BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

BMC HealthNet Plan Drug List – Commonwealth Care II & III (Updated 11/01/2012)The BMC HealthNet Plan (Plan) Drug Formulary includes prescribed drugs and devices covered and excluded by the Plan. Restrictions may apply. The Drug Formulary is subject to change with notification. All newly approveddrugs require prior authorization until reviewed by the Plan and a coverage determination is made. The Drug Formulary is also subject to the Plan’s mandatory generic program. For further detail on the Pharmacy Program,please visit the pharmacy page at bmchp.org.For further questions, please contact the Plan or the Pharmacy Benefits Manager at: Commonwealth Care II & III Members: 1‐877‐957‐5300 Providers: 1‐888‐566‐0008Pharmacy Benefit Manager – Catamaran 1‐866‐795‐0049 (Phone) | 1‐866‐795‐8834 (Fax)AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary Status5‐ALPHA‐REDUCTASE INHIBITORS AVODART CAP 0.5MG BRAND TIER 02 PA QLFINASTERIDE TAB 5MG GENERIC TIER 01 QLJALYN CAP BRAND TIER 02 PA QLPROSCAR TAB 5MG Brand‐O TIER 03 PA QL5‐HT3 RECEPTOR ANTAGONISTS ALOXI INJ 0.25MG/5 BRAND TIER 03 PAANZEMET INJ 20MG/ML BRAND TIER 03 PAANZEMET TAB 100MG BRAND TIER 02 PA QLANZEMET TAB 50MG BRAND TIER 02 PA QLGRANISETRON INJ 0.1MG/ML GENERIC TIER 01 PAGRANISETRON INJ 1MG/ML GENERIC TIER 01 PAGRANISETRON INJ 4MG/4ML GENERIC TIER 01 PAGRANISETRON TAB 1MG GENERIC TIER 01 PA QLGRANISOL SOL 2MG/10ML BRAND TIER 03 PA QLONDANSETRON INJ 32/50ML GENERIC TIER 01 SPONDANSETRON INJ 40/20ML GENERIC TIER 01ONDANSETRON INJ 4MG/2ML GENERIC TIER 01ONDANSETRON SOL 32MG/50M GENERIC TIER 01ONDANSETRON SOL 4MG/5ML GENERIC TIER 01 QLONDANSETRON TAB 24MG GENERIC TIER 01 QLONDANSETRON TAB 4MG GENERIC TIER 01 QLONDANSETRON TAB 4MG ODT GENERIC TIER 01 QLONDANSETRON TAB 8MG GENERIC TIER 01 QLONDANSETRON TAB 8MG ODT GENERIC TIER 01 QLSANCUSO DIS 3.1MG BRAND TIER 02 PA QLZOFRAN INJ 40/20ML Brand‐O TIER 03 PAZOFRAN SOL 4MG/5ML Brand‐O TIER 03 PA QLZOFRAN TAB 4MG Brand‐O TIER 03 PA QLZOFRAN TAB 4MG ODT Brand‐O TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion1

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary Status5‐HT3 RECEPTOR ANTAGONISTS ZOFRAN TAB 8MG Brand‐O TIER 03 PA QLZOFRAN TAB 8MG ODT Brand‐O TIER 03 PA QLZUPLENZ MIS 4MG BRAND TIER 03 PA QLZUPLENZ MIS 8MG BRAND TIER 03 PA QLACIDIFYING AGENTS AMMONIUM CHL INJ 5MEQ/ML GENERIC TIER 01K‐PHOS TAB MF BRAND TIER 03K‐PHOS TAB NO 2 BRAND TIER 03ADAMANTANES FLUMADINE TAB 100MG Brand‐O TIER 03 PARIMANTADINE TAB 100MG GENERIC TIER 01RIMANTALIST PAK BRAND TIER 03 SPADAMANTANES (CNS) AMANTADINE CAP 100MG GENERIC TIER 01AMANTADINE SYP 50MG/5ML GENERIC TIER 01AMANTADINE TAB 100MG GENERIC TIER 01ADRENALS A‐HYDROCORT INJ 100MG GENERIC TIER 01ALVESCO AER 160MCG BRAND TIER 02ALVESCO AER 80MCG BRAND TIER 02A‐METHAPRED INJ 125MG GENERIC TIER 01A‐METHAPRED INJ 40MG GENERIC TIER 01ARISTOSPAN INJ 20MG/ML BRAND TIER 03ARISTOSPAN INJ 5MG/ML BRAND TIER 03ASMALPRED SOL 15MG/5ML GENERIC TIER 01ASMALPRED SOL PLUS GENERIC TIER 01ASMANEX 120 AER 220MCG BRAND TIER 02ASMANEX 14 AER 220MCG BRAND TIER 02ASMANEX 30 AER 110MCG BRAND TIER 02ASMANEX 30 AER 220MCG BRAND TIER 02ASMANEX 60 AER 220MCG BRAND TIER 02ASMANEX 7 AER 110MCG BRAND TIER 02BAYCADRON ELX 0.5/5ML GENERIC TIER 01BETA‐PHOS/AC INJ 3‐3MG/ML GENERIC TIER 01BUDESONIDE CAP 3MG/24HR GENERIC TIER 01BUDESONIDE SUS 0.25MG/2 GENERIC TIER 01 QLBUDESONIDE SUS 0.5MG/2 GENERIC TIER 01 QLCELESTONE INJ SOLUSPAN Brand‐O TIER 03 PACELESTONE SOL 0.6MG/5 BRAND TIER 03CORTEF TAB 10MG Brand‐O TIER 03 PACORTEF TAB 20MG Brand‐O TIER 03 PACORTEF TAB 5MG Brand‐O TIER 03 PACORTISONE AC TAB 25MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion2

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusADRENALS DEPO‐MEDROL INJ 20MG/ML BRAND TIER 03DEPO‐MEDROL INJ 40MG/ML Brand‐O TIER 03 PADEPO‐MEDROL INJ 80MG/ML Brand‐O TIER 03 PADEXAMETH PHO INJ 10MG/ML GENERIC TIER 01DEXAMETH PHO INJ 4MG/ML GENERIC TIER 01DEXAMETHASON CON 1MG/ML BRAND TIER 03DEXAMETHASON ELX 0.5/5ML GENERIC TIER 01DEXAMETHASON SOL 0.5/5ML GENERIC TIER 01DEXAMETHASON TAB 0.5MG GENERIC TIER 01DEXAMETHASON TAB 0.75MG GENERIC TIER 01DEXAMETHASON TAB 1.5MG GENERIC TIER 01DEXAMETHASON TAB 1MG GENERIC TIER 01DEXAMETHASON TAB 2MG GENERIC TIER 01DEXAMETHASON TAB 4MG GENERIC TIER 01DEXAMETHASON TAB 6MG GENERIC TIER 01DEXPAK PAK 10 DAY BRAND TIER 03DEXPAK PAK 13 DAY BRAND TIER 03DEXPAK PAK 6 DAY BRAND TIER 03DULERA AER 100‐5MCG BRAND TIER 03 PA QLDULERA AER 200‐5MCG BRAND TIER 03 PA QLENTOCORT EC CAP 3MG/24HR Brand‐O TIER 03 PAFLO‐PRED SUS BRAND TIER 03FLOVENT DISK AER 100MCG BRAND TIER 02 QLFLOVENT DISK AER 250MCG BRAND TIER 02 QLFLOVENT DISK AER 50MCG BRAND TIER 02 QLFLOVENT HFA AER 110MCG BRAND TIER 02 QLFLOVENT HFA AER 220MCG BRAND TIER 02 QLFLOVENT HFA AER 44MCG BRAND TIER 02 QLFLUDROCORT TAB 0.1MG GENERIC TIER 01HYDROCORT TAB 10MG GENERIC TIER 01HYDROCORT TAB 20MG GENERIC TIER 01HYDROCORT TAB 5MG GENERIC TIER 01KENALOG‐10 INJ 10MG/ML BRAND TIER 03KENALOG‐40 INJ 40MG/ML BRAND TIER 03MEDROL PAK 4MG Brand‐O TIER 03 PAMEDROL TAB 16MG Brand‐O TIER 03 PAMEDROL TAB 2MG BRAND TIER 03MEDROL TAB 32MG Brand‐O TIER 03 PAMEDROL TAB 4MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion3

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusADRENALS MEDROL TAB 8MG Brand‐O TIER 03 PAMETHYLPR ACE INJ 40MG/ML GENERIC TIER 01METHYLPR ACE INJ 80MG/ML GENERIC TIER 01METHYLPR SS INJ 1000MG GENERIC TIER 01METHYLPR SS INJ 125MG GENERIC TIER 01METHYLPR SS INJ 1GM GENERIC TIER 01METHYLPR SS INJ 40MG GENERIC TIER 01METHYLPR SS INJ 500MG GENERIC TIER 01METHYLPRED PAK 4MG GENERIC TIER 01METHYLPRED TAB 16MG GENERIC TIER 01METHYLPRED TAB 32MG GENERIC TIER 01METHYLPRED TAB 4MG GENERIC TIER 01METHYLPRED TAB 8MG GENERIC TIER 01MILLIPRED SOL 10MG/5ML BRAND TIER 03MILLIPRED TAB 5MG BRAND TIER 03MILLIPRED DP PAK 5MG BRAND TIER 03ORAPRED SOL 15MG/5ML Brand‐O TIER 03 PAORAPRED ODT TAB 10MG BRAND TIER 99 DEORAPRED ODT TAB 15MG BRAND TIER 99 DEORAPRED ODT TAB 30MG BRAND TIER 99 DEPEDIAPRED SOL 6.7/5ML Brand‐O TIER 03 PAPRED SOD PHO SOL 5MG/5ML GENERIC TIER 01PRED SOD PHO SOL 6.7/5ML GENERIC TIER 01PREDNISOLONE SOL 15MG/5ML GENERIC TIER 01PREDNISOLONE SOL 25MG/5ML GENERIC TIER 01PREDNISONE CON 5MG/ML BRAND TIER 03PREDNISONE PAK 10MG GENERIC TIER 01PREDNISONE PAK 5MG GENERIC TIER 01PREDNISONE SOL 5MG/5ML GENERIC TIER 01PREDNISONE TAB 10MG GENERIC TIER 01PREDNISONE TAB 1MG GENERIC TIER 01PREDNISONE TAB 2.5MG GENERIC TIER 01PREDNISONE TAB 20MG GENERIC TIER 01PREDNISONE TAB 50MG GENERIC TIER 01PREDNISONE TAB 5MG GENERIC TIER 01PRELONE SYP 15MG/5ML Brand‐O TIER 03 PAPULMICORT INH 180MCG BRAND TIER 02 QLPULMICORT INH 90MCG BRAND TIER 02 QLPULMICORT SUS 0.25MG/2 Brand‐O TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion4

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusADRENALS PULMICORT SUS 0.5MG/2 Brand‐O TIER 03 PA QLPULMICORT SUS 1MG/2ML BRAND TIER 02 QLQVAR AER 40MCG BRAND TIER 02 QLQVAR AER 80MCG BRAND TIER 02 QLRAYOS TAB 1MG BRAND TIER 03RAYOS TAB 2MG BRAND TIER 03RAYOS TAB 5MG BRAND TIER 03SOLU‐CORTEF INJ 1000MG BRAND TIER 03SOLU‐CORTEF INJ 100MG Brand‐O TIER 03 PASOLU‐CORTEF INJ 250MG BRAND TIER 03SOLU‐CORTEF INJ 500MG BRAND TIER 03SOLU‐MEDROL INJ 125MG Brand‐O TIER 03 PASOLU‐MEDROL INJ 1GM Brand‐O TIER 03 PASOLU‐MEDROL INJ 2GM BRAND TIER 03SOLU‐MEDROL INJ 40MG Brand‐O TIER 03 PASOLU‐MEDROL INJ 500MG Brand‐O TIER 03 PASYMBICORT AER 160‐4.5 BRAND TIER 03 PA QLSYMBICORT AER 80‐4.5 BRAND TIER 03 PA QLVERIPRED 20 SOL 20MG/5ML BRAND TIER 03ZEMA‐PAK PAK 10 DAY GENERIC TIER 01ZEMA‐PAK PAK 13 DAY GENERIC TIER 01ZEMA‐PAK PAK 6 DAY GENERIC TIER 01ADRENOCORTICAL INSUFFICIENCY CORTROSYN INJ 0.25MG Brand‐O TIER 03 PACOSYNTROPIN INJ 0.25MG GENERIC TIER 01ALCOHOL DETERRENTS ANTABUSE TAB 250MG Brand‐O TIER 03 PAANTABUSE TAB 500MG Brand‐O TIER 03 PADISULFIRAM TAB 250MG GENERIC TIER 01DISULFIRAM TAB 500MG GENERIC TIER 01ALKALINIZING AGENTS CITRIC ACID/ SOL SOD CITR GENERIC TIER 01CITROLITH TAB BRAND TIER 03CYTRA K GRA CRYSTALS GENERIC TIER 01CYTRA‐2 SOL GENERIC TIER 01CYTRA‐3 SYP GENERIC TIER 01CYTRA‐K SOL GENERIC TIER 01K CITRATE SOL CITR ACD GENERIC TIER 01NEUT INJ 4% BRAND TIER 03ORACIT SOL BRAND TIER 03POLYCITRA‐K POW CRYSTALS Brand‐O TIER 03 PAPOT CITRATE TAB 1080MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion5

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusALKALINIZING AGENTS POT CITRATE TAB 540MG GENERIC TIER 01SHOHLS SOL MODIFIED Brand‐O TIER 03 PASOD ACETATE CRY ANHYDR GENERIC TIER 99 DESOD ACETATE INJ 2MEQ/ML GENERIC TIER 01SOD ACETATE INJ 4MEQ/ML GENERIC TIER 01SOD BICARB INJ 4.2% GENERIC TIER 01SOD BICARB INJ 7.5% GENERIC TIER 01SOD BICARB INJ 8.4% GENERIC TIER 01SOD LACTATE INJ 1/6M GENERIC TIER 01SOD LACTATE INJ 5MEQ/ML GENERIC TIER 01SODIUM ACETA GRA GENERIC TIER 99 DESODIUM ACETA GRA USP GENERIC TIER 99 DESODIUM CITRA GRA GENERIC TIER 01TARON GRA CRYSTALS GENERIC TIER 01THAM INJ 30MEQ BRAND TIER 03TRICITRATES SOL GENERIC TIER 01UROCIT‐K 10 TAB Brand‐O TIER 03 PAUROCIT‐K 15 TAB BRAND TIER 02UROCIT‐K 5 TAB Brand‐O TIER 03 PAALLYLAMINES LAMISIL GRA 125MG BRAND TIER 03 PA QLLAMISIL GRA 187.5MG BRAND TIER 03 PA QLLAMISIL TAB 250MG Brand‐O TIER 03 PA QLTERBINAFINE TAB 250MG GENERIC TIER 01 QLTERBINEX KIT BRAND TIER 99 DEALLYLAMINES (SKIN & MUCOUS MEMBRANE) LAMISIL SPR 1% BRAND TIER 03NAFTIN CRE 1% BRAND TIER 03NAFTIN CRE 2% BRAND TIER 03NAFTIN GEL 1% BRAND TIER 03ALPHA‐ AND BETA‐ADRENERGIC AGONISTS ADRENALIN INJ 1MG/ML Brand‐O TIER 03 PAEPHEDRINE SU INJ 50MG/ML GENERIC TIER 01EPINEPHRINE INJ 0.15MG GENERIC TIER 01EPINEPHRINE INJ 0.1MG/ML GENERIC TIER 01EPINEPHRINE INJ 0.3MG GENERIC TIER 01 QLEPINEPHRINE INJ 1MG/ML GENERIC TIER 01EPIPEN INJ 0.3MG BRAND TIER 02 QLEPIPEN 2‐PAK INJ 0.3MG BRAND TIER 02 QLEPIPEN‐JR INJ 0.15MG BRAND TIER 02 QLEPIPEN‐JR INJ 2‐PAK BRAND TIER 02 QLLEVOPHED INJ 1MG/ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion6

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusALPHA‐ AND BETA‐ADRENERGIC AGONISTS LEVOPHED INJ 1MG/ML GENERIC TIER 01NOREPINEPHR INJ 1MG/ML GENERIC TIER 01PSEUDOEPHEDR CRY HCL GENERIC TIER 99 DERESPIVENT‐D TAB GENERIC TIER 99 DETWINJECT INJ 0.15MG BRAND TIER 03TWINJECT INJ 0.3MG BRAND TIER 02 QLALLERX‐D TAB 120/2.5 Brand‐O TIER 99 PA DEALPHA‐ADRENERGIC AGONISTS LUSONAL LIQ BRAND TIER 03MIDODRINE TAB 10MG GENERIC TIER 01MIDODRINE TAB 2.5MG GENERIC TIER 01MIDODRINE TAB 5MG GENERIC TIER 01NEO‐SYNEPHRI INJ 10MG/ML Brand‐O TIER 03 PAPHENYLEPHRIN CRY GENERIC TIER 99 DEPHENYLEPHRIN INJ 10MG/ML GENERIC TIER 01ALPHA‐ADRENERGIC AGONISTS (EENT) ALPHAGAN P SOL 0.1% BRAND TIER 02ALPHAGAN P SOL 0.15% Brand‐O TIER 03 PABRIMONIDINE SOL 0.15% GENERIC TIER 01BRIMONIDINE SOL 0.2% OP GENERIC TIER 01COMBIGAN SOL 0.2/0.5% BRAND TIER 03ALPHA‐ADRENERGIC BLOCKING AGENTS CARDURA TAB 1MG Brand‐O TIER 03 PACARDURA TAB 2MG Brand‐O TIER 03 PACARDURA TAB 4MG Brand‐O TIER 03 PACARDURA TAB 8MG Brand‐O TIER 03 PACARDURA XL TAB 4MG BRAND TIER 03 PA QLCARDURA XL TAB 8MG BRAND TIER 03 PA QLDOXAZOSIN TAB 1MG GENERIC TIER 01DOXAZOSIN TAB 2MG GENERIC TIER 01DOXAZOSIN TAB 4MG GENERIC TIER 01DOXAZOSIN TAB 8MG GENERIC TIER 01MINIPRESS CAP 1MG Brand‐O TIER 03 PAMINIPRESS CAP 2MG Brand‐O TIER 03 PAMINIPRESS CAP 5MG Brand‐O TIER 03 PAPRAZOSIN HCL CAP 1MG GENERIC TIER 01PRAZOSIN HCL CAP 2MG GENERIC TIER 01PRAZOSIN HCL CAP 5MG GENERIC TIER 01TERAZOSIN CAP 10MG GENERIC TIER 01TERAZOSIN CAP 1MG GENERIC TIER 01TERAZOSIN CAP 2MG GENERIC TIER 01TERAZOSIN CAP 5MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion7

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusALPHA‐GLUCOSIDASE INHIBITORS ACARBOSE TAB 100MG GENERIC TIER 01ACARBOSE TAB 25MG GENERIC TIER 01ACARBOSE TAB 50MG GENERIC TIER 01GLYSET TAB 100MG BRAND TIER 03GLYSET TAB 25MG BRAND TIER 03GLYSET TAB 50MG BRAND TIER 03PRECOSE TAB 100MG Brand‐O TIER 03 PAPRECOSE TAB 25MG Brand‐O TIER 03 PAPRECOSE TAB 50MG Brand‐O TIER 03 PAAMEBICIDES PAROMOMYCIN CAP 250MG GENERIC TIER 01YODOXIN TAB 210MG BRAND TIER 02YODOXIN TAB 650MG BRAND TIER 02AMINOGLYCOSIDES AMIKACIN INJ 100/2ML GENERIC TIER 01 SPAMIKACIN INJ 1GM/4ML GENERIC TIER 01 SPAMIKACIN INJ 500/2ML GENERIC TIER 01 SPGENTAM/NACL INJ 0.9MG/ML GENERIC TIER 01GENTAM/NACL INJ 1.4MG/ML GENERIC TIER 01GENTAM/NACL INJ 100MG GENERIC TIER 01GENTAM/NACL INJ 100MG PB GENERIC TIER 01GENTAM/NACL INJ 120MG GENERIC TIER 01GENTAM/NACL INJ 60MG GENERIC TIER 01GENTAM/NACL INJ 60MG PB GENERIC TIER 01GENTAM/NACL INJ 80MG GENERIC TIER 01GENTAM/NACL INJ 80MG PB GENERIC TIER 01GENTAMICIN INJ 10MG/ML GENERIC TIER 01GENTAMICIN INJ 40MG/ML GENERIC TIER 01KANAMYCIN INJ 333MG/ML GENERIC TIER 01NEO‐FRADIN SOL 125/5ML BRAND TIER 03NEOMYCIN TAB 500MG GENERIC TIER 01STREPTOMYCIN INJ 1GM GENERIC TIER 01TOBI NEB 300/5ML BRAND TIER 02 SPTOBRA/NACL INJ 60/0.9 GENERIC TIER 01TOBRA/NACL INJ 80/0.9 GENERIC TIER 01TOBRAMYCIN INJ 1.2/30ML GENERIC TIER 01TOBRAMYCIN INJ 1.2GM GENERIC TIER 01TOBRAMYCIN INJ 10MG/ML GENERIC TIER 01TOBRAMYCIN INJ 40MG/ML GENERIC TIER 01TOBRAMYCIN INJ 80MG/2ML GENERIC TIER 01AMINOPENICILLINS AMOX/K CLAV CHW 200MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion8

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusAMINOPENICILLINS AMOX/K CLAV CHW 400MG GENERIC TIER 01AMOX/K CLAV SUS 200/5ML GENERIC TIER 01AMOX/K CLAV SUS 250/5ML GENERIC TIER 01AMOX/K CLAV SUS 400/5ML GENERIC TIER 01AMOX/K CLAV SUS 600/5ML GENERIC TIER 01AMOX/K CLAV TAB 250MG GENERIC TIER 01AMOX/K CLAV TAB 500MG GENERIC TIER 01AMOX/K CLAV TAB 875MG GENERIC TIER 01AMOXICILLIN CAP 250MG GENERIC TIER 01AMOXICILLIN CAP 500MG GENERIC TIER 01AMOXICILLIN CHW 125MG GENERIC TIER 01AMOXICILLIN CHW 250MG GENERIC TIER 01AMOXICILLIN SUS 125/5ML GENERIC TIER 01AMOXICILLIN SUS 200/5ML GENERIC TIER 01AMOXICILLIN SUS 250/5ML GENERIC TIER 01AMOXICILLIN SUS 400/5ML GENERIC TIER 01AMOXICILLIN TAB 500MG GENERIC TIER 01AMOXICILLIN TAB 875MG GENERIC TIER 01AMOX‐POT CLA TAB ER GENERIC TIER 01AMPICILLIN CAP 250MG GENERIC TIER 01AMPICILLIN CAP 500MG GENERIC TIER 01AMPICILLIN INJ 10GM GENERIC TIER 01AMPICILLIN INJ 125MG GENERIC TIER 01AMPICILLIN INJ 1GM GENERIC TIER 01AMPICILLIN INJ 250MG GENERIC TIER 01AMPICILLIN INJ 2GM GENERIC TIER 01AMPICILLIN INJ 500MG GENERIC TIER 01AMPICILLIN SUS 125/5ML GENERIC TIER 01AMPICILLIN SUS 250/5ML GENERIC TIER 01AMP‐SULBACTA INJ 1.5GM GENERIC TIER 01AMP‐SULBACTA INJ 1‐0.5GM GENERIC TIER 01AMP‐SULBACTA INJ 10‐5GM GENERIC TIER 01AMP‐SULBACTA INJ 15GM GENERIC TIER 01AMP‐SULBACTA INJ 2‐1GM GENERIC TIER 01AMP‐SULBACTA INJ 3GM GENERIC TIER 01AUGMENTIN SUS 125/5ML BRAND TIER 02AUGMENTIN SUS 250/5ML Brand‐O TIER 03 PAAUGMENTIN TAB 500MG Brand‐O TIER 03 PAAUGMENTIN TAB 875MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion9

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusAMINOPENICILLINS AUGMENTIN XR TAB 12HR Brand‐O TIER 03 PAMOXATAG TAB 775MG BRAND TIER 03UNASYN INJ 1.5GM Brand‐O TIER 03 PAUNASYN INJ 1.5GM PB Brand‐O TIER 03 PAUNASYN INJ 15GM Brand‐O TIER 03 PAUNASYN INJ 3GM Brand‐O TIER 03 PAUNASYN INJ 3GM PB Brand‐O TIER 03 PAAUGMENTIN SUS ES‐600 Brand‐O TIER 03 PAAMMONIA DETOXICANTS AMMONUL INJ 10% BRAND TIER 03BUPHENYL POW BRAND TIER 02BUPHENYL TAB 500MG BRAND TIER 02CARBAGLU TAB 200MG BRAND TIER 02CONSTULOSE SOL 10GM/15 GENERIC TIER 01ENULOSE SOL 10GM/15 GENERIC TIER 01GENERLAC SOL 10GM/15 GENERIC TIER 01KRISTALOSE PAK 10GM BRAND TIER 02KRISTALOSE PAK 20GM BRAND TIER 02LACTULOSE SOL 10GM/15 GENERIC TIER 01LACTULOSE SOL 20GM/30 GENERIC TIER 01LITHOSTAT TAB 250MG BRAND TIER 03AMPHETAMINES ADDERALL TAB 10MG Brand‐O TIER 03 PA QLADDERALL TAB 12.5MG Brand‐O TIER 03 PA QLADDERALL TAB 15MG Brand‐O TIER 03 PA QLADDERALL TAB 20MG Brand‐O TIER 03 PA QLADDERALL TAB 30MG Brand‐O TIER 03 PA QLADDERALL TAB 5MG Brand‐O TIER 03 PA QLADDERALL TAB 7.5MG Brand‐O TIER 03 PA QLADDERALL XR CAP 10MG Brand‐O TIER 03 PA QLADDERALL XR CAP 15MG Brand‐O TIER 03 PA QLADDERALL XR CAP 20MG Brand‐O TIER 03 PA QLADDERALL XR CAP 25MG Brand‐O TIER 03 PA QLADDERALL XR CAP 30MG Brand‐O TIER 03 PA QLADDERALL XR CAP 5MG Brand‐O TIER 03 PA QLAMPHETAMINE CAP 10MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 15MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 20MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 25MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 30MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 5MG ER GENERIC TIER 01 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion10

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusAMPHETAMINES AMPHETAMINE TAB 10MG GENERIC TIER 01 QLAMPHETAMINE TAB 12.5MG GENERIC TIER 01 QLAMPHETAMINE TAB 15MG GENERIC TIER 01 QLAMPHETAMINE TAB 20MG GENERIC TIER 01 QLAMPHETAMINE TAB 30MG GENERIC TIER 01 QLAMPHETAMINE TAB 5MG GENERIC TIER 01 QLAMPHETAMINE TAB 7.5MG GENERIC TIER 01 QLBENZPHETAMIN TAB 50MG GENERIC TIER 99 DEDESOXYN TAB 5MG Brand‐O TIER 03 PADEXEDRINE CAP 10MG CR Brand‐O TIER 03 PA QLDEXEDRINE CAP 15MG CR Brand‐O TIER 03 PA QLDEXEDRINE CAP 5MG CR Brand‐O TIER 03 PA QLDEXTROAMPHET CAP 10MG ER GENERIC TIER 01 QLDEXTROAMPHET CAP 15MG ER GENERIC TIER 01 QLDEXTROAMPHET CAP 5MG ER GENERIC TIER 01 QLDEXTROAMPHET TAB 10MG GENERIC TIER 01 QLDEXTROAMPHET TAB 5MG GENERIC TIER 01 QLMETHAMPHETAM TAB 5MG GENERIC TIER 01PROCENTRA SOL 5MG/5ML BRAND TIER 03REGIMEX TAB 25MG BRAND TIER 99 DEVYVANSE CAP 20MG BRAND TIER 02 PA QLVYVANSE CAP 30MG BRAND TIER 02 PA QLVYVANSE CAP 40MG BRAND TIER 02 PA QLVYVANSE CAP 50MG BRAND TIER 02 PA QLVYVANSE CAP 60MG BRAND TIER 02 PA QLVYVANSE CAP 70MG BRAND TIER 02 PA QLDIDREX TAB 50MG Brand‐O TIER 99 PA DEAMYLINOMIMETICS SYMLIN INJ 600MCG BRAND TIER 02SYMLINPEN 60 INJ 1000MCG BRAND TIER 02SYMLNPEN 120 INJ 1000MCG BRAND TIER 02ANALGESICS AND ANTIPYRETICS, MISC. ALAGESIC CAP GENERIC TIER 01ALAGESIC LQ SOL BRAND TIER 03ANABAR TAB GENERIC TIER 01ANOLOR 300 CAP GENERIC TIER 01BUPAP TAB 50‐650MG GENERIC TIER 01BUT/APAP/CAF CAP GENERIC TIER 01BUT/APAP/CAF TAB GENERIC TIER 01BUTAL/APAP TAB 50‐325MG GENERIC TIER 01CAFGESIC CAP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion11

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANALGESICS AND ANTIPYRETICS, MISC. CAFGESIC TAB GENERIC TIER 01CAPACET CAP GENERIC TIER 01CEPHADYN TAB 50‐650MG GENERIC TIER 01DOLGIC PLUS TAB BRAND TIER 03DURABAC CAP Brand‐O TIER 03 PADURABAC TAB FORTE BRAND TIER 03DURAXIN CAP GENERIC TIER 01ED‐FLEX CAP GENERIC TIER 01ESGIC CAP Brand‐O TIER 03 PAESGIC TAB Brand‐O TIER 03 PAESGIC‐PLUS CAP Brand‐O TIER 03 PAESGIC‐PLUS TAB Brand‐O TIER 03 PAFIORICET TAB Brand‐O TIER 03 PAFRENADOL TAB GENERIC TIER 01GRALISE TAB 300MG BRAND TIER 03 PA QLGRALISE TAB 600MG BRAND TIER 03 PA QLGRALISE STAR MIS 300/600 BRAND TIER 03ILARIS INJ 180MG BRAND TIER 03 PA QL SPMARGESIC CAP GENERIC TIER 01MARTEN‐TAB TAB 50‐325MG GENERIC TIER 01OFIRMEV INJ 10MG/ML BRAND TIER 03ORBIVAN CAP BRAND TIER 03ORBIVAN CF TAB 50‐300MG BRAND TIER 03PHRENILIN CAP FORTE BRAND TIER 03PRIALT INJ 100MCG BRAND TIER 99 DEPRIALT INJ 25MCG/ML BRAND TIER 99 DEPRIALT INJ 500MCG BRAND TIER 99 DEPROMACET TAB 50‐650MG GENERIC TIER 01REPAN TAB GENERIC TIER 01SEDAPAP TAB 50‐650MG Brand‐O TIER 03 PATENCON TAB 50‐650MG GENERIC TIER 01ZEBUTAL CAP GENERIC TIER 01ANDROGENS ANADROL‐50 TAB 50MG BRAND TIER 03 PAANDRODERM DIS 2.5MG/24 BRAND TIER 02ANDRODERM DIS 2MG/24HR BRAND TIER 02ANDRODERM DIS 4MG/24HR BRAND TIER 02ANDRODERM DIS 5MG/24HR BRAND TIER 02ANDROGEL GEL 1%(25MG) BRAND TIER 02ANDROGEL GEL 1%(50MG) BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion12

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANDROGENS ANDROGEL GEL 1.62% BRAND TIER 02ANDROGEL GEL PUMP 1% BRAND TIER 02ANDROID CAP 10MG BRAND TIER 03ANDROXY TAB 10MG BRAND TIER 02AXIRON SOL 30MG/ACT BRAND TIER 02DANAZOL CAP 100MG GENERIC TIER 01DANAZOL CAP 200MG GENERIC TIER 01DANAZOL CAP 50MG GENERIC TIER 01DELATESTRYL INJ 200MG/ML Brand‐O TIER 03 PADEPO‐TESTOST INJ 100MG/ML Brand‐O TIER 03 PADEPO‐TESTOST INJ 200MG/ML Brand‐O TIER 03 PAFIRST‐TESTOS CRE MC 2% BRAND TIER 03FIRST‐TESTOS OIN 2% BRAND TIER 03FORTESTA GEL 10MG/ACT BRAND TIER 02METHITEST TAB 10MG BRAND TIER 02OXANDRIN TAB 10MG Brand‐O TIER 03 PAOXANDRIN TAB 2.5MG Brand‐O TIER 03 PAOXANDROLONE TAB 10MG GENERIC TIER 01 PAOXANDROLONE TAB 2.5MG GENERIC TIER 01 PASTRIANT MIS 30MG BRAND TIER 03TESTIM GEL 1%(50MG) BRAND TIER 03TESTOPEL MIS PELLETS BRAND TIER 03TESTOST CYP INJ 100MG/ML GENERIC TIER 01TESTOST CYP INJ 200MG/ML GENERIC TIER 01TESTOST ENAN INJ 200MG/ML GENERIC TIER 01TESTRED CAP 10MG BRAND TIER 03ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND TAB 16MG BRAND TIER 02 PAATACAND TAB 32MG BRAND TIER 02 PAATACAND TAB 4MG BRAND TIER 02 PAATACAND TAB 8MG BRAND TIER 02 PAATACAND HCT TAB 16‐12.5 BRAND TIER 02 PAATACAND HCT TAB 32‐12.5 BRAND TIER 02 PAATACAND HCT TAB 32‐25MG BRAND TIER 02 PAAVALIDE TAB 150‐12.5 Brand‐O TIER 03 PAAVALIDE TAB 300‐12.5 Brand‐O TIER 03 PAAVALIDE TAB 300‐25MG BRAND TIER 03 PAAVAPRO TAB 150MG Brand‐O TIER 03 PAAVAPRO TAB 300MG Brand‐O TIER 03 PAAVAPRO TAB 75MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion13

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 20MG BRAND TIER 02 PABENICAR TAB 40MG BRAND TIER 02 PABENICAR TAB 5MG BRAND TIER 02 PABENICAR HCT TAB 20‐12.5 BRAND TIER 02 PABENICAR HCT TAB 40‐12.5 BRAND TIER 02 PABENICAR HCT TAB 40‐25MG BRAND TIER 02 PACOZAAR TAB 100MG Brand‐O TIER 03 PACOZAAR TAB 25MG Brand‐O TIER 03 PACOZAAR TAB 50MG Brand‐O TIER 03 PADIOVAN TAB 160MG BRAND TIER 02 PADIOVAN TAB 320MG BRAND TIER 02 PADIOVAN TAB 40MG BRAND TIER 02 PADIOVAN TAB 80MG BRAND TIER 02 PADIOVAN HCT TAB 160‐12.5 Brand‐O TIER 03 PADIOVAN HCT TAB 160‐25MG Brand‐O TIER 03 PADIOVAN HCT TAB 320‐12.5 Brand‐O TIER 03 PADIOVAN HCT TAB 320‐25MG Brand‐O TIER 03 PADIOVAN HCT TAB 80/12.5 Brand‐O TIER 03 PAEDARBI TAB 40MG BRAND TIER 03 PAEDARBI TAB 80MG BRAND TIER 03 PAEDARBYCLOR TAB 40‐12.5 BRAND TIER 03EDARBYCLOR TAB 40‐25MG BRAND TIER 03EPROSART MES TAB 600MG GENERIC TIER 01 PAHYZAAR TAB 100‐12.5 Brand‐O TIER 03 PAHYZAAR TAB 100‐25 Brand‐O TIER 03 PAHYZAAR TAB 50‐12.5 Brand‐O TIER 03 PAIRBESAR/HCTZ TAB 150‐12.5 GENERIC TIER 01 PAIRBESAR/HCTZ TAB 300‐12.5 GENERIC TIER 01 PAIRBESARTAN TAB 150MG GENERIC TIER 01 PAIRBESARTAN TAB 150MGIRBESARTAN TAB 300MG GENERIC TIER 01 PAIRBESARTAN TAB 300MGIRBESARTAN TAB 75MG GENERIC TIER 01 PAIRBESARTAN TAB 75MGLOSARTAN POT TAB 100MG GENERIC TIER 01 PALOSARTAN POT TAB 25MG GENERIC TIER 01 PALOSARTAN POT TAB 50MG GENERIC TIER 01 PALOSARTAN/HCT TAB 100‐12.5 GENERIC TIER 01 PALOSARTAN/HCT TAB 100‐25 GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion14

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN/HCT TAB 50‐12.5 GENERIC TIER 01 PAMICARDIS TAB 20MG BRAND TIER 02 PAMICARDIS TAB 40MG BRAND TIER 02 PAMICARDIS TAB 80MG BRAND TIER 02 PAMICARDIS HCT TAB 40/12.5 BRAND TIER 02 PAMICARDIS HCT TAB 80/12.5 BRAND TIER 02 PAMICARDIS HCT TAB 80‐25MG BRAND TIER 02 PATEVETEN TAB 400MG BRAND TIER 03 PATEVETEN TAB 600MG Brand‐O TIER 03 PATEVETEN HCT TAB 600‐12.5 BRAND TIER 03 PATEVETEN HCT TAB 600‐25MG BRAND TIER 03 PAVALSART/HCTZ TAB 160‐12.5 GENERIC TIER 01 PAVALSART/HCTZ TAB 160‐25MG GENERIC TIER 01 PAVALSART/HCTZ TAB 320‐12.5 GENERIC TIER 01 PAVALSART/HCTZ TAB 320‐25MG GENERIC TIER 01 PAVALSART/HCTZ TAB 80‐12.5 GENERIC TIER 01 PAANGIOTENSIN‐CONVERTING ENZYME INHIBITORS ACCUPRIL TAB 10MG Brand‐O TIER 03 PAACCUPRIL TAB 20MG Brand‐O TIER 03 PAACCUPRIL TAB 40MG Brand‐O TIER 03 PAACCUPRIL TAB 5MG Brand‐O TIER 03 PAACCURETIC TAB 10‐12.5 Brand‐O TIER 03 PAACCURETIC TAB 20‐12.5 Brand‐O TIER 03 PAACCURETIC TAB 20‐25MG Brand‐O TIER 03 PAACEON TAB 2MG Brand‐O TIER 03 PAACEON TAB 4MG Brand‐O TIER 03 PAACEON TAB 8MG Brand‐O TIER 03 PAALTACE CAP 1.25MG Brand‐O TIER 03 PAALTACE CAP 10MG Brand‐O TIER 03 PAALTACE CAP 2.5MG Brand‐O TIER 03 PAALTACE CAP 5MG Brand‐O TIER 03 PABENAZEP/HCTZ TAB 10‐12.5 GENERIC TIER 01BENAZEP/HCTZ TAB 20‐12.5 GENERIC TIER 01BENAZEP/HCTZ TAB 20‐25MG GENERIC TIER 01BENAZEP/HCTZ TAB 5‐6.25 GENERIC TIER 01BENAZEPRIL TAB 10MG GENERIC TIER 01BENAZEPRIL TAB 20MG GENERIC TIER 01BENAZEPRIL TAB 40MG GENERIC TIER 01BENAZEPRIL TAB 5MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion15

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANGIOTENSIN‐CONVERTING ENZYME INHIBITORS CAPTOPR/HCTZ TAB 25‐15MG GENERIC TIER 01CAPTOPR/HCTZ TAB 25‐25MG GENERIC TIER 01CAPTOPR/HCTZ TAB 50‐15MG GENERIC TIER 01CAPTOPR/HCTZ TAB 50‐25MG GENERIC TIER 01CAPTOPRIL TAB 100MG GENERIC TIER 01CAPTOPRIL TAB 12.5MG GENERIC TIER 01CAPTOPRIL TAB 25MG GENERIC TIER 01CAPTOPRIL TAB 50MG GENERIC TIER 01ENALAPR/HCTZ TAB 10‐25MG GENERIC TIER 01ENALAPR/HCTZ TAB 5‐12.5MG GENERIC TIER 01ENALAPRIL TAB 10MG GENERIC TIER 01ENALAPRIL TAB 2.5MG GENERIC TIER 01ENALAPRIL TAB 20MG GENERIC TIER 01ENALAPRIL TAB 5MG GENERIC TIER 01ENALAPRILAT INJ 1.25/ML GENERIC TIER 01FOSINOP/HCTZ TAB 10/12.5 GENERIC TIER 01FOSINOP/HCTZ TAB 20/12.5 GENERIC TIER 01FOSINOPRIL TAB 10MG GENERIC TIER 01FOSINOPRIL TAB 20MG GENERIC TIER 01FOSINOPRIL TAB 40MG GENERIC TIER 01LISINOP/HCTZ TAB 10‐12.5 GENERIC TIER 01LISINOP/HCTZ TAB 20‐12.5 GENERIC TIER 01LISINOP/HCTZ TAB 20‐25MG GENERIC TIER 01LISINOPRIL TAB 10MG GENERIC TIER 01LISINOPRIL TAB 2.5MG GENERIC TIER 01LISINOPRIL TAB 20MG GENERIC TIER 01LISINOPRIL TAB 30MG GENERIC TIER 01LISINOPRIL TAB 40MG GENERIC TIER 01LISINOPRIL TAB 5MG GENERIC TIER 01LOTENSIN TAB 10MG Brand‐O TIER 03 PALOTENSIN TAB 20MG Brand‐O TIER 03 PALOTENSIN TAB 40MG Brand‐O TIER 03 PALOTENSIN HCT TAB 10‐12.5 Brand‐O TIER 03 PALOTENSIN HCT TAB 20‐12.5 Brand‐O TIER 03 PALOTENSIN HCT TAB 20‐25MG Brand‐O TIER 03 PALYTENSOPRIL PAK BRAND TIER 03LYTENSOPRIL PAK ‐90 BRAND TIER 03MAVIK TAB 1MG Brand‐O TIER 03 PAMAVIK TAB 2MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion16

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANGIOTENSIN‐CONVERTING ENZYME INHIBITORS MAVIK TAB 4MG Brand‐O TIER 03 PAMOEXIPR/HCTZ TAB 15‐12.5 GENERIC TIER 01MOEXIPR/HCTZ TAB 15‐25MG GENERIC TIER 01MOEXIPR/HCTZ TAB 7.5‐12.5 GENERIC TIER 01MOEXIPRIL TAB 15MG GENERIC TIER 01MOEXIPRIL TAB 7.5MG GENERIC TIER 01PERINDOPRIL TAB 2MG GENERIC TIER 01PERINDOPRIL TAB 4MG GENERIC TIER 01PERINDOPRIL TAB 8MG GENERIC TIER 01PRINIVIL TAB 10MG Brand‐O TIER 03 PAPRINIVIL TAB 20MG Brand‐O TIER 03 PAPRINIVIL TAB 5MG Brand‐O TIER 03 PAPRINZIDE TAB 10‐12.5 Brand‐O TIER 03 PAPRINZIDE TAB 20‐12.5 Brand‐O TIER 03 PAQNAPRIL/HCTZ TAB 10‐12.5 GENERIC TIER 01QNAPRIL/HCTZ TAB 20‐12.5 GENERIC TIER 01QNAPRIL/HCTZ TAB 20‐25MG GENERIC TIER 01QUINAPRIL TAB 10MG GENERIC TIER 01QUINAPRIL TAB 20MG GENERIC TIER 01QUINAPRIL TAB 40MG GENERIC TIER 01QUINAPRIL TAB 5MG GENERIC TIER 01RAMIPRIL CAP 1.25MG GENERIC TIER 01RAMIPRIL CAP 10MG GENERIC TIER 01RAMIPRIL CAP 2.5MG GENERIC TIER 01RAMIPRIL CAP 5MG GENERIC TIER 01TRANDOLAPRIL TAB 1MG GENERIC TIER 01TRANDOLAPRIL TAB 2MG GENERIC TIER 01TRANDOLAPRIL TAB 4MG GENERIC TIER 01UNIRETIC TAB 15‐12.5 Brand‐O TIER 03 PAUNIRETIC TAB 15‐25MG Brand‐O TIER 03 PAUNIRETIC TAB 7.5‐12.5 Brand‐O TIER 03 PAUNIVASC TAB 15MG Brand‐O TIER 03 PAUNIVASC TAB 7.5MG Brand‐O TIER 03 PAVASERETIC TAB 10‐25MG Brand‐O TIER 03 PAVASOTEC TAB 10MG Brand‐O TIER 03 PAVASOTEC TAB 2.5MG Brand‐O TIER 03 PAVASOTEC TAB 20MG Brand‐O TIER 03 PAVASOTEC TAB 5MG Brand‐O TIER 03 PAZESTORETIC TAB 10‐12.5 Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion17

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANGIOTENSIN‐CONVERTING ENZYME INHIBITORS ZESTORETIC TAB 20‐12.5 Brand‐O TIER 03 PAZESTORETIC TAB 20‐25MG Brand‐O TIER 03 PAZESTRIL TAB 10MG Brand‐O TIER 03 PAZESTRIL TAB 2.5MG Brand‐O TIER 03 PAZESTRIL TAB 20MG Brand‐O TIER 03 PAZESTRIL TAB 30MG Brand‐O TIER 03 PAZESTRIL TAB 40MG Brand‐O TIER 03 PAZESTRIL TAB 5MG Brand‐O TIER 03 PAANOREX.,RESPIR.,CEREBRAL STIMULANTS,MISC CAFCIT INJ 60MG/3ML Brand‐O TIER 03 PACAFCIT SOL 60MG/3ML Brand‐O TIER 03 PACAFFEINE CIT INJ 20MG/ML GENERIC TIER 01CAFFEINE CIT INJ 60MG/3ML GENERIC TIER 01CAFFEINE CIT SOL 20MG/ML GENERIC TIER 01CAFFEINE CIT SOL 60MG/3ML GENERIC TIER 01CAFFEINE/SOD INJ BENZOATE GENERIC TIER 01CONCERTA TAB 18MG BRAND TIER 03 PA QLCONCERTA TAB 27MG BRAND TIER 03 PA QLCONCERTA TAB 36MG BRAND TIER 03 PA QLCONCERTA TAB 54MG BRAND TIER 03 PA QLDAYTRANA DIS 10MG/9HR BRAND TIER 02 PA QLDAYTRANA DIS 15MG/9HR BRAND TIER 02 PA QLDAYTRANA DIS 20MG/9HR BRAND TIER 02 PA QLDAYTRANA DIS 30MG/9HR BRAND TIER 02 PA QLDEXMETHYLPH TAB 10MG GENERIC TIER 01 QLDEXMETHYLPH TAB 2.5MG GENERIC TIER 01 QLDEXMETHYLPH TAB 5MG GENERIC TIER 01 QLDIETHYLPROP TAB 25MG GENERIC TIER 99 DEDIETHYLPROP TAB 75MG ER GENERIC TIER 99 DEDOPRAM INJ 20MG/ML Brand‐O TIER 03 PA SPDOXAPRAM HCL INJ 20MG/ML GENERIC TIER 01 SPFOCALIN TAB 10MG Brand‐O TIER 03 PA QLFOCALIN TAB 2.5MG Brand‐O TIER 03 PA QLFOCALIN TAB 5MG Brand‐O TIER 03 PA QLFOCALIN XR CAP 10MG BRAND TIER 03 QLFOCALIN XR CAP 15MG BRAND TIER 03 QLFOCALIN XR CAP 20MG BRAND TIER 03 QLFOCALIN XR CAP 25MG BRAND TIER 03 QLFOCALIN XR CAP 30MG BRAND TIER 03 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion18

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANOREX.,RESPIR.,CEREBRAL STIMULANTS,MISC METHYLPHENID TAB 54MG ER GENERIC TIER 01 PA QLMETHYLPHENID TAB 5MG GENERIC TIER 01 QLMODAFINIL TAB 100MG GENERIC TIER 01 PA QLMODAFINIL TAB 200MG GENERIC TIER 01 PA QLNUVIGIL TAB 150MG BRAND TIER 03 PA QLNUVIGIL TAB 250MG BRAND TIER 03 PA QLNUVIGIL TAB 50MG BRAND TIER 03 PA QLPHENDIMETRAZ CAP 105MG ER GENERIC TIER 99 DEPHENDIMETRAZ TAB 35MG GENERIC TIER 99 DEPHENTERMINE CAP 15MG GENERIC TIER 99 DEPHENTERMINE CAP 30MG GENERIC TIER 99 DEPHENTERMINE CAP 37.5MG GENERIC TIER 99 DEPHENTERMINE TAB 37.5MG GENERIC TIER 99 DEPROVIGIL TAB 100MG Brand‐O TIER 03 PA QLPROVIGIL TAB 200MG Brand‐O TIER 03 PA QLQSYMIA CAP 11.25‐69 BRAND TIER 99 DEQSYMIA CAP 15‐92MG BRAND TIER 99 DEQSYMIA CAP 3.75‐23 BRAND TIER 99 DEQSYMIA CAP 7.5‐46MG BRAND TIER 99 DERITALIN TAB 10MG Brand‐O TIER 03 PA QLRITALIN TAB 20MG Brand‐O TIER 03 PA QLRITALIN TAB 20MG SR Brand‐O TIER 03 PA QLRITALIN TAB 5MG Brand‐O TIER 03 PA QLRITALIN LA CAP 10MG BRAND TIER 03 QLRITALIN LA CAP 20MG Brand‐O TIER 03 PA QLRITALIN LA CAP 30MG Brand‐O TIER 03 PA QLRITALIN LA CAP 40MG Brand‐O TIER 03 PA QLSENTRAMODAFI PAK AM‐100 BRAND TIER 03SUPRENZA TAB 15MG BRAND TIER 99 DESUPRENZA TAB 30MG BRAND TIER 99 DEADIPEX‐P CAP 37.5MG Brand‐O TIER 99 PA DEBONTRIL PDM TAB 35MG Brand‐O TIER 99 PA DEADIPEX‐P TAB 37.5MG Brand‐O TIER 99 PA DEBONTRIL SR CAP 105MG Brand‐O TIER 99 PA DEAMMONIA AROM INH GENERIC TIER 01ANTHELMINTICS ALBENZA TAB 200MG BRAND TIER 02BILTRICIDE TAB 600MG BRAND TIER 02MEBENDAZOLE CHW 100MG GENERIC TIER 01SKLICE LOT 0.5% BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion20

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTHELMINTICS STROMECTOL TAB 3MG BRAND TIER 02ANTIALLERGIC AGENTS ALAMAST DRO 0.1% BRAND TIER 03 PAALOCRIL SOL 2% BRAND TIER 03 PAALOMIDE SOL 0.1% OP BRAND TIER 03 PAASTELIN NASA SPR 137MCG Brand‐O TIER 02 PAASTEPRO SPR 0.15% BRAND TIER 02 PAAZELASTINE DRO 0.05% GENERIC TIER 01AZELASTINE SPR 0.1% GENERIC TIER 01 PABEPREVE DRO 1.5% BRAND TIER 03 PACROMOLYN SOD SOL 4% OP GENERIC TIER 01DYMISTA SPR 137‐50 BRAND TIER 03ELESTAT DRO 0.05% Brand‐O TIER 03 PAEMADINE SOL 0.05% OP BRAND TIER 03 PAEPINASTINE DRO 0.05% GENERIC TIER 01 PALASTACAFT SOL 0.25% BRAND TIER 03 PAOPTIVAR DRO 0.05% Brand‐O TIER 03 PAPATADAY SOL 0.2% BRAND TIER 02 PAPATANASE SPR 0.6% BRAND TIER 03 PAPATANOL SOL 0.1% OP BRAND TIER 02 PAANTIBACTERIALS (EENT) AK‐POLY‐BAC OIN OP GENERIC TIER 01ARESTIN MIS 1MG BRAND TIER 03AZASITE SOL 1% BRAND TIER 03 PABACIT/POLYMY OIN OP GENERIC TIER 01BACITRACIN OIN OP GENERIC TIER 01BESIVANCE SUS 0.6% BRAND TIER 02 PABLEPH‐10 SOL 10% OP Brand‐O TIER 03 PACETRAXAL SOL 0.2% BRAND TIER 03CILOXAN OIN 0.3% OP BRAND TIER 02 PACILOXAN SOL 0.3% OP Brand‐O TIER 03 PACIPROFLOXACN SOL 0.2% GENERIC TIER 01CIPROFLOXACN SOL 0.3% OP GENERIC TIER 01 PACRESYLATE SOL 25% OTIC BRAND TIER 03ERYTHROMYCIN OIN OP GENERIC TIER 01GARAMYCIN OIN 0.3% OP GENERIC TIER 01GARAMYCIN SOL 0.3% OP Brand‐O TIER 03 PAGENTAK OIN 0.3% OP GENERIC TIER 01GENTAK SOL 0.3% OP GENERIC TIER 01GENTAMICIN OIN 0.3% OP GENERIC TIER 01GENTAMICIN SOL 0.3% OP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion21

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIBACTERIALS (EENT) ILOTYCIN OIN OP GENERIC TIER 01IQUIX SOL 1.5% BRAND TIER 03 PALEVOFLOXACIN SOL 0.5% GENERIC TIER 01 PAMITOSOL KIT 0.2MG BRAND TIER 03MOXEZA SOL 0.5% BRAND TIER 02 PANEO/BAC/POLY OIN OP GENERIC TIER 01NEO/POLY/GRA SOL OP GENERIC TIER 01NEO‐POLYCIN OIN OP GENERIC TIER 01NEOSPORIN SOL OP Brand‐O TIER 03 PAOCUFLOX DRO 0.3% OP Brand‐O TIER 03 PAOFLOXACIN DRO 0.3% OP GENERIC TIER 01OFLOXACIN DRO 0.3%OTIC GENERIC TIER 01POLYCIN B OIN OP GENERIC TIER 01POLYMYXIN B/ SOL TRIMETHP GENERIC TIER 01POLYTRIM SOL OP Brand‐O TIER 03 PAQUIXIN SOL 0.5% Brand‐O TIER 03 PAROMYCIN OIN OP GENERIC TIER 01SOD SULFACET SOL 10% OP GENERIC TIER 01SULFACET SOD OIN 10% OP GENERIC TIER 01SULFACET SOD SOL 10% OP GENERIC TIER 01TOBRAMYCIN SOL 0.3% OP GENERIC TIER 01TOBRASOL SOL 0.3% OP GENERIC TIER 01TOBREX OIN 0.3% OP BRAND TIER 02TOBREX SOL 0.3% OP Brand‐O TIER 03 PATRIMETHOPRIM SOL POLYMYXN GENERIC TIER 01VIGAMOX DRO 0.5% BRAND TIER 02 PAZYMAXID SOL 0.5% BRAND TIER 02 PAANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) ACANYA GEL 1.2‐2.5% BRAND TIER 02 PAAKNE‐MYCIN OIN 2% BRAND TIER 03ALTABAX OIN 1% BRAND TIER 03 PABACTROBAN CRE 2% BRAND TIER 03 PABACTROBAN OIN 2% Brand‐O TIER 03 PABACTROBAN OIN NASAL 2% BRAND TIER 03BENZACLIN GEL 1‐5% Brand‐O TIER 03 PABENZACLIN GEL 1‐5%PUMP Brand‐O TIER 03 PABENZAMYCIN GEL Brand‐O TIER 03 PABENZAMYCIN GEL PAK BRAND TIER 03 PACENTANY OIN 2% GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion22

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) CENTANY AT KIT 2% BRAND TIER 03CLEOCIN CRE 2% VAG Brand‐O TIER 03 PACLEOCIN SUP 100MG BRAND TIER 03CLEOCIN‐T GEL 1% Brand‐O TIER 03 PACLEOCIN‐T LOT 1% Brand‐O TIER 03 PACLEOCIN‐T PAD 1% Brand‐O TIER 03 PACLEOCIN‐T SOL 1% Brand‐O TIER 03 PACLINDACIN KIT PAC 1% BRAND TIER 03CLINDACIN‐P PAD 1% GENERIC TIER 01CLINDAGEL GEL 1% BRAND TIER 03CLINDAMAX GEL 1% GENERIC TIER 01CLINDAMAX LOT 10MG/ML GENERIC TIER 01CLINDAMY/BEN GEL 1.2‐5% GENERIC TIER 01 PACLINDAMY/BEN GEL 1‐5% GENERIC TIER 01 PACLINDAMYCIN AER 1% GENERIC TIER 01 PACLINDAMYCIN CRE 2% VAG GENERIC TIER 01CLINDAMYCIN GEL 1% GENERIC TIER 01CLINDAMYCIN LOT 1% GENERIC TIER 01CLINDAMYCIN LOT 10MG/ML GENERIC TIER 01CLINDAMYCIN PAD 1% GENERIC TIER 01CLINDAMYCIN SOL 1% GENERIC TIER 01CLINDAREACH KIT 1% GENERIC TIER 01 PADUAC GEL 1.2‐5% Brand‐O TIER 02 PAERY PAD 2% GENERIC TIER 01ERYTHROMYCIN GEL /BENZOYL GENERIC TIER 01 PAERYTHROMYCIN GEL 2% GENERIC TIER 01ERYTHROMYCIN PAD 2% GENERIC TIER 01ERYTHROMYCIN SOL 2% GENERIC TIER 01EVOCLIN AER 1% Brand‐O TIER 03 PAGENTAMICIN CRE 0.1% GENERIC TIER 01GENTAMICIN OIN 0.1% GENERIC TIER 01KLARON LOT 10% Brand‐O TIER 03 PAMETROCREAM CRE 0.75% Brand‐O TIER 03 PAMETROGEL GEL 1% BRAND TIER 02METROGEL‐VAG GEL 0.75% Brand‐O TIER 03 PAMETROLOTION LOT 0.75% Brand‐O TIER 03 PAMETRONIDAZOL CRE 0.75% GENERIC TIER 01METRONIDAZOL GEL 0.75% GENERIC TIER 01METRONIDAZOL GEL 0.75%VAG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion23

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) METRONIDAZOL LOT 0.75% GENERIC TIER 01MEXAR WASH LIQ 10% GENERIC TIER 01MUPIROCIN OIN 2% GENERIC TIER 01 PANEO/POLY GU SOL 40/ML IR GENERIC TIER 01NEOSPORIN GU SOL 40/ML IR Brand‐O TIER 03 PANORITATE CRE 1% BRAND TIER 03OVACE PLUS CRE 10% BRAND TIER 02OVACE PLUS GEL 10% WASH BRAND TIER 03OVACE PLUS SHA 10% BRAND TIER 02OVACE WASH LIQ 10% Brand‐O TIER 03 PAROSADAN CRE 0.75% GENERIC TIER 01ROSADAN GEL 0.75% GENERIC TIER 01ROSADAN KIT 0.75% BRAND TIER 03SEB‐PREV LIQ WASH GENERIC TIER 01SEB‐PREV LOT 10% GENERIC TIER 01SOD SULFACET PAD 10% GENERIC TIER 01SODIUM SULFA LIQ 10% WASH GENERIC TIER 01SULFACETAMID LOT 10% GENERIC TIER 01SULFACETAMID SUS 10% GENERIC TIER 01VANDAZOLE GEL 0.75% GENERIC TIER 01VITAZOL CRE 0.75% GENERIC TIER 01ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE INJ 1MG/ML GENERIC TIER 01BENZTROPINE TAB 0.5MG GENERIC TIER 01BENZTROPINE TAB 2MG GENERIC TIER 01COGENTIN INJ 1MG/ML Brand‐O TIER 03 PATRIHEXYPHEN ELX 0.4MG/ML GENERIC TIER 01TRIHEXYPHEN TAB 2MG GENERIC TIER 01TRIHEXYPHEN TAB 5MG GENERIC TIER 01ANTICOAGULANTS, MISCELLANEOUS ACD FORMULA SOL A GENERIC TIER 01ACD FORMULA SOL B GENERIC TIER 01ACD‐A SOL BRAND TIER 03ANTICOAG CPD SOL BRAND TIER 03ANTICOAGULNT SOL SOD CITR GENERIC TIER 01ATRYN INJ 1750 BRAND TIER 03CEPROTIN INJ 1000UNIT BRAND TIER 03CEPROTIN INJ 500 UNIT BRAND TIER 03NOCLOT‐50 SOL ACD‐A GENERIC TIER 01THROMBAT III INJ 1000UNIT BRAND TIER 03THROMBAT III INJ 500UNIT BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion24

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTICOAGULANTS, MISCELLANEOUS TRICITRASOL CON BRAND TIER 03ANTICONVULSANTS, MISCELLANEOUS BANZEL SUS 40MG/ML BRAND TIER 03 QLBANZEL TAB 200MG BRAND TIER 02 QLBANZEL TAB 400MG BRAND TIER 02 QLCARBAMAZEPIN CAP 100MG ER GENERIC TIER 01CARBAMAZEPIN CAP 200MG ER GENERIC TIER 01CARBAMAZEPIN CAP 300MG ER GENERIC TIER 01CARBAMAZEPIN CHW 100MG GENERIC TIER 01CARBAMAZEPIN SUS 100/5ML GENERIC TIER 01CARBAMAZEPIN TAB 200MG GENERIC TIER 01CARBAMAZEPIN TAB 200MG ER GENERIC TIER 01CARBAMAZEPIN TAB 400MG ER GENERIC TIER 01CARBATROL CAP 100MG Brand‐O TIER 03 PACARBATROL CAP 200MG Brand‐O TIER 03 PACARBATROL CAP 300MG Brand‐O TIER 03 PADEPACON INJ 100MG/ML Brand‐O TIER 03 PADEPAKENE CAP 250MG Brand‐O TIER 03 PADEPAKENE SYP 250/5ML Brand‐O TIER 03 PADEPAKOTE TAB 125MG DR Brand‐O TIER 03 PADEPAKOTE TAB 250MG DR Brand‐O TIER 03 PADEPAKOTE TAB 500MG DR Brand‐O TIER 03 PADEPAKOTE ER TAB 250MG Brand‐O TIER 03 PADEPAKOTE ER TAB 500MG Brand‐O TIER 03 PADEPAKOTE SPR CAP 125MG Brand‐O TIER 03 PADIVALPROEX CAP 125MG GENERIC TIER 01DIVALPROEX TAB 125MG DR GENERIC TIER 01DIVALPROEX TAB 250MG DR GENERIC TIER 01DIVALPROEX TAB 250MG ER GENERIC TIER 01DIVALPROEX TAB 500MG DR GENERIC TIER 01DIVALPROEX TAB 500MG ER GENERIC TIER 01EPITOL TAB 200MG GENERIC TIER 01EQUETRO CAP 100MG BRAND TIER 03EQUETRO CAP 200MG BRAND TIER 03EQUETRO CAP 300MG BRAND TIER 03FELBAMATE SUS 600/5ML GENERIC TIER 01FELBAMATE TAB 400MG GENERIC TIER 01FELBAMATE TAB 600MG GENERIC TIER 01FELBATOL SUS 600/5ML Brand‐O TIER 03 PAFELBATOL TAB 400MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion25

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTICONVULSANTS, MISCELLANEOUS FELBATOL TAB 600MG Brand‐O TIER 03 PAGABAPENTIN CAP 100MG GENERIC TIER 01GABAPENTIN CAP 300MG GENERIC TIER 01GABAPENTIN CAP 400MG GENERIC TIER 01GABAPENTIN SOL 250/5ML GENERIC TIER 01GABAPENTIN TAB 600MG GENERIC TIER 01GABAPENTIN TAB 800MG GENERIC TIER 01GABITRIL TAB 12MG BRAND TIER 02GABITRIL TAB 16MG BRAND TIER 02GABITRIL TAB 2MG Brand‐O TIER 02 PAGABITRIL TAB 4MG Brand‐O TIER 02 PAHORIZANT TAB 600MG BRAND TIER 03 PA QLKEPPRA SOL 100MG/ML Brand‐O TIER 03 PAKEPPRA TAB 1000MG Brand‐O TIER 03 PAKEPPRA TAB 250MG Brand‐O TIER 03 PAKEPPRA TAB 500MG Brand‐O TIER 03 PAKEPPRA TAB 750MG Brand‐O TIER 03 PAKEPPRA XR TAB 500MG Brand‐O TIER 03 PA QLKEPPRA XR TAB 750MG Brand‐O TIER 03 PA QLLAMICTAL CHW 25MG Brand‐O TIER 03 PALAMICTAL CHW 2MG BRAND TIER 03LAMICTAL CHW 5MG Brand‐O TIER 03 PALAMICTAL KIT START 35 BRAND TIER 02 PALAMICTAL KIT START 49 BRAND TIER 02 PALAMICTAL KIT START 98 BRAND TIER 02 PALAMICTAL TAB 100MG Brand‐O TIER 03 PA QLLAMICTAL TAB 150MG Brand‐O TIER 03 PA QLLAMICTAL TAB 200MG Brand‐O TIER 03 PA QLLAMICTAL TAB 25MG Brand‐O TIER 03 PA QLLAMICTAL ODT TAB 100MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 200MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 25MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 50MG BRAND TIER 02 PA QLLAMICTAL XR TAB 100MG BRAND TIER 02 PA QLLAMICTAL XR TAB 200MG BRAND TIER 02 PA QLLAMICTAL XR TAB 250MG BRAND TIER 02 PALAMICTAL XR TAB 25MG BRAND TIER 02 PA QLLAMICTAL XR TAB 300MG BRAND TIER 02 PALAMICTAL XR TAB 50MG BRAND TIER 02 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion26

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE CHW 25MG GENERIC TIER 01LAMOTRIGINE CHW 5MG GENERIC TIER 01LAMOTRIGINE TAB 100MG GENERIC TIER 01 QLLAMOTRIGINE TAB 150MG GENERIC TIER 01 QLLAMOTRIGINE TAB 200MG GENERIC TIER 01 QLLAMOTRIGINE TAB 25MG GENERIC TIER 01 QLLEVETIRACETA INJ 10MG/ML GENERIC TIER 01LEVETIRACETA INJ 15MG/ML GENERIC TIER 01LEVETIRACETA INJ 5MG/ML GENERIC TIER 01LEVETIRACETA SOL 100MG/ML GENERIC TIER 01LEVETIRACETA SOL 500/5ML GENERIC TIER 01LEVETIRACETA TAB 1000MG GENERIC TIER 01LEVETIRACETA TAB 250MG GENERIC TIER 01LEVETIRACETA TAB 500MG GENERIC TIER 01LEVETIRACETA TAB 500MG ER GENERIC TIER 01 PA QLLEVETIRACETA TAB 750MG GENERIC TIER 01LEVETIRACETA TAB 750MG ER GENERIC TIER 01 PA QLLYRICA CAP 100MG BRAND TIER 02 PA QLLYRICA CAP 150MG BRAND TIER 02 PA QLLYRICA CAP 200MG BRAND TIER 02 PA QLLYRICA CAP 225MG BRAND TIER 02 PA QLLYRICA CAP 25MG BRAND TIER 02 PA QLLYRICA CAP 300MG BRAND TIER 02 PA QLLYRICA CAP 50MG BRAND TIER 02 PA QLLYRICA CAP 75MG BRAND TIER 02 PA QLLYRICA SOL 20MG/ML BRAND TIER 02 PAMAGNESIUM SU INJ 40MG/ML GENERIC TIER 01MAGNESIUM SU INJ 50% GENERIC TIER 01MAGNESIUM SU INJ 80MG/ML GENERIC TIER 01NEURONTIN CAP 100MG Brand‐O TIER 03 PANEURONTIN CAP 300MG Brand‐O TIER 03 PANEURONTIN CAP 400MG Brand‐O TIER 03 PANEURONTIN SOL 250/5ML Brand‐O TIER 03 PANEURONTIN TAB 600MG Brand‐O TIER 03 PANEURONTIN TAB 800MG Brand‐O TIER 03 PAOXCARBAZEPIN SUS 300MG/5M GENERIC TIER 01OXCARBAZEPIN TAB 150MG GENERIC TIER 01OXCARBAZEPIN TAB 300MG GENERIC TIER 01OXCARBAZEPIN TAB 600MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion27

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTICONVULSANTS, MISCELLANEOUS POTIGA TAB 200MG BRAND TIER 03POTIGA TAB 300MG BRAND TIER 03POTIGA TAB 400MG BRAND TIER 03POTIGA TAB 50MG BRAND TIER 03SABRIL POW 500MG BRAND TIER 03 PA QLSABRIL TAB 500MG BRAND TIER 03 PA QLSTAVZOR CAP 125MG BRAND TIER 03 PASTAVZOR CAP 250MG BRAND TIER 03 PASTAVZOR CAP 500MG BRAND TIER 03 PATEGRETOL CHW 100MG Brand‐O TIER 03 PATEGRETOL SUS 100/5ML Brand‐O TIER 03 PATEGRETOL TAB 200MG Brand‐O TIER 03 PATEGRETOL XR TAB 100MG BRAND TIER 02TEGRETOL XR TAB 200MG Brand‐O TIER 03 PATEGRETOL XR TAB 400MG Brand‐O TIER 03 PATHERAPENTIN PAK ‐60 BRAND TIER 03THERAPENTIN PAK ‐90 BRAND TIER 03TOPAMAX TAB 100MG Brand‐O TIER 03 PATOPAMAX TAB 200MG Brand‐O TIER 03 PATOPAMAX TAB 25MG Brand‐O TIER 03 PATOPAMAX TAB 50MG Brand‐O TIER 03 PATOPAMAX SPR CAP 15MG Brand‐O TIER 03 PATOPAMAX SPR CAP 25MG Brand‐O TIER 03 PATOPIRAGEN TAB 100MG GENERIC TIER 01TOPIRAGEN TAB 200MG GENERIC TIER 01TOPIRAGEN TAB 25MG GENERIC TIER 01TOPIRAGEN TAB 50MG GENERIC TIER 01TOPIRAMATE CAP 15MG GENERIC TIER 01TOPIRAMATE CAP 25MG GENERIC TIER 01TOPIRAMATE TAB 100MG GENERIC TIER 01TOPIRAMATE TAB 200MG GENERIC TIER 01TOPIRAMATE TAB 25MG GENERIC TIER 01TOPIRAMATE TAB 50MG GENERIC TIER 01TRILEPTAL SUS 300MG/5M Brand‐O TIER 02 PATRILEPTAL TAB 150MG Brand‐O TIER 03 PATRILEPTAL TAB 300MG Brand‐O TIER 03 PATRILEPTAL TAB 600MG Brand‐O TIER 03 PAVALPROATE INJ 100MG/ML GENERIC TIER 01VALPROATE INJ 500/5ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion28

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTICONVULSANTS, MISCELLANEOUS VALPROIC ACD CAP 250MG GENERIC TIER 01VALPROIC ACD SOL 250/5ML GENERIC TIER 01VALPROIC ACD SYP 250/5ML GENERIC TIER 01VIMPAT INJ 200MG/20 BRAND TIER 03 PAVIMPAT SOL 10MG/ML BRAND TIER 02 PA QLVIMPAT TAB 100MG BRAND TIER 02 PA QLVIMPAT TAB 150MG BRAND TIER 02 PA QLVIMPAT TAB 200MG BRAND TIER 02 PA QLVIMPAT TAB 50MG BRAND TIER 02 PA QLZONEGRAN CAP 100MG Brand‐O TIER 03 PAZONEGRAN CAP 25MG Brand‐O TIER 03 PAZONISAMIDE CAP 100MG GENERIC TIER 01ZONISAMIDE CAP 25MG GENERIC TIER 01ZONISAMIDE CAP 50MG GENERIC TIER 01TIAGABINE TAB 2MG GENERIC TIER 01TIAGABINE TAB 4MG GENERIC TIER 01KEPPRA INJ 500/5ML Brand‐O TIER 99 PA DELEVETIRACETM INJ 500/5ML GENERIC TIER 99 DEANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG BRAND TIER 03 PA QLAPLENZIN TAB 348MG BRAND TIER 03 PA QLAPLENZIN TAB 522MG BRAND TIER 03 PA QLAPPBUTAMONE PAK BRAND TIER 03APPBUTAMONE PAK ‐D BRAND TIER 03BUDEPRION TAB 100MG SR GENERIC TIER 01 QLBUDEPRION TAB 150MG SR GENERIC TIER 01 QLBUDEPRION XL TAB 150MG GENERIC TIER 01 QLBUDEPRION XL TAB 300MG GENERIC TIER 01 QLBUPROBAN TAB 150MG GENERIC TIER 01BUPROPION TAB 100MG GENERIC TIER 01 QLBUPROPION TAB 100MG ER GENERIC TIER 01 QLBUPROPION TAB 100MG SR GENERIC TIER 01 QLBUPROPION TAB 150MG GENERIC TIER 01BUPROPION TAB 150MG ER GENERIC TIER 01 QLBUPROPION TAB 150MG SR GENERIC TIER 01 QLBUPROPION TAB 200MG ER GENERIC TIER 01 QLBUPROPION TAB 200MG SR GENERIC TIER 01 QLBUPROPION TAB 75MG GENERIC TIER 01 QLBUPROPN HCL TAB 150MG XL GENERIC TIER 01 QLBUPROPN HCL TAB 300MG XL GENERIC TIER 01 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion29

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIDEPRESSANTS, MISCELLANEOUS FORFIVO XL TAB 450MG BRAND TIER 03MIRTAZAPINE TAB 15MG GENERIC TIER 01 QLMIRTAZAPINE TAB 15MG ODT GENERIC TIER 01 QLMIRTAZAPINE TAB 30MG GENERIC TIER 01 QLMIRTAZAPINE TAB 30MG ODT GENERIC TIER 01 QLMIRTAZAPINE TAB 45MG GENERIC TIER 01 QLMIRTAZAPINE TAB 45MG ODT GENERIC TIER 01 QLMIRTAZAPINE TAB 7.5MG GENERIC TIER 01 QLREMERON TAB 15MG Brand‐O TIER 03 PA QLREMERON TAB 30MG Brand‐O TIER 03 PA QLREMERON TAB 45MG Brand‐O TIER 03 PA QLREMERON SLTB TAB 15MG Brand‐O TIER 03 PA QLREMERON SLTB TAB 30MG Brand‐O TIER 03 PA QLREMERON SLTB TAB 45MG Brand‐O TIER 03 PA QLWELLBUTRIN TAB 100MG Brand‐O TIER 03 PA QLWELLBUTRIN TAB 100MG SR Brand‐O TIER 03 PA QLWELLBUTRIN TAB 150MG SR Brand‐O TIER 03 PA QLWELLBUTRIN TAB 200MG SR Brand‐O TIER 03 PA QLWELLBUTRIN TAB 75MG Brand‐O TIER 03 PA QLWELLBUTRIN TAB XL 150MG Brand‐O TIER 03 PA QLWELLBUTRIN TAB XL 300MG Brand‐O TIER 03 PA QLZYBAN TAB 150MG SR Brand‐O TIER 02 PAANTIDIABETIC AGENTS, MISCELLANEOUS CYCLOSET TAB 0.8MG BRAND TIER 03 PA QLKORLYM TAB 300MG BRAND TIER 03ANTIDIARRHEA AGENTS DIPHEN/ATROP LIQ 2.5/5 GENERIC TIER 01DIPHEN/ATROP TAB 2.5MG GENERIC TIER 01LOFENE TAB 2.5MG GENERIC TIER 01LOMOTIL TAB 2.5MG Brand‐O TIER 03 PALONOX TAB 2.5MG GENERIC TIER 01LOPERAMIDE CAP 2MG GENERIC TIER 01MOTOFEN TAB BRAND TIER 02OPIUM TIN 1% GENERIC TIER 01PAREGORIC TIN 2MG/5ML GENERIC TIER 01REZYST CHW 250MG BRAND TIER 03REZYST IM CHW BRAND TIER 03VSL#3 DS PAK BRAND TIER 03ANTIDOTES ACETADOTE INJ 200MG/ML BRAND TIER 03ACETYLCYST SOL 10% GENERIC TIER 99 DEACETYLCYST SOL 20% GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion30

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIDOTES ANTIZOL INJ 1GM/ML Brand‐O TIER 03 PACALC FOLINAT INJ 100/10ML GENERIC TIER 01 SPCALC FOLINAT INJ 300/30ML GENERIC TIER 01 SPCYANOKIT INJ 5GM BRAND TIER 03DUODOTE INJ BRAND TIER 03FOMEPIZOLE INJ 1.5GM GENERIC TIER 01FOMEPIZOLE INJ 1GM/ML GENERIC TIER 01FUSILEV INJ 50MG BRAND TIER 03 SPLEUCOVOR CA INJ 100MG GENERIC TIER 01 SPLEUCOVOR CA INJ 10MG/ML GENERIC TIER 01 SPLEUCOVOR CA INJ 200MG GENERIC TIER 01 SPLEUCOVOR CA INJ 350MG GENERIC TIER 01 SPLEUCOVOR CA INJ 50MG GENERIC TIER 01 SPLEUCOVOR CA TAB 10MG GENERIC TIER 01LEUCOVOR CA TAB 15MG GENERIC TIER 01LEUCOVOR CA TAB 25MG GENERIC TIER 01LEUCOVOR CA TAB 5MG GENERIC TIER 01LEUCOVORIN INJ CALCIUM GENERIC TIER 01 SPMETHYLENE BL INJ 1% GENERIC TIER 01PRALIDOXIME INJ 600/2ML GENERIC TIER 01PROTOPAM CHL INJ 1GM BRAND TIER 03VORAXAZE INJ 1000UNIT BRAND TIER 99 DEANTIEMETICS, MISCELLANEOUS CESAMET CAP 1MG BRAND TIER 03 PADRONABINOL CAP 10MG GENERIC TIER 01 PA QLDRONABINOL CAP 2.5MG GENERIC TIER 01 PA QLDRONABINOL CAP 5MG GENERIC TIER 01 PA QLEMEND CAP 125MG BRAND TIER 02 PA QLEMEND CAP 40MG BRAND TIER 02 PA QLEMEND CAP 80MG BRAND TIER 02 PA QLEMEND PAK 80 & 125 BRAND TIER 02 PA QLEMEND SOL 150MG BRAND TIER 03 PAMARINOL CAP 10MG Brand‐O TIER 03 PA QLMARINOL CAP 2.5MG Brand‐O TIER 03 PA QLMARINOL CAP 5MG Brand‐O TIER 03 PA QLSCOPACE TAB 0.4MG BRAND TIER 99 DETRANSDERM‐SC DIS 1.5MG BRAND TIER 02COCA COLA SYP BRAND TIER 03ANTIFULGALS(SKIN & MUCOUS MEMBRANE),MISC ALA QUIN CRE 3‐0.5% BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion31

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIFULGALS(SKIN & MUCOUS MEMBRANE),MISC ALOQUIN GEL 1.25‐1% BRAND TIER 03BENSAL HP OIN BRAND TIER 03EXODERM LOT 25‐1% GENERIC TIER 01HALOTIN CRE 1% BRAND TIER 03KERR TRIPLE MIS DYE SWAB BRAND TIER 03THIOSULFATE CRY SODIUM GENERIC TIER 99 DETRIPLE DYE LIQ GENERIC TIER 01VERSICLEAR LOT GENERIC TIER 01BENZOIC ACID CRY GENERIC TIER 99 DEANTIFUNGALS (EENT) NATACYN SUS 5% OP BRAND TIER 02ANTIFUNGALS, MISCELLANEOUS GRIFULVIN V TAB 500MG BRAND TIER 03GRISEOFULVIN SUS 125/5ML GENERIC TIER 01GRIS‐PEG TAB 125MG BRAND TIER 03GRIS‐PEG TAB 250MG BRAND TIER 03ANTIGOUT AGENTS ALLOPURINOL INJ 500MG GENERIC TIER 01ALLOPURINOL TAB 100MG GENERIC TIER 01ALLOPURINOL TAB 300MG GENERIC TIER 01ALOPRIM INJ 500MG Brand‐O TIER 03 PACOLCHICINE TAB 0.6MG GENERIC TIER 01COLCRYS TAB 0.6MG BRAND TIER 02KRYSTEXXA INJ 8MG/ML BRAND TIER 02 PA SPULORIC TAB 40MG BRAND TIER 02 PAULORIC TAB 80MG BRAND TIER 02 PAZYLOPRIM TAB 100MG Brand‐O TIER 03 PAZYLOPRIM TAB 300MG Brand‐O TIER 03 PAANTIHEPARIN AGENTS PROTAMINE SU SOL 10MG/ML GENERIC TIER 01ANTIHISTAMINE DRUGS PHENER FORT SYP 25MG/5ML BRAND TIER 03ANTIHISTAMINES (GI DRUGS) ANTIVERT TAB 12.5MG Brand‐O TIER 03 PAANTIVERT TAB 25MG Brand‐O TIER 03 PAANTIVERT TAB 50MG BRAND TIER 03DIMENHYDRIN INJ 50MG/ML GENERIC TIER 01TIGAN CAP 300MG Brand‐O TIER 03 PATIGAN INJ 100MG/ML Brand‐O TIER 03 PATRIMETHOBENZ CAP 300MG GENERIC TIER 01TRIMETHOBENZ INJ 100MG/ML GENERIC TIER 01UNIVERT TAB 32MG GENERIC TIER 01MECLIZINE TAB 12.5MG GENERIC TIER 01MECLIZINE TAB 25MG GENERIC TIER 01ANTI‐INFLAMMATORY AGENTS (GI DRUGS) APRISO CAP 0.375GM BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion32

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (GI DRUGS) ASACOL TAB 400MG DR BRAND TIER 02ASACOL HD TAB 800MG BRAND TIER 02BALSALAZIDE CAP 750MG GENERIC TIER 01CANASA SUP 1000MG BRAND TIER 02COLAZAL CAP 750MG Brand‐O TIER 03 PADIPENTUM CAP 250MG BRAND TIER 03LIALDA TAB 1.2GM BRAND TIER 03LOTRONEX TAB 0.5MG BRAND TIER 02LOTRONEX TAB 1MG BRAND TIER 02MESALAMINE ENE 4GM GENERIC TIER 01MESALAMINE KIT 4GM GENERIC TIER 99 DEPENTASA CAP 250MG CR BRAND TIER 02PENTASA CAP 500MG CR BRAND TIER 02SFROWASA ENE 4GM BRAND TIER 03ROWASA KIT 4GM Brand‐O TIER 99 PA DEANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) ACLOVATE CRE 0.05% Brand‐O TIER 03 PAALA SCALP LOT 2% Brand‐O TIER 03 PAALCLOMETASON CRE 0.05% GENERIC TIER 01ALCLOMETASON OIN 0.05% GENERIC TIER 01ALPHATREX GEL 0.05% GENERIC TIER 01AMCINONIDE CRE 0.1% GENERIC TIER 01AMCINONIDE LOT 0.1% GENERIC TIER 01AMCINONIDE OIN 0.1% GENERIC TIER 01ANUCORT‐HC SUP 25MG GENERIC TIER 99 DEANUSOL‐HC CRE 2.5% Brand‐O TIER 02 PAAPEXICON OIN 0.05% GENERIC TIER 01APEXICON E CRE 0.05% GENERIC TIER 01AQUA GLYC HC KIT SCLP/BDY BRAND TIER 03AUG BETAMET CRE 0.05% GENERIC TIER 01AUG BETAMET GEL 0.05% GENERIC TIER 01AUG BETAMET LOT 0.05% GENERIC TIER 01AUG BETAMET OIN 0.05% GENERIC TIER 01BETAMETH DIP CRE 0.05% GENERIC TIER 01BETAMETH DIP LOT 0.05% GENERIC TIER 01BETAMETH DIP OIN 0.05% GENERIC TIER 01BETAMETH VAL CRE 0.1% GENERIC TIER 01BETAMETH VAL LOT 0.1% GENERIC TIER 01BETAMETH VAL OIN 0.1% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion33

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) CAPEX SHA 0.01% BRAND TIER 02 PACARMOL‐HC CRE 1% Brand‐O TIER 03 PACLOBETA KIT CREAM BRAND TIER 03CLOBETA KIT OINTMENT BRAND TIER 03CLOBETASOL AER 0.05% GENERIC TIER 01CLOBETASOL CRE 0.05% GENERIC TIER 01CLOBETASOL GEL 0.05% GENERIC TIER 01CLOBETASOL LOT 0.05% GENERIC TIER 01 PACLOBETASOL OIN 0.05% GENERIC TIER 01CLOBETASOL SHA 0.05% GENERIC TIER 01 PACLOBETASOL SOL 0.05% GENERIC TIER 01CLOBETASOL E CRE 0.05% GENERIC TIER 01CLOBEX LOT 0.05% Brand‐O TIER 02 PACLOBEX SHA 0.05% Brand‐O TIER 02 PACLOBEX SPR 0.05% BRAND TIER 02 PACLODERM CRE 0.1% BRAND TIER 03CLODERM CRE 0.1% PMP BRAND TIER 03COLOCORT ENE 100MG GENERIC TIER 01CORDRAN LOT 0.05% BRAND TIER 03CORDRAN 24X3 TAP 4MCG/CM BRAND TIER 02CORDRAN 80X3 TAP 4MCG/CM BRAND TIER 02CORDRAN SP CRE 0.05% BRAND TIER 03CORMAX OIN 0.05% GENERIC TIER 01CORMAX SOL 0.05% GENERIC TIER 01CORMAX SCALP SOL 0.05% GENERIC TIER 01CORTALO GEL 2% GENERIC TIER 01CORTANE‐B LOT BRAND TIER 99 DECORTENEMA ENE 100MG Brand‐O TIER 03 PACORTIFOAM AER 90MG BRAND TIER 02CORTISPORIN CRE 0.5% BRAND TIER 03CORTISPORIN OIN 1% BRAND TIER 03CUTIVATE CRE 0.05% Brand‐O TIER 03 PACUTIVATE LOT 0.05% Brand‐O TIER 03 PACUTIVATE OIN 0.005% Brand‐O TIER 03 PADERMA‐SMOOTH OIL /FS BODY Brand‐O TIER 03 PADERMA‐SMOOTH OIL /FS SCLP Brand‐O TIER 03 PADERMATOP CRE 0.1% Brand‐O TIER 03 PADERMATOP OIN 0.1% Brand‐O TIER 03 PADESONATE GEL 0.05% BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion34

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) DESONIDE CRE 0.05% GENERIC TIER 01DESONIDE LOT 0.05% GENERIC TIER 01DESONIDE OIN 0.05% GENERIC TIER 01DESONIL KIT 0.05% BRAND TIER 03DESONIL PLUS KIT CREAM BRAND TIER 03DESONIL PLUS KIT OINTMENT BRAND TIER 03DESOWEN CRE 0.05% Brand‐O TIER 03 PADESOWEN LOT 0.05% Brand‐O TIER 03 PADESOWEN OIN 0.05% Brand‐O TIER 03 PADESOWEN CRM KIT 0.05% BRAND TIER 03DESOWEN LOT KIT 0.05% BRAND TIER 99 DEDESOWEN OINT KIT 0.05% BRAND TIER 03DESOXIMETAS CRE 0.05% GENERIC TIER 01DESOXIMETAS CRE 0.25% GENERIC TIER 01DESOXIMETAS GEL 0.05% GENERIC TIER 01DESOXIMETAS OIN 0.05% GENERIC TIER 01DESOXIMETAS OIN 0.25% GENERIC TIER 01DIFLORASONE CRE 0.05% GENERIC TIER 01DIFLORASONE OIN 0.05% GENERIC TIER 01DIPROLENE LOT 0.05% Brand‐O TIER 03 PADIPROLENE OIN 0.05% Brand‐O TIER 03 PADIPROLENE AF CRE 0.05% Brand‐O TIER 03 PAELOCON CRE 0.1% Brand‐O TIER 03 PAELOCON LOT 0.1% Brand‐O TIER 03 PAELOCON OIN 0.1% Brand‐O TIER 03 PAEPIFOAM AER 1% BRAND TIER 03FLUOCIN ACET CRE 0.01% GENERIC TIER 01 PAFLUOCIN ACET CRE 0.025% GENERIC TIER 01 PAFLUOCIN ACET OIL BODY GENERIC TIER 01 PAFLUOCIN ACET OIL SCALP GENERIC TIER 01 PAFLUOCIN ACET OIN 0.025% GENERIC TIER 01 PAFLUOCIN ACET SOL 0.01% GENERIC TIER 01 PAFLUOCINONIDE CRE 0.05% GENERIC TIER 01FLUOCINONIDE CRE ‐E 0.05% GENERIC TIER 01FLUOCINONIDE GEL 0.05% GENERIC TIER 01FLUOCINONIDE OIN 0.05% GENERIC TIER 01FLUOCINONIDE SOL 0.05% GENERIC TIER 01FLUTICASONE CRE 0.05% GENERIC TIER 01 PAFLUTICASONE LOT 0.05% GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion35

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) FLUTICASONE OIN 0.005% GENERIC TIER 01 PAFRST‐HYDRCRT GEL 10% BRAND TIER 03HALAC KIT GENERIC TIER 01HALOBETASOL CRE 0.05% GENERIC TIER 01HALOBETASOL OIN 0.05% GENERIC TIER 01HALOG CRE 0.1% BRAND TIER 02HALOG OIN 0.1% BRAND TIER 02HALONATE KIT BRAND TIER 03HALONATE PAC KIT GENERIC TIER 01HC AC/ALOE GEL 2% GENERIC TIER 01HC BUTYRATE CRE 0.1% GENERIC TIER 01HC BUTYRATE OIN 0.1% GENERIC TIER 01HC BUTYRATE SOL 0.1% GENERIC TIER 01HC PRAMOXINE CRE 1‐2.5% GENERIC TIER 99 DEHC VALERATE CRE 0.2% GENERIC TIER 01HC VALERATE OIN 0.2% GENERIC TIER 01HEMRIL‐30 SUP 30MG GENERIC TIER 99 DEHYDROCORT CRE 2.5% GENERIC TIER 01HYDROCORT ENE 100MG GENERIC TIER 01HYDROCORT LOT 2.5% GENERIC TIER 01HYDROCORT OIN 2.5% GENERIC TIER 01HYDROCORT AC SUP 25MG GENERIC TIER 99 DEHYDROCORT AC SUP 30MG GENERIC TIER 99 DEKENALOG AER SPRAY BRAND TIER 02LIDAMANTLE CRE HC3‐0.5% Brand‐O TIER 03 PALOCOID CRE 0.1% Brand‐O TIER 03 PALOCOID LOT 0.1% BRAND TIER 02LOCOID OIN 0.1% Brand‐O TIER 03 PALOCOID SOL 0.1% Brand‐O TIER 03 PALOCOID LIPO CRE 0.1% BRAND TIER 02LOKARA LOT 0.05% GENERIC TIER 01LUXIQ AER 0.12% BRAND TIER 03MOMETASONE CRE 0.1% GENERIC TIER 01MOMETASONE OIN 0.1% GENERIC TIER 01MOMETASONE SOL 0.1% GENERIC TIER 01MOMEXIN KIT BRAND TIER 99 DENAPRO CRE 15% BRAND TIER 03NAPRODERM CRE 15% BRAND TIER 03NOVACORT GEL BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion36

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) NUCORT LOT 2% BRAND TIER 03NUZON GEL 2% Brand‐O TIER 03 PANYSTAT/TRIAM CRE GENERIC TIER 01NYSTAT/TRIAM OIN GENERIC TIER 01OLUX AER 0.05% Brand‐O TIER 03 PAOLUX‐E AER 0.05% BRAND TIER 03ORALONE PST 0.1% GENERIC TIER 01PANDEL CRE 0.1% BRAND TIER 03PEDIADERM HC KIT BRAND TIER 03PEDIADERM TA KIT BRAND TIER 03PRAMCORT CRE 1‐1% GENERIC TIER 01PRAMOSONE CRE 1% Brand‐O TIER 02 PAPRAMOSONE LOT 1% BRAND TIER 02PRAMOSONE LOT 2.5% BRAND TIER 02PRAMOSONE OIN 1% BRAND TIER 99 DEPRAMOSONE OIN 2.5% BRAND TIER 99 DEPRAMOSONE E CRE 1‐2.5% BRAND TIER 99 DEPREDNICARBAT CRE 0.1% GENERIC TIER 01 PAPREDNICARBAT OIN 0.1% GENERIC TIER 01 PAPROCTOCORT CRE 1% Brand‐O TIER 03 PAPROCTOCREAM CRE HC 2.5% GENERIC TIER 01PROCTO‐PAK CRE 1% GENERIC TIER 01PROCTOSOL HC CRE 2.5% GENERIC TIER 01PROCTOZONE CRE ‐HC 2.5% GENERIC TIER 01RECTACORT‐HC SUP 25MG GENERIC TIER 99 DESCALACORT LOT 2% GENERIC TIER 01SCALACORT DK KIT BRAND TIER 03SYNALAR SOL 0.01% Brand‐O TIER 03 PASYNALAR TS KIT 0.01% BRAND TIER 03TACLONEX OIN BRAND TIER 03TACLONEX SUS SCALP BRAND TIER 03TEMOVATE CRE 0.05% Brand‐O TIER 03 PATEMOVATE GEL 0.05% Brand‐O TIER 03 PATEMOVATE OIN 0.05% Brand‐O TIER 03 PATEMOVATE SOL 0.05% Brand‐O TIER 03 PATEMOVATE E CRE 0.05%EML Brand‐O TIER 03 PATEXACORT SOL 2.5% BRAND TIER 03TOPICORT CRE 0.05% BRAND TIER 03TOPICORT CRE 0.25% Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion37

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) TOPICORT GEL 0.05% Brand‐O TIER 03 PATOPICORT OIN 0.05% BRAND TIER 03TOPICORT OIN 0.25% Brand‐O TIER 03 PATRIAMCIN/ORA PST 0.1% GENERIC TIER 01TRIAMCINOLON CRE 0.025% GENERIC TIER 01TRIAMCINOLON CRE 0.1% GENERIC TIER 01TRIAMCINOLON CRE 0.5% GENERIC TIER 01TRIAMCINOLON LOT 0.025% GENERIC TIER 01TRIAMCINOLON LOT 0.1% GENERIC TIER 01TRIAMCINOLON OIN 0.025% GENERIC TIER 01TRIAMCINOLON OIN 0.05% GENERIC TIER 01TRIAMCINOLON OIN 0.1% GENERIC TIER 01TRIAMCINOLON OIN 0.5% GENERIC TIER 01TRIAMCINOLON PST 0.1% GENERIC TIER 01TRIANEX OIN 0.05% GENERIC TIER 01TRIDERM CRE 0.1% GENERIC TIER 01U‐CORT CRE 1% GENERIC TIER 01ULTRAVATE CRE 0.05% Brand‐O TIER 03 PAULTRAVATE KIT Brand‐O TIER 03 PAULTRAVATE KIT PAC BRAND TIER 99 DEULTRAVATE OIN 0.05% Brand‐O TIER 03 PAULTRAVATE X KIT 0.05‐10% BRAND TIER 03VANOS CRE 0.1% BRAND TIER 03VANOXIDE HC KIT BRAND TIER 03VANOXIDE‐HC LOT 5‐0.5% BRAND TIER 03VERDESO AER 0.05% BRAND TIER 03WESTCORT OIN 0.2% Brand‐O TIER 03 PAHYDROCORT CRE 1% GENERIC TIER 99 DEALA CORT CRE 1% GENERIC TIER 99 DEPRAMOSONE CRE 1‐2.5% Brand‐O TIER 99 PA DEHYDROCORT OIN 1% GENERIC TIER 99 DEHYDROCORT/AB OIN 1% GENERIC TIER 99 DEANUSOL‐HC SUP 25MG Brand‐O TIER 99 PA DEPROCTOCORT SUP 30MG Brand‐O TIER 99 PA DEANTILIPEMIC AGENTS, MISCELLANEOUS LOVAZA CAP 1GM BRAND TIER 02 PANIASPAN TAB 1000 ER BRAND TIER 02NIASPAN TAB 500MG ER BRAND TIER 02NIASPAN TAB 750MG ER BRAND TIER 02VASCAZEN CAP 1GM BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion38

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIMALARIALS ARALEN TAB 500MG Brand‐O TIER 03 PA QLATOVAQ/PROGU TAB 250‐100 GENERIC TIER 01ATOVAQ/PROGU TAB 62.5‐25 GENERIC TIER 01CHLOROQUINE TAB 250MG GENERIC TIER 01 QLCHLOROQUINE TAB 500MG GENERIC TIER 01 QLCOARTEM TAB 20‐120MG BRAND TIER 02DARAPRIM TAB 25MG BRAND TIER 02HYDROXYCHLOR TAB 200MG GENERIC TIER 01MALARONE TAB 250‐100 Brand‐O TIER 03 PAMALARONE TAB 62.5‐25 BRAND TIER 03MEFLOQUINE TAB 250MG GENERIC TIER 01PLAQUENIL TAB 200MG Brand‐O TIER 03 PAPRIMAQUINE TAB 26.3MG GENERIC TIER 01QUALAQUIN CAP 324MG GENERIC TIER 01QUININE SULF CAP 324MG GENERIC TIER 01ANTIMANIC AGENTS LITHIUM CARB CAP 150MG GENERIC TIER 01LITHIUM CARB CAP 300MG GENERIC TIER 01LITHIUM CARB CAP 600MG GENERIC TIER 01LITHIUM CARB TAB 300MG GENERIC TIER 01LITHIUM CARB TAB 300MG ER GENERIC TIER 01LITHIUM CARB TAB 450MG ER GENERIC TIER 01LITHIUM CITR SOL 8MEQ/5ML GENERIC TIER 01LITHOBID TAB 300MG CR Brand‐O TIER 03 PAANTIMIGRAINE AGENTS, MISCELLANEOUS CAFERGOT TAB 1‐100MG BRAND TIER 02EPIDRIN CAP GENERIC TIER 99 DEERGOTAM/CAFF TAB 1/100 GENERIC TIER 01ISOMETH/APAP CAP DICHLOR GENERIC TIER 99 DEISOMETH/CAFF TAB /APAP GENERIC TIER 99 DEMIGERGOT SUP 2/100 BRAND TIER 03MIGRAGESIC CAP IDA GENERIC TIER 99 DEMIGRAL TAB 130MG BRAND TIER 03MIGRALAM CAP GENERIC TIER 99 DENODOLOR CAP GENERIC TIER 99 DEPRODRIN TAB Brand‐O TIER 99 PA DEANTIMUSCARINICS/ANTISPASMODICS ANASPAZ TAB 0.125MG Brand‐O TIER 03 PAATROPEN INJ 0.25MG BRAND TIER 03ATROPEN INJ 0.5MG BRAND TIER 03ATROPEN INJ 1MG BRAND TIER 03ATROPEN INJ 2MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion39

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIMUSCARINICS/ANTISPASMODICS ATROPINE SUL INJ 0.05MG/1 GENERIC TIER 01ATROPINE SUL INJ 0.1MG/ML GENERIC TIER 01ATROPINE SUL INJ 0.4/0.5 GENERIC TIER 01ATROPINE SUL INJ 0.4MG/ML GENERIC TIER 01ATROPINE SUL INJ 1MG/ML GENERIC TIER 01ATROVENT HFA AER 17MCG BRAND TIER 02 QLATROVENT NAS SOL 0.03% Brand‐O TIER 03 PAATROVENT NAS SOL 0.06% Brand‐O TIER 03 PABELLA ALK/PB TAB 16.2MG GENERIC TIER 99 DEBELLA/OPIUM SUP 16.2‐30 GENERIC TIER 01BELLA/OPIUM SUP 16.2‐60 GENERIC TIER 01BELLADONNA TIN 30/100ML GENERIC TIER 01BENTYL CAP 10MG Brand‐O TIER 03 PABENTYL INJ 10MG/ML BRAND TIER 03BENTYL SYP 10MG/5ML Brand‐O TIER 03 PABENTYL TAB 20MG Brand‐O TIER 03 PACANTIL TAB 25MG BRAND TIER 03CHLORD/CLIDI CAP 5‐2.5MG GENERIC TIER 99 DECOLIDROPS DRO 0.125/ML GENERIC TIER 01CUVPOSA SOL 1MG/5ML BRAND TIER 03DICYCLOMINE CAP 10MG GENERIC TIER 01DICYCLOMINE SOL 10MG/5ML GENERIC TIER 01DICYCLOMINE TAB 20MG GENERIC TIER 01DIGEX NF CAP Brand‐O TIER 03 PADONNATAL TAB EXTENTAB BRAND TIER 99 DEED‐SPAZ TAB 0.125MG GENERIC TIER 01GASTRINEX NF CAP GENERIC TIER 01GLYCOPYRROL INJ 0.2MG/ML GENERIC TIER 01GLYCOPYRROL TAB 1MG GENERIC TIER 01GLYCOPYRROL TAB 2MG GENERIC TIER 01HYOMAX TAB 0.125MG GENERIC TIER 01HYOMAX‐DT TAB GENERIC TIER 01HYOMAX‐FT TAB 0.125MG GENERIC TIER 01HYOMAX‐SL SUB 0.125MG GENERIC TIER 01HYOMAX‐SR TAB 0.375MG GENERIC TIER 01HYOSCYAMINE DRO 0.125/ML GENERIC TIER 01HYOSCYAMINE ELX 0.125/5 GENERIC TIER 01HYOSCYAMINE SUB 0.125MG GENERIC TIER 01HYOSCYAMINE TAB 0.125MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion40

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE TAB 0.375 ER GENERIC TIER 01HYOSCYAMINE TAB 0.375 SR GENERIC TIER 01HYOSYNE DRO 0.125/ML GENERIC TIER 01HYOSYNE ELX 0.125/5 GENERIC TIER 01IPRATROPIUM SOL 0.02%INH GENERIC TIER 01IPRATROPIUM SPR 0.03% GENERIC TIER 01IPRATROPIUM SPR 0.06% GENERIC TIER 01LEVBID TAB 0.375 ER Brand‐O TIER 02 PALEVSIN INJ 0.5MG/ML BRAND TIER 03LEVSIN TAB 0.125MG Brand‐O TIER 03 PALEVSIN/SL SUB 0.125MG Brand‐O TIER 03 PAMETHSCOPOLAM TAB 2.5MG GENERIC TIER 01METHSCOPOLAM TAB 5MG GENERIC TIER 01NULEV TAB 0.125MG GENERIC TIER 01OSCIMIN SUB 0.125MG GENERIC TIER 01OSCIMIN TAB 0.125MG GENERIC TIER 01OSCIMIN SR TAB 0.375MG GENERIC TIER 01PAMINE TAB 2.5MG Brand‐O TIER 03 PAPAMINE FORTE TAB 5MG Brand‐O TIER 03 PAPAMINE FQ KIT BRAND TIER 03PROPANTHELIN TAB 15MG GENERIC TIER 01QUADRAPAX ELX GENERIC TIER 99 DEROBINUL INJ 0.2MG/ML Brand‐O TIER 03 PAROBINUL TAB 1MG Brand‐O TIER 03 PAROBINUL FORT TAB 2MG Brand‐O TIER 03 PASAL‐TROPINE TAB 0.4MG BRAND TIER 99 DESCOPOLAMINE INJ 0.4MG/ML GENERIC TIER 01SE‐DONNA ELX PB HYOS GENERIC TIER 99 DESIMETYL ELX BRAND TIER 03SPIRIVA CAP HANDIHLR BRAND TIER 02 QLSYMAX DUOTAB TAB Brand‐O TIER 03 PASYMAX FASTAB TAB 0.125MG GENERIC TIER 01SYMAX‐SL SUB 0.125MG GENERIC TIER 01SYMAX‐SR TAB 0.375MG GENERIC TIER 01TUDORZA PRES AER 400/ACT BRAND TIER 03LIBRAX CAP 5‐2.5MG Brand‐O TIER 99 PA DEDONNATAL TAB Brand‐O TIER 99 PA DEDONNATAL ELX Brand‐O TIER 99 PA DEANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 100MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion41

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 25MG GENERIC TIER 01ANTINEOPLASTIC AGENTS ABRAXANE INJ 100MG BRAND TIER 03 SPADCETRIS INJ 50MG BRAND TIER 02ADRIAMYC INJ 50MG GENERIC TIER 01 SPADRIAMYCIN INJ 10MG GENERIC TIER 01 SPADRIAMYCIN INJ 20MG GENERIC TIER 01 SPADRIAMYCIN INJ 2MG/ML GENERIC TIER 01 SPADRUCIL INJ 50MG/ML GENERIC TIER 01 SPAFINITOR TAB 10MG BRAND TIER 02 QL SPAFINITOR TAB 2.5MG BRAND TIER 02 QL SPAFINITOR TAB 5MG BRAND TIER 02 QL SPAFINITOR TAB 7.5MG BRAND TIER 02 QLALFERON N INJ 5MU/ML BRAND TIER 03 SPALIMTA INJ 100MG BRAND TIER 03 SPALIMTA INJ 500MG BRAND TIER 03 SPALKERAN INJ 50MG Brand‐O TIER 03 PA SPALKERAN TAB 2MG BRAND TIER 02ANASTROZOLE TAB 1MG GENERIC TIER 01ARIMIDEX TAB 1MG Brand‐O TIER 03 PAAROMASIN TAB 25MG Brand‐O TIER 03 PAARRANON INJ 5MG/ML BRAND TIER 03 SPARZERRA CON 100/50ML BRAND TIER 03 SPARZERRA CON 100/5ML BRAND TIER 02 SPAVASTIN INJ BRAND TIER 02 SPBEXXAR CON 14MG/ML BRAND TIER 03 SPBEXXAR 131 I INJ 0.61/ML BRAND TIER 03BEXXAR 131 I INJ 5.6MCI/M BRAND TIER 03BICALUTAMIDE TAB 50MG GENERIC TIER 01BICNU INJ 100MG BRAND TIER 03 SPBLEOMYCIN INJ 15UNIT GENERIC TIER 01 SPBLEOMYCIN INJ 30UNIT GENERIC TIER 01 SPBOSULIF TAB 100MG BRAND TIER 03BOSULIF TAB 500MG BRAND TIER 03BUSULFEX INJ 6MG/ML BRAND TIER 03 SPCAMPATH INJ 30MG/ML BRAND TIER 03 SPCAMPTOSAR INJ 100/5ML Brand‐O TIER 03 PA SPCAMPTOSAR INJ 300/15ML BRAND TIER 03 SPCAMPTOSAR INJ 40MG/2ML Brand‐O TIER 03 PA SPCAPRELSA TAB 100MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion42

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS CAPRELSA TAB 300MG BRAND TIER 02CARBOPLATIN INJ 150/15ML GENERIC TIER 01 SPCARBOPLATIN INJ 150MG GENERIC TIER 01 SPCARBOPLATIN INJ 450/45ML GENERIC TIER 01 SPCARBOPLATIN INJ 50MG/5ML GENERIC TIER 01 SPCARBOPLATIN INJ 600/60ML GENERIC TIER 01 SPCASODEX TAB 50MG Brand‐O TIER 03 PACEENU CAP 100MG BRAND TIER 02CEENU CAP 10MG BRAND TIER 02CEENU CAP 40MG BRAND TIER 02CERUBIDINE INJ 20MG Brand‐O TIER 03 PA SPCISPLATIN INJ 100MG GENERIC TIER 01 SPCISPLATIN INJ 1MG/ML GENERIC TIER 01 SPCISPLATIN INJ 200MG GENERIC TIER 01 SPCISPLATIN INJ 50/50ML GENERIC TIER 01 SPCISPLATIN INJ 50MG GENERIC TIER 01 SPCLADRIBINE INJ 1MG/ML GENERIC TIER 01 SPCLOLAR INJ 1MG/ML BRAND TIER 03 SPCOSMEGEN INJ 0.5MG Brand‐O TIER 03 PA SPCYCLOPHOSPH INJ 1GM GENERIC TIER 01 SPCYCLOPHOSPH INJ 2GM GENERIC TIER 01 SPCYCLOPHOSPH INJ 500MG GENERIC TIER 01 SPCYCLOPHOSPH TAB 25MG GENERIC TIER 01CYCLOPHOSPH TAB 50MG GENERIC TIER 01CYTARABINE INJ 100MG GENERIC TIER 01 SPCYTARABINE INJ 100MG/ML GENERIC TIER 01 SPCYTARABINE INJ 1GM GENERIC TIER 01 SPCYTARABINE INJ 20MG/ML GENERIC TIER 01 SPCYTARABINE INJ 500MG GENERIC TIER 01 SPDACARBAZINE INJ 100MG GENERIC TIER 01 SPDACARBAZINE INJ 200MG GENERIC TIER 01 SPDACOGEN INJ 50MG BRAND TIER 03 SPDACTINOMYCIN INJ 0.5MG GENERIC TIER 01 SPDAUNORUBICIN INJ 20MG GENERIC TIER 01 SPDAUNORUBICIN INJ 5MG/ML GENERIC TIER 01 SPDAUNOXOME INJ 2MG/ML BRAND TIER 03 SPDEPOCYT INJ 50MG/5ML BRAND TIER 03 SPDOCEFREZ INJ 20MG BRAND TIER 03 SPDOCEFREZ INJ 80MG BRAND TIER 03 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion43

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS DOCETAXEL INJ 160/16ML GENERIC TIER 01 SPDOCETAXEL INJ 160/8ML GENERIC TIER 01 SPDOCETAXEL INJ 20/0.5ML GENERIC TIER 01 SPDOCETAXEL INJ 20MG/2ML GENERIC TIER 01 SPDOCETAXEL INJ 20MG/ML GENERIC TIER 01 SPDOCETAXEL INJ 80MG/2ML GENERIC TIER 01 SPDOCETAXEL INJ 80MG/4ML GENERIC TIER 01 SPDOCETAXEL INJ 80MG/8ML GENERIC TIER 01 SPDOXIL INJ 2MG/ML Brand‐O TIER 03 PA SPDOXORUBICIN INJ 10MG GENERIC TIER 01 SPDOXORUBICIN INJ 200MG GENERIC TIER 01 SPDOXORUBICIN INJ 2MG/ML GENERIC TIER 01 SPDOXORUBICIN INJ 50MG GENERIC TIER 01 SPDROXIA CAP 200MG BRAND TIER 02DROXIA CAP 300MG BRAND TIER 02DROXIA CAP 400MG BRAND TIER 02ELIGARD INJ 22.5MG BRAND TIER 03 SPELIGARD INJ 30MG BRAND TIER 03 PA SPELIGARD INJ 45MG BRAND TIER 03 PA SPELIGARD INJ 7.5MG BRAND TIER 03 PA SPELLENCE INJ 2MG/ML Brand‐O TIER 03 PA SPELOXATIN INJ 100MG Brand‐O TIER 03 PA SPELOXATIN INJ 200MG BRAND TIER 03 SPELOXATIN INJ 50MG Brand‐O TIER 03 PA SPELSPAR INJ 10000UNT BRAND TIER 03 SPEMCYT CAP 140MG BRAND TIER 02EPIRUBICIN INJ 200MG GENERIC TIER 01 SPEPIRUBICIN INJ 50/25ML GENERIC TIER 01 SPEPIRUBICIN INJ 50MG GENERIC TIER 01 SPERBITUX INJ 100MG BRAND TIER 02 SPERBITUX INJ 200MG BRAND TIER 02 SPERIVEDGE CAP 150MG BRAND TIER 02ERWINAZE INJ 10000UNT BRAND TIER 03ETOPOPHOS INJ 100MG BRAND TIER 03 SPETOPOSIDE CAP 50MG GENERIC TIER 01 SPETOPOSIDE INJ 20MG/ML GENERIC TIER 01 SPEXEMESTANE TAB 25MG GENERIC TIER 01FARESTON TAB 60MG BRAND TIER 03FASLODEX INJ 250MG BRAND TIER 03 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion44

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS FEMARA TAB 2.5MG Brand‐O TIER 03 PAFIRMAGON INJ 120MG BRAND TIER 02FIRMAGON INJ 120MG GENERIC TIER 01 PA SPFIRMAGON INJ 80MG BRAND TIER 02FIRMAGON INJ 80MG GENERIC TIER 01 PA SPFLOXURIDINE INJ 0.5GM GENERIC TIER 01 SPFLUDARA INJ 50MG Brand‐O TIER 03 PA SPFLUDARABINE INJ 50MG GENERIC TIER 01 SPFLUDARABINE INJ 50MG/2ML GENERIC TIER 01 SPFLUOROURACIL INJ 1GM/20ML GENERIC TIER 01 SPFLUOROURACIL INJ 2.5G/50M GENERIC TIER 01 SPFLUOROURACIL INJ 500MG/10 GENERIC TIER 01 SPFLUOROURACIL INJ 50MG/ML GENERIC TIER 01 SPFLUOROURACIL INJ 5GM/100M GENERIC TIER 01 SPFLUTAMIDE CAP 125MG GENERIC TIER 01FOLOTYN INJ 20MG/ML BRAND TIER 02FOLOTYN INJ 40MG/2ML BRAND TIER 02GEMCITABINE INJ 1GM GENERIC TIER 01GEMCITABINE INJ 1GM SPGEMCITABINE INJ 200MG GENERIC TIER 01GEMCITABINE INJ 200MG SPGEMCITABINE INJ 2GM GENERIC TIER 01GEMZAR INJ 1GM Brand‐O TIER 03 PA SPGEMZAR INJ 200MG Brand‐O TIER 03 PA SPGLEEVEC TAB 100MG BRAND TIER 02 QL SPGLEEVEC TAB 400MG BRAND TIER 02 QL SPGLIADEL WAF 7.7MG BRAND TIER 03HALAVEN INJ 1MG/2ML BRAND TIER 02HERCEPTIN INJ 440MG BRAND TIER 02 SPHEXALEN CAP 50MG BRAND TIER 02HYCAMTIN CAP 0.25MG BRAND TIER 02 SPHYCAMTIN CAP 1MG BRAND TIER 02 SPHYCAMTIN INJ 4MG Brand‐O TIER 03 PA SPHYDREA CAP 500MG Brand‐O TIER 03 PAHYDROXYUREA CAP 500MG GENERIC TIER 01IDAMYCIN PFS INJ 10/10ML Brand‐O TIER 03 PA SPIDAMYCIN PFS INJ 20/20ML Brand‐O TIER 03 PA SPIDAMYCIN PFS INJ 5MG/5ML Brand‐O TIER 03 PA SPIDARUBICIN INJ 10/10ML GENERIC TIER 01 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion45

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS IDARUBICIN INJ 20/20ML GENERIC TIER 01 SPIDARUBICIN INJ 5MG/5ML GENERIC TIER 01 SPIFEX INJ 1GM Brand‐O TIER 03 PA SPIFEX INJ 3GM BRAND TIER 03 SPIFOSFAMIDE INJ 1GM GENERIC TIER 01 SPIFOSFAMIDE INJ 1GM/20ML GENERIC TIER 01IFOSFAMIDE INJ 3GM GENERIC TIER 01 SPIFOSFAMIDE INJ 3GM/60ML GENERIC TIER 01IFOSFAMIDE KIT MESNA GENERIC TIER 01 SPINLYTA TAB 1MG BRAND TIER 03INLYTA TAB 5MG BRAND TIER 03INTRON‐A INJ 10MU BRAND TIER 02 SPINTRON‐A INJ 18MU BRAND TIER 02 SPINTRON‐A INJ 25MU BRAND TIER 02 SPINTRON‐A INJ 50MU BRAND TIER 02 SPIRESSA TAB 250MG BRAND TIER 03 QL SPIRINOTECAN INJ 100/5ML GENERIC TIER 01 SPIRINOTECAN INJ 40MG/2ML GENERIC TIER 01 SPIRINOTECAN INJ 500MG/25 GENERIC TIER 01 SPISTODAX INJ 10MG BRAND TIER 02IXEMPRA KIT INJ 15MG BRAND TIER 99 DEIXEMPRA KIT INJ 45MG BRAND TIER 99 DEJAKAFI TAB 10MG BRAND TIER 02JAKAFI TAB 15MG BRAND TIER 02JAKAFI TAB 20MG BRAND TIER 02JAKAFI TAB 25MG BRAND TIER 02JAKAFI TAB 5MG BRAND TIER 02JEVTANA INJ 60/1.5ML BRAND TIER 02 SPKYPROLIS SOL 60MG BRAND TIER 03LETROZOLE TAB 2.5MG GENERIC TIER 01LEUKERAN TAB 2MG BRAND TIER 02LEUPROLIDE INJ 1MG/0.2 GENERIC TIER 01 PA SPLEUSTATIN INJ 1MG/ML Brand‐O TIER 03 PA SPLIPODOX INJ 2MG/ML GENERIC TIER 01 SPLIPODOX 50 INJ 2MG/ML GENERIC TIER 01 SPLUPR DEP‐PED INJ 11.25MG BRAND TIER 02 PA SPLUPR DEP‐PED INJ 11.25MG SPLUPR DEP‐PED INJ 15MG BRAND TIER 02 SPLUPR DEP‐PED INJ 30MG BRAND TIER 02 PA SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion46

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS LUPR DEP‐PED INJ 7.5MG BRAND TIER 02 SPLUPRON DEPOT INJ 11.25MG BRAND TIER 02 SPLUPRON DEPOT INJ 22.5MG BRAND TIER 02 SPLUPRON DEPOT INJ 3.75MG BRAND TIER 02 PA SPLUPRON DEPOT INJ 30MG BRAND TIER 02 PA SPLUPRON DEPOT INJ 45MG BRAND TIER 02 PA SPLUPRON DEPOT INJ 7.5MG BRAND TIER 02 PA SPLYSODREN TAB 500MG BRAND TIER 02MATULANE CAP 50MG BRAND TIER 02 SPMEGACE ORAL SUS 40MG/ML Brand‐O TIER 03 PAMEGESTROL AC SUS 400MG/10 GENERIC TIER 01MEGESTROL AC SUS 40MG/ML GENERIC TIER 01MEGESTROL AC TAB 20MG GENERIC TIER 01MEGESTROL AC TAB 40MG GENERIC TIER 01MELPHALAN INJ 50MG GENERIC TIER 01 SPMERCAPTOPUR TAB 50MG GENERIC TIER 01METHOTREXATE INJ 100/4ML GENERIC TIER 01METHOTREXATE INJ 1GM GENERIC TIER 01METHOTREXATE INJ 1GM/40ML GENERIC TIER 01METHOTREXATE INJ 200/8ML GENERIC TIER 01METHOTREXATE INJ 250MG/10 GENERIC TIER 01METHOTREXATE INJ 25MG/ML GENERIC TIER 01METHOTREXATE INJ 50MG/2ML GENERIC TIER 01METHOTREXATE TAB 2.5MG GENERIC TIER 01MITOMYCIN INJ 20MG GENERIC TIER 01 SPMITOMYCIN INJ 40MG GENERIC TIER 01 SPMITOMYCIN INJ 5MG GENERIC TIER 01 SPMITOXANTRON INJ 2MG/ML GENERIC TIER 01 SPMUSTARGEN INJ 10MG BRAND TIER 03 SPMYLERAN TAB 2MG BRAND TIER 02 SPNAVELBINE INJ 10MG/ML Brand‐O TIER 03 PA SPNAVELBINE INJ 50MG/5ML Brand‐O TIER 03 PA SPNEXAVAR TAB 200MG BRAND TIER 02 QL SPNILANDRON TAB 150MG BRAND TIER 03NIPENT INJ 10MG Brand‐O TIER 03 PA SPNOVANTRONE INJ 2MG/ML Brand‐O TIER 03 PA SPOFORTA TAB 10MG BRAND TIER 02 SPONCASPAR INJ 750/ML BRAND TIER 03 SPONTAK INJ 150/ML BRAND TIER 03 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion47

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS OXALIPLATIN INJ 100MG GENERIC TIER 01 SPOXALIPLATIN INJ 50MG GENERIC TIER 01 SPPACLITAXEL INJ 100MG GENERIC TIER 01 SPPACLITAXEL INJ 150/25ML GENERIC TIER 01 SPPACLITAXEL INJ 300/50ML GENERIC TIER 01 SPPACLITAXEL INJ 30MG/5ML GENERIC TIER 01 SPPENTOSTATIN INJ 10MG GENERIC TIER 01 SPPERJETA INJ 420/14ML BRAND TIER 03PHOTOFRIN INJ 75MG BRAND TIER 03 SPPROLEUKIN INJ 22MU BRAND TIER 02 SPPURINETHOL TAB 50MG Brand‐O TIER 03 PAREVLIMID CAP 10MG BRAND TIER 02 QL SPREVLIMID CAP 15MG BRAND TIER 02 QL SPREVLIMID CAP 2.5MG BRAND TIER 02 SPREVLIMID CAP 25MG BRAND TIER 02 QL SPREVLIMID CAP 5MG BRAND TIER 02 QL SPRHEUMATREX TAB 2.5MG BRAND TIER 03RITUXAN INJ 100MG BRAND TIER 02 PA SPRITUXAN INJ 500MG BRAND TIER 02 PA SPSOLTAMOX SOL 10MG/5ML BRAND TIER 03SPRYCEL TAB 100MG BRAND TIER 02 QL SPSPRYCEL TAB 140MG BRAND TIER 02 SPSPRYCEL TAB 20MG BRAND TIER 02 QL SPSPRYCEL TAB 50MG BRAND TIER 02 QL SPSPRYCEL TAB 70MG BRAND TIER 02 QL SPSPRYCEL TAB 80MG BRAND TIER 02 SPSTIVARGA TAB 40MG BRAND TIER 03SUPPRELIN LA KIT 50MG BRAND TIER 02 PA QL SPSUTENT CAP 12.5MG BRAND TIER 02 QL SPSUTENT CAP 25MG BRAND TIER 02 QL SPSUTENT CAP 50MG BRAND TIER 02 QL SPSYLATRON KIT 296MCG BRAND TIER 03SYLATRON KIT 444MCG BRAND TIER 03SYLATRON KIT 888MCG BRAND TIER 03TABLOID TAB 40MG BRAND TIER 02TAMOXIFEN TAB 10MG GENERIC TIER 01TAMOXIFEN TAB 20MG GENERIC TIER 01TARCEVA TAB 100MG BRAND TIER 02 QL SPTARCEVA TAB 150MG BRAND TIER 02 QL SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion48

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS TARCEVA TAB 25MG BRAND TIER 02 QL SPTARGRETIN CAP 75MG BRAND TIER 03 SPTASIGNA CAP 150MG BRAND TIER 02 QL SPTASIGNA CAP 200MG BRAND TIER 02 QL SPTAXOTERE INJ 20/0.5ML BRAND TIER 03 SPTAXOTERE INJ 20MG/ML BRAND TIER 03 SPTAXOTERE INJ 80MG/2ML BRAND TIER 03 SPTAXOTERE INJ 80MG/4ML BRAND TIER 03 SPTEMODAR CAP 100MG BRAND TIER 02 SPTEMODAR CAP 140MG BRAND TIER 02 SPTEMODAR CAP 180MG BRAND TIER 02 SPTEMODAR CAP 20MG BRAND TIER 02 SPTEMODAR CAP 250MG BRAND TIER 02 SPTEMODAR CAP 5MG BRAND TIER 02 SPTEMODAR INJ 100MG BRAND TIER 03 SPTHIOTEPA INJ 15MG GENERIC TIER 01 SPTOPOSAR INJ 100/5ML GENERIC TIER 01 SPTOPOSAR INJ 1GM/50ML GENERIC TIER 01 SPTOPOSAR INJ 500/25ML GENERIC TIER 01 SPTOPOTECAN INJ 4MG GENERIC TIER 01 SPTOPOTECAN INJ 4MG/4ML GENERIC TIER 01 SPTORISEL SOL 25MG/ML BRAND TIER 02 SPTREANDA INJ 100MG BRAND TIER 02 SPTREANDA INJ 25MG BRAND TIER 02 SPTRELSTAR DEP INJ 3.75MG BRAND TIER 03 PA SPTRELSTAR LA INJ 11.25MG BRAND TIER 03 PA SPTRELSTAR MIX INJ 22.5MG BRAND TIER 03 PA SPTRETINOIN CAP 10MG GENERIC TIER 01TREXALL TAB 10MG BRAND TIER 02TREXALL TAB 15MG BRAND TIER 02TREXALL TAB 5MG BRAND TIER 02TREXALL TAB 7.5MG BRAND TIER 02TRISENOX SOL 10MG/10M BRAND TIER 03 SPTYKERB TAB 250MG BRAND TIER 02 QL SPVALSTAR SOL 40MG/ML BRAND TIER 03 SPVANDETANIB TAB 100MG GENERIC TIER 01VANDETANIB TAB 300MG GENERIC TIER 01VANTAS KIT 50MG BRAND TIER 02 PA SPVECTIBIX INJ 100MG BRAND TIER 03 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion49

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTINEOPLASTIC AGENTS VECTIBIX INJ 400MG BRAND TIER 03 SPVELCADE INJ 3.5MG BRAND TIER 02 SPVIDAZA INJ 100MG BRAND TIER 02 SPVINBLASTINE INJ 10MG GENERIC TIER 01 SPVINBLASTINE INJ 1MG/ML GENERIC TIER 01 SPVINCASAR PFS INJ 1MG/ML GENERIC TIER 01 SPVINCRISTINE INJ 1MG/ML GENERIC TIER 01 SPVINORELBINE INJ 10MG/ML GENERIC TIER 01 SPVINORELBINE INJ 50MG/5ML GENERIC TIER 01 SPVOTRIENT TAB 200MG BRAND TIER 02 QL SPVUMON INJ 50MG/5ML BRAND TIER 03 SPXALKORI CAP 200MG BRAND TIER 02XALKORI CAP 250MG BRAND TIER 02XELODA TAB 150MG BRAND TIER 02 SPXELODA TAB 500MG BRAND TIER 02 SPXTANDI CAP 40MG BRAND TIER 03YERVOY INJ 200MG BRAND TIER 02YERVOY INJ 50MG BRAND TIER 02ZALTRAP INJ 100/4ML BRAND TIER 03ZALTRAP INJ 200/8ML BRAND TIER 03ZANOSAR INJ 1GM BRAND TIER 03 SPZELBORAF TAB 240MG BRAND TIER 02ZEVALIN KIT IN‐111 BRAND TIER 03 SPZEVALIN KIT Y‐90 BRAND TIER 99 DEZOLADEX IMP 10.8MG BRAND TIER 02 PA SPZOLADEX IMP 3.6MG BRAND TIER 02 PA SPZOLINZA CAP 100MG BRAND TIER 03 QL SPZYTIGA TAB 250MG BRAND TIER 02ANTIPARKINSONIAN AGENTS BENZTROPINE TAB 1MG GENERIC TIER 01ANTIPROTOZOALS, MISCELLANEOUS ALINIA SUS 100MG/5M BRAND TIER 02ALINIA TAB 500MG BRAND TIER 02FLAGYL CAP 375MG Brand‐O TIER 03 PAFLAGYL TAB 250MG Brand‐O TIER 03 PAFLAGYL TAB 500MG Brand‐O TIER 03 PAFLAGYL ER TAB 750MG BRAND TIER 03MEPRON SUS BRAND TIER 02METRO IV INJ 5MG/ML BRAND TIER 03METRON/NACL INJ 500MG GENERIC TIER 01METRONIDAZOL CAP 375MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion50

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOL TAB 250MG GENERIC TIER 01METRONIDAZOL TAB 500MG GENERIC TIER 01NEBUPENT INH 300MG BRAND TIER 02NEUTREXIN INJ 25MG BRAND TIER 03PENTAM 300 INJ 300MG BRAND TIER 03TINDAMAX TAB 250MG Brand‐O TIER 03 PATINDAMAX TAB 500MG Brand‐O TIER 03 PATINIDAZOLE TAB 250MG GENERIC TIER 01TINIDAZOLE TAB 500MG GENERIC TIER 01ANTIPRURITICS AND LOCAL ANESTHETICS ANACAINE OIN BRAND TIER 03ANALPRAM KIT ADVANCED BRAND TIER 02ANALPRAM‐HC CRE 1‐1% Brand‐O TIER 02 PAANALPRAM‐HC CRE SINGLES Brand‐O TIER 02 PAANALPRAM‐HC CRE SINGLES TIER 99 PA DEANALPRAM‐HC LOT 2.5% BRAND TIER 02ANAMANTLE HC CRE Brand‐O TIER 03 PAANAMANTLE HC KIT Brand‐O TIER 03 PACAMPHOR GUM GUM BLOCKS GENERIC TIER 99 DEEMLA CRE Brand‐O TIER 03 PAETHYL CHLOR AER FINE PIN GENERIC TIER 01ETHYL CHLOR AER FN STRM GENERIC TIER 01ETHYL CHLOR AER MED JET GENERIC TIER 01ETHYL CHLOR AER MED STRM GENERIC TIER 01ETHYL CHLOR AER MIST GENERIC TIER 01ETHYL CHLOR AER SPRAY GENERIC TIER 01EXACTACAIN AER GENERIC TIER 99 DEFIRST‐MOUTHW SUS BLM BRAND TIER 03GEBAUERS SPR AER /STRETCH BRAND TIER 03HC PRAMOXINE CRE 1‐1% GENERIC TIER 01HC PRAMOXINE CRE 1‐1% TIER 99 DEHC PRAMOXINE CRE 2.5‐1% GENERIC TIER 99 DEHYDROCORT/ KIT PRAMOXIN GENERIC TIER 99 DELIDAZONE CRE GENERIC TIER 01LIDO/PRILOCN CRE 2.5‐2.5% GENERIC TIER 01LIDO/PRILOCN KIT 2.5‐2.5% GENERIC TIER 01LIDOCAINE CRE 3% GENERIC TIER 01LIDOCAINE GEL 2% GENERIC TIER 01LIDOCAINE GEL 2% JELLY GENERIC TIER 01LIDOCAINE LOT 3% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion51

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE OIN 5% GENERIC TIER 01LIDOCAINE SOL 4% GENERIC TIER 01LIDOCAINE/HC CRE 3%‐0.5% GENERIC TIER 01LIDOCAINE/HC KIT 2‐2% GENERIC TIER 01LIDOCAINE/HC KIT 3%‐0.5% GENERIC TIER 01LIDOCAINE/HC KIT 3%‐1% GENERIC TIER 01LIDOCAINE/HC KIT 3‐2.5% GENERIC TIER 01LIDODERM DIS 5% BRAND TIER 02LIDO‐HYDRO GEL 2.8‐0.55 GENERIC TIER 01PAIN EASE AER MD STRM BRAND TIER 03PAIN EASE AER MIST BRAND TIER 03PHENAZO TAB 200MG GENERIC TIER 01PHENAZOPYRID TAB 100MG GENERIC TIER 01PHENAZOPYRID TAB 200MG GENERIC TIER 01PHENAZOPYRID TAB PLUS GENERIC TIER 99 DEPONTOCAINE SOL 2% BRAND TIER 03PRAM‐HCA KIT 2.35‐1% GENERIC TIER 99 DEPRAMOX GEL 1% GENERIC TIER 01PROCORT CRE BRAND TIER 03PROCTOFOAM AER HC 1% BRAND TIER 02PRUDOXIN CRE 5% GENERIC TIER 01PYRIDIUM TAB 100MG Brand‐O TIER 03 PAPYRIDIUM TAB 200MG Brand‐O TIER 03 PAREGENECARE GEL BRAND TIER 03SYNERA DIS 70‐70MG BRAND TIER 03TOPEX TOPCAL SPR ANESTHET GENERIC TIER 01URELIEF PLUS TAB GENERIC TIER 99 DEXYLOCAINE GEL 2% Brand‐O TIER 03 PAXYLOCAINE SOL 4% Brand‐O TIER 03 PAZONALON CRE 5% BRAND TIER 03Z‐PRAM KIT 2.35‐1% GENERIC TIER 99 DEZYPRAM CRE 2.35‐1% BRAND TIER 03ANALPRAM‐HC CRE 1‐2.5% Brand‐O TIER 99 PA DEANALPRAM E KIT Brand‐O TIER 99 PA DEBENZYL ALC LIQ GENERIC TIER 99 DECAMPHOR GRA GENERIC TIER 99 DECAMPHOR CRY SYNTHET GENERIC TIER 99 DECAMPHOR CRY GENERIC TIER 99 DEANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE CAP 10MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion52

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE CAP 25MG GENERIC TIER 01LOXAPINE CAP 50MG GENERIC TIER 01LOXAPINE CAP 5MG GENERIC TIER 01LOXITANE CAP 10MG Brand‐O TIER 03 PALOXITANE CAP 25MG Brand‐O TIER 03 PALOXITANE CAP 50MG Brand‐O TIER 03 PALOXITANE CAP 5MG Brand‐O TIER 03 PAORAP TAB 1MG BRAND TIER 02ORAP TAB 2MG BRAND TIER 02ANTIRETROVIRALS, MISCELLANEOUS ATRIPLA TAB BRAND TIER 02ANTITHYROID AGENTS METHIMAZOLE TAB 10MG GENERIC TIER 01METHIMAZOLE TAB 5MG GENERIC TIER 01PROPYLTHIOUR TAB 50MG GENERIC TIER 01SSKI SOL 1GM/ML BRAND TIER 03TAPAZOLE TAB 10MG Brand‐O TIER 03 PATAPAZOLE TAB 5MG Brand‐O TIER 03 PAANTITUBERCULOSIS AGENTS CAPASTAT SUL INJ 1GM BRAND TIER 03CYCLOSERINE CAP 250MG GENERIC TIER 01ETHAMBUTOL TAB 100MG GENERIC TIER 01ETHAMBUTOL TAB 400MG GENERIC TIER 01ISONARIF CAP GENERIC TIER 01ISONIAZID INJ 100MG/ML GENERIC TIER 01ISONIAZID SYP 50MG/5ML GENERIC TIER 01ISONIAZID TAB 100MG GENERIC TIER 01ISONIAZID TAB 300MG GENERIC TIER 01MYAMBUTOL TAB 100MG Brand‐O TIER 03 PAMYAMBUTOL TAB 400MG Brand‐O TIER 03 PAMYCOBUTIN CAP 150MG BRAND TIER 02PASER GRA 4GM BRAND TIER 03PRIFTIN TAB 150MG BRAND TIER 03PYRAZINAMIDE TAB 500MG GENERIC TIER 01RIFADIN CAP 150MG Brand‐O TIER 03 PARIFADIN CAP 300MG Brand‐O TIER 03 PARIFADIN INJ 600 MG Brand‐O TIER 03 PARIFAMATE CAP Brand‐O TIER 03 PARIFAMPIN CAP 150MG GENERIC TIER 01RIFAMPIN CAP 300MG GENERIC TIER 01RIFAMPIN INJ 600 MG GENERIC TIER 01RIFATER TAB BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion53

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTITUBERCULOSIS AGENTS SEROMYCIN CAP 250MG BRAND TIER 02TRECATOR TAB 250MG BRAND TIER 03ANTITUSSIVES AIRACOF SYP GENERIC TIER 99 DEALAHIST AC LIQ 7.5‐10 BRAND TIER 99 DEALAHIST DHC LIQ 7.5‐3 BRAND TIER 99 DEALBATUSSIN CAP BRAND TIER 99 DEALBATUSSIN LIQ NN GENERIC TIER 99 DEALLFEN CD TAB 400‐10MG BRAND TIER 99 DEALLFEN CDX LIQ BRAND TIER 99 DEALLFEN CDX TAB 400‐20MG BRAND TIER 99 DEAMBIFED CD TAB BRAND TIER 99 DEAMBIFED CDX TAB BRAND TIER 99 DEAMBIFED‐G TAB CDX BRAND TIER 99 DEAMBIFED‐G CD TAB BRAND TIER 99 DEBALACALL DM SYP 5‐2‐10MG GENERIC TIER 99 DEBENZONATATE CAP 100MG GENERIC TIER 99 DEBENZONATATE CAP 200MG GENERIC TIER 99 DEBIOTUSS LIQ GENERIC TIER 99 DEBIOTUSS LIQ PEDIATRC GENERIC TIER 99 DEBROMATAN SUS PLUS GENERIC TIER 99 DEBROMFED DM SYP GENERIC TIER 99 DEBROMHIST‐DM SYP PED GENERIC TIER 99 DEBROMHIST‐PDX SYP GENERIC TIER 99 DEBRONCOPECTOL SYP BRAND TIER 99 DECARBAPHEN 12 LIQ BRAND TIER 99 DECARBAPHEN 12 SUS PED BRAND TIER 99 DECARBATUSS SYP BRAND TIER 99 DECARBATUSS‐12 SUS BRAND TIER 99 DECARBATUSS‐CL LIQ BRAND TIER 99 DECARBA‐XP LIQ BRAND TIER 99 DECENTERGY DM DRO GENERIC TIER 99 DECERON‐DM SYP GENERIC TIER 99 DECHLORDEX GP SYP GENERIC TIER 99 DECOLDEC DM SYP GENERIC TIER 99 DECORZALL LIQ 20‐30MG BRAND TIER 99 DECORZALL PLUS LIQ BRAND TIER 99 DECORZALL‐PE LIQ BRAND TIER 99 DECOTAB A TAB 4‐10MG BRAND TIER 99 DECOTAB AX TAB 4‐20MG BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion54

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTITUSSIVES COTABFLU TAB 20‐4‐500 BRAND TIER 99 DECPB WC LIQ BRAND TIER 99 DEDACEX‐DM SYP GENERIC TIER 99 DEDE‐CHLOR DM LIQ LIQUID GENERIC TIER 99 DEDE‐CHLOR DR SYP LIQUID GENERIC TIER 99 DEDELTUSS DMX LIQ BRAND TIER 99 DEDESPEC‐EXP SYP GENERIC TIER 99 DEDESPEC‐PDC LIQ BRAND TIER 99 DEDEX‐TUSS LIQ 300‐10/5 GENERIC TIER 99 DEDIHYDRO‐CP SYP GENERIC TIER 99 DEDIHYDRO‐PE SYP GENERIC TIER 99 DEDM/CPM/PE DRO GENERIC TIER 99 DEDM/PE/CPM DRO GENERIC TIER 99 DEDM‐PE‐CHLOR DRO GENERIC TIER 99 DEDONATUSS DC SYP BRAND TIER 99 DEDONATUSS XP SUS BRAND TIER 99 DEDONATUSSIN SUS DM BRAND TIER 99 DEDONATUSSIN SYP BRAND TIER 99 DEDURAFLU TAB BRAND TIER 99 DEED DM CHW BRAND TIER 99 DEED‐A‐HIST DM LIQ GENERIC TIER 99 DEEXACTUSS LIQ BRAND TIER 99 DEEXALL LIQ 10‐100MG BRAND TIER 99 DEEXALL‐D LIQ BRAND TIER 99 DEEXPECTUSS LIQ 20‐75MG/ GENERIC TIER 99 DEGANI‐TUSS DM LIQ 100‐10/5 GENERIC TIER 99 DEGANI‐TUSS NR LIQ 100‐10/5 GENERIC TIER 99 DEGENTEX LQ SYP GENERIC TIER 99 DEGFN1200/DM60 TAB GENERIC TIER 99 DEGILTUSS LIQ BRAND TIER 99 DEGILTUSS LIQ PED‐C BRAND TIER 99 DEGILTUSS PED LIQ BRAND TIER 99 DEGILTUSS TR CAP 7‐14‐288 GENERIC TIER 99 DEGILTUSS TR TAB BRAND TIER 99 DEHDC DM SYP GENERIC TIER 99 DEHYD POLST‐CH LIQ LOR POLS GENERIC TIER 99 DEHYDROCOD/HOM SYP 5‐1.5/5 GENERIC TIER 99 DEHYDROCODONE/ TAB HOMATROP GENERIC TIER 99 DEHYDROMET SYP 5‐1.5/5 GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion55

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTITUSSIVES INDAMIX DM SUS GENERIC TIER 99 DEJ‐COF DHC LIQ BRAND TIER 99 DEJ‐MAX DHC LIQ BRAND TIER 99 DELARTUS LIQ BRAND TIER 99 DEMAXIFED CD TAB BRAND TIER 99 DEMAXIFED CDX TAB BRAND TIER 99 DEMAXIFED‐G TAB CDX BRAND TIER 99 DEMAXIFED‐G CD TAB BRAND TIER 99 DEMAXIFLU CD TAB BRAND TIER 99 DEMAXIFLU CDX TAB BRAND TIER 99 DEMAXIPHEN CD TAB BRAND TIER 99 DEMAXIPHEN CDX TAB BRAND TIER 99 DEMYCI‐GC SOL 100‐10/5 GENERIC TIER 99 DEMYTUSSIN AC SYP 100‐10/5 GENERIC TIER 99 DENASOTUSS LIQ BRAND TIER 99 DENEO DM SUS BRAND TIER 99 DENEOTUSS PLUS LIQ BRAND TIER 99 DENEOTUSS‐D LIQ BRAND TIER 99 DENOHIST DMX TAB GENERIC TIER 99 DENORTUSS‐DE DRO GENERIC TIER 99 DENORTUSS‐EX LIQ 200‐20/5 GENERIC TIER 99 DENOTUSS‐PE LIQ BRAND TIER 99 DEP CHLOR DM DRO GENERIC TIER 99 DEPANATUSS DXP LIQ BRAND TIER 99 DEPEDIATEX TDM SUS BRAND TIER 99 DEPHENFLU CD TAB BRAND TIER 99 DEPHENFLU CDX TAB BRAND TIER 99 DEPOLY HIST LIQ DHC BRAND TIER 99 DEPOLY HIST NC LIQ BRAND TIER 99 DEPOLY‐TUSSIN LIQ DHC BRAND TIER 99 DEPOLY‐TUSSIN SYP EX BRAND TIER 99 DEPROHIST CD LIQ BRAND TIER 99 DEPROHIST CF LIQ BRAND TIER 99 DEPROMETH VC/ SYP CODEINE GENERIC TIER 99 DEPROMETH/COD SYP 6.25‐10 GENERIC TIER 99 DEPROMETHAZINE SYP DM GENERIC TIER 99 DEPULMARI‐GP LIQ 20‐100MG GENERIC TIER 99 DERELACON‐DM LIQ NR GENERIC TIER 99 DERELASIN DM LIQ GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion56

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTITUSSIVES RESPERAL‐DM DRO 12‐1‐5MG GENERIC TIER 99 DEREZIRA SOL 60‐5/5ML BRAND TIER 99 DEROBAFEN AC SYP 100‐10/5 GENERIC TIER 99 DEROMILAR AC SOL 100‐10/5 GENERIC TIER 99 DERU‐TUSS DM SYP GENERIC TIER 99 DERYNATUSS TAB BRAND TIER 99 DESUDATEX‐DM TAB GENERIC TIER 99 DESUTAN‐DM SUS GENERIC TIER 99 DETANNIHIST‐12 SUS 4‐30MG/5 GENERIC TIER 99 DETGQ 15DM/5PE SYP H/2CPM GENERIC TIER 99 DETGQ 30/ SYP 150/15 GENERIC TIER 99 DETGQ 30/PSE/3 SYP BRM/15DM GENERIC TIER 99 DETGQ 50PSE/3 SYP BRM/30DM GENERIC TIER 99 DETGQ 7.5PEH/4 LIQ BRM/15DM GENERIC TIER 99 DETL‐DEX DM LIQ GENERIC TIER 99 DETL‐HIST CD LIQ GENERIC TIER 99 DETL‐HIST CM LIQ GENERIC TIER 99 DETREXBROM LIQ GENERIC TIER 99 DETRISPEC DMX DRO PEDIATRC BRAND TIER 99 DETRISPEC DMX LIQ BRAND TIER 99 DETRISPEC PSE DRO PEDIATRC BRAND TIER 99 DETRISPEC PSE LIQ BRAND TIER 99 DETRITUSS SYP BRAND TIER 99 DETUSNEL PED‐C SYP BRAND TIER 99 DETUSSAFED EX LIQ GENERIC TIER 99 DETUSSI‐12 TAB 5‐60MG BRAND TIER 99 DETUSSI‐12D TAB 10‐40‐60 BRAND TIER 99 DETUSSI‐12D S SUS BRAND TIER 99 DETUSSICAPS CAP 10‐8MG BRAND TIER 99 DETUSSICAPS CAP 5‐4MG BRAND TIER 99 DETUSSIGON TAB 5MG GENERIC TIER 99 DETUSSO‐C LIQ 200‐10MG BRAND TIER 99 DETUSSO‐DMR CAP 7‐14‐288 BRAND TIER 99 DETUSSO‐ZMR CAP 8‐200MG BRAND TIER 99 DETUSSO‐ZR SYP 7.5‐150 BRAND TIER 99 DEVAZOTAN SUS BRAND TIER 99 DEV‐COF SUS GENERIC TIER 99 DEZ‐COF I SUS BRAND TIER 99 DEZ‐DEX SYP GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion57

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTITUSSIVES Z‐DEX 12D TAB GENERIC TIER 99 DEZONATUSS CAP 150MG BRAND TIER 99 DEZOTEX‐12D TAB GENERIC TIER 99 DEZOTEX‐C SYP BRAND TIER 99 DEZOTEX‐D SYP BRAND TIER 99 DEZOTEX‐DM SYP BRAND TIER 99 DEZOTEX‐EX TAB BRAND TIER 99 DEZOTEX‐G SYP BRAND TIER 99 DEZ‐TUSS DM LIQ GENERIC TIER 99 DEZUTRIPRO LIQ BRAND TIER 99 DETESSALON PER CAP 100MG Brand‐O TIER 99 PA DETESSALON CAP 200MG Brand‐O TIER 99 PA DEPRO‐CLEAR CAP 200‐9MG Brand‐O TIER 99 PA DEGENTEX 30 LIQ Brand‐O TIER 99 PA DENOTUSS‐AC LIQ 2‐10MG/5 Brand‐O TIER 99 PA DESERADEX LIQ Brand‐O TIER 99 PA DEZOTEX PED DRO Brand‐O TIER 99 PA DENASOHIST DM DRO Brand‐O TIER 99 PA DETUSSIONEX SUS EXT‐REL Brand‐O TIER 99 PA DEDALLERGY DM SYP Brand‐O TIER 99 PA DESUTTAR‐SF SYP Brand‐O TIER 99 PA DESUTTAR‐2 SYP Brand‐O TIER 99 PA DEZOTEX SYP Brand‐O TIER 99 PA DEDONATUSSIN SYP DM Brand‐O TIER 99 PA DETUSSI‐12 S SUS 4‐30MG/5 Brand‐O TIER 99 PA DEATUSS DS SUS Brand‐O TIER 99 PA DECGU WC LIQ Brand‐O TIER 99 PA DETUSSI‐PRES LIQ PEDIATRC Brand‐O TIER 99 PA DEANTIULCER AGENTS & ACID SUPPRESS., MISC HELIDAC MIS BRAND TIER 03 PAPYLERA CAP BRAND TIER 02 PAANTIVIRALS (EENT) TRIFLURIDINE SOL 1% OP GENERIC TIER 01VIROPTIC SOL 1% OP Brand‐O TIER 03 PAVITRASERT IMP 4.5MG BRAND TIER 03ZIRGAN GEL 0.15% BRAND TIER 03ANTIVIRALS (SKIN & MUCOUS MEMBRANE) DENAVIR CRE 1% BRAND TIER 03LIDOVIR OIN 4‐4% BRAND TIER 03XERESE CRE 5‐1% BRAND TIER 03ZOVIRAX CRE 5% BRAND TIER 02ZOVIRAX OIN 5% BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion58

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIVIRALS, MISCELLANEOUS FOSCARNET INJ 24MG/ML GENERIC TIER 01FOSCAVIR INJ 24MG/ML BRAND TIER 03ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. AMBIEN TAB 10MG Brand‐O TIER 03 PA QLAMBIEN TAB 5MG Brand‐O TIER 03 PA QLAMBIEN CR TAB 12.5MG Brand‐O TIER 03 PA QLAMBIEN CR TAB 6.25MG Brand‐O TIER 03 PA QLBUSPIRONE TAB 10MG GENERIC TIER 01BUSPIRONE TAB 15MG GENERIC TIER 01BUSPIRONE TAB 30MG GENERIC TIER 01BUSPIRONE TAB 5MG GENERIC TIER 01BUSPIRONE TAB 7.5MG GENERIC TIER 01CHLORAL CRY HYDRATE GENERIC TIER 99 DECHLORAL HYDR SYP 500/5ML GENERIC TIER 01DROPERIDOL INJ 2.5MG/ML GENERIC TIER 01EDLUAR SUB 10MG BRAND TIER 03 PA QLEDLUAR SUB 5MG BRAND TIER 03 PA QLEQUAGESIC TAB 200‐325 BRAND TIER 03GABAZOLPIDEM PAK 5MG BRAND TIER 03HYDROXYZ HCL INJ 25MG/ML GENERIC TIER 01HYDROXYZ HCL INJ 50MG/ML GENERIC TIER 01HYDROXYZ HCL SOL 10MG/5ML GENERIC TIER 01HYDROXYZ HCL SYP 10MG/5ML GENERIC TIER 01HYDROXYZ HCL TAB 10MG GENERIC TIER 01HYDROXYZ HCL TAB 25MG GENERIC TIER 01HYDROXYZ HCL TAB 50MG GENERIC TIER 01HYDROXYZ PAM CAP 100MG GENERIC TIER 01HYDROXYZ PAM CAP 25MG GENERIC TIER 01HYDROXYZ PAM CAP 50MG GENERIC TIER 01INTERMEZZO SUB 1.75MG BRAND TIER 03 PAINTERMEZZO SUB 3.5MG BRAND TIER 03 PALUNESTA TAB 1MG BRAND TIER 03 PA QLLUNESTA TAB 2MG BRAND TIER 03 PA QLLUNESTA TAB 3MG BRAND TIER 03 PA QLMEPROBAMATE TAB 200MG GENERIC TIER 01MEPROBAMATE TAB 400MG GENERIC TIER 01PARALDEHYDE LIQ GENERIC TIER 99 DEPRECEDEX INJ 100MCG BRAND TIER 03ROZEREM TAB 8MG BRAND TIER 03SENTRAZOLPID PAK PM‐5 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion59

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. SOMNOTE CAP 500MG BRAND TIER 03SONATA CAP 10MG Brand‐O TIER 03 PA QLSONATA CAP 5MG Brand‐O TIER 03 PA QLTRYPTOPHAN CAP 500MG GENERIC TIER 01VISTARIL CAP 25MG Brand‐O TIER 03 PAVISTARIL CAP 50MG Brand‐O TIER 03 PAZALEPLON CAP 10MG GENERIC TIER 01 QLZALEPLON CAP 5MG GENERIC TIER 01 QLZOLPIDEM TAB 10MG GENERIC TIER 01 QLZOLPIDEM TAB 5MG GENERIC TIER 01 QLZOLPIDEM ER TAB 12.5MG GENERIC TIER 01 PA QLZOLPIDEM ER TAB 6.25MG GENERIC TIER 01 PA QLZOLPIMIST SPR 5MG BRAND TIER 03 PA QLASTRINGENTS ALUMINUM SOL ACETATE GENERIC TIER 01ALUMINUM CL CRY GENERIC TIER 99 DEALUMINUM CL CRY HEXAHYDR GENERIC TIER 99 DEDRYSOL SOL 20% Brand‐O TIER 03 PAHYPERCARE SOL 20% GENERIC TIER 01XERAC‐AC SOL 6.25% BRAND TIER 03WITCH HAZEL LIQ USP GENERIC TIER 01ATYPICAL ANTIPSYCHOTICS ABILIFY SOL 1MG/ML BRAND TIER 02 PA QLABILIFY TAB 10MG BRAND TIER 02 PA QLABILIFY TAB 15MG BRAND TIER 02 PA QLABILIFY TAB 20MG BRAND TIER 02 PA QLABILIFY TAB 2MG BRAND TIER 02 PA QLABILIFY TAB 30MG BRAND TIER 02 PA QLABILIFY TAB 5MG BRAND TIER 02 PA QLABILIFY DISC TAB 10MG BRAND TIER 02 PA QLABILIFY DISC TAB 15MG BRAND TIER 02 PA QLCLOZAPINE TAB 100/ODT GENERIC TIER 01 PACLOZAPINE TAB 100MG GENERIC TIER 01CLOZAPINE TAB 12.5/ODT GENERIC TIER 01 PACLOZAPINE TAB 200MG GENERIC TIER 01CLOZAPINE TAB 25MG GENERIC TIER 01CLOZAPINE TAB 25MG ODT GENERIC TIER 01 PACLOZAPINE TAB 50MG GENERIC TIER 01CLOZARIL TAB 100MG Brand‐O TIER 02 PACLOZARIL TAB 25MG Brand‐O TIER 02 PAFANAPT PAK BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion60

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusATYPICAL ANTIPSYCHOTICS FANAPT TAB 10MG BRAND TIER 03 PA QLFANAPT TAB 12MG BRAND TIER 03 PA QLFANAPT TAB 1MG BRAND TIER 03 PA QLFANAPT TAB 2MG BRAND TIER 03 PA QLFANAPT TAB 4MG BRAND TIER 03 PA QLFANAPT TAB 6MG BRAND TIER 03 PA QLFANAPT TAB 8MG BRAND TIER 03 PA QLFAZACLO TAB 100MG BRAND TIER 03 PAFAZACLO TAB 12.5MG BRAND TIER 03 PAFAZACLO TAB 150MG BRAND TIER 03 PAFAZACLO TAB 200MG BRAND TIER 03 PAFAZACLO TAB 25MG BRAND TIER 03 PAGEODON CAP 20MG Brand‐O TIER 03 PA QLGEODON CAP 40MG Brand‐O TIER 03 PA QLGEODON CAP 60MG Brand‐O TIER 03 PA QLGEODON CAP 80MG Brand‐O TIER 03 PA QLGEODON INJ 20MG BRAND TIER 03 QLINVEGA TAB 1.5MG BRAND TIER 03 PAINVEGA TAB 3MG BRAND TIER 03 PA QLINVEGA TAB 6MG BRAND TIER 03 PA QLINVEGA TAB 9MG BRAND TIER 03 PA QLINVEGA SUST INJ 117/0.75 BRAND TIER 03INVEGA SUST INJ 156MG/ML BRAND TIER 03INVEGA SUST INJ 234/1.5 BRAND TIER 03INVEGA SUST INJ 39/0.25 BRAND TIER 03INVEGA SUST INJ 78/0.5ML BRAND TIER 03LATUDA TAB 120MG BRAND TIER 02 PALATUDA TAB 20MG BRAND TIER 02 PALATUDA TAB 40MG BRAND TIER 02 PALATUDA TAB 80MG BRAND TIER 02 PAOLANZAPINE INJ 10MG GENERIC TIER 01 QLOLANZAPINE TAB 10MG GENERIC TIER 01 QLOLANZAPINE TAB 10MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 15MG GENERIC TIER 01 QLOLANZAPINE TAB 15MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 2.5MG GENERIC TIER 01 QLOLANZAPINE TAB 20MG GENERIC TIER 01 QLOLANZAPINE TAB 20MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 5MG GENERIC TIER 01 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion61

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 5MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 7.5MG GENERIC TIER 01 QLQUETIAPINE TAB 100MG GENERIC TIER 01 QLQUETIAPINE TAB 200MG GENERIC TIER 01 QLQUETIAPINE TAB 25MG GENERIC TIER 01 QLQUETIAPINE TAB 300MG GENERIC TIER 01 QLQUETIAPINE TAB 400MG GENERIC TIER 01 QLQUETIAPINE TAB 50MG GENERIC TIER 01 QLRISPERDAL INJ 12.5MG BRAND TIER 03 QLRISPERDAL INJ 25MG BRAND TIER 03 QLRISPERDAL INJ 37.5MG BRAND TIER 03 QLRISPERDAL INJ 50MG BRAND TIER 03 QLRISPERDAL SOL 1MG/ML Brand‐O TIER 03 PA QLRISPERDAL TAB 0.25MG Brand‐O TIER 03 PA QLRISPERDAL TAB 0.5MG Brand‐O TIER 03 PA QLRISPERDAL TAB 1MG Brand‐O TIER 03 PA QLRISPERDAL TAB 2MG Brand‐O TIER 03 PA QLRISPERDAL TAB 3MG Brand‐O TIER 03 PA QLRISPERDAL TAB 4MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 0.5MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 1MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 2MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 3MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 4MG Brand‐O TIER 03 PA QLRISPERIDONE SOL 1MG/ML GENERIC TIER 01 QLRISPERIDONE TAB 0.25 ODT GENERIC TIER 01 PARISPERIDONE TAB 0.25MG GENERIC TIER 01 QLRISPERIDONE TAB 0.5MG GENERIC TIER 01 QLRISPERIDONE TAB 0.5MG OD GENERIC TIER 01 PA QLRISPERIDONE TAB 1MG GENERIC TIER 01 QLRISPERIDONE TAB 1MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 2MG GENERIC TIER 01 QLRISPERIDONE TAB 2MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 3MG GENERIC TIER 01 QLRISPERIDONE TAB 3MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 4MG GENERIC TIER 01 QLRISPERIDONE TAB 4MG ODT GENERIC TIER 01 PA QLSAPHRIS SUB 10MG BRAND TIER 03 PA QLSAPHRIS SUB 5MG BRAND TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion62

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusATYPICAL ANTIPSYCHOTICS SEROQUEL TAB 100MG Brand‐O TIER 03 PA QLSEROQUEL TAB 200MG Brand‐O TIER 03 PA QLSEROQUEL TAB 25MG Brand‐O TIER 03 PA QLSEROQUEL TAB 300MG Brand‐O TIER 03 PA QLSEROQUEL TAB 400MG Brand‐O TIER 03 PA QLSEROQUEL TAB 50MG Brand‐O TIER 03 PA QLSEROQUEL XR TAB 150MG BRAND TIER 02 PA QLSEROQUEL XR TAB 200MG BRAND TIER 02 PA QLSEROQUEL XR TAB 300MG BRAND TIER 02 PA QLSEROQUEL XR TAB 400MG BRAND TIER 02 PA QLSEROQUEL XR TAB 50MG BRAND TIER 02 PA QLZIPRASIDONE CAP 20MG GENERIC TIER 01 QLZIPRASIDONE CAP 40MG GENERIC TIER 01 QLZIPRASIDONE CAP 60MG GENERIC TIER 01 QLZIPRASIDONE CAP 80MG GENERIC TIER 01 QLZYPREXA INJ 10MG Brand‐O TIER 03 PA QLZYPREXA TAB 10MG Brand‐O TIER 03 PA QLZYPREXA TAB 15MG Brand‐O TIER 03 PA QLZYPREXA TAB 2.5MG Brand‐O TIER 03 PA QLZYPREXA TAB 20MG Brand‐O TIER 03 PA QLZYPREXA TAB 5MG Brand‐O TIER 03 PA QLZYPREXA TAB 7.5MG Brand‐O TIER 03 PA QLZYPREXA RELP INJ 210MG BRAND TIER 03ZYPREXA RELP INJ 300MG BRAND TIER 03ZYPREXA RELP INJ 405MG BRAND TIER 03ZYPREXA ZYDI TAB 10MG Brand‐O TIER 03 PA QLZYPREXA ZYDI TAB 15MG Brand‐O TIER 03 PA QLZYPREXA ZYDI TAB 20MG Brand‐O TIER 03 PA QLZYPREXA ZYDI TAB 5MG Brand‐O TIER 03 PA QLAUTONOMIC DRUGS, MISCELLANEOUS CHANTIX PAK 0.5& 1MG BRAND TIER 02 QLCHANTIX PAK 1MG BRAND TIER 02 QLCHANTIX TAB 0.5MG BRAND TIER 02 QLCHANTIX TAB 1MG BRAND TIER 02 QLNICOTROL INH BRAND TIER 02 QLNICOTROL NS SPR 10MG/ML BRAND TIER 02AZOLES DIFLUCAN SUS 10MG/ML Brand‐O TIER 03 PADIFLUCAN SUS 40MG/ML Brand‐O TIER 03 PADIFLUCAN TAB 100MG Brand‐O TIER 03 PADIFLUCAN TAB 150MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion63

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusAZOLES DIFLUCAN TAB 200MG Brand‐O TIER 03 PADIFLUCAN TAB 50MG Brand‐O TIER 03 PAFLUCONAZOLE SUS 10MG/ML GENERIC TIER 01FLUCONAZOLE SUS 40MG/ML GENERIC TIER 01FLUCONAZOLE TAB 100MG GENERIC TIER 01FLUCONAZOLE TAB 150MG GENERIC TIER 01FLUCONAZOLE TAB 200MG GENERIC TIER 01FLUCONAZOLE TAB 50MG GENERIC TIER 01FLUCONAZOLE/ INJ DEX 200 GENERIC TIER 01FLUCONAZOLE/ INJ DEX 400 GENERIC TIER 01FLUCONAZOLE/ INJ NACL 100 GENERIC TIER 99 DEFLUCONAZOLE/ INJ NACL 200 GENERIC TIER 01FLUCONAZOLE/ INJ NACL 400 GENERIC TIER 01ITRACONAZOLE CAP 100MG GENERIC TIER 01 PA QLKETOCONAZOLE TAB 200MG GENERIC TIER 01NOXAFIL SUS 40MG/ML BRAND TIER 03 PASPORANOX CAP 100MG Brand‐O TIER 03 PA QLSPORANOX CAP PULSEPAK Brand‐O TIER 03 PA QLSPORANOX SOL 10MG/ML BRAND TIER 02 PAVFEND SUS 40MG/ML BRAND TIER 03 PAVFEND TAB 200MG Brand‐O TIER 03 PAVFEND TAB 50MG Brand‐O TIER 03 PAVFEND IV INJ 200MG Brand‐O TIER 03 PAVORICONAZOLE INJ 200MG GENERIC TIER 01 PAVORICONAZOLE TAB 200MG GENERIC TIER 01 PAVORICONAZOLE TAB 50MG GENERIC TIER 01 PAAZOLES (SKIN & MUCOUS MEMBRANE) CLOTRIM/BETA CRE 1‐0.05% GENERIC TIER 01CLOTRIM/BETA CRE DIPROP GENERIC TIER 01CLOTRIM/BETA LOT DIPROP GENERIC TIER 01CLOTRIMAZOLE CRY GENERIC TIER 99 DECLOTRIMAZOLE LOZ 10MG GENERIC TIER 01CLOTRIMAZOLE SOL 1% GENERIC TIER 01CLOTRIMAZOLE TRO 10MG GENERIC TIER 01ECONAZOLE CRE 1% GENERIC TIER 01ERTACZO CRE 2% BRAND TIER 03EXELDERM CRE 1% BRAND TIER 02EXELDERM SOL 1% BRAND TIER 02EXTINA AER 2% Brand‐O TIER 03 PAKETOCON KIT BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion64

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusAZOLES (SKIN & MUCOUS MEMBRANE) KETOCONAZOLE AER 2% GENERIC TIER 01 PAKETOCONAZOLE CRE 2% GENERIC TIER 01KETOCONAZOLE SHA 2% GENERIC TIER 01KETODAN AER 2% GENERIC TIER 01 PAKETODAN KIT 2% BRAND TIER 03LOTRISONE CRE Brand‐O TIER 03 PAMICONAZOLE 3 KIT COMBO PK GENERIC TIER 01MICONAZOLE 3 SUP 200MG GENERIC TIER 01NIZORAL SHA 2% Brand‐O TIER 03 PANUZOLE CRE 2% GENERIC TIER 01ORAVIG TAB 50MG BRAND TIER 03 QLOXISTAT CRE 1% BRAND TIER 03OXISTAT LOT 1% BRAND TIER 03TERAZOL 3 CRE 0.8% Brand‐O TIER 03 PATERAZOL 3 SUP 80MG Brand‐O TIER 03 PATERAZOL 7 CRE 0.4% Brand‐O TIER 03 PATERCONAZOLE CRE 0.4% GENERIC TIER 01TERCONAZOLE CRE 0.8% GENERIC TIER 01TERCONAZOLE SUP 80MG GENERIC TIER 01VUSION OIN BRAND TIER 03XOLEGEL GEL 2% BRAND TIER 03XOLEGEL KIT COREPAK BRAND TIER 99 DEXOLEGEL DUO/ KIT HEAD&SHD BRAND TIER 99 DEXOLEGEL DUO/ KIT XOLEX BRAND TIER 99 DEZAZOLE CRE 0.4% GENERIC TIER 01ZAZOLE CRE 0.8% GENERIC TIER 01ZAZOLE SUP 80MG GENERIC TIER 01CLOTRIMAZOLE CRE 1% GENERIC TIER 01BACITRACINS BACIIM INJ 50000UNT GENERIC TIER 01BACITRACIN INJ 50000UNT GENERIC TIER 01BARBITURATES (ANTICONVULSANTS) MYSOLINE TAB 250MG Brand‐O TIER 03 PAMYSOLINE TAB 50MG Brand‐O TIER 03 PAPRIMIDONE TAB 250MG GENERIC TIER 01PRIMIDONE TAB 50MG GENERIC TIER 01BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) AMYTAL SOD INJ 500MG BRAND TIER 03BUTISOL SOD ELX 30MG/5ML BRAND TIER 03BUTISOL SOD TAB 30MG BRAND TIER 03BUTISOL SOD TAB 50MG BRAND TIER 03LUMINAL INJ 130MG/ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion65

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) LUMINAL INJ 60MG/ML BRAND TIER 03NEMBUTAL INJ 50MG/ML BRAND TIER 03NEMBUTAL SOD INJ 50MG/ML BRAND TIER 03PHENOBARB ELX 20MG/5ML GENERIC TIER 01PHENOBARB INJ 130MG/ML GENERIC TIER 01PHENOBARB INJ 65MG/ML GENERIC TIER 01PHENOBARB SOL 20MG/5ML GENERIC TIER 01PHENOBARB TAB 100MG GENERIC TIER 01PHENOBARB TAB 15MG GENERIC TIER 01PHENOBARB TAB 16.2MG GENERIC TIER 01PHENOBARB TAB 30MG GENERIC TIER 01PHENOBARB TAB 32.4MG GENERIC TIER 01PHENOBARB TAB 60MG GENERIC TIER 01PHENOBARB TAB 64.8MG GENERIC TIER 01PHENOBARB TAB 97.2MG GENERIC TIER 01SECONAL CAP 100MG BRAND TIER 03BARBITURATES (GENERAL ANESTHETICS) BREVITAL SOD INJ 2.5GM BRAND TIER 03BREVITAL SOD INJ 500MG BRAND TIER 03PENTOTHAL INJ 1GM BRAND TIER 03PENTOTHAL INJ 250MG BRAND TIER 03PENTOTHAL INJ 400MG BRAND TIER 03PENTOTHAL INJ 500MG BRAND TIER 03BASIC LOTIONS AND LINIMENTS AMMONIUM LAC CRE 12% GENERIC TIER 01COCOA BUTTER MIS GENERIC TIER 99 DEEUCALYPTUS OIL GENERIC TIER 01HYALURONATE GEL 0.2% GENERIC TIER 01HYGEL GEL 0.2% GENERIC TIER 01HYLIRA GEL 0.2% Brand‐O TIER 03 PAHYLIRA LOT 0.1% BRAND TIER 03LAC‐HYDRIN CRE 12% Brand‐O TIER 03 PALAC‐HYDRIN LOT 12% Brand‐O TIER 03 PALACLOTION LOT 12% GENERIC TIER 01LACTIC ACID LOT 10% GENERIC TIER 01MEDROX‐RX OIN BRAND TIER 03METHYL SALIC LIQ GENERIC TIER 01NEOSALUS LOT BRAND TIER 03SHEA BUTTER MIS GENERIC TIER 99 DESHEA BUTTER MIS ORGANIC GENERIC TIER 99 DESTEARYL MIS ALCOHOL GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion66

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBASIC LOTIONS AND LINIMENTS TROPAZONE LOT BRAND TIER 03TURPENTINE SOL SPIRITS GENERIC TIER 01METHYL SALIC OIL NATURAL GENERIC TIER 99 DEAMMONIUM LAC LOT 12% GENERIC TIER 01BASIC OILS AND OTHER SOLVENTS LACTIC ACID CRE /VIT E GENERIC TIER 01LACTIC ACID CRE E GENERIC TIER 01BASIC OINTMENTS AND PROTECTANTS ATOPICLAIR CRE BRAND TIER 03ELETONE CRE BRAND TIER 03EMULSIFYING MIS WAX GENERIC TIER 99 DEHPR AER BRAND TIER 03HPR PLUS AER BRAND TIER 03HPR PLUS CRE BRAND TIER 03HYLATOPIC AER BRAND TIER 03HYLATOPIC AER PLUS BRAND TIER 03HYLATOPIC CRE PLUS BRAND TIER 03LANOLIN OIL GENERIC TIER 01LANOLIN OIN ALCOHOL GENERIC TIER 99 DELANOLIN/UREA OIN BASE GENERIC TIER 99 DEMIMYX CRE BRAND TIER 03NEOSALUS AER BRAND TIER 03NEOSALUS CRE BRAND TIER 03NEOSALUS CRE 180 PACK BRAND TIER 03PETROLATUM OIN WHITE GENERIC TIER 01PETROLATUM OIN YELLOW GENERIC TIER 01PRUCLAIR CRE BRAND TIER 03PRUMYX CRE BRAND TIER 03ZENIEVA CRE BRAND TIER 03LANOLIN ANHY OIN GENERIC TIER 01BENZODIAZEPINES (ANTICONVULSANTS) CLONAZEP ODT TAB 0.125MG GENERIC TIER 01CLONAZEP ODT TAB 0.25MG GENERIC TIER 01CLONAZEP ODT TAB 0.5MG GENERIC TIER 01CLONAZEP ODT TAB 1MG GENERIC TIER 01CLONAZEP ODT TAB 2MG GENERIC TIER 01CLONAZEPAM TAB 0.5MG GENERIC TIER 01CLONAZEPAM TAB 1MG GENERIC TIER 01CLONAZEPAM TAB 2MG GENERIC TIER 01KLONOPIN TAB 0.5MG Brand‐O TIER 03 PAKLONOPIN TAB 1MG Brand‐O TIER 03 PAKLONOPIN TAB 2MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion67

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBENZODIAZEPINES (ANTICONVULSANTS) ONFI TAB 10MG BRAND TIER 03ONFI TAB 20MG BRAND TIER 03ONFI TAB 5MG BRAND TIER 03BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM CON 1 MG/ML BRAND TIER 03ALPRAZOLAM TAB 0.25 ODT GENERIC TIER 01ALPRAZOLAM TAB 0.25MG GENERIC TIER 01ALPRAZOLAM TAB 0.5MG GENERIC TIER 01ALPRAZOLAM TAB 0.5MG ER GENERIC TIER 01ALPRAZOLAM TAB 0.5MG OD GENERIC TIER 01ALPRAZOLAM TAB 1MG GENERIC TIER 01ALPRAZOLAM TAB 1MG ER GENERIC TIER 01ALPRAZOLAM TAB 1MG ODT GENERIC TIER 01ALPRAZOLAM TAB 2MG GENERIC TIER 01ALPRAZOLAM TAB 2MG ER GENERIC TIER 01ALPRAZOLAM TAB 2MG ODT GENERIC TIER 01ALPRAZOLAM TAB 3MG ER GENERIC TIER 01ALPRAZOLAM TAB XR 0.5MG GENERIC TIER 01ALPRAZOLAM TAB XR 1MG GENERIC TIER 01ALPRAZOLAM TAB XR 2MG GENERIC TIER 01ALPRAZOLAM TAB XR 3MG GENERIC TIER 01ATIVAN INJ 2MG/ML Brand‐O TIER 03 PA SPATIVAN INJ 4MG/ML Brand‐O TIER 03 PA SPATIVAN TAB 0.5MG Brand‐O TIER 03 PAATIVAN TAB 1MG Brand‐O TIER 03 PAATIVAN TAB 2MG Brand‐O TIER 03 PACHLORDIAZEP CAP 10MG GENERIC TIER 01CHLORDIAZEP CAP 25MG GENERIC TIER 01CHLORDIAZEP CAP 5MG GENERIC TIER 01CLORAZ DIPOT TAB 15MG GENERIC TIER 01CLORAZ DIPOT TAB 3.75MG GENERIC TIER 01CLORAZ DIPOT TAB 7.5MG GENERIC TIER 01DIASTAT ACDL GEL 12.5‐20 BRAND TIER 03DIASTAT ACDL GEL 5‐10MG BRAND TIER 03DIASTAT PED GEL 2.5M GEL BRAND TIER 02DIAZEPAM CON 5MG/ML BRAND TIER 03DIAZEPAM GEL 10MG GENERIC TIER 01DIAZEPAM GEL 2.5MG GENERIC TIER 01DIAZEPAM GEL 20MG GENERIC TIER 01DIAZEPAM INJ 10MG/2ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion68

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM INJ 5MG/ML GENERIC TIER 01DIAZEPAM SOL 1MG/ML GENERIC TIER 01DIAZEPAM TAB 10MG GENERIC TIER 01DIAZEPAM TAB 2MG GENERIC TIER 01DIAZEPAM TAB 5MG GENERIC TIER 01DORAL TAB 15MG BRAND TIER 03ESTAZOLAM TAB 1MG GENERIC TIER 01ESTAZOLAM TAB 2MG GENERIC TIER 01FLURAZEPAM CAP 15MG GENERIC TIER 01FLURAZEPAM CAP 30MG GENERIC TIER 01GABAVALE‐5 PAK BRAND TIER 03GABAZOLAMINE PAK BRAND TIER 03GABAZOLAMINE PAK 0.5MG BRAND TIER 03HALCION TAB 0.25MG Brand‐O TIER 03 PALORAZEPAM CON 2MG/ML Brand‐O TIER 03 PALORAZEPAM CON 2MG/ML GENERIC TIER 01LORAZEPAM INJ 2MG/ML GENERIC TIER 01 SPLORAZEPAM INJ 4MG/ML GENERIC TIER 01 SPLORAZEPAM TAB 0.5MG GENERIC TIER 01LORAZEPAM TAB 1MG GENERIC TIER 01LORAZEPAM TAB 2MG GENERIC TIER 01MIDAZOLAM INJ 10MG/10 GENERIC TIER 01MIDAZOLAM INJ 10MG/2ML GENERIC TIER 01MIDAZOLAM INJ 1MG/ML GENERIC TIER 01MIDAZOLAM INJ 25MG/5ML GENERIC TIER 01MIDAZOLAM INJ 2MG/2ML GENERIC TIER 01MIDAZOLAM INJ 50MG/10 GENERIC TIER 01MIDAZOLAM INJ 5MG/5ML GENERIC TIER 01MIDAZOLAM INJ 5MG/ML GENERIC TIER 01MIDAZOLAM SYP 2MG/ML GENERIC TIER 01NIRAVAM TAB 0.25MG Brand‐O TIER 03 PANIRAVAM TAB 0.5MG Brand‐O TIER 03 PANIRAVAM TAB 1MG Brand‐O TIER 03 PANIRAVAM TAB 2MG Brand‐O TIER 03 PAOXAZEPAM CAP 10MG GENERIC TIER 01OXAZEPAM CAP 15MG GENERIC TIER 01OXAZEPAM CAP 30MG GENERIC TIER 01RESTORIL CAP 15MG Brand‐O TIER 03 PARESTORIL CAP 22.5MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion69

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) RESTORIL CAP 30MG Brand‐O TIER 03 PARESTORIL CAP 7.5MG Brand‐O TIER 03 PASENTRAZOLAM PAK AM 0.25 BRAND TIER 03STRAZEPAM PAK BRAND TIER 03TEMAZEPAM CAP 15MG GENERIC TIER 01TEMAZEPAM CAP 22.5MG GENERIC TIER 01TEMAZEPAM CAP 30MG GENERIC TIER 01TEMAZEPAM CAP 7.5MG GENERIC TIER 01TRANXENE T TAB 15MG Brand‐O TIER 03 PATRANXENE T TAB 3.75MG Brand‐O TIER 03 PATRANXENE T TAB 7.5MG Brand‐O TIER 03 PATRIAZOLAM TAB 0.125MG GENERIC TIER 01TRIAZOLAM TAB 0.25MG GENERIC TIER 01VALIUM TAB 10MG Brand‐O TIER 03 PAVALIUM TAB 2MG Brand‐O TIER 03 PAVALIUM TAB 5MG Brand‐O TIER 03 PAXANAX TAB 0.25MG Brand‐O TIER 03 PAXANAX TAB 0.5MG Brand‐O TIER 03 PAXANAX TAB 1MG Brand‐O TIER 03 PAXANAX TAB 2MG Brand‐O TIER 03 PAXANAX XR TAB 0.5MG Brand‐O TIER 03 PAXANAX XR TAB 1MG Brand‐O TIER 03 PAXANAX XR TAB 2MG Brand‐O TIER 03 PAXANAX XR TAB 3MG Brand‐O TIER 03 PABENZYLAMINES (SKIN & MUCOUS MEMBRANE) MENTAX CRE 1% BRAND TIER 02BETA‐ADRENERGIC BLOCKING AGENTS ACEBUTOLOL CAP 200MG GENERIC TIER 01ACEBUTOLOL CAP 400MG GENERIC TIER 01ATENOL/CHLOR TAB 100‐25MG GENERIC TIER 01ATENOL/CHLOR TAB 50‐25MG GENERIC TIER 01ATENOLOL TAB 100MG GENERIC TIER 01ATENOLOL TAB 25MG GENERIC TIER 01ATENOLOL TAB 50MG GENERIC TIER 01BETAPACE TAB 120MG Brand‐O TIER 03 PABETAPACE TAB 160MG Brand‐O TIER 03 PABETAPACE TAB 80MG Brand‐O TIER 03 PABETAPACE AF TAB 120MG Brand‐O TIER 03 PABETAPACE AF TAB 160MG Brand‐O TIER 03 PABETAPACE AF TAB 80MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion70

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBETA‐ADRENERGIC BLOCKING AGENTS BETAXOLOL TAB 10MG GENERIC TIER 01BETAXOLOL TAB 20MG GENERIC TIER 01BISOPRL/HCTZ TAB 10/6.25 GENERIC TIER 01BISOPRL/HCTZ TAB 2.5/6.25 GENERIC TIER 01BISOPRL/HCTZ TAB 5‐6.25MG GENERIC TIER 01BISOPROL FUM TAB 10MG GENERIC TIER 01BISOPROL FUM TAB 5MG GENERIC TIER 01BREVIBLOC INJ 10MG/ML Brand‐O TIER 03 PABREVIBLOC SOL BRAND TIER 03BREVIBLOC SOL 10MG/ML BRAND TIER 03BYSTOLIC TAB 10MG BRAND TIER 02 PABYSTOLIC TAB 2.5MG BRAND TIER 02 PABYSTOLIC TAB 20MG BRAND TIER 02 PABYSTOLIC TAB 5MG BRAND TIER 02 PACARVEDILOL TAB 12.5MG GENERIC TIER 01CARVEDILOL TAB 25MG GENERIC TIER 01CARVEDILOL TAB 3.125MG GENERIC TIER 01CARVEDILOL TAB 6.25MG GENERIC TIER 01COREG TAB 12.5MG Brand‐O TIER 03 PACOREG TAB 25MG Brand‐O TIER 03 PACOREG TAB 3.125MG Brand‐O TIER 03 PACOREG TAB 6.25MG Brand‐O TIER 03 PACOREG CR CAP 10MG BRAND TIER 02 PACOREG CR CAP 20MG BRAND TIER 02 PACOREG CR CAP 40MG BRAND TIER 02 PACOREG CR CAP 80MG BRAND TIER 02 PACORGARD TAB 20MG Brand‐O TIER 03 PACORGARD TAB 40MG Brand‐O TIER 03 PACORGARD TAB 80MG Brand‐O TIER 03 PACORZIDE TAB 40‐5MG Brand‐O TIER 03 PACORZIDE TAB 80‐5MG Brand‐O TIER 03 PADUTOPROL TAB 100‐12.5 BRAND TIER 03DUTOPROL TAB 25‐12.5 BRAND TIER 03DUTOPROL TAB 50‐12.5 BRAND TIER 03ESMOLOL HCL INJ 100MG/10 GENERIC TIER 01ESMOLOL HCL INJ 10MG/ML GENERIC TIER 01HYPERTENEVID PAK 12.5MG BRAND TIER 03HYPERTENSOLO PAK BRAND TIER 03INDERAL LA CAP 120MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion71

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBETA‐ADRENERGIC BLOCKING AGENTS INDERAL LA CAP 160MG Brand‐O TIER 03 PAINDERAL LA CAP 60MG Brand‐O TIER 03 PAINDERAL LA CAP 80MG Brand‐O TIER 03 PAINNOPRAN XL CAP 120MG BRAND TIER 03INNOPRAN XL CAP 80MG BRAND TIER 03KERLONE TAB 10MG Brand‐O TIER 03 PAKERLONE TAB 20MG Brand‐O TIER 03 PALABETALOL INJ 5MG/ML GENERIC TIER 01LABETALOL TAB 100MG GENERIC TIER 01LABETALOL TAB 200MG GENERIC TIER 01LABETALOL TAB 300MG GENERIC TIER 01LEVATOL TAB 20MG BRAND TIER 03LOPRESS HCT TAB 100‐25MG Brand‐O TIER 03 PALOPRESS HCT TAB 50‐25MG Brand‐O TIER 03 PALOPRESSOR INJ 5MG/5ML Brand‐O TIER 03 PALOPRESSOR TAB 100MG Brand‐O TIER 03 PALOPRESSOR TAB 50MG Brand‐O TIER 03 PAMETOPRL/HCTZ TAB 100‐25MG GENERIC TIER 01METOPRL/HCTZ TAB 100‐50MG GENERIC TIER 01METOPRL/HCTZ TAB 50‐25MG GENERIC TIER 01METOPROL TAR TAB 100MG GENERIC TIER 01METOPROL TAR TAB 25MG GENERIC TIER 01METOPROL TAR TAB 50MG GENERIC TIER 01METOPROLOL INJ 1MG/ML GENERIC TIER 01METOPROLOL INJ 5MG/5ML GENERIC TIER 01METOPROLOL TAB 100MG ER GENERIC TIER 01METOPROLOL TAB 200MG ER GENERIC TIER 01METOPROLOL TAB 25MG ER GENERIC TIER 01METOPROLOL TAB 50MG ER GENERIC TIER 01NADOLOL TAB 20MG GENERIC TIER 01NADOLOL TAB 40MG GENERIC TIER 01NADOLOL TAB 80MG GENERIC TIER 01NADOLOL/BEND TAB 40‐5MG GENERIC TIER 01NADOLOL/BEND TAB 80‐5MG GENERIC TIER 01PINDOLOL TAB 10MG GENERIC TIER 01PINDOLOL TAB 5MG GENERIC TIER 01PROPRAN/HCTZ TAB 40/25 GENERIC TIER 01PROPRAN/HCTZ TAB 80/25 GENERIC TIER 01PROPRANOLOL CAP 120MG ER GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion72

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBETA‐ADRENERGIC BLOCKING AGENTS PROPRANOLOL CAP 160MG ER GENERIC TIER 01PROPRANOLOL CAP 60MG ER GENERIC TIER 01PROPRANOLOL CAP 80MG ER GENERIC TIER 01PROPRANOLOL INJ 1MG/ML GENERIC TIER 01PROPRANOLOL SOL 20MG/5ML GENERIC TIER 01PROPRANOLOL SOL 40MG/5ML GENERIC TIER 01PROPRANOLOL TAB 10MG GENERIC TIER 01PROPRANOLOL TAB 20MG GENERIC TIER 01PROPRANOLOL TAB 40MG GENERIC TIER 01PROPRANOLOL TAB 60MG GENERIC TIER 01PROPRANOLOL TAB 80MG GENERIC TIER 01SECTRAL CAP 200MG Brand‐O TIER 03 PASECTRAL CAP 400MG Brand‐O TIER 03 PASORINE TAB 120MG GENERIC TIER 01SORINE TAB 160MG GENERIC TIER 01SORINE TAB 240MG GENERIC TIER 01SORINE TAB 80MG GENERIC TIER 01SOTALOL AF TAB 120MG GENERIC TIER 01SOTALOL AF TAB 160MG GENERIC TIER 01SOTALOL AF TAB 80MG GENERIC TIER 01SOTALOL HCL INJ 150/10ML GENERIC TIER 01SOTALOL HCL TAB 120MG GENERIC TIER 01SOTALOL HCL TAB 160MG GENERIC TIER 01SOTALOL HCL TAB 240MG GENERIC TIER 01SOTALOL HCL TAB 80MG GENERIC TIER 01TENORETIC TAB 100 Brand‐O TIER 03 PATENORETIC TAB 50 Brand‐O TIER 03 PATENORMIN TAB 100MG Brand‐O TIER 03 PATENORMIN TAB 25MG Brand‐O TIER 03 PATENORMIN TAB 50MG Brand‐O TIER 03 PATIMOLOL MAL TAB 10MG GENERIC TIER 01TIMOLOL MAL TAB 20MG GENERIC TIER 01TIMOLOL MAL TAB 5MG GENERIC TIER 01TOPROL XL TAB 100MG Brand‐O TIER 03 PATOPROL XL TAB 200MG Brand‐O TIER 03 PATOPROL XL TAB 25MG Brand‐O TIER 03 PATOPROL XL TAB 50MG Brand‐O TIER 03 PATRANDATE TAB 100MG Brand‐O TIER 03 PATRANDATE TAB 200MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion73

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBETA‐ADRENERGIC BLOCKING AGENTS TRANDATE TAB 300MG Brand‐O TIER 03 PAZEBETA TAB 10MG Brand‐O TIER 03 PAZEBETA TAB 5MG Brand‐O TIER 03 PAZIAC TAB 10/6.25 Brand‐O TIER 03 PAZIAC TAB 2.5/6.25 Brand‐O TIER 03 PAZIAC TAB 5‐6.25MG Brand‐O TIER 03 PABETA‐ADRENERGIC BLOCKING AGENTS (EENT) BETAGAN SOL 0.5% OP Brand‐O TIER 03 PABETAXOLOL SOL 0.5% OP GENERIC TIER 01BETIMOL SOL 0.25% BRAND TIER 03BETIMOL SOL 0.5% BRAND TIER 03BETOPTIC‐S SUS 0.25% OP BRAND TIER 02CARTEOLOL SOL 1% OP GENERIC TIER 01ISTALOL SOL 0.5% OP BRAND TIER 03ISTALOL SOL 0.5% OP GENERIC TIER 01LEVOBUNOLOL SOL 0.25% OP GENERIC TIER 01LEVOBUNOLOL SOL 0.5% OP GENERIC TIER 01METIPRANOLOL SOL 0.3% GENERIC TIER 01METIPRANOLOL SOL 0.3% OPH GENERIC TIER 01OPTIPRANOLOL SOL 0.3% OP Brand‐O TIER 03 PATIMOLOL GEL SOL 0.25% OP GENERIC TIER 01TIMOLOL GEL SOL 0.5% OP GENERIC TIER 01TIMOLOL MAL SOL 0.25% OP GENERIC TIER 01TIMOLOL MAL SOL 0.5% OP GENERIC TIER 01TIMOPTIC SOL 0.25% OP Brand‐O TIER 03 PATIMOPTIC SOL 0.5% OP Brand‐O TIER 03 PATIMOPTIC OCU SOL 0.25% OP BRAND TIER 03TIMOPTIC OCU SOL 0.5% OP BRAND TIER 03TIMOPTIC‐XE SOL 0.25% OP Brand‐O TIER 03 PATIMOPTIC‐XE SOL 0.5% OP Brand‐O TIER 03 PABIGUANIDES APPFORMIN PAK BRAND TIER 03APPFORMIN‐D PAK BRAND TIER 03FORTAMET TAB 1000MG Brand‐O TIER 03 PAFORTAMET TAB 500MG Brand‐O TIER 03 PAGLUCOPHAGE TAB 1000MG Brand‐O TIER 03 PAGLUCOPHAGE TAB 500MG Brand‐O TIER 03 PAGLUCOPHAGE TAB 850MG Brand‐O TIER 03 PAGLUCOPHAGE TAB XR 500MG Brand‐O TIER 03 PAGLUCOPHAGE TAB XR 750MG Brand‐O TIER 03 PAGLUMETZA TAB 1000MG BRAND TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion74

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBIGUANIDES GLUMETZA TAB 500MG BRAND TIER 03 PAMETFORMIN TAB 1000MG GENERIC TIER 01METFORMIN TAB 500MG GENERIC TIER 01METFORMIN TAB 500MG ER GENERIC TIER 01 PAMETFORMIN TAB 750MG ER GENERIC TIER 01 PAMETFORMIN TAB 850MG GENERIC TIER 01METFORMIN ER TAB 1000MG GENERIC TIER 01 PARIOMET SOL BRAND TIER 02BILE ACID SEQUESTRANTS CHOLESTYRAM POW 4GM GENERIC TIER 01CHOLESTYRAM POW 4GM LITE GENERIC TIER 01COLESTID GRA 5GM Brand‐O TIER 03 PACOLESTID POW 5GM Brand‐O TIER 03 PACOLESTID TAB 1GM Brand‐O TIER 03 PACOLESTID FLA GRA 5/7.5GM Brand‐O TIER 03 PACOLESTID FLA GRA 5GM Brand‐O TIER 03 PACOLESTIPOL GRA 5GM GENERIC TIER 01COLESTIPOL TAB 1GM GENERIC TIER 01PREVALITE POW 4GM GENERIC TIER 01PREVALITE POW 4GM PK GENERIC TIER 01QUESTRAN POW 4GM Brand‐O TIER 03 PAQUESTRAN POW 4GM LITE Brand‐O TIER 03 PAWELCHOL PAK 3.75GM BRAND TIER 02WELCHOL TAB 625MG BRAND TIER 02BIOLOGIC RESPONSE MODIFIERS ACTIMMUNE INJ 2MU/0.5 BRAND TIER 02 SPAVONEX KIT 30MCG BRAND TIER 02 SPAVONEX PEN KIT 30MCG BRAND TIER 02 SPAVONEX PREFL KIT 30MCG BRAND TIER 02 SPBETASERON INJ 0.3MG BRAND TIER 03 SPCOPAXONE KIT 20MG/ML BRAND TIER 02 SPEXTAVIA INJ 0.3MG BRAND TIER 03 SPGILENYA CAP 0.5MG BRAND TIER 03 PA QLREBIF INJ 22/0.5 BRAND TIER 02 SPREBIF INJ 44/0.5 BRAND TIER 02 SPREBIF TITRTN SOL PACK BRAND TIER 02 SPTHALOMID CAP 100MG BRAND TIER 02 QL SPTHALOMID CAP 150MG BRAND TIER 02 QL SPTHALOMID CAP 200MG BRAND TIER 02 QL SPTHALOMID CAP 50MG BRAND TIER 02 QL SPTYSABRI INJ BRAND TIER 03 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion75

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBLOOD DERIVATIVES ALBUKED 25 INJ 25% GENERIC TIER 01ALBUKED 5 INJ 5% GENERIC TIER 01ALBUMIN HUM INJ 25% GENERIC TIER 01ALBUMIN HUM INJ 5% GENERIC TIER 01ALBUMINAR‐25 INJ 25% GENERIC TIER 01ALBUMINAR‐5 INJ 5% GENERIC TIER 01ALBUMIN‐ZLB INJ GENERIC TIER 01ALBUMIN‐ZLB SOL 25% GENERIC TIER 01ALBURX INJ 5% GENERIC TIER 01ALBUTEIN INJ 25% GENERIC TIER 01ALBUTEIN INJ 5% GENERIC TIER 01BUMINATE INJ 25% GENERIC TIER 01BUMINATE INJ 5% GENERIC TIER 01FLEXBUMIN INJ 25% GENERIC TIER 01HSA DILUENT SOL STERILE GENERIC TIER 01KEDBUMIN INJ 25% GENERIC TIER 01PANHEMATIN INJ 313MG BRAND TIER 03PLASBUMIN‐25 INJ 25% GENERIC TIER 01PLASBUMIN‐5 INJ 5% GENERIC TIER 01PLASMANATE INJ 5% BRAND TIER 03BONE RESORPTION INHIBITORS ACTONEL TAB 150MG BRAND TIER 03 PAACTONEL TAB 30MG BRAND TIER 03 PAACTONEL TAB 35MG BRAND TIER 03 PAACTONEL TAB 5MG BRAND TIER 03 PAALENDRONATE TAB 10MG GENERIC TIER 01ALENDRONATE TAB 35MG GENERIC TIER 01ALENDRONATE TAB 40MG GENERIC TIER 01ALENDRONATE TAB 5MG GENERIC TIER 01ALENDRONATE TAB 70MG GENERIC TIER 01AREDIA INJ 30MG Brand‐O TIER 03 PA SPATELVIA TAB BRAND TIER 03 PABINOSTO TAB 70MG BRAND TIER 03BONIVA TAB 150MG Brand‐O TIER 03 PADIDRONEL TAB 400MG Brand‐O TIER 03 PAETIDRON DISD TAB 200MG GENERIC TIER 01ETIDRON DISD TAB 400MG GENERIC TIER 01FOSAMAX TAB 10MG Brand‐O TIER 03 PAFOSAMAX TAB 35MG Brand‐O TIER 03 PAFOSAMAX TAB 40MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion76

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusBONE RESORPTION INHIBITORS FOSAMAX TAB 5MG Brand‐O TIER 03 PAFOSAMAX TAB 70MG Brand‐O TIER 03 PAFOSAMAX + D TAB 70‐2800 BRAND TIER 03 PAFOSAMAX + D TAB 70‐5600 BRAND TIER 03 PAGANITE INJ 25MG/ML BRAND TIER 03IBANDRONATE TAB 150MG GENERIC TIER 01 PAPAMIDRONATE INJ 30/10ML GENERIC TIER 01PAMIDRONATE INJ 30MG GENERIC TIER 01 SPPAMIDRONATE INJ 6MG/ML GENERIC TIER 01PAMIDRONATE INJ 90/10ML GENERIC TIER 01PAMIDRONATE INJ 90MG GENERIC TIER 01 SPPROLIA SOL 60MG/ML BRAND TIER 03 PA QL SPSKELID TAB 200MG BRAND TIER 03XGEVA INJ BRAND TIER 02 PA QL SPZOMETA INJ 4MG/5ML BRAND TIER 03 SPBUTYROPHENONES HALDOL INJ 5MG/ML Brand‐O TIER 03 PAHALDOL DECAN INJ 100MG/ML Brand‐O TIER 03 PAHALDOL DECAN INJ 50MG/ML Brand‐O TIER 03 PAHALOPER DEC INJ 100MG/ML GENERIC TIER 01HALOPER DEC INJ 50MG/ML GENERIC TIER 01HALOPER LAC INJ 5MG/ML GENERIC TIER 01HALOPERIDOL CON 2MG/ML GENERIC TIER 01HALOPERIDOL TAB 0.5MG GENERIC TIER 01HALOPERIDOL TAB 10MG GENERIC TIER 01HALOPERIDOL TAB 1MG GENERIC TIER 01HALOPERIDOL TAB 20MG GENERIC TIER 01HALOPERIDOL TAB 2MG GENERIC TIER 01HALOPERIDOL TAB 5MG GENERIC TIER 01CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. CALAN TAB 120MG Brand‐O TIER 03 PACALAN TAB 80MG Brand‐O TIER 03 PACALAN SR TAB 120MG Brand‐O TIER 03 PACALAN SR TAB 180MG Brand‐O TIER 03 PACALAN SR TAB 240MG Brand‐O TIER 03 PACARDIZEM TAB 120MG Brand‐O TIER 03 PACARDIZEM TAB 30MG Brand‐O TIER 03 PACARDIZEM TAB 60MG Brand‐O TIER 03 PACARDIZEM TAB 90MG Brand‐O TIER 03 PACARDIZEM CD CAP 120MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 180MG/24 Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion77

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALCIUM‐CHANNEL BLOCKING AGENTS, MISC. CARDIZEM CD CAP 240MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 300MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 360MG/24 Brand‐O TIER 03 PACARDIZEM LA TAB 120MG BRAND TIER 02CARDIZEM LA TAB 180MG Brand‐O TIER 03 PACARDIZEM LA TAB 240MG Brand‐O TIER 03 PACARDIZEM LA TAB 300MG/24 Brand‐O TIER 03 PACARDIZEM LA TAB 360MG Brand‐O TIER 03 PACARDIZEM LA TAB 420MG/24 Brand‐O TIER 03 PACARTIA XT CAP 120/24HR GENERIC TIER 01CARTIA XT CAP 180/24HR GENERIC TIER 01CARTIA XT CAP 240/24HR GENERIC TIER 01CARTIA XT CAP 300/24HR GENERIC TIER 01COVERA‐HS TAB 180MG BRAND TIER 03COVERA‐HS TAB 240MG BRAND TIER 03DILACOR XR CAP 240MG/24 Brand‐O TIER 03 PADILT‐CD CAP 120MG GENERIC TIER 01DILT‐CD CAP 180MG GENERIC TIER 01DILT‐CD CAP 240MG GENERIC TIER 01DILT‐CD CAP 300MG GENERIC TIER 01DILTIAZEM CAP 120MG CD GENERIC TIER 01DILTIAZEM CAP 120MG ER GENERIC TIER 01DILTIAZEM CAP 120MG/24 GENERIC TIER 01DILTIAZEM CAP 180MG CD GENERIC TIER 01DILTIAZEM CAP 180MG ER GENERIC TIER 01DILTIAZEM CAP 180MG/24 GENERIC TIER 01DILTIAZEM CAP 240MG CD GENERIC TIER 01DILTIAZEM CAP 240MG ER GENERIC TIER 01DILTIAZEM CAP 240MG/24 GENERIC TIER 01DILTIAZEM CAP 300MG CD GENERIC TIER 01DILTIAZEM CAP 300MG ER GENERIC TIER 01DILTIAZEM CAP 300MG/24 GENERIC TIER 01DILTIAZEM CAP 360MG CD GENERIC TIER 01DILTIAZEM CAP 360MG ER GENERIC TIER 01DILTIAZEM CAP 360MG/24 GENERIC TIER 01DILTIAZEM CAP 420MG/24 GENERIC TIER 01DILTIAZEM CAP 60MG ER GENERIC TIER 01DILTIAZEM CAP 90MG ER GENERIC TIER 01DILTIAZEM INJ 100MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion78

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALCIUM‐CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM INJ 125/25ML GENERIC TIER 01DILTIAZEM INJ 25MG/5ML GENERIC TIER 01DILTIAZEM INJ 50/10ML GENERIC TIER 01DILTIAZEM TAB 120MG GENERIC TIER 01DILTIAZEM TAB 30MG GENERIC TIER 01DILTIAZEM TAB 60MG GENERIC TIER 01DILTIAZEM TAB 90MG GENERIC TIER 01DILT‐XR CAP 120MG GENERIC TIER 01DILT‐XR CAP 180MG GENERIC TIER 01DILT‐XR CAP 240MG GENERIC TIER 01DILTZAC CAP 120MG/24 GENERIC TIER 01DILTZAC CAP 180MG/24 GENERIC TIER 01DILTZAC CAP 240MG/24 GENERIC TIER 01DILTZAC CAP 300MG/24 GENERIC TIER 01DILTZAC CAP 360MG/24 GENERIC TIER 01ISOPTIN SR TAB 120MG Brand‐O TIER 03 PAISOPTIN SR TAB 180MG Brand‐O TIER 03 PAISOPTIN SR TAB 240MG Brand‐O TIER 03 PAMATZIM LA TAB 180MG/24 GENERIC TIER 01MATZIM LA TAB 240MG/24 GENERIC TIER 01MATZIM LA TAB 300MG/24 GENERIC TIER 01MATZIM LA TAB 360MG/24 GENERIC TIER 01MATZIM LA TAB 420MG/24 GENERIC TIER 01TARKA TAB 1‐240 CR BRAND TIER 02TARKA TAB 2‐180 CR BRAND TIER 02TARKA TAB 2‐240 CR BRAND TIER 02TARKA TAB 4‐240 CR BRAND TIER 02TAZTIA XT CAP 120MG/24 GENERIC TIER 01TAZTIA XT CAP 180MG/24 GENERIC TIER 01TAZTIA XT CAP 240MG/24 GENERIC TIER 01TAZTIA XT CAP 300MG/24 GENERIC TIER 01TAZTIA XT CAP 360MG/24 GENERIC TIER 01TIAZAC CAP 120MG/24 Brand‐O TIER 03 PATIAZAC CAP 180MG/24 Brand‐O TIER 03 PATIAZAC CAP 240MG/24 Brand‐O TIER 03 PATIAZAC CAP 300MG/24 Brand‐O TIER 03 PATIAZAC CAP 360MG/24 Brand‐O TIER 03 PATIAZAC CAP 420MG/24 Brand‐O TIER 03 PATRANDO/VERAP TAB 1‐240 CR GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion79

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALCIUM‐CHANNEL BLOCKING AGENTS, MISC. TRANDO/VERAP TAB 2‐180 CR GENERIC TIER 01TRANDO/VERAP TAB 2‐240 CR GENERIC TIER 01TRANDO/VERAP TAB 4‐240 CR GENERIC TIER 01VERAPAMIL CAP 100MG ER GENERIC TIER 01VERAPAMIL CAP 120MG ER GENERIC TIER 01VERAPAMIL CAP 120MG SR GENERIC TIER 01VERAPAMIL CAP 180MG ER GENERIC TIER 01VERAPAMIL CAP 180MG SR GENERIC TIER 01VERAPAMIL CAP 200MG ER GENERIC TIER 01VERAPAMIL CAP 240MG ER GENERIC TIER 01VERAPAMIL CAP 240MG SR GENERIC TIER 01VERAPAMIL CAP 300MG ER GENERIC TIER 01VERAPAMIL CAP 360MG SR GENERIC TIER 01VERAPAMIL INJ 2.5MG/ML GENERIC TIER 01VERAPAMIL TAB 120MG GENERIC TIER 01VERAPAMIL TAB 120MG ER GENERIC TIER 01VERAPAMIL TAB 120MG SR GENERIC TIER 01VERAPAMIL TAB 180MG ER GENERIC TIER 01VERAPAMIL TAB 180MG SR GENERIC TIER 01VERAPAMIL TAB 240MG ER GENERIC TIER 01VERAPAMIL TAB 240MG SR GENERIC TIER 01VERAPAMIL TAB 40MG GENERIC TIER 01VERAPAMIL TAB 80MG GENERIC TIER 01VERELAN CAP 120MG SR Brand‐O TIER 03 PAVERELAN CAP 180MG Brand‐O TIER 03 PAVERELAN CAP 240MG SR Brand‐O TIER 03 PAVERELAN CAP 360MG SR Brand‐O TIER 03 PAVERELAN PM CAP 100MG Brand‐O TIER 03 PAVERELAN PM CAP 200MG Brand‐O TIER 03 PAVERELAN PM CAP 300MG Brand‐O TIER 03 PACALORIC AGENTS ALCOHOL INJ 95% GENERIC TIER 01ALCOHOL INJ 98% GENERIC TIER 01AMINO ACIDS INJ 15% GENERIC TIER 01AMINOSYN INJ 10% BRAND TIER 03AMINOSYN INJ 3.5% BRAND TIER 03AMINOSYN INJ 7% BRAND TIER 03AMINOSYN INJ 8.5% BRAND TIER 03AMINOSYN INJ 8.5/LYTE GENERIC TIER 01AMINOSYN 7% INJ /LYTES BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion80

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALORIC AGENTS AMINOSYN II INJ 10% BRAND TIER 03AMINOSYN II INJ 15% Brand‐O TIER 03 PAAMINOSYN II INJ 4.25/D25 BRAND TIER 03AMINOSYN II INJ 5/D25 BRAND TIER 03AMINOSYN II INJ 7% BRAND TIER 03AMINOSYN II INJ 8.5% BRAND TIER 03AMINOSYN II INJ 8.5/LYTE GENERIC TIER 01AMINOSYN M INJ 3.5% BRAND TIER 03AMINOSYN‐HBC INJ 7% BRAND TIER 03AMINOSYN‐HF INJ 8% GENERIC TIER 01AMINOSYN‐PF INJ 10% BRAND TIER 03AMINOSYN‐PF INJ 7% BRAND TIER 03AMINOSYN‐RF INJ 5.2% BRAND TIER 03APPTRIM CAP BRAND TIER 99 DEAPPTRIM LIFE CAP BARIATRC BRAND TIER 99 DEAPPTRIM LIFE CAP OBESITY BRAND TIER 99 DEAPPTRIM‐D CAP BRAND TIER 99 DEAXONA POW BRAND TIER 03CESINEX SUS BRAND TIER 03CLINIMIX INJ 2.75/D5W BRAND TIER 03CLINIMIX INJ 4.25/D10 BRAND TIER 03CLINIMIX INJ 4.25/D10 GENERIC TIER 01CLINIMIX INJ 4.25/D20 BRAND TIER 03CLINIMIX INJ 4.25/D20 GENERIC TIER 01CLINIMIX INJ 4.25/D25 BRAND TIER 03CLINIMIX INJ 4.25/D25 GENERIC TIER 01CLINIMIX INJ 4.25/D5W BRAND TIER 03CLINIMIX INJ 5%/D15W BRAND TIER 03CLINIMIX INJ 5%/D20W BRAND TIER 03CLINIMIX INJ 5%/D25W BRAND TIER 03CLINIMIX E INJ 2.75/D10 BRAND TIER 03CLINIMIX E INJ 2.75/D5W BRAND TIER 03CLINIMIX E INJ 4.25/D10 BRAND TIER 03CLINIMIX E INJ 4.25/D25 BRAND TIER 03CLINIMIX E INJ 4.25/D25 GENERIC TIER 01CLINIMIX E INJ 4.25/D5W BRAND TIER 03CLINIMIX E INJ 5%/D15W BRAND TIER 03CLINIMIX E INJ 5%/D20W BRAND TIER 03CLINIMIX E INJ 5%/D25W BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion81

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALORIC AGENTS CLINISOL SF INJ 15% GENERIC TIER 01CYSTEINE HCL INJ 50MG/ML GENERIC TIER 01DEXTROSE INJ 10% GENERIC TIER 01 SPDEXTROSE INJ 2.5% GENERIC TIER 01 SPDEXTROSE INJ 20% GENERIC TIER 01 SPDEXTROSE INJ 25% GENERIC TIER 01 SPDEXTROSE INJ 30% GENERIC TIER 01 SPDEXTROSE INJ 40% GENERIC TIER 01 SPDEXTROSE INJ 5% GENERIC TIER 01 SPDEXTROSE INJ 5% PGBK GENERIC TIER 01 SPDEXTROSE INJ 50% GENERIC TIER 01 SPDEXTROSE INJ 70% GENERIC TIER 01 SPENLYTE CAP BRAND TIER 99 DEFOVEX CAP BRAND TIER 99 DEFREAMINE HBC INJ 6.9% BRAND TIER 03FREAMINE III INJ 10% BRAND TIER 03FREAMINE III INJ 3% BRAND TIER 03FREAMINE III INJ 8.5% GENERIC TIER 01FRUCTOSE GRA GENERIC TIER 99 DEGABADONE CAP BRAND TIER 99 DEGLUTATHIONE CRY REDUCED GENERIC TIER 99 DEGLUTATHIONE POW GENERIC TIER 99 DEGLUTATHIONE POW REDUCED GENERIC TIER 99 DEHEPATAMINE SOL 8% GENERIC TIER 01HEPATASOL INJ 8% GENERIC TIER 01HYPERTENSA CAP BRAND TIER 99 DEINTRALIPID INJ 20% GENERIC TIER 01INTRALIPID INJ 30% Brand‐O TIER 03 PAL‐CYSTEINE INJ 50MG/ML GENERIC TIER 01L‐GLUTAMINE CRY FCC GENERIC TIER 99 DELIPOSYN II INJ 10% Brand‐O TIER 03 PALIPOSYN II INJ 20% Brand‐O TIER 03 PALIPOSYN III INJ 10% Brand‐O TIER 03 PALIPOSYN III INJ 20% Brand‐O TIER 03 PALIPOSYN III INJ 30% GENERIC TIER 01LISTER‐V CAP BRAND TIER 99 DEL‐THREONINE CRY GENERIC TIER 99 DELUKAID GLA EMU 1GM/ML BRAND TIER 99 DELUNGLAID EMU 1GM/ML BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion82

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCALORIC AGENTS L‐VALINE CRY GENERIC TIER 99 DEMACUTEK TAB BRAND TIER 03MICROLIPID EMU 50% BRAND TIER 03N‐ACETYL‐L‐ CAP CYSTEINE GENERIC TIER 01NEPHRAMINE INJ 5.4% BRAND TIER 03PCCA ACACIA SYP BASE BRAND TIER 03PERCURA CAP BRAND TIER 99 DEPREMASOL SOL 10% BRAND TIER 03PREMASOL SOL 6% GENERIC TIER 01PROBARIMIN CHW QT BRAND TIER 99 DEPROCALAMINE INJ 3% BRAND TIER 03PROSOL INJ 20% BRAND TIER 03PROTEOLIN TAB BRAND TIER 03PULMONA CAP BRAND TIER 99 DERENASTART POW BRAND TIER 99 DESENTRA AM CAP BRAND TIER 99 DESENTRA PM CAP BRAND TIER 99 DETAURINE LIQ GENERIC TIER 99 DETHERAMINE CAP BRAND TIER 99 DETOZAL CAP BRAND TIER 99 DETRAVASOL INJ 10% BRAND TIER 03TREPADONE CAP BRAND TIER 99 DETROPHAMINE INJ 10% BRAND TIER 03TROPHAMINE INJ 6% Brand‐O TIER 03 PAVASCULERA TAB BRAND TIER 03VIRILEX CAP BRAND TIER 99 DEWHEY PROTEIN POW GENERIC TIER 01CARBAPENEMS DORIBAX INJ 250MG BRAND TIER 03DORIBAX INJ 500MG BRAND TIER 03IMIPENEM/CIL INJ 250MG GENERIC TIER 01IMIPENEM/CIL INJ 500MG GENERIC TIER 01INVANZ INJ 1GM BRAND TIER 03MEROPENEM INJ 1GM GENERIC TIER 01MEROPENEM INJ 500MG GENERIC TIER 01MERREM INJ 1GM Brand‐O TIER 03 PAMERREM INJ 500MG Brand‐O TIER 03 PAPRIMAXIN IV INJ 250MG Brand‐O TIER 03 PAPRIMAXIN IV INJ 500MG Brand‐O TIER 03 PACARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMID CAP 500MG ER GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion83

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMID INJ 500MG GENERIC TIER 01ACETAZOLAMID TAB 125MG GENERIC TIER 01ACETAZOLAMID TAB 250MG GENERIC TIER 01AZOPT SUS 1% OP BRAND TIER 02COSOPT SOL 2‐0.5%OP Brand‐O TIER 03 PACOSOPT PF SOL BRAND TIER 03DIAMOX SEQUE CAP 500MG CR Brand‐O TIER 03 PADORZOL/TIMOL SOL 2‐0.5%OP GENERIC TIER 01DORZOLAMIDE SOL 2% OP GENERIC TIER 01METHAZOLAMID TAB 25MG GENERIC TIER 01METHAZOLAMID TAB 50MG GENERIC TIER 01NEPTAZANE TAB 25MG Brand‐O TIER 03 PANEPTAZANE TAB 50MG Brand‐O TIER 03 PATRUSOPT SOL 2% OP Brand‐O TIER 03 PACARDIAC DRUGS, MISCELLANEOUS RANEXA TAB 1000MG BRAND TIER 02 PARANEXA TAB 500MG BRAND TIER 02 PACARDIAC FUNCTION ADENOSCAN INJ 3MG/ML BRAND TIER 03DEXTROSE INJ 5% BRAND TIER 03INDOCYANINE INJ 25MG GENERIC TIER 99 DELEXISCAN INJ 0.4MG BRAND TIER 03MYOVIEW KIT BRAND TIER 99 DESODIUM CHLOR INJ 0.9% BRAND TIER 03THALLOUS CL INJ TL 201 GENERIC TIER 99 DEIC GREEN INJ 25MG Brand‐O TIER 99 PA DECARDIOTONIC AGENTS DIGOXIN INJ 0.25MG/1 GENERIC TIER 01DIGOXIN SOL 50MCG/ML GENERIC TIER 01DIGOXIN TAB 0.125MG GENERIC TIER 01DIGOXIN TAB 0.25MG GENERIC TIER 01LANOXIN INJ 0.1MG/ML BRAND TIER 03LANOXIN INJ 0.25MG/1 Brand‐O TIER 03 PALANOXIN TAB 0.125MG Brand‐O TIER 03 PALANOXIN TAB 0.25MG Brand‐O TIER 03 PAMILRINONE INJ 1MG/ML GENERIC TIER 01MILRINONE INJ DW5 GENERIC TIER 01CARIOSTATIC AGENTS CAVAREST GEL 1.1% GENERIC TIER 01CAVIRINSE SOL 0.2% GENERIC TIER 01CLINPRO 5000 PST 1.1% GENERIC TIER 01CONTROLRX CRE 1.1% GENERIC TIER 01CONTROLRX PST 1.1% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion84

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCARIOSTATIC AGENTS DENTA 5000 CRE PLUS GENERIC TIER 01DENTA 5000 CRE PLUS 2PK GENERIC TIER 01DENTAGEL GEL 1.1% GENERIC TIER 01EASYGEL GEL 0.4% GENERIC TIER 01EASYGEL GEL 0.4%CHRY GENERIC TIER 01EASYGEL GEL 0.4%CITR GENERIC TIER 01EASYGEL GEL 0.4%MINT GENERIC TIER 01EPIFLUR CHW 0.25MG F GENERIC TIER 01EPIFLUR CHW 0.5MG F GENERIC TIER 01EPIFLUR CHW 1MG F GENERIC TIER 01FLUORABON DRO BRAND TIER 02FLUOR‐A‐DAY CHW 0.25MG F BRAND TIER 02FLUOR‐A‐DAY CHW 0.5MG F BRAND TIER 02FLUOR‐A‐DAY CHW 1MG F BRAND TIER 03FLUOR‐A‐DAY DRO 0.125MG GENERIC TIER 01FLUORIDE CHW 0.25MG F GENERIC TIER 01FLUORIDE CHW 0.5MG F GENERIC TIER 01FLUORIDE CHW 1MG F GENERIC TIER 01FLUORIDEX GEL 1.1% GENERIC TIER 01FLUORIDEX GEL WHITENIN GENERIC TIER 01FLUORITAB CHW 0.25MG F GENERIC TIER 01FLUORITAB CHW 0.5MG F GENERIC TIER 01FLUORITAB CHW 1MG F GENERIC TIER 01FLUORITAB CHW 2.2MG GENERIC TIER 01FLUORITAB DRO 0.125MG GENERIC TIER 01FLURA‐DROPS DRO 0.125MG GENERIC TIER 01FLURA‐DROPS DRO 0.25MG F GENERIC TIER 01GEL‐KAM CON 0.63% Brand‐O TIER 03 PAKARIDIUM DRO 0.125MG GENERIC TIER 01KARIGEL GEL 0.5% GENERIC TIER 01KARIGEL‐N GEL 1.1% GENERIC TIER 01LOZI‐FLUR LOZ 1MG F GENERIC TIER 01LUDENT CHW 0.25MG F GENERIC TIER 01LUDENT CHW 0.5MG F GENERIC TIER 01LUDENT CHW 1MG F GENERIC TIER 01LURIDE CHW 0.25MG F Brand‐O TIER 02 PALURIDE CHW 0.5MG F Brand‐O TIER 02 PALURIDE CHW 1MG F Brand‐O TIER 03 PALURIDE DRO 0.5MG/ML Brand‐O TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion85

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCARIOSTATIC AGENTS NAFRINSE CHW 1MG F GENERIC TIER 01NAFRINSE DRO 0.125MG GENERIC TIER 01NAFRINSE DLY SOL /NEUTRAL BRAND TIER 03NAFRINSE WK SOL 0.2% BRAND TIER 03NEUTRAGARD GEL 1.1% GENERIC TIER 01PERIO MED CON 0.63% GENERIC TIER 01PHOS‐FLUR GEL 1.1% GENERIC TIER 01PREVIDENT CRE 5000 PLS Brand‐O TIER 03 PAPREVIDENT GEL 1.1% BER Brand‐O TIER 03 PAPREVIDENT GEL 1.1% CHR Brand‐O TIER 03 PAPREVIDENT GEL 1.1% MIN Brand‐O TIER 03 PAPREVIDENT PST 1.1% Brand‐O TIER 03 PAPREVIDENT PST 5000 BST Brand‐O TIER 03 PAPREVIDENT SOL RINSE Brand‐O TIER 03 PASF GEL 1.1% GENERIC TIER 01SF 5000 PLUS CRE 1.1% GENERIC TIER 01SOD FLUORIDE CHW 0.25MG F GENERIC TIER 01SOD FLUORIDE CHW 0.5MG F GENERIC TIER 01SOD FLUORIDE CHW 1.1MG GENERIC TIER 01SOD FLUORIDE CHW 1MG F GENERIC TIER 01SOD FLUORIDE CHW 2.2MG GENERIC TIER 01SOD FLUORIDE DRO 0.5MG/ML GENERIC TIER 01SOD FLUORIDE SOL 0.2%MINT GENERIC TIER 01SOD FLUORIDE TAB 0.5MG F GENERIC TIER 01SOD FLUORIDE TAB 1MG F GENERIC TIER 01STAN FLUORID CON 0.63% GENERIC TIER 01THERA‐FLUR‐N DRO 1.1% Brand‐O TIER 03 PACATECHOL‐O‐METHYLTRANSFERASE(COMT)INHIB. COMTAN TAB 200MG BRAND TIER 03ENTACAPONE TAB 200MG GENERIC TIER 01TASMAR TAB 100MG BRAND TIER 03CATHARTICS AND LAXATIVES BASE C PEG LIQ 300 GENERIC TIER 99 DECASCARA EXT SAGRADA GENERIC TIER 01CASCARA SAGR EXT GENERIC TIER 01CASCARA SAGR EXT AROMATIC GENERIC TIER 01COLYTE/FLAVR SOL PACKS BRAND TIER 02 PACOLYTE/FLAVR SOL PACKS Brand‐O TIER 03 PAGAVILYTE‐C SOL GENERIC TIER 01 PAGAVILYTE‐G SOL GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion86

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCATHARTICS AND LAXATIVES GAVILYTE‐N SOL FLAV PK GENERIC TIER 01 PAGOLYTELY SOL Brand‐O TIER 02 PAGOLYTELY SOL PINEAPPL Brand‐O TIER 02 PAHALFLYTELY KIT FLAV PKS BRAND TIER 02KARAYA GUM GENERIC TIER 99 DEMEDIBASE C LIQ GENERIC TIER 99 DEMOVIPREP SOL BRAND TIER 03MURI‐LUBE OIL BRAND TIER 99 DENULYTELY SOL FLAV PKS Brand‐O TIER 02 PAOSMOPREP TAB 1.5GM BRAND TIER 03PEG 3350 SOL ELECTROL GENERIC TIER 01 PAPEG 400 LIQ GENERIC TIER 99 DEPEG‐3350 SOL ELECTROL GENERIC TIER 01 PAPEG‐3350/KCL SOL /SODIUM GENERIC TIER 01 PAPLURONIC L64 LIQ BRAND TIER 99 DEPOLY GLYCOL GRA 3350 GENERIC TIER 99 DEPOLY GLYCOL LIQ 1450 GENERIC TIER 99 DEPOLYETH GLYC OIN 8000 GENERIC TIER 01POLYETH GLYC POW 3350 NF GENERIC TIER 01POLYETHYLENE LIQ GLYCOL GENERIC TIER 99 DEPREPOPIK PAK BRAND TIER 03SENNA LEAVES MIS GENERIC TIER 01SORBITOL MIS LOLLIPOP BRAND TIER 99 DESORBITOL SOL GENERIC TIER 99 DESUPREP BOWEL SOL PREP BRAND TIER 02TRILYTE SOL GENERIC TIER 01 PAVISICOL TAB 1.5GM BRAND TIER 03POLYETHYLENE LIQ GLY 400 GENERIC TIER 99 DEPEG 300 LIQ GENERIC TIER 99 DEMINERAL OIL HEAVY GENERIC TIER 01MINERAL OIL HEAVY TIER 99 DEMINERAL OIL LIGHT GENERIC TIER 99 DESORBITOL SOL 70% GENERIC TIER 99 DEMAGN SULFATE GRA USP GENERIC TIER 99 DECELL STIMULANTS AND PROLIFERANTS ATRALIN GEL 0.05% BRAND TIER 02 PAAVITA CRE 0.025% GENERIC TIER 01AVITA GEL 0.025% GENERIC TIER 01 PAKEPIVANCE INJ 6.25MG BRAND TIER 02 SPREFISSA CRE 0.05% BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion87

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCELL STIMULANTS AND PROLIFERANTS RENOVA CRE 0.02% BRAND TIER 03RENOVA PUMP CRE 0.02% BRAND TIER 03RETIN‐A CRE 0.025% Brand‐O TIER 03 PARETIN‐A CRE 0.05% Brand‐O TIER 03 PARETIN‐A CRE 0.1% Brand‐O TIER 03 PARETIN‐A GEL 0.01% Brand‐O TIER 03 PARETIN‐A GEL 0.025% Brand‐O TIER 03 PARETIN‐A MICR GEL 0.04% BRAND TIER 03 PARETIN‐A MICR GEL 0.04%PMP BRAND TIER 03 PARETIN‐A MICR GEL 0.1% BRAND TIER 03 PARETIN‐A MICR GEL 0.1%PUMP BRAND TIER 03 PATRETINOIN CRE 0.025% GENERIC TIER 01TRETINOIN CRE 0.05% GENERIC TIER 01TRETINOIN CRE 0.1% GENERIC TIER 01TRETINOIN GEL 0.01% GENERIC TIER 01 PATRETINOIN GEL 0.025% GENERIC TIER 01 PATRETINOIN EM CRE 0.05% GENERIC TIER 01TRETIN‐X CRE 0.0375% BRAND TIER 03TRETIN‐X CRE KIT 0.025% BRAND TIER 03 PATRETIN‐X CRE KIT 0.05% BRAND TIER 03 PATRETIN‐X CRE KIT 0.1% BRAND TIER 03 PATRETIN‐X GEL KIT 0.01% BRAND TIER 03 PATRETIN‐X GEL KIT 0.025% BRAND TIER 03 PACELLULAR THERAPY PROVENGE INJ BRAND TIER 03CENTRAL ALPHA‐AGONISTS CATAPRES TAB 0.1MG Brand‐O TIER 03 PACATAPRES TAB 0.2MG Brand‐O TIER 03 PACATAPRES TAB 0.3MG Brand‐O TIER 03 PACATAPRES‐TTS DIS 0.1/24HR Brand‐O TIER 03 PACATAPRES‐TTS DIS 0.2/24HR Brand‐O TIER 03 PACATAPRES‐TTS DIS 0.3/24HR Brand‐O TIER 03 PACLONIDINE DIS 0.1/24HR GENERIC TIER 01CLONIDINE DIS 0.2/24HR GENERIC TIER 01CLONIDINE DIS 0.3/24HR GENERIC TIER 01CLONIDINE INJ GENERIC TIER 01CLONIDINE TAB 0.1MG GENERIC TIER 01CLONIDINE TAB 0.2MG GENERIC TIER 01CLONIDINE TAB 0.3MG GENERIC TIER 01CLORPRES TAB 0.1‐15MG BRAND TIER 03CLORPRES TAB 0.2‐15MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion88

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCENTRAL ALPHA‐AGONISTS CLORPRES TAB 0.3‐15MG BRAND TIER 03DURACLON INJ Brand‐O TIER 03 PAGUANABENZ TAB 4MG GENERIC TIER 01GUANFACINE TAB 1MG GENERIC TIER 01GUANFACINE TAB 2MG GENERIC TIER 01KAPVAY MIS 0.1&0.2 BRAND TIER 03KAPVAY TAB 0.1 MG BRAND TIER 03 PA QLMETHYLD/HCTZ TAB 250/15 GENERIC TIER 01METHYLD/HCTZ TAB 250/25 GENERIC TIER 01METHYLDOPA TAB 250MG GENERIC TIER 01METHYLDOPA TAB 500MG GENERIC TIER 01METHYLDOPATE INJ 250/5ML GENERIC TIER 01NEXICLON XR SUS 0.09/ML BRAND TIER 03NEXICLON XR TAB 0.17MG BRAND TIER 03 PATENEX TAB 1MG Brand‐O TIER 03 PATENEX TAB 2MG Brand‐O TIER 03 PACENTRAL NERVOUS SYSTEM AGENTS, MISC. CAMPRAL TAB 333MG BRAND TIER 03FLUMAZENIL INJ 0.1MG/ML GENERIC TIER 01FLUMAZENIL INJ 0.5MG/5 GENERIC TIER 01FLUMAZENIL INJ 1MG/10ML GENERIC TIER 01INTUNIV TAB 1MG BRAND TIER 02 PA QLINTUNIV TAB 2MG BRAND TIER 02 PA QLINTUNIV TAB 3MG BRAND TIER 02 PA QLINTUNIV TAB 4MG BRAND TIER 02 PA QLNAMENDA SOL 10MG/5ML BRAND TIER 02NAMENDA TAB 10MG BRAND TIER 02NAMENDA TAB 5‐10MG BRAND TIER 02NAMENDA TAB 5MG BRAND TIER 02NUEDEXTA CAP 20‐10MG BRAND TIER 02RILUTEK TAB 50MG BRAND TIER 02ROMAZICON INJ 0.1MG/ML Brand‐O TIER 03 PASTRATTERA CAP 100MG BRAND TIER 02 PA QLSTRATTERA CAP 10MG BRAND TIER 02 PA QLSTRATTERA CAP 18MG BRAND TIER 02 PA QLSTRATTERA CAP 25MG BRAND TIER 02 PA QLSTRATTERA CAP 40MG BRAND TIER 02 PA QLSTRATTERA CAP 60MG BRAND TIER 02 PA QLSTRATTERA CAP 80MG BRAND TIER 02 PA QLXENAZINE TAB 12.5MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion89

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCENTRAL NERVOUS SYSTEM AGENTS, MISC. XENAZINE TAB 25MG BRAND TIER 02XYREM SOL 500MG/ML BRAND TIER 02CENTRALLY ACTING SKELETAL MUSCLE RELAXNT AMRIX CAP 15MG BRAND TIER 03 PAAMRIX CAP 30MG BRAND TIER 03 PACARISOPR/ASA TAB 200‐325 GENERIC TIER 01 QLCARISOPRODOL TAB 250MG GENERIC TIER 01 PA QLCARISOPRODOL TAB 350MG GENERIC TIER 01 QLCARISOPRODOL TAB ASA/COD GENERIC TIER 01CHLORZOXAZON TAB 500MG GENERIC TIER 01CYCLOBENZAPR CAP 15MG ER GENERIC TIER 01 PACYCLOBENZAPR CAP 30MG ER GENERIC TIER 01 PACYCLOBENZAPR CRE 20MG/GM GENERIC TIER 01CYCLOBENZAPR KIT COMFORT BRAND TIER 03CYCLOBENZAPR TAB 10MG GENERIC TIER 01CYCLOBENZAPR TAB 5MG GENERIC TIER 01CYCLOBENZAPR TAB 7.5MG GENERIC TIER 01 PAFEXMID TAB 7.5MG Brand‐O TIER 03 PAFLEXERIL TAB 10MG Brand‐O TIER 03 PAFLEXERIL TAB 5MG Brand‐O TIER 03 PALORZONE TAB 375MG BRAND TIER 03LORZONE TAB 750MG BRAND TIER 03METAXALONE TAB 800MG GENERIC TIER 01 PAMETHOCARBAM TAB 500MG GENERIC TIER 01METHOCARBAM TAB 750MG GENERIC TIER 01PARAFON FORT TAB DSC Brand‐O TIER 03 PAPRAZOLAMINE PAK BRAND TIER 03ROBAXIN INJ 100MG/ML BRAND TIER 03ROBAXIN TAB 500MG Brand‐O TIER 03 PAROBAXIN‐750 TAB 750MG Brand‐O TIER 03 PASKELAXIN TAB 800MG Brand‐O TIER 03 PASOMA TAB 250MG BRAND TIER 03 PA QLSOMA TAB 350MG Brand‐O TIER 03 PA QLTHERABENZAPR PAK ‐60 BRAND TIER 03THERABENZAPR PAK ‐90 BRAND TIER 03THERABENZAPR PAK ‐90‐5 BRAND TIER 03TIZANIDINE CAP 2MG GENERIC TIER 01 PATIZANIDINE CAP 4MG GENERIC TIER 01 PATIZANIDINE CAP 6MG GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion90

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE TAB 2MG GENERIC TIER 01 PATIZANIDINE TAB 4MG GENERIC TIER 01 PAZANAFLEX CAP 2MG Brand‐O TIER 03 PAZANAFLEX CAP 4MG Brand‐O TIER 03 PAZANAFLEX CAP 6MG Brand‐O TIER 03 PAZANAFLEX TAB 4MG Brand‐O TIER 03 PACEPHAMYCINS CEFOTET/DEX INJ 1‐3.58% GENERIC TIER 01CEFOTET/DEX INJ 2‐2.08% GENERIC TIER 01CEFOTETAN INJ 10G GENERIC TIER 01CEFOTETAN INJ 1GM/10ML GENERIC TIER 01CEFOTETAN INJ 2GM/20ML GENERIC TIER 01CEFOXITIN INJ 10GM GENERIC TIER 01CEFOXITIN INJ 1GM GENERIC TIER 01CEFOXITIN INJ 2GM GENERIC TIER 01MEFOXIN INJ 1GM/50ML BRAND TIER 99 DEMEFOXIN INJ 2GM/50ML BRAND TIER 99 DECHLORAMPHENICOL CHLORAMPHEN INJ 1GM GENERIC TIER 01CHOLELITHOLYTIC AGENTS ACTIGALL CAP 300MG Brand‐O TIER 03 PACHENODAL TAB 250MG BRAND TIER 03URSO 250 TAB 250MG Brand‐O TIER 03 PAURSO FORTE TAB 500MG Brand‐O TIER 03 PAURSODIOL CAP 300MG GENERIC TIER 01URSODIOL TAB 250MG GENERIC TIER 01URSODIOL TAB 500MG GENERIC TIER 01CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB 10MG BRAND TIER 02 PACLASS IA ANTIARRHYTHMICS DISOPYRAMIDE CAP 100MG GENERIC TIER 01DISOPYRAMIDE CAP 150MG GENERIC TIER 01NORPACE CAP 100MG Brand‐O TIER 03 PANORPACE CAP 100MG CR BRAND TIER 03NORPACE CAP 150MG Brand‐O TIER 03 PANORPACE CAP 150MG CR BRAND TIER 03PROCAINAMIDE INJ 100MG/ML GENERIC TIER 01PROCAINAMIDE INJ 500MG/ML GENERIC TIER 01QUINIDINE GL INJ 80MG/ML GENERIC TIER 01QUINIDINE GL TAB 324MG CR GENERIC TIER 01QUINIDINE GL TAB 324MG ER GENERIC TIER 01QUINIDINE SU TAB 200MG GENERIC TIER 01QUINIDINE SU TAB 300MG GENERIC TIER 01QUINIDINE SU TAB 300MG ER GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion91

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCLASS IB ANTIARRHYTHMICS LIDOCAIN/D5W INJ 4MG/ML GENERIC TIER 01LIDOCAIN/D5W INJ 8MG/ML GENERIC TIER 01LIDOCAINE INJ 10MG/ML GENERIC TIER 01LIDOCAINE INJ 20MG/ML GENERIC TIER 01MEXILETINE CAP 150MG GENERIC TIER 01MEXILETINE CAP 200MG GENERIC TIER 01MEXILETINE CAP 250MG GENERIC TIER 01CLASS IC ANTIARRHYTHMICS FLECAINIDE TAB 100MG GENERIC TIER 01FLECAINIDE TAB 150MG GENERIC TIER 01FLECAINIDE TAB 50MG GENERIC TIER 01PROPAFENONE CAP 225MG ER GENERIC TIER 01PROPAFENONE CAP 325MG ER GENERIC TIER 01PROPAFENONE CAP 425MG SR GENERIC TIER 01PROPAFENONE TAB 150MG GENERIC TIER 01PROPAFENONE TAB 225MG GENERIC TIER 01PROPAFENONE TAB 300MG GENERIC TIER 01RYTHMOL TAB 150MG Brand‐O TIER 03 PARYTHMOL TAB 225MG Brand‐O TIER 03 PARYTHMOL SR CAP 225MG Brand‐O TIER 03 PARYTHMOL SR CAP 325MG Brand‐O TIER 03 PARYTHMOL SR CAP 425MG Brand‐O TIER 03 PATAMBOCOR TAB 100MG Brand‐O TIER 03 PATAMBOCOR TAB 150MG Brand‐O TIER 03 PATAMBOCOR TAB 50MG Brand‐O TIER 03 PACLASS III ANTIARRHYTHMICS AMIODARONE INJ 150MG/3M GENERIC TIER 01AMIODARONE INJ 50MG/ML GENERIC TIER 01AMIODARONE TAB 200MG GENERIC TIER 01AMIODARONE TAB 400MG GENERIC TIER 01CORDARONE TAB 200MG Brand‐O TIER 03 PACORVERT INJ 1MG/10ML Brand‐O TIER 03 PAIBUTILIDE INJ 1MG/10ML GENERIC TIER 01MULTAQ TAB 400MG BRAND TIER 02NEXTERONE INJ BRAND TIER 99 DEPACERONE TAB 100MG BRAND TIER 02PACERONE TAB 200MG GENERIC TIER 01PACERONE TAB 400MG Brand‐O TIER 03 PATIKOSYN CAP 125MCG BRAND TIER 02 SPTIKOSYN CAP 250MCG BRAND TIER 02 SPTIKOSYN CAP 500MCG BRAND TIER 02 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion92

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCLASS IV ANTIARRHYTHMICS ADENOCARD INJ 12MG/4ML Brand‐O TIER 03 PAADENOCARD INJ 3MG/ML Brand‐O TIER 03 PAADENOCARD INJ 6MG/2ML Brand‐O TIER 03 PAADENOSINE INJ 12MG/4ML GENERIC TIER 01ADENOSINE INJ 3MG/ML GENERIC TIER 01ADENOSINE INJ 6MG/2ML GENERIC TIER 01COMPLEMENT INHIBITORS BERINERT INJ 500UNIT BRAND TIER 03 PA SPCINRYZE SOL 500 UNIT BRAND TIER 03 PA SPFIRAZYR INJ 30MG/3ML BRAND TIER 03 PA SPKALBITOR INJ 10MG/ML BRAND TIER 03 PASOLIRIS INJ 10MG/ML BRAND TIER 02 SPCONTRACEPTIVES ALTAVERA TAB GENERIC TIER 01ALYACEN TAB 1/35 GENERIC TIER 01ALYACEN TAB 7/7/7 GENERIC TIER 01AMETHIA TAB GENERIC TIER 01AMETHIA LO TAB GENERIC TIER 01AMETHYST TAB 90‐20MCG GENERIC TIER 01APRI TAB GENERIC TIER 01ARANELLE TAB GENERIC TIER 01AVIANE TAB GENERIC TIER 01AZURETTE TAB 28 DAY GENERIC TIER 01BALZIVA TAB GENERIC TIER 01BEYAZ TAB BRAND TIER 02BREVICON TAB 0.5/35 Brand‐O TIER 03 PABRIELLYN TAB GENERIC TIER 01CAMILA TAB 0.35MG GENERIC TIER 01CAMRESE TAB GENERIC TIER 01CAMRESE LO TAB GENERIC TIER 01CAZIANT PAK GENERIC TIER 01CESIA PAK GENERIC TIER 01CRYSELLE‐28 TAB 28 TABS GENERIC TIER 01CYCLAFEM TAB 1/35 GENERIC TIER 01CYCLAFEM TAB 7/7/7 GENERIC TIER 01CYCLESSA PAK Brand‐O TIER 03 PADASETTA TAB 1/35 GENERIC TIER 01DASETTA TAB 7/7/7 GENERIC TIER 01DESOGEN‐28 TAB Brand‐O TIER 03 PAELINEST TAB GENERIC TIER 01ELLA TAB 30MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion93

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES EMOQUETTE TAB GENERIC TIER 01ENPRESSE‐28 TAB GENERIC TIER 01ERRIN TAB 0.35MG GENERIC TIER 01ESTROSTEP FE TAB Brand‐O TIER 03 PAFALMINA TAB GENERIC TIER 01FEMCON FE CHW Brand‐O TIER 03 PAGENERESS FE CHW BRAND TIER 03GIANVI TAB 3‐0.02MG GENERIC TIER 01GILDESS FE TAB 1.5/30 GENERIC TIER 01GILDESS FE TAB 1/20 GENERIC TIER 01HEATHER TAB 0.35MG GENERIC TIER 01IMPLANON IMP 68MG BRAND TIER 99 DEINTROVALE TAB GENERIC TIER 01JOLESSA TAB GENERIC TIER 01JOLIVETTE TAB 0.35MG GENERIC TIER 01JUNEL 1.5/30 TAB GENERIC TIER 01JUNEL 1/20 TAB GENERIC TIER 01JUNEL FE TAB 1.5/30 GENERIC TIER 01JUNEL FE TAB 1/20 GENERIC TIER 01KARIVA TAB 28 DAY GENERIC TIER 01KELNOR TAB 1/35 GENERIC TIER 01LEENA TAB GENERIC TIER 01LESSINA‐28 TAB GENERIC TIER 01LEVONEST TAB GENERIC TIER 01LEVONOR/ETHI TAB ESTRADIO GENERIC TIER 01LEVONORGESTR TAB 0.75MG GENERIC TIER 01LEVORA‐28 TAB 0.15/30 GENERIC TIER 01LO LOESTRIN TAB BRAND TIER 02LO/OVRAL‐28 TAB Brand‐O TIER 03 PALOESTRIN TAB 1/20‐21 Brand‐O TIER 03 PALOESTRIN 21 TAB 1.5/30 Brand‐O TIER 03 PALOESTRIN 24 TAB FE BRAND TIER 02LOESTRIN FE TAB 1.5/30 Brand‐O TIER 03 PALOESTRIN FE TAB 1/20 Brand‐O TIER 03 PALORYNA TAB 3‐0.02MG GENERIC TIER 01LOSEASONIQUE TAB Brand‐O TIER 03 PALOW‐OGESTREL TAB GENERIC TIER 01LUTERA TAB GENERIC TIER 01LYBREL TAB 90‐20MCG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion94

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES MARLISSA TAB 0.15/30 GENERIC TIER 01MICROGESTIN TAB 1.5/30 GENERIC TIER 01MICROGESTIN TAB 1/20 GENERIC TIER 01MICROGESTIN TAB FE 1/20 GENERIC TIER 01MICROGESTIN TAB FE1.5/30 GENERIC TIER 01MIRCETTE TAB 28 DAY Brand‐O TIER 03 PAMIRENA IUD SYSTEM BRAND TIER 03MODICON TAB 0.5/35 Brand‐O TIER 03 PAMONONESSA TAB GENERIC TIER 01MYZILRA TAB GENERIC TIER 01NATAZIA TAB BRAND TIER 02NECON TAB 0.5/35 GENERIC TIER 01NECON TAB 1/35‐28 GENERIC TIER 01NECON TAB 1/50‐28 GENERIC TIER 01NECON TAB 10/11‐28 GENERIC TIER 01NECON 7/7/7 TAB 28 DAY GENERIC TIER 01NEXPLANON IMP 68MG BRAND TIER 99 DENEXT CHOICE TAB 0.75MG GENERIC TIER 01NEXT CHOICE TAB 1.5MG GENERIC TIER 01NORA‐BE TAB 0.35MG GENERIC TIER 01NORDETTE‐28 TAB Brand‐O TIER 03 PANORETHINDRON TAB 0.35MG GENERIC TIER 01NORGEST/ETH TAB ESTRAD GENERIC TIER 01NORGEST/ETHI TAB 0.25/35 GENERIC TIER 01NORGEST/ETHI TAB ESTRADIO GENERIC TIER 01NORINYL TAB 1+35‐28 Brand‐O TIER 03 PANORINYL TAB 1+50‐28 BRAND TIER 03NOR‐QD TAB 0.35MG Brand‐O TIER 03 PANORTREL (21) TAB 1/35 GENERIC TIER 01NORTREL (28) TAB 1/35 GENERIC TIER 01NORTREL 28 TAB 0.5/35 GENERIC TIER 01NORTREL7/7/7 TAB 28 DAYS GENERIC TIER 01NUVARING MIS BRAND TIER 02OCELLA TAB 3‐0.03MG GENERIC TIER 01OGESTREL TAB GENERIC TIER 01ORSYTHIA TAB GENERIC TIER 01ORTHO EVRA DIS WEEK BRAND TIER 03ORTHO MICRON TAB 0.35MG Brand‐O TIER 03 PAORTHO TRI‐ TAB CYCLEN Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion95

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES ORTHO TRI‐ TAB CYCLN LO BRAND TIER 03ORTHO‐CEPT TAB 28 Brand‐O TIER 03 PAORTHO‐CYCLEN TAB 0.25/35 Brand‐O TIER 03 PAORTHO‐NOVUM TAB 1/35‐28 Brand‐O TIER 03 PAORTHO‐NOVUM TAB 7/7/7‐28 Brand‐O TIER 03 PAOVCON 50 TAB 28 BRAND TIER 03OVCON‐35 TAB Brand‐O TIER 03 PAPHILITH TAB 0.4‐35 GENERIC TIER 01PLAN B TAB 0.75MG Brand‐O TIER 03 PAPLAN B TAB 1.5MG Brand‐O TIER 03 PAPORTIA‐28 TAB GENERIC TIER 01PREVIFEM TAB GENERIC TIER 01QUASENSE TAB GENERIC TIER 01RECLIPSEN TAB GENERIC TIER 01SAFYRAL TAB BRAND TIER 02SEASONALE TAB Brand‐O TIER 03 PASEASONIQUE TAB Brand‐O TIER 03 PASOLIA TAB GENERIC TIER 01SPRINTEC 28 TAB 28 DAY GENERIC TIER 01SRONYX TAB GENERIC TIER 01SYEDA TAB 3‐0.03MG GENERIC TIER 01TILIA FE TAB GENERIC TIER 01TRI‐LEGEST TAB FE GENERIC TIER 01TRINESSA TAB GENERIC TIER 01TRI‐NORINYL TAB 28 Brand‐O TIER 03 PATRI‐PREVIFEM TAB GENERIC TIER 01TRI‐SPRINTEC TAB GENERIC TIER 01TRIVORA‐28 TAB GENERIC TIER 01VELIVET PAK GENERIC TIER 01VESTURA TAB 3‐0.02MG GENERIC TIER 01VIORELE TAB GENERIC TIER 01WERA TAB 0.5/35 GENERIC TIER 01WYMZYA FE CHW 0.4MG‐35 GENERIC TIER 01YASMIN 28 TAB 3‐0.03MG Brand‐O TIER 03 PAYAZ TAB 3‐0.02MG Brand‐O TIER 02 PAZARAH TAB GENERIC TIER 01ZENCHENT TAB GENERIC TIER 01ZENCHENT FE CHW 0.4MG‐35 GENERIC TIER 01ZEOSA CHW GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion96

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES ZOVIA 1/35E TAB GENERIC TIER 01ZOVIA 1/50E TAB GENERIC TIER 01CONTRACEPTIVES (E.G. FOAMS, DEVICES) FEMCAP MIS 22MM BRAND TIER 99 DEFEMCAP MIS 26MM BRAND TIER 99 DEFEMCAP MIS 30MM BRAND TIER 99 DEOMNIFLEX DPR BRAND TIER 03ORTHO COIL DPR KIT 100 BRAND TIER 03ORTHO COIL DPR KIT 105 BRAND TIER 03ORTHO COIL DPR KIT 50 BRAND TIER 03ORTHO FLAT DPR KIT 55 BRAND TIER 03ORTHO FLAT DPR KIT 60 BRAND TIER 03ORTHO FLAT DPR KIT 65 BRAND TIER 03ORTHO FLAT DPR KIT 70 BRAND TIER 03ORTHO FLAT DPR KIT 75 BRAND TIER 03ORTHO FLAT DPR KIT 80 BRAND TIER 03ORTHO FLAT DPR KIT 85 BRAND TIER 03ORTHO FLAT DPR KIT 90 BRAND TIER 03ORTHO FLAT DPR KIT 95 BRAND TIER 03ORTHO FLEX DPR 65MM BRAND TIER 03ORTHO FLEX DPR 70MM BRAND TIER 03ORTHO FLEX DPR 75MM BRAND TIER 03ORTHO FLEX DPR 80MM BRAND TIER 03PARAGARD IUD T380A BRAND TIER 03PRENTIF MIS 22MM BRAND TIER 99 DEPRENTIF MIS 25MM BRAND TIER 99 DEPRENTIF MIS 28MM BRAND TIER 99 DEPRENTIF MIS 31MM BRAND TIER 99 DEPRENTIF MIS FITTING BRAND TIER 03WIDE‐SEAL DPR KIT 60 BRAND TIER 03WIDE‐SEAL DPR KIT 65 BRAND TIER 03WIDE‐SEAL DPR KIT 70 BRAND TIER 03WIDE‐SEAL DPR KIT 75 BRAND TIER 03WIDE‐SEAL DPR KIT 80 BRAND TIER 03WIDE‐SEAL DPR KIT 85 BRAND TIER 03WIDE‐SEAL DPR KIT 90 BRAND TIER 03WIDE‐SEAL DPR KIT 95 BRAND TIER 03CORTICOSTEROIDS (EENT) ACETASOL HC SOL OTIC GENERIC TIER 01AERO OTIC HC SOL GENERIC TIER 99 DEALREX SUS 0.2% BRAND TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion97

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCORTICOSTEROIDS (EENT) BECONASE AQ SUS 0.042% BRAND TIER 03 PABLEPHAMIDE OIN S.O.P. BRAND TIER 02BLEPHAMIDE SUS OP BRAND TIER 03CIPRO HC SUS OTIC BRAND TIER 03CIPRODEX SUS 0.3‐0.1% BRAND TIER 02COLY‐MYCIN S SUS OTIC BRAND TIER 03CORTIC‐ND DRO GENERIC TIER 99 DECORTISPORIN SOL 1% OTIC Brand‐O TIER 03 PACORTISPORIN SUS ‐TC OTIC BRAND TIER 03CORTOMYCIN SUS 1% OTIC GENERIC TIER 01CYOTIC DRO GENERIC TIER 99 DEDERMOTIC OIL 0.01% Brand‐O TIER 03 PADEXAMETH PHO SOL 0.1% OP GENERIC TIER 01DUREZOL EMU 0.05% BRAND TIER 02 PAEXOTIC‐HC DRO OTIC GENERIC TIER 99 DEFLAREX SUS 0.1% OP BRAND TIER 03FLONASE SPR 0.05% Brand‐O TIER 03 PAFLUNISOLIDE SPR 0.025% GENERIC TIER 01FLUNISOLIDE SPR 29MCG GENERIC TIER 01FLUOCIN ACET OIL 0.01% GENERIC TIER 01FLUOROMETHOL SUS 0.1% OP GENERIC TIER 01FLUOR‐OP SUS 0.1% OP GENERIC TIER 01FLUTICASONE SPR 50MCG GENERIC TIER 01FML OIN 0.1% OP BRAND TIER 02FML FORTE SUS 0.25% OP BRAND TIER 03FML LIQUIFLM SUS 0.1% OP Brand‐O TIER 03 PAHC/ACET ACID SOL OTIC GENERIC TIER 01LOTEMAX OIN 0.5% BRAND TIER 03 PALOTEMAX SUS 0.5% BRAND TIER 02 PAMAXIDEX SUS 0.1% OP BRAND TIER 03MAXITROL OIN 0.1% OP Brand‐O TIER 03 PAMAXITROL SUS 0.1% OP Brand‐O TIER 03 PANASACORT AQ AER 55MCG/AC Brand‐O TIER 03 PANASONEX SPR 50MCG/AC BRAND TIER 02 PANEO/POLY/BAC OIN /HC 1%OP GENERIC TIER 01NEO/POLY/DEX OIN 0.1% OP GENERIC TIER 01NEO/POLY/DEX SUS 0.1% OP GENERIC TIER 01NEO/POLY/HC SOL 1% OTIC GENERIC TIER 01NEO/POLY/HC SUS 1% OTIC GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion98

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCORTICOSTEROIDS (EENT) NEO/POLY/HC SUS OP GENERIC TIER 01OMNARIS SPR BRAND TIER 03 PAOMNIPRED SUS 1% OP Brand‐O TIER 03 PAOTO‐END 10 SOL GENERIC TIER 99 DEOTOMAR SOL OTIC GENERIC TIER 99 DEOTOMAX‐HC DRO GENERIC TIER 99 DEOZURDEX IMP 0.7MG BRAND TIER 02POLY‐DEX OIN 0.1% OP GENERIC TIER 01POLY‐PRED SUS OP BRAND TIER 03PRAMOXINE‐HC DRO AQ OTIC GENERIC TIER 99 DEPRED FORTE SUS 1% OP Brand‐O TIER 03 PAPRED MILD SUS 0.12% OP BRAND TIER 02PRED SOD PHO SOL 1% OP GENERIC TIER 01PRED‐G SUS OP BRAND TIER 03PRED‐G S.O.P OIN OP BRAND TIER 03PREDNISOLONE SUS 1% OP GENERIC TIER 01QNASL AER 80MCG BRAND TIER 03RETISERT IMP 0.59MG BRAND TIER 02RHINOCORT SUS AQUA BRAND TIER 02 PASULF/PRED NA SOL OP GENERIC TIER 01TOBRA/DEXAME SUS 0.3‐0.1% GENERIC TIER 01 PATOBRADEX OIN 0.3‐0.1% BRAND TIER 02TOBRADEX SUS 0.3‐0.1% Brand‐O TIER 03 PATOBRADEX ST SUS 0.3‐0.05 BRAND TIER 02 PATRIAMCINOLON SPR 55MCG/AC GENERIC TIER 01 PATRIESENCE INJ 40MG/ML BRAND TIER 99 DEVERAMYST SPR 27.5MCG BRAND TIER 02 PAVEXOL SUS 1% OP BRAND TIER 03VOSOL HC SOL OTIC Brand‐O TIER 03 PAZETONNA AER 37MCG BRAND TIER 03 PAZYLET SUS 0.5‐0.3% BRAND TIER 02 PACORTANE‐B DRO OTIC Brand‐O TIER 99 PA DECORTANE‐B DRO AQ OTIC Brand‐O TIER 99 PA DEOTICIN HC DRO Brand‐O TIER 99 PA DECOUMARIN DERIVATIVES COUMADIN INJ 5 MG BRAND TIER 03COUMADIN TAB 10MG Brand‐O TIER 03 PACOUMADIN TAB 1MG Brand‐O TIER 03 PACOUMADIN TAB 2.5MG Brand‐O TIER 03 PACOUMADIN TAB 2MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion99

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCOUMARIN DERIVATIVES COUMADIN TAB 3MG Brand‐O TIER 03 PACOUMADIN TAB 4MG Brand‐O TIER 03 PACOUMADIN TAB 5MG Brand‐O TIER 03 PACOUMADIN TAB 6MG Brand‐O TIER 03 PACOUMADIN TAB 7.5MG Brand‐O TIER 03 PAJANTOVEN TAB 10MG GENERIC TIER 01JANTOVEN TAB 1MG GENERIC TIER 01JANTOVEN TAB 2.5MG GENERIC TIER 01JANTOVEN TAB 2MG GENERIC TIER 01JANTOVEN TAB 3MG GENERIC TIER 01JANTOVEN TAB 4MG GENERIC TIER 01JANTOVEN TAB 5MG GENERIC TIER 01JANTOVEN TAB 6MG GENERIC TIER 01JANTOVEN TAB 7.5MG GENERIC TIER 01WARFARIN TAB 10MG GENERIC TIER 01WARFARIN TAB 1MG GENERIC TIER 01WARFARIN TAB 2.5MG GENERIC TIER 01WARFARIN TAB 2MG GENERIC TIER 01WARFARIN TAB 3MG GENERIC TIER 01WARFARIN TAB 4MG GENERIC TIER 01WARFARIN TAB 5MG GENERIC TIER 01WARFARIN TAB 6MG GENERIC TIER 01WARFARIN TAB 7.5MG GENERIC TIER 01CYCLIC LIPOPEPTIDES CUBICIN SOL 500MG BRAND TIER 03CYCLOOXYGENASE‐2 (COX‐2) INHIBITORS CELEBREX CAP 100MG BRAND TIER 02 PA QLCELEBREX CAP 200MG BRAND TIER 02 PA QLCELEBREX CAP 400MG BRAND TIER 02 PA QLCELEBREX CAP 50MG BRAND TIER 02 PA QLDENTAL AGENTS FLUORIDEX GEL SENSITIV BRAND TIER 03FLUORIDEX DD PST SENSITIV GENERIC TIER 01MI PASTE PST BRAND TIER 03MI PLUS PST BRAND TIER 03NAFRINSE SOL DAILY BRAND TIER 03PREVIDENT PST 5000 SEN Brand‐O TIER 03 PAPRVDNT 5000 PST ENAML PR Brand‐O TIER 03 PAQ4 ORAL CLEA KIT SYSTEM BRAND TIER 03REMESENSE MIS BRAND TIER 03Q2 ORAL CLEA KIT SYSTEM BRAND TIER 03DEPIGMENTING AGENTS ACLARO EMU BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion100

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEPIGMENTING AGENTS ACLARO PD EMU 4% BRAND TIER 99 DEALPHAQUIN HP CRE 4% GENERIC TIER 01ELDOPAQUE CRE 4% FORTE Brand‐O TIER 03 PAELDOQUIN CRE 4% FORTE Brand‐O TIER 03 PAEPIQUIN MICR CRE 4% Brand‐O TIER 03 PAEPIQUIN MICR CRE 4% PUMP Brand‐O TIER 03 PAHYDROQUINONE CRE 4% GENERIC TIER 01HYDROQUINONE CRE 4% TR GENERIC TIER 01HYDROQUINONE CRE 4%/SUNS GENERIC TIER 01HYDROQUINONE EMU 4% GENERIC TIER 99 DEHYDROQUINONE GEL 4%/SUNS GENERIC TIER 01LUSTRA CRE 4% Brand‐O TIER 03 PALUSTRA‐AF CRE 4% Brand‐O TIER 03 PALUSTRA‐ULTRA CRE 4% Brand‐O TIER 03 PAMELPAQUE HP CRE 4% GENERIC TIER 01MELQUIN 3 SOL 3% GENERIC TIER 01MELQUIN HP CRE 4% GENERIC TIER 01NAVA‐SC CRE 4% GENERIC TIER 01NUQUIN HP CRE 4% GENERIC TIER 01NUQUIN HP GEL 4% GENERIC TIER 01REMERGENT HQ CRE 4% GENERIC TIER 01SKIN BLEACH CRE 4% GENERIC TIER 01SKIN BLEACH CRE SUNSCREE GENERIC TIER 01TL HYDROQUIN CRE 4% GENERIC TIER 01TRI‐LUMA CRE BRAND TIER 03DEVICES 1 ML SYRIMGE MIS 18GX1" BRAND TIER 0310ML SYRINGE MIS 20GX1" BRAND TIER 0310ML SYRINGE MIS 20GX1.5" BRAND TIER 0310ML SYRINGE MIS 21GX1.5" BRAND TIER 0310ML SYRINGE MIS 22GX1.5" BRAND TIER 0312ML SYRINGE MIS /SHIELD BRAND TIER 0312ML SYRINGE MIS CANNULA BRAND TIER 0312ML SYRINGE MIS ECC LUER BRAND TIER 0312ML SYRINGE MIS LUER LOK BRAND TIER 031ML SYRINGE MIS 25GX1" BRAND TIER 031ML SYRINGE MIS 27GX1/2" BRAND TIER 031ML TB SYRNG MIS /LUER BRAND TIER 031ML TB SYRNG MIS LUER LOK BRAND TIER 031ML TB SYRNG MIS LUER SLP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion101

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES 20ML SYRINGE MIS LUER LOK BRAND TIER 0320ML SYRINGE MIS REG LUER BRAND TIER 032‐WAY CATH MIS 18FR‐5ML BRAND TIER 0330ML SYRINGE MIS LUER SLP BRAND TIER 0335ML SYRINGE MIS ECC LUER BRAND TIER 0335ML SYRINGE MIS REG LUER BRAND TIER 033ML GLAS SYR KIT NA HEPAR GENERIC TIER 013ML LL SYRNG MIS 25GX1.25 BRAND TIER 033ML SYRINGE MIS /SHIELD BRAND TIER 033ML SYRINGE MIS 18GX1" BRAND TIER 033ML SYRINGE MIS 20GX1" BRAND TIER 033ML SYRINGE MIS 20GX1.5" BRAND TIER 033ML SYRINGE MIS 21GX1" BRAND TIER 033ML SYRINGE MIS 22GX1" BRAND TIER 033ML SYRINGE MIS LUER LK BRAND TIER 033ML SYRINGE MIS LUER LOK BRAND TIER 033ML SYRINGE MIS REG LUER BRAND TIER 035ML GLAS SYR KIT NA HEPAR GENERIC TIER 015ML SYRINGE MIS 20GX1" BRAND TIER 035ML SYRINGE MIS 20GX1.5" BRAND TIER 035ML SYRINGE MIS 21GX1.5" BRAND TIER 0360ML SYRINGE MIS ECC LUER BRAND TIER 0360ML SYRINGE MIS REG LUER BRAND TIER 0360ML SYRINGE MIS TOOMEY BRAND TIER 036ML SYRINGE MIS BRAND TIER 036ML SYRINGE MIS /SHIELD BRAND TIER 036ML SYRINGE MIS 18GX1" BRAND TIER 036ML SYRINGE MIS 20GX1.5" BRAND TIER 036ML SYRINGE MIS 21GX1" BRAND TIER 036ML SYRINGE MIS 21GX1.5" BRAND TIER 036ML SYRINGE MIS 22GX1.5" BRAND TIER 036ML SYRINGE MIS CANNULA BRAND TIER 036ML SYRINGE MIS LUER LOK BRAND TIER 036ML SYRINGE MIS REG LUER BRAND TIER 0380ML SYRINGE MIS ANGIO GENERIC TIER 01ACCU‐CHEK KIT SPIRIT BRAND TIER 99 DEACCU‐CHEK MIS ADAPTER BRAND TIER 03ACCU‐CHEK MIS BATTERY BRAND TIER 03ACE AERO CLD MIS ENHANCER BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion102

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES ACTIVITY PCH MIS BRAND TIER 03ADJ ONE BOTL MIS TUBING BRAND TIER 03ADULT MASK MIS GENERIC TIER 01ADULT MASK MIS LARGE GENERIC TIER 01AERCHMBR PLS MIS LRG MASK BRAND TIER 03AERCHMBR PLS MIS MASK BRAND TIER 03AERCHMBR PLS MIS SM MASK BRAND TIER 03AERCHMBR Z‐ MIS STAT PLS BRAND TIER 03AEROCHAMBER KIT ACTION BRAND TIER 03AEROCHAMBER MIS CHAMBER BRAND TIER 03AEROCHAMBER MIS FLOSIGNA BRAND TIER 03AEROCHAMBER MIS MAX/MASK BRAND TIER 03AEROCHAMBER MIS MV BRAND TIER 03AEROCHAMBER MIS PLUS BRAND TIER 03AEROECLIPSE MIS II NEB BRAND TIER 03AEROSOL MASK MIS ADULT GENERIC TIER 01AEROSOL MASK MIS PED GENERIC TIER 01AEROTRC PLUS MIS BRAND TIER 03AIR TUBE MIS /PLUGS GENERIC TIER 01AIR WATCH MIS MONITOR GENERIC TIER 01AIRIAL MIS COMPACT BRAND TIER 03AIRIAL MIS VOYAGER BRAND TIER 03AIRIAL COMP MIS COMPRESS BRAND TIER 03AIRIAL PEDIA MIS BUILDING BRAND TIER 03AIRIAL PEDIA MIS DUCK BRAND TIER 03AIRIAL PEDIA MIS FIRE ENG BRAND TIER 03AIRIAL PEDIA MIS PANDA BRAND TIER 03AIRIAL PEDIA MIS PENGUIN BRAND TIER 03AIRS DISPOSA KIT NEBULIZE BRAND TIER 03ALLERGIST KIT 0.5/26G BRAND TIER 03ALLERGIST KIT 0.5/28G BRAND TIER 03ALLERGIST KIT 1MLX26G BRAND TIER 03ALLERGIST KIT 1MLX27G BRAND TIER 03ALLERGIST KIT 1MLX28G BRAND TIER 03AMD FOAM PAD 2"X2" BRAND TIER 03AMD FOAM PAD 3.5"X3" BRAND TIER 03AMD FOAM PAD 4"X4" BRAND TIER 03AMD FOAM PAD 4"X8" BRAND TIER 03AMD FOAM PAD 6"X6" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion103

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES AMD FOAM PAD 8"X8" BRAND TIER 03ANESTH NEEDL MIS 23X1‐3/8 GENERIC TIER 01ANGEL WING MIS 19GX3/4" BRAND TIER 03ANGEL WING MIS 21GX3/4" BRAND TIER 03ANGEL WING MIS 23GX3/4" BRAND TIER 03ANGEL WING MIS 25GX3/4" BRAND TIER 03ANGEL WING MIS TRANSFER BRAND TIER 03ANGEL WING MIS TUBE HLD BRAND TIER 03AQUA‐SEAL MIS UNIT BRAND TIER 03ARGYLE PLUG MIS INFUSION BRAND TIER 03ASSEMBLY MIS FIXTURE BRAND TIER 03ASTHMA CNTRL KIT GENERIC TIER 01ASTHMAPACK KIT II BRAND TIER 03ASTHMAPACK KIT III BRAND TIER 03ASTHMAPACK I KIT BRAND TIER 03AUTOSHIELD MIS 30GX3/16 BRAND TIER 03AUTOTRANSFUS MIS ACC UNT BRAND TIER 03AVOSTARTGRIP MIS BRAND TIER 03BARD URETHR MIS CATH 16" BRAND TIER 03BD ECLIPSE MIS 18GX1.5" BRAND TIER 03BD ECLIPSE MIS 22GX1" BRAND TIER 03BD ECLIPSE MIS 23GX1" BRAND TIER 03BD FIL NEED MIS 5 MICRON GENERIC TIER 01BD NEXIVA MIS 18GX1.25 BRAND TIER 03BD NEXIVA MIS 18GX1.75 BRAND TIER 03BD NEXIVA MIS 20GX1" BRAND TIER 03BD NEXIVA MIS 20GX1.25 BRAND TIER 03BD NEXIVA MIS 20GX1.75 BRAND TIER 03BD NEXIVA MIS 22GX1" BRAND TIER 03BD NEXIVA MIS 24GX0.56 BRAND TIER 03BD NEXIVA MIS 24GX0.75 BRAND TIER 03BD SAF‐T‐INT KIT 22GX0.75 BRAND TIER 03BD SAF‐T‐INT KIT 24GX0.75 BRAND TIER 03BLADE HANDLE MIS 3L GENERIC TIER 01BLADE HANDLE MIS 3LA GENERIC TIER 01BLADE HANDLE MIS 3S BRAND TIER 03BLADE HANDLE MIS 4 GENERIC TIER 01BLADE HANDLE MIS 4L GENERIC TIER 01BLADE HANDLE MIS 4S BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion104

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES BLADE HANDLE MIS 5 GENERIC TIER 01BLADE HANDLE MIS 6 GENERIC TIER 01BLADE HANDLE MIS 7 GENERIC TIER 01BLADE HANDLE MIS 8 GENERIC TIER 01BLADE HANDLE MIS 9 GENERIC TIER 01BLUESTAR MIS BRAND TIER 99 DEBLUNT FILTER MIS CANNULA BRAND TIER 03BLUNT NEEDLE MIS 15GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 16GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 17GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 18GX1" BRAND TIER 03BLUNT NEEDLE MIS 19GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 20GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 21GX1" BRAND TIER 03BLUNT NEEDLE MIS 22GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 23GX1" BRAND TIER 03BLUNTITE MIS CLIP BRAND TIER 03BOLUS FEEDIN MIS SET BRAND TIER 03BOTTLE SINGL MIS 2000ML BRAND TIER 03BREATHERITE MIS BRAND TIER 03BREATHERITE MIS LG MASK BRAND TIER 03BREATHERITE MIS MDI CHMB BRAND TIER 03BREATHERITE MIS MED MASK BRAND TIER 03BREATHERITE MIS SM MASK BRAND TIER 03BREATHERITE MIS SPACER BRAND TIER 03BREATHERITE MIS W/MASK BRAND TIER 03BURETTE SET MIS 100ML BRAND TIER 03CARTRIDGE MIS 3.15ML BRAND TIER 03CARTRIDGE MIS 3ML GENERIC TIER 01CARTRIDGE MIS IR 1000 GENERIC TIER 01CARTRIDGE MIS IR 1200 GENERIC TIER 01CARTRIDGE MIS PUMP GENERIC TIER 01CATH TRAY KIT BRAND TIER 03CATH TRAY KIT 14FR BRAND TIER 03CATH TRAY KIT 14FR‐5ML BRAND TIER 03CATH TRAY KIT 16FR‐5ML BRAND TIER 03CATH TRAY KIT 18FR‐5ML BRAND TIER 03CATH TRAY KIT UNIVERSL BRAND TIER 03CATHETER KIT INSERT BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion105

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES CATHETER MIS 14FR‐5ML BRAND TIER 03CATHETER MIS 16FR‐5ML BRAND TIER 03CATHETER MIS 30FR‐30 BRAND TIER 03CGMS MIS SOFTWARE BRAND TIER 03CGMS CABLE MIS BRAND TIER 03CGMS SYSTEM MIS GOLD BRAND TIER 03CHEMOSAFETY KIT SPILL BRAND TIER 03CLINICAL PRD MIS PUMP ADP BRAND TIER 03CO MONITOR KIT GENERIC TIER 01CO MONITOR MIS GENERIC TIER 01CO MONITOR MIS T PIECES GENERIC TIER 01COMFORT SET MIS 23"/17MM BRAND TIER 03COMFORT SET MIS 31"/17MM BRAND TIER 03COMFORT SET MIS 43"/17MM BRAND TIER 03COMFORT SHRT MIS 23"/13MM BRAND TIER 03COMFORT SHRT MIS 31"/13MM BRAND TIER 03COMFORT SHRT MIS 43"/13MM BRAND TIER 03COMP AIR MIS COMP/NEB BRAND TIER 03COMP AIR MIS ELITE BRAND TIER 03CONCEPTION KIT GENERIC TIER 99 DECONFIRM NOW MIS DETECTOR BRAND TIER 03CONNECT TUBE MIS 3/16"X6' BRAND TIER 03CONNECTOR MIS LUER LOC BRAND TIER 03CONNECTOR MIS Y‐SITE BRAND TIER 03CONTINUOUS MIS FEED SET BRAND TIER 03CONVERSION MIS BABY SZ1 BRAND TIER 03CONVERSION MIS BABY SZ2 BRAND TIER 03CONVERSION MIS BABY SZ3 BRAND TIER 03CURAFOAM PAD 4"X5" BRAND TIER 03CURAFOAM PAD 6"X8" BRAND TIER 03CURI‐STRIP MIS 1/2"X4" BRAND TIER 03CURI‐STRIP MIS 1/4"X1.5 BRAND TIER 03CURI‐STRIP MIS 1/4"X3" BRAND TIER 03CURI‐STRIP MIS 1/4"X4" BRAND TIER 03CURI‐STRIP MIS 1/8"X3" BRAND TIER 03CURITY AMD PAD 2"X2" BRAND TIER 03CURITY AMD PAD 4"X4" BRAND TIER 03CURITY CATH KIT 14FRENCH BRAND TIER 03CURITY FOLEY KIT 16FR‐5ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion106

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES DELTEC COZMO MIS INL PUMP BRAND TIER 03DENTAL NEEDL MIS 25GX21MM GENERIC TIER 01DENTAL NEEDL MIS 25GX32MM GENERIC TIER 01DENTAL NEEDL MIS 27GX21MM GENERIC TIER 01DENTAL NEEDL MIS 27GX32MM GENERIC TIER 01DENTAL NEEDL MIS 30GX12MM GENERIC TIER 01DENTAL NEEDL MIS 30GX21MM GENERIC TIER 01DENTAL NEEDL MIS 30GX32MM GENERIC TIER 01DISPENSER MIS MEGAPUMP BRAND TIER 03DOVER TRAY KIT 14FR‐5ML BRAND TIER 03DOVER TRAY KIT 16FR‐5ML BRAND TIER 03DOVER TRAY KIT 18FR‐5ML BRAND TIER 03DOVER URETH MIS 10FR BRAND TIER 03DRAINAGE BAG MIS BRAND TIER 03DRAINAGE BAG MIS 2000ML BRAND TIER 03DRIHEP PLUS KIT 100UNIT BRAND TIER 03DRIHEP SYRNG KIT 100UNIT BRAND TIER 03DUAL THORACI MIS DRAIN BRAND TIER 03DURASAF MINI KIT SPIN/EPI BRAND TIER 03DURASAFE SET KIT SPIN/EPI BRAND TIER 03EARPOPPER MIS MID EAR GENERIC TIER 01EASIVENT MIS BRAND TIER 03EASIVENT MIS MASK LG BRAND TIER 03EASIVENT MIS MASK SM BRAND TIER 03EASIVENT MIS MASK MED BRAND TIER 03ECLIPSE NDL MIS 21GX1" BRAND TIER 03EFLOW SCF MIS AEROSOL BRAND TIER 03EFLOW SCF MIS NEBULIZR BRAND TIER 03ELITE DC AUT MIS ADAPTER BRAND TIER 03ELITE SYSTEM MIS NEBULIZR BRAND TIER 03EMJOI TENS MIS BRAND TIER 03ENTENSION ST MIS 4 FOOT BRAND TIER 03ENTERAL PUMP MIS JOEY BRAND TIER 03EPIDUR NEEDL MIS 18GX2.5" BRAND TIER 03EPIDURAL KIT 17GX3.5" BRAND TIER 03EPIDURAL KIT 18GX3.5" BRAND TIER 03ERECAID KIT CLASSIC BRAND TIER 99 DEERECAID KIT ESTEEM BRAND TIER 99 DEEROS‐CTD MIS BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion107

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES EXTENDER CAP MIS 1ML/3ML BRAND TIER 03EXTENSION MIS SET BRAND TIER 03E‐Z SPACER MIS BRAND TIER 03E‐Z SPACER MIS BODY GRD BRAND TIER 03FEED/IRRIGAT MIS KIT BRAND TIER 03FEEDING SET MIS 5FR 16" BRAND TIER 03FEEDING SET MIS 8FR 16" BRAND TIER 03FEEDING TUBE MIS 10FR 42" BRAND TIER 03FEEDING TUBE MIS 10FR 43" BRAND TIER 03FEEDING TUBE MIS 10FR 55" BRAND TIER 03FEEDING TUBE MIS 12FR 43" BRAND TIER 03FEEDING TUBE MIS 12FR 55" BRAND TIER 03FEEDING TUBE MIS 12FR 60" BRAND TIER 03FEEDING TUBE MIS 3.5FR12" BRAND TIER 03FEEDING TUBE MIS 5FR 20" BRAND TIER 03FEEDING TUBE MIS 5FR 36" BRAND TIER 03FEEDING TUBE MIS 6.5FR16" BRAND TIER 03FEEDING TUBE MIS 6.5FR20" BRAND TIER 03FEEDING TUBE MIS 6.5FR36" BRAND TIER 03FEEDING TUBE MIS 6FR 20" BRAND TIER 03FEEDING TUBE MIS 6FR 36" BRAND TIER 03FEEDING TUBE MIS 8FR 16" BRAND TIER 03FEEDING TUBE MIS 8FR 20" BRAND TIER 03FEEDING TUBE MIS 8FR 42" BRAND TIER 03FEEDING TUBE MIS 8FR 43" BRAND TIER 03FEEDING TUBE MIS 8FR 55" BRAND TIER 03FEEDING TUBE MIS 9FR 35" BRAND TIER 03FEEDING TUBE MIS 9FR/16FR BRAND TIER 03FEEDING TUBE MIS SYSTEM BRAND TIER 03FERGUSN CATH MIS 28FR BRAND TIER 03FERGUSN CATH MIS 32FR BRAND TIER 03FERGUSN CATH MIS 36FR BRAND TIER 03FILTER AIR MIS PP GENERIC TIER 01FILTER ASPIR MIS 18GX3" BRAND TIER 03FILTER CONN MIS 5 MICRON BRAND TIER 03FILTER NEEDL MIS 18GX1" BRAND TIER 03FILTER NEEDL MIS 20GX1.5" BRAND TIER 03FINGER GRIP MIS EXTENDER BRAND TIER 03FLEXI‐SEAL MIS FMS BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion108

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES FLEXLINK MIS PLS/10MM BRAND TIER 03FLEXLINK MIS PLUS/6MM BRAND TIER 03FLEXLINK MIS PLUS/8MM BRAND TIER 03FLUTTER MIS GENERIC TIER 01FOAM RING MIS 2" GENERIC TIER 01FOLEY CATH KIT 14FRENCH BRAND TIER 03FOLEY CATH KIT 16FRENCH BRAND TIER 03FOLEY CATH KIT 18FRENCH BRAND TIER 03FOLEY TRAY KIT 14FR‐5ML BRAND TIER 03FOLEY TRAY KIT 16FR‐5ML BRAND TIER 03FOLEY TRAY KIT 18FR‐5ML BRAND TIER 03FOLEY TRAY KIT 5ML BRAND TIER 03FREESTYLE KIT SENSOR BRAND TIER 03FULL KIT NEB MIS SET BRAND TIER 03GASTROS TUBE MIS 12FRENCH BRAND TIER 03GASTROS TUBE MIS 14FRENCH BRAND TIER 03GASTROS TUBE MIS 16FRENCH BRAND TIER 03GASTROS TUBE MIS 18FRENCH BRAND TIER 03GASTROS TUBE MIS 20FRENCH BRAND TIER 03GASTROS TUBE MIS 28FRENCH BRAND TIER 03GIENTRI PORT MIS BRAND TIER 03GLUCOPRO SYR MIS RES 3ML BRAND TIER 03GUARDIAN MIS TRANSMTR BRAND TIER 03GUARDIAN RT KIT BRAND TIER 03GUARDIAN RT KIT STARTER BRAND TIER 03GUARDIAN RT KIT SYST PED BRAND TIER 03GUARDIAN RT KIT SYSTEM BRAND TIER 03GUARDIAN RT MIS CHARGER BRAND TIER 03GUARDIAN RT MIS REPL PED BRAND TIER 03GUARDIAN RT MIS REPLACE BRAND TIER 03GUARDIAN RT MIS SOFTWARE BRAND TIER 03GUARDIAN RT MIS SYSTEM BRAND TIER 03GUARDIAN RT MIS TST PLUG BRAND TIER 03HEALTHY LIV MIS COMPRESS BRAND TIER 03HISTOACRYL LIQ BRAND TIER 03HUMAPEN MIS LUXURA BRAND TIER 03HUMAPEN MIS MEMOIR BRAND TIER 03HYPO NEEDLE MIS 14GX1" BRAND TIER 03HYPO NEEDLE MIS 14GX1.5" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion109

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES HYPO NEEDLE MIS 14GX2" BRAND TIER 03HYPO NEEDLE MIS 15GX1.5" BRAND TIER 03HYPO NEEDLE MIS 16GX3/4" BRAND TIER 03HYPO NEEDLE MIS 16GX5/8" BRAND TIER 03HYPO NEEDLE MIS 19GX1.25 BRAND TIER 03HYPO NEEDLE MIS 20GX3" BRAND TIER 03HYPO NEEDLE MIS 21GX2" BRAND TIER 03HYPO NEEDLE MIS 23GX1/2" BRAND TIER 03HYPO NEEDLE MIS 25GX1.25 BRAND TIER 03HYPO NEEDLE MIS 25GX2" BRAND TIER 03HYPO NEEDLE MIS 26GX1.5" BRAND TIER 03HYPO NEEDLE MIS 30GX3/4" BRAND TIER 03IN‐CHK DIAL MIS TRAINER BRAND TIER 03IN‐CHK FLOW MIS METER BRAND TIER 03INCISION/ KIT DRAINAGE BRAND TIER 03INFUS NEEDLE MIS 15GX2" GENERIC TIER 01INFUSION MIS ADAPTER BRAND TIER 03INFUSION MIS CLAMP BRAND TIER 03INFUSION SET MIS 23" BRAND TIER 03INFUSION SET MIS 23" GENERIC TIER 01INFUSION SET MIS 23" 10MM GENERIC TIER 01INFUSION SET MIS 23" 6MM BRAND TIER 03INFUSION SET MIS 23" 8MM BRAND TIER 03INFUSION SET MIS 23" 8MM GENERIC TIER 01INFUSION SET MIS 23" 9MM BRAND TIER 03INFUSION SET MIS 23" COMF GENERIC TIER 01INFUSION SET MIS 23"/COMF GENERIC TIER 01INFUSION SET MIS 23"COMFO GENERIC TIER 01INFUSION SET MIS 24" BRAND TIER 03INFUSION SET MIS 24" 6MM BRAND TIER 03INFUSION SET MIS 24" 6MM GENERIC TIER 01INFUSION SET MIS 24" 9MM BRAND TIER 03INFUSION SET MIS 24"/9MM GENERIC TIER 01INFUSION SET MIS 31" BRAND TIER 03INFUSION SET MIS 31" 6MM BRAND TIER 03INFUSION SET MIS 31" 9MM BRAND TIER 03INFUSION SET MIS 42" 6MM BRAND TIER 03INFUSION SET MIS 42" 6MM GENERIC TIER 01INFUSION SET MIS 42" 9MM BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion110

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES INFUSION SET MIS 42" 9MM GENERIC TIER 01INFUSION SET MIS 43" BRAND TIER 03INFUSION SET MIS 43" GENERIC TIER 01INFUSION SET MIS 43" 10MM GENERIC TIER 01INFUSION SET MIS 43" 6MM BRAND TIER 03INFUSION SET MIS 43" 8MM BRAND TIER 03INFUSION SET MIS 43" 9MM BRAND TIER 03INFUSION SET MIS 43"/COMF GENERIC TIER 01INFUSION SET MIS 43"COMFO GENERIC TIER 01INFUSION SET MIS CATH 23" GENERIC TIER 01INFUSION SET MIS CATH 31" GENERIC TIER 01INFUSION SET MIS CATH 43" GENERIC TIER 01INJECTOR MIS LUER LOC BRAND TIER 03INJECTOR CAP MIS PHASEAL BRAND TIER 03INSERTION KIT 16FRENCH BRAND TIER 03INSERTION KIT 18FRENCH BRAND TIER 03INSPIRATION MIS ELITE BRAND TIER 03INSPIRATION MIS NEBULIZR BRAND TIER 03INSPIREASE MIS DD SYST BRAND TIER 03INSUFLON MIS 25GX0.71 BRAND TIER 03INSULIN PUMP KIT IR2020 GENERIC TIER 99 DEINSULIN PUMP MIS AMIGO BRAND TIER 03INSULIN PUMP MIS PEDIATRI BRAND TIER 03INSULIN PUMP MIS PROGRAM BRAND TIER 03INSYTE AUTOG MIS 14GX1.75 BRAND TIER 03INSYTE AUTOG MIS 18GX1.16 BRAND TIER 03INSYTE AUTOG MIS 22GX1" BRAND TIER 03INSYTE AUTOG MIS 24GX3/4" BRAND TIER 03INTERMITTENT MIS 14FR40CM BRAND TIER 03INTRO NEEDLE MIS 18GX1.25 BRAND TIER 03I‐PORT MIS 6MM BRAND TIER 03I‐PORT MIS 9MM BRAND TIER 03IRRIGAT SYRG MIS 50ML BUL BRAND TIER 03IV BAG HANGR MIS PHASEAL BRAND TIER 03J‐TIP KIT KIT ADAPTERS BRAND TIER 03KANG EXTENSN MIS Y‐SITE BRAND TIER 03KANGAROO KIT 12FR/0.8 BRAND TIER 03KANGAROO KIT 12FR/1.2 BRAND TIER 03KANGAROO KIT 12FR/1.5 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion111

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES KANGAROO KIT 12FR/1.7 BRAND TIER 03KANGAROO KIT 12FR/2.3 BRAND TIER 03KANGAROO KIT 16FR/2.5 BRAND TIER 03KANGAROO MIS IRRIGATI BRAND TIER 03KENGUARD MIS DRAINAGE BRAND TIER 03KLATSKIN BIO MIS 16X4" BRAND TIER 03KNEE LENGTH MIS MED/REG BRAND TIER 03LACERATION KIT BRAND TIER 03LEFT VENTRIC MIS CATHETER BRAND TIER 03LIQUIHEP KIT 500UNIT BRAND TIER 03LIQUIHEP II KIT 500UNIT BRAND TIER 03LITEAIRE MIS BRAND TIER 03LITH HEPARIN KIT 100UNIT GENERIC TIER 01LITH HEPARIN KIT 500UNIT BRAND TIER 03LITH HEPARIN KIT 70UNIT GENERIC TIER 01LLX EXTENSIO MIS NEEDLE BRAND TIER 03LUMBAR KIT PUNCTURE BRAND TIER 03LUMINEB II MIS NEBULIZR BRAND TIER 03MEDICAL LEG MIS WAIST HI GENERIC TIER 01MICRO AIR MIS NEBULIZR BRAND TIER 03MICRO PLUS MIS NEBULIZR BRAND TIER 03MICROCHAMBER MIS BRAND TIER 03MICROELITE MIS COMP/NEB BRAND TIER 03MICROSPACER MIS BRAND TIER 03MILLEX‐FG MIS 0.2UM BRAND TIER 03MINI COMPRES MIS NEBULIZR BRAND TIER 03MINI PLUS MIS NEBULIZR BRAND TIER 03MINIELITE MIS BATTERY BRAND TIER 03MINIELITE MIS COMP/NEB BRAND TIER 03MINIMED PUMP MIS RES 3ML BRAND TIER 03MIO INF SET MIS 18"/6MM BRAND TIER 03MIO INF SET MIS 23"/6MM BRAND TIER 03MIO INF SET MIS 32"/6MM BRAND TIER 03MIO INF SET MIS 32"/9MM BRAND TIER 03MISTERNEB MIS NEBULIZE BRAND TIER 03MONOJECT MIS 20GX1" BRAND TIER 03MONOJECT MIS 20GX1.5 BRAND TIER 03MONOJECT MIS 21GX1" BRAND TIER 03MONOJECT MIS 21GX1.5 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion112

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES MONOJECT MIS 22GX1" BRAND TIER 03MONOJECT MIS 22GX1.5 BRAND TIER 03MONOJECT MIS CANNULA BRAND TIER 03MONOJECT MIS TIP CAPS BRAND TIER 03MONOJECT LS MIS CANN/BLN BRAND TIER 03MONOJECT LUE MIS ADAPTER BRAND TIER 03MOUTHPIECE MIS DISP LOW GENERIC TIER 01MOUTHPIECE MIS DISP UNI GENERIC TIER 01MOUTHPIECE MIS DISPOSAB GENERIC TIER 01MULTI‐DRAW MIS 20GX1" GENERIC TIER 01MULTI‐DRAW MIS 21GX1" GENERIC TIER 01MULTI‐DRAW MIS 22GX1" GENERIC TIER 01NASONEB NSL MIS REPLACEM BRAND TIER 03NASONEB NSL MIS STARTER BRAND TIER 03NEBULIZER KIT GENERIC TIER 01NEBULIZER KIT CMPRESS GENERIC TIER 01NEBULIZER KIT MASK GENERIC TIER 01NEBULIZER KIT SAMI BRAND TIER 03NEBULIZER MIS CMPRESSR BRAND TIER 03NEBULIZER MIS COMPRESS GENERIC TIER 01NEBULIZER MIS POCKET BRAND TIER 03NEBULIZER MIS ULTRASNC BRAND TIER 03NEBULIZER MIS ULTRASON GENERIC TIER 01NEEDLE MIS 18GX1" GENERIC TIER 01NEEDLE‐FREE KIT A BRAND TIER 03NEEDLE‐FREE KIT B BRAND TIER 03NEEDLE‐FREE KIT C BRAND TIER 03NORDIPEN 5 MIS DEVICE BRAND TIER 03NUTRIPORT KIT 20FR/2.5 BRAND TIER 03NUTRIPORT KIT 20FR/2.7 BRAND TIER 03NUTRIPORT KIT 20FR/3.5 BRAND TIER 03NUTRIPORT KIT 20FR/4.5 BRAND TIER 03NUTRIPORT KIT 20FR/4CM BRAND TIER 03NUTRIPORT KIT 20FR/5CM BRAND TIER 03NUTRIPORT KIT 24FR/0.8 BRAND TIER 03NUTRIPORT KIT 24FR/1.2 BRAND TIER 03NUTRIPORT KIT 24FR/1.5 BRAND TIER 03NUTRIPORT KIT 24FR/1.7 BRAND TIER 03NUTRIPORT KIT 24FR/1CM BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion113

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES NUTRIPORT KIT 24FR/2.3 BRAND TIER 03NUTRIPORT KIT 24FR/2.5 BRAND TIER 03NUTRIPORT KIT 24FR/2.7 BRAND TIER 03NUTRIPORT KIT 24FR/2CM BRAND TIER 03NUTRIPORT KIT 24FR/3.5 BRAND TIER 03NUTRIPORT KIT 24FR/3CM BRAND TIER 03NUTRIPORT KIT 24FR/4.5 BRAND TIER 03NUTRIPORT KIT 24FR/4CM BRAND TIER 03OFFICE SAFET KIT 3.2QT BRAND TIER 03OMNIPOD KIT STARTER BRAND TIER 03OMNIPOD MIS BRAND TIER 03OMNITROPE 5 MIS DEVICE BRAND TIER 03ONE FLOW KIT SPIROMTR BRAND TIER 03ONE FLOW MIS SPIROMTR BRAND TIER 03ONETOUCH PNG KIT INS PUMP BRAND TIER 99 DEOPTICHAMBER MIS ADV LRG BRAND TIER 03OPTICHAMBER MIS ADV MED BRAND TIER 03OPTICHAMBER MIS ADVANTAG BRAND TIER 03OPTICHAMBER MIS DIA LG BRAND TIER 03OPTICHAMBER MIS DIA MD BRAND TIER 03OPTICHAMBER MIS DIA SM BRAND TIER 03OPTICHAMBER MIS DIAMOND BRAND TIER 03OPTIHALER MIS BRAND TIER 03OPTIONHOME MIS NEBULIZR BRAND TIER 03ORAL SYRINGE MIS 6ML BRAND TIER 03ORTHO FIT MIS ALL‐FLEX BRAND TIER 03OSGOOD BIOPS MIS BRAND TIER 03OSGOOD BIOPS MIS 18GX1" BRAND TIER 03PARADIGM KIT LINK BRAND TIER 03PARADIGM MIS UPGRADE BRAND TIER 03PARADIGM QR MIS POLY 24" BRAND TIER 03PARADIGM QR MIS POLY 42" BRAND TIER 03PARADIGM REA MIS TRANSMIT BRAND TIER 03PARADIGM RES MIS 1.76ML BRAND TIER 03PARADIGM RES MIS 3ML BRAND TIER 03PARADIGM SOF MIS ‐SET 24" BRAND TIER 03PARADIGM SOF MIS ‐SET 42" BRAND TIER 03PARALLEL Y MIS CON ADLT BRAND TIER 03PARI BABY MIS SIZE 0 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion114

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES PARI BABY MIS SIZE 1 BRAND TIER 03PARI BABY MIS SIZE 2 BRAND TIER 03PARI EXPIRAT MIS FILTER BRAND TIER 03PARI LC MIS SPRINT BRAND TIER 03PARI LC D MIS NEBULIZR BRAND TIER 03PARI LC PLUS KIT PED BRAND TIER 03PARI LC PLUS MIS BRAND TIER 03PARI LC PLUS MIS NEBULIZR BRAND TIER 03PARI LC STAR MIS BRAND TIER 03PARI LC STAR MIS NEBULIZR BRAND TIER 03PARI MANUAL MIS INTERRUP BRAND TIER 03PARI MASK MIS SIZE 3 BRAND TIER 03PARI PLASTIC MIS MASK BRAND TIER 03PARI PLASTIC MIS MASK PED BRAND TIER 03PARI PRONEB MIS ULTRA II BRAND TIER 03PARI SINUS MIS AERO SYS BRAND TIER 03PARI TREK S KIT COMBO BRAND TIER 03PARI TREK S KIT POWER BRAND TIER 03PARI TREK S MIS BRAND TIER 03PATROL PUMP MIS 40MM CAP BRAND TIER 03PCA INJECTOR MIS GENERIC TIER 01PEDIATRIC MIS MASK GENERIC TIER 01PEDI‐TUBE MIS 20" BRAND TIER 03PEDI‐TUBE MIS 36" BRAND TIER 03PEG ENTERAL MIS CONNECTR BRAND TIER 03PELVIC MUSCL MIS TRAINER GENERIC TIER 01PFLEX MIS BRAND TIER 03PFT FILTER KIT 1000 BRAND TIER 03PFT FILTER KIT 3000 BRAND TIER 03PFT FILTER KIT 4000 BRAND TIER 03PFT FILTER KIT 5000 BRAND TIER 03PFT FILTER KIT 6000 BRAND TIER 03PFT FILTER MIS 1000 BRAND TIER 03PFT FILTER MIS 2000 BRAND TIER 03PFT FILTER MIS 3000 BRAND TIER 03PFT FILTER MIS 4000 BRAND TIER 03PFT FILTER MIS 5000 BRAND TIER 03PFT FILTER MIS 6000 BRAND TIER 03PFT FILTER MIS 7000 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion115

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES PHARM SYRNG MIS TRAY 1ML BRAND TIER 03PHARM TRAY MIS 12ML/LL BRAND TIER 03PHARM TRAY MIS 20ML/LL BRAND TIER 03PHARM TRAY MIS 35ML/LL BRAND TIER 03PHARM TRAY MIS 3ML/LL BRAND TIER 03PHARM TRAY MIS 60ML/LL BRAND TIER 03PHARM TRAY MIS 6ML BRAND TIER 03PILLOW MASK MIS ADULT GENERIC TIER 01PILLOW MASK MIS CHILD GENERIC TIER 01PILLOW MASK MIS PEDIATRI GENERIC TIER 01PIPETTING MIS 10ML BRAND TIER 03PIPETTING MIS 1ML BRAND TIER 03PIPETTING MIS 2ML BRAND TIER 03PIPETTING MIS 5ML BRAND TIER 03POCKET CHAMB MIS GENERIC TIER 01POCKET SPACE MIS GENERIC TIER 01POLYFIN 24" MIS INFUSION BRAND TIER 03POLYFIN 42" MIS INFUSION BRAND TIER 03POLYFIN 42" MIS QR INFUS BRAND TIER 03POLYFIN 60" MIS TUBING BRAND TIER 03PRIMABELLA MIS BRAND TIER 03PRIMEAIRE MIS CHAMBER BRAND TIER 03PRONEB ULTRA MIS II/LCD BRAND TIER 03PRONEB ULTRA MIS II/PED BRAND TIER 03PRONEB ULTRA MIS LC PLUS BRAND TIER 03PRONEB ULTRA MIS LC SPRNT BRAND TIER 03PRONEB ULTRA MIS LC STAR BRAND TIER 03PROTECTOR 14 MIS PHASEAL BRAND TIER 03PROTECTOR 21 MIS PHASEAL BRAND TIER 03PROTECTOR 28 MIS PHASEAL BRAND TIER 03PROTECTOR 50 MIS PHASEAL BRAND TIER 03PROVENT HR MIS BRAND TIER 99 DEPROVENT SR MIS BRAND TIER 99 DEPUDEND/LOCAL KIT BLOCK BRAND TIER 03PUDEND/LOCAL KIT BLOCK GENERIC TIER 01PULMO‐AIDE MIS LT NEBUL BRAND TIER 03PULMO‐AIDE MIS NEBULIZE BRAND TIER 03PULMO‐AIDE MIS TRAVELER BRAND TIER 03PULMOMATE/ MIS NEBULIZR BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion116

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES PUMP SET MIS 100ML BRAND TIER 03PUMP SET MIS 500ML BRAND TIER 03PUMP SET EXT MIS TUBING BRAND TIER 03QUAKE MIS BRAND TIER 03QUICK‐SET MIS 18"/6MM BRAND TIER 03QUICK‐SET MIS 23"/6MM BRAND TIER 03QUICK‐SET MIS 23"/9MM BRAND TIER 03QUICK‐SET MIS 32"/6MM BRAND TIER 03QUICK‐SET MIS 32"/9MM BRAND TIER 03QUICK‐SET MIS 43"/6MM BRAND TIER 03QUICK‐SET MIS 43"/9MM BRAND TIER 03RAPID‐D INF MIS 24"/10MM BRAND TIER 03RAPID‐D INF MIS 24"/6MM BRAND TIER 03RAPID‐D INF MIS 24"/8MM BRAND TIER 03RAPID‐D INF MIS 31"/10MM BRAND TIER 03RAPID‐D INF MIS 31"/6MM BRAND TIER 03RAPID‐D INF MIS 31"/8MM BRAND TIER 03RAPID‐D INF MIS 43"/10MM BRAND TIER 03RAPID‐D INF MIS 43"/6MM BRAND TIER 03RAPID‐D INF MIS 43"/8MM BRAND TIER 03RAPPORT RLS KIT BRAND TIER 99 DERAPPORT VTD KIT BRAND TIER 99 DEREAL‐TIME KIT BRAND TIER 03REPLACEMENT MIS FILTER GENERIC TIER 01RESERVIOR MIS 3ML GENERIC TIER 01RESPERATE KIT 1.0 BRAND TIER 03RESPERATE KIT 1.1 BRAND TIER 03RITEFLO MIS BRAND TIER 03ROSENTHAL MIS BRAND TIER 03RT ANG CATH MIS 16FR/20" BRAND TIER 03RT ANG CATH MIS 20FR/20" BRAND TIER 03RT ANG CATH MIS 24FR/20" BRAND TIER 03RT ANG CATH MIS 28FR/20" BRAND TIER 03RT ANG CATH MIS 32FR/20" BRAND TIER 03RT ANG CATH MIS 36FR/20" BRAND TIER 03RT ANG CATH MIS 40FR/20" BRAND TIER 03SAFETY PEG MIS KIT 16FR BRAND TIER 03SAFETY PEG MIS KIT 20FR BRAND TIER 03SAFETYGLIDE MIS 21GX1.5" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion117

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES SAFTY NEEDLE MIS 18GX1" BRAND TIER 03SAFTY NEEDLE MIS 18GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 19GX1" BRAND TIER 03SAFTY NEEDLE MIS 19GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 20GX1" BRAND TIER 03SAFTY NEEDLE MIS 20GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 21GX1" BRAND TIER 03SAFTY NEEDLE MIS 21GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 21GX5/8" BRAND TIER 03SAFTY NEEDLE MIS 22GX1" BRAND TIER 03SAFTY NEEDLE MIS 22GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 23GX1" BRAND TIER 03SAFTY NEEDLE MIS 23GX5/8" BRAND TIER 03SAFTY NEEDLE MIS 25GX1" BRAND TIER 03SAFTY NEEDLE MIS 25GX5/8" BRAND TIER 03SALEM SUMP MIS 10FR BRAND TIER 03SALEM SUMP MIS 12FR BRAND TIER 03SALEM SUMP MIS 14FR BRAND TIER 03SALEM SUMP MIS 16FR BRAND TIER 03SALEM SUMP MIS 18FR BRAND TIER 03SCALPEL/BLAD MIS SIZE 12 BRAND TIER 03SCALPEL/BLAD MIS SIZE 12 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 12B GENERIC TIER 01SCALPEL/BLAD MIS SIZE 20 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 21 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 23 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 25T GENERIC TIER 01SECONDARY MIS SET/DRIP BRAND TIER 03SEVEN PLUS KIT STARTER BRAND TIER 03SEVEN PLUS MIS RECEIVER BRAND TIER 03SEVEN PLUS MIS TRANSMIT BRAND TIER 03SEVEN SYSTEM MIS SENSOR BRAND TIER 03SHARPS CONT MIS 1.1QT BRAND TIER 03SHARPS CONT MIS 4QT BRAND TIER 03SIDESTREAM KIT NEBULIZE BRAND TIER 03SIDESTREAM MIS MASK BRAND TIER 03SIDESTREAM MIS NEBULIZR BRAND TIER 03SIDESTREAM MIS PLUS BRAND TIER 03SIL MEDIASTN MIS CATHETER BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion118

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES SIL RT ANGLE MIS THOR CTH BRAND TIER 03SIL STR THOR MIS CATHETER BRAND TIER 03SILHOUETTE MIS 13MM BRAND TIER 03SILHOUETTE MIS 17MM BRAND TIER 03SILHOUETTE MIS 18"/13MM BRAND TIER 03SILHOUETTE MIS 23" SET BRAND TIER 03SILHOUETTE MIS 32"/17MM BRAND TIER 03SILHOUETTE MIS 43" SET BRAND TIER 03SILHOUETTE MIS COMBO BRAND TIER 03SILHOUETTE MIS FULL SET BRAND TIER 03SILICONE MSK MIS ADULT GENERIC TIER 01SILICONE MSK MIS INFANT GENERIC TIER 01SILICONE MSK MIS PED GENERIC TIER 01SINUSTAR MIS NEBULIZE BRAND TIER 03SINUSTAR MIS SYSTEM BRAND TIER 03SKIN SCRUB KIT TRAY DRY BRAND TIER 03SLEEVE COVER MIS UNIVERSA GENERIC TIER 01SMARTIP SYR MIS /CANNULA BRAND TIER 03SOF‐SENSOR MIS BRAND TIER 03SOF‐SET 24" KIT INFUSION BRAND TIER 03SOF‐SET 24" KIT MICRO QR BRAND TIER 03SOF‐SET 24" KIT ULTIM QR BRAND TIER 03SOF‐SET 42" KIT INFUSION BRAND TIER 03SOF‐SET 42" KIT MICRO QR BRAND TIER 03SOF‐SET 42" KIT ULTIM QR BRAND TIER 03SPINAL NEEDL MIS 25GX2.5" BRAND TIER 03SPIRO PD MIS BRAND TIER 03STOPCOCK MIS 1‐WAY BRAND TIER 03STOPCOCK MIS 3‐WAY BRAND TIER 03STOPCOCK MIS 4‐WAY BRAND TIER 03STOPCOCK DBL MIS 3‐WAY BRAND TIER 03STR CATHETER MIS 12FR/20" BRAND TIER 03STR CATHETER MIS 16FR/20" BRAND TIER 03STR CATHETER MIS 20FR/20" BRAND TIER 03STR CATHETER MIS 24FR/20" BRAND TIER 03STR CATHETER MIS 28FR/20" BRAND TIER 03STR CATHETER MIS 32FR/20" BRAND TIER 03STR CATHETER MIS 36FR/20" BRAND TIER 03STR CATHETER MIS 40FR/20" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion119

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES SUMP DRAIN MIS 16FR/12" BRAND TIER 03SUMP DRAIN MIS 20FR/12" BRAND TIER 03SUMP DRAIN MIS 20FR/20" BRAND TIER 03SUMP DRAIN MIS 24FR/20" BRAND TIER 03SUMP DRAIN MIS 28FR/12" BRAND TIER 03SUMP DRAIN MIS 28FR/20" BRAND TIER 03SUPPOSISTRIP MIS 1.4GM BRAND TIER 03SUPPOSISTRIP MIS 1.9GM GENERIC TIER 01SUPPOSITORY MIS 1.46GM GENERIC TIER 01SUPPOSITORY MIS 2.25GM GENERIC TIER 01SURE‐T MIS 23"/6MM BRAND TIER 03SURE‐T MIS 23"/8MM BRAND TIER 03SURE‐T INFUS MIS SET 18" BRAND TIER 03SURE‐T INFUS MIS SET 23" BRAND TIER 03SURE‐T INFUS MIS SET 32" BRAND TIER 03SURG BLADES MIS SIZE 10A BRAND TIER 03SURG BLADES MIS SIZE 12 BRAND TIER 03SURG BLADES MIS SIZE 12 GENERIC TIER 01SURG BLADES MIS SIZE 12B BRAND TIER 03SURG BLADES MIS SIZE 15C BRAND TIER 03SURG BLADES MIS SIZE 23 BRAND TIER 03SURG BLADES MIS SIZE 23 GENERIC TIER 01SURG BLADES MIS SIZE 24 BRAND TIER 03SURG BLADES MIS SIZE 24 GENERIC TIER 01SURG BLADES MIS SIZE 25 BRAND TIER 03SURG BLADES MIS SIZE 25 GENERIC TIER 01SURG BLADES MIS SIZE 60 BRAND TIER 03SURGUARD2 MIS 18GX1" BRAND TIER 03SURGUARD2 MIS 18GX1.5" BRAND TIER 03SURGUARD2 MIS 19GX1" BRAND TIER 03SURGUARD2 MIS 19GX1.5" BRAND TIER 03SURGUARD2 MIS 20GX1" BRAND TIER 03SURGUARD2 MIS 20GX1.5" BRAND TIER 03SURGUARD2 MIS 21GX1" BRAND TIER 03SURGUARD2 MIS 21GX1.5" BRAND TIER 03SURGUARD2 MIS 22GX1" BRAND TIER 03SURGUARD2 MIS 22GX1.5" BRAND TIER 03SURGUARD2 MIS 23GX1" BRAND TIER 03SURGUARD2 MIS 23GX1.5" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion120

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES SURGUARD2 MIS 25GX1.5" BRAND TIER 03SURGUARD2 MIS 25GX5/8" BRAND TIER 03SURGUARD2 MIS 26GX1/2" BRAND TIER 03SURGUARD2 MIS 27GX1/2" BRAND TIER 03SURGUARD2 MIS 30GX1/2" BRAND TIER 03SYRINGE FILT MIS 25MM BRAND TIER 03SYRINGE TRAY MIS PHASEAL BRAND TIER 03SYRNG BARREL MIS 1.5OZ GENERIC TIER 01SYRNG BARREL MIS 1OZ GENERIC TIER 01SYRNG BARREL MIS 2OZ GENERIC TIER 01SYRNG BARREL MIS 3OZ GENERIC TIER 01SYRNG BARREL MIS 4OZ GENERIC TIER 01T.E.D. MIS LG/LONG BRAND TIER 03T.E.D. MIS LG/REG BRAND TIER 03T.E.D. MIS LG/SHORT BRAND TIER 03T.E.D. MIS MD/SHORT BRAND TIER 03T.E.D. MIS MED/LONG BRAND TIER 03T.E.D. MIS MED/REG BRAND TIER 03T.E.D. MIS MED‐LONG BRAND TIER 03T.E.D. MIS SM/LONG BRAND TIER 03T.E.D. MIS SM/REG BRAND TIER 03T.E.D. MIS SM/SHORT BRAND TIER 03T.E.D. MIS XL/LONG BRAND TIER 03T.E.D. MIS XL/REG BRAND TIER 03T.E.D. MIS XSM/LONG BRAND TIER 03T.E.D. MIS X‐SM/REG BRAND TIER 03TB SYRINGE MIS 0.5/28G BRAND TIER 03TENDER 1 KIT 31" BRAND TIER 03TENDER 1 KIT 43" BRAND TIER 03TENDER 1 KIT INFUSION BRAND TIER 03TENDER 2 KIT 24" BRAND TIER 03TENDER 2 KIT 31" BRAND TIER 03TEXAS CATH MIS MALE BRAND TIER 03THI AORTIC MIS CANNULA BRAND TIER 03THINSET MIS 23"/6MM BRAND TIER 03THINSET MIS 23"/9MM BRAND TIER 03THINSET MIS 43"/6MM BRAND TIER 03THINSET MIS 43"/9MM BRAND TIER 03THINSET SYR MIS RES 1.8 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion121

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES THINSET SYR MIS RES 3ML BRAND TIER 03THORACENTESI KIT 16GX3.5" BRAND TIER 03THORACENTESI KIT 17GX6" BRAND TIER 03THORA‐SEAL MIS III CHMB BRAND TIER 03THORA‐SEAL MIS III SYST BRAND TIER 03THORA‐SEAL MIS III UNIT BRAND TIER 03THRESHOLD MIS IMT BRAND TIER 03THRESHOLD MIS PEP BRAND TIER 03TIP CAPS MIS GENERIC TIER 01TITUS NEEDLE MIS 18X1‐1/4 GENERIC TIER 01TONSIL NEEDL MIS 23GX1/2" GENERIC TIER 01TONSIL NEEDL MIS 23GX3/4" GENERIC TIER 01TOOMEY SYRIN MIS 70ML GENERIC TIER 99 DETOPI‐CLICK MIS BLUE BRAND TIER 03TOPI‐CLICK MIS GREEN BRAND TIER 03TOPI‐CLICK MIS PINK BRAND TIER 03TOPI‐CLICK MIS PURPLE BRAND TIER 03TOPI‐CLICK MIS RED BRAND TIER 03TOPI‐CLICK MIS SILVER BRAND TIER 03TOPI‐CLICK MIS WHITE BRAND TIER 03TRANSFER NDL MIS 20G BRAND TIER 03TRAVEL‐AIRE MIS COMPRES BRAND TIER 03TROCAR CATH MIS 10FR/9" BRAND TIER 03TROCAR CATH MIS 12FR/9" BRAND TIER 03TROCAR CATH MIS 16FR/10" BRAND TIER 03TROCAR CATH MIS 20FR/16" BRAND TIER 03TROCAR CATH MIS 24FR/16" BRAND TIER 03TROCAR CATH MIS 28FR/16" BRAND TIER 03TROCAR CATH MIS 32FR/16" BRAND TIER 03TROCAR CATH MIS 8FR/9" BRAND TIER 03TROCHE MOLD MIS 30 CAVIT BRAND TIER 03TRUZONE PEAK MIS FLOW MTR BRAND TIER 03TUBING EXT MIS SET BRAND TIER 03TWO BOTTLE MIS SNGL DRN BRAND TIER 03TWO BOTTLE MIS TUBING BRAND TIER 03ULTRAFLEX II MIS 31"/8MM BRAND TIER 03UNGUATOR MIS 36MM BRAND TIER 03UNGUATOR MIS 57MM BRAND TIER 03UNGUATOR 1MM MIS VARIONOZ BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion122

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES UNGUATOR 4MM MIS VARIONOZ BRAND TIER 03UNGUATOR AIR MIS 300/390 BRAND TIER 03UNGUATOR AIR MIS 500/600 BRAND TIER 03UNGUATOR JAR MIS 100/140 BRAND TIER 03UNGUATOR JAR MIS 200/280 BRAND TIER 03UNGUATOR JAR MIS 30/42 BRAND TIER 03UNGUATOR JAR MIS 300/390 BRAND TIER 03UNGUATOR JAR MIS 50/70 BRAND TIER 03UNGUATOR JAR MIS 500/600 BRAND TIER 03UNGUTOR 50 MIS 43MM BRAND TIER 03UNIVERSAL MIS PUMP ADP BRAND TIER 03URETHR CATH MIS 14FRENCH BRAND TIER 03URINE METER MIS KIDS BRAND TIER 03VAGINAL APPL MIS SUPPOSIT GENERIC TIER 01VALVD HOLDNG MIS CHAMBER BRAND TIER 03V‐GO 20 KIT BRAND TIER 02V‐GO 30 KIT BRAND TIER 02V‐GO 40 KIT BRAND TIER 02VIOS MIS SYSTEM BRAND TIER 03VIOS LC MIS SPRINT BRAND TIER 03VIOS LC PLUS MIS BRAND TIER 03VIOS LC PLUS MIS DELUXE BRAND TIER 03VIOS LC PLUS MIS PEDIATRC BRAND TIER 03VIXONE DISP MIS NEBULIZR BRAND TIER 03VORTEX VALVE MIS CHAMBER BRAND TIER 03VORTEX/MASK MIS CHILDS BRAND TIER 03VORTEX/MASK MIS TODDLER BRAND TIER 03WATCHHALER MIS BRAND TIER 03WINDMILL MIS TRAINER BRAND TIER 03XEROFORM MIS DRESSING BRAND TIER 03XEROFORM MIS OVERWRAP BRAND TIER 03XEROFORM PET MIS OVERWRAP BRAND TIER 03XEROFORM PET MIS ROLL BRAND TIER 03XEROFORM PET PAD 1"X8" BRAND TIER 03XEROFORM PET PAD 2"X2" BRAND TIER 03XEROFORM PET PAD 4"X4" BRAND TIER 03XEROFORM PET PAD 5"X9" BRAND TIER 03XROFORM PET MIS OVERWRAP BRAND TIER 03YIELD NON‐AD PAD 2"X3" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion123

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES YIELD NON‐AD PAD 3"X4" BRAND TIER 03ZEWA TENS MIS 502 BRAND TIER 03ZEWA TENS MIS 504 BRAND TIER 03MONOJECT MIS HOLDER BRAND TIER 03COMPRESSION MIS THIGH GENERIC TIER 01COMPRESSION MIS PANTYHSE GENERIC TIER 01TRANSMITTER MIS G4 BRAND TIER 03LITETOUCH MIS MASK SM BRAND TIER 03LITETOUCH MIS MASK MD BRAND TIER 03LITETOUCH MIS MASK LG BRAND TIER 03PROVENT MIS STARTER BRAND TIER 99 DEMINILINK RT KIT REPLACE BRAND TIER 03KANGAROO KIT 12FR/1CM BRAND TIER 03KANGAROO KIT 12FR/2CM BRAND TIER 03KANGAROO KIT 12FR/2.5 BRAND TIER 03KANGAROO KIT 12FR/2.7 BRAND TIER 03KANGAROO KIT 12FR/3CM BRAND TIER 03KANGAROO KIT 12FR/3.5 BRAND TIER 03KANGAROO KIT 12FR/4CM BRAND TIER 03KANGAROO KIT 12FR/4.5 BRAND TIER 03KANGAROO KIT 12FR/5CM BRAND TIER 03KANGAROO KIT 14FR/0.8 BRAND TIER 03KANGAROO KIT 14FR/1CM BRAND TIER 03KANGAROO KIT 14FR/1.2 BRAND TIER 03KANGAROO KIT 14FR/1.5 BRAND TIER 03KANGAROO KIT 14FR/1.7 BRAND TIER 03KANGAROO KIT 14FR/2CM BRAND TIER 03KANGAROO KIT 14FR/2.3 BRAND TIER 03KANGAROO KIT 14FR/2.5 BRAND TIER 03KANGAROO KIT 14FR/2.7 BRAND TIER 03KANGAROO KIT 14FR/3CM BRAND TIER 03KANGAROO KIT 14FR/3.5 BRAND TIER 03KANGAROO KIT 14FR/4CM BRAND TIER 03KANGAROO KIT 14FR/4.5 BRAND TIER 03KANGAROO KIT 14FR/5CM BRAND TIER 03KANGAROO KIT 16FR/0.8 BRAND TIER 03KANGAROO KIT 16FR/1CM BRAND TIER 03KANGAROO KIT 16FR/1.2 BRAND TIER 03KANGAROO KIT 16FR/1.5 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion124

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES KANGAROO KIT 16FR/1.7 BRAND TIER 03KANGAROO KIT 16FR/2CM BRAND TIER 03KANGAROO KIT 16FR/2.3 BRAND TIER 03KANGAROO KIT 16FR/2.7 BRAND TIER 03KANGAROO KIT 16FR/3CM BRAND TIER 03KANGAROO KIT 16FR/3.5 BRAND TIER 03KANGAROO KIT 16FR/4CM BRAND TIER 03KANGAROO KIT 16FR/4.5 BRAND TIER 03KANGAROO KIT 16FR/5CM BRAND TIER 03KANGAROO KIT 18FR/2CM BRAND TIER 03KANGAROO KIT 18FR/2.3 BRAND TIER 03KANGAROO KIT 18FR/2.5 BRAND TIER 03KANGAROO KIT 18FR/2.7 BRAND TIER 03KANGAROO KIT 18FR/3CM BRAND TIER 03KANGAROO KIT 18FR/3.5 BRAND TIER 03KANGAROO KIT 18FR/4CM BRAND TIER 03KANGAROO KIT 18FR/4.5 BRAND TIER 03KANGAROO KIT 18FR/5CM BRAND TIER 03KANGAROO KIT 20FR/0.8 BRAND TIER 03KANGAROO KIT 20FR/1CM BRAND TIER 03KANGAROO KIT 20FR/1.2 BRAND TIER 03KANGAROO KIT 20FR/1.5 BRAND TIER 03KANGAROO KIT 20FR/1.7 BRAND TIER 03KANGAROO KIT 20FR/2CM BRAND TIER 03KANGAROO KIT 20FR/2.3 BRAND TIER 03G4 PLATINUM KIT RECEIVER BRAND TIER 03G4 SENSOR KIT BRAND TIER 03CURITY COMB MIS PREP RZR BRAND TIER 03SPECIMEN MIS CONATINR BRAND TIER 03THIGH LENGTH MIS SM/REG BRAND TIER 03THIGH LENGTH MIS MED/LONG BRAND TIER 03SPONGE COUNT MIS BAGS BRAND TIER 03GRAVITY SET MIS 1000ML BRAND TIER 03FEEDING TUBE MIS 14FR 36" BRAND TIER 03FEEDING TUBE MIS 10FR 36" BRAND TIER 03GASTROS TUBE MIS 22FRENCH BRAND TIER 03GASTROS TUBE MIS 26FRENCH BRAND TIER 03FEEDING TUBE MIS 8FR 36" BRAND TIER 03FEEDING TUBE MIS 12FR 36" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion125

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES GASTROS TUBE MIS 24FRENCH BRAND TIER 03PUMP SET MIS 1000ML BRAND TIER 03PUMP SET MIS 1200ML BRAND TIER 03PUMP SET MIS 600ML BRAND TIER 03AMIELLE VAG MIS TRAINER BRAND TIER 03BD SAFETY‐LO MIS SET BRAND TIER 03PUMP SET MIS SPIKE BRAND TIER 03PULMO‐AIDE MIS COMP/NEB BRAND TIER 03DEVILBISS MIS NEBULIZR BRAND TIER 03NEBULIZER MIS GENERIC TIER 01COMPRESSION MIS STOCKING GENERIC TIER 01COMPRESSION MIS SOCKS GENERIC TIER 01SUPPOSITORY MIS MOLD GENERIC TIER 01INSPIREASE MIS RES BAG BRAND TIER 03 QLINSPIREASE MIS BAGS BRAND TIER 03 QLINSPIREASE MIS MOUTHPCE BRAND TIER 03 QLINSPIREASE MIS REP MOUT BRAND TIER 03 QLURINE METER MIS BRAND TIER 03ROBINSN CATH MIS 8FR BRAND TIER 03SHARPS CONT MIS 14QT BRAND TIER 03SHARPS CONT MIS 8QT BRAND TIER 03KENGUARD MIS IRRIGATN BRAND TIER 03KANGAROO MIS IRRIGAT BRAND TIER 03STOMA MEASUR MIS DEVICE BRAND TIER 03SURG BLADES MIS SIZE 10 BRAND TIER 03SURG BLADES MIS SIZE 10 GENERIC TIER 01SURG BLADES MIS SIZE 20 BRAND TIER 03SURG BLADES MIS SIZE 20 GENERIC TIER 01SURG BLADES MIS SIZE 21 BRAND TIER 03SURG BLADES MIS SIZE 21 GENERIC TIER 01SURG BLADES MIS SIZE 22 BRAND TIER 03SURG BLADES MIS SIZE 22 GENERIC TIER 01SURG BLADES MIS SIZE 11 BRAND TIER 03SURG BLADES MIS SIZE 11 GENERIC TIER 01SURG BLADES MIS SIZE 15 BRAND TIER 03SURG BLADES MIS SIZE 15 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 10 BRAND TIER 03SCALPEL/BLAD MIS SIZE 10 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 11 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion126

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES SCALPEL/BLAD MIS SIZE 11 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 15 BRAND TIER 03SCALPEL/BLAD MIS SIZE 15 GENERIC TIER 01SIDESTREAM MIS PED MASK BRAND TIER 03ORAL SYRINGE MIS 1ML BRAND TIER 03ORAL SYRINGE MIS 3ML BRAND TIER 03ORAL SYRINGE MIS 10ML BRAND TIER 03SPEEDICATH MIS FEMALE BRAND TIER 03ULTRAFLEX MIS 24"/8MM BRAND TIER 03ULTRAFLEX MIS 31"/8MM BRAND TIER 03ULTRAFLEX MIS 43"/8MM BRAND TIER 03ULTRAFLEX MIS 24"/10MM BRAND TIER 03ULTRAFLEX MIS 31"/10MM BRAND TIER 03ULTRAFLEX MIS 43"/10MM BRAND TIER 03ULTRAFLEX II MIS 24"/8MM BRAND TIER 03ULTRAFLEX II MIS 43"/8MM BRAND TIER 03ULTRAFLEX II MIS 24"/10MM BRAND TIER 03ULTRAFLEX II MIS 31"/10MM BRAND TIER 03ULTRAFLEX II MIS 43"/10MM BRAND TIER 03ORAL SYRINGE MIS 5ML BRAND TIER 031ML TB SYRNG MIS REG LUER BRAND TIER 033ML SYRINGE MIS CANNULA BRAND TIER 0312ML SYRINGE MIS 18GX1" BRAND TIER 03HYPO NEEDLE MIS 26GX1/2" BRAND TIER 03HYPO NEEDLE MIS 27GX1/2" BRAND TIER 035ML SYRINGE MIS CANNULA BRAND TIER 03INSULIN SYRG MIS 0.3/29G BRAND TIER 03INSULIN SYRG MIS 0.3/30G BRAND TIER 03HYPO NEEDLE MIS 25GX5/8" BRAND TIER 0312ML SYRINGE MIS REG LUER BRAND TIER 03SPINAL NEEDL MIS 22GX1.5" BRAND TIER 03HYPO NEEDLE MIS 23GX3/4" BRAND TIER 033ML LL SYRNG MIS 20GX3/4" BRAND TIER 03INSULIN SYRG MIS 1ML BRAND TIER 03HYPO NEEDLE MIS 22GX1" BRAND TIER 03HYPO NEEDLE MIS 23GX1" BRAND TIER 03HYPO NEEDLE MIS 25GX1" BRAND TIER 03INSULIN SYRG MIS 0.5/28G BRAND TIER 0320ML SYRINGE MIS ECC LUER BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion127

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES HYPO NEEDLE MIS 16GX1" BRAND TIER 03HYPO NEEDLE MIS 18GX1" BRAND TIER 03HYPO NEEDLE MIS 19GX1" BRAND TIER 03HYPO NEEDLE MIS 20GX1" BRAND TIER 03HYPO NEEDLE MIS 21GX1" BRAND TIER 03FILTER NEEDL MIS 18GX1.5" BRAND TIER 033ML LL SYRNG MIS 20GX1" BRAND TIER 03SURGUARD2 MIS 25GX1" BRAND TIER 03SPINAL NEEDL MIS 20GX2.5" BRAND TIER 03SPINAL NEEDL MIS 22GX2.5" BRAND TIER 0312ML SYRINGE MIS 20GX1.5" BRAND TIER 03HYPO NEEDLE MIS 27GX1.25 BRAND TIER 033ML LL SYRNG MIS 20GX1.5" BRAND TIER 036ML LL SYRNG MIS 20GX1.5" BRAND TIER 03INSULIN SYRG MIS 0.5/29G BRAND TIER 03INSULIN SYRG MIS 0.5/30G BRAND TIER 03HYPO NEEDLE MIS 22GX1.5" BRAND TIER 03HYPO NEEDLE MIS 25GX1.5" BRAND TIER 03HYPO NEEDLE MIS 27GX1.5" BRAND TIER 03HYPO NEEDLE MIS 16GX1.5" BRAND TIER 03HYPO NEEDLE MIS 18GX1.5" BRAND TIER 03HYPO NEEDLE MIS 19GX1.5" BRAND TIER 03HYPO NEEDLE MIS 20GX1.5" BRAND TIER 03HYPO NEEDLE MIS 21GX1.5" BRAND TIER 03INSULIN SYRG MIS 1ML/25G BRAND TIER 031ML TB SYRNG MIS 25GX5/8" BRAND TIER 0312ML SYRINGE MIS 21GX1" BRAND TIER 033ML LL SYRNG MIS 21GX1" BRAND TIER 036ML LL SYRNG MIS 21GX1" BRAND TIER 035ML SYRINGE MIS 21GX1" BRAND TIER 0330ML SYRINGE MIS LUER‐LOK BRAND TIER 0330ML SYRINGE MIS ECC LUER BRAND TIER 03SPINAL NEEDL MIS 18GX3.5" BRAND TIER 03SPINAL NEEDL MIS 19GX3.5" BRAND TIER 03SPINAL NEEDL MIS 20GX3.5" BRAND TIER 03SPINAL NEEDL MIS 22GX3.5" BRAND TIER 03SPINAL NEEDL MIS 25GX3.5" BRAND TIER 03SPINAL NEEDL MIS 26GX3.5" BRAND TIER 03EPIDUR NEEDL MIS 18GX3.5" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion128

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEVICES EPIDUR NEEDL MIS 20GX3.5" BRAND TIER 0312ML SYRINGE MIS 21GX1.5" BRAND TIER 031ML TB SYRNG MIS 26GX3/8" BRAND TIER 033ML LL SYRNG MIS 21GX1.5" BRAND TIER 036ML LL SYRNG MIS 21GX1.5" BRAND TIER 031ML SYRINGE MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 21GX1.5" BRAND TIER 031ML TB SYRNG MIS 27GX1/2" BRAND TIER 03INSULIN SYRG MIS 1ML/27G BRAND TIER 033ML LL SYRNG MIS 22GX1" BRAND TIER 035ML SYRINGE MIS 22GX1" BRAND TIER 033ML LL SYRNG MIS 22GX1.25 BRAND TIER 0360ML SYRINGE MIS LUER LOK BRAND TIER 0360ML SYRINGE MIS CATH TIP BRAND TIER 031ML TB SYRNG MIS 28GX1/2" BRAND TIER 0312ML SYRINGE MIS 22GX1.5" BRAND TIER 033ML LL SYRNG MIS 22GX1.5" BRAND TIER 036ML LL SYRNG MIS 22GX1.5" BRAND TIER 031ML SYRINGE MIS 25GX5/8" BRAND TIER 033ML SYRINGE MIS 22GX1.5" BRAND TIER 035ML SYRINGE MIS 22GX1.5" BRAND TIER 033ML LL SYRNG MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 23GX1.5" BRAND TIER 031ML SYRINGE MIS 26GX3/8" BRAND TIER 03INSULIN SYRG MIS 1ML/28G BRAND TIER 033ML LL SYRNG MIS 25GX5/8" BRAND TIER 033ML SYRINGE MIS 25GX5/8" BRAND TIER 033ML LL SYRNG MIS 25GX1" BRAND TIER 033ML SYRINGE MIS 25GX1" BRAND TIER 03INSULIN SYRG MIS 1ML/29G BRAND TIER 03INSULIN SYRG MIS 1ML/30G BRAND TIER 033ML LL SYRNG MIS 27GX1.25 BRAND TIER 03TRACHEOSTOMY KIT CARE BRAND TIER 03NEBULIZER KIT MASK PED GENERIC TIER 011ML ALLERGIS KIT TRAY SYR BRAND TIER 03DIAGNOSTIC AGENTS ABLAVAR INJ 244MG/ML BRAND TIER 99 DEASPERGILLUS INJ 1:500 GENERIC TIER 99 DECERETEC INJ BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion129

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIAGNOSTIC AGENTS CHOLETEC INJ BRAND TIER 99 DECYSVIEW INJ 100MG BRAND TIER 99 DEDATSCAN SOL BRAND TIER 99 DEDEFINITY SUS 1.1MG/ML BRAND TIER 99 DEDIAGNOSTIC KIT GENERIC TIER 99 DEEOVIST INJ BRAND TIER 99 DEINDIUM IN111 INJ OXYQUINO GENERIC TIER 99 DEISOSULFAN INJ BLUE 1% GENERIC TIER 99 DELYMPHAZURIN INJ 1% Brand‐O TIER 99 DEMAGNEVIST INJ 46.9% BRAND TIER 99 DEMDP KIT MULTIDOS BRAND TIER 99 DEMETHACHOLINE CRY CHLORIDE GENERIC TIER 99 DEOMNISCAN INJ /NACL BRAND TIER 99 DEOMNISCAN INJ 287MG/ML BRAND TIER 99 DEOPTIMARK INJ 330.9MG BRAND TIER 99 DEOPTISON INJ BRAND TIER 99 DEPROHANCE INJ 279.3/ML BRAND TIER 99 DEPROVOCHOLINE SOL 100MG BRAND TIER 99 DET.R.U.E. TES BRAND TIER 99 DETHYREL TRH INJ 0.5MG/ML BRAND TIER 99 DEDIGESTANTS CREON CAP 12000UNT BRAND TIER 02CREON CAP 24000UNT BRAND TIER 02CREON CAP 3000UNIT BRAND TIER 02CREON CAP 6000UNIT BRAND TIER 02HYDROCHLORIC INJ 1:500 GENERIC TIER 01PANCREAZE CAP 10500UNT BRAND TIER 03PANCREAZE CAP 16800UNT BRAND TIER 03PANCREAZE CAP 21000UNT BRAND TIER 03PANCREAZE CAP 4200UNIT BRAND TIER 03PANCRELIPASE CAP 5000UNIT GENERIC TIER 01PERTZYE CAP BRAND TIER 03VIOKACE TAB BRAND TIER 03ZENPEP CAP 10000UNT BRAND TIER 02ZENPEP CAP 15000UNT BRAND TIER 02ZENPEP CAP 20000UNT BRAND TIER 02ZENPEP CAP 25000UNT BRAND TIER 02ZENPEP CAP 3000UNIT BRAND TIER 02ZENPEP CAP 5000UNIT BRAND TIER 02DIHYDROPYRIDINES ADALAT CC TAB 30MG ER Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion130

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIHYDROPYRIDINES ADALAT CC TAB 60MG ER Brand‐O TIER 03 PAADALAT CC TAB 90MG ER Brand‐O TIER 03 PAAFEDITAB TAB 30MG CR GENERIC TIER 01AFEDITAB TAB 60MG CR GENERIC TIER 01AMLOD/ATORVA TAB 10‐10MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 10‐20MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 10‐40MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 10‐80MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 2.5‐10MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 2.5‐20MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 2.5‐40MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 5‐10MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 5‐20MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 5‐40MG GENERIC TIER 01 PAAMLOD/ATORVA TAB 5‐80MG GENERIC TIER 01 PAAMLOD/BENAZP CAP 10‐20MG GENERIC TIER 01AMLOD/BENAZP CAP 10‐40MG GENERIC TIER 01AMLOD/BENAZP CAP 2.5‐10MG GENERIC TIER 01AMLOD/BENAZP CAP 5‐10MG GENERIC TIER 01AMLOD/BENAZP CAP 5‐20MG GENERIC TIER 01AMLOD/BENAZP CAP 5‐40MG GENERIC TIER 01AMLODIPINE TAB 10MG GENERIC TIER 01AMLODIPINE TAB 2.5MG GENERIC TIER 01AMLODIPINE TAB 5MG GENERIC TIER 01AZOR TAB 10‐20MG BRAND TIER 02 PAAZOR TAB 10‐40MG BRAND TIER 02 PAAZOR TAB 5‐20MG BRAND TIER 02 PAAZOR TAB 5‐40MG BRAND TIER 02 PACADUET TAB 10‐10MG BRAND TIER 03 PACADUET TAB 10‐20MG BRAND TIER 03 PACADUET TAB 10‐40MG BRAND TIER 03 PACADUET TAB 10‐80MG BRAND TIER 03 PACADUET TAB 2.5‐10MG BRAND TIER 03 PACADUET TAB 2.5‐20MG BRAND TIER 03 PACADUET TAB 2.5‐40MG BRAND TIER 03 PACADUET TAB 5‐10MG BRAND TIER 03 PACADUET TAB 5‐20MG BRAND TIER 03 PACADUET TAB 5‐40MG BRAND TIER 03 PACADUET TAB 5‐80MG BRAND TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion131

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIHYDROPYRIDINES CARDENE IV INJ 40/200ML BRAND TIER 03CARDENE IV INJ 40/200ML TIER 99 DECARDENE IV SOL 20/200ML BRAND TIER 03CARDENE SR CAP 30MG BRAND TIER 99 DECARDENE SR CAP 45MG BRAND TIER 99 DECARDENE SR CAP 60MG BRAND TIER 99 DECLEVIPREX EMU 0.5MG/ML BRAND TIER 99 DEDYNACIRC CR TAB 10MG BRAND TIER 03DYNACIRC CR TAB 5MG BRAND TIER 03EXFORGE TAB 10‐160MG BRAND TIER 02 PAEXFORGE TAB 10‐320MG BRAND TIER 02 PAEXFORGE TAB 5‐160MG BRAND TIER 02 PAEXFORGE TAB 5‐320MG BRAND TIER 02 PAEXFORGEH/10‐ TAB 160‐12.5 BRAND TIER 02 PAEXFORGEH/10‐ TAB 160‐25 BRAND TIER 02 PAEXFORGEH/10‐ TAB 320‐25 BRAND TIER 02 PAEXFORGEH/5‐ TAB 160‐12.5 BRAND TIER 02 PAEXFORGEH/5‐ TAB 160‐25 BRAND TIER 02 PAFELODIPINE TAB 10MG ER GENERIC TIER 01FELODIPINE TAB 2.5MG ER GENERIC TIER 01FELODIPINE TAB 5MG ER GENERIC TIER 01HYPERTENIPIN PAK 2.5MG BRAND TIER 03ISRADIPINE CAP 2.5MG GENERIC TIER 01ISRADIPINE CAP 5MG GENERIC TIER 01LOTREL CAP 10‐20MG Brand‐O TIER 03 PALOTREL CAP 10‐40MG Brand‐O TIER 03 PALOTREL CAP 2.5‐10MG Brand‐O TIER 03 PALOTREL CAP 5‐10MG Brand‐O TIER 03 PALOTREL CAP 5‐20MG Brand‐O TIER 03 PALOTREL CAP 5‐40MG Brand‐O TIER 03 PANICARDIPINE CAP 20MG GENERIC TIER 99 DENICARDIPINE CAP 30MG GENERIC TIER 99 DENICARDIPINE INJ 25/10ML GENERIC TIER 99 DENIFEDIAC CC TAB 30MG ER GENERIC TIER 01NIFEDIAC CC TAB 60MG ER GENERIC TIER 01NIFEDIAC CC TAB 90MG ER GENERIC TIER 01NIFEDICAL XL TAB 30MG GENERIC TIER 01NIFEDICAL XL TAB 60MG GENERIC TIER 01NIFEDIPINE CAP 10MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion132

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIHYDROPYRIDINES NIFEDIPINE CAP 20MG GENERIC TIER 01NIFEDIPINE TAB 30MG ER GENERIC TIER 01NIFEDIPINE TAB 60MG ER GENERIC TIER 01NIFEDIPINE TAB 90MG ER GENERIC TIER 01NIMODIPINE CAP 30MG GENERIC TIER 01NIMOTOP CAP 30MG Brand‐O TIER 03 PANISOLDIPINE TAB 17MG ER GENERIC TIER 01NISOLDIPINE TAB 20MG GENERIC TIER 01NISOLDIPINE TAB 25.5MG GENERIC TIER 01NISOLDIPINE TAB 30MG GENERIC TIER 01NISOLDIPINE TAB 34MG ER GENERIC TIER 01NISOLDIPINE TAB 40MG GENERIC TIER 01NISOLDIPINE TAB 8.5MG ER GENERIC TIER 01NORVASC TAB 10MG Brand‐O TIER 03 PANORVASC TAB 2.5MG Brand‐O TIER 03 PANORVASC TAB 5MG Brand‐O TIER 03 PAPROCARDIA CAP 10MG Brand‐O TIER 03 PAPROCARDIA XL TAB 30MG CR Brand‐O TIER 03 PAPROCARDIA XL TAB 60MG CR Brand‐O TIER 03 PAPROCARDIA XL TAB 90MG CR Brand‐O TIER 03 PASULAR TAB 17MG Brand‐O TIER 03 PASULAR TAB 25.5MG Brand‐O TIER 03 PASULAR TAB 34MG Brand‐O TIER 03 PASULAR TAB 8.5MG Brand‐O TIER 03 PATRIBENZOR20‐ TAB 5‐12.5MG BRAND TIER 02 PATRIBENZOR40‐ TAB 10‐12.5 BRAND TIER 02 PATRIBENZOR40‐ TAB 10‐25MG BRAND TIER 02 PATRIBENZOR40‐ TAB 5‐12.5MG BRAND TIER 02 PATRIBENZOR40‐ TAB 5‐25MG BRAND TIER 02 PATWYNSTA TAB 40‐10MG BRAND TIER 02 PATWYNSTA TAB 40‐5MG BRAND TIER 02 PATWYNSTA TAB 80‐10MG BRAND TIER 02 PATWYNSTA TAB 80‐5MG BRAND TIER 02 PACARDENE I.V. INJ 2.5MG/ML Brand‐O TIER 99 PA DEDIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS JANUMET TAB 50‐1000 BRAND TIER 02 PAJANUMET TAB 50‐500MG BRAND TIER 02 PAJANUMET XR TAB 100‐1000 BRAND TIER 02 PAJANUMET XR TAB 50‐1000 BRAND TIER 02 PAJANUMET XR TAB 50‐500MG BRAND TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion133

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS JANUVIA TAB 100MG BRAND TIER 02 PAJANUVIA TAB 25MG BRAND TIER 02 PAJANUVIA TAB 50MG BRAND TIER 02 PAJENTADUETO TAB 2.5‐1000 BRAND TIER 03 PAJENTADUETO TAB 2.5‐500 BRAND TIER 03 PAJENTADUETO TAB 2.5‐850 BRAND TIER 03 PAJUVISYNC TAB 100‐10MG BRAND TIER 03 PAJUVISYNC TAB 100‐20MG BRAND TIER 03 PAJUVISYNC TAB 100‐40MG BRAND TIER 03 PAKOMBIGLYZE TAB 2.5‐1000 BRAND TIER 02 PAKOMBIGLYZE TAB 5‐1000MG BRAND TIER 02 PAKOMBIGLYZE TAB 5‐500MG BRAND TIER 02 PAONGLYZA TAB 2.5MG BRAND TIER 02 PAONGLYZA TAB 5MG BRAND TIER 02 PATRADJENTA TAB 5MG BRAND TIER 02 PAJUVISYNC TAB 50‐10MG BRAND TIER 03JUVISYNC TAB 50‐20MG BRAND TIER 03JUVISYNC TAB 50‐40MG BRAND TIER 03DIRECT FACTOR XA INHIBITORS ARIXTRA SOL 10/0.8 Brand‐O TIER 03 PAARIXTRA SOL 2.5/0.5 Brand‐O TIER 03 PAARIXTRA SOL 5.0/0.4 Brand‐O TIER 03 PAARIXTRA SOL 7.5/0.6 Brand‐O TIER 03 PAFONDAPARINUX SOL 10/0.8 GENERIC TIER 01FONDAPARINUX SOL 2.5/0.5 GENERIC TIER 01FONDAPARINUX SOL 5.0/0.4 GENERIC TIER 01FONDAPARINUX SOL 7.5/0.6 GENERIC TIER 01XARELTO TAB 10MG BRAND TIER 03 PA QLXARELTO TAB 15MG BRAND TIER 03 PA QLXARELTO TAB 20MG BRAND TIER 03 PA QLDIRECT THROMBIN INHIBITORS ANGIOMAX INJ 250MG BRAND TIER 03ARGATROBAN INJ 100MG/ML GENERIC TIER 01ARGATROBAN INJ 125/125 GENERIC TIER 01ARGATROBAN INJ 50MG/50M GENERIC TIER 01IPRIVASK INJ 15MG BRAND TIER 03 PAPRADAXA CAP 150MG BRAND TIER 02 PA QLPRADAXA CAP 75MG BRAND TIER 02 PA QLREFLUDAN INJ 50MG BRAND TIER 03DIRECT VASODILATORS CORLOPAM INJ 10MG/ML Brand‐O TIER 03 PAFENOLDOPAM INJ 10MG/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion134

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDIRECT VASODILATORS FENOLDOPAM INJ 20MG/2ML GENERIC TIER 01HYDRALAZINE INJ 20MG/ML GENERIC TIER 01HYDRALAZINE TAB 100MG GENERIC TIER 01HYDRALAZINE TAB 10MG GENERIC TIER 01HYDRALAZINE TAB 25MG GENERIC TIER 01HYDRALAZINE TAB 50MG GENERIC TIER 01MINOXIDIL TAB 10MG GENERIC TIER 01MINOXIDIL TAB 2.5MG GENERIC TIER 01NITROPRESS INJ 25MG/ML BRAND TIER 03PROGLYCEM SUS 50MG/ML BRAND TIER 03DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS DANTRIUM CAP 100MG Brand‐O TIER 03 PADANTRIUM CAP 25MG Brand‐O TIER 03 PADANTRIUM CAP 50MG Brand‐O TIER 03 PADANTRIUM IV INJ 20MG Brand‐O TIER 03 PADANTROLENE CAP 100MG GENERIC TIER 01DANTROLENE CAP 25MG GENERIC TIER 01DANTROLENE CAP 50MG GENERIC TIER 01REVONTO INJ 20MG GENERIC TIER 01DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA INJ 200/10ML BRAND TIER 03 PA SPACTEMRA INJ 400/20ML BRAND TIER 03 PA SPACTEMRA INJ 80MG/4ML BRAND TIER 03 PA SPARAVA TAB 10MG Brand‐O TIER 03 PAARAVA TAB 20MG Brand‐O TIER 03 PACIMZIA KIT BRAND TIER 03 PA SPCIMZIA KIT 200MG/ML BRAND TIER 03 PA QL SPCIMZIA KIT STARTER BRAND TIER 03 PA SPENBREL INJ 25/0.5ML BRAND TIER 02 PA QL SPENBREL INJ 25MG BRAND TIER 02 PA QL SPENBREL INJ 50MG/ML BRAND TIER 02 PA QL SPENBREL SRCLK INJ 50MG/ML BRAND TIER 02 PA QL SPHUMIRA KIT 20MG/0.4 BRAND TIER 02 PA QL SPHUMIRA KIT 40MG/0.8 BRAND TIER 02 PA QL SPHUMIRA PEN KIT 40MG/0.8 BRAND TIER 02 PA QL SPHUMIRA PEN KIT CROHNS BRAND TIER 02 PA QL SPHUMIRA PEN KIT PSORIASI BRAND TIER 02 PA QL SPKINERET INJ BRAND TIER 03 PA QL SPLEFLUNOMIDE TAB 10MG GENERIC TIER 01LEFLUNOMIDE TAB 20MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion135

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ORENCIA INJ 125MG/ML BRAND TIER 03 PA QLORENCIA INJ 250MG BRAND TIER 03 PA QL SPREMICADE INJ 100MG BRAND TIER 03 PA SPSIMPONI INJ 50MG BRAND TIER 03 PA QL SPDISINFECTANTS (FOR NON‐DERMATOLOGIC USE) FORMADON SOL GENERIC TIER 99 DEFORMALDEHYDE SOL 10% GENERIC TIER 99 DEFORMA‐RAY SOL 20% GENERIC TIER 01LAZERFORMALY SOL 10% GENERIC TIER 99 DEGLUTARALDEHY SOL 25% GENERIC TIER 01FORMALDEHYDE SOL 37% GENERIC TIER 01DOPAMINE PRECURSORS CARB/LEVO TAB 10‐100MG GENERIC TIER 01CARB/LEVO TAB 25‐100MG GENERIC TIER 01CARB/LEVO TAB 25‐250MG GENERIC TIER 01CARB/LEVO 50 TAB /ENTACAP GENERIC TIER 01CARB/LEVO 75 TAB /ENTACAP GENERIC TIER 01CARB/LEVO ER TAB 25‐100MG GENERIC TIER 01CARB/LEVO ER TAB 50‐200MG GENERIC TIER 01CARB/LEVO SR TAB 25‐100MG GENERIC TIER 01CARB/LEVO SR TAB 50‐200MG GENERIC TIER 01CARB/LEVO100 TAB /ENTACAP GENERIC TIER 01CARB/LEVO125 TAB /ENTACAP GENERIC TIER 01CARB/LEVO150 TAB /ENTACAP GENERIC TIER 01CARB/LEVO200 TAB /ENTACAP GENERIC TIER 01LODOSYN TAB 25MG BRAND TIER 02PARCOPA TAB 10‐100MG Brand‐O TIER 03 PAPARCOPA TAB 25‐100MG Brand‐O TIER 03 PAPARCOPA TAB 25‐250MG Brand‐O TIER 03 PASINEMET TAB 10‐100MG Brand‐O TIER 03 PASINEMET TAB 25‐100MG Brand‐O TIER 03 PASINEMET TAB 25‐250MG Brand‐O TIER 03 PASINEMET CR TAB 25‐100MG Brand‐O TIER 03 PASINEMET CR TAB 50‐200MG Brand‐O TIER 03 PASTALEVO 100 TAB BRAND TIER 03STALEVO 125 TAB BRAND TIER 03STALEVO 150 TAB BRAND TIER 03STALEVO 200 TAB BRAND TIER 03STALEVO 50 TAB BRAND TIER 03STALEVO 75 TAB BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion136

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDRUG HYPERSENSITIVITY CANDIN INJ BRAND TIER 03PRE‐PEN INJ BRAND TIER 03ECHINOCANDINS CANCIDAS INJ 50MG BRAND TIER 03CANCIDAS INJ 70MG BRAND TIER 03ERAXIS INJ 100MG BRAND TIER 99 DEERAXIS INJ 50MG BRAND TIER 99 DEMYCAMINE INJ 100MG BRAND TIER 99 DEMYCAMINE INJ 50MG BRAND TIER 03EENT ANTI‐INFECTIVES, MISCELLANEOUS ARZOL SILVER MIS NITR APP GENERIC TIER 01BETADINE SOL 5% OP BRAND TIER 03CHLORHEX GLU SOL 0.12% GENERIC TIER 01GRAFCO SILVR MIS NIT APPL GENERIC TIER 01PERIDEX SOL 0.12% Brand‐O TIER 03 PAPERIOGARD SOL 0.12% GENERIC TIER 01SILVER CRY NITRATE GENERIC TIER 99 DESILVER NITRA OIN 10% GENERIC TIER 01SILVER NITRA SOL 0.5% GENERIC TIER 01SILVER NITRA SOL 10% GENERIC TIER 01SILVER NITRA SOL 25% GENERIC TIER 01SILVER NITRA SOL 50% GENERIC TIER 01EENT ANTI‐INFLAMMATORY AGENTS, MISC. RESTASIS EMU 0.05% BRAND TIER 02 PA QLEENT DRUGS, MISCELLANEOUS ACE ACD/ALUM SOL 2% OTIC GENERIC TIER 01ACETIC ACID SOL 2% OTIC GENERIC TIER 01AKORN BALANC SOL SALT OP GENERIC TIER 01AMVISC INJ 12MG/ML BRAND TIER 03AMVISC PLUS INJ 16MG/ML BRAND TIER 03APHTHASOL PST 5% BRAND TIER 03APRACLONIDIN SOL 0.5% OP GENERIC TIER 01AQUORAL AER GENERIC TIER 01BAL SALT SOL OP GENERIC TIER 01BALANCED SAL SOL OP GENERIC TIER 01BSS SOL OP GENERIC TIER 01BSS PLUS SOL OP Brand‐O TIER 03 PACAPHOSOL SOL BRAND TIER 03CELLUGEL SOL 2% Brand‐O TIER 03 PADEBACTEROL SOL 30‐50% BRAND TIER 03DISCOVISC SOL BRAND TIER 03DUOVISC KIT 0.35/0.4 BRAND TIER 03DUOVISC KIT 0.5/0.55 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion137

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusEENT DRUGS, MISCELLANEOUS EYLEA INJ 2/0.05ML BRAND TIER 03HEALON INJ 10MG/ML BRAND TIER 03HEALON GV INJ 14MG/ML BRAND TIER 03HEALON5 INJ 23MG/ML BRAND TIER 03INTROL SOL 75% BRAND TIER 03IOPIDINE SOL 0.5% OP Brand‐O TIER 03 PAIOPIDINE SOL 1% OP BRAND TIER 03LACRISERT MIS 5MG OP BRAND TIER 02LUCENTIS SOL 0.3MG BRAND TIER 02 SPLUCENTIS SOL 0.5MG BRAND TIER 02 SPMACUGEN INJ BRAND TIER 03 SPNEUTRASAL POW BRAND TIER 03NUMOISYN LIQ GENERIC TIER 01NUMOISYN LOZ Brand‐O TIER 03 PAOCUCOAT SOL 2% OP GENERIC TIER 01PROPYLENE GL SOL USP GENERIC TIER 01PROVISC INJ 1% BRAND TIER 03SHELLGEL SOL BRAND TIER 03VISCOAT SOL BRAND TIER 03VISUDYNE INJ 15MG BRAND TIER 03 SPVOSOL SOL 2% OTIC Brand‐O TIER 03 PAEENT NONSTEROIDAL ANTI‐INFLAM. AGENTS ACULAR SOL 0.5% OP Brand‐O TIER 03 PAACULAR LS SOL 0.4% Brand‐O TIER 03 PAACUVAIL SOL 0.45% BRAND TIER 03 PABROMDAY SOL 0.09% BRAND TIER 03 PABROMFENAC SOL 0.09% GENERIC TIER 01 PADICLOFENAC SOL 0.1% OP GENERIC TIER 01FLURBIPROFEN SOL 0.03% OP GENERIC TIER 01KETOROLAC SOL 0.4% GENERIC TIER 01 PAKETOROLAC SOL 0.5% GENERIC TIER 01 PANEVANAC SUS 0.1% BRAND TIER 02 PAOCUFEN SOL 0.03% OP Brand‐O TIER 03 PAVOLTAREN SOL 0.1% OP Brand‐O TIER 03 PAXIBROM SOL 0.09% Brand‐O TIER 03 PAEMOLLIENTS, DEMULCENTS, AND PROTECTANTS AURSTAT KIT BRAND TIER 03HYLATOPC PLS KIT /AURSTAT BRAND TIER 99 DEMB HYDROGEL KIT BRAND TIER 03HPR PLUS MB KIT HYDROGEL BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion138

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusEMOLLIENTS, DEMULCENTS, AND PROTECTANTS VASELINE GEL BRAND TIER 99 DEENZYMES ADAGEN INJ 250/ML BRAND TIER 02 SPALDURAZYME INJ 2.9MG/5M BRAND TIER 02 SPAMPHADASE INJ 150/ML BRAND TIER 03CEREDASE INJ 80UNT/ML BRAND TIER 03 SPCEREZYME INJ 200UNIT BRAND TIER 02 SPCEREZYME INJ 400UNIT BRAND TIER 02 SPELAPRASE INJ 6MG/3ML BRAND TIER 02 SPELELYSO INJ 200UNIT BRAND TIER 03ELITEK INJ 1.5MG BRAND TIER 03 SPELITEK INJ 7.5MG BRAND TIER 03 SPFABRAZYME INJ 35MG BRAND TIER 02 SPFABRAZYME INJ 5MG BRAND TIER 02 SPHYLENEX INJ 150 UNIT BRAND TIER 03LUMIZYME INJ 50MG BRAND TIER 02 SPMYOZYME INJ 50MG BRAND TIER 02 SPNAGLAZYME INJ 1MG/ML BRAND TIER 02 SPSUCRAID SOL 8500/ML BRAND TIER 03VITRASE INJ 200/ML BRAND TIER 03VPRIV INJ 400UNIT BRAND TIER 02XIAFLEX INJ 0.9MG BRAND TIER 02 PA SPERGOT‐DERIV. DOPAMINE RECEPTOR AGONISTS BROMOCRIPTIN CAP 5MG GENERIC TIER 01BROMOCRIPTIN TAB 2.5MG GENERIC TIER 01CABERGOLINE TAB 0.5MG GENERIC TIER 01PARLODEL CAP 5MG Brand‐O TIER 03 PAPARLODEL TAB 2.5MG Brand‐O TIER 03 PAERYTHROMYCINS E.E.S. 400 TAB 400MG GENERIC TIER 01E.E.S. GRAN SUS 200/5ML BRAND TIER 03E.S.P. SUS 200‐600 GENERIC TIER 01EES/SULFISOX SUS 200‐600 GENERIC TIER 01ERYPED SUS 200/5ML BRAND TIER 03ERYPED SUS 400/5ML BRAND TIER 03ERY‐TAB TAB 250MG EC BRAND TIER 03ERY‐TAB TAB 333MG EC BRAND TIER 03ERY‐TAB TAB 500MG EC BRAND TIER 03ERYTHROCIN INJ 1000MG BRAND TIER 03ERYTHROCIN INJ 500MG BRAND TIER 03ERYTHROCIN INJ 500MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion139

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusERYTHROMYCINS ERYTHROCIN TAB 250MG BRAND TIER 03ERYTHROCIN TAB 250MG GENERIC TIER 01ERYTHROM ETH TAB 400MG GENERIC TIER 01ERYTHROMYCIN CAP 250MG EC GENERIC TIER 01ERYTHROMYCIN TAB 250MG BS GENERIC TIER 01ERYTHROMYCIN TAB 500MG BS GENERIC TIER 01PCE TAB 333MG EC BRAND TIER 03PCE TAB 500MG EC BRAND TIER 03ESTROGEN AGONIST‐ANTAGONISTS CLOMIPHENE TAB 50MG GENERIC TIER 99 DEEVISTA TAB 60MG BRAND TIER 02SEROPHENE TAB 50MG GENERIC TIER 99 DECLOMID TAB 50MG Brand‐O TIER 99 PA DEESTROGENS ACTIVELLA TAB 0.5‐0.1 Brand‐O TIER 03 PAACTIVELLA TAB 1‐0.5MG Brand‐O TIER 03 PAALORA DIS 0.025MG BRAND TIER 03ALORA DIS 0.05MG BRAND TIER 03ALORA DIS 0.075MG BRAND TIER 03ALORA DIS 0.1MG BRAND TIER 03ANGELIQ TAB 0.25‐0.5 BRAND TIER 03ANGELIQ TAB 0.5‐1MG BRAND TIER 03CENESTIN TAB 0.3MG BRAND TIER 02CENESTIN TAB 0.45MG BRAND TIER 02CENESTIN TAB 0.625MG BRAND TIER 02CENESTIN TAB 0.9MG BRAND TIER 02CENESTIN TAB 1.25MG BRAND TIER 02CLIMARA DIS 0.025MG Brand‐O TIER 02 PACLIMARA DIS 0.0375MG Brand‐O TIER 02 PACLIMARA DIS 0.05MG Brand‐O TIER 02 PACLIMARA DIS 0.06MG Brand‐O TIER 02 PACLIMARA DIS 0.075MG Brand‐O TIER 02 PACLIMARA DIS 0.1MG Brand‐O TIER 02 PACLIMARA PRO DIS WEEKLY BRAND TIER 03COMBIPATCH DIS .05/.14 BRAND TIER 02COMBIPATCH DIS .05/.25 BRAND TIER 02COVARYX TAB GENERIC TIER 99 DECOVARYX HS TAB GENERIC TIER 99 DEDELESTROGEN INJ 10MG/ML Brand‐O TIER 03 PADELESTROGEN INJ 20MG/ML Brand‐O TIER 03 PADELESTROGEN INJ 40MG/ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion140

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusESTROGENS DEPO‐ESTRADI INJ 5MG/ML BRAND TIER 03DIVIGEL GEL 0.25MG BRAND TIER 02DIVIGEL GEL 0.5MG BRAND TIER 02DIVIGEL GEL 1MG/GM BRAND TIER 02EEMT TAB GENERIC TIER 99 DEEEMT HS TAB GENERIC TIER 99 DEELESTRIN GEL 0.06% BRAND TIER 03ENJUVIA TAB 0.3MG BRAND TIER 02ENJUVIA TAB 0.45MG BRAND TIER 02ENJUVIA TAB 0.625MG BRAND TIER 02ENJUVIA TAB 0.9MG BRAND TIER 02ENJUVIA TAB 1.25MG BRAND TIER 02ESSIAN TAB GENERIC TIER 99 DEESSIAN H.S. TAB GENERIC TIER 99 DEEST ESTROGEN TAB MTEST GENERIC TIER 99 DEEST ESTROGEN TAB MTEST DS GENERIC TIER 99 DEEST ESTROGEN TAB MTEST HS GENERIC TIER 99 DEESTRA/NORETH TAB 0.5‐0.1 GENERIC TIER 01ESTRA/NORETH TAB 1‐0.5MG GENERIC TIER 01ESTRACE TAB 0.5MG Brand‐O TIER 03 PAESTRACE TAB 1MG Brand‐O TIER 03 PAESTRACE TAB 2MG Brand‐O TIER 03 PAESTRACE VAG CRE 0.1MG/GM BRAND TIER 02ESTRAD VAL INJ 10MG/ML GENERIC TIER 01ESTRAD VAL INJ 200MG/5 GENERIC TIER 01ESTRAD VAL INJ 20MG/ML GENERIC TIER 01ESTRAD VAL INJ 40MG/ML GENERIC TIER 01ESTRADERM DIS 0.05MG BRAND TIER 03ESTRADERM DIS 0.1MG BRAND TIER 03ESTRADIOL DIS 0.025MG GENERIC TIER 01ESTRADIOL DIS 0.0375MG GENERIC TIER 01ESTRADIOL DIS 0.05MG GENERIC TIER 01ESTRADIOL DIS 0.06MG GENERIC TIER 01ESTRADIOL DIS 0.075MG GENERIC TIER 01ESTRADIOL DIS 0.1MG GENERIC TIER 01ESTRADIOL TAB 0.5MG GENERIC TIER 01ESTRADIOL TAB 1MG GENERIC TIER 01ESTRADIOL TAB 2MG GENERIC TIER 01ESTRASORB EMU BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion141

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusESTROGENS ESTRING MIS 2MG BRAND TIER 02ESTROGEL GEL BRAND TIER 03ESTRONE CRY USP GENERIC TIER 99 DEESTROPIPATE TAB 0.75MG GENERIC TIER 01ESTROPIPATE TAB 1.5MG GENERIC TIER 01ESTROPIPATE TAB 3MG GENERIC TIER 01EVAMIST SPR 1.53MG BRAND TIER 02FEMHRT TAB 0.5‐2.5 BRAND TIER 03FEMHRT 1/5 TAB Brand‐O TIER 03 PAFEMRING MIS 0.05/24H BRAND TIER 03FEMRING MIS 0.1MG/24 BRAND TIER 03FEMTRACE TAB 0.45MG BRAND TIER 03FEMTRACE TAB 0.9MG BRAND TIER 03FEMTRACE TAB 1.8MG BRAND TIER 03JEVANTIQUE TAB 1MG‐5MCG GENERIC TIER 01JINTELI TAB 1MG‐5MCG GENERIC TIER 01MENEST TAB 0.3MG BRAND TIER 03MENEST TAB 0.625MG BRAND TIER 03MENEST TAB 1.25MG BRAND TIER 03MENEST TAB 2.5MG BRAND TIER 03MENOSTAR DIS 14MCG BRAND TIER 03MIMVEY TAB 1‐0.5MG GENERIC TIER 01MTEST HS/EST TAB ESTROGEN GENERIC TIER 99 DEMTEST/EST TAB ESTROGEN GENERIC TIER 99 DEORTHO‐EST TAB 0.625 GENERIC TIER 01ORTHO‐EST TAB 1.25 GENERIC TIER 01PREFEST TAB BRAND TIER 03PREMARIN INJ 25MG BRAND TIER 03PREMARIN TAB 0.3MG BRAND TIER 02PREMARIN TAB 0.45MG BRAND TIER 02PREMARIN TAB 0.625MG BRAND TIER 02PREMARIN TAB 0.9MG BRAND TIER 02PREMARIN TAB 1.25MG BRAND TIER 02PREMARIN VAG CRE 0.625MG BRAND TIER 03PREMPHASE TAB BRAND TIER 02PREMPRO TAB .625‐2.5 BRAND TIER 02PREMPRO TAB 0.3‐1.5 BRAND TIER 02PREMPRO TAB 0.45‐1.5 BRAND TIER 02PREMPRO TAB 0.625‐5 BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion142

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusESTROGENS VAGIFEM TAB 10MCG BRAND TIER 02VIVELLE‐DOT DIS 0.025MG BRAND TIER 02VIVELLE‐DOT DIS 0.0375MG BRAND TIER 02VIVELLE‐DOT DIS 0.05MG BRAND TIER 02VIVELLE‐DOT DIS 0.075MG BRAND TIER 02VIVELLE‐DOT DIS 0.1MG BRAND TIER 02ETHANOLAMINE DERIVATIVES ACUFLEX TAB BRAND TIER 03ALI‐FLEX TAB 50‐500MG GENERIC TIER 01ALPAIN TAB GENERIC TIER 01ARBINOXA LIQ 4MG/5ML GENERIC TIER 01ARBINOXA TAB 4MG GENERIC TIER 01BIOGESIC TAB 30‐500MG GENERIC TIER 01BIOREGESIC TAB 50‐650MG BRAND TIER 03BP POLY‐650 TAB GENERIC TIER 01CARBINOXAMIN LIQ 4MG/5ML GENERIC TIER 01CARBINOXAMIN TAB 4MG GENERIC TIER 01CLEMASTINE SYP 0.5/5ML GENERIC TIER 01CLEMASTINE TAB 2.68MG GENERIC TIER 01DIPHENHYDRAM ELX 12.5/5ML GENERIC TIER 01DIPHENHYDRAM INJ 50MG/ML GENERIC TIER 01DOLOGESIC LIQ 30‐500MG BRAND TIER 03DOLOGESIC TAB 30‐500MG GENERIC TIER 01DOLOREX TAB 50‐500MG GENERIC TIER 01DOXYTEX LIQ BRAND TIER 03DYTUSS SYP 12.5/5ML GENERIC TIER 01FLEXTRA CAP BRAND TIER 03FLEXTRA DS TAB 50‐500MG Brand‐O TIER 03 PAFLEXTRA‐650 TAB Brand‐O TIER 03 PALAGESIC TAB 66‐600MG Brand‐O TIER 03 PANOVAGESIC TAB 30‐500MG GENERIC TIER 01PALGIC LIQ 4MG/5ML Brand‐O TIER 03 PAPALGIC TAB 4MG Brand‐O TIER 03 PARELAGESIC LIQ 5‐160MG BRAND TIER 03RELAGESIC TAB 50‐650MG BRAND TIER 03RHINOFLEX TAB 50‐500MG GENERIC TIER 01RHINOFLEX TAB 50‐650MG GENERIC TIER 01STAFLEX TAB 55‐500MG Brand‐O TIER 03 PATEKRAL TAB BRAND TIER 99 DEZFLEX TAB GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion143

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusETHANOLAMINE DERIVATIVES ZGESIC TAB 66‐600MG GENERIC TIER 01DIPHENHYDRAM CAP 50MG GENERIC TIER 01ETHYLENEDIAMINE DERIVATIVES PYRILAMINE CRY USP NF GENERIC TIER 99 DERYNA‐12 TAB 60‐25MG BRAND TIER 99 DEEXPECTORANTS DECON‐G DRO 2‐1‐40MG BRAND TIER 99 DEEXEFEN‐IR TAB 60‐400MG GENERIC TIER 99 DEG/P TAB 1200‐75 GENERIC TIER 99 DEGANIDIN‐NR LIQ 100/5ML GENERIC TIER 99 DEGENEXA LA CAP 30‐400MG GENERIC TIER 99 DEGFN550/PSE60 TAB GENERIC TIER 99 DEGG/PE SYP GENERIC TIER 99 DEGILPHEX TR TAB 10‐388MG BRAND TIER 99 DEIODINE SOL STRONG GENERIC TIER 01KGS‐PE LIQ 5MG‐75MG GENERIC TIER 99 DELEMOHIST CAP PLUS BRAND TIER 99 DEORGANIDIN NR TAB 200MG GENERIC TIER 99 DEPE/GUAIFENES DRO 1.5‐20MG GENERIC TIER 99 DEPE‐GUAI DRO 1.5‐20MG GENERIC TIER 99 DEQUAL‐TUSSIN DRO PED GENERIC TIER 99 DERYNA‐12X TAB BRAND TIER 99 DESIMUC‐GP TAB 25‐1200 GENERIC TIER 99 DESINA‐12X TAB 25‐200MG BRAND TIER 99 DETUSNEL CAP BRAND TIER 99 DETUSSI PRES‐B LIQ GENERIC TIER 99 DEZOTEX‐GP TAB BRAND TIER 99 DENARIZ LIQ 7.5‐200 Brand‐O TIER 99 PA DEEXTENDED‐SPECTRUM PENICILLINS PIPER/TAZOBA INJ 2‐0.25GM GENERIC TIER 01PIPER/TAZOBA INJ 3‐0.375G GENERIC TIER 01PIPER/TAZOBA INJ 36‐4.5GM GENERIC TIER 01PIPER/TAZOBA INJ 4‐0.5GM GENERIC TIER 01TIMENTIN INJ 3.1GM BRAND TIER 03TIMENTIN INJ 31GM BRAND TIER 03ZOSYN INJ 2‐0.25GM Brand‐O TIER 03 PAZOSYN INJ 3‐0.375G Brand‐O TIER 03 PAZOSYN INJ 36‐4.5GM Brand‐O TIER 03 PAZOSYN INJ 4‐0.5GM Brand‐O TIER 03 PAZOSYN SOL 2‐0.25GM BRAND TIER 03ZOSYN SOL 3‐0.375G BRAND TIER 03ZOSYN SOL 4‐0.50GM BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion144

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusFIBRIC ACID DERIVATIVES ANTARA CAP 130MG BRAND TIER 02 PA QLANTARA CAP 43MG BRAND TIER 02 PA QLFENOFIBRATE CAP 134MG GENERIC TIER 01 PA QLFENOFIBRATE CAP 200MG GENERIC TIER 01 PA QLFENOFIBRATE CAP 67MG GENERIC TIER 01 PA QLFENOFIBRATE TAB 160MG GENERIC TIER 01 PA QLFENOFIBRATE TAB 54MG GENERIC TIER 01 PA QLFENOFIBRIC TAB 105MG GENERIC TIER 01 PA QLFENOFIBRIC TAB 35MG GENERIC TIER 01 PA QLFENOGLIDE TAB 120MG BRAND TIER 02 PA QLFENOGLIDE TAB 40MG BRAND TIER 02 PA QLFIBRICOR TAB 105MG BRAND TIER 03 PA QLFIBRICOR TAB 35MG BRAND TIER 03 PA QLGEMFIBROZIL TAB 600MG GENERIC TIER 01LIPOFEN CAP 150MG BRAND TIER 02 PA QLLIPOFEN CAP 50MG BRAND TIER 02 PA QLLOFIBRA CAP 134MG Brand‐O TIER 03 PA QLLOFIBRA CAP 200MG Brand‐O TIER 03 PA QLLOFIBRA CAP 67MG Brand‐O TIER 03 PA QLLOFIBRA TAB 160MG Brand‐O TIER 03 PA QLLOFIBRA TAB 54MG Brand‐O TIER 03 PA QLLOPID TAB 600MG Brand‐O TIER 03 PATRICOR TAB 145MG BRAND TIER 02 PA QLTRICOR TAB 48MG BRAND TIER 02 PA QLTRIGLIDE TAB 160MG BRAND TIER 02 PA QLTRIGLIDE TAB 50MG BRAND TIER 02 PA QLTRILIPIX CAP 135MG BRAND TIER 02 PA QLTRILIPIX CAP 45MG BRAND TIER 02 PA QLFIBROMYALGIA AGENTS SAVELLA MIS TITR PAK BRAND TIER 03 QLSAVELLA TAB 100MG BRAND TIER 02 PA QLSAVELLA TAB 12.5MG BRAND TIER 02 PA QLSAVELLA TAB 25MG BRAND TIER 02 PA QLSAVELLA TAB 50MG BRAND TIER 02 PA QLFIFTH GENERATION CEPHALOSPORINS TEFLARO INJ 400MG BRAND TIER 03TEFLARO INJ 600MG BRAND TIER 03FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CYPROHEPTAD SYP 2MG/5ML GENERIC TIER 01CYPROHEPTAD TAB 4MG GENERIC TIER 01NOREL SR TAB BRAND TIER 99 DEFIRST GENERATION CEPHALOSPORINS CEFADROXIL CAP 500MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion145

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusFIRST GENERATION CEPHALOSPORINS CEFADROXIL SUS 250/5ML GENERIC TIER 01CEFADROXIL SUS 500/5ML GENERIC TIER 01CEFADROXIL TAB 1GM GENERIC TIER 01CEFAZOL/DEX SOL 1GM GENERIC TIER 99 DECEFAZOL/DEX SOL 2GM GENERIC TIER 99 DECEFAZOLIN INJ 100GM GENERIC TIER 01CEFAZOLIN INJ 10GM GENERIC TIER 01CEFAZOLIN INJ 1GM GENERIC TIER 01CEFAZOLIN INJ 1GM/50ML GENERIC TIER 01CEFAZOLIN INJ 20GM GENERIC TIER 01CEFAZOLIN INJ 300GM GENERIC TIER 01CEFAZOLIN INJ 500MG GENERIC TIER 01CEPHALEXIN CAP 250MG GENERIC TIER 01CEPHALEXIN CAP 500MG GENERIC TIER 01CEPHALEXIN SUS 125/5ML GENERIC TIER 01CEPHALEXIN SUS 250/5ML GENERIC TIER 01CEPHALEXIN TAB 250MG GENERIC TIER 01CEPHALEXIN TAB 500MG GENERIC TIER 01KEFLEX CAP 250MG Brand‐O TIER 03 PAKEFLEX CAP 500MG Brand‐O TIER 03 PAKEFLEX CAP 750MG BRAND TIER 03FOURTH GENERATION CEPHALOSPORINS CEFEPIME INJ 1GM GENERIC TIER 01CEFEPIME INJ 2GM GENERIC TIER 01GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT BACLOFEN TAB 10MG GENERIC TIER 01BACLOFEN TAB 20MG GENERIC TIER 01ED BACLOFEN TAB 10MG GENERIC TIER 01GABLOFEN INJ 10000/20 BRAND TIER 03 SPGABLOFEN INJ 20000/20 BRAND TIER 03 SPGABLOFEN INJ 40000/20 BRAND TIER 03 SPGABLOFEN INJ 50MCG/ML BRAND TIER 03 SPLIORESAL INT INJ 0.05MG/1 BRAND TIER 03 SPLIORESAL INT INJ 10MG/20 BRAND TIER 03 SPLIORESAL INT INJ 10MG/5ML BRAND TIER 03 SPLIORESAL INT INJ 40MG/20 BRAND TIER 03 SPGALLBLADDER FUNCTION KINEVAC INJ 5MCG BRAND TIER 03GENERAL ANESTHETICS, MISCELLANEOUS AMIDATE INJ 2MG/ML Brand‐O TIER 03 PADIPRIVAN INJ 10MG/ML Brand‐O TIER 03 PAETOMIDATE INJ 2MG/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion146

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusGENERAL ANESTHETICS, MISCELLANEOUS KETAMINE INJ 100MG/ML GENERIC TIER 99 DEKETAMINE INJ 10MG/ML GENERIC TIER 99 DEKETAMINE INJ 50MG/ML GENERIC TIER 99 DELUSEDRA INJ BRAND TIER 03PROPOFOL INJ 10MG/ML GENERIC TIER 01PROPOVEN INJ 10MG/ML GENERIC TIER 01KETALAR INJ 10MG/ML Brand‐O TIER 99 PA DEKETALAR INJ 50MG/ML Brand‐O TIER 99 PA DEKETALAR INJ 100MG/ML Brand‐O TIER 99 PA DEGENITOURINARY SMOOTH MUSCLE RELAXANTS DETROL TAB 1MG Brand‐O TIER 03 PADETROL TAB 2MG Brand‐O TIER 03 PADETROL LA CAP 2MG BRAND TIER 02 QLDETROL LA CAP 4MG BRAND TIER 02 QLDITROPAN XL TAB 10MG Brand‐O TIER 03 PADITROPAN XL TAB 15MG Brand‐O TIER 03 PADITROPAN XL TAB 5MG Brand‐O TIER 03 PAENABLEX TAB 15MG BRAND TIER 02 QLENABLEX TAB 7.5MG BRAND TIER 02 QLFLAVOXATE TAB 100MG GENERIC TIER 01GELNIQUE GEL 10% BRAND TIER 02 PA QLGELNIQUE GEL 3% BRAND TIER 02 PA QLMYRBETRIQ TAB 25MG BRAND TIER 03MYRBETRIQ TAB 50MG BRAND TIER 03OXYBUTYNIN SYP 5MG/5ML GENERIC TIER 01OXYBUTYNIN TAB 10MG ER GENERIC TIER 01OXYBUTYNIN TAB 15MG ER GENERIC TIER 01OXYBUTYNIN TAB 5MG GENERIC TIER 01OXYBUTYNIN TAB 5MG ER GENERIC TIER 01OXYTROL DIS 3.9MG/24 BRAND TIER 02 PA QLSANCTURA TAB 20MG Brand‐O TIER 03 PASANCTURA XR CAP 60MG Brand‐O TIER 02 PATOLTERODINE TAB 1MG GENERIC TIER 01TOLTERODINE TAB 2MG GENERIC TIER 01TOVIAZ TAB 4MG BRAND TIER 02TOVIAZ TAB 8MG BRAND TIER 02TROSPIUM CL TAB 20MG GENERIC TIER 01VESICARE TAB 10MG BRAND TIER 02 QLVESICARE TAB 5MG BRAND TIER 02 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion147

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusGENITOURINARY SMOOTH MUSCLE RELAXANTS TROSPIUM CHL CAP 60MG ER GENERIC TIER 01GI DRUGS, MISCELLANEOUS AMITIZA CAP 24MCG BRAND TIER 02AMITIZA CAP 8MCG BRAND TIER 02ENTEREG CAP 12MG BRAND TIER 99 DENUTRESTORE PAK 5GM BRAND TIER 03RELISTOR INJ 12/0.6ML BRAND TIER 02 PA QLRELISTOR INJ 8/0.4ML BRAND TIER 02 PARELISTOR KIT 12/0.6ML BRAND TIER 02 PA QLXENICAL CAP 120MG BRAND TIER 99 DELINZESS CAP 145MCG BRAND TIER 03LINZESS CAP 290MCG BRAND TIER 03GLYCOGENOLYTIC AGENTS GLUCAGEN INJ 1MG BRAND TIER 03GLUCAGEN INJ HYPOKIT BRAND TIER 03GLUCAGON KIT 1MG BRAND TIER 02GLYCOPEPTIDES VANCOCIN HCL CAP 125MG Brand‐O TIER 03 PAVANCOCIN HCL CAP 250MG Brand‐O TIER 03 PAVANCOMYC/DEX INJ 1GM GENERIC TIER 01VANCOMYC/DEX INJ 500MG GENERIC TIER 01VANCOMYC/DEX INJ 750MG GENERIC TIER 01VANCOMYCIN CAP 125MG GENERIC TIER 01VANCOMYCIN CAP 250MG GENERIC TIER 01VANCOMYCIN INJ 1 GM GENERIC TIER 01VANCOMYCIN INJ 1000MG GENERIC TIER 01VANCOMYCIN INJ 10GM GENERIC TIER 01VANCOMYCIN INJ 500MG GENERIC TIER 01VANCOMYCIN INJ 5GM GENERIC TIER 01VANCOMYCIN INJ 750MG GENERIC TIER 01VIBATIV INJ 250MG BRAND TIER 03VIBATIV INJ 750MG BRAND TIER 03GLYCYLCYCLINES TYGACIL INJ 50MG BRAND TIER 03GOLD COMPOUNDS MYOCHRYSINE INJ 50MG/ML Brand‐O TIER 03 PARIDAURA CAP 3MG BRAND TIER 02GONADOTROPIN‐RELEASING HORMONE ANTAGNTS CETROTIDE KIT 0.25MG BRAND TIER 99 DECETROTIDE KIT 3MG BRAND TIER 99 DEGANIRELIX AC INJ GENERIC TIER 99 DEGONADOTROPINS BRAVELLE INJ 75UNIT BRAND TIER 99 DECHOR GONADOT INJ 10000UNT GENERIC TIER 99 DEFOLLISTIM AQ INJ 150UNIT BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion148

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusGONADOTROPINS FOLLISTIM AQ INJ 300UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 600UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 75UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 900UNIT BRAND TIER 99 DEGONAL‐F INJ 1050UNIT BRAND TIER 99 DEGONAL‐F INJ 450UNIT BRAND TIER 99 DEGONAL‐F RFF INJ 300 BRAND TIER 99 DEGONAL‐F RFF INJ 450 BRAND TIER 99 DEGONAL‐F RFF INJ 75UNIT BRAND TIER 99 DEGONAL‐F RFF INJ 900 BRAND TIER 99 DELUVERIS INJ 75UNIT BRAND TIER 99 DEMENOPUR INJ 75UNIT BRAND TIER 99 DENOVAREL INJ 10000UNT GENERIC TIER 99 DEOVIDREL INJ BRAND TIER 99 DEPREGNYL INJ 10000UNT GENERIC TIER 99 DEREPRONEX INJ 75UNIT BRAND TIER 99 DESYNAREL SOL 2MG/ML BRAND TIER 02 SPHCV PROTEASE INHIBITORS INCIVEK TAB 375MG BRAND TIER 02 PA SPVICTRELIS CAP 200MG BRAND TIER 02 PA SPHEAVY METAL ANTAGONISTS BAL IN OIL INJ 100MG/ML BRAND TIER 03CA‐DTPA SOL 1000MG GENERIC TIER 01CALCIUM DISO INJ 500/2.5M GENERIC TIER 01CHEMET CAP 100MG BRAND TIER 02CUPRIMINE CAP 250MG BRAND TIER 02CYANIDE ANTI KIT PKG UNIT GENERIC TIER 01DEFEROXAMINE INJ 2GM GENERIC TIER 01 SPDEFEROXAMINE INJ 500MG GENERIC TIER 01 SPDEPEN TITRA TAB 250MG BRAND TIER 03DESFERAL INJ 2GM Brand‐O TIER 03 PA SPDESFERAL INJ 500MG Brand‐O TIER 03 PA SPENDRATE INJ 150MG/ML BRAND TIER 03EXJADE TAB 125MG BRAND TIER 03 PAEXJADE TAB 250MG BRAND TIER 03 PAEXJADE TAB 500MG BRAND TIER 03 PAFERRIPROX TAB 500MG BRAND TIER 03 PANITHIODOTE KIT BRAND TIER 03SOD NITRITE INJ 30MG/ML GENERIC TIER 01SOD THIOSULF INJ 10% GENERIC TIER 01SOD THIOSULF INJ 25% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion149

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEAVY METAL ANTAGONISTS SYPRINE CAP 250MG BRAND TIER 03ZN‐DTPA SOL 1000MG GENERIC TIER 01HEMATOPOIETIC AGENTS ARANESP INJ 100MCG BRAND TIER 02 PA SPARANESP INJ 150MCG BRAND TIER 02 PA SPARANESP INJ 200MCG BRAND TIER 02 PA SPARANESP INJ 25MCG BRAND TIER 02 PA SPARANESP INJ 300MCG BRAND TIER 02 PA SPARANESP INJ 40MCG BRAND TIER 02 PA SPARANESP INJ 500MCG BRAND TIER 02 PA SPARANESP INJ 60MCG BRAND TIER 02 PA SPEPOGEN INJ 10000/ML BRAND TIER 03 PA SPEPOGEN INJ 2000/ML BRAND TIER 03 PA SPEPOGEN INJ 20000/ML BRAND TIER 03 PA SPEPOGEN INJ 3000/ML BRAND TIER 03 PA SPEPOGEN INJ 4000/ML BRAND TIER 03 PA SPLEUKINE INJ 250MCG BRAND TIER 02LEUKINE INJ 500 MCG BRAND TIER 02MOZOBIL INJ BRAND TIER 02 PA SPNEULASTA INJ 6MG/0.6M BRAND TIER 02 SPNEUMEGA INJ 5MG BRAND TIER 02NEUPOGEN INJ 300/0.5 BRAND TIER 02 SPNEUPOGEN INJ 300MCG BRAND TIER 02 SPNEUPOGEN INJ 480/0.8 BRAND TIER 02 SPNEUPOGEN INJ 480MCG BRAND TIER 02 SPNPLATE INJ 250MCG BRAND TIER 02 PA SPNPLATE INJ 500MCG BRAND TIER 02 PA SPOMONTYS INJ 10MG/ML BRAND TIER 03 SPOMONTYS INJ 20MG/2ML BRAND TIER 03 SPPROCRIT INJ 10000/ML BRAND TIER 02 PA SPPROCRIT INJ 2000/ML BRAND TIER 02 PA SPPROCRIT INJ 20000/ML BRAND TIER 02 PA SPPROCRIT INJ 3000/ML BRAND TIER 02 PA SPPROCRIT INJ 4000/ML BRAND TIER 02 PA SPPROCRIT INJ 40000/ML BRAND TIER 02 PA SPPROMACTA TAB 12.5MG BRAND TIER 02 PA SPPROMACTA TAB 25MG BRAND TIER 02 PA SPPROMACTA TAB 50MG BRAND TIER 02 PA SPPROMACTA TAB 75MG BRAND TIER 02 PA SPHEMORRHEOLOGIC AGENTS PENTOPAK TAB 400MG CR GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion150

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEMORRHEOLOGIC AGENTS PENTOXIFYLLI TAB 400MG ER GENERIC TIER 01TRENTAL TAB 400MG CR Brand‐O TIER 03 PAHEMOSTATICS ACTIFOAM MIS 12.7X8.9 BRAND TIER 03ACTIFOAM MIS 7X5X0.6 BRAND TIER 03ADVATE INJ 1000UNIT BRAND TIER 02 SPADVATE INJ 1500UNIT BRAND TIER 02 SPADVATE INJ 2000UNIT BRAND TIER 02 SPADVATE INJ 250UNIT BRAND TIER 02 SPADVATE INJ 3000UNIT BRAND TIER 02 SPADVATE INJ 4000UNIT BRAND TIER 02 SPADVATE INJ 500UNIT BRAND TIER 02 SPALPHANATE INJ VWF/HUM BRAND TIER 02 PA SPALPHANINE SD INJ 1000UNIT BRAND TIER 02 PA SPALPHANINE SD INJ 1500UNIT BRAND TIER 02 PA SPALPHANINE SD INJ 500UNIT BRAND TIER 02 PA SPAMICAR SYP 25% Brand‐O TIER 03 PAAMICAR TAB 1000MG BRAND TIER 03AMICAR TAB 500MG Brand‐O TIER 03 PAAMINOCAPR AC INJ 250MG/ML GENERIC TIER 01AMINOCAPR AC SYP 25% GENERIC TIER 01AMINOCAPR AC TAB 1000MG GENERIC TIER 01AMINOCAPR AC TAB 500MG GENERIC TIER 01ASTRINGYN SOL 259MG/GM BRAND TIER 03AVITENE PAD 35X35MM BRAND TIER 03AVITENE PAD 70X35MM BRAND TIER 03AVITENE PAD 70X70MM BRAND TIER 03AVITENE SYRG MIS 1GM BRAND TIER 03BEBULIN INJ 200‐1200 BRAND TIER 03 PA SPBEBULIN VH INJ 200‐1200 BRAND TIER 03 PA SPBENEFIX INJ 1000UNIT BRAND TIER 02 PA SPBENEFIX INJ 2000UNIT BRAND TIER 02 PA SPBENEFIX INJ 250UNIT BRAND TIER 02 PA SPBENEFIX INJ 3000UNIT BRAND TIER 02 PA SPBENEFIX INJ 500UNIT BRAND TIER 02 PA SPCORIFACT KIT BRAND TIER 02 PA SPCYKLOKAPRON INJ 100MG/ML Brand‐O TIER 03 PAENDO AVITENE MIS 10MM DIA BRAND TIER 03ENDO AVITENE MIS 5MM DIA BRAND TIER 03EVITHROM SOL 800‐1200 BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion151

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEMOSTATICS FEIBA NF INJ BRAND TIER 03 PA SPFEIBA VH INJ IMMUNO BRAND TIER 03 PA SPFEIBA VH INJ IMMUNO GENERIC TIER 01 PA SPGELFILM MIS ENVELOPE BRAND TIER 03GELFILM MIS OP BRAND TIER 03GELFOAM MIS DENTAL 4 BRAND TIER 03GELFOAM MIS SPON COM BRAND TIER 03GELFOAM MIS SPONG 50 BRAND TIER 03GELFOAM MIS SPONG100 BRAND TIER 03GELFOAM MIS SPONG200 BRAND TIER 03GELFOAM POW BRAND TIER 03GELFOAM SPNG MIS 12‐7MM BRAND TIER 03HELISTAT MIS 5MM BRAND TIER 03HELIXATE FS INJ 1000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 2000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 250UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 3000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 500UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 1000UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 250UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 500UNIT BRAND TIER 02 PA SPHEMOFIL M INJ 220‐400 BRAND TIER 02 PA SPHEMOFIL M INJ 401‐800 BRAND TIER 02 PA SPHEMOFIL M SOL 501‐2000 BRAND TIER 03 PA SPHEMOFIL M SOL 801‐1500 BRAND TIER 03 PA SPHUMATE‐P INJ 600UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 1200UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 2400UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 600UNIT BRAND TIER 02 PA SPINSTAT PAD 2.5X5.1 BRAND TIER 03INSTAT PAD 7.6X10.2 BRAND TIER 03KOATE‐DVI INJ 1000UNIT BRAND TIER 02 PA SPKOATE‐DVI INJ 250UNIT BRAND TIER 02 PA SPKOATE‐DVI INJ 500UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 1000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 1000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 2000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 2000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 250/BS BRAND TIER 02 PA SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion152

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEMOSTATICS KOGENATE FS INJ 250UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 3000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 3000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 500/BS BRAND TIER 02 PA SPKOGENATE FS INJ 500UNIT BRAND TIER 02 PA SPLYSTEDA TAB 650MG BRAND TIER 02 PAMONOCLATE‐P INJ 1000UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 1500UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 250UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 500UNIT BRAND TIER 02 PA SPMONONINE INJ 1000UNIT BRAND TIER 02 PA SPMONONINE INJ 250UNIT BRAND TIER 03 PA SPMONONINE INJ 500UNIT BRAND TIER 02 PA SPMONSELS FERR SOL SUBSULF BRAND TIER 99 DENOVOSEVEN INJ 2400MCG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 1MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 2MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 5MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 8MG BRAND TIER 02 PA SPPROFILNINE INJ 1000UNIT BRAND TIER 03 PA SPPROFILNINE INJ 1500UNIT BRAND TIER 03 PA SPPROFILNINE INJ 500UNIT BRAND TIER 03 PA SPRECOMBINATE INJ BRAND TIER 02 PA SPRECOMBINATE INJ 220‐400 BRAND TIER 02 PA SPRECOMBINATE INJ 401‐800 BRAND TIER 02 PA SPRECOMBINATE INJ 801‐1240 BRAND TIER 02 PA SPRECOTHROM SOL 20000UNT BRAND TIER 03RECOTHROM SOL 5000UNIT BRAND TIER 99 DEREFACTO INJ 500UNIT BRAND TIER 02 PA SPRIASTAP SOL 1GM BRAND TIER 03 SPSURGIFOAM MIS 12‐7MM BRAND TIER 03SURGIFOAM MIS SIZE 100 BRAND TIER 03THROMBI‐GEL PAD 10 BRAND TIER 99 DETHROMBI‐GEL PAD 100 BRAND TIER 99 DETHROMBI‐GEL PAD 40 BRAND TIER 99 DETHROMBIN KIT 5000UNIT BRAND TIER 99 DETHROMBIN‐JMI KIT 20000UNT BRAND TIER 99 DETHROMBIN‐JMI KIT 5000UNIT BRAND TIER 99 DETHROMBIN‐JMI SOL 20000UNT BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion153

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEMOSTATICS THROMBIN‐JMI SOL 5000UNIT BRAND TIER 99 DETHROMBI‐PAD PAD 3"X3" BRAND TIER 03THROMBOGEN KIT 10000UNT BRAND TIER 99 DETHROMBOGEN SOL 10000UNT BRAND TIER 99 DETHROMBOGEN SOL 1000UNIT BRAND TIER 99 DETRANEXAMIC INJ ACID GENERIC TIER 01 PATRASYLOL INJ 10000/ML BRAND TIER 03ULTRAFOAM MIS 2X6.25X7 BRAND TIER 03ULTRAFOAM MIS 8X12.5X1 BRAND TIER 03ULTRAFOAM MIS 8X12.5X3 BRAND TIER 03ULTRAFOAM MIS 8X25X1 BRAND TIER 03ULTRAFOAM MIS 8X6.25X1 BRAND TIER 03WILATE INJ BRAND TIER 02 PA SPXYNTHA INJ 1000UNIT BRAND TIER 02 PA SPXYNTHA INJ 2000UNIT BRAND TIER 02 PA SPXYNTHA INJ 250UNIT BRAND TIER 02 PA SPXYNTHA INJ 3000UNIT BRAND TIER 02 PA SPXYNTHA INJ 500UNIT BRAND TIER 02 PA SPXYNTHA SOLOF INJ 500UNIT BRAND TIER 02 PA SPXYNTHA SOLOF KIT 250UNIT BRAND TIER 02 PA SPFERRIC SUBSU SOL GENERIC TIER 99 DEHEPARINS ENOXAPARIN INJ 100MG/ML GENERIC TIER 01ENOXAPARIN INJ 120/0.8 GENERIC TIER 01ENOXAPARIN INJ 150MG/ML GENERIC TIER 01ENOXAPARIN INJ 30/0.3ML GENERIC TIER 01ENOXAPARIN INJ 300/3ML GENERIC TIER 01ENOXAPARIN INJ 40/0.4ML GENERIC TIER 01ENOXAPARIN INJ 60/0.6ML GENERIC TIER 01ENOXAPARIN INJ 80/0.8ML GENERIC TIER 01FRAGMIN INJ 10000/ML BRAND TIER 02FRAGMIN INJ 12500UNT BRAND TIER 02FRAGMIN INJ 15000UNT BRAND TIER 02FRAGMIN INJ 18000UNT BRAND TIER 02FRAGMIN INJ 2500/0.2 BRAND TIER 02FRAGMIN INJ 25000/ML BRAND TIER 02FRAGMIN INJ 5000/0.2 BRAND TIER 02FRAGMIN INJ 7500/0.3 BRAND TIER 02HEP FLUSH‐10 INJ 10UNT/ML GENERIC TIER 01HEP SOD/D5W INJ 100/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion154

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEPARINS HEP SOD/D5W INJ 20000UNT GENERIC TIER 01HEP SOD/D5W INJ 25000UNT GENERIC TIER 01HEP SOD/D5W INJ 50UNT/ML GENERIC TIER 01HEP SOD/NACL INJ 1000UNIT GENERIC TIER 01HEP SOD/NACL INJ 12500UNT GENERIC TIER 01HEP SOD/NACL INJ 2000UNIT GENERIC TIER 01HEP SOD/NACL INJ 25000UNT GENERIC TIER 01HEP SOD/NACL INJ 2UNIT/ML GENERIC TIER 01HEPARIN LOCK INJ 100/ML GENERIC TIER 01HEPARIN LOCK INJ 10UNT/ML GENERIC TIER 01HEPARIN LOCK INJ 1UNIT/ML GENERIC TIER 01HEPARIN LOCK INJ 2UNIT/ML GENERIC TIER 01HEPARIN LOCK KIT 100/ML GENERIC TIER 01HEPARIN LOCK KIT 10UNT/ML GENERIC TIER 01HEPARIN SOD INJ 1000/ML GENERIC TIER 01HEPARIN SOD INJ 10000/ML GENERIC TIER 01HEPARIN SOD INJ 2000/ML GENERIC TIER 01HEPARIN SOD INJ 20000/ML GENERIC TIER 01HEPARIN SOD INJ 2500/ML GENERIC TIER 01HEPARIN SOD INJ 5000/0.5 GENERIC TIER 01HEPARIN SOD INJ 5000/ML GENERIC TIER 01LOVENOX INJ 100MG/ML Brand‐O TIER 03 PALOVENOX INJ 120/0.8 Brand‐O TIER 03 PALOVENOX INJ 150MG/ML Brand‐O TIER 03 PALOVENOX INJ 30/0.3ML Brand‐O TIER 03 PALOVENOX INJ 300/3ML Brand‐O TIER 03 PALOVENOX INJ 40/0.4ML Brand‐O TIER 03 PALOVENOX INJ 60/0.6ML Brand‐O TIER 03 PALOVENOX INJ 80/0.8ML Brand‐O TIER 03 PASASH KIT 100/ML GENERIC TIER 01SASH KIT 10UNT/ML GENERIC TIER 01HISTAMINE H2‐ANTAGONISTS AXID CAP 150MG Brand‐O TIER 03 PAAXID CAP 300MG Brand‐O TIER 03 PAAXID SOL 15MG/ML Brand‐O TIER 02 PACIMETIDINE INJ 150MG/ML GENERIC TIER 01CIMETIDINE SOL 300/5ML GENERIC TIER 01CIMETIDINE TAB 300MG GENERIC TIER 01CIMETIDINE TAB 400MG GENERIC TIER 01CIMETIDINE TAB 800MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion155

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHISTAMINE H2‐ANTAGONISTS FAMOTIDINE INJ 10MG/ML GENERIC TIER 01FAMOTIDINE INJ 200/20ML GENERIC TIER 01FAMOTIDINE INJ 20MG/2ML GENERIC TIER 01FAMOTIDINE INJ 20MG/50M GENERIC TIER 01FAMOTIDINE INJ 40MG/4ML GENERIC TIER 01FAMOTIDINE SUS 40MG/5ML GENERIC TIER 01FAMOTIDINE TAB 20MG GENERIC TIER 01FAMOTIDINE TAB 40MG GENERIC TIER 01GABITIDINE PAK BRAND TIER 03NIZATIDINE CAP 150MG GENERIC TIER 01NIZATIDINE CAP 300MG GENERIC TIER 01NIZATIDINE SOL 15MG/ML GENERIC TIER 01PEPCID SUS 40MG/5ML Brand‐O TIER 03 PAPEPCID TAB 20MG Brand‐O TIER 03 PAPEPCID TAB 40MG Brand‐O TIER 03 PARANITIDINE CAP 150MG GENERIC TIER 01RANITIDINE CAP 300MG GENERIC TIER 01RANITIDINE INJ 150/6ML GENERIC TIER 01RANITIDINE INJ 25MG/ML GENERIC TIER 01RANITIDINE INJ 50MG/2ML GENERIC TIER 01RANITIDINE SYP 150/10ML GENERIC TIER 01RANITIDINE SYP 15MG/ML GENERIC TIER 01RANITIDINE SYP 75MG/5ML GENERIC TIER 01RANITIDINE TAB 150MG GENERIC TIER 01RANITIDINE TAB 300MG GENERIC TIER 01SENTRADINE PAK BRAND TIER 03ZANTAC INJ 25MG/ML Brand‐O TIER 03 PAZANTAC INJ 50/50ML BRAND TIER 03ZANTAC SYP 15MG/ML Brand‐O TIER 03 PAZANTAC TAB 150MG Brand‐O TIER 03 PAZANTAC TAB 25MG EF BRAND TIER 03ZANTAC TAB 300MG Brand‐O TIER 03 PACIMETIDINE TAB 200MG GENERIC TIER 01HIV ENTRY AND FUSION INHIBITORS FUZEON INJ 90MG BRAND TIER 03FUZEON KIT BRAND TIER 02 SPSELZENTRY TAB 150MG BRAND TIER 02 PASELZENTRY TAB 300MG BRAND TIER 02 PAHIV PROTEASE INHIBITORS APTIVUS CAP 250MG BRAND TIER 02APTIVUS SOL BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion156

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHIV PROTEASE INHIBITORS CRIXIVAN CAP 100MG BRAND TIER 02CRIXIVAN CAP 200MG BRAND TIER 02CRIXIVAN CAP 400MG BRAND TIER 02INVIRASE CAP 200MG BRAND TIER 02INVIRASE TAB 500MG BRAND TIER 02KALETRA SOL BRAND TIER 02KALETRA TAB 100‐25MG BRAND TIER 02KALETRA TAB 200‐50MG BRAND TIER 02LEXIVA SUS 50MG/ML BRAND TIER 02LEXIVA TAB 700MG BRAND TIER 02NORVIR CAP 100MG BRAND TIER 02NORVIR SOL 80MG/ML BRAND TIER 02NORVIR TAB 100MG BRAND TIER 02PREZISTA TAB 150MG BRAND TIER 02PREZISTA TAB 400MG BRAND TIER 02PREZISTA TAB 600MG BRAND TIER 02PREZISTA TAB 75MG BRAND TIER 02REYATAZ CAP 100MG BRAND TIER 02REYATAZ CAP 150MG BRAND TIER 02REYATAZ CAP 200MG BRAND TIER 02REYATAZ CAP 300MG BRAND TIER 02VIRACEPT POW 50MG/GM BRAND TIER 02VIRACEPT TAB 250MG BRAND TIER 02VIRACEPT TAB 625MG BRAND TIER 02HMG‐COA REDUCTASE INHIBITORS ADVICOR TAB 1000‐20 BRAND TIER 03 PAADVICOR TAB 1000‐40 BRAND TIER 03 PAADVICOR TAB 500‐20MG BRAND TIER 03 PAADVICOR TAB 750‐20MG BRAND TIER 03 PAALTOPREV TAB 20MG ER BRAND TIER 02 PAALTOPREV TAB 40MG ER BRAND TIER 02 PAALTOPREV TAB 60MG ER BRAND TIER 02 PAATORVASTATIN TAB 10MG GENERIC TIER 01ATORVASTATIN TAB 20MG GENERIC TIER 01ATORVASTATIN TAB 40MG GENERIC TIER 01ATORVASTATIN TAB 80MG GENERIC TIER 01CRESTOR TAB 10MG BRAND TIER 02 PACRESTOR TAB 20MG BRAND TIER 02 PACRESTOR TAB 40MG BRAND TIER 02 PACRESTOR TAB 5MG BRAND TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion157

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHMG‐COA REDUCTASE INHIBITORS FLUVASTATIN CAP 20MG GENERIC TIER 01 PAFLUVASTATIN CAP 40MG GENERIC TIER 01 PALESCOL CAP 20MG Brand‐O TIER 03 PALESCOL CAP 40MG Brand‐O TIER 03 PALESCOL XL TAB 80MG BRAND TIER 03 PALIPITOR TAB 10MG Brand‐O TIER 03 PALIPITOR TAB 20MG Brand‐O TIER 03 PALIPITOR TAB 40MG Brand‐O TIER 03 PALIPITOR TAB 80MG Brand‐O TIER 03 PALIVALO TAB 1MG BRAND TIER 03 PALIVALO TAB 2MG BRAND TIER 03 PALIVALO TAB 4MG BRAND TIER 03 PALOVASTATIN TAB 10MG GENERIC TIER 01LOVASTATIN TAB 20MG GENERIC TIER 01LOVASTATIN TAB 40MG GENERIC TIER 01MEVACOR TAB 20MG Brand‐O TIER 03 PAMEVACOR TAB 40MG Brand‐O TIER 03 PAPRAVACHOL TAB 10MG Brand‐O TIER 03 PAPRAVACHOL TAB 20MG Brand‐O TIER 03 PAPRAVACHOL TAB 40MG Brand‐O TIER 03 PAPRAVACHOL TAB 80MG Brand‐O TIER 03 PAPRAVASTATIN TAB 10MG GENERIC TIER 01PRAVASTATIN TAB 20MG GENERIC TIER 01PRAVASTATIN TAB 40MG GENERIC TIER 01PRAVASTATIN TAB 80MG GENERIC TIER 01SIMCOR TAB 1000‐20 BRAND TIER 02 PASIMCOR TAB 1000‐40 BRAND TIER 02 PASIMCOR TAB 500‐20MG BRAND TIER 02 PASIMCOR TAB 500‐40MG BRAND TIER 02 PASIMCOR TAB 750‐20MG BRAND TIER 02 PASIMVASTATIN TAB 10MG GENERIC TIER 01SIMVASTATIN TAB 20MG GENERIC TIER 01SIMVASTATIN TAB 40MG GENERIC TIER 01SIMVASTATIN TAB 5MG GENERIC TIER 01SIMVASTATIN TAB 80MG GENERIC TIER 01VYTORIN TAB 10‐10MG BRAND TIER 02 PAVYTORIN TAB 10‐20MG BRAND TIER 02 PAVYTORIN TAB 10‐40MG BRAND TIER 02 PAVYTORIN TAB 10‐80MG BRAND TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion158

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHMG‐COA REDUCTASE INHIBITORS ZOCOR TAB 10MG Brand‐O TIER 03 PAZOCOR TAB 20MG Brand‐O TIER 03 PAZOCOR TAB 40MG Brand‐O TIER 03 PAZOCOR TAB 5MG Brand‐O TIER 03 PAZOCOR TAB 80MG Brand‐O TIER 03 PAHYDANTOINS DILANTIN CAP 100MG Brand‐O TIER 03 PADILANTIN CAP 30MG BRAND TIER 02DILANTIN CHW 50MG BRAND TIER 02DILANTIN‐125 SUS 125/5ML Brand‐O TIER 03 PAFOSPHENYTOIN INJ 100/2ML GENERIC TIER 99 DEFOSPHENYTOIN INJ 500/10ML GENERIC TIER 99 DEPEGANONE TAB 250MG BRAND TIER 02PHENYTEK CAP 200MG Brand‐O TIER 03 PAPHENYTEK CAP 300MG Brand‐O TIER 03 PAPHENYTOIN INJ 50MG/ML GENERIC TIER 01 SPPHENYTOIN SUS 125/5ML GENERIC TIER 01PHENYTOIN EX CAP 100MG GENERIC TIER 01PHENYTOIN EX CAP 200MG GENERIC TIER 01PHENYTOIN EX CAP 300MG GENERIC TIER 01HYDROXYPYRIDONES(SKIN & MUCOUS MEMBRANE) CICLODAN CRE 0.77% GENERIC TIER 01CICLODAN SOL 8% GENERIC TIER 01CICLODAN CRE KIT 0.77% BRAND TIER 03CICLODAN SOL KIT 8% Brand‐O TIER 03 PACICLOPIROX CRE 0.77% GENERIC TIER 01CICLOPIROX GEL 0.77% GENERIC TIER 01CICLOPIROX KIT 8% GENERIC TIER 01CICLOPIROX SHA 1% GENERIC TIER 01CICLOPIROX SOL 8% GENERIC TIER 01CICLOPIROX SUS 0.77% GENERIC TIER 01CNL8 NAIL KIT BRAND TIER 03LOPROX GEL 0.77% Brand‐O TIER 03 PALOPROX SHA 1% Brand‐O TIER 03 PAPEDIPIROX‐4 KIT NAIL BRAND TIER 03PENLAC SOL 8% Brand‐O TIER 03 PAIMMUNOSUPPRESSIVE AGENTS ATGAM INJ 250MG BRAND TIER 03 SPAZASAN TAB 100MG BRAND TIER 02AZASAN TAB 75 MG BRAND TIER 02AZATHIOPRINE INJ 100MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion159

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50MG GENERIC TIER 01BENLYSTA INJ 120MG BRAND TIER 03 PABENLYSTA INJ 400MG BRAND TIER 03 PACELLCEPT CAP 250MG Brand‐O TIER 03 PACELLCEPT SUS 200MG/ML BRAND TIER 02CELLCEPT TAB 500MG Brand‐O TIER 03 PACELLCEPT IV INJ 500MG BRAND TIER 03CYCLOSPORINE CAP 100MG GENERIC TIER 01CYCLOSPORINE CAP 100MG MD GENERIC TIER 01CYCLOSPORINE CAP 25MG GENERIC TIER 01CYCLOSPORINE CAP 25MG MOD GENERIC TIER 01CYCLOSPORINE CAP 50MG MOD GENERIC TIER 01CYCLOSPORINE INJ 50MG/ML GENERIC TIER 01CYCLOSPORINE SOL MODIFIED GENERIC TIER 01GENGRAF CAP 100MG GENERIC TIER 01GENGRAF CAP 25MG GENERIC TIER 01GENGRAF SOL 100MG/ML GENERIC TIER 01HECORIA CAP 0.5MG GENERIC TIER 01HECORIA CAP 1MG GENERIC TIER 01HECORIA CAP 5MG GENERIC TIER 01IMURAN TAB 50MG Brand‐O TIER 03 PAMYCOPHENOLAT CAP 250MG GENERIC TIER 01MYCOPHENOLAT TAB 500MG GENERIC TIER 01MYFORTIC TAB 180MG BRAND TIER 03MYFORTIC TAB 360MG BRAND TIER 03NEORAL CAP 100MG Brand‐O TIER 02 PANEORAL CAP 25MG Brand‐O TIER 02 PANEORAL SOL 100MG/ML Brand‐O TIER 02 PANULOJIX INJ 250MG BRAND TIER 03ORTHOCLONE INJ OKT3 BRAND TIER 03PROGRAF CAP 0.5MG Brand‐O TIER 03 PAPROGRAF CAP 1MG Brand‐O TIER 03 PAPROGRAF CAP 5MG Brand‐O TIER 03 PAPROGRAF INJ 5MG/ML BRAND TIER 03 SPRAPAMUNE SOL 1MG/ML BRAND TIER 02RAPAMUNE TAB 0.5MG BRAND TIER 02RAPAMUNE TAB 1MG BRAND TIER 02RAPAMUNE TAB 2MG BRAND TIER 02SANDIMMUNE CAP 100MG Brand‐O TIER 02 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion160

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIMMUNOSUPPRESSIVE AGENTS SANDIMMUNE CAP 25MG Brand‐O TIER 02 PASANDIMMUNE INJ 50MG/ML Brand‐O TIER 03 PASANDIMMUNE SOL 100MG/ML BRAND TIER 02SIMULECT INJ 10MG BRAND TIER 03 SPSIMULECT INJ 20MG BRAND TIER 03 SPTACROLIMUS CAP 0.5MG GENERIC TIER 01TACROLIMUS CAP 1MG GENERIC TIER 01TACROLIMUS CAP 5MG GENERIC TIER 01THYMOGLOBULN INJ 25MG BRAND TIER 03 SPZORTRESS TAB 0.25MG BRAND TIER 03ZORTRESS TAB 0.5MG BRAND TIER 03ZORTRESS TAB 0.75MG BRAND TIER 03INCRETIN MIMETICS BYDUREON INJ BRAND TIER 02 PABYETTA INJ 10MCG BRAND TIER 02 PABYETTA INJ 5MCG BRAND TIER 02 PAVICTOZA INJ 18MG/3ML BRAND TIER 02 PAINHALATION ANESTHETICS COMPOUND 347 LIQ GENERIC TIER 01ETHRANE INH Brand‐O TIER 03 PAFORANE SOL Brand‐O TIER 03 PAISOFLURANE SOL GENERIC TIER 01SEVOFLURANE SOL GENERIC TIER 01SOJOURN SOL GENERIC TIER 01SUPRANE INH BRAND TIER 03SUPRANE SOL BRAND TIER 03TERRELL SOL GENERIC TIER 01ULTANE SOL Brand‐O TIER 03 PAINSULINS APIDRA INJ SOLOSTAR BRAND TIER 02APIDRA INJ U‐100 BRAND TIER 02HUMALOG INJ 100/ML BRAND TIER 02HUMALOG KWIK INJ 100/ML BRAND TIER 02HUMALOG MIX INJ 50/50 BRAND TIER 02HUMALOG MIX INJ 50/50KWP BRAND TIER 02HUMALOG MIX INJ 75/25KWP BRAND TIER 02HUMALOG MIX SUS 75/25 BRAND TIER 02HUMULIN R INJ U‐500 BRAND TIER 02LANTUS INJ 100/ML BRAND TIER 02LANTUS INJ SOLOSTAR BRAND TIER 02LEVEMIR INJ BRAND TIER 02LEVEMIR INJ FLEXPEN BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion161

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusINSULINS NOVOLOG INJ 100/ML BRAND TIER 02NOVOLOG INJ FLEXPEN BRAND TIER 02NOVOLOG INJ PENFILL BRAND TIER 02NOVOLOG MIX INJ 70/30 BRAND TIER 02NOVOLOG MIX INJ FLEXPEN BRAND TIER 02INTEGRASE INHIBITORS ISENTRESS CHW 100MG BRAND TIER 02ISENTRESS CHW 25MG BRAND TIER 02ISENTRESS TAB 400MG BRAND TIER 02STRIBILD TAB BRAND TIER 03INTERFERONS INFERGEN INJ 15MCG BRAND TIER 03 PA SPINFERGEN INJ 9MCG BRAND TIER 03 PA SPPEGASYS INJ BRAND TIER 02 PA SPPEGASYS INJ 180MCG/M BRAND TIER 02 PA SPPEGASYS INJ PROCLICK BRAND TIER 02 PA SPPEGASYS KIT BRAND TIER 02 PA SPPEG‐INTRON KIT 120 RP BRAND TIER 02 PA SPPEG‐INTRON KIT 120MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 150 RP BRAND TIER 02 PA SPPEG‐INTRON KIT 150MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 50MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 50MCG RP BRAND TIER 02 PA SPPEG‐INTRON KIT 80MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 80MCG RP BRAND TIER 02 PA SPIRON PREPARATIONS ALBAFORT INJ BRAND TIER 03BIFERARX TAB BRAND TIER 03CENTRATEX CAP BRAND TIER 03CORVITA 150 TAB GENERIC TIER 01CORVITE 150 TAB Brand‐O TIER 03 PACORVITE FE TAB BRAND TIER 03DEXFERRUM INJ 50MG/ML GENERIC TIER 01 SPED CYTE F TAB GENERIC TIER 01FE C PLUS TAB GENERIC TIER 01FERAHEME INJ 510/17ML BRAND TIER 99 DEFEROCON CAP GENERIC TIER 01FEROTRIN CAP GENERIC TIER 01FEROTRINSIC CAP GENERIC TIER 01FERRALET 90 TAB BRAND TIER 03FERRAPLUS 90 TAB GENERIC TIER 01FERREX 150 CAP FORTE GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion162

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIRON PREPARATIONS FERREX 150 CAP FORTE PL GENERIC TIER 01FERREX 28 TAB GENERIC TIER 01FERRIC GLUCO INJ 12.5MG/M GENERIC TIER 01FERRLECIT INJ 12.5MG/M Brand‐O TIER 03 PAFERROCITE TAB PLUS GENERIC TIER 01FERROGELS FO CAP FORTE GENERIC TIER 01FERRO‐PLEX TAB BRAND TIER 03FERROTRIN CAP BRAND TIER 03FETRIN CAP BRAND TIER 03FOLITAB TAB GENERIC TIER 01FOLIVANE‐F CAP BRAND TIER 03FOLIVANE‐PLS CAP BRAND TIER 03FOLTRIN CAP GENERIC TIER 01FUMATINIC CAP BRAND TIER 03HEMATINIC PL TAB VIT/MIN GENERIC TIER 01HEMATINIC/FA TAB GENERIC TIER 01HEMATOGEN CAP GENERIC TIER 01HEMATOGEN CAP FORTE GENERIC TIER 01HEMATOGEN FA CAP GENERIC TIER 01HEMATRON‐AF TAB Brand‐O TIER 03 PAHEMETAB TAB BRAND TIER 03HEMOCYTE TAB ‐PLUS GENERIC TIER 01HEMOCYTE PLS CAP BRAND TIER 03HEMOCYTE‐F ELX BRAND TIER 03HEMOCYTE‐F TAB GENERIC TIER 01ICAR‐C PLUS CAP SR BRAND TIER 03ICAR‐C PLUS TAB Brand‐O TIER 03 PAIFEREX 150 CAP FORTE GENERIC TIER 01INFED INJ 50MG/ML GENERIC TIER 01 SPINTEGRA F CAP BRAND TIER 03INTEGRA PLUS CAP BRAND TIER 03IROSPAN 24/6 MIS BRAND TIER 03MARTINIC CAP GENERIC TIER 01MAXARON TAB FORTE BRAND TIER 03MAXARON FORT CAP BRAND TIER 03MULTIGEN TAB GENERIC TIER 01MULTIGEN TAB FOLIC GENERIC TIER 01MULTIGEN PLS TAB GENERIC TIER 01MYFERON 150 CAP FORTE GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion163

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIRON PREPARATIONS NEPHRON FA TAB BRAND TIER 03NIRON KOMPLE TAB 30‐1MG BRAND TIER 03NOVAFERRUM SOL BRAND TIER 03NULECIT INJ 12.5MG/M GENERIC TIER 01POLY‐IRON CAP 150 FORT GENERIC TIER 01POLYSACCHARI CAP IRON GENERIC TIER 01PROFERRIN‐ TAB FORTE BRAND TIER 03PROMAR CAP BRAND TIER 03PUREFE CAP PLUS BRAND TIER 03PUREVIT DUAL CAP FE PLUS GENERIC TIER 01RENATABS MIS IRON BRAND TIER 03SENILEZOL ELX GENERIC TIER 01SE‐TAN PLUS CAP GENERIC TIER 01TANDEM F CAP GENERIC TIER 01TANDEM PLUS CAP Brand‐O TIER 03 PATARON FORTE CAP BRAND TIER 03TL ICON CAP GENERIC TIER 01TL‐FOL 500 TAB GENERIC TIER 01TL‐HEM 150 TAB GENERIC TIER 01TRICON CAP GENERIC TIER 01TRIGELS‐F CAP FORTE GENERIC TIER 01VENOFER INJ 20MG/ML BRAND TIER 03VITAFOL SYP BRAND TIER 03VITAFOL TAB Brand‐O TIER 03 PAFERROUS SULF GRA GENERIC TIER 99 DEIRRIGATING SOLUTIONS ACETIC ACID SOL 0.25%IRR GENERIC TIER 01AMINOAC ACID SOL 1.5% IRR GENERIC TIER 01CURITY SALIN SOL 0.9% IRR GENERIC TIER 01DELFLEX‐LC/ SOL 1.5% DEX GENERIC TIER 01DELFLEX‐LC/ SOL 2.5% DEX GENERIC TIER 01DELFLEX‐LC/ SOL 4.25 DEX GENERIC TIER 01DELFLEX‐LM SOL 1.5% DEX GENERIC TIER 01DELFLEX‐LM SOL 2.5% DEX GENERIC TIER 01DELFLEX‐LM/ SOL 4.25 DEX GENERIC TIER 01DELFLEX‐SM/ SOL 1.5% DEX GENERIC TIER 01DELFLEX‐SM/ SOL 2.5% DEX GENERIC TIER 01DELFLEX‐SM/ SOL 4.25 DEX BRAND TIER 03DIANEAL SOL LOW CALC BRAND TIER 03DIANEAL PD‐2 SOL 1.5% DEX BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion164

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIRRIGATING SOLUTIONS DIANEAL PD‐2 SOL 2.5% DEX BRAND TIER 03DIANEAL PD‐2 SOL 4.25%DEX BRAND TIER 03EXTRANEAL SOL BRAND TIER 03GLYCINE SOL 1.5% IRR GENERIC TIER 01HYSKON SOL BRAND TIER 03INPERSOL/DEX SOL 1.5% GENERIC TIER 01INPERSOL/DEX SOL 2.5% GENERIC TIER 01INPERSOL/DEX SOL 4.25% GENERIC TIER 01INPERSOL‐LM/ SOL 1.5% DEX GENERIC TIER 01INPERSOL‐LM/ SOL 2.5% DEX GENERIC TIER 01INPERSOL‐LM/ SOL 4.25 DEX GENERIC TIER 01LACTATED RIN SOL IRRIGAT GENERIC TIER 01PHYSIOLYTE SOL GENERIC TIER 01PHYSIOSOL SOL IRRIGAT BRAND TIER 03PHYSIOSOL SOL IRRIGAT GENERIC TIER 01RENACIDIN SOL IRR BRAND TIER 03RESECTISOL SOL 5% BRAND TIER 03RINGERS IRR SOL GENERIC TIER 01SODIUM CHLOR SOL 0.9% IRR GENERIC TIER 01SORBITOL SOL 3% IRR GENERIC TIER 01SORBITOL SOL 3.3% IRR GENERIC TIER 01SORBITOL‐MAN SOL GENERIC TIER 01STERIL WATER SOL IRRIG GENERIC TIER 01TIS‐U‐SOL SOL GENERIC TIER 01ULTRABAG/ SOL DIANEAL BRAND TIER 03ULTRABAG/PD2 SOL DIANEAL BRAND TIER 03KERATOLYTIC AGENTS ALICLEN SHA 6% GENERIC TIER 01ALUVEA CRE 39% Brand‐O TIER 03 PAAVAR CLEANSE EMU 10‐5% GENERIC TIER 01AVAR LS LIQ 10‐2% BRAND TIER 03AVAR‐E EMOLL CRE 10‐5% GENERIC TIER 01AVAR‐E GREEN CRE 10‐5% GENERIC TIER 01AVAR‐E LS CRE 10‐2% BRAND TIER 03BP 10‐1 EMU GENERIC TIER 01BP CLEANSING EMU 10‐4% GENERIC TIER 01CEM‐UREA SOL 45% GENERIC TIER 01CERISA WASH EMU 10‐1% GENERIC TIER 01CEROVEL GEL 40% GENERIC TIER 01CEROVEL LOT 40% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion165

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusKERATOLYTIC AGENTS CLARIFOAM EF AER 10‐5% Brand‐O TIER 03 PACLARIS WASH EMU 10‐4% GENERIC TIER 01CLENIA CRE 10‐5% GENERIC TIER 01CLENIA EMU FOAMING GENERIC TIER 01DURASAL SOL 26% GENERIC TIER 01GORDOFILM SOL BRAND TIER 03GORDONS UREA OIN 40% BRAND TIER 03HYDRO 35 AER Brand‐O TIER 03 PAHYDRO 40 AER FOAM Brand‐O TIER 03 PAHYDRO 40 AER FOAM GENERIC TIER 01KERAFOAM AER 30% BRAND TIER 03KERAFOAM 42 AER 42% BRAND TIER 03KERALYT GEL 6% Brand‐O TIER 03 PAKERALYT KIT SCALP 6% BRAND TIER 99 DEKEROL EMU 50% Brand‐O TIER 03 PAKEROL SUS 50% Brand‐O TIER 03 PAKEROL AD EMU 45% Brand‐O TIER 03 PALATRIX SUS 50% GENERIC TIER 01LATRIX XM EMU 45% GENERIC TIER 01MONOCHLOROAC CRY ACID GENERIC TIER 99 DEPLEXION CLNS EMU 10‐5% Brand‐O TIER 03 PAPLEXION CLTH MIS 10‐5% Brand‐O TIER 03 PAPLEXION SCT CRE 10‐5% Brand‐O TIER 03 PAPRASCION EMU GENERIC TIER 01PRASCION FC PAD 10‐5% GENERIC TIER 01PRASCION RA CRE 10‐5% GENERIC TIER 01PROMISEB CRE BRAND TIER 03PROMISEB KIT COMPLETE BRAND TIER 03PYROGALL ACD OIN GENERIC TIER 01REMEVEN CRE 50% GENERIC TIER 01RINNOVI NAIL KIT SYSTEM BRAND TIER 99 DEROSANIL EMU CLEANSER GENERIC TIER 01ROSANIL KIT BRAND TIER 03SALACYN CRE 6% GENERIC TIER 01SALACYN LOT 6% GENERIC TIER 01SALEX SHA 6% Brand‐O TIER 03 PASALEX CREAM KIT 6% Brand‐O TIER 03 PASALEX LOTION KIT 6% Brand‐O TIER 03 PASALICYLIC AER 6% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion166

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusKERATOLYTIC AGENTS SALICYLIC CRY ACID GENERIC TIER 99 DESALICYLIC AC AER 6% GENERIC TIER 01SALICYLIC AC CRE 6% GENERIC TIER 01SALICYLIC AC GEL 6% GENERIC TIER 01SALICYLIC AC KIT 6% GENERIC TIER 01SALICYLIC AC KIT 6% CREAM GENERIC TIER 01SALICYLIC AC KIT 6% LOTN GENERIC TIER 01SALICYLIC AC LIQ 26% GENERIC TIER 01SALICYLIC AC LIQ 27.5% GENERIC TIER 01SALICYLIC AC LOT 6% GENERIC TIER 01SALICYLIC AC SHA 6% GENERIC TIER 01SALKERA AER 6% BRAND TIER 03SALVAX AER 6% Brand‐O TIER 03 PASALVAX AER 6% GENERIC TIER 01SALVAX DUO KIT PLUS BRAND TIER 03SE 10‐5 SS CRE 10‐5% GENERIC TIER 01SOD SUL/SULF AER 10‐5% GENERIC TIER 01SOD SUL/SULF CRE 10‐5% GENERIC TIER 01SOD SUL/SULF EMU 10‐5% GENERIC TIER 01SOD SUL/SULF GEL 10‐5% GENERIC TIER 01SOD SUL/SULF LIQ 9‐4.5% GENERIC TIER 01SOD SUL/SULF LIQ WASH GENERIC TIER 01SOD SUL/SULF LOT 10‐5% GENERIC TIER 01SOD SUL/SULF PAD 10‐4% GENERIC TIER 01SOD SUL/SULF PAD 10‐5% GENERIC TIER 01SOD SUL/SULF SUS 10‐5% GENERIC TIER 01SOD SUL/SULF SUS 8‐4% GENERIC TIER 01SSS 10‐4 AER 10‐4% BRAND TIER 03SULFACLEANSE SUS 8‐4% GENERIC TIER 01SULFOAM SHA 2% BRAND TIER 03SUMADAN KIT BRAND TIER 03SUMADAN WASH LIQ 9‐4.5% Brand‐O TIER 03 PASUMAXIN PAD 10‐4% Brand‐O TIER 03 PASUMAXIN CP KIT BRAND TIER 03SUMAXIN TS SUS 8‐4% Brand‐O TIER 03 PASUMAXIN WASH LIQ 9‐4% Brand‐O TIER 03 PASUPHERA CRE 10‐5% GENERIC TIER 01TL UREA LOT 45% GENERIC TIER 01U‐KERA E CRE 40% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion167

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusKERATOLYTIC AGENTS UMECTA EMU BRAND TIER 03UMECTA SUS 40% Brand‐O TIER 03 PAUMECTA MOUSS AER 40% GENERIC TIER 01UMECTA NAIL SUS FILM Brand‐O TIER 03 PAUMECTA PD EMU 40‐0.3% BRAND TIER 03UMECTA PD SUS 40‐0.3% BRAND TIER 03URAMAXIN AER 20% GENERIC TIER 01URAMAXIN CRE 45% Brand‐O TIER 03 PAURAMAXIN GEL 45% Brand‐O TIER 03 PAURAMAXIN LOT 45% Brand‐O TIER 03 PAURAMAXIN GT KIT 45% BRAND TIER 03URAMAXIN GT SOL 45% Brand‐O TIER 03 PAUREA CRE 39% GENERIC TIER 01UREA CRE 40% GENERIC TIER 01UREA CRE 45% GENERIC TIER 01UREA CRE 50% GENERIC TIER 01UREA EMU 50% GENERIC TIER 01UREA GEL 40% GENERIC TIER 01UREA LOT 40% GENERIC TIER 01UREA LOT 45% GENERIC TIER 01UREA OIN 50% GENERIC TIER 01UREA SUS 50% GENERIC TIER 01UREA 40% SUS NAIL GENERIC TIER 01UREA HYDRATI AER 35% GENERIC TIER 01UREA NAIL GEL 45% GENERIC TIER 01UREA NAIL KIT GENERIC TIER 01UREA NAIL MIS 50% BRAND TIER 03UREA TOPICAL SUS 40% GENERIC TIER 01UREA‐C40 LOT 40% GENERIC TIER 01VIRASAL LIQ 27.5% Brand‐O TIER 03 PAVIRTI‐SULF CRE 10‐5% GENERIC TIER 01X‐VIATE CRE 40% GENERIC TIER 01X‐VIATE GEL 40% GENERIC TIER 01X‐VIATE LOT 40% GENERIC TIER 01ZENCIA LIQ 9‐4% GENERIC TIER 01KERATOPLASTIC AGENTS COAL TAR OIN 1% GENERIC TIER 01COAL TAR SOL 20% GENERIC TIER 01KETOLIDES KETEK TAB 300MG BRAND TIER 03KETEK TAB 400MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion168

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusKIDNEY FUNCTION AMINOHIPPURA INJ 20% GENERIC TIER 01DMSA KIT BRAND TIER 99 DEDRAX IMAGE KIT DTPA BRAND TIER 99 DEINDIGO CARMI INJ 8MG/ML GENERIC TIER 01INULIN INJ 100MG/ML GENERIC TIER 01LEUKOTRIENE MODIFIERS ACCOLATE TAB 10MG Brand‐O TIER 03 PAACCOLATE TAB 20MG Brand‐O TIER 03 PAMONTELUKAST CHW 4MG GENERIC TIER 01 PAMONTELUKAST CHW 5MG GENERIC TIER 01 PAMONTELUKAST GRA 4MG GENERIC TIER 01 PAMONTELUKAST TAB 10MG GENERIC TIER 01 PAMONTELUKAST TAB 10MGSINGULAIR CHW 4MG Brand‐O TIER 03 PASINGULAIR CHW 5MG Brand‐O TIER 03 PASINGULAIR GRA 4MG Brand‐O TIER 03 PASINGULAIR TAB 10MG Brand‐O TIER 03 PAZAFIRLUKAST TAB 10MG GENERIC TIER 01 PAZAFIRLUKAST TAB 20MG GENERIC TIER 01 PAZYFLO TAB 600MG BRAND TIER 03 PAZYFLO CR TAB 600MG BRAND TIER 03 PALINCOMYCINS CLEOCIN CAP 150MG Brand‐O TIER 03 PACLEOCIN CAP 300MG Brand‐O TIER 03 PACLEOCIN CAP 75MG Brand‐O TIER 03 PACLEOCIN INJ 600MG BRAND TIER 03CLEOCIN INJ 900MG BRAND TIER 03CLEOCIN PED SOL 75MG/5ML Brand‐O TIER 03 PACLEOCIN PHOS INJ 300MG Brand‐O TIER 03 PA SPCLEOCIN PHOS INJ 600MG Brand‐O TIER 03 PA SPCLEOCIN PHOS INJ 900MG Brand‐O TIER 03 PA SPCLEOCIN PHOS INJ 9GM Brand‐O TIER 03 PA SPCLEOCIN/D5W INJ 300MG BRAND TIER 03CLINDAMYCIN CAP 150MG GENERIC TIER 01CLINDAMYCIN CAP 300MG GENERIC TIER 01CLINDAMYCIN CAP 75MG GENERIC TIER 01CLINDAMYCIN INJ 150MG/ML GENERIC TIER 01 SPCLINDAMYCIN INJ 300/2ML GENERIC TIER 01 SPCLINDAMYCIN INJ 300MG GENERIC TIER 01 SPCLINDAMYCIN INJ 600/4ML GENERIC TIER 01 SPCLINDAMYCIN INJ 600MG GENERIC TIER 01 SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion169

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLINCOMYCINS CLINDAMYCIN INJ 900/6ML GENERIC TIER 01 SPCLINDAMYCIN INJ 9000/60 GENERIC TIER 01 SPCLINDAMYCIN INJ 900MG GENERIC TIER 01 SPCLINDAMYCIN SOL 75MG/5ML GENERIC TIER 01LINCOCIN INJ 300MG/ML BRAND TIER 03LIPOTROPIC AGENTS CHOLINE BIT CRY FCC GENERIC TIER 99 DELECITHIN GRA GENERIC TIER 01LIPMAX SOL BRAND TIER 99 DEPCCA LECITHI SOL ISOPROPY BRAND TIER 99 DELOCAL ANESTHETICS (EENT) AKTEN GEL 3.5% BRAND TIER 99 DEALCAINE SOL 0.5% OP Brand‐O TIER 03 PAALTACAINE SOL 0.5% OP GENERIC TIER 01ANTIPY/BENZO DRO OTIC GENERIC TIER 01ANTIPY/BENZO SOL 14‐54MG GENERIC TIER 01ANTIPY/BENZO SOL OTIC GENERIC TIER 01AURALGAN SOL 1.4‐5.5% Brand‐O TIER 03 PAAURAX SOL 1.4‐5.5% GENERIC TIER 01AURODEX SOL OTIC GENERIC TIER 01COCAINE HCL SOL 10% GENERIC TIER 01COCAINE HCL SOL 4% GENERIC TIER 01LIDOCAINE SOL 2% VISC GENERIC TIER 01LTA 360 KIT SOL 4% Brand‐O TIER 03 PAMYOXIN SUS OTIC GENERIC TIER 01NEOTIC DRO Brand‐O TIER 03 PAOTIC CARE DRO GENERIC TIER 01OTICIN DRO 1‐0.1% GENERIC TIER 01OTOZIN DRO GENERIC TIER 01PARCAINE SOL 0.5% OP GENERIC TIER 01PINNACAINE DRO 20% OTIC BRAND TIER 03PRAMOTIC DRO 1‐0.1% Brand‐O TIER 03 PAPROPARACAINE SOL 0.5% OP GENERIC TIER 01TETCAINE SOL 0.5% OP GENERIC TIER 01TETRACAINE SOL 0.5% OP GENERIC TIER 01TETRAVISC SOL 0.5% OP GENERIC TIER 01TETRAVISC SOL FORTE GENERIC TIER 01TREAGAN OTIC DRO Brand‐O TIER 03 PATRIOXIN SUS OTIC Brand‐O TIER 03 PAZINOTIC DRO BRAND TIER 03ZINOTIC ES DRO BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion170

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANESTHETICS (PARENTERAL) BASIC BIOPSY KIT 20GX1.5" BRAND TIER 03BONE MARROW KIT 16G BRAND TIER 03BONE MARROW KIT 16GX2" BRAND TIER 03BONE MARROW KIT BIOPSY BRAND TIER 03BUPIVACAINE INJ 0.25% GENERIC TIER 01BUPIVACAINE INJ 0.5% GENERIC TIER 01BUPIVACAINE INJ 0.75% GENERIC TIER 01BUPIVACAINE INJ SPINAL GENERIC TIER 01BUPIVACAINE/ INJ EPI 0.25 GENERIC TIER 01BUPIVACAINE/ INJ EPI 0.5% GENERIC TIER 01CARBOCAINE INJ 1% Brand‐O TIER 03 PACARBOCAINE INJ 1% PF Brand‐O TIER 03 PACARBOCAINE INJ 1.5% PF Brand‐O TIER 03 PACARBOCAINE INJ 2% Brand‐O TIER 03 PACARBOCAINE INJ 2% PF Brand‐O TIER 03 PACHLOROPROC INJ 2% GENERIC TIER 01CHLOROPROC INJ 3% GENERIC TIER 01DUOCAINE INJ BRAND TIER 03EXPAREL INJ 1.3% BRAND TIER 03LIDO/DEXTROS INJ 5‐7.5% GENERIC TIER 01LIDO/EPI INJ 0.5% GENERIC TIER 01LIDO/EPI INJ 1.5% GENERIC TIER 01LIDO/EPI INJ 2% GENERIC TIER 01LIDO/EPI 1%‐ INJ 1:100000 GENERIC TIER 01LIDOCAINE INJ 0.5% GENERIC TIER 01LIDOCAINE INJ 1% GENERIC TIER 01LIDOCAINE INJ 1.5% GENERIC TIER 01LIDOCAINE INJ 2% GENERIC TIER 01LIDOCAINE INJ 4% GENERIC TIER 01MARCAINE INJ 0.25% Brand‐O TIER 03 PAMARCAINE INJ 0.5% Brand‐O TIER 03 PAMARCAINE INJ 0.75% Brand‐O TIER 03 PAMARCAINE INJ SPINAL Brand‐O TIER 03 PAMARCAINE/EPI INJ 0.25% Brand‐O TIER 03 PAMARCAINE/EPI INJ 0.5% Brand‐O TIER 03 PAMEPIVACAINE INJ 3% GENERIC TIER 01NAROPIN INJ 10MG/ML BRAND TIER 03NAROPIN INJ 2MG/ML BRAND TIER 03NAROPIN INJ 5MG/ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion171

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANESTHETICS (PARENTERAL) NAROPIN INJ 7.5MG/ML BRAND TIER 03NESACAINE INJ 1% BRAND TIER 03NESACAINE INJ 2% Brand‐O TIER 03 PANESACAINE INJ ‐MPF 2% Brand‐O TIER 03 PANESACAINE INJ ‐MPF 3% Brand‐O TIER 03 PAPNEUMOTHORX KIT TRAY 8FR BRAND TIER 03POLOCAINE INJ 1% GENERIC TIER 01POLOCAINE INJ 2% GENERIC TIER 01POLOCAINE INJ ‐MPF 1% GENERIC TIER 01POLOCAINE INJ MPF 1.5% GENERIC TIER 01POLOCAINE INJ ‐MPF 2% GENERIC TIER 01PONTOCAINE INJ 1% Brand‐O TIER 03 PAPONTOCAINE INJ 20MG BRAND TIER 03PROCAINE HCL CRY GENERIC TIER 99 DEPUDEND/LOCAL KIT 1% LIDO GENERIC TIER 01SENSORCAINE INJ 0.25% GENERIC TIER 01SENSORCAINE INJ 0.5% GENERIC TIER 01SENSORCAINE INJ MPF 0.5% GENERIC TIER 01SENSORCAINE INJ MPF SPIN GENERIC TIER 01SENSORCAINE INJ ‐MPF/EPI BRAND TIER 03SENSORCAINE INJ ‐MPF/EPI GENERIC TIER 01SENSORCAINE INJ MPF0.25% GENERIC TIER 01SENSORCAINE INJ MPF0.75% GENERIC TIER 01SENSORCAINE/ INJ EPI 0.25 GENERIC TIER 01SENSORCAINE/ INJ EPI 0.5% GENERIC TIER 01SPINAL/EPIDU KIT CL CATH BRAND TIER 03SPINAL/EPIDU KIT OPN CATH BRAND TIER 03TETRACAINE INJ 1% GENERIC TIER 01XYLO/EPI INJ 0.5% Brand‐O TIER 03 PAXYLO/EPI INJ 2% Brand‐O TIER 03 PAXYLO/EPI 1%‐ INJ 1:100000 Brand‐O TIER 03 PAXYLOCAINE INJ 0.5% Brand‐O TIER 03 PAXYLOCAINE INJ 1% Brand‐O TIER 03 PAXYLOCAINE INJ 2% Brand‐O TIER 03 PAXYLOCAINE INJ MPF 0.5% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 1% Brand‐O TIER 03 PAXYLOCAINE INJ MPF 1.5% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 2% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 4% Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion172

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANESTHETICS (PARENTERAL) XYLO‐MPF/EPI INJ 1% BRAND TIER 03XYLO‐MPF/EPI INJ 1.5% Brand‐O TIER 03 PAXYLO‐MPF/EPI INJ 2% Brand‐O TIER 03 PALOCAL ANTI‐INFECTIVES, MISCELLANEOUS ACID JELLY GEL VAG/APPL GENERIC TIER 01ALCOHOL SOL REGENT GENERIC TIER 99 DEALCORTIN A GEL BRAND TIER 99 DEAVC CRE 15% BRAND TIER 02BENZAC AC LIQ 5% WASH Brand‐O TIER 03 PABENZAC W LIQ 5% WASH Brand‐O TIER 03 PABENZALKONIUM SOL 17% GENERIC TIER 01BENZALKONIUM SOL 50% GENERIC TIER 01BENZALKONIUM SOL NF GENERIC TIER 01BENZEFOAM AER 9.8% Brand‐O TIER 03 PABENZEPRO AER 5.3% GENERIC TIER 99 DEBENZEPRO SC AER 9.8% GENERIC TIER 01BENZIQ GEL 5.25% BRAND TIER 03BENZIQ LS GEL 2.75% BRAND TIER 03BENZIQ WASH LIQ 5.25% GENERIC TIER 01BENZOYL PER AER 5.3% GENERIC TIER 99 DEBENZOYL PER GEL 10% GENERIC TIER 01BENZOYL PER GEL 2.5% GENERIC TIER 01BENZOYL PER LIQ 10% WASH GENERIC TIER 01BENZOYL PER LIQ 2.5%WASH GENERIC TIER 01BENZOYL PER LIQ 5% WASH GENERIC TIER 01BENZOYL PER LIQ 7% WASH GENERIC TIER 01BENZOYL PER LOT 3% GENERIC TIER 01BENZOYL PER LOT 4% GENERIC TIER 01BENZOYL PER LOT 6% GENERIC TIER 01BENZOYL PER LOT 9% GENERIC TIER 01BENZOYL PER PAD 3% GENERIC TIER 01BENZOYL PER PAD 6% GENERIC TIER 01BENZOYL PER PAD 9% GENERIC TIER 01BENZOYL PERO AER 9.8% GENERIC TIER 01BENZOYL PERO KIT ACNE PCK GENERIC TIER 01BORIC ACID GRA BRAND TIER 03BORIC ACID GRA GENERIC TIER 01BP CLEANSER LIQ 4.25% GENERIC TIER 01BP WASH LIQ 2.5% GENERIC TIER 01BP WASH LIQ 5.25% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion173

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANTI‐INFECTIVES, MISCELLANEOUS BP WASH LIQ 7% GENERIC TIER 01BPO GEL 4% GENERIC TIER 01BPO GEL 8% GENERIC TIER 01BPO CLOTHS MIS 3% GENERIC TIER 01BPO CLOTHS MIS 6% GENERIC TIER 01BPO CLOTHS MIS 9% GENERIC TIER 01BPO CREAMY KIT 8% WASH GENERIC TIER 01BUCALSEP SOL BRAND TIER 03BUCALSEP SPR BRAND TIER 03CHLORHEX DIG SOL 20% GENERIC TIER 01CHLORHEX GLU SOL 20% GENERIC TIER 01CLEARPLEX X GEL 10% GENERIC TIER 01CURITY SPONG MIS STICKS BRAND TIER 03DELOS LIQ 3.5% BRAND TIER 03DELOS LOT 3.5% BRAND TIER 03DERMAZENE CRE 1% GENERIC TIER 99 DEDESQUAM‐X LIQ 10% WASH Brand‐O TIER 03 PADESQUAM‐X LIQ 5% WASH Brand‐O TIER 03 PAETHYL ALCOHO SOL 100% GENERIC TIER 99 DEFEM PH GEL BRAND TIER 03HYDROCORT/ CRE IODOQUIN GENERIC TIER 99 DEHYDROGEN PER SOL 35% FCC GENERIC TIER 01HYDRO‐IODOQU GEL 2‐1 GENERIC TIER 99 DEHYPOCHLORITE SOL SODIUM GENERIC TIER 99 DEINOVA KIT 4% BRAND TIER 03INOVA KIT 8% BRAND TIER 03INOVA 4/1 KIT ACNE CON BRAND TIER 03INOVA 8/2 KIT ACNE CON BRAND TIER 03IODINE TIN 2% MILD GENERIC TIER 01IODINE TIN STRONG GENERIC TIER 01IODOFLEX PAD PAD BRAND TIER 03IODOSORB GEL BRAND TIER 03IODOSORB GEL 0.9% BRAND TIER 03LAVOCLEN‐4 KIT ACNE WSH GENERIC TIER 01LAVOCLEN‐4 LIQ CREM WSH GENERIC TIER 01LAVOCLEN‐8 KIT ACNE WSH GENERIC TIER 01LAVOCLEN‐8 LIQ CREM WSH GENERIC TIER 01MEDIHOL BASE GEL BRAND TIER 03NEOBENZ MICR CRE 3.5% BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion174

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANTI‐INFECTIVES, MISCELLANEOUS NEOBENZ MICR CRE 5.5% BRAND TIER 03NEOBENZ MICR CRE 8.5% BRAND TIER 03NEOBENZ MICR KIT PLUS PK Brand‐O TIER 03 PANEOBENZ MICR LIQ 7% WASH Brand‐O TIER 03 PAOSCION CLNSR LOT 6% GENERIC TIER 01OSCION CLNSR LOT 9% GENERIC TIER 01PACNEX HP PAD 7% BRAND TIER 03PACNEX LP PAD 4.25% BRAND TIER 03PACNEX MX LIQ 4.25% Brand‐O TIER 03 PAPACNEX WASH LIQ 7% GENERIC TIER 01PHENOL CRY GENERIC TIER 99 DEPHENOL LIQ GENERIC TIER 99 DEPHENOL LIQ 89% GENERIC TIER 99 DEPHISOHEX LIQ 3% BRAND TIER 03PR BENZOYL LIQ 7% WASH GENERIC TIER 01RA RENEWAL GEL 10% GENERIC TIER 01RELAGARD GEL BRAND TIER 03SE BPO 7‐5.5 KIT WASH KIT GENERIC TIER 01SE BPO CLOTH MIS 3% GENERIC TIER 01SE BPO CLOTH MIS 6% GENERIC TIER 01SE BPO CLOTH MIS 9% GENERIC TIER 01SE BPO WASH LIQ 7% GENERIC TIER 01SELENIUM SUL LOT 2.5% GENERIC TIER 01SELENIUM SUL SHA 2.25% GENERIC TIER 01SELENIUM SUL SHA 2.5% GENERIC TIER 01SELSUN SHA 2.5% Brand‐O TIER 03 PASILVADENE CRE 1% Brand‐O TIER 03 PASILVER SULFA CRE 1% GENERIC TIER 01SKIN SCRUB KIT PACK BRAND TIER 03SKIN SCRUB KIT PACK WET BRAND TIER 03SKIN SCRUB KIT TRAY WET BRAND TIER 03SOD HYPOCHLR SOL 5% GENERIC TIER 01SSD CRE 1% GENERIC TIER 01SSD AF CRE 1% GENERIC TIER 01SULFAMYLON CRE 85MG/GM BRAND TIER 03SULFAMYLON PAK 5% BRAND TIER 03TERSI FOAM AER 2.25% BRAND TIER 03THERMAZENE CRE 1% GENERIC TIER 01TL BPO MX LIQ 4.25% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion175

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOCAL ANTI‐INFECTIVES, MISCELLANEOUS TRIAZ PAD 3% Brand‐O TIER 03 PATRIAZ PAD 6% Brand‐O TIER 03 PATRIAZ PAD 9% Brand‐O TIER 03 PATRIAZ CLEANS LOT 3% Brand‐O TIER 03 PATRIAZ CLEANS LOT 6% Brand‐O TIER 03 PATRIAZ CLEANS LOT 9% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 3% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 6% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 9% Brand‐O TIER 03 PAUNIVERSAL GEL WATER BRAND TIER 03VAGINAL PREP KIT PACK BRAND TIER 03VAGINAL PREP KIT TRAY BRAND TIER 03WINGED GRIP MIS SPONGE BRAND TIER 03ZACARE KIT KIT 4% BRAND TIER 03ZACARE KIT KIT 8% BRAND TIER 03ZACLIR LOT 4% GENERIC TIER 01ZACLIR LOT 8% GENERIC TIER 01BENZEFOAM AER 5.3% Brand‐O TIER 99 PA DEIODINE TIN 2% GENERIC TIER 01HYDROGEN PER SOL 30% GENERIC TIER 01POT PERMANGT GRA GENERIC TIER 99 DEBENZOYL PER GEL 5% GENERIC TIER 01LOOP DIURETICS BUMETANIDE INJ 0.25/ML GENERIC TIER 01BUMETANIDE TAB 0.5MG GENERIC TIER 01BUMETANIDE TAB 1MG GENERIC TIER 01BUMETANIDE TAB 2MG GENERIC TIER 01DEMADEX TAB 100MG Brand‐O TIER 03 PADEMADEX TAB 10MG Brand‐O TIER 03 PADEMADEX TAB 20MG Brand‐O TIER 03 PADEMADEX TAB 5MG Brand‐O TIER 03 PAEDECRIN TAB 25MG BRAND TIER 03FUROSEMIDE INJ 10MG/ML GENERIC TIER 01FUROSEMIDE SOL 10MG/ML GENERIC TIER 01FUROSEMIDE SOL 8MG/ML GENERIC TIER 01FUROSEMIDE TAB 20MG GENERIC TIER 01FUROSEMIDE TAB 40MG GENERIC TIER 01FUROSEMIDE TAB 80MG GENERIC TIER 01LASIX TAB 20MG Brand‐O TIER 03 PALASIX TAB 40MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion176

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusLOOP DIURETICS LASIX TAB 80MG Brand‐O TIER 03 PASOD EDECRIN INJ 50MG BRAND TIER 03TORSEMIDE INJ 20MG/2ML GENERIC TIER 01TORSEMIDE INJ 50MG/5ML GENERIC TIER 01TORSEMIDE TAB 100MG GENERIC TIER 01TORSEMIDE TAB 10MG GENERIC TIER 01TORSEMIDE TAB 20MG GENERIC TIER 01TORSEMIDE TAB 5MG GENERIC TIER 01MAST‐CELL STABILIZERS CROMOLYN SOD CON 100/5ML GENERIC TIER 01CROMOLYN SOD NEB 20MG/2ML GENERIC TIER 01GASTROCROM CON 100/5ML Brand‐O TIER 03 PAMEGLITINIDES NATEGLINIDE TAB 120MG GENERIC TIER 01NATEGLINIDE TAB 60MG GENERIC TIER 01PRANDIMET TAB 1‐500MG BRAND TIER 03PRANDIMET TAB 2‐500MG BRAND TIER 03PRANDIN TAB 0.5MG BRAND TIER 02PRANDIN TAB 1MG BRAND TIER 02PRANDIN TAB 2MG BRAND TIER 02STARLIX TAB 120MG Brand‐O TIER 03 PASTARLIX TAB 60MG Brand‐O TIER 03 PAMINERALOCORTICOID (ALDOSTERONE) ANTAGNTS ALDACTAZIDE TAB 25/25 Brand‐O TIER 03 PAALDACTAZIDE TAB 50/50 BRAND TIER 03ALDACTONE TAB 100MG Brand‐O TIER 03 PAALDACTONE TAB 25MG Brand‐O TIER 03 PAALDACTONE TAB 50MG Brand‐O TIER 03 PAEPLERENONE TAB 25MG GENERIC TIER 01EPLERENONE TAB 50MG GENERIC TIER 01INSPRA TAB 25MG Brand‐O TIER 03 PAINSPRA TAB 50MG Brand‐O TIER 03 PASPIRONO/HCTZ TAB 25/25 GENERIC TIER 01SPIRONOLACT TAB 100MG GENERIC TIER 01SPIRONOLACT TAB 25MG GENERIC TIER 01SPIRONOLACT TAB 50MG GENERIC TIER 01MIOTICS ISO CARBACHO SOL 1.5% OP BRAND TIER 02ISO CARBACHO SOL 3% OP BRAND TIER 02ISOPTO CARP SOL 1% OP Brand‐O TIER 03 PAISOPTO CARP SOL 2% OP Brand‐O TIER 03 PAISOPTO CARP SOL 4% OP Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion177

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMIOTICS MIOCHOL‐E SOL 1:100 BRAND TIER 03MIOSTAT INJ 0.01% OP BRAND TIER 03PHOSPHOLINE SOL 0.125%OP BRAND TIER 02PILOCARPINE SOL 1% OP GENERIC TIER 01PILOCARPINE SOL 2% OP GENERIC TIER 01PILOCARPINE SOL 4% OP GENERIC TIER 01PILOPINE HS GEL 4% OP BRAND TIER 02MONOAMINE OXIDASE B INHIBITORS AZILECT TAB 0.5MG BRAND TIER 02AZILECT TAB 1MG BRAND TIER 02ELDEPRYL CAP 5MG Brand‐O TIER 03 PAEMSAM DIS 12MG/24H BRAND TIER 03EMSAM DIS 6MG/24HR BRAND TIER 03EMSAM DIS 9MG/24HR BRAND TIER 03SELEGILINE CAP 5MG GENERIC TIER 01SELEGILINE TAB 5MG GENERIC TIER 01ZELAPAR TAB 1.25MG BRAND TIER 03MONOAMINE OXIDASE INHIBITORS MARPLAN TAB 10MG BRAND TIER 03NARDIL TAB 15MG Brand‐O TIER 03 PAPARNATE TAB 10MG Brand‐O TIER 03 PAPHENELZINE TAB 15MG GENERIC TIER 01TRANYLCYPROM TAB 10MG GENERIC TIER 01MONOBACTAMS AZACTAM INJ 1GM Brand‐O TIER 03 PAAZACTAM INJ 2GM Brand‐O TIER 03 PAAZACTAM/DEX INJ 1GM BRAND TIER 03AZACTAM/DEX INJ 2GM BRAND TIER 03AZTREONAM INJ 1GM GENERIC TIER 01AZTREONAM INJ 2GM GENERIC TIER 01CAYSTON INH 75MG BRAND TIER 02MONOCLONAL ANTIBODIES SYNAGIS INJ 100MG/ML BRAND TIER 02 PA QL SPSYNAGIS INJ 50MG BRAND TIER 02 PA QL SPMOUTHWASHES AND GARGLES DOBELLS SOL GENERIC TIER 01MUCOLYTIC AGENTS HYPERSAL NEB 3.5% BRAND TIER 99 DENEBUSAL NEB 6% BRAND TIER 99 DEPULMOZYME SOL 1MG/ML BRAND TIER 02 SPSODIUM CHLOR NEB 10% GENERIC TIER 99 DESODIUM CHLOR NEB 3% GENERIC TIER 99 DESODIUM CHLOR NEB 7% GENERIC TIER 99 DEHYPER‐SAL NEB 7% Brand‐O TIER 99 PA DEHYPERSAL NEB 7% Brand‐O TIER 99 PA DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion178

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMUCOLYTIC AGENTS SOD CHLORIDE NEB 0.9% GENERIC TIER 99 DEMULTIVITAMIN PREPARATIONS ACD/FLUORIDE DRO 0.25MG GENERIC TIER 01ADRENAL C TAB FORMULA BRAND TIER 03ADVANCED MIS AM/PM BRAND TIER 03AP‐ZEL TAB BRAND TIER 03ATABEX TAB PRENATAL BRAND TIER 03ATABEX EC TAB BRAND TIER 03BACMIN TAB BRAND TIER 03BAL‐CARE MIS DHA BRAND TIER 03BAL‐CARE DHA MIS ESSNTIAL BRAND TIER 03BIOCEL TAB GENERIC TIER 01B‐NEXA TAB BRAND TIER 03BP FOLINATAL TAB PLUS B GENERIC TIER 01BP MULTINATL CHW PLUS GENERIC TIER 01BP MULTINATL TAB PLUS GENERIC TIER 01B‐PLEX TAB GENERIC TIER 01 PAB‐PLEX PLUS TAB GENERIC TIER 01CAROMEGA TAB Brand‐O TIER 03 PACAVAN TAB PRENATAL GENERIC TIER 01CAVAN ONE CAP OMEGA GENERIC TIER 01CAVAN‐ALPHA KIT BRAND TIER 03CAVAN‐EC SOD MIS DHA GENERIC TIER 01CAVAN‐FOLATE MIS DHA BRAND TIER 03CAVAN‐FOLATE TAB OB BRAND TIER 03 PACITRANATAL CAP HARMONY BRAND TIER 03CITRANATAL MIS 90 DHA BRAND TIER 03CITRANATAL MIS B‐CALM BRAND TIER 03CITRANATAL PAK ASSURE BRAND TIER 03CITRANATAL PAK DHA BRAND TIER 03CITRANATAL TAB RX BRAND TIER 03COD LIVER OIL GENERIC TIER 01COMPLETE NAT PAK DHA GENERIC TIER 01COMPLETENATE CHW GENERIC TIER 01COMPLETE‐RF TAB PRENATAL BRAND TIER 03CO‐NATAL FA TAB 29‐1MG GENERIC TIER 01 PACONCEPT DHA CAP BRAND TIER 03CONCEPT OB CAP BRAND TIER 03CORENATE‐DHA MIS BRAND TIER 03CORVITA TAB GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion179

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS CORVITE TAB Brand‐O TIER 03 PACORVITE FREE TAB GENERIC TIER 01CRNATAL PAK BRAND TIER 03DIALYVITE TAB GENERIC TIER 01 PADIALYVITE TAB 3000 BRAND TIER 03DIALYVITE TAB 5000 BRAND TIER 03DIALYVITE TAB SUPREM D BRAND TIER 03DIALYVITE/ TAB ZINC BRAND TIER 03DIATX ZN TAB Brand‐O TIER 03 PADUET DHA MIS 25‐1‐400 BRAND TIER 03DUET DHA MIS 25‐1‐430 BRAND TIER 03DUET DHA MIS BALANCED BRAND TIER 03DUET DHA EC MIS 25‐1‐400 BRAND TIER 03DUET DHA EC MIS 25‐1‐430 BRAND TIER 03ELITE OB CAP W/DHA GENERIC TIER 01ELITE‐OB TAB GENERIC TIER 01ELITE‐OB 400 CAP BRAND TIER 03ESCAVITE CHW BRAND TIER 03FOLBECAL TAB GENERIC TIER 01FOLBEE PLUS TAB GENERIC TIER 01 PAFOLBEE PLUS TAB CZ GENERIC TIER 01FOLCAL DHA CAP BRAND TIER 03FOLCAPS CAP OMEGA 3 BRAND TIER 03FOLGARD OS TAB BRAND TIER 03FOLIVANE‐EC PAK CA DHA BRAND TIER 03FOLIVANE‐OB CAP BRAND TIER 03FOLIVANE‐PRX CAP DHA NF BRAND TIER 03FORTAVIT CAP BRAND TIER 03GENTEX ADE TAB 28‐1MG GENERIC TIER 01GESTICARE PAK DHA BRAND TIER 03GESTICARE TAB BRAND TIER 03HEMENATAL OB MIS + DHA BRAND TIER 03HEMENATAL OB TAB 28‐6‐1MG BRAND TIER 03INATAL ADV TAB GENERIC TIER 01INATAL GT TAB GENERIC TIER 01INATAL ULTRA TAB GENERIC TIER 01INFUVITE INJ GENERIC TIER 01INFUVITE INJ ADULT GENERIC TIER 01INFUVITE INJ PEDIATRI GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion180

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS LACTOCAL‐F TAB BRAND TIER 03 PALEVOMEFOLATE CAP DHA BRAND TIER 02LEVOMEFOLATE MIS BRAND TIER 03L‐METHYLFOLA CAP PNV DHA BRAND TIER 02LYSIPLEX TAB PLUS GENERIC TIER 01M.V.I PEDIAT INJ BRAND TIER 03M.V.I. ADULT INJ BRAND TIER 03M.V.I‐12 W/O INJ VIT K BRAND TIER 03MACNATAL CN CAP DHA GENERIC TIER 01MARNATAL‐F CAP BRAND TIER 03MARNATAL‐F MIS PLUS DUO BRAND TIER 03MAXINATE TAB BRAND TIER 03MULTICHEW CHW BRAND TIER 03MULTI‐VIT/FE DRO /FL 0.25 GENERIC TIER 01MULTIVIT/FL CHW 0.25MG GENERIC TIER 01MULTIVIT/FL CHW 0.5MG GENERIC TIER 01MULTIVIT/FL CHW 1MG GENERIC TIER 01MULTI‐VIT/FL CHW 0.25MG GENERIC TIER 01MULTI‐VIT/FL CHW 0.5MG GENERIC TIER 01MULTI‐VIT/FL CHW 1MG GENERIC TIER 01MULTI‐VIT/FL DRO /FE 0.25 GENERIC TIER 01MULTI‐VIT/FL DRO 0.25MG GENERIC TIER 01MULTI‐VIT/FL DRO 0.5MG/ML GENERIC TIER 01MULT‐VIT/FL CHW 0.5MG GENERIC TIER 01MVC‐FLUORIDE CHW 0.25MG GENERIC TIER 01MVC‐FLUORIDE CHW 0.5MG GENERIC TIER 01MVC‐FLUORIDE CHW 1MG GENERIC TIER 01M‐VIT TAB 27‐1MG GENERIC TIER 01 PAMYKIDZ IRON SUS FL BRAND TIER 03MYNATAL CAP BRAND TIER 03MYNATAL TAB GENERIC TIER 01MYNATAL TAB ADVANCE GENERIC TIER 01MYNATAL PLUS TAB GENERIC TIER 01 PAMYNATAL‐Z TAB GENERIC TIER 01 PAMYNATE 90 TAB PLUS GENERIC TIER 01MYNEPHROCAPS CAP GENERIC TIER 01NATA KOMPLET TAB 25‐1MG BRAND TIER 03NATAFORT TAB BRAND TIER 03NATALVIT TAB 75‐1MG BRAND TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion181

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS NATELLE ONE CAP BRAND TIER 03NATELLE‐EZ TAB BRAND TIER 03 PANEEVO PAK BRAND TIER 02NEEVO DHA CAP BRAND TIER 02NEPHPLEX RX TAB BRAND TIER 03NEPHROCAPS CAP Brand‐O TIER 03 PANEPHROCAPS TAB QT BRAND TIER 03NEPHRONEX TAB 1MG GENERIC TIER 01 PANEPHRO‐VITE TAB RX Brand‐O TIER 03 PANESTABS TAB BRAND TIER 03NESTABS DHA PAK BRAND TIER 03NEURODEP SOL GENERIC TIER 01NEXA PLUS CAP BRAND TIER 03NEXA SELECT CAP BRAND TIER 03NICAZEL TAB BRAND TIER 03NICOMIDE TAB BRAND TIER 03NICOTINAMIDE TAB ZN/CU/FA GENERIC TIER 01NUTRICAP TAB GENERIC TIER 01NUTRIFAC ZX TAB GENERIC TIER 01NUTRI‐TAB OB MIS + DHA BRAND TIER 03NUTRI‐TAB OB TAB 32‐1MG BRAND TIER 03NUTRIVIT LIQ 800‐15‐1 BRAND TIER 03OB COMPLETE CAP 400 BRAND TIER 03OB COMPLETE CAP ONE BRAND TIER 03OB COMPLETE CAP WITH DHA BRAND TIER 03OB COMPLETE CHW BRAND TIER 03OB COMPLETE TAB BRAND TIER 03OB COMPLETE TAB PREMIER BRAND TIER 03OB COMPLETE/ CAP DHA BRAND TIER 03OB‐NATAL ONE CAP 20‐7‐1MG GENERIC TIER 01OB‐NATAL ONE CAP 27‐1MG GENERIC TIER 01OBSTETRIX PAK DHA BRAND TIER 03OBSTETRIX EC TAB GENERIC TIER 01O‐CAL TAB PRENATAL BRAND TIER 03 PAO‐CAL FA TAB BRAND TIER 03 PAPAIRE OB MIS BRAND TIER 03PNV OB+DHA PAK BRAND TIER 03PNV‐DHA CAP GENERIC TIER 01PNV‐DHA CAP DOCUSATE BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion182

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS PNV‐OMEGA CAP BRAND TIER 03PNV‐SELECT TAB GENERIC TIER 01PNV‐TOTAL CAP BRAND TIER 03POLY‐VI‐FLOR CHW 0.25MG BRAND TIER 03POLY‐VI‐FLOR CHW 0.5MG BRAND TIER 03POLY‐VI‐FLOR CHW 1MG BRAND TIER 03POLY‐VI‐FLOR CHW W/IRON BRAND TIER 03POLY‐VI‐FLOR SUS /IRON BRAND TIER 03POLY‐VI‐FLOR SUS 0.25/ML BRAND TIER 03POLY‐VIT/FE DRO /FL 0.25 GENERIC TIER 01POLY‐VIT/FE DRO /FL 0.5 GENERIC TIER 01POLYVIT/FL DRO 0.5MG/ML GENERIC TIER 01POLY‐VIT/FL DRO 0.25MG GENERIC TIER 01PR NATAL 400 PAK GENERIC TIER 01PR NATAL 400 PAK EC GENERIC TIER 01PR NATAL 430 PAK GENERIC TIER 01PR NATAL 430 PAK EC GENERIC TIER 01PREFERA OB MIS + DHA BRAND TIER 02PREFERA OB TAB BRAND TIER 02PREFERAOB CAP ONE BRAND TIER 02PRENA1 CAP QUATREFO BRAND TIER 03PRENA1 CHW QUATREFO BRAND TIER 03PRENA1 PLUS MIS QUATREFO BRAND TIER 03PRENAFIRST TAB GENERIC TIER 01 PAPRENAISSANCE CAP BRAND TIER 03PRENAISSANCE CAP BALANCE BRAND TIER 03PRENAISSANCE CAP PLUS GENERIC TIER 01PRENAISSANCE MIS HARMONY BRAND TIER 03PRENAISSANCE TAB NEXT BRAND TIER 03PRENAPLUS TAB GENERIC TIER 01 PAPRENATA CHW 29‐1MG BRAND TIER 02PRENATABS TAB OBN GENERIC TIER 01PRENATABS FA TAB GENERIC TIER 01 PAPRENATABS RX TAB GENERIC TIER 01PRENATAL TAB LOW IRON BRAND TIER 03 PAPRENATAL TAB LOW IRON GENERIC TIER 01 PAPRENATAL TAB PLUS BRAND TIER 03 PAPRENATAL TAB PLUS GENERIC TIER 01 PAPRENATAL TAB PLUS/FE GENERIC TIER 01 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion183

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS PRENATAL 19 CHW TAB GENERIC TIER 01PRENATAL 19 TAB GENERIC TIER 01PRENATAL AD TAB GENERIC TIER 01PRENATAL VIT TAB PLUS BRAND TIER 03 PAPRENATAL‐U CAP GENERIC TIER 01PRENATE CAP ESSENTIL BRAND TIER 02PRENATE TAB ELITE BRAND TIER 02PRENATE DHA CAP BRAND TIER 02PRENATE ELIT TAB BRAND TIER 02PRENATE MINI CAP BRAND TIER 03PRENEXA CAP BRAND TIER 03PREQUE 10 TAB BRAND TIER 03PROTECT PLUS CAP BRAND TIER 03PROTECT PLUS CAP NR BRAND TIER 03PROTECT PLUS LIQ BRAND TIER 03PROTECTBONE WAF BRAND TIER 03PROTECTIRON TAB BRAND TIER 03PROTECTNATAL TAB BRAND TIER 03PUREFE OB CAP PLUS BRAND TIER 03REAPHIRM CAP BRAND TIER 03REDICHEW CHW RX BRAND TIER 03RELNATE DHA CAP BRAND TIER 03RENAL CAP SOFTGEL GENERIC TIER 01RENALPREN CAP GENERIC TIER 01RENATABS TAB BRAND TIER 03RENA‐VITE RX TAB GENERIC TIER 01 PARENAX TAB 2.5MG BRAND TIER 03RENAX 5.5 TAB BRAND TIER 03RENO CAP GENERIC TIER 01REQ 49+ TAB BRAND TIER 03SE‐CARE CHW GENERIC TIER 01SE‐CARE TAB CONCEIVE GENERIC TIER 01SELECT‐OB CHW BRAND TIER 03SELECT‐OB+ PAK DHA BRAND TIER 03SE‐NATAL 19 CHW GENERIC TIER 01SE‐NATAL 19 TAB GENERIC TIER 01SE‐NATAL 90 TAB GENERIC TIER 01SE‐NATAL ONE TAB GENERIC TIER 01 PASENETONIC LIQ Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion184

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS SE‐PLETE DHA CAP GENERIC TIER 01SE‐TAN DHA CAP GENERIC TIER 01SETON ET‐EC PAK GENERIC TIER 01SETONET PAK GENERIC TIER 01SIDEROL LIQ GENERIC TIER 01SIDEROL TAB GENERIC TIER 01STROVITE TAB Brand‐O TIER 03 PASTROVITE TAB ADVANCE Brand‐O TIER 03 PASTROVITE FOR SYP BRAND TIER 03STROVITE FOR TAB GENERIC TIER 01STROVITE ONE TAB BRAND TIER 03STROVITE PLU TAB GENERIC TIER 01SUPERVITE LIQ BRAND TIER 03SUPERVITE EC TAB BRAND TIER 03SUPPORT LIQ BRAND TIER 03SYNAGEX CAP 1.25MG BRAND TIER 03SYNATEK CAP BRAND TIER 03TANDEM DHA CAP BRAND TIER 03TANDEM OB CAP BRAND TIER 03TARON EC PAK CALCIUM GENERIC TIER 01TARON‐BC MIS BRAND TIER 03TARON‐C DHA CAP BRAND TIER 03TARON‐DUO EC PAK BRAND TIER 03TARON‐EC CAL TAB 28‐1MG GENERIC TIER 01TARON‐PREX CAP GENERIC TIER 01THEROBEC TAB GENERIC TIER 01 PATL G‐FOL OS TAB BRAND TIER 03TL NICOTINAM TAB IDE GENERIC TIER 01TL‐ASSURE CAP ONE BRAND TIER 03TL‐ASSURE+ MIS DHA BRAND TIER 03TL‐SELECT CAP BRAND TIER 03TRI PRENATAL CAP DHA ONE BRAND TIER 03TRI RX TAB GENERIC TIER 01TRIADVANCE TAB GENERIC TIER 01TRICARE TAB PRENATAL GENERIC TIER 01 PATRICARE DHA CAP 301 BRAND TIER 03TRIMESIS RX TAB GENERIC TIER 01TRINATAL TAB ULTRA BRAND TIER 03TRINATAL GT TAB BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion185

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS TRINATAL RX TAB 1 GENERIC TIER 01 PATRINATE TAB GENERIC TIER 01 PATRIPHROCAPS CAP GENERIC TIER 01TRIVEEN‐DUO PAK DHA BRAND TIER 03TRIVEEN‐ONE CAP BRAND TIER 03TRIVEEN‐PRX CAP RNF BRAND TIER 03TRIVEEN‐TEN TAB BRAND TIER 03TRIVEEN‐U CAP BRAND TIER 03TRI‐VI‐FLOR SUS 0.25/ML BRAND TIER 03TRI‐VI‐FLOR SUS 0.5MG/ML BRAND TIER 03TRI‐VIT/FE DRO /FL 0.25 GENERIC TIER 01TRI‐VIT/FL DRO 0.25MG GENERIC TIER 01TRI‐VIT/FL DRO 0.5MG GENERIC TIER 01TRI‐VIT/FLUO DRO 0.25MG GENERIC TIER 01TRI‐VIT/FLUO DRO 0.5MG GENERIC TIER 01TRI‐VITA/FL DRO 0.25MG GENERIC TIER 01TRI‐ZEL TAB BRAND TIER 03TRUST NATAL PAK DHA GENERIC TIER 01ULTIMATE OB MIS DHA BRAND TIER 03ULTIMATECARE CAP ONE GENERIC TIER 01ULTIMATECARE CAP ONE NF GENERIC TIER 01ULTIMATECARE MIS ADVANTAG BRAND TIER 03ULTIMATECARE MIS COMBO BRAND TIER 03ULTRA TABS TAB GENERIC TIER 01UROSEX TAB GENERIC TIER 99 DEV‐C FORTE CAP GENERIC TIER 01VEMAVITE‐ CAP PRX 2 BRAND TIER 03VENA‐BAL MIS DHA BRAND TIER 03VENATAL COMP MIS DHA BRAND TIER 03VENATAL‐FA TAB BRAND TIER 03 PAVICAP FORTE CAP GENERIC TIER 01VIC‐FORTE CAP GENERIC TIER 01VINACAL TAB BRAND TIER 03VINATE AZ TAB GENERIC TIER 01VINATE AZ EX TAB BRAND TIER 02VINATE C TAB GENERIC TIER 01VINATE CAL TAB BRAND TIER 03VINATE CARE CHW GENERIC TIER 01VINATE GT TAB GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion186

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS VINATE IC CAP GENERIC TIER 01VINATE II TAB GENERIC TIER 01VINATE M TAB GENERIC TIER 01VINATE ONE TAB GENERIC TIER 01 PAVINATE PN TAB CARE GENERIC TIER 01VINATE ULTRA TAB GENERIC TIER 01VIRT‐BAL DHA MIS BRAND TIER 03VIRT‐BAL DHA MIS PLUS BRAND TIER 03VIRT‐PN TAB BRAND TIER 03VIRT‐PN DHA CAP BRAND TIER 03VITA S FORTE TAB GENERIC TIER 01VITACEL TAB GENERIC TIER 01VITAFOL‐OB PAK +DHA BRAND TIER 03VITAFOL‐OB TAB 65‐1MG GENERIC TIER 01 PAVITAFOL‐ONE CAP BRAND TIER 03VITAFOL‐PLUS CAP BRAND TIER 03VITAFOL‐PN TAB BRAND TIER 03 PAVITAJECT INJ BRAND TIER 03VITAL‐D RX TAB BRAND TIER 03VITAMAX PED DRO BRAND TIER 03VITAMEDMD CAP ONE RX BRAND TIER 03VITAMEDMD MIS PLUS RX BRAND TIER 03VITAMN FORTE CAP GENERIC TIER 01VITA‐PREN TAB BRAND TIER 03VITAROCA PLU TAB Brand‐O TIER 03 PAVITASPIRE TAB GENERIC TIER 01VIVA CT CHW 28‐1MG BRAND TIER 03VIVA DHA CAP BRAND TIER 03V‐NATAL TAB 32‐1MG BRAND TIER 03V‐NATAL DHA MIS BRAND TIER 03VOL‐CARE RX TAB GENERIC TIER 01 PAVOL‐NATE TAB BRAND TIER 03 PAVOL‐PLUS TAB BRAND TIER 03 PAVOL‐TAB RX TAB BRAND TIER 03VP‐CH‐PNV CAP BRAND TIER 03VP‐ERA OB PAK PLUS BRAND TIER 03VP‐GGR‐B6 TAB PRENATAL BRAND TIER 03VP‐PNV‐DHA CAP BRAND TIER 03VP‐ZEL TAB GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion187

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusMULTIVITAMIN PREPARATIONS ZATEAN‐CH CAP BRAND TIER 03ZATEAN‐PN CAP DHA BRAND TIER 03ZATEAN‐PN CAP PLUS BRAND TIER 03ZATEAN‐PN TAB BRAND TIER 03ZINGIBER TAB BRAND TIER 03SUPPORT‐500 CAP BRAND TIER 99 DEPROTECT CAP CARDIO BRAND TIER 99 DEOB COMPLETE CAP PETITE BRAND TIER 03VIRT‐SELECT CAP BRAND TIER 03UDAMIN TAB BRAND TIER 99 DEUDAMIN SP TAB BRAND TIER 99 DETL‐FLUORIVIT CHW BRAND TIER 03NATACHEW CHW BRAND TIER 03VITA‐MIN CAP GENERIC TIER 01MYASTHENIA GRAVIS ENLON INJ 150/15ML BRAND TIER 03MYDRIATICS AK‐PENTOLATE SOL 1% OP GENERIC TIER 01ATROPIN‐CARE SOL 1% OP GENERIC TIER 01ATROPINE SUL OIN 1% OP GENERIC TIER 01ATROPINE SUL SOL 1% OP GENERIC TIER 01CYCLOGYL SOL 0.5% OP BRAND TIER 03CYCLOGYL SOL 1% OP Brand‐O TIER 03 PACYCLOGYL SOL 2% OP Brand‐O TIER 03 PACYCLOMYDRIL SOL OP BRAND TIER 03CYCLOPENTOL SOL 1% OP GENERIC TIER 01CYCLOPENTOL SOL 2% OP GENERIC TIER 01CYLATE SOL 1% OP GENERIC TIER 01HOMATROPAIRE SOL 5% OP GENERIC TIER 01HOMATROPINE SOL 5% OP GENERIC TIER 01ISO ATROPINE SOL 1% OP Brand‐O TIER 03 PAISO HOMATROP SOL 2% OP BRAND TIER 03ISO HOMATROP SOL 5% OP Brand‐O TIER 03 PAISO HYOSCINE SOL 0.25% OP BRAND TIER 03MYDRAL SOL 0.5% OP GENERIC TIER 01MYDRAL SOL 1% OP GENERIC TIER 01MYDRIACYL SOL 1% OP Brand‐O TIER 03 PATROPICAMIDE SOL 0.5% OP GENERIC TIER 01TROPICAMIDE SOL 1% OP GENERIC TIER 01NATURAL PENICILLINS BICILLIN C‐R INJ 1200000 BRAND TIER 03BICILLIN C‐R INJ 900/300 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion188

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNATURAL PENICILLINS BICILLIN L‐A INJ 1200000 BRAND TIER 03BICILLIN L‐A INJ 2400000 BRAND TIER 03BICILLIN L‐A INJ 600000 BRAND TIER 03PEN G PROC INJ 600000 GENERIC TIER 01PEN G SOD INJ 5000000 GENERIC TIER 01PENICILL GK/ INJ DEX 1MU GENERIC TIER 01PENICILL GK/ INJ DEX 2MU GENERIC TIER 01PENICILL GK/ INJ DEX 3MU GENERIC TIER 01PENICILLN GK INJ 20MU GENERIC TIER 01PENICILLN GK INJ 5MU GENERIC TIER 01PENICILLN VK SOL 125/5ML GENERIC TIER 01PENICILLN VK SOL 250/5ML GENERIC TIER 01PENICILLN VK TAB 250MG GENERIC TIER 01PENICILLN VK TAB 500MG GENERIC TIER 01PFIZERPEN‐G INJ 20MU Brand‐O TIER 03 PAPFIZERPEN‐G INJ 5MU GENERIC TIER 01NEURAMINIDASE INHIBITORS RELENZA MIS DISKHALE BRAND TIER 02 QLTAMIFLU CAP 30MG BRAND TIER 02 QLTAMIFLU CAP 45MG BRAND TIER 02 QLTAMIFLU CAP 75MG BRAND TIER 02 QLTAMIFLU SUS 12MG/ML BRAND TIER 02 QLTAMIFLU SUS 6MG/ML BRAND TIER 02 QLNEUROMUSCULAR BLOCKING AGENTS ANECTINE INJ 20MG/ML Brand‐O TIER 03 PAATRACURIUM INJ 10MG/ML GENERIC TIER 01CISATRACURIU INJ 10MG/ML GENERIC TIER 01CISATRACURIU INJ 2MG/ML GENERIC TIER 01NIMBEX INJ 10MG/ML Brand‐O TIER 03 PANIMBEX INJ 2MG/ML Brand‐O TIER 03 PAPANCURONIUM INJ 1MG/ML GENERIC TIER 01PANCURONIUM INJ 2MG/ML GENERIC TIER 01QUELICIN INJ ‐1000 BRAND TIER 03QUELICIN INJ 20MG/ML Brand‐O TIER 03 PAROCURONIUM INJ 100MG/10 GENERIC TIER 01ROCURONIUM INJ 10MG/ML GENERIC TIER 01ROCURONIUM INJ 50MG/5ML GENERIC TIER 01TIZANIDINE KIT COMFORT BRAND TIER 03VECURONIUM INJ 10MG GENERIC TIER 01VECURONIUM INJ 20MG GENERIC TIER 01ZEMURON INJ 10MG/ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion189

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNITRATES AND NITRITES AMYL NITRITE INH 0.3ML GENERIC TIER 01BIDIL TAB BRAND TIER 02DILATRATE SR CAP 40MG BRAND TIER 02IMDUR TAB 120MG ER Brand‐O TIER 03 PAIMDUR TAB 30MG ER Brand‐O TIER 03 PAIMDUR TAB 60MG ER Brand‐O TIER 03 PAISOCHRON TAB 40MG CR GENERIC TIER 01ISODITRATE TAB 40MG ER GENERIC TIER 01ISORDIL TAB 40MG BRAND TIER 03ISORDIL TAB 5MG Brand‐O TIER 03 PAISOSORB DIN SUB 2.5MG GENERIC TIER 01ISOSORB DIN SUB 5MG GENERIC TIER 01ISOSORB DIN TAB 10MG GENERIC TIER 01ISOSORB DIN TAB 20MG GENERIC TIER 01ISOSORB DIN TAB 30MG GENERIC TIER 01ISOSORB DIN TAB 40MG ER GENERIC TIER 01ISOSORB DIN TAB 5MG GENERIC TIER 01ISOSORB MONO TAB 10MG GENERIC TIER 01ISOSORB MONO TAB 120MG ER GENERIC TIER 01ISOSORB MONO TAB 20MG GENERIC TIER 01ISOSORB MONO TAB 30MG ER GENERIC TIER 01ISOSORB MONO TAB 60MG ER GENERIC TIER 01MINITRAN DIS 0.1MG/HR GENERIC TIER 01MINITRAN DIS 0.2MG/HR GENERIC TIER 01MINITRAN DIS 0.4MG/HR GENERIC TIER 01MINITRAN DIS 0.6MG/HR GENERIC TIER 01MONOKET TAB 10MG Brand‐O TIER 03 PAMONOKET TAB 20MG Brand‐O TIER 03 PANITRO‐BID OIN 2% BRAND TIER 02NITRO‐DUR DIS 0.1MG/HR Brand‐O TIER 02 PANITRO‐DUR DIS 0.2MG/HR Brand‐O TIER 02 PANITRO‐DUR DIS 0.3MG/HR BRAND TIER 02NITRO‐DUR DIS 0.4MG/HR Brand‐O TIER 02 PANITRO‐DUR DIS 0.6MG/HR Brand‐O TIER 02 PANITRO‐DUR DIS 0.8MG/HR BRAND TIER 02NITROGLY/D5W INJ GENERIC TIER 01NITROGLY/D5W INJ 100MG GENERIC TIER 01NITROGLY/D5W INJ 200MG GENERIC TIER 01NITROGLY/D5W INJ 25MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion190

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNITRATES AND NITRITES NITROGLY/D5W INJ 50MG GENERIC TIER 01NITROGLYCER CAP 2.5MG ER GENERIC TIER 99 DENITROGLYCER CAP 6.5MG ER GENERIC TIER 99 DENITROGLYCER CAP 9MG ER GENERIC TIER 99 DENITROGLYCER DIS 0.1MG/HR GENERIC TIER 01NITROGLYCER DIS 0.2MG/HR GENERIC TIER 01NITROGLYCER DIS 0.4MG/HR GENERIC TIER 01NITROGLYCER DIS 0.6MG/HR GENERIC TIER 01NITROGLYCER INJ 5MG/ML GENERIC TIER 01NITROGLYCERI DIS 0.6MG/HR GENERIC TIER 01NITROGLYCRN SPR LINGUAL GENERIC TIER 01NITROLINGUAL SPR PUMPSPRA BRAND TIER 02NITROMIST AER 400MCG BRAND TIER 03NITROSTAT SUB 0.3MG BRAND TIER 02NITROSTAT SUB 0.4MG BRAND TIER 02NITROSTAT SUB 0.6MG BRAND TIER 02NITRO‐TIME CAP 2.5MG CR GENERIC TIER 99 DENITRO‐TIME CAP 6.5MG CR GENERIC TIER 99 DENITRO‐TIME CAP 9MG CR GENERIC TIER 99 DENONERGOT‐DERIV.DOPAMINE RECEPTOR AGONIST APOKYN INJ BRAND TIER 02APOKYN INJ 10MG/ML BRAND TIER 02MIRAPEX TAB 0.125MG Brand‐O TIER 03 PAMIRAPEX TAB 0.25MG Brand‐O TIER 03 PAMIRAPEX TAB 0.5MG Brand‐O TIER 03 PAMIRAPEX TAB 0.75MG Brand‐O TIER 03 PAMIRAPEX TAB 1.5MG Brand‐O TIER 03 PAMIRAPEX TAB 1MG Brand‐O TIER 03 PAMIRAPEX ER TAB 0.375MG BRAND TIER 02 PA QLMIRAPEX ER TAB 0.75MG BRAND TIER 02 PA QLMIRAPEX ER TAB 1.5MG BRAND TIER 02 PA QLMIRAPEX ER TAB 2.25MG BRAND TIER 02 PA QLMIRAPEX ER TAB 3.75MG BRAND TIER 02 PA QLMIRAPEX ER TAB 3MG BRAND TIER 02 PA QLMIRAPEX ER TAB 4.5MG BRAND TIER 02 PA QLNEUPRO DIS 1MG/24HR BRAND TIER 03NEUPRO DIS 2MG/24HR BRAND TIER 03NEUPRO DIS 3MG/24HR BRAND TIER 03NEUPRO DIS 4MG/24HR BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion191

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNONERGOT‐DERIV.DOPAMINE RECEPTOR AGONIST NEUPRO DIS 6MG/24HR BRAND TIER 03NEUPRO DIS 8MG/24HR BRAND TIER 03PRAMIPEXOLE TAB 0.125MG GENERIC TIER 01PRAMIPEXOLE TAB 0.25MG GENERIC TIER 01PRAMIPEXOLE TAB 0.5MG GENERIC TIER 01PRAMIPEXOLE TAB 0.75MG GENERIC TIER 01PRAMIPEXOLE TAB 1.5MG GENERIC TIER 01PRAMIPEXOLE TAB 1MG GENERIC TIER 01REQUIP TAB 0.25MG Brand‐O TIER 03 PAREQUIP TAB 0.5MG Brand‐O TIER 03 PAREQUIP TAB 1MG Brand‐O TIER 03 PAREQUIP TAB 2MG Brand‐O TIER 03 PAREQUIP TAB 3MG Brand‐O TIER 03 PAREQUIP TAB 4MG Brand‐O TIER 03 PAREQUIP TAB 5MG Brand‐O TIER 03 PAREQUIP XL TAB 12MG Brand‐O TIER 03 PA QLREQUIP XL TAB 2MG Brand‐O TIER 03 PA QLREQUIP XL TAB 4MG Brand‐O TIER 03 PA QLREQUIP XL TAB 6MG Brand‐O TIER 03 PA QLREQUIP XL TAB 8MG Brand‐O TIER 03 PA QLROPINIROLE TAB 0.25MG GENERIC TIER 01ROPINIROLE TAB 0.5MG GENERIC TIER 01ROPINIROLE TAB 12MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 1MG GENERIC TIER 01ROPINIROLE TAB 2MG GENERIC TIER 01ROPINIROLE TAB 2MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 3MG GENERIC TIER 01ROPINIROLE TAB 4MG GENERIC TIER 01ROPINIROLE TAB 4MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 5MG GENERIC TIER 01ROPINIROLE TAB 6MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 8MG ER GENERIC TIER 01 PA QLNONNUCLEOSIDE REV.TRANSCRIPTASE INHIB. COMPLERA TAB BRAND TIER 02EDURANT TAB 25MG BRAND TIER 02INTELENCE TAB 100MG BRAND TIER 02INTELENCE TAB 200MG BRAND TIER 02INTELENCE TAB 25MG BRAND TIER 02NEVIRAPINE SUS 50MG/5ML GENERIC TIER 01NEVIRAPINE TAB 200MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion192

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNONNUCLEOSIDE REV.TRANSCRIPTASE INHIB. RESCRIPTOR TAB 100 MG BRAND TIER 02RESCRIPTOR TAB 200MG BRAND TIER 02SUSTIVA CAP 200MG BRAND TIER 02SUSTIVA CAP 50MG BRAND TIER 02SUSTIVA TAB 600MG BRAND TIER 02VIRAMUNE SUS 50MG/5ML BRAND TIER 03VIRAMUNE TAB 200MG Brand‐O TIER 03 PAVIRAMUNE XR TAB BRAND TIER 03NON‐SEL.ALPHA‐ADRENERGIC BLOCKING AGENTS D.H.E. 45 INJ 1MG/ML Brand‐O TIER 03 PADIBENZYLINE CAP 10MG BRAND TIER 02DIHYDROERGOT CRY MESYLATE GENERIC TIER 99 DEDIHYDROERGOT INJ 1MG/ML GENERIC TIER 01ERGOLOID MES TAB 1MG ORAL GENERIC TIER 01ERGOMAR SUB 2MG BRAND TIER 02MIGRANAL SPR 4MG/ML BRAND TIER 03 QLPHENTOL MESY INJ 5MG GENERIC TIER 01PHENTOLAMINE INJ MESYLATE GENERIC TIER 01NON‐SELECTIVE BETA‐ADRENERGIC AGONISTS ISUPREL INJ 0.2MG/ML BRAND TIER 03NUCLEOSIDE,NUCLEOTIDE REV.TRNSCRIP.INHIB ABACAVIR TAB 300MG GENERIC TIER 01COMBIVIR TAB 150‐300 Brand‐O TIER 03 PADIDANOSINE CAP 125MG GENERIC TIER 01DIDANOSINE CAP 200MG GENERIC TIER 01DIDANOSINE CAP 250MG GENERIC TIER 01DIDANOSINE CAP 400MG GENERIC TIER 01EMTRIVA CAP 200MG BRAND TIER 02EMTRIVA SOL 10MG/ML BRAND TIER 02EPIVIR SOL 10MG/ML BRAND TIER 02EPIVIR TAB 150MG Brand‐O TIER 03 PAEPIVIR TAB 300MG Brand‐O TIER 03 PAEPIVIR HBV SOL 5MG/ML BRAND TIER 02EPIVIR HBV TAB 100MG BRAND TIER 02EPZICOM TAB BRAND TIER 02LAMIVUD/ZIDO TAB 150‐300 GENERIC TIER 01LAMIVUDINE TAB 150MG GENERIC TIER 01LAMIVUDINE TAB 300MG GENERIC TIER 01RETROVIR CAP 100MG Brand‐O TIER 03 PARETROVIR INJ 10MG/ML BRAND TIER 03RETROVIR SYP 50MG/5ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion193

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNUCLEOSIDE,NUCLEOTIDE REV.TRNSCRIP.INHIB RETROVIR TAB 300MG Brand‐O TIER 03 PASTAVUDINE CAP 15MG GENERIC TIER 01STAVUDINE CAP 20MG GENERIC TIER 01STAVUDINE CAP 30MG GENERIC TIER 01STAVUDINE CAP 40MG GENERIC TIER 01STAVUDINE SOL 1MG/ML GENERIC TIER 01TRIZIVIR TAB BRAND TIER 02TRUVADA TAB BRAND TIER 02VIDEX SOL 2GM BRAND TIER 02VIDEX SOL 4GM BRAND TIER 02VIDEX EC CAP 125MG Brand‐O TIER 03 PAVIDEX EC CAP 200MG Brand‐O TIER 03 PAVIDEX EC CAP 250MG Brand‐O TIER 03 PAVIDEX EC CAP 400MG Brand‐O TIER 03 PAVIREAD POW 40MG/GM BRAND TIER 02VIREAD TAB 150MG BRAND TIER 02VIREAD TAB 200MG BRAND TIER 02VIREAD TAB 250MG BRAND TIER 02VIREAD TAB 300MG BRAND TIER 02ZERIT CAP 15MG Brand‐O TIER 03 PAZERIT CAP 20MG Brand‐O TIER 03 PAZERIT CAP 30MG Brand‐O TIER 03 PAZERIT CAP 40MG Brand‐O TIER 03 PAZERIT SOL 1MG/ML Brand‐O TIER 02 PAZIAGEN SOL 20MG/ML BRAND TIER 02ZIAGEN TAB 300MG Brand‐O TIER 03 PAZIDOVUDINE CAP 100MG GENERIC TIER 01ZIDOVUDINE SYP 50MG/5ML GENERIC TIER 01ZIDOVUDINE TAB 300MG GENERIC TIER 01NUCLEOSIDES AND NUCLEOTIDES ACYCLOVIR CAP 200MG GENERIC TIER 01ACYCLOVIR SUS 200/5ML GENERIC TIER 01ACYCLOVIR TAB 400MG GENERIC TIER 01ACYCLOVIR TAB 800MG GENERIC TIER 01ACYCLOVIR NA INJ 1000MG GENERIC TIER 01ACYCLOVIR NA INJ 500MG GENERIC TIER 01ACYCLOVIR NA INJ 50MG/ML GENERIC TIER 01BARACLUDE SOL .05MG/ML BRAND TIER 02BARACLUDE TAB 0.5MG BRAND TIER 02BARACLUDE TAB 1MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion194

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNUCLEOSIDES AND NUCLEOTIDES COPEGUS TAB 200MG Brand‐O TIER 03 PA SPCYTOVENE INJ 500MG Brand‐O TIER 03 PAFAMCICLOVIR TAB 125MG GENERIC TIER 01FAMCICLOVIR TAB 250MG GENERIC TIER 01FAMCICLOVIR TAB 500MG GENERIC TIER 01FAMVIR TAB 125MG Brand‐O TIER 03 PAFAMVIR TAB 250MG Brand‐O TIER 03 PAFAMVIR TAB 500MG Brand‐O TIER 03 PAGANCICLOVIR INJ 500MG GENERIC TIER 01HEPSERA TAB 10MG BRAND TIER 02REBETOL CAP 200MG Brand‐O TIER 03 PA SPREBETOL SOL 40MG/ML BRAND TIER 03 SPRIBAPAK MIS 600/DAY BRAND TIER 02 PA SPRIBAPAK PAK 1000/DAY BRAND TIER 03 PA SPRIBAPAK PAK 1200/DAY GENERIC TIER 01 PA SPRIBAPAK PAK 800/DAY GENERIC TIER 01 PA SPRIBASPHERE CAP 200MG GENERIC TIER 01 SPRIBASPHERE TAB 200MG GENERIC TIER 01 SPRIBASPHERE TAB 400MG GENERIC TIER 01 PA SPRIBASPHERE TAB 600MG GENERIC TIER 01 PA SPRIBATAB PAK 1000/DAY GENERIC TIER 01 PA SPRIBATAB TAB 1200/DAY GENERIC TIER 01 PA SPRIBATAB TAB 800/DAY GENERIC TIER 01 PA SPRIBAVIRIN CAP 200MG GENERIC TIER 01 SPRIBAVIRIN TAB 200MG GENERIC TIER 01 SPTYZEKA TAB 600MG BRAND TIER 03VALACYCLOVIR TAB 1GM GENERIC TIER 01VALACYCLOVIR TAB 500MG GENERIC TIER 01VALCYTE SOL 50MG/ML BRAND TIER 03VALCYTE TAB 450MG BRAND TIER 02VALTREX TAB 1GM Brand‐O TIER 03 PAVALTREX TAB 500MG Brand‐O TIER 03 PAVIRAZOLE INH 6GM BRAND TIER 03VISTIDE INJ 75MG/ML BRAND TIER 03ZOVIRAX CAP 200MG Brand‐O TIER 03 PAZOVIRAX SUS 200/5ML Brand‐O TIER 03 PAZOVIRAX TAB 400MG Brand‐O TIER 03 PAZOVIRAX TAB 800MG Brand‐O TIER 03 PAOCULAR DISORDERS AK‐FLUOR INJ 10% OP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion195

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOCULAR DISORDERS ALTAFLUOR SOL 0.25‐0.4 GENERIC TIER 01BIO GLO TES 1MG OP GENERIC TIER 01FLUCAINE SOL 0.25‐0.5 GENERIC TIER 01FLUORACAINE SOL OP Brand‐O TIER 03 PAFLUORE‐BENOX SOL 0.25‐0.4 GENERIC TIER 01FLUORESCEIN INJ 10% OP GENERIC TIER 01FLUORESCEIN INJ 25% OP GENERIC TIER 01FLUORESCEIN/ SOL PROPARAC GENERIC TIER 01FLUORESCITE INJ 10% OP Brand‐O TIER 03 PAFLUORETS TES 1MG OP GENERIC TIER 01FLUOR‐I‐STRI TES 1MG OP GENERIC TIER 01FLURA‐SAFE SOL BRAND TIER 99 DEFLURESS SOL OP Brand‐O TIER 03 PAFLUROX SOL OP GENERIC TIER 01FUL‐GLO TES 0.6MG OP BRAND TIER 03FUL‐GLO TES 1MG OP GENERIC TIER 01LISSAMINE GR TES 1.5MG GENERIC TIER 01MEMBRANEBLUE SOL 0.15% BRAND TIER 99 DEPAREMYD SOL 1‐0.25% BRAND TIER 03PROP‐FLUORE SOL 0.5‐0.25 GENERIC TIER 01ROSE GLO TES 1.5MG BRAND TIER 03VISIONBLUE SOL 0.06% BRAND TIER 99 DEOPIATE AGONISTS ABSTRAL SUB 100MCG BRAND TIER 03 PAABSTRAL SUB 200MCG BRAND TIER 03 PAABSTRAL SUB 300MCG BRAND TIER 03 PAABSTRAL SUB 400MCG BRAND TIER 03 PAABSTRAL SUB 600MCG BRAND TIER 03 PAABSTRAL SUB 800MCG BRAND TIER 03 PAACTIQ LOZ 1200MCG Brand‐O TIER 03 PA QLACTIQ LOZ 1600MCG Brand‐O TIER 03 PA QLACTIQ LOZ 200MCG Brand‐O TIER 03 PA QLACTIQ LOZ 400MCG Brand‐O TIER 03 PA QLACTIQ LOZ 600MCG Brand‐O TIER 03 PA QLACTIQ LOZ 800MCG Brand‐O TIER 03 PA QLALFENTA INJ 500/ML Brand‐O TIER 03 PAALFENTANIL INJ 500/ML GENERIC TIER 01APAP/CAFF/DI TAB HYDROCOD GENERIC TIER 01APAP/CODEINE SOL 120‐12/5 GENERIC TIER 01APAP/CODEINE TAB 300‐15MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion196

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS APAP/CODEINE TAB 300‐30MG GENERIC TIER 01APAP/CODEINE TAB 300‐60MG GENERIC TIER 01ASCOMP/COD CAP 30MG GENERIC TIER 01ASTRAMORPH INJ 10/10ML GENERIC TIER 01ASTRAMORPH INJ 1MG/2ML GENERIC TIER 01ASTRAMORPH INJ 2MG/2ML GENERIC TIER 01AVINZA CAP 120MG BRAND TIER 02 PA QLAVINZA CAP 30MG BRAND TIER 02 PA QLAVINZA CAP 45MG BRAND TIER 02 PA QLAVINZA CAP 60MG BRAND TIER 02 PA QLAVINZA CAP 75MG BRAND TIER 02 PA QLAVINZA CAP 90MG BRAND TIER 02 PA QLBUT/APAP/CAF CAP CODEINE GENERIC TIER 01BUT/ASA/CAF/ CAP COD 30MG GENERIC TIER 01CAPITAL/COD SUS 120‐12/5 BRAND TIER 03COCET TAB 650‐30MG BRAND TIER 03COCET PLUS TAB 650‐60MG BRAND TIER 03CODEINE PHOS INJ 30MG/2ML GENERIC TIER 01CODEINE PHOS INJ 60MG/2ML GENERIC TIER 01CODEINE SULF SOL 30MG/5ML GENERIC TIER 01CODEINE SULF TAB 15MG GENERIC TIER 01CODEINE SULF TAB 30MG GENERIC TIER 01CODEINE SULF TAB 60MG GENERIC TIER 01CO‐GESIC TAB 5‐500MG GENERIC TIER 01CONZIP CAP 100MG BRAND TIER 03CONZIP CAP 200MG BRAND TIER 03CONZIP CAP 300MG BRAND TIER 03DEMEROL INJ 100/2ML BRAND TIER 03DEMEROL INJ 100MG/ML Brand‐O TIER 03 PADEMEROL INJ 25MG/0.5 BRAND TIER 03DEMEROL INJ 25MG/ML Brand‐O TIER 03 PADEMEROL INJ 50MG/ML Brand‐O TIER 03 PADEMEROL INJ 75MG/1.5 BRAND TIER 03DEMEROL INJ 75MG/ML BRAND TIER 03DEMEROL TAB 100MG Brand‐O TIER 03 PADEMEROL TAB 50MG Brand‐O TIER 03 PADEPODUR INJ 10MG/ML BRAND TIER 03DEPODUR INJ 15/1.5ML BRAND TIER 03DILAUDID INJ 1MG/ML Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion197

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS DILAUDID INJ 2MG/ML Brand‐O TIER 03 PADILAUDID INJ 4MG/ML Brand‐O TIER 03 PADILAUDID TAB 2MG Brand‐O TIER 03 PADILAUDID TAB 4MG Brand‐O TIER 03 PADILAUDID TAB 8MG Brand‐O TIER 03 PADILAUDID‐5 LIQ 1MG/ML Brand‐O TIER 03 PADILAUDID‐HP INJ 10MG/ML Brand‐O TIER 03 PADILAUDID‐HP INJ 250MG BRAND TIER 03DOLOPHINE TAB 10MG Brand‐O TIER 03 PADOLOPHINE TAB 5MG Brand‐O TIER 03 PADURAGESIC DIS 100MCG/H Brand‐O TIER 03 PA QLDURAGESIC DIS 12MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 25MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 50MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 75MCG/HR Brand‐O TIER 03 PA QLDURAMORPH INJ 0.5MG/ML GENERIC TIER 01DURAMORPH INJ 1MG/ML GENERIC TIER 01ENDOCET TAB 10‐325MG GENERIC TIER 01 QLENDOCET TAB 10‐650MG GENERIC TIER 01 QLENDOCET TAB 5‐325MG GENERIC TIER 01 QLENDOCET TAB 7.5‐325M GENERIC TIER 01 QLENDOCET TAB 7.5‐500M GENERIC TIER 01 QLENDODAN TAB GENERIC TIER 01 QLEXALGO TAB 12MG BRAND TIER 03 PA QLEXALGO TAB 16MG BRAND TIER 03 PA QLEXALGO TAB 32MG BRAND TIER 03 PAEXALGO TAB 8MG BRAND TIER 03 PA QLFENTANYL DIS 100MCG/H GENERIC TIER 01 QLFENTANYL DIS 12MCG/HR GENERIC TIER 01 QLFENTANYL DIS 25MCG/HR GENERIC TIER 01 QLFENTANYL DIS 50MCG/HR GENERIC TIER 01 QLFENTANYL DIS 75MCG/HR GENERIC TIER 01 QLFENTANYL CIT INJ 0.05MG/1 GENERIC TIER 01 PAFENTANYL CIT INJ 1000MCG GENERIC TIER 01 PAFENTANYL CIT INJ 100MCG GENERIC TIER 01 PAFENTANYL CIT INJ 2500MCG GENERIC TIER 01 PAFENTANYL CIT INJ 250MCG GENERIC TIER 01 PAFENTANYL OT LOZ 1200MCG GENERIC TIER 01 PA QLFENTANYL OT LOZ 1600MCG GENERIC TIER 01 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion198

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS FENTANYL OT LOZ 200MCG GENERIC TIER 01 PA QLFENTANYL OT LOZ 400MCG GENERIC TIER 01 PA QLFENTANYL OT LOZ 600MCG GENERIC TIER 01 PA QLFENTANYL OT LOZ 800MCG GENERIC TIER 01 PA QLFENTORA TAB 100MCG BRAND TIER 02 PA QLFENTORA TAB 200MCG BRAND TIER 02 PA QLFENTORA TAB 400MCG BRAND TIER 02 PA QLFENTORA TAB 600MCG BRAND TIER 02 PA QLFENTORA TAB 800MCG BRAND TIER 02 PA QLFIORICET/COD CAP Brand‐O TIER 03 PAFIORINAL/COD CAP 30MG Brand‐O TIER 03 PAHYCET SOL 7.5‐325 Brand‐O TIER 03 PAHYDROCO/APAP SOL 10‐325MG GENERIC TIER 01HYDROCO/APAP SOL 7.5‐325 GENERIC TIER 01HYDROCO/APAP SOL 7.5‐500 GENERIC TIER 01HYDROCO/APAP TAB 10‐300MG GENERIC TIER 01HYDROCO/APAP TAB 10‐325MG GENERIC TIER 01HYDROCO/APAP TAB 10‐500MG GENERIC TIER 01HYDROCO/APAP TAB 10‐650MG GENERIC TIER 01HYDROCO/APAP TAB 10‐660MG GENERIC TIER 01HYDROCO/APAP TAB 10‐750MG GENERIC TIER 01HYDROCO/APAP TAB 2.5‐325 GENERIC TIER 01HYDROCO/APAP TAB 2.5‐500 GENERIC TIER 01HYDROCO/APAP TAB 5‐300MG GENERIC TIER 01HYDROCO/APAP TAB 5‐325MG GENERIC TIER 01HYDROCO/APAP TAB 5‐500MG GENERIC TIER 01HYDROCO/APAP TAB 7.5‐300 GENERIC TIER 01HYDROCO/APAP TAB 7.5‐325 GENERIC TIER 01HYDROCO/APAP TAB 7.5‐500 GENERIC TIER 01HYDROCO/APAP TAB 7.5‐650 GENERIC TIER 01HYDROCO/APAP TAB 7.5‐750 GENERIC TIER 01HYDROCOD/IBU TAB 10‐200MG GENERIC TIER 01HYDROCOD/IBU TAB 2.5‐200 GENERIC TIER 01HYDROCOD/IBU TAB 5‐200MG GENERIC TIER 01HYDROCOD/IBU TAB 7.5‐200 GENERIC TIER 01HYDROCODONE CRY BITARTRA GENERIC TIER 99 DEHYDROGESIC CAP 5‐500MG GENERIC TIER 01HYDROMORPHON INJ 10MG/ML GENERIC TIER 01HYDROMORPHON INJ 1MG/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion199

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS HYDROMORPHON INJ 2MG/ML GENERIC TIER 01HYDROMORPHON INJ 4MG/ML GENERIC TIER 01HYDROMORPHON INJ 500/50ML GENERIC TIER 01HYDROMORPHON INJ 50MG/5ML GENERIC TIER 01HYDROMORPHON LIQ 1MG/ML GENERIC TIER 01HYDROMORPHON SUP 3MG GENERIC TIER 01HYDROMORPHON TAB 2MG GENERIC TIER 01HYDROMORPHON TAB 4MG GENERIC TIER 01HYDROMORPHON TAB 8MG GENERIC TIER 01IBUDONE TAB 10‐200MG Brand‐O TIER 03 PAIBUDONE TAB 5‐200MG GENERIC TIER 01INFUMORPH INJ 10MG/ML BRAND TIER 03INFUMORPH INJ 10MG/ML GENERIC TIER 01INFUMORPH INJ 25MG/ML BRAND TIER 03INFUMORPH INJ 25MG/ML GENERIC TIER 01KADIAN CAP 100MG CR Brand‐O TIER 03 PA QLKADIAN CAP 10MG CR BRAND TIER 03 PA QLKADIAN CAP 130MG CR BRAND TIER 03 PAKADIAN CAP 150MG CR BRAND TIER 03 PAKADIAN CAP 200MG CR BRAND TIER 03 PA QLKADIAN CAP 20MG CR Brand‐O TIER 03 PA QLKADIAN CAP 30MG CR Brand‐O TIER 03 PA QLKADIAN CAP 40MG CR BRAND TIER 03 PAKADIAN CAP 50MG CR Brand‐O TIER 03 PA QLKADIAN CAP 60MG CR Brand‐O TIER 03 PA QLKADIAN CAP 70MG CR BRAND TIER 03 PAKADIAN CAP 80MG CR Brand‐O TIER 03 PA QLLAZANDA SPR 100MCG BRAND TIER 03 PALAZANDA SPR 400MCG BRAND TIER 03 PALEVORPHANOL TAB 2MG GENERIC TIER 01LIQUICET SOL 10‐500MG BRAND TIER 03LORCET TAB 10‐650MG Brand‐O TIER 03 PALORCET PLUS TAB 7.5‐650 Brand‐O TIER 03 PALORTAB ELX 7.5‐500 Brand‐O TIER 03 PALORTAB TAB 10‐500MG Brand‐O TIER 03 PALORTAB TAB 5‐500MG Brand‐O TIER 03 PALORTAB TAB 7.5‐500 Brand‐O TIER 03 PAMAGNACET TAB 10‐400MG BRAND TIER 03 QLMAGNACET TAB 5‐400MG BRAND TIER 03 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion200

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS MAGNACET TAB 7.5‐400 BRAND TIER 03 QLMAXIDONE TAB 10‐750MG Brand‐O TIER 03 PAMEPERIDINE INJ 100MG/ML GENERIC TIER 01MEPERIDINE INJ 10MG/ML GENERIC TIER 01MEPERIDINE INJ 25MG/ML GENERIC TIER 01MEPERIDINE INJ 50MG/ML GENERIC TIER 01MEPERIDINE SOL 50MG/5ML GENERIC TIER 01MEPERIDINE TAB 100MG GENERIC TIER 01MEPERIDINE TAB 50MG GENERIC TIER 01MEPERITAB TAB 100MG GENERIC TIER 01MEPERITAB TAB 50MG GENERIC TIER 01METHADONE CON 10MG/ML Brand‐O TIER 03 PAMETHADONE CON 10MG/ML GENERIC TIER 01METHADONE INJ 10MG/ML GENERIC TIER 01METHADONE SOL 10MG/5ML GENERIC TIER 01METHADONE SOL 5MG/5ML GENERIC TIER 01METHADONE TAB 10MG GENERIC TIER 01METHADONE TAB 40MG GENERIC TIER 01METHADONE TAB 5MG GENERIC TIER 01METHADOSE CON 10MG/ML GENERIC TIER 01METHADOSE TAB 10MG GENERIC TIER 01METHADOSE TAB 40MG GENERIC TIER 01METHADOSE SF CON 10MG/ML GENERIC TIER 01MORPHINE SUL CAP 100MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 20MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 30MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 50MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 60MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 80MG ER GENERIC TIER 01 PA QLMORPHINE SUL INJ 0.5MG/ML GENERIC TIER 01MORPHINE SUL INJ 10/0.7ML GENERIC TIER 01MORPHINE SUL INJ 10MG/ML GENERIC TIER 01MORPHINE SUL INJ 150/30ML GENERIC TIER 01MORPHINE SUL INJ 15MG/ML GENERIC TIER 01MORPHINE SUL INJ 1MG/ML GENERIC TIER 01MORPHINE SUL INJ 25MG/ML GENERIC TIER 01MORPHINE SUL INJ 2MG/ML GENERIC TIER 01MORPHINE SUL INJ 4MG/ML GENERIC TIER 01MORPHINE SUL INJ 50MG/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion201

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS MORPHINE SUL INJ 5MG/ML GENERIC TIER 01MORPHINE SUL INJ 8MG/ML GENERIC TIER 01MORPHINE SUL SOL 100/5ML GENERIC TIER 01MORPHINE SUL SOL 10MG/5ML GENERIC TIER 01MORPHINE SUL SOL 20MG/5ML GENERIC TIER 01MORPHINE SUL SOL 20MG/ML GENERIC TIER 01MORPHINE SUL SUP 10MG GENERIC TIER 01MORPHINE SUL SUP 20MG GENERIC TIER 01MORPHINE SUL SUP 30MG GENERIC TIER 01MORPHINE SUL SUP 5MG GENERIC TIER 01MORPHINE SUL TAB 100MG ER GENERIC TIER 01MORPHINE SUL TAB 15MG GENERIC TIER 01MORPHINE SUL TAB 15MG ER GENERIC TIER 01MORPHINE SUL TAB 200MG ER GENERIC TIER 01MORPHINE SUL TAB 30MG GENERIC TIER 01MORPHINE SUL TAB 30MG ER GENERIC TIER 01MORPHINE SUL TAB 60MG ER GENERIC TIER 01MORPHINE/D5W INJ 1MG/ML GENERIC TIER 01MS CONTIN TAB 100MG CR Brand‐O TIER 03 PAMS CONTIN TAB 15MG CR Brand‐O TIER 03 PAMS CONTIN TAB 200MG CR Brand‐O TIER 03 PAMS CONTIN TAB 30MG CR Brand‐O TIER 03 PAMS CONTIN TAB 60MG CR Brand‐O TIER 03 PANORCO TAB 10‐325MG Brand‐O TIER 03 PANORCO TAB 5‐325MG Brand‐O TIER 03 PANORCO TAB 7.5‐325 Brand‐O TIER 03 PANUCYNTA TAB 100MG BRAND TIER 02 PA QLNUCYNTA TAB 50MG BRAND TIER 02 PA QLNUCYNTA TAB 75MG BRAND TIER 02 PA QLNUCYNTA ER TAB 100MG BRAND TIER 02NUCYNTA ER TAB 150MG BRAND TIER 02NUCYNTA ER TAB 200MG BRAND TIER 02NUCYNTA ER TAB 250MG BRAND TIER 02NUCYNTA ER TAB 50MG BRAND TIER 02ONSOLIS MIS 1200MCG BRAND TIER 03 PA QLONSOLIS MIS 200MCG BRAND TIER 03 PA QLONSOLIS MIS 400MCG BRAND TIER 03 PAONSOLIS MIS 600MCG BRAND TIER 03 PAONSOLIS MIS 800MCG BRAND TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion202

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS OPANA TAB 10MG Brand‐O TIER 03 PAOPANA TAB 5MG Brand‐O TIER 03 PAOPANA ER TAB 10MG BRAND TIER 03 PAOPANA ER TAB 10MG QLOPANA ER TAB 20MG BRAND TIER 03 PAOPANA ER TAB 20MG QLOPANA ER TAB 30MG BRAND TIER 03 PAOPANA ER TAB 30MG QLOPANA ER TAB 40MG BRAND TIER 03 PAOPANA ER TAB 40MG QLOPANA ER TAB 5MG BRAND TIER 03 PAOPANA ER TAB 5MG QLORAMORPH SR TAB 100MG BRAND TIER 03ORAMORPH SR TAB 15MG BRAND TIER 03ORAMORPH SR TAB 30MG BRAND TIER 03ORAMORPH SR TAB 60MG BRAND TIER 03OXECTA TAB 5MG BRAND TIER 03OXECTA TAB 7.5MG BRAND TIER 03OXYCOD/APAP CAP 5‐500MG GENERIC TIER 01 QLOXYCOD/APAP TAB 10‐325MG GENERIC TIER 01 QLOXYCOD/APAP TAB 10‐650MG GENERIC TIER 01 QLOXYCOD/APAP TAB 2.5‐325 GENERIC TIER 01 QLOXYCOD/APAP TAB 5‐325MG GENERIC TIER 01 QLOXYCOD/APAP TAB 7.5‐325 GENERIC TIER 01 QLOXYCOD/APAP TAB 7.5‐500 GENERIC TIER 01 QLOXYCOD/ASA TAB GENERIC TIER 01 QLOXYCOD/IBU TAB 5‐400MG GENERIC TIER 01 QLOXYCODONE CAP 5MG GENERIC TIER 01OXYCODONE CON 20MG/ML GENERIC TIER 01OXYCODONE SOL 5MG/5ML GENERIC TIER 01OXYCODONE TAB 10MG GENERIC TIER 01OXYCODONE TAB 15MG GENERIC TIER 01OXYCODONE TAB 20MG GENERIC TIER 01OXYCODONE TAB 30MG GENERIC TIER 01OXYCODONE TAB 5MG GENERIC TIER 01OXYCONTIN TAB 10MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 15MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 20MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 30MG CR BRAND TIER 02 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion203

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS OXYCONTIN TAB 40MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 60MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 80MG CR BRAND TIER 02 PA QLOXYMORPHONE TAB 15MG ER GENERIC TIER 01 PA QLOXYMORPHONE TAB 7.5MG ER GENERIC TIER 01 PA QLOXYMORPHONE TAB HCL 10MG GENERIC TIER 01 PAOXYMORPHONE TAB HCL 5MG GENERIC TIER 01 PAPERCOCET TAB 10‐325MG Brand‐O TIER 03 PA QLPERCOCET TAB 10‐650MG Brand‐O TIER 03 PA QLPERCOCET TAB 2.5‐325 Brand‐O TIER 03 PA QLPERCOCET TAB 5‐325MG Brand‐O TIER 03 PA QLPERCOCET TAB 7.5‐325M Brand‐O TIER 03 PA QLPERCOCET TAB 7.5‐500 Brand‐O TIER 03 PA QLPERCODAN TAB Brand‐O TIER 03 PA QLPRIMLEV TAB 10‐300MG BRAND TIER 03 QLPRIMLEV TAB 5‐300MG BRAND TIER 03 QLPRIMLEV TAB 7.5‐300 BRAND TIER 03 QLREPREXAIN TAB 10‐200MG GENERIC TIER 01REPREXAIN TAB 2.5‐200 BRAND TIER 03REPREXAIN TAB 5‐200MG Brand‐O TIER 03 PAROXICET SOL 5‐325/5 BRAND TIER 03ROXICET TAB 5‐325MG GENERIC TIER 01 QLROXICET TAB 5‐500MG BRAND TIER 03 QLROXICODONE TAB 15MG Brand‐O TIER 03 PAROXICODONE TAB 30MG Brand‐O TIER 03 PAROXICODONE TAB 5MG Brand‐O TIER 03 PARYBIX ODT TAB 50MG BRAND TIER 03 PARYZOLT TAB 100MG Brand‐O TIER 03 PARYZOLT TAB 200MG Brand‐O TIER 03 PARYZOLT TAB 300MG Brand‐O TIER 03 PASTAGESIC CAP 5‐500MG GENERIC TIER 01SUBLIMAZE INJ 0.05MG/1 Brand‐O TIER 03 PASUBSYS SPR 100MCG BRAND TIER 03SUBSYS SPR 1200MCG BRAND TIER 03SUBSYS SPR 1600MCG BRAND TIER 03SUBSYS SPR 200MCG BRAND TIER 03SUBSYS SPR 400MCG BRAND TIER 03SUBSYS SPR 600MCG BRAND TIER 03SUBSYS SPR 800MCG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion204

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS SUFENTA INJ 50MCG/ML Brand‐O TIER 03 PASUFENTANIL INJ 100/2ML GENERIC TIER 01SUFENTANIL INJ 250/5ML GENERIC TIER 01SUFENTANIL INJ 50MCG/ML GENERIC TIER 01SYNALGOS‐DC CAP BRAND TIER 03THERACODEINE PAK ‐300 BRAND TIER 03THERACODOPHE PAK ‐750 BRAND TIER 03THERACODOPHN PAK ‐325 BRAND TIER 03THERACODOPHN PAK ‐650 BRAND TIER 03THERACODOPHN PAK ‐LOW‐90 BRAND TIER 03THERATRAMADO PAK ‐60 BRAND TIER 03THERATRAMADO PAK ‐90 BRAND TIER 03TRAMADL/APAP TAB 37.5‐325 GENERIC TIER 01TRAMADOL HCL CAP 150MG ER GENERIC TIER 01TRAMADOL HCL TAB 100MG ER GENERIC TIER 01 PATRAMADOL HCL TAB 200MG ER GENERIC TIER 01 PATRAMADOL HCL TAB 300MG ER GENERIC TIER 01 PATRAMADOL HCL TAB 50MG GENERIC TIER 01TREZIX CAP GENERIC TIER 01TYLENOL/COD TAB #3 Brand‐O TIER 03 PATYLENOL/COD TAB #4 Brand‐O TIER 03 PATYLOX CAP 5‐500MG Brand‐O TIER 03 PA QLULTIVA INJ 1MG BRAND TIER 03ULTIVA INJ 2MG BRAND TIER 03ULTIVA INJ 5MG BRAND TIER 03ULTRACET TAB 37.5‐325 Brand‐O TIER 03 PAULTRAM TAB 50MG Brand‐O TIER 03 PAULTRAM ER TAB 100MG Brand‐O TIER 03 PAULTRAM ER TAB 200MG Brand‐O TIER 03 PAULTRAM ER TAB 300MG Brand‐O TIER 03 PAVICODIN TAB 5‐300MG GENERIC TIER 01VICODIN TAB 5‐500MG Brand‐O TIER 03 PAVICODIN ES TAB 7.5‐300 GENERIC TIER 01VICODIN ES TAB 7.5‐750 Brand‐O TIER 03 PAVICODIN HP TAB 10‐300MG GENERIC TIER 01VICODIN HP TAB 10‐660MG GENERIC TIER 01VICOPROFEN TAB 7.5‐200 Brand‐O TIER 03 PAXODOL TAB 10‐300MG Brand‐O TIER 03 PAXODOL TAB 5‐300MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion205

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS XODOL TAB 7.5‐300 Brand‐O TIER 03 PAXOLOX TAB 10‐500MG BRAND TIER 03 QLZAMICET SOL 10‐325MG BRAND TIER 03ZOLVIT SOL 10‐300MG BRAND TIER 03ZYDONE TAB 10‐400MG BRAND TIER 03ZYDONE TAB 5‐400MG BRAND TIER 03ZYDONE TAB 7.5‐400 BRAND TIER 03OPIATE ANTAGONISTS DEPADE TAB 50MG GENERIC TIER 01NALOXONE INJ 0.4MG/ML GENERIC TIER 01NALOXONE INJ 1MG/ML GENERIC TIER 01NALTREXONE TAB 50MG GENERIC TIER 01REVIA TAB 50MG Brand‐O TIER 03 PAVIVITROL INJ 380MG BRAND TIER 02 PA SPOPIATE PARTIAL AGONISTS BUPRENEX INJ 0.3MG/ML Brand‐O TIER 03 PABUPRENORPHIN INJ 0.3MG/ML GENERIC TIER 01 PABUPRENORPHIN SUB 2MG GENERIC TIER 01 PA QLBUPRENORPHIN SUB 8MG GENERIC TIER 01 PA QLBUTORPHANOL INJ 1MG/ML GENERIC TIER 01BUTORPHANOL INJ 2MG/ML GENERIC TIER 01BUTORPHANOL SOL 10MG/ML GENERIC TIER 01 QLBUTRANS DIS 10MCG/HR BRAND TIER 02 PABUTRANS DIS 20MCG/HR BRAND TIER 02 PABUTRANS DIS 5MCG/HR BRAND TIER 02 PANALBUPHINE INJ 10MG/ML GENERIC TIER 01NALBUPHINE INJ 20MG/ML GENERIC TIER 01PENTA/APAP TAB 25‐650MG GENERIC TIER 01PENTAZ/NALOX TAB 50‐0.5MG GENERIC TIER 01SUBOXONE MIS 2‐0.5MG BRAND TIER 02 PA QLSUBOXONE MIS 8‐2MG BRAND TIER 02 PA QLSUBOXONE SUB 2‐0.5MG BRAND TIER 03 QLSUBOXONE SUB 8‐2MG BRAND TIER 03 QLSUBUTEX SUB 2MG Brand‐O TIER 03 PA QLSUBUTEX SUB 8MG Brand‐O TIER 03 PA QLTALWIN INJ 30MG/ML BRAND TIER 03OSMOTIC DIURETICS MANNITOL INJ 10% GENERIC TIER 01MANNITOL INJ 15% GENERIC TIER 01MANNITOL INJ 20% GENERIC TIER 01MANNITOL INJ 25% GENERIC TIER 01MANNITOL INJ 5% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion206

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOSMOTIC DIURETICS OSMITROL INJ 10% GENERIC TIER 01OSMITROL INJ 15% GENERIC TIER 01OSMITROL INJ 5% GENERIC TIER 01OSMITROL VFX INJ 20% GENERIC TIER 01OTHER MACROLIDES AZITHROMYCIN INJ 2.5GM GENERIC TIER 01AZITHROMYCIN INJ 500MG GENERIC TIER 01AZITHROMYCIN POW 1GM PAK GENERIC TIER 01AZITHROMYCIN SUS 100/5ML GENERIC TIER 01AZITHROMYCIN SUS 200/5ML GENERIC TIER 01AZITHROMYCIN TAB 250MG GENERIC TIER 01AZITHROMYCIN TAB 500MG GENERIC TIER 01AZITHROMYCIN TAB 600MG GENERIC TIER 01BIAXIN SUS 250/5ML Brand‐O TIER 03 PABIAXIN TAB 250MG Brand‐O TIER 03 PABIAXIN TAB 500MG Brand‐O TIER 03 PABIAXIN XL TAB 500MG Brand‐O TIER 03 PABIAXIN XL TAB PAC 500 Brand‐O TIER 03 PACLARITHROMYC SUS 125/5ML GENERIC TIER 01CLARITHROMYC SUS 250/5ML GENERIC TIER 01CLARITHROMYC TAB 250MG GENERIC TIER 01CLARITHROMYC TAB 500MG GENERIC TIER 01CLARITHROMYC TAB 500MG ER GENERIC TIER 01DIFICID TAB 200MG BRAND TIER 02 PA QLZITHROMAX INJ 500MG Brand‐O TIER 03 PAZITHROMAX POW 1GM PAK BRAND TIER 03ZITHROMAX SUS 100/5ML Brand‐O TIER 03 PAZITHROMAX SUS 200/5ML Brand‐O TIER 03 PAZITHROMAX TAB 250MG Brand‐O TIER 03 PAZITHROMAX TAB 500MG Brand‐O TIER 03 PAZITHROMAX TAB 600MG Brand‐O TIER 03 PAZITHROMAX TAB TRI‐PAK Brand‐O TIER 03 PAZITHROMAX TAB Z‐PAK Brand‐O TIER 03 PAZMAX SUS 2GM BRAND TIER 03OTHER MISCELLANEOUS THERAPEUTIC AGENTS ACUNOL TAB 600MG BRAND TIER 99 DEAMPYRA TAB 10MG BRAND TIER 03 PA QL SPAPLIGRAF MIS BRAND TIER 03ARCALYST INJ 220MG BRAND TIER 02 PA QL SPARGENTUM‐D20 INJ GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion207

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS ASTHMA RX TAB BRAND TIER 99 DEATROPINUM SUB COMPOSIT BRAND TIER 99 DEAUBAGIO TAB 14MG BRAND TIER 03AUBAGIO TAB 7MG BRAND TIER 03AURUM LIQ 12X GENERIC TIER 01AURUMHEEL DRO BRAND TIER 99 DEAVAILNEX CHW 750MG BRAND TIER 99 DEBEE VENOM INJ 1300MCG BRAND TIER 03BEE VENOM INJ 550MCG BRAND TIER 03BOTOX INJ 100UNIT BRAND TIER 03 PA SPBOTOX INJ 200UNIT BRAND TIER 03 PA SPBOTOX COSMET INJ 100UNIT BRAND TIER 03BOTOX COSMET INJ 50UNIT BRAND TIER 03CACTUS LIQ COMPOSIT BRAND TIER 99 DECALAFOL RX TAB BRAND TIER 03CARDIOVID CAP PLUS BRAND TIER 99 DECARNITOR INJ 1GM/5ML Brand‐O TIER 03 PACARNITOR SOL 1GM/10ML Brand‐O TIER 03 PACARNITOR TAB 330MG Brand‐O TIER 03 PACARNITOR SF SOL 1GM/10ML Brand‐O TIER 03 PACARTICEL IMP BRAND TIER 99 DECAT HAIR INJ EXTRACT BRAND TIER 03CERECOMP INJ BRAND TIER 99 DECHELIDONIUM LIQ COMPOUND BRAND TIER 03COENZYME INJ COMPOSIT BRAND TIER 99 DECOR COMPOSIT LIQ BRAND TIER 99 DECRALONIN DRO BRAND TIER 99 DECRALONIN LIQ BRAND TIER 99 DECUTIS COMPOS INJ BRAND TIER 99 DECYSTADANE POW BRAND TIER 02 SPCYSTAGON CAP 150MG BRAND TIER 02CYSTAGON CAP 50MG BRAND TIER 02DEMSER CAP 250MG BRAND TIER 02DEPLIN TAB 15MG BRAND TIER 99 DEDEPLIN TAB 7.5MG BRAND TIER 03DERMAGRAFT MIS BRAND TIER 03DERMATODORON LIQ BRAND TIER 99 DEDIGESTODORON LIQ BRAND TIER 99 DEDISCUS INJ COMPOSIT BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion208

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS DISCUS LIQ COMPOSIT BRAND TIER 99 DEDISCUS SUB COMPOSIT BRAND TIER 99 DEDYSPORT INJ 300UNIT BRAND TIER 03 PADYSPORT INJ 500UNIT BRAND TIER 03 PA SPECHINACEA LIQ COMPOSIT BRAND TIER 99 DEECHINACEA SUB COMPOSIT BRAND TIER 99 DEECZEMOL TAB BRAND TIER 99 DEELMIRON CAP 100MG BRAND TIER 02ENGYSTOL INJ BRAND TIER 99 DEERYSIDORON LIQ #1 GENERIC TIER 99 DEERYSIDORON TAB #2 GENERIC TIER 01EUFLEXXA INJ 10MG/ML BRAND TIER 03 PA QL SPFOSTEUM CAP BRAND TIER 03GALIUM‐HEEL INJ BRAND TIER 99 DEGLONOIN DRO HOMACCOR BRAND TIER 99 DEGLYOXAL INJ COMPOSIT BRAND TIER 99 DEGRAFIX CORE MIS 2CMX2CM BRAND TIER 99 DEGRAFIX CORE MIS 5CMX5CM BRAND TIER 99 DEGRAFIX PRIME MIS 2CMX2CM BRAND TIER 99 DEGRAFIX PRIME MIS 5CMX5CM BRAND TIER 99 DEGRAFIX PRIME MIS 7.5X15CM BRAND TIER 99 DEGRIPP‐HEEL INJ BRAND TIER 99 DEHEPAR INJ COMPOSIT BRAND TIER 99 DEHONEY BEE INJ 1000MCG GENERIC TIER 01HONEY BEE KIT 100MCG GENERIC TIER 01HORMEEL LIQ BRAND TIER 99 DEHORNET VENOM INJ 1300MCG BRAND TIER 03HORNET VENOM INJ 550MCG BRAND TIER 03HYALGAN INJ 20MG/2ML BRAND TIER 03 PA QL SPINDICLOR INJ BRAND TIER 99 DEINDIUM IN111 INJ DTPA GENERIC TIER 99 DEISCAR MALI INJ 5MG/ML BRAND TIER 03KUVAN TAB 100MG BRAND TIER 02 SPLEVOCARNITIN INJ 200MG/ML GENERIC TIER 01LEVOCARNITIN SOL 1GM/10ML GENERIC TIER 01LEVOCARNITIN TAB 330MG GENERIC TIER 01LIMBREL CAP 250MG BRAND TIER 03LIMBREL CAP 500MG BRAND TIER 03LIMBREL250 CAP 250‐50MG BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion209

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS LIMBREL500 CAP 500‐50MG BRAND TIER 99 DELIMBREL525 CAP 525‐50MG BRAND TIER 03L‐METHYLFOLA TAB 15MG GENERIC TIER 99 DEL‐METHYLFOLA TAB 7.5MG GENERIC TIER 01LYMPHOMYOSOT INJ BRAND TIER 99 DELYMPHOMYSOT INJ BRAND TIER 99 DEMELILOTUS DRO HOMACCOR BRAND TIER 99 DEMELILOTUS LIQ HOMACCOR BRAND TIER 99 DEMETASTRON INJ BRAND TIER 03 SPMIXED VESPID INJ 1650MCG GENERIC TIER 01MIXED VESPID INJ 3900MCG GENERIC TIER 01MIXED VESPID KIT 3000MCG GENERIC TIER 01MIXED VESPID KIT 300MCG GENERIC TIER 01MOMORDICA DRO COMPOSIT BRAND TIER 99 DEMOMORDICA LIQ COMPOSIT BRAND TIER 99 DEMUCOSA INJ COMPOSIT BRAND TIER 99 DEMYOBLOC INJ 10000/2 BRAND TIER 03 PA SPMYOBLOC INJ 2500/0.5 BRAND TIER 03 PA SPMYOBLOC INJ 5000/ML BRAND TIER 03 PA SPNEURALGO INJ RHEUM BRAND TIER 99 DENEXAVIR INJ BRAND TIER 03OCTREOSCAN KIT BRAND TIER 03OCTREOTIDE INJ 1000MCG GENERIC TIER 01OCTREOTIDE INJ 100MCG GENERIC TIER 01OCTREOTIDE INJ 200MCG GENERIC TIER 01OCTREOTIDE INJ 500MCG GENERIC TIER 01OCTREOTIDE INJ 50MCG/ML GENERIC TIER 01OLEIC ACID LIQ GENERIC TIER 99 DEORFADIN CAP 10MG BRAND TIER 02 SPORFADIN CAP 2MG BRAND TIER 02 SPORFADIN CAP 5MG BRAND TIER 02 SPORTHOVISC INJ 15MG/ML BRAND TIER 03 PA QL SPPLACENTA INJ COMPOSIT BRAND TIER 99 DEPNEUMODORON LIQ BRAND TIER 99 DEPOLYPEG SUP MIS BASE GENERIC TIER 99 DEPROSTASCINT KIT BRAND TIER 03PRYFLEX TAB BRAND TIER 03PSORINOHEEL DRO BRAND TIER 99 DEPSORINOHEEL LIQ BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion210

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS PSORIZIDE TAB FORTE GENERIC TIER 99 DEPSORIZIDE TAB ULTRA BRAND TIER 99 DEPULSATILLA INJ COMPOSIT BRAND TIER 99 DEQUINZYME TAB 90MG BRAND TIER 99 DERASPBERRY SYP GENERIC TIER 01RAUWOLFIA LIQ COMPOSIT GENERIC TIER 99 DERAUWOLFIA SUB COMPOSIT GENERIC TIER 99 DEREJUVESOL SOL BRAND TIER 03RELAMINE TAB BRAND TIER 03RENEEL SUB BRAND TIER 99 DERHEUMADORON LIQ 102A BRAND TIER 99 DERIMSO‐50 SOL 50% BRAND TIER 03SANDOSTATIN INJ 1000MCG Brand‐O TIER 03 PASANDOSTATIN INJ 100MCG Brand‐O TIER 03 PASANDOSTATIN INJ 200MCG Brand‐O TIER 03 PASANDOSTATIN INJ 500MCG Brand‐O TIER 03 PASANDOSTATIN INJ 50MCG/ML Brand‐O TIER 03 PASANDOSTATIN KIT LAR 10MG BRAND TIER 02SANDOSTATIN KIT LAR 20MG BRAND TIER 02SANDOSTATIN KIT LAR 30MG BRAND TIER 02SARAPIN INJ BRAND TIER 03SENSIPAR TAB 30MG BRAND TIER 02 SPSENSIPAR TAB 60MG BRAND TIER 02 SPSENSIPAR TAB 90MG BRAND TIER 02 SPSOLESTA INJ 50‐15ML BRAND TIER 03SOMATULINE INJ 120/.5ML BRAND TIER 02 SPSOMATULINE INJ 60/0.2ML BRAND TIER 02 SPSOMATULINE INJ 90/0.3ML BRAND TIER 02 SPSPASCUPREEL INJ BRAND TIER 99 DESPEED GEL GEL TRAUMA BRAND TIER 99 DESPEED GEL RX GEL BRAND TIER 99 DESPG SUPPOSI‐ MIS BASE BRAND TIER 99 DESTAPHAGE LYS INJ GENERIC TIER 01STERYMINE GEL BRAND TIER 99 DESTRUMEEL DRO FORTE BRAND TIER 99 DESTRUMEEL SUB BRAND TIER 99 DESUPARTZ INJ 25/2.5ML BRAND TIER 03 PA QL SPSUPPOSIBLEND MIS BRAND TIER 99 DESYNVISC INJ 8MG/ML BRAND TIER 02 PA QL SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion211

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS SYNVISC ONE INJ 8MG/ML BRAND TIER 02 PA QL SPSYZYGIUM DRO COMPOSIT BRAND TIER 99 DETEARS AGAIN CAP HYDRATE Brand‐O TIER 03 PATHALAMUS SUB COMPOSIT BRAND TIER 99 DETHIOLA TAB 100MG BRAND TIER 03THYREOIDEA LIQ COMPOSIT BRAND TIER 99 DETHYREOIDEA SUB COMPOSIT BRAND TIER 99 DETRANZGEL GEL BRAND TIER 99 DETRAUMANIL GEL BRAND TIER 99 DETRAUMEEL INJ BRAND TIER 99 DETRI‐CHLOR LIQ 80% BRAND TIER 03UBICHINON INJ COMPOSIT BRAND TIER 99 DEURI‐CLEANSE TAB RX BRAND TIER 99 DEURI‐CONTROL TAB RX BRAND TIER 99 DEVALERIAN EXT ROOT GENERIC TIER 01VAYACOG CAP BRAND TIER 99 DEVAYARIN CAP BRAND TIER 99 DEVAYAROL CAP BRAND TIER 03VENOMIL KIT HONEYBEE BRAND TIER 03VENOMIL KIT WASP BRAND TIER 03VENOMIL KIT WHT HORN BRAND TIER 03VENOMIL KIT YEL HORN BRAND TIER 03VENOMIL KIT YEL JACK BRAND TIER 03VENOMIL MIX INJ VESPID BRAND TIER 03VERTIGOHEEL DRO BRAND TIER 99 DEVERTIGOHEEL LIQ BRAND TIER 99 DEVERTIGOHEEL SUB BRAND TIER 99 DEVIASPAN SOL BRAND TIER 03VP‐GSTN CAP GENERIC TIER 01VP‐PRECIP CAP GENERIC TIER 01WASP VENOM INJ 1000MCG GENERIC TIER 01WASP VENOM INJ 1300MCG GENERIC TIER 01WASP VENOM INJ 550MCG GENERIC TIER 01WASP VENOM KIT 100MCG GENERIC TIER 01WHITE HORNET KIT 100MCG GENERIC TIER 01WHITE HORNET SOL 1000MCG GENERIC TIER 01XEOMIN INJ 100UNIT BRAND TIER 03 PA SPXEOMIN INJ 50 UNIT BRAND TIER 03 PA SPXIGRIS INJ 20MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion212

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS XIGRIS INJ 5MG BRAND TIER 03YELLOW HORN INJ 550MCG GENERIC TIER 01YELLOW HORNT KIT 100MCG GENERIC TIER 01YELLOW HORNT SOL 1000MCG GENERIC TIER 01YELLOW JACK INJ 1300MCG GENERIC TIER 01YELLOW JACK INJ 550MCG GENERIC TIER 01YELLOW JACKT KIT 100MCG GENERIC TIER 01YELLOW JACKT SOL 1000MCG GENERIC TIER 01ZAVESCA CAP 100MG BRAND TIER 03 SPZEEL INJ BRAND TIER 99 DETRICHLOROACE CRY ACID GENERIC TIER 99 DEOTHER NONSTEROIDAL ANTI‐INFLAM. AGENTS ANAPROX TAB 275MG Brand‐O TIER 03 PAANAPROX DS TAB 550MG Brand‐O TIER 03 PAARTHROTEC 50 TAB BRAND TIER 03ARTHROTEC 75 TAB BRAND TIER 03CALDOLOR INJ 400/4ML BRAND TIER 99 DECALDOLOR INJ 800/8ML BRAND TIER 99 DECAMBIA POW 50MG BRAND TIER 03 PACATAFLAM TAB 50MG Brand‐O TIER 03 PACLINORIL TAB 200MG Brand‐O TIER 03 PADAYPRO TAB 600MG Brand‐O TIER 03 PADICLOFEN POT TAB 50MG GENERIC TIER 01DICLOFENAC TAB 100MG ER GENERIC TIER 01DICLOFENAC TAB 100MG XR GENERIC TIER 01DICLOFENAC TAB 25MG DR GENERIC TIER 01DICLOFENAC TAB 50MG DR GENERIC TIER 01DICLOFENAC TAB 75MG DR GENERIC TIER 01DIFLUNISAL TAB 500MG GENERIC TIER 01DUEXIS TAB 800‐26.6 BRAND TIER 03EC‐NAPROSYN TAB 375MG Brand‐O TIER 03 PAEC‐NAPROSYN TAB 500MG Brand‐O TIER 03 PAETODOLAC CAP 200MG GENERIC TIER 01ETODOLAC CAP 300MG GENERIC TIER 01ETODOLAC TAB 400MG GENERIC TIER 01ETODOLAC TAB 500MG GENERIC TIER 01ETODOLAC ER TAB 400MG GENERIC TIER 01ETODOLAC ER TAB 500MG GENERIC TIER 01ETODOLAC ER TAB 600MG GENERIC TIER 01FELDENE CAP 10MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion213

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER NONSTEROIDAL ANTI‐INFLAM. AGENTS FELDENE CAP 20MG Brand‐O TIER 03 PAFENOPROFEN TAB 600MG GENERIC TIER 01FLURBIPROFEN TAB 100MG GENERIC TIER 01FLURBIPROFEN TAB 50MG GENERIC TIER 01IBUPROFEN KIT COMFORT BRAND TIER 03IBUPROFEN TAB 400MG GENERIC TIER 01IBUPROFEN TAB 600MG GENERIC TIER 01IBUPROFEN TAB 800MG GENERIC TIER 01IC 400 KIT 400MG BRAND TIER 99 DEIC 800 KIT 800MG BRAND TIER 99 DEINDOCIN SUP 50MG BRAND TIER 03INDOCIN SUS 25MG/5ML BRAND TIER 03INDOCIN IV INJ 1MG Brand‐O TIER 03 PAINDOMETHACIN CAP 25MG GENERIC TIER 01INDOMETHACIN CAP 50MG GENERIC TIER 01INDOMETHACIN CAP 75MG ER GENERIC TIER 01INDOMETHACIN INJ 1MG GENERIC TIER 01KETOPROFEN CAP 200MG ER GENERIC TIER 01KETOPROFEN CAP 50MG GENERIC TIER 01KETOPROFEN CAP 75MG GENERIC TIER 01KETOROLAC INJ 15MG/ML GENERIC TIER 01 PAKETOROLAC INJ 30MG/ML GENERIC TIER 01 PAKETOROLAC INJ 60MG/2ML GENERIC TIER 01 PAKETOROLAC TAB 10MG GENERIC TIER 01MECLOFEN SOD CAP 100MG GENERIC TIER 01MECLOFEN SOD CAP 50MG GENERIC TIER 01MEFENAM ACID CAP 250MG GENERIC TIER 01 PAMELOXICAM KIT COMFORT BRAND TIER 03MELOXICAM SUS 7.5/5ML GENERIC TIER 01MELOXICAM TAB 15MG GENERIC TIER 01MELOXICAM TAB 7.5MG GENERIC TIER 01MOBIC SUS 7.5/5ML BRAND TIER 03MOBIC TAB 15MG Brand‐O TIER 03 PAMOBIC TAB 7.5MG Brand‐O TIER 03 PANABUMETONE TAB 500MG GENERIC TIER 01NABUMETONE TAB 750MG GENERIC TIER 01NALFON CAP 200MG BRAND TIER 03NALFON CAP 400MG BRAND TIER 03NAPRELAN PAK BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion214

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER NONSTEROIDAL ANTI‐INFLAM. AGENTS NAPRELAN TAB 375MG CR BRAND TIER 03NAPRELAN TAB 500MG CR BRAND TIER 03NAPRELAN TAB 750MG CR BRAND TIER 03NAPROSYN SUS 125/5ML Brand‐O TIER 03 PANAPROSYN TAB 250MG Brand‐O TIER 03 PANAPROSYN TAB 375MG Brand‐O TIER 03 PANAPROSYN TAB 500MG Brand‐O TIER 03 PANAPROXEN KIT COMFORT BRAND TIER 03NAPROXEN SUS 125/5ML GENERIC TIER 01NAPROXEN TAB 250MG GENERIC TIER 01NAPROXEN TAB 375MG GENERIC TIER 01NAPROXEN TAB 500MG GENERIC TIER 01NAPROXEN DR TAB 375MG GENERIC TIER 01NAPROXEN DR TAB 500MG GENERIC TIER 01NAPROXEN SOD TAB 275MG GENERIC TIER 01NAPROXEN SOD TAB 550MG GENERIC TIER 01NEOPROFEN SOL 10MG/ML BRAND TIER 03OXAPROZIN TAB 600MG GENERIC TIER 01PIROXICAM CAP 10MG GENERIC TIER 01PIROXICAM CAP 20MG GENERIC TIER 01PONSTEL CAP 250MG Brand‐O TIER 03 PASPRIX SPR 15.75MG BRAND TIER 03 PA QLSULINDAC TAB 150MG GENERIC TIER 01SULINDAC TAB 200MG GENERIC TIER 01THERAFELDAMI PAK BRAND TIER 03THERAPROFEN PAK ‐60 BRAND TIER 03THERAPROFEN PAK 800MG BRAND TIER 03THERAPROFEN PAK ‐90 BRAND TIER 03THERAPROXEN PAK BRAND TIER 03THERAPROXEN PAK 500MG BRAND TIER 03THERAPROXEN PAK ‐60 BRAND TIER 03THERAPROXEN PAK ‐90 BRAND TIER 03TOLMETIN SOD CAP 400MG GENERIC TIER 01TOLMETIN SOD TAB 200MG GENERIC TIER 01TOLMETIN SOD TAB 600MG GENERIC TIER 01TREPADICLOFE PAK 25MG BRAND TIER 03TREPOXEN PAK 250MG BRAND TIER 03TREPOXICAM PAK 7.5MG BRAND TIER 03VIMOVO TAB 375‐20MG BRAND TIER 02 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion215

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER NONSTEROIDAL ANTI‐INFLAM. AGENTS VIMOVO TAB 500‐20MG BRAND TIER 02 PA QLVOLTAREN‐XR TAB 100MG Brand‐O TIER 03 PAZIPSOR CAP 25MG BRAND TIER 03 PA QLIBUPROFEN SUS 100/5ML GENERIC TIER 01OXAZOLIDINONES ZYVOX SOL 2MG/ML BRAND TIER 03 PAZYVOX SUS 100MG/5M BRAND TIER 02 PA QLZYVOX TAB 600MG BRAND TIER 02 PA QLOXYTOCICS CERVIDIL VAG MIS 10MG INS BRAND TIER 03HEMABATE INJ 250MCG BRAND TIER 03METHERGINE INJ 0.2MG/ML Brand‐O TIER 03 PAMETHERGINE TAB 0.2MG Brand‐O TIER 03 PAMETHYLERGON INJ 0.2MG/ML GENERIC TIER 01METHYLERGON TAB 0.2MG GENERIC TIER 01MIFEPREX TAB 200MG BRAND TIER 03OXYTOCIN INJ 10UNT/ML GENERIC TIER 01PITOCIN INJ 10UNT/ML Brand‐O TIER 03 PAPREPIDIL GEL 0.5MG/3G BRAND TIER 03PROSTIN E2 SUP 20MG BRAND TIER 03PANCREATIC FUNCTION CHIRHOSTIM SOL 16MCG BRAND TIER 99 DESECREFLO INJ 16MCG BRAND TIER 03PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) ARICEPT TAB 10MG Brand‐O TIER 03 PAARICEPT TAB 23MG BRAND TIER 02ARICEPT TAB 5MG Brand‐O TIER 03 PAARICEPT ODT TAB 10MG Brand‐O TIER 03 PAARICEPT ODT TAB 5MG Brand‐O TIER 03 PABETHANECHOL TAB 10MG GENERIC TIER 01BETHANECHOL TAB 25MG GENERIC TIER 01BETHANECHOL TAB 50MG GENERIC TIER 01BETHANECHOL TAB 5MG GENERIC TIER 01DONEPEZIL TAB 10MG GENERIC TIER 01DONEPEZIL TAB 10MG ODT GENERIC TIER 01DONEPEZIL TAB 5MG GENERIC TIER 01DONEPEZIL TAB 5MG ODT GENERIC TIER 01ENLON‐PLUS INJ 10‐0.14 BRAND TIER 03EVOXAC CAP 30MG Brand‐O TIER 02 PAEXELON CAP 1.5MG Brand‐O TIER 03 PAEXELON CAP 3MG Brand‐O TIER 03 PAEXELON CAP 4.5MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion216

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) EXELON CAP 6MG Brand‐O TIER 03 PAEXELON DIS 13.3/24 BRAND TIER 02EXELON DIS 4.6MG/24 BRAND TIER 02EXELON DIS 9.5MG/24 BRAND TIER 02EXELON SOL 2MG/ML BRAND TIER 02GALANTAMINE CAP 16MG ER GENERIC TIER 01GALANTAMINE CAP 24MG ER GENERIC TIER 01GALANTAMINE CAP 8MG ER GENERIC TIER 01GALANTAMINE SOL 4MG/ML GENERIC TIER 01GALANTAMINE TAB 12MG GENERIC TIER 01GALANTAMINE TAB 4MG GENERIC TIER 01GALANTAMINE TAB 8MG GENERIC TIER 01GUANIDINE TAB 125MG GENERIC TIER 01MESTINON SYP 60MG/5ML BRAND TIER 02MESTINON TAB 60MG Brand‐O TIER 03 PAMESTINON TAB TIMESPAN BRAND TIER 02MYTELASE TAB 10MG BRAND TIER 03NEOSTIG METH INJ 0.5MG/ML GENERIC TIER 01NEOSTIG METH INJ 1MG/ML GENERIC TIER 01PHYSOS SALIC INJ 1MG/ML GENERIC TIER 01PILOCARPINE TAB 5MG GENERIC TIER 01PILOCARPINE TAB 7.5MG GENERIC TIER 01PROSTIGMIN INJ 0.5MG/ML Brand‐O TIER 03 PAPROSTIGMIN TAB 15MG BRAND TIER 02PYRIDOSTIGM TAB 60MG GENERIC TIER 01RAZADYNE SOL 4MG/ML Brand‐O TIER 03 PARAZADYNE TAB 12MG Brand‐O TIER 03 PARAZADYNE TAB 4MG Brand‐O TIER 03 PARAZADYNE TAB 8MG Brand‐O TIER 03 PARAZADYNE ER CAP 16MG Brand‐O TIER 03 PARAZADYNE ER CAP 24MG Brand‐O TIER 03 PARAZADYNE ER CAP 8MG Brand‐O TIER 03 PAREGONOL INJ 5MG/ML BRAND TIER 03REGONOL INJ 5MG/ML GENERIC TIER 01RIVASTIGMINE CAP 1.5MG GENERIC TIER 01RIVASTIGMINE CAP 3MG GENERIC TIER 01RIVASTIGMINE CAP 4.5MG GENERIC TIER 01RIVASTIGMINE CAP 6MG GENERIC TIER 01SALAGEN TAB 5MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion217

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) SALAGEN TAB 7.5MG Brand‐O TIER 03 PAURECHOLINE TAB 10MG Brand‐O TIER 03 PAURECHOLINE TAB 25MG Brand‐O TIER 03 PAURECHOLINE TAB 50MG Brand‐O TIER 03 PAURECHOLINE TAB 5MG Brand‐O TIER 03 PACEVIMELINE CAP 30MG GENERIC TIER 01PARATHYROID CALCITONIN SPR 200/ACT GENERIC TIER 01FORTEO SOL 600/2.4 BRAND TIER 02 PA SPFORTICAL SPR 200/ACT GENERIC TIER 01MIACALCIN INJ 200/ML BRAND TIER 03MIACALCIN SPR 200/ACT Brand‐O TIER 03 PAPENICILLINASE‐RESISTANT PENICILLINS BACTOCILL INJ DEX 1GM BRAND TIER 03BACTOCILL INJ DEX 2GM BRAND TIER 03DICLOXACILL CAP 250MG GENERIC TIER 01DICLOXACILL CAP 500MG GENERIC TIER 01NAFCILLIN INJ 10GM GENERIC TIER 01 SPNAFCILLIN INJ 1GM GENERIC TIER 01 SPNAFCILLIN INJ 2GM GENERIC TIER 01 SPNALLPEN/DEX INJ 1GM/50ML BRAND TIER 03NALLPEN/DEX INJ 2GM/100 BRAND TIER 03OXACILLIN INJ 10GM GENERIC TIER 01OXACILLIN INJ 1GM GENERIC TIER 01OXACILLIN INJ 2GM GENERIC TIER 01PERIPHERAL ADRENERGIC INHIBITORS RESERPINE TAB 0.1MG GENERIC TIER 01RESERPINE TAB 0.25MG GENERIC TIER 01PHARMACEUTICAL AIDS ALBA‐DERM CRE BRAND TIER 03ALMOND OIL LIQ BITTER GENERIC TIER 99 DEANHYDROUS GEL BASE GENERIC TIER 99 DEANHYDROUS OIN BASE BRAND TIER 03ANHYDROUS OIN BASE GENERIC TIER 01ANISE EXTRAC LIQ FLAVOR GENERIC TIER 99 DEANISE FLAVOR OIL GENERIC TIER 99 DEAPPLE FLAVOR LIQ GENERIC TIER 99 DEAPRICOT LIQ FLAVOR GENERIC TIER 99 DEAZ CREAM CRE BRAND TIER 03BACON FLAVOR LIQ GENERIC TIER 99 DEBACTER WATER INJ BENZ ALC GENERIC TIER 01BACTER WATER INJ PARABENS GENERIC TIER 01BANANA LIQ FLAVOR GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion218

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS BANANA CREME LIQ FLAVOR GENERIC TIER 99 DEBASE W301 CRE GENERIC TIER 01BASE X MIS GENERIC TIER 99 DEBEES WAX MIS WHITE GENERIC TIER 99 DEBENZALDEHYDE ELX GENERIC TIER 99 DEBIOPEPTIDE CRE BASE BRAND TIER 03BITTER STOP LIQ FLAVOR GENERIC TIER 99 DEBLACK WALNUT LIQ FLAVOR GENERIC TIER 99 DEBLACKBERRY LIQ FLAVOR GENERIC TIER 99 DEBLUEBERRY LIQ FLAVOR GENERIC TIER 99 DEBUBBLE GUM LIQ CONCENTR GENERIC TIER 99 DEBUBBLE GUM LIQ FLAVOR GENERIC TIER 99 DEBUTTER LIQ FLAVOR GENERIC TIER 99 DEBUTTER RUM LIQ FLAVOR GENERIC TIER 99 DEBUTTERSCOTCH LIQ FLAVOR GENERIC TIER 99 DECAP POSILOK CAP #0 GENERIC TIER 01CAP POSILOK CAP #00 GENERIC TIER 01CAP POSILOK CAP #2 GENERIC TIER 01CAP POSILOK CAP #3 GENERIC TIER 01CAPSULE #1 CAP DRCAPS GENERIC TIER 01CAPSULE CONI CAP ‐SN #000 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #1 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #2 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #3 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #4 GENERIC TIER 01CAPSULE LOCK CAP #0 CLEAR GENERIC TIER 01CAPSULE LOCK CAP #1 CLEAR GENERIC TIER 01CAPSULE LOCK CAP #3 CLEAR GENERIC TIER 01CARBOGEL GEL 940 GENERIC TIER 01CARBOHOL GEL 940 BRAND TIER 03CARBOMER GEL AQUEOUS GENERIC TIER 01CARBOMER GEL HYDROALC GENERIC TIER 01CAVIAR FLAVO LIQ NATURAL GENERIC TIER 99 DECETYL ALCOHO MIS GENERIC TIER 99 DECHCK FLAVOR LIQ OIL SOLU GENERIC TIER 99 DECHCK FLAVOR LIQ WTR MISC GENERIC TIER 99 DECHEESECAKE LIQ FLAVOR GENERIC TIER 99 DECHEMSIL K‐12 PST BRAND TIER 99 DECHEMSIL K‐51 GEL BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion219

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS CHERRY LIQ FLAVOR GENERIC TIER 99 DECHERRY SYP GENERIC TIER 01CHLORHEXIDIN CON FLAVOR GENERIC TIER 99 DECHOC HAZELNT LIQ FLAVOR GENERIC TIER 99 DECHOCOLATE LIQ FLAVOR GENERIC TIER 99 DECHRYSADERM CRE DAY BRAND TIER 03CHRYSADERM CRE NIGHT BRAND TIER 03CINNAMON OIL FLAVOR GENERIC TIER 99 DECOCONUT LIQ FLAVOR GENERIC TIER 99 DECOFFEE LIQ FLAVOR GENERIC TIER 99 DECOLA FLAVOR LIQ GENERIC TIER 99 DECOLLODION LIQ GENERIC TIER 99 DECONCENTRATE CRE GENERIC TIER 01CORIANDER OIL GENERIC TIER 99 DECOTTON CANDY LIQ FLAVOR GENERIC TIER 99 DECRAN‐RASPBER LIQ FLAVOR GENERIC TIER 99 DECREME DE MNT LIQ FLAVOR GENERIC TIER 99 DECREME DEMENT LIQ FLAVOR GENERIC TIER 99 DECUST LIPOTHN GEL 110 BRAND TIER 99 DECUST LIPOTHN GEL 133 BRAND TIER 99 DEDOW CORNING LIQ 9011 BRAND TIER 99 DEDRCAPS CLEAR CAP SIZE 1 BRAND TIER 03EGGNOG LIQ FLAVOR GENERIC TIER 99 DEEMOLLIENT CRE GENERIC TIER 01EMULGADE CM LIQ BRAND TIER 99 DEEMULSIFIX LIQ 205 BASE BRAND TIER 99 DEEMULSION LIQ CONCENTR BRAND TIER 99 DEENG TOFFEE LIQ FLAVOR GENERIC TIER 99 DEETHYL ACETAT SOL GENERIC TIER 99 DEEUCALYPTOL LIQ FLAVOR GENERIC TIER 99 DEEUCALYPTUS OIL FLAVOR GENERIC TIER 99 DEEUGENOL LIQ FLAVOR GENERIC TIER 99 DEFISH FLAVOR LIQ GENERIC TIER 99 DEFLAVOR BLEND SUS BRAND TIER 03FLAVOR PLUS LIQ BRAND TIER 03FLAVOR SWEET LIQ S/F BRAND TIER 03FLAVOR SWEET SYP BRAND TIER 03FOOD COLOR LIQ BLUE GENERIC TIER 01FOOD COLOR LIQ GREEN GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion220

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS FOOD COLOR LIQ PINK GENERIC TIER 99 DEFOOD COLOR LIQ RED GENERIC TIER 99 DEFOOD COLOR LIQ WHITE GENERIC TIER 99 DEFOOD COLOR LIQ YELLOW GENERIC TIER 99 DEGELATIN EMPT CAP LOCKING GENERIC TIER 01GRAPEFRUIT OIL FLAVOR GENERIC TIER 99 DEGUAVA FLAVOR LIQ GENERIC TIER 99 DEGUMMY TROCHE GEL GELATIN GENERIC TIER 99 DEHAM FLAVOR LIQ GENERIC TIER 99 DEHONEY FLAVOR LIQ GENERIC TIER 99 DEHOREHOUND LIQ FLAVOR GENERIC TIER 99 DEHRT BASE CRE GENERIC TIER 99 DEHRT BASE CRE BOTANICA GENERIC TIER 99 DEHRT BASE CRE HEAVY GENERIC TIER 99 DEHRT BASE CRE SUPREME BRAND TIER 99 DEHRT BASE CRE WOMEN GENERIC TIER 99 DEHRT BASE GEL FOR MEN GENERIC TIER 99 DEHRT NATURAL CRE BASE GENERIC TIER 99 DEHRT NATURAL LOT BASE GENERIC TIER 99 DEHYDROGEL GEL BRAND TIER 03IRON OXIDE PST BLACK GENERIC TIER 99 DEIRON OXIDE PST RED GENERIC TIER 99 DEIRON OXIDE PST YELLOW GENERIC TIER 99 DEKAHLUA LIQ FLAVOR GENERIC TIER 99 DEKRIS‐ESTER LIQ 236 GENERIC TIER 99 DEKRISGEL 100 GEL BRAND TIER 03LECITHIN GEL GENERIC TIER 01LEMON LIQ FLAVOR GENERIC TIER 99 DELEMON EXTRAC LIQ GENERIC TIER 99 DELEMON FLAVOR OIL GENERIC TIER 99 DELEMONADE OIL FLAVOR GENERIC TIER 99 DEL‐HISTIDINE CRY MONOHYDR GENERIC TIER 99 DELICORICE LIQ FLAVOR GENERIC TIER 99 DELIME FLAVOR OIL GENERIC TIER 99 DELIPO CREAM CRE BASE BRAND TIER 03LIPOBASE CRE HEAVY GENERIC TIER 01LIPOBASE CRE REGULAR GENERIC TIER 01LIPODERM HMW GEL PCCA BRAND TIER 99 DELIPOPEN CRE BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion221

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS LIPOPEN CRE PLUS BRAND TIER 03LIQUIGEL LIQ COMPLEX BRAND TIER 99 DELIVER FLAVOR LIQ GENERIC TIER 99 DELUBRAJEL NP GEL BRAND TIER 99 DEMAPLE FLAVOR LIQ GENERIC TIER 99 DEMARGARITA LIQ FLAVOR GENERIC TIER 99 DEMARSHMALLOW LIQ FLAVOR GENERIC TIER 99 DEMEDIDERM CRE BRAND TIER 03MENTHOL LIQ EUCALYPT GENERIC TIER 99 DEMETER BUFFER SOL PH 10 GENERIC TIER 99 DEMINT CHOCOLA LIQ FLAVOR GENERIC TIER 99 DEMULTIBASE CRE BRAND TIER 03NATACREAM CRE BRAND TIER 03NON GELATIN CAP EMPTY GENERIC TIER 01OCCLUSADERM GEL PCCA BRAND TIER 99 DEOINTMENT BAS OIN EMULSIFY GENERIC TIER 99 DEOLEABASE OIN PLASTICI BRAND TIER 99 DEORANGE LIQ FLAVOR GENERIC TIER 99 DEORANGE CREAM LIQ FLAVOR GENERIC TIER 99 DEORANGE OIL LIQ FLAVOR GENERIC TIER 99 DEPCCA ALADERM CRE BASE BRAND TIER 03PCCA BASE MIS TRSDRML BRAND TIER 03PCCA COBASE OIN #1 BRAND TIER 03PCCA COSMETI CRE HRT BASE BRAND TIER 03PCCA CUSTOM CRE LIPO‐MAX BRAND TIER 03PCCA FIXED LIQ OIL BASE BRAND TIER 99 DEPCCA GELATIN OIN BASE BRAND TIER 99 DEPCCA LIPODER CRE BASE BRAND TIER 03PCCA LIPOSOM CRE DEHYDRAT BRAND TIER 03PCCA LIPOSOM CRE DRY BRAND TIER 03PCCA LIPOSOM CRE NORMAL BRAND TIER 03PCCA LIPOSOM CRE OILY BRAND TIER 03PCCA LIPOSOM CRE PROBLEM BRAND TIER 03PCCA LIPOSOM CRE SENSITIV BRAND TIER 03PCCA MVC CRE BASE BRAND TIER 03PCCA PLASTIC OIN BASE BRAND TIER 99 DEPCCA PLURONI GEL F127 20% BRAND TIER 99 DEPCCA PLURONI GEL F127 30% BRAND TIER 99 DEPCCA SWEET SYP ‐SF BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion222

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS PCCA SYRUP SYP VEHICLE BRAND TIER 03PCCA VANISH CRE BASE BRAND TIER 03PCCA VANISHI CRE LIGHT BRAND TIER 03PCCA VANPEN CRE BASE BRAND TIER 03PCCA‐PLUS SUS BRAND TIER 03PEACH FLAVOR LIQ GENERIC TIER 99 DEPEANUT BUTTR LIQ FLAVOR GENERIC TIER 99 DEPEG OIN BASE L GENERIC TIER 01PENCREAM CRE BRAND TIER 03PENDERM CRE BRAND TIER 03PEPPERMINT OIL FLAVOR GENERIC TIER 99 DEPHARMABASE CRE COSMETIC BRAND TIER 03PHARMABASE CRE HEAVY BRAND TIER 03PINA COLADA LIQ FLAVOR GENERIC TIER 99 DEPINEAPPLE LIQ FLAVOR GENERIC TIER 99 DEPIZZA FLAVOR LIQ GENERIC TIER 99 DEPLACEBO #00 CAP GENERIC TIER 01PLO GEL MEDIFLO GENERIC TIER 01PLO MEDIFLO KIT KIT BRAND TIER 99 DEPLO TRANSDER CRE BRAND TIER 03PLURONIC GEL F127 20% BRAND TIER 99 DEPLURONIC GEL F127 30% BRAND TIER 99 DEPOLYGLYCOL MIS TROCHE BRAND TIER 99 DEPOLYPEG OIN BASE BRAND TIER 03POT PERMANGT CRY GENERIC TIER 99 DEPOTASSIUM GRA SORBATE GENERIC TIER 99 DEPRACAMAC OIL BASE BRAND TIER 99 DEPRACASIL TM‐ CRE PLUS BRAND TIER 03PRALINES/CRM LIQ FLAVOR GENERIC TIER 99 DEPUMPKIN LIQ FLAVOR GENERIC TIER 99 DERASPBERRY CON FLAVOR GENERIC TIER 99 DESALT STABLE CRE BRAND TIER 03SARSAPARILLA LIQ FLAVOR GENERIC TIER 99 DESEPINEO P600 LIQ BRAND TIER 99 DESHRIMP LIQ FLAVOR GENERIC TIER 99 DESIMPLE SYP GENERIC TIER 01SIMPLGEL 30 GEL BRAND TIER 99 DESOD CITRATE CRY GENERIC TIER 99 DESPEARMINT OIL FLAVOR GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion223

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS SPIRA‐WASH GEL BASE BRAND TIER 99 DESTEARIC ACID MIS GENERIC TIER 99 DESTERIL WATER INJ GENERIC TIER 01STERILE DILU SOL FLOLAN BRAND TIER 03STRAWBERRY LIQ FLAVOR GENERIC TIER 99 DESWEETNESS LIQ ENHANCER BRAND TIER 99 DESYRPALTA SYP BRAND TIER 03SYRPALTA SYP CLEAR BRAND TIER 03TANGERINE OIL FLAVOR GENERIC TIER 99 DETEABERRY OIL FLAVOR GENERIC TIER 99 DETEQUILA SUNR LIQ FLAVOR GENERIC TIER 99 DETOMMY GEL GEL BRAND TIER 99 DETRAGACANTH MIS RIBBON GENERIC TIER 99 DETRANSDERMAL CRE PAIN BAS BRAND TIER 03TRANSDERMAL DIS 2" X 3" GENERIC TIER 01TROLAMINE LIQ GENERIC TIER 99 DETROLAMINE LIQ 99% GENERIC TIER 99 DETUTTI FRUTTI LIQ FLAVOR GENERIC TIER 99 DETUTTI‐FRUTTI LIQ FLAVOR GENERIC TIER 99 DEULTRADERM CRE BRAND TIER 03VANILLA LIQ FLAVOR GENERIC TIER 99 DEVANILLA EXTR LIQ FLAVOR GENERIC TIER 99 DEVANISHING CRE BRAND TIER 03VANISHING CRE BASE II GENERIC TIER 01VANISH‐PEN CRE BRAND TIER 03VERSABASE AER BRAND TIER 99 DEVERSABASE CRE BRAND TIER 99 DEVERSABASE GEL BRAND TIER 99 DEVERSABASE LIQ TRANSDML BRAND TIER 99 DEVERSABASE LOT BRAND TIER 99 DEVERSABASE SHA BRAND TIER 99 DEVERSAFREE SYP BRAND TIER 03VERSAPLUS SYP BRAND TIER 03VERSAPRO CRE BRAND TIER 03VERSAPRO GEL BRAND TIER 99 DEWATERMELON LIQ FLAVOR GENERIC TIER 99 DEWHITE WAX MIS GENERIC TIER 99 DEWILD CHERRY LIQ FLAVOR GENERIC TIER 99 DEWILEY BASIC OIN BHRT BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion224

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS WITEPSOL H15 MIS BASE F GENERIC TIER 99 DEZINC ACETATE CRY USP GENERIC TIER 99 DEZINC SULFATE GRA HEPTAHYR GENERIC TIER 99 DEMETER BUFFER SOL PH 4 GENERIC TIER 99 DEMETER BUFFER SOL PH 7 GENERIC TIER 99 DECOLD CRE GENERIC TIER 01EMPTY CAPSUL CAP SIZE 1 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 2 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 3 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 4 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 5 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 7 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 0 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 00 GENERIC TIER 01CARAMEL LIQ COLOR GENERIC TIER 99 DEGRAPE LIQ FLAVOR GENERIC TIER 99 DEROOT BEER LIQ FLAVOR GENERIC TIER 99 DERASPBERRY LIQ FLAVOR GENERIC TIER 99 DECARAMEL LIQ FLAVOR GENERIC TIER 99 DEVANILLA LIQ BUTTERNU GENERIC TIER 99 DETROPICAL PUN LIQ FLAVOR GENERIC TIER 99 DEBEEF LIQ FLAVOR GENERIC TIER 99 DEBEEF FLAVOR LIQ GENERIC TIER 99 DEBEEF FLAVOR LIQ NATURAL GENERIC TIER 99 DEBITTER MASK LIQ FLAVOR GENERIC TIER 99 DEORA‐PLUS LIQ BRAND TIER 03ORA‐SWEET SYP BRAND TIER 03ORA‐BLEND SUS BRAND TIER 03ORA‐BLEND SF SUS BRAND TIER 03COLLODION LIQ FLEXIBLE GENERIC TIER 01CHOCOLATE CON FLAVOR GENERIC TIER 99 DEHORMONE CRE BASE GENERIC TIER 99 DEVANISHING CRE BOTANCAL BRAND TIER 03CREAM BASE CRE GENERIC TIER 01BASE CRE LIPOSOME GENERIC TIER 01POT SORBATE CRY GENERIC TIER 99 DEPLO20 BASE GEL BRAND TIER 03PLO20 BASE GEL GENERIC TIER 01CETYL ALCOHO GRA GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion225

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS WITEPSOL MIS BRAND TIER 99 DEBEESWAX MIS WHITE GENERIC TIER 99 DEBEESWAX MIS YELLOW GENERIC TIER 99 DEPHENOTHIAZINE DERIVATIVES PHENADOZ SUP 12.5MG GENERIC TIER 01PHENADOZ SUP 25MG GENERIC TIER 01PHENERGAN INJ 25MG/ML Brand‐O TIER 03 PAPHENERGAN INJ 50MG/ML Brand‐O TIER 03 PAPROMETH VC SYP 6.25‐5/5 GENERIC TIER 99 DEPROMETH VC SYP PLAIN GENERIC TIER 99 DEPROMETHAZINE INJ 25MG/ML GENERIC TIER 01PROMETHAZINE INJ 50MG/ML GENERIC TIER 01PROMETHAZINE SOL 6.25/5ML GENERIC TIER 01PROMETHAZINE SUP 12.5MG GENERIC TIER 01PROMETHAZINE SUP 25MG GENERIC TIER 01PROMETHAZINE SYP 6.25/5ML GENERIC TIER 01PROMETHAZINE TAB 12.5MG GENERIC TIER 01PROMETHAZINE TAB 25MG GENERIC TIER 01PROMETHAZINE TAB 50MG GENERIC TIER 01PROMETHEGAN SUP 12.5MG GENERIC TIER 01PROMETHEGAN SUP 25MG GENERIC TIER 01PROMETHEGAN SUP 50MG GENERIC TIER 01PHENOTHIAZINES CHLORPROMAZ INJ 25MG/ML GENERIC TIER 01CHLORPROMAZ TAB 100MG GENERIC TIER 01CHLORPROMAZ TAB 10MG GENERIC TIER 01CHLORPROMAZ TAB 200MG GENERIC TIER 01CHLORPROMAZ TAB 25MG GENERIC TIER 01CHLORPROMAZ TAB 50MG GENERIC TIER 01COMPRO SUP 25MG GENERIC TIER 01FLUPHENAZ DE INJ 25MG/ML GENERIC TIER 01FLUPHENAZINE CON 5MG/ML GENERIC TIER 01FLUPHENAZINE ELX 2.5/5ML GENERIC TIER 01FLUPHENAZINE INJ 2.5MG/ML GENERIC TIER 01FLUPHENAZINE TAB 10MG GENERIC TIER 01FLUPHENAZINE TAB 1MG GENERIC TIER 01FLUPHENAZINE TAB 2.5MG GENERIC TIER 01FLUPHENAZINE TAB 5MG GENERIC TIER 01PERPHENAZINE TAB 16MG GENERIC TIER 01PERPHENAZINE TAB 2MG GENERIC TIER 01PERPHENAZINE TAB 4MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion226

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHENOTHIAZINES PERPHENAZINE TAB 8MG GENERIC TIER 01PROCHLORPER INJ 5MG/ML GENERIC TIER 01PROCHLORPER SUP 25MG GENERIC TIER 01PROCHLORPER TAB 10MG GENERIC TIER 01PROCHLORPER TAB 5MG GENERIC TIER 01THIORIDAZINE TAB 100MG GENERIC TIER 01THIORIDAZINE TAB 10MG GENERIC TIER 01THIORIDAZINE TAB 25MG GENERIC TIER 01THIORIDAZINE TAB 50MG GENERIC TIER 01TRIFLUOPERAZ TAB 10MG GENERIC TIER 01TRIFLUOPERAZ TAB 1MG GENERIC TIER 01TRIFLUOPERAZ TAB 2MG GENERIC TIER 01TRIFLUOPERAZ TAB 5MG GENERIC TIER 01PHEOCHROMOCYTOMA ADREVIEW INJ BRAND TIER 99 DEHISTATROL INJ 0.275/ML BRAND TIER 03PHOSPHATE‐REMOVING AGENTS FOSRENOL CHW 1000MG BRAND TIER 02FOSRENOL CHW 500MG BRAND TIER 02FOSRENOL CHW 750MG BRAND TIER 02RENAGEL TAB 400MG BRAND TIER 03RENAGEL TAB 800MG BRAND TIER 03RENVELA PAK 0.8GM BRAND TIER 03RENVELA PAK 2.4GM BRAND TIER 03RENVELA TAB 800MG BRAND TIER 02PHOSPHODIESTERASE TYPE 4 INHIBITORS DALIRESP TAB 500MCG BRAND TIER 03 PAPHOSPHODIESTERASE TYPE 5 INHIBITORS ADCIRCA TAB 20MG BRAND TIER 03 PA SPLEVITRA TAB 10MG BRAND TIER 99 DELEVITRA TAB 2.5MG BRAND TIER 99 DELEVITRA TAB 20MG BRAND TIER 99 DELEVITRA TAB 5MG BRAND TIER 99 DEREVATIO INJ BRAND TIER 02 PA SPREVATIO TAB 20MG BRAND TIER 02 PA SPSTAXYN TAB 10MG BRAND TIER 99 DECIALIS TAB 2.5MG BRAND TIER 99 DECIALIS TAB 10MG BRAND TIER 99 DEVIAGRA TAB 25MG BRAND TIER 99 DECIALIS TAB 20MG BRAND TIER 99 DEVIAGRA TAB 50MG BRAND TIER 99 DEVIAGRA TAB 100MG BRAND TIER 99 DEPIGMENTING AGENTS 8‐MOP CAP 10MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion227

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPIGMENTING AGENTS METHOXSALEN CRY USP/NF GENERIC TIER 99 DEOXSORALEN LOT 1% BRAND TIER 02OXSORALEN‐UL CAP 10MG BRAND TIER 02UVADEX INJ 20MCG/ML BRAND TIER 03 SPPITUITARY ACTHAR HP INJ 80UNIT BRAND TIER 02 PA SPDDAVP INJ 4MCG/ML Brand‐O TIER 03 PADDAVP SOL 0.01% Brand‐O TIER 03 PADDAVP SPR 0.01% Brand‐O TIER 03 PADDAVP TAB 0.1MG Brand‐O TIER 03 PADDAVP TAB 0.2MG Brand‐O TIER 03 PADESMOPRESSIN INJ 4MCG/ML GENERIC TIER 01DESMOPRESSIN SOL 0.01% GENERIC TIER 01DESMOPRESSIN SPR 0.01% GENERIC TIER 01DESMOPRESSIN TAB 0.1MG GENERIC TIER 01DESMOPRESSIN TAB 0.2MG GENERIC TIER 01MINIRIN SPR NASAL GENERIC TIER 01PITRESSIN INJ 20UNT/ML Brand‐O TIER 03 PASTIMATE SOL 1.5MG/ML BRAND TIER 02VASOPRESSIN INJ 10/0.5ML GENERIC TIER 01VASOPRESSIN INJ 20UNT/ML GENERIC TIER 01PITUITARY FUNCTION ACTHREL INJ 100MCG BRAND TIER 03METOPIRONE CAP 250MG BRAND TIER 03R‐GENE 10 INJ 10% BRAND TIER 03PLATELET‐AGGREGATION INHIBITORS AGGRASTAT INJ 25MG/500 BRAND TIER 03AGGRENOX CAP 25‐200MG BRAND TIER 02BRILINTA TAB 90MG BRAND TIER 02CILOSTAZOL TAB 100MG GENERIC TIER 01CILOSTAZOL TAB 50MG GENERIC TIER 01CLOPIDOGREL TAB 300MG GENERIC TIER 01CLOPIDOGREL TAB 75MG GENERIC TIER 01EFFIENT TAB 10MG BRAND TIER 02EFFIENT TAB 5MG BRAND TIER 02INTEGRILIN INJ 0.75MG/1 BRAND TIER 03INTEGRILIN INJ 2MG/ML BRAND TIER 03PLAVIX TAB 300MG Brand‐O TIER 03 PAPLAVIX TAB 75MG Brand‐O TIER 03 PAPLETAL TAB 100MG Brand‐O TIER 03 PAPLETAL TAB 50MG Brand‐O TIER 03 PAREOPRO INJ 2MG/ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion228

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPLATELET‐AGGREGATION INHIBITORS TICLOPIDINE TAB 250MG GENERIC TIER 01PLATELET‐REDUCING AGENTS AGRYLIN CAP 0.5MG Brand‐O TIER 03 PAANAGRELIDE CAP 0.5MG GENERIC TIER 01ANAGRELIDE CAP 1MG GENERIC TIER 01POLYENES ABELCET INJ 5MG/ML BRAND TIER 03AMBISOME INJ 50MG BRAND TIER 03AMPHOTEC INJ 100MG BRAND TIER 03AMPHOTEC INJ 50MG BRAND TIER 03AMPHOTERICIN INJ 50MG GENERIC TIER 01BIO‐STATIN CAP 1000000 BRAND TIER 03BIO‐STATIN CAP 500000 BRAND TIER 03BXN MOUTHWSH SUS BRAND TIER 03FIRST DUKES SUS MOUTHWSH BRAND TIER 03FIRST‐MARYS SUS MOUTHWSH BRAND TIER 03NYSTATIN POW GENERIC TIER 99 DENYSTATIN POW 10BU GENERIC TIER 99 DENYSTATIN POW 150MU GENERIC TIER 99 DENYSTATIN POW 1BU GENERIC TIER 99 DENYSTATIN POW 2BU GENERIC TIER 99 DENYSTATIN POW 500MU GENERIC TIER 99 DENYSTATIN POW 50MU GENERIC TIER 99 DENYSTATIN POW 5BU GENERIC TIER 99 DENYSTATIN POW DOMESTIC GENERIC TIER 99 DENYSTATIN SUS 100000 GENERIC TIER 01NYSTATIN TAB 500000 GENERIC TIER 01POLYENES (SKIN & MUCOUS MEMBRANE) NYSTATIN CRE 100000 GENERIC TIER 01NYSTATIN OIN 100000 GENERIC TIER 01NYSTATIN VAG TAB 100000 GENERIC TIER 01PEDIADERM AF KIT COMPLETE BRAND TIER 03POLYMYXINS COLISTIMETH INJ 150MG GENERIC TIER 01COLY‐MYCIN M INJ 150MG Brand‐O TIER 03 PAPOLYMYXIN B INJ 500000 GENERIC TIER 01POTASSIUM‐REMOVING AGENTS KIONEX SUS 15GM/60 GENERIC TIER 01SOD POLY SUL SUS 15GM/60 GENERIC TIER 01SPS SUS 15GM/60 GENERIC TIER 01POTASSIUM‐SPARING DIURETICS AMILOR/HCTZ TAB 5‐50 GENERIC TIER 01AMILORIDE TAB 5MG GENERIC TIER 01DYAZIDE CAP 37.5‐25 Brand‐O TIER 03 PADYRENIUM CAP 100MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion229

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPOTASSIUM‐SPARING DIURETICS DYRENIUM CAP 50MG BRAND TIER 03MAXZIDE TAB 75‐50 Brand‐O TIER 03 PAMAXZIDE‐25 TAB Brand‐O TIER 03 PAMIDAMOR TAB 5MG Brand‐O TIER 03 PATRIAMT/HCTZ CAP 37.5‐25 GENERIC TIER 01TRIAMT/HCTZ TAB 37.5‐25 GENERIC TIER 01TRIAMT/HCTZ TAB 75‐50MG GENERIC TIER 01PROGESTINS AYGESTIN TAB 5MG Brand‐O TIER 03 PACRINONE GEL 4% VAG BRAND TIER 99 DECRINONE GEL 8% VAG BRAND TIER 99 DEDEPO‐PROVERA INJ 150MG/ML Brand‐O TIER 03 PADEPO‐PROVERA INJ 400/ML BRAND TIER 02 SPDEPO‐SQ PROV INJ 104 BRAND TIER 03ENDOMETRIN SUP 100MG BRAND TIER 99 DEMAKENA INJ 250MG/ML BRAND TIER 02 PA QLMEDROXYPR AC INJ 150MG/ML GENERIC TIER 01MEDROXYPR AC TAB 10MG GENERIC TIER 01 QLMEDROXYPR AC TAB 2.5MG GENERIC TIER 01 QLMEDROXYPR AC TAB 5MG GENERIC TIER 01 QLMEGACE ES SUS 625/5ML BRAND TIER 03NORETHIN ACE TAB 5MG GENERIC TIER 01PROGESTERONE CAP 100MG GENERIC TIER 01PROGESTERONE CAP 200MG GENERIC TIER 01PROGESTERONE INJ 50MG/ML GENERIC TIER 01PROGESTERONE SUP VGS 100 BRAND TIER 99 DEPROGESTERONE SUP VGS 200 BRAND TIER 99 DEPROGESTERONE SUP VGS 25 BRAND TIER 99 DEPROGESTERONE SUP VGS 400 BRAND TIER 99 DEPROGESTERONE SUP VGS 50 BRAND TIER 99 DEPROMETRIUM CAP 100MG Brand‐O TIER 03 PAPROMETRIUM CAP 200MG Brand‐O TIER 03 PAPROVERA TAB 10MG Brand‐O TIER 03 PA QLPROVERA TAB 2.5MG Brand‐O TIER 03 PA QLPROVERA TAB 5MG Brand‐O TIER 03 PA QLPROKINETIC AGENTS METOCLOPRAM INJ 5MG/ML GENERIC TIER 01METOCLOPRAM SOL 10/10ML GENERIC TIER 01METOCLOPRAM SOL 5MG/5ML GENERIC TIER 01METOCLOPRAM TAB 10MG GENERIC TIER 01METOCLOPRAM TAB 5MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion230

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROKINETIC AGENTS METOZOLV ODT TAB 10MG BRAND TIER 03 PA QLMETOZOLV ODT TAB 5MG BRAND TIER 03 PA QLREGLAN INJ 5MG/ML Brand‐O TIER 03 PAREGLAN TAB 10MG Brand‐O TIER 03 PAREGLAN TAB 5MG Brand‐O TIER 03 PAPROPYLAMINE DERIVATIVES AEROHIST TAB 8‐2.5MG BRAND TIER 03AEROKID SYP BRAND TIER 99 DEAHIST TAB 12MG BRAND TIER 03ALA‐HIST TAB 6‐25MG BRAND TIER 03ALA‐HIST D TAB 6‐25‐20 BRAND TIER 99 DEALENAZE‐D LIQ GENERIC TIER 99 DEALENAZE‐D NR LIQ GENERIC TIER 99 DEALLERSCRIPT MIS TABLETS BRAND TIER 99 DEALLERX MIS BRAND TIER 99 DEALLERX DF MIS Brand‐O TIER 03 PAALLERX DF 30 MIS Brand‐O TIER 03 PAALLERX PE MIS BRAND TIER 99 DEBIDHIST‐D TAB 6‐45MG GENERIC TIER 99 DEBPM TAB 6MG GENERIC TIER 01BPM PSEUDO TAB 6‐45MG GENERIC TIER 99 DEBROMAX TAB 11MG GENERIC TIER 01BROMPHENIRAM CHW 12MG GENERIC TIER 01BROMSPIRO LIQ 2MG/5ML GENERIC TIER 01CENHIST CHW 6‐15MG BRAND TIER 99 DECENTERGY DRO 1‐2MG/ML GENERIC TIER 99 DECHLOR‐MES D SYP LIQUID GENERIC TIER 99 DECHLOR‐MES JR CAP 4‐20MG GENERIC TIER 99 DEC‐TAN D PLUS SUS BRAND TIER 99 DEDALLERGY CHW BRAND TIER 99 DEDALLERGY SYP BRAND TIER 99 DEDALLERGY TAB BRAND TIER 99 DEDALLERGY TAB ER BRAND TIER 99 DEDALLERGY PE SYP BRAND TIER 99 DEDALLERGY PE TAB GENERIC TIER 99 DEDALLERGY PSE TAB BRAND TIER 99 DEDALLERGY‐JR SUS BRAND TIER 99 DEDECON‐A ELX 2‐5MG/5M BRAND TIER 99 DEDEHISTINE SYP GENERIC TIER 99 DEDEXCHLORPHEN SYP 2MG/5ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion231

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROPYLAMINE DERIVATIVES DEXCHLORPHEN TAB 4MG CR GENERIC TIER 01DRYMAX SYP BRAND TIER 99 DEED CHLORPED SUS 2MG/ML BRAND TIER 03ED CHLORPED SUS D BRAND TIER 99 DEED‐CHLOR‐TAN TAB 8MG BRAND TIER 03ENTRE‐B SUS 6‐10MG/5 GENERIC TIER 99 DEJ‐TAN D SUS BRAND TIER 99 DELODRANE 24 CAP BRAND TIER 03LODRANE 24D CAP 12‐90MG BRAND TIER 99 DELOHIST‐12 TAB 12 HOUR GENERIC TIER 01LOHIST‐12D TAB 6‐45MG GENERIC TIER 99 DEMYHIST‐PD LIQ GENERIC TIER 99 DENASOHIST DRO 1‐2MG/ML GENERIC TIER 99 DENEUTRAHIST DRO 0.8‐9MG GENERIC TIER 99 DENOHIST TAB 8‐20MG GENERIC TIER 99 DENOREL SD SYP GENERIC TIER 99 DEPHENA‐PLUS TAB BRAND TIER 99 DEPHENA‐S LIQ BRAND TIER 99 DEPOLY HIST PD LIQ BRAND TIER 99 DEPROHIST LQ LIQ BRAND TIER 99 DEPROTID TAB CR GENERIC TIER 99 DEQV‐ALLERGY SYP GENERIC TIER 99 DERELCOF CPM TAB 8‐2.5MG GENERIC TIER 01RELCOF DN MIS PSE BRAND TIER 99 DERELCOF DN PE MIS BRAND TIER 99 DERELCOF PE TAB GENERIC TIER 99 DERELCOF PSE TAB GENERIC TIER 99 DERELERA TAB GENERIC TIER 99 DERELHIST CHW BRAND TIER 99 DERESCON TAB BRAND TIER 99 DERESCON‐JR TAB GENERIC TIER 99 DERESCON‐MX TAB BRAND TIER 99 DERESPA‐A.R. TAB BRAND TIER 99 DERESPA‐BR TAB 11MG GENERIC TIER 01RESPIVENT MIS DF 30 GENERIC TIER 01RESPIVENT DF MIS GENERIC TIER 01RINATE SUS PEDI GENERIC TIER 99 DER‐TANNA SUS PEDI GENERIC TIER 99 DER‐TANNA TAB 9‐25MG GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion232

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROPYLAMINE DERIVATIVES RU‐HIST TAB FORTE GENERIC TIER 99 DERU‐TUSS TAB GENERIC TIER 99 DERYNATAN PEDI CHW 4.5‐5MG BRAND TIER 99 DERYNEZE LIQ BRAND TIER 03SUDAHIST TAB 12‐120MG GENERIC TIER 99 DEVAZOL LIQ 2MG/5ML BRAND TIER 03VAZOTAB CHW GENERIC TIER 99 DEV‐HIST SUS 6‐10MG/5 GENERIC TIER 99 DEZOTEX PE TAB BRAND TIER 99 DEZOTEX‐PE TAB 6‐30MG GENERIC TIER 99 DERYNATAN TAB 9‐25MG Brand‐O TIER 99 PA DEJ‐TAN D CHW 2.2‐1.58 Brand‐O TIER 99 PA DEPEDIATEX TD LIQ Brand‐O TIER 99 PA DERYNATAN PED SUS Brand‐O TIER 99 PA DEVAZOBID SUS 6‐10MG/5 Brand‐O TIER 99 PA DEDALLERGY JR CAP 4‐20MG Brand‐O TIER 99 PA DELODRANE 12D TAB 6‐45MG Brand‐O TIER 99 PA DESTAHIST TAB Brand‐O TIER 99 PA DEJ‐TAN D SR TAB 6‐30MG Brand‐O TIER 99 PA DEPROSTAGLANDIN ANALOGS LATANOPROST SOL 0.005% GENERIC TIER 01LUMIGAN SOL 0.01% BRAND TIER 02LUMIGAN SOL 0.03% BRAND TIER 02TRAVATAN Z DRO 0.004% BRAND TIER 02XALATAN SOL 0.005% Brand‐O TIER 03 PAZIOPTAN DRO 0.0015% BRAND TIER 03PROSTAGLANDINS CYTOTEC TAB 100MCG Brand‐O TIER 03 PACYTOTEC TAB 200MCG Brand‐O TIER 03 PAMISOPROSTOL TAB 100MCG GENERIC TIER 01MISOPROSTOL TAB 200MCG GENERIC TIER 01PROTECTANTS CARAFATE SUS 1GM/10ML BRAND TIER 02CARAFATE TAB 1GM Brand‐O TIER 03 PASUCRALFATE TAB 1GM GENERIC TIER 01PROTECTIVE AGENTS AMIFOSTINE INJ 500MG GENERIC TIER 01 SPDEXRAZOXANE INJ 250MG GENERIC TIER 01 SPDEXRAZOXANE INJ 500MG GENERIC TIER 99 DEETHYOL INJ 500MG Brand‐O TIER 03 PA SPMESNA INJ 1GM GENERIC TIER 01 SPMESNEX INJ 1GM Brand‐O TIER 03 PA SPMESNEX TAB 400MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion233

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROTECTIVE AGENTS TOTECT INJ 500MG BRAND TIER 99 DEZINECARD INJ 250MG Brand‐O TIER 03 PA SPZINECARD INJ 500MG Brand‐O TIER 99 PA DEPROTON‐PUMP INHIBITORS ACIPHEX TAB 20MG BRAND TIER 03 PA QLDEXILANT CAP 30MG DR BRAND TIER 03 PA QLDEXILANT CAP 60MG DR BRAND TIER 03 PA QLFIRST‐OMEPRA SUS 2MG/ML BRAND TIER 03 PALANSOPRAZOLE CAP 15MG DR GENERIC TIER 01 PA QLLANSOPRAZOLE CAP 30MG DR GENERIC TIER 01 PA QLLANSOPRAZOLE SUS 3MG/ML BRAND TIER 03 PALANSOPRAZOLE TAB 15MG ODT GENERIC TIER 01 PA QLLANSOPRAZOLE TAB 30MG ODT GENERIC TIER 01 PA QLNEXIUM CAP 20MG BRAND TIER 02 PA QLNEXIUM CAP 40MG BRAND TIER 02 PA QLNEXIUM GRA 10MG DR BRAND TIER 02 PA QLNEXIUM GRA 2.5MG DR BRAND TIER 02 PANEXIUM GRA 20MG DR BRAND TIER 02 PA QLNEXIUM GRA 40MG DR BRAND TIER 02 PA QLNEXIUM GRA 5MG DR BRAND TIER 02 PANEXIUM I.V. INJ 20MG BRAND TIER 03NEXIUM I.V. INJ 40MG BRAND TIER 03OMECLAMOX‐ MIS PAK BRAND TIER 03OMEPRA/BICAR CAP 20‐1100 GENERIC TIER 01 PA QLOMEPRA/BICAR CAP 40‐1100 GENERIC TIER 01 PA QLOMEPRAZOLE CAP 10MG GENERIC TIER 01 PA QLOMEPRAZOLE CAP 20MG GENERIC TIER 01 PA QLOMEPRAZOLE CAP 40MG GENERIC TIER 01 PA QLPANTOPRAZOLE TAB 20MG GENERIC TIER 01 PA QLPANTOPRAZOLE TAB 40MG GENERIC TIER 01 PA QLPREVACID CAP 15MG DR Brand‐O TIER 03 PA QLPREVACID CAP 30MG DR Brand‐O TIER 03 PA QLPREVACID TAB 15MG STB BRAND TIER 03 PA QLPREVACID TAB 30MG STB BRAND TIER 03 PA QLPREVPAC MIS BRAND TIER 03 PAPRILOSEC CAP 10MG Brand‐O TIER 03 PA QLPRILOSEC CAP 20MG Brand‐O TIER 03 PA QLPRILOSEC CAP 40MG Brand‐O TIER 03 PA QLPRILOSEC POW 10MG BRAND TIER 03 PA QLPRILOSEC POW 2.5MG BRAND TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion234

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROTON‐PUMP INHIBITORS PROTONIX INJ 40MG BRAND TIER 03 PAPROTONIX PAK BRAND TIER 03 PA QLPROTONIX TAB 20MG Brand‐O TIER 03 PA QLPROTONIX TAB 40MG Brand‐O TIER 03 PA QLZEGERID CAP 20‐1100 Brand‐O TIER 03 PA QLZEGERID CAP 40‐1100 Brand‐O TIER 03 PA QLZEGERID POW 20‐1680 BRAND TIER 03 PA QLZEGERID POW 40‐1680 BRAND TIER 03 PA QLPULMONARY SURFACTANTS CUROSURF SUS 80MG/ML BRAND TIER 03INFASURF SUS 35MG/ML BRAND TIER 03SURVANTA INH BRAND TIER 03PYRIMIDINES ANCOBON CAP 250MG Brand‐O TIER 03 PAANCOBON CAP 500MG Brand‐O TIER 03 PAFLUCYTOSINE CAP 250MG GENERIC TIER 01FLUCYTOSINE CAP 500MG GENERIC TIER 01QUINOLONES AVELOX INJ BRAND TIER 02AVELOX TAB 400MG BRAND TIER 02AVELOX ABC TAB 400MG BRAND TIER 02CIPRO TAB 250MG Brand‐O TIER 03 PACIPRO TAB 500MG Brand‐O TIER 03 PACIPRO (10%) SUS 500MG/5 BRAND TIER 02CIPRO (5%) SUS 250MG/5 BRAND TIER 02CIPROFLOXACN INJ 200MG GENERIC TIER 99 DECIPROFLOXACN INJ 400MG GENERIC TIER 99 DECIPROFLOXACN TAB 1000MG GENERIC TIER 01CIPROFLOXACN TAB 100MG GENERIC TIER 01CIPROFLOXACN TAB 250MG GENERIC TIER 01CIPROFLOXACN TAB 500MG GENERIC TIER 01CIPROFLOXACN TAB 500MG ER GENERIC TIER 01CIPROFLOXACN TAB 750MG GENERIC TIER 01FACTIVE TAB 320MG BRAND TIER 03LEVAQUIN INJ 25MG/ML Brand‐O TIER 03 PALEVAQUIN SOL 25MG/ML Brand‐O TIER 03 PALEVAQUIN TAB 250MG Brand‐O TIER 03 PALEVAQUIN TAB 500MG Brand‐O TIER 03 PALEVAQUIN TAB 750MG Brand‐O TIER 03 PALEVAQUIN/D5W INJ 250/50ML Brand‐O TIER 03 PALEVAQUIN/D5W INJ 500/100M Brand‐O TIER 03 PALEVAQUIN/D5W INJ 750/150 Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion235

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusQUINOLONES LEVOFLOX/D5W INJ 250/50ML GENERIC TIER 01LEVOFLOX/D5W INJ 500/100M GENERIC TIER 01LEVOFLOX/D5W INJ 750/150 GENERIC TIER 01LEVOFLOXACIN INJ 25MG/ML GENERIC TIER 01LEVOFLOXACIN SOL 25MG/ML GENERIC TIER 01LEVOFLOXACIN TAB 250MG GENERIC TIER 01LEVOFLOXACIN TAB 500MG GENERIC TIER 01LEVOFLOXACIN TAB 750MG GENERIC TIER 01NOROXIN TAB 400MG BRAND TIER 02OFLOXACIN TAB 200MG GENERIC TIER 01OFLOXACIN TAB 300MG GENERIC TIER 01OFLOXACIN TAB 400MG GENERIC TIER 01CIPRO I.V. INJ 200MG Brand‐O TIER 99 PA DECIPRO I.V. INJ 400MG Brand‐O TIER 99 PA DERADIOACTIVE AGENTS AMYVID INJ BRAND TIER 03QUADRAMET INJ BRAND TIER 99 DERENIN INHIBITORS AMTURNIDE150 TAB ‐5‐12.5 BRAND TIER 02 PAAMTURNIDE300 TAB ‐10‐12.5 BRAND TIER 02 PAAMTURNIDE300 TAB ‐10‐25MG BRAND TIER 02 PAAMTURNIDE300 TAB ‐5‐12.5 BRAND TIER 02 PAAMTURNIDE300 TAB ‐5‐25MG BRAND TIER 02 PATEKAMLO TAB 150‐10MG BRAND TIER 02 PATEKAMLO TAB 150‐5MG BRAND TIER 02 PATEKAMLO TAB 300‐10MG BRAND TIER 02 PATEKAMLO TAB 300‐5MG BRAND TIER 02 PATEKTURNA TAB 150MG BRAND TIER 02 PATEKTURNA TAB 300MG BRAND TIER 02 PATEKTURNA HCT TAB 150‐12.5 BRAND TIER 02 PATEKTURNA HCT TAB 150‐25MG BRAND TIER 02 PATEKTURNA HCT TAB 300‐12.5 BRAND TIER 02 PATEKTURNA HCT TAB 300‐25MG BRAND TIER 02 PAVALTURNA TAB 150‐160 BRAND TIER 02 PAVALTURNA TAB 300‐320 BRAND TIER 02 PAREPLACEMENT PREPARATIONS AMMON MOLYBD INJ 25MCG/ML GENERIC TIER 01BD POSIFLUSH INJ 0.9% GENERIC TIER 01CA CHLORIDE GRA ANHYDR GENERIC TIER 99 DECALC ACETATE CAP 667MG GENERIC TIER 01CALC ACETATE TAB 667MG GENERIC TIER 01CALC CHLORID GRA DIHYDRAT GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion236

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusREPLACEMENT PREPARATIONS CALCIFOL WAF BRAND TIER 03CALCIFOLIC‐D WAF Brand‐O TIER 03 PACALCIUM CL INJ 10% GENERIC TIER 01CALCIUM GLUC INJ 10% GENERIC TIER 01CALCIUM‐FA WAF PLUS D GENERIC TIER 01CARDIOPLEGIC SOL GENERIC TIER 01CHLOROMAG INJ 20% GENERIC TIER 99 DECHROMIUM CL INJ 4MCG/ML GENERIC TIER 01COPPER SULF INJ 0.4MG/ML GENERIC TIER 01CUPRIC CHLOR INJ 0.4MG/ML GENERIC TIER 01CUPRIC SULF GRA PENTAHYD GENERIC TIER 99 DED10W/NACL INJ 0.2% GENERIC TIER 01D10W/NACL INJ 0.225% GENERIC TIER 01D10W/NACL INJ 0.45% GENERIC TIER 01D10W/NACL INJ 0.9% GENERIC TIER 01D2.5W/NACL INJ 0.45% GENERIC TIER 01D5W/LR INJ GENERIC TIER 01D5W/LYTES INJ #48 GENERIC TIER 01D5W/NACL INJ 0.2% GENERIC TIER 01D5W/NACL INJ 0.225% GENERIC TIER 01D5W/NACL INJ 0.3% GENERIC TIER 01D5W/NACL INJ 0.33% GENERIC TIER 01D5W/NACL INJ 0.45% GENERIC TIER 01D5W/NACL INJ 0.9% GENERIC TIER 01D5W/RINGERS INJ GENERIC TIER 01DEXTRAN 70 INJ 6% GENERIC TIER 01DEXTRAN HM INJ 32% GENERIC TIER 01DOLOMITE GRA GENERIC TIER 99 DEEFFER‐K TAB 10MEQ BRAND TIER 02EFFER‐K TAB 20MEQ BRAND TIER 02EFFER‐K TAB 25MEQ EF GENERIC TIER 01ELIPHOS TAB 667MG Brand‐O TIER 03 PAELLIOTTS B INJ BRAND TIER 03EPIKLOR POW 20MEQ GENERIC TIER 01EPIKLOR/25 POW 25MEQ GENERIC TIER 01GALZIN CAP 25MG BRAND TIER 03GALZIN CAP 50MG BRAND TIER 03HESPAN INJ 6%/NACL Brand‐O TIER 03 PAHETASTARCH INJ 6%/NACL GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion237

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusREPLACEMENT PREPARATIONS HEXTEND SOL 6% BRAND TIER 03HYPERLYTE‐CR INJ GENERIC TIER 01IONOSOL‐B/ INJ D5W BRAND TIER 03IONOSOL‐MB INJ /D5W BRAND TIER 03ISOLYTE‐H INJ /D5W BRAND TIER 03ISOLYTE‐M INJ /D5W GENERIC TIER 01ISOLYTE‐P INJ /D5W BRAND TIER 03ISOLYTE‐S INJ BRAND TIER 03ISOLYTE‐S INJ /D5W BRAND TIER 03ISOLYTE‐S INJ PH 7.4 BRAND TIER 03KCL IN NACL INJ GENERIC TIER 01KCL/D5W INJ 0.15% GENERIC TIER 01 SPKCL/D5W INJ 0.224% GENERIC TIER 01 SPKCL/D5W INJ 0.3% GENERIC TIER 01 SPKCL/D5W/LR INJ 0.15% GENERIC TIER 01 SPKCL/D5W/LR INJ 0.3% GENERIC TIER 01 SPKCL/D5W/NACL INJ .075/.2% GENERIC TIER 01 SPKCL/D5W/NACL INJ .075/.45 GENERIC TIER 01 SPKCL/D5W/NACL INJ .15‐.45% GENERIC TIER 01 SPKCL/D5W/NACL INJ .15/.33% GENERIC TIER 01 SPKCL/D5W/NACL INJ .15/.45% GENERIC TIER 01 SPKCL/D5W/NACL INJ .22/.45 GENERIC TIER 01 SPKCL/D5W/NACL INJ .224/.45 GENERIC TIER 01 SPKCL/D5W/NACL INJ 0.15/0.2 GENERIC TIER 01 SPKCL/D5W/NACL INJ 0.15/0.9 GENERIC TIER 01 SPKCL/D5W/NACL INJ 0.3/0.2% GENERIC TIER 01 SPKCL/D5W/NACL INJ 0.3/0.45 GENERIC TIER 01 SPKCL/D5W/NACL INJ 0.3/0.9% GENERIC TIER 01 SPKCL/NACL INJ 0.15‐0.9 GENERIC TIER 01KCL/NACL INJ 0.3‐0.9 GENERIC TIER 01K‐EFFERVESCE TAB 25MEQ EF GENERIC TIER 01K‐LOR POW 20MEQ Brand‐O TIER 03 PAKLOR‐CON POW 20MEQ GENERIC TIER 01KLOR‐CON 10 TAB 10MEQ ER GENERIC TIER 01KLOR‐CON 8 TAB 8MEQ ER GENERIC TIER 01KLOR‐CON M10 TAB 10MEQ ER GENERIC TIER 01KLOR‐CON M15 TAB BRAND TIER 03KLOR‐CON M20 TAB 20MEQ ER GENERIC TIER 01KLOR‐CON/EF TAB 25MEQ FR GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion238

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusREPLACEMENT PREPARATIONS KLOR‐CON‐25 POW 25MEQ BRAND TIER 03K‐PHOS TAB BRAND TIER 03K‐PHOS TAB NEUTRAL Brand‐O TIER 03 PAK‐PRIME TAB 25MEQ EF GENERIC TIER 01K‐TABS TAB 10MEQ CR Brand‐O TIER 03 PAK‐VESCENT POW 20MEQ GENERIC TIER 01K‐VESCENT TAB 25MEQ EF GENERIC TIER 01LACTATED RIN INJ GENERIC TIER 01LMD 10%/D5W INJ GENERIC TIER 01LMD 10%/NACL INJ 0.9% GENERIC TIER 01MAG CARB GRA GENERIC TIER 99 DEMAGN CHLORID CRY HEXAHYDR GENERIC TIER 99 DEMAGN CHLORID MIS FLAKES GENERIC TIER 99 DEMAGNEBIND TAB 400 BRAND TIER 03MAGNESIUM CL INJ 20% GENERIC TIER 99 DEMANGANESE CL INJ 0.1MG/ML GENERIC TIER 01MANGANESE SU INJ 0.1MG/ML GENERIC TIER 01MG SO4/D5W INJ 10MG/ML GENERIC TIER 01MG SO4/D5W INJ 20MG/ML GENERIC TIER 01MICRO‐K CAP 10MEQ CR Brand‐O TIER 03 PAMICRO‐K CAP 8MEQ CR Brand‐O TIER 03 PAMONOJECT INJ PREFILL GENERIC TIER 01MULTITRACE‐4 INJ GENERIC TIER 01 SPMULTITRACE‐4 INJ CONC GENERIC TIER 01 SPMULTITRACE‐4 INJ NEONATAL GENERIC TIER 01 SPMULTITRACE‐4 INJ PED BRAND TIER 03 SPMULTITRACE‐5 INJ GENERIC TIER 01MULTITRACE‐5 INJ CONC GENERIC TIER 01MULTITRACE‐5 INJ REGULAR GENERIC TIER 01NACL/BACT INJ 0.9%BENZ GENERIC TIER 01NORMAL SALIN INJ 0.9% GENERIC TIER 01NORML SALINE INJ FLUSH GENERIC TIER 01NORML SALINE INJ IV FLUSH GENERIC TIER 01NORMOSOL ‐M INJ /D5W GENERIC TIER 01NORMOSOL ‐R INJ GENERIC TIER 01NORMOSOL ‐R INJ /D5W GENERIC TIER 01NORMOSOL‐R INJ PH 7.4 BRAND TIER 03NUTRILYTE INJ GENERIC TIER 99 DENUTRILYTE II INJ GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion239

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusREPLACEMENT PREPARATIONS PHOSLO CAP 667MG Brand‐O TIER 02 PAPHOSLYRA SOL BRAND TIER 03PHOSPHA 250 TAB NEUTRAL GENERIC TIER 01PLASMA‐LYTE INJ ‐148 BRAND TIER 03PLASMA‐LYTE INJ 56/D5W BRAND TIER 03PLASMA‐LYTE INJ ‐A BRAND TIER 03PLEGISOL SOL Brand‐O TIER 03 PAPOT ACETATE INJ 2MEQ/ML GENERIC TIER 01POT ACETATE INJ 4MEQ/ML GENERIC TIER 01POT BICARBON GRA GENERIC TIER 99 DEPOT BICARBON TAB 25MEQ EF GENERIC TIER 01POT CHLORIDE CAP 10MEQ ER GENERIC TIER 01POT CHLORIDE CAP 8MEQ ER GENERIC TIER 01POT CHLORIDE GRA GENERIC TIER 99 DEPOT CHLORIDE INJ 10MEQ GENERIC TIER 01POT CHLORIDE INJ 20MEQ GENERIC TIER 01POT CHLORIDE INJ 2MEQ/ML GENERIC TIER 01POT CHLORIDE INJ 30MEQ GENERIC TIER 01POT CHLORIDE INJ 40MEQ GENERIC TIER 01POT CHLORIDE LIQ 10% GENERIC TIER 01POT CHLORIDE LIQ 20% GENERIC TIER 01POT CHLORIDE LIQ 20% SF GENERIC TIER 01POT CHLORIDE SOL 10% SF GENERIC TIER 01POT CHLORIDE TAB 10MEQ CR GENERIC TIER 01POT CHLORIDE TAB 10MEQ ER GENERIC TIER 01POT CHLORIDE TAB 25MEQ EF GENERIC TIER 01POT CHLORIDE TAB 8MEQ ER GENERIC TIER 01POT CHLORIDE TAB 8MEQ SR GENERIC TIER 01POT CITRATE GRA MONOHYDR GENERIC TIER 99 DEPOT CL MICRO TAB 10MEQ CR GENERIC TIER 01POT CL MICRO TAB 10MEQ ER GENERIC TIER 01POT CL MICRO TAB 20MEQ ER GENERIC TIER 01POT PHOSPHAT CRY MONOBASI GENERIC TIER 99 DEPOT PHOSPHAT GRA DIBASIC GENERIC TIER 99 DEPOT PHOSPHAT INJ 3MM/ML GENERIC TIER 01POT/CHLORIDE TAB 25MEQ EF GENERIC TIER 01POTASSIUM TAB 25MEQ EF GENERIC TIER 01PRISMASOL SOL 0/0/1.2 BRAND TIER 03PRISMASOL SOL 0/2.5 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion240

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusREPLACEMENT PREPARATIONS PRISMASOL SOL 2/0 BRAND TIER 03PRISMASOL SOL 2/3.5 BRAND TIER 03PRISMASOL SOL 4/0/1.2 BRAND TIER 03PRISMASOL SOL 4/2.5 BRAND TIER 03PRISMASOL SOL B22GK2/0 BRAND TIER 03PRISMASOL SOL B22GK4/0 BRAND TIER 03RINGERS INJ GENERIC TIER 01SALINE FLUSH INJ 0.9% GENERIC TIER 01SALINE/PHENO SOL GENERIC TIER 01SELENIUM INJ 40MCG/ML GENERIC TIER 01SOD CHLORIDE INJ 0.45% GENERIC TIER 01SOD CHLORIDE INJ 0.9% GENERIC TIER 01SOD CHLORIDE INJ 0.9%BACT GENERIC TIER 01SOD CHLORIDE INJ 2.5/ML GENERIC TIER 01SOD CHLORIDE INJ 23.4% GENERIC TIER 01SOD CHLORIDE INJ 3% GENERIC TIER 01SOD CHLORIDE INJ 4MEQ/ML GENERIC TIER 01SOD CHLORIDE INJ 5% GENERIC TIER 01SOD PHOSPHAT INJ 3MM/ML GENERIC TIER 01TPN ELECTROL INJ GENERIC TIER 99 DETPN ELECTROL INJ II GENERIC TIER 01TRACE ELEM 4 INJ PED BRAND TIER 03 SPTRACE METALS INJ GENERIC TIER 01 SPVOLUVEN INJ 6%/NACL BRAND TIER 03ZINC ACETATE CRY GENERIC TIER 99 DEZINC SULFATE GRA USP/NF GENERIC TIER 99 DEZINC SULFATE INJ 1MG/ML GENERIC TIER 01ZINC SULFATE INJ 5MG/ML GENERIC TIER 01ZINC TRACE INJ 1MG/ML GENERIC TIER 01ZINCATE CAP 220MG GENERIC TIER 01ZYTAZE CAP 25‐500 BRAND TIER 99 DEZINC SULFATE CAP 220MG GENERIC TIER 01POT CITRATE GRA GENERIC TIER 99 DESOD CHLORIDE GRA GENERIC TIER 99 DEZINC CHLORID GRA GENERIC TIER 99 DERESPIRATORY FUNCTION ARIDOL KIT BRAND TIER 99 DERESPIRATORY SMOOTH MUSCLE RELAXANTS AMINOPHYLLIN INJ 25MG/ML GENERIC TIER 01AMINOPHYLLIN TAB 100MG GENERIC TIER 01AMINOPHYLLIN TAB 200MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion241

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusRESPIRATORY SMOOTH MUSCLE RELAXANTS BRONCOMAR‐1 ELX BRAND TIER 03BRONDIL LIQ BRAND TIER 03COPD TAB 200‐200 GENERIC TIER 01DG 200 TAB 200‐200 GENERIC TIER 01DIFIL‐G 400 TAB GENERIC TIER 01DIFIL‐G FORT LIQ 100‐100 GENERIC TIER 01DILEX‐G 200 SYP BRAND TIER 03DILEX‐G 400 TAB Brand‐O TIER 03 PADYFLEX‐G TAB 200‐200 GENERIC TIER 01DY‐G LIQ 100‐100 GENERIC TIER 01DYLIX ELX 100/15ML GENERIC TIER 01DYPHYLLIN GG TAB 200‐200 GENERIC TIER 01DYPHYLLIN‐GG ELX 100‐100 GENERIC TIER 01ED‐BRON G SYP BRAND TIER 03ELIXOPHYLLIN ELX 80/15ML BRAND TIER 02JAY‐PHYL SYP GENERIC TIER 01LUFYLLIN TAB 200MG BRAND TIER 03LUFYLLIN TAB 400MG BRAND TIER 03LUFYLLIN‐GG ELX 100‐100 Brand‐O TIER 03 PAPULMOPHYLLIN PAK BRAND TIER 03SENOPHYLLINE PAK BRAND TIER 03THEO‐24 CAP 100MG CR BRAND TIER 03THEO‐24 CAP 200MG CR BRAND TIER 03THEO‐24 CAP 300MG CR BRAND TIER 03THEO‐24 CAP 400MG ER BRAND TIER 03THEOCHRON TAB 100MG CR GENERIC TIER 01THEOCHRON TAB 200MG CR GENERIC TIER 01THEOCHRON TAB 300MG CR GENERIC TIER 01THEOPHYL/D5W INJ 0.8MG/ML GENERIC TIER 01THEOPHYL/D5W INJ 1.6MG/ML GENERIC TIER 01THEOPHYL/D5W INJ 3.2MG/ML GENERIC TIER 01THEOPHYLLINE SOL 80/15ML GENERIC TIER 01THEOPHYLLINE TAB 100MG CR GENERIC TIER 01THEOPHYLLINE TAB 100MG ER GENERIC TIER 01THEOPHYLLINE TAB 200MG CR GENERIC TIER 01THEOPHYLLINE TAB 200MG ER GENERIC TIER 01THEOPHYLLINE TAB 300MG ER GENERIC TIER 01THEOPHYLLINE TAB 400MG ER GENERIC TIER 01THEOPHYLLINE TAB 450MG ER GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion242

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusRESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE TAB 600MG ER GENERIC TIER 01RESPIRATORY TRACT AGENTS, MISCELLANEOUS ARALAST NP INJ 1000MG BRAND TIER 02 SPARALAST NP INJ 400MG BRAND TIER 03 SPARALAST NP INJ 500MG BRAND TIER 02 SPARALAST NP INJ 800MG BRAND TIER 03 SPGLASSIA INJ BRAND TIER 03 SPKALYDECO TAB 150MG BRAND TIER 02PROLASTIN INJ 1000MG BRAND TIER 02 SPPROLASTIN INJ 500MG BRAND TIER 02 SPPROLASTIN‐C INJ 1000MG BRAND TIER 02 SPXOLAIR SOL 150MG BRAND TIER 03 PA SPZEMAIRA INJ 1000MG BRAND TIER 02 SPRIFAMYCINS XIFAXAN TAB 200MG BRAND TIER 03 PA QLXIFAXAN TAB 550MG BRAND TIER 02 PA QLROENTGENOGRAPHY BAR‐TEST TAB 650MG BRAND TIER 03CHOLOGRAFIN INJ 52% BRAND TIER 03CONRAY INJ 60% BRAND TIER 03CONRAY 30 INJ 30% BRAND TIER 03CONRAY 43 INJ 43% BRAND TIER 03CYSTO‐CONRAY INJ II 17.2% BRAND TIER 03CYSTOGRAFIN INJ 30% BRAND TIER 03CYSTOGRAFIN‐ INJ DILUTE BRAND TIER 03DIGIBAR 190 SUS BRAND TIER 99 DEENTERO VU POW 13% BRAND TIER 99 DEENTERO VU SUS 13% BRAND TIER 03ENTERO VU SUS 24% BRAND TIER 03ESOPHO‐CAT CRE 3% BRAND TIER 03E‐Z‐CAT DRY PAK BRAND TIER 03E‐Z‐DISK TAB 700MG BRAND TIER 99 DEE‐Z‐DOSE ENE BRAND TIER 03E‐Z‐HD SUS 98% BRAND TIER 03E‐Z‐PAQUE SUS 60% BRAND TIER 03E‐Z‐PAQUE SUS 96% BRAND TIER 03E‐Z‐PASTE CRE 60% BRAND TIER 99 DEFERIDEX I.V. INJ 11.2MF F BRAND TIER 03GADAVIST INJ 1MMOL/ML BRAND TIER 99 DEGASTROGRAFIN SOL Brand‐O TIER 03 PAGASTROMARK SUS 175MCG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion243

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusROENTGENOGRAPHY GLOFIL‐125 INJ 0.1% BRAND TIER 03ISOVUE‐200 INJ 41% BRAND TIER 03ISOVUE‐250 INJ 51% BRAND TIER 03ISOVUE‐250 INJ 51%MLTPK BRAND TIER 03ISOVUE‐300 INJ 61% BRAND TIER 03ISOVUE‐300 INJ 61%MLTPK BRAND TIER 03ISOVUE‐370 INJ 76% BRAND TIER 03ISOVUE‐370 INJ 76%MLTPK BRAND TIER 03ISOVUE‐M 200 INJ 41% BRAND TIER 03ISOVUE‐M 300 INJ 61% BRAND TIER 03MAXIBAR SUS 210% BRAND TIER 03MD‐76 R INJ BRAND TIER 03MD‐GASTROVIE SOL 66‐10% GENERIC TIER 01MULTIHANCE SOL BRAND TIER 03OMNIPAQUE INJ 180MG/ML BRAND TIER 03OMNIPAQUE INJ 240MG/ML BRAND TIER 03OMNIPAQUE INJ 300MG/ML BRAND TIER 03OMNIPAQUE INJ 350MG/ML BRAND TIER 03OPTIRAY 160 INJ 34% BRAND TIER 03OPTIRAY 240 INJ 51% BRAND TIER 03OPTIRAY 300 INJ 64% BRAND TIER 03OPTIRAY 320 INJ 68% BRAND TIER 03OPTIRAY 350 INJ 74% BRAND TIER 03POLIBAR SUS 100% BRAND TIER 03POLIBAR ACB KIT 96% BRAND TIER 03POLIBAR PLUS SUS 105% BRAND TIER 99 DEREADI‐CAT SUS 1.3% BRAND TIER 03READI‐CAT 2 SUS 2.1% BRAND TIER 03READI‐CAT 2 SUS APPLE BRAND TIER 03READI‐CAT 2 SUS BANANA BRAND TIER 03READI‐CAT 2 SUS BERRY BRAND TIER 03READI‐CAT 2 SUS MOCHACCI BRAND TIER 03READI‐CAT 2 SUS VANILLA BRAND TIER 03SINOGRAFIN INJ BRAND TIER 03SITZMARKS CAP BRAND TIER 03TAGITOL V SUS 40% BRAND TIER 03ULTRAVIST INJ 150MG/ML BRAND TIER 03ULTRAVIST INJ 240MG/ML BRAND TIER 03ULTRAVIST INJ 300MG/ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion244

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusROENTGENOGRAPHY ULTRAVIST INJ 370MG/ML BRAND TIER 03VARIBAR PST PUDDING BRAND TIER 99 DEVARIBAR HONE SUS 40% BRAND TIER 03VARIBAR NECT SUS 40% BRAND TIER 03VARIBAR THIN SUS HONEY BRAND TIER 03VARIBAR THIN SUS LIQUID BRAND TIER 99 DEVISIPAQUE INJ 270MG/ML BRAND TIER 03VISIPAQUE INJ 320MG/ML BRAND TIER 03VOLUMEN SUS 0.1% BRAND TIER 03SALICYLATES BUT/ASA/CAFF CAP GENERIC TIER 01BUT/ASA/CAFF TAB GENERIC TIER 01BUTALBITAL TAB CPD GENERIC TIER 01CHO MAG TRIS LIQ 500/5ML GENERIC TIER 01CHO MAG TRIS TAB 1000MG GENERIC TIER 01CHO MAG TRIS TAB 500MG GENERIC TIER 01CHO MAG TRIS TAB 750MG GENERIC TIER 01FIORINAL CAP Brand‐O TIER 03 PALEVACET TAB BRAND TIER 03MST 600 TAB GENERIC TIER 01ORPHEN CPD TAB DS GENERIC TIER 01SALSALATE TAB 500MG GENERIC TIER 01SALSALATE TAB 750MG GENERIC TIER 01SOD SALICYLA CRY USP GENERIC TIER 99 DESOD SALICYLA CRY USP NF GENERIC TIER 99 DEORPH/ASA/CAF TAB GENERIC TIER 99 DESALT AND SUGAR SUBSTITUTES ASPARTAME POW BRAND TIER 99 DESOD SACCHARI GRA USP GENERIC TIER 01SOD SACCHARI GRA GENERIC TIER 01SCABICIDES AND PEDICULICIDES ACTICIN CRE 5% GENERIC TIER 01EURAX CRE 10% BRAND TIER 02EURAX LOT 10% BRAND TIER 02LINDANE LOT 1% GENERIC TIER 01LINDANE SHA 1% GENERIC TIER 01LYCELLE GEL BRAND TIER 03MALATHION LOT 0.5% GENERIC TIER 01NATROBA SUS 0.9% BRAND TIER 03OVIDE LOT 0.5% Brand‐O TIER 03 PAPERMETHRIN CRE 5% GENERIC TIER 01SPINOSAD SUS 0.9% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion245

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSCABICIDES AND PEDICULICIDES SULF LIME SOL USP GENERIC TIER 01ULESFIA LOT 5% BRAND TIER 02ELIMITE CRE 5% Brand‐O TIER 03 PASCLEROSING AGENTS ASCLERA INJ 0.5% BRAND TIER 03ASCLERA INJ 1% BRAND TIER 03ETHAMOLIN INJ 5% BRAND TIER 03MORRHUAT SOD INJ 5% GENERIC TIER 01SCLEROMATE INJ 5% GENERIC TIER 01SCLEROSOL AER INTRAPLE BRAND TIER 03SOTRADECOL INJ 1% BRAND TIER 03SOTRADECOL INJ 3% BRAND TIER 03STERIL TALC SUS 5GM BRAND TIER 03SECOND GENERATION ANTIHISTAMINES CETIRIZINE SYP 5MG/5ML GENERIC TIER 01 PACLARINEX SYP 0.5MG/ML BRAND TIER 02 PACLARINEX TAB 5MG Brand‐O TIER 03 PACLARINEX RDT TAB 2.5MG BRAND TIER 02 PACLARINEX RDT TAB 5MG BRAND TIER 02 PADESLORATADIN TAB 5MG GENERIC TIER 01 PAFEXOFENADINE TAB 180MG GENERIC TIER 01 PAFEXOFENADINE TAB 30MG GENERIC TIER 01 PAFEXOFENADINE TAB 60MG GENERIC TIER 01 PALEVOCETIRIZI SOL 2.5/5ML GENERIC TIER 01 PALEVOCETIRIZI TAB DHCL 5MG GENERIC TIER 01 PASEMPREX‐D CAP 8‐60MG BRAND TIER 99 DEXYZAL SOL Brand‐O TIER 03 PAXYZAL TAB 5MG Brand‐O TIER 03 PAFEXOFEN/PSE TAB 60‐120MG GENERIC TIER 99 DECETIRIZINE SYP 1MG/ML GENERIC TIER 01 PASECOND GENERATION CEPHALOSPORINS CEFACLOR CAP 250MG GENERIC TIER 01CEFACLOR CAP 500MG GENERIC TIER 01CEFACLOR ER TAB 500MG GENERIC TIER 01CEFPROZIL SUS 125/5ML GENERIC TIER 01CEFPROZIL SUS 250/5ML GENERIC TIER 01CEFPROZIL TAB 250MG GENERIC TIER 01CEFPROZIL TAB 500MG GENERIC TIER 01CEFTIN SUS 125/5ML Brand‐O TIER 02 PACEFTIN SUS 250/5ML BRAND TIER 02CEFTIN TAB 250MG Brand‐O TIER 03 PACEFTIN TAB 500MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion246

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSECOND GENERATION CEPHALOSPORINS CEFUROX/DEXT INJ 1.5GM GENERIC TIER 01CEFUROX/DEXT INJ 750MG GENERIC TIER 01CEFUROXIME INJ 1.5GM GENERIC TIER 01CEFUROXIME INJ 225GM GENERIC TIER 01CEFUROXIME INJ 7.5GM GENERIC TIER 01CEFUROXIME INJ 750MG GENERIC TIER 01CEFUROXIME INJ 75GM GENERIC TIER 01CEFUROXIME SUS 125/5ML GENERIC TIER 01CEFUROXIME TAB 250MG GENERIC TIER 01CEFUROXIME TAB 500MG GENERIC TIER 01ZINACEF INJ 1.5GM Brand‐O TIER 03 PAZINACEF INJ 7.5GM GENERIC TIER 01ZINACEF INJ 750MG BRAND TIER 03ZINACEF/D5W INJ 750MG PB BRAND TIER 03ZINACEF/H20 INJ 1.5GM PB BRAND TIER 03SEL. SEROTONIN & NOREPI REUPTAKE INHIBTR CYMBALTA CAP 20MG BRAND TIER 02 PA QLCYMBALTA CAP 30MG BRAND TIER 02 PA QLCYMBALTA CAP 60MG BRAND TIER 02 PA QLEFFEXOR XR CAP 150MG Brand‐O TIER 03 PA QLEFFEXOR XR CAP 37.5MG Brand‐O TIER 03 PA QLEFFEXOR XR CAP 75MG Brand‐O TIER 03 PA QLPRISTIQ TAB 100MG BRAND TIER 02 PA QLPRISTIQ TAB 50MG BRAND TIER 02 PA QLVENLAFAXINE CAP 150MG ER GENERIC TIER 01 QLVENLAFAXINE CAP 37.5MG GENERIC TIER 01 QLVENLAFAXINE CAP 75MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 100MG GENERIC TIER 01 QLVENLAFAXINE TAB 150MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 225MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 25MG GENERIC TIER 01 QLVENLAFAXINE TAB 37.5 ER GENERIC TIER 01 QLVENLAFAXINE TAB 37.5MG GENERIC TIER 01 QLVENLAFAXINE TAB 50MG GENERIC TIER 01 QLVENLAFAXINE TAB 75MG GENERIC TIER 01 QLVENLAFAXINE TAB 75MG ER GENERIC TIER 01 QLSELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT ALFUZOSIN TAB 10MG GENERIC TIER 01 PA QLFLOMAX CAP 0.4MG Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion247

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT RAPAFLO CAP 4MG BRAND TIER 02 PA QLRAPAFLO CAP 8MG BRAND TIER 02 PA QLTAMSULOSIN CAP 0.4MG GENERIC TIER 01UROXATRAL TAB 10MG Brand‐O TIER 03 PA QLSELECTIVE BETA‐1‐ADRENERGIC AGONISTS DOBUTAM/D5W INJ 1MG/ML GENERIC TIER 01DOBUTAM/D5W INJ 2MG/ML GENERIC TIER 01DOBUTAM/D5W INJ 4MG/ML GENERIC TIER 01DOBUTAMINE INJ 250MG GENERIC TIER 01DOBUTAMINE INJ 500MG GENERIC TIER 01DOPAMINE INJ 160MG/ML GENERIC TIER 01DOPAMINE INJ 40MG/ML GENERIC TIER 01DOPAMINE INJ 80MG/ML GENERIC TIER 01DOPAMINE/D5W INJ 0.8MG/ML GENERIC TIER 01DOPAMINE/D5W INJ 1.6MG/ML GENERIC TIER 01 SPDOPAMINE/D5W INJ 3.2MG/ML GENERIC TIER 01SELECTIVE BETA‐2‐ADRENERGIC AGONISTS ACCUNEB NEB 0.63MG/3 Brand‐O TIER 03 PA QLACCUNEB NEB 1.25MG/3 Brand‐O TIER 03 PA QLADVAIR DISKU AER 100/50 BRAND TIER 03 PA QLADVAIR DISKU AER 250/50 BRAND TIER 03 PA QLADVAIR DISKU AER 500/50 BRAND TIER 03 PA QLADVAIR HFA AER 115/21 BRAND TIER 03 PA QLADVAIR HFA AER 230/21 BRAND TIER 03 PA QLADVAIR HFA AER 45/21 BRAND TIER 03 PA QLALBUTEROL NEB 0.083% GENERIC TIER 01 QLALBUTEROL NEB 0.5% GENERIC TIER 01 QLALBUTEROL NEB 0.63MG/3 GENERIC TIER 01 QLALBUTEROL NEB 1.25MG/3 GENERIC TIER 01 QLALBUTEROL SYP 2MG/5ML GENERIC TIER 01ALBUTEROL TAB 2MG GENERIC TIER 01ALBUTEROL TAB 4MG GENERIC TIER 01ALBUTEROL TAB 4MG ER GENERIC TIER 01ALBUTEROL TAB 8MG ER GENERIC TIER 01ARCAPTA CAP 75MCG BRAND TIER 03 PA QLBROVANA NEB 15MCG BRAND TIER 03COMBIVENT AER BRAND TIER 02 QLCOMBIVENT AER RESPIMAT BRAND TIER 02DUONEB SOL Brand‐O TIER 03 PA QLFORADIL CAP AEROLIZE BRAND TIER 02 QLIPRATROPIUM/ SOL ALBUTER GENERIC TIER 01 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion248

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE BETA‐2‐ADRENERGIC AGONISTS LEVALBUTEROL NEB 0.31MG GENERIC TIER 01 PA QLLEVALBUTEROL NEB 0.63MG GENERIC TIER 01 PA QLLEVALBUTEROL NEB 1.25/0.5 GENERIC TIER 01 PALEVALBUTEROL NEB 1.25MG GENERIC TIER 01 PA QLMAXAIR AUTOH AER 200MCG BRAND TIER 03 QLMETAPROTEREN SYP 10MG/5ML GENERIC TIER 01METAPROTEREN TAB 10MG GENERIC TIER 01METAPROTEREN TAB 20MG GENERIC TIER 01PERFOROMIST NEB 20MCG BRAND TIER 02PROAIR HFA AER BRAND TIER 02 QLPROVENTIL AER HFA BRAND TIER 03 QLSEREVENT DIS AER 50MCG BRAND TIER 02 QLTERBUTALINE INJ 1MG/ML GENERIC TIER 01TERBUTALINE TAB 2.5MG GENERIC TIER 01TERBUTALINE TAB 5MG GENERIC TIER 01VENTOLIN HFA AER BRAND TIER 03 QLVOSPIRE ER TAB 4MG Brand‐O TIER 03 PAVOSPIRE ER TAB 8MG Brand‐O TIER 03 PAXOPENEX NEB 0.31MG BRAND TIER 03 PA QLXOPENEX NEB 0.63MG BRAND TIER 03 PA QLXOPENEX NEB 1.25/3ML BRAND TIER 03 PA QLXOPENEX CONC NEB 1.25/0.5 Brand‐O TIER 03 PAXOPENEX HFA AER BRAND TIER 02 QLSELECTIVE SEROTONIN AGONISTS ALSUMA INJ 6MG/0.5 BRAND TIER 03 PA QLAMERGE TAB 1MG Brand‐O TIER 03 PA QLAMERGE TAB 2.5MG Brand‐O TIER 03 PA QLAXERT TAB 12.5MG BRAND TIER 03 PA QLAXERT TAB 6.25MG BRAND TIER 03 PA QLFROVA TAB 2.5MG BRAND TIER 02 PA QLIMITREX INJ 4MG/0.5 Brand‐O TIER 03 PA QLIMITREX INJ 6MG/0.5 Brand‐O TIER 03 PA QLIMITREX SPR 20MG/ACT BRAND TIER 03 PA QLIMITREX SPR 5MG/ACT BRAND TIER 03 PA QLIMITREX TAB 100MG Brand‐O TIER 03 PA QLIMITREX TAB 25MG Brand‐O TIER 03 PA QLIMITREX TAB 50MG Brand‐O TIER 03 PA QLMAXALT TAB 10MG BRAND TIER 02 PA QLMAXALT TAB 5MG BRAND TIER 02 PA QLMAXALT‐MLT TAB 10MG BRAND TIER 02 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion249

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE SEROTONIN AGONISTS MAXALT‐MLT TAB 5MG BRAND TIER 02 QLNARATRIPTAN TAB 1MG GENERIC TIER 01 QLNARATRIPTAN TAB 2.5MG GENERIC TIER 01 QLRELPAX TAB 20MG BRAND TIER 02 PA QLRELPAX TAB 40MG BRAND TIER 02 PA QLSUMATRIPTAN INJ 4MG/0.5 GENERIC TIER 01 PA QLSUMATRIPTAN INJ 6MG/0.5 GENERIC TIER 01 PA QLSUMATRIPTAN SPR 20MG/ACT GENERIC TIER 01 PA QLSUMATRIPTAN SPR 5MG/ACT GENERIC TIER 01 PA QLSUMATRIPTAN TAB 100MG GENERIC TIER 01 QLSUMATRIPTAN TAB 25MG GENERIC TIER 01 QLSUMATRIPTAN TAB 50MG GENERIC TIER 01 QLSUMAVEL DOSE INJ 6MG/0.5 BRAND TIER 03 PATREXIMET TAB 85‐500MG BRAND TIER 02 PA QLZOMIG SPR 5MG BRAND TIER 02 PAZOMIG TAB 2.5MG BRAND TIER 02 PA QLZOMIG TAB 5MG BRAND TIER 02 PA QLZOMIG ZMT TAB 2.5 MG BRAND TIER 02 QLZOMIG ZMT TAB 5MG BRAND TIER 02 QLSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS CELEXA TAB 10MG Brand‐O TIER 03 PA QLCELEXA TAB 20MG Brand‐O TIER 03 PA QLCELEXA TAB 40MG Brand‐O TIER 03 PA QLCITALOPRAM SOL 10MG/5ML GENERIC TIER 01CITALOPRAM TAB 10MG GENERIC TIER 01 QLCITALOPRAM TAB 20MG GENERIC TIER 01 QLCITALOPRAM TAB 40MG GENERIC TIER 01 QLESCITALOPRAM SOL 5MG/5ML GENERIC TIER 01 PAESCITALOPRAM TAB 10MG GENERIC TIER 01 PA QLESCITALOPRAM TAB 20MG GENERIC TIER 01 PA QLESCITALOPRAM TAB 5MG GENERIC TIER 01 PA QLFLUOXETINE CAP 10MG GENERIC TIER 01FLUOXETINE CAP 10MG QLFLUOXETINE CAP 20MG GENERIC TIER 01FLUOXETINE CAP 20MG QLFLUOXETINE CAP 40MG GENERIC TIER 01 QLFLUOXETINE CAP 90MG DR GENERIC TIER 01 PA QLFLUOXETINE SOL 20MG/5ML GENERIC TIER 01FLUOXETINE TAB 10MG GENERIC TIER 01 QLFLUOXETINE TAB 20MG GENERIC TIER 01 QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion250

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS FLUOXETINE TAB 60MG GENERIC TIER 01FLUVOXAMINE TAB 100MG GENERIC TIER 01 QLFLUVOXAMINE TAB 25MG GENERIC TIER 01 QLFLUVOXAMINE TAB 50MG GENERIC TIER 01 QLGABOXETINE PAK BRAND TIER 03LEXAPRO SOL 5MG/5ML Brand‐O TIER 03 PALEXAPRO TAB 10MG Brand‐O TIER 03 PA QLLEXAPRO TAB 20MG Brand‐O TIER 03 PA QLLEXAPRO TAB 5MG Brand‐O TIER 03 PA QLLUVOX CR CAP 100MG BRAND TIER 03 PA QLLUVOX CR CAP 150MG BRAND TIER 03 PA QLOLANZA/FLUOX CAP 12‐25MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 12‐50MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 6‐25MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 6‐50MG GENERIC TIER 01 QLPAROXETIN ER TAB 12.5MG GENERIC TIER 01 QLPAROXETIN ER TAB 37.5MG GENERIC TIER 01 QLPAROXETINE SUS 10MG/5ML GENERIC TIER 01PAROXETINE TAB 10MG GENERIC TIER 01 QLPAROXETINE TAB 20MG GENERIC TIER 01 QLPAROXETINE TAB 25MG ER GENERIC TIER 01 QLPAROXETINE TAB 30MG GENERIC TIER 01 QLPAROXETINE TAB 40MG GENERIC TIER 01 QLPAXIL SUS 10MG/5ML Brand‐O TIER 02 PAPAXIL TAB 10MG Brand‐O TIER 03 PA QLPAXIL TAB 30MG Brand‐O TIER 03 PA QLPAXIL TAB 40MG Brand‐O TIER 03 PA QLPAXIL CR TAB 12.5MG Brand‐O TIER 03 PA QLPAXIL CR TAB 25MG Brand‐O TIER 03 PA QLPAXIL CR TAB 37.5MG Brand‐O TIER 03 PA QLPEXEVA TAB 10MG BRAND TIER 03 PA QLPEXEVA TAB 20MG BRAND TIER 03 PA QLPEXEVA TAB 30MG BRAND TIER 03 PA QLPEXEVA TAB 40MG BRAND TIER 03 PA QLPROZAC CAP 10MG Brand‐O TIER 03 PA QLPROZAC CAP 20MG Brand‐O TIER 03 PA QLPROZAC CAP 40MG Brand‐O TIER 03 PA QLPROZAC WEEKL CAP 90MG Brand‐O TIER 03 PA QLSARAFEM TAB 10MG BRAND TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion251

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS SARAFEM TAB 20MG BRAND TIER 03 PA QLSENTRAFLOX PAK AM‐10 BRAND TIER 03SENTRALOPRAM PAK AM‐10 BRAND TIER 03SENTROXATINE PAK BRAND TIER 03SERTRALINE CON 20MG/ML GENERIC TIER 01SERTRALINE TAB 100MG GENERIC TIER 01SERTRALINE TAB 100MG QLSERTRALINE TAB 25MG GENERIC TIER 01SERTRALINE TAB 25MG QLSERTRALINE TAB 50MG GENERIC TIER 01SERTRALINE TAB 50MG QLSYMBYAX CAP 12‐25MG Brand‐O TIER 03 PA QLSYMBYAX CAP 12‐50MG Brand‐O TIER 03 PA QLSYMBYAX CAP 3‐25MG BRAND TIER 03 QLSYMBYAX CAP 6‐25MG Brand‐O TIER 03 PA QLSYMBYAX CAP 6‐50MG Brand‐O TIER 03 PA QLZOLOFT CON 20MG/ML Brand‐O TIER 03 PAZOLOFT TAB 100MG Brand‐O TIER 03 PA QLZOLOFT TAB 25MG Brand‐O TIER 03 PA QLZOLOFT TAB 50MG Brand‐O TIER 03 PA QLPAXIL TAB 20MG Brand‐O TIER 03 PA QLSEROTONIN MODULATORS NEFAZODONE TAB 100MG GENERIC TIER 01NEFAZODONE TAB 150MG GENERIC TIER 01NEFAZODONE TAB 200MG GENERIC TIER 01NEFAZODONE TAB 250MG GENERIC TIER 01NEFAZODONE TAB 50MG GENERIC TIER 01OLEPTRO TAB 24HR150 BRAND TIER 03 PA QLOLEPTRO TAB 24HR300 BRAND TIER 03 PA QLTRAZAMINE PAK BRAND TIER 03TRAZODONE TAB 100MG GENERIC TIER 01TRAZODONE TAB 150MG GENERIC TIER 01TRAZODONE TAB 300MG GENERIC TIER 01TRAZODONE TAB 50MG GENERIC TIER 01VIIBRYD KIT BRAND TIER 02 PAVIIBRYD TAB 10MG BRAND TIER 02 PA QLVIIBRYD TAB 20MG BRAND TIER 02 PA QLVIIBRYD TAB 40MG BRAND TIER 02 PA QLSERUMS ANASCORP INJ BRAND TIER 03ANTIVENIN KIT LAT MACT GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion252

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSERUMS ANTIVENIN MI KIT GENERIC TIER 01CARIMUNE NF INJ 12GM GENERIC TIER 01 PA SPCARIMUNE NF INJ 3GM GENERIC TIER 01 PA SPCARIMUNE NF INJ 6GM GENERIC TIER 01 PA SPCROFAB INJ BRAND TIER 03CYTOGAM INJ BRAND TIER 03 SPDIGIFAB INJ 40MG BRAND TIER 03FLEBOGAMMA INJ 10% BRAND TIER 03 PA SPFLEBOGAMMA INJ 5% GENERIC TIER 01 PA SPFLEBOGAMMA INJ DIF 5% BRAND TIER 03 PA SPGAMASTAN S/D INJ GENERIC TIER 01 PA SPGAMMAGARD INJ 10GM/100 GENERIC TIER 01 SPGAMMAGARD INJ 1GM/10ML GENERIC TIER 01 SPGAMMAGARD INJ 2.5GM/25 GENERIC TIER 01 SPGAMMAGARD INJ 20GM/200 GENERIC TIER 01 SPGAMMAGARD INJ 30GM/300 BRAND TIER 02 SPGAMMAGARD INJ 5GM/50ML GENERIC TIER 01 SPGAMMAGARD SD INJ 10GM HU BRAND TIER 03 PA SPGAMMAGARD SD INJ 2.5GM HU GENERIC TIER 01 PA SPGAMMAGARD SD INJ 5GM HU BRAND TIER 03 PA SPGAMMAKED INJ 10GM/100 BRAND TIER 03 SPGAMMAKED INJ 1GM/10ML BRAND TIER 03 SPGAMMAKED INJ 2.5GM/25 BRAND TIER 03 SPGAMMAKED INJ 20GM/200 BRAND TIER 03 SPGAMMAKED INJ 5GM/50ML BRAND TIER 03 SPGAMMAPLEX INJ 10GM BRAND TIER 03 PA SPGAMMAPLEX INJ 2.5GM BRAND TIER 03 PA SPGAMMAPLEX INJ 5GM BRAND TIER 03 PA SPGAMUNEX INJ 10% BRAND TIER 02 PA SPGAMUNEX‐C INJ 10GM/100 BRAND TIER 03 SPGAMUNEX‐C INJ 1GM/10ML BRAND TIER 03 SPGAMUNEX‐C INJ 2.5GM/25 BRAND TIER 03 SPGAMUNEX‐C INJ 20GM/200 BRAND TIER 03 SPGAMUNEX‐C INJ 5GM/50ML BRAND TIER 03 SPHEPAGAM B INJ BRAND TIER 03 SPHEPAGAM B INJ GENERIC TIER 01 SPHIZENTRA INJ 1GM/5ML BRAND TIER 02 PA SPHIZENTRA INJ 2GM/10ML BRAND TIER 02 PA SPHIZENTRA INJ 4GM/20ML BRAND TIER 02 PA SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion253

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSERUMS HYPERHEP B INJ S/D BRAND TIER 03 SPHYPERRAB S/D INJ 150/ML BRAND TIER 03 SPHYPERRHO S/D INJ 300MCG BRAND TIER 03 SPHYPERRHO S/D INJ 50MCG GENERIC TIER 01 SPHYPERTET S/D INJ 250/ML BRAND TIER 03 SPIMOGAM RABIE INJ 150/ML GENERIC TIER 01 SPMICRHOGAM PL INJ 50MCG BRAND TIER 03 SPNABI‐HB INJ GENERIC TIER 01 SPOCTAGAM INJ 10GM BRAND TIER 03 PA SPOCTAGAM INJ 1GM BRAND TIER 03 PA SPOCTAGAM INJ 2.5GM BRAND TIER 03 PA SPOCTAGAM INJ 25GM BRAND TIER 03 PA SPOCTAGAM INJ 5GM BRAND TIER 03 PA SPPRIVIGEN INJ 10GRAMS BRAND TIER 02 PA SPPRIVIGEN INJ 20GRAMS BRAND TIER 02 PA SPPRIVIGEN INJ 5 GRAMS BRAND TIER 02 PA SPRHOGAM PLUS INJ 300MCG BRAND TIER 03 SPRHOPHYLAC INJ 1500/2ML BRAND TIER 03 SPWINRHO SDF INJ 15000UNT BRAND TIER 03 SPWINRHO SDF INJ 1500UNIT BRAND TIER 03 SPWINRHO SDF INJ 2500UNIT BRAND TIER 03 SPWINRHO SDF INJ 5000UNIT BRAND TIER 03 SPSKELETAL MUSCLE RELAXANTS, MISCELLANEOUS NORFLEX INJ 30MG/ML Brand‐O TIER 03 PAORPHENADRINE INJ 30MG/ML GENERIC TIER 01 PAORPHENADRINE TAB 100MG ER GENERIC TIER 01 PASKIN AND MUCOUS MEMBRANE AGENTS, MISC. ACZONE GEL 5% BRAND TIER 02 PAADAPALENE CRE 0.1% GENERIC TIER 01 PAADAPALENE GEL 0.1% GENERIC TIER 01 PAALDARA CRE 5% Brand‐O TIER 03 PA QLAMEVIVE INJ 15MG BRAND TIER 03 PA SPAMNESTEEM CAP 10MG GENERIC TIER 01AMNESTEEM CAP 20MG GENERIC TIER 01AMNESTEEM CAP 40MG GENERIC TIER 01AQUAFLO MIS 3" BRAND TIER 03AQUAFLO MIS 4.75" BRAND TIER 03ARNICA TIN FLOWER GENERIC TIER 01ARTISS SOL 10ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion254

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. ARTISS SOL 2ML BRAND TIER 03ARTISS SOL 4ML BRAND TIER 03ATRAPRO GEL HYDROGEL BRAND TIER 03ATRAPRO DERM SPR BRAND TIER 03AVAGE CRE 0.1% BRAND TIER 02AVO CREAM EMU BRAND TIER 03AZELEX CRE 20% BRAND TIER 02 PABIAFINE EMU BRAND TIER 03BIONECT CRE 0.2% BRAND TIER 03BIONECT GEL 0.2% BRAND TIER 03BIONECT SPR 0.2% BRAND TIER 03CALCIPOTRIEN CRE 0.005% GENERIC TIER 01CALCIPOTRIEN OIN 0.005% GENERIC TIER 01CALCIPOTRIEN SOL 0.005% GENERIC TIER 01CALCITRENE OIN 0.005% BRAND TIER 03CALCITRIOL OIN 3MCG/GM GENERIC TIER 01CARAC CRE 0.5% BRAND TIER 02CETYLCIDE‐G CON BRAND TIER 99 DECLARAVIS CAP 10MG GENERIC TIER 01CLARAVIS CAP 20MG GENERIC TIER 01CLARAVIS CAP 30MG GENERIC TIER 01CLARAVIS CAP 40MG GENERIC TIER 01CONDYLOX GEL 0.5% BRAND TIER 02 PACONDYLOX SOL 0.5% Brand‐O TIER 02 PACURAFIL HYDR PAD 1"X36" BRAND TIER 03CURAFIL HYDR PAD 2"X2" BRAND TIER 03CURAFIL HYDR PAD 4"X4" BRAND TIER 03CURAFIL HYDR PAD 8"X4" BRAND TIER 03CURAFIL WOUN GEL DRESSING BRAND TIER 03CURAGEL HYDR PAD 2"X3" BRAND TIER 03CURAGEL HYDR PAD 3"X4" BRAND TIER 03CURAGEL HYDR PAD 4"X4" BRAND TIER 03CURAGEL HYDR PAD 5"X5" BRAND TIER 03CURAGEL HYDR PAD 8"X8" BRAND TIER 03CURAGEL HYDR PAD 8.5"X9.5 BRAND TIER 03CURASORB MIS 12" ROPE BRAND TIER 03CURASORB MIS 12"X24" BRAND TIER 03CURASORB MIS 2"X2" BRAND TIER 03CURASORB MIS 24" ROPE BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion255

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. CURASORB MIS 36" ROPE BRAND TIER 03CURASORB MIS 4"X4" BRAND TIER 03CURASORB MIS 4"X5.5" BRAND TIER 03CURASORB MIS 4"X8" BRAND TIER 03CURASORB MIS 6"X10" BRAND TIER 03CURASORB PLS MIS 4"X4" BRAND TIER 03CURASORB ZN MIS 12" ROPE BRAND TIER 03CURASORB ZN PAD 2"X2" BRAND TIER 03CURASORB ZN PAD 4"X4" BRAND TIER 03CURASORB ZN PAD 4"X8" BRAND TIER 03CURITY HYPER MIS 1/2"X15' BRAND TIER 03CURITY NACL PAD 6"X6‐3/4 BRAND TIER 03CURITY WET PAD 8"X4" BRAND TIER 03DIAB GEL GENERIC TIER 01DIAB F.D.G. GEL GENERIC TIER 01DIFFERIN CRE 0.1% Brand‐O TIER 02 PADIFFERIN GEL 0.1% Brand‐O TIER 02 PADIFFERIN GEL 0.3% BRAND TIER 02 PADIFFERIN LOT 0.1% BRAND TIER 02 PADOVONEX CRE 0.005% Brand‐O TIER 03 PADOVONX SCALP SOL 0.005% Brand‐O TIER 03 PADRITHO‐CREME CRE HP 1% GENERIC TIER 01DRITHO‐SCALP CRE 0.5% BRAND TIER 02EFUDEX CRE 5% Brand‐O TIER 03 PAELIDEL CRE 1% BRAND TIER 02 PA QLEMULSION SB EMU BRAND TIER 03EPICERAM EMU BRAND TIER 03EPIDUO GEL 0.1‐2.5% BRAND TIER 02 PAEPISIL LIQ BRAND TIER 03EVICEL KIT 2ML BRAND TIER 03EVICEL KIT 5ML BRAND TIER 03FINACEA GEL 15% BRAND TIER 02 PAFINACEA PLUS KIT BRAND TIER 99 DEFLECTOR DIS 1.3% BRAND TIER 03 PA QLFLUOROPLEX CRE 1% BRAND TIER 03FLUOROURACIL CRE 5% GENERIC TIER 01FLUOROURACIL DRO 2% GENERIC TIER 01FLUOROURACIL DRO 5% GENERIC TIER 01FLUOROURACIL SOL 2% GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion256

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. FLUOROURACIL SOL 5% GENERIC TIER 01GELCLAIR GEL BRAND TIER 03GENADUR LIQ BRAND TIER 03HYDROFERA PAD 4"X4" BRAND TIER 03HYLASE WOUND GEL BRAND TIER 03IMIQUIMOD CRE 5% GENERIC TIER 01 PA QLINTERCED TC7 PAD 1.5"X2" BRAND TIER 03INTERCED TC7 PAD 3"X4" BRAND TIER 03LATISSE SOL 0.03% BRAND TIER 99 DELEVULAN KERA SOL 20% BRAND TIER 03MEDIHONEY PAD 2"X2" BRAND TIER 03MEDIHONEY PAD 4"X5" BRAND TIER 03METVIXIA CRE 16.8% BRAND TIER 03MINOCYCLINE TAB 135MG ER GENERIC TIER 01 PAMINOCYCLINE TAB 45MG ER GENERIC TIER 01 PAMINOCYCLINE TAB 90MG ER GENERIC TIER 01 PAMUCOTROL WAF BRAND TIER 03MUGARD LIQ BRAND TIER 03MYORISAN CAP 10MG GENERIC TIER 01MYORISAN CAP 20MG GENERIC TIER 01MYORISAN CAP 40MG GENERIC TIER 01NUOX GEL 6‐3% BRAND TIER 03NUVAIL SOL 16% BRAND TIER 99 DEOASIS BURN MIS 7X20CM BRAND TIER 03OASIS ULTRA MIS TRI MESH BRAND TIER 03OASIS WOUND MIS 3X3.5CM BRAND TIER 03OASIS WOUND MIS 3X7CM BRAND TIER 03OASIS WOUND MIS 7X10CM BRAND TIER 03OASIS WOUND MIS 7X20CM BRAND TIER 03OPTASE GEL BRAND TIER 99 DEORACEA CAP 40MG BRAND TIER 02 PAORAMAGICRX SUS BRAND TIER 03OXYCEL COTTN PAD 2"X1"X1" BRAND TIER 03OXYCEL GAUZE PAD 18"X2" BRAND TIER 03OXYCEL GAUZE PAD 3"X3" BRAND TIER 03OXYCEL GAUZE PAD 36"X1/2" BRAND TIER 03OXYCEL GAUZE PAD 5"X1/2" BRAND TIER 03PANRETIN GEL 0.1% BRAND TIER 02PENNSAID SOL 1.5% BRAND TIER 03 PA QLKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion257

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. PICATO GEL 0.015% BRAND TIER 02PICATO GEL 0.05% BRAND TIER 02PODOCON SOL 25% GENERIC TIER 01PODOFILOX SOL 0.5% GENERIC TIER 01 PAPR CREAM KIT BRAND TIER 03PROPECIA TAB 1MG BRAND TIER 99 DEPROTOPIC OIN 0.03% BRAND TIER 02 PA QLPROTOPIC OIN 0.1% BRAND TIER 02 PA QLPRUTECT EMU GENERIC TIER 01QUTENZA KIT 8% 1‐PCH BRAND TIER 03 PA QLQUTENZA KIT 8% 2‐PCH BRAND TIER 03 PA QLRADIAGEL GEL GENERIC TIER 01RADIAPLEXRX GEL BRAND TIER 03RADIGEL GEL BRAND TIER 03RECTIV OIN 0.4% BRAND TIER 03REGRANEX GEL 0.01% BRAND TIER 03RESTORE SILV PAD 2"X2" BRAND TIER 03RESTORE SILV PAD 4"X4" BRAND TIER 03RESTORE SILV PAD 4"X4.75" BRAND TIER 03RESTORE SILV PAD 4"X5" BRAND TIER 03RESTORE SILV PAD 6"X8" BRAND TIER 03REVINA OIN GENERIC TIER 99 DESALICEPT SOL GENERIC TIER 01SALICEPT SUS BRAND TIER 03SANTYL OIN 250/GM BRAND TIER 02SILVASORB GEL BRAND TIER 03SILVRSTAT GEL DRESSING BRAND TIER 03SOLARAZE GEL 3% W/W BRAND TIER 03SOLODYN TAB 105MG BRAND TIER 03 PASOLODYN TAB 115MG BRAND TIER 03 PASOLODYN TAB 135MG Brand‐O TIER 03 PASOLODYN TAB 45MG Brand‐O TIER 03 PASOLODYN TAB 55MG BRAND TIER 03 PASOLODYN TAB 65MG BRAND TIER 03 PASOLODYN TAB 80MG BRAND TIER 03 PASOLODYN TAB 90MG Brand‐O TIER 03 PASONAFINE EMU GENERIC TIER 01SORIATANE CAP 10MG BRAND TIER 02SORIATANE CAP 17.5MG BRAND TIER 02Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion258

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. SORIATANE CAP 25MG BRAND TIER 02SORILUX AER 0.005% BRAND TIER 03SOTRET CAP 10MG GENERIC TIER 01SOTRET CAP 20MG GENERIC TIER 01SOTRET CAP 30MG GENERIC TIER 01SPECTRAGEL GEL BRAND TIER 03STELARA INJ 45MG/0.5 BRAND TIER 03 PA QL SPSTELARA INJ 90MG/ML BRAND TIER 03 PA QL SPSURGICEL PAD 0.5"X2" BRAND TIER 03SURGICEL PAD 1"X 1" BRAND TIER 03SURGICEL PAD 1"X2" BRAND TIER 03SURGICEL PAD 1"X3.5" BRAND TIER 03SURGICEL PAD 2"X14" BRAND TIER 03SURGICEL PAD 2"X3" BRAND TIER 03SURGICEL PAD 2"X4" BRAND TIER 03SURGICEL PAD 3"X4" BRAND TIER 03SURGICEL PAD 4"X4" BRAND TIER 03SURGICEL PAD 4"X8" BRAND TIER 03SURGICEL PAD 6"X9" BRAND TIER 03TACHOSIL PAD BRAND TIER 99 DETARGRETIN GEL 1% BRAND TIER 03 SPTAZORAC CRE 0.05% BRAND TIER 02 PATAZORAC CRE 0.1% BRAND TIER 02 PATAZORAC GEL 0.05% BRAND TIER 02 PATAZORAC GEL 0.1% BRAND TIER 02 PATBC AER GENERIC TIER 99 DETEGADERM AG PAD 2"X2" BRAND TIER 03TEGADERM AG PAD 4"X5" BRAND TIER 03TEGADERM AG PAD 4"X8" BRAND TIER 03TEGADERM AG PAD 8"X8" BRAND TIER 03TETRIX KIT BRAND TIER 03TISSEEL KIT BRAND TIER 03TISSEEL SOL BRAND TIER 03TL‐CERMIDE EMU BRAND TIER 03TROPAZONE CRE GENERIC TIER 01ULTEC PRO PAD 4"X4" BRAND TIER 03ULTEC PRO PAD 4"X5" BRAND TIER 03ULTEC PRO PAD 6"X6" BRAND TIER 03ULTEC PRO PAD 8"X8" BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion259

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. VANIQA CRE 13.9% BRAND TIER 03VASOLEX OIN GENERIC TIER 99 DEVECTICAL OIN 3MCG/GM BRAND TIER 02VELTIN GEL BRAND TIER 02 PAVENELEX OIN BRAND TIER 03VEREGEN OIN 15% BRAND TIER 03VOLTAREN GEL 1% BRAND TIER 03 PA QLXCLAIR CRE GENERIC TIER 01ZIANA GEL BRAND TIER 03 PAZITHRANOL SHA 1% BRAND TIER 03ZITHRANOL‐RR CRE 1.2% BRAND TIER 03ZYCLARA CRE 3.75% BRAND TIER 03 PA QLZYCLARA PUMP CRE 2.5% BRAND TIER 03 PAZYCLARA PUMP CRE 3.75% BRAND TIER 03 PA QLGRANULEX AER Brand‐O TIER 99 PA DEXENADERM OIN Brand‐O TIER 99 PA DEGLYCOLIC ACD SOL 70% GENERIC TIER 01CARRASYN GEL DRESSING BRAND TIER 03PARAFFIN MIS GENERIC TIER 99 DESOMATOTROPIN AGONISTS EGRIFTA INJ 1MG BRAND TIER 03 PA QL SPEGRIFTA SOL 2MG BRAND TIER 03 PAGENOTROPIN INJ 0.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 12MG BRAND TIER 03 PA SPGENOTROPIN INJ 1MG BRAND TIER 03 PA SPGENOTROPIN INJ 2MG BRAND TIER 03 PA SPGENOTROPIN INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 12MG BRAND TIER 03 PA SPHUMATROPE INJ 24MG BRAND TIER 03 PA SPHUMATROPE INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 6MG BRAND TIER 03 PA SPINCRELEX INJ 40MG/4ML BRAND TIER 03 PA SPNORDITROPIN INJ 10/1.5ML BRAND TIER 02 PA SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion260

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSOMATOTROPIN AGONISTS NORDITROPIN INJ 15/1.5ML BRAND TIER 02 PA SPNORDITROPIN INJ 30/3ML BRAND TIER 02 PA SPNORDITROPIN INJ 5/1.5ML BRAND TIER 02 PA SPNUTROPIN INJ 10MG BRAND TIER 02 PA SPNUTROPIN AQ INJ 10MG/2ML BRAND TIER 02 PA SPNUTROPIN AQ INJ 20MG/2ML BRAND TIER 02 PA SPNUTROPIN AQ INJ NUSPIN 5 BRAND TIER 02 PA SPOMNITROPE INJ 10/1.5ML BRAND TIER 03 PA SPOMNITROPE INJ 5.8MG BRAND TIER 03 PA SPOMNITROPE INJ 5/1.5ML BRAND TIER 03 PA SPSAIZEN INJ 5MG BRAND TIER 03 PA SPSAIZEN INJ 8.8MG BRAND TIER 03 PA SPSEROSTIM INJ 4MG BRAND TIER 03 PA SPSEROSTIM INJ 5MG BRAND TIER 03 PA SPSEROSTIM INJ 6MG BRAND TIER 03 PA SPTEV‐TROPIN INJ 5MG BRAND TIER 03 PA SPZORBTIVE INJ 8.8MG BRAND TIER 03 PA SPSOMATOTROPIN ANTAGONISTS SOMAVERT INJ 10MG BRAND TIER 02 SPSOMAVERT INJ 15MG BRAND TIER 02 SPSOMAVERT INJ 20MG BRAND TIER 02 SPSTREPTOGRAMINS SYNERCID INJ 500MG BRAND TIER 03SUCCINIMIDES CELONTIN CAP 300MG BRAND TIER 02ETHOSUXIMIDE CAP 250MG GENERIC TIER 01ETHOSUXIMIDE SOL 250/5ML GENERIC TIER 01ZARONTIN CAP 250MG Brand‐O TIER 03 PAZARONTIN SOL 250/5ML Brand‐O TIER 03 PASULFONAMIDES (SYSTEMIC) AZULFIDINE TAB 500MG Brand‐O TIER 03 PAAZULFIDINE TAB 500MG EN Brand‐O TIER 03 PABACTRIM TAB 400‐80MG Brand‐O TIER 03 PABACTRIM DS TAB 800‐160 Brand‐O TIER 03 PASEPTRA DS TAB 800‐160 Brand‐O TIER 03 PASMZ/TMP DS TAB 800‐160 GENERIC TIER 01SMZ‐TMP INJ 400‐80/5 GENERIC TIER 01SMZ‐TMP SUS GENERIC TIER 01SMZ‐TMP SUS 200‐40/5 GENERIC TIER 01SMZ‐TMP TAB 400‐80MG GENERIC TIER 01SULFADIAZINE TAB 500MG GENERIC TIER 01SULFASALAZIN TAB 500MG GENERIC TIER 01SULFASALAZIN TAB 500MG DR GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion261

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSULFONAMIDES (SYSTEMIC) SULFAZINE TAB 500MG GENERIC TIER 01SULFAZINE EC TAB 500MG GENERIC TIER 01SULFISOXIZOL CRY GENERIC TIER 99 DESULFISOXIZOL CRY USP NF GENERIC TIER 99 DESULFONYLUREAS AMARYL TAB 1MG Brand‐O TIER 03 PAAMARYL TAB 2MG Brand‐O TIER 03 PAAMARYL TAB 4MG Brand‐O TIER 03 PACHLORPROPAM TAB 100MG GENERIC TIER 01CHLORPROPAM TAB 250MG GENERIC TIER 01DIABETA TAB 1.25MG BRAND TIER 03DIABETA TAB 2.5MG BRAND TIER 03DIABETA TAB 5MG BRAND TIER 03GLIMEPIRIDE TAB 1MG GENERIC TIER 01GLIMEPIRIDE TAB 2MG GENERIC TIER 01GLIMEPIRIDE TAB 4MG GENERIC TIER 01GLIP/METFORM TAB 2.5‐250M GENERIC TIER 01GLIP/METFORM TAB 2.5‐500M GENERIC TIER 01GLIP/METFORM TAB 5‐500MG GENERIC TIER 01GLIPIZIDE TAB 10MG GENERIC TIER 01GLIPIZIDE TAB 5MG GENERIC TIER 01GLIPIZIDE ER TAB 10MG GENERIC TIER 01GLIPIZIDE ER TAB 2.5MG GENERIC TIER 01GLIPIZIDE ER TAB 5MG GENERIC TIER 01GLIPIZIDE XL TAB 10MG GENERIC TIER 01GLIPIZIDE XL TAB 2.5MG GENERIC TIER 01GLIPIZIDE XL TAB 5MG GENERIC TIER 01GLUCOTROL TAB 10MG Brand‐O TIER 03 PAGLUCOTROL TAB 5MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 10MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 2.5MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 5MG Brand‐O TIER 03 PAGLUCOVANCE TAB 1.25‐250 Brand‐O TIER 03 PAGLUCOVANCE TAB 2.5‐500 Brand‐O TIER 03 PAGLUCOVANCE TAB 5‐500MG Brand‐O TIER 03 PAGLYB/METFORM TAB 1.25‐250 GENERIC TIER 01GLYB/METFORM TAB 2.5‐500 GENERIC TIER 01GLYB/METFORM TAB 5‐500MG GENERIC TIER 01GLYBURID MCR TAB 1.5MG GENERIC TIER 01GLYBURID MCR TAB 3MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion262

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSULFONYLUREAS GLYBURID MCR TAB 6MG GENERIC TIER 01GLYBURIDE TAB 1.25MG GENERIC TIER 01GLYBURIDE TAB 2.5MG GENERIC TIER 01GLYBURIDE TAB 5MG GENERIC TIER 01GLYCRON TAB 1.5MG GENERIC TIER 01GLYCRON TAB 3MG GENERIC TIER 01GLYCRON TAB 4.5MG BRAND TIER 03GLYCRON TAB 6MG GENERIC TIER 01GLYNASE TAB 1.5MG Brand‐O TIER 03 PAGLYNASE TAB 3MG Brand‐O TIER 03 PAGLYNASE TAB 6MG Brand‐O TIER 03 PAMETAGLIP TAB 2.5‐250M Brand‐O TIER 03 PATOLAZAMIDE TAB 250MG GENERIC TIER 01TOLAZAMIDE TAB 500MG GENERIC TIER 01TOLBUTAMIDE TAB 500MG GENERIC TIER 01TETRACYCLINES ADOXA CAP 150MG Brand‐O TIER 03 PAADOXA TAB 100MG Brand‐O TIER 03 PAADOXA TAB 50MG Brand‐O TIER 03 PAADOXA TAB 75MG Brand‐O TIER 03 PAADOXA PAK 1/ TAB 100MG Brand‐O TIER 03 PAADOXA PAK 1/ TAB 150MG Brand‐O TIER 03 PAADOXA PAK 2/ TAB 100MG Brand‐O TIER 03 PAALODOX KIT 20MG BRAND TIER 99 DEAVIDOXY TAB 100MG GENERIC TIER 01AVIDOXY DK KIT BRAND TIER 03CHLORTETRACY CRY HCL GENERIC TIER 99 DEDEMECLOCYCL TAB 150MG GENERIC TIER 01DEMECLOCYCL TAB 300MG GENERIC TIER 01DORYX TAB 100MG Brand‐O TIER 03 PADORYX TAB 150MG BRAND TIER 03DOXYCYC MONO CAP 100MG GENERIC TIER 01DOXYCYC MONO CAP 50MG GENERIC TIER 01DOXYCYC MONO TAB 100MG GENERIC TIER 01DOXYCYC MONO TAB 150MG GENERIC TIER 01DOXYCYC MONO TAB 50MG GENERIC TIER 01DOXYCYC MONO TAB 75MG GENERIC TIER 01DOXYCYCL HYC CAP 100MG GENERIC TIER 01DOXYCYCL HYC CAP 50MG GENERIC TIER 01DOXYCYCL HYC INJ 100MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion263

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTETRACYCLINES DOXYCYCL HYC TAB 100MG GENERIC TIER 01DOXYCYCL HYC TAB 150MG GENERIC TIER 01DOXYCYCL HYC TAB 75MG GENERIC TIER 01DOXYCYCLINE CAP 150MG GENERIC TIER 01DOXYCYCLINE CAP 75MG GENERIC TIER 01DOXYCYCLINE TAB 20MG GENERIC TIER 01DYNACIN TAB 100MG Brand‐O TIER 03 PADYNACIN TAB 50MG Brand‐O TIER 03 PADYNACIN TAB 75MG Brand‐O TIER 03 PAMINOCIN CAP 100MG Brand‐O TIER 03 PAMINOCIN CAP 50MG Brand‐O TIER 03 PAMINOCIN INJ 100MG BRAND TIER 03MINOCIN KIT 100MG BRAND TIER 03MINOCIN KIT 50MG BRAND TIER 03MINOCYCLINE CAP 100MG GENERIC TIER 01MINOCYCLINE CAP 50MG GENERIC TIER 01MINOCYCLINE CAP 75MG GENERIC TIER 01MINOCYCLINE TAB 100MG GENERIC TIER 01MINOCYCLINE TAB 50MG GENERIC TIER 01MINOCYCLINE TAB 75MG GENERIC TIER 01MONODOX CAP 100MG Brand‐O TIER 03 PAMONODOX CAP 50MG Brand‐O TIER 03 PAMONODOX CAP 75MG Brand‐O TIER 03 PAMORGIDOX CAP 1X100MG GENERIC TIER 01MORGIDOX CAP 2X100MG GENERIC TIER 01MORGIDOX KIT 1X100MG BRAND TIER 03MORGIDOX KIT 2X100MG BRAND TIER 03NUTRIDOX KIT BRAND TIER 03OCUDOX KIT BRAND TIER 03ORAXYL CAP 20MG BRAND TIER 03TETRACYCLINE CAP 250MG GENERIC TIER 01TETRACYCLINE CAP 500MG GENERIC TIER 01VIBRAMYCIN CAP 100MG Brand‐O TIER 03 PAVIBRAMYCIN SUS 25MG/5ML BRAND TIER 02VIBRAMYCIN SYP 50MG/5ML BRAND TIER 03THIAZIDE DIURETICS CHLOROTHIAZ INJ 500MG GENERIC TIER 01CHLOROTHIAZ TAB 250MG GENERIC TIER 01CHLOROTHIAZ TAB 500MG GENERIC TIER 01DIURIL SUS 250/5ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion264

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHIAZIDE DIURETICS HYDROCHLOROT CAP 12.5MG GENERIC TIER 01HYDROCHLOROT TAB 12.5MG GENERIC TIER 01HYDROCHLOROT TAB 25MG GENERIC TIER 01HYDROCHLOROT TAB 50MG GENERIC TIER 01METHYCLOTHIA TAB 5MG GENERIC TIER 01MICROZIDE CAP 12.5MG Brand‐O TIER 03 PASOD DIURIL INJ 500MG Brand‐O TIER 03 PATHIAZIDE‐LIKE DIURETICS CHLORTHALID TAB 100MG GENERIC TIER 99 DECHLORTHALID TAB 25MG GENERIC TIER 01CHLORTHALID TAB 50MG GENERIC TIER 01INDAPAMIDE TAB 1.25MG GENERIC TIER 01INDAPAMIDE TAB 2.5MG GENERIC TIER 01METOLAZONE TAB 10MG GENERIC TIER 01METOLAZONE TAB 2.5MG GENERIC TIER 01METOLAZONE TAB 5MG GENERIC TIER 01THALITONE TAB 15MG BRAND TIER 03ZAROXOLYN TAB 2.5MG Brand‐O TIER 03 PAZAROXOLYN TAB 5MG Brand‐O TIER 03 PATHIAZOLIDINEDIONES ACTOPLUS MET TAB 15‐500MG Brand‐O TIER 03 PAACTOPLUS MET TAB 15‐850MG Brand‐O TIER 03 PAACTOPLUS MET TAB XR BRAND TIER 03ACTOS TAB 15MG Brand‐O TIER 03 PAACTOS TAB 30MG Brand‐O TIER 03 PAACTOS TAB 45MG Brand‐O TIER 03 PAAVANDAMET TAB 2‐1000MG BRAND TIER 02AVANDAMET TAB 2‐500MG BRAND TIER 02AVANDAMET TAB 4‐1000MG BRAND TIER 02AVANDAMET TAB 4‐500MG BRAND TIER 02AVANDARYL TAB 4‐1MG BRAND TIER 02AVANDARYL TAB 4‐2MG BRAND TIER 02AVANDARYL TAB 4‐4MG BRAND TIER 02AVANDARYL TAB 8‐2MG BRAND TIER 02AVANDARYL TAB 8‐4MG BRAND TIER 02AVANDIA TAB 2MG BRAND TIER 02AVANDIA TAB 4MG BRAND TIER 02AVANDIA TAB 8MG BRAND TIER 02DUETACT TAB 30‐2MG BRAND TIER 02DUETACT TAB 30‐4MG BRAND TIER 02PIOGLITA/MET TAB 15‐500MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion265

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHIAZOLIDINEDIONES PIOGLITA/MET TAB 15‐850MG GENERIC TIER 01PIOGLITAZONE TAB 15MG GENERIC TIER 01PIOGLITAZONE TAB 30MG GENERIC TIER 01PIOGLITAZONE TAB 45MG GENERIC TIER 01THIOXANTHENES NAVANE CAP 10MG Brand‐O TIER 03 PANAVANE CAP 20MG BRAND TIER 03NAVANE CAP 2MG Brand‐O TIER 03 PATHIOTHIXENE CAP 10MG GENERIC TIER 01THIOTHIXENE CAP 1MG GENERIC TIER 01THIOTHIXENE CAP 2MG GENERIC TIER 01THIOTHIXENE CAP 5MG GENERIC TIER 01THIRD GENERATION CEPHALOSPORINS CEDAX CAP 400MG BRAND TIER 03CEDAX SUS 180/5ML BRAND TIER 03CEDAX SUS 90MG/5ML BRAND TIER 03CEFDINIR CAP 300MG GENERIC TIER 01CEFDINIR SUS 125/5ML GENERIC TIER 01CEFDINIR SUS 250/5ML GENERIC TIER 01CEFDITOREN TAB 200MG GENERIC TIER 01CEFDITOREN TAB 400MG GENERIC TIER 01CEFOTAXIME INJ 10GM GENERIC TIER 01CEFOTAXIME INJ 1GM GENERIC TIER 01CEFOTAXIME INJ 20GM GENERIC TIER 01CEFOTAXIME INJ 2GM GENERIC TIER 01CEFOTAXIME INJ 500MG GENERIC TIER 01CEFPODO PROX SUS 100/5ML GENERIC TIER 01CEFPODO PROX SUS 50MG/5ML GENERIC TIER 01CEFPODOXIME TAB 100MG GENERIC TIER 01CEFPODOXIME TAB 200MG GENERIC TIER 01CEFTAZIDIME INJ 100GM GENERIC TIER 01CEFTAZIDIME INJ 1GM GENERIC TIER 01CEFTAZIDIME INJ 2GM GENERIC TIER 01CEFTAZIDIME INJ 500MG GENERIC TIER 01CEFTAZIDIME INJ 6GM GENERIC TIER 01CEFTAZIDIME/ SOL D5W 1GM GENERIC TIER 01CEFTAZIDIME/ SOL D5W 2GM GENERIC TIER 01CEFTRIAX/DEX INJ 1GM GENERIC TIER 01CEFTRIAX/DEX INJ 2GM GENERIC TIER 01CEFTRIAXONE INJ 10GM GENERIC TIER 01CEFTRIAXONE INJ 1GM GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion266

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHIRD GENERATION CEPHALOSPORINS CEFTRIAXONE INJ 250MG GENERIC TIER 01CEFTRIAXONE INJ 2GM GENERIC TIER 01CEFTRIAXONE INJ 500MG GENERIC TIER 01CEFTRIAXONE/ INJ DEX 1GM GENERIC TIER 01CEFTRIAXONE/ INJ DEX 2GM GENERIC TIER 01CLAFORAN INJ 10GM Brand‐O TIER 03 PACLAFORAN INJ 1GM Brand‐O TIER 03 PACLAFORAN INJ 2GM Brand‐O TIER 03 PACLAFORAN INJ 500MG Brand‐O TIER 03 PACLAFORAN/D5W INJ 1GM BRAND TIER 03CLAFORAN/D5W INJ 2GM BRAND TIER 03FORTAZ INJ 1GM BRAND TIER 03FORTAZ INJ 2GM Brand‐O TIER 03 PAFORTAZ INJ 500MG BRAND TIER 03FORTAZ INJ 6GM Brand‐O TIER 03 PAROCEPHIN INJ 1GM Brand‐O TIER 03 PAROCEPHIN INJ 500MG Brand‐O TIER 03 PASPECTRACEF TAB 200MG BRAND TIER 03SPECTRACEF TAB 400MG BRAND TIER 03SUPRAX SUS 100/5ML BRAND TIER 03SUPRAX SUS 200/5ML BRAND TIER 03SUPRAX TAB 400MG BRAND TIER 03TAZICEF INJ 1GM GENERIC TIER 01TAZICEF INJ 1GM/50ML BRAND TIER 03TAZICEF INJ 2GM GENERIC TIER 01TAZICEF INJ 6GM GENERIC TIER 01SUPRAX CHW 100MG BRAND TIER 03SUPRAX CHW 200MG BRAND TIER 03THROMBOLYTIC AGENTS ACTIVASE INJ 100MG BRAND TIER 03ACTIVASE INJ 50MG BRAND TIER 03CATHFLO ACTI INJ VASE BRAND TIER 03KINLYTIC INJ 250000 BRAND TIER 03RETAVASE INJ BRAND TIER 03RETAVASE INJ HALF‐KIT BRAND TIER 03TNKASE KIT 50MG BRAND TIER 03THYROID AGENTS ARMOUR THYRO TAB 120MG BRAND TIER 03ARMOUR THYRO TAB 15MG BRAND TIER 03ARMOUR THYRO TAB 180MG BRAND TIER 03ARMOUR THYRO TAB 240MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion267

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHYROID AGENTS ARMOUR THYRO TAB 300MG BRAND TIER 03ARMOUR THYRO TAB 30MG Brand‐O TIER 03 PAARMOUR THYRO TAB 60MG Brand‐O TIER 03 PAARMOUR THYRO TAB 90MG Brand‐O TIER 03 PACYTOMEL TAB 25MCG Brand‐O TIER 03 PACYTOMEL TAB 50MCG Brand‐O TIER 03 PACYTOMEL TAB 5MCG Brand‐O TIER 03 PALEVOTHROID TAB 100MCG GENERIC TIER 01LEVOTHROID TAB 112MCG GENERIC TIER 01LEVOTHROID TAB 125MCG GENERIC TIER 01LEVOTHROID TAB 137MCG GENERIC TIER 01LEVOTHROID TAB 150MCG GENERIC TIER 01LEVOTHROID TAB 175MCG GENERIC TIER 01LEVOTHROID TAB 200MCG GENERIC TIER 01LEVOTHROID TAB 25MCG GENERIC TIER 01LEVOTHROID TAB 300MCG GENERIC TIER 01LEVOTHROID TAB 50MCG GENERIC TIER 01LEVOTHROID TAB 75MCG GENERIC TIER 01LEVOTHROID TAB 88MCG GENERIC TIER 01LEVOTHYROXIN INJ 100MCG GENERIC TIER 01LEVOTHYROXIN INJ 200MCG GENERIC TIER 01LEVOTHYROXIN INJ 500MCG GENERIC TIER 01LEVOTHYROXIN TAB 100MCG GENERIC TIER 01LEVOTHYROXIN TAB 112MCG GENERIC TIER 01LEVOTHYROXIN TAB 125MCG GENERIC TIER 01LEVOTHYROXIN TAB 137MCG GENERIC TIER 01LEVOTHYROXIN TAB 150MCG GENERIC TIER 01LEVOTHYROXIN TAB 175MCG GENERIC TIER 01LEVOTHYROXIN TAB 200MCG GENERIC TIER 01LEVOTHYROXIN TAB 25MCG GENERIC TIER 01LEVOTHYROXIN TAB 300MCG GENERIC TIER 01LEVOTHYROXIN TAB 50MCG GENERIC TIER 01LEVOTHYROXIN TAB 75MCG GENERIC TIER 01LEVOTHYROXIN TAB 88MCG GENERIC TIER 01LEVOXYL TAB 100MCG GENERIC TIER 01LEVOXYL TAB 112MCG GENERIC TIER 01LEVOXYL TAB 125MCG GENERIC TIER 01LEVOXYL TAB 137MCG GENERIC TIER 01LEVOXYL TAB 150MCG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion268

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHYROID AGENTS LEVOXYL TAB 175MCG GENERIC TIER 01LEVOXYL TAB 200MCG GENERIC TIER 01LEVOXYL TAB 25MCG GENERIC TIER 01LEVOXYL TAB 50MCG GENERIC TIER 01LEVOXYL TAB 75MCG GENERIC TIER 01LEVOXYL TAB 88MCG GENERIC TIER 01LIOTHYRONINE INJ 10MCG/ML GENERIC TIER 01LIOTHYRONINE TAB 25MCG GENERIC TIER 01LIOTHYRONINE TAB 50MCG GENERIC TIER 01LIOTHYRONINE TAB 5MCG GENERIC TIER 01NATURE THROI TAB 162.5MG BRAND TIER 03NATURE‐THROI TAB 113.75MG BRAND TIER 03NATURE‐THROI TAB 130MG GENERIC TIER 01NATURE‐THROI TAB 146.25MG BRAND TIER 03NATURE‐THROI TAB 16.25MG GENERIC TIER 01NATURE‐THROI TAB 195MG GENERIC TIER 01NATURE‐THROI TAB 260MG BRAND TIER 03NATURE‐THROI TAB 32.5MG GENERIC TIER 01NATURE‐THROI TAB 325MG BRAND TIER 03NATURE‐THROI TAB 48.75MG BRAND TIER 03NATURE‐THROI TAB 65MG GENERIC TIER 01NATURE‐THROI TAB 81.25MG BRAND TIER 03NATURE‐THROI TAB 97.5MG BRAND TIER 03NP THYROID TAB 30MG GENERIC TIER 01NP THYROID TAB 60MG GENERIC TIER 01NP THYROID TAB 90MG GENERIC TIER 01SYNTHROID TAB 100MCG Brand‐O TIER 02 PASYNTHROID TAB 112MCG Brand‐O TIER 02 PASYNTHROID TAB 125MCG Brand‐O TIER 02 PASYNTHROID TAB 137MCG Brand‐O TIER 02 PASYNTHROID TAB 150MCG Brand‐O TIER 02 PASYNTHROID TAB 175MCG Brand‐O TIER 02 PASYNTHROID TAB 200MCG Brand‐O TIER 02 PASYNTHROID TAB 25MCG Brand‐O TIER 02 PASYNTHROID TAB 300MCG Brand‐O TIER 02 PASYNTHROID TAB 50MCG Brand‐O TIER 02 PASYNTHROID TAB 75MCG Brand‐O TIER 02 PASYNTHROID TAB 88MCG Brand‐O TIER 02 PATHYROLAR‐1 TAB 60MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion269

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHYROID AGENTS THYROLAR‐1/2 TAB 30MG BRAND TIER 03THYROLAR‐1/4 TAB 15MG BRAND TIER 03THYROLAR‐2 TAB 120MG BRAND TIER 03THYROLAR‐3 TAB 180MG BRAND TIER 03TIROSINT CAP 100MCG BRAND TIER 03TIROSINT CAP 112MCG BRAND TIER 03TIROSINT CAP 125MCG BRAND TIER 03TIROSINT CAP 137MCG BRAND TIER 03TIROSINT CAP 13MCG BRAND TIER 03TIROSINT CAP 150MCG BRAND TIER 03TIROSINT CAP 25MCG BRAND TIER 03TIROSINT CAP 50MCG BRAND TIER 03TIROSINT CAP 75MCG BRAND TIER 03TIROSINT CAP 88MCG BRAND TIER 03TRIOSTAT INJ 10MCG/ML Brand‐O TIER 03 PAUNITH DIRECT TAB 100MCG GENERIC TIER 01UNITH DIRECT TAB 112MCG GENERIC TIER 01UNITH DIRECT TAB 125MCG GENERIC TIER 01UNITH DIRECT TAB 150MCG GENERIC TIER 01UNITH DIRECT TAB 175MCG GENERIC TIER 01UNITH DIRECT TAB 200MCG GENERIC TIER 01UNITH DIRECT TAB 25MCG GENERIC TIER 01UNITH DIRECT TAB 300MCG GENERIC TIER 01UNITH DIRECT TAB 50MCG GENERIC TIER 01UNITH DIRECT TAB 75MCG GENERIC TIER 01UNITH DIRECT TAB 88MCG GENERIC TIER 01UNITHROID TAB 100MCG GENERIC TIER 01UNITHROID TAB 112MCG GENERIC TIER 01UNITHROID TAB 125MCG GENERIC TIER 01UNITHROID TAB 137MCG GENERIC TIER 01UNITHROID TAB 150MCG GENERIC TIER 01UNITHROID TAB 175MCG GENERIC TIER 01UNITHROID TAB 200MCG GENERIC TIER 01UNITHROID TAB 25MCG GENERIC TIER 01UNITHROID TAB 300MCG GENERIC TIER 01UNITHROID TAB 50MCG GENERIC TIER 01UNITHROID TAB 75MCG GENERIC TIER 01UNITHROID TAB 88MCG GENERIC TIER 01WESTHROID TAB 113.75MG BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion270

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHYROID AGENTS WESTHROID TAB 130MG GENERIC TIER 01WESTHROID TAB 146.25MG BRAND TIER 03WESTHROID TAB 16.25MG BRAND TIER 03WESTHROID TAB 162.50MG BRAND TIER 03WESTHROID TAB 195MG BRAND TIER 03WESTHROID TAB 260MG BRAND TIER 03WESTHROID TAB 32.5MG GENERIC TIER 01WESTHROID TAB 325MG BRAND TIER 03WESTHROID TAB 48.75MG BRAND TIER 03WESTHROID TAB 65MG GENERIC TIER 01WESTHROID TAB 81.25MG BRAND TIER 03WESTHROID TAB 97.5MG BRAND TIER 03THYROID FUNCTION IODOPEN INJ 100MCG BRAND TIER 03SODIUM IODID CAP I‐123 GENERIC TIER 99 DETHYROGEN INJ 1.1MG BRAND TIER 03 SPTOXOIDS ADACEL INJ BRAND TIER 03BOOSTRIX INJ BRAND TIER 03DAPTACEL INJ BRAND TIER 03DECAVAC INJ 5‐2LF GENERIC TIER 01DIP/TET PED INJ 25‐5LFU GENERIC TIER 01DIP/TET PED INJ 6.7‐5LF GENERIC TIER 01INFANRIX INJ BRAND TIER 03KINRIX INJ BRAND TIER 99 DETENIVAC INJ 5‐2LF BRAND TIER 03TET/DIP TOX INJ 2‐2 LF GENERIC TIER 01TETANUS TOX INJ 5LF ADS GENERIC TIER 01TRIHIBIT KIT P/F BRAND TIER 03TRIPEDIA SUS P/F BRAND TIER 03TRICHINOSIS TRICHOPHYTON INJ 1:200 GENERIC TIER 01TRICHOPHYTON INJ 1:500 BRAND TIER 03TRYCYCLICS & OTHER NOREPINEPH.‐RU INHIB AMITRIPTYLIN TAB 100MG GENERIC TIER 01AMITRIPTYLIN TAB 10MG GENERIC TIER 01AMITRIPTYLIN TAB 150MG GENERIC TIER 01AMITRIPTYLIN TAB 25MG GENERIC TIER 01AMITRIPTYLIN TAB 50MG GENERIC TIER 01AMITRIPTYLIN TAB 75MG GENERIC TIER 01AMOXAPINE TAB 100MG GENERIC TIER 01AMOXAPINE TAB 150MG GENERIC TIER 01AMOXAPINE TAB 25MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion271

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTRYCYCLICS & OTHER NOREPINEPH.‐RU INHIB AMOXAPINE TAB 50MG GENERIC TIER 01ANAFRANIL CAP 25MG Brand‐O TIER 03 PAANAFRANIL CAP 50MG Brand‐O TIER 03 PAANAFRANIL CAP 75MG Brand‐O TIER 03 PACDP/AMITRIP TAB 10‐25MG GENERIC TIER 01CDP/AMITRIP TAB 5‐12.5MG GENERIC TIER 01CLOMIPRAMINE CAP 25MG GENERIC TIER 01CLOMIPRAMINE CAP 50MG GENERIC TIER 01CLOMIPRAMINE CAP 75MG GENERIC TIER 01DESIPRAMINE TAB 100MG GENERIC TIER 01DESIPRAMINE TAB 10MG GENERIC TIER 01DESIPRAMINE TAB 150MG GENERIC TIER 01DESIPRAMINE TAB 25MG GENERIC TIER 01DESIPRAMINE TAB 50MG GENERIC TIER 01DESIPRAMINE TAB 75MG GENERIC TIER 01DOXEPIN HCL CAP 100MG GENERIC TIER 01DOXEPIN HCL CAP 10MG GENERIC TIER 01DOXEPIN HCL CAP 150MG GENERIC TIER 01DOXEPIN HCL CAP 25MG GENERIC TIER 01DOXEPIN HCL CAP 50MG GENERIC TIER 01DOXEPIN HCL CAP 75MG GENERIC TIER 01DOXEPIN HCL CON 10MG/ML GENERIC TIER 01IMIPRAM HCL TAB 10MG GENERIC TIER 01IMIPRAM HCL TAB 25MG GENERIC TIER 01IMIPRAM HCL TAB 50MG GENERIC TIER 01IMIPRAM PAM CAP 100MG GENERIC TIER 01IMIPRAM PAM CAP 125MG GENERIC TIER 01IMIPRAM PAM CAP 150MG GENERIC TIER 01IMIPRAM PAM CAP 75MG GENERIC TIER 01MAPROTILINE TAB 25MG GENERIC TIER 01MAPROTILINE TAB 50MG GENERIC TIER 01MAPROTILINE TAB 75MG GENERIC TIER 01NORPRAMIN TAB 100MG Brand‐O TIER 03 PANORPRAMIN TAB 10MG Brand‐O TIER 03 PANORPRAMIN TAB 150MG Brand‐O TIER 03 PANORPRAMIN TAB 25MG Brand‐O TIER 03 PANORPRAMIN TAB 50MG Brand‐O TIER 03 PANORPRAMIN TAB 75MG Brand‐O TIER 03 PANORTRIPTYLIN CAP 10MG GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion272

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTRYCYCLICS & OTHER NOREPINEPH.‐RU INHIB NORTRIPTYLIN CAP 25MG GENERIC TIER 01NORTRIPTYLIN CAP 50MG GENERIC TIER 01NORTRIPTYLIN CAP 75MG GENERIC TIER 01NORTRIPTYLIN SOL 10MG/5ML GENERIC TIER 01PAMELOR CAP 10MG Brand‐O TIER 03 PAPAMELOR CAP 25MG Brand‐O TIER 03 PAPAMELOR CAP 50MG Brand‐O TIER 03 PAPAMELOR CAP 75MG Brand‐O TIER 03 PAPERPHEN/AMIT TAB 2‐10MG GENERIC TIER 01PERPHEN/AMIT TAB 2‐25MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐10MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐25MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐50MG GENERIC TIER 01PROTRIPTYLIN TAB 10MG GENERIC TIER 01PROTRIPTYLIN TAB 5MG GENERIC TIER 01SENTRAVIL PM PAK ‐25 BRAND TIER 03SILENOR TAB 3MG BRAND TIER 02 PA QLSILENOR TAB 6MG BRAND TIER 02 PA QLSURMONTIL CAP 100MG Brand‐O TIER 03 PASURMONTIL CAP 25MG Brand‐O TIER 03 PASURMONTIL CAP 50MG Brand‐O TIER 03 PATOFRANIL TAB 10MG Brand‐O TIER 03 PATOFRANIL TAB 25MG Brand‐O TIER 03 PATOFRANIL TAB 50MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 100MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 125MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 150MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 75MG Brand‐O TIER 03 PATRIMIPRAMINE CAP 100MG GENERIC TIER 01TRIMIPRAMINE CAP 25MG GENERIC TIER 01TRIMIPRAMINE CAP 50MG GENERIC TIER 01VIVACTIL TAB 10MG Brand‐O TIER 03 PAVIVACTIL TAB 5MG Brand‐O TIER 03 PATUBERCULOSIS APLISOL INJ 5/0.1ML BRAND TIER 03TUBERSOL INJ 5/0.1ML BRAND TIER 03URICOSURIC AGENTS PROBEN/COLCH TAB 500‐0.5 GENERIC TIER 01PROBENECID TAB 500MG GENERIC TIER 01URINARY ANTI‐INFECTIVES FURADANTIN SUS 25MG/5ML Brand‐O TIER 03 PAHIPREX TAB 1GM Brand‐O TIER 03 PAKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion273

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusURINARY ANTI‐INFECTIVES HYOPHEN TAB GENERIC TIER 01MACROBID CAP 100MG Brand‐O TIER 03 PAMACRODANTIN CAP 100MG Brand‐O TIER 03 PAMACRODANTIN CAP 25MG BRAND TIER 03MACRODANTIN CAP 50MG Brand‐O TIER 03 PAMETHENAM HIP TAB 1GM GENERIC TIER 01METHENAM MAN TAB 1000MG GENERIC TIER 01METHENAM MAN TAB 1GM GENERIC TIER 01METHENAM MAN TAB 500MG GENERIC TIER 01MONUROL PAK GRANULES BRAND TIER 03NITROFUR MAC CAP 100MG GENERIC TIER 01NITROFUR MAC CAP 50MG GENERIC TIER 01NITROFURANTN CAP 100MG GENERIC TIER 01NITROFURANTN SUS 25MG/5ML GENERIC TIER 01PHOSPHASAL TAB GENERIC TIER 01PRIMSOL SOL 50MG/5ML BRAND TIER 03PROSED/DS TAB Brand‐O TIER 03 PATRIMETHOPRIM TAB 100MG GENERIC TIER 01UR N‐C TAB GENERIC TIER 01URELLE TAB BRAND TIER 03URETRON D/S TAB BRAND TIER 03URETRON D/S TAB GENERIC TIER 01UREX TAB 1GM Brand‐O TIER 03 PAURIBEL CAP 118MG BRAND TIER 03URIN D/S TAB GENERIC TIER 01UROGESIC‐ TAB BLUE Brand‐O TIER 03 PAUROQID #2 TAB BRAND TIER 03URYL TAB GENERIC TIER 01USTELL CAP GENERIC TIER 01UTA CAP 120MG GENERIC TIER 01UTICAP CAP GENERIC TIER 01UTIRA‐C TAB GENERIC TIER 01UTRONA‐C TAB GENERIC TIER 01VACCINES ACTHIB INJ BRAND TIER 03AFLURIA INJ 2009‐10 BRAND TIER 03AFLURIA INJ 2011‐12 BRAND TIER 03AFLURIA INJ 2012‐13 BRAND TIER 03AFLURIA INJ PF 10‐11 BRAND TIER 03AFLURIA INJ PF 11‐12 BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion274

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVACCINES AFLURIA INJ PF 12‐13 BRAND TIER 03AGRIFLU INJ 2010‐11 BRAND TIER 03BIOTHRAX INJ BRAND TIER 99 DECERVARIX INJ BRAND TIER 03 PACOMVAX INJ BRAND TIER 03ENGERIX‐B INJ 10/0.5ML BRAND TIER 03ENGERIX‐B INJ 20MCG/ML BRAND TIER 03FLUARIX INJ PF 10‐11 BRAND TIER 03FLUARIX INJ PF 11‐12 BRAND TIER 03FLUARIX INJ PF 12‐13 BRAND TIER 03FLULAVAL INJ 2010‐11 BRAND TIER 03FLULAVAL INJ 2011‐12 BRAND TIER 03FLULAVAL INJ 2012‐13 BRAND TIER 03FLUMIST NASA LIQ 2010‐11 BRAND TIER 03FLUMIST NASA LIQ 2011‐12 BRAND TIER 03FLUMIST NASA LIQ 2012‐13 BRAND TIER 03FLUVIRIN INJ 2010‐11 BRAND TIER 03FLUVIRIN INJ 2011‐12 BRAND TIER 03FLUVIRIN INJ 2012‐13 BRAND TIER 03FLUVIRIN INJ PF 11‐12 BRAND TIER 03FLUVIRIN INJ PF 12‐13 BRAND TIER 03FLUZONE INJ INTRADRM BRAND TIER 03FLUZONE INJ PF 10‐11 BRAND TIER 03FLUZONE INJ PF 11‐12 BRAND TIER 03FLUZONE INJ PF 12‐13 BRAND TIER 03FLUZONE HD INJ PF 10‐11 BRAND TIER 03FLUZONE HD INJ PF 11‐12 BRAND TIER 03FLUZONE HD INJ PF 12‐13 BRAND TIER 03FLUZONE PED/ INJ PF 10‐11 BRAND TIER 03FLUZONE PED/ INJ PF 11‐12 BRAND TIER 03FLUZONE PED/ INJ PF 12‐13 BRAND TIER 03FLUZONE SPLT INJ 2010‐11 BRAND TIER 03FLUZONE SPLT INJ 2011‐12 BRAND TIER 03FLUZONE SPLT INJ 2012‐13 BRAND TIER 03GARDASIL INJ BRAND TIER 03 PAHAVRIX INJ 1440UNIT BRAND TIER 03HAVRIX INJ 720UNIT BRAND TIER 03HIBERIX SOL 10‐25MCG BRAND TIER 99 DEIMOVAX RABIE INJ 2.5/ML BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion275

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVACCINES INFLUENZA A INJ PF09H1N1 GENERIC TIER 01INFLUENZA A SPR 09 H1N1 GENERIC TIER 01IPOL INJ INACTIVE BRAND TIER 03IXIARO INJ BRAND TIER 99 DEJE‐VAX INJ BRAND TIER 03MENACTRA INJ BRAND TIER 03MENHIBRIX INJ BRAND TIER 03MENOMUNE INJ A/C/Y/W BRAND TIER 03MENVEO INJ BRAND TIER 03M‐M‐R II INJ LIVE BRAND TIER 03PEDIARIX INJ 0.5ML BRAND TIER 03PEDVAX HIB INJ BRAND TIER 03PENTACEL INJ BRAND TIER 99 DEPNEUMOVAX 23 INJ 25/0.5 BRAND TIER 03PNEUMOVAX 23 INJ 25/0.5 GENERIC TIER 01PREVNAR 13 INJ BRAND TIER 03PROQUAD INJ BRAND TIER 03RABAVERT INJ BRAND TIER 03RECOMBIVA HB INJ 10MCG/ML BRAND TIER 03RECOMBIVA HB INJ 5MCG/0.5 BRAND TIER 03RECOMBIVA‐HB INJ 40MCG/ML BRAND TIER 03ROTARIX SUS BRAND TIER 03ROTATEQ SUS BRAND TIER 99 DETHERACYS INJ BRAND TIER 03 SPTICE BCG INJ BRAND TIER 03 SPTWINRIX INJ BRAND TIER 03TYPHIM VI INJ BRAND TIER 03VAQTA INJ 25/0.5ML BRAND TIER 03VAQTA INJ 50UNT/ML BRAND TIER 03VARIVAX INJ BRAND TIER 03VIVOTIF BERN CAP EC BRAND TIER 03YF‐VAX INJ GENERIC TIER 01ZOSTAVAX INJ BRAND TIER 99 DEVASOCONSTRICTORS ADRENALIN SOL 1:1000 BRAND TIER 03AK‐CON SOL 0.1% OP GENERIC TIER 01ALTAFRIN SOL 10% OP GENERIC TIER 01ALTAFRIN SOL 2.5% OP GENERIC TIER 01MYDFRIN SOL 2.5% OP Brand‐O TIER 03 PANEOFRIN SOL 10% OP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion276

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVASOCONSTRICTORS NEOFRIN SOL 2.5% OP GENERIC TIER 01PHENYLEPHRIN SOL 10% OP GENERIC TIER 01PHENYLEPHRIN SOL 2.5% OP GENERIC TIER 01TYZINE SOL 0.1% BRAND TIER 03TYZINE PED DRO 0.05% BRAND TIER 03VASODILATING AGENTS, MISCELLANEOUS ALPROSTADIL INJ 500MCG GENERIC TIER 01CAVERJECT INJ 20MCG BRAND TIER 99 DECAVERJECT INJ 40MCG BRAND TIER 99 DECAVERJECT KIT 10MCG BRAND TIER 99 DECAVERJECT KIT 20MCG BRAND TIER 99 DEDIPYRIDAMOLE INJ 5MG/ML GENERIC TIER 01DIPYRIDAMOLE TAB 25MG GENERIC TIER 01DIPYRIDAMOLE TAB 50MG GENERIC TIER 01DIPYRIDAMOLE TAB 75MG GENERIC TIER 01EDEX KIT 10MCG BRAND TIER 99 DEEDEX KIT 20MCG BRAND TIER 99 DEEDEX KIT 40MCG BRAND TIER 99 DEEPOPROSTENOL INJ 0.5MG GENERIC TIER 01 PA SPEPOPROSTENOL INJ 1.5MG GENERIC TIER 01 PA SPFLOLAN INJ 0.5MG Brand‐O TIER 02 PA SPFLOLAN INJ 1.5MG Brand‐O TIER 02 PA SPISOXSUPRINE TAB 10MG GENERIC TIER 99 DELETAIRIS TAB 10MG BRAND TIER 02 PA SPLETAIRIS TAB 5MG BRAND TIER 02 PA SPMUSE SUP 1000MCG BRAND TIER 99 DEMUSE SUP 125MCG BRAND TIER 99 DEMUSE SUP 250MCG BRAND TIER 99 DEMUSE SUP 500MCG BRAND TIER 99 DENATRECOR INJ 1.5MG BRAND TIER 03PAPAVERINE INJ 30MG/ML GENERIC TIER 01PAPAVERINE SOL 30MG/ML GENERIC TIER 01PERSANTINE TAB 25MG Brand‐O TIER 03 PAPERSANTINE TAB 50MG Brand‐O TIER 03 PAPERSANTINE TAB 75MG Brand‐O TIER 03 PAPROSTIN VR INJ 500MCG Brand‐O TIER 03 PAREMODULIN INJ 10MG/ML BRAND TIER 02 PA SPREMODULIN INJ 1MG/ML BRAND TIER 02 PA SPREMODULIN INJ 2.5MG/ML BRAND TIER 02 PA SPREMODULIN INJ 5MG/ML BRAND TIER 02 PA SPKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion277

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVASODILATING AGENTS, MISCELLANEOUS TRACLEER TAB 125MG BRAND TIER 02 PA SPTRACLEER TAB 62.5MG BRAND TIER 02 PA SPTYVASO SOL 0.6MG/ML BRAND TIER 02 PA SPTYVASO REFIL SOL 0.6MG/ML BRAND TIER 02 PA SPTYVASO START SOL 0.6MG/ML BRAND TIER 02 PA SPVELETRI INJ 0.5MG BRAND TIER 02 PA SPVELETRI INJ 1.5MG BRAND TIER 02 PA SPVELETRI INJ 1.5MG GENERIC TIER 01 PA SPVENTAVIS SOL 10MCG/ML BRAND TIER 02 PA SPVENTAVIS SOL 20MCG/ML BRAND TIER 02 PA SPVASOPRESSIN ANTAGONISTS SAMSCA TAB 15MG BRAND TIER 02 PA QLSAMSCA TAB 30MG BRAND TIER 02 PA QLVAPRISOL INJ BRAND TIER 99 DEVITAMIN A AQUASOL A INJ 50000/ML BRAND TIER 03VITAMIN B COMPLEX AIRAVITE TAB GENERIC TIER 99 DEALZ‐NAC TAB BRAND TIER 03AMINOBEZ POT POW GENERIC TIER 99 DEANIMI‐3 CAP Brand‐O TIER 03 PAANIMI‐3 CAP VIT D BRAND TIER 03B6 FOLIC ACD CAP GENERIC TIER 01B‐COMPLEX INJ GENERIC TIER 99 DEB‐COMPLEX INJ 100 GENERIC TIER 99 DEBP VIT 3 CAP GENERIC TIER 01CARDIOTEK‐RX TAB BRAND TIER 03CEREFOLIN TAB BRAND TIER 03CEREFOLIN TAB NAC BRAND TIER 03CYANOCOBALAM CRY GENERIC TIER 99 DECYANOCOBALAM INJ 1000MCG GENERIC TIER 01DEXPANTHENOL INJ 250MG/ML GENERIC TIER 01DIVISTA CAP BRAND TIER 99 DEFA‐B6‐B12 TAB GENERIC TIER 99 DEFABB TAB GENERIC TIER 99 DEFOLASTIN TAB GENERIC TIER 99 DEFOLBEE TAB GENERIC TIER 99 DEFOLBEE AR TAB BRAND TIER 03FOLBIC TAB GENERIC TIER 99 DEFOLCAPS TAB GENERIC TIER 99 DEFOLIC ACID INJ 5MG/ML GENERIC TIER 01FOLIC ACID TAB GENERIC TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion278

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVITAMIN B COMPLEX FOLIC ACID TAB 1MG GENERIC TIER 01FOLPACE RX TAB BRAND TIER 03FOLPLEX 2.2 TAB GENERIC TIER 99 DEFOLTRATE TAB BRAND TIER 02HYDROXOCOBAL INJ 1000MCG GENERIC TIER 01L‐METHYL‐ TAB B6‐B12 GENERIC TIER 01L‐METHYL‐MC TAB BRAND TIER 03METANX TAB BRAND TIER 03METHYLFOL/ME TAB ‐CBL/NAC GENERIC TIER 01METHYLFOL/ME TAB ‐CBL/P5P GENERIC TIER 01MI‐OMEGA NF CAP GENERIC TIER 01NASCOBAL SPR 500MCG BRAND TIER 03NEURIN‐SL SUB BRAND TIER 03NIACIN POW USP/NF GENERIC TIER 01NIACOR TAB 500MG GENERIC TIER 01NUFOL TAB GENERIC TIER 99 DEPOTABA CAP 500MG BRAND TIER 99 DEPOTABA TAB 500MG BRAND TIER 99 DEPRE‐FOLIC TAB 1‐100MG BRAND TIER 03PYRIDOXINE INJ 100MG/ML GENERIC TIER 01THIAMINE HCL INJ 100MG/ML GENERIC TIER 01TL GARD RX TAB GENERIC TIER 99 DEVIT B‐COMPLX INJ 100 GENERIC TIER 99 DEVITACIRC‐B TAB BRAND TIER 03VITA‐RESPA TAB BRAND TIER 03FOLGARD RX TAB Brand‐O TIER 99 PA DECENFOL TAB BRAND TIER 99 DEFOLTX TAB Brand‐O TIER 99 PA DEVITAMIN C ASCOR L 500 INJ 500MG/ML GENERIC TIER 01ASCOR L NC INJ 500MG/ML GENERIC TIER 01ASCORBIC ACD INJ 500MG/ML GENERIC TIER 01CENOLATE INJ 500MG/ML GENERIC TIER 01MEGA‐C/A PLU INJ 500MG/ML GENERIC TIER 01ORTHO‐CS 250 INJ 250MG/ML GENERIC TIER 01SOD ASCORBAT GRA GENERIC TIER 99 DESOD ASCORBAT GRA USP GENERIC TIER 99 DESOD ASCORBAT GRA USP NF GENERIC TIER 99 DEVITAMIN C INJ 222MG/ML GENERIC TIER 01ASCORBIC ACD GRA GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion279

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVITAMIN D CALCIJEX INJ 1MCG/ML Brand‐O TIER 03 PACALCITRIOL CAP 0.25MCG GENERIC TIER 01CALCITRIOL CAP 0.5MCG GENERIC TIER 01CALCITRIOL INJ 1MCG/ML GENERIC TIER 01CALCITRIOL SOL 1MCG/ML GENERIC TIER 01DECARA CAP 25000 IU BRAND TIER 03DRISDOL CAP 50000UNT Brand‐O TIER 03 PAERGOCALCIFER CAP 50000UNT GENERIC TIER 01HECTOROL CAP 0.5MCG BRAND TIER 02HECTOROL CAP 1MCG BRAND TIER 02HECTOROL CAP 2.5MCG BRAND TIER 02HECTOROL INJ 2MCG/ML BRAND TIER 03HECTOROL INJ 4MCG/2ML BRAND TIER 03ROCALTROL CAP 0.25MCG Brand‐O TIER 03 PAROCALTROL CAP 0.5MCG Brand‐O TIER 03 PAROCALTROL SOL 1MCG/ML Brand‐O TIER 03 PAVITAMIN D CAP 50000UNT GENERIC TIER 01ZEMPLAR CAP 1MCG BRAND TIER 02ZEMPLAR CAP 2MCG BRAND TIER 02ZEMPLAR CAP 4MCG BRAND TIER 02ZEMPLAR INJ 2MCG/ML BRAND TIER 03ZEMPLAR INJ 5MCG/ML BRAND TIER 03VITAMIN E WHEAT GERM OIL GENERIC TIER 01VITAMIN K ACTIVITY MEPHYTON TAB 5MG BRAND TIER 02PHYTONADIONE INJ 1MG/0.5 GENERIC TIER 01VITAMIN K1 INJ 10MG/ML GENERIC TIER 01VITAMIN K1 INJ 1MG/0.5 GENERIC TIER 01ANTIFLATULENTS SIMETHICONE LIQ GENERIC TIER 99 DEBASIC POWDERS AND DEMULCENTS BENZOIN CMPD TIN GENERIC TIER 01BENZOIN TIN NF GENERIC TIER 01DETERGENTS GREEN SOAP TIN GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion280