FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option

Effective July 1, 2021

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION ...... 5 PREFACE ...... 5 MANAGED NOT COVERED DRUGS ...... 6 PRIOR APPROVAL ...... 6 QUANTITY LIMITATIONS ...... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ...... 6 PRODUCT SELECTION CRITERIA ...... 6 FORMULARY PRODUCT DESCRIPTIONS ...... 7 GENERIC SUBSTITUTION ...... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ...... 8 EDITOR ...... 8 NOTICE ...... 8 LEGEND ...... 8 ANALGESICS ...... 10 ANALGESICS, OTHER ...... 10 NSAIDs ...... 10 NSAIDs, COMBINATIONS ...... 10 NSAIDs, TOPICAL ...... 10 COX-2 INHIBITORS ...... 10 GOUT ...... 10 OPIOID ANALGESICS ...... 10 NON-OPIOID ANALGESICS ...... 11 VISCOSUPPLEMENTS ...... 11 ANTI-INFECTIVES ...... 12 ANTIBACTERIALS ...... 12 ANTIFUNGALS ...... 13 ANTIMALARIALS ...... 14 ANTIRETROVIRAL AGENTS ...... 14 ANTITUBERCULAR AGENTS ...... 15 ANTIVIRALS ...... 15 MISCELLANEOUS ...... 16 ANTINEOPLASTIC AGENTS ...... 17 ALKYLATING AGENTS ...... 17 ANTIMETABOLITES ...... 17 HORMONAL ANTINEOPLASTIC AGENTS ...... 17 IMMUNOMODULATORS ...... 18 KINASE INHIBITORS ...... 18 MULTIPLE MYELOMA ...... 19 TOPOISOMERASE INHIBITORS ...... 19 MISCELLANEOUS ...... 20 CARDIOVASCULAR ...... 22 ACE INHIBITORS ...... 22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 22 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 22 ADRENOLYTICS, CENTRAL ...... 22

1 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 23 ALPHA BLOCKERS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 23 ANTIARRHYTHMICS ...... 23 ANTILIPEMICS ...... 24 BETA-BLOCKERS ...... 24 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 25 CALCIUM CHANNEL BLOCKERS ...... 25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 25 DIGITALIS GLYCOSIDES ...... 25 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 25 DIURETICS ...... 25 HEART FAILURE ...... 26 NITRATES ...... 26 PULMONARY ARTERIAL HYPERTENSION ...... 26 MISCELLANEOUS ...... 27 CENTRAL NERVOUS SYSTEM ...... 27 ANTIANXIETY ...... 27 ANTICONVULSANTS ...... 27 ANTIDEMENTIA...... 28 ANTIDEPRESSANTS ...... 28 ANTIPARKINSONIAN AGENTS ...... 30 ANTIPSYCHOTICS ...... 30 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 31 FIBROMYALGIA ...... 31 HYPNOTICS ...... 32 MIGRAINE ...... 32 MOOD STABILIZERS ...... 33 MOVEMENT DISORDERS ...... 33 MULTIPLE SCLEROSIS ...... 33 MUSCULOSKELETAL THERAPY AGENTS ...... 33 MYASTHENIA GRAVIS ...... 33 NARCOLEPSY/CATAPLEXY ...... 33 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 34 MISCELLANEOUS ...... 34 ENDOCRINE AND METABOLIC ...... 35 ANDROGENS ...... 35 ANTIDIABETICS ...... 35 CALCIUM RECEPTOR ANTAGONISTS ...... 37 CALCIUM REGULATORS ...... 37 CARNITINE DEFICIENCY AGENTS ...... 38 CONTRACEPTIVES ...... 38 ENDOMETRIOSIS ...... 39 ESTROGENS ...... 40 ESTROGEN/PROGESTINS ...... 40 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ...... 40 FERTILITY REGULATORS ...... 40 GAUCHER DISEASE ...... 41 GLUCOCORTICOIDS ...... 41 GLUCOSE ELEVATING AGENTS ...... 41 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ...... 41 HUMAN GROWTH HORMONES ...... 41 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 41 INSULIN-LIKE GROWTH FACTOR-1 AGENTS ...... 41 PHENYLKETONURIA TREATMENT AGENTS ...... 41 PHOSPHATE BINDER AGENTS ...... 42 POTASSIUM-REMOVING AGENTS ...... 42 PROGESTINS ...... 42 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 42 THYROID AGENTS ...... 42 UREA CYCLE DISORDERS ...... 42 UTERINE FIBROIDS ...... 42 VASOPRESSINS ...... 42

2 MISCELLANEOUS ...... 43 GASTROINTESTINAL ...... 43 ANTIDIARRHEALS ...... 44 ANTIEMETICS ...... 44 ANTISPASMODICS ...... 44 CHOLELITHOLYTICS ...... 44 H2 RECEPTOR ANTAGONISTS ...... 44 INFLAMMATORY BOWEL DISEASE ...... 44 IRRITABLE BOWEL SYNDROME ...... 45 LAXATIVES ...... 45 OPIOID-INDUCED CONSTIPATION ...... 45 PANCREATIC ENZYMES ...... 45 PROSTAGLANDINS ...... 45 PROTON PUMP INHIBITORS ...... 45 SALIVA STIMULANTS ...... 45 STEROIDS, RECTAL ...... 46 ULCER THERAPY COMBINATIONS ...... 46 MISCELLANEOUS ...... 46 GENITOURINARY ...... 46 BENIGN PROSTATIC HYPERPLASIA ...... 46 URINARY ANTISPASMODICS ...... 46 VAGINAL ANTI-INFECTIVES ...... 46 MISCELLANEOUS ...... 47 HEMATOLOGIC ...... 47 ANTICOAGULANTS ...... 47 HEMATOPOIETIC GROWTH FACTORS ...... 47 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ...... 47 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...... 48 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ...... 48 PLATELET AGGREGATION INHIBITORS ...... 48 PLATELET SYNTHESIS INHIBITORS ...... 49 SICKLE CELL DISEASE ...... 49 STEM CELL MOBILIZERS ...... 49 THROMBOCYTOPENIA AGENTS ...... 49 MISCELLANEOUS ...... 49 IMMUNOLOGIC AGENTS ...... 49 ALLERGENIC EXTRACTS ...... 49 AUTOIMMUNE AGENTS ...... 49 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 50 HEREDITARY ANGIOEDEMA AGENTS ...... 50 IMMUNE GLOBULINS ...... 50 IMMUNOMODULATORS ...... 51 IMMUNOSUPPRESSANTS ...... 51 NUTRITIONAL/SUPPLEMENTS ...... 51 ELECTROLYTES ...... 51 VITAMINS AND MINERALS ...... 52 MISCELLANEOUS ...... 52 RESPIRATORY ...... 52 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ...... 52 ANAPHYLAXIS TREATMENT AGENTS ...... 52 ANTICHOLINERGICS ...... 52 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 53 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ...... 53 ANTIHISTAMINES, SEDATING ...... 53 ANTITUSSIVES ...... 53 ANTITUSSIVE COMBINATIONS ...... 53 BETA AGONISTS ...... 53 CYSTIC FIBROSIS ...... 54 LEUKOTRIENE MODULATORS ...... 54 MAST CELL STABILIZERS ...... 54 NASAL ANTIHISTAMINES ...... 54 NASAL STEROIDS/COMBINATIONS ...... 54 PHOSPHODIESTERASE-4 INHIBITORS...... 54 PULMONARY FIBROSIS AGENTS ...... 54

3 SEVERE ASTHMA AGENTS ...... 54 STEROID/BETA AGONIST COMBINATIONS ...... 54 STEROID INHALANTS ...... 55 XANTHINES ...... 55 MISCELLANEOUS ...... 55 TOPICAL ...... 55 DERMATOLOGY ...... 55 MOUTH/THROAT/DENTAL AGENTS ...... 59 OPHTHALMIC ...... 59 OTIC ...... 62 WEBSITES ...... 63 2021 FEP MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART ...... 65 INDEX ...... 73

The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.

INTRODUCTION FEP is pleased to provide the 2021 FEP 5 Tier Managed Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Managed Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/ on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication. PREFACE The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Managed Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 generic drugs preferred brand- non-preferred brand-name preferred non-preferred name drugs drugs and all compounded specialty drugs specialty drugs medications Basic Option Preferred $10 copay for $55 copay for a 60% coinsurance* $65 copay $90 copay Retail Pharmacy a 0 to 30-day 0 to 30-day Limit***: one 30- Limit***: one 30- supply supply day supply fill at day supply fill at retail retail $30 copay for $165 copay for 31 to 90-day 31 to 90-day supply supply Basic Option Specialty $85 for a 0 to 30- $110 for a 0 to Drug Pharmacy Program day supply 30-day supply

$235 for 31 to $300 for 31 to 90-day supply 90-day supply Basic Option Retail $10 copay $50 copay for a 50% coinsurance** $60 copay $80 copay Pharmacy (Med B for a 0 to 30- 0 to 30-day Limit***: one 30- Limit***: one 30- Primary) day supply supply day supply fill at day supply fill at retail retail $30 copay for $150 copay for 31 to 90-day 31 to 90-day supply supply Basic Option Mail $20 copay $100 copay $125 copay Pharmacy (Med B Primary) Basic Option Specialty $80 for a 0 to 30- $100 for a 0 to Drug Pharmacy Program day supply 30-day supply (Med B Primary)

$210 for 31 to $255 for 31 to 90-day supply 90-day supply * With a minimum payment of $75 for a 0 to 30-day supply ($210 for a 31 to 90-day supply)

** With a minimum payment of $60 for a 0 to 30-day supply ($175 for a 31 to 90-day supply)

*** First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication.

Drug products shown in boldface type indicate generic availability.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non- preferred, typically if the cost-effectiveness is less than other similar drugs. MANAGED NOT COVERED DRUGS Effective January 1, 2021, selected medications will no longer be covered on the Basic Option drug benefit plan. These medications known as Managed Not Covered drugs have available covered options in the same therapeutic class. For a full listing of these Managed Not Covered medications please see the MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART located on page 65 before the INDEX in this document.

Patients taking a Managed Not Covered medication on or after January 1, 2021 should expect to pay the full cost of the prescription. PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page. QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page. PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes the evaluation of new medications, and making recommendations to FEP for their designation as preferred or non-preferred on the FEP 5 Tier Managed Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP. PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

• Safety • Efficacy • Comparison studies • Drug interactions • Approved indications • Formulation and administration • Adverse effects • Contraindications

• Pharmacokinetics • Patient compliance considerations • Medical outcome and pharmacoeconomic studies

When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Managed Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber. FORMULARY PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Preferred products include all strengths and dosage forms of the cited brand-name product. sevelamer carbonate Renvela Oral powder packets, tabs and all strengths of Renvela would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not. acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.

sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary.

Dosage forms will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI- INFECTIVES section of the formulary.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand- name equivalents. Prescription generic drugs are:

• Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. • Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. • Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. DRUG EFFICACY STUDY IMPLEMENTATION DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products. EDITOR Your comments and suggestions regarding this FEP 5 Tier Managed Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115 NOTICE The information contained in this FEP 5 Tier Managed Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Managed Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Managed Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date. LEGEND † Generic contraceptives are covered at no charge to qualifying members ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for both brands and generics ST Step Therapy - indicates the requirement for previous use of one or more drugs before coverage is provided for the targeted drug

boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org

ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org

acetaminophen inj Tier 1 OFIRMEV Tier 3

NSAIDs diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac ext-rel Tier 1 flurbiprofen Tier 1 ibuprofen Tier 1 indomethacin (except caps 20 mg, 40 mg) Tier 1 indomethacin ext-rel Tier 1 ketoprofen Tier 1 ketoprofen ext-rel Tier 1 ketorolac Tier 1 meloxicam tabs Tier 1 MOBIC Tier 3 nabumetone Tier 1 naproxen Tier 1 naproxen sodium Tier 1 oxaprozin Tier 1 DAYPRO Tier 3 piroxicam Tier 1 sulindac Tier 1 ibuprofen inj CALDOLOR Tier 2 indomethacin susp INDOCIN susp Tier 3 PA ketorolac tromethamine nasal spray SPRIX Tier 3

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1

NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1 diclofenac sodium soln Tier 1

COX-2 INHIBITORS QL celecoxib Tier 1 CELEBREX Tier 3

GOUT allopurinol Tier 1 ZYLOPRIM Tier 3 colchicine Tier 1 COLCRYS Tier 3 colchicine Tier 1 MITIGARE Tier 3 PA febuxostat Tier 1 ULORIC Tier 3 probenecid Tier 1 PA pegloticase KRYSTEXXA Tier 5

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org

Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html

QL buprenorphine transdermal Tier 1 BUTRANS Tier 3 QL butalbital/acetaminophen/caffeine/codeine Tier 1 FIORICET w/CODEINE Tier 3 QL butalbital/aspirin/caffeine/codeine Tier 1 QL butorphanol nasal spray Tier 1 QL codeine/acetaminophen Tier 1 PA fentanyl citrate buccal Tier 1 FENTORA Tier 3 QL fentanyl transdermal Tier 1 DURAGESIC Tier 3 PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3 PA hydrocodone ext-rel caps Tier 1 ZOHYDRO ER Tier 3 QL hydrocodone/acetaminophen Tier 1 QL hydromorphone Tier 1 DILAUDID Tier 3 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine ext-rel Tier 1 MS CONTIN Tier 3 QL morphine supp Tier 1 QL oxycodone Tier 1 ROXICODONE Tier 3 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3 QL oxymorphone Tier 1 OPANA Tier 3 QL tramadol (except 100 mg tabs) Tier 1 ULTRAM Tier 3 QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3 QL tramadol/acetaminophen Tier 1 QL morphine/naltrexone ext-rel EMBEDA Tier 2 QL oxycodone ext-rel XTAMPZA ER Tier 2 QL tapentadol NUCYNTA Tier 2 QL tapentadol ext-rel NUCYNTA ER Tier 2 QL buprenorphine BELBUCA Tier 3 PA fentanyl sublingual spray SUBSYS Tier 3 QL morphine ext-rel MORPHABOND Tier 3

NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3 QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3 ziconotide PRIALT Tier 4

VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 4 PA sodium hyaluronate GELSYN-3 Tier 4 PA sodium hyaluronate HYALGAN Tier 4 PA sodium hyaluronate SUPARTZ FX Tier 4 PA high molecular weight hyaluronan HYMOVIS Tier 5 PA high molecular weight hyaluronan ORTHOVISC Tier 5 PA hyaluronate sodium TRIVISC Tier 5 PA hylan G-F 20 SYNVISC Tier 5 PA hylan G-F 20 SYNVISC-ONE Tier 5 PA sodium hyaluronate DUROLANE Tier 5 PA sodium hyaluronate EUFLEXXA Tier 5 PA sodium hyaluronate MONOVISC Tier 5

ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org

Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org

HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html

International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html

Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

ANTIBACTERIALS Cephalosporins First Generation cephalexin Tier 1 KEFLEX Tier 3

Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1

Third Generation cefdinir Tier 1 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 SUPRAX Tier 2 QL cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 QL ceftriaxone Tier 1 ROCEPHIN Tier 3

Fourth Generation cefepime Tier 1

Fifth Generation ceftaroline fosamil TEFLARO Tier 2

Erythromycins/Macrolides azithromycin Tier 1 ZITHROMAX Tier 3 clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3 erythromycin ethylsuccinate Tier 1 ERYPED Tier 3 erythromycin stearate Tier 1 fidaxomicin DIFICID Tier 2

Fluoroquinolones ciprofloxacin Tier 1 CIPRO Tier 3 levofloxacin Tier 1 LEVAQUIN Tier 3 ofloxacin Tier 1

Penicillins amoxicillin, except film-coated tabs Tier 1 amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3 amoxicillin/clavulanate ext-rel Tier 1 amoxicillin/clavulanate susp 600 mg Tier 1 ampicillin Tier 1 ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3 dicloxacillin Tier 1 penicillin VK Tier 1 piperacillin/tazobactam Tier 1 ZOSYN Tier 3

Tetracyclines doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3 doxycycline hyclate delayed-rel tabs Tier 1 DORYX/MPC Tier 3 doxycycline monohydrate Tier 1 minocycline Tier 1 MINOCIN Tier 3 minocycline ext-rel Tier 1 SOLODYN Tier 3 tetracycline Tier 1 QL omadacycline NUZYRA Tier 3

Miscellaneous QL lefamulin XENLETA Tier 3 QL rifamycin delayed-rel AEMCOLO Tier 3

ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1 DIFLUCAN Tier 3 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 PA itraconazole Tier 1 SPORANOX Tier 3 PA ketoconazole tabs Tier 1 micafungin Tier 1 MYCAMINE Tier 3 nystatin Tier 1 PA posaconazole delayed-rel tabs Tier 1 NOXAFIL tabs Tier 3 terbinafine tabs Tier 1 QL voriconazole Tier 1 VFEND Tier 3 amphotericin B lipid complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 anidulafungin ERAXIS Tier 2 PA posaconazole susp NOXAFIL susp Tier 2

PA isavuconazonium CRESEMBA Tier 3

ANTIMALARIALS atovaquone/proguanil Tier 1 MALARONE Tier 3 chloroquine Tier 1 mefloquine Tier 1 primaquine Tier 1 PA pyrimethamine Tier 1 DARAPRIM Tier 3 artemether/lumefantrine COARTEM Tier 2 tafenoquine ARAKODA Tier 3 tafenoquine KRINTAFEL Tier 3

ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants cobicistat TYBOST Tier 2

Antiretroviral Combinations abacavir/lamivudine Tier 1 EPZICOM Tier 3 abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3 efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 1 ATRIPLA Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI LO Tier 3 emtricitabine/tenofovir disoproxil fumarate Tier 1 TRUVADA Tier 3 lamivudine/zidovudine Tier 1 COMBIVIR Tier 3 abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 atazanavir/cobicistat EVOTAZ Tier 2 bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY Tier 2 darunavir/cobicistat PREZCOBIX Tier 2 darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2 dolutegravir/lamivudine DOVATO Tier 2 doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2 emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY Tier 2 emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 2 dolutegravir/rilpivirine JULUCA Tier 3 lamivudine/tenofovir disoproxil fumarate CIMDUO Tier 3 lamivudine/tenofovir disoproxil fumarate TEMIXYS Tier 3

Chemokine Receptor Antagonists maraviroc SELZENTRY Tier 2

Fusion Inhibitors enfuvirtide FUZEON Tier 4

Gp120-Directed Attachment Inhibitors fostemsavir ext-rel RUKOBIA Tier 2

Integrase Inhibitors dolutegravir TIVICAY Tier 2 raltegravir ISENTRESS Tier 2

Monoclonal Antibody PA ibalizumab-uiyk TROGARZO Tier 4

Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 SUSTIVA Tier 3 nevirapine Tier 1 VIRAMUNE Tier 3 nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3 etravirine INTELENCE Tier 2 rilpivirine EDURANT Tier 2 doravirine PIFELTRO Tier 3

Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 ZIAGEN Tier 3 abacavir soln Tier 1 ZIAGEN soln Tier 3 emtricitabine caps Tier 1 EMTRIVA Tier 2 lamivudine Tier 1 EPIVIR Tier 3 stavudine Tier 1 zidovudine Tier 1 RETROVIR Tier 3

Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate tabs 300 mg Tier 1 VIREAD Tier 2

Protease Inhibitors atazanavir caps Tier 1 REYATAZ Tier 3 fosamprenavir Tier 1 LEXIVA Tier 3 ritonavir tabs Tier 1 NORVIR Tier 2 darunavir PREZISTA Tier 2 indinavir CRIXIVAN Tier 2 lopinavir/ritonavir KALETRA Tier 2 nelfinavir VIRACEPT Tier 2 saquinavir mesylate INVIRASE Tier 2 tipranavir APTIVUS Tier 2

ANTITUBERCULAR AGENTS ethambutol Tier 1 MYAMBUTOL Tier 3 isoniazid Tier 1 pyrazinamide Tier 1 rifampin Tier 1 RIFADIN Tier 3 pretomanid tabs PRETOMANID Tier 2 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 rifapentine PRIFTIN Tier 2 bedaquiline SIRTURO Tier 3

ANTIVIRALS Cytomegalovirus Agents cidofovir Tier 1 VISTIDE Tier 3 PA valganciclovir Tier 1 VALCYTE Tier 3 ganciclovir inj Tier 4 cytomegalovirus immune globulin CYTOGAM Tier 4 PA letermovir PREVYMIS Tier 4

Hepatitis Agents Hepatitis B lamivudine Tier 1 EPIVIR-HBV Tier 3 adefovir dipivoxil Tier 4 entecavir tabs Tier 4 entecavir soln BARACLUDE soln Tier 4 telbivudine TYZEKA Tier 4 tenofovir alafenamide VEMLIDY Tier 4

Hepatitis C PA ledipasvir/sofosbuvir Tier 4 HARVONI Tier 4 PA ribavirin caps Tier 4 PA ribavirin caps - Ribasphere Tier 4 PA ribavirin tabs Tier 4 PA sofosbuvir/velpatasvir Tier 4 EPCLUSA Tier 4 PA glecaprevir/pibrentasvir MAVYRET Tier 4 PA sofosbuvir SOVALDI Tier 4 PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4

Herpes Agents acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3 famciclovir Tier 1 valacyclovir Tier 1 VALTREX Tier 3

Influenza Agents QL oseltamivir Tier 1 TAMIFLU Tier 3 rimantadine Tier 1 QL zanamivir RELENZA Tier 2 QL baloxavir XOFLUZA Tier 3

Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 4

MISCELLANEOUS PA albendazole Tier 1 ALBENZA Tier 3 atovaquone Tier 1 MEPRON Tier 3 aztreonam Tier 1 AZACTAM Tier 3 clindamycin Tier 1 CLEOCIN Tier 3 QL dapsone Tier 1 ACZONE Tier 3 daptomycin 500 mg Tier 1 CUBICIN Tier 3 ertapenem Tier 1 INVANZ Tier 3 imipenem/cilastatin Tier 1 PRIMAXIN Tier 3 QL linezolid Tier 1 ZYVOX Tier 3 meropenem Tier 1 MERREM Tier 3 methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3 metronidazole tabs Tier 1 FLAGYL Tier 3 nitazoxanide tabs Tier 1 ALINIA Tier 2 nitrofurantoin ext-rel Tier 1 MACROBID Tier 3 nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3 rifabutin Tier 1 MYCOBUTIN Tier 3 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tigecycline Tier 1 TYGACIL Tier 3 tinidazole Tier 1 trimethoprim Tier 1 vancomycin caps Tier 1 VANCOCIN Tier 3 PA mebendazole EMVERM Tier 2 miltefosine IMPAVIDO Tier 2 QL rifaximin XIFAXAN Tier 2 vancomycin oral soln FIRVANQ Tier 2 nifurtimox LAMPIT Tier 3 secnidazole SOLOSEC Tier 3 QL tedizolid SIVEXTRO Tier 3 telavancin VIBATIV Tier 3

ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org

ALKYLATING AGENTS busulfan Tier 1 BUSULFEX Tier 2 ifosfamide/mesna Tier 1 carmustine Tier 4 BICNU Tier 5 cyclophosphamide caps Tier 4 CYCLOPHOSPHAMIDE Tier 4 CAPSULES cyclophosphamide inj Tier 4 dacarbazine Tier 4 melphalan inj Tier 4 ALKERAN inj Tier 5 melphalan tabs Tier 4 ALKERAN tabs Tier 5 temozolomide Tier 4 thiotepa Tier 4 TEPADINA Tier 5 busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 lomustine GLEOSTINE Tier 2 PA mechlorethamine gel VALCHLOR Tier 4 streptozocin ZANOSAR Tier 4 PA trabectedin YONDELIS Tier 4 PA bendamustine BELRAPZO Tier 5 PA bendamustine TREANDA Tier 5 PA lurbinectedin ZEPZELCA Tier 5

ANTIMETABOLITES mercaptopurine Tier 1 capecitabine Tier 4 cladribine Tier 4 clofarabine Tier 4 CLOLAR Tier 5 cytarabine Tier 4 floxuridine Tier 4 fludarabine Tier 4 fluorouracil inj Tier 4 gemcitabine inj Tier 4 GEMCITABINE Tier 4 thioguanine TABLOID Tier 2 pemetrexed ALIMTA Tier 4 pentostatin NIPENT Tier 4 pralatrexate FOLOTYN Tier 4 rasburicase ELITEK Tier 4 PA azacitidine ONUREG Tier 5 mercaptopurine susp PURIXAN Tier 5

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 CASODEX Tier 3 flutamide Tier 1 PA nilutamide Tier 1 NILANDRON Tier 3 PA abiraterone Tier 4 PA enzalutamide XTANDI Tier 4 PA abiraterone YONSA Tier 5 PA apalutamide ERLEADA Tier 5

PA darolutamide NUBEQA Tier 5

Antiestrogens tamoxifen Tier 1 toremifene Tier 1 FARESTON Tier 3 fulvestrant Tier 4

Aromatase Inhibitors anastrozole Tier 1 ARIMIDEX Tier 3 exemestane Tier 1 AROMASIN Tier 3 letrozole Tier 1 FEMARA Tier 3

Gonadotropin-Releasing Hormone (GnRH) Antagonists PA degarelix acetate FIRMAGON Tier 4 PA relugolix ORGOVYX Tier 5

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 4 PA goserelin acetate ZOLADEX Tier 4 PA histrelin acetate VANTAS Tier 4 PA leuprolide acetate ELIGARD Tier 4 PA leuprolide acetate LUPRON DEPOT Tier 4 PA triptorelin pamoate TRELSTAR Tier 4 PA triptorelin pamoate TRELSTAR DEPOT Tier 4 PA triptorelin pamoate TRELSTAR LA Tier 4 PA leuprolide acetate FENSOLVI Tier 5

Progestins megestrol acetate Tier 1

IMMUNOMODULATORS PA pembrolizumab KEYTRUDA Tier 4 PA pomalidomide POMALYST Tier 5

KINASE INHIBITORS PA erlotinib Tier 4 PA everolimus 2.5 mg, 5 mg, 7.5 mg Tier 4 PA imatinib mesylate Tier 4 PA lapatinib Tier 4 TYKERB Tier 5 temsirolimus Tier 4 TORISEL Tier 5 PA abemaciclib VERZENIO Tier 4 PA acalabrutinib CALQUENCE Tier 4 PA afatinib GILOTRIF Tier 4 PA alpelisib PIQRAY Tier 4 PA axitinib INLYTA Tier 4 PA bosutinib BOSULIF Tier 4 PA cabozantinib CABOMETYX Tier 4 PA cabozantinib COMETRIQ Tier 4 PA ceritinib ZYKADIA Tier 4 PA cobimetinib COTELLIC Tier 4 PA crizotinib XALKORI Tier 4 PA dabrafenib TAFINLAR Tier 4 PA dasatinib SPRYCEL Tier 4 PA entrectinib ROZLYTREK Tier 4 PA erdafitinib BALVERSA Tier 4 PA everolimus 10 mg AFINITOR 10 mg Tier 4

PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 4 PA ibrutinib IMBRUVICA Tier 4 PA idelalisib ZYDELIG Tier 4 PA larotrectinib VITRAKVI Tier 4 PA lenvatinib LENVIMA Tier 4 PA midostaurin RYDAPT Tier 4 PA palbociclib IBRANCE Tier 4 PA pazopanib VOTRIENT Tier 4 PA pexidartinib TURALIO Tier 4 PA ponatinib ICLUSIG Tier 4 PA regorafenib STIVARGA Tier 4 PA ribociclib KISQALI Tier 4 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4 PA ruxolitinib JAKAFI Tier 4 PA selpercatinib RETEVMO Tier 4 PA selumetinib KOSELUGO Tier 4 PA sorafenib NEXAVAR Tier 4 PA sunitinib SUTENT Tier 4 PA trametinib MEKINIST Tier 4 PA vandetanib CAPRELSA Tier 4 PA vemurafenib ZELBORAF Tier 4 PA alectinib ALECENSA Tier 5 PA avapritinib AYVAKIT Tier 5 PA binimetinib MEKTOVI Tier 5 PA brigatinib ALUNBRIG Tier 5 PA capmatinib TABRECTA Tier 5 PA dacomitinib VIZIMPRO Tier 5 PA duvelisib COPIKTRA Tier 5 PA encorafenib BRAFTOVI Tier 5 PA fedratinib INREBIC Tier 5 PA gefitinib IRESSA Tier 5 PA gilteritinib XOSPATA Tier 5 PA lorlatinib LORBRENA Tier 5 PA neratinib NERLYNX Tier 5 PA nilotinib TASIGNA Tier 5 PA osimertinib TAGRISSO Tier 5 PA pemigatinib PEMAZYRE Tier 5 PA pralsetinib GAVRETO Tier 5 PA ripretinib QINLOCK Tier 5 PA tazemetostat TAZVERIK Tier 5 PA tucatinib TUKYSA Tier 5 PA zanubrutinib BRUKINSA Tier 5

MULTIPLE MYELOMA Immunomodulators PA lenalidomide REVLIMID Tier 4 thalidomide THALOMID Tier 4 PA isatuximab-irfc SARCLISA Tier 5

Proteasome Inhibitors PA ixazomib NINLARO Tier 4 PA bortezomib VELCADE Tier 5

TOPOISOMERASE INHIBITORS topotecan inj Tier 4 HYCAMTIN inj Tier 5 topotecan HYCAMTIN Tier 4

PA irinotecan liposome inj ONIVYDE Tier 5

MISCELLANEOUS hydroxyurea Tier 1 HYDREA Tier 3 leucovorin calcium Tier 1 amifostine Tier 4 ETHYOL Tier 5 arsenic trioxide Tier 4 TRISENOX Tier 5 azacitidine Tier 4 VIDAZA Tier 5 PA bexarotene caps Tier 4 bleomycin sulfate Tier 4 carboplatin Tier 4 cisplatin Tier 4 dactinomycin Tier 4 COSMEGEN Tier 5 daunorubicin Tier 4 decitabine Tier 4 DACOGEN Tier 5 dexrazoxane Tier 4 dexrazoxane Tier 4 TOTECT Tier 5 docetaxel Tier 4 doxorubicin Tier 4 doxorubicin liposomal Tier 4 DOXIL Tier 5 epirubicin Tier 4 epirubicin Tier 4 ELLENCE Tier 5 etoposide Tier 4 idarubicin Tier 4 IDAMYCIN PFS Tier 5 ifosfamide Tier 4 IFEX Tier 5 irinotecan Tier 4 CAMPTOSAR Tier 5 levoleucovorin calcium Tier 4 mesna inj Tier 4 MESNEX inj Tier 5 mitomycin Tier 4 mitoxantrone Tier 4 oxaliplatin Tier 4 paclitaxel Tier 4 PA romidepsin Tier 4 ISTODAX Tier 5 teniposide Tier 4 valrubicin Tier 4 VALSTAR Tier 5 vinblastine Tier 4 vincristine Tier 4 vinorelbine Tier 4 NAVELBINE Tier 5 PA mitotane LYSODREN Tier 2 PA ado-trastuzumab emtansine KADCYLA Tier 4 aldesleukin PROLEUKIN Tier 4 asparaginase ELSPAR Tier 4 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4 PA atezolizumab TECENTRIQ Tier 4 BCG live vaccine TICE BCG Tier 4 PA belinostat BELEODAQ Tier 4 PA bendamustine BENDEKA Tier 4 PA bevacizumab-awwb MVASI Tier 4 PA bevacizumab-bvzr ZIRABEV Tier 4 PA bexarotene gel TARGRETIN gel Tier 4 PA blinatumomab BLINCYTO Tier 4 PA brentuximab vedotin ADCETRIS Tier 4 PA cabazitaxel JEVTANA Tier 4 PA cetuximab ERBITUX Tier 4 PA daratumumab DARZALEX Tier 4 PA decitabine-cedazuridine INQOVI Tier 4

doxorubicin ADRIAMYCIN Tier 4 PA elotuzumab EMPLICITI Tier 4 PA eribulin HALAVEN Tier 4 etoposide phosphate ETOPOPHOS Tier 4 glucarpidase VORAXAZE Tier 4 PA ipilimumab YERVOY Tier 4 ixabepilone IXEMPRA Tier 4 mesna tabs 400 mg MESNEX Tier 4 PA necitumumab PORTRAZZA Tier 4 nelarabine ARRANON Tier 4 PA niraparib ZEJULA Tier 4 PA nivolumab OPDIVO Tier 4 PA obinutuzumab GAZYVA Tier 4 PA ofatumumab ARZERRA Tier 4 PA olaparib LYNPARZA Tier 4 PA omacetaxine mepesuccinate SYNRIBO Tier 4 paclitaxel protein-bound particles ABRAXANE Tier 4 PA panitumumab VECTIBIX Tier 4 PA pegaspargase ONCASPAR Tier 4 PA pertuzumab PERJETA Tier 4 PA pertuzumab/trastuzumab/hyaluronidase-zzxf PHESGO Tier 4 procarbazine MATULANE Tier 4 PA rituximab-abbs TRUXIMA Tier 4 PA rituximab-arrx RIABNI Tier 4 PA rituximab-pvvr RUXIENCE Tier 4 PA rucaparib RUBRACA Tier 4 PA talazoparib TALZENNA Tier 4 PA talimogene laherparepvec IMLYGIC Tier 4 PA trastuzumab-anns KANJINTI Tier 4 PA trastuzumab-dkst OGIVRI Tier 4 PA trastuzumab-dttb ONTRUZANT Tier 4 PA trastuzumab-pkrb HERZUMA Tier 4 PA trastuzumab-qyyp TRAZIMERA Tier 4 PA venetoclax VENCLEXTA Tier 4 PA vincristine sulfate liposomal MARQIBO Tier 4 PA vismodegib ERIVEDGE Tier 4 PA vorinostat ZOLINZA Tier 4 PA ziv-aflibercept ZALTRAP Tier 4 PA avelumab BAVENCIO Tier 5 PA belantamab mafodotin-blmf BLENREP Tier 5 PA bevacizumab AVASTIN Tier 5 PA calaspargase pegol-mknl ASPARLAS Tier 5 PA carfilzomib KYPROLIS Tier 5 PA daratumumab/hyaluronidase-fihj DARZALEX FASPRO Tier 5 PA durvalumab IMFINZI Tier 5 PA enasidenib IDHIFA Tier 5 PA enfortumab vedotin-ejfv PADCEV Tier 5 PA fam-trastuzumab deruxtecan-nxki ENHERTU Tier 5 PA gemtuzumab ozogamicin MYLOTARG Tier 5 PA glasdegib DAURISMO Tier 5 PA hydroxyurea SIKLOS Tier 5 PA inotuzumab ozogamicin BESPONSA Tier 5 PA ivosidenib TIBSOVO Tier 5 levoleucovorin KHAPZORY Tier 5 PA melphalan EVOMELA Tier 5 PA mogamulizumab-kpkc POTELIGEO Tier 5

PA moxetumomab pasudotox-tdfk LUMOXITI Tier 5 PA panobinostat FARYDAK Tier 5 PA polatuzumab vedotin-piiq POLIVY Tier 5 PA ramucirumab CYRAMZA Tier 5 PA rituximab RITUXAN Tier 5 PA rituximab/hyaluronidase human RITUXAN HYCELA Tier 5 PA sacituzumab govitecan-hziy TRODELVY Tier 5 PA selinexor XPOVIO Tier 5 PA sonidegib ODOMZO Tier 5 PA trastuzumab HERCEPTIN Tier 5 PA trastuzumab/hyaluronidase-oysk HERCEPTIN HYLECTA Tier 5 PA trifluridine/tipiracil LONSURF Tier 5

CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org

benazepril Tier 1 LOTENSIN Tier 3 enalapril Tier 1 VASOTEC Tier 3 fosinopril Tier 1 lisinopril Tier 1 PRINIVIL Tier 3 lisinopril Tier 1 ZESTRIL Tier 3 perindopril Tier 1 quinapril Tier 1 ACCUPRIL Tier 3 ramipril Tier 1 ALTACE Tier 3 trandolapril Tier 1 enalapril oral soln EPANED Tier 3 lisinopril oral soln QBRELIS Tier 3

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine Tier 1 LOTREL Tier 3 trandolapril/verapamil ext-rel Tier 1 TARKA Tier 3 perindopril arginine/amlodipine PRESTALIA Tier 3

ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3 captopril/hydrochlorothiazide Tier 1 enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3 quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3

ADRENOLYTICS, CENTRAL clonidine Tier 1 CATAPRES Tier 3

clonidine transdermal Tier 1 CATAPRES-TTS Tier 3

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 INSPRA Tier 3 spironolactone Tier 1 ALDACTONE Tier 3

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

doxazosin Tier 1 CARDURA Tier 3 prazosin Tier 1 MINIPRESS Tier 3 terazosin Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 BENICAR Tier 3 olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 AZOR Tier 3 amlodipine/telmisartan Tier 1 TWYNSTA Tier 3 amlodipine/valsartan Tier 1 EXFORGE Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 EXFORGE HCT Tier 3 olmesartan/amlodipine/hydrochlorothiazide Tier 1 TRIBENZOR Tier 3

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org

amiodarone Tier 1 disopyramide Tier 1 NORPACE Tier 3 flecainide Tier 1 mexiletine Tier 1 propafenone ext-rel Tier 1 RYTHMOL SR Tier 3 quinidine gluconate ext-rel Tier 1 sotalol Tier 1 sotalol AF Tier 1 dofetilide Tier 4 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2

ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625

ACL Inhibitor/Combinations PA bempedoic acid NEXLETOL Tier 3 PA bempedoic acid/ezetimibe NEXLIZET Tier 3

Bile Acid Resins cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3 colesevelam Tier 1 WELCHOL Tier 3 colestipol Tier 1 COLESTID Tier 3

Cholesterol Absorption Inhibitors ezetimibe Tier 1 ZETIA Tier 3

Fibrates fenofibrate Tier 1 LIPOFEN Tier 3 fenofibrate Tier 1 TRICOR Tier 3 fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3 gemfibrozil Tier 1 LOPID Tier 3 fenofibrate ANTARA Tier 3

HMG-CoA Reductase Inhibitors/Combinations ‡, * atorvastatin Tier 1 ezetimibe/simvastatin Tier 1 ‡, * fluvastatin Tier 1 ‡, * fluvastatin ext-rel Tier 1 ‡, * lovastatin Tier 1 ‡, * pravastatin Tier 1 ‡, * rosuvastatin Tier 1 ‡, * simvastatin Tier 1

* Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.

Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID Tier 4

Niacins niacin ext-rel Tier 1 NIASPAN Tier 3

Omega-3 Fatty Acids icosapent ethyl caps 1 gm Tier 1 VASCEPA Tier 2 omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3

PCSK9 Inhibitors PA evolocumab REPATHA Tier 4

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

acebutolol Tier 1 atenolol Tier 1 TENORMIN Tier 3 carvedilol Tier 1 COREG Tier 3 carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3 esmolol Tier 1 BREVIBLOC Tier 3 metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3 metoprolol tartrate Tier 1 LOPRESSOR Tier 3 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 INDERAL LA Tier 3 nebivolol BYSTOLIC Tier 2 metoprolol succinate ext-rel KAPSPARGO Tier 3 penbutolol LEVATOL Tier 3 propranolol ext-rel INNOPRAN XL Tier 3

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3 metoprolol/hydrochlorothiazide Tier 1

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine tabs Tier 1 NORVASC Tier 3 felodipine ext-rel Tier 1 nicardipine Tier 1 nifedipine ext-rel Tier 1 nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3 nimodipine Tier 1 NIMOTOP Tier 3 nisoldipine ext-rel Tier 1 SULAR Tier 3

Nondihydropyridines diltiazem Tier 1 CARDIZEM Tier 3 diltiazem ext-rel Tier 1 CARDIZEM CD Tier 3 diltiazem ext-rel Tier 1 TIAZAC Tier 3 verapamil Tier 1 verapamil ext-rel Tier 1 CALAN SR Tier 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1

DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 TEKTURNA Tier 3 aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1

PA dichlorphenamide KEVEYIS Tier 3

Loop Diuretics bumetanide Tier 1 ethacrynic acid Tier 1 EDECRIN Tier 3 furosemide Tier 1 LASIX Tier 3 torsemide Tier 1

Potassium-sparing Diuretics amiloride Tier 1

Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1

Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3 triamterene/hydrochlorothiazide 37.5/25 Tier 1 MAXZIDE-25 Tier 3 triamterene/hydrochlorothiazide 50/25 Tier 1

HEART FAILURE isosorbide dinitrate/hydralazine BIDIL Tier 2 PA ivabradine CORLANOR Tier 3 PA sacubitril/valsartan ENTRESTO Tier 3 PA tafamidis VYNDAMAX Tier 4 PA tafamidis meglumine VYNDAQEL Tier 4

NITRATES Oral isosorbide dinitrate oral Tier 1 ISORDIL Tier 3 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1

Sublingual/Translingual nitroglycerin lingual spray Tier 1 NITROLINGUAL Tier 3 nitroglycerin sublingual Tier 1 NITROSTAT Tier 3 nitroglycerin sublingual aerosol NITROMIST Tier 3 nitroglycerin sublingual powder GONITRO Tier 3

Transdermal nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3 nitroglycerin ointment NITRO-BID Tier 3

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan Tier 4 PA bosentan Tier 4 TRACLEER Tier 5 PA macitentan OPSUMIT Tier 4

Phosphodiesterase Inhibitors PA sildenafil Tier 4 PA tadalafil tabs 20 mg Tier 4 PA tadalafil tabs 20 mg - Alyq Tier 4

Prostacyclin Receptor Agonists PA selexipag UPTRAVI Tier 5

Prostaglandin Vasodilators PA epoprostenol Tier 4 VELETRI Tier 5 PA epoprostenol sodium Tier 4 FLOLAN Tier 5 PA treprostinil Tier 4 REMODULIN Tier 5 PA iloprost VENTAVIS Tier 4 PA treprostinil ext-rel ORENITRAM Tier 4 PA treprostinil TYVASO Tier 5

Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Tier 5

MISCELLANEOUS hydralazine Tier 1 midodrine Tier 1 minoxidil tabs Tier 1 ranolazine ext-rel Tier 1 RANEXA Tier 3 PA droxidopa Tier 4 NORTHERA Tier 5 mecamylamine VECAMYL Tier 3

CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org

ANTIANXIETY Benzodiazepines alprazolam Tier 1 XANAX Tier 3 alprazolam ext-rel Tier 1 XANAX XR Tier 3 chlordiazepoxide Tier 1 clonazepam Tier 1 KLONOPIN Tier 3 clorazepate Tier 1 TRANXENE T-TAB Tier 3 diazepam Tier 1 VALIUM Tier 3 lorazepam Tier 1 ATIVAN Tier 3 oxazepam Tier 1

Miscellaneous buspirone Tier 1 clomipramine Tier 1 ANAFRANIL Tier 3 fluvoxamine Tier 1 fluvoxamine ext-rel Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com

carbamazepine Tier 1 TEGRETOL Tier 3 carbamazepine ext-rel Tier 1 CARBATROL Tier 3

carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3 clobazam Tier 1 ONFI Tier 3 diazepam rectal gel Tier 1 DIASTAT Tier 3 divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3 divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3 divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3 ethosuximide Tier 1 ZARONTIN Tier 3 felbamate Tier 1 FELBATOL Tier 3 QL gabapentin Tier 1 NEURONTIN Tier 3 lamotrigine Tier 1 LAMICTAL Tier 3 lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3 lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3 levetiracetam Tier 1 KEPPRA Tier 3 levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3 oxcarbazepine Tier 1 TRILEPTAL Tier 3 phenobarbital Tier 1 phenytoin Tier 1 DILANTIN INFATABS Tier 3 phenytoin sodium extended Tier 1 DILANTIN Tier 3 primidone Tier 1 MYSOLINE Tier 3 rufinamide Tier 1 BANZEL Tier 3 tiagabine Tier 1 GABITRIL Tier 3 topiramate Tier 1 TOPAMAX Tier 3 topiramate ext-rel Tier 1 QUDEXY XR Tier 3 valproic acid Tier 1 zonisamide Tier 1 ZONEGRAN Tier 3 PA vigabatrin Tier 4 PA vigabatrin powder - Vigadrone Tier 4 lacosamide VIMPAT Tier 2 brivaracetam BRIVIACT Tier 3 PA cenobamate XCOPRI Tier 3 PA diazepam nasal spray VALTOCO Tier 3 eslicarbazepine APTIOM Tier 3 PA midazolam nasal spray NAYZILAM Tier 3 oxcarbazepine ext-rel OXTELLAR XR Tier 3 perampanel FYCOMPA Tier 3 topiramate ext-rel TROKENDI XR Tier 3 PA cannabidiol EPIDIOLEX Tier 5 PA fenfluramine FINTEPLA Tier 5 PA stiripentol DIACOMIT Tier 5

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com

donepezil Tier 1 ARICEPT Tier 3 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 galantamine ext-rel Tier 1 RAZADYNE ER Tier 3 memantine soln Tier 1 memantine tabs Tier 1 NAMENDA tabs Tier 3 rivastigmine Tier 1 rivastigmine transdermal Tier 1 EXELON PATCH Tier 3

ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.

Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org

Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 NARDIL Tier 3 tranylcypromine Tier 1 PARNATE Tier 3 isocarboxazid MARPLAN Tier 3 selegiline transdermal EMSAM Tier 3

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 CELEXA Tier 3 escitalopram Tier 1 LEXAPRO Tier 3 fluoxetine Tier 1 fluoxetine Tier 1 PROZAC Tier 3 fluoxetine delayed-rel Tier 1 paroxetine HCl Tier 1 PAXIL Tier 3 paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3 sertraline Tier 1 ZOLOFT Tier 3 paroxetine mesylate PEXEVA Tier 3 vilazodone VIIBRYD Tier 3 vortioxetine TRINTELLIX Tier 3

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3 duloxetine delayed-rel Tier 1 CYMBALTA Tier 3 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3 venlafaxine ext-rel tabs Tier 1 duloxetine delayed-release sprinkle capsule DRIZALMA SPRINKLE Tier 3 levomilnacipran ext-rel FETZIMA Tier 3

Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 desipramine Tier 1 NORPRAMIN Tier 3 doxepin Tier 1 imipramine HCl Tier 1 imipramine pamoate Tier 1 nortriptyline Tier 1 PAMELOR Tier 3 protriptyline Tier 1

Miscellaneous Agents amitriptyline/perphenazine Tier 1 bupropion Tier 1 bupropion ext-rel Tier 1 FORFIVO XL Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3 mirtazapine Tier 1 REMERON Tier 3 nefazodone Tier 1 trazodone Tier 1 bupropion ext-rel APLENZIN Tier 3 PA esketamine nasal solution SPRAVATO Tier 3

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com

amantadine, except tabs Tier 1 benztropine Tier 1 bromocriptine Tier 1 PARLODEL Tier 3 carbidopa/levodopa Tier 1 SINEMET Tier 3 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3 diphenhydramine Tier 1 entacapone Tier 1 COMTAN Tier 3 pramipexole Tier 1 MIRAPEX Tier 3 pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3 rasagiline Tier 1 AZILECT Tier 3 ropinirole Tier 1 ropinirole ext-rel Tier 1 selegiline caps Tier 1 tolcapone Tier 1 trihexyphenidyl Tier 1 rotigotine transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 PA amantadine ext-rel GOCOVRI Tier 3 PA apomorphine KYNMOBI Tier 3 carbidopa/levodopa enteral susp DUOPA Tier 3 carbidopa/levodopa ext-rel RYTARY Tier 3 opicapone ONGENTYS Tier 3 safinamide XADAGO Tier 3 PA apomorphine APOKYN Tier 4 PA istradefylline NOURIANZ Tier 5 PA levodopa inhalation powder INBRIJA Tier 5

ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 ABILIFY Tier 3 aripiprazole orally disintegrating tabs Tier 1 asenapine Tier 1 SAPHRIS Tier 3 clozapine Tier 1 CLOZARIL Tier 3 clozapine orally disintegrating tabs Tier 1 olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3 olanzapine/fluoxetine Tier 1 paliperidone ext-rel Tier 1 INVEGA Tier 3 quetiapine Tier 1 SEROQUEL Tier 3 quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3 risperidone Tier 1 RISPERDAL Tier 3 risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3 ziprasidone Tier 1 GEODON Tier 3 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3 aripiprazole lauroxil ext-rel inj ARISTADA Tier 3 PA aripiprazole tab with sensor ABILIFY MYCITE Tier 3 brexpiprazole REXULTI Tier 3 cariprazine VRAYLAR Tier 3 iloperidone FANAPT Tier 3

lumateperone CAPLYTA Tier 3 lurasidone LATUDA Tier 3 PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3 paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3 risperidone ext-rel inj PERSERIS Tier 3

Miscellaneous fluphenazine Tier 1 haloperidol Tier 1 haloperidol decanoate inj Tier 1 HALDOL DECANOATE 100 Tier 3 haloperidol lactate inj Tier 1 HALDOL Tier 3 loxapine Tier 1 perphenazine Tier 1 thioridazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1 PA pimavanserin NUPLAZID Tier 5

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org

PA amphetamine ext-rel susp Tier 1 ADZENYS ER SUSP Tier 3 PA amphetamine sulfate Tier 1 EVEKEO Tier 3 PA amphetamine/dextroamphetamine mixed salts Tier 1 ADDERALL Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR Tier 3 atomoxetine Tier 1 STRATTERA Tier 3 clonidine ext-rel Tier 1 KAPVAY Tier 3 PA dexmethylphenidate Tier 1 FOCALIN Tier 3 PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3 PA dextroamphetamine Tier 1 PA dextroamphetamine Tier 1 ZENZEDI Tier 3 PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3 PA dextroamphetamine soln - Procentra Tier 1 guanfacine ext-rel Tier 1 INTUNIV Tier 3 PA methamphetamine Tier 1 PA methylphenidate Tier 1 METHYLIN Tier 3 PA methylphenidate Tier 1 RITALIN Tier 3 PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3 PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3 PA methylphenidate ext-rel (except methylphenidate tab ER Tier 1 osmotic release 72 mg) PA methylphenidate ext-rel caps Tier 1 APTENSIO XR Tier 3 PA lisdexamfetamine VYVANSE Tier 2 PA amphetamine ext-rel orally disintegrating tabs ADZENYS XR-ODT Tier 3 PA amphetamine ext-rel suspension DYANAVEL XR Tier 3 PA amphetamine sulfate orally disintegrating tablet EVEKEO ODT Tier 3 PA amphetamine/dextroamphetamine mixed salts MYDAYIS Tier 3 PA methylphenidate ext-rel chewable tabs QUILLICHEW ER Tier 3 PA methylphenidate ext-rel orally disintegrating tablets COTEMPLA XR-ODT Tier 3 PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3 PA methylphenidate transdermal DAYTRANA Tier 3

FIBROMYALGIA QL pregabalin (does not include ext-rel tabs) Tier 1

QL milnacipran SAVELLA Tier 3

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org

Benzodiazepines QL estazolam Tier 1 QL flurazepam Tier 1 quazepam Tier 1 DORAL Tier 3 QL temazepam Tier 1 RESTORIL Tier 3 QL triazolam Tier 1

Nonbenzodiazepines QL eszopiclone Tier 1 QL ramelteon Tier 1 QL zaleplon Tier 1 QL zolpidem Tier 1 QL zolpidem ext-rel Tier 1 QL lemborexant DAYVIGO Tier 3 QL suvorexant BELSOMRA Tier 3 QL zolpidem spray ZOLPIMIST Tier 3 PA tasimelteon HETLIOZ Tier 4

Tricyclics doxepin Tier 1 SILENOR Tier 3

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com

Calcitonin Gene-Related Peptide Receptor Antagonist PA rimegepant NURTEC ODT Tier 3

Ergotamine Derivatives dihydroergotamine inj Tier 1 D.H.E. 45 Tier 3 PA dihydroergotamine spray Tier 1 MIGRANAL Tier 3 ergotamine/caffeine supp Tier 1 MIGERGOT Tier 1 ergotamine/caffeine tabs Tier 1 CAFERGOT Tier 3

Monoclonal Antibodies PA erenumab-aooe AIMOVIG Tier 2 PA galcanezumab-gnlm 100 mg/mL EMGALITY 100 mg/mL Tier 2 PA galcanezumab-gnlm 120 mg/mL EMGALITY 120 mg/mL Tier 2 PA eptinezumab-jjmr VYEPTI Tier 5

Selective Serotonin Agonists QL almotriptan Tier 1 QL eletriptan Tier 1 RELPAX Tier 3 QL frovatriptan Tier 1 FROVA Tier 3 QL naratriptan Tier 1 AMERGE Tier 3 QL rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3 QL sumatriptan Tier 1 IMITREX Tier 3 QL zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3 QL zolmitriptan nasal spray Tier 1 ZOMIG Tier 3

QL sumatriptan nasal powder ONZETRA XSAIL Tier 3

Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations QL sumatriptan/naproxen sodium TREXIMET Tier 3

MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 1 LITHOBID Tier 3 lithium carbonate ext-rel tabs 450 mg Tier 1 carbamazepine EQUETRO Tier 3

MOVEMENT DISORDERS PA tetrabenazine Tier 4 PA deutetrabenazine AUSTEDO Tier 5

MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: https://www.aan.com

PA dalfampridine ext-rel Tier 4 PA dimethyl fumarate delayed-rel Tier 4 TECFIDERA Tier 5 PA glatiramer Tier 4 PA glatiramer - Glatopa Tier 4 PA fingolimod GILENYA Tier 4 PA interferon beta-1a AVONEX Tier 4 PA interferon beta-1a REBIF Tier 4 PA interferon beta-1a REBIF REBIDOSE Tier 4 PA interferon beta-1b BETASERON Tier 4 PA natalizumab TYSABRI Tier 4 PA ocrelizumab OCREVUS Tier 4 PA ozanimod ZEPOSIA Tier 4 PA peginterferon beta-1a PLEGRIDY Tier 4 PA peginterferon beta-1a PLEGRIDY PEN Tier 4 PA siponimod MAYZENT Tier 4 PA teriflunomide AUBAGIO Tier 4 PA alemtuzumab LEMTRADA Tier 5 PA cladribine MAVENCLAD Tier 5 PA diroximel fumarate delayed-rel VUMERITY Tier 5 PA interferon beta-1b EXTAVIA Tier 5 PA monomethyl fumarate BAFIERTAM Tier 5 PA ofatumumab KESIMPTA Tier 5

MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 LIORESAL INTRATHECAL Tier 2 cyclobenzaprine Tier 1 dantrolene Tier 1 DANTRIUM Tier 3

MYASTHENIA GRAVIS pyridostigmine Tier 1 MESTINON Tier 3 pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 3

NARCOLEPSY/CATAPLEXY PA armodafinil Tier 1 NUVIGIL Tier 3 PA modafinil Tier 1 PROVIGIL Tier 3 PA sodium oxybate XYREM Tier 2

PA calcium, magnesium, potassium, and sodium oxybates XYWAV Tier 3 PA solriamfetol SUNOSI Tier 3 PA pitolisant WAKIX Tier 5

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 4

Opioid Antagonists PA, * naloxone auto-injector Tier 1 EVZIO Tier 3 naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 1

* Brand EVZIO requires prior approval

Partial Opioid Agonists QL buprenorphine Tier 1 PA buprenorphine ext-rel inj SUBLOCADE Tier 5

Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film Tier 1 SUBOXONE FILM Tier 3 QL buprenorphine/naloxone sublingual tabs Tier 1 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2

Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2

Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2

MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 RILUTEK Tier 3 riluzole TIGLUTIK Tier 3 PA edaravone RADICAVA Tier 5

Botulinum Toxins PA abobotulinumtoxinA DYSPORT Tier 4 PA incobotulinumtoxinA XEOMIN Tier 4 PA onabotulinumtoxinA BOTOX Tier 4 PA rimabotulinumtoxinB MYOBLOC Tier 4

Duchenne Muscular Dystrophy PA deflazacort EMFLAZA Tier 5 PA eteplirsen EXONDYS 51 Tier 5 PA golodirsen VYONDYS 53 Tier 5 PA viltolarsen VILTEPSO Tier 5

Lambert-Eaton Myasthenic Syndrome PA amifampridine FIRDAPSE Tier 4 PA amifampridine RUZURGI Tier 5

Spinal Muscular Atrophy PA risdiplam EVRYSDI Tier 5

Tardive Dyskinesia PA valbenazine INGREZZA Tier 5

ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com

PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 PA testosterone gel Tier 1 FORTESTA Tier 3 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone buccal STRIANT Tier 3 PA testosterone enanthate auto-injector XYOSTED Tier 3 PA testosterone undecanoate inj AVEED Tier 4 PA testosterone pellets TESTOPEL Tier 5

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org

Alpha-glucosidase Inhibitors acarbose Tier 1 PRECOSE Tier 3 miglitol Tier 1

Amylin Analogs pramlintide SYMLINPEN Tier 2

Biguanides metformin Tier 1 * metformin ext-rel Tier 1 PA metformin oral soln Tier 1

* Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require PA

Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 glyburide/metformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin Tier 1 sitagliptin phosphate JANUVIA Tier 2

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations alogliptin/metformin Tier 1 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/pioglitazone Tier 1

Incretin Mimetic Agents dulaglutide TRULICITY Tier 2 liraglutide VICTOZA Tier 2 semaglutide OZEMPIC Tier 2 semaglutide RYBELSUS Tier 3

Incretin Mimetic Agent/Insulin Combinations PA liraglutide/insulin degludec XULTOPHY Tier 3 PA lixisenatide/insulin glargine SOLIQUA Tier 3

Insulins insulin aspart FIASP Tier 2 insulin aspart FIASP FLEXTOUCH Tier 2 insulin aspart INSULIN ASPART Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/insulin aspart 30% INSULIN ASPART PROTAMINE Tier 2 70%/INSULIN ASPART 30% insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2 insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin human HUMULIN R U-500 Tier 2 OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 insulin degludec TRESIBA Tier 3 PA insulin human inhalation powder AFREZZA Tier 3

Insulin Sensitizers pioglitazone Tier 1 ACTOS Tier 3 rosiglitazone AVANDIA Tier 3

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3 pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 3

Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 1 DUETACT Tier 3

Meglitinides nateglinide Tier 1 STARLIX Tier 3 repaglinide Tier 1

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST dapagliflozin FARXIGA Tier 2 ST empagliflozin JARDIANCE Tier 2

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST empagliflozin/metformin SYNJARDY Tier 2 ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2

Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations ST dapagliflozin/saxagliptin QTERN Tier 2 ST empagliflozin/linagliptin GLYXAMBI Tier 2

Sodium Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations PA/ST empagliflozin/linagliptin/metformin ext-rel TRIJARDY XR Tier 3

Sulfonylureas glimepiride Tier 1 AMARYL Tier 3 glipizide Tier 1 GLUCOTROL Tier 3 glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3 glyburide Tier 1 glyburide, micronized Tier 1 GLYNASE Tier 3

Supplies PA blood glucose continuous monitoring receivers, sensors, FREESTYLE LIBRE / Tier 2 transmitters FREESTYLE LIBRE 2 CONTINUOUS GLUCOSE MONITORING SYST OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin pen needles NOVOFINE PEN NEEDLES Tier 2 OTC insulin syringes, needles BD INSULIN SYRINGES AND Tier 2 NEEDLES OTC lancet device ACCU-CHEK FASTCLIX LANCET Tier 2 DEVICE OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX Tier 2 LANCETS OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC urine test strips CHEMSTRIP K URINE KETONE Tier 2 STRIPS OTC urine test strips CHEMSTRIP UGK URINE Tier 2 GLUCOSE/KETONE STRIPS OTC urine test strips CHEMSTRIP UG URINE Tier 2 GLUCOSE STRIPS PA blood glucose continuous monitoring receivers, sensors, DEXCOM CONTINUOUS Tier 3 transmitters GLUCOSE MONITORING SYSTEM

CALCIUM RECEPTOR ANTAGONISTS PA cinacalcet Tier 4 PA etelcalcetide PARSABIV Tier 5

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org

Bisphosphonates alendronate Tier 1 FOSAMAX Tier 3

ibandronate Tier 1 BONIVA Tier 3 risedronate Tier 1 ACTONEL Tier 3 risedronate delayed-rel Tier 1 ATELVIA Tier 3 pamidronate Tier 4 zoledronic acid 4 mg/100 mL Tier 4 zoledronic acid 5 mg/100 mL Tier 4 alendronate/vitamin D3 FOSAMAX PLUS D Tier 3

Calcitonins calcitonin-salmon spray Tier 1 MIACALCIN Tier 3 calcitonin-salmon inj MIACALCIN inj Tier 3

Parathyroid Hormones PA teriparatide FORTEO Tier 4 PA abaloparatide TYMLOS Tier 5 PA parathyroid hormone (recombinant) NATPARA Tier 5

Miscellaneous PA denosumab PROLIA Tier 4 PA denosumab XGEVA Tier 4 PA romosozumab-aqqg EVENITY Tier 5

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CARNITOR Tier 3

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen † drospirenone/EE 3/20 Tier 1 YAZ Tier 3 † levonorgestrel/EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 TAYTULLA Tier 3

30 mcg Estrogen † desogestrel/EE 0.15/30 Tier 1 † drospirenone/EE 3/30 Tier 1 YASMIN Tier 3 † drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 SAFYRAL Tier 3 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 † norethindrone acetate/EE 1.5/30 and iron Tier 1 † norgestrel/EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 † norethindrone/EE 0.4/35 Tier 1 † norethindrone/EE 0.5/35 Tier 1 † norethindrone/EE 1/35 Tier 1 † norgestimate/EE 0.25/35 Tier 1

50 mcg Estrogen † ethynodiol diacetate/EE 1/50 Tier 1

† norgestrel/EE 0.5/50 Tier 1

Biphasic † desogestrel/EE Tier 1 MIRCETTE Tier 3 norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE Tier 3

Triphasic † desogestrel/EE Tier 1 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3 † norethindrone/EE Tier 1 † norgestimate/EE Tier 1

Four Phase estradiol valerate and dienogest/estradiol valerate NATAZIA Tier 3

Extended Cycle † levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3 † levonorgestrel/EE 0.15/30 - Jolessa Tier 1 † levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3

Continuous † levonorgestrel/EE 0.09/20 - Amethyst Tier 1

Progestin Only † norethindrone Tier 1 ORTHO MICRONOR Tier 3 drospirenone SLYND Tier 3

Implant ‡ etonogestrel implant NEXPLANON Tier 4

Injectable † medroxyprogesterone acetate 150 mg/mL Tier 1 DEPO-PROVERA Tier 3

Intrauterine Devices ‡ intrauterine copper contraceptive PARAGARD T 380A Tier 2 ‡ levonorgestrel-releasing IUD KYLEENA Tier 4 ‡ levonorgestrel-releasing IUD MIRENA Tier 4 ‡ levonorgestrel-releasing IUD SKYLA Tier 4 levonorgestrel-releasing IUD LILETTA Tier 5

Transdermal † norelgestromin/EE Tier 1 ethinyl estradiol-levonorgestrel TWIRLA Tier 3

Vaginal †, * etonogestrel/EE - EluRyng Tier 1 NUVARING Tier 3 segesterone acetate/EE ring ANNOVERA Tier 3

* Generic versions are covered at no charge to qualifying members

ENDOMETRIOSIS danazol Tier 1 PA nafarelin SYNAREL Tier 2 PA elagolix ORILISSA Tier 3 leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf

Injectable estradiol valerate Tier 1 DELESTROGEN Tier 2

Oral estradiol Tier 1 ESTRACE Tier 3 estrogens, esterified/methyltestosterone Tier 1 estrogens, conjugated PREMARIN Tier 2

Transdermal estradiol Tier 1 CLIMARA Tier 3 estradiol Tier 1 MINIVELLE Tier 3 estradiol Tier 1 VIVELLE-DOT Tier 3 estradiol transdermal spray EVAMIST Tier 2 estradiol ALORA Tier 3 estradiol transdermal gel ESTROGEL Tier 3

Vaginal estradiol vaginal crm Tier 1 ESTRACE Tier 3 estradiol vaginal tabs Tier 1 VAGIFEM Tier 3 estradiol vaginal ring ESTRING Tier 2 estrogens, conjugated crm PREMARIN crm Tier 2 estradiol vaginal inserts IMVEXXY Tier 3 estradiol vaginal ring FEMRING Tier 3

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 FEMHRT Tier 3 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3 estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2 estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2 drospirenone/estradiol ANGELIQ Tier 3 estradiol/norgestimate PREFEST Tier 3 estradiol/progesterone BIJUVA Tier 3

Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 estradiol/norethindrone acetate COMBIPATCH Tier 3

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene DUAVEE Tier 3

FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic gonadotropin Tier 4 PA ganirelix acetate inj Tier 4 GANIRELIX ACETATE Tier 4 PA gonadorelin LUTREPULSE Tier 2 PA cetrorelix CETROTIDE Tier 4 PA choriogonadotropin alfa OVIDREL Tier 4 PA chorionic gonadotropin NOVAREL Tier 4

PA chorionic gonadotropin PREGNYL Tier 4 PA follitropin beta FOLLISTIM AQ Tier 4 PA menotropins MENOPUR Tier 4 PA follitropin alfa GONAL-F Tier 5 PA follitropin alfa GONAL-F RFF Tier 5

GAUCHER DISEASE PA eliglustat CERDELGA Tier 4 PA imiglucerase CEREZYME Tier 4

GLUCOCORTICOIDS cortisone acetate Tier 1 dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 methylprednisolone Tier 1 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally disintegrating tabs Tier 1 prednisolone syrup Tier 1 prednisone Tier 1 PA dexamethasone HEMADY Tier 3

GLUCOSE ELEVATING AGENTS diazoxide Tier 1 PROGLYCEM Tier 3 glucagon, human recombinant (KIT) Tier 1 GLUCAGON EMERGENCY KIT Tier 3 glucagon nasal powder BAQSIMI Tier 2 glucagon subcutaneous soln GVOKE Tier 2 glucagon, human recombinant GLUCAGEN Tier 2

HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 4 ORFADIN Tier 4 nitisinone NITYR Tier 5

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines

PA somatropin NORDITROPIN Tier 4 PA, * somatropin SEROSTIM Tier 4 PA, ** somatropin ZORBTIVE Tier 4

* Indicated for AIDS wasting only ** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3 doxercalciferol Tier 1 HECTOROL Tier 3 paricalcitol Tier 1 ZEMPLAR Tier 3 calcifediol ext-rel RAYALDEE Tier 3

INSULIN-LIKE GROWTH FACTOR-1 AGENTS PA mecasermin INCRELEX Tier 4

PHENYLKETONURIA TREATMENT AGENTS PA sapropterin Tier 4 KUVAN Tier 5

PA pegvaliase-pqpz PALYNZIQ Tier 5

PHOSPHATE BINDER AGENTS calcium acetate Tier 1 lanthanum carbonate chew tabs Tier 1 FOSRENOL CHEWABLE Tier 3 TABLETS sevelamer carbonate Tier 1 RENVELA Tier 3 sevelamer HCl Tier 1 RENAGEL Tier 3 lanthanum oral powder FOSRENOL ORAL POWDER Tier 2 ferric citrate AURYXIA Tier 3 sucroferric oxyhydroxide VELPHORO Tier 3

POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate Tier 1 PA patiromer VELTASSA Tier 3 PA sodium zirconium cyclosilicate LOKELMA Tier 3

PROGESTINS Injectable hydroxyprogesterone caproate Tier 4 MAKENA Tier 5

Oral medroxyprogesterone acetate Tier 1 PROVERA Tier 3 megestrol acetate susp Tier 1 norethindrone acetate Tier 1 AYGESTIN Tier 3 PA progesterone, micronized Tier 1 PROMETRIUM Tier 3

Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2

SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene Tier 1 EVISTA Tier 3 ospemifene OSPHENA Tier 3

THYROID AGENTS Antithyroid Agents methimazole Tier 1 TAPAZOLE Tier 3 propylthiouracil Tier 1

Thyroid Supplements levothyroxine Tier 1 SYNTHROID Tier 2 levothyroxine Tier 1 TIROSINT Tier 3 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 CYTOMEL Tier 3 thyroid ARMOUR THYROID Tier 3

UREA CYCLE DISORDERS PA sodium phenylbutyrate Tier 4 BUPHENYL Tier 5

UTERINE FIBROIDS PA elagolix sodium/estradiol/norethindrone acetate ORIAHNN Tier 3

VASOPRESSINS desmopressin spray, tabs Tier 1 DDAVP Tier 3

MISCELLANEOUS acetylcysteine Tier 1 ACETADOTE Tier 3 methylergonovine Tier 1 trientine Tier 1 SYPRINE Tier 3 corticotropin powder Tier 4 PA miglustat Tier 4 ZAVESCA Tier 5 octreotide acetate Tier 4 PA tolvaptan Tier 4 SAMSCA Tier 5 hydroxocobalamin CYANOKIT Tier 2 prasterone vaginal inserts INTRAROSA Tier 3 PA uridine triacetate XURIDEN Tier 3 PA agalsidase beta FABRAZYME Tier 4 PA alglucosidase alfa LUMIZYME Tier 4 PA asfotase alfa STRENSIQ Tier 4 betaine anhydrous CYSTADANE Tier 4 PA burosumab-twza CRYSVITA Tier 4 PA carglumic acid CARBAGLU Tier 4 cysteamine CYSTAGON Tier 4 PA cysteamine delayed-rel PROCYSBI Tier 4 PA elosulfase alfa VIMIZIM Tier 4 PA galsulfase NAGLAZYME Tier 4 PA glycerol phenylbutyrate RAVICTI Tier 4 PA histrelin acetate SUPPRELIN LA Tier 4 PA idursulfase ELAPRASE Tier 4 PA lanreotide acetate SOMATULINE DEPOT Tier 4 PA laronidase ALDURAZYME Tier 4 PA leuprolide acetate LUPRON DEPOT-PED Tier 4 PA lonafarnib ZOKINVY Tier 4 PA mifepristone KORLYM Tier 4 PA octreotide acetate SANDOSTATIN LAR Tier 4 PA pasireotide SIGNIFOR Tier 4 pegvisomant SOMAVERT Tier 4 PA sebelipase alfa KANUMA Tier 4 PA taliglucerase alfa ELELYSO Tier 4 PA tesamorelin EGRIFTA Tier 4 thyrotropin alfa THYROGEN Tier 4 PA tolvaptan JYNARQUE Tier 4 PA velaglucerase alfa VPRIV Tier 4 PA vestronidase alfa-vjbk MEPSEVII Tier 4 PA corticotropin ACTHAR Tier 5 PA elapegademase-lvlr REVCOVI Tier 5 PA inotersen TEGSEDI Tier 5 PA metreleptin MYALEPT Tier 5 PA migalastat GALAFOLD Tier 5 PA octreotide MYCAPSSA Tier 5 PA octreotide acetate BYNFEZIA Tier 5 PA osilodrostat phosphate ISTURISA Tier 5 PA triptorelin pamoate TRIPTODUR Tier 5

GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org

ANTIDIARRHEALS diphenoxylate/atropine Tier 1 LOMOTIL Tier 3 loperamide Tier 1 crofelemer delayed-rel MYTESI Tier 3

ANTIEMETICS QL aprepitant caps Tier 1 EMEND Tier 3 PA doxylamine/pyridoxine delayed-rel Tier 1 DICLEGIS Tier 3 QL dronabinol Tier 1 MARINOL Tier 3 granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 REGLAN Tier 3 QL ondansetron Tier 1 ZOFRAN Tier 3 QL ondansetron orally disintegrating tabs Tier 1 PA palonosetron Tier 1 ALOXI Tier 3 prochlorperazine Tier 1 promethazine Tier 1 scopolamine transdermal Tier 1 TRANSDERM SCOP Tier 3 trimethobenzamide Tier 1 TIGAN Tier 3 QL granisetron transdermal SANCUSO Tier 2 QL rolapitant VARUBI Tier 2 QL aprepitant CINVANTI Tier 3 QL aprepitant susp EMEND Tier 3 PA granisetron ext-rel inj SUSTOL Tier 3 QL netupitant/palonosetron AKYNZEO Tier 3

ANTISPASMODICS d atropine/hyoscyamine/scopolamine/phenobarbital Tier 1 chlordiazepoxide/clidinium Tier 1 dicyclomine Tier 1 d hyoscyamine sulfate Tier 1 LEVSIN Tier 3 d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3 propantheline 15 mg Tier 1

CHOLELITHOLYTICS ursodiol Tier 1 ACTIGALL Tier 3 ursodiol Tier 1 URSO Tier 3 ursodiol Tier 1 URSO FORTE Tier 3

H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 * famotidine Tier 1 nizatidine Tier 1

* Except OTC available versions like 10 mg and 20 mg

INFLAMMATORY BOWEL DISEASE Injectable Agents PA vedolizumab ENTYVIO Tier 5

Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 ENTOCORT EC Tier 3 mesalamine delayed-rel caps Tier 1 mesalamine delayed-rel tabs Tier 1 LIALDA Tier 3 mesalamine ext-rel caps Tier 1 APRISO Tier 3

sulfasalazine Tier 1 AZULFIDINE Tier 3 sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3 mesalamine ext-rel caps PENTASA Tier 2 budesonide ext-rel caps ORTIKOS Tier 3 olsalazine DIPENTUM Tier 3

Rectal Agents hydrocortisone enema Tier 1 mesalamine rectal susp Tier 1 ROWASA Tier 3 mesalamine supp Tier 1 CANASA Tier 3 hydrocortisone acetate foam CORTIFOAM Tier 2

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA lubiprostone Tier 1 AMITIZA Tier 3 PA linaclotide LINZESS Tier 2 PA tegaserod maleate ZELNORM Tier 3

Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 LOTRONEX Tier 3 PA eluxadoline VIBERZI Tier 3

LAXATIVES lactulose soln Tier 1 peg 3350/electrolytes Tier 1 GOLYTELY Tier 3 peg 3350/electrolytes Tier 1 MOVIPREP Tier 3 peg 3350/electrolytes Tier 1 NULYTELY Tier 3 sodium sulfate/potassium sulfate/magnesium sulfate SUPREP Tier 2 lactulose packets KRISTALOSE pak Tier 3 peg 3350/electrolytes PLENVU Tier 3 sodium phosphates OSMOPREP Tier 3 sodium picosulfate/magnesium oxide/citric acid CLENPIQ Tier 3 sodium picosulfate/magnesium oxide/citric acid PREPOPIK Tier 3

OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK Tier 2 PA methylnaltrexone RELISTOR Tier 3

PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 pancrelipase delayed-rel PANCREAZE Tier 3

PROSTAGLANDINS misoprostol Tier 1 CYTOTEC Tier 3

PROTON PUMP INHIBITORS QL esomeprazole magnesium delayed-rel Tier 1 QL lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel (except rabeprazole capsule Tier 1 sprinkle delayed-rel)

SALIVA STIMULANTS cevimeline Tier 1 EVOXAC Tier 3

pilocarpine tabs Tier 1 SALAGEN Tier 3

STEROIDS, RECTAL d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2 d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2

ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + clarithromycin Tier 1 QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2 QL amoxicillin/rifabutin/omeprazole TALICIA Tier 3

MISCELLANEOUS alvimopan Tier 1 ENTEREG Tier 3 cromolyn sodium Tier 1 GASTROCROM Tier 3 sucralfate Tier 1 QL dronabinol solution SYNDROS Tier 3 glycopyrrolate CUVPOSA Tier 3 nitroglycerin rectal oint 0.4% RECTIV Tier 3 PA plecanatide TRULANCE Tier 3 dextranomer/sodium hyaluronate SOLESTA Tier 4 PA palifermin KEPIVANCE Tier 4 PA teduglutide GATTEX Tier 4 PA cholic acid CHOLBAM Tier 5 PA givosiran GIVLAARI Tier 5 PA obeticholic acid OCALIVA Tier 5 PA telotristat XERMELO Tier 5

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines

alfuzosin ext-rel Tier 1 dutasteride Tier 1 AVODART Tier 3 dutasteride/tamsulosin Tier 1 finasteride Tier 1 PROSCAR Tier 3 silodosin Tier 1 RAPAFLO Tier 3 PA tadalafil 2.5 mg, 5 mg Tier 1 CIALIS Tier 3 tamsulosin Tier 1 FLOMAX Tier 3

URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 oxybutynin Tier 1 oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3 solifenacin Tier 1 tolterodine Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 fesoterodine ext-rel TOVIAZ Tier 2 mirabegron ext-rel MYRBETRIQ Tier 2

VAGINAL ANTI-INFECTIVES metronidazole vaginal Tier 1 terconazole crm Tier 1

terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2 clindamycin vaginal cream CLINDESSE Tier 2

MISCELLANEOUS bethanechol Tier 1 phenazopyridine Tier 1 PYRIDIUM Tier 3 potassium citrate ext-rel Tier 1 UROCIT-K Tier 3 PA tiopronin Tier 1 THIOLA Tier 3 pentosan polysulfate sodium ELMIRON Tier 2 PA tiopronin delayed-rel THIOLA EC Tier 3

HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular

Injectable enoxaparin Tier 1 LOVENOX Tier 3 dalteparin FRAGMIN Tier 2

Oral warfarin Tier 1 apixaban ELIQUIS Tier 2 rivaroxaban XARELTO Tier 2

Synthetic Heparinoid-like Agents fondaparinux Tier 1 ARIXTRA Tier 3

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org

Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines

PA darbepoetin alfa ARANESP Tier 4 PA epoetin alfa-epbx RETACRIT Tier 4 PA filgrastim-aafi NIVESTYM Tier 4 PA filgrastim-sndz ZARXIO Tier 4 PA pegfilgrastim-apgf NYVEPRIA Tier 4 PA pegfilgrastim-bmez ZIEXTENZO Tier 4 PA pegfilgrastim-cbqv UDENYCA Tier 4 PA pegfilgrastim-jmdb FULPHILA Tier 4 PA tbo-filgrastim GRANIX Tier 4 PA epoetin alfa EPOGEN Tier 5 PA methoxy polyethylene glycol/epoetin beta MIRCERA Tier 5 PA sargramostim LEUKINE Tier 5

HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org

AHF, human/VWF, human HUMATE-P Tier 4 antihemophilic factor ALPHANATE Tier 4 antihemophilic factor HEMOFIL M Tier 4

antihemophilic factor KOATE-DVI Tier 4 antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 4 antihemophilic factor, recombinant ADVATE Tier 4 antihemophilic factor, recombinant AFSTYLA Tier 4 antihemophilic factor, recombinant KOGENATE FS Tier 4 antihemophilic factor, recombinant KOVALTRY Tier 4 antihemophilic factor, recombinant NOVOEIGHT Tier 4 antihemophilic factor, recombinant RECOMBINATE Tier 4 antihemophilic factor, recombinant XYNTHA Tier 4 antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4 anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4 coagulation factor IX (recombinant), glycopegylated REBINYN Tier 4 coagulation factor IX, recombinant IDELVION Tier 4 coagulation factor IX, recombinant IXINITY Tier 4 coagulation factor VIIa NOVOSEVEN RT Tier 4 coagulation factor X, human COAGADEX Tier 4 desmopressin spray STIMATE Tier 4 emicizumab-kxwh HEMLIBRA Tier 4 factor IX concentrate ALPHANINE SD Tier 4 factor IX concentrate BENEFIX Tier 4 factor IX concentrate MONONINE Tier 4 factor IX concentrate PROFILNINE Tier 4 factor IX concentrate RIXUBIS Tier 4 factor IX recombinant, Fc fusion protein ALPROLIX Tier 4 factor XIII A-subunit recombinant TRETTEN Tier 4 factor XIII concentrate CORIFACT Tier 4 fibrinogen RIASTAP Tier 4 human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ Tier 4 von Willebrand factor, recombinant VONVENDI Tier 4 VWF, human/factor VIII complex WILATE Tier 4 antihemophilic factor (recombinant) pegylated ADYNOVATE Tier 5 antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 5 antihemophilic factor (recombinant) porcine sequence OBIZUR Tier 5 antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT Tier 5 coagulation factor VIIa-jncw SEVENFACT Tier 5 fibrinogen FIBRYGA Tier 5

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 4 PA romiplostim NPLATE Tier 4 PA fostamatinib TAVALISSE Tier 5

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PA eculizumab SOLIRIS Tier 4 PA ravulizumab-cwvz ULTOMIRIS Tier 5

PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 PLAVIX Tier 3 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 AGGRENOX Tier 3 prasugrel Tier 1 EFFIENT Tier 3 PA aspirin ext-rel DURLAZA Tier 3 cangrelor KENGREAL Tier 3 eptifibatide INTEGRILIN Tier 3 ticagrelor BRILINTA Tier 3 tirofiban inj AGGRASTAT Tier 3

vorapaxar ZONTIVITY Tier 3

PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 AGRYLIN Tier 3

SICKLE CELL DISEASE PA crizanlizumab-tmca ADAKVEO Tier 4 PA voxelotor OXBRYTA Tier 4

STEM CELL MOBILIZERS PA plerixafor MOZOBIL Tier 4

THROMBOCYTOPENIA AGENTS QL lusutrombopag MULPLETA Tier 5

MISCELLANEOUS aminocaproic acid Tier 1 AMICAR Tier 3 cilostazol Tier 1 pentoxifylline ext-rel Tier 1 tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3 tranexamic acid Tier 1 LYSTEDA Tier 3 PA deferasirox Tier 4 PA deferasirox Tier 4 JADENU Tier 5 PA deferiprone Tier 4 FERRIPROX Tier 4 deferoxamine Tier 4 DESFERAL Tier 5 alteplase CATHFLO ACTIVASE Tier 2 PA luspatercept-aamt REBLOZYL Tier 4 PA protein C concentrate, human CEPROTIN Tier 4 PA avatrombopag DOPTELET Tier 5 PA L-glutamine oral powder ENDARI Tier 5

IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org

ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 5 PA peanut allergen-dfnp PALFORZIA Tier 5

AUTOIMMUNE AGENTS PA adalimumab HUMIRA Tier 4 PA apremilast OTEZLA Tier 4 PA etanercept ENBREL Tier 4 PA etanercept ENBREL SURECLICK Tier 4 PA golimumab SIMPONI 100 mg Tier 4 PA ixekizumab TALTZ Tier 4 PA risankizumab-rzaa SKYRIZI Tier 4 PA tocilizumab ACTEMRA Tier 4 PA tofacitinib XELJANZ Tier 4 PA tofacitinib ext-rel XELJANZ XR Tier 4 PA upadacitinib RINVOQ ER Tier 4 PA ustekinumab STELARA SUBCUTANEOUS Tier 4 PA abatacept ORENCIA Tier 5 PA anakinra KINERET Tier 5 PA baricitinib OLUMIANT Tier 5

PA brodalumab SILIQ Tier 5 PA certolizumab pegol CIMZIA Tier 5 PA golimumab SIMPONI 50 mg Tier 5 PA, * infliximab REMICADE PA, * infliximab-abda RENFLEXIS PA, * infliximab-dyyb INFLECTRA PA sarilumab KEVZARA Tier 5 PA satralizumab-mwge ENSPRYNG Tier 5 PA tildrakizumab-asmn ILUMYA Tier 5

* Medical Benefit only drug

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 PLAQUENIL Tier 3 leflunomide Tier 1 ARAVA Tier 3 methotrexate inj Tier 1 methotrexate oral Tier 1 penicillamine tabs Tier 1 DEPEN Tier 3 auranofin RIDAURA Tier 3 PA methotrexate auto-injector RASUVO Tier 3 PA methotrexate inj OTREXUP Tier 3

HEREDITARY ANGIOEDEMA AGENTS PA icatibant Tier 4 PA C1 esterase inhibitor BERINERT Tier 4 PA C1 esterase inhibitor CINRYZE Tier 4 PA ecallantide KALBITOR Tier 4 PA berotralstat ORLADEYO Tier 5 PA C1 esterase inhibitor HAEGARDA Tier 5 PA C1 esterase inhibitor, recombinant RUCONEST Tier 5 PA lanadelumab-flyo TAKHZYRO Tier 5

IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 4 hepatitis B immune globulin HYPERHEP B S-D Tier 4 hepatitis B immune globulin NABI-HB Tier 4 PA immune globulin (human)-ifas PANZYGA Tier 4 PA immune globulin, gamma GAMASTAN Tier 4 PA immune globulin, gamma GAMASTAN S-D Tier 4 PA immune globulin, gamma GAMUNEX-C Tier 4 PA immune globulin, gamma (IGG) GAMMAKED Tier 4 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4 PA immune globulin, intravenous BIVIGAM Tier 4 PA immune globulin, intravenous FLEBOGAMMA Tier 4 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4 PA immune globulin, intravenous GAMMAGARD S-D Tier 4 PA immune globulin, intravenous OCTAGAM Tier 4 PA immune globulin, intravenous PRIVIGEN Tier 4 PA immune globulin, subcutaneous HIZENTRA Tier 4 PA immune globulin/hyaluronidase HYQVIA Tier 4 Rho (D) immune globulin HYPERRHO S-D Tier 4 Rho (D) immune globulin MICRHOGAM Tier 4 Rho (D) immune globulin MICRHOGAM PLUS Tier 4 Rho (D) immune globulin RHOGAM Tier 4 Rho (D) immune globulin RHOGAM PLUS Tier 4 Rho (D) immune globulin RHOPHYLAC Tier 4

Rho (D) immune globulin WINRHO SDF Tier 4 varicella zoster immune globulin VARIZIG Tier 4 PA immune globulin (human)-klhw XEMBIFY Tier 5 PA immune globulin (human)-slra ASCENIV Tier 5 PA immune globulin, subcutaneous CUVITRU Tier 5 PA immune globulin-hipp CUTAQUIG Tier 5

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of hepatitis are available at: https://www.aasld.org

Interferons PA interferon alfa-2b INTRON A Tier 4 PA interferon gamma-1b, recombinant ACTIMMUNE Tier 4 PA peginterferon alfa-2a PEGASYS Tier 4 PA peginterferon alfa-2b PEGINTRON Tier 4

Miscellaneous bezlotoxumab ZINPLAVA Tier 3 PA canakinumab ILARIS Tier 4 PA rilonacept ARCALYST Tier 4

IMMUNOSUPPRESSANTS Antimetabolites azathioprine Tier 1 IMURAN Tier 3 mycophenolate mofetil Tier 1 CELLCEPT Tier 3 mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 3

Calcineurin Inhibitors cyclosporine Tier 1 SANDIMMUNE Tier 3 cyclosporine, modified Tier 1 NEORAL Tier 3 tacrolimus Tier 1 PROGRAF Tier 3 tacrolimus ext-rel ASTAGRAF XL Tier 2 tacrolimus ext-rel ENVARSUS XR Tier 3 PA voclosporin LUPKYNIS Tier 5

Rapamycin Derivatives sirolimus Tier 1 RAPAMUNE Tier 3 everolimus 0.25 mg, 0.5 mg, 0.75 mg Tier 4 ZORTRESS 0.25 mg, 0.5 mg, 0.75 Tier 5 mg everolimus 1 mg ZORTRESS 1 mg Tier 4

Miscellaneous belatacept NULOJIX Tier 4 PA belimumab BENLYSTA Tier 4

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1 potassium chloride powder Tier 1

VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1

Prenatal Vitamins prenatal vitamins/folic acid DUET DHA Tier 2 prenatal vitamins/folic acid PRENATE ELITE Tier 2 prenatal vitamins/docusate/folic acid CITRANATAL RX Tier 3 prenatal vitamins/folic acid VITAFOL-OB Tier 3

Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 phytonadione Tier 1 MEPHYTON Tier 3 sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3 cyanocobalamin spray NASCOBAL Tier 2 iron sucrose inj VENOFER Tier 2 zinc acetate GALZIN Tier 2 ferric carboxymaltose inj INJECTAFER Tier 3 ferric derisomaltose inj MONOFERRIC Tier 3 ferumoxytol inj FERAHEME Tier 3

MISCELLANEOUS PA triheptanoin DOJOLVI Tier 5

RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov

The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS PA alpha-1 proteinase inhibitor ARALAST NP Tier 4 PA alpha-1 proteinase inhibitor GLASSIA Tier 4 PA alpha-1 proteinase inhibitor PROLASTIN-C Tier 4 PA alpha-1 proteinase inhibitor ZEMAIRA Tier 4

ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 3 epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 3 epinephrine inj (0.15 mg and 0.30 mg) SYMJEPI Tier 2

ANTICHOLINERGICS ipratropium soln Tier 1 tiotropium SPIRIVA Tier 2 tiotropium SPIRIVA RESPIMAT Tier 2 glycopyrrolate inhalation powder SEEBRI NEOHALER Tier 3 glycopyrrolate inhalation solution LONHALA MAGNAIR Tier 3 ipratropium, CFC-free aerosol ATROVENT HFA Tier 3 revefenacin inhalation solution YUPELRI Tier 3

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 3

Long Acting tiotropium/olodaterol STIOLTO RESPIMAT Tier 2 umeclidinium/vilanterol ANORO ELLIPTA Tier 2 glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3 indacaterol/glycopyrrolate inhalation powder UTIBRON NEOHALER Tier 3

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2 budesonide/glycopyrrolate/formoterol BREZTRI AEROSPHERE Tier 3

ANTIHISTAMINES, SEDATING cyproheptadine Tier 1 diphenhydramine Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3 promethazine Tier 1

ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate Tier 1 TESSALON Tier 3

ANTITUSSIVE COMBINATIONS Opioid QL codeine/promethazine Tier 1 QL codeine/promethazine/phenylephrine Tier 1 QL hydrocodone/homatropine Tier 1

BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 2 levalbuterol inhalation soln Tier 1 XOPENEX SOLUTION Tier 3 levalbuterol nebulizer soln concentrate Tier 1 XOPENEX CONCENTRATE Tier 3 levalbuterol tartrate, CFC-free aerosol Tier 1 albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2 albuterol sulfate aerosol powder 108mcg/actuation with sensor PROAIR DIGIHALER Tier 3

Long Acting Hand-held Active Inhalation salmeterol xinafoate SEREVENT DISKUS Tier 2 formoterol inhalation caps FORADIL Tier 3 olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Tier 3

Nebulized Passive Inhalation arformoterol soln BROVANA Tier 3 formoterol inhalation soln PERFOROMIST Tier 3

Oral Agents albuterol Tier 1

albuterol ext-rel Tier 1 terbutaline Tier 1

CYSTIC FIBROSIS tobramycin inhalation soln Tier 4 BETHKIS Tier 5 tobramycin inhalation soln Tier 4 KITABIS PAK Tier 5 tobramycin inhalation soln Tier 4 TOBI Tier 5 aztreonam lysine inhalation soln CAYSTON Tier 4 PA dornase alfa PULMOZYME Tier 4 PA elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA Tier 4 PA ivacaftor KALYDECO Tier 4 PA lumacaftor/ivacaftor ORKAMBI Tier 4 PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4 tobramycin inhalation powder TOBI PODHALER Tier 4 PA amikacin liposome inhalation susp ARIKAYCE Tier 5 PA mannitol inhalation powder BRONCHITOL Tier 5

LEUKOTRIENE MODULATORS montelukast Tier 1 SINGULAIR Tier 3 zafirlukast Tier 1 ACCOLATE Tier 3

MAST CELL STABILIZERS cromolyn soln Tier 1

NASAL ANTIHISTAMINES azelastine spray Tier 1 olopatadine spray Tier 1 PATANASE Tier 3

NASAL STEROIDS/COMBINATIONS azelastine/fluticasone nasal spray Tier 1 flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 PA fluticasone propionate XHANCE Tier 3

PHOSPHODIESTERASE-4 INHIBITORS roflumilast DALIRESP Tier 3

PULMONARY FIBROSIS AGENTS PA nintedanib OFEV Tier 4 PA pirfenidone ESBRIET Tier 4

SEVERE ASTHMA AGENTS PA omalizumab XOLAIR Tier 4 PA mepolizumab NUCALA Tier 5

STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol Tier 1 SYMBICORT Tier 2 fluticasone/salmeterol Tier 1 ADVAIR Tier 3 fluticasone/salmeterol Tier 1 AIRDUO RESPICLICK Tier 3 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 2 mometasone/formoterol DULERA Tier 2 fluticasone/salmeterol AIRDUO DIGIHALER Tier 3

STEROID INHALANTS budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3 beclomethasone breath-activated aerosol QVAR REDIHALER Tier 2 beclomethasone, CFC-free aerosol QVAR Tier 2 budesonide PULMICORT FLEXHALER Tier 2 fluticasone ARNUITY ELLIPTA Tier 2 fluticasone FLOVENT Tier 2 fluticasone, CFC-free aerosol FLOVENT HFA Tier 2 fluticasone propionate ARMONAIR DIGIHALER Tier 3 mometasone ASMANEX Tier 3 mometasone, CFC-free aerosol ASMANEX HFA Tier 3

XANTHINES caffeine citrate Tier 1 CAFCIT Tier 3 theophylline ext-rel tabs Tier 1 theophylline ext-rel caps THEO-24 Tier 2 theophylline liquid ELIXOPHYLLIN Tier 2

MISCELLANEOUS ipratropium nasal spray Tier 1 PA benralizumab FASENRA Tier 5 PA reslizumab inj CINQAIR Tier 5

TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Oral isotretinoin Tier 1 PA * isotretinoin Tier 1 ABSORICA Tier 3 minocycline ext-rel caps Tier 1 XIMINO Tier 3

* Brand ABSORICA requires PA

Topical PA adapalene crm, gel Tier 1 DIFFERIN Tier 3 PA adapalene/benzoyl peroxide Tier 1 EPIDUO Tier 3 benzoyl peroxide Tier 1 BENZAC AC Tier 3 QL clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 clindamycin/benzoyl peroxide Tier 1 ACANYA Tier 3 clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 3 PA clindamycin/tretinoin Tier 1 VELTIN Tier 3 PA clindamycin/tretinoin Tier 1 ZIANA Tier 3 QL erythromycin gel 2% Tier 1 ERYGEL Tier 3 QL erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3 QL, * sulfacetamide sodium Tier 1 PA tazarotene crm 0.1% Tier 1 TAZORAC Tier 3 PA tretinoin Tier 1 ATRALIN Tier 3 PA tretinoin Tier 1 RETIN-A Tier 3 PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3 PA adapalene/benzoyl peroxide EPIDUO FORTE Tier 3

azelaic acid AZELEX Tier 3 clindamycin/benzoyl peroxide ONEXTON Tier 3 QL minocycline hcl micronized foam AMZEEQ Tier 3 PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3 PA tazarotene foam 0.1% FABIOR Tier 3 PA tazarotene lotion 0.045% ARAZLO Tier 3 PA trifarotene cream 0.005% AKLIEF Tier 3

* generic for OVACE and OVACE PLUS

Actinic Keratosis PA diclofenac sodium gel 3% Tier 1 fluorouracil Tier 1 EFUDEX Tier 3 PA aminolevulinic acid gel 10% AMELUZ Tier 3 PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3 fluorouracil FLUOROPLEX Tier 3 fluorouracil crm 4% TOLAK Tier 3

Antibiotics QL gentamicin crm Tier 1 mafenide acetate packets 5% Tier 1 SULFAMYLON Tier 3 QL mupirocin Tier 1 silver sulfadiazine Tier 1 SILVADENE Tier 3 retapamulin ALTABAX Tier 2

Antifungals QL ciclopirox Tier 1 QL clotrimazole Tier 1 QL clotrimazole/betamethasone Tier 1 QL econazole Tier 1 QL ketoconazole Tier 1 PA luliconazole Tier 1 QL miconazole nitrate/zinc oxide Tier 1 QL naftifine Tier 1 QL nystatin Tier 1 PA oxiconazole crm Tier 1 PA sulconazole Tier 1 EXELDERM Tier 3 PA tavaborole sol 5% Tier 1 PA econazole foam ECOZA Tier 3

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org

Injectable PA guselkumab TREMFYA Tier 4 PA ustekinumab STELARA Tier 4 PA secukinumab COSENTYX Tier 5

Oral acitretin Tier 1 methoxsalen oral Tier 1 OXSORALEN-ULTRA Tier 3

Topical QL betamethasone dipropionate/calcipotriene oint, susp Tier 1 QL calcipotriene Tier 1 DOVONEX Tier 3

QL, * calcipotriene foam Tier 1 SORILUX Tier 3 calcitriol oint Tier 1 VECTICAL Tier 3 QL calcipotriene/betamethasone foam ENSTILAR Tier 3

* Does not include NDC 73308-0357-60

Antiseborrheics QL ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Injectable PA dupilumab DUPIXENT Tier 5

Topical pimecrolimus Tier 1 ELIDEL Tier 3 tacrolimus Tier 1 PROTOPIC Tier 3 PA crisaborole oint EUCRISA Tier 3

Corticosteroids Low Potency QL alclometasone crm, oint 0.05% Tier 1 QL desonide crm 0.05% Tier 1 DESOWEN Tier 3 QL desonide gel 0.05% Tier 1 DESONATE Tier 3 QL desonide lotion, oint 0.05% Tier 1 QL fluocinolone acetonide soln 0.01% Tier 1 QL hydrocortisone crm 2.5% Tier 1 QL desonide foam 0.05% VERDESO Tier 2 QL fluocinolone shampoo 0.01% CAPEX Tier 3 pramoxine/hydrocortisone PRAMOSONE Tier 3

Medium Potency QL betamethasone valerate crm, lotion, oint 0.1% Tier 1 QL clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3 QL desoximetasone crm, oint 0.05% Tier 1 QL fluocinolone acetonide crm, oint 0.025% Tier 1 SYNALAR Tier 3 QL fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3 QL flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3 QL fluticasone propionate crm 0.05%, oint 0.005% Tier 1 QL fluticasone propionate lotion 0.005% Tier 1 CUTIVATE Tier 3 QL hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3 QL hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1 LOCOID Tier 3 QL hydrocortisone valerate crm, oint 0.2% Tier 1 QL mometasone crm, lotion, oint 0.1% Tier 1 QL triamcinolone acetonide crm, lotion 0.025% Tier 1 QL triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 QL flurandrenolide tape CORDRAN TAPE Tier 2 QL hydrocortisone probutate crm 0.1% PANDEL Tier 3

High Potency QL amcinonide crm, lotion, oint 0.1% Tier 1 QL betamethasone dipropionate augmented crm 0.05% Tier 1 DIPROLENE AF Tier 3 QL betamethasone dipropionate augmented gel, lot 0.05% Tier 1 QL betamethasone dipropionate augmented ointment 0.05% Tier 1 DIPROLENE Tier 3

QL betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 QL desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 TOPICORT Tier 3 QL diflorasone diacetate crm 0.05% Tier 1 QL fluocinonide crm, gel, oint, soln 0.05% Tier 1 QL triamcinolone acetonide crm 0.5% Tier 1 QL triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3 QL betamethasone dipropionate spray 0.05% SERNIVO Tier 3 QL diflorasone diacetate emollient crm 0.05% APEXICON E Tier 3 QL halcinonide crm, oint, soln 0.1% HALOG Tier 3

Very High Potency QL betamethasone dipropionate augmented gel, oint 0.05% Tier 1 DIPROLENE Tier 3 QL clobetasol propionate crm, gel, oint, soln 0.05% Tier 1 TEMOVATE Tier 3 QL clobetasol propionate lotion, shampoo, spray 0.05% Tier 1 CLOBEX Tier 3 QL diflorasone diacetate oint 0.05% Tier 1 QL fluocinonide crm 0.1% Tier 1 QL halobetasol propionate crm, oint 0.05% Tier 1 ULTRAVATE Tier 3

Emollients ammonium lactate 12% Tier 1

Local Analgesics QL lidocaine patch Tier 1 LIDODERM Tier 3 PA capsaicin 8% patch QUTENZA Tier 3

Local Anesthetics QL lidocaine Tier 1 XYLOCAINE Tier 3 QL lidocaine/prilocaine Tier 1

Rosacea PA azelaic acid gel Tier 1 FINACEA Tier 3 doxycycline monohydrate delayed-rel caps Tier 1 ORACEA Tier 3 PA ivermectin crm 1% Tier 1 SOOLANTRA Tier 3 QL metronidazole crm 0.75% Tier 1 METROCREAM Tier 3 QL metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 METROGEL Tier 3 metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3 PA brimonidine topical gel MIRVASO Tier 3 QL minocycline foam ZILXI Tier 3 PA oxymetazoline crm 1% RHOFADE Tier 3

Scabicides and Pediculicides crotamiton lotion Tier 1 EURAX lotion Tier 2 ivermectin Tier 1 lindane Tier 1 permethrin 5% Tier 1 spinosad Tier 1 NATROBA Tier 3 crotamiton crm EURAX crm Tier 2 benzyl alcohol

Miscellaneous Skin and Mucous Membrane acyclovir Tier 1 ZOVIRAX Tier 3 QL doxepin crm Tier 1 ZONALON Tier 3 d, PA hydrocortisone/aloe polysaccharide/iodoquinol Tier 1 d, PA hydrocortisone/iodoquinol Tier 1 PA imiquimod Tier 1 ALDARA Tier 3

PA imiquimod crm 3.75% Tier 1 ZYCLARA Tier 2 podofilox Tier 1 CONDYLOX Tier 3 alitretinoin PANRETIN Tier 2 PA becaplermin REGRANEX Tier 2 absorbable fibrin sealant TACHOSIL Tier 3 penciclovir DENAVIR Tier 3 PA collagenase clostridium histolyticum XIAFLEX Tier 4 PA interferon alfa-n3 ALFERON N Tier 4

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1

Steroids - Mouth/Throat triamcinolone paste Tier 1

Miscellaneous sodium fluoride Tier 1 PREVIDENT Tier 3

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org

Antiallergics bepotastine Tier 1 BEPREVE Tier 3 cromolyn sodium Tier 1 epinastine Tier 1 olopatadine Tier 1 phenylephrine Tier 1 alcaftadine LASTACAFT Tier 3 lodoxamide ALOMIDE Tier 3 olopatadine PAZEO Tier 3

Antifungals natamycin NATACYN Tier 2

Anti-infectives bacitracin Tier 1 ciprofloxacin Tier 1 CILOXAN Tier 3 erythromycin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 MOXEZA Tier 3 moxifloxacin Tier 1 VIGAMOX Tier 3 neomycin/polymyxin B/gramicidin Tier 1 ofloxacin Tier 1 OCUFLOX Tier 3 polymyxin B/bacitracin Tier 1 polymyxin B/trimethoprim Tier 1 POLYTRIM Tier 3 sulfacetamide soln 10% Tier 1 BLEPH-10 Tier 3 tobramycin Tier 1 TOBREX Tier 3 azithromycin AZASITE Tier 2 besifloxacin BESIVANCE Tier 2

Anti-infective/Anti-inflammatory Combinations neomycin/dexamethasone Tier 1 neomycin/polymyxin B/dexamethasone Tier 1 MAXITROL Tier 3 neomycin/polymyxin B/hydrocortisone susp Tier 1

sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 TOBRADEX SUSPENSION Tier 3 tobramycin/dexamethasone oint 0.3%/0.1% TOBRADEX OINTMENT Tier 2 tobramycin/loteprednol ZYLET Tier 2 gentamicin/prednisolone acetate PRED-G Tier 3 sulfacetamide/prednisolone acetate oint 10%/0.2% BLEPHAMIDE SOP Tier 3

Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 flurbiprofen Tier 1 ketorolac 0.5% Tier 1 ACULAR Tier 3 bromfenac 0.075% BROMSITE Tier 3 bromfenac sodium 0.07% PROLENSA Tier 3 ketorolac 0.45% ACUVAIL Tier 3 nepafenac NEVANAC Tier 3 nepafenac 0.3% ILEVRO Tier 3

Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 FML Tier 3 loteprednol 0.5% gel, susp Tier 1 LOTEMAX Gel, Susp Tier 3 prednisolone acetate 1% Tier 1 PRED FORTE Tier 3 prednisolone phosphate 1% Tier 1 difluprednate DUREZOL Tier 2 loteprednol LOTEMAX SM Tier 2 loteprednol 0.2% ALREX Tier 2 loteprednol oint LOTEMAX Oint Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 rimexolone VEXOL Tier 2 dexamethasone MAXIDEX Tier 3 fluorometholone acetate FLAREX Tier 3 loteprednol 1.0% INVELTYS Tier 3

Antivirals trifluridine Tier 1 ganciclovir ZIRGAN Tier 2

Beta-blockers Nonselective carteolol Tier 1 levobunolol Tier 1 timolol maleate Tier 1 ISTALOL Tier 3 timolol maleate Tier 1 TIMOPTIC Tier 3 timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3 timolol hemihydrate BETIMOL Tier 3

Selective betaxolol BETOPTIC S Tier 3

Carbonic Anhydrase Inhibitors Topical brinzolamide Tier 1 AZOPT Tier 3 dorzolamide Tier 1 TRUSOPT Tier 3

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 COSOPT Tier 3

Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Tier 2

Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA lifitegrast XIIDRA Tier 2 PA cyclosporine eye solution CEQUA Tier 3

Mydriatics atropine sulfate soln Tier 1 cyclopentolate Tier 1 CYCLOGYL Tier 3 scopolamine ISOPTO HYOSCINE Tier 2

Neurotrophic Keratitis PA cenegermin-bkbj OXERVATE Tier 4

Parasympathomimetics pilocarpine PILOPINE HS GEL Tier 3

Prostaglandins latanoprost Tier 1 XALATAN Tier 3 travoprost Tier 1 TRAVATAN Z Tier 3 latanoprost ophthalmic emulsion XELPROS Tier 3 latanoprostene bunod VYZULTA Tier 3 tafluprost ZIOPTAN Tier 3

Retinal Disorders PA aflibercept EYLEA Tier 4 PA ranibizumab LUCENTIS Tier 4 PA brolucizumab-dbll BEOVU Tier 5

Rho Kinase Inhibitors netarsudil RHOPRESSA Tier 3

Rho Kinase Inhibitor/Prostaglandin Combinations netarsudil/latanoprost ROCKLATAN Tier 3

Sympathomimetics brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3 brimonidine 0.2% Tier 1 brimonidine 0.1% ALPHAGAN P 0.1% Tier 2

Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Tier 2

Miscellaneous naphazoline Tier 1 PA oxymetazoline opth soln UPNEEQ Tier 3 cysteamine CYSTARAN Tier 4 verteporfin VISUDYNE Tier 4 cysteamine CYSTADROPS Tier 5 PA teprotumumab-trbw for IV soln TEPEZZA Tier 5

OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org

Anti-infectives acetic acid Tier 1 ciprofloxacin otic Tier 1 CETRAXAL Tier 3 ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 ciprofloxacin/dexamethasone Tier 1 CIPRODEX Tier 3 neomycin/polymyxin B/hydrocortisone Tier 1 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2

Miscellaneous fluocinolone acetonide Tier 1 DERMOTIC Tier 3 triethanolamine polypeptide oleate CERUMENEX Tier 3

WEBSITES Agency for Healthcare Research and Quality American Congress of Obstetricians and https://www.ahrq.gov Gynecologists https://www.acog.org Alzheimer's Association https://www.alz.org American Diabetes Association http://www.diabetes.org American Academy of Allergy, Asthma and Immunology American Gastroenterological Association https://www.aaaai.org https://www.gastro.org

American Academy of Child & Adolescent Psychiatry American Headache Society Committee for Headache https://www.aacap.org Education https://americanheadachesociety.org American Academy of Dermatology https://www.aad.org American Heart Association https://professional.heart.org American Academy of Neurology https://www.aan.com American Lung Association https://www.lung.org American Academy of Ophthalmology https://www.aao.org American Medical Association https://www.ama-assn.org American Academy of Pediatrics https://www.aap.org American Psychiatric Association https://www.psychiatry.org American Association for the Study of Liver Disease https://www.aasld.org American Society of Anesthesiologists https://www.asahq.org American Association of Clinical Endocrinologists https://www.aace.com American Society of Clinical Oncology https://www.asco.org American Association of Diabetes Educators https://www.diabeteseducator.org American Society of Interventional Pain Physicians https://www.asipp.org American Cancer Society https://www.cancer.org American Urological Association https://www.auanet.org American College of Allergy, Asthma and Immunology https://www.acaai.org Centers for Disease Control and Prevention https://www.cdc.gov American College of Cardiology https://www.acc.org Centers for Disease Control and Prevention Guideline topics: AIDS American College of Chest Physicians https://www.cdc.gov/hiv/default.html https://www.chestnet.org Centers for Disease Control and Prevention American College of Gastroenterology Guideline topics: Sexually Transmitted Diseases https://gi.org https://www.cdc.gov/std/treatment/default.htm

American College of Physicians CVS Caremark® https://www.acponline.org https://www.caremark.com

American College of Rheumatology The Food and Drug Administration https://www.rheumatology.org https://www.fda.gov

Global Initiative for Asthma http://www.nfid.org https://ginasthma.org National Guideline Clearinghouse Infectious Diseases Society of America https://www.ahrq.gov https://www.idsociety.org National Heart, Lung and Blood Institute Institute for Safe Medication Practices https://www.nhlbi.nih.gov https://www.ismp.org National Institutes of Health Johns Hopkins AIDS Service https://www.nih.gov https://www.thebody.com/content/art12096.html National Kidney Foundation Juvenile Diabetes Research Foundation International https://www.kidney.org https://www.jdrf.org National Osteoporosis Foundation MedWatch https://www.nof.org https://www.fda.gov/Safety/MedWatch/default.htm North American Menopause Society National Agricultural Library https://www.menopause.org https://www.nal.usda.gov United States Department of Health and Human National Cancer Institute Services https://www.cancer.gov/about-cancer https://www.hhs.gov

National Comprehensive Cancer Network World Health Organization https://www.nccn.org https://www.who.int

National Foundation for Infectious Diseases

2021 FEP MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART These listed drugs are not covered under Basic Option. If you use any of these Managed Not Covered Drugs, you will need to pay the full cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION ACNE MINOLIRA, SEYSARA azithromycin, doxycycline (except 20 mg), ORAL ANTIBIOTICS minocycline, minocycline ext-rel, sulfamethoxazole/trimethoprim, MINOCIN, SOLODYN, VIBRAMYCIN, ZITHROMAX ACNE adapalene pad, adapalene soln 0.1% adapalene crm, adapalene gel, DIFFERIN TOPICAL ABSORICA LD isotretinoin, ABSORICA ALLERGIES carbinoxamine 6 mg, cetirizine solution, montelukast, zafirlukast, ACCOLATE, ANTIHISTAMINES desloratadine, levocetirizine, CLARINEX, SINGULAIR CLARINEX-D, RYVENT, XYZAL ALLERGIES BECONASE AQ, DYMISTA, NASONEX, azelastine/fluticasone nasal spray, flunisolide NASAL STEROIDS OMNARIS, QNASL, RHINOCORT AQUA, spray, fluticasone spray VERAMYST, ZETONNA ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection/auto-injector (0.15 mg, 0.30 mg), EPIPEN, EPIPEN JR., SYMJEPI ANTICOAGULANTS PRADAXA, SAVAYSA warfarin, ELIQUIS, XARELTO ANTIDIARRHEALS opium tincture diphenoxylate/atropine, loperamide ANTIFUNGALS TOLSURA fluconazole, itraconazole, ketoconazole, posaconazole delayed-rel tabs, voriconazole, DIFLUCAN, NOXAFIL susp, NOXAFIL tabs, SPORANOX, VFEND ANTI-INFLAMMATORIES fenoprofen caps 200 mg, indomethacin diclofenac DR/ER, diclofenac gel/soln, NONSTEROIDAL ANTI- caps 20 mg, 40 mg, meloxicam caps (5 etodolac/ER, flurbiprofen, ibuprofen, INFLAMMATORIES (NSAIDs) mg, 10 mg), naproxen sodium ext-rel tabs, indomethacin/ER (except indomethacin caps 20 ANAPROX DS, CAMBIA, FELDENE, mg, 40 mg), ketoprofen/ER, meloxicam tabs, FENORTHO, NAPRELAN, NAPROSYN, nabumetone, naproxen, oxaprozin, piroxicam, PENNSAID 2%, QMIIZ, RELAFEN DS, sulindac TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX ANTI-INFLAMMATORIES naproxen/esomeprazole magnesium tabs diclofenac/misoprostol, esomeprazole NONSTEROIDAL ANTI- DR, ARTHROTEC, DUEXIS, VIMOVO magnesium delayed-rel, famotidine, ibuprofen, INFLAMMATORIES (NSAIDs) naproxen COMBINATIONS

CONSENSI celecoxib, CELEBREX, AND amlodipine tabs, NORVASC ANTINEOPLASTIC AGENTS ZYTIGA abiraterone (ANTI)HORMONAL FASLODEX fulvestrant

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION ANTINEOPLASTIC AGENTS GLEEVEC imatinib mesylate KINASE INHIBITORS AFINITOR 2.5 mg, 5 mg, 7.5 mg everolimus 2.5 mg, 5 mg, 7.5 mg

ANTINEOPLASTIC AGENTS XELODA capecitabine MISCELLANEOUS TEMODAR temozolomide

TARGRETIN CAPSULES bexarotene capsules

ANTIRHEUMATICS penicillamine caps, CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate, penicillamine tabs, DEPEN ANTISPASMOTICS LIBRAX chlordiazepoxide/clidinium, dicyclomine, hyoscyamine DONNATAL atropine/hyoscyamine/scopolamine/phenobarbital

ASTHMA PROVENTIL HFA, VENTOLIN HFA, albuterol solution, albuterol sulfate CFC-free BETA AGONIST (RESCUE INHALER) XOPENEX HFA aerosol, levalbuterol inhalation solution, levalbuterol nebulizer solution concentrate, levalbuterol tartrate CFC-free aerosol, PROAIR HFA, XOPENEX CONCENTRATE, XOPENEX SOLUTION ASTHMA AEROSPAN, ALVESCO budesonide inhalation suspension, ASMANEX, INHALED CORTICOSTEROID FLOVENT HFA, PULMICORT, QVAR, QVAR REDIHALER ASTHMA zileuton ext-rel, ZYFLO CR montelukast, zafirlukast, SINGULAIR, LEUKOTRIENE MODULATORS ACCOLATE BENIGN PROSTATIC HYPERPLASIA JALYN, UROXATRAL alfuzosin ext-rel, dutasteride, (BPH) dutasteride/tamsulosin, finasteride, silodosin, tadalafil (2.5mg, 5mg), tamsulosin, AVODART, CIALIS (2.5mg, 5mg), PROSCAR, RAPAFLO, FLOMAX BLADDER AGENTS DETROL, DETROL LA, ENABLEX, darifenacin ext-rel, oxybutynin, oxybutynin ext- GELNIQUE, OXYTROL, VESICARE, rel, solifenacin, tolterodine, tolterodine ext-rel, VESICARE LS trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ CARDIOVASCULAR aspirin/omeprazole delayed-rel tabs, aspirin*** and esomeprazole magnesium HEART YOSPRALA delayed-rel, lansoprazole, omeprazole, pantoprazole, rabeprazole CARDIOVASCULAR TIKOSYN dofetilide ANTIARRHYTHMICS BETAPACE, BETAPACE AF sotalol, sotalol AF

CENTRAL NERVOUS SYSTEM SABRIL vigabatrin, vigadrone ANTICONVULSANTS CENTRAL NERVOUS SYSTEM SYMBYAX olanzapine/fluoxetine

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION ANTIDEPRESSANT COMBINATIONS CENTRAL NERVOUS SYSTEM methylphenidate tab ER osmotic release amphetamine ext-rel susp, amphetamine sulfate, MISCELLANEOUS 72 mg, ADHANSIA XR, DESOXYN, amphetamine/dextroamphetamine mixed JORNAY PM, RELEXXII salts/ER, dexmethylphenidate/ER, dextroamphetamine/ER, methylphenidate/ER (except methylphenidate tab ER osmotic release 72 mg), ADDERALL, ADDERALL XR, ADZENYS ER SUSP, ADZENYS XR-ODT, APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA, DEXEDRINE, DYANAVEL XR, EVEKEO, EVEKEO ODT, FOCALIN, FOCALIN XR, METHYLIN, MYDAYIS, PROCENTRA, QUILLICHEW ER, QUILLIVANT XR, RITALIN, RITALIN LA, VYVANSE, ZENZEDI COPD INCRUSE ELLIPTA, TUDORZA ipratropium, ATROVENT HFA, SPIRIVA INHALED LONG-ACTING MUSCARINIC PRESSAIR RECEPTOR ANTAGONIST (LAMA) COPD DUAKLIR PRESSAIR ANORO ELLIPTA, INHALED LONG-ACTING MUSCARINIC BEVESPI AEROSPHERE, RECEPTOR ANTAGONIST STIOLTO RESPIMAT, (LAMA)/LONG-ACTING BETA AGONIST UTIBRON NEOHALER (LABA) COMBINATIONS CORTICOSTEROIDS ALKINDI SPRINKLE CAPS, CORTEF, cortisone acetate, dexamethasone, DELTASONE, DEXABLISS, DXEVO 11- fludrocortisone, hydrocortisone, DAY, MEDROL, MILLIPRED, ORAPRED methylprednisolone, prednisone ODT, RAYOS, TAPERDEX DERMATOLOGY fluorouracil cream 0.5%, CARAC, KLISYRI diclofenac sodium gel 3%, fluorouracil (does not ACTINIC KERATOSIS include fluorouracil cream 0.5%), EFUDEX, FLUOROPLEX, TOLAK DERMATOLOGY ALCORTIN-A, ERTACZO, JUBLIA, ciclopirox, clotrimazole, ANTIFUNGAL KERYDIN*, LOPROX, LOTRISONE*, clotrimazole/betamethasone, econazole, LUZU, MENTAX, NAFTIN*, OXISTAT, hydrocortisone/iodoquinol, VUSION*, XOLEGEL* hydrocortisone/iodoquinol/aloe, ketoconazole, luliconazole, miconazole nitrate/zinc oxide, naftifine, nystatin, oxiconazole crm, sulconazole, tavaborole sol 5%, terbinafine tablets, ECOZA, EXELDERM DERMATOLOGY halobetasol propionate topical foam, betamethasone dipropionate (crm, lotion, oint), CORTICOSTEROIDS triamcinolone oint 0.05%, BRYHALI, betamethasone dipropionate augmented (crm, IMPEKLO, IMPOYZ, LEXETTE, lotion, gel, oint), clobetasol propionate, NOVACORT, OLUX, OLUX-E, diflorasone diacetate, fluocinonide (crm, gel, oint, PSORCON, TRIANEX, VANOS soln), halobetasol propionate crm, hydrocortisone/pramoxine, triamcinolone acetonide (except triamcinolone oint 0.05%), APEXICON E, CLOBEX, DIPROLENE, DIPROLENE AF, HALOG, KENALOG SPRAY, PRAMOSONE, SERNIVO, TEMOVATE, TOPICORT, ULTRAVATE DERMATOLOGY XEPI CREAM 1% mupirocin cream 2%, mupirocin ointment 2%, IMPETIGO ALTABAX OINTMENT 1%

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION DERMATOLOGY XERESE acyclovir, hydrocortisone MISCELLANEOUS VEREGEN imiquimod, ALDARA, ZYCLARA

EXTINA ketoconazole foam 2%

OVACE, OVACE PLUS sulfacetamide sodium

DERMATOLOGY SORIATANE, TACLONEX, WYNZORA acitretin, betamethasone PSORIASIS dipropionate/calcipotriene (oint, susp), calcipotriene, calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA, SORILUX DERMATOLOGY NORITATE azelaic acid gel, doxycycline (except 20 mg), ROSACEA flurandrenolide, ivermectin crm 1%, metronidazole cream/gel/lotion, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVASO, ORACEA, SOOLANTRA, ZILXI DIABETES JENTADUETO, JENTADUETO XR, alogliptin, alogliptin/metformin, DIPEPTIDYL PEPTIDASE-4 (DPP-4) KAZANO, KOMBIGLYZE XR, NESINA, alogliptin/pioglitazone, JANUMET, INHIBITORS/COMBINATIONS ONGLYZA, OSENI, TRADJENTA JANUMET XR, JANUVIA DIABETES ADLYXIN, BYDUREON, BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA INCRETIN MIMETIC AGENTS BCISE, BYETTA DIABETES insulin lispro, ADMELOG/SOLOSTAR, insulin aspart, FIASP/FLEXTOUCH, NOVOLOG INSULINS APIDRA/SOLOSTAR, HUMALOG, LYUMJEV/KWIKPEN HUMALOG MIX 50/50 insulin aspart protamine 70%/insulin aspart 30%, NOVOLOG MIX 70/30 insulin lispro protamine/insulin lispro insulin aspart protamine 70%/insulin aspart 30%, 75/25, HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 NOVOLIN 70/30 HUMULIN N NOVOLIN N HUMULIN R NOVOLIN R LANTUS, SEMGLEE, TOUJEO BASAGLAR, LEVEMIR, TRESIBA

NOTE: HUMULIN R U-500 concentrate will continue to be covered DIABETES FORTAMET, GLUMETZA, RIOMET ER, metformin ext-rel, metformin oral soln METFORMIN RIOMET IR DIABETES CYCLOSET alogliptin, alogliptin/metformin, OTHER alogliptin/pioglitazone, bromocriptine mesylate, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide DIABETES INVOKAMET, INVOKAMET XR, FARXIGA, JARDIANCE, SYNJARDY, SGLT2 INHIBITORS INVOKANA, SEGLUROMET, SYNJARDY XR, XIGDUO XR STEGLATRO, STEGLUJAN

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION ENDOCRINE AND METABOLIC RECLAST zoledronic acid MISCELLANEOUS SANDOSTATIN octreotide

SENSIPAR cinacalcet

GASTROINTESTINAL GIMOTI metoclopramide, REGLAN DIABETIC GASTROPARESIS GLAUCOMA LUMIGAN latanoprost, travoprost, TRAVATAN Z, XALATAN, ZIOPTAN GROWTH HORMONE GENOTROPIN, HUMATROPE, NORDITROPIN NUTROPIN, NUTROPIN AQ, OMNITROPE, SAIZEN, ZOMACTON H2 RECEPTOR ANTAGONISTS PEPCID famotidine 40mg, cimetidine, nizatidine HEMATOPOIETIC GROWTH FACTORS NEUPOGEN GRANIX, ZARXIO

NEULASTA, NEULASTA ONPRO FULPHILA, NYVEPRIA, UDENYCA, ZIEXTENZO PROCRIT ARANESP, EPOGEN, RETACRIT HEPATITIS B BARACLUDE TABLETS entecavir tablets HEPSERA adefovir dipivoxil

HEPATITIS C ZEPATIER ledipasvir/sofosbuvir, sofosbuvir/velpatasvir, EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI HEREDITARY ANGIOEDEMA (HAE) FIRAZYR icatibant HIGH BLOOD PRESSURE ATACAND, ATACAND HCT, AVALIDE, candesartan, candesartan/HCTZ, irbesartan, ANGIOTENSIN II RECEPTOR AVAPRO, irbesartan/HCTZ, losartan, BLOCKERS/COMBINATIONS (ARBs) COZAAR, DIOVAN, DIOVAN HCT, losartan/HCTZ, olmesartan, EDARBI, EDARBYCLOR, HYZAAR, olmesartan/HCTZ, telmisartan, MICARDIS, MICARDIS HCT telmisartan/HCTZ, valsartan, valsartan/HCTZ, BENICAR, BENICAR HCT HIGH BLOOD PRESSURE DUTOPROL metoprolol succinate ext-rel, hydrochlorothiazide BETA-BLOCKERS/COMBINATIONS HIGH BLOOD PRESSURE CONJUPRI, KATERZIA amlodipine tabs, felodipine ext-rel, nicardipine, CALCIUM CHANNEL BLOCKERS nifedipine ext-rel, nisoldipine ext-rel, NORVASC, PROCARDIA XL, SULAR HIGH CHOLESTEROL FENOGLIDE fenofibrate, fenofibric acid del-rel, gemfibrozil, FIBRATES LIPOFEN, TRICOR, TRIPLEX, LOPID, ANTARA HIGH CHOLESTEROL PRALUENT REPATHA PCSK9 INHIBITORS HIGH CHOLESTEROL simvastatin susp, ALTOPREV, amlodipine/atorvastatin, atorvastatin, STATINS CADUET,CRESTOR, EZALLOR ezetimibe/simvastatin, fluvastatin, lovastatin, SPRINKLE, pravastatin, rosuvastatin, simvastatin

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION FLOLIPID, LESCOL/XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, PRAVACHOL, VYTORIN, ZOCOR, ZYPITAMAG INFLUENZA AGENTS FLUMADINE oseltamivir, rimantadine, RELENZA, TAMIFLU, XOFLUZA IRON OVERLOAD EXJADE deferasirox LAXATIVES LACTULOSE PAK 10MG, PCP 100, lactulose solution, PEG 3350/electrolytes, SUTAB CLENPIQ, GOLYTELY, KRISTALOSE, MOVIPREP, NULYTELY, OSMOPREP, PLENVU, PREPOPIK, SUPREP MIGRAINE AGENTS AJOVY AIMOVIG, EMGALITY 120 mg/mL, VYEPTI CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS UBRELVY NURTEC ODT

MIGRAINE AGENTS REYVOW, TOSYMRA almotriptan, eletriptan, frovatriptan, naratriptan, SELECTIVE SEROTONIN AGONISTS rizatriptan, sumatriptan, zolmitriptan, AMERGE, FROVA, IMITREX, MAXALT, MAXALT-MLT, ONZETRA XSAIL, RELPAX, ZOMIG, ZOMIG- ZMT MOVEMENT DISORDERS OSMOLEX ER, TASMAR amantadine IR, benztropine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, rasagiline, ropinirole/ER, selegiline, tolcapone, APOKYN, AZILECT, COMTAN, DUOPA, GOCOVRI, KYNMOBI, MIRAPEX, MIRAPEX XR, NEUPRO, PARLODEL, RYTARY, SINEMET, STALEVO, XADAGO, ZELAPAR XENAZINE tetrabenazine

MULTIPLE SCLEROSIS AMPYRA dalfampridine ER

COPAXONE glatiramer, GLATOPA MUSCLE RELAXANTS cyclobenzaprine ext-rel, AMRIX baclofen, cyclobenzaprine MUSCULOSKELETAL AGENTS chlorzoxazone tab (250mg, 375mg, chlorzoxazone tab 500mg MISCELLANEOUS 750mg), LORZONE NAUSEA AND VOMITING THERAPY ANZEMET, ZUPLENZ granisetron, ondansetron, palonosetron, (5HT-3 BLOCKER) promethazine, ALOXI, SANCUSO, ZOFRAN NAUSEA AND VOMITING BONJESTA doxylamine§, doxylamine/pyridoxine delayed- PREGNANCY rel, pyridoxine (vitamin B6)§, DICLEGIS, UNISOM§ OPHTHALMOLOGY BACIGUENT bacitracin ophthalmic ANTI-INFECTIVES OPHTHALMOLOGY EYSUVIS CEQUA, RESTASIS, XIIDRA DRY EYE DISEASE OPHTHALMOLOGY atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION MISCELLANEOUS ophthalmic solution PAIN MEDICATIONS pregabalin ext-rel tabs, GRALISE, gabapentin, pregabalin (does not include ext-rel NEUROPATHIC PAIN HORIZANT, LYRICA, LYRICA CR tabs), NEURONTIN PAIN MEDICATIONS ARYMO ER, HYSINGLA ER, hydrocodone ext-rel, hydromorphone ext-rel, OPIOIDS OXYCONTIN morphine ext-rel, tramadol ext-rel, EMBEDA, MORPHABOND, MS CONTIN, NUCYNTA ER, OPANA ER, ULTRAM ER, XTAMPZA ER, ZOHYDRO ER benzhydrocodone/acetaminophen, codeine/acetaminophen, hydrocodone/acetaminophen soln 10-325 hydrocodone/acetaminophen, mg/15 mL, oxycodone/acetaminophen tab oxycodone/acetaminophen (except 2.5 mg - 300 (2.5 mg - 300 mg, 5 mg - 300mg, 10 mg - mg, 5 mg - 300mg, 10 mg - 300 mg tabs), 300 mg), APADAZ, NALOCET, PRIMLEV, tramadol/acetaminophen, ENDOCET, LORTAB, PROLATE PERCOCET LAZANDA fentanyl buccal, fentanyl sublingual, fentanyl transmucosal, ACTIQ, FENTORA, SUBSYS levorphanol hydromorphone, morphine, oxycodone, tramadol (except 100mg tab), DILAUDID, NUCYNTA, OPANA, ROXICODONE

tramadol 100 mg tabs, CONZIP, QDOLO tramadol (except 100 mg tabs), tramadol ext-rel, tramadol/acetaminophen, ULTRAM, ULTRAM ER PAIN MEDICATIONS ZTLIDO lidocaine cream, lidocaine gel, lidocaine lotion, TOPICAL lidocaine ointment, lidocaine patch 5%, LIDODERM PATCH, QUTENZA PATCH, XYLOCAINE PANCREATIC ENZYMES PERTZYE, ZENPEP CREON, PANCREAZE, VIOKACE PROTON PUMP INHIBITORS esomeprazole strontium, esomeprazole magnesium delayed-rel, omeprazole/sodium bicarbonate, lansoprazole delayed-rel, omeprazole delayed- rabeprazole capsule sprinkle delayed-rel, rel, pantoprazole delayed-rel, rabeprazole ACIPHEX, DEXILANT, FIRST- (except rabeprazole capsule sprinkle delayed-rel) LANSOPRAZOLE, FIRST- OMEPRAZOLE, NEXIUM, PREVACID, PRILOSEC, PROTONIX, ZEGERID PULMONARY ARTERIAL LETAIRIS ambrisentan HYPERTENSION (PAH) REVATIO sildenafil (PAH)

ADCIRCA tadalafil (PAH), Alyq

SLEEP AGENTS AMBIEN, AMBIEN CR, estazolam, eszopiclone, flurazepam, EDLUAR, INTERMEZZO, LUNESTA, ramelteon, temazepam, triazolam, zaleplon, ROZEREM, SECONAL, SONATA zolpidem/ER, BELSOMRA, ZOLPIMIST TESTOSTERONE AGENTS ANDROGEL, NATESTO, TESTIM, testosterone gel, ANDRODERM, FORTESTA VOGELXO

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR BASIC OPTION ULCER THERAPY CARAFATE sucralfate MISCELLANEOUS ULCERATIVE COLITIS ASACOL HD, COLAZAL, DELZICOL balsalazide, mesalamine delayed-rel (caps, tabs), mesalamine ext-rel caps, sulfasalazine, sulfasalazine delayed, rel, APRISO, AZULFIDINE, DIPENTIUM, LIALDA, PENTASA

*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.

**For more covered options, consult 2021 Basic Option formulary.

***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 12 through 79 and for pregnant women at risk of preeclampsia.

§ denotes over-the-counter (OTC) availability only, and not covered through the prescription benefit.

INDEX

A adefovir dipivoxil, 15 ADEMPAS, 27 abacavir, 15 ado-trastuzumab emtansine, 20 abacavir soln, 15 ADRIAMYCIN, 21 abacavir/dolutegravir/lamivudine, 14 ADVAIR, 54 abacavir/lamivudine, 14 ADVAIR HFA, 54 abacavir/lamivudine/zidovudine, 14 ADVATE, 48 abaloparatide, 38 ADYNOVATE, 48 abatacept, 49 ADZENYS ER SUSP, 31 ABELCET, 13 ADZENYS XR-ODT, 31 abemaciclib, 18 AEMCOLO, 13 ABILIFY, 30 afatinib, 18 ABILIFY MAINTENA, 30 AFINITOR 10 mg, 18 ABILIFY MYCITE, 30 AFINITOR DISPERZ, 19 abiraterone, 17 aflibercept, 61 abobotulinumtoxinA, 34 AFREZZA, 36 ABRAXANE, 21 AFSTYLA, 48 absorbable fibrin sealant, 59 agalsidase beta, 43 ABSORICA, 55 AGGRASTAT, 48 acalabrutinib, 18 AGGRENOX, 48 acamprosate calcium, 34 AGRYLIN, 49 ACANYA, 55 AHF, human/VWF, human, 47 acarbose, 35 AIMOVIG, 32 ACCOLATE, 54 AIRDUO DIGIHALER, 54 ACCU-CHEK FASTCLIX LANCET DEVICE, 37 AIRDUO RESPICLICK, 54 ACCU-CHEK FASTCLIX LANCETS, 37 AKLIEF, 56 ACCU-CHEK METERS AND KITS, 37 AKYNZEO, 44 ACCU-CHEK TEST STRIPS, 37 albendazole, 16 ACCUPRIL, 22 ALBENZA, 16 ACCURETIC, 22 albuterol, 53 acebutolol, 25 albuterol ext-rel, 54 ACETADOTE, 43 albuterol soln, 53 acetaminophen inj, 10 albuterol sulfate aerosol powder 108mcg/actuation with sensor, 53 acetazolamide, 25 albuterol sulfate aerosol powder breath-activated, 53 acetazolamide ext-rel, 25 albuterol sulfate, CFC-free aerosol, 53 acetic acid, 62 alcaftadine, 59 acetic acid/hydrocortisone, 62 alclometasone crm, oint 0.05%, 57 acetylcysteine, 43 ALDACTAZIDE, 26 acitretin, 56 ALDACTONE, 23 ACTEMRA, 49 ALDARA, 58 ACTHAR, 43 aldesleukin, 20 ACTIGALL, 44 ALDURAZYME, 43 ACTIMMUNE, 51 ALECENSA, 19 ACTIQ, 11 alectinib, 19 ACTIVELLA, 40 alemtuzumab, 33 ACTONEL, 38 alendronate, 37 ACTOPLUS MET, 36 alendronate/vitamin D3, 38 ACTOPLUS MET XR, 36 ALFERON N, 59 ACTOS, 36 alfuzosin ext-rel, 46 ACULAR, 60 alglucosidase alfa, 43 ACUVAIL, 60 ALIMTA, 17 acyclovir, 58 ALINIA, 16 acyclovir caps, susp, tabs, 16 aliskiren, 25 ACZONE, 16 aliskiren/hydrochlorothiazide, 25 ADAKVEO, 49 alitretinoin, 59 adalimumab, 49 ALKERAN inj, 17 adapalene crm, gel, 55 ALKERAN tabs, 17 adapalene/benzoyl peroxide, 55 allopurinol, 10 ADCETRIS, 20 almotriptan, 32 ADDERALL, 31 alogliptin, 35 ADDERALL XR, 31 alogliptin/metformin, 35

alogliptin/pioglitazone, 36 AMZEEQ, 56 ALOMIDE, 59 ANAFRANIL, 27 ALORA, 40 anagrelide, 49 alosetron, 45 anakinra, 49 ALOXI, 44 anastrozole, 18 alpelisib, 18 ANDRODERM, 35 alpha-1 proteinase inhibitor, 52 ANGELIQ, 40 ALPHAGAN P 0.1%, 61 anidulafungin, 13 ALPHAGAN P 0.15%, 61 ANNOVERA, 39 ALPHANATE, 47 ANORO ELLIPTA, 53 ALPHANINE SD, 48 ANTARA, 24 alprazolam, 27 antihemophilic factor, 47, 48 alprazolam ext-rel, 27 antihemophilic factor (recombinant) pegylated, 48 ALPROLIX, 48 antihemophilic factor (recombinant) pegylated-aucl, 48 ALREX, 60 antihemophilic factor (recombinant) porcine sequence, 48 ALTABAX, 56 antihemophilic factor (recombinant), glycopegylated-exei, 48 ALTACE, 22 antihemophilic factor recombinant, Fc fusion protein, 48 alteplase, 49 antihemophilic factor, recombinant, 48 ALUNBRIG, 19 anti-inhibitor coagulant complex, 48 alvimopan, 46 apalutamide, 17 amantadine ext-rel, 30 APEXICON E, 58 amantadine, except tabs, 30 apixaban, 47 AMARYL, 37 APLENZIN, 29 AMBISOME, 13 APOKYN, 30 ambrisentan, 26 apomorphine, 30 amcinonide crm, lotion, oint 0.1%, 57 apremilast, 49 AMELUZ, 56 aprepitant, 44 AMERGE, 32 aprepitant caps, 44 AMICAR, 49 aprepitant susp, 44 amifampridine, 35 APRISO, 44 amifostine, 20 APTENSIO XR, 31 amikacin liposome inhalation susp, 54 APTIOM, 28 amiloride, 26 APTIVUS, 15 amiloride/hydrochlorothiazide, 26 ARAKODA, 14 aminocaproic acid, 49 ARALAST NP, 52 aminolevulinic acid gel 10%, 56 ARANESP, 47 aminolevulinic acid soln, 56 ARAVA, 50 amiodarone, 23 ARAZLO, 56 AMITIZA, 45 ARCALYST, 51 amitriptyline, 29 arformoterol soln, 53 amitriptyline/perphenazine, 29 ARICEPT, 28 amlodipine tabs, 25 ARIKAYCE, 54 amlodipine/atorvastatin, 25 ARIMIDEX, 18 amlodipine/olmesartan, 23 aripiprazole, 30 amlodipine/telmisartan, 23 aripiprazole ext-rel inj, 30 amlodipine/valsartan, 23 aripiprazole lauroxil ext-rel inj, 30 amlodipine/valsartan/hydrochlorothiazide, 23 aripiprazole orally disintegrating tabs, 30 ammonium lactate 12%, 58 aripiprazole tab with sensor, 30 amoxicillin, except film-coated tabs, 13 ARISTADA, 30 amoxicillin/clavulanate, 13 ARIXTRA, 47 amoxicillin/clavulanate ext-rel, 13 armodafinil, 33 amoxicillin/clavulanate susp 600 mg, 13 ARMONAIR DIGIHALER, 55 amoxicillin/rifabutin/omeprazole, 46 ARMOUR THYROID, 42 amphetamine ext-rel orally disintegrating tabs, 31 ARNUITY ELLIPTA, 55 amphetamine ext-rel susp, 31 AROMASIN, 18 amphetamine ext-rel suspension, 31 ARRANON, 21 amphetamine sulfate, 31 arsenic trioxide, 20 amphetamine sulfate orally disintegrating tablet, 31 artemether/lumefantrine, 14 amphetamine/dextroamphetamine mixed salts, 31 ARZERRA, 21 amphetamine/dextroamphetamine mixed salts ext-rel, 31 ASCENIV, 51 amphotericin B lipid complex inj, 13 asenapine, 30 amphotericin B liposome inj, 13 asfotase alfa, 43 ampicillin, 13 ASMANEX, 55 ampicillin sodium/sulbactam sodium, 13 ASMANEX HFA, 55

asparaginase, 20 BAQSIMI, 41 asparaginase Erwinia chrysanthemi, 20 BARACLUDE soln, 15 ASPARLAS, 21 baricitinib, 49 aspirin ext-rel, 48 BASAGLAR, 36 ASTAGRAF XL, 51 BAVENCIO, 21 atazanavir caps, 15 BCG live vaccine, 20 atazanavir/cobicistat, 14 BD INSULIN SYRINGES AND NEEDLES, 37 ATELVIA, 38 becaplermin, 59 atenolol, 25 beclomethasone breath-activated aerosol, 55 atenolol/chlorthalidone, 25 beclomethasone, CFC-free aerosol, 55 atezolizumab, 20 bedaquiline, 15 ATIVAN, 27 belantamab mafodotin-blmf, 21 atomoxetine, 31 belatacept, 51 atorvastatin, 24 BELBUCA, 11 atovaquone, 16 BELEODAQ, 20 atovaquone/proguanil, 14 belimumab, 51 ATRALIN, 55 belinostat, 20 ATRIPLA, 14 BELRAPZO, 17 atropine sulfate soln, 61 BELSOMRA, 32 atropine/hyoscyamine/scopolamine/phenobarbital, 44 bempedoic acid, 24 ATROVENT HFA, 52 bempedoic acid/ezetimibe, 24 AUBAGIO, 33 benazepril, 22 AUGMENTIN, 13 benazepril/amlodipine, 22 auranofin, 50 benazepril/hydrochlorothiazide, 22 AURYXIA, 42 bendamustine, 17, 20 AUSTEDO, 33 BENDEKA, 20 AVANDIA, 36 BENEFIX, 48 avapritinib, 19 BENICAR, 23 AVASTIN, 21 BENICAR HCT, 23 avatrombopag, 49 BENLYSTA, 51 AVEED, 35 benralizumab, 55 avelumab, 21 BENZAC AC, 55 AVODART, 46 BENZACLIN, 55 AVONEX, 33 BENZAMYCIN, 55 axitinib, 18 benzonatate, 53 AYGESTIN, 42 benzoyl peroxide, 55 AYVAKIT, 19 benztropine, 30 azacitidine, 17, 20 benzyl alcohol, 58 AZACTAM, 16 BEOVU, 61 AZASITE, 59 bepotastine, 59 azathioprine, 51 BEPREVE, 59 azelaic acid, 56 BERINERT, 50 azelaic acid gel, 58 berotralstat, 50 azelastine spray, 54 besifloxacin, 59 azelastine/fluticasone nasal spray, 54 BESIVANCE, 59 AZELEX, 56 BESPONSA, 21 AZILECT, 30 betaine anhydrous, 43 azithromycin, 13, 59 betamethasone dipropionate augmented crm 0.05%, 57 AZOPT, 60 betamethasone dipropionate augmented gel, lot 0.05%, 57 AZOR, 23 betamethasone dipropionate augmented gel, oint 0.05%, 58 aztreonam, 16 betamethasone dipropionate augmented ointment 0.05%, 57 aztreonam lysine inhalation soln, 54 betamethasone dipropionate crm, lotion, oint 0.05%, 58 AZULFIDINE, 45 betamethasone dipropionate spray 0.05%, 58 AZULFIDINE EN-TABS, 45 betamethasone dipropionate/calcipotriene oint, susp, 56 B betamethasone valerate crm, lotion, oint 0.1%, 57 BETASERON, 33 bacitracin, 59 betaxolol, 60 baclofen, 33 bethanechol, 47 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 33 BETHKIS, 54 BAFIERTAM, 33 BETIMOL, 60 baloxavir, 16 BETOPTIC S, 60 balsalazide, 44 bevacizumab, 21 BALVERSA, 18 bevacizumab-awwb, 20 BANZEL, 28 bevacizumab-bvzr, 20

BEVESPI AEROSPHERE, 53 BUPHENYL, 42 bexarotene caps, 20 buprenorphine, 11, 34 bexarotene gel, 20 buprenorphine ext-rel inj, 34 bezlotoxumab, 51 buprenorphine transdermal, 11 bicalutamide, 17 buprenorphine/naloxone sublingual film, 34 BICNU, 17 buprenorphine/naloxone sublingual tabs, 34 bictegravir/emtricitabine/tenofovir alafenamide, 14 bupropion, 29 BIDIL, 26 bupropion ext-rel, 29, 34 BIJUVA, 40 burosumab-twza, 43 BIKTARVY, 14 buspirone, 27 binimetinib, 19 busulfan, 17 bismuth subsalicylate + metronidazole + tetracycline, 46 BUSULFEX, 17 bisoprolol/hydrochlorothiazide, 25 butalbital/acetaminophen, 11 BIVIGAM, 50 butalbital/acetaminophen/caffeine, 11 BLENREP, 21 butalbital/acetaminophen/caffeine/codeine, 11 bleomycin sulfate, 20 butalbital/aspirin/caffeine, 11 BLEPH-10, 59 butalbital/aspirin/caffeine/codeine, 11 BLEPHAMIDE SOP, 60 butorphanol nasal spray, 11 blinatumomab, 20 BUTRANS, 11 BLINCYTO, 20 BYNFEZIA, 43 blood glucose continuous monitoring receivers, sensors, transmitters, BYSTOLIC, 25 37 C blood glucose meters and kits, 37 C1 esterase inhibitor, 50 blood glucose test strips, 37 C1 esterase inhibitor, recombinant, 50 BONIVA, 38 cabazitaxel, 20 bortezomib, 19 CABOMETYX, 18 bosentan, 26 cabozantinib, 18 BOSULIF, 18 CAFCIT, 55 bosutinib, 18 CAFERGOT, 32 BOTOX, 34 caffeine citrate, 55 BRAFTOVI, 19 CALAN SR, 25 brentuximab vedotin, 20 calaspargase pegol-mknl, 21 BREO ELLIPTA, 54 calcifediol ext-rel, 41 BREVIBLOC, 25 calcipotriene, 56 brexpiprazole, 30 calcipotriene foam, 57 BREZTRI AEROSPHERE, 53 calcipotriene/betamethasone foam, 57 brigatinib, 19 calcitonin-salmon inj, 38 BRILINTA, 48 calcitonin-salmon spray, 38 brimonidine 0.1%, 61 calcitriol (1,25-D3), 41 brimonidine 0.15%, 61 calcitriol oint, 57 brimonidine 0.2%, 61 calcium acetate, 42 brimonidine topical gel, 58 calcium, magnesium, potassium, and sodium oxybates, 34 brimonidine/timolol, 61 CALDOLOR, 10 brinzolamide, 60 CALQUENCE, 18 brinzolamide/brimonidine, 61 CAMPTOSAR, 20 brivaracetam, 28 canakinumab, 51 BRIVIACT, 28 CANASA, 45 brodalumab, 50 candesartan, 23 brolucizumab-dbll, 61 candesartan/hydrochlorothiazide, 23 bromfenac 0.075%, 60 cangrelor, 48 bromfenac sodium, 60 cannabidiol, 28 bromfenac sodium 0.07%, 60 capecitabine, 17 bromocriptine, 30 CAPEX, 57 BROMSITE, 60 CAPLYTA, 31 BRONCHITOL, 54 capmatinib, 19 BROVANA, 53 CAPRELSA, 19 BRUKINSA, 19 capsaicin 8% patch, 58 budesonide, 55 captopril/hydrochlorothiazide, 22 budesonide delayed-rel caps, 44 CARBAGLU, 43 budesonide ext-rel caps, 45 carbamazepine, 27, 33 budesonide inhalation suspension, 55 carbamazepine ext-rel, 27, 28 budesonide/formoterol, 54 CARBATROL, 27 budesonide/glycopyrrolate/formoterol, 53 carbidopa/levodopa, 30 bumetanide, 26

carbidopa/levodopa enteral susp, 30 choriogonadotropin alfa, 40 carbidopa/levodopa ext-rel, 30 chorionic gonadotropin, 40, 41 carbidopa/levodopa orally disintegrating tabs, 30 CIALIS, 46 carbidopa/levodopa/entacapone, 30 ciclopirox, 56 carboplatin, 20 cidofovir, 15 CARDIZEM, 25 cilostazol, 49 CARDIZEM CD, 25 CILOXAN, 59 CARDURA, 23 CIMDUO, 14 carfilzomib, 21 cimetidine, 44 carglumic acid, 43 CIMZIA, 50 cariprazine, 30 cinacalcet, 37 carmustine, 17 CINQAIR, 55 CARNITOR, 38 CINRYZE, 50 carteolol, 60 CINVANTI, 44 carvedilol, 25 CIPRO, 13 carvedilol phosphate ext-rel, 25 CIPRO HC OTIC, 62 CASODEX, 17 CIPRODEX, 62 CATAPRES, 22 ciprofloxacin, 13, 59 CATAPRES-TTS, 23 ciprofloxacin otic, 62 CATHFLO ACTIVASE, 49 ciprofloxacin/dexamethasone, 62 CAYSTON, 54 ciprofloxacin/hydrocortisone, 62 cefaclor, 12 cisplatin, 20 cefdinir, 12 citalopram, 29 cefepime, 12 CITRANATAL RX, 52 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 12 cladribine, 17, 33 cefotaxime, 12 clarithromycin, 13 cefoxitin, 12 clarithromycin ext-rel, 13 cefpodoxime, 12 CLENPIQ, 45 cefprozil, 12 CLEOCIN, 16 ceftaroline fosamil, 12 CLEOCIN T, 55 ceftazidime, 12 CLEOCIN vaginal supp, 47 ceftriaxone, 12 CLIMARA, 40 cefuroxime axetil, 12 CLIMARA PRO, 40 CELEBREX, 10 clindamycin, 16 celecoxib, 10 clindamycin gel, lotion, soln, 55 CELEXA, 29 clindamycin supp, 47 CELLCEPT, 51 clindamycin swabs, 55 cenegermin-bkbj, 61 clindamycin vaginal cream, 47 cenobamate, 28 clindamycin/benzoyl peroxide, 55, 56 cephalexin, 12 clindamycin/tretinoin, 55 CEPROTIN, 49 CLINDESSE, 47 CEQUA, 61 clobazam, 28 CERDELGA, 41 clobetasol propionate crm, gel, oint, soln 0.05%, 58 CEREZYME, 41 clobetasol propionate lotion, shampoo, spray 0.05%, 58 ceritinib, 18 CLOBEX, 58 certolizumab pegol, 50 clocortolone pivalate crm 0.1%, 57 CERUMENEX, 62 CLODERM, 57 CETRAXAL, 62 clofarabine, 17 cetrorelix, 40 CLOLAR, 17 CETROTIDE, 40 clomiphene, 40 cetuximab, 20 clomipramine, 27 cevimeline, 45 clonazepam, 27 CHANTIX, 34 clonidine, 22 CHEMSTRIP K URINE KETONE STRIPS, 37 clonidine ext-rel, 31 CHEMSTRIP UG URINE GLUCOSE STRIPS, 37 clonidine transdermal, 23 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 37 clopidogrel, 48 chlorambucil, 17 clorazepate, 27 chlordiazepoxide, 27 clotrimazole, 56 chlordiazepoxide/clidinium, 44 clotrimazole troches, 13 chloroquine, 14 clotrimazole/betamethasone, 56 chlorthalidone, 26 clozapine, 30 CHOLBAM, 46 clozapine orally disintegrating tabs, 30 cholestyramine pkt, 24 CLOZARIL, 30 cholic acid, 46 COAGADEX, 48

coagulation factor IX (recombinant), glycopegylated, 48 CYCLOGYL, 61 coagulation factor IX, recombinant, 48 cyclopentolate, 61 coagulation factor VIIa, 48 cyclophosphamide caps, 17 coagulation factor VIIa-jncw, 48 CYCLOPHOSPHAMIDE CAPSULES, 17 coagulation factor X, human, 48 cyclophosphamide inj, 17 COARTEM, 14 cyclosporine, 51 cobicistat, 14 cyclosporine eye solution, 61 cobimetinib, 18 cyclosporine, emulsion, 61 codeine/acetaminophen, 11 cyclosporine, modified, 51 codeine/promethazine, 53 CYKLOKAPRON inj, 49 codeine/promethazine/phenylephrine, 53 CYMBALTA, 29 colchicine, 10 cyproheptadine, 53 COLCRYS, 10 CYRAMZA, 22 colesevelam, 24 CYSTADANE, 43 COLESTID, 24 CYSTADROPS, 61 colestipol, 24 CYSTAGON, 43 collagenase clostridium histolyticum, 59 CYSTARAN, 61 COMBIGAN, 61 cysteamine, 43, 61 COMBIPATCH, 40 cysteamine delayed-rel, 43 COMBIVENT RESPIMAT, 53 cytarabine, 17 COMBIVIR, 14 CYTOGAM, 15 COMETRIQ, 18 cytomegalovirus immune globulin, 15 COMPLERA, 14 CYTOMEL, 42 COMTAN, 30 CYTOTEC, 45 CONCERTA, 31 D CONDYLOX, 59 D.H.E. 45, 32 conjugated estrogens/bazedoxifene, 40 dabrafenib, 18 COPIKTRA, 19 dacarbazine, 17 CORDRAN crm, lotion, oint, 57 DACOGEN, 20 CORDRAN TAPE, 57 dacomitinib, 19 COREG, 25 dactinomycin, 20 COREG CR, 25 dalfampridine ext-rel, 33 CORIFACT, 48 DALIRESP, 54 CORLANOR, 26 dalteparin, 47 corticotropin, 43 danazol, 39 corticotropin powder, 43 DANTRIUM, 33 CORTIFOAM, 45 dantrolene, 33 cortisone acetate, 41 dapagliflozin, 36 COSENTYX, 56 dapagliflozin/metformin ext-rel, 36 COSMEGEN, 20 dapagliflozin/saxagliptin, 37 COSOPT, 61 dapsone, 16 COTELLIC, 18 daptomycin 500 mg, 16 COTEMPLA XR-ODT, 31 DARAPRIM, 14 CREON, 45 daratumumab, 20 CRESEMBA, 14 daratumumab/hyaluronidase-fihj, 21 crisaborole oint, 57 darbepoetin alfa, 47 CRIXIVAN, 15 darifenacin ext-rel, 46 crizanlizumab-tmca, 49 darolutamide, 18 crizotinib, 18 darunavir, 15 crofelemer delayed-rel, 44 darunavir/cobicistat, 14 cromolyn sodium, 46, 59 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 14 cromolyn soln, 54 DARZALEX, 20 crotamiton crm, 58 DARZALEX FASPRO, 21 crotamiton lotion, 58 dasatinib, 18 CRYSVITA, 43 daunorubicin, 20 CUBICIN, 16 DAURISMO, 21 CUTAQUIG, 51 DAYPRO, 10 CUTIVATE, 57 DAYTRANA, 31 CUVITRU, 51 DAYVIGO, 32 CUVPOSA, 46 DDAVP, 42 cyanocobalamin inj, 52 decitabine, 20 cyanocobalamin spray, 52 decitabine-cedazuridine, 20 CYANOKIT, 43 deferasirox, 49 cyclobenzaprine, 33

deferiprone, 49 diflorasone diacetate emollient crm 0.05%, 58 deferoxamine, 49 diflorasone diacetate oint 0.05%, 58 deflazacort, 34 DIFLUCAN, 13 degarelix acetate, 18 diflunisal, 10 DELESTROGEN, 40 difluprednate, 60 DELSTRIGO, 14 digoxin, 25 DENAVIR, 59 dihydroergotamine inj, 32 denosumab, 38 dihydroergotamine spray, 32 DEPAKOTE, 28 DILANTIN, 28 DEPAKOTE ER, 28 DILANTIN INFATABS, 28 DEPAKOTE SPRINKLE, 28 DILAUDID, 11 DEPEN, 50 diltiazem, 25 DEPO-PROVERA, 39 diltiazem ext-rel, 25 DERMA-SMOOTHE/FS, 57 dimethyl fumarate delayed-rel, 33 DERMOTIC, 62 DIPENTUM, 45 DESCOVY, 14 diphenhydramine, 30, 53 DESFERAL, 49 diphenoxylate/atropine, 44 desipramine, 29 DIPROLENE, 57, 58 desmopressin spray, 48 DIPROLENE AF, 57 desmopressin spray, tabs, 42 dipyridamole, 48 desogestrel/EE, 39 dipyridamole ext-rel/aspirin, 48 desogestrel/EE 0.15/30, 38 diroximel fumarate delayed-rel, 33 DESONATE, 57 disopyramide, 23 desonide crm 0.05%, 57 disopyramide ext-rel, 23 desonide foam 0.05%, 57 disulfiram, 34 desonide gel 0.05%, 57 DITROPAN XL, 46 desonide lotion, oint 0.05%, 57 divalproex sodium delayed-rel, 28 DESOWEN, 57 divalproex sodium ext-rel, 28 desoximetasone crm, oint 0.05%, 57 divalproex sodium sprinkle caps, 28 desoximetasone crm, oint, spray 0.25%, gel 0.05%, 58 docetaxel, 20 desvenlafaxine ext-rel, 29 dofetilide, 23 deutetrabenazine, 33 DOJOLVI, 52 dexamethasone, 41, 60 dolutegravir, 14 dexamethasone sodium phosphate, 60 dolutegravir/lamivudine, 14 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 37 dolutegravir/rilpivirine, 14 DEXEDRINE SPANSULE, 31 donepezil, 28 dexmethylphenidate, 31 donepezil orally disintegrating tabs, 28 dexmethylphenidate ext-rel, 31 DOPTELET, 49 dexrazoxane, 20 DORAL, 32 dextranomer/sodium hyaluronate, 46 doravirine, 15 dextroamphetamine, 31 doravirine/lamivudine/tenofovir disoproxil fumarate, 14 dextroamphetamine ext-rel, 31 dornase alfa, 54 dextroamphetamine soln - Procentra, 31 DORYX/MPC, 13 dextromethorphan/quinidine, 34 dorzolamide, 60 DIACOMIT, 28 dorzolamide/timolol maleate, 61 DIASTAT, 28 DOVATO, 14 diazepam, 27 DOVONEX, 56 diazepam nasal spray, 28 doxazosin, 23 diazepam rectal gel, 28 doxepin, 29, 32 diazoxide, 41 doxepin crm, 58 dichlorphenamide, 26 doxercalciferol, 41 DICLEGIS, 44 DOXIL, 20 diclofenac sodium, 60 doxorubicin, 20, 21 diclofenac sodium delayed-rel, 10 doxorubicin liposomal, 20 diclofenac sodium delayed-rel/misoprostol, 10 doxycycline hyclate, 13 diclofenac sodium ext-rel, 10 doxycycline hyclate delayed-rel tabs, 13 diclofenac sodium gel 1%, 10 doxycycline monohydrate, 13 diclofenac sodium gel 3%, 56 doxycycline monohydrate delayed-rel caps, 58 diclofenac sodium soln, 10 doxylamine/pyridoxine delayed-rel, 44 dicloxacillin, 13 DRIZALMA SPRINKLE, 29 dicyclomine, 44 dronabinol, 44 DIFFERIN, 55 dronabinol solution, 46 DIFICID, 13 dronedarone, 23 diflorasone diacetate crm 0.05%, 58 drospirenone, 39

drospirenone/EE 3/20, 38 ELSPAR, 20 drospirenone/EE 3/30, 38 eltrombopag, 48 drospirenone/EE/levomefolate 3/30 and levomefolate, 38 eluxadoline, 45 drospirenone/estradiol, 40 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 14 droxidopa, 27 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 14 DUAVEE, 40 EMBEDA, 11 DUET DHA, 52 EMEND, 44 DUETACT, 36 EMFLAZA, 34 dulaglutide, 36 EMGALITY 100 mg/mL, 32 DULERA, 54 EMGALITY 120 mg/mL, 32 duloxetine delayed-rel, 29 emicizumab-kxwh, 48 duloxetine delayed-release sprinkle capsule, 29 empagliflozin, 36 DUOPA, 30 empagliflozin/linagliptin, 37 dupilumab, 57 empagliflozin/linagliptin/metformin ext-rel, 37 DUPIXENT, 57 empagliflozin/metformin, 36 DURAGESIC, 11 empagliflozin/metformin ext-rel, 36 DUREZOL, 60 EMPLICITI, 21 DURLAZA, 48 EMSAM, 29 DUROLANE, 11 emtricitabine caps, 15 durvalumab, 21 emtricitabine/rilpivirine/tenofovir alafenamide, 14 dutasteride, 46 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 14 dutasteride/tamsulosin, 46 emtricitabine/tenofovir alafenamide, 14 duvelisib, 19 emtricitabine/tenofovir disoproxil fumarate, 14 DYANAVEL XR, 31 EMTRIVA, 15 DYAZIDE, 26 EMVERM, 16 DYSPORT, 34 enalapril, 22 E enalapril oral soln, 22 enalapril/hydrochlorothiazide, 22 E.E.S., 13 enasidenib, 21 ecallantide, 50 ENBREL, 49 econazole, 56 ENBREL SURECLICK, 49 econazole foam, 56 encorafenib, 19 ECOZA, 56 ENDARI, 49 eculizumab, 48 ENDOMETRIN, 42 edaravone, 34 enfortumab vedotin-ejfv, 21 EDECRIN, 26 enfuvirtide, 14 EDURANT, 15 ENHERTU, 21 EE/norethindrone acetate, 40 enoxaparin, 47 EE/norethindrone acetate - Jinteli, 40 ENSPRYNG, 50 efavirenz, 15 ENSTILAR, 57 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 14 entacapone, 30 efavirenz/lamivudine/tenofovir disoproxil fumarate, 14 entecavir soln, 15 EFFEXOR XR, 29 entecavir tabs, 15 EFFIENT, 48 ENTEREG, 46 EFUDEX, 56 ENTOCORT EC, 44 EGRIFTA, 43 entrectinib, 18 elagolix, 39 ENTRESTO, 26 elagolix sodium/estradiol/norethindrone acetate, 42 ENTYVIO, 44 elapegademase-lvlr, 43 ENVARSUS XR, 51 ELAPRASE, 43 enzalutamide, 17 ELELYSO, 43 EPANED, 22 eletriptan, 32 EPCLUSA, 16 elexacaftor/tezacaftor/ivacaftor + ivacaftor, 54 EPIDIOLEX, 28 ELIDEL, 57 EPIDUO, 55 ELIGARD, 18 EPIDUO FORTE, 55 eliglustat, 41 EPIFOAM, 46 ELIQUIS, 47 epinastine, 59 ELITEK, 17 epinephrine auto-injector 0.15 mg, 52 ELIXOPHYLLIN, 55 epinephrine auto-injector 0.30 mg, 52 ELLENCE, 20 epinephrine inj (0.15 mg and 0.30 mg), 52 ELMIRON, 47 EPIPEN, 52 ELOCTATE, 48 EPIPEN JR., 52 elosulfase alfa, 43 epirubicin, 20 elotuzumab, 21 EPIVIR, 15

EPIVIR-HBV, 15 etanercept, 49 eplerenone, 23 etelcalcetide, 37 epoetin alfa, 47 eteplirsen, 34 epoetin alfa-epbx, 47 ethacrynic acid, 26 EPOGEN, 47 ethambutol, 15 epoprostenol, 27 ethinyl estradiol-levonorgestrel, 39 epoprostenol sodium, 27 ethosuximide, 28 eptifibatide, 48 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 38 eptinezumab-jjmr, 32 ethynodiol diacetate/EE 1/50, 38 EPZICOM, 14 ETHYOL, 20 EQUETRO, 33 etodolac, 10 ERAXIS, 13 etodolac ext-rel, 10 ERBITUX, 20 etonogestrel implant, 39 erdafitinib, 18 etonogestrel/EE - EluRyng, 39 erenumab-aooe, 32 ETOPOPHOS, 21 ergocalciferol (D2), 52 etoposide, 20 ergotamine/caffeine supp, 32 etoposide phosphate, 21 ergotamine/caffeine tabs, 32 etravirine, 15 eribulin, 21 EUCRISA, 57 ERIVEDGE, 21 EUFLEXXA, 11 ERLEADA, 17 EURAX crm, 58 erlotinib, 18 EURAX lotion, 58 ertapenem, 16 EVAMIST, 40 ERWINAZE, 20 EVEKEO, 31 ERYGEL, 55 EVEKEO ODT, 31 ERYPED, 13 EVENITY, 38 erythromycin, 59 everolimus 0.25 mg, 0.5 mg, 0.75 mg, 51 erythromycin delayed-rel, 13 everolimus 1 mg, 51 erythromycin delayed-rel - Ery-tab, 13 everolimus 10 mg, 18 erythromycin ethylsuccinate, 13 everolimus 2.5 mg, 5 mg, 7.5 mg, 18 erythromycin gel 2%, 55 everolimus tabs for oral suspension, 19 erythromycin soln, 55 EVISTA, 42 erythromycin stearate, 13 evolocumab, 24 erythromycin/benzoyl peroxide, 55 EVOMELA, 21 ESBRIET, 54 EVOTAZ, 14 escitalopram, 29 EVOXAC, 45 esketamine nasal solution, 29 EVRYSDI, 35 eslicarbazepine, 28 EVZIO, 34 esmolol, 25 EXELDERM, 56 esomeprazole magnesium delayed-rel, 45 EXELON PATCH, 28 ESPEROCT, 48 exemestane, 18 estazolam, 32 EXFORGE, 23 ESTRACE, 40 EXFORGE HCT, 23 estradiol, 40 EXONDYS 51, 34 estradiol transdermal gel, 40 EXTAVIA, 33 estradiol transdermal spray, 40 EYLEA, 61 estradiol vaginal crm, 40 ezetimibe, 24 estradiol vaginal inserts, 40 ezetimibe/simvastatin, 24 estradiol vaginal ring, 40 F estradiol vaginal tabs, 40 FABIOR, 56 estradiol valerate, 40 FABRAZYME, 43 estradiol valerate and dienogest/estradiol valerate, 39 factor IX concentrate, 48 estradiol/levonorgestrel, 40 factor IX recombinant, Fc fusion protein, 48 estradiol/norethindrone acetate, 40 factor XIII A-subunit recombinant, 48 estradiol/norgestimate, 40 factor XIII concentrate, 48 estradiol/progesterone, 40 famciclovir, 16 ESTRING, 40 famotidine, 44 ESTROGEL, 40 fam-trastuzumab deruxtecan-nxki, 21 estrogens, conjugated, 40 FANAPT, 30 estrogens, conjugated crm, 40 FARESTON, 18 estrogens, conjugated/medroxyprogesterone, 40 FARXIGA, 36 estrogens, esterified/methyltestosterone, 40 FARYDAK, 22 ESTROSTEP FE, 39 FASENRA, 55 eszopiclone, 32

febuxostat, 10 fluorometholone, 60 fedratinib, 19 fluorometholone acetate, 60 FEIBA VH IMMUNO, 48 FLUOROPLEX, 56 felbamate, 28 fluorouracil, 56 FELBATOL, 28 fluorouracil crm 4%, 56 felodipine ext-rel, 25 fluorouracil inj, 17 FEMARA, 18 fluoxetine, 29 FEMHRT, 40 fluoxetine delayed-rel, 29 FEMRING, 40 fluphenazine, 31 fenfluramine, 28 flurandrenolide crm, lotion, oint 0.05%, 57 fenofibrate, 24 flurandrenolide tape, 57 fenofibric acid delayed-rel, 24 flurazepam, 32 FENSOLVI, 18 flurbiprofen, 10, 60 fentanyl citrate buccal, 11 flutamide, 17 fentanyl sublingual spray, 11 fluticasone, 55 fentanyl transdermal, 11 fluticasone propionate, 54, 55 fentanyl transmucosal lozenge, 11 fluticasone propionate crm 0.05%, oint 0.005%, 57 FENTORA, 11 fluticasone propionate lotion 0.005%, 57 FERAHEME, 52 fluticasone spray, 54 ferric carboxymaltose inj, 52 fluticasone, CFC-free aerosol, 55 ferric citrate, 42 fluticasone/salmeterol, 54 ferric derisomaltose inj, 52 fluticasone/salmeterol, CFC-free aerosol, 54 FERRIPROX, 49 fluticasone/umeclidinium/vilanterol, 53 FERRLECIT, 52 fluticasone/vilanterol, 54 ferumoxytol inj, 52 fluvastatin, 24 fesoterodine ext-rel, 46 fluvastatin ext-rel, 24 FETZIMA, 29 fluvoxamine, 27 FIASP, 36 fluvoxamine ext-rel, 27 FIASP FLEXTOUCH, 36 FML, 60 fibrinogen, 48 FOCALIN, 31 FIBRYGA, 48 FOCALIN XR, 31 fidaxomicin, 13 folic acid, 52 filgrastim-aafi, 47 FOLLISTIM AQ, 41 filgrastim-sndz, 47 follitropin alfa, 41 FINACEA, 58 follitropin beta, 41 finasteride, 46 FOLOTYN, 17 fingolimod, 33 fondaparinux, 47 FINTEPLA, 28 FORADIL, 53 FIORICET, 11 FORFIVO XL, 29 FIORICET w/CODEINE, 11 formoterol inhalation caps, 53 FIORINAL, 11 formoterol inhalation soln, 53 FIRDAPSE, 35 FORTEO, 38 FIRMAGON, 18 FORTESTA, 35 FIRVANQ, 16 FOSAMAX, 37 FLAGYL, 16 FOSAMAX PLUS D, 38 FLAREX, 60 fosamprenavir, 15 FLEBOGAMMA, 50 fosinopril, 22 flecainide, 23 fosinopril/hydrochlorothiazide, 22 FLOLAN, 27 FOSRENOL CHEWABLE TABLETS, 42 FLOMAX, 46 FOSRENOL ORAL POWDER, 42 FLOVENT, 55 fostamatinib, 48 FLOVENT HFA, 55 fostemsavir ext-rel, 14 floxuridine, 17 FRAGMIN, 47 fluconazole, 13 FREESTYLE LIBRE / FREESTYLE LIBRE 2 CONTINUOUS fludarabine, 17 GLUCOSE MONITORING SYST, 37 fludrocortisone, 41 FROVA, 32 flunisolide spray, 54 frovatriptan, 32 fluocinolone acetonide, 62 FULPHILA, 47 fluocinolone acetonide crm, oint 0.025%, 57 fulvestrant, 18 fluocinolone acetonide oil 0.01%, 57 furosemide, 26 fluocinolone acetonide soln 0.01%, 57 FUZEON, 14 fluocinolone shampoo 0.01%, 57 FYCOMPA, 28 fluocinonide crm 0.1%, 58 fluocinonide crm, gel, oint, soln 0.05%, 58

G glycerol phenylbutyrate, 43 gabapentin, 28 glycopyrrolate, 46 GABITRIL, 28 glycopyrrolate inhalation powder, 52 GALAFOLD, 43 glycopyrrolate inhalation solution, 52 galantamine, 28 glycopyrrolate/formoterol, 53 galantamine ext-rel, 28 GLYNASE, 37 galcanezumab-gnlm 100 mg/mL, 32 GLYXAMBI, 37 galcanezumab-gnlm 120 mg/mL, 32 GOCOVRI, 30 galsulfase, 43 golimumab, 49, 50 GALZIN, 52 golodirsen, 34 GAMASTAN, 50 GOLYTELY, 45 GAMASTAN S-D, 50 gonadorelin, 40 GAMMAGARD LIQUID, 50 GONAL-F, 41 GAMMAGARD S-D, 50 GONAL-F RFF, 41 GAMMAKED, 50 GONITRO, 26 GAMMAPLEX, 50 goserelin acetate, 18 GAMUNEX-C, 50 granisetron, 44 ganciclovir, 60 granisetron ext-rel inj, 44 ganciclovir inj, 15 granisetron transdermal, 44 GANIRELIX ACETATE, 40 GRANIX, 47 ganirelix acetate inj, 40 grass mixed pollen allergen extract, 49 GASTROCROM, 46 griseofulvin microsize, 13 GATTEX, 46 griseofulvin ultramicrosize, 13 GAVRETO, 19 guanfacine ext-rel, 31 GAZYVA, 21 guselkumab, 56 gefitinib, 19 GVOKE, 41 GEL-ONE, 11 H GELSYN-3, 11 HAEGARDA, 50 GEMCITABINE, 17 HALAVEN, 21 gemcitabine inj, 17 halcinonide crm, oint, soln 0.1%, 58 gemfibrozil, 24 HALDOL, 31 gemtuzumab ozogamicin, 21 HALDOL DECANOATE 100, 31 gentamicin crm, 56 halobetasol propionate crm, oint 0.05%, 58 gentamicin/prednisolone acetate, 60 HALOG, 58 GENVOYA, 14 haloperidol, 31 GEODON, 30 haloperidol decanoate inj, 31 GILENYA, 33 haloperidol lactate inj, 31 GILOTRIF, 18 HARVONI, 16 gilteritinib, 19 HECTOROL, 41 GIVLAARI, 46 HEMADY, 41 givosiran, 46 HEMLIBRA, 48 glasdegib, 21 HEMOFIL M, 47 GLASSIA, 52 HEPAGAM B, 50 glatiramer, 33 hepatitis B immune globulin, 50 glatiramer - Glatopa, 33 HERCEPTIN, 22 glecaprevir/pibrentasvir, 16 HERCEPTIN HYLECTA, 22 GLEOSTINE, 17 HERZUMA, 21 glimepiride, 37 HETLIOZ, 32 glipizide, 37 high molecular weight hyaluronan, 11 glipizide ext-rel, 37 HIPREX, 16 glipizide/metformin, 35 histrelin acetate, 18, 43 GLUCAGEN, 41 HIZENTRA, 50 GLUCAGON EMERGENCY KIT, 41 human coagulation factor VIII (rDNA) simoctocog alfa, 48 glucagon nasal powder, 41 HUMATE-P, 47 glucagon subcutaneous soln, 41 HUMIRA, 49 glucagon, human recombinant, 41 HUMULIN R U-500, 36 glucagon, human recombinant (KIT), 41 HYALGAN, 11 glucarpidase, 21 hyaluronate sodium, 11 GLUCOTROL, 37 HYCAMTIN, 19 GLUCOTROL XL, 37 HYCAMTIN inj, 19 glyburide, 37 hydralazine, 27 glyburide, micronized, 37 HYDREA, 20 glyburide/metformin, 35 hydrochlorothiazide, 26

hydrocodone ext-rel caps, 11 IMLYGIC, 21 hydrocodone/acetaminophen, 11 immune globulin (human)-ifas, 50 hydrocodone/homatropine, 53 immune globulin (human)-klhw, 51 hydrocortisone, 41 immune globulin (human)-slra, 51 hydrocortisone acetate foam, 45 immune globulin, gamma, 50 hydrocortisone acetate/pramoxine foam, 46 immune globulin, gamma (IGG), 50 hydrocortisone butyrate crm 0.1%, 57 immune globulin, intravenous, 50 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 57 immune globulin, subcutaneous, 50, 51 hydrocortisone crm 2.5%, 57 immune globulin/hyaluronidase, 50 hydrocortisone enema, 45 immune globulin-hipp, 51 hydrocortisone probutate crm 0.1%, 57 IMPAVIDO, 16 hydrocortisone valerate crm, oint 0.2%, 57 IMURAN, 51 hydrocortisone/aloe polysaccharide/iodoquinol, 58 IMVEXXY, 40 hydrocortisone/iodoquinol, 58 INBRIJA, 30 hydromorphone, 11 incobotulinumtoxinA, 34 hydromorphone ext-rel, 11 INCRELEX, 41 hydroxocobalamin, 43 indacaterol/glycopyrrolate inhalation powder, 53 hydroxychloroquine, 50 indapamide, 26 hydroxyprogesterone caproate, 42 INDERAL LA, 25 hydroxyurea, 20, 21 indinavir, 15 hydroxyzine HCl, 27, 53 INDOCIN susp, 10 hydroxyzine pamoate, 27, 53 indomethacin (except caps 20 mg, 40 mg), 10 hylan G-F 20, 11 indomethacin ext-rel, 10 HYMOVIS, 11 indomethacin susp, 10 hyoscyamine sulfate, 44 INFLECTRA, 50 hyoscyamine sulfate ext-rel, 44 infliximab, 50 HYPERHEP B S-D, 50 infliximab-abda, 50 HYPERRHO S-D, 50 infliximab-dyyb, 50 HYQVIA, 50 INGREZZA, 35 I INJECTAFER, 52 INLYTA, 18 ibalizumab-uiyk, 14 INNOPRAN XL, 25 ibandronate, 38 inotersen, 43 IBRANCE, 19 inotuzumab ozogamicin, 21 ibrutinib, 19 INQOVI, 20 ibuprofen, 10 INREBIC, 19 ibuprofen inj, 10 INSPRA, 23 icatibant, 50 insulin aspart, 36 ICLUSIG, 19 INSULIN ASPART, 36 icosapent ethyl caps 1 gm, 24 insulin aspart protamine 70%/insulin aspart 30%, 36 IDAMYCIN PFS, 20 INSULIN ASPART PROTAMINE 70%/INSULIN ASPART 30%, 36 idarubicin, 20 insulin degludec, 36 idelalisib, 19 insulin detemir, 36 IDELVION, 48 insulin glargine, 36 IDHIFA, 21 insulin human, 36 idursulfase, 43 insulin human inhalation powder, 36 IFEX, 20 insulin isophane human, 36 ifosfamide, 20 insulin isophane human 70%/regular 30%, 36 ifosfamide/mesna, 17 insulin pen needles, 37 ILARIS, 51 insulin syringes, needles, 37 ILEVRO, 60 INTEGRILIN, 48 iloperidone, 30 INTELENCE, 15 iloprost, 27 interferon alfa-2b, 51 ILUMYA, 50 interferon alfa-n3, 59 imatinib mesylate, 18 interferon beta-1a, 33 IMBRUVICA, 19 interferon beta-1b, 33 IMFINZI, 21 interferon gamma-1b, recombinant, 51 imiglucerase, 41 INTRAROSA, 43 imipenem/cilastatin, 16 intrauterine copper contraceptive, 39 imipramine HCl, 29 INTRON A, 51 imipramine pamoate, 29 INTUNIV, 31 imiquimod, 58 INVANZ, 16 imiquimod crm 3.75%, 59 INVEGA, 30 IMITREX, 32 INVEGA SUSTENNA, 30

INVEGA TRINZA, 31 KAPVAY, 31 INVELTYS, 60 KEFLEX, 12 INVIRASE, 15 KENALOG SPRAY, 58 ipilimumab, 21 KENGREAL, 48 ipratropium nasal spray, 55 KEPIVANCE, 46 ipratropium soln, 52 KEPPRA, 28 ipratropium, CFC-free aerosol, 52 KEPPRA XR, 28 ipratropium/albuterol soln, 53 KESIMPTA, 33 ipratropium/albuterol, CFC-free aerosol, 53 ketoconazole, 56 irbesartan, 23 ketoconazole shampoo 2%, 57 irbesartan/hydrochlorothiazide, 23 ketoconazole tabs, 13 IRESSA, 19 ketoprofen, 10 irinotecan, 20 ketoprofen ext-rel, 10 irinotecan liposome inj, 20 ketorolac, 10 iron sucrose inj, 52 ketorolac 0.45%, 60 isatuximab-irfc, 19 ketorolac 0.5%, 60 isavuconazonium, 14 ketorolac tromethamine nasal spray, 10 ISENTRESS, 14 KEVEYIS, 26 isocarboxazid, 29 KEVZARA, 50 isoniazid, 15 KEYTRUDA, 18 ISOPTO HYOSCINE, 61 KHAPZORY, 21 ISORDIL, 26 KINERET, 49 isosorbide dinitrate oral, 26 KISQALI, 19 isosorbide dinitrate/hydralazine, 26 KISQALI FEMARA CO-PACK, 19 isosorbide mononitrate, 26 KITABIS PAK, 54 isosorbide mononitrate ext-rel, 26 KLONOPIN, 27 isotretinoin, 55 KOATE-DVI, 48 ISTALOL, 60 KOGENATE FS, 48 ISTODAX, 20 KORLYM, 43 istradefylline, 30 KOSELUGO, 19 ISTURISA, 43 KOVALTRY, 48 itraconazole, 13 KRINTAFEL, 14 ivabradine, 26 KRISTALOSE pak, 45 ivacaftor, 54 KRYSTEXXA, 10 ivermectin, 58 KUVAN, 41 ivermectin crm 1%, 58 KYLEENA, 39 ivosidenib, 21 KYNMOBI, 30 ixabepilone, 21 KYPROLIS, 21 ixazomib, 19 L ixekizumab, 49 lacosamide, 28 IXEMPRA, 21 lactulose packets, 45 IXINITY, 48 lactulose soln, 45 J LAMICTAL, 28 JADENU, 49 LAMICTAL ODT, 28 JAKAFI, 19 LAMICTAL XR, 28 JANUMET, 35 lamivudine, 15 JANUMET XR, 35 lamivudine/tenofovir disoproxil fumarate, 14 JANUVIA, 35 lamivudine/zidovudine, 14 JARDIANCE, 36 lamotrigine, 28 JEVTANA, 20 lamotrigine ext-rel, 28 JIVI, 48 lamotrigine orally disintegrating tabs, 28 JULUCA, 14 LAMPIT, 16 JUXTAPID, 24 lanadelumab-flyo, 50 JYNARQUE, 43 lancet device, 37 K lancets, 37 LANOXIN, 25 KADCYLA, 20 lanreotide acetate, 43 KALBITOR, 50 lansoprazole + amoxicillin + clarithromycin, 46 KALETRA, 15 lansoprazole delayed-rel, 45 KALYDECO, 54 lanthanum carbonate chew tabs, 42 KANJINTI, 21 lanthanum oral powder, 42 KANUMA, 43 lapatinib, 18 KAPSPARGO, 25 laronidase, 43

larotrectinib, 19 linezolid, 16 LASIX, 26 LINZESS, 45 LASTACAFT, 59 LIORESAL INTRATHECAL, 33 latanoprost, 61 liothyronine, 42 latanoprost ophthalmic emulsion, 61 LIPOFEN, 24 latanoprostene bunod, 61 liraglutide, 36 LATUDA, 31 liraglutide/insulin degludec, 36 ledipasvir/sofosbuvir, 16 lisdexamfetamine, 31 lefamulin, 13 lisinopril, 22 leflunomide, 50 lisinopril oral soln, 22 lemborexant, 32 lisinopril/hydrochlorothiazide, 22 LEMTRADA, 33 lithium carbonate, 33 lenalidomide, 19 lithium carbonate ext-rel tabs 300 mg, 33 lenvatinib, 19 lithium carbonate ext-rel tabs 450 mg, 33 LENVIMA, 19 LITHOBID, 33 letermovir, 15 lixisenatide/insulin glargine, 36 letrozole, 18 LO LOESTRIN FE, 39 leucovorin calcium, 20 LOCOID, 57 LEUKERAN, 17 LOCOID LIPOCREAM, 57 LEUKINE, 47 lodoxamide, 59 leuprolide acetate, 18, 43 LOKELMA, 42 leuprolide acetate/norethindrone acetate, 39 lomitapide, 24 levalbuterol inhalation soln, 53 LOMOTIL, 44 levalbuterol nebulizer soln concentrate, 53 lomustine, 17 levalbuterol tartrate, CFC-free aerosol, 53 lonafarnib, 43 LEVAQUIN, 13 LONHALA MAGNAIR, 52 LEVATOL, 25 LONSURF, 22 LEVBID, 44 loperamide, 44 LEVEMIR, 36 LOPID, 24 levetiracetam, 28 lopinavir/ritonavir, 15 levetiracetam ext-rel, 28 LOPRESSOR, 25 levobunolol, 60 lorazepam, 27 levocarnitine, 38 LORBRENA, 19 levodopa inhalation powder, 30 lorlatinib, 19 levofloxacin, 13, 59 losartan, 23 levoleucovorin, 21 losartan/hydrochlorothiazide, 23 levoleucovorin calcium, 20 LOSEASONIQUE, 39 levomilnacipran ext-rel, 29 LOTEMAX Gel, Susp, 60 levonorgestrel/EE - Trivora, 39 LOTEMAX Oint, 60 levonorgestrel/EE 0.09/20 - Amethyst, 39 LOTEMAX SM, 60 levonorgestrel/EE 0.1/20, 38 LOTENSIN, 22 levonorgestrel/EE 0.1/20 and EE 10, 39 LOTENSIN HCT, 22 levonorgestrel/EE 0.15/30, 38 loteprednol, 60 levonorgestrel/EE 0.15/30 - Jolessa, 39 loteprednol 0.2%, 60 levonorgestrel/EE 0.15/30 - Levora, 38 loteprednol 0.5% gel, susp, 60 levonorgestrel/EE 0.15/30 and EE 10, 39 loteprednol 1.0%, 60 levonorgestrel-releasing IUD, 39 loteprednol oint, 60 levothyroxine, 42 LOTREL, 22 levothyroxine - Levoxyl, 42 LOTRONEX, 45 LEVSIN, 44 lovastatin, 24 LEVULAN KERASTICK, 56 LOVAZA, 24 LEXAPRO, 29 LOVENOX, 47 LEXIVA, 15 loxapine, 31 L-glutamine oral powder, 49 lubiprostone, 45 LIALDA, 44 LUCENTIS, 61 lidocaine, 58 luliconazole, 56 lidocaine patch, 58 lumacaftor/ivacaftor, 54 lidocaine viscous, 59 lumateperone, 31 lidocaine/prilocaine, 58 LUMIZYME, 43 LIDODERM, 58 LUMOXITI, 22 lifitegrast, 61 LUPANETA PACK, 39 LILETTA, 39 LUPKYNIS, 51 linaclotide, 45 LUPRON DEPOT, 18 lindane, 58 LUPRON DEPOT-PED, 43

lurasidone, 31 mesna tabs 400 mg, 21 lurbinectedin, 17 MESNEX, 21 luspatercept-aamt, 49 MESNEX inj, 20 lusutrombopag, 49 MESTINON, 33 LUTREPULSE, 40 MESTINON TIMESPAN, 33 LYNPARZA, 21 metformin, 35 LYSODREN, 20 metformin ext-rel, 35 LYSTEDA, 49 metformin oral soln, 35 M methadone, 11 methamphetamine, 31 macitentan, 26 methazolamide, 25 MACROBID, 16 methenamine hippurate, prophylaxis, 16 MACRODANTIN, 16 methimazole, 42 mafenide acetate packets 5%, 56 methotrexate auto-injector, 50 MAKENA, 42 methotrexate inj, 50 MALARONE, 14 methotrexate oral, 50 mannitol inhalation powder, 54 methoxsalen oral, 56 maraviroc, 14 methoxy polyethylene glycol/epoetin beta, 47 MARINOL, 44 methylergonovine, 43 MARPLAN, 29 METHYLIN, 31 MARQIBO, 21 methylnaltrexone, 45 MATULANE, 21 methylphenidate, 31 MAVENCLAD, 33 methylphenidate ext-rel, 31 MAVYRET, 16 methylphenidate ext-rel (except methylphenidate tab ER osmotic MAXALT/MAXALT-MLT, 32 release 72 mg), 31 MAXIDEX, 60 methylphenidate ext-rel caps, 31 MAXITROL, 59 methylphenidate ext-rel chewable tabs, 31 MAXZIDE, 26 methylphenidate ext-rel orally disintegrating tablets, 31 MAXZIDE-25, 26 methylphenidate ext-rel susp, 31 MAYZENT, 33 methylphenidate transdermal, 31 mebendazole, 16 methylprednisolone, 41 mecamylamine, 27 metoclopramide, 44 mecasermin, 41 metolazone, 26 mechlorethamine gel, 17 metoprolol succinate ext-rel, 25 meclizine, 44 metoprolol tartrate, 25 medroxyprogesterone acetate, 42 metoprolol/hydrochlorothiazide, 25 medroxyprogesterone acetate 150 mg/mL, 39 metreleptin, 43 mefloquine, 14 METROCREAM, 58 megestrol acetate, 18 METROGEL, 58 megestrol acetate susp, 42 METROLOTION, 58 MEKINIST, 19 metronidazole crm 0.75%, 58 MEKTOVI, 19 metronidazole gel 0.75%, 58 meloxicam tabs, 10 metronidazole gel 1%, 58 melphalan, 21 metronidazole lotion 0.75%, 58 melphalan inj, 17 metronidazole tabs, 16 melphalan tabs, 17 metronidazole vaginal, 46 memantine soln, 28 mexiletine, 23 memantine tabs, 28 MIACALCIN, 38 MENOPUR, 41 MIACALCIN inj, 38 menotropins, 41 micafungin, 13 MEPHYTON, 52 miconazole nitrate/zinc oxide, 56 mepolizumab, 54 MICRHOGAM, 50 MEPRON, 16 MICRHOGAM PLUS, 50 MEPSEVII, 43 midazolam nasal spray, 28 mercaptopurine, 17 midodrine, 27 mercaptopurine susp, 17 midostaurin, 19 meropenem, 16 mifepristone, 43 MERREM, 16 migalastat, 43 mesalamine delayed-rel caps, 44 MIGERGOT, 32 mesalamine delayed-rel tabs, 44 miglitol, 35 mesalamine ext-rel caps, 44, 45 miglustat, 43 mesalamine rectal susp, 45 MIGRANAL, 32 mesalamine supp, 45 milnacipran, 32 mesna inj, 20 miltefosine, 16

MINIPRESS, 23 MYSOLINE, 28 MINIVELLE, 40 MYTESI, 44 MINOCIN, 13 N minocycline, 13 NABI-HB, 50 minocycline ext-rel, 13 nabumetone, 10 minocycline ext-rel caps, 55 nafarelin, 39 minocycline foam, 58 naftifine, 56 minocycline hcl micronized foam, 56 NAGLAZYME, 43 minoxidil tabs, 27 naloxegol, 45 mirabegron ext-rel, 46 naloxone auto-injector, 34 MIRAPEX, 30 naloxone inj, 34 MIRAPEX ER, 30 naloxone nasal spray, 34 MIRCERA, 47 naltrexone, 34 MIRCETTE, 39 naltrexone microspheres, 34 MIRENA, 39 NAMENDA tabs, 28 mirtazapine, 29 naphazoline, 61 MIRVASO, 58 naproxen, 10 misoprostol, 45 naproxen sodium, 10 MITIGARE, 10 naratriptan, 32 mitomycin, 20 NARCAN, 34 mitotane, 20 NARDIL, 29 mitoxantrone, 20 NASCOBAL, 52 MOBIC, 10 NATACYN, 59 modafinil, 33 natalizumab, 33 mogamulizumab-kpkc, 21 natamycin, 59 mometasone, 55 NATAZIA, 39 mometasone crm, lotion, oint 0.1%, 57 nateglinide, 36 mometasone spray, 54 NATPARA, 38 mometasone, CFC-free aerosol, 55 NATROBA, 58 mometasone/formoterol, 54 NAVELBINE, 20 MONOFERRIC, 52 NAYZILAM, 28 monomethyl fumarate, 33 nebivolol, 25 MONONINE, 48 necitumumab, 21 MONOVISC, 11 nefazodone, 29 montelukast, 54 nelarabine, 21 MORPHABOND, 11 nelfinavir, 15 morphine, 11 neomycin/dexamethasone, 59 morphine ext-rel, 11 neomycin/polymyxin B/dexamethasone, 59 morphine supp, 11 neomycin/polymyxin B/gramicidin, 59 morphine/naltrexone ext-rel, 11 neomycin/polymyxin B/hydrocortisone, 62 MOVANTIK, 45 neomycin/polymyxin B/hydrocortisone susp, 59 MOVIPREP, 45 NEORAL, 51 moxetumomab pasudotox-tdfk, 22 nepafenac, 60 MOXEZA, 59 nepafenac 0.3%, 60 moxifloxacin, 59 neratinib, 19 MOZOBIL, 49 NERLYNX, 19 MS CONTIN, 11 netarsudil, 61 MULPLETA, 49 netarsudil/latanoprost, 61 MULTAQ, 23 netupitant/palonosetron, 44 mupirocin, 56 NEUPRO, 30 MVASI, 20 NEURONTIN, 28 MYALEPT, 43 NEVANAC, 60 MYAMBUTOL, 15 nevirapine, 15 MYCAMINE, 13 nevirapine ext-rel, 15 MYCAPSSA, 43 NEXAVAR, 19 MYCOBUTIN, 16 NEXLETOL, 24 mycophenolate mofetil, 51 NEXLIZET, 24 mycophenolate sodium delayed-rel, 51 NEXPLANON, 39 MYDAYIS, 31 niacin ext-rel, 24 MYFORTIC, 51 NIASPAN, 24 MYLERAN, 17 nicardipine, 25 MYLOTARG, 21 nifedipine ext-rel, 25 MYOBLOC, 34 nifurtimox, 16 MYRBETRIQ, 46

NILANDRON, 17 NOVOLOG, 36 nilotinib, 19 NOVOLOG MIX 70/30, 36 nilutamide, 17 NOVOSEVEN RT, 48 nimodipine, 25 NOXAFIL susp, 13 NIMOTOP, 25 NOXAFIL tabs, 13 NINLARO, 19 NPLATE, 48 nintedanib, 54 NUBEQA, 18 NIPENT, 17 NUCALA, 54 niraparib, 21 NUCYNTA, 11 nisoldipine ext-rel, 25 NUCYNTA ER, 11 nitazoxanide tabs, 16 NUEDEXTA, 34 nitisinone, 41 NULOJIX, 51 NITRO-BID, 26 NULYTELY, 45 NITRO-DUR, 26 NUPLAZID, 31 nitrofurantoin ext-rel, 16 NURTEC ODT, 32 nitrofurantoin macrocrystals, 16 NUVARING, 39 nitroglycerin lingual spray, 26 NUVIGIL, 33 nitroglycerin ointment, 26 NUWIQ, 48 nitroglycerin rectal oint 0.4%, 46 NUZYRA, 13 nitroglycerin sublingual, 26 nystatin, 13, 56 nitroglycerin sublingual aerosol, 26 NYVEPRIA, 47 nitroglycerin sublingual powder, 26 O nitroglycerin transdermal, 26 obeticholic acid, 46 NITROLINGUAL, 26 obinutuzumab, 21 NITROMIST, 26 OBIZUR, 48 NITROSTAT, 26 OCALIVA, 46 NITYR, 41 ocrelizumab, 33 NIVESTYM, 47 OCREVUS, 33 nivolumab, 21 OCTAGAM, 50 nizatidine, 44 octreotide, 43 NIZORAL SHAMPOO, 57 octreotide acetate, 43 NORDITROPIN, 41 OCUFLOX, 59 norelgestromin/EE, 39 ODEFSEY, 14 norethindrone, 39 ODOMZO, 22 norethindrone acetate, 42 ofatumumab, 21, 33 norethindrone acetate/EE 1.5/30, 38 OFEV, 54 norethindrone acetate/EE 1.5/30 and iron, 38 OFIRMEV, 10 norethindrone acetate/EE 1/10 and EE 10 and iron, 39 ofloxacin, 13, 59 norethindrone acetate/EE 1/20, 38 ofloxacin otic, 62 norethindrone acetate/EE 1/20 and iron, 38 OGIVRI, 21 norethindrone acetate/EE and iron, 39 olanzapine, 30 norethindrone/EE, 39 olanzapine pamoate ext-rel inj, 31 norethindrone/EE 0.4/35, 38 olanzapine/fluoxetine, 30 norethindrone/EE 0.5/35, 38 olaparib, 21 norethindrone/EE 1/35, 38 olmesartan, 23 norgestimate/EE, 39 olmesartan/amlodipine/hydrochlorothiazide, 23 norgestimate/EE 0.25/35, 38 olmesartan/hydrochlorothiazide, 23 norgestrel/EE 0.3/30 - Cryselle, 38 olodaterol, CFC-free aerosol, 53 norgestrel/EE 0.3/30 - Low-Ogestrel, 38 olopatadine, 59 norgestrel/EE 0.5/50, 39 olopatadine spray, 54 NORPACE, 23 olsalazine, 45 NORPACE CR, 23 OLUMIANT, 49 NORPRAMIN, 29 omacetaxine mepesuccinate, 21 NORTHERA, 27 omadacycline, 13 nortriptyline, 29 omalizumab, 54 NORVASC, 25 omega-3 acid ethyl esters, 24 NORVIR, 15 omeprazole delayed-rel, 45 NOURIANZ, 30 onabotulinumtoxinA, 34 NOVAREL, 40 ONCASPAR, 21 NOVOEIGHT, 48 ondansetron, 44 NOVOFINE PEN NEEDLES, 37 ondansetron orally disintegrating tabs, 44 NOVOLIN 70/30, 36 ONETOUCH LANCETS, 37 NOVOLIN N, 36 ONETOUCH METERS AND KITS, 37 NOVOLIN R, 36

ONETOUCH TEST STRIPS, 37 paliperidone ext-rel, 30 ONEXTON, 56 paliperidone palmitate ext-rel inj, 30, 31 ONFI, 28 palivizumab, 16 ONGENTYS, 30 palonosetron, 44 ONIVYDE, 20 PALYNZIQ, 42 ONTRUZANT, 21 PAMELOR, 29 ONUREG, 17 pamidronate, 38 ONZETRA XSAIL, 33 PANCREAZE, 45 OPANA, 11 pancrelipase, 45 OPDIVO, 21 pancrelipase delayed-rel, 45 opicapone, 30 PANDEL, 57 OPSUMIT, 26 panitumumab, 21 ORACEA, 58 panobinostat, 22 ORALAIR, 49 PANRETIN, 59 ORENCIA, 49 pantoprazole delayed-rel, 45 ORENITRAM, 27 PANZYGA, 50 ORFADIN, 41 PARAGARD T 380A, 39 ORGOVYX, 18 parathyroid hormone (recombinant), 38 ORIAHNN, 42 paricalcitol, 41 ORILISSA, 39 PARLODEL, 30 ORKAMBI, 54 PARNATE, 29 ORLADEYO, 50 paroxetine HCl, 29 ORTHO MICRONOR, 39 paroxetine HCl ext-rel, 29 ORTHOVISC, 11 paroxetine mesylate, 29 ORTIKOS, 45 PARSABIV, 37 oseltamivir, 16 pasireotide, 43 osilodrostat phosphate, 43 PATANASE, 54 osimertinib, 19 patiromer, 42 OSMOPREP, 45 PAXIL, 29 ospemifene, 42 PAXIL CR, 29 OSPHENA, 42 PAZEO, 59 OTEZLA, 49 pazopanib, 19 OTREXUP, 50 peanut allergen-dfnp, 49 OVIDREL, 40 peg 3350/electrolytes, 45 oxaliplatin, 20 pegaspargase, 21 oxaprozin, 10 PEGASYS, 51 oxazepam, 27 pegfilgrastim-apgf, 47 OXBRYTA, 49 pegfilgrastim-bmez, 47 oxcarbazepine, 28 pegfilgrastim-cbqv, 47 oxcarbazepine ext-rel, 28 pegfilgrastim-jmdb, 47 OXERVATE, 61 peginterferon alfa-2a, 51 oxiconazole crm, 56 peginterferon alfa-2b, 51 OXSORALEN-ULTRA, 56 peginterferon beta-1a, 33 OXTELLAR XR, 28 PEGINTRON, 51 oxybutynin, 46 pegloticase, 10 oxybutynin ext-rel, 46 pegvaliase-pqpz, 42 oxycodone, 11 pegvisomant, 43 oxycodone concentrate 20 mg/mL, 11 PEMAZYRE, 19 oxycodone ext-rel, 11 pembrolizumab, 18 oxycodone soln, 11 pemetrexed, 17 oxycodone/acetaminophen 5/325, 11 pemigatinib, 19 oxymetazoline crm 1%, 58 penbutolol, 25 oxymetazoline opth soln, 61 penciclovir, 59 oxymorphone, 11 penicillamine tabs, 50 ozanimod, 33 penicillin VK, 13 OZEMPIC, 36 PENTASA, 45 P pentosan polysulfate sodium, 47 pentostatin, 17 paclitaxel, 20 pentoxifylline ext-rel, 49 paclitaxel protein-bound particles, 21 perampanel, 28 PADCEV, 21 PERCOCET, 11 palbociclib, 19 PERFOROMIST, 53 PALFORZIA, 49 perindopril, 22 palifermin, 46 perindopril arginine/amlodipine, 22

PERJETA, 21 prasugrel, 48 permethrin 5%, 58 pravastatin, 24 perphenazine, 31 prazosin, 23 PERSERIS, 31 PRECOSE, 35 pertuzumab, 21 PRED FORTE, 60 pertuzumab/trastuzumab/hyaluronidase-zzxf, 21 PRED MILD, 60 PEXEVA, 29 PRED-G, 60 pexidartinib, 19 prednisolone, 41 phenazopyridine, 47 prednisolone acetate 0.12%, 60 phenelzine, 29 prednisolone acetate 1%, 60 phenobarbital, 28 prednisolone phosphate 1%, 60 phenylephrine, 59 prednisolone sodium phosphate, 41 phenytoin, 28 prednisolone sodium phosphate orally disintegrating tabs, 41 phenytoin sodium extended, 28 prednisolone syrup, 41 PHESGO, 21 prednisone, 41 phytonadione, 52 PREFEST, 40 PIFELTRO, 15 pregabalin (does not include ext-rel tabs), 31 pilocarpine, 61 PREGNYL, 41 pilocarpine tabs, 46 PREMARIN, 40 PILOPINE HS GEL, 61 PREMARIN crm, 40 pimavanserin, 31 PREMPHASE, 40 pimecrolimus, 57 PREMPRO, 40 pindolol, 25 prenatal vitamins/docusate/folic acid, 52 pioglitazone, 36 prenatal vitamins/folic acid, 52 pioglitazone/glimepiride, 36 PRENATE ELITE, 52 pioglitazone/metformin, 36 PREPOPIK, 45 pioglitazone/metformin ext-rel, 36 PRESTALIA, 22 piperacillin/tazobactam, 13 PRETOMANID, 15 PIQRAY, 18 pretomanid tabs, 15 pirfenidone, 54 PREVIDENT, 59 piroxicam, 10 PREVYMIS, 15 pitolisant, 34 PREZCOBIX, 14 PLAQUENIL, 50 PREZISTA, 15 PLAVIX, 48 PRIALT, 11 plecanatide, 46 PRIFTIN, 15 PLEGRIDY, 33 primaquine, 14 PLEGRIDY PEN, 33 PRIMAXIN, 16 PLENVU, 45 primidone, 28 plerixafor, 49 PRINIVIL, 22 podofilox, 59 PRISTIQ, 29 polatuzumab vedotin-piiq, 22 PRIVIGEN, 50 POLIVY, 22 PROAIR DIGIHALER, 53 polymyxin B/bacitracin, 59 PROAIR HFA, 53 polymyxin B/trimethoprim, 59 PROAIR RESPICLICK, 53 POLYTRIM, 59 probenecid, 10 pomalidomide, 18 procarbazine, 21 POMALYST, 18 PROCARDIA XL, 25 ponatinib, 19 prochlorperazine, 44 PORTRAZZA, 21 PROCTOFOAM-HC, 46 posaconazole delayed-rel tabs, 13 PROCYSBI, 43 posaconazole susp, 13 PROFILNINE, 48 potassium chloride ext-rel, 51 progesterone vaginal inserts, 42 potassium chloride liquid, 51 progesterone, micronized, 42 potassium chloride powder, 51 PROGLYCEM, 41 potassium citrate ext-rel, 47 PROGRAF, 51 POTELIGEO, 21 PROLASTIN-C, 52 pralatrexate, 17 PROLENSA, 60 pralsetinib, 19 PROLEUKIN, 20 pramipexole, 30 PROLIA, 38 pramipexole ext-rel, 30 PROMACTA, 48 pramlintide, 35 promethazine, 44, 53 PRAMOSONE, 57 PROMETRIUM, 42 pramoxine/hydrocortisone, 57 propafenone ext-rel, 23 prasterone vaginal inserts, 43 propantheline 15 mg, 44

propranolol, 25 RECOMBINATE, 48 propranolol ext-rel, 25 RECTIV, 46 propylthiouracil, 42 REGLAN, 44 PROSCAR, 46 regorafenib, 19 protein C concentrate, human, 49 REGRANEX, 59 PROTOPIC, 57 RELENZA, 16 protriptyline, 29 RELISTOR, 45 PROVERA, 42 RELPAX, 32 PROVIGIL, 33 relugolix, 18 PROZAC, 29 REMERON, 29 PULMICORT FLEXHALER, 55 REMICADE, 50 PULMICORT RESPULES, 55 REMODULIN, 27 PULMOZYME, 54 RENAGEL, 42 PURIXAN, 17 RENFLEXIS, 50 PYLERA, 46 RENVELA, 42 pyrazinamide, 15 repaglinide, 36 PYRIDIUM, 47 REPATHA, 24 pyridostigmine, 33 reslizumab inj, 55 pyridostigmine ext-rel tabs 180 mg, 33 RESTASIS, 61 pyrimethamine, 14 RESTORIL, 32 Q RETACRIT, 47 retapamulin, 56 QBRELIS, 22 RETEVMO, 19 QINLOCK, 19 RETIN-A, 55 QTERN, 37 RETIN-A MICRO, 55 quazepam, 32 RETROVIR, 15 QUDEXY XR, 28 REVCOVI, 43 QUESTRAN/QUESTRAN LIGHT, 24 revefenacin inhalation solution, 52 quetiapine, 30 REVLIMID, 19 quetiapine ext-rel, 30 REXULTI, 30 QUILLICHEW ER, 31 REYATAZ, 15 QUILLIVANT XR, 31 Rho (D) immune globulin, 50, 51 quinapril, 22 RHOFADE, 58 quinapril/hydrochlorothiazide, 22 RHOGAM, 50 quinidine gluconate ext-rel, 23 RHOGAM PLUS, 50 QUTENZA, 58 RHOPHYLAC, 50 QVAR, 55 RHOPRESSA, 61 QVAR REDIHALER, 55 RIABNI, 21 R RIASTAP, 48 rabeprazole delayed-rel (except rabeprazole capsule sprinkle ribavirin caps, 16 delayed-rel), 45 ribavirin caps - Ribasphere, 16 RADICAVA, 34 ribavirin tabs, 16 raloxifene, 42 ribociclib, 19 raltegravir, 14 ribociclib + letrozole, 19 ramelteon, 32 RIDAURA, 50 ramipril, 22 rifabutin, 16 ramucirumab, 22 RIFADIN, 15 RANEXA, 27 rifampin, 15 ranibizumab, 61 rifampin/isoniazid/pyrazinamide, 15 ranolazine ext-rel, 27 rifamycin delayed-rel, 13 RAPAFLO, 46 rifapentine, 15 RAPAMUNE, 51 RIFATER, 15 rasagiline, 30 rifaximin, 16 rasburicase, 17 rilonacept, 51 RASUVO, 50 rilpivirine, 15 RAVICTI, 43 RILUTEK, 34 ravulizumab-cwvz, 48 riluzole, 34 RAYALDEE, 41 rimabotulinumtoxinB, 34 RAZADYNE ER, 28 rimantadine, 16 REBIF, 33 rimegepant, 32 REBIF REBIDOSE, 33 rimexolone, 60 REBINYN, 48 RINVOQ ER, 49 REBLOZYL, 49 riociguat, 27 ripretinib, 19

risankizumab-rzaa, 49 SANDIMMUNE, 51 risdiplam, 35 SANDOSTATIN LAR, 43 risedronate, 38 SAPHRIS, 30 risedronate delayed-rel, 38 sapropterin, 41 RISPERDAL, 30 saquinavir mesylate, 15 RISPERDAL CONSTA, 30 SARCLISA, 19 RISPERDAL M-TABS, 30 sargramostim, 47 risperidone, 30 sarilumab, 50 risperidone ext-rel inj, 31 satralizumab-mwge, 50 risperidone long-acting inj, 30 SAVELLA, 32 risperidone orally disintegrating tabs, 30 scopolamine, 61 RITALIN, 31 scopolamine transdermal, 44 RITALIN LA, 31 SEASONIQUE, 39 ritonavir tabs, 15 sebelipase alfa, 43 RITUXAN, 22 secnidazole, 16 RITUXAN HYCELA, 22 secukinumab, 56 rituximab, 22 SEEBRI NEOHALER, 52 rituximab/hyaluronidase human, 22 segesterone acetate/EE ring, 39 rituximab-abbs, 21 selegiline caps, 30 rituximab-arrx, 21 selegiline orally disintegrating tabs, 30 rituximab-pvvr, 21 selegiline transdermal, 29 rivaroxaban, 47 selexipag, 27 rivastigmine, 28 selinexor, 22 rivastigmine transdermal, 28 selpercatinib, 19 RIXUBIS, 48 selumetinib, 19 rizatriptan, 32 SELZENTRY, 14 ROCALTROL, 41 semaglutide, 36 ROCEPHIN, 12 SEREVENT DISKUS, 53 ROCKLATAN, 61 SERNIVO, 58 roflumilast, 54 SEROQUEL, 30 rolapitant, 44 SEROQUEL XR, 30 romidepsin, 20 SEROSTIM, 41 romiplostim, 48 sertraline, 29 romosozumab-aqqg, 38 sevelamer carbonate, 42 ropinirole, 30 sevelamer HCl, 42 ropinirole ext-rel, 30 SEVENFACT, 48 rosiglitazone, 36 SIGNIFOR, 43 rosuvastatin, 24 SIKLOS, 21 rotigotine transdermal, 30 sildenafil, 27 ROWASA, 45 SILENOR, 32 ROXICODONE, 11 SILIQ, 50 ROZLYTREK, 18 silodosin, 46 RUBRACA, 21 SILVADENE, 56 rucaparib, 21 silver sulfadiazine, 56 RUCONEST, 50 SIMBRINZA, 61 rufinamide, 28 SIMPONI 100 mg, 49 RUKOBIA, 14 SIMPONI 50 mg, 50 RUXIENCE, 21 simvastatin, 24 ruxolitinib, 19 SINEMET, 30 RUZURGI, 35 SINGULAIR, 54 RYBELSUS, 36 siponimod, 33 RYDAPT, 19 sirolimus, 51 RYTARY, 30 SIRTURO, 15 RYTHMOL SR, 23 sitagliptin phosphate, 35 S sitagliptin/metformin, 35 sitagliptin/metformin ext-rel, 35 sacituzumab govitecan-hziy, 22 SIVEXTRO, 16 sacubitril/valsartan, 26 SKYLA, 39 safinamide, 30 SKYRIZI, 49 SAFYRAL, 38 SLYND, 39 SALAGEN, 46 sodium ferric gluconate inj, 52 salmeterol xinafoate, 53 sodium fluoride, 59 SAMSCA, 43 sodium hyaluronate, 11 SANCUSO, 44 sodium oxybate, 33

sodium phenylbutyrate, 42 sulfacetamide/prednisolone phosphate 10%/0.25%, 60 sodium phosphates, 45 sulfamethoxazole/trimethoprim, 16 sodium picosulfate/magnesium oxide/citric acid, 45 sulfamethoxazole/trimethoprim DS, 16 sodium polystyrene sulfonate, 42 SULFAMYLON, 56 sodium sulfate/potassium sulfate/magnesium sulfate, 45 sulfasalazine, 45 sodium zirconium cyclosilicate, 42 sulfasalazine delayed-rel, 45 sofosbuvir, 16 sulindac, 10 sofosbuvir/velpatasvir, 16 sumatriptan, 32 sofosbuvir/velpatasvir/voxilaprevir, 16 sumatriptan nasal powder, 33 SOFTCLIX LANCET DEVICE, 37 sumatriptan/naproxen sodium, 33 SOFTCLIX LANCETS, 37 sunitinib, 19 SOFTTOUCH LANCET DEVICE, 37 SUNOSI, 34 SOFTTOUCH LANCETS, 37 SUPARTZ FX, 11 SOLESTA, 46 SUPPRELIN LA, 43 solifenacin, 46 SUPRAX, 12 SOLIQUA, 36 SUPREP, 45 SOLIRIS, 48 SUSTIVA, 15 SOLODYN, 13 SUSTOL, 44 SOLOSEC, 16 SUTENT, 19 solriamfetol, 34 suvorexant, 32 somatropin, 41 SYMBICORT, 54 SOMATULINE DEPOT, 43 SYMDEKO, 54 SOMAVERT, 43 SYMFI, 14 sonidegib, 22 SYMFI LO, 14 SOOLANTRA, 58 SYMJEPI, 52 sorafenib, 19 SYMLINPEN, 35 SORILUX, 57 SYMTUZA, 14 sotalol, 23 SYNAGIS, 16 sotalol AF, 23 SYNALAR, 57 SOVALDI, 16 SYNAREL, 39 spinosad, 58 SYNDROS, 46 SPIRIVA, 52 SYNJARDY, 36 SPIRIVA RESPIMAT, 52 SYNJARDY XR, 36 spironolactone, 23 SYNRIBO, 21 spironolactone/hydrochlorothiazide, 26 SYNTHROID, 42 SPORANOX, 13 SYNVISC, 11 SPRAVATO, 29 SYNVISC-ONE, 11 SPRIX, 10 SYPRINE, 43 SPRYCEL, 18 T STALEVO, 30 TABLOID, 17 STARLIX, 36 TABRECTA, 19 stavudine, 15 TACHOSIL, 59 STELARA, 56 tacrolimus, 51, 57 STELARA SUBCUTANEOUS, 49 tacrolimus ext-rel, 51 STIMATE, 48 tadalafil 2.5 mg, 5 mg, 46 STIOLTO RESPIMAT, 53 tadalafil tabs 20 mg, 27 stiripentol, 28 tadalafil tabs 20 mg - Alyq, 27 STIVARGA, 19 tafamidis, 26 STRATTERA, 31 tafamidis meglumine, 26 STRENSIQ, 43 tafenoquine, 14 streptozocin, 17 TAFINLAR, 18 STRIANT, 35 tafluprost, 61 STRIBILD, 14 TAGRISSO, 19 STRIVERDI RESPIMAT, 53 TAKHZYRO, 50 SUBLOCADE, 34 talazoparib, 21 SUBOXONE FILM, 34 TALICIA, 46 SUBSYS, 11 taliglucerase alfa, 43 sucralfate, 46 talimogene laherparepvec, 21 sucroferric oxyhydroxide, 42 TALTZ, 49 SULAR, 25 TALZENNA, 21 sulconazole, 56 TAMIFLU, 16 sulfacetamide sodium, 55 tamoxifen, 18 sulfacetamide soln 10%, 59 tamsulosin, 46 sulfacetamide/prednisolone acetate oint 10%/0.2%, 60

TAPAZOLE, 42 testosterone undecanoate inj, 35 tapentadol, 11 tetrabenazine, 33 tapentadol ext-rel, 11 tetracycline, 13 TARGRETIN gel, 20 tezacaftor/ivacaftor + ivacaftor, 54 TARKA, 22 thalidomide, 19 TASIGNA, 19 THALOMID, 19 tasimelteon, 32 THEO-24, 55 tavaborole sol 5%, 56 theophylline ext-rel caps, 55 TAVALISSE, 48 theophylline ext-rel tabs, 55 TAYTULLA, 38 theophylline liquid, 55 tazarotene crm 0.05%, gel 0.05%, 0.1%, 56 thioguanine, 17 tazarotene crm 0.1%, 55 THIOLA, 47 tazarotene foam 0.1%, 56 THIOLA EC, 47 tazarotene lotion 0.045%, 56 thioridazine, 31 tazemetostat, 19 thiotepa, 17 TAZORAC, 55, 56 thiothixene, 31 TAZVERIK, 19 THYROGEN, 43 tbo-filgrastim, 47 thyroid, 42 TECENTRIQ, 20 thyrotropin alfa, 43 TECFIDERA, 33 tiagabine, 28 tedizolid, 16 TIAZAC, 25 teduglutide, 46 TIBSOVO, 21 TEFLARO, 12 ticagrelor, 48 tegaserod maleate, 45 TICE BCG, 20 TEGRETOL, 27 TIGAN, 44 TEGRETOL-XR, 28 tigecycline, 16 TEGSEDI, 43 TIGLUTIK, 34 TEKTURNA, 25 tildrakizumab-asmn, 50 TEKTURNA HCT, 25 timolol hemihydrate, 60 telavancin, 16 timolol maleate, 60 telbivudine, 15 timolol maleate gel, 60 telmisartan, 23 TIMOPTIC, 60 telmisartan/hydrochlorothiazide, 23 TIMOPTIC-XE, 60 telotristat, 46 tinidazole, 16 temazepam, 32 tiopronin, 47 TEMIXYS, 14 tiopronin delayed-rel, 47 TEMOVATE, 58 tiotropium, 52 temozolomide, 17 tiotropium/olodaterol, 53 temsirolimus, 18 tipranavir, 15 teniposide, 20 tirofiban inj, 48 tenofovir alafenamide, 15 TIROSINT, 42 tenofovir disoproxil fumarate tabs 300 mg, 15 TIVICAY, 14 TENORMIN, 25 TOBI, 54 TEPADINA, 17 TOBI PODHALER, 54 TEPEZZA, 61 TOBRADEX OINTMENT, 60 teprotumumab-trbw for IV soln, 61 TOBRADEX SUSPENSION, 60 terazosin, 23 tobramycin, 59 terbinafine tabs, 13 tobramycin inhalation powder, 54 terbutaline, 54 tobramycin inhalation soln, 54 terconazole crm, 46 tobramycin/dexamethasone oint 0.3%/0.1%, 60 terconazole supp 80 mg, 47 tobramycin/dexamethasone susp 0.3%/0.1%, 60 teriflunomide, 33 tobramycin/loteprednol, 60 teriparatide, 38 TOBREX, 59 tesamorelin, 43 tocilizumab, 49 TESSALON, 53 tofacitinib, 49 TESTOPEL, 35 tofacitinib ext-rel, 49 testosterone buccal, 35 TOLAK, 56 testosterone cypionate, 35 tolcapone, 30 testosterone enanthate, 35 tolterodine, 46 testosterone enanthate auto-injector, 35 tolterodine ext-rel, 46 testosterone gel, 35 tolvaptan, 43 testosterone pellets, 35 TOPAMAX, 28 testosterone soln, 35 TOPICORT, 58 testosterone transdermal, 35 topiramate, 28

topiramate ext-rel, 28 TRIJARDY XR, 37 topotecan, 19 TRIKAFTA, 54 topotecan inj, 19 TRILEPTAL, 28 TOPROL-XL, 25 TRILIPIX, 24 toremifene, 18 trimethobenzamide, 44 TORISEL, 18 trimethoprim, 16 torsemide, 26 TRINTELLIX, 29 TOTECT, 20 TRIPTODUR, 43 TOVIAZ, 46 triptorelin pamoate, 18, 43 trabectedin, 17 TRISENOX, 20 TRACLEER, 26 TRIUMEQ, 14 tramadol (except 100 mg tabs), 11 TRIVISC, 11 tramadol ext-rel, 11 TRIZIVIR, 14 tramadol/acetaminophen, 11 TRODELVY, 22 trametinib, 19 TROGARZO, 14 trandolapril, 22 TROKENDI XR, 28 trandolapril/verapamil ext-rel, 22 trospium, 46 tranexamic acid, 49 trospium ext-rel, 46 TRANSDERM SCOP, 44 TRULANCE, 46 TRANXENE T-TAB, 27 TRULICITY, 36 tranylcypromine, 29 TRUSOPT, 60 trastuzumab, 22 TRUVADA, 14 trastuzumab/hyaluronidase-oysk, 22 TRUXIMA, 21 trastuzumab-anns, 21 tucatinib, 19 trastuzumab-dkst, 21 TUKYSA, 19 trastuzumab-dttb, 21 TURALIO, 19 trastuzumab-pkrb, 21 TWIRLA, 39 trastuzumab-qyyp, 21 TWYNSTA, 23 TRAVATAN Z, 61 TYBOST, 14 travoprost, 61 TYGACIL, 16 TRAZIMERA, 21 TYKERB, 18 trazodone, 29 TYMLOS, 38 TREANDA, 17 TYSABRI, 33 TRELEGY ELLIPTA, 53 TYVASO, 27 TRELSTAR, 18 TYZEKA, 15 TRELSTAR DEPOT, 18 U TRELSTAR LA, 18 UDENYCA, 47 TREMFYA, 56 ULORIC, 10 treprostinil, 27 ULTOMIRIS, 48 treprostinil ext-rel, 27 ULTRAM, 11 TRESIBA, 36 ULTRAM ER, 11 tretinoin, 55 ULTRAVATE, 58 tretinoin gel microsphere, 55 umeclidinium/vilanterol, 53 TRETTEN, 48 UNASYN, 13 TREXIMET, 33 upadacitinib, 49 triamcinolone acetonide crm 0.5%, 58 UPNEEQ, 61 triamcinolone acetonide crm, lotion 0.025%, 57 UPTRAVI, 27 triamcinolone acetonide crm, lotion, oint 0.1%, 57 uridine triacetate, 43 triamcinolone acetonide topical spray, 58 urine test strips, 37 triamcinolone paste, 59 UROCIT-K, 47 triamterene/hydrochlorothiazide, 26 URSO, 44 triamterene/hydrochlorothiazide 37.5/25, 26 URSO FORTE, 44 triamterene/hydrochlorothiazide 50/25, 26 ursodiol, 44 triazolam, 32 ustekinumab, 49, 56 TRIBENZOR, 23 UTIBRON NEOHALER, 53 TRICOR, 24 trientine, 43 V triethanolamine polypeptide oleate, 62 VAGIFEM, 40 trifarotene cream 0.005%, 56 valacyclovir, 16 trifluoperazine, 31 valbenazine, 35 trifluridine, 60 VALCHLOR, 17 trifluridine/tipiracil, 22 VALCYTE, 15 triheptanoin, 52 valganciclovir, 15 trihexyphenidyl, 30

VALIUM, 27 vinorelbine, 20 valproic acid, 28 VIOKACE, 45 valrubicin, 20 VIRACEPT, 15 valsartan, 23 VIRAMUNE, 15 valsartan/hydrochlorothiazide, 23 VIRAMUNE XR, 15 VALSTAR, 20 VIREAD, 15 VALTOCO, 28 vismodegib, 21 VALTREX, 16 VISTARIL, 27, 53 VANCOCIN, 16 VISTIDE, 15 vancomycin caps, 16 VISUDYNE, 61 vancomycin oral soln, 16 VITAFOL-OB, 52 vandetanib, 19 VITRAKVI, 19 VANTAS, 18 VIVELLE-DOT, 40 varenicline, 34 VIVITROL, 34 varicella zoster immune globulin, 51 VIZIMPRO, 19 VARIZIG, 51 voclosporin, 51 VARUBI, 44 von Willebrand factor, recombinant, 48 VASCEPA, 24 VONVENDI, 48 VASERETIC, 22 vorapaxar, 49 VASOTEC, 22 VORAXAZE, 21 VECAMYL, 27 voriconazole, 13 VECTIBIX, 21 vorinostat, 21 VECTICAL, 57 vortioxetine, 29 vedolizumab, 44 VOSEVI, 16 velaglucerase alfa, 43 VOTRIENT, 19 VELCADE, 19 voxelotor, 49 VELETRI, 27 VPRIV, 43 VELPHORO, 42 VRAYLAR, 30 VELTASSA, 42 VUMERITY, 33 VELTIN, 55 VWF, human/factor VIII complex, 48 VEMLIDY, 15 VYEPTI, 32 vemurafenib, 19 VYNDAMAX, 26 VENCLEXTA, 21 VYNDAQEL, 26 venetoclax, 21 VYONDYS 53, 34 venlafaxine, 29 VYVANSE, 31 venlafaxine ext-rel, 29 VYZULTA, 61 venlafaxine ext-rel tabs, 29 W VENOFER, 52 WAKIX, 34 VENTAVIS, 27 warfarin, 47 verapamil, 25 WELCHOL, 24 verapamil ext-rel, 25 WELLBUTRIN SR, 29 VERDESO, 57 WELLBUTRIN XL, 29 verteporfin, 61 WILATE, 48 VERZENIO, 18 WINRHO SDF, 51 vestronidase alfa-vjbk, 43 VEXOL, 60 X VFEND, 13 XADAGO, 30 VIBATIV, 16 XALATAN, 61 VIBERZI, 45 XALKORI, 18 VIBRAMYCIN, 13 XANAX, 27 VICTOZA, 36 XANAX XR, 27 VIDAZA, 20 XARELTO, 47 vigabatrin, 28 XCOPRI, 28 vigabatrin powder - Vigadrone, 28 XELJANZ, 49 VIGAMOX, 59 XELJANZ XR, 49 VIIBRYD, 29 XELPROS, 61 vilazodone, 29 XEMBIFY, 51 VILTEPSO, 34 XENLETA, 13 viltolarsen, 34 XEOMIN, 34 VIMIZIM, 43 XERMELO, 46 VIMPAT, 28 XGEVA, 38 vinblastine, 20 XHANCE, 54 vincristine, 20 XIAFLEX, 59 vincristine sulfate liposomal, 21

XIFAXAN, 16 ZIAC, 25 XIGDUO XR, 36 ZIAGEN, 15 XIIDRA, 61 ZIAGEN soln, 15 XIMINO, 55 ZIANA, 55 XOFLUZA, 16 ziconotide, 11 XOLAIR, 54 zidovudine, 15 XOPENEX CONCENTRATE, 53 ZIEXTENZO, 47 XOPENEX SOLUTION, 53 ZILXI, 58 XOSPATA, 19 zinc acetate, 52 XPOVIO, 22 ZINPLAVA, 51 XTAMPZA ER, 11 ZIOPTAN, 61 XTANDI, 17 ziprasidone, 30 XULTOPHY, 36 ZIRABEV, 20 XURIDEN, 43 ZIRGAN, 60 XYLOCAINE, 58 ZITHROMAX, 13 XYNTHA, 48 ziv-aflibercept, 21 XYNTHA SOLOFUSE, 48 ZOFRAN, 44 XYOSTED, 35 ZOHYDRO ER, 11 XYREM, 33 ZOKINVY, 43 XYWAV, 34 ZOLADEX, 18 Y zoledronic acid 4 mg/100 mL, 38 zoledronic acid 5 mg/100 mL, 38 YASMIN, 38 ZOLINZA, 21 YAZ, 38 zolmitriptan, 32 YERVOY, 21 zolmitriptan nasal spray, 32 YONDELIS, 17 ZOLOFT, 29 YONSA, 17 zolpidem, 32 YUPELRI, 52 zolpidem ext-rel, 32 Z zolpidem spray, 32 zafirlukast, 54 ZOLPIMIST, 32 zaleplon, 32 ZOMIG, 32 ZALTRAP, 21 ZOMIG/ZOMIG-ZMT, 32 zanamivir, 16 ZONALON, 58 ZANOSAR, 17 ZONEGRAN, 28 zanubrutinib, 19 zonisamide, 28 ZARONTIN, 28 ZONTIVITY, 49 ZARXIO, 47 ZORBTIVE, 41 ZAVESCA, 43 ZORTRESS 0.25 mg, 0.5 mg, 0.75 mg, 51 ZEJULA, 21 ZORTRESS 1 mg, 51 ZELAPAR, 30 ZOSYN, 13 ZELBORAF, 19 ZOVIRAX, 16, 58 ZELNORM, 45 ZUBSOLV, 34 ZEMAIRA, 52 ZYCLARA, 59 ZEMPLAR, 41 ZYDELIG, 19 ZENZEDI, 31 ZYKADIA, 18 ZEPOSIA, 33 ZYLET, 60 ZEPZELCA, 17 ZYLOPRIM, 10 ZESTORETIC, 22 ZYPREXA RELPREVV, 31 ZESTRIL, 22 ZYPREXA/ZYPREXA ZYDIS, 30 ZETIA, 24 ZYVOX, 16