Effective September 2021

2021 Drug Formulary

For members covered through large employer groups with a 1-tier or 2-tier in-network

pharmacy benefit and no out-of-network pharmacy benefit

Alliance

Core

All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. XB0001338-50-17 Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost. How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers. How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs. Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage. Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/ formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug. Prior authorization, step therapy and nonformulary requests are considered based on coverage criteria requirements approved by the P&T Committee. To request review of an exception to Kaiser Permanente requirements for coverage of prescription drugs, you or your prescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request an exception. If the evidence your prescriber provides meets medical necessity, an exception may be approved. Exceptions to required therapy that may be approved include: contraindications, clinical factors associated with adverse reactions, clinical factors reducing effect, other risks of clinical harm, and barriers to compliance with clinical care. Your prescriber may also request temporary coverage while the exception request is being processed. Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 60 days prior to the effective date.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:  Preferred blood glucose strips: o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required  Disposable insulin syringes and needles  Lancing devices and lancets Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy. Address: Kaiser Permanente Mail Order Pharmacy PO Box 34383 Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630- 4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full.

Excluded Prescription Products for Medications that have Over-The- Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), triamcinolone nasal spray (Nasacort), and fluticasone propionate nasal spray (Flonase).

Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

How do I get additional information?

Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.

The most current drug formulary is available at www.kp.org/wa/formulary. Table of Contents Analgesics - Drugs for Pain and Inflammation ...... 11 Analgesics - Drugs for Pain ...... 11 Anesthetics ...... 12 Anti-Addiction / Substance Abuse Treatment Agents...... 12 Antibacterials ...... 12 Anticoagulants ...... 13 Anticonvulsants - Drugs for Seizures ...... 14 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia ...... 14 Antidepressants ...... 14 Antiemetics - Drugs for Nausea and Vomiting ...... 15 Antifungals ...... 15 Antigout Agents ...... 15 Antimigraine Agents ...... 15 Antimyasthenic Agents ...... 16 Antimycobacterials ...... 16 Antineoplastics - Drugs for Cancer ...... 16 Antiparasitics ...... 17 Antiparkinson Agents ...... 17 Antiplatelets ...... 17 Antipsychotics - Drugs for Mood Disorders ...... 17 Antivirals ...... 18 Anxiolytics - Drugs for Anxiety ...... 19 Bipolar Agents - Drugs for Mood Disorders ...... 19 Blood Products and Modifiers - Drugs for Blood Disorders ...... 19 Cardiovascular Agents - Drugs for Heart and Circulation Conditions ...... 19 Central Nervous System Agents - Drugs for Attention Deficit Disorder ...... 22 Central Nervous System Agents - Drugs for Multiple Sclerosis...... 22 Central Nervous System Agents - Miscellaneous ...... 22 Dental and Oral Agents - Drugs for Mouth and Throat Conditions ...... 22 Dermatological Agents - Drugs for Skin Conditions ...... 22 Diabetes - Antidiabetic Agents ...... 25 Diabetes - Glucose Monitoring ...... 25 Diabetes - Glycemic Agents ...... 26 Diabetes - Insulins ...... 26 Electrolytes / Minerals / Metals / Vitamins ...... 27 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ...... 27 9 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ...... 28 Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment ...... 28 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ...... 28 Genitourinary Agents - Drugs for Prostate Conditions ...... 29 Hormonal Agents - Adrenal ...... 29 Hormonal Agents - Men's Health ...... 29 Hormonal Agents - Osteoporosis ...... 29 Hormonal Agents - Pituitary ...... 29 Hormonal Agents - Sex Hormones and Birth Control ...... 30 Hormonal Agents - Thyroid ...... 32 Immunological Agents - Drugs for Immune System Stimulation or Suppression ...... 32 Immunological Agents - Drugs for Vaccination ...... 33 Inflammatory Bowel Disease Agents ...... 34 Metabolic Bone Disease Agents - Drugs for Osteoporosis ...... 34 Metabolic Bone Disease Agents - Other ...... 34 Miscellaneous Therapeutic Agents ...... 34 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ...... 35 Ophthalmic Agents - Drugs for Glaucoma ...... 36 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ...... 36 Otic Agents - Drugs for Ear Conditions ...... 36 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ...... 37 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions ...... 37 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ...... 38 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ...... 38 Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ...... 38 Sleep Disorder Agents ...... 38 Index of Drugs ...... 40

10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for Pain and codeine sulfate 1 QL

Inflammation endocet 1 QL celecoxib oral 1 fentanyl transdermal diclofenac potassium 1 patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 1 PA; QL diclofenac sodium er 1 mcg/hr, 50 mcg/hr, 75 diclofenac sodium oral 1 mcg/hr diflunisal oral 1 hydrocodone- acetaminophen oral 1 etodolac solution 2.5-108 mg/5ml, 1 QL flurbiprofen oral 1 5-217 mg/10ml, 7.5-325 mg/15ml ibuprofen 1 hydrocodone- 1 indomethacin er acetaminophen oral tablet 1 QL indomethacin oral capsule 10-325 mg, 5-325 mg, 1 25 mg, 50 mg 7.5-325 mg ketorolac tromethamine hydromorphone hcl oral 1 QL 1 injection hydromorphone hcl rectal 1 QL ketorolac tromethamine 1 levorphanol tartrate oral 1 PA; QL intramuscular methadone hcl oral meclofenamate sodium 1 ST; QL 1 solution oral methadone hcl oral tablet 1 ST; QL meloxicam oral tablet 1 methadone hcl oral tablet 1 ST; QL nabumetone oral 1 soluble naproxen oral suspension 1 methadose oral tablet 1 ST; QL naproxen oral tablet 1 soluble naproxen sodium oral morphine sulfate 1 tablet 275 mg, 550 mg (concentrate) oral solution 1 QL 100 mg/5ml, 20 mg/ml piroxicam oral 1 morphine sulfate er oral 1 ST; QL salsalate oral 1 tablet extended release sulindac oral 1 morphine sulfate oral 1 QL Analgesics - Drugs for Pain morphine sulfate rectal 1 QL acetaminophen-codeine 1 QL OXYCODONE HCL ER 2 ST; QL acetaminophen-codeine oxycodone hcl oral 1 QL 1 QL #2 concentrate 100 mg/5ml acetaminophen-codeine oxycodone hcl oral 1 QL 1 QL #3 solution acetaminophen-codeine oxycodone hcl oral tablet 1 QL 1 QL #4 oxycodone- acetaminophen oral tablet bac 1 1 QL 10-325 mg, 2.5-325 mg, butalbital-apap-caffeine 1 5-325 mg, 7.5-325 mg oral tablet OXYCONTIN 2 ST; QL butalbital-aspirin-caffeine 1 Effective Date: 09/01/2021 11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tramadol hcl ir 1 QL nicotine polacrilex mini 2 tramadol-acetaminophen 1 QL nicotine polacrilex 2 Anesthetics mouth/throat glydo 1 nicotine step 1 1 lidocaine external patch 5 nicotine step 2 1 1 % nicotine step 3 1 lidocaine hcl (pf) injection 1 VIVITROL 2 QL solution 1 %, 2 % Antibacterials lidocaine hcl injection 1 solution amoxicillin 1 lidocaine hcl amoxicillin-potassium 1 1 urethral/mucosal clavulanate oral lidocaine-prilocaine 1 ampicillin 1 prilovix ultralite 1 ampicillin sodium injection solution reconstituted 1 1 prilovix ultralite plus 1 gm, 125 mg, 250 mg, 500 Anti-Addiction / Substance Abuse mg

Treatment Agents avidoxy 1 acamprosate calcium 1 azithromycin oral 1 APO-VARENICLINE 2 BICILLIN L-A 2 buprenorphine hcl 1 QL cefadroxil 1 sublingual cefazolin sodium injection buprenorphine hcl- solution reconstituted 1 1 naloxone hcl sublingual 1 QL gm tablet sublingual cefdinir 1 bupropion hcl er (smoking 1 det) cefixime 1 CHANTIX 2 cefprozil 1 CHANTIX CONTINUING ceftazidime injection 2 MONTH PAK solution reconstituted 1 1 gm CHANTIX STARTING 2 MONTH PAK ceftriaxone sodium injection solution disulfiram oral 1 1 reconstituted 1 gm, 2 gm, goodsense nicotine 250 mg, 500 mg mouth/throat lozenge 4 2 cefuroxime axetil 1 mg cephalexin oral capsule habitrol 1 1 250 mg, 500 mg naloxone hcl injection 1 cephalexin oral 1 naltrexone hcl oral 1 suspension reconstituted NARCAN 1 CIPRO ORAL SUSPENSION NICORETTE 2 RECONSTITUTED 250 MOUTH/THROAT GUM 2 2 MG/5ML (5%) MG Effective Date: 09/01/2021 12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 nitrofurantoin ciprofloxacin hcl oral 1 macrocrystal clarithromycin oral 1 nitrofurantoin clindamycin hcl oral 1 monohydrate 1 clindamycin palmitate hcl 1 macrocrystals clindamycin phosphate penicillin v potassium 1 injection solution 300 1 PRIMSOL 2 mg/2ml silver sulfadiazine clindamycin phosphate 1 1 external vaginal SIVEXTRO ORAL 2 QL dicloxacillin sodium 1 ssd 1 doxycycline hyclate oral 1 sulfamethoxazole- capsule 1 trimethoprim oral doxycycline hyclate oral tablet 100 mg, 150 mg, 50 1 sulfatrim pediatric 1 mg, 75 mg SUPRAX ORAL doxycycline monohydrate SUSPENSION 1 2 oral capsule RECONSTITUTED 500 MG/5ML doxycycline monohydrate 1 tazicef injection solution oral tablet 1 reconstituted 1 gm FIRVANQ 2 trimethoprim oral 1 gentamicin sulfate 1 vancomycin hcl oral external 1 QL capsule gentamicin sulfate vancomycin hcl oral injection solution 40 1 1 mg/ml solution reconstituted levofloxacin oral 1 vandazole 1 linezolid oral suspension Anticoagulants 1 QL reconstituted enoxaparin sodium 1 QL linezolid oral tablet 1 fondaparinux sodium 1 QL methenamine hippurate 1 heparin sodium (porcine) injection solution 1000 metronidazole oral tablet 1 1 unit/ml, 10000 unit/ml, metronidazole vaginal 1 5000 unit/ml minocycline hcl oral heparin sodium (porcine) 1 1 capsule pf mondoxyne nl 1 jantoven 1 morgidox oral 1 LOVENOX 1 QL moxifloxacin hcl oral 1 PRADAXA 2 mupirocin calcium 1 warfarin sodium oral 1 mupirocin external 1 XARELTO 2 PA neomycin sulfate oral 1 XARELTO STARTER 2 PA PACK nitrofurantoin 1 Effective Date: 09/01/2021 13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Anticonvulsants - Drugs for Seizures Antidementia Agents - Drugs for

Alzheimer's Disease and Dementia carbamazepine er 1 donepezil hcl oral tablet 1 carbamazepine oral 1 10 mg, 5 mg CELONTIN 2 galantamine 1 DIASTAT PEDIATRIC 1 QL hydrobromide galantamine diazepam rectal 1 QL 1 DILANTIN ORAL hydrobromide er 2 memantine hcl oral tablet CAPSULE 30 MG 1 10 mg, 5 mg divalproex sodium er 1 rivastigmine tartrate 1 divalproex sodium oral 1 Antidepressants epitol 1 amitriptyline hcl oral 1 ethosuximide oral 1 amoxapine 1 gabapentin oral 1 bupropion hcl er (sr) 1 lamotrigine oral tablet 1 bupropion hcl er (xl) oral lamotrigine oral tablet 1 tablet extended release 1 chewable 24 hour 150 mg, 300 mg levetiracetam er 1 bupropion hcl oral 1 levetiracetam oral 1 citalopram hydrobromide 1 NAYZILAM 2 PA; QL clomipramine hcl oral 1 oxcarbazepine 1 desipramine hcl oral 1 phenobarbital oral 1 doxepin hcl oral capsule 1 phenobarbital sodium doxepin hcl oral injection solution 130 1 1 mg/ml concentrate duloxetine hcl oral phenytoin infatabs 1 capsule delayed release 1 phenytoin oral 1 particles 20 mg, 30 mg, phenytoin sodium 60 mg extended oral capsule 1 escitalopram oxalate 1 100 mg fluoxetine hcl oral capsule 1 phenytoin sodium 1 injection fluoxetine hcl oral solution 1 primidone oral 1 QL fluvoxamine maleate 1 roweepra 1 imipramine hcl oral 1 subvenite 1 mirtazapine oral 1 topiramate oral 1 nortriptyline hcl oral 1 valproic acid oral 1 paroxetine hcl 1 PAXIL ORAL VALTOCO 2 PA; QL 2 SUSPENSION zonisamide oral 1 perphenazine- 1 amitriptyline Effective Date: 09/01/2021 14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier phenelzine sulfate oral 1 clotrimazole mouth/throat 1 1 clotrimazole- protriptyline hcl 1 betamethasone sertraline hcl oral 1 CRESEMBA ORAL 2 PA; QL tranylcypromine sulfate 1 fluconazole oral 1 trazodone hcl oral 1 flucytosine oral 2 QL venlafaxine hcl 1 griseofulvin microsize oral 1 venlafaxine hcl er oral capsule extended release 1 griseofulvin ultramicrosize 1 24 hour itraconazole oral 1 PA Antiemetics - Drugs for Nausea and ketoconazole external 1 Vomiting cream aprepitant oral 1 ketoconazole external 1 aprepitant oral capsule shampoo 125 mg, 80 & 125 mg, 80 1 ketoconazole oral 1 mg nyamyc 1 compro 1 nystatin external 1 dimenhydrinate injection 1 nystatin mouth/throat 1 dronabinol 1 nystatin oral 1 metoclopramide hcl 1 injection nystatin-triamcinolone 1 metoclopramide hcl oral nystop 1 1 solution terbinafine hcl oral 1 metoclopramide hcl oral 1 voriconazole oral 1 PA tablet Antigout Agents ondansetron hcl injection 1 allopurinol oral 1 ondansetron hcl oral 1 COLCHICINE ORAL 1 ondansetron odt 1 CAPSULE perphenazine oral 1 colchicine oral tablet 1 prochlorperazine 1 colchicine-probenecid 1 prochlorperazine 1 probenecid 1 edisylate injection Antimigraine Agents prochlorperazine maleate 1 dihydroergotamine oral 1 QL mesylate injection Antifungals dihydroergotamine 1 ciclodan 1 mesylate nasal ciclopirox external gel 1 ERGOMAR 2 ciclopirox external 1 ergotamine-caffeine 1 solution MIGERGOT 2 ciclopirox olamine 1 external naratriptan hcl 1 rizatriptan benzoate 1 Effective Date: 09/01/2021 15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sumatriptan nasal 1 exemestane 1 sumatriptan succinate 1 1 flutamide oral GILOTRIF 2 PA; QL sumatriptan succinate 1 GLEOSTINE 2 refill sumatriptan succinate hydroxyurea oral 1 1 subcutaneous imatinib mesylate 1 QL 1 IMBRUVICA ORAL zolmitriptan oral 2 PA; QL CAPSULE Antimyasthenic Agents IMBRUVICA ORAL MESTINON ORAL 2 TABLET 140 MG, 420 2 PA; QL SOLUTION MG, 560 MG pyridostigmine bromide er 1 IRESSA 2 PA; QL pyridostigmine bromide 1 lapatinib ditosylate 1 PA; QL oral letrozole oral 1 Antimycobacterials leucovorin calcium oral 1 dapsone oral 1 LEUKERAN 2 ethambutol hcl oral 1 MATULANE 2 QL isoniazid oral 1 MEKINIST 2 PA; QL PRIFTIN 2 melphalan 1 QL pyrazinamide oral 1 mercaptopurine oral 1 rifabutin 1 mesna 1 rifampin oral 1 MESNEX ORAL 2 Antineoplastics - Drugs for Cancer MYLERAN 2 QL abiraterone acetate 1 QL NEXAVAR 2 PA AFINITOR DISPERZ 2 PA; QL REVLIMID 2 PA; QL AFINITOR ORAL 2 PA; QL ROZLYTREK 2 PA; QL TABLET 10 MG RYDAPT 2 PA; QL anastrozole oral 1 SPRYCEL 2 PA; QL bicalutamide 1 STIVARGA 2 PA BRUKINSA 2 PA; QL SUTENT 2 PA; QL CALQUENCE 2 PA; QL TABLOID 2 capecitabine 1 QL TAFINLAR 2 PA; QL COTELLIC 2 PA; QL TAGRISSO 2 PA; QL cyclophosphamide oral 1 capsule tamoxifen citrate oral 1 DROXIA 2 temozolomide 1 QL erlotinib hcl 1 PA THALOMID 2 PA; QL etoposide oral 1 QL tretinoin oral 1 QL everolimus oral tablet 2.5 VENCLEXTA 2 PA; QL 1 PA; QL mg, 5 mg, 7.5 mg Effective Date: 09/01/2021 16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VENCLEXTA STARTING pramipexole 2 PA; QL 1 PACK dihydrochloride VOTRIENT 2 PA; QL rasagiline mesylate oral 1 PA XTANDI ORAL CAPSULE 2 PA; QL ropinirole hcl 1 ZELBORAF 2 PA selegiline hcl oral 1 ZYDELIG 2 PA; QL trihexyphenidyl hcl 1 Antiparasitics Antiplatelets albendazole oral 1 aspirin-dipyridamole er 1 ALINIA ORAL BRILINTA 2 SUSPENSION 2 RECONSTITUTED cilostazol 1 atovaquone oral 1 clopidogrel bisulfate oral 1 chloroquine phosphate dipyridamole oral 1 1 oral prasugrel hcl 1 crotan 2 Antipsychotics - Drugs for Mood Disorders hydroxychloroquine 1 ABILIFY MAINTENA 2 QL sulfate oral aripiprazole oral solution 1 KRINTAFEL 2 aripiprazole oral tablet 1 nitazoxanide oral 2 ARISTADA 2 QL permethrin external 1 ARISTADA INITIO 2 QL praziquantel oral 1 chlorpromazine hcl 1 primaquine phosphate 1 injection pyrimethamine oral 1 PA; QL chlorpromazine hcl oral 1 Antiparkinson Agents tablet amantadine hcl oral 1 clozapine oral tablet 1 fluphenazine decanoate benztropine mesylate 1 1 injection bromocriptine mesylate 1 oral fluphenazine hcl 1 haloperidol decanoate carbidopa oral 1 1 intramuscular carbidopa-levodopa er 1 haloperidol lactate 1 carbidopa-levodopa oral 1 tablet haloperidol oral 1 carbidopa-levodopa oral INVEGA SUSTENNA 2 tablet dispersible 10-100 1 INVEGA TRINZA 2 QL mg, 25-100 mg loxapine succinate 1 carbidopa-levodopa- 1 entacapone olanzapine 1 DUOPA 2 PA PERSERIS 2 entacapone 1 pimozide 1 quetiapine fumarate 1

Effective Date: 09/01/2021 17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 EPIVIR HBV ORAL quetiapine fumarate er 2 SOLUTION RISPERDAL CONSTA 2 etravirine 1 risperidone oral solution 1 fosamprenavir calcium 1 QL risperidone oral tablet 1 GENVOYA 2 thiothixene 1 HARVONI 2 PA; QL trifluoperazine hcl 1 INTELENCE 2 ziprasidone hcl 1 INTRON A 2 QL ZYPREXA RELPREVV 2 INVIRASE 2 Antivirals ISENTRESS HD 2 abacavir sulfate 1 ISENTRESS ORAL abacavir sulfate- 2 1 QL TABLET lamivudine ISENTRESS ORAL abacavir-lamivudine- 2 1 QL TABLET CHEWABLE zidovudine JULUCA 2 QL acyclovir oral 1 KALETRA ORAL TABLET 2 adefovir dipivoxil 1 QL lamivudine 1 APTIVUS 2 QL lamivudine-zidovudine 1 atazanavir sulfate 1 QL LEDIPASVIR- BARACLUDE ORAL 2 PA; QL 2 QL SOFOSBUVIR SOLUTION LEXIVA ORAL 2 QL BIKTARVY 2 QL SUSPENSION CIMDUO 2 QL lopinavir-ritonavir 1 COMPLERA 2 PA; QL nevirapine er 1 CRIXIVAN 2 nevirapine oral tablet 1 DESCOVY 2 QL NORVIR ORAL PACKET 2 DOVATO 2 QL NORVIR ORAL 2 EDURANT 2 SOLUTION efavirenz 1 ODEFSEY 2 QL efavirenz-emtricitab- oseltamivir phosphate 2 QL 1 tenofovir oral efavirenz-lamivudine- 1 PEGASYS 2 QL tenofovir PREVYMIS ORAL 2 PA; QL emtricitabine 1 PREZCOBIX 2 QL emtricitabine-tenofovir df 1 PREZISTA 2 EMTRIVA ORAL 2 RELENZA DISKHALER 2 SOLUTION REYATAZ ORAL entecavir 1 QL 2 PACKET EPCLUSA 2 PA; QL ribavirin oral 1 QL rimantadine hcl 1 Effective Date: 09/01/2021 18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ritonavir 1 diazepam injection 1 QL SELZENTRY ORAL diazepam intramuscular 1 QL 2 QL SOLUTION diazepam oral solution 1 QL SELZENTRY ORAL diazepam oral tablet 1 QL TABLET 150 MG, 300 2 QL MG hydroxyzine hcl oral 1 SELZENTRY ORAL hydroxyzine pamoate oral 1 2 TABLET 25 MG, 75 MG lorazepam injection 1 QL SOFOSBUVIR- solution 2 mg/ml 2 PA; QL VELPATASVIR lorazepam intensol 1 QL stavudine 1 lorazepam oral 1 QL STRIBILD 2 PA; QL concentrate 2 mg/ml SYMFI 1 lorazepam oral tablet 1 QL midazolam hcl (pf) SYMFI LO 1 injection solution 10 1 QL SYMTUZA 2 QL mg/2ml, 5 mg/ml TAMIFLU 2 midazolam hcl injection TEMIXYS 2 QL solution 10 mg/2ml, 5 1 QL mg/ml tenofovir disoproxil 1 fumarate oxazepam 1 QL TIVICAY 2 triazolam 1 QL TIVICAY PD 2 Bipolar Agents - Drugs for Mood Disorders TRIUMEQ 2 QL lithium carbonate er 1 TYBOST 2 PA lithium carbonate oral 1 Blood Products and Modifiers - Drugs for valacyclovir hcl oral 1 Blood Disorders valganciclovir hcl 1 QL anagrelide hcl 1 VIRACEPT 2 EPOGEN 2 PA VIREAD ORAL POWDER 2 HEMLIBRA 2 PA; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 2 LEUKINE 2 MG NEUPOGEN 2 QL VOSEVI 2 PA; QL NIVESTYM 2 QL zidovudine 1 PROCRIT 2 PA Anxiolytics - Drugs for Anxiety tranexamic acid oral 1 QL alprazolam er 1 QL ZARXIO 2 QL Cardiovascular Agents - Drugs for Heart alprazolam oral tablet 1 QL and Circulation Conditions alprazolam xr 1 QL acebutolol hcl oral 1 buspirone hcl oral 1 ALDACTAZIDE ORAL chlordiazepoxide hcl 1 QL 2 TABLET 50-50 MG clonazepam oral 1 QL alprostadil injection 1 clorazepate dipotassium 1 QL Effective Date: 09/01/2021 19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier amiloride hcl oral 1 diltiazem hcl oral 1 amiloride- 1 1 dilt-xr hydrochlorothiazide disopyramide phosphate 1 amiodarone hcl oral tablet 1 200 mg DIURIL 2 amlodipine besylate oral 1 doxazosin mesylate oral 1 amlodipine besylate- enalapril maleate oral 1 1 benazepril hcl enalapril- 1 amlodipine-olmesartan 1 hydrochlorothiazide ENTRESTO 2 PA atenolol oral 1 epinephrine injection atenolol-chlorthalidone 1 1 solution prefilled syringe atorvastatin calcium oral 1 epinephrine pf 1 benazepril hcl oral 1 eplerenone 1 benazepril- 1 ethacrynic acid 1 PA hydrochlorothiazide ezetimibe 1 betaxolol hcl oral 1 ezetimibe-simvastatin 1 bisoprolol fumarate oral 1 felodipine er 1 bisoprolol- 1 hydrochlorothiazide fenofibrate micronized 1 1 fenofibrate oral capsule bumetanide oral 1 134 mg, 200 mg, 67 mg captopril oral 1 fenofibrate oral tablet 160 1 cartia xt 1 mg, 54 mg carvedilol 1 fenofibric acid oral tablet 1 chlorthalidone 1 flecainide acetate 1 cholestyramine light 1 fosinopril sodium 1 cholestyramine oral 1 fosinopril sodium-hctz 1 clonidine 1 furosemide injection 1 clonidine hcl oral 1 furosemide oral 1 colestipol hcl 1 gemfibrozil oral 1 digitek 1 guanfacine hcl 1 digox 1 hydralazine hcl oral 1 digoxin injection 1 hydrochlorothiazide oral 1 digoxin oral 1 indapamide 1 diltiazem hcl er 1 irbesartan 1 diltiazem hcl er coated irbesartan- 1 beads oral capsule hydrochlorothiazide extended release 24 hour 1 120 mg, 180 mg, 240 mg, isosorbide dinitrate 1 300 mg isosorbide mononitrate 1

Effective Date: 09/01/2021 20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 olmesartan medoxomil- isosorbide mononitrate er 1 hctz isradipine 1 pacerone oral tablet 200 1 labetalol hcl oral 1 mg lisinopril oral 1 papaverine hcl injection 1 lisinopril- 1 pentoxifylline er 1 hydrochlorothiazide perindopril erbumine 1 losartan potassium oral 1 phenoxybenzamine hcl 1 losartan potassium-hctz 1 oral lovastatin oral 1 phentolamine mesylate 1 methyldopa 1 injection metolazone 1 pindolol 1 metoprolol succinate er 1 pravastatin sodium 1 metoprolol tartrate oral 1 prazosin hcl oral 1 metoprolol- prevalite 1 1 hydrochlorothiazide procainamide hcl injection 1 mexiletine hcl oral 1 propafenone hcl 1 midodrine hcl 1 propranolol hcl er 1 minitran 1 propranolol hcl oral 1 minoxidil oral 1 quinapril hcl 1 moexipril hcl 1 quinapril- 1 nadolol oral 1 hydrochlorothiazide nicardipine hcl oral 1 quinidine gluconate er 1 nifedipine er 1 quinidine sulfate 1 nifedipine er osmotic ramipril 1 1 release RECTIV 2 nifedipine oral 1 rosuvastatin calcium 1 nimodipine oral 1 simvastatin oral 1 NITRO-BID 2 sorine 1 NITRO-DUR sotalol hcl (af) 1 TRANSDERMAL PATCH 2 24 HOUR 0.3 MG/HR, 0.8 sotalol hcl oral 1 MG/HR spironolactone oral 1 nitroglycerin sublingual 1 spironolactone-hctz 1 nitroglycerin transdermal 1 timolol maleate oral 1 nitro-time oral capsule 1 torsemide 1 extended release 9 mg trandolapril 1 NORPACE CR 2 triamterene oral 1 olmesartan medoxomil 1 oral triamterene-hctz 1 Effective Date: 09/01/2021 21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier valsartan 1 GILENYA 2 PA; QL valsartan- glatiramer acetate 1 QL 1 hydrochlorothiazide glatopa 1 QL verapamil hcl er oral REBIF 2 PA; QL capsule extended release 1 24 hour 120 mg, 180 mg, REBIF REBIDOSE 2 PA; QL 240 mg, 360 mg REBIF REBIDOSE 2 PA; QL verapamil hcl er oral TITRATION PACK 1 tablet extended release REBIF TITRATION PACK 2 PA; QL Central Nervous System Agents - verapamil hcl oral 1 Miscellaneous Central Nervous System Agents - Drugs for

Attention Deficit Disorder caffeine citrate oral 1 amphetamine- pregabalin oral 1 QL 1 dextroamphetamine riluzole 1 QL amphetamine- Dental and Oral Agents - Drugs for Mouth 1 QL dextroamphetamine er and Throat Conditions atomoxetine hcl 1 chlorhexidine gluconate 1 dexmethylphenidate hcl 1 mouth/throat dextroamphetamine lidocaine viscous hcl 1 1 QL sulfate er oralone 1 dextroamphetamine 1 periogard 1 sulfate oral tablet pilocarpine hcl oral tablet 1 guanfacine hcl er 1 5 mg methylphenidate hcl er 1 QL triamcinolone acetonide 1 methylphenidate hcl er mouth/throat 1 QL (cd) Dermatological Agents - Drugs for Skin methylphenidate hcl er Conditions (la) oral capsule extended 1 ST; QL accutane 1 release 24 hour 20 mg, 30 mg, 40 mg, 60 mg acitretin 1 QL methylphenidate hcl oral adapalene external cream 1 1 tablet adapalene external gel 1 relexxii 1 QL adapalene treatment 1 zenzedi oral tablet 10 mg, ala-cort external cream 1 1 5 mg 2.5 % Central Nervous System Agents - Drugs for alclometasone 1 Multiple Sclerosis dipropionate AVONEX PEN 2 PA; QL AMELUZ 2 QL AVONEX PREFILLED 2 PA; QL amnesteem 1 dimethyl fumarate oral 1 avar cleanser 1 dimethyl fumarate starter 1 1 pack avita EXTAVIA 1 QL azelaic acid external 1 Effective Date: 09/01/2021 22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 2 clobetasol propionate AZELEX 1 external ointment benzoyl peroxide- 1 clobetasol propionate erythromycin 1 external solution betamethasone 1 dipropionate aug CONDYLOX 2 betamethasone CORDRAN EXTERNAL 1 2 dipropionate external TAPE betamethasone valerate 1 1 desonide external cream external desonide external lotion 1 calcipotriene external 1 desonide external cream 1 ointment calcipotriene external 1 desoximetasone external ointment 1 cream calcipotriene external 1 desoximetasone external solution 1 gel calcitrene 1 desoximetasone external 1 calcitriol external 1 ointment 2 DIFFERIN EXTERNAL CAPEX 1 CREAM CARAC 2 DIFFERIN EXTERNAL 2 claravis 1 LOTION clindacin etz external 1 DRYSOL 2 swab erythromycin external 1 clindacin-p 1 FINACEA EXTERNAL clindamycin phos-benzoyl 2 FOAM perox external gel 1-5 %, 1 fluocinolone acetonide 1.2-5 % 1 body clindamycin phosphate 1 fluocinolone acetonide external gel 1 external clindamycin phosphate 1 fluocinolone acetonide external lotion 1 scalp clindamycin phosphate 1 fluocinonide emulsified external solution 1 base clindamycin phosphate 1 fluocinonide external external swab 1 cream 0.05 % clobetasol prop emollient 1 base fluocinonide external gel 1 fluocinonide external clobetasol propionate e 1 1 ointment clobetasol propionate 1 fluocinonide external external cream 1 solution clobetasol propionate 1 external gel FLUOROPLEX 2 clobetasol propionate 1 external lotion Effective Date: 09/01/2021 23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLUOROURACIL myorisan 1 EXTERNAL CREAM 0.5 2 neuac external gel 1 % pimecrolimus cream 1 % fluorouracil external 1 1 external cream 5 % PIMECROLIMUS CREAM fluorouracil external 1 1 1 % EXTERNAL solution fluticasone propionate podofilox external 1 1 external cream PRAMOSONE fluticasone propionate EXTERNAL CREAM 1-1 2 1 external ointment % halobetasol propionate PRAMOSONE 1 2 external cream EXTERNAL LOTION halobetasol propionate RETIN-A 1 1 external ointment RETIN-A MICRO GEL 1 hydrocortisone ace- 0.04 %, 0.1 % pramoxine external cream 1 RETIN-A MICRO PUMP 2.5-1 % EXTERNAL GEL 0.04 %, 1 hydrocortisone butyrate 0.1 % 1 external cream rosadan external cream 1 hydrocortisone butyrate 1 rosadan external gel 1 external ointment SANTYL 2 hydrocortisone butyrate 1 selenium sulfide external external solution 1 lotion hydrocortisone external 1 cream 2.5 % sodium sulfacetamide 1 hydrocortisone external sulfacetamide sodium 1 1 lotion 2.5 % (acne) hydrocortisone external sulfacetamide sodium- 1 1 ointment 2.5 % sulfur external emulsion hydrocortisone ointment 1 sulfacetamide sodium- 1 % external (rx) sulfur external lotion 10-5 1 % hydrocortisone valerate 1 sulfacetamide-sulfur in imiquimod external cream 1 1 urea 5 % synalar external cream 1 isotretinoin oral 1 synalar external ointment 1 LEVULAN KERASTICK 2 QL tacrolimus external 1 methoxsalen rapid 1 QL metronidazole external tazarotene external cream 1 1 cream TAZORAC EXTERNAL 2 metronidazole external CREAM 0.05 % 1 gel 0.75 % TAZORAC EXTERNAL 2 mometasone furoate GEL 1 external tretinoin external cream 1 Effective Date: 09/01/2021 24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tretinoin external gel 0.01 ACCU-CHEK SOFTCLIX 1 1 %, 0.025 % LANCET DEVICE KIT 1 AGAMATRIX CONTROL tretinoin microsphere 1 LEVEL 2 tretinoin microsphere 1 AGAMATRIX CONTROL pump 1 LEVEL 4 triamcinolone acetonide 1 AUTOLET LANCING external cream 1 DEVICE triamcinolone acetonide 1 BLULINK CONTROL external lotion 1 HIGH & LOW triamcinolone acetonide CARETOUCH CONTROL external ointment 0.025 1 1 %, 0.1 %, 0.5 % SOL LEVEL 2 CARETOUCH triderm 1 1 LANCING/EJECTOR urea external cream 40 % 1 CONTOUR CONTROL 1 uremez-40 1 SOLUTION VECTICAL 1 CONTOUR NEXT 1 zenatane 1 CONTROL SOLUTION CONTOUR NEXT TEST Diabetes - Antidiabetic Agents 1 PA; QL STRIPS acarbose oral 1 DIATHRIVE GLUCOSE 1 glimepiride 1 CONTROL SOLN glipizide er 1 DIATHRIVE LANCING 1 glipizide ir 1 DEVICE DROPLET GENTEEL glipizide xl 1 1 LANCING DEVICE glyburide oral 1 EASY TRAK II CONTROL 1 JARDIANCE 2 PA; QL EASYMAX 15 LEVEL 2-3 1 metformin hcl er 1 CONTROL metformin hcl ir 1 EASYMAX CONTROL 1 tolbutamide 1 GLUCOSE CONTROL 1 SOLUTIONS Diabetes - Glucose Monitoring EMBRACE LANCING ACCU-CHEK AVIVA 1 1 DEVICE/EJECTOR DEVICE EMBRACE TALK ACCU-CHEK COMPACT 1 1 GLUCOSE CONTROL PLUS CONTROL 1 ACCU-CHEK FASTCLIX FORTISCARE CONTROL 1 LANCET KIT FREESTYLE TEST 1 PA; QL ACCU-CHEK GUIDE GENTEEL LANCING KIT 1 1 CONTROL (BLUE) ACCU-CHEK GUIDE GOJJI CONTROL 1 1 PA; QL TEST STRIPS GOJJI LANCING 1 ACCU-CHEK DEVICE/CLEAR CAP 1 SMARTVIEW CONTROL Effective Date: 09/01/2021 25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 BD ULTRA-FINE PEN LANCETS 1 NEEDLES MICROLET NEXT 1 BD VEO INSULIN SYR LANCING DEVICE 1 U/F 1/2UNIT ONETOUCH DELICA 1 LANCING DEVICE HUMALOG 2 ONETOUCH DELICA 2 1 HUMALOG KWIKPEN PLUS LANCING DEVICE HUMALOG U-100 2 ONETOUCH ULTRA 1 QL JUNIOR KWIKPEN ONETOUCH VERIO IN HUMULIN 70/30 1 1 VITRO SOLUTION HIGH KWIKPEN ONETOUCH VERIO 1 QL HUMULIN 70/30 VIAL 1 TEST STRIPS HUMULIN N KWIKPEN 1 SURESTEP PRO HIGH 1 GLUCOSE HUMULIN N VIAL 1 SURESTEP PRO LOW HUMULIN R U-500 1 1 GLUCOSE KWIKPEN SURESTEP PRO HUMULIN R U-500 VIAL 1 1 NORMAL GLUCOSE HUMULIN R VIAL 1 TRUE METRIX LEVEL 1 1 INSULIN LISPRO 2 TRUE METRIX LEVEL 2 1 INSULIN LISPRO (1 2 TRUE METRIX LEVEL 3 1 UNIT DIAL) UNISTRIP CONTROL IN INSULIN PEN NEEDLES 1 1 VITRO SOLUTION LOW INSULIN SYRINGES 27G VIVAGUARD INO X 1/2" 0.5 ML, 27G X 1/2" 1 CONTROL SOLUTION 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X VIVAGUARD LANCING 1 1/2" 0.3 ML, 29G X 1/2" DEVICE 0.5 ML, 29G X 1/2" 1 ML, Diabetes - Glycemic Agents 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 BAQSIMI ONE PACK 2 1 ML, 30G X 5/16" 0.3 ML, BAQSIMI TWO PACK 2 30G X 5/16" 0.5 ML, 30G diazoxide oral 2 X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X GLUCAGEN HYPOKIT 2 15/64" 0.5 ML, 31G X glucagon emergency kit 1 15/64" 1 ML, 31G X 5/16" 1 mg injection 1 mg 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML GLUCAGON EMERGENCY KIT 1 MG 2 LANTUS SOLOSTAR 2 PA INJECTION 1 MG LANTUS U-100 VIAL 2 PA Diabetes - Insulins LEVEMIR U-100 2 PA BD AUTOSHIELD DUO FLEXTOUCH 1 PEN NEEDLES LEVEMIR U-100 VIAL 2 PA BD ULTRA-FINE 1 INSULIN SYRINGES

Effective Date: 09/01/2021 26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NOVOFINE phosphorous 1 AUTOCOVER PEN 1 phospho-trin 250 neutral 1 NEEDLE 30G X 8 MM NOVOFINE PEN phytonadione injection 1 1 NEEDLE 32G X 6 MM phytonadione oral 1 NOVOFINE PLUS PEN 1 potassium chloride crys er NEEDLE 32G X 4 MM oral tablet extended 1 NOVOTWIST PEN release 10 meq, 20 meq 1 NEEDLE 32G X 5 MM potassium chloride crys er ULTIGUARD SAFEPACK oral tablet extended 2 1 SYR/NEEDLE release 15 meq Electrolytes / Minerals / Metals / Vitamins potassium chloride er 1 argyle sterile saline 1 potassium chloride oral 1 CARNITOR ORAL 1 potassium citrate er 1 potassium citrate-citric CARNITOR SF 1 1 acid curity sterile saline 1 sod citrate-citric acid 1 cyanocobalamin injection 1 solution 1000 mcg/ml sodium chloride (pf) 1 cytra k crystals 1 sodium chloride irrigation 1 sodium fluoride oral ergocalciferol oral capsule 1 1 solution 1.1 (0.5 f) mg/ml folic acid injection 1 sodium fluoride oral tablet 1 folic acid oral tablet 1 mg 1 1.1 (0.5 f) mg klor-con 1 sodium fluoride oral tablet 1 chewable klor-con 10 1 sodium polystyrene klor-con m10 1 1 sulfonate klor-con m15 2 sps 1 klor-con m20 1 tricitrates 1 K-TAB ORAL TABLET virt-phos 250 neutral 1 EXTENDED RELEASE 1 10 MEQ vitamin d (ergocalciferol) oral capsule 1.25 mg 1 K-TAB ORAL TABLET (50000 ut) EXTENDED RELEASE 2 20 MEQ, 8 MEQ vitamin k1 injection 1 Gastrointestinal Agents - Drugs for Acid levocarnitine oral solution 1 Reflux and Ulcer levocarnitine oral tablet 1 cimetidine hcl 1 levocarnitine sf 1 cimetidine oral 1 MEPHYTON 1 famotidine oral 1 nafrinse 1 suspension reconstituted ORACIT 2 famotidine oral tablet 20 1 phospha 250 neutral 1 mg, 40 mg

Effective Date: 09/01/2021 27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lansoprazole oral capsule Genetic or Enzyme Disorder - Drugs for 1 delayed release Replacement, Modification, Treatment misoprostol oral 1 CERDELGA 2 PA; QL omeprazole oral capsule CREON 2 1 delayed release CYSTAGON 2 PA pantoprazole sodium oral 1 ZENPEP 2 tablet delayed release Genitourinary Agents - Drugs for Bladder, rabeprazole sodium oral 1 ST Genital and Kidney Conditions tablet delayed release acetic acid irrigation 1 sucralfate oral 1 bethanechol chloride oral 1 Gastrointestinal Agents - Drugs for Bowel, calcium acetate (phos Intestine and Stomach Conditions 1 binder) belladonna alkaloids- 1 QL calcium acetate oral tablet opium 1 667 mg chlordiazepoxide- 1 QL clidinium CERVIDIL 2 1 darifenacin hydrobromide constulose 1 er dicyclomine hcl oral 1 ELMIRON 2 diphenoxylate-atropine 1 flavoxate hcl 1 enulose 1 oxybutynin chloride er 1 gavilyte-c 1 oxybutynin chloride oral 1 gavilyte-g 1 penicillamine oral capsule 1 PA; QL gavilyte-n with flavor pack 1 penicillamine oral tablet 2 PA; QL generlac 1 PENTOSAN glycopyrrolate injection 1 POLYSULFATE SODIUM 2 solution ORAL glycopyrrolate oral 1 phenazo oral tablet 200 1 HELIDAC THERAPY 2 mg phenazopyridine hcl oral lactulose encephalopathy 1 1 tablet 100 mg, 200 mg lactulose oral solution 1 PREPIDIL 2 loperamide hcl oral 1 capsule PROSTIN E2 2 opium 1 QL sevelamer carbonate 1 peg 3350-kcl-na bicarb- sevelamer hcl 1 1 nacl solifenacin succinate 1 peg-3350/electrolytes 1 tolterodine tartrate 1 PYLERA 2 tolterodine tartrate er 1 RELISTOR 2 PA trospium chloride 1 SUBCUTANEOUS trospium chloride er 1 ursodiol oral 1

Effective Date: 09/01/2021 28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Genitourinary Agents - Drugs for Prostate DEPO-TESTOSTERONE

Conditions (brand testosterone 1 PA cypionate intramuscular) alfuzosin hcl er 1 TESTOSTERONE dutasteride oral 1 1 PA CYPIONATE INJECTION finasteride oral tablet 5 1 testosterone cypionate mg 1 PA intramuscular tamsulosin hcl 1 testosterone enanthate 1 PA terazosin hcl 1 intramuscular Hormonal Agents - Adrenal testosterone transdermal gel 1.62 %, 12.5 mg/act DEPO-MEDROL (1%), 20.25 mg/act 1 PA; QL INJECTION 2 (1.62%), 25 mg/2.5gm SUSPENSION 20 MG/ML (1%), 50 mg/5gm (1%) dexamethasone intensol 2 Hormonal Agents - Osteoporosis dexamethasone oral elixir 1 raloxifene hcl 1 dexamethasone oral 1 Hormonal Agents - Pituitary solution ACTHAR 2 PA; QL dexamethasone oral 1 tablet cabergoline 1 dexamethasone sod desmopressin ace spray 1 phosphate pf injection 1 refrig solution desmopressin acetate 1 dexamethasone sodium injection 1 phosphate injection DESMOPRESSIN 2 fludrocortisone acetate ACETATE NASAL 1 oral desmopressin acetate 1 hydrocortisone oral 1 oral MEDROL ORAL TABLET desmopressin acetate pf 1 2 2 MG desmopressin acetate 1 methylprednisolone oral 1 spray leuprolide acetate methylprednisolone 1 sodium succ injection injection 1 solution reconstituted 125 LUPRON DEPOT (1- 2 mg MONTH) prednisolone oral solution 1 LUPRON DEPOT (3- 2 prednisolone sodium MONTH) phosphate oral solution 1 LUPRON DEPOT (4- 15 mg/5ml, 25 mg/5ml, MONTH) 2 6.7 (5 base) mg/5ml INTRAMUSCULAR KIT prednisone oral 1 30MG SOLU-CORTEF 2 LUPRON DEPOT (6- MONTH) 2 Hormonal Agents - Men's Health INTRAMUSCULAR KIT danazol oral 1 45MG

Effective Date: 09/01/2021 29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LUPRON DEPOT-PED 1 2 cyclafem 1/35 (1-MONTH) cyclafem 7/7/7 1 LUPRON DEPOT-PED 2 (3-MONTH) cyred 1 octreotide acetate 1 cyred eq 1 OMNITROPE dasetta 1/35 1 SUBCUTANEOUS 2 PA; QL dasetta 7/7/7 1 SOLUTION 1 RECONSTITUTED deblitane SANDOSTATIN LAR DELESTROGEN 2 2 QL DEPOT delyla 1 STIMATE 2 DEPO-ESTRADIOL 2 Hormonal Agents - Sex Hormones and Birth desogestrel-ethinyl Control estradiol oral tablet 0.15- 1 afirmelle 1 30 mg-mcg AFTERPILL 1 drospirenone-ethinyl estradiol oral tablet 3-0.03 1 altavera 1 mg alyacen 1/35 1 elinest 1 alyacen 7/7/7 1 ELLA 2 apri 1 eluryng 1 aranelle 1 emoquette 1 aubra 1 enpresse-28 1 aubra eq 1 enskyce 1 aurovela 1.5/30 1 errin 1 aurovela 1/20 1 estarylla 1 aurovela fe 1.5/30 1 estradiol oral 1 aurovela fe 1/20 1 estradiol transdermal 1 aviane 1 patch weekly ayuna 1 estradiol vaginal 1 estradiol valerate balziva 1 1 intramuscular blisovi fe 1.5/30 1 ESTRING 2 blisovi fe 1/20 1 ethynodiol diac-eth 1 briellyn 1 estradiol 1 etonogestrel-ethinyl camila 1 estradiol caziant 1 falmina 1 chateal 1 FEMRING 2 chateal eq 1 femynor 1 CLIMARA 1 hailey 1.5/30 1 cryselle-28 1 Effective Date: 09/01/2021 30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 MAKENA hailey fe 1.5/30 2 QL SUBCUTANEOUS hailey fe 1/20 1 marlissa 1 heather 1 medroxyprogesterone hydroxyprogesterone 1 1 acetate intramuscular caproate intramuscular oil medroxyprogesterone 1 incassia 1 acetate oral isibloom 1 megestrol acetate oral jencycla 1 suspension 40 mg/ml, 1 400 mg/10ml juleber 1 megestrol acetate oral 1 junel 1.5/30 1 tablet junel 1/20 1 microgestin 1.5/30 1 junel fe 1.5/30 1 microgestin 1/20 1 junel fe 1/20 1 microgestin fe 1.5/30 1 kalliga 1 microgestin fe 1/20 1 kelnor 1/35 1 mili 1 kelnor 1/50 1 MIRENA (52 MG) 2 kurvelo 1 mono-linyah 1 larin 1.5/30 1 necon 0.5/35 (28) 1 larin 1/20 1 nora-be 1 larin fe 1.5/30 1 norethin ace-eth estrad-fe 1 larin fe 1/20 1 oral tablet norethindrone acetate larissia 1 1 oral leena 1 norethindrone acet-ethinyl 1 lessina 1 est levonest 1 norethindrone oral 1 levonorgestrel 1 norgestimate-eth estradiol 1 levonorgestrel-ethinyl norgestimate-ethinyl 1 estrad oral tablet 0.1-20 1 estradiol triphasic mg-mcg, 0.15-30 mg-mcg norlyda 1 levonorg-eth estrad 1 triphasic norlyroc 1 levora 0.15/30 (28) 1 nortrel 0.5/35 (28) 1 lillow 1 nortrel 1/35 (21) 1 low-ogestrel 1 nortrel 1/35 (28) 1 lutera 1 nortrel 7/7/7 1 lyleq 1 nylia 7/7/7 1 lyza 1 nymyo 1 ocella 1 Effective Date: 09/01/2021 31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier orsythia 1 tyblume 1 PARAGARD velivet 1 INTRAUTERINE 2 vienva 1 COPPER vyfemla 1 philith 1 vylibra 1 pirmella 1/35 1 wera 1 pirmella 7/7/7 1 xulane 1 portia-28 1 yuvafem 1 PREMARIN VAGINAL 2 zafemy 1 preventeza 1 zarah 1 previfem 1 progesterone zovia 1/35 (28) 1 1 intramuscular zovia 1/35e (28) 1 progesterone oral 1 zumandimine 1 reclipsen 1 Hormonal Agents - Thyroid sharobel 1 levothyroxine sodium oral 1 tablet SKYLA 2 liothyronine sodium oral 1 sprintec 28 1 methimazole oral 1 sronyx 1 propylthiouracil oral 1 syeda 1 Immunological Agents - Drugs for Immune tarina fe 1/20 1 System Stimulation or Suppression tarina fe 1/20 eq 1 azathioprine oral 1 tri femynor 1 BERINERT 2 PA; QL tri-estarylla 1 COSENTYX (300 MG 2 PA; QL tri-linyah 1 DOSE) tri-lo-estarylla 1 COSENTYX 150 MG/ML 2 PA; QL COSENTYX tri-lo-marzia 1 2 PA; QL SENSOREADY (300 MG) tri-lo-mili 1 COSENTYX 2 PA; QL tri-lo-sprintec 1 SENSOREADY PEN tri-mili 1 CUVITRU 2 PA; QL tri-nymyo 1 cyclosporine modified 1 tri-previfem 1 cyclosporine oral 1 tri-sprintec 1 ENBREL 2 PA; QL trivora (28) 1 ENBREL MINI 2 PA; QL tri-vylibra 1 ENBREL SURECLICK 2 PA; QL tri-vylibra lo 1 gengraf 1 tulana 1 HIZENTRA 2 PA; QL

Effective Date: 09/01/2021 32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HUMIRA 2 PA; QL Immunological Agents - Drugs for

HUMIRA PEDIATRIC Vaccination 2 PA; QL CROHNS START ACTHIB 2 HUMIRA PEN 2 PA; QL ADACEL 2 HUMIRA PEN-CD/UC/HS AFLURIA 2 PA; QL 1 STARTER QUADRIVALENT HUMIRA PEN- 2 PA; QL BEXSERO 2 PEDIATRIC UC START BOOSTRIX 2 HUMIRA PEN- 2 PA; QL PS/UV/ADOL HS START DAPTACEL 2 HUMIRA PEN- DIPHTHERIA-TETANUS 2 PA; QL 2 PSOR/UVEIT STARTER TOXOIDS DT HYPERHEP B 2 ENGERIX-B 2 FLUARIX HYQVIA 2 PA; QL 1 QUADRIVALENT icatibant acetate 2 PA; QL FLUBLOK 1 leflunomide oral 1 QUADRIVALENT methotrexate oral 1 FLUCELVAX 1 methotrexate sodium 1 QUADRIVALENT FLULAVAL methotrexate sodium (pf) 1 1 QUADRIVALENT mycophenolate mofetil 1 FLUMIST oral 1 QUADRIVALENT mycophenolate sodium 1 FLUZONE HIGH-DOSE 1 NABI-HB 2 QUADRIVALENT ORENCIA CLICKJECT 2 PA; QL FLUZONE 1 ORENCIA QUADRIVALENT 2 PA; QL SUBCUTANEOUS GARDASIL 9 2 OTEZLA 2 PA; QL HAVRIX 2 RASUVO 2 HEPLISAV-B 2 RIDAURA 2 QL HIBERIX 2 sirolimus oral 1 INFANRIX 2 SKYRIZI 2 PA; QL IPOL 2 SKYRIZI (150 MG DOSE) 2 PA; QL KINRIX 2 SKYRIZI PEN 2 PA; QL MENACTRA 2 STELARA 2 PA; QL SUBCUTANEOUS MENQUADFI 2 tacrolimus oral 1 MENVEO 2 TREMFYA 2 PA; QL M-M-R II 2 XELJANZ ORAL TABLET 2 PA; QL PEDIARIX 2 XELJANZ XR 2 PA; QL PEDVAX HIB 2 PENTACEL 2 Effective Date: 09/01/2021 33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 2 Metabolic Bone Disease Agents - Drugs for PNEUMOVAX 23 Osteoporosis PREVNAR 13 2 alendronate sodium 1 PROQUAD 2 ibandronate sodium oral 1 QUADRACEL 2 risedronate sodium oral 1 RECOMBIVAX HB 2 tablet ROTARIX 2 Metabolic Bone Disease Agents - Other ROTATEQ 2 calcitriol oral 1 SHINGRIX 2 cinacalcet hcl 1 PA TDVAX 2 Miscellaneous Therapeutic Agents TENIVAC 2 ALCOHOL PREP PADS 1 TETANUS-DIPHTHERIA PAD 2 TOXOIDS TD ALCOHOL PREP PADS 1 TRUMENBA 2 PAD 70 % ALCOHOL PREP PADS VAQTA 1 INTRAMUSCULAR SHEET 70 % 2 SUSPENSION 50 BREATHE EASE LARGE 2 UNIT/ML BREATHE EASE 2 VARIVAX 2 MEDIUM VAXELIS 2 BREATHE EASE SMALL 2 Inflammatory Bowel Disease Agents CAYA 2 APRISO 1 ST CLEVER CHOICE 2 balsalazide disodium 1 HOLDING CHAMBER COMPACT SPACE CORTIFOAM 2 2 CHAMBER/LG MASK hydrocortisone (perianal) 1 COMPACT SPACE external cream 2.5 % 2 CHAMBER/MED MASK hydrocortisone rectal 1 COMPACT SPACE 2 LIALDA 1 CHAMBER/SM MASK mesalamine er oral deferoxamine mesylate 1 ST capsule 0.375 gm injection solution 1 mesalamine oral capsule reconstituted 500 mg 1 ST delayed release 400 mg EASIVENT 2 mesalamine oral tablet 1 FEMCAP 2 delayed release 1.2 gm FLEXICHAMBER ADULT 2 mesalamine rectal 1 MASK/SMALL PENTASA 2 PA FLEXICHAMBER CHILD 2 PROCTOFOAM HC 2 MASK/LARGE FLEXICHAMBER CHILD procto-med hc 1 2 MASK/SMALL proctozone-hc 1 GLUCAGEN 2 sulfasalazine oral 1 DIAGNOSTIC

Effective Date: 09/01/2021 34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GLUCAGON HCL Ophthalmic Agents - Drugs for Eye Allergy, 2 (DIAGNOSTIC) Infection and Inflammation methergine 1 ACULAR 2 methylergonovine 2 1 ALOMIDE maleate azelastine hcl ophthalmic 1 MICROCHAMBER 2 bacitracin ophthalmic 1 NOZIN NASAL 1 CILOXAN OPHTHALMIC SANITIZER POPSWAB 2 OINTMENT PANDA MASK LARGE 2 ciprofloxacin hcl 1 PANDA MASK MEDIUM 2 ophthalmic 2 cromolyn sodium PANDA MASK SMALL 1 ophthalmic PEDIATRIC PANDA 2 dexamethasone sodium MASK 1 phosphate ophthalmic pocket spacer 2 diclofenac sodium PRO COMFORT 1 2 ophthalmic SPACER ADULT DUREZOL 2 PRO COMFORT 2 SPACER CHILD erythromycin ophthalmic 1 PRO COMFORT 1 2 fluorometholone SPACER INFANT flurbiprofen sodium 1 PROCARE 2 SPACER/ADULT MASK FML 2 PROCARE FML FORTE 2 2 SPACER/CHILD MASK gatifloxacin ophthalmic 1 WIDE-SEAL 2 gentak 1 DIAPHRAGM 60 gentamicin sulfate WIDE-SEAL 1 2 ophthalmic DIAPHRAGM 65 ketorolac tromethamine WIDE-SEAL 1 2 ophthalmic DIAPHRAGM 70 moxifloxacin hcl (2x day) 1 WIDE-SEAL 2 moxifloxacin hcl DIAPHRAGM 75 1 ophthalmic solution WIDE-SEAL 2 DIAPHRAGM 80 NATACYN 2 WIDE-SEAL ofloxacin ophthalmic 1 2 DIAPHRAGM 85 olopatadine hcl 1 WIDE-SEAL ophthalmic solution 0.1 % 2 DIAPHRAGM 90 PRED MILD 2 WIDE-SEAL prednisolone acetate 2 1 DIAPHRAGM 95 ophthalmic ZEVRX STERILE 1 prednisolone acetate p-f 1 ALCOHOL PREP PAD sulfacetamide sodium 1 ophthalmic Effective Date: 09/01/2021 35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 atropine sulfate tobramycin ophthalmic 1 ophthalmic solution 1 % TOBREX OPHTHALMIC 2 bacitracin-polymyxin b OINTMENT 1 ophthalmic trifluridine 1 bacitra-neomycin- 1 VIGAMOX 2 polymyxin-hc Ophthalmic Agents - Drugs for Glaucoma BLEPHAMIDE 2 acetazolamide er 1 BLEPHAMIDE S.O.P. 2 acetazolamide oral 1 CEQUA 2 PA betaxolol hcl ophthalmic 1 cyclopentolate hcl 1 BETOPTIC-S 2 ophthalmic CYCLOSPORINE IN bimatoprost ophthalmic 1 2 PA KLARITY brimonidine tartrate 1 ophthalmic solution 0.2 % homatropaire 1 brinzolamide 1 ISOPTO ATROPINE 2 carteolol hcl 1 LACRISERT 2 dorzolamide hcl neomycin-polymyxin- 1 ophthalmic dexameth ophthalmic 1 ointment dorzolamide hcl-timolol 1 mal neomycin-polymyxin- dexameth ophthalmic 1 latanoprost ophthalmic 1 suspension 3.5-10000-0.1 levobunolol hcl 1 neomycin-polymyxin- 1 LUMIGAN 2 gramicidin methazolamide oral 1 neo-polycin hc 1 phenylephrine hcl pilocarpine hcl ophthalmic 1 1 ophthalmic timolol maleate ophthalmic gel forming 1 polycin 1 solution polymyxin b-trimethoprim 1 timolol maleate PRED-G 2 ophthalmic solution 0.25 1 %, 0.5 % PRED-G S.O.P. 2 travoprost (bak free) 1 sulfacetamide- prednisolone ophthalmic 1 Ophthalmic Agents - Drugs for solution Miscellaneous Eye Conditions TOBRADEX ak-poly-bac 1 OPHTHALMIC 2 altafrin 1 OINTMENT atropine sulfate tobramycin- 1 1 ophthalmic ointment dexamethasone ATROPINE SULFATE XIIDRA 2 PA OPHTHALMIC 1 Otic Agents - Drugs for Ear Conditions SOLUTION 0.01 % acetic acid otic 1 Effective Date: 09/01/2021 36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CIPRO HC 2 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung ciprofloxacin- 1 Conditions dexamethasone neomycin-polymyxin-hc acetylcysteine inhalation 1 1 otic ADVAIR HFA 2 ofloxacin otic 1 albuterol sulfate hfa Respiratory Tract / Pulmonary Agents - aerosol solution 108 (90 1 QL

Drugs for Allergies, Cough, Cold base) mcg/act inhalation ALBUTEROL SULFATE azelastine hcl nasal 1 HFA AEROSOL benzonatate oral capsule 1 SOLUTION 108 (90 1 QL 100 mg, 200 mg BASE) MCG/ACT carbinoxamine maleate 1 INHALATION clemastine fumarate oral albuterol sulfate inhalation 1 1 syrup albuterol sulfate oral 1 clemastine fumarate oral 1 ALVESCO 2 tablet 2.68 mg ASMANEX (120 2 ST cyproheptadine hcl oral 1 METERED DOSES) desloratadine 1 ASMANEX (14 2 ST diphenhydramine hcl METERED DOSES) 1 injection ASMANEX (30 2 ST flunisolide nasal 1 METERED DOSES) hydrocodone- ASMANEX (60 1 2 ST homatropine METERED DOSES) ASMANEX (7 METERED hydromet 1 2 ST DOSES) ipratropium bromide nasal 1 ASMANEX HFA 2 ST levocetirizine 1 dihydrochloride oral ATROVENT HFA 2 promethazine hcl oral 1 budesonide inhalation 1 promethazine hcl rectal 1 BUDESONIDE- FORMOTEROL 2 PA promethazine vc 1 FUMARATE promethazine-dm 1 COMBIVENT RESPIMAT 2 promethazine- cromolyn sodium 1 1 phenylephrine inhalation promethegan 1 epinephrine injection 1 ryvent 1 solution auto-injector sodium chloride inhalation ESBRIET 2 PA; QL nebulization solution 0.9 1 FLOVENT DISKUS 2 PA %, 3 %, 7 % FLOVENT HFA INHALATION AEROSOL SSKI 2 2 PA 110 MCG/ACT, 220 2 SURVANTA MCG/ACT

Effective Date: 09/01/2021 37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLOVENT HFA sildenafil citrate oral tablet 1 PA INHALATION AEROSOL 2 20 mg 44 MCG/ACT TYVASO 2 PA; QL fluticasone-salmeterol TYVASO REFILL 2 PA; QL inhalation aerosol powder breath activated 100-50 TYVASO STARTER 2 PA; QL 1 mcg/dose, 250-50 UPTRAVI 2 PA; QL mcg/dose, 500-50 VENTAVIS 2 PA; QL mcg/dose Skeletal Muscle Relaxants - Drugs for ipratropium bromide 1 Muscle Pain and Spasm inhalation baclofen oral 1 ipratropium-albuterol 1 cyclobenzaprine hcl oral 1 QL montelukast sodium oral 1 tablet 10 mg, 5 mg OFEV 2 PA; QL dantrolene sodium oral 1 SEREVENT DISKUS 2 ST methocarbamol injection 1 2 SPIRIVA HANDIHALER methocarbamol oral 1 QL SPIRIVA RESPIMAT orphenadrine citrate er 1 QL INHALATION AEROSOL 2 ST SOLUTION 1.25 tizanidine hcl oral tablet 1 MCG/ACT Sleep Disorder Agents SPIRIVA RESPIMAT eszopiclone 1 QL INHALATION AEROSOL 2 SOLUTION 2.5 flurazepam hcl 1 QL MCG/ACT modafinil 1 STIOLTO RESPIMAT 2 temazepam oral capsule 1 QL STRIVERDI RESPIMAT 2 PA 15 mg, 30 mg, 7.5 mg SYMBICORT 2 PA zaleplon 1 QL terbutaline sulfate oral 1 zolpidem tartrate oral 1 QL theophylline 1 theophylline er 1 wixela inhub 1 Respiratory Tract / Pulmonary Agents -

Drugs for Cystic Fibrosis PULMOZYME 2 tobramycin inhalation nebulization solution 300 1 PA; QL mg/5ml Respiratory Tract / Pulmonary Agents -

Drugs for Pulmonary Hypertension ambrisentan 1 PA; QL bosentan 1 PA; QL OPSUMIT 2 PA; QL

Effective Date: 09/01/2021 38 Effective Date: 09/01/2021 39 Index of Drugs

A AGAMATRIX CONTROL anastrozole ...... 16 abacavir sulfate ...... 18 LEVEL 2 ...... 25 APO-VARENICLINE ...... 12 abacavir sulfate-lamivudine AGAMATRIX CONTROL aprepitant ...... 15 ...... 18 LEVEL 4 ...... 25 apri ...... 30 abacavir-lamivudine- ak-poly-bac...... 36 APRISO ...... 34 zidovudine ...... 18 ala-cort ...... 22 APTIVUS...... 18 ABILIFY MAINTENA ...... 17 albendazole ...... 17 aranelle ...... 30 abiraterone acetate...... 16 albuterol sulfate ...... 37 argyle sterile saline ...... 27 acamprosate calcium ...... 12 albuterol sulfate hfa ...... 37 aripiprazole ...... 17 acarbose ...... 25 ALBUTEROL SULFATE ARISTADA ...... 17 ACCU-CHEK AVIVA HFA ...... 37 ARISTADA INITIO ...... 17 DEVICE ...... 25 alclometasone dipropionate ASMANEX (120 METERED ACCU-CHEK COMPACT ...... 22 DOSES) ...... 37 PLUS CONTROL ...... 25 ALCOHOL PREP PADS .. 34 ASMANEX (14 METERED ACCU-CHEK FASTCLIX ALDACTAZIDE ...... 19 DOSES) ...... 37 LANCET KIT ...... 25 alendronate sodium ...... 34 ASMANEX (30 METERED ACCU-CHEK GUIDE alfuzosin hcl er ...... 29 DOSES) ...... 37 CONTROL ...... 25 ALINIA ...... 17 ASMANEX (60 METERED ACCU-CHEK GUIDE TEST allopurinol ...... 15 DOSES) ...... 37 STRIPS ...... 25 ALOMIDE ...... 35 ASMANEX (7 METERED ACCU-CHEK SMARTVIEW alprazolam...... 19 DOSES) ...... 37 CONTROL ...... 25 alprazolam er ...... 19 ASMANEX HFA ...... 37 ACCU-CHEK SOFTCLIX alprazolam xr ...... 19 aspirin-dipyridamole er .... 17 LANCET DEVICE KIT .. 25 alprostadil ...... 19 atazanavir sulfate ...... 18 accutane ...... 22 altafrin ...... 36 atenolol ...... 20 acebutolol hcl ...... 19 altavera ...... 30 atenolol-chlorthalidone .... 20 acetaminophen-codeine .. 11 ALVESCO ...... 37 atomoxetine hcl ...... 22 acetaminophen-codeine #2 alyacen 1/35 ...... 30 atorvastatin calcium ...... 20 ...... 11 alyacen 7/7/7 ...... 30 atovaquone ...... 17 acetaminophen-codeine #3 amantadine hcl ...... 17 atropine sulfate ...... 36 ...... 11 ambrisentan ...... 38 ATROPINE SULFATE ..... 36 acetaminophen-codeine #4 AMELUZ ...... 22 ATROVENT HFA ...... 37 ...... 11 amiloride hcl ...... 20 aubra ...... 30 acetazolamide ...... 36 amiloride- aubra eq ...... 30 acetazolamide er ...... 36 hydrochlorothiazide ..... 20 aurovela 1.5/30 ...... 30 acetic acid ...... 28, 36 amiodarone hcl ...... 20 aurovela 1/20 ...... 30 acetylcysteine ...... 37 amitriptyline hcl ...... 14 aurovela fe 1.5/30 ...... 30 acitretin ...... 22 amlodipine besylate ...... 20 aurovela fe 1/20 ...... 30 ACTHAR ...... 29 amlodipine besylate- AUTOLET LANCING ACTHIB ...... 33 benazepril hcl ...... 20 DEVICE ...... 25 ACULAR ...... 35 amlodipine-olmesartan .... 20 avar cleanser ...... 22 acyclovir ...... 18 amnesteem ...... 22 aviane ...... 30 ADACEL ...... 33 amoxapine...... 14 avidoxy ...... 12 adapalene ...... 22 amoxicillin ...... 12 avita ...... 22 adapalene treatment ...... 22 amoxicillin-potassium AVONEX PEN ...... 22 adefovir dipivoxil ...... 18 clavulanate ...... 12 AVONEX PREFILLED ..... 22 ADVAIR HFA ...... 37 amphetamine- ayuna ...... 30 AFINITOR ...... 16 dextroamphetamine ..... 22 azathioprine ...... 32 AFINITOR DISPERZ ...... 16 amphetamine- azelaic acid ...... 22 afirmelle ...... 30 dextroamphetamine er . 22 azelastine hcl ...... 35, 37 AFLURIA QUADRIVALENT ampicillin ...... 12 AZELEX ...... 23 ...... 33 ampicillin sodium ...... 12 azithromycin ...... 12 AFTERPILL ...... 30 anagrelide hcl ...... 19

40 B BREATHE EASE MEDIUM cartia xt ...... 20 bac ...... 11 ...... 34 carvedilol ...... 20 bacitracin ...... 35 BREATHE EASE SMALL 34 CAYA ...... 34 bacitracin-polymyxin b ..... 36 briellyn ...... 30 caziant ...... 30 bacitra-neomycin- BRILINTA ...... 17 cefadroxil...... 12 polymyxin-hc ...... 36 brimonidine tartrate ...... 36 cefazolin sodium ...... 12 baclofen ...... 38 brinzolamide ...... 36 cefdinir ...... 12 balsalazide disodium ...... 34 bromocriptine mesylate ... 17 cefixime ...... 12 balziva ...... 30 BRUKINSA ...... 16 cefprozil ...... 12 BAQSIMI ONE PACK ...... 26 budesonide...... 37 ceftazidime ...... 12 BAQSIMI TWO PACK ..... 26 BUDESONIDE- ceftriaxone sodium ...... 12 BARACLUDE ...... 18 FORMOTEROL cefuroxime axetil ...... 12 BD AUTOSHIELD DUO FUMARATE...... 37 celecoxib ...... 11 PEN NEEDLES ...... 26 bumetanide ...... 20 CELONTIN ...... 14 BD ULTRA-FINE INSULIN buprenorphine hcl...... 12 cephalexin ...... 12 SYRINGES ...... 26 buprenorphine hcl-naloxone CEQUA ...... 36 BD ULTRA-FINE PEN hcl ...... 12 CERDELGA ...... 28 NEEDLES ...... 26 bupropion hcl ...... 14 CERVIDIL ...... 28 BD VEO INSULIN SYR U/F bupropion hcl er (smoking CHANTIX ...... 12 1/2UNIT ...... 26 det) ...... 12 CHANTIX CONTINUING belladonna alkaloids-opium bupropion hcl er (sr) ...... 14 MONTH PAK ...... 12 ...... 28 bupropion hcl er (xl) ...... 14 CHANTIX STARTING benazepril hcl ...... 20 buspirone hcl ...... 19 MONTH PAK ...... 12 benazepril- butalbital-apap-caffeine ... 11 chateal ...... 30 hydrochlorothiazide ..... 20 butalbital-aspirin-caffeine . 11 chateal eq ...... 30 benzonatate ...... 37 C chlordiazepoxide hcl ...... 19 benzoyl peroxide- cabergoline...... 29 chlordiazepoxide-clidinium erythromycin ...... 23 caffeine citrate ...... 22 ...... 28 benztropine mesylate ...... 17 calcipotriene ...... 23 chlorhexidine gluconate ... 22 BERINERT ...... 32 calcitrene ...... 23 chloroquine phosphate .... 17 betamethasone calcitriol ...... 23, 34 chlorpromazine hcl ...... 17 dipropionate ...... 23 calcium acetate ...... 28 chlorthalidone ...... 20 betamethasone calcium acetate (phos cholestyramine ...... 20 dipropionate aug ...... 23 binder) ...... 28 cholestyramine light ...... 20 betamethasone valerate .. 23 CALQUENCE ...... 16 ciclodan ...... 15 betaxolol hcl ...... 20, 36 camila ...... 30 ciclopirox ...... 15 bethanechol chloride ...... 28 capecitabine ...... 16 ciclopirox olamine ...... 15 BETOPTIC-S ...... 36 CAPEX ...... 23 cilostazol ...... 17 BEXSERO ...... 33 captopril ...... 20 CILOXAN ...... 35 bicalutamide ...... 16 CARAC ...... 23 CIMDUO ...... 18 BICILLIN L-A ...... 12 carbamazepine ...... 14 cimetidine ...... 27 BIKTARVY ...... 18 carbamazepine er...... 14 cimetidine hcl ...... 27 bimatoprost ...... 36 carbidopa ...... 17 cinacalcet hcl ...... 34 bisoprolol fumarate ...... 20 carbidopa-levodopa ...... 17 CIPRO ...... 12 bisoprolol- carbidopa-levodopa er ..... 17 CIPRO HC ...... 37 hydrochlorothiazide ..... 20 carbidopa-levodopa- ciprofloxacin hcl...... 13, 35 BLEPHAMIDE ...... 36 entacapone ...... 17 ciprofloxacin- BLEPHAMIDE S.O.P...... 36 carbinoxamine maleate ... 37 dexamethasone ...... 37 blisovi fe 1.5/30 ...... 30 CARETOUCH CONTROL citalopram hydrobromide . 14 blisovi fe 1/20 ...... 30 SOL LEVEL 2 ...... 25 claravis ...... 23 BLULINK CONTROL HIGH CARETOUCH clarithromycin ...... 13 & LOW ...... 25 LANCING/EJECTOR ... 25 clemastine fumarate ...... 37 BOOSTRIX ...... 33 CARNITOR ...... 27 CLEVER CHOICE bosentan ...... 38 CARNITOR SF ...... 27 HOLDING CHAMBER . 34 BREATHE EASE LARGE 34 carteolol hcl ...... 36 CLIMARA ...... 30

41 clindacin etz...... 23 COTELLIC...... 16 dexamethasone...... 29 clindacin-p ...... 23 CREON ...... 28 dexamethasone intensol . 29 clindamycin hcl ...... 13 CRESEMBA ...... 15 dexamethasone sod clindamycin palmitate hcl . 13 CRIXIVAN ...... 18 phosphate pf ...... 29 clindamycin phosphate ... 13, cromolyn sodium ...... 35, 37 dexamethasone sodium 23 crotan ...... 17 phosphate ...... 29, 35 clindamycin phosphate- cryselle-28 ...... 30 dexmethylphenidate hcl ... 22 benzoyl peroxide ...... 23 curity sterile saline ...... 27 dextroamphetamine sulfate clobetasol prop emollient CUVITRU ...... 32 ...... 22 base ...... 23 cyanocobalamin ...... 27 dextroamphetamine sulfate clobetasol propionate ...... 23 cyclafem 1/35 ...... 30 er ...... 22 clobetasol propionate e ... 23 cyclafem 7/7/7 ...... 30 DIASTAT PEDIATRIC ..... 14 clomipramine hcl ...... 14 cyclobenzaprine hcl ...... 38 DIATHRIVE GLUCOSE clonazepam ...... 19 cyclopentolate hcl ...... 36 CONTROL SOLN ...... 25 clonidine ...... 20 cyclophosphamide ...... 16 DIATHRIVE LANCING clonidine hcl ...... 20 cyclosporine ...... 32 DEVICE ...... 25 clopidogrel bisulfate ...... 17 CYCLOSPORINE IN diazepam ...... 14, 19 clorazepate dipotassium .. 19 KLARITY ...... 36 diazoxide ...... 26 clotrimazole ...... 15 cyclosporine modified ...... 32 diclofenac potassium ...... 11 clotrimazole-betamethasone cyproheptadine hcl ...... 37 diclofenac sodium ..... 11, 35 ...... 15 cyred ...... 30 diclofenac sodium er ...... 11 clozapine ...... 17 cyred eq ...... 30 dicloxacillin sodium ...... 13 codeine sulfate ...... 11 CYSTAGON ...... 28 dicyclomine hcl ...... 28 colchicine ...... 15 cytra k crystals ...... 27 DIFFERIN ...... 23 COLCHICINE ...... 15 D diflunisal ...... 11 colchicine-probenecid ...... 15 danazol ...... 29 digitek ...... 20 colestipol hcl ...... 20 dantrolene sodium ...... 38 digox ...... 20 COMBIVENT RESPIMAT 37 dapsone ...... 16 digoxin ...... 20 COMPACT SPACE DAPTACEL ...... 33 dihydroergotamine mesylate CHAMBER/LG MASK .. 34 darifenacin hydrobromide er ...... 15 COMPACT SPACE ...... 28 DILANTIN...... 14 CHAMBER/MED MASK dasetta 1/35 ...... 30 diltiazem hcl ...... 20 ...... 34 dasetta 7/7/7 ...... 30 diltiazem hcl er ...... 20 COMPACT SPACE deblitane ...... 30 diltiazem hcl er coated CHAMBER/SM MASK . 34 deferoxamine mesylate ... 34 beads ...... 20 COMPLERA ...... 18 DELESTROGEN ...... 30 dilt-xr ...... 20 compro ...... 15 delyla...... 30 dimenhydrinate ...... 15 CONDYLOX ...... 23 DEPO-ESTRADIOL ...... 30 dimethyl fumarate ...... 22 constulose ...... 28 DEPO-MEDROL ...... 29 dimethyl fumarate starter CONTOUR CONTROL DEPO-TESTOSTERONE 29 pack ...... 22 SOLUTION ...... 25 DESCOVY...... 18 diphenhydramine hcl ...... 37 CONTOUR NEXT desipramine hcl ...... 14 diphenoxylate-atropine .... 28 CONTROL SOLUTION 25 desloratadine ...... 37 DIPHTHERIA-TETANUS CONTOUR NEXT TEST desmopressin ace spray TOXOIDS DT ...... 33 STRIPS ...... 25 refrig ...... 29 dipyridamole ...... 17 CORDRAN ...... 23 desmopressin acetate ..... 29 disopyramide phosphate . 20 CORTIFOAM ...... 34 DESMOPRESSIN disulfiram...... 12 COSENTYX (300 MG ACETATE ...... 29 DIURIL ...... 20 DOSE) ...... 32 desmopressin acetate pf . 29 divalproex sodium ...... 14 COSENTYX 150 MG/ML . 32 desmopressin acetate spray divalproex sodium er ...... 14 COSENTYX ...... 29 donepezil hcl ...... 14 SENSOREADY (300 MG) desogestrel-ethinyl estradiol dorzolamide hcl ...... 36 ...... 32 ...... 30 dorzolamide hcl-timolol mal COSENTYX desonide ...... 23 ...... 36 SENSOREADY PEN ... 32 desoximetasone ...... 23 DOVATO ...... 18

42 doxazosin mesylate ...... 20 EPCLUSA ...... 18 FLEXICHAMBER CHILD doxepin hcl ...... 14 epinephrine ...... 20, 37 MASK/SMALL ...... 34 doxycycline hyclate...... 13 epinephrine pf ...... 20 FLOVENT DISKUS ...... 37 doxycycline monohydrate 13 epitol ...... 14 FLOVENT HFA ...... 37, 38 dronabinol ...... 15 EPIVIR HBV ...... 18 FLUARIX QUADRIVALENT DROPLET GENTEEL eplerenone ...... 20 ...... 33 LANCING DEVICE ...... 25 EPOGEN ...... 19 FLUBLOK QUADRIVALENT drospirenone-ethinyl ergocalciferol ...... 27 ...... 33 estradiol ...... 30 ERGOMAR...... 15 FLUCELVAX DROXIA ...... 16 ergotamine-caffeine ...... 15 QUADRIVALENT ...... 33 DRYSOL ...... 23 erlotinib hcl ...... 16 fluconazole ...... 15 duloxetine hcl ...... 14 errin ...... 30 flucytosine ...... 15 DUOPA ...... 17 erythromycin ...... 23, 35 fludrocortisone acetate .... 29 DUREZOL ...... 35 ESBRIET ...... 37 FLULAVAL dutasteride ...... 29 escitalopram oxalate ...... 14 QUADRIVALENT ...... 33 E estarylla ...... 30 FLUMIST QUADRIVALENT EASIVENT ...... 34 estradiol ...... 30 ...... 33 EASY TRAK II CONTROL estradiol valerate ...... 30 flunisolide ...... 37 ...... 25 ESTRING ...... 30 fluocinolone acetonide..... 23 EASYMAX 15 LEVEL 2-3 eszopiclone ...... 38 fluocinolone acetonide body CONTROL ...... 25 ethacrynic acid ...... 20 ...... 23 EASYMAX CONTROL ..... 25 ethambutol hcl ...... 16 fluocinolone acetonide scalp EDURANT ...... 18 ethosuximide ...... 14 ...... 23 efavirenz ...... 18 ethynodiol diac-eth estradiol fluocinonide ...... 23 efavirenz-emtricitab- ...... 30 fluocinonide emulsified base tenofovir...... 18 etodolac ...... 11 ...... 23 efavirenz-lamivudine- etonogestrel-ethinyl fluorometholone ...... 35 tenofovir...... 18 estradiol ...... 30 FLUOROPLEX ...... 23 elinest ...... 30 etoposide ...... 16 fluorouracil ...... 24 ELLA ...... 30 etravirine ...... 18 FLUOROURACIL ...... 24 ELMIRON ...... 28 everolimus ...... 16 fluoxetine hcl ...... 14 eluryng ...... 30 exemestane ...... 16 fluphenazine decanoate .. 17 EMBRACE LANCING EXTAVIA ...... 22 fluphenazine hcl ...... 17 DEVICE/EJECTOR ..... 25 ezetimibe ...... 20 flurazepam hcl ...... 38 EMBRACE TALK ezetimibe-simvastatin ...... 20 flurbiprofen ...... 11 GLUCOSE CONTROL . 25 F flurbiprofen sodium ...... 35 emoquette ...... 30 falmina ...... 30 flutamide ...... 16 emtricitabine ...... 18 famotidine ...... 27 fluticasone propionate ..... 24 emtricitabine-tenofovir df . 18 felodipine er ...... 20 fluticasone-salmeterol ..... 38 EMTRIVA ...... 18 FEMCAP ...... 34 fluvoxamine maleate ...... 14 enalapril maleate ...... 20 FEMRING ...... 30 FLUZONE HIGH-DOSE enalapril- femynor ...... 30 QUADRIVALENT ...... 33 hydrochlorothiazide ..... 20 fenofibrate ...... 20 FLUZONE ENBREL ...... 32 fenofibrate micronized ..... 20 QUADRIVALENT ...... 33 ENBREL MINI ...... 32 fenofibric acid ...... 20 FML ...... 35 ENBREL SURECLICK ..... 32 fentanyl ...... 11 FML FORTE ...... 35 endocet ...... 11 FINACEA ...... 23 folic acid ...... 27 ENGERIX-B...... 33 finasteride ...... 29 fondaparinux sodium ...... 13 enoxaparin sodium ...... 13 FIRVANQ ...... 13 FORTISCARE CONTROL enpresse-28 ...... 30 flavoxate hcl ...... 28 ...... 25 enskyce ...... 30 flecainide acetate ...... 20 fosamprenavir calcium .... 18 entacapone ...... 17 FLEXICHAMBER ADULT fosinopril sodium ...... 20 entecavir ...... 18 MASK/SMALL ...... 34 fosinopril sodium-hctz ..... 20 ENTRESTO ...... 20 FLEXICHAMBER CHILD FREESTYLE TEST ...... 25 enulose ...... 28 MASK/LARGE ...... 34 furosemide ...... 20

43 G haloperidol ...... 17 hydroxychloroquine sulfate gabapentin ...... 14 haloperidol decanoate ..... 17 ...... 17 galantamine hydrobromide haloperidol lactate ...... 17 hydroxyprogesterone ...... 14 HARVONI ...... 18 caproate ...... 31 galantamine hydrobromide HAVRIX ...... 33 hydroxyurea ...... 16 er ...... 14 heather ...... 31 hydroxyzine hcl ...... 19 GARDASIL 9 ...... 33 HELIDAC THERAPY ...... 28 hydroxyzine pamoate ...... 19 gatifloxacin ...... 35 HEMLIBRA ...... 19 HYPERHEP B ...... 33 gavilyte-c ...... 28 heparin sodium (porcine) . 13 HYQVIA ...... 33 gavilyte-g ...... 28 heparin sodium (porcine) pf I gavilyte-n with flavor pack 28 ...... 13 ibandronate sodium ...... 34 gemfibrozil ...... 20 HEPLISAV-B ...... 33 ibuprofen ...... 11 generlac ...... 28 HIBERIX ...... 33 icatibant acetate ...... 33 gengraf ...... 32 HIZENTRA ...... 32 imatinib mesylate ...... 16 gentak ...... 35 homatropaire ...... 36 IMBRUVICA ...... 16 gentamicin sulfate ..... 13, 35 HUMALOG ...... 26 imipramine hcl ...... 14 GENTEEL LANCING KIT HUMALOG KWIKPEN ..... 26 imiquimod...... 24 (BLUE) ...... 25 HUMALOG U-100 JUNIOR incassia ...... 31 GENVOYA ...... 18 KWIKPEN ...... 26 indapamide ...... 20 GILENYA ...... 22 HUMIRA ...... 32 indomethacin ...... 11 GILOTRIF ...... 16 HUMIRA PEDIATRIC indomethacin er...... 11 glatiramer acetate ...... 22 CROHNS START ...... 33 INFANRIX ...... 33 glatopa ...... 22 HUMIRA PEN ...... 33 INSULIN LISPRO ...... 26 GLEOSTINE ...... 16 HUMIRA PEN-CD/UC/HS INSULIN LISPRO (1 UNIT glimepiride ...... 25 STARTER ...... 33 DIAL) ...... 26 glipizide er ...... 25 HUMIRA PEN-PEDIATRIC INSULIN PEN NEEDLES 26 glipizide ir ...... 25 UC START ...... 33 INSULIN SYRINGES ...... 26 glipizide xl ...... 25 HUMIRA PEN-PS/UV/ADOL INTELENCE ...... 18 GLUCAGEN DIAGNOSTIC HS START ...... 33 INTRON A ...... 18 ...... 34 HUMIRA PEN- INVEGA SUSTENNA ...... 17 GLUCAGEN HYPOKIT .... 26 PSOR/UVEIT STARTER INVEGA TRINZA ...... 17 glucagon emergency kit ... 26 ...... 33 INVIRASE ...... 18 GLUCAGON EMERGENCY HUMULIN 70/30 KWIKPEN IPOL ...... 33 KIT ...... 26 ...... 26 ipratropium bromide .. 37, 38 GLUCAGON HCL HUMULIN 70/30 VIAL ..... 26 ipratropium-albuterol ...... 38 (DIAGNOSTIC) ...... 35 HUMULIN N KWIKPEN ... 26 irbesartan ...... 20 GLUCOSE CONTROL HUMULIN N VIAL...... 26 irbesartan- SOLUTIONS ...... 25 HUMULIN R U-500 hydrochlorothiazide ..... 20 glyburide ...... 25 KWIKPEN ...... 26 IRESSA ...... 16 glycopyrrolate ...... 28 HUMULIN R U-500 VIAL . 26 ISENTRESS ...... 18 glydo ...... 12 HUMULIN R VIAL...... 26 ISENTRESS HD ...... 18 GOJJI CONTROL ...... 25 hydralazine hcl ...... 20 isibloom ...... 31 GOJJI LANCING hydrochlorothiazide ...... 20 isoniazid ...... 16 DEVICE/CLEAR CAP .. 25 hydrocodone- ISOPTO ATROPINE ...... 36 goodsense nicotine...... 12 acetaminophen ...... 11 isosorbide dinitrate ...... 20 griseofulvin microsize ...... 15 hydrocodone-homatropine isosorbide mononitrate .... 20 griseofulvin ultramicrosize15 ...... 37 isosorbide mononitrate er 21 guanfacine hcl ...... 20 hydrocortisone ..... 24, 29, 34 isotretinoin ...... 24 guanfacine hcl er ...... 22 hydrocortisone (perianal) . 34 isradipine...... 21 H hydrocortisone ace- itraconazole ...... 15 habitrol ...... 12 pramoxine ...... 24 J hailey 1.5/30 ...... 30 hydrocortisone butyrate ... 24 jantoven ...... 13 hailey fe 1.5/30 ...... 30 hydrocortisone valerate ... 24 JARDIANCE ...... 25 hailey fe 1/20 ...... 31 hydromet ...... 37 jencycla ...... 31 halobetasol propionate .... 24 hydromorphone hcl ...... 11 juleber ...... 31

44 JULUCA ...... 18 levetiracetam er ...... 14 INTRAMUSCULAR KIT junel 1.5/30 ...... 31 levobunolol hcl ...... 36 45MG ...... 29 junel 1/20 ...... 31 levocarnitine ...... 27 LUPRON DEPOT-PED (1- junel fe 1.5/30 ...... 31 levocarnitine sf ...... 27 MONTH) ...... 29 junel fe 1/20 ...... 31 levocetirizine LUPRON DEPOT-PED (3- K dihydrochloride ...... 37 MONTH) ...... 30 KALETRA ...... 18 levofloxacin ...... 13 lutera ...... 31 kalliga ...... 31 levonest ...... 31 lyleq ...... 31 kelnor 1/35 ...... 31 levonorgestrel ...... 31 lyza ...... 31 kelnor 1/50 ...... 31 levonorgestrel-ethinyl estrad M ketoconazole ...... 15 ...... 31 MAKENA ...... 31 ketorolac tromethamine .. 11, levonorg-eth estrad triphasic marlissa ...... 31 35 ...... 31 MATULANE ...... 16 KINRIX ...... 33 levora 0.15/30 (28) ...... 31 meclofenamate sodium ... 11 klor-con ...... 27 levorphanol tartrate ...... 11 MEDROL...... 29 klor-con 10 ...... 27 levothyroxine sodium ...... 32 medroxyprogesterone klor-con m10...... 27 LEVULAN KERASTICK ... 24 acetate ...... 31 klor-con m15...... 27 LEXIVA ...... 18 megestrol acetate ...... 31 klor-con m20...... 27 LIALDA ...... 34 MEKINIST ...... 16 KRINTAFEL...... 17 lidocaine ...... 12 meloxicam ...... 11 K-TAB...... 27 lidocaine hcl ...... 12 melphalan ...... 16 kurvelo...... 31 lidocaine hcl (pf) ...... 12 memantine hcl ...... 14 L lidocaine hcl MENACTRA ...... 33 labetalol hcl ...... 21 urethral/mucosal ...... 12 MENQUADFI ...... 33 LACRISERT ...... 36 lidocaine viscous hcl ...... 22 MENVEO ...... 33 lactulose ...... 28 lidocaine-prilocaine ...... 12 MEPHYTON ...... 27 lactulose encephalopathy 28 lillow ...... 31 mercaptopurine ...... 16 lamivudine ...... 18 linezolid ...... 13 mesalamine ...... 34 lamivudine-zidovudine ..... 18 liothyronine sodium ...... 32 mesalamine er oral capsule lamotrigine ...... 14 lisinopril ...... 21 0.375 gm ...... 34 LANCETS ...... 26 lisinopril-hydrochlorothiazide mesna ...... 16 lansoprazole ...... 28 ...... 21 MESNEX ...... 16 LANTUS SOLOSTAR ...... 26 lithium carbonate ...... 19 MESTINON ...... 16 LANTUS U-100 VIAL ...... 26 lithium carbonate er ...... 19 metformin hcl er ...... 25 lapatinib ditosylate ...... 16 loperamide hcl ...... 28 metformin hcl ir ...... 25 larin 1.5/30 ...... 31 lopinavir-ritonavir ...... 18 methadone hcl ...... 11 larin 1/20 ...... 31 lorazepam ...... 19 methadose ...... 11 larin fe 1.5/30...... 31 lorazepam intensol ...... 19 methazolamide ...... 36 larin fe 1/20 ...... 31 losartan potassium ...... 21 methenamine hippurate ... 13 larissia ...... 31 losartan potassium-hctz... 21 methergine ...... 35 latanoprost ...... 36 lovastatin ...... 21 methimazole ...... 32 LEDIPASVIR- LOVENOX ...... 13 methocarbamol ...... 38 SOFOSBUVIR ...... 18 low-ogestrel ...... 31 methotrexate ...... 33 leena ...... 31 loxapine succinate ...... 17 methotrexate sodium ...... 33 leflunomide ...... 33 LUMIGAN ...... 36 methotrexate sodium (pf) 33 lessina ...... 31 LUPRON DEPOT (1- methoxsalen rapid ...... 24 letrozole ...... 16 MONTH) ...... 29 methyldopa ...... 21 leucovorin calcium ...... 16 LUPRON DEPOT (3- methylergonovine maleate LEUKERAN ...... 16 MONTH) ...... 29 ...... 35 LEUKINE ...... 19 LUPRON DEPOT (4- methylphenidate hcl ...... 22 leuprolide acetate ...... 29 MONTH) methylphenidate hcl er .... 22 LEVEMIR U-100 INTRAMUSCULAR KIT methylphenidate hcl er (cd) FLEXTOUCH ...... 26 30MG ...... 29 ...... 22 LEVEMIR U-100 VIAL ..... 26 LUPRON DEPOT (6- methylphenidate hcl er (la) levetiracetam ...... 14 MONTH) ...... 22

45 methylprednisolone ...... 29 naltrexone hcl ...... 12 NORPACE CR ...... 21 methylprednisolone sodium naproxen ...... 11 nortrel 0.5/35 (28) ...... 31 succ ...... 29 naproxen sodium ...... 11 nortrel 1/35 (21)...... 31 metoclopramide hcl ...... 15 naratriptan hcl ...... 15 nortrel 1/35 (28)...... 31 metolazone ...... 21 NARCAN ...... 12 nortrel 7/7/7 ...... 31 metoprolol succinate er ... 21 NATACYN ...... 35 nortriptyline hcl ...... 14 metoprolol tartrate ...... 21 NAYZILAM ...... 14 NORVIR ...... 18 metoprolol- necon 0.5/35 (28) ...... 31 NOVOFINE AUTOCOVER hydrochlorothiazide ..... 21 neomycin sulfate ...... 13 PEN NEEDLE ...... 27 metronidazole ...... 13, 24 neomycin-polymyxin- NOVOFINE PEN NEEDLE mexiletine hcl ...... 21 dexameth ...... 36 ...... 27 MICROCHAMBER...... 35 neomycin-polymyxin- NOVOFINE PLUS PEN microgestin 1.5/30 ...... 31 gramicidin ...... 36 NEEDLE ...... 27 microgestin 1/20 ...... 31 neomycin-polymyxin-hc ... 37 NOVOTWIST PEN microgestin fe 1.5/30 ...... 31 neo-polycin hc ...... 36 NEEDLE ...... 27 microgestin fe 1/20 ...... 31 neuac ...... 24 NOZIN NASAL SANITIZER MICROLET NEXT NEUPOGEN ...... 19 POPSWAB ...... 35 LANCING DEVICE ...... 26 nevirapine ...... 18 nyamyc ...... 15 midazolam hcl ...... 19 nevirapine er ...... 18 nylia 7/7/7...... 31 midazolam hcl (pf) ...... 19 NEXAVAR ...... 16 nymyo ...... 31 midodrine hcl ...... 21 nicardipine hcl ...... 21 nystatin ...... 15 MIGERGOT ...... 15 NICORETTE ...... 12 nystatin-triamcinolone ..... 15 mili ...... 31 nicotine polacrilex ...... 12 nystop ...... 15 minitran ...... 21 nicotine polacrilex mini .... 12 O minocycline hcl ...... 13 nicotine step 1 ...... 12 ocella ...... 31 minoxidil ...... 21 nicotine step 2 ...... 12 octreotide acetate ...... 30 MIRENA (52 MG) ...... 31 nicotine step 3 ...... 12 ODEFSEY ...... 18 mirtazapine ...... 14 nifedipine ...... 21 OFEV ...... 38 misoprostol ...... 28 nifedipine er ...... 21 ofloxacin ...... 35, 37 M-M-R II ...... 33 nifedipine er osmotic olanzapine ...... 17 modafinil ...... 38 release ...... 21 olmesartan medoxomil .... 21 moexipril hcl ...... 21 nimodipine ...... 21 olmesartan medoxomil-hctz mometasone furoate ...... 24 nitazoxanide ...... 17 ...... 21 mondoxyne nl ...... 13 NITRO-BID ...... 21 olopatadine hcl ...... 35 mono-linyah ...... 31 NITRO-DUR ...... 21 omeprazole ...... 28 montelukast sodium ...... 38 nitrofurantoin ...... 13 OMNITROPE ...... 30 morgidox ...... 13 nitrofurantoin macrocrystal ondansetron hcl...... 15 morphine sulfate ...... 11 ...... 13 ondansetron odt ...... 15 morphine sulfate nitrofurantoin monohydrate ONETOUCH DELICA (concentrate) ...... 11 macrocrystals ...... 13 LANCING DEVICE ...... 26 morphine sulfate er ...... 11 nitroglycerin ...... 21 ONETOUCH DELICA PLUS moxifloxacin hcl ...... 13, 35 nitro-time ...... 21 LANCING DEVICE ...... 26 moxifloxacin hcl (2x day) . 35 NIVESTYM ...... 19 ONETOUCH ULTRA ...... 26 mupirocin ...... 13 nora-be ...... 31 ONETOUCH VERIO KIT mupirocin calcium ...... 13 norethin ace-eth estrad-fe 31 W/DEVICE ...... 26 mycophenolate mofetil ..... 33 norethindrone ...... 31 opium ...... 28 mycophenolate sodium .... 33 norethindrone acetate ..... 31 OPSUMIT...... 38 MYLERAN ...... 16 norethindrone acet-ethinyl ORACIT ...... 27 myorisan ...... 24 est ...... 31 oralone ...... 22 N norgestimate-eth estradiol ORENCIA...... 33 NABI-HB ...... 33 ...... 31 ORENCIA CLICKJECT ... 33 nabumetone ...... 11 norgestimate-ethinyl orphenadrine citrate er .... 38 nadolol...... 21 estradiol triphasic ...... 31 orsythia ...... 31 nafrinse ...... 27 norlyda ...... 31 oseltamivir phosphate ..... 18 naloxone hcl ...... 12 norlyroc ...... 31 OTEZLA ...... 33

46 oxazepam ...... 19 phenytoin sodium extended PRIFTIN ...... 16 oxcarbazepine ...... 14 ...... 14 prilovix ultralite ...... 12 oxybutynin chloride ...... 28 philith...... 32 prilovix ultralite plus ...... 12 oxybutynin chloride er ...... 28 phospha 250 neutral ...... 27 primaquine phosphate ..... 17 oxycodone hcl ...... 11 phosphorous ...... 27 primidone ...... 14 OXYCODONE HCL ER ... 11 phospho-trin 250 neutral.. 27 PRIMSOL ...... 13 oxycodone-acetaminophen phytonadione ...... 27 PRO COMFORT SPACER ...... 11 pilocarpine hcl ...... 22, 36 ADULT ...... 35 OXYCONTIN ...... 11 pimecrolimus ...... 24 PRO COMFORT SPACER P PIMECROLIMUS...... 24 CHILD ...... 35 pacerone ...... 21 pimozide ...... 17 PRO COMFORT SPACER PANDA MASK LARGE .... 35 pindolol ...... 21 INFANT ...... 35 PANDA MASK MEDIUM.. 35 pirmella 1/35 ...... 32 probenecid ...... 15 PANDA MASK SMALL .... 35 pirmella 7/7/7 ...... 32 procainamide hcl ...... 21 pantoprazole sodium ...... 28 piroxicam ...... 11 PROCARE papaverine hcl ...... 21 PNEUMOVAX 23 ...... 33 SPACER/ADULT MASK PARAGARD pocket spacer ...... 35 ...... 35 INTRAUTERINE podofilox ...... 24 PROCARE SPACER/CHILD COPPER ...... 32 polycin ...... 36 MASK ...... 35 paroxetine hcl ...... 14 polymyxin b-trimethoprim 36 prochlorperazine ...... 15 PAXIL ...... 14 portia-28 ...... 32 prochlorperazine edisylate PEDIARIX ...... 33 potassium chloride ...... 27 ...... 15 PEDIATRIC PANDA MASK potassium chloride crys er prochlorperazine maleate 15 ...... 35 ...... 27 PROCRIT ...... 19 PEDVAX HIB ...... 33 potassium chloride er ...... 27 PROCTOFOAM HC ...... 34 peg 3350-kcl-na bicarb-nacl potassium citrate er ...... 27 procto-med hc ...... 34 ...... 28 potassium citrate-citric acid proctozone-hc ...... 34 peg-3350/electrolytes ...... 28 ...... 27 progesterone ...... 32 PEGASYS ...... 18 PRADAXA ...... 13 promethazine hcl ...... 37 penicillamine...... 28 pramipexole dihydrochloride promethazine vc ...... 37 penicillin v potassium ...... 13 ...... 17 promethazine-dm ...... 37 PENTACEL ...... 33 PRAMOSONE ...... 24 promethazine- PENTASA ...... 34 prasugrel hcl ...... 17 phenylephrine ...... 37 PENTOSAN pravastatin sodium ...... 21 promethegan ...... 37 POLYSULFATE SODIUM praziquantel ...... 17 propafenone hcl ...... 21 ...... 28 prazosin hcl ...... 21 propranolol hcl ...... 21 pentoxifylline er ...... 21 PRED MILD ...... 35 propranolol hcl er ...... 21 perindopril erbumine ...... 21 PRED-G ...... 36 propylthiouracil ...... 32 periogard ...... 22 PRED-G S.O.P...... 36 PROQUAD ...... 34 permethrin ...... 17 prednisolone ...... 29 PROSTIN E2 ...... 28 perphenazine...... 15 prednisolone acetate ...... 35 protriptyline hcl ...... 15 perphenazine-amitriptyline prednisolone acetate p-f .. 35 PULMOZYME ...... 38 ...... 14 prednisolone sodium PYLERA ...... 28 PERSERIS ...... 17 phosphate ...... 29 pyrazinamide ...... 16 phenazo ...... 28 prednisone ...... 29 pyridostigmine bromide ... 16 phenazopyridine hcl ...... 28 pregabalin ...... 22 pyridostigmine bromide er16 phenelzine sulfate ...... 15 PREMARIN ...... 32 pyrimethamine ...... 17 phenobarbital...... 14 PREPIDIL ...... 28 Q phenobarbital sodium ...... 14 prevalite ...... 21 QUADRACEL ...... 34 phenoxybenzamine hcl .... 21 preventeza ...... 32 quetiapine fumarate ...... 17 phentolamine mesylate .... 21 previfem ...... 32 quetiapine fumarate er .... 18 phenylephrine hcl ...... 36 PREVNAR 13 ...... 34 quinapril hcl ...... 21 phenytoin ...... 14 PREVYMIS...... 18 quinapril- phenytoin infatabs ...... 14 PREZCOBIX ...... 18 hydrochlorothiazide ..... 21 phenytoin sodium ...... 14 PREZISTA...... 18 quinidine gluconate er ..... 21

47 quinidine sulfate ...... 21 sevelamer carbonate ...... 28 sulfamethoxazole- R sevelamer hcl ...... 28 trimethoprim ...... 13 rabeprazole sodium ...... 28 sharobel ...... 32 sulfasalazine ...... 34 raloxifene hcl ...... 29 SHINGRIX ...... 34 sulfatrim pediatric ...... 13 ramipril ...... 21 sildenafil citrate ...... 38 sulindac ...... 11 rasagiline mesylate ...... 17 silver sulfadiazine ...... 13 sumatriptan ...... 16 RASUVO ...... 33 simvastatin ...... 21 sumatriptan succinate ..... 16 REBIF...... 22 sirolimus ...... 33 sumatriptan succinate refill REBIF REBIDOSE ...... 22 SIVEXTRO ...... 13 ...... 16 REBIF REBIDOSE SKYLA ...... 32 SUPRAX ...... 13 TITRATION PACK ...... 22 SKYRIZI ...... 33 SURESTEP PRO HIGH REBIF TITRATION PACK22 SKYRIZI (150 MG DOSE)33 GLUCOSE...... 26 reclipsen ...... 32 SKYRIZI PEN ...... 33 SURESTEP PRO LOW RECOMBIVAX HB...... 34 sod citrate-citric acid ...... 27 GLUCOSE...... 26 RECTIV ...... 21 sodium chloride ...... 27, 37 SURESTEP PRO NORMAL RELENZA DISKHALER ... 18 sodium chloride (pf) ...... 27 GLUCOSE...... 26 relexxii ...... 22 sodium fluoride ...... 27 SURVANTA ...... 37 RELISTOR ...... 28 sodium polystyrene SUTENT ...... 16 RETIN-A ...... 24 sulfonate ...... 27 syeda ...... 32 RETIN-A MICRO GEL 0.04 sodium sulfacetamide ...... 24 SYMBICORT ...... 38 %, 0.1 % ...... 24 SOFOSBUVIR- SYMFI ...... 19 RETIN-A MICRO PUMP .. 24 VELPATASVIR ...... 19 SYMFI LO ...... 19 REVLIMID ...... 16 solifenacin succinate ...... 28 SYMTUZA ...... 19 REYATAZ ...... 18 SOLU-CORTEF ...... 29 synalar ...... 24 ribavirin ...... 18 sorine ...... 21 T RIDAURA ...... 33 sotalol hcl ...... 21 TABLOID...... 16 rifabutin ...... 16 sotalol hcl (af) ...... 21 tacrolimus...... 24, 33 rifampin ...... 16 SPIRIVA HANDIHALER .. 38 TAFINLAR ...... 16 riluzole ...... 22 SPIRIVA RESPIMAT ...... 38 TAGRISSO ...... 16 rimantadine hcl ...... 18 spironolactone ...... 21 TAMIFLU...... 19 risedronate sodium ...... 34 spironolactone-hctz ...... 21 tamoxifen citrate ...... 16 RISPERDAL CONSTA .... 18 sprintec 28...... 32 tamsulosin hcl ...... 29 risperidone ...... 18 SPRYCEL ...... 16 tarina fe 1/20 ...... 32 ritonavir ...... 19 sps ...... 27 tarina fe 1/20 eq ...... 32 rivastigmine tartrate ...... 14 sronyx ...... 32 tazarotene ...... 24 rizatriptan benzoate ...... 15 ssd ...... 13 tazicef ...... 13 ropinirole hcl ...... 17 SSKI ...... 37 TAZORAC ...... 24 rosadan ...... 24 stavudine ...... 19 TDVAX ...... 34 rosuvastatin calcium ...... 21 STELARA ...... 33 temazepam ...... 38 ROTARIX ...... 34 STIMATE ...... 30 TEMIXYS ...... 19 ROTATEQ ...... 34 STIOLTO RESPIMAT ...... 38 temozolomide ...... 16 roweepra ...... 14 STIVARGA ...... 16 TENIVAC ...... 34 ROZLYTREK ...... 16 STRIBILD ...... 19 tenofovir disoproxil fumarate RYDAPT ...... 16 STRIVERDI RESPIMAT .. 38 ...... 19 ryvent ...... 37 subvenite ...... 14 terazosin hcl ...... 29 S sucralfate ...... 28 terbinafine hcl ...... 15 salsalate ...... 11 sulfacetamide sodium ...... 35 terbutaline sulfate ...... 38 SANDOSTATIN LAR sulfacetamide sodium testosterone ...... 29 DEPOT ...... 30 (acne) ...... 24 testosterone cypionate .... 29 SANTYL ...... 24 sulfacetamide sodium-sulfur TESTOSTERONE selegiline hcl ...... 17 ...... 24 CYPIONATE ...... 29 selenium sulfide ...... 24 sulfacetamide-prednisolone testosterone enanthate.... 29 SELZENTRY ...... 19 ...... 36 TETANUS-DIPHTHERIA SEREVENT DISKUS ...... 38 sulfacetamide-sulfur in urea TOXOIDS TD ...... 34 sertraline hcl ...... 15 ...... 24 THALOMID ...... 16

48 theophylline ...... 38 trospium chloride ...... 28 voriconazole ...... 15 theophylline er ...... 38 trospium chloride er ...... 28 VOSEVI ...... 19 thiothixene ...... 18 TRUE METRIX LEVEL 1 . 26 VOTRIENT ...... 17 timolol maleate ...... 21, 36 TRUE METRIX LEVEL 2 . 26 vyfemla ...... 32 TIVICAY ...... 19 TRUE METRIX LEVEL 3 . 26 vylibra ...... 32 TIVICAY PD ...... 19 TRUMENBA ...... 34 W tizanidine hcl...... 38 tulana ...... 32 warfarin sodium ...... 13 TOBRADEX...... 36 tyblume ...... 32 wera ...... 32 tobramycin ...... 36, 38 TYBOST ...... 19 WIDE-SEAL DIAPHRAGM tobramycin-dexamethasone TYVASO ...... 38 60 ...... 35 ...... 36 TYVASO REFILL...... 38 WIDE-SEAL DIAPHRAGM TOBREX ...... 36 TYVASO STARTER ...... 38 65 ...... 35 tolbutamide ...... 25 U WIDE-SEAL DIAPHRAGM tolterodine tartrate ...... 28 ULTIGUARD SAFEPACK 70 ...... 35 tolterodine tartrate er ...... 28 SYR/NEEDLE ...... 27 WIDE-SEAL DIAPHRAGM topiramate ...... 14 UNISTRIP CONTROL ..... 26 75 ...... 35 torsemide ...... 21 UPTRAVI ...... 38 WIDE-SEAL DIAPHRAGM tramadol hcl ir ...... 12 urea ...... 25 80 ...... 35 tramadol-acetaminophen . 12 uremez-40 ...... 25 WIDE-SEAL DIAPHRAGM trandolapril ...... 21 ursodiol ...... 28 85 ...... 35 tranexamic acid ...... 19 V WIDE-SEAL DIAPHRAGM tranylcypromine sulfate .... 15 valacyclovir hcl ...... 19 90 ...... 35 travoprost (bak free) ...... 36 valganciclovir hcl ...... 19 WIDE-SEAL DIAPHRAGM trazodone hcl ...... 15 valproic acid ...... 14 95 ...... 35 TREMFYA ...... 33 valsartan ...... 22 wixela inhub ...... 38 tretinoin ...... 16, 24, 25 valsartan- X tretinoin microsphere ...... 25 hydrochlorothiazide ..... 22 XARELTO ...... 13 tretinoin microsphere pump VALTOCO ...... 14 XARELTO STARTER PACK ...... 25 vancomycin hcl ...... 13 ...... 13 tri femynor ...... 32 vandazole ...... 13 XELJANZ ...... 33 triamcinolone acetonide .. 22, VAQTA ...... 34 XELJANZ XR ...... 33 25 VARIVAX ...... 34 XIIDRA ...... 36 triamterene ...... 21 VAXELIS ...... 34 XTANDI ...... 17 triamterene-hctz ...... 21 VECTICAL...... 25 xulane ...... 32 triazolam ...... 19 velivet ...... 32 Y tricitrates ...... 27 VENCLEXTA ...... 16 yuvafem ...... 32 triderm ...... 25 VENCLEXTA STARTING Z tri-estarylla ...... 32 PACK ...... 17 zafemy ...... 32 trifluoperazine hcl ...... 18 venlafaxine hcl ...... 15 zaleplon ...... 38 trifluridine ...... 36 venlafaxine hcl er ...... 15 zarah ...... 32 trihexyphenidyl hcl ...... 17 VENTAVIS ...... 38 ZARXIO ...... 19 tri-linyah ...... 32 verapamil hcl ...... 22 ZELBORAF ...... 17 tri-lo-estarylla ...... 32 verapamil hcl er ...... 22 zenatane ...... 25 tri-lo-marzia ...... 32 vienva ...... 32 ZENPEP ...... 28 tri-lo-mili ...... 32 VIGAMOX ...... 36 zenzedi ...... 22 tri-lo-sprintec...... 32 VIRACEPT ...... 19 ZEVRX STERILE trimethoprim ...... 13 VIREAD ...... 19 ALCOHOL PREP PAD 35 tri-mili...... 32 virt-phos 250 neutral ...... 27 zidovudine ...... 19 tri-nymyo ...... 32 vitamin d (ergocalciferol) . 27 ziprasidone hcl ...... 18 tri-previfem ...... 32 vitamin k1 ...... 27 zolmitriptan ...... 16 tri-sprintec ...... 32 VIVAGUARD INO zolpidem tartrate ...... 38 TRIUMEQ ...... 19 CONTROL SOLUTION 26 zonisamide ...... 14 trivora (28) ...... 32 VIVAGUARD LANCING zovia 1/35 (28) ...... 32 tri-vylibra ...... 32 DEVICE ...... 26 zovia 1/35e (28) ...... 32 tri-vylibra lo ...... 32 VIVITROL ...... 12 zumandimine ...... 32

49 ZYDELIG ...... 17 ZYPREXA RELPREVV ... 18

50 Kaiser Permanente Nondiscrimination Notice and Language Access Services

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© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted 2018-XB-7_ACA_Notice_Taglines LANGUAGE ACCESS SERVICES English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711). Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711). 中文 (Chinese)：注意：如果您使用繁體中文，您可 以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。 Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711). 한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오. Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711). Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

徶羶ខ្មែរ (Khmer)៖ របយ័ត៖ េេបើសិនអកនិខ្យមរ , េ សជំនួខ្យផក េយមិនគិតល គឺចនសំប់បំេរអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។ 日本語 (Japanese): 注意事項：日本語を話される場 合、無料の言語支援をご利用いただけます。 1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、 お電話にてご連絡ください。 አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711). Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711). ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।ﹱ ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸਾ ਧ 1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ। العربية :(Arabic) لديكم حق الحصول على مساعدة ومعلومات في ملحوظة :إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان .اتصل برقم 4636-901-888-1 رقم هاتف الصم والبكم: (1-800-833-6388 / 711) . Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711). ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວ ້ າພາສາລາວ, ການບໍ ິລການຊ່ ວຍເຫ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່ າ, ແມ່ ນມີ ພ້ ອມ ໃຫ້ ທ່ ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711). Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711). Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711). فارسی :(Farsi) توجه :اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد .با (TTY: 1-800-833-6388 / 711) 4636-901-888-1 تماس بگيريد.

XB0001444-56-18