misc - Gel HYLATOPIC PLUS 3 Dermatological Products Misc - Gel NEOSALUS 3 Dermatological Products Misc - Gel TETRIX 3 DERMATOLOGICALS DUPIXENT 2 DERMATOLOGICALS EUCRISA 3 Diabetic Other GLUCAGON EMERGENCY KIT 2 Diabetic Supplies ACCU-CHEK AVIVA PLUS 3 Diabetic Supplies ACCU-CHEK FASTCLIX LANCET 2 Diabetic Supplies ACCU-CHEK MULTICLIX LANCE 2 Diabetic Supplies ACCU-CHEK SAFE-T-PRO PLUS 2 Diabetic Supplies ACCU-CHEK SOFTCLIX LANCET 2 Diabetic Supplies BAYER CONTOUR NEXT EZ BLO 3 Diabetic Supplies BAYER MICROLET LANCETS 2 Diabetic Supplies BD LANCET ULTRAFINE 33G 2 Diabetic Supplies CVS ADVANCED GLUCOSE METE 3 Diabetic Supplies EASY COMFORT LANCETS 30G/ 2 Diabetic Supplies EASY TOUCH LANCETS 33G/TW 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Diabetic Supplies EMBRACE LANCETS ULTRA THI 2 Diabetic Supplies EMBRACE PRO BLOOD GLUCOSE 3 Diabetic Supplies FIFTY50 UNILET LANCETS 33 2 Diabetic Supplies FREESTYLE FREEDOM LITE 2 Diabetic Supplies FREESTYLE LANCETS 2 Diabetic Supplies GNP LANCETS MICRO THIN 33 2 Diabetic Supplies KROGER LANCETS MICRO THIN 2 Diabetic Supplies LANCETS ULTRA THIN 2 Diabetic Supplies MEIJER LANCETS THIN 2 Diabetic Supplies MICROLET LANCETS 2 Diabetic Supplies MIO INFUSION SET/18"/6MM 2 Diabetic Supplies ONETOUCH DELICA LANCETS E 2 Diabetic Supplies ONETOUCH DELICA LANCETS F 2 Diabetic Supplies ONETOUCH ULTRA 2 2 Diabetic Supplies ONETOUCH ULTRA CONTROL 2 Diabetic Supplies ONETOUCH ULTRA MINI 2 Diabetic Supplies ONETOUCH ULTRASOFT LANCET 2 Diabetic Supplies ONETOUCH VERIO 2 Diabetic Supplies ONETOUCH VERIO MID CONTRO 2 Diabetic Supplies PHARMACIST CHOICE ULTRA T 2 Diabetic Supplies PRODIGY TWIST TOP LANCETS 2 Diabetic Supplies PX LANCETS ULTRA THIN 28G 2 Diabetic Supplies RELION CONFIRM BLOOD GLUC 3 Diabetic Supplies RELION LANCETS ULTRA-THIN 2 Diabetic Supplies SIMPLE DIAGNOSTICS LANCIN 2 Diabetic Supplies TRUE METRIX BLOOD GLUCOSE 3 Diabetic Supplies TRUEDRAW LANCING DEVICE 2 Diabetic Supplies TRUEPLUS LANCETS 28G 2 Diabetic Supplies TRUEPLUS LANCETS 30G ULTR 2 Diabetic Supplies TRUEPLUS LANCETS 33G 2 Diabetic Supplies WALGREENS ULTRA THIN LANC 2 Diagnostic Drugs THYROGEN 2 Diagnostic Tests ACCU-CHEK AVIVA PLUS 3 Diagnostic Tests ACCU-CHEK COMPACT PLUS 3 Diagnostic Tests ACCU-CHEK GUIDE 3 Diagnostic Tests ACCU-CHEK SMARTVIEW STRIP 3 Diagnostic Tests AGAMATRIX PRESTO TEST STR 3 Diagnostic Tests BAYER BREEZE 2 TEST DISC 3 Diagnostic Tests BAYER CONTOUR BLOOD GLUCO 3 Diagnostic Tests BAYER CONTOUR NEXT BLOOD 3 Diagnostic Tests CVS ADVANCED GLUCOSE METE 3 Diagnostic Tests EMBRACE PRO BLOOD GLUCOSE 3 Diagnostic Tests FIFTY50 GLUCOSE TEST STRI 3 Diagnostic Tests FREESTYLE INSULINX BLOOD 2 Diagnostic Tests FREESTYLE LITE TEST STRIP 2 Diagnostic Tests FREESTYLE PRECISION NEO B 3 Diagnostic Tests FREESTYLE TEST STRIPS 2 Diagnostic Tests KETOCARE 2 Diagnostic Tests KETO-DIASTIX 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Diagnostic Tests KETONE TEST STRIPS 2 Diagnostic Tests KETOSTIX 2 Diagnostic Tests ONETOUCH ULTRA BLUE 2 Diagnostic Tests ONETOUCH VERIO TEST STRIP 2 Diagnostic Tests PRODIGY NO CODING BLOOD G 3 Diagnostic Tests RELION CONFIRM/MICRO TEST 3 Diagnostic Tests RELION PRIME BLOOD GLUCOS 3 Diagnostic Tests TRUE METRIX BLOOD GLUCOSE 3 Diagnostic Tests TRUE METRIX SELF MONITORI 3 Diagnostic Tests TRUETRACK TEST 3 Dibenzapines CLOZAPINE 1 Dibenzapines OLANZAPINE 1 Dibenzapines OLANZAPINE ODT 1 Dibenzapines QUETIAPINE FUMARATE 1 Dibenzapines QUETIAPINE FUMARATE ER 1 Dibenzapines SAPHRIS 3 Dibenzapines SEROQUEL 3 Dibenzapines SEROQUEL XR 3 Dietary Management Products DEPLIN 15 3 Dietary Management Products ELFOLATE 2 Dietary Management Products ENLYTE 3 Dietary Management Products ENTERAGAM 3 Dietary Management Products FOLTANX 2 Dietary Management Products LIMBREL 3 Dietary Management Products L-METHYLFOLATE 2 Dietary Management Products L-METHYLFOLATE CALCIUM 2 Dietary Management Products L-METHYLFOLATE FORTE 3 Dietary Management Products METANX 3 Dietary Management Products NICAPRIN 3 Dietary Management Products PODIAPN 3 Dietary Management Products VASCULERA 3 Dietary Management Products VAYACOG 3 Dietary Management Products VAYARIN 3 Dietary Management Products XYZBAC 3 Digestive Enzymes CREON 2 Digestive Enzymes SUCRAID 2 Digestive Enzymes ZENPEP 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN 3 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ONGLYZA 3 ST

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors TRADJENTA 2 Direct Factor Xa Inhibitors ELIQUIS 2 Direct Factor Xa Inhibitors SAVAYSA 3 Direct Factor Xa Inhibitors XARELTO 2 Direct Factor Xa Inhibitors XARELTO STARTER PACK 2 Direct Muscle Relaxants DANTROLENE SODIUM 1 Direct Renin Inhibitors TEKTURNA 2 Diuretic Combinations AMILORIDE/HYDROCHLOROTHIA 1 Diuretic Combinations MAXZIDE 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Diuretic Combinations MAXZIDE-25 3 Diuretic Combinations SPIRONOLACTONE/HYDROCHLOR 1 Diuretic Combinations TRIAMTERENE/HYDROCHLOROTH 1 Dopamine Receptor Agonists - Antidiabetic CYCLOSET 3 E Emergency Contraceptives ELLA 3 Emollient - Lotion AMLACTIN 1 Emollient - Lotion AMMONIUM LACTATE 1 Emollient - Lotion COPASIL 3 Emollient - Lotion VANICREAM 3 Emollient/Keratolytic Agents CEM-UREA 2 Emollient/Keratolytic Agents KERALAC 3 Emollient/Keratolytic Agents REA LO 40 1 Emollient/Keratolytic Agents UMECTA MOUSSE 1 Emollient/Keratolytic Agents UREA 1 Emollient/Keratolytic Agents UTOPIC 3 Enzymes XIAFLEX 2 Enzymes - Topical SANTYL 2 Erythromycins E.E.S. 400 1 Erythromycins E.E.S. GRANULES 3 Erythromycins ERY-TAB 2 Erythromycins ERY-TAB 3 Erythromycins ERYTHROCIN STEARATE 2 Erythromycins ERYTHROMYCIN 1 Erythromycins ERYTHROMYCIN BASE 1 Erythromycins ERYTHROMYCIN BASE 2 Erythromycins ERYTHROMYCIN ETHYLSUCCINA 1 Estrogen Combinations ANGELIQ 3 Estrogen Combinations CLIMARA PRO 3 Estrogen Combinations COMBIPATCH 2 Estrogen Combinations DUAVEE 2 Estrogen Combinations EEMT HS 1 Estrogen Combinations ESTERIFIED ESTROGENS/METH 1 Estrogen Combinations ESTRADIOL/NORETHINDRONE A 1 Estrogen Combinations JINTELI 1 Estrogen Combinations LOPREEZA 1 Estrogen Combinations MIMVEY 1 Estrogen Combinations MIMVEY LO 1 Estrogen Combinations NORETHINDRONE ACETATE/ETH 1 Estrogen Combinations PREMPHASE 2 Estrogen Combinations PREMPRO 2 Estrogens CLIMARA 3 Estrogens DELESTROGEN 3 Estrogens DEPO-ESTRADIOL 2 Estrogens DIVIGEL 2 Estrogens ESTRADIOL 1 Estrogens ESTRADIOL VALERATE 1 Estrogens ESTROGEL 3 Estrogens ESTROPIPATE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Estrogens EVAMIST 3 Estrogens MENEST 3 Estrogens MINIVELLE 2 Estrogens PREMARIN 2 Estrogens VIVELLE-DOT 3 F Fertility Regulators CHORIONIC GONADOTROPIN 1 Fertility Regulators CLOMIPHENE CITRATE 1 Fertility Regulators FOLLISTIM AQ 3 Fertility Regulators GONAL-F 2 Fertility Regulators GONAL-F RFF REDIJECT 2 Fertility Regulators MENOPUR 2 Fertility Regulators NOVAREL 2 Fertility Regulators OVIDREL 3 Fertility Regulators PREGNYL W/DILUENT BENZYL 3 Fibric Acid Derivatives ANTARA 3 Fibric Acid Derivatives FENOFIBRATE 1 Fibric Acid Derivatives FENOFIBRATE 3 Fibric Acid Derivatives FENOFIBRATE MICRONIZED 1 Fibric Acid Derivatives FENOFIBRIC ACID DR 1 Fibric Acid Derivatives GEMFIBROZIL 1 Fibric Acid Derivatives TRICOR 3 Fibromyalgia Agents SAVELLA 2 Fidaxomicin DIFICID 3 Fluoride FLORIVA 3 Fluoride FLUORABON 3 Fluoride FLUORIDE 1 Fluoride LUDENT 1 Fluoride SODIUM FLUORIDE 1 Fluoroquinolones CIPRO 3 Fluoroquinolones CIPROFLOXACIN HCL 1 Fluoroquinolones LEVOFLOXACIN 1 Fluoroquinolones LEVOFLOXACIN IN D5W 1 Fluoroquinolones MOXIFLOXACIN HCL 1 Folic Acid/Folates FOLIC ACID 1 G Gallstone Solubilizing Agents URSO FORTE 3 Gallstone Solubilizing Agents URSODIOL 1 GASTROINTESTINAL AGENTS - MISC. TRULANCE 3 Gastrointestinal Antiallergy Agents CROMOLYN SODIUM 1 Gastrointestinal Chloride Channel Activators AMITIZA 2 Gastrointestinal Stimulants METOCLOPRAMIDE HCL 1 Gelatin Capsules (Empty) CAPSULE CONI-SNAP #0 CLEA 3 Gelatin Capsules (Empty) CAPSULE CONI-SNAP #3 PINK 3 Genitourinary Irrigants SODIUM CHLORIDE 0.9% 1 Genitourinary Irrigants SODIUM CHLORIDE 0.9% 1 GI-GU Ostomy & Irrigation Supplies ADVANCE PLUS COUDE 14FR 4 2 Glucocorticosteroids BETAMETHASONE SODIUM PHOS 1 Glucocorticosteroids BUDESONIDE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Glucocorticosteroids CELESTONE-SOLUSPAN 3 Glucocorticosteroids DEXAMETHASONE 1 Glucocorticosteroids DEXAMETHASONE 2 Glucocorticosteroids DEXAMETHASONE INTENSOL 2 Glucocorticosteroids DEXAMETHASONE SODIUM PHOS 1 Glucocorticosteroids DEXPAK 6 DAY 3 Glucocorticosteroids EMFLAZA 3 Glucocorticosteroids HYDROCORTISONE 1 Glucocorticosteroids KENALOG-40 3 Glucocorticosteroids METHYLPREDNISOLONE 1 Glucocorticosteroids METHYLPREDNISOLONE DOSE P 1 Glucocorticosteroids METHYLPREDNISOLONE SODIUM 1 Glucocorticosteroids MILLIPRED 3 Glucocorticosteroids PREDNISOLONE 1 Glucocorticosteroids PREDNISOLONE SODIUM PHOSP 1 Glucocorticosteroids PREDNISOLONE SODIUM PHOSP 2 Glucocorticosteroids PREDNISONE 1 Glucocorticosteroids PREDNISONE 2 Glucocorticosteroids PREDNISONE INTENSOL 2 Glucocorticosteroids RAYOS 3 Glucocorticosteroids UCERIS 2 GnRH/LHRH Antagonists CETROTIDE 2 GnRH/LHRH Antagonists GANIRELIX ACETATE 3 Gout Agent Combinations PROBENECID/COLCHICINE 1 Gout Agents ALLOPURINOL 1 Gout Agents COLCHICINE 3 Gout Agents COLCRYS 2 Gout Agents MITIGARE 2 Gout Agents ULORIC 2 Growth Hormones NORDITROPIN FLEXPRO 2 H H-2 Antagonists CIMETIDINE 1 H-2 Antagonists CIMETIDINE HCL 1 H-2 Antagonists FAMOTIDINE 1 H-2 Antagonists NIZATIDINE 2 H-2 Antagonists RANITIDINE HCL 1 Hair Growth Agents FINASTERIDE 1 Hematopoietic Growth Factors EPOGEN 3 Hematopoietic Growth Factors LEUKINE 2 Hematopoietic Growth Factors NEULASTA 2 Hematopoietic Growth Factors NEUPOGEN 2 Hematopoietic Growth Factors PROCRIT 2 Hematopoietic Growth Factors PROMACTA 2 Hematopoietic Growth Factors ZARXIO 2 Hematopoietic Mixtures CIFRAZOL 3 Hematopoietic Mixtures CORVITE FE 3 Hematopoietic Mixtures FERIVA 21/7 3 Hematopoietic Mixtures FERRALET 90 3 Hematopoietic Mixtures FOLBEE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Hematopoietic Mixtures HEMOCYTE PLUS 3 Hematopoietic Mixtures INTEGRA F 3 Hematopoietic Mixtures INTEGRA PLUS 3 Hematopoietic Mixtures IROSPAN 24/6 3 Hematopoietic Mixtures MULTIGEN 2 Hematopoietic Mixtures MULTIGEN PLUS 2 Hematopoietic Mixtures NEPHRON FA 3 Hematopoietic Mixtures ORTHO D 2 Hematorheologic Agents PENTOXIFYLLINE ER 1 Hemostatics - Systemic AMICAR 2 Hemostatics - Systemic TRANEXAMIC ACID 1 Heparins And Heparinoid-Like Agents ENOXAPARIN SODIUM 1 Heparins And Heparinoid-Like Agents FRAGMIN 2 Heparins And Heparinoid-Like Agents HEPARIN LOCK FLUSH 1 Heparins And Heparinoid-Like Agents HEPARIN SODIUM 1 Hepatitis Agents BARACLUDE 3 Hepatitis Agents ENTECAVIR 1 Hepatitis Agents EPCLUSA 2 Hepatitis Agents HARVONI 2 Hepatitis Agents LAMIVUDINE 1 Hepatitis Agents MAVYRET 2 Hepatitis Agents RIBAVIRIN 1 Hepatitis Agents VEMLIDY 2 Hepatitis Agents ZEPATIER 2 Herpes Agents ACYCLOVIR 1 Herpes Agents FAMCICLOVIR 1 Herpes Agents VALACYCLOVIR HCL 1 Herpes Agents VALTREX 3 HMG CoA Reductase Inhibitors ATORVASTATIN CALCIUM 1 HMG CoA Reductase Inhibitors CRESTOR 3 HMG CoA Reductase Inhibitors FLUVASTATIN 1 HMG CoA Reductase Inhibitors LIPITOR 3 HMG CoA Reductase Inhibitors LIVALO 2 ST

HMG CoA Reductase Inhibitors LOVASTATIN 1 HMG CoA Reductase Inhibitors PRAVASTATIN SODIUM 1 HMG CoA Reductase Inhibitors ROSUVASTATIN CALCIUM 1 HMG CoA Reductase Inhibitors SIMVASTATIN 1 Hormone Receptor Modulators EVISTA 3 Hormone Receptor Modulators OSPHENA 3 Hormone Receptor Modulators RALOXIFENE HYDROCHLORIDE 1 Hydantoins PHENYTOIN SODIUM EXTENDED 1 Hypnotics - Tricyclic Agents SILENOR 3 ST

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS BELSOMRA 3 ST

I Imidazole-Related Antifungals DIFLUCAN 3 Imidazole-Related Antifungals FLUCONAZOLE 1 Imidazole-Related Antifungals ITRACONAZOLE 1 Imidazole-Related Antifungals KETOCONAZOLE 1 Imidazole-Related Antifungals NOXAFIL 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Imidazole-Related Antifungals VORICONAZOLE 1 Immune Serums HIZENTRA 2 Immune Serums HYPERRHO S/D 2 Immune Serums RHOGAM ULTRA-FILTERED PLU 3 Immunomodulating Agents - Topical ALDARA 3 Immunomodulating Agents - Topical IMIQUIMOD 1 Immunomodulators REVLIMID 2 Immunosuppressive Agents AZATHIOPRINE 1 Immunosuppressive Agents CYCLOSPORINE 1 Immunosuppressive Agents CYCLOSPORINE MODIFIED 1 Immunosuppressive Agents MYCOPHENOLATE MOFETIL 1 Immunosuppressive Agents MYCOPHENOLIC ACID DR 1 Immunosuppressive Agents NEORAL 3 Immunosuppressive Agents SIROLIMUS 1 Immunosuppressive Agents TACROLIMUS 1 Immunosuppressive Agents - Topical ELIDEL 2 Immunosuppressive Agents - Topical TACROLIMUS 1 Impotence Agents CIALIS 2 QL

Impotence Agents LEVITRA 3 QL

Impotence Agents MUSE 2 QL

Impotence Agents SILDENAFIL CITRATE 1 QL

Impotence Agents VIAGRA 3 QL

Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYDUREON PEN 2 Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYETTA 2 Incretin Mimetic Agents (GLP-1 Receptor Agonists) OZEMPIC 3 Incretin Mimetic Agents (GLP-1 Receptor Agonists) TANZEUM 3 Incretin Mimetic Agents (GLP-1 Receptor Agonists) TRULICITY 2 Incretin Mimetic Agents (GLP-1 Receptor Agonists) VICTOZA 2 Inflammatory Bowel Agents APRISO 3 Inflammatory Bowel Agents ASACOL HD 2 ST

Inflammatory Bowel Agents BALSALAZIDE DISODIUM 1 Inflammatory Bowel Agents CANASA 2 Inflammatory Bowel Agents CIMZIA 3 Inflammatory Bowel Agents DELZICOL 2 ST

Inflammatory Bowel Agents LIALDA 3 Inflammatory Bowel Agents MESALAMINE 1 Inflammatory Bowel Agents MESALAMINE DR 1 Inflammatory Bowel Agents MESALAMINE DR 3 Inflammatory Bowel Agents PENTASA 2 Inflammatory Bowel Agents REMICADE 2 Inflammatory Bowel Agents STELARA 3 Inflammatory Bowel Agents SULFASALAZINE 1 Influenza Agents OSELTAMIVIR PHOSPHATE 1 QL

Influenza Agents RELENZA DISKHALER 2 QL

Influenza Agents TAMIFLU 3 QL

Influenza Agents TAMIFLU 2 QL

Insulin AFREZZA 3 Insulin APIDRA 3 Insulin APIDRA SOLOSTAR 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Insulin BASAGLAR KWIKPEN 2 Insulin HUMALOG 2 Insulin HUMALOG JUNIOR KWIKPEN 2 Insulin HUMALOG KWIKPEN 2 Insulin HUMALOG MIX 50/50 KWIKPEN 2 Insulin HUMALOG MIX 75/25 2 Insulin HUMALOG MIX 75/25 KWIKPEN 2 Insulin HUMULIN 70/30 2 Insulin HUMULIN 70/30 KWIKPEN 2 Insulin HUMULIN N 2 Insulin HUMULIN N KWIKPEN 2 Insulin HUMULIN R 2 Insulin HUMULIN R U-500 (CONCENTR 2 Insulin HUMULIN R U-500 KWIKPEN 2 Insulin LANTUS 2 Insulin LANTUS SOLOSTAR 2 Insulin LEVEMIR 2 Insulin LEVEMIR FLEXTOUCH 2 Insulin NOVOLIN 70/30 2 Insulin NOVOLIN 70/30 RELION 2 Insulin NOVOLIN N 2 Insulin NOVOLIN N RELION 2 Insulin NOVOLIN R 2 Insulin NOVOLIN R RELION 2 Insulin NOVOLOG 2 Insulin NOVOLOG FLEXPEN 2 Insulin NOVOLOG MIX 70/30 2 Insulin NOVOLOG MIX 70/30 PREFILL 2 Insulin NOVOLOG PENFILL 2 Insulin TOUJEO SOLOSTAR 2 Insulin TRESIBA FLEXTOUCH 2 Insulin Sensitizing Agents PIOGLITAZONE HCL 1 Interleukin-6 Receptor Inhibitors ACTEMRA 2 Interstitial Cystitis Agents ELMIRON 2 Intestinal Acidifiers GENERLAC 1 Intestinal Acidifiers LACTULOSE 1 Intestinal Cholesterol Absorption Inhibitors EZETIMIBE 1 Intestinal Cholesterol Absorption Inhibitors ZETIA 3 Intrarectal Steroids HYDROCORTISONE 1 Intrarectal Steroids UCERIS 3 Iron FERROUS GLUCONATE 3 Iron INJECTAFER 3 Irritable Bowel Syndrome (IBS) Agents ALOSETRON HYDROCHLORIDE 1 Irritable Bowel Syndrome (IBS) Agents LINZESS 2 Irritable Bowel Syndrome (IBS) Agents VIBERZI 2 K Keratolytic/Antimitotic Agents BENSAL HP 3 Keratolytic/Antimitotic Agents CONDYLOX 3 Keratolytic/Antimitotic Agents PODOFILOX 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Keratolytic/Antimitotic Agents SALEX CREAM 3 Keratolytic/Antimitotic Agents SALICYLIC ACID 1 Keratolytic/Antimitotic Agents SALICYLIC ACID WART REMOV 1 Keratolytic/Antimitotic Agents VIRASAL 3 L Laxative Combinations GAVILYTE-C 1 Laxative Combinations GAVILYTE-G 1 Laxative Combinations GAVILYTE-N/FLAVOR PACK 1 Laxative Combinations GOLYTELY 3 Laxative Combinations MOVIPREP 3 Laxative Combinations NULYTELY/FLAVOR PACKS 3 Laxative Combinations PEG 3350/ELECTROLYTES 1 Laxative Combinations PEG-3350/ELECTROLYTES 1 Laxative Combinations PEG-3350/NACL/NA BICARBON 1 Laxative Combinations PREPOPIK 2 Laxative Combinations SUPREP BOWEL PREP KIT 2 Laxatives - Miscellaneous CONSTULOSE 1 Laxatives - Miscellaneous KRISTALOSE 3 Laxatives - Miscellaneous LACTULOSE 1 Laxatives - Miscellaneous POLYETHYLENE GLYCOL 3350 1 Leprostatics DAPSONE 1 Leukotriene Modulators MONTELUKAST SODIUM 1 Leukotriene Modulators SINGULAIR 3 Leukotriene Modulators ZAFIRLUKAST 1 LHRH/GnRH Agonist Analog Pituitary Suppressants LUPRON DEPOT-PED (1-MONTH 2 Lincosamides CLINDAMYCIN HCL 1 Lincosamides CLINDAMYCIN PALMITATE HCL 1 Liquid Vehicles BACTERIOSTATIC WATER FOR 1 Liquid Vehicles ORA-SWEET 3 Liquid Vehicles PURIFIED WATER 1 Liquid Vehicles SIMPLE SYRUP 3 Liquid Vehicles SORBITOL 1 Liquid Vehicles STERILE WATER FOR INJECTI 1 Liquids DIMETHYL SULFOXIDE 2 Local Anesthetics - Amides LIDOCAINE HCL 1 Local Anesthetics - Amides XYLOCAINE 3 Local Anesthetics - Amides XYLOCAINE-MPF 3 Local Anesthetics - Esters TETRACAINE HCL 3 Local Anesthetics - Topical DERMACINRX ZRM PAK 3 Local Anesthetics - Topical LIDOCAINE 1 Local Anesthetics - Topical LIDOCAINE HCL JELLY 1 Local Anesthetics - Topical LIDOCAINE/PRILOCAINE 1 Local Anesthetics - Topical LIDODERM 3 Local Anesthetics - Topical LIDOTRANS 5 PAK 3 Local Anesthetics - Topical SYNERA 3 Loop Diuretics BUMETANIDE 1 Loop Diuretics FUROSEMIDE 1 Loop Diuretics TORSEMIDE 1 M

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Meglitinide Analogues NATEGLINIDE 1 Meglitinide Analogues REPAGLINIDE 1 Metabolic Modifiers CALCITRIOL 1 Metabolic Modifiers KUVAN 2 Metabolic Modifiers LEVOCARNITINE 1 Metabolic Modifiers PARICALCITOL 1 Metabolic Modifiers SENSIPAR 2 Migraine Combinations ISOMETHEPTENE/DICHLORALPH 1 Migraine Combinations TREXIMET 3 QL

Migraine Products DIHYDROERGOTAMINE MESYLAT 1 QL

Migraine Products DIHYDROERGOTAMINE MESYLAT 2 QL

Migraine Products - NSAIDs CAMBIA 3 QL

Mineralocorticoids FLUDROCORTISONE ACETATE 1 Miotics PILOCARPINE HCL 1 Misc Throat Products - Aero Soln AQUORAL 3 Misc Throat Products - Aero Soln CEVIMELINE HCL 1 Misc Throat Products - Aero Soln PILOCARPINE HCL 1 Misc Throat Products - Aero Soln PILOCARPINE HYDROCHLORIDE 1 Misc Throat Products - Aero Soln SALIVAMAX 3 Misc Vaginal Products - Kit FEM PH 2 Misc. Anti-Ulcer CARAFATE 2 Misc. Anti-Ulcer SUCRALFATE 1 Misc. Anti-Ulcer SUCRALFATE 2 Misc. Devices ALCOHOL SWABS 2 Misc. Devices GNP ALCOHOL SWABS 2 Misc. Devices REALITY SWABS 2 Misc. Respiratory Inhalants SODIUM CHLORIDE 1 Misc. Topical AVENOVA 3 Misc. Topical CERAMAX 1 Misc. Topical DRYSOL 3 Monoamine Oxidase Inhibitors (MAOIs) EMSAM 3 Monoamine Oxidase Inhibitors (MAOIs) MARPLAN 3 Monoamine Oxidase Inhibitors (MAOIs) PHENELZINE SULFATE 1 Monoamine Oxidase Inhibitors (MAOIs) TRANYLCYPROMINE SULFATE 1 Monoclonal Antibodies SYNAGIS 2 Multiple Sclerosis Agents AMPYRA 2 Multiple Sclerosis Agents AUBAGIO 3 Multiple Sclerosis Agents AVONEX 2 Multiple Sclerosis Agents AVONEX PEN 2 Multiple Sclerosis Agents COPAXONE 2 Multiple Sclerosis Agents GILENYA 2 Multiple Sclerosis Agents GLATIRAMER ACETATE 1 Multiple Sclerosis Agents GLATOPA 1 Multiple Sclerosis Agents REBIF REBIDOSE 2 Multiple Sclerosis Agents TECFIDERA 2 Multiple Sclerosis Agents TYSABRI 2 Multiple Vitamins w/ Minerals Pack NICADAN 3 N Nasal Agent Combinations DYMISTA 2 ST

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Special Instructions (PA, ST, QL)

Nasal Antiallergy AZELASTINE HCL 1 Nasal Antiallergy AZELASTINE HYDROCHLORIDE 1 Nasal Antiallergy OLOPATADINE HCL 1 Nasal Antiallergy PATANASE 3 Nasal Anticholinergics IPRATROPIUM BROMIDE 1 Nasal Steroids BECONASE AQ 3 ST

Nasal Steroids FLUNISOLIDE 1 Nasal Steroids FLUTICASONE PROPIONATE 1 Nasal Steroids MOMETASONE FUROATE 1 Nasal Steroids NASONEX 3 Nasal Steroids OMNARIS 3 ST

Nasal Steroids QNASL 2 ST

Nasal Steroids QNASL CHILDRENS 2 ST

Nasal Steroids ZETONNA 3 ST

Natural Penicillins BICILLIN L-A 2 Natural Penicillins PENICILLIN V POTASSIUM 1 Neuromuscular Blocking Agent - Neurotoxins BOTOX 2 Nicotinic Acid Derivatives NIACIN ER 1 Nicotinic Acid Derivatives NIACOR 3 Nicotinic Acid Derivatives NIASPAN 3 Nitrates ISOSORBIDE DINITRATE 1 Nitrates ISOSORBIDE MONONITRATE ER 1 Nitrates NITRO-BID 2 Nitrates NITROGLYCERIN 1 Nitrates NITROGLYCERIN LINGUAL 1 Nitrates NITROGLYCERIN TRANSDERMAL 1 Nitrates NITROSTAT 3 Non-Barbiturate Hypnotics AMBIEN 3 Non-Barbiturate Hypnotics AMBIEN CR 3 Non-Barbiturate Hypnotics ESZOPICLONE 1 Non-Barbiturate Hypnotics FLURAZEPAM HCL 1 Non-Barbiturate Hypnotics LUNESTA 3 Non-Barbiturate Hypnotics RESTORIL 3 Non-Barbiturate Hypnotics TEMAZEPAM 1 Non-Barbiturate Hypnotics TRIAZOLAM 2 Non-Barbiturate Hypnotics TRIAZOLAM 1 Non-Barbiturate Hypnotics ZALEPLON 1 Non-Barbiturate Hypnotics ZOLPIDEM TARTRATE 1 Non-Barbiturate Hypnotics ZOLPIDEM TARTRATE ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) CELEBREX 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) CELECOXIB 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) DICLOFENAC POTASSIUM 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) DICLOFENAC SODIUM DR 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) DICLOFENAC SODIUM ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) DICLOFENAC SODIUM/MISOPRO 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) DUEXIS 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) ETODOLAC 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) ETODOLAC ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) FLURBIPROFEN 1

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Special Instructions (PA, ST, QL)

Nonsteroidal Anti-inflammatory Agents (NSAIDs) FLURBIPROFEN 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) IBU 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) IBUPROFEN 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) INDOMETHACIN 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) INDOMETHACIN ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) KETOPROFEN 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) KETOPROFEN ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) KETOROLAC TROMETHAMINE 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) MEFENAMIC ACID 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) MELOXICAM 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NABUMETONE 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NAPROXEN 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NAPROXEN DR 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NAPROXEN SODIUM 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NAPROXEN SODIUM CR 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) NAPROXEN SODIUM ER 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) PIROXICAM 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) SPRIX 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) SULINDAC 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) VIMOVO 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) VIVLODEX 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) ZIPSOR 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) ZORVOLEX 3 O Oil Soluble Vitamins D3 1 Oil Soluble Vitamins D3-50 1 Oil Soluble Vitamins ERGOCALCIFEROL 1 Oil Soluble Vitamins MAXIMUM D3 1 Oil Soluble Vitamins RA VITAMIN D-3 1 Oil Soluble Vitamins VITAMIN D 1 Oil Soluble Vitamins VITAMIN D3 1 Ophthalmic Adrenergic Agents ALPHAGAN P 2 Ophthalmic Adrenergic Agents APRACLONIDINE 1 ST

Ophthalmic Adrenergic Agents BRIMONIDINE TARTRATE 1 Ophthalmic Adrenergic Agents SIMBRINZA 3 OPHTHALMIC AGENTS XIIDRA 2 Ophthalmic Anti-infectives AZASITE 2 Ophthalmic Anti-infectives BACITRACIN 2 Ophthalmic Anti-infectives BACITRACIN/POLYMYXIN B 1 Ophthalmic Anti-infectives BESIVANCE 3 Ophthalmic Anti-infectives CIPROFLOXACIN HCL 1 Ophthalmic Anti-infectives ERYTHROMYCIN 1 Ophthalmic Anti-infectives GATIFLOXACIN 1 Ophthalmic Anti-infectives GENTAK 2 Ophthalmic Anti-infectives GENTAMICIN SULFATE 1 Ophthalmic Anti-infectives MOXEZA 2 Ophthalmic Anti-infectives MOXIFLOXACIN HCL 1 Ophthalmic Anti-infectives NEOMYCIN/POLYMYXIN/GRAMIC 1 Ophthalmic Anti-infectives OFLOXACIN 1

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Ophthalmic Anti-infectives POLYCIN 1 Ophthalmic Anti-infectives POLYMYXIN B SULFATE/TRIME 1 Ophthalmic Anti-infectives SODIUM SULFACETAMIDE 1 Ophthalmic Anti-infectives SULFACETAMIDE SODIUM 1 Ophthalmic Anti-infectives TOBRAMYCIN 1 Ophthalmic Anti-infectives TOBRAMYCIN SULFATE 1 Ophthalmic Anti-infectives TOBREX 3 Ophthalmic Anti-infectives TRIFLURIDINE 1 Ophthalmic Anti-infectives TRIMETHOPRIM SULFATE/POLY 1 Ophthalmic Anti-infectives VIGAMOX 3 Ophthalmic Anti-infectives ZIRGAN 3 Ophthalmic Immunomodulators RESTASIS 2 Ophthalmic Immunomodulators RESTASIS MULTIDOSE 2 Ophthalmic Steroids ALREX 2 Ophthalmic Steroids BLEPHAMIDE S.O.P. 3 Ophthalmic Steroids DEXAMETHASONE SODIUM PHOS 1 Ophthalmic Steroids DUREZOL 3 Ophthalmic Steroids FLUOROMETHOLONE 1 Ophthalmic Steroids FML 3 Ophthalmic Steroids FML FORTE 3 Ophthalmic Steroids FML LIQUIFILM 3 Ophthalmic Steroids LOTEMAX 2 Ophthalmic Steroids MAXIDEX 3 Ophthalmic Steroids NEOMYCIN/POLYMYXIN/DEXAME 1 Ophthalmic Steroids NEOMYCIN/POLYMYXIN/HYDROC 1 Ophthalmic Steroids PRED FORTE 3 Ophthalmic Steroids PRED-G S.O.P. 3 Ophthalmic Steroids PREDNISOLONE ACETATE 1 Ophthalmic Steroids SULFACETAMIDE SODIUM/PRED 1 Ophthalmic Steroids TOBRADEX 2 Ophthalmic Steroids TOBRADEX ST 2 Ophthalmic Steroids TOBRAMYCIN/DEXAMETHASONE 1 Ophthalmic Steroids ZYLET 2 Ophthalmics - Misc. ALAWAY 1 Ophthalmics - Misc. ALOCRIL 3 Ophthalmics - Misc. AZELASTINE HCL 1 Ophthalmics - Misc. AZOPT 3 Ophthalmics - Misc. BEPREVE 2 Ophthalmics - Misc. BROMFENAC 1 Ophthalmics - Misc. BROMSITE 3 Ophthalmics - Misc. CROMOLYN SODIUM 1 Ophthalmics - Misc. DICLOFENAC SODIUM 1 Ophthalmics - Misc. DORZOLAMIDE HCL 1 Ophthalmics - Misc. EPINASTINE HCL 1 Ophthalmics - Misc. FLURBIPROFEN SODIUM 1 Ophthalmics - Misc. ILEVRO 2 Ophthalmics - Misc. KETOROLAC TROMETHAMINE 1 Ophthalmics - Misc. KETOTIFEN FUMARATE 1 Ophthalmics - Misc. NEVANAC 2

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Special Instructions (PA, ST, QL)

Ophthalmics - Misc. OLOPATADINE HCL 1 Ophthalmics - Misc. OLOPATADINE HYDROCHLORIDE 1 Ophthalmics - Misc. PATADAY 3 ST

Ophthalmics - Misc. PATANOL 3 Ophthalmics - Misc. PAZEO 2 Ophthalmics - Misc. PROLENSA 2 Opioid Agonists CODEINE SULFATE 1 Opioid Agonists DURAGESIC 3 Opioid Agonists FENTANYL 3 Opioid Agonists FENTANYL 1 Opioid Agonists HYDROMORPHONE HCL 1 Opioid Agonists HYSINGLA ER 2 Opioid Agonists MEPERIDINE HCL 1 Opioid Agonists METHADONE HCL 2 Opioid Agonists METHADONE HCL 1 Opioid Agonists MORPHINE SULFATE 1 Opioid Agonists MORPHINE SULFATE ER 1 Opioid Agonists NUCYNTA 2 Opioid Agonists NUCYNTA ER 2 Opioid Agonists OPANA ER (CRUSH RESISTANT 3 Opioid Agonists OXAYDO 3 Opioid Agonists OXYCODONE HCL 1 Opioid Agonists OXYCODONE HCL ER 3 Opioid Agonists OXYCONTIN 2 Opioid Agonists OXYMORPHONE HYDROCHLORIDE 1 Opioid Agonists ROXICODONE 3 Opioid Agonists TRAMADOL HCL 1 Opioid Agonists TRAMADOL HCL ER 1 Opioid Agonists TRAMADOL HCL ER 3 Opioid Agonists ULTRAM 3 Opioid Agonists XTAMPZA ER 3 Opioid Antagonists NALOXONE HCL 1 Opioid Antagonists NALTREXONE HCL 1 Opioid Antagonists NARCAN 2 Opioid Combinations ACETAMINOPHEN/CAFFEINE/DI 1 Opioid Combinations ACETAMINOPHEN/CODEINE 1 Opioid Combinations ACETAMINOPHEN/CODEINE PHO 1 Opioid Combinations ASCOMP/CODEINE 1 Opioid Combinations BUTALBITAL/ACETAMINOPHEN/ 1 Opioid Combinations BUTALBITAL/ASPIRIN/CAFFEI 1 Opioid Combinations HYDROCODONE BITARTRATE/AC 1 Opioid Combinations HYDROCODONE/ACETAMINOPHEN 1 Opioid Combinations HYDROCODONE/IBUPROFEN 1 Opioid Combinations LORCET 1 Opioid Combinations LORTAB 3 Opioid Combinations OXYCODONE/ACETAMINOPHEN 1 Opioid Combinations OXYCODONE/ASPIRIN 1 Opioid Combinations TRAMADOL HYDROCHLORIDE/AC 1 Opioid Combinations VICODIN 1

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Opioid Combinations VICODIN ES 1 Opioid Combinations VICODIN HP 1 Opioid Partial Agonists BUPRENORPHINE 3 Opioid Partial Agonists BUPRENORPHINE HCL 1 Opioid Partial Agonists BUPRENORPHINE HCL/NALOXON 1 Opioid Partial Agonists BUTORPHANOL TARTRATE 1 QL

Opioid Partial Agonists BUTRANS 2 Opioid Partial Agonists PENTAZOCINE/NALOXONE HCL 1 Opioid Partial Agonists SUBOXONE 2 Opioid Partial Agonists ZUBSOLV 2 Otic Agents - Miscellaneous ACETIC ACID 1 Otic Anti-infectives CIPROFLOXACIN 2 Otic Anti-infectives OFLOXACIN 1 Otic Combinations CIPRO HC 3 Otic Combinations CIPRODEX 2 Otic Combinations COLY-MYCIN S 3 Otic Combinations NEOMYCIN/POLYMYXIN/HC 1 Otic Combinations NEOMYCIN/POLYMYXIN/HYDROC 1 Otic Combinations OTOVEL 2 Otic Steroids FLUOCINOLONE ACETONIDE 1 Otic Steroids FLUOCINOLONE ACETONIDE EA 1 Otic Steroids HYDROCORTISONE/ACETIC ACI 1 Oxazolidinones LINEZOLID 1 Oxytocics METHERGINE 2 P Parenteral Therapy Supplies - Misc 3ML LUER-LOK SYRINGE 22G 2 Parenteral Therapy Supplies - Misc BD 30ML SYRINGE SLIP TIP 2 Parenteral Therapy Supplies - Misc BD 3ML SYRINGE LUER-LOK T 2 Parenteral Therapy Supplies - Misc BD INSULIN SYRINGE MICROF 2 Parenteral Therapy Supplies - Misc B-D INSULIN SYRINGE ULTRA 2 Parenteral Therapy Supplies - Misc BD INSULIN SYRINGE ULTRAF 2 Parenteral Therapy Supplies - Misc BD INSULIN SYRINGE/DETACH 2 Parenteral Therapy Supplies - Misc BD INTEGRA 3ML SYRINGE W/ 2 Parenteral Therapy Supplies - Misc BD NEEDLE/18G 1-1/2" 2 Parenteral Therapy Supplies - Misc BD NEEDLE/22G X 1-1/2" 2 Parenteral Therapy Supplies - Misc BD NEEDLE/27G X 1/2" 2 Parenteral Therapy Supplies - Misc BD PEN NEEDLE/MINI/ULTRAF 2 Parenteral Therapy Supplies - Misc BD PEN NEEDLE/NANO/ULTRA 2 Parenteral Therapy Supplies - Misc BD PEN NEEDLE/ULTRAFINE/2 2 Parenteral Therapy Supplies - Misc BD PEN NEEDLES SHORT/ULTR 2 Parenteral Therapy Supplies - Misc BD SHARPS CONTAINER HOME 2 Parenteral Therapy Supplies - Misc BD ULTRA-FINE MICRO PEN N 2 Parenteral Therapy Supplies - Misc CAREONE UNIFINE PENTIPS P 2 Parenteral Therapy Supplies - Misc CLICKFINE PEN NEEDLE 32GX 2 Parenteral Therapy Supplies - Misc EASY COMFORT PEN NEEDLES 2 Parenteral Therapy Supplies - Misc EASY TOUCH 32GX6MM 2 Parenteral Therapy Supplies - Misc EASY TOUCH INSULIN SYRING 2 Parenteral Therapy Supplies - Misc EASY TOUCH PEN NEEDLES 31 2 Parenteral Therapy Supplies - Misc FREDS PHARMACY UNIFINE PE 2

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Parenteral Therapy Supplies - Misc GLOBAL EASE INJECT PEN NE 2 Parenteral Therapy Supplies - Misc INSULIN SYRINGE/0.5ML/31G 2 Parenteral Therapy Supplies - Misc INSULIN SYRINGE/U-100/1ML 2 Parenteral Therapy Supplies - Misc MONOJECT INSULIN SYRINGE/ 2 Parenteral Therapy Supplies - Misc MONOJECT ULTRA COMFORT IN 2 Parenteral Therapy Supplies - Misc NOVOFINE 30GX8MM 2 Parenteral Therapy Supplies - Misc NOVOFINE 32GX6MM 2 Parenteral Therapy Supplies - Misc NOVOFINE AUTOCOVER 30GX8M 2 Parenteral Therapy Supplies - Misc NOVOFINE PLUS 32GX4MM 2 Parenteral Therapy Supplies - Misc NOVOTWIST 32GX5MM 2 Parenteral Therapy Supplies - Misc RELION INSULIN SYRINGE/U- 2 Parenteral Therapy Supplies - Misc RELION PEN NEEDLES 31GX8M 2 Parenteral Therapy Supplies - Misc RELION PEN NEEDLES 32GX4M 2 Parenteral Therapy Supplies - Misc SAFETY-LOK SAFETY SYRINGE 2 Parenteral Therapy Supplies - Misc SURE COMFORT INSULIN SYRI 2 Parenteral Therapy Supplies - Misc SURE COMFORT PEN NEEDLES 2 Parenteral Therapy Supplies - Misc TECHLITE PEN NEEDLES/32G 2 Parenteral Therapy Supplies - Misc TRUEPLUS INSULIN SYRINGE/ 2 Parenteral Therapy Supplies - Misc ULTICARE INSULIN SAFETY S 2 Parenteral Therapy Supplies - Misc ULTICARE INSULIN SYRINGE 2 Parenteral Therapy Supplies - Misc ULTICARE MICRO PEN NEEDLE 2 Parenteral Therapy Supplies - Misc ULTICARE MINI PEN NEEDLES 2 Parenteral Therapy Supplies - Misc ULTICARE SHORT PEN NEEDLE 2 Parenteral Therapy Supplies - Misc UNIFINE PENTIPS 31GX6MM 2 Parenteral Therapy Supplies - Misc UNIFINE PENTIPS 32GX4MM 2 Parenteral Therapy Supplies - Misc UNIFINE PENTIPS PLUS 32GX 2 Ped Multiple Vitamin w/ Fl-Fe Biphasic Susp 0.25-7 MG/ML ESCAVITE LQ 3 Ped Multiple Vitamin w/ Fl-Fe Biphasic Susp 0.25-7 MG/ML MULTI-VIT/IRON/FLUORIDE 1 Ped Multiple Vitamin w/ Fl-Fe Biphasic Susp 0.25-7 MG/ML MULTI-VITAMIN/FLUORIDE/IR 1 Ped MV w/ Fluoride MULTIVITAMIN WITH FLUORID 1 Ped MV w/ Fluoride MULTIVITAMIN/FLUORIDE 1 Ped MV w/ Fluoride MULTI-VITAMIN/FLUORIDE DR 1 Ped MV w/ Fluoride TRI-VIT/FLUORIDE 1 Penicillin Combinations AMOXICILLIN/CLAVULANATE P 1 Penicillinase-Resistant Penicillins DICLOXACILLIN SODIUM 1 Periodontal Products ARESTIN 3 Peripheral Opioid Receptor Antagonists MOVANTIK 2 Peripheral Opioid Receptor Antagonists RELISTOR 3 QL

Peripheral Opioid Receptor Antagonists SYMPROIC 3 Pharmaceutical Excipients PCCA LOXASPERSE BASE 3 Pharmaceutical Excipients WITEPSOL H15 BASE F 3 Phenothiazines CHLORPROMAZINE HCL 1 Phenothiazines COMPRO 1 Phenothiazines FLUPHENAZINE DECANOATE 1 Phenothiazines FLUPHENAZINE HCL 1 Phenothiazines PERPHENAZINE 1

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Phenothiazines PROCHLORPERAZINE MALEATE 1 Phosphate PHOSPHA 250 NEUTRAL 1 Phosphate VIRT-PHOS 250 NEUTRAL 1 Phosphate Binder Agents AURYXIA 3 Phosphate Binder Agents CALCIUM ACETATE 1 Phosphate Binder Agents FOSRENOL 3 Phosphate Binder Agents RENAGEL 3 Phosphate Binder Agents RENVELA 3 Phosphate Binder Agents SEVELAMER CARBONATE 1 Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA 2 Pigmenting-Depigmenting Agents HYDROQUINONE 1 Pigmenting-Depigmenting Agents HYDROQUINONE 3 Pigmenting-Depigmenting Agents TRI-LUMA 3 Platelet Aggregation Inhibitors AGGRENOX 3 Platelet Aggregation Inhibitors ASPIRIN/DIPYRIDAMOLE 1 Platelet Aggregation Inhibitors BRILINTA 2 Platelet Aggregation Inhibitors CILOSTAZOL 1 Platelet Aggregation Inhibitors CLOPIDOGREL 1 Platelet Aggregation Inhibitors DIPYRIDAMOLE 1 Platelet Aggregation Inhibitors EFFIENT 3 Platelet Aggregation Inhibitors PLAVIX 3 Platelet Aggregation Inhibitors PRASUGREL 1 Platelet Aggregation Inhibitors ZONTIVITY 2 Posterior Pituitary Hormones DESMOPRESSIN ACETATE 1 Posterior Pituitary Hormones STIMATE 2 Postherpetic Neuralgia (PHN)/Neuropathic Pain Agents GRALISE 2 Potassium EFFER-K 3 Potassium KLOR-CON 10 1 Potassium KLOR-CON 8 1 Potassium KLOR-CON M10 1 Potassium KLOR-CON M20 1 Potassium KLOR-CON SPRINKLE 1 Potassium POTASSIUM CHLORIDE 1 Potassium POTASSIUM CHLORIDE CR 1 Potassium POTASSIUM CHLORIDE ER 1 Potassium POTASSIUM CHLORIDE ER 2 Potassium Removing Agents KIONEX 1 Potassium Removing Agents SODIUM POLYSTYRENE SULFON 1 Potassium Removing Agents VELTASSA 2 Potassium Sparing Diuretics AMILORIDE HCL 1 Potassium Sparing Diuretics DYRENIUM 3 Potassium Sparing Diuretics SPIRONOLACTONE 1 Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE HCL 1 Prenatal Vitamin Fast Dissolving Tab CITRANATAL 90 DHA 3 Prenatal Vitamin Fast Dissolving Tab CITRANATAL ASSURE 3 Prenatal Vitamin Fast Dissolving Tab CITRANATAL B-CALM 3 Prenatal Vitamin Fast Dissolving Tab CITRANATAL DHA 3 Prenatal Vitamin Fast Dissolving Tab CITRANATAL HARMONY 3 Prenatal Vitamin Fast Dissolving Tab COMPLETE NATAL DHA 1

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Prenatal Vitamin Fast Dissolving Tab CONCEPT DHA 3 Prenatal Vitamin Fast Dissolving Tab MULTI PRENATAL 3 Prenatal Vitamin Fast Dissolving Tab NEEVO DHA 3 Prenatal Vitamin Fast Dissolving Tab NESTABS DHA 3 Prenatal Vitamin Fast Dissolving Tab OB COMPLETE GOLD 3 Prenatal Vitamin Fast Dissolving Tab OB COMPLETE ONE 3 Prenatal Vitamin Fast Dissolving Tab OB COMPLETE PETITE 3 Prenatal Vitamin Fast Dissolving Tab OB COMPLETE PREMIER 3 Prenatal Vitamin Fast Dissolving Tab OB COMPLETE/DHA 3 Prenatal Vitamin Fast Dissolving Tab PNV PRENATAL PLUS MULTIVI 3 Prenatal Vitamin Fast Dissolving Tab PNV PRENATAL PLUS MULTIVI 2 Prenatal Vitamin Fast Dissolving Tab PNV TABS 29-1 2 Prenatal Vitamin Fast Dissolving Tab PNV-DHA 1 Prenatal Vitamin Fast Dissolving Tab PRENA 1 TRUE 2 Prenatal Vitamin Fast Dissolving Tab PRENA1 PEARL 2 Prenatal Vitamin Fast Dissolving Tab PRENATA 3 Prenatal Vitamin Fast Dissolving Tab PRENATABS RX 1 Prenatal Vitamin Fast Dissolving Tab PRENATAL 3 Prenatal Vitamin Fast Dissolving Tab PRENATAL 2 Prenatal Vitamin Fast Dissolving Tab PRENATAL 19 1 Prenatal Vitamin Fast Dissolving Tab PRENATAL MULTIVITAMIN + D 3 Prenatal Vitamin Fast Dissolving Tab PRENATAL PLUS IRON 2 Prenatal Vitamin Fast Dissolving Tab PRENATAL VITAMINS 3 Prenatal Vitamin Fast Dissolving Tab PRENATAL VITAMINS PLUS LO 2 Prenatal Vitamin Fast Dissolving Tab PRENATAL-U 2 Prenatal Vitamin Fast Dissolving Tab PRENATE DHA 3 Prenatal Vitamin Fast Dissolving Tab PRENATE ELITE 3 Prenatal Vitamin Fast Dissolving Tab PRENATE ENHANCE 3 Prenatal Vitamin Fast Dissolving Tab PRENATE ESSENTIAL 3 Prenatal Vitamin Fast Dissolving Tab PRENATE MINI 3 Prenatal Vitamin Fast Dissolving Tab PRENATE PIXIE 3 Prenatal Vitamin Fast Dissolving Tab PREPLUS 2 Prenatal Vitamin Fast Dissolving Tab PRETAB 2 Prenatal Vitamin Fast Dissolving Tab PRIMACARE 3 Prenatal Vitamin Fast Dissolving Tab SELECT-OB+DHA 3 Prenatal Vitamin Fast Dissolving Tab SE-NATAL 19 1 Prenatal Vitamin Fast Dissolving Tab TRICARE PRENATAL DHA ONE 3 Prenatal Vitamin Fast Dissolving Tab TRISTART DHA 3 Prenatal Vitamin Fast Dissolving Tab VIRT-PN DHA 2 Prenatal Vitamin Fast Dissolving Tab VIRT-PN PLUS 2 Prenatal Vitamin Fast Dissolving Tab VITAFOL FE+ 3 Prenatal Vitamin Fast Dissolving Tab VITAFOL ULTRA 3 Prenatal Vitamin Fast Dissolving Tab VITAFOL-OB 3 Prenatal Vitamin Fast Dissolving Tab VITAFOL-OB+DHA 3 Prenatal Vitamin Fast Dissolving Tab VITAFOL-ONE 3 Prenatal Vitamin Fast Dissolving Tab VITAMEDMD ONE RX/QUATREFO 3 Prenatal Vitamin Fast Dissolving Tab VITAMEDMD REDICHEW RX 3 Prenatal Vitamin Fast Dissolving Tab VITAPEARL 3 Prenatal Vitamin Fast Dissolving Tab VITATRUE 3

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Prenatal Vitamin Fast Dissolving Tab VOL-PLUS 2 Prenatal Vitamin Fast Dissolving Tab VP-HEME OB 2 Prenatal Vitamin Fast Dissolving Tab VP-PNV-DHA 3 Prenatal Vitamin Fast Dissolving Tab ZATEAN-PN DHA 2 Progestin Contraceptives - Implants NEXPLANON 2 Progestin Contraceptives - Injectable DEPO-SUBQ PROVERA 104 3 Progestin Contraceptives - Injectable MEDROXYPROGESTERONE ACETA 1 Progestin Contraceptives - IUD KYLEENA 2 Progestin Contraceptives - IUD LILETTA 3 Progestin Contraceptives - IUD MIRENA 2 Progestin Contraceptives - IUD SKYLA 2 Progestin Contraceptives - Oral CAMILA 1 Progestin Contraceptives - Oral DEBLITANE 1 Progestin Contraceptives - Oral ERRIN 1 Progestin Contraceptives - Oral HEATHER 1 Progestin Contraceptives - Oral JENCYCLA 1 Progestin Contraceptives - Oral JOLIVETTE 1 Progestin Contraceptives - Oral LYZA 1 Progestin Contraceptives - Oral NORA-BE 1 Progestin Contraceptives - Oral NORETHINDRONE 1 Progestin Contraceptives - Oral NORLYDA 1 Progestin Contraceptives - Oral SHAROBEL 1 Progestins MAKENA 2 Progestins MEDROXYPROGESTERONE ACETA 1 Progestins MEGESTROL ACETATE 1 Progestins NORETHINDRONE ACETATE 1 Progestins PROGESTERONE 1 Progestins PROVERA 3 Prolactin Inhibitors CABERGOLINE 1 ST

Prostaglandins - Ophthalmic BIMATOPROST 2 Prostaglandins - Ophthalmic LATANOPROST 1 Prostaglandins - Ophthalmic LUMIGAN 2 Prostaglandins - Ophthalmic TRAVATAN Z 2 Prostaglandins - Ophthalmic VYZULTA 3 Prostaglandins - Ophthalmic ZIOPTAN 3 Prostatic Hypertrophy Agents ALFUZOSIN HCL ER 1 Prostatic Hypertrophy Agents CARDURA XL 3 Prostatic Hypertrophy Agents DUTASTERIDE 1 QL

Prostatic Hypertrophy Agents DUTASTERIDE/TAMSULOSIN HC 1 Prostatic Hypertrophy Agents DUTASTERIDE/TAMSULOSIN HY 1 Prostatic Hypertrophy Agents FINASTERIDE 1 Prostatic Hypertrophy Agents JALYN 3 Prostatic Hypertrophy Agents RAPAFLO 2 Prostatic Hypertrophy Agents TAMSULOSIN HCL 1 Proton Pump Inhibitors ACIPHEX 3 Proton Pump Inhibitors ACIPHEX SPRINKLE 3 Proton Pump Inhibitors DEXILANT 3 ST

Proton Pump Inhibitors ESOMEPRAZOLE MAGNESIUM 1 Proton Pump Inhibitors FIRST-LANSOPRAZOLE 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Proton Pump Inhibitors FIRST-OMEPRAZOLE 2 Proton Pump Inhibitors LANSOPRAZOLE 1 Proton Pump Inhibitors NEXIUM 2 Proton Pump Inhibitors NEXIUM 3 Proton Pump Inhibitors OMEPRAZOLE 1 Proton Pump Inhibitors OMEPRAZOLE 2 Proton Pump Inhibitors PANTOPRAZOLE SODIUM 1 Proton Pump Inhibitors PREVACID SOLUTAB 3 Proton Pump Inhibitors PRILOSEC OTC 2 Proton Pump Inhibitors PROTONIX 3 Proton Pump Inhibitors RA OMEPRAZOLE 2 Proton Pump Inhibitors RABEPRAZOLE SODIUM 1 Pseudobulbar Affect (PBA) Agents NUEDEXTA 2 Psychotherapeutic and Neurological Agents - Misc. ADDYI 3 Psychotherapeutic and Neurological Agents - Misc. PIMOZIDE 1 Pyrimidine Synthesis Inhibitors LEFLUNOMIDE 1 Q Quinolinone Derivatives ABILIFY 3 Quinolinone Derivatives ARIPIPRAZOLE 1 Quinolinone Derivatives REXULTI 3 R Rectal Combinations ANALPRAM-HC 3 Rectal Combinations HYDROCORTISONE ACETATE/PR 1 Rectal Combinations LIDOCAINE HCL/HYDROCORTIS 1 Rectal Combinations PROCTOFOAM HC 3 Rectal Steroids ANUCORT-HC 1 Rectal Steroids ANUSOL-HC 1 Rectal Steroids HEMMOREX-HC 1 Rectal Steroids HYDROCORTISONE 1 Rectal Steroids HYDROCORTISONE ACETATE 1 Rectal Steroids PROCTOCORT 3 Rectal Steroids PROCTO-MED HC 1 Rectal Steroids PROCTOSOL HC 1 Rectal Steroids PROCTOZONE-HC 1 Respiratory Agents - Misc. ESBRIET 2 Respiratory Therapy Supplies - Misc AEROCHAMBER PLUS FLOW-VU 2 Respiratory Therapy Supplies - Misc AEROCHAMBER PLUS FLOW-VU/ 2 Respiratory Therapy Supplies - Misc ALL FLOW 1000 PULMONARY F 3 Respiratory Therapy Supplies - Misc EASIVENT 2 Respiratory Therapy Supplies - Misc EASIVENT/MASK-MEDIUM 2 Respiratory Therapy Supplies - Misc OPTICHAMBER DIAMOND 2 Respiratory Therapy Supplies - Misc OPTICHAMBER DIAMOND/LARGE 2 Respiratory Therapy Supplies - Misc OPTICHAMBER DIAMOND/MEDIU 2 Respiratory Therapy Supplies - Misc PARI SINUSTAR NASAL AEROS 2 Respiratory Therapy Supplies - Misc PILLOW MASK/ADULT 2 Respiratory Therapy Supplies - Misc VALVED HOLDING CHAMBER 2 Respiratory Therapy Supplies - Misc VIOS AEROSOL DELIVERY SYS 2 Restless Leg Syndrome (RLS) Agents HORIZANT 3 Rosacea Agents DOXYCYCLINE 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Rosacea Agents FINACEA 2 Rosacea Agents METRONIDAZOLE 1 Rosacea Agents MIRVASO 2 Rosacea Agents NORITATE 3 Rosacea Agents ORACEA 2 Rosacea Agents RHOFADE 3 Rosacea Agents ROSADAN 1 Rosacea Agents SOOLANTRA 2 S Salicylates ASPIRIN 1 Salicylates ASPIRIN ADULT LOW STRENGT 1 Salicylates ASPIRIN EC 1 Salicylates ASPIRIN EC LOW DOSE 1 Salicylates ASPIRIN LOW DOSE 1 Salicylates ASPIR-LOW 1 Salicylates DIFLUNISAL 1 Salicylates ENTERIC COATED ASPIRIN 1 Salicylates RA ASPIRIN EC 1 Salicylates SM ASPIRIN ENTERIC COATED 1 Saline Laxatives OSMOPREP 3 Scabicides and Pediculicides EURAX 3 Scabicides and Pediculicides MALATHION 1 Scabicides and Pediculicides PERMETHRIN 1 Scabicides and Pediculicides SKLICE 3 Scabicides and Pediculicides SPINOSAD 2 Scar Treatment Products - Gel CELACYN 1 Scar Treatment Products - Gel RECEDO 2 Selective Aldosterone Receptor Antagonists (SARAs) EPLERENONE 1 Selective Melatonin Receptor Agonists ROZEREM 2 ST

Selective Serotonin Reuptake Inhibitors (SSRIs) CITALOPRAM HYDROBROMIDE 1 Selective Serotonin Reuptake Inhibitors (SSRIs) ESCITALOPRAM OXALATE 1 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUOXETINE DR 1 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUOXETINE HCL 1 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUOXETINE HCL 2 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUOXETINE HYDROCHLORIDE 1 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUVOXAMINE MALEATE 1 Selective Serotonin Reuptake Inhibitors (SSRIs) FLUVOXAMINE MALEATE ER 1 Selective Serotonin Reuptake Inhibitors (SSRIs) LEXAPRO 3 Selective Serotonin Reuptake Inhibitors (SSRIs) PAROXETINE HCL 1 Selective Serotonin Reuptake Inhibitors (SSRIs) PAROXETINE HCL ER 1 Selective Serotonin Reuptake Inhibitors (SSRIs) PROZAC 3 Selective Serotonin Reuptake Inhibitors (SSRIs) SERTRALINE HCL 1 Selective Serotonin Reuptake Inhibitors (SSRIs) ZOLOFT 3 Semi Solid Vehicles FAGRON SUPREME CREAM 3 Semi Solid Vehicles HRT CREAM BASE WOMEN 3 Semi Solid Vehicles LANOLIN ANHYDROUS 1 Semi Solid Vehicles LANOLIN ANHYDROUS 3 Semi Solid Vehicles PCCA ANHYDROUS LIPODERM B 3 Semi Solid Vehicles PCCA LIPODERM BASE 3

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Semi Solid Vehicles PCCA NATACREAM 3 Semi Solid Vehicles PCCA PLASTICIZED BASE 3 Semi Solid Vehicles PCCA VANISHING CREAM/LOTI 3 Semi Solid Vehicles PCCA VANPEN BASE 3 Semi Solid Vehicles VERSABASE 3 Semi Solid Vehicles VERSAPRO 3 Semi Solid Vehicles WHITE PETROLATUM 3 Serotonin Agonists ALMOTRIPTAN 1 QL

Serotonin Agonists ALMOTRIPTAN MALATE 1 QL

Serotonin Agonists ELETRIPTAN HYDROBROMIDE 1 QL

Serotonin Agonists FROVA 3 QL

Serotonin Agonists FROVATRIPTAN SUCCINATE 1 QL

Serotonin Agonists IMITREX 3 QL

Serotonin Agonists MAXALT 3 QL

Serotonin Agonists NARATRIPTAN HCL 1 QL

Serotonin Agonists RELPAX 3 QL

Serotonin Agonists RIZATRIPTAN BENZOATE 1 QL

Serotonin Agonists RIZATRIPTAN BENZOATE ODT 1 QL

Serotonin Agonists SUMATRIPTAN 1 QL

Serotonin Agonists SUMATRIPTAN SUCCINATE 1 QL

Serotonin Agonists SUMATRIPTAN SUCCINATE REF 1 QL

Serotonin Agonists SUMAVEL DOSEPRO 3 QL

Serotonin Agonists ZEMBRACE SYMTOUCH 3 QL

Serotonin Agonists ZOLMITRIPTAN 1 QL

Serotonin Agonists ZOLMITRIPTAN ODT 1 QL

Serotonin Agonists ZOMIG 2 QL

Serotonin Modulators TRAZODONE HCL 1 Serotonin Modulators TRINTELLIX 3 ST

Serotonin Modulators VIIBRYD 2 Serotonin Modulators VIIBRYD STARTER PACK 2 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) CYMBALTA 3 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) DESVENLAFAXINE ER 1 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) DESVENLAFAXINE ER 3 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) DULOXETINE HCL 1 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) DULOXETINE HCL 2 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) EFFEXOR XR 3 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) FETZIMA 2 ST

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) PRISTIQ 3 ST

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) VENLAFAXINE HCL 1 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) VENLAFAXINE HCL ER 1 Smoking Deterrents CHANTIX 2 QL

Smoking Deterrents CHANTIX CONTINUING MONTH 2 QL

Smoking Deterrents CHANTIX STARTING MONTH PA 2 QL

Sodium NORMAL SALINE FLUSH 1 Sodium NORMAL SALINE FLUSH FOR F 1 Sodium NORMAL SALINE I.V. FLUSH 1 Sodium SODIUM CHLORIDE 1 Sodium SODIUM CHLORIDE FLUSH 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors FARXIGA 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors INVOKANA 2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors JARDIANCE 2 Solids PREGNENOLONE 3 Soluble Tumor Necrosis Factor Receptor Agents ENBREL 2 Soluble Tumor Necrosis Factor Receptor Agents ENBREL SURECLICK 2 Somatostatic Agents OCTREOTIDE ACETATE 1 Somatostatic Agents SOMATULINE DEPOT 2 Steroid Inhalants AEROSPAN 3 Steroid Inhalants ALVESCO 3 Steroid Inhalants ARNUITY ELLIPTA 2 Steroid Inhalants ASMANEX HFA 2 Steroid Inhalants ASMANEX TWISTHALER 120 ME 2 Steroid Inhalants ASMANEX TWISTHALER 30 MET 2 Steroid Inhalants ASMANEX TWISTHALER 60 MET 2 Steroid Inhalants BUDESONIDE 1 Steroid Inhalants FLOVENT DISKUS 2 Steroid Inhalants FLOVENT HFA 2 Steroid Inhalants PULMICORT 3 Steroid Inhalants PULMICORT FLEXHALER 2 Steroid Inhalants QVAR 2 Steroid Inhalants QVAR REDIHALER 3 Steroids - Mouth/Throat TRIAMCINOLONE ACETONIDE D 1 Stimulants - Misc. ARMODAFINIL 1 Stimulants - Misc. CONCERTA 3 Stimulants - Misc. DAYTRANA 2 Stimulants - Misc. DEXMETHYLPHENIDATE HCL 1 Stimulants - Misc. DEXMETHYLPHENIDATE HCL ER 1 Stimulants - Misc. FOCALIN 3 Stimulants - Misc. FOCALIN XR 3 Stimulants - Misc. METADATE ER 1 Stimulants - Misc. METHYLPHENIDATE HCL 1 Stimulants - Misc. METHYLPHENIDATE HCL CD 1 Stimulants - Misc. METHYLPHENIDATE HCL ER 1 Stimulants - Misc. MODAFINIL 1 Stimulants - Misc. NUVIGIL 3 Stimulants - Misc. PROVIGIL 3 Stimulants - Misc. QUILLICHEW ER 2 Stimulants - Misc. QUILLIVANT XR 2 Stimulants - Misc. RITALIN 3 Stimulants - Misc. RITALIN LA 3 Substance P/Neurokinin 1 (NK1) Receptor Antagonists APREPITANT 1 QL

Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND 3 QL

Substance P/Neurokinin 1 (NK1) Receptor Antagonists VARUBI 2 Succinimides CELONTIN 2 Succinimides ETHOSUXIMIDE 1 Sulfonylureas CHLORPROPAMIDE 1 Sulfonylureas GLIMEPIRIDE 1 Sulfonylureas GLIPIZIDE 1 Sulfonylureas GLIPIZIDE ER 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Sulfonylureas GLIPIZIDE XL 1 Sulfonylureas GLUCOTROL 3 Sulfonylureas GLYBURIDE 1 Sulfonylureas GLYBURIDE MICRONIZED 1 Sympathomimetics ADVAIR DISKUS 2 Sympathomimetics ADVAIR HFA 2 Sympathomimetics AIRDUO RESPICLICK 113/14 3 Sympathomimetics AIRDUO RESPICLICK 232/14 3 Sympathomimetics AIRDUO RESPICLICK 55/14 3 Sympathomimetics ALBUTEROL SULFATE 1 Sympathomimetics ANORO ELLIPTA 2 Sympathomimetics BEVESPI AEROSPHERE 2 Sympathomimetics BREO ELLIPTA 2 Sympathomimetics BROVANA 3 Sympathomimetics COMBIVENT RESPIMAT 2 Sympathomimetics DULERA 2 Sympathomimetics FLUTICASONE PROPIONATE/SA 2 Sympathomimetics IPRATROPIUM BROMIDE/ALBUT 1 Sympathomimetics LEVALBUTEROL HCL 1 Sympathomimetics LEVALBUTEROL TARTRATE HFA 3 Sympathomimetics PROAIR HFA 2 Sympathomimetics PROAIR RESPICLICK 2 Sympathomimetics PROVENTIL HFA 3 Sympathomimetics SEREVENT DISKUS 2 Sympathomimetics STIOLTO RESPIMAT 2 Sympathomimetics SYMBICORT 2 Sympathomimetics VENTOLIN HFA 2 T Tetracyclines ACTICLATE 3 Tetracyclines DEMECLOCYCLINE HCL 1 Tetracyclines DORYX 3 Tetracyclines DORYX MPC 3 Tetracyclines DOXYCYCLINE 1 Tetracyclines DOXYCYCLINE HYCLATE 1 Tetracyclines DOXYCYCLINE HYCLATE 3 Tetracyclines DOXYCYCLINE HYCLATE DR 1 Tetracyclines DOXYCYCLINE MONOHYDRATE 1 Tetracyclines MINOCYCLINE HCL 1 Tetracyclines MINOCYCLINE HCL ER 1 Tetracyclines MONDOXYNE NL 1 Tetracyclines SOLODYN 2 Tetracyclines TARGADOX 3 Tetracyclines TETRACYCLINE HCL 2 Tetracyclines TETRACYCLINE HCL 1 Tetracyclines TETRACYCLINE HYDROCHLORID 1 Tetracyclines VIBRAMYCIN 3 Tetracyclines XIMINO 3 Thiazides and Thiazide-Like Diuretics CHLORTHALIDONE 1 Thiazides and Thiazide-Like Diuretics HYDROCHLOROTHIAZIDE 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Thiazides and Thiazide-Like Diuretics INDAPAMIDE 1 Thiazides and Thiazide-Like Diuretics METOLAZONE 1 Thrombin Inhibitors PRADAXA 3 Thyroid Hormones ARMOUR THYROID 2 Thyroid Hormones CYTOMEL 3 Thyroid Hormones LEVOTHYROXINE SODIUM 1 Thyroid Hormones LEVOTHYROXINE/LIOTHYRONIN 1 Thyroid Hormones LEVOXYL 1 Thyroid Hormones LIOTHYRONINE SODIUM 1 Thyroid Hormones NATURE-THROID 2 Thyroid Hormones NATURE-THROID NT-2.5 2 Thyroid Hormones NP THYROID 120 1 Thyroid Hormones NP THYROID 15 1 Thyroid Hormones NP THYROID 30 1 Thyroid Hormones NP THYROID 60 1 Thyroid Hormones NP THYROID 90 1 Thyroid Hormones SYNTHROID 3 Thyroid Hormones THYROID 2 Thyroid Hormones TIROSINT 3 Thyroid Hormones UNITHROID 1 Thyroid Hormones WESTHROID 2 Thyroid Hormones WP THYROID 3 Toxoid Combinations ADACEL 2 Toxoid Combinations BOOSTRIX 2 Toxoid Combinations DAPTACEL 2 Tricyclic Agents AMITRIPTYLINE HCL 1 Tricyclic Agents ANAFRANIL 3 Tricyclic Agents CLOMIPRAMINE HCL 1 Tricyclic Agents DESIPRAMINE HCL 1 Tricyclic Agents DOXEPIN HCL 1 Tricyclic Agents IMIPRAMINE HCL 1 Tricyclic Agents NORTRIPTYLINE HCL 1 U Ulcer Drugs - Prostaglandins MISOPROSTOL 1 Ulcer Therapy Combinations LANSOPRAZOLE/AMOXICILLIN/ 1 Ulcer Therapy Combinations OMECLAMOX-PAK 3 Ulcer Therapy Combinations OMEPRAZOLE/SODIUM BICARBO 1 Ulcer Therapy Combinations PYLERA 2 Uricosurics PROBENECID 1 Urinary Analgesics PHENAZOPYRIDINE HCL 1 Urinary Analgesics PYRIDIUM 3 Urinary Anti-infective Combinations URIBEL 1 Urinary Anti-infective Combinations URIMAR-T 2 Urinary Anti-infective Combinations UROGESIC-BLUE 2 Urinary Anti-infective Combinations URO-MP 1 Urinary Anti-infectives METHENAMINE HIPPURATE 1 Urinary Anti-infectives MONUROL 3 Urinary Anti-infectives NITROFURANTOIN 1 Urinary Anti-infectives NITROFURANTOIN MACROCRYST 1

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Urinary Anti-infectives NITROFURANTOIN MONOHYDRAT 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) DETROL LA 3 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) DITROPAN XL 3 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) OXYBUTYNIN CHLORIDE 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) OXYBUTYNIN CHLORIDE ER 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) TOLTERODINE TARTRATE 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) TOLTERODINE TARTRATE ER 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) TOVIAZ 2 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) TROSPIUM CHLORIDE 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) TROSPIUM CHLORIDE ER 1 Urinary Antispasmodic - Antimuscarinic (Anticholinergic) VESICARE 2 Urinary Antispasmodics - Beta-3 Adrenergic Agonists MYRBETRIQ 2 Urinary Antispasmodics - Cholinergic Agonists BETHANECHOL CHLORIDE 1 V Vaginal Anti-infectives CLEOCIN 3 Vaginal Anti-infectives CLINDAMYCIN PHOSPHATE 1 Vaginal Anti-infectives CLINDESSE 3 Vaginal Anti-infectives GYNAZOLE-1 3 Vaginal Anti-infectives METRONIDAZOLE VAGINAL 1 Vaginal Anti-infectives TERCONAZOLE 1 Vaginal Estrogens ESTRACE 3 Vaginal Estrogens ESTRADIOL 1 Vaginal Estrogens ESTRING 2 Vaginal Estrogens FEMRING 3 Vaginal Estrogens PREMARIN 2 Vaginal Estrogens VAGIFEM 3 Vaginal Estrogens YUVAFEM 1 Vaginal Progestins CRINONE 2 Vaginal Progestins ENDOMETRIN 3 Valproic Acid DEPAKOTE ER 3 Valproic Acid DIVALPROEX SODIUM 1 Valproic Acid DIVALPROEX SODIUM DR 1 Valproic Acid DIVALPROEX SODIUM ER 1 Valproic Acid VALPROIC ACID 1 Vasodilating Agents RECTIV 2 Vasodilators HYDRALAZINE HCL 1 Vasodilators MINOXIDIL 1 Vasomotor Symptom Agents PAROXETINE 1 Vasopressors MIDODRINE HCL 1 Viral Vaccines AFLURIA 2017-2018 2 Viral Vaccines AFLURIA PF 2017-2018 2 Viral Vaccines AFLURIA QUADRIVALENT 2017 2 Viral Vaccines ENGERIX-B 2 Viral Vaccines FLUAD 2017-2018 2 Viral Vaccines FLUARIX QUADRIVALENT 2017 2 Viral Vaccines FLUBLOK QUADRIVALENT 2017 2 Viral Vaccines FLUCELVAX QUADRIVALENT 20 2 Viral Vaccines FLULAVAL QUADRIVALENT 201 2 Viral Vaccines FLUVIRIN 2017-2018 2

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THERAPEUTIC CLASS NAME PRODUCT NAME TIER

Special Instructions (PA, ST, QL)

Viral Vaccines FLUZONE HIGH-DOSE PF 2017 2 Viral Vaccines FLUZONE QUADRIVALENT 2017 2 Viral Vaccines GARDASIL 9 2 Viral Vaccines HAVRIX 2 Viral Vaccines IPOL INACTIVATED IPV 2 Viral Vaccines M-M-R II 2 Viral Vaccines PROQUAD 2 Viral Vaccines RECOMBIVAX HB 2 Viral Vaccines SHINGRIX 3 Viral Vaccines TWINRIX 2 Viral Vaccines VAQTA 2 Viral Vaccines VAQTA 3 Viral Vaccines VARIVAX 2 Viral Vaccines YF-VAX 2 Viral Vaccines ZOSTAVAX 2 Viscosupplements HYALGAN 3 Viscosupplements SYNVISC ONE 3 W Water Soluble Vitamins PYRIDOXINE HCL 1 Wound Care Products ALEVICYN DERMAL SPRAY 1 Wound Care Products BIONECT 3 Wound Care Products LUXAMEND 2 X Xanthines THEO-24 3 Xanthines THEOPHYLLINE ER 1


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