NLPDP Coverage Status Table December 2021

1 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02234510282 TABLETOPENI nitial and maintenance fills are limited to a maximum 30 TABLETOPENI nitial and maintenance fills are limited to a maximum 30 10 MG/ML SOLUTIONOPENI nitial and maintenance fills are limited to a maximum 30 150MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 300MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 IHLES PASTE FORMULA ALBALON A/SULAMYD 10% 1 5MG/50MG 100-25 MG 50-25 MG 100 MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 200MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 25 MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 50MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 30 MG 60 MG MICRO 67 MG 200 MG CR 100MG/25MG CR 200MG/50MG LA 100 MG TABLET LA 200 MG TABLET LA 300 MG December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02414570 ABBOTT CITALOPRAM 10MG TABLETOPENI nitial fills are limited to a maximum 30 120MG SUPPOSITORYOPENB eneficiary of 325MG SUPPOSITORYOPENB eneficiary of 10MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 15MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 20MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 2MG TABLETSPEC AUTHI nitial

2 Fills are limited to a maximum 30 30MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 5MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 MAINTENA ER 300MG/VIAL INJECTABLE SUSPENSIONSPEC AUTHI nitial fills are limited to a maximum 30 MAINTENA ER 400MG/VIAL INJECTABLE SUSPENSIONSPEC AUTHI nitial fills are limited to a maximum 30 BOYZ CHAMBER W/MOUTHPIECEOPENL imit of one per year without Special GIRLZ CHAMBER W/MOUTHPIECEOPENL imit of one per year without Special 100MG 50MG 10 MG 800MG TABLETSPEC 20MG TABLETSPEC December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP00977062 ACCU-CHEK ADVANTAGE TEST STRIPOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA).

3 SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or AVIVA TEST STRIPSOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or COMPACT TEST STRIPOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or FASTCLIK 6 LANCET DRUM (102s) FASTCLIK 6 LANCET DRUM (204s) GUIDE TEST STRIPS 100'sOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA).

4 SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP97799178 ACCU-CHEK GUIDE TEST STRIPS 50'sOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or MOBILE TEST STRIPS 100sOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year.

5 B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or MOBILE TEST STRIPS 50sOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year. B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or MULTICLIX 10 MG 20 MG 40 MG 5 MG 10 MG 20 MG 20/25 MG ROCHE 10 MG ROCHE 40 MG December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP00977031 ACCUTREND TEST STRIPOPENA)Limit of 2550 714 or 102 test strips/year without special authorization (SA). SA required if client does not have diabetic medication within previous year.

6 B)Limit of 51 test strips/year without SA for clients receiving no diabetic medication or 80 MG/ML DROPSOPENB eneficiary of 250 MG FORTE C8 TABLETOPENB eneficiary of CSSD. Initial and maintenance fills are limited to a maximum 30 FORTE TABLETOPENB eneficiary of CALCIUM 10MG CALCIUM 20MG CALCIUM 40MG CALCIUM 80MG 150MG TABLETSPEC 500MG TABLETSPEC FUMARATE 120MG DELAYED RELEASE CAPSULESPEC FUMARATE 240MG DELAYED RELEASE CAPSULESPEC 10MG TABLETOPENI nitial fills are limited to a maximum 30 days. Maximum of tablets 20MG TABLETOPENI nitial fills are limited to a maximum 30 December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02425610 ACH-EZETIMIBE 10MG TABLETOPENL imit of 1 per 100MG 400MG 100MG TABLETSPEC 150MG TABLETSPEC 200MG TABLETSPEC 50MG TABLETSPEC 250MG 20MG TABLETOPENL imit of 1 per 40MG TABLETOPENL imit of 1 per 20 TABLETOPENL imit of 1 per 40 TABLETOPENL imit of 1 per 40MG/25M TABLETOPENL imit of 1 per 10MG 20MG 40MG 150 MG CAPSULESPEC 225 MG CAPSULESPEC 25 MG CAPSULESPEC 300 MG CAPSULESPEC 50 MG CAPSULESPEC 75 MG CAPSULESPEC 10MG 20MG 40MG 5MG TABLETOPENL imit of 1 per December 2021

7 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02419114 ACH-TELMISARTAN HCTZ 80 TABLETOPENL imit of 1 per HCTZ 80MG/25MG TABLETOPENL imit of 1 per AMLODIPINE AMPHETAMINE XR 10MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per AMPHETAMINE XR 15MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per AMPHETAMINE XR 20MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per AMPHETAMINE XR 25MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per AMPHETAMINE XR 30MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days.

8 Limit of 1 per AMPHETAMINE XR 5MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per BUPRENORPHINE/NALOXONE 2 SUBLINGUAL TABLETOPENFor use in Methadone Maintenance Therapy BUPRENORPHINE/NALOXONE 8MG/2MG SUBLINGUAL TABLETOPENFor use in Methadone Maintenance Therapy BUPROPION XL 150MG TABLETOPENa) Limited to 1 per day b) Special Authorization required if beneficiary has not had a paid claim for an anti-depressant or Bupropion in past BUPROPION XL 300MG TABLETOPENa) Limited to 1 per day b) Special Authorization required if beneficiary has not had a paid claim for an anti-depressant or Bupropion in past CELECOXIB 100MG CAPSULEOPENL imit of 2 per CELECOXIB 200MG CAPSULEOPENL imit of 2 per December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02403196 ACT CLARITHROMYCIN XL 500MG DEXTROAMPHETAMINE SR 10MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 DEXTROAMPHETAMINE SR 15MG CAPSULEOPENI nitial and maintenance fills are limited to a maximum 30 FLUCONAZOLE 100 MG FLUCONAZOLE 50 MG LATANOPROST/TIMOLOL 50UG/ML / 5MG/ML OPHTHALMIC METFORMIN 500 MG METFORMIN 850 MG METHYLPHENIDATE ER 18MG TABLETOPENI nitial and

9 Maintenance fills are limited to a maximum 30 days. Limit of 1 per day without Special METHYLPHENIDATE ER 27MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per day without Special METHYLPHENIDATE ER 36MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per day without Special METHYLPHENIDATE ER 54MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 days. Limit of 1 per day without Special OLMESARTAN 20MG TABLETOPENL imit of 1 per OLMESARTAN 40MG TABLETOPENL imit of 1 per OLMESARTAN HCT 20 TABLETOPENL imit of 1 per OLMESARTAN HCT 40 TABLETOPENL imit of 1 per OLMESARTAN HCT 40MG/25MG TABLETOPENL imit of 1 per December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02403986 ACT OLOPATADINE OPHTHALMIC OLOPATADINE OPHTHALMIC ONDANSETRON 4MG TABLETOPENL imit of 3 tablets per cycle - first fill only.

10 Special Authorization is required for higher quantities and/or subsequent ONDANSETRON 8MG TABLETOPENL imit of 3 tablets per cycle - first fill only. Special Authorization is required for higher quantities and/or subsequent RIZATRIPTAN 10MG TABLETOPENC overage limited to 6 doses/30 TEMOZOLOMIDE 5MG CAPSULESPEC VENLAFAXINE XR 150 MG CAPOPENI nitial fills are limited to a maximum 30 VENLAFAXINE XR MG CAPOPENI nitial fills are limited to a maximum 30 VENLAFAXINE XR 75 MG CAPOPENI nitial fills are limited to a maximum 30 162 INJECTORSPEC 162 SYRINGESPEC 200MG/10ML VIALSPEC 400MG/20ML VIALSPEC 80MG/4ML VIALSPEC 150 MG TABLETOPENOpen benefit if beneficiary is 65 years of age or older. Special Authorization can be considered if less than 65 years of 30 MG TABLETSPEC 35 MG TABLETOPENOpen benefit if beneficiary is 65 years of age or older.