Preferred Drug List (PDL)

Rhode Island Effective Date: 8/1/2021

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 6:00 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 6:00 p.m.

CSRI15MC4116789_000 UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad o origen nacional. Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o origen nacional, puede enviar una queja a: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo. Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 6:00 p.m. Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos. Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro. Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 6:00 p.m.

UnitedHealthcare Community Plan List of Preferred Drugs

Frequently Asked Questions (FAQ) Find answers here to questions you have about this UnitedHealthcare Community Plan List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1 What drugs are on the Preferred Drug List? (We call the Preferred Drug List the “Drug List” for short.) The drugs on Preferred Drug List that starts on page <4> are the drugs covered by UnitedHealthcare Community Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

UnitedHealthcare will cover all medically necessary drugs if: · your doctor or other prescriber says you need them to get better or stay healthy, and · you fill the prescription at a UnitedHealthcare Community Plan network pharmacy. UnitedHealthcare may have additional steps to access certain drugs (see question <#5> below). You can also see an up-to-date drug list on our website at or call Member Services at <1-800-587-5187> TTY 711.

2 Does the Drug List ever change? Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: · a cheaper drug comes along that works as well as a drug on the Drug List now, or · we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: · Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Community Plan before you can get a drug.) · Add or change the amount of a drug you can get (called “quantity limits”).

9/28/2016 · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see pages <4, 5 and 9>. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check the up-to-date Drug List online at You can also call Member Services to check the current Drug List at <1-800-587-5187, TTY 711>.

3 What happens when another drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because another drug that works just as well is available, we will tell you. You will get a letter letting you know about the change. We will also tell you what alternate drugs are available to you. Contact your doctor or other prescriber to make sure another drug will work for you.

4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases your doctor must do something before you can get the drug. For example: · Prior approval (or prior authorization): For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. · Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug you can get. · Step therapy: Sometimes UnitedHealthcare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If

9/28/2016 your doctor thinks the first drug doesn’t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages <4-51>. You can also get more information by visiting our website at . We have posted online documents that explain our prior authorization and step therapy restrictions. You may also call Member Services and ask us to send you information about our prior authorization and step therapy restrictions.

6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The Preferred Drug List on pages <4-51> has a column labeled “Requirements and Limits.”

7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you before the restriction is added.. This gives you time to talk to your doctor or other prescriber about what to do next.

8 How can you find a drug on the Drug List? There are two ways to find a drug: · You can search by medical condition. To search by medical condition, find the section labeled “List of drugs by medical condition” on pages <4-51>. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. · You can also search for drugs alphabetically. To search alphabetically, go to the starting on page <52> Find the name of your drug. The page number where you can find the drug will be next to it.

9/28/2016 9 What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services and ask about it. If you learn that UnitedHealthcare does not prefer the drug, you can do one of these things: · Ask Member Services for a list of drugs that are similar to the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or · You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

10 What if you just joined UnitedHealthcare Community Plan and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to request an exception.

11Can you ask for an exception to cover your drug? Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to cover a drug that is not on the Drug List. Your doctor can also ask us to change the rules on your drug. · For example, we may limit the amount of a drug we will cover. If your drug has a limit, your doctor can ask us to change the limit and cover more. · Other examples: Your doctor can ask us to drop step therapy restrictions or prior approval requirements.

12 How long does it take to get an exception? First, we must receive some information from your doctor supporting your request for an exception. After we receive the information, we will give you a decision on your exception request within the timeframes required by the state, generally within 24 hours.

9/28/2016

13 How can you ask for an exception? To ask for an exception, you can do one of two things: - Call Member Services. A Member Services representative will work with you and your doctor to help ask for an exception. - Call your doctor and ask them to request an exception by calling the Prior Notification Service at <1-800-310-6826<, or they can fax a request to<866-940- 7328>.

14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). In most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand name drug is medically necessary, you will need to ask your doctor to submit for prior approval.

15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs are preferred.

16 Does UnitedHealthcare cover OTC non-drug products? UnitedHealthcare covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC non- drug products are covered.

17 What is a Specialty Pharmacy Medication? A specialty pharmacy medication is a drug that generally has one or more of the following characteristics:  It’s used by a small number of people  It treats rare, chronic, and/or potentially life-threatening diseases

9/28/2016  It has special storage or handling requirements such as needing to be refrigerated  It may need close monitoring, ongoing clinical support and management, and complete patient education and engagement  It’s a high cost medication  It may not be available at retail pharmacies  It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network. If you have questions, call Member Services at <1-800-587-5187, TTY 711>.

List of Preferred Drugs The List of Preferred Drugs that begins gives you information about the drugs covered by UnitedHealthcare Community Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page <52> . The first column of the chart lists the generic name of the drug. The second column of the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR). The third column in the list tells you if the preferred drug covered is the brand or generic version. The information in the “Requirements & Limits” column tells you if UnitedHealthcare has any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization) For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare Community Plan before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Community Plan limits the amount of a drug you can get. ST - Step therapy

9/28/2016 Sometimes UnitedHealthcare Community Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then your doctor can ask for approval to cover the second.

Other special requirements for coverage

SP – Specialty Pharmacy Drug needs to be accessed through a network Specialty Pharmacy. Specialty Pharmacy Drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.

Drug Tiers

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

[ABBREVIATIONS]

OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy

[You can find information on what the symbols and abbreviations in this table mean by going to page <4-51 in the footnotes>]

9/28/2016

9/28/2016 Table of Contents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions ...... 3 Anesthetics - Drugs for Numbing ...... 12 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence ...... 12 Antibacterials ...... 14 Antibacterials - Drugs to Treat Bacterial Infections ...... 14 Anticonvulsants - Drugs to Treat Seizures ...... 18 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia ...... 20 Antidepressants - Drugs to Treat Depression ...... 21 Antiemetics - Drugs to Treat Nausea and Vomiting ...... 22 Antifungals - Drugs to Treat Fungal Infections ...... 23 Antigout Agents - Drugs to Treat Gout ...... 25 Antimigraine Agents - Drugs to Treat Migraines...... 26 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis ...... 26 Antimycobacterials - Drugs to Treat Infections ...... 27 Antineoplastics - Drugs to Treat Cancer ...... 27 Antiparasitics - Drugs to Treat Parasitic Infections ...... 31 Antiparkinson Agents - Drugs to Treat Parkinson's Disease ...... 32 Antipsychotics - Drugs to Treat Mood Disorders ...... 33 Antivirals - Drugs to Treat Viral Infections ...... 35 Anxiolytics - Drugs to Treat Anxiety ...... 38 Bipolar Agents - Drugs to Treat Mood Disorders ...... 39 Blood Glucose Regulators - Drugs to Regulate Blood Sugar ...... 39 Blood Products and Modifiers ...... 42 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders ...... 42 Cardiovascular Agents ...... 44 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions ...... 44

1 Central Nervous System Agents ...... 49 Central Nervous System Agents - Drugs to Treat Nerve Conditions ...... 49 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions ...... 51 Dermatological Agents - Drugs to Treat Skin Conditions ...... 51 Electrolytes/Minerals/Metals/Vitamins ...... 57 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions ...... 70 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ...... 86 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions ...... 86 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones ...... 88 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones ...... 88 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones ...... 89 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones ...... 89 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones ...... 95 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones ...... 95 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones ...... 96 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones ...... 96 Immunological Agents - Drugs that Stimulate or Suppress the Immune System ...... 96 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease ...... 99 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions ...... 99 Metabolic Bone Disease Agents - Other ...... 100 Miscellaneous Therapeutic Agents ...... 100 Ophthalmic Agents - Drugs to Treat Eye Conditions ...... 104 Otic Agents - Drugs to Treat Ear Conditions ...... 110 Regulators - Drugs to Regulate Blood Sugar ...... 111 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions ...... 111 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm ...... 130 Sleep Disorder Agents - Drugs for Sedation and Sleep ...... 130 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies ...... 131 2 Preferred Agents Non-Preferred Agents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1 8 hour pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen childrens - Tier 1 acetaminophen childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1 acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml - Tier 1 acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 3 Preferred Agents Non-Preferred Agents acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1 acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1 acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1 apra (generic for MEDI-TABS CHILDRENS) - Tier 1 arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1 arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1 arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1 aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1 bac (generic for BAC) - Tier 1 betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1 butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1 butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1 butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1 butalbital-aspirin-caffeine - Tier 1 capsaicin external cream 0.025 % (generic for DERMACINRX PENETRAL) - Tier 1; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1 childrens apap (generic for MAPAP CHILDRENS) - Tier 1 childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1 childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1 childrens tactinal (generic for MAPAP CHILDRENS) - Tier 1 childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1 DERMACINRX PENETRAL (brand for capsaicin) - Tier 2; QL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1 EXCEDRIN EXTRA STRENGTH (brand for goodsense headache relief) - Tier 2 EXCEDRIN MIGRAINE (brand for goodsense headache relief) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1 fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1 feverall adults (generic for FEVERALL ADULTS) - Tier 1 feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1 FEVERALL JUNIOR STRENGTH - Tier 2 headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1 infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1 infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1 liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1 liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1 mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1 mapap childrens (generic for MAPAP CHILDRENS) - Tier 1 mapap oral capsule - Tier 1 migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1 m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1 non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1 non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1 non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1 non-aspirin oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL non-aspirin oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain & fever childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1 pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1 pain relief childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1 pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1 pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1 pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1 pain reliever extra strength (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain reliever oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL pain reliever oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 PANADOL CHILDRENS (brand for qc pain relief childrens) - Tier 2 PANADOL EXTRA STRENGTH (brand for eql acetaminophen ex st) - Tier 2 PANADOL INFANTS (brand for qc pain relief childrens) - Tier 2 PHARBETOL EXTRA STRENGTH (brand for eql acetaminophen ex st) - Tier 2 PHARBETOL ORAL TABLET 325 MG (brand for non-aspirin pain relief) - Tier 2; QL sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1 sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1 sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1 sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1; QL tactinal extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 TENCON (brand for butalbital-acetaminophen) - Tier 2 TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for qc pain relief childrens) - Tier 2 TYLENOL ORAL TABLET 325 MG (brand for non-aspirin pain relief) - Tier 2; QL TYLENOL ORAL TABLET 500 MG (brand for eql acetaminophen ex st) - Tier 2 TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for gnp acetaminophen) - Tier 2 TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for hm arthritis pain relief) - Tier 2

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents etodolac oral capsule - Tier 1; QL etodolac oral tablet (generic for LODINE) - Tier 1 h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ibu (generic for IBU) - Tier 1 ibu-200 (generic for ADDAPRIN) - Tier 1 ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS ADVIL) - Tier 1 ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ibuprofen oral capsule 200 mg (generic for ADVIL) - Tier 1 ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS ADVIL) - Tier 1; QL ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1 indomethacin oral capsule 25 mg, 50 mg - Tier 1 INFANTS ADVIL (brand for goodsense ibuprofen infants) - Tier 2 infants ibuprofen (generic for INFANTS ADVIL) - Tier 1 ketoprofen oral capsule 25 mg - Tier 1; QL ketoprofen oral capsule 50 mg, 75 mg - Tier 1 ketorolac tromethamine oral - Tier 1; QL mediproxen (generic for MEDIPROXEN) - Tier 1; QL meloxicam oral tablet (generic for MOBIC) - Tier 1; QL MOTRIN CHILDRENS (brand for ibuprofen) - Tier 2 MOTRIN IB (brand for ibuprofen) - Tier 2 MOTRIN INFANTS DROPS (brand for goodsense ibuprofen infants) - Tier 2 nabumetone oral tablet 500 mg (generic for RELAFEN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents nabumetone oral tablet 750 mg (generic for RELAFEN) - Tier 1; QL naproxen oral suspension (generic for NAPROSYN) - Tier 1; QL naproxen oral tablet - Tier 1 naproxen oral tablet delayed release (generic for EC-NAPROSYN) - Tier 1; QL naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier 1; QL oxaprozin (generic for DAYPRO) - Tier 1; QL piroxicam oral (generic for FELDENE) - Tier 1; QL provil (generic for ADDAPRIN) - Tier 1 salsalate oral - Tier 1 sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE (brand for ra aspirin adult low dose) - Tier 2 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE (brand for cvs aspirin low strength) - Tier 2; QL sulindac oral tablet 150 mg - Tier 1; QL sulindac oral tablet 200 mg - Tier 1

Opioid Analgesics, Long-acting - Opioid Pain Relievers buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 100 mcg/hr (generic for NUCYNTA ER - Tier 2; PA; QL DURAGESIC-100) - Tier 1; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr (generic for DURAGESIC- ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL 12) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr (generic for DURAGESIC- 25) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr (generic for DURAGESIC- 50) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 75 mcg/hr (generic for DURAGESIC- 75) - Tier 1; PA; QL hydrocodone bitartrate er oral capsule extended release 12 hour 10 mg, 20 mg (generic for ZOHYDRO ER) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents morphine sulfate er oral tablet extended release (generic for MS CONTIN) - Tier 1; PA; QL oxymorphone hcl er - Tier 1; PA; QL

Opioid Analgesics, Short-acting - Opioid Pain Relievers acetaminophen-codeine - Tier 1; QL apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA; acetaminophen-codeine #2 - Tier 1; QL QL acetaminophen-codeine #3 - Tier 1; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL acetaminophen-codeine #4 - Tier 1; QL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butorphanol tartrate nasal - Tier 1; QL codeine sulfate - Tier 1; QL endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg - Tier 1; QL hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL hydromorphone hcl rectal - Tier 1; QL morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier 1; QL morphine sulfate oral - Tier 1; QL morphine sulfate rectal - Tier 1; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL oxycodone hcl oral solution - Tier 1; QL oxycodone hcl oral tablet - Tier 1; QL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL oxycodone-aspirin - Tier 1; QL pentazocine-naloxone hcl - Tier 1; QL tramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents Anesthetics - Drugs for Numbing Local Anesthetics anecream external cream (generic for ANECREAM) - Tier 1 blue tube/ aloe (generic for ANECREAM) - Tier 1 glydo (generic for GLYDO) - Tier 1; QL lidocaine external cream 4 % (generic for ANECREAM) - Tier 1 lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; DX2RX; QL lidocaine hcl external cream 3 % - Tier 1; QL lidocaine hcl mouth/throat - Tier 1 lidocaine hcl urethral/mucosal - Tier 1; QL lidocaine viscous hcl - Tier 1; QL lidocaine-prilocaine external cream - Tier 1; QL lidopin external cream 3 % - Tier 1; QL LMX 4 (brand for blue tube/ aloe) - Tier 2

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium - Tier 1 disulfiram oral - Tier 1 naltrexone hcl oral - Tier 1

Opioid Dependence Treatments - Antidotes/Deterrents/Protectants buprenorphine hcl sublingual - Tier 1; DX2RX; QL BUNAVAIL - Tier 2; PA; QL buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 8-2 mg SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG (brand for (generic for SUBOXONE) - Tier 1; DX2RX; QL buprenorphine hcl-naloxone hcl) - Tier 2; PA; QL buprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1; QL SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 8-2 MG (brand for buprenorphine hcl-naloxone hcl) - Tier 2; DX2RX; QL ZUBSOLV - Tier 2; PA; QL

Opioid Reversal Agents - Antidotes/Deterrents/Protectants

Smoking Cessation Agents - Deterrents CHANTIX - Tier 2; PA; QL CHANTIX CONTINUING MONTH PAK - Tier 2; PA; QL CHANTIX STARTING MONTH PAK - Tier 2; PA; QL habitrol (generic for HABITROL) - Tier 1; QL mini nicotine (generic for KLS QUIT2) - Tier 1; QL NICODERM CQ (brand for nicotine) - Tier 2; QL NICORETTE (brand for cvs nicotine polacrilex) - Tier 2; QL NICORETTE MINI (brand for gnp nicotine polacrilex) - Tier 2; QL NICORETTE STARTER KIT (brand for cvs nicotine polacrilex) - Tier 2; QL nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mini (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL nicotine step 1 (generic for HABITROL) - Tier 1; QL nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 13 Preferred Agents Non-Preferred Agents nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; QL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; QL quit2 (generic for KLS QUIT2) - Tier 1; QL quit4 (generic for KLS QUIT4) - Tier 1; QL THRIVE (brand for cvs nicotine polacrilex) - Tier 2; QL

Antibacterials Antibacterials, Other methenamine hippurate (generic for HIPREX) - Tier 1; QL nitrofurantoin - Tier 1; Members >= 8 years of age will require PA; QL; AL nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg (generic for MACRODANTIN) - Tier 1 nitrofurantoin macrocrystal oral capsule 25 mg (generic for MACRODANTIN) - Tier 1; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - Tier 1

Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics gentamicin sulfate external - Tier 1; QL neomycin sulfate oral - Tier 1 paromomycin sulfate oral - Tier 1; QL

Antibacterials, Other - Antibiotics antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL CLEOCIN VAGINAL SUPPOSITORY - Tier 2; PA; QL antiseptic (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 CLINDESSE - Tier 2; PA; QL bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1 FLAGYL ORAL CAPSULE (brand for metronidazole) - Tier 2; PA; QL bacitracin external ointment 500 unit/gm - Tier 1; QL FLAGYL ORAL TABLET (brand for metronidazole) - Tier 2; PA bacitracin zinc external - Tier 1; QL METROGEL (brand for metronidazole) - Tier 2; PA; QL bacitracin zinc first aid - Tier 1; QL NORITATE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) - VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL Tier 1; QL XENLETA ORAL - Tier 2; PA; QL clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL double antibiotic (generic for POLYSPORIN) - Tier 1 first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg-unit (generic for NEOSPORIN ORIGINAL) - Tier 1; QL first aid antiseptic external solution 10 % (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 FIRVANQ (brand for vancomycin hcl) - Tier 2; DX2RX; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA; QL linezolid oral tablet (generic for ZYVOX) - Tier 1; PA medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL metronidazole external (generic for ROSADAN) - Tier 1; QL metronidazole oral tablet - Tier 1 metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL mupirocin external (generic for CENTANY) - Tier 1; QL NEOSPORIN ORIGINAL (brand for gnp triple antibiotic) - Tier 2; QL poly bacitracin (generic for POLYSPORIN) - Tier 1 POLYSPORIN (brand for sm double antibiotic) - Tier 2 povidone iodine (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 povidone-iodine external solution (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 rosadan external cream (generic for ROSADAN) - Tier 1; QL rosadan external gel (generic for ROSADAN) - Tier 1; QL SCRUB CARE POVIDONE-IODINE (brand for gnp povidone-iodine) - Tier 2 trimethoprim oral - Tier 1 triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1; QL vandazole (generic for VANDAZOLE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents Beta-Lactam, Cephalosporins - Antibiotics cefaclor - Tier 1 cefadroxil - Tier 1 cefdinir oral capsule - Tier 1 cefdinir oral suspension reconstituted - Tier 1; QL cefpodoxime proxetil oral tablet - Tier 1 cefprozil - Tier 1; QL cefuroxime axetil - Tier 1 cephalexin oral capsule 250 mg - Tier 1 cephalexin oral capsule 500 mg - Tier 1; QL cephalexin oral capsule 750 mg (generic for KEFLEX) - Tier 1; QL cephalexin oral suspension reconstituted 125 mg/5ml - Tier 1 cephalexin oral suspension reconstituted 250 mg/5ml - Tier 1; QL

Beta-Lactam, Penicillins - Antibiotics amoxicillin oral capsule - Tier 1 amoxicillin oral suspension reconstituted - Tier 1; QL amoxicillin oral tablet 875 mg - Tier 1; QL amoxicillin oral tablet chewable - Tier 1 amoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier 1; QL ampicillin - Tier 1; QL dicloxacillin sodium - Tier 1 penicillin v potassium - Tier 1

Macrolides - Antibiotics azithromycin oral suspension reconstituted (generic for ZITHROMAX) - Tier 1; QL azithromycin oral tablet - Tier 1; QL clarithromycin er - Tier 1; QL clarithromycin oral - Tier 1 DIFICID - Tier 2; PA; QL erythromycin base oral capsule delayed release particles - Tier 1 erythromycin base oral tablet 250 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents erythromycin base oral tablet 500 mg - Tier 1 erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QL

Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%) - MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QL Tier 2; QL VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%) - XEPI - Tier 2; PA; QL Tier 2 ciprofloxacin hcl oral tablet 100 mg - Tier 1; QL ciprofloxacin hcl oral tablet 250 mg, 500 mg (generic for CIPRO) - Tier 1 ciprofloxacin hcl oral tablet 750 mg - Tier 1 levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QL ofloxacin oral - Tier 1

Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1; QL ssd (generic for SSD) - Tier 1; QL sulfacetamide sodium ophthalmic ointment - Tier 1; QL sulfacetamide sodium ophthalmic solution (generic for BLEPH-10) - Tier 1 sulfamethoxazole-trimethoprim oral suspension (generic for SULFATRIM PEDIATRIC) - Tier 1; QL sulfamethoxazole-trimethoprim oral tablet (generic for BACTRIM) - Tier 1 sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL

Tetracyclines - Antibiotics doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; QL; ORACEA (brand for doxycycline) - Tier 2; PA AL SOLODYN (brand for minocycline hcl er) - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL doxycycline monohydrate oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents doxycycline monohydrate oral capsule 50 mg - Tier 1; QL minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1; AL minocycline hcl oral capsule 50 mg - Tier 1; AL mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL morgidox oral (generic for MORGIDOX) - Tier 1; QL; AL NUZYRA ORAL - Tier 2; PA; QL

Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other - Seizure Control Drugs levetiracetam oral solution (generic for KEPPRA) - Tier 1; Maximum age BRIVIACT ORAL - Tier 2; PA; QL of 9 years for solution; QL; AL XCOPRI - Tier 2; PA; QL levetiracetam oral tablet (generic for KEPPRA) - Tier 1; PA; QL XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & NAYZILAM - Tier 2; PA; QL 200 MG - Tier 2; PA; QL phenobarbital oral tablet - Tier 1; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL roweepra (generic for ROWEEPRA) - Tier 1; PA; QL

Calcium Channel Modifying Agents - Seizure Control Drugs CELONTIN - Tier 2; QL ethosuximide oral (generic for ZARONTIN) - Tier 1; QL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL

Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs clobazam (generic for ONFI) - Tier 1; DX2RX; QL SYMPAZAN - Tier 2; PA; QL diazepam rectal (generic for DIASTAT PEDIATRIC) - Tier 1; QL VALTOCO 10 MG DOSE - Tier 2; PA; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL VALTOCO 15 MG DOSE - Tier 2; PA; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL VALTOCO 20 MG DOSE - Tier 2; PA; QL phenobarbital oral elixir - Tier 1; QL VALTOCO 5 MG DOSE - Tier 2; PA; QL primidone oral (generic for MYSOLINE) - Tier 1; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; AL valproic acid oral capsule - Tier 1; QL; AL valproic acid oral solution - Tier 1; QL

Glutamate Reducing Agents - Seizure Control Drugs felbamate oral suspension (generic for FELBATOL) - Tier 1; Members FYCOMPA - Tier 2; PA; QL >= 8 years of age will require PA; QL; AL felbamate oral tablet (generic for FELBATOL) - Tier 1; QL lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; Members >= 8 years of age will require PA; QL; AL lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL subvenite (generic for SUBVENITE) - Tier 1; QL subvenite starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL subvenite starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier 1; Members >= 8 years of age will require PA; QL; AL topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL

Sodium Channel Agents - Seizure Control Drugs BANZEL ORAL TABLET - Tier 2; DX2RX; QL APTIOM - Tier 2; PA; QL carbamazepine er (generic for CARBATROL) - Tier 1; QL carbamazepine oral - Tier 1; QL DILANTIN ORAL CAPSULE 30 MG - Tier 2; QL epitol (generic for EPITOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 19 Preferred Agents Non-Preferred Agents oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; Maximum age of 9 years for solution; QL; AL oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; QL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL rufinamide (generic for BANZEL) - Tier 1; DX2RX; QL VIMPAT ORAL - Tier 2; PA; QL; AL

Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1; Members <18 years of age will require PA; QL; AL donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST; Members <18 years of age will require PA; QL; AL donepezil hcl oral tablet dispersible 10 mg - Tier 1; QL galantamine hydrobromide oral solution - Tier 1; QL; AL galantamine hydrobromide oral tablet 12 mg, 8 mg - Tier 1; QL; AL galantamine hydrobromide oral tablet 4 mg - Tier 1; Members <18 years of age will require PA; QL; AL rivastigmine (generic for EXELON) - Tier 1; Members <18 years of age will require PA; QL; AL rivastigmine tartrate - Tier 1; QL; AL

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl oral solution 2 mg/ml - Tier 1; QL memantine hcl oral tablet (generic for NAMENDA) - Tier 1; Members <18 years of age will require PA; QL; AL

Antidepressants - Drugs to Treat Depression Antidepressants, Other - Antidepressants bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg (generic for WELLBUTRIN XL) - Tier 1; QL bupropion hcl oral - Tier 1; QL mirtazapine oral tablet 15 mg, 30 mg (generic for REMERON) - Tier 1; Tabs (not soltabs); QL mirtazapine oral tablet 45 mg, 7.5 mg - Tier 1; QL perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50 mg - Tier 1 perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; QL

Monoamine Oxidase Inhibitors - Antidepressants tranylcypromine sulfate (generic for PARNATE) - Tier 1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide (generic for CELEXA) - Tier 1; QL CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 FETZIMA - Tier 2; PA; QL mg (generic for CYMBALTA) - Tier 1; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL trazodone hcl oral tablet 300 mg - Tier 1; PA; QL fluoxetine hcl oral capsule 10 mg, 20 mg (generic for PROZAC) - Tier 1; TRINTELLIX - Tier 2; PA; QL QL VIIBRYD - Tier 2; PA; QL fluoxetine hcl oral solution - Tier 1; QL fluvoxamine maleate - Tier 1; QL maprotiline hcl - Tier 1; QL nefazodone hcl - Tier 1; QL paroxetine hcl (generic for PAXIL) - Tier 1; QL sertraline hcl oral (generic for ZOLOFT) - Tier 1; QL trazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QL venlafaxine hcl - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents venlafaxine hcl er oral capsule extended release 24 hour (generic for EFFEXOR XR) - Tier 1; QL

Tricyclics - Antidepressants amitriptyline hcl oral - Tier 1 amoxapine oral tablet 100 mg, 25 mg, 50 mg - Tier 1 amoxapine oral tablet 150 mg - Tier 1; QL desipramine hcl oral (generic for NORPRAMIN) - Tier 1 doxepin hcl oral capsule 10 mg, 150 mg, 25 mg, 50 mg, 75 mg - Tier 1 doxepin hcl oral capsule 100 mg - Tier 1; QL doxepin hcl oral concentrate - Tier 1 imipramine hcl oral - Tier 1 nortriptyline hcl oral (generic for PAMELOR) - Tier 1

Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea - Tier 1 BONINE (brand for ra motion sickness relief) - Tier 2 compro (generic for COMPRO) - Tier 1 driminate (generic for DRIMINATE) - Tier 1 formula em - Tier 1 meclizine hcl oral tablet 12.5 mg - Tier 1 meclizine hcl oral tablet 25 mg (generic for TRAVEL-EASE) - Tier 1 meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 metoclopramide hcl oral solution - Tier 1 motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet chewable 25 mg (generic for BONINE) - Tier 1 motion-time (generic for BONINE) - Tier 1 nausea control - Tier 1 nausea relief - Tier 1 perphenazine oral tablet 16 mg, 2 mg - Tier 1

Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs aprepitant (generic for EMEND) - Tier 1; QL AKYNZEO ORAL - Tier 2; PA; QL dronabinol (generic for MARINOL) - Tier 1; PA; QL EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL ondansetron hcl oral (generic for ZOFRAN) - Tier 1; QL VARUBI (180 MG DOSE) - Tier 2; PA; QL ondansetron odt - Tier 1; QL

Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day (generic for MONISTAT 3) - Tier 1 DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 GYNAZOLE-1 - Tier 2; PA; QL 3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - Tier 1 af spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 ALOE VESTA CLEAR ANTIFUNGAL - Tier 2 antifungal external cream 2 % (generic for CAVILON) - Tier 1 antifungal foot care (generic for LAMISIL AT) - Tier 1; QL antifungal miconazole (generic for CAVILON) - Tier 1 atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL athletes foot external aerosol powder 2 % (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1; QL athletes foot powder spray (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot spray (generic for TINACTIN) - Tier 1 CAVILON (brand for miconazole antifungal) - Tier 2 ciclodan (generic for CICLODAN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents ciclopirox external solution (generic for CICLODAN) - Tier 1; QL ciclopirox olamine external suspension (generic for LOPROX) - Tier 1; QL clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1 clotrimazole external (generic for DESENEX) - Tier 1; QL clotrimazole mouth/throat - Tier 1 clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1 clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1 CRUEX PRESCRIPTION STRENGTH (brand for cvs athletes foot) - Tier 2 DESENEX JOCK ITCH (brand for cvs athletes foot) - Tier 2 fluconazole oral (generic for DIFLUCAN) - Tier 1; QL foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL griseofulvin microsize oral - Tier 1; QL griseofulvin ultramicrosize - Tier 1; QL GYNE-LOTRIMIN (brand for clotrimazole) - Tier 2 GYNE-LOTRIMIN 3 (brand for gnp clotrimazole 3) - Tier 2 itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; QL jock itch max st (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 ketoconazole external cream - Tier 1 ketoconazole external shampoo - Tier 1; QL ketoconazole oral - Tier 1 LAMISIL AT EXTERNAL CREAM (brand for qc athletes foot) - Tier 2; QL LAMISIL AT JOCK ITCH (brand for qc athletes foot) - Tier 2; QL micaderm (generic for CAVILON) - Tier 1 miconazole 3 - Tier 1; QL miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBO PACK APP) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents miconazole 3 combo pack app (generic for MONISTAT 3 COMBO PACK APP) - Tier 1; QL miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBINATION PACK) - Tier 1; QL miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal suppository 100 mg - Tier 1 miconazole antifungal (generic for CAVILON) - Tier 1 miconazole nitrate external (generic for CAVILON) - Tier 1 miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL nyamyc (generic for NYAMYC) - Tier 1; QL nystatin external cream - Tier 1 nystatin external ointment - Tier 1; QL nystatin external powder (generic for NYAMYC) - Tier 1; QL nystatin mouth/throat - Tier 1 nystatin oral - Tier 1; QL nystop (generic for NYAMYC) - Tier 1; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1; QL terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1; QL terconazole vaginal cream 0.4 % - Tier 1; QL terconazole vaginal cream 0.8 % - Tier 1 TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2 tinaspore (generic for BLIS-TO-SOL) - Tier 1 voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL

Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL COLCHICINE ORAL CAPSULE - Tier 2; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL

Antimigraine Agents - Drugs to Treat Migraines Ergot Alkaloids - Migraine Drugs dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1 ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL

Prophylactic - Migraine Drugs AIMOVIG - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; QL EMGALITY - Tier 2; PA; QL REYVOW - Tier 2; PA; QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL UBRELVY - Tier 2; PA; QL NURTEC - Tier 2; PA; QL

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs naratriptan hcl (generic for AMERGE) - Tier 1; ST; QL rizatriptan benzoate - Tier 1; QL sumatriptan nasal (generic for IMITREX) - Tier 1; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - Tier 1; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL

Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL

Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1 rifabutin (generic for MYCOBUTIN) - Tier 1; QL

Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL ethambutol hcl oral - Tier 1 isoniazid oral - Tier 1 PASER - Tier 2; QL PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1 rifampin oral - Tier 1 SIRTURO - Tier 2; QL

Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide oral capsule - Tier 1 CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 GLEOSTINE - Tier 2 LEUKERAN - Tier 2 MATULANE - Tier 2; SP; QL melphalan (generic for ALKERAN) - Tier 1 MYLERAN - Tier 2 temozolomide - Tier 1; PA; SP; QL

Antiandrogens - Hormone Suppressants abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL XTANDI ORAL CAPSULE - Tier 2; PA; SP; QL bicalutamide (generic for CASODEX) - Tier 1 YONSA - Tier 2; PA; SP; QL ERLEADA - Tier 2; PA; SP; QL ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL

Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL

Antiestrogens/Modifiers - Chemotherapy Agents tamoxifen citrate oral - Tier 1; QL toremifene citrate (generic for FARESTON) - Tier 1; QL

Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; SP; QL XELODA (brand for capecitabine) - Tier 2; PA; SP; QL DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2 DROXIA ORAL CAPSULE 400 MG - Tier 2; QL hydroxyurea oral (generic for HYDREA) - Tier 1 mercaptopurine oral - Tier 1; QL TABLOID - Tier 2; SP

Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg - Tier 1 KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL leucovorin calcium oral tablet 25 mg - Tier 1; QL KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL LONSURF - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL NINLARO - Tier 2; PA; SP; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL ROZLYTREK - Tier 2; PA; SP; QL VERZENIO - Tier 2; PA; SP; QL ZOLINZA - Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1; QL exemestane (generic for AROMASIN) - Tier 1; QL letrozole oral (generic for FEMARA) - Tier 1; QL

Enzyme Inhibitors - Chemotherapy Agents BALVERSA - Tier 2; PA; SP; QL etoposide oral - Tier 1 HYCAMTIN ORAL - Tier 2; PA; SP; QL RUBRACA - Tier 2; PA; SP; QL ZEJULA - Tier 2; PA; SP; QL

Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL AFINITOR ORAL TABLET 10 MG - Tier 2; PA; SP; QL ALECENSA - Tier 2; PA; SP; QL ALUNBRIG - Tier 2; PA; SP; QL BOSULIF - Tier 2; PA; SP; QL BRUKINSA - Tier 2; PA; SP; QL CABOMETYX - Tier 2; PA; SP; QL CALQUENCE - Tier 2; PA; SP; QL CAPRELSA - Tier 2; PA; SP; QL COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL COTELLIC - Tier 2; PA; SP; QL DAURISMO - Tier 2; PA; SP; QL ERIVEDGE - Tier 2; PA; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP; QL FARYDAK - Tier 2; PA; SP; QL

Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL PANRETIN - Tier 2; PA TARGRETIN EXTERNAL - Tier 2; PA; SP; QL tretinoin oral - Tier 1; SP; QL

Treatment Adjuncts - Supportive Chemotherapy Drugs MESNEX ORAL - Tier 2; SP; QL

Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; DX2RX; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL

Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; QL; AL ARAKODA - Tier 2; PA; QL atovaquone oral (generic for MEPRON) - Tier 1; PA; QL BENZNIDAZOLE - Tier 2; DX2RX; QL chloroquine phosphate oral - Tier 1; QL hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; QL IMPAVIDO - Tier 2; PA; QL KRINTAFEL - Tier 2; QL mefloquine hcl - Tier 1; QL nitazoxanide (generic for ALINIA) - Tier 1; DX2RX; QL pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1 primaquine phosphate - Tier 1 pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Pediculicides/Scabicides - Scabies and Lice Drugs crotan - Tier 1; QL lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice treatment - Tier 1 lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1 lice treatment external shampoo 0.33-4 % (generic for RID LICE KILLING SHAMPOO) - Tier 1 malathion (generic for OVIDE) - Tier 1; QL permethrin external (generic for ELIMITE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for hm lice killing max st) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 spinosad (generic for NATROBA) - Tier 1; QL

Antiparkinson Agents - Drugs to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease Drugs benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL

Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral capsule - Tier 1; QL amantadine hcl oral syrup - Tier 1; QL entacapone (generic for COMTAN) - Tier 1; QL tolcapone (generic for TASMAR) - Tier 1; QL

Dopamine Agonists - Parkinson's Disease Drugs

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa er - Tier 1; QL carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs selegiline hcl oral - Tier 1; QL

Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs chlorpromazine hcl oral tablet 10 mg, 100 mg, 50 mg - Tier 1 chlorpromazine hcl oral tablet 200 mg, 25 mg - Tier 1; QL fluphenazine decanoate injection - Tier 1; QL fluphenazine hcl injection - Tier 1 fluphenazine hcl oral concentrate - Tier 1 fluphenazine hcl oral elixir - Tier 1 fluphenazine hcl oral tablet 1 mg - Tier 1 fluphenazine hcl oral tablet 10 mg, 2.5 mg, 5 mg - Tier 1; QL haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; QL haloperidol oral - Tier 1 loxapine succinate - Tier 1 pimozide - Tier 1; QL; AL prochlorperazine maleate oral - Tier 1 thioridazine hcl oral - Tier 1; QL thiothixene oral capsule 1 mg, 2 mg - Tier 1 thiothixene oral capsule 10 mg, 5 mg - Tier 1; QL trifluoperazine hcl - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY MAINTENA - Tier 2; PA; QL; AL ABILIFY (brand for aripiprazole) - Tier 2; PA; QL; AL aripiprazole oral tablet (generic for ABILIFY) - Tier 1; QL; AL aripiprazole oral solution - Tier 1; PA; QL; AL ARISTADA - Tier 2; PA; QL; AL aripiprazole oral tablet dispersible - Tier 1; PA; QL; AL INVEGA SUSTENNA - Tier 2; PA; QL; AL ARISTADA INITIO - Tier 2; PA; QL; AL INVEGA TRINZA - Tier 2; PA; QL; AL FANAPT - Tier 2; PA; QL; AL olanzapine oral tablet (generic for ZYPREXA) - Tier 1; QL; AL GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; QL; AL PERSERIS - Tier 2; PA; QL; AL INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, quetiapine fumarate (generic for SEROQUEL) - Tier 1; QL; AL 9 MG (brand for paliperidone er) - Tier 2; PA; AL RISPERDAL CONSTA - Tier 2; PA; QL; AL INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 6 MG (brand for risperidone oral solution (generic for RISPERDAL) - Tier 1; Members >= paliperidone er) - Tier 2; PA; QL; AL 8 years of age will require PA; QL; AL LATUDA - Tier 2; PA; QL; AL risperidone oral tablet (generic for RISPERDAL) - Tier 1; QL; AL olanzapine oral tablet dispersible 10 mg, 20 mg (generic for ZYPREXA ziprasidone hcl (generic for GEODON) - Tier 1; QL; AL ZYDIS) - Tier 1; PA; QL; AL olanzapine oral tablet dispersible 15 mg, 5 mg (generic for ZYPREXA ZYDIS) - Tier 1; PA; AL paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg (generic for INVEGA) - Tier 1; PA; AL paliperidone er oral tablet extended release 24 hour 6 mg (generic for INVEGA) - Tier 1; PA; QL; AL quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA; QL; AL REXULTI - Tier 2; PA; QL; AL RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA; Members >= 8 years of age will require PA; QL; AL RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; PA; QL; AL risperidone oral tablet dispersible - Tier 1; PA; QL; AL SAPHRIS (brand for asenapine maleate) - Tier 2; PA; QL; AL SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; QL; AL SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL; AL VRAYLAR - Tier 2; PA; QL; AL ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; QL; AL ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 20 MG (brand for olanzapine) - Tier 2; PA; QL; AL ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 15 MG, 5 MG (brand for olanzapine) - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents Treatment-Resistant - Mood Disorder Drugs clozapine oral tablet 100 mg, 25 mg (generic for CLOZARIL) - Tier 1; CLOZARIL ORAL TABLET 100 MG, 25 MG (brand for clozapine) - Tier 2; QL; AL PA; QL; AL clozapine oral tablet 50 mg (generic for CLOZARIL) - Tier 1; AL CLOZARIL ORAL TABLET 200 MG (brand for clozapine) - Tier 2; PA; QL; AL CLOZARIL ORAL TABLET 50 MG (brand for clozapine) - Tier 2; PA; AL

Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL

Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs BARACLUDE ORAL SOLUTION - Tier 2; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; QL

Anti-hepatitis C (HCV) Agents, Direct Acting Agents - Hepatitis C Drugs MAVYRET - Tier 2; PA; SP; QL; *If RI PAR prescriber, PA does not EPCLUSA (brand for sofosbuvir-velpatasvir) - Tier 2; PA; SP; QL apply HARVONI (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL VOSEVI - Tier 2; PA; SP; QL; *If RI PAR prescriber, ST LEDIPASVIR-SOFOSBUVIR - Tier 2; PA; SP; QL SOFOSBUVIR-VELPATASVIR - Tier 2; PA; SP; QL SOVALDI - Tier 2; PA; SP; QL VIEKIRA PAK - Tier 2; PA; SP; QL ZEPATIER - Tier 2; PA; SP; QL

Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP; QL PEGASYS - Tier 2; PA; SP; QL

Antiherpetic Agents - Herpes Drugs ABREVA (brand for docosanol) - Tier 2; QL acyclovir oral - Tier 1; QL docosanol external (generic for ABREVA) - Tier 1; QL trifluridine - Tier 1; QL valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs DOVATO - Tier 2; QL GENVOYA - Tier 2; PA; QL ISENTRESS HD - Tier 2; QL ISENTRESS ORAL PACKET - Tier 2; Members >= 2 years of age will require PA; QL; AL ISENTRESS ORAL TABLET - Tier 2; QL ISENTRESS ORAL TABLET CHEWABLE - Tier 2; QL STRIBILD - Tier 2; PA; QL TIVICAY - Tier 2; QL TIVICAY PD - Tier 2; QL; AL TRIUMEQ - Tier 2; QL TYBOST - Tier 2; QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs COMPLERA - Tier 2; PA; QL ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; PA; QL DELSTRIGO - Tier 2; QL SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL EDURANT - Tier 2; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL efavirenz (generic for SUSTIVA) - Tier 1; QL efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; QL INTELENCE - Tier 2; QL JULUCA - Tier 2; QL nevirapine - Tier 1; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs abacavir sulfate (generic for ZIAGEN) - Tier 1; QL CIMDUO - Tier 2; PA; QL abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; QL BIKTARVY - Tier 2; PA; QL emtricitabine (generic for EMTRIVA) - Tier 1; QL emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL EMTRIVA ORAL SOLUTION - Tier 2; QL lamivudine oral solution (generic for EPIVIR) - Tier 1; QL lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; QL lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; QL stavudine - Tier 1; QL TEMIXYS - Tier 2; QL tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL VIREAD ORAL POWDER - Tier 2; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; QL zidovudine (generic for RETROVIR) - Tier 1; QL

Anti-HIV Agents, Other - HIV Drugs FUZEON - Tier 2; QL SELZENTRY - Tier 2; QL

Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS - Tier 2; QL KALETRA ORAL SOLUTION (brand for lopinavir-ritonavir) - Tier 2; PA; QL atazanavir sulfate (generic for REYATAZ) - Tier 1; QL REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA; QL CRIXIVAN - Tier 2; QL SYMTUZA - Tier 2; PA; QL EVOTAZ - Tier 2; QL fosamprenavir calcium (generic for LEXIVA) - Tier 1; QL INVIRASE - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents KALETRA ORAL TABLET - Tier 2; QL LEXIVA ORAL SUSPENSION - Tier 2; QL lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL NORVIR ORAL PACKET - Tier 2; QL NORVIR ORAL SOLUTION - Tier 2; QL PREZCOBIX - Tier 2; QL PREZISTA - Tier 2; QL REYATAZ ORAL PACKET - Tier 2; Members >= 8 years of age will require PA; QL; AL ritonavir (generic for NORVIR) - Tier 1; QL VIRACEPT - Tier 2; QL

Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA; oseltamivir phosphate oral suspension reconstituted (generic for QL TAMIFLU) - Tier 1; QL; AL TAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir RELENZA DISKHALER - Tier 2; QL phosphate) - Tier 2; PA; QL; AL rimantadine hcl - Tier 1 XOFLUZA (40 MG DOSE) - Tier 2; PA; QL XOFLUZA (80 MG DOSE) - Tier 2; PA; QL

Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs buspirone hcl oral - Tier 1 hydroxyzine hcl oral syrup - Tier 1; QL hydroxyzine hcl oral tablet 10 mg, 25 mg - Tier 1; QL hydroxyzine hcl oral tablet 50 mg - Tier 1

Benzodiazepines - Anxiety Drugs alprazolam oral tablet (generic for XANAX) - Tier 1; QL chlordiazepoxide hcl - Tier 1 clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL clorazepate dipotassium oral tablet 15 mg - Tier 1 clorazepate dipotassium oral tablet 3.75 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents clorazepate dipotassium oral tablet 7.5 mg (generic for TRANXENE-T) - Tier 1; QL diazepam oral solution - Tier 1; QL diazepam oral tablet (generic for VALIUM) - Tier 1; QL lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1 lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM INTENSOL) - Tier 1 lorazepam oral tablet (generic for ATIVAN) - Tier 1 oxazepam - Tier 1 triazolam - Tier 1

Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs divalproex sodium oral capsule delayed release sprinkle (generic for DEPAKOTE SPRINKLES) - Tier 1; Members >= 8 years of age will require PA; QL; AL divalproex sodium oral tablet delayed release (generic for DEPAKOTE) - Tier 1; Minimum age of 2 years; QL; AL lithium - Tier 1; QL lithium carbonate er oral tablet extended release 300 mg (generic for LITHOBID) - Tier 1; QL lithium carbonate er oral tablet extended release 450 mg - Tier 1 lithium carbonate oral - Tier 1

Blood Glucose Regulators - Drugs to Regulate Blood Sugar Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL ADLYXIN - Tier 2; PA; QL BYETTA 10 MCG PEN - Tier 2; PA; QL ADLYXIN STARTER PACK - Tier 2; PA; QL BYETTA 5 MCG PEN - Tier 2; PA; QL ALOGLIPTIN BENZOATE - Tier 2; ST; QL GLYXAMBI - Tier 2; PA; QL ALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QL INVOKAMET - Tier 2; PA; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QL INVOKAMET XR - Tier 2; PA; QL FARXIGA - Tier 2; PA; QL INVOKANA - Tier 2; PA; QL

Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; PA; QL BAQSIMI TWO PACK - Tier 2; QL GLUCAGEN HYPOKIT - Tier 2; QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - Tier 2; QL glucagon emergency kit 1 mg injection - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1 GVOKE HYPOPEN 1-PACK - Tier 2; QL GVOKE HYPOPEN 2-PACK - Tier 2; QL GVOKE PFS - Tier 2; QL soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1

Insulins - Diabetic Drugs ADMELOG (brand for insulin lispro) - Tier 2; QL AFREZZA - Tier 2; PA; QL ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; APIDRA SOLOSTAR - Tier 2; PA; QL PA; QL APIDRA VIAL - Tier 2; PA; QL BASAGLAR KWIKPEN - Tier 2; QL FIASP - Tier 2; PA; QL HUMALOG MIX 50/50 - Tier 2; QL FIASP FLEXTOUCH - Tier 2; PA; QL HUMALOG MIX 75/25 - Tier 2; QL HUMALOG (brand for insulin lispro) - Tier 2; PA; QL HUMULIN 70/30 VIAL - Tier 2; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - HUMULIN N VIAL - Tier 2; QL Tier 2; PA; QL HUMULIN R VIAL - Tier 2; QL HUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QL INSULIN ASPART PROT & ASPART - Tier 2; QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL NOVOLIN 70/30 RELION - Tier 2; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - NOVOLIN 70/30 VIAL - Tier 2; QL Tier 2; PA; QL NOVOLIN N RELION - Tier 2; QL HUMULIN 70/30 KWIKPEN - Tier 2; PA; QL NOVOLIN N VIAL - Tier 2; QL HUMULIN N KWIKPEN - Tier 2; PA; QL NOVOLIN R RELION - Tier 2; QL HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL NOVOLIN R VIAL - Tier 2; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL SEMGLEE - Tier 2; QL INSULIN ASP PROT & ASP FLEXPEN - Tier 2; PA; QL INSULIN ASPART - Tier 2; PA; QL INSULIN LISPRO - Tier 2; PA; QL INSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QL LANTUS SOLOSTAR - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; PA; QL LEVEMIR U-100 FLEXTOUCH - Tier 2; PA; QL LEVEMIR U-100 VIAL - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL NOVOLIN N FLEXPEN - Tier 2; PA; QL NOVOLIN R FLEXPEN - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; PA; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL TOUJEO SOLOSTAR - Tier 2; PA; QL TRESIBA - Tier 2; PA; QL TRESIBA FLEXTOUCH - Tier 2; PA; QL

Blood Products and Modifiers Blood Products and Modifiers, Other NYVEPRIA - Tier 2; PA; SP

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2; DX2RX; QL PRADAXA - Tier 2; PA; QL ELIQUIS DVT/PE STARTER PACK - Tier 2; DX2RX; QL XARELTO - Tier 2; PA; QL enoxaparin sodium (generic for LOVENOX) - Tier 1; QL XARELTO STARTER PACK - Tier 2; PA; QL heparin sodium (porcine) injection solution 1000 unit/ml - Tier 1; SP; QL heparin sodium (porcine) injection solution 10000 unit/ml, 20000 unit/ml, 5000 unit/ml - Tier 1; QL heparin sodium (porcine) injection solution prefilled syringe - Tier 1; QL heparin sodium (porcine) pf injection solution 5000 unit/0.5ml - Tier 1; QL heparin sodium (porcine) pf injection solution 5000 unit/ml - Tier 1; SP; QL jantoven oral tablet 1 mg, 10 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg (generic for JANTOVEN) - Tier 1 jantoven oral tablet 2.5 mg (generic for JANTOVEN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents SAVAYSA - Tier 2; DX2RX; QL warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg (generic for JANTOVEN) - Tier 1 warfarin sodium oral tablet 2.5 mg (generic for JANTOVEN) - Tier 1; QL

Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 DOPTELET - Tier 2; PA; SP; QL ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL EPOGEN - Tier 2; PA; SP; QL LEUKINE - Tier 2; PA; SP; QL FULPHILA - Tier 2; PA; SP; QL MOZOBIL - Tier 2; PA; SP; QL GRANIX - Tier 2; PA; SP; QL MULPLETA - Tier 2; PA; SP; QL MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 NEULASTA - Tier 2; PA; SP; QL MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2; NEULASTA ONPRO - Tier 2; PA; SP; QL PA; QL PROMACTA ORAL PACKET 25 MG - Tier 2 NEUPOGEN - Tier 2; PA; SP; QL PROMACTA ORAL TABLET - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, PROCRIT - Tier 2; PA; SP; QL 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP; QL UDENYCA - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP ZIEXTENZO - Tier 2; PA; SP ZARXIO - Tier 2; PA; SP; QL

Hemostasis Agents - Drugs to Stop Bleeding aminocaproic acid oral (generic for AMICAR) - Tier 1; QL HEMLIBRA - Tier 2; PA; SP; QL tranexamic acid oral (generic for LYSTEDA) - Tier 1; DX2RX; QL

Platelet Modifying Agents - Platelet Modifying Drugs CABLIVI - Tier 2; PA; SP; QL cilostazol - Tier 1; QL clopidogrel bisulfate oral tablet 300 mg - Tier 1 clopidogrel bisulfate oral tablet 75 mg (generic for PLAVIX) - Tier 1; QL dipyridamole oral - Tier 1; QL prasugrel hcl (generic for EFFIENT) - Tier 1; DX2RX; QL

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs clonidine hcl oral - Tier 1; QL guanfacine hcl - Tier 1; QL methyldopa - Tier 1; QL midodrine hcl - Tier 1

Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL

Angiotensin II Receptor Antagonists - Blood Pressure Drugs losartan potassium oral (generic for COZAAR) - Tier 1; QL EDARBI - Tier 2; PA; QL

Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL captopril oral - Tier 1; QL enalapril maleate oral (generic for VASOTEC) - Tier 1; QL EPANED - Tier 2; QL; AL fosinopril sodium - Tier 1; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL ramipril (generic for ALTACE) - Tier 1; QL trandolapril - Tier 1; QL

Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL disopyramide phosphate (generic for NORPACE) - Tier 1; QL MULTAQ - Tier 2; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL flecainide acetate - Tier 1; QL NORPACE CR - Tier 2; PA; QL mexiletine hcl oral - Tier 1; QL PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL propafenone hcl - Tier 1; QL RYTHMOL SR (brand for propafenone hcl er) - Tier 2; PA; QL quinidine gluconate er - Tier 1; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL quinidine sulfate - Tier 1; QL sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

Beta-adrenergic Blocking Agents - Blood Pressure Drugs acebutolol hcl oral - Tier 1; QL HEMANGEOL - Tier 2; PA; QL atenolol oral (generic for TENORMIN) - Tier 1; QL betaxolol hcl oral - Tier 1; QL bisoprolol fumarate oral - Tier 1; QL carvedilol (generic for COREG) - Tier 1; QL labetalol hcl oral - Tier 1; QL metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL metoprolol tartrate oral tablet 100 mg, 50 mg (generic for LOPRESSOR) - Tier 1; QL metoprolol tartrate oral tablet 25 mg - Tier 1; QL propranolol hcl er (generic for INDERAL LA) - Tier 1; DX2RX; QL propranolol hcl oral - Tier 1; QL

Calcium Channel Blocking Agents - Blood Pressure Drugs amlodipine besylate oral (generic for NORVASC) - Tier 1; QL cartia xt (generic for CARTIA XT) - Tier 1; QL diltiazem hcl er - Tier 1; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents diltiazem hcl er coated beads (generic for CARTIA XT) - Tier 1; QL diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL dilt-xr - Tier 1; QL felodipine er - Tier 1; QL matzim la (generic for MATZIM LA) - Tier 1; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; QL nifedipine oral (generic for PROCARDIA) - Tier 1; QL nimodipine oral - Tier 1; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL verapamil hcl er (generic for CALAN SR) - Tier 1; QL verapamil hcl oral - Tier 1; QL

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL BIDIL - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL CORLANOR - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL captopril-hydrochlorothiazide - Tier 1; QL digitek (generic for DIGITEK) - Tier 1; QL digox (generic for DIGITEK) - Tier 1; QL digoxin oral (generic for DIGITEK) - Tier 1; QL enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL ENTRESTO - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL methyldopa-hydrochlorothiazide - Tier 1; QL pentoxifylline er - Tier 1; QL propranolol-hctz - Tier 1; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL ranolazine er (generic for RANEXA) - Tier 1; ST; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL

Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral - Tier 1; QL

Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1; QL furosemide oral solution 10 mg/ml - Tier 1; QL furosemide oral tablet (generic for LASIX) - Tier 1; QL torsemide - Tier 1; QL

Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL

Diuretics, Thiazide - Cardiac Drugs chlorthalidone - Tier 1; QL hydrochlorothiazide oral - Tier 1; QL indapamide - Tier 1; QL metolazone - Tier 1; QL

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral tablet 160 mg, 54 mg - Tier 1; ST; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light oral powder (generic for PREVALITE) - Tier 1; QL NEXLETOL - Tier 2; PA; QL cholestyramine oral powder (generic for QUESTRAN) - Tier 1; Only the PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL bulk products are covered (cans) Individual packets are not covered; QL ezetimibe (generic for ZETIA) - Tier 1; PA; QL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QL niacor (generic for NIACOR) - Tier 1; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL prevalite oral powder (generic for PREVALITE) - Tier 1; QL REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/PA; SP; QL

Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg - Tier 1; QL isosorbide dinitrate oral tablet 5 mg (generic for ISORDIL TITRADOSE) - Tier 1; QL isosorbide mononitrate - Tier 1; QL isosorbide mononitrate er - Tier 1; QL minitran (generic for MINITRAN) - Tier 1; QL NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (brand for nitroglycerin) - Tier 2; QL nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1

Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL

Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA; SP; QL KESIMPTA - Tier 2; PA; SP; QL

Central Nervous System Agents - Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; ADZENYS XR-ODT - Tier 2; PA; QL; AL DX2RX; QL; AL DYANAVEL XR - Tier 2; PA; QL; AL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - Tier EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL; AL 1; DX2RX; QL; AL EVEKEO ODT - Tier 2; PA; QL; AL MYDAYIS - Tier 2; PA; QL; AL VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 60 MG, 70 MG - Tier 2; PA; QL; AL VYVANSE ORAL CAPSULE 50 MG - Tier 2; PA; AL VYVANSE ORAL TABLET CHEWABLE - Tier 2; PA; QL; AL ZENZEDI - Tier 2; PA; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; QL; AL APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; PA; QL; AL guanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; QL; AL CONCERTA (brand for methylphenidate hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er (cd) - Tier 1; DX2RX; QL; AL COTEMPLA XR-ODT - Tier 2; PA; QL; AL methylphenidate hcl er (la) oral capsule extended release 24 hour 20 DAYTRANA - Tier 2; PA; QL; AL mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX; QL; AL FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents methylphenidate hcl er oral tablet extended release 10 mg, 20 mg - Tier JORNAY PM - Tier 2; PA; QL; AL 1; DX2RX; QL; AL KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 METHYLIN (brand for methylphenidate hcl) - Tier 2; PA; QL; AL mg, 54 mg (generic for CONCERTA) - Tier 1; QL; AL RITALIN (brand for methylphenidate hcl) - Tier 2; DX2RX; QL; AL methylphenidate hcl er oral tablet extended release 24 hour - Tier 1; STRATTERA (brand for atomoxetine hcl) - Tier 2; DX2RX; QL; AL DX2RX; Mallinckrodt and Kremers Urban labelers; QL; AL methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX; QL; AL

Central Nervous System, Other - Miscellaneous Central Nervous System Drugs AUSTEDO - Tier 2; PA; SP; QL caffeine citrate oral - Tier 1; QL; AL INGREZZA ORAL CAPSULE 40 MG, 80 MG - Tier 2; PA; SP; QL INGREZZA ORAL CAPSULE THERAPY PACK - Tier 2; PA; SP; QL riluzole (generic for RILUTEK) - Tier 1; QL tetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; QL

Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain pregabalin oral (generic for LYRICA) - Tier 1; QL

Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO - Tier 2; DX2RX; SP; QL AVONEX PEN - Tier 2; PA; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; DX2RX; SP; AVONEX PREFILLED - Tier 2; PA; SP; QL QL BETASERON - Tier 2; PA; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; COPAXONE (brand for glatiramer acetate) - Tier 2; DX2RX; SP; QL DX2RX; SP; QL EXTAVIA - Tier 2; PA; SP; QL GILENYA - Tier 2; DX2RX; SP; QL MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL glatiramer acetate (generic for GLATOPA) - Tier 1; DX2RX; SP; QL MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL glatopa (generic for GLATOPA) - Tier 1; DX2RX; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; DX2RX; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL PLEGRIDY SUBCUTANEOUS - Tier 2; DX2RX; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 50 Preferred Agents Non-Preferred Agents MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL REBIF - Tier 2; PA; SP; QL REBIF REBIDOSE - Tier 2; PA; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; PA; SP; QL TECFIDERA (brand for dimethyl fumarate) - Tier 2; DX2RX; SP; QL VUMERITY - Tier 2; PA; SP; QL

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier 1; QL DENTA 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL DENTAGEL (brand for sf) - Tier 2 easygel - Tier 1 fluoridex daily renewal - Tier 1 oralone (generic for ORALONE) - Tier 1; QL periogard (generic for PERIOGARD) - Tier 1; QL pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2 PREVIDENT 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL PREVIDENT DENTAL (brand for sf) - Tier 2 sf (generic for CAVAREST) - Tier 1 sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental gel (generic for CAVAREST) - Tier 1 triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL

Dermatological Agents - Drugs to Treat Skin Conditions

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents accutane (generic for ACCUTANE) - Tier 1; PA; QL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL acitretin (generic for SORIATANE) - Tier 1; PA; QL ABSORICA LD - Tier 2; PA; QL acne (generic for CLEARSKIN) - Tier 1 ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL acne control cleanser (generic for CLEARSKIN) - Tier 1 ACZONE EXTERNAL GEL 7.5 % (brand for dapsone) - Tier 2; PA; QL acne medication 10 external lotion - Tier 1; QL ALDARA (brand for imiquimod) - Tier 2; PA; QL acne medication 5 external lotion - Tier 1 AMZEEQ - Tier 2; PA; QL acne treatment external cream 10 % (generic for CLEARSKIN) - Tier 1 ATRALIN (brand for tretinoin) - Tier 2; PA; QL; AL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL WASH) - Tier 1 BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - advanced acne spot treat (generic for CLEAN & CLEAR ACNE SCRUB) Tier 2; PA; QL - Tier 1 BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL advanced healing external ointment (generic for FLANDERS CARAC (brand for fluorouracil) - Tier 2; PA; QL BUTTOCKS) - Tier 1 CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL alclometasone dipropionate external ointment - Tier 1; QL DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL amcinonide external ointment - Tier 1 DIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QL ammonium lactate external (generic for AL12) - Tier 1; QL DIFFERIN EXTERNAL LOTION - Tier 2; PA; QL amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL DOVONEX (brand for calcipotriene) - Tier 2; PA; ST; QL arthritis pain relieving - Tier 1; QL DUPIXENT - Tier 2; PA; SP; QL astringent solution (generic for DOMEBORO) - Tier 1 EFUDEX (brand for fluorouracil) - Tier 2; PA; QL AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2 ELIDEL (brand for pimecrolimus) - Tier 2; PA; ST; Minimum age of 2 years; AVAR-E GREEN (brand for sss 10-5) - Tier 2 QL; AL AVITA EXTERNAL CREAM (brand for tretinoin) - Tier 2; ST; QL; AL ENSTILAR - Tier 2; PA; QL azelaic acid external (generic for FINACEA) - Tier 1; QL EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - EPIDUO FORTE - Tier 2; PA; QL Tier 1; QL EUCRISA - Tier 2; PA; QL beauty 360 pure glycerin - Tier 1 FABIOR (brand for tazarotene) - Tier 2; PA; QL BENZAC AC WASH (brand for bp wash) - Tier 2; QL FINACEA (brand for azelaic acid) - Tier 2; PA; QL betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier 1; LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL QL MIRVASO - Tier 2; PA; QL betamethasone dipropionate external lotion - Tier 1 OLUX (brand for clobetasol propionate) - Tier 2; PA; QL betamethasone dipropionate external ointment - Tier 1; QL OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL betamethasone valerate external cream - Tier 1; QL ONEXTON - Tier 2; PA; QL betamethasone valerate external lotion - Tier 1 PROTOPIC EXTERNAL OINTMENT 0.03 % (brand for tacrolimus) - Tier 2; betamethasone valerate external ointment - Tier 1; QL PA; ST; Minimum age of 2 years; QL; AL BETASEPT SURGICAL SCRUB - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents boro-packs (generic for DOMEBORO) - Tier 1 PROTOPIC EXTERNAL OINTMENT 0.1 % (brand for tacrolimus) - Tier 2; BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % (brand for PA; ST; Minimum age of 16 years; QL; AL zinc oxide) - Tier 2; QL QBREXZA - Tier 2; PA; QL bp 10-1 - Tier 1 RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL; AL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL; AL calamine external lotion , 8-8 % - Tier 1 RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere calamine-zinc oxide external lotion - Tier 1 pump) - Tier 2; PA; QL; AL calcipotriene external cream (generic for DOVONEX) - Tier 1; ST; QL RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; AL calcipotriene external ointment (generic for CALCITRENE) - Tier 1; ST; RHOFADE - Tier 2; PA; QL QL SERNIVO - Tier 2; PA; QL calcipotriene external solution - Tier 1; QL SILIQ - Tier 2; PA; SP; QL calcitriol external (generic for VECTICAL) - Tier 1; ST; QL SOOLANTRA - Tier 2; PA; QL capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; QL SORILUX (brand for calcipotriene) - Tier 2; PA; QL capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL capzix (generic for ZOSTRIX HP) - Tier 1; QL TALTZ - Tier 2; PA; SP; QL cerovel (generic for CEROVEL) - Tier 1; QL TAZORAC EXTERNAL CREAM - Tier 2; PA; QL; AL claravis (generic for AMNESTEEM) - Tier 1; PA; QL TAZORAC EXTERNAL GEL 0.1 % - Tier 2; PA; QL; AL clearskin (generic for CLEARSKIN) - Tier 1 TEMOVATE EXTERNAL CREAM (brand for clobetasol propionate) - Tier 2; clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL PA; QL; AL clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL TEMOVATE EXTERNAL OINTMENT (brand for clobetasol propionate) - clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; Tier 2; PA; QL QL TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL clindamycin phosphate external solution - Tier 1; QL TREMFYA - Tier 2; PA; SP; QL clindamycin phosphate external swab (generic for CLINDACIN ETZ) - VANOS (brand for fluocinonide) - Tier 2; PA; QL Tier 1; QL VECTICAL (brand for calcitriol) - Tier 2; PA; ST; QL clobetasol prop emollient base - Tier 1; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL clobetasol propionate e - Tier 1; QL ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL clobetasol propionate external solution - Tier 1; QL ZYCLARA (brand for imiquimod) - Tier 2; PA; QL clotrimazole-betamethasone - Tier 1; QL corn & callus remover (generic for COMPOUND W) - Tier 1 COSENTYX - Tier 2; PA; SP; QL daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1 DERMAPHOR (brand for dry skin treatment) - Tier 2; QL diaper rash external ointment (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene) - Tier 2; QL DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL DR SMITHS DIAPER - Tier 2; QL erythromycin external (generic for ERYGEL) - Tier 1; QL flanders buttocks (generic for FLANDERS BUTTOCKS) - Tier 1 fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; QL fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; QL fluocinonide emulsified base - Tier 1; QL fluocinonide external solution - Tier 1; QL fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL fluorouracil external solution - Tier 1 fluticasone propionate external cream - Tier 1; QL fluticasone propionate external ointment - Tier 1; QL glycerin external - Tier 1 glycerin external liquid 99.5 % - Tier 1 gormel - Tier 1; QL gormel 10 (generic for NUTRAPLUS) - Tier 1; QL halobetasol propionate external cream - Tier 1; QL hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 HIBICLENS - Tier 2 hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL hydrocortisone butyrate external ointment - Tier 1; QL hydrocortisone butyrate external solution - Tier 1; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL hydrocortisone external lotion 2.5 % - Tier 1; QL hydrocortisone external ointment 0.5 % - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH RELIEF MAX STR) - Tier 1; QL hydrocortisone external ointment 2.5 % - Tier 1; QL hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone-aloe - Tier 1 hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrolatum (generic for FLANDERS BUTTOCKS) - Tier 1 ILUMYA - Tier 2; PA; SP; QL imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL instacort 5 - Tier 1; QL isotretinoin oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; QL isotretinoin oral capsule 20 mg, 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; PA; QL LAC-HYDRIN FIVE - Tier 2 lactic acid external - Tier 1 medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1 methoxsalen rapid - Tier 1 mometasone furoate external - Tier 1; QL myorisan (generic for AMNESTEEM) - Tier 1; PA; QL NEUTROGENA OIL-FREE ACNE WASH (brand for daily face wash) - Tier 2 NUTRAPLUS (brand for urea 10 hydrating) - Tier 2; QL ointment base (generic for FLANDERS BUTTOCKS) - Tier 1 OVACE PLUS WASH EXTERNAL LIQUID (brand for sodium sulfacetamide wash) - Tier 2 OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2 PANOXYL (brand for bp wash) - Tier 2 pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2 years; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents podofilox external - Tier 1; QL prednicarbate external cream - Tier 1; QL REGRANEX - Tier 2; DX2RX; QL renewal soothing bath (generic for AVEENO BABY BATH TREATMENT) - Tier 1 scalp relief (generic for PSORIASIN) - Tier 1 selenium sulfide external lotion - Tier 1; QL sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1 sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1 sulfacetamide sodium external liquid (generic for OVACE PLUS WASH) - Tier 1 sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR- E EMOLLIENT) - Tier 1 sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1 sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; QL sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfamez wash - Tier 1 SUMADAN WASH (brand for sulfacetamide sodium-sulfur) - Tier 2; QL tacrolimus external ointment 0.03 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 2 years; QL; AL tacrolimus external ointment 0.1 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 16 years; QL; AL tretinoin external cream (generic for AVITA) - Tier 1; ST; QL; AL triamcinolone acetonide external cream - Tier 1; QL triamcinolone acetonide external lotion 0.025 % - Tier 1 triamcinolone acetonide external lotion 0.1 % - Tier 1; QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier 1; QL triderm (generic for TRIDERM) - Tier 1; QL urea 20 intensive hydrating - Tier 1; QL urea external lotion (generic for CEROVEL) - Tier 1; QL ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL ureacin-20 - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1 wart remover maximum strength external liquid (generic for COMPOUND W) - Tier 1 zaclir cleansing - Tier 1 zenatane (generic for AMNESTEEM) - Tier 1; PA; QL zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL ZOSTRIX HP (brand for capsaicin hp) - Tier 2; QL

Dermatological Agents - Skin Agents ZILXI - Tier 2; PA; QL

Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs aqueous vitamin e (generic for SOLUVITA E) - Tier 1 BPROTECTED PEDIA IRON (brand for fe-vite iron) - Tier 2; QL cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1 calcium 500/d oral tablet (generic for RA HI CAL) - Tier 1 calcium 500/vitamin d3 - Tier 1 calcium 600 oral tablet 1500 (600 ca) mg - Tier 1 calcium 600/vit d/minerals - Tier 1 calcium 600/vitamin d - Tier 1 calcium 600/vitamin d-3 - Tier 1; QL calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1 calcium 600+d oral tablet 600-400 mg-unit - Tier 1; QL calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1 calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1 calcium carbonate-vitamin d oral tablet 600-200 mg-unit, 600-400 mg- unit - Tier 1 calcium carbonate-vitamin d3 - Tier 1; QL calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents calcium citrate + d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1 calcium citrate +d3 (generic for CALCITRATE) - Tier 1 calcium citrate plus vit d - Tier 1 calcium citrate+d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 w/magne (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1 calcium citrate-vit d - Tier 1 calcium citrate-vitamin d oral tablet 315-200 mg-unit - Tier 1 calcium fast dissolution - Tier 1 calcium high potency - Tier 1 calcium high potency/vitamin d - Tier 1 calcium oral tablet 1500 (600 ca) mg - Tier 1 calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1 calcium plus 600 +d - Tier 1 calcium plus vitamin d - Tier 1 calcium plus vitamin d3 - Tier 1; QL calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier 1 calcium/minerals/vitamin d - Tier 1 calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5 mg - Tier 1 calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL CARBAGLU - Tier 2; PA; SP; QL effer-k oral tablet effervescent 25 meq - Tier 1; QL electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL ENFAMIL ENFALYTE (brand for pediatric electrolyte-zinc) - Tier 2; QL EZFE 200 - Tier 2 ferate (generic for FERATE) - Tier 1 FER-IN-SOL (brand for fe-vite iron) - Tier 2; QL ferocon (generic for TRICON) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents magnesium oral tablet 500 mg - Tier 1 magnesium oxide oral tablet 400 (241.3 mg) mg (generic for MAGNESIUM-OXIDE) - Tier 1 magnesium oxide oral tablet 500 mg - Tier 1 magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 myferon 150 (generic for FERREX 150) - Tier 1 myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 nafrinse (generic for NAFRINSE) - Tier 1 nafrinse drops (generic for NAFRINSE DROPS) - Tier 1 NU-IRON (brand for polysaccharide iron complex) - Tier 2 oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL OS-CAL CALCIUM + D3 (brand for sm calcium-vitamin d) - Tier 2 oysco 500+d (generic for OYSCO 500+D) - Tier 1 oyster shell calcium 500 + d - Tier 1 oyster shell calcium oral tablet 500 mg (generic for OYSTERCAL) - Tier 1 oyster shell calcium plus d oral tablet 500-200 mg-unit (generic for OYSCO 500+D) - Tier 1 oyster shell calcium/d oral tablet 250-125 mg-unit, 250-250 mg-unit, 500-400 mg-unit - Tier 1 oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1 oyster shell calcium/vit d - Tier 1 oyster shell calcium/vitamin d oral tablet (generic for OYSCO 500+D) - Tier 1 ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - Tier 1; QL ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL PEDIALYTE FREEZER POPS (brand for pediatric electrolyte-zinc) - Tier 2; QL PEDIALYTE ORAL SOLUTION (brand for pediatric electrolyte-zinc) - Tier 2; QL PEDIALYTE SINGLES (brand for pediatric electrolyte-zinc) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents pediatric electrolyte oral solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL PHOSPHA 250 NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL poly-iron 150 (generic for FERREX 150) - Tier 1 poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide-iron complex (generic for FERREX 150) - Tier 1 potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL potassium chloride er oral capsule extended release 10 meq - Tier 1; QL potassium chloride er oral tablet extended release (generic for KLOR- CON 10) - Tier 1; QL potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) - Tier 1; QL potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL potassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1 potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 potassium citrate-citric acid - Tier 1 PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2 REHYDRALYTE (brand for pediatric electrolyte-zinc) - Tier 2; QL sod citrate-citric acid - Tier 1 sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1 sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1 sodium fluoride oral tablet chewable - Tier 1 soluvita e (generic for SOLUVITA E) - Tier 1 TRICON (brand for foltrin) - Tier 2 virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents vitamin e oral solution 15 unit/0.3ml (generic for SOLUVITA E) - Tier 1 zinc chelated oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL

Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2; QL deferasirox (generic for EXJADE) - Tier 1; PA; SP; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL LOKELMA - Tier 2; PA; QL sps - Tier 1; QL VELTASSA - Tier 2; PA; QL

Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) oral tablet (generic for CALPHRON) - Tier AURYXIA - Tier 2; PA; QL 1; QL VELPHORO - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; QL sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; ST; QL

Vitamins a-25 - Tier 1; QL adc/f (0.5mg/ml) - Tier 1; QL animal shapes complete (generic for CEROVITE JR) - Tier 1; QL; AL animal shapes kids first (generic for DINO-LIFE) - Tier 1 animal shapes/iron (generic for CEROVITE JR) - Tier 1; QL; AL AQUADEKS ORAL LIQUID - Tier 2; DX2RX; QL AQUADEKS ORAL TABLET CHEWABLE (brand for immune support) - Tier 2; DX2RX; QL; AL aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL ATABEX OB - Tier 2; QL; GE b complex oral capsule - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents b complex vitamins - Tier 1; QL b-1 - Tier 1; QL b6 - Tier 1; QL biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL BPROTECTED PEDIA D-VITE (brand for pharmacist choice d-vitamin) - Tier 2; QL BPROTECTED PEDIA POLY-VITE/FE (brand for pc pediatric poly- vita/fe drop) - Tier 2; QL BPROTECTED VITAMIN C (brand for vitamin c) - Tier 2; QL c 250 oral tablet - Tier 1; QL c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL c-1000/rose hips - Tier 1; QL calcidol (generic for CALCIDOL) - Tier 1; QL CENTRUM FLAVOR BURST KIDS (brand for cvs gummy dinos) - Tier 2; QL; AL CENTRUM KIDS (brand for cvs gummy dinos) - Tier 2; QL; AL cerovite jr (generic for CEROVITE JR) - Tier 1; QL; AL chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL; AL child chewable vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1 childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL; AL childrens chewable vitamins (generic for DINO-LIFE) - Tier 1 childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1 childrens chewables/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1 childrens complete oral tablet chewable 18 mg (generic for CEROVITE JR) - Tier 1; QL; AL childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1 childrens vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1 classic prenatal - Tier 1; GE CO-NATAL FA (brand for pretab) - Tier 2; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents cyanocobalamin injection solution 1000 mcg/ml - Tier 1; QL CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML - Tier 2; QL d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1 d 400 oral tablet - Tier 1 d 400 oral tablet chewable (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 d 5000 oral tablet (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 d3 high potency oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; QL d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 super strength - Tier 1; QL d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3-50 (generic for D3-50) - Tier 1; QL daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3) - Tier 2; QL DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for vitamin d3) - Tier 2 DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2 DIALYVITE 800 ORAL TABLET (brand for renal-vite) - Tier 2; QL DIALYVITE VITAMIN D 5000 (brand for d 5000) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL mynephrocaps (generic for MYNEPHRON) - Tier 1 MYNEPHRON (brand for virt-caps) - Tier 2 natural vitamin e (generic for ESTER-E) - Tier 1; QL NEOMULTIVITE (brand for daily-vitamin) - Tier 2 NEONATAL COMPLETE ORAL TABLET 27-1 MG - Tier 2; QL; GE NEONATAL COMPLETE ORAL TABLET 29-1 MG - Tier 2; GE NEONATAL PLUS (brand for pnv prenatal plus multivitamin) - Tier 2; QL; GE NEONATAL VITAMIN (brand for cvs prenatal) - Tier 2; GE nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL NEPHRO-VITE (brand for renal-vite) - Tier 2; QL niacin er oral capsule extended release 250 mg - Tier 1; QL NIVA-PLUS (brand for pnv prenatal plus multivitamin) - Tier 2; QL; GE NOVAMV PEDIATRIC MULTI-VITAMIN - Tier 2 nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 once daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one daily plus iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONE VITE WOMENS - Tier 2; GE ONE VITE WOMENS PLUS - Tier 2; QL; GE one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONEVITE - Tier 2; GE pediavit - Tier 1 phytonadione oral (generic for MEPHYTON) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 67 Preferred Agents Non-Preferred Agents tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thiamine hcl oral - Tier 1; QL thiamine mononitrate oral - Tier 1; QL THRIVITE 19 - Tier 2; GE THRIVITE RX - Tier 2; GE TRICARE (brand for pnv prenatal plus multivitamin) - Tier 2; QL; GE TRINATE - Tier 2; GE tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1; QL tri-vite/fluoride - Tier 1; QL UDAMIN SP (brand for thrivite 19) - Tier 2; GE VINATE II - Tier 2; QL; GE VINATE ONE - Tier 2; GE virt-caps (generic for MYNEPHRON) - Tier 1 vit c/rose hips - Tier 1; QL vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1; QL vitamin b-1 - Tier 1; QL vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1 vitamin b12 oral tablet extended release 1000 mcg - Tier 1 vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1 vitamin b-6 - Tier 1; QL vitamin b-6 er - Tier 1; QL vitamin c cr oral tablet extended release 500 mg (generic for ENDUR-C) - Tier 1; QL vitamin c er oral tablet extended release 1500 mg - Tier 1; QL vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN C) - Tier 1; QL vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; QL vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/rose hips oral tablet 1000 mg - Tier 1; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; QL vitamin d (cholecalciferol) oral tablet - Tier 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QL vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1; QL vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 oral tablet chewable 25 mcg, 25 mcg (1000 ut) (generic for KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1 vitamin d-400 - Tier 1 vitamin e natural - Tier 1 vitamin e oral capsule 100 unit, 1000 unit, 200 unit - Tier 1 vitamin e oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL vitamins acd-fluoride - Tier 1; QL vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL; AL VITATHELY WITH GINGER (brand for pnv prenatal plus multivitamin) - Tier 2; QL; GE weekly-d (generic for D3-50) - Tier 1; QL WESTAB PLUS - Tier 2; QL; GE WEST-VITE W/FOLIC ACID - Tier 2; QL womens prenatal+dha - Tier 1 zoo friends gummies (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1 zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1 zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; QL dicyclomine hcl oral - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents ED-SPAZ - Tier 2; QL glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL hyoscyamine sulfate oral - Tier 1; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL hyosyne - Tier 1; QL LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL NULEV (brand for hyoscyamine sulfate) - Tier 2; QL oscimin (generic for LEVSIN) - Tier 1; QL oscimin sr (generic for LEVBID) - Tier 1; QL SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex (generic for ABATINEX) - Tier 1 OMECLAMOX-PAK - Tier 2; PA acid gone (generic for ACID GONE) - Tier 1 PYLERA - Tier 2; PA acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1 RELISTOR - Tier 2; PA; QL acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1 SYMPROIC - Tier 2; PA; QL acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier 1 acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) - Tier 1 acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1 adult 50+ probiotic (generic for RESTORA) - Tier 1; QL adult probiotic (generic for RESTORA) - Tier 1; QL advanced antacid max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 almacone double strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 alum & mag hydroxide-simeth (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 alumina-magnesia-simethicone (generic for MINTOX) - Tier 1 antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid & gas relief (generic for MINTOX) - Tier 1 antacid advanced (generic for MINTOX) - Tier 1 antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid anti-gas (generic for MINTOX) - Tier 1 antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid anti-gas max strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid anti-gas reg strength (generic for MINTOX) - Tier 1 antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid extra strength oral suspension (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 antacid extra strength oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid fast relief (generic for MINTOX) - Tier 1 antacid i (generic for MINTOX) - Tier 1 antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid liquid (generic for MINTOX) - Tier 1 antacid m (generic for MINTOX) - Tier 1 antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid maximum strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents antacid oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid regular strength (generic for MINTOX) - Tier 1 antacid supreme - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1 antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1; AL anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1 anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 biotinex (generic for ABATINEX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents bismatrol maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL bismuth (generic for SOOTHE) - Tier 1; QL bismuth subsalicylate oral suspension (generic for SOOTHE) - Tier 1 bismuth subsalicylate oral tablet chewable (generic for SOOTHE) - Tier 1; QL calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium carbonate antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium carbonate oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 childrens soothe - Tier 1 comfort gel (generic for MINTOX) - Tier 1 comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 diamode (generic for IMODIUM A-D) - Tier 1 diarrhea (generic for SOOTHE) - Tier 1 diarrhea relief (generic for SOOTHE) - Tier 1 digestive probiotic oral capsule (generic for RESTORA) - Tier 1; QL digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 diotame instydose (generic for SOOTHE) - Tier 1 diphenoxylate-atropine oral liquid - Tier 1; QL diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1 floranex tablet oral (generic for FLORANEX) - Tier 1 FLORANEX TABLET ORAL (brand for cvs acidophilus probiotic) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1 gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral tablet chewable - Tier 1 gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for ra gas relief) - Tier 2 GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for cvs gas relief extra strength) - Tier 2 GAS-X ULTRA STRENGTH (brand for cvs gas relief ultra strength) - Tier 2 GATTEX - Tier 2; PA; SP; QL GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for gnp antacid extra strength) - Tier 2 GAVISCON ORAL SUSPENSION - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1 geri-lanta supreme - Tier 1 geri-mox (generic for MINTOX) - Tier 1 geri-pectate (generic for SOOTHE) - Tier 1 heartburn antacid (generic for ACID GONE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents mi-acid gas relief - Tier 1 milantex (generic for MINTOX) - Tier 1 milantex extra strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 mintox plus - Tier 1 mood support probiotic (generic for RESTORA) - Tier 1; QL MOTEGRITY - Tier 2; DX2RX; ST; QL MOVANTIK - Tier 2; DX2RX; ST; QL MYTESI - Tier 2; DX2RX; QL peptic relief (generic for SOOTHE) - Tier 1; QL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for hm stomach relief) - Tier 2 PHAZYME (brand for cvs gas relief extra strength) - Tier 2 PHAZYME ULTRA STRENGTH (brand for cvs gas relief ultra strength) - Tier 2 pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1 pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL pink-bismuth (generic for SOOTHE) - Tier 1; QL pro-biotic blend (generic for RESTORA) - Tier 1; QL probiotic colon care (generic for RESTORA) - Tier 1; QL probiotic complex (generic for RESTORA) - Tier 1; QL probiotic maximum strength (generic for RESTORA) - Tier 1; QL probiotic oral capsule (generic for RESTORA) - Tier 1; QL probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 probiotic pearls ex st (generic for RESTORA) - Tier 1; QL RESTORA (brand for cvs mood support probiotic) - Tier 2; QL RESTORA RX - Tier 2 RISAQUAD (brand for cvs mood support probiotic) - Tier 2; QL RISAQUAD-2 (brand for cvs mood support probiotic) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents TUMS E-X 750 (brand for sm calcium antacid ex st) - Tier 2 TUMS EXTRA STRENGTH 750 (brand for sm calcium antacid ex st) - Tier 2 TUMS LASTING EFFECTS (brand for goodsense antacid) - Tier 2 TUMS SMOOTHIES (brand for sm calcium antacid ex st) - Tier 2 TUMS ULTRA 1000 (brand for antacid ultra strength) - Tier 2 ursodiol oral - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs mood support probiotic) - Tier 2; QL ZELAC - Tier 2; QL

Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1 acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1 acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL; AL cimetidine hcl oral solution 300 mg/5ml - Tier 1; QL cimetidine oral (generic for TAGAMET HB) - Tier 1; QL; AL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1 famotidine oral tablet 20 mg (generic for MM ACID-PEP MAXIMUM STRENGTH) - Tier 1; QL famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL famotidine orig st (generic for PEPCID AC) - Tier 1 heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1 heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1 heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL; AL

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LUBIPROSTONE - Tier 2; DX2RX; ST; QL AMITIZA (brand for lubiprostone) - Tier 2; DX2RX; ST; QL LINZESS - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents Laxatives - Drugs to treat Constipation bisacodyl ec (generic for GNP BISA-LAX) - Tier 1; QL bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1 bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1 bisa-lax (generic for GNP BISA-LAX) - Tier 1; QL citrate of magnesia (generic for CITROMA) - Tier 1 citroma (generic for CITROMA) - Tier 1 CITRUCEL - Tier 2 c-lax laxative (generic for GNP BISA-LAX) - Tier 1; QL clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL COLACE (brand for qc stool softener) - Tier 2 col-rite oral capsule 250 mg - Tier 1 constulose - Tier 1; QL daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 docu - Tier 1; QL docusate calcium (generic for SURFAK) - Tier 1 docusate mini (generic for DOCUSOL MINI) - Tier 1; QL docusate sodium oral capsule (generic for DOK) - Tier 1 docusate sodium oral liquid 50 mg/5ml - Tier 1; QL docusate sodium oral syrup - Tier 1 DOCUSOL MINI (brand for docusate mini) - Tier 2; QL docuzen (generic for SENEXON-S) - Tier 1 dok oral capsule (generic for DOK) - Tier 1 dss (generic for DOK) - Tier 1 ducodyl (generic for GNP BISA-LAX) - Tier 1; QL easy-lax plus (generic for SENEXON-S) - Tier 1 enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL enulose - Tier 1; QL EVAC (brand for cvs natural fiber supplement) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents EX-LAX ULTRA (brand for veracolate) - Tier 2; QL fast relief laxative (generic for THE MAGIC BULLET) - Tier 1 fiber laxative (generic for FIBERCON) - Tier 1 fiber laxative + calcium (generic for FIBERCON) - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber oral powder 30.9 % - Tier 1 fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber-caps (generic for FIBERCON) - Tier 1 FIBERCON (brand for cvs fiber laxative) - Tier 2 fiber-lax (generic for FIBERCON) - Tier 1 FLEET BISACODYL - Tier 2; QL FLEET ENEMA (brand for sm enema) - Tier 2 FLEET OIL (brand for cvs mineral oil enema) - Tier 2 FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL gavilyte-c - Tier 1; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL generlac - Tier 1; QL gentle laxative oral tablet delayed release 5 mg (generic for GNP BISA- LAX) - Tier 1; QL gentle laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1 gentle laxative womens (generic for GNP BISA-LAX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for qc natura-lax) - Tier 2; ONLY powder bottle; QL mm clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL mm stool softener laxative (generic for DOK) - Tier 1 natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL natural fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber supplement oral powder (generic for EVAC) - Tier 1 natural laxative (generic for SENNO) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENNO) - Tier 1 natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natural vegetable laxative (generic for SENNO) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL p col-rite (generic for SENEXON-S) - Tier 1 PEDIA-LAX ORAL LIQUID - Tier 2 PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for glycerin (pediatric)) - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for eql milk of magnesia) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL psyldex - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 saline enema (generic for FLEET ENEMA) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENNO) - Tier 1 senna laxative (generic for SENNO) - Tier 1 senna oral liquid - Tier 1 senna oral syrup - Tier 1 senna oral tablet (generic for SENNO) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-lax (generic for SENNO) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENNO) - Tier 1 senna-time (generic for SENNO) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1 senno (generic for SENNO) - Tier 1 SENOKOT (brand for sm senna laxative) - Tier 2 SENOKOT S (brand for senna-docusate sodium) - Tier 2 silace oral liquid - Tier 1; QL silace oral syrup - Tier 1 smooth lax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL soluble fiber therapy - Tier 1 sorbitol oral - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener laxative oral capsule (generic for DOK) - Tier 1 stool softener oral capsule 100 mg (generic for DOK) - Tier 1 stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral capsule 250 mg - Tier 1 stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 the magic bullet (generic for THE MAGIC BULLET) - Tier 1 vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 womans laxative (generic for GNP BISA-LAX) - Tier 1; QL womens gentle laxative (generic for GNP BISA-LAX) - Tier 1; QL womens laxative (generic for GNP BISA-LAX) - Tier 1; QL

Protectants - Ulcer and Stomach Acid Drugs misoprostol oral (generic for CYTOTEC) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members 10 years of age up to 65 years of age will require PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL

Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs acid reducer oral capsule delayed release 20.6 (20 base) mg - Tier 1; ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL QL DEXILANT - Tier 2; PA; QL esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; esomeprazole magnesium oral capsule delayed release (generic for Members >= 2 years of age will require PA; QL; AL NEXIUM) - Tier 1; PA; QL lansoprazole oral capsule delayed release 15 mg, 30 mg (generic for NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for qc PREVACID) - Tier 1; QL esomeprazole magnesium) - Tier 2; PA; QL lansoprazole oral tablet delayed release dispersible 15 mg (generic for NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG (brand for esomeprazole PREVACID SOLUTAB) - Tier 1; QL; AL magnesium) - Tier 2; PA; Members >= 2 years of age will require PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents lansoprazole oral tablet delayed release dispersible 30 mg (generic for omeprazole magnesium oral tablet delayed release (generic for PRILOSEC PREVACID SOLUTAB) - Tier 1; Members >= 2 years of age will require OTC) - Tier 1; PA; QL PA; QL; AL omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members >= 2 years of pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA; QL age will require PA; QL; AL PREVACID (brand for sm lansoprazole) - Tier 2; PA; QL omeprazole magnesium oral capsule delayed release - Tier 1; QL PRILOSEC - Tier 2; PA; QL omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20 base) ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL mg, 40 mg - Tier 1; QL pantoprazole sodium oral tablet delayed release (generic for PROTONIX) - Tier 1; QL PREVACID 24HR (brand for sm lansoprazole) - Tier 2; QL

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CHOLBAM - Tier 2; PA; SP; QL CERDELGA - Tier 2; PA; SP; QL CREON - Tier 2; QL ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL CYSTAGON - Tier 2; SP; QL PANCREAZE - Tier 2; PA; QL NITYR - Tier 2; DX2RX; SP; QL VIOKACE ORAL TABLET 10440-39150 UNIT - Tier 2; PA; QL RAVICTI - Tier 2; PA; SP; QL ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL sapropterin dihydrochloride (generic for KUVAN) - Tier 1; DX2RX; SP; ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000- QL 32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 3000-10000 UNIT, sodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1; 40000-126000 UNIT, 5000-24000 UNIT - Tier 2; PA; QL DX2RX; SP; QL STRENSIQ - Tier 2; PA; SP; QL TEGSEDI - Tier 2; PA; SP; QL

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs flavoxate hcl - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QL oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL oxybutynin chloride oral - Tier 1; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL OXYTROL FOR WOMEN - Tier 2; QL ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG tolterodine tartrate (generic for DETROL) - Tier 1; ST; QL (brand for darifenacin hydrobromide er) - Tier 2; PA; QL trospium chloride - Tier 1; ST; QL MYRBETRIQ - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL tamsulosin hcl (generic for FLOMAX) - Tier 1; QL terazosin hcl - Tier 1; QL

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL azo tabs (generic for PHENAZO) - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; DX2RX; SP; QL bethanechol chloride oral - Tier 1 ELMIRON - Tier 2; DX2RX; QL penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1; DX2RX; SP; QL phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1 phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL PHOSPHASAL (brand for urin ds) - Tier 2; QL PYRIDIUM ORAL TABLET 100 MG (brand for phenazopyridine hcl) - Tier 2 PYRIDIUM ORAL TABLET 200 MG (brand for phenazopyridine hcl) - Tier 2; QL SHUR-SEAL CONTRACEPTIVE - Tier 2 urin ds (generic for PHOSPHASAL) - Tier 1; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 UTIRA-C (brand for urin ds) - Tier 2; QL VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs dexamethasone intensol - Tier 1 dexamethasone oral elixir - Tier 1 dexamethasone oral solution - Tier 1 dexamethasone oral tablet (generic for DECADRON) - Tier 1 fludrocortisone acetate oral - Tier 1 hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - Tier 1 methylprednisolone oral tablet 16 mg, 4 mg (generic for MEDROL) - Tier 1 methylprednisolone oral tablet 32 mg, 8 mg (generic for MEDROL) - Tier 1; QL methylprednisolone oral tablet therapy pack (generic for MEDROL) - Tier 1 prednisolone oral solution - Tier 1; QL prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml (generic for PEDIAPRED) - Tier 1; QL prednisone intensol - Tier 1 prednisone oral solution - Tier 1; QL prednisone oral tablet 1 mg, 2.5 mg, 5 mg, 50 mg - Tier 1 prednisone oral tablet 10 mg, 20 mg - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) - Tier 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 88 Preferred Agents Non-Preferred Agents chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; GENOTROPIN - Tier 2; PA; SP; QL DX2RX HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, desmopressin ace spray refrig - Tier 1; QL 6 MG - Tier 2; PA; SP; QL desmopressin acetate oral (generic for DDAVP) - Tier 1; QL NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL desmopressin acetate spray - Tier 1; QL NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QL INCRELEX - Tier 2; PA; SP; QL NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QL NOCDURNA - Tier 2; PA; QL NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QL novarel intramuscular solution reconstituted 10000 unit (generic for OMNITROPE - Tier 2; PA; SP; QL NOVAREL) - Tier 1; DX2RX SAIZEN - Tier 2; PA; SP; QL NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT - Tier 2; DX2RX OVIDREL - Tier 2; DX2RX pregnyl (generic for NOVAREL) - Tier 1; DX2RX ZOMACTON - Tier 2; PA; SP; QL ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs danazol oral - Tier 1 testosterone cypionate intramuscular (generic for DEPO- TESTOSTERONE) - Tier 1; QL testosterone enanthate intramuscular - Tier 1 testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; QL testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; QL

Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL; GE ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE ANGELIQ - Tier 2; PA; QL alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE CLIMARA (brand for estradiol) - Tier 2; PA; QL apri (generic for APRI) - Tier 1; QL; GE CLIMARA PRO - Tier 2; PA; QL aranelle - Tier 1; QL; GE COMBIPATCH - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1; QL; GE DIVIGEL - Tier 2; PA; QL aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE ELESTRIN - Tier 2; PA aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE ESTRACE (brand for estradiol) - Tier 2; PA; QL aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE estradiol transdermal patch twice weekly (generic for ALORA) - Tier 1; PA; aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE QL aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE estradiol-norethindrone acet oral tablet 1-0.5 mg (generic for MIMVEY) - aviane (generic for AFIRMELLE) - Tier 1; QL; GE Tier 1; PA; QL ayuna (generic for ALTAVERA) - Tier 1; QL; GE ESTRING - Tier 2; PA; QL azurette (generic for AZURETTE) - Tier 1; QL; GE ESTROGEL - Tier 2; PA; QL balziva (generic for BALZIVA) - Tier 1; QL; GE EVAMIST - Tier 2; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL; GE FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG (brand for blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE norethindrone-eth estradiol) - Tier 2; PA; QL blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE FEMRING - Tier 2; PA; QL briellyn (generic for BALZIVA) - Tier 1; QL; GE fyavolv - Tier 1; PA; QL caziant - Tier 1; QL; GE jinteli - Tier 1; PA; QL chateal (generic for ALTAVERA) - Tier 1; QL; GE MENEST - Tier 2; PA; QL chateal eq (generic for ALTAVERA) - Tier 1; QL; GE MENOSTAR - Tier 2; PA; QL cryselle-28 - Tier 1; QL; GE mimvey (generic for MIMVEY) - Tier 1; PA; QL cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE MINIVELLE (brand for estradiol) - Tier 2; PA; QL cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE PREFEST - Tier 2; PA; QL cyred (generic for APRI) - Tier 1; QL; GE PREMARIN VAGINAL - Tier 2; PA; QL cyred eq (generic for APRI) - Tier 1; QL; GE VAGIFEM (brand for estradiol) - Tier 2; PA; QL dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE delyla (generic for AFIRMELLE) - Tier 1; QL; GE desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GE DUAVEE - Tier 2; QL

Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL; GE DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL; GE camila (generic for CAMILA) - Tier 1; QL; GE deblitane (generic for CAMILA) - Tier 1; QL; GE econtra ez (generic for AFTERA) - Tier 1; QL; GE econtra one-step (generic for AFTERA) - Tier 1; QL; GE errin (generic for CAMILA) - Tier 1; QL; GE heather (generic for CAMILA) - Tier 1; QL; GE incassia (generic for CAMILA) - Tier 1; QL; GE jencycla (generic for CAMILA) - Tier 1; QL; GE levonorgestrel (generic for AFTERA) - Tier 1; QL; GE lyleq (generic for CAMILA) - Tier 1; QL; GE lyza (generic for CAMILA) - Tier 1; QL; GE medroxyprogesterone acetate intramuscular (generic for DEPO- PROVERA) - Tier 1; QL; GE medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QL megestrol acetate oral suspension 40 mg/ml - Tier 1; QL megestrol acetate oral tablet 20 mg - Tier 1 megestrol acetate oral tablet 40 mg - Tier 1; QL my choice (generic for AFTERA) - Tier 1; QL; GE my way (generic for AFTERA) - Tier 1; QL; GE new day (generic for AFTERA) - Tier 1; QL; GE nora-be (generic for CAMILA) - Tier 1; QL; GE norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1; QL; GE norlyda (generic for CAMILA) - Tier 1; QL; GE norlyroc (generic for CAMILA) - Tier 1; QL; GE

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs raloxifene hcl (generic for EVISTA) - Tier 1; QL OSPHENA - Tier 2; PA; QL; GE

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs euthyrox (generic for EUTHYROX) - Tier 1; QL levo-t (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL levoxyl (generic for EUTHYROX) - Tier 1; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL unithroid (generic for EUTHYROX) - Tier 1; QL

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 95 Preferred Agents Non-Preferred Agents Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 7.5 MG - Tier 2; SP; LUPANETA PACK - Tier 2; PA; SP; QL QL ORIAHNN - Tier 2; PA; QL leuprolide acetate injection - Tier 1; PA; SP; QL SYNAREL - Tier 2; PA LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL TRIPTODUR - Tier 2; PA; SP; QL LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL ORILISSA - Tier 2; PA; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL

Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1; QL propylthiouracil oral - Tier 1; QL

Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin HAEGARDA - Tier 2; PA; SP; QL BERINERT - Tier 2; PA; SP; QL

Immune Suppressants - Immune System Drugs azathioprine oral (generic for IMURAN) - Tier 1; QL KINERET - Tier 2; PA; SP; QL CIMZIA - Tier 2; PA; SP; QL ORENCIA CLICKJECT - Tier 2; PA; SP; QL cyclosporine modified oral capsule 100 mg (generic for GENGRAF) - ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL Tier 1; QL OTREXUP - Tier 2; PA; QL cyclosporine modified oral capsule 25 mg (generic for GENGRAF) - Tier RASUVO - Tier 2; PA; QL 1 REDITREX - Tier 2; PA; QL cyclosporine modified oral capsule 50 mg - Tier 1; QL SIMPONI - Tier 2; PA; SP; QL cyclosporine modified oral solution (generic for GENGRAF) - Tier 1 SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL ENBREL - Tier 2; PA; SP; QL XELJANZ ORAL TABLET - Tier 2; PA; SP; QL gengraf oral capsule 100 mg (generic for GENGRAF) - Tier 1; QL XELJANZ XR - Tier 2; PA; SP; QL gengraf oral capsule 25 mg (generic for GENGRAF) - Tier 1 gengraf oral solution (generic for GENGRAF) - Tier 1 HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL methotrexate oral - Tier 1 methotrexate sodium (pf) - Tier 1; QL methotrexate sodium injection - Tier 1; QL methotrexate sodium oral - Tier 1 mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL mycophenolate sodium (generic for MYFORTIC) - Tier 1 OLUMIANT - Tier 2; PA; SP; QL sirolimus oral solution (generic for RAPAMUNE) - Tier 1; QL sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; QL sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1 tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1

Immunomodulators - Immune System Drugs ACTIMMUNE - Tier 2; PA; SP; QL ACTEMRA ACTPEN - Tier 2; PA; SP; QL ILARIS - Tier 2; PA; SP; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL RINVOQ - Tier 2; PA; SP; QL leflunomide oral (generic for ARAVA) - Tier 1; QL OTEZLA - Tier 2; PA; SP; QL SYNAGIS - Tier 2; PA; SP; QL XOLAIR - Tier 2; PA; SP; QL

Vaccines ADACEL - Tier 2; QL BEXSERO - Tier 2; QL BOOSTRIX - Tier 2; QL DAPTACEL - Tier 2; QL DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; PA; QL ENGERIX-B - Tier 2; QL GARDASIL 9 - Tier 2; PA; QL HAVRIX - Tier 2; QL HEPLISAV-B - Tier 2; QL; AL HYPERTET S/D - Tier 2; QL INFANRIX - Tier 2; QL JANSSEN COVID-19 VACCINE - Tier 2; QL MENACTRA - Tier 2; QL MENQUADFI - Tier 2; QL MENVEO - Tier 2; QL M-M-R II - Tier 2; QL PNEUMOVAX 23 - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL; AL TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL TENIVAC - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents TETANUS-DIPHTHERIA TOXOIDS TD - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL

Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs balsalazide disodium (generic for COLAZAL) - Tier 1; QL APRISO (brand for mesalamine er) - Tier 2; PA; QL mesalamine oral capsule delayed release 400 mg (generic for ASACOL HD (brand for mesalamine) - Tier 2; PA; QL DELZICOL) - Tier 1; QL COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL mesalamine rectal - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL SFROWASA - Tier 2; QL DIPENTUM - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; PA; QL PENTASA - Tier 2; PA; QL

Glucocorticoids - Drugs to Treat Inflammation budesonide oral (generic for ENTOCORT EC) - Tier 1; DX2RX; QL CORTIFOAM - Tier 2; PA; QL hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO- PROCTOFOAM HC - Tier 2; PA MED HC) - Tier 1; QL hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) - Tier 1 procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL

Sulfonamides - Antibiotics sulfasalazine oral tablet (generic for AZULFIDINE) - Tier 1; QL; AL sulfasalazine oral tablet delayed release (generic for AZULFIDINE EN- TABS) - Tier 1; QL

Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium - Tier 1; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL TYMLOS - Tier 2; PA; SP; QL

Metabolic Bone Disease Agents - Other calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members >= 8 years of age will require PA; QL; AL

Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA DEVICE (brand for supreme ii high/low control) - ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for premium blood Tier 2; QL glucose test) - Tier 2; PA; QL ACCU-CHEK COMPACT PLUS CONTROL (brand for supreme ii ACCU-CHEK COMPACT PLUS (brand for premium blood glucose test) - high/low control) - Tier 2; QL Tier 2; PA; QL ACCU-CHEK GUIDE CONTROL (brand for supreme ii high/low control) ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite device/lancets) - Tier 2; QL - Tier 2; PA; QL ACCU-CHEK MULTICLIX LANCETS (brand for lite touch lancets) - Tier ACCU-CHEK GUIDE TEST STRIPS (brand for one drop blood glucose 2; QL monitor) - Tier 2; PA; QL ACCU-CHEK SMARTVIEW CONTROL (brand for supreme ii high/low ACCU-CHEK MULTICLIX LANCETS (brand for lite touch lancets) - Tier 2; control) - Tier 2; QL PA; QL ACCUTREND GLUCOSE CONTROL (brand for supreme ii high/low ACCU-CHEK SMARTVIEW (brand for premium blood glucose test) - Tier 2; control) - Tier 2; QL PA; QL AEROCHAMBER PLUS FLO-VU (brand for pro comfort spacer child) - ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite Tier 2; QL device/lancets) - Tier 2; PA; QL AEROCHAMBER PLUS FLO-VU LARGE (brand for pro comfort spacer AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; child) - Tier 2; QL QL AEROCHAMBER PLUS FLO-VU SMALL (brand for pro comfort spacer CONTOUR NEXT TEST STRIPS (brand for premium blood glucose test) - child) - Tier 2; QL Tier 2; PA; QL AEROCHAMBER PLUS FLO-VU W/MASK (brand for pro comfort CONTOUR TEST STRIPS (brand for premium blood glucose test) - Tier 2; spacer child) - Tier 2; QL PA; QL ALCOHOL PREP PADS PAD , 70 % - Tier 2; QL FREESTYLE PRECISION NEO TEST (brand for premium blood glucose antifungal external powder (generic for DESENEX) - Tier 1; QL test) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents anti-fungal external powder (generic for ODOR EATERS ANTIFUNGAL) INSULIN PEN NEEDLES 30G X 8 MM (brand for sure comfort pen - Tier 1 needles) - Tier 2; PA; QL athletes foot external powder 2 % (generic for DESENEX) - Tier 1; QL INSULIN PEN NEEDLES 32G X 4 MM (brand for h-e-b incontrol pen BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier needles) - Tier 2; PA; QL 2; QL INSULIN PEN NEEDLES 32G X 6 MM (brand for pure comfort pen needle) BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL - Tier 2; PA; QL BD ULTRA-FINE PEN NEEDLES (brand for pure comfort pen needle) - NOVOTWIST PEN NEEDLE (brand for ultracare pen needles) - Tier 2; PA; Tier 2; QL QL BREATHE EASE HUMIDIFIER - Tier 2; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for one drop CARETOUCH CONTROL SOL LEVEL 2 (brand for supreme ii high/low blood glucose monitor) - Tier 2; PA; QL control) - Tier 2; QL ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for one drop blood CAYA - Tier 2; QL; GE glucose monitor) - Tier 2; PA; QL CHEMSTRIP 10 MD - Tier 2 PRECISION LINK (brand for one drop blood glucose monitor) - Tier 2; PA; CHEMSTRIP 10/SG - Tier 2 QL CHEMSTRIP 2 GP - Tier 2 PRECISION PCX PLUS TEST (brand for premium blood glucose test) - CHEMSTRIP 5 OB - Tier 2 Tier 2; PA; QL CHEMSTRIP 7 - Tier 2 PRECISION POINT OF CARE TEST (brand for premium blood glucose CHEMSTRIP 9 - Tier 2 test) - Tier 2; PA; QL CHEMSTRIP K (brand for ketone test) - Tier 2 PRECISION QID MONITOR (brand for element compact glucose system) - CHEMSTRIP UGK - Tier 2 Tier 2; PA; QL COMFORT TOUCH ALCOHOL PREP (brand for sm alcohol prep) - Tier PRECISION QID TEST (brand for premium blood glucose test) - Tier 2; PA; 2; QL QL CONDOMS - Tier 2 PRECISION SOF-TACT MONITOR (brand for element compact glucose COOL MIST HUMIDIFER - Tier 2; QL system) - Tier 2; PA; QL DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2; QL PRECISION XTRA BLOOD GLUCOSE (brand for premium blood glucose EASIVENT (brand for pro comfort spacer child) - Tier 2; QL test) - Tier 2; PA; QL EASIVENT MASK LARGE (brand for pro comfort spacer child) - Tier 2; PRECISION XTRA DEVICE (brand for element compact glucose system) - QL Tier 2; PA; QL EASIVENT MASK MEDIUM (brand for pro comfort spacer child) - Tier 2; PRECISION XTRA MONITOR (brand for element compact glucose system) QL - Tier 2; PA; QL EASIVENT MASK SMALL (brand for pro comfort spacer child) - Tier 2; TRUETRACK TEST (brand for premium blood glucose test) - Tier 2; PA; QL QL EASYMAX 15 LEVEL 2 CONTROL (brand for supreme ii high/low control) - Tier 2; QL EASYMAX 15 LEVEL 2-3 CONTROL (brand for supreme ii high/low control) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents GLUCOSE CONTROL SOLUTIONS (brand for supreme ii high/low control) - Tier 2; QL FLEXICHAMBER (brand for pro comfort spacer child) - Tier 2; QL GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for supreme ii high/low control) - Tier 2; QL INSPIRACHAMBER/LARGE (brand for pro comfort spacer child) - Tier 2; QL INSPIRACHAMBER/MEDIUM (brand for pro comfort spacer child) - Tier 2; QL INSPIRACHAMBER/MOUTHPIECE (brand for pro comfort spacer child) - Tier 2; QL INSPIRACHAMBER/SMALL (brand for pro comfort spacer child) - Tier 2; QL INSPIREASE (brand for pro comfort spacer child) - Tier 2; QL INSPIREASE RESERVOIR BAGS - Tier 2; QL KETO-DIASTIX - Tier 2 KETONE CARE - Tier 2 KETONE TEST - Tier 2 KETOSTIX (brand for ketone test) - Tier 2 LANCETS (brand for lite touch lancets) - Tier 2; QL LOTRIMIN AF EXTERNAL POWDER (brand for antifungal) - Tier 2; QL MASK VORTEX/CHILD/FROG - Tier 2; QL MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL MEDISENSE GLUCOSE KETONE CONTR (brand for supreme ii high/low control) - Tier 2; QL MEDISENSE HI/MID/LOW CONTROL (brand for supreme ii high/low control) - Tier 2; QL MEDISENSE HIGH/LOW CONTROL (brand for supreme ii high/low control) - Tier 2; QL MEDISENSE MID CONTROL (brand for supreme ii high/low control) - Tier 2; QL methergine (generic for METHERGINE) - Tier 1; QL methylergonovine maleate oral (generic for METHERGINE) - Tier 1; QL miconazorb af (generic for DESENEX) - Tier 1; QL MYCOZYL AP (brand for antifungal) - Tier 2; QL NEODOT THERMOMETER - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents NEUTEK 2TEK CONTROL (brand for supreme ii high/low control) - Tier 2; QL OMNIFLEX DIAPHRAGM - Tier 2; QL; GE ONETOUCH ULTRA (brand for premium blood glucose test) - Tier 2; QL for non-insulin dependent members: allow twice daily testing; QL ONETOUCH ULTRA 2 KIT W/DEVICE (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH ULTRA CONTROL (brand for supreme ii high/low control) - Tier 2; QL ONETOUCH ULTRA MINI KIT W/DEVICE (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH VERIO KIT W/DEVICE (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH VERIO IN VITRO SOLUTION (brand for supreme ii high/low control) - Tier 2; QL ONETOUCH VERIO TEST STRIPS (brand for premium blood glucose test) - Tier 2; QL for non-insulin dependent members: allow twice daily testing; QL ONETOUCH VERIO IQ SYSTEM (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for one drop blood glucose monitor) - Tier 2; QL ONETOUCH VERIO SYNC SYSTEM (brand for one drop blood glucose monitor) - Tier 2; QL PRECISION GLUCOSE CONTROL (brand for supreme ii high/low control) - Tier 2; QL PRECISION GLUCOSE CONTROL SOLN (brand for supreme ii high/low control) - Tier 2; QL PRECISION GLUCOSE KETONE CONTR (brand for supreme ii high/low control) - Tier 2; QL PRECISION GLUCOSE/KETONE CONTR (brand for supreme ii high/low control) - Tier 2; QL PREMIUM CONDOMS LUBRICATED - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 103 Preferred Agents Non-Preferred Agents QUINTET CONTROL HIGH/NORMAL (brand for supreme ii high/low control) - Tier 2; QL RUZURGI - Tier 2; PA; SP; QL SOLARTEK GLUCOSE CONTROL (brand for supreme ii high/low control) - Tier 2; QL tolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) - Tier 1 TRUECONTROL GLUCOSE CONT LEV 0 (brand for supreme ii high/low control) - Tier 2; QL TRUECONTROL GLUCOSE CONT LEV 1 (brand for supreme ii high/low control) - Tier 2; QL VAPORIZER WARM STEAM - Tier 2; QL VISTOGARD - Tier 2; QL VORTEX VALVED HOLDING CHAMBER (brand for pro comfort spacer child) - Tier 2; QL WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL; GE WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL; GE ZEASORB-AF (brand for antifungal) - Tier 2; QL

Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1 CEQUA - Tier 2; PA; QL altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 RESTASIS - Tier 2; PA; QL altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL RESTASIS MULTIDOSE - Tier 2; PA; QL altafrin (generic for ALTAFRIN) - Tier 1 TOBRADEX ST - Tier 2; PA altalube (generic for ALTALUBE) - Tier 1; QL ZYLET - Tier 2; PA; QL artificial eye (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents artificial tears ophthalmic solution (generic for GENTEAL TEARS) - Tier 1 artificial tears ophthalmic solution 1.4 % - Tier 1 astringent eye drops (generic for VISINE-AC) - Tier 1; QL atropine sulfate ophthalmic ointment - Tier 1 atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE) - Tier 1; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1 bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; QL BIOLLE TEARS (brand for hm lubricating plus) - Tier 2 carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) - Tier 1; QL cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - Tier 1; QL CYSTARAN - Tier 2; DX2RX; SP; QL dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL eye drops long lasting (generic for SYSTANE) - Tier 1; QL eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye lubricant (generic for ALTALUBE) - Tier 1; QL for sty relief (generic for ALTALUBE) - Tier 1; QL GENTEAL TEARS (brand for just tears eye drops) - Tier 2 GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) - Tier 2 GENTEAL TEARS NIGHT-TIME (brand for lubricant eye nighttime) - Tier 2; QL GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2 HYPOTEARS (brand for lubricant eye nighttime) - Tier 2; QL ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL lubricant drops fast act (generic for SYSTANE) - Tier 1; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for SYSTANE HYDRATION PF) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - Tier 1; QL lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye pm (generic for ALTALUBE) - Tier 1; QL lubricant pm (generic for ALTALUBE) - Tier 1; QL lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 MURO 128 OPHTHALMIC OINTMENT (brand for sodium chloride (hypertonic)) - Tier 2 MURO 128 OPHTHALMIC SOLUTION 5 % (brand for sodium chloride (hypertonic)) - Tier 2; QL natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents neomycin-polymyxin-gramicidin - Tier 1 neo-polycin (generic for NEO-POLYCIN) - Tier 1 neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1 polycin (generic for POLYCIN) - Tier 1 polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1 polyvinyl alcohol ophthalmic - Tier 1 PURALUBE (brand for lubricant eye nighttime) - Tier 2; QL pure & gentle lubricant - Tier 1 REFRESH LACRI-LUBE (brand for lubricant eye nighttime) - Tier 2; QL REFRESH P.M. (brand for lubricant eye nighttime) - Tier 2; QL REFRESH PLUS (brand for hm lubricating plus) - Tier 2 REFRESH TEARS (brand for ra lubricant eye drops) - Tier 2; QL relief eye drops (generic for VISINE-AC) - Tier 1; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1 restore pm (generic for ALTALUBE) - Tier 1; QL sodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1 sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) - Tier 1 sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - Tier 1; QL sulfacetamide-prednisolone ophthalmic solution - Tier 1 SYSTANE COMPLETE (brand for lubricant eye drops) - Tier 2; QL SYSTANE CONTACTS (brand for just tears eye drops) - Tier 2 SYSTANE NIGHTTIME (brand for lubricant eye nighttime) - Tier 2; QL TEARS AGAIN (brand for lubricant eye nighttime) - Tier 2; QL TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for just tears eye drops) - Tier 2 tears pure (generic for GENTEAL TEARS) - Tier 1 tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1 ultra fresh (generic for ULTRA FRESH) - Tier 1; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; QL

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs azelastine hcl ophthalmic - Tier 1; ST cromolyn sodium ophthalmic - Tier 1 eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1 NAPHCON-A (brand for allergy eye) - Tier 2 olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % (brand for olopatadine hcl) - Tier 2; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; QL VISINE (brand for allergy eye) - Tier 2

Ophthalmic Antibiotics - Drugs to treat Eye Infections bacitracin ophthalmic - Tier 1 AZASITE - Tier 2; PA; QL ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QL BESIVANCE - Tier 2; PA; QL erythromycin ophthalmic - Tier 1; QL CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA; QL gentak - Tier 1 ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL gentamicin sulfate ophthalmic - Tier 1; QL ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL

Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL acetazolamide oral - Tier 1; QL AZOPT (brand for brinzolamide) - Tier 2; PA; QL apraclonidine hcl - Tier 1; QL BETIMOL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents betaxolol hcl ophthalmic - Tier 1; QL BETOPTIC-S - Tier 2; PA; QL brimonidine tartrate ophthalmic - Tier 1; QL COMBIGAN - Tier 2; PA; QL carteolol hcl - Tier 1; QL COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISTALOL (brand for timolol maleate) - Tier 2; PA; QL 1; QL SIMBRINZA - Tier 2; PA; QL dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL levobunolol hcl - Tier 1; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1; QL TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for TIMOPTIC) - Tier 1; QL

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALAWAY (brand for cvs allergy eye drops) - Tier 2; QL ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA ALAWAY CHILDRENS ALLERGY (brand for cvs allergy eye drops) - ACUVAIL - Tier 2; PA; QL Tier 2; QL ILEVRO - Tier 2; PA; QL allergy eye drops (generic for ALAWAY) - Tier 1; QL NEVANAC - Tier 2; PA; QL CLARITIN EYE (brand for cvs allergy eye drops) - Tier 2; QL PROLENSA - Tier 2; PA; QL dexamethasone sodium phosphate ophthalmic - Tier 1 diclofenac sodium ophthalmic - Tier 1 eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - Tier 1; QL fluorometholone (generic for FML LIQUIFILM) - Tier 1 flurbiprofen sodium - Tier 1 ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1 ketorolac tromethamine ophthalmic solution 0.5 % (generic for ACULAR) - Tier 1; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; QL prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL prednisolone sodium phosphate ophthalmic - Tier 1 ZADITOR (brand for cvs allergy eye drops) - Tier 2; QL

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL ZIOPTAN - Tier 2; PA; QL

Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1; QL

Otic Agents - Drugs for the Ear acetic acid otic - Tier 1; QL CLEARCANAL EARWAX SOFTENER (brand for ear wax removal system) - Tier 2 ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear drops earwax aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal kit otic solution 6.5 % (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1

Regulators - Drugs to Regulate Blood Sugar Insulins - Diabetic Drugs LYUMJEV - Tier 2; PA; QL

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1 allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1 chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1 CHLOR-TRIMETON ALLERGY (brand for chlorpheniramine maleate er) - Tier 2 CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2 ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1

Antihistamines - Drugs to Treat Allergies ALAVERT (brand for gnp loratadine) - Tier 2 all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE - Tier 2 allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1; QL allergy antihistamine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents allergy medication oral capsule 25 mg (generic for BANOPHEN) - Tier 1 allergy medication oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy medication oral tablet 25 mg (generic for BANOPHEN) - Tier 1 allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1 allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1 allergy rel child (loratadine) (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1 allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1 allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1 allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1 allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL anti-hist allergy (generic for BANOPHEN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL azelastine hcl nasal solution 137 mcg/spray - Tier 1; QL azelastine hcl solution 0.1 % nasal - Tier 1; QL banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1 banophen oral tablet (generic for BANOPHEN) - Tier 1 BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for allergy relief childrens) - Tier 2; QL BENADRYL ALLERGY ORAL TABLET (brand for complete allergy relief) - Tier 2 cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) - Tier 1; QL cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; QL childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL CLARITIN ALLERGY CHILDRENS (brand for loratadine childrens) - Tier 2; QL CLARITIN ORAL TABLET (brand for sb loratadine) - Tier 2; QL CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for gnp loratadine) - Tier 2 clemastine fumarate oral syrup - Tier 1 clemastine fumarate oral tablet 2.68 mg - Tier 1 complete allergy (generic for BANOPHEN) - Tier 1 complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1 complete allergy relief (generic for BANOPHEN) - Tier 1 cyproheptadine hcl oral syrup - Tier 1; QL cyproheptadine hcl oral tablet - Tier 1 DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2 diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL di-phen - Tier 1; QL diphen oral elixir - Tier 1; QL diphen oral tablet (generic for BANOPHEN) - Tier 1

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL ALVESCO - Tier 2; PA; QL aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL ASMANEX (120 METERED DOSES) - Tier 2; PA; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - ASMANEX (14 METERED DOSES) - Tier 2; PA; QL Tier 1; QL ASMANEX (30 METERED DOSES) - Tier 2; PA; QL ARNUITY ELLIPTA - Tier 2; QL ASMANEX (60 METERED DOSES) - Tier 2; PA; QL ASMANEX HFA - Tier 2; Members >= 8 years of age will require PA; ASMANEX (7 METERED DOSES) - Tier 2; PA; QL QL; AL FLOVENT DISKUS - Tier 2; PA; QL FLOVENT HFA - Tier 2; PA; QL

Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL SEEBRI NEOHALER - Tier 2; PA; QL INCRUSE ELLIPTA - Tier 2; QL SPIRIVA HANDIHALER - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL SPIRIVA RESPIMAT - Tier 2; PA; QL ipratropium bromide nasal - Tier 1; QL TUDORZA PRESSAIR - Tier 2; PA; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation AUVI-Q (brand for epinephrine) - Tier 2; PA; QL (generic for PROAIR HFA) - Tier 1; QL BROVANA - Tier 2; PA; QL ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL MCG/ACT INHALATION - Tier 2; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, PERFOROMIST - Tier 2; PA; QL 2.5 mg/0.5ml - Tier 1; QL PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL mg/3ml - Tier 1; Members >= 8 years of age will require PA; QL; AL SEREVENT DISKUS - Tier 2; PA; QL ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL INHALATION - Tier 2; QL XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier 1; QL albuterol sulfate oral syrup - Tier 1 epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier 1; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; ST; QL STRIVERDI RESPIMAT - Tier 2; QL SYMJEPI - Tier 2; QL

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis CAYSTON - Tier 2; DX2RX; SP; QL BETHKIS (brand for tobramycin) - Tier 2; DX2RX; SP; QL KALYDECO - Tier 2; PA; SP; QL KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL ORKAMBI - Tier 2; PA; SP; QL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL SYMDEKO - Tier 2; PA; SP; QL TOBI PODHALER - Tier 2; PA; SP; QL tobramycin inhalation nebulization solution 300 mg/4ml (generic for tobramycin nebulization solution 300 mg/5ml inhalation (generic for BETHKIS) - Tier 1; DX2RX; SP; QL KITABIS PAK) - Tier 1; PA; SP; QL TRIKAFTA - Tier 2; PA; SP; QL TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP; QL

Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1 cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL NASALCROM (brand for cromolyn sodium) - Tier 2; QL

Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs theophylline - Tier 1; QL theophylline er - Tier 1; QL

Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS - Tier 2; DX2RX; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; DX2RX; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; DX2RX; SP; QL TRACLEER (brand for bosentan) - Tier 2; DX2RX; SP; QL

Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis ESBRIET ORAL TABLET - Tier 2; PA; SP; QL

Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL 12 hour decongestant (generic for SUDAFED SINUS CONGESTION ADVAIR HFA - Tier 2; PA; QL 12HR) - Tier 1 AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour mucus relief oral tablet extended release 12 hour 1200 mg PA; QL (generic for EQ MUCUS ER) - Tier 1; QL; AL AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal decongestant (generic for SUDAFED SINUS PA; QL CONGESTION 12HR) - Tier 1 AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; PA; 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - Tier QL 1 ANORO ELLIPTA - Tier 2; PA; QL 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 BEVESPI AEROSPHERE - Tier 2; PA; QL 4-WAY FAST ACTING (brand for sinus relief extra strength) - Tier 2 BREO ELLIPTA - Tier 2; PA; QL 4-WAY MENTHOL (brand for sinus relief extra strength) - Tier 2 DULERA - Tier 2; PA; QL acetylcysteine inhalation solution 10 % - Tier 1; QL SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA; ST; acetylcysteine inhalation solution 20 % - Tier 1 QL; AL adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG TRELEGY ELLIPTA - Tier 2; PA; QL DM CHILD) - Tier 1 ADVIL COLD/SINUS (brand for qc ibuprofen cold/sinus) - Tier 2; AL AFRIN NODRIP ORIGINAL (brand for qc nasal relief moisturizing) - Tier 2 AFRIN SALINE NASAL MIST (brand for cvs saline nasal spray) - Tier 2 AFRIN SINUS (brand for qc nasal relief moisturizing) - Tier 2 ALAVERT ALLERGY/SINUS (brand for cvs allergy relief-d12) - Tier 2; QL; AL all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; AL benzonatate oral capsule 200 mg - Tier 1; QL; AL cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; QL; AL chest congest/cough child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 chest congestion relief dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL chest congestion relief oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL chest congestion relief oral tablet (generic for XPECT) - Tier 1 childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL childrens cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 CLARITIN-D 12 HOUR (brand for cvs allergy relief-d12) - Tier 2; QL; AL CLARITIN-D 24 HOUR (brand for gnp allergy & congestion) - Tier 2; QL; AL cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & sinus relief oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 120 Preferred Agents Non-Preferred Agents cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL COMBIVENT RESPIMAT - Tier 2; QL CORICIDIN HBP COUGH/COLD (brand for cvs cough & cold hbp) - Tier 2; AL cough & chest congestion (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough dm (generic for DELSYM) - Tier 1; QL; AL cough dm childrens (generic for DELSYM) - Tier 1; QL; AL cough dm er (generic for DELSYM) - Tier 1; QL; AL cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH) - Tier 1; AL cough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL decongestant 12hour max st (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 DELSYM (brand for hm cough dm) - Tier 2; QL; AL DELSYM CGH/CHEST CONG DM CHILD (brand for qc mucus relief dm max) - Tier 2 DELSYM COUGH CHILDRENS (brand for hm cough dm) - Tier 2; QL; AL DELSYM COUGH/CHEST CONGEST DM (brand for qc mucus relief dm max) - Tier 2 desgen dm oral liquid (generic for DESGEN DM) - Tier 1; AL dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL DIABETIC TUSSIN MAX ST (brand for maxi-tuss gmx) - Tier 2; AL dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL DIMETAPP COLD RELIEF CHILDRENS (brand for ra cold & cough childrens) - Tier 2; QL; AL DIMETAPP COLD/ALLERGY (brand for px dibromm cold/allergy child) - Tier 2; AL DIMETAPP DM COLD/COUGH (brand for ra cold & cough childrens) - Tier 2; QL; AL dm maximum adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 DRISTAN SPRAY (brand for qc nasal relief moisturizing) - Tier 2 ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL; AL ed bron gp - Tier 1; AL ENDACOF-DM (brand for ra cold & cough childrens) - Tier 2; QL; AL ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 FASENRA PEN - Tier 2; PA; SP; QL fluticasone-salmeterol inhalation aerosol powder breath activated 100- 50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; QL g tussin ac - Tier 1; QL; AL genaphed (generic for SUDOGEST) - Tier 1 geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 guaiatussin ac - Tier 1; QL; AL guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL guaifenesin ac - Tier 1; QL; AL guaifenesin er (generic for EQ MUCUS ER) - Tier 1; QL; AL guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents guaifenesin-codeine - Tier 1; QL; AL guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL hydrocodone-homatropine (generic for HYCODAN) - Tier 1; QL; AL hydromet (generic for HYCODAN) - Tier 1; QL; AL HYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for sodium chloride) - Tier 2 ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; AL ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ipratropium-albuterol - Tier 1; QL liquibid (generic for XPECT) - Tier 1 long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; QL; AL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; QL; AL loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL; AL loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; QL; AL loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL; AL loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; QL; AL maxi-tuss ac - Tier 1; QL; AL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL maxi-tuss pe max - Tier 1; AL m-clear wc - Tier 1; QL; AL medifin 400 (generic for XPECT) - Tier 1 meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL; AL MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for qc mucus relief dm max) - Tier 2 MUCINEX CHILDRENS STUFFY NOSE (brand for qc nasal relief moisturizing) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents MUCINEX COUGH CHILDRENS (brand for qc mucus relief dm max) - Tier 2 MUCINEX D (brand for mucus d) - Tier 2; AL MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) - Tier 2; AL MUCINEX DM (brand for mucus-dm) - Tier 2; QL; AL MUCINEX FAST-MAX DM MAX (brand for qc mucus relief dm max) - Tier 2 MUCINEX MAXIMUM STRENGTH (brand for cvs mucus extended release) - Tier 2; QL; AL MUCINEX SINUS-MAX CLEAR & COOL (brand for qc nasal relief moisturizing) - Tier 2 MUCINEX SINUS-MAX SINUS/ALLRGY (brand for qc nasal relief moisturizing) - Tier 2 mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus d (generic for MUCINEX D) - Tier 1; AL mucus d extended release (generic for MUCINEX D) - Tier 1; AL mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1 mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; QL; AL mucus relief er (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief max strength oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief oral tablet (generic for XPECT) - Tier 1 mucus-d (generic for MUCINEX D) - Tier 1; AL mucus-dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL nasal decongestant 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant max st (generic for SUDOGEST) - Tier 1 nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1 nasal decongestant oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal four (generic for 4-WAY FAST ACTING) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for cvs saline nasal spray) - Tier 2 nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents promethazine vc/codeine - Tier 1; QL; AL promethazine-codeine - Tier 1; QL; AL promethazine-dm - Tier 1; QL; AL promethazine-phenyleph-codeine - Tier 1; QL; AL promethazine-phenylephrine - Tier 1; QL; AL pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1 pseudoephedrine-bromphen-dm - Tier 1; QL; AL pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1; AL PULMOZYME - Tier 2; DX2RX; SP; QL refenesen 400 (generic for XPECT) - Tier 1 robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL ROBITUSSIN 12 HOUR COUGH (brand for hm cough dm) - Tier 2; QL; AL ROBITUSSIN 12 HOUR COUGH CHILD (brand for hm cough dm) - Tier 2; QL; AL ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; AL ROBITUSSIN CHILDRENS COUGH LA - Tier 2; AL ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for qc mucus relief dm max) - Tier 2 ROBITUSSIN NIGHTTIME COUGH - Tier 2; AL ROBITUSSIN PEAK COLD MULTI-SYM (brand for qc tussin cf) - Tier 2; AL rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL rynex pse - Tier 1; AL saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 sb mucus relief (generic for XPECT) - Tier 1 siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1; AL siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin maximum strength oral syrup 15 mg/5ml (generic for WAL- TUSSIN COUGH) - Tier 1; AL tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; AL tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL virtussin a/c - Tier 1; QL; AL virtussin ac w/alc - Tier 1; QL; AL virtussin dac - Tier 1; QL; AL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL XPECT (brand for liquibid) - Tier 2 ZYRTEC-D ALLERGY & CONGESTION (brand for hm allergy complete- d) - Tier 2; QL; AL

Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1; QL chlorzoxazone oral tablet 500 mg - Tier 1 cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1 dantrolene sodium oral capsule 100 mg - Tier 1 dantrolene sodium oral capsule 25 mg, 50 mg (generic for DANTRIUM) - Tier 1; QL methocarbamol oral - Tier 1 orphenadrine citrate er - Tier 1; QL tizanidine hcl oral tablet - Tier 1; QL

Sleep Disorder Agents - Drugs for Sedation and Sleep GABA Receptor Modulators - Drugs for Sleeping

Sleep Disorders, Other - Drugs for Sleeping armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QL SILENOR (brand for doxepin hcl) - Tier 2; PA

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs prenatal gummy oral tablet chewable 0.4-25 mg (generic for ALIVE PRENATAL) - Tier 1; QL

Title Drugs Impacted Prior Authorization Criteria / Class Criteria

1 acamprosate calcium ...... acetaminophen oral tablet 500 mg ...... 12 hour allergy-d ...... ACANYA ...... acetaminophen oral tablet chewable 160 mg 12 hour decongestant ...... acarbose oral ...... acetaminophen rectal suppository 120 mg .... 12 hour mucus relief oral tablet extended ACCU-CHEK AVIVA DEVICE ...... acetaminophen rectal suppository 650 mg .... release 12 hour 1200 mg ...... ACCU-CHEK AVIVA PLUS TEST STRIPS .. acetaminophen-codeine ...... 12 hour nasal decongestant ...... ACCU-CHEK COMPACT PLUS ...... acetaminophen-codeine #2 ...... 12 hour nasal relief spray ...... ACCU-CHEK COMPACT PLUS CONTROL. acetaminophen-codeine #3 ...... 12 hour nasal spray ...... ACCU-CHEK FASTCLIX LANCET KIT...... acetaminophen-codeine #4 ...... 2 ACCU-CHEK GUIDE CONTROL ...... acetazolamide er ...... 24 hour nasal allergy ...... ACCU-CHEK GUIDE TEST STRIPS ...... acetazolamide oral ...... 3 ACCU-CHEK MULTICLIX LANCETS ...... , acetic acid otic ...... 3 day ...... ACCU-CHEK SMARTVIEW ...... acetylcysteine inhalation solution 10 % ...... 3 day vaginal ...... ACCU-CHEK SMARTVIEW CONTROL ...... acetylcysteine inhalation solution 20 % ...... 3-day vaginal vaginal cream 2 % ...... ACCU-CHEK SOFTCLIX LANCET DEVICE acid controller ...... 4 KIT ...... acid gone ...... 4-WAY FAST ACTING ...... accutane ...... acid reducer oral capsule delayed release 4-WAY MENTHOL ...... ACCUTREND GLUCOSE CONTROL ...... 20.6 (20 base) mg...... 8 acebutolol hcl oral ...... acid reducer oral tablet 10 mg ...... 8 hour arthritis pain reliever...... acetaminophen 8 hour ...... acid reducer oral tablet 200 mg ...... 8 hour arthritis relief ...... acetaminophen 8 hours ...... acidophilus lactobacillus oral ...... 8 hour pain relief oral tablet extended acetaminophen 8hr arth pain ...... acidophilus oral capsule , 10 mg ...... release 650 mg ...... acetaminophen 8hr musc ache ...... acidophilus probiotic oral capsule 10 mg ...... 8 hour pain reliever ...... acetaminophen childrens ...... acidophilus probiotic oral tablet , 0.5 mg ...... 8 hr arthritis pain relief ...... acetaminophen childrens oral suspension acidophilus/l-sporogenes ...... 8hr arthritis pain relief ...... 160 mg/5ml ...... ACIPHEX ...... 8hr muscle aches & pain ...... acetaminophen er ...... acitretin ...... A acetaminophen ex st oral liquid 500 mg/15ml acne ...... a-25 ...... acne control cleanser ...... abacavir sulfate ...... acetaminophen ex st oral tablet 500 mg ...... acne medication 10 external lotion ...... abacavir sulfate-lamivudine ...... acetaminophen extra strength ...... acne medication 5 external lotion ...... abacavir-lamivudine-zidovudine ...... acetaminophen infants oral suspension 160 acne treatment external cream 10 % ...... abatinex ...... mg/5ml ...... ACTEMRA ACTPEN ...... ABILIFY ...... acetaminophen oral liquid 500 mg/15ml ...... ACTEMRA SUBCUTANEOUS ...... ABILIFY MAINTENA ...... acetaminophen oral solution 160 mg/5ml, ACTIMMUNE ...... abiraterone acetate ...... 325 mg/10.15ml, 650 mg/20.3ml ...... ACTIVELLA ...... ABREVA ...... acetaminophen oral suspension 160 ACULAR LS ...... ABSORICA ...... mg/5ml, 650 mg/20.3ml ...... ACUVAIL ...... ABSORICA LD ...... acetaminophen oral tablet 325 mg ...... acyclovir oral ......

133 ACZONE EXTERNAL GEL 7.5 % ...... AIRDUO RESPICLICK 55/14 ...... all day allergy d-12 ...... ADACEL ...... AJOVY SUBCUTANEOUS SOLUTION all day allergy oral tablet 10 mg ...... adc/f (0.5mg/ml) ...... AUTO-INJECTOR ...... all day allergy-d ...... addaprin ...... AJOVY SUBCUTANEOUS SOLUTION all day pain relief ...... ADEMPAS ...... PREFILLED SYRINGE ...... all day relief ...... ADLYXIN ...... ak-poly-bac ...... ALLEGRA ALLERGY CHILDRENS ORAL ADLYXIN STARTER PACK ...... AKYNZEO ORAL ...... TABLET DISPERSIBLE ...... ADMELOG ...... ala-cort ...... allerclear ...... ADMELOG SOLOSTAR...... ALAVERT ...... allerclear d-12hr ...... adult 50+ probiotic ...... ALAVERT ALLERGY/SINUS ...... allerclear d-24hr ...... adult probiotic ...... ALAWAY ...... aller-cort ...... adult tussin cough & chest ...... ALAWAY CHILDRENS ALLERGY ...... allergy & congestion ...... adv acne spot treatment ...... albendazole oral ...... allergy 24hour indoor/outdoor ...... ADVAIR DISKUS ...... albuterol sulfate hfa aerosol solution 108 (90 allergy antihistamine ...... ADVAIR HFA ...... base) mcg/act inhalation ...... allergy childrens ...... advanced acne spot treat ...... ALBUTEROL SULFATE HFA AEROSOL allergy complete-d ...... advanced antacid max st ...... SOLUTION 108 (90 BASE) MCG/ACT allergy eye drops ...... advanced healing external ointment ...... INHALATION ...... allergy medication oral capsule 25 mg ...... ADVIL ...... albuterol sulfate inhalation nebulization allergy medication oral liquid 12.5 mg/5ml .... ADVIL COLD/SINUS ...... solution (2.5 mg/3ml) 0.083%, 2.5 allergy medication oral tablet 25 mg ...... ADVIL JUNIOR STRENGTH ...... mg/0.5ml ...... allergy oral capsule 25 mg ...... ADVIL LIQUI-GELS MINIS...... albuterol sulfate inhalation nebulization allergy oral liquid 12.5 mg/5ml ...... ADVIL MIGRAINE ...... solution 0.63 mg/3ml, 1.25 mg/3ml ...... allergy oral tablet 25 mg ...... ADZENYS XR-ODT ...... albuterol sulfate nebulization solution (5 allergy oral tablet extended release 12 mg .... AEROCHAMBER PLUS FLO-VU ...... mg/ml) 0.5% inhalation ...... allergy rel child (loratadine) ...... AEROCHAMBER PLUS FLO-VU LARGE .... ALBUTEROL SULFATE NEBULIZATION allergy relief (cetirizine) oral tablet 10 mg ...... AEROCHAMBER PLUS FLO-VU SMALL ..... SOLUTION (5 MG/ML) 0.5% allergy relief adult ...... AEROCHAMBER PLUS FLO-VU W/MASK .. INHALATION ...... allergy relief cetirizine ...... af spray powder ...... albuterol sulfate oral syrup ...... allergy relief child ...... AFINITOR DISPERZ ...... alclometasone dipropionate external allergy relief childrens oral liquid 12.5 AFINITOR ORAL TABLET 10 MG ...... ointment ...... mg/5ml ...... afirmelle ...... ALCOHOL PREP PADS PAD , 70 % ...... allergy relief childrens oral syrup 5 mg/5ml ... AFREZZA ...... ALDARA ...... allergy relief d oral tablet extended release AFRIN NODRIP ORIGINAL ...... ALECENSA ...... 12 hour ...... AFRIN SALINE NASAL MIST ...... alendronate sodium ...... allergy relief d-12 ...... AFRIN SINUS ...... ALEVE ORAL TABLET ...... allergy relief d-24 ...... aftera ...... alfuzosin hcl er ...... allergy relief oral capsule 25 mg ...... AIMOVIG ...... ALINIA ORAL SUSPENSION allergy relief oral liquid 12.5 mg/5ml, 25 AIRDUO RESPICLICK 113/14 ...... RECONSTITUTED ...... mg/10ml ...... AIRDUO RESPICLICK 232/14 ...... all day allergy d ...... allergy relief oral tablet 10 mg ......

134 allergy relief oral tablet 25 mg ...... ALVESCO ...... antacid & anti-gas oral suspension 200-200- allergy relief oral tablet chewable 12.5 mg .... alyacen 1/35 ...... 20 mg/5ml ...... allergy relief oral tablet dispersible 10 mg ..... alyacen 7/7/7 ...... antacid & anti-gas oral suspension 400-400- allergy relief oral tablet extended release 12 amantadine hcl oral capsule ...... 40 mg/5ml ...... hour 5-120 mg ...... amantadine hcl oral syrup ...... antacid & gas relief ...... allergy relief oral tablet extended release 12 AMBIEN ...... antacid advanced ...... mg ...... AMBIEN CR ...... antacid advanced max st ...... allergy relief(cetirizine) ...... ambrisentan ...... antacid anti-gas ...... allergy relief/indoor/outdoor oral tablet 10 mg amcinonide external ointment ...... antacid anti-gas ex st oral suspension 400- ...... amiloride hcl oral ...... 400-40 mg/5ml ...... allergy relief/nasal decong ...... amiloride-hydrochlorothiazide ...... antacid anti-gas max strength ...... allergy relief/nasal decongest...... aminocaproic acid oral ...... antacid anti-gas reg strength ...... allergy relief-d oral tablet extended release amiodarone hcl oral tablet 200 mg, 400 mg . antacid calcium ...... 12 hour 5-120 mg ...... AMITIZA ...... antacid calcium rich ...... allergy relief-d12 ...... amitriptyline hcl oral ...... antacid extra ...... allergy spray 24 hour nasal aerosol ...... amlodipine besylate oral ...... antacid extra strength oral suspension ...... allergy/congestion relief ...... ammonium lactate external ...... antacid extra strength oral tablet chewable aller-tec ...... amnesteem ...... 160-105 mg...... aller-tec d ...... amoxapine oral tablet 100 mg, 25 mg, 50 mg antacid extra strength oral tablet chewable allopurinol oral ...... 750 mg ...... almacone double strength ...... amoxapine oral tablet 150 mg ...... antacid fast relief ...... ALOE VESTA CLEAR ANTIFUNGAL ...... amoxicillin oral capsule ...... antacid i ...... ALOGLIPTIN BENZOATE...... amoxicillin oral suspension reconstituted ..... antacid iii ...... ALOGLIPTIN-METFORMIN HCL ...... amoxicillin oral tablet 875 mg ...... antacid kids ...... ALOGLIPTIN-PIOGLITAZONE ...... amoxicillin oral tablet chewable ...... antacid liquid ...... ALORA ...... amoxicillin-potassium clavulanate oral ...... antacid m ...... ALPHAGAN P ...... amphetamine-dextroamphetamine ...... antacid maximum ...... alprazolam oral tablet ...... amphetamine-dextroamphetamine er ...... antacid maximum strength ...... altachlore ophthalmic ointment ...... ampicillin ...... antacid maximum strength oral tablet altachlore ophthalmic solution ...... AMZEEQ ...... chewable 1000 mg ...... altafrin ...... anagrelide hcl ...... antacid oral suspension 200-200-20 mg/5ml, altalube ...... ANASPAZ ...... 400-400-40 mg/10ml...... altamist spray ...... anastrozole oral ...... antacid oral suspension 400-400-40 mg/5ml . altarussin ...... anecream external cream ...... antacid oral tablet chewable 1000 mg ...... altarussin dm ...... anefrin spray ...... antacid oral tablet chewable 500 mg ...... altarussin-pe ...... ANGELIQ ...... antacid oral tablet chewable 750 mg ...... altavera ...... animal shapes complete ...... antacid plus antigas ...... alum & mag hydroxide-simeth...... animal shapes kids first ...... antacid plus anti-gas relief ...... alumina-magnesia-simethicone ...... animal shapes/iron ...... antacid regular strength ...... ALUNBRIG ...... ANORO ELLIPTA ...... antacid supreme ......

135 antacid ultra strength oral tablet chewable ARANESP (ALBUMIN FREE) ...... atazanavir sulfate ...... 1000 mg ...... aripiprazole oral solution ...... atenolol oral ...... antacid/anti-gas ...... aripiprazole oral tablet ...... atenolol-chlorthalidone ...... antacid/anti-gas max st ...... aripiprazole oral tablet dispersible ...... atheletes foot ...... antacid/antigas oral suspension 200-200-20 ARISTADA ...... athletes foot (terbinafine) ...... mg/5ml ...... ARISTADA INITIO ...... athletes foot external aerosol powder 2 % .... antacid/gas relief max st ...... armodafinil ...... athletes foot external cream 1 % ...... antibiotic ...... ARNUITY ELLIPTA ...... athletes foot external powder 2 % ...... anti-diarr/ant-gas ...... arthritis pain oral tablet extended release athletes foot powder spray ...... anti-diarrheal anti-gas ...... 650 mg ...... athletes foot spray ...... anti-diarrheal oral liquid 1 mg/5ml ...... arthritis pain relief oral tablet extended atomoxetine hcl ...... anti-diarrheal oral suspension 262 mg/15ml . release 650 mg ...... atorvastatin calcium oral ...... anti-diarrheal oral tablet 2 mg ...... arthritis pain reliever oral ...... atovaquone oral ...... antifungal external cream 2 % ...... arthritis pain relieving ...... ATRALIN ...... antifungal external powder ...... artificial eye ...... ATRIPLA ...... anti-fungal external powder ...... artificial tears ophthalmic ointment ...... atropine sulfate ophthalmic ointment ...... antifungal foot care ...... artificial tears ophthalmic solution ...... atropine sulfate ophthalmic solution 1 % ...... antifungal miconazole ...... artificial tears ophthalmic solution 1.4 % ...... ATROVENT HFA ...... anti-gas oral capsule 180 mg ...... ASACOL HD ...... AUBAGIO ...... anti-hist allergy ...... ascomp-codeine ...... aubra ...... anti-nausea ...... ascorbic acid oral tablet 500 mg ...... aubra eq ...... antiseptic ...... ASMANEX (120 METERED DOSES) ...... aurodryl allergy childrens ...... apap-caff-dihydrocodeine oral capsule ...... ASMANEX (14 METERED DOSES) ...... aurophen childrens ...... APIDRA SOLOSTAR ...... ASMANEX (30 METERED DOSES) ...... aurovela 1.5/30 ...... APIDRA VIAL ...... ASMANEX (60 METERED DOSES) ...... aurovela 1/20 ...... apra ...... ASMANEX (7 METERED DOSES) ...... aurovela fe 1.5/30 ...... apraclonidine hcl ...... ASMANEX HFA ...... aurovela fe 1/20 ...... aprepitant ...... aspirin childrens ...... AURYXIA ...... apri ...... aspirin ec ...... AUSTEDO ...... APRISO ...... aspirin ec oral tablet 325 mg ...... AUVI-Q ...... aprodine ...... aspirin oral tablet 325 mg ...... AVAR-E EMOLLIENT ...... APTENSIO XR ...... aspirin oral tablet chewable 81 mg ...... AVAR-E GREEN ...... APTIOM ...... aspirin oral tablet delayed release 325 mg ... aviane ...... APTIVUS ...... aspirin oral tablet delayed release 81 mg ..... AVITA EXTERNAL CREAM ...... AQUADEKS ORAL LIQUID ...... ASPIRIN ORAL TABLET DELAYED AVONEX PEN ...... AQUADEKS ORAL TABLET CHEWABLE .... RELEASE 81 MG ...... AVONEX PREFILLED ...... aqueous vitamin d ...... aspirin rectal suppository 300 mg, 600 mg ... AYR ...... aqueous vitamin e ...... astringent eye drops ...... ayuna ...... ARAKODA ...... astringent solution ...... AZASITE ...... aranelle ...... ATABEX OB ...... azathioprine oral ......

136 azelaic acid external ...... BD AUTOSHIELD DUO PEN NEEDLES ...... BEXSERO ...... azelastine hcl nasal solution 137 mcg/spray . BD ULTRA-FINE INSULIN SYRINGES ...... bicalutamide ...... azelastine hcl ophthalmic ...... BD ULTRA-FINE PEN NEEDLES ...... BIDIL ...... azelastine hcl solution 0.1 % nasal ...... beauty 360 pure glycerin ...... BIKTARVY ...... azithromycin oral suspension reconstituted .. bekyree ...... biocel ...... azithromycin oral tablet ...... BENADRYL ALLERGY CHILDRENS ORAL BIOLLE TEARS ...... azo ...... LIQUID ...... biotinex ...... azo tabs ...... BENADRYL ALLERGY ORAL TABLET ...... bisacodyl ec ...... AZOPT ...... benazepril hcl oral ...... bisacodyl laxative ...... azurette ...... benazepril-hydrochlorothiazide ...... bisacodyl rectal ...... B BENZAC AC WASH ...... bisa-lax ...... b complex oral capsule ...... BENZACLIN ...... bismatrol maximum strength ...... b complex vitamins ...... BENZACLIN WITH PUMP ...... bismatrol oral tablet chewable ...... b-1 ...... BENZAMYCIN ...... bismuth ...... b6 ...... BENZNIDAZOLE ...... bismuth subsalicylate oral suspension ...... BABY AYR SALINE ...... benzonatate oral capsule 100 mg ...... bismuth subsalicylate oral tablet chewable ... baby basics diaper rash ...... benzonatate oral capsule 200 mg ...... bisoprolol fumarate oral ...... bac ...... benztropine mesylate oral ...... bisoprolol-hydrochlorothiazide ...... bacitracin external ...... BERINERT ...... blisovi fe 1.5/30 ...... bacitracin external ointment 500 unit/gm ...... BESIVANCE ...... blisovi fe 1/20 ...... bacitracin ophthalmic ...... betamethasone dipropionate aug ...... blue tube/ aloe ...... bacitracin zinc external ...... betamethasone dipropionate external lotion . BONINE ...... bacitracin zinc first aid ...... betamethasone dipropionate external BOOSTRIX ...... bacitracin-polymyxin b ophthalmic ...... ointment ...... boro-packs ...... bacitra-neomycin-polymyxin-hc ...... betamethasone valerate external cream ...... bosentan ...... baclofen oral ...... betamethasone valerate external lotion ...... BOSULIF ...... BAFIERTAM ...... betamethasone valerate external ointment ... BOUDREAUXS BUTT PASTE EXTERNAL balsalazide disodium ...... BETAPACE ...... OINTMENT 40 % ...... BALVERSA ...... BETAPACE AF ...... bp 10-1 ...... balziva ...... BETASEPT SURGICAL SCRUB ...... bp wash external liquid 2.5 % ...... banophen oral capsule 25 mg ...... BETASERON ...... b-plex plus ...... banophen oral tablet ...... betatemp childrens ...... BPROTECTED PEDIA D-VITE ...... BANZEL ORAL TABLET ...... betaxolol hcl ophthalmic ...... BPROTECTED PEDIA IRON ...... BAQSIMI ONE PACK ...... betaxolol hcl oral ...... BPROTECTED PEDIA POLY-VITE/FE ...... BAQSIMI TWO PACK ...... bethanechol chloride oral ...... BPROTECTED VITAMIN C ...... BARACLUDE ORAL SOLUTION ...... BETHKIS ...... BREATHE EASE HUMIDIFIER ...... BASAGLAR KWIKPEN ...... BETIMOL ...... BREO ELLIPTA ...... BAYER ASPIRIN ORAL TABLET ...... BETOPTIC-S ...... briellyn ...... BAYER ASPIRIN ORAL TABLET DELAYED BEVESPI AEROSPHERE ...... brimonidine tartrate ophthalmic ...... RELEASE ...... bexarotene ...... BRIVIACT ORAL ......

137 BROVANA ...... calamine-zinc oxide external lotion ...... calcium citrate+d oral tablet 315-250 mg-unit BRUKINSA ...... calcidol ...... calcium citrate+d3 oral tablet 315-250 mg- budesonide inhalation ...... calcipotriene external cream ...... unit ...... budesonide oral ...... calcipotriene external ointment ...... calcium citrate+d3 w/magne ...... bumetanide oral ...... calcipotriene external solution ...... calcium citrate-vit d ...... BUNAVAIL ...... calcitriol external ...... calcium citrate-vitamin d oral tablet 315-200 buprenorphine hcl sublingual ...... calcitriol oral capsule ...... mg-unit ...... buprenorphine hcl-naloxone hcl sublingual calcitriol oral solution ...... calcium fast dissolution ...... film 2-0.5 mg, 8-2 mg ...... calcium 500/d oral tablet ...... calcium high potency ...... buprenorphine hcl-naloxone hcl sublingual calcium 500/vitamin d3 ...... calcium high potency/vitamin d ...... tablet sublingual ...... calcium 600 oral tablet 1500 (600 ca) mg ..... calcium oral tablet 1500 (600 ca) mg ...... buprenorphine transdermal ...... calcium 600/vit d/minerals ...... calcium oyster shell oral tablet 1250 (500 ca) bupropion hcl er (sr) ...... calcium 600/vitamin d ...... mg ...... bupropion hcl er (xl) oral tablet extended calcium 600/vitamin d-3 ...... calcium plus 600 +d ...... release 24 hour 150 mg, 300 mg ...... calcium 600+d oral tablet 600-200 mg-unit, calcium plus vitamin d ...... bupropion hcl oral ...... 600-400 mg-unit ...... calcium plus vitamin d3 ...... buspirone hcl oral ...... calcium 600+d oral tablet 600-400 mg-unit ... calcium soft chews oral tablet chewable 500- butalbital-acetaminophen oral tablet 50-325 calcium acetate (phos binder) oral tablet ...... 200-40 mg-unt-mcg ...... mg ...... calcium acetate oral tablet 667 mg ...... calcium/minerals/vitamin d ...... butalbital-apap-caff-cod oral capsule 50-325- calcium antacid ...... calcium-magnesium-zinc oral tablet 333- 40-30 mg ...... calcium antacid ex st ...... 133-5 mg, 333.33-133.33-5 mg ...... butalbital-apap-caffeine oral capsule 50-325- calcium antacid extra strength ...... calcium-vitamin d oral tablet 600-400 mg- 40 mg ...... calcium carb-cholecalciferol oral tablet 600- unit ...... butalbital-apap-caffeine oral tablet ...... 400 mg-unit ...... calcium-vitamin d3 oral tablet 600-400 mg- butalbital-asa-caff-codeine ...... calcium carbonate antacid ...... unit ...... butalbital-aspirin-caffeine ...... calcium carbonate oral tablet 1500 (600 ca) cal-gest antacid ...... butorphanol tartrate nasal ...... mg ...... CALQUENCE ...... BYDUREON BCISE AUTOINJECTOR ...... calcium carbonate oral tablet chewable 1250 camila ...... BYETTA 10 MCG PEN ...... (500 ca) mg ...... capecitabine ...... BYETTA 5 MCG PEN ...... calcium carbonate oral tablet chewable 500 CAPRELSA ...... C mg ...... capsaicin external cream 0.025 % ...... c 250 oral tablet ...... calcium carbonate-vitamin d oral tablet 600- capsaicin external cream 0.1 % ...... c 500/rose hips ...... 200 mg-unit, 600-400 mg-unit ...... capsaicin hp ...... c-1000/rose hips ...... calcium carbonate-vitamin d3 ...... captopril oral ...... cabergoline ...... calcium cit plus vit d-3 ...... captopril-hydrochlorothiazide ...... CABLIVI ...... calcium citrate + d oral tablet 315-250 mg- capzix ...... CABOMETYX ...... unit ...... CARAC ...... caffeine citrate oral ...... calcium citrate + d3 maximum ...... CARBAGLU ...... cal mag zinc +d3 ...... calcium citrate +d3 ...... carbamazepine er ...... calamine external lotion , 8-8 % ...... calcium citrate plus vit d ...... carbamazepine oral ......

138 carbidopa-levodopa er ...... CHANTIX STARTING MONTH PAK...... childrens vitamins/extra c ...... carbidopa-levodopa oral tablet ...... chateal ...... childrens vitamins/iron ...... carboxymethylcellulose sodium ophthalmic .. chateal eq ...... childs non-aspirin ...... CARETOUCH CONTROL SOL LEVEL 2 ..... CHEMET ...... chlordiazepoxide hcl ...... carteolol hcl ...... CHEMSTRIP 10 MD ...... chlorhexidine gluconate mouth/throat ...... cartia xt ...... CHEMSTRIP 10/SG ...... chloroquine phosphate oral ...... carvedilol ...... CHEMSTRIP 2 GP ...... chlorpheniramine maleate er ...... cavarest ...... CHEMSTRIP 5 OB ...... chlorpromazine hcl oral tablet 10 mg, 100 CAVILON ...... CHEMSTRIP 7 ...... mg, 50 mg ...... CAYA ...... CHEMSTRIP 9 ...... chlorpromazine hcl oral tablet 200 mg, 25 CAYSTON ...... CHEMSTRIP K ...... mg ...... caziant ...... CHEMSTRIP UGK ...... chlorthalidone ...... cefaclor ...... chest congest/cough child ...... CHLOR-TRIMETON ALLERGY ...... cefadroxil ...... chest congestion relief dm ...... CHLOR-TRIMETON ORAL SYRUP ...... cefdinir oral capsule ...... chest congestion relief oral syrup ...... chlorzoxazone oral tablet 500 mg ...... cefdinir oral suspension reconstituted ...... chest congestion relief oral tablet ...... CHOLBAM ...... cefpodoxime proxetil oral tablet ...... chewable c ...... cholestyramine light oral powder ...... cefprozil ...... chewable c with rose hips ...... cholestyramine oral powder ...... cefuroxime axetil ...... chewable childrens vitamin ...... chorionic gonadotropin intramuscular ...... celecoxib oral ...... chewy not chalky flavor ...... ciclodan ...... CELONTIN ...... child chewable vitamins/iron ...... ciclopirox external solution ...... CENTRUM FLAVOR BURST KIDS ...... childrens acetaminophen ...... ciclopirox olamine external suspension ...... CENTRUM KIDS ...... childrens allergy oral liquid 12.5 mg/5ml ...... cilostazol ...... cephalexin oral capsule 250 mg...... childrens animal shapes ...... CILOXAN ...... cephalexin oral capsule 500 mg...... childrens apap ...... CIMDUO ...... cephalexin oral capsule 750 mg...... childrens aspirin low strength ...... cimetidine hcl oral solution 300 mg/5ml ...... cephalexin oral suspension reconstituted childrens aspirin oral tablet chewable 81 mg cimetidine oral ...... 125 mg/5ml ...... childrens chewable vitamins ...... CIMZIA ...... cephalexin oral suspension reconstituted childrens chewables/ex c ...... cinacalcet hcl ...... 250 mg/5ml ...... childrens chewables/iron ...... CIPRO ORAL SUSPENSION CEQUA ...... childrens cold & allergy ...... RECONSTITUTED 250 MG/5ML (5%) ...... CERDELGA ...... childrens complete oral tablet chewable 18 CIPRO ORAL SUSPENSION cerovel ...... mg ...... RECONSTITUTED 500 MG/5ML (10%) .... cerovite jr ...... childrens cough ...... ciprofloxacin hcl ophthalmic ...... cetiri-d ...... childrens loratadine ...... ciprofloxacin hcl oral tablet 100 mg ...... cetirizine hcl oral solution ...... childrens mucus relief cough ...... ciprofloxacin hcl oral tablet 250 mg, 500 mg . cetirizine hcl oral tablet ...... childrens non-aspirin ...... ciprofloxacin hcl oral tablet 750 mg ...... cetirizine-pseudoephedrine er ...... childrens silapap ...... citalopram hydrobromide ...... CHANTIX ...... childrens soothe ...... citrate of magnesia ...... CHANTIX CONTINUING MONTH PAK ...... childrens tactinal ...... citroma ......

139 CITRUCEL ...... clopidogrel bisulfate oral tablet 75 mg ...... COMETRIQ (60 MG DAILY DOSE) ...... claravis ...... clorazepate dipotassium oral tablet 15 mg ... comfort gel ...... clarithromycin er ...... clorazepate dipotassium oral tablet 3.75 mg comfort gel antacid anti-gas oral suspension clarithromycin oral ...... clorazepate dipotassium oral tablet 7.5 mg .. 400-400-40 mg/5ml...... CLARITIN ALLERGY CHILDRENS ...... clotrimazole 3 ...... COMFORT TOUCH ALCOHOL PREP ...... CLARITIN EYE ...... clotrimazole 7 ...... COMPLERA ...... CLARITIN ORAL TABLET ...... clotrimazole external ...... complete allergy ...... CLARITIN REDITABS ORAL TABLET clotrimazole mouth/throat ...... complete allergy medicine oral capsule ...... DISPERSIBLE 10 MG ...... clotrimazole vaginal ...... , complete allergy relief ...... CLARITIN-D 12 HOUR ...... clotrimazole-betamethasone ...... compro ...... CLARITIN-D 24 HOUR ...... clozapine oral tablet 100 mg, 25 mg ...... CO-NATAL FA ...... classic prenatal ...... clozapine oral tablet 50 mg ...... CONCERTA ...... c-lax laxative ...... CLOZARIL ORAL TABLET 100 MG, 25 MG CONDOMS ...... CLEARCANAL EARWAX SOFTENER ...... CLOZARIL ORAL TABLET 200 MG ...... constulose ...... clearlax oral powder 17 gm/scoop ...... CLOZARIL ORAL TABLET 50 MG ...... CONTOUR NEXT TEST STRIPS ...... clearskin ...... codeine sulfate ...... CONTOUR TEST STRIPS ...... clemastine fumarate oral syrup ...... COLACE ...... COOL MIST HUMIDIFER ...... clemastine fumarate oral tablet 2.68 mg ...... COLAZAL ...... COPAXONE ...... CLEOCIN VAGINAL SUPPOSITORY ...... COLCHICINE ORAL CAPSULE ...... CORICIDIN HBP COUGH/COLD ...... CLIMARA ...... colchicine oral tablet ...... CORLANOR ...... CLIMARA PRO ...... COLCRYS ...... corn & callus remover ...... clindacin etz external swab ...... cold & allergy ...... CORTIFOAM ...... clindacin-p ...... cold & allergy childrens oral elixir 1-15 COSENTYX ...... clindamycin hcl oral capsule 150 mg, 300 mg/5ml ...... COSOPT ...... mg ...... cold & cough childrens oral liquid 2.5-1-5 COSOPT PF ...... clindamycin palmitate hcl ...... mg/5ml ...... COTELLIC ...... clindamycin phosphate external lotion ...... cold & cough dm childrens oral liquid 2.5-1-5 COTEMPLA XR-ODT ...... clindamycin phosphate external solution ...... mg/5ml ...... cough & chest congestion ...... clindamycin phosphate external swab ...... cold & sinus relief oral tablet 30-200 mg ...... cough & cold ...... clindamycin phosphate vaginal ...... cold/cough ...... cough & cold hbp ...... CLINDESSE ...... cold/cough childrens ...... cough childrens ...... clobazam ...... cold/cough dm childrens oral liquid 2.5-1-5 cough dm ...... clobetasol prop emollient base...... mg/5ml ...... cough dm childrens ...... clobetasol propionate e ...... cold/cough dm oral liquid 2.5-1-5 mg/5ml ..... cough dm er ...... clobetasol propionate external solution ...... col-rite oral capsule 250 mg ...... cough relief oral syrup 15 mg/5ml ...... CLOBEX ...... COMBIGAN ...... cough/chest congestion dm ...... CLOBEX SPRAY ...... COMBIPATCH ...... cough/chest dm childrens oral liquid ...... clonazepam oral tablet ...... COMBIVENT RESPIMAT ...... cough/cold hbp ...... clonidine hcl oral ...... COMETRIQ (100 MG DAILY DOSE) ...... CREON ...... clopidogrel bisulfate oral tablet 300 mg ...... COMETRIQ (140 MG DAILY DOSE) ...... CRIXIVAN ......

140 cromolyn sodium inhalation ...... d3 oral capsule 25 mcg (1000 ut) ...... delyla ...... cromolyn sodium nasal ...... d3 super strength ...... DELZICOL ...... cromolyn sodium ophthalmic...... d-3-5 ...... DENTA 5000 PLUS ...... crotan ...... d3-50 ...... DENTAGEL ...... CRUEX PRESCRIPTION STRENGTH ...... daily acne wash ...... DEPEN TITRATABS ...... cryselle-28 ...... daily fiber oral capsule 0.52 gm ...... DEPO-SUBQ PROVERA 104 ...... CUPRIMINE ...... daily multiple vitamins ...... DERMACINRX PENETRAL ...... cyanocobalamin injection solution 1000 daily multivitamins/iron ...... DERMAPHOR ...... mcg/ml ...... daily vitamin formula+iron ...... DESENEX EXTERNAL POWDER ...... CYANOCOBALAMIN INJECTION daily vitamins ...... DESENEX JOCK ITCH ...... SOLUTION 2000 MCG/ML ...... daily vite ...... desgen dm oral liquid ...... cyclafem 1/35 ...... daily vites ...... desipramine hcl oral ...... cyclafem 7/7/7 ...... daily-vite ...... desmopressin ace spray refrig ...... cyclobenzaprine hcl oral tablet 10 mg, 5 mg . danazol oral ...... desmopressin acetate oral ...... cyclopentolate hcl ophthalmic solution 1 %... dantrolene sodium oral capsule 100 mg ...... desmopressin acetate spray ...... cyclophosphamide oral capsule ...... dantrolene sodium oral capsule 25 mg, 50 desogestrel-ethinyl estradiol ...... CYCLOPHOSPHAMIDE ORAL TABLET ...... mg ...... DETROL ...... cycloserine oral ...... dapsone oral ...... DETROL LA ...... cyclosporine modified oral capsule 100 mg .. DAPTACEL ...... dexamethasone intensol ...... cyclosporine modified oral capsule 25 mg .... dasetta 1/35 ...... dexamethasone oral elixir ...... cyclosporine modified oral capsule 50 mg .... dasetta 7/7/7 ...... dexamethasone oral solution ...... cyclosporine modified oral solution ...... DAURISMO ...... dexamethasone oral tablet ...... cyclosporine oral ...... DAYHIST ALLERGY 12 HOUR RELIEF...... dexamethasone sodium phosphate CYMBALTA ...... DAYTRANA ...... ophthalmic ...... cyproheptadine hcl oral syrup ...... deblitane ...... DEXILANT ...... cyproheptadine hcl oral tablet ...... DECARA ORAL CAPSULE 1.25 MG (50000 dextromethorphan polistirex er ...... cyred ...... UT) ...... dextromethorphan-guaifenesin oral syrup ..... cyred eq ...... DECARA ORAL CAPSULE 250 MCG DIABETIC TUSSIN MAX ST ...... CYSTAGON ...... (10000 UT) ...... DIALYVITE 800 ORAL TABLET ...... CYSTARAN ...... DECARA ORAL CAPSULE 625 MCG DIALYVITE VITAMIN D 5000 ...... D (25000 UT) ...... diamode ...... d 1000 oral tablet ...... decongestant 12hour max st ...... diaper rash external ointment ...... d 400 oral tablet ...... deep sea nasal spray ...... diarrhea ...... d 400 oral tablet chewable ...... deferasirox ...... diarrhea relief ...... d 5000 oral tablet ...... deferasirox granules ...... diazepam oral solution ...... d3 high potency oral capsule 25 mcg (1000 DELSTRIGO ...... diazepam oral tablet ...... ut) ...... DELSYM ...... diazepam rectal ...... d3 oral capsule 10 mcg (400 unit), 50 mcg DELSYM CGH/CHEST CONG DM CHILD ... diclofenac potassium ...... (2000 ut) ...... DELSYM COUGH CHILDRENS ...... diclofenac sodium er ...... d3 oral capsule 125 mcg (5000 ut) ...... DELSYM COUGH/CHEST CONGEST DM .. diclofenac sodium external gel 1 % ......

141 diclofenac sodium ophthalmic ...... diphenhydramine hcl oral tablet ...... doxepin hcl oral capsule 100 mg ...... diclofenac sodium oral ...... diphenhydramine hcl oral tablet chewable .... doxepin hcl oral concentrate ...... dicloxacillin sodium ...... diphenoxylate-atropine oral liquid ...... doxycycline hyclate oral capsule ...... dicyclomine hcl oral ...... diphenoxylate-atropine oral tablet ...... doxycycline hyclate oral tablet 100 mg ...... DIFFERIN EXTERNAL CREAM ...... DIPHTHERIA-TETANUS TOXOIDS DT ...... doxycycline monohydrate oral capsule 100 DIFFERIN EXTERNAL GEL 0.1 % ...... dipyridamole oral ...... mg ...... DIFFERIN EXTERNAL GEL 0.3 % ...... disopyramide phosphate ...... doxycycline monohydrate oral capsule 50 DIFFERIN EXTERNAL LOTION ...... disulfiram oral ...... mg ...... DIFICID ...... DITROPAN XL ...... DR SMITHS ADULT BARRIER EXTERNAL DIFLUCAN ...... divalproex sodium oral capsule delayed OINTMENT ...... digestive probiotic oral capsule ...... release sprinkle ...... DR SMITHS DIAPER ...... digestive probiotic oral capsule 250 mg ...... divalproex sodium oral tablet delayed driminate ...... digitek ...... release ...... DRISTAN SPRAY ...... digox ...... DIVIGEL ...... dronabinol ...... digoxin oral ...... dm maximum adult ...... DROXIA ORAL CAPSULE 200 MG, 300 MG dihydroergotamine mesylate injection ...... docosanol external ...... DROXIA ORAL CAPSULE 400 MG ...... DILANTIN ORAL CAPSULE 30 MG ...... docu ...... dry-eye relief nighttime ...... diltiazem hcl er ...... docusate calcium ...... dss ...... diltiazem hcl er beads ...... docusate mini ...... DUAVEE ...... diltiazem hcl er coated beads ...... docusate sodium oral capsule ...... ducodyl ...... diltiazem hcl oral ...... docusate sodium oral liquid 50 mg/5ml ...... DULERA ...... dilt-xr ...... docusate sodium oral syrup ...... duloxetine hcl oral capsule delayed release dimaphen dm cold/cough ...... DOCUSOL MINI ...... particles 20 mg, 30 mg, 60 mg ...... DIMETAPP COLD RELIEF CHILDRENS ..... docuzen ...... DUPIXENT ...... DIMETAPP COLD/ALLERGY ...... dofetilide ...... D-VI-SOL ...... DIMETAPP DM COLD/COUGH ...... dok oral capsule ...... d-vite pediatric ...... dimethyl fumarate oral...... donepezil hcl oral tablet 10 mg, 5 mg ...... DYANAVEL XR ...... dimethyl fumarate starter pack ...... donepezil hcl oral tablet 23 mg ...... dye-free allergy relief ...... dino-life ...... donepezil hcl oral tablet dispersible 10 mg ... E dino-life w/extra c ...... DOPTELET ...... e diotame instydose ...... dorzolamide hcl solution 2 % ophthalmic ...... e-400-clear ...... DIPENTUM ...... DORZOLAMIDE HCL SOLUTION 2 % ear drops ...... diphedryl allergy ...... OPHTHALMIC ...... ear drops earwax aid ...... di-phen ...... dorzolamide hcl-timolol mal ...... ear wax kit ...... diphen oral elixir ...... double antibiotic ...... ear wax removal ...... diphen oral tablet ...... DOVATO ...... ear wax removal drops ...... diphenhist ...... DOVONEX ...... ear wax removal kit ...... diphenhydramine hcl oral capsule ...... doxazosin mesylate oral ...... ear wax removal system ...... diphenhydramine hcl oral elixir ...... doxepin hcl oral capsule 10 mg, 150 mg, 25 earwax removal ...... diphenhydramine hcl oral liquid 12.5 mg/5ml mg, 50 mg, 75 mg ...... earwax removal drops ......

142 earwax removal kit otic solution 6.5 % ...... EMTRIVA ORAL SOLUTION ...... ergotamine-caffeine ...... EASIVENT ...... ENABLEX ORAL TABLET EXTENDED ERIVEDGE ...... EASIVENT MASK LARGE ...... RELEASE 24 HOUR 7.5 MG ...... ERLEADA ...... EASIVENT MASK MEDIUM...... enalapril maleate oral ...... erlotinib hcl ...... EASIVENT MASK SMALL ...... enalapril-hydrochlorothiazide ...... errin ...... easygel ...... ENBREL ...... erythromycin base oral capsule delayed easy-lax plus ...... ENDACOF-DM ...... release particles...... EASYMAX 15 LEVEL 2 CONTROL ...... endocet oral tablet 10-325 mg, 5-325 mg, erythromycin base oral tablet 250 mg ...... EASYMAX 15 LEVEL 2-3 CONTROL ...... 7.5-325 mg ...... erythromycin base oral tablet 500 mg ...... ec-naproxen ...... enema ...... erythromycin ethylsuccinate oral ...... econtra ez ...... enema disposable ...... erythromycin external ...... econtra one-step ...... enema mineral oil ...... erythromycin ophthalmic ...... ED A-HIST ORAL LIQUID ...... enema ready-to-use ...... ESBRIET ORAL TABLET ...... ed bron gp ...... enema rectal enema 16-6 gm/133ml, 19-7 escitalopram oxalate oral tablet ...... ed chlorped jr ...... gm/118ml ...... esomeprazole magnesium oral capsule ed-apap ...... ENEMEEZ MINI ...... delayed release ...... EDARBI ...... ENFAMIL ENFALYTE ...... esomeprazole magnesium oral packet ...... EDARBYCLOR ...... ENFAMIL EXPECTA ...... essential one daily ...... ED-SPAZ ...... ENGERIX-B ...... essentials ...... EDURANT ...... enoxaparin sodium ...... estarylla ...... efavirenz ...... enpresse-28 ...... ESTRACE ...... efavirenz-lamivudine-tenofovir ...... enskyce ...... estradiol oral ...... effer-k oral tablet effervescent 25 meq...... ENSTILAR ...... estradiol transdermal patch twice weekly ...... EFUDEX ...... entacapone ...... estradiol transdermal patch weekly ...... electrolyte solution ...... entecavir ...... estradiol vaginal ...... ELESTRIN ...... enteric aspirin ...... estradiol-norethindrone acet oral tablet 1-0.5 ELIDEL ...... ENTRESTO ...... mg ...... ELIGARD SUBCUTANEOUS KIT 22.5 MG, enulose ...... ESTRING ...... 30 MG, 7.5 MG ...... EPANED ...... ESTROGEL ...... elinest ...... EPCLUSA ...... ethambutol hcl oral ...... ELIQUIS ...... ephrine nose drops ...... ethosuximide oral ...... ELIQUIS DVT/PE STARTER PACK ...... EPIDUO ...... ethynodiol diac-eth estradiol ...... ELMIRON ...... EPIDUO FORTE ...... etodolac oral capsule ...... eluryng ...... epinephrine injection solution auto-injector ... etodolac oral tablet ...... EMEND ORAL ...... EPIPEN 2-PAK ...... etonogestrel-ethinyl estradiol ...... EMGALITY ...... EPIPEN JR 2-PAK ...... etoposide oral ...... EMGALITY (300 MG DOSE) ...... epitol ...... EUCRISA ...... emoquette ...... EPIVIR HBV ORAL SOLUTION ...... euthyrox ...... emtricitabine ...... EPOGEN ...... EVAC ...... emtricitabine-tenofovir df ...... ergocalciferol oral ...... EVAMIST ......

143 EVEKEO ...... FEMRING ...... FEVERALL JUNIOR STRENGTH ...... EVEKEO ODT ...... femynor ...... fe-vite iron ...... everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg . fenofibrate micronized oral capsule 134 mg, FIASP ...... EVOTAZ ...... 200 mg, 67 mg ...... FIASP FLEXTOUCH ...... EXCEDRIN EXTRA STRENGTH ...... fenofibrate oral capsule 134 mg, 200 mg, 67 fiber laxative ...... EXCEDRIN MIGRAINE ...... mg ...... fiber laxative + calcium ...... exemestane ...... fenofibrate oral tablet 160 mg, 54 mg ...... fiber laxative oral capsule 0.52 gm ...... EX-LAX ULTRA ...... FENSOLVI (6 MONTH) ...... fiber laxative oral tablet 500 mg ...... EXTAVIA ...... fentanyl transdermal patch 72 hour 100 fiber oral capsule 0.52 gm ...... eye drops advanced relief ...... mcg/hr ...... fiber oral powder 28.3 % ...... eye drops allergy relief ...... fentanyl transdermal patch 72 hour 12 fiber oral powder 30.9 % ...... eye drops long lasting ...... mcg/hr ...... fiber oral powder 48.57 % ...... eye drops ophthalmic solution 0.05 % ...... fentanyl transdermal patch 72 hour 25 fiber oral powder 58.6 % ...... eye drops ophthalmic solution 0.05-0.1-1-1 mcg/hr ...... fiber oral tablet 500 mg ...... % ...... fentanyl transdermal patch 72 hour 50 fiber oral tablet 625 mg ...... eye itch relief ophthalmic solution 0.025 % ... mcg/hr ...... fiber therapy oral capsule 0.52 gm ...... eye lubricant ...... fentanyl transdermal patch 72 hour 75 fiber therapy oral powder 28.3 % ...... ezetimibe ...... mcg/hr ...... fiber therapy oral tablet 500 mg ...... EZFE 200 ...... ferate ...... fiber therapy oral tablet 625 mg ...... F FER-IN-SOL ...... fiber-caps ...... fa-8 ...... ferocon ...... FIBERCON ...... FABIOR ...... ferosul ...... fiber-lax ...... falmina ...... ferotrinsic ...... FINACEA ...... famotidine oral suspension reconstituted 40 ferretts ...... finasteride oral tablet 5 mg ...... mg/5ml ...... ferrex 150 ...... FIRAZYR ...... famotidine oral tablet 10 mg ...... ferric x-150 ...... first aid antibiotic external ointment 3.5-400- famotidine oral tablet 20 mg ...... ferrous fumarate oral tablet 324 (106 fe) mg 5000 , 3.5-400-5000 mg-unit ...... famotidine oral tablet 40 mg ...... ferrous gluconate oral tablet 240 (27 fe) mg . first aid antiseptic external solution 10 % ...... famotidine orig st ...... ferrous gluconate oral tablet 324 (37.5 fe) FIRVANQ ...... FANAPT ...... mg ...... FLAGYL ORAL CAPSULE ...... FARXIGA ...... ferrous gluconate oral tablet 324 (38 fe) mg . FLAGYL ORAL TABLET ...... FARYDAK ...... ferrous sulfate oral elixir ...... flanders buttocks ...... FASENRA PEN ...... ferrous sulfate oral solution 75 (15 fe) mg/ml flavoxate hcl ...... fast relief laxative ...... ferrous sulfate oral tablet 325 (65 fe) mg ...... flecainide acetate ...... febuxostat ...... ferrous sulfate oral tablet delayed release .... FLEET BISACODYL ...... felbamate oral suspension ...... FETZIMA ...... FLEET ENEMA ...... felbamate oral tablet ...... fever reducer/pain reliever ...... FLEET OIL ...... felodipine er ...... fever reducing childrens ...... FLEET PEDIATRIC ...... FEMHRT LOW DOSE ORAL TABLET 0.5- feverall adults ...... FLEXICHAMBER ...... 2.5 MG-MCG ...... feverall childrens ...... floranex tablet oral ......

144 FLORANEX TABLET ORAL ...... fluvoxamine maleate ...... gas relief oral capsule 125 mg ...... FLOVENT DISKUS ...... foaming antacid oral tablet chewable 80-20 gas relief oral suspension ...... FLOVENT HFA ...... mg ...... gas relief oral tablet chewable ...... fluconazole oral ...... FOCALIN ...... gas relief oral tablet chewable 125 mg ...... fludrocortisone acetate oral ...... folic acid oral capsule 20 mg, 5 mg ...... gas relief ultra strength ...... fluocinolone acetonide body ...... folic acid oral tablet 1 mg ...... gas relief ultstrength ...... fluocinolone acetonide external cream 0.025 folic acid oral tablet 400 mcg, 800 mcg ...... GAS-X EXTRA STRENGTH ORAL % ...... foltrin ...... CAPSULE ...... fluocinolone acetonide external ointment ...... foot & sneaker ...... GAS-X EXTRA STRENGTH ORAL TABLET fluocinolone acetonide external solution ...... foot care (terbinafine) ...... CHEWABLE...... fluocinolone acetonide scalp ...... for sty relief ...... GAS-X ULTRA STRENGTH ...... fluocinonide emulsified base ...... formula em ...... GATTEX ...... fluocinonide external solution ...... fosamprenavir calcium ...... gavilax oral powder ...... fluoridex daily renewal ...... fosinopril sodium ...... gavilyte-c ...... fluoritab ...... fosinopril sodium-hctz ...... gavilyte-n with flavor pack ...... fluorometholone ...... FREESTYLE PRECISION NEO TEST ...... GAVISCON EXTRA RELIEF FORMULA ...... fluorouracil external cream 5 % ...... freeze dried acidophilus ...... GAVISCON EXTRA STRENGTH ...... fluorouracil external solution ...... fruity c ...... GAVISCON ORAL SUSPENSION ...... fluoxetine hcl oral capsule 10 mg, 20 mg ...... full spectrum b/vitamin c ...... GELUSIL ...... fluoxetine hcl oral solution ...... FULPHILA ...... gemfibrozil oral ...... fluphenazine decanoate injection ...... furosemide oral solution 10 mg/ml ...... genaphed ...... fluphenazine hcl injection ...... furosemide oral tablet ...... generlac ...... fluphenazine hcl oral concentrate ...... FUZEON ...... gengraf oral capsule 100 mg ...... fluphenazine hcl oral elixir ...... fyavolv ...... gengraf oral capsule 25 mg ...... fluphenazine hcl oral tablet 1 mg ...... FYCOMPA ...... gengraf oral solution ...... fluphenazine hcl oral tablet 10 mg, 2.5 mg, 5 G GENOTROPIN ...... mg ...... g tussin ac ...... gentak ...... flurbiprofen sodium ...... gabapentin oral capsule ...... gentamicin sulfate external ...... flutamide ...... gabapentin oral tablet ...... gentamicin sulfate ophthalmic ...... fluticasone propionate external cream ...... galantamine hydrobromide oral solution ...... GENTEAL TEARS ...... fluticasone propionate external ointment ...... galantamine hydrobromide oral tablet 12 mg, GENTEAL TEARS MODERATE PF ...... fluticasone propionate nasal ...... 8 mg ...... GENTEAL TEARS NIGHT-TIME ...... fluticasone-salmeterol inhalation aerosol galantamine hydrobromide oral tablet 4 mg . GENTEAL TEARS PF ...... powder breath activated 100-50 GARDASIL 9 ...... gentle laxative oral tablet delayed release 5 mcg/dose, 250-50 mcg/dose, 500-50 gas relief antiflatuent ...... mg ...... mcg/dose ...... gas relief drops infants ...... gentle laxative rectal suppository 10 mg ...... FLUTICASONE-SALMETEROL gas relief extra strength ...... gentle laxative womens ...... INHALATION AEROSOL POWDER gas relief extstrength ...... gentlelax ...... BREATH ACTIVATED 113-14 MCG/ACT, gas relief infants ...... GENVOYA ...... 232-14 MCG/ACT, 55-14 MCG/ACT ...... gas relief infants drops ...... GEODON ORAL ......

145 geri-dryl oral liquid ...... glycerin external liquid 99.5 % ...... healthy hair/skin/nails ...... geri-dryl oral tablet ...... glycerin pediatric rectal suppository 1.2 gm .. heartburn antacid ...... geri-kot ...... glycolax ...... heartburn antacid ex st ...... geri-lanta ...... glycopyrrolate oral tablet 1 mg, 2 mg ...... heartburn prevention oral tablet 10 mg ...... geri-lanta supreme ...... glydo ...... heartburn relief ex st ...... geri-mox ...... GLYXAMBI ...... heartburn relief oral tablet 10 mg ...... geri-pectate ...... gormel ...... heartburn relief oral tablet 200 mg ...... geri-tussin dm ...... gormel 10 ...... heartburn relief oral tablet chewable 160-105 GILENYA ...... GRANIX ...... mg ...... GILOTRIF ...... griseofulvin microsize oral ...... heather ...... giltuss severe sinus ...... griseofulvin ultramicrosize ...... h-e-b aspirin ...... glatiramer acetate ...... guaiatussin ac ...... h-e-b childrens allergy ...... glatopa ...... guaicon dms ...... HELIDAC THERAPY ...... GLEOSTINE ...... guaifenesin ac ...... HEMANGEOL ...... glimepiride ...... guaifenesin er ...... HEMLIBRA ...... glipizide er ...... guaifenesin oral tablet 400 mg ...... hemorrhoidal rectal suppository 0.25-3-85.5 glipizide ir ...... guaifenesin-codeine ...... % ...... glipizide xl ...... guaifenesin-dm oral syrup ...... heparin sodium (porcine) injection solution GLUCAGEN HYPOKIT ...... guanfacine hcl ...... 1000 unit/ml ...... GLUCAGON EMERGENCY INJECTION guanfacine hcl er ...... heparin sodium (porcine) injection solution SOLUTION RECONSTITUTED ...... GVOKE HYPOPEN 1-PACK ...... 10000 unit/ml, 20000 unit/ml, 5000 unit/ml glucagon emergency kit 1 mg injection ...... GVOKE HYPOPEN 2-PACK ...... heparin sodium (porcine) injection solution GLUCAGON EMERGENCY KIT 1 MG GVOKE PFS ...... prefilled syringe...... INJECTION ...... GYNAZOLE-1 ...... heparin sodium (porcine) pf injection solution GLUCOSE CONTROL SOLUTION IN GYNE-LOTRIMIN ...... 5000 unit/0.5ml ...... VITRO SOLUTION ...... GYNE-LOTRIMIN 3 ...... heparin sodium (porcine) pf injection solution GLUCOSE CONTROL SOLUTIONS ...... H 5000 unit/ml ...... glucose oral tablet chewable 4 gm ...... habitrol ...... HEPLISAV-B ...... glyburide micronized ...... HAEGARDA ...... hi cal ...... glyburide oral ...... hailey 1.5/30 ...... HIBICLENS ...... glyburide-metformin ...... hailey fe 1.5/30 ...... high potency probiotic ...... glycerin (adult) rectal suppository 2 gm ...... hailey fe 1/20 ...... HUMALOG ...... glycerin (infants & children) rectal halobetasol propionate external cream ...... HUMALOG JUNIOR KWIKPEN ...... suppository 1 gm ...... haloperidol decanoate intramuscular ...... HUMALOG KWIKPEN ...... glycerin (pediatric) rectal suppository 1 gm ... haloperidol oral ...... HUMALOG MIX 50/50 ...... glycerin adult rectal suppository 2 gm ...... HARVONI ...... HUMALOG MIX 50/50 KWIKPEN ...... glycerin child rectal suppository 1 gm ...... HAVRIX ...... HUMALOG MIX 75/25 ...... glycerin child rectal suppository 1.2 gm ...... headache formula ...... HUMALOG MIX 75/25 KWIKPEN ...... glycerin childrens ...... headache relief extra str ...... HUMATROPE INJECTION SOLUTION glycerin external ...... headache relief oral tablet 250-250-65 mg ... RECONSTITUTED 12 MG, 24 MG, 6 MG .

146 HUMIRA PEN-PEDIATRIC UC START ...... hydrocortisone oral tablet 10 mg, 20 mg, 5 ibuprofen ib childrens ...... HUMIRA PEN-PSOR/UVEIT STARTER ...... mg ...... ibuprofen ib oral tablet 200 mg ...... HUMIRA SUBCUTANEOUS PEN- hydrocortisone plus external cream 1 % ...... ibuprofen ib oral tablet chewable 100 mg ...... INJECTOR KIT 40 MG/0.4ML, 40 hydrocortisone rectal enema 100 mg/60ml ... ibuprofen infants oral suspension 50 MG/0.8ML, 80 MG/0.8ML ...... hydrocortisone/aloe ...... mg/1.25ml ...... HUMIRA SUBCUTANEOUS PREFILLED hydrocortisone/aloe max str ...... ibuprofen jr oral tablet 100 mg ...... SYRINGE KIT 10 MG/0.1ML, 20 hydrocortisone-acetic acid ...... ibuprofen junior ...... MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, hydrocortisone-aloe ...... ibuprofen junior strength ...... 80 MG/0.8ML, 80 MG/0.8ML & hydrocortisone-aloe max st ...... ibuprofen oral capsule 200 mg ...... 40MG/0.4ML ...... hydrolatum ...... ibuprofen oral suspension 100 mg/5ml ...... HUMULIN 70/30 KWIKPEN ...... hydromet ...... ibuprofen oral tablet 200 mg ...... HUMULIN 70/30 VIAL ...... hydromorphone hcl oral ...... ibuprofen oral tablet 400 mg, 600 mg, 800 HUMULIN N KWIKPEN ...... hydromorphone hcl rectal ...... mg ...... HUMULIN N VIAL ...... hydroxychloroquine sulfate oral ...... icatibant acetate ...... HUMULIN R U-500 KWIKPEN ...... hydroxyurea oral ...... iclevia ...... HUMULIN R U-500 VIAL hydroxyzine hcl oral syrup ...... ICLUSIG ...... (CONCENTRATED) ...... hydroxyzine hcl oral tablet 10 mg, 25 mg ..... IDHIFA ...... HUMULIN R VIAL ...... hydroxyzine hcl oral tablet 50 mg ...... iferex 150 forte ...... HYCAMTIN ORAL...... hydroxyzine pamoate oral capsule 100 mg .. ILARIS ...... hydralazine hcl oral ...... hydroxyzine pamoate oral capsule 25 mg .... ILEVRO ...... hydrochlorothiazide oral ...... hydroxyzine pamoate oral capsule 50 mg .... ILUMYA ...... hydrocodone bitartrate er oral capsule hyoscyamine sulfate er ...... imatinib mesylate ...... extended release 12 hour 10 mg, 20 mg .. hyoscyamine sulfate oral ...... IMBRUVICA ...... hydrocodone-acetaminophen oral solution hyoscyamine sulfate sl ...... imipramine hcl oral ...... 7.5-325 mg/15ml ...... hyoscyamine sulfate sublingual ...... imiquimod external cream 5 % ...... hydrocodone-acetaminophen oral tablet 10- hyosyne ...... IMODIUM A-D ORAL TABLET ...... 325 mg, 5-325 mg, 7.5-325 mg ...... HYPERSAL INHALATION NEBULIZATION IMODIUM MULTI-SYMPTOM RELIEF ...... hydrocodone-homatropine ...... SOLUTION 7 % ...... IMPAVIDO ...... hydrocortisone (perianal) external cream 2.5 HYPERTET S/D ...... INATAL GT ...... % ...... HYPOTEARS ...... incassia ...... hydrocortisone anti-itch external cream 0.5 HYSINGLA ER ...... INCRELEX ...... % ...... I INCRUSE ELLIPTA ...... hydrocortisone butyrate external ointment .... IBRANCE ...... indapamide ...... hydrocortisone butyrate external solution ..... ibu ...... indomethacin oral capsule 25 mg, 50 mg ...... hydrocortisone external cream 0.5 %, 2.5 % ibu-200 ...... indoor/outdoor allergy rlf ...... hydrocortisone external cream 1 %...... ibuprofen childrens oral tablet chewable 100 INFANRIX ...... hydrocortisone external lotion 2.5 % ...... mg ...... infant gas relief ...... hydrocortisone external ointment 0.5 % ...... ibuprofen cold & sinus ...... INFANTS ADVIL ...... hydrocortisone external ointment 1 % ...... ibuprofen cold/sinus oral tablet 30-200 mg ... infants gas relief ...... hydrocortisone external ointment 2.5 % ...... ibu-profen cold/sinus oral tablet 30-200 mg .. infants ibuprofen ......

147 infants pain & fever ...... ipratropium-albuterol ...... jock itch spray powder ...... infants pain relief drops ...... IRESSA ...... jolessa ...... infants pain/fever ...... iron oral tablet 240 (27 fe) mg ...... JORNAY PM ...... infants simethicone ...... iron oral tablet 325 (65 fe) mg ...... juleber ...... INGREZZA ORAL CAPSULE 40 MG, 80 MG iron supplement ...... JULUCA ...... iron supplement childrens ...... junel 1.5/30 ...... INGREZZA ORAL CAPSULE THERAPY ISENTRESS HD ...... junel 1/20 ...... PACK ...... ISENTRESS ORAL PACKET ...... junel fe oral tablet 1.5-30 mg-mcg ...... INLYTA ...... ISENTRESS ORAL TABLET ...... junel fe oral tablet 1-20 mg-mcg ...... INSPIRACHAMBER/LARGE ...... ISENTRESS ORAL TABLET CHEWABLE ... K INSPIRACHAMBER/MEDIUM ...... isibloom ...... KALETRA ORAL SOLUTION ...... INSPIRACHAMBER/MOUTHPIECE ...... isoniazid oral ...... KALETRA ORAL TABLET ...... INSPIRACHAMBER/SMALL ...... ISOPTO ATROPINE ...... kalliga ...... INSPIREASE ...... isosorbide dinitrate oral tablet 10 mg, 20 mg, KALYDECO ...... INSPIREASE RESERVOIR BAGS ...... 30 mg ...... KAPVAY ...... instacort 5 ...... isosorbide dinitrate oral tablet 5 mg ...... kariva ...... INSULIN ASP PROT & ASP FLEXPEN ...... isosorbide mononitrate ...... KAZANO ...... INSULIN ASPART ...... isosorbide mononitrate er ...... kelnor 1/35 ...... INSULIN ASPART PROT & ASPART ...... isotretinoin oral capsule 10 mg ...... kelnor 1/50 ...... INSULIN LISPRO ...... isotretinoin oral capsule 20 mg, 30 mg, 40 KESIMPTA ...... INSULIN LISPRO (1 UNIT DIAL) ...... mg ...... ketoconazole external cream ...... INSULIN PEN NEEDLES 30G X 8 MM ...... ISTALOL ...... ketoconazole external shampoo ...... INSULIN PEN NEEDLES 32G X 4 MM ...... itraconazole oral ...... ketoconazole oral ...... INSULIN PEN NEEDLES 32G X 6 MM ...... ivermectin oral ...... KETO-DIASTIX ...... INTELENCE ...... J KETONE CARE ...... INTRON A ...... JAKAFI ...... KETONE TEST ...... introvale ...... JANSSEN COVID-19 VACCINE ...... ketoprofen oral capsule 25 mg ...... INVEGA ORAL TABLET EXTENDED jantoven oral tablet 1 mg, 10 mg, 2 mg, 3 ketoprofen oral capsule 50 mg, 75 mg ...... RELEASE 24 HOUR 1.5 MG, 3 MG, 9 MG mg, 4 mg, 5 mg, 6 mg, 7.5 mg ...... ketorolac tromethamine ophthalmic solution ...... jantoven oral tablet 2.5 mg ...... 0.4 % ...... INVEGA ORAL TABLET EXTENDED JANUMET ...... ketorolac tromethamine ophthalmic solution RELEASE 24 HOUR 6 MG ...... JANUMET XR ...... 0.5 % ...... INVEGA SUSTENNA ...... JANUVIA ...... ketorolac tromethamine oral ...... INVEGA TRINZA ...... JARDIANCE ...... KETOSTIX ...... INVIRASE ...... jencycla ...... ketotifen fumarate ophthalmic ...... INVOKAMET ...... JENTADUETO ...... KEVZARA ...... INVOKAMET XR ...... JENTADUETO XR ...... KINERET ...... INVOKANA ...... jinteli ...... KISQALI (200 MG DOSE) ...... ipratropium bromide inhalation ...... jock itch external cream 1 % ...... KISQALI (400 MG DOSE) ...... ipratropium bromide nasal ...... jock itch max st ...... KISQALI (600 MG DOSE) ......

148 KITABIS PAK ...... lansoprazole oral tablet delayed release leucovorin calcium oral tablet 10 mg, 15 mg, klor-con ...... dispersible 15 mg ...... 5 mg ...... klor-con 10 ...... lansoprazole oral tablet delayed release leucovorin calcium oral tablet 25 mg ...... klor-con m10 ...... dispersible 30 mg ...... LEUKERAN ...... klor-con m20 ...... LANTUS SOLOSTAR ...... LEUKINE ...... klor-con/ef ...... LANTUS U-100 VIAL ...... leuprolide acetate injection ...... KOMBIGLYZE XR ...... lapatinib ditosylate ...... levalbuterol hcl inhalation ...... KONSYL DAILY FIBER ORAL POWDER larin 1.5/30 ...... LEVBID ...... 100 % ...... larin 1/20 ...... LEVEMIR U-100 FLEXTOUCH ...... konsyl daily fiber oral powder 28.3 %...... larin fe 1.5/30 ...... LEVEMIR U-100 VIAL ...... KORLYM ...... larin fe 1/20 ...... levetiracetam oral solution ...... K-PHOS ...... larissia ...... levetiracetam oral tablet ...... K-PHOS-NEUTRAL ...... latanoprost ophthalmic ...... levobunolol hcl ...... k-prime ...... LATUDA ...... levocetirizine dihydrochloride oral tablet ...... KRINTAFEL ...... laxacin ...... levofloxacin oral tablet ...... kurvelo ...... laxaclear ...... levonest ...... L laxative max str ...... levonorgest-eth estrad 91-day oral tablet labetalol hcl oral ...... laxative maximum strength oral tablet 25 mg 0.15-0.03 mg...... LAC-HYDRIN FIVE ...... laxative oral powder 17 gm/scoop ...... levonorgestrel ...... lactic acid external ...... laxative oral tablet delayed release 5 mg ..... levonorgestrel-ethinyl estrad oral tablet 0.1- lactobacillus oral tablet ...... laxative pills ...... 20 mg-mcg ...... LACTOJEN ...... laxative pills max st ...... levonorgestrel-ethinyl estrad oral tablet 0.15- lacto-pectin ...... laxative pills oral tablet 25 mg ...... 30 mg-mcg ...... lactulose encephalopathy ...... laxative rectal suppository 10 mg ...... levonorg-eth estrad triphasic ...... lactulose oral solution ...... laxative regular strength ...... levora 0.15/30 (28) ...... LAMISIL AT EXTERNAL CREAM ...... LEDIPASVIR-SOFOSBUVIR ...... levo-t ...... LAMISIL AT JOCK ITCH ...... leena ...... levothyroxine sodium oral tablet ...... lamivudine oral solution ...... leflunomide oral ...... levoxyl ...... lamivudine oral tablet 100 mg ...... LENVIMA (10 MG DAILY DOSE) ...... LEXIVA ORAL SUSPENSION ...... lamivudine oral tablet 150 mg, 300 mg ...... LENVIMA (12 MG DAILY DOSE) ...... LIALDA ...... lamivudine-zidovudine ...... LENVIMA (14 MG DAILY DOSE) ...... lice killing ...... lamotrigine oral tablet ...... LENVIMA (18 MG DAILY DOSE) ...... lice killing max st ...... lamotrigine oral tablet chewable ...... LENVIMA (20 MG DAILY DOSE) ...... lice killing max strength ...... lamotrigine starter kit-blue ...... LENVIMA (24 MG DAILY DOSE) ...... lice killing maximum strength ...... lamotrigine starter kit-green ...... LENVIMA (4 MG DAILY DOSE) ...... lice maximum strength ...... lamotrigine starter kit-orange ...... LENVIMA (8 MG DAILY DOSE) ...... lice treatment ...... LANCETS ...... lessina ...... lice treatment creme rinse ...... lansoprazole oral capsule delayed release LETAIRIS ...... lice treatment external shampoo 0.33-4 % .... 15 mg, 30 mg ...... letrozole oral ...... lidocaine external cream 4 % ...... lidocaine external patch 5 % ......

149 lidocaine hcl external cream 3 % ...... lorata-dine d ...... lubricating eye drops ophthalmic solution lidocaine hcl mouth/throat ...... loratadine d 12hr ...... 0.4-0.3 % ...... lidocaine hcl urethral/mucosal ...... loratadine oral syrup 5 mg/5ml ...... lubricating eye/overnight ...... lidocaine viscous hcl ...... loratadine oral tablet 10 mg ...... lubricating plus ...... lidocaine-prilocaine external cream ...... loratadine oral tablet dispersible 10 mg ...... lubricating plus eye drops ...... lidopin external cream 3 % ...... loratadine-d ...... lubricating tears ...... lillow ...... loratadine-d 12hr ...... lubricating tears eye drops ...... linezolid oral suspension reconstituted ...... loratadine-d 24hr ...... LUMIGAN ...... linezolid oral tablet ...... lorazepam intensol ...... LUNESTA ...... LINZESS ...... lorazepam oral concentrate 2 mg/ml ...... LUPANETA PACK ...... liothyronine sodium oral ...... lorazepam oral tablet ...... LUPRON DEPOT (1-MONTH) ...... liquibid ...... LORBRENA ...... LUPRON DEPOT (3-MONTH) ...... liquid acetaminophen ...... losartan potassium oral ...... LUPRON DEPOT (4-MONTH) liquid allergy relief ...... losartan potassium-hctz ...... INTRAMUSCULAR KIT 30MG ...... liquid pain relief ...... LOTRIMIN AF EXTERNAL POWDER ...... LUPRON DEPOT (6-MONTH) lisinopril oral ...... lovastatin oral ...... INTRAMUSCULAR KIT 45MG ...... lisinopril-hydrochlorothiazide ...... low-ogestrel ...... LUPRON DEPOT-PED (1-MONTH) ...... lithium ...... loxapine succinate ...... LUPRON DEPOT-PED (3-MONTH) ...... lithium carbonate er oral tablet extended LUBIPROSTONE ...... lutera ...... release 300 mg ...... lubricant drops fast act ...... LUXIQ ...... lithium carbonate er oral tablet extended lubricant drops long last ...... lyleq ...... release 450 mg ...... lubricant drops ophthalmic gel 0.25-0.3 % .... LYNPARZA ...... lithium carbonate oral ...... lubricant drops ophthalmic solution ...... lysiplex plus oral tablet ...... little ones childrens ...... lubricant eye drops (pf) ophthalmic solution LYSODREN ...... LMX 4 ...... 0.4-0.3 %...... LYUMJEV ...... LOKELMA ...... lubricant eye drops (pf) ophthalmic solution lyza ...... long acting nasal spray ...... 0.5 % ...... M long lasting antacid ...... lubricant eye drops ophthalmic solution 0.4- MAALOX ...... long lasting nasal spray...... 0.3 % ...... MAALOX CHILDRENS ...... LONSURF ...... lubricant eye drops ophthalmic solution 0.5 MAALOX MAX ORAL SUSPENSION ...... loperamide hcl oral capsule ...... % ...... MAALOX MULTI SYMPTOM MAX ST ...... loperamide hcl oral tablet ...... lubricant eye drops ophthalmic solution 0.6 mag-al plus ...... lopinavir-ritonavir ...... % ...... mag-al plus xs ...... loradamed ...... lubricant eye drops pf ...... magnesium citrate oral solution ...... lorata-d ...... lubricant eye nighttime ...... magnesium oral tablet 500 mg ...... loratadine allergy relief oral tablet 10 mg ...... lubricant eye ophthalmic solution 0.4-0.3 % . magnesium oxide oral tablet 400 (241.3 mg) loratadine allergy relief oral tablet dispersible lubricant eye pm ...... mg ...... 10 mg ...... lubricant pm ...... magnesium oxide oral tablet 400 mg ...... loratadine childrens oral solution 5 mg/5ml ... lubricating eye drop ...... magnesium oxide oral tablet 420 mg ...... loratadine childrens oral syrup 5 mg/5ml ...... magnesium oxide oral tablet 500 mg ......

150 magnesium-oxide ...... mefloquine hcl ...... methylphenidate hcl er (cd) ...... malathion ...... mega probiotic ...... methylphenidate hcl er (la) oral capsule MAOX ...... megestrol acetate oral suspension 40 mg/ml extended release 24 hour 20 mg, 30 mg, mapap acetaminophen extra str...... megestrol acetate oral tablet 20 mg ...... 40 mg ...... mapap arthritis pain ...... megestrol acetate oral tablet 40 mg ...... methylphenidate hcl er oral tablet extended mapap childrens ...... meijer allergy relief-d ...... release 10 mg, 20 mg ...... mapap oral capsule ...... meijer antacid ...... methylphenidate hcl er oral tablet extended maprotiline hcl ...... meijer anti-diarrheal ...... release 18 mg, 27 mg, 36 mg, 54 mg ...... marlissa ...... MEKINIST ...... methylphenidate hcl er oral tablet extended MASK VORTEX/CHILD/FROG ...... meloxicam oral tablet ...... release 24 hour ...... MASK VORTEX/TODDLER/LADYBUG ...... melphalan ...... methylphenidate hcl oral tablet ...... MATULANE ...... memantine hcl oral solution 2 mg/ml ...... methylprednisolone oral tablet 16 mg, 4 mg .. matzim la ...... memantine hcl oral tablet ...... methylprednisolone oral tablet 32 mg, 8 mg .. MAVENCLAD (10 TABS) ...... MENACTRA ...... methylprednisolone oral tablet therapy pack . MAVENCLAD (4 TABS) ...... MENEST ...... metoclopramide hcl oral solution ...... MAVENCLAD (5 TABS) ...... MENOSTAR ...... metoclopramide hcl oral tablet ...... MAVENCLAD (6 TABS) ...... MENQUADFI ...... metolazone ...... MAVENCLAD (7 TABS) ...... MENVEO ...... metoprolol succinate er ...... MAVENCLAD (8 TABS) ...... mercaptopurine oral ...... metoprolol tartrate oral tablet 100 mg, 50 mg MAVENCLAD (9 TABS) ...... mesalamine oral capsule delayed release metoprolol tartrate oral tablet 25 mg ...... MAVYRET ...... 400 mg ...... METROGEL ...... maxi-tuss ac ...... mesalamine rectal ...... metronidazole external ...... maxi-tuss gmx ...... MESNEX ORAL ...... metronidazole oral tablet ...... maxi-tuss pe max ...... metformin hcl er ...... metronidazole vaginal ...... MAYZENT ...... metformin hcl er (osm) ...... mexiletine hcl oral ...... m-clear wc ...... metformin hcl oral tablet ...... mi-acid gas relief ...... m-dryl ...... methazolamide oral ...... micaderm ...... meclizine hcl oral tablet 12.5 mg ...... methenamine hippurate ...... miconazole 3 ...... meclizine hcl oral tablet 25 mg ...... methergine ...... miconazole 3 applicator vaginal kit 200 & 2 meclizine hcl oral tablet chewable ...... methimazole oral ...... mg-% (9gm) ...... medicated spot ...... methocarbamol oral ...... miconazole 3 combo pack app ...... medifin 400 ...... methotrexate oral ...... miconazole 3 combo pack vaginal kit 200 & medi-first triple antibiotic ...... methotrexate sodium (pf) ...... 2 mg-% (9gm) ...... mediproxen ...... methotrexate sodium injection ...... miconazole 7 day treatment ...... MEDISENSE GLUCOSE KETONE CONTR . methotrexate sodium oral ...... miconazole 7 vaginal cream 2 % ...... MEDISENSE HI/MID/LOW CONTROL ...... methoxsalen rapid ...... miconazole 7 vaginal suppository 100 mg ..... MEDISENSE HIGH/LOW CONTROL ...... methyldopa ...... miconazole antifungal ...... MEDISENSE MID CONTROL ...... methyldopa-hydrochlorothiazide ...... miconazole nitrate external ...... medroxyprogesterone acetate intramuscular methylergonovine maleate oral ...... miconazole nitrate vaginal ...... medroxyprogesterone acetate oral ...... METHYLIN ...... miconazorb af ......

151 microgestin 1.5/30 ...... M-NATAL PLUS ...... mucus d extended release ...... microgestin 1/20 ...... mometasone furoate external ...... mucus d max st er ...... microgestin fe 1.5/30 ...... mondoxyne nl oral capsule 100 mg ...... mucus dm ...... microgestin fe 1/20 ...... mono-linyah ...... mucus er oral tablet extended release 12 midodrine hcl ...... montelukast sodium oral ...... hour 1200 mg ...... migraine formula ...... mood support probiotic ...... mucus extended release oral tablet migraine relief ...... morgidox oral ...... extended release 12 hour 1200 mg ...... milantex ...... morphine sulfate (concentrate) oral solution mucus relief chest oral tablet 400 mg ...... milantex extra strength ...... 100 mg/5ml, 20 mg/ml ...... mucus relief cough children ...... mili ...... morphine sulfate er oral tablet extended mucus relief cough childrens ...... milk of magnesia ...... release ...... mucus relief d max strength ...... mimvey ...... morphine sulfate oral ...... mucus relief d oral tablet extended release mineral oil enema ...... morphine sulfate rectal ...... 12 hour 60-600 mg ...... mineral oil heavy oral ...... MOTEGRITY ...... mucus relief dm max oral liquid ...... mineral oil oral oil ...... motion sickness oral tablet 50 mg ...... mucus relief dm oral liquid ...... MINERAL OIL ORAL OIL ...... motion sickness relief oral tablet 50 mg ...... mucus relief dm oral tablet extended release mineral oil rectal enema ...... motion sickness relief oral tablet chewable 12 hour 30-600 mg ...... mini nicotine ...... 25 mg ...... mucus relief er ...... minitran ...... motion-time ...... mucus relief max st ...... MINIVELLE ...... MOTRIN CHILDRENS ...... mucus relief max strength oral tablet minocycline hcl oral capsule 100 mg ...... MOTRIN IB ...... extended release 12 hour 1200 mg ...... minocycline hcl oral capsule 50 mg ...... MOTRIN INFANTS DROPS ...... mucus relief oral tablet ...... minoxidil oral ...... MOVANTIK ...... mucus-d ...... mintox maximum strength ...... MOXEZA ...... mucus-dm ...... mintox plus ...... MOZOBIL ...... mucus-er oral tablet extended release 12 MIRALAX ORAL POWDER ...... m-pap ...... hour 1200 mg ...... MIRCERA INJECTION SOLUTION MUCINEX CHILDRENS FREEFROM ORAL MULPLETA ...... PREFILLED SYRINGE 100 MCG/0.3ML, LIQUID 5-100 MG/5ML ...... MULTAQ ...... 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MUCINEX CHILDRENS STUFFY NOSE ..... multi vitamin ...... MCG/0.3ML ...... MUCINEX COUGH CHILDRENS ...... multi vitamin w/d-3 ...... mirtazapine oral tablet 15 mg, 30 mg ...... MUCINEX D ...... multiple vitamin-folic acid ...... mirtazapine oral tablet 45 mg, 7.5 mg ...... MUCINEX D MAX STRENGTH ...... multiple vitamins essential ...... MIRVASO ...... MUCINEX DM ...... multiple vitamins/iron ...... misoprostol oral ...... MUCINEX FAST-MAX DM MAX ...... multi-vit/iron/fluoride ...... MITIGARE ...... MUCINEX MAXIMUM STRENGTH ...... multi-vitamin ...... mm arthritis pain ...... MUCINEX SINUS-MAX CLEAR & COOL ..... multi-vitamin/fluoride ...... mm cetirizine hcl ...... MUCINEX SINUS-MAX SINUS/ALLRGY ..... multivitamin/fluoride oral solution ...... mm clearlax ...... mucus & cough relief child ...... multivitamin/fluoride oral tablet chewable mm stool softener laxative ...... mucus & cough relief childrens ...... 0.25 mg, 0.5 mg, 1 mg ...... M-M-R II ...... mucus d ...... multi-vitamin/fluoride/iron ......

152 multi-vitamin/iron ...... nasal decongestant max st ...... natura-lax ...... mupirocin external ...... nasal decongestant oral tablet 30 mg ...... nausea control ...... MURO 128 OPHTHALMIC OINTMENT ...... nasal decongestant oral tablet extended nausea relief ...... MURO 128 OPHTHALMIC SOLUTION 5 % . release 12 hour 120 mg ...... NAYZILAM ...... my choice ...... nasal decongestant pe ...... necon 0.5/35 (28) ...... my way ...... nasal decongestant pe max st ...... nefazodone hcl ...... mycophenolate mofetil oral ...... nasal decongestant spray ...... NEODOT THERMOMETER ...... mycophenolate sodium ...... nasal four ...... NEOMULTIVITE ...... MYCOZYL AP ...... nasal mist nasal solution ...... neomycin sulfate oral ...... MYDAYIS ...... NASAL MOIST NASAL SOLUTION...... neomycin-bacitracin zn-polymyx ...... myferon 150 ...... nasal moisturizing spray ...... neomycin-polymyxin-dexameth ophthalmic myferon 150 forte ...... nasal relief ...... ointment ...... MYLERAN ...... nasal relief moisturizing ...... neomycin-polymyxin-dexameth ophthalmic mynephrocaps ...... nasal spray ...... suspension 3.5-10000-0.1 ...... MYNEPHRON ...... nasal spray 12 hour ...... neomycin-polymyxin-gramicidin ...... myorisan ...... nasal spray anti-drip ...... neomycin-polymyxin-hc otic ...... MYRBETRIQ ...... nasal spray extra moist ...... NEONATAL COMPLETE ORAL TABLET MYTESI ...... nasal spray extra moisturizing ...... 27-1 MG ...... N nasal spray fast acting ...... NEONATAL COMPLETE ORAL TABLET nabumetone oral tablet 500 mg ...... nasal spray moisturizing ...... 29-1 MG ...... nabumetone oral tablet 750 mg ...... nasal spray no drip ...... NEONATAL PLUS ...... nafrinse ...... nasal spray saline ...... NEONATAL VITAMIN ...... nafrinse drops ...... nasal spray sinus ...... neo-polycin ...... naloxone hcl injection ...... NASALCROM ...... neo-polycin hc ...... naltrexone hcl oral ...... nateglinide ...... NEOSPORIN ORIGINAL ...... NAPHCON-A ...... natural daily fiber ...... NEO-SYNEPHRINE COLD/ALLRG MILD ..... naproxen oral suspension ...... natural fiber laxative oral powder 58.6 % ...... NEO-SYNEPHRINE COLD/ALLRGY EXT .... naproxen oral tablet ...... natural fiber oral capsule 0.52 gm ...... NEO-SYNEPHRINE COLD/ALLRGY REG ... naproxen oral tablet delayed release ...... natural fiber oral powder 28.3 % ...... nephro vitamins ...... naproxen sodium oral tablet 220 mg ...... natural fiber oral powder 48.57 % ...... NEPHRO-VITE ...... NARAMIN ...... natural fiber oral powder 58.6 % ...... NESINA ...... naratriptan hcl ...... natural fiber supplement oral powder ...... NEULASTA ...... NARCAN ...... natural laxative ...... NEULASTA ONPRO ...... NASACORT ALLERGY 24HR ...... natural laxative/stool soft ...... NEUPOGEN ...... NASACORT ALLERGY 24HR CHILDREN ... natural senna laxative ...... NEUTEK 2TEK CONTROL ...... nasal allergy 24 hour ...... natural tears pf ...... NEUTROGENA OIL-FREE ACNE WASH ..... nasal allergy nasal aerosol 55 mcg/act ...... natural vegetable ...... NEVANAC ...... nasal allergy spray ...... natural vegetable fiber ...... nevirapine ...... nasal decongestant 12 hour ...... natural vegetable laxative ...... nevirapine er ...... nasal decongestant 12hr ...... natural vitamin e ...... new day ......

153 NEXAVAR ...... nighttime sleep aid max st ...... NORITATE ...... NEXIUM ORAL CAPSULE DELAYED nimodipine oral ...... norlyda ...... RELEASE ...... NINLARO ...... norlyroc ...... NEXIUM ORAL PACKET 10 MG, 20 MG, 40 nitazoxanide ...... NORPACE ...... MG ...... NITRO-DUR TRANSDERMAL PATCH 24 NORPACE CR ...... NEXIUM ORAL PACKET 2.5 MG, 5 MG ...... HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 nortrel 0.5/35 (28) ...... NEXLETOL ...... MG/HR, 0.6 MG/HR ...... nortrel 1/35 (21) ...... NEXLIZET ...... nitrofurantoin ...... nortrel 1/35 (28) ...... niacin (antihyperlipidemic) ...... nitrofurantoin macrocrystal oral capsule 100 nortrel 7/7/7 ...... niacin er (antihyperlipidemic) ...... mg, 50 mg ...... nortriptyline hcl oral ...... niacin er oral capsule extended release 250 nitrofurantoin macrocrystal oral capsule 25 NORVIR ORAL PACKET ...... mg ...... mg ...... NORVIR ORAL SOLUTION ...... niacor ...... nitrofurantoin monohydrate macrocrystals .... nose drops extstrength ...... NICODERM CQ ...... nitroglycerin sublingual ...... nose drops nasal decongest ...... NICORETTE ...... nitroglycerin transdermal ...... nose drops nasal solution 1 % ...... NICORETTE MINI ...... nitroglycerin translingual ...... NOVAMV PEDIATRIC MULTI-VITAMIN ...... NICORETTE STARTER KIT ...... NITYR ...... novarel intramuscular solution reconstituted nicotine gum mouth/throat gum 2 mg...... NIVA-PLUS ...... 10000 unit ...... nicotine gum mouth/throat gum 4 mg...... NIVESTYM ...... NOVAREL INTRAMUSCULAR SOLUTION nicotine gum mouth/throat lozenge 2 mg ...... no drip nasal relief ...... RECONSTITUTED 5000 UNIT ...... nicotine gum mouth/throat lozenge 4 mg ...... no drip nasal spray ...... NOVOLIN 70/30 FLEXPEN ...... nicotine mini ...... NOCDURNA ...... NOVOLIN 70/30 RELION ...... nicotine mouth/throat gum 2 mg ...... nohist-lq ...... NOVOLIN 70/30 VIAL ...... nicotine mouth/throat gum 4 mg ...... non-aspirin 8 hour ...... NOVOLIN N FLEXPEN ...... nicotine mouth/throat lozenge 2 mg ...... non-aspirin childrens ...... NOVOLIN N RELION ...... nicotine mouth/throat lozenge 4 mg ...... non-aspirin extra strength ...... NOVOLIN N VIAL ...... nicotine polacrilex mini ...... non-aspirin jr strength ...... NOVOLIN R FLEXPEN ...... nicotine polacrilex mouth/throat ...... non-aspirin oral tablet 325 mg ...... NOVOLIN R RELION ...... nicotine step 1 ...... non-aspirin oral tablet 500 mg ...... NOVOLIN R VIAL ...... nicotine step 2 ...... non-aspirin pain relief ...... NOVOLOG FLEXPEN ...... nicotine step 3 ...... non-pseudo sinus decongestant ...... NOVOLOG MIX 70/30 FLEXPEN ...... nicotine transdermal patch 24 hour 14 nora-be ...... NOVOLOG MIX 70/30 VIAL ...... mg/24hr, 7 mg/24hr ...... NORDITROPIN FLEXPRO ...... NOVOLOG PENFILL ...... nicotine transdermal patch 24 hour 21 norethin ace-eth estrad-fe oral tablet ...... NOVOLOG U-100 VIAL ...... mg/24hr ...... norethindrone acetate oral ...... NOVOTWIST PEN NEEDLE ...... nicotine transdermal system ...... norethindrone acet-ethinyl est ...... NUBEQA ...... nifedipine er ...... norethindrone oral ...... NUCALA SUBCUTANEOUS SOLUTION nifedipine er osmotic release ...... norgestimate-eth estradiol ...... AUTO-INJECTOR ...... nifedipine oral ...... norgestimate-ethinyl estradiol triphasic oral NUCALA SUBCUTANEOUS SOLUTION nighttime dry-eye relief ...... tablet 0.18/0.215/0.25 mg-35 mcg ...... PREFILLED SYRINGE ......

154 NUCYNTA ER ...... omega-3-acid ethyl esters ...... opcicon one-step ...... NU-IRON ...... omeprazole magnesium oral capsule OPSUMIT ...... NULEV ...... delayed release...... option 2 ...... NURTEC ...... omeprazole magnesium oral tablet delayed ORACEA ...... NUTRAPLUS ...... release ...... oralone ...... nutrifac zx ...... omeprazole oral capsule delayed release 10 oralyte freezer pops ...... NUTROPIN AQ NUSPIN 10 ...... mg, 20 mg, 20.6 (20 base) mg, 40 mg ...... ORENCIA CLICKJECT ...... NUTROPIN AQ NUSPIN 20 ...... omeprazole oral tablet delayed release 20 ORENCIA SUBCUTANEOUS ...... NUTROPIN AQ NUSPIN 5 ...... mg ...... ORFADIN ...... NUZYRA ORAL ...... OMNARIS ...... ORIAHNN ...... nyamyc ...... OMNIFLEX DIAPHRAGM ...... ORILISSA ...... nylia 7/7/7 ...... OMNITROPE ...... ORKAMBI ...... nymyo ...... once daily ...... orphenadrine citrate er ...... nystatin external cream ...... once daily/iron ...... orsythia ...... nystatin external ointment ...... ondansetron hcl oral ...... OS-CAL CALCIUM + D3 ...... nystatin external powder ...... ondansetron odt ...... oscimin ...... nystatin mouth/throat ...... one daily ...... oscimin sr ...... nystatin oral ...... one daily plus iron ...... oseltamivir phosphate oral capsule ...... nystop ...... ONE VITE WOMENS ...... oseltamivir phosphate oral suspension NYVEPRIA ...... ONE VITE WOMENS PLUS ...... reconstituted ...... O one-daily multi vitamins ...... OSENI ...... OCEAN FOR KIDS ...... one-daily multi-vitamin oral tablet ...... OSPHENA ...... OCEAN NASAL SPRAY ...... one-daily multi-vitamin/iron ...... OTEZLA ...... octreotide acetate ...... one-daily/iron ...... OTREXUP ...... ODEFSEY ...... ONETOUCH ULTRA ...... OVACE PLUS WASH EXTERNAL LIQUID ... ODOMZO ...... ONETOUCH ULTRA 2 KIT W/DEVICE ...... OVACE WASH ...... ofloxacin ophthalmic ...... ONETOUCH ULTRA CONTROL ...... OVIDREL ...... ofloxacin oral ...... ONETOUCH ULTRA MINI KIT W/DEVICE... oxaprozin ...... ofloxacin otic ...... ONETOUCH VERIO FLEX SYSTEM KIT oxazepam ...... ointment base ...... W/DEVICE ...... , oxcarbazepine oral suspension ...... olanzapine oral tablet ...... ONETOUCH VERIO IN VITRO SOLUTION . oxcarbazepine oral tablet ...... olanzapine oral tablet dispersible 10 mg, 20 ONETOUCH VERIO IQ SYSTEM ...... oxybutynin chloride er ...... mg ...... ONETOUCH VERIO KIT W/DEVICE ...... oxybutynin chloride oral ...... olanzapine oral tablet dispersible 15 mg, 5 ONETOUCH VERIO REFLECT KIT oxycodone hcl oral concentrate 100 mg/5ml . mg ...... W/DEVICE ...... , oxycodone hcl oral solution ...... olopatadine hcl ophthalmic ...... ONETOUCH VERIO SYNC SYSTEM ...... oxycodone hcl oral tablet ...... OLUMIANT ...... ONETOUCH VERIO TEST STRIPS ...... oxycodone-acetaminophen oral tablet 10- OLUX ...... ONEVITE ...... 325 mg, 5-325 mg, 7.5-325 mg ...... OLUX-E ...... ONEXTON ...... oxycodone-aspirin ...... OMECLAMOX-PAK ...... ONGLYZA ...... OXYCONTIN ......

155 oxymorphone hcl er ...... pain relief/rapid burst ...... pediatric electrolyte oral solution ...... OXYTROL FOR WOMEN ...... pain relieve child dye-free ...... pediavit ...... oysco 500+d ...... pain reliever childrens oral suspension 160 peg 3350 oral powder ...... oyster shell calcium 500 + d ...... mg/5ml ...... peg 3350-kcl-na bicarb-nacl ...... oyster shell calcium oral tablet 500 mg ...... pain reliever ex st oral liquid 500 mg/15ml ... PEGASYS ...... oyster shell calcium plus d oral tablet 500- pain reliever ex st oral tablet 500 mg ...... penicillamine oral tablet ...... 200 mg-unit ...... pain reliever ex st oral tablet extended penicillin v potassium ...... oyster shell calcium/d oral tablet 250-125 release 650 mg ...... pentamidine isethionate inhalation ...... mg-unit, 250-250 mg-unit, 500-400 mg- pain reliever extra strength ...... PENTASA ...... unit ...... pain reliever infants oral suspension 160 pentazocine-naloxone hcl ...... oyster shell calcium/d oral tablet 500-200 mg/5ml ...... pentoxifylline er ...... mg-unit ...... pain reliever oral tablet 325 mg ...... peptic relief ...... oyster shell calcium/vit d ...... pain reliever oral tablet 500 mg ...... PEPTO-BISMOL ORAL SUSPENSION 524 oyster shell calcium/vitamin d oral tablet...... pain reliever plus ...... MG/30ML ...... OZEMPIC SUBCUTANEOUS SOLUTION pain-off ...... PERDIEM OVERNIGHT RELIEF ...... PEN-INJECTOR 2 MG/1.5ML ...... paliperidone er oral tablet extended release PERFOROMIST ...... P 24 hour 1.5 mg, 3 mg, 9 mg ...... periogard ...... p col-rite ...... paliperidone er oral tablet extended release permethrin external ...... PACERONE ...... 24 hour 6 mg ...... perphenazine oral tablet 16 mg, 2 mg ...... pain & fever child ...... PANADOL CHILDRENS ...... perphenazine oral tablet 4 mg, 8 mg ...... pain & fever childrens oral suspension 160 PANADOL EXTRA STRENGTH ...... perphenazine-amitriptyline oral tablet 2-10 mg/5ml ...... PANADOL INFANTS ...... mg, 4-10 mg, 4-25 mg, 4-50 mg ...... pain & fever childrens oral tablet chewable PANCREAZE ...... perphenazine-amitriptyline oral tablet 2-25 160 mg ...... PANOXYL ...... mg ...... pain & fever infants ...... PANRETIN ...... PERSERIS ...... pain relief childrens oral suspension 160 pantoprazole sodium oral packet ...... pharbedryl ...... mg/5ml ...... pantoprazole sodium oral tablet delayed PHARBETOL EXTRA STRENGTH ...... pain relief childrens oral tablet chewable 160 release ...... PHARBETOL ORAL TABLET 325 MG ...... mg ...... paromomycin sulfate oral ...... pharbinex ...... pain relief extra st ...... paroxetine hcl ...... PHAZYME ...... pain relief extra strength ...... PASER ...... PHAZYME ULTRA STRENGTH ...... pain relief infants oral suspension 160 PATADAY OPHTHALMIC SOLUTION 0.1 phenazo oral tablet 200 mg ...... mg/5ml ...... %, 0.2 %...... phenazo oral tablet 95 mg ...... pain relief oral liquid 500 mg/15ml ...... ped electrolyte freeze pop ...... phenazopyridine hcl oral tablet 100 mg ...... pain relief oral tablet 325 mg ...... ped electrolyte freezer pops ...... phenazopyridine hcl oral tablet 200 mg ...... pain relief oral tablet 500 mg ...... PEDIA-LAX ORAL LIQUID ...... phenobarbital oral elixir ...... pain relief oral tablet extended release 650 PEDIA-LAX RECTAL SUPPOSITORY 1 GM phenobarbital oral tablet ...... mg ...... PEDIALYTE FREEZER POPS ...... phenylephrine hcl ophthalmic ...... pain relief regular st ...... PEDIALYTE ORAL SOLUTION ...... phenylephrine hcl oral ...... pain relief regular strength ...... PEDIALYTE SINGLES ...... phenytoin infatabs ......

156 phenytoin oral suspension 125 mg/5ml ...... polymyxin b-trimethoprim ...... PRECISION SOF-TACT MONITOR ...... phenytoin oral tablet chewable ...... polysaccharide iron complex ...... PRECISION XTRA BLOOD GLUCOSE ...... phenytoin sodium extended ...... polysaccharide iron forte ...... PRECISION XTRA DEVICE ...... philith ...... polysaccharide-iron complex ...... PRECISION XTRA MONITOR ...... PHILLIPS MILK OF MAGNESIA ORAL POLYSPORIN ...... prednicarbate external cream ...... SUSPENSION 400 MG/5ML ...... polyvinyl alcohol ophthalmic ...... prednisolone acetate ophthalmic ...... PHOSPHA 250 NEUTRAL ...... POMALYST ...... prednisolone acetate p-f ...... PHOSPHASAL ...... portia-28 ...... prednisolone oral solution ...... phosphorous ...... potassium chloride crys er ...... prednisolone sodium phosphate ophthalmic . phospho-trin 250 neutral ...... potassium chloride er oral capsule extended prednisolone sodium phosphate oral solution phytonadione oral ...... release 10 meq ...... 15 mg/5ml ...... pilocarpine hcl ophthalmic ...... potassium chloride er oral tablet extended prednisolone sodium phosphate oral solution pilocarpine hcl oral ...... release ...... 6.7 (5 base) mg/5ml ...... pimecrolimus ...... potassium chloride oral packet ...... prednisone intensol ...... pimozide ...... potassium chloride oral solution 20 prednisone oral solution ...... pimtrea ...... meq/15ml (10%), 40 meq/15ml (20%) ...... prednisone oral tablet 1 mg, 2.5 mg, 5 mg, pink bismuth maximum strength ...... potassium citrate er oral tablet extended 50 mg ...... pink bismuth oral suspension 262 mg/15ml .. release 10 meq (1080 mg) ...... prednisone oral tablet 10 mg, 20 mg ...... pink bismuth oral tablet 262 mg ...... potassium citrate er oral tablet extended prednisone oral tablet therapy pack 10 mg pink bismuth oral tablet chewable 262 mg .... release 15 meq (1620 mg) ...... (21) ...... pink-bismuth ...... potassium citrate er oral tablet extended prednisone oral tablet therapy pack 10 mg pioglitazone hcl ...... release 5 meq (540 mg) ...... (48), 5 mg (21), 5 mg (48) ...... PIQRAY (200 MG DAILY DOSE) ...... potassium citrate-citric acid ...... PREFEST ...... PIQRAY (250 MG DAILY DOSE) ...... povidone iodine ...... pregabalin oral ...... PIQRAY (300 MG DAILY DOSE) ...... povidone-iodine external solution ...... pregnyl ...... pirmella 1/35 ...... PRADAXA ...... PREMARIN ORAL ...... pirmella 7/7/7 ...... PRALUENT ...... PREMARIN VAGINAL ...... piroxicam oral ...... pramipexole dihydrochloride ...... PREMIUM CONDOMS LUBRICATED ...... PLAN B ONE-STEP ...... prasugrel hcl ...... PREMPHASE ...... PLEGRIDY STARTER PACK ...... praziquantel oral ...... PREMPRO ...... PLEGRIDY SUBCUTANEOUS ...... prazosin hcl oral ...... PRENATABS RX ...... PNEUMOVAX 23 ...... PRECISION GLUCOSE CONTROL ...... prenatal formula oral tablet 28-0.8 mg ...... pnv tabs 29-1 ...... PRECISION GLUCOSE CONTROL SOLN .. prenatal gummy oral tablet chewable 0.4-25 podofilox external ...... PRECISION GLUCOSE KETONE CONTR .. mg ...... poly bacitracin ...... PRECISION GLUCOSE/KETONE CONTR .. prenatal low iron ...... polycin ...... PRECISION LINK ...... prenatal multi+dha ...... polyethylene glycol 3350 oral powder ...... PRECISION PCX PLUS TEST ...... prenatal multivitamins ...... polyethylene glycol 3350-grx oral powder ..... PRECISION POINT OF CARE TEST ...... prenatal oral tablet 27-0.8 mg ...... poly-iron 150 ...... PRECISION QID MONITOR ...... prenatal oral tablet 27-1 mg ...... poly-iron 150 forte ...... PRECISION QID TEST ...... prenatal oral tablet 28-0.8 mg ......

157 prenatal plus iron ...... proctozone-hc ...... pyridostigmine bromide oral solution ...... prenatal vitamin plus low iron ...... progesterone oral ...... pyridostigmine bromide oral tablet 60 mg ...... prenatal vitamins oral tablet 28-0.8 mg ...... PROLENSA ...... pyridoxine hcl oral ...... prenatal/iron ...... PROMACTA ORAL PACKET 25 MG ...... pyrimethamine oral ...... PRENATAL-U ...... PROMACTA ORAL TABLET ...... Q PRENATRIX ...... promethazine hcl oral ...... QBREXZA ...... PRENATRYL ...... promethazine hcl rectal ...... QTERN ...... PRENATVITE RX ...... promethazine vc ...... quetiapine fumarate ...... preplus ...... promethazine vc/codeine ...... quetiapine fumarate er ...... PRETAB ...... promethazine-codeine ...... QUFLORA PEDIATRIC ORAL SOLUTION PREVACID ...... promethazine-dm ...... 0.5 MG/ML ...... PREVACID 24HR ...... promethazine-phenyleph-codeine ...... quinapril hcl ...... prevalite oral powder ...... promethazine-phenylephrine ...... quinapril-hydrochlorothiazide ...... PREVIDENT 5000 DRY MOUTH ...... promethegan ...... quinidine gluconate er ...... PREVIDENT 5000 PLUS ...... PRONUTRIENTS VITAMIN D3 ...... quinidine sulfate ...... PREVIDENT DENTAL ...... propafenone hcl ...... QUINTET CONTROL HIGH/NORMAL ...... PREVIDENT MOUTH/THROAT ...... propranolol hcl er ...... quit2 ...... previfem ...... propranolol hcl oral ...... quit4 ...... PREVNAR 13 ...... propranolol-hctz ...... QVAR REDIHALER ...... PREZCOBIX ...... propylthiouracil oral ...... R PREZISTA ...... PROTOPIC EXTERNAL OINTMENT 0.03 % radiance platinum vitamin d3 ...... PRIFTIN ...... PROTOPIC EXTERNAL OINTMENT 0.1 % . raloxifene hcl ...... PRILOSEC ...... PROVENTIL HFA ...... ramipril ...... primaquine phosphate ...... provil ...... ranolazine er ...... primidone oral ...... pseudoephedrine hcl 12 hr ...... RASUVO ...... PRISTIQ ...... pseudoephedrine hcl er ...... RAVICTI ...... PROAIR HFA ...... pseudoephedrine hcl oral tablet 30 mg ...... react ...... probenecid ...... pseudoephedrine-bromphen-dm ...... ready-to-use enema rectal enema ...... pro-biotic blend ...... pseudoephedrine-guaifenesin er ...... REBIF ...... probiotic colon care ...... psyldex ...... REBIF REBIDOSE ...... probiotic complex ...... PULMICORT FLEXHALER ...... REBIF REBIDOSE TITRATION PACK ...... probiotic maximum strength ...... PULMOZYME ...... REBIF TITRATION PACK ...... probiotic oral capsule ...... PURALUBE ...... reclipsen ...... probiotic oral capsule 250 mg ...... pure & gentle lubricant ...... RECOMBIVAX HB ...... probiotic pearls ex st ...... purelax oral powder ...... RECTIV ...... prochlorperazine ...... PYLERA ...... REDITREX ...... prochlorperazine maleate oral ...... pyrazinamide oral ...... redness relief ophthalmic solution 0.012-0.2 PROCRIT ...... PYRIDIUM ORAL TABLET 100 MG ...... % ...... PROCTOFOAM HC ...... PYRIDIUM ORAL TABLET 200 MG ...... refenesen 400 ...... procto-med hc ...... pyridostigmine bromide er ...... REFRESH LACRI-LUBE ......

158 REFRESH P.M...... rifampin oral ...... rynex pe ...... REFRESH PLUS ...... riluzole ...... rynex pse ...... REFRESH TEARS ...... rimantadine hcl ...... RYTHMOL SR ...... REGRANEX ...... RINVOQ ...... S REHYDRALYTE ...... RISAQUAD ...... saccharomyces boulardii ...... RELENZA DISKHALER ...... RISAQUAD-2 ...... SAIZEN ...... relief eye drops ...... RISPERDAL CONSTA ...... saline enema ...... RELISTOR ...... RISPERDAL ORAL SOLUTION ...... saline mist spray ...... RENAL ...... RISPERDAL ORAL TABLET ...... saline nasal spray ...... RENAL MULTIVITAMIN FORMULA ...... risperidone oral solution ...... salsalate oral ...... renal-vite ...... risperidone oral tablet ...... SAPHRIS ...... rena-vite ...... risperidone oral tablet dispersible ...... sapropterin dihydrochloride ...... renewal soothing bath ...... RITALIN ...... SAVAYSA ...... repaglinide ...... ritonavir ...... sb allergy medicine oral tablet ...... REPATHA ...... rivastigmine ...... sb arthritis pain relief ...... RESTASIS ...... rivastigmine tartrate ...... sb aspirin oral tablet delayed release ...... RESTASIS MULTIDOSE ...... rizatriptan benzoate ...... sb docusate sodium/senna ...... RESTORA ...... robafen cf multi-symptom cold ...... sb lice killing max st ...... RESTORA RX ...... ROBITUSSIN 12 HOUR COUGH ...... sb mucus relief ...... restore plus lubricant eye ...... ROBITUSSIN 12 HOUR COUGH CHILD ..... sb pain reliever childrens ...... restore pm ...... ROBITUSSIN CHILD COUGH/COLD LA ..... sb pain reliever ex st ...... RETACRIT INJECTION SOLUTION 10000 ROBITUSSIN CHILDRENS COUGH LA ...... scalp relief ...... UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, ROBITUSSIN COUGH+CHEST CONG DM SCRUB CARE POVIDONE-IODINE ...... 4000 UNIT/ML, 40000 UNIT/ML ...... ORAL LIQUID 20-400 MG/20ML ...... SEEBRI NEOHALER ...... RETACRIT INJECTION SOLUTION 20000 ROBITUSSIN NIGHTTIME COUGH ...... SEGLUROMET ...... UNIT/ML ...... ROBITUSSIN PEAK COLD MULTI-SYM...... selegiline hcl oral ...... RETIN-A EXTERNAL CREAM ...... ropinirole hcl ...... selenium sulfide external lotion ...... RETIN-A EXTERNAL GEL...... rosadan external cream ...... SELZENTRY ...... RETIN-A MICRO GEL 0.04 %, 0.1 % ...... rosadan external gel ...... SEMGLEE ...... RETIN-A MICRO PUMP EXTERNAL GEL rosuvastatin calcium ...... senexon-s ...... 0.06 % ...... roweepra ...... senior probiotic ...... REVLIMID ...... ROZEREM ...... senna lax ...... REXULTI ...... ROZLYTREK ...... senna laxative ...... REYATAZ ORAL CAPSULE ...... RUBRACA ...... senna oral liquid ...... REYATAZ ORAL PACKET ...... RUCONEST ...... senna oral syrup ...... REYVOW ...... rufinamide ...... senna oral tablet ...... RHOFADE ...... RUZURGI ...... senna plus oral tablet ...... ribavirin oral ...... RYBELSUS ...... senna s ...... RID LICE KILLING SHAMPOO ...... RYDAPT ...... senna smooth ...... rifabutin ...... rynex dm ...... senna-docusate sodium ......

159 senna-lax ...... sinus 12 hour ...... sodium fluoride oral solution 1.1 (0.5 f) senna-plus ...... sinus congestion max strength ...... mg/ml ...... senna-s ...... sinus nasal spray ...... sodium fluoride oral tablet 1.1 (0.5 f) mg ...... senna-tabs ...... sinus pe decongestant ...... sodium fluoride oral tablet chewable ...... senna-time ...... sinus relief ext st ...... sodium phenylbutyrate oral powder ...... senna-time s ...... sinus relief extra strength ...... sodium sulfacetamide wash ...... sennazon ...... sinus/congestion relief pe ...... SOFOSBUVIR-VELPATASVIR ...... senno ...... sirolimus oral solution ...... soft glucose ...... SENOKOT ...... sirolimus oral tablet 0.5 mg, 1 mg ...... SOLARTEK GLUCOSE CONTROL ...... SENOKOT S ...... sirolimus oral tablet 2 mg ...... SOLIQUA ...... SEREVENT DISKUS ...... SIRTURO ...... SOLODYN ...... SERNIVO ...... SKYRIZI (150 MG DOSE) ...... soluble fiber therapy ...... SEROQUEL ...... sleep aid max st ...... soluvita e ...... SEROQUEL XR ...... sleep aid nighttime oral capsule 50 mg ...... SOMAVERT ...... sertraline hcl oral ...... sleep aid oral capsule 50 mg ...... SOOLANTRA ...... setlakin ...... sleep-aid max st ...... soothe maximum strength ...... sevelamer carbonate oral tablet ...... sleep-aid nighttime oral capsule 50 mg ...... soothe oral suspension ...... sf sleep-aid oral capsule 50 mg ...... soothe oral tablet ...... sf 5000 plus ...... smooth antacid ex st oral tablet chewable soothe oral tablet chewable ...... SFROWASA ...... 750 mg ...... sorbitol oral ...... sharobel ...... smooth antacid extra st ...... SORILUX ...... SHINGRIX ...... smooth lax oral powder ...... sotalol hcl (af) ...... SHUR-SEAL CONTRACEPTIVE ...... sod citrate-citric acid ...... sotalol hcl oral ...... SIGNIFOR ...... sodium bicarbonate oral tablet ...... SOVALDI ...... silace oral liquid ...... sodium chloride (hypertonic) ophthalmic spinosad ...... silace oral syrup ...... ointment ...... SPIRIVA HANDIHALER ...... siladryl allergy ...... sodium chloride (hypertonic) ophthalmic SPIRIVA RESPIMAT ...... sildenafil citrate oral tablet 20 mg...... solution...... spironolactone oral ...... SILENOR ...... sodium chloride inhalation nebulization spironolactone-hctz ...... SILIQ ...... solution 0.9 %, 10 %, 3 % ...... sprintec 28 ...... siltussin sa ...... sodium chloride inhalation nebulization SPRYCEL ...... siltussin-dm alcohol free ...... solution 7 % ...... sps ...... silver sulfadiazine external ...... sodium chloride ophthalmic ointment 5 % .... sronyx ...... SIMBRINZA ...... sodium chloride ophthalmic solution 5 % ...... ssd ...... simeped ...... sodium fluoride 5000 plus ...... sss 10-5 external cream ...... simethicone oral ...... sodium fluoride 5000 ppm dental cream ...... ST JOSEPH LOW DOSE ORAL TABLET simethicone ultra strength ...... sodium fluoride dental cream ...... CHEWABLE...... simliya ...... sodium fluoride dental gel ...... ST JOSEPH LOW DOSE ORAL TABLET SIMPONI ...... sodium fluoride mouth/throat ...... DELAYED RELEASE ...... simvastatin oral ...... stavudine ......

160 STEGLATRO ...... subvenite starter kit-green ...... sumatriptan nasal ...... STEGLUJAN ...... subvenite starter kit-orange ...... sumatriptan succinate oral ...... STELARA SUBCUTANEOUS ...... sucralfate oral suspension ...... sumatriptan succinate refill ...... stimulant laxative oral tablet 8.6-50 mg...... sucralfate oral tablet ...... sumatriptan succinate subcutaneous ...... STIOLTO RESPIMAT ...... SUDAFED ...... suphedrin ...... STIVARGA ...... SUDAFED CHILDRENS ...... suphedrine maximum strength ...... stomach relief extra strength ...... SUDAFED CONGESTION ...... suphedrine oral tablet 30 mg ...... stomach relief max st oral suspension 525 SUDAFED PE CONGESTION ORAL suphedrine oral tablet extended release 12 mg/15ml ...... TABLET 10 MG ...... hour 120 mg...... stomach relief max strength ...... SUDAFED PE SINUS CONGESTION ...... sure result sr relief ...... stomach relief oral suspension 1050 SUDAFED SINUS CONGESTION ...... SUTENT ...... mg/30ml, 525 mg/15ml ...... SUDAFED SINUS CONGESTION 12HR ..... SYMAX-SR ...... stomach relief oral suspension 262 mg/15ml, sudogest 12 hour ...... SYMBICORT ...... 525 mg/30ml, 527 mg/30ml ...... sudogest maximum strength ...... SYMDEKO ...... stomach relief oral tablet 262 mg ...... sudogest oral tablet 30 mg ...... SYMFI ...... stomach relief oral tablet chewable 262 mg .. sulfacetamide sodium external liquid ...... SYMFI LO ...... stomach relief plus ...... sulfacetamide sodium ophthalmic ointment .. SYMJEPI ...... stomach relief ultra ...... sulfacetamide sodium ophthalmic solution ... SYMLINPEN 120 ...... stool softener laxative oral capsule ...... sulfacetamide sodium-sulfur external cream SYMLINPEN 60 ...... stool softener oral capsule 100 mg ...... 10-5 %...... SYMPAZAN ...... stool softener oral capsule 240 mg ...... sulfacetamide sodium-sulfur external liquid SYMPROIC ...... stool softener oral capsule 250 mg ...... 9-4.5 %...... SYMTUZA ...... stool softener oral capsule 50 mg ...... sulfacetamide sodium-sulfur external lotion SYNAGIS ...... stool softener oral tablet 8.6-50 mg...... 10-5 %...... SYNAREL ...... stool softener pls laxative ...... sulfacetamide sodium-sulfur external SYNJARDY ...... stool softener plus laxative ...... suspension 10-5 % ...... SYNJARDY XR ...... stool softener/laxative ...... sulfacetamide sod-sulfur wash external SYSTANE COMPLETE ...... stool softener/stimulant ...... liquid 9-4.5 % ...... SYSTANE CONTACTS ...... STRATTERA ...... sulfacetamide-prednisolone ophthalmic SYSTANE NIGHTTIME ...... STRENSIQ ...... solution...... T stress formula ...... sulfamethoxazole-trimethoprim oral tab tussin ...... stress formula/iron...... suspension ...... tab-a-vite ...... STRIBILD ...... sulfamethoxazole-trimethoprim oral tablet .... tab-a-vite/beta carotene ...... STRIVERDI RESPIMAT...... sulfamez wash ...... tab-a-vite/iron ...... SUBOXONE SUBLINGUAL FILM 12-3 MG, sulfasalazine oral tablet ...... TABLOID ...... 4-1 MG ...... sulfasalazine oral tablet delayed release ...... TACLONEX ...... SUBOXONE SUBLINGUAL FILM 2-0.5 MG, sulfatrim pediatric ...... tacrolimus external ointment 0.03 % ...... 8-2 MG ...... sulindac oral tablet 150 mg ...... tacrolimus external ointment 0.1 % ...... subvenite ...... sulindac oral tablet 200 mg ...... tacrolimus oral capsule 0.5 mg, 5 mg ...... subvenite starter kit-blue ...... SUMADAN WASH ...... tacrolimus oral capsule 1 mg ......

161 tactinal extra strength ...... testosterone enanthate intramuscular ...... tobramycin nebulization solution 300 mg/5ml TAFINLAR ...... testosterone transdermal gel 12.5 mg/act inhalation ...... take action ...... (1%) ...... TOBRAMYCIN NEBULIZATION SOLUTION TALTZ ...... testosterone transdermal gel 25 mg/2.5gm 300 MG/5ML INHALATION ...... TAMIFLU ORAL CAPSULE ...... (1%), 50 mg/5gm (1%) ...... tobramycin ophthalmic ...... TAMIFLU ORAL SUSPENSION TETANUS-DIPHTHERIA TOXOIDS TD ...... tobramycin-dexamethasone ...... RECONSTITUTED ...... tetrabenazine ...... tolcapone ...... tamoxifen citrate oral ...... THALOMID ...... tolnaftate external powder ...... tamsulosin hcl ...... the magic bullet ...... tolterodine tartrate ...... TARGRETIN EXTERNAL ...... theophylline ...... TOPICORT SPRAY ...... tarina fe 1/20 ...... theophylline er ...... topiramate oral capsule sprinkle ...... tarina fe 1/20 eq ...... thera ...... topiramate oral tablet ...... TASIGNA ...... thera-tabs ...... toremifene citrate ...... TAZORAC EXTERNAL CREAM ...... thiamine hcl oral ...... torsemide ...... TAZORAC EXTERNAL GEL 0.1 %...... thiamine mononitrate oral ...... total allergy ...... taztia xt ...... thioridazine hcl oral ...... total allergy medicine ...... TDVAX ...... thiothixene oral capsule 1 mg, 2 mg ...... TOUJEO MAX SOLOSTAR ...... TEARS AGAIN ...... thiothixene oral capsule 10 mg, 5 mg ...... TOUJEO SOLOSTAR ...... TEARS AGAIN ADVANCED EYELID THRIVE ...... TOVIAZ ...... OPHTHALMIC ...... THRIVITE 19 ...... TRACLEER ...... tears pure ...... THRIVITE RX ...... TRADJENTA ...... TECFIDERA ...... tiadylt er ...... tramadol hcl oral tablet 50 mg ...... TEGSEDI ...... tiagabine hcl ...... trandolapril ...... temazepam oral capsule 15 mg, 30 mg ...... TIBSOVO ...... tranexamic acid oral ...... TEMIXYS ...... TIKOSYN ...... tranylcypromine sulfate ...... TEMOVATE EXTERNAL CREAM ...... tilia fe ...... TRAVATAN Z ...... TEMOVATE EXTERNAL OINTMENT ...... timolol maleate ophthalmic solution 0.25 %, travel ease ...... temozolomide ...... 0.5 % ...... trazodone hcl oral tablet 100 mg, 150 mg, 50 TENCON ...... TIMOPTIC ...... mg ...... TENIVAC ...... TIMOPTIC-XE ...... trazodone hcl oral tablet 300 mg ...... tenofovir disoproxil fumarate ...... TINACTIN EXTERNAL AEROSOL ...... TRELEGY ELLIPTA ...... terazosin hcl ...... tinaspore ...... TREMFYA ...... terbinafine hcl external ...... TIVICAY ...... TRESIBA ...... terbinafine hcl oral ...... TIVICAY PD ...... TRESIBA FLEXTOUCH ...... terbinafine hydrochloride external cream 1 % tizanidine hcl oral tablet ...... tretinoin external cream ...... TOBI NEBULIZER ...... tretinoin oral ...... terconazole vaginal cream 0.4 % ...... TOBI PODHALER ...... TREZIX ...... terconazole vaginal cream 0.8 % ...... TOBRADEX ST ...... tri femynor ...... TERIPARATIDE (RECOMBINANT) ...... tobramycin inhalation nebulization solution triamcinolone acetonide external cream ...... testosterone cypionate intramuscular ...... 300 mg/4ml ......

162 triamcinolone acetonide external lotion 0.025 TRUETRACK TEST ...... tussin dm oral syrup 100-10 mg/5ml ...... % ...... TRULANCE ...... tussin maximum strength oral syrup 15 triamcinolone acetonide external lotion 0.1 TRULICITY ...... mg/5ml ...... % ...... TRUMENBA ...... tussin mucus+chest congestion oral syrup .... triamcinolone acetonide external ointment TRUSOPT ...... tussin multi-symptom cold cf ...... 0.025 %, 0.1 %, 0.5 % ...... TUDORZA PRESSAIR ...... tussin oral syrup 100 mg/5ml ...... triamcinolone acetonide mouth/throat ...... tulana ...... TWINRIX ...... TRIAMINIC ALLERCHEWS ...... TUMS ...... tyblume ...... triamterene-hctz ...... TUMS CHEWY BITES ...... TYBOST ...... triazolam ...... TUMS E-X 750 ...... TYLENOL ORAL SUSPENSION 160 TRICARE ...... TUMS EXTRA STRENGTH 750 ...... MG/5ML ...... TRICON ...... TUMS LASTING EFFECTS ...... TYLENOL ORAL TABLET 325 MG ...... triderm ...... TUMS SMOOTHIES ...... TYLENOL ORAL TABLET 500 MG ...... tri-estarylla ...... TUMS ULTRA 1000 ...... TYLENOL ORAL TABLET CHEWABLE 160 trifluoperazine hcl ...... TURALIO ...... MG ...... trifluridine ...... tussin adult dm oral liquid 10-200 mg/5ml .... TYLENOL ORAL TABLET EXTENDED trihexyphenidyl hcl ...... tussin adult multi-symptom ...... RELEASE 650 MG ...... TRIJARDY XR ...... tussin cf cough & cold oral liquid 5-10-100 TYMLOS ...... TRIKAFTA ...... mg/5ml ...... U tri-legest fe ...... tussin cf multi-symptom cold ...... UBRELVY ...... tri-linyah ...... tussin cf oral liquid 30-10-100 mg/5ml ...... UDAMIN SP ...... trimethobenzamide hcl oral ...... tussin cf oral liquid 5-10-100 mg/5ml ...... UDENYCA ...... trimethoprim oral ...... tussin chest congestion oral syrup 100 ultra fresh ...... tri-mili ...... mg/5ml ...... ultra fresh pm ...... TRINATE ...... tussin cough dm sugar free ...... ultra lubricant drop ...... TRINTELLIX ...... tussin cough long acting ...... ultra lubricating eye drops ...... tri-nymyo ...... tussin cough long-acting ...... unithroid ...... triple antibiotic ...... tussin cough oral syrup ...... urea 20 intensive hydrating ...... triple antibiotic original ...... tussin cough/chest congest oral syrup 100- urea external lotion ...... tri-previfem ...... 10 mg/5ml ...... ureacin-10 ...... TRIPTODUR ...... tussin cough/chest dm max oral liquid 10- ureacin-20 ...... tri-sprintec ...... 200 mg/5ml ...... urin ds ...... TRIUMEQ ...... tussin dm cough/chest cong ...... urinary pain relief oral tablet 95 mg ...... tri-vite pediatric ...... tussin dm cough/chest oral syrup 10-100 ursodiol oral ...... tri-vite/fluoride ...... mg/5ml ...... UTIRA-C ...... trivora (28) ...... tussin dm max adult ...... V tri-vylibra ...... tussin dm max daytime ...... VAGIFEM ...... trospium chloride ...... tussin dm max oral liquid 10-200 mg/5ml ..... valacyclovir hcl oral ...... TRUECONTROL GLUCOSE CONT LEV 0 .. tussin dm max oral liquid 20-400 mg/20ml ... valganciclovir hcl oral tablet ...... TRUECONTROL GLUCOSE CONT LEV 1 .. tussin dm max st ...... valproic acid oral capsule ......

163 valproic acid oral solution ...... VINATE ONE ...... vitamin c oral tablet chewable 100 mg, 250 VALTOCO 10 MG DOSE ...... VIOKACE ORAL TABLET 10440-39150 mg ...... VALTOCO 15 MG DOSE ...... UNIT...... vitamin c oral tablet chewable 500 mg ...... VALTOCO 20 MG DOSE ...... viorele ...... vitamin c/acerola ...... VALTOCO 5 MG DOSE ...... VIRACEPT ...... vitamin c/rose hips oral tablet 1000 mg ...... VANCOCIN ...... VIREAD ORAL POWDER ...... vitamin c/rose hips oral tablet 500 mg ...... vandazole ...... VIREAD ORAL TABLET 150 MG, 200 MG, vitamin c-rose hips oral tablet ...... VANOS ...... 250 MG ...... vitamin d (cholecalciferol) oral tablet ...... VAPORIZER WARM STEAM ...... virt-caps ...... vitamin d (ergocalciferol) oral capsule 1.25 VAQTA ...... virt-phos 250 neutral ...... mg (50000 ut) ...... VARIVAX ...... virtussin a/c ...... vitamin d oral capsule 25 mcg (1000 ut) ...... VARUBI (180 MG DOSE) ...... virtussin ac w/alc ...... vitamin d oral liquid ...... VCF VAGINAL CONTRACEPTIVE virtussin dac ...... vitamin d oral tablet 25 mcg (1000 ut) ...... VAGINAL FOAM ...... VISBIOME HIGH POTENCY ORAL vitamin d oral tablet 50 mcg (2000 ut) ...... VECTICAL ...... CAPSULE ...... vitamin d oral tablet chewable 10 mcg (400 vegetable lax+stool softener ...... VISINE ...... unit) ...... velivet ...... VISINE ADVANCED RELIEF ...... vitamin d3 oral capsule 1.25 mg (50000 ut) .. VELPHORO ...... VISTA MEIBO TEARS ...... vitamin d3 oral capsule 125 mcg (5000 ut) .... VELTASSA ...... VISTOGARD ...... vitamin d-3 oral capsule 125 mcg (5000 ut) .. VELTIN ...... vit c/rose hips ...... vitamin d3 oral capsule 25 mcg (1000 ut) ...... VENCLEXTA ...... vita s forte ...... vitamin d3 oral capsule 250 mcg (10000 ut) .. VENCLEXTA STARTING PACK ...... vitacel ...... vitamin d3 oral capsule 50 mcg (2000 ut) ...... venlafaxine hcl ...... vitamin a oral capsule 2400 mcg (8000 ut), 3 vitamin d-3 oral capsule 50 mcg (2000 ut) .... venlafaxine hcl er oral capsule extended mg (10000 ut) ...... vitamin d3 oral liquid 10 mcg/ml ...... release 24 hour ...... vitamin b-1 ...... vitamin d3 oral tablet 10 mcg (400 unit) ...... VENTOLIN HFA ...... vitamin b-12 er oral tablet extended release vitamin d3 oral tablet 125 mcg (5000 ut) ...... verapamil hcl er ...... 1000 mcg ...... vitamin d3 oral tablet 25 mcg (1000 ut) ...... verapamil hcl oral ...... vitamin b12 oral tablet extended release vitamin d-3 oral tablet 25 mcg (1000 ut) ...... VERZENIO ...... 1000 mcg ...... vitamin d3 oral tablet 50 mcg (2000 ut) ...... VESICARE ...... vitamin b-12 tr oral tablet extended release vitamin d3 oral tablet chewable 10 mcg (400 VICTOZA SOLUTION PEN-INJECTOR 18 1000 mcg ...... unit) ...... MG/3ML SUBCUTANEOUS ...... , vitamin b-6 ...... vitamin d3 oral tablet chewable 25 mcg, 25 VIEKIRA PAK ...... vitamin b-6 er ...... mcg (1000 ut)...... vienva ...... vitamin c cr oral tablet extended release 500 vitamin d-400 ...... vigabatrin oral packet ...... mg ...... vitamin e natural ...... vigadrone ...... vitamin c er oral tablet extended release vitamin e oral capsule 100 unit, 1000 unit, VIGAMOX ...... 1500 mg ...... 200 unit ...... VIIBRYD ...... vitamin c oral liquid 500 mg/5ml ...... vitamin e oral capsule 400 unit ...... VIMPAT ORAL ...... vitamin c oral tablet 1000 mg, 250 mg ...... vitamin e oral solution 15 unit/0.3ml ...... VINATE II ...... vitamin c oral tablet 500 mg ...... vitamins acd-fluoride ......

164 vitamins complete childrens ...... womens gentle laxative ...... zaleplon ...... VITATHELY WITH GINGER ...... womens laxative ...... ZARXIO ...... VITRAKVI ...... womens prenatal+dha ...... ZAVESCA ...... VIVELLE-DOT ...... X ZEASORB-AF ...... volnea ...... XALATAN ...... ZEGERID ...... voriconazole oral tablet ...... XALKORI ...... ZEJULA ...... VORTEX VALVED HOLDING CHAMBER .... XARELTO ...... ZELAC ...... VOSEVI ...... XARELTO STARTER PACK ...... ZELBORAF ...... VOTRIENT ...... XCOPRI ...... zenatane ...... VRAYLAR ...... XCOPRI (250 MG DAILY DOSE) ORAL ZENPEP ORAL CAPSULE DELAYED VUMERITY ...... TABLET THERAPY PACK 50 & 200 MG . RELEASE PARTICLES 10000-32000 vyfemla ...... XCOPRI (350 MG DAILY DOSE) ...... UNIT, 15000-47000 UNIT, 20000-63000 vylibra ...... XELJANZ ORAL TABLET ...... UNIT, 3000-10000 UNIT, 40000-126000 VYNDAMAX ...... XELJANZ XR ...... UNIT, 5000-24000 UNIT ...... VYNDAQEL ...... XELODA ...... ZENZEDI ...... VYVANSE ORAL CAPSULE 10 MG, 20 MG, XENLETA ORAL ...... ZEPATIER ...... 30 MG, 40 MG, 60 MG, 70 MG ...... XEPI ...... ZEPOSIA ...... VYVANSE ORAL CAPSULE 50 MG ...... XIGDUO XR ORAL TABLET EXTENDED ZETONNA ...... VYVANSE ORAL TABLET CHEWABLE...... RELEASE 24 HOUR 10-1000 MG, 10-500 ZIANA ...... W MG ...... zidovudine ...... warfarin sodium oral tablet 1 mg, 10 mg, 2 XIGDUO XR ORAL TABLET EXTENDED ZIEXTENZO ...... mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg ...... RELEASE 24 HOUR 2.5-1000 MG, 5- ZILXI ...... warfarin sodium oral tablet 2.5 mg ...... 1000 MG, 5-500 MG ...... zinc chelated oral tablet 50 mg ...... wart remover external liquid 17 % ...... XIIDRA ...... zinc oral tablet 50 mg ...... wart remover maximum strength external XIMINO ...... zinc oxide external ointment 40 % ...... liquid ...... XOFLUZA (40 MG DOSE) ...... ZIOPTAN ...... weekly-d ...... XOFLUZA (80 MG DOSE) ...... ziprasidone hcl ...... wera ...... XOLAIR ...... ZOHYDRO ER ...... WESTAB PLUS ...... XOPENEX HFA ...... ZOLINZA ...... WEST-VITE W/FOLIC ACID ...... XPECT ...... zolpidem tartrate oral ...... WIDE-SEAL DIAPHRAGM 60 ...... XTANDI ORAL CAPSULE ...... zolpidem tartrate sublingual ...... WIDE-SEAL DIAPHRAGM 65 ...... xulane ...... ZOMACTON ...... WIDE-SEAL DIAPHRAGM 70 ...... XULTOPHY ...... ZOMACTON (FOR ZOMA-JET 10) ...... WIDE-SEAL DIAPHRAGM 75 ...... Y zonisamide oral ...... WIDE-SEAL DIAPHRAGM 80 ...... YONSA ...... zoo friends gummies ...... WIDE-SEAL DIAPHRAGM 85 ...... yuvafem ...... zoo friends plus extra c ...... WIDE-SEAL DIAPHRAGM 90 ...... Z zoo friends plus iron ...... WIDE-SEAL DIAPHRAGM 95 ...... zaclir cleansing ...... ZOSTRIX HP ...... wixela inhub ...... ZADITOR ...... zovia 1/35 (28) ...... womans laxative ...... zafemy ...... zovia 1/35e (28) ......

165 ZUBSOLV ...... ZYMAXID ...... ZYPREXA ZYDIS ORAL TABLET ZYCLARA ...... ZYPREXA ORAL ...... DISPERSIBLE 15 MG, 5 MG ...... ZYDELIG ...... ZYPREXA ZYDIS ORAL TABLET ZYRTEC ALLERGY ORAL TABLET ...... ZYKADIA ...... DISPERSIBLE 10 MG, 20 MG ...... ZYRTEC-D ALLERGY & CONGESTION ...... ZYLET ...... ZYTIGA ......

166