2021 Rx Select - PRAM

94
STC Description Label Name Tier 1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION Centergy Pediatric Drops 1 1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION Promethazine-phenylephrine Syr 1 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL Tinidazole 250 Mg Tablet 1 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL Tinidazole 500 Mg Tablet 1 5-LIPOXYGENASE INHIBITORS Zileuton Er 600 Mg Tablet 1 ABORTIFACIENT-PROGESTERONE RECEPTOR ANTAGONISTS Mifepristone 200 Mg Tablet 1 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfadiazine 500 Mg Tablet 1 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Ds Tablet 1 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Ss Tablet 1 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Susp 1 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfatrim Pediatric Suspension 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 10-20 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 10-40 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 2.5-10 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-10 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-20 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-40 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 1-240 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 2-180 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 2-240 Mg 1 ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 4-240 Mg 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 10-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 20-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 20-25 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 5-6.25 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 25-15 Mg Tablet 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 25-25 Mg Tablet 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 50-15 Mg Tablet 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 50-25 Mg Tablet 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Enalapril-hctz 10-25 Mg Tablet 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Enalapril-hctz 5-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Fosinopril-hctz 10-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Fosinopril-hctz 20-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 10-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 20-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 20-25 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 10-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 20-12.5 Mg Tab 1 ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 20-25 Mg Tab 1 ACNE AGENTS,SYSTEMIC Absorica 10 Mg Capsule 2 ACNE AGENTS,SYSTEMIC Absorica 20 Mg Capsule 2 2021 Rx Select "Enhanced" Formulary PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Transcript of 2021 Rx Select - PRAM

Page 1: 2021 Rx Select - PRAM

STC Description Label Name Tier1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION Centergy Pediatric Drops 11ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION Promethazine-phenylephrine Syr 12ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL Tinidazole 250 Mg Tablet 12ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL Tinidazole 500 Mg Tablet 15-LIPOXYGENASE INHIBITORS Zileuton Er 600 Mg Tablet 1ABORTIFACIENT-PROGESTERONE RECEPTOR ANTAGONISTS Mifepristone 200 Mg Tablet 1ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfadiazine 500 Mg Tablet 1ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Ds Tablet 1ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Ss Tablet 1ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfamethoxazole-tmp Susp 1ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS Sulfatrim Pediatric Suspension 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 10-20 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 10-40 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 2.5-10 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-10 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-20 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Amlodipine-benazepril 5-40 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 1-240 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 2-180 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 2-240 Mg 1ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Trandolapr-verapam Er 4-240 Mg 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 10-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 20-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 20-25 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Benazepril-hctz 5-6.25 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 25-15 Mg Tablet 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 25-25 Mg Tablet 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 50-15 Mg Tablet 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Captopril-hctz 50-25 Mg Tablet 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Enalapril-hctz 10-25 Mg Tablet 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Enalapril-hctz 5-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Fosinopril-hctz 10-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Fosinopril-hctz 20-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 10-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 20-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Lisinopril-hctz 20-25 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 10-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 20-12.5 Mg Tab 1ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC Quinapril-hctz 20-25 Mg Tab 1ACNE AGENTS,SYSTEMIC Absorica 10 Mg Capsule 2ACNE AGENTS,SYSTEMIC Absorica 20 Mg Capsule 2

2021 Rx Select"Enhanced" Formulary

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 2: 2021 Rx Select - PRAM

ACNE AGENTS,SYSTEMIC Absorica 25 Mg Capsule 2ACNE AGENTS,SYSTEMIC Absorica 30 Mg Capsule 2ACNE AGENTS,SYSTEMIC Absorica 35 Mg Capsule 2ACNE AGENTS,SYSTEMIC Absorica 40 Mg Capsule 2ACNE AGENTS,SYSTEMIC Amnesteem 10 Mg Capsule 1ACNE AGENTS,SYSTEMIC Amnesteem 20 Mg Capsule 1ACNE AGENTS,SYSTEMIC Amnesteem 40 Mg Capsule 1ACNE AGENTS,SYSTEMIC Claravis 10 Mg Capsule 1ACNE AGENTS,SYSTEMIC Claravis 20 Mg Capsule 1ACNE AGENTS,SYSTEMIC Claravis 30 Mg Capsule 1ACNE AGENTS,SYSTEMIC Claravis 40 Mg Capsule 1ACNE AGENTS,SYSTEMIC Isotretinoin 10 Mg Capsule 1ACNE AGENTS,SYSTEMIC Isotretinoin 20 Mg Capsule 1ACNE AGENTS,SYSTEMIC Isotretinoin 30 Mg Capsule 1ACNE AGENTS,SYSTEMIC Isotretinoin 40 Mg Capsule 1ACNE AGENTS,SYSTEMIC Myorisan 10 Mg Capsule 1ACNE AGENTS,SYSTEMIC Myorisan 20 Mg Capsule 1ACNE AGENTS,SYSTEMIC Myorisan 30 Mg Capsule 1ACNE AGENTS,SYSTEMIC Myorisan 40 Mg Capsule 1ACNE AGENTS,SYSTEMIC Zenatane 10 Mg Capsule 1ACNE AGENTS,SYSTEMIC Zenatane 20 Mg Capsule 1ACNE AGENTS,SYSTEMIC Zenatane 30 Mg Capsule 1ACNE AGENTS,SYSTEMIC Zenatane 40 Mg Capsule 1ACNE AGENTS,TOPICAL Adapalene-bnzyl Perox 0.1-2.5% 1ACNE AGENTS,TOPICAL Clind Ph-benzoyl Pero 1.2-2.5% 1ACNE AGENTS,TOPICAL Clind Ph-benzoyl Perox 1.2-5% 1ACNE AGENTS,TOPICAL Clinda-benzoyl Perox 1-5% Pump 1ACNE AGENTS,TOPICAL Clindamycin-benzoyl Perox 1-5% 1ACNE AGENTS,TOPICAL Clinda-tretinoin 1.2%-0.025% 1ACNE AGENTS,TOPICAL Dapsone 5% Gel 1ACNE AGENTS,TOPICAL Neuac Gel 1ACNE AGENTS,TOPICAL Onexton Gel Pump 2ACNE AGENTS,TOPICAL Sodium Sulfacetamide 10% Lotn 1ACNE AGENTS,TOPICAL Sulfacetamide Sod 10% Top Susp 1ACNE AGENTS,TOPICAL Ziana Gel 2ADRENERGIC VASOPRESSOR AGENTS Midodrine Hcl 10 Mg Tablet 1ADRENERGIC VASOPRESSOR AGENTS Midodrine Hcl 2.5 Mg Tablet 1ADRENERGIC VASOPRESSOR AGENTS Midodrine Hcl 5 Mg Tablet 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Amphetamine Sulfate 10 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Amphetamine Sulfate 5 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 10 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 15 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 20 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 25 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 30 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphet Er 5 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetam 12.5 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetam 7.5 Mg Tab 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 3: 2021 Rx Select - PRAM

ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetamin 10 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetamin 15 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetamin 20 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetamin 30 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamp-amphetamine 5 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine 10 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine 5 Mg Tab 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine 5 Mg/5 Ml 3ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine Er 10 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine Er 15 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Dextroamphetamine Er 5 Mg Cap 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Methamphetamine 5 Mg Tablet 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Mydayis Er 12.5 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Mydayis Er 25 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Mydayis Er 37.5 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Mydayis Er 50 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Procentra 5 Mg/5 Ml Solution 3ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 10 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 20 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 30 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 40 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 50 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 60 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Vyvanse 70 Mg Capsule 2ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Zenzedi 10 Mg Tablet 1ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Zenzedi 5 Mg Tablet 1AGENTS FOR STOMATOLOGICAL USE Debacterol Solution 2AGENTS FOR STOMATOLOGICAL USE Debacterol Swabstick 2AGENTS FOR STOMATOLOGICAL USE Prothelial 1 Gm/10 Ml Paste 2AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS) Proglycem 50 Mg/Ml Oral Susp 2AGENTS TO TREAT MULTIPLE SCLEROSIS Aubagio 14 Mg Tablet 2AGENTS TO TREAT MULTIPLE SCLEROSIS Aubagio 7 Mg Tablet 2AGENTS TO TREAT MULTIPLE SCLEROSIS Gilenya 0.5 Mg Capsule 2AGENTS TO TREAT MULTIPLE SCLEROSIS Tecfidera Dr 120 Mg Capsule 2AGENTS TO TREAT MULTIPLE SCLEROSIS Tecfidera Dr 240 Mg Capsule 2AGENTS TO TREAT MULTIPLE SCLEROSIS Tecfidera Starter Pack 2AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR Dalfampridine Er 10 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol 12.5 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol 25 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol 3.125 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol 6.25 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol Er 10 Mg Capsule 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol Er 20 Mg Capsule 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol Er 40 Mg Capsule 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Carvedilol Er 80 Mg Capsule 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Labetalol Hcl 100 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Labetalol Hcl 200 Mg Tablet 1ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Labetalol Hcl 300 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 4: 2021 Rx Select - PRAM

ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS Mirtazapine 15 Mg Tablet 1ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS Mirtazapine 30 Mg Tablet 1ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS Mirtazapine 45 Mg Odt 1ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS Mirtazapine 45 Mg Tablet 1ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS Mirtazapine 7.5 Mg Tablet 1ALPHA-ADRENERGIC BLOCKING AGENTS Doxazosin Mesylate 1 Mg Tab 1ALPHA-ADRENERGIC BLOCKING AGENTS Doxazosin Mesylate 2 Mg Tab 1ALPHA-ADRENERGIC BLOCKING AGENTS Doxazosin Mesylate 4 Mg Tab 1ALPHA-ADRENERGIC BLOCKING AGENTS Doxazosin Mesylate 8 Mg Tab 1ALPHA-ADRENERGIC BLOCKING AGENTS Phenoxybenzamine Hcl 10 Mg Cap 1ALPHA-ADRENERGIC BLOCKING AGENTS Prazosin 1 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Prazosin 2 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Prazosin 5 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Terazosin 1 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Terazosin 10 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Terazosin 2 Mg Capsule 1ALPHA-ADRENERGIC BLOCKING AGENTS Terazosin 5 Mg Capsule 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine 5-10 Mg Titration Pk 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl 10 Mg Tablet 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl 10 Mg/5 Ml Soln 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl 2 Mg/Ml Solution 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl 5 Mg Tablet 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl Er 14 Mg Capsule 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl Er 21 Mg Capsule 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl Er 28 Mg Capsule 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Memantine Hcl Er 7 Mg Capsule 1ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS Namenda 5-10 Mg Titration Pk 2ALZHEIMER'S THX,NMDA RECEPTOR ANTAG-CHOLINES INHIB Namzaric 14 Mg-10 Mg Capsule 2ALZHEIMER'S THX,NMDA RECEPTOR ANTAG-CHOLINES INHIB Namzaric 21 Mg-10 Mg Capsule 2ALZHEIMER'S THX,NMDA RECEPTOR ANTAG-CHOLINES INHIB Namzaric 28 Mg-10 Mg Capsule 2ALZHEIMER'S THX,NMDA RECEPTOR ANTAG-CHOLINES INHIB Namzaric 7 Mg-10 Mg Capsule 2ALZHEIMER'S THX,NMDA RECEPTOR ANTAG-CHOLINES INHIB Namzaric Titration Pack 2AMEBICIDES Paromomycin 250 Mg Capsule 1AMINOGLYCOSIDE ANTIBIOTICS Bethkis 300 Mg/4 Ml Ampule 2AMINOGLYCOSIDE ANTIBIOTICS Kitabis Pak 300 Mg/5 Ml 2AMINOGLYCOSIDE ANTIBIOTICS Neomycin 500 Mg Tablet 1AMINOGLYCOSIDE ANTIBIOTICS Tobi Podhaler 28 Mg Inhale Cap 2AMMONIA INHIBITORS Carbaglu 200 Mg Disper Tablet 2AMMONIA INHIBITORS Enulose 10 Gm/15 Ml Solution 1AMMONIA INHIBITORS Generlac 10 Gm/15 Ml Solution 1AMMONIA INHIBITORS Ravicti 1.1 Gram/Ml Liquid 2AMMONIA INHIBITORS Sodium Phenylbutyrate 500mg Tb 1AMMONIA INHIBITORS Sodium Phenylbutyrate Powder 1AMYOTROPHIC LATERAL SCLEROSIS AGENTS Riluzole 50 Mg Tablet 1AMYOTROPHIC LATERAL SCLEROSIS AGENTS Tiglutik 50 Mg/10 Ml Susp 2ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS Metronidazole 250 Mg Tablet 1ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS Metronidazole 375 Mg Capsule 1ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS Metronidazole 500 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 5: 2021 Rx Select - PRAM

ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT Bupap 50 Mg-300 Mg Tablet 1ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT Butalbital-acetaminophn 50-300 1ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT Butalbital-acetaminophn 50-325 1ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT Tencon 50-325 Mg Tablet 1ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB. Butalb-aspirin-caffe 50-325-40 1ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB. Butalbital-asa-caffeine Cap 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Butalb-acetamin-caff 50-300-40 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Butalb-acetamin-caff 50-325-40 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Esgic Capsule 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Fioricet 50-300-40 Mg Capsule 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Phrenilin Forte 50-300-40 Mg 1ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Vanatol Lq Oral Solution 3ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Vanatol S Oral Solution 3ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMB Zebutal 50-325-40 Mg Capsule 1ANALGESIC/ANTIPYRETICS, SALICYLATES Choline Mag Trisal Liquid 1ANALGESIC/ANTIPYRETICS, SALICYLATES Diflunisal 500 Mg Tablet 1ANALGESIC/ANTIPYRETICS, SALICYLATES Salsalate 500 Mg Tablet 1ANALGESIC/ANTIPYRETICS, SALICYLATES Salsalate 750 Mg Tablet 1ANDROGENIC AGENTS Androderm 2 Mg/24hr Patch 2ANDROGENIC AGENTS Androderm 4 Mg/24hr Patch 2ANDROGENIC AGENTS Methyltestosterone 10 Mg Cap 1ANDROGENIC AGENTS Oxandrolone 10 Mg Tablet 1ANDROGENIC AGENTS Oxandrolone 2.5 Mg Tablet 1ANDROGENIC AGENTS Testosterone 1.62% (2.5 G) Pkt 1ANDROGENIC AGENTS Testosterone 1.62% Gel Pump 1ANDROGENIC AGENTS Testosterone 1.62%(1.25 G) Pkt 1ANDROGENIC AGENTS Testosterone 10 Mg Gel Pump 1ANDROGENIC AGENTS Testosterone 12.5 Mg/1.25 Gram 1ANDROGENIC AGENTS Testosterone 25 Mg/2.5 Gm Pkt 1ANDROGENIC AGENTS Testosterone 30 Mg/1.5 Ml Pump 1ANDROGENIC AGENTS Testosterone 50 Mg/5 Gram Gel 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Amlod-valsa-hctz 10-160-12.5mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Amlod-valsa-hctz 10-160-25 Mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Amlod-valsa-hctz 10-320-25 Mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Amlod-valsa-hctz 5-160-12.5 Mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Amlod-valsa-hctz 5-160-25 Mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Olmsrtn-amldpn-hctz 20-5-12.5 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Olmsrtn-amldpn-hctz 40-10-12.5 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Olmsrtn-amldpn-hctz 40-10-25mg 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Olmsrtn-amldpn-hctz 40-5-12.5 1ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE Olmsrtn-amldpn-hctz 40-5-25 Mg 1ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI) Entresto 24 Mg-26 Mg Tablet 2ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI) Entresto 49 Mg-51 Mg Tablet 2ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI) Entresto 97 Mg-103 Mg Tablet 2ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Candesartan-hctz 16-12.5 Mg Tb 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Candesartan-hctz 32-12.5 Mg Tb 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Candesartan-hctz 32-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Irbesartan-hctz 150-12.5 Mg Tb 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 6: 2021 Rx Select - PRAM

ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Irbesartan-hctz 300-12.5 Mg Tb 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Losartan-hctz 100-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Losartan-hctz 100-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Losartan-hctz 50-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Olmesartan-hctz 20-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Olmesartan-hctz 40-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Olmesartan-hctz 40-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Telmisartan-hctz 80-12.5 Mg Tb 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Telmisartan-hctz 80-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Valsartan-hctz 160-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Valsartan-hctz 160-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Valsartan-hctz 320-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Valsartan-hctz 320-25 Mg Tab 1ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Valsartan-hctz 80-12.5 Mg Tab 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-olmesartan 10-20 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-olmesartan 10-40 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-olmesartan 5-20 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-olmesartan 5-40 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-valsartan 10-160 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-valsartan 10-320 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-valsartan 5-160 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Amlodipine-valsartan 5-320 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Telmisartan-amlodipine 40-10 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Telmisartan-amlodipine 40-5 Mg 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Telmisartan-amlodipine 80-10 1ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR Telmisartan-amlodipine 80-5 Mg 1ANP - SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) Bexarotene 75 Mg Capsule 1ANTHELMINTICS Albendazole 200 Mg Tablet 1ANTHELMINTICS Emverm 100 Mg Tablet Chew 2ANTHELMINTICS Ivermectin 3 Mg Tablet 1ANTHELMINTICS Praziquantel 600 Mg Tablet 1ANTI-ALCOHOLIC PREPARATIONS Acamprosate Calc Dr 333 Mg Tab 1ANTI-ALCOHOLIC PREPARATIONS Disulfiram 250 Mg Tablet 1ANTI-ALCOHOLIC PREPARATIONS Disulfiram 500 Mg Tablet 1ANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC Ranolazine Er 1,000 Mg Tablet 1ANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC Ranolazine Er 500 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam 0.25 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam 0.5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam 1 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam 2 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Er 0.5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Er 1 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Er 2 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Er 3 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Intensol 1 Mg/Ml 3ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Odt 0.25 Mg Tab 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Odt 0.5 Mg Tab 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Odt 1 Mg Tab 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 7: 2021 Rx Select - PRAM

ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Odt 2 Mg Tab 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Xr 0.5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Xr 1 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Xr 2 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Alprazolam Xr 3 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Chlordiazepoxide 10 Mg Capsule 1ANTI-ANXIETY - BENZODIAZEPINES Chlordiazepoxide 25 Mg Capsule 1ANTI-ANXIETY - BENZODIAZEPINES Chlordiazepoxide 5 Mg Capsule 1ANTI-ANXIETY - BENZODIAZEPINES Clorazepate 15 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Clorazepate 3.75 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Clorazepate 7.5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 10 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 2 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 5 Mg/5 Ml Oral Soln 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 5 Mg/5 Ml Solution 1ANTI-ANXIETY - BENZODIAZEPINES Diazepam 5 Mg/Ml Oral Conc 1ANTI-ANXIETY - BENZODIAZEPINES Lorazepam 0.5 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Lorazepam 1 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Lorazepam 2 Mg Tablet 1ANTI-ANXIETY - BENZODIAZEPINES Lorazepam 2 Mg/Ml Oral Concent 1ANTI-ANXIETY - BENZODIAZEPINES Lorazepam Intensol 2 Mg/Ml 1ANTI-ANXIETY - BENZODIAZEPINES Oxazepam 10 Mg Capsule 1ANTI-ANXIETY - BENZODIAZEPINES Oxazepam 15 Mg Capsule 1ANTI-ANXIETY - BENZODIAZEPINES Oxazepam 30 Mg Capsule 1ANTI-ANXIETY DRUGS Buspirone Hcl 10 Mg Tablet 1ANTI-ANXIETY DRUGS Buspirone Hcl 15 Mg Tablet 1ANTI-ANXIETY DRUGS Buspirone Hcl 30 Mg Tablet 1ANTI-ANXIETY DRUGS Buspirone Hcl 5 Mg Tablet 1ANTI-ANXIETY DRUGS Buspirone Hcl 7.5 Mg Tablet 1ANTI-ANXIETY DRUGS Meprobamate 200 Mg Tablet 1ANTI-ANXIETY DRUGS Meprobamate 400 Mg Tablet 1ANTIARRHYTHMICS Amiodarone Hcl 100 Mg Tablet 1ANTIARRHYTHMICS Amiodarone Hcl 200 Mg Tablet 1ANTIARRHYTHMICS Amiodarone Hcl 400 Mg Tablet 1ANTIARRHYTHMICS Disopyramide 100 Mg Capsule 1ANTIARRHYTHMICS Disopyramide 150 Mg Capsule 1ANTIARRHYTHMICS Dofetilide 125 Mcg Capsule 1ANTIARRHYTHMICS Dofetilide 250 Mcg Capsule 1ANTIARRHYTHMICS Dofetilide 500 Mcg Capsule 1ANTIARRHYTHMICS Flecainide Acetate 100 Mg Tab 1ANTIARRHYTHMICS Flecainide Acetate 150 Mg Tab 1ANTIARRHYTHMICS Flecainide Acetate 50 Mg Tab 1ANTIARRHYTHMICS Mexiletine 150 Mg Capsule 1ANTIARRHYTHMICS Mexiletine 200 Mg Capsule 1ANTIARRHYTHMICS Mexiletine 250 Mg Capsule 1ANTIARRHYTHMICS Multaq 400 Mg Tablet 2ANTIARRHYTHMICS Norpace Cr 100 Mg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 8: 2021 Rx Select - PRAM

ANTIARRHYTHMICS Norpace Cr 150 Mg Capsule 2ANTIARRHYTHMICS Pacerone 200 Mg Tablet 1ANTIARRHYTHMICS Propafenone Hcl 150 Mg Tablet 1ANTIARRHYTHMICS Propafenone Hcl 225 Mg Tab 1ANTIARRHYTHMICS Propafenone Hcl 300 Mg Tab 1ANTIARRHYTHMICS Propafenone Hcl Er 225 Mg Cap 1ANTIARRHYTHMICS Propafenone Hcl Er 325 Mg Cap 1ANTIARRHYTHMICS Propafenone Hcl Er 425 Mg Cap 1ANTIARRHYTHMICS Quinidine Gluc Er 324 Mg Tab 1ANTIARRHYTHMICS Quinidine Sulfate 200 Mg Tab 1ANTIARRHYTHMICS Quinidine Sulfate 300 Mg Tab 1ANTI-ARTHRITIC AND CHELATING AGENTS Depen 250 Mg Titratab 2ANTI-ARTHRITIC AND CHELATING AGENTS Penicillamine 250 Mg Capsule 1ANTIBACTERIAL AGENTS,MISCELLANEOUS Glycine 1.5% Irrigation 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Hyophen Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Me-naphos-mb-hyo 1 Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Methenamine Hipp 1 Gm Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Methenamine Md 1 Gm Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Methenamine Md 500 Mg Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Trimethoprim 100 Mg Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Urelle Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Uribel Capsule 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Urimar-t Tablet 3ANTIBIOTIC, ANTIBACTERIAL, MISC. Urin D.s. Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Uro-458 Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Urogesic-blue Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Uro-mp Capsule 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Uryl Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Ustell Capsule 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Utira-c Tablet 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Vilamit Mb Capsule 1ANTIBIOTIC, ANTIBACTERIAL, MISC. Vilevev Mb Tablet 1ANTICHOLINERGICS, ORALLY INHALED LONG ACTING Incruse Ellipta 62.5 Mcg Inh 2ANTICHOLINERGICS, ORALLY INHALED LONG ACTING Spiriva 18 Mcg Cp-handihaler 2ANTICHOLINERGICS, ORALLY INHALED LONG ACTING Spiriva Respimat 1.25 Mcg Inh 2ANTICHOLINERGICS, ORALLY INHALED LONG ACTING Spiriva Respimat 2.5 Mcg Inh 2ANTICHOLINERGICS, ORALLY INHALED SHORT ACTING Atrovent 17 Mcg Hfa Inhaler 2ANTICHOLINERGICS,QUATERNARY AMMONIUM Chlordiazepoxide-clidinium Cap 1ANTICHOLINERGICS,QUATERNARY AMMONIUM Glycopyrrolate 1 Mg Tablet 1ANTICHOLINERGICS,QUATERNARY AMMONIUM Glycopyrrolate 1.5 Mg Tablet 1ANTICHOLINERGICS,QUATERNARY AMMONIUM Glycopyrrolate 2 Mg Tablet 1ANTICHOLINERGICS,QUATERNARY AMMONIUM Propantheline 15 Mg Tablet 1ANTICHOLINERGICS/ANTISPASMODICS Dicyclomine 10 Mg Capsule 1ANTICHOLINERGICS/ANTISPASMODICS Dicyclomine 20 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 1 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 10 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 2 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 2.5 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 9: 2021 Rx Select - PRAM

ANTICOAGULANTS,COUMARIN TYPE Jantoven 3 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 4 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 5 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 6 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Jantoven 7.5 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 1 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 10 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 2 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 2.5 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 3 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 4 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 5 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 6 Mg Tablet 1ANTICOAGULANTS,COUMARIN TYPE Warfarin Sodium 7.5 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clobazam 10 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clobazam 2.5 Mg/Ml Suspension 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clobazam 20 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.125 Mg Dis Tab 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.125 Mg Odt 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.25 Mg Odt 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.5 Mg Dis Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.5 Mg Odt 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 0.5 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 1 Mg Dis Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 1 Mg Odt 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 1 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 2 Mg Odt 1ANTICONVULSANT - BENZODIAZEPINE TYPE Clonazepam 2 Mg Tablet 1ANTICONVULSANT - BENZODIAZEPINE TYPE Diazepam 10 Mg Rectal Gel Syst 1ANTICONVULSANT - BENZODIAZEPINE TYPE Diazepam 2.5 Mg Rectal Gel Sys 1ANTICONVULSANT - BENZODIAZEPINE TYPE Diazepam 20 Mg Rectal Gel Syst 1ANTICONVULSANT - CANNABINOID TYPE Epidiolex 100 Mg/Ml Solution 2ANTICONVULSANTS Active-pac Kit 2ANTICONVULSANTS Banzel 200 Mg Tablet 2ANTICONVULSANTS Banzel 40 Mg/Ml Suspension 2ANTICONVULSANTS Banzel 400 Mg Tablet 2ANTICONVULSANTS Carbamazepine 100 Mg Tab Chew 1ANTICONVULSANTS Carbamazepine 100 Mg/5 Ml Susp 1ANTICONVULSANTS Carbamazepine 200 Mg Tablet 1ANTICONVULSANTS Carbamazepine 200 Mg/10ml Susp 1ANTICONVULSANTS Carbamazepine Er 100 Mg Cap 1ANTICONVULSANTS Carbamazepine Er 100 Mg Tablet 1ANTICONVULSANTS Carbamazepine Er 200 Mg Cap 1ANTICONVULSANTS Carbamazepine Er 200 Mg Tablet 1ANTICONVULSANTS Carbamazepine Er 300 Mg Cap 1ANTICONVULSANTS Carbamazepine Er 400 Mg Tablet 1ANTICONVULSANTS Celontin 300 Mg Kapseal 2ANTICONVULSANTS Dilantin 100 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 10: 2021 Rx Select - PRAM

ANTICONVULSANTS Dilantin 30 Mg Capsule 2ANTICONVULSANTS Divalproex Dr 125 Mg Cap Sprnk 1ANTICONVULSANTS Divalproex Sod Dr 125 Mg Tab 1ANTICONVULSANTS Divalproex Sod Dr 250 Mg Tab 1ANTICONVULSANTS Divalproex Sod Dr 500 Mg Tab 1ANTICONVULSANTS Divalproex Sod Er 250 Mg Tab 1ANTICONVULSANTS Divalproex Sod Er 500 Mg Tab 1ANTICONVULSANTS Epitol 200 Mg Tablet 1ANTICONVULSANTS Ethosuximide 250 Mg Capsule 1ANTICONVULSANTS Ethosuximide 250 Mg/5 Ml Soln 1ANTICONVULSANTS Felbamate 400 Mg Tablet 1ANTICONVULSANTS Felbamate 600 Mg Tablet 1ANTICONVULSANTS Felbamate 600 Mg/5 Ml Susp 1ANTICONVULSANTS Fycompa 0.5 Mg/Ml Oral Susp 2ANTICONVULSANTS Fycompa 10 Mg Tablet 2ANTICONVULSANTS Fycompa 12 Mg Tablet 2ANTICONVULSANTS Fycompa 2 Mg Tablet 2ANTICONVULSANTS Fycompa 4 Mg Tablet 2ANTICONVULSANTS Fycompa 6 Mg Tablet 2ANTICONVULSANTS Fycompa 8 Mg Tablet 2ANTICONVULSANTS Gabapentin 100 Mg Capsule 1ANTICONVULSANTS Gabapentin 250 Mg/5 Ml Soln 1ANTICONVULSANTS Gabapentin 300 Mg Capsule 1ANTICONVULSANTS Gabapentin 300 Mg/6 Ml Soln 1ANTICONVULSANTS Gabapentin 400 Mg Capsule 1ANTICONVULSANTS Gabapentin 600 Mg Tablet 1ANTICONVULSANTS Gabapentin 800 Mg Tablet 1ANTICONVULSANTS Lamotrigine 100 Mg Tablet 1ANTICONVULSANTS Lamotrigine 150 Mg Tablet 1ANTICONVULSANTS Lamotrigine 200 Mg Tablet 1ANTICONVULSANTS Lamotrigine 25 Mg Disper Tab 1ANTICONVULSANTS Lamotrigine 25 Mg Tablet 1ANTICONVULSANTS Lamotrigine 5 Mg Disper Tablet 1ANTICONVULSANTS Lamotrigine Er 100 Mg Tablet 1ANTICONVULSANTS Lamotrigine Er 200 Mg Tablet 1ANTICONVULSANTS Lamotrigine Er 25 Mg Tablet 1ANTICONVULSANTS Lamotrigine Er 250 Mg Tablet 1ANTICONVULSANTS Lamotrigine Er 300 Mg Tablet 1ANTICONVULSANTS Lamotrigine Er 50 Mg Tablet 1ANTICONVULSANTS Lamotrigine Odt 100 Mg Tablet 1ANTICONVULSANTS Lamotrigine Odt 200 Mg Tablet 1ANTICONVULSANTS Lamotrigine Odt 25 Mg Tablet 1ANTICONVULSANTS Lamotrigine Odt 50 Mg Tablet 1ANTICONVULSANTS Lamotrigine Odt Kit (blue) 1ANTICONVULSANTS Lamotrigine Odt Kit (green) 1ANTICONVULSANTS Lamotrigine Odt Kit (orange) 1ANTICONVULSANTS Lamotrigine Tab Start Kit-blue 1ANTICONVULSANTS Lamotrigine Tab Start Kt-green 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 11: 2021 Rx Select - PRAM

ANTICONVULSANTS Lamotrigine Tab Start Kt-orang 1ANTICONVULSANTS Levetiracetam 1,000 Mg Tablet 1ANTICONVULSANTS Levetiracetam 250 Mg Tablet 1ANTICONVULSANTS Levetiracetam 500 Mg Tablet 1ANTICONVULSANTS Levetiracetam 750 Mg Tablet 1ANTICONVULSANTS Levetiracetam Er 500 Mg Tablet 1ANTICONVULSANTS Levetiracetam Er 750 Mg Tablet 1ANTICONVULSANTS Lyrica 100 Mg Capsule 2ANTICONVULSANTS Lyrica 150 Mg Capsule 2ANTICONVULSANTS Lyrica 20 Mg/Ml Oral Solution 2ANTICONVULSANTS Lyrica 200 Mg Capsule 2ANTICONVULSANTS Lyrica 225 Mg Capsule 2ANTICONVULSANTS Lyrica 25 Mg Capsule 2ANTICONVULSANTS Lyrica 300 Mg Capsule 2ANTICONVULSANTS Lyrica 50 Mg Capsule 2ANTICONVULSANTS Lyrica 75 Mg Capsule 2ANTICONVULSANTS Oxcarbazepine 150 Mg Tablet 1ANTICONVULSANTS Oxcarbazepine 300 Mg Tablet 1ANTICONVULSANTS Oxcarbazepine 300 Mg/5 Ml Susp 1ANTICONVULSANTS Oxcarbazepine 600 Mg Tablet 1ANTICONVULSANTS Oxtellar Xr 150 Mg Tablet 2ANTICONVULSANTS Oxtellar Xr 300 Mg Tablet 2ANTICONVULSANTS Oxtellar Xr 600 Mg Tablet 2ANTICONVULSANTS Peganone 250 Mg Tablet 2ANTICONVULSANTS Phenytoin 100 Mg/4 Ml Susp 1ANTICONVULSANTS Phenytoin 125 Mg/5 Ml Susp 1ANTICONVULSANTS Phenytoin 50 Mg Infatab 1ANTICONVULSANTS Phenytoin 50 Mg Tablet Chew 1ANTICONVULSANTS Phenytoin Sod Ext 100 Mg Cap 1ANTICONVULSANTS Phenytoin Sod Ext 200 Mg Cap 1ANTICONVULSANTS Phenytoin Sod Ext 300 Mg Cap 1ANTICONVULSANTS Pregabalin 100 Mg Capsule 1ANTICONVULSANTS Pregabalin 150 Mg Capsule 1ANTICONVULSANTS Pregabalin 20 Mg/Ml Solution 1ANTICONVULSANTS Pregabalin 200 Mg Capsule 1ANTICONVULSANTS Pregabalin 225 Mg Capsule 1ANTICONVULSANTS Pregabalin 25 Mg Capsule 1ANTICONVULSANTS Pregabalin 300 Mg Capsule 1ANTICONVULSANTS Pregabalin 50 Mg Capsule 1ANTICONVULSANTS Pregabalin 75 Mg Capsule 1ANTICONVULSANTS Primidone 250 Mg Tablet 1ANTICONVULSANTS Primidone 50 Mg Tablet 1ANTICONVULSANTS Roweepra 1,000 Mg Tablet 1ANTICONVULSANTS Roweepra 500 Mg Tablet 1ANTICONVULSANTS Roweepra 750 Mg Tablet 1ANTICONVULSANTS Roweepra Xr 500 Mg Tablet 1ANTICONVULSANTS Roweepra Xr 750 Mg Tablet 1ANTICONVULSANTS Subvenite 100 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 12: 2021 Rx Select - PRAM

ANTICONVULSANTS Subvenite 150 Mg Tablet 1ANTICONVULSANTS Subvenite 200 Mg Tablet 1ANTICONVULSANTS Subvenite 25 Mg Tablet 1ANTICONVULSANTS Subvenite Tab Start Kit (blue) 1ANTICONVULSANTS Subvenite Tab Start Kit(green) 1ANTICONVULSANTS Subvenite Tab Start Kt(orange) 1ANTICONVULSANTS Tiagabine Hcl 12 Mg Tablet 1ANTICONVULSANTS Tiagabine Hcl 16 Mg Tablet 1ANTICONVULSANTS Tiagabine Hcl 2 Mg Tablet 1ANTICONVULSANTS Tiagabine Hcl 4 Mg Tablet 1ANTICONVULSANTS Topiramate 100 Mg Tablet 1ANTICONVULSANTS Topiramate 15 Mg Sprinkle Cap 1ANTICONVULSANTS Topiramate 200 Mg Tablet 1ANTICONVULSANTS Topiramate 25 Mg Sprinkle Cap 1ANTICONVULSANTS Topiramate 25 Mg Tablet 1ANTICONVULSANTS Topiramate 50 Mg Tablet 1ANTICONVULSANTS Topiramate Er 100 Mg Capsule 1ANTICONVULSANTS Topiramate Er 150 Mg Capsule 1ANTICONVULSANTS Topiramate Er 200 Mg Capsule 1ANTICONVULSANTS Topiramate Er 25 Mg Capsule 1ANTICONVULSANTS Topiramate Er 50 Mg Capsule 1ANTICONVULSANTS Trokendi Xr 100 Mg Capsule 2ANTICONVULSANTS Trokendi Xr 200 Mg Capsule 2ANTICONVULSANTS Trokendi Xr 25 Mg Capsule 2ANTICONVULSANTS Trokendi Xr 50 Mg Capsule 2ANTICONVULSANTS Valproic Acid 250 Mg Capsule 1ANTICONVULSANTS Valproic Acid 250 Mg/5 Ml Soln 1ANTICONVULSANTS Valproic Acid 500 Mg/10 Ml Sol 1ANTICONVULSANTS Vigabatrin 500 Mg Powder Packt 1ANTICONVULSANTS Vigabatrin 500 Mg Tablet 1ANTICONVULSANTS Vigadrone 500 Mg Powder Packet 1ANTICONVULSANTS Vimpat 10 Mg/Ml Solution 2ANTICONVULSANTS Vimpat 100 Mg Tablet 2ANTICONVULSANTS Vimpat 150 Mg Tablet 2ANTICONVULSANTS Vimpat 200 Mg Tablet 2ANTICONVULSANTS Vimpat 200 Mg/20 Ml Vial 2ANTICONVULSANTS Vimpat 50 Mg Tablet 2ANTICONVULSANTS Zonisamide 100 Mg Capsule 1ANTICONVULSANTS Zonisamide 25 Mg Capsule 1ANTICONVULSANTS Zonisamide 50 Mg Capsule 1ANTIDIARRHEALS Diphenoxylat-atrop 2.5-0.025/5 1ANTIDIARRHEALS Diphenoxylate-atrop 2.5-0.025 1ANTIDIARRHEALS Opium Tincture 10 Mg/Ml 1ANTIDIARRHEALS Paregoric Liquid 1ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin 0.01% Solution 1ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin 0.01% Spray 1ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin 10 Mcg/0.1 Ml Spr 1ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin 40 Mcg/10 Ml Vial 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 13: 2021 Rx Select - PRAM

ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin Acetate 0.1 Mg Tb 1ANTIDIURETIC AND VASOPRESSOR HORMONES Desmopressin Acetate 0.2 Mg Tb 1ANTIDIURETIC AND VASOPRESSOR HORMONES Stimate 1.5 Mg/Ml Nasal Spray 2ANTIEMETIC, CANNABINOID-TYPE Dronabinol 10 Mg Capsule 1ANTIEMETIC, CANNABINOID-TYPE Dronabinol 2.5 Mg Capsule 1ANTIEMETIC, CANNABINOID-TYPE Dronabinol 5 Mg Capsule 1ANTIEMETIC/ANTIVERTIGO AGENTS Akynzeo 300-0.5 Mg Capsule 2ANTIEMETIC/ANTIVERTIGO AGENTS Aprepitant 125 Mg Capsule 1ANTIEMETIC/ANTIVERTIGO AGENTS Aprepitant 125-80-80 Mg Pack 1ANTIEMETIC/ANTIVERTIGO AGENTS Aprepitant 40 Mg Capsule 1ANTIEMETIC/ANTIVERTIGO AGENTS Aprepitant 80 Mg Capsule 1ANTIEMETIC/ANTIVERTIGO AGENTS Bonjesta Er 20-20 Mg Tablet 2ANTIEMETIC/ANTIVERTIGO AGENTS Compro 25 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Diclegis Dr 10-10 Mg Tablet 2ANTIEMETIC/ANTIVERTIGO AGENTS Dimenhydrinate 50 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Granisetron Hcl 1 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron 4 Mg/5 Ml Solution 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron 40 Mg/20 Ml Vial 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron Hcl 24 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron Hcl 4 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron Hcl 8 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron Odt 4 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Ondansetron Odt 8 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Phenadoz 12.5 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Phenadoz 25 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Prochlorperazine 10 Mg Tab 1ANTIEMETIC/ANTIVERTIGO AGENTS Prochlorperazine 25 Mg Supp 1ANTIEMETIC/ANTIVERTIGO AGENTS Prochlorperazine 5 Mg Tablet 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethazine 12.5 Mg Suppos 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethazine 25 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethazine 50 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethegan 12.5 Mg Suppos 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethegan 25 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Promethegan 50 Mg Suppository 1ANTIEMETIC/ANTIVERTIGO AGENTS Sancuso 3.1 Mg/24 Hr Patch 2ANTIEMETIC/ANTIVERTIGO AGENTS Scopolamine 1 Mg/3 Day Patch 1ANTIEMETIC/ANTIVERTIGO AGENTS Trimethobenzamide 300 Mg Cap 1ANTIEMETIC/ANTIVERTIGO AGENTS Varubi 90 Mg Tablet 2ANTIFIBRINOLYTIC AGENTS Amicar 0.25 Gram/Ml Oral Soln 2ANTIFIBRINOLYTIC AGENTS Aminocaproic Acid 1,000 Mg Tab 1ANTIFIBRINOLYTIC AGENTS Aminocaproic Acid 500 Mg Tab 1ANTIFIBRINOLYTIC AGENTS Tranexamic Acid 650 Mg Tablet 1ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS Esbriet 267 Mg Capsule 2ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS Esbriet 267 Mg Tablet 2ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS Esbriet 801 Mg Tablet 2ANTIFUNGAL AGENTS Clotrimazole 10 Mg Troche 1ANTIFUNGAL AGENTS Cresemba 186 Mg Capsule 2ANTIFUNGAL AGENTS Fluconazole 10 Mg/Ml Susp 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 14: 2021 Rx Select - PRAM

ANTIFUNGAL AGENTS Fluconazole 100 Mg Tablet 1ANTIFUNGAL AGENTS Fluconazole 150 Mg Tablet 1ANTIFUNGAL AGENTS Fluconazole 200 Mg Tablet 1ANTIFUNGAL AGENTS Fluconazole 40 Mg/Ml Susp 1ANTIFUNGAL AGENTS Fluconazole 50 Mg Tablet 1ANTIFUNGAL AGENTS Flucytosine 250 Mg Capsule 1ANTIFUNGAL AGENTS Flucytosine 500 Mg Capsule 1ANTIFUNGAL AGENTS Itraconazole 10 Mg/Ml Solution 1ANTIFUNGAL AGENTS Itraconazole 100 Mg Capsule 1ANTIFUNGAL AGENTS Ketoconazole 200 Mg Tablet 1ANTIFUNGAL AGENTS Noxafil 40 Mg/Ml Suspension 2ANTIFUNGAL AGENTS Noxafil Dr 100 Mg Tablet 2ANTIFUNGAL AGENTS Posaconazole Dr 100 Mg Tablet 1ANTIFUNGAL AGENTS Terbinafine Hcl 250 Mg Tablet 1ANTIFUNGAL AGENTS Voriconazole 200 Mg Tablet 1ANTIFUNGAL AGENTS Voriconazole 40 Mg/Ml Susp 1ANTIFUNGAL AGENTS Voriconazole 50 Mg Tablet 1ANTIFUNGAL ANTIBIOTICS Griseofulvin 125 Mg/5 Ml Susp 1ANTIFUNGAL ANTIBIOTICS Griseofulvin Micro 500 Mg Tab 1ANTIFUNGAL ANTIBIOTICS Griseofulvin Ultra 125 Mg Tab 1ANTIFUNGAL ANTIBIOTICS Griseofulvin Ultra 250 Mg Tab 1ANTIFUNGAL ANTIBIOTICS Nystatin 100,000 Unit/Ml Susp 1ANTIFUNGAL ANTIBIOTICS Nystatin 500,000 Unit Oral Tab 1ANTIFUNGAL ANTIBIOTICS Nystatin 500,000 Unit/5 Ml Sus 1ANTIHISTAMINES - 1ST GENERATION Carbinoxamine 4 Mg/5 Ml Liquid 1ANTIHISTAMINES - 1ST GENERATION Carbinoxamine Maleate 4 Mg Tab 1ANTIHISTAMINES - 1ST GENERATION Carbinoxamine Maleate 6 Mg Tab 1ANTIHISTAMINES - 1ST GENERATION Clemastine Fum 1.34 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Clemastine Fum 2.68 Mg Tab 1ANTIHISTAMINES - 1ST GENERATION Cyproheptadine 2 Mg/5 Ml Soln 1ANTIHISTAMINES - 1ST GENERATION Cyproheptadine 2 Mg/5 Ml Syrup 1ANTIHISTAMINES - 1ST GENERATION Cyproheptadine 4 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Cyproheptadine 4 Mg/10 Ml Syrp 1ANTIHISTAMINES - 1ST GENERATION Dexchlorpheniramine 2 Mg/5 Ml 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine 10 Mg/5 Ml Soln 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine 10 Mg/5 Ml Syrup 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine 50 Mg/25 Ml Syrup 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Hcl 10 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Hcl 25 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Hcl 50 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Pam 100 Mg Cap 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Pam 25 Mg Cap 1ANTIHISTAMINES - 1ST GENERATION Hydroxyzine Pam 50 Mg Cap 1ANTIHISTAMINES - 1ST GENERATION Promethazine 12.5 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Promethazine 25 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Promethazine 50 Mg Tablet 1ANTIHISTAMINES - 1ST GENERATION Promethazine 6.25 Mg/5 Ml Soln 1ANTIHISTAMINES - 1ST GENERATION Promethazine 6.25 Mg/5 Ml Syrp 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 15: 2021 Rx Select - PRAM

ANTIHISTAMINES - 1ST GENERATION Ryvent 6 Mg Tablet 1ANTIHISTAMINES - 2ND GENERATION Cetirizine Hcl 1 Mg/Ml Soln 1ANTIHISTAMINES - 2ND GENERATION Cetirizine Hcl 1 Mg/Ml Syrup 1ANTIHISTAMINES - 2ND GENERATION Desloratadine 2.5 Mg Odt 1ANTIHISTAMINES - 2ND GENERATION Desloratadine 5 Mg Odt 1ANTIHISTAMINES - 2ND GENERATION Desloratadine 5 Mg Tablet 1ANTIHISTAMINES - 2ND GENERATION Levocetirizine 2.5 Mg/5 Ml Sol 1ANTIHISTAMINES - 2ND GENERATION Levocetirizine 5 Mg Tablet 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 12.5-15 Mg 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 12.5-30 Mg 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 12.5-45 Mg 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 25-15 Mg Tb 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 25-30 Mg Tb 1ANTIHYPERGLY,DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE Alogliptin-pioglit 25-45 Mg Tb 1ANTIHYPERGLY,INSULIN,LONG ACT-GLP-1 RECEPT.AGONIST Soliqua 100 Unit-33 Mcg/Ml Pen 2ANTIHYPERGLY,INSULIN,LONG ACT-GLP-1 RECEPT.AGONIST Xultophy 100 Unit-3.6mg/Ml Pen 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Farxiga 10 Mg Tablet 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Farxiga 5 Mg Tablet 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Invokana 100 Mg Tablet 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Invokana 300 Mg Tablet 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Jardiance 10 Mg Tablet 2ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB Jardiance 25 Mg Tablet 2ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS Cycloset 0.8 Mg Tablet 2ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Acarbose 100 Mg Tablet 1ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Acarbose 25 Mg Tablet 1ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Acarbose 50 Mg Tablet 1ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Miglitol 100 Mg Tablet 1ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Miglitol 25 Mg Tablet 1ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS Miglitol 50 Mg Tablet 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Dm2 Kit 2ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Er 1,000 Mg Osm-tab 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Er 500 Mg Osmotic Tb 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl 1,000 Mg Tablet 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl 500 Mg Tablet 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl 500 Mg/5 Ml Soln 3ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl 850 Mg Tablet 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl Er 500 Mg Tablet 1ANTIHYPERGLYCEMIC, BIGUANIDE TYPE Metformin Hcl Er 750 Mg Tablet 1ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Alogliptin 12.5 Mg Tablet 1ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Alogliptin 25 Mg Tablet 1ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Alogliptin 6.25 Mg Tablet 1ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Januvia 100 Mg Tablet 2ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Januvia 25 Mg Tablet 2ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Januvia 50 Mg Tablet 2ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS Tradjenta 5 Mg Tablet 2ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glimepiride 1 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glimepiride 2 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glimepiride 4 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 16: 2021 Rx Select - PRAM

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide 10 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide 5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Er 10 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Er 2.5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Er 5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Xl 10 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Xl 2.5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glipizide Xl 5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide 1.25 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide 2.5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide 5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide Micro 1.5 Mg Tab 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide Micro 3 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Glyburide Micro 6 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Nateglinide 120 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Nateglinide 60 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Repaglinide 0.5 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Repaglinide 1 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Repaglinide 2 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Tolazamide 250 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Tolazamide 500 Mg Tablet 1ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Tolbutamide 500 Mg Tablet 1ANTIHYPERGLYCEMIC, SGLT-2 AND DPP-4 INHIBITOR COMB Glyxambi 10 Mg-5 Mg Tablet 2ANTIHYPERGLYCEMIC, SGLT-2 AND DPP-4 INHIBITOR COMB Glyxambi 25 Mg-5 Mg Tablet 2ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDE Pioglitazone-metformin 15-500 1ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDE Pioglitazone-metformin 15-850 1ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE-SULFONYLUREA Pioglitazone-glimepiride 30-2 1ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE-SULFONYLUREA Pioglitazone-glimepiride 30-4 1ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Alogliptin-metformin 12.5-1000 1ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Alogliptin-metformin 12.5-500 1ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Janumet 50-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Janumet 50-500 Mg Tablet 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Janumet Xr 100-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Janumet Xr 50-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Janumet Xr 50-500 Mg Tablet 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Jentadueto 2.5 Mg-1000 Mg Tab 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Jentadueto 2.5 Mg-500 Mg Tab 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Jentadueto 2.5 Mg-850 Mg Tab 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Jentadueto Xr 2.5 Mg-1,000 Mg 2ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS. Jentadueto Xr 5 Mg-1,000 Mg Tb 2ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glipizide-metformin 2.5-250 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glipizide-metformin 2.5-500 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glipizide-metformin 5-500 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glyburide-metformin 2.5-500 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glyburide-metformin 5-500 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Glyburid-metformin 1.25-250 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Repaglinide-metformin 1-500 Mg 1ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDE Repaglinide-metformin 2-500 Mg 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 17: 2021 Rx Select - PRAM

ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) Pioglitazone Hcl 15 Mg Tablet 1ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) Pioglitazone Hcl 30 Mg Tablet 1ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) Pioglitazone Hcl 45 Mg Tablet 1ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet 150-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet 150-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet 50-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet 50-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet Xr 150-1,000 Mg Tab 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet Xr 150-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet Xr 50-1,000 Mg Tab 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Invokamet Xr 50-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy 12.5-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy 12.5-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy 5-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy 5-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy Xr 10-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy Xr 12.5-1,000 Mg Tab 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy Xr 25-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Synjardy Xr 5-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Xigduo Xr 10 Mg-1,000 Mg Tab 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Xigduo Xr 10 Mg-500 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Xigduo Xr 2.5 Mg-1,000 Mg Tab 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Xigduo Xr 5 Mg-1,000 Mg Tablet 2ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. Xigduo Xr 5 Mg-500 Mg Tablet 2ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB Ezetimibe-simvastatin 10-10 Mg 1ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB Ezetimibe-simvastatin 10-20 Mg 1ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB Ezetimibe-simvastatin 10-40 Mg 1ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB Ezetimibe-simvastatin 10-80 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 10-10 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 10-20 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 10-40 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 10-80 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 2.5-10 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 2.5-20 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 2.5-40 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 5-10 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 5-20 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 5-40 Mg 1ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER Amlodipine-atorvast 5-80 Mg 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Atorvastatin 10 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Atorvastatin 20 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Atorvastatin 40 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Atorvastatin 80 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Fluvastatin Er 80 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Fluvastatin Sodium 20 Mg Cap 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Fluvastatin Sodium 40 Mg Cap 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Livalo 1 Mg Tablet 2ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Livalo 2 Mg Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 18: 2021 Rx Select - PRAM

ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Livalo 4 Mg Tablet 2ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Lovastatin 10 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Lovastatin 20 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Lovastatin 40 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Pravastatin Sodium 10 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Pravastatin Sodium 20 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Pravastatin Sodium 40 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Pravastatin Sodium 80 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Rosuvastatin Calcium 10 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Rosuvastatin Calcium 20 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Rosuvastatin Calcium 40 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Rosuvastatin Calcium 5 Mg Tab 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Simvastatin 10 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Simvastatin 20 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Simvastatin 40 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Simvastatin 5 Mg Tablet 1ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) Simvastatin 80 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Benazepril Hcl 10 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Benazepril Hcl 20 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Benazepril Hcl 40 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Benazepril Hcl 5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Captopril 100 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Captopril 12.5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Captopril 25 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Captopril 50 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Enalapril Maleate 10 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Enalapril Maleate 2.5 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Enalapril Maleate 20 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Enalapril Maleate 5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Fosinopril Sodium 10 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Fosinopril Sodium 20 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Fosinopril Sodium 40 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 10 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 2.5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 20 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 30 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 40 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Lisinopril 5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Moexipril Hcl 15 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Moexipril Hcl 7.5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Perindopril Erbumine 2 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Perindopril Erbumine 4 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Perindopril Erbumine 8 Mg Tab 1ANTIHYPERTENSIVES, ACE INHIBITORS Quinapril 10 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Quinapril 20 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Quinapril 40 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Quinapril 5 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Ramipril 1.25 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 19: 2021 Rx Select - PRAM

ANTIHYPERTENSIVES, ACE INHIBITORS Ramipril 10 Mg Capsule 1ANTIHYPERTENSIVES, ACE INHIBITORS Ramipril 2.5 Mg Capsule 1ANTIHYPERTENSIVES, ACE INHIBITORS Ramipril 5 Mg Capsule 1ANTIHYPERTENSIVES, ACE INHIBITORS Trandolapril 1 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Trandolapril 2 Mg Tablet 1ANTIHYPERTENSIVES, ACE INHIBITORS Trandolapril 4 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Candesartan Cilexetil 16 Mg Tb 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Candesartan Cilexetil 32 Mg Tb 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Candesartan Cilexetil 4 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Candesartan Cilexetil 8 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Eprosartan Mesylate 600 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Irbesartan 150 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Irbesartan 300 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Irbesartan 75 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Losartan Potassium 100 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Losartan Potassium 25 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Losartan Potassium 50 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Olmesartan Medoxomil 20 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Olmesartan Medoxomil 40 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Olmesartan Medoxomil 5 Mg Tab 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Telmisartan 20 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Telmisartan 40 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Telmisartan 80 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Valsartan 160 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Valsartan 320 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Valsartan 40 Mg Tablet 1ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST Valsartan 80 Mg Tablet 1ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS Vecamyl 2.5 Mg Tablet 3ANTIHYPERTENSIVES, MISCELLANEOUS Demser 250 Mg Capsule 2ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine 0.1 Mg/Day Patch 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine 0.2 Mg/Day Patch 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine 0.3 Mg/Day Patch 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine Hcl 0.1 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine Hcl 0.2 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Clonidine Hcl 0.3 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Guanfacine 1 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Guanfacine 2 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Methyldopa 250 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Methyldopa 500 Mg Tablet 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Methyldopa-hctz 250-15 Mg Tab 1ANTIHYPERTENSIVES, SYMPATHOLYTIC Methyldopa-hctz 250-25 Mg Tab 1ANTIHYPERTENSIVES, VASODILATORS Hydralazine 10 Mg Tablet 1ANTIHYPERTENSIVES, VASODILATORS Hydralazine 100 Mg Tablet 1ANTIHYPERTENSIVES, VASODILATORS Hydralazine 25 Mg Tablet 1ANTIHYPERTENSIVES, VASODILATORS Hydralazine 50 Mg Tablet 1ANTIHYPERTENSIVES, VASODILATORS Minoxidil 10 Mg Tablet 1ANTIHYPERTENSIVES, VASODILATORS Minoxidil 2.5 Mg Tablet 1ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR Leflunomide 10 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 20: 2021 Rx Select - PRAM

ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR Leflunomide 20 Mg Tablet 1ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB. Otezla 28 Day Starter Pack 2ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB. Otezla 30 Mg Tablet 2ANTILEPROTICS Dapsone 100 Mg Tablet 1ANTILEPROTICS Dapsone 25 Mg Tablet 1ANTILEPROTICS Thalomid 100 Mg Capsule 2ANTILEPROTICS Thalomid 150 Mg Capsule 2ANTILEPROTICS Thalomid 200 Mg Capsule 2ANTILEPROTICS Thalomid 50 Mg Capsule 2ANTIMALARIAL DRUGS Atovaquone-proguanil 250-100 1ANTIMALARIAL DRUGS Atovaquone-proguanil 62.5-25 1ANTIMALARIAL DRUGS Chloroquine Ph 250 Mg Tablet 1ANTIMALARIAL DRUGS Chloroquine Ph 500 Mg Tablet 1ANTIMALARIAL DRUGS Coartem Tablets 2ANTIMALARIAL DRUGS Daraprim 25 Mg Tablet 2ANTIMALARIAL DRUGS Hydroxychloroquine 200 Mg Tab 1ANTIMALARIAL DRUGS Mefloquine Hcl 250 Mg Tablet 1ANTIMALARIAL DRUGS Primaquine 26.3 Mg Tablet 1ANTIMALARIAL DRUGS Quinine Sulfate 324 Mg Capsule 1ANTIMIGRAINE PREPARATIONS Almotriptan Malate 12.5 Mg Tab 1ANTIMIGRAINE PREPARATIONS Almotriptan Malate 6.25 Mg Tab 1ANTIMIGRAINE PREPARATIONS Cafergot Tablet 1ANTIMIGRAINE PREPARATIONS Dihydroergotamine 4 Mg/Ml Spry 1ANTIMIGRAINE PREPARATIONS Eletriptan Hbr 20 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Eletriptan Hbr 40 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Ergotamine-caffeine 1-100mg Tb 1ANTIMIGRAINE PREPARATIONS Frovatriptan Succ 2.5 Mg Tab 1ANTIMIGRAINE PREPARATIONS Migergot Suppository 1ANTIMIGRAINE PREPARATIONS Migranow Kit 2ANTIMIGRAINE PREPARATIONS Naratriptan Hcl 1 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Naratriptan Hcl 2.5 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Rizatriptan 10 Mg Odt 1ANTIMIGRAINE PREPARATIONS Rizatriptan 10 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Rizatriptan 5 Mg Odt 1ANTIMIGRAINE PREPARATIONS Rizatriptan 5 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Sumatriptan 20 Mg Nasal Spray 1ANTIMIGRAINE PREPARATIONS Sumatriptan 5 Mg Nasal Spray 1ANTIMIGRAINE PREPARATIONS Sumatriptan Succ 100 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Sumatriptan Succ 25 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Sumatriptan Succ 50 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Sumatriptan-naproxen 85-500 Mg 1ANTIMIGRAINE PREPARATIONS Zolmitriptan 2.5 Mg Odt 1ANTIMIGRAINE PREPARATIONS Zolmitriptan 2.5 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Zolmitriptan 5 Mg Odt 1ANTIMIGRAINE PREPARATIONS Zolmitriptan 5 Mg Tablet 1ANTIMIGRAINE PREPARATIONS Zomig 2.5 Mg Nasal Spray 2ANTIMIGRAINE PREPARATIONS Zomig 5 Mg Nasal Spray 2ANTI-MYCOBACTERIUM AGENTS Ethambutol Hcl 100 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 21: 2021 Rx Select - PRAM

ANTI-MYCOBACTERIUM AGENTS Ethambutol Hcl 400 Mg Tablet 1ANTI-MYCOBACTERIUM AGENTS Isoniazid 100 Mg Tablet 1ANTI-MYCOBACTERIUM AGENTS Isoniazid 300 Mg Tablet 1ANTI-MYCOBACTERIUM AGENTS Isoniazid 50 Mg/5 Ml Solution 1ANTI-MYCOBACTERIUM AGENTS Pyrazinamide 500 Mg Tablet 1ANTI-MYCOBACTERIUM AGENTS Rifabutin 150 Mg Capsule 1ANTI-NARCOLEPSY,ANTI-CATAPLEXY,SEDATIVE-TYPE AGENT Xyrem 500 Mg/Ml Oral Solution 2ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS Zolinza 100 Mg Capsule 2ANTINEOPLASTIC - ALKYLATING AGENTS Cyclophosphamide 25 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Cyclophosphamide 50 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Gleostine 10 Mg Capsule 2ANTINEOPLASTIC - ALKYLATING AGENTS Gleostine 100 Mg Capsule 2ANTINEOPLASTIC - ALKYLATING AGENTS Gleostine 40 Mg Capsule 2ANTINEOPLASTIC - ALKYLATING AGENTS Gleostine 5 Mg Capsule 2ANTINEOPLASTIC - ALKYLATING AGENTS Hydroxyurea 500 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Leukeran 2 Mg Tablet 2ANTINEOPLASTIC - ALKYLATING AGENTS Melphalan 2 Mg Tablet 1ANTINEOPLASTIC - ALKYLATING AGENTS Myleran 2 Mg Tablet 2ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 100 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 140 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 180 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 20 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 250 Mg Capsule 1ANTINEOPLASTIC - ALKYLATING AGENTS Temozolomide 5 Mg Capsule 1ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Abiraterone Acetate 250 Mg Tab 1ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Bicalutamide 50 Mg Tablet 1ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Erleada 60 Mg Tablet 2ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Flutamide 125 Mg Capsule 1ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Nilutamide 150 Mg Tablet 1ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Yonsa 125 Mg Tablet 2ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Zytiga 500 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Capecitabine 150 Mg Tablet 1ANTINEOPLASTIC - ANTIMETABOLITES Capecitabine 500 Mg Tablet 1ANTINEOPLASTIC - ANTIMETABOLITES Lonsurf 15 Mg-6.14 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Lonsurf 20 Mg-8.19 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Mercaptopurine 50 Mg Tablet 1ANTINEOPLASTIC - ANTIMETABOLITES Methotrexate 2.5 Mg Tablet 1ANTINEOPLASTIC - ANTIMETABOLITES Purixan 20 Mg/Ml Oral Susp 2ANTINEOPLASTIC - ANTIMETABOLITES Tabloid 40 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Trexall 10 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Trexall 15 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Trexall 5 Mg Tablet 2ANTINEOPLASTIC - ANTIMETABOLITES Trexall 7.5 Mg Tablet 2ANTINEOPLASTIC - AROMATASE INHIBITORS Anastrozole 1 Mg Tablet 1ANTINEOPLASTIC - AROMATASE INHIBITORS Exemestane 25 Mg Tablet 1ANTINEOPLASTIC - AROMATASE INHIBITORS Letrozole 2.5 Mg Tablet 1ANTINEOPLASTIC - BRAF KINASE INHIBITORS Tafinlar 50 Mg Capsule 2ANTINEOPLASTIC - BRAF KINASE INHIBITORS Tafinlar 75 Mg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 22: 2021 Rx Select - PRAM

ANTINEOPLASTIC - BRAF KINASE INHIBITORS Zelboraf 240 Mg Tablet 2ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR Daurismo 25 Mg Tablet 2ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR Erivedge 150 Mg Capsule 2ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS Jakafi 10 Mg Tablet 2ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS Jakafi 15 Mg Tablet 2ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS Jakafi 20 Mg Tablet 2ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS Jakafi 25 Mg Tablet 2ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS Jakafi 5 Mg Tablet 2ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS Cotellic 20 Mg Tablet 2ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS Mekinist 0.5 Mg Tablet 2ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS Mekinist 2 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor 10 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor 2.5 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor 5 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor 7.5 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor Disperz 2 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor Disperz 3 Mg Tablet 2ANTINEOPLASTIC - MTOR KINASE INHIBITORS Afinitor Disperz 5 Mg Tablet 2ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS Hycamtin 0.25 Mg Capsule 2ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS Hycamtin 1 Mg Capsule 2ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT Kisqali Femara 200 Mg Co-pack 2ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT Kisqali Femara 400 Mg Co-pack 2ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT Kisqali Femara 600 Mg Co-pack 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Pomalyst 1 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Pomalyst 2 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Pomalyst 3 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Pomalyst 4 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 10 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 15 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 2.5 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 20 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 25 Mg Capsule 2ANTINEOPLASTIC IMMUNOMODULATOR AGENTS Revlimid 5 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Alecensa 150 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Bosulif 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Bosulif 400 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Bosulif 500 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Caprelsa 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Caprelsa 300 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Erlotinib Hcl 100 Mg Tablet 1ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Erlotinib Hcl 150 Mg Tablet 1ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Erlotinib Hcl 25 Mg Tablet 1ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Gilotrif 20 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Gilotrif 30 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Gilotrif 40 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ibrance 100 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ibrance 125 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ibrance 75 Mg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 23: 2021 Rx Select - PRAM

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Iclusig 15 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Iclusig 45 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imatinib Mesylate 100 Mg Tab 1ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imatinib Mesylate 400 Mg Tab 1ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 140 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 140 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 280 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 420 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 560 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Imbruvica 70 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Inlyta 1 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Inlyta 5 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Iressa 250 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Kisqali 200 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Kisqali 400 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Kisqali 600 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 10 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 12 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 14 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 18 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 20 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 24 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 4 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lenvima 8 Mg Daily Dose 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lynparza 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Lynparza 150 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Nexavar 200 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ninlaro 2.3 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ninlaro 3 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Ninlaro 4 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Rubraca 200 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Rubraca 300 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 140 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 20 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 50 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 70 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sprycel 80 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Stivarga 40 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sutent 12.5 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sutent 25 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sutent 37.5 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Sutent 50 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tagrisso 40 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tagrisso 80 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tarceva 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tarceva 150 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tarceva 25 Mg Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 24: 2021 Rx Select - PRAM

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tasigna 150 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tasigna 200 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tasigna 50 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Tykerb 250 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Verzenio 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Verzenio 150 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Verzenio 200 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Verzenio 50 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vitrakvi 100 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vitrakvi 20 Mg/Ml Solution 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vitrakvi 25 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vizimpro 15 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vizimpro 30 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Vizimpro 45 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Votrient 200 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Xalkori 200 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Xalkori 250 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Xospata 40 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Zejula 100 Mg Capsule 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Zydelig 100 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Zydelig 150 Mg Tablet 2ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Zykadia 150 Mg Capsule 2ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS Venclexta 10 Mg Tablet 2ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS Venclexta 100 Mg Tablet 2ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS Venclexta 50 Mg Tablet 2ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS Venclexta Starting Pack 2ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORS Idhifa 100 Mg Tablet 2ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORS Idhifa 50 Mg Tablet 2ANTINEOPLASTICS,MISCELLANEOUS Etoposide 50 Mg Capsule 1ANTINEOPLASTICS,MISCELLANEOUS Lysodren 500 Mg Tablet 2ANTINEOPLASTICS,MISCELLANEOUS Matulane 50 Mg Capsule 2ANTINEOPLASTICS,MISCELLANEOUS Tretinoin 10 Mg Capsule 1ANTIPARASITICS Alinia 100 Mg/5 Ml Suspension 2ANTIPARASITICS Alinia 500 Mg Tablet 2ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Benztropine Mes 0.5 Mg Tab 1ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Benztropine Mes 1 Mg Tablet 1ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Benztropine Mes 2 Mg Tablet 1ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Trihexyphenidyl 2 Mg Tablet 1ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Trihexyphenidyl 2 Mg/5 Ml Elx 1ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC Trihexyphenidyl 5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Amantadine 100 Mg Capsule 1ANTIPARKINSONISM DRUGS,OTHER Amantadine 100 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Amantadine 100 Mg/10 Ml Soln 1ANTIPARKINSONISM DRUGS,OTHER Amantadine 50 Mg/5 Ml Solution 1ANTIPARKINSONISM DRUGS,OTHER Bromocriptine 2.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Bromocriptine 5 Mg Capsule 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levo 10-100 Mg Odt 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levo 25-100 Mg Odt 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 25: 2021 Rx Select - PRAM

ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levo 25-250 Mg Odt 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levo Er 25-100 Tab 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levo Er 50-200 Tab 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 100 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 10-100 Tab 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 125 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 150 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 200 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 25-100 Tab 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 25-250 Tab 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 50 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Carbidopa-levodopa 75 Mg-enta 1ANTIPARKINSONISM DRUGS,OTHER Entacapone 200 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Neupro 1 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Neupro 2 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Neupro 3 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Neupro 4 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Neupro 6 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Neupro 8 Mg/24 Hr Patch 2ANTIPARKINSONISM DRUGS,OTHER Pramipexole 0.125 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole 0.25 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole 0.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole 0.75 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole 1 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole 1.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 0.375 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 0.75 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 1.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 2.25 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 3 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 3.75 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Pramipexole Er 4.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Rasagiline Mesylate 0.5 Mg Tab 1ANTIPARKINSONISM DRUGS,OTHER Rasagiline Mesylate 1 Mg Tab 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 0.25 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 0.5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 1 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 2 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 3 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 4 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl 5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl Er 12 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl Er 2 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl Er 4 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl Er 6 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Ropinirole Hcl Er 8 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Rytary Er 23.75 Mg-95 Mg Cap 2ANTIPARKINSONISM DRUGS,OTHER Rytary Er 36.25 Mg-145 Mg Cap 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 26: 2021 Rx Select - PRAM

ANTIPARKINSONISM DRUGS,OTHER Rytary Er 48.75 Mg-195 Mg Cap 2ANTIPARKINSONISM DRUGS,OTHER Rytary Er 61.25 Mg-245 Mg Cap 2ANTIPARKINSONISM DRUGS,OTHER Selegiline Hcl 5 Mg Capsule 1ANTIPARKINSONISM DRUGS,OTHER Selegiline Hcl 5 Mg Tablet 1ANTIPARKINSONISM DRUGS,OTHER Tolcapone 100 Mg Tablet 1ANTIPROTOZOAL DRUGS,MISCELLANEOUS Atovaquone 750 Mg/5 Ml Susp 1ANTIPROTOZOAL DRUGS,MISCELLANEOUS Benznidazole 100 Mg Tablet 1ANTIPROTOZOAL DRUGS,MISCELLANEOUS Benznidazole 12.5 Mg Tablet 1ANTIPROTOZOAL DRUGS,MISCELLANEOUS Impavido 50 Mg Capsule 2ANTIPRURITICS,TOPICAL Doxepin 5% Cream 1ANTIPSORIATIC AGENTS,SYSTEMIC Acitretin 10 Mg Capsule 1ANTIPSORIATIC AGENTS,SYSTEMIC Acitretin 17.5 Mg Capsule 1ANTIPSORIATIC AGENTS,SYSTEMIC Acitretin 25 Mg Capsule 1ANTIPSORIATIC AGENTS,SYSTEMIC Methoxsalen 10 Mg Capsule 1ANTIPSORIATIC AGENTS,SYSTEMIC Methoxsalen 10 Mg Softgel 1ANTIPSORIATICS AGENTS Calcipotriene 0.005% Cream 1ANTIPSORIATICS AGENTS Calcipotriene 0.005% Ointment 1ANTIPSORIATICS AGENTS Calcipotriene 0.005% Solution 1ANTIPSORIATICS AGENTS Calcitrene 0.005% Ointment 1ANTIPSORIATICS AGENTS Calcitriol 3 Mcg/G Ointment 1ANTIPSORIATICS AGENTS Tazarotene 0.1% Cream 1ANTIPSORIATICS AGENTS Tazorac 0.05% Cream 2ANTIPSORIATICS AGENTS Tazorac 0.05% Gel 2ANTIPSORIATICS AGENTS Tazorac 0.1% Cream 2ANTIPSORIATICS AGENTS Tazorac 0.1% Gel 2ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES Pimozide 1 Mg Tablet 1ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES Pimozide 2 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine 100 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine 200 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine 25 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine 50 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine Odt 100 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine Odt 12.5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine Odt 150 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine Odt 200 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Clozapine Odt 25 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Latuda 120 Mg Tablet 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Latuda 20 Mg Tablet 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Latuda 40 Mg Tablet 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Latuda 60 Mg Tablet 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Latuda 80 Mg Tablet 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 10 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 15 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 2.5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 20 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine 7.5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine Odt 10 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 27: 2021 Rx Select - PRAM

ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine Odt 15 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine Odt 20 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Olanzapine Odt 5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Paliperidone Er 1.5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Paliperidone Er 3 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Paliperidone Er 6 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Paliperidone Er 9 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Er 150 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Er 200 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Er 300 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Er 400 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Er 50 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 100 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 200 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 25 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 300 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 400 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Quetiapine Fumarate 50 Mg Tab 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 0.25 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 0.25 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 0.5 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 0.5 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 1 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 1 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 1 Mg/1 Ml Oral Syr 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 1 Mg/Ml Solution 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 2 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 2 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 2 Mg/2 Ml Oral Syr 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 3 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 3 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 3 Mg/3 Ml Oral Syr 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 4 Mg Odt 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Risperidone 4 Mg Tablet 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Saphris 10 Mg Tab Sublingual 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Saphris 2.5 Mg Tab Sublingual 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Saphris 5 Mg Tab Sublingual 2ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Ziprasidone Hcl 20 Mg Capsule 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Ziprasidone Hcl 40 Mg Capsule 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Ziprasidone Hcl 60 Mg Capsule 1ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST Ziprasidone Hcl 80 Mg Capsule 1ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED Vraylar 1.5 Mg Capsule 2ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED Vraylar 1.5 Mg-3 Mg Pack 2ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED Vraylar 3 Mg Capsule 2ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED Vraylar 4.5 Mg Capsule 2ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED Vraylar 6 Mg Capsule 2ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 1 Mg/Ml Solution 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 10 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 28: 2021 Rx Select - PRAM

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 15 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 2 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 20 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 30 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole 5 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole Odt 10 Mg Tablet 1ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED Aripiprazole Odt 15 Mg Tablet 1ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS Loxapine 10 Mg Capsule 1ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS Loxapine 25 Mg Capsule 1ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS Loxapine 5 Mg Capsule 1ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS Loxapine 50 Mg Capsule 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES Thiothixene 1 Mg Capsule 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES Thiothixene 10 Mg Capsule 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES Thiothixene 2 Mg Capsule 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES Thiothixene 5 Mg Capsule 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 0.5 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 1 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 10 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 2 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 20 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol 5 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES Haloperidol Lac 2 Mg/Ml Conc 1ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES Molindone Hcl 10 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES Molindone Hcl 25 Mg Tablet 1ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES Molindone Hcl 5 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Chlorpromazine 10 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Chlorpromazine 100 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Chlorpromazine 200 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Chlorpromazine 25 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Chlorpromazine 50 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 1 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 10 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 2.5 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 2.5 Mg/5 Ml Elix 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 5 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Fluphenazine 5 Mg/Ml Conc 1ANTIPSYCHOTICS,PHENOTHIAZINES Perphenazine 16 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Perphenazine 2 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Perphenazine 4 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Perphenazine 8 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Thioridazine 10 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Thioridazine 100 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Thioridazine 25 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Thioridazine 50 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Trifluoperazine 1 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Trifluoperazine 10 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Trifluoperazine 2 Mg Tablet 1ANTIPSYCHOTICS,PHENOTHIAZINES Trifluoperazine 5 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 29: 2021 Rx Select - PRAM

ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMB Triumeq 600-50-300 Mg Tablet 2ANTISEBORRHEIC AGENTS Selenium Sulfide 2.25% Shampoo 1ANTISEBORRHEIC AGENTS Selenium Sulfide 2.3% Shampoo 1ANTISEBORRHEIC AGENTS Selenium Sulfide 2.5% Lotion 1ANTISEBORRHEIC AGENTS Sod Sulfacetam 10% Clnsng Gel 1ANTISEBORRHEIC AGENTS Sod Sulfacetamide 10% Shampoo 1ANTISEBORRHEIC AGENTS Sodium Sulfacetamide 10% Wash 1ANTISEPTICS,MISCELLANEOUS Guaiacol Liquid Purified 1ANTITHYROID PREPARATIONS Methimazole 10 Mg Tablet 1ANTITHYROID PREPARATIONS Methimazole 5 Mg Tablet 1ANTITHYROID PREPARATIONS Propylthiouracil 50 Mg Tablet 1ANTITUBERCULAR ANTIBIOTICS Cycloserine 250 Mg Capsule 1ANTITUBERCULAR ANTIBIOTICS Priftin 150 Mg Tablet 2ANTITUBERCULAR ANTIBIOTICS Rifadin 150 Mg Capsule 1ANTITUBERCULAR ANTIBIOTICS Rifampin 150 Mg Capsule 1ANTITUBERCULAR ANTIBIOTICS Rifampin 300 Mg Capsule 1ANTITUBERCULAR ANTIBIOTICS Sirturo 100 Mg Tablet 2ANTITUSSIVES, NON-OPIOID Benzonatate 100 Mg Capsule 1ANTITUSSIVES, NON-OPIOID Benzonatate 150 Mg Capsule 1ANTITUSSIVES, NON-OPIOID Benzonatate 200 Mg Capsule 1ANTI-ULCER PREPARATIONS Misoprostol 100 Mcg Tablet 1ANTI-ULCER PREPARATIONS Misoprostol 200 Mcg Tablet 1ANTI-ULCER PREPARATIONS Sucralfate 1 Gm Tablet 1ANTI-ULCER-H.PYLORI AGENTS Lansoprazol-amoxicil-clarithro 1ANTI-ULCER-H.PYLORI AGENTS Pylera Capsule 2ANTIVIRALS, GENERAL Acyclovir 200 Mg Capsule 1ANTIVIRALS, GENERAL Acyclovir 200 Mg/5 Ml Susp 1ANTIVIRALS, GENERAL Acyclovir 400 Mg Tablet 1ANTIVIRALS, GENERAL Acyclovir 800 Mg Tablet 1ANTIVIRALS, GENERAL Famciclovir 125 Mg Tablet 1ANTIVIRALS, GENERAL Famciclovir 250 Mg Tablet 1ANTIVIRALS, GENERAL Famciclovir 500 Mg Tablet 1ANTIVIRALS, GENERAL Oseltamivir 6 Mg/Ml Suspension 1ANTIVIRALS, GENERAL Oseltamivir Phos 30 Mg Capsule 1ANTIVIRALS, GENERAL Oseltamivir Phos 45 Mg Capsule 1ANTIVIRALS, GENERAL Oseltamivir Phos 75 Mg Capsule 1ANTIVIRALS, GENERAL Prevymis 240 Mg Tablet 2ANTIVIRALS, GENERAL Prevymis 480 Mg Tablet 2ANTIVIRALS, GENERAL Relenza 5 Mg Diskhaler 2ANTIVIRALS, GENERAL Ribavirin 6 Gm Inhalation Vial 1ANTIVIRALS, GENERAL Rimantadine Hcl 100 Mg Tablet 1ANTIVIRALS, GENERAL Valacyclovir Hcl 1 Gram Tablet 1ANTIVIRALS, GENERAL Valacyclovir Hcl 500 Mg Tablet 1ANTIVIRALS, GENERAL Valganciclovir 450 Mg Tablet 1ANTIVIRALS, GENERAL Valganciclovir Hcl 50 Mg/Ml 1ANTIVIRALS, GENERAL Xofluza 20 Mg Tab (40 Mg Dose) 2ANTIVIRALS, GENERAL Xofluza 40 Mg Tab (80 Mg Dose) 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Aptivus 100 Mg/Ml Solution 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 30: 2021 Rx Select - PRAM

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Aptivus 250 Mg Capsule 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezcobix 800 Mg-150 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezista 100 Mg/Ml Suspension 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezista 150 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezista 600 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezista 75 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB Prezista 800 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Cimduo 300-300 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Descovy 200-25 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Temixys 300-300 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Truvada 100 Mg-150 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Truvada 133 Mg-200 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Truvada 167 Mg-250 Mg Tablet 2ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG Truvada 200 Mg-300 Mg Tablet 2ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB Abacavir-lamivudine 600-300 Mg 1ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB Abacavir-lamivudine-zidov Tab 1ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB Lamivudine-zidovudine Tablet 1ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. Selzentry 150 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. Selzentry 25 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. Selzentry 300 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. Selzentry 75 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Edurant 25 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Efavirenz 200 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Efavirenz 50 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Efavirenz 600 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Intelence 100 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Intelence 200 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Intelence 25 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Nevirapine 200 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Nevirapine 50 Mg/5 Ml Susp 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Nevirapine Er 100 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Nevirapine Er 400 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI Rescriptor 200 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Abacavir 20 Mg/Ml Solution 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Abacavir 300 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Didanosine Dr 125 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Didanosine Dr 200 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Didanosine Dr 250 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Didanosine Dr 400 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Emtriva 10 Mg/Ml Solution 2ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Emtriva 200 Mg Capsule 2ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Lamivudine 10 Mg/Ml Oral Soln 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Lamivudine 150 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Lamivudine 300 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Stavudine 15 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Stavudine 20 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Stavudine 30 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Stavudine 40 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 31: 2021 Rx Select - PRAM

ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Videx 2 Gm Pediatric Soln 2ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Videx Ec 125 Mg Capsule 2ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Zidovudine 100 Mg Capsule 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Zidovudine 300 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI Zidovudine 50 Mg/5 Ml Syrup 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI Tenofovir Disop Fum 300 Mg Tb 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI Viread Powder 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB Kaletra 100-25 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB Kaletra 200-50 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB Lopinavir-ritonavir 80-20mg/Ml 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Atazanavir Sulfate 150 Mg Cap 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Atazanavir Sulfate 200 Mg Cap 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Atazanavir Sulfate 300 Mg Cap 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Crixivan 200 Mg Capsule 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Crixivan 400 Mg Capsule 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Fosamprenavir 700 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Invirase 500 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Lexiva 50 Mg/Ml Suspension 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Norvir 100 Mg Powder Packet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Norvir 80 Mg/Ml Solution 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Reyataz 50 Mg Powder Packet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Ritonavir 100 Mg Tablet 1ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Viracept 250 Mg Tablet 2ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS Viracept 625 Mg Tablet 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Isentress 100 Mg Powder Packet 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Isentress 100 Mg Tablet Chew 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Isentress 25 Mg Tablet Chew 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Isentress 400 Mg Tablet 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Tivicay 10 Mg Tablet 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Tivicay 25 Mg Tablet 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR Tivicay 50 Mg Tablet 2APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. Megestrol 625 Mg/5 Ml Susp 1APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. Megestrol 800 Mg/20 Ml Susp 1APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. Megestrol Acet 40 Mg/Ml Susp 1APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. Megestrol Acet 400 Mg/10 Ml 1APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. Megestrol Acet 800 Mg/20 Ml 1ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS Jynarque 15 Mg Tablet 2ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS Jynarque 30 Mg Tablet 2ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS Samsca 15 Mg Tablet 2ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS Samsca 30 Mg Tablet 2ARTIFICIAL TEARS Klarity(chondroitin) 2.5 Mg/Ml 1ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB Atripla Tablet 2ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB Complera Tablet 2ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB Odefsey Tablet 2ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB Symfi 600-300-300 Mg Tablet 2ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB Symfi Lo 400-300-300 Mg Tablet 2ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORS Biktarvy 50-200-25 Mg Tablet 2ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORS Stribild Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 32: 2021 Rx Select - PRAM

BARBITURATES Phenobarbital 100 Mg Tablet 1BARBITURATES Phenobarbital 15 Mg Tablet 1BARBITURATES Phenobarbital 16.2 Mg Tablet 1BARBITURATES Phenobarbital 20 Mg/5 Ml Elix 1BARBITURATES Phenobarbital 20 Mg/5 Ml Soln 1BARBITURATES Phenobarbital 30 Mg Tablet 1BARBITURATES Phenobarbital 32.4 Mg Tablet 1BARBITURATES Phenobarbital 60 Mg Tablet 1BARBITURATES Phenobarbital 64.8 Mg Tablet 1BARBITURATES Phenobarbital 97.2 Mg Tablet 1BARBITURATES Seconal Sodium 100 Mg Capsule 2BELLADONNA ALKALOIDS Anaspaz 0.125 Mg Tablet Odt 1BELLADONNA ALKALOIDS Belladonna-phenobarbital Tab 1BELLADONNA ALKALOIDS Ed-spaz 0.125 Mg Odt 1BELLADONNA ALKALOIDS Hyoscyamine 0.125 Mg Odt 1BELLADONNA ALKALOIDS Hyoscyamine 0.125 Mg Tab Sl 1BELLADONNA ALKALOIDS Hyoscyamine 0.125 Mg/5 Ml Elix 1BELLADONNA ALKALOIDS Hyoscyamine 0.125 Mg/Ml Drop 1BELLADONNA ALKALOIDS Hyoscyamine Er 0.375 Mg Tab 1BELLADONNA ALKALOIDS Hyoscyamine Sr 0.375 Mg Tab 1BELLADONNA ALKALOIDS Hyoscyamine Sulf 0.125 Mg Tab 1BELLADONNA ALKALOIDS Hyosyne 0.125 Mg/Ml Drop 1BELLADONNA ALKALOIDS Hyosyne 125 Mcg/5 Ml Elixir 1BELLADONNA ALKALOIDS Methscopolamine Brom 2.5 Mg Tb 1BELLADONNA ALKALOIDS Methscopolamine Brom 5 Mg Tab 1BELLADONNA ALKALOIDS Nulev 0.125 Mg Chewable Melt 1BELLADONNA ALKALOIDS Oscimin 0.125 Mg Odt 1BELLADONNA ALKALOIDS Oscimin 0.125 Mg Tablet 1BELLADONNA ALKALOIDS Oscimin Sl 0.125 Mg Tablet 1BELLADONNA ALKALOIDS Oscimin Sr 0.375 Mg Tablet 1BELLADONNA ALKALOIDS Phenobarbital-belladonna Elixr 1BELLADONNA ALKALOIDS Phenohytro Elixir 1BELLADONNA ALKALOIDS Phenohytro Tablet 1BELLADONNA ALKALOIDS Symax Fastabs 0.125 Mg Tablet 1BELLADONNA ALKALOIDS Symax-sl 0.125 Mg Tablet Sl 1BELLADONNA ALKALOIDS Symax-sr 0.375 Mg Tablet 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Alfuzosin Hcl Er 10 Mg Tablet 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Dutasteride 0.5 Mg Capsule 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Finasteride 5 Mg Tablet 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Silodosin 4 Mg Capsule 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Silodosin 8 Mg Capsule 1BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS Tamsulosin Hcl 0.4 Mg Capsule 1BETA-ADRENERGIC AGENTS Albuterol Sulf 2 Mg/5 Ml Syrup 1BETA-ADRENERGIC AGENTS Albuterol Sulfate 2 Mg Tab 1BETA-ADRENERGIC AGENTS Albuterol Sulfate 4 Mg Tab 1BETA-ADRENERGIC AGENTS Albuterol Sulfate Er 4 Mg Tab 1BETA-ADRENERGIC AGENTS Albuterol Sulfate Er 8 Mg Tab 1BETA-ADRENERGIC AGENTS Metaproterenol 10 Mg/5 Ml Syr 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 33: 2021 Rx Select - PRAM

BETA-ADRENERGIC AGENTS Terbutaline Sulfate 2.5 Mg Tab 1BETA-ADRENERGIC AGENTS Terbutaline Sulfate 5 Mg Tab 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Albuterol 2.5 Mg/0.5 Ml Sol 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Albuterol 5 Mg/Ml Solution 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Albuterol Hfa 90 Mcg Inhaler 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Albuterol Sul 0.63 Mg/3 Ml Sol 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Albuterol Sul 1.25 Mg/3 Ml Sol 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Levalbuterol 0.31 Mg/3 Ml Sol 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Levalbuterol Conc 1.25 Mg/0.5 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Levalbuterol Tar Hfa 45mcg Inh 1BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Proair Hfa 90 Mcg Inhaler 2BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Proair Respiclick 90 Mcg Inhlr 2BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Ventolin Hfa 90 Mcg Inhaler 2BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING Arcapta Neohaler 75 Mcg Cap 2BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING Striverdi Respimat Inhal Spray 2BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTING Perforomist 20 Mcg/2 Ml Soln 2BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTING Serevent Diskus 50 Mcg 2BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED Anoro Ellipta 62.5-25 Mcg Inh 2BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED Bevespi Aerosphere Inhaler 2BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED Combivent Respimat 20-100 Mcg 2BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED Stiolto Respimat Inhal Spray 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Advair Hfa 115-21 Mcg Inhaler 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Advair Hfa 230-21 Mcg Inhaler 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Advair Hfa 45-21 Mcg Inhaler 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Breo Ellipta 100-25 Mcg Inh 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Breo Ellipta 200-25 Mcg Inh 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 100-50 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 113-14 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 232-14 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 250-50 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 500-50 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Fluticasone-salmeterol 55-14 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Symbicort 160-4.5 Mcg Inhaler 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Symbicort 80-4.5 Mcg Inhaler 2BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Wixela 100-50 Inhub 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Wixela 250-50 Inhub 1BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED Wixela 500-50 Inhub 1BETA-ADRENERGIC BLOCKING AGENTS Acebutolol 200 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Acebutolol 400 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Atenolol 100 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Atenolol 25 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Atenolol 50 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Betaxolol 10 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Betaxolol 20 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Bisoprolol Fumarate 10 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Bisoprolol Fumarate 5 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Bystolic 10 Mg Tablet 2BETA-ADRENERGIC BLOCKING AGENTS Bystolic 2.5 Mg Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 34: 2021 Rx Select - PRAM

BETA-ADRENERGIC BLOCKING AGENTS Bystolic 20 Mg Tablet 2BETA-ADRENERGIC BLOCKING AGENTS Bystolic 5 Mg Tablet 2BETA-ADRENERGIC BLOCKING AGENTS Hemangeol 4.28 Mg/Ml Oral Soln 2BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Succ Er 100 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Succ Er 200 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Succ Er 25 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Succ Er 50 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Tartrate 100 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Tartrate 25 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Tartrate 37.5 Mg Tb 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Tartrate 50 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Metoprolol Tartrate 75 Mg Tab 1BETA-ADRENERGIC BLOCKING AGENTS Nadolol 20 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Nadolol 40 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Nadolol 80 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Pindolol 10 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Pindolol 5 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 10 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 20 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 20 Mg/5 Ml Soln 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 40 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 40 Mg/5 Ml Soln 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 60 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol 80 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol Er 120 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol Er 160 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol Er 60 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Propranolol Er 80 Mg Capsule 1BETA-ADRENERGIC BLOCKING AGENTS Sorine 120 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sorine 160 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sorine 240 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sorine 80 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol 120 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol 160 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol 240 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol 80 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol Af 120 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol Af 160 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotalol Af 80 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Sotylize 5 Mg/Ml Oral Solution 2BETA-ADRENERGIC BLOCKING AGENTS Timolol Maleate 10 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Timolol Maleate 20 Mg Tablet 1BETA-ADRENERGIC BLOCKING AGENTS Timolol Maleate 5 Mg Tablet 1BETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED Trelegy Ellipta 100-62.5-25 2BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Atenolol-chlorthalidone 100-25 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Atenolol-chlorthalidone 50-25 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Bisoprolol-hctz 10-6.25 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Bisoprolol-hctz 2.5-6.25 Mg Tb 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 35: 2021 Rx Select - PRAM

BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Bisoprolol-hctz 5-6.25 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Metoprolol Er-hctz 100-12.5 Mg 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Metoprolol Er-hctz 25-12.5 Mg 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Metoprolol-hctz 100-25 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Metoprolol-hctz 100-50 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Metoprolol-hctz 50-25 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Nadolol-bendroflu 80-5 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Propranolol-hctz 40-25 Mg Tab 1BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICS Propranolol-hctz 80-25 Mg Tab 1BETALACTAMS Cayston 75 Mg Inhal Solution 2BILE SALT SEQUESTRANTS Cholestyramine Light Packet 1BILE SALT SEQUESTRANTS Cholestyramine Light Powder 1BILE SALT SEQUESTRANTS Cholestyramine Packet 1BILE SALT SEQUESTRANTS Cholestyramine Powder 1BILE SALT SEQUESTRANTS Colesevelam 625 Mg Tablet 1BILE SALT SEQUESTRANTS Colesevelam Hcl 3.75 G Packet 1BILE SALT SEQUESTRANTS Colestipol Hcl 1 Gm Tablet 1BILE SALT SEQUESTRANTS Colestipol Hcl Granules 1BILE SALT SEQUESTRANTS Colestipol Hcl Granules Packet 1BILE SALT SEQUESTRANTS Colestipol Micronized 1 Gm Tab 1BILE SALT SEQUESTRANTS Prevalite Packet 1BILE SALT SEQUESTRANTS Prevalite Powder 1BILE SALTS Cholbam 250 Mg Capsule 2BILE SALTS Cholbam 50 Mg Capsule 2BILE SALTS Ursodiol 250 Mg Tablet 1BILE SALTS Ursodiol 300 Mg Capsule 1BILE SALTS Ursodiol 500 Mg Tablet 1BIPOLAR DISORDER DRUGS Lithium 8 Meq/5 Ml Solution 1BIPOLAR DISORDER DRUGS Lithium Carbonate 150 Mg Cap 1BIPOLAR DISORDER DRUGS Lithium Carbonate 300 Mg Cap 1BIPOLAR DISORDER DRUGS Lithium Carbonate 300 Mg Tab 1BIPOLAR DISORDER DRUGS Lithium Carbonate 600 Mg Cap 1BIPOLAR DISORDER DRUGS Lithium Carbonate Er 300 Mg Tb 1BIPOLAR DISORDER DRUGS Lithium Carbonate Er 450 Mg Tb 1BLOOD SUGAR DIAGNOSTICS Easy Touch Glucose Test Strip 2BLOOD SUGAR DIAGNOSTICS Freestyle Insulinx Strip Nfrs 2BLOOD SUGAR DIAGNOSTICS Freestyle Insulinx Test Strip 2BLOOD SUGAR DIAGNOSTICS Freestyle Insulinx Test Strips 2BLOOD SUGAR DIAGNOSTICS Freestyle Lite Test Strip 2BLOOD SUGAR DIAGNOSTICS Freestyle Lite Test Strip Nfrs 2BLOOD SUGAR DIAGNOSTICS Freestyle Prec Neo Test Strips 2BLOOD SUGAR DIAGNOSTICS Freestyle Test Strips 2BLOOD SUGAR DIAGNOSTICS Freestyle Test Strips Nfrs 2BLOOD SUGAR DIAGNOSTICS Onetouch Ultra Blue Test Strp 2BLOOD SUGAR DIAGNOSTICS Onetouch Verio Test Strip 2BLOOD SUGAR DIAGNOSTICS Optium Test Strip 2BLOOD SUGAR DIAGNOSTICS Precision Pcx Plus Test Str 2BLOOD SUGAR DIAGNOSTICS Precision Pcx Test Strips 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 36: 2021 Rx Select - PRAM

BLOOD SUGAR DIAGNOSTICS Precision Point Of Care Str 2BLOOD SUGAR DIAGNOSTICS Precision Q-i-d Test Strips 2BLOOD SUGAR DIAGNOSTICS Precision Xtra Test Strips 2BONE RESORPTION INHIBITORS Alendronate Sod 70 Mg/75 Ml 1BONE RESORPTION INHIBITORS Alendronate Sodium 10 Mg Tab 1BONE RESORPTION INHIBITORS Alendronate Sodium 35 Mg Tab 1BONE RESORPTION INHIBITORS Alendronate Sodium 40 Mg Tab 1BONE RESORPTION INHIBITORS Alendronate Sodium 5 Mg Tablet 1BONE RESORPTION INHIBITORS Alendronate Sodium 70 Mg Tab 1BONE RESORPTION INHIBITORS Calcitonin-salmon 200 Units Sp 1BONE RESORPTION INHIBITORS Etidronate Disodium 200 Mg Tab 1BONE RESORPTION INHIBITORS Etidronate Disodium 400 Mg Tab 1BONE RESORPTION INHIBITORS Ibandronate Sodium 150 Mg Tab 1BONE RESORPTION INHIBITORS Raloxifene Hcl 60 Mg Tablet 1BONE RESORPTION INHIBITORS Risedronate Sod Dr 35 Mg Tab 1BONE RESORPTION INHIBITORS Risedronate Sodium 150 Mg Tab 1BONE RESORPTION INHIBITORS Risedronate Sodium 30 Mg Tab 1BONE RESORPTION INHIBITORS Risedronate Sodium 35 Mg Tab 1BONE RESORPTION INHIBITORS Risedronate Sodium 5 Mg Tablet 1BPH 5-ALPHA-REDUCTASE INHIB-ALPHA1-ADRENOCEP ANTAG Dutasteride-tamsulosin 0.5-0.4 1CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER Cinacalcet Hcl 30 Mg Tablet 1CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER Cinacalcet Hcl 60 Mg Tablet 1CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER Cinacalcet Hcl 90 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Amlodipine Besylate 10 Mg Tab 1CALCIUM CHANNEL BLOCKING AGENTS Amlodipine Besylate 2.5 Mg Tab 1CALCIUM CHANNEL BLOCKING AGENTS Amlodipine Besylate 5 Mg Tab 1CALCIUM CHANNEL BLOCKING AGENTS Cartia Xt 120 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Cartia Xt 180 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Cartia Xt 240 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Cartia Xt 300 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Dilt Xr 120 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Dilt Xr 180 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Dilt Xr 240 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 120 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 12hr Er 120 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 12hr Er 60 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 12hr Er 90 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(cd) 120 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(cd) 180 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(cd) 240 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(cd) 300 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(cd) 360 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(la) 180 Mg Tb 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(la) 240 Mg Tb 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(la) 300 Mg Tb 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(la) 360 Mg Tb 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(la) 420 Mg Tb 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(xr) 120 Mg Cp 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 37: 2021 Rx Select - PRAM

CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(xr) 180 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24h Er(xr) 240 Mg Cp 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 120 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 180 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 240 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 300 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 360 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 24hr Er 420 Mg Cap 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 30 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 60 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Diltiazem 90 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Felodipine Er 10 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Felodipine Er 2.5 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Felodipine Er 5 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Isradipine 2.5 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Isradipine 5 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Matzim La 180 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Matzim La 240 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Matzim La 300 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Matzim La 360 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Matzim La 420 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nicardipine 20 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Nicardipine 30 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Nifedipine 10 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Nifedipine 20 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Nifedipine Er 30 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nifedipine Er 60 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nifedipine Er 90 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nimodipine 30 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 17 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 20 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 25.5 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 30 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 34 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 40 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Nisoldipine Er 8.5 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Taztia Xt 120 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Taztia Xt 180 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Taztia Xt 240 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Taztia Xt 300 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Taztia Xt 360 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil 120 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil 360 Mg Cap Pellet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil 40 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil 80 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 120 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 120 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 180 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 38: 2021 Rx Select - PRAM

CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 180 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 240 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er 240 Mg Tablet 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er Pm 100 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er Pm 200 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Er Pm 300 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Sr 120 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Sr 180 Mg Capsule 1CALCIUM CHANNEL BLOCKING AGENTS Verapamil Sr 240 Mg Capsule 1CARBONIC ANHYDRASE INHIBITORS Acetazolamide 125 Mg Tablet 1CARBONIC ANHYDRASE INHIBITORS Acetazolamide 250 Mg Tablet 1CARBONIC ANHYDRASE INHIBITORS Acetazolamide Er 500 Mg Cap 1CARBONIC ANHYDRASE INHIBITORS Methazolamide 25 Mg Tablet 1CARBONIC ANHYDRASE INHIBITORS Methazolamide 50 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cefadroxil 1 Gm Tablet 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cefadroxil 250 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cefadroxil 500 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cefadroxil 500 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 125 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 250 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 250 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 250 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 500 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 500 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION Cephalexin 750 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor 125 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor 250 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor 250 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor 375 Mg/5 Ml Suspen 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor 500 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefaclor Er 500 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefprozil 125 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefprozil 250 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefprozil 250 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefprozil 500 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefuroxime Axetil 250 Mg Tab 1CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION Cefuroxime Axetil 500 Mg Tab 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefdinir 125 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefdinir 250 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefdinir 300 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefditoren Pivoxil 200 Mg Tab 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefditoren Pivoxil 400 Mg Tab 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefixime 100 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefixime 200 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefixime 400 Mg Capsule 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefpodoxime 100 Mg Tablet 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefpodoxime 100 Mg/5 Ml Susp 1CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefpodoxime 200 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 39: 2021 Rx Select - PRAM

CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION Cefpodoxime 50 Mg/5 Ml Susp 1CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Leucovorin Calcium 10 Mg Tab 1CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Leucovorin Calcium 15 Mg Tab 1CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Leucovorin Calcium 25 Mg Tab 1CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Leucovorin Calcium 5 Mg Tab 1CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Mesnex 400 Mg Tablet 2CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS Vistogard 10 Gram Packet 2CHOLINESTERASE INHIBITORS Donepezil Hcl 10 Mg Tablet 1CHOLINESTERASE INHIBITORS Donepezil Hcl 23 Mg Tablet 1CHOLINESTERASE INHIBITORS Donepezil Hcl 5 Mg Tablet 1CHOLINESTERASE INHIBITORS Donepezil Hcl Odt 10 Mg Tablet 1CHOLINESTERASE INHIBITORS Donepezil Hcl Odt 5 Mg Tablet 1CHOLINESTERASE INHIBITORS Galantamine 4 Mg/Ml Oral Soln 1CHOLINESTERASE INHIBITORS Galantamine Er 16 Mg Capsule 1CHOLINESTERASE INHIBITORS Galantamine Er 24 Mg Capsule 1CHOLINESTERASE INHIBITORS Galantamine Er 8 Mg Capsule 1CHOLINESTERASE INHIBITORS Galantamine Hbr 12 Mg Tablet 1CHOLINESTERASE INHIBITORS Galantamine Hbr 4 Mg Tablet 1CHOLINESTERASE INHIBITORS Galantamine Hbr 8 Mg Tablet 1CHOLINESTERASE INHIBITORS Pyridostigmine 60 Mg/5 Ml Soln 1CHOLINESTERASE INHIBITORS Pyridostigmine Br 30 Mg Tablet 1CHOLINESTERASE INHIBITORS Pyridostigmine Br 60 Mg Tablet 1CHOLINESTERASE INHIBITORS Pyridostigmine Er 180 Mg Tab 1CHOLINESTERASE INHIBITORS Rivastigmine 1.5 Mg Capsule 1CHOLINESTERASE INHIBITORS Rivastigmine 13.3 Mg/24hr Ptch 1CHOLINESTERASE INHIBITORS Rivastigmine 3 Mg Capsule 1CHOLINESTERASE INHIBITORS Rivastigmine 4.5 Mg Capsule 1CHOLINESTERASE INHIBITORS Rivastigmine 4.6 Mg/24hr Patch 1CHOLINESTERASE INHIBITORS Rivastigmine 6 Mg Capsule 1CHOLINESTERASE INHIBITORS Rivastigmine 9.5 Mg/24hr Patch 1CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX Mesalamine 1,000 Mg Supp 1CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX Mesalamine 4 Gm/60 Ml Enema 1CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX Mesalamine 4 Gm/60 Ml Kit 1CITRATES AS ANTICOAGULANTS Acd-a Solution 2CITRATES AS ANTICOAGULANTS Citrate Phos Dextrose Soln 2CITRATES AS ANTICOAGULANTS Sodium Citrate 4% Soln 1CITRATES AS ANTICOAGULANTS Sodium Citrate 4% Syringe 3COLCHICINE Colchicine 0.6 Mg Capsule 1COLCHICINE Colchicine 0.6 Mg Tablet 1COLCHICINE Colcrys 0.6 Mg Tablet 2CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC Nuvaring Vaginal Ring 2CONTRACEPTIVES,ORAL Afirmelle-28 Tablet 1CONTRACEPTIVES,ORAL Altavera-28 Tablet 1CONTRACEPTIVES,ORAL Alyacen 1-35 28 Tablet 1CONTRACEPTIVES,ORAL Alyacen 7-7-7-28 Tablet 1CONTRACEPTIVES,ORAL Amethia 0.15-0.03-0.01 Mg Tab 1CONTRACEPTIVES,ORAL Amethia Lo Tablet 1CONTRACEPTIVES,ORAL Amethyst 90-20 Mcg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 40: 2021 Rx Select - PRAM

CONTRACEPTIVES,ORAL Apri 28 Day Tablet 1CONTRACEPTIVES,ORAL Aranelle 28 Tablet 1CONTRACEPTIVES,ORAL Ashlyna 0.15-0.03-0.01 Mg Tab 1CONTRACEPTIVES,ORAL Aubra Eq-28 Tablet 1CONTRACEPTIVES,ORAL Aubra-28 Tablet 1CONTRACEPTIVES,ORAL Aurovela 1 Mg-20 Mcg Tablet 1CONTRACEPTIVES,ORAL Aurovela 21 1.5-30 Tablet 1CONTRACEPTIVES,ORAL Aurovela 24 Fe 1 Mg-20 Mcg Tab 1CONTRACEPTIVES,ORAL Aurovela Fe 1.5 Mg-30 Mcg Tab 1CONTRACEPTIVES,ORAL Aurovela Fe 1-20 Tablet 1CONTRACEPTIVES,ORAL Aviane-28 Tablet 1CONTRACEPTIVES,ORAL Ayuna-28 Tablet 1CONTRACEPTIVES,ORAL Azurette 28 Day Tablet 1CONTRACEPTIVES,ORAL Balziva 28 Tablet 1CONTRACEPTIVES,ORAL Bekyree 28 Day Tablet 1CONTRACEPTIVES,ORAL Blisovi 24 Fe Tablet 1CONTRACEPTIVES,ORAL Blisovi Fe 1.5-30 Tablet 1CONTRACEPTIVES,ORAL Blisovi Fe 1-20 Tablet 1CONTRACEPTIVES,ORAL Briellyn Tablet 1CONTRACEPTIVES,ORAL Camila 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Camrese 0.15-0.03-0.01 Mg Tab 1CONTRACEPTIVES,ORAL Camrese Lo Tablet 1CONTRACEPTIVES,ORAL Caziant 28 Day Tablet 1CONTRACEPTIVES,ORAL Chateal Eq-28 Tablet 1CONTRACEPTIVES,ORAL Chateal-28 Tablet 1CONTRACEPTIVES,ORAL Cryselle-28 Tablet 1CONTRACEPTIVES,ORAL Cyclafem 1-35-28 Tablet 1CONTRACEPTIVES,ORAL Cyclafem 7-7-7-28 Tablet 1CONTRACEPTIVES,ORAL Cyred 28 Day Tablet 1CONTRACEPTIVES,ORAL Cyred Eq 28 Day Tablet 1CONTRACEPTIVES,ORAL Dasetta 1-35-28 Tablet 1CONTRACEPTIVES,ORAL Dasetta 7/7/7-28 Tablet 1CONTRACEPTIVES,ORAL Daysee 0.15-0.03-0.01 Mg Tab 1CONTRACEPTIVES,ORAL Deblitane 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Delyla-28 Tablet 1CONTRACEPTIVES,ORAL Desogest-eth Estra 0.15-0.03mg 1CONTRACEPTIVES,ORAL Desogestr-eth Estrad Eth Estra 1CONTRACEPTIVES,ORAL Drosp-ee-levomef 3-0.02-0.451 1CONTRACEPTIVES,ORAL Drosp-ee-levomef 3-0.03-0.451 1CONTRACEPTIVES,ORAL Drospirenone-ee 3-0.02 Mg Tab 1CONTRACEPTIVES,ORAL Drospirenone-ee 3-0.03 Mg Tab 1CONTRACEPTIVES,ORAL Elinest-28 Tablet 1CONTRACEPTIVES,ORAL Emoquette 28 Day Tablet 1CONTRACEPTIVES,ORAL Enpresse-28 Tablet 1CONTRACEPTIVES,ORAL Enskyce 28 Tablet 1CONTRACEPTIVES,ORAL Errin 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Estarylla 0.25-0.035 Mg Tablet 1CONTRACEPTIVES,ORAL Ethynodiol-eth Estra 1mg-35mcg 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 41: 2021 Rx Select - PRAM

CONTRACEPTIVES,ORAL Ethynodiol-eth Estra 1mg-50mcg 1CONTRACEPTIVES,ORAL Falmina-28 Tablet 1CONTRACEPTIVES,ORAL Fayosim Tablet 1CONTRACEPTIVES,ORAL Femynor 28 Tablet 1CONTRACEPTIVES,ORAL Gianvi 3 Mg-0.02 Mg Tablet 1CONTRACEPTIVES,ORAL Hailey 21 1.5 Mg-30 Mcg Tab 1CONTRACEPTIVES,ORAL Hailey 24 Fe 1 Mg-20 Mcg Tab 1CONTRACEPTIVES,ORAL Heather 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Incassia 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Introvale 0.15-0.03 Mg Tablet 1CONTRACEPTIVES,ORAL Isibloom 28 Day Tablet 1CONTRACEPTIVES,ORAL Jasmiel 3 Mg-0.02 Mg Tablet 1CONTRACEPTIVES,ORAL Jencycla 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Jolessa 0.15 Mg-0.03 Mg Tablet 1CONTRACEPTIVES,ORAL Juleber 28 Day Tablet 1CONTRACEPTIVES,ORAL Junel 1 Mg-20 Mcg Tablet 1CONTRACEPTIVES,ORAL Junel 1.5 Mg-30 Mcg Tablet 1CONTRACEPTIVES,ORAL Junel Fe 1 Mg-20 Mcg Tablet 1CONTRACEPTIVES,ORAL Junel Fe 1.5 Mg-30 Mcg Tablet 1CONTRACEPTIVES,ORAL Junel Fe 24 Tablet 1CONTRACEPTIVES,ORAL Kaitlib Fe Chewable Tablet 1CONTRACEPTIVES,ORAL Kalliga 28 Day Tablet 1CONTRACEPTIVES,ORAL Kariva 28 Day Tablet 1CONTRACEPTIVES,ORAL Kelnor 1-35 28 Tablet 1CONTRACEPTIVES,ORAL Kelnor 1-50 Tablet 1CONTRACEPTIVES,ORAL Kurvelo Tablet 1CONTRACEPTIVES,ORAL Larin 1.5 Mg-30 Mcg Tablet 1CONTRACEPTIVES,ORAL Larin 21 1-20 Tablet 1CONTRACEPTIVES,ORAL Larin 24 Fe 1 Mg-20 Mcg Tablet 1CONTRACEPTIVES,ORAL Larin Fe 1.5-30 Tablet 1CONTRACEPTIVES,ORAL Larin Fe 1-20 Tablet 1CONTRACEPTIVES,ORAL Larissia-28 Tablet 1CONTRACEPTIVES,ORAL Leena 28 Tablet 1CONTRACEPTIVES,ORAL Lessina-28 Tablet 1CONTRACEPTIVES,ORAL Levonest-28 Tablet 1CONTRACEPTIVES,ORAL Levono-e Estrad 0.10-0.02-0.01 1CONTRACEPTIVES,ORAL Levono-e Estrad 0.15-0.03-0.01 1CONTRACEPTIVES,ORAL Levonor-eth Estra 0.09-0.02 Mg 1CONTRACEPTIVES,ORAL Levonor-eth Estrad 0.1-0.02 Mg 1CONTRACEPTIVES,ORAL Levonor-eth Estrad 0.15-0.03 1CONTRACEPTIVES,ORAL Levonor-eth Estrad Triphasic 1CONTRACEPTIVES,ORAL Levonorg 0.15mg-ee 20-25-30mcg 1CONTRACEPTIVES,ORAL Levonorgestrel 1.5 Mg Tablet 1CONTRACEPTIVES,ORAL Levora-28 Tablet 1CONTRACEPTIVES,ORAL Lillow-28 Tablet 1CONTRACEPTIVES,ORAL Lo Loestrin Fe 1-10 Tablet 2CONTRACEPTIVES,ORAL Loryna 3 Mg-0.02 Mg Tablet 1CONTRACEPTIVES,ORAL Low-ogestrel-28 Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 42: 2021 Rx Select - PRAM

CONTRACEPTIVES,ORAL Lo-zumandimine 3 Mg-0.02 Mg Tb 1CONTRACEPTIVES,ORAL Lutera-28 Tablet 1CONTRACEPTIVES,ORAL Lyza 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Marlissa-28 Tablet 1CONTRACEPTIVES,ORAL Melodetta 24 Fe Chewable Tab 1CONTRACEPTIVES,ORAL Mibelas 24 Fe Chewable Tablet 1CONTRACEPTIVES,ORAL Microgestin 21 1.5-30 Tab 1CONTRACEPTIVES,ORAL Microgestin 21 1-20 Tablet 1CONTRACEPTIVES,ORAL Microgestin Fe 1.5-30 Tab 1CONTRACEPTIVES,ORAL Microgestin Fe 1-20 Tablet 1CONTRACEPTIVES,ORAL Mili 0.25-0.035 Mg Tablet 1CONTRACEPTIVES,ORAL Mono-linyah 28 Tablet 1CONTRACEPTIVES,ORAL Necon 0.5-35-28 Tablet 1CONTRACEPTIVES,ORAL Nikki 3 Mg-0.02 Mg Tablet 1CONTRACEPTIVES,ORAL Nora-be Tablet 1CONTRACEPTIVES,ORAL Noret-estr-fe 0.4-0.035(21)-75 1CONTRACEPTIVES,ORAL Noreth-estrad-fe 1-0.02(21)-75 1CONTRACEPTIVES,ORAL Noreth-estrad-fe 1-0.02(24)-75 1CONTRACEPTIVES,ORAL Norethind-eth Estrad 1-0.02 Mg 1CONTRACEPTIVES,ORAL Norethindrone 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Norethin-estra-fe 0.8-0.025 Mg 1CONTRACEPTIVES,ORAL Norg-ee 0.18-0.215-0.25/0.025 1CONTRACEPTIVES,ORAL Norg-ee 0.18-0.215-0.25/0.035 1CONTRACEPTIVES,ORAL Norg-ethin Estr 0.5-0.05 Mg Tb 2CONTRACEPTIVES,ORAL Norg-ethin Estra 0.25-0.035 Mg 1CONTRACEPTIVES,ORAL Norlyda 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Norlyroc 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Nortrel 0.5-35-28 Tablet 1CONTRACEPTIVES,ORAL Nortrel 1-35 21 Tablet 1CONTRACEPTIVES,ORAL Nortrel 1-35 28 Tablet 1CONTRACEPTIVES,ORAL Nortrel 7-7-7-28 Tablet 1CONTRACEPTIVES,ORAL Ocella 3 Mg-0.03 Mg Tablet 1CONTRACEPTIVES,ORAL Ogestrel Tablet 2CONTRACEPTIVES,ORAL Orsythia-28 Tablet 1CONTRACEPTIVES,ORAL Philith 0.4-0.035 Mg Tablet 1CONTRACEPTIVES,ORAL Pimtrea 28 Day Tablet 1CONTRACEPTIVES,ORAL Pirmella 1-35-28 Tablet 1CONTRACEPTIVES,ORAL Pirmella 7-7-7-28 Tablet 1CONTRACEPTIVES,ORAL Portia-28 Tablet 1CONTRACEPTIVES,ORAL Previfem Tablet 1CONTRACEPTIVES,ORAL Reclipsen 28 Day Tablet 1CONTRACEPTIVES,ORAL Rivelsa Tablet 1CONTRACEPTIVES,ORAL Setlakin 0.15 Mg-0.03 Mg Tab 1CONTRACEPTIVES,ORAL Sharobel 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Simliya 28 Day Tablet 1CONTRACEPTIVES,ORAL Simpesse 0.15-0.03-0.01 Mg Tab 1CONTRACEPTIVES,ORAL Sprintec 28 Day Tablet 1CONTRACEPTIVES,ORAL Sronyx 0.10-0.02 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 43: 2021 Rx Select - PRAM

CONTRACEPTIVES,ORAL Syeda 28 Tablet 1CONTRACEPTIVES,ORAL Tarina 24 Fe 1 Mg-20 Mcg Tab 1CONTRACEPTIVES,ORAL Tarina Fe 1-20 Eq Tablet 1CONTRACEPTIVES,ORAL Tarina Fe 1-20 Tablet 1CONTRACEPTIVES,ORAL Taytulla 1 Mg-20 Mcg Capsule 2CONTRACEPTIVES,ORAL Tilia Fe 28 Tablet 1CONTRACEPTIVES,ORAL Tri Femynor 28 Tablet 1CONTRACEPTIVES,ORAL Tri-estarylla Tablet 1CONTRACEPTIVES,ORAL Tri-legest Fe-28 Day Tablet 1CONTRACEPTIVES,ORAL Tri-linyah Tablet 1CONTRACEPTIVES,ORAL Tri-lo-estarylla Tablet 1CONTRACEPTIVES,ORAL Tri-lo-marzia Tablet 1CONTRACEPTIVES,ORAL Tri-lo-mili Tablet 1CONTRACEPTIVES,ORAL Tri-lo-sprintec Tablet 1CONTRACEPTIVES,ORAL Tri-mili 28 Tablet 1CONTRACEPTIVES,ORAL Tri-previfem Tablet 1CONTRACEPTIVES,ORAL Tri-sprintec Tablet 1CONTRACEPTIVES,ORAL Trivora-28 Tablet 1CONTRACEPTIVES,ORAL Tri-vylibra 28 Tablet 1CONTRACEPTIVES,ORAL Tri-vylibra Lo Tablet 1CONTRACEPTIVES,ORAL Tulana 0.35 Mg Tablet 1CONTRACEPTIVES,ORAL Tydemy Tablet 1CONTRACEPTIVES,ORAL Velivet 28 Day Tablet 1CONTRACEPTIVES,ORAL Vienva-28 Tablet 1CONTRACEPTIVES,ORAL Viorele 28 Day Tablet 1CONTRACEPTIVES,ORAL Vyfemla 28 Tablet 1CONTRACEPTIVES,ORAL Vylibra 28 Tablet 1CONTRACEPTIVES,ORAL Wera 0.5/0.035 Mg 28 Tablet 1CONTRACEPTIVES,ORAL Wymzya Fe Chewable Tablet 1CONTRACEPTIVES,ORAL Zarah Tablet 1CONTRACEPTIVES,ORAL Zovia 1-35e Tablet 1CONTRACEPTIVES,ORAL Zumandimine 3 Mg-0.03 Mg Tab 1CONTRACEPTIVES,TRANSDERMAL Xulane Patch 1CRYOPRESERVATIVE AGENTS Cryoserv Solution 2CYSTIC FIBROSIS-CFTR POTENTIATOR-CORRECTOR COMBIN. Orkambi 100 Mg-125 Mg Tablet 2CYSTIC FIBROSIS-CFTR POTENTIATOR-CORRECTOR COMBIN. Orkambi 200 Mg-125 Mg Tablet 2CYSTIC FIBROSIS-CFTR POTENTIATOR-CORRECTOR COMBIN. Symdeko 100/150 Mg-150 Mg Tabs 2CYSTIC FIB-TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR Kalydeco 150 Mg Tablet 2CYSTIC FIB-TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR Kalydeco 50 Mg Granules Packet 2CYSTIC FIB-TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR Kalydeco 75 Mg Granules Packet 2CYSTINE-DEPLETING AGENTS, NEPHROPATHIC CYSTINOSIS Cystagon 150 Mg Capsule 2CYSTINE-DEPLETING AGENTS, NEPHROPATHIC CYSTINOSIS Cystagon 50 Mg Capsule 2DECARBOXYLASE INHIBITORS Carbidopa 25 Mg Tablet 1DECARBOXYLASE INHIBITORS Lodosyn 25 Mg Tablet 1DENTAL AIDS AND PREPARATIONS Chlorhexidine 0.12% Rinse 1DENTAL AIDS AND PREPARATIONS Oralone 0.1% Paste 1DENTAL AIDS AND PREPARATIONS Paroex 0.12% Oral Rinse 1DENTAL AIDS AND PREPARATIONS Periogard 0.12% Oral Rinse 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 44: 2021 Rx Select - PRAM

DENTAL AIDS AND PREPARATIONS Triamcinolone 0.1% Paste 1DIABETIC SUPPLIES Lancing Device 2DIABETIC ULCER PREPARATIONS,TOPICAL Regranex 0.01% Gel 2DIAGNOSTIC PREPARATIONS,MISCELLANEOUS Adv Dna Medicated Cllct Kt Iii 2DIAGNOSTIC PREPARATIONS,MISCELLANEOUS Adv Dna Medicated Collct Kt Ii 2DIAGNOSTIC PREPARATIONS,MISCELLANEOUS Adv Dna Medicated Collect Kit 2DIAGNOSTIC PREPARATIONS,MISCELLANEOUS Toxicology Saliva Collect Kit 1DIALYSIS SOLUTIONS Phoxillum Bk4/2.5 Solution Bag 2DIALYSIS SOLUTIONS Prismasol Bgk 2/0 Dialysis 2DIALYSIS SOLUTIONS Prismasol Bgk 2/3.5 Dialysis 2DIGITALIS GLYCOSIDES Digitek 125 Mcg Tablet 1DIGITALIS GLYCOSIDES Digitek 250 Mcg Tablet 1DIGITALIS GLYCOSIDES Digox 125 Mcg Tablet 1DIGITALIS GLYCOSIDES Digox 250 Mcg Tablet 1DIGITALIS GLYCOSIDES Digoxin 0.05 Mg/Ml Solution 1DIGITALIS GLYCOSIDES Digoxin 0.125 Mg Tablet 1DIGITALIS GLYCOSIDES Digoxin 0.125 Mg/2.5 Ml Soln 1DIGITALIS GLYCOSIDES Digoxin 0.25 Mg Tablet 1DIGITALIS GLYCOSIDES Digoxin 125 Mcg Tablet 1DIGITALIS GLYCOSIDES Digoxin 250 Mcg Tablet 1DIRECT FACTOR XA INHIBITORS Bevyxxa 40 Mg Capsule 2DIRECT FACTOR XA INHIBITORS Bevyxxa 80 Mg Capsule 2DIRECT FACTOR XA INHIBITORS Eliquis 2.5 Mg Tablet 2DIRECT FACTOR XA INHIBITORS Eliquis 5 Mg Starter Pack 2DIRECT FACTOR XA INHIBITORS Eliquis 5 Mg Tablet 2DIRECT FACTOR XA INHIBITORS Xarelto 10 Mg Tablet 2DIRECT FACTOR XA INHIBITORS Xarelto 15 Mg Tablet 2DIRECT FACTOR XA INHIBITORS Xarelto 20 Mg Tablet 2DIRECT FACTOR XA INHIBITORS Xarelto Starter Pack 2DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Apriso Er 0.375 Gram Capsule 2DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Balsalazide Disodium 750 Mg Cp 1DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Delzicol Dr 400 Mg Capsule 2DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Mesalamine 800 Mg Dr Tablet 1DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Mesalamine Dr 1.2 Gm Tablet 1DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Mesalamine Dr 400 Mg Capsule 1DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Pentasa 250 Mg Capsule 2DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Pentasa 500 Mg Capsule 2DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Sulfasalazine 500 Mg Tablet 1DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT Sulfasalazine Dr 500 Mg Tab 1DRUGS TO TREAT HEREDITARY TYROSINEMIA Nitisinone 10 Mg Capsule 1DRUGS TO TREAT HEREDITARY TYROSINEMIA Nitisinone 2 Mg Capsule 1DRUGS TO TREAT HEREDITARY TYROSINEMIA Nitisinone 5 Mg Capsule 1DRUGS TO TREAT HEREDITARY TYROSINEMIA Orfadin 10 Mg Capsule 2DRUGS TO TREAT HEREDITARY TYROSINEMIA Orfadin 2 Mg Capsule 2DRUGS TO TREAT HEREDITARY TYROSINEMIA Orfadin 20 Mg Capsule 2DRUGS TO TREAT HEREDITARY TYROSINEMIA Orfadin 4 Mg/Ml Suspension 2DRUGS TO TREAT HEREDITARY TYROSINEMIA Orfadin 5 Mg Capsule 2DRUGS TO TREAT MOVEMENT DISORDERS Ingrezza 40 Mg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 45: 2021 Rx Select - PRAM

DRUGS TO TREAT MOVEMENT DISORDERS Ingrezza 80 Mg Capsule 2DRUGS TO TREAT MOVEMENT DISORDERS Tetrabenazine 12.5 Mg Tablet 1DRUGS TO TREAT MOVEMENT DISORDERS Tetrabenazine 25 Mg Tablet 1DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING Cerdelga 84 Mg Capsule 2DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING Miglustat 100 Mg Capsule 1EAR PREPARATIONS ANTI-INFLAMMATORY Flac Otic Oil 0.01% Ear Drop 1EAR PREPARATIONS ANTI-INFLAMMATORY Fluocinolone Oil 0.01% Ear Drp 1EAR PREPARATIONS, MISC. ANTI-INFECTIVES Acetic Acid 2% Ear Solution 1EAR PREPARATIONS, MISC. ANTI-INFECTIVES Hydrocortison-acetic Acid Soln 1EAR PREPARATIONS,ANTIBIOTICS Ciprofloxacin 0.2% Otic Soln 1EAR PREPARATIONS,ANTIBIOTICS Neomycin-polymyxin-hc Ear Soln 1EAR PREPARATIONS,ANTIBIOTICS Neomycin-polymyxin-hc Ear Susp 1EAR PREPARATIONS,ANTIBIOTICS Ofloxacin 0.3% Ear Drops 1EAR PREPARATIONS,ANTIBIOTICS Otiprio 6% Vial 2ELECTROLYTE DEPLETERS Calcium Acetate 667 Mg Capsule 1ELECTROLYTE DEPLETERS Calcium Acetate 667 Mg Gelcap 1ELECTROLYTE DEPLETERS Calcium Acetate 667 Mg Tablet 1ELECTROLYTE DEPLETERS Calcium Acetate 668 Mg Tablet 1ELECTROLYTE DEPLETERS Lanthanum Carb 1,000 Mg Tb Chw 1ELECTROLYTE DEPLETERS Lanthanum Carb 500 Mg Tab Chew 1ELECTROLYTE DEPLETERS Lanthanum Carb 750 Mg Tab Chew 1ELECTROLYTE DEPLETERS Phoslyra 667 Mg/5 Ml Solution 2ELECTROLYTE DEPLETERS Renvela 800 Mg Tablet 2ELECTROLYTE DEPLETERS Sevelamer 0.8 Gm Powder Packet 1ELECTROLYTE DEPLETERS Sevelamer 2.4 Gm Powder Packet 1ELECTROLYTE DEPLETERS Sevelamer Carbonate 800 Mg Tab 1ELECTROLYTE DEPLETERS Sevelamer Hcl 400 Mg Tablet 1ELECTROLYTE DEPLETERS Sevelamer Hcl 800 Mg Tablet 1ELECTROLYTE DEPLETERS Sodium Polystyrene Sulf Powder 1ELECTROLYTE DEPLETERS Sps 15 Gm/60 Ml Suspension 1ELECTROLYTE DEPLETERS Sps 30 Gm/120 Ml Enema 1ELECTROLYTE DEPLETERS Sps 50 Gm/200 Ml Enema 1ELECTROLYTE DEPLETERS Veltassa 16.8 Gm Powder Packet 2ELECTROLYTE DEPLETERS Veltassa 25.2 Gm Powder Packet 2ELECTROLYTE DEPLETERS Veltassa 8.4 Gm Powder Packet 2EMOLLIENTS Ammonium Lactate 12% Cream 1EMOLLIENTS Atopaderm Cream 2EMOLLIENTS Atopiclair Cream 2EMOLLIENTS Avo Cream Topical Emulsion 3EMOLLIENTS Ceramax Skin Barrier Cream 1EMOLLIENTS Dexeryl Cream 2EMOLLIENTS Eletone Cream 2EMOLLIENTS Eletone Cream Twin Pack 2EMOLLIENTS Emulsion Sb Topical Emulsion 3EMOLLIENTS Emulsion Sb Topical Twin Pack 3EMOLLIENTS Hpr Emollient Foam 3EMOLLIENTS Hpr Plus Cream 2EMOLLIENTS Hpr Plus Emollient Foam 3

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 46: 2021 Rx Select - PRAM

EMOLLIENTS Hpr Plus Hydrogel Kit 3EMOLLIENTS Hpr Plus-mb Hydrogel Kit 1EMOLLIENTS Hylatopicplus Cream 2EMOLLIENTS Mb Hydrogel Kit 3EMOLLIENTS Mimyx Cream 2EMOLLIENTS Neocera Advanced Cream 2EMOLLIENTS Neosalus Cp Cream 2EMOLLIENTS Neosalus Cream 2EMOLLIENTS Nivatopic Plus Cream 2EMOLLIENTS Penlen Spray Emulsion 1EMOLLIENTS Pruclair Nonsteroidal Cream 2EMOLLIENTS Prumyx Cream 2EMOLLIENTS Prutect Topical Emulsion 3EMOLLIENTS Sebuderm Gel 1EMOLLIENTS Sonafine Topical Emulsion 3ENTERIC VIRUS VACCINES Rotarix Vaccine Suspension 2ESTROGEN/ANDROGEN COMBINATIONS Covaryx H.s. Tablet 1ESTROGEN/ANDROGEN COMBINATIONS Covaryx Tablet 1ESTROGEN/ANDROGEN COMBINATIONS Eemt Ds 1.25-2.5 Mg Tablet 1ESTROGEN/ANDROGEN COMBINATIONS Eemt Hs 0.625-1.25 Mg Tablet 1ESTROGEN/ANDROGEN COMBINATIONS Estrogen-methyltestos F.s. Tab 1ESTROGEN/ANDROGEN COMBINATIONS Estrogen-methyltestos H.s. Tab 1ESTROGENIC AGENTS Amabelz 0.5 Mg-0.1 Mg Tablet 1ESTROGENIC AGENTS Amabelz 1 Mg-0.5 Mg Tablet 1ESTROGENIC AGENTS Combipatch 0.05-0.14 Mg Ptch 2ESTROGENIC AGENTS Combipatch 0.05-0.25 Mg Ptch 2ESTROGENIC AGENTS Divigel 0.25 Mg Gel Packet 2ESTROGENIC AGENTS Divigel 0.5 Mg Gel Packet 2ESTROGENIC AGENTS Divigel 0.75 Mg Gel Packet 2ESTROGENIC AGENTS Divigel 1 Mg Gel Packet 2ESTROGENIC AGENTS Dotti 0.025 Mg Patch 1ESTROGENIC AGENTS Dotti 0.0375 Mg Patch 1ESTROGENIC AGENTS Dotti 0.05 Mg Patch 1ESTROGENIC AGENTS Dotti 0.075 Mg Patch 1ESTROGENIC AGENTS Dotti 0.1 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.025 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.0375 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.0375 Mg/Day Patch 1ESTROGENIC AGENTS Estradiol 0.05 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.06 Mg/Day Patch 1ESTROGENIC AGENTS Estradiol 0.075 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.075 Mg/Day Patch 1ESTROGENIC AGENTS Estradiol 0.1 Mg Patch 1ESTROGENIC AGENTS Estradiol 0.5 Mg Tablet 1ESTROGENIC AGENTS Estradiol 1 Mg Tablet 1ESTROGENIC AGENTS Estradiol 2 Mg Tablet 1ESTROGENIC AGENTS Estradiol Tds 0.025 Mg/Day 1ESTROGENIC AGENTS Estradiol Tds 0.0375 Mg/Day 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 47: 2021 Rx Select - PRAM

ESTROGENIC AGENTS Estradiol Tds 0.05 Mg/Day 1ESTROGENIC AGENTS Estradiol Tds 0.06 Mg/Day 1ESTROGENIC AGENTS Estradiol Tds 0.075 Mg/Day 1ESTROGENIC AGENTS Estradiol Tds 0.1 Mg/Day 1ESTROGENIC AGENTS Estradiol-noreth 0.5-0.1 Mg Tb 1ESTROGENIC AGENTS Estradiol-noreth 1-0.5 Mg Tab 1ESTROGENIC AGENTS Fyavolv 0.5 Mg-2.5 Mcg Tablet 1ESTROGENIC AGENTS Fyavolv 1 Mg-5 Mcg Tablet 1ESTROGENIC AGENTS Jinteli 1 Mg-5 Mcg Tablet 1ESTROGENIC AGENTS Lopreeza 0.5 Mg-0.1 Mg Tablet 1ESTROGENIC AGENTS Lopreeza 1 Mg-0.5 Mg Tablet 1ESTROGENIC AGENTS Mimvey 1-0.5 Mg Tablet 1ESTROGENIC AGENTS Mimvey Lo 0.5-0.1 Mg Tablet 1ESTROGENIC AGENTS Minivelle 0.025 Mg Patch 2ESTROGENIC AGENTS Minivelle 0.0375 Mg Patch 2ESTROGENIC AGENTS Minivelle 0.05 Mg Patch 2ESTROGENIC AGENTS Minivelle 0.075 Mg Patch 2ESTROGENIC AGENTS Minivelle 0.1 Mg Patch 2ESTROGENIC AGENTS Norethind-eth Estrad 0.5-2.5 1ESTROGENIC AGENTS Norethin-eth Estrad 1 Mg-5 Mcg 1ESTROGENIC AGENTS Premarin 0.3 Mg Tablet 2ESTROGENIC AGENTS Premarin 0.45 Mg Tablet 2ESTROGENIC AGENTS Premarin 0.625 Mg Tablet 2ESTROGENIC AGENTS Premarin 0.9 Mg Tablet 2ESTROGENIC AGENTS Premarin 1.25 Mg Tablet 2ESTROGENIC AGENTS Premphase 0.625-5 Mg Tablet 2ESTROGENIC AGENTS Prempro 0.3 Mg-1.5 Mg Tablet 2ESTROGENIC AGENTS Prempro 0.45-1.5 Mg Tablet 2ESTROGENIC AGENTS Prempro 0.625-2.5 Mg Tablet 2ESTROGENIC AGENTS Prempro 0.625-5 Mg Tablet 2ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MOD(SERM)COMB Duavee 0.45-20 Mg Tablet 2EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Gatifloxacin 0.5%-dexamet 0.1% 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Neo-bacit-poly-hc Eye Ointment 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Neomycin-poly-hc Eye Drops 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Neomyc-polym-dexamet Eye Ointm 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Neomyc-polym-dexameth Eye Drop 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Neo-polycin Hc Eye Ointment 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Prednisolone Acet 1%-gati 0.5% 3EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Prednisolone Acet 1%-moxi 0.5% 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Prednisolone Phos 1%-gati 0.5% 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Tobradex Eye Drops 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Tobradex Eye Ointment 2EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Tobradex St Eye Drops 2EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Tobramycin-dexameth Ophth Susp 1EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS Zylet Eye Drops 2EYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB. Pred Ac-gati-brom 1-0.5-0.075% 3EYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB. Pred Ac-moxi-nepaf 1-0.5-0.1% 1EYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB. Pred Ph-gati-brom 1-0.5-0.075% 3

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 48: 2021 Rx Select - PRAM

EYE ANTIHISTAMINES Azelastine Hcl 0.05% Drops 1EYE ANTIHISTAMINES Bepreve 1.5% Eye Drops 2EYE ANTIHISTAMINES Epinastine Hcl 0.05% Eye Drops 1EYE ANTIHISTAMINES Olopatadine Hcl 0.1% Eye Drops 1EYE ANTIHISTAMINES Olopatadine Hcl 0.2% Eye Drop 1EYE ANTIHISTAMINES Pazeo 0.7% Eye Drops 2EYE ANTI-INFLAMMATORY AGENTS Alrex 0.2% Eye Drops 2EYE ANTI-INFLAMMATORY AGENTS Bromfenac Sodium 0.09% Eye Drp 1EYE ANTI-INFLAMMATORY AGENTS Dexamethasone 0.1% Eye Drop 1EYE ANTI-INFLAMMATORY AGENTS Diclofenac 0.1% Eye Drops 1EYE ANTI-INFLAMMATORY AGENTS Durezol 0.05% Eye Drops 2EYE ANTI-INFLAMMATORY AGENTS Fluorometholone 0.1% Drops 1EYE ANTI-INFLAMMATORY AGENTS Flurbiprofen 0.03% Eye Drop 1EYE ANTI-INFLAMMATORY AGENTS Ilevro 0.3% Ophth Drops 2EYE ANTI-INFLAMMATORY AGENTS Ketorolac 0.4% Ophth Solution 1EYE ANTI-INFLAMMATORY AGENTS Ketorolac 0.5% Ophth Solution 1EYE ANTI-INFLAMMATORY AGENTS Lotemax 0.5% Eye Drops 2EYE ANTI-INFLAMMATORY AGENTS Lotemax 0.5% Eye Ointment 2EYE ANTI-INFLAMMATORY AGENTS Lotemax 0.5% Ophthalmic Gel 2EYE ANTI-INFLAMMATORY AGENTS Loteprednol Etabonate 0.5% Drp 1EYE ANTI-INFLAMMATORY AGENTS Nevanac 0.1% Droptainer 2EYE ANTI-INFLAMMATORY AGENTS Prednisolone 1%-bromfen 0.075% 3EYE ANTI-INFLAMMATORY AGENTS Prednisolone 1%-nepafenac 0.1% 1EYE ANTI-INFLAMMATORY AGENTS Prednisolone Ac 1% Eye Drop 1EYE ANTI-INFLAMMATORY AGENTS Prednisolone Acet 1% Eye Drop 1EYE ANTI-INFLAMMATORY AGENTS Prednisolone Ph 1%-brom 0.075% 1EYE ANTI-INFLAMMATORY AGENTS Prednisolone Sod 1% Eye Drop 1EYE ANTI-INFLAMMATORY AGENTS Prolensa 0.07% Eye Drops 2EYE ANTIVIRALS Trifluridine 1% Eye Drops 1EYE ANTIVIRALS Zirgan 0.15% Ophthalmic Gel 2EYE DIAGNOSTIC AGENTS Ful-glo 1 Mg Opth Strip 1EYE DIAGNOSTIC AGENTS Glostrips 1 Mg Ophth Strip 1EYE DIAGNOSTIC AGENTS Green Glo 1.5 Mg Strips 1EYE LOCAL ANESTHETICS Altacaine 0.5% Eye Drop 1EYE LOCAL ANESTHETICS Flucaine Eye Drops 1EYE LOCAL ANESTHETICS Fluorescein-proparacaine Drops 1EYE LOCAL ANESTHETICS Proparacaine 0.5% Eye Drops 1EYE LOCAL ANESTHETICS Tetcaine 0.5% Eye Drop 1EYE LOCAL ANESTHETICS Tetracaine 0.5% Eye Drop 1EYE LOCAL ANESTHETICS Tetracaine 0.5% Steri-unit Sol 1EYE LOCAL ANESTHETICS Tetravisc 0.5% Eye Drops 1EYE LOCAL ANESTHETICS Tetravisc Forte 0.5% Eye Drops 1EYE MAST CELL STABILIZERS Cromolyn 4% Eye Drops 1EYE SULFONAMIDES Sulfacetamide 10% Eye Drops 1EYE SULFONAMIDES Sulfacetamide 10% Eye Ointment 1EYE SULFONAMIDES Sulf-pred 10-0.23% Eye Drops 1EYE VASOCONSTRICTORS Phenylephrine 10% Eye Drops 1EYE VASOCONSTRICTORS Phenylephrine 2.5% Eye Drop 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 49: 2021 Rx Select - PRAM

FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG Ocaliva 10 Mg Tablet 2FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG Ocaliva 5 Mg Tablet 2FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB Savella 100 Mg Tablet 2FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB Savella 12.5 Mg Tablet 2FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB Savella 25 Mg Tablet 2FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB Savella 50 Mg Tablet 2FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB Savella Titration Pack 2FLUORESCENCE IMAGING AGENTS - MALIGNANT TISSUE Gleolan 1,500 Mg/50 Ml Soln 2GASTRIC ENZYMES Sucraid 8,500 Units/Ml Soln 2GASTROINTESTINAL RADIOPAQUE DIAGNOSTICS E-z Disk 700 Mg Tablet 2GENERAL ANESTHETICS,INHALANT Desflurane Inhalation Liquid 1GENERAL ANESTHETICS,INHALANT Isoflurane Liquid 1GENERAL ANESTHETICS,INHALANT Sevoflurane Inhalation Liquid 1GENERAL ANESTHETICS,INHALANT Terrell Liquid 1GENERAL INHALATION AGENTS Hyper-sal 3.5% Vial 2GENERAL INHALATION AGENTS Pulmosal 7% Vial 1GENERAL INHALATION AGENTS Sodium Chloride 10% Vial 1GENERAL INHALATION AGENTS Sodium Chloride 3% Vial 1GENERAL INHALATION AGENTS Sodium Chloride 7% Vial 1GLUCOCORTICOIDS Betaloan Suik Kit 2GLUCOCORTICOIDS Budesonide Ec 3 Mg Capsule 1GLUCOCORTICOIDS Budesonide Er 9 Mg Tablet 1GLUCOCORTICOIDS Cortisone 25 Mg Tablet 1GLUCOCORTICOIDS Decadron 0.5 Mg Tablet 1GLUCOCORTICOIDS Decadron 0.5 Mg/5 Ml Elixir 1GLUCOCORTICOIDS Decadron 0.75 Mg Tablet 1GLUCOCORTICOIDS Decadron 4 Mg Tablet 1GLUCOCORTICOIDS Decadron 6 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 0.5 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 0.5 Mg/5 Ml Elx 1GLUCOCORTICOIDS Dexamethasone 0.5 Mg/5 Ml Liq 1GLUCOCORTICOIDS Dexamethasone 0.75 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 1 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 1.5 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 10 Day 1.5 Mg Tb 1GLUCOCORTICOIDS Dexamethasone 10 Mg/50 Ml-ns 1GLUCOCORTICOIDS Dexamethasone 13 Day 1.5 Mg Tb 1GLUCOCORTICOIDS Dexamethasone 2 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 4 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone 6 Day 1.5 Mg Tab 1GLUCOCORTICOIDS Dexamethasone 6 Mg Tablet 1GLUCOCORTICOIDS Dexamethasone Intensol 1 Mg/Ml 1GLUCOCORTICOIDS Dexonto 0.4% Solution 2GLUCOCORTICOIDS Dexpak 10 Day 1.5 Mg Tablet 1GLUCOCORTICOIDS Dexpak 13 Day 1.5 Mg Tablet 1GLUCOCORTICOIDS Dexpak 6 Day 1.5 Mg Tablet 1GLUCOCORTICOIDS Dmt Suik Kit 2GLUCOCORTICOIDS Hidex 6 Day 1.5 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 50: 2021 Rx Select - PRAM

GLUCOCORTICOIDS Hydrocortisone 10 Mg Tablet 1GLUCOCORTICOIDS Hydrocortisone 20 Mg Tablet 1GLUCOCORTICOIDS Hydrocortisone 5 Mg Tablet 1GLUCOCORTICOIDS Medrol 2 Mg Tablet 2GLUCOCORTICOIDS Medroloan Ii Suik Kit 2GLUCOCORTICOIDS Medroloan Suik Kit 2GLUCOCORTICOIDS Methylpred Dp 4 Mg Dosepak 1GLUCOCORTICOIDS Methylprednisolone 16 Mg Tab 1GLUCOCORTICOIDS Methylprednisolone 32 Mg Tab 1GLUCOCORTICOIDS Methylprednisolone 4 Mg Dosepk 1GLUCOCORTICOIDS Methylprednisolone 4 Mg Tablet 1GLUCOCORTICOIDS Methylprednisolone 8 Mg Tab 1GLUCOCORTICOIDS Millipred 5 Mg Tablet 1GLUCOCORTICOIDS Millipred Dp 5 Mg 12-day Pack 1GLUCOCORTICOIDS Millipred Dp 5 Mg 6-day Pack 1GLUCOCORTICOIDS Prednisolone 10 Mg/5 Ml Soln 1GLUCOCORTICOIDS Prednisolone 15 Mg/5 Ml Soln 1GLUCOCORTICOIDS Prednisolone 15 Mg/5 Ml Syrup 1GLUCOCORTICOIDS Prednisolone 20 Mg/5 Ml Soln 1GLUCOCORTICOIDS Prednisolone 5 Mg/5 Ml Soln 1GLUCOCORTICOIDS Prednisolone Odt 10 Mg Tablet 1GLUCOCORTICOIDS Prednisolone Odt 15 Mg Tablet 1GLUCOCORTICOIDS Prednisolone Odt 30 Mg Tablet 1GLUCOCORTICOIDS Prednisolone Sod Ph 25 Mg/5 Ml 1GLUCOCORTICOIDS Prednisone 1 Mg Tablet 1GLUCOCORTICOIDS Prednisone 10 Mg Tab Dose Pack 1GLUCOCORTICOIDS Prednisone 10 Mg Tablet 1GLUCOCORTICOIDS Prednisone 2.5 Mg Tablet 1GLUCOCORTICOIDS Prednisone 20 Mg Tablet 1GLUCOCORTICOIDS Prednisone 5 Mg Tab Dose Pack 1GLUCOCORTICOIDS Prednisone 5 Mg Tablet 1GLUCOCORTICOIDS Prednisone 5 Mg/5 Ml Solution 1GLUCOCORTICOIDS Prednisone 50 Mg Tablet 1GLUCOCORTICOIDS Prednisone Intensol 5 Mg/Ml 1GLUCOCORTICOIDS Taperdex 12 Day 1.5 Mg Tablet 1GLUCOCORTICOIDS Taperdex 6 Day 1.5 Mg Tablet 1GLUCOCORTICOIDS Taperdex 7 Day 1.5 Mg Tab Pack 1GLUCOCORTICOIDS Triloan Ii Suik Kit 2GLUCOCORTICOIDS Triloan Suik Kit 2GLUCOCORTICOIDS, ORALLY INHALED Arnuity Ellipta 100 Mcg Inh 2GLUCOCORTICOIDS, ORALLY INHALED Arnuity Ellipta 200 Mcg Inh 2GLUCOCORTICOIDS, ORALLY INHALED Arnuity Ellipta 50 Mcg Inh 2GLUCOCORTICOIDS, ORALLY INHALED Budesonide 0.25 Mg/2 Ml Susp 1GLUCOCORTICOIDS, ORALLY INHALED Budesonide 0.5 Mg/2 Ml Susp 1GLUCOCORTICOIDS, ORALLY INHALED Budesonide 1 Mg/2 Ml Inh Susp 1GLUCOCORTICOIDS, ORALLY INHALED Flovent 100 Mcg Diskus 2GLUCOCORTICOIDS, ORALLY INHALED Flovent 250 Mcg Diskus 2GLUCOCORTICOIDS, ORALLY INHALED Flovent 50 Mcg Diskus 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 51: 2021 Rx Select - PRAM

GLUCOCORTICOIDS, ORALLY INHALED Flovent Hfa 110 Mcg Inhaler 2GLUCOCORTICOIDS, ORALLY INHALED Flovent Hfa 220 Mcg Inhaler 2GLUCOCORTICOIDS, ORALLY INHALED Flovent Hfa 44 Mcg Inhaler 2GLUCOCORTICOIDS, ORALLY INHALED Pulmicort 180 Mcg Flexhaler 2GLUCOCORTICOIDS, ORALLY INHALED Pulmicort 90 Mcg Flexhaler 2GLUCOCORTICOIDS, ORALLY INHALED Qvar Redihaler 40 Mcg 2GLUCOCORTICOIDS, ORALLY INHALED Qvar Redihaler 80 Mcg 2GRAM (-) BACILLI (NON-ENTERIC) VACCINES Vivotif Ec Capsule 2HEART RATE REDUCING, SELECTIVE I(F) CURRENT INHIB. Corlanor 5 Mg Tablet 2HEART RATE REDUCING, SELECTIVE I(F) CURRENT INHIB. Corlanor 7.5 Mg Tablet 2HEMORRHEOLOGIC AGENTS Pentoxifylline Er 400 Mg Tab 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Ana-lex 2-2% Kit 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Hydrocort-pramoxine 1%-1% Crm 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Hydrocort-pramoxine 2.5%-1% Cm 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Lidocaine-hc 2.8-0.55% Gel 2HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Lidocaine-hc 2-2% Cream Kit 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Lidocaine-hc 3-0.5% Cream Kit 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Lidocaine-hc 3-1% Cream Kit 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Lidocaine-hc 3-2.5% Gel Kit 1HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET Proctofoam-hc 1%-1% Foam 2HEP C VIRUS-NS5B POLYMERASE AND NS5A INHIB. COMBO. Ledipasvir-sofosbuvir 90-400mg 1HEP C VIRUS-NS5B POLYMERASE AND NS5A INHIB. COMBO. Sofosbuvir-velpatasvir 400-100 1HEPATITIS B TREATMENT AGENTS Adefovir Dipivoxil 10 Mg Tab 1HEPATITIS B TREATMENT AGENTS Baraclude 0.05 Mg/Ml Solution 2HEPATITIS B TREATMENT AGENTS Entecavir 0.5 Mg Tablet 1HEPATITIS B TREATMENT AGENTS Entecavir 1 Mg Tablet 1HEPATITIS B TREATMENT AGENTS Epivir Hbv 25 Mg/5 Ml Soln 2HEPATITIS B TREATMENT AGENTS Lamivudine Hbv 100 Mg Tablet 1HEPATITIS B TREATMENT AGENTS Vemlidy 25 Mg Tablet 2HEPATITIS C TREATMENT AGENTS Ribasphere 200 Mg Capsule 1HEPATITIS C TREATMENT AGENTS Ribasphere 600 Mg Tablet 2HEPATITIS C TREATMENT AGENTS Ribasphere Ribapak 600-400 Mg 2HEPATITIS C TREATMENT AGENTS Ribavirin 200 Mg Capsule 1HEPATITIS C TREATMENT AGENTS Ribavirin 200 Mg Tablet 1HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB Mavyret 100-40 Mg Tablet 2HISTAMINE H2-RECEPTOR INHIBITORS Nizatidine 15 Mg/Ml Solution 1HISTAMINE H2-RECEPTOR INHIBITORS Nizatidine 150 Mg Capsule 1HISTAMINE H2-RECEPTOR INHIBITORS Nizatidine 300 Mg Capsule 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 15 Mg/Ml Syrup 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 150 Mg Capsule 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 150 Mg Tablet 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 150 Mg/10 Ml Syrup 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 300 Mg Capsule 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 300 Mg Tablet 1HISTAMINE H2-RECEPTOR INHIBITORS Ranitidine 75 Mg Tablet 1HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Doxercalciferol 0.5 Mcg Cap 1HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Doxercalciferol 1 Mcg Capsule 1HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Doxercalciferol 2.5 Mcg Cap 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 52: 2021 Rx Select - PRAM

HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Paricalcitol 1 Mcg Capsule 1HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Paricalcitol 2 Mcg Capsule 1HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE Paricalcitol 4 Mcg Capsule 1HYPERTROPHIC CARDIOMYOPATHY TX AGENTS, ABLATIVE Ablysinol 99% Ampule 2HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Allopurinol 100 Mg Tablet 1HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Allopurinol 300 Mg Tablet 1HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Febuxostat 40 Mg Tablet 1HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Febuxostat 80 Mg Tablet 1HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Uloric 40 Mg Tablet 2HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Uloric 80 Mg Tablet 2HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS Ramelteon 8 Mg Tablet 1HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS Rozerem 8 Mg Tablet 2HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) TX AGENTS Addyi 100 Mg Tablet 2HYPOPIGMENTATION AGENTS Blanche 4% Cream 1HYPOPIGMENTATION AGENTS Hydroquinone 4% Cream 1HYPOPIGMENTATION AGENTS Hydroquinone Tr 4% Cream 1HYPOPIGMENTATION AGENTS Obagi Elastiderm Skin 4% Cream 1HYPOPIGMENTATION AGENTS Obagi Nu-derm Blender 4% Cream 1HYPOPIGMENTATION AGENTS Obagi Nu-derm Clear 4% Cream 1IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTS Viberzi 100 Mg Tablet 2IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTS Viberzi 75 Mg Tablet 2IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONIST Linzess 145 Mcg Capsule 2IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONIST Linzess 290 Mcg Capsule 2IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONIST Linzess 72 Mcg Capsule 2IMMUNOMODULATORS Imiquimod 3.75% Cream Pump 1IMMUNOSUPPRESSIVES Azasan 100 Mg Tablet 2IMMUNOSUPPRESSIVES Azasan 75 Mg Tablet 2IMMUNOSUPPRESSIVES Azathioprine 50 Mg Tablet 1IMMUNOSUPPRESSIVES Cyclosporine 100 Mg Capsule 1IMMUNOSUPPRESSIVES Cyclosporine 25 Mg Capsule 1IMMUNOSUPPRESSIVES Cyclosporine Modified 100 Mg 1IMMUNOSUPPRESSIVES Cyclosporine Modified 100mg/Ml 1IMMUNOSUPPRESSIVES Cyclosporine Modified 25 Mg 1IMMUNOSUPPRESSIVES Cyclosporine Modified 50 Mg 1IMMUNOSUPPRESSIVES Gengraf 100 Mg Capsule 1IMMUNOSUPPRESSIVES Gengraf 100 Mg/Ml Solution 1IMMUNOSUPPRESSIVES Gengraf 25 Mg Capsule 1IMMUNOSUPPRESSIVES Mycophenolate 200 Mg/Ml Susp 1IMMUNOSUPPRESSIVES Mycophenolate 250 Mg Capsule 1IMMUNOSUPPRESSIVES Mycophenolate 500 Mg Tablet 1IMMUNOSUPPRESSIVES Mycophenolic Acid Dr 180 Mg Tb 1IMMUNOSUPPRESSIVES Mycophenolic Acid Dr 360 Mg Tb 1IMMUNOSUPPRESSIVES Prograf 1 Mg Granule Packet 2IMMUNOSUPPRESSIVES Sirolimus 0.5 Mg Tablet 1IMMUNOSUPPRESSIVES Sirolimus 1 Mg Tablet 1IMMUNOSUPPRESSIVES Sirolimus 1 Mg/Ml Solution 1IMMUNOSUPPRESSIVES Sirolimus 2 Mg Tablet 1IMMUNOSUPPRESSIVES Tacrolimus 0.5 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 53: 2021 Rx Select - PRAM

IMMUNOSUPPRESSIVES Tacrolimus 1 Mg Capsule 1IMMUNOSUPPRESSIVES Tacrolimus 5 Mg Capsule 1IMMUNOSUPPRESSIVES Zortress 0.25 Mg Tablet 2IMMUNOSUPPRESSIVES Zortress 0.5 Mg Tablet 2IMMUNOSUPPRESSIVES Zortress 0.75 Mg Tablet 2INSULINS Fiasp 100 Unit/Ml Flextouch 2INSULINS Fiasp 100 Unit/Ml Vial 2INSULINS Humalog 100 Units/Ml Cartridge 2INSULINS Humalog 200 Units/Ml Kwikpen 2INSULINS Humalog Mix 50-50 Kwikpen 2INSULINS Humalog Mix 50-50 Vial 2INSULINS Humalog Mix 75-25 Kwikpen 2INSULINS Humalog Mix 75-25 Vial 2INSULINS Humulin 70/30 Kwikpen 2INSULINS Humulin 70-30 Vial 2INSULINS Humulin N 100 Unit/Ml Vial 2INSULINS Humulin N 100 Units/Ml Kwikpen 2INSULINS Humulin R 100 Unit/Ml Vial 2INSULINS Humulin R 500 Units/Ml Kwikpen 2INSULINS Humulin R 500 Units/Ml Vial 2INSULINS Insulin Lispro 100 Unit/Ml Pen 1INSULINS Insulin Lispro 100 Unit/Ml Vl 1INSULINS Lantus 100 Unit/Ml Vial 2INSULINS Lantus Solostar 100 Unit/Ml 2INSULINS Levemir 100 Unit/Ml Vial 2INSULINS Levemir Flextouch 100 Unit/Ml 2INSULINS Novolin 70-30 100 Unit/Ml Vial 2INSULINS Novolin 70-30 Flexpen 2INSULINS Novolin N 100 Unit/Ml Vial 2INSULINS Novolin R 100 Unit/Ml Vial 2INSULINS Novolog 100 Unit/Ml Cartridge 2INSULINS Novolog 100 Unit/Ml Flexpen 2INSULINS Novolog 100 Unit/Ml Vial 2INSULINS Novolog Mix 70-30 Flexpen Syrn 2INSULINS Novolog Mix 70-30 Vial 2INSULINS Relion Novolin 70-30 Flexpen 2INSULINS Relion Novolin 70-30 Vial 2INSULINS Relion Novolin N 100 Unit/Ml 2INSULINS Relion Novolin R 100 Unit/Ml 2INSULINS Toujeo Max Solostr 300 Unit/Ml 2INSULINS Toujeo Solostar 300 Unit/Ml 2INSULINS Tresiba 100 Unit/Ml Vial 2INSULINS Tresiba Flextouch 100 Unit/Ml 2INSULINS Tresiba Flextouch 200 Unit/Ml 2INTESTINAL MOTILITY STIMULANTS Metoclopramide 10 Mg Tablet 1INTESTINAL MOTILITY STIMULANTS Metoclopramide 10 Mg/10 Ml Sol 1INTESTINAL MOTILITY STIMULANTS Metoclopramide 5 Mg Tablet 1INTESTINAL MOTILITY STIMULANTS Metoclopramide 5 Mg/5 Ml Soln 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 54: 2021 Rx Select - PRAM

INTESTINAL MOTILITY STIMULANTS Metoclopramide Hcl 10 Mg Odt 1INTESTINAL MOTILITY STIMULANTS Metoclopramide Hcl 5 Mg Odt 1IODINE CONTAINING AGENTS Sski 1 Gm/Ml Solution 3IODINE CONTAINING AGENTS Strong Iodine Solution 1IRON REPLACEMENT Citranatal Bloom Tablet 2IRON REPLACEMENT Ferrex 150 Forte Capsule 1IRON REPLACEMENT Myferon-150 Forte Capsule 1IRRIGANTS Acetic Acid 0.25% Irrig Soln 1IRRIGANTS Aqua Care 0.9% Nacl Irrigation 1IRRIGANTS Lactated Ringers Irrigation 1IRRIGANTS Neomy-polymyxin B 40 Mg/Ml Amp 1IRRIGANTS Neomy-polymyxin B 40 Mg/Ml Vl 1IRRIGANTS Physiolyte Irrigation Soln 1IRRIGANTS Physiosol Irrigation Soln 1IRRIGANTS Ringers Irrigation Solution 1IRRIGANTS Sodium Chloride 0.9% Irrig. 1IRRIGANTS Sorbitol 3% Urologic Irrig 1IRRIGANTS Sorbitol 3.3% Urologic Soln 1IRRIGANTS Sorbitol-mannitol Irrig 1IRRIGANTS Sterile Water For Irrigation 1IRRITABLE BOWEL SYNDROME AGENTS, 5-HT3 ANTAGONIST Alosetron Hcl 0.5 Mg Tablet 1IRRITABLE BOWEL SYNDROME AGENTS, 5-HT3 ANTAGONIST Alosetron Hcl 1 Mg Tablet 1IRRITANTS/COUNTER-IRRITANTS Cantharidin 0.7%-acetone Soln 1JANUS KINASE (JAK) INHIBITORS Xeljanz 10 Mg Tablet 2JANUS KINASE (JAK) INHIBITORS Xeljanz 5 Mg Tablet 2JANUS KINASE (JAK) INHIBITORS Xeljanz Xr 11 Mg Tablet 2KERATOLYTICS Bensal Hp 3% Ointment 1KERATOLYTICS Bpo 4% Gel 2KERATOLYTICS Bpo 8% Gel 2KERATOLYTICS Cem-urea 45% Pre-filled Appl 3KERATOLYTICS Podocon-25 Liquid 1KERATOLYTICS Podofilox 0.5% Topical Soln 1KERATOLYTICS Pr Benzoyl Peroxide 7% Wash 1KERATOLYTICS Salicylic Acid 26% Liquid 1KERATOLYTICS Salicylic Acid 27.5% Liquid 1KERATOLYTICS Salicylic Acid 3% Ointment 1KERATOLYTICS Salicylic Acid 6% Cream 1KERATOLYTICS Salicylic Acid 6% Cream Kit 1KERATOLYTICS Salicylic Acid 6% Foam 1KERATOLYTICS Salicylic Acid 6% Gel 1KERATOLYTICS Salicylic Acid 6% Lotion 1KERATOLYTICS Salicylic Acid 6% Shampoo 1KERATOLYTICS Salicylic Acid Er 28.5% Soln 1KERATOLYTICS Salimez 6% Cream 1KERATOLYTICS Salimez Forte 10% Cream 1KERATOLYTICS Silver Nitrate 10% Solution 1KERATOLYTICS Silver Nitrate Applicator 1KERATOLYTICS Umecta 40% Mousse 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 55: 2021 Rx Select - PRAM

KERATOLYTICS Urea 40% Lotion 1KERATOLYTICS Urea 41% Cream 1KERATOLYTICS Urea 45% Cream 1KERATOLYTICS Urea 45% Nail Gel 1KERATOLYTICS Urea 47% Cream 1KERATOLYTICS Urea 50% Cream 3KERATOLYTICS Urea 50% Nail Stick 1KERATOLYTICS Ure-k 50% Cream 3LAXATIVES AND CATHARTICS Amitiza 24 Mcg Capsules 2LAXATIVES AND CATHARTICS Amitiza 8 Mcg Capsule 2LAXATIVES AND CATHARTICS Clenpiq Solution 2LAXATIVES AND CATHARTICS Constulose 10 Gm/15 Ml Soln 1LAXATIVES AND CATHARTICS Gavilyte-c Solution 1LAXATIVES AND CATHARTICS Gavilyte-g Solution 1LAXATIVES AND CATHARTICS Gavilyte-n Solution 1LAXATIVES AND CATHARTICS Lactulose 10 Gm Packet 1LAXATIVES AND CATHARTICS Lactulose 10 Gm/15 Ml Solution 1LAXATIVES AND CATHARTICS Lactulose 20 Gm/30 Ml Solution 1LAXATIVES AND CATHARTICS Moviprep Powder Packet 2LAXATIVES AND CATHARTICS Peg 3350 Electrolyte Soln 1LAXATIVES AND CATHARTICS Peg 3350-electrolyte Solution 1LAXATIVES AND CATHARTICS Peg-3350 And Electrolytes Soln 1LAXATIVES AND CATHARTICS Prepopik Powder Packet 2LAXATIVES AND CATHARTICS Suprep Bowel Prep Kit 2LAXATIVES AND CATHARTICS Trilyte With Flavor Packets 1LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Sod 10 Mg Tablet 1LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Sod 4 Mg Granules 1LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Sod 4 Mg Tab Chew 1LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Sod 5 Mg Tab Chew 1LEUKOTRIENE RECEPTOR ANTAGONISTS Zafirlukast 10 Mg Tablet 1LEUKOTRIENE RECEPTOR ANTAGONISTS Zafirlukast 20 Mg Tablet 1LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB Lupaneta Pk 11.25-5 Mg 3mo Kit 2LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB Lupaneta Pk 3.75-5 Mg 1mo Kit 2LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS Synarel 2 Mg/Ml Nasal Spray 2LINCOSAMIDE ANTIBIOTICS Clindamycin Hcl 150 Mg Capsule 1LINCOSAMIDE ANTIBIOTICS Clindamycin Hcl 300 Mg Capsule 1LINCOSAMIDE ANTIBIOTICS Clindamycin Hcl 75 Mg Capsule 1LINCOSAMIDE ANTIBIOTICS Clindamycin Pediatr 75 Mg/5 Ml 1LIPOTROPICS Ezetimibe 10 Mg Tablet 1LIPOTROPICS Fenofibrate 120 Mg Tablet 1LIPOTROPICS Fenofibrate 130 Mg Capsule 1LIPOTROPICS Fenofibrate 134 Mg Capsule 1LIPOTROPICS Fenofibrate 145 Mg Tablet 1LIPOTROPICS Fenofibrate 150 Mg Capsule 1LIPOTROPICS Fenofibrate 160 Mg Tablet 1LIPOTROPICS Fenofibrate 200 Mg Capsule 1LIPOTROPICS Fenofibrate 40 Mg Tablet 1LIPOTROPICS Fenofibrate 43 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 56: 2021 Rx Select - PRAM

LIPOTROPICS Fenofibrate 48 Mg Tablet 1LIPOTROPICS Fenofibrate 50 Mg Capsule 1LIPOTROPICS Fenofibrate 54 Mg Tablet 1LIPOTROPICS Fenofibrate 67 Mg Capsule 1LIPOTROPICS Fenofibric Acid 105 Mg Tablet 1LIPOTROPICS Fenofibric Acid 35 Mg Tablet 1LIPOTROPICS Fenofibric Acid Dr 135 Mg Cap 1LIPOTROPICS Fenofibric Acid Dr 45 Mg Cap 1LIPOTROPICS Gemfibrozil 600 Mg Tablet 1LIPOTROPICS Lipofen 150 Mg Capsule 2LIPOTROPICS Lipofen 50 Mg Capsule 2LIPOTROPICS Niacin 500 Mg Tablet 3LIPOTROPICS Niacin Er 1,000 Mg Tablet 1LIPOTROPICS Niacin Er 500 Mg Tablet 1LIPOTROPICS Niacin Er 750 Mg Tablet 1LIPOTROPICS Niacor 500 Mg Tablet 3LIPOTROPICS Triklo 1 Gm Capsule 1LIPOTROPICS Vascepa 0.5 Gm Capsule 2LIPOTROPICS Vascepa 1 Gm Capsule 2LOCAL ANESTHETICS Glydo 2% Jelly Syringe 1LOCAL ANESTHETICS Lidocaine 2% Viscous Soln 1LOCAL ANESTHETICS Lidocaine Hcl 2% Jelly 1LOCAL ANESTHETICS Lidocaine Hcl 2% Jelly Uro-jet 1LOCAL ANESTHETICS Lidocaine Hcl 4% Solution 1LOCAL ANESTHETICS Marvona Suik Kit 2LOCAL ANORECTAL NITRATE PREPARATIONS Rectiv 0.4% Ointment 2LOOP DIURETICS Bumetanide 0.5 Mg Tablet 1LOOP DIURETICS Bumetanide 1 Mg Tablet 1LOOP DIURETICS Bumetanide 2 Mg Tablet 1LOOP DIURETICS Ethacrynic Acid 25 Mg Tablet 1LOOP DIURETICS Furosemide 10 Mg/Ml Solution 1LOOP DIURETICS Furosemide 20 Mg Tablet 1LOOP DIURETICS Furosemide 40 Mg Tablet 1LOOP DIURETICS Furosemide 40 Mg/4 Ml Oral Sol 1LOOP DIURETICS Furosemide 80 Mg Tablet 1LOOP DIURETICS Torsemide 10 Mg Tablet 1LOOP DIURETICS Torsemide 100 Mg Tablet 1LOOP DIURETICS Torsemide 20 Mg Tablet 1LOOP DIURETICS Torsemide 5 Mg Tablet 1LUNG SURFACTANTS Curosurf 120 Mg/1.5 Ml Vial 2LUNG SURFACTANTS Infasurf 35 Mg/Ml Vial 2LUNG SURFACTANTS Surfaxin 34 Mg/Ml Vial 2LUNG SURFACTANTS Survanta 25 Mg/Ml Vial 2MACROLIDE ANTIBIOTICS Azithromycin 1 Gm Pwd Packet 1MACROLIDE ANTIBIOTICS Azithromycin 100 Mg/5 Ml Susp 1MACROLIDE ANTIBIOTICS Azithromycin 200 Mg/5 Ml Susp 1MACROLIDE ANTIBIOTICS Azithromycin 250 Mg Tablet 1MACROLIDE ANTIBIOTICS Azithromycin 500 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 57: 2021 Rx Select - PRAM

MACROLIDE ANTIBIOTICS Azithromycin 600 Mg Tablet 1MACROLIDE ANTIBIOTICS Clarithromycin 125 Mg/5 Ml Sus 1MACROLIDE ANTIBIOTICS Clarithromycin 250 Mg Tablet 1MACROLIDE ANTIBIOTICS Clarithromycin 250 Mg/5 Ml Sus 1MACROLIDE ANTIBIOTICS Clarithromycin 500 Mg Tablet 1MACROLIDE ANTIBIOTICS Clarithromycin Er 500 Mg Tab 1MACROLIDE ANTIBIOTICS E.e.s. 400 Filmtab 1MACROLIDE ANTIBIOTICS Ery-tab Dr 250 Mg Tablet 1MACROLIDE ANTIBIOTICS Ery-tab Dr 333 Mg Tablet 1MACROLIDE ANTIBIOTICS Ery-tab Dr 500 Mg Tablet 1MACROLIDE ANTIBIOTICS Erythromycin 200 Mg/5 Ml Susp 1MACROLIDE ANTIBIOTICS Erythromycin 250 Mg Filmtab 1MACROLIDE ANTIBIOTICS Erythromycin 400 Mg/5 Ml Susp 1MACROLIDE ANTIBIOTICS Erythromycin 500 Mg Filmtab 1MACROLIDE ANTIBIOTICS Erythromycin Dr 250 Mg Cap 1MACROLIDE ANTIBIOTICS Erythromycin Dr 250 Mg Tablet 1MACROLIDE ANTIBIOTICS Erythromycin Dr 333 Mg Tablet 1MACROLIDE ANTIBIOTICS Erythromycin Dr 500 Mg Tablet 1MACROLIDE ANTIBIOTICS Erythromycin Es 400 Mg Tab 1MACROLIDE ANTIBIOTICS Erythromycin St 250 Mg Tab 1MAOIS -NON-SELECTIVE,IRREVERSIBLE ANTIDEPRESSANTS Phenelzine Sulfate 15 Mg Tab 1MAOIS -NON-SELECTIVE,IRREVERSIBLE ANTIDEPRESSANTS Tranylcypromine Sulf 10 Mg Tab 1MAST CELL STABILIZERS Cromolyn 100 Mg/5 Ml Oral Conc 1MAST CELL STABILIZERS, ORALLY INHALED Cromolyn 20 Mg/2 Ml Neb Soln 1MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR Osphena 60 Mg Tablet 2MENOPAUSAL SYMPTOMS SUPPRESSANT - SSRIS Paroxetine Mesylate 7.5 Mg Cap 1METABOLIC DEFICIENCY AGENTS Cystadane 1 Gram/1.7 Ml Powder 2METABOLIC DEFICIENCY AGENTS Levocarnitine 1 G/10 Ml Soln 1METABOLIC DEFICIENCY AGENTS Levocarnitine 330 Mg Tablet 1METALLIC POISON,AGENTS TO TREAT Chemet 100 Mg Capsule 2METALLIC POISON,AGENTS TO TREAT Deferasirox 125 Mg Tablet 1METALLIC POISON,AGENTS TO TREAT Deferasirox 250 Mg Tablet 1METALLIC POISON,AGENTS TO TREAT Deferasirox 500 Mg Tablet 1METALLIC POISON,AGENTS TO TREAT Ferriprox 100 Mg/Ml Solution 2METALLIC POISON,AGENTS TO TREAT Ferriprox 500 Mg Tablet 2METALLIC POISON,AGENTS TO TREAT Galzin 25 Mg Capsule 2METALLIC POISON,AGENTS TO TREAT Galzin 50 Mg Capsule 2METALLIC POISON,AGENTS TO TREAT Jadenu 180 Mg Tablet 2METALLIC POISON,AGENTS TO TREAT Jadenu 360 Mg Tablet 2METALLIC POISON,AGENTS TO TREAT Jadenu 90 Mg Tablet 2METALLIC POISON,AGENTS TO TREAT Jadenu Sprinkle 180 Mg Granule 2METALLIC POISON,AGENTS TO TREAT Jadenu Sprinkle 360 Mg Granule 2METALLIC POISON,AGENTS TO TREAT Jadenu Sprinkle 90 Mg Granule 2METALLIC POISON,AGENTS TO TREAT Trientine Hcl 250 Mg Capsule 1MINERALOCORTICOIDS Fludrocortisone 0.1 Mg Tablet 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Alphagan P 0.1% Drops 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Alphagan P 0.15% Eye Drops 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Apraclonidine Hcl 0.5% Drops 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 58: 2021 Rx Select - PRAM

MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Azopt 1% Eye Drops 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Betaxolol Hcl 0.5% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Bimatoprost 0.03% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Brimonidine 0.15%-dorzolam 2% 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Brimonidine 0.2% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Brimonidine Tartrate 0.15% Drp 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Carteolol Hcl 1% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Combigan 0.2%-0.5% Eye Drops 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Dorzolamide 2% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Dorzolamide Hcl 2% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Dorzolamide-timolol 2%-0.5% 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Dorzolamide-timolol Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Latanoprost 0.005% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Latanoprost 0.005% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Lumigan 0.01% Eye Drops 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Metipranolol 0.3% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Phospholine Iodide 0.125% 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Pilocarpine 1% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Pilocarpine 2% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Pilocarpine 4% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Rhopressa 0.02% Ophth Solution 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timo 0.5%-dorz 2%-latan 0.005% 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timol 0.5%-brim 0.15%-dorzo 2% 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.25% Gel-solution 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.25% Gfs Gel-solution 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.5% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.5% Gel-solution 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.5% Gfs Gel-solution 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.5%-dorzolamide 2% 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol 0.5%-latanopros 0.005% 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol Maleate 0.25% Eye Drop 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol Maleate 0.5% Eye Drops 1MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Timolol-brimoni-dorzol-latanop 3MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Travatan Z 0.004% Eye Drop 2MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Vyzulta 0.024% Ophth Solution 2MUCOLYTICS Pulmozyme 1 Mg/Ml Ampul 2MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING Movantik 12.5 Mg Tablet 2MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING Movantik 25 Mg Tablet 2MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING Symproic 0.2 Mg Tablet 2MYDRIATICS Atropine 0.01%-ns Eye Drops 1MYDRIATICS Atropine 1% Eye Drops 1MYDRIATICS Atropine 1% Eye Ointment 1MYDRIATICS Cyclopen 1%-tropica 1%-pe 2.5% 3MYDRIATICS Cyclopentolate 0.5% Eye Drops 1MYDRIATICS Cyclopentolate 1% Eye Drop 1MYDRIATICS Cyclopentolate 1% Eye Drops 1MYDRIATICS Cyclopentolate Hcl 2% Drops 1MYDRIATICS Homatropaire 5% Eye Drops 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 59: 2021 Rx Select - PRAM

MYDRIATICS Homatropine 5% Eye Drops 1MYDRIATICS Mydriatic3 1-1-2.5% Drop 3MYDRIATICS Tropicamide 0.5% Eye Drop 1MYDRIATICS Tropicamide 0.5% Eye Drops 1MYDRIATICS Tropicamide 1% Eye Drop 1MYDRIATICS Tropicamide 1% Eye Drops 1MYDRIATICS Tropicamide 1%-phenylephr 2.5% 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Armodafinil 150 Mg Tablet 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Armodafinil 200 Mg Tablet 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Armodafinil 250 Mg Tablet 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Armodafinil 50 Mg Tablet 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Modafinil 100 Mg Tablet 1NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS Modafinil 200 Mg Tablet 1NASAL ANTIHISTAMINE Azelastine 0.1% (137 Mcg) Spry 1NASAL ANTIHISTAMINE Azelastine 0.15% Nasal Spray 1NASAL ANTIHISTAMINE Olopatadine 665 Mcg Nasal Spry 1NASAL ANTIHISTAMINE AND ANTI-INFLAM. STEROID COMB. Dymista Nasal Spray 2NASAL ANTI-INFLAMMATORY STEROIDS Flunisolide 0.025% Spray 1NASAL ANTI-INFLAMMATORY STEROIDS Fluticasone Prop 50 Mcg Spray 1NASAL ANTI-INFLAMMATORY STEROIDS Mometasone Furoate 50 Mcg Spry 1NASAL ANTI-INFLAMMATORY STEROIDS Ticaspray Kit 1NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Nitrofurantoin 25 Mg/5 Ml Susp 1NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Nitrofurantoin Mcr 100 Mg Cap 1NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Nitrofurantoin Mcr 25 Mg Cap 1NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Nitrofurantoin Mcr 50 Mg Cap 1NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Nitrofurantoin Mono-mcr 100 Mg 1NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGEST Bromfed Dm Cough Syrup 1NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGEST Bromphenir-pseudoephed-dm Syr 1NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGEST Centergy Dm Pediatric Drops 1NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. Promethazine-dm Solution 1NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. Promethazine-dm Syrup 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl 100 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl 75 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Er 200 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Sr 100 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Sr 150 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Sr 200 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Xl 150 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Xl 300 Mg Tablet 1NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Bupropion Hcl Xl 450 Mg Tablet 1NOSE PREPARATIONS, MISCELLANEOUS (RX) Cocaine Hcl 4% Nasal Solution 1NOSE PREPARATIONS, MISCELLANEOUS (RX) Ipratropium 0.03% Spray 1NOSE PREPARATIONS, MISCELLANEOUS (RX) Ipratropium 0.06% Spray 1NOSE PREPARATIONS, VASOCONSTRICTORS (RX) Adrenalin 1 Mg/Ml Nasal Soln 1NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Comfort Pac-meloxicam Kit 1NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Comfort Pac-naproxen Kit 1NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Inflammacin Kit 1NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Nudroxipak Dsdr-75 Pak 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 60: 2021 Rx Select - PRAM

NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Nudroxipak E-400 Pak 2NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Nudroxipak I-800 Pak 2NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Nudroxipak N-500 Pak 2NSAID AND TOPICAL IRRITANT COUNTER-IRRITANT COMB. Xenaflamm Kit 1NSAIDS(COX NON-SPEC.INHIB)AND PROSTAGLANDIN ANALOG Diclofenac-misoprost 50-0.2 Tb 1NSAIDS(COX NON-SPEC.INHIB)AND PROSTAGLANDIN ANALOG Diclofenac-misoprost 50-200 Tb 1NSAIDS(COX NON-SPEC.INHIB)AND PROSTAGLANDIN ANALOG Diclofenac-misoprost 75-0.2 Tb 1NSAIDS(COX NON-SPEC.INHIB)AND PROSTAGLANDIN ANALOG Diclofenac-misoprost 75-200 Tb 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Pot 50 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Dr 25 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Dr 50 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Dr 75 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Ec 25 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Ec 50 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Ec 75 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Diclofenac Sod Er 100 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ec-naproxen Dr 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ec-naproxen Dr 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac 200 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac 300 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac 400 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac Er 400 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac Er 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Etodolac Er 600 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Fenoprofen 200 Mg Capsule 3NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Fenoprofen 400 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Fenoprofen 600 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Fenortho 200 Mg Capsule 3NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Flurbiprofen 100 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Flurbiprofen 50 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibu 400 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibu 600 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibu 800 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibuprofen 100 Mg/5 Ml Susp 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibuprofen 600 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ibuprofen 800 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Indomethacin 25 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Indomethacin 50 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Indomethacin Er 75 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ketoprofen 25 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ketoprofen 50 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ketoprofen 75 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ketoprofen Er 200 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Ketorolac 10 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Meclofenamate 100 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Meclofenamate 50 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Mefenamic Acid 250 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 61: 2021 Rx Select - PRAM

NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Meloxicam 15 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Meloxicam 7.5 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Nabumetone 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Nabumetone 750 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen 125 Mg/5 Ml Suspen 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen 250 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen 500 Mg Kit 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Dr 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Dr 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Ec 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Ec 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sod Cr 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sod Cr 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sod Er 375 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sod Er 500 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sodium 220 Mg Caplet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sodium 220 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sodium 220 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sodium 275 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Naproxen Sodium 550 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Oxaprozin 600 Mg Caplet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Oxaprozin 600 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Piroxicam 10 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Piroxicam 20 Mg Capsule 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Sulindac 150 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Sulindac 200 Mg Tablet 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Tolmetin Sodium 200 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Tolmetin Sodium 400 Mg Cap 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Tolmetin Sodium 600 Mg Tab 1NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Toronova Ii Suik Kit 2NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Toronova Suik Kit 2NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITOR Celecoxib 100 Mg Capsule 1NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITOR Celecoxib 200 Mg Capsule 1NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITOR Celecoxib 400 Mg Capsule 1NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITOR Celecoxib 50 Mg Capsule 1NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTS Xuriden Granule Packet 2OINTMENT/CREAM BASES Radiagel 1OPHTHALMIC ANTIBIOTICS Ak-poly-bac Eye Ointment 1OPHTHALMIC ANTIBIOTICS Azasite 1% Eye Drops 2OPHTHALMIC ANTIBIOTICS Bacitracin 500 Unit/Gm Ophth 1OPHTHALMIC ANTIBIOTICS Bacitracin-polymyxin Eye Oint 1OPHTHALMIC ANTIBIOTICS Ciprofloxacin 0.3% Eye Drop 1OPHTHALMIC ANTIBIOTICS Erythromycin 0.5% Eye Ointment 1OPHTHALMIC ANTIBIOTICS Gatifloxacin 0.5% Eye Drops 1OPHTHALMIC ANTIBIOTICS Gentak 0.3 % Eye Ointment 1OPHTHALMIC ANTIBIOTICS Gentamicin 0.3% Eye Drop 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 62: 2021 Rx Select - PRAM

OPHTHALMIC ANTIBIOTICS Gentamicin 3 Mg/Gm Eye Oint 1OPHTHALMIC ANTIBIOTICS Gentamicin 3 Mg/Ml Eye Drop 1OPHTHALMIC ANTIBIOTICS Levofloxacin 0.5% Eye Drops 1OPHTHALMIC ANTIBIOTICS Moxeza 0.5% Eye Drops 2OPHTHALMIC ANTIBIOTICS Moxifloxacin 0.5% Eye Drop 1OPHTHALMIC ANTIBIOTICS Moxifloxacin 0.5% Eye Drops 1OPHTHALMIC ANTIBIOTICS Neomyc-bacit-polymix Eye Oint 1OPHTHALMIC ANTIBIOTICS Neomyc-polym-gramicid Eye Drop 1OPHTHALMIC ANTIBIOTICS Neo-polycin Eye Ointment 1OPHTHALMIC ANTIBIOTICS Ofloxacin 0.3% Eye Drop 1OPHTHALMIC ANTIBIOTICS Ofloxacin 0.3% Eye Drops 1OPHTHALMIC ANTIBIOTICS Polycin Eye Ointment 1OPHTHALMIC ANTIBIOTICS Polymyxin B-tmp Eye Drops 1OPHTHALMIC ANTIBIOTICS Tobramycin 0.3% Eye Drop 1OPHTHALMIC ANTIFIBROTIC AGENTS Mitosol 0.2 Mg Kit 2OPHTHALMIC ANTIFUNGAL AGENTS Natacyn Eye Drops 2OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE Cyclosporine 0.1% In Klarity 1OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE Restasis 0.05% Eye Emulsion 2OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE Restasis Multidose 0.05% Eye 2OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE Xiidra 5% Eye Drops 2OPHTHALMIC CYSTINE DEPLETING AGENTS Cystaran 0.44% Eye Drops 2OPHTHALMIC PREPARATIONS, MISCELLANEOUS Acuicyn Eyelid-eyelash Cleansr 2OPHTHALMIC PREPARATIONS, MISCELLANEOUS Avenova Lid-lash Spray 2OPHTHALMIC PREPARATIONS, MISCELLANEOUS Hypocyn 0.01% Spray Solution 2OPHTHALMIC SURGICAL AIDS Edetate Disodium 3% Eye Drop 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Acetamin-codein 300-30 Mg/12.5 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Acetaminop-codeine 120-12 Mg/5 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Acetaminophen-cod #2 Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Acetaminophen-cod #3 Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Acetaminophen-cod #4 Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Benzhydrocod-acetamin 4.08-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Benzhydrocod-acetamin 6.12-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Benzhydrocod-acetamin 8.16-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Endocet 10-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Endocet 2.5-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Endocet 5-325 Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Endocet 7.5-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 10-300 Mg 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 10-325 Mg 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 10-325/15 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 2.5-108/5 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 2.5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 5-217/10 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 5-300 Mg 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 5-325 Mg 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 7.5-300 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamin 7.5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Hydrocodone-acetamn 7.5-325/15 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 63: 2021 Rx Select - PRAM

OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Lorcet 5-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Lorcet Hd 10-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Lorcet Plus 7.5-325 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Lortab 10 Mg-300 Mg/15 Ml Elxr 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Nalocet 2.5-300 Mg Tablet 3OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Oxycodon-acetaminophen 2.5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Oxycodon-acetaminophen 7.5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Oxycodone-acetaminophen 10-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Oxycodone-acetaminophen 5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Primlev 10-300 Mg Tablet 3OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Primlev 5-300 Mg Tablet 3OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Primlev 7.5-300 Mg Tablet 3OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Tramadol-acetaminophn 37.5-325 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Vicodin 5-300 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Vicodin Es 7.5-300 Mg Tablet 1OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Vicodin Hp 10-300 Mg Tablet 1OPIOID ANALGESIC AND NSAID COMBINATION Hydrocodone-ibuprofen 10-200 1OPIOID ANALGESIC AND NSAID COMBINATION Hydrocodone-ibuprofen 5-200 Mg 1OPIOID ANALGESIC AND NSAID COMBINATION Hydrocodone-ibuprofen 7.5-200 1OPIOID ANALGESIC AND NSAID COMBINATION Oxycodone-ibuprofen 5-400 Tab 1OPIOID ANALGESIC AND SALICYLATE ANALGESIC COMB Oxycodone-aspirin 4.8355-325 1OPIOID ANALGESIC,NON-SALICYLATE,XANTHINE COMB Acetamin-caff-dihydrocod 320.5 1OPIOID ANALGESIC,NON-SALICYLATE,XANTHINE COMB Dvorah 325-30-16 Mg Tablet 1OPIOID ANALGESIC,NON-SALICYLATE,XANTHINE COMB Trezix 320.5-30-16 Mg Capsule 1OPIOID ANALGESICS Belbuca 150 Mcg Film 2OPIOID ANALGESICS Belbuca 300 Mcg Film 2OPIOID ANALGESICS Belbuca 450 Mcg Film 2OPIOID ANALGESICS Belbuca 600 Mcg Film 2OPIOID ANALGESICS Belbuca 75 Mcg Film 2OPIOID ANALGESICS Belbuca 750 Mcg Film 2OPIOID ANALGESICS Belbuca 900 Mcg Film 2OPIOID ANALGESICS Belladonna-opium 16.2-30 Supp 1OPIOID ANALGESICS Belladonna-opium 16.2-60 Supp 1OPIOID ANALGESICS Buprenorphine 10 Mcg/Hr Patch 1OPIOID ANALGESICS Buprenorphine 15 Mcg/Hr Patch 1OPIOID ANALGESICS Buprenorphine 20 Mcg/Hr Patch 1OPIOID ANALGESICS Buprenorphine 5 Mcg/Hr Patch 1OPIOID ANALGESICS Buprenorphine 7.5 Mcg/Hr Patch 1OPIOID ANALGESICS Butorphanol 10 Mg/Ml Spray 1OPIOID ANALGESICS Butrans 10 Mcg/Hr Patch 2OPIOID ANALGESICS Butrans 15 Mcg/Hr Patch 2OPIOID ANALGESICS Butrans 20 Mcg/Hr Patch 2OPIOID ANALGESICS Butrans 5 Mcg/Hr Patch 2OPIOID ANALGESICS Butrans 7.5 Mcg/Hr Patch 2OPIOID ANALGESICS Codeine Sulfate 15 Mg Tablet 1OPIOID ANALGESICS Codeine Sulfate 30 Mg Tablet 1OPIOID ANALGESICS Codeine Sulfate 60 Mg Tablet 1OPIOID ANALGESICS Fentanyl 100 Mcg/Hr Patch 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 64: 2021 Rx Select - PRAM

OPIOID ANALGESICS Fentanyl 12 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 25 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 37.5 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 50 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 62.5 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 75 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl 87.5 Mcg/Hr Patch 1OPIOID ANALGESICS Fentanyl Cit 100 Mcg Buccal Tb 1OPIOID ANALGESICS Fentanyl Cit 200 Mcg Buccal Tb 1OPIOID ANALGESICS Fentanyl Cit 400 Mcg Buccal Tb 1OPIOID ANALGESICS Fentanyl Cit 600 Mcg Buccal Tb 1OPIOID ANALGESICS Fentanyl Cit 800 Mcg Buccal Tb 1OPIOID ANALGESICS Fentanyl Cit Otfc 1,200 Mcg 1OPIOID ANALGESICS Fentanyl Cit Otfc 1,600 Mcg 1OPIOID ANALGESICS Fentanyl Citrate Otfc 200 Mcg 1OPIOID ANALGESICS Fentanyl Citrate Otfc 400 Mcg 1OPIOID ANALGESICS Fentanyl Citrate Otfc 600 Mcg 1OPIOID ANALGESICS Fentanyl Citrate Otfc 800 Mcg 1OPIOID ANALGESICS Hydromorphone 1 Mg/Ml Solution 1OPIOID ANALGESICS Hydromorphone 2 Mg Tablet 1OPIOID ANALGESICS Hydromorphone 3 Mg Suppos 1OPIOID ANALGESICS Hydromorphone 4 Mg Tablet 1OPIOID ANALGESICS Hydromorphone 8 Mg Tablet 1OPIOID ANALGESICS Hydromorphone Hcl Er 12 Mg Tab 1OPIOID ANALGESICS Hydromorphone Hcl Er 16 Mg Tab 1OPIOID ANALGESICS Hydromorphone Hcl Er 32 Mg Tab 1OPIOID ANALGESICS Hydromorphone Hcl Er 8 Mg Tab 1OPIOID ANALGESICS Hysingla Er 100 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 120 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 20 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 30 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 40 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 60 Mg Tablet 2OPIOID ANALGESICS Hysingla Er 80 Mg Tablet 2OPIOID ANALGESICS Levorphanol 2 Mg Tablet 2OPIOID ANALGESICS Levorphanol 3 Mg Tablet 1OPIOID ANALGESICS Meperidine 100 Mg Tablet 1OPIOID ANALGESICS Meperidine 50 Mg Tablet 1OPIOID ANALGESICS Meperidine 50 Mg/5 Ml Solution 1OPIOID ANALGESICS Methadone 10 Mg/5 Ml Solution 3OPIOID ANALGESICS Methadone 10 Mg/Ml Oral Conc 1OPIOID ANALGESICS Methadone 40 Mg Tablet Dispr 1OPIOID ANALGESICS Methadone 5 Mg/5 Ml Solution 1OPIOID ANALGESICS Methadone Hcl 10 Mg Tablet 1OPIOID ANALGESICS Methadone Hcl 5 Mg Tablet 1OPIOID ANALGESICS Methadone Intensol 10 Mg/Ml 1OPIOID ANALGESICS Methadose 40 Mg Tablet Dispr 1OPIOID ANALGESICS Morphine Sulf 10 Mg Suppos 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 65: 2021 Rx Select - PRAM

OPIOID ANALGESICS Morphine Sulf 10 Mg/5 Ml Soln 1OPIOID ANALGESICS Morphine Sulf 100 Mg/5 Ml Conc 1OPIOID ANALGESICS Morphine Sulf 20 Mg Suppos 1OPIOID ANALGESICS Morphine Sulf 20 Mg/5 Ml Soln 1OPIOID ANALGESICS Morphine Sulf 30 Mg Suppos 1OPIOID ANALGESICS Morphine Sulf 5 Mg Suppos 1OPIOID ANALGESICS Morphine Sulf Cr 100 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Cr 60 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Er 100 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Er 15 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Er 200 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Er 30 Mg Tablet 1OPIOID ANALGESICS Morphine Sulf Er 60 Mg Tablet 1OPIOID ANALGESICS Morphine Sulfate Er 10 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 100 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 120 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 20 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 30 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 40 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 45 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 50 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 60 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 75 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 80 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Er 90 Mg Cap 1OPIOID ANALGESICS Morphine Sulfate Ir 15 Mg Tab 1OPIOID ANALGESICS Morphine Sulfate Ir 30 Mg Tab 1OPIOID ANALGESICS Nucynta 100 Mg Tablet 2OPIOID ANALGESICS Nucynta 50 Mg Tablet 2OPIOID ANALGESICS Nucynta 75 Mg Tablet 2OPIOID ANALGESICS Nucynta Er 100 Mg Tablet 2OPIOID ANALGESICS Nucynta Er 150 Mg Tablet 2OPIOID ANALGESICS Nucynta Er 200 Mg Tablet 2OPIOID ANALGESICS Nucynta Er 250 Mg Tablet 2OPIOID ANALGESICS Nucynta Er 50 Mg Tablet 2OPIOID ANALGESICS Oxycodon 10 Mg/0.5 Ml Oral Syr 1OPIOID ANALGESICS Oxycodone Hcl 10 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl 100 Mg/5 Ml Conc 1OPIOID ANALGESICS Oxycodone Hcl 15 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl 20 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl 30 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl 5 Mg Capsule 1OPIOID ANALGESICS Oxycodone Hcl 5 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl 5 Mg/5 Ml Soln 1OPIOID ANALGESICS Oxycodone Hcl Er 10 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl Er 15 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl Er 20 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl Er 30 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 66: 2021 Rx Select - PRAM

OPIOID ANALGESICS Oxycodone Hcl Er 40 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl Er 60 Mg Tablet 1OPIOID ANALGESICS Oxycodone Hcl Er 80 Mg Tablet 1OPIOID ANALGESICS Oxycontin Er 10 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 15 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 20 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 30 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 40 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 60 Mg Tablet 2OPIOID ANALGESICS Oxycontin Er 80 Mg Tablet 2OPIOID ANALGESICS Oxymorphone Hcl 10 Mg Tablet 1OPIOID ANALGESICS Oxymorphone Hcl 5 Mg Tablet 1OPIOID ANALGESICS Oxymorphone Hcl Er 10 Mg Tab 1OPIOID ANALGESICS Oxymorphone Hcl Er 15 Mg Tab 1OPIOID ANALGESICS Oxymorphone Hcl Er 20 Mg Tab 1OPIOID ANALGESICS Oxymorphone Hcl Er 30 Mg Tab 1OPIOID ANALGESICS Oxymorphone Hcl Er 40 Mg Tab 1OPIOID ANALGESICS Oxymorphone Hcl Er 5 Mg Tablet 1OPIOID ANALGESICS Oxymorphone Hcl Er 7.5 Mg Tab 1OPIOID ANALGESICS Pentazocine-naloxone Tablet 1OPIOID ANALGESICS Tramadol Er 100 Mg Tablet 1OPIOID ANALGESICS Tramadol Er 200 Mg Tablet 1OPIOID ANALGESICS Tramadol Er 300 Mg Tablet 1OPIOID ANALGESICS Tramadol Hcl 50 Mg Tablet 1OPIOID ANALGESICS Tramadol Hcl Er 100 Mg Capsule 1OPIOID ANALGESICS Tramadol Hcl Er 100 Mg Tablet 1OPIOID ANALGESICS Tramadol Hcl Er 150 Mg Capsule 1OPIOID ANALGESICS Tramadol Hcl Er 200 Mg Capsule 1OPIOID ANALGESICS Tramadol Hcl Er 200 Mg Tablet 1OPIOID ANALGESICS Tramadol Hcl Er 300 Mg Capsule 1OPIOID ANALGESICS Tramadol Hcl Er 300 Mg Tablet 1OPIOID ANALGESICS Zohydro Er 10 Mg Capsule 2OPIOID ANALGESICS Zohydro Er 15 Mg Capsule 2OPIOID ANALGESICS Zohydro Er 20 Mg Capsule 2OPIOID ANALGESICS Zohydro Er 30 Mg Capsule 2OPIOID ANALGESICS Zohydro Er 40 Mg Capsule 2OPIOID ANALGESICS Zohydro Er 50 Mg Capsule 2OPIOID AND SALICYLATE ANALGESICS,BARBIT,XANTHINE Asa-butalb-caff-cod #3 Capsule 1OPIOID AND SALICYLATE ANALGESICS,BARBIT,XANTHINE Ascomp With Codeine Capsule 1OPIOID AND SALICYLATE ANALGESICS,BARBIT,XANTHINE Butalbital Comp-codeine #3 Cap 1OPIOID ANTAGONISTS Naltrexone 50 Mg Tablet 1OPIOID ANTAGONISTS Narcan 4 Mg Nasal Spray 2OPIOID ANTITUSSIV-1ST GEN. ANTIHISTAMINE-DECONGEST Promethazine-pe-codeine Syrup 1OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Hydrocodone-chlorphen Er Susp 1OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Promethazine-codeine Syrup 1OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Prometh-codein 6.25-10 Mg/5 Ml 1OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Tussicaps 10 Mg-8 Mg Capsule 2OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Tussicaps 5 Mg-4 Mg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 67: 2021 Rx Select - PRAM

OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS Hydrocodone Compound Syrup 1OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS Hydrocodone-homatropine 5-1.5 1OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS Hydrocodone-homatropine Soln 1OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS Hydrocodone-homatropine Syrup 1OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS Hydromet Syrup 1OPIOID ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMB Guaifenesin Dac Oral Solution 1OPIOID ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMB Lortuss Ex Liquid 1OPIOID ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMB Virtussin Dac Liquid 1OPIOID ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMB Zodryl Dec 30 Suspension 2OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Codeine-guaifen 10-100 Mg/5 Ml 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Coditussin Ac Liquid 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION G Tussin Ac Liquid 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Guaiatussin Ac Liquid 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Guaifen-codeine 100-10 Mg/5 Ml 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Guaifen-codeine 200-20 Mg/10ml 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin Ac Cough Syrup 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin-codeine Syrup 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION M-clear Wc Liquid 1OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION Virtussin Ac Liquid 1OPIOID WITHDRAWAL THER, ALPHA-2 ADRENERGIC AGONIST Lucemyra 0.18 Mg Tablet 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Bupreno-nalox 2-0.5 Mg Sl Film 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenor-nalox 12-3 Mg Sl Film 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorphine 2 Mg Tablet Sl 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorphine 8 Mg Tablet Sl 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorphin-naloxon 8-2 Mg Sl 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorphn-naloxn 2-0.5 Mg Sl 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorp-nalox 4-1 Mg Sl Film 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Buprenorp-nalox 8-2 Mg Sl Film 1OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 0.7-0.18 Mg Tablet Sl 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 1.4-0.36 Mg Tablet Sl 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 11.4-2.9 Mg Tablet Sl 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 2.9-0.71 Mg Tablet Sl 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 5.7-1.4 Mg Tablet Sl 2OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE Zubsolv 8.6-2.1 Mg Tablet Sl 2OPIOID,NON-SALICYL.ANALGESIC,BARBITURATE,XANTHINE Butalb-acetaminoph-caff-codein 1OPIOID,NON-SALICYL.ANALGESIC,BARBITURATE,XANTHINE Butalb-caff-acetaminoph-codein 1OSMOTIC DIURETICS Resectisol 5% Solution 2OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS Ciprodex Otic Suspension 2OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS Otovel 0.3%-0.025% Ear Drops 2OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP Myrbetriq Er 25 Mg Tablet 2OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP Myrbetriq Er 50 Mg Tablet 2OXAZOLIDINONE ANTIBIOTICS Linezolid 100 Mg/5 Ml Susp 1OXAZOLIDINONE ANTIBIOTICS Linezolid 600 Mg Tablet 1OXIDIZING AGENTS Epicyn Facial Cleanser Spray 2OXYTOCICS Methergine 0.2 Mg Tablet 1OXYTOCICS Methylergonovine 0.2 Mg Tablet 1PANCREATIC ENZYMES Creon Dr 12,000 Units Capsule 2PANCREATIC ENZYMES Creon Dr 24,000 Units Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 68: 2021 Rx Select - PRAM

PANCREATIC ENZYMES Creon Dr 3,000 Units Capsule 2PANCREATIC ENZYMES Creon Dr 36,000 Units Capsule 2PANCREATIC ENZYMES Creon Dr 6,000 Units Capsule 2PANCREATIC ENZYMES Viokace 10,440-39,150 Units Tb 2PANCREATIC ENZYMES Viokace 20,880-78,300 Units Tb 2PANCREATIC ENZYMES Zenpep Dr 10,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 15,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 20,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 25,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 3,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 40,000 Unit Capsule 2PANCREATIC ENZYMES Zenpep Dr 5,000 Unit Capsule 2PARASYMPATHETIC AGENTS Bethanechol 10 Mg Tablet 1PARASYMPATHETIC AGENTS Bethanechol 25 Mg Tablet 1PARASYMPATHETIC AGENTS Bethanechol 5 Mg Tablet 1PARASYMPATHETIC AGENTS Bethanechol 50 Mg Tablet 1PARASYMPATHETIC AGENTS Cevimeline Hcl 30 Mg Capsule 1PARASYMPATHETIC AGENTS Guanidine Hcl 125 Mg Tablet 1PARASYMPATHETIC AGENTS Pilocarpine Hcl 5 Mg Tablet 1PARASYMPATHETIC AGENTS Pilocarpine Hcl 7.5 Mg Tablet 1PENICILLIN ANTIBIOTICS Amox-clav 200-28.5 Mg Tab Chew 1PENICILLIN ANTIBIOTICS Amox-clav 200-28.5 Mg/5 Ml Sus 1PENICILLIN ANTIBIOTICS Amox-clav 250-125 Mg Tablet 1PENICILLIN ANTIBIOTICS Amox-clav 250-62.5 Mg/5 Ml Sus 1PENICILLIN ANTIBIOTICS Amox-clav 400-57 Mg Tab Chew 1PENICILLIN ANTIBIOTICS Amox-clav 400-57 Mg/5 Ml Susp 1PENICILLIN ANTIBIOTICS Amox-clav 500-125 Mg Tablet 1PENICILLIN ANTIBIOTICS Amox-clav 600-42.9 Mg/5 Ml Sus 1PENICILLIN ANTIBIOTICS Amox-clav 875-125 Mg Tablet 1PENICILLIN ANTIBIOTICS Amox-clav Er 1,000-62.5 Mg Tab 1PENICILLIN ANTIBIOTICS Amoxicillin 125 Mg Tab Chew 1PENICILLIN ANTIBIOTICS Amoxicillin 125 Mg/5 Ml Susp 1PENICILLIN ANTIBIOTICS Amoxicillin 200 Mg/5 Ml Susp 1PENICILLIN ANTIBIOTICS Amoxicillin 250 Mg Capsule 1PENICILLIN ANTIBIOTICS Amoxicillin 250 Mg Tab Chew 1PENICILLIN ANTIBIOTICS Amoxicillin 250 Mg/5 Ml Susp 1PENICILLIN ANTIBIOTICS Amoxicillin 400 Mg/5 Ml Susp 1PENICILLIN ANTIBIOTICS Amoxicillin 500 Mg Capsule 1PENICILLIN ANTIBIOTICS Amoxicillin 500 Mg Tablet 1PENICILLIN ANTIBIOTICS Amoxicillin 875 Mg Tablet 1PENICILLIN ANTIBIOTICS Ampicillin 250 Mg Capsule 1PENICILLIN ANTIBIOTICS Ampicillin 500 Mg Capsule 1PENICILLIN ANTIBIOTICS Augmentin 125-31.25 Mg/5 Ml 2PENICILLIN ANTIBIOTICS Dicloxacillin 250 Mg Capsule 1PENICILLIN ANTIBIOTICS Dicloxacillin 500 Mg Capsule 1PENICILLIN ANTIBIOTICS Penicillin Vk 125 Mg/5 Ml Soln 1PENICILLIN ANTIBIOTICS Penicillin Vk 250 Mg Tablet 1PENICILLIN ANTIBIOTICS Penicillin Vk 250 Mg/5 Ml Soln 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 69: 2021 Rx Select - PRAM

PENICILLIN ANTIBIOTICS Penicillin Vk 250 Mg/5 Ml Sus 1PENICILLIN ANTIBIOTICS Penicillin Vk 500 Mg Tablet 1PERIODONTAL COLLAGENASE INHIBITORS Doxycycline Hyclate 20 Mg Tab 1PHOSPHODIESTERASE-4 (PDE4) INHIBITORS Daliresp 250 Mcg Tablet 2PHOSPHODIESTERASE-4 (PDE4) INHIBITORS Daliresp 500 Mcg Tablet 2PITUITARY SUPPRESSIVE AGENTS Cabergoline 0.5 Mg Tablet 1PITUITARY SUPPRESSIVE AGENTS Danazol 100 Mg Capsule 1PITUITARY SUPPRESSIVE AGENTS Danazol 200 Mg Capsule 1PITUITARY SUPPRESSIVE AGENTS Danazol 50 Mg Capsule 1PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE Kuvan 100 Mg Powder Packet 2PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE Kuvan 100 Mg Tablet 2PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE Kuvan 500 Mg Powder Packet 2PLATELET AGGREGATION INHIBITORS Brilinta 60 Mg Tablet 2PLATELET AGGREGATION INHIBITORS Brilinta 90 Mg Tablet 2PLATELET AGGREGATION INHIBITORS Cilostazol 100 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Cilostazol 50 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Clopidogrel 300 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Clopidogrel 75 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Dipyridamole 25 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Dipyridamole 50 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Dipyridamole 75 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Prasugrel 10 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Prasugrel 5 Mg Tablet 1PLATELET AGGREGATION INHIBITORS Zontivity 2.08 Mg Tablet 2PLATELET REDUCING AGENTS Anagrelide Hcl 0.5 Mg Capsule 1PLATELET REDUCING AGENTS Anagrelide Hcl 1 Mg Capsule 1POSTHERPETIC NEURALGIA AGENTS Gralise 30-day Starter Pack 2POSTHERPETIC NEURALGIA AGENTS Gralise Er 300 Mg Tablet 2POSTHERPETIC NEURALGIA AGENTS Gralise Er 600 Mg Tablet 2POTASSIUM REPLACEMENT Effer-k 25 Meq Tablet Eff 1POTASSIUM REPLACEMENT Klor-con 10 Meq Tablet 1POTASSIUM REPLACEMENT Klor-con 20 Meq Packet 1POTASSIUM REPLACEMENT Klor-con 8 Meq Tablet 1POTASSIUM REPLACEMENT Klor-con M10 Tablet 1POTASSIUM REPLACEMENT Klor-con M20 Tablet 1POTASSIUM REPLACEMENT Klor-con Sprinkle Er 8 Meq Cap 1POTASSIUM REPLACEMENT Klor-con-ef 25 Meq Tab Eff 1POTASSIUM REPLACEMENT K-tab Er 10 Meq Tablet 1POTASSIUM REPLACEMENT K-tab Er 8 Meq Tablet 1POTASSIUM REPLACEMENT Potassium Cl 10% (20 Meq/15ml) 1POTASSIUM REPLACEMENT Potassium Cl 10% (40 Meq/30ml) 1POTASSIUM REPLACEMENT Potassium Cl 20 Meq Packet 1POTASSIUM REPLACEMENT Potassium Cl 20% (40 Meq/15ml) 1POTASSIUM REPLACEMENT Potassium Cl Er 10 Meq Capsule 1POTASSIUM REPLACEMENT Potassium Cl Er 10 Meq Tablet 1POTASSIUM REPLACEMENT Potassium Cl Er 20 Meq Tablet 1POTASSIUM REPLACEMENT Potassium Cl Er 8 Meq Capsule 1POTASSIUM REPLACEMENT Potassium Cl Er 8 Meq Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 70: 2021 Rx Select - PRAM

POTASSIUM SPARING DIURETICS Amiloride Hcl 5 Mg Tablet 1POTASSIUM SPARING DIURETICS Eplerenone 25 Mg Tablet 1POTASSIUM SPARING DIURETICS Eplerenone 50 Mg Tablet 1POTASSIUM SPARING DIURETICS Spironolactone 100 Mg Tablet 1POTASSIUM SPARING DIURETICS Spironolactone 25 Mg Tablet 1POTASSIUM SPARING DIURETICS Spironolactone 50 Mg Tablet 1POTASSIUM SPARING DIURETICS Triamterene 100 Mg Capsule 1POTASSIUM SPARING DIURETICS Triamterene 50 Mg Capsule 1POTASSIUM SPARING DIURETICS IN COMBINATION Amiloride Hcl-hctz 5-50 Mg Tab 1POTASSIUM SPARING DIURETICS IN COMBINATION Spironolactone-hctz 25-25 Tab 1POTASSIUM SPARING DIURETICS IN COMBINATION Triamterene-hctz 37.5-25 Mg Cp 1POTASSIUM SPARING DIURETICS IN COMBINATION Triamterene-hctz 37.5-25 Mg Tb 1POTASSIUM SPARING DIURETICS IN COMBINATION Triamterene-hctz 75-50 Mg Tab 1PRENATAL VITAMIN PREPARATIONS Bal-care Dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Citranatal 90 Dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Citranatal Assure Combo Pack 2PRENATAL VITAMIN PREPARATIONS Citranatal Dha Pack 2PRENATAL VITAMIN PREPARATIONS Citranatal Harmony Capsule 2PRENATAL VITAMIN PREPARATIONS Citranatal Rx Tablet 2PRENATAL VITAMIN PREPARATIONS C-nate Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Complete Natal Dha 2PRENATAL VITAMIN PREPARATIONS Concept Dha Capsule 2PRENATAL VITAMIN PREPARATIONS Concept Ob Capsule 2PRENATAL VITAMIN PREPARATIONS Duet Dha 400 Combo Pack 2PRENATAL VITAMIN PREPARATIONS Duet Dha Balanced (25 Mg Iron) 2PRENATAL VITAMIN PREPARATIONS Elite-ob Caplet 2PRENATAL VITAMIN PREPARATIONS Enbrace Hr Softgel 2PRENATAL VITAMIN PREPARATIONS Folet One Softgel 2PRENATAL VITAMIN PREPARATIONS Kosher Prenatal Plus Iron Tab 2PRENATAL VITAMIN PREPARATIONS Marnatal-f Capsule 2PRENATAL VITAMIN PREPARATIONS M-natal Plus Tablet 2PRENATAL VITAMIN PREPARATIONS Mynatal Advance Tablet 2PRENATAL VITAMIN PREPARATIONS Mynatal Capsule 2PRENATAL VITAMIN PREPARATIONS Mynatal Plus Captab 2PRENATAL VITAMIN PREPARATIONS Mynatal Ultracaplet 2PRENATAL VITAMIN PREPARATIONS Mynatal-z Captab 2PRENATAL VITAMIN PREPARATIONS Mynate 90 Plus Caplet Sa 2PRENATAL VITAMIN PREPARATIONS Natachew Tablet 2PRENATAL VITAMIN PREPARATIONS Neevodha Capsule 2PRENATAL VITAMIN PREPARATIONS Nestabs Abc Prenatal Combo Pk 2PRENATAL VITAMIN PREPARATIONS Nestabs Dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Nestabs One Softgel 2PRENATAL VITAMIN PREPARATIONS Nestabs Tablet 2PRENATAL VITAMIN PREPARATIONS Newgen Tablet 2PRENATAL VITAMIN PREPARATIONS Nexa Plus Softgel 2PRENATAL VITAMIN PREPARATIONS Obstetrix Dha Combo Pak 1PRENATAL VITAMIN PREPARATIONS Obstetrix Ec Caplet 2PRENATAL VITAMIN PREPARATIONS Obstetrix One Softgel 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 71: 2021 Rx Select - PRAM

PRENATAL VITAMIN PREPARATIONS Obtrex Dha Prenatal Vitamin 1PRENATAL VITAMIN PREPARATIONS O-cal Prenatal Tablet 2PRENATAL VITAMIN PREPARATIONS Pnv 29-1 Tablet 2PRENATAL VITAMIN PREPARATIONS Pnv Ob+dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Pnv Prenatal Plus Multivit Tab 2PRENATAL VITAMIN PREPARATIONS Pnv-dha + Docusate Softgel 2PRENATAL VITAMIN PREPARATIONS Pnv-dha Softgel 2PRENATAL VITAMIN PREPARATIONS Pnv-omega Softgel 2PRENATAL VITAMIN PREPARATIONS Pnv-select Tablet 2PRENATAL VITAMIN PREPARATIONS Pr Natal 400 Combo Pack 2PRENATAL VITAMIN PREPARATIONS Pr Natal 400 Ec Combo Pack 2PRENATAL VITAMIN PREPARATIONS Pr Natal 430 Combo Pack 2PRENATAL VITAMIN PREPARATIONS Pr Natal 430 Ec Combo Pack 2PRENATAL VITAMIN PREPARATIONS Prena1 Chew Tablet 2PRENATAL VITAMIN PREPARATIONS Prena1 Pearl Softgel 2PRENATAL VITAMIN PREPARATIONS Prena1 True Combo Pack 2PRENATAL VITAMIN PREPARATIONS Prenaissance Capsule 2PRENATAL VITAMIN PREPARATIONS Prenaissance Plus Softgel 2PRENATAL VITAMIN PREPARATIONS Prenata Chewable Tablet 2PRENATAL VITAMIN PREPARATIONS Prenatabs Fa Tablet 2PRENATAL VITAMIN PREPARATIONS Prenatabs Rx Tablet 2PRENATAL VITAMIN PREPARATIONS Prenatal-u Capsule 2PRENATAL VITAMIN PREPARATIONS Prenate Am Tablet 2PRENATAL VITAMIN PREPARATIONS Prenate Chewable Tablet 2PRENATAL VITAMIN PREPARATIONS Prenate Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Elite Tablet 2PRENATAL VITAMIN PREPARATIONS Prenate Enhance Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Essential Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Mini Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Pixie Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Restore Softgel 2PRENATAL VITAMIN PREPARATIONS Prenate Star Tablet 2PRENATAL VITAMIN PREPARATIONS Preplus Ca-fe 27 Mg-fa 1 Mg Tb 2PRENATAL VITAMIN PREPARATIONS Primacare Softgel 2PRENATAL VITAMIN PREPARATIONS Provida Dha Capsule 2PRENATAL VITAMIN PREPARATIONS Provida Ob Capsule 2PRENATAL VITAMIN PREPARATIONS R-natal Ob Softgel 2PRENATAL VITAMIN PREPARATIONS Se-natal 19 Chewable Tablet 2PRENATAL VITAMIN PREPARATIONS Se-natal 19 Tablet 1PRENATAL VITAMIN PREPARATIONS Thrivite Rx Tablet 2PRENATAL VITAMIN PREPARATIONS Tricare Prenatal Tablet 2PRENATAL VITAMIN PREPARATIONS Trinatal Rx 1 Tablet 2PRENATAL VITAMIN PREPARATIONS Trinate Tablet 2PRENATAL VITAMIN PREPARATIONS Tristart Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Triveen-duo Dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Trust Natal Dha 2PRENATAL VITAMIN PREPARATIONS Vinate Dha Rf Gelcap 2PRENATAL VITAMIN PREPARATIONS Vinate One Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 72: 2021 Rx Select - PRAM

PRENATAL VITAMIN PREPARATIONS Vinate-m Tablet 2PRENATAL VITAMIN PREPARATIONS Virt-c Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Virt-nate Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Virt-pn Dha Softgel 2PRENATAL VITAMIN PREPARATIONS Virt-pn Plus Softgel 2PRENATAL VITAMIN PREPARATIONS Vitafol Fe+ Docusate Combo Pck 2PRENATAL VITAMIN PREPARATIONS Vitafol Gummies 2PRENATAL VITAMIN PREPARATIONS Vitafol Nano Tablet 2PRENATAL VITAMIN PREPARATIONS Vitafol Ultra Softgel 2PRENATAL VITAMIN PREPARATIONS Vitafol-ob Caplet 2PRENATAL VITAMIN PREPARATIONS Vitafol-ob+dha Combo Pack 2PRENATAL VITAMIN PREPARATIONS Vitafol-one Capsule 2PRENATAL VITAMIN PREPARATIONS Vitamedmd One Rx Softgel 2PRENATAL VITAMIN PREPARATIONS Vitamedmd Redichew Rx Tab Chew 2PRENATAL VITAMIN PREPARATIONS Vitapearl Softgel 2PRENATAL VITAMIN PREPARATIONS Vitatrue Combo Pack 2PRENATAL VITAMIN PREPARATIONS Vp-ch-pnv Prenatal Softgel 2PRENATAL VITAMIN PREPARATIONS Vp-pnv-dha Softgel 2PRENATAL VITAMIN PREPARATIONS Zatean-pn Dha Capsule 2PRENATAL VITAMIN PREPARATIONS Zatean-pn Plus Softgel 2PRENATAL VITAMINS WITH LOW OR NO IRON Zingiber Tablet 2PROGESTATIONAL AGENTS Medroxyprogesterone 10 Mg Tab 1PROGESTATIONAL AGENTS Medroxyprogesterone 2.5 Mg Tab 1PROGESTATIONAL AGENTS Medroxyprogesterone 5 Mg Tab 1PROGESTATIONAL AGENTS Norethindrone 5 Mg Tablet 1PROGESTATIONAL AGENTS Progesterone 100 Mg Capsule 1PROGESTATIONAL AGENTS Progesterone 200 Mg Capsule 1PROTECTIVES Bionect 0.2% Cream 2PROTECTIVES Bionect 0.2% Gel 2PROTECTIVES Hygel 2.5% Gel 2PROTECTIVES Luradrox Gel 2PROTECTIVES Pr Cream Kit 3PROTECTIVES Radiaplexrx Gel 2PROTECTIVES Recedo Topical Gel 1PROTECTIVES Tetrix Cream 2PROTECTIVES Zinc Oxide Paste 1PROTON-PUMP INHIBITORS Esomeprazole Dr 49.3 Mg Cap 1PROTON-PUMP INHIBITORS Esomeprazole Mag Dr 20 Mg Cap 1PROTON-PUMP INHIBITORS Esomeprazole Mag Dr 40 Mg Cap 1PROTON-PUMP INHIBITORS Lansoprazole Dr 15 Mg Capsule 1PROTON-PUMP INHIBITORS Lansoprazole Dr 30 Mg Capsule 1PROTON-PUMP INHIBITORS Lansoprazole Odt 15 Mg Tablet 1PROTON-PUMP INHIBITORS Lansoprazole Odt 30 Mg Tablet 1PROTON-PUMP INHIBITORS Omeppi 20 Mg-1,100 Mg Capsule 1PROTON-PUMP INHIBITORS Omeppi 40 Mg-1,100 Mg Capsule 1PROTON-PUMP INHIBITORS Omeprazole Dr 10 Mg Capsule 1PROTON-PUMP INHIBITORS Omeprazole Dr 20 Mg Capsule 1PROTON-PUMP INHIBITORS Omeprazole Dr 40 Mg Capsule 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 73: 2021 Rx Select - PRAM

PROTON-PUMP INHIBITORS Omeprazole-bicarb 20-1,100 Cap 1PROTON-PUMP INHIBITORS Omeprazole-bicarb 20-1,680 Pkt 1PROTON-PUMP INHIBITORS Omeprazole-bicarb 40-1,100 Cap 1PROTON-PUMP INHIBITORS Omeprazole-bicarb 40-1,680 Pkt 1PROTON-PUMP INHIBITORS Pantoprazole Sod Dr 20 Mg Tab 1PROTON-PUMP INHIBITORS Pantoprazole Sod Dr 40 Mg Tab 1PROTON-PUMP INHIBITORS Rabeprazole Dr 10 Mg Sprnkl Cp 1PROTON-PUMP INHIBITORS Rabeprazole Sod Dr 20 Mg Tab 1PROTON-PUMP INHIBITORS Zegerid 20 Mg Capsule 2PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS Nuedexta 20-10 Mg Capsule 2PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR Adempas 0.5 Mg Tablet 2PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR Adempas 1 Mg Tablet 2PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR Adempas 1.5 Mg Tablet 2PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR Adempas 2 Mg Tablet 2PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR Adempas 2.5 Mg Tablet 2PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB Alyq 20 Mg Tablet 1PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Ambrisentan 10 Mg Tablet 1PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Ambrisentan 5 Mg Tablet 1PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Bosentan 125 Mg Tablet 1PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Bosentan 62.5 Mg Tablet 1PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Letairis 10 Mg Tablet 2PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Letairis 5 Mg Tablet 2PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Opsumit 10 Mg Tablet 2PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Tracleer 125 Mg Tablet 2PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Tracleer 32 Mg Tablet For Susp 2PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST Tracleer 62.5 Mg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Orenitram Er 0.125 Mg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Orenitram Er 0.25 Mg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Orenitram Er 1 Mg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Orenitram Er 2.5 Mg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Tyvaso 1.74 Mg/2.9 Ml Solution 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Tyvaso Inhalation Refill Kit 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Tyvaso Inhalation Starter Kit 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Tyvaso Institutional Start Kit 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 1,200 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 1,400 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 1,600 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 200 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 200-800 Titration Pack 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 400 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 600 Mcg Tablet 2PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE Uptravi 800 Mcg Tablet 2PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS Ofev 100 Mg Capsule 2PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS Ofev 150 Mg Capsule 2QUINOLONE ANTIBIOTICS Ciprofloxacin 250 Mg/5 Ml Susp 1QUINOLONE ANTIBIOTICS Ciprofloxacin 500 Mg/5 Ml Susp 1QUINOLONE ANTIBIOTICS Ciprofloxacin Hcl 100 Mg Tab 1QUINOLONE ANTIBIOTICS Ciprofloxacin Hcl 250 Mg Tab 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 74: 2021 Rx Select - PRAM

QUINOLONE ANTIBIOTICS Ciprofloxacin Hcl 500 Mg Tab 1QUINOLONE ANTIBIOTICS Ciprofloxacin Hcl 750 Mg Tab 1QUINOLONE ANTIBIOTICS Levofloxacin 250 Mg Tablet 1QUINOLONE ANTIBIOTICS Levofloxacin 500 Mg Tablet 1QUINOLONE ANTIBIOTICS Levofloxacin 750 Mg Tablet 1QUINOLONE ANTIBIOTICS Moxifloxacin Hcl 400 Mg Tablet 1QUINOLONE ANTIBIOTICS Ofloxacin 300 Mg Tablet 1QUINOLONE ANTIBIOTICS Ofloxacin 400 Mg Tablet 1RECTAL PREPARATIONS Anucort-hc 25 Mg Suppository 1RECTAL PREPARATIONS Anusol-hc 25 Mg Suppository 1RECTAL PREPARATIONS Hemmorex-hc 25 Mg Suppository 1RECTAL PREPARATIONS Hydrocortisone Ac 25 Mg Supp 1RECTAL PREPARATIONS Hydrocortisone Ac 30 Mg Supp 1RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR) Hydrocortisone 100 Mg/60 Ml 1RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR) Uceris 2 Mg Rectal Foam 2RENIN INHIBITOR, DIRECT Aliskiren 150 Mg Tablet 1RENIN INHIBITOR, DIRECT Aliskiren 300 Mg Tablet 1RENIN INHIBITOR, DIRECT Tekturna 150 Mg Tablet 2RENIN INHIBITOR, DIRECT Tekturna 300 Mg Tablet 2RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB Tekturna Hct 150-12.5 Mg Tab 2RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB Tekturna Hct 150-25 Mg Tablet 2RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB Tekturna Hct 300-12.5 Mg Tab 2RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB Tekturna Hct 300-25 Mg Tablet 2RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS Xifaxan 200 Mg Tablet 2RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS Xifaxan 550 Mg Tablet 2ROSACEA AGENTS, TOPICAL Azelaic Acid 15% Gel 1ROSACEA AGENTS, TOPICAL Finacea 15% Foam 2ROSACEA AGENTS, TOPICAL Metronidazole 0.75% Cream 1ROSACEA AGENTS, TOPICAL Metronidazole 0.75% Lotion 1ROSACEA AGENTS, TOPICAL Metronidazole Top 1% Gel Pump 1ROSACEA AGENTS, TOPICAL Metronidazole Topical 0.75% Gl 1ROSACEA AGENTS, TOPICAL Metronidazole Topical 1% Gel 1ROSACEA AGENTS, TOPICAL Mirvaso 0.33% Gel 2ROSACEA AGENTS, TOPICAL Mirvaso 0.33% Gel Pump 2ROSACEA AGENTS, TOPICAL Rosadan 0.75% Cream 1ROSACEA AGENTS, TOPICAL Rosadan 0.75% Gel 1ROSACEA AGENTS, TOPICAL Soolantra 1% Cream 2SALIVA SUBSTITUTE AGENTS Bocasal 538 Mg Powder Packet 2SALIVA SUBSTITUTE AGENTS Neutrasal Powder Packet 2SALIVA SUBSTITUTE AGENTS Numoisyn Liquid 2SALIVA SUBSTITUTE AGENTS Salivamax Powder Packet 2SALIVA SUBSTITUTE AGENTS Xerostomia Relief Spray 2SEDATIVE-HYPNOTICS - BENZODIAZEPINES Estazolam 1 Mg Tablet 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Estazolam 2 Mg Tablet 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Flurazepam 15 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Flurazepam 30 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Midazolam Hcl 10 Mg/5 Ml Syrup 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Midazolam Hcl 2 Mg/Ml Syrup 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 75: 2021 Rx Select - PRAM

SEDATIVE-HYPNOTICS - BENZODIAZEPINES Midazolam Hcl 5 Mg/2.5 Ml Syrp 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Quazepam 15 Mg Tablet 3SEDATIVE-HYPNOTICS - BENZODIAZEPINES Temazepam 15 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Temazepam 22.5 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Temazepam 30 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Temazepam 7.5 Mg Capsule 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Triazolam 0.125 Mg Tablet 1SEDATIVE-HYPNOTICS - BENZODIAZEPINES Triazolam 0.25 Mg Tablet 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Belsomra 10 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Belsomra 15 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Belsomra 20 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Belsomra 5 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Eszopiclone 1 Mg Tablet 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Eszopiclone 2 Mg Tablet 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Eszopiclone 3 Mg Tablet 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Ketamine 100 Mg Troche 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Mko (midaz-keta-ond) 3-25-2 Mg 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Silenor 3 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Silenor 6 Mg Tablet 2SEDATIVE-HYPNOTICS,NON-BARBITURATE Zaleplon 10 Mg Capsule 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zaleplon 5 Mg Capsule 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tart 1.75 Mg Tab Sl 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tart 3.5 Mg Tablet Sl 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tart Er 12.5 Mg Tab 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tart Er 6.25 Mg Tab 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tartrate 10 Mg Tablet 1SEDATIVE-HYPNOTICS,NON-BARBITURATE Zolpidem Tartrate 5 Mg Tablet 1SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) Tamoxifen 10 Mg Tablet 1SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) Tamoxifen 20 Mg Tablet 1SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) Toremifene Citrate 60 Mg Tab 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Citalopram Hbr 10 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Citalopram Hbr 10 Mg/5 Ml Soln 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Citalopram Hbr 20 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Citalopram Hbr 20 Mg/10 Ml Sol 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Citalopram Hbr 40 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Escitalopram 10 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Escitalopram 20 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Escitalopram 5 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Escitalopram Oxalate 10mg/10ml 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Escitalopram Oxalate 5 Mg/5 Ml 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine 20 Mg/5 Ml Solution 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Dr 90 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 10 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 10 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 20 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 20 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 40 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluoxetine Hcl 60 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 76: 2021 Rx Select - PRAM

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluvoxamine Er 100 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluvoxamine Er 150 Mg Capsule 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluvoxamine Maleate 100 Mg Tab 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluvoxamine Maleate 25 Mg Tab 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Fluvoxamine Maleate 50 Mg Tab 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Cr 12.5 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Cr 25 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Cr 37.5 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Er 12.5 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Er 25 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Er 37.5 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Hcl 10 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Hcl 20 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Hcl 30 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Paroxetine Hcl 40 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Sertraline 20 Mg/Ml Oral Conc 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Sertraline Hcl 100 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Sertraline Hcl 25 Mg Tablet 1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Sertraline Hcl 50 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Nefazodone Hcl 100 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Nefazodone Hcl 150 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Nefazodone Hcl 200 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Nefazodone Hcl 250 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Nefazodone Hcl 50 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Trazodone 100 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Trazodone 150 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Trazodone 300 Mg Tablet 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) Trazodone 50 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Er 100 Mg Tab 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Er 50 Mg Tab 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Er 50 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Suc Er 100 Mg 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Suc Er 25 Mg Tb 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Desvenlafaxine Suc Er 50 Mg Tb 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Duloxetine Hcl Dr 20 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Duloxetine Hcl Dr 30 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Duloxetine Hcl Dr 40 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Duloxetine Hcl Dr 60 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Fetzima 20-40 Mg Titration Pak 2SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Fetzima Er 120 Mg Capsule 2SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Fetzima Er 20 Mg Capsule 2SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Fetzima Er 40 Mg Capsule 2SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Fetzima Er 80 Mg Capsule 2SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl 100 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl 25 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl 37.5 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl 50 Mg Tablet 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl 75 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 77: 2021 Rx Select - PRAM

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 150 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 150 Mg Tab 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 225 Mg Tab 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 37.5 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 37.5 Mg Tab 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 75 Mg Cap 1SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Venlafaxine Hcl Er 75 Mg Tab 1SICKLE CELL ANEMIA AGENTS Droxia 200 Mg Capsule 2SICKLE CELL ANEMIA AGENTS Droxia 300 Mg Capsule 2SICKLE CELL ANEMIA AGENTS Droxia 400 Mg Capsule 2SKELETAL MUSCLE RELAX.-TOP. IRRITANT COUNTER-IRRIT Comfort Pac-cyclobenzaprine Kt 1SKELETAL MUSCLE RELAXANT,SALICYLAT,OPIOID ANALGESC Carisoprodol-aspirin-codein Tb 1SKELETAL MUSCLE RELAXANTS Baclofen 10 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Baclofen 20 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Baclofen 5 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Carisoprodl-aspirin 200-325 Mg 1SKELETAL MUSCLE RELAXANTS Carisoprodol 250 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Carisoprodol 350 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Carisoprodol Compound Tab 1SKELETAL MUSCLE RELAXANTS Chlorzoxazone 250 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Chlorzoxazone 375 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Chlorzoxazone 500 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Chlorzoxazone 750 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Cyclobenzaprine 10 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Cyclobenzaprine 5 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Cyclobenzaprine 7.5 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Cyclotens Refill Pak 2SKELETAL MUSCLE RELAXANTS Dantrolene Sodium 100 Mg Cap 1SKELETAL MUSCLE RELAXANTS Dantrolene Sodium 25 Mg Cap 1SKELETAL MUSCLE RELAXANTS Dantrolene Sodium 50 Mg Cap 1SKELETAL MUSCLE RELAXANTS Metaxall 800 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Metaxalone 400 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Metaxalone 800 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Methocarbamol 500 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Methocarbamol 750 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Orphenad-asa-caff 50-770-60 Mg 1SKELETAL MUSCLE RELAXANTS Orphenadrine Er 100 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Orphengesic Forte 50-770-60 Mg 1SKELETAL MUSCLE RELAXANTS Tizanidine Hcl 2 Mg Capsule 1SKELETAL MUSCLE RELAXANTS Tizanidine Hcl 2 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Tizanidine Hcl 4 Mg Capsule 1SKELETAL MUSCLE RELAXANTS Tizanidine Hcl 4 Mg Tablet 1SKELETAL MUSCLE RELAXANTS Tizanidine Hcl 6 Mg Capsule 1SKIN TISSUE REPLACEMENT Endoform 2" X 2" Template 1SKIN TISSUE REPLACEMENT Endoform 4" X 5" Template 1SKIN TISSUE REPLACEMENT Endoform Fenestrated 2" X 2" 1SKIN TISSUE REPLACEMENT Endoform Fenestrated 4" X 5" 1SOLVENTS Muri-lube Mineral Oil Vial 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 78: 2021 Rx Select - PRAM

SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS Viibryd 10 Mg Tablet 2SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS Viibryd 10-20 Mg Starter Pack 2SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS Viibryd 20 Mg Tablet 2SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS Viibryd 40 Mg Tablet 2SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS Trintellix 10 Mg Tablet 2SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS Trintellix 20 Mg Tablet 2SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS Trintellix 5 Mg Tablet 2SSRI-ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG Olanzapine-fluoxetine 12-25 Mg 1SSRI-ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG Olanzapine-fluoxetine 12-50 Mg 1SSRI-ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG Olanzapine-fluoxetine 3-25 Mg 1SSRI-ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG Olanzapine-fluoxetine 6-25 Mg 1SSRI-ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG Olanzapine-fluoxetine 6-50 Mg 1STEROID ANTINEOPLASTICS Emcyt 140 Mg Capsule 2STEROID ANTINEOPLASTICS Megestrol 20 Mg Tablet 1STEROID ANTINEOPLASTICS Megestrol 40 Mg Tablet 1SUSPENDING AGENTS Hydroxypropylcellulose Powder 1SYRINGES AND ACCESSORIES Careone Syr 0.3 Ml 30gx1/2" 2SYRINGES AND ACCESSORIES Careone Syr 0.3 Ml 31gx5/16" 2SYRINGES AND ACCESSORIES Careone Syr 0.5 Ml 30gx1/2" 2SYRINGES AND ACCESSORIES Careone Syr 0.5 Ml 31gx5/16" 2SYRINGES AND ACCESSORIES Careone Syr 1 Ml 30gx1/2" 2SYRINGES AND ACCESSORIES Careone Syr 1 Ml 31gx5/16" 2TETRACYCLINE ANTIBIOTICS Avidoxy 100 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Avidoxy Dk Kit 2TETRACYCLINE ANTIBIOTICS Coremino Er 135 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Coremino Er 45 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Coremino Er 90 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Demeclocycline 150 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Demeclocycline 300 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Doxycycline 25 Mg/5 Ml Susp 1TETRACYCLINE ANTIBIOTICS Doxycycline 50 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyc Dr 100 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyc Dr 150 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyc Dr 200 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyc Dr 50 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyc Dr 75 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 100 Mg Cap 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 100 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 100 Mg Vl 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 150 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 50 Mg Cap 1TETRACYCLINE ANTIBIOTICS Doxycycline Hyclate 75 Mg Tab 1TETRACYCLINE ANTIBIOTICS Doxycycline Ir-dr 40 Mg Cap 3TETRACYCLINE ANTIBIOTICS Doxycycline Mono 100 Mg Cap 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 100 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 150 Mg Cap 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 150 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 50 Mg Cap 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 79: 2021 Rx Select - PRAM

TETRACYCLINE ANTIBIOTICS Doxycycline Mono 50 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 75 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Doxycycline Mono 75 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline 100 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Minocycline 50 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Minocycline 75 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Minocycline Er 105 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 115 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 135 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 45 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 55 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 65 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 80 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Er 90 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Hcl 100 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Hcl 50 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Minocycline Hcl 75 Mg Tablet 1TETRACYCLINE ANTIBIOTICS Mondoxyne Nl 100 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Mondoxyne Nl 75 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Morgidox 100 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Morgidox 1x100 Mg Kit 2TETRACYCLINE ANTIBIOTICS Morgidox 2x100 Mg Kit 2TETRACYCLINE ANTIBIOTICS Morgidox 50 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Okebo 75 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Tetracycline 250 Mg Capsule 1TETRACYCLINE ANTIBIOTICS Tetracycline 500 Mg Capsule 1THIAZIDE AND RELATED DIURETICS Chlorothiazide 250 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Chlorothiazide 500 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Chlorthalidone 25 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Chlorthalidone 50 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Hydrochlorothiazide 12.5 Mg Cp 1THIAZIDE AND RELATED DIURETICS Hydrochlorothiazide 12.5 Mg Tb 1THIAZIDE AND RELATED DIURETICS Hydrochlorothiazide 25 Mg Tab 1THIAZIDE AND RELATED DIURETICS Hydrochlorothiazide 50 Mg Tab 1THIAZIDE AND RELATED DIURETICS Indapamide 1.25 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Indapamide 2.5 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Methyclothiazide 5 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Metolazone 10 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Metolazone 2.5 Mg Tablet 1THIAZIDE AND RELATED DIURETICS Metolazone 5 Mg Tablet 1THROMBOPOIETIN RECEPTOR AGONISTS Doptelet (10 Tab Pk) 20 Mg Tab 2THROMBOPOIETIN RECEPTOR AGONISTS Doptelet (15 Tab Pk) 20 Mg Tab 2THROMBOPOIETIN RECEPTOR AGONISTS Doptelet (30 Tab Pk) 20 Mg Tab 2THROMBOPOIETIN RECEPTOR AGONISTS Promacta 12.5 Mg Suspen Packet 2THROMBOPOIETIN RECEPTOR AGONISTS Promacta 12.5 Mg Tablet 2THROMBOPOIETIN RECEPTOR AGONISTS Promacta 25 Mg Tablet 2THROMBOPOIETIN RECEPTOR AGONISTS Promacta 50 Mg Tablet 2THROMBOPOIETIN RECEPTOR AGONISTS Promacta 75 Mg Tablet 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 80: 2021 Rx Select - PRAM

THYROID HORMONES Armour Thyroid 120 Mg Tablet 2THYROID HORMONES Armour Thyroid 15 Mg Tablet 2THYROID HORMONES Armour Thyroid 180 Mg Tablet 2THYROID HORMONES Armour Thyroid 240 Mg Tablet 2THYROID HORMONES Armour Thyroid 30 Mg Tablet 2THYROID HORMONES Armour Thyroid 300 Mg Tablet 2THYROID HORMONES Armour Thyroid 60 Mg Tablet 2THYROID HORMONES Armour Thyroid 90 Mg Tablet 2THYROID HORMONES Euthyrox 100 Mcg Tablet 1THYROID HORMONES Euthyrox 112 Mcg Tablet 1THYROID HORMONES Euthyrox 125 Mcg Tablet 1THYROID HORMONES Euthyrox 137 Mcg Tablet 1THYROID HORMONES Euthyrox 150 Mcg Tablet 2THYROID HORMONES Euthyrox 175 Mcg Tablet 1THYROID HORMONES Euthyrox 200 Mcg Tablet 1THYROID HORMONES Euthyrox 25 Mcg Tablet 1THYROID HORMONES Euthyrox 50 Mcg Tablet 1THYROID HORMONES Euthyrox 75 Mcg Tablet 1THYROID HORMONES Euthyrox 88 Mcg Tablet 1THYROID HORMONES Levo-t 100 Mcg Tablet 1THYROID HORMONES Levo-t 112 Mcg Tablet 1THYROID HORMONES Levo-t 125 Mcg Tablet 1THYROID HORMONES Levo-t 137 Mcg Tablet 1THYROID HORMONES Levo-t 150 Mcg Tablet 1THYROID HORMONES Levo-t 175 Mcg Tablet 1THYROID HORMONES Levo-t 200 Mcg Tablet 1THYROID HORMONES Levo-t 25 Mcg Tablet 1THYROID HORMONES Levo-t 300 Mcg Tablet 1THYROID HORMONES Levo-t 50 Mcg Tablet 1THYROID HORMONES Levo-t 75 Mcg Tablet 1THYROID HORMONES Levo-t 88 Mcg Tablet 1THYROID HORMONES Levothyroxine 0.025 Mg Tablet 1THYROID HORMONES Levothyroxine 0.125 Mg Tablet 1THYROID HORMONES Levothyroxine 0.175 Mg Tablet 1THYROID HORMONES Levothyroxine 100 Mcg Tablet 1THYROID HORMONES Levothyroxine 112 Mcg Tablet 1THYROID HORMONES Levothyroxine 125 Mcg Tablet 1THYROID HORMONES Levothyroxine 137 Mcg Tablet 1THYROID HORMONES Levothyroxine 150 Mcg Tablet 1THYROID HORMONES Levothyroxine 175 Mcg Tablet 1THYROID HORMONES Levothyroxine 200 Mcg Tablet 1THYROID HORMONES Levothyroxine 25 Mcg Tablet 1THYROID HORMONES Levothyroxine 300 Mcg Tablet 1THYROID HORMONES Levothyroxine 50 Mcg Tablet 1THYROID HORMONES Levothyroxine 75 Mcg Tablet 1THYROID HORMONES Levothyroxine 88 Mcg Tablet 1THYROID HORMONES Levoxyl 100 Mcg Tablet 1THYROID HORMONES Levoxyl 112 Mcg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 81: 2021 Rx Select - PRAM

THYROID HORMONES Levoxyl 125 Mcg Tablet 1THYROID HORMONES Levoxyl 137 Mcg Tablet 1THYROID HORMONES Levoxyl 150 Mcg Tablet 1THYROID HORMONES Levoxyl 175 Mcg Tablet 1THYROID HORMONES Levoxyl 200 Mcg Tablet 1THYROID HORMONES Levoxyl 25 Mcg Tablet 1THYROID HORMONES Levoxyl 50 Mcg Tablet 1THYROID HORMONES Levoxyl 75 Mcg Tablet 1THYROID HORMONES Levoxyl 88 Mcg Tablet 1THYROID HORMONES Liothyronine Sod 25 Mcg Tab 1THYROID HORMONES Liothyronine Sod 5 Mcg Tab 1THYROID HORMONES Liothyronine Sod 50 Mcg Tab 1THYROID HORMONES Nature-throid 130 Mg Tablet 1THYROID HORMONES Nature-throid 16.25 Mg Tablet 1THYROID HORMONES Nature-throid 32.5 Mg Tablet 1THYROID HORMONES Nature-throid 65 Mg Tablet 1THYROID HORMONES Nature-throid 97.5 Mg Tablet 1THYROID HORMONES Np Thyroid 120 Mg Tablet 1THYROID HORMONES Np Thyroid 15 Mg Tablet 1THYROID HORMONES Np Thyroid 30 Mg Tablet 1THYROID HORMONES Np Thyroid 60 Mg Tablet 1THYROID HORMONES Np Thyroid 90 Mg Tablet 1THYROID HORMONES Synthroid 100 Mcg Tablet 2THYROID HORMONES Synthroid 112 Mcg Tablet 2THYROID HORMONES Synthroid 125 Mcg Tablet 2THYROID HORMONES Synthroid 137 Mcg Tablet 2THYROID HORMONES Synthroid 150 Mcg Tablet 2THYROID HORMONES Synthroid 175 Mcg Tablet 2THYROID HORMONES Synthroid 200 Mcg Tablet 2THYROID HORMONES Synthroid 25 Mcg Tablet 2THYROID HORMONES Synthroid 300 Mcg Tablet 2THYROID HORMONES Synthroid 50 Mcg Tablet 2THYROID HORMONES Synthroid 75 Mcg Tablet 2THYROID HORMONES Synthroid 88 Mcg Tablet 2THYROID HORMONES Thyroid 120 Mg Tablet 1THYROID HORMONES Thyroid 15 Mg Tablet 1THYROID HORMONES Thyroid 30 Mg Tablet 1THYROID HORMONES Thyroid 60 Mg Tablet 1THYROID HORMONES Thyroid 90 Mg Tablet 1THYROID HORMONES Tirosint 100 Mcg Capsule 2THYROID HORMONES Tirosint 112 Mcg Capsule 2THYROID HORMONES Tirosint 125 Mcg Capsule 2THYROID HORMONES Tirosint 13 Mcg Capsule 2THYROID HORMONES Tirosint 137 Mcg Capsule 2THYROID HORMONES Tirosint 150 Mcg Capsule 2THYROID HORMONES Tirosint 175 Mcg Capsule 2THYROID HORMONES Tirosint 200 Mcg Capsule 2THYROID HORMONES Tirosint 25 Mcg Capsule 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 82: 2021 Rx Select - PRAM

THYROID HORMONES Tirosint 50 Mcg Capsule 2THYROID HORMONES Tirosint 75 Mcg Capsule 2THYROID HORMONES Tirosint 88 Mcg Capsule 2THYROID HORMONES Tirosint-sol 100 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 112 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 125 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 13 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 137 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 150 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 175 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 25 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 50 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 75 Mcg/Ml Soln 2THYROID HORMONES Tirosint-sol 88 Mcg/Ml Soln 2THYROID HORMONES Unithroid 100 Mcg Tablet 1THYROID HORMONES Unithroid 112 Mcg Tablet 1THYROID HORMONES Unithroid 125 Mcg Tablet 1THYROID HORMONES Unithroid 137 Mcg Tablet 1THYROID HORMONES Unithroid 150 Mcg Tablet 1THYROID HORMONES Unithroid 175 Mcg Tablet 1THYROID HORMONES Unithroid 200 Mcg Tablet 1THYROID HORMONES Unithroid 25 Mcg Tablet 1THYROID HORMONES Unithroid 300 Mcg Tablet 1THYROID HORMONES Unithroid 50 Mcg Tablet 1THYROID HORMONES Unithroid 75 Mcg Tablet 1THYROID HORMONES Unithroid 88 Mcg Tablet 1THYROID HORMONES Westhroid 130 Mg Tablet 1THYROID HORMONES Westhroid 32.5 Mg Tablet 1THYROID HORMONES Westhroid 65 Mg Tablet 1THYROID HORMONES Westhroid 97.5 Mg Tablet 1THYROID HORMONES Wp Thyroid 130 Mg Tablet 1THYROID HORMONES Wp Thyroid 16.25 Mg Tablet 1THYROID HORMONES Wp Thyroid 32.5 Mg Tablet 1THYROID HORMONES Wp Thyroid 65 Mg Tablet 1THYROID HORMONES Wp Thyroid 97.5 Mg Tablet 1TOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4) INHIB Eucrisa 2% Ointment 2TOPICAL AGENTS,MISCELLANEOUS Collatyl Wound Gel 1TOPICAL AGENTS,MISCELLANEOUS Saf-clens Af Wound Cleanser 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 100% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 20% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 25% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 30% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 35% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 40% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 50% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 75% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 80% 1TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 85% 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 83: 2021 Rx Select - PRAM

TOPICAL AGENTS,MISCELLANEOUS Trichloroacetic Acid 90% 1TOPICAL ANTIBIOTICS Clindacin Etz 1% Pledget 1TOPICAL ANTIBIOTICS Clindacin P 1% Pledgets 1TOPICAL ANTIBIOTICS Clindamycin Ph 1% Gel 1TOPICAL ANTIBIOTICS Clindamycin Ph 1% Solution 1TOPICAL ANTIBIOTICS Clindamycin Phos 1% Pledget 1TOPICAL ANTIBIOTICS Clindamycin Phosp 1% Lotion 1TOPICAL ANTIBIOTICS Clindamycin Phosphate 1% Foam 1TOPICAL ANTIBIOTICS Clindamycin Phosphate 1% Gel 1TOPICAL ANTIBIOTICS Ery 2% Pads 1TOPICAL ANTIBIOTICS Erythromycin 2% Gel 1TOPICAL ANTIBIOTICS Erythromycin 2% Pledgets 1TOPICAL ANTIBIOTICS Erythromycin 2% Solution 1TOPICAL ANTIBIOTICS Erythromycin-benzoyl Gel 1TOPICAL ANTIBIOTICS Gentamicin 0.1% Cream 1TOPICAL ANTIBIOTICS Gentamicin 0.1% Ointment 1TOPICAL ANTIBIOTICS Mupirocin 2% Cream 1TOPICAL ANTIBIOTICS Mupirocin 2% Oint Topical Syrg 1TOPICAL ANTIBIOTICS Mupirocin 2% Ointment 1TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY,STEROID AGENT Clotrimazole-betamethasone Crm 1TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY,STEROID AGENT Clotrimazole-betamethasone Lot 1TOPICAL ANTIFUNGALS Ciclodan 0.77% Cream 1TOPICAL ANTIFUNGALS Ciclodan 8% Solution 1TOPICAL ANTIFUNGALS Ciclopirox 0.77% Cream 1TOPICAL ANTIFUNGALS Ciclopirox 0.77% Gel 1TOPICAL ANTIFUNGALS Ciclopirox 0.77% Topical Susp 1TOPICAL ANTIFUNGALS Ciclopirox 1% Shampoo 1TOPICAL ANTIFUNGALS Ciclopirox 8% Solution 1TOPICAL ANTIFUNGALS Ciclopirox 8% Treatment Kit 1TOPICAL ANTIFUNGALS Clotrimazole 1% Cream 1TOPICAL ANTIFUNGALS Clotrimazole 1% Cream Grx 1TOPICAL ANTIFUNGALS Clotrimazole 1% Solution 1TOPICAL ANTIFUNGALS Econazole Nitrate 1% Cream 1TOPICAL ANTIFUNGALS Exoderm Lotion 3TOPICAL ANTIFUNGALS Jublia 10% Topical Solution 2TOPICAL ANTIFUNGALS Ketoconazole 2% Cream 1TOPICAL ANTIFUNGALS Ketoconazole 2% Foam 1TOPICAL ANTIFUNGALS Ketoconazole 2% Shampoo 1TOPICAL ANTIFUNGALS Luliconazole 1% Cream 3TOPICAL ANTIFUNGALS Miconazole-zinc-petro 0.25-15% 1TOPICAL ANTIFUNGALS Naftifine Hcl 1% Cream 1TOPICAL ANTIFUNGALS Naftifine Hcl 1% Gel 1TOPICAL ANTIFUNGALS Naftifine Hcl 2% Cream 1TOPICAL ANTIFUNGALS Nyamyc 100,000 Units/Gm Powder 1TOPICAL ANTIFUNGALS Nystatin 100,000 Unit/Gm Cream 1TOPICAL ANTIFUNGALS Nystatin 100,000 Unit/Gm Oint 1TOPICAL ANTIFUNGALS Nystatin 100,000 Unit/Gm Powd 1TOPICAL ANTIFUNGALS Nystatin-triamcinolone Cream 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 84: 2021 Rx Select - PRAM

TOPICAL ANTIFUNGALS Nystatin-triamcinolone Ointm 1TOPICAL ANTIFUNGALS Nystop 100,000 Units/Gm Powder 1TOPICAL ANTIFUNGALS Oxiconazole Nitrate 1% Cream 1TOPICAL ANTI-INFLAMMATORY NSAID-LOCAL ANESTHETIC Trixylitral 1.5%-3.88% Kit 2TOPICAL ANTI-INFLAMMATORY STEROIDAL Alclometasone Dipr 0.05% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Alclometasone Dipro 0.05% Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Amcinonide 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Amcinonide 0.1% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Amcinonide 0.1% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Anusol-hc 2.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Apexicon E 0.05% Cream 3TOPICAL ANTI-INFLAMMATORY STEROIDAL Beser 0.05% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp 0.05% Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp 0.05% Lot 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp 0.05% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp Aug 0.05% Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp Aug 0.05% Gel 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp Aug 0.05% Lot 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Dp Aug 0.05% Oin 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Va 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Va 0.1% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Valer 0.1% Ointm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Betamethasone Valer 0.12% Foam 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Gel 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Shampoo 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Solution 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol 0.05% Topical Lotn 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol Emollient 0.05% Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol Emollnt 0.05% Foam 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol Emulsion 0.05% Foam 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol Prop 0.05% Foam 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clobetasol Prop 0.05% Spray 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clocortolone 0.1% Cream Pump 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clocortolone Pivalate 0.1% Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Clodan 0.05% Shampoo 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Cormax 0.05% Solution 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desonide 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desonide 0.05% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desonide 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.05% Gel 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.25% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.25% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Desoximetasone 0.25% Spray 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Diflorasone 0.05% Cream 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 85: 2021 Rx Select - PRAM

TOPICAL ANTI-INFLAMMATORY STEROIDAL Diflorasone 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.01% Body Oil 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.01% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.01% Scalp Oil 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.01% Solution 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.025% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinolone 0.025% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide 0.05% Gel 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide 0.05% Solution 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluocinonide-e 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Flurandrenolide 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Flurandrenolide 0.05% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Flurandrenolide 0.05% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluticasone Prop 0.005% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluticasone Prop 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Fluticasone Prop 0.05% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Halcinonide 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Halobetasol Prop 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Halobetasol Prop 0.05% Foam 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Halobetasol Prop 0.05% Ointmnt 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocort Buty 0.1% Lipid Crm 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocort Buty 0.1% Lipo Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone 1% Cream 3TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone 2.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone 2.5% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone 2.5% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Buty 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Butyr 0.1% Lotn 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Butyr 0.1% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Butyr 0.1% Soln 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Val 0.2% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Hydrocortisone Val 0.2% Ointmt 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Micort Hc 2.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Mometasone Furoate 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Mometasone Furoate 0.1% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Mometasone Furoate 0.1% Soln 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Nolix 0.05% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Nolix 0.05% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Nutriarx Creampak 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Prednicarbate 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Prednicarbate 0.1% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Procto-med Hc 2.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Procto-pak 1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Proctosol-hc 2.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Proctozone-hc 2.5% Cream 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 86: 2021 Rx Select - PRAM

TOPICAL ANTI-INFLAMMATORY STEROIDAL Quinosone Combo Pack 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Sanadermrx Skin Repair Soln 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.025% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.025% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.025% Oint 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.1% Lotion 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.1% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.147 Mg/G Spray 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triamcinolone 0.5% Ointment 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Trianex 0.05% Ointment 3TOPICAL ANTI-INFLAMMATORY STEROIDAL Triderm 0.1% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Triderm 0.5% Cream 1TOPICAL ANTI-INFLAMMATORY STEROIDAL Whytederm Tdpak 2TOPICAL ANTI-INFLAMMATORY STEROIDAL Whytederm Trilasil Pak 2TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC Hydrocort-pramoxine 2.5-1% Crm 1TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC Lidocaine-hc 3-0.5% Cream 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Capsfenac Pak 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclo Gel 1% Pak 3TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclofenac 1.5% Topical Soln 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclofenac Epolamine 1.3% Ptch 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclofenac Sodium 1% Gel 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclofex Dc Pack 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclopak Kit 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclosaicin Topical Therapy Kt 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Diclotral Pak 1TOPICAL ANTI-INFLAMMATORY, NSAIDS Inflamma-k Kit 2TOPICAL ANTI-INFLAMMATORY, NSAIDS Lexixryl 1.5% Kit 3TOPICAL ANTI-INFLAMMATORY, NSAIDS Xelitral Pack 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Carac 0.5% Cream 2TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Diclofenac Sodium 3% Gel 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Fluorouracil 0.5% Cream 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Fluorouracil 2% Topical Soln 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Fluorouracil 5% Cream 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Fluorouracil 5% Topical Soln 1TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Picato 0.015% Gel 2TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Picato 0.05% Gel 2TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Tolak 4% Cream 2TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Valchlor 0.016% Gel 2TOPICAL ANTIPARASITICS Crotan 10% Lotion 1TOPICAL ANTIPARASITICS Lindane 1% Shampoo 2TOPICAL ANTIPARASITICS Malathion 0.5% Lotion 1TOPICAL ANTIPARASITICS Permethrin 5% Cream 1TOPICAL ANTIPARASITICS Spinosad 0.9% Topical Susp 3TOPICAL ANTIVIRALS Acyclovir 5% Cream 1TOPICAL ANTIVIRALS Acyclovir 5% Ointment 1TOPICAL HEMOSTATICS Avitene Flour 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 87: 2021 Rx Select - PRAM

TOPICAL HEMOSTATICS Gelfoam Powder 2TOPICAL HEMOSTATICS Monsel's Ferric Subsulfate Sol 2TOPICAL HEMOSTATICS Surgifoam Sponge Size 100 3TOPICAL HEMOSTATICS Surgifoam Sponge Size 100c 1TOPICAL HEMOSTATICS Surgifoam Sponge Size 12-7 1TOPICAL HEMOSTATICS Syringe Avitene Flour 2TOPICAL IMMUNOSUPPRESSIVE AGENTS Pimecrolimus 1% Cream 1TOPICAL IMMUNOSUPPRESSIVE AGENTS Tacrolimus 0.03% Ointment 1TOPICAL IMMUNOSUPPRESSIVE AGENTS Tacrolimus 0.1% Ointment 1TOPICAL LOCAL ANESTHETICS Agoneaze 2.5%-2.5% Cream Dress 1TOPICAL LOCAL ANESTHETICS Anodyne Lpt 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Aprizio Pak 1TOPICAL LOCAL ANESTHETICS Astero 4% Gel Pump 1TOPICAL LOCAL ANESTHETICS Dermacinrx Empricaine Kit 1TOPICAL LOCAL ANESTHETICS Dermacinrx Prizopak Kit 1TOPICAL LOCAL ANESTHETICS Dermazyl Kit 3TOPICAL LOCAL ANESTHETICS Dolotranz 2.5%-2.5% Crm-4% Gel 3TOPICAL LOCAL ANESTHETICS Leva Set 2.5%-2.5% Cream-dress 1TOPICAL LOCAL ANESTHETICS Lidocaine 3% Cream 1TOPICAL LOCAL ANESTHETICS Lidocaine 5% Ointment 1TOPICAL LOCAL ANESTHETICS Lidocaine 5% Patch 1TOPICAL LOCAL ANESTHETICS Lidocaine Hcl 3% Lotion 1TOPICAL LOCAL ANESTHETICS Lidocaine Hcl 3.88% Cream 1TOPICAL LOCAL ANESTHETICS Lidocaine-epinephr-tetra Soln 3TOPICAL LOCAL ANESTHETICS Lidocaine-prilocaine Cream 1TOPICAL LOCAL ANESTHETICS Lidocaine-tetracaine 7%-7% Crm 1TOPICAL LOCAL ANESTHETICS Lido-k 3% Lotion 1TOPICAL LOCAL ANESTHETICS Lidopin 3% Cream 1TOPICAL LOCAL ANESTHETICS Lidopril 2.5%-2.5% Cream-dress 1TOPICAL LOCAL ANESTHETICS Lidopril Xr 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Lido-prilo Caine Pack 1TOPICAL LOCAL ANESTHETICS Lidorx 3% Gel 2TOPICAL LOCAL ANESTHETICS Lido-sorb 3% Lotion 1TOPICAL LOCAL ANESTHETICS Lidotrex 2%-1.2%-1% Wound Gel 2TOPICAL LOCAL ANESTHETICS Lidozion 3% Lotion 1TOPICAL LOCAL ANESTHETICS Liprozonepak 2.5-2.5% Crm-drss 1TOPICAL LOCAL ANESTHETICS Livixil Pak 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Medolor Pak 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Neurcaine 5% Kit 3TOPICAL LOCAL ANESTHETICS Nuvakaan Kit 1TOPICAL LOCAL ANESTHETICS Prikaan 2.5%-2.5% Cream Dress 1TOPICAL LOCAL ANESTHETICS Prikaan Lite 2.5-2.5% Crm Drss 1TOPICAL LOCAL ANESTHETICS Prilolid 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Prilovix 2.5%-2.5% Cream Dress 1TOPICAL LOCAL ANESTHETICS Prilovix Lite 2.5%-2.5% Cream 1TOPICAL LOCAL ANESTHETICS Prilovix Lite Plus 2.5%-2.5% 1TOPICAL LOCAL ANESTHETICS Prilovix Plus 2.5%-2.5% Cream 1TOPICAL LOCAL ANESTHETICS Prilovix Ultralite 2.5%-2.5% 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 88: 2021 Rx Select - PRAM

TOPICAL LOCAL ANESTHETICS Relador Pak 2.5-2.5% Crm-dress 1TOPICAL LOCAL ANESTHETICS Relador Pak Plus 2.5%-2.5% 1TOPICAL LOCAL ANESTHETICS Solupak Kit 2TOPICAL LOCAL ANESTHETICS Vexasyn Wound Gel 2TOPICAL LOCAL ANESTHETICS Ztlido 1.8% Topical System 2TOPICAL PREPARATIONS,ANTIBACTERIALS Dermazene Cream 1TOPICAL PREPARATIONS,ANTIBACTERIALS Hydrocort-iodoquinol-aloe Sach 1TOPICAL PREPARATIONS,ANTIBACTERIALS Hydrocortisone-iodoquinol Crm 1TOPICAL PREPARATIONS,ANTIBACTERIALS Iodine 5% Strong Solution 1TOPICAL PREPARATIONS,ANTIBACTERIALS Iodine Strong Solution 1TOPICAL PREPARATIONS,ANTIBACTERIALS Iodoquinol-hydrocort-aloe Gel 1TOPICAL PREPARATIONS,ANTIBACTERIALS Lugol's Strong Iodine Solution 1TOPICAL PREPARATIONS,ANTIBACTERIALS Silver Nitrate 0.5% Soln 1TOPICAL PREPARATIONS,ANTIBACTERIALS Silver Nitrate 25% Solution 1TOPICAL PREPARATIONS,ANTIBACTERIALS Silver Nitrate 50% Solution 1TOPICAL PREPARATIONS,ANTIBACTERIALS Silvrstat Dressing Gel 2TOPICAL PREPARATIONS,ANTIBACTERIALS Solox Wound Gel 2TOPICAL SULFONAMIDES Avar Cleanser 1TOPICAL SULFONAMIDES Avar-e Emollient Cream 1TOPICAL SULFONAMIDES Avar-e Green Emollient Cream 1TOPICAL SULFONAMIDES Mafenide Acetate 50 Gm Powd Pk 1TOPICAL SULFONAMIDES Rosanil Cleanser Lotion 1TOPICAL SULFONAMIDES Rosula 10%-5% Cloths 3TOPICAL SULFONAMIDES Silver Sulfadiazine 1% Cream 1TOPICAL SULFONAMIDES Sod Sulface-sulf 9.8-4.8% Clsr 1TOPICAL SULFONAMIDES Sod Sulface-sulfur 9-4.5% Wash 1TOPICAL SULFONAMIDES Sod Sulfacetamide-sulfur Lotn 1TOPICAL SULFONAMIDES Sod Sulfacetamide-sulfur Susp 1TOPICAL SULFONAMIDES Sod Sulfacet-sulfur 10-2% Clsr 1TOPICAL SULFONAMIDES Sod Sulfacet-sulfur 10-4% Pad 1TOPICAL SULFONAMIDES Sod Sulfacet-sulfur 10-5% Clsr 1TOPICAL SULFONAMIDES Sod Sulfac-sulfur 9.8-4.8% Crm 1TOPICAL SULFONAMIDES Sod Sulfac-sulfur 9.8-4.8% Lot 1TOPICAL SULFONAMIDES Sodium Sulfacet-sulfur Wash 1TOPICAL SULFONAMIDES Sodium Sulf-sulfur Cleanser 1TOPICAL SULFONAMIDES Sss 10-5 Cream 1TOPICAL SULFONAMIDES Sss 10-5 Foam 1TOPICAL SULFONAMIDES Sulfacet Sod-sulfur 10-4% Pad 1TOPICAL SULFONAMIDES Sulfacetamide-sulfur 10-2% Crm 1TOPICAL SULFONAMIDES Sulfacetamide-sulfur 10-5% Crm 1TOPICAL SULFONAMIDES Sulfacetamide-sulfur 8-4% Susp 1TOPICAL SULFONAMIDES Sulfacleanse 8-4 Suspension 1TOPICAL SULFONAMIDES Sulfamylon 8.5% Cream 2TOPICAL VIT D ANALOG/ANTI-INFLAMMATORY STEROID Calcipotriene-betameth Dp Oint 1TOPICAL VIT D ANALOG/ANTI-INFLAMMATORY STEROID Enstilar 0.005%-0.064% Foam 2TOPICAL VIT D ANALOG/ANTI-INFLAMMATORY STEROID Taclonex 0.005%-0.064% Suspens 2TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES Santyl Ointment 2TOXIN-PRODUCING BACILLI VACCINES/TOXOIDS Vaxchora Vaccine 2

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 89: 2021 Rx Select - PRAM

TRICYCLIC ANTIDEPRESSANT-BENZODIAZEPINE COMBINATNS Chlordiazepo-amitriptyl 5-12.5 1TRICYCLIC ANTIDEPRESSANT-BENZODIAZEPINE COMBINATNS Chlordiazepox-amitriptyl 10-25 1TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS Perphen-amitrip 2 Mg-10 Mg Tab 1TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS Perphen-amitrip 2 Mg-25 Mg Tab 1TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS Perphen-amitrip 4 Mg-10 Mg Tab 1TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS Perphen-amitrip 4 Mg-25 Mg Tab 1TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS Perphen-amitrip 4 Mg-50 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 10 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 100 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 150 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 25 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 50 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amitriptyline Hcl 75 Mg Tab 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amoxapine 100 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amoxapine 150 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amoxapine 25 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Amoxapine 50 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Clomipramine 25 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Clomipramine 50 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Clomipramine 75 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 10 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 100 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 150 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 25 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 50 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Desipramine 75 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 10 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 10 Mg/Ml Oral Conc 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 100 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 150 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 25 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 50 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Doxepin 75 Mg Capsule 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Hcl 10 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Hcl 25 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Hcl 50 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Pamoate 100 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Pamoate 125 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Pamoate 150 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Imipramine Pamoate 75 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Maprotiline 25 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Maprotiline 50 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Maprotiline 75 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Nortriptyline 10 Mg/5 Ml Soln 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Nortriptyline Hcl 10 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Nortriptyline Hcl 25 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Nortriptyline Hcl 50 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Nortriptyline Hcl 75 Mg Cap 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 90: 2021 Rx Select - PRAM

TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Protriptyline Hcl 10 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Protriptyline Hcl 5 Mg Tablet 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Trimipramine Maleate 100 Mg Cp 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Trimipramine Maleate 25 Mg Cap 1TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIB Trimipramine Maleate 50 Mg Cap 1TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Clonidine Hcl Er 0.1 Mg Tablet 1TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Guanfacine Hcl Er 1 Mg Tablet 1TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Guanfacine Hcl Er 2 Mg Tablet 1TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Guanfacine Hcl Er 3 Mg Tablet 1TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Guanfacine Hcl Er 4 Mg Tablet 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Daytrana 10 Mg/9 Hr Patch 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Daytrana 15 Mg/9 Hr Patch 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Daytrana 20 Mg/9 Hour Patch 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Daytrana 30 Mg/9 Hour Patch 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate 10 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate 2.5 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate 5 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 10 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 15 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 20 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 25 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 30 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 35 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 40 Mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Dexmethylphenidate Er 5 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Metadate Er 20 Mg Tablet 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 10 Mg Chew Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 10 Mg Tablet 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 10 Mg/5 Ml Sol 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 2.5 Mg Chew Tb 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 20 Mg Tablet 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 5 Mg Chew Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 5 Mg Tablet 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate 5 Mg/5 Ml Soln 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 10 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 20 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 30 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 40 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 50 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Cd 60 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 10 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 18 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 20 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 27 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 36 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 54 Mg Tab 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er 72 Mg Tab 3TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 10mg Cp 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 91: 2021 Rx Select - PRAM

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 20mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 30mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 40mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 50mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(cd) 60mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(la) 10mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(la) 20mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(la) 30mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate Er(la) 40mg Cp 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate La 10 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate La 20 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate La 30 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate La 40 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Methylphenidate La 60 Mg Cap 1TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Quillichew Er 20 Mg Chew Tab 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Quillichew Er 30 Mg Chew Tab 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Quillichew Er 40 Mg Chew Tab 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Quillivant Xr 25 Mg/5 Ml Susp 2TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY Relexxii Er 72 Mg Tablet 3TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 10 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 100 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 18 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 25 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 40 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 60 Mg Capsule 1TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE Atomoxetine Hcl 80 Mg Capsule 1URICOSURIC AGENTS Probenecid 500 Mg Tablet 1URICOSURIC AGENTS Probenecid-colchicine Tablet 1URINARY PH MODIFIERS K-phos #2 Tablet 2URINARY PH MODIFIERS K-phos Neutral Tablet 1URINARY PH MODIFIERS K-phos Original Tablet 2URINARY PH MODIFIERS Potassium Citrate Er 10 Meq Tb 1URINARY PH MODIFIERS Potassium Citrate Er 15 Meq Tb 1URINARY PH MODIFIERS Potassium Citrate Er 5 Meq Tab 1URINARY PH MODIFIERS Renacidin Irrigation Solution 2URINARY TRACT ANALGESIC AGENTS Elmiron 100 Mg Capsule 2URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) Phenazopyridine 100 Mg Tab 1URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) Phenazopyridine 200 Mg Tab 1URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) Phenazopyridine 95 Mg Tablet 1URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Darifenacin Er 15 Mg Tablet 1URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Darifenacin Er 7.5 Mg Tablet 1URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Solifenacin 10 Mg Tablet 2URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Solifenacin 5 Mg Tablet 2URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Vesicare 10 Mg Tablet 2URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. Vesicare 5 Mg Tablet 2URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Flavoxate Hcl 100 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Oxybutynin 5 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Oxybutynin 5 Mg/5 Ml Syrup 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 92: 2021 Rx Select - PRAM

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Oxybutynin Cl Er 10 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Oxybutynin Cl Er 15 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Oxybutynin Cl Er 5 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Tolterodine Tart Er 2 Mg Cap 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Tolterodine Tart Er 4 Mg Cap 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Tolterodine Tartrate 1 Mg Tab 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Tolterodine Tartrate 2 Mg Tab 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Toviaz Er 4 Mg Tablet 2URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Toviaz Er 8 Mg Tablet 2URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Trospium Chloride 20 Mg Tablet 1URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT Trospium Chloride Er 60 Mg Cap 1URINARY TRACT RADIOPAQUE DIAGNOSTICS Md-gastroview 66%-10% Soln 1URINE ACETONE TEST AIDS Ketostix Reagent Strip 2URINE GLUCOSE TEST AIDS Diastix Reagent Strips 2URINE GLUCOSE TEST AIDS No-stick Glucose Test Strips 2URINE GLUCOSE/ACETONE TEST AIDS,STRIPS Keto-diastix Reagent Strips 1URINE MULTIPLE TEST AIDS Chek-stix Strips 1URINE MULTIPLE TEST AIDS Chemstrip 10 Md 1URINE MULTIPLE TEST AIDS Chemstrip 10 With Sg 1URINE MULTIPLE TEST AIDS Chemstrip 2 Gp 1URINE MULTIPLE TEST AIDS Chemstrip 50b 1URINE MULTIPLE TEST AIDS Chemstrip 7 1URINE MULTIPLE TEST AIDS Chemstrip-9 1URINE MULTIPLE TEST AIDS Combistix Reagent Strips 1URINE MULTIPLE TEST AIDS Hema-combistix Reagent Strips 1URINE MULTIPLE TEST AIDS Labstix Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix 10 Sg Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix 5 Strips 1URINE MULTIPLE TEST AIDS Multistix 7 Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix 8 Sg Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix 9 Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix 9 Sg Reagent Strips 1URINE MULTIPLE TEST AIDS Multistix Reagent Strips 1URINE MULTIPLE TEST AIDS Uristix 4 Reagent Strips 1URINE MULTIPLE TEST AIDS Uristix Reagent Strips 1URINE TEST AIDS,MISCELLANEOUS Azo Test Strip 1URINE TEST AIDS,MISCELLANEOUS Chemstrip 2 Ln 1URINE TEST AIDS,MISCELLANEOUS Reveal Uti Test Strip 1VAGINAL ANTIBIOTICS Clindamycin 2% Vaginal Cream 1VAGINAL ANTIBIOTICS Metronidazole Vaginal 0.75% Gl 1VAGINAL ANTIFUNGALS Gynazole 1 2% Cream 3VAGINAL ANTIFUNGALS Terconazole 0.4% Cream 1VAGINAL ANTIFUNGALS Terconazole 0.8% Cream 1VAGINAL ANTIFUNGALS Terconazole 80 Mg Suppository 1VAGINAL ANTISEPTICS Relagard Vaginal Gel 2VAGINAL ESTROGEN PREPARATIONS Estrace 0.01% Cream 1VAGINAL ESTROGEN PREPARATIONS Estradiol 0.01% Cream 1VAGINAL ESTROGEN PREPARATIONS Estradiol 10 Mcg Vaginal Insrt 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 93: 2021 Rx Select - PRAM

VAGINAL ESTROGEN PREPARATIONS Estring 2 Mg Vaginal Ring 2VAGINAL ESTROGEN PREPARATIONS Premarin Vaginal Cream-appl 2VAGINAL ESTROGEN PREPARATIONS Yuvafem 10 Mcg Vaginal Insert 1VAGINAL ESTROGEN PREPARATIONS Yuvafem 10 Mcg Vaginal Tablet 1VANCOMYCIN ANTIBIOTICS AND DERIVATIVES Vancomycin Hcl 125 Mg Capsule 1VANCOMYCIN ANTIBIOTICS AND DERIVATIVES Vancomycin Hcl 250 Mg Capsule 1VASODILATORS,CORONARY Dilatrate-sr 40 Mg Capsule 2VASODILATORS,CORONARY Isochron 40 Mg Tablet Sa 1VASODILATORS,CORONARY Isosorbide Dinitr Er 40 Mg Tab 1VASODILATORS,CORONARY Isosorbide Dinitrate 10 Mg Tab 1VASODILATORS,CORONARY Isosorbide Dinitrate 20 Mg Tab 1VASODILATORS,CORONARY Isosorbide Dinitrate 30 Mg Tab 1VASODILATORS,CORONARY Isosorbide Dinitrate 5 Mg Tab 1VASODILATORS,CORONARY Isosorbide Mononit 10 Mg Tab 1VASODILATORS,CORONARY Isosorbide Mononit 20 Mg Tab 1VASODILATORS,CORONARY Isosorbide Mononit Er 120 Mg 1VASODILATORS,CORONARY Isosorbide Mononit Er 30 Mg Tb 1VASODILATORS,CORONARY Isosorbide Mononit Er 60 Mg Tb 1VASODILATORS,CORONARY Minitran 0.1 Mg/Hr Patch 1VASODILATORS,CORONARY Minitran 0.2 Mg/Hr Patch 1VASODILATORS,CORONARY Minitran 0.4 Mg/Hr Patch 1VASODILATORS,CORONARY Minitran 0.6 Mg/Hr Patch 1VASODILATORS,CORONARY Nitro-bid 2% Ointment 2VASODILATORS,CORONARY Nitro-dur 0.3 Mg/Hr Patch 2VASODILATORS,CORONARY Nitro-dur 0.8 Mg/Hr Patch 2VASODILATORS,CORONARY Nitroglycerin 0.1 Mg/Hr Patch 1VASODILATORS,CORONARY Nitroglycerin 0.2 Mg/Hr Patch 1VASODILATORS,CORONARY Nitroglycerin 0.3 Mg Tablet Sl 1VASODILATORS,CORONARY Nitroglycerin 0.4 Mg Tablet Sl 1VASODILATORS,CORONARY Nitroglycerin 0.4 Mg/Hr Patch 1VASODILATORS,CORONARY Nitroglycerin 0.6 Mg Tablet Sl 1VASODILATORS,CORONARY Nitroglycerin 0.6 Mg/Hr Patch 1VASODILATORS,CORONARY Nitroglycerin Er 2.5 Mg Cap 1VASODILATORS,CORONARY Nitroglycerin Er 6.5 Mg Cap 1VASODILATORS,CORONARY Nitroglycerin Er 9 Mg Capsule 1VASODILATORS,CORONARY Nitroglycerin Lingual 0.4 Mg 1VASODILATORS,CORONARY Nitro-time Er 2.5 Mg Capsule 1VASODILATORS,CORONARY Nitro-time Er 6.5 Mg Capsule 1VASODILATORS,CORONARY Nitro-time Er 9 Mg Capsule 1VASODILATORS,PERIPHERAL Ergoloid Mesylates 1 Mg Tab 1VASODILATORS,PERIPHERAL Isoxsuprine 10 Mg Tablet 1VASODILATORS,PERIPHERAL Isoxsuprine 20 Mg Tablet 1VITAMIN A DERIVATIVES Adapalene 0.1% Cream 1VITAMIN A DERIVATIVES Adapalene 0.1% Gel 1VITAMIN A DERIVATIVES Adapalene 0.1% Lotion 1VITAMIN A DERIVATIVES Adapalene 0.1% Solution 1VITAMIN A DERIVATIVES Adapalene 0.1% Swab 1VITAMIN A DERIVATIVES Adapalene 0.3% Gel 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary

Page 94: 2021 Rx Select - PRAM

VITAMIN A DERIVATIVES Adapalene 0.3% Gel Pump 1VITAMIN A DERIVATIVES Avita 0.025% Gel 1VITAMIN A DERIVATIVES Retin-a 0.025% Gel 1VITAMIN A DERIVATIVES Tretinoin 0.01% Gel 1VITAMIN A DERIVATIVES Tretinoin 0.025% Cream 1VITAMIN A DERIVATIVES Tretinoin 0.025% Gel 1VITAMIN A DERIVATIVES Tretinoin 0.05% Cream 1VITAMIN A DERIVATIVES Tretinoin 0.05% Gel 1VITAMIN A DERIVATIVES Tretinoin 0.1% Cream 1VITAMIN A DERIVATIVES Tretinoin Gel Micro 0.04% Pump 1VITAMIN A DERIVATIVES Tretinoin Gel Micro 0.04% Tube 1VITAMIN A DERIVATIVES Tretinoin Gel Micro 0.1% Pump 1VITAMIN A DERIVATIVES Tretinoin Gel Micro 0.1% Tube 1WOUND HEALING AGENTS, LOCAL Balsam Peru-castor Oil Oint 2WOUND HEALING AGENTS, LOCAL Bpco Ointment 2WOUND HEALING AGENTS, LOCAL Dermulcera Ointment 2WOUND HEALING AGENTS, LOCAL Nusurgepak Surgical Prep 1XANTHINES Caffeine Cit 60 Mg/3 Ml Oral 1XANTHINES Theochron Er 100 Mg Tablet 1XANTHINES Theochron Er 200 Mg Tablet 1XANTHINES Theochron Er 300 Mg Tablet 1XANTHINES Theophylline 80 Mg/15 Ml Soln 1XANTHINES Theophylline Er 100 Mg Tablet 1XANTHINES Theophylline Er 200 Mg Tablet 1XANTHINES Theophylline Er 300 Mg Tab 1XANTHINES Theophylline Er 400 Mg Tablet 1XANTHINES Theophylline Er 450 Mg Tab 1XANTHINES Theophylline Er 600 Mg Tablet 1

PRAM Insurance Services, Inc. 2021 RxSelect "Enhanced" Formulary