2020 Pharmacy Benefit Dimensions 5 Tier Drug Formulary The following information applies to most members enrolled in a Pharmacy Benefit Dimensions pharmacy plan.

Note: If you are reading a printed version of this drug formulary, content may have been updated since it was last printed. For the most up-to-date information, please visit www.pbdrx.com.

Drug Formulary Introduction

• Generic drugs appear in lower case. Brand name drugs are capitalized.

• Preferred generic drugs and a few select brand name drugs are assigned to Tier 1. In most instances, once a generic product is available for which there are no bioequivalence concerns, the brand product is removed from the formulary (not covered), and the generic product is assigned to Tier 1. Certain generic drugs may also be covered in a non-preferred tier when efficacy, safety, or cost factors suggest that better alternatives exist on the formulary.

• Pharmacy Benefit Dimensions reserves the right to modify drug tiers as necessary.

• Some medications are considered non-formulary (not covered). To obtain a medication that is non-formulary, your health care provider is encouraged to submit a Prior Authorization request for coverage through the exception process. If the request is approved, you will be responsible for the cost share associated with a non- preferred drug tier.

• Certain self-funded employer groups may not follow this base formulary and certain exclusions may apply. Members in these pharmacy benefit management groups should refer to their summary plan description and/or their benefit administrator.

Prior-Authorization Prior Authorization is required for certain medications. To obtain coverage for a medication requiring Prior Authorization, a Prior Authorization request for medical exception must be submitted by your health care provider and approved by Pharmacy Benefit Dimensions. Medications that require prior authorization are listed with a “PA” in the formulary.

Step Therapy In some cases, you may be required to try certain medications before Pharmacy Benefit Dimensions will cover a prescribed medication to treat your medical condition. Medications that require step therapy are listed with an “ST” in the formulary.

Quantity Limitations Quantity limitations may apply to certain medications. Some medications are covered up to a specific quantity per fill or period of time. Medications with quantity limitations are listed with a “QL” in the formulary.

Specialty Medications Specialty medications are medications that must be filled at a specialty pharmacy. Specialty medications can include but are not limited to those that are self-injectable, require special distribution, handling and/or are in limited supply. Specialty medications are listed with an “SP” in the formulary. 2020 Pharmacy Benefit Dimensions

Limited Access Medications Limited access medications are restricted to designated pharmacies. Limited access medications are listed with an “LA” in the formulary.

Reliance Rx Reliance Rx, Pharmacy Benefit Dimensions’ preferred specialty pharmacy, specializes in the highest quality patient- centric care for individuals with chronic conditions such as hepatitis, multiple sclerosis, cancer and rheumatoid arthritis. Reliance Rx provides a convenient way for you to receive your medication, by arranging delivery at no charge directly to your home. They can also provide you with education on the medication you’re taking, refill reminders, and even the necessary supplies, if applicable and available.

Most specialty medications and limited access medications listed on the formulary are required to be filled at Reliance Rx. Please contact Pharmacy Benefit Dimensions Member Services to determine where you need to obtain your medication. Pharmacy Benefit Dimensions Member Services can be reached at (716) 635-7880 or toll-free at 1-888-878- 9172. Reliance Rx can be reached at 1-800-809-4763.

Age Restriction Some prescription medications are restricted by age limits due to safety reasons or Food and Drug Administration (FDA) approved labeling. Medications with an age limit are listed with an “AL” in the formulary.

Maximum Daily Dose (MDD) Certain medications are restricted by a maximum daily dose (MDD) as recommended by the Food and Drug Administration (FDA). Limits may be set by the number of units per day or the total daily dose.

Maintenance Medications Pharmacy Benefit Dimensions allows up to a 90-day supply of certain medications to be filled. Medications eligible for a 90-day supply are listed with an “MO” on the formulary.

Over-the-Counter (OTC) Medications Certain medications listed in the formulary are also available over the counter. A prescription is required for coverage of eligible OTC products.

Compounded Prescription Medications Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to submit for prior approval. If approved, the compounded prescription will be available at a Tier 2 copayment/coinsurance. Bulk products and are excluded from coverage because they are not prescription medication products that are approved under sections 505, 505(j) or 507 of the Federal Food, Drug and Cosmetic Act.

Diabetic Devices/Supplies/Equipment OneTouch blood glucose meters, lancets, test strips, and supplies are our preferred diabetic supplies and do not require Prior Authorization.

Test strips are limited to 100 strips per 30 days, for up to a 90-day supply. Copayments vary by plan.

2020 Pharmacy Benefit Dimensions OneTouch will provide a glucose meter to you with no copayment. One Touch Glucose Meters can be obtained by calling LifeScan, Inc. at 1-888-377-5227, please reference offer code 289IHA001. Please have your ID number available when you contact the manufacturer. Quantities are limited to one meter per member.

BD needles and are our preferred needle/ products. Copayments vary by plan.

Freestyle Libre reader device and sensors are our preferred continuous glucose monitoring system supplies. For insulin- dependent members, no prior authorization is required. Freestyle Libre products are available at participating pharmacies. Copayments vary by plan.

Affordable Care Act (ACA) Preventive Services Medications listed on the formulary that are covered as preventive services under the Affordable Care Act may be covered. Certain restrictions may apply.

Lost/Stolen/Damaged Medications Replacement of any lost, stolen, or damaged medications is the responsibility of the member.

Dental Formulary Drugs covered on our Dental Formulary are available when prescribed by a dental provider. Unless otherwise specified, all products are limited to a 10-day supply with one refill. Drugs included in our Dental Formulary are listed with a “DF” on the formulary. Drugs without a “DF” will not be covered when written by a dental provider.

Medical Benefit Drugs Medical benefit drugs are medications that are typically administered by a healthcare provider, such as injections and infusions. Some medical benefit drugs are available through a retail pharmacy or specialty pharmacy but may not be listed in the formulary. Copayments for these medications vary by plan. Please contact Pharmacy Benefit Dimensions Member Services to determine if your medication is a covered benefit. Pharmacy Benefit Dimensions Member Services can be reached at (716) 635-7880 or toll-free at 1-888-878-9172.

Additional Formulary Information • Appetite suppressants/weight-loss medications are excluded from coverage.

• Medications used for cosmetic purposes are excluded from coverage.

• Medical devices (which may or may not require a prescription) are excluded from coverage.

• Medical foods other than PKU supplements (which may or may not require a prescription) are excluded from coverage.

• Prenatal vitamins classified as medical foods are not covered. Multivitamins are NOT included in the Formulary as various OTC products are available.

• Medications listed on the drug formulary as covered without restriction may require prior authorization or may not be covered if it is determined that they are being used in conjunction with a procedure or treatment not covered under the employer group’s benefit design.

• Medications not recognized by the FDA without a National Drug Code (NDC) are excluded from coverage. • Bulk products and powders are excluded from coverage.

2020 Pharmacy Benefit Dimensions AFFORDABLE CARE ACT PREVENTATIVE SERVICES **where applicable

Prescription and OTC versions (where applicable) will be covered only with a prescription written by a licensed healthcare provider. This list is subject to change based on national or federal guidelines. Coverage of listed products may vary by plan. Aspirin for Cardiovascular Disease Prevention Aspirin will be covered for men and women (ages 50 to 59) when the benefits outweigh the potential bleeding risks for cardiovascular disease prevention.

Bowel Prep for Colonoscopy Prescription and OTC products will be covered for adults older than age 50 and younger than age 75 receiving screening for colorectal cancer.

Contraceptive Coverage All formulary generic and preferred brand name drugs (without a generic equivalent) will have a zero dollar ($0) copayment. Cervical caps, diaphragms, female condoms and spermicides will have a zero ($0) copayment. Both prescription and over-the-counter (OTC) products will be covered only when prescribed by a licensed healthcare provider.

Erythromycin Ophthalmic Ointment Erythromycin ophthalmic ointment will be covered for newborns less than 1 year of age for the prevention of gonococcal ophthalmia neonatorum. Fluoride Oral fluoride products (chewable tablets and ) will be covered for children 6 months of age and older who do not receive the recommended amount of fluoride in their supply.

Folic Acid Supplements Supplements containing 0.4mg to 0.8mg of folic acid will be covered for women who are planning or are capable of pregnancy.

Iron Supplementation for Children Iron supplements will be covered for children aged 6 months to 12 months who are at high risk for iron deficiency anemia.

Statins The USPSTF recommends that adults without a history of cardiovascular disease (CVD) use a low- to moderate-dose statin for the prevention of CVD events and mortality. Low- to moderate-dose statins will be covered at a zero dollar ($0) copayment for those who meet the following criteria: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or ); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.

Tobacco Cessation Products (FDA Approved) Prescription and OTC products will be covered for adults 18 years of age and older and for pregnant women with no age limit. The following products are covered: patches, gums, nasal sprays, , lozenges, Chantix and bupropion sr (generic version of Zyban).

Vaccines Flu, Pneumonia vaccinations will be covered when administered at a network pharmacy.

The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce Women, Increased Risk for Breast Cancer their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.

Key AL – Age Limit MO – 90-day supply QL – Quantity Limits Apply DF – Dental Formulary PA – Prior Authorization SP – Specialty Medication LA – Limited Access Required ST – Step Therapy

2020 Pharmacy Benefit Dimension

2020 Pharmacy Benefit Dimension TABLE OF CONTENTS

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...... 3 *Allergenic Extracts/Biologicals Misc*...... 4 *Aminoglycosides*...... 4 *Analgesics - Anti-Inflammatory*...... 5 *Analgesics - Nonnarcotic*...... 7 *Analgesics - Opioid*...... 8 *Androgens-Anabolic*...... 10 *Anorectal And Related Products*...... 10 *Anthelmintics*...... 11 *Antianginal Agents*...... 11 *Antianxiety Agents*...... 11 *Antiarrhythmics*...... 12 *Antiasthmatic And Bronchodilator Agents*...... 13 *Anticoagulants*...... 14 *Anticonvulsants*...... 15 *Antidepressants*...... 17 *Antidiabetics*...... 19 *Antidiarrheal/Probiotic Agents*...... 21 *Antidotes And Specific Antagonists*...... 22 *Antiemetics*...... 22 *Antifungals*...... 23 **...... 23 *Antihyperlipidemics*...... 24 *Antihypertensives*...... 25 *Anti-Infective Agents - Misc.*...... 27 *Antimalarials*...... 27 *Antimyasthenic/Cholinergic Agents*...... 27 *Antimycobacterial Agents*...... 28 *Antineoplastics And Adjunctive Therapies*...... 29 *Antiparkinson And Related Therapy Agents*...... 33 *Antipsychotics/Antimanic Agents*...... 34 *Antivirals*...... 36 *Beta Blockers*...... 37 *Calcium Channel Blockers*...... 38 *Cardiotonics*...... 39 *Cardiovascular Agents - Misc.*...... 39 *Cephalosporins*...... 39 *Contraceptives*...... 40 *Corticosteroids*...... 44 *Cough/Cold/*...... 45 *Dermatologicals*...... 46 *Diagnostic Products*...... 51 *Digestive Aids*...... 52 *Diuretics*...... 52 *Endocrine And Metabolic Agents - Misc.*...... 53 *Estrogens*...... 54 *Fluoroquinolones*...... 54 *Gastrointestinal Agents - Misc.*...... 55 *Genitourinary Agents - Miscellaneous*...... 55 *Gout Agents*...... 56 *Hematological Agents - Misc.*...... 56 *Hematopoietic Agents*...... 56 *Hemostatics*...... 56 *//Sleep Disorder Agents*...... 57

Last Updated 12.1.2020 1 *Laxatives*...... 57 *Macrolides*...... 58 *Medical Devices And Supplies*...... 58 *Migraine Products*...... 59 *Minerals & Electrolytes*...... 60 *Miscellaneous Therapeutic Classes*...... 61 *Mouth/Throat/Dental Agents*...... 62 *Multivitamins*...... 63 *Musculoskeletal Therapy Agents*...... 64 *Nasal Agents - Systemic And Topical*...... 64 *Neuromuscular Agents*...... 64 *Nutrients*...... 64 *Ophthalmic Agents*...... 65 *Otic Agents*...... 68 *Oxytocics*...... 68 *Penicillins*...... 68 *Pharmaceutical Adjuvants*...... 68 *Progestins*...... 69 *Psychotherapeutic And Neurological Agents - Misc.*...... 70 *Respiratory Agents - Misc.*...... 72 *Sulfonamides*...... 72 *Tetracyclines*...... 72 *Thyroid Agents*...... 72 *Ulcer Drugs/Antispasmodics/Anticholinergics*...... 73 *Urinary Antispasmodics*...... 74 *Vaginal And Related Products*...... 74 *Vasopressors*...... 74 *Vitamins*...... 75

Last Updated 12.1.2020 2 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 amphetamine- COTEMPLA XR-ODT ORAL clonidine hcl er oral dextroamphet er oral EXTENDED tablet extended release extended release RELEASE DISPERSIBLE 12 hour MO 24 hour AL PA; AL DAYTRANA amphetamine- VYVANSE ORAL CAPSULE PATCH dextroamphetamine oral AL AL tablet AL VYVANSE ORAL TABLET dexmethylphenidate hcl armodafinil oral tablet CHEWABLE AL er oral capsule extended PA release 24 hour 10 mg, 15 atomoxetine hcl oral mg, 20 mg, 25 mg, 30 mg, capsule MO 35 mg, 40 mg, 5 mg dextroamphetamine MO; AL sulfate er oral capsule dexmethylphenidate hcl extended release 24 hour oral tablet AL AL guanfacine hcl er oral dextroamphetamine tablet extended release sulfate oral AL 24 hour MO; AL dextroamphetamine INTUNIV ORAL TABLET sulfate oral tablet AL EXTENDED RELEASE 24 methylphenidate hcl er HOUR MO; AL (cd) oral capsule methylphenidate hcl er extended release AL (xr) oral capsule extended methylphenidate hcl er release 24 hour AL (la) oral capsule extended methylphenidate hcl oral release 24 hour 10 mg, 60 tablet chewable MO; mg MO AL methylphenidate hcl er MYDAYIS ORAL CAPSULE (la) oral capsule extended EXTENDED RELEASE 24 release 24 hour 20 mg, 30 HOUR ST; AL mg, 40 mg AL QUILLICHEW ER ORAL methylphenidate hcl er TABLET CHEWABLE oral tablet extended EXTENDED RELEASE ST; release 10 mg, 18 mg, 20 AL mg, 27 mg, 36 mg, 54 mg QUILLIVANT XR ORAL AL methylphenidate hcl er RECONSTITUTED ER ST; oral tablet extended AL release 24 hour AL SUNOSI ORAL TABLET methylphenidate hcl er PA oral tablet extended WAKIX ORAL TABLET release 72 mg MO; AL PA; LA methylphenidate hcl oral solution AL methylphenidate hcl oral tablet MO; AL modafinil oral tablet PA; AL

Last Updated 12.1.2020 3 *Allergenic Extracts/Biologicals Misc*

GRASTEK SUBLINGUAL ORALAIR ADULT SAMPLE TABLET SUBLINGUAL KIT SUBLINGUAL TABLET PA SUBLINGUAL PA; SP ODACTRA SUBLINGUAL ORALAIR ADULT STARTER TABLET SUBLINGUAL PACK SUBLINGUAL PA TABLET SUBLINGUAL ORALAIR CHILDRENS PA; SP SAMPLE KIT SUBLINGUAL ORALAIR SUBLINGUAL THERAPY PACK PA; LA TABLET SUBLINGUAL ORALAIR CHILDRENS PA; SP STARTER PACK SUBLINGUAL TABLET SUBLINGUAL PA; LA RAGWITEK SUBLINGUAL TABLET SUBLINGUAL PA

*Aminoglycosides*

amikacin sulfate TOBI PODHALER ARIKAYCE solution 500 mg/2ml INHALATION CAPSULE SUSPENSION PA; SP PA; LA PA; PA Except Cystic BETHKIS INHALATION neomycin sulfate oral Fibrosis Specialists; QL; SP NEBULIZATION SOLUTION tablet PA; QL; SP paromomycin sulfate oral KITABIS PAK INHALATION capsule NEBULIZATION SOLUTION tobramycin inhalation PA; QL; SP nebulization solution 300 TOBI INHALATION mg/5ml PA; QL; SP NEBULIZATION SOLUTION PA; PA Except Cystic Fibrosis Specialists; QL; SP

Last Updated 12.1.2020 4 *Analgesics - Anti-Inflammatory*

celecoxib oral capsule fenoprofen calcium oral ARAVA ORAL TABLET ACTEMRA ACTPEN KEVZARA MO tablet MO PA; PA except SUBCUTANEOUS SUBCUTANEOUS diclofenac potassium oral RIDAURA ORAL CAPSULE Rheumatology; MO SOLUTION AUTO- SOLUTION AUTO- tablet MO DAYPRO ORAL TABLET INJECTOR PA; SP INJECTOR PA; SP diclofenac sodium er oral MO ACTEMRA KEVZARA tablet extended release ketoprofen er oral SUBCUTANEOUS SUBCUTANEOUS 24 hour MO capsule extended release SOLUTION PREFILLED SOLUTION PREFILLED diclofenac sodium oral 24 hour MO SYRINGE PA; SP SYRINGE PA; SP tablet delayed release OTREXUP ARCALYST KINERET SUBCUTANEOUS MO SUBCUTANEOUS SUBCUTANEOUS SOLUTION PREFILLED etodolac er oral tablet SOLUTION AUTO- SOLUTION SYRINGE PA; SP extended release 24 hour INJECTOR 10 MG/0.4ML, RECONSTITUTED PA; SP ORENCIA CLICKJECT MO 15 MG/0.4ML, 17.5 ENBREL MINI SUBCUTANEOUS etodolac oral capsule MG/0.4ML, 20 SUBCUTANEOUS SOLUTION AUTO- MO MG/0.4ML, 22.5 SOLUTION CARTRIDGE INJECTOR PA; SP etodolac oral tablet MG/0.4ML, 25 MG/0.4ML PA; SP ORENCIA MO ENBREL SUBCUTANEOUS SUBCUTANEOUS flurbiprofen oral tablet PA; LA RASUVO SUBCUTANEOUS SOLUTION 25 MG/0.5ML SOLUTION PREFILLED MO ibuprofen oral tablet 400 SOLUTION AUTO- PA; SP SYRINGE PA; SP ENBREL SUBCUTANEOUS SIMPONI mg, 600 mg, 800 mg INJECTOR 10 MG/0.2ML, SOLUTION PREFILLED SUBCUTANEOUS DF; MO 12.5 MG/0.25ML, 15 indomethacin er oral MG/0.3ML, 17.5 SYRINGE PA; SP SOLUTION AUTO- ENBREL SUBCUTANEOUS capsule extended release MG/0.35ML, 20 INJECTOR PA; SP SOLUTION SIMPONI MO; AL MG/0.4ML, 22.5 indomethacin oral MG/0.45ML, 25 RECONSTITUTED PA; SP SUBCUTANEOUS ENBREL SURECLICK capsule 25 mg, 50 mg MG/0.5ML PA; LA SOLUTION PREFILLED SUBCUTANEOUS MO; AL SPRIX NASAL SOLUTION SYRINGE PA; SP ketoprofen oral capsule PA; QL; AL SOLUTION AUTO- 50 mg, 75 mg MO INJECTOR PA; SP ketorolac tromethamine HUMIRA PEDIATRIC injection solution 30 CROHNS START mg/ml PA; LA SUBCUTANEOUS ketorolac tromethamine PREFILLED SYRINGE KIT intramuscular solution 60 80 MG/0.8ML, 80 mg/2ml PA; LA MG/0.8ML & ketorolac tromethamine 40MG/0.4ML PA; SP oral tablet QL; AL HUMIRA PEN leflunomide oral tablet SUBCUTANEOUS PEN- PA; PA except INJECTOR KIT PA; SP Rheumatology; MO HUMIRA PEN-CD/UC/HS meloxicam oral tablet STARTER SUBCUTANEOUS MO PEN-INJECTOR KIT PA; nabumetone oral tablet SP MO HUMIRA PEN- naproxen dr oral tablet PS/UV/ADOL HS START delayed release DF; MO SUBCUTANEOUS PEN- naproxen oral tablet INJECTOR KIT 40 DF; MO oxaprozin oral tablet MG/0.8ML PA; SP HUMIRA SUBCUTANEOUS MO piroxicam oral capsule PREFILLED SYRINGE KIT MO PA; SP sulindac oral tablet MO OTEZLA ORAL TABLET tolmetin sodium oral PA; SP capsule MO OTEZLA ORAL TABLET tolmetin sodium oral THERAPY PACK PA; SP tablet 600 mg MO

Last Updated 12.1.2020 5 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR PA; SP XELJANZ ORAL TABLET PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; SP

Last Updated 12.1.2020 6 *Analgesics - Nonnarcotic*

butalbital-acetaminophen BUPAP ORAL TABLET 50- oral tablet 50-325 mg 300 MG AL AL butalbital-apap-caffeine butalbital-apap-caffeine oral capsule 50-325-40 oral capsule 50-300-40 mg AL mg AL DURACLON EPIDURAL butalbital-apap-caffeine SOLUTION 100 MCG/ML oral tablet 50-325-40 mg MO AL ESGIC ORAL CAPSULE clonidine hcl (analgesia) AL epidural solution MO ZEBUTAL ORAL CAPSULE diflunisal oral tablet 50-325-40 MG AL MO salsalate oral tablet MO

Last Updated 12.1.2020 7 *Analgesics - Opioid*

acetaminophen- HYSINGLA ER ORAL ASCOMP-CODEINE ORAL #2 oral tablet DF TABLET ER 24 HOUR CAPSULE AL acetaminophen-codeine ABUSE-DETERRENT butalbital-asa-caff- #3 oral tablet DF NUCYNTA ER ORAL codeine oral capsule AL acetaminophen-codeine TABLET EXTENDED DILAUDID ORAL #4 oral tablet DF RELEASE 12 HOUR PA acetaminophen-codeine NUCYNTA ORAL TABLET DILAUDID ORAL TABLET oral solution DF OXYCONTIN ORAL TABLET fentanyl citrate buccal buprenorphine ER 12 HOUR ABUSE- lozenge on a handle weekly DETERRENT 10 MG, 15 PA; ST; PA Except butalbital-apap-caff-cod MG, 20 MG, 30 MG, 40 Oncology oral capsule 50-325-40-30 MG fentanyl citrate buccal mg AL OXYCONTIN ORAL TABLET tablet PA; ST; PA Except butorphanol tartrate ER 12 HOUR ABUSE- Oncology nasal solution PA DETERRENT 60 MG, 80 hydromorphone hcl er codeine sulfate oral MG ST oral tablet extended tablet ZUBSOLV SUBLINGUAL release 24 hour ST fentanyl transdermal TABLET SUBLINGUAL LAZANDA NASAL patch 72 hour 100 SOLUTION PA; ST mcg/hr, 50 mcg/hr, 75 METHADOSE ORAL mcg/hr ST TABLET SOLUBLE fentanyl transdermal morphine sulfate er patch 72 hour 12 mcg/hr, beads oral capsule 25 mcg/hr extended release 24 hour hydrocodone- ST acetaminophen oral oxymorphone hcl oral solution 2.5-108 mg/5ml, tablet PA 5-217 mg/10ml, 7.5-325 tramadol-acetaminophen mg/15ml DF oral tablet PA; PA hydrocodone- Except Pain Management acetaminophen oral XTAMPZA ER ORAL tablet 10-325 mg, 5-325 CAPSULE ER 12 HOUR mg, 7.5-325 mg DF ABUSE-DETERRENT hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 200 mg, 7.5-200 mg DF hydromorphone hcl oral liquid PA; ST hydromorphone hcl oral tablet hydromorphone hcl rectal PA; ST METHADONE HCL INTENSOL ORAL CONCENTRATE methadone hcl oral concentrate methadone hcl oral solution methadone hcl oral tablet methadone hcl oral tablet soluble morphine sulfate (concentrate) oral solution 100 mg/5ml ST morphine sulfate (concentrate) oral solution 20 mg/ml

Last Updated 12.1.2020 8 morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine sulfate er oral capsule extended release 24 hour 100 mg, 80 mg ST morphine sulfate er oral tablet extended release 100 mg, 200 mg ST morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg morphine sulfate oral solution morphine sulfate oral tablet morphine sulfate rectal suppository oxycodone hcl er oral tablet er 12 hour abuse- deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg oxycodone hcl er oral tablet er 12 hour abuse- deterrent 60 mg, 80 mg ST oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet oxycodone- acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg oxymorphone hcl er oral tablet extended release 12 hour ST pentazocine-naloxone hcl oral tablet AL tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg ST tramadol hcl er oral capsule extended release 24 hour ST tramadol hcl er oral tablet extended release 24 hour

Last Updated 12.1.2020 9 tramadol hcl oral tablet 50 mg

*Androgens-Anabolic*

danazol oral capsule ANDRODERM ANADROL-50 ORAL oxandrolone oral tablet TRANSDERMAL PATCH 24 TABLET testosterone cypionate HOUR PA FORTESTA injection solution 200 methitest oral tablet TRANSDERMAL PA mg/ml PA PA; RM methyltestosterone oral testosterone cypionate capsule PA intramuscular solution NATESTO NASAL GEL 100 mg/ml, 200 mg/ml PA PA; PA Except Endocrinology/Urology testosterone enanthate intramuscular solution PA testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) PA testosterone transdermal solution PA

*Anorectal And Related Products*

hydrocortisone acetate RECTIV RECTAL rectal suppository 25 mg OINTMENT hydrocortisone rectal lidocaine-hydrocortisone ace rectal gel lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 %

Last Updated 12.1.2020 10 *Anthelmintics*

ivermectin oral tablet albendazole oral tablet praziquantel oral tablet PA; PA except Infectious Disease or Gastroenterology EMVERM ORAL TABLET CHEWABLE QL; AL

*Antianginal Agents*

isosorbide dinitrate oral DILATRATE-SR ORAL NITRO-BID tablet MO CAPSULE EXTENDED TRANSDERMAL isosorbide mononitrate RELEASE MO OINTMENT er oral tablet extended NITRO-DUR release 24 hour MO TRANSDERMAL PATCH 24 isosorbide mononitrate HOUR 0.3 MG/HR MO oral tablet MO nitroglycerin translingual nitroglycerin er oral solution MO capsule extended release ranolazine er oral tablet MO extended release 12 hour nitroglycerin sublingual MO tablet sublingual nitroglycerin transdermal patch 24 hour MO

*Antianxiety Agents*

alprazolam oral tablet alprazolam er oral tablet alprazolam oral tablet extended release 24 hour dispersible PA ALPRAZOLAM INTENSOL buspirone hcl oral tablet ORAL CONCENTRATE chlordiazepoxide hcl oral alprazolam xr oral tablet capsule AL extended release 24 hour clorazepate dipotassium LORAZEPAM INTENSOL oral tablet ORAL CONCENTRATE diazepam intensol oral lorazepam oral concentrate AL concentrate 2 mg/ml diazepam oral tablet AL VALIUM ORAL TABLET hydroxyzine hcl oral AL AL hydroxyzine hcl oral tablet AL hydroxyzine pamoate oral capsule AL lorazepam oral tablet oxazepam oral capsule

Last Updated 12.1.2020 11 *Antiarrhythmics*

amiodarone hcl oral NORPACE CR ORAL MULTAQ ORAL TABLET tablet MO CAPSULE EXTENDED MO disopyramide phosphate RELEASE 12 HOUR MO; oral capsule MO; AL AL dofetilide oral capsule MO flecainide acetate oral tablet MO mexiletine hcl oral capsule MO pacerone oral tablet 100 mg, 200 mg, 400 mg MO propafenone hcl er oral capsule extended release 12 hour MO propafenone hcl oral tablet MO quinidine gluconate er oral tablet extended release MO quinidine sulfate oral tablet MO

Last Updated 12.1.2020 12 *Antiasthmatic And Bronchodilator Agents*

albuterol sulfate er oral ADVAIR HFA INHALATION ACCOLATE ORAL TABLET FASENRA PEN tablet extended release AEROSOL MO MO SUBCUTANEOUS 12 hour MO albuterol sulfate BROVANA INHALATION SOLUTION AUTO- albuterol sulfate oral inhalation nebulization NEBULIZATION SOLUTION INJECTOR PA; SP syrup MO solution (2.5 mg/3ml) PA; MO NUCALA SUBCUTANEOUS albuterol sulfate oral 0.083%, (5 mg/ml) 0.5%, DALIRESP ORAL TABLET SOLUTION AUTO- tablet MO 0.63 mg/3ml, 1.25 PA INJECTOR PA; AL; SP ARNUITY ELLIPTA mg/3ml MO ELIXOPHYLLIN ORAL NUCALA SUBCUTANEOUS INHALATION AEROSOL ARCAPTA NEOHALER ELIXIR SOLUTION PREFILLED BREATH INHALATION CAPSULE levalbuterol hcl inhalation SYRINGE PA; AL; SP ACTIVATED 100 MO nebulization solution 0.31 MCG/ACT, 200 MCG/ACT, ATROVENT HFA mg/3ml, 0.63 mg/3ml, 50 MCG/ACT MO; AL INHALATION AEROSOL 1.25 mg/0.5ml, 1.25 ASMANEX (120 METERED SOLUTION MO mg/3ml PA; MO DOSES) INHALATION BREO ELLIPTA PERFOROMIST AEROSOL POWDER INHALATION AEROSOL INHALATION BREATH ACTIVATED POWDER BREATH NEBULIZATION SOLUTION MO ACTIVATED 100-25 PA; MO ASMANEX (14 METERED MCG/INH MO; AL YUPELRI INHALATION DOSES) INHALATION BREO ELLIPTA SOLUTION PA AEROSOL POWDER INHALATION AEROSOL zafirlukast oral tablet BREATH ACTIVATED POWDER BREATH MO zileuton er oral tablet MO ACTIVATED 200-25 extended release 12 hour ASMANEX (30 METERED MCG/INH MO DOSES) INHALATION COMBIVENT PA ZYFLO ORAL TABLET PA AEROSOL POWDER INHALATION AEROSOL BREATH ACTIVATED SOLUTION MO MO PROAIR HFA INHALATION ASMANEX (60 METERED AEROSOL SOLUTION DOSES) INHALATION PROAIR RESPICLICK AEROSOL POWDER INHALATION AEROSOL BREATH ACTIVATED POWDER BREATH MO ACTIVATED ASMANEX (7 METERED SEREVENT DISKUS DOSES) INHALATION INHALATION AEROSOL AEROSOL POWDER POWDER BREATH BREATH ACTIVATED ACTIVATED ST; MO MO SPIRIVA HANDIHALER ASMANEX HFA INHALATION CAPSULE INHALATION AEROSOL MO MO SPIRIVA RESPIMAT budesonide inhalation INHALATION AEROSOL suspension MO; AL SOLUTION 1.25 cromolyn sodium MCG/ACT, 2.5 MCG/ACT inhalation nebulization MO solution MO STIOLTO RESPIMAT FLOVENT DISKUS INHALATION AEROSOL INHALATION AEROSOL SOLUTION 2.5-2.5 POWDER BREATH MCG/ACT MO ACTIVATED MO STRIVERDI RESPIMAT FLOVENT HFA INHALATION AEROSOL INHALATION AEROSOL SOLUTION MO MO SYMBICORT INHALATION fluticasone-salmeterol AEROSOL MO inhalation aerosol THEO-24 ORAL CAPSULE powder breath activated EXTENDED RELEASE 24 MO HOUR MO

Last Updated 12.1.2020 13 ipratropium bromide VENTOLIN HFA inhalation solution MO INHALATION AEROSOL ipratropium-albuterol SOLUTION inhalation solution MO levalbuterol tartrate inhalation aerosol MO montelukast sodium oral packet MO; AL montelukast sodium oral tablet MO; AL montelukast sodium oral tablet chewable 4 mg, 5 mg MO; AL PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED MO QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED MO terbutaline sulfate oral tablet MO theophylline er oral tablet extended release 12 hour 300 mg, 450 mg MO theophylline er oral tablet extended release 24 hour theophylline oral solution WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED MO

*Anticoagulants*

enoxaparin sodium ELIQUIS DVT/PE STARTER injection solution PA; PACK ORAL TABLET QL THERAPY PACK enoxaparin sodium ELIQUIS ORAL TABLET subcutaneous solution MO PA; QL FRAGMIN fondaparinux sodium SUBCUTANEOUS subcutaneous solution SOLUTION 10000 PA; PA required for UNIT/ML, 12500 duration of greater than UNIT/0.5ML, 15000 14 days except when UNIT/0.6ML, 18000 written by Oncology; QL UNT/0.72ML, 2500 JANTOVEN ORAL TABLET UNIT/0.2ML, 5000 MO UNIT/0.2ML, 7500 warfarin sodium oral UNIT/0.3ML, 95000 tablet MO UNIT/3.8ML PA; PA required for duration of greater than 14 days except when written by Oncology; QL PRADAXA ORAL CAPSULE 110 MG PRADAXA ORAL CAPSULE 150 MG, 75 MG MO XARELTO ORAL TABLET MO XARELTO STARTER PACK ORAL TABLET THERAPY PACK

Last Updated 12.1.2020 14 *Anticonvulsants*

carbamazepine er oral BANZEL ORAL TABLET APTIOM ORAL TABLET DIACOMIT ORAL CAPSULE capsule extended release CELONTIN ORAL CAPSULE MO PA; SP 12 hour MO MO BRIVIACT ORAL DIACOMIT ORAL PACKET carbamazepine er oral VIMPAT ORAL SOLUTION SOLUTION PA; PA PA; SP tablet extended release AL Except Neurology EPIDIOLEX ORAL 12 hour MO VIMPAT ORAL TABLET BRIVIACT ORAL TABLET SOLUTION PA; SP carbamazepine oral AL PA; PA Except Neurology suspension MO XCOPRI (250 MG DAILY DIASTAT ACUDIAL RECTAL carbamazepine oral DOSE) ORAL TABLET GEL PA; AL tablet MO THERAPY PACK PA DIASTAT PEDIATRIC carbamazepine oral XCOPRI (350 MG DAILY RECTAL GEL PA; AL tablet chewable MO DOSE) ORAL TABLET diazepam rectal gel PA; clobazam oral suspension THERAPY PACK PA AL PA XCOPRI ORAL TABLET DILANTIN ORAL CAPSULE clobazam oral tablet PA PA 30 MG MO clonazepam oral tablet XCOPRI ORAL TABLET FYCOMPA ORAL clonazepam oral tablet THERAPY PACK PA SUSPENSION AL dispersible PA FYCOMPA ORAL TABLET divalproex sodium er oral AL tablet extended release KLONOPIN ORAL TABLET 24 hour MO 2 MG divalproex sodium oral LAMICTAL XR ORAL KIT capsule delayed release MO; AL sprinkle MO lamotrigine er oral tablet divalproex sodium oral extended release 24 hour tablet delayed release MO; AL MO lamotrigine oral kit 25 & ethosuximide oral 50 & 100 mg capsule MO lamotrigine oral tablet ethosuximide oral dispersible PA; MO solution MO lamotrigine starter kit- felbamate oral blue oral kit suspension MO lamotrigine starter kit- felbamate oral tablet green oral kit MO lamotrigine starter kit- gabapentin oral capsule orange oral kit MO MYSOLINE ORAL TABLET gabapentin oral solution MO 250 mg/5ml MO NAYZILAM NASAL gabapentin oral tablet SOLUTION PA MO OXTELLAR XR ORAL lamotrigine oral tablet TABLET EXTENDED MO RELEASE 24 HOUR ST; lamotrigine oral tablet MO chewable MO SPRITAM ORAL TABLET levetiracetam er oral DISINTEGRATING tablet extended release SOLUBLE ST 24 hour MO topiramate er oral levetiracetam oral capsule er 24 hour solution MO sprinkle PA; PA Except levetiracetam oral tablet Neurology; MO; AL MO TROKENDI XR ORAL oxcarbazepine oral CAPSULE EXTENDED suspension RELEASE 24 HOUR PA; oxcarbazepine oral tablet MO MO VALTOCO 10 MG DOSE phenytoin infatabs oral NASAL LIQUID PA; QL tablet chewable MO

Last Updated 12.1.2020 15 phenytoin oral VALTOCO 15 MG DOSE suspension 125 mg/5ml NASAL LIQUID THERAPY MO PACK PA; QL phenytoin oral tablet VALTOCO 20 MG DOSE chewable MO NASAL LIQUID THERAPY phenytoin sodium PACK PA; QL extended oral capsule VALTOCO 5 MG DOSE MO NASAL LIQUID PA; QL pregabalin oral capsule ZONEGRAN ORAL MO CAPSULE MO pregabalin oral solution primidone oral tablet MO rufinamide oral suspension tiagabine hcl oral tablet MO topiramate oral capsule sprinkle MO topiramate oral tablet MO valproic acid oral capsule MO valproic acid oral solution MO vigabatrin oral packet PA; SP vigabatrin oral tablet PA; SP VIGADRONE ORAL PACKET PA; SP zonisamide oral capsule MO

Last Updated 12.1.2020 16 *Antidepressants*

amitriptyline hcl oral PAXIL ORAL SUSPENSION amoxapine oral tablet tablet AL EMSAM TRANSDERMAL bupropion hcl er (sr) oral PATCH 24 HOUR PA; PA tablet extended release Except Psychiatry 12 hour MO FETZIMA ORAL CAPSULE bupropion hcl er (xl) oral EXTENDED RELEASE 24 tablet extended release HOUR ST 24 hour 150 mg, 300 mg fluoxetine hcl oral MO capsule delayed release bupropion hcl oral tablet fluvoxamine maleate er MO oral capsule extended citalopram hydrobromide release 24 hour oral solution MO MARPLAN ORAL TABLET citalopram hydrobromide MO oral tablet MO NORPRAMIN ORAL clomipramine hcl oral TABLET 10 MG, 25 MG capsule AL PEXEVA ORAL TABLET desipramine hcl oral TRINTELLIX ORAL TABLET tablet ST desvenlafaxine succinate VIIBRYD ORAL TABLET er oral tablet extended MO release 24 hour MO doxepin hcl oral capsule AL doxepin hcl oral concentrate AL duloxetine hcl oral capsule delayed release particles MO escitalopram oxalate oral solution MO escitalopram oxalate oral tablet HT; MO fluoxetine hcl oral capsule MO fluoxetine hcl oral solution fluvoxamine maleate oral tablet MO imipramine hcl oral tablet AL maprotiline hcl oral tablet PA; PA Except Psychiatry; MO mirtazapine oral tablet MO mirtazapine oral tablet dispersible MO nefazodone hcl oral tablet PA; MO nortriptyline hcl oral capsule nortriptyline hcl oral solution paroxetine hcl er oral tablet extended release 24 hour ST; MO paroxetine hcl oral tablet MO

Last Updated 12.1.2020 17 phenelzine sulfate oral tablet MO protriptyline hcl oral tablet sertraline hcl oral concentrate MO sertraline hcl oral tablet MO tranylcypromine sulfate oral tablet MO trazodone hcl oral tablet MO trimipramine maleate oral capsule AL venlafaxine hcl er oral capsule extended release 24 hour MO venlafaxine hcl oral tablet MO

Last Updated 12.1.2020 18 *Antidiabetics*

acarbose oral tablet GLUCAGEN HYPOKIT AVANDIA ORAL TABLET 2 KORLYM ORAL TABLET MO INJECTION SOLUTION MG, 4 MG PA; MO PA; SP BAQSIMI ONE PACK RECONSTITUTED CYCLOSET ORAL TABLET NASAL POWDER GLYXAMBI ORAL TABLET miglitol oral tablet PA BAQSIMI TWO PACK MO NASAL POWDER HUMALOG JUNIOR diazoxide oral suspension KWIKPEN PA; PA Except SUBCUTANEOUS Endocrinology SOLUTION PEN-INJECTOR glimepiride oral tablet MO MO HUMALOG KWIKPEN glipizide er oral tablet SUBCUTANEOUS extended release 24 hour SOLUTION PEN-INJECTOR MO 100 UNIT/ML, 200 glipizide oral tablet MO glipizide xl oral tablet UNIT/ML MO HUMALOG MIX 50/50 extended release 24 hour KWIKPEN MO glipizide-metformin hcl SUBCUTANEOUS oral tablet MO SUSPENSION PEN- glucagon emergency INJECTOR MO injection kit HUMALOG MIX 50/50 glyburide micronized oral SUBCUTANEOUS tablet MO; AL SUSPENSION MO glyburide oral tablet HUMALOG MIX 75/25 MO; AL KWIKPEN glyburide-metformin oral SUBCUTANEOUS tablet MO SUSPENSION PEN- GVOKE HYPOPEN 1-PACK INJECTOR MO SUBCUTANEOUS HUMALOG MIX 75/25 SOLUTION AUTO- SUBCUTANEOUS INJECTOR SUSPENSION MO GVOKE HYPOPEN 2-PACK HUMALOG SUBCUTANEOUS SUBCUTANEOUS SOLUTION AUTO- SOLUTION MO INJECTOR HUMALOG GVOKE PFS SUBCUTANEOUS SUBCUTANEOUS SOLUTION CARTRIDGE SOLUTION PREFILLED MO SYRINGE HUMULIN 70/30 metformin hcl er oral KWIKPEN tablet extended release SUBCUTANEOUS 24 hour MO SUSPENSION PEN- metformin hcl oral INJECTOR OTC; MO solution HUMULIN 70/30 metformin hcl oral tablet SUBCUTANEOUS MO SUSPENSION OTC; MO nateglinide oral tablet HUMULIN N KWIKPEN MO SUBCUTANEOUS pioglitazone hcl oral SUSPENSION PEN- tablet MO pioglitazone hcl- INJECTOR OTC; MO HUMULIN N glimepiride oral tablet SUBCUTANEOUS MO pioglitazone hcl- SUSPENSION OTC; MO HUMULIN R INJECTION metformin hcl oral tablet SOLUTION OTC; MO MO

Last Updated 12.1.2020 19 repaglinide oral tablet HUMULIN R U-500 MO (CONCENTRATED) SUBCUTANEOUS SOLUTION MO HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR MO INVOKAMET ORAL TABLET MO INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO INVOKANA ORAL TABLET MO JARDIANCE ORAL TABLET MO JENTADUETO ORAL TABLET MO JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO LANTUS SUBCUTANEOUS SOLUTION MO LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR MO LEVEMIR SUBCUTANEOUS SOLUTION MO LYUMJEV INJECTION SOLUTION LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; Step except endocrinology OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; Step except endocrinology RIOMET ORAL SOLUTION RYBELSUS ORAL TABLET ST; ST Except Endocrinology

Last Updated 12.1.2020 20 SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR ST SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; PA except Endocrinology; MO SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; PA except Endocrinology; MO SYNJARDY ORAL TABLET MO SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TRADJENTA ORAL TABLET MO TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TRESIBA SUBCUTANEOUS SOLUTION MO TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; ST Except Endocrinology VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR ST

*Antidiarrheal/Probiotic Agents*

diphenoxylate-atropine loperamide hcl oral oral liquid capsule diphenoxylate-atropine MOTOFEN ORAL TABLET oral tablet AL opium oral MYTESI ORAL TABLET DELAYED RELEASE PA; LA

Last Updated 12.1.2020 21 *Antidotes And Specific Antagonists*

naloxone hcl injection NARCAN NASAL LIQUID VISTOGARD ORAL PACKET deferasirox granules oral solution 0.4 mg/ml, 4 SP packet PA; SP mg/10ml QL deferasirox oral tablet naloxone hcl injection PA; SP solution cartridge QL FERRIPROX ORAL TABLET naloxone hcl injection PA; SP solution prefilled syringe FERRIPROX TWICE-A-DAY QL ORAL TABLET PA; SP naltrexone hcl oral tablet

*Antiemetics*

aprepitant oral capsule BONJESTA ORAL TABLET AKYNZEO ORAL CAPSULE 125 mg, 80 mg ST; ST EXTENDED RELEASE ST; QL Except EMEND ORAL ANZEMET ORAL TABLET Hematology/Oncology; SUSPENSION ST; QL QL RECONSTITUTED PA; ST dronabinol oral capsule aprepitant oral capsule PA 40 mg QL granisetron hcl oral tablet doxylamine-pyridoxine ST; QL oral tablet delayed SANCUSO TRANSDERMAL release QL PATCH ST; QL meclizine hcl oral tablet scopolamine transdermal 12.5 mg, 25 mg MO patch 72 hour QL ondansetron hcl oral SYNDROS ORAL solution SOLUTION PA ondansetron hcl oral VARUBI (180 MG DOSE) tablet ORAL TABLET THERAPY ondansetron oral tablet PACK PA; LA; QL dispersible ZUPLENZ ORAL FILM trimethobenzamide hcl ST; QL oral capsule PA; AL

Last Updated 12.1.2020 22 *Antifungals*

fluconazole oral NOXAFIL ORAL flucytosine oral capsule suspension reconstituted SUSPENSION PA; MO fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule PA; PA except Infectious Disease, Hematology and Oncology itraconazole oral solution PA; PA except Infectious Disease, Hematology and Oncology ketoconazole oral tablet PA nystatin oral tablet posaconazole oral tablet delayed release PA; MO terbinafine hcl oral tablet voriconazole oral suspension reconstituted PA; PA Except Infectious Disease voriconazole oral tablet PA; PA Except Infectious Disease

*Antihistamines*

carbinoxamine maleate desloratadine oral tablet oral solution AL PA carbinoxamine maleate desloratadine oral tablet oral tablet 4 mg AL dispersible PA; AL cyproheptadine hcl oral syrup AL cyproheptadine hcl oral tablet AL hcl oral elixir AL levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet promethazine hcl oral solution AL promethazine hcl oral syrup AL promethazine hcl oral tablet AL promethazine hcl rectal suppository 12.5 mg, 25 mg AL

Last Updated 12.1.2020 23 *Antihyperlipidemics*

atorvastatin calcium oral PRALUENT ezetimibe-simvastatin JUXTAPID ORAL CAPSULE tablet MO SUBCUTANEOUS oral tablet 10-10 mg, 10- 10 MG, 20 MG, 30 MG, 5 cholestyramine light oral SOLUTION AUTO- 20 mg, 10-40 mg MO MG PA; SP packet MO INJECTOR PA; LA ezetimibe-simvastatin cholestyramine light oral REPATHA PUSHTRONEX oral tablet 10-80 mg powder MO SYSTEM SUBCUTANEOUS PA; MO cholestyramine oral SOLUTION CARTRIDGE fluvastatin sodium er oral packet MO PA; LA tablet extended release cholestyramine oral REPATHA 24 hour MO powder MO SUBCUTANEOUS fluvastatin sodium oral colesevelam hcl oral SOLUTION PREFILLED capsule MO packet MO LIVALO ORAL TABLET colestipol hcl oral SYRINGE PA; LA REPATHA SURECLICK MO granules MO NEXLETOL ORAL TABLET colestipol hcl oral packet SUBCUTANEOUS SOLUTION AUTO- PA MO NEXLIZET ORAL TABLET INJECTOR PA; LA colestipol hcl oral tablet PA MO VASCEPA ORAL CAPSULE ezetimibe oral tablet MO MO WELCHOL ORAL PACKET fenofibrate micronized MO oral capsule 134 mg, 67 WELCHOL ORAL TABLET mg MO MO fenofibrate oral capsule 134 mg, 67 mg MO fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg MO fenofibric acid oral capsule delayed release 45 mg MO gemfibrozil oral tablet MO icosapent ethyl oral capsule MO lovastatin oral tablet MO pravastatin sodium oral tablet MO rosuvastatin calcium oral tablet MO simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg MO simvastatin oral tablet 80 mg PA; MO

Last Updated 12.1.2020 24 *Antihypertensives*

amlodipine besy- aliskiren fumarate oral benazepril hcl oral tablet ST; MO capsule MO amlodipine besylate- atenolol-chlorthalidone valsartan oral tablet ST; oral tablet MO MO benazepril hcl oral tablet amlodipine-olmesartan MO oral tablet ST; MO benazepril- amlodipine-valsartan-hctz hydrochlorothiazide oral oral tablet ST; MO tablet MO EDARBI ORAL TABLET bisoprolol- ST; MO hydrochlorothiazide oral EDARBYCLOR ORAL tablet MO TABLET 40-12.5 MG ST; candesartan cilexetil oral MO tablet ST; MO EPANED ORAL SOLUTION candesartan cilexetil-hctz PA oral tablet ST; MO MAVIK ORAL TABLET 4 captopril- MG MO hydrochlorothiazide oral olmesartan-amlodipine- tablet MO hctz oral tablet ST; MO clonidine hcl oral tablet TEKTURNA HCT ORAL MO TABLET ST; MO clonidine transdermal telmisartan-amlodipine patch weekly MO oral tablet ST; MO doxazosin mesylate oral trandolapril-verapamil hcl tablet MO er oral tablet extended enalapril maleate oral release tablet MO VASERETIC ORAL TABLET enalapril- MO hydrochlorothiazide oral VECAMYL ORAL TABLET tablet MO PA; LA eplerenone oral tablet PA; MO fosinopril sodium oral tablet MO fosinopril sodium-hctz oral tablet MO guanfacine hcl oral tablet MO; AL hydralazine hcl oral tablet MO irbesartan oral tablet MO irbesartan- hydrochlorothiazide oral tablet MO lisinopril oral tablet MO lisinopril- hydrochlorothiazide oral tablet MO losartan potassium oral tablet MO losartan potassium-hctz oral tablet MO methyldopa oral tablet MO; AL methyldopa- hydrochlorothiazide oral tablet MO

Last Updated 12.1.2020 25 metoprolol- hydrochlorothiazide oral tablet MO metyrosine oral capsule minoxidil oral tablet MO moexipril hcl oral tablet MO olmesartan medoxomil oral tablet MO olmesartan medoxomil- hctz oral tablet ST; MO perindopril erbumine oral tablet MO phenoxybenzamine hcl oral capsule PA prazosin hcl oral capsule MO propranolol-hctz oral tablet MO quinapril hcl oral tablet MO quinapril- hydrochlorothiazide oral tablet MO ramipril oral capsule MO telmisartan oral tablet ST; MO telmisartan-hctz oral tablet ST; MO terazosin hcl oral capsule MO trandolapril oral tablet MO valsartan oral tablet MO valsartan- hydrochlorothiazide oral tablet MO

Last Updated 12.1.2020 26 *Anti-Infective Agents - Misc.*

atovaquone oral ALINIA ORAL FIRVANQ ORAL CAYSTON INHALATION suspension SUSPENSION SOLUTION SOLUTION clindamycin hcl oral RECONSTITUTED PA; AL RECONSTITUTED PA; RECONSTITUTED PA; capsule DF ALINIA ORAL TABLET PA Except Infectious PA Except Cystic Fibrosis clindamycin palmitate hcl PA Disease or Specialists; AL; SP oral solution PRIMSOL ORAL SOLUTION Gastroenterology reconstituted DF XIFAXAN ORAL TABLET fosfomycin dapsone oral tablet 200 MG QL tromethamine oral linezolid oral suspension XIFAXAN ORAL TABLET packet reconstituted 550 MG PA LAMPIT ORAL TABLET linezolid oral tablet methenamine hippurate PA MACRODANTIN ORAL oral tablet MO methenamine mandelate CAPSULE 25 MG AL metronidazole oral oral tablet metronidazole oral tablet capsule nitrofurantoin nitrofurantoin oral macrocrystal oral capsule suspension AL nitrofurantoin monohyd SIVEXTRO ORAL TABLET macro oral capsule PA pentamidine isethionate URIBEL ORAL CAPSULE uroav-b oral capsule inhalation solution uro-mp oral capsule reconstituted PA; PA Except Infectious Disease sulfamethoxazole- trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole- trimethoprim oral tablet tinidazole oral tablet trimethoprim oral tablet vancomycin hcl oral capsule PA; PA except Infectious Disease or Gastroenterology

*Antimalarials*

atovaquone-proguanil hcl COARTEM ORAL TABLET QUALAQUIN ORAL oral tablet QL CAPSULE PA; QL; AL chloroquine phosphate oral tablet hydroxychloroquine sulfate oral tablet MO mefloquine hcl oral tablet primaquine phosphate oral tablet pyrimethamine oral tablet PA; PA Except Infectious Disease; SP quinine sulfate oral capsule PA; QL; AL

*Antimyasthenic/Cholinergic Agents*

guanidine hcl oral tablet MESTINON ORAL FIRDAPSE ORAL TABLET MO SOLUTION PA pyridostigmine bromide RUZURGI ORAL TABLET er oral tablet extended PA; LA release pyridostigmine bromide oral solution pyridostigmine bromide oral tablet 60 mg MO

Last Updated 12.1.2020 27 *Antimycobacterial Agents*

ethambutol hcl oral MYCOBUTIN ORAL tablet CAPSULE PA isoniazid oral syrup MO PASER ORAL PACKET isoniazid oral tablet pretomanid oral tablet MO PA pyrazinamide oral tablet PRIFTIN ORAL TABLET rifabutin oral capsule SIRTURO ORAL TABLET PA PA rifampin oral capsule TRECATOR ORAL TABLET

Last Updated 12.1.2020 28 *Antineoplastics And Adjunctive Therapies*

abiraterone acetate oral LYSODREN ORAL TABLET GLEOSTINE ORAL AFINITOR DISPERZ ORAL ALECENSA ORAL CAPSULE tablet PA; SP LA CAPSULE 10 MG, 100 MG, TABLET SOLUBLE PA; SP PA; SP anastrozole oral tablet NILANDRON ORAL 40 MG AFINITOR ORAL TABLET ALUNBRIG ORAL TABLET PA; LA; MO TABLET PA; PA except XATMEP ORAL SOLUTION 10 MG PA; SP 30 MG PA; SP bexarotene oral capsule Oncology & Urology PA ALKERAN ORAL TABLET AYVAKIT ORAL TABLET PA; SP SOLTAMOX ORAL SP PA; SP bicalutamide oral tablet SOLUTION MO CAPRELSA ORAL TABLET BALVERSA ORAL TABLET SP TABLOID ORAL TABLET PA; SP PA; SP capecitabine oral tablet TREXALL ORAL TABLET EMCYT ORAL CAPSULE BOSULIF ORAL TABLET SP MO SP PA; SP cyclophosphamide oral ERIVEDGE ORAL CAPSULE BRAFTOVI ORAL CAPSULE capsule SP PA; SP 75 MG PA; SP erlotinib hcl oral tablet ERLEADA ORAL TABLET BRUKINSA ORAL CAPSULE PA; PA Except Oncology; PA; SP PA; SP SP HYCAMTIN ORAL CABOMETYX ORAL etoposide oral capsule CAPSULE PA; SP TABLET PA; SP SP INTRON A INJECTION CALQUENCE ORAL everolimus oral tablet 2.5 SOLUTION PA; SP CAPSULE PA; SP mg, 5 mg, 7.5 mg PA; INTRON A INJECTION COMETRIQ (60 MG DAILY PA except Renal SOLUTION DOSE) ORAL KIT PA; SP Transplant Surgeons and RECONSTITUTED PA; SP COPIKTRA ORAL CAPSULE Nephrology; SP JAKAFI ORAL TABLET PA; SP exemestane oral tablet PA; SP COTELLIC ORAL TABLET LA; MO lapatinib ditosylate oral PA; SP flutamide oral capsule tablet PA; SP DAURISMO ORAL TABLET SP LEUKERAN ORAL TABLET PA; SP hydroxyurea oral capsule SP FARYDAK ORAL CAPSULE imatinib mesylate oral MATULANE ORAL PA; SP tablet PA; SP CAPSULE SP GAVRETO ORAL CAPSULE letrozole oral tablet PA; MESNEX ORAL TABLET PA; SP PA Except Fertility and PA; PA Except Oncology; GILOTRIF ORAL TABLET Oncology; QL & AL for SP PA; SP IBRANCE ORAL CAPSULE Fertility; QL MYLERAN ORAL TABLET leucovorin calcium oral SP PA; SP IBRANCE ORAL TABLET tablet SPRYCEL ORAL TABLET megestrol acetate oral PA; SP PA; SP ICLUSIG ORAL TABLET suspension 40 mg/ml, SUTENT ORAL CAPSULE PA; SP PA; SP 400 mg/10ml LA IDHIFA ORAL TABLET megestrol acetate oral TASIGNA ORAL CAPSULE PA; SP PA; SP tablet LA IMBRUVICA ORAL mercaptopurine oral VOTRIENT ORAL TABLET PA; SP CAPSULE PA; SP tablet IMBRUVICA ORAL TABLET methotrexate oral tablet XTANDI ORAL CAPSULE PA; SP PA; SP MO INLYTA ORAL TABLET methotrexate sodium (pf) ZEJULA ORAL CAPSULE PA; SP injection solution 1 PA; SP ZOLINZA ORAL CAPSULE INQOVI ORAL TABLET gm/40ml, 250 mg/10ml, PA; SP PA; SP 50 mg/2ml PA; PA INREBIC ORAL CAPSULE Except Rheumatology and PA; SP Dermatology IRESSA ORAL TABLET methotrexate sodium PA; SP injection solution 250 KISQALI FEMARA (400 mg/10ml, 50 mg/2ml MG DOSE) ORAL TABLET PA; PA Except THERAPY PACK PA; SP Rheumatology and KISQALI FEMARA (600 Dermatology MG DOSE) ORAL TABLET THERAPY PACK PA; SP

Last Updated 12.1.2020 29 methotrexate sodium KISQALI FEMARA(200 MG injection solution DOSE) ORAL TABLET reconstituted PA; PA THERAPY PACK PA; SP Except Rheumatology and KOSELUGO ORAL Dermatology CAPSULE PA; SP tamoxifen citrate oral LENVIMA (10 MG DAILY tablet MO DOSE) ORAL CAPSULE temozolomide oral THERAPY PACK PA; SP capsule SP LENVIMA (12 MG DAILY toremifene citrate oral DOSE) ORAL CAPSULE tablet LA; MO THERAPY PACK PA; SP tretinoin oral capsule LENVIMA (14 MG DAILY LA DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LONSURF ORAL TABLET PA; SP LORBRENA ORAL TABLET PA; SP LYNPARZA ORAL TABLET PA; SP MEKINIST ORAL TABLET PA; SP MEKTOVI ORAL TABLET PA; SP NERLYNX ORAL TABLET PA; SP NEXAVAR ORAL TABLET PA; SP NINLARO ORAL CAPSULE PA; SP NUBEQA ORAL TABLET PA; SP ODOMZO ORAL CAPSULE PA; SP ONUREG ORAL TABLET PA; SP PEMAZYRE ORAL TABLET PA; SP PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP

Last Updated 12.1.2020 30 PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP POMALYST ORAL CAPSULE PA; SP QINLOCK ORAL TABLET PA; SP RETEVMO ORAL CAPSULE PA; SP ROZLYTREK ORAL CAPSULE PA; SP RUBRACA ORAL TABLET PA; SP RYDAPT ORAL CAPSULE PA; SP STIVARGA ORAL TABLET PA; SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP TABRECTA ORAL TABLET PA; SP TAFINLAR ORAL CAPSULE PA; SP TAGRISSO ORAL TABLET PA; SP TALZENNA ORAL CAPSULE PA; SP TAZVERIK ORAL TABLET PA; SP TIBSOVO ORAL TABLET PA; SP TUKYSA ORAL TABLET PA; SP TURALIO ORAL CAPSULE PA; SP VENCLEXTA ORAL TABLET PA; SP VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK PA; SP VERZENIO ORAL TABLET PA; SP VITRAKVI ORAL CAPSULE PA; SP VITRAKVI ORAL SOLUTION PA; SP VIZIMPRO ORAL TABLET PA; SP XALKORI ORAL CAPSULE PA; SP XOSPATA ORAL TABLET PA; SP ZELBORAF ORAL TABLET PA; SP

Last Updated 12.1.2020 31 ZYDELIG ORAL TABLET PA; SP ZYKADIA ORAL TABLET PA; SP

Last Updated 12.1.2020 32 *Antiparkinson And Related Therapy Agents*

amantadine hcl oral ZELAPAR ORAL TABLET bromocriptine mesylate APOKYN SUBCUTANEOUS capsule MO DISPERSIBLE PA; PA oral capsule MO SOLUTION CARTRIDGE amantadine hcl oral syrup Except Neurology; MO carbidopa oral tablet PA; PA Except Neurology; MO MO SP amantadine hcl oral KYNMOBI SUBLINGUAL DUOPA ENTERAL tablet MO FILM PA; PA Except SUSPENSION PA; SP benztropine mesylate Neurology GOCOVRI ORAL CAPSULE oral tablet MO; AL KYNMOBI TITRATION KIT EXTENDED RELEASE 24 bromocriptine mesylate SUBLINGUAL KIT PA; PA HOUR PA; SP oral tablet MO Except Neurology INBRIJA INHALATION carbidopa-levodopa er NEUPRO TRANSDERMAL CAPSULE PA; SP oral tablet extended PATCH 24 HOUR PA release 25-100 mg, 50- ONGENTYS ORAL 200 mg MO CAPSULE ST carbidopa-levodopa oral OSMOLEX ER ORAL tablet MO TABLET ER 24 HOUR carbidopa-levodopa oral THERAPY PACK PA tablet dispersible ST; OSMOLEX ER ORAL MO TABLET EXTENDED carbidopa-levodopa- RELEASE 24 HOUR PA entacapone oral tablet pramipexole MO dihydrochloride er oral entacapone oral tablet tablet extended release ST; MO 24 hour PA; PA Except pramipexole Neurology; MO dihydrochloride oral XADAGO ORAL TABLET tablet MO PA; LA rasagiline mesylate oral tablet PA; PA Except Neurology; MO ropinirole hcl er oral tablet extended release 24 hour PA; PA Except Neurology; MO ropinirole hcl oral tablet MO selegiline hcl oral capsule MO selegiline hcl oral tablet MO trihexyphenidyl hcl oral solution MO; AL trihexyphenidyl hcl oral tablet MO; AL

Last Updated 12.1.2020 33 *Antipsychotics/Antimanic Agents*

aripiprazole oral solution LATUDA ORAL TABLET ABILIFY MYCITE ORAL NUPLAZID ORAL CAPSULE aripiprazole oral tablet 10 MO; AL TABLET PA; LA PA; SP mg, 15 mg, 2 mg, 20 mg CAPLYTA ORAL CAPSULE NUPLAZID ORAL TABLET PA Except Psychiatry; PA PA 10 MG PA; SP Except Psychiatry; MO clozapine oral tablet aripiprazole oral tablet 30 dispersible PA mg, 5 mg PA Except EQUETRO ORAL CAPSULE Psychiatry; MO EXTENDED RELEASE 12 chlorpromazine hcl oral HOUR PA; MO tablet MO FANAPT ORAL TABLET clozapine oral tablet AL PA COMPRO RECTAL FANAPT TITRATION PACK SUPPOSITORY ORAL TABLET PA fluphenazine hcl oral paliperidone er oral concentrate tablet extended release fluphenazine hcl oral 24 hour PA; PA Except elixir Psychiatry; MO fluphenazine hcl oral REXULTI ORAL TABLET tablet MO PA; MO haloperidol lactate oral SAPHRIS SUBLINGUAL concentrate MO TABLET SUBLINGUAL haloperidol oral tablet VRAYLAR ORAL CAPSULE MO PA lithium carbonate er oral VRAYLAR ORAL CAPSULE tablet extended release THERAPY PACK PA MO lithium carbonate oral capsule MO lithium carbonate oral tablet MO lithium oral solution MO loxapine succinate oral capsule MO olanzapine oral tablet MO olanzapine oral tablet dispersible PA perphenazine oral tablet MO prochlorperazine maleate oral tablet AL Except Oncology; MO; AL prochlorperazine rectal suppository quetiapine fumarate er oral tablet extended release 24 hour MO quetiapine fumarate oral tablet MO risperidone oral solution MO; AL risperidone oral tablet MO risperidone oral tablet dispersible PA thioridazine hcl oral tablet MO; AL

Last Updated 12.1.2020 34 thiothixene oral capsule MO trifluoperazine hcl oral tablet MO ziprasidone hcl oral capsule MO

Last Updated 12.1.2020 35 *Antivirals*

abacavir sulfate oral BARACLUDE ORAL APTIVUS ORAL CAPSULE FUZEON SUBCUTANEOUS PREVYMIS ORAL TABLET solution LA SOLUTION PA; PA LA SOLUTION PA; SP abacavir sulfate oral Except Infectious Disease APTIVUS ORAL SOLUTION RECONSTITUTED PA; SP tablet LA; MO or Gastroenterology LA HARVONI ORAL PACKET abacavir sulfate- BIKTARVY ORAL TABLET COMPLERA ORAL TABLET PA; SP lamivudine oral tablet LA LA HARVONI ORAL TABLET LA CIMDUO ORAL TABLET DESCOVY ORAL TABLET PA; SP abacavir-lamivudine- LA PA; LA MAVYRET ORAL TABLET zidovudine oral tablet CRIXIVAN ORAL CAPSULE DOVATO ORAL TABLET PA; SP PA; LA; MO 200 MG, 400 MG LA PA; LA PEGASYS acyclovir oral capsule DELSTRIGO ORAL TABLET EDURANT ORAL TABLET SUBCUTANEOUS acyclovir oral suspension LA LA SOLUTION PA; SP acyclovir oral tablet EMTRIVA ORAL EPZICOM ORAL TABLET SOVALDI ORAL PACKET adefovir dipivoxil oral SOLUTION LA LA PA; SP tablet PA; PA Except EPCLUSA ORAL TABLET EVOTAZ ORAL TABLET SOVALDI ORAL TABLET Gastro/Infectious 200-50 MG PA; SP LA PA; SP Disease; MO EPIVIR HBV ORAL HEPSERA ORAL TABLET VOSEVI ORAL TABLET didanosine oral capsule SOLUTION LA PA; PA Except PA; SP delayed release 200 mg, GENVOYA ORAL TABLET Gastro/Infectious 250 mg, 400 mg LA LA; AL Disease; MO efavirenz oral capsule INTELENCE ORAL TABLET INVIRASE ORAL TABLET LA LA LA efavirenz oral tablet LA ISENTRESS HD ORAL JULUCA ORAL TABLET efavirenz-emtricitab- TABLET LA LA tenofovir oral tablet LA ISENTRESS ORAL PACKET ODEFSEY ORAL TABLET efavirenz-lamivudine- LA LA tenofovir oral tablet LA ISENTRESS ORAL TABLET PREZCOBIX ORAL TABLET emtricitabine oral capsule LA LA LA ISENTRESS ORAL TABLET XOFLUZA (40 MG DOSE) emtricitabine-tenofovir df CHEWABLE LA ORAL TABLET THERAPY oral tablet LA KALETRA ORAL TABLET PACK QL entecavir oral tablet LA XOFLUZA (80 MG DOSE) PA; PA Except Infectious LEXIVA ORAL ORAL TABLET THERAPY Disease or SUSPENSION LA PACK QL Gastroenterology; MO NORVIR ORAL SOLUTION famciclovir oral tablet LA fosamprenavir calcium PIFELTRO ORAL TABLET oral tablet LA LA lamivudine oral solution PREZISTA ORAL LA SUSPENSION ST; LA lamivudine oral tablet PREZISTA ORAL TABLET LA; MO 150 MG, 600 MG, 75 MG, lamivudine-zidovudine 800 MG ST; LA oral tablet LA; MO RELENZA DISKHALER ledipasvir-sofosbuvir oral INHALATION AEROSOL tablet PA; SP POWDER BREATH lopinavir-ritonavir oral ACTIVATED QL; AL solution LA REYATAZ ORAL CAPSULE nevirapine er oral tablet 150 MG, 200 MG, 300 extended release 24 hour MG LA LA REYATAZ ORAL PACKET nevirapine oral LA suspension LA rukobia oral tablet nevirapine oral tablet extended release 12 hour LA LA oseltamivir phosphate SELZENTRY ORAL oral capsule QL SOLUTION PA; LA SELZENTRY ORAL TABLET PA; LA

Last Updated 12.1.2020 36 oseltamivir phosphate STRIBILD ORAL TABLET oral suspension LA reconstituted QL SYMTUZA ORAL TABLET ribavirin oral capsule SP LA ribavirin oral tablet 200 TIVICAY ORAL TABLET mg SP LA rimantadine hcl oral TIVICAY PD ORAL TABLET tablet SOLUBLE LA ritonavir oral tablet LA TRIUMEQ ORAL TABLET sofosbuvir-velpatasvir PA; LA oral tablet PA; SP TRUVADA ORAL TABLET stavudine oral capsule 100-150 MG, 133-200 LA MG, 167-250 MG LA tenofovir disoproxil TYBOST ORAL TABLET fumarate oral tablet LA ST; LA valacyclovir hcl oral tablet VEMLIDY ORAL TABLET QL PA; PA Except Infectious valganciclovir hcl oral Disease or tablet PA Gastroenterology zidovudine oral capsule VIRACEPT ORAL TABLET LA; MO LA zidovudine oral syrup VIREAD ORAL POWDER LA LA zidovudine oral tablet VIREAD ORAL TABLET 150 LA; MO MG, 200 MG, 250 MG LA

*Beta Blockers*

acebutolol hcl oral betaxolol hcl oral tablet HEMANGEOL ORAL capsule MO MO SOLUTION PA; SP atenolol oral tablet MO BYSTOLIC ORAL TABLET bisoprolol fumarate oral MO tablet MO carvedilol phosphate er carvedilol oral tablet oral capsule extended MO release 24 hour MO labetalol hcl oral tablet SOTYLIZE ORAL MO SOLUTION metoprolol succinate er oral tablet extended release 24 hour MO metoprolol tartrate oral tablet MO nadolol oral tablet 20 mg, 40 mg, 80 mg MO pindolol oral tablet MO propranolol hcl er oral capsule extended release 24 hour MO propranolol hcl oral solution MO propranolol hcl oral tablet MO SORINE ORAL TABLET MO sotalol hcl (af) oral tablet MO sotalol hcl oral tablet MO timolol maleate oral tablet MO

Last Updated 12.1.2020 37 *Calcium Channel Blockers*

AFEDITAB CR ORAL CARDIZEM CD ORAL TABLET EXTENDED CAPSULE EXTENDED RELEASE 24 HOUR MO RELEASE 24 HOUR MO amlodipine besylate oral CARDIZEM LA ORAL tablet MO TABLET EXTENDED CARTIA XT ORAL CAPSULE RELEASE 24 HOUR MO EXTENDED RELEASE 24 CARDIZEM ORAL TABLET HOUR MO 120 MG, 30 MG, 60 MG diltiazem hcl er beads MO oral capsule extended isradipine oral capsule release 24 hour MO MO diltiazem hcl er coated nicardipine hcl oral beads oral capsule capsule MO extended release 24 hour nisoldipine er oral tablet MO extended release 24 hour diltiazem hcl er oral MO capsule extended release NYMALIZE ORAL 12 hour MO SOLUTION 6 MG/ML PA diltiazem hcl er oral TIAZAC ORAL CAPSULE capsule extended release EXTENDED RELEASE 24 24 hour 120 mg, 180 mg, HOUR MO 240 mg MO diltiazem hcl oral tablet MO dilt-xr oral capsule extended release 24 hour MO felodipine er oral tablet extended release 24 hour MO MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR MO nifedipine er oral tablet extended release 24 hour MO nifedipine er osmotic release oral tablet extended release 24 hour MO nifedipine oral capsule PA; PA Except OB/GYN; MO; AL nimodipine oral capsule PA TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR MO verapamil hcl er oral capsule extended release 24 hour MO verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg MO verapamil hcl oral tablet MO

Last Updated 12.1.2020 38 *Cardiotonics*

digoxin oral solution LANOXIN ORAL TABLET MO 62.5 MCG MO digoxin oral tablet 125 mcg MO digoxin oral tablet 250 mcg MO; AL

*Cardiovascular Agents - Misc.*

ambrisentan oral tablet CAVERJECT IMPULSE amlodipine-atorvastatin TRACLEER ORAL TABLET ADEMPAS ORAL TABLET PA; SP INTRACAVERNOSAL KIT oral tablet MO SOLUBLE PA; SP PA; SP bosentan oral tablet PA; QL BIDIL ORAL TABLET MO OPSUMIT ORAL TABLET PA; SP CAVERJECT CORLANOR ORAL PA; SP isoxsuprine hcl oral tablet INTRACAVERNOSAL SOLUTION PA ORENITRAM ORAL MO; AL SOLUTION CORLANOR ORAL TABLET TABLET EXTENDED sildenafil citrate oral RECONSTITUTED 40 MCG PA RELEASE PA; SP suspension reconstituted PA; QL UPTRAVI ORAL TABLET PA EDEX INTRACAVERNOSAL PA; SP sildenafil citrate oral KIT PA; QL UPTRAVI ORAL TABLET tablet 100 mg, 25 mg, 50 ENTRESTO ORAL TABLET THERAPY PACK PA; SP mg QL AL VENTAVIS INHALATION sildenafil citrate oral MUSE URETHRAL PELLET SOLUTION PA; SP tablet 20 mg PA; AL PA; QL VYNDAMAX ORAL tadalafil (pah) oral tablet CAPSULE PA; SP PA; Generic Adcirca VYNDAQEL ORAL tadalafil oral tablet 10 CAPSULE PA; SP mg, 20 mg QL tadalafil oral tablet 2.5 mg, 5 mg MO

*Cephalosporins*

cefaclor oral capsule SUPRAX ORAL cefaclor oral suspension cefaclor oral suspension SUSPENSION reconstituted 250 reconstituted 125 RECONSTITUTED 500 mg/5ml PA mg/5ml, 375 mg/5ml MG/5ML cefpodoxime proxetil oral cefadroxil oral capsule SUPRAX ORAL TABLET tablet cefadroxil oral suspension CHEWABLE reconstituted cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension reconstituted cefixime oral capsule cefixime oral suspension reconstituted cefpodoxime proxetil oral suspension reconstituted cefprozil oral suspension reconstituted cefprozil oral tablet ceftriaxone sodium injection solution reconstituted PA ceftriaxone sodium intravenous solution reconstituted PA cefuroxime axetil oral tablet cephalexin oral capsule DF cephalexin oral suspension reconstituted DF

Last Updated 12.1.2020 39 *Contraceptives*

ALTAVERA ORAL TABLET AMETHYST ORAL TABLET ANNOVERA VAGINAL MO BALCOLTRA ORAL TABLET RING alyacen 1/35 oral tablet MO NATAZIA ORAL TABLET MO ELLA ORAL TABLET QL PA alyacen 7/7/7 oral tablet LO LOESTRIN FE ORAL SLYND ORAL TABLET MO TABLET MO MO AMETHIA LO ORAL NUVARING VAGINAL TABLET RING MO; QL AMETHIA ORAL TABLET APRI ORAL TABLET MO ARANELLE ORAL TABLET MO ASHLYNA ORAL TABLET AVIANE ORAL TABLET MO AZURETTE ORAL TABLET MO BALZIVA ORAL TABLET MO briellyn oral tablet MO CAMILA ORAL TABLET MO CAMRESE LO ORAL TABLET CAMRESE ORAL TABLET CAZIANT ORAL TABLET MO CESIA ORAL TABLET MO CHATEAL ORAL TABLET MO CRYSELLE-28 ORAL TABLET MO CYCLAFEM 1/35 ORAL TABLET MO CYCLAFEM 7/7/7 ORAL TABLET MO CYRED ORAL TABLET MO DASETTA 1/35 ORAL TABLET MO DASETTA 7/7/7 ORAL TABLET MO DAYSEE ORAL TABLET DEBLITANE ORAL TABLET desogestrel-ethinyl estradiol oral tablet 0.15- 0.02/0.01 mg (21/5) MO drospiren-eth estrad- levomefol oral tablet MO drospirenone-ethinyl estradiol oral tablet MO ELINEST ORAL TABLET MO EMOQUETTE ORAL TABLET MO

Last Updated 12.1.2020 40 ENPRESSE-28 ORAL TABLET MO ENSKYCE ORAL TABLET 0.15-30 MG-MCG MO ERRIN ORAL TABLET MO ESTARYLLA ORAL TABLET MO FALMINA ORAL TABLET MO GIANVI ORAL TABLET MO HEATHER ORAL TABLET MO INTROVALE ORAL TABLET ISIBLOOM ORAL TABLET MO JENCYCLA ORAL TABLET MO JOLESSA ORAL TABLET JULEBER ORAL TABLET MO JUNEL 1.5/30 ORAL TABLET MO JUNEL 1/20 ORAL TABLET MO JUNEL FE 1.5/30 ORAL TABLET MO JUNEL FE 1/20 ORAL TABLET MO JUNEL FE 24 ORAL TABLET MO KARIVA ORAL TABLET MO KELNOR 1/35 ORAL TABLET MO KURVELO ORAL TABLET MO LARIN 1.5/30 ORAL TABLET MO LARIN 1/20 ORAL TABLET MO LARIN 24 FE ORAL TABLET MO LARIN FE 1.5/30 ORAL TABLET MO LARIN FE 1/20 ORAL TABLET MO LEENA ORAL TABLET MO LESSINA ORAL TABLET MO LEVONEST ORAL TABLET MO levonorgest-eth est & eth est oral tablet MO levonorgest-eth estrad 91-day oral tablet levonorgestrel oral tablet 1.5 mg OTC; QL

Last Updated 12.1.2020 41 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg MO LEVORA 0.15/30 (28) ORAL TABLET MO LORYNA ORAL TABLET MO LOW-OGESTREL ORAL TABLET MO LUTERA ORAL TABLET MO LYZA ORAL TABLET MO marlissa oral tablet MO MELODETTA 24 FE ORAL TABLET CHEWABLE MO MIBELAS 24 FE ORAL TABLET CHEWABLE MO MICROGESTIN 1.5/30 ORAL TABLET MO MICROGESTIN 1/20 ORAL TABLET MO MICROGESTIN FE 1.5/30 ORAL TABLET MO MICROGESTIN FE 1/20 ORAL TABLET MO MONO-LINYAH ORAL TABLET MO MONONESSA ORAL TABLET MO NECON 0.5/35 (28) ORAL TABLET MO NECON 1/35 (28) ORAL TABLET MO NIKKI ORAL TABLET MO NORA-BE ORAL TABLET MO norethin ace-eth estrad- fe oral tablet 1-20 mg- mcg MO norethin ace-eth estrad- fe oral tablet chewable MO norethindrone acet- ethinyl est oral tablet 1- 20 mg-mcg MO norethindrone oral tablet MO norgestimate-eth estradiol oral tablet 0.25- 35 mg-mcg MO norgestim-eth estrad triphasic oral tablet MO NORLYROC ORAL TABLET NORTREL 0.5/35 (28) ORAL TABLET MO NORTREL 1/35 (21) ORAL TABLET MO

Last Updated 12.1.2020 42 NORTREL 1/35 (28) ORAL TABLET MO NORTREL 7/7/7 ORAL TABLET MO OCELLA ORAL TABLET MO ORSYTHIA ORAL TABLET MO PHILITH ORAL TABLET MO PIMTREA ORAL TABLET MO PIRMELLA 1/35 ORAL TABLET MO PIRMELLA 7/7/7 ORAL TABLET MO PORTIA-28 ORAL TABLET MO PREVIFEM ORAL TABLET MO RECLIPSEN ORAL TABLET MO SHAROBEL ORAL TABLET SOLIA ORAL TABLET MO SPRINTEC 28 ORAL TABLET MO SRONYX ORAL TABLET MO SYEDA ORAL TABLET MO TARINA FE 1/20 ORAL TABLET MO TILIA FE ORAL TABLET MO TRI-ESTARYLLA ORAL TABLET MO TRI-LEGEST FE ORAL TABLET MO TRI-LINYAH ORAL TABLET MO TRI-LO-ESTARYLLA ORAL TABLET MO TRI-LO-MARZIA ORAL TABLET TRI-LO-SPRINTEC ORAL TABLET MO TRINESSA (28) ORAL TABLET MO TRI-PREVIFEM ORAL TABLET MO TRI-SPRINTEC ORAL TABLET MO TRIVORA (28) ORAL TABLET MO TYDEMY ORAL TABLET MO VELIVET ORAL TABLET MO viorele oral tablet MO

Last Updated 12.1.2020 43 VYFEMLA ORAL TABLET MO WERA ORAL TABLET MO WYMZYA FE ORAL TABLET CHEWABLE MO XULANE TRANSDERMAL PATCH WEEKLY MO ZARAH ORAL TABLET MO ZOVIA 1/35E (28) ORAL TABLET MO

*Corticosteroids*

budesonide er oral tablet SOLU-CORTEF INJECTION MILLIPRED ORAL TABLET EMFLAZA ORAL extended release 24 hour SOLUTION QL SUSPENSION PA; SP budesonide oral capsule RECONSTITUTED 100 MG PEDIAPRED ORAL EMFLAZA ORAL TABLET delayed release particles PA; LA SOLUTION PA; SP PA prednisolone sodium cortisone acetate oral phosphate oral solution tablet MO 10 mg/5ml, 20 mg/5ml dexamethasone intensol RAYOS ORAL TABLET oral concentrate DF DELAYED RELEASE PA dexamethasone oral elixir DF dexamethasone oral solution DF dexamethasone oral tablet DF dexamethasone oral tablet therapy pack fludrocortisone acetate oral tablet MO hydrocortisone oral tablet MO methylprednisolone oral tablet DF methylprednisolone oral tablet therapy pack prednisolone oral solution prednisolone oral syrup 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml PREDNISONE INTENSOL ORAL CONCENTRATE prednisone oral solution DF prednisone oral tablet DF

Last Updated 12.1.2020 44 *Cough/Cold/Allergy*

acetylcysteine inhalation TUSSICAPS ORAL CLARINEX-D 12 HOUR solution CAPSULE EXTENDED ORAL TABLET EXTENDED benzonatate oral capsule RELEASE 12 HOUR 10-8 RELEASE 12 HOUR PA 100 mg, 200 mg QL MG SSKI ORAL SOLUTION hydrocodone- homatropine oral syrup hydrocodone- homatropine oral tablet promethazine vc oral syrup AL promethazine vc/codeine oral syrup AL promethazine-codeine oral syrup AL promethazine-dm oral syrup AL promethazine-phenyleph- codeine oral syrup AL promethazine- phenylephrine oral syrup AL sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

Last Updated 12.1.2020 45 *Dermatologicals*

acitretin oral capsule AZELEX EXTERNAL ABSORICA ORAL CAPSULE COSENTYX (300 MG SILIQ SUBCUTANEOUS PA; PA Except coal tar external solution PA DOSE) SUBCUTANEOUS SOLUTION PREFILLED Dermatology DRYSOL EXTERNAL AKLIEF EXTERNAL CREAM SOLUTION PREFILLED SYRINGE PA; SP acyclovir external SOLUTION PA; AL SYRINGE PA; SP TALTZ SUBCUTANEOUS ointment EUCRISA EXTERNAL ALTABAX EXTERNAL COSENTYX SENSOREADY SOLUTION AUTO- adapalene external gel OINTMENT ST; AL OINTMENT ST (300 MG) INJECTOR PA; SP FABIOR EXTERNAL FOAM 0.3 % ANACAINE EXTERNAL SUBCUTANEOUS TALTZ SUBCUTANEOUS PA adapalene-benzoyl OINTMENT SOLUTION AUTO- SOLUTION PREFILLED FINACEA EXTERNAL AVITA EXTERNAL CREAM peroxide external gel INJECTOR PA; SP SYRINGE PA; SP alclometasone FOAM AVITA EXTERNAL GEL TARGRETIN EXTERNAL FINACEA EXTERNAL GEL BENZAC AC WASH COSENTYX SENSOREADY dipropionate external GEL PA; SP spinosad external EXTERNAL LIQUID PEN SUBCUTANEOUS cream SOLUTION AUTO- VALCHLOR EXTERNAL GEL alclometasone suspension QL BENZEPRO EXTERNAL TAZORAC EXTERNAL INJECTOR 150 MG/ML PA; SP dipropionate external FOAM 5.3 % CREAM 0.05 % PA betamethasone valerate PA; SP ointment TAZORAC EXTERNAL GEL COSENTYX amcinonide external external foam PA BRYHALI EXTERNAL SUBCUTANEOUS AMNESTEEM ORAL LOTION SOLUTION PREFILLED calcipotriene-betameth CAPSULE PA; PA Except SYRINGE PA; SP diprop external ointment DUPIXENT Dermatology azelaic acid external gel PA; PA Except Derm SUBCUTANEOUS benzoyl peroxide external calcipotriene-betameth SOLUTION PEN-INJECTOR gel 10 % diprop external PA; SP benzoyl peroxide external suspension PA; PA DUPIXENT gel 5 % OTC Except Dermatology SUBCUTANEOUS benzoyl peroxide wash CENTANY AT EXTERNAL SOLUTION PREFILLED external liquid 10 % KIT SYRINGE PA; SP betamethasone CENTANY EXTERNAL SKYRIZI (150 MG DOSE) dipropionate aug external OINTMENT SUBCUTANEOUS ciclopirox olamine cream PREFILLED SYRINGE KIT betamethasone external suspension ciclopirox treatment PA; SP dipropionate aug external TREMFYA gel external kit CLEOCIN-T EXTERNAL SUBCUTANEOUS betamethasone SOLUTION PEN-INJECTOR dipropionate aug external LOTION clobetasol propionate PA; SP lotion TREMFYA betamethasone external liquid clobetasol propionate SUBCUTANEOUS dipropionate aug external external SOLUTION PREFILLED ointment dapsone external gel 5 % SYRINGE PA; SP betamethasone dapsone external gel 7.5 dipropionate external % ST cream DIPROLENE AF EXTERNAL betamethasone CREAM dipropionate external DIPROLENE EXTERNAL lotion OINTMENT betamethasone DRITHO-CREME HP dipropionate external EXTERNAL CREAM ointment DUOBRII EXTERNAL betamethasone valerate LOTION PA external cream EFUDEX EXTERNAL betamethasone valerate CREAM external lotion ELIMITE EXTERNAL betamethasone valerate CREAM external ointment EPIDUO FORTE EXTERNAL calcipotriene external GEL PA; PA Except cream PA Dermatology and calcipotriene external Pediatrics ointment PA

Last Updated 12.1.2020 46 calcipotriene external ERTACZO EXTERNAL solution PA CREAM calcitriol external FLUOROPLEX EXTERNAL ointment PA CREAM ciclopirox external gel fluorouracil external ciclopirox external cream 0.5 % ST shampoo flurandrenolide external ciclopirox external lotion solution hydrocortisone- ciclopirox olamine iodoquinol external external cream cream 1-1 % CLARAVIS ORAL CAPSULE iodoquinol- PA; PA Except hydrocortisone-aloe Dermatology external cream clindamycin phos-benzoyl JUBLIA EXTERNAL perox external gel 1-5 %, SOLUTION PA 1.2-5 % KETODAN EXTERNAL KIT clindamycin phosphate MEDROX-RX EXTERNAL external gel OINTMENT PA clindamycin phosphate MENTAX EXTERNAL external lotion CREAM clindamycin phosphate METROLOTION EXTERNAL external solution LOTION clindamycin phosphate miconazole-zinc oxide- external swab petrolat external clobetasol propionate e ointment external cream MIRVASO EXTERNAL GEL clobetasol propionate PA external cream mupirocin calcium clobetasol propionate external cream external ointment naftifine hcl external clobetasol propionate cream external solution NAFTIN EXTERNAL GEL clotrimazole external NUCORT EXTERNAL cream LOTION clotrimazole external oxiconazole nitrate solution external cream clotrimazole- OXISTAT EXTERNAL betamethasone external LOTION cream OXSORALEN ULTRA ORAL clotrimazole- CAPSULE betamethasone external PANDEL EXTERNAL lotion CREAM CROTAN EXTERNAL PANRETIN EXTERNAL GEL LOTION PA desonide external cream PICATO EXTERNAL GEL desonide external PA; PA Except ointment ST Dermatology desoximetasone external PLEXION EXTERNAL cream CREAM desoximetasone external PRAMOSONE EXTERNAL gel OINTMENT 1-2.5 % desoximetasone external QBREXZA EXTERNAL PAD ointment 0.25 % PA diflorasone diacetate REGRANEX EXTERNAL GEL external cream PA diflorasone diacetate ROSADAN EXTERNAL KIT external ointment SILVADENE EXTERNAL CREAM

Last Updated 12.1.2020 47 econazole nitrate SKLICE EXTERNAL LOTION external cream ST; QL erythromycin external gel SOOLANTRA EXTERNAL erythromycin external CREAM PA; PA Except solution Dermatology fluocinolone acetonide sulconazole nitrate body external oil external cream fluocinolone acetonide sulconazole nitrate external cream external solution fluocinolone acetonide sulfacetamide sodium- external ointment sulfur external cream 9.8- fluocinolone acetonide 4.8 % external solution SULFAMYLON EXTERNAL fluocinolone acetonide CREAM scalp external oil SULFAMYLON EXTERNAL fluocinonide external PACKET cream 0.05 % SUMAXIN EXTERNAL PAD fluocinonide external gel SYNALAR (OINTMENT) fluocinonide external EXTERNAL KIT ointment SYNALAR EXTERNAL fluocinonide external CREAM solution SYNALAR EXTERNAL fluorouracil external OINTMENT cream 5 % SYNALAR EXTERNAL fluorouracil external SOLUTION solution tavaborole external fluticasone propionate solution PA external cream TOLAK EXTERNAL CREAM fluticasone propionate TOPICORT EXTERNAL external ointment CREAM 0.05 % gentamicin sulfate tretinoin external gel 0.05 external cream % gentamicin sulfate tretinoin microsphere external ointment external gel halobetasol propionate tretinoin microsphere external cream pump external gel 0.04 % halobetasol propionate urea external cream 40 external ointment %, 45 % hydrocortisone ace- urea external lotion 40 % pramoxine external urea hydrating external cream 2.5-1 % foam hydrocortisone butyr lipo VANOXIDE-HC EXTERNAL base external cream LOTION hydrocortisone butyrate XERAC AC EXTERNAL external ointment SOLUTION hydrocortisone butyrate XOLEGEL EXTERNAL GEL external solution ZITHRANOL EXTERNAL hydrocortisone external SHAMPOO PA; PA cream 2.5 % Except Dermatology hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % hydrocortisone valerate external cream hydrocortisone valerate external ointment

Last Updated 12.1.2020 48 imiquimod external cream PA; PA Except Dermatology, Urology, OBGYN, Colorectal Surgery isotretinoin oral capsule PA; PA Except Dermatology ketoconazole external cream ketoconazole external foam ketoconazole external shampoo 2 % KETODAN EXTERNAL FOAM lidocaine external cream 3 % OTC lidocaine external ointment lidocaine external patch 5 % lidocaine hcl external cream 3 % lidocaine-prilocaine external cream LIDOCARE ARM/NECK/LEG EXTERNAL PATCH OTC LIDOCARE BACK/SHOULDER EXTERNAL PATCH OTC lindane external shampoo malathion external lotion methoxsalen rapid oral capsule metronidazole external cream metronidazole external gel metronidazole external lotion mometasone furoate external cream mometasone furoate external ointment MO mometasone furoate external solution mupirocin external ointment MYORISAN ORAL CAPSULE PA; PA Except Dermatology nystatin external cream nystatin external ointment nystatin external powder nystatin-triamcinolone external cream

Last Updated 12.1.2020 49 nystatin-triamcinolone external ointment NYSTOP EXTERNAL POWDER permethrin external cream pimecrolimus external cream AL prednicarbate external cream prednicarbate external ointment ROSADAN EXTERNAL CREAM ROSADAN EXTERNAL GEL selenium sulfide external lotion silver sulfadiazine external cream SSD EXTERNAL CREAM sulfacetamide sodium (acne) external lotion sulfacetamide sodium external liquid sulfacetamide sodium- sulfur external sulfacetamide sodium- sulfur external liquid 10-2 %, 9-4 %, 9-4.5 % sulfacetamide sodium- sulfur external pad 10-4 % sulfacetamide sodium- sulfur external suspension 8-4 % sulfacetamide-sulfur in urea external emulsion tacrolimus external ointment 0.03 % AL Except Dermatology/Allergy; AL tacrolimus external ointment 0.1 % PA; PA Except Dermatology/Allergy; AL tazarotene external cream PA tretinoin external cream tretinoin external gel 0.01 %, 0.025 % triamcinolone acetonide external aerosol solution triamcinolone acetonide external cream triamcinolone acetonide external lotion triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

Last Updated 12.1.2020 50 ZENATANE ORAL CAPSULE PA; PA Except Dermatology

*Diagnostic Products*

METOPIRONE ORAL CAPSULE PA; LA

Last Updated 12.1.2020 51 *Digestive Aids*

CREON ORAL CAPSULE PANCREAZE ORAL SUCRAID ORAL SOLUTION DELAYED RELEASE CAPSULE DELAYED PA; SP PARTICLES MO RELEASE PARTICLES PANCREAZE ORAL 10500 UNIT, 16800 UNIT, CAPSULE DELAYED 21000 UNIT, 2600 UNIT RELEASE PARTICLES 4200 MO UNIT MO PERTZYE ORAL CAPSULE ZENPEP ORAL CAPSULE DELAYED RELEASE DELAYED RELEASE PARTICLES MO PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000- 14000 UNIT, 40000- 126000 UNIT, 5000- 24000 UNIT MO

*Diuretics*

acetazolamide er oral ALDACTAZIDE ORAL ALDACTAZIDE ORAL KEVEYIS ORAL TABLET capsule extended release TABLET 50-50 MG MO TABLET 25-25 MG MO PA; SP 12 hour MO DIURIL ORAL EDECRIN ORAL TABLET acetazolamide oral tablet SUSPENSION MO amiloride hcl oral tablet MO amiloride- hydrochlorothiazide oral tablet MO bumetanide oral tablet MO chlorthalidone oral tablet 25 mg, 50 mg MO ethacrynic acid oral tablet MO furosemide oral solution 10 mg/ml, 8 mg/ml MO furosemide oral tablet MO hydrochlorothiazide oral capsule MO hydrochlorothiazide oral tablet MO indapamide oral tablet MO methazolamide oral tablet MO metolazone oral tablet MO spironolactone oral tablet MO spironolactone-hctz oral tablet MO torsemide oral tablet MO triamterene-hctz oral capsule 37.5-25 mg MO triamterene-hctz oral tablet MO

Last Updated 12.1.2020 52 *Endocrine And Metabolic Agents - Misc.*

alendronate sodium oral BUPHENYL ORAL TABLET BINOSTO ORAL TABLET CARBAGLU ORAL TABLET GALAFOLD ORAL solution MO PA EFFERVESCENT ST; MO PA; SP CAPSULE PA; SP alendronate sodium oral CYSTADANE ORAL BUPHENYL ORAL GENOTROPIN MINIQUICK JYNARQUE ORAL TABLET tablet 10 mg, 35 mg, 5 POWDER PA POWDER 3 GM/TSP PA SUBCUTANEOUS THERAPY PACK PA; SP mg, 70 mg MO FOLLISTIM AQ CETROTIDE SOLUTION KANUMA INTRAVENOUS cabergoline oral tablet SUBCUTANEOUS SUBCUTANEOUS KIT 0.25 RECONSTITUTED PA; SP SOLUTION PA; SP calcitonin (salmon) nasal SOLUTION PA MG PA GENOTROPIN MYALEPT solution MO FORTEO SUBCUTANEOUS DDAVP RHINAL TUBE SUBCUTANEOUS SUBCUTANEOUS calcitriol oral capsule SOLUTION PEN-INJECTOR NASAL SOLUTION SOLUTION SOLUTION MO PA; LA ibandronate sodium oral RECONSTITUTED PA; SP RECONSTITUTED PA; SP calcitriol oral solution MENOPUR tablet MO; QL INCRELEX NATPARA MO SUBCUTANEOUS OVIDREL SUBCUTANEOUS SUBCUTANEOUS SUBCUTANEOUS chorionic gonadotropin SOLUTION INJECTABLE ST SOLUTION PA; SP CARTRIDGE PA; SP intramuscular solution RECONSTITUTED PA RAYALDEE ORAL CAPSULE NITYR ORAL TABLET PA; PALYNZIQ reconstituted ST; SP ORILISSA ORAL TABLET EXTENDED RELEASE ST SP SUBCUTANEOUS cinacalcet hcl oral tablet PA SAMSCA ORAL TABLET 15 ORFADIN ORAL CAPSULE SOLUTION PREFILLED MO STIMATE NASAL MG PA 20 MG PA; SP SYRINGE PA; SP clomiphene citrate oral SOLUTION tolvaptan oral tablet 30 ORFADIN ORAL RAVICTI ORAL LIQUID tablet PA; PA Except SYNAREL NASAL mg PA; LA SUSPENSION PA; SP PA; SP OB/GYN and Fertility; QL SOLUTION PA SOMAVERT SAIZEN INJECTION desmopressin ace spray teriparatide SUBCUTANEOUS SOLUTION refrig nasal solution (recombinant) SOLUTION RECONSTITUTED PA; MO subcutaneous solution RECONSTITUTED PA; SP ST; SP desmopressin acetate pen-injector PA; LA STRENSIQ SEROSTIM oral tablet MO TYMLOS SUBCUTANEOUS SUBCUTANEOUS SUBCUTANEOUS desmopressin acetate SOLUTION PEN-INJECTOR SOLUTION PA; SP SOLUTION spray nasal solution PA; LA XURIDEN ORAL PACKET RECONSTITUTED 4 MG, 5 MO PA; SP doxercalciferol oral MG, 6 MG PA; ST; SP SIGNIFOR capsule ST; MO ganirelix acetate SUBCUTANEOUS subcutaneous solution SOLUTION PA; SP ZORBTIVE prefilled syringe PA levocarnitine oral SUBCUTANEOUS solution PA SOLUTION levocarnitine oral tablet RECONSTITUTED PA; PA ST; SP mifepristone oral tablet nitisinone oral capsule PA; SP octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml PA; PA Except Heme/Onc/Endo paricalcitol oral capsule ST; MO raloxifene hcl oral tablet MO risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg MO risedronate sodium oral tablet delayed release MO

Last Updated 12.1.2020 53 sapropterin dihydrochloride oral packet PA; SP sapropterin dihydrochloride oral tablet soluble PA; SP sodium phenylbutyrate oral powder 3 gm/tsp PA

*Estrogens*

COVARYX HS ORAL COMBIPATCH ANGELIQ ORAL TABLET TABLET AL TRANSDERMAL PATCH MO; AL COVARYX ORAL TABLET TWICE WEEKLY MO; AL CLIMARA PRO AL MENOSTAR TRANSDERMAL PATCH DOTTI TRANSDERMAL TRANSDERMAL PATCH WEEKLY MO; AL PATCH TWICE WEEKLY WEEKLY MO; AL DIVIGEL TRANSDERMAL MO; AL PREMARIN ORAL TABLET GEL 0.25 MG/0.25GM, EEMT ORAL TABLET AL MO; AL 0.5 MG/0.5GM, 1 est estrogens-methyltest PREMPHASE ORAL MG/GM AL ds oral tablet AL TABLET MO; AL DUAVEE ORAL TABLET est estrogens-methyltest PREMPRO ORAL TABLET AL hs oral tablet AL MO; AL ELESTRIN TRANSDERMAL est estrogens-methyltest GEL AL oral tablet AL ESTROGEL estradiol oral tablet TRANSDERMAL GEL AL MO; AL EVAMIST TRANSDERMAL estradiol transdermal SOLUTION MO; AL patch twice weekly MENEST ORAL TABLET 0.3 MO; AL MG, 0.625 MG, 1.25 MG estradiol transdermal MO; AL patch weekly MO; AL ORIAHNN ORAL CAPSULE estradiol-norethindrone THERAPY PACK PA acet oral tablet MO; AL PREFEST ORAL TABLET JINTELI ORAL TABLET MO MO; AL MIMVEY ORAL TABLET MO; AL norethindrone-eth estradiol oral tablet MO; AL

*Fluoroquinolones*

ciprofloxacin hcl oral CIPRO ORAL SUSPENSION tablet 250 mg, 500 mg, RECONSTITUTED 750 mg ciprofloxacin hcl oral levofloxacin oral solution tablet 100 mg levofloxacin oral tablet moxifloxacin hcl oral tablet

Last Updated 12.1.2020 54 *Gastrointestinal Agents - Misc.*

balsalazide disodium oral LINZESS ORAL CAPSULE alosetron hcl oral tablet CHENODAL ORAL TABLET capsule AL ST; ST except PA PA; SP calcium acetate (phos Gastroenterology and AMITIZA ORAL CAPSULE CHOLBAM ORAL CAPSULE binder) oral tablet MO Colon-Rectal surgery; MO ST PA; SP cromolyn sodium oral MOVANTIK ORAL TABLET AURYXIA ORAL TABLET GATTEX SUBCUTANEOUS concentrate MO PENTASA ORAL CAPSULE mesalamine er oral KIT PA; SP lactulose encephalopathy EXTENDED RELEASE capsule extended release OCALIVA ORAL TABLET oral solution MO 24 hour ST; MO PA; SP lanthanum carbonate oral PHOSLYRA ORAL mesalamine-cleanser XERMELO ORAL TABLET tablet chewable MO SOLUTION MO rectal kit PA; SP LIALDA ORAL TABLET RELISTOR ORAL TABLET DELAYED RELEASE MO PA mesalamine oral capsule RELISTOR delayed release MO SUBCUTANEOUS mesalamine oral tablet SOLUTION 12 MG/0.6ML, delayed release 800 mg 8 MG/0.4ML PA MO VELPHORO ORAL TABLET mesalamine rectal enema CHEWABLE mesalamine rectal VIBERZI ORAL TABLET suppository PA metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet sevelamer carbonate oral packet MO sevelamer hcl oral tablet MO sulfasalazine oral tablet MO sulfasalazine oral tablet delayed release MO ursodiol oral capsule ursodiol oral tablet

*Genitourinary Agents - Miscellaneous*

acetic acid irrigation ELMIRON ORAL CAPSULE CARDURA XL ORAL CYSTAGON ORAL PROCYSBI ORAL CAPSULE solution RENACIDIN IRRIGATION TABLET EXTENDED CAPSULE PA; SP DELAYED RELEASE PA; alfuzosin hcl er oral tablet SOLUTION RELEASE 24 HOUR MO SP extended release 24 hour THIOLA ORAL TABLET dutasteride-tamsulosin PROCYSBI ORAL PACKET MO PA; LA hcl oral capsule PA; SP aminoacetic acid LITHOSTAT ORAL TABLET irrigation solution RESECTISOL IRRIGATION dutasteride oral capsule SOLUTION MO THIOLA EC ORAL TABLET finasteride oral tablet 5 DELAYED RELEASE PA; mg MO LA glycine irrigation solution glycine urologic irrigation solution neomycin-polymyxin b gu irrigation solution phenazopyridine hcl oral tablet 100 mg, 200 mg potassium citrate er oral tablet extended release silodosin oral capsule MO tamsulosin hcl oral capsule MO

Last Updated 12.1.2020 55 *Gout Agents*

allopurinol oral tablet MO colchicine oral tablet colchicine-probenecid oral tablet MO febuxostat oral tablet ST; MO probenecid oral tablet MO

*Hematological Agents - Misc.*

anagrelide hcl oral BRILINTA ORAL TABLET ZONTIVITY ORAL TABLET TAKHZYRO HAEGARDA capsule PA; MO MO PA; MO SUBCUTANEOUS SUBCUTANEOUS aspirin-dipyridamole er SOLUTION PA; QL; AL; SOLUTION oral capsule extended SP RECONSTITUTED PA; SP release 12 hour PA; PA TAVALISSE ORAL TABLET Except Neurology; MO PA; SP cilostazol oral tablet MO clopidogrel bisulfate oral tablet MO dipyridamole oral tablet MO; AL icatibant acetate subcutaneous solution PA; SP pentoxifylline er oral tablet extended release DF; MO prasugrel hcl oral tablet MO

*Hematopoietic Agents*

cyanocobalamin injection ARANESP (ALBUMIN FERRALET 90 ORAL DOPTELET ORAL TABLET CERDELGA ORAL CAPSULE solution 1000 mcg/ml FREE) INJECTION TABLET 20 MG PA; SP PA; SP DROXIA ORAL CAPSULE SOLUTION 100 MCG/ML, ferraplus 90 oral tablet NEULASTA MULPLETA ORAL TABLET folic acid oral tablet 1 mg 200 MCG/ML, 25 FERREX 150 FORTE PLUS SUBCUTANEOUS PA; SP MO MCG/ML, 300 MCG/ML, ORAL CAPSULE OTC SOLUTION PREFILLED OXBRYTA ORAL TABLET miglustat oral capsule FERROCITE PLUS ORAL 40 MCG/ML, 60 MCG/ML SYRINGE PA; SP PA; SP PA; SP TABLET NIVESTYM INJECTION polysaccharide iron forte PA; LA SIKLOS ORAL TABLET ARANESP (ALBUMIN SOLUTION PREFILLED oral capsule PA FREE) INJECTION SYRINGE SP SOLUTION PREFILLED PROMACTA ORAL PACKET SYRINGE PA; LA PA; SP MULTIGEN PLUS ORAL PROMACTA ORAL TABLET TABLET PA; SP poly-iron 150 forte oral UDENYCA capsule SUBCUTANEOUS RETACRIT INJECTION SOLUTION PREFILLED SOLUTION 10000 SYRINGE PA; SP UNIT/ML, 2000 UNIT/ML, ZARXIO INJECTION 3000 UNIT/ML, 4000 SOLUTION PREFILLED UNIT/ML, 40000 SYRINGE SP UNIT/ML PA; LA

*Hemostatics*

aminocaproic acid oral aminocaproic acid oral tablet solution tranexamic acid oral tablet AL

Last Updated 12.1.2020 56 *Hypnotics/Sedatives/Sleep Disorder Agents*

estazolam oral tablet BELSOMRA ORAL TABLET DAYVIGO ORAL TABLET HETLIOZ ORAL CAPSULE QL ST; QL PA PA; SP eszopiclone oral tablet doxepin hcl oral tablet QL/AL Except Psychiatry QL and Sleep Specialists; QL; EDLUAR SUBLINGUAL AL TABLET SUBLINGUAL flurazepam hcl oral ST; QL; AL capsule QL; AL quazepam oral tablet midazolam hcl oral syrup zolpidem tartrate phenobarbital oral elixir sublingual tablet AL sublingual ST; QL; AL phenobarbital oral tablet AL ramelteon oral tablet QL temazepam oral capsule QL triazolam oral tablet QL zaleplon oral capsule QL; AL zolpidem tartrate er oral tablet extended release QL/AL Except Sleep Specialty and Psychiatry; QL; AL zolpidem tartrate oral tablet QL; AL

*Laxatives*

GAVILYTE-G ORAL CLENPIQ ORAL SOLUTION KRISTALOSE ORAL SOLUTION SUPREP BOWEL PREP KIT PACKET 20 GM RECONSTITUTED ORAL SOLUTION lactulose oral packet lactulose oral solution peg 3350-kcl-na bicarb- nacl oral solution reconstituted peg-3350/electrolytes oral solution reconstituted

Last Updated 12.1.2020 57 *Macrolides*

azithromycin oral packet ERY-TAB ORAL TABLET DIFICID ORAL TABLET azithromycin oral DELAYED RELEASE 500 PA suspension reconstituted MG E.E.S. 400 ORAL TABLET azithromycin oral tablet ERYTHROCIN STEARATE 250 mg, 600 mg ORAL TABLET 250 MG azithromycin oral tablet 500 mg DF clarithromycin er oral tablet extended release 24 hour clarithromycin oral suspension reconstituted clarithromycin oral tablet erythromycin base oral capsule delayed release particles DF erythromycin base oral tablet DF erythromycin ethylsuccinate oral suspension reconstituted erythromycin ethylsuccinate oral tablet DF

*Medical Devices And Supplies*

BD AUTOSHIELD DUO OMNIPOD 5 PACK OTC; MO OMNIPOD DASH 5 PACK PODS V-GO 20 KIT V-GO 30 KIT V-GO 40 KIT

Last Updated 12.1.2020 58 *Migraine Products*

eletriptan hydrobromide AIMOVIG almotriptan malate oral oral tablet QL SUBCUTANEOUS tablet QL naratriptan hcl oral tablet SOLUTION AUTO- CAMBIA ORAL PACKET QL INJECTOR 140 MG/ML PA; QL rizatriptan benzoate oral PA; LA dihydroergotamine tablet QL AIMOVIG mesylate nasal solution rizatriptan benzoate oral SUBCUTANEOUS PA; QL tablet dispersible QL SOLUTION AUTO- frovatriptan succinate sumatriptan nasal INJECTOR 70 MG/ML oral tablet QL solution QL MIGERGOT RECTAL sumatriptan succinate PA; LA; QL AJOVY SUBCUTANEOUS SUPPOSITORY oral tablet QL sumatriptan succinate SOLUTION AUTO- refill subcutaneous INJECTOR PA; LA AJOVY SUBCUTANEOUS solution cartridge QL sumatriptan succinate SOLUTION PREFILLED subcutaneous solution 6 SYRINGE PA; LA EMGALITY (300 MG mg/0.5ml QL sumatriptan succinate DOSE) SUBCUTANEOUS subcutaneous solution SOLUTION PREFILLED auto-injector 4 mg/0.5ml, SYRINGE PA; LA EMGALITY 6 mg/0.5ml QL zolmitriptan oral tablet SUBCUTANEOUS QL SOLUTION AUTO- zolmitriptan oral tablet INJECTOR PA; LA dispersible QL EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LA ERGOMAR SUBLINGUAL TABLET SUBLINGUAL NURTEC ORAL TABLET DISPERSIBLE ST ONZETRA XSAIL NASAL EXHALER POWDER ST; QL REYVOW ORAL TABLET ST UBRELVY ORAL TABLET ST ZOMIG NASAL SOLUTION QL

Last Updated 12.1.2020 59 *Minerals & Electrolytes*

av-phos 250 neutral oral GALZIN ORAL CAPSULE K-PHOS-NEUTRAL ORAL tablet MO iodine strong oral TABLET MO dextrose-nacl intravenous solution solution 5-0.45 % PA; LA EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ MO KLOR-CON 10 ORAL TABLET EXTENDED RELEASE MO KLOR-CON ORAL TABLET EXTENDED RELEASE MO KLOR-CON/EF ORAL TABLET EFFERVESCENT MO K-PRIME ORAL TABLET EFFERVESCENT MO PHOSPHA 250 NEUTRAL ORAL TABLET MO PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET MO potassium chloride crys er oral tablet extended release MO potassium chloride er oral capsule extended release MO potassium chloride er oral tablet extended release MO potassium chloride oral solution 20 meq/15ml (10%) MO sodium fluoride oral solution DF; MO sodium fluoride oral tablet chewable DF; MO virt-phos 250 neutral oral tablet MO

Last Updated 12.1.2020 60 *Miscellaneous Therapeutic Classes*

azathioprine oral tablet AZASAN ORAL TABLET ASTAGRAF XL ORAL REVLIMID ORAL CAPSULE BENLYSTA MO MO CAPSULE EXTENDED PA; SP SUBCUTANEOUS cyclosporine modified LOKELMA ORAL PACKET RELEASE 24 HOUR PA THALOMID ORAL SOLUTION AUTO- oral capsule MO SANDIMMUNE ORAL ENVARSUS XR ORAL CAPSULE SP INJECTOR PA; SP cyclosporine modified SOLUTION MO TABLET EXTENDED BENLYSTA oral solution MO VELTASSA ORAL PACKET RELEASE 24 HOUR PA SUBCUTANEOUS ZORTRESS ORAL TABLET 1 cyclosporine oral capsule SOLUTION PREFILLED MG PA; PA Except MO SYRINGE PA; SP everolimus oral tablet Renal Transplant and ENSPRYNG 0.25 mg, 0.5 mg, 0.75 mg Nephrology SUBCUTANEOUS PA; PA Except Renal SOLUTION PREFILLED Transplant and SYRINGE PA; SP Nephrology GENGRAF ORAL CAPSULE 100 MG, 25 MG MO GENGRAF ORAL SOLUTION MO lactated ringers irrigation solution mycophenolate mofetil oral capsule MO mycophenolate mofetil oral suspension reconstituted mycophenolate mofetil oral tablet MO mycophenolate sodium oral tablet delayed release PA; PA except Renal Transplant Surgeons and Nephrology; MO penicillamine oral capsule PA; SP penicillamine oral tablet PA; SP PHYSIOLYTE IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution sirolimus oral solution PA; MO sirolimus oral tablet PA; PA except Renal Transplant Surgeons and Nephrology; MO sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal suspension sterile water for irrigation irrigation solution

Last Updated 12.1.2020 61 tacrolimus oral capsule MO trientine hcl oral capsule PA; SP

*Mouth/Throat/Dental Agents*

cevimeline hcl oral DEBACTEROL capsule MO MOUTH/THROAT chlorhexidine gluconate SOLUTION mouth/throat solution ORAVIG BUCCAL TABLET DF PA; AL CLINPRO 5000 DENTAL clotrimazole mouth/throat troche DF dobells mouth/throat solution OTC FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE nystatin mouth/throat suspension DF pilocarpine hcl oral tablet MO sf 5000 plus dental cream DF sf dental gel triamcinolone acetonide mouth/throat paste DF

Last Updated 12.1.2020 62 *Multivitamins*

activite oral tablet PA; completenate oral tablet CITRANATAL 90 DHA PA Except Nephrology; chewable MO ORAL 90-1 & 300 MG MO DUET DHA 400 ORAL MO DIALYVITE ORAL TABLET MO; AL CITRANATAL ASSURE PA; PA Except DUET DHA BALANCED ORAL 35-1 & 300 MG Nephrology; MO ORAL 25-1 & 267 MG MO GENICIN VITA-S ORAL MO; AL CITRANATAL B-CALM TABLET PA; PA Except NATALVIT ORAL TABLET ORAL MO Nephrology; MO MO CITRANATAL BLOOM lorid oral tablet PA; PA NESTABS DHA ORAL ORAL TABLET MO Except Nephrology; MO MO CITRANATAL DHA ORAL multivitamin/fluoride oral NESTABS ORAL TABLET MO tablet chewable 1 mg MO CITRANATAL HARMONY MO OBTREX ORAL TABLET ORAL CAPSULE 27-1-260 NEPHRONEX ORAL OTC; MO MG MO TABLET PA; PA Except onevite oral tablet MO CITRANATAL RX ORAL pnv prenatal plus Nephrology; MO TABLET MO NEPHRO-VITE RX ORAL multivitamin oral tablet POLY-VI-FLOR ORAL TABLET PA; PA Except MO TABLET CHEWABLE MO pnv tabs 29-1 oral tablet Nephrology; MO VITAFOL-ONE ORAL prenatal formula a-free MO CAPSULE MO pnv-dha oral capsule oral tablet OTC; MO prenatal low iron oral MO pnv-dha+docusate oral tablet 27-0.8 mg OTC; capsule MO MO pnv-omega oral capsule prenatal multi +dha oral PRENATABS RX ORAL capsule 27-0.8-228 mg TABLET MO OTC; MO prenatal 19 oral tablet prenatal one daily oral OTC; MO tablet OTC; MO prenatal 19 oral tablet prenatal oral tablet 27- 29-1 mg MO 0.8 mg MO prenatal 19 oral tablet prenatal oral tablet 28- chewable MO 0.8 mg, 6.75-0.2 mg prenatal oral tablet 27-1 OTC; MO mg MO prenatal vitamins oral prenatal plus iron oral tablet 28-0.8 mg OTC; tablet MO MO prenatal plus oral tablet tronvite oral tablet PA; MO PA Except Nephrology; prenatal plus/iron oral MO tablet MO vitasure oral tablet PA; preplus oral tablet MO PA Except Nephrology; se-natal 19 oral tablet MO MO vp-vite rx oral tablet se-natal 19 oral tablet PA; PA Except chewable MO thrivite 19 oral tablet 1 Nephrology; MO xvite oral tablet PA; PA mg MO UDAMIN SP ORAL TABLET Except Nephrology; MO MO VITAFOL-OB+DHA ORAL MO vol-plus oral tablet MO vol-tab rx oral tablet MO

Last Updated 12.1.2020 63 *Musculoskeletal Therapy Agents*

baclofen oral tablet MO FEXMID ORAL TABLET chlorzoxazone oral tablet AL 500 mg AL metaxalone oral tablet cyclobenzaprine hcl oral AL tablet AL tizanidine hcl oral capsule dantrolene sodium oral MO capsule methocarbamol oral tablet AL tizanidine hcl oral tablet MO

*Nasal Agents - Systemic And Topical*

azelastine hcl nasal ADRENALIN NASAL solution 0.1 %, 0.15 % SOLUTION BUDESONIDE NASAL SUSPENSION Only OTC version covered flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension ipratropium bromide nasal solution olopatadine hcl nasal solution triamcinolone acetonide nasal aerosol

*Neuromuscular Agents*

riluzole oral tablet MO TIGLUTIK ORAL SUSPENSION

*Nutrients*

n-acetyl-l-cysteine oral capsule

Last Updated 12.1.2020 64 *Ophthalmic Agents*

ALAWAY CHILDRENS ALOMIDE OPHTHALMIC ALOCRIL OPHTHALMIC CYSTARAN OPHTHALMIC OXERVATE OPHTHALMIC ALLERGY OPHTHALMIC SOLUTION ST SOLUTION ST SOLUTION PA; SP SOLUTION PA; SP SOLUTION OTC ALPHAGAN P bacitra-neomycin- ALAWAY OPHTHALMIC OPHTHALMIC SOLUTION polymyxin-hc ophthalmic SOLUTION OTC 0.1 % ointment apraclonidine hcl AZOPT OPHTHALMIC BEPREVE OPHTHALMIC ophthalmic solution SUSPENSION SOLUTION ST atropine sulfate bimatoprost ophthalmic BETADINE OPHTHALMIC ophthalmic ointment solution MO PREP OPHTHALMIC atropine sulfate BLEPHAMIDE SOLUTION ophthalmic solution 1 % OPHTHALMIC betaxolol hcl ophthalmic azelastine hcl ophthalmic SUSPENSION solution solution BLEPHAMIDE S.O.P. FLAREX OPHTHALMIC bacitracin-polymyxin b OPHTHALMIC OINTMENT SUSPENSION ophthalmic ointment COMBIGAN OPHTHALMIC FML FORTE OPHTHALMIC 500-10000 unit/gm SOLUTION SUSPENSION balanced salt intraocular LACRISERT OPHTHALMIC FML OPHTHALMIC solution INSERT OINTMENT brimonidine tartrate LOTEMAX OPHTHALMIC LASTACAFT OPHTHALMIC ophthalmic solution GEL SOLUTION ST bromfenac sodium (once- LOTEMAX OPHTHALMIC MAXIDEX OPHTHALMIC daily) ophthalmic solution OINTMENT SUSPENSION carteolol hcl ophthalmic LOTEMAX SM MYDRIACYL OPHTHALMIC solution OPHTHALMIC GEL SOLUTION ciprofloxacin hcl LUMIGAN OPHTHALMIC PRED MILD OPHTHALMIC ophthalmic solution SOLUTION 0.01 % SUSPENSION cromolyn sodium NATACYN OPHTHALMIC PRED-G OPHTHALMIC ophthalmic solution SUSPENSION PA SUSPENSION PA; MO OZURDEX INTRAVITREAL PRED-G S.O.P. dexamethasone sodium IMPLANT PA; LA OPHTHALMIC OINTMENT phosphate ophthalmic PHOSPHOLINE IODIDE PROLENSA OPHTHALMIC solution OPHTHALMIC SOLUTION SOLUTION PA; ST; Max diclofenac sodium RECONSTITUTED 2 fills/year ophthalmic solution RESTASIS MULTIDOSE RHOPRESSA PA; PA except OPHTHALMIC EMULSION OPHTHALMIC SOLUTION Ophthalmology 0.05 % PA; PA except ST dorzolamide hcl Ophthalmology/Optomet ROCKLATAN ophthalmic solution ry OPHTHALMIC SOLUTION dorzolamide hcl-timolol RESTASIS OPHTHALMIC ST mal ophthalmic solution EMULSION PA; PA TIMOPTIC OCUDOSE dorzolamide hcl-timolol except OPHTHALMIC SOLUTION mal pf ophthalmic Ophthalmology/Optomet UPNEEQ OPHTHALMIC solution ry SOLUTION PA epinastine hcl ophthalmic SIMBRINZA OPHTHALMIC VYZULTA OPHTHALMIC solution SUSPENSION SOLUTION ST erythromycin ophthalmic TOBRADEX ST ZIOPTAN OPHTHALMIC ointment OPHTHALMIC SOLUTION fluorometholone SUSPENSION ophthalmic suspension XIIDRA OPHTHALMIC flurbiprofen sodium SOLUTION PA; PA ophthalmic solution Except gentamicin sulfate Ophthalmology/Optomet ophthalmic solution ketorolac tromethamine ry ZIRGAN OPHTHALMIC ophthalmic solution PA ketotifen fumarate GEL ophthalmic solution latanoprost ophthalmic solution

Last Updated 12.1.2020 65 levobunolol hcl ophthalmic solution 0.5 % levofloxacin ophthalmic solution loteprednol etabonate ophthalmic suspension neomycin-bacitracin zn- polymyx ophthalmic ointment 5-400-10000 neomycin-polymyxin- dexameth ophthalmic ointment neomycin-polymyxin- dexameth ophthalmic suspension 3.5-10000-0.1 neomycin-polymyxin- gramicidin ophthalmic solution 1.75-10000-.025 ofloxacin ophthalmic solution QL olopatadine hcl ophthalmic solution phenylephrine hcl ophthalmic solution 10 %, 2.5 % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % polymyxin b- trimethoprim ophthalmic solution prednisolone acetate ophthalmic suspension prednisolone sodium phosphate ophthalmic solution sulfacetamide sodium ophthalmic solution sulfacetamide- prednisolone ophthalmic solution timolol maleate ophthalmic gel forming solution timolol maleate ophthalmic solution 0.25 %, 0.5 % tobramycin ophthalmic solution tobramycin- dexamethasone ophthalmic suspension travoprost (bak free) ophthalmic solution trifluridine ophthalmic solution tropicamide ophthalmic solution

Last Updated 12.1.2020 66 ZADITOR OPHTHALMIC SOLUTION OTC

Last Updated 12.1.2020 67 *Otic Agents*

acetic acid otic solution ACETASOL HC OTIC ciprofloxacin hcl otic SOLUTION solution CIPRO HC OTIC ciprofloxacin- SUSPENSION PA dexamethasone otic suspension PA; PA Except Otolaryngology fluocinolone acetonide otic oil hydrocortisone-acetic acid otic solution neomycin-polymyxin-hc otic solution neomycin-polymyxin-hc otic suspension ofloxacin otic solution

*Oxytocics*

methylergonovine cervidil vaginal insert maleate oral tablet PREPIDIL VAGINAL GEL PROSTIN E2 VAGINAL SUPPOSITORY

*Penicillins*

amoxicillin oral capsule BICILLIN L-A AUGMENTIN ORAL DF INTRAMUSCULAR SUSPENSION amoxicillin oral SUSPENSION 1200000 RECONSTITUTED 125- suspension reconstituted UNIT/2ML, 600000 31.25 MG/5ML DF UNIT/ML PA; LA amoxicillin oral tablet DF amoxicillin oral tablet chewable 125 mg, 250 mg DF amoxicillin-pot clavulanate er oral tablet extended release 12 hour DF amoxicillin-pot clavulanate oral suspension reconstituted DF amoxicillin-pot clavulanate oral tablet DF amoxicillin-pot clavulanate oral tablet chewable DF ampicillin oral capsule 500 mg dicloxacillin sodium oral capsule penicillin v potassium oral solution reconstituted penicillin v potassium oral tablet DF

*Pharmaceutical Adjuvants*

sterile water for injection injection solution PA sterile water for injection intravenous solution PA

Last Updated 12.1.2020 68 *Progestins*

medroxyprogesterone acetate oral tablet MO megestrol acetate oral suspension 625 mg/5ml LA norethindrone acetate oral tablet MO progesterone intramuscular oil PA progesterone micronized oral capsule MO

Last Updated 12.1.2020 69 *Psychotherapeutic And Neurological Agents - Misc.*

acamprosate calcium oral CHANTIX CONTINUING GRALISE ORAL TABLET AUBAGIO ORAL TABLET AUSTEDO ORAL TABLET tablet delayed release MONTH PAK ORAL ST PA; PA Except Neurology; PA; SP bupropion hcl er TABLET HORIZANT ORAL TABLET SP EXTAVIA SUBCUTANEOUS (smoking det) oral tablet CHANTIX ORAL TABLET EXTENDED RELEASE ST AVONEX PEN KIT PA; PA Except extended release 12 hour CHANTIX STARTING LUCEMYRA ORAL TABLET INTRAMUSCULAR AUTO- Neurology; SP chlordiazepoxide- MONTH PAK ORAL PA; QL INJECTOR KIT PA; PA INGREZZA ORAL CAPSULE amitriptyline oral tablet TABLET NAMZARIC ORAL Except Neurology; SP PA; SP AL LYRICA CR ORAL TABLET CAPSULE ER 24 HOUR AVONEX PREFILLED INGREZZA ORAL CAPSULE dalfampridine er oral EXTENDED RELEASE 24 THERAPY PACK PA INTRAMUSCULAR THERAPY PACK PA; SP tablet extended release HOUR NAMZARIC ORAL PREFILLED SYRINGE KIT MAVENCLAD (10 TABS) 12 hour PA; SP NAMENDA XR TITRATION CAPSULE EXTENDED PA; PA Except Neurology; ORAL TABLET THERAPY dimethyl fumarate oral PACK ORAL CAPSULE RELEASE 24 HOUR PA SP PACK PA; QL; SP capsule delayed release EXTENDED RELEASE 24 NICOTROL INHALATION COPAXONE MAVENCLAD (4 TABS) PA; PA Except Neurology; HOUR MO QL SUBCUTANEOUS ORAL TABLET THERAPY NICOTROL NS NASAL SP NUEDEXTA ORAL SOLUTION PREFILLED PACK PA; QL; SP SOLUTION QL MAVENCLAD (5 TABS) disulfiram oral tablet CAPSULE LA SYRINGE 40 MG/ML SAVELLA ORAL TABLET olanzapine-fluoxetine hcl ORAL TABLET THERAPY MO PA; PA Except Neurology; donepezil hcl oral tablet MO oral capsule PA; MO PACK PA; QL; SP SAVELLA TITRATION PACK paroxetine mesylate oral SP MAVENCLAD (6 TABS) 10 mg, 5 mg MO GILENYA ORAL CAPSULE donepezil hcl oral tablet ORAL capsule ORAL TABLET THERAPY PA; PA Except Neurology; dispersible MO rivastigmine tartrate oral PACK PA; QL; SP ergoloid mesylates oral capsule MO SP MAVENCLAD (7 TABS) KESIMPTA tablet rivastigmine transdermal ORAL TABLET THERAPY SUBCUTANEOUS galantamine patch 24 hour MO PACK PA; QL; SP hydrobromide er oral SOLUTION AUTO- MAVENCLAD (8 TABS) capsule extended release INJECTOR PA; PA ORAL TABLET THERAPY 24 hour MO Except Neurology; SP PACK PA; QL; SP galantamine MAYZENT ORAL TABLET MAVENCLAD (9 TABS) hydrobromide oral PA; PA Except Neurology; ORAL TABLET THERAPY solution MO SP PACK PA; QL; SP galantamine MAYZENT STARTER PACK TEGSEDI SUBCUTANEOUS hydrobromide oral tablet ORAL TABLET THERAPY SOLUTION PREFILLED MO PACK PA; PA Except SYRINGE PA; SP glatiramer acetate Neurology; SP VUMERITY ORAL subcutaneous solution PLEGRIDY STARTER PACK CAPSULE DELAYED prefilled syringe PA; PA SUBCUTANEOUS RELEASE PA; SP Except Neurology; SP SOLUTION PEN-INJECTOR XYREM ORAL SOLUTION GLATOPA PA; PA Except Neurology; PA; PA Except Neurology, SUBCUTANEOUS SP Psychiatry, and Sleep SOLUTION PREFILLED PLEGRIDY STARTER PACK Specialists; SP SYRINGE 20 MG/ML SUBCUTANEOUS PA; PA Except Neurology; SOLUTION PREFILLED SP SYRINGE PA; PA Except memantine hcl er oral Neurology; SP capsule extended release PLEGRIDY 24 hour MO SUBCUTANEOUS memantine hcl oral SOLUTION PEN-INJECTOR solution 2 mg/ml MO PA; PA Except Neurology; memantine hcl oral tablet SP MO PLEGRIDY perphenazine- SUBCUTANEOUS amitriptyline oral tablet SOLUTION PREFILLED AL SYRINGE PA; PA Except pimozide oral tablet AL Neurology; SP

Last Updated 12.1.2020 70 REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR PA; PA Except Neurology; SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR PA; PA Except Neurology; SP REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; PA Except Neurology; SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; PA Except Neurology; SP tetrabenazine oral tablet PA; QL; SP ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK PA; PA Except Neurology; SP ZEPOSIA ORAL CAPSULE PA; PA Except Neurology; SP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; PA Except Neurology; SP

Last Updated 12.1.2020 71 *Respiratory Agents - Misc.*

PULMOZYME KALYDECO ORAL PACKET ESBRIET ORAL CAPSULE INHALATION SOLUTION PA; SP PA; SP SYMDEKO ORAL TABLET KALYDECO ORAL TABLET ESBRIET ORAL TABLET THERAPY PACK 50-75 & PA; AL; SP PA; SP 75 MG PA; LA; AL ORKAMBI ORAL PACKET OFEV ORAL CAPSULE PA; SP PA; SP ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; AL; SP SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG PA; AL; SP TRIKAFTA ORAL TABLET THERAPY PACK PA; AL; SP

*Sulfonamides*

sulfadiazine oral tablet

*Tetracyclines*

doxycycline hyclate oral demeclocycline hcl oral capsule DF tablet doxycycline hyclate oral doxycycline monohydrate tablet 100 mg oral suspension doxycycline hyclate oral reconstituted DF tablet 20 mg DF doxycycline hyclate oral tablet 50 mg DF; AL doxycycline monohydrate oral capsule 100 mg DF; AL doxycycline monohydrate oral capsule 50 mg minocycline hcl oral capsule tetracycline hcl oral capsule

*Thyroid Agents*

levothyroxine sodium ARMOUR THYROID ORAL NATURE-THROID ORAL intravenous solution TABLET MO TABLET MO reconstituted 500 mcg SYNTHROID ORAL TABLET WESTHROID ORAL PA MO TABLET 130 MG, 195 MG, levothyroxine sodium 32.5 MG, 65 MG, 97.5 oral tablet MO MG MO liothyronine sodium oral WP THYROID ORAL tablet MO TABLET 130 MG, 16.25 methimazole oral tablet MG, 32.5 MG, 48.75 MG, MO 65 MG, 97.5 MG MO np thyroid oral tablet 30 mg, 60 mg, 90 mg MO propylthiouracil oral tablet MO UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG MO

Last Updated 12.1.2020 72 *Ulcer Drugs/Antispasmodics/Anticholinergics*

belladonna alkaloids- amoxicill-clarithro- opium rectal suppository lansopraz oral 16.2-60 mg AL CUVPOSA ORAL chlordiazepoxide- SOLUTION ST clidinium oral capsule methscopolamine AL bromide oral tablet cimetidine hcl oral nizatidine oral capsule solution MO MO cimetidine oral tablet 300 nizatidine oral solution mg, 400 mg, 800 mg MO MO PYLERA ORAL CAPSULE dicyclomine hcl oral sucralfate oral suspension TALICIA ORAL CAPSULE capsule dicyclomine hcl oral DELAYED RELEASE PA solution dicyclomine hcl oral tablet esomeprazole magnesium oral capsule delayed release MO famotidine oral suspension reconstituted MO famotidine oral tablet 20 mg, 40 mg MO glycopyrrolate oral tablet 1 mg, 2 mg hyoscyamine sulfate er oral tablet extended release 12 hour MO; AL hyoscyamine sulfate oral elixir MO; AL hyoscyamine sulfate oral tablet MO; AL hyoscyamine sulfate oral tablet dispersible MO; AL hyoscyamine sulfate sublingual tablet sublingual MO; AL lansoprazole oral capsule delayed release MO misoprostol oral tablet MO omeprazole oral capsule delayed release MO pantoprazole sodium oral tablet delayed release MO pb-hyoscy-atropine- scopolamine oral tablet phenobarbital-belladonna alk oral elixir PHENOHYTRO ORAL TABLET propantheline bromide oral tablet

Last Updated 12.1.2020 73 rabeprazole sodium oral tablet delayed release MO sucralfate oral tablet MO

*Urinary Antispasmodics*

bethanechol chloride oral MYRBETRIQ ORAL TABLET GELNIQUE tablet EXTENDED RELEASE 24 TRANSDERMAL GEL 10 % darifenacin HOUR MO MO; AL hydrobromide er oral TOVIAZ ORAL TABLET tablet extended release EXTENDED RELEASE 24 24 hour ST; MO; AL HOUR MO; AL flavoxate hcl oral tablet MO oxybutynin chloride er oral tablet extended release 24 hour MO oxybutynin chloride oral syrup MO oxybutynin chloride oral tablet MO solifenacin succinate oral tablet AL tolterodine tartrate er oral capsule extended release 24 hour MO tolterodine tartrate oral tablet MO trospium chloride er oral capsule extended release 24 hour MO trospium chloride oral tablet MO

*Vaginal And Related Products*

clindamycin phosphate CLEOCIN VAGINAL CLINDESSE VAGINAL vaginal cream SUPPOSITORY CREAM estradiol vaginal cream ESTRING VAGINAL RING ENDOMETRIN VAGINAL estradiol vaginal tablet MO INSERT PA; QL metronidazole vaginal gel PREMARIN VAGINAL FEM PH VAGINAL GEL YUVAFEM VAGINAL CREAM FEMRING VAGINAL RING TABLET GYNAZOLE-1 VAGINAL CREAM NUVESSA VAGINAL GEL terconazole vaginal cream terconazole vaginal suppository

*Vasopressors*

epinephrine injection SYMJEPI INJECTION NORTHERA ORAL solution auto-injector SOLUTION PREFILLED CAPSULE PA; SP 0.15 mg/0.3ml, 0.3 SYRINGE 0.15 MG/0.3ML, mg/0.3ml QL 0.3 MG/0.3ML QL midodrine hcl oral tablet

Last Updated 12.1.2020 74 *Vitamins*

ergocalciferol oral capsule MO phytonadione oral tablet vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) MO

Last Updated 12.1.2020 75 Last Updated 12.1.2020 76 INDEX I n d e x I n d e x A alprazolam xr...... 11 ALTABAX...... 46 abacavir sulfate...... 36 ALTAVERA...... 40 abacavir sulfate-lamivudine...... 36 ALUNBRIG...... 29 abacavir-lamivudine-zidovudine...... 36 alyacen 1/35...... 40 ABILIFY MYCITE...... 34 alyacen 7/7/7...... 40 abiraterone acetate...... 29 amantadine hcl...... 33 ABSORICA...... 46 ambrisentan...... 39 acamprosate calcium...... 70 amcinonide...... 46 acarbose...... 19 AMETHIA...... 40 ACCOLATE...... 13 AMETHIA LO...... 40 acebutolol hcl...... 37 AMETHYST...... 40 acetaminophen-codeine...... 8 amikacin sulfate...... 4 acetaminophen-codeine #2...... 8 amiloride hcl...... 52 acetaminophen-codeine #3...... 8 amiloride-hydrochlorothiazide...... 52 acetaminophen-codeine #4...... 8 aminoacetic acid...... 55 ACETASOL HC...... 68 aminocaproic acid...... 56 acetazolamide...... 52 amiodarone hcl...... 12 acetazolamide er...... 52 AMITIZA...... 55 acetic acid...... 55, 68 amitriptyline hcl...... 17 acetylcysteine...... 45 amlodipine besy-benazepril hcl...... 25 acitretin...... 46 amlodipine besylate...... 38 ACTEMRA...... 5 amlodipine besylate-valsartan...... 25 ACTEMRA ACTPEN...... 5 amlodipine-atorvastatin...... 39 activite...... 63 amlodipine-olmesartan...... 25 acyclovir...... 36, 46 amlodipine-valsartan-hctz...... 25 adapalene...... 46 AMNESTEEM...... 46 adapalene-benzoyl peroxide...... 46 amoxapine...... 17 adefovir dipivoxil...... 36 amoxicill-clarithro-lansopraz...... 73 ADEMPAS...... 39 amoxicillin...... 68 ADRENALIN...... 64 amoxicillin-pot clavulanate...... 68 ADVAIR HFA...... 13 amoxicillin-pot clavulanate er...... 68 AFEDITAB CR...... 38 amphetamine-dextroamphet er...... 3 AFINITOR...... 29 amphetamine-dextroamphetamine...... 3 AFINITOR DISPERZ...... 29 ampicillin...... 68 AIMOVIG...... 59 ANACAINE...... 46 AJOVY...... 59 ANADROL-50...... 10 AKLIEF...... 46 anagrelide hcl...... 56 AKYNZEO...... 22 anastrozole...... 29 ALAWAY...... 65 ANDRODERM...... 10 ALAWAY CHILDRENS ALLERGY...... 65 ANGELIQ...... 54 albendazole...... 11 ANNOVERA...... 40 albuterol sulfate...... 13 ANZEMET...... 22 albuterol sulfate er...... 13 APOKYN...... 33 alclometasone dipropionate...... 46 apraclonidine hcl...... 65 ALDACTAZIDE...... 52 aprepitant...... 22 ALECENSA...... 29 APRI...... 40 alendronate sodium...... 53 APTIOM...... 15 alfuzosin hcl er...... 55 APTIVUS...... 36 ALINIA...... 27 ARANELLE...... 40 aliskiren fumarate...... 25 ARANESP (ALBUMIN FREE)...... 56 ALKERAN...... 29 ARAVA...... 5 allopurinol...... 56 ARCALYST...... 5 almotriptan malate...... 59 ARCAPTA NEOHALER...... 13 ALOCRIL...... 65 ARIKAYCE...... 4 ALOMIDE...... 65 aripiprazole...... 34 alosetron hcl...... 55 armodafinil...... 3 ALPHAGAN P...... 65 ARMOUR THYROID...... 72 alprazolam...... 11 ARNUITY ELLIPTA...... 13 alprazolam er...... 11 ASCOMP-CODEINE...... 8 ALPRAZOLAM INTENSOL...... 11 ASHLYNA...... 40

Last Updated 12.1.2020 77 I n d e x I n d e x ASMANEX (120 METERED DOSES)...... 13 betamethasone valerate...... 46 ASMANEX (14 METERED DOSES)...... 13 betaxolol hcl...... 37, 65 ASMANEX (30 METERED DOSES)...... 13 bethanechol chloride...... 74 ASMANEX (60 METERED DOSES)...... 13 BETHKIS...... 4 ASMANEX (7 METERED DOSES)...... 13 bexarotene...... 29 ASMANEX HFA...... 13 bicalutamide...... 29 aspirin-dipyridamole er...... 56 BICILLIN L-A...... 68 ASTAGRAF XL...... 61 BIDIL...... 39 atenolol...... 37 BIKTARVY...... 36 atenolol-chlorthalidone...... 25 bimatoprost...... 65 atomoxetine hcl...... 3 BINOSTO...... 53 atorvastatin calcium...... 24 bisoprolol fumarate...... 37 atovaquone...... 27 bisoprolol-hydrochlorothiazide...... 25 atovaquone-proguanil hcl...... 27 BLEPHAMIDE...... 65 atropine sulfate...... 65 BLEPHAMIDE S.O.P...... 65 ATROVENT HFA...... 13 BONJESTA...... 22 AUBAGIO...... 70 bosentan...... 39 AUGMENTIN...... 68 BOSULIF...... 29 AURYXIA...... 55 BRAFTOVI...... 29 AUSTEDO...... 70 BREO ELLIPTA...... 13 AVANDIA...... 19 briellyn...... 40 AVIANE...... 40 BRILINTA...... 56 AVITA...... 46 brimonidine tartrate...... 65 AVONEX PEN...... 70 BRIVIACT...... 15 AVONEX PREFILLED...... 70 bromfenac sodium (once-daily)...... 65 av-phos 250 neutral...... 60 bromocriptine mesylate...... 33 AYVAKIT...... 29 BROVANA...... 13 AZASAN...... 61 BRUKINSA...... 29 azathioprine...... 61 BRYHALI...... 46 azelaic acid...... 46 budesonide...... 13, 44 azelastine hcl...... 64, 65 BUDESONIDE...... 64 AZELEX...... 46 budesonide er...... 44 azithromycin...... 58 bumetanide...... 52 AZOPT...... 65 BUPAP...... 7 AZURETTE...... 40 BUPHENYL...... 53 B buprenorphine...... 8 bupropion hcl...... 17 bacitracin-polymyxin b...... 65 bupropion hcl er (smoking det)...... 70 bacitra-neomycin-polymyxin-hc...... 65 bupropion hcl er (sr)...... 17 baclofen...... 64 bupropion hcl er (xl)...... 17 balanced salt...... 65 buspirone hcl...... 11 BALCOLTRA...... 40 butalbital-acetaminophen...... 7 balsalazide disodium...... 55 butalbital-apap-caff-cod...... 8 BALVERSA...... 29 butalbital-apap-caffeine...... 7 BALZIVA...... 40 butalbital-asa-caff-codeine...... 8 BANZEL...... 15 butorphanol tartrate...... 8 BAQSIMI ONE PACK...... 19 BYSTOLIC...... 37 BAQSIMI TWO PACK...... 19 C BARACLUDE...... 36 BD AUTOSHIELD DUO...... 58 cabergoline...... 53 belladonna alkaloids-opium...... 73 CABOMETYX...... 29 BELSOMRA...... 57 calcipotriene...... 46 benazepril hcl...... 25 calcipotriene-betameth diprop...... 47 benazepril-hydrochlorothiazide...... 25 calcitonin (salmon)...... 53 BENLYSTA...... 61 calcitriol...... 47, 53 BENZAC AC WASH...... 46 calcium acetate (phos binder)...... 55 BENZEPRO...... 46 CALQUENCE...... 29 benzonatate...... 45 CAMBIA...... 59 benzoyl peroxide...... 46 CAMILA...... 40 benzoyl peroxide wash...... 46 CAMRESE...... 40 benztropine mesylate...... 33 CAMRESE LO...... 40 BEPREVE...... 65 candesartan cilexetil...... 25 BETADINE OPHTHALMIC PREP...... 65 candesartan cilexetil-hctz...... 25 betamethasone dipropionate...... 46 capecitabine...... 29 betamethasone dipropionate aug...... 46 CAPLYTA...... 34

Last Updated 12.1.2020 78 I n d e x I n d e x CAPRELSA...... 29 CIPRO...... 54 captopril-hydrochlorothiazide...... 25 CIPRO HC...... 68 CARBAGLU...... 53 ciprofloxacin hcl...... 54, 65, 68 carbamazepine...... 15 ciprofloxacin-dexamethasone...... 68 carbamazepine er...... 15 citalopram hydrobromide...... 17 carbidopa...... 33 CITRANATAL 90 DHA...... 63 carbidopa-levodopa...... 33 CITRANATAL ASSURE...... 63 carbidopa-levodopa er...... 33 CITRANATAL B-CALM...... 63 carbidopa-levodopa-entacapone...... 33 CITRANATAL BLOOM...... 63 carbinoxamine maleate...... 23 CITRANATAL DHA...... 63 CARDIZEM...... 38 CITRANATAL HARMONY...... 63 CARDIZEM CD...... 38 CITRANATAL RX...... 63 CARDIZEM LA...... 38 CLARAVIS...... 47 CARDURA XL...... 55 CLARINEX-D 12 HOUR...... 45 carteolol hcl...... 65 clarithromycin...... 58 CARTIA XT...... 38 clarithromycin er...... 58 carvedilol...... 37 CLENPIQ...... 57 carvedilol phosphate er...... 37 CLEOCIN...... 74 CAVERJECT...... 39 CLEOCIN-T...... 47 CAVERJECT IMPULSE...... 39 CLIMARA PRO...... 54 CAYSTON...... 27 clindamycin hcl...... 27 CAZIANT...... 40 clindamycin palmitate hcl...... 27 cefaclor...... 39 clindamycin phos-benzoyl perox...... 47 cefadroxil...... 39 clindamycin phosphate...... 47, 74 cefdinir...... 39 CLINDESSE...... 74 cefixime...... 39 CLINPRO 5000...... 62 cefpodoxime proxetil...... 39 clobazam...... 15 cefprozil...... 39 clobetasol propionate...... 47 ceftriaxone sodium...... 39 clobetasol propionate e...... 47 cefuroxime axetil...... 39 clomiphene citrate...... 53 celecoxib...... 5 clomipramine hcl...... 17 CELONTIN...... 15 clonazepam...... 15 CENTANY...... 47 clonidine...... 25 CENTANY AT...... 47 clonidine hcl...... 25 cephalexin...... 39 clonidine hcl (analgesia)...... 7 CERDELGA...... 56 clonidine hcl er...... 3 cervidil...... 68 clopidogrel bisulfate...... 56 CESIA...... 40 clorazepate dipotassium...... 11 CETROTIDE...... 53 clotrimazole...... 47, 62 cevimeline hcl...... 62 clotrimazole-betamethasone...... 47 CHANTIX...... 70 clozapine...... 34 CHANTIX CONTINUING MONTH PAK...... 70 coal tar...... 47 CHANTIX STARTING MONTH PAK...... 70 COARTEM...... 27 CHATEAL...... 40 codeine sulfate...... 8 CHENODAL...... 55 colchicine...... 56 chlordiazepoxide hcl...... 11 colchicine-probenecid...... 56 chlordiazepoxide-amitriptyline...... 70 colesevelam hcl...... 24 chlordiazepoxide-clidinium...... 73 colestipol hcl...... 24 chlorhexidine gluconate...... 62 COMBIGAN...... 65 chloroquine phosphate...... 27 COMBIPATCH...... 54 chlorpromazine hcl...... 34 COMBIVENT RESPIMAT...... 13 chlorthalidone...... 52 COMETRIQ (60 MG DAILY DOSE)...... 29 chlorzoxazone...... 64 COMPLERA...... 36 CHOLBAM...... 55 completenate...... 63 cholestyramine...... 24 COMPRO...... 34 cholestyramine light...... 24 COPAXONE...... 70 chorionic gonadotropin...... 53 COPIKTRA...... 29 ciclopirox...... 47 CORLANOR...... 39 ciclopirox olamine...... 47 cortisone acetate...... 44 ciclopirox treatment...... 47 COSENTYX...... 47 cilostazol...... 56 COSENTYX (300 MG DOSE)...... 47 CIMDUO...... 36 COSENTYX SENSOREADY (300 MG)...... 47 cimetidine...... 73 COSENTYX SENSOREADY PEN...... 47 cimetidine hcl...... 73 COTELLIC...... 29 cinacalcet hcl...... 53 COTEMPLA XR-ODT...... 3

Last Updated 12.1.2020 79 I n d e x I n d e x COVARYX...... 54 diazepam...... 11, 15 COVARYX HS...... 54 diazepam intensol...... 11 CREON...... 52 diazoxide...... 19 CRIXIVAN...... 36 diclofenac potassium...... 5 cromolyn sodium...... 13, 55, 65 diclofenac sodium...... 5, 65 CROTAN...... 47 diclofenac sodium er...... 5 CRYSELLE-28...... 40 dicloxacillin sodium...... 68 CUVPOSA...... 73 dicyclomine hcl...... 73 cyanocobalamin...... 56 didanosine...... 36 CYCLAFEM 1/35...... 40 DIFICID...... 58 CYCLAFEM 7/7/7...... 40 diflorasone diacetate...... 47 cyclobenzaprine hcl...... 64 diflunisal...... 7 cyclophosphamide...... 29 digoxin...... 39 CYCLOSET...... 19 dihydroergotamine mesylate...... 59 cyclosporine...... 61 DILANTIN...... 15 cyclosporine modified...... 61 DILATRATE-SR...... 11 cyproheptadine hcl...... 23 DILAUDID...... 8 CYRED...... 40 diltiazem hcl...... 38 CYSTADANE...... 53 diltiazem hcl er...... 38 CYSTAGON...... 55 diltiazem hcl er beads...... 38 CYSTARAN...... 65 diltiazem hcl er coated beads...... 38 D dilt-xr...... 38 dimethyl fumarate...... 70 dalfampridine er...... 70 diphenhydramine hcl...... 23 DALIRESP...... 13 diphenoxylate-atropine...... 21 danazol...... 10 DIPROLENE...... 47 dantrolene sodium...... 64 DIPROLENE AF...... 47 dapsone...... 27, 47 dipyridamole...... 56 darifenacin hydrobromide er...... 74 disopyramide phosphate...... 12 DASETTA 1/35...... 40 disulfiram...... 70 DASETTA 7/7/7...... 40 DIURIL...... 52 DAURISMO...... 29 divalproex sodium...... 15 DAYPRO...... 5 divalproex sodium er...... 15 DAYSEE...... 40 DIVIGEL...... 54 DAYTRANA...... 3 dobells...... 62 DAYVIGO...... 57 dofetilide...... 12 DDAVP RHINAL TUBE...... 53 donepezil hcl...... 70 DEBACTEROL...... 62 DOPTELET...... 56 DEBLITANE...... 40 dorzolamide hcl...... 65 deferasirox...... 22 dorzolamide hcl-timolol mal...... 65 deferasirox granules...... 22 dorzolamide hcl-timolol mal pf...... 65 DELSTRIGO...... 36 DOTTI...... 54 demeclocycline hcl...... 72 DOVATO...... 36 DESCOVY...... 36 doxazosin mesylate...... 25 desipramine hcl...... 17 doxepin hcl...... 17, 57 desloratadine...... 23 doxercalciferol...... 53 desmopressin ace spray refrig...... 53 doxycycline hyclate...... 72 desmopressin acetate...... 53 doxycycline monohydrate...... 72 desmopressin acetate spray...... 53 doxylamine-pyridoxine...... 22 desogestrel-ethinyl estradiol...... 40 DRITHO-CREME HP...... 47 desonide...... 47 dronabinol...... 22 desoximetasone...... 47 drospiren-eth estrad-levomefol...... 40 desvenlafaxine succinate er...... 17 drospirenone-ethinyl estradiol...... 40 dexamethasone...... 44 DROXIA...... 56 dexamethasone intensol...... 44 DRYSOL...... 47 dexamethasone sodium phosphate...... 65 DUAVEE...... 54 dexmethylphenidate hcl...... 3 DUET DHA 400...... 63 dexmethylphenidate hcl er...... 3 DUET DHA BALANCED...... 63 dextroamphetamine sulfate...... 3 duloxetine hcl...... 17 dextroamphetamine sulfate er...... 3 DUOBRII...... 47 dextrose-nacl...... 60 DUOPA...... 33 DIACOMIT...... 15 DUPIXENT...... 47 DIALYVITE...... 63 DURACLON...... 7 DIASTAT ACUDIAL...... 15 dutasteride...... 55 DIASTAT PEDIATRIC...... 15 dutasteride-tamsulosin hcl...... 55

Last Updated 12.1.2020 80 I n d e x I n d e x E erlotinib hcl...... 29 ERRIN...... 41 E.E.S. 400...... 58 ERTACZO...... 48 econazole nitrate...... 47 ERY-TAB...... 58 EDARBI...... 25 ERYTHROCIN STEARATE...... 58 EDARBYCLOR...... 25 erythromycin...... 48, 65 EDECRIN...... 52 erythromycin base...... 58 EDEX...... 39 erythromycin ethylsuccinate...... 58 EDLUAR...... 57 ESBRIET...... 72 EDURANT...... 36 escitalopram oxalate...... 17 EEMT...... 54 ESGIC...... 7 efavirenz...... 36 esomeprazole magnesium...... 73 efavirenz-emtricitab-tenofovir...... 36 est estrogens-methyltest...... 54 efavirenz-lamivudine-tenofovir...... 36 est estrogens-methyltest ds...... 54 EFFER-K...... 60 est estrogens-methyltest hs...... 54 EFUDEX...... 48 ESTARYLLA...... 41 ELESTRIN...... 54 estazolam...... 57 eletriptan hydrobromide...... 59 estradiol...... 54, 74 ELIMITE...... 48 estradiol-norethindrone acet...... 54 ELINEST...... 40 ESTRING...... 74 ELIQUIS...... 14 ESTROGEL...... 54 ELIQUIS DVT/PE STARTER PACK...... 14 eszopiclone...... 57 ELIXOPHYLLIN...... 13 ethacrynic acid...... 52 ELLA...... 40 ethambutol hcl...... 28 ELMIRON...... 55 ethosuximide...... 15 EMCYT...... 29 etodolac...... 5 EMEND...... 22 etodolac er...... 5 EMFLAZA...... 44 etoposide...... 29 EMGALITY...... 59 EUCRISA...... 48 EMGALITY (300 MG DOSE)...... 59 EVAMIST...... 54 EMOQUETTE...... 40 everolimus...... 29, 61 EMSAM...... 17 EVOTAZ...... 36 emtricitabine...... 36 exemestane...... 29 emtricitabine-tenofovir df...... 36 EXTAVIA...... 70 EMTRIVA...... 36 ezetimibe...... 24 EMVERM...... 11 ezetimibe-simvastatin...... 24 enalapril maleate...... 25 F enalapril-hydrochlorothiazide...... 25 ENBREL...... 5 FABIOR...... 48 ENBREL MINI...... 5 FALMINA...... 41 ENBREL SURECLICK...... 5 famciclovir...... 36 ENDOMETRIN...... 74 famotidine...... 73 enoxaparin sodium...... 14 FANAPT...... 34 ENPRESSE-28...... 40 FANAPT TITRATION PACK...... 34 ENSKYCE...... 41 FARYDAK...... 29 ENSPRYNG...... 61 FASENRA PEN...... 13 entacapone...... 33 febuxostat...... 56 entecavir...... 36 felbamate...... 15 ENTRESTO...... 39 felodipine er...... 38 ENVARSUS XR...... 61 FEM PH...... 74 EPANED...... 25 FEMRING...... 74 EPCLUSA...... 36 fenofibrate...... 24 EPIDIOLEX...... 15 fenofibrate micronized...... 24 EPIDUO FORTE...... 48 fenofibric acid...... 24 epinastine hcl...... 65 fenoprofen calcium...... 5 epinephrine...... 74 fentanyl...... 8 EPIVIR HBV...... 36 fentanyl citrate...... 8 eplerenone...... 25 FERRALET 90...... 56 EPZICOM...... 36 ferraplus 90...... 56 EQUETRO...... 34 FERREX 150 FORTE PLUS...... 56 ergocalciferol...... 75 FERRIPROX...... 22 ergoloid mesylates...... 70 FERRIPROX TWICE-A-DAY...... 22 ERGOMAR...... 59 FERROCITE PLUS...... 56 ERIVEDGE...... 29 FETZIMA...... 17 ERLEADA...... 29 FEXMID...... 64

Last Updated 12.1.2020 81 I n d e x I n d e x FINACEA...... 48 GENOTROPIN...... 53 finasteride...... 55 GENOTROPIN MINIQUICK...... 53 FIRDAPSE...... 27 gentamicin sulfate...... 48, 65 FIRVANQ...... 27 GENVOYA...... 36 FLAREX...... 65 GIANVI...... 41 flavoxate hcl...... 74 GILENYA...... 70 flecainide acetate...... 12 GILOTRIF...... 29 FLOVENT DISKUS...... 13 glatiramer acetate...... 70 FLOVENT HFA...... 13 GLATOPA...... 70 fluconazole...... 23 GLEOSTINE...... 29 flucytosine...... 23 glimepiride...... 19 fludrocortisone acetate...... 44 glipizide...... 19 flunisolide...... 64 glipizide er...... 19 fluocinolone acetonide...... 48, 68 glipizide xl...... 19 fluocinolone acetonide body...... 48 glipizide-metformin hcl...... 19 fluocinolone acetonide scalp...... 48 GLUCAGEN HYPOKIT...... 19 fluocinonide...... 48 glucagon emergency...... 19 FLUORIDEX SENSITIVITY RELIEF...... 62 glyburide...... 19 fluorometholone...... 65 glyburide micronized...... 19 FLUOROPLEX...... 48 glyburide-metformin...... 19 fluorouracil...... 48 glycine...... 55 fluoxetine hcl...... 17 glycine urologic...... 55 fluphenazine hcl...... 34 glycopyrrolate...... 73 flurandrenolide...... 48 GLYXAMBI...... 19 flurazepam hcl...... 57 GOCOVRI...... 33 flurbiprofen...... 5 GRALISE...... 70 flurbiprofen sodium...... 65 granisetron hcl...... 22 flutamide...... 29 GRASTEK...... 4 fluticasone propionate...... 48, 64 griseofulvin microsize...... 23 fluticasone-salmeterol...... 13 griseofulvin ultramicrosize...... 23 fluvastatin sodium...... 24 guanfacine hcl...... 25 fluvastatin sodium er...... 24 guanfacine hcl er...... 3 fluvoxamine maleate...... 17 guanidine hcl...... 27 fluvoxamine maleate er...... 17 GVOKE HYPOPEN 1-PACK...... 19 FML...... 65 GVOKE HYPOPEN 2-PACK...... 19 FML FORTE...... 65 GVOKE PFS...... 19 folic acid...... 56 GYNAZOLE-1...... 74 FOLLISTIM AQ...... 53 H fondaparinux sodium...... 14 FORTEO...... 53 HAEGARDA...... 56 FORTESTA...... 10 halobetasol propionate...... 48 fosamprenavir calcium...... 36 haloperidol...... 34 fosfomycin tromethamine...... 27 haloperidol lactate...... 34 fosinopril sodium...... 25 HARVONI...... 36 fosinopril sodium-hctz...... 25 HEATHER...... 41 FRAGMIN...... 14 HEMANGEOL...... 37 frovatriptan succinate...... 59 HEPSERA...... 36 furosemide...... 52 HETLIOZ...... 57 FUZEON...... 36 HORIZANT...... 70 FYCOMPA...... 15 HUMALOG...... 19 HUMALOG JUNIOR KWIKPEN...... 19 G HUMALOG KWIKPEN...... 19 gabapentin...... 15 HUMALOG MIX 50/50...... 19 GALAFOLD...... 53 HUMALOG MIX 50/50 KWIKPEN...... 19 galantamine hydrobromide...... 70 HUMALOG MIX 75/25...... 19 galantamine hydrobromide er...... 70 HUMALOG MIX 75/25 KWIKPEN...... 19 GALZIN...... 60 HUMIRA...... 5 ganirelix acetate...... 53 HUMIRA PEDIATRIC CROHNS START...... 5 GATTEX...... 55 HUMIRA PEN...... 5 GAVILYTE-G...... 57 HUMIRA PEN-CD/UC/HS STARTER...... 5 GAVRETO...... 29 HUMIRA PEN-PS/UV/ADOL HS START...... 5 GELNIQUE...... 74 HUMULIN 70/30...... 19 gemfibrozil...... 24 HUMULIN 70/30 KWIKPEN...... 19 GENGRAF...... 61 HUMULIN N...... 19 GENICIN VITA-S...... 63 HUMULIN N KWIKPEN...... 19

Last Updated 12.1.2020 82 I n d e x I n d e x HUMULIN R...... 19 ISIBLOOM...... 41 HUMULIN R U-500 (CONCENTRATED)...... 19 isoniazid...... 28 HUMULIN R U-500 KWIKPEN...... 20 isosorbide dinitrate...... 11 HYCAMTIN...... 29 isosorbide mononitrate...... 11 hydralazine hcl...... 25 isosorbide mononitrate er...... 11 hydrochlorothiazide...... 52 isotretinoin...... 49 hydrocodone-acetaminophen...... 8 isoxsuprine hcl...... 39 hydrocodone-homatropine...... 45 isradipine...... 38 hydrocodone-ibuprofen...... 8 itraconazole...... 23 hydrocortisone...... 10, 44, 48 ivermectin...... 11 hydrocortisone ace-pramoxine...... 48 J hydrocortisone acetate...... 10 hydrocortisone butyr lipo base...... 48 JAKAFI...... 29 hydrocortisone butyrate...... 48 JANTOVEN...... 14 hydrocortisone valerate...... 48 JARDIANCE...... 20 hydrocortisone-acetic acid...... 68 JENCYCLA...... 41 hydrocortisone-iodoquinol...... 48 JENTADUETO...... 20 hydromorphone hcl...... 8 JENTADUETO XR...... 20 hydromorphone hcl er...... 8 JINTELI...... 54 hydroxychloroquine sulfate...... 27 JOLESSA...... 41 hydroxyurea...... 29 JUBLIA...... 49 hydroxyzine hcl...... 11 JULEBER...... 41 hydroxyzine pamoate...... 11 JULUCA...... 36 hyoscyamine sulfate...... 73 JUNEL 1.5/30...... 41 hyoscyamine sulfate er...... 73 JUNEL 1/20...... 41 HYSINGLA ER...... 8 JUNEL FE 1.5/30...... 41 JUNEL FE 1/20...... 41 I JUNEL FE 24...... 41 ibandronate sodium...... 53 JUXTAPID...... 24 IBRANCE...... 29 JYNARQUE...... 53 ibuprofen...... 5 K icatibant acetate...... 56 ICLUSIG...... 29 KALETRA...... 36 icosapent ethyl...... 24 KALYDECO...... 72 IDHIFA...... 29 KANUMA...... 53 imatinib mesylate...... 29 KARIVA...... 41 IMBRUVICA...... 29 KELNOR 1/35...... 41 imipramine hcl...... 17 KESIMPTA...... 70 imiquimod...... 48 ketoconazole...... 23, 49 INBRIJA...... 33 KETODAN...... 49 INCRELEX...... 53 ketoprofen...... 5 indapamide...... 52 ketoprofen er...... 5 indomethacin...... 5 ketorolac tromethamine...... 5, 65 indomethacin er...... 5 ketotifen fumarate...... 65 INGREZZA...... 70 KEVEYIS...... 52 INLYTA...... 29 KEVZARA...... 5 INQOVI...... 29 KINERET...... 5 INREBIC...... 29 KISQALI FEMARA (400 MG DOSE)...... 29 INTELENCE...... 36 KISQALI FEMARA (600 MG DOSE)...... 29 INTRON A...... 29 KISQALI FEMARA(200 MG DOSE)...... 29 INTROVALE...... 41 KITABIS PAK...... 4 INTUNIV...... 3 KLONOPIN...... 15 INVIRASE...... 36 KLOR-CON...... 60 INVOKAMET...... 20 KLOR-CON 10...... 60 INVOKAMET XR...... 20 KLOR-CON/EF...... 60 INVOKANA...... 20 KORLYM...... 20 iodine strong...... 60 KOSELUGO...... 30 iodoquinol-hydrocortisone-aloe...... 49 K-PHOS-NEUTRAL...... 60 ipratropium bromide...... 13, 64 K-PRIME...... 60 ipratropium-albuterol...... 14 KRISTALOSE...... 57 irbesartan...... 25 KURVELO...... 41 irbesartan-hydrochlorothiazide...... 25 KYNMOBI...... 33 IRESSA...... 29 KYNMOBI TITRATION KIT...... 33 ISENTRESS...... 36 L ISENTRESS HD...... 36 labetalol hcl...... 37

Last Updated 12.1.2020 83 I n d e x I n d e x LACRISERT...... 65 lidocaine-prilocaine...... 49 lactated ringers...... 61 LIDOCARE ARM/NECK/LEG...... 49 lactulose...... 57 LIDOCARE BACK/SHOULDER...... 49 lactulose encephalopathy...... 55 lindane...... 49 LAMICTAL XR...... 15 linezolid...... 27 lamivudine...... 36 LINZESS...... 55 lamivudine-zidovudine...... 36 liothyronine sodium...... 72 lamotrigine...... 15 lisinopril...... 25 lamotrigine er...... 15 lisinopril-hydrochlorothiazide...... 25 lamotrigine starter kit-blue...... 15 lithium...... 34 lamotrigine starter kit-green...... 15 lithium carbonate...... 34 lamotrigine starter kit-orange...... 15 lithium carbonate er...... 34 LAMPIT...... 27 LITHOSTAT...... 55 LANOXIN...... 39 LIVALO...... 24 lansoprazole...... 73 LO LOESTRIN FE...... 42 lanthanum carbonate...... 55 LOKELMA...... 61 LANTUS...... 20 LONSURF...... 30 LANTUS SOLOSTAR...... 20 loperamide hcl...... 21 lapatinib ditosylate...... 30 lopinavir-ritonavir...... 36 LARIN 1.5/30...... 41 lorazepam...... 11 LARIN 1/20...... 41 LORAZEPAM INTENSOL...... 11 LARIN 24 FE...... 41 LORBRENA...... 30 LARIN FE 1.5/30...... 41 lorid...... 63 LARIN FE 1/20...... 41 LORYNA...... 42 LASTACAFT...... 65 losartan potassium...... 25 latanoprost...... 65 losartan potassium-hctz...... 25 LATUDA...... 34 LOTEMAX...... 66 LAZANDA...... 8 LOTEMAX SM...... 66 ledipasvir-sofosbuvir...... 36 loteprednol etabonate...... 66 LEENA...... 41 lovastatin...... 24 leflunomide...... 5 LOW-OGESTREL...... 42 LENVIMA (10 MG DAILY DOSE)...... 30 loxapine succinate...... 34 LENVIMA (12 MG DAILY DOSE)...... 30 LUCEMYRA...... 70 LENVIMA (14 MG DAILY DOSE)...... 30 LUMIGAN...... 66 LENVIMA (18 MG DAILY DOSE)...... 30 LUTERA...... 42 LENVIMA (20 MG DAILY DOSE)...... 30 LYNPARZA...... 30 LENVIMA (24 MG DAILY DOSE)...... 30 LYRICA CR...... 70 LENVIMA (4 MG DAILY DOSE)...... 30 LYSODREN...... 30 LENVIMA (8 MG DAILY DOSE)...... 30 LYUMJEV...... 20 LESSINA...... 41 LYUMJEV KWIKPEN...... 20 letrozole...... 30 LYZA...... 42 leucovorin calcium...... 30 M LEUKERAN...... 30 levalbuterol hcl...... 14 MACRODANTIN...... 27 levalbuterol tartrate...... 14 malathion...... 49 LEVEMIR...... 20 maprotiline hcl...... 17 LEVEMIR FLEXTOUCH...... 20 marlissa...... 42 levetiracetam...... 15 MARPLAN...... 17 levetiracetam er...... 15 MATULANE...... 30 levobunolol hcl...... 65 MATZIM LA...... 38 levocarnitine...... 53 MAVENCLAD (10 TABS)...... 70 levocetirizine dihydrochloride...... 23 MAVENCLAD (4 TABS)...... 70 levofloxacin...... 54, 66 MAVENCLAD (5 TABS)...... 70 LEVONEST...... 41 MAVENCLAD (6 TABS)...... 70 levonorgest-eth est & eth est...... 41 MAVENCLAD (7 TABS)...... 70 levonorgest-eth estrad 91-day...... 41 MAVENCLAD (8 TABS)...... 70 levonorgestrel...... 41 MAVENCLAD (9 TABS)...... 70 levonorgestrel-ethinyl estrad...... 41 MAVIK...... 25 LEVORA 0.15/30 (28)...... 42 MAVYRET...... 36 levothyroxine sodium...... 72 MAXIDEX...... 66 LEXIVA...... 36 MAYZENT...... 70 LIALDA...... 55 MAYZENT STARTER PACK...... 70 lidocaine...... 49 meclizine hcl...... 22 lidocaine hcl...... 49 MEDROX-RX...... 49 lidocaine-hydrocortisone ace...... 10 medroxyprogesterone acetate...... 69

Last Updated 12.1.2020 84 I n d e x I n d e x mefloquine hcl...... 27 miglitol...... 20 megestrol acetate...... 30, 69 miglustat...... 56 MEKINIST...... 30 MILLIPRED...... 44 MEKTOVI...... 30 MIMVEY...... 54 MELODETTA 24 FE...... 42 minocycline hcl...... 72 meloxicam...... 5 minoxidil...... 26 memantine hcl...... 70 mirtazapine...... 17 memantine hcl er...... 70 MIRVASO...... 49 MENEST...... 54 misoprostol...... 73 MENOPUR...... 53 modafinil...... 3 MENOSTAR...... 54 moexipril hcl...... 26 MENTAX...... 49 mometasone furoate...... 49 mercaptopurine...... 30 MONO-LINYAH...... 42 mesalamine...... 55 MONONESSA...... 42 mesalamine er...... 55 montelukast sodium...... 14 mesalamine-cleanser...... 55 morphine sulfate...... 9 MESNEX...... 30 morphine sulfate (concentrate)...... 8 MESTINON...... 27 morphine sulfate er...... 8, 9 metaxalone...... 64 morphine sulfate er beads...... 8 metformin hcl...... 20 MOTOFEN...... 21 metformin hcl er...... 20 MOVANTIK...... 55 methadone hcl...... 8 moxifloxacin hcl...... 54 METHADONE HCL INTENSOL...... 8 MULPLETA...... 56 METHADOSE...... 8 MULTAQ...... 12 methazolamide...... 52 MULTIGEN PLUS...... 56 methenamine hippurate...... 27 multivitamin/fluoride...... 63 methenamine mandelate...... 27 mupirocin...... 49 methimazole...... 72 mupirocin calcium...... 49 methitest...... 10 MUSE...... 39 methocarbamol...... 64 MYALEPT...... 53 methotrexate...... 30 MYCOBUTIN...... 28 methotrexate sodium...... 30 mycophenolate mofetil...... 61 methotrexate sodium (pf)...... 30 mycophenolate sodium...... 61 methoxsalen rapid...... 49 MYDAYIS...... 3 methscopolamine bromide...... 73 MYDRIACYL...... 66 methyldopa...... 25 MYLERAN...... 30 methyldopa-hydrochlorothiazide...... 25 MYORISAN...... 49 methylergonovine maleate...... 68 MYRBETRIQ...... 74 methylphenidate hcl...... 3 MYSOLINE...... 15 methylphenidate hcl er...... 3 MYTESI...... 21 methylphenidate hcl er (cd)...... 3 N methylphenidate hcl er (la)...... 3 methylphenidate hcl er (xr)...... 3 nabumetone...... 5 methylprednisolone...... 44 n-acetyl-l-cysteine...... 64 methyltestosterone...... 10 nadolol...... 37 metoclopramide hcl...... 55 naftifine hcl...... 49 metolazone...... 52 NAFTIN...... 49 METOPIRONE...... 51 naloxone hcl...... 22 metoprolol succinate er...... 37 naltrexone hcl...... 22 metoprolol tartrate...... 37 NAMENDA XR TITRATION PACK...... 70 metoprolol-hydrochlorothiazide...... 25 NAMZARIC...... 70 METROLOTION...... 49 naproxen...... 5 metronidazole...... 27, 49, 74 naproxen dr...... 5 metyrosine...... 26 naratriptan hcl...... 59 mexiletine hcl...... 12 NARCAN...... 22 MIBELAS 24 FE...... 42 NATACYN...... 66 miconazole-zinc oxide-petrolat...... 49 NATALVIT...... 63 MICROGESTIN 1.5/30...... 42 NATAZIA...... 42 MICROGESTIN 1/20...... 42 nateglinide...... 20 MICROGESTIN FE 1.5/30...... 42 NATESTO...... 10 MICROGESTIN FE 1/20...... 42 NATPARA...... 53 midazolam hcl...... 57 NATURE-THROID...... 72 midodrine hcl...... 74 NAYZILAM...... 15 mifepristone...... 53 NECON 0.5/35 (28)...... 42 MIGERGOT...... 59 NECON 1/35 (28)...... 42

Last Updated 12.1.2020 85 I n d e x I n d e x nefazodone hcl...... 17 NUCYNTA ER...... 9 neomycin sulfate...... 4 NUEDEXTA...... 70 neomycin-bacitracin zn-polymyx...... 66 NUPLAZID...... 34 neomycin-polymyxin b gu...... 55 NURTEC...... 59 neomycin-polymyxin-dexameth...... 66 NUVARING...... 43 neomycin-polymyxin-gramicidin...... 66 NUVESSA...... 74 neomycin-polymyxin-hc...... 68 NYMALIZE...... 38 NEPHRONEX...... 63 nystatin...... 23, 49, 62 NEPHRO-VITE RX...... 63 nystatin-triamcinolone...... 49 NERLYNX...... 30 NYSTOP...... 50 NESTABS...... 63 O NESTABS DHA...... 63 NEULASTA...... 56 OBTREX...... 63 NEUPRO...... 33 OCALIVA...... 55 nevirapine...... 36 OCELLA...... 43 nevirapine er...... 36 octreotide acetate...... 53 NEXAVAR...... 30 ODACTRA...... 4 NEXLETOL...... 24 ODEFSEY...... 36 NEXLIZET...... 24 ODOMZO...... 30 nicardipine hcl...... 38 OFEV...... 72 NICOTROL...... 70 ofloxacin...... 66, 68 NICOTROL NS...... 70 olanzapine...... 34 nifedipine...... 38 olanzapine-fluoxetine hcl...... 70 nifedipine er...... 38 olmesartan medoxomil...... 26 nifedipine er osmotic release...... 38 olmesartan medoxomil-hctz...... 26 NIKKI...... 42 olmesartan-amlodipine-hctz...... 26 NILANDRON...... 30 olopatadine hcl...... 64, 66 nimodipine...... 38 omeprazole...... 73 NINLARO...... 30 OMNIPOD 5 PACK...... 58 nisoldipine er...... 38 OMNIPOD DASH 5 PACK PODS...... 58 nitisinone...... 53 ondansetron...... 22 NITRO-BID...... 11 ondansetron hcl...... 22 NITRO-DUR...... 11 onevite...... 63 nitrofurantoin...... 27 ONGENTYS...... 33 nitrofurantoin macrocrystal...... 27 ONUREG...... 30 nitrofurantoin monohyd macro...... 27 ONZETRA XSAIL...... 59 nitroglycerin...... 11 opium...... 21 nitroglycerin er...... 11 OPSUMIT...... 39 NITYR...... 53 ORALAIR...... 4 NIVESTYM...... 56 ORALAIR ADULT SAMPLE KIT...... 4 nizatidine...... 73 ORALAIR ADULT STARTER PACK...... 4 NORA-BE...... 42 ORALAIR CHILDRENS SAMPLE KIT...... 4 norethin ace-eth estrad-fe...... 42 ORALAIR CHILDRENS STARTER PACK...... 4 norethindrone...... 42 ORAVIG...... 62 norethindrone acetate...... 69 ORENCIA...... 5 norethindrone acet-ethinyl est...... 42 ORENCIA CLICKJECT...... 5 norethindrone-eth estradiol...... 54 ORENITRAM...... 39 norgestimate-eth estradiol...... 42 ORFADIN...... 53 norgestim-eth estrad triphasic...... 42 ORIAHNN...... 54 NORLYROC...... 42 ORILISSA...... 53 NORPACE CR...... 12 ORKAMBI...... 72 NORPRAMIN...... 17 ORSYTHIA...... 43 NORTHERA...... 74 oseltamivir phosphate...... 36 NORTREL 0.5/35 (28)...... 42 OSMOLEX ER...... 33 NORTREL 1/35 (21)...... 42 OTEZLA...... 5 NORTREL 1/35 (28)...... 42 OTREXUP...... 5 NORTREL 7/7/7...... 43 OVIDREL...... 53 nortriptyline hcl...... 17 oxandrolone...... 10 NORVIR...... 36 oxaprozin...... 5 NOXAFIL...... 23 oxazepam...... 11 np thyroid...... 72 OXBRYTA...... 56 NUBEQA...... 30 oxcarbazepine...... 15 NUCALA...... 14 OXERVATE...... 66 NUCORT...... 49 oxiconazole nitrate...... 50 NUCYNTA...... 9 OXISTAT...... 50

Last Updated 12.1.2020 86 I n d e x I n d e x OXSORALEN ULTRA...... 50 PHYSIOSOL IRRIGATION...... 61 OXTELLAR XR...... 15 phytonadione...... 75 oxybutynin chloride...... 74 PICATO...... 50 oxybutynin chloride er...... 74 PIFELTRO...... 37 oxycodone hcl...... 9 pilocarpine hcl...... 62, 66 oxycodone hcl er...... 9 pimecrolimus...... 50 oxycodone-acetaminophen...... 9 pimozide...... 70 oxycodone-aspirin...... 9 PIMTREA...... 43 OXYCONTIN...... 9 pindolol...... 37 oxymorphone hcl...... 9 pioglitazone hcl...... 20 oxymorphone hcl er...... 9 pioglitazone hcl-glimepiride...... 20 OZEMPIC (0.25 OR 0.5 MG/DOSE)...... 20 pioglitazone hcl-metformin hcl...... 20 OZEMPIC (1 MG/DOSE)...... 20 PIQRAY (200 MG DAILY DOSE)...... 30 OZURDEX...... 66 PIQRAY (250 MG DAILY DOSE)...... 30 P PIQRAY (300 MG DAILY DOSE)...... 31 PIRMELLA 1/35...... 43 pacerone...... 12 PIRMELLA 7/7/7...... 43 paliperidone er...... 34 piroxicam...... 5 PALYNZIQ...... 53 PLEGRIDY...... 70 PANCREAZE...... 52 PLEGRIDY STARTER PACK...... 70 PANDEL...... 50 PLEXION...... 50 PANRETIN...... 50 pnv prenatal plus multivitamin...... 63 pantoprazole sodium...... 73 pnv tabs 29-1...... 63 paricalcitol...... 53 pnv-dha...... 63 paromomycin sulfate...... 4 pnv-dha+docusate...... 63 paroxetine hcl...... 17 pnv-omega...... 63 paroxetine hcl er...... 17 poly-iron 150 forte...... 56 paroxetine mesylate...... 70 polymyxin b-trimethoprim...... 66 PASER...... 28 polysaccharide iron forte...... 56 PAXIL...... 17 POLY-VI-FLOR...... 63 pb-hyoscy-atropine-scopolamine...... 73 POMALYST...... 31 PEDIAPRED...... 44 PORTIA-28...... 43 peg 3350-kcl-na bicarb-nacl...... 57 posaconazole...... 23 peg-3350/electrolytes...... 57 potassium chloride...... 60 PEGASYS...... 37 potassium chloride crys er...... 60 PEMAZYRE...... 30 potassium chloride er...... 60 penicillamine...... 61 potassium citrate er...... 55 penicillin v potassium...... 68 PRADAXA...... 14 pentamidine isethionate...... 27 PRALUENT...... 24 PENTASA...... 55 pramipexole dihydrochloride...... 33 pentazocine-naloxone hcl...... 9 pramipexole dihydrochloride er...... 33 pentoxifylline er...... 56 PRAMOSONE...... 50 PERFOROMIST...... 14 prasugrel hcl...... 56 perindopril erbumine...... 26 pravastatin sodium...... 24 permethrin...... 50 praziquantel...... 11 perphenazine...... 34 prazosin hcl...... 26 perphenazine-amitriptyline...... 70 PRED MILD...... 66 PERTZYE...... 52 PRED-G...... 66 PEXEVA...... 17 PRED-G S.O.P...... 66 phenazopyridine hcl...... 55 prednicarbate...... 50 phenelzine sulfate...... 17 prednisolone...... 44 phenobarbital...... 57 prednisolone acetate...... 66 phenobarbital-belladonna alk...... 73 prednisolone sodium phosphate...... 44, 66 PHENOHYTRO...... 73 prednisone...... 44 phenoxybenzamine hcl...... 26 PREDNISONE INTENSOL...... 44 phenylephrine hcl...... 66 PREFEST...... 54 phenytoin...... 15, 16 pregabalin...... 16 phenytoin infatabs...... 15 PREMARIN...... 54, 74 phenytoin sodium extended...... 16 PREMPHASE...... 54 PHILITH...... 43 PREMPRO...... 54 PHOSLYRA...... 55 PRENATABS RX...... 63 PHOSPHA 250 NEUTRAL...... 60 prenatal...... 63 PHOSPHOLINE IODIDE...... 66 prenatal 19...... 63 PHOSPHO-TRIN 250 NEUTRAL...... 60 prenatal formula a-free...... 63 PHYSIOLYTE...... 61 prenatal low iron...... 63

Last Updated 12.1.2020 87 I n d e x I n d e x prenatal multi +dha...... 63 QVAR REDIHALER...... 14 prenatal one daily...... 63 R prenatal plus...... 63 prenatal plus iron...... 63 rabeprazole sodium...... 73 prenatal plus/iron...... 63 RAGWITEK...... 4 prenatal vitamins...... 63 raloxifene hcl...... 53 PREPIDIL...... 68 ramelteon...... 57 preplus...... 63 ramipril...... 26 pretomanid...... 28 ranolazine er...... 11 PREVIFEM...... 43 rasagiline mesylate...... 33 PREVYMIS...... 37 RASUVO...... 5 PREZCOBIX...... 37 RAVICTI...... 53 PREZISTA...... 37 RAYALDEE...... 53 PRIFTIN...... 28 RAYOS...... 44 primaquine phosphate...... 27 REBIF...... 71 primidone...... 16 REBIF REBIDOSE...... 70 PRIMSOL...... 27 REBIF REBIDOSE TITRATION PACK...... 71 PROAIR HFA...... 14 REBIF TITRATION PACK...... 71 PROAIR RESPICLICK...... 14 RECLIPSEN...... 43 probenecid...... 56 RECTIV...... 10 prochlorperazine...... 34 REGRANEX...... 50 prochlorperazine maleate...... 34 RELENZA DISKHALER...... 37 PROCYSBI...... 55 RELISTOR...... 55 progesterone...... 69 RENACIDIN...... 55 progesterone micronized...... 69 repaglinide...... 20 PROLENSA...... 66 REPATHA...... 24 PROMACTA...... 56 REPATHA PUSHTRONEX SYSTEM...... 24 promethazine hcl...... 23 REPATHA SURECLICK...... 24 promethazine vc...... 45 RESECTISOL...... 55 promethazine vc/codeine...... 45 RESTASIS...... 66 promethazine-codeine...... 45 RESTASIS MULTIDOSE...... 66 promethazine-dm...... 45 RETACRIT...... 56 promethazine-phenyleph-codeine...... 45 RETEVMO...... 31 promethazine-phenylephrine...... 45 REVLIMID...... 61 propafenone hcl...... 12 REXULTI...... 34 propafenone hcl er...... 12 REYATAZ...... 37 propantheline bromide...... 73 REYVOW...... 59 propranolol hcl...... 37 RHOPRESSA...... 66 propranolol hcl er...... 37 ribavirin...... 37 propranolol-hctz...... 26 RIDAURA...... 5 propylthiouracil...... 72 rifabutin...... 28 PROSTIN E2...... 68 rifampin...... 28 protriptyline hcl...... 18 riluzole...... 64 PULMICORT FLEXHALER...... 14 rimantadine hcl...... 37 PULMOZYME...... 72 ringers irrigation...... 61 PYLERA...... 73 RINVOQ...... 5 pyrazinamide...... 28 RIOMET...... 20 pyridostigmine bromide...... 27 risedronate sodium...... 53 pyridostigmine bromide er...... 27 risperidone...... 34 pyrimethamine...... 27 ritonavir...... 37 rivastigmine...... 71 Q rivastigmine tartrate...... 71 QBREXZA...... 50 rizatriptan benzoate...... 59 QINLOCK...... 31 ROCKLATAN...... 66 QUALAQUIN...... 27 ropinirole hcl...... 33 quazepam...... 57 ropinirole hcl er...... 33 quetiapine fumarate...... 34 ROSADAN...... 50 quetiapine fumarate er...... 34 rosuvastatin calcium...... 24 QUILLICHEW ER...... 3 ROZLYTREK...... 31 QUILLIVANT XR...... 3 RUBRACA...... 31 quinapril hcl...... 26 rufinamide...... 16 quinapril-hydrochlorothiazide...... 26 rukobia...... 37 quinidine gluconate er...... 12 RUZURGI...... 27 quinidine sulfate...... 12 RYBELSUS...... 20 quinine sulfate...... 27 RYDAPT...... 31

Last Updated 12.1.2020 88 I n d e x I n d e x S SPRYCEL...... 31 SRONYX...... 43 SAIZEN...... 53 SSD...... 50 salsalate...... 7 SSKI...... 45 SAMSCA...... 53 stavudine...... 37 SANCUSO...... 22 sterile water for injection...... 68 SANDIMMUNE...... 61 sterile water for irrigation...... 61 SAPHRIS...... 34 STIMATE...... 54 sapropterin dihydrochloride...... 53, 54 STIOLTO RESPIMAT...... 14 SAVELLA...... 71 STIVARGA...... 31 SAVELLA TITRATION PACK...... 71 STRENSIQ...... 54 scopolamine...... 22 STRIBILD...... 37 selegiline hcl...... 33 STRIVERDI RESPIMAT...... 14 selenium sulfide...... 50 SUCRAID...... 52 SELZENTRY...... 37 sucralfate...... 74 se-natal 19...... 63 sulconazole nitrate...... 50 SEREVENT DISKUS...... 14 sulfacetamide sodium...... 50, 66 SEROSTIM...... 54 sulfacetamide sodium (acne)...... 50 sertraline hcl...... 18 sulfacetamide sodium-sulfur...... 50 sevelamer carbonate...... 55 sulfacetamide-prednisolone...... 66 sevelamer hcl...... 55 sulfacetamide-sulfur in urea...... 50 sf...... 62 sulfadiazine...... 72 sf 5000 plus...... 62 sulfamethoxazole-trimethoprim...... 27 SHAROBEL...... 43 SULFAMYLON...... 50 SIGNIFOR...... 54 sulfasalazine...... 55 SIKLOS...... 56 sulindac...... 6 sildenafil citrate...... 39 sumatriptan...... 59 SILIQ...... 50 sumatriptan succinate...... 59 silodosin...... 55 sumatriptan succinate refill...... 59 SILVADENE...... 50 SUMAXIN...... 50 silver sulfadiazine...... 50 SUNOSI...... 3 SIMBRINZA...... 66 SUPRAX...... 39 SIMPONI...... 6 SUPREP BOWEL PREP KIT...... 57 simvastatin...... 24 SUTENT...... 31 sirolimus...... 61 SYEDA...... 43 SIRTURO...... 28 SYMBICORT...... 14 SIVEXTRO...... 27 SYMDEKO...... 72 SKLICE...... 50 SYMJEPI...... 74 SKYRIZI (150 MG DOSE)...... 50 SYMLINPEN 120...... 21 SLYND...... 43 SYMLINPEN 60...... 21 sodium chloride...... 45 SYMTUZA...... 37 sodium fluoride...... 60 SYNALAR...... 50 sodium phenylbutyrate...... 54 SYNALAR (OINTMENT)...... 50 sodium polystyrene sulfonate...... 61 SYNAREL...... 54 sofosbuvir-velpatasvir...... 37 SYNDROS...... 22 SOLIA...... 43 SYNJARDY...... 21 solifenacin succinate...... 74 SYNJARDY XR...... 21 SOLIQUA...... 20 SYNRIBO...... 31 SOLTAMOX...... 31 SYNTHROID...... 72 SOLU-CORTEF...... 44 T SOMAVERT...... 54 SOOLANTRA...... 50 TABLOID...... 31 SORINE...... 37 TABRECTA...... 31 sotalol hcl...... 37 tacrolimus...... 50, 61 sotalol hcl (af)...... 37 tadalafil...... 39 SOTYLIZE...... 37 tadalafil (pah)...... 39 SOVALDI...... 37 TAFINLAR...... 31 spinosad...... 50 TAGRISSO...... 31 SPIRIVA HANDIHALER...... 14 TAKHZYRO...... 56 SPIRIVA RESPIMAT...... 14 TALICIA...... 74 spironolactone...... 52 TALTZ...... 50 spironolactone-hctz...... 52 TALZENNA...... 31 SPRINTEC 28...... 43 tamoxifen citrate...... 31 SPRITAM...... 16 tamsulosin hcl...... 55 SPRIX...... 6 TARGRETIN...... 50

Last Updated 12.1.2020 89 I n d e x I n d e x TARINA FE 1/20...... 43 TRADJENTA...... 21 TASIGNA...... 31 tramadol hcl...... 9 tavaborole...... 50 tramadol hcl er...... 9 TAVALISSE...... 56 tramadol hcl er (biphasic)...... 9 tazarotene...... 50 tramadol-acetaminophen...... 10 TAZORAC...... 50 trandolapril...... 26 TAZTIA XT...... 38 trandolapril-verapamil hcl er...... 26 TAZVERIK...... 31 tranexamic acid...... 56 TEGSEDI...... 71 tranylcypromine sulfate...... 18 TEKTURNA HCT...... 26 travoprost (bak free)...... 66 telmisartan...... 26 trazodone hcl...... 18 telmisartan-amlodipine...... 26 TRECATOR...... 28 telmisartan-hctz...... 26 TREMFYA...... 50 temazepam...... 57 TRESIBA...... 21 temozolomide...... 31 TRESIBA FLEXTOUCH...... 21 tenofovir disoproxil fumarate...... 37 tretinoin...... 31, 50 terazosin hcl...... 26 tretinoin microsphere...... 50 terbinafine hcl...... 23 tretinoin microsphere pump...... 50 terbutaline sulfate...... 14 TREXALL...... 31 terconazole...... 74 triamcinolone acetonide...... 50, 62, 64 teriparatide (recombinant)...... 54 triamterene-hctz...... 52 testosterone...... 10 triazolam...... 57 testosterone cypionate...... 10 trientine hcl...... 62 testosterone enanthate...... 10 TRI-ESTARYLLA...... 43 tetrabenazine...... 71 trifluoperazine hcl...... 35 tetracycline hcl...... 72 trifluridine...... 66 THALOMID...... 62 trihexyphenidyl hcl...... 33 THEO-24...... 14 TRIJARDY XR...... 21 theophylline...... 14 TRIKAFTA...... 72 theophylline er...... 14 TRI-LEGEST FE...... 43 THIOLA...... 55 TRI-LINYAH...... 43 THIOLA EC...... 55 TRI-LO-ESTARYLLA...... 43 thioridazine hcl...... 34 TRI-LO-MARZIA...... 43 thiothixene...... 34 TRI-LO-SPRINTEC...... 43 thrivite 19...... 63 trimethobenzamide hcl...... 22 tiagabine hcl...... 16 trimethoprim...... 27 TIAZAC...... 38 trimipramine maleate...... 18 TIBSOVO...... 31 TRINESSA (28)...... 43 TIGLUTIK...... 64 TRINTELLIX...... 18 TILIA FE...... 43 TRI-PREVIFEM...... 43 timolol maleate...... 37, 66 TRI-SPRINTEC...... 43 TIMOPTIC OCUDOSE...... 66 TRIUMEQ...... 37 tinidazole...... 27 TRIVORA (28)...... 43 TIVICAY...... 37 TROKENDI XR...... 16 TIVICAY PD...... 37 tronvite...... 63 tizanidine hcl...... 64 tropicamide...... 66 TOBI...... 4 trospium chloride...... 74 TOBI PODHALER...... 4 trospium chloride er...... 74 TOBRADEX ST...... 66 TRULICITY...... 21 tobramycin...... 4, 66 TRUVADA...... 37 tobramycin-dexamethasone...... 66 TUKYSA...... 31 TOLAK...... 50 TURALIO...... 31 tolmetin sodium...... 6 TUSSICAPS...... 45 tolterodine tartrate...... 74 TYBOST...... 37 tolterodine tartrate er...... 74 TYDEMY...... 43 tolvaptan...... 54 TYMLOS...... 54 TOPICORT...... 50 U topiramate...... 16 topiramate er...... 16 UBRELVY...... 59 toremifene citrate...... 31 UDAMIN SP...... 63 torsemide...... 52 UDENYCA...... 56 TOUJEO MAX SOLOSTAR...... 21 UNITHROID...... 72 TOUJEO SOLOSTAR...... 21 UPNEEQ...... 66 TOVIAZ...... 74 UPTRAVI...... 39 TRACLEER...... 39 urea...... 50

Last Updated 12.1.2020 90 I n d e x I n d e x urea hydrating...... 50 VYFEMLA...... 43 URIBEL...... 27 VYNDAMAX...... 39 uroav-b...... 27 VYNDAQEL...... 39 uro-mp...... 27 VYVANSE...... 3 ursodiol...... 55 VYZULTA...... 66 V W valacyclovir hcl...... 37 WAKIX...... 3 VALCHLOR...... 50 warfarin sodium...... 14 valganciclovir hcl...... 37 WELCHOL...... 24 VALIUM...... 11 WERA...... 44 valproic acid...... 16 WESTHROID...... 72 valsartan...... 26 WIXELA INHUB...... 14 valsartan-hydrochlorothiazide...... 26 WP THYROID...... 72 VALTOCO 10 MG DOSE...... 16 WYMZYA FE...... 44 VALTOCO 15 MG DOSE...... 16 X VALTOCO 20 MG DOSE...... 16 VALTOCO 5 MG DOSE...... 16 XADAGO...... 33 vancomycin hcl...... 27 XALKORI...... 31 VANOXIDE-HC...... 50 XARELTO...... 14 VARUBI (180 MG DOSE)...... 22 XARELTO STARTER PACK...... 14 VASCEPA...... 24 XATMEP...... 31 VASERETIC...... 26 XCOPRI...... 16 VECAMYL...... 26 XCOPRI (250 MG DAILY DOSE)...... 16 VELIVET...... 43 XCOPRI (350 MG DAILY DOSE)...... 16 VELPHORO...... 55 XELJANZ...... 6 VELTASSA...... 62 XELJANZ XR...... 6 VEMLIDY...... 37 XERAC AC...... 50 VENCLEXTA...... 31 XERMELO...... 55 VENCLEXTA STARTING PACK...... 31 XIFAXAN...... 27 venlafaxine hcl...... 18 XIIDRA...... 66 venlafaxine hcl er...... 18 XOFLUZA (40 MG DOSE)...... 37 VENTAVIS...... 39 XOFLUZA (80 MG DOSE)...... 37 VENTOLIN HFA...... 14 XOLEGEL...... 50 verapamil hcl...... 38 XOSPATA...... 31 verapamil hcl er...... 38 XTAMPZA ER...... 10 VERZENIO...... 31 XTANDI...... 31 V-GO 20...... 58 XULANE...... 44 V-GO 30...... 58 XURIDEN...... 54 V-GO 40...... 58 xvite...... 63 VIBERZI...... 55 XYREM...... 71 VICTOZA...... 21 Y vigabatrin...... 16 YUPELRI...... 14 VIGADRONE...... 16 YUVAFEM...... 74 VIIBRYD...... 18 Z VIMPAT...... 16 viorele...... 43 ZADITOR...... 66 VIRACEPT...... 37 zafirlukast...... 14 VIREAD...... 37 zaleplon...... 57 virt-phos 250 neutral...... 60 ZARAH...... 44 VISTOGARD...... 22 ZARXIO...... 56 VITAFOL-OB+DHA...... 63 ZEBUTAL...... 7 VITAFOL-ONE...... 63 ZEJULA...... 31 vitamin d (ergocalciferol)...... 75 ZELAPAR...... 33 vitasure...... 63 ZELBORAF...... 31 VITRAKVI...... 31 ZENATANE...... 50 VIZIMPRO...... 31 ZENPEP...... 52 vol-plus...... 63 ZEPOSIA...... 71 vol-tab rx...... 63 ZEPOSIA 7-DAY STARTER PACK...... 71 voriconazole...... 23 ZEPOSIA STARTER KIT...... 71 VOSEVI...... 37 zidovudine...... 37 VOTRIENT...... 31 zileuton er...... 14 vp-vite rx...... 63 ZIOPTAN...... 67 VRAYLAR...... 35 ziprasidone hcl...... 35 VUMERITY...... 71 ZIRGAN...... 67

Last Updated 12.1.2020 91 I n d e x

ZITHRANOL...... 51 ZOLINZA...... 31 zolmitriptan...... 59 zolpidem tartrate...... 57 zolpidem tartrate er...... 57 ZOMIG...... 59 ZONEGRAN...... 16 zonisamide...... 16 ZONTIVITY...... 56 ZORBTIVE...... 54 ZORTRESS...... 62 ZOVIA 1/35E (28)...... 44 ZUBSOLV...... 10 ZUPLENZ...... 22 ZYDELIG...... 31 ZYFLO...... 14 ZYKADIA...... 32

Last Updated 12.1.2020 92 Language Assistance Services

English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-878-9172 (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-878-9172 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-878-9172（TTY：711）。 Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-878-9172 (телетайп: 711). French ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Creole Rele 1-888-878-9172 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-878-9172 (TTY: 711) 번으로 전화해 주십시오. Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-878-9172 (TTY: 711). ﺗوﺟﮫ: اﮔر ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺗﮕو ﻣﯽ ﮐﻧﯾد، ﺗﺳﮭﯾﻼت زﺑﺎﻧﯽ ﺑﺻورت راﯾﮕﺎن ﺑرای ﺷﻣﺎ ﻓراھم ﻣﯽ ﺑﺎﺷد. ﺑﺎ Farsi (TTY: 711) 9172-878-888-1 ﺗﻣﺎس ﺑﮕﯾرﯾد. Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-878-9172 (TTY: 711). Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-888-878-9172 (TTY: 711). . ب ال مجا ن ل ك ت توا ف ر ا ل ل غو ي ة ال م سا عدة خد ما ت ف إن ال ل غة ، اذ ك ر ت تحدث ك نت إذا : م لحوظة Arabic .(711 :و ال ب كم ال صم ها ت ف ر ق م) 9172-878-888-1 ب ر ا ت ص ل French ATTENTION : Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-888-878-9172 (TTY : 711). Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-878-9172 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-878-9172 (TTY: 711). Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-888-878-9172（TTY: 711）まで、お電話にてご連絡ください。 German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-878-9172 (TTY: 711).

Discrimination is Against the Law

Pharmacy Benefit Dimensions is a subsidiary of Independent Health and complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Pharmacy Benefit Dimensions does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Pharmacy Benefit Dimensions: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, contact Pharmacy Benefit Dimensions’ Member Services Department.

If you believe that Pharmacy Benefit Dimensions has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Pharmacy Benefit Dimensions’ Member Services Department, P.O. Box 1642, Buffalo, NY 14231, (888)-878-9172, TTY users call 711, fax (716) 250-7163 , [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Pharmacy Benefit Dimensions’ Member Services Department is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

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