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MedStar Family Choice - Maryland HealthChoice Prescribing Guide 2018 (710)

(04/01/2018)

INTRODUCTION ...... 5 NONDISCRIMINATION STATEMENT ...... 6 PREFACE ...... 8 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...... 8 PRODUCT SELECTION CRITERIA ...... 8 GENERIC AVAILABILITY ...... 8 GENERIC SUBSTITUTION ...... 8 DRUG STUDY IMPLEMENTATION (DESI) DRUGS ...... 9 MAIL SERVICE PRESCRIPTIONS ...... 9 MEDICAL EXCEPTION ...... 9 PRIOR AUTHORIZATION (PA) ...... 9 MANAGED DRUG LIMITATIONS (MDL) ...... 10 STEP THERAPY (ST) ...... 12 OVER-THE-COUNTER (OTC) DRUG COVERAGE ...... 12 EDITOR ...... 15 NOTICE ...... 16 LEGEND ...... 16 ANALGESICS ...... 17 NSAIDs ...... 17 NSAIDs, TOPICAL ...... 17 COX-2 INHIBITORS ...... 17 GOUT ...... 17 ANALGESICS ...... 17 NON-OPIOID ANALGESICS ...... 18 VISCOSUPPLEMENTS...... 18 ANTI-INFECTIVES ...... 18 ANTIBACTERIALS ...... 19 ANTIFUNGALS ...... 20 ANTIMALARIALS ...... 20 ANTIRETROVIRAL AGENTS...... 20 ANTITUBERCULAR AGENTS ...... 20 ANTIVIRALS ...... 20 MISCELLANEOUS ...... 20 ANTINEOPLASTIC AGENTS ...... 21 ALKYLATING AGENTS ...... 21 ANTIMETABOLITES ...... 21 HORMONAL ANTINEOPLASTIC AGENTS ...... 21 KINASE INHIBITORS ...... 22 TOPOISOMERASE INHIBITORS ...... 22 MISCELLANEOUS ...... 22

1 CARDIOVASCULAR ...... 22 ACE INHIBITORS ...... 23 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS...... 23 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 23 ADRENOLYTICS, CENTRAL ...... 23 ALDOSTERONE ANTAGONISTS...... 23 ALPHA BLOCKERS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 23 ANGIOTENSIN II /CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 24 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 24 ANTIARRHYTHMICS ...... 24 ANTILIPEMICS ...... 24 BETA-BLOCKERS ...... 25 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 25 CALCIUM CHANNEL BLOCKERS...... 25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 26 DIGITALIS GLYCOSIDES ...... 26 DIURETICS ...... 26 HEART FAILURE ...... 26 NITRATES ...... 26 PULMONARY ARTERIAL HYPERTENSION ...... 27 MISCELLANEOUS ...... 27 CENTRAL NERVOUS SYSTEM ...... 27 ANTIANXIETY ...... 27 ANTICONVULSANTS ...... 27 ANTIDEMENTIA ...... 28 ...... 28 ANTIPARKINSONIAN AGENTS ...... 28 ...... 28 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 28 FIBROMYALGIA ...... 28 HYPNOTICS ...... 29 MIGRAINE ...... 29 MOOD STABILIZERS ...... 29 MOVEMENT DISORDERS ...... 29 MULTIPLE SCLEROSIS AGENTS ...... 29 MUSCULOSKELETAL THERAPY AGENTS...... 29 MYASTHENIA GRAVIS...... 30 NARCOLEPSY/CATAPLEXY ...... 30 NEUROMUSCULAR BLOCKING AGENTS ...... 30 POSTHERPETIC NEURALGIA (PHN) ...... 30 PSYCHOTHERAPEUTIC - MISCELLANEOUS ...... 30 ENDOCRINE AND METABOLIC ...... 31 ANDROGENS ...... 31 ANTIDIABETICS ...... 31 CALCIUM RECEPTOR ANTAGONISTS...... 32 CALCIUM REGULATORS...... 32 CONTRACEPTIVES...... 33 ESTROGENS ...... 34 ESTROGEN/PROGESTINS ...... 35 GLUCOCORTICOIDS ...... 35 GLUCOSE ELEVATING AGENTS ...... 35 GROWTH HORMONES ...... 35 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS...... 35 PHOSPHATE BINDER AGENTS ...... 35 POTASSIUM-REMOVING AGENTS ...... 35 PRE-TERM BIRTH RISK REDUCTION ...... 35

2 PROGESTINS ...... 35 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 36 THYROID AGENTS...... 36 VASOPRESSINS ...... 36 MISCELLANEOUS ...... 36 GASTROINTESTINAL ...... 36 ANTACIDS ...... 36 ANTIDIARRHEALS ...... 36 ANTIEMETICS ...... 36 ...... 37 CHOLELITHOLYTICS ...... 37 H2 RECEPTOR ANTAGONISTS ...... 37 INFLAMMATORY BOWEL DISEASE ...... 37 IRRITABLE BOWEL SYNDROME ...... 37 LAXATIVES/STOOL SOFTENERS ...... 38 OPIOID-INDUCED ...... 38 PANCREATIC ENZYMES ...... 38 ...... 38 PROTON PUMP INHIBITORS ...... 38 RECTAL PREPARATIONS, STEROIDS/OTHER ...... 38 ULCER THERAPY COMBINATIONS...... 38 MISCELLANEOUS ...... 38 GENITOURINARY ...... 38 BENIGN PROSTATIC HYPERPLASIA ...... 38 URINARY ANTISPASMODICS ...... 39 VAGINAL ANTI-INFECTIVES ...... 39 MISCELLANEOUS ...... 39 HEMATOLOGIC ...... 39 ANTICOAGULANTS...... 39 HEMATOPOIETIC GROWTH FACTORS ...... 40 HEREDITARY ANGIOEDEMA AGENTS ...... 40 PLATELET AGGREGATION INHIBITORS ...... 40 PLATELET SYNTHESIS INHIBITORS...... 40 MISCELLANEOUS ...... 40 IMMUNOLOGIC AGENTS ...... 40 ALLERGEN EXTRACTS ...... 40 AUTOIMMUNE AGENTS ...... 40 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 41 IMMUNOSUPPRESSANTS ...... 41 NUTRITIONAL/SUPPLEMENTS ...... 41 ELECTROLYTES ...... 41 VITAMINS AND MINERALS...... 41 RESPIRATORY ...... 42 ANAPHYLAXIS TREATMENT AGENTS ...... 42 ...... 42 /BETA COMBINATIONS ...... 42 , LOW SEDATING ...... 42 ANTIHISTAMINES, NONSEDATING ...... 42 ANTIHISTAMINES, SEDATING ...... 42 /DECONGESTANT COMBINATIONS ...... 43 ANTITUSSIVES ...... 43 ANTITUSSIVE COMBINATIONS ...... 43 BETA ...... 43 CYSTIC FIBROSIS ...... 44 DECONGESTANTS ...... 44 DECONGESTANT/EXPECTORANT COMBINATIONS ...... 44

3 EXPECTORANTS ...... 44 LEUKOTRIENE MODULATORS ...... 44 MAST CELL STABILIZERS...... 44 NASAL ANTIHISTAMINES...... 44 NASAL STEROIDS ...... 44 PULMONARY FIBROSIS AGENTS ...... 44 RESPIRATORY SYNCYTIAL VIRUS ...... 44 STEROID/BETA AGONIST COMBINATIONS ...... 44 STEROID ...... 45 ...... 45 MISCELLANEOUS ...... 45 TOPICAL ...... 45 DERMATOLOGY ...... 45 MOUTH/THROAT/DENTAL AGENTS...... 47 OPHTHALMIC ...... 48 OTIC ...... 49 WEBSITES ...... 50 INDEX ...... 52

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INTRODUCTION MedStar Family Choice is pleased to provide the 2018 MedStar Family Choice - Maryland HealthChoice Prescribing Guide to be used when prescribing for patients covered by the pharmacy plan offered by MedStar Family Choice. This is a closed formulary and only those drugs listed in this formulary will be covered by MedStar Family Choice. The drugs listed in the MedStar Family Choice - Maryland HealthChoice Prescribing Guide have been reviewed and approved by the MedStar Family Choice Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have drug benefits administered through MedStar Family Choice - Maryland HealthChoice. There may be occasions when an unlisted drug is desired for medical management of a specific patient. In those instances, the unlisted medication may be requested through the Medical Exception process. The information contained in this formulary and its appendices is provided solely for the convenience of medical providers. This formulary is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. MedStar Family Choice does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. MedStar Family Choice does not assume responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

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NONDISCRIMINATION STATEMENT It is the policy of MedStar Family Choice not to discriminate on the basis of race, color, national origin, sex, age or disability. MedStar Family Choice has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the Compliance Department of MedStar Family Choice. The following individual has been designated to coordinate MedStar Family Choice’s efforts to comply with Section 1557. Ms. Jayne Hunt Director, Medicaid Contract Oversight, Maryland 5233 King Avenue Suite 400 Baltimore, MD 21237 410-933-2283 [email protected] Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for MedStar Family Choice to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. Procedure: • Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action. • A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought. • The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of MedStar Family Choice relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know. • The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies, including but not limited to the ability to appeal to the President of MedStar Family Choice.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination. MedStar Family Choice will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.

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Language Accessibility Statement Interpreter Services Are Available for Free ATTENTION: If you speak [language], language assistance services, free of charge, are available to you. Call (800) 905-1722#1 (TTY:711).

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PREFACE The MedStar Family Choice - Maryland HealthChoice Prescribing Guide is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. All drugs listed were selected to be on this formulary. Products are listed by generic name. Brand-name products are included as a reference to assist in product recognition. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are covered. This formulary covers selected over-the-counter (OTC) products. You are encouraged to prescribe them when clinically appropriate. A prescription (written or telephoned) is required and refills are permitted. The prescription expires under Maryland Pharmacy Law in 12 months. Condoms do not require a prescription. For covered products refer to the Over- The-Counter (OTC) Drug Coverage section that is located near the end of the introductory sections of this formulary. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The MedStar Family Choice P&T Committee includes physicians, pharmacists, and nurses. The Committee meets bimonthly to evaluate drugs for formulary inclusion and to develop policies concerning formulary and drug utilization management. Please visit the MedStar Family Choice website at www.medstarfamilychoice.com to view the decisions of the MedStar Family Choice P&T Committee and any applicable changes. The main features of the MedStar Family Choice P&T Policies are also on the website in the FAQs.

Please visit www.mdmahealthchoicerx.com to view the MedStar Family Choice - Maryland HealthChoice Prescribing Guide. This Maryland Department of Health and Mental Hygiene (D.H.M.H.) sponsored site contains the formularies of all the Managed Care Organizations (MCO) and is updated frequently. PRODUCT SELECTION CRITERIA The MedStar Family Choice Pharmacy and Therapeutics Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: • Safety • Efficacy • Comparison studies • Approved indications • Adverse effects • Contraindications/Warnings/Precautions • • Patient administration/compliance considerations When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire MedStar Family Choice - Maryland HealthChoice Prescribing Guide is reviewed on an annual basis. All the information in the MedStar Family Choice - Maryland HealthChoice Prescribing Guide is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. GENERIC AVAILABILITY Boldface type of a generic drug name in this book indicates generic availability of that product. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In some cases, the brand name listed is a generic drug. Examples of the latter include Levoxyl and Trivora. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand-name product. 2. The FDA has given the generic an "A" rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic

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drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand-name product. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange Book and carry a "B" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. Some plans will not pay for DESI "less than fully effective" drug products. DESI drugs are excluded by MedStar Family Choice. Exceptions: Donnatal and Midrin are covered. MAIL SERVICE PRESCRIPTIONS Mail order is available for chronic medications. A 90-day supply will be provided to members using mail order services. Practitioners may submit a mail order prescription to the CVS Caremark Mail Service Pharmacy™. Additional information can be found at www.caremark.com. MEDICAL EXCEPTION If a non-covered drug is desired for medical management of a patient, a medication exception may be requested by calling MedStar Family Choice at: 1-800-905-1722. PRIOR AUTHORIZATION (PA) The following drugs and generic versions, if available, require prior authorization. This list is subject to change. ALBENZA FASENRA MEKINIST ALECENSA FIRAZYR midazolam injection ALUNBRIG GRALISE MINASTRIN 24 FE AMITIZA HAEGARDA ext-rel beads AMPYRA HYCAMTIN CAPS MOVANTIK BETHKIS IBRANCE MS CONTIN BEYAZ ICLUSIG NATAZIA BOSULIF IMBRUVICA NORDITROPIN BOTOX INGREZZA NOXAFIL CABOMETYX JAKAFI NUCALA COMETRIQ JUXTAPID OFEV COTELLIC KALYDECO ORKAMBI DDAVP spray KEVZARA OTEZLA DIFICID KISQALI oxymorphone ext-rel DOLOPHINE leuprolide acetate PROLIA DUPIXENT LINZESS PULMOZYME DURAGESIC LO LOESTRIN FE RASUVO ELIGARD LOVAZA REPATHA ENDARI LUPRON DEPOT RITUXAN HYCELA ERWINAZE LYNPARZA RUBRACA ESBRIET MAVYRET SANTYL MedStar Family Choice - Maryland HealthChoice Program 9

SEROSTIM TARCEVA XIIDRA SILIQ TASIGNA XOLAIR SIRTURO TAYTULLA XYREM STIMATE TYKERB ZEJULA STIVARGA VENCLEXTA ZELBORAF SYNAGIS XADAGO ZOLADEX SYNRIBO XALKORI ZONTIVITY TAFINLAR XELJANZ ZURAMPIC TAGRISSO XELJANZ XR ZYDELIG TALTZ XGEVA MANAGED DRUG LIMITATIONS (MDL) The Managed Drug Limitation program provides for a maximum quantity of drug product that a member may receive per prescription and/or over a specific period of time. Many drug products on the MedStar Family Choice - Maryland HealthChoice Prescribing Guide have quantity limits based upon the dosage described in product labeling. The following drugs are subject to MDL because they are typically not taken on a regular schedule and/or because of potential safety and utilization concerns. This list is subject to change. Contact MedStar Family Choice at 1-800-905-1722 for an updated list. Drugs Limits azelastine spray 2 bottles per 23 days butalbital/acetaminophen 60 units per 23 days butalbital/acetaminophen/ (FIORICET) 60 units per 23 days butalbital/acetaminophen/caffeine/ (FIORICET w/CODEINE) 180 units per 23 days butalbital/aspirin/caffeine (FIORINAL) 60 units per 23 days butalbital/aspirin/caffeine/codeine (FIORINAL w/CODEINE) 180 units per 23 days codeine sulfate oral solution 1000 mL per 23 days codeine sulfate tabs 180 tablets per 23 days codeine/acetaminophen oral solution 1000 mL per 23 days codeine/acetaminophen tabs (TYLENOL w/CODEINE) 180 tablets per 23 days DICLEGIS 120 tablets per 23 days ELLA 3 fills per 365 days esomeprazole magnesium delayed-rel (NEXIUM 24HR) 60 capsules per 23 days fentanyl transdermal (DURAGESIC) 10 patches per 23 days FLEET ENEMA 2 kits per 72 hours fluconazole 150 mg (DIFLUCAN) 4 tablets per 23 days 1 mg 10 tablets per 23 days /acetaminophen oral solution (HYCET) 2750 mL per 23 days hydrocodone/acetaminophen tabs (NORCO) 180 tablets per 23 days oral liquid 1 mg/mL (DILAUDID) 675 mL per 23 days hydromorphone suppository 180 suppositories per 23 days hydromorphone tabs 2 mg (DILAUDID) 180 tablets per 23 days hydromorphone tabs 4 mg (DILAUDID) 168 tablets per 23 days hydromorphone tabs 8 mg (DILAUDID) 84 tablets per 23 days ketorolac 20 tablets per 23 days lansoprazole (PREVACID) 60 units per 23 days levonorgestrel - Next Choice One Dose (PLAN B ONE-STEP) 3 fills per 365 days metformin 500 mg (GLUCOPHAGE) 120 tablets per 23 days metformin 1000 mg (GLUCOPHAGE) 90 tablets per 23 days oral concentrate 10 mg/mL 450 mL per 23 days methadone oral solution 5 mg/5 mL 900 mL per 23 days methadone oral solution 10 mg/5 mL 450 mL per 23 days methadone tabs 5 mg (DOLOPHINE) 180 tablets per 23 days methadone tabs 10 mg (DOLOPHINE) 90 tablets per 23 days methadone tabs 40 mg 23 tablets per 23 days morphine sulfate ext-rel beads 30 mg 90 capsules per 23 days morphine sulfate ext-rel beads 45 mg 60 capsules per 23 days morphine sulfate ext-rel beads 60 mg 45 capsules per 23 days MedStar Family Choice - Maryland HealthChoice Program 10

Drugs Limits morphine sulfate ext-rel beads 75 mg 36 capsules per 23 days morphine sulfate ext-rel beads 90 mg 30 capsules per 23 days morphine sulfate ext-rel beads 120 mg 23 capsules per 23 days morphine sulfate ext-rel tabs 15 mg (MS CONTIN) 180 tablets per 23 days morphine sulfate ext-rel tabs 30 mg (MS CONTIN) 90 tablets per 23 days morphine sulfate ext-rel tabs 60 mg (MS CONTIN) 45 tablets per 23 days morphine sulfate ext-rel tabs 100 mg (MS CONTIN) 27 tablets per 23 days morphine sulfate ext-rel tabs 200 mg (MS CONTIN) 13.5 tablets per 23 days morphine sulfate immediate-release tabs 15 mg 180 tablets per 23 days morphine sulfate immediate-release tabs 30 mg 90 tablets per 23 days morphine sulfate oral concentrate 10 mg/mL 135 mL per 23 days morphine sulfate oral solution 20 mg/5 mL 675 mL per 23 days morphine suppository 5 mg, 10 mg 180 suppositories per 23 days morphine suppository 20 mg 135 suppositories per 23 days morphine suppository 30 mg 90 suppositories per 23 days (AMERGE) 12 tablets per 23 days omeprazole 40 mg (PRILOSEC) 60 capsules per 23 days omeprazole, except 40 mg (PRILOSEC) 30 capsules per 23 days oseltamivir (TAMIFLU) 1 course of treatment per calendar year oxycodone immediate release tabs 15 mg (ROXICODONE) 120 tablets per 23 days oxycodone immediate release tabs 20 mg 90 tablets per 23 days oxycodone immediate release tabs 30 mg (ROXICODONE) 60 tablets per 23 days oxycodone immediate-release caps 5 mg, tabs 5 mg, 10 mg 180 units per 23 days oxycodone oral concentrate 20 mg/mL 90 mL per 23 days oxycodone oral solution 5 mg/5 mL (ROXICODONE) 1800 mL per 23 days oxycodone/acetaminophen oral solution 1800 mL per 23 days oxycodone/acetaminophen tabs (PERCOCET) 180 tablets per 23 days oxycodone/aspirin tabs (PERCODAN) 180 tablets per 23 days oxymorphone ext-rel tabs 5 mg 180 tablets per 23 days oxymorphone ext-rel tabs 7.5 mg 120 tablets per 23 days oxymorphone ext-rel tabs 10 mg 90 tablets per 23 days oxymorphone ext-rel tabs 15 mg 60 tablets per 23 days oxymorphone ext-rel tabs 20 mg 45 tablets per 23 days oxymorphone ext-rel tabs 30 mg 30 tablets per 23 days oxymorphone ext-rel tabs 40 mg 23 tablets per 23 days pantoprazole 20 mg, 40 mg (PROTONIX) 60 tablets per 23 days PREVACID SOLUTAB 30 tablets per 23 days orally disintegrating tabs (MAXALT-MLT) 18 tablets per 23 days rizatriptan (MAXALT) 18 tablets per 23 days SEREVENT 1 inhaler per 23 days 25 mg, 50 mg, 100 mg (IMITREX) 9 tablets per 23 days sumatriptan injection (IMITREX) 12 injections (0.5 mL) = 6 mL per 23 days sumatriptan nasal spray 5 mg/actuation (IMITREX) 24 units (4 packages) per 23 days sumatriptan nasal spray 20 mg/actuation (IMITREX) 12 units (2 packages) per 23 days (ULTRAM) 180 tablets per 23 days ZANTAC 75 240 tablets per 23 days 2.5 mg, 5 mg (ZOMIG) 12 tablets per 23 days zolmitriptan orally disintegrating tabs 2.5 mg, 5 mg (ZOMIG-ZMT) 12 tablets per 23 days

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STEP THERAPY (ST) Drugs indicated with a "ST" require Step Therapy authorization for coverage. When using drugs within select drug classes, this program requires a certain order to be followed for the "ST" designated drugs to be covered by your benefit plan. Within the Step Therapy program, drug therapy is begun with the most cost-effective and safest drugs. If this initial therapy proves unsuccessful, treatment may move to other, more costly therapy. Step Therapy helps ensure that a plan member receives clinically appropriate, cost-effective medication. The following drugs are subject to Step Therapy: Drugs ciclopirox cream, suspension (LOPROX) RANEXA SKLICE

OVER-THE-COUNTER (OTC) DRUG COVERAGE In addition to prescription benefits, all over-the-counter medications on this list are covered by MedStar Family Choice with a written or telephoned prescription. Refills are permitted. Prescriptions may be written for the State limited 12 month maximum. OTC products covered are restricted to generics when available. Brand names are provided as reference only. If both prescription and OTC products are available, you are encouraged to prescribe OTC products when clinically appropriate. Antacids aluminum hydroxide AlternaGEL aluminum hydroxide/ Alamag aluminum hydroxide/magnesium hydroxide/simethicone Maalox calcium carbonate Maalox sodium bicarbonate

Antifungals, Topical butenafine Lotrimin Ultra clotrimazole Lotrimin AF miconazole Desenex terbinafine Lamisil AT tolnaftate Tinactin

Antifungals, Vaginal clotrimazole Gyne-Lotrimin miconazole Monistat

Antihistamines cetirizine Zyrtec chlorpheniramine Chlor-Trimeton Tavist-1 Benadryl fexofenadine susp, tabs Allegra loratadine Claritin

Antihistamine/Decongestant Combinations cetirizine/ ext-rel Zyrtec-D chlorpheniramine/ tabs Cold & Allergy Relief loratadine/pseudoephedrine ext-rel Claritin-D

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Antilipemic Agents, Miscellaneous niacin omega-3 fatty acids Fish Oil omega-3 fatty acids 300 mg Krill Oil omega-3 fatty acids/vitamin E Fish Oil omega-3 fatty acids/vitamins chewable Omega-3 Gummies

Contraceptives, Barrier condoms (prescription not needed) Trojan spermicide gel Gynol II, Shur-Seal

Contraceptives, Emergency levonorgestrel - Next Choice One Dose (prescription not needed) Plan B One-Step

Cough/Cold/Allergy (OTC products not covered for members under 4 years of age) gelcaps, liquid Robitussin Long-Acting Cough dextromethorphan/chlorpheniramine liquid Robitussin Children's Cough & Cold, Long-Acting dextromethorphan/ ext-rel Mucinex DM dextromethorphan/guaifenesin/pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL dextromethorphan/guaifenesin syrup Robitussin Cough + Chest Congestion DM dextromethorphan/pyrilamine/phenylephrine Codituss DM eucalyptus/menthol/compound rub Vicks Vaporub fluticasone mist Flonase Sensimist fluticasone spray Flonase Allergy Relief guaifenesin ext-rel Mucinex guaifenesin liquid Diabetic Tussin guaifenesin liquid Mucinex for Kids guaifenesin/pseudoephedrine ext-rel Mucinex D Afrin phenylephrine Neo- phenylephrine drops PediaCare pseudoephedrine Sudafed sodium chloride inhalation solution Simply Saline sodium chloride nasal spray Ocean triamcinolone acetonide spray Nasacort Allergy 24HR

Gastrointestinal esomeprazole magnesium delayed-rel Nexium 24HR famotidine Pepcid AC famotidine chewable tabs Pepcid AC lansoprazole delayed-rel Prevacid 24HR omeprazole magnesium delayed-rel Prilosec OTC omeprazole/sodium bicarbonate Zegerid OTC ranitidine 75 mg Zantac 75 ranitidine 150 mg Zantac 150

Gastrointestinal, Miscellaneous bismuth subsalicylate Pepto-Bismol dextrose/fructose/phosphoric acid Emetrol Dramamine docusate sodium caps Colace docusate sodium liquid loperamide liquid, tabs Anti-Diarrheal pyrantel Reese's Pinworm Medicine simethicone Mylicon

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witch hazel medicated pads/wipes Tucks

Laxatives bisacodyl Dulcolax glycerin rectal suppository, adult glycerin rectal suppository, pediatric magnesium citrate methylcellulose Citrucel mineral oil polyethylene glycol 3350 MiraLax psyllium/aspartame Natural Fiber sennosides 8.6 mg tablets Senokot sennosides 15 mg tablets Ex-Lax sennosides/docusate sodium Peri-Colace sodium phosphate/sodium biphosphate enema, adult Fleet Enema sodium phosphate/sodium biphosphate enema, pediatric Fleet Enema

Nutritional/Supplements calcium Tums cholecalciferol (D3) Vitamin D3 cyanocobalamin tabs 1000 mg Vitamin B12 electrolyte rehydrating soln Pedialyte ergocalciferol (D2) drops ferrous fumarate Ferrimin 150 ferrous gluconate Fergon ferrous sulfate Feosol ferrous sulfate delayed-rel Slow FE magnesium oxide Mag-Ox multivitamins drops multivitamins/iron drops polysaccharide iron complex 150 mg Nu-Iron 150 polysaccharide iron complex/vitamin B12/folic acid Ferrex 150 prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid One Daily Prenatal prenatal vitamins/folic acid pyridoxine 25 mg, 50 mg Vitamin B6 sodium chloride tabs 1 gm

Overactive Bladder transdermal * Oxytrol for Women * Gender restriction - Coverage for females

Pain & Fever acetaminophen Tylenol aspirin 81 mg (not chewable) Bayer enteric coated aspirin Ecotrin ibuprofen Advil naproxen sodium Aleve

Pediculocides permethrin 1% NIX Creme Rinse

Radioactive Iodine Blockers Iosat potassium iodide Thyrosafe

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Sleep Aids Unisom melatonin

Smoking Deterrents nicotine polacrilex gum, lozenge * Nicorette nicotine transdermal * * Covered by State

Topical, Acne adapalene gel 0.1% Differin benzoyl peroxide Panoxyl

Topical, Antibacterial antibacterial cleanser bar, liquid cleanser, cleansing cloths Cetaphil bacitracin bacitracin/polymyxin B Polysporin chlorhexidine Hibiclens neomycin/bacitracin/polymyxin B Neosporin

Topical, Ear carbamide peroxide Debrox

Topical, Eye artificial tears Zaditor

Topical, Miscellaneous ammonium lactate 12% Lac-Hydrin calamine lotion coal tar shampoo Neutrogena docosanol Abreva hydrocortisone crm, oint 0.5%, 1% Cortizone lidocaine crm 4% LMX 4 oatmeal, colloidal oatmeal, colloidal/dimethicone Aveeno petrolatum/mineral oil Eucerin salicylic acid gel 17% salicylic acid pad, plaster 40% salicylic acid 17%/collodion Duofilm crm 20% Carmol 20 urea lotion 10% Carmol 10 zinc oxide Desitin

EDITOR Your comments and suggestions regarding the MedStar Family Choice - Maryland HealthChoice Prescribing Guide are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to: Medical Director MedStar Family Choice 5233 King Avenue Baltimore, MD 21237 Phone: 1-800-905-1722 or 410-933-2200

MedStar Family Choice - Maryland HealthChoice Program 15

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of MedStar Family Choice. ©2018. All rights reserved. This MedStar Family Choice - Maryland HealthChoice Prescribing Guide contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with MedStar Family Choice.

MedStar Family Choice does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by MedStar Family Choice. LEGEND AL Age Limit DESI DESI drug; found by the FDA to be not effective MDL Managed Drug Limitation OTC Over the counter PA Prior Authorization required ST Step Therapy required boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

MedStar Family Choice - Maryland HealthChoice Program 16

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

Treatment recommendations for osteoarthritis are available at: http://www.rheumatology.org

NSAIDs OTC ibuprofen ADVIL OTC naproxen sodium ALEVE choline magnesium trisalicylate diclofenac potassium diclofenac sodium delayed-rel etodolac flurbiprofen ibuprofen indomethacin MDL ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN oxaprozin DAYPRO sulindac

NSAIDs, TOPICAL diclofenac sodium gel VOLTAREN

COX-2 INHIBITORS celecoxib CELEBREX

GOUT allopurinol ZYLOPRIM colchicine tabs COLCRYS colchicine/probenecid probenecid PA lesinurad ZURAMPIC

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

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

For complete information regarding the requirements of the Maryland Medicaid Opioid Drug Utilization Review for opioid prescribing, please visit: https://www.medstarfamilychoice.com/maryland-healthchoice/for-maryland-healthchoice- physicians/pharmacy/opioid/#q={}

MDL butalbital/acetaminophen/caffeine/codeine FIORICET w/CODEINE MDL butalbital/aspirin/caffeine/codeine FIORINAL w/CODEINE MDL codeine sulfate MDL codeine/acetaminophen TYLENOL w/CODEINE MDL, PA fentanyl transdermal DURAGESIC MDL hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg NORCO MedStar Family Choice - Maryland HealthChoice Program 17

MDL hydrocodone/acetaminophen soln 7.5/325 per 15 mL HYCET MDL hydromorphone DILAUDID MDL, PA methadone DOLOPHINE MDL morphine MDL, PA morphine ext-rel beads MDL, PA morphine ext-rel tabs MS CONTIN MDL morphine supp MDL oxycodone caps, tabs 5 mg MDL oxycodone concentrate 20 mg/mL MDL oxycodone tabs 10 mg, 20 mg MDL oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL ROXICODONE MDL oxycodone/acetaminophen 5/325, 7.5/325 PERCOCET MDL oxycodone/aspirin PERCODAN MDL, PA oxymorphone ext-rel MDL tramadol ULTRAM

NON-OPIOID ANALGESICS MDL butalbital/acetaminophen MDL butalbital/acetaminophen/caffeine ESGIC MDL butalbital/aspirin/caffeine FIORINAL

VISCOSUPPLEMENTS sodium hyaluronate HYALGAN sodium hyaluronate SUPARTZ FX

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

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

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

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

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm

International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: http://www.cdc.gov/flu/

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

MedStar Family Choice - Maryland HealthChoice Program 18

ANTIBACTERIALS Aminoglycosides neomycin

Cephalosporins First Generation cefadroxil cephalexin KEFLEX

Second Generation cefuroxime axetil CEFTIN

Third Generation cefdinir cefpodoxime tablets ceftriaxone ROCEPHIN

Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin clarithromycin ext-rel erythromycin base erythromycin delayed-rel erythromycin delayed-rel - Ery-tab erythromycin ethylsuccinate E.E.S. erythromycin stearate PA fidaxomicin DIFICID

Fluoroquinolones ciprofloxacin CIPRO ciprofloxacin ext-rel levofloxacin LEVAQUIN moxifloxacin AVELOX

Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin VK penicillin G benzathine BICILLIN L-A penicillin G benzathine/penicillin G procaine BICILLIN C-R

Sulfonamides sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS sulfadiazine

Tetracyclines doxycycline hyclate caps VIBRAMYCIN doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate susp VIBRAMYCIN minocycline MINOCIN tetracycline

MedStar Family Choice - Maryland HealthChoice Program 19

ANTIFUNGALS clotrimazole troches MDL fluconazole DIFLUCAN griseofulvin microsize susp, tabs griseofulvin ultramicrosize GRIS-PEG nystatin terbinafine tabs LAMISIL voriconazole susp, tabs VFEND PA posaconazole NOXAFIL

MDL 150 mg only (4 tabs/23 days)

ANTIMALARIALS atovaquone/proguanil MALARONE chloroquine mefloquine primaquine

ANTIRETROVIRAL AGENTS Bill to State: Fee for Service - Medicaid

ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN PA bedaquiline SIRTURO

ANTIVIRALS Cytomegalovirus Agents foscarnet valganciclovir VALCYTE

Hepatitis Agents Hepatitis B entecavir BARACLUDE lamivudine EPIVIR-HBV

Hepatitis C ribavirin caps REBETOL ribavirin tabs COPEGUS PA glecaprevir/pibrentasvir MAVYRET

# MAVYRET for genotypes 1, 2, 3, 4, 5, 6

Herpes Agents acyclovir caps, susp, tabs ZOVIRAX famciclovir valacyclovir VALTREX

Influenza Agents MDL oseltamivir TAMIFLU

MISCELLANEOUS OTC pyrantel - Reese's Pinworm Medicine atovaquone MEPRON clindamycin CLEOCIN MedStar Family Choice - Maryland HealthChoice Program 20

dapsone tabs ivermectin STROMECTOL linezolid ZYVOX metronidazole FLAGYL nitrofurantoin ext-rel MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin susp FURADANTIN paromomycin rifabutin MYCOBUTIN trimethoprim tabs vancomycin VANCOCIN PA albendazole ALBENZA pentamidine aerosol NEBUPENT rifaximin 550 mg XIFAXAN

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

ALKYLATING AGENTS melphalan ALKERAN temozolomide TEMODAR altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide caps

ANTIMETABOLITES capecitabine XELODA mercaptopurine

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX flutamide

Antiestrogens tamoxifen fulvestrant FASLODEX toremifene FARESTON

Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate PA goserelin acetate ZOLADEX PA leuprolide acetate ELIGARD PA leuprolide acetate LUPRON DEPOT

Progestins megestrol acetate

MedStar Family Choice - Maryland HealthChoice Program 21

KINASE INHIBITORS imatinib mesylate GLEEVEC PA alectinib ALECENSA PA bosutinib BOSULIF PA brigatinib ALUNBRIG PA cabozantinib CABOMETYX PA cabozantinib COMETRIQ PA cobimetinib COTELLIC PA crizotinib XALKORI PA dabrafenib TAFINLAR PA erlotinib TARCEVA PA ibrutinib IMBRUVICA PA idelalisib ZYDELIG PA lapatinib TYKERB PA nilotinib TASIGNA PA osimertinib TAGRISSO PA palbociclib IBRANCE PA ponatinib ICLUSIG PA regorafenib STIVARGA PA ribociclib KISQALI PA ruxolitinib JAKAFI PA trametinib MEKINIST PA vemurafenib ZELBORAF

TOPOISOMERASE INHIBITORS doxorubicin liposomal DOXIL PA topotecan caps HYCAMTIN CAPS

MISCELLANEOUS bexarotene caps TARGRETIN etoposide hydroxyurea HYDREA leucovorin tretinoin caps PA asparaginase erwinia ERWINAZE hydroxyurea DROXIA mitotane LYSODREN PA niraparib ZEJULA PA olaparib LYNPARZA PA omacetaxine mepesuccinate SYNRIBO procarbazine MATULANE PA rituximab/hyaluronidase human RITUXAN HYCELA PA rucaparib RUBRACA trifluridine/tipiracil LONSURF PA venetoclax VENCLEXTA

CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org

MedStar Family Choice - Maryland HealthChoice Program 22

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org

benazepril LOTENSIN captopril enalapril VASOTEC fosinopril lisinopril ZESTRIL moexipril quinapril ACCUPRIL ramipril ALTACE trandolapril

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL trandolapril/verapamil ext-rel TARKA

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

ADRENOLYTICS, CENTRAL CATAPRES clonidine transdermal CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS spironolactone ALDACTONE

ALPHA BLOCKERS Guidelines for the use of blockers in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497

CARDURA MINIPRESS

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org

candesartan ATACAND candesartan/hydrochlorothiazide ATACAND HCT irbesartan AVAPRO irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR MedStar Family Choice - Maryland HealthChoice Program 23

valsartan DIOVAN valsartan/hydrochlorothiazide DIOVAN HCT

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/valsartan EXFORGE

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide EXFORGE HCT

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

amiodarone amiodarone PACERONE disopyramide NORPACE dofetilide TIKOSYN flecainide BETAPACE sotalol BETAPACE AF

ANTILIPEMICS The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults is available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a

Bile Acid Resins cholestyramine QUESTRAN/QUESTRAN LIGHT

Cholesterol Absorption Inhibitors ezetimibe ZETIA

Fibrates fenofibrate TRICOR fenofibrate, micronized LOFIBRA fenofibric acid FIBRICOR gemfibrozil LOPID

HMG-CoA Reductase Inhibitors/Combinations atorvastatin LIPITOR ezetimibe/simvastatin VYTORIN lovastatin pravastatin PRAVACHOL rosuvastatin CRESTOR simvastatin ZOCOR

Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID

Niacins OTC niacin niacin NIACOR niacin ext-rel NIASPAN

MedStar Family Choice - Maryland HealthChoice Program 24

Omega-3 Fatty Acids OTC omega-3 fatty acids FISH OIL OTC omega-3 fatty acids 300 mg KRILL OIL OTC omega-3 fatty acids/vitamin E FISH OIL OTC omega-3 fatty acids/vitamins chewable OMEGA-3 GUMMIES PA omega-3 acid ethyl esters LOVAZA

PCSK9 Inhibitors PA evolocumab REPATHA

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

TENORMIN COREG TRANDATE succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR CORGARD propranolol ext-rel INDERAL LA maleate tabs carvedilol phosphate ext-rel COREG CR AL propranolol oral soln HEMANGEOL

AL Covered for age 5 or younger

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

atenolol/chlorthalidone bisoprolol/hydrochlorothiazide ZIAC

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nicardipine nifedipine PROCARDIA nifedipine ext-rel ADALAT CC nifedipine ext-rel PROCARDIA XL nimodipine

Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC verapamil CALAN verapamil ext-rel CALAN SR

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verapamil ext-rel VERELAN

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin CADUET

DIGITALIS GLYCOSIDES digoxin LANOXIN

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide

Loop Diuretics bumetanide furosemide LASIX torsemide DEMADEX

Potassium-sparing Diuretics amiloride triamterene DYRENIUM

Thiazides and Thiazide-like Diuretics chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide metolazone chlorothiazide susp DIURIL

Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE

HEART FAILURE sacubitril/valsartan ENTRESTO

NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide dinitrate oral ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel

Sublingual/Translingual nitroglycerin lingual spray NITROLINGUAL nitroglycerin sublingual NITROSTAT

Transdermal nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR nitroglycerin oint NITRO-BID

MedStar Family Choice - Maryland HealthChoice Program 26

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists ambrisentan LETAIRIS macitentan OPSUMIT

Phosphodiesterase Inhibitors REVATIO

Prostacyclin Receptor Agonists selexipag UPTRAVI

Prostaglandin Vasodilators epoprostenol sodium FLOLAN treprostinil REMODULIN treprostinil TYVASO treprostinil ext-rel ORENITRAM

MISCELLANEOUS hydralazine methyldopa/hydrochlorothiazide minoxidil ST ranolazine ext-rel RANEXA

ST 30-day trial of a nitrate plus a or calcium channel blocker required first

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

ANTIANXIETY Refer to State D.H.M.H. Mental Health Formulary for a complete listing. Products are covered by State.

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

* carbamazepine TEGRETOL * carbamazepine ext-rel CARBATROL * carbamazepine ext-rel TEGRETOL-XR * clonazepam KLONOPIN * diazepam rectal gel DIASTAT * divalproex sodium delayed-rel DEPAKOTE * divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN * felbamate FELBATOL * gabapentin NEURONTIN * lamotrigine LAMICTAL * levetiracetam KEPPRA * oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN primidone MYSOLINE * tiagabine GABITRIL MedStar Family Choice - Maryland HealthChoice Program 27

* topiramate sprinkle caps, tabs TOPAMAX * valproic acid DEPAKENE * zonisamide ZONEGRAN

* Covered by State

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

donepezil ARICEPT RAZADYNE NAMENDA rivastigmine caps, soln

ANTIDEPRESSANTS Refer to State D.H.M.H. Mental Health Formulary for a complete listing.

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

caps, syrup * benztropine PARLODEL LODOSYN carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR carbidopa/levodopa/ STALEVO entacapone COMTAN MIRAPEX REQUIP caps ELDEPRYL selegiline tabs * rotigotine transdermal NEUPRO PA XADAGO

* Covered by State

ANTIPSYCHOTICS Refer to State D.H.M.H. Mental Health Formulary for a complete listing.

ATTENTION DEFICIT HYPERACTIVITY DISORDER Refer to State D.H.M.H. Mental Health Formulary for a complete listing.

Intuniv, Kapvay and their generics: For recipients 6-17 years old, Intuniv (guanfacine ext-rel) and Kapvay (clonidine ext-rel) are part of the mental health formulary and billed fee-for-service. For individuals not in this age range, a medical exception may be requested by calling MedStar Family Choice.

FIBROMYALGIA milnacipran SAVELLA * pregabalin LYRICA

* Covered by State

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HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic are available at: http://www.aasmnet.org

Refer to State D.H.M.H. Mental Health Formulary for a complete listing.

Nonbenzodiazepines OTC doxylamine UNISOM

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

Ergotamine Derivatives /caffeine CAFERGOT

Selective Agonists MDL naratriptan AMERGE MDL rizatriptan MAXALT MDL sumatriptan IMITREX MDL sumatriptan injection IMITREX MDL sumatriptan nasal spray IMITREX MDL zolmitriptan tabs ZOMIG

Miscellaneous DESI acetaminophen/dichloralphenazone/ MIDRIN

MOOD STABILIZERS Refer to State D.H.M.H. Mental Health Formulary for a complete listing.

MOVEMENT DISORDERS PA valbenazine INGREZZA

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

glatiramer COPAXONE PA dalfampridine ext-rel AMPYRA dimethyl fumarate delayed-rel TECFIDERA fingolimod GILENYA interferon beta-1a AVONEX interferon beta-1b EXTAVIA

MUSCULOSKELETAL THERAPY AGENTS baclofen carisoprodol SOMA chlorzoxazone 5 mg, 10 mg dantrolene DANTRIUM * diazepam VALIUM methocarbamol ROBAXIN ext-rel caps, tabs ZANAFLEX

* Covered by State MedStar Family Choice - Maryland HealthChoice Program 29

MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN

NARCOLEPSY/CATAPLEXY PA sodium oxybate XYREM

NEUROMUSCULAR BLOCKING AGENTS PA onabotulinumtoxinA BOTOX

POSTHERPETIC NEURALGIA (PHN) PA gabapentin ext-rel GRALISE

PSYCHOTHERAPEUTIC - MISCELLANEOUS Refer to State D.H.M.H Mental health formulary for a complete listing.

Alcohol Deterrents * acamprosate calcium * disulfiram ANTABUSE

* Covered by State

Opioid Antagonists * naloxone inj * naltrexone * naloxone nasal spray NARCAN

* Covered by State

Partial Opioid Agonists * buprenorphine sublingual

* Covered by State

Partial Opioid Agonist/Opioid Antagonist Combinations * buprenorphine/naloxone sublingual tabs * buprenorphine/naloxone sublingual film SUBOXONE

* Covered by State

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

*, OTC nicotine polacrilex gum, lozenge NICORETTE *, OTC nicotine transdermal * ext-rel ZYBAN * nicotine inhaler NICOTROL INHALER * nicotine nasal spray NICOTROL NS * varenicline CHANTIX

* Covered by State

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

oxandrolone OXANDRIN cypionate inj DEPO-TESTOSTERONE testosterone enanthate inj DELATESTRYL testosterone gel 1% testosterone gel 2% FORTESTA testosterone soln

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

Alpha-glucosidase Inhibitors acarbose PRECOSE

Biguanides MDL metformin GLUCOPHAGE metformin ext-rel GLUCOPHAGE XR

Biguanide/Sulfonylurea Combinations glipizide/metformin glyburide/metformin GLUCOVANCE

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors sitagliptin phosphate JANUVIA

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

Incretin Mimetic Agents albiglutide TANZEUM liraglutide VICTOZA semaglutide OZEMPIC

Insulins OTC insulin human HUMULIN R OTC insulin human NOVOLIN R *, OTC insulin isophane human HUMULIN N OTC insulin isophane human NOVOLIN N *, OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 * insulin aspart NOVOLOG * insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 insulin glargine BASAGLAR * insulin lispro 100 units/mL ADMELOG * insulin lispro protamine 50%/insulin lispro 50% HUMALOG MIX 50/50 * insulin lispro protamine 75%/insulin lispro 25% HUMALOG MIX 75/25 insulin degludec TRESIBA

* Cartridges and pens are covered for participants 0-18 years of age

MedStar Family Choice - Maryland HealthChoice Program 31

Insulin Sensitizers pioglitazone ACTOS

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride DUETACT

Meglitinides nateglinide STARLIX repaglinide PRANDIN

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors canagliflozin INVOKANA empagliflozin JARDIANCE

Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations canagliflozin/metformin INVOKAMET canagliflozin/metformin ext-rel INVOKAMET XR empagliflozin/metformin SYNJARDY empagliflozin/metformin ext-rel SYNJARDY XR

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

Supplies OTC blood glucose monitoring kits, test strips ACCU-CHEK KITS AND TEST STRIPS OTC glucose meter control solution ACCU-CHEK CONTROL SOLUTION OTC insulin syringes, needles OTC lancets, lancet devices OTC urine test strips CHEMSTRIP URINE TEST STRIPS OTC urine test strips KETOSTIX URINE TEST STRIPS

CALCIUM RECEPTOR ANTAGONISTS cinacalcet SENSIPAR

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

Bisphosphonates alendronate tabs FOSAMAX alendronate/vitamin D3 FOSAMAX PLUS D

Calcitonins calcitonin-salmon MIACALCIN

MedStar Family Choice - Maryland HealthChoice Program 32

RANK (RANKL) Inhibitors PA denosumab PROLIA PA denosumab XGEVA

CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol

Monophasic 10 mcg Estrogen PA norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE

20 mcg Estrogen drospirenone/EE 3/20 - Gianvi YAZ PA drospirenone/EE/levomefolate 3/20 and levomefolate BEYAZ drospirenone/EE/levomefolate 3/20 and levomefolate - Rajani levonorgestrel/EE 0.1/20 - Aviane norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 PA norethindrone acetate/EE 1/20 and iron chewable MINASTRIN 24 FE PA norethindrone acetate/EE 1/20 and iron gel caps TAYTULLA

25 mcg Estrogen norethindrone/EE 0.8/25 chewable GENERESS FE

30 mcg Estrogen desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN levonorgestrel/EE 0.15/30 - Levora norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30 - Low-Ogestrel

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 norethindrone/EE 0.4/35 - Briellyn norethindrone/EE 0.4/35 chewable - Wymzya FE norethindrone/EE 0.5/35 - Necon 0.5/35 norethindrone/EE 1/35 ORTHO-NOVUM 1/35 norgestimate/EE 0.25/35 ORTHO-CYCLEN

50 mcg Estrogen ethynodiol diacetate/EE 1/50 - Zovia 1/50 norgestrel/EE 0.5/50 - Ogestrel

Biphasic desogestrel/EE MIRCETTE desogestrel/EE PIMTREA

Triphasic desogestrel/EE CYCLESSA levonorgestrel/EE - Trivora norethindrone acetate/EE and iron ESTROSTEP FE norethindrone/EE ORTHO-NOVUM 7/7/7 norethindrone/EE TRI-NORINYL norgestimate/EE ORTHO TRI-CYCLEN

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norgestimate/EE ORTHO TRI-CYCLEN LO

Four Phase PA estradiol valerate and dienogest/estradiol valerate NATAZIA

Extended Cycle levonorgestrel/EE 0.1/20 and EE 10 LOSEASONIQUE levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10 QUARTETTE levonorgestrel/EE 0.15/30 - Quasense levonorgestrel/EE 0.15/30 and EE 10 SEASONIQUE

Progestin Only norethindrone ORTHO MICRONOR

Emergency Contraception MDL levonorgestrel - Next Choice One Dose PLAN B ONE-STEP MDL ulipristal ELLA

Injectable medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA

Intrauterine Devices intrauterine device PARAGARD T 380A levonorgestrel-releasing IUD KYLEENA levonorgestrel-releasing IUD LILETTA levonorgestrel-releasing IUD MIRENA levonorgestrel-releasing IUD SKYLA

Transdermal norelgestromin/EE

Vaginal etonogestrel/EE ring NUVARING

Miscellaneous OTC nonoxynol-9 SHUR-SEAL OTC nonoxynol 9 gel GYNOL II diaphragm ORTHO-DIAPHRAGM etonogestrel implant NEXPLANON

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

Injectable estradiol cypionate inj DEPO-ESTRADIOL

Oral estradiol ESTRACE estropipate

Transdermal estradiol CLIMARA estradiol VIVELLE-DOT estradiol ALORA

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Vaginal estradiol vaginal cream ESTRACE estradiol vaginal ring FEMRING

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estrogens, conjugated/medroxyprogesterone PREMPHASE estrogens, conjugated/medroxyprogesterone PREMPRO

Transdermal estradiol/levonorgestrel CLIMARA PRO estradiol/norethindrone acetate COMBIPATCH

GLUCOCORTICOIDS cortisone acetate dexamethasone fludrocortisone hydrocortisone CORTEF methylprednisolone MEDROL prednisolone sodium phosphate soln 5 mg/5 mL, 15 mg/5 mL, 25 mg/5 mL prednisolone syrup prednisone

GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGON EMERGENCY KIT

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

PA somatropin NORDITROPIN PA somatropin SEROSTIM

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL

PHOSPHATE BINDER AGENTS calcium acetate PHOSLO lanthanum FOSRENOL sevelamer carbonate RENVELA

POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate SPS

PRE-TERM BIRTH RISK REDUCTION hydroxyprogesterone caproate MAKENA

PROGESTINS Oral medroxyprogesterone acetate PROVERA megestrol acetate susp MEGACE ES norethindrone acetate AYGESTIN

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progesterone, micronized PROMETRIUM

Vaginal progesterone gel CRINONE

SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene EVISTA

THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil potassium iodide SSKI

Radioactive Iodine Blockers OTC potassium iodide IOSAT OTC potassium iodide THYROSAFE

Thyroid Supplements levothyroxine SYNTHROID levothyroxine - Levoxyl liothyronine CYTOMEL

VASOPRESSINS PA desmopressin spray DDAVP desmopressin tabs DDAVP PA desmopressin spray STIMATE

MISCELLANEOUS methylergonovine METHERGINE succimer CHEMET

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

ANTACIDS OTC aluminum hydroxide ALTERNAGEL OTC aluminum hydroxide/magnesium hydroxide ALAMAG OTC calcium carbonate MAALOX OTC sodium bicarbonate

ANTIDIARRHEALS OTC bismuth subsalicylate PEPTO-BISMOL OTC loperamide liquid, tabs ANTI-DIARRHEAL diphenoxylate/ LOMOTIL

ANTIEMETICS OTC dextrose/fructose/phosphoric acid EMETROL OTC dimenhydrinate DRAMAMINE OTC meclizine aprepitant EMEND MDL granisetron meclizine MedStar Family Choice - Maryland HealthChoice Program 36

REGLAN ZOFRAN transdermal TRANSDERM SCOP TIGAN MDL doxylamine/pyridoxine delayed-rel DICLEGIS

ANTISPASMODICS dicyclomine BENTYL glycopyrrolate 0.15 mg tabs hyoscyamine sulfate 0.125 mg hyoscyamine sulfate 125 mcg/5 mL elixir hyoscyamine sulfate ext-rel 0.375 mg methscopolamine PAMINE propantheline DESI atropine/hyoscyamine/scopolamine/phenobarbital 16.2 mg tabs DONNATAL DESI atropine/hyoscyamine/scopolamine/phenobarbital elixir DONNATAL

CHOLELITHOLYTICS ursodiol ACTIGALL ursodiol URSO ursodiol URSO FORTE

H2 RECEPTOR ANTAGONISTS OTC famotidine PEPCID AC OTC, MDL ranitidine 75 mg ZANTAC 75 OTC ranitidine 150 mg ZANTAC 150 OTC famotidine chewable tabs PEPCID AC cimetidine famotidine PEPCID ranitidine ZANTAC

INFLAMMATORY BOWEL DISEASE Oral Agents budesonide delayed-rel caps ENTOCORT EC mesalamine delayed-rel tabs ASACOL HD mesalamine delayed-rel tabs LIALDA sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS mesalamine ext-rel caps PENTASA

Rectal Agents hydrocortisone enema mesalamine rectal susp ROWASA hydrocortisone acetate foam CORTIFOAM mesalamine supp CANASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA linaclotide LINZESS PA lubiprostone AMITIZA

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LAXATIVES/STOOL SOFTENERS OTC docusate sodium caps COLACE OTC docusate sodium liquid OTC methylcellulose CITRUCEL OTC mineral oil OTC polyethylene glycol 3350 MIRALAX OTC psyllium/aspartame NATURAL FIBER OTC sennosides SENOKOT lactulose peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY

OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK

PANCREATIC ENZYMES pancrelipase VIOKACE pancrelipase delayed-rel CREON pancrelipase delayed-rel ZENPEP

PROSTAGLANDINS misoprostol CYTOTEC

PROTON PUMP INHIBITORS OTC lansoprazole delayed-rel PREVACID 24HR OTC omeprazole/sodium bicarbonate ZEGERID OTC OTC, MDL esomeprazole magnesium delayed-rel NEXIUM 24HR OTC omeprazole magnesium delayed-rel PRILOSEC OTC MDL lansoprazole delayed-rel PREVACID MDL omeprazole delayed-rel caps MDL pantoprazole delayed-rel PROTONIX *, MDL lansoprazole delayed-rel orally-disintegrating 15 mg tabs PREVACID SOLUTAB

* Covered for members eight years of age and under

RECTAL PREPARATIONS, STEROIDS/OTHER OTC witch hazel medicated pads/wipes TUCKS hydrocortisone crm ANUSOL-HC 2.5% hydrocortisone rectal crm, oint hydrocortisone/pramoxine crm 1-1% ANALPRAM-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin PREVPAC

MISCELLANEOUS OTC simethicone MYLICON sucralfate CARAFATE

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

ext-rel UROXATRAL doxazosin CARDURA dutasteride AVODART MedStar Family Choice - Maryland HealthChoice Program 38

finasteride PROSCAR FLOMAX terazosin

URINARY ANTISPASMODICS OTC, * oxybutynin transdermal OXYTROL FOR WOMEN oxybutynin oxybutynin ext-rel DITROPAN XL trospium

* Gender restriction – Coverage for females

VAGINAL ANTI-INFECTIVES OTC clotrimazole GYNE-LOTRIMIN OTC miconazole MONISTAT clindamycin crm CLEOCIN metronidazole METROGEL-VAGINAL terconazole TERAZOL 7 terconazole 3

MISCELLANEOUS URECHOLINE methenamine/hyoscyamine/methylene blue/ benzoic acid/ - Hyophen PYRIDIUM potassium citrate ext-rel, except 15 mEq UROCIT-K potassium/sodium phosphates K-PHOS NEUTRAL sodium citrate/citric acid acetohydroxamic acid LITHOSTAT sodium ELMIRON

HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: http://www.hemophilia.org

ANTICOAGULANTS CHEST guidelines are available at: http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines- 9th-Ed

Injectable enoxaparin LOVENOX

Oral warfarin COUMADIN apixaban ELIQUIS dabigatran etexilate PRADAXA rivaroxaban XARELTO

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

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

darbepoetin alfa ARANESP epoetin alfa EPOGEN epoetin alfa PROCRIT filgrastim-sndz ZARXIO sargramostim LEUKINE

HEREDITARY ANGIOEDEMA AGENTS PA C1 esterase inhibitor HAEGARDA ecallantide KALBITOR PA icatibant FIRAZYR

PLATELET AGGREGATION INHIBITORS clopidogrel PLAVIX dipyridamole dipyridamole extended-release/aspirin AGGRENOX prasugrel EFFIENT ticagrelor BRILINTA PA vorapaxar ZONTIVITY

PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN pentoxifylline ext-rel

MISCELLANEOUS cilostazol tranexamic acid LYSTEDA PA L-glutamine oral powder ENDARI

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

ALLERGEN EXTRACTS grass mixed pollen allergen extract ORALAIR ragweed pollen allergen extract RAGWITEK timothy grass pollen allergen extract GRASTEK

AUTOIMMUNE AGENTS adalimumab HUMIRA PA apremilast OTEZLA PA brodalumab SILIQ etanercept ENBREL PA ixekizumab TALTZ PA sarilumab KEVZARA PA tofacitinib XELJANZ PA tofacitinib ext-rel XELJANZ XR

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DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate 2.5 mg PA methotrexate inj RASUVO

IMMUNOSUPPRESSANTS Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT

Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus PROGRAF

Rapamycin Derivatives sirolimus RAPAMUNE

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride effervescent potassium chloride ext-rel potassium chloride liquid potassium chloride powder 20 mEq potassium chloride powder 25 mEq KLOR-CON/25

Sodium OTC sodium chloride tabs 1 gm

VITAMINS AND MINERALS Folic Acid Agents folic acid

Prenatal Vitamins OTC prenatal vitamins/folic acid OTC prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid ONE DAILY PRENATAL prenatal vitamins/folic acid prenatal vitamins/folic acid PRENATABS RX prenatal vitamins/folic acid PRENATAL LOW IRON prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA

Miscellaneous OTC cholecalciferol (D3) drops VITAMIN D3 OTC cyanocobalamin tabs 1000 mg VITAMIN B-12 OTC ergocalciferol (D2) drops OTC ferrous gluconate FERGON OTC ferrous sulfate FEOSOL OTC ferrous sulfate delayed-rel SLOW FE OTC magnesium oxide MAG-OX OTC melatonin OTC multivitamins drops OTC multivitamins/iron drops OTC polysaccharide iron complex 150 mg - Nu-Iron 150 OTC polysaccharide iron complex/vitamin B12/folic acid - Ferrex 150 MedStar Family Choice - Maryland HealthChoice Program 41

OTC pyridoxine 25 mg, 50 mg VITAMIN B6 OTC vitamin ADC drops OTC ferrous fumarate FERRIMIN 150 OTC multivitamins drops TRI-VI-SOL cyanocobalamin inj ergocalciferol (D2) caps ferrous fumarate/polysaccharide iron complex/ TANDEM PLUS folic acid/B complex/vitamin C/minerals fluoride drops, tabs multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid NEPHRO-VITE RX phytonadione MEPHYTON zinc acetate GALZIN

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

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

ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector epinephrine auto-injector EPIPEN epinephrine auto-injector EPIPEN JR.

ANTICHOLINERGICS ipratropium inhalation solution tiotropium SPIRIVA RESPIMAT

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol inhalation solution ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT

Long Acting umeclidinium/ ANORO ELLIPTA

ANTIHISTAMINES, LOW SEDATING OTC cetirizine ZYRTEC levocetirizine XYZAL

ANTIHISTAMINES, NONSEDATING OTC fexofenadine susp, tabs ALLEGRA OTC loratadine CLARITIN

ANTIHISTAMINES, SEDATING OTC chlorpheniramine CHLOR-TRIMETON *, OTC diphenhydramine clemastine MedStar Family Choice - Maryland HealthChoice Program 42

** HCl

* Both OTC and Rx products covered ** Covered by State

ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC cetirizine/pseudoephedrine ext-rel ZYRTEC-D OTC chlorpheniramine/phenylephrine tabs COLD & ALLERGY RELIEF OTC loratadine/pseudoephedrine ext-rel CLARITIN-D

ANTITUSSIVES Clinical practice guidelines are available at: http://journal.publications.chestnet.org/article.aspx?articleID=1084267

OTC dextromethorphan gelcaps, liquid ROBITUSSIN LONG-ACTING COUGH TESSALON

ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine

Non-opioid OTC dextromethorphan/chlorpheniramine liquid ROBITUSSIN CHILDREN'S COUGH & COLD, LONG ACTING OTC dextromethorphan/guaifenesin ext-rel MUCINEX DM OTC dextromethorphan/guaifenesin syrup ROBITUSSIN COUGH + CHEST CONGESTION DM OTC dextromethorphan/guaifenesin/pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL OTC dextromethorphan/pyrilamine/phenylephrine - Codituss DM dextromethorphan//pseudoephedrine - Bromfed-DM dextromethorphan/promethazine

BETA AGONISTS Inhalants Short Acting albuterol inhalation solution levalbuterol inhalation solution levalbuterol tartrate, CFC-free aerosol XOPENEX HFA albuterol sulfate, CFC-free aerosol PROAIR HFA albuterol sulfate, CFC-free aerosol VENTOLIN HFA

Long Acting Hand-held Active Inhalation MDL xinafoate SEREVENT

Oral Agents albuterol albuterol ext-rel MedStar Family Choice - Maryland HealthChoice Program 43

CYSTIC FIBROSIS tobramycin inhalation solution TOBI PA dornase alfa PULMOZYME PA ivacaftor KALYDECO PA lumacaftor/ivacaftor ORKAMBI PA tobramycin inhalation soln BETHKIS

DECONGESTANTS OTC oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE OTC pseudoephedrine SUDAFED

DECONGESTANT/EXPECTORANT COMBINATIONS OTC pseudoephedrine/guaifenesin ext-rel MUCINEX D phenylephrine/guaifenesin syrup

EXPECTORANTS OTC guaifenesin ext-rel MUCINEX OTC guaifenesin liquid DIABETIC TUSSIN OTC guaifenesin liquid MUCINEX FOR KIDS

LEUKOTRIENE MODULATORS montelukast SINGULAIR zafirlukast ACCOLATE

MAST CELL STABILIZERS cromolyn inhalation solution

NASAL ANTIHISTAMINES MDL azelastine spray olopatadine spray PATANASE

NASAL STEROIDS OTC fluticasone spray FLONASE ALLERGY RELIEF OTC triamcinolone acetonide spray NASACORT ALLERGY 24HR OTC fluticasone mist FLONASE SENSIMIST flunisolide spray fluticasone spray triamcinolone acetonide spray

PULMONARY FIBROSIS AGENTS PA nintedanib OFEV PA pirfenidone ESBRIET

RESPIRATORY SYNCYTIAL VIRUS PA palivizumab SYNAGIS

STEROID/BETA AGONIST COMBINATIONS fluticasone/salmeterol AIRDUO RESPICLICK budesonide/ SYMBICORT fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA mometasone/formoterol DULERA

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STEROID INHALANTS * budesonide inhalation suspension PULMICORT RESPULES beclomethasone, CFC-free aerosol QVAR fluticasone FLOVENT DISKUS fluticasone, CFC-free aerosol FLOVENT HFA

* Covered for individuals one through three years of age

XANTHINES aminophylline liquid, tabs theophylline ext-rel tabs theophylline liquid ELIXOPHYLLIN

MISCELLANEOUS OTC sodium chloride nasal spray OCEAN OTC sodium chloride inhalation solution SIMPLY SALINE ipratropium nasal spray sodium chloride inhalation solution PA benralizumab FASENRA PA mepolizumab NUCALA PA omalizumab XOLAIR

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

Oral isotretinoin

Topical OTC benzoyl peroxide bar, gel 10% PANOXYL OTC benzoyl peroxide bar, gel, lotion 5% PANOXYL OTC adapalene gel 0.1% DIFFERIN OTC benzoyl peroxide gel 2.5% adapalene crm 0.1%, gel 0.3% DIFFERIN benzoyl peroxide liquid 2.5% BENZAC AC clindamycin pads, soln 1% CLEOCIN T erythromycin gel 2% erythromycin soln sulfacetamide/sulfur emulsion 10-5% tretinoin RETIN-A

Actinic Keratosis fluorouracil crm 5% EFUDEX fluorouracil crm 1% FLUOROPLEX

Antibiotics OTC bacitracin OTC neomycin/polymyxin B crm OTC neomycin/polymyxin B/bacitracin/lidocaine oint OTC polymyxin B/bacitracin POLYSPORIN gentamicin crm, oint 0.1% mupirocin oint silver sulfadiazine SILVADENE MedStar Family Choice - Maryland HealthChoice Program 45

Antifungals *, OTC clotrimazole crm 1% LOTRIMIN AF OTC miconazole DESENEX OTC butenafine LOTRIMIN ULTRA OTC terbinafine LAMISIL AT ST ciclopirox crm, susp LOPROX ketoconazole crm 2% nystatin

* Both OTC and Rx products covered ST Clotrimazole, ketoconazole or nystatin required before ciclopirox crm or susp

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

calcipotriene crm, oint, soln 0.005% DOVONEX

Antiseborrheics OTC coal tar shampoo NEUTROGENA T/GEL ketoconazole shampoo 2% NIZORAL selenium sulfide shampoo 2.5%

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

Injectable PA dupilumab DUPIXENT

Topical tacrolimus oint 0.03%, 0.1% PROTOPIC pimecrolimus ELIDEL

Corticosteroids Low Potency OTC hydrocortisone crm, oint 0.5%, 1% CORTIZONE alclometasone crm, oint 0.05% desonide oint 0.05% DESOWEN fluocinolone acetonide soln 0.01% hydrocortisone crm 2.5%

Medium Potency betamethasone valerate crm, lotion, oint 0.1% fluocinolone acetonide crm, oint 0.025% hydrocortisone valerate crm, oint 0.2% WESTCORT mometasone crm, oint, soln 0.1% ELOCON triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1%

High Potency betamethasone dipropionate crm, lotion, oint 0.05% fluocinonide crm, gel, oint, soln 0.05% triamcinolone acetonide crm 0.5%

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Very High Potency clobetasol propionate soln 0.05% TEMOVATE halobetasol propionate crm, oint 0.05% ULTRAVATE

Local Anesthetics OTC lidocaine crm 4% LMX 4 lidocaine/prilocaine crm tetracaine soln 2% PONTOCAINE

Rosacea metronidazole crm 0.75% METROCREAM metronidazole gel 0.75% metronidazole lotion 0.75% METROLOTION

Scabicides and Pediculicides OTC permethrin 1% NIX CREME RINSE malathion OVIDE permethrin 5% ST ivermectin SKLICE

ST OTC permethrin 1% required before Sklice for members younger than age 6; malathion required before Sklice for members age 6 and older

Miscellaneous Skin and Mucous Membrane OTC ammonium lactate 12% LAC-HYDRIN OTC calamine lotion OTC chlorhexidine HIBICLENS OTC oatmeal, colloidal OTC petrolatum/mineral oil EUCERIN OTC salicylic acid gel 17% OTC salicylic acid pad, plaster 40% OTC urea crm 20% CARMOL 20 OTC urea lotion 10% CARMOL 10 OTC antibacterial cleanser bar, liquid cleanser, cleansing cloths CETAPHIL OTC docosanol ABREVA OTC oatmeal, colloidal/dimethicone AVEENO imiquimod ALDARA podofilox CONDYLOX ST urea crm 40% urea lotion 40%, 45% aluminum chloride hexahydrate DRYSOL becaplermin REGRANEX PA collagenase SANTYL

ST OTC Lac-Hydrin required first

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

Steroids - Mouth/Throat triamcinolone paste

Miscellaneous chlorhexidine gluconate PERIDEX sodium fluoride crm PREVIDENT

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

Antiallergics OTC ketotifen ZADITOR azelastine cromolyn sodium

Anti-infectives bacitracin ciprofloxacin soln CILOXAN erythromycin gentamicin neomycin/polymyxin B/gramicidin NEOSPORIN ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide soln 10% BLEPH-10 tobramycin soln TOBREX tobramycin oint TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone susp sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone susp 0.3%/0.1% TOBRADEX gentamicin/prednisolone acetate PRED-G

Anti-inflammatories Nonsteroidal flurbiprofen ketorolac ACULAR

Steroidal dexamethasone sodium phosphate fluorometholone 0.1% FML prednisolone acetate 1% PRED FORTE prednisolone phosphate 1% fluorometholone 0.25% FML FORTE fluorometholone ointment FML S.O.P. loteprednol oint, susp 0.5% LOTEMAX prednisolone acetate 0.12% PRED MILD

Antivirals trifluridine VIROPTIC

Beta-blockers Nonselective BETAGAN timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE timolol hemihydrate BETIMOL

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Selective 0.5%

Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT brinzolamide AZOPT

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

Dry Eye Disease PA lifitegrast XIIDRA

Local Anesthetic Combinations fluorescein/benoxinate 0.25%/0.4%

Mydriatics atropine homatropine ISOPTO HOMATROPINE tropicamide

Prostaglandins latanoprost XALATAN bimatoprost 0.01% LUMIGAN

Sympathomimetics 0.15% ALPHAGAN P brimonidine 0.2% brimonidine 0.1% ALPHAGAN P

Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN

Miscellaneous OTC artificial tears soln

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

Anti-infectives acetic acid ciprofloxacin otic CETRAXAL ofloxacin otic

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/hydrocortisone

Miscellaneous OTC carbamide peroxide DEBROX fluocinolone acetonide oil DERMOTIC hydrocortisone/pramoxine/chloroxylenol CORTANE-B

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

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

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

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

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Global Initiative for Asthma National Foundation for Infectious Diseases http://www.ginasthma.com http://www.nfid.org

Infectious Diseases Society of America National Guideline Clearinghouse http://www.idsociety.org http://www.guideline.gov

Institute for Safe Medication Practices National Heart, Lung and Blood Institute http://www.ismp.org http://www.nhlbi.nih.gov

Johns Hopkins AIDS Service National Institutes of Health http://www.thebody.com/content/art12096.html http://www.nih.gov

Juvenile Diabetes Research Foundation International National Kidney Foundation http://jdrf.org http://www.kidney.org

MedWatch National Osteoporosis Foundation http://www.fda.gov/Safety/MedWatch/default.htm http://www.nof.org

National Agricultural Library North American Menopause Society http://www.nal.usda.gov http://www.menopause.org

National Cancer Institute United States Department of Health and Human http://www.cancer.gov/cancertopics Services http://www.hhs.gov National Comprehensive Cancer Network http://www.nccn.org World Health Organization http://www.who.int

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INDEX

A amantadine caps, syrup, 28 AMARYL, 32 ABREVA, 47 ambrisentan, 27 acamprosate calcium, 30 AMERGE, 11, 29 acarbose, 31 amiloride, 26 ACCOLATE, 44 amiloride/hydrochlorothiazide, 26 ACCU-CHEK CONTROL SOLUTION, 32 aminophylline liquid, tabs, 45 ACCU-CHEK KITS AND TEST STRIPS, 32 amiodarone, 24 ACCUPRIL, 23 AMITIZA, 9, 37 ACCURETIC, 23 amlodipine, 25 acetaminophen/dichloralphenazone/isometheptene, 29 amlodipine/atorvastatin, 26 acetazolamide, 26 amlodipine/benazepril, 23 acetazolamide ext-rel, 26 amlodipine/valsartan, 24 acetic acid, 49 amlodipine/valsartan/hydrochlorothiazide, 24 acetohydroxamic acid, 39 ammonium lactate 12%, 47 ACTIGALL, 37 amoxicillin, 19 ACTOPLUS MET, 32 amoxicillin/clavulanate, 19 ACTOS, 32 ampicillin, 19 ACULAR, 48 AMPYRA, 9, 29 acyclovir caps, susp, tabs, 20 anagrelide, 40 ADALAT CC, 25 ANALPRAM-HC, 38 adalimumab, 40 anastrozole, 21 adapalene crm 0.1%, gel 0.3%, 45 ANORO ELLIPTA, 42 adapalene gel 0.1%, 45 ANTABUSE, 30 ADMELOG, 31 antibacterial cleanser bar, liquid cleanser, cleansing cloths, 47 ADVAIR HFA, 44 ANTI-DIARRHEAL, 36 ADVIL, 17 ANUSOL-HC 2.5%, 38 AFRIN, 44 apixaban, 39 AGGRENOX, 40 apremilast, 40 AGRYLIN, 40 aprepitant, 36 AIRDUO RESPICLICK, 44 ARANESP, 40 ALAMAG, 36 ARAVA, 41 albendazole, 21 ARICEPT, 28 ALBENZA, 9, 21 ARIMIDEX, 21 albiglutide, 31 AROMASIN, 21 albuterol, 43 artificial tears soln, 49 albuterol ext-rel, 43 ASACOL HD, 37 albuterol inhalation solution, 43 asparaginase erwinia, 22 albuterol sulfate, CFC-free aerosol, 43 ATACAND, 23 alclometasone crm, oint 0.05%, 46 ATACAND HCT, 23 ALDACTAZIDE, 26 atenolol, 25 ALDACTONE, 23 atenolol/chlorthalidone, 25 ALDARA, 47 atorvastatin, 24 ALECENSA, 9, 22 atovaquone, 20 alectinib, 22 atovaquone/proguanil, 20 alendronate tabs, 32 atropine, 49 alendronate/vitamin D3, 32 atropine/hyoscyamine/scopolamine/ ALEVE, 17 phenobarbital 16.2 mg tabs, 37 alfuzosin ext-rel, 38 atropine/hyoscyamine/scopolamine/phenobarbital elixir, 37 ALKERAN, 21 AUGMENTIN, 19 ALLEGRA, 42 AVALIDE, 23 allopurinol, 17 AVAPRO, 23 ALORA, 34 AVEENO, 47 ALPHAGAN P, 49 AVELOX, 19 ALTACE, 23 AVODART, 38 ALTERNAGEL, 36 AVONEX, 29 altretamine, 21 AYGESTIN, 35 aluminum chloride hexahydrate, 47 azathioprine, 41 aluminum hydroxide, 36 azelastine, 48 aluminum hydroxide/magnesium hydroxide, 36 azelastine spray, 10, 44 ALUNBRIG, 9, 22 azithromycin, 19 MedStar Family Choice - Maryland HealthChoice Program 52

AZOPT, 49 butalbital/acetaminophen, 10, 18 AZULFIDINE, 37 butalbital/acetaminophen/caffeine, 10, 18 AZULFIDINE EN-TABS, 37 butalbital/acetaminophen/caffeine/codeine, 10, 17 B butalbital/aspirin/caffeine, 10, 18 butalbital/aspirin/caffeine/codeine, 10, 17 bacitracin, 45, 48 butenafine, 46 baclofen, 29 BARACLUDE, 20 C BASAGLAR, 31 C1 esterase inhibitor, 40 becaplermin, 47 cabergoline, 36 beclomethasone, CFC-free aerosol, 45 CABOMETYX, 9, 22 bedaquiline, 20 cabozantinib, 22 benazepril, 23 CADUET, 26 benazepril/hydrochlorothiazide, 23 CAFERGOT, 29 benralizumab, 45 calamine lotion, 47 BENTYL, 37 CALAN, 25 BENZAC AC, 45 CALAN SR, 25 benzonatate, 43 calcipotriene crm, oint, soln 0.005%, 46 benzoyl peroxide bar, gel 10%, 45 calcitonin-salmon, 32 benzoyl peroxide bar, gel, lotion 5%, 45 calcitriol (1,25-D3), 35 benzoyl peroxide gel 2.5%, 45 calcium acetate, 35 benzoyl peroxide liquid 2.5%, 45 calcium carbonate, 36 benztropine, 28 canagliflozin, 32 BETAGAN, 48 canagliflozin/metformin, 32 betamethasone dipropionate crm, lotion, oint 0.05%, 46 canagliflozin/metformin ext-rel, 32 betamethasone valerate crm, lotion, oint 0.1%, 46 CANASA, 37 BETAPACE, 24 candesartan, 23 BETAPACE AF, 24 candesartan/hydrochlorothiazide, 23 betaxolol 0.5%, 49 capecitabine, 21 bethanechol, 39 captopril, 23 BETHKIS, 9, 44 captopril/hydrochlorothiazide, 23 BETIMOL, 48 CARAFATE, 38 bexarotene caps, 22 carbamazepine, 27 BEYAZ, 9, 33 carbamazepine ext-rel, 27 bicalutamide, 21 carbamide peroxide, 49 BICILLIN C-R, 19 CARBATROL, 27 BICILLIN L-A, 19 carbidopa, 28 bimatoprost 0.01%, 49 carbidopa/levodopa, 28 bismuth subsalicylate, 36 carbidopa/levodopa ext-rel, 28 bisoprolol, 25 carbidopa/levodopa/entacapone, 28 bisoprolol/hydrochlorothiazide, 25 CARDIZEM, 25 BLEPH-10, 48 CARDIZEM CD, 25 blood glucose monitoring kits, test strips, 32 CARDURA, 23, 38 BOSULIF, 9, 22 carisoprodol, 29 bosutinib, 22 CARMOL 10, 47 BOTOX, 9, 30 CARMOL 20, 47 brigatinib, 22 carteolol, 48 BRILINTA, 40 carvedilol, 25 brimonidine 0.1%, 49 carvedilol phosphate ext-rel, 25 brimonidine 0.15%, 49 CASODEX, 21 brimonidine 0.2%, 49 CATAPRES, 23 brimonidine/timolol, 49 CATAPRES-TTS, 23 brinzolamide, 49 cefadroxil, 19 brodalumab, 40 cefdinir, 19 bromocriptine, 28 cefpodoxime tablets, 19 budesonide delayed-rel caps, 37 CEFTIN, 19 budesonide inhalation suspension, 45 ceftriaxone, 19 budesonide/formoterol, 44 cefuroxime axetil, 19 bumetanide, 26 CELEBREX, 17 buprenorphine sublingual, 30 celecoxib, 17 buprenorphine/naloxone sublingual film, 30 CELLCEPT, 41 buprenorphine/naloxone sublingual tabs, 30 cephalexin, 19 bupropion ext-rel, 30 CETAPHIL, 47 busulfan, 21 cetirizine, 42

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cetirizine/pseudoephedrine ext-rel, 43 codeine/promethazine/phenylephrine, 43 CETRAXAL, 49 COLACE, 38 CHANTIX, 30 colchicine tabs, 17 CHEMET, 36 colchicine/probenecid, 17 CHEMSTRIP URINE TEST STRIPS, 32 COLCRYS, 17 chlorambucil, 21 COLD & ALLERGY RELIEF, 43 chlorhexidine, 47 collagenase, 47 chlorhexidine gluconate, 47 COMBIGAN, 49 chloroquine, 20 COMBIPATCH, 35 chlorothiazide, 26 COMBIVENT RESPIMAT, 42 chlorothiazide susp, 26 COMETRIQ, 9, 22 chlorpheniramine, 42 COMTAN, 28 chlorpheniramine/phenylephrine tabs, 43 CONDYLOX, 47 chlorthalidone, 26 COPAXONE, 29 CHLOR-TRIMETON, 42 COPEGUS, 20 chlorzoxazone, 29 COREG, 25 cholecalciferol (D3) drops, 41 COREG CR, 25 cholestyramine, 24 CORGARD, 25 choline magnesium trisalicylate, 17 CORTANE-B, 49 ciclopirox cream, suspension, 12 CORTEF, 35 ciclopirox crm, susp, 46 CORTIFOAM, 37 cilostazol, 40 cortisone acetate, 35 CILOXAN, 48 CORTIZONE, 46 cimetidine, 37 COSOPT, 49 cinacalcet, 32 COTELLIC, 9, 22 CIPRO, 19 COUMADIN, 39 ciprofloxacin, 19 COZAAR, 23 ciprofloxacin ext-rel, 19 CREON, 38 ciprofloxacin otic, 49 CRESTOR, 24 ciprofloxacin soln, 48 CRINONE, 36 CITRANATAL DHA, 41 crizotinib, 22 CITRUCEL, 38 cromolyn inhalation solution, 44 clarithromycin, 19 cromolyn sodium, 48 clarithromycin ext-rel, 19 cyanocobalamin inj, 42 CLARITIN, 42 cyanocobalamin tabs 1000 mg, 41 CLARITIN-D, 43 CYCLESSA, 33 clemastine, 42 cyclobenzaprine 5 mg, 10 mg, 29 CLEOCIN, 20, 39 cyclophosphamide caps, 21 CLEOCIN T, 45 cyclosporine, 41 CLIMARA, 34 cyclosporine, modified, 41 CLIMARA PRO, 35 cyproheptadine, 43 clindamycin, 20 CYTOMEL, 36 clindamycin crm, 39 CYTOTEC, 38 clindamycin pads, soln 1%, 45 D clobetasol propionate soln 0.05%, 47 clonazepam, 27 dabigatran etexilate, 39 clonidine, 23 dabrafenib, 22 clonidine transdermal, 23 dalfampridine ext-rel, 29 clopidogrel, 40 DANTRIUM, 29 clotrimazole, 39 dantrolene, 29 clotrimazole crm 1%, 46 dapsone tabs, 21 clotrimazole troches, 20 darbepoetin alfa, 40 coal tar shampoo, 46 DAYPRO, 17 cobimetinib, 22 DDAVP, 36 codeine sulfate, 17 DDAVP spray, 9 codeine sulfate oral solution, 10 DEBROX, 49 codeine sulfate tabs, 10 DELATESTRYL, 31 codeine/acetaminophen, 17 DEMADEX, 26 codeine/acetaminophen oral solution, 10 denosumab, 33 codeine/acetaminophen tabs, 10 DEPAKENE, 28 codeine/chlorpheniramine/pseudoephedrine, 43 DEPAKOTE, 27 codeine/guaifenesin liquid, 43 DEPAKOTE ER, 27 codeine/guaifenesin/pseudoephedrine, 43 DEPO-ESTRADIOL, 34 codeine/promethazine, 43 DEPO-PROVERA, 34 MedStar Family Choice - Maryland HealthChoice Program 54

DEPO-TESTOSTERONE, 31 dornase alfa, 44 DERMOTIC, 49 dorzolamide, 49 DESENEX, 46 dorzolamide/timolol maleate, 49 desmopressin spray, 36 DOVONEX, 46 desmopressin tabs, 36 doxazosin, 23, 38 desogestrel/EE, 33 doxercalciferol, 35 desogestrel/EE 0.15/30 - Apri, 33 DOXIL, 22 desonide oint 0.05%, 46 doxorubicin liposomal, 22 DESOWEN, 46 doxycycline hyclate caps, 19 dexamethasone, 35 doxycycline hyclate tabs 20 mg, 100 mg, 19 dexamethasone sodium phosphate, 48 doxycycline monohydrate susp, 19 dextromethorphan gelcaps, liquid, 43 doxylamine, 29 dextromethorphan/brompheniramine/pseudoephedrine - doxylamine/pyridoxine delayed-rel, 37 Bromfed-DM, 43 DRAMAMINE, 36 dextromethorphan/chlorpheniramine liquid, 43 drospirenone/EE 3/20 - Gianvi, 33 dextromethorphan/guaifenesin ext-rel, 43 drospirenone/EE 3/30, 33 dextromethorphan/guaifenesin syrup, 43 drospirenone/EE/levomefolate 3/20 and levomefolate, 33 dextromethorphan/guaifenesin/pseudoephedrine liq drospirenone/EE/levomefolate 3/20 and levomefolate - 10 mg/100 mg/30 mg/5 mL, 43 Rajani, 33 dextromethorphan/promethazine, 43 DROXIA, 22 dextromethorphan/pyrilamine/phenylephrine - DRYSOL, 47 Codituss DM, 43 DUETACT, 32 dextrose/fructose/phosphoric acid, 36 DULERA, 44 DIABETIC TUSSIN, 44 dupilumab, 46 diaphragm, 34 DUPIXENT, 9, 46 DIASTAT, 27 DURAGESIC, 9, 10, 17 diazepam, 29 dutasteride, 38 diazepam rectal gel, 27 DYAZIDE, 26 DICLEGIS, 10, 37 DYRENIUM, 26 diclofenac potassium, 17 E diclofenac sodium delayed-rel, 17 diclofenac sodium gel, 17 E.E.S., 19 dicloxacillin, 19 ecallantide, 40 dicyclomine, 37 EE/norethindrone acetate, 35 DIFFERIN, 45 EE/norethindrone acetate - Jinteli, 35 DIFICID, 9, 19 EFFIENT, 40 DIFLUCAN, 10, 20 EFUDEX, 45 digoxin, 26 ELDEPRYL, 28 DILANTIN, 27 ELIDEL, 46 DILANTIN INFATABS, 27 ELIGARD, 9, 21 DILAUDID, 10, 18 ELIQUIS, 39 diltiazem, 25 ELIXOPHYLLIN, 45 diltiazem ext-rel, 25 ELLA, 10, 34 dimenhydrinate, 36 ELMIRON, 39 dimethyl fumarate delayed-rel, 29 ELOCON, 46 DIOVAN, 24 EMEND, 36 DIOVAN HCT, 24 EMETROL, 36 diphenhydramine, 42 empagliflozin, 32 diphenoxylate/atropine, 36 empagliflozin/metformin, 32 dipyridamole, 40 empagliflozin/metformin ext-rel, 32 dipyridamole extended-release/aspirin, 40 enalapril, 23 disopyramide, 24 enalapril/hydrochlorothiazide, 23 disulfiram, 30 ENBREL, 40 DITROPAN XL, 39 ENDARI, 9, 40 DIURIL, 26 enoxaparin, 39 divalproex sodium delayed-rel, 27 entacapone, 28 divalproex sodium ext-rel, 27 entecavir, 20 docosanol, 47 ENTOCORT EC, 37 docusate sodium caps, 38 ENTRESTO, 26 docusate sodium liquid, 38 epinephrine auto-injector, 42 dofetilide, 24 EPIPEN, 42 DOLOPHINE, 9, 10, 18 EPIPEN JR., 42 donepezil, 28 EPIVIR-HBV, 20 DONNATAL, 37 epoetin alfa, 40 MedStar Family Choice - Maryland HealthChoice Program 55

EPOGEN, 40 fentanyl transdermal, 10, 17 epoprostenol sodium, 27 FEOSOL, 41 ergocalciferol (D2) caps, 42 FERGON, 41 ergocalciferol (D2) drops, 41 FERRIMIN 150, 42 ergotamine/caffeine, 29 ferrous fumarate, 42 erlotinib, 22 ferrous fumarate/polysaccharide iron complex/ ERWINAZE, 9, 22 folic acid/B complex/vitamin C/minerals, 42 erythromycin, 48 ferrous gluconate, 41 erythromycin base, 19 ferrous sulfate, 41 erythromycin delayed-rel, 19 ferrous sulfate delayed-rel, 41 erythromycin delayed-rel - Ery-tab, 19 fexofenadine susp, tabs, 42 erythromycin ethylsuccinate, 19 FIBRICOR, 24 erythromycin gel 2%, 45 fidaxomicin, 19 erythromycin soln, 45 filgrastim-sndz, 40 erythromycin stearate, 19 finasteride, 39 ESBRIET, 9, 44 fingolimod, 29 ESGIC, 18 FIORICET, 10 esomeprazole magnesium delayed-rel, 10, 38 FIORICET w/CODEINE, 10, 17 ESTRACE, 34, 35 FIORINAL, 10, 18 estradiol, 34 FIORINAL w/CODEINE, 10, 17 estradiol cypionate inj, 34 FIRAZYR, 9, 40 estradiol vaginal cream, 35 FISH OIL, 25 estradiol vaginal ring, 35 FLAGYL, 21 estradiol valerate and dienogest/estradiol valerate, 34 flecainide, 24 estradiol/levonorgestrel, 35 FLEET ENEMA, 10 estradiol/norethindrone acetate, 35 FLOLAN, 27 estrogens, conjugated/medroxyprogesterone, 35 FLOMAX, 39 estropipate, 34 FLONASE ALLERGY RELIEF, 44 ESTROSTEP FE, 33 FLONASE SENSIMIST, 44 etanercept, 40 FLOVENT DISKUS, 45 ethambutol, 20 FLOVENT HFA, 45 ethosuximide, 27 fluconazole, 20 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 33 fluconazole 150 mg, 10 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 33 fludrocortisone, 35 etodolac, 17 flunisolide spray, 44 etonogestrel implant, 34 fluocinolone acetonide crm, oint 0.025%, 46 etonogestrel/EE ring, 34 fluocinolone acetonide oil, 49 etoposide, 22 fluocinolone acetonide soln 0.01%, 46 EUCERIN, 47 fluocinonide crm, gel, oint, soln 0.05%, 46 EVISTA, 36 fluorescein/benoxinate 0.25%/0.4%, 49 evolocumab, 25 fluoride drops, tabs, 42 exemestane, 21 fluorometholone 0.1%, 48 EXFORGE, 24 fluorometholone 0.25%, 48 EXFORGE HCT, 24 fluorometholone ointment, 48 EXTAVIA, 29 FLUOROPLEX, 45 ezetimibe, 24 fluorouracil crm 1%, 45 ezetimibe/simvastatin, 24 fluorouracil crm 5%, 45 F flurbiprofen, 17, 48 flutamide, 21 famciclovir, 20 fluticasone, 45 famotidine, 37 fluticasone mist, 44 famotidine chewable tabs, 37 fluticasone spray, 44 FARESTON, 21 fluticasone, CFC-free aerosol, 45 FASENRA, 9, 45 fluticasone/salmeterol, 44 FASLODEX, 21 fluticasone/salmeterol, CFC-free aerosol, 44 felbamate, 27 FML, 48 FELBATOL, 27 FML FORTE, 48 felodipine ext-rel, 25 FML S.O.P., 48 FEMARA, 21 folic acid, 41 FEMHRT, 35 FORTESTA, 31 FEMRING, 35 FOSAMAX, 32 fenofibrate, 24 FOSAMAX PLUS D, 32 fenofibrate, micronized, 24 foscarnet, 20 fenofibric acid, 24 fosinopril, 23 MedStar Family Choice - Maryland HealthChoice Program 56

fosinopril/hydrochlorothiazide, 23 HUMULIN 70/30, 31 FOSRENOL, 35 HUMULIN N, 31 fulvestrant, 21 HUMULIN R, 31 FURADANTIN, 21 HYALGAN, 18 furosemide, 26 HYCAMTIN CAPS, 9, 22 G HYCET, 10, 18 hydralazine, 27 gabapentin, 27 HYDREA, 22 gabapentin ext-rel, 30 hydrochlorothiazide, 26 GABITRIL, 27 hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, galantamine, 28 10/325 mg, 17 GALZIN, 42 hydrocodone/acetaminophen oral solution, 10 gemfibrozil, 24 hydrocodone/acetaminophen soln 7.5/325 per 15 mL, 18 GENERESS FE, 33 hydrocodone/acetaminophen tabs, 10 gentamicin, 48 hydrocodone/homatropine, 43 gentamicin crm, oint 0.1%, 45 hydrocortisone, 35 gentamicin/prednisolone acetate, 48 hydrocortisone acetate foam, 37 GILENYA, 29 hydrocortisone crm, 38 glatiramer, 29 hydrocortisone crm 2.5%, 46 glecaprevir/pibrentasvir, 20 hydrocortisone crm, oint 0.5%, 1%, 46 GLEEVEC, 22 hydrocortisone enema, 37 glimepiride, 32 hydrocortisone rectal crm, oint, 38 glipizide, 32 hydrocortisone valerate crm, oint 0.2%, 46 glipizide ext-rel, 32 hydrocortisone/pramoxine crm 1-1%, 38 glipizide/metformin, 31 hydrocortisone/pramoxine/chloroxylenol, 49 GLUCAGON EMERGENCY KIT, 35 hydromorphone, 18 glucagon, human recombinant, 35 hydromorphone oral liquid 1 mg/mL, 10 GLUCOPHAGE, 10, 31 hydromorphone suppository, 10 GLUCOPHAGE XR, 31 hydromorphone tabs 2 mg, 10 glucose meter control solution, 32 hydromorphone tabs 4 mg, 10 GLUCOTROL, 32 hydromorphone tabs 8 mg, 10 GLUCOTROL XL, 32 hydroxychloroquine, 41 GLUCOVANCE, 31 hydroxyprogesterone caproate, 35 glyburide, 32 hydroxyurea, 22 glyburide, micronized, 32 hydroxyzine HCl, 43 glyburide/metformin, 31 hyoscyamine 0.15 mg tabs, 37 glycopyrrolate, 37 hyoscyamine sulfate 0.125 mg, 37 GLYNASE, 32 hyoscyamine sulfate 125 mcg/5 mL elixir, 37 GOLYTELY, 38 hyoscyamine sulfate ext-rel 0.375 mg, 37 goserelin acetate, 21 HYZAAR, 23 GRALISE, 9, 30 granisetron, 36 I granisetron 1 mg, 10 IBRANCE, 9, 22 grass mixed pollen allergen extract, 40 ibrutinib, 22 GRASTEK, 40 ibuprofen, 17 griseofulvin microsize susp, tabs, 20 icatibant, 40 griseofulvin ultramicrosize, 20 ICLUSIG, 9, 22 GRIS-PEG, 20 idelalisib, 22 guaifenesin ext-rel, 44 imatinib mesylate, 22 guaifenesin liquid, 44 IMBRUVICA, 9, 22 guanfacine, 23 imiquimod, 47 GYNE-LOTRIMIN, 39 IMITREX, 11, 29 GYNOL II, 34 IMURAN, 41 H indapamide, 26 INDERAL LA, 25 HAEGARDA, 9, 40 indomethacin, 17 halobetasol propionate crm, oint 0.05%, 47 INGREZZA, 9, 29 HECTOROL, 35 insulin aspart, 31 HEMANGEOL, 25 insulin aspart protamine 70%/insulin aspart 30%, 31 HEXALEN, 21 insulin degludec, 31 HIBICLENS, 47 insulin glargine, 31 homatropine, 49 insulin human, 31 HUMALOG MIX 50/50, 31 insulin isophane human, 31 HUMALOG MIX 75/25, 31 insulin isophane human 70%/regular 30%, 31 HUMIRA, 40 MedStar Family Choice - Maryland HealthChoice Program 57

insulin lispro 100 units/mL, 31 LANOXIN, 26 insulin lispro protamine 50%/insulin lispro 50%, 31 lansoprazole, 10 insulin lispro protamine 75%/insulin lispro 25%, 31 lansoprazole + amoxicillin + clarithromycin, 38 insulin syringes, needles, 32 lansoprazole delayed-rel, 38 interferon beta-1a, 29 lansoprazole delayed-rel orally-disintegrating 15 mg tabs, 38 interferon beta-1b, 29 lanthanum, 35 intrauterine device, 34 lapatinib, 22 INVOKAMET, 32 LASIX, 26 INVOKAMET XR, 32 latanoprost, 49 INVOKANA, 32 leflunomide, 41 IOSAT, 36 lesinurad, 17 ipratropium inhalation solution, 42 LETAIRIS, 27 ipratropium nasal spray, 45 letrozole, 21 ipratropium/albuterol inhalation solution, 42 leucovorin, 22 ipratropium/albuterol, CFC-free aerosol, 42 LEUKERAN, 21 irbesartan, 23 LEUKINE, 40 irbesartan/hydrochlorothiazide, 23 leuprolide acetate, 9, 21 isoniazid, 20 levalbuterol inhalation solution, 43 ISOPTO HOMATROPINE, 49 levalbuterol tartrate, CFC-free aerosol, 43 ISORDIL, 26 LEVAQUIN, 19 isosorbide dinitrate ext-rel tabs, 26 levetiracetam, 27 isosorbide dinitrate oral, 26 levobunolol, 48 isosorbide mononitrate, 26 levocetirizine, 42 isosorbide mononitrate ext-rel, 26 levofloxacin, 19 isotretinoin, 45 levonorgestrel - Next Choice One Dose, 10, 34 ivacaftor, 44 levonorgestrel/EE - Trivora, 33 ivermectin, 21, 47 levonorgestrel/EE 0.1/20 - Aviane, 33 ixekizumab, 40 levonorgestrel/EE 0.1/20 and EE 10, 34 J levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10, 34 levonorgestrel/EE 0.15/30 - Levora, 33 JAKAFI, 9, 22 levonorgestrel/EE 0.15/30 - Quasense, 34 JANUMET, 31 levonorgestrel/EE 0.15/30 and EE 10, 34 JANUMET XR, 31 levonorgestrel-releasing IUD, 34 JANUVIA, 31 levothyroxine, 36 JARDIANCE, 32 levothyroxine - Levoxyl, 36 JUXTAPID, 9, 24 L-glutamine oral powder, 40 K LIALDA, 37 KALBITOR, 40 lidocaine crm 4%, 47 KALYDECO, 9, 44 lidocaine viscous, 47 KEFLEX, 19 lidocaine/prilocaine crm, 47 KEPPRA, 27 lifitegrast, 49 ketoconazole crm 2%, 46 LILETTA, 34 ketoconazole shampoo 2%, 46 linaclotide, 37 ketorolac, 10, 17, 48 linezolid, 21 KETOSTIX URINE TEST STRIPS, 32 LINZESS, 9, 37 ketotifen, 48 liothyronine, 36 KEVZARA, 9, 40 LIPITOR, 24 KISQALI, 9, 22 liraglutide, 31 KLONOPIN, 27 lisinopril, 23 KLOR-CON/25, 41 lisinopril/hydrochlorothiazide, 23 K-PHOS NEUTRAL, 39 LITHOSTAT, 39 KRILL OIL, 25 LMX 4, 47 KYLEENA, 34 LO LOESTRIN FE, 9, 33 LODOSYN, 28 L LOESTRIN 1.5/30, 33 labetalol, 25 LOESTRIN 1/20, 33 LAC-HYDRIN, 47 LOESTRIN FE 1.5/30, 33 lactulose, 38 LOESTRIN FE 1/20, 33 LAMICTAL, 27 LOFIBRA, 24 LAMISIL, 20 lomitapide, 24 LAMISIL AT, 46 LOMOTIL, 36 lamivudine, 20 LONSURF, 22 lamotrigine, 27 loperamide liquid, tabs, 36 lancets, lancet devices, 32 LOPID, 24 MedStar Family Choice - Maryland HealthChoice Program 58

LOPRESSOR, 25 MESTINON TIMESPAN, 30 LOPROX, 12, 46 metformin, 31 loratadine, 42 metformin 1000 mg, 10 loratadine/pseudoephedrine ext-rel, 43 metformin 500 mg, 10 losartan, 23 metformin ext-rel, 31 losartan/hydrochlorothiazide, 23 methadone, 18 LOSEASONIQUE, 34 methadone oral concentrate 10 mg/mL, 10 LOTEMAX, 48 methadone oral solution 10 mg/5 mL, 10 LOTENSIN, 23 methadone oral solution 5 mg/5 mL, 10 LOTENSIN HCT, 23 methadone tabs 10 mg, 10 loteprednol oint, susp 0.5%, 48 methadone tabs 40 mg, 10 LOTREL, 23 methadone tabs 5 mg, 10 LOTRIMIN AF, 46 methazolamide, 26 LOTRIMIN ULTRA, 46 methenamine/hyoscyamine/methylene blue/ lovastatin, 24 benzoic acid/phenyl salicylate - Hyophen, 39 LOVAZA, 9, 25 METHERGINE, 36 LOVENOX, 39 methimazole, 36 lubiprostone, 37 methocarbamol, 29 lumacaftor/ivacaftor, 44 methotrexate 2.5 mg, 41 LUMIGAN, 49 methotrexate inj, 41 LUPRON DEPOT, 9, 21 methscopolamine, 37 LYNPARZA, 9, 22 methyclothiazide, 26 LYRICA, 28 methylcellulose, 38 LYSODREN, 22 methyldopa, 27 LYSTEDA, 40 methyldopa/hydrochlorothiazide, 27 M methylergonovine, 36 methylprednisolone, 35 MAALOX, 36 metipranolol, 48 macitentan, 27 metoclopramide, 37 MACROBID, 21 metolazone, 26 MACRODANTIN, 21 metoprolol succinate ext-rel, 25 magnesium oxide, 41 metoprolol tartrate 25 mg, 50 mg, 100 mg, 25 MAG-OX, 41 METROCREAM, 47 MAKENA, 35 METROGEL-VAGINAL, 39 MALARONE, 20 METROLOTION, 47 malathion, 47 metronidazole, 21, 39 MATULANE, 22 metronidazole crm 0.75%, 47 MAVYRET, 9, 20 metronidazole gel 0.75%, 47 MAXALT, 11, 29 metronidazole lotion 0.75%, 47 MAXALT-MLT, 11 MIACALCIN, 32 MAXITROL, 48 miconazole, 39, 46 MAXZIDE, 26 midazolam injection, 9 meclizine, 36 midodrine, 27 MEDROL, 35 MIDRIN, 29 medroxyprogesterone acetate, 35 milnacipran, 28 medroxyprogesterone acetate 150 mg/mL, 34 MINASTRIN 24 FE, 9, 33 mefloquine, 20 mineral oil, 38 MEGACE ES, 35 MINIPRESS, 23 megestrol acetate, 21 MINOCIN, 19 megestrol acetate susp, 35 minocycline, 19 MEKINIST, 9, 22 minoxidil, 27 melatonin, 41 MIRALAX, 38 meloxicam, 17 MIRAPEX, 28 melphalan, 21 MIRCETTE, 33 memantine, 28 MIRENA, 34 MEPHYTON, 42 misoprostol, 38 mepolizumab, 45 mitotane, 22 MEPRON, 20 MOBIC, 17 mercaptopurine, 21 moexipril, 23 mesalamine delayed-rel tabs, 37 moexipril/hydrochlorothiazide, 23 mesalamine ext-rel caps, 37 mometasone crm, oint, soln 0.1%, 46 mesalamine rectal susp, 37 mometasone/formoterol, 44 mesalamine supp, 37 MONISTAT, 39 MESTINON, 30 montelukast, 44 MedStar Family Choice - Maryland HealthChoice Program 59

morphine, 18 neomycin/polymyxin B/gramicidin, 48 morphine ext-rel beads, 9, 18 neomycin/polymyxin B/hydrocortisone, 49 morphine ext-rel tabs, 18 neomycin/polymyxin B/hydrocortisone susp, 48 morphine sulfate ext-rel beads 120 mg, 11 NEORAL, 41 morphine sulfate ext-rel beads 30 mg, 10 NEOSPORIN, 48 morphine sulfate ext-rel beads 45 mg, 10 NEO-SYNEPHRINE, 44 morphine sulfate ext-rel beads 60 mg, 10 NEPHRO-VITE RX, 42 morphine sulfate ext-rel beads 75 mg, 11 NEUPRO, 28 morphine sulfate ext-rel beads 90 mg, 11 NEURONTIN, 27 morphine sulfate ext-rel tabs 100 mg, 11 NEUTROGENA T/GEL, 46 morphine sulfate ext-rel tabs 15 mg, 11 NEXIUM 24HR, 10, 38 morphine sulfate ext-rel tabs 200 mg, 11 NEXPLANON, 34 morphine sulfate ext-rel tabs 30 mg, 11 niacin, 24 morphine sulfate ext-rel tabs 60 mg, 11 niacin ext-rel, 24 morphine sulfate immediate-release tabs 15 mg, 11 NIACOR, 24 morphine sulfate immediate-release tabs 30 mg, 11 NIASPAN, 24 morphine sulfate oral concentrate 10 mg/mL, 11 nicardipine, 25 morphine sulfate oral solution 20 mg/5 mL, 11 NICORETTE, 30 morphine supp, 18 nicotine inhaler, 30 morphine suppository 20 mg, 11 nicotine nasal spray, 30 morphine suppository 30 mg, 11 nicotine polacrilex gum, lozenge, 30 morphine suppository 5 mg, 10 mg, 11 nicotine transdermal, 30 MOVANTIK, 9, 38 NICOTROL INHALER, 30 moxifloxacin, 19 NICOTROL NS, 30 MS CONTIN, 9, 11, 18 nifedipine, 25 MUCINEX, 44 nifedipine ext-rel, 25 MUCINEX D, 44 nilotinib, 22 MUCINEX DM, 43 nimodipine, 25 MUCINEX FOR KIDS, 44 nintedanib, 44 multivitamins drops, 41, 42 niraparib, 22 multivitamins/fluoride drops, tabs, 42 NITRO-BID, 26 multivitamins/fluoride/iron drops, tabs, 42 NITRO-DUR, 26 multivitamins/iron drops, 41 nitrofurantoin ext-rel, 21 mupirocin oint, 45 nitrofurantoin macrocrystals, 21 MYAMBUTOL, 20 nitrofurantoin susp, 21 MYCOBUTIN, 21 nitroglycerin lingual spray, 26 mycophenolate mofetil, 41 nitroglycerin oint, 26 MYLERAN, 21 nitroglycerin sublingual, 26 MYLICON, 38 nitroglycerin transdermal, 26 MYSOLINE, 27 NITROLINGUAL, 26 N NITROSTAT, 26 NIX CREME RINSE, 47 nabumetone, 17 NIZORAL, 46 nadolol, 25 nonoxynol 9 gel, 34 naloxegol, 38 nonoxynol-9, 34 naloxone inj, 30 NORCO, 10, 17 naloxone nasal spray, 30 NORDITROPIN, 9, 35 naltrexone, 30 norelgestromin/EE, 34 NAMENDA, 28 norethindrone, 34 NAPROSYN, 17 norethindrone acetate, 35 naproxen, 17 norethindrone acetate/EE 1.5/30, 33 naproxen sodium, 17 norethindrone acetate/EE 1.5/30 and iron, 33 naratriptan, 11, 29 norethindrone acetate/EE 1/10 and EE 10 and iron, 33 NARCAN, 30 norethindrone acetate/EE 1/20, 33 NASACORT ALLERGY 24HR, 44 norethindrone acetate/EE 1/20 and iron, 33 NATAZIA, 9, 34 norethindrone acetate/EE 1/20 and iron chewable, 33 nateglinide, 32 norethindrone acetate/EE 1/20 and iron gel caps, 33 NATURAL FIBER, 38 norethindrone acetate/EE and iron, 33 NEBUPENT, 21 norethindrone/EE, 33 neomycin, 19 norethindrone/EE 0.4/35 - Briellyn, 33 neomycin/polymyxin B crm, 45 norethindrone/EE 0.4/35 chewable - Wymzya FE, 33 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 48 norethindrone/EE 0.5/35 - Necon 0.5/35, 33 neomycin/polymyxin B/bacitracin/lidocaine oint, 45 norethindrone/EE 0.8/25 chewable, 33 neomycin/polymyxin B/dexamethasone, 48 norethindrone/EE 1/35, 33 MedStar Family Choice - Maryland HealthChoice Program 60

norgestimate/EE, 33, 34 oxybutynin ext-rel, 39 norgestimate/EE 0.25/35, 33 oxybutynin transdermal, 39 norgestrel/EE 0.3/30 - Low-Ogestrel, 33 oxycodone caps, tabs 5 mg, 18 norgestrel/EE 0.5/50 - Ogestrel, 33 oxycodone concentrate 20 mg/mL, 18 NORPACE, 24 oxycodone immediate release tabs 15 mg, 11 NORVASC, 25 oxycodone immediate release tabs 20 mg, 11 NOVOLIN 70/30, 31 oxycodone immediate release tabs 30 mg, 11 NOVOLIN N, 31 oxycodone immediate-release caps 5 mg, tabs 5 mg, 10 mg, 11 NOVOLIN R, 31 oxycodone oral concentrate 20 mg/mL, 11 NOVOLOG, 31 oxycodone oral solution 5 mg/5 mL, 11 NOVOLOG MIX 70/30, 31 oxycodone tabs 10 mg, 20 mg, 18 NOXAFIL, 9, 20 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 18 NUCALA, 9, 45 oxycodone/acetaminophen 5/325, 7.5/325, 18 NULYTELY, 38 oxycodone/acetaminophen oral solution, 11 NUVARING, 34 oxycodone/acetaminophen tabs, 11 nystatin, 20, 46 oxycodone/aspirin, 18 O oxycodone/aspirin tabs, 11 oxymetazoline, 44 oatmeal, colloidal, 47 oxymorphone ext-rel, 9, 18 oatmeal, colloidal/dimethicone, 47 oxymorphone ext-rel tabs 10 mg, 11 OCEAN, 45 oxymorphone ext-rel tabs 15 mg, 11 OCUFLOX, 48 oxymorphone ext-rel tabs 20 mg, 11 OFEV, 9, 44 oxymorphone ext-rel tabs 30 mg, 11 ofloxacin, 48 oxymorphone ext-rel tabs 40 mg, 11 ofloxacin otic, 49 oxymorphone ext-rel tabs 5 mg, 11 olaparib, 22 oxymorphone ext-rel tabs 7.5 mg, 11 olopatadine spray, 44 OXYTROL FOR WOMEN, 39 omacetaxine mepesuccinate, 22 OZEMPIC, 31 omalizumab, 45 omega-3 acid ethyl esters, 25 P omega-3 fatty acids, 25 PACERONE, 24 omega-3 fatty acids 300 mg, 25 palbociclib, 22 omega-3 fatty acids/vitamin E, 25 palivizumab, 44 omega-3 fatty acids/vitamins chewable, 25 PAMINE, 37 OMEGA-3 GUMMIES, 25 pancrelipase, 38 omeprazole 40 mg, 11 pancrelipase delayed-rel, 38 omeprazole delayed-rel caps, 38 PANOXYL, 45 omeprazole magnesium delayed-rel, 38 pantoprazole 20 mg, 40 mg, 11 omeprazole, except 40 mg, 11 pantoprazole delayed-rel, 38 omeprazole/sodium bicarbonate, 38 PARAGARD T 380A, 34 onabotulinumtoxinA, 30 PARLODEL, 28 ondansetron, 37 paromomycin, 21 ONE DAILY PRENATAL, 41 PATANASE, 44 OPSUMIT, 27 peg 3350/electrolytes, 38 ORALAIR, 40 penicillin G benzathine, 19 ORENITRAM, 27 penicillin G benzathine/penicillin G procaine, 19 ORKAMBI, 9, 44 penicillin VK, 19 orphenadrine ext-rel, 29 pentamidine aerosol, 21 ORTHO MICRONOR, 34 PENTASA, 37 ORTHO TRI-CYCLEN, 33 pentosan polysulfate sodium, 39 ORTHO TRI-CYCLEN LO, 34 pentoxifylline ext-rel, 40 ORTHO-CYCLEN, 33 PEPCID, 37 ORTHO-DIAPHRAGM, 34 PEPCID AC, 37 ORTHO-NOVUM 1/35, 33 PEPTO-BISMOL, 36 ORTHO-NOVUM 7/7/7, 33 PERCOCET, 11, 18 oseltamivir, 11, 20 PERCODAN, 11, 18 osimertinib, 22 PERIDEX, 47 OTEZLA, 9, 40 permethrin 1%, 47 OVIDE, 47 permethrin 5%, 47 OXANDRIN, 31 petrolatum/mineral oil, 47 oxandrolone, 31 phenazopyridine, 39 oxaprozin, 17 phenobarbital, 27 oxcarbazepine, 27 phenylephrine, 44 oxybutynin, 39 phenylephrine/guaifenesin syrup, 44

MedStar Family Choice - Maryland HealthChoice Program 61

phenytoin, 27 PREVPAC, 38 phenytoin sodium extended, 27 PRILOSEC, 11 PHOSLO, 35 PRILOSEC OTC, 38 phytonadione, 42 primaquine, 20 pimecrolimus, 46 primidone, 27 PIMTREA, 33 PROAIR HFA, 43 pindolol, 25 probenecid, 17 pioglitazone, 32 procarbazine, 22 pioglitazone/glimepiride, 32 PROCARDIA, 25 pioglitazone/metformin, 32 PROCARDIA XL, 25 pirfenidone, 44 prochlorperazine, 37 PLAN B ONE-STEP, 10, 34 PROCRIT, 40 PLAQUENIL, 41 progesterone gel, 36 PLAVIX, 40 progesterone, micronized, 36 podofilox, 47 PROGRAF, 41 polyethylene glycol 3350, 38 PROLIA, 9, 33 polymyxin B/bacitracin, 45, 48 promethazine, 37 polymyxin B/trimethoprim, 48 PROMETRIUM, 36 polysaccharide iron complex 150 mg - Nu-Iron 150, 41 propafenone, 24 polysaccharide iron complex/vitamin B12/folic acid - propantheline, 37 Ferrex 150, 41 propranolol, 25 POLYSPORIN, 45 propranolol ext-rel, 25 POLYTRIM, 48 propranolol oral soln, 25 ponatinib, 22 propylthiouracil, 36 PONTOCAINE, 47 PROSCAR, 39 posaconazole, 20 PROTONIX, 11, 38 potassium chloride effervescent, 41 PROTOPIC, 46 potassium chloride ext-rel, 41 PROVERA, 35 potassium chloride liquid, 41 pseudoephedrine, 44 potassium chloride powder 20 mEq, 41 pseudoephedrine/guaifenesin ext-rel, 44 potassium chloride powder 25 mEq, 41 psyllium/aspartame, 38 potassium citrate ext-rel, except 15 mEq, 39 PULMICORT RESPULES, 45 potassium iodide, 36 PULMOZYME, 9, 44 potassium/sodium phosphates, 39 pyrantel - Reese's Pinworm Medicine, 20 PRADAXA, 39 pyrazinamide, 20 pramipexole, 28 PYRIDIUM, 39 PRANDIN, 32 pyridostigmine, 30 prasugrel, 40 pyridostigmine ext-rel, 30 PRAVACHOL, 24 pyridoxine 25 mg, 50 mg, 42 pravastatin, 24 Q prazosin, 23 PRECOSE, 31 QUARTETTE, 34 PRED FORTE, 48 QUESTRAN/QUESTRAN LIGHT, 24 PRED MILD, 48 quinapril, 23 PRED-G, 48 quinapril/hydrochlorothiazide, 23 prednisolone acetate 0.12%, 48 QVAR, 45 prednisolone acetate 1%, 48 R prednisolone phosphate 1%, 48 ragweed pollen allergen extract, 40 prednisolone sodium phosphate soln 5 mg/5 mL, RAGWITEK, 40 15 mg/5 mL, 25 mg/5 mL, 35 raloxifene, 36 prednisolone syrup, 35 ramipril, 23 prednisone, 35 RANEXA, 12, 27 pregabalin, 28 ranitidine, 37 PREMPHASE, 35 ranitidine 150 mg, 37 PREMPRO, 35 ranitidine 75 mg, 37 PRENATABS RX, 41 ranolazine ext-rel, 27 PRENATAL LOW IRON, 41 RAPAMUNE, 41 prenatal vitamins/DHA/docusate/folic acid, 41 RASUVO, 9, 41 prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid, 41 RAZADYNE, 28 prenatal vitamins/folic acid, 41 REBETOL, 20 PREVACID, 10, 38 REGLAN, 37 PREVACID 24HR, 38 regorafenib, 22 PREVACID SOLUTAB, 11, 38 REGRANEX, 47 PREVIDENT, 47 REMODULIN, 27 MedStar Family Choice - Maryland HealthChoice Program 62

RENVELA, 35 simethicone, 38 repaglinide, 32 SIMPLY SALINE, 45 REPATHA, 9, 25 simvastatin, 24 REQUIP, 28 SINEMET, 28 RETIN-A, 45 SINEMET CR, 28 REVATIO, 27 SINGULAIR, 44 ribavirin caps, 20 sirolimus, 41 ribavirin tabs, 20 SIRTURO, 10, 20 ribociclib, 22 sitagliptin phosphate, 31 rifabutin, 21 sitagliptin/metformin, 31 RIFADIN, 20 sitagliptin/metformin ext-rel, 31 rifampin, 20 SKLICE, 12, 47 rifaximin 550 mg, 21 SKYLA, 34 RITUXAN HYCELA, 9, 22 SLOW FE, 41 rituximab/hyaluronidase human, 22 sodium bicarbonate, 36 rivaroxaban, 39 sodium chloride inhalation solution, 45 rivastigmine caps, soln, 28 sodium chloride nasal spray, 45 rizatriptan, 11, 29 sodium chloride tabs 1 gm, 41 rizatriptan orally disintegrating tabs, 11 sodium citrate/citric acid, 39 ROBAXIN, 29 sodium fluoride crm, 47 ROBITUSSIN CHILDREN'S COUGH & COLD, sodium hyaluronate, 18 LONG ACTING, 43 sodium oxybate, 30 ROBITUSSIN COUGH + CHEST CONGESTION DM, 43 sodium polystyrene sulfonate, 35 ROBITUSSIN LONG-ACTING COUGH, 43 SOMA, 29 ROCALTROL, 35 somatropin, 35 ROCEPHIN, 19 sotalol, 24 ropinirole, 28 SPIRIVA RESPIMAT, 42 rosuvastatin, 24 spironolactone, 23 rotigotine transdermal, 28 spironolactone/hydrochlorothiazide, 26 ROWASA, 37 SPS, 35 ROXICODONE, 11, 18 SSKI, 36 RUBRACA, 9, 22 STALEVO, 28 rucaparib, 22 STARLIX, 32 ruxolitinib, 22 STIMATE, 10, 36 S STIVARGA, 10, 22 STROMECTOL, 21 sacubitril/valsartan, 26 SUBOXONE, 30 safinamide, 28 succimer, 36 salicylic acid gel 17%, 47 sucralfate, 38 salicylic acid pad, plaster 40%, 47 SUDAFED, 44 salmeterol xinafoate, 43 sulfacetamide soln 10%, 48 SANDIMMUNE, 41 sulfacetamide/prednisolone phosphate 10%/0.25%, 48 SANTYL, 9, 47 sulfacetamide/sulfur emulsion 10-5%, 45 sargramostim, 40 sulfadiazine, 19 sarilumab, 40 sulfamethoxazole/trimethoprim, 19 SAVELLA, 28 sulfamethoxazole/trimethoprim DS, 19 scopolamine transdermal, 37 sulfasalazine, 37 SEASONIQUE, 34 sulfasalazine delayed-rel, 37 selegiline caps, 28 sulindac, 17 selegiline tabs, 28 sumatriptan, 29 selenium sulfide shampoo 2.5%, 46 sumatriptan 25 mg, 50 mg, 100 mg, 11 selexipag, 27 sumatriptan injection, 11, 29 semaglutide, 31 sumatriptan nasal spray, 29 sennosides, 38 sumatriptan nasal spray 20 mg/actuation, 11 SENOKOT, 38 sumatriptan nasal spray 5 mg/actuation, 11 SENSIPAR, 32 SUPARTZ FX, 18 SEREVENT, 11, 43 SYMBICORT, 44 SEROSTIM, 10, 35 SYNAGIS, 10, 44 sevelamer carbonate, 35 SYNJARDY, 32 SHUR-SEAL, 34 SYNJARDY XR, 32 sildenafil, 27 SYNRIBO, 10, 22 SILIQ, 10, 40 SYNTHROID, 36 SILVADENE, 45 silver sulfadiazine, 45

MedStar Family Choice - Maryland HealthChoice Program 63

T tofacitinib, 40 tacrolimus, 41 tofacitinib ext-rel, 40 tacrolimus oint 0.03%, 0.1%, 46 TOPAMAX, 28 TAFINLAR, 10, 22 topiramate sprinkle caps, tabs, 28 TAGRISSO, 10, 22 topotecan caps, 22 TALTZ, 10, 40 TOPROL-XL, 25 TAMIFLU, 11, 20 toremifene, 21 tamoxifen, 21 torsemide, 26 tamsulosin, 39 tramadol, 11, 18 TANDEM PLUS, 42 trametinib, 22 TANZEUM, 31 TRANDATE, 25 TAPAZOLE, 36 trandolapril, 23 TARCEVA, 10, 22 trandolapril/verapamil ext-rel, 23 TARGRETIN, 22 tranexamic acid, 40 TARKA, 23 TRANSDERM SCOP, 37 TASIGNA, 10, 22 treprostinil, 27 TAYTULLA, 10, 33 treprostinil ext-rel, 27 TECFIDERA, 29 TRESIBA, 31 TEGRETOL, 27 tretinoin, 45 TEGRETOL-XR, 27 tretinoin caps, 22 TEMODAR, 21 triamcinolone acetonide crm 0.5%, 46 TEMOVATE, 47 triamcinolone acetonide crm, lotion 0.025%, 46 temozolomide, 21 triamcinolone acetonide crm, lotion, oint 0.1%, 46 TENORMIN, 25 triamcinolone acetonide spray, 44 TERAZOL 7, 39 triamcinolone paste, 47 terazosin, 23, 39 triamterene, 26 terbinafine, 46 triamterene/hydrochlorothiazide, 26 terbinafine tabs, 20 TRICOR, 24 terbutaline, 44 trifluridine, 48 terconazole, 39 trifluridine/tipiracil, 22 terconazole 3, 39 trihexyphenidyl, 28 TESSALON, 43 TRILEPTAL, 27 testosterone cypionate inj, 31 trimethobenzamide, 37 testosterone enanthate inj, 31 trimethoprim tabs, 21 testosterone gel 1%, 31 TRI-NORINYL, 33 testosterone gel 2%, 31 TRI-VI-SOL, 42 testosterone soln, 31 tropicamide, 49 tetracaine soln 2%, 47 trospium, 39 tetracycline, 19 TRUSOPT, 49 theophylline ext-rel tabs, 45 TUCKS, 38 theophylline liquid, 45 TYKERB, 10, 22 THYROSAFE, 36 TYLENOL w/CODEINE, 10, 17 tiagabine, 27 TYVASO, 27 TIAZAC, 25 U ticagrelor, 40 ulipristal, 34 TIGAN, 37 ULTRAM, 11, 18 TIKOSYN, 24 ULTRAVATE, 47 timolol hemihydrate, 48 umeclidinium/vilanterol, 42 timolol maleate, 48 UNISOM, 29 timolol maleate gel, 48 UPTRAVI, 27 timolol maleate tabs, 25 urea crm 20%, 47 TIMOPTIC, 48 urea crm 40%, 47 TIMOPTIC-XE, 48 urea lotion 10%, 47 timothy grass pollen allergen extract, 40 urea lotion 40%, 45%, 47 tiotropium, 42 URECHOLINE, 39 tizanidine caps, tabs, 29 urine test strips, 32 TOBI, 44 UROCIT-K, 39 TOBRADEX, 48 UROXATRAL, 38 tobramycin inhalation soln, 44 URSO, 37 tobramycin inhalation solution, 44 URSO FORTE, 37 tobramycin oint, 48 ursodiol, 37 tobramycin soln, 48 tobramycin/dexamethasone susp 0.3%/0.1%, 48 V TOBREX, 48 valacyclovir, 20 MedStar Family Choice - Maryland HealthChoice Program 64

valbenazine, 29 XGEVA, 10, 33 VALCYTE, 20 XIFAXAN, 21 valganciclovir, 20 XIIDRA, 10, 49 VALIUM, 29 XOLAIR, 10, 45 valproic acid, 28 XOPENEX HFA, 43 valsartan, 24 XYREM, 10, 30 valsartan/hydrochlorothiazide, 24 XYZAL, 42 VALTREX, 20 Y VANCOCIN, 21 vancomycin, 21 YASMIN, 33 varenicline, 30 YAZ, 33 VASERETIC, 23 Z VASOTEC, 23 ZADITOR, 48 vemurafenib, 22 zafirlukast, 44 VENCLEXTA, 10, 22 ZANAFLEX, 29 venetoclax, 22 ZANTAC, 37 VENTOLIN HFA, 43 ZANTAC 150, 37 verapamil, 25 ZANTAC 75, 11, 37 verapamil ext-rel, 25, 26 ZARONTIN, 27 VERELAN, 26 ZARXIO, 40 VFEND, 20 ZEGERID OTC, 38 VIBRAMYCIN, 19 ZEJULA, 10, 22 VICTOZA, 31 ZELBORAF, 10, 22 VIOKACE, 38 ZENPEP, 38 VIROPTIC, 48 ZESTORETIC, 23 vitamin ADC drops, 42 ZESTRIL, 23 vitamin ADC/fluoride drops, 42 ZETIA, 24 vitamin ADC/fluoride/iron drops, 42 ZIAC, 25 vitamin B complex/vitamin C/folic acid, 42 zinc acetate, 42 VITAMIN B-12, 41 ZITHROMAX, 19 VITAMIN B6, 42 ZOCOR, 24 VITAMIN D3, 41 ZOFRAN, 37 VIVELLE-DOT, 34 ZOLADEX, 10, 21 VOLTAREN, 17 zolmitriptan 2.5 mg, 5 mg, 11 vorapaxar, 40 zolmitriptan orally disintegrating tabs 2.5 mg, 5 mg, 11 voriconazole susp, tabs, 20 zolmitriptan tabs, 29 VYTORIN, 24 ZOMIG, 11, 29 W ZOMIG-ZMT, 11 warfarin, 39 ZONEGRAN, 28 WESTCORT, 46 zonisamide, 28 witch hazel medicated pads/wipes, 38 ZONTIVITY, 10, 40 ZOVIRAX, 20 X ZURAMPIC, 10, 17 XADAGO, 10, 28 ZYBAN, 30 XALATAN, 49 ZYDELIG, 10, 22 XALKORI, 10, 22 ZYLOPRIM, 17 XARELTO, 39 ZYRTEC, 42 XELJANZ, 10, 40 ZYRTEC-D, 43 XELJANZ XR, 10, 40 ZYVOX, 21 XELODA, 21

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