BlueCross BlueShield of Western New York Formulary 3/ Exclusive Please bring this guide with you the next time you visit your doctor.

If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com. CRP2107_009678.1 MG009678G (Revise Date 07/01/2021)

A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association. Inside front cover TABLE OF CONTENTS

Introduction ...... iii

Understanding the symbols used throughout this book ...... iii Using this formulary book to help contain costs . iv Save Money on Your Prescription Drugs...... iv Finding Medications in the Guide ...... v

Section 1 — Therapeutic Drug Categories...... 1

Section II — Index...... 8

ii The BlueCross BlueShield of Western New York Formulary 3/Exclusive is a list of drugs to help guide physi- cians and pharmacists to select the medication that provides the appropriate treatment for the best price.

Introduction

BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

Understanding the symbols used throughout this book Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows:

Key

P = A step edit applies to this drug. Step therapy means that in order to receive the medication with a step edit, a preferred medication must be tried first. z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication.  = Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. + = Access restricted to specialty pharmacy. Medications must be obtained through a specialty pharmacy.  = Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA Preventive Drug List.

iii Using this formulary book to help contain costs

The formulary offers a wide range of outpatient medications.

Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed for- mulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card.

Save Money on Your Prescription Drugs Here’s what you can do to save money:

1. Bring this member guide to your doctor and review the cost-saving information below.

2. Ask your doctor whether a drug listed in this guide is right for you.

The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans also exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage.

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan. Affordable Care Act (ACA) Preventive Drug List The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at $0. They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan documents to confirm if the ACA Preventive Drug List applies to you.

We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on page iii. This list is reviewed periodically and is subject to change.

The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care provider and require a valid prescription.

* Some plan designs require that you use a Tier 1 generic drug if a generic is available.

Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3/Exclusive. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.

iv Contraceptive Coverage under New York Insurance Law Contraceptives (for members whose benefits align with contraceptive coverage requirements under New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives with a generic equivalent are covered at the copayment based on your plan design unless deemed medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on the prescription in order for the brand-name contraceptive with a generic equivalent to be considered medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC) products are covered only when prescribed by a licensed health care provider and require a valid prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan.

Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide for specific product examples.

Finding Medications in the Guide This guide lists medications two different ways:

Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)

Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).

Section 2: Alphabetically by drug name. Use this list to find your drug.

Questions? Please call Pharmacy Services at 1 866 237-0333 if you have any questions about the BlueCross BlueShield of Western New York Formulary 3/Exclusive. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com.

v Section I — Therapeutic drug categories

TIER TIER TIER TIER z z Allergy/Cough & Cold P Detrol LA 3 Leukeran 2 + Idhifa 3 z Ditropan XL 3 Myleran 2 + z Inrebic 3 Antihistamines & Decongestants P  z Enablex 3 Antimetabolites + z Kesimpta 3 brompheniramine/ phenylephrine 1 P  z z Gelnique 3 + capecitabine 1 +P Kisqali 3 brompheniramine/ pseudoephedrine 1 Pz + z Kisqali Femara Co-Pack 3 z carbinoxamine 1 P Myrbetriq 3 mercaptopurine 1  P z Oxytrol 3 methotrexate 1 z Koselugo 3 cetirizine 1 P  z z Sanctura 3 Purixan 2 + Lorbrena 3 clemastine 1 P z Mektovi 3 cyproheptadine 1 z Sanctura XR 3 + z Inqovi 3  zP  + z Nerlynx 3 dexchlorpheniramine 1 solifenacin 3 + Onureg 3  z Toviaz 3 Trexall 3 z Orgovyx 3 diphenhydramine 1 P z z Vesicare 3 z Xatmep 3  Pemazyre 3 hydroxyzine HCl 1 P  z Cholinergic Agents + Piqray 3 hydroxyzine pamoate 1 Hormones z Qinlock 3 z levocetirizine 1 Urecholine 3 anastrozole 1  z  + Retevmo 3 loratadine 1 Miscellaneous bicalutamide 1 + z Rozlytrek 3 loratadine-D 1 z exemestane 1  P Gemtesa 3  + z Rubraca 3 pseudoephedrine 1 z Jynarque 3 flutamide 1 z   Rydapt 3 Semprex-D 2 letrozole 1 + z Tabrecta 3 z Clarinex-D 3 Blood    leuprolide 1 + z Talzenna 3 z desloratadine 3 Anticoagulants/Antithrombotics megestrol 1 z z + Tarceva 3  Grastek 3 anagrelide 1 tamoxifen 1 z z   Tazverik 3  Odactra 3 aspirin 325mg OTC 1 Fareston 2 z  + Temodar 3  Oralair 3 aspirin 81mg OTC 1 + z Nubeqa 3 z z    Tepmetko 3  Palforzia 3 aspirin-dipyridamole 1 Miscellaneous z Tibsovo 3 z Ragwitek 3 clopidogrel 1 z   + abiraterone acetate 1 z Tukysa 3 Expectorant & Cough Products dipyridamole 1 z z + erlotinib 1  Turalio 3 benzonatate 1 enoxaparin 1 etoposide 1 + z Tykerb 3 guaifenesin/codeine 1 fondaparinux sodium 1 z  + everolimus (generic Afinitor) 1  Ukoniq 3 hydrocodone/chlorpheniramine 1 heparin 1 hydroxyurea 1 z Venclexta 3 hydrocodone/homatropine 1 z  jantoven 1 + imatinib 1 + z Vitrakvi 3 promethazine/codeine 1 + z lapatinib 1 z ticlopidine 1  + Vizimpro 3 promethazine/DM 1 warfarin 1 nilutamide 1 + Xgeva 3 promethazine/phenylephrine/ codeine 1 + temozolamide 1 z Coumadin 2   Xospata 3 pseudoephedrine/codeine 1 Eliquis 2 + z Arcalyst 2 z Xpovio 3 z  Cardec/DM 3 Fragmin 2 + Bosulif 2 + z Yonsa 3 + z Cabometyx 2 z Guaifenesin DM 3 Xarelto 2   Zejula 3 Hycodan 3 Bevyxxa 3 z Caprelsa 2 + z Zytiga 3  z P Rondec DM/TR 3 Brilinta 3 + Cometriq 2 Rexinoids Vituz 3 z + z Cotellic 2 Durlaza 3  + bexarotene 1 Mucolytic Agents Innohep 3 + z Erivedge 2 z + Targretin gel 2 acetylcysteine inh soln. 1 prasugrel 3 + Farydak 2 + z Gilotrif 2 Diabetes Nasal Medications z Pradaxa 3  z Savaysa 3 + Hycamtin capsule 2 Please refer to your plan documents to confirm your azelastine nasal spray 1 + z Ibrance 2 budesonide nasal spray 1 z Zontivity 3  cost share for diabetic drugs. Cost share may vary z Iclusig 2 by plan. Clarispray 1 Other Blood Modifiers z  Imbruvica 2 Antidiabetic Agents, Injectable Flonase Allergy Relief 1 cilostazol 1 + z Inlyta 2 Flonase Sensimist 1 + deferasirox 1  Basaglar 2 + Intron A 2 z Bydureon 2 z fluticasone nasal spray 1 pentoxifylline 1 + z Iressa 2 z  z Byetta 2 ipratropium nasal spray 1  trientine 1 + z Jakafi 2 z Nasacort Allergy 24HR 1 + z Actimmune 2 z Humalog insulin 2  + Lenvima 2 Humulin (all types) 2 Rhinocort Allergy 1 + Aranesp 2 + z Lonsurf 2 triamcinolone nasal spray 1 + Fulphila 2 z Lantus 2 + Lynparza 2 Lyumjev 2 Atrovent Nasal Spray 3 + Leukine 2 Lysodren 2 z Miacalcin inj. 2 z Ozempic 2 P Beconase AQ 3 Matulane 2 z Dymista 3 Neulasta 2 + z Mekinist 2 Soliqua 2 z  z Symlin 2 z flunisolide nasal spray 3 + Promacta 2 Mesnex 2  z + Retacrit 2 z Toujeo 2 P mometasone nasal spray 3 + Nexavar 2 z z + z Revlimid 2 + z Ninlaro 2 Trulicity 2 P Nasacort AQ 3   z Victoza 2 z Omnaris 3 z Zarxio 2 + z Odomzo 2 P + Alprolix 3 z z Adlyxin 3 z Qnasl 3 + Pomalyst 2 P Pz z Cablivi 3 + z Sprycel 2 P Admelog 3  Xhance 3   Apidra 3 z deferiprone 3 + Stivarga 2 P P Zetonna 3  z  Fiasp 3 + Doptelet 3 + z Sutent 2 P Alzheimer Agents + Eloctate 3 z Insulin Lispro 3  Sylatron 2 P z donepezil 1 + z Endari 3 z Synribo 2 P Levemir 3   Novolin 3 ergoloid mesylates 1 + Epogen 3 + z Tafinlar 2 P + Exjade 3 z Novolog 3 z galantamine 1 + Tagrisso 2 P z Ferriprox 3 z Semglee 3 galantamine ER 1  + Tasigna 2 Pz z memantine 1 + Granix 3 + Thalomid 2 P Tanzeum 3  Tresiba 3 z rivastigmine 1 + Hemlibra 3 + z Valchlor 2 P + Jadenu 3 z z Xultophy 3 z rivastigmine patch 1 + Verzenio 2 z memantine ER 3 + Jivi 3 + z Votrient 2 Antidiabetic Agents, Glucose Elevating Agents Mircera 3 z acarbose 1 z Namzaric 3  + Xalkori 2 + z Mulpleta 3 + z Xtandi 2 chlorpropamide 1 Bladder/Kidney   z + Neupogen 3 + z Zelboraf 2 glimepiride 1 + Nivestym 3 z glipizide 1 Acidifiers  + Zolinza 2 K-Phos 2 + Nyvepria 3 + z Zydelig 2 z glipizide ER 1 P  z Alkalinizers  Omontys 3 + z Zykadia 2 glipizide/metformin 1 + z Oxbryta 3  z glyburide 1 potassium citrate 1  +P Afinitor 3 + Procrit 3 + z Alecensa 3 glyburide micronized 1 Oracit 3 z Tavalisse 3 z metformin 1  + Alunbrig 3 Analgesics + Udenyca 3 z Ayvakit 3 z metformin ER (generic Glucophage XR) 1 phenazopyridine 1 P  z +P Ziextenzo 3 z Balversa 3 metformin/glyburide 1 Anticholinergics z z z nateglinide 1 Zontivity 3  Braftovi 3 z oxybutynin 1 z Brukinsa 3 z pioglitazone/metformin 1 z oxybutynin ER 1 Cancer Drugs z z repaglinide 1  Calquence 3 z Oxytrol for Women 1 Alkylating Agents z Copiktra 3 tolazamide 1 z tolterodine 1 cyclophosphamide 1  z tolbutamide 1 + Daurismo 3 z tolterodine ER 1 Alkeran 2 + z Erleada 3 z Avandamet 2 z  z trospium 1 CeeNu 2  Fotivda 3 Avandaryl 2 z trospium ER 1 Emcyt 2 Gavreto 3 z Avandia 2 z  z z P Detrol 3 Hexalen 2 +P Gleevec 3 Duetact 2 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

1 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER z Farxiga 2 Tobrex ointment 2 colchicine/probenecid 1 Antara 3 Glucagon 2 Azasite 3 probenecid 1 colesevelam 3 z zu Invokamet/XR 2 Besivance 3 z Mitigare 2  Crestor 3 z Invokana 2 Ciloxan 3 z z Epanova 3  Duzallo 3 z Janumet 2 Tobrex solution 3 z z Ezallor 3 P febuxostat 3  z Janumet XR 2 Anti-inflammatory z Gloperba 3 z ezetimibe-simvastatin 3 z Januvia 2 fluorometholone ophth 1 z Fenofibrate (brand) 3 P Uloric 3 z Jardiance 2 loteprednol 1 z Zurampic 3 z fenofibric acid, capsule, delayed release 3 Jentadueto 2 loteprednol etabonate susp 1  Fenoglide 3 z Jentadueto XR 2 prednisolone acetate 1 Heart Fibricor 3 z Juvisync 2 prednisolone sod phosphate 1 Angiotensin Converting Enzyme Inhibitors  fluvastatin 3 z Rybelsus 2 FML Forte 2 benazepril 1 + z Juxtapid 3 z zu Synjardy/XR 2 FML S.O.P. 2 captopril 1  Lescol 3 Tradjenta 2 Lotemax ointment 2 enalapril 1 z Lescol XL 3 z zu Trijardy XR 2 Lotemax SM 2 fosinopril 1  Lipitor 3 z Xigduo XR 2 Pred Mild 2 lisinopril 1 Lipofen 3  Afrezza 3 Flarex 3 moexipril 1  Livalo 3 Baqsimi 3 Lotemax gel 3 perindopril 1 zu Mevacor 3 z P Fortamet 3 Maxidex 3 quinapril 1 z Nexletol 3 z z P Glumetza 3 Anti-inflammatory/Anti-infective combinations ramipril 1  Nexlizet 3 z Glyxambi 3 dexameth/neomycin/poly B 1 trandolapril 1 z Nikita 3 Kazano 3 z z omega-3 acid ethyl esters 3 P neomycin/bacitracin/poly B/HC 1  Epaned 3 P Kombiglyze XR 3 sulfacetamide/prednisolone ophth 1 z Qbrelis 3 z Omtryg 3 z  zu P metformin ER (except generic tobramycin/dexameth 1 Angiotensin II Antagonists  Pravachol 3 Glucophage XR) 3 Tobradex ointment 2 z candesartan 1 Tricor 3 miglitol 3 Maxitrol ophth 3 z eprosartan 600mg 1 Triglide 3 P Nesina 3 Pred-G 3 z irbesartan 1 Vascepa 3 zu P Onglyza 3 Zylet 3 z losartan 1  Zocor 3 Oseni 3 z olmesartan 1 z Zypitamag 3 zP Antiviral  Qtern 3 z famciclovir ophth 1 z telmisartan 1 Beta Blockers repaglinide/metformin 3 trifluridine 1 z valsartan 1 acebutolol 1 z Segluromet 3 z atenolol 1 Beta-Blockers (Eye) P Atacand 3 z Steglatro 3 z Avapro 3 betaxolol 1 z Steglujan 3 betaxolol HCl 1 P carteolol 1 z Benicar 3 bisoprolol 1 Pz carvedilol 1 Diabetic Test Strips levobunolol 1 P Cozaar 3 metipranolol 1 z Diovan 3 carvedilol ER 1 Please refer to your plan documents to confirm your Pz labetalol 1 timolol 1 P Edarbi 3 cost share for diabetic supplies. Cost share may vary z Micardis 3 metoprolol 1 by plan. Test strips other than OneTouch require Betoptic-S 2 P Istalol 3 z Prexxartan 3 metoprolol ER 1 prior authorization. P Carbonic Anhydrase Inhibitors Anti-Adrenergic Blockers Centrally acting metoprolol/HCTZ 1 OneTouch brinzolamide 1 clonidine, oral, patch 1 nadolol 1 P Accu-Chek dorzolamide 2% eye drops 1 guanfacine 1 pindolol 1 P Ascensia Breeze dorzolamide/timolol eye drops 1 methyldopa 1 propranolol 1 timolol 1 P Contour Azopt 3 midodrine 1 z Innopran XL 2 P Freestyle Miotics + droxidopa 3 Precision + z Northera 3 Bystolic 3 P pilocarpine 1  Hemangeol 3 TRUEtest Phospholine Iodide 2 Anti-Adrenergic Blockers Peripheral P Calcium Channel Blockers P TRUEtrack Miscellaneous doxazosin 1 prazosin 1 amlodipine 1 Ear Cystaran 2 cartia XT 1 z Restasis 2 terazosin 1 Anti-infective Agents Cardura XL 3 diltia XT 1 acetic acid otic 1 z Cequa 3 diltiazem 1 + z Oxervate 3 Antiarrhythmics acetic acid/aluminum acetate 1  amiodarone 1 diltiazem CD/SR/ER/XR 1 ciprofloxacin otic 1 P Rhopressa 3 felodipine ER 1 z Rocklatan 3 digoxin 1 ofloxacin otic 1  isradipine 1 z Xiidra 3 disopyramide 1 Domeboro 3 dofetilide 1 nicardipine 1 Xtoro 3 Mydriatics nifediac CC 1 atropine sulfate ophth 1 flecainide 1 Anti-infective/Anti-inflammatory combinations mexiletine 1 nifedical XL 1 homatropine 1 nifedipine 1 acetic acid HC otic 1 tropicamide 1 procainamide 1 ciprofloxacin/dexamethasone 1 propafenone 1 nifedipine SR 1 NSAIDs propafenone SR 1 nimodipine 1 neomycin/polymyxin/HC otic 1 bromfenac 1 Cipro HC 3 quinidine gluconate 1 nisoldipine 1 diclofenac 1 quinidine sulfate SR 1 verapamil/SR 1 flurbiprofen ophth 1 z Eye sotalol 1 P Conjupri 3 Antiallergy Agents (Eye) Nevanac 2 Lanoxin 2 Dynacirc/CR 3 azelastine ophth 1 Acular PF 3 Multaq 3 Katerzia 3 Prolensa 3 P cromolyn ophth 1 Norpace CR 3 z Nymalize 3 olopatadine ophth 1 Prostaglandin Analogues/Prostamines Antilipidemics Combination Anti-Hypertensive Alomide 3 bimatoprost 0.03% 1 zu aliskiren 1 latanoprost 1  atorvastatin calcium 1 Bepreve 3 z amlodipine/atorvastatin 1 Xelpros 2 cholestyramine 1 ketotifen opthalmic solution 3 colestipol 1 amlodipine/benazepril 1 P Izba 3 z amlodipine/valsartan 1 olopatadine 0.2% drop 3 Lumigan 3 z ezetimibe 1 Pazeo 3 P atenolol/chlorthalidone 1 Rescula 3 fenofibrate (generic) 1 benazepril/HCTZ 1 Cystadrops 3 P fenofibric acid, tab 1  P Travatan Z 3 bisoprolol/HCTZ 1 Zaditor 3 travoprost (generic Travatan Z) 3 gemfibrozil 1 z candesartan/HCTZ 1 Zerviate 3 zu lovastatin 1 P P Vyzulta 3  captopril/HCTZ 1 Anti-infective Agents Xalatan 3 niacin ER 1 enalapril/HCTZ 1 bacitracin ophth 1 P niacin IR 500mg tablet 1 P Zioptan 3 P fosinopril/HCTZ 1 bacitracin/polymyxin 1 Sympathomimetics niacin (OTC) 1 z irbesartan/HCTZ 1 ciprofloxacin ophth 1 brimonidine 1 z niacin/simvastatin 1 lisinopril/HCTZ 1 zu erythromycin ophth 1 Alphagan P 0.1% 2  pravastatin 1 z losartan/HCTZ 1 z gatifloxacin 1 Upneeq 3  rosuvastatin 1 methyldopa/HCTZ 1  zu gentamicin ophth 1 Vasoconstrictors  simvastatin 1 metoprolol/HCTZ 1 moxifloxacin 0.5% (generic Vigamox) 1 naphazoline 1 Advicor 2 z olmesartan/HCTZ 1 neomycin/bacitracin/poly B 1 phenylephrine ophth 1 Colestid 2 propranolol/HCTZ 1 z ofloxacin ophth 1 + Kynamro 2 quinapril/HCTZ 1 Gout z z polymyxin B/TMP 1  Praluent 2 telmisartan/HCTZ 1 sulfacetamide 10% 1 allopurinol 1 z Repatha 2 z valsartan/HCTZ 1 z z tobramycin soln 1 colchicine (generic Colcrys) 1  Altoprev 3 P Tekturna HCT 2 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

2 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER z amlodipine/valsartan/HCTZ 3 HIV - Antivirals azithromycin tablets 1 ganciclovir 1 z Amturnide 3 cefaclor 1 +z moderiba 1 Pz Non-Nucleoside Reverse Transcriptase Inhibitor P Atacand HCT 3 cefadroxil 1 oseltamivir 1 z Avalide 3 efavirenz 1 cefdinir 1 P efavirenz/emtricit/tenofovr df 1 + ribapak 1 z Benicar HCT 3 cefpodoxime 1 + ribasphere 1 z P Edurant 2  Byvalson 3 cefprozil 1 + ribavirin 1 z Diovan HCT 3 Intelence 2  P cefuroxime 1 rimantadine 1 z Edarbyclor 3 Rescriptor 2 cephalexin 1 Pz Viramune, XR 2 z valacyclovir 1 P Hyzaar 3 ciprofloxacin 1 z Micardis HCT 3 Atripla 3 clarithromycin susp 1 valganciclovir tablets 1 P z z olmesartan/amlodipine 3 Nucleoside Analog Reverse Transcriptase Inhibitor clarithromycin tabs 1 + Epclusa 2 z olmesartan/amlodipine/HCTZ 3 Combination clindamycin 1 Epivir-HBV solution 2 z z Prestalia 3 abacavir/lamivudine/zidovudine 1 dicloxacillin 1 + Harvoni 2 z z P Tekturna 3 efavirenz/lamivu/tenofovr diop 1 doxycycline 1 Hepsera 2 z z telmisartan/amlodipine 3  emtricitabine/tenofovir disop 1 ery-tab 250mg, 333mg 1 + Mavyret 2 trandolapril/verapamil 3 lamivudine/zidovudine 1 erythromycin base 1 + Pegasys 2 z  P Valturna 3  tenofovir 300mg 1 erythromycin DR 1 Relenza 2 Diuretics Biktarvy 2 erythromycin ethylsuccinate 1 + z Sovaldi 2 acetazolamide 1 Cimduo 2 erythromycin stearate 1  + Victrelis 2 acetazolamide ER 1 Complera 2 erythromycin/sulfisoxazole 1 + z Viekira 2 Descovy 2 P amiloride 1  levofloxacin 1 Baraclude solution 3 amiloride/HCTZ 1 Dutrebis 2 minocycline 1 Odesfey 2 entecavir tablets 3 bumetanide 1 nitrofurantoin 1 + z Ledipasvir/Sofosbuvir 3 chlorothiazide 1 Stribild 2 ofloxacin 1 P chlorthalidone 1 Triumeq 2 penicillin VK 1 +P Peg-Intron 3 z Prevymis tablets 3 furosemide 1  Viread 150mg, 200mg, 250mg, sulfamethoxazole/trimethoprim 1  hydrochlorothiazide 1 40mg/scoop powder 2 tetracycline 1 + Rebetol 3 indapamide 1 Symfi 3 Ketek 2 + Ribatab 3 z methazolamide 1 Symfi Lo 3 Zmax 2 P Sitavig 3 Truvada 3 z methyclothiazide 1  Baxdela 3 +P Sofosbuvir/Velpatasvir 3 metolazone 1 Nucleoside Reverse Transcriptase Inhibitors Biaxin XL 3 z Tyzeka 3 spironolactone 1 abacavir-lamivudine 1 cefixime 3 valganciclovir solution 3 spironolactone/HCTZ 1 didanosine 1 Ceftin 3 z Valtrex 3 torsemide 1 emtricitabine 1 Cleocin 3 z Vemlidy 3 triamterene/HCTZ 1 lamivudine tabs 1 z doxycycline hyclate 50mg, 75mg, 150mg tab 3 + z Vosevi 3 z  Carospir 3 stavudine 1 erythromycin estolate 3 z Xofluza 3 Miscellaneous Cardiovascular Agents zidovudine 1 erythromycin suspension 3 + z Zepatier 3 z eplerenone 1 Emtriva solution 2 Factive 3 P z Epivir solution 2 z Other Anti-Infectives + icatibant 1 Lymepak 3 atovaquone 1 ranolazine ER 1 Videx 2 Minocin 3 Ziagen 2 dapsone tablets 1 + z tolvaptan 1 moxifloxacin 3 z z Other Noroxin 3 linezolid 1 + Berinert 2 methenamine combination 1 + z Cinryze 2 Fuzeon 2 PCE 3 z  Genvoya 2 Spectracef 3 metronidazole 1 Entresto 2 neomycin 1 + z Ruconest 2 Isentress 2 Vibramycin 3 z Juluca 2 nitrofurantoin 1 + Samsca 15mg 2 Antifungals pentamidine inhal powder 1 z Consensi 3 Selzentry 2 clotrimazole lozenge 1 Pz Tivicay 2 paromomycin 1  Corlanor 3 fluconazole 1 tinidazole 1 + z Firazyr 3 Tybost 2 flucytosine 1 z Vitekta 2 + tobramycin ampule/neb 1 + Haegarda 3 griseofulvin 1 trimethoprim 1 z Orladeyo 3 Protease Inhibitors z itraconazole 1  atazanavir 1 vancomycin caps 1 Ranexa 3 ketoconazole 1 Firvanq 2 + z Samsca 30mg 3 ritonavir tablet 1  Aptivus 2 nystatin 1 z Sivextro 2 + z Takhzyro 3 z  Crixivan 2 P oxiconazole 1 + Tobi Podhaler 2 Vecamyl 3 z z Evotaz 2 terbinafine 1 + Bethkis 3  Verquvo 3 z z Invirase 2 voriconazole 1 + Cayston 3 + Vyndamax 3 z z Dificid 3 + z Vyndaqel 3 Lexiva 2 P Oxistat lotion 2  Norvir capsule, solution 2 z Posaconazole 2 Flagyl/ER 3 Pulmonary Arterial Hypertension Prezcobix 2 z z Impavido 3 z alyq 1 Sporanox suspension 2  z Prezista 2 z Cresemba 3 + Kitabis Pak 3 + ambrisentan 1 Viracept 2 Macrodantin 3 + z bosentan 1 Ecoza 3  Protease Inhibitors Combinations z + Tobi 3 + z sildenafil 20 mg tab 1 P Ertaczo 3 z Kaletra 2 z Lamisil Oral 3 Vancocin 3 + tadalafil (generic Adcirca) 1 z z  Xifaxan 3 + Tracleer tab for susp 2 Huntington’s Disease Luzu 3 + z Tyvaso 2 z z Noxafil 3 Men’s Health z + Austedo 3 + Uptravi 2 z Ingrezza 3 Oravig 3 Impotence + z Adempas 3  z z Oxistat cream 3  + tetrabenazine 3 P z Caverject 3 + epoprostenol 3 z Tolsura 3 z + z Letairis 3 Immunosuppressants P Cialis 3 P Antimalarials z Edex 3 + z Opsumit 3 azathioprine 1  atovaquone/proguanil HCl 1 z Levitra 3 + Orenitram 3 cyclosporine 1 + z Revatio 3 chloroquine phosphate 1 z MUSE 3 P gengraf 1 mefloquine 1 + z sildenafil suspension 3 mycophenolate mofetil 1 z sildenafil citrate 25mg, 50mg, 100mg 3 Pz pyrimethamine 1 z +P Tracleer tab 3 mycophenolic acid 1 Staxyn 3 + z veletri 3 sirolimus 1 Primaquine 2 z Stendra 3  z +P Ventavis 3 tacrolimus 1 quinine sulfate 3 z tadalafil (generic Cialis) 3 Vasodilators Neoral 2 Antituberculosis z vardenafil 3 hydralazine 1 Sandimmune 2 ethambutol 1 z vardenafil ODT 3 isosorbide dinitrate 1 Astagraf XL 3 isoniazid 1 z Viagra 3 isosorbide mononitrate 1 Cellcept 3 pyrazinamide 1 Male Hormones isosorbide mononitrate SA 1 Envarsus XR 3 rifabutin 1 testosterone cypionate 1 z isoxsuprine 1  Lupkynis 3 rifampin 1 testosterone enanthate 1 minoxidil oral 1 Prograf 3 Coartem 2 z nitroglycerin pumpspray 1 Zortress 3 testosterone gel 1 nitroglycerin SR 1 Rifater 2 z testosterone pump 1 Infection Rifamate 3 nitroglycerin transdermal patch 1 P Androderm patch 3 Dilatrate SR 2 Antibacterial Agents/Antibiotics Sirturo 3 Android 3 Nitrostat SL tabs 2 amoxicillin 1 Antivirals fluoxymesterone 3 z z Gonitro 3 amoxicillin-clavulanate ER 1 acyclovir oral 1 P Axiron 3 z Minitran 3 ampicillin 1 amantadine 1 P Fortesta 3 z z NitroDur patches 3 azithromycin suspension 1 famciclovir 1 P Jatenzo 3 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

3 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER z z P Natesto 3 P Caplyta 3 Miscellaneous Multiple Sclerosis Agents P Striant 3 P Fanapt 3 + z dimethyl fumarate 1 z Antidiuretic Agents  P Testim 3 Fazaclo 3 + glatiramer acetate 1 z z desmopressin solution 1  P Testosterone gel (brand) 3 P Geodon 3 desmopressin tabs 1 + z glatopa 1 z z  P Vogelxo 3 P Invega 3 Stimate 2 + Avonex 2 z z  P Xyosted 3 P Latuda 3 DDAVP nasal spray 3 + z Gilenya 2 + z Nuplazid 3 z Prostate Health  DDAVP sol, tab 3 + Mayzent 2 z alfuzosin 1 z olanzapine/fluoxetine 3 z Nocdurna 3 + z Plegridy 2 z   z finasteride 5mg 1 P paliperidone 3 z Noctiva 3 + Rebif 2 z  z tamsulosin 1 quetiapine fumarate ER 3 Other CNS + Vumerity 2 z z z dutasteride 3 P Rexulti 3 acamprosate calcium tablet EC 1 + Zeposia 2 P z + z Aubagio 3 dutasteride/tamsulosin 3 P Risperdal 3 buprenorphine 1  z + z Bafiertam 3 P Flomax 3 P Saphris 3 buprenorphine-naloxone 1  z z + Betaseron 3  Proscar 3 P Secuado 3 buprenorphine/naloxone film 1 P P z + Copaxone 3 Rapaflo 3 P Seroquel 3 disulfiram 1  P z + z dalfampridine ER 3 silodosin 3 P Seroquel XR 3 naltrexone 1  z Uroxatral 3 z Symbyax 3 +P Extavia 3 P P riluzole 1 + z Mavenclad 3 P Versacloz 3 z Narcan Nasal Spray 2  Mental Health z Ponvory 3 P Vraylar 3 Bunavail 3  z Antidepressants z + Tecfidera 3 P Zyprexa 3 Campral dosepack 3 amitriptyline 1 z Zyprexa Zydis 3 z Evzio 3 Muscle Relaxants amitriptyline/ chlordiazepoxide 1 P Anxiolytics, Sedatives, and Hypnotics  Exservan 3 baclofen 1 amitriptyline/perphenazine 1 alprazolam/ER 1 z Gralise 3 amoxapine 1  carisoprodol 1 buspirone 1 Lucemyra 3 carisoprodol/ASA 1 bupropion 1 chloral hydrate 1 z z bupropion 12HR 1 P Horizant 3 P chlorzoxazone 1 chlordiazepoxide 1 Savella 3 cyclobenzaprine 1 bupropion 24HR 1 clorazepate 1 z z u citalopram 1 + Tegsedi 3 P cyclobenzaprine 7.5mg 1 diazepam 1 z Tiglutik 3 dantrolene sodium 1 clomipramine 1 estazolam 1 P desipramine 1 Zubsolv 3 metaxalone 1 z eszopiclone 1 Other Endocrine methocarbamol 1 desvenlafaxine succinate ER 1 flurazepam 1 doxepin 1 cinacalcet 1 orphenadrine 1 lorazepam 1 danazol 1  orphenadrine/aspirin/caffeine 1 duloxetine 1 meprobamate 1 u escitalopram 1 fludrocortisone 1 tizanidine 1 u oxazepam 1 + miglustat 1 cyclobenzaprine ER 3 fluoxetine 10mg and 20mg tablet 1 temazepam 1  fluoxetine capsule 1 + octreotide 1  Lorzone 3 triazolam 1 z z Ozobax 3 u fluvoxamine tablet 1 + Cerdelga 2 P z zaleplon 1 z imipramine 1 + Egrifta 2 Osteoporosis z zolpidem 1 z maprotiline 1 z + HP Acthar Gel 2 z alendronate 1 u mirtazapine 1 zolpidem ER 1 + Norditropin 2 + z Xyrem 2  z calcitonin-salmon 1 nefazodone 1 z + Sensipar 2 z fortical NS 1 nortriptyline 1 P Ambien 3 z Synarel 2 z Ambien CR 3  z ibandronate tabs 1 u paroxetine 1 P + Zavesca 2 z Ativan 3   raloxifene 1 phenelzine 1 z +P Genotropin 3 + z Forteo 2 P Belsomra 3  protriptyline 1 z + Humatrope 3 + z Tymlos 2 u  Dayvigo 3 P  sertraline 1 z + Increlex 3 z Actonel 3 P Edluar 3 z P tranylcypromine 1 z + Myalept 3 z Atelvia 3 trazodone 1 + Hetlioz 3 z P z Intermezzo 3  Mycapssa 3 z Binosto 3 u venlafaxine 1 P + z Natpara 3 Pz Librium 3  P Boniva 3 venlafaxine ER 1 + Nutropin/AQ 3 z Fosamax 3 u ramelteon 3 P P P Celexa 3 P + Omnitrope 3 z Fosamax D 3 Desvenlafaxine ER 3 P Rozerem 3 P P P z Silenor 3 +P Saizen 3 z risedronate 150mg 3 Desvenlafaxine fumarate ER 3 P z P Somnote 3 + Sandostatin 3 P risedronate DR 3 P Drizalma Sprinkle 3 z + Serostim 3 Fetzima 3 P Sonata 3 P Pain/Arthritis + z Xywav 3 + Somatuline Depot 3 P fluoxetine 60mg tablet 3 z + z Somavert 3 Analgesics, Opioid - Medications listed under this fluvoxamine ER capsule 3 P zolpidem ER sublingual tablet 3  category may require additional review for coverage P z Zolpimist 3 +P Tev-Tropin 3 Forfivo 3 P + Zorbtive 3 based on recommendations from the Centers for Khedezla 3 Cerebral Stimulants P Disease Control and Prevention (CDC). P z armodafinil 1 Other Miscellaneous z u Lexapro 3 z acetaminophen w/codeine 1 P dexmethylphenidate 1 + Keveyis 2 z belladonna & opium supp 1 P Luvox CR 3 + z Signifor 2 zu Oleptro ER 3 dexmethylphenidate XR 1  z butalbital/APAP/codeine 1 u dextroamphetamine tabs 1 + Carbaglu 3 z butalbital/aspirin/codeine 1 P Paxil/CR 3 Pexeva 3 generic Adderall 1 Cystadane 3 z butorphanol NS 1 P Cystagon 3 z codeine sulfate 1 P Pristiq ER 3 generic Adderall XR 1 u + Dojolvi 3 z endocet 1 P Prozac 3 generic Concerta 1 z + Enspryng 3 z fentanyl lozenge 1 P Sarafem 3 generic Dexedrine spansules 1 z  Trintellix 3 + Evrysdi 3 fentanyl patch 1 metadate ER 1 z  Viibryd 3  Firdapse 3 z hydrocodone/APAP 1 methylphenidate CD 1 z u Zoloft 3 + Galafold 3 z hydrocodone/ibuprofen 1 P methylphenidate/SR 1 z z  Isturisa 3 hydromorphone 1 Antimanic Agents z modafinil 1 z z meperidine 1 lithium carbonate 1  Korlym 3 procentra 1 + Procysbi 3 methadone 1 Antipsychotic Agents z Adhansia XR 3  P + Ravicti 3  morphine SR 1 aripiprazole 1 z Adzenys 3  z morphine sulfate ER 1 chlorpromazine 1 P  Revcovi 3  P Aptensio XR 3 + z Ruzurgi 3  morphine tab, soln, supp 1 clozapine 1 atomoxetine 3  z oxycodone 1 fluphenazine 1 sodium phenylbutyrate 3 z Cotempla XR 3 Strensiq 3 z oxycodone/acetaminophen 1 haloperidol 1 P  z z Dyanavel XR 3 z Veltassa 3 oxycodone/aspirin 1 loxapine 1 P z oxycodone/ibuprofen 1 z P Focalin XR 3 z Xuriden 3 olanzapine 1 guanfacine ER 3  oxymorphone/ER 1 perphenazine 1 z Zokinvy 3  z Jornay PM 3  z pentazocine/naloxone 1 z quetiapine 1 P Miscellaneous Immunologicals z Abstral 3 z risperidone 1 Methylphenidate ER (brand) 3 + Cutaquig 3 Pz z  P Actiq 3 z risperidone m-tab 1 P Mydayis 3 + Cuvitru 3 z Belbuca 3 z Quillichew ER 3  thioridazine 1 P + Gammagard Liquid 3 Buprenorphine 7.5mg TD patch 3 thiothixene 1 Quillivant XR 3 + Gammaked 3 buprenorphine TD patch (generic) 3 Vyvanse 3  trifluoperazine 1 P + Gamunex-C 3 Butrans 3 z ziprasidone caps 1 Miscellaneous + Hizentra 3 z Demerol 3 z  z Abilify 3  Sunosi 3 + HyQvia 3  Embeda 3 Pz z z  Abilify Mycite 3 + Wakix 3 + Xembify 3  Fentanyl buccal tablet 3 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

4 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER

 fentanyl patch 37.5mcg/hr, 62.5mcg/hr, tramadol ER capsule 3 Respiratory/Asthma theophylline/SR tabs, liquid 1 and 87.5mcg/hr 3 z Theo-24 2 P Treximet 3 Adrenergic z Fentora 3 z Elixophyllin 3 P +P Zecuity 3 epinephrine auto-injector 1 Fioricet/codeine 3 z  P Zembrace 3 Epinephrine (Impax) 2 Seizures Fiorinal/codeine 3 z Zomig 3  P Epinephrine 0.15mg/0.3ml (Mylan) 2 Barbiturates  hydromorphone ER 3 z Zomig Nasal 3 P P Adrenaclick 3 mephobarbital 1  Hysingla ER 3 z Zomig ZMT 3 P P Auvi-Q 3 phenobarbital 1  Kadian 3 Nonsteroidal Anti-Inflammatory/Combination Epipen/Jr. 3 z Lazanda 3 P Hydantoins P Products P Symjepi 3 phenytoin 1  MorphaBond 3 Nucynta/ER 3 diclofenac potassium 1 Corticosteroids Dilantin 3  budesonide inh. Oxycodone ER 3 diclofenac sodium 1 Peganone 3  z diclofenac sodium gel 1% 1 (0.25mg/2ml, 0.5mg/2ml) 1 Oxycontin 3 z Miscellaneous  etodolac 1 Asmanex 2 carbamazepine 1 z Roxicet solution 3 z Pulmicort flexhaler/powder 2 z etodolac SA 1 carbamazepine XR 200mg, 400mg 1 P Subsys 3 Pulmicort respules (1mg/2ml) 2 z Tylenol/codeine 3 z fenoprofen tablet 1 clobazam 1 P z Qvar 2 clonazepam 1 z Vicodin/ES 3 flurbiprofen 1 z Aerobid/M 3 ibuprofen 1 divalproex sodium/ER 1  Xartemis XR 3 z Alvesco 3 felbamate 1 z Xtampza ER 3 indomethacin 1 Pz  P ArmonAir 3 gabapentin 1  Zohydro ER 3 ketoprofen 1 z Arnuity Ellipta 3 lamotrigine/ODT 1 Pz Analgesics, Salicylates ketorolac inj. 1 P Flovent HFA/Diskus 3 levetiracetam 1 choline mag. trisalicylate 1 z ketorolac tab 1 Leukotrienes oxcarbazepine 1 diflunisal 1 meclofenamate 1 montelukast 1 primidone 1 salsalate 1 meloxicam 1 zafirlukast 1 topiramate 1 z Yosprala 3 nabumetone 1 z zileuton ER 3 topiramate ER 1 valproic acid 1 Anti-Rheumatic naproxen/EC 1 z Zyflo 3 hydroxychloroquine 1 Other Agents zonisamide 1 oxaprozin 1 Tegretol 2 leflunomide 1 piroxicam 1 cromolyn inh. soln. 1 z fluticasone-salmeterol (Prasco) 1 Vimpat 2 methotrexate 1 sulindac 1 Aptiom 3 z ipratropium inh. soln. 1  penicillamine 1 tolmetin 1 Banzel 3 z ipratropium/albuterol 1 +P Actemra 2 z Diclofenac Epolamine patch 3 z Briviact 3 z P z wixela inhub 1 +P Cimzia 2 z diclofenac sodium 3% gel 3 z Diacomit 3 + z Enbrel 2 P Anoro Ellipta 2   diclofenac sodium/misoprostol 3 z + Epidiolex 3 + z Humira 2 Atrovent HFA 2   z diclofenac sodium topical solution 3 z Bevespi 2  Fintepla 3 + z Otezla 2 P z Fycompa 3  z Duexis 3 z Combivent Respimat 2 Ridaura 2 P z lamotrigine ER 3 z z Flector 3 Dulera 2 z + Rinvoq 2 P + z Esbriet 2 P Lyrica CR 3 z z indomethacin 20mg 3  z + Xeljanz 2 P z Fluticasone-Salmeterol (Teva) 2  Nuedexta 3 z z Licart 3 + Xeljanz XR 2 P z Incruse Ellipta 2 Oxtellar XR 3 z mefenamic acid 3 Potiga 3  Cuprimine 3 + z Kalydeco 2 z naproxen CR 375mg tablet 3  pregabalin 3  Depen 3 + z Ofev 2 z z Pennsaid 3  Qudexy XR 3 + Kevzara 3 P + z Orkambi 2 z z Qmiiz ODT 3  + Sabril 3 P Kineret 3 P + Pulmozyme 2 z z z Sympazan 3 +P Olumiant 3 Sprix 3 z Spiriva 2 P z z Tegretol XR 100mg 3 +P Orencia SC 3 Tivorbex 3 Spiriva Respimat 2 z z Stiolto Respimat 2 tiagabine 3 Otrexup 3 P Vimovo 3 Rasuvo 3 z z Symbicort 2 Trokendi XR 3 P Vivlodex 3 + vigabatrin oral powder 3 + z Simponi 3 z + z Symdeko 2 P P Zipsor 3  z Xcopri 3 Cox-2s z z Trelegy Ellipta 2  P Zorvolex 3 z Succinimides z celecoxib 3 + Trikafta 2 Parkinson’s Disease z Advair diskus 3 ethosuximide 1 Migraine (Miscellaneous) P Celontin 3 z benztropine 1 P Advair HFA 3  Aimovig 2 z z bromocriptine 1 P AirDuo 3 Skin  Ajovy 2 Breo Ellipta 3 z carbidopa/levodopa 1 P  Emgality 2 + Bronchitol 3 Acne/Rosacea z carbidopa/levodopa SA 1   Nurtec ODT 3 Budesonide-Formoterol 3 adapalene/benzoyl peroxide 1 z P adapalene cream/gel 1  Ubrelvy 3 entacapone 1 Daliresp 3 Migraine (Analgesics, Non-opioid) pramipexole 1 z Duaklir Pressair 3 amnesteem 1 butalbital/APAP 50mg-325mg 1 ropinirole 1 P avita cream 1  Fasenra pen 3 benzoyl peroxide 1 butalbital/APAP/caffeine 1 z selegiline 1 + Glassia 3 z  claravis 1 butalbital/aspirin/caffeine 1 trihexyphenidyl 1 Lonhala Magnair 3 clindamycin/benzoyl peroxide z dihydroergotamine mesylate 1 z + z Nucala syringe/auto-inject 3 P + Apokyn 3  1.2%-2.5% gel 1 z eletriptan 1 carbidopa 3  Orkambi granules 3 clindamycin/benzoyl peroxide 1-5% gel 1 ergotamine/caffeine 1 z z Seebri 3 + Duopa 3 clindamycin phospate 1 isometh/dichloralphen/APAP 1 z Tudorza 3 erythromycin/benz peroxide 1  Gocovri 3 z z naratriptan 1 z Utibron 3 minocycline 1  Inbrija 3 z Yupelri 3 z rizatriptan 1 z P prascion RA 1  Kynmobi 3 Sympathomimetics z sumatriptan 1 z sodium sulfacetamide 1 + Nourianz 3 albuterol sulfate ER 1 sod. sulfacetamide/sulfur emulsion cleanser 1 tramadol/ER tablet 1 z Ongentys 3 tramadol/acetaminopen 1  z albuterol sulfate HFA sod. sulfacetamide/sulfur lot 1 z Osmolex ER 3 z zolmitriptan 1 P (generic ProAir HFA, Proventil HFA) 1 sotret 1 z pergolide 3 albuterol tab, syr 1 tretinoin cr/gel 1 P Amerge 3 z pramipexole ER 3 metaproterenol syr 1 Absorica 3 P Axert 3 z rasagiline 3 terbutaline tab 1 P Acanya 3 butalbital/APAP 50mg-300mg 3 z Foradil 2 Aczone 3 Cafergot 3 ropinirole ER 3 P Rytary 3 z Maxair Autohaler 2 Adapalene lotion 3 z Cambia 3 z P P tolcapone 3 Serevent Diskus 2 adapalene solution 3 z Ergomar 3 Albuterol Sulfate HFA 3 adapalene swab 3 z Frova 3 z Xadago 3 P P P Arcapta 3 P Aklief 3 z frovatriptan 3 Potassium Levalbuterol Tartrate HFA 3 Altreno 3 z P P P Imitrex 3 z ProAir HFA/RespiClick 3 Amzeeq 3 z Potassium agents P P Maxalt 3 z Proventil HFA 3 Avar 3 z potassium bicarb/potassium chloride 1 P P P Maxalt MLT 3 z Striverdi Respimat 3 Avita gel 3 z potassium bicarbonate 1 z P P Onzetra 3 P Ventolin HFA 3 azelaic acid gel 3 z potassium citrate ER 1 P Relpax 3 P Xopenex HFA 3 P Azelex 3 z potassium chloride 1  Reyvow 3 Xanthine Derivatives P Benzaclin 3 z Sumavel 3 Potassium Removing agent aminophylline 1 P Benzamycin 3 z P Tosymra 3 sod. polystyrene sulfonate 1 theochron 1 P Cleocin T 3 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

5 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER clindamycin/benzoyl peroxide Picato 2 methylprednisolone 4mg, 8mg, 16mg, 32mg 1 mesalamine enema 1 1.2%-2.5% pump 3 Regranex 2 z prednisolone oral 1 + sapropterin 1 clindamycin/benzoyl peroxide 1-5% pump 3 Carac 3 prednisone oral 1 sulfasalazine 1 dapsone 5% 3 z sulfasalazine EC 1 + Dupixent 3 Medrol 2mg 2 Differin 3 z Cholbam 2 P  Eucrisa 3 + Emflaza 3  P Doryx 3 Fluoroplex 3 Hemady 3 z Amitiza 3 doxycycline hyclate DR 3 P Apriso 3 P Fluorouracil 0.5% cr 3  Rayos 3 Doxycycline IR-DR 3 z Azulfidine 3 P  Klisyri 3 Stomach/Ulcer Duac 3 z budesonide ER tablet 3 P P Qbrexza 3 P Duac CS 3 Regenecare 3 Anorectal z Dipentum 3 Epiduo 3 z hydrocortisone rectal cr. & supp. 1 + Gattex 3 P  Zonalon 3  P Evoclin 3 hydrocortisone rectal enema 1 Giazo 3 Fabior 3 Psoralens P pramoxine/HC acetate 2.5% 1 + Kuvan 3 Finacea 3 methoxsalen capsule 1 Linzess 3 P 8-MOP 2 Analpram-HC 1-1% 3 Metrogel topical 1% 3 Analpram-HC 2.5% cr/lot 3 mesalamine DR capsule 400mg 3 P Scabicides & Pediculicides minocycline HCl ER 3 Cortifoam 3 mesalamine DR tablet 1.2g 3 Pz acticin 1 P Minolira ER 3 Proctofoam-HC 3 mesalamine DR tablet 800mg 3 Mirvaso 3 permethrin 1 P Anticholinergics/Antispasmodic/GI Motility mesalamine suppository 3 P Noritate 3 spinosad 1 z Motegrity 3 Onexton 3 Lindane 2 belladonna/phenobarbital 1 z P chlordiazepoxide/clindinium 1  Movantik 3 Oracea 3 Ulesfia 2 + z Palynziq 3 P dicyclomine 1  P Retin-A/Micro 3 Eurax 3 Pentasa 3 Rhofade 3 Sklice 3 glycopyrrolate 1 Relistor 3 P hyoscyamine/CR 1  Rosula 3 Topical Anti-Inflammatory Agents z Symproic 3 P metoclopramide 1  z Seysara 3 alclometasone 1 z Trulance 3 P Donnatal tablet 2 P Solodyn 3 amcinonide 1 Uceris 3 Soolantra 3 Antidiarrheal z aug. betamethasone diprop 1  Xermelo 3 P tazarotene cream 3 betamethasone dipropionate 1 diphenoxylate/atropine 1 z Zelnorm 3 z P Tazorac 3 betamethasone valerate 1 nitazoxanide 1 Proton Pump Inhibitors tretinoin microsphere gel 3 P clobetasol emol/emuls 1 paregoric 1 z esomeprazole magnesium 1 Veltin gel 3 z P clobetasol proprionate Alinia suspension 2 z lansoprazole 1 P Winlevi 3 Fulyzaq 2 z lansoprazole DR ODT 1 Ximino 3 foam/gel/oint/cr/sol 1 P P desonide 1 z Alinia tablet 3 z Nexium 24HR 1 P Ziana gel 3 Antiemetic/Antivertigo z omeprazole 1 Antibiotics (Topical) desoximetasone 1 diflorasone 1 z aprepitant 1 z pantoprazole 1 clindamycin sol/swabs/gel/lotion 1 z fluocinolone acetonide 1  granisetron 1 z Prevacid 24HR 1 erythromycin sol/swabs/gel 1 meclizine 1 z Prilosec-OTC 1 gentamicin cr/oint 1 fluocinonide 1 z fluticasone propionate 1  ondansetron 1 z rabeprazole 1 metronidazole cream/lotion/ 0.75% gel 1 z halobetasol 1 prochlorperazine 1 Zegerid OTC 1 mupirocin 1 promethazine 1 z Nexium DR 2.5mg, 5mg packet 2 Bactroban cream 3 halobetasol propionate 1 z z scopolamine patch 1 P Aciphex 3 Centany 3  halobetasol propionate foam 1 z trimethobenzamide 1 P Dexilant 3 Xepi 3 hydrocortisone 2.5% 1 Antivert 50mg 2 z P P Nexium 3 Antipsoriatics hydrocortisone valerate 1 z Anzemet 2 z Nexium DR 10mg, 20mg, 40mg packet 3 acitretin 1 hydrocortisone/iodoquinol 1 z  Emend 2 z omeprazole/sodium bicarbonate 3 calcipotriene 1 mometasone cr/oint 1 z Akynzeo 3 Pz P P Prevacid 3 tacrolimus 1 prednicarbate 1 z Bonjesta 3 z Prilosec 3 + z Cosentyx 2 triamcinolone acetonide 1 z doxylamine-pyridoxine 3 Pz  P Protonix 3 Dritho-Scalp 2 Cordran tape 2 z Granisol 3 z Zegerid 3 betamethasone valerate foam 3 z P  Elidel 2  Sancuso 3 z Capex Shampoo 3 z Syndros 3 Thyroid + Skyrizi 2 Soriatane CK 2 clobetasol propionate lotion/shampoo/spray 3 z Varubi 3 Antithyroid z + z Stelara 2 Cordran ointment 3  Zuplenz 3 methimazole 1  z + z Tremfya 2 P Duobrii 3 Bowel Evacuants propylthiouracil 1  fluocinonide cream (generic Vanos) 3 calcipotriene-betamethasone ointment 3  peg 3350/electrolyte 1 Thyroid P flurandrenolide cream 3 calcitriol ointment 3  Trilyte 1 levothroid 1 halcinonide cream 3 Nulytely 3 levothyroxine 1 P Enstilar 3 z hydrocortisone butyrate/emoll cream 3 Prepopik 3 levoxyl 1 +P Siliq 3  Impoyz 3 Suprep 3 liothyronine 1 P Taclonex 3 P  + z Taltz 3 Kenalog/aerosol 3 Digestants thyroid 1 P z Wynzora 3  Lexette 3 Zenpep 2 unithroid 1 P z triamcinolone spray 3 Synthroid 2 Burn preparation  P Creon 3 Topical Antipruritics/Anesthetics Thyroid (Armour) 2 silver sulfadiazine 1 P Pancreaze 3 lidocaine 1 Thyrolar 2 Fungicides P Pertzye 3 z lidocaine patch 1 Tirosint 3 betamethasone/clotrimazole 1  Sucraid 3 selenium sulf 2.5% suspension 1 ciclopirox cream 1 P Ultresa 3 Vaccines ciclopirox soln 1 Rectiv 3 Viokace 3 Adacel 2 econazole 1 Topical Antivirals Gallstone Solubilizing Agents   Bexsero 2 ketoconazole 1 acyclovir cream 1 ursodiol 1 Boostrix 2 nystatin 1 acyclovir ointment 1 z  + Ocaliva 3  Daptacel 2 nystatin/triamcinolone 1 Denavir 3 H2 Antagonists  Diphtheria-Tetanus Toxoids-Ped 2 nystop 1 cimetidine 1 Infanrix 2 Exelderm 2 Smoking Cessation  famotidine 1  Influenza 2 z Jublia 3  bupropion 1 Menactra 2 z Nicorelief gum 1 nizatidine 1  Kerydin 3  ranitidine (all) 1 Menhibrix 2 naftifine 3 Nicorelief lozenge 1   Other Antiulcer Menomune-A-C-Y-W-135 2 Miscellaneous Nicotine Gum 1   misoprostol 1  Menveo A-C-Y-W-135-Dip 2 aluminum chloride 20% 1  Nicotine lozenges 1 Pneumovax 23 2 z propantheline bromide 1   doxepin cream 1  Nicotine patches various 1 Prevnar 13 2 fluorouracil 5% cr/sol 1 Chantix 2 sucralfate 1    Shingrix 2 fluorouracil 2% sol 1 Commit 2 Helidac 3   Tenivac 2 imiquimod 5% cream 1 Nicotrol Inhaler 2 lansoprazole/amox/clarith 3 Tetanus Diphtheria Toxoids 2 ivermectin 1  Other GI Products   Nicotrol NS 2  Trumenba 2 podofilox 1 Zyban 3 alosetron 1 Zostavax 2 z    prudoxin 1 balsalazide 1 sodium chloride irrigating soln 1 Steroids budesonide EC 1 Vitamins z + Benlysta SC 2 cortisone acetate 1 cromolyn sodium 1 calcitriol 1  Panretin 2 dexamethasone oral 1 enulose 1 calcitriol inj 1 Phisohex 2 hydrocortisone oral 1 lactulose 1 calcium acetate 1

KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

6 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER cholecalciferol 1  Chorionic gonadotropin 3  dasetta 1  norlyda 1 cyanocobalamin inj. 1  Ganirelix 3  daysee 1  norlyroc 1 ergocalciferol capsule 1 P Gonal F 3  deblitane 1  nortrel 1 etidronate 1  Menopur 3  delyla 1  ocella 1  fluoride drops OTC 1  Pregnyl 3  desogestrel-ethinyl estradiol 1  ogestrel 1  fluoride tablets OTC 1 Hormones  desogestr-eth estrad eth estra 1  opcicon one-step 1 folic acid Rx 1mg tab 1 dotti 1  drospirenone-ethinyl estradiol 1  option 2 1  folic acid tablets OTC 1 z estradiol/noreth ac 1  econtra ez 1  orsythia 1 leucovorin 1 z estradiol oral 1  econtra one-step 1  philith 1 levocarnitine 1 z estradiol patches 1  elinest 1  pimtrea 1 multivitamin + fluoride (Rx-only) 1 z estropipate 1  emoquette 1  pirmella 1 + nitisinone 1 z estrogen/methyltesterone 1  enpresse 1  portia 1 Pediatric sodium fluoride chewable tab & z jinteli 1  enskyce 1  previfem 1 drops 1 medroxyprogesterone 1  errin 1  quasense 1 potassium aminobenzoate 1 norethindrone 1  estarylla 1  react 1 pre-natal vitamins (Rx-only) 1 z Combipatch 2  ethynodiol-ethinyl estradiol 1  reclipsen 1 sevelamer 1 Premphase 2  fallback solo 1  setlakin 1 vit A,D,C + fluoride (Rx-only) 1 Prempro 2  falmina 1  sharobel 1 vit A,D,C + fluoride and iron (Rx-only) 1 z Alora 3  femynor 1  simliya 1 Galzin 2 Cenestin 3  gianvi 1  simpesse 1 Mephyton 2 z Climara Pro 3  gildagia 1  sprintec 1 Nascobal 2 Crinone 3  gildess 1  sronyx 1 phytonadione 2 Duavee 3  gildess 24 fe 1  syeda 1 Prenate Elite 2 Enjuvia 3  gildess fe 1  tarina 24 Fe 1 Renagel 2 z Estraderm 3  hailey 24 Fe 1  tarina fe 1 Auryxia 3 estradiol 0.01% cream 3  heather 1  tarina Fe 1-20 eq 1 lanthanum carbonate tablet 3 z Estrasorb packet 3  incassia 1  tilia fe 1 paricalcitol 3 z Estring 3  introvale 1  tri femynor 1 Poly-Vi-Flor + Iron 3 z Estrogel 3  isibloom 1  tri-estarylla 1 z Rayaldee 3 Evamist 3  jasmiel 1  tri-legest fe 1 Tri-Vi-Flor 3 z Femring 3  jencycla 1  tri-linyah 1 Velphoro 3 z Imvexxy 3  jolessa 1  tri-lo-marzia 1 Weight Loss z Intrarosa 3  jolivette 1  tri-lo-mili 1 Menest 3 juleber 1 tri-mili 1 benzphetamine 1    z Menostar 3  junel 1  trinessa 1  diethylpropion 1 z junel fe 1 trinessa lo 1  Oriahnn 3    phendimetrazine 1 z kaitlib fe 1 tri-previfem 1  Orilissa 3    phentermine 1 Ortho-Est 3 kalliga 1 tri-sprintec 1 Belviq 3    Osphena 3 kariva 1  trivora 1 z Belviq XR 3   z Prefest 3 kelnor 1-35 1  tri-vylibra 1 z Contrave 3   Premarin 3 kelnor 1-50 1  tri-vylibra lo 1 z Imcivree 3   Premarin vag cream 3 kimidess 1  tulana 1 z Lomaira 3   progesterone, micronized 3 kurvelo 1  velivet 1 z Qsymia 3   yuvafem 3 larin 1  vestura 1 z Saxenda 3   larin fe 1  vienva 1 Suprenza ODT 3 Miscellaneous   paroxetine 7.5mg 1  larissia 1  viorele 1  Xenical 3 z layolis fe 1 vyfemla 1  Addyi 3   Women’s Health z Vyleesi 3  leena 1  vylibra 1  wera 1 Oral Contraceptives  lessina 1  Please refer to your plan documents to confirm your wymzya fe 1 afirmelle 1  levonest 1  cost share for contraceptives. Cost share may vary  zarah 1 altavera 1  levonorgestrel 1  by plan.  zenchent 1 alyacen 1  levonorgestrel-eth estradiol 1  Contraceptives - Other  zenchent fe 1 amethia 1  levonorg-eth estrad eth estrad 1  eluryng vaginal ring 1  levora 1 zeosa 1  amethia lo 1    etonogestrel/ethinyl estradiol vaginal ring 1  lillow 1 zovia 1 xulane 1 amethyst 1     lomedia 24 fe 1  zumandimine 1 Mirena 2 apri 1    loryna 1  Lo Loestrin Fe 2 Caya Contoured Diaphragm 3 aranelle 1    low-ogestrel 1  Natazia 2 Conceptrol 3 ashlyna 1     lo-zumandimine 1  Balcoltra 3 Depo-SubQ Provera 3 aubra 1    lutera 1  drospirenone-eth estra-levomef 3 FC2 Female Condom 3 aubra eq 1    lyza 1  Ella 3 Femcap 3  aurovela 1   marlissa 1  fayosim 3 gynol II 3  aurovela 24 Fe 1   melodetta 24 fe 1  norgestimate-ethinyl estradiol 3 Kyleena 3  aviane 1   mibelas 24 fe 1  rajani 3 + Liletta 3  ayuna 1   microgestin 1  rivelsa 3 + Nexplanon 3  azurette 1   microgestin fe 1  Slynd 3 NuvaRing 3  balziva 1   mili 1  Taytulla 3 Paragard 3  bekyree 1   mono-linyah 1  tri-lo-estarylla 3 Skyla 3  blisovi 24 fe 1   mononessa 1  tri-lo-sprintec 3 Today Contraceptive Sponge 3  blisovi fe 1   my choice 1  tydemy 3 VCF 3  briellyn 1  camila 1  my way 1 Oxytocic Agents Fertility Induction Agents  camrese 1  myzilra 1 methylergonovine maleate 1 clomiphene 1  camrese lo 1  necon 1 Methergine 3 progesterone in oil 1  new day 1  caziant 1  Vaginal Preparations serophene 1   next choice one dose 1 miconazole vag supp 1  chateal 1  Bravelle 2  nikki 1 nystatin vag tab 1  chateal eq 1  Cetrotide 2  nora-be 1 terconazole 1  cryselle 1  Follistim AQ 2  norethindrone acetate 1 vandazole vag 1  cyclafem 1  Novarel 2  norethindrone-ethin estradiol 1 Cleocin Vag/Ovules 3  cyred 1 Clindesse 3  Ovidrel 2  norethin-eth estra ferrous fum 1  cyred eq 1 Gynazole-1 3  Repronex 2  norgestrel-ethiny estra 1

KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

7 Section II — Index

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE A amitriptyline 4 B butalbital/APAP/caffeine 5 Ciloxan 2 Cystagon 4 abacavir-lamivudine 3 amitriptyline/ chlordiazepoxide 4 bacitracin ophth 2 butalbital/APAP/codeine 4 Cimduo 3 Cystaran 2 abacavir/lamivudine/zidovudine 3 amitriptyline/perphenazine 4 bacitracin/polymyxin 2 butalbital/aspirin/caffeine 5 cimetidine 6 D Abilify 4 amlodipine 2 baclofen 4 butalbital/aspirin/codeine 4 Cimzia 5 amlodipine/atorvastatin 2 butorphanol NS 4 cinacalcet 4 dalfampridine ER 4 Abilify Mycite 4 Bactroban cream 6 Daliresp 5 abiraterone acetate 1 amlodipine/benazepril 2 Bafiertam 4 Butrans 4 Cinryze 3 amlodipine/valsartan 2 Bydureon 1 Cipro HC 2 danazol 4 Absorica 5 Balcoltra 7 dantrolene sodium 4 amlodipine/valsartan/HCTZ 3 Byetta 1 ciprofloxacin 3 Abstral 4 balsalazide 6 dapsone 5% 6 amnesteem 5 Bystolic 2 ciprofloxacin/dexamethasone 2 acamprosate calcium tablet EC 4 Balversa 1 dapsone tablets 3 amoxapine 4 Byvalson 3 ciprofloxacin ophth 2 Acanya 5 balziva 7 Daptacel 6 amoxicillin 3 ciprofloxacin otic 2 acarbose 1 Banzel 5 C dasetta 7 Accu-Chek 2 amoxicillin-clavulanate ER 3 Baqsimi 2 citalopram 4 Cablivi 1 claravis 5 Daurismo 1 acebutolol 2 ampicillin 3 Baraclude solution 3 Cabometyx 1 daysee 7 acetaminophen w/codeine 4 Amturnide 3 Basaglar 1 Clarinex-D 1 Cafergot 5 Clarispray 1 Dayvigo 4 acetazolamide 3 Amzeeq 5 Baxdela 3 calcipotriene 6 DDAVP nasal spray 4 acetazolamide ER 3 anagrelide 1 Beconase AQ 1 clarithromycin susp 3 calcipotriene-betamethasone clarithromycin tabs 3 DDAVP sol, tab 4 acetic acid HC otic 2 Analpram-HC 1-1% 6 bekyree 7 ointment 6 clemastine 1 deblitane 7 acetic acid otic 2 Analpram-HC 2.5% cr/lot 6 Belbuca 4 calcitonin-salmon 4 Cleocin 3 deferasirox 1 acetic acid/aluminum acetate 2 anastrozole 1 belladonna & opium supp 4 calcitriol 6 Cleocin T 5 deferiprone 1 acetylcysteine inh soln. 1 Androderm patch 3 belladonna/phenobarbital 6 calcitriol inj 6 Cleocin Vag/Ovules 7 delyla 7 Aciphex 6 Android 3 Belsomra 4 calcitriol ointment 6t Climara Pro 7 Demerol 4 acitretin 6 Anoro Ellipta 5 Belviq 7 calcium acetate 6 clindamycin 3 Denavir 6 Actemra 5 Antara 2 Belviq XR 7 Calquence 1 clindamycin/benzoyl peroxide Depen 5 acticin 6 Antivert 50mg 6 benazepril 2 Cambia 5 1.2%-2.5% gel 5 Depo-SubQ Provera 6 Actimmune 1 Anzemet 6 benazepril/HCTZ 2 camila 7 Descovy 3 Actiq 4 Benicar 2 clindamycin/benzoyl peroxide Apidra 1 Campral dosepack 4 1.2%-2.5% pump 6 desipramine 4 Actonel 4 Apokyn 5 Benicar HCT 3 camrese 7 desloratadine 1 Acular PF 2 Benlysta SC 6 clindamycin/benzoyl peroxide aprepitant 6 camrese lo 7 1-5% gel 5 desmopressin solution 4 acyclovir cream 6 Benzaclin 5 apri 7 candesartan 2 clindamycin/benzoyl peroxide desmopressin tabs 4 acyclovir ointment 6 Benzamycin 5 Apriso 6 candesartan/HCTZ 2 1-5% pump 6 desogestr-eth estrad eth estra 7 acyclovir oral 3 benzonatate 1 Aptensio XR 4 capecitabine 1 clindamycin phospate 5 desogestrel-ethinyl estradiol 7 Aczone 5 benzoyl peroxide 5 Aptiom 5 Capex Shampoo 6 clindamycin sol/swabs/gel/lotion 6 desonide 6 Adacel 6 benzphetamine 7 Aptivus 3 Caplyta 4 Clindesse 7 desoximetasone 6 adapalene/benzoyl peroxide 5 benztropine 5 aranelle 7 Caprelsa 1 clobazam 5 Desvenlafaxine ER 4 adapalene cream/gel 5 Bepreve 2 Aranesp 1 captopril 2 clobetasol emol/emuls 6 Desvenlafaxine fumarate ER 4 Adapalene lotion 5 Berinert 3 Arcalyst 1 captopril/HCTZ 2 clobetasol propionate lotion/ desvenlafaxine succinate ER 4 adapalene solution 5 Besivance 2 Arcapta 5 Carac 6 shampoo/spray 6 Detrol 1 adapalene swab 5 betamethasone dipropionate 6 aripiprazole 4 Carbaglu 4 clobetasol proprionate foam/gel/oint/ Detrol LA 1 Addyi 7 betamethasone valerate 6 armodafinil 4 carbamazepine 5 cr/sol 6 dexameth/neomycin/poly B 2 Adempas 3 betamethasone valerate foam 6 ArmonAir 5 carbamazepine XR clomiphene 7 dexamethasone oral 6 Adhansia XR 4 betamethasone/clotrimazole 6 200mg, 400mg 5 Arnuity Ellipta 5 clomipramine 4 dexchlorpheniramine 1 Adlyxin 1 Betaseron 4 carbidopa 5 Ascensia Breeze 2 clonazepam 5 Dexilant 6 Admelog 1 betaxolol 2 carbidopa/levodopa 5 ashlyna 7 clonidine, oral, patch 2 dexmethylphenidate 4 Adrenaclick 5 betaxolol HCl 2 carbidopa/levodopa SA 5 Asmanex 5 clopidogrel 1 dexmethylphenidate XR 4 Advair diskus 5 Bethkis 3 carbinoxamine 1 dextroamphetamine tabs 4 aspirin 325mg OTC 1 clorazepate 4 Advair HFA 5 Betoptic-S 2 Cardec/DM 1 clotrimazole lozenge 3 Diacomit 5 aspirin 81mg OTC 1 Advicor 2 Bevespi 5 Cardura XL 2 clozapine 4 diazepam 4 aspirin-dipyridamole 1 Adzenys 4 Bevyxxa 1 carisoprodol 4 Coartem 3 diclofenac 2 Astagraf XL 3 Aerobid/M 5 bexarotene 1 carisoprodol/ASA 4 codeine sulfate 4 Diclofenac Epolamine patch 5 Atacand 2 Afinitor 1 Bexsero 6 Carospir 3 colchicine/probenecid 2 diclofenac potassium 5 afirmelle 7 Atacand HCT 3 Biaxin XL 3 carteolol 2 colchicine (generic Colcrys) 2 diclofenac sodium 5 Afrezza 2 atazanavir 3 bicalutamide 1 cartia XT 2 colesevelam 2 diclofenac sodium 3% gel 5 Aimovig 5 Atelvia 4 Biktarvy 3 carvedilol 2 Colestid 2 diclofenac sodium gel 1% 5 AirDuo 5 atenolol 2 bimatoprost 0.03% 2 carvedilol ER 2 colestipol 2 diclofenac sodium Ajovy 5 atenolol/chlorthalidone 2 Binosto 4 Caverject 3 Combipatch 7 topical solution 5 Aklief 5 Ativan 4 bisoprolol 2 Caya Contoured Diaphragm 7 Combivent Respimat 5 diclofenac sodium/misoprostol 5 Akynzeo 6 atomoxetine 4 bisoprolol/HCTZ 2 Cayston 3 Cometriq 1 dicloxacillin 3 albuterol sulfate ER 5 atorvastatin calcium 2 blisovi 24 fe 7 caziant 7 Commit 6 dicyclomine 6 Albuterol Sulfate HFA 5 atovaquone 3 blisovi fe 7 CeeNu 1 Complera 3 didanosine 3 albuterol sulfate HFA atovaquone/proguanil HCl 3 Boniva 4 cefaclor 3 Conceptrol 7 diethylpropion 7 (generic ProAir HFA, Proventil HFA) 5 Atripla 3 Bonjesta 6 cefadroxil 3 Conjupri 2 Differin 6 albuterol tab, syr 5 atropine sulfate ophth 2 Boostrix 6 cefdinir 3 Consensi 3 Dificid 3 alclometasone 6 Atrovent HFA 5 bosentan 3 cefixime 3 Contour 2 diflorasone 6 Alecensa 1 Atrovent Nasal Spray 1 Bosulif 1 cefpodoxime 3 Contrave 7 diflunisal 5 alendronate 4 Aubagio 4 Braftovi 1 cefprozil 3 Copaxone 4 digoxin 2 alfuzosin 4 aubra 7 Bravelle 7 Ceftin 3 Copiktra 1 dihydroergotamine mesylate 5 Cordran ointment 6 Alinia tablet 6 aubra eq 7 Breo Ellipta 5 cefuroxime 3 Dilantin 5 Cordran tape 6 Alinia suspension 6 aug. betamethasone diprop 6 briellyn 7 celecoxib 5 Dilatrate SR 3 aliskiren 2 Brilinta 1 Celexa 4 Corlanor 3 diltia XT 2 aurovela 7 Cortifoam 6 Alkeran 1 brimonidine 2 Cellcept 3 diltiazem 2 aurovela 24 Fe 7 cortisone acetate 6 allopurinol 2 brinzolamide 2 Celontin 5 diltiazem CD/SR/ER/XR 2 Auryxia 7 Cosentyx 6 Alomide 2 Briviact 5 Cenestin 7 dimethyl fumarate 4 Austedo 3 Cotellic 1 Alora 7 Brukinsa 1 Centany 6 Diovan 2 Auvi-Q 5 Cotempla XR 4 alosetron 6 bromfenac 2 cephalexin 3 Diovan HCT 3 Avalide 3 Coumadin 1 Alphagan P 0.1% 2 bromocriptine 5 Cequa 2 Dipentum 6 Avandamet 1 Cozaar 2 alprazolam/ER 4 Cerdelga 4 Avandaryl 1 brompheniramine/phenylephrine 1 Creon 6 diphenhydramine 1 Alprolix 1 cetirizine 1 Avandia 1 brompheniramine/ Cresemba 3 diphenoxylate/atropine 6 altavera 7 pseudoephedrine 1 Cetrotide 7 Avapro 2 Crestor 2 Diphtheria-Tetanus Toxoids-Ped 6 Altoprev 2 Bronchitol 5 Chantix 6 Avar 5 Crinone 7 dipyridamole 1 Altreno 5 budesonide EC 6 chateal 7 aviane 7 Crixivan 3 disopyramide 2 aluminum chloride 20% 6 budesonide ER tablet 6 chateal eq 7 disulfiram 4 avita cream 5 cromolyn inh. soln. 5 Alunbrig 1 Budesonide-Formoterol 5 chloral hydrate 4 Ditropan XL 1 Avita gel 5 cromolyn ophth 2 Alvesco 5 budesonide inh. (0.25mg/2ml, chlordiazepoxide 4 divalproex sodium/ER 5 Avonex 4 cromolyn sodium 6 alyacen 7 0.5mg/2ml) 5 chlordiazepoxide/clindinium 6 dofetilide 2 Axert 5 cryselle 7 alyq 3 budesonide nasal spray 1 chloroquine phosphate 3 Dojolvi 4 Axiron 3 Cuprimine 4 amantadine 3 bumetanide 3 chlorothiazide 3 Cutaquig 4 Domeboro 2 Ambien 4 ayuna 7 Bunavail 4 chlorpromazine 4 donepezil 1 Ayvakit 1 Cuvitru 4 Ambien CR 4 buprenorphine 4 chlorpropamide 1 cyanocobalamin inj. 7 Donnatal tablet 6 Azasite 2 ambrisentan 3 Buprenorphine 7.5mg TD patch 4 chlorthalidone 3 cyclafem 7 Doptelet 1 azathioprine 3 amcinonide 6 buprenorphine TD patch (generic) 4 chlorzoxazone 4 cyclobenzaprine 4 Doryx 6 Amerge 5 azelaic acid gel 5 buprenorphine-naloxone 4 Cholbam 6 cyclobenzaprine 7.5mg 4 dorzolamide 2% eye drops 2 amethia 7 azelastine nasal spray 1 buprenorphine/naloxone film 4 cholecalciferol 7 cyclobenzaprine ER 4 dorzolamide/timolol eye drops 2 amethia lo 7 azelastine ophth 2 bupropion 4 cholestyramine 2 cyclophosphamide 1 dotti 7 amethyst 7 Azelex 5 bupropion 6 choline mag. trisalicylate 5 cyclosporine 3 doxazosin 2 amiloride 3 azithromycin suspension 3 bupropion 12HR 4 Chorionic gonadotropin 7 cyproheptadine 1 doxepin 4 amiloride/HCTZ 3 azithromycin tablets 3 bupropion 24HR 4 Cialis 3 cyred 7 doxepin cream 6 aminophylline 5 Azopt 2 buspirone 4 ciclopirox cream 6 cyred eq 7 doxycycline 3 amiodarone 2 Azulfidine 6 butalbital/APAP 50mg-300mg 5 ciclopirox soln 6 Cystadane 4 doxycycline hyclate 50mg, 75mg, Amitiza 6 azurette 7 butalbital/APAP 50mg-325mg 5 cilostazol 1 Cystadrops 2 150mg tab 3

8 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE doxycycline hyclate DR 6 erlotinib 1 Firazyr 3 gildagia 7 imiquimod 5% cream 6 Kevzara 5 Doxycycline IR-DR 6 errin 7 Firdapse 4 gildess 7 Imitrex 5 Khedezla 4 doxylamine-pyridoxine 6 Ertaczo 3 Firvanq 3 gildess 24 fe 7 Impavido 3 kimidess 7 Dritho-Scalp 6 ery-tab 250mg, 333mg 3 Flagyl/ER 3 gildess fe 7 Impoyz 6 Kineret 5 Drizalma Sprinkle 4 erythromycin base 3 Flarex 2 Gilenya 4 Imvexxy 7 Kisqali 1 drospirenone-eth estra-levomef 7 erythromycin DR 3 flecainide 2 Gilotrif 1 Inbrija 5 Kisqali Femara Co-Pack 1 drospirenone-ethinyl estradiol 7 erythromycin estolate 3 Flector 5 Glassia 5 incassia 7 Kitabis Pak 3 droxidopa 2 erythromycin ethylsuccinate 3 Flomax 4 glatiramer acetate 4 Increlex 4 Klisyri 6 Duac 6 erythromycin ophth 2 Flonase Allergy Relief 1 glatopa 4 Incruse Ellipta 5 Kombiglyze XR 2 Duac CS 6 erythromycin sol/swabs/gel 6 Flonase Sensimist 1 Gleevec 1 indapamide 3 Korlym 4 Duaklir Pressair 5 erythromycin stearate 3 Flovent HFA/Diskus 5 glimepiride 1 indomethacin 5 Koselugo 1 Duavee 7 erythromycin/benz peroxide 5 fluconazole 3 glipizide 1 indomethacin 20mg 5 kurvelo 7 Duetact 1 erythromycin/sulfisoxazole 3 flucytosine 3 glipizide ER 1 Infanrix 6 Kuvan 6 Duexis 5 erythromycin suspension 3 fludrocortisone 4 glipizide/metformin 1 Influenza 6 Kyleena 7 Dulera 5 Esbriet 5 flunisolide nasal spray 1 Gloperba 2 Ingrezza 3 Kynamro 2 duloxetine 4 escitalopram 4 fluocinolone acetonide 6 Glucagon 2 Inlyta 1 Kynmobi 5 esomeprazole magnesium 6 Glumetza 2 Innohep 1 Duobrii 6 fluocinonide 6 L Duopa 5 estarylla 7 fluocinonide cream (generic Vanos) 6 glyburide 1 Innopran XL 2 Dupixent 6 estazolam 4 fluoride drops OTC 7 glyburide micronized 1 Inqovi 1 labetalol 2 Durlaza 1 Estraderm 7 fluoride tablets OTC 7 glycopyrrolate 6 Inrebic 1 lactulose 6 dutasteride 4 estradiol 0.01% cream 7 fluorometholone ophth 2 Glyxambi 2 Insulin Lispro 1 Lamisil Oral 3 dutasteride/tamsulosin 4 estradiol oral 7 Fluoroplex 6 Gocovri 5 Intelence 3 lamivudine tabs 3 Dutrebis 3 estradiol patches 7 Fluorouracil 0.5% cr 6 Gonal F 7 Intermezzo 4 lamivudine/zidovudine 3 Duzallo 2 estradiol/noreth ac 7 fluorouracil 2% sol 6 Gonitro 3 Intrarosa 7 lamotrigine ER 5 Dyanavel XR 4 Estrasorb packet 7 fluorouracil 5% cr/sol 6 Gralise 4 Intron A 1 lamotrigine/ODT 5 Dymista 1 Estring 7 fluoxetine 10mg and 20mg tablet 4 granisetron 6 introvale 7 Lanoxin 2 Dynacirc/CR 2 Estrogel 7 fluoxetine 60mg tablet 4 Granisol 6 Invega 4 lansoprazole 6 estrogen/methyltesterone 7 fluoxetine capsule 4 Granix 1 Invirase 3 lansoprazole DR ODT 6 E estropipate 7 fluoxymesterone 3 Grastek 1 Invokamet/XR 2 lansoprazole/amox/clarith 6 econazole 6 eszopiclone 4 fluphenazine 4 griseofulvin 3 Invokana 2 lanthanum carbonate tablet 7 econtra ez 7 ethambutol 3 flurandrenolide cream 6 Guaifenesin DM 1 ipratropium inh. soln. 5 Lantus 1 econtra one-step 7 ethosuximide 5 flurazepam 4 guaifenesin/codeine 1 ipratropium nasal spray 1 lapatinib 1 Ecoza 3 ethynodiol-ethinyl estradiol 7 flurbiprofen 5 guanfacine 2 ipratropium/albuterol 5 larin 7 Edarbi 2 etidronate 7 flurbiprofen ophth 2 guanfacine ER 4 irbesartan 2 larin fe 7 Edarbyclor 3 etodolac 5 flutamide 1 Gynazole-1 7 irbesartan/HCTZ 2 larissia 7 Edex 3 etodolac SA 5 fluticasone nasal spray 1 gynol II 7 Iressa 1 latanoprost 2 Edluar 4 etonogestrel/ethinyl estradiol fluticasone propionate 6 H Isentress 3 Latuda 4 Edurant 3 vaginal ring 7 fluticasone-salmeterol (Prasco) 5 isibloom 7 layolis fe 7 Haegarda 3 efavirenz 3 etoposide 1 Fluticasone-Salmeterol (Teva) 5 isometh/dichloralphen/APAP 5 Lazanda 5 hailey 24 Fe 7 efavirenz/lamivu/tenofovr diop 3 Eucrisa 6 fluvastatin 2 isoniazid 3 Ledipasvir/Sofosbuvir 3 halcinonide cream 6 efavirenz/emtricit/tenofovr df 3 Eurax 6 fluvoxamine ER capsule 4 isosorbide dinitrate 3 leena 7 halobetasol 6 Egrifta 4 Evamist 7 isosorbide mononitrate 3 leflunomide 5 fluvoxamine tablet 4 halobetasol propionate 6 8-MOP 6 everolimus (generic Afinitor) 1 isosorbide mononitrate SA 3 Lenvima 1 FML Forte 2 halobetasol propionate foam 6 eletriptan 5 Evoclin 6 isoxsuprine 3 Lescol 2 FML S.O.P. 2 haloperidol 4 Elidel 5 Evotaz 3 isradipine 2 Lescol XL 2 Focalin XR 4 Harvoni 3 elinest 7 Evrysdi 4 folic acid Rx 1mg tab 7 Istalol 2 lessina 7 Evzio 4 heather 7 Eliquis 1 folic acid tablets OTC 7 Isturisa 4 Letairis 3 Exelderm 6 Helidac 6 Elixophyllin 5 Follistim AQ 7 itraconazole 3 letrozole 1 exemestane 1 Hemady 6 Ella 7 fondaparinux sodium 1 ivermectin 6 leucovorin 7 Exjade 1 Hemangeol 2 eluryng vaginal ring 7 Foradil 5 Izba 2 Leukeran 1 Exservan 4 Hemlibra 1 Eloctate 1 Forfivo 4 Leukine 1 Extavia 4 heparin 1 J Embeda 4 Fortamet 2 leuprolide 1 Ezallor 2 Hepsera 3 Jadenu 1 Emcyt 1 Forteo 4 Levalbuterol Tartrate HFA 5 ezetimibe 2 Hetlioz 4 Jakafi 1 Emend 6 Fortesta 3 Levemir 1 Emflaza 6 ezetimibe-simvastatin 2 Hexalen 1 jantoven 1 levetiracetam 5 fortical NS 4 Hizentra 4 Emgality 5 Janumet 2 Levitra 3 F Fosamax 4 homatropine 2 Janumet XR 2 emoquette 7 levobunolol 2 Fabior 6 Fosamax D 4 Horizant 4 Januvia 2 emtricitabine 3 levocarnitine 7 Factive 3 fosinopril 2 HP Acthar Gel 4 Jardiance 2 emtricitabine/tenofovir disop 3 levocetirizine 1 fallback solo 7 fosinopril/HCTZ 2 Humalog insulin 1 jasmiel 7 Emtriva solution 3 levofloxacin 3 falmina 7 Fotivda 1 Humatrope 4 Jatenzo 3 Enablex 1 levonest 7 famciclovir 3 Fragmin 1 Humira 5 jencycla 7 enalapril 2 levonorg-eth estrad eth estrad 7 famciclovir ophth 2 Freestyle 2 Humulin (all types) 1 Jentadueto 2 enalapril/HCTZ 2 levonorgestrel 7 famotidine 6 Frova 5 Hycamtin capsule 1 Jentadueto XR 2 Enbrel 5 jinteli 7 levonorgestrel-eth estradiol 7 Fanapt 4 frovatriptan 5 Hycodan 1 Endari 1 Jivi 1 levora 7 Fareston 1 Fulphila 1 hydralazine 3 endocet 4 jolessa 7 levothroid 6 Farxiga 2 Fulyzaq 6 hydrochlorothiazide 3 Enjuvia 7 jolivette 7 levothyroxine 6 Farydak 1 furosemide 3 hydrocodone/APAP 4 enoxaparin 1 Jornay PM 4 levoxyl 6 Fasenra pen 5 Fuzeon 3 hydrocodone/chlorpheniramine 1 enpresse 7 Jublia 6 Lexapro 4 fayosim 7 Fycompa 5 hydrocodone/homatropine 1 enskyce 7 juleber 7 Lexette 6 Fazaclo 4 hydrocodone/ibuprofen 4 Enspryng 4 G Juluca 3 Lexiva 3 FC2 Female Condom 7 hydrocortisone 2.5% 6 junel 7 Enstilar 6 gabapentin 5 Librium 4 febuxostat 2 hydrocortisone butyrate/emoll cream 6 junel fe 7 Galafold 4 Licart 5 entacapone 5 felbamate 5 hydrocortisone oral 6 Juvisync 2 galantamine 1 lidocaine 6 entecavir tablets 3 felodipine ER 2 hydrocortisone rectal cr. & supp. 6 Juxtapid 2 galantamine ER 1 lidocaine patch 6 Entresto 3 Femcap 7 hydrocortisone rectal enema 6 Jynarque 1 Galzin 7 Liletta 7 enulose 6 Femring 7 hydrocortisone valerate 6 K lillow 7 Envarsus XR 3 femynor 7 Gammagard Liquid 4 hydrocortisone/iodoquinol 6 Epaned 2 Fenofibrate (brand) 2 Gammaked 4 hydromorphone 4 K-Phos 1 Lindane 6 Epanova 2 fenofibrate (generic) 2 Gamunex-C 4 hydromorphone ER 5 Kadian 5 linezolid 3 Epclusa 3 fenofibric acid, capsule, delayed ganciclovir 3 hydroxychloroquine 5 kaitlib fe 7 Linzess 6 Epidiolex 5 release 2 Ganirelix 7 hydroxyurea 1 Kaletra 3 liothyronine 6 Epiduo 6 fenofibric acid, tab 2 gatifloxacin 2 hydroxyzine HCl 1 kalliga 7 Lipitor 2 Epinephrine (Impax) 5 Fenoglide 2 Gattex 6 hydroxyzine pamoate 1 Kalydeco 5 Lipofen 2 Epinephrine fenoprofen tablet 5 Gavreto 1 hyoscyamine/CR 6 kariva 7 lisinopril 2 0.15mg/0.3ml (Mylan) 5 fentanyl lozenge 4 Gelnique 1 HyQvia 4 Katerzia 2 lisinopril/HCTZ 2 epinephrine auto-injector 5 fentanyl lozenge 4 gemfibrozil 2 Hysingla ER 5 Kazano 2 lithium carbonate 4 Epipen/Jr. 5 fentanyl patch 4 Gemtesa 1 Hyzaar 3 kelnor 1-35 7 Livalo 2 Epivir solution 3 fentanyl patch 37.5mcg/hr, generic Adderall 4 kelnor 1-50 7 Lo Loestrin Fe 7 Epivir-HBV solution 3 62.5mcg/hr, and 87.5mcg/hr 5 generic Adderall XR 4 I Kenalog/aerosol 6 Lomaira 7 eplerenone 3 Fentora 5 generic Concerta 4 ibandronate tabs 4 Kerydin 6 lomedia 24 fe 7 Epogen 1 Ferriprox 1 generic Dexedrine spansules 4 Ibrance 1 Kesimpta 1 Lonhala Magnair 5 epoprostenol 3 Fetzima 4 gengraf 3 ibuprofen 5 Ketek 3 Lonsurf 1 eprosartan 600mg 2 Fiasp 1 Genotropin 4 icatibant 3 ketoconazole 3 loratadine 1 ergocalciferol capsule 7 Fibricor 2 gentamicin cr/oint 6 Iclusig 1 ketoconazole 6 loratadine-D 1 ergoloid mesylates 1 Finacea 5 gentamicin ophth 2 Idhifa 1 ketoprofen 5 lorazepam 4 Ergomar 5 finasteride 5mg 4 Genvoya 3 imatinib 1 ketorolac inj. 5 Lorbrena 1 ergotamine/caffeine 5 Fintepla 5 Geodon 4 Imbruvica 1 ketorolac tab 5 loryna 7 Erivedge 1 Fioricet/codeine 5 gianvi 7 Imcivree 7 ketotifen opthalmic solution 2 Lorzone 4 Erleada 1 Fiorinal/codeine 5 Giazo 6 imipramine 4 Keveyis 4 losartan 2

9 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE losartan/HCTZ 2 metoprolol/HCTZ 2 Nexium DR 2.5mg, 5mg packet 6 Olumiant 5 perphenazine 4 propafenone SR 2 Lotemax gel 2 Metrogel topical 1% 6 Nexletol 2 omega-3 acid ethyl esters 2 Pertzye 6 propantheline bromide 6 Lotemax ointment 2 metronidazole 3 Nexplanon 7 omeprazole 6 Pexeva 4 propranolol 2 Lotemax SM 2 metronidazole cream/lotion/ next choice one dose 7 omeprazole/sodium bicarbonate 6 phenazopyridine 1 propranolol/HCTZ 2 loteprednol 2 0.75% gel 6 niacin ER 2 Omnaris 1 phendimetrazine 7 propylthiouracil 6 loteprednol etabonate susp 2 Mevacor 2 niacin IR 500mg tablet 2 Omnitrope 4 phenelzine 4 Proscar 4 lovastatin 2 mexiletine 2 niacin (OTC) 2 Omontys 1 phenobarbital 5 Protonix 6 low-ogestrel 7 Miacalcin inj. 1 niacin/simvastatin 2 Omtryg 2 phentermine 6 protriptyline 4 loxapine 4 mibelas 24 fe 7 nicardipine 2 ondansetron 6 phenylephrine ophth 2 Proventil HFA 5 lo-zumandimine 7 Micardis 2 Nicorelief gum 6 OneTouch 2 phenytoin 5 Prozac 4 Lucemyra 4 Micardis HCT 3 Nicorelief lozenge 6 Onexton 6 philith 7 prudoxin 6 Lumigan 2 miconazole vag supp 7 Nicotine Gum 6 Ongentys 5 Phisohex 6 pseudoephedrine 1 Lupkynis 3 microgestin 7 Nicotine lozenges 6 Onglyza 2 Phospholine Iodide 2 pseudoephedrine/codeine 1 lutera 7 microgestin fe 7 Nicotine patches various 6 Onureg 1 phytonadione 7 Pulmicort flexhaler/powder 5 Luvox CR 4 midodrine 2 Nicotrol Inhaler 6 Onzetra 5 Picato 6 Pulmicort respules (1mg/2ml) 5 Luzu 3 miglitol 2 Nicotrol NS 6 opcicon one-step 7 pilocarpine 2 Pulmozyme 5 Lymepak 3 miglustat 4 nifediac CC 2 Opsumit 3 pimtrea 7 Purixan 1 Lynparza 1 mili 7 nifedical XL 2 option 2 7 pindolol 2 pyrazinamide 3 Lyrica CR 5 Minitran 3 nifedipine 2 Oracea 6 pioglitazone/metformin 1 pyrimethamine 3 Lysodren 1 Minocin 3 nifedipine SR 2 Oracit 1 Piqray 1 Q Lyumjev 1 minocycline 3 Nikita 2 Oralair 1 pirmella 7 lyza 7 minocycline 5 nikki 7 Oravig 3 piroxicam 5 Qbrelis 2 Qbrexza 6 minocycline HCl ER 6 nilutamide 1 Orencia SC 5 Plegridy 4 M Qinlock 1 Minolira ER 6 nimodipine 2 Orenitram 3 Pneumovax 23 6 Macrodantin 3 Qmiiz ODT 5 minoxidil oral 3 Ninlaro 1 Orgovyx 1 podofilox 6 maprotiline 4 Qnasl 1 Mircera 1 nisoldipine 2 Oriahnn 7 Poly-Vi-Flor + Iron 7 marlissa 7 Qsymia 7 Mirena 7 nitazoxanide 6 Orilissa 7 polymyxin B/TMP 2 Matulane 1 Qtern 2 mirtazapine 4 nitisinone 7 Orkambi 5 Pomalyst 1 Mavenclad 4 quasense 7 Mirvaso 6 NitroDur patches 3 Orkambi granules 5 Ponvory 4 Mavyret 3 Qudexy XR 5 misoprostol 6 nitrofurantoin 3 Orladeyo 3 portia 7 Maxair Autohaler 5 quetiapine 4 Mitigare 2 nitrofurantoin 3 orphenadrine 4 Posaconazole 3 Maxalt 5 quetiapine fumarate ER 4 modafinil 4 nitroglycerin pumpspray 3 orphenadrine/aspirin/caffeine 4 potassium aminobenzoate 7 Maxalt MLT 5 Quillichew ER 4 moderiba 3 nitroglycerin SR 3 orsythia 7 potassium bicarb/potassium Maxidex 2 Quillivant XR 4 moexipril 2 nitroglycerin transdermal patch 3 Ortho-Est 7 chloride 5 Maxitrol ophth 2 quinapril 2 mometasone cr/oint 6 Nitrostat SL tabs 3 oseltamivir 3 potassium bicarbonate 5 Mayzent 4 quinapril/HCTZ 2 mometasone nasal spray 1 Nivestym 1 Oseni 2 potassium chloride 5 meclizine 6 quinidine gluconate 2 mono-linyah 7 nizatidine 6 Osmolex ER 5 potassium citrate 1 meclofenamate 5 quinidine sulfate SR 2 mononessa 7 Nocdurna 4 Osphena 7 potassium citrate ER 5 Medrol 2mg 6 quinine sulfate 3 montelukast 5 Noctiva 4 Potiga 5 medroxyprogesterone 7 Otezla 4 Qvar 5 MorphaBond 5 nora-be 7 Pradaxa 1 mefenamic acid 5 Otrexup 5 morphine SR 4 Norditropin 4 Ovidrel 6 Praluent 2 R mefloquine 3 pramipexole 5 megestrol 1 morphine sulfate ER 4 norethin-eth estra ferrous fum 7 oxaprozin 5 rabeprazole 6 pramipexole ER 5 Mekinist 1 morphine tab, soln, supp 4 norethindrone 7 oxazepam 4 Ragwitek 1 pramoxine/HC acetate 2.5% 6 Mektovi 1 Motegrity 6 norethindrone acetate 7 Oxbryta 1 rajani 7 prascion RA 5 melodetta 24 fe 7 Movantik 6 norethindrone-ethin estradiol 7 oxcarbazepine 5 raloxifene 4 prasugrel 1 meloxicam 5 moxifloxacin 3 norgestimate-ethinyl estradiol 7 Oxervate 2 ramelteon 4 Pravachol 2 memantine 1 moxifloxacin 0.5% (generic Vigamox) 2 norgestrel-ethiny estra 7 oxiconazole 3 ramipril 2 pravastatin 2 memantine ER 1 Mulpleta 1 Noritate 6 oxiconazole 6 Ranexa 3 prazosin 2 Menactra 6 Multaq 2 norlyda 7 Oxistat ceram 3 ranitidine (all) 6 pre-natal vitamins (Rx-only) 7 Menest 7 multivitamin + fluoride (Rx-only) 7 norlyroc 7 Oxistat lotion 3 ranolazine ER 3 Precision 2 Menhibrix 6 mupirocin 6 Noroxin 3 Oxistat lotion 6 Rapaflo 4 Pred Mild 2 Menomune-A-C-Y-W-135 6 MUSE 3 Norpace CR 2 Oxtellar XR 5 rasagiline 5 Pred-G 2 Menopur 6 my choice 7 Northera 2 oxybutynin 1 Rasuvo 5 prednicarbate 6 Menostar 7 my way 7 nortrel 7 oxybutynin ER 1 Ravicti 4 prednisolone acetate 2 Menveo A-C-Y-W-135-Dip 6 Myalept 4 nortriptyline 4 oxycodone 4 Rayaldee 6 prednisolone oral 6 meperidine 4 Mycapssa 4 Norvir capsule, solution 3 Oxycodone ER 5 Rayos 6 prednisolone sod phosphate 2 mephobarbital 5 mycophenolate mofetil 3 Nourianz 5 oxycodone/acetaminophen 4 react 7 prednisone oral 6 Mephyton 7 mycophenolic acid 3 Novarel 6 oxycodone/aspirin 4 Rebetol 3 Prefest 7 meprobamate 4 Mydayis 4 Novolin 1 oxycodone/ibuprofen 4 Rebif 4 pregabalin 5 mercaptopurine 1 Myleran 1 Novolog 1 Oxycontin 5 reclipsen 7 Pregnyl 6 mesalamine DR capsule 400mg 6 Myrbetriq 1 Noxafil 3 oxymorphone/ER 4 Rectiv 6 Premarin 7 mesalamine DR tablet 1.2g 6 myzilra 7 Nubeqa 1 Oxytrol 1 Regenecare 6 Premarin vag cream 7 mesalamine DR tablet 800mg 6 N Nucala syringe/auto-inject 5 Oxytrol for Women 1 Regranex 6 mesalamine enema 6 Nucynta/ER 5 Ozempic 1 Premphase 7 Relenza 3 nabumetone 5 mesalamine suppository 6 Nuedexta 5 Ozobax 4 Prempro 7 Relistor 6 nadolol 2 Mesnex 1 Nulytely 6 Prenate Elite 7 Relpax 5 naftifine 6 P metadate ER 4 Nuplazid 4 Prepopik 6 Renagel 7 naltrexone 4 metaproterenol syr 5 Nurtec 5 Palforzia 1 Prestalia 3 repaglinide 1 metaxalone 4 Namzaric 1 Nutropin/AQ 4 paliperidone 4 Prevacid 6 repaglinide/metformin 2 metformin 1 naphazoline 2 NuvaRing 7 Palynziq 6 Prevacid 24HR 6 Repatha 2 metformin ER (except generic naproxen CR 375mg tablet 5 Nymalize 2 Pancreaze 6 previfem 7 Repronex 6 Glucophage XR) 2 naproxen/EC 5 nystatin 3 Panretin 6 Prevnar 13 6 Rescriptor 3 metformin ER (generic naratriptan 5 nystatin 6 pantoprazole 6 Prevymis tablets 3 Rescula 2 Glucophage XR) 1 Narcan Nasal Spray 4 nystatin vag tab 7 Paragard 7 Prexxartan 2 Restasis 2 metformin/glyburide 1 Nasacort Allergy 24HR 1 nystatin/triamcinolone 6 paregoric 6 Prezcobix 3 Retacrit 1 methadone 4 Nasacort AQ 1 nystop 6 paricalcitol 7 Prezista 3 Retevmo 1 methazolamide 3 Nascobal 7 Nyvepria 1 paromomycin 3 Prilosec 6 Retin-A/Micro 6 methenamine combination 3 Natazia 7 paroxetine 4 Prilosec-OTC 6 Revatio 3 Methergine 7 nateglinide 1 O paroxetine 7.5mg 7 Primaquine 3 Revcovi 4 methimazole 6 Natesto 4 Ocaliva 6 Paxil/CR 4 primidone 5 Revlimid 1 methocarbamol 4 Natpara 4 ocella 7 Pazeo 2 Pristiq ER 4 Rexulti 4 methotrexate 1 necon 7 octreotide 4 PCE 3 ProAir HFA/RespiClick 5 Reyvow 5 methotrexate 5 nefazodone 4 Odactra 1 Pediatric sodium fluoride chewable abt probenecid 2 Rhinocort Allergy 1 methoxsalen capsule 6 neomycin 3 Odesfey 3 & drops 7 procainamide 2 Rhofade 6 methyclothiazide 3 neomycin/bacitracin/poly B 2 Odomzo 1 peg 3350/electrolyte 6 procentra 4 Rhopressa 2 methyldopa 2 neomycin/bacitracin/poly B/HC 2 Ofev 5 Peg-Intron 3 prochlorperazine 6 ribapak 3 methyldopa/HCTZ 2 neomycin/polymyxin/HC otic 2 ofloxacin 3 Peganone 5 Procrit 1 ribasphere 3 methylergonovine maleate 7 Neoral 3 ofloxacin ophth 2 Pegasys 3 Proctofoam-HC 6 Ribatab 3 methylphenidate CD 4 Nerlynx 1 ofloxacin otic 2 Pemazyre 1 Procysbi 4 ribavirin 3 Methylphenidate ER (brand) 4 Nesina 2 ogestrel 7 penicillamine 6 progesterone in oil 6 Ridaura 5 methylphenidate/SR 4 Neulasta 1 olanzapine 4 penicillin VK 3 progesterone, micronized 7 rifabutin 3 methylprednisolone 4mg, 8mg, Neupogen 1 olanzapine/fluoxetine 4 Pennsaid 5 Prograf 3 Rifamate 3 16mg, 32mg 6 Nevanac 2 Oleptro ER 4 pentamidine inhal powder, 3 Prolensa 2 rifampin 3 metipranolol 2 new day 7 olmesartan 2 Pentasa 6 Promacta 1 Rifater 3 metoclopramide 6 Nexavar 1 olmesartan/amlodipine 3 pentazocine/naloxone 4 promethazine 6 riluzole 4 metolazone 3 Nexium 6 olmesartan/amlodipine/HCTZ 3 pentoxifylline 1 promethazine/codeine 1 rimantadine 3 metoprolol 2 Nexium 24HR 6 olmesartan/HCTZ 2 pergolide 5 promethazine/DM 1 Rinvoq 6 metoprolol ER 2 Nexium DR 10mg, 20mg, olopatadine 0.2% drop 2 perindopril 2 promethazine/phenylephrine/ codeine 1 risedronate 150mg 4 metoprolol/HCTZ 2 40mg packet 6 olopatadine ophth 2 permethrin 6 propafenone 2 risedronate DR 4

10 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE Risperdal 4 Somatuline Depot 4 Tegsedi 4 tri-lo-marzia 7 venlafaxine 4 Y risperidone 4 Somavert 4 Tekturna 3 tri-lo-mili 7 venlafaxine ER 4 risperidone m-tab 4 Somnote 4 Tekturna HCT 2 tri-lo-sprintec 7 Ventavis 3 Yonsa 1 ritonavir tablet 3 Sonata 4 telmisartan 2 tri-mili 7 Ventolin HFA 5 Yosprala 5 rivastigmine 1 Soolantra 6 telmisartan/amlodipine 3 tri-previfem 7 verapamil/SR 2 Yupelri 5 rivastigmine patch 1 Soriatane CK 5 telmisartan/HCTZ 2 tri-sprintec 7 Verquvo 3 yuvafem 7 rivelsa 7 sotalol 2 temazepam 4 Tri-Vi-Flor 7 Versacloz 4 rizatriptan 5 sotret 5 Temodar 1 tri-vylibra 7 Verzenio 1 Z Rocklatan 2 Sovaldi 3 temozolamide 1 tri-vylibra lo 7 Vesicare 1 Rondec DM/TR 1 Spectracef 3 Tenivac 6 triamcinolone acetonide 6 vestura 7 Zaditor 2 ropinirole 5 spinosad 6 tenofovir 300mg 3 triamcinolone nasal spray 1 Viagra 3 zafirlukast 5 ropinirole ER 5 Spiriva 5 Tepmetko 1 triamcinolone spray 6 Vibramycin 3 zaleplon 4 Rosula 6 Spiriva Respimat 5 terazosin 2 triamterene/HCTZ 3 Vicodin/ES 5 rosuvastatin 2 spironolactone 3 terbinafine 3 triazolam 4 Victoza 1 zarah 7 Roxicet solution 5 spironolactone/HCTZ 3 terbutaline tab 5 Trijardy XR 2 Victrelis 3 Zarxio 1 Rozerem 4 Sporanox suspension 3 terconazole 7 Trikafta 5 Videx 3 Zavesca 4 Rozlytrek 1 sprintec 7 Testim 4 Tricor 2 Viekira 3 Zecuity 5 Rubraca 1 Sprix 5 testosterone cypionate 3 trientine 1 vienva 7 Ruconest 3 Sprycel 1 testosterone enanthate 3 trifluoperazine 4 vigabatrin oral powder 5 Zegerid 6 testosterone gel 3 Ruzurgi 4 sronyx 7 trifluridine 2 Viibryd 4 Zegerid OTC 6 Rybelsus 2 stavudine 3 Testosterone gel (brand) 4 Triglide 2 Vimovo 5 Zejula 1 Rydapt 1 Staxyn 3 testosterone pump 3 trihexyphenidyl 5 Vimpat 5 Rytary 5 Steglatro 2 Tetanus Diphtheria Toxoids 6 Trilyte 6 Viokace 6 Zelboraf 1 Steglujan 2 tetrabenazine 3 trimethobenzamide 6 viorele 7 Zelnorm 6 S tetracycline 3 Stelara 6 trimethoprim 3 Viracept 3 Sabril 5 Tev-Tropin 4 Zembrace 5 Stendra 3 trinessa 7 Viramune, XR 3 Saizen 4 Stimate 4 Thalomid 1 trinessa lo 7 zenchent 7 salsalate 5 Viread 150mg, 200mg, 250mg, Stiolto Respimat 5 Theo-24 5 Trintellix 4 40mg/scoop powder 3 zenchent fe 7 Samsca 15mg 3 theochron 5 Stivarga 1 Triumeq 3 vit A,D,C + fluoride (Rx-only) 7 Samsca 30mg 3 theophylline/SR tabs, liquid 5 Zenpep 6 Strensiq 4 trivora 7 vit A,D,C + fluoride and iron Sanctura 1 zeosa 7 Striant 4 thioridazine 4 Trokendi XR 5 (Rx-only) 7 Sanctura XR 1 Stribild 3 thiothixene 4 tropicamide 2 Vitekta 3 Zepatier 3 Sancuso 6 thyroid 6 Striverdi Respimat 5 trospium 1 Vitrakvi 1 Sandimmune 3 Thyroid (Armour) 6 Zeposia 4 Subsys 5 trospium ER 1 Vituz 1 Sandostatin 4 Thyrolar 6 Zerviate 2 Sucraid 6 TRUEtest 2 Vivlodex 5 Saphris 4 tiagabine 5 sucralfate 6 TRUEtrack 2 Vizimpro 1 Zetonna 1 sapropterin 6 Tibsovo 1 sulfacetamide 10% 2 Trulance 6 Vogelxo 4 Ziagen 3 Sarafem 4 ticlopidine 1 sulfacetamide/prednisolone ophth 2 Trulicity 1 voriconazole 3 Savaysa 1 sulfamethoxazole/trimethoprim 3 Tiglutik 4 Ziana gel 6 Trumenba 6 Vosevi 3 Savella 4 sulfasalazine 6 tilia fe 7 Truvada 3 Votrient 1 zidovudine 3 Saxenda 7 sulfasalazine EC 6 timolol 2 Tudorza 5 Vraylar 4 Ziextenzo 1 scopolamine patch 6 sulindac 5 timolol 2 Tukysa 1 Vumerity 4 Secuado 4 sumatriptan 5 tinidazole 3 zileuton ER 5 tulana 7 vyfemla 7 Seebri 5 Sumavel 5 Tirosint 6 Zioptan 2 Turalio 1 Vyleesi 7 Segluromet 2 Sunosi 4 Tivicay 3 Tybost 3 vylibra 7 ziprasidone caps 4 selegiline 5 Suprenza ODT 7 Tivorbex 5 tydemy 7 Vyndamax 3 Zipsor 5 selenium sulf 2.5% suspension 6 Suprep 6 tizanidine 4 Tykerb 1 Vyndaqel 3 Selzentry 3 Sutent 1 Tobi 3 Tylenol/codeine 5 Zmax 3 Vyvanse 4 Semglee 1 syeda 7 Tobi Podhaler 3 Tymlos 4 Zocor 2 Semprex-D 1 Sylatron 1 Tobradex ointment 2 Vyzulta 2 Tyvaso 3 Zohydro ER 5 Sensipar 4 Symbicort 5 tobramycin ampule/neb 3 Tyzeka 3 W Serevent Diskus 5 tobramycin soln 2 Zokinvy 4 Symbyax 4 Wakix 4 serophene 6 tobramycin/dexameth 2 U Symdeko 5 warfarin 1 Zolinza 1 Seroquel 4 Symfi 3 Tobrex ointment 2 Ubrelvy 5 wera 7 zolmitriptan 5 Seroquel XR 4 Tobrex solution 2 Uceris 6 Symfi Lo 3 Winlevi 6 Serostim 4 Symjepi 5 Today Contraceptive Sponge 7 Udenyca 1 Zoloft 4 wixela inhub 5 sertraline 4 Symlin 1 tolazamide 1 Ukoniq 1 wymzya fe 7 zolpidem 4 setlakin 7 Sympazan 5 tolbutamide 1 Ulesfia 6 Wynzora 6 zolpidem ER 4 sevelamer 7 Symproic 6 tolcapone 5 Uloric 2 Seysara 5 Synarel 4 tolmetin 5 Ultresa 6 X zolpidem ER sublingual tablet 4 sharobel 7 Syndros 6 Tolsura 3 unithroid 6 Xadago 5 Zolpimist 4 Shingrix 6 tolterodine 1 Synjardy/XR 2 Upneeq 2 Xalatan 2 Zomig 5 Signifor 4 Synribo 1 tolterodine ER 1 Uptravi 3 Xalkori 1 sildenafil 20 mg tab 3 tolvaptan 3 Zomig Nasal 5 Synthroid 6 Urecholine 1 Xarelto 1 sildenafil citrate 25mg, 50mg, topiramate 5 Uroxatral 4 Xartemis XR 5 Zomig ZMT 5 100mg 3 T topiramate ER 5 ursodiol 6 Xatmep 1 Zonalon 6 sildenafil suspension 3 Tabrecta 1 torsemide 3 Utibron 5 Xcopri 5 Silenor 4 Taclonex 6 Tosymra 5 zonisamide 5 Xeljanz 5 Siliq 6 tacrolimus 3 Toujeo 1 V Zontivity 1 Xeljanz XR 5 silodosin 4 tacrolimus 5 Toviaz 1 valacyclovir 3 Xelpros 2 Zontivity 1 silver sulfadiazine 6 tadalafil (generic Adcirca) 3 Tracleer tab 3 Valchlor 1 simliya 7 tadalafil (generic Cialis) 3 Tracleer tab for susp 3 valganciclovir solution 3 Xembify 4 Zorbtive 4 simpesse 7 Tafinlar 1 Tradjenta 2 valganciclovir tablets 3 Xenical 7 Zortress 3 Xepi 6 Simponi 5 Tagrisso 1 tramadol ER capsule 5 valproic acid 5 Zorvolex 5 simvastatin 2 Takhzyro 3 tramadol/acetaminopen 5 valsartan 2 Xermelo 6 sirolimus 3 Taltz 6 tramadol/ER tablet 5 valsartan/HCTZ 2 Xgeva 1 Zostavax 6 Sirturo 3 Talzenna 1 trandolapril 2 Valtrex 3 Xhance 1 zovia 7 Xifaxan 3 Sitavig 3 tamoxifen 1 trandolapril/verapamil 3 Valturna 3 Zubsolv 4 Sivextro 3 tamsulosin 3 tranylcypromine 4 Vancocin 3 Xigduo XR 2 zumandimine 7 Sklice 6 Tanzeum 1 Travatan Z 2 vancomycin caps 3 Xiidra 2 Skyla 7 Tarceva 1 travoprost (generic Travatan Z) 2 vandazole vag 7 Ximino 6 Zuplenz 6 Skyrizi 6 Targretin gel 1 trazodone 4 vardenafil 3 Xofluza 3 Zurampic 2 Slynd 7 tarina 24 Fe 7 Trelegy Ellipta 5 vardenafil ODT 3 Xopenex HFA 5 Zyban 6 sod. polystyrene sulfonate 5 tarina fe 7 Tremfya 6 Varubi 6 Xospata 1 sod. sulfacetamide/sulfur emulsion tarina Fe 1-20 eq 7 Tresiba 1 Vascepa 2 Xpovio 1 Zydelig 1 cleanser 5 Tasigna 1 tretinoin cr/gel 5 VCF 7 Xtampza ER 5 Zyflo 5 sod. sulfacetamide/sulfur lot 5 Tavalisse 1 Vecamyl 3 Xtandi 1 tretinoin microsphere gel 6 Zykadia 1 sodium chloride irrigating soln 6 Taytulla 7 Trexall 1 veletri 3 Xtoro 2 sodium phenylbutyrate 4 tazarotene cream 6 Treximet 5 velivet 7 xulane 7 Zylet 2 sodium sulfacetamide 5 Tazorac 6 tri femynor 7 Velphoro 7 Xultophy 1 Zypitamag 2 Xuriden 4 Sofosbuvir/Velpatasvir 3 Tazverik 1 tri-estarylla 7 Veltassa 4 Zyprexa 4 solifenacin 1 Tecfidera 4 tri-legest fe 7 Veltin gel 6 Xyosted 4 Soliqua 1 Tegretol 5 tri-linyah 7 Vemlidy 3 Xyrem 4 Zyprexa Zydis 4 Solodyn 6 Tegretol XR 100mg 5 tri-lo-estarylla 7 Venclexta 1 Xywav 4 Zytiga 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