Your Pharmacy Benefits Retail Pharmacies and Retail 90 Rx

Your Pharmacy Benefits Retail pharmacies and Retail 90 Rx

A well-balanced pharmacy network offers you convenient access and competitive discounts for brand and generic medications. Our national retail pharmacy network includes more than 67,000 chain and independent retail pharmacies, so you’re sure to find one close to home or work.

Using your ID card When you fill a prescription through a participating pharmacy, show the pharmacy your ID card so they can submit a claim for coverage by your pharmacy benefit plan. When you pick up your prescription, the pharmacy then collects your applicable member contribution as defined by your plan. If you do not present your ID card or you fill a prescription at a non-participating pharmacy, you pay the full retail price for your medication. If the prescription is eligible for coverage under your pharmacy benefit plan, you may submit a claim to request reimbursement (forms are available at optumrx or by calling customer service). When you submit a claim using the reimbursement form, OptumRx first determines if your plan covers the medication. If it is covered, the amount you receive is based on contracted pharmacy rates less your plan’s out-of-pocket member contribution. All prescription claims are subject to your pharmacy benefit plan’s rules and restrictions. Retail pharmacies and Retail 90 Rx

Retail 90 Rx program The Retail 90 Rx Program allows you to receive up to a three-month supply of your medication from more than 57,000 participating retail pharmacies. Like a traditional mail service pharmacy, you can avoid refilling a prescription every month while still getting personalized counsel from a local pharmacy professional. See your benefit plan documents for Retail 90 Rx copayment information. To use Retail 90 Rx, talk with your doctor to see if the program is right for you. If it is, get a prescription written for up to a 90-day supply and take it to a participating Retail 90 Rx pharmacy. Please note, some medications are limited by law and cannot be dispensed as a three-month supply. Not all medications are eligible for this program.

Finding a network pharmacy You can choose from three easy ways to find participating pharmacies near you: 1. Review the partial list included on the following pages. 2. Go to our website and use the LOCATE A PHARMACY tool. 3. Contact customer service using the number on the back of your benefit plan member ID card.

A 90 Bi-Mart 90 Dillon - Kroger

90 AADP 90 BioRx 90 Discount Drug Mart 90 Aberdeen Area IHS 90 Brookshire DMVA Pharmacies 90 Access Health 90 Brookshire Brothers E Accredo Health – Olsten Health C Elevate Provider 90 AHS St. John Pharmacy 90 Cardinal Health 90 E-MedRx Solutions 90 Albertsons Caremark – CVS Pharmacy 90 Epic Pharmacy 90 Albuquerque Area IHS 90 Carrs - Albertsons F 90 American Drug - Albertsons Central Dakota Pharmacies Fairview Pharmacy 90 American Pharmacy Choctow Nation Health Care Center Family Pharmacy Amerita Cigna Medical Group Fitzgerald’s 90 Arete 90 City Market - Kroger 90 Food City 90 A-S Medication Solutions 90 Clinic Pharmacies Kelsey Seybo 90 Food Lion - Hannaford 90 Aurora Pharmacy 90 Community Health Centers *Complete 90 Fred Meyer - Kroger Claims Processing B 90 Fred’s 90 Cook County 90 Balls Four B 90 Fruth 90 Costco 90 Bartell Drugs 90 Fry’s Food and Drug - Kroger 90 CVS Pharmacy 90 Bashas G 90 Bemidji Area IHS D 90 GeriMed LTC 90 Bi Lo - Winn Dixie 90 Dallas Metrocare Services 90 Giant Eagle 90 Billins Area IHS 90 Denver Health Global Pharmacy

OptumRx | optumrx.com H M Procare – CVS Pharmacy 90 90 H.E.B. Pharmacy 90 M K Stores Progressive – Sav-Mor 90 Hannaford 90 Manatee County Rural Health Provider Services of America 90 90 Harris County Hospital District 90 Mariano’s – Kroger Publix Super Markets 90 Harris Teeter - Kroger 90 Maricopa IHS Q 90 Harvard Community Health Plan Marshfield Clinic 90 Quality Care Pharmacy NetwoRx 90 Health Partners – Access Health/ 90 MAXORXPRESS 90 Quality Food - Kroger McKesson 90 Mayo Clinic 90 Quick Chek 90 Henry Ford Health System 90 MDS Rx R 90 HIP Pharmacy Services 90 Med College VA 90 Raley’s 90 Homechoice Partners 90 Medicap – Cardinal Health 90 Ralph’s - Kroger 90 Horton & Converse 90 Medicine Shoppe – Cardinal Health 90 Randalls - Albertsons 90 Hy-Vee 90 Meijer Recept Pharmacy I 90 MHA Long Term Care 90 Red Cross Pharmacy 90 90 Ihc Pharmacy Services Muscogee Creek Nation 90 Redners Markets IHS Acquisition XXX MyRx RightSource – Humana Pharmacy 90 Ingles N 90 Rite Aid 90 Innovatix Network 90 NAI Saturn Eastern – Albertsons 90 Ronetco - Shoprite Supermarkets 90 Inserra - Shoprite Supermarkets 90 Navajo Area IHS 90 Roundy’s – Kroger 90 INSTYMEDS 90 Navarro Discount - CVS Pharmacy 90 Rural Health Care J 90 NCPRx S 90 JPS Health Network Neighborcare – CVS/Omnicare 90 Safeway - Albertsons 90 K New England Home Therapies 90 Saker - Shoprite Supermarkets 90 Northeast Service Pharmacy 90 KC Medical Management 90 Sam’s Club 90 King Soopers - Kroger O 90 Santa Clara Valley Health 90 Kinney Drugs 90 OK Area IHS 90 Save Mart 90 Klein’s Family - Shoprite Supermarkets Omnicare – CVS/Omnicare 90 Sav-Mor 90 Klingensmiths Oncology Pharmacy Services 90 Schnuck Markets 90 K-Mart 90 OPUS-ISM 90 Seip Drug 90 Kohll’s P 90 Shaw’s - Albertsons 90 Kroger Pacific Medical Clinics 90 Shopko 90 L 90 Patient First Shoprite Supermarkets 90 Smith’s Food & Drug - Kroger 90 Leader - Cardinal Health 90 Pharmacy Providers Of Oklahoma Leader Drug Stores – Cardinal Health Pharmerica 90 SRS - Shoprite Supermarkets 90 Stop & Shop 90 LML - Shoprite Supermarkets 90 Phoenix Area IHS 90 Long’s – CVS Pharmacy 90 Physicians’ Pharmaceutical SuperValu 90 90 Planned Parenthood Swift Rx 90 POC Network Technologies Portland Area IHS Presbyterian Medical Services 90 Price Chopper House T V

90 Tampa Family Health Centers 90 Valley Wholesale Drug 90 Target - CVS Pharmacy 90 Vantage Rx Dispensing Services 90 Tempest Med 90 Village - Shoprite Supermarkets 90 Third Party 90 Von’s - Albertsons 90 Third Party Station W 90 Thrifty White Drug 90 Walgreens 90 Tom Thumb - Albertsons 90 Walmart Tops Markets 90 Wegman’s 90 Tucson Area IHS 90 Weis U 90 Welgo 90 UCSD Medical Center Pharmacies 90 Winn Dixie 90 United Pharmacy - Albertsons 90 Wishard Health Services 90 University of Kansas Hospital Y 90 University of Utah 90 Yakima Valley Farm Workers Clinic University of Virginia Health System Z

90 Zallie - Shoprite Supermarkets

90 All Pharmacy locations may not dispense 90 day supplies. Many independent pharmacies also participate in Retail 90 Rx, and additional chains join monthly. To determine if your pharmacy participates, please go to optumrx.com, locate a pharmacy tool.

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Effective January 1, 2019

For the most current list of covered medications or if you have questions:

Call the member phone number on your ID card.

Visit your plan’s member website listed on your ID card to: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

Innoviant Premium Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and are this formulary and your benefit placed into cost levels known as tiers. It includes both brand plan documents, the benefit plan and generic prescription medications approved by the documents rule. This may not be U.S. Food and Drug Administration (FDA). a complete list of medications, and not all medications listed How do I use my formulary? may be covered by your plan. You and your doctor can consult the formulary to help you Please look at the benefit plan select the most cost-effective prescription medications. documents provided by your This guide tells you if a medication is generic or brand, and employer or plan sponsor for if special rules apply. Bring this list with you when you see full details. your doctor. If your medication is not listed here, please visit your plan’s member website or call the member phone number on your ID card.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equivalent becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the member phone number on your ID card.

2 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter medications Generic medications contain the same active ingredients An OTC medication may be (what makes the medication work) as brand-name the right treatment option for medications, but they often cost less. Once the patent for some conditions. Talk to your a brand-name medication ends, the FDA can approve a doctor about available OTC generic version with the same active ingredients. options. Even though these medications may not be What if my doctor writes a brand-name prescription? covered by your pharmacy If your doctor gives you a prescription for a brand-name benefit, they may cost less medication, ask if a generic equivalent or lower-cost option than a prescription medication. is available and could be right for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx® specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered right to your home or doctor’s office.

3 Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips Tier 1 $ Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs. and some brand-name Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of Tier 3, to help reduce your preferred brand-name out-of-pocket costs. Tier 3 $$$ Highest-cost Many Tier 3 drugs have lower-cost options in Tier 1 or 2. non-preferred Ask your doctor if they could work for you. Tier i-G Generic Check your benefit plan documents to find out your specialty injectables specific pharmacy plan costs. Tier i-P Preferred Check your benefit plan documents to find out your specialty injectables specific pharmacy plan costs. Tier i-NP Non-preferred Check your benefit plan documents to find out your specialty injectables specific pharmacy plan costs. Tier E Excluded May be excluded from coverage or subject to prior authorization. Lower-cost options are available and covered.

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

M Authorized generic or co-branded product PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity. SP Specialty Medication – Medication is designated as specialty. ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

3P Tier 3 preferred ++ Benefit Design Options – Coverage is determined by consumer’s prescription medication benefit plan.

4 Table of Contents Analgesics - Drugs for Pain...... 6 Genitourinary Agents - Drugs for Prostate Analgesics - Drugs for Pain and Inflammation. 6 Conditions...... 20 Anesthetics...... 7 Hormonal Agents - Adrenal...... 20 Anti-Addiction / Substance Abuse Treatment Hormonal Agents - Men's Health...... 21 Agents...... 7 Hormonal Agents - Osteoporosis...... 21 Antibacterials...... 7 Hormonal Agents - Pituitary...... 21 Anticoagulants...... 8 Hormonal Agents - Sex Hormones and Birth Anticonvulsants - Drugs for Seizures...... 8 Control...... 22 Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Thyroid...... 23 Disease and Dementia...... 9 Immunological Agents - Drugs for Immune Antidepressants...... 9 System Stimulation or Suppression...... 24 Antiemetics - Drugs for Nausea and Vomiting..9 Immunological Agents - Drugs for Antifungals...... 9 Vaccination...... 25 Antigout Agents...... 10 Inflammatory Bowel Disease Agents...... 25 Antimigraine Agents...... 10 Metabolic Bone Disease Agents - Drugs for Antineoplastics - Drugs for Cancer...... 10 Osteoporosis...... 25 Antiparasitics...... 10 Miscellaneous Therapeutic Agents...... 25 Antiparkinson Agents...... 10 Ophthalmic Agents - Drugs for Eye Allergy, Antiplatelets...... 10 Infection and Inflammation...... 25 Antipsychotics - Drugs for Mood Disorders.... 10 Ophthalmic Agents - Drugs for Glaucoma...... 26 Antivirals...... 11 Ophthalmic Agents - Drugs for Miscellaneous Anxiolytics - Drugs for Anxiety...... 11 Eye Conditions...... 26 Bipolar Agents - Drugs for Mood Disorders....11 Otic Agents - Drugs for Ear Conditions...... 26 Blood Products / Modifiers / Volume Respiratory Tract / Pulmonary Agents - Expanders - Drugs for Bleeding Disorders...12 Drugs for Allergies, Cough, Cold...... 26 Cardiovascular Agents - Drugs for Heart and Respiratory Tract / Pulmonary Agents - Circulation Conditions...... 12 Drugs for Asthma and Other Lung Central Nervous System Agents - Drugs for Conditions 27 Attention Deficit Disorder...... 14 Respiratory Tract / Pulmonary Agents - Central Nervous System Agents - Drugs for Drugs for Cystic Fibrosis...... 28 Multiple Sclerosis...... 14 Respiratory Tract / Pulmonary Agents - Central Nervous System Agents - Drugs for Pulmonary Hypertension...... 28 Miscellaneous...... 15 Skeletal Muscle Relaxants - Drugs for Dental and Oral Agents - Drugs for Mouth Muscle Pain and Spasm...... 29 and Throat Conditions...... 15 Sleep Disorder Agents...... 29 Dermatological Agents - Drugs for Skin Index of Drugs...... 30 Conditions...... 15 Diabetes - Antidiabetic Agents...... 16 Diabetes - Glucose Monitoring...... 17 Diabetes - Glycemic Agents...... 18 Diabetes - Insulins...... 18 Electrolytes / Minerals / Metals / Vitamins...... 19 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...... 19 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...... 19 Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment...... 20 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions...... 20

5 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for Pain KADIAN ORAL ABSTRAL E CAPSULE EXTENDED RELEASE 24 HOUR 10 E acetaminophen-codeine 1 QL MG, 100 MG, 20 MG, #2 200 MG, 30 MG, 40 MG, acetaminophen-codeine 1 QL 50 MG, 60 MG, 80 MG #3 LAZANDA E acetaminophen-codeine morphine sulfate er oral 1 QL 1 PA; QL #4 tablet extended release acetaminophen-codeine 1 QL NORCO E oral tablet NUCYNTA E ARYMO ER E NUCYNTA ER E BELBUCA 3 PA; QL OPANA ER ORAL butalbital-apap-caffeine 1 TABLET ER 12 HOUR E oral capsule ABUSE-DETERRENT butalbital-apap-caffeine 1 oxycodone hcl oral tablet 1 QL oral tablet 50-325-40 mg oxycodone- E DURAGESIC-100 acetaminophen oral DURAGESIC-12 E tablet 10-325 mg, 2.5- 1 QL DURAGESIC-25 E 325 mg, 5-325 mg, 7.5- 325 mg DURAGESIC-50 E OXYCONTIN ORAL E DURAGESIC-75 TABLET ER 12 HOUR 2 PA; QL EMBEDA 2 PA; QL ABUSE-DETERRENT fentanyl 1 PA; QL PERCOCET ORAL FENTORA BUCCAL TABLET 10-325 MG, 2.5- E 325 MG, 5-325 MG, 7.5- TABLET 100 MCG, 200 E MCG, 400 MCG, 600 325 MG MCG, 800 MCG SUBSYS E hydrocodone- tramadol hcl ir 1 QL acetaminophen oral tramadol-acetaminophen 1 QL tablet 10-300 mg, 10-325 1 QL mg, 2.5-325 mg, 5-300 XTAMPZA ER E mg, 5-325 mg, 7.5-300 ZOHYDRO ER ORAL mg, 7.5-325 mg CAPSULE ER 12 HOUR E ABUSE-DETERRENT hydromorphone hcl oral 1 QL tablet Analgesics - Drugs for Pain and HYSINGLA ER 2 PA; QL Inflammation CAMBIA E CELEBREX E celecoxib oral 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

6 Drug Drug Drug Name Notes Drug Name Notes Tier Tier diclofenac potassium 1 buprenorphine hcl 1 QL diclofenac sodium oral 1 sublingual buprenorphine hcl- diclofenac sodium 1 QL transdermal gel 1 % naloxone hcl sublingual 1 QL tablet sublingual DUEXIS E CHANTIX STARTING 3 ++; QL etodolac oral tablet 1 MONTH PAK FLECTOR 3 QL naltrexone hcl oral 1 ibuprofen oral tablet 400 1 NARCAN 2 mg, 600 mg, 800 mg SUBOXONE 2 QL indomethacin oral 1 SUBLINGUAL FILM ketorolac tromethamine 1 QL ZUBSOLV 2 QL oral Antibacterials meloxicam oral tablet 1 ACTICLATE E nabumetone oral 1 amoxicillin oral capsule 1 naproxen oral tablet 1 amoxicillin oral naproxen sodium oral 1 1 suspension reconstituted tablet 275 mg, 550 mg amoxicillin oral tablet 1 PENNSAID TRANSDERMAL E amoxicillin-potassium SOLUTION 2 % clavulanate oral suspension reconstituted 1 SPRIX E 200-28.5 mg/5ml, 250- sulindac oral 1 62.5 mg/5ml, 400-57 VIMOVO E mg/5ml, 600-42.9 mg/5ml VOLTAREN GEL 1% E amoxicillin-potassium clavulanate oral tablet 1 ZORVOLEX E 250-125 mg, 500-125 Anesthetics mg, 875-125 mg azithromycin oral lidocaine external 1 1 ointment suspension reconstituted azithromycin oral tablet lidocaine external patch 5 1 1 % 250 mg, 500 mg, 600 mg lidocaine-prilocaine cefdinir 1 1 external cream cefuroxime axetil oral 1 LIDODERM E tablet Anti-Addiction / Substance Abuse cephalexin oral capsule 1 Treatment Agents cephalexin oral 1 BUNAVAIL 3 QL suspension reconstituted ciprofloxacin hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

7 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clarithromycin oral tablet 1 Anticoagulants clindamycin hcl oral 1 ELIQUIS 2 QL CLINDESSE 3 enoxaparin sodium i-G SP; QL DORYX MPC E PRADAXA 2 QL SAVAYSA 3 QL doxycycline hyclate oral 1 capsule warfarin sodium oral 1 doxycycline hyclate oral XARELTO 2 QL tablet 100 mg, 150 mg, 1 20 mg, 50 mg, 75 mg XARELTO STARTER 2 QL PACK doxycycline monohydrate 1 Anticonvulsants - Drugs for Seizures oral capsule doxycycline monohydrate carbamazepine oral 1 1 oral tablet tablet E levofloxacin oral tablet 1 DILANTIN INFATABS metronidazole oral tablet 1 DILANTIN ORAL E CAPSULE 100 MG metronidazole vaginal 1 DILANTIN ORAL minocycline hcl oral E 1 SUSPENSION capsule divalproex sodium er oral mupirocin external 1 tablet extended release 1 24 hour nitrofurantoin 1 macrocrystal oral divalproex sodium oral 1 nitrofurantoin tablet delayed release monohydrate 1 gabapentin oral capsule 1 macrocrystals gabapentin oral tablet 1 penicillin v potassium 1 1 oral tablet lamotrigine oral tablet 1 SOLODYN ORAL levetiracetam oral tablet TABLET EXTENDED oxcarbazepine oral tablet 1 RELEASE 24 HOUR 105 3 OXTELLAR XR E MG, 115 MG, 55 MG, 65 MG, 80 MG phenytoin sodium 1 extended sulfamethoxazole- SABRIL ORAL PACKET E SP trimethoprim oral 1 suspension 200-40 topiramate er 1 ST mg/5ml topiramate oral tablet 1 sulfamethoxazole- 1 TROKENDI XR E trimethoprim oral tablet VIMPAT INTRAVENOUS E XIFAXAN 3 PA VIMPAT ORAL 3 zonisamide oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

8 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Antidementia Agents - Drugs for PROZAC ORAL E Alzheimer's Disease and Dementia CAPSULE donepezil hcl oral tablet 1 sertraline hcl oral tablet 1 1 memantine hcl oral tablet 1 trazodone hcl oral 10 mg, 5 mg TRINTELLIX 3 ST; QL NAMZARIC ORAL venlafaxine hcl 1 CAPSULE EXTENDED 2 QL RELEASE 24 HOUR 14- venlafaxine hcl er 1 10 MG, 28-10 MG VIIBRYD ORAL TABLET 3 QL Antidepressants VIIBRYD STARTER 3 QL amitriptyline hcl oral 1 PACK bupropion hcl er (sr) 1 QL WELLBUTRIN SR E bupropion hcl er (xl) 1 QL WELLBUTRIN XL E bupropion hcl oral 1 ZOLOFT E citalopram hydrobromide Antiemetics - Drugs for Nausea and 1 oral tablet Vomiting CYMBALTA E meclizine hcl oral tablet E ++ metoclopramide hcl oral desvenlafaxine succinate 1 QL 1 er tablet ondansetron hcl oral doxepin hcl oral capsule 1 1 QL tablet 24 mg duloxetine hcl oral 1 QL ondansetron hcl oral E 1 EFFEXOR XR tablet 4 mg, 8 mg escitalopram oxalate oral 1 ondansetron odt 1 tablet prochlorperazine maleate 1 fluoxetine hcl oral 1 oral capsule SANCUSO E fluoxetine hcl oral tablet 1 scopolamine 1 fluvoxamine maleate 1 VARUBI ORAL 3 QL FORFIVO XL 2 QL Antifungals LEXAPRO ORAL E TABLET fluconazole oral tablet 1 mirtazapine oral tablet 1 GYNAZOLE-1 3 nortriptyline hcl oral JUBLIA E ++ 1 capsule KERYDIN E ++ paroxetine hcl er 1 ketoconazole external 1 paroxetine hcl oral tablet 1 cream ketoconazole external PRISTIQ E 1 shampoo

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

9 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nystatin external cream 1 Antiparasitics nystatin mouth/throat 1 EMVERM 2 1 QL terbinafine hcl oral hydroxychloroquine 1 sulfate oral terconazole vaginal 1 cream permethrin external 1 Antigout Agents cream Antiparkinson Agents allopurinol oral 1 benztropine mesylate COLCHICINE ORAL 3 ST 1 TABLET oral COLCRYS 2 carbidopa-levodopa oral 1 tablet DUZALLO 3 ST pramipexole 1 ULORIC 2 ST dihydrochloride ZURAMPIC 3 ST ropinirole hcl 1 Antimigraine Agents ZELAPAR 3 eletriptan hydrobromide 1 QL Antiplatelets MIGRANAL 3 QL BRILINTA 2 ONZETRA XSAIL E cilostazol 1 rizatriptan benzoate 1 QL clopidogrel bisulfate oral 1 sumatriptan succinate 1 QL Antipsychotics - Drugs for Mood Disorders oral ABILIFY MAINTENA ZEMBRACE E INTRAMUSCULAR E SYMTOUCH PREFILLED SYRINGE ZOMIG ORAL E ABILIFY MAINTENA E ZOMIG ZMT INTRAMUSCULAR E Antineoplastics - Drugs for Cancer SUSPENSION RECONSTITUTED ER anastrozole oral 1 aripiprazole oral tablet 1 QL CABOMETYX 2 PA; SP; QL ARISTADA capecitabine 1 PA; SP INTRAMUSCULAR 3 PA; SP; QL PREFILLED SYRINGE IBRANCE E letrozole oral 1 441 MG/1.6ML, 662 MG/2.4ML, 882 mercaptopurine oral 1 SP MG/3.2ML REVLIMID 2 PA; SP haloperidol oral 1 SPRYCEL 2 PA; SP; QL INVEGA SUSTENNA E tamoxifen citrate oral 1 INVEGA TRINZA E XTANDI 3 PA; SP LATUDA 3 QL ZYTIGA 3 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier olanzapine oral tablet 1 QL SYMFI 2 SP quetiapine fumarate 1 QL SYMFI LO 2 SP 3 QL REXULTI TAMIFLU ORAL E risperidone oral tablet 1 QL CAPSULE SAPHRIS 2 QL TAMIFLU ORAL SUSPENSION 3 QL VRAYLAR 3 ST; QL RECONSTITUTED 6 ziprasidone hcl 1 QL MG/ML Antivirals tenofovir disoproxil 1 SP fumarate abacavir sulfate- 1 SP lamivudine TIVICAY 2 SP acyclovir oral tablet 1 TRIUMEQ 2 SP ATRIPLA E SP TRUVADA 2 SP CIMDUO 2 SP valacyclovir hcl oral 1 QL COMPLERA 2 SP VOSEVI 2 PA; SP; QL DESCOVY 3 SP ZOVIRAX EXTERNAL 2 entecavir 1 SP; QL CREAM EPCLUSA 2 PA; SP; QL ZOVIRAX EXTERNAL E OINTMENT GENVOYA 3 SP ZOVIRAX ORAL E HARVONI 2 PA; SP; QL Anxiolytics - Drugs for Anxiety INTELENCE 2 SP alprazolam oral tablet 1 QL ISENTRESS 2 SP ATIVAN ORAL E ISENTRESS HD 2 SP buspirone hcl oral 1 JULUCA 2 SP clonazepam oral tablet 1 QL MAVYRET 2 PA; SP; QL diazepam oral tablet 1 NORVIR ORAL TABLET 3 SP hydroxyzine hcl oral 1 ODEFSEY 3 SP tablet oseltamivir phosphate hydroxyzine pamoate 1 QL 1 oral oral PREZCOBIX 2 SP lorazepam oral tablet 1 QL PREZISTA ORAL triazolam 1 QL TABLET 150 MG, 600 2 SP E MG, 75 MG, 800 MG VALIUM E REYATAZ ORAL XANAX CAPSULE 150 MG, 200 3 SP XANAX XR E MG, 300 MG Bipolar Agents - Drugs for Mood Disorders STRIBILD 3 SP lithium carbonate er 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lithium carbonate oral amlodipine-olmesartan 1 1 capsule atenolol oral 1 Blood Products / Modifiers / Volume atenolol-chlorthalidone 1 Expanders - Drugs for Bleeding Disorders atorvastatin calcium oral 1 AFSTYLA i-P SP AZOR E ARANESP (ALBUMIN FREE) INJECTION benazepril hcl oral 1 SOLUTION 100 benazepril- 1 MCG/ML, 200 MCG/ML, E SP hydrochlorothiazide 25 MCG/ML, 300 BENICAR E MCG/ML, 40 MCG/ML, 60 MCG/ML BENICAR HCT E ARANESP (ALBUMIN bisoprolol fumarate 1 FREE) INJECTION E SP bisoprolol- 1 SOLUTION PREFILLED hydrochlorothiazide SYRINGE bumetanide oral 1 EPOGEN INJECTION BYSTOLIC 2 SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, E SP BYVALSON 2 20000 UNIT/ML, 3000 cartia xt 1 UNIT/ML, 4000 UNIT/ML carvedilol 1 i-P PA; SP; QL GRANIX chlorthalidone oral tablet 1 NEUPOGEN INJECTION 25 mg, 50 mg SOLUTION 300 i-P PA; SP; QL choline fenofibrate 1 MCG/ML, 480 MCG/1.6ML clonidine hcl oral 1 NEUPOGEN INJECTION CORLANOR 3 PA; QL SOLUTION PREFILLED i-P PA; SP; QL CRESTOR E SYRINGE digoxin oral tablet 1 i-P SP NUWIQ diltiazem hcl er beads 1 i-P PA; SP; QL PROCRIT diltiazem hcl er coated ZARXIO i-P PA; SP; QL beads oral capsule 1 Cardiovascular Agents - Drugs for Heart extended release 24 hour and Circulation Conditions diltiazem hcl oral 1 amiodarone hcl oral 1 DIOVAN E amlodipine besylate oral 1 DIOVAN HCT E 1 amlodipine besylate- 1 doxazosin mesylate oral benazepril hcl EDARBI 3 ST amlodipine besylate- 1 EDARBYCLOR 3 ST valsartan enalapril maleate oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ENTRESTO 2 QL nadolol oral tablet 20 mg, 1 ezetimibe 1 40 mg, 80 mg ezetimibe-simvastatin niacin er 1 oral tablet 10-10 mg, 10- 1 (antihyperlipidemic) 20 mg, 10-40 mg nifedipine er 1 ezetimibe-simvastatin 1 PA nifedipine er osmotic 1 oral tablet 10-80 mg release fenofibrate micronized nitroglycerin sublingual 1 1 oral capsule 134 mg, 200 NITROSTAT E mg, 67 mg NORVASC E fenofibrate oral tablet 1 olmesartan medoxomil fenofibric acid oral 1 1 oral capsule delayed release olmesartan medoxomil- 1 flecainide acetate 1 hctz furosemide oral tablet 1 omega-3-acid ethyl 1 gemfibrozil oral 1 esters guanfacine hcl oral 1 pentoxifylline er 1 hydralazine hcl oral 1 PRALUENT hydrochlorothiazide oral 1 SUBCUTANEOUS i-P PA; SP; QL SOLUTION PEN- irbesartan 1 INJECTOR irbesartan- 1 pravastatin sodium 1 hydrochlorothiazide prazosin hcl oral 1 isosorbide mononitrate er 1 propranolol hcl er 1 labetalol hcl oral 1 propranolol hcl oral tablet 1 LIPITOR E quinapril hcl 1 LIPOFEN 2 ramipril 1 lisinopril oral 1 RANEXA 2 ST lisinopril- 1 hydrochlorothiazide REPATHA i-P PA; SP; QL REPATHA LIVALO 3 ST i-P PA; SP; QL PUSHTRONEX SYSTEM losartan potassium 1 REPATHA SURECLICK i-P PA; SP; QL losartan potassium-hctz 1 rosuvastatin calcium 1 lovastatin 1 simvastatin oral tablet 10 1 LOVAZA E mg, 20 mg, 40 mg, 5 mg metoprolol succinate er 1 simvastatin oral tablet 80 1 PA metoprolol tartrate oral 1 mg MULTAQ 3 sotalol hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier spironolactone oral 1 guanfacine hcl er 1 TEKTURNA 2 ST methylphenidate hcl er TEKTURNA HCT 2 ST oral tablet extended release 10 mg, 18 mg, 20 1 QL telmisartan 1 mg, 27 mg, 36 mg, 54 TOPROL XL E mg torsemide oral 1 methylphenidate hcl er oral tablet extended 1 QL triamterene-hctz oral 1 capsule 37.5-25 mg release 24 hour methylphenidate hcl oral triamterene-hctz oral 1 1 QL tablet tablet 2 QL TRIBENZOR E VYVANSE Central Nervous System Agents - Drugs for valsartan 1 Multiple Sclerosis valsartan- 1 2 PA; SP; QL hydrochlorothiazide AMPYRA 3 PA; SP; QL VASCEPA 2 AUBAGIO verapamil hcl er oral AVONEX PEN i-P PA; SP; QL tablet extended release 1 INTRAMUSCULAR 120 mg, 180 mg, 240 mg AUTO-INJECTOR KIT verapamil hcl oral 1 AVONEX PREFILLED INTRAMUSCULAR i-P PA; SP; QL VYTORIN E PREFILLED SYRINGE ZETIA E KIT E AVONEX VIAL ZYPITAMAG i-P PA; SP; QL Central Nervous System Agents - Drugs for INTRAMUSCULAR KIT Attention Deficit Disorder BETASERON i-P PA; SP; QL ADDERALL XR E SUBCUTANEOUS KIT ADZENYS ER 3 ST; QL COPAXONE SUBCUTANEOUS i-P PA; SP; QL ADZENYS XR-ODT 3 ST; QL SOLUTION PREFILLED SYRINGE amphetamine- 1 QL dextroamphetamine EXTAVIA E SP SUBCUTANEOUS KIT amphetamine- 1 QL dextroamphetamine er PA; 3P; 3 atomoxetine hcl 1 QL GILENYA SP; QL CONCERTA E PLEGRIDY E SP 3 ST; QL PLEGRIDY STARTER COTEMPLA XR-ODT E SP dexmethylphenidate hcl 1 QL PACK dexmethylphenidate hcl 1 QL er

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier REBIF REBIDOSE ACZONE EXTERNAL 2 SUBCUTANEOUS i-NP PA; SP; QL GEL 7.5 % SOLUTION AUTO- adapalene external gel E ++ INJECTOR 0.1 % REBIF REBIDOSE adapalene external gel 1 ++ TITRATION PACK 0.3 % SUBCUTANEOUS i-NP PA; SP; QL SOLUTION AUTO- AKTIPAK E INJECTOR ATRALIN 3 ++ REBIF BENZACLIN E SUBCUTANEOUS i-NP PA; SP; QL BENZACLIN WITH E SOLUTION PREFILLED PUMP SYRINGE BENZAMYCIN E REBIF TITRATION claravis 1 PA PACK SUBCUTANEOUS i-NP PA; SP; QL SOLUTION PREFILLED CLINDAGEL E SYRINGE CLINDAMYCIN PHOS- TECFIDERA 2 PA; SP; QL BENZOYL PEROX E M Central Nervous System Agents - EXTERNAL GEL 1.2-2.5 Miscellaneous % ADDYI 3 ++; QL clindamycin phosphate- benzoyl peroxide 1 2 ++ CONTRAVE external gel 1-5 % GRALISE 3 ST; QL clindamycin phosphate 1 GRALISE STARTER 3 ST; QL external lotion LYRICA ORAL clindamycin phosphate 2 QL 1 CAPSULE external solution phentermine hcl oral 1 ++ CLINDAMYCIN tablet PHOSPHATE GEL 1 % E M Dental and Oral Agents - Drugs for Mouth EXTERNAL and Throat Conditions clindamycin phosphate 1 gel 1 % external chlorhexidine gluconate 1 mouth/throat clotrimazole- lidocaine viscous 1 betamethasone external 1 cream Dermatological Agents - Drugs for Skin Conditions DIFFERIN EXTERNAL 3 ++ GEL 0.3 % ABSORICA 3 PA DIFFERIN EXTERNAL E 3 ++ ACANYA LOTION ACZONE EXTERNAL E DUAC E GEL 5 % DUPIXENT i-P PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELIDEL 2 ST Diabetes - Antidiabetic Agents ENSTILAR 3 PA; QL ADLYXIN E 3 EPIDUO ADLYXIN STARTER E EPIDUO FORTE 3 PACK EUCRISA 2 ST ALOGLIPTIN E M BENZOATE FLUOROPLEX 3 ALOGLIPTIN- E M METROGEL EXTERNAL 3 METFORMIN HCL GEL ALOGLIPTIN- E M metronidazole external 1 PIOGLITAZONE gel BYDUREON BCISE 2 ST; QL MIRVASO 2 AUTOINJECTOR myorisan 1 PA BYDUREON PEN 2 ST; QL NORITATE E BYDUREON VIAL 2 ST; QL ONEXTON 3 BYETTA 10 MCG PEN 2 ST; QL ORACEA 3 BYETTA 5 MCG PEN 2 ST; QL OXSORALEN ULTRA 2 FARXIGA E RETIN-A MICRO GEL E ++ FORTAMET E 0.04 %, 0.1 % glimepiride 1 RETIN-A MICRO PUMP 1 EXTERNAL GEL 0.04 %, E ++ glipizide er 0.1 % glipizide ir 1 RETIN-A MICRO PUMP glipizide xl 1 EXTERNAL GEL 0.06 %, 2 ++ GLUMETZA E 0.08 % glyburide oral 1 SOOLANTRA 2 glyburide-metformin 1 TACLONEX EXTERNAL E 2 ST OINTMENT GLYXAMBI INVOKAMET 2 ST TACLONEX EXTERNAL 3 QL SUSPENSION INVOKAMET XR 2 ST TAZORAC 3 INVOKANA 2 ST tretinoin external cream 1 ++ JANUMET 2 ST VECTICAL 3 JANUMET XR 2 ST VELTIN E JANUVIA 2 ST ZIANA E JARDIANCE 2 ST ZYCLARA 3 JENTADUETO 2 ST ZYCLARA PUMP 3 JENTADUETO XR 2 ST KAZANO E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KOMBIGLYZE XR E ACCU-CHEK FASTCLIX 2 ++ metformin hcl er 1 LANCETS metformin hcl er (mod) E ACCU-CHEK GUIDE E ++ metformin hcl er (osm) ACCU-CHEK MULTICLIX LANCET 2 ++ oral tablet extended E release 24 hour 1000 DEVICE KIT mg, 500 mg ACCU-CHEK 2 ++ metformin hcl oral tablet 1 MULTICLIX LANCETS NESINA E ACCU-CHEK NANO SMARTVIEW KIT E ++ ONGLYZA E W/DEVICE OSENI E ACCU-CHEK OZEMPIC 2 ST; QL SMARTVIEW TEST E ++ pioglitazone hcl 1 STRIPS QTERN E ACCU-CHEK SOFT 2 ++ TOUCH LANCETS SEGLUROMET E ACCU-CHEK SOFTCLIX 2 ++ SOLIQUA 2 ST; QL LANCET DEVICE KIT STEGLATRO E ACCU-CHEK SOFTCLIX 2 ++ STEGLUJAN E LANCETS SYNJARDY 2 ST DEXCOM G4 PLATINUM E ++ SYNJARDY XR 2 ST PEDIATRIC RECEIVER DEVICE TRADJENTA 2 ST DEXCOM G4 PLATINUM TRULICITY 2 ST; QL RECEIVER, SENSOR, E ++ VICTOZA 2 ST; QL TRANSMITTER DEVICE XIGDUO XR E DEXCOM G5 SENSOR, Diabetes - Glucose Monitoring TRANSMITTER, E ++ MOBILE RECEIVER ACCU-CHEK AVIVA CONNECT KIT E ++ ONETOUCH ULTRA 2 2 ++ W/DEVICE KIT W/DEVICE ONETOUCH ULTRA ACCU-CHEK AVIVA E ++ 2 ++; QL PLUS BLUE TEST STRIPS ONETOUCH ULTRA ACCU-CHEK COMPACT E ++ 2 ++ PLUS CARE KIT MINI KIT W/DEVICE ACCU-CHEK COMPACT ONETOUCH VERIO 2 ++ E ++ PLUS TEST STRIPS ONETOUCH VERIO ACCU-CHEK FASTCLIX FLEX SYSTEM KIT 2 ++ 2 ++ LANCET KIT W/DEVICE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ONETOUCH VERIO IQ HUMULIN R U-500 2 ++ 2 ++ SYSTEM KIT W/DEVICE KWIKPEN

ONETOUCH VERIO 2 ++; QL HUMULIN R U-500 VIAL 2 ++ STRIP IN VITRO (CONCENTRATED) V-GO 20 2 ++ HUMULIN R VIAL 2 ++ 2 ++ V-GO 30 LANTUS U-100 2 ++ V-GO 40 2 ++ SOLOSTAR Diabetes - Glycemic Agents LANTUS U-100 VIAL 2 ++ LEVEMIR U-100 GLUCAGON 2 E ++ EMERGENCY FLEXTOUCH Diabetes - Insulins LEVEMIR U-100 VIAL E ++ ADMELOG E ++ NOVOFINE AUTOCOVER PEN 2 ++ E ++ ADMELOG SOLOSTAR NEEDLE E ++ APIDRA SOLOSTAR NOVOFINE PEN 2 ++ APIDRA VIAL E ++ NEEDLE 32G X 6 MM BASAGLAR KWIKPEN E ++ NOVOFINE PLUS PEN 2 ++ FIASP E ++ NEEDLE FIASP FLEXTOUCH E ++ NOVOLIN 70/30 RELION E ++ HUMALOG U-100 AND NOVOLIN 70/30 VIAL E ++ 2 ++ U-200 KWIKPEN NOVOLIN N RELION E ++ HUMALOG MIX 50/50 E ++ 2 ++ NOVOLIN N VIAL KWIKPEN NOVOLIN R RELION E ++ HUMALOG MIX 50/50 2 ++ NOVOLIN R VIAL E ++ VIAL NOVOLOG U-100 E ++ HUMALOG MIX 75/25 2 ++ FLEXPEN KWIKPEN NOVOLOG MIX 70/30 E ++ HUMALOG MIX 75/25 2 ++ FLEXPEN VIAL NOVOLOG MIX 70/30 E ++ HUMALOG U-100 2 ++ VIAL JUNIOR KWIKPEN NOVOLOG U-100 HUMALOG U-100 VIAL E ++ 2 ++ PENFILL AND CARTRIDGE NOVOLOG U-100 VIAL E ++ HUMULIN 70/30 2 ++ KWIKPEN NOVOTWIST PEN 2 ++ NEEDLE 32G X 5 MM HUMULIN 70/30 VIAL 2 ++ TOUJEO SOLOSTAR 2 ++ HUMULIN N KWIKPEN 2 ++ TRESIBA FLEXTOUCH E ++ HUMULIN N VIAL 2 ++

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Electrolytes / Minerals / Metals / Vitamins omeprazole-sodium cyanocobalamin injection 1 ++ bicarbonate oral capsule E ++ 20-1100 mg folic acid oral tablet 1 mg 1 ++ omeprazole-sodium 1 klor-con m20 bicarbonate oral capsule E potassium chloride crys 1 40-1100 mg er omeprazole-sodium E potassium chloride er 1 bicarbonate oral packet potassium citrate er 1 pantoprazole sodium oral 1 ++; QL VELTASSA 3 PREVACID E ++ VITAFOL ORAL TABLET E rabeprazole sodium 1 ++; QL 1 ++ vitamin d (ergocalciferol) 1 ++ ranitidine hcl oral capsule oral capsule 50000 unit ranitidine hcl oral syrup 1 ++ Gastrointestinal Agents - Drugs for Acid ranitidine hcl oral tablet Reflux and Ulcer E ++ 150 mg E ++ ACIPHEX ranitidine hcl oral tablet 1 ++ CARAFATE ORAL E 300 mg TABLET sucralfate oral tablet 1 DEXILANT 2 ++; QL ZEGERID ORAL E ++ esomeprazole E ++ CAPSULE 20-1100 MG magnesium ZEGERID ORAL E famotidine oral tablet 20 E ++ CAPSULE 40-1100 MG mg ZEGERID ORAL E famotidine oral tablet 40 1 ++ PACKET mg Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions lansoprazole oral capsule E ++ delayed release 15 mg AMITIZA E lansoprazole oral capsule 1 ++; QL CLENPIQ 3 delayed release 30 mg dicyclomine hcl oral 1 NEXIUM ORAL capsule CAPSULE DELAYED E ++ dicyclomine hcl oral RELEASE 1 tablet omeppi oral capsule 20- E ++ 1100 mg diphenoxylate-atropine 1 oral tablet omeppi oral capsule 40- E 1100 mg gavilyte-g 1 LINZESS 2 ST; QL omeprazole oral capsule 1 ++; QL delayed release MOTOFEN E MOVANTIK E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MOVIPREP 3 LEVITRA E ++ OMECLAMOX-PAK 2 MYRBETRIQ 2 1 polyethylene glycol 3350 E ++ oxybutynin chloride er oral powder oxybutynin chloride oral 1 PREPOPIK 3 tablet 2 PYLERA phenazopyridine hcl oral 1 RELISTOR ORAL E tablet 100 mg, 200 mg RELISTOR RENVELA 3 SUBCUTANEOUS E sildenafil citrate oral SOLUTION 12 tablet 100 mg, 25 mg, 50 1 ++; QL MG/0.6ML, 8 MG/0.4ML mg SUPREP BOWEL PREP STAXYN E ++ 3 KIT STENDRA E ++ SYMPROIC 2 ST; QL tolterodine tartrate er 1 TRULANCE E TOVIAZ 3 VIBERZI 3 PA; QL VELPHORO 3 Genetic or Enzyme Disorder: Drugs for VESICARE 2 Replacement, Modifiers, Treatment VIAGRA E ++ CERDELGA 3 PA; SP Genitourinary Agents - Drugs for Prostate CREON 2 Conditions NITYR 3 PA; SP alfuzosin hcl er 1 PANCREAZE E finasteride oral tablet 5 1 PERTZYE E mg VIOKACE E RAPAFLO 2 ZENPEP ORAL tamsulosin hcl 1 CAPSULE DELAYED terazosin hcl oral 1 RELEASE PARTICLES Hormonal Agents - Adrenal 10000-32000 UNIT, 15000-47000 UNIT, ala-cort external cream 1 2 E 20000-63000 UNIT, % 25000-79000 UNIT, betamethasone valerate 1 3000-14000 UNIT, external cream 40000-126000 UNIT, clobetasol propionate 5000-24000 UNIT 1 external cream Genitourinary Agents - Drugs for Bladder, clobetasol propionate Genital and Kidney Conditions 1 external ointment AURYXIA 3 clobetasol propionate 2 ++; QL 1 CIALIS external solution DEPEN TITRATABS 2 SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CLOBEX SPRAY 3 Hormonal Agents - Men's Health ANDRODERM dexamethasone oral 1 solution TRANSDERMAL PATCH 2 PA 24 HOUR dexamethasone oral 1 tablet ANDROGEL PUMP TRANSDERMAL GEL 2 PA fluocinonide external 1 cream 20.25 MG/ACT (1.62%) HALOG E ANDROGEL TRANSDERMAL GEL hydrocortisone external E 20.25 MG/1.25GM 2 PA cream 1 % (1.62%), 40.5 MG/2.5GM hydrocortisone external (1.62%) 1 cream 2.5 % ANDROGEL hydrocortisone external TRANSDERMAL GEL 25 1 E ointment 2.5 % MG/2.5GM (1%), 50 hydrocortisone in MG/5GM (1%) E absorbase DEPO-TESTOSTERONE E hydrocortisone oral 1 INTRAMUSCULAR SOLUTION methylprednisolone oral 1 FORTESTA E mometasone furoate 1 E external cream TESTIM prednisolone oral testosterone cypionate 1 1 PA solution intramuscular solution 100 mg/ml, 200 mg/ml prednisolone sodium phosphate oral solution TESTOSTERONE E M 10 mg/5ml, 15 mg/5ml, 1 TRANSDERMAL GEL 10 20 mg/5ml, 25 mg/5ml, MG/ACT (2%) 6.7 (5 base) mg/5ml VOGELXO PUMP E prednisone oral tablet 1 VOGELXO TRANSDERMAL GEL 50 E prednisone oral tablet 1 therapy pack MG/5GM (1%) Hormonal Agents - Osteoporosis RAYOS E 3 TOPICORT SPRAY E OSPHENA raloxifene hcl 1 triamcinolone acetonide 1 external cream Hormonal Agents - Pituitary BRAVELLE E ++; SP triamcinolone acetonide 1 external ointment CETROTIDE SUBCUTANEOUS KIT i-P PA; ++; SP 0.25 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FOLLISTIM AQ SANDOSTATIN E ++; SP SUBCUTANEOUS INJECTION SOLUTION E SP GENOTROPIN E ++; SP 100 MCG/ML, 50 MCG/ML, 500 MCG/ML GENOTROPIN E ++; SP MINIQUICK ZOMACTON E ++; SP Hormonal Agents - Sex Hormones and GONAL-F i-P PA; ++; SP Birth Control GONAL-F RFF i-P PA; ++; SP apri 1 ++ GONAL-F RFF i-P PA; ++; SP 1 ++ REDIJECT aviane E ++ HP ACTHAR i-P PA; SP BEYAZ 1 ++ HUMATROPE E ++; SP blisovi 24 fe 1 ++ LUPRON DEPOT (1- blisovi fe 1.5/30 MONTH) blisovi fe 1/20 1 ++ i-P PA; SP INTRAMUSCULAR KIT CLIMARA PRO 2 7.5 MG cryselle-28 1 ++ LUPRON DEPOT (3- DIVIGEL 3 MONTH) i-P PA; SP drospirenone-ethinyl INTRAMUSCULAR KIT 1 ++ 22.5 MG estradiol LUPRON DEPOT (4- DUAVEE 2 MONTH) i-P PA; SP ELESTRIN 3 INTRAMUSCULAR KIT 2 ++ 30MG ENDOMETRIN LUPRON DEPOT (6- enskyce oral tablet 0.15- 1 ++ MONTH) 30 mg-mcg i-P PA; SP INTRAMUSCULAR KIT estradiol oral 1 45MG estradiol transdermal 1 NORDITROPIN i-P PA; ++; SP estradiol vaginal cream 1 FLEXPRO gianvi 1 ++ NUTROPIN AQ NUSPIN i-P PA; ++; SP 1 ++ 10 junel 1/20 junel fe 1.5/30 1 ++ NUTROPIN AQ NUSPIN i-P PA; ++; SP 20 junel fe 1/20 1 ++ NUTROPIN AQ NUSPIN levonorgestrel-ethinyl i-P PA; ++; SP estrad oral tablet 0.1-20 5 1 ++ OMNITROPE i-P PA; ++; SP mg-mcg, 0.15-30 mg- mcg OVIDREL i-P ++; SP LO LOESTRIN FE 3 ++ SAIZEN E ++; SP loryna 1 ++ SAIZENPREP E ++; SP low-ogestrel 1 ++

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MAKENA PREMPHASE 2 i-NP PA; SP INTRAMUSCULAR PREMPRO 2 medroxyprogesterone 1 ++; QL progesterone micronized 1 acetate intramuscular oral medroxyprogesterone 1 sprintec 28 1 ++ acetate oral tri-estarylla 1 ++ MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 2 tri-linyah 1 ++ MG tri-lo-marzia 1 ++ microgestin 1.5/30 1 ++ trinessa (28) 1 ++ microgestin 1/20 1 ++ trinessa lo 1 ++ microgestin fe 1/20 1 ++ tri-previfem 1 ++ MINASTRIN 24 FE E ++ tri-sprintec 1 ++ MINIVELLE 3 VAGIFEM VAGINAL E mono-linyah 1 ++ TABLET 10 MCG mononessa 1 ++ vienva 1 ++ NATAZIA 2 ++ viorele 1 ++ nikki 1 ++ VIVELLE-DOT E norethindrone acet- xulane 1 ++ 1 ++ ethinyl est oral tablet YAZ E ++ norethindrone oral 1 ++ yuvafem 1 norgestimate-eth Hormonal Agents - Thyroid estradiol oral tablet 0.25- 1 ++ ARMOUR THYROID 3 35 mg-mcg CYTOMEL E norgestimate-ethinyl 1 ++ 1 estradiol triphasic levo-t 1 nortrel 1/35 (21) 1 ++ levothyroxine sodium oral 1 nortrel 1/35 (28) 1 ++ levoxyl 1 NUVARING 2 ++ liothyronine sodium oral 1 ocella 1 ++ methimazole oral ORTHO TRI-CYCLEN NATURE-THROID ORAL E ++ (28) TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 ORTHO TRI-CYCLEN E ++ MG, 195 MG, 260 MG, 3 LO 32.5 MG, 325 MG, 48.75 portia-28 1 ++ MG, 65 MG, 81.25 MG, PREMARIN ORAL 2 97.5 MG 3 PREMARIN VAGINAL 2 SYNTHROID TIROSINT 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Immunological Agents - Drugs for Immune HUMIRA PEN-PS/UV System Stimulation or Suppression STARTER azathioprine oral 1 SUBCUTANEOUS PEN- i-P PA; SP INJECTOR KIT 40 i-P PA; SP CIMZIA PREFILLED KIT MG/0.8ML i-P PA; SP CIMZIA STARTER KIT HUMIRA CIMZIA VIAL KIT i-P PA; SP SUBCUTANEOUS i-P PA; SP COSENTYX 150 MG/ML i-P PA; 3P; SP PREFILLED SYRINGE KIT COSENTYX 300 DOSE i-P PA; 3P; SP INFLECTRA E SP COSENTYX SENSOREADY 300 i-P PA; 3P; SP KEVZARA DOSE SUBCUTANEOUS i-P PA; 3P; SP SOLUTION PREFILLED COSENTYX SYRINGE SENSOREADY PEN SUBCUTANEOUS i-P PA; 3P; SP methotrexate oral 1 SOLUTION AUTO- methotrexate sodium oral 1 INJECTOR 150 MG/ML mycophenolate mofetil 1 SP ENBREL oral capsule SUBCUTANEOUS i-NP PA; SP mycophenolate mofetil 1 SP SOLUTION PREFILLED oral tablet SYRINGE mycophenolate sodium 1 SP ENBREL SURECLICK SUBCUTANEOUS OTEZLA ORAL TABLET 2 PA; SP i-NP PA; SP SOLUTION AUTO- OTEZLA ORAL TABLET 2 PA; SP INJECTOR THERAPY PACK HAEGARDA i-P PA; SP PROGRAF ORAL 3 SP HUMIRA PEDIATRIC RASUVO CROHNS START SUBCUTANEOUS SUBCUTANEOUS i-P PA; SP SOLUTION AUTO- PREFILLED SYRINGE INJECTOR 10 KIT 40 MG/0.8ML MG/0.2ML, 12.5 HUMIRA PEN MG/0.25ML, 15 SUBCUTANEOUS PEN- i-P PA; SP MG/0.3ML, 17.5 2 PA; QL INJECTOR KIT MG/0.35ML, 20 MG/0.4ML, 22.5 HUMIRA PEN- MG/0.45ML, 25 CD/UC/HS STARTER MG/0.5ML, 30 i-P PA; SP SUBCUTANEOUS PEN- MG/0.6ML, 7.5 INJECTOR KIT 40 MG/0.15ML MG/0.8ML REMICADE i-P PA; SP SIMPONI ARIA i-P PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SIMPONI mesalamine oral 1 SUBCUTANEOUS i-P PA; SP PENTASA 3 SOLUTION AUTO- INJECTOR PROCTOFOAM HC 2 SIMPONI sulfasalazine oral tablet 1 3 SUBCUTANEOUS i-P PA; SP UCERIS SOLUTION PREFILLED Metabolic Bone Disease Agents - Drugs for SYRINGE Osteoporosis STELARA i-P PA; SP alendronate sodium oral INTRAVENOUS tablet 10 mg, 40 mg, 5 1 STELARA mg SUBCUTANEOUS alendronate sodium oral i-P PA; SP 1 QL SOLUTION PREFILLED tablet 35 mg, 70 mg SYRINGE BINOSTO 3 QL tacrolimus oral 1 SP calcitriol oral capsule 1 TALTZ E SP FORTEO TREMFYA i-P PA; SP SUBCUTANEOUS i-P PA; SP SOLUTION 600 XELJANZ ORAL 3 PA; 3P; SP TABLET 5 MG MCG/2.4ML XELJANZ XR 3 PA; 3P; SP ibandronate sodium oral 1 QL Immunological Agents - Drugs for TYMLOS i-P PA; SP Vaccination Miscellaneous Therapeutic Agents AFLURIA PA; Non- PRESERVATIVE FREE i-NP Cosmetic; INTRAMUSCULAR E BOTOX SP SUSPENSION 3 PREFILLED SYRINGE CETYLEV FLUCELVAX EUFLEXXA INTRA- i-P PA; SP QUADRIVALENT ARTICULAR SOLUTION INTRAMUSCULAR E PREFILLED SYRINGE SUSPENSION SYNVISC INTRA- PREFILLED SYRINGE ARTICULAR SOLUTION i-P PA; SP SHINGRIX E PREFILLED SYRINGE Inflammatory Bowel Disease Agents SYNVISC ONE INTRA- ARTICULAR SOLUTION i-P PA; SP 2 APRISO PREFILLED SYRINGE ASACOL HD E Ophthalmic Agents - Drugs for Eye Allergy, CANASA 2 Infection and Inflammation DELZICOL E AZASITE 3 DIPENTUM E BESIVANCE 3 LIALDA E BROMSITE E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ciprofloxacin hcl LUMIGAN 1 ophthalmic OPHTHALMIC 2 QL erythromycin ophthalmic 1 SOLUTION 0.01 % RHOPRESSA E gentamicin sulfate 1 ophthalmic solution SIMBRINZA 2 E ILEVRO timolol maleate 1 ophthalmic solution ketorolac tromethamine 1 ophthalmic TIMOPTIC OCUDOSE 3 MOXEZA 2 TRAVATAN Z 2 QL E moxifloxacin hcl 1 ZIOPTAN ophthalmic Ophthalmic Agents - Drugs for NEVANAC E Miscellaneous Eye Conditions ofloxacin ophthalmic 1 LASTACAFT 3 ST olopatadine hcl neomycin-polymyxin- 1 dexameth ophthalmic ophthalmic 1 PAZEO 2 suspension 3.5-10000- 0.1 prednisolone acetate 1 1 ophthalmic polymyxin b-trimethoprim 2 PA PROLENSA 2 QL RESTASIS 2 PA tobramycin ophthalmic 1 RESTASIS MULTIDOSE Ophthalmic Agents - Drugs for Glaucoma TOBRADEX OPHTHALMIC E ALPHAGAN P SUSPENSION OPHTHALMIC 2 SOLUTION 0.1 % tobramycin- 1 dexamethasone ALPHAGAN P OPHTHALMIC E XIIDRA 2 PA SOLUTION 0.15 % Otic Agents - Drugs for Ear Conditions AZOPT 2 CIPRODEX 2 3 neomycin-polymyxin-hc BETIMOL 1 BETOPTIC-S 3 otic 1 brimonidine tartrate ofloxacin otic 1 ophthalmic Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold COMBIGAN 2 COSOPT PF 3 ASTEPRO NASAL 3 QL SOLUTION 0.15 % dorzolamide hcl-timolol 1 1 QL mal azelastine hcl nasal 1 latanoprost ophthalmic 1 QL benzonatate cetirizine hcl oral solution E ++

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier desloratadine oral tablet 1 ++ AIRDUO RESPICLICK E DYMISTA 2 QL 55/14 albuterol sulfate fluticasone propionate E 1 QL nasal inhalation hydrocodone polst-cpm ALVESCO E 2 QL polst er oral suspension 1 PA; QL ANORO ELLIPTA extended release 10-8 ARMONAIR E mg/5ml RESPICLICK 113 ipratropium bromide 1 ARMONAIR E nasal RESPICLICK 232 levocetirizine ARMONAIR E dihydrochloride oral E ++ RESPICLICK 55 tablet ARNUITY ELLIPTA mometasone furoate 1 QL INHALATION AEROSOL nasal POWDER BREATH 2 QL NASONEX E ACTIVATED 100 OMNARIS 3 QL MCG/ACT, 200 MCG/ACT promethazine hcl oral 1 tablet ASMANEX 120 E METERED DOSES promethazine-codeine 1 PA; QL ASMANEX 14 oral syrup E METERED DOSES promethazine-dm 1 ASMANEX 30 E pseudoephedrine- METERED DOSES bromphen-dm oral syrup E ASMANEX 60 30-2-10 mg/5ml E METERED DOSES QNASL 3 QL ASMANEX 7 METERED E QNASL CHILDRENS 3 QL DOSES XOLAIR i-NP PA; SP ASMANEX HFA E ZETONNA 3 QL AUVI-Q INJECTION Respiratory Tract / Pulmonary Agents - SOLUTION AUTO- Drugs for Asthma and Other Lung INJECTOR 0.15 E Conditions MG/0.15ML, 0.3 ADVAIR DISKUS 2 QL MG/0.3ML BEVESPI ADVAIR HFA 2 QL E AEROSPHERE AIRDUO RESPICLICK E 113/14 BREO ELLIPTA 2 QL budesonide inhalation 1 QL AIRDUO RESPICLICK E 232/14 COMBIVENT RESPIMAT 2 QL DULERA E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EPINEPHRINE SEEBRI NEOHALER E Made by E INJECTION SOLUTION Impax; M SEREVENT DISKUS 2 QL 0.3 MG/0.3ML SINGULAIR E EPINEPHRINE Made by SPIRIVA HANDIHALER 2 QL INJECTION SOLUTION E AUTO-INJECTOR 0.15 Impax; M SPIRIVA RESPIMAT MG/0.15ML INHALATION AEROSOL EPINEPHRINE SOLUTION 1.25 2 QL INJECTION SOLUTION MCG/ACT, 2.5 Made by AUTO-INJECTOR 0.15 2 MCG/ACT Mylan MG/0.3ML, 0.3 STIOLTO RESPIMAT MG/0.3ML INHALATION AEROSOL 2 QL EPIPEN 2-PAK SOLUTION 2.5-2.5 INJECTION SOLUTION E MCG/ACT AUTO-INJECTOR SYMBICORT 2 QL EPIPEN JR 2-PAK TUDORZA PRESSAIR INJECTION SOLUTION E INHALATION AEROSOL E AUTO-INJECTOR POWDER BREATH FLOVENT DISKUS 2 QL ACTIVATED FLOVENT HFA 2 QL UTIBRON NEOHALER E INCRUSE ELLIPTA 2 QL VENTOLIN HFA 2 QL ipratropium bromide XOPENEX HFA E 1 QL inhalation Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ipratropium-albuterol 1 QL 2 SP LEVALBUTEROL HFA BETHKIS INHALATION AEROSOL E M KITABIS PAK E SP 45 MCG/ACT TOBI NEBULIZER E SP montelukast sodium oral 1 TOBI PODHALER E SP tablet tobramycin nebulization montelukast sodium oral 1 solution 300 mg/5ml 1 SP tablet chewable inhalation PERFOROMIST 3 QL TOBRAMYCIN 2 QL PROAIR HFA NEBULIZATION E M; SP PROAIR RESPICLICK 2 QL SOLUTION 300 MG/5ML INHALATION PROVENTIL HFA E Respiratory Tract / Pulmonary Agents - PULMICORT 2 QL Drugs for Pulmonary Hypertension FLEXHALER ADCIRCA 3 PA; SP; QL PULMICORT E 2 PA; SP; QL SUSPENSION ADEMPAS 2 PA; SP; QL QVAR REDIHALER E LETAIRIS

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

28 Drug Drug Name Notes Tier OPSUMIT 2 PA; SP; QL ORENITRAM 3 PA; SP sildenafil citrate oral 1 PA; SP; QL tablet 20 mg TRACLEER 2 PA; SP; QL Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm AMRIX E baclofen oral 1 carisoprodol oral 1 cyclobenzaprine hcl oral 1 LORZONE 3 metaxalone 1 methocarbamol oral 1 orphenadrine citrate er 1 tizanidine hcl oral tablet 1 Sleep Disorder Agents AMBIEN E AMBIEN CR E eszopiclone 1 QL LUNESTA E modafinil 1 PA; QL NUVIGIL E SILENOR 3 QL temazepam 1 QL zolpidem tartrate er 1 QL zolpidem tartrate oral 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

29 Index of Drugs abacavir sulfate-lamivudine 11 ADZENYS ER...... 14 APRISO...... 25 ABILIFY MAINTENA...... 10 ADZENYS XR-ODT...... 14 ARANESP (ALBUMIN ABSORICA...... 15 AFLURIA FREE)...... 12 ABSTRAL...... 6 PRESERVATIVE FREE...... 25 aripiprazole...... 10 ACANYA...... 15 AFSTYLA...... 12 ARISTADA...... 10 ACCU-CHEK AVIVA AIRDUO RESPICLICK ARMONAIR RESPICLICK CONNECT KIT W/DEVICE.17 113/14...... 27 113...... 27 ACCU-CHEK AVIVA PLUS 17 AIRDUO RESPICLICK ARMONAIR RESPICLICK ACCU-CHEK COMPACT 232/14...... 27 232...... 27 PLUS CARE KIT...... 17 AIRDUO RESPICLICK ARMONAIR RESPICLICK ACCU-CHEK COMPACT 55/14...... 27 55...... 27 PLUS TEST STRIPS...... 17 AKTIPAK...... 15 ARMOUR THYROID...... 23 ACCU-CHEK FASTCLIX ala-cort...... 20 ARNUITY ELLIPTA...... 27 LANCET KIT...... 17 albuterol sulfate...... 27 ARYMO ER...... 6 ACCU-CHEK FASTCLIX alendronate sodium...... 25 ASACOL HD...... 25 LANCETS...... 17 alfuzosin hcl er...... 20 ASMANEX 120 METERED ACCU-CHEK GUIDE...... 17 allopurinol...... 10 DOSES...... 27 ACCU-CHEK MULTICLIX ALOGLIPTIN BENZOATE.. 16 ASMANEX 14 METERED LANCET DEVICE KIT...... 17 ALOGLIPTIN- DOSES...... 27 ACCU-CHEK MULTICLIX METFORMIN HCL...... 16 ASMANEX 30 METERED LANCETS...... 17 ALOGLIPTIN- DOSES...... 27 ACCU-CHEK NANO PIOGLITAZONE...... 16 ASMANEX 60 METERED SMARTVIEW KIT ALPHAGAN P...... 26 DOSES...... 27 W/DEVICE...... 17 alprazolam...... 11 ASMANEX 7 METERED ACCU-CHEK ALVESCO...... 27 DOSES...... 27 SMARTVIEW TEST AMBIEN...... 29 ASMANEX HFA...... 27 STRIPS...... 17 AMBIEN CR...... 29 ASTEPRO...... 26 ACCU-CHEK SOFT amiodarone hcl...... 12 atenolol...... 12 TOUCH LANCETS...... 17 AMITIZA...... 19 atenolol-chlorthalidone...... 12 ACCU-CHEK SOFTCLIX amitriptyline hcl...... 9 ATIVAN...... 11 LANCET DEVICE KIT...... 17 amlodipine besylate...... 12 atomoxetine hcl...... 14 ACCU-CHEK SOFTCLIX amlodipine besylate- atorvastatin calcium...... 12 LANCETS...... 17 benazepril hcl...... 12 ATRALIN...... 15 acetaminophen-codeine...... 6 amlodipine besylate- ATRIPLA...... 11 acetaminophen-codeine #2.. 6 valsartan...... 12 AUBAGIO...... 14 acetaminophen-codeine #3.. 6 amlodipine-olmesartan...... 12 AURYXIA...... 20 acetaminophen-codeine #4.. 6 amoxicillin...... 7 AUVI-Q...... 27 ACIPHEX...... 19 amoxicillin-potassium aviane...... 22 ACTICLATE...... 7 clavulanate...... 7 AVONEX PEN...... 14 acyclovir...... 11 amphetamine- AVONEX PREFILLED...... 14 ACZONE...... 15 dextroamphetamine...... 14 AVONEX VIAL adapalene...... 15 amphetamine- INTRAMUSCULAR KIT..... 14 ADCIRCA...... 28 dextroamphetamine er...... 14 AZASITE...... 25 ADDERALL XR...... 14 AMPYRA...... 14 azathioprine...... 24 ADDYI...... 15 AMRIX...... 29 azelastine hcl...... 26 ADEMPAS...... 28 anastrozole...... 10 azithromycin...... 7 ADLYXIN...... 16 ANDRODERM...... 21 AZOPT...... 26 ADLYXIN STARTER ANDROGEL...... 21 AZOR...... 12 PACK...... 16 ANDROGEL PUMP...... 21 baclofen...... 29 ADMELOG...... 18 ANORO ELLIPTA...... 27 BASAGLAR KWIKPEN...... 18 ADMELOG SOLOSTAR..... 18 APIDRA SOLOSTAR...... 18 BELBUCA...... 6 ADVAIR DISKUS...... 27 APIDRA VIAL...... 18 benazepril hcl...... 12 ADVAIR HFA...... 27 apri...... 22 30 benazepril- CARAFATE...... 19 COMBIVENT RESPIMAT... 27 hydrochlorothiazide...... 12 carbamazepine...... 8 COMPLERA...... 11 BENICAR...... 12 carbidopa-levodopa...... 10 CONCERTA...... 14 BENICAR HCT...... 12 carisoprodol...... 29 CONTRAVE...... 15 BENZACLIN...... 15 cartia xt...... 12 COPAXONE...... 14 BENZACLIN WITH PUMP.. 15 carvedilol...... 12 CORLANOR...... 12 BENZAMYCIN...... 15 cefdinir...... 7 COSENTYX 150 MG/ML.... 24 benzonatate...... 26 cefuroxime axetil...... 7 COSENTYX 300 DOSE...... 24 benztropine mesylate...... 10 CELEBREX...... 6 COSENTYX BESIVANCE...... 25 celecoxib...... 6 SENSOREADY 300 DOSE.24 betamethasone valerate..... 20 cephalexin...... 7 COSENTYX BETASERON...... 14 CERDELGA...... 20 SENSOREADY PEN...... 24 BETHKIS...... 28 cetirizine hcl...... 26 COSOPT PF...... 26 BETIMOL...... 26 CETROTIDE...... 21 COTEMPLA XR-ODT...... 14 BETOPTIC-S...... 26 CETYLEV...... 25 CREON...... 20 BEVESPI AEROSPHERE.. 27 CHANTIX STARTING CRESTOR...... 12 BEYAZ...... 22 MONTH PAK...... 7 cryselle-28...... 22 BINOSTO...... 25 chlorhexidine gluconate...... 15 cyanocobalamin...... 19 bisoprolol fumarate...... 12 chlorthalidone...... 12 cyclobenzaprine hcl...... 29 bisoprolol- choline fenofibrate...... 12 CYMBALTA...... 9 hydrochlorothiazide...... 12 CIALIS...... 20 CYTOMEL...... 23 blisovi 24 fe...... 22 cilostazol...... 10 DELZICOL...... 25 blisovi fe 1.5/30...... 22 CIMDUO...... 11 DEPEN TITRATABS...... 20 blisovi fe 1/20...... 22 CIMZIA...... 24 DEPO-TESTOSTERONE... 21 BOTOX...... 25 CIMZIA PREFILLED KIT.... 24 DESCOVY...... 11 BRAVELLE...... 21 CIMZIA STARTER KIT...... 24 desloratadine...... 27 BREO ELLIPTA...... 27 CIPRODEX...... 26 desvenlafaxine succinate BRILINTA...... 10 ciprofloxacin hcl...... 7, 26 er...... 9 brimonidine tartrate...... 26 citalopram hydrobromide...... 9 dexamethasone...... 21 BROMSITE...... 25 claravis...... 15 DEXCOM G4 PLATINUM budesonide...... 27 clarithromycin...... 8 PEDIATRIC RECEIVER..... 17 bumetanide...... 12 CLENPIQ...... 19 DEXCOM G4 PLATINUM BUNAVAIL...... 7 CLIMARA PRO...... 22 RECEIVER, SENSOR, buprenorphine hcl...... 7 CLINDAGEL...... 15 TRANSMITTER...... 17 buprenorphine hcl- clindamycin hcl...... 8 DEXCOM G5 SENSOR, naloxone hcl...... 7 CLINDAMYCIN PHOS- TRANSMITTER, MOBILE bupropion hcl...... 9 BENZOYL PEROX...... 15 RECEIVER...... 17 bupropion hcl er (sr)...... 9 clindamycin phos-benzoyl DEXILANT...... 19 bupropion hcl er (xl)...... 9 perox...... 15 dexmethylphenidate hcl...... 14 buspirone hcl...... 11 clindamycin phosphate...... 15 dexmethylphenidate hcl er..14 butalbital-apap-caffeine...... 6 CLINDAMYCIN diazepam...... 11 BYDUREON...... 16 PHOSPHATE...... 15 diclofenac potassium...... 7 BYDUREON BCISE CLINDESSE...... 8 diclofenac sodium...... 7 AUTOINJECTOR...... 16 clobetasol propionate...... 20 dicyclomine hcl...... 19 BYETTA 10 MCG PEN...... 16 CLOBEX SPRAY...... 21 DIFFERIN...... 15 BYETTA 5 MCG PEN...... 16 clonazepam...... 11 digoxin...... 12 BYSTOLIC...... 12 clonidine hcl...... 12 DILANTIN...... 8 BYVALSON...... 12 clopidogrel bisulfate...... 10 DILANTIN INFATABS...... 8 CABOMETYX...... 10 clotrimazole- diltiazem hcl...... 12 calcitriol...... 25 betamethasone...... 15 diltiazem hcl er beads...... 12 CAMBIA...... 6 COLCHICINE...... 10 diltiazem hcl er coated CANASA...... 25 COLCRYS...... 10 beads...... 12 capecitabine...... 10 COMBIGAN...... 26 DIOVAN...... 12

31 DIOVAN HCT...... 12 erythromycin...... 26 glipizide xl...... 16 DIPENTUM...... 25 escitalopram oxalate...... 9 GLUCAGON diphenoxylate-atropine...... 19 esomeprazole magnesium..19 EMERGENCY...... 18 divalproex sodium...... 8 estradiol...... 22 GLUMETZA...... 16 divalproex sodium er...... 8 eszopiclone...... 29 glyburide...... 16 DIVIGEL...... 22 etodolac...... 7 glyburide-metformin...... 16 donepezil hcl...... 9 EUCRISA...... 16 GLYXAMBI...... 16 DORYX MPC...... 8 EUFLEXXA...... 25 GONAL-F...... 22 dorzolamide hcl-timolol mal 26 EXTAVIA...... 14 GONAL-F RFF...... 22 doxazosin mesylate...... 12 ezetimibe...... 13 GONAL-F RFF REDIJECT. 22 doxepin hcl...... 9 ezetimibe-simvastatin...... 13 GRALISE...... 15 doxycycline hyclate...... 8 famotidine...... 19 GRALISE STARTER...... 15 doxycycline monohydrate..... 8 FARXIGA...... 16 GRANIX...... 12 drospirenone-ethinyl fenofibrate...... 13 guanfacine hcl...... 13 estradiol...... 22 fenofibrate micronized...... 13 guanfacine hcl er...... 14 DUAC...... 15 fenofibric acid...... 13 GYNAZOLE-1...... 9 DUAVEE...... 22 fentanyl...... 6 HAEGARDA...... 24 DUEXIS...... 7 FENTORA...... 6 HALOG...... 21 DULERA...... 27 FIASP...... 18 haloperidol...... 10 duloxetine hcl...... 9 FIASP FLEXTOUCH...... 18 HARVONI...... 11 DUPIXENT...... 15 finasteride...... 20 HP ACTHAR...... 22 DURAGESIC-100...... 6 flecainide acetate...... 13 HUMALOG KWIKPEN...... 18 DURAGESIC-12...... 6 FLECTOR...... 7 HUMALOG MIX 50/50 DURAGESIC-25...... 6 FLOVENT DISKUS...... 28 KWIKPEN...... 18 DURAGESIC-50...... 6 FLOVENT HFA...... 28 HUMALOG MIX 50/50 DURAGESIC-75...... 6 FLUCELVAX VIAL...... 18 DUZALLO...... 10 QUADRIVALENT...... 25 HUMALOG MIX 75/25 DYMISTA...... 27 fluconazole...... 9 KWIKPEN...... 18 EDARBI...... 12 fluocinonide...... 21 HUMALOG MIX 75/25 EDARBYCLOR...... 12 FLUOROPLEX...... 16 VIAL...... 18 EFFEXOR XR...... 9 fluoxetine hcl...... 9 HUMALOG U-100 JUNIOR ELESTRIN...... 22 fluticasone propionate...... 27 KWIKPEN...... 18 eletriptan hydrobromide...... 10 fluvoxamine maleate...... 9 HUMALOG U-100 VIAL ELIDEL...... 16 folic acid...... 19 AND CARTRIDGE...... 18 ELIQUIS...... 8 FOLLISTIM AQ...... 22 HUMATROPE...... 22 EMBEDA...... 6 FORFIVO XL...... 9 HUMIRA...... 24 EMVERM...... 10 FORTAMET...... 16 HUMIRA PEDIATRIC enalapril maleate...... 12 FORTEO...... 25 CROHNS START...... 24 ENBREL...... 24 FORTESTA...... 21 HUMIRA PEN...... 24 ENBREL SURECLICK...... 24 furosemide...... 13 HUMIRA PEN-CD/UC/HS ENDOMETRIN...... 22 gabapentin...... 8 STARTER...... 24 enoxaparin sodium...... 8 gavilyte-g...... 19 HUMIRA PEN-PS/UV enskyce...... 22 gemfibrozil...... 13 STARTER...... 24 ENSTILAR...... 16 GENOTROPIN...... 22 HUMULIN 70/30 entecavir...... 11 GENOTROPIN KWIKPEN...... 18 ENTRESTO...... 13 MINIQUICK...... 22 HUMULIN 70/30 VIAL...... 18 EPCLUSA...... 11 gentamicin sulfate...... 26 HUMULIN N KWIKPEN...... 18 EPIDUO...... 16 GENVOYA...... 11 HUMULIN N VIAL...... 18 EPIDUO FORTE...... 16 gianvi...... 22 HUMULIN R U-500 EPINEPHRINE...... 28 GILENYA...... 14 KWIKPEN...... 18 EPIPEN 2-PAK...... 28 glimepiride...... 16 HUMULIN R U-500 VIAL EPIPEN JR 2-PAK...... 28 glipizide...... 16 (CONCENTRATED)...... 18 EPOGEN...... 12 glipizide er...... 16 HUMULIN R VIAL...... 18

32 hydralazine hcl...... 13 klor-con m20...... 19 LUNESTA...... 29 hydrochlorothiazide...... 13 KOMBIGLYZE XR...... 17 LUPRON DEPOT (1- hydrocodone polst-cpm labetalol hcl...... 13 MONTH)...... 22 polst er...... 27 lamotrigine...... 8 LUPRON DEPOT (3- hydrocodone- lansoprazole...... 19 MONTH)...... 22 acetaminophen...... 6 LANTUS SOLOSTAR...... 18 LUPRON DEPOT (4- hydrocortisone...... 21 LANTUS U-100 VIAL...... 18 MONTH) hydrocortisone in LASTACAFT...... 26 INTRAMUSCULAR KIT absorbase...... 21 latanoprost...... 26 30MG...... 22 hydromorphone hcl...... 6 LATUDA...... 10 LUPRON DEPOT (6- hydroxychloroquine sulfate. 10 LAZANDA...... 6 MONTH) hydroxyzine hcl...... 11 LETAIRIS...... 28 INTRAMUSCULAR KIT hydroxyzine pamoate...... 11 letrozole...... 10 45MG...... 22 HYSINGLA ER...... 6 LEVALBUTEROL HFA...... 28 LYRICA...... 15 ibandronate sodium...... 25 LEVEMIR U-100 MAKENA...... 23 IBRANCE...... 10 FLEXTOUCH...... 18 MAVYRET...... 11 ibuprofen...... 7 LEVEMIR U-100 VIAL...... 18 meclizine hcl...... 9 ILEVRO...... 26 levetiracetam...... 8 medroxyprogesterone INCRUSE ELLIPTA...... 28 LEVITRA...... 20 acetate...... 23 indomethacin...... 7 levocetirizine meloxicam...... 7 INFLECTRA...... 24 dihydrochloride...... 27 memantine hcl...... 9 INTELENCE...... 11 levofloxacin...... 8 MENEST...... 23 INVEGA SUSTENNA...... 10 levonorgestrel-ethinyl mercaptopurine...... 10 INVEGA TRINZA...... 10 estrad...... 22 mesalamine...... 25 INVOKAMET...... 16 levo-t...... 23 metaxalone...... 29 INVOKAMET XR...... 16 levothyroxine sodium...... 23 metformin hcl...... 17 INVOKANA...... 16 levoxyl...... 23 metformin hcl er...... 17 ipratropium bromide...... 27, 28 LEXAPRO...... 9 metformin hcl er (mod)...... 17 ipratropium-albuterol...... 28 LIALDA...... 25 metformin hcl er (osm)...... 17 irbesartan...... 13 lidocaine...... 7 methimazole...... 23 irbesartan- lidocaine viscous...... 15 methocarbamol...... 29 hydrochlorothiazide...... 13 lidocaine-prilocaine...... 7 methotrexate...... 24 ISENTRESS...... 11 LIDODERM...... 7 methotrexate sodium...... 24 ISENTRESS HD...... 11 LINZESS...... 19 methylphenidate hcl...... 14 isosorbide mononitrate er... 13 liothyronine sodium...... 23 methylphenidate hcl er...... 14 JANUMET...... 16 LIPITOR...... 13 methylprednisolone...... 21 JANUMET XR...... 16 LIPOFEN...... 13 metoclopramide hcl...... 9 JANUVIA...... 16 lisinopril...... 13 metoprolol succinate er...... 13 JARDIANCE...... 16 lisinopril- metoprolol tartrate...... 13 JENTADUETO...... 16 hydrochlorothiazide...... 13 METROGEL...... 16 JENTADUETO XR...... 16 lithium carbonate...... 12 metronidazole...... 8, 16 JUBLIA...... 9 lithium carbonate er...... 11 microgestin 1.5/30...... 23 JULUCA...... 11 LIVALO...... 13 microgestin 1/20...... 23 junel 1/20...... 22 LO LOESTRIN FE...... 22 microgestin fe 1/20...... 23 junel fe 1.5/30...... 22 lorazepam...... 11 MIGRANAL...... 10 junel fe 1/20...... 22 loryna...... 22 MINASTRIN 24 FE...... 23 KADIAN...... 6 LORZONE...... 29 MINIVELLE...... 23 KAZANO...... 16 losartan potassium...... 13 minocycline hcl...... 8 KERYDIN...... 9 losartan potassium-hctz...... 13 mirtazapine...... 9 ketoconazole...... 9 lovastatin...... 13 MIRVASO...... 16 ketorolac tromethamine.. 7, 26 LOVAZA...... 13 modafinil...... 29 KEVZARA...... 24 low-ogestrel...... 22 mometasone furoate.....21, 27 KITABIS PAK...... 28 LUMIGAN...... 26 mono-linyah...... 23

33 mononessa...... 23 nortrel 1/35 (28)...... 23 ONETOUCH ULTRA 2...... 17 montelukast sodium...... 28 nortriptyline hcl...... 9 ONETOUCH ULTRA morphine sulfate er...... 6 NORVASC...... 13 BLUE TEST STRIPS...... 17 MOTOFEN...... 19 NORVIR...... 11 ONETOUCH ULTRA MINI..17 MOVANTIK...... 19 NOVOFINE AUTOCOVER ONETOUCH VERIO..... 17, 18 MOVIPREP...... 20 PEN NEEDLE...... 18 ONETOUCH VERIO FLEX MOXEZA...... 26 NOVOFINE PEN NEEDLE. 18 SYSTEM KIT W/DEVICE....17 moxifloxacin hcl...... 26 NOVOFINE PLUS PEN ONETOUCH VERIO IQ MULTAQ...... 13 NEEDLE...... 18 SYSTEM...... 18 mupirocin...... 8 NOVOLIN 70/30 RELION... 18 ONEXTON...... 16 mycophenolate mofetil...... 24 NOVOLIN 70/30 VIAL...... 18 ONGLYZA...... 17 mycophenolate sodium...... 24 NOVOLIN N RELION...... 18 ONZETRA XSAIL...... 10 myorisan...... 16 NOVOLIN N VIAL...... 18 OPANA ER...... 6 MYRBETRIQ...... 20 NOVOLIN R RELION...... 18 OPSUMIT...... 29 nabumetone...... 7 NOVOLIN R VIAL...... 18 ORACEA...... 16 nadolol...... 13 NOVOLOG FLEXPEN...... 18 ORENITRAM...... 29 naltrexone hcl...... 7 NOVOLOG MIX 70/30 orphenadrine citrate er...... 29 NAMZARIC...... 9 FLEXPEN...... 18 ORTHO TRI-CYCLEN (28).23 naproxen...... 7 NOVOLOG MIX 70/30 ORTHO TRI-CYCLEN LO.. 23 naproxen sodium...... 7 VIAL...... 18 oseltamivir phosphate...... 11 NARCAN...... 7 NOVOLOG PENFILL...... 18 OSENI...... 17 NASONEX...... 27 NOVOLOG U-100 VIAL...... 18 OSPHENA...... 21 NATAZIA...... 23 NOVOTWIST PEN OTEZLA...... 24 NATURE-THROID...... 23 NEEDLE...... 18 OVIDREL...... 22 neomycin-polymyxin- NUCYNTA...... 6 oxcarbazepine...... 8 dexameth...... 26 NUCYNTA ER...... 6 OXSORALEN ULTRA...... 16 neomycin-polymyxin-hc...... 26 NUTROPIN AQ NUSPIN OXTELLAR XR...... 8 NESINA...... 17 10...... 22 oxybutynin chloride...... 20 NEUPOGEN...... 12 NUTROPIN AQ NUSPIN oxybutynin chloride er...... 20 NEVANAC...... 26 20...... 22 oxycodone hcl...... 6 NEXIUM...... 19 NUTROPIN AQ NUSPIN 5. 22 oxycodone-acetaminophen...6 niacin er NUVARING...... 23 OXYCONTIN...... 6 (antihyperlipidemic)...... 13 NUVIGIL...... 29 OZEMPIC...... 17 nifedipine er...... 13 NUWIQ...... 12 PANCREAZE...... 20 nifedipine er osmotic nystatin...... 10 pantoprazole sodium...... 19 release...... 13 ocella...... 23 paroxetine hcl...... 9 nikki...... 23 ODEFSEY...... 11 paroxetine hcl er...... 9 nitrofurantoin macrocrystal... 8 ofloxacin...... 26 PAZEO...... 26 nitrofurantoin monohydrate olanzapine...... 11 penicillin v potassium...... 8 macrocrystals...... 8 olmesartan medoxomil...... 13 PENNSAID...... 7 nitroglycerin...... 13 olmesartan medoxomil- PENTASA...... 25 NITROSTAT...... 13 hctz...... 13 pentoxifylline er...... 13 NITYR...... 20 olopatadine hcl...... 26 PERCOCET...... 6 NORCO...... 6 OMECLAMOX-PAK...... 20 PERFOROMIST...... 28 NORDITROPIN FLEXPRO.22 omega-3-acid ethyl esters.. 13 permethrin...... 10 norethindrone...... 23 omeppi...... 19 PERTZYE...... 20 norethindrone acet-ethinyl omeprazole...... 19 phenazopyridine hcl...... 20 est...... 23 omeprazole-sodium phentermine hcl...... 15 norgestimate-eth estradiol.. 23 bicarbonate...... 19 phenytoin sodium norgestimate-ethinyl OMNARIS...... 27 extended...... 8 estradiol triphasic...... 23 OMNITROPE...... 22 pioglitazone hcl...... 17 NORITATE...... 16 ondansetron hcl...... 9 PLEGRIDY...... 14 nortrel 1/35 (21)...... 23 ondansetron odt...... 9

34 PLEGRIDY STARTER QVAR REDIHALER...... 28 SOLIQUA...... 17 PACK...... 14 rabeprazole sodium...... 19 SOLODYN...... 8 polyethylene glycol 3350.... 20 raloxifene hcl...... 21 SOOLANTRA...... 16 polymyxin b-trimethoprim....26 ramipril...... 13 sotalol hcl...... 13 portia-28...... 23 RANEXA...... 13 SPIRIVA HANDIHALER..... 28 potassium chloride crys er.. 19 ranitidine hcl...... 19 SPIRIVA RESPIMAT...... 28 potassium chloride er...... 19 RAPAFLO...... 20 spironolactone...... 14 potassium citrate er...... 19 RASUVO...... 24 sprintec 28...... 23 PRADAXA...... 8 RAYOS...... 21 SPRIX...... 7 PRALUENT...... 13 REBIF...... 15 SPRYCEL...... 10 pramipexole REBIF REBIDOSE...... 15 STAXYN...... 20 dihydrochloride...... 10 REBIF REBIDOSE STEGLATRO...... 17 pravastatin sodium...... 13 TITRATION PACK...... 15 STEGLUJAN...... 17 prazosin hcl...... 13 REBIF TITRATION PACK.. 15 STELARA...... 25 prednisolone...... 21 RELISTOR...... 20 STENDRA...... 20 prednisolone acetate...... 26 REMICADE...... 24 STIOLTO RESPIMAT...... 28 prednisolone sodium RENVELA...... 20 STRIBILD...... 11 phosphate...... 21 REPATHA...... 13 SUBOXONE...... 7 prednisone...... 21 REPATHA PUSHTRONEX SUBSYS...... 6 PREMARIN...... 23 SYSTEM...... 13 sucralfate...... 19 PREMPHASE...... 23 REPATHA SURECLICK..... 13 sulfamethoxazole- PREMPRO...... 23 RESTASIS...... 26 trimethoprim...... 8 PREPOPIK...... 20 RESTASIS MULTIDOSE.... 26 sulfasalazine...... 25 PREVACID...... 19 RETIN-A MICRO...... 16 sulindac...... 7 PREZCOBIX...... 11 RETIN-A MICRO PUMP..... 16 sumatriptan succinate...... 10 PREZISTA...... 11 REVLIMID...... 10 SUPREP BOWEL PREP PRISTIQ...... 9 REXULTI...... 11 KIT...... 20 PROAIR HFA...... 28 REYATAZ...... 11 SYMBICORT...... 28 PROAIR RESPICLICK...... 28 RHOPRESSA...... 26 SYMFI...... 11 prochlorperazine maleate..... 9 risperidone...... 11 SYMFI LO...... 11 PROCRIT...... 12 rizatriptan benzoate...... 10 SYMPROIC...... 20 PROCTOFOAM HC...... 25 ropinirole hcl...... 10 SYNJARDY...... 17 progesterone micronized.... 23 rosuvastatin calcium...... 13 SYNJARDY XR...... 17 PROGRAF...... 24 SABRIL...... 8 SYNTHROID...... 23 PROLENSA...... 26 SAIZEN...... 22 SYNVISC...... 25 promethazine hcl...... 27 SAIZENPREP...... 22 SYNVISC ONE...... 25 promethazine-codeine...... 27 SANCUSO...... 9 TACLONEX...... 16 promethazine-dm...... 27 SANDOSTATIN...... 22 tacrolimus...... 25 propranolol hcl...... 13 SAPHRIS...... 11 TALTZ...... 25 propranolol hcl er...... 13 SAVAYSA...... 8 TAMIFLU...... 11 PROVENTIL HFA...... 28 scopolamine...... 9 tamoxifen citrate...... 10 PROZAC...... 9 SEEBRI NEOHALER...... 28 tamsulosin hcl...... 20 pseudoephedrine- SEGLUROMET...... 17 TAZORAC...... 16 bromphen-dm...... 27 SEREVENT DISKUS...... 28 TECFIDERA...... 15 PULMICORT FLEXHALER.28 sertraline hcl...... 9 TEKTURNA...... 14 PULMICORT SHINGRIX...... 25 TEKTURNA HCT...... 14 SUSPENSION...... 28 sildenafil citrate...... 20, 29 telmisartan...... 14 PYLERA...... 20 SILENOR...... 29 temazepam...... 29 QNASL...... 27 SIMBRINZA...... 26 tenofovir disoproxil QNASL CHILDRENS...... 27 SIMPONI...... 25 fumarate...... 11 QTERN...... 17 SIMPONI ARIA...... 24 terazosin hcl...... 20 quetiapine fumarate...... 11 simvastatin...... 13 terbinafine hcl...... 10 quinapril hcl...... 13 SINGULAIR...... 28 terconazole...... 10

35 TESTIM...... 21 UTIBRON NEOHALER...... 28 XIGDUO XR...... 17 TESTOSTERONE...... 21 VAGIFEM...... 23 XIIDRA...... 26 testosterone cypionate...... 21 valacyclovir hcl...... 11 XOLAIR...... 27 timolol maleate...... 26 VALIUM...... 11 XOPENEX HFA...... 28 TIMOPTIC OCUDOSE...... 26 valsartan...... 14 XTAMPZA ER...... 6 TIROSINT...... 23 valsartan- XTANDI...... 10 TIVICAY...... 11 hydrochlorothiazide...... 14 xulane...... 23 tizanidine hcl...... 29 VARUBI...... 9 YAZ...... 23 TOBI NEBULIZER...... 28 VASCEPA...... 14 yuvafem...... 23 TOBI PODHALER...... 28 VECTICAL...... 16 ZARXIO...... 12 TOBRADEX...... 26 VELPHORO...... 20 ZEGERID...... 19 tobramycin...... 26, 28 VELTASSA...... 19 ZELAPAR...... 10 TOBRAMYCIN...... 28 VELTIN...... 16 ZEMBRACE SYMTOUCH.. 10 tobramycin- venlafaxine hcl...... 9 ZENPEP...... 20 dexamethasone...... 26 venlafaxine hcl er...... 9 ZETIA...... 14 tolterodine tartrate er...... 20 VENTOLIN HFA...... 28 ZETONNA...... 27 TOPICORT SPRAY...... 21 verapamil hcl...... 14 ZIANA...... 16 topiramate...... 8 verapamil hcl er...... 14 ZIOPTAN...... 26 topiramate er...... 8 VESICARE...... 20 ziprasidone hcl...... 11 TOPROL XL...... 14 V-GO 20...... 18 ZOHYDRO ER...... 6 torsemide...... 14 V-GO 30...... 18 ZOLOFT...... 9 TOUJEO SOLOSTAR...... 18 V-GO 40...... 18 zolpidem tartrate...... 29 TOVIAZ...... 20 VIAGRA...... 20 zolpidem tartrate er...... 29 TRACLEER...... 29 VIBERZI...... 20 ZOMACTON...... 22 TRADJENTA...... 17 VICTOZA...... 17 ZOMIG...... 10 tramadol hcl...... 6 vienva...... 23 ZOMIG ZMT...... 10 tramadol-acetaminophen...... 6 VIIBRYD...... 9 zonisamide...... 8 TRAVATAN Z...... 26 VIIBRYD STARTER PACK...9 ZORVOLEX...... 7 trazodone hcl...... 9 VIMOVO...... 7 ZOVIRAX...... 11 TREMFYA...... 25 VIMPAT...... 8 ZUBSOLV...... 7 TRESIBA FLEXTOUCH...... 18 VIOKACE...... 20 ZURAMPIC...... 10 tretinoin...... 16 viorele...... 23 ZYCLARA...... 16 triamcinolone acetonide...... 21 VITAFOL...... 19 ZYCLARA PUMP...... 16 triamterene-hctz...... 14 vitamin d (ergocalciferol).....19 ZYPITAMAG...... 14 triazolam...... 11 VIVELLE-DOT...... 23 ZYTIGA...... 10 TRIBENZOR...... 14 VOGELXO...... 21 tri-estarylla...... 23 VOGELXO PUMP...... 21 tri-linyah...... 23 VOLTAREN...... 7 tri-lo-marzia...... 23 VOSEVI...... 11 trinessa (28)...... 23 VRAYLAR...... 11 trinessa lo...... 23 VYTORIN...... 14 TRINTELLIX...... 9 VYVANSE...... 14 tri-previfem...... 23 warfarin sodium...... 8 tri-sprintec...... 23 WELLBUTRIN SR...... 9 TRIUMEQ...... 11 WELLBUTRIN XL...... 9 TROKENDI XR...... 8 XANAX...... 11 TRULANCE...... 20 XANAX XR...... 11 TRULICITY...... 17 XARELTO...... 8 TRUVADA...... 11 XARELTO STARTER TUDORZA PRESSAIR...... 28 PACK...... 8 TYMLOS...... 25 XELJANZ...... 25 UCERIS...... 25 XELJANZ XR...... 25 ULORIC...... 10 XIFAXAN...... 8

36 Nondiscrimination notice and access to communication services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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

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

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card. Multi-language interpreter services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

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تنبيه: إذا كنت تتحدث العربية )Arabic(، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّمعرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuite- ment. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an. 注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی )Farsi( است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. لطفا با شماره تلفن رایگانی که روی کارت شناسايی شما قید شده تماس بگيريد.

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OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com/optumrx. All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners. © 2018 Optum, Inc. All rights reserved. 68257C-062018 Innoviant Premium Welcome to your specialty pharmacy

Specialty medications can be important to maintaining or improving your health — and your quality of life. BriovaRx®, the OptumRx® specialty pharmacy, provides the resources and personalized, condition-specific support you need to help you better manage your condition.

What is a specialty medication?

We define an injectable, oral or inhaled medication as a specialty medication if it:

• May require ongoing clinical oversight and Specialty medication additional education for best management resources • Has unique storage or shipping requirements Customer service • May not be available at retail pharmacies Call 1-855-4BRIOVA (1-855-427-4682)

BriovaRx: A specialty pharmacy to meet your needs Online at optumrx.com Price your medication BriovaRx offers support to help you and find additional manage your condition. Take advantage resources including of personalized patient support from information specific knowledgeable pharmacists and nurses to your condition. who specialize in your condition at no additional cost to you. In addition, you’ll receive:

• Access to your medications at the lowest cost

• 24/7 access to pharmacists

• Support through clinical and adherence programs

• Any medication-related supplies at no additional cost

• Proactive refill reminders

• Timely delivery and shipping in confidential packaging Rx guide for specialty medications

Guiding your health journey under your pharmacy benefit We understand the challenge of living with and managing a complex health condition. That’s where BriovaRx comes in, to assist you every step of the way.

Getting started: Transfer your prescriptions Monitor your health. Enroll in the specialty pharmacy program If you need help with anything else from with BriovaRx. weight loss to back pain and even smoking If you haven’t done so yet, call BriovaRx cessation, your specialty pharmacist or nurse at 1-855-4BRIOVA (1-855-427-4682) can help you locate wellness coaching and to get started. disease management programs to help you stay on track with your health. Access to a pharmacist 24/7. Follow your care plan. Our specialty pharmacists and patient care coordinators are available 24/7 and will take If you’re part of a clinical management program, care of everything for you, including: be sure to follow your care plan and tell your pharmacist or nurse about any new medications • Transferring your prescription to BriovaRx you’re taking. • Helping you find affordable access to your medication and manage any side effects Staying on track with your treatment • Explaining how the specialty pharmacy works Quick and easy refills. Personalized support. We make it easy for you to remember to take Once you start getting your specialty your medication with a reminder phone call a medications through BriovaRx, you’ll also few days prior to the time when you need to experience personalized, one-on-one support refill your prescription. You can even sign up for from pharmacists and nurses. They’re there for text message reminders online or by phone. you any time you have questions about your Overnight delivery. medication, side effects and more. With your specialty pharmacy, shipping your medication is quick, easy and safe. Refrigerated Working with your pharmacist or nurse medications will be delivered overnight directly Continued conversations. to your home or office, in a temperature- controlled package. Others will be shipped Tell your pharmacist or nurse about any changes within one to three days. Supplies will also be or complications in your therapy, such as: provided at no extra cost. • Any side effects Save more time and money. • Trouble remembering to take your medication If you’re looking to save money on your medications, finding lower-cost alternatives and transferring your non-specialty prescriptions through the mail can help.

optumrx.com

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

January 1, 2019

BriovaRx®, the OptumRx® specialty pharmacy, provides comprehensive support services, including access to pharmacists around the clock, for high-cost oral and injectable medications used to treat rare and complex conditions. In addition, your medications will be shipped to you at no extra cost.

OptumRx | optumrx.com Specialty pharmacy drug list

Characteristics of specialty medications

Specialty medications are used to give care for rare and complex conditions. They are often drugs you take by mouth or inject. For a medication to be filled through BriovaRx, our specialty pharmacy, it must be at least one of the following:

High-priced • Can cost more than $1,000/30 day supply.

Complex • Drug imitates compounds found in the body.

• Part of a specialty drug class.

High-touch • Special shipping or handling like refrigeration.

• Needs a doctor or pharmacist to measure how well it works for you.

• Special steps to follow as you take. Specialty pharmacy drug list

Adult incontinence Asthma Duchenne muscular Carbaglu dystrophy Cerdelga PA Solesta Cinqair PA Cerezyme PA Fasenra PA EmflazaPA Cholbam PA Nucala PA Ammonia detoxicants Cystagon PA Endocrine Xolair PA PA Elaprase Ravicti PA Cuprimine PA Cardiovascular Elelyso PA Egrifta Fabrazyme PA Anemia PA PA Northera Firmagon Galafold PA Aranesp PA Hydroxy Capr Glassia PA Central nervous PA Epogen PA Korlym Kanuma PA system agents PA Mircera PA Kuvan Lumizyme PA PA Procrit PA Austedo PA Lupaneta Mepsevii PA PA Brineura PA Makena Miglustat PA PA PA Myalept PA Anticoagulation Hetlioz Naglazyme PA Radicava PA Natpara Olumiant PA PA Arixtra Sabril PA Nityr Onpattro PA Enoxaparin Tetrabenazine PA Octreotide Orfadin PA Fondaparinux Vigabatrin PA Parsabiv Palynziq PA PA Fragmin Vigadrone PA Procysbi Phenylbutyrate Lovenox Xenazine PA Samsca Prolastin-C PA PA Sandostatin Sodium Pheny Cystic fibrosis PA Anti-Gout agent Signifor Strensiq PA Somatuline PA PA Bethkis Sucraid Krystexxa PA Cayston PA Somavert Vimizim PA PA Kalydeco PA Supprelin LA Vpriv PA Antihyperlipidemic PA Kitabis Pak ST Syprine Zavesca PA PA Thiola PA Juxtapid PA Orkambi Zemaira PA PA Thyrogen Kynamro PA Pulmozyme PA PA Trientine Praluent PA Symdeko Gastrointestinal agents Triptodur PA Repatha PA Tobi PA PA Tobramycin ST Xuriden Gattex Ocaliva PA Anti-infective Enzyme therapy Diagnostic Xermelo PA PA Daraprim Acthrel Adagen Prevymis Aldurazyme PA Aralast NP PA Buphenyl

PA – Prior authorization required • ST – Step therapy 3 Specialty pharmacy drug list

Specialty pharmacy drug list

GROWTH HORMONE Feiba Hepatitis C Delstrigo DEFICIENCY Helixate FS Descovy Daklinza PA Hemlibra Didanosine Genotropin PA Epclusa PA. Hemofil M Edurant Humatrope PA Harvoni PA Humate-P Efavirenz Increlex PA Mavyret PA Jivi Emtriva Norditropin PA Moderiba Idelvion Epivir Nutropin AQ PA Pegasys PA Ixinity Epzicom Omnitrope PA Pegintron PA Koate Evotaz Saizen PA Rebetol Koate-DVI Fosamprenavir Serostim PA Ribapak Kogenate FS Fuzeon Zomacton PA Ribasphere Kovaltry Genvoya Zorbtive PA Ribavirin Monoclate-P Intelence Sovaldi PA Hematological agents Mononine Invirase Technivie PA Novoeight Isentress Viekira PA Doptelet Novoseven RT Kaletra Vosevi PA Fibryga Nuwiq Juluca PA Zepatier PA Mozobil Obizur Lamivud/Zido Mulpleta Profilnine Hereditary angioedema Lamivudine PA Nplate Rebinyn Lexiva PA Panhematin Recombinate Berinert Lopin/Riton PA PA Promacta Rixubis Cinryze Nevirapine PA Riastap Tretten Firazyr Norvir PA PA Soliris Vonvendi Haegarda Odefsey PA Thrombat III Wilate Kalbitor Pifeltro Ruconest PA Hemophilia Xyntha Prezcobix Takhzyro Prezista Advate Hepatitis B HIV Rescriptor Adynovate Adefov Dipiv Retrovir Afstyla Baraclude Abacav/Lamiv Reyataz Alphanate Entecavir Abacavir Ritonavir Alphanine SD Epivir HBV Atazanavir Selzentry Alprolix Hepsera Aptivus Stavudine ST Bebulin Lamivudine Atripla Stribild Benefix Vemlidy Biktarvy Sustiva Ceprotin Cimduo Symfi Coagadex Combivir Symfi Lo Corifact Complera Eloctate Crixivan

4 OptumRx | optumrx.com Symtuza Immunological agents Taltz PA Neutropenia Tenofovir Tremfya PA Actimmune PA Fulphila Tivicay Xeljanz PA Arcalyst PA Granix PA Triumeq Benlysta PA Metabolic bone disease H.P. Acthar PA Trizivir Ilaris PA Leukine PA Trogarzo Reclast Lemtrada PA Neulasta PA Truvada Zoledronic Neupogen PA Tybost Infertility Zometa Nivestym Videx PA Zarxio PA Viracept Bravelle Multiple sclerosis Cetrotide PA Viramune Ampyra PA Oncology - injectable Chor Gonadot PA Viread Aubagio PA Follistim AQ PA Abraxane Zerit Avonex PA Ganirelix AC PA Adcetris PA Ziagen Betaseron PA Gonal-F PA Adriamycin Zidovudine Copaxone PA Menopur PA Adrucil Extavia PA Immune globulin Novarel PA Alferon N Gilenya PA Ovidrel Alimta Atgam Glatiramer PA Pregnyl PA Aliqopa PA Bivigam PA Glatopa PA Alkeran Carimune NF PA Inflammatory conditions Ocrevus PA Arranon Cuvitru PA Plegridy PA PA PA PA Actemra Arzerra Cytogam Rebif PA PA PA Cimzia Avastin Flebogamma TecfideraPA PA PA Cosentyx Azacitidine Gamastan S/D Tysabri PA PA PA PA Dupixent Bavencio Gammagard Zinbryta PA PA Beleodaq PA Gammaked PA Enbrel PA Bendeka Gammaplex PA Entyvio Musculoskeletal agents PA PA PA Humira Besponsa Gamunex-C Exondys 51 PA PA Ilumya Bicnu Hizentra Spinraza PA InflectraPA Bleomycin Hyperrho S/D PA PA Xiaflex Blincyto PA Hyqvia PA Kevzara PA Bortezomib PA Micrhogam Kineret Narcolepsy PA PA Olumiant Busulfan Octagam PA PA Xyrem Busulfex Privigen PA Orencia PA Campath Winrho SDF Otezla Neurological agents Remicade PA Camptosar RenflexisPA Botox PA Carboplatin Siliq PA Dysport PA Cisplatin Injectable Simponi PA Myobloc PA Cladribine Stelara PA Xeomin PA

PA – Prior authorization required • ST – Step therapy 5 Specialty pharmacy drug list

Specialty pharmacy drug list

Clofarabine Ifex Proleukin Oncology - oral Clolar Ifosfamide Rituxan PA AfinitorPA Cosmegen ImfinziPA Romidepsin Alecensa PA Cyclophosph Imlygic Sylatron PA Alunbrig PA Cyramza PA Intron A PA Sylvant PA Bexarotene PA Cytarabine Irinotecan Synribo PA Bosulif PA Dacarbazine Istodax OVR PA Taxotere Braftovi PA Dacogen PA Ixempra kit Tecentriq PA Cabometyx PA Dactinomycin Jevtana PA Temodar PA Calquence PA Darzalex PA Kadcyla PA Teniposide Capecitabine PA Daunorubicin Kepivance Tepadina Caprelsa PA Decitabine PA Keytruda PA Theracys Cometriq PA Dexrazoxane Kymriah PA Thiotepa Cotellic PA Docetaxel Kyprolis PA Tice BCG Erivedge PA Doxil Lartruvo PA Toposar Erleada PA Doxorubicin Leuprolide Injectable PA Topotecan Etoposide Capsule Eligard PA Levoleucovor Torisel Farydak PA Ellence Lipodox 50 Totect Gilotrif PA Empliciti PA Lupron Depot PA Treanda Gleevec PA Epirubicin Marqibo Trelstar mix PA Gleostine Erbitux PA Melphalan Trisenox Hycamtin Erwinaze Mesna Unituxin PA Ibrance PA Etopophos Mesnex Valstar Iclusig PA Etoposide Injectable Mitomycin Injectable Vectibix Idhifa PA Evomela Mitoxantron PA Velcade PA Imatinib Mes PA Faslodex Mustargen Vidaza Imbruvica PA Floxuridine Injectable Mutamycin Vinblastine Injectable Inlyta PA Fludarabine Mylotarg PA Vincasar PFS Iressa PA Fluorouracil Injectable Navelbine Vincristine JakafiPA Folotyn PA Nipent Vinorelbine Kisqali PA Fusilev Oncaspar Vyxeos PA Lenvima PA Gazyva PA Onivyde Xgeva PA Lonsurf PA Gemcitabine Opdivo PA Yervoy PA Lynparza PA Gemzar Oxaliplatin Yescarta PA Matulane Halaven PA Paclitaxel Yondelis Mekinist PA Herceptin PA Pamidronate Zaltrap PA Mektovi PA Hycamtin Perjeta PA Zanosar Mercaptopurine Idamycin PFS Photofrin Zevalin Mesnex Idarubicin Portrazza PA Zinecard Nerlynx PA Poteligeo Zoladex

6 OptumRx | optumrx.com Nexavar PA Oncology - topical Tymlos PA Substance abuse Nilandron treatment Valchlor PA Pain management Nilutamide Sublocade PA Ninlaro PA Ophthalmic agents Prialt Vivitrol Odomzo PA PA Bevacizumab Parkinson’s disease Pomalyst Transplant Cystaran PA Purixan Apokyn PA Revlimid PA Eylea Astagraf XL Rubraca PA Iluvien Pulmonary fibrosis Cellcept PA Jetrea Cellcept IV Rydapt PA PA Esbriet Sprycel PA Keveyis Cyclosporine Ofev PA Stivarga PA Lucentis Envarsus XR PA Sutent PA Luxturna Pulmonary hypertension Gengraf Tabloid Macugen Mycophenolate Adcirca PA TafinlarPA Ozurdex Mycophenolic Adempas PA Tagrisso PA Retisert Myfortic Epoprostenol PA Tarceva PA Visudyne Neoral Flolan PA PA Targretin PA Nulojix Opioid Antagonists Letairis PA Tasigna PA Prograf Opsumit PA Temodar PA Sublocade Rapamune Orenitram PA Temozolomide PA Sandimmune Osteoarthritis Remodulin PA Thalomid PA Sirolimus Tab Revatio PA Tibsovo Durolane PA Tacrolimus SildenafilPA PA Tretinoin EuflexxaPA Zortress Tadalafil Tab Tykerb PA Gel-one PA Tracleer PA Venclexta PA Gelsyn-3 PA Tyvaso PA Verzenio PA Genvisc 850 PA Uptravi PA Votrient PA Hyalgan PA Veletri PA Xalkori PA Hymovis PA Ventavis PA Xeloda PA Monovisc PA Xtandi PA Orthovisc PA RSV Yonsa PA Supartz PA PA Zejula PA Synvisc PA Synagis Zelboraf PA Visco-3 PA Zolinza PA Osteoporosis Zydelig PA Zykadia PA Forteo PA Zytiga PA Prolia PA

PA – Prior authorization required • ST – Step therapy 7 Specialty pharmacy drug list

About OptumRx

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. BriovaRx is our specialty pharmacy. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

To fill a prescription for a specialty medication on this list, please call 1-855-4BRIOVA (855-427-4682) or visit optumrx.com.

This specialty pharmacy drug list may not be a complete list of all specialty medications; this list can change at any time without notice.

Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your doctor.

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com/optumrx. All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners. © 2018 OptumRx, Inc. ORX2700_190101 75365A-102018 ACT NOW to get all the benefits of medication home delivery.

OptumRx home delivery is safe and reliable.

Cost savings You may pay less for your medication with Need your medication a three-month supply through OptumRx. right away?

Convenience Ask your doctor for a Get free standard shipping on medications one-month supply that can delivered to your mailbox. be immediately filled at a participating retail pharmacy. 24/7 access and reminders Speak to a pharmacist who can answer your questions any time, any day. Whether you have a new prescription or need to transfer an existing one, it’s easy to get started with OptumRx.

Here’s how: ePrescribe Ask your doctor to send an electronic prescription to OptumRx.

Online Visit optumrx.com and select Get Started or use the OptumRx app. From there, you can fill new prescriptions, transfer others to home delivery and more.

Phone Call the toll-free number on your member ID card to speak to a customer service advocate. Once OptumRx receives your complete order for a new prescription, your medication should arrive within 10 business days. Completed refill orders should arrive in about seven business days. We look forward to serving you. optumrx.com

All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

(Additional coverage, if applicable) Secondary Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy) Gender Email  M  F Physician Name

Physician Phone Number with Area Code

2 Health history Medication Allergies:  Aspirin  Erythromycin  Quinolones  Others:  None known  Cephalosporins  NSAIDs  Sulfa  Amoxil/Ampicillin  Codeine  Penicillin  Tetracyclines Health Conditions:  Asthma  Glaucoma  High cholesterol  Others:  None known  Cancer  Heart condition  Osteoporosis  Arthritis  Diabetes  High blood pressure  Thyroid Disease Over-the-counter/herbal medications taken regularly:

3 Payment and shipping information — do not send cash Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications. You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment. Ship overnight. Add $12.50 to New Credit Card Number order amount (subject to change). Check enclosed. All checks must be signed and made payable to: OptumRx. Expiration Date (Month/Year) Visa, MasterCard, AMEX Charge to my credit card on file. and Discover are accepted. Charge to my NEW credit card. Signature: Date: For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time. 4 Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

ORX5633_140915 NRX001 Free Meter Program

Diabetes can harm your eyes, kidneys, nerves, heart and blood vessels. The impact can be long-term. Regular blood sugar testing can help you manage your diabetes and may lead to better glucose control.

Take advantage of this great offer To help you monitor blood sugar levels, your pharmacy benefit plan offers a Free Meter Program. With this program, you may be able to get a blood sugar meter at no charge to you. You and your doctor can choose from various meters. For more details, call OptumRx customer service at the phone number on your ID card. Or contact the meter manufacturer Service Center.

How to get your free meter The first step in every diabetes care plan is talking with your health care team. If you would like a new blood sugar meter, tell your doctor or diabetes educator. They will help you select the no-charge meter that’s right for you. Once you decide, it’s easy to place your order. Just call the manufacturer’s Service Center any time.

Your free meter choices are inside Select PDL Free Meter Program Free Meter Program

Choose from these brand-name meters

To obtain one of these ACCU-CHEK® meters call their Service Center at 1-877-411-9833 http://meters.accu-chek.com

Monitor Test Strips

ACCU-CHEK Guide ACCU-CHEK Guide Test Strips

ACCU-CHEK Aviva Plus ACCU-CHEK Aviva Plus Test Strips

ACCU-CHEK Nano SmartView ACCU-CHEK SmartView Test Strips

ACCU-CHEK Aviva Expert ACCU-CHEK Aviva Plus Test Strips

• The ACCU-CHEK Aviva Expert meter is designed for carbohydrate counting insulin users and may be available through your healthcare professional. To learn more, visit accu-chek.com/expert, and talk to your doctor to see if Expert is right for you.

OptumRx | optumrx.com To order one of these OneTouch® meters call their Service Center at 1-866-355-9962 Order Code: 594PRX100

Monitor Test Strips

OneTouch Verio® Meter OneTouch Verio® Test Strips

OneTouch Verio Flex® Meter OneTouch Verio® Test Strips

OneTouch Verio IQ® Meter OneTouch Verio® Test Strips Free Meter Program

Don’t delay. Talk with your doctor about choosing the best brand-name meter for you. Then order your meter by calling the manufacturer’s Service Center.

optumrx.com

All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

www.optumrx.com

2300 Main Street, Irvine, CA 92614 The information in this educational tool does not substitute for the medical advice, diagnosis or treatment of your physician. Always seek the help of your physician or qualified health provider for any questions you may have regarding your medical condition. OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX2333_120629 ©2012 OptumRx, Inc.