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An Introduction to Independent Health’s 2020 MediSource and Child Health Plus Formulary

The following information applies to medication is prescribed before a more Independent Health’s New York State expensive brand-name Sponsored Plans, Child Health Plus and medication. Step therapy may also ensure that two MediSource (Medicaid). Check your medications are used together if they are more summary of benefits to ensure this effective. Medications that require Step Therapy formulary is associated with your plan prior are listed with a “ST” in the formulary. to using your prescription drug benefit. Quantity Limitations This drug formulary lists covered generic and Quantity limitations may apply to certain brand-name drugs covered under our Managed medications. Some medications are covered up Medicaid Plans, MediSource and Child Health to a specific quantity per 30 days. Some Plus. Independent Health makes every attempt examples of medications with a quantity to provide you with as accurate a listing of limitation are: sumatriptan (generic Imitrex®) medications as possible. However, the list of and zolpidem tartrate (generic Ambien®). drugs and availability of generic medications can Medications with quantity limitations are listed change frequently. When a generic medication with a “QL” in the formulary. becomes available for a formulary brand-name For items that come pre-packaged (for example: medication, the generic medication will be tube/container, device, single dose units, covered, and the brand-name medication will or container), one package size is allowed become non-formulary and will require prior per fill of these items. If a quantity limit is authorization to be covered. Please discuss any designated on the formulary, this restriction will questions you may have about the formulary take precedence over the pre-packaged with your provider. limitations, when applicable. Prior-Authorization Age Restriction Independent Health requires you to get prior Some prescription medications are restricted by authorization for certain medications. To obtain age due to safety reasons or Food and Drug coverage for a medication requiring prior Administration (FDA) recommended labeling. authorization, a prior authorization request for Medications with an Age Limit are listed with an medical exception must be submitted by your “AL” in the formulary. health care provider and approved by Independent Health. Medications that require Dental Formulary Prior Authorization are listed with a “PA” in the Drugs covered on our Dental Formulary are formulary. available when prescribed by a dental provider. Drugs included in our Dental Formulary are listed Step Therapy with a “DF” on the formulary. Drugs without a “DF” In some cases, Independent Health requires you to first try certain medications to treat your will not be covered when written by a Dental medical condition before we cover another Provider. medication for that condition. Step therapy is a Limited Distribution Drugs way to help you get the best quality and value Some specialty medications can only be obtained from your prescription medication benefit. This through designated specialty pharmacies due to usually means that an equally effective generic limited distribution placed on the medication by the coverage because they are not prescription manufacturer. These medications are listed with a medication products that are approved under “LDD” on the formulary. sections 505, 505(j) or 507 of the Federal Food Drug and Cosmetic Act. Key AL – Age Limit Diabetic Supplies/Medications DF – Dental Formulary Products listed in this section are a covered benefit LDD – Limited Distribution Drugs based on your plan. Products not listed require PA – Prior Authorization Required prior authorization. Copayments vary by plan. PR – Prescriber Prevails BD needles and are our QL – Quantity Limits Apply preferred needle/ products. ST – Step Therapy XCHP – Not covered for Child Health Plus OneTouch glucose meters, lancets, test strips, and supplies are our preferred diabetic supplies and do Over-the-Counter (OTC) Medications not require prior authorization. The New York State Medicaid program approved certain medications (such as ibuprofen, OneTouch will provide a glucose meter to you acetaminophen, , etc.) to be with no copayment. Quantities are limited to one covered under this plan’s formulary. For a full list meter per member. You can obtain a meter by of covered OTC medications visit calling LifeScan, Inc. at 1-888-377-5227, offer www.emedny.org/info/formfile.aspx. A code 289IHA001. Please have your ID number prescription is required for coverage of these available when you call. OTC medications. Diabetic test strips are limited to a maximum of 100 per 30 days for non-insulin dependent / Medications diabetics. Diabetic test strips are limited to a Sedative/hypnotic medications are limited for all maximum of 300 per 30 days for insulin prescribers except sleep specialists to 14 dependent diabetics. tablets/capsules per month with a maximum of 3 fills per year (3 fills/365 days). Lost/Stolen/Damaged Medications and Vacation Supplies Compounded Prescription Replacement of any lost, stolen or damaged Medications Compounded prescriptions medications is the responsibility of the member. (medications that are not commercially Vacation supplies are not covered under this manufactured) must be prepared by a benefit. Prior authorization cannot be used to participating pharmacy and contain at least one obtain early refills for lost, stolen, or damaged prescription component. The dispensing medications; or for extended supplies or pharmacy is required to submit for prior vacation supplies. approval and when covered, will take the Pharmacy Administered applicable copayment. Compounds which cost Immunizations vaccinations are covered under $250 do not require prior authorization if when administered by licensed pharmacists who all other requirements are met. Compounds obtain additional certification to administer which cost more than $250 will require prior vaccinations to adults 19 years of age and older. authorization. Vaccines for children 18 years and younger can be Coverage is provided in accordance with our obtained through any New York Vaccines for Compounding Medication Products Policy. Bulk Children (VFC) Program. products and are excluded from

Additional Formulary Information: • Generic substitution is used only as required by • Appetite suppressants/weight-loss medications state pharmacy laws. Therapeutic interchange are excluded from coverage. is not utilized. • Medications used for cosmetic purposes • Prescriptions are generally limited to a maximum are excluded from coverage. of a 30-day supply per fill. • Medical foods other than PKU supplements • FreeStyle Libre continuous glucose monitors and (which may or may not require a prescription) sensors are also available at retail pharmacies, if are excluded from coverage. member is concurrently on insulin. • Prenatal vitamins classified as medical foods are not covered.

• Medications used for the treatment of sexual or

are not covered.

• Up to three cycles of the following drugs used to promote fertility are covered: Bromocriptine, Clomiphene Citrate, Letrozole

and . Prior authorization may be needed before we will cover these drugs for infertility. All other drugs used to promote fertility are not covered. • Growth are excluded from coverage when prescribed for the treatment of short stature.

• Medications that are excluded from coverage under state and/or federal law are not covered by Independent Health.

• In order to ensure the safest and most appropriate care, Independent Health’s drug coverage criteria is limited to medically- accepted indications based on FDA approved labeling and guidelines not otherwise excluded from New York State Medicaid. • Medications listed on the drug formulary as covered without restriction may require prior authorization or may not be covered if it is determined that they are being used in Additional Services for MediSource Members on Next conjunction with a procedure or treatment not Page covered under the member’s Health Contract. • Prescription medications not recognized by the

FDA without a National Drug Code (NDC) are excluded from coverage. REV 1020 MEDICAL SUPPLIES FOR MEDISOURCE MEMBERS ONLY (NOT APPLICABLE TO CHILD HEALTH PLUS) Covered medical supplies must have a prescription. Formulary restrictions, quantity limits, or coverage limits may apply

Adhesive Tape/Remover Ostomy Supplies Adhesive remover or (for tape, cement or Ostomy supplies; pouch, belt, clamp, filter, vent, other adhesive), per ounce; tape, non-waterproof, ring, face, plate, deodorant, barrier, misc.; per 18 square inches; tape, waterproof, per 18 adhesive remover, wipes, any type; adhesive, square inches liquid or equal, any type, per ounce; continent devices; bags; irrigation supply lubricant, Antiseptics per ounce; stoma cap or peroxide, per pint; alcohol wipes, per box (100’s); Betadine® or pHisohex® , Respiratory/Tracheostomy Care per pint Supplies Administration set, with small volume non-filtered Breast Pump pneumatic ; aerosol mark, used with Breast pump, electric (AC/DC), any type; breast DME nebulizer; canister, disposable, used with pump, manual, any type suction pump; cannula nasal face tent; cleaning Canes/Crutches/Accessories device used with tracheoesophageal voice Cane, includes canes of all materials, adjustable or prosthesis, pipet, brush or equal, replacement fixed, with tip; crutch forearm, includes crutches of only; filter, disposable and non-disposable, used various materials; crutch underarm; replacement with aerosol compressor, airway pressure device; handgrip, cane, crutch or walker; replacement tip, holding chamber or spacer for use with an inhaler cane, crutch or walker; underarm pad, crutch or nebulizer; nebulizer, disposable; oropharyngeal replacement suction catheter; peak expiratory flow rate meter, hand-held; tracheostomy care kit for new Commode Accessories tracheostomy; tracheostomy cleaning brush; Bed pan, standard/fracture metal or plastic pail or tracheostomy mask; tracheostomy supplies; pan for use with commode chair; sitz type bath or vaporizer, room type equipment; portable urinal; female jug-type, any material; male jug-type, any material Heat Application Electric heat pad, moist or standard; hot Diabetic Daily Care bottle, ice cap or collar; non-electric heating Alcohol or peroxide, per pint; alcohol wipes, per pad, moist; surgical dressing holder, reusable; box (100’s); infusion set for external insulin pump, surgical stockings, below knee length; surgical needle and non-needle type; infusion set for stockings, full length; surgical stockings, thigh external insulin pump, non-needle cannula type length; heel or elbow protector

Enteral and Parenteral Synthetic Sheep Skin and Decubitius Care Supplies that are necessary to administer the Synthetic sheepskin pad specific type of feeding and maintain the feeding site are covered. This includes, but is not limited Thermometers to syringes, measuring containers, tip adapters, Oral thermometer, reusable, any type; rectal anchoring devices, gauze pads, protective- thermometer, reusable, any type; basal dressing wipes, tape, and tube cleaning brushes. thermometer

Support Goods for lancet; supplies for self-administration; Cervical, flexible, non-adjustable foam collar; syringe with needle, sterile; syringe, sterile; slings; splint syringe, with or without needle; blood ketone test or reagent strip; test or reagent strips or Underpads/Diapers/Liners (covered tablets; normal, low and high calibrator for ages 3 and above) solution/chips; replacement battery for use with Adult disposable incontinence product, home blood glucose monitor brief/diaper; disposable incontinence product, Hearing Aids brief/diaper bariatric; adhesive, liquid or equal, Battery for use in hearing device; air battery any type, per ounce; disposable liner, shield, for cochlear guard or pad undergarment for incontinence; disposable underpads, all sizes; incontinence Mastectomy Care product, diaper/brief, reusable, any size; Breast prosthesis, mastectomy bra; breast incontinence product, protective underpad, prosthesis, mastectomy foam; breast prosthesis, reusable, chair size; stoma cap; pediatric sized silicone or equal, with integral adhesive; disposable incontinence product, brief/diaper; camisole, post-mastectomy youth sized disposable incontinence product, brief/diaper Various Miscellaneous: Automatic blood pressure monitor; incentive Incontinence Appliances and Care spirometer; nasal aspirator; plastic strips; Supplies restraints, any type (body, chest, wrist, ankle); Bedside drainage bag; extension urethral clamp misc. DMS supply or accessory not otherwise or compression device; incontinence supply, specified; sterile 6-inch wood applicator misc.; indwelling catheter, Foley type; insertion w/cotton tips; surgical supply misc.; tray with or without drainage bag; intermittent sphygmomanometer/blood pressure apparatus urinary catheter, with insertion supplies; irrigation with cuff and stethoscope, kit; syringe/cartridge syringe, bulb or piston; irrigation tray with bulb or for external drug ; sterile water, piston syringe, any purpose; male external saline and/or dextrose (diluent); sterile catheter; urinary catheter anchoring device, water/saline 500ml; supplies for maintenance of adhesive skin attachment; oral thermometer, drug infusion catheter; alginate or other fiber reusable, any type; urinary catheter anchoring dressing; collagen-based wound filler; collagen device, leg strap; urinary drainage bag; adhesive dressing, sterile; composite dressing, sterile; or non-adhesive disk or foam pad; appliance conforming bandages; contact layer, sterile; eye cleaner, incontinence and ostomy appliances; leg pad, sterile and non-sterile; eye patch, strap, foam or fabric replacement; leg strap, latex, occlusive; roam dressing, wound cover; gauze replacement only, per set; percutaneous pads, sterile and non-sterile; gauze, catheter/tube anchoring device, adhesive impregnated and non-impregnated; high compression bandage, elastic, knitted/woven; Family Planning Products hydrocolloid dressing, wound cover; Contraceptive supply, condom, female; hydrocolloid dressing, wound filler; light contraceptive supply, condom, male; diaphragm compression bandage, elastic; packing strips, kit non-impregnated; padding bandage; self- Gloves adherent bandage, elastic; specialty absorptive Gloves, sterile and non-sterile dressing, wound cover; transparent film, sterile; tubular dressing, with or without elastic; zinc Diabetic Diagnostics impregnated bandage Insulin pen, reusable; insulin syringes; lancets; needle, sterile, any-size; spring-powered device Table of Contents

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...... 3 *Aminoglycosides*...... 3 *Analgesics - Anti-Inflammatory*...... 3 *Analgesics - Nonnarcotic*...... 3 *Analgesics - Opioid*...... 3 *-Anabolic*...... 4 *Anorectal And Related Products*...... 4 *Anthelmintics*...... 4 *Antianginal Agents*...... 4 *Antianxiety Agents*...... 5 *Antiarrhythmics*...... 5 *Antiasthmatic And Bronchodilator Agents*...... 5 *Anticoagulants*...... 5 *Anticonvulsants*...... 6 *Antidepressants*...... 6 *Antidiabetics*...... 6 *Antidiarrheal/Probiotic Agents*...... 7 *Antidotes And Specific Antagonists*...... 7 *Antiemetics*...... 7 *Antifungals*...... 8 **...... 8 *Antihyperlipidemics*...... 8 *Antihypertensives*...... 8 *Anti-Infective Agents - Misc.*...... 9 *Antimalarials*...... 9 *Antimyasthenic/Cholinergic Agents*...... 9 *Antimycobacterial Agents*...... 9 *Antineoplastics And Adjunctive Therapies*...... 9 *Antiparkinson And Related Therapy Agents*...... 10 *Antipsychotics/Antimanic Agents*...... 10 *Antiseptics & Disinfectants*...... 10 *Antivirals*...... 11 *Beta Blockers*...... 12 * Channel Blockers*...... 12 *Cardiotonics*...... 12 *Cardiovascular Agents - Misc.*...... 12 *Cephalosporins*...... 12 *Contraceptives*...... 12 *Corticosteroids*...... 14 *Cough/Cold/*...... 14 *Dermatologicals*...... 14 *Digestive Aids*...... 16 *Diuretics*...... 16 *Endocrine And Metabolic Agents - Misc.*...... 16 **...... 17 *Fluoroquinolones*...... 17 *Gastrointestinal Agents - Misc.*...... 17 *Genitourinary Agents - Miscellaneous*...... 17 *Gout Agents*...... 17 *Hematological Agents - Misc.*...... 17 *Hematopoietic Agents*...... 17

1 *Hemostatics*...... 18 *//Sleep Disorder Agents*...... 18 *Laxatives*...... 18 *Local Anesthetics-Parenteral*...... 18 *Macrolides*...... 18 *Medical Devices And Supplies*...... 18 *Migraine Products*...... 18 *Minerals & Electrolytes*...... 18 *Miscellaneous Therapeutic Classes*...... 19 *Mouth/Throat/Dental Agents*...... 19 *Multivitamins*...... 19 *Musculoskeletal Therapy Agents*...... 19 *Nasal Agents - Systemic And Topical*...... 19 *Neuromuscular Agents*...... 19 *Ophthalmic Agents*...... 19 *Otic Agents*...... 20 *Oxytocics*...... 20 *Passive Immunizing And Treatment Agents*...... 20 **...... 20 *Pharmaceutical Adjuvants*...... 21 *Progestins*...... 21 *Psychotherapeutic And Neurological Agents - Misc.*...... 21 *Respiratory Agents - Misc.*...... 21 *Sulfonamides*...... 21 *Tetracyclines*...... 21 *Thyroid Agents*...... 21 *Ulcer Drugs/Antispasmodics/Anticholinergics*...... 21 *Urinary Antispasmodics*...... 22 *Vaginal And Related Products*...... 22 *Vasopressors*...... 22 *Vitamins*...... 22

2 Drug Tier Notes Drug Tier Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* HUMIRA PEN SUBCUTANEOUS 2 PA; PR amphetamine-dextroamphet er 1 AL PEN-INJECTOR KIT oral extended release 24 HUMIRA PEN-CD/UC/HS STARTER 2 PA; PR hour SUBCUTANEOUS PEN-INJECTOR amphetamine-dextroamphetamine 1 QL; AL KIT oral 10 mg, 15 mg HUMIRA PEN-PS/UV/ADOL HS 2 PA; PR amphetamine-dextroamphetamine 1 AL START SUBCUTANEOUS PEN- oral tablet 12.5 mg, 20 mg, 30 mg, INJECTOR KIT 40 MG/0.8ML 5 mg, 7.5 mg HUMIRA SUBCUTANEOUS 2 PA; PR armodafinil oral tablet 1 PA PREFILLED SYRINGE KIT atomoxetine hcl oral capsule 1 AL ibuprofen oral 1 dexmethylphenidate hcl oral tablet 1 AL ibuprofen oral tablet 400 mg, 600 1 dextroamphetamine sulfate er oral 1 AL mg, 800 mg capsule extended release 24 hour indomethacin er oral capsule 1 AL dextroamphetamine sulfate oral 1 AL extended release tablet indomethacin oral capsule 25 mg, 1 AL guanfacine hcl er oral tablet 1 50 mg extended release 24 hour ketoprofen er oral capsule 1 methylphenidate hcl er (cd) oral 1 AL extended release 24 hour capsule extended release ketorolac tromethamine oral tablet 1 PA; QL; AL methylphenidate hcl er (la) oral 1 AL leflunomide oral tablet 1 PA capsule extended release 24 hour meloxicam oral tablet 1 methylphenidate hcl er oral tablet 1 AL nabumetone oral tablet 1 extended release naproxen dr oral tablet delayed 1 methylphenidate hcl oral solution 1 AL release methylphenidate hcl oral tablet 10 1 AL naproxen oral tablet 1 mg, 20 mg piroxicam oral capsule 1 methylphenidate hcl oral tablet 5 1 QL; AL RIDAURA ORAL CAPSULE 2 mg sulindac oral tablet 1 modafinil oral tablet 1 PA; AL *Analgesics - Nonnarcotic* *Aminoglycosides* butalbital-acetaminophen oral 1 AL neomycin sulfate oral tablet 1 tablet 50-325 mg paromomycin sulfate oral capsule 1 butalbital-apap-caffeine oral tablet 1 AL TOBI PODHALER 2 PA; QL 50-325-40 mg CAPSULE diflunisal oral tablet 1 tobramycin inhalation nebulization 1 PA; QL salsalate oral tablet 1 solution 300 mg/5ml *Analgesics - Opioid* *Analgesics - Anti-Inflammatory* acetaminophen- #2 oral 1 AL ARCALYST SUBCUTANEOUS 2 PA; PR tablet SOLUTION RECONSTITUTED acetaminophen-codeine #3 oral 1 AL celecoxib oral capsule 1 tablet diclofenac potassium oral tablet 1 acetaminophen-codeine #4 oral 1 AL diclofenac sodium er oral tablet 1 tablet extended release 24 hour acetaminophen-codeine oral 1 diclofenac sodium oral tablet 1 solution delayed release buprenorphine hcl-naloxone hcl 1 SUD ENBREL SUBCUTANEOUS 2 PA sublingual tablet sublingual SOLUTION 25 MG/0.5ML buprenorphine patch 1 ENBREL SUBCUTANEOUS 2 PA; PR weekly SOLUTION PREFILLED SYRINGE butalbital-apap-caff-cod oral 1 AL ENBREL SURECLICK 2 PA; PR capsule 50-325-40-30 mg SUBCUTANEOUS SOLUTION AUTO- butorphanol tartrate nasal solution 1 PA INJECTOR codeine sulfate oral tablet 30 mg, 1 etodolac oral capsule 1 60 mg etodolac oral tablet 1 fentanyl citrate buccal lozenge on a 1 PA flurbiprofen oral tablet 1 handle HUMIRA PEDIATRIC CROHNS 2 PA; PR fentanyl 72 hour 1 ST START SUBCUTANEOUS PREFILLED 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, SYRINGE KIT 80 MG/0.8ML, 80 50 mcg/hr, 75 mcg/hr MG/0.8ML & 40MG/0.4ML

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3 Drug Tier Notes Drug Tier Notes

hydrocodone-acetaminophen oral 1 pentazocine-naloxone hcl oral 1 AL solution 7.5-325 mg/15ml tablet hydrocodone-acetaminophen oral 1 SUBOXONE SUBLINGUAL FILM 2 SUD tablet 10-325 mg, 5-325 mg, 7.5- tramadol hcl er (biphasic) oral 1 ST 325 mg tablet extended release 24 hour hydrocodone-ibuprofen oral tablet 1 100 mg, 200 mg, 300 mg 7.5-200 mg tramadol hcl er oral tablet 1 hydromorphone hcl oral liquid 1 extended release 24 hour hydromorphone hcl oral tablet 1 tramadol hcl oral tablet 50 mg 1 hydromorphone hcl rectal 1 tramadol-acetaminophen oral 1 PA; PA except tablet Medicine HYSINGLA ER ORAL TABLET ER 24 2 *Androgens-Anabolic* HOUR ABUSE-DETERRENT oral capsule 1 methadone hcl oral concentrate 1 methitest oral tablet 2 PA methadone hcl oral solution 1 oral tablet 1 methadone hcl oral tablet 1 cypionate 1 PA methadone hcl oral tablet soluble 1 solution 200 mg/ml morphine sulfate er oral capsule 1 1 PA extended release 24 hour 10 mg, intramuscular solution 100 mg/ml, 20 mg, 30 mg, 50 mg, 60 mg 200 mg/ml morphine sulfate er oral capsule 1 ST 1 PA extended release 24 hour 100 mg, intramuscular solution 80 mg testosterone transdermal gel 12.5 1 PA; PR morphine sulfate er oral tablet 1 ST mg/act (1%), 25 mg/2.5gm (1%), 50 extended release 100 mg, 200 mg mg/5gm (1%) morphine sulfate er oral tablet 1 extended release 15 mg, 30 mg, 60 *Anorectal And Related Products* mg hydrocortisone acetate rectal 1 morphine sulfate oral solution 1 suppository 25 mg morphine sulfate oral tablet 1 hydrocortisone rectal enema 1 morphine sulfate rectal 1 lidocaine-hydrocortisone ace rectal 1 suppository gel NUCYNTA ER ORAL TABLET 2 ST lidocaine-hydrocortisone ace rectal 1 EXTENDED RELEASE 12 HOUR 100 kit 3-0.5 %, 3-1 %, 3-2.5 % MG, 150 MG, 200 MG, 250 MG *Anthelmintics* NUCYNTA ER ORAL TABLET 2 albendazole oral tablet 1 PA; PA except EXTENDED RELEASE 12 HOUR 50 Gastroenterology or MG Infectious Disease NUCYNTA ORAL TABLET 2 benznidazole oral tablet 2 PA; LDD oxycodone hcl er oral tablet er 12 1 EMVERM ORAL TABLET 2 hour abuse-deterrent 10 mg, 15 CHEWABLE mg, 20 mg, 30 mg, 40 mg ivermectin oral tablet 1 oxycodone hcl er oral tablet er 12 1 ST *Antianginal Agents* hour abuse-deterrent 80 mg ISORDIL TITRADOSE ORAL TABLET 2 oxycodone hcl oral tablet 1 40 MG oxycodone-acetaminophen oral 1 isosorbide dinitrate oral tablet 10 1 tablet 10-325 mg, 2.5-325 mg, 5- mg, 20 mg, 30 mg, 5 mg 325 mg, 7.5-325 mg isosorbide mononitrate er oral 1 oxycodone-aspirin oral tablet 1 tablet extended release 24 hour 4.8355-325 mg isosorbide mononitrate oral tablet 1 OXYCONTIN ORAL TABLET ER 12 2 NITRO-BID TRANSDERMAL 2 HOUR ABUSE-DETERRENT 10 MG, OINTMENT 15 MG, 20 MG, 30 MG, 40 MG nitroglycerin er oral capsule 1 OXYCONTIN ORAL TABLET ER 12 2 ST extended release HOUR ABUSE-DETERRENT 60 MG, nitroglycerin sublingual tablet 1 80 MG sublingual oxymorphone hcl er oral tablet 1 ST nitroglycerin transdermal patch 24 1 extended release 12 hour 10 mg, hour 15 mg, 20 mg, 30 mg, 40 mg, 7.5 mg oxymorphone hcl oral tablet 1 PA

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4 Drug Tier Notes Drug Tier Notes

*Antianxiety Agents* cromolyn sodium inhalation 1 QL alprazolam er oral tablet extended 1 nebulization solution release 24 hour FASENRA PEN SUBCUTANEOUS 2 PA ALPRAZOLAM INTENSOL ORAL 2 SOLUTION AUTO-INJECTOR CONCENTRATE FLOVENT DISKUS INHALATION 2 alprazolam oral tablet 1 AEROSOL BREATH alprazolam oral tablet dispersible 1 PA ACTIVATED alprazolam xr oral tablet extended 1 FLOVENT HFA INHALATION 2 release 24 hour AEROSOL buspirone hcl oral tablet 1 fluticasone-salmeterol inhalation 1 chlordiazepoxide hcl oral capsule 1 AL aerosol powder breath activated clorazepate dipotassium oral tablet 1 ipratropium bromide inhalation 1 DIAZEPAM INTENSOL ORAL 2 PR solution CONCENTRATE ipratropium-albuterol inhalation 1 diazepam oral tablet 1 PR solution hydroxyzine hcl oral 1 AL montelukast sodium oral packet 1 AL hydroxyzine hcl oral tablet 1 AL montelukast sodium oral tablet 1 AL hydroxyzine pamoate oral capsule 1 AL montelukast sodium oral tablet 1 AL lorazepam oral concentrate 2 1 chewable 4 mg, 5 mg mg/ml NUCALA SUBCUTANEOUS 2 PA lorazepam oral tablet 1 SOLUTION AUTO-INJECTOR oxazepam oral capsule 1 NUCALA SUBCUTANEOUS 2 PA SOLUTION PREFILLED SYRINGE *Antiarrhythmics* QVAR REDIHALER INHALATION 2 amiodarone hcl oral tablet 200 mg, 1 AEROSOL BREATH ACTIVATED 400 mg SEREVENT DISKUS INHALATION 2 ST disopyramide phosphate oral 1 AL AEROSOL POWDER BREATH capsule ACTIVATED dofetilide oral capsule 1 SPIRIVA HANDIHALER 2 AL flecainide acetate oral tablet 1 INHALATION CAPSULE mexiletine hcl oral capsule 1 SPIRIVA INHALATION 2 AL NORPACE CR ORAL CAPSULE 2 AL AEROSOL SOLUTION 1.25 EXTENDED RELEASE 12 HOUR MCG/ACT, 2.5 MCG/ACT pacerone oral tablet 100 mg, 200 1 STIOLTO RESPIMAT INHALATION 2 AL mg AEROSOL SOLUTION 2.5-2.5 propafenone hcl er oral capsule 1 MCG/ACT extended release 12 hour STRIVERDI RESPIMAT INHALATION 2 AL propafenone hcl oral tablet 1 AEROSOL SOLUTION quinidine gluconate er oral tablet 1 terbutaline sulfate oral tablet 1 extended release theophylline er oral tablet 1 quinidine sulfate oral tablet 1 extended release 12 hour 300 mg, *Antiasthmatic And Bronchodilator Agents* 450 mg albuterol sulfate er oral tablet 1 theophylline er oral tablet 1 extended release 12 hour extended release 24 hour albuterol sulfate hfa inhalation 1 theophylline oral solution 1 aerosol solution 108 (90 base) WIXELA INHUB INHALATION 1 mcg/act AEROSOL POWDER BREATH albuterol sulfate inhalation 1 ACTIVATED nebulization solution (2.5 mg/3ml) *Anticoagulants* 0.083%, (5 mg/ml) 0.5%, 0.63 ELIQUIS DVT/PE STARTER PACK 2 mg/3ml, 1.25 mg/3ml ORAL TABLET THERAPY PACK albuterol sulfate oral syrup 1 ELIQUIS ORAL TABLET 2 PR albuterol sulfate oral tablet 1 enoxaparin sodium injection 1 PR ANORO ELLIPTA INHALATION 2 solution AEROSOL POWDER BREATH enoxaparin sodium subcutaneous 1 PR ACTIVATED solution ATROVENT HFA INHALATION 2 fondaparinux sodium 1 PA; PR; QL AEROSOL SOLUTION subcutaneous solution budesonide inhalation suspension 1 QL; AL COMBIVENT RESPIMAT 2 INHALATION AEROSOL SOLUTION

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5 Drug Tier Notes Drug Tier Notes

FRAGMIN SUBCUTANEOUS 2 PA; PR; QL tiagabine hcl oral tablet 1 PR SOLUTION 10000 UNIT/ML, 12500 topiramate oral capsule sprinkle 1 PR UNIT/0.5ML, 15000 UNIT/0.6ML, topiramate oral tablet 1 PR 18000 UNT/0.72ML, 2500 valproic acid oral capsule 1 UNIT/0.2ML, 5000 UNIT/0.2ML, valproic acid oral solution 1 7500 UNIT/0.3ML, 95000 vigabatrin oral packet 1 PA; LDD; PR UNIT/3.8ML vigabatrin oral tablet 1 PA; LDD; PR JANTOVEN ORAL TABLET 1 PR VIMPAT ORAL SOLUTION 2 PR; AL PRADAXA ORAL CAPSULE 2 PR VIMPAT ORAL TABLET 2 PR; AL warfarin sodium oral tablet 1 PR zonisamide oral capsule 1 PR XARELTO ORAL TABLET 2 PR *Antidepressants* XARELTO STARTER PACK ORAL 2 PR amitriptyline hcl oral tablet 1 AL TABLET THERAPY PACK amoxapine oral tablet 1 *Anticonvulsants* bupropion hcl er (sr) oral tablet 1 BANZEL ORAL TABLET 2 PR extended release 12 hour carbamazepine er oral capsule 1 PR bupropion hcl er (xl) oral tablet 1 extended release 12 hour extended release 24 hour 150 mg, carbamazepine er oral tablet 1 PR 300 mg extended release 12 hour 200 mg, bupropion hcl oral tablet 1 400 mg citalopram hydrobromide oral 1 PR carbamazepine oral suspension 1 PR solution carbamazepine oral tablet 1 PR citalopram hydrobromide oral 1 PR carbamazepine oral tablet 1 PR tablet chewable clomipramine hcl oral capsule 1 AL CELONTIN ORAL CAPSULE 2 desipramine hcl oral tablet 1 clobazam oral suspension 1 PA; AL doxepin hcl oral capsule 1 AL clobazam oral tablet 1 PA; AL doxepin hcl oral concentrate 1 AL clonazepam oral tablet 1 duloxetine hcl oral capsule delayed 1 PR clonazepam oral tablet dispersible 1 PA release particles DILANTIN ORAL CAPSULE 30 MG 2 escitalopram oxalate oral solution 1 PR divalproex sodium er oral tablet 1 escitalopram oxalate oral tablet 1 PR extended release 24 hour fluoxetine hcl oral capsule 1 PR divalproex sodium oral tablet 1 fluoxetine hcl oral capsule delayed 1 PR delayed release release ethosuximide oral capsule 1 fluoxetine hcl oral solution 1 PR ethosuximide oral solution 1 fluvoxamine maleate oral tablet 1 PR felbamate oral suspension 1 PR imipramine hcl oral tablet 1 AL felbamate oral tablet 1 PR maprotiline hcl oral tablet 1 PA; PA Except gabapentin oral capsule 1 PR Psychiatry gabapentin oral solution 250 1 PR mirtazapine oral tablet 1 mg/5ml mirtazapine oral tablet dispersible 1 gabapentin oral tablet 1 PR nortriptyline hcl oral capsule 1 AL lamotrigine oral tablet 1 PR nortriptyline hcl oral solution 1 AL lamotrigine oral tablet chewable 1 PR paroxetine hcl er oral tablet 1 ST; PR levetiracetam er oral tablet 1 PR extended release 24 hour extended release 24 hour paroxetine hcl oral tablet 1 PR levetiracetam oral solution 1 PR PAXIL ORAL SUSPENSION 2 PR levetiracetam oral tablet 1 PR phenelzine sulfate oral tablet 1 oxcarbazepine oral tablet 1 PR protriptyline hcl oral tablet 1 infatabs oral tablet 1 sertraline hcl oral concentrate 1 PR chewable sertraline hcl oral tablet 1 PR phenytoin oral suspension 125 1 tranylcypromine sulfate oral tablet 1 mg/5ml trazodone hcl oral tablet 1 phenytoin oral tablet chewable 1 trimipramine maleate oral capsule 1 AL phenytoin sodium extended oral 1 venlafaxine hcl er oral capsule 1 PR capsule extended release 24 hour pregabalin oral capsule 1 venlafaxine hcl oral tablet 1 PR pregabalin oral solution 1 *Antidiabetics* primidone oral tablet 1 acarbose oral tablet 1 PR rufinamide oral suspension 1 AL

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6 Drug Tier Notes Drug Tier Notes

ADMELOG SOLOSTAR 2 repaglinide oral tablet 1 PR SUBCUTANEOUS SOLUTION PEN- RIOMET ORAL SOLUTION 2 PR INJECTOR RYBELSUS ORAL TABLET 2 ST; ST except ADMELOG SUBCUTANEOUS 2 endocrinology SOLUTION SEGLUROMET ORAL TABLET 2 BAQSIMI ONE PACK NASAL 1 STEGLATRO ORAL TABLET 2 PR POWDER SYMLINPEN 120 SUBCUTANEOUS 2 PA; PA except BAQSIMI TWO PACK NASAL 1 SOLUTION PEN-INJECTOR Endocrinology POWDER SYMLINPEN 60 SUBCUTANEOUS 2 PA; PA except BASAGLAR KWIKPEN 2 PR SOLUTION PEN-INJECTOR Endocrinology SUBCUTANEOUS SOLUTION PEN- tolbutamide oral tablet 2 PR INJECTOR TRADJENTA ORAL TABLET 2 PR glimepiride oral tablet 1 PR TRULICITY SUBCUTANEOUS 2 ST; PR; Step except glipizide er oral tablet extended 1 SOLUTION PEN-INJECTOR 0.75 Endocrine release 24 hour MG/0.5ML, 1.5 MG/0.5ML glipizide oral tablet 1 VICTOZA SUBCUTANEOUS 2 ST; PR; Step except glipizide-metformin hcl oral tablet 1 SOLUTION PEN-INJECTOR Endocrine glucagon emergency injection kit 1 *Antidiarrheal/Probiotic Agents* glyburide micronized oral tablet 1 AL diphenoxylate-atropine oral liquid 1 glyburide oral tablet 1 AL diphenoxylate-atropine oral tablet 1 glyburide-metformin oral tablet 1 AL loperamide hcl oral capsule 1 GVOKE HYPOPEN 1-PACK 1 opium oral 1 SUBCUTANEOUS SOLUTION AUTO- INJECTOR *Antidotes And Specific Antagonists* GVOKE HYPOPEN 2-PACK 1 deferasirox granules oral packet 1 PA; AL SUBCUTANEOUS SOLUTION AUTO- deferasirox oral tablet 1 PA; AL INJECTOR naloxone hcl injection solution 0.4 1 SUD GVOKE PFS SUBCUTANEOUS 1 mg/ml SOLUTION PREFILLED SYRINGE naloxone hcl injection solution 1 SUD HUMALOG MIX 50/50 KWIKPEN 2 PR cartridge SUBCUTANEOUS SUSPENSION naloxone hcl injection solution 1 SUD PEN-INJECTOR prefilled syringe HUMALOG MIX 50/50 2 PR naltrexone hcl oral tablet 1 SUBCUTANEOUS SUSPENSION NARCAN NASAL LIQUID 2 SUD HUMALOG MIX 75/25 KWIKPEN 2 PR VISTOGARD ORAL PACKET 2 LDD SUBCUTANEOUS SUSPENSION VIVITROL INTRAMUSCULAR 2 QL PEN-INJECTOR SUSPENSION RECONSTITUTED HUMALOG MIX 75/25 2 PR *Antiemetics* SUBCUTANEOUS SUSPENSION aprepitant oral capsule 125 mg, 80 1 ST; ST applies except HUMALOG SUBCUTANEOUS 2 PR & 125 mg, 80 mg hematology/oncolog SOLUTION CARTRIDGE y; QL HUMULIN R U-500 2 PR aprepitant oral capsule 40 mg 1 QL (CONCENTRATED) BONJESTA ORAL TABLET 2 QL SUBCUTANEOUS SOLUTION EXTENDED RELEASE JENTADUETO ORAL TABLET 2 PR doxylamine-pyridoxine oral tablet 1 QL KORLYM ORAL TABLET 2 PA; LDD delayed release metformin hcl er oral tablet 1 PR dronabinol oral capsule 1 PA extended release 24 hour EMEND ORAL SUSPENSION 2 ST; ST applies except metformin hcl oral tablet 1 PR RECONSTITUTED hematology/oncolog nateglinide oral tablet 1 PR y; QL; AL OZEMPIC (0.25 OR 0.5 MG/DOSE) 2 ST; Step except granisetron hcl oral tablet 1 ST; QL SUBCUTANEOUS SOLUTION PEN- Endocrine meclizine hcl oral tablet 12.5 mg, 1 INJECTOR 25 mg OZEMPIC (1 MG/DOSE) 2 ST; Step except ondansetron hcl oral solution 1 SUBCUTANEOUS SOLUTION PEN- Endocrine ondansetron hcl oral tablet 1 INJECTOR ondansetron oral tablet dispersible 1 pioglitazone hcl oral tablet 1 PR trimethobenzamide hcl oral 1 AL pioglitazone hcl-glimepiride oral 1 PR capsule tablet pioglitazone hcl-metformin hcl oral 1 PR tablet

12.01.2020

7 Drug Tier Notes Drug Tier Notes

*Antifungals* gemfibrozil oral tablet 1 fluconazole oral suspension 1 icosapent ethyl oral capsule 1 reconstituted lovastatin oral tablet 1 fluconazole oral tablet 100 mg, 200 1 pravastatin sodium oral tablet 1 mg, 50 mg rosuvastatin calcium oral tablet 1 fluconazole oral tablet 150 mg 1 QL simvastatin oral tablet 10 mg, 20 1 griseofulvin ultramicrosize oral 1 mg, 40 mg, 5 mg tablet simvastatin oral tablet 80 mg 1 PA itraconazole oral capsule 1 PA; PA except *Antihypertensives* ID/Hematology or aliskiren fumarate oral tablet 1 ST Oncology amlodipine besy-benazepril hcl oral 1 itraconazole oral solution 1 PA; PA except capsule ID/Hematology or atenolol-chlorthalidone oral tablet 1 Oncology benazepril hcl oral tablet 1 oral tablet 1 PA benazepril-hydrochlorothiazide 1 NOXAFIL ORAL SUSPENSION 2 PA oral tablet nystatin oral tablet 1 bisoprolol-hydrochlorothiazide oral 1 posaconazole oral tablet delayed 1 PA tablet release candesartan cilexetil oral tablet 1 terbinafine hcl oral tablet 1 candesartan cilexetil-hctz oral 1 voriconazole oral suspension 1 PA; PA except tablet reconstituted Infectious Disease; captopril-hydrochlorothiazide oral 1 AL tablet voriconazole oral tablet 1 PA; PA except clonidine hcl oral tablet 1 infectious disease; AL clonidine transdermal patch 1 *Antihistamines* weekly carbinoxamine maleate oral tablet 1 AL doxazosin mesylate oral tablet 1 4 mg enalapril maleate oral tablet 1 cetirizine hcl oral solution 1 enalaprilat intravenous injectable 1 hcl oral syrup 1 AL enalapril-hydrochlorothiazide oral 1 cyproheptadine hcl oral tablet 1 AL tablet diphenhydramine hcl oral capsule 1 AL eplerenone oral tablet 1 PA 50 mg fosinopril sodium oral tablet 1 levocetirizine dihydrochloride oral 1 fosinopril sodium-hctz oral tablet 1 solution guanfacine hcl oral tablet 1 AL levocetirizine dihydrochloride oral 1 hydralazine hcl oral tablet 1 tablet irbesartan oral tablet 1 promethazine hcl oral tablet 1 AL irbesartan-hydrochlorothiazide 1 oral tablet *Antihyperlipidemics* lisinopril oral tablet 1 atorvastatin calcium oral tablet 1 lisinopril-hydrochlorothiazide oral 1 cholestyramine light oral packet 1 tablet cholestyramine light oral powder 1 losartan potassium oral tablet 1 cholestyramine oral packet 1 losartan potassium-hctz oral tablet 1 cholestyramine oral powder 1 methyldopa oral tablet 1 AL colesevelam hcl oral packet 1 methyldopa-hydrochlorothiazide 1 AL colesevelam hcl oral tablet 1 oral tablet colestipol hcl oral granules 1 AL metoprolol-hydrochlorothiazide 1 colestipol hcl oral packet 1 AL oral tablet colestipol hcl oral tablet 1 AL minoxidil oral tablet 1 ezetimibe oral tablet 1 moexipril hcl oral tablet 1 fenofibrate micronized oral capsule 1 olmesartan medoxomil oral tablet 1 134 mg olmesartan medoxomil-hctz oral 1 fenofibrate oral capsule 134 mg, 67 1 tablet mg perindopril erbumine oral tablet 1 fenofibrate oral tablet 145 mg, 160 1 phenoxybenzamine hcl oral 1 PA mg, 48 mg, 54 mg capsule fenofibric acid oral capsule delayed 1 prazosin hcl oral capsule 1 release 45 mg propranolol-hctz oral tablet 1 fluvastatin sodium oral capsule 40 1 quinapril hcl oral tablet 1 mg

12.01.2020

8 Drug Tier Notes Drug Tier Notes

quinapril-hydrochlorothiazide oral 1 pyrimethamine oral tablet 1 PA; LDD; PA except tablet Infectious Disease ramipril oral capsule 1 quinine sulfate oral capsule 1 PA; AL TEKTURNA HCT ORAL TABLET 2 ST *Antimyasthenic/Cholinergic Agents* telmisartan oral tablet 1 guanidine hcl oral tablet 1 telmisartan-hctz oral tablet 1 pyridostigmine bromide er oral 1 terazosin hcl oral capsule 1 tablet extended release trandolapril oral tablet 1 pyridostigmine bromide oral tablet 1 valsartan oral tablet 1 60 mg valsartan-hydrochlorothiazide oral 1 tablet *Antimycobacterial Agents* ethambutol hcl oral tablet 1 *Anti-Infective Agents - Misc.* isoniazid oral syrup 1 ALINIA ORAL SUSPENSION 2 PA; PA except isoniazid oral tablet 1 RECONSTITUTED Gastroenterology or pretomanid oral tablet 2 PA Infectious Disease pyrazinamide oral tablet 1 ALINIA ORAL TABLET 2 PA; PA except rifabutin oral capsule 1 PA Gastroenterology or rifampin oral capsule 1 Infectious Disease atovaquone oral suspension 1 *Antineoplastics And Adjunctive Therapies* CAYSTON INHALATION SOLUTION 2 PA; LDD; PA except oral tablet 1 PA; LDD RECONSTITUTED Cystic Fibrosis AFINITOR ORAL TABLET 10 MG 2 PA Specialist; AL anastrozole oral tablet 1 PA clindamycin hcl oral capsule 1 except for infectious oral tablet 1 disease specialist; QL BRAFTOVI ORAL CAPSULE 75 MG 2 PA; LDD clindamycin palmitate hcl oral 1 capecitabine oral tablet 1 solution reconstituted CAPRELSA ORAL TABLET 2 PA; LDD dapsone oral tablet 1 cyclophosphamide oral capsule 1 LAMPIT ORAL TABLET 2 PA EMCYT ORAL CAPSULE 2 linezolid oral suspension 1 ERLEADA ORAL TABLET 2 PA; LDD reconstituted erlotinib hcl oral tablet 1 PA; LDD linezolid oral tablet 1 etoposide oral capsule 1 methenamine mandelate oral 1 everolimus oral tablet 2.5 mg, 5 1 PA tablet mg, 7.5 mg metronidazole oral tablet 1 oral tablet 1 nitrofurantoin macrocrystal oral 1 AL FIRMAGON SUBCUTANEOUS 2 PA capsule SOLUTION RECONSTITUTED 80 MG nitrofurantoin monohyd macro 1 AL oral capsule 1 oral capsule HYCAMTIN ORAL CAPSULE 2 PA nitrofurantoin oral suspension 1 AL hydroxyurea oral capsule 1 pentamidine isethionate inhalation 1 PA; PA except imatinib mesylate oral tablet 1 PA solution reconstituted Infectious Disease JAKAFI ORAL TABLET 2 PA; LDD sulfamethoxazole-trimethoprim 1 lapatinib ditosylate oral tablet 1 PA oral suspension 200-40 mg/5ml letrozole oral tablet 1 sulfamethoxazole-trimethoprim 1 leucovorin calcium oral tablet 1 oral tablet LEUKERAN ORAL TABLET 2 tinidazole oral tablet 1 LYSODREN ORAL TABLET 2 LDD trimethoprim oral tablet 1 MATULANE ORAL CAPSULE 2 LDD vancomycin hcl oral capsule 1 PA; PA except oral suspension 1 Gastroenterology or 40 mg/ml, 400 mg/10ml Infectious Disease megestrol acetate oral tablet 1 MEKTOVI ORAL TABLET 2 PA; LDD *Antimalarials* melphalan oral tablet 1 atovaquone-proguanil hcl oral 1 mercaptopurine oral tablet 1 tablet MESNEX ORAL TABLET 2 PA; PA except chloroquine phosphate oral tablet 1 Oncology COARTEM ORAL TABLET 2 QL methotrexate oral tablet 1 hydroxychloroquine sulfate oral 1 methotrexate sodium (pf) injection 1 PA; PA except tablet solution 50 mg/2ml rheumatology, mefloquine hcl oral tablet 1 dermatology and primaquine phosphate oral tablet 1 gastroenterology

12.01.2020

9 Drug Tier Notes Drug Tier Notes

methotrexate sodium injection 1 PA; PA except ABILIFY MAINTENA 2 PA; PR solution 50 mg/2ml rheumatology, INTRAMUSCULAR SUSPENSION dermatology and RECONSTITUTED ER gastroenterology aripiprazole oral solution 1 PR MYLERAN ORAL TABLET 2 aripiprazole oral tablet 1 nilutamide oral tablet 1 PA; PA except ARISTADA INITIO 2 PA urology or oncology INTRAMUSCULAR PREFILLED specialist SYRINGE SPRYCEL ORAL TABLET 2 PA ARISTADA INTRAMUSCULAR 2 PA; PR SUTENT ORAL CAPSULE 12.5 MG, 2 PA PREFILLED SYRINGE 25 MG, 50 MG hcl oral tablet 1 SUTENT ORAL CAPSULE 37.5 MG 2 PA; LDD clozapine oral tablet 1 PR; QL; AL TABLOID ORAL TABLET 2 fluphenazine decanoate injection 1 PR tamoxifen citrate oral tablet 1 solution TASIGNA ORAL CAPSULE 2 PA fluphenazine hcl injection solution 1 PR temozolomide oral capsule 1 LDD fluphenazine hcl oral tablet 1 PR toremifene citrate oral tablet 1 GEODON INTRAMUSCULAR 2 PA; PR tretinoin oral capsule 1 SOLUTION RECONSTITUTED TREXALL ORAL TABLET 2 decanoate 1 PR ZOLINZA ORAL CAPSULE 2 PA intramuscular solution 100 mg/ml, *Antiparkinson And Related Therapy Agents* 50 mg/ml amantadine hcl oral capsule 1 haloperidol lactate oral 1 PR amantadine hcl oral syrup 1 concentrate amantadine hcl oral tablet 1 haloperidol oral tablet 1 PR benztropine mesylate oral tablet 1 AL lithium carbonate er oral tablet 1 bromocriptine mesylate oral 1 extended release capsule lithium carbonate oral capsule 1 bromocriptine mesylate oral tablet 1 lithium carbonate oral tablet 1 carbidopa-levodopa er oral tablet 1 lithium oral solution 1 extended release 25-100 mg, 50- loxapine succinate oral capsule 1 200 mg olanzapine intramuscular solution 2 PR carbidopa-levodopa oral tablet 1 reconstituted carbidopa-levodopa oral tablet 1 PA; ST olanzapine oral tablet 10 mg, 15 2 PR dispersible mg, 2.5 mg, 20 mg, 5 mg carbidopa-levodopa-entacapone 1 olanzapine oral tablet 7.5 mg 1 PR oral tablet olanzapine oral tablet dispersible 1 PA; PR entacapone oral tablet 1 ST perphenazine oral tablet 1 pramipexole dihydrochloride oral 1 PERSERIS SUBCUTANEOUS 2 PA; PR tablet PREFILLED SYRINGE rasagiline mesylate oral tablet 1 PA; PA except prochlorperazine maleate oral 1 Neurology tablet ropinirole hcl er oral tablet 1 PA; PA except prochlorperazine rectal 1 extended release 24 hour neurology suppository ropinirole hcl oral tablet 1 quetiapine fumarate er oral tablet 1 PR selegiline hcl oral capsule 1 extended release 24 hour selegiline hcl oral tablet 1 quetiapine fumarate oral tablet 1 PR STALEVO 100 ORAL TABLET 2 oral solution 1 PR; AL STALEVO 125 ORAL TABLET 2 risperidone oral tablet 1 PR STALEVO 150 ORAL TABLET 2 risperidone oral tablet dispersible 1 PA; PR STALEVO 200 ORAL TABLET 2 thioridazine hcl oral tablet 1 AL STALEVO 50 ORAL TABLET 2 thiothixene oral capsule 1 STALEVO 75 ORAL TABLET 2 trifluoperazine hcl oral tablet 1 trihexyphenidyl hcl oral solution 1 AL ziprasidone hcl oral capsule 1 PR trihexyphenidyl hcl oral tablet 1 AL ZYPREXA RELPREVV 2 PA; PR ZELAPAR ORAL TABLET 2 PA; PA except INTRAMUSCULAR SUSPENSION DISPERSIBLE Neurology RECONSTITUTED *Antipsychotics/Antimanic Agents* *Antiseptics & Disinfectants* ABILIFY MAINTENA 2 PA; PR benzalkonium chloride external 2 INTRAMUSCULAR PREFILLED solution 50 % SYRINGE

12.01.2020

10 Drug Tier Notes Drug Tier Notes

*Antivirals* KALETRA ORAL TABLET 2 PR abacavir sulfate oral solution 1 PR lamivudine oral solution 1 PR abacavir sulfate oral tablet 1 PR lamivudine oral tablet 1 PR abacavir sulfate-lamivudine oral 1 PR lamivudine-zidovudine oral tablet 1 PR tablet LEXIVA ORAL SUSPENSION 2 PR abacavir-lamivudine-zidovudine 1 PR lopinavir-ritonavir oral solution 1 PR oral tablet MAVYRET ORAL TABLET 2 LDD acyclovir oral capsule 1 nevirapine er oral tablet extended 1 PR acyclovir oral suspension 1 release 24 hour 400 mg acyclovir oral tablet 1 nevirapine oral suspension 1 PR adefovir dipivoxil oral tablet 1 PA; PA except nevirapine oral tablet 1 PR gastroenterology and NORVIR ORAL SOLUTION 2 PR infectious disease NORVIR ORAL TABLET 2 PR APTIVUS ORAL CAPSULE 2 PR ODEFSEY ORAL TABLET 2 PR APTIVUS ORAL SOLUTION 2 PR oseltamivir phosphate oral capsule 1 QL atazanavir sulfate oral capsule 1 PR oseltamivir phosphate oral 1 QL BARACLUDE ORAL SOLUTION 2 PA; PA except suspension reconstituted gastroenterology or PEGASYS SUBCUTANEOUS 2 PA infectious disease SOLUTION specialist PEGINTRON SUBCUTANEOUS KIT 2 PA BIKTARVY ORAL TABLET 2 PR 50 MCG/0.5ML COMPLERA ORAL TABLET 2 PR PIFELTRO ORAL TABLET 2 PR CRIXIVAN ORAL CAPSULE 200 MG, 2 PR PREZCOBIX ORAL TABLET 2 PR 400 MG PREZISTA ORAL SUSPENSION 2 PR DELSTRIGO ORAL TABLET 2 PR PREZISTA ORAL TABLET 150 MG, 2 PR DESCOVY ORAL TABLET 2 PR 600 MG, 75 MG, 800 MG didanosine oral capsule delayed 1 PR RELENZA DISKHALER INHALATION 2 release 200 mg, 250 mg, 400 mg AEROSOL POWDER BREATH DOVATO ORAL TABLET 2 PR ACTIVATED EDURANT ORAL TABLET 2 PR REYATAZ ORAL CAPSULE 150 MG, 2 PR efavirenz oral capsule 1 PR 200 MG, 300 MG efavirenz oral tablet 1 PR ribavirin oral capsule 1 efavirenz-emtricitab-tenofovir oral 1 PR ribavirin oral tablet 200 mg 1 tablet rimantadine hcl oral tablet 1 efavirenz-lamivudine-tenofovir oral 1 PR ritonavir oral tablet 1 PR tablet rukobia oral tablet extended 2 emtricitabine oral capsule 1 PR release 12 hour emtricitabine-tenofovir df oral 1 PR SELZENTRY ORAL SOLUTION 2 PR tablet SELZENTRY ORAL TABLET 2 PR EMTRIVA ORAL SOLUTION 2 PR stavudine oral capsule 1 PR entecavir oral tablet 1 PA; PA except STRIBILD ORAL TABLET 2 PR gasteroenterology or SUSTIVA ORAL CAPSULE 2 PR infectious disease SUSTIVA ORAL TABLET 2 PR specialist SYMTUZA ORAL TABLET 2 EPIVIR HBV ORAL SOLUTION 2 PR TEMIXYS ORAL TABLET 2 EVOTAZ ORAL TABLET 2 PR tenofovir disoproxil fumarate oral 1 PR famciclovir oral tablet 1 tablet fosamprenavir calcium oral tablet 1 PR TIVICAY ORAL TABLET 2 PR FUZEON SUBCUTANEOUS 2 PA; PR TIVICAY PD ORAL TABLET SOLUBLE 2 PR SOLUTION RECONSTITUTED TRIUMEQ ORAL TABLET 2 PR GENVOYA ORAL TABLET 2 PR TRUVADA ORAL TABLET 2 PR INTELENCE ORAL TABLET 2 PR TYBOST ORAL TABLET 2 ST; PR INVIRASE ORAL TABLET 2 PR valacyclovir hcl oral tablet 1 ISENTRESS HD ORAL TABLET 2 valganciclovir hcl oral solution 1 PA; PA except ISENTRESS ORAL PACKET 2 PR reconstituted Infectious Disease, ISENTRESS ORAL TABLET 2 PR Nephrology, ISENTRESS ORAL TABLET 2 PR Ophthalmology, CHEWABLE Renal Specialist JULUCA ORAL TABLET 2 KALETRA ORAL SOLUTION 2 PR

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11 Drug Tier Notes Drug Tier Notes

valganciclovir hcl oral tablet 1 PA; PA except MATZIM LA ORAL TABLET 1 Infectious Disease, EXTENDED RELEASE 24 HOUR Renal Transplant hcl oral capsule 1 Surgeons and nifedipine er oral tablet extended 1 Nephrology release 24 hour VEMLIDY ORAL TABLET 2 PA; PA except nifedipine er osmotic release oral 1 Gastroenterology or tablet extended release 24 hour Infectious Disease nifedipine oral capsule 1 AL VIRACEPT ORAL TABLET 2 PR nisoldipine er oral tablet extended 1 VIRAMUNE ORAL SUSPENSION 2 PR release 24 hour VIREAD ORAL TABLET 2 PR TAZTIA XT ORAL CAPSULE 1 zidovudine oral capsule 1 PR EXTENDED RELEASE 24 HOUR zidovudine oral syrup 1 PR verapamil hcl er oral capsule 1 zidovudine oral tablet 1 PR extended release 24 hour *Beta Blockers* verapamil hcl er oral tablet 1 acebutolol hcl oral capsule 1 extended release 120 mg, 180 mg, atenolol oral tablet 1 240 mg betaxolol hcl oral tablet 1 verapamil hcl oral tablet 1 bisoprolol fumarate oral tablet 1 *Cardiotonics* carvedilol oral tablet 1 digox oral tablet 125 mcg 1 labetalol hcl oral tablet 1 digox oral tablet 250 mcg 1 AL metoprolol succinate er oral tablet 1 digoxin oral solution 1 extended release 24 hour digoxin oral tablet 125 mcg 1 metoprolol tartrate oral tablet 100 1 digoxin oral tablet 250 mcg 1 AL mg, 25 mg, 50 mg *Cardiovascular Agents - Misc.* nadolol oral tablet 20 mg, 40 mg, 1 ambrisentan oral tablet 1 PA; LDD 80 mg bosentan oral tablet 1 PA; LDD pindolol oral tablet 1 ENTRESTO ORAL TABLET 2 propranolol hcl er oral capsule 1 OPSUMIT ORAL TABLET 2 PA; LDD extended release 24 hour sildenafil citrate oral suspension 1 PA; AL propranolol hcl oral solution 1 reconstituted propranolol hcl oral tablet 1 sildenafil citrate oral tablet 20 mg 1 PA sotalol hcl (af) oral tablet 1 tadalafil (pah) oral tablet 1 PA sotalol hcl oral tablet 1 TRACLEER ORAL TABLET SOLUBLE 2 PA; LDD timolol maleate oral tablet 1 *Cephalosporins* *Calcium Channel Blockers* cefaclor oral capsule 1 AFEDITAB CR ORAL TABLET 1 cefadroxil oral capsule 1 EXTENDED RELEASE 24 HOUR cefadroxil oral suspension 1 amlodipine besylate oral tablet 1 reconstituted CARTIA XT ORAL CAPSULE 1 cefadroxil oral tablet 1 EXTENDED RELEASE 24 HOUR cefdinir oral capsule 1 diltiazem hcl er beads oral capsule 1 cefdinir oral suspension 1 extended release 24 hour reconstituted diltiazem hcl er coated beads oral 1 cefixime oral capsule 1 capsule extended release 24 hour cefpodoxime proxetil oral 1 diltiazem hcl er coated beads oral 1 suspension reconstituted tablet extended release 24 hour cefpodoxime proxetil oral tablet 1 180 mg cefprozil oral suspension 1 diltiazem hcl er oral capsule 1 reconstituted extended release 12 hour cefprozil oral tablet 1 diltiazem hcl er oral capsule 1 cefuroxime axetil oral tablet 1 extended release 24 hour 120 mg, cephalexin oral capsule 250 mg, 1 180 mg, 240 mg 500 mg diltiazem hcl oral tablet 1 cephalexin oral suspension 1 dilt-xr oral capsule extended 1 reconstituted release 24 hour SUPRAX ORAL TABLET CHEWABLE 2 felodipine er oral tablet extended 1 release 24 hour *Contraceptives* isradipine oral capsule 1 ALTAVERA ORAL TABLET 1 alyacen 1/35 oral tablet 1

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12 Drug Tier Notes Drug Tier Notes

alyacen 7/7/7 oral tablet 1 KAITLIB FE ORAL TABLET 1 AMETHIA LO ORAL TABLET 1 CHEWABLE AMETHIA ORAL TABLET 1 KARIVA ORAL TABLET 1 ANNOVERA VAGINAL RING 2 KELNOR 1/35 ORAL TABLET 1 APRI ORAL TABLET 1 KURVELO ORAL TABLET 1 ARANELLE ORAL TABLET 1 LARIN 1.5/30 ORAL TABLET 1 ASHLYNA ORAL TABLET 1 LARIN 1/20 ORAL TABLET 1 AUBRA ORAL TABLET 1 LARIN 24 FE ORAL TABLET 1 AVIANE ORAL TABLET 1 LARIN FE 1.5/30 ORAL TABLET 1 AZURETTE ORAL TABLET 1 LARIN FE 1/20 ORAL TABLET 1 BALCOLTRA ORAL TABLET 2 LARISSIA ORAL TABLET 1 BALZIVA ORAL TABLET 1 LAYOLIS FE ORAL TABLET 1 BEKYREE ORAL TABLET 1 CHEWABLE BLISOVI 24 FE ORAL TABLET 1 LEENA ORAL TABLET 1 BLISOVI FE 1.5/30 ORAL TABLET 1 LESSINA ORAL TABLET 1 briellyn oral tablet 1 LEVONEST ORAL TABLET 1 CAMILA ORAL TABLET 1 levonorgest-eth estrad 91-day oral 1 CAMRESE LO ORAL TABLET 1 tablet CAMRESE ORAL TABLET 1 -ethinyl estrad oral 1 CAZIANT ORAL TABLET 1 tablet CESIA ORAL TABLET 1 LEVORA 0.15/30 (28) ORAL 1 CHATEAL ORAL TABLET 1 TABLET CRYSELLE-28 ORAL TABLET 1 LO LOESTRIN FE ORAL TABLET 2 CYCLAFEM 1/35 ORAL TABLET 1 LORYNA ORAL TABLET 1 CYCLAFEM 7/7/7 ORAL TABLET 1 LOW-OGESTREL ORAL TABLET 1 CYRED ORAL TABLET 1 LUTERA ORAL TABLET 1 DASETTA 1/35 ORAL TABLET 1 LYZA ORAL TABLET 1 DASETTA 7/7/7 ORAL TABLET 1 marlissa oral tablet 1 DAYSEE ORAL TABLET 1 MIBELAS 24 FE ORAL TABLET 1 DEBLITANE ORAL TABLET 1 CHEWABLE DELYLA ORAL TABLET 1 MICROGESTIN 1.5/30 ORAL 1 -ethinyl oral 1 TABLET tablet 0.15-0.02/0.01 mg (21/5) MICROGESTIN 1/20 ORAL TABLET 1 drospiren-eth estrad-levomefol 1 MICROGESTIN FE 1.5/30 ORAL 1 oral tablet 3-0.03-0.451 mg TABLET -ethinyl estradiol oral 1 MICROGESTIN FE 1/20 ORAL 1 tablet TABLET ELINEST ORAL TABLET 1 MONO-LINYAH ORAL TABLET 1 ELLA ORAL TABLET 2 QL MONONESSA ORAL TABLET 1 EMOQUETTE ORAL TABLET 1 NATAZIA ORAL TABLET 2 ENPRESSE-28 ORAL TABLET 1 NECON 0.5/35 (28) ORAL TABLET 1 ENSKYCE ORAL TABLET 0.15-30 1 NECON 1/35 (28) ORAL TABLET 1 MG-MCG NIKKI ORAL TABLET 1 ERRIN ORAL TABLET 1 NORA-BE ORAL TABLET 1 ESTARYLLA ORAL TABLET 1 norethin ace-eth estrad-fe oral 1 ethynodiol diac-eth estradiol oral 1 tablet 1-20 mg-mcg tablet 1-50 mg-mcg norethindrone acet-ethinyl est oral 1 FALMINA ORAL TABLET 1 tablet 1-20 mg-mcg FEMYNOR ORAL TABLET 1 norethindrone oral tablet 1 GIANVI ORAL TABLET 1 norethin-eth estradiol-fe oral 1 HEATHER ORAL TABLET 1 tablet chewable INTROVALE ORAL TABLET 1 -eth estradiol oral 1 JENCYCLA ORAL TABLET 1 tablet 0.25-35 mg-mcg JOLESSA ORAL TABLET 1 norgestim-eth estrad triphasic oral 1 JULEBER ORAL TABLET 1 tablet JUNEL 1.5/30 ORAL TABLET 1 NORLYROC ORAL TABLET 1 JUNEL 1/20 ORAL TABLET 1 NORTREL 0.5/35 (28) ORAL 1 JUNEL FE 1.5/30 ORAL TABLET 1 TABLET JUNEL FE 1/20 ORAL TABLET 1 NORTREL 1/35 (21) ORAL TABLET 1 JUNEL FE 24 ORAL TABLET 1 NORTREL 1/35 (28) ORAL TABLET 1 NORTREL 7/7/7 ORAL TABLET 1

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OCELLA ORAL TABLET 1 prednisolone sodium phosphate 1 PR ORSYTHIA ORAL TABLET 1 oral solution 10 mg/5ml, 15 PHILITH ORAL TABLET 1 mg/5ml, 20 mg/5ml, 25 mg/5ml, PIMTREA ORAL TABLET 1 6.7 (5 base) mg/5ml PIRMELLA 1/35 ORAL TABLET 1 PREDNISONE INTENSOL ORAL 2 PR PIRMELLA 7/7/7 ORAL TABLET 1 CONCENTRATE PORTIA-28 ORAL TABLET 1 prednisone oral tablet 1 mg, 10 1 PR PREVIFEM ORAL TABLET 1 mg, 2.5 mg, 20 mg, 5 mg RECLIPSEN ORAL TABLET 1 *Cough/Cold/Allergy* SETLAKIN ORAL TABLET 1 acetylcysteine inhalation solution 1 SHAROBEL ORAL TABLET 1 benzonatate oral capsule 100 mg, 1 SOLIA ORAL TABLET 1 200 mg SPRINTEC 28 ORAL TABLET 1 NEOTUSS PLUS ORAL LIQUID 2 SRONYX ORAL TABLET 1 promethazine vc/codeine oral 1 AL SYEDA ORAL TABLET 1 syrup TARINA FE 1/20 ORAL TABLET 1 promethazine-codeine oral syrup 1 AL TILIA FE ORAL TABLET 1 promethazine-dm oral syrup 1 AL TRI FEMYNOR ORAL TABLET 1 sodium chloride inhalation 1 TRI-ESTARYLLA ORAL TABLET 1 nebulization solution 10 %, 3 %, 7 TRI-LEGEST FE ORAL TABLET 1 % TRI-LINYAH ORAL TABLET 1 TRI-LO-ESTARYLLA ORAL TABLET 1 *Dermatologicals* TRI-LO-MARZIA ORAL TABLET 1 acitretin oral capsule 1 PA; PA except TRI-LO-SPRINTEC ORAL TABLET 1 dermatology TRINESSA (28) ORAL TABLET 1 acyclovir external ointment 1 TRI-PREVIFEM ORAL TABLET 1 adapalene external 1 PA TRI-SPRINTEC ORAL TABLET 1 adapalene external gel 1 PA TRIVORA (28) ORAL TABLET 1 ala-cort external cream 1 % 1 TRI-VYLIBRA ORAL TABLET 1 ALA-QUIN EXTERNAL CREAM 2 TYDEMY ORAL TABLET 1 alclometasone dipropionate 1 VELIVET ORAL TABLET 1 external cream VIENVA ORAL TABLET 1 alclometasone dipropionate 1 viorele oral tablet 1 external ointment VYFEMLA ORAL TABLET 1 amcinonide external 1 WERA ORAL TABLET 1 ammonium lactate external cream 1 WYMZYA FE ORAL TABLET 1 ammonium lactate external lotion 1 CHEWABLE AMNESTEEM ORAL CAPSULE 1 PA; PA except XULANE TRANSDERMAL PATCH 1 dermatology WEEKLY ANACAINE EXTERNAL OINTMENT 2 ZARAH ORAL TABLET 1 benzoyl peroxide external gel 10 % 1 ZOVIA 1/35E (28) ORAL TABLET 1 betamethasone dipropionate aug 1 external cream *Corticosteroids* betamethasone dipropionate aug 1 budesonide oral capsule delayed 1 PA; PA except external gel release particles Gastroenterology or betamethasone dipropionate aug 1 Colorectal Surgery external lotion cortisone acetate oral tablet 1 PR betamethasone dipropionate aug 1 INTENSOL 2 PR external ointment ORAL CONCENTRATE betamethasone dipropionate 1 dexamethasone oral elixir 1 PR external cream dexamethasone oral solution 1 PR betamethasone dipropionate 1 dexamethasone oral tablet 1 PR external lotion EMFLAZA ORAL SUSPENSION 2 PA; LDD; PR betamethasone dipropionate 1 EMFLAZA ORAL TABLET 2 PA; LDD; PR external ointment fludrocortisone acetate oral tablet 1 betamethasone valerate external 1 hydrocortisone oral tablet 1 PR cream methylprednisolone oral tablet 1 PR betamethasone valerate external 1 prednisolone oral solution 1 PR lotion betamethasone valerate external 1 ointment

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14 Drug Tier Notes Drug Tier Notes

calcipotriene external cream 1 PA; PA except fluticasone propionate external 1 Dermatology cream calcipotriene external ointment 1 PA; PA except fluticasone propionate external 1 Dermatology lotion calcipotriene external solution 1 PA; PA except fluticasone propionate external 1 Dermatology ointment calcitriol external ointment 1 PA; PA except gentamicin sulfate external cream 1 dermatology gentamicin sulfate external 1 ciclopirox external gel 1 ointment ciclopirox external 1 halobetasol propionate external 1 ciclopirox external solution 1 AL cream ciclopirox olamine external cream 1 halobetasol propionate external 1 ciclopirox olamine external 1 ointment suspension hydrocortisone butyrate external 1 CLARAVIS ORAL CAPSULE 1 PA; PA except ointment Dermatology hydrocortisone butyrate external 1 clindamycin phos-benzoyl perox 1 solution external gel 1-5 % hydrocortisone external cream 1 1 clindamycin phosphate external gel 1 %, 2.5 % clindamycin phosphate external 1 hydrocortisone external lotion 2.5 1 lotion % clindamycin phosphate external 1 hydrocortisone external ointment 1 solution 1 %, 2.5 % clindamycin phosphate external 1 hydrocortisone valerate external 1 swab cream clobetasol propionate external 1 hydrocortisone valerate external 1 ointment ointment clotrimazole external cream 1 imiquimod external cream 1 PA; PA except clotrimazole external solution 1 Dermatology, clotrimazole-betamethasone 1 QL Urology, OBGYN, and external cream Colorectal Surgery clotrimazole-betamethasone 1 QL isotretinoin oral capsule 1 PA; PA except external lotion dermatology coal tar external solution 2 ketoconazole external cream 1 CROTAN EXTERNAL LOTION 1 ketoconazole external shampoo 2 1 desonide external cream 1 % desonide external lotion 1 ST lidocaine external ointment 1 desonide external ointment 1 ST lidocaine external patch 5 % 1 desoximetasone external cream 1 lidocaine hcl external cream 3 % 1 desoximetasone external gel 1 lidocaine hcl external solution 1 desoximetasone external ointment 1 lidocaine-prilocaine external cream 1 0.25 % external shampoo 1 DRYSOL EXTERNAL SOLUTION 2 malathion external lotion 1 DUPIXENT SUBCUTANEOUS 2 PA metronidazole external gel 1 % 1 SOLUTION PEN-INJECTOR metronidazole external lotion 1 DUPIXENT SUBCUTANEOUS 2 PA mometasone furoate external 1 SOLUTION PREFILLED SYRINGE cream econazole nitrate external cream 1 mometasone furoate external 1 erythromycin external gel 1 ointment erythromycin external solution 1 mometasone furoate external 1 ethyl chloride external aerosol 2 solution EUCRISA EXTERNAL OINTMENT 2 ST; AL mupirocin calcium external cream 1 FABIOR EXTERNAL FOAM 2 PA; ST except mupirocin external ointment 1 dermatology; QL MYORISAN ORAL CAPSULE 1 PA; PA except fluocinonide external cream 0.05 % 1 Dermatology fluocinonide external gel 1 nystatin external cream 1 fluocinonide external ointment 1 nystatin external ointment 1 fluocinonide external solution 1 nystatin external powder 1 fluorouracil external cream 5 % 1 nystatin-triamcinolone external 1 fluorouracil external solution 1 cream

12.01.2020

15 Drug Tier Notes Drug Tier Notes

nystatin-triamcinolone external 1 chlorthalidone oral tablet 25 mg, 1 ointment 50 mg permethrin external cream 1 DIURIL ORAL SUSPENSION 2 pimecrolimus external cream 1 AL oral solution 10 mg/ml 1 prednicarbate external cream 1 furosemide oral tablet 1 prednicarbate external ointment 1 hydrochlorothiazide oral capsule 1 salicylic acid external cream 1 PA hydrochlorothiazide oral tablet 1 salicylic acid external foam 1 PA indapamide oral tablet 1 salicylic acid external gel 1 PA methazolamide oral tablet 1 salicylic acid external lotion 1 PA metolazone oral tablet 1 salicylic acid external shampoo 1 PA oral tablet 1 salicylic acid-cleanser external kit 6 1 PA spironolactone-hctz oral tablet 1 % (cream) torsemide oral tablet 1 selenium sulfide external lotion 1 triamterene-hctz oral capsule 37.5- 1 silver nitrate external solution 1 25 mg silver sulfadiazine external cream 1 triamterene-hctz oral tablet 1 SKLICE EXTERNAL LOTION 2 *Endocrine And Metabolic Agents - Misc.* spinosad external suspension 1 QL alendronate sodium oral tablet 10 1 PR sulfacetamide sodium () 1 PA mg, 35 mg, 5 mg, 70 mg external lotion cabergoline oral tablet 1 QL sulfacetamide sodium external 1 PA calcitonin (salmon) nasal solution 1 PR liquid calcitriol oral capsule 1 sulfacetamide sodium-sulfur 1 PA calcitriol oral solution 1 external liquid 9-4 % CARBAGLU ORAL TABLET 2 PA; LDD sulfacetamide sodium-sulfur 1 PA cinacalcet hcl oral tablet 1 external pad 10-4 % clomiphene citrate oral tablet 1 PA; PA except sulfacetamide sodium-sulfur 1 PA OBGYN/Fertility; external suspension 8-4 % XCHP; QL sulfacetamide-sulfur in urea 1 PA CYSTADANE ORAL POWDER 2 PA; LDD external desmopressin ace spray refrig 1 tacrolimus external ointment 0.03 1 AL nasal solution %, 0.1 % desmopressin acetate oral tablet 1 tretinoin external cream 1 PA desmopressin acetate spray nasal 1 tretinoin external gel 0.01 %, 0.025 1 PA solution % FORTEO SUBCUTANEOUS 2 PA triamcinolone acetonide external 1 SOLUTION PEN-INJECTOR cream INCRELEX SUBCUTANEOUS 2 PA; LDD triamcinolone acetonide external 1 SOLUTION lotion levocarnitine oral tablet 1 PA triamcinolone acetonide external 1 octreotide acetate injection 1 PA; PA except ointment 0.025 %, 0.1 %, 0.5 % solution 100 mcg/ml, 1000 hematology, ZITHRANOL EXTERNAL SHAMPOO 2 PA; PA except mcg/ml, 200 mcg/ml, 50 mcg/ml, oncology, dermatology 500 mcg/ml endocrinology *Digestive Aids* paricalcitol oral capsule 1 ST CREON ORAL CAPSULE DELAYED 2 PR raloxifene hcl oral tablet 1 RELEASE PARTICLES risedronate sodium oral tablet 150 1 PR PANCREAZE ORAL CAPSULE 2 PR mg, 30 mg, 35 mg, 5 mg DELAYED RELEASE PARTICLES risedronate sodium oral tablet 1 PR SUCRAID ORAL SOLUTION 2 PA; LDD; PR delayed release *Diuretics* sapropterin dihydrochloride oral 1 PA; LDD acetazolamide er oral capsule 1 packet extended release 12 hour sapropterin dihydrochloride oral 1 PA; LDD acetazolamide oral tablet 1 tablet soluble ALDACTAZIDE ORAL TABLET 50-50 2 SOMAVERT SUBCUTANEOUS 2 PA; LDD; PR MG SOLUTION RECONSTITUTED 20 MG amiloride hcl oral tablet 1 STRENSIQ SUBCUTANEOUS 2 PA; LDD amiloride-hydrochlorothiazide oral 1 SOLUTION tablet SYNAREL NASAL SOLUTION 2 PA bumetanide oral tablet 1 teriparatide (recombinant) 2 PA subcutaneous solution pen-injector

12.01.2020

16 Drug Tier Notes Drug Tier Notes

TYMLOS SUBCUTANEOUS 2 PA sulfasalazine oral tablet 1 SOLUTION PEN-INJECTOR sulfasalazine oral tablet delayed 1 XURIDEN ORAL PACKET 2 PA; LDD release *Estrogens* ursodiol oral capsule 1 COMBIPATCH TRANSDERMAL 2 ursodiol oral tablet 1 PATCH TWICE WEEKLY *Genitourinary Agents - Miscellaneous* est estrogens-methyltest ds oral 1 AL acetic acid irrigation solution 1 tablet alfuzosin hcl er oral tablet 1 est estrogens-methyltest hs oral 1 AL extended release 24 hour tablet aminoacetic acid irrigation solution 1 estradiol oral tablet 1 AL CYSTAGON ORAL CAPSULE 2 PA; LDD estradiol transdermal patch twice 1 AL oral capsule 1 weekly ELMIRON ORAL CAPSULE 2 PA; PA except estradiol transdermal patch weekly 1 AL Urology estradiol-norethindrone acet oral 1 AL oral tablet 5 mg 1 tablet glycine irrigation solution 1 JINTELI ORAL TABLET 1 AL glycine urologic irrigation solution 1 MENOSTAR TRANSDERMAL 2 neomycin-polymyxin b gu irrigation 1 PATCH WEEKLY solution MIMVEY ORAL TABLET 1 AL ORACIT ORAL SOLUTION 2 norethindrone-eth estradiol oral 1 AL phenazopyridine hcl oral tablet 100 1 tablet mg, 200 mg PREMARIN ORAL TABLET 2 AL potassium citrate er oral tablet 1 PREMPRO ORAL TABLET 2 AL extended release *Fluoroquinolones* potassium citrate-citric acid oral 1 CIPRO ORAL SUSPENSION 2 solution RECONSTITUTED 250 MG/5ML RENACIDIN IRRIGATION SOLUTION 2 (5%) irrigation solution 2 hcl oral tablet 1 sorbitol-mannitol irrigation 2 oral solution 1 solution levofloxacin oral tablet 1 tamsulosin hcl oral capsule 1 moxifloxacin hcl oral tablet 1 THIOLA ORAL TABLET 2 PA; LDD tricitrates oral solution 2 *Gastrointestinal Agents - Misc.* *Gout Agents* balsalazide disodium oral capsule 1 AL calcium acetate (phos binder) oral 1 allopurinol oral tablet 1 tablet colchicine oral capsule 1 cromolyn sodium oral concentrate 1 colchicine oral tablet 1 generlac oral solution 1 colchicine-probenecid oral tablet 1 lactulose encephalopathy oral 1 probenecid oral tablet 1 solution *Hematological Agents - Misc.* lanthanum carbonate oral tablet 1 anagrelide hcl oral capsule 1 PA chewable aspirin-dipyridamole er oral 1 PA; PR mesalamine er oral capsule 1 ST capsule extended release 12 hour extended release 24 hour BRILINTA ORAL TABLET 2 PR mesalamine oral capsule delayed 1 CABLIVI INJECTION KIT 2 PA release cilostazol oral tablet 1 mesalamine oral tablet delayed 1 clopidogrel bisulfate oral tablet 1 PR release dipyridamole oral tablet 1 PR; AL mesalamine rectal enema 1 pentoxifylline er oral tablet 1 DF mesalamine rectal suppository 1 extended release hcl oral solution 1 prasugrel hcl oral tablet 1 PR; AL 10 mg/10ml, 5 mg/5ml *Hematopoietic Agents* metoclopramide hcl oral tablet 1 ARANESP (ALBUMIN FREE) 2 PA; PR PENTASA ORAL CAPSULE 2 INJECTION SOLUTION 100 EXTENDED RELEASE MCG/ML, 200 MCG/ML, 25 PHOSLYRA ORAL SOLUTION 2 MCG/ML, 300 MCG/ML, 40 sevelamer carbonate oral packet 1 MCG/ML, 60 MCG/ML sevelamer carbonate oral tablet 1 sevelamer hcl oral tablet 1 SFROWASA RECTAL ENEMA 2

12.01.2020

17 Drug Tier Notes Drug Tier Notes

ARANESP (ALBUMIN FREE) 2 PA; PR *Local Anesthetics-Parenteral* INJECTION SOLUTION PREFILLED lidocaine hcl injection solution 1 %, 2 SYRINGE 100 MCG/0.5ML, 150 2 % MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 *Macrolides* MCG/0.4ML, 500 MCG/ML, 60 azithromycin oral suspension 1 MCG/0.3ML reconstituted CORVITA 150 ORAL TABLET 1 azithromycin oral tablet 250 mg, 1 cyanocobalamin injection solution 1 500 mg, 600 mg 1000 mcg/ml clarithromycin er oral tablet 1 DROXIA ORAL CAPSULE 1 extended release 24 hour fa-vitamin b-6-vitamin b-12 oral 1 clarithromycin oral suspension 1 tablet reconstituted folic acid oral tablet 1 mg 1 clarithromycin oral tablet 1 FULPHILA SUBCUTANEOUS 2 PA ERYTHROCIN STEARATE ORAL 2 SOLUTION PREFILLED SYRINGE TABLET 250 MG HEMATOGEN FORTE ORAL 1 erythromycin base oral capsule 1 CAPSULE delayed release particles polysaccharide iron forte oral 1 erythromycin base oral tablet 1 capsule erythromycin ethylsuccinate oral 1 PROMACTA ORAL PACKET 2 PA suspension reconstituted PROMACTA ORAL TABLET 2 PA erythromycin ethylsuccinate oral 1 RETACRIT INJECTION SOLUTION 2 PA; PR tablet 10000 UNIT/ML, 2000 UNIT/ML, *Medical Devices And Supplies* 3000 UNIT/ML, 4000 UNIT/ML, OMNIPOD DASH 5 PACK PODS 2 40000 UNIT/ML V-GO 20 KIT 2 UDENYCA SUBCUTANEOUS 2 PA V-GO 30 KIT 2 SOLUTION PREFILLED SYRINGE V-GO 40 KIT 2 ZARXIO INJECTION SOLUTION 2 *Migraine Products* PREFILLED SYRINGE AIMOVIG SUBCUTANEOUS 2 PA *Hemostatics* SOLUTION AUTO-INJECTOR tranexamic acid oral tablet 1 AL dihydroergotamine mesylate nasal 1 PA; PA except *Hypnotics/Sedatives/Sleep Disorder Agents* solution Neurology; QL estazolam oral tablet 1 QL; AL ERGOMAR SUBLINGUAL TABLET 2 LDD eszopiclone oral tablet 1 QL; AL SUBLINGUAL flurazepam hcl oral capsule 1 QL; AL naratriptan hcl oral tablet 1 QL midazolam hcl oral syrup 1 rizatriptan benzoate oral tablet 1 QL phenobarbital oral elixir 1 AL rizatriptan benzoate oral tablet 1 QL phenobarbital oral tablet 16.2 mg, 1 AL dispersible 32.4 mg, 64.8 mg, 97.2 mg sumatriptan succinate oral tablet 1 QL quazepam oral tablet 1 QL; AL sumatriptan succinate refill 1 QL temazepam oral capsule 1 QL; AL subcutaneous solution cartridge 6 triazolam oral tablet 1 QL mg/0.5ml zaleplon oral capsule 1 QL; AL sumatriptan succinate 1 QL zolpidem tartrate er oral tablet 1 QL; AL subcutaneous solution 6 mg/0.5ml extended release sumatriptan succinate 1 QL zolpidem tartrate oral tablet 1 QL; AL subcutaneous solution auto- injector 6 mg/0.5ml *Laxatives* zolmitriptan oral tablet 1 QL GAVILYTE-N WITH PACK 1 ORAL SOLUTION RECONSTITUTED *Minerals & Electrolytes* lactulose oral packet 1 GALZIN ORAL CAPSULE 2 lactulose oral solution 1 potassium chloride crys er oral 1 peg 3350-kcl-na bicarb-nacl oral 1 tablet extended release solution reconstituted potassium chloride er oral capsule 1 peg-3350/electrolytes oral solution 1 extended release reconstituted potassium chloride er oral tablet 1 polyethylene glycol 3350 oral 1 extended release powder potassium chloride oral solution 20 1 SUPREP BOWEL PREP KIT ORAL 2 meq/15ml (10%) SOLUTION

12.01.2020

18 Drug Tier Notes Drug Tier Notes

sodium fluoride oral tablet 1 chlorhexidine gluconate 1 chewable mouth/throat solution virt-phos 250 neutral oral tablet 1 clotrimazole mouth/throat troche 1 *Miscellaneous Therapeutic Classes* nystatin mouth/throat suspension 1 ARGYLE STERILE WATER 1 pilocarpine hcl oral tablet 1 IRRIGATION SOLUTION sf 5000 plus dental cream 1 DF AZASAN ORAL TABLET 2 PR triamcinolone acetonide 1 azathioprine oral tablet 1 PR mouth/throat paste cyclosporine modified oral capsule 1 PR *Multivitamins* cyclosporine modified oral solution 1 PR DIALYVITE ORAL TABLET 1 PA; PA except cyclosporine oral capsule 1 PR Nephrology everolimus oral tablet 0.25 mg, 0.5 2 PA; PA except multivitamin/fluoride oral tablet 1 mg, 0.75 mg RenalTransplant chewable 0.25 mg, 0.5 mg Surgeonsand prenatal 19 oral tablet chewable 2 Nephrology prenatal oral tablet 27-1 mg 2 GENGRAF ORAL CAPSULE 100 MG, 1 PR prenatal plus iron oral tablet 2 25 MG prenatal plus/iron oral tablet 2 GENGRAF ORAL SOLUTION 1 PR vol-plus oral tablet 2 KIONEX ORAL SUSPENSION 1 *Musculoskeletal Therapy Agents* lactated ringers irrigation solution 1 oral tablet 1 LOKELMA ORAL PACKET 2 chlorzoxazone oral tablet 500 mg 1 AL mycophenolate mofetil oral 1 PR cyclobenzaprine hcl oral tablet 1 AL capsule dantrolene sodium oral capsule 1 mycophenolate mofetil oral tablet 1 PR metaxalone oral tablet 1 AL mycophenolate sodium oral tablet 1 PA; PR; PA except methocarbamol oral tablet 1 AL delayed release Renal Transplant orphenadrine citrate er oral tablet 1 AL Surgeons and extended release 12 hour Nephrology tizanidine hcl oral capsule 1 penicillamine oral capsule 1 PA tizanidine hcl oral tablet 1 PHYSIOLYTE IRRIGATION 1 SOLUTION *Nasal Agents - Systemic And Topical* PHYSIOSOL IRRIGATION 2 azelastine hcl nasal solution 0.1 % 1 IRRIGATION SOLUTION budesonide nasal suspension 1 REVLIMID ORAL CAPSULE 2 PA; LDD flunisolide nasal solution 25 1 ringers irrigation irrigation solution 1 mcg/act (0.025%) sirolimus oral solution 1 PA; PR; PA except fluticasone propionate nasal 1 Renal Transplant suspension Surgeons and ipratropium bromide nasal solution 1 Nephrology *Neuromuscular Agents* sirolimus oral tablet 1 PA; PR; PA except riluzole oral tablet 1 Renal Transplant *Ophthalmic Agents* Surgeons and ALOMIDE OPHTHALMIC SOLUTION 2 ST Nephrology apraclonidine hcl ophthalmic 1 sodium polystyrene sulfonate oral 1 solution powder azelastine hcl ophthalmic solution 1 sodium polystyrene sulfonate oral 1 AZOPT OPHTHALMIC SUSPENSION 2 suspension bacitracin-polymyxin b ophthalmic 1 SPS ORAL SUSPENSION 1 ointment 500-10000 unit/gm sterile water for irrigation irrigation 1 bacitra-neomycin-polymyxin-hc 1 solution ophthalmic ointment tacrolimus oral capsule 1 PR balanced salt intraocular solution 1 THALOMID ORAL CAPSULE 2 LDD bimatoprost ophthalmic solution 1 AL trientine hcl oral capsule 1 PA BLEPHAMIDE OPHTHALMIC 2 VELTASSA ORAL PACKET 2 SUSPENSION ZORTRESS ORAL TABLET 2 PA; PA except Renal BLEPHAMIDE S.O.P. OPHTHALMIC 2 Transplant Surgeons OINTMENT and Nephrology brimonidine tartrate ophthalmic 1 *Mouth/Throat/Dental Agents* solution cevimeline hcl oral capsule 1 bromfenac sodium (once-daily) 1 ophthalmic solution

12.01.2020

19 Drug Tier Notes Drug Tier Notes

carteolol hcl ophthalmic solution 1 pilocarpine hcl ophthalmic solution 1 ciprofloxacin hcl ophthalmic 1 1 %, 2 %, 4 % solution polymyxin b-trimethoprim 1 COMBIGAN OPHTHALMIC 2 ophthalmic solution SOLUTION PRED MILD OPHTHALMIC 2 cromolyn sodium ophthalmic 1 PA except SUSPENSION solution ophthamology prednisolone acetate ophthalmic 1 CYSTARAN OPHTHALMIC 2 PA; LDD suspension SOLUTION prednisolone sodium phosphate 1 dexamethasone sodium phosphate 1 ophthalmic solution ophthalmic solution SIMBRINZA OPHTHALMIC 2 diclofenac sodium ophthalmic 1 PA; PA Except SUSPENSION solution Opthalmology sulfacetamide sodium ophthalmic 1 dorzolamide hcl ophthalmic 1 solution solution sulfacetamide-prednisolone 1 dorzolamide hcl-timolol mal 1 ophthalmic solution ophthalmic solution timolol maleate ophthalmic gel 1 epinastine hcl ophthalmic solution 1 forming solution erythromycin ophthalmic ointment 1 timolol maleate ophthalmic 1 FLAREX OPHTHALMIC 2 solution 0.25 %, 0.5 % SUSPENSION tobramycin ophthalmic solution 1 fluorometholone ophthalmic 1 tobramycin-dexamethasone 1 suspension ophthalmic suspension flurbiprofen sodium ophthalmic 1 travoprost (bak free) ophthalmic 1 solution solution FML FORTE OPHTHALMIC 2 trifluridine ophthalmic solution 1 SUSPENSION tropicamide ophthalmic solution 1 1 FML OPHTHALMIC OINTMENT 2 % gentamicin sulfate ophthalmic 1 *Otic Agents* solution acetic acid otic solution 1 ketorolac tromethamine 1 ciprofloxacin hcl otic solution 1 ophthalmic solution ciprofloxacin-dexamethasone otic 1 PA; PA except ketotifen fumarate ophthalmic 1 suspension otolaryngology solution hydrocortisone-acetic acid otic 1 LACRISERT OPHTHALMIC INSERT 2 solution latanoprost ophthalmic solution 1 AL neomycin-polymyxin-hc otic 1 levobunolol hcl ophthalmic 1 solution solution 0.5 % neomycin-polymyxin-hc otic 1 levofloxacin ophthalmic solution 1 suspension LUMIGAN OPHTHALMIC 2 AL otic solution 1 SOLUTION 0.01 % NATACYN OPHTHALMIC 2 PA; PA except *Oxytocics* SUSPENSION Ophthalmology methylergonovine maleate oral 1 QL neomycin-bacitracin zn-polymyx 1 tablet ophthalmic ointment 5-400-10000 *Passive Immunizing And Treatment Agents* neomycin-polymyxin-dexameth 1 SYNAGIS INTRAMUSCULAR 2 PA ophthalmic ointment SOLUTION neomycin-polymyxin-dexameth 1 *Penicillins* ophthalmic suspension 3.5-10000- amoxicillin oral capsule 1 0.1 amoxicillin oral suspension 1 neomycin-polymyxin-gramicidin 1 reconstituted ophthalmic solution 1.75-10000- amoxicillin oral tablet 1 .025 amoxicillin oral tablet chewable 1 ofloxacin ophthalmic solution 1 125 mg, 250 mg olopatadine hcl ophthalmic 1 amoxicillin-pot clavulanate er oral 1 solution tablet extended release 12 hour phenylephrine hcl ophthalmic 1 amoxicillin-pot clavulanate oral 1 solution 10 %, 2.5 % suspension reconstituted PHOSPHOLINE IODIDE 2 amoxicillin-pot clavulanate oral 1 OPHTHALMIC SOLUTION tablet RECONSTITUTED

12.01.2020

20 Drug Tier Notes Drug Tier Notes

amoxicillin-pot clavulanate oral 1 perphenazine-amitriptyline oral 1 AL tablet chewable tablet ampicillin oral capsule 500 mg 1 pimozide oral tablet 1 AL dicloxacillin sodium oral capsule 1 rivastigmine tartrate oral capsule 1 v potassium oral solution 1 tetrabenazine oral tablet 1 PA reconstituted ZEPOSIA 7-DAY STARTER PACK 2 PA; PA except penicillin v potassium oral tablet 1 ORAL CAPSULE THERAPY PACK neurology *Pharmaceutical Adjuvants* ZEPOSIA ORAL CAPSULE 2 PA; PA except cherry flavor liquid 2 neurology polyethylene glycol 3350 powder 1 ZEPOSIA STARTER KIT ORAL 2 PA; PA except CAPSULE THERAPY PACK neurology *Progestins* *Respiratory Agents - Misc.* medroxyprogesterone acetate oral 1 tablet KALYDECO ORAL PACKET 2 PA; LDD megestrol acetate oral suspension 1 KALYDECO ORAL TABLET 2 PA; LDD 625 mg/5ml ORKAMBI ORAL PACKET 2 PA; LDD; AL norethindrone acetate oral tablet 1 ORKAMBI ORAL TABLET 100-125 2 PA; LDD; AL progesterone micronized oral 1 MG, 200-125 MG capsule PULMOZYME INHALATION 2 SOLUTION *Psychotherapeutic And Neurological Agents - Misc.* SYMDEKO ORAL TABLET THERAPY 2 PA; LDD; AL acamprosate calcium oral tablet 1 PACK delayed release *Sulfonamides* AVONEX PEN INTRAMUSCULAR 2 PA; PR; PA except AUTO-INJECTOR KIT neurology sulfadiazine oral tablet 1 AVONEX PREFILLED 2 PA; PR; PA except *Tetracyclines* INTRAMUSCULAR PREFILLED neurology doxycycline hyclate oral capsule 1 SYRINGE KIT doxycycline hyclate oral tablet 100 1 bupropion hcl er ( det) oral 1 mg, 20 mg, 50 mg tablet extended release 12 hour doxycycline monohydrate oral 1 CHANTIX CONTINUING MONTH 2 AL capsule 100 mg, 50 mg PAK ORAL TABLET doxycycline monohydrate oral 2 PA CHANTIX ORAL TABLET 2 AL suspension reconstituted CHANTIX STARTING MONTH PAK 2 AL minocycline hcl oral capsule 1 AL ORAL TABLET tetracycline hcl oral capsule 1 chlordiazepoxide-amitriptyline oral 1 AL *Thyroid Agents* tablet ARMOUR THYROID ORAL TABLET 2 oral tablet 1 EUTHYROX ORAL TABLET 1 donepezil hcl oral tablet 10 mg, 5 1 levothyroxine sodium oral tablet 1 mg LEVOXYL ORAL TABLET 1 donepezil hcl oral tablet dispersible 1 PA liothyronine sodium oral tablet 1 ergoloid mesylates oral tablet 1 methimazole oral tablet 1 galantamine hydrobromide er oral 1 np thyroid oral tablet 1 capsule extended release 24 hour propylthiouracil oral tablet 1 galantamine hydrobromide oral 1 SYNTHROID ORAL TABLET 2 solution UNITHROID ORAL TABLET 2 galantamine hydrobromide oral 1 tablet *Ulcer Drugs/Antispasmodics/Anticholinergics* glatiramer acetate subcutaneous 1 PA; PA except chlordiazepoxide-clidinium oral 1 AL solution prefilled syringe neurology;PR capsule GLATOPA SUBCUTANEOUS 1 PA; PA except hcl oral solution 1 SOLUTION PREFILLED SYRINGE neurology;PR cimetidine oral tablet 1 LUCEMYRA ORAL TABLET 2 PA; QL dicyclomine hcl oral capsule 1 memantine hcl er oral capsule 1 dicyclomine hcl oral solution 1 extended release 24 hour dicyclomine hcl oral tablet 1 memantine hcl oral solution 2 1 esomeprazole oral 1 mg/ml capsule delayed release memantine hcl oral tablet 1 famotidine oral suspension 1 NICOTROL INHALATION INHALER 2 reconstituted NICOTROL NS NASAL SOLUTION 2 famotidine oral tablet 20 mg, 40 1 NUEDEXTA ORAL CAPSULE 2 PA; PR mg glycopyrrolate injection solution 1

12.01.2020

21 Drug Tier Notes Drug Tier Notes

glycopyrrolate oral tablet 1 mg, 2 1 vitamin d (ergocalciferol) oral 1 mg capsule 1.25 mg (50000 ut) hyoscyamine sulfate oral elixir 1 AL hyoscyamine sulfate oral tablet 1 AL lansoprazole oral capsule delayed 1 release 30 mg methscopolamine bromide oral 1 tablet misoprostol oral tablet 1 nizatidine oral capsule 1 nizatidine oral solution 1 omeprazole oral capsule delayed 1 release pantoprazole sodium oral tablet 1 delayed release pb-hyoscy-atropine-scopolamine 1 oral tablet propantheline bromide oral tablet 1 PYLERA ORAL CAPSULE 2 PA rabeprazole sodium oral tablet 1 delayed release sucralfate oral tablet 1 *Urinary Antispasmodics* bethanechol chloride oral tablet 1 flavoxate hcl oral tablet 1 oxybutynin chloride er oral tablet 1 extended release 24 hour oxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 1 solifenacin succinate oral tablet 1 AL tolterodine tartrate er oral capsule 1 AL extended release 24 hour tolterodine tartrate oral tablet 1 AL trospium chloride er oral capsule 1 AL extended release 24 hour trospium chloride oral tablet 1 AL *Vaginal And Related Products* CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin phosphate vaginal 1 cream estradiol vaginal cream 1 estradiol vaginal tablet 1 ESTRING VAGINAL RING 2 FEMRING VAGINAL RING 2 metronidazole vaginal gel 1 PREMARIN VAGINAL CREAM 2 terconazole vaginal cream 1 terconazole vaginal suppository 1 YUVAFEM VAGINAL TABLET 1 *Vasopressors* epinephrine injection solution 1 QL auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml midodrine hcl oral tablet 1 SYMJEPI INJECTION SOLUTION 2 QL PREFILLED SYRINGE *Vitamins* ergocalciferol oral capsule 1 phytonadione oral tablet 1

12.01.2020

22 Index I n d e x I n d e x I n d e x abacavir sulfate...... 11 amoxicillin-pot clavulanate...... 20, 21 benztropine mesylate...... 10 abacavir sulfate-lamivudine...... 11 amoxicillin-pot clavulanate er...... 20 betamethasone dipropionate...... 14 abacavir-lamivudine-zidovudine...... 11 amphetamine-dextroamphet er...... 3 betamethasone dipropionate aug...... 14 ABILIFY MAINTENA...... 10 amphetamine-dextroamphetamine...... 3 betamethasone valerate...... 14 abiraterone acetate...... 9 ampicillin...... 21 betaxolol hcl...... 12 acamprosate calcium...... 21 ANACAINE...... 14 bethanechol chloride...... 22 acarbose...... 6 anagrelide hcl...... 17 bicalutamide...... 9 acebutolol hcl...... 12 anastrozole...... 9 BIKTARVY...... 11 acetaminophen-codeine...... 3 ANNOVERA...... 13 bimatoprost...... 19 acetaminophen-codeine #2...... 3 ANORO ELLIPTA...... 5 bisoprolol fumarate...... 12 acetaminophen-codeine #3...... 3 apraclonidine hcl...... 19 bisoprolol-hydrochlorothiazide...... 8 acetaminophen-codeine #4...... 3 aprepitant...... 7 BLEPHAMIDE...... 19 acetazolamide...... 16 APRI...... 13 BLEPHAMIDE S.O.P...... 19 acetazolamide er...... 16 APTIVUS...... 11 BLISOVI 24 FE...... 13 acetic acid...... 17, 20 ARANELLE...... 13 BLISOVI FE 1.5/30...... 13 acetylcysteine...... 14 ARANESP (ALBUMIN FREE)...... 17, 18 BONJESTA...... 7 acitretin...... 14 ARCALYST...... 3 bosentan...... 12 acyclovir...... 11, 14 ARGYLE STERILE WATER...... 19 BRAFTOVI...... 9 adapalene...... 14 aripiprazole...... 10 briellyn...... 13 adefovir dipivoxil...... 11 ARISTADA...... 10 BRILINTA...... 17 ADMELOG...... 7 ARISTADA INITIO...... 10 brimonidine tartrate...... 19 ADMELOG SOLOSTAR...... 7 armodafinil...... 3 bromfenac sodium (once-daily)...... 19 AFEDITAB CR...... 12 ARMOUR THYROID...... 21 bromocriptine mesylate...... 10 AFINITOR...... 9 ASHLYNA...... 13 budesonide...... 5, 14, 19 AIMOVIG...... 18 aspirin-dipyridamole er...... 17 bumetanide...... 16 ala-cort...... 14 atazanavir sulfate...... 11 buprenorphine...... 3 ALA-QUIN...... 14 atenolol...... 12 buprenorphine hcl-naloxone hcl...... 3 albendazole...... 4 atenolol-chlorthalidone...... 8 bupropion hcl...... 6 albuterol sulfate...... 5 atomoxetine hcl...... 3 bupropion hcl er (smoking det)...... 21 albuterol sulfate er...... 5 atorvastatin calcium...... 8 bupropion hcl er (sr)...... 6 albuterol sulfate hfa...... 5 atovaquone...... 9 bupropion hcl er (xl)...... 6 alclometasone dipropionate...... 14 atovaquone-proguanil hcl...... 9 buspirone hcl...... 5 ALDACTAZIDE...... 16 ATROVENT HFA...... 5 butalbital-acetaminophen...... 3 alendronate sodium...... 16 AUBRA...... 13 butalbital-apap-caff-cod...... 3 alfuzosin hcl er...... 17 AVIANE...... 13 butalbital-apap-caffeine...... 3 ALINIA...... 9 AVONEX PEN...... 21 butorphanol tartrate...... 3 aliskiren fumarate...... 8 AVONEX PREFILLED...... 21 cabergoline...... 16 allopurinol...... 17 AZASAN...... 19 CABLIVI...... 17 ALOMIDE...... 19 azathioprine...... 19 calcipotriene...... 15 alprazolam...... 5 azelastine hcl...... 19 calcitonin (salmon)...... 16 alprazolam er...... 5 azithromycin...... 18 calcitriol...... 15, 16 ALPRAZOLAM INTENSOL...... 5 AZOPT...... 19 calcium acetate (phos binder)...... 17 alprazolam xr...... 5 AZURETTE...... 13 CAMILA...... 13 ALTAVERA...... 12 bacitracin-polymyxin b...... 19 CAMRESE...... 13 alyacen 1/35...... 12 bacitra-neomycin-polymyxin-hc...... 19 CAMRESE LO...... 13 alyacen 7/7/7...... 13 baclofen...... 19 candesartan cilexetil...... 8 amantadine hcl...... 10 balanced salt...... 19 candesartan cilexetil-hctz...... 8 ambrisentan...... 12 BALCOLTRA...... 13 capecitabine...... 9 amcinonide...... 14 balsalazide disodium...... 17 CAPRELSA...... 9 AMETHIA...... 13 BALZIVA...... 13 captopril-hydrochlorothiazide...... 8 AMETHIA LO...... 13 BANZEL...... 6 CARBAGLU...... 16 amiloride hcl...... 16 BAQSIMI ONE PACK...... 7 carbamazepine...... 6 amiloride-hydrochlorothiazide...... 16 BAQSIMI TWO PACK...... 7 carbamazepine er...... 6 aminoacetic acid...... 17 BARACLUDE...... 11 carbidopa-levodopa...... 10 amiodarone hcl...... 5 BASAGLAR KWIKPEN...... 7 carbidopa-levodopa er...... 10 amitriptyline hcl...... 6 BEKYREE...... 13 carbidopa-levodopa-entacapone...... 10 amlodipine besy-benazepril hcl...... 8 benazepril hcl...... 8 carbinoxamine maleate...... 8 amlodipine besylate...... 12 benazepril-hydrochlorothiazide...... 8 carteolol hcl...... 20 ammonium lactate...... 14 benzalkonium chloride...... 10 CARTIA XT...... 12 AMNESTEEM...... 14 benznidazole...... 4 carvedilol...... 12 amoxapine...... 6 benzonatate...... 14 CAYSTON...... 9 amoxicillin...... 20 benzoyl peroxide...... 14 CAZIANT...... 13

12.01.2020

23 I n d e x I n d e x I n d e x cefaclor...... 12 colestipol hcl...... 8 diltiazem hcl er...... 12 cefadroxil...... 12 COMBIGAN...... 20 diltiazem hcl er beads...... 12 cefdinir...... 12 COMBIPATCH...... 17 diltiazem hcl er coated beads...... 12 cefixime...... 12 COMBIVENT RESPIMAT...... 5 dilt-xr...... 12 cefpodoxime proxetil...... 12 COMPLERA...... 11 diphenhydramine hcl...... 8 cefprozil...... 12 cortisone acetate...... 14 diphenoxylate-atropine...... 7 cefuroxime axetil...... 12 CORVITA 150...... 18 dipyridamole...... 17 celecoxib...... 3 CREON...... 16 disopyramide phosphate...... 5 CELONTIN...... 6 CRIXIVAN...... 11 disulfiram...... 21 cephalexin...... 12 cromolyn sodium...... 5, 17, 20 DIURIL...... 16 CESIA...... 13 CROTAN...... 15 divalproex sodium...... 6 cetirizine hcl...... 8 CRYSELLE-28...... 13 divalproex sodium er...... 6 cevimeline hcl...... 19 cyanocobalamin...... 18 dofetilide...... 5 CHANTIX...... 21 CYCLAFEM 1/35...... 13 donepezil hcl...... 21 CHANTIX CONTINUING MONTH PAK...... 21 CYCLAFEM 7/7/7...... 13 dorzolamide hcl...... 20 CHANTIX STARTING MONTH PAK...... 21 cyclobenzaprine hcl...... 19 dorzolamide hcl-timolol mal...... 20 CHATEAL...... 13 cyclophosphamide...... 9 DOVATO...... 11 cherry flavor...... 21 cyclosporine...... 19 doxazosin mesylate...... 8 chlordiazepoxide hcl...... 5 cyclosporine modified...... 19 doxepin hcl...... 6 chlordiazepoxide-amitriptyline...... 21 cyproheptadine hcl...... 8 doxycycline hyclate...... 21 chlordiazepoxide-clidinium...... 21 CYRED...... 13 doxycycline monohydrate...... 21 chlorhexidine gluconate...... 19 CYSTADANE...... 16 doxylamine-pyridoxine...... 7 chloroquine phosphate...... 9 CYSTAGON...... 17 dronabinol...... 7 chlorpromazine hcl...... 10 CYSTARAN...... 20 drospiren-eth estrad-levomefol...... 13 chlorthalidone...... 16 danazol...... 4 drospirenone-ethinyl estradiol...... 13 chlorzoxazone...... 19 dantrolene sodium...... 19 DROXIA...... 18 cholestyramine...... 8 dapsone...... 9 DRYSOL...... 15 cholestyramine light...... 8 DASETTA 1/35...... 13 duloxetine hcl...... 6 ciclopirox...... 15 DASETTA 7/7/7...... 13 DUPIXENT...... 15 ciclopirox olamine...... 15 DAYSEE...... 13 dutasteride...... 17 cilostazol...... 17 DEBLITANE...... 13 econazole nitrate...... 15 cimetidine...... 21 deferasirox...... 7 EDURANT...... 11 cimetidine hcl...... 21 deferasirox granules...... 7 efavirenz...... 11 cinacalcet hcl...... 16 DELSTRIGO...... 11 efavirenz-emtricitab-tenofovir...... 11 CIPRO...... 17 DELYLA...... 13 efavirenz-lamivudine-tenofovir...... 11 ciprofloxacin hcl...... 17, 20 DESCOVY...... 11 ELINEST...... 13 ciprofloxacin-dexamethasone...... 20 desipramine hcl...... 6 ELIQUIS...... 5 citalopram hydrobromide...... 6 desmopressin ace spray refrig...... 16 ELIQUIS DVT/PE STARTER PACK...... 5 CLARAVIS...... 15 desmopressin acetate...... 16 ELLA...... 13 clarithromycin...... 18 desmopressin acetate spray...... 16 ELMIRON...... 17 clarithromycin er...... 18 desogestrel-ethinyl estradiol...... 13 EMCYT...... 9 CLEOCIN...... 22 desonide...... 15 EMEND...... 7 clindamycin hcl...... 9 desoximetasone...... 15 EMFLAZA...... 14 clindamycin palmitate hcl...... 9 dexamethasone...... 14 EMOQUETTE...... 13 clindamycin phos-benzoyl perox...... 15 DEXAMETHASONE INTENSOL...... 14 emtricitabine...... 11 clindamycin phosphate...... 15, 22 dexamethasone sodium phosphate...... 20 emtricitabine-tenofovir df...... 11 clobazam...... 6 dexmethylphenidate hcl...... 3 EMTRIVA...... 11 clobetasol propionate...... 15 dextroamphetamine sulfate...... 3 EMVERM...... 4 clomiphene citrate...... 16 dextroamphetamine sulfate er...... 3 enalapril maleate...... 8 clomipramine hcl...... 6 DIALYVITE...... 19 enalaprilat...... 8 clonazepam...... 6 diazepam...... 5 enalapril-hydrochlorothiazide...... 8 clonidine...... 8 DIAZEPAM INTENSOL...... 5 ENBREL...... 3 clonidine hcl...... 8 diclofenac potassium...... 3 ENBREL SURECLICK...... 3 clopidogrel bisulfate...... 17 diclofenac sodium...... 3, 20 enoxaparin sodium...... 5 clorazepate dipotassium...... 5 diclofenac sodium er...... 3 ENPRESSE-28...... 13 clotrimazole...... 15, 19 dicloxacillin sodium...... 21 ENSKYCE...... 13 clotrimazole-betamethasone...... 15 dicyclomine hcl...... 21 entacapone...... 10 clozapine...... 10 didanosine...... 11 entecavir...... 11 coal tar...... 15 diflunisal...... 3 ENTRESTO...... 12 COARTEM...... 9 digox...... 12 epinastine hcl...... 20 codeine sulfate...... 3 digoxin...... 12 epinephrine...... 22 colchicine...... 17 dihydroergotamine mesylate...... 18 EPIVIR HBV...... 11 colchicine-probenecid...... 17 DILANTIN...... 6 eplerenone...... 8 colesevelam hcl...... 8 diltiazem hcl...... 12 ergocalciferol...... 22

12.01.2020

24 I n d e x I n d e x I n d e x ergoloid mesylates...... 21 flurbiprofen sodium...... 20 HUMIRA PEN...... 3 ERGOMAR...... 18 flutamide...... 9 HUMIRA PEN-CD/UC/HS STARTER...... 3 ERLEADA...... 9 fluticasone propionate...... 15, 19 HUMIRA PEN-PS/UV/ADOL HS START...... 3 erlotinib hcl...... 9 fluticasone-salmeterol...... 5 HUMULIN R U-500 (CONCENTRATED)...... 7 ERRIN...... 13 fluvastatin sodium...... 8 HYCAMTIN...... 9 ERYTHROCIN STEARATE...... 18 fluvoxamine maleate...... 6 hydralazine hcl...... 8 erythromycin...... 15, 20 FML...... 20 hydrochlorothiazide...... 16 erythromycin base...... 18 FML FORTE...... 20 hydrocodone-acetaminophen...... 4 erythromycin ethylsuccinate...... 18 folic acid...... 18 hydrocodone-ibuprofen...... 4 escitalopram oxalate...... 6 fondaparinux sodium...... 5 hydrocortisone...... 4, 14, 15 esomeprazole magnesium...... 21 FORTEO...... 16 hydrocortisone acetate...... 4 est estrogens-methyltest ds...... 17 fosamprenavir calcium...... 11 hydrocortisone butyrate...... 15 est estrogens-methyltest hs...... 17 fosinopril sodium...... 8 hydrocortisone valerate...... 15 ESTARYLLA...... 13 fosinopril sodium-hctz...... 8 hydrocortisone-acetic acid...... 20 estazolam...... 18 FRAGMIN...... 6 hydromorphone hcl...... 4 estradiol...... 17, 22 FULPHILA...... 18 hydroxychloroquine sulfate...... 9 estradiol-norethindrone acet...... 17 furosemide...... 16 hydroxyurea...... 9 ESTRING...... 22 FUZEON...... 11 hydroxyzine hcl...... 5 eszopiclone...... 18 gabapentin...... 6 hydroxyzine pamoate...... 5 ethambutol hcl...... 9 galantamine hydrobromide...... 21 hyoscyamine sulfate...... 22 ethosuximide...... 6 galantamine hydrobromide er...... 21 HYSINGLA ER...... 4 ethyl chloride...... 15 GALZIN...... 18 ibuprofen...... 3 ethynodiol diac-eth estradiol...... 13 GAVILYTE-N WITH FLAVOR PACK...... 18 icosapent ethyl...... 8 etodolac...... 3 gemfibrozil...... 8 imatinib mesylate...... 9 etoposide...... 9 generlac...... 17 imipramine hcl...... 6 EUCRISA...... 15 GENGRAF...... 19 imiquimod...... 15 EUTHYROX...... 21 gentamicin sulfate...... 15, 20 INCRELEX...... 16 everolimus...... 9, 19 GENVOYA...... 11 indapamide...... 16 EVOTAZ...... 11 GEODON...... 10 indomethacin...... 3 exemestane...... 9 GIANVI...... 13 indomethacin er...... 3 ezetimibe...... 8 glatiramer acetate...... 21 INTELENCE...... 11 FABIOR...... 15 GLATOPA...... 21 INTROVALE...... 13 FALMINA...... 13 glimepiride...... 7 INVIRASE...... 11 famciclovir...... 11 glipizide...... 7 ipratropium bromide...... 5, 19 famotidine...... 21 glipizide er...... 7 ipratropium-albuterol...... 5 FASENRA PEN...... 5 glipizide-metformin hcl...... 7 irbesartan...... 8 fa-vitamin b-6-vitamin b-12...... 18 glucagon emergency...... 7 irbesartan-hydrochlorothiazide...... 8 felbamate...... 6 glyburide...... 7 ISENTRESS...... 11 felodipine er...... 12 glyburide micronized...... 7 ISENTRESS HD...... 11 FEMRING...... 22 glyburide-metformin...... 7 isoniazid...... 9 FEMYNOR...... 13 glycine...... 17 ISORDIL TITRADOSE...... 4 fenofibrate...... 8 glycine urologic...... 17 isosorbide dinitrate...... 4 fenofibrate micronized...... 8 glycopyrrolate...... 21, 22 isosorbide mononitrate...... 4 fenofibric acid...... 8 granisetron hcl...... 7 isosorbide mononitrate er...... 4 fentanyl...... 3 griseofulvin ultramicrosize...... 8 isotretinoin...... 15 fentanyl citrate...... 3 guanfacine hcl...... 8 isradipine...... 12 finasteride...... 17 guanfacine hcl er...... 3 itraconazole...... 8 FIRMAGON...... 9 guanidine hcl...... 9 ivermectin...... 4 FLAREX...... 20 GVOKE HYPOPEN 1-PACK...... 7 JAKAFI...... 9 flavoxate hcl...... 22 GVOKE HYPOPEN 2-PACK...... 7 JANTOVEN...... 6 flecainide acetate...... 5 GVOKE PFS...... 7 JENCYCLA...... 13 FLOVENT DISKUS...... 5 halobetasol propionate...... 15 JENTADUETO...... 7 FLOVENT HFA...... 5 haloperidol...... 10 JINTELI...... 17 fluconazole...... 8 haloperidol decanoate...... 10 JOLESSA...... 13 fludrocortisone acetate...... 14 haloperidol lactate...... 10 JULEBER...... 13 flunisolide...... 19 HEATHER...... 13 JULUCA...... 11 fluocinonide...... 15 HEMATOGEN FORTE...... 18 JUNEL 1.5/30...... 13 fluorometholone...... 20 HUMALOG...... 7 JUNEL 1/20...... 13 fluorouracil...... 15 HUMALOG MIX 50/50...... 7 JUNEL FE 1.5/30...... 13 fluoxetine hcl...... 6 HUMALOG MIX 50/50 KWIKPEN...... 7 JUNEL FE 1/20...... 13 fluphenazine decanoate...... 10 HUMALOG MIX 75/25...... 7 JUNEL FE 24...... 13 fluphenazine hcl...... 10 HUMALOG MIX 75/25 KWIKPEN...... 7 KAITLIB FE...... 13 flurazepam hcl...... 18 HUMIRA...... 3 KALETRA...... 11 flurbiprofen...... 3 HUMIRA PEDIATRIC CROHNS START...... 3 KALYDECO...... 21

12.01.2020

25 I n d e x I n d e x I n d e x KARIVA...... 13 lorazepam...... 5 MICROGESTIN FE 1/20...... 13 KELNOR 1/35...... 13 LORYNA...... 13 midazolam hcl...... 18 ketoconazole...... 8, 15 losartan potassium...... 8 midodrine hcl...... 22 ketoprofen er...... 3 losartan potassium-hctz...... 8 MIMVEY...... 17 ketorolac tromethamine...... 3, 20 lovastatin...... 8 minocycline hcl...... 21 ketotifen fumarate...... 20 LOW-OGESTREL...... 13 minoxidil...... 8 KIONEX...... 19 loxapine succinate...... 10 mirtazapine...... 6 KORLYM...... 7 LUCEMYRA...... 21 misoprostol...... 22 KURVELO...... 13 LUMIGAN...... 20 modafinil...... 3 labetalol hcl...... 12 LUTERA...... 13 moexipril hcl...... 8 LACRISERT...... 20 LYSODREN...... 9 mometasone furoate...... 15 lactated ringers...... 19 LYZA...... 13 MONO-LINYAH...... 13 lactulose...... 18 malathion...... 15 MONONESSA...... 13 lactulose encephalopathy...... 17 maprotiline hcl...... 6 montelukast sodium...... 5 lamivudine...... 11 marlissa...... 13 morphine sulfate...... 4 lamivudine-zidovudine...... 11 MATULANE...... 9 morphine sulfate er...... 4 lamotrigine...... 6 MATZIM LA...... 12 moxifloxacin hcl...... 17 LAMPIT...... 9 MAVYRET...... 11 multivitamin/fluoride...... 19 lansoprazole...... 22 meclizine hcl...... 7 mupirocin...... 15 lanthanum carbonate...... 17 medroxyprogesterone acetate...... 21 mupirocin calcium...... 15 lapatinib ditosylate...... 9 mefloquine hcl...... 9 mycophenolate mofetil...... 19 LARIN 1.5/30...... 13 megestrol acetate...... 9, 21 mycophenolate sodium...... 19 LARIN 1/20...... 13 MEKTOVI...... 9 MYLERAN...... 10 LARIN 24 FE...... 13 meloxicam...... 3 MYORISAN...... 15 LARIN FE 1.5/30...... 13 melphalan...... 9 nabumetone...... 3 LARIN FE 1/20...... 13 memantine hcl...... 21 nadolol...... 12 LARISSIA...... 13 memantine hcl er...... 21 naloxone hcl...... 7 latanoprost...... 20 MENOSTAR...... 17 naltrexone hcl...... 7 LAYOLIS FE...... 13 mercaptopurine...... 9 naproxen...... 3 LEENA...... 13 mesalamine...... 17 naproxen dr...... 3 leflunomide...... 3 mesalamine er...... 17 naratriptan hcl...... 18 LESSINA...... 13 MESNEX...... 9 NARCAN...... 7 letrozole...... 9 metaxalone...... 19 NATACYN...... 20 leucovorin calcium...... 9 metformin hcl...... 7 NATAZIA...... 13 LEUKERAN...... 9 metformin hcl er...... 7 nateglinide...... 7 levetiracetam...... 6 methadone hcl...... 4 NECON 0.5/35 (28)...... 13 levetiracetam er...... 6 methazolamide...... 16 NECON 1/35 (28)...... 13 levobunolol hcl...... 20 methenamine mandelate...... 9 neomycin sulfate...... 3 levocarnitine...... 16 methimazole...... 21 neomycin-bacitracin zn-polymyx...... 20 levocetirizine dihydrochloride...... 8 methitest...... 4 neomycin-polymyxin b gu...... 17 levofloxacin...... 17, 20 methocarbamol...... 19 neomycin-polymyxin-dexameth...... 20 LEVONEST...... 13 methotrexate...... 9 neomycin-polymyxin-gramicidin...... 20 levonorgest-eth estrad 91-day...... 13 methotrexate sodium...... 10 neomycin-polymyxin-hc...... 20 levonorgestrel-ethinyl estrad...... 13 methotrexate sodium (pf)...... 9 NEOTUSS PLUS...... 14 LEVORA 0.15/30 (28)...... 13 methscopolamine bromide...... 22 nevirapine...... 11 levothyroxine sodium...... 21 methyldopa...... 8 nevirapine er...... 11 LEVOXYL...... 21 methyldopa-hydrochlorothiazide...... 8 nicardipine hcl...... 12 LEXIVA...... 11 methylergonovine maleate...... 20 NICOTROL...... 21 lidocaine...... 15 methylphenidate hcl...... 3 NICOTROL NS...... 21 lidocaine hcl...... 15, 18 methylphenidate hcl er...... 3 nifedipine...... 12 lidocaine-hydrocortisone ace...... 4 methylphenidate hcl er (cd)...... 3 nifedipine er...... 12 lidocaine-prilocaine...... 15 methylphenidate hcl er (la)...... 3 nifedipine er osmotic release...... 12 lindane...... 15 methylprednisolone...... 14 NIKKI...... 13 linezolid...... 9 metoclopramide hcl...... 17 nilutamide...... 10 liothyronine sodium...... 21 metolazone...... 16 nisoldipine er...... 12 lisinopril...... 8 metoprolol succinate er...... 12 NITRO-BID...... 4 lisinopril-hydrochlorothiazide...... 8 metoprolol tartrate...... 12 nitrofurantoin...... 9 lithium...... 10 metoprolol-hydrochlorothiazide...... 8 nitrofurantoin macrocrystal...... 9 lithium carbonate...... 10 metronidazole...... 9, 15, 22 nitrofurantoin monohyd macro...... 9 lithium carbonate er...... 10 mexiletine hcl...... 5 nitroglycerin...... 4 LO LOESTRIN FE...... 13 MIBELAS 24 FE...... 13 nitroglycerin er...... 4 LOKELMA...... 19 MICROGESTIN 1.5/30...... 13 nizatidine...... 22 loperamide hcl...... 7 MICROGESTIN 1/20...... 13 NORA-BE...... 13 lopinavir-ritonavir...... 11 MICROGESTIN FE 1.5/30...... 13 norethin ace-eth estrad-fe...... 13

12.01.2020

26 I n d e x I n d e x I n d e x norethindrone...... 13 pb-hyoscy-atropine-scopolamine...... 22 pregabalin...... 6 norethindrone acetate...... 21 peg 3350-kcl-na bicarb-nacl...... 18 PREMARIN...... 17, 22 norethindrone acet-ethinyl est...... 13 peg-3350/electrolytes...... 18 PREMPRO...... 17 norethindrone-eth estradiol...... 17 PEGASYS...... 11 prenatal...... 19 norethin-eth estradiol-fe...... 13 PEGINTRON...... 11 prenatal 19...... 19 norgestimate-eth estradiol...... 13 penicillamine...... 19 prenatal plus iron...... 19 norgestim-eth estrad triphasic...... 13 penicillin v potassium...... 21 prenatal plus/iron...... 19 NORLYROC...... 13 pentamidine isethionate...... 9 pretomanid...... 9 NORPACE CR...... 5 PENTASA...... 17 PREVIFEM...... 14 NORTREL 0.5/35 (28)...... 13 pentazocine-naloxone hcl...... 4 PREZCOBIX...... 11 NORTREL 1/35 (21)...... 13 pentoxifylline er...... 17 PREZISTA...... 11 NORTREL 1/35 (28)...... 13 perindopril erbumine...... 8 primaquine phosphate...... 9 NORTREL 7/7/7...... 13 permethrin...... 16 primidone...... 6 nortriptyline hcl...... 6 perphenazine...... 10 probenecid...... 17 NORVIR...... 11 perphenazine-amitriptyline...... 21 prochlorperazine...... 10 NOXAFIL...... 8 PERSERIS...... 10 prochlorperazine maleate...... 10 np thyroid...... 21 phenazopyridine hcl...... 17 progesterone micronized...... 21 NUCALA...... 5 phenelzine sulfate...... 6 PROMACTA...... 18 NUCYNTA...... 4 phenobarbital...... 18 promethazine hcl...... 8 NUCYNTA ER...... 4 phenoxybenzamine hcl...... 8 promethazine vc/codeine...... 14 NUEDEXTA...... 21 phenylephrine hcl...... 20 promethazine-codeine...... 14 nystatin...... 8, 15, 19 phenytoin...... 6 promethazine-dm...... 14 nystatin-triamcinolone...... 15, 16 phenytoin infatabs...... 6 propafenone hcl...... 5 OCELLA...... 14 phenytoin sodium extended...... 6 propafenone hcl er...... 5 octreotide acetate...... 16 PHILITH...... 14 propantheline bromide...... 22 ODEFSEY...... 11 PHOSLYRA...... 17 propranolol hcl...... 12 ofloxacin...... 20 PHOSPHOLINE IODIDE...... 20 propranolol hcl er...... 12 olanzapine...... 10 PHYSIOLYTE...... 19 propranolol-hctz...... 8 olmesartan medoxomil...... 8 PHYSIOSOL IRRIGATION...... 19 propylthiouracil...... 21 olmesartan medoxomil-hctz...... 8 phytonadione...... 22 protriptyline hcl...... 6 olopatadine hcl...... 20 PIFELTRO...... 11 PULMOZYME...... 21 omeprazole...... 22 pilocarpine hcl...... 19, 20 PYLERA...... 22 OMNIPOD DASH 5 PACK PODS...... 18 pimecrolimus...... 16 pyrazinamide...... 9 ondansetron...... 7 pimozide...... 21 pyridostigmine bromide...... 9 ondansetron hcl...... 7 PIMTREA...... 14 pyridostigmine bromide er...... 9 opium...... 7 pindolol...... 12 pyrimethamine...... 9 OPSUMIT...... 12 pioglitazone hcl...... 7 quazepam...... 18 ORACIT...... 17 pioglitazone hcl-glimepiride...... 7 quetiapine fumarate...... 10 ORKAMBI...... 21 pioglitazone hcl-metformin hcl...... 7 quetiapine fumarate er...... 10 orphenadrine citrate er...... 19 PIRMELLA 1/35...... 14 quinapril hcl...... 8 ORSYTHIA...... 14 PIRMELLA 7/7/7...... 14 quinapril-hydrochlorothiazide...... 9 oseltamivir phosphate...... 11 piroxicam...... 3 quinidine gluconate er...... 5 oxandrolone...... 4 polyethylene glycol 3350...... 18, 21 quinidine sulfate...... 5 oxazepam...... 5 polymyxin b-trimethoprim...... 20 quinine sulfate...... 9 oxcarbazepine...... 6 polysaccharide iron forte...... 18 QVAR REDIHALER...... 5 oxybutynin chloride...... 22 PORTIA-28...... 14 rabeprazole sodium...... 22 oxybutynin chloride er...... 22 posaconazole...... 8 raloxifene hcl...... 16 oxycodone hcl...... 4 potassium chloride...... 18 ramipril...... 9 oxycodone hcl er...... 4 potassium chloride crys er...... 18 rasagiline mesylate...... 10 oxycodone-acetaminophen...... 4 potassium chloride er...... 18 RECLIPSEN...... 14 oxycodone-aspirin...... 4 potassium citrate er...... 17 RELENZA DISKHALER...... 11 OXYCONTIN...... 4 potassium citrate-citric acid...... 17 RENACIDIN...... 17 oxymorphone hcl...... 4 PRADAXA...... 6 repaglinide...... 7 oxymorphone hcl er...... 4 pramipexole dihydrochloride...... 10 RETACRIT...... 18 OZEMPIC (0.25 OR 0.5 MG/DOSE)...... 7 prasugrel hcl...... 17 REVLIMID...... 19 OZEMPIC (1 MG/DOSE)...... 7 pravastatin sodium...... 8 REYATAZ...... 11 pacerone...... 5 prazosin hcl...... 8 ribavirin...... 11 PANCREAZE...... 16 PRED MILD...... 20 RIDAURA...... 3 pantoprazole sodium...... 22 prednicarbate...... 16 rifabutin...... 9 paricalcitol...... 16 prednisolone...... 14 rifampin...... 9 paromomycin sulfate...... 3 prednisolone acetate...... 20 riluzole...... 19 paroxetine hcl...... 6 prednisolone sodium phosphate...... 14, 20 rimantadine hcl...... 11 paroxetine hcl er...... 6 prednisone...... 14 ringers irrigation...... 19 PAXIL...... 6 PREDNISONE INTENSOL...... 14 RIOMET...... 7

12.01.2020

27 I n d e x I n d e x I n d e x risedronate sodium...... 16 STRIBILD...... 11 TIVICAY...... 11 risperidone...... 10 STRIVERDI RESPIMAT...... 5 TIVICAY PD...... 11 ritonavir...... 11 SUBOXONE...... 4 tizanidine hcl...... 19 rivastigmine tartrate...... 21 SUCRAID...... 16 TOBI PODHALER...... 3 rizatriptan benzoate...... 18 sucralfate...... 22 tobramycin...... 3, 20 ropinirole hcl...... 10 sulfacetamide sodium...... 16, 20 tobramycin-dexamethasone...... 20 ropinirole hcl er...... 10 sulfacetamide sodium (acne)...... 16 tolbutamide...... 7 rosuvastatin calcium...... 8 sulfacetamide sodium-sulfur...... 16 tolterodine tartrate...... 22 rufinamide...... 6 sulfacetamide-prednisolone...... 20 tolterodine tartrate er...... 22 rukobia...... 11 sulfacetamide-sulfur in urea...... 16 topiramate...... 6 RYBELSUS...... 7 sulfadiazine...... 21 toremifene citrate...... 10 salicylic acid...... 16 sulfamethoxazole-trimethoprim...... 9 torsemide...... 16 salicylic acid-cleanser...... 16 sulfasalazine...... 17 TRACLEER...... 12 salsalate...... 3 sulindac...... 3 TRADJENTA...... 7 sapropterin dihydrochloride...... 16 sumatriptan succinate...... 18 tramadol hcl...... 4 SEGLUROMET...... 7 sumatriptan succinate refill...... 18 tramadol hcl er...... 4 selegiline hcl...... 10 SUPRAX...... 12 tramadol hcl er (biphasic)...... 4 selenium sulfide...... 16 SUPREP BOWEL PREP KIT...... 18 tramadol-acetaminophen...... 4 SELZENTRY...... 11 SUSTIVA...... 11 trandolapril...... 9 SEREVENT DISKUS...... 5 SUTENT...... 10 tranexamic acid...... 18 sertraline hcl...... 6 SYEDA...... 14 tranylcypromine sulfate...... 6 SETLAKIN...... 14 SYMDEKO...... 21 travoprost (bak free)...... 20 sevelamer carbonate...... 17 SYMJEPI...... 22 trazodone hcl...... 6 sevelamer hcl...... 17 SYMLINPEN 120...... 7 tretinoin...... 10, 16 sf 5000 plus...... 19 SYMLINPEN 60...... 7 TREXALL...... 10 SFROWASA...... 17 SYMTUZA...... 11 TRI FEMYNOR...... 14 SHAROBEL...... 14 SYNAGIS...... 20 triamcinolone acetonide...... 16, 19 sildenafil citrate...... 12 SYNAREL...... 16 triamterene-hctz...... 16 silver nitrate...... 16 SYNTHROID...... 21 triazolam...... 18 silver sulfadiazine...... 16 TABLOID...... 10 tricitrates...... 17 SIMBRINZA...... 20 tacrolimus...... 16, 19 trientine hcl...... 19 simvastatin...... 8 tadalafil (pah)...... 12 TRI-ESTARYLLA...... 14 sirolimus...... 19 tamoxifen citrate...... 10 trifluoperazine hcl...... 10 SKLICE...... 16 tamsulosin hcl...... 17 trifluridine...... 20 sodium chloride...... 14 TARINA FE 1/20...... 14 trihexyphenidyl hcl...... 10 sodium fluoride...... 19 TASIGNA...... 10 TRI-LEGEST FE...... 14 sodium polystyrene sulfonate...... 19 TAZTIA XT...... 12 TRI-LINYAH...... 14 SOLIA...... 14 TEKTURNA HCT...... 9 TRI-LO-ESTARYLLA...... 14 solifenacin succinate...... 22 telmisartan...... 9 TRI-LO-MARZIA...... 14 SOMAVERT...... 16 telmisartan-hctz...... 9 TRI-LO-SPRINTEC...... 14 sorbitol...... 17 temazepam...... 18 trimethobenzamide hcl...... 7 sorbitol-mannitol...... 17 TEMIXYS...... 11 trimethoprim...... 9 sotalol hcl...... 12 temozolomide...... 10 trimipramine maleate...... 6 sotalol hcl (af)...... 12 tenofovir disoproxil fumarate...... 11 TRINESSA (28)...... 14 spinosad...... 16 terazosin hcl...... 9 TRI-PREVIFEM...... 14 SPIRIVA HANDIHALER...... 5 terbinafine hcl...... 8 TRI-SPRINTEC...... 14 SPIRIVA RESPIMAT...... 5 terbutaline sulfate...... 5 TRIUMEQ...... 11 spironolactone...... 16 terconazole...... 22 TRIVORA (28)...... 14 spironolactone-hctz...... 16 teriparatide (recombinant)...... 16 TRI-VYLIBRA...... 14 SPRINTEC 28...... 14 testosterone...... 4 tropicamide...... 20 SPRYCEL...... 10 testosterone cypionate...... 4 trospium chloride...... 22 SPS...... 19 testosterone enanthate...... 4 trospium chloride er...... 22 SRONYX...... 14 tetrabenazine...... 21 TRULICITY...... 7 STALEVO 100...... 10 tetracycline hcl...... 21 TRUVADA...... 11 STALEVO 125...... 10 THALOMID...... 19 TYBOST...... 11 STALEVO 150...... 10 theophylline...... 5 TYDEMY...... 14 STALEVO 200...... 10 theophylline er...... 5 TYMLOS...... 17 STALEVO 50...... 10 THIOLA...... 17 UDENYCA...... 18 STALEVO 75...... 10 thioridazine hcl...... 10 UNITHROID...... 21 stavudine...... 11 thiothixene...... 10 ursodiol...... 17 STEGLATRO...... 7 tiagabine hcl...... 6 valacyclovir hcl...... 11 sterile water for irrigation...... 19 TILIA FE...... 14 valganciclovir hcl...... 11, 12 STIOLTO RESPIMAT...... 5 timolol maleate...... 12, 20 valproic acid...... 6 STRENSIQ...... 16 tinidazole...... 9 valsartan...... 9

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28 I n d e x valsartan-hydrochlorothiazide...... 9 vancomycin hcl...... 9 VELIVET...... 14 VELTASSA...... 19 VEMLIDY...... 12 venlafaxine hcl...... 6 venlafaxine hcl er...... 6 verapamil hcl...... 12 verapamil hcl er...... 12 V-GO 20...... 18 V-GO 30...... 18 V-GO 40...... 18 VICTOZA...... 7 VIENVA...... 14 vigabatrin...... 6 VIMPAT...... 6 viorele...... 14 VIRACEPT...... 12 VIRAMUNE...... 12 VIREAD...... 12 virt-phos 250 neutral...... 19 VISTOGARD...... 7 vitamin d (ergocalciferol)...... 22 VIVITROL...... 7 vol-plus...... 19 voriconazole...... 8 VYFEMLA...... 14 warfarin sodium...... 6 WERA...... 14 WIXELA INHUB...... 5 WYMZYA FE...... 14 XARELTO...... 6 XARELTO STARTER PACK...... 6 XULANE...... 14 XURIDEN...... 17 YUVAFEM...... 22 zaleplon...... 18 ZARAH...... 14 ZARXIO...... 18 ZELAPAR...... 10 ZEPOSIA...... 21 ZEPOSIA 7-DAY STARTER PACK...... 21 ZEPOSIA STARTER KIT...... 21 zidovudine...... 12 ziprasidone hcl...... 10 ZITHRANOL...... 16 ZOLINZA...... 10 zolmitriptan...... 18 zolpidem tartrate...... 18 zolpidem tartrate er...... 18 zonisamide...... 6 ZORTRESS...... 19 ZOVIA 1/35E (28)...... 14 ZYPREXA RELPREVV...... 10

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