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Select Drug Program® Formulary Effective July 1, 2021

www.amerihealth.com

INFORMATION FOR MEMBERS AND PROVIDERS

This Select Drug Program® Formulary is intended to help members and providers understand coverage under the AmeriHealth Select Drug Program Formulary. We are committed to providing comprehensive prescription drug coverage. To achieve this, we include a formulary feature in your prescription drug benefit. The drugs are approved by the U.S. Food and Drug Administration (FDA). They are also reviewed by our Pharmacy and Therapeutics Committee, a group of doctors and from the area. These prescription drugs have been added to the Select Drug Program Formulary for their reported medical effectiveness, safety, and value. FutureScripts®, an independent company, is our pharmacy benefits manager. They monitor all drugs to ensure they are safe and effective drugs. Please note: Prescription drug benefits vary by group. Therefore, a drug on this formulary does not imply coverage. Drug coverage is based on medical necessity. This formulary guide was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your provider or .

What is a formulary? A formulary is a list of prescribed or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications. To create the list, FutureScripts is guided by the Pharmacy and Therapeutics Committee. This group of doctors and pharmacists review which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

What are tiers? Tiers are the different cost levels you pay for a . Each drug on the formulary is in a tier.

Select Formulary Tier Structure Below is a summary of tiers in the general order from lowest to highest level of cost-share. Benefits vary by group, so the inclusion of a drug in this formulary does not guarantee coverage. All cost-share tiers may not be available on all plan. - Low-Cost Generic (availability varies by benefit) - Generic - Preferred Brand - Non-preferred Drug - Specialty (availability varies by benefit)

• Generally, if a brand-name drug has a generic equivalent, the brand-name drug is non-preferred while the generic equivalent is covered at the generic level of cost-sharing. For example: Cipro® is the brand drug and is considered non-preferred; its generic equivalent is available at the generic level of cost-sharing. •  Some brand-name drugs without generic equivalents, authorized generic (also referred to as authorized brand alternative) drugs and generic drugs are also considered non-preferred. This is because there are other more cost-effective alternatives covered on the formulary to treat the same condition.

(continued) 1 Covered generic drugs not listed in the formulary guide are available at the generic level of cost-sharing; covered brand drugs not listed in the formulary guide are available at the non-preferred level of cost-sharing.

The Low-Cost Generic [LCG] Tier offers copays lower than the cost-share for the generic tier, when possible. This applies to certain generic drugs that are typically used to treat chronic conditions such as high , high cholesterol, , heart failure, and depression. Benefits may vary. Not all plans provide this incentive. The drug list is subject to change. When this incentive is not available on a plan, these drugs will be covered at the generic cost-share level.

Specialty Drugs [SP] meet certain criteria, including, but not limited to drugs used to treat rare, complex, or chronic diseases, drugs that have complex storage and/or shipping requirements, and drugs that require comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may be managed by the FutureScripts Specialty Pharmacy Program. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing. For cost-sharing purposes, drugs on the specialty tier are not eligible for tier lowering.

Authorized Generics [AG] are brand-name drugs that are marketed without the brand name on its label. An authorized generic may be marketed by the brand-name drug company, or another company with the brand company’s permission. These drugs are approved by the FDA. But they are not approved through the abbreviated new drug application (ANDA) process like a standard . For cost sharing purposes, authorized generics are treated as brand-name drugs and are not eligible for coverage on the generic tier(s). Another name for AGs is Authorized Brand Alternative [ABA]. For example: oxycodone ER , an authorized generic of brand OxyContin®, is listed as non-preferred and is available at the non-preferred level of cost-sharing.

What are Affordable Care Act (ACA) Preventive Medications? Certain preventive medications, as described in the Patient Protection and Affordable Care Act and detailed by the U.S. Preventive Services Task Force, are covered without cost-sharing with a prescription when provided by a participating retail or mail-order pharmacy. The following categories of drugs may be available at no member cost-share with a prescription. Please note that individual benefits may vary. Always refer to your benefits to determine your coverage. This list is subject to change. Refer to the searchable drug lookup tool on your health insurance plan’s website to check the status of a specific drug.

(continued) 2 Category Product(s) Available at $0 at the Pharmacy products (OTC) aspirin 81mg (tab/chewable) For adults age 50-59 to prevent and colorectal cancer; low dose (81mg) for women after 12 weeks’ gestation who are at high risk for preeclampsia Bowel Preparations generic bowel preparation products such as Bowel preparation for colonoscopy needed for Gavilyte-C™, Gavilyte-G™, Gavilyte-N™, preventive colon cancer screening, for ages 50-75 Gavilyte-H™ with bisacodyl, polyethylene glycol (PEG) 3350 oral powder, Trilyte® w/packets Breast cancer chemo prevention tamoxifen 20mg For asymptomatic females age 35 years and older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, who are at high risk for breast cancer and at low risk for adverse effects from breast cancer chemoprevention Contraceptives - Oral: all generics such as Amethia, Cryselle-28, Includes, but not limited to, oral, injectable, Emoquette, Fayosim, Necon, Ocella, Sprintec, transdermal, diaphragms, cervical caps, intravaginal Trivora, Natazia devices, female condoms, and contraceptive film - Injectable: all generics such as and jelly (in accordance with the women’s preventive medroxyprogesterone injection services provisions of the ACA). - Transdermal: Xulane® patches Note: IUDs and implantable products are covered - Diaphragms under the medical benefit. - Cervical Caps - Female condoms - Contraceptive film - Contraceptive gel/jelly/foam: such as VCF® foam 12.5%, 28%, Options Conceptrol® 4%, Options Gynol® 3% - Emergency: all generics such as 1.5mg tab, My Way® 1.5mg tab - Intravaginal devices: -ethinyl vaginal ring

3 (continued) Category Product(s) Available at $0 at the Pharmacy Fluoride sodium fluoride 1.1 (0.5f) mg/ml solution For children ages 6 months to 16 years. Includes sodium fluoride 0.55 (0.25f) mg chewable tab generics strengths up to 0.5mg Fluoritab 0.275 (0.125f) mg/drop solution Fluoritab 1.1 (0.5f) mg chewable tab Folic folic acid 400mcg tab For women planning for or capable of folic acid 800mcg tab . Limited to 0.4 to 0.8mg of folic acid. folic acid 0.8mg capsule For women younger than 51 years of age (including generic prenatal vitamins with the above listed folic acid dose) Tobacco Cessation Medication Chantix® For adults ages 18+ years, who use tobacco products SR (generic Zyban®) tablet and want to quit nicotine polacrilex lozenge nicotine patch 24 hour transdermal Nicotrol® Inhaler Nicotrol® NS Solution lovastatin 10mg Low-to-moderate dose for prevention of lovastatin 20mg cardiovascular disease, recommended for ages 40-75 lovastatin 40mg years without a history of CVD when 1 or more CVD risk factors are present (e.g., dyslipidemia, diabetes, , or smoking) and a calculated 10-year risk of a cardiovascular event of 10% or greater HIV PrEP Emtricitabine-Tenofovir Disoproxil Fumarate Tab Preexposure prophylaxis (PrEP) with effective anti- 200-300mg retroviral therapy for persons who are at high risk of Tenofovir 300mg HIV acquisition

4 (continued) PROCEDURES THAT SUPPORT SAFE PRESCRIBING AmeriHealth utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and their providers. The effectiveness and safety of drugs and drug-prescribing patterns are monitored by FutureScripts®. Several procedures, such as prior authorization, age limits, and quantity limits, have been established to support safe prescribing patterns and to provide optimal clinical outcomes for members. What is prior authorization? Prior authorization is a requirement that your provider obtain approval from your health plan for coverage of, or payment for, prescription drugs. AmeriHealth requires prior authorization of certain covered drugs to confirm that the drug prescribed is medically necessary, clinically appropriate, and is being prescribed according to FDA approved labeled or medically accepted use. The approval criteria were developed and approved by the Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s provider, and the member’s available prescription drug therapy history. The clinical pharmacists’ evaluation may include a review of potential drug-drug interactions or contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies, if necessary. Please note, coverage of certain drugs on the formulary (e.g., weight loss drugs) requires a benefit rider. Please contact the health insurance plan for member eligibility information and benefit details. Prior Authorization Requirements for Selected Drugs Prior Authorization Requirements for Selected Drugs are in place for certain medications. This expedites the review process by using information available in the member’s pharmacy benefit claim history to determine coverage for the requested medication at the pharmacy. For example, Tirosint® is a medication that requires previous trial of generic levothyroxine. With the Prior Authorization Requirements for Selected Drugs, a member will be able to immediately receive coverage for Tirosint® if the claim history shows a previous paid claim for generic levothyroxine. A manual prior authorization request will not be needed. If the claim history does not show a previous use of either drug (e.g., if the prescriber provided a sample for the member to try) then a prior authorization request will be needed in accordance with the standard prior authorization process. Without prior authorization, the member’s prescription will not be covered at the retail or mail-order pharmacy. The prior authorization review process may take up to two business days once complete information from the provider has been received. Incomplete information may result in a delayed decision. Prior authorization approvals for some drugs may have a limited timeframe, for example six to twelve months. If the prior authorization approval for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the provider wants a member to continue the drug therapy as requested after the expiration date, a new prior authorization request will need to be submitted and approved for coverage to continue.

5 (continued) Safety Edits Safety edits are applied to prescription medications to ensure safe and appropriate use of drugs. They are designed to align with the clinical practice guideline and FDA approved use outlined in the manufacturer package insert. Some of these safety edits will prompt member counseling at the point of sale, while some will require prior authorization review. Safety edits include age limits, quantity limits, morphine milligram equivalent (MME) limits, and concurrent drug utilization review (cDUR). Each safety edit is described below. Age Limits Some drugs, such as zafirlukast, are approved by the FDA only for individuals age five and older. If the member’s prescription falls outside of the FDA guidelines, it may not be covered unless prior authorization is obtained. In addition, an age limit may be applied when certain drugs are more likely to be used in certain age groups. For example, drugs to treat Alzheimer’s disease may require prior authorization for use in young adults. The provider may request coverage for drugs outside of the age limit when medically necessary. The approval criteria for this review were developed and approved by the Pharmacy and Therapeutics Committee. The member should contact the provider to initiate the prior authorization process. Quantity Limits Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses, standard dosing, and/or length of therapy of a drug. AmeriHealth has several different types of quantity limits that are explained in detail below. The purpose of these limits is to ensure safe and appropriate utilization. If a member requires more than the limit, the member’s provider will need to submit a prior authorization request. Similar to other prior authorization requests, quantity limit override requests for certain drugs may have a limited approval timeframe. • Quantity Over Time: This quantity limit is based on dosing guidelines over a rolling time period. For example, if a drug has a quantity limit over a 30-day time period and a member went to the pharmacy on January 1, 2021, for one of these medications, the plan would have looked back 30 days to December 2, 2020, to see how much medication was dispensed. The purpose of these limits is to prevent the dispensing of excessive quantities. Examples of quantity limits over time are: ◦ Etonogestrel-ethinyl estradiol (Nuvaring®) = 1 ring per 28 days ◦ Ibandronate (Boniva®) 150mg = 1 tablet per 30 days ◦ Sumatriptan (Imitrex®) 50mg = 18 tablets per 30 days ◦ Diabetic supplies such as blood glucose test strips = 200 strips per 30 days ◦  (Viagra®), (Cialis® 10mg, 20mg) = 8 tablets per 30 days • Maximum daily dose: This quantity limit defines the maximum number of units of the drug allowed per day. Examples of maximum daily dose quantity limits are: ◦ Zolpidem (Ambien®) = 1 tablet per day ◦ Oxycodone/acetaminophen (Percocet®) 5/325mg = 12 tablets per day ◦ Guanfacine Extended Release 24 Hour = 1 tablet per day

6 (continued) • Refill too soon: This limit is in place to encourage appropriate utilization and minimize stockpiling of prescription medications. Based on this edit, a member can receive a refill of a prescription after 75% utilization. Additional refills will be covered once 75% of the supply has been consumed. The following examples illustrate how refill too soon limit works: ◦ A 30 days’ supply of a prescription filled on 1/1/2021 will be refillable again on or after 1/24/2021 ◦ A 90 days’ supply of a prescription filled on 7/1/2021 will be refillable again on or after 9/7/2021 • Day Supply Limit: This limit is based on the day supply and not the quantity. However, quantity limits may apply as well. Day Supply Limits apply to some classes of drugs, such as . If a quantity limit applies, the member will also be limited to the maximum daily dose for that drug. The following are examples of drugs that have a day supply and a quantity limit: ◦ Short acting opioids, such as oxycodone/acetaminophen 5mg/325mg • Day supply limit = Two 5 days’ supplies limit per 60 days for adults, two 3 days’ supply limit for children under 18 years of age.

◦ Butalbital containing agents, such as butalbital/aspirin • Day supply limit = 5-day supply per 30 days • Quantity Limit = 6 tablets per 1 day • Maximum quantity allowed without prior authorization = 30 tablets (6 tablets per day for 5 days)

◦  containing and cold products, such as /homatropine • Day supply limit = Two 5-days’ supplies limit per 60 days for adults, and two 3 days’ supply limit for children under 18 years of age • Quantity Limit = 30 ml per 1 day • Maximum quantity allowed without prior authorization = 150 ml (30 ml per day for 5 days)

Morphine Milligram Equivalent (MME) Limit AmeriHealth applies additional safety measures to opioid products by limiting the total daily dose. This limit accounts for various opioid products through a measurement called the Morphine Milligram Equivalent (MME) dose. The MME is a number that is used to determine and compare the potency of opioid medications. It helps to identify when additional caution is needed. The daily limit is calculated based on the number of opioid drugs, their potencies and the total daily usage. Prior authorization is required for an opioid dose that exceeds 90 MME per day. MME Limit applies to the opioid products containing the active ingredients listed below:  Active Ingredient fentanyl hydrocodone levorphanol meperidine morphine oxycodone oxymorphone tapentadol Tramadol benzhydrocodone

7 (continued) Cumulative Limit Central nervous system (CNS) such as and , when used in high doses, are associated with increased risk for cardiac related adverse events such as hypertension and new or worsening psychosis including manic behavior. Cumulative stimulant limit is a safety measure designed to ensure the provider has assessed the members for alternative medication and advised the members about the risks associated with stimulant use. The cumulative stimulant limit works by calculating the total daily stimulant dose by the drug’s active ingredient. Stimulant claims that exceed the limit outlined below would require prior authorization.

Active ingredient Medications impacted High cumulative daily dose (brands and generics) Amphetamine Adzenys ER[ODT], Dyanavel, 60mg/day Evekeo [ODT] Amphetamine-Dextroamphetamine Adderall [IR/XR], Mydayis 60mg/day Dextroamphetamine Dexedrine, Zenzedi, ProCentra 60mg/day Lisdexamfetamine Vyvanse 70mg/day Desoxyn 60mg/day Dexmethylphenidate Focalin [IR/XR] 40mg/day Methylphenidate Ritalin [IR/LA], Daytrana, 72mg/day Cotempla, Metadate [ER/CD], Methylin, Quillivant XR, Concerta, Aptensio XR, QuilliChew ER, Jornay PM, Adhansia XR *Prior authorization and other safety edits including quantity limit and age limit continue to apply.

Concurrent Drug Utilization Review (cDUR) These reviews are built into the pharmacy claim adjudication system to review a member’s prescription history for possible drug related problems including drug-drug interactions and drug therapy duplications. Drugs may reject at the Point-of-Sale (POS) and/or generate a message to the dispensing pharmacist when there is a safety concern. The dispensing pharmacist can review the issue with the provider and override the rejection if appropriate for most edits. Examples of cDURs are: • Drug-drug interaction: sildenafil (Viagra®/Revatio®) and in combination may lead to potentially fatal . • Drug therapy duplication: and atorvastatin in combination will trigger a message in the claim adjudication system to alert the dispensing pharmacist there is a duplication of statin therapy. To determine if a covered prescription drug prescribed for you has a prior authorization requirement, an age limit, a quantity limit, or a morphine milligram equivalent (MME) limit, see the plan website at www.amerihealth.com or call FutureScripts® at the phone number on the back of your ID card.

8 (continued) 96-Hour Temporary Supply Program The 96-Hour Temporary Supply Program is available for certain formulary medications that require prior authorization. Under the 96-Hour Temporary Supply Program, the dispensing pharmacist has the option to release a 96-hour supply as follows: 1. The dispensing pharmacist may place an override to release a 96-hour supply of the drug to the member with either no out-of-pocket co-pay or the appropriate percentage cost-sharing as defined by the member’s benefit. 2. The next business day, FutureScripts®, will contact the member’s provider to request submit documentation of medical necessity or medical appropriateness for review. 3. Once the completed medical documentation is received by FutureScripts®, the review will be completed, and the request will either be approved or denied. 4. If approved, the remainder of the prescription may be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied. 5. If denied, notification will be sent to both the provider and the member. Obtaining a 96-hour temporary supply does not guarantee that the prior authorization request will be approved. This program limits a one-time release of 96-hour supply per drug. Some drugs are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations. How to submit a Prior Authorization? Here is the process to request a prior authorization/preapproval or override: 1. The provider prescribing the drug can access electronic prior authorization (ePA) platforms such as CoverMyMeds® and SureScripts™ to submit a prior authorization request. Alternatively, the provider can complete a prior authorization fax form or write a letter of medical necessity and submit it to FutureScripts® by fax at 1-888-671-5285. The forms are available online at: https://www.futurescripts. com/prior-authorization1.html. 2. FutureScripts® will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on established criteria, a medical director will review the document. 3. A decision is made regarding the request. • If approved, the provider will be notified of the approval via fax and/or telephone, and the pharmacy claim adjudication system will be coded with the approval. Note: ePA approval can occur in real time, this means the member can be approved for the drug prior to leaving the provider’s office with a prescription. The member may call the Customer Service phone number on his or her ID card to determine if the request is approved. • If denied, the prescribing provider will be notified via letter, fax, or telephone. The member is also notified via letter. The appeals process is detailed within the denial letters sent to the member and provider.

9 (continued) Formulary Exception Requests Tier exceptions: Providers may request consideration for preferred coverage of a non-preferred drug when there has been a trial of, or contraindication to, at least three formulary alternatives when applicable. • Requests for a generic medication that is located on the non-preferred drug tier to be lowered to the generic tier will be approved if the exception criteria are met. • Requests for a brand medication or an authorized generic (also referred to as authorized brand alternative) non-preferred that is located on the non-preferred drug tier to be lowered to the preferred brand tier will be approved if the exception criteria are met. Please note, restrictions apply to formulary exception requests. Drugs on the generic tier, the preferred brand tier and the specialty tier are not eligible for tier exceptions. Tier exceptions are not available under some plans; please refer to the member benefit booklet for details. When requesting an exception, the provider should complete the formulary exception request form, providing detail to support the request, and fax the request to 1-888-671-5285. If the formulary exception request is approved for a non-preferred drug, the drug will pay at the appropriate preferred brand or generic level of cost-sharing. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. The forms are available online at: https://www.futurescripts.com/prior-authorization1.html. Appealing a decision If a request for prior authorization or exception results in a denial, the member, or the provider on the member’s behalf (with the member’s consent), may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. To assist in the appeals process, it is recommended that the provider be involved to provide any additional information on the basis of the appeal.

10 Prior authorization applies to all formulations of the following specific drugs, including but not limited to, tablet, capsule, and oral suspensions.* Abilify Androderm® Bonjesta® Contour Test Strips abiraterone Androgel® Contrave ER® Absorica™ Apidra® Bosulif® Conzip™ Absorica LD™ Apidra® SoloSTAR® Brand prenatal vitamins1 Cordran® Abstral® Aplenzin™ Bravelle® Corifact® Acanya® Apokyn® Breeze2 test strips/ Corlanor® Aciphex® Aptensio XR® glucometer Cosentyx™ Actemra® SC Aptiom® Briviact® Cotellic™ Acticlate™ Arazlo™ lotion BromSite® Cozaar®/Hyzaar® Actimmune® Arikayce® Brukinsa™ Cresemba® Actiq® armodafinil budesonide-formoterol Crestor® Aczone® ArmonAir™ butalbital-acetaminophen Cuprimine® pad Digihaler® 50-300mg Cutivate® Adcirca™ ArmonAir™ Buphenyl® cyclobenzaprine ER Adderall® RespiClick® buprenorphine patch Cystadrops® Addyi® Arthrotec® Butrans® Cystaran™ Adempas® Arymo™ ER Bynfezia Pen™ Daklinza™ Adhansia™ XR Asacol®HD Byvalson™ gel 7.5% Adipex-P® Asmanex® Cabometyx™ Daypro® Adlyxin™ Asmanex® HFA Calquence® Daytrana™ Admelog® Atacand® (HCT) Capex® Dayvigo™ Advate® Ativan® Caplyta™ DDAVP® Adynovate® Atralin® Caprelsa® deferasirox tab/granules Adzenys™ XR-ODT Aubagio® Carac® deferiprone tab Aerospan™ Austedo™ Carbaglu® Delatestryl® Afinitor® Auvi-Q® Carbatrol® Demerol® Afrezza® Avapro®/Avalide® Cardizem® CD Desonate® Afstyla® Avita® Caverject® Desowen® AirDuo® Digihaler® Axert® Cayston™ Desoxyn® AirDuo® RespiClick® Axiron® Celebrex® dexchlorpheniramine soln Ajovy® Ayvakit™ Cequa™ Dexedrine® Aklief® azelastine/fluticasone Cerdelga™ Dexilant™ Aktipak™ spray Cholbam® D.H.E.® 45 Albuterol HFA (AG for Azelex® Cialis® Diabetic test strips2 Ventolin) Azor® Ciclodan® Dibenzyline® Alecensa® Banzel® Cimzia® Diclegis® Alkindi® Sprinkle Basaglar® Cinryze® Diclofenac cap 35mg Alphanate® Bebulin® Cleocin T® diclofenac gel 3% Alphanine® SD Beconase AQ® Clindagel® diethylpropion HCL Alprolix™ Belbuca™ /benzoyl Differin® Altabax™ Belsomra® peroxide 1%/5% dihydroergotamine Alunbrig™ Belviq® [XR] clobazam Dilaudid® Alvesco® BeneFIX® Clobex® Diovan® (HCT) Ambien® Benicar® Cloderm® Dojolvi™ Ambien CR® Benicar HCT® clovique Dolophine® Amerge® Benlysta® Coagadex® Doral® Amitiza® Benzaclin® Colcrys® Doryx® DR amphetamine ER susp Benzamycin® Cometriq™ doxepin tablet amphetamine Benzamycinpak® Comtempla XR ODT™ DR 40 mg (generic Evekeo) benzphetamine Concerta® Doxycycline Hyclate DR Ampyra™ Berinert® Conjupri® 80mg Amzeeq™ Bevespi Aerosphere™ Contour Glucometer Doxycycline Hyclate Tab Anaprox® DS Contour Next Test Strips 50mg

(continued) 11 doxylamine-pyridoxine Ezzalor™ Sprinkle Cap Humulin® Kevzara® Drizalma Sprinkle™ Fabior® Hycamtin® Khedezla® Duac® Factive® hydrocodone ER Kineret® Duaklir® Fanapt™ hydromorphone ER Kisqali™ Dulera® Farydak® Hysingla™ Klonopin® Duobrii™ Fasenra® Ibrance® Koate®-DVI Dupixent® febuxostat Ibudone® Kogenate® FS Duragesic® Feiba® icatibant inj Korlym™ Durlaza® Felbatol® Iclusig™ Koselugo™ Duzallo® Femring® Idelvion® Kuvan® Dyanavel XR™ fentanyl citrate-OTFC Idhifa® Kynamro® Dymista® Fentanyl citrate tablet mesylate Kynmobi™Mis/Kit EC-Naprosyn® fentanyl transdermal Imbruvica™ Lamictal® (ODT) Ecoza™ Fentora® Imcivree™ Lansoprazole Solutab Edarbi™ Ferriprox® Imitrex® lapatinib Edarbyclor™ Fetzima™ Impeklo™ Latuda® Edex® Fiasp® Inbrija® Lazanda® Edluar™ Fintepla® Increlex® ledipasvir-sofosbuvir Effexor XR® Fioricet® with Codeine Inderal® LA Lenvima™ Elidel® Fiorinal® with Codeine indomethacin 20mg Letairis® Elmiron® Firazyr® Ingrezza™ Levemir® Eloctate™ Flector® patch Inlyta® Levitra® Embeda® Focalin® XR Inqovi® levothyroxine cap Emflaza™ Follistim® AQ Inrebic® Lexapro® Emgality® Fortamet® insulin aspart Licart™ Enbrel® Forteo™ insulin aspart protamin Lidoderm® Endari™ Fortesta™ insulin lispro Lipitor® Enspryng™ Freestyle test strips/ insulin lispro inj junior Livalo® Enstilar® glucometer insulin lispro inj protamin Locoid® Entocort® EC Frova® Intermezzo® Locoid® lipocream Entresto™ Fulyzaq™ Intrarosa® Lomaira™ Epclusa® Gattex® Intuniv™ Lonhala™ Magnair™ Erivedge™ Gavreto® Invega™ Lonsurf® Erleada® Genotropin® Invokamet® [XR] Loprox® erlotinib Gilenya® Invokana® Lorzone® Ertaczo® Gilotrif™ Iressa® Lotronex® Esbriet® Gimoti™ Isturisa® Lovaza® esomeprazole Gleevec® Ixinity® Lunesta® esomeprazole granules Gloperba® Jadenu™ tab/granules Luxiq® Esperoct® Glucagen® Hypokit® Jakafi™ Luzu® Estrace® Cream Golytely® Jatenzo® Lynparza™ eszopiclone 3mg Gralise™ Jentadueto™ Lyrica® CR Eucrisa™ Grastek® Jornay™ PM Lyumjev™ Evekeo™ Haegarda® Jublia® Mavenclad® everolimus (generic for Halcion® Juxtapid™ Mavyret™ Afinitor) Halog® Jynarque® Maxalt® (MLT) Evoclin® foam Harvoni™ Kadian® Mekinist® Evrysdi™ Helixate® FS Kalydeco™ meloxicam cap Evzio™ Hemlibra® Soln Kapvay® Menopur® Exalgo™ Hemofil® M Katerzia™ methadone Exelderm® Hetlioz™ Kazano® Methitest™ Exforge® (HCT) Horizant™ Kenalog™ Exjade® Humalog® Keppra® methylphenidate ER (XR) Extavia® Humate-P® Kerydin™ Micardis® (HCT) Extina® Humatrope® ketoprofen cap miglustat Eysuvis™ Humira® Keveyis™ Migranal®

(continued) 12 Minocin® Nurtec™ chw ODT Pennsaid® Rescula® ER cap Nutropin® (AQ) Pepcid® Restoril® Mitigare® Nuvigil® Percocet® Retevmo™ Mobic® Nuwiq® phendimetrazine tartrate Retin-A® (Micro) modafinil Obizur Picato® Revatio™ mometasone furoate Ocaliva™ Piqray® Revlimid® Monoclate-P® Odactra® SL Plenvu® Rexulti® Monodox® Odomzo® Pomalyst® Reyvow™ Mononine® Ofev® Praluent® Riastap® MorphaBond™ ER Olumiant® Precision Glucometer Rinvoq™ morphine ER Olux®[E] Precision XTRA Test Ritalin® LA Motegrity™ Omnaris® Strips Rixubis™ Movantik® Omnitrope® Pretomanid® Roxicodone® MoviPrep® Onfi® Prevacid® Rozlytrek™ MS Contin® Ongentys® Prilosec® Rubraca® Muse® Onmel™ Pristiq™ Ruconest® Myalept™ Onureg® ProAir®Digihaler™ rufinamide Mycapssa® Onzetra Xsail™ Proctocort® Supp 30mg Rukobia® Mydayis™ Opana® Procysbi® Ruzurgi® Mytesi™ Opana ER® Profilnine® Ryclora™ Nalfon® Opsumit® Prolate™ Rydapt® Naprelan® Oracea® Promacta® Rytary™ Naprosyn® Oralair® Protonix® Sabril® Nascobal® Orencia® SQ Protopic® Saizen® Nasonex® Orenitram™ Proventil® HFA Samsca™ Natesto™ orphenadrine-asa- Provigil® Saphris® Natpara® Orfadin® Prozac® sapropterin pow/tab Nayzilam® Orgovyx™ Qdolo® Saxenda® Nerlynx™ Oriahnn® Qinlock™ Secuado® Nesina® Orkambi™ Qnasl™ Segluromet® Nestabs® One Orladeyo™ Qsymia® ER Semglee™ Neurontin® Orphengesic® Forte Qtern® Sernivo™ Nexavar® Ortikos™ Qualaquin® Serostim® Nexium® Oseni® Qudexy® XR Sevenfact® Nexletol™ Osmoprep® QuilliChew ER™ Signifor® Nexlizet™ Otezla™ Quillivant XR™ sildenafil Ninlaro® Otrexup™ quinine sulfate Silenor® nitisinone Oxaydo® Qvar RediHaler® Siliq™ Noctiva™ Oxbryta™ rabeprazole Simponi™ Non Preferred Diabetic oxiconazole Ragwitek™ Sirturo™ Meters Oxistat® Rasuvo™ Sivextro™ Norco® Oxtellar® XR Ravicti™ Skelaxin® Norditropin® oxycodone/APAP tab Rayaldee® Skyrizi™ Norgesic™ Forte oxycodone ER Rayos® sofosbuvir-velpatasvir Northera™ Oxycontin® Rebif® Rebidose® Solaraze® Gel Nourianz™ oxymorphone ER Rebinyn® Solodyn® Novoeight® Ozempic® Recombinate™ Somavert® Novoseven® RT Ozobax™ RediTrex® Sonata® Noxafil® Palforzia™ cap/powder Regimex® Sovaldi™ Nubeqa™ Pamelor™ Regranex® Sprycel® Nucala® Soln Pancreaze® Relafen™ Staxyn™ Nucynta® Pandel® Relafen™DS Steglatro™ Nucynta ER® pantoprazole pak ReliOn® Steglujan™ Nuedexta™ Pemazyre™ Relistor® Stelara® Nulytely® penicillamine capsule Relpax® Stendra™ Nuplazid™ Penlac® Repatha™ Stivarga®

(continued) 13 Strattera™ Topamax® tab Veltin™ Xtampza® XR Strensiq™ Topicort® Venclexta® Xtandi® Striant® topiramate ER sprinkle Ventavis® Xultophy® Subsys® Tosymra™ Ventolin® HFA Xuriden™ Sucraid® Toviaz™ Verdeso® Xyntha® sulconazole Tracleer® Verzenio™ Xyrem® sumatriptan/naproxen Tradjenta™ Vesicare® Xywav™ Sunosi™ Tremfya™ Viagra® Zavesca® Sutab® Tresiba® Viberzi™ Zejula™ Sutent® caps Vibramycin® Zelboraf® Sylatron™ Tretten® Viekira Pak™ Zelnorm® Symdeko® Treximet™ vigabatrin tab/packet Zembrace Symtouch™ Symlin® triamcinolone 0.05% vigadrone Zepatier™ Sympazan™ Film ointment Viibryd® Zerviate™ Synalar® Trianex® Vivlodex™ Zestril® Syprine® Tribenzor® Vogelxo® Zetia® Tabrecta™ trientine Voltaren XR® Zetonna™ Taclonex® Trikafta™ Vonvendi Ziana® tadalafil (generic Adcirca) Trileptal® tab/susp Vosevi™ zileuton ER tab Tafinlar® Trintellix® Votrient™ Zilxi™ Tagrisso™ Trokendi®XR Vraylar™ Zioptan™ Taltz Autoinjector® Trulance™ Vusion® Zipsor™ Tanzeum™ Tudorza® Pressair® Vyleesi™ Zmax™ Tarceva® Tukysa™ Vyndamax® Zohydro® ER Targadox™ Turalio™ Vyndaqel® Zolinza® Targretin® Twynsta® Vytorin™ Zoloft® Tasigna® Tykerb® Vyzulta™ Zolpidem 10mg tavaborole soln 5% Tylenol® w/Codeine Wakix® Zolpidem ER 12.5mg Tazorac® Tymlos™ Wellbutrin® XL Zolpidem SL 3.5mg Tazverik™ Tyvaso® Wilate® Zomacton™ Tecfidera® Ubrelvy™ Winlevi® Zomig® (ZMT) Technivie™ Uceris® Wynzora® Zomig Nasal Spray Tegretol® [XR] Uloric® Xadago™ Zonegran® Tekturna® (HCT) Ultracet® Xalkori® Zorbtive™ Temodar® Oral Ultram® Xanax® Zorvolex® temozolomide Ultravate® Xcopri® pak/tab Zurampic® Tenoretic® Upneeq® Xeljanz® [XR] Zydelig® Tenormin® Uptravi® Xenazine™ Zykadia™ Teriparatide® inj Utibron™ Neohaler Xenical® Zypitamag™ Testim® Vagifem® Xermelo™ Zytiga™ enanthate Valchlor™ Xhance™ MIS 93mcg Zyvox® testosterone topical Valium® Xifaxan® Thalomid® Valtoco® Xiidra™ Thiola® Valtrex™ Ximino ER™ Tirosint® [ODT] Xodol® Tivorbex® Vascepa® Xolegel® tolvaptan Vasotec® Xopenex HFA® Topamax® Sprinkle Vecamyl™ Xpovio™ Pak

1All brand prenatal vitamins require prior authorization 2 All diabetic test strips require prior authorization except for OneTouch® *Compound products with total cost equal to or greater than $75 per prescription

14 Reading the formulary drug list How can I tell if a drug is generic or brand? The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications start with an uppercase letter and are written in bold. Generic medications are shown in lowercase and in italic.

Brand name Drug Starts with UPPERCASE in Bold Ex: Augmentin Generic drug Lowercase italic Ex: avidoxy

Tier information Tiers are the different cost levels you pay for a medication. Each drug on the formulary is in a tier. Below is a reference guide to use as you review your formulary to see the abbreviation for each drug tier on the formulary list. Drug Tier Abbreviation Generic G Non-preferred Drug NPD Specialty Drug SP Low-cost Generic LCG Preferred Brand PB $0 Preventive Drug ACA

Drug list requirements and/or limits Some medications are noted with letters next to them to help you see which drugs may have coverage requirements and/or limits. Below is a reference guide to use as you review your formulary to see the abbreviation for each requirement/limit on the formulary list.

Requirements/Limits Abbreviation Prior Authorization PA Quantity Limits Apply QL Age Limit AL Limited Distribution Drug LDD Day Supply Limit 5DS Requires Rider R Quantity Over time Q/T Morphine Milligram Equivalent MME PA for Selected NPD +

(continued) 15 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS & OTHER DRUGS USED FOR avidoxy G INFECTION azithromycin G abacavir sulfate Bactrim, G NPD tab, soln Bactrim DS abacavir sulfate/ Baraclude NPD, SP G lamivudine Baxdela NPD QL abacavir/ Benznidazole NPD lamivudine/ G Bethkis Neb NPD, SP zidovudine Biaxin NPD Acticlate + NPD AL, PA Biktarvy NPD acyclovir G Biltricide NPD acyclovir 5% G QL cefaclor G cream cefaclor ER G adefovir dipivoxil G, SP cefadroxil G Aemcolo DR NPD QL cefdinir G albendazole G cefixime susp/cap G Alinia NPD ceftibuten G Altabax NPD PA Ceftin NPD amoxicillin G cefuroxime axetil G Amoxicillin PB cephalexin G 775mg chlorhexidine amoxicillin/ LCG G gluconate soln clavulanate chloroquine amoxicillin/ G phosphate clavulanate G extended-release Cimduo NPD ampicillin G Cipro NPD Amzeeq NPD PA Cipro XR NPD Ancobon NPD ciprofloxacin LCG ciprofloxacin ER Arakoda NPD G tabs Arikayce NPD, SP PA clarithromycin G G clarithromycin atovaquone G G ER atovaquone/ G Cleocin NPD proguanil clotrimazole Atripla NPD G troches Augmentin NPD Combivir NPD Augmentin XR NPD Complera PB Avelox NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 16 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Cresemba NPD PA, QL doxycycline Crixivan PB monohydrate cap G 50mg, 100mg Daklinza NPD, SP PA, QL, Q/T doxycycline dapsone tab G monohydrate cap NPD AL Daraprim Tab NPD, SP 75mg, 150mg Daxbia NPD doxycycline Delstrigo NPD monohydrate tab NPD AL 150mg demeclocycline G Edurant PB dicloxacillin G E.E.S. NPD didanosine G efavirenz G Dificid tab/susp NPD QL efavirenz- Diflucan NPD emtricitab- G Doryx 50mg tenofovir tab NPD PA DR tablet efavirenz- Doryx 200mg lamivudine- G NPD PA, QL DR tablet tenofovir tab Dovato NPD Egaten 250mg tablet NPD doxycycline DR G PA emtricitabine cap G 40mg emtricitabine- doxycycline tenofovir hyclate tab NPD AL disoproxil G, ACA QL 75mg, 150mg fumarate tab doxycycline 200-300mg hyclate tab NPD PA Emtriva NPD 50mg Emverm NPD QL doxycycline entecavir G, SP hyclate tab DR NPD 50mg, 100mg Epclusa PB, SP PA, QL, Q/T doxycycline Epivir NPD hyclate tab DR NPD AL Epzicom NPD 75mg, 150mg EryPed NPD doxycycline Ery-Tab NPD hyclate tab DR NPD QL, QT Erythrocin NPD 200mg doxycycline G NPD PA delayed release hyclate DR 80mg + erythromycin doxycycline ethylsuccinate G monohydrate G erythromycin 50mg, 75mg, stearate G 100mg tab ethambutol G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 17 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

famciclovir G lamivudine/ G Firvanq Soln NPD AL zidovudine Flagyl NPD Lampit tab NPD fluconazole ledipasvir- suspension/tabs G sofosbuvir tablet NPD, SP PA, QL 90-400mg flucytosine G Levaquin NPD Flumadine NPD levofloxacin LCG fosamprenavir tab G Lexiva NPD fosfomycin pow G linezolid G QL Fuzeon NPD lopinavir/ ritonavir G griseofulvin microsize G Luliconazole cream NPD PA griseofulvin ultramicrosize G Macrodantin NPD Gris-PEG NPD Malarone NPD Harvoni PB, SP PA, QL, Q/T Mavyret PB, SP PA, QL, Q/T Hepsera NPD, SP mefloquine G Hiprex NPD Mepron NPD hydroxychlor- methenamine G oquine G hippurate Impavido NPD Q/T LCG Invirase PB Minocin + NPD PA Isentress PB minocycline caps G isoniazid G minocycline ER cap NPD Q/T, PA G minocycline ER ivermectin G tablet G Q/T Juluca NPD minocycline G Kaletra Soln NPD tablet Kaletra Tabs PB Minolira NPD PA, Q/T Kalydeco Tabs/ moderiba G, SP Pack NPD, SP PA, LDD Mondoxyne NL NPD AL, Q/T Keflex NPD 75mg cap tab G Monurol Pak NPD Krintafel NPD Granules Lamisil Tabs NPD Moxatag NPD moxifloxacin hcl G lamivudine tablet G 150mg, 300mg Myambutol NPD lamivudine Mycobutin NPD 100mg tab G, SP

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 18 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Mytesi + NPD PA Ribasphere Ribapak Nebupent INH NPD G, SP 200mg & 400mg/ nevirapine G 400mg & 600mg nevirapine ER G rifabutin G nitazoxanide G Rifadin NPD nitrofurantoin rifampin G macrocrystals G rimantadine G nitrofurantoin susp G AL ritonavir G Norvir powder PB Rukobia NPD PA Norvir tablet NPD Selzentry PB Noxafil NPD PA, QL Seysara NPD Q/T, PA Nuzyra NPD QL Sirturo NPD PA Onmel NPD PA Sitavig NPD QL Oracea NPD PA Sivextro NPD PA, QL Orkambi tablet/ Sklice Lot 0.5% NPD NPD, SP PA, LDD packet sofosbuvir- oseltamivir caps/ velpatasvir tablet NPD, SP PA, QL G QL 400-100mg soln Solodyn + NPD PA, QL, Q/T Pegasys NPD, SP Solosec GRA NPD PegIntron NPD, SP Sovaldi NPD, SP PA, QL, Q/T penicillin v LCG potassium tablet Sporanox NPD INH G SSKI Solution NPD Pifeltro NPD stavudine G Plaquenil NPD QL Stribild PB G QL Stromectol NPD praziquantel G sulfamethox- azole/tmp LCG Pretomanid NPD PA Prevymis NPD, SP Suprax Susp 100mg/5ml, NPD Prezista PB 200mg/5ml pyrimethamin G, SP Sustiva NPD Qualaquin NPD PA Symfi NPD quinine sulfate G PA Symfi-Lo NPD Relenza NPD QL, AL Symtuza NPD Retrovir NPD Talicia NPD Reyataz NPD Tamiflu NPD QL Targadox NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 19 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Technivie NPD, SP PA, QL, Q/T Xofluza therapy NPD Q/T Temixys NPD pack tenofovir G Zepatier NPD PA, QL, Q/T terbinafine tabs G Zerit NPD Tindamax NPD Ziagen NPD tinidazole G zidovudine LCG Tivicay PD NPD Zithromax NPD Tobi NPD, SP Zmax + NPD PA tobramycin Zovirax NPD nebulization G, SP Zyvox NPD PA, QL soln. Tolsura NPD CANCER & ORGAN TRANSPLANT DRUGS Trikafta NPD, SP PA abiraterone G, SP PA Triumeq PB Afinitor NPD, SP PA Trizivir NPD Alecensa NPD, SP PA Truvada NPD QL Alkeran NPD, SP valacyclovir tab G Alunbrig NPD, SP PA Valcyte NPD tab/pak valganciclovir G anastrazole G Valtrex + NPD PA Arimidex NPD vancomycin G Aromasin NPD Vemlidy NPD, SP Ayvakit NPD, SP PA, QL Vfend NPD azathioprine G Vibramycin + NPD PA Balversa NPD, SP PA Videx EC NPD Benlysta NPD, SP PA Viekira Pak NPD, SP PA, QL, Q/T bexarotene G, SP PA Viekira XR NPD, SP PA, QL, Q/T G Viramune NPD Bosulif NPD, SP PA Viramune XR NPD Braftovi NPD, SP PA Viread NPD Brukinsa NPD, SP PA voriconazole G Cabometyx NPD, SP PA Vosevi PB, SP PA, QL, Q/T Calquence NPD, SP PA Xenleta NPD QL capecitabine G, SP Xepi Cream 1% NPD PA Caprelsa NPD, SP PA Xifaxan 200mg NPD QL Casodex NPD Xifaxan 550mg NPD PA, QL, Q/T Cellcept NPD Ximino ER + NPD PA, Q/T Cometriq NPD, SP PA Copiktra NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 20 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Cotellic NPD, SP PA, LDD Imuran NPD cyclophos- Inlyta NPD, SP PA G, SP phamide Inqovi tab NPD, SP PA cyclosporine G Inrebic NPD, SP PA Cytoxan NPD, SP Iressa tab NPD, SP PA G Kisqali NPD, SP PA, LDD Danocrine NPD Koselugo NPD, SP PA Daurismo NPD, SP PA lapatinib G, SP PA Deltasone NPD Lenvima NPD, SP PA, LDD Emcyt NPD letrozole G Erivedge NPD, SP PA leucovorin G Erleada NPD, SP PA calcium erlotinib G, SP PA Leukeran PB etoposide G, SP leuprolide G, SP Eulexin NPD Lonsurf NPD, SP PA everolimus Lorbrena NPD, SP PA (generic for G, SP PA Lynparza PB, SP PA Afinitor) Lysodren NPD everolimus (generic for G Matulane PB, SP Zortress) Mavenclad pak + NPD, SP PA G Megace NPD Fareston tab NPD megestrol G Farydak NPD, SP PA, LDD G Femara NPD Mekinist NPD, SP PA G Mektovi NPD, SP PA Gavreto NPD, SP PA melphalan G, SP Gilotrif NPD, SP PA mercaptopurine G Gleevec NPD, SP PA Mesnex NPD, SP Gleostine NPD, SP methotrexate tab G Hexalen NPD mycophenolate G Hycamtin NPD, SP PA mycophenolic G Hydrea NPD acid hydroxyurea G Myfortic NPD Ibrance NPD, SP PA, LDD Myleran NPD Iclusig NPD, SP PA Neoral NPD Idhifa NPD, SP PA Nerlynx NPD, SP PA imatinib mesylate G, SP PA Nexavar NPD, SP PA Imbruvica NPD, SP PA Nilandron NPD, SP

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 21 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS G, SP tacrolimus G Ninlaro NPD, SP PA Tafinlar NPD, SP PA Nubeqa NPD, SP PA Tagrisso NPD, SP PA Odomzo NPD, SP PA Talzenna NPD, SP PA Onureg NPD, SP PA tamoxifen 10mg G Orgovyx NPD, SP PA Tarceva NPD, SP PA Ortikos ER Cap NPD PA Targretin cap NPD, SP PA Pemazyre NPD, SP PA Tasigna NPD, SP PA Piqray NPD, SP PA Tazverik 200mg NPD, SP PA Pomalyst NPD, SP PA Temodar NPD, SP PA prednisone LCG temozolomide G, SP PA prednisone Thalomid NPD, SP PA therapy pack/ thioguanine G solution/ G concentrate Tibsovo NPD, SP PA Prograf cap/ toremifene tab G NPD packets tretinoin caps G, SP PA Protopic NPD PA Trexall tab NPD Purixan NPD, SP Tukysa NPD, SP PA Qinlock tab NPD, SP PA Turalio NPD, SP PA Rapamune NPD Tykerb NPD, SP PA 1mg/ml Sol Valchlor NPD, SP PA Rapamune tab NPD Venclexta NPD, SP PA RediTrex Inj NPD PA Verzenio NPD, SP PA Retevmo cap NPD, SP PA Vitrakvi NPD, SP PA Revlimid NPD, SP PA Vizimpro NPD, SP PA Rozlytrek NPD, SP PA Votrient NPD, SP PA Rubraca PB, SP PA Xalkori NPD, SP PA Rydapt NPD, SP PA Xatmep NPD AL Sandimmune, Xeloda NPD, SP Neoral NPD Xospata NPD, SP PA Siklos NPD Xpovio Pak NPD, SP PA sirolimus tab/ soln G Xtandi NPD, SP PA, LDD Sprycel NPD, SP PA Yonsa NPD, SP PA Stivarga NPD, SP PA Zejula PB, SP PA, LDD Sutent NPD, SP PA Zelboraf NPD, SP PA, LDD Tabloid NPD Zolinza NPD, SP PA, LDD Tabrecta tab NPD, SP PA Zortress NPD Zydelig NPD, SP PA, LDD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 22 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUGDRUG DRUG NAME DRUG TIERTIER LIMITS TIER LIMITS Zykadia NPD, SP PA, LDD amphetamine Zytiga NPD, SP PA, LDD aspartate/ amphetamine G QL PAIN, NERVOUS SYSTEM, & PSYCH sulfate/dextro- amphetamine ER Abilify NPD PA amphetamine Abilify Mycite NPD PA tablet G QL Abstral NPD PA, QL, MME amphetamine acamprosate DR tablet (generic G PA, QL tab 333mg G Evekeo) acetaminophen/ amphetamine ER NPD PA, QL codeine LCG AL, QL, 5DS, MME suspension Actiq NPD PA, QL, MME Anafranil NPD Adderall NPD PA, QL Antabuse NPD PA, QL, 5DS, Adderall XR NPD QL Apadaz + NPD MME Adhansia XR Capsule NPD PA, QL Aplenzin + NPD PA Adipex-P NPD PA, R Apokyn Solution Adzenys ER NPD, SP PA NPD PA, QL Cartridge Susp 30 mg/3ml Adzenys XR NPD PA, QL Aptensio XR NPD PA, QL ODT Aptiom NPD PA Aimovig PB PA Aricept NPD AL Ajovy PB PA G Allzital 25- 325mg NPD PA, QL, 5DS armodafinil G PA Arymo ER NPD PA, QL, MME almotriptan G QL, AL maleate asenapine tab G alprazolam LCG AL sub alprazolam ER G AL Ativan NPD PA, AL G atomoxetine G QL Ambien NPD PA, QL Aubagio NPD, SP Ambien CR NPD PA, QL Austedo NPD, SP PA Amerge NPD PA, QL, AL Avonex PB, SP QL amitriptyline hcl G Axert NPD PA, QL, AL G Azilect NPD amphetamine Banzel NPD PA aspartate/ Banzel Susp NPD PA, AL amphetamine G QL sulfate/dextro- Belbuca PB PA, QL, MME amphetamine Belsomra + NPD PA, QL Belviq [XR] NPD PA, R

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 23 REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG DRUG NAME TIER LIMITS TIER LIMITS benzphetamine G R, PA Butrans NPD PA, QL, MME benzhydro- PA, QL, 5DS, Cafergot NPD codone-aceta- NPD Caplyta NPD PA minophen + MME carbamazepine G benztropine G carbamazepine Betaseron PB, SP QL susp G AL Brisdelle NPD carbamazepine G Briviact + NPD PA XR Briviact soln + NPD PA, AL Carbatrol NPD PA bromocriptine carbidopa G G mesylate carbidopa/ G Bunavail NPD QL levodopa buprenorphine carbidopa/ G QL levodopa ER G hcl/naloxone hcl carbidopa/ buprenorphine G G PA, QL, MME levodopa ODT patch carbidopa/ buprenorphine SL G QL levodopa/ G bupropion G entacapone bupropion ER carisoprodol- QL, 5DS, AL, G QL G 150mg aspirin-codeine MME bupropion ER Celexa NPD NPD 450mg Celontin PB bupropion SR G Chantix ACA QL bupropion XL G chlordiazepoxide LCG AL Buspar NPD chlorpromazine G G HCl butalbital- citalopram LCG acetaminophen NPD QL, 5DS clobazam G PA 25-325mg clobazam susp G PA, AL butalbital- clomipramine acetaminophen NPD PA, QL, 5DS HCl G 50-300mg clonazepam G butalbital/apap/ caffeine G QL, 5DS clorazepate dipotassium G AL butalbital/apap/ QL, 5DS, AL, caffeine/codeine G MME G clozapine ODT G butalbital/ QL, 5DS, AL, aspirin/caffeine/ G Clozaril NPD codeine MME codeine tabs G QL, 5DS, AL, MME G QL, 5DS, AL, tartrate nasal MME coditussin AC QL, AL, 5DS, MME liquid G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 24 DRUG REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG NAME DRUG TIER LIMITS TIER LIMITS Comtan NPD Diclofenac cap NPD PA Concerta + NPD PA, QL 35mg Contrave ER NPD PA, R diclofenac potassium G Conzip + NPD PA, AL, QL, MME diclofenac Copaxone PB, SP QL sodium G Cotempla XR NPD PA, QL diclofenac ODT + sodium gel 1% G Cymbalta NPD PA diethylpropion G R, PA Dantrium NPD diflunisal G dantrolene NPD dihydrocodein/ G QL, 5DS, AL, Daypro NPD PA APAP/caff MME QL, 5DS, AL, Daytrana + NPD PA, QL dihydrocodeine/ G Dayvigo NPD PA, QL aspirin/caffeine MME Demerol NPD PA, QL, 5DS, MME dihydroergo- tamine inj G PA Depakene NPD dihydroergo- Depakote NPD tamine G PA Depakote ER NPD nasal spray Dilantin Depakote PB Sprinkle Caps NPD chewable tablets desipramine G Dilaudid NPD PA, QL, 5DS, MME Desoxyn + NPD PA, QL dimethyl G, SP Desvenlafaxine fumarate DR cap ER 24 HR PB disulfiram G Dexedrine + NPD PA, QL divalproex G dexmethyl- sodium phenidate ER G QL divalproex sodium ER G dexmethyl- G QL phenidate hcl divalproex G dextroam- sprinkle cap phetamine G QL Dolophine NPD PA, QL, MME dextroam- donepezil LCG AL phetamine ER G QL hydrochloride D.H.E.45 NPD PA Doral + NPD PA, AL Diacomit NPD, SP PA doxepin capsule G Diastat NPD doxepin tablet G PA Drizalma tabs LCG NPD PA diazepam Sprinkle rectal gel G duloxetine G Duragesic patch NPD PA, QL, MME diazepam G solution Dyanavel XR + NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 25 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Effexor XR + NPD PA Fioricet NPD QL, AL, 5DS, PA, Eldepryl NPD with codeine MME eletriptan G QL, AL Fiorinal QL, AL, 5DS, PA, with codeine NPD MME Embeda NPD PA, QL, MME fluoxetine G QL (Weekly Only) Emgality PB PA, QL fluoxetine 10mg, LCG endocet G 5DS, QL, MME 20mg, 40mg entacapone G fluoxetine soln G AL Epidiolex Soln NPD, SP PA G ergotamine flurazepam G QL, AL tartrate/caffeine G flurbiprofen G escitalopram LCG fluvoxamine G Esgic capsule G QL, 5DS fluvoxamine ER G Esgic tablet NPD QL, 5DS Focalin NPD QL estazolam G QL, AL Focalin XR + NPD PA, QL eszopiclone G PA, QL (3mg only) ForFivo XL NPD ethosuximide G Frova NPD PA, QL, AL etodolac G frovatriptan Evekeo [ODT] + NPD PA, QL succinate NPD QL, AL Evzio NPD PA, QL Fycompa NPD Exalgo NPD PA, QL, MME gabapentin G Exelon NPD AL gabapentin soln G AL Extavia + NPD, SP PA Gabitril NPD Fanapt + NPD PA galantamine G AL Fazaclo NPD galantamine ER G AL felbamate G Geodon NPD Felbatol NPD PA Gilenya NPD, SP Feldene NPD glatiramer G, SP QL fenoprofen NPD PA acetate calcium glatopa G, SP QL fentanyl citrate Gocovri NPD OTFC G PA, QL, MME Fentanyl citrate - QL, AL, 5DS, tablet NPD PA, QL, MME codeine soln LCG 10mg/5ml MME fentanyl transdermal G PA, QL, MME guanfacine ER G QL Halcion + Fentora NPD PA, QL, MME NPD PA, QL, AL Fetzima + NPD PA haloperidol G Hetlioz Fintepla sol NPD, SP PA NPD, SP PA, QL Horizant Fioricet NPD QL, 5DS NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 26 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS hydrocodone ER G PA, QL, MME Kynmobi Kit NPD, SP PA Titration hydrocodone/ G QL, 5DS, AL, acetaminophen MME Lamictal + NPD PA QL, 5DS, AL, hydrocodone- G Lamictal ODT NPD PA homatropine tab MME Lamictal XR NPD PA hydromorphone lamotrigine G ER G PA, QL, MME lamotrigine ER G hydromorphone IR G QL, 5DS, MME lamotrigine ODT G Hysingla ER NPD PA, QL, MME Latuda + NPD PA Lazanda NPD PA, QL, MME Ibudone NPD QL, AL, 5DS, PA, MME levetiracetam G / G QL, 5DS, MME, levetiracetam ER G hydrocodone AL levorphanol G QL, 5DS, MME Imcivree Inj Lexapro + NPD PA 10mg/ml NPD, SP PA Librax NPD imipramine G Licart Dis 1.3% NPD PA, QL Imitrex NPD AL lithium Inbrija NPD, SP PA carbonate G Indocin susp NPD AL lithium Ingrezza NPD, SP PA carbonate ER G Intermezzo NPD PA, QL Lithobid NPD Intuniv + NPD PA, QL Lodine NPD Invega ER Lodosyn NPD NPD PA tablet + Lomaira NPD PA, R isometheptene/ lorazepam LCG AL dichloralphen- G lorazaepam azone/apap concentrate G AL Jakafi NPD, SP PA, LDD Lortab NPD QL, 5DS, AL, PA Jornay PM NPD PA, QL G Capsule Lucemyra NPD QL, Q/T Kadian ER NPD PA, QL, MME Lunesta NPD PA, QL Kapvay + NPD PA, QL Lyrica Cap NPD Keppra + NPD PA Lyrica CR NPD PA Keppra XR NPD PA Lyrica soln NPD AL ketoprofen G maprotiline G ketorolac G Maxalt, Maxalt- Khedezla + NPD PA MLT NPD AL, QL Klonopin NPD PA Mayzent tablet, NPD, SP Kynmobi Mis NPD, SP PA, QL starter pak

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 27 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS meclofenamate G Nalfon NPD PA memantine G AL Nalocet NPD QL, 5DS, MME memantine ER G AL Naloxone NPD QL meperidine HCl G QL, 5DS, MME Injection 2mg meprobamate G naltrexone 50mg G Mestinon syrup NPD AL Namenda [XR] NPD AL Mestinon tablet NPD Namzaric NPD AL methadone G PA, QL, MME naratriptan G QL, AL methamphet- Narcan 4mg/ NPD QL PB QL actuation spray methocarbamol G Nardil NPD Methylin NPD QL Nayzilam NPD PA, QL methylphenidate G QL G methylphenidate Neurontin NPD PA G QL ER Neurontin soln NPD PA, AL methylphenidate ninjacof-XG QL, AL, 5DS, G QL G ER (CD) liquid MME methylphenidate Norpramin NPD G QL ER (LA) nortriptyline G methylphenidate nortriptyline soln G AL NPD PA, QL ER(XR) Nourianz NPD PA Midrin NPD Nucynta NPD QL, 5DS, MME Migranal NPD PA Nucynta ER NPD PA, QL, MME Mirapex NPD Nuplazid NPD PA Mirapex ER NPD Nurtec chw PB PA, QL, AL G 75mg ODT modafinil G PA Nuvigil NPD PA molindone hcl G G MorphaBond olanzapine ODT G NPD PA, QL, MME ER olanzapine/ G morphine IR G QL, 5DS, MME fluoxetine hcl morphine sulfate Onfi NPD PA ER G PA, QL, MME Onfi Susp NPD PA, AL morphine G QL, 5DS, MME Ongentys NPD PA suppositories Onzetra Xsail NPD PA, QL, AL MS Contin NPD PA, QL, MME Opana QL, 5DS, PA, Mydayis + NPD PA, QL NPD MME Mysoline NPD Opana ER NPD PA, QL, MME nabumetone G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 28 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

Orap NPD phendimetrazine G PA, R Osmolex ER NPD tartrate oxaprozin G phenelzine G phenobarbital G Oxaydo PA, QL, 5DS, NPD MME phentermine hcl G PA, R oxazepam G AL Phenytek NPD phenytoin G oxcarbazepine G tab pimozide G oxcarbazepine piroxicam G susp G AL Plegridy PB, SP QL Oxtellar XR NPD PA G oxycodone ER tablet NPD PA, QL, MME pramipexole ER G oxycodone IR G QL, 5DS, MME pregabalin cap G pregabalin soln G AL oxycodone/ G QL, 5DS, MME acetaminophen primidone G oxycodone/APAP Primlev NPD PA, QL, 5DS, MME 2.5-300mg, PA, QL, 5DS, Pristiq + NPD PA 5-300mg, NPD MME 10-300mg tab Procentra 1mg/ml NPD QL oxycodone/ aspirin G QL, 5DS, MME Prolate tab NPD PA, QL, 5DS, MME oxycodone/ promethegan G ibuprofen G QL, 5DS, MME supp OxyContin NPD PA, QL, MME Provigil NPD PA oxymorphone ER G PA, QL, MME Prozac + NPD PA oxymorphone IR G QL, 5DS, MME pyridostigmine G paliperidone er pyridostigmine G G AL tablet soln Pamelor NPD PA Qdolo Soln 5mg/ml NPD PA, QL, AL Parlodel NPD Qmiiz ODT + NPD PA Parnate NPD Qsymia ER NPD PA, R paroxetine G quazepam G QL, AL paroxetine ER G Qudexy XR NPD PA Paxil NPD quetiapine ER G Paxil CR NPD quetiapine pentazocine- fumarate G naloxone G QL, 5DS, MME Quillichew ER + NPD PA, QL Percocet NPD QL, 5DS, PA, MME Quillivant XR + NPD PA, QL G ramelteon G QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 29 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS rasagiline G Secuado Patch NPD PA Razadyne NPD AL selegiline HCl G Razadyne ER NPD AL Seroquel NPD Rebif Rebidose + NPD, SP PA, QL Seroquel XR NPD Regimex NPD PA, R sertraline LCG Relafen NPD PA Silenor + NPD PA Relafen DS NPD PA Sinemet NPD Relpax NPD PA, QL, AL Sinemet CR NPD Remeron NPD Sonata + NPD PA, QL Remeron Sprix NPD NPD QL SolTab Nasal Spray Requip NPD Stalevo NPD Requip XL NPD Strattera + NPD PA, QL Restoril + NPD PA, AL Suboxone NPD QL Rexulti + NPD PA Sublingual Film Reyvow NPD PA, QL, AL Subsys NPD PA, QL, MME Rilutek NPD sulindac G riluzole G sumatriptan G QL, AL sumatriptan/ Risperdal, G PA, QL Risperdal NPD naproxen M-Tab Sunosi PB PA risperidone LCG Sylatron NPD, SP PA Ritalin LA NPD PA, QL Symbyax NPD rivastigmine G AL Sympazan Film NPD PA rizatriptan G QL, AL Tasmar NPD benzoate Tecfidera NPD, SP PA, LDD Robaxin NPD Tegretol susp NPD PA, AL G Tegretol [XR] NPD PA ropinirole ER G temazepam G QL, AL Roxicodone NPD QL, 5DS, PA, MME tetrabenazine G, SP PA Roxybond NPD QL, 5DS, MME thioridazine G Rozerem NPD QL thiothixene G rufinamide susp G PA, AL tiagabine hcl G 40mg/ml Tiglutik Susp NPD, SP Rytary + NPD PA Tivorbex NPD PA Sabril NPD, SP PA Tofranil NPD Saphris + NPD PA tolcapone G Saxenda NPD PA, R tolmetin sodium G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 30 REQUIREMENTS/REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUGDRUG DRUG NAME DRUG TIERTIER LIMITSLIMITS TIER LIMITS Topamax + NPD PA Valtoco NPD PA, QL Topamax Vanatol S/LQ NPD PA, QL, 5DS Sprinkle NPD PA venlafaxine G Capsules + venlafaxine ER G topiramate G vigabatrin G, SP PA topiramate sprinkle cap G PA vigadrone G, SP PA Tosymra Nasal Vimpat tab, soln NPD NPD PA, QL, AL Solution Vivlodex NPD PA tramadol LCG QL, AL, MME Vraylar + NPD PA tramadol ER cap NPD QL, AL, MME Vyvanse PB QL Wakix NPD, SP PA, QL tramadol ER G QL, AL, MME (biphasic) tablet Wellbutrin SR NPD tramadol ER G QL, AL, MME Wellbutrin XL + NPD PA tablet Xadago + NPD PA tramadol/ Xanax + NPD PA, AL acetaminophen G QL, AL, MME Xanax XR NPD AL Tranxene T NPD AL Xcopri pak/tab NPD PA tranycypromine sulfate G Xenazine NPD G Xodol, Norco QL, 5DS, PA, AL, NPD MME Treximet NPD PA, QL, AL Xtampza ER PB PA, QL, MME Trezix NPD Xyrem NPD, SP PA, QL triazolam G QL, AL Xywav Soln NPD, SP PA, QL G zaleplon G QL trihexyphenidyl G Zarontin NPD Trileptal Susp NPD PA, AL Zembrace Trileptal Tab NPD PA NPD PA, QL Symtouch trimipramine G Zenzedi NPD QL Trintellix + NPD PA G Trokendi XR NPD PA Zohydro ER NPD PA, QL, MME trymine CG AL, QL, 5DS, G zolmitriptan G QL, AL liquid MME Zoloft + NPD PA Tylenol w/ NPD AL, QL, 5DS, PA, Codeine MME PA, QL zolpidem tartrate LCG (10mg only) Ubrelvy PB PA, QL, AL zolpidem tartrate PA, QL Ultracet NPD QL, AL, PA, MME ER G (12.5mg only) Ultram NPD QL, AL, PA, MME zolpidem tartrate PA, QL Valium + NPD PA SL G (3.5mg only) valproic acid G Zomig NPD PA, QL, AL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 31 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Zonegran NPD PA LCG zonsinamide G amlodipine Zorvolex NPD PA besylate/ G olmesartan Zubsolv PB QL amlodipine/ Zyban NPD QL benazepril G Zyprexa NPD amlodipine/ G Zyprexa Zydis NPD valsartan HEART, BLOOD PRESSURE, & amlodipine/ G CHOLESTEROL valsartan/HCTZ G Accupril NPD Antara NPD Accuretic NPD Arixtra NPD acebutolol G aspirin- G acetazolamide G er acetazolamide ER G Atacand + NPD PA Actimmune NPD, SP PA Atacand HCT + NPD PA Adalat CC NPD atenolol LCG Adcirca NPD, SP PA atenolol/ Adempas PB, SP PA chlorthalidone G Advate PB, SP PA atorvastatin G Adynovate NPD, SP PA atorvastatin/ G Afstyla NPD, SP PA amlodipine Aggrenox NPD Avalide + NPD PA Agrylin NPD Avapro + NPD PA Aldactazide NPD Azor + NPD PA Aldactone NPD Bebulin NPD, SP PA aliskiren G benazepril LCG Alphanate PB, SP PA benazepril/HCTZ G Alphanine NPD, SP PA BeneFIX PB, SP PA Alprolix NPD, SP PA, LDD Benicar + NPD PA Altace NPD Benicar HCT + NPD PA Altoprev NPD Betapace AF NPD G, SP PA betaxolol G Amicar NPD Bevyxxa NPD QL amiloride G bisoprolol G amiloride/HCTZ G bisoprolol/HCTZ G bumetanide G aminocaproic G acid Bystolic PB G Byvalson + NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 32 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Caduet NPD Corgard NPD Calan NPD Corifact NPD PA Calan SR NPD Corlanor NPD PA candesartan G Corzide NPD candesartan/ Coumadin PB hydrochloro- G Cozaar + NPD PA thiazide Crestor + NPD PA G Demadex NPD captopril/HCTZ G Dibenzyline NPD PA Cardizem NPD digitek G Cardizem CD NPD PA digox G Cardizem LA NPD G Cardura NPD Dilt-CD G Carospir NPD diltiazem HCl G Cartia XT G diltiazem HCl CD G carvedilol LCG diltiazem HCl ER G carvedilol ER G diltiazem HCl LA G Catapres tablets NPD diltiazem HCl SR G Catapres-TTS NPD Diltzac ER G chlorothiazide G Diovan + NPD PA chlorthalidone G Diovan HCT + NPD PA cholestyramine G dipyridamole G cholestyramine G disopyramide G light dofetilide G G doxazosin G clonidine ER G QL mesylate 12 HR tab Durlaza + NPD PA clonidine IR Dutoprol NPD tablet LCG Dyazide NPD clonidine patches G Dyrenium NPD clopidogrel G Edarbi + NPD PA Coagadex NPD, SP PA Edarbyclor + NPD PA colesevelam G Edecrin NPD Colestid NPD Effient NPD colestipol HCl G Eliquis PB Conjupri NPD PA Eloctate NPD, SP PA Coreg NPD enalapril G Coreg CR NPD enalapril/HCTZ G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 33 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS enoxaparin G Humate-P PB, SP PA Entresto PB QL hydralazine G Epaned Sol hydrochloro- NPD AL LCG 1mg/ml thiazide eplerenone G Hyzaar + NPD PA eprosartan G PA icosapent cap G Esperoct NPD, SP PA indapamide G ethacrynic acid G Inderal LA + NPD PA Exforge + NPD PA InnoPran XL NPD Exforge HCT + NPD PA Inspra NPD Ezzalor irbesartan G NPD PA Sprinkle Cap irbesartan ezetimibe G hydrochloro- G ezetimibe/ thiazide G Isordil simvastatin NPD Feiba NPD, SP PA Titradose Tabs felodipine ER G G fenofibrate G isosorbide fenofibrate dinitrate ER G nanocrystallized G isosorbide fenofibric acid G mononitrate G Fenoglide NPD isosorbide G Fibricor NPD mononitrate ER flecainide G isradipine G Flolipid susp NPD AL Ixinity NPD, SP PA Jantoven G fluvastatin G sodium Jivi NPD, SP PA fondaparinux G Juxtapid NPD, SP PA fosinopril G Kapspargo NPD PA fosinopril/HCTZ G Katerzia Susp NPD PA, AL Fragmin NPD Koate-DVI PB, SP PA furosemide Kogenate FS NPD, SP PA solution G Kynamro NPD, SP PA furosemide tabs LCG labetalol HCl G gemfibrozil G Lanoxin NPD guanfacine G Lasix NPD Helixate FS NPD, SP PA Lescol NPD Hemlibra Soln NPD, SP PA Letairis NPD, SP PA Hemofil M NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 34 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Lipitor + NPD PA nadolol- Lipofen NPD bendroflume G thiazide lisinopril LCG Nexletol PB PA lisinopril/HCTZ LCG Nexlizet PB PA Livalo + NPD PA niacin ER G Lopid NPD Niaspan NPD Lopressor HCT NPD nicardipine G LCG Nifedical XL G losartan-HCTZ G G Lotensin NPD Nymalize Sol NPD Lotrel NPD nifedipine ER G lovastatin G nimodipine G Lovaza NPD PA nisoldipine ER G Lovenox NPD Nitro-Bid PB Maxzide NPD Nitro-Dur NPD methyldopa G Nitro-Time cap G metolazone G nitroglycerin ER LCG metoprolol succinate G nitroglycerin patches G metoprolol tartrate LCG nitroglycerin SL G metoprolol nitroglycerin G tartrate/HCT G spray Mevacor NPD Nitrolingual Spray NPD mexiletine HCl G Nitromist NPD Micardis + NPD PA Nitrostat SL NPD Micardis HCT + NPD PA Nocdurna SL NPD Microzide NPD Norpace NPD Minipress NPD Northera NPD, SP PA minitran G Norvasc NPD minoxidil G Novoeight PB, SP PA moexipril G NovoSeven RT NPD, SP PA moexipril/HCTZ G Nuwiq PB, SP PA Monoclate-P NPD, SP PA Obizur NPD PA Mononine PB, SP PA olmesartan Mulpleta NPD, SP PA medoxomil G Multaq PB olmesartan/ G nadolol G amlodipine/hctz olmesartan/hctz G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 35 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Rebinyn Soln NPD, SP PA omega-3 acid G ethyl Recombinate PB, SP PA Opsumit NPD, SP PA Repatha PB PA Orenitram NPD, SP PA Revatio NPD, SP PA Pacerone G Riastap NPD PA ER G Rixubis NPD, SP PA perindopril G rosuvastatin G Persantine NPD Rythmol NPD phenoxybenz- Rythmol SR NPD amine hcl G PA Samsca NPD, SP PA, LDD pindolol ER G Sevenfact Inj NPD, SP PA Plavix NPD sildenafil citrate Pradaxa PB 20mg tab, G, SP PA Praluent PB PA 10mg/ml susp prasugrel G sildenafil citrate 25mg, 50mg, LCG QL Pravachol NPD 100mg pravastatin G simvastatin LCG prazosin G simvastatin susp NPD AL Prevalite G sotalol HCl G Prinivil NPD PA Sotylize soln NPD Procardia NPD G Procardia XL NPD spironolactone/ Profilnine NPD, SP PA HCTZ G Promacta NPD, SP PA Stimate NPD propafenone G Sular NPD propafenone ER G tadalafil (generic G, SP PA propranolol G Adcirca) propranolol ER G tadalafil (generic Cialis) G QL propranolol/ HCTZ G Tarka NPD Qbrelis NPD AL Taztia XT G Questran NPD Tekturna/ Tekturna HCT + NPD PA Questran Light NPD telmisartan G quinapril G telmisartan- quinapril/HCTZ G amlodipine G ramipril G telmisartan/ Ranexa NPD hydrochloro- G tab ER G thiazide

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 36 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Tenoretic + NPD PA Verelan ER, PM NPD Tenormin + NPD PA Vonvendi NPD, SP PA tiadylt ER G Vyndaqel, NPD, SP PA Tiazac NPD Vyndamax ticlopidine HCl G Vytorin + NPD PA Tikosyn NPD G Welchol NPD timolol maleate G tab Wilate PB, SP PA tolvaptan 15mg Xarelto PB tab NPD, SP PA Xyntha PB, SP PA tolvaptan 30mg tab G, SP PA Zestoretic NPD Toprol XL NPD Zestril NPD PA torsemide G Zetia NPD PA Tracleer PB, SP PA, LDD Ziac NPD trandolapril G Zocor NPD trandolapril/ Zypitamag NPD PA verapamil ER G MEDICATIONS Tretten NPD, SP PA Absorica + NPD PA triamterene/ G HCTZ Absorica LD NPD PA triamterene cap G Acanya + NPD PA Tribenzor + NPD PA G Tricor NPD acyclovir G Trilipix NPD Aczone + NPD PA, AL Twynsta + NPD PA Adapalene NPD AL Tyvaso NPD, SP PA 0.1% lotion adapalene Uptravi NPD, SP PA G AL valsartan G 0.1% soln adapalene valsartan/ G AL hydrochloro- G 0.3% gel thiazide adapalene cream G AL Vascepa NPD PA adapalene- benzoyl-peroxide G AL Vaseretic NPD gel 0.1-2.5% Vasotec NPD PA adapalene pad Vecamyl + G PA 0.1% NPD PA, AL Ventavis NPD, SP PA Aklief Cream NPD PA, AL verapamil HCl G 0.005% verapamil HCl ER G Aktipak NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 37 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS ala-cort cream LCG calcitriol G ointment alclometasone G cream, ointment Capex + NPD PA Aldara NPD Carac + NPD PA Altreno Centany 2% NPD PA, AL NPD 0.05% lotion oint amcinonide G ciclopirox G anthralin G 0.77% cream ApexiCon E NPD PA ciclopirox G Arazlo lotion 8% solution NPD PA, AL 0.045% ciclopirox cream, Atralin + NPD PA, AL gel, shampoo, G suspension Avita G AL Cleocin T + NPD PA gel G 15% Clindagel + NPD PA Azelex + NPD PA clindamycin, clindamycin- Benzaclin + NPD PA G Benzamycin gel + NPD PA gel [w/pump] Benzamycinpak + NPD PA clindamycin/ benzoyl peroxide NPD PA benzoyl peroxide/ 1-5% erythromycin G clindamycin/ beser lotion tretinoin gel G AL 0.05% G clobetasol betamethasone G cream, ointment, G dipropionate solution betamethasone Clobex + NPD PA valerate G clocortolone betamethasone/ NPD PA clotrimazole G pivalate Bryhali lotion clodan G 0.01% NPD PA Cloderm + NPD PA Condylox NPD calcipotriene G cream Cordran + NPD PA calcipotriene Cosentyx NPD, SP PA foam NPD Crotan lotion G calcipotriene- betamethasone dp G Cutivate + NPD PA oint dapsone gel 5% G AL dapsone gel calcipotriene- NPD PA, AL betamethasone dp G 7.5% susp Denavir NPD QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 38 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Derma-Smoothe erythromycin gel, NPD PA G FS + soln, swabs Dermatop NPD Eucrisa PB PA Desonate + NPD PA Eurax Lotion NPD desonide gel Evoclin + NPD PA G 0.05% Exelderm + NPD PA Desowen + NPD PA Extina + NPD PA desoximetasone Fabior NPD PA, AL cream, gel, G ointment Fasenra PB, SP PA diclofenac Finacea NPD PA 3% gel G PA fluocinolone Differin + acetonide cream, G 0.1% cream NPD PA, AL sol, oil Differin + fluocinonide gel, G 0.1% lotion NPD PA, AL ointment Fluorouracil Differin + PB 0.3% gel NPD PA, AL cream 0.5% diflorasone fluorouracil NPD PA solution 2% G, SP diacetate flurandrenolide Diprolene, NPD PA NPD cream, lotn, oint Diprolene AF fluticasone Dovonex cream NPD propionate G doxepin cream cream, lotn, oint. G QL 5% gentamicin Duac + NPD PA topical cream, G ointment Duobrii Lotion + NPD PA halcinonide Dupixent PB, SP PA cream 0.1% G econazole G halobetasol G Ecoza + NPD PA propionate Efudex cream NPD, SP halobetasol Elidel NPD PA propionate foam NPD PA 0.05% Elimite NPD Halog + NPD PA Elocon NPD hydrocortisone Enstilar + NPD PA 2.5% G Epiduo NPD AL hydrocortisone G Epiduo Forte butyrate 0.1% gel NPD AL hydrocortisone LCG Ertaczo + NPD PA lot 0.1% Erygel NPD hydrocortisone butyrate/emoll G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 39 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS MetroGel NPD hydrocortisone G supp MetroLotion NPD hydrocortisone G metronidazole valerate 0.2% cream, lotion, gel G hydrocortisone/ G miconazole- lidocaine HCl ointment NPD PA imiquimod cream G Mirvaso PB Imiquimod mometasone Cream 3.75% NPD cream, ointment, G Pump solution Impeklo Lotion NPD PA cream, 0.05% ointment G Impoyz Cream NPD naftifine cream, 0.025% gel G G Naftin NPD Jublia NPD PA Natroba NPD Kenalog Spray + NPD PA Nizoral NPD Kerydin NPD PA shampoo ketoconazole G Noritate NPD PA cream nystatin/ ketoconazole G triamcinolone G shampoo cream, ointment Klaron NPD Olux [E] + NPD PA Lexette Foam NPD PA Onexton NPD 0.05% Ovide NPD lidocaine patch G oxiconazole 5% nitrate + NPD PA lidocaine Oxistat + NPD PA solution, gel, G ointment Oxsoralen Ultra NPD Lidoderm + NPD PA Pandel + NPD PA Locoid + NPD PA Penlac NPD PA Locoid permethrin G NPD PA Lipocream + pimecrolimus cre G Loprox + NPD PA 1% Lotrisone NPD podofilox soln G Luxiq + NPD PA prednicarbate G Luzu + NPD PA ointment malathion lotion G prilocaine/ lidocaine G methoxsalen G Proctofoam HC PB MetroCream NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 40 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

Prudoxin cream tretinoin gel, G AL 5% NPD QL cream Qbrexza Pad tretinoin 2.4% NPD PA, QL microspheres gel NPD AL Retin-A + NPD PA, AL triamcinolone G Retin-A Micro + NPD PA, AL acetonide Rhofade triamcinolone NPD PA 1% cream NPD PA oint 0.05% Trianex NPD PA selenium sulfide G shampoo/lotion triderm cream LCG Sernivo NPD PA Ultravate + NPD PA Siliq NPD, SP PA Vectical NPD Silvadene NPD Veltin + NPD PA, AL silver G Verdeso + NPD PA sulfadiazine Vusion + NPD PA Skyrizi Inj PB, SP PA Winlevi Cream sodium 1% NPD PA G Wynzora Cream NPD PA suspension Xolegel + NPD PA Solaraze NPD PA Ziana NPD PA, AL Soolantra PB Zilxi Aer NPD PA Soriatane NPD Zonalon cream spinosad G 5% NPD QL sulconazole Zovirax cream NPD QL cream/solution NPD PA Zovirax oint NPD Sulfamylon NPD Ztlido Patch NPD PA, QL Synalar + NPD PA Taclonex + NPD PA EAR, NOSE, THROAT MEDICATIONS Taltz Autoinjector NPD, SP PA acetasol HC, acetic acid HC G Targretin gel PB PA otic tavaborole soln azelastine G 5% G PA Bactroban nasal cream PB G AL oint 0.1% Cetraxal NPD Tazorac cream/ gel NPD PA, AL cevimeline hcl G Temovate NPD Ciprodex NPD Topicort + NPD PA ciprofloxacin G Tremfya PB, SP PA ciprofloxacin- dexamethasone G otic susp

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 41 REQUIREMENTS/REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITSLIMITS TIER LIMITS Alogliptin ciprofloxacin- PB fluocinolone PF NPD benzoate otic soln Amaryl NPD cortane B otic G Androderm drops patch NPD PA Dermotic NPD Androgel 1.62% NPD PA Evoxac NPD Packet, Pump fluocinolone Androgel 1% NPD PA G acetonide oil Apidra NPD PA, QL mometasone Axiron NPD PA G PA furoate nasal spray Bafiertam DR PB, SP Nasonex NPD PA Cap neomycin/ Baqsimi PB polymyxin/ LCG Basaglar + NPD PA, QL hydrocortisone Breeze2 PB PA, QL ofloxacin otic LCG Glucometer Breeze2 olopatadine G NPD PA, QL Omnaris NPD PA Test Strips Patanase NPD Bydureon PB pilocarpine HCl G Byetta PB Qnasl NPD PA Bynfezia Pen NPD, SP PA ribavirin G, SP calcitriol capsules G Salagen NPD Carnitor NPD Virazole NPD, SP Cetrotide Kit NPD, SP R Xhance NPD PA cinacalcet G Zetonna NPD PA Contour PB PA, QL DIABETES, THYROID, STEROIDS, & OTHER Glucometer MISCELLANEOUS Contour Next NPD PA, QL acarbose G Test Strips Actos NPD Contour Test Strips NPD PA, QL Adlyxin + NPD PA Cortef NPD Admelog NPD PA, QL Cytomel NPD Afrezza NPD PA danazol G Alkindi Sprinkle Cap NPD PA DDAVP + NPD PA Alogliptin benz/ Delatestryl NPD PA metformin hcl PB Demser NPD Alogliptin benz/ desmopressin G pioglitazone PB acetate

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 42 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Dexabliss tab Freestyle 1.5mg NPD InsuLinx NPD PA, QL dexamethasone G Test Strips Freestyle Lite dexamethasone NPD PA, QL tablet 6-day, G Test Strips Freestyle 10-day, 13-day NPD PA, QL Dexcom Test Strips Continuous Genotropin NPD, SP PA Glucose NPD PA glimepiride G Monitor Receiver glipizide G Dexcom glipizide ER G Continuous glipizide XL G Glucose NPD PA Glucagen Inj Monitor NPD PA Transmitter Hypokit Glucagon Dexcom PB Continuous Emergency Kit Glucose NPD PA Glucophage NPD Monitor G6, G5, G4 Sensors Glucophage XR NPD Dexpak pak Glucotrol NPD NPD 10-day, 13-day Glucotrol XL NPD diazoxide Glucovance NPD suspension G glyburide G 50mg/ml glyburide doxercalciferol G micronized G Duetact NPD Glynase NPD Dxevo 11-day NPD Glyset NPD Pak 1.5mg Glyxambi PB Emflaza NPD PA Gvoke hypo inj PB Enspryng Inj NPD, SP PA Gvoke PFS inj PB euthyrox G Hectorol NPD Evrysdi Soln NPD, SP PA Hemady NPD Farxiga PB Humalog + NPD PA, QL Fiasp NPD PA, QL Humatrope NPD, SP PA fludrocortisone Humulin + NPD PA, QL acetate G hydrocortisone G Fortamet + NPD PA Increlex NPD, SP PA, LDD Forteo NPD, SP PA, Q/T insulin aspart Fortesta NPD PA inj + NPD PA, QL Freestyle Glucometer PB PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 43 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS insulin aspart Medtronic protamin inj NPD PA, QL Continuous Glucose flexpen + NPD PA insulin lispro Monitor 100 units/ml + NPD PA, QL Guardian Transmitter insulin lispro inj junior + NPD PA, QL Medtronic Continuous insulin lispro inj NPD PA, QL Glucose protamin+ Monitor Enlite, NPD PA Invokamet [XR] NPD PA MiniMed Invokana NPD PA Guardian Sensors Janumet PB Medrol NPD Janumet XR PB metformin LCG Januvia PB metformin ER Jardiance PB (generic for G Jatenzo NPD PA Glucophage XR) Jentadueto metformin HCL G AL tablet + NPD PA 500mg/5ml soln Jentadueto XR NPD PA metformin/ glyburide G Kesimpta Inj PB, SP methimazole G Kazano tablet + NPD PA Methitest Tab NPD PA Kombiglyze XR PB methylpred- Korlym tablet NPD, SP PA nisolone G Lantus PB QL methyltest- Levemir + NPD PA, QL, AL osterone G PA levocarnitine LCG metyrosine G levothyroxine cap NPD PA miglitol G levothyroxine tab G Millipred NPD levo-T tab G Myalept NPD, SP PA Levoxyl G Mycapssa cap NPD, SP PA liothyronine G nateglinide G Lyumjev Inj/ NPD PA, QL Natesto NPD PA Pen Natpara NPD, SP PA Medtronic Nesina tablet + NPD PA Continuous Noctiva Glucose NPD PA NPD Monitor Emulsion Receiver Non Preferred Diabetic Meters PB PA, QL Norditropin PB, SP PA Novolin PB QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 44 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Novolin R PB QL Rayos NPD PA Novolog PB QL Regranex gel NPD PA Nutropin AQ PB, SP PA repaglinide G Omnipod 5 PB Riomet [ER] Pack solution/ NPD AL Omnipod Dash suspension PB System 500mg/5ml Omnipod Dash Rocaltrol PB NPD 5 Pack capsules Omnipod Rybelsus PB QL PB Starter Kit Saizen NPD, SP PA Omnitrope NPD, SP PA Segluromet NPD PA One Touch Semglee Inj PB QL NPD PA, QL Glucometer 100U/ML One Touch Test Sensipar NPD PB QL Strips Serostim NPD, SP PA, LDD Onglyza PB Signifor NPD, SP PA Orapred ODT NPD Soliqua PB Orilissa NPD PA, QL Somavert NPD, SP PA Oseni + NPD PA Starlix NPD Oxandrin NPD Steglatro NPD PA G QL Steglujan NPD PA Ozempic PB Striant buccal system NPD PA paricalcitol G Symlin + PB PA pioglitazone G Synjardy PB pioglitazone/ G glimepiride Synjardy XR PB Prandin NPD Synthroid NPD Precision Tanzeum + NPD PA PB PA, QL Glucometer Tapazole NPD Precision XTRA Teriparatide inj NPD PA, QL PB, SP PA, Q/T Test Strips Testim Gel NPD PA Precose NPD testosterone gel G PA prednisolone G 10mg/act (2%) Prelone NPD testosterone gel G PA Procysbi NPD, SP PA 1%, 1.62% Proglycem Susp NPD testosterone solution G PA propylthiouracil G 30mg/act Qtern NPD PA Tirosint NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 45 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

tolbutamide G budesonide ER G Toujeo Solostar PB QL tab Tradjenta tablet + NPD PA Canasa supp NPD Tresiba + NPD PA, QL, AL Carafate susp NPD Trijardy XR PB Carafate tabs NPD Trulicity PB Chenodal NPD, SP Tymlos PB, SP PA, Q/T chlordiaze- Uceris NPD PA poxide/ G clidinium Unithroid G Cholbam NPD, SP PA Veripred soln 20mg/5ml NPD G Victoza PB Clenpiq Soln NPD Vogelxo NPD PA Colazal NPD Xigduo XR PB Colocort NPD Xultophy + NPD PA Creon PB Xyosted Soln NPD PA cromolyn sodium solution G Zcort 7-day tab NPD Cytotec NPD Zemplar NPD Delzicol NPD Zomacton NPD, SP PA Dexilant NPD PA, QL STOMACH, ULCER, & BOWEL MEDS Diclegis NPD PA Aciphex NPD PA, QL dicyclomine G Aciphex diphenoxylate NPD PA, QL, AL G Sprinkle HCl/atropine Actigall NPD doxylamine- pyridoxine G PA Amitiza + NPD PA dronabinol G amoxicill- Emend clarithro- G NPD QL lansoprazole Emverm NPD QL Ampyra NPD, SP PA, QL Endari powder NPD PA Anusol-HC Entocort EC NPD PA NPD cream esomeprazole G PA, QL aprepitant G QL esomeprazole G PA, QL Asacol HD NPD PA granules Azulfidine NPD esomeprazole NPD PA, QL balsalazide G famotidine 40mg Bentyl NPD tab, suspension G Bonjesta NPD PA Gastrocrom NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 46 REQUIREMENTS/REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITSLIMITS TIER LIMITS Gattex NPD, SP PA Nexium packets NPD PA, QL, AL Gimoti Spray NPD PA, Q/T nizatidine G Golytely solution solution Nulytely NPD PA, QL reconstituted NPD PA 227.1gm omeprazole G QL Golytely ondansetron HCl LCG solution orlistat G PA, R NPD PA, QL reconstituted Osmoprep tab NPD PA 236gm Pancreaze NPD PA granisetron G pancrelipase EC/ hydrocortisone SA G cream LCG pantoprazole G QL hydrocortisone retention enema G pantoprazole pak G PA, QL Kristalose Pak NPD PA peg-kcl-nacl- nasulf-na lactulose pak NPD PA asc-c soln G lactulose soln G reconstituted PEG 3350 & lansoprazole cap G QL G lansoprazole electrolytes G PA, QL solutab Pentasa PB Lialda NPD Pepcid tabs, suspension NPD PA Linzess PB Pertzye NPD PA Lomotil NPD Plenvu Soln NPD PA loperamide G Prevacid caps NPD PA, QL Marinol NPD Prevacid LCG NPD PA, QL SoluTab mesalamine G Prilosec packets NPD PA, QL mesalamine DR G mesalamine G G suppository rectal susp prochlorperazine metoclopramide G tabs G misoprostol LCG Protonix NPD PA, QL Motegrity tab + NPD PA Protonix NPD PA, QL Movantik NPD PA packets MoviPrep Pylera NPD Solution rabeprazole DR G QL RECONSTITU- NPD PA tab 20mg TED 100 GM Rabeprazole Oral Sprinkle Cap NPD PA, QL Nexium capsule NPD PA, QL 10mg

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD y G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 47 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS ranitidine 300mg G Amrix + NPD PA Reglan NPD Anaprox DS + NPD PA Relistor + NPD PA Arava NPD Arcalyst NPD, SP PA scopolamine G patch Arthrotec + NPD PA SFRowasa Atelvia NPD QL enema NPD baclofen G sucralfate tabs G Binosto NPD QL sulfasalazine G Boniva NPD QL Sutab NPD PA calcitonin- Symproic PB salmon Syndros NPD (rDNA origin) G Tigan NPD nasal spray Transderm- carisoprodol G NPD Scop patch Celebrex + NPD PA celecoxib G trimetho- G benzamide chlorzoxazone Trulance + NPD PA 375mg, 500mg, G 750mg ursodiol G Cimzia PB, SP PA Varubi NPD Colchicine Cap NPD Viberzi + NPD PA 0.6mg Viokace NPD PA colchicine 0.6mg G Xenical NPD PA, R tab Xermelo NPD PA colchicine/ G Zantac NPD probenecid Zegerid packets NPD PA, QL Colcrys NPD PA Zelnorm NPD PA Cuprimine + NPD, SP PA Zenpep PB Cuvposa NPD Zofran NPD cyclobenzaprine LCG Zorbtive NPD, SP PA cyclobenzaprine NPD PA Zuplenz NPD ER Dantrium NPD BONE, JOINT, & MUSCLE dantrolene G Actemra SC NPD, SP PA diclofenac Actonel NPD QL epolamine NPD PA, QL transdermal 1.3% alendronate LCG QL diclofenac allopurinol G potassium G alosetron hcl G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 48 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

diclofenac G leflunomide G sodium DR Lorzone + NPD PA diclofenac Lotronex NPD PA sodium ER G meclofenamate G diclofenac G sodium soln 1.5% meloxicam cap G PA meloxicam tab LCG diclofenac/ G misoprostol metaxalone NPD EC-Naprosyn + NPD PA methocarbamol G Enbrel NPD, SP PA Miacalcin NPD etidronate G Mitigare + NPD PA disodium Mobic + NPD PA etodolac G nabumetone G Evista NPD Nalfon NPD PA febuxostat G PA Naprelan + NPD PA Feldene NPD Naprosyn + NPD PA fenoprofen Naprosyn susp NPD AL calcium NPD PA naproxen sodium LCG Fenortho NPD PA naproxen sodium Fexmid NPD DR G Flector Patch NPD PA, QL naproxen sodium flurbiprofen G ER G Fosamax NPD QL naproxen sodium G AL Fosamax Plus D NPD QL susp Gloperba Soln NPD PA Norgesic Forte Tab NPD PA Humira PB, SP PA Olumiant NPD, SP PA ibandronate G QL Orencia NPD, SP PA ibuprofen LCG orphenadrine- indomethacin G asa-caffeine NPD PA indomethacin orphenadrine ER G 20mg capsule NPD PA Orphengesic indomethacin SR G NPD PA Forte Tab ketoprofen 25mg cap NPD PA Otezla PB, SP PA ketoprofen ER G Otrexup NPD PA ketorolac G oxaprozin G ketorolac sol Ozobax Soln NPD PA tromethamine NPD QL Pennsaid NPD PA Kevzara NPD, SP PA piroxicam G Kineret NPD, SP PA probenecid G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 49 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS raloxifene hcl G Brevicon NPD Rasuvo NPD PA Cenestin PB risedronate G QL Cleocin vaginal NPD risedronate DR G QL Climara patch PB Robaxin NPD clomiphene G silodosin G citrate Simponi PB, SP PA Cyclessa NPD Depo SubqQ Skelaxin + NPD PA NPD QL Soma + NPD PA Provera Stelara PB PA Depo-Provera NPD QL sulindac G Desogen NPD - tizanidine G ACA ethinyl estradiol tolmetin G Diflucan NPD Toviaz + NPD PA Divigel NPD Uloric + NPD PA - Viibryd + NPD PA ACA ethinyl estradiol Voltaren Gel NPD eluryng mis ACA QL Xeljanz [XR] PB, SP PA Estrace Cream NPD PA Zanaflex + NPD PA Estrace Tab NPD Zeposia NPD, SP estradiol G Zipsor + NPD PA, QL estradiol cream Zurampic G NPD PA 0.1% 200mg estradiol Zyloprim NPD G transdermal FEMALE, REPLACEMENT, & Estring PB BIRTH CONTROL estropipate G The Injectable Fertility Agents in this section are Estrostep FE NPD covered only under certain benefits programs. Please check your handbook to determine coverage. Evista NPD Activella NPD Femcon FE NPD Addyi NPD PA FemHRT NPD Alora NPD Femring NPD PA Annovera Mis NPD QL Follistim AQ + NPD, SP PA, QL, R Gemmily cap Aygestin NPD ACA 1/20 Balcoltra NPD Generess FE NPD Beyaz NPD Gonal PB, SP QL, R Bijuva cap NPD hailey 1.5/30 ACA Bravelle + NPD, SP PA, QL, R

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 50 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Imvexxy NPD Nuvaring NPD QL Intrarosa NPD PA OB Complete NPD PA Oriahnn cap NPD PA levonorgestrel- ACA ethinyl estradiol Ortho Micronor NPD levonorgestrel/ Ortho Novum NPD my way/next dose ACA Ortho Tri- Loestrin NPD NPD Cyclen Lo Loestrin FE PB Ortho Tri- NPD Loseasonique NPD Cyclen Lo Lyllana Dis G Ortho Cyclen NPD Lysteda NPD Ovidrel NPD, SP R medroxypro- Plan B One- NPD QL gesterone ACA QL Step acetate suspension IM Premarin PB Premarin medroxypro- PB gesterone LCG vaginal cream acetate tab Premphase PB Menopur NPD, SP QL, R Prempro PB Metrogel , NPD G vaginal micronized metronidazole LCG Prometrium NPD metronidazole G Provera NPD vaginal gel Quartette NPD Minastrin 24 FE NPD raloxifene G Minivelle NPD Safyral NPD Mircette NPD Seasonique NPD Natazia ACA Slynd NPD norethin-ethynil- Synarel NPD fer cap 1/20 ACA Taytulla NPD norethindrone G terconazole norethindrone G acetate G cream Tri-norinyl NPD norethindrone- ACA ethinyl estradiol Twirla Dis NPD QL norethindrone- ACA Vagifem NPD PA mestranol Vandazole NPD norgestimate- Vivelle Dot NPD ethinyl estradiol ACA Vyleesi NPD PA, QL - ethinyl estradiol ACA xulane ACA QL Yasmin NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 51 DRUG REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG NAME DRUG TIER LIMITS TIER LIMITS YAZ NPD Cosopt NPD yuvafem G Cosopt PF NPD EYE MEDICATIONS cromolyn ophth G Cyclogyl NPD Acular/Acular LS NPD cyclopentolate Alcaine NPD HCl G Alphagan P NPD Cystadrops Soln NPD, SP PA, QL 0.15% soln dexamethasone Alphagan P ophth G PB 0.01% soln Diamox Sequels NPD Alrex NPD diclofenac soln G apraclonidine G 0.1% opth atropine sulfate G dorzolamide HCl 2% G azelastine HCL drops G dorzolamide- timolol G Azopt PB Elestat NPD bacitracin ophth G epinastine HCl G bacitracin/ polymyxin B G erythromycin ophth oint etyhylsuccinate G susp Besivance PB erythromycin Betagan NPD ophth oint G betaxolol G Eysuvis Ophth NPD PA Betimol NPD fluorometholone G Betoptic S NPD flurbiprofen G bimatoprost G FML Liquifilm Bleph 10 NPD suspension NPD Blephamide NPD gentak oint 0.3% S.O.P. ointment OP G brimonidine G gentamicin ophth LCG tartrate homatropine Bromsite sol LCG NPD PA opthalmic 0.075% homatropaire sol carteolol G 5% OP G Cequa Sol NPD PA, QL Ilevro Susp 0.3% NPD PA 0.09% Inveltys Susp 1% NPD Ciloxan Sol NPD Iopidine NPD ciprofloxacin G Isopto Carpine NPD Combigan soln PB Istalol Drops NPD 0.2-0.5%

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 52 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS ketorolac opth prednisolone soln G sodium G latanoprost G phosphate levobunolol G prednisolone/ sodium G Lotemax [SM] NPD sulfacetamide loteprednol susp Prolensa sol G PB 0.5% 0.07% Lumigan PB proparacaine G Maxitrol NPD Rescula + NPD PA methazolamide G Restasis PB QL Moxeza PB Rhopressa Soln NPD moxifloxacin 0.02% ophthalmic soln G Rocklatan Soln NPD PA Mydriacyl NPD 0.02-0.005% + neomycin/ Simbrinza Susp polymyxin B/ G PB PA dexamethasone 1-0.2% Neosporin soln NPD sulfacetamide G Nevanac Susp timolol ophth G NPD PA 0.1% Timoptic NPD Ocufen NPD Timoptic XE NPD Ocuflox NPD Tobradex NPD tobramycin- ofloxacin G G olopatadine hcl G dexamethasone tobramycin Omnipred NPD G ophthalmic Oxervate soln NPD, SP PA, QL 200mcg/ml Tobrex NPD Patanol NPD Travatan Z NPD Phospholine travoprost G PB Iodide trifluridine G pilocarpine G trimethoprim polymyxin B/neo/ sulfate/ G bacitracin G polymyxin B trimethoprim tab G polymyxin B/neo/ G gramicidin tropicamide G Polytrim NPD Trusopt NPD Pred-Forte NPD Upneeq Soln NPD PA prednisolone Vigamox NPD acetate G Viroptic NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 53 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Vyzulta Soln Arnuity NPD PA PB 0.024% OP Ellipta Xalatan NPD Asmanex NPD PA Xelpros Asmanex HFA NPD PA Emulsion NPD PA Atrovent HFA PB 0.005% Auvi-Q 0.1mg NPD QL, AL Xiidra PB Auvi-Q 0.15mg Zerviate Drops NPD PA, QL NPD PA and 0.3mg 0.24% azelastine Zioptan + NPD PA nasal spray G Zymaxid NPD azelastine/ fluticasone spray G PA , COUGH & COLD, LUNG MEDS 137-50 Accolate NPD AL Beconase AQ NPD PA G benzonatate LCG Advair Diskus PB Bevespi Aerosphere + NPD PA Advair HFA PB bosentan G, SP PA Aerospan + NPD PA Breo Ellipta PB AirDuo NPD PA Digihaler Breztri Aerosphere PB AirDuo NPD PA Bromfed DM G RespiClick + budesonide susp. G Albuterol AER HFA budesonide- NPD PA (authorized NPD PA, QL formoterol generic for carbinoxamine G Ventolin HFA) Cayston NPD, SP PA albuterol AER Cheratussin AC 5DS, QL, AL, HFA (generic of G MME ProAir HFA and G QL Cheratussin Proventil HFA) G 5DS, QL, AL, DAC MME albuterol G sulfate er Clarinex NPD albuterol sulfate clemastine G nebulizer soln, G Combivent syrup, tab Respimat PB Alvesco + NPD PA cromolyn G Anoro Ellipta PB inhalation soln ArmonAir G NPD PA Digihaler dalfampridin ER G, SP PA, QL ArmonAir NPD PA Daliresp NPD RespiClick +

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 54 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS dexchlor- Hypersal G pheniramine NPD PA Incruse Ellipta PB soln ipratropium- Duaklir NPD PA albuterol G Dulera + NPD PA ipratropium Dymista NPD PA inhalation soln G Elixophyllin NPD ipratropium Elixir nasal spray G Epinephrine PB QL Isturisa NPD, SP QL, PA pen 0.15mg Kitabis Pak NPD, SP LDD epinephrine pen Kuvan NPD, SP PA 0.3mg G QL levalbuterol neb G EpiPen NPD QL Levalbuterol EpiPen Jr. NPD QL tartrate HFA NPD QL Esbriet NPD, SP PA, LDD Lonhala NPD PA Flovent Diskus PB Magnair Soln Flovent HFA PB metaproterenol G flunisolide G montelukast LCG fluticasone sodium propionate nasal G Nucala Soln PB, SP PA susp Obredon NPD QL, 5DS, AL, MME fluticasone- salmeterol AER G Odactra SL NPD PA powder Ofev NPD, SP PA Grastek NPD PA Oralair NPD PA Hycofenix NPD QL, 5DS Palforzia cap/ NPD, SP PA powder hydrocodon-cpm- G QL, 5DS, AL, phenylephrine MME ProAir NPD PA, QL Digihaler hydrocod-cpm- G QL, 5DS, AL, pseudoephedrine MME ProAir HFA NPD QL hydrocodone bit/ QL, 5DS, AL, ProAir G PB QL homatrop syrup MME RespiClick hydrocodone- promethazine LCG chlorphenira- G QL, 5DS, AL, mine susp MME promethazine/ codeine LCG QL, 5DS, AL, MME QL, 5DS, AL, hydromet G MME promethazine/ dextrometh- LCG HCL orphan syrup G promethazine/ hydroxyzine HCl phenylephrine G tabs LCG Proventil HFA + NPD PA, QL hydroxyzine pamoate LCG

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 55 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Pulmicort Tussicap NPD QL, 5DS, AL, MME PB Flexhaler Tuxarin ER NPD QL, 5DS, AL, MME Pulmicort tabs NPD Respules Tuzistra XR NPD QL, 5DS, AL, MME Pulmozyme PB, SP Utibron NPD PA Qvar NPD PA Neohaler + Ragwitek NPD PA Ventolin HFA + NPD PA, QL Rebetol NPD, SP Vistaril NPD Rezira NPD QL, 5DS, AL, MME Vituz NPD QL, 5DS, AL, MME Ryclora NPD PA VoSpire ER NPD Ryvent NPD wixela inhub aer G sapropterin pow/ Xhance NPD PA G, SP PA tab Xopenex NPD Seebri NPD PA Xopenex HFA + NPD PA, QL Semprex-D NPD QL Yupelri Soln NPD PA Serevent Diskus PB Z-Tuss AC NPD QL, 5DS, AL, MME Singulair NPD zafirlukast G AL sodium chloride G zileuton ER 600mg G PA inhalation Zutripro NPD QL, 5DS, AL, MME Spiriva PB Zyflo 600mg tab NPD AL Stiolto Respimat PB Zyflo CR 600mg NPD AL Striverdi Respimat Aer PB URINARY & PROSTATE MEDS Solution Symbicort PB alfuzosin G Symdeko NPD, SP PA Avodart NPD AL Symjepi Inj NPD QL bethanechol G terbutaline Cardura NPD sulfate tabs G Caverject PB PA, QL Tessalon Perles NPD Cialis NPD PA, QL Theo-24 PB darifenacin ER G Theochron G Detrol NPD soln G Detrol LA NPD theophylline Ditropan XL NPD extended release G doxazosin G Thiola [EC] NPD, SP PA mesylate Tracleer NPD, SP PA G AL Trelegy Ellipta PB dutasteride/ G Tudorza tamsulosin hcl Pressair NPD PA Edex NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 56 DRUG REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG NAME DRUG TIER LIMITS TIER LIMITS Elmiron NPD PA Calciferol NPD Enablex NPD Dailyvite w/Zinc NPD G AL & NephlexRx flavoxate G Dojolvi Liq NPD PA Flomax NPD Duzallo NPD PA IFE-PG 20 NPD PA, QL ergocalciferol G Jalyn NPD fluoritab chew LCG Levitra NPD PA, QL tab Muse PB PA, QL Fosrenol NPD Myrbetriq PB Jynarque NPD, SP PA oxybutynin syrup LCG K-Phos NPD oxybutynin [XR] G K-Tab NPD potassium citrate Klor-Con G G ER lanthanum G Proscar NPD AL chewable tab Rapaflo NPD Lokelma PAK NPD solifenacin G Mephyton NPD Staxyn NPD PA, QL multivitamin with fluoride drops, LCG Stendra NPD PA, QL tabs tamsulosin G Nascobal NPD PA terazosin G nebusal tolterodine G nebulization G tartrate solution tolterodine Nestabs One NPD PA tartrate LA G phytonadione tab G trospium chloride G potassium bicarbonate/ G Urecholine NPD potassium citrate Urocit-K NPD effervescent Uroxatral NPD potassium G vardenafil G PA, QL chloride vardenafil ODT G PA, QL PulmoSal Vesicare NPD PA nebulization G solution Viagra NPD PA, QL Quflora NPD VITAMINS & ELECTROLYTES Rayaldee + NPD PA sodium fluoride Brand Prenatal LCG NPD PA chew tab Vitamins Buphenyl + NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 57 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

sodium kionex G phenylbutyrate G, SP suspension tab Metopirone NPD Tri-Vi-Flor, midodrine HCl G Poly-Vi-Flor NPD miglustat G, SP PA with and without iron nitisinone G, SP PA Nityr NPD, SP DIAGNOSTICS & MISCELLANEOUS AGENTS Novarel NPD, SP Berinert NPD, SP PA 5000 units Cablivi Kit NPD, SP QL Novarel PB, SP calcium acetate G 10000 units Carbaglu NPD, SP PA Ocaliva NPD, SP PA Cerdelga NPD, SP PA Orfadin NPD, SP PA Chemet PB Orladeyo NPD, SP PA Chorionic Oxbryta NPD, SP PA NPD, SP gonadotropin Palynziq NPD, SP PA Cinryze NPD, SP PA penicillamine G, SP PA clovique G, SP PA capsule penicillamine Cystadane NPD, SP G, SP Cystagon NPD, SP PA tablet deferasirox tab/ PhosLo NPD G PA granules phospha G deferiprone tab G PA Potaba NPD D-Penamine Pregnyl PB, SP NPD, SP 125mg tablet Renagel NPD Doptelet NPD, SP PA Renvela NPD Exjade NPD PA Ridaura NPD, SP Ferriprox NPD PA Rinvoq PB, SP PA Firazyr NPD, SP PA, QL Ruconest NPD, SP PA Firdapse NPD, SP PA Ruzurgi NPD, SP PA sevelamer Galafold NPD, SP PA, QL G ganirelix acetate carbonate G, SP R soln Strensiq NPD, SP PA Haegarda NPD, SP PA Sucraid icatibant inj G, SP PA Solution 8500 NPD, SP PA Idelvion NPD, SP PA unit/ml Jadenu tab/ Syprine + NPD, SP PA NPD PA granules Takhzyro Inj NPD, SP PA Keveyis NPD, SP PA Tavalisse NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 58 REQUIREMENTS/ DRUG NAME DRUG TIER LIMITS Tegsedi NPD, SP PA trientine G, SP PA V-GO PB Vumerity PB, SP Xuriden NPD, SP PA Zavesca NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 59

Language Assistance Services Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong Spanish: ATENCIÓN: Si habla español, cuenta con sa wika nang walang bayad. Tumawag sa servicios de asistencia en idiomas disponibles 1-800-275-2583. de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711). French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés Chinese: 注意：如果您讲中文，您可以得到免费的语言 gratuitement. Appelez le 1-800-275-2583. 协助服务。致电 1-800-275-2583。 Pennsylvania Dutch: BASS UFF: Wann du Korean: 안내사항: 한국어를 사용하시는 경우, 언어 Pennsylvania Deitsch schwetzscht, kannscht du Hilf 지원 서비스를 무료로 이용하실 수 있습니다. griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. 1-800-275-2583 번으로 전화하십시오.

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Chiamare il numero 1-800-275-2583. Urdu:

توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے Arabic: مفت ميں زبان معاون خدمات دستياب ہيں۔ کال کريں ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية .1-800-275-2583 متاحة لك بالمجان. اتصل برقم 1-800-275-2583.

French Creole: ATANSYON: Si w pale Kreyòl Mon-Khmer, Cambodian: សូ�េ��䮏 ចប់�រ�មណ៍ ៖ Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583. 䮚បសិនេបើអនកនិ�យ���ន-ែខមរ ���ែខមរ េនះ ជំនួយែផនក��នឹងមនផ䮏ល់ជូនដល់េ�កអនកេ�យ�ត គិតៃថ䮛។ ទូរសពទេទេលខ 1-800-275-2583។

Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

60

Discrimination is Against the Law If you need these services, contact our Civil Rights This Plan complies with applicable Federal civil rights Coordinator. If you believe that This Plan has failed laws and does not discriminate on the basis of race, to provide these services or discriminated in another color, national origin, age, disability, or sex. This Plan way on the basis of race, color, national origin, age, does not exclude people or treat them differently disability, or sex, you can file a grievance with our Civil because of race, color, national origin, age, disability, Rights Coordinator. You can file a grievance in the or sex. following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, This Plan provides: Philadelphia, PA 19103, By phone: 1-888-377-  Free aids and services to people with disabilities 3933 (TTY: 711) By fax: 215-761-0245, By email: to communicate effectively with us, such as: [email protected]. If you need qualified sign language interpreters, and written help filing a grievance, our Civil Rights Coordinator is information in other formats (large print, audio, available to help you. accessible electronic formats, other formats).  Free language services to people whose You can also file a civil rights complaint with the U.S. primary language is not English, such as: Department of Health and Human Services, Office for qualified interpreters and information written in Civil Rights electronically through the Office for Civil other languages. Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

61 Index

A adapalene-benzoyl-peroxide gel 0.1-2.5%, 37 abacavir sulfate tab, soln, 16 Adcirca, 32, 36 abacavir sulfate/ lamivudine, 16 Adderall, 23 abacavir/ lamivudine/ zidovudine, 16 Adderall XR, 23 Abilify, 23 Addyi, 50 Abilify Mycite, 23 adefovir dipivoxil, 16 abiraterone, 20 Adempas, 32 Absorica, 37 Adhansia XR Capsule, 23 Absorica LD, 37 Adipex-P, 23 Abstral, 23 Adlyxin, 42 acamprosate DR tab 333mg, 23 Admelog, 42 Acanya, 37 Advair Diskus, 54 acarbose, 42 Advair HFA, 54 Accolate, 54 Advate, 32 Accupril, 32 Adynovate, 32 Accuretic, 32 Adzenys ER Susp, 23 acebutolol, 32 Adzenys XR ODT, 23 acetaminophen/ codeine, 23 Aemcolo DR, 16 acetasol HC, acetic acid HC otic, 41 Aerospan, 54 acetazolamide, 32 Afinitor, 20–21 acetazolamide ER, 32 Afrezza, 42 acetylcysteine, 54 Afstyla, 32 Aciphex, 46 Aggrenox, 32 Aciphex Sprinkle, 46 Agrylin, 32 acitretin, 37 Aimovig, 23 Actemra SC, 48 AirDuo, 54 Acticlate, 16 AirDuo Digihaler, 54 Actigall, 46 Ajovy, 23 Actimmune, 32 Aklief Cream 0.005%, 37 Actiq, 23 Aktipak, 37 Activella, 50 ala-cort cream, 38 Actonel, 48 albendazole, 16 Actos, 42 Albuterol AER HFA (authorized generic Acular/ Acular LS, 52 for Ventolin HFA), 54 acyclovir, 16, 37 albuterol AER HFA (generic of ProAir acyclovir 5% cream, 16 HFA and Proventil HFA), 54 Aczone, 37 albuterol sulfate er, 54 Adalat CC, 32 albuterol sulfate nebulizer soln, syrup, Adapalene 0.1% lotion, 37 tab, 54 adapalene 0.1% soln, 37 Alcaine, 52 adapalene 0.3% gel, 37 alclometasone cream, ointment, 38 adapalene cream, 37 Aldactazide, 32 adapalene pad 0.1%, 37 Aldactone, 32 Aldara, 38 i Index

Alecensa, 20 amlodipine/valsartan/HCTZ, 32 alendronate, 48 amoxapine, 23 alfuzosin, 56 amoxicill-clarithro-lansoprazole, 46 Alinia, 16 amoxicillin, 16 aliskiren, 32 Amoxicillin 775mg, 16 Alkeran, 20 amoxicillin/ clavulanate, 16 Alkindi Sprinkle Cap, 42 amoxicillin/ clavulanate extended-release, 16 allopurinol, 48 amphetamine aspartate/ amphetamine Allzital 25-325mg, 23 sulfate/dextroamphetamine ER, 23 almotriptan maleate, 23 amphetamine aspartate/amphetamine Alogliptin benz/ metformin hcl, 42 sulfate/dextroamphetamine, 23 Alogliptin benz/ pioglitazone, 42 amphetamine ER suspension, 23 Alogliptin benzoate, 42 amphetamine tablet, 23 Alora, 50 amphetamine tablet (generic Evekeo), 23 alosetron hcl, 48 ampicillin, 16 Alphagan P 0.01% soln, 52 Ampyra, 46 Alphagan P 0.15% soln, 52 Amrix, 48 Alphanate, 32 Amzeeq, 16 Alphanine, 32 Anafranil, 23 alprazolam, 23 anagrelide, 32 alprazolam ER, 23 Anaprox DS, 48 Alprolix, 32 anastrazole, 20 Alrex, 52 Ancobon, 16 Altabax, 16 Androderm patch, 42 Altace, 32 Androgel 1%, 42 Altoprev, 32 Androgel 1.62% Packet, Pump, 42 Altreno 0.05% lotion, 38 Annovera Mis, 50 Alunbrig tab/pak, 20 Anoro Ellipta, 54 Alvesco, 54 Antabuse, 23 amantadine, 23 Antara, 32 Amaryl, 42 anthralin, 38 Ambien, 23 Anusol-HC cream, 46 Ambien CR, 23 Apadaz, 23 ambrisentan, 32 ApexiCon E, 38 amcinonide, 38 Apidra, 42 Amerge, 23 Aplenzin, 23 Amicar, 32 Apokyn Solution Cartridge 30 mg/ 3ml, 23 amiloride, 32 apraclonidine, 52 amiloride/HCTZ, 32 aprepitant, 46 amine, 28 Aptensio XR, 23 aminocaproic acid, 32 Aptiom, 23 amiodarone, 32 Arakoda, 16 Amitiza, 46 Arava, 48 amitriptyline hcl, 23 Arazlo lotion 0.045%, 38 amlodipine, 32, 35 Arcalyst, 48 amlodipine besylate/ olmesartan, 32 Aricept, 23 amlodipine/ benazepril, 32 Arikayce, 16 amlodipine/ valsartan, 32 Arimidex, 20 ii Index

aripiprazole, 23 azelaic acid gel 15%, 38 Arixtra, 32 azelastine, 41, 52, 54 armodafinil, 23 azelastine HCL drops, 52 ArmonAir Digihaler, 54 azelastine nasal spray, 54 ArmonAir RespiClick, 54 azelastine/ fluticasone spray 137-50, 54 Arnuity Ellipta, 54 Azelex, 38 Aromasin, 20 Azilect, 23 Arthrotec, 48 azithromycin, 16 Arymo ER, 23 Azopt, 52 Asacol HD, 46 Azor, 32 asenapine tab sub, 23 Azulfidine, 46 Asmanex, 54 Asmanex HFA, 54 B aspirin-dipyridamole er, 32 Atacand, 32 bacitracin ophth, 52 Atacand HCT, 32 bacitracin/ polymyxin B ophth oint, 52 atazanavir, 16 baclofen, 48 Atelvia, 48 Bactrim, Bactrim DS, 16 atenolol, 32 Bactroban nasal oint, 41 atenolol/ chlorthalidone, 32 Bafiertam DR Cap, 42 Ativan, 23 Balcoltra, 50 atomoxetine, 23 balsalazide, 46 atorvastatin, 32 Balversa, 20 atorvastatin/ amlodipine, 32 Banzel, 23 atovaquone, 16 Banzel Susp, 23 atovaquone/ proguanil, 16 Baqsimi, 42 Atralin, 38 Baraclude, 16 Atripla, 16 Basaglar, 42 atropine sulfate, 52 Baxdela, 16 Atrovent HFA, 54 Bebulin, 32 Aubagio, 23 Beconase AQ, 54 Augmentin, 16 Belbuca, 23 Augmentin XR, 16 Belsomra, 23 Austedo, 23 Belviq [XR], 23 Auvi-Q 0.1mg, 54 benazepril, 32 Auvi-Q 0.15mg and 0.3mg, 54 benazepril/HCTZ, 32 Avalide, 32 BeneFIX, 32 Avapro, 32 Benicar, 32 Avelox, 16 Benicar HCT, 32 avidoxy, 16 Benlysta, 20 Avita, 38 Bentyl, 46 Avodart, 56 Benzaclin, 38 Avonex, 23 Benzamycin gel, 38 Axert, 23 Benzamycinpak, 38 Axiron, 42 benzhydrocodone-acetaminophen, 24 Aygestin, 50 Benznidazole, 16 Ayvakit, 20 benzonatate, 54 azathioprine, 20 benzoyl peroxide/ erythromycin, 38 iii Index

benzphetamine, 24 bromocriptine mesylate, 24 benztropine, 24 Bromsite sol 0.075%, 52 Berinert, 58 Brukinsa, 20 beser lotion 0.05%, 38 Bryhali lotion 0.01%, 38 Besivance, 52 budesonide ER tab, 46 Betagan, 52 budesonide susp., 54 betamethasone dipropionate, 38 budesonide-formoterol, 54 betamethasone valerate, 38 bumetanide, 32 betamethasone/ clotrimazole, 38 Bunavail, 24 Betapace AF, 32 Buphenyl, 57 Betaseron, 24 buprenorphine hcl/naloxone hcl, 24 betaxolol, 32, 52 buprenorphine patch, 24 bethanechol, 56 buprenorphine SL, 24 Bethkis Neb, 16 bupropion, 24 Betimol, 52 bupropion ER 150mg, 24 Betoptic S, 52 bupropion ER 450mg, 24 Bevespi Aerosphere, 54 bupropion SR, 24 Bevyxxa, 32 bupropion XL, 24 bexarotene, 20 Buspar, 24 Beyaz, 50 buspirone, 24 Biaxin, 16 butalbital-acetaminophen 25-325mg, 24 bicalutamide, 20 butalbital-acetaminophen 50-300mg, 24 Bijuva cap, 50 butalbital/ apap/ caffeine, 24 Biktarvy, 16 butalbital/ apap/ caffeine/ codeine, 24 Biltricide, 16 butalbital/ aspirin/ caffeine/ codeine, 24 bimatoprost, 52 butorphanol tartrate nasal, 24 Binosto, 48 Butrans, 24 bisoprolol, 32 Bydureon, 42 bisoprolol/HCTZ, 32 Byetta, 42 Bleph 10, 52 Bynfezia Pen, 42 Blephamide S.O.P. ointment, 52 Bystolic, 32 Boniva, 48 Byvalson, 32 Bonjesta, 46 bosentan, 54 C Bosulif, 20 Braftovi, 20 Cablivi Kit, 58 Brand Prenatal Vitamins, 57 Cabometyx, 20 Bravelle, 50 Caduet, 33 Breeze2, 42 Cafergot, 24 Breeze2 Test Strips, 42 Calan, 33 Breo Ellipta, 54 Calan SR, 33 Brevicon, 50 Calciferol, 57 Breztri Aerosphere, 54 calcipotriene cream, 38 brimonidine tartrate, 52 calcipotriene foam, 38 Brisdelle, 24 calcipotriene-betamethasone dp oint, 38 Briviact, 24 calcipotriene-betamethasone dp susp, 38 Briviact soln, 24 calcitonin-salmon (rDNA origin) nasal spray, 48 Bromfed DM, 54 calcitriol capsules, 42 iv Index

calcitriol ointment, 38 ceftibuten, 16 calcium acetate, 58 Ceftin, 16 Calquence, 20 cefuroxime axetil, 16 Canasa supp, 46 Celebrex, 48 candesartan, 33 celecoxib, 48 candesartan/ hydrochlorothiazide, 33 Celexa, 24 capecitabine, 20 Cellcept, 20 Capex, 38 Celontin, 24 Caplyta, 24 Cenestin, 50 Caprelsa, 20 Centany 2% oint, 38 captopril, 33 cephalexin, 16 captopril/HCTZ, 33 Cequa Sol 0.09%, 52 Carac, 38 Cerdelga, 58 Carafate susp, 46 Cetraxal, 41 Carafate tabs, 46 Cetrotide Kit, 42 Carbaglu, 58 cevimeline hcl, 41 carbamazepine, 24 Chantix, 24 carbamazepine susp, 24 Chemet, 58 carbamazepine XR, 24 Chenodal, 46 Carbatrol, 24 Cheratussin AC, 54 carbidopa, 24 Cheratussin DAC, 54 carbidopa/ levodopa, 24 chlordiazepoxide, 24, 46 carbidopa/ levodopa ER, 24 chlordiazepoxide/ clidinium, 46 carbidopa/ levodopa ODT, 24 chlorhexidine gluconate soln, 16 carbidopa/ levodopa/ entacapone, 24 chloroquine phosphate, 16 carbinoxamine, 54 chlorothiazide, 33 Cardizem, 33 chlorpromazine HCl, 24 Cardizem CD, 33 chlorthalidone, 32–33 Cardizem LA, 33 chlorzoxazone 375mg, 500mg, 750mg, 48 Cardura, 33, 56 Cholbam, 46 carisoprodol, 48 cholestyramine, 33 carisoprodol-aspirin-codeine, 24 cholestyramine light, 33 Carnitor, 42 Chorionic gonadotropin, 58 Carospir, 33 Cialis, 36, 56 carteolol, 52 ciclopirox 0.77% cream, 38 Cartia XT, 33 ciclopirox 8% solution, 38 carvedilol, 33 ciclopirox cream, gel, shampoo, suspension, 38 carvedilol ER, 33 cilostazol, 33 Casodex, 20 Ciloxan Sol, 52 Catapres tablets, 33 Cimduo, 16 Catapres-TTS, 33 cimetidine, 46 Caverject, 56 Cimzia, 48 Cayston, 54 cinacalcet, 42 cefaclor, 16 Cinryze, 58 cefaclor ER, 16 Cipro, 16 cefadroxil, 16 Cipro XR, 16 cefdinir, 16 Ciprodex, 41 cefixime susp/cap, 16 ciprofloxacin, 16, 41, 52 v Index

ciprofloxacin ER tabs, 16 colestipol HCl, 33 ciprofloxacin-dexamethasone otic susp, 41 Colocort, 46 ciprofloxacin-fluocinolone PF otic soln, 42 Combigan soln 0.2-0.5%, 52 citalopram, 24 Combivent Respimat, 54 Clarinex, 54 Combivir, 16 clarithromycin, 16 Cometriq, 20 clarithromycin ER, 16 Complera, 16 clemastine, 54 Comtan, 25 Clenpiq Soln, 46 Concerta, 25 Cleocin, 16, 38, 50 Condylox, 38 Cleocin T, 38 Conjupri, 33 Cleocin vaginal, 50 Contour Glucometer, 42 Climara patch, 50 Contour Next Test Strips, 42 Clindagel, 38 Contour Test Strips, 42 clindamycin, clindamycin-benzoyl peroxide gel [w/ Contrave ER, 25 pump], 38 Conzip, 25 clindamycin/ tretinoin gel, 38 Copaxone, 25 clindamycin/benzoyl peroxide 1-5%, 38 Copiktra, 20 clobazam, 24 Cordran, 38 clobazam susp, 24 Coreg, 33 clobetasol cream, ointment, solution, 38 Coreg CR, 33 Clobex, 38 Corgard, 33 clocortolone pivalate, 38 Corifact, 33 clodan, 38 Corlanor, 33 Cloderm, 38 cortane B otic drops, 42 clomiphene citrate, 50 Cortef, 42 clomipramine HCl, 24 Corzide, 33 clonazepam, 24 Cosentyx, 38 clonidine ER 12 HR tab, 33 Cosopt, 52 clonidine IR tablet, 33 Cosopt PF, 52 clonidine patches, 33 Cotellic, 21 clopidogrel, 33 Cotempla XR ODT, 25 clorazepate dipotassium, 24 Coumadin, 33 clotrimazole troches, 16 Cozaar, 33 clovique, 58 Creon, 46 clozapine, 24 Cresemba, 17 clozapine ODT, 24 Crestor, 33 Clozaril, 24 Crixivan, 17 Coagadex, 33 cromolyn inhalation soln, 54 codeine tabs, 24 cromolyn ophth, 52 coditussin AC liquid, 24 cromolyn sodium solution, 46 Colazal, 46 Crotan lotion, 38 colchicine 0.6mg tab, 48 Cuprimine, 48 Colchicine Cap 0.6mg, 48 Cutivate, 38 colchicine/ probenecid, 48 Cuvposa, 48 Colcrys, 48 Cyclessa, 50 colesevelam, 33 cyclobenzaprine, 48 Colestid, 33 cyclobenzaprine ER, 48 vi Index

Cyclogyl, 52 Depakote, 25 cyclopentolate HCl, 52 Depakote ER, 25 cyclophosphamide, 21 Depakote Sprinkle Caps, 25 cyclosporine, 21 Depo SubqQ Provera, 50 Cymbalta, 25 Depo-Provera, 50 cyproheptadine, 54 Derma-Smoothe FS, 39 Cystadane, 58 Dermatop, 39 Cystadrops Soln, 52 Dermotic, 42 Cystagon, 58 desipramine, 25 Cytomel, 42 desmopressin acetate, 42 Cytotec, 46 Desogen, 50 Cytoxan, 21 desogestrel-ethinyl estradiol, 50 Desonate, 39 D desonide gel 0.05%, 39 Desowen, 39 D-Penamine 125mg tablet, 58 desoximetasone cream, gel, ointment, 39 D.H.E.45, 25 Desoxyn, 25 Dailyvite w/ Zinc & NephlexRx, 57 Desvenlafaxine ER 24 HR, 25 Daklinza, 17 Detrol, 56 dalfampridin ER, 54 Detrol LA, 56 Daliresp, 54 Dexabliss tab 1.5mg, 43 danazol, 21, 42 dexamethasone, 43, 52–53 Danocrine, 21 dexamethasone ophth, 52 Dantrium, 25, 48 dexamethasone tablet 6-day, 10-day, 13-day, 43 dantrolene, 25, 48 dexchlor pheniramine soln, 55 dapsone gel 5%, 38 Dexcom Continuous Glucose Monitor G6, G5, G4 dapsone gel 7.5%, 38 Sensors, 43 dapsone tab, 17 Dexcom Continuous Glucose Monitor Receiver, 43 Daraprim Tab, 17 Dexcom Continuous Glucose Monitor Transmitter, darifenacin ER, 56 43 Daurismo, 21 Dexedrine, 25 Daxbia, 17 Dexilant, 46 Daypro, 25 dexmethylphenidate ER, 25 Daytrana, 25 dexmethylphenidate hcl, 25 Dayvigo, 25 Dexpak pak 10-day, 13-day, 43 DDAVP, 42 dextroamphetamine, 23, 25 deferasirox tab/ granules, 58 dextroamphetamine ER, 25 deferiprone tab, 58 Diacomit, 25 Delatestryl, 42 Diamox Sequels, 52 Delstrigo, 17 Diastat, 25 Deltasone, 21 diazepam rectal gel, 25 Delzicol, 46 diazepam solution, 25 Demadex, 33 diazepam tabs, 25 demeclocycline, 17 diazoxide suspension 50mg/ml, 43 Demerol, 25 Dibenzyline, 33 Demser, 42 Diclegis, 46 Denavir, 38 diclofenac 3% gel, 39 Depakene, 25 Diclofenac cap 35mg, 25 vii Index

diclofenac epolamine transdermal 1.3%, 48 Divigel, 50 diclofenac potassium, 25, 48 dofetilide, 33 diclofenac sodium, 25, 49 Dojolvi Liq, 57 diclofenac sodium DR, 49 Dolophine, 25 diclofenac sodium ER, 49 donepezil hydrochloride, 25 diclofenac sodium gel 1%, 25 Doptelet, 58 diclofenac sodium soln 1.5%, 49 Doral, 25 diclofenac soln 0.1% opth, 52 Doryx 50mg, 17 diclofenac/ misoprostol, 49 Doryx 200mg DR tablet, 17 dicloxacillin, 17 dorzolamide HCl 2%, 52 dicyclomine, 46 dorzolamide-timolol, 52 didanosine, 17 Dovato, 17 diethylpropion, 25 Dovonex cream, 39 Differin 0.1% cream, 39 doxazosin mesylate, 33, 56 Differin 0.1% lotion, 39 doxepin capsule, 25 Differin 0.3% gel, 39 doxepin cream 5%, 39 Dificid tab/ susp, 17 doxepin tablet, 25 diflorasone diacetate, 39 doxercalciferol, 43 Diflucan, 17, 50 doxycycline DR 40mg, 17 diflunisal, 25 doxycycline hyclate DR 80mg, 17 digitek, 33 doxycycline hyclate tab 50mg, 17 digox, 33 doxycycline hyclate tab 75mg, 150mg, 17 digoxin, 33 doxycycline hyclate tab DR 50mg, 100mg, 17 dihydrocodein/APAP/caff, 25 doxycycline hyclate tab DR 75mg, 150mg, 17 dihydrocodeine/aspirin/caffeine, 25 doxycycline hyclate tab DR 200mg, 17 dihydroergotamine inj, 25 doxycycline monohydrate 50mg, 75mg, 100mg tab, dihydroergotamine nasal spray, 25 17 Dilantin chewable tablets, 25 doxycycline monohydrate cap 50mg, 100mg, 17 Dilaudid, 25 doxycycline monohydrate cap 75mg, 150mg, 17 Dilt-CD, 33 doxycycline monohydrate tab 150mg, 17 diltiazem HCl, 33 doxylamine-pyridoxine, 46 diltiazem HCl CD, 33 Drizalma Sprinkle, 25 diltiazem HCl ER, 33 dronabinol, 46 diltiazem HCl LA, 33 drospirenone-ethinyl estradiol, 50 diltiazem HCl SR, 33 Duac, 39 Diltzac ER, 33 Duaklir, 55 dimethyl fumarate DR cap, 25 Duetact, 43 Diovan, 33 Dulera, 55 Diovan HCT, 33 duloxetine, 25 diphenoxylate HCl/atropine, 46 Duobrii Lotion, 39 Diprolene, Diprolene AF, 39 Dupixent, 39 dipyridamole, 33 Duragesic patch, 25 disopyramide, 33 Durlaza, 33 disulfiram, 25 dutasteride, 56 Ditropan XL, 56 dutasteride/ tamsulosin hcl, 56 divalproex sodium, 25 Dutoprol, 33 divalproex sodium ER, 25 Duzallo, 57 divalproex sprinkle cap, 25 Dxevo 11-day Pak 1.5mg, 43 viii Index

Dyanavel XR, 25 Endari powder, 46 Dyazide, 33 endocet, 26 Dymista, 55 enoxaparin, 34 Dyrenium, 33 Enspryng Inj, 43 Enstilar, 39 E entacapone, 24, 26 entecavir, 17 E.E.S., 17 Entocort EC, 46 EC-Naprosyn, 49 Entresto, 34 econazole, 39 Epaned Sol 1mg/ml, 34 Ecoza, 39 Epclusa, 17 Edarbi, 33 Epidiolex Soln, 26 Edarbyclor, 33 Epiduo, 39 Edecrin, 33 Epiduo Forte gel, 39 Edex, 56 epinastine HCl, 52 Edurant, 17 epinephrine pen 0.3mg, 55 efavirenz, 17 Epinephrine pen 0.15mg, 55 efavirenz-emtricitab-tenofovir tab, 17 EpiPen, 55 efavirenz-lamivudine-tenofovir tab, 17 EpiPen Jr., 55 Effexor XR, 26 Epivir, 17 Effient, 33 eplerenone, 34 Efudex cream, 39 eprosartan, 34 Egaten 250mg tablet, 17 Epzicom, 17 Eldepryl, 26 ergocalciferol, 57 Elestat, 52 ergotamine tartrate/caffeine, 26 eletriptan, 26 Erivedge, 21 Elidel, 39 Erleada, 21 Elimite, 39 erlotinib, 21 Eliquis, 33 Ertaczo, 39 Elixophyllin Elixir, 55 Ery-Tab, 17 Elmiron, 57 Erygel, 39 Elocon, 39 EryPed, 17 Eloctate, 33 Erythrocin, 17 eluryng mis, 50 erythromycin delayed release, 17 Embeda, 26 erythromycin ethylsuccinate, 17 Emcyt, 21 erythromycin etyhylsuccinate susp, 52 Emend, 46 erythromycin gel, soln, swabs, 39 Emflaza, 43 erythromycin ophth oint, 52 Emgality, 26 erythromycin stearate, 17 emtricitabine cap, 17 Esbriet, 55 emtricitabine-tenofovir disoproxil fumarate tab escitalopram, 26 200-300mg, 17 Esgic capsule, 26 Emtriva, 17 Esgic tablet, 26 Emverm, 17, 46 esomeprazole, 46 Enablex, 57 esomeprazole granules, 46 enalapril, 33 esomeprazole strontium, 46 enalapril/HCTZ, 33 Esperoct, 34 Enbrel, 49 estazolam, 26 ix Index

Estrace Cream, 50 Farxiga, 43 Estrace Tab, 50 Farydak, 21 estradiol, 50–51 Fasenra, 39 estradiol cream 0.1%, 50 Fazaclo, 26 estradiol transdermal, 50 febuxostat, 49 Estring, 50 Feiba, 34 estropipate, 50 felbamate, 26 Estrostep FE, 50 Felbatol, 26 eszopiclone, 26 Feldene, 26, 49 ethacrynic acid, 34 felodipine ER, 34 ethambutol, 17 Femara, 21 ethosuximide, 26 Femcon FE, 50 etidronate disodium, 49 FemHRT, 50 etodolac, 26, 49 Femring, 50 etoposide, 21 fenofibrate, 34 Eucrisa, 39 fenofibrate nanocrystallized, 34 Eulexin, 21 fenofibric acid, 34 Eurax Lotion, 39 Fenoglide, 34 euthyrox, 43 fenoprofen calcium, 26, 49 Evekeo [ODT], 26 Fenortho, 49 everolimus (generic for Afinitor), 21 fentanyl citrate OTFC, 26 everolimus (generic for Zortress), 21 Fentanyl citrate tablet, 26 Evista, 49–50 fentanyl transdermal, 26 Evoclin, 39 Fentora, 26 Evoxac, 42 Ferriprox, 58 Evrysdi Soln, 43 Fetzima, 26 Evzio, 26 Fexmid, 49 Exalgo, 26 Fiasp, 43 Exelderm, 39 Fibricor, 34 Exelon, 26 Finacea, 39 exemestane, 21 finasteride, 57 Exforge, 34 Fintepla sol, 26 Exforge HCT, 34 Fioricet, 26 Exjade, 58 Fioricet with codeine, 26 Extavia, 26 Fiorinal with codeine, 26 Extina, 39 Firazyr, 58 Eysuvis Ophth, 52 Firdapse, 58 ezetimibe, 34 Firvanq Soln, 18 ezetimibe/ simvastatin, 34 Flagyl, 18 Ezzalor Sprinkle Cap, 34 flavoxate, 57 flecainide, 34 F Flector Patch, 49 Flolipid susp, 34 Fabior, 39 Flomax, 57 famciclovir, 18 Flovent Diskus, 55 famotidine 40mg tab, suspension, 46 Flovent HFA, 55 Fanapt, 26 fluconazole suspension/tabs, 18 Fareston tab, 21 flucytosine, 18 x Index

fludrocortisone acetate, 43 Fuzeon, 18 Flumadine, 18 Fycompa, 26 flunisolide, 55 fluocinolone acetonide cream, sol, oil, 39 G fluocinolone acetonide oil, 42 fluocinonide gel, ointment, 39 gabapentin, 26 fluoritab chew tab, 57 gabapentin soln, 26 fluorometholone, 52 Gabitril, 26 Fluorouracil cream 0.5%, 39 Galafold, 58 fluorouracil solution 2%, 39 galantamine, 26 fluoxetine, 26, 28 galantamine ER, 26 fluoxetine 10mg, 20mg, 40mg, 26 ganirelix acetate soln, 58 fluoxetine soln, 26 Gastrocrom, 46 fluphenazine, 26 Gattex, 47 flurandrenolide cream, lotn, oint, 39 Gavreto, 21 flurazepam, 26 gemfibrozil, 34 flurbiprofen, 26, 49, 52 Gemmily cap 1/20, 50 flutamide, 21 Generess FE, 50 fluticasone propionate cream, lotn, oint., 39 Genotropin, 43 fluticasone propionate nasal susp, 55 gentak oint 0.3% OP, 52 fluticasone-salmeterol AER powder, 55 gentamicin ophth, 52 fluvastatin sodium, 34 gentamicin topical cream, ointment, 39 fluvoxamine, 26 Geodon, 26 fluvoxamine ER, 26 Gilenya, 26 FML Liquifilm suspension, 52 Gilotrif, 21 Focalin, 26 Gimoti Spray, 47 Focalin XR, 26 glatiramer acetate, 26 Follistim AQ, 50 glatopa, 26 fondaparinux, 34 Gleevec, 21 ForFivo XL, 26 Gleostine, 21 Fortamet, 43 glimepiride, 43, 45 Forteo, 43 glipizide, 43 Fortesta, 43 glipizide ER, 43 Fosamax, 49 glipizide XL, 43 Fosamax Plus D, 49 Gloperba Soln, 49 fosamprenavir calcium tab, 18 Glucagen Inj Hypokit, 43 fosfomycin pow, 18 Glucagon Emergency Kit, 43 fosinopril, 34 Glucometer, 42–43, 45 fosinopril/HCTZ, 34 Glucophage, 43–44 Fosrenol, 57 Glucophage XR, 43–44 Fragmin, 34 Glucotrol, 43 Freestyle Glucometer, 43 Glucotrol XL, 43 Freestyle InsuLinx Test Strips, 43 Glucovance, 43 Freestyle Lite Test Strips, 43 glyburide, 43–44 Freestyle Test Strips, 43 glyburide micronized, 43 Frova, 26 Glynase, 43 frovatriptan succinate, 26 Glyset, 43 furosemide tabs, 34 Glyxambi, 43 xi Index

Gocovri, 26 hydrocod-cpm-pseudoephedrine, 55 Golytely solution reconstituted 227.1gm, 47 hydrocodon-cpm-phenylephrine, 55 Golytely solution reconstituted 236gm, 47 hydrocodone bit/ homatrop syrup, 55 Gonal, 50 hydrocodone chlorpheniramine susp, 55 granisetron, 47 hydrocodone ER, 27 Grastek, 55 hydrocodone-homatropine tab, 55 Gris-PEG, 18 hydrocodone/ acetaminophen, 27 griseofulvin microsize, 18 hydrocortisone, 39–40, 42–43, 47 griseofulvin ultramicrosize, 18 hydrocortisone 2.5%, 39 guaifenesin-codeine soln 10mg/ 5ml, 26 hydrocortisone butyrate 0.1%, 39 guanfacine, 26, 34 hydrocortisone butyrate/ emoll, 39 guanfacine ER, 26 hydrocortisone cream, 47 Gvoke hypo inj, 43 hydrocortisone lot 0.1%, 39 Gvoke PFS inj, 43 hydrocortisone retention enema, 47 hydrocortisone supp, 40 H hydrocortisone valerate 0.2%, 40 hydrocortisone/ lidocaine HCl, 40 Haegarda, 58 hydromet, 55 hailey 1.5/30, 50 hydromorphone ER, 27 halcinonide cream 0.1%, 39 hydromorphone IR, 27 Halcion, 26 hydroxychloroquine, 18 halobetasol propionate, 39 hydroxyurea, 21 halobetasol propionate foam 0.05%, 39 hydroxyzine HCL syrup, 55 Halog, 39 hydroxyzine HCl tabs, 55 haloperidol, 26 hydroxyzine pamoate, 55 Harvoni, 18 Hypersal, 55 Hectorol, 43 Hysingla ER, 27 Helixate FS, 34 Hyzaar, 34 Hemady, 43 Hemlibra Soln, 34 I Hemofil M, 34 Hepsera, 18 ibandronate, 49 Hetlioz, 26 Ibrance, 21 Hexalen, 21 Ibudone, 27 Hiprex, 18 ibuprofen, 27, 29, 49 homatropaire sol 5% OP, 52 ibuprofen/ hydrocodone, 27 homatropine opthalmic, 52 icatibant inj, 58 Horizant, 26 Iclusig, 21 Humalog, 43 icosapent cap, 34 Humate-P, 34 Idelvion, 58 Humatrope, 43 Idhifa, 21 Humira, 49 IFE-PG 20, 57 Humulin, 43 Ilevro Susp 0.3%, 52 Hycamtin, 21 imatinib mesylate, 21 Hycofenix, 55 Imbruvica, 21 hydralazine, 34 Imcivree Inj 10mg/ ml, 27 Hydrea, 21 imipramine, 27 hydrochlorothiazide, 33–34, 36–37 imiquimod cream, 40 xii Index

Imiquimod Cream 3.75% Pump, 40 isosorbide dinitrate ER, 34 Imitrex, 27 , 34 Impavido, 18 isosorbide mononitrate ER, 34 Impeklo Lotion 0.05%, 40 isotretinoin, 40 Impoyz Cream 0.025%, 40 isradipine, 34 Imuran, 21 Istalol Drops, 52 Imvexxy, 51 Isturisa, 55 Inbrija, 27 itraconazole, 18 Increlex, 43 ivermectin, 18 Incruse Ellipta, 55 Ixinity, 34 indapamide, 34 Inderal LA, 34 J Indocin susp, 27 indomethacin, 49 Jadenu tab/ granules, 58 indomethacin 20mg capsule, 49 Jakafi, 27 indomethacin SR, 49 Jalyn, 57 Ingrezza, 27 Jantoven, 34 Inlyta, 21 Janumet, 44 InnoPran XL, 34 Janumet XR, 44 Inqovi tab, 21 Januvia, 44 Inrebic, 21 Jardiance, 44 Inspra, 34 Jatenzo, 44 insulin aspart inj, 43 Jentadueto tablet, 44 insulin aspart protamin inj flexpen, 44 Jentadueto XR, 44 insulin lispro 100 units/ml, 44 Jivi, 34 insulin lispro inj junior, 44 Jornay PM Capsule, 27 insulin lispro inj protamin, 44 Jublia, 40 Intermezzo, 27 Juluca, 18 Intrarosa, 51 Juxtapid, 34 Intuniv, 27 Jynarque, 57 Invega ER tablet, 27 Inveltys Susp 1%, 52 K Invirase, 18 Invokamet [XR], 44 K-Phos, 57 Invokana, 44 K-Tab, 57 Iopidine, 52 Kadian ER, 27 ipratropium inhalation soln, 55 Kaletra Soln, 18 ipratropium nasal spray, 55 Kaletra Tabs, 18 ipratropium-albuterol, 55 Kalydeco Tabs/ Pack, 18 irbesartan, 34 Kapspargo, 34 irbesartan hydrochlorothiazide, 34 Kapvay, 27 Iressa tab, 21 Katerzia Susp, 34 Isentress, 18 Kazano tablet, 44 isometheptene/dichloralphenazone/ apap, 27 Keflex, 18 isoniazid, 18 Kenalog Spray, 40 Isopto Carpine, 52 Keppra, 27 Isordil Titradose Tabs, 34 Keppra XR, 27 isosorbide dinitrate, 34 Kerydin, 40 xiii Index

Kesimpta Inj, 44 Lanoxin, 34 ketoconazole cream, 40 lansoprazole cap, 47 ketoconazole shampoo, 40 lansoprazole solutab, 47 ketoconazole tab, 18 lanthanum chewable tab, 57 ketoprofen, 27, 49 Lantus, 44 ketoprofen 25mg cap, 49 lapatinib, 21 ketoprofen ER, 49 Lasix, 34 ketorolac, 27, 49, 53 latanoprost, 53 ketorolac opth soln, 53 Latuda, 27 ketorolac sol tromethamine, 49 Lazanda, 27 Keveyis, 58 ledipasvir-sofosbuvir tablet 90-400mg, 18 Kevzara, 49 leflunomide, 49 Khedezla, 27 Lenvima, 21 Kineret, 49 Lescol, 34 kionex suspension, 58 Letairis, 34 Kisqali, 21 letrozole, 21 Kitabis Pak, 55 leucovorin calcium, 21 Klaron, 40 Leukeran, 21 Klonopin, 27 leuprolide, 21 Klor-Con, 57 levalbuterol neb, 55 Koate-DVI, 34 Levalbuterol tartrate HFA, 55 Kogenate FS, 34 Levaquin, 18 Kombiglyze XR, 44 Levemir, 44 Korlym tablet, 44 levetiracetam, 27 Koselugo, 21 levetiracetam ER, 27 Krintafel, 18 Levitra, 57 Kristalose Pak, 47 levo-T tab, 44 Kuvan, 55 levobunolol, 53 Kynamro, 34 levocarnitine, 44 Kynmobi Kit Titration, 27 levofloxacin, 18 Kynmobi Mis, 27 levonorgestrel-ethinyl estradiol, 51 levonorgestrel/my way/next dose, 51 L levorphanol, 27 levothyroxine cap, 44 labetalol HCl, 34 levothyroxine tab, 44 lactulose pak, 47 Levoxyl, 44 lactulose soln, 47 Lexapro, 27 Lamictal, 27 Lexette Foam 0.05%, 40 Lamictal ODT, 27 Lexiva, 18 Lamictal XR, 27 Lialda, 47 Lamisil Tabs, 18 Librax, 27 lamivudine 100mg tab, 18 Licart Dis 1.3%, 27 lamivudine tablet 150mg, 300mg, 18 lidocaine patch 5%, 40 lamivudine/ zidovudine, 16, 18 lidocaine solution, gel, ointment, 40 lamotrigine, 27 Lidoderm, 40 lamotrigine ER, 27 linezolid, 18 lamotrigine ODT, 27 Linzess, 47 Lampit tab, 18 liothyronine, 44 xiv Index

Lipitor, 35 Lyllana Dis, 51 Lipofen, 35 Lynparza, 21 lisinopril, 35 Lyrica Cap, 27 lisinopril/HCTZ, 35 Lyrica CR, 27 lithium carbonate, 27 Lyrica soln, 27 lithium carbonate ER, 27 Lysodren, 21 Lithobid, 27 Lysteda, 51 Livalo, 35 Lyumjev Inj/ Pen, 44 Lo Loestrin FE, 51 Locoid, 40 M Locoid Lipocream, 40 Lodine, 27 Macrodantin, 18 Lodosyn, 27 Malarone, 18 Loestrin, 51 malathion lotion, 40 Lokelma PAK, 57 maprotiline, 27 Lomaira, 27 Marinol, 47 Lomotil, 47 Matulane, 21 Lonhala Magnair Soln, 55 Mavenclad pak, 21 Lonsurf, 21 Mavyret, 18 loperamide, 47 Maxalt, Maxalt-MLT, 27 Lopid, 35 Maxitrol, 53 lopinavir/ ritonavir, 18 Maxzide, 35 Lopressor HCT, 35 Mayzent tablet, starter pak, 27 Loprox, 40 meclizine, 47 lorazaepam concentrate, 27 meclofenamate, 28, 49 lorazepam, 27 Medrol, 44 Lorbrena, 21 medroxyprogesterone acetate, 51 Lortab, 27 medroxyprogesterone acetate tab, 51 Lorzone, 49 Medtronic Continuous Glucose Monitor Guardian losartan, 35 Transmitter, 44 losartan-HCTZ, 35 Medtronic Continuous Glucose Monitor Enlite, Loseasonique, 51 MiniMed Guardian Sensors, 44 Lotemax [SM], 53 Medtronic Continuous Glucose Monitor Receiver, Lotensin, 35 44 loteprednol susp 0.5%, 53 mefloquine, 18 Lotrel, 35 Megace, 21 Lotrisone, 40 megestrol, 21 Lotronex, 49 megestrol acetate, 21 lovastatin, 35 Mekinist, 21 Lovaza, 35 Mektovi, 21 Lovenox, 35 meloxicam cap, 49 loxapine, 27 meloxicam tab, 49 Lucemyra, 27 melphalan, 21 Luliconazole cream, 18 memantine, 28 Lumigan, 53 memantine ER, 28 Lunesta, 27 Menopur, 51 Luxiq, 40 meperidine HCl, 28 Luzu, 40 Mephyton, 57 xv Index

meprobamate, 28 mexiletine HCl, 35 Mepron, 18 Miacalcin, 49 mercaptopurine, 21 Micardis, 35 mesalamine, 47 Micardis HCT, 35 mesalamine DR, 47 miconazole-zinc ointment, 40 mesalamine rectal susp, 47 Microzide, 35 Mesnex, 21 midodrine HCl, 58 Mestinon syrup, 28 Midrin, 28 Mestinon tablet, 28 miglitol, 44 metaproterenol, 55 miglustat, 58 metaxalone, 49 Migranal, 28 metformin, 42, 44 Millipred, 44 metformin ER (generic for Glucophage XR), 44 Minastrin 24 FE, 51 metformin HCL 500mg/5ml soln, 44 Minipress, 35 metformin/ glyburide, 44 minitran, 35 methadone, 28 Minivelle, 51 methamphet-, 28 Minocin, 18 methazolamide, 53 minocycline caps, 18 methenamine hippurate, 18 minocycline ER cap, 18 methimazole, 44 minocycline ER tablet, 18 Methitest Tab, 44 minocycline tablet, 18 methocarbamol, 28, 49 Minolira, 18 methotrexate tab, 21 minoxidil, 35 methoxsalen, 40 Mirapex, 28 methyldopa, 35 Mirapex ER, 28 Methylin, 28 Mircette, 51 methylphenidate, 28 mirtazapine, 28 methylphenidate ER, 28 Mirvaso, 40 methylphenidate ER (CD), 28 misoprostol, 47, 49 methylphenidate ER (LA), 28 Mitigare, 49 methylphenidate ER(XR), 28 Mobic, 49 methylprednisolone, 44 modafinil, 28 methyltestosterone, 44 moderiba, 18 metoclopramide, 47 moexipril, 35 metolazone, 35 moexipril/HCTZ, 35 Metopirone, 58 molindone hcl, 28 metoprolol succinate, 35 mometasone cream, ointment, solution, 40 metoprolol tartrate, 35 mometasone furoate nasal spray, 42 metoprolol tartrate/ HCT, 35 Mondoxyne NL 75mg cap, 18 MetroCream, 40 Monoclate-P, 35 MetroGel, 40, 51 Mononine, 35 Metrogel vaginal, 51 montelukast sodium, 55 MetroLotion, 40 Monurol Pak Granules, 18 metronidazole, 18, 40, 51 MorphaBond ER, 28 metronidazole cream, lotion, gel, 40 morphine IR, 28 metronidazole vaginal gel, 51 morphine sulfate ER, 28 metyrosine, 44 morphine suppositories, 28 Mevacor, 35 Motegrity tab, 47 xvi Index

Movantik, 47 Narcan 4mg/ actuation spray, 28 MoviPrep Solution RECONSTITUTED 100 GM Nardil, 28 Oral, 47 Nascobal, 57 Moxatag, 18 Nasonex, 42 Moxeza, 53 Natazia, 51 moxifloxacin hcl, 18 nateglinide, 44 moxifloxacin ophthalmic soln, 53 Natesto, 44 MS Contin, 28 Natpara, 44 Mulpleta, 35 Natroba, 40 Multaq, 35 Nayzilam, 28 multivitamin with fluoride drops, tabs, 57 Nebupent INH, 19 mupirocin cream, ointment, 40 nebusal nebulization solution, 57 Muse, 57 nefazodone, 28 Myalept, 44 neomycin/polymyxin B/dexamethasone, 53 Myambutol, 18 neomycin/polymyxin/hydrocortisone, 42 Mycapssa cap, 44 Neoral, 21–22 Mycobutin, 18 Neosporin soln, 53 mycophenolate, 21 Nerlynx, 21 mycophenolic acid, 21 Nesina tablet, 44 Mydayis, 28 Nestabs One, 57 Mydriacyl, 53 Neurontin, 28 Myfortic, 21 Neurontin soln, 28 Myleran, 21 Nevanac Susp 0.1%, 53 Myrbetriq, 57 nevirapine, 19 Mysoline, 28 nevirapine ER, 19 Mytesi, 19 Nexavar, 21 Nexium capsule, 47 N Nexium packets, 47 Nexletol, 35 nabumetone, 28, 49 Nexlizet, 35 nadolol, 35 niacin ER, 35 nadolol-bendroflume thiazide, 35 Niaspan, 35 naftifine cream, gel, 40 nicardipine, 35 Naftin, 40 Nifedical XL, 35 Nalfon, 28, 49 nifedipine, 35 Nalocet, 28 nifedipine ER, 35 Naloxone Injection 2mg, 28 Nilandron, 21 naltrexone 50mg, 28 nilutamide, 22 Namenda [XR], 28 nimodipine, 35 Namzaric, 28 ninjacof-XG liquid, 28 Naprelan, 49 Ninlaro, 22 Naprosyn, 49 nisoldipine ER, 35 Naprosyn susp, 49 nitazoxanide, 19 naproxen sodium, 49 nitisinone, 58 naproxen sodium DR, 49 Nitro-Bid, 35 naproxen sodium ER, 49 Nitro-Dur, 35 naproxen sodium susp, 49 Nitro-Time cap, 35 naratriptan, 28 nitrofurantoin macrocrystals, 19 xvii Index

nitrofurantoin susp, 19 Nutropin AQ, 45 nitroglycerin ER, 35 Nuvaring, 51 nitroglycerin patches, 35 Nuvigil, 28 nitroglycerin SL, 35 Nuwiq, 35 nitroglycerin spray, 35 Nuzyra, 19 Nitrolingual Spray, 35 Nymalize Sol, 35 Nitromist, 35 nystatin/ triamcinolone cream, ointment, 40 Nitrostat SL, 35 Nityr, 58 O nizatidine solution, 47 Nizoral shampoo, 40 OB Complete, 51 Nocdurna SL, 35 Obizur, 35 Noctiva Emulsion, 44 Obredon, 55 Non Preferred Diabetic Meters, 44 Ocaliva, 58 Norditropin, 44 Ocufen, 53 norethin-ethynil-fer cap 1/ 20, 51 Ocuflox, 53 norethindrone, 51 Odactra SL, 55 norethindrone acetate, 51 Odomzo, 22 norethindrone-ethinyl estradiol, 51 Ofev, 55 norethindrone-mestranol, 51 ofloxacin, 42, 53 Norgesic Forte Tab, 49 ofloxacin otic, 42 norgestimate-ethinyl estradiol, 51 olanzapine, 28 norgestrel-ethinyl estradiol, 51 olanzapine ODT, 28 Noritate, 40 olanzapine/ fluoxetine hcl, 28 Norpace, 35 olmesartan medoxomil, 35 Norpramin, 28 olmesartan/amlodipine/hctz, 35 Northera, 35 olmesartan/hctz, 35 nortriptyline, 28 olopatadine, 42, 53 nortriptyline soln, 28 olopatadine hcl, 53 Norvasc, 35 Olumiant, 49 Norvir powder, 19 Olux [E], 40 Norvir tablet, 19 omega-3 acid ethyl esters, 36 Nourianz, 28 omeprazole, 47 Novarel 5000 units, 58 Omnaris, 42 Novarel 10000 units, 58 Omnipod 5 Pack, 45 Novoeight, 35 Omnipod Dash 5 Pack, 45 Novolin, 44–45 Omnipod Dash System, 45 Novolin R, 45 Omnipod Starter Kit, 45 Novolog, 45 Omnipred, 53 NovoSeven RT, 35 Omnitrope, 45 Noxafil, 19 ondansetron HCl, 47 Nubeqa, 22 One Touch Glucometer, 45 Nucala Soln, 55 One Touch Test Strips, 45 Nucynta, 28 Onexton, 40 Nucynta ER, 28 Onfi, 28 Nulytely, 47 Onfi Susp, 28 Nuplazid, 28 Ongentys, 28 Nurtec chw 75mg ODT, 28 Onglyza, 45 xviii Index

Onmel, 19 Oxtellar XR, 29 Onureg, 22 oxybutynin [XR], 57 Onzetra Xsail, 28 oxybutynin syrup, 57 Opana, 28 oxycodone ER tablet, 29 Opana ER, 28 oxycodone IR, 29 Opsumit, 36 oxycodone/ acetaminophen, 29 Oracea, 19 oxycodone/ aspirin, 29 Oralair, 55 oxycodone/ ibuprofen, 29 Orap, 29 oxycodone/APAP 2.5-300mg, 5-300mg, 10-300mg Orapred ODT, 45 tab, 29 Orencia, 49 OxyContin, 29 Orenitram, 36 oxymorphone ER, 29 Orfadin, 58 oxymorphone IR, 29 Orgovyx, 22 Ozempic, 45 Oriahnn cap, 51 Ozobax Soln, 49 Orilissa, 45 Orkambi tablet/ packet, 19 P Orladeyo, 58 orlistat, 47 Pacerone, 36 orphenadrine ER, 49 Palforzia cap/ powder, 55 orphenadrine-asa-caffeine, 49 paliperidone er tablet, 29 Orphengesic Forte Tab, 49 Palynziq, 58 Ortho Cyclen, 51 Pamelor, 29 Ortho Micronor, 51 Pancreaze, 47 Ortho Novum, 51 pancrelipase EC/ SA, 47 Ortho Tri-Cyclen, 51 Pandel, 40 Ortho Tri-Cyclen Lo, 51 pantoprazole, 47 Ortikos ER Cap, 22 pantoprazole pak, 47 oseltamivir caps/ soln, 19 paricalcitol, 45 Oseni, 45 Parlodel, 29 Osmolex ER, 29 Parnate, 29 Osmoprep tab, 47 paroxetine, 29 Otezla, 49 paroxetine ER, 29 Otrexup, 49 Patanase, 42 Ovide, 40 Patanol, 53 Ovidrel, 51 Paxil, 29 Oxandrin, 45 Paxil CR, 29 oxandrolone, 45 PEG 3350 & electrolytes, 47 oxaprozin, 29, 49 peg-kcl-nacl-nasulf-na asc-c soln reconstituted, 47 Oxaydo, 29 Pegasys, 19 oxazepam, 29 PegIntron, 19 Oxbryta, 58 Pemazyre, 22 oxcarbazepine susp, 29 penicillamine capsule, 58 oxcarbazepine tab, 29 penicillamine tablet, 58 Oxervate soln 200mcg/ ml, 53 penicillin v potassium tablet, 19 oxiconazole nitrate, 40 Penlac, 40 Oxistat, 40 Pennsaid, 49 Oxsoralen Ultra, 40 pentamidine INH, 19 xix Index

Pentasa, 47 Praluent, 36 pentazocine-naloxone, 29 pramipexole, 29 pentoxifylline ER, 36 pramipexole ER, 29 Pepcid tabs, suspension, 47 Prandin, 45 Percocet, 29 prasugrel, 36 perindopril, 36 Pravachol, 36 permethrin, 40 pravastatin, 36 perphenazine, 29 praziquantel, 19 Persantine, 36 prazosin, 36 Pertzye, 47 Precision Glucometer, 45 phendimetrazine tartrate, 29 Precision XTRA Test Strips, 45 phenelzine, 29 Precose, 45 phenobarbital, 29 Pred-Forte, 53 phenoxybenzamine hcl, 36 prednicarbate ointment, 40 phentermine hcl, 29 prednisolone, 45, 53 Phenytek, 29 prednisolone acetate, 53 phenytoin, 29 prednisolone sodium phosphate, 53 PhosLo, 58 prednisolone/ sodium sulfacetamide, 53 phospha, 58 prednisone, 22 Phospholine Iodide, 53 prednisone therapy pack/ solution/ concentrate, 22 phytonadione tab, 57 pregabalin cap, 29 Pifeltro, 19 pregabalin soln, 29 pilocarpine, 42, 53 Pregnyl, 58 pilocarpine HCl, 42 Prelone, 45 pimecrolimus cre 1%, 40 Premarin, 51 pimozide, 29 Premarin vaginal cream, 51 pindolol ER, 36 Premphase, 51 pioglitazone, 42, 45 Prempro, 51 pioglitazone/ glimepiride, 45 Pretomanid, 19 Piqray, 22 Prevacid caps, 47 piroxicam, 29, 49 Prevacid SoluTab, 47 Plan B One-Step, 51 Prevalite, 36 Plaquenil, 19 Prevymis, 19 Plavix, 36 Prezista, 19 Plegridy, 29 prilocaine/ lidocaine, 40 Plenvu Soln, 47 Prilosec packets, 47 podofilox soln, 40 primidone, 29 polymyxin B/ neo/gramicidin, 53 Primlev, 29 polymyxin B/neo/bacitracin, 53 Prinivil, 36 Polytrim, 53 Pristiq, 29 Pomalyst, 22 ProAir Digihaler, 55 posaconazole, 19 ProAir HFA, 54–55 Potaba, 58 ProAir RespiClick, 55 potassium bicarbonate/ potassium citrate probenecid, 48–49 effervescent, 57 Procardia, 36 potassium chloride, 57 Procardia XL, 36 potassium citrate ER, 57 Procentra 1mg/ml, 29 Pradaxa, 36 prochlorperazine suppository, 47 xx Index

prochlorperazine tabs, 47 Qmiiz ODT, 29 Proctofoam HC, 40 Qnasl, 42 Procysbi, 45 Qsymia ER, 29 Profilnine, 36 Qtern, 45 progesterone, micronized, 51 Qualaquin, 19 Proglycem Susp, 45 Quartette, 51 Prograf cap/ packets, 22 quazepam, 29 Prolate tab, 29 Qudexy XR, 29 Prolensa sol 0.07%, 53 Questran, 36 Promacta, 36 Questran Light, 36 promethazine, 55 quetiapine ER, 29 promethazine/ codeine, 55 quetiapine fumarate, 29 promethazine/ , 55 Quflora, 57 promethazine/ phenylephrine, 55 Quillichew ER, 29 promethegan supp, 29 Quillivant XR, 29 Prometrium, 51 quinapril, 36 propafenone, 36 quinapril/HCTZ, 36 propafenone ER, 36 quinine sulfate, 19 proparacaine, 53 Qvar, 56 propranolol, 36 propranolol ER, 36 R propranolol/ HCTZ, 36 propylthiouracil, 45 rabeprazole DR tab 20mg, 47 Proscar, 57 Rabeprazole Sprinkle Cap 10mg, 47 Protonix, 47 Ragwitek, 56 Protonix packets, 47 raloxifene, 50–51 Protopic, 22 raloxifene hcl, 50 Proventil HFA, 54–55 ramelteon, 29 Provera, 50–51 ramipril, 36 Provigil, 29 Ranexa, 36 Prozac, 29 ranitidine 300mg, 48 Prudoxin cream 5%, 41 ranolazine tab ER, 36 Pulmicort Flexhaler, 56 Rapaflo, 57 Pulmicort Respules, 56 Rapamune 1mg/ml Sol, 22 PulmoSal nebulization solution, 57 Rapamune tab, 22 Pulmozyme, 56 rasagiline, 30 Purixan, 22 Rasuvo, 50 Pylera, 47 Rayaldee, 57 pyridostigmine, 29 Rayos, 45 pyridostigmine soln, 29 Razadyne, 30 pyrimethamin, 19 Razadyne ER, 30 Rebetol, 56 Q Rebif Rebidose, 30 Rebinyn Soln, 36 Qbrelis, 36 Recombinate, 36 Qbrexza Pad 2.4%, 41 RediTrex Inj, 22 Qdolo Soln 5mg/ml, 29 Regimex, 30 Qinlock tab, 22 Reglan, 48 xxi Index

Regranex gel, 45 ritonavir, 18–19 Relafen, 30 rivastigmine, 30 Relafen DS, 30 Rixubis, 36 Relenza, 19 rizatriptan benzoate, 30 Relistor, 48 Robaxin, 30, 50 Relpax, 30 Rocaltrol capsules, 45 Remeron, 30 Rocklatan Soln 0.02-0.005%, 53 Remeron SolTab, 30 ropinirole, 30 Renagel, 58 ropinirole ER, 30 Renvela, 58 rosuvastatin, 36 repaglinide, 45 Roxicodone, 30 Repatha, 36 Roxybond, 30 Requip, 30 Rozerem, 30 Requip XL, 30 Rozlytrek, 22 Rescula, 53 Rubraca, 22 RespiClick, 54–55 Ruconest, 58 Restasis, 53 rufinamide susp 40mg/ml, 30 Restoril, 30 Rukobia, 19 Retevmo cap, 22 Ruzurgi, 58 Retin-A, 41 Rybelsus, 45 Retin-A Micro, 41 Ryclora, 56 Retrovir, 19 Rydapt, 22 Revatio, 36 Rytary, 30 Revlimid, 22 Rythmol, 36 Rexulti, 30 Rythmol SR, 36 Reyataz, 19 Ryvent, 56 Reyvow, 30 Rezira, 56 S Rhofade 1% cream, 41 Rhopressa Soln 0.02%, 53 Sabril, 30 Riastap, 36 Safyral, 51 Ribasphere Ribapak 200mg & 400mg/ 400mg & Saizen, 45 600mg, 19 Salagen, 42 ribavirin, 42 Samsca, 36 Ridaura, 58 Sandimmune, Neoral, 22 rifabutin, 19 Saphris, 30 Rifadin, 19 sapropterin pow/ tab, 56 rifampin, 19 Saxenda, 30 Rilutek, 30 scopolamine patch, 48 riluzole, 30 Seasonique, 51 rimantadine, 19 Secuado Patch, 30 Rinvoq, 58 Seebri, 56 Riomet [ER] solution/ suspension 500mg/ 5ml, 45 Segluromet, 45 risedronate, 50 selegiline HCl, 30 risedronate DR, 50 selenium sulfide shampoo/lotion, 41 Risperdal, Risperdal M-Tab, 30 Selzentry, 19 risperidone, 30 Semglee Inj 100U/ ML, 45 Ritalin LA, 30 Semprex-D, 56 xxii Index

Sensipar, 45 Soolantra, 41 Serevent Diskus, 56 Soriatane, 41 Sernivo, 41 sotalol HCl, 36 Seroquel, 30 Sotylize soln, 36 Seroquel XR, 30 Sovaldi, 19 Serostim, 45 spinosad, 41 sertraline, 30 Spiriva, 56 sevelamer carbonate, 58 spironolactone, 36 Sevenfact Inj, 36 spironolactone/ HCTZ, 36 Seysara, 19 Sporanox, 19 SFRowasa enema, 48 Sprix Nasal Spray, 30 Signifor, 45 Sprycel, 22 Siklos, 22 SSKI Solution, 19 sildenafil citrate 20mg tab, 10mg/ ml susp, 36 Stalevo, 30 sildenafil citrate 25mg, 50mg, 100mg, 36 Starlix, 45 Silenor, 30 stavudine, 19 Siliq, 41 Staxyn, 57 silodosin, 50 Steglatro, 45 Silvadene, 41 Steglujan, 45 silver sulfadiazine, 41 Stelara, 50 Simbrinza Susp 1-0.2%, 53 Stendra, 57 Simponi, 50 Stimate, 36 simvastatin, 34, 36 Stiolto Respimat, 56 simvastatin susp, 36 Stivarga, 22 Sinemet, 30 Strattera, 30 Sinemet CR, 30 Strensiq, 58 Singulair, 56 Striant buccal system, 45 sirolimus tab/ soln, 22 Stribild, 19 Sirturo, 19 Striverdi Respimat Aer Solution, 56 Sitavig, 19 Stromectol, 19 Sivextro, 19 Suboxone Sublingual Film, 30 Skelaxin, 50 Subsys, 30 Sklice Lot 0.5%, 19 Sucraid Solution 8500 unit/ ml, 58 Skyrizi Inj, 41 sucralfate tabs, 48 Slynd, 51 Sular, 36 sodium chloride inhalation, 56 sulconazole cream/solution, 41 sodium fluoride chew tab, 57 sulfacetamide, 41, 53 sodium phenylbutyrate tab, 58 sulfamethoxazole/tmp, 19 sodium sulfacetamide suspension, 41 Sulfamylon, 41 sofosbuvir-velpatasvir tablet 400-100mg, 19 sulfasalazine, 48 Solaraze, 41 sulindac, 30, 50 solifenacin, 57 sumatriptan, 30 Soliqua, 45 sumatriptan/ naproxen, 30 Solodyn, 19 Sunosi, 30 Solosec GRA, 19 Suprax Susp 100mg/5ml, 200mg/5ml, 19 Soma, 50 suspension IM, 51 Somavert, 45 Sustiva, 19 Sonata, 30 Sutab, 48 xxiii Index

Sutent, 22 Taytulla, 51 Sylatron, 30 tazarotene cream 0.1%, 41 Symbicort, 56 Tazorac cream/ gel, 41 Symbyax, 30 Taztia XT, 36 Symdeko, 56 Tazverik 200mg, 22 Symfi, 19 Tecfidera, 30 Symfi-Lo, 19 Technivie, 20 Symjepi Inj, 56 Tegretol [XR], 30 Symlin, 45 Tegretol susp, 30 Sympazan Film, 30 Tegsedi, 59 Symproic, 48 Tekturna/ Tekturna HCT, 36 Symtuza, 19 telmisartan, 36 Synalar, 41 telmisartan-amlodipine, 36 Synarel, 51 telmisartan/ hydrochlorothiazide, 36 Syndros, 48 temazepam, 30 Synjardy, 45 Temixys, 20 Synjardy XR, 45 Temodar, 22 Synthroid, 45 Temovate, 41 Syprine, 58 temozolomide, 22 tenofovir, 20 T Tenoretic, 37 Tenormin, 37 Tabloid, 22 terazosin, 57 Tabrecta tab, 22 terbinafine tabs, 20 Taclonex, 41 terbutaline sulfate tabs, 56 tacrolimus, 22 terconazole cream, 51 tadalafil (generic Adcirca), 36 Teriparatide inj, 45 tadalafil (generic Cialis), 36 Tessalon Perles, 56 Tafinlar, 22 Testim Gel, 45 Tagrisso, 22 testosterone gel 1%, 1.62%, 45 Takhzyro Inj, 58 testosterone gel 10mg/act (2%), 44 Talicia, 19 testosterone solution 30mg/act, 44 Taltz Autoinjector, 41 tetrabenazine, 30 Talzenna, 22 Thalomid, 22 Tamiflu, 19 Theo-24, 56 tamoxifen 10mg, 22 Theochron, 56 tamsulosin, 56–57 theophylline extended release, 56 Tanzeum, 45 theophylline soln, 56 Tapazole, 45 thioguanine, 22 Tarceva, 22 Thiola [EC], 56 Targadox, 19 thioridazine, 30 Targretin cap, 22 thiothixene, 30 Targretin gel, 41 tiadylt ER, 37 Tarka, 36 tiagabine hcl, 30 Tasigna, 22 Tiazac, 37 Tasmar, 30 Tibsovo, 22 tavaborole soln 5%, 41 ticlopidine HCl, 37 Tavalisse, 58 Tigan, 48 xxiv Index

Tiglutik Susp, 30 Transderm-Scop patch, 48 Tikosyn, 37 Tranxene T, 31 timolol maleate tab, 37 tranycypromine sulfate, 31 timolol ophth, 53 Travatan Z, 53 Timoptic, 53 travoprost, 53 Timoptic XE, 53 trazodone, 31 Tindamax, 20 Trelegy Ellipta, 56 tinidazole, 20 Tremfya, 41 Tirosint, 45 Tresiba, 46 Tivicay PD, 20 tretinoin caps, 22 Tivorbex, 30 tretinoin gel, cream, 41 tizanidine, 50 tretinoin microspheres gel, 41 Tobi, 20 Tretten, 37 Tobradex, 53 Trexall tab, 22 tobramycin nebulization soln., 20 Treximet, 31 tobramycin ophthalmic, 53 Trezix, 31 tobramycin- dexamethasone, 53 Tri-norinyl, 51 Tobrex, 53 Tri-Vi-Flor, Poly-Vi-Flor with and without iron, 58 Tofranil, 30 triamcinolone acetonide, 41 tolbutamide, 46 triamcinolone oint 0.05%, 41 tolcapone, 30 triamterene cap, 37 tolmetin, 30, 50 triamterene/ HCTZ, 37 tolmetin sodium, 30 Trianex, 41 Tolsura, 20 triazolam, 31 tolterodine tartrate, 57 Tribenzor, 37 tolterodine tartrate LA, 57 Tricor, 37 tolvaptan 15mg tab, 37 triderm cream, 41 tolvaptan 30mg tab, 37 trientine, 59 Topamax, 31 trifluoperazine, 31 Topamax Sprinkle Capsules, 31 trifluridine, 53 Topicort, 41 trihexyphenidyl, 31 topiramate, 31 Trijardy XR, 46 topiramate sprinkle cap, 31 Trikafta, 20 Toprol XL, 37 Trileptal Susp, 31 toremifene tab, 22 Trileptal Tab, 31 torsemide, 37 Trilipix, 37 Tosymra Nasal Solution, 31 trimethobenzamide, 48 Toujeo Solostar, 46 trimethoprim sulfate/ polymyxin B, 53 Toviaz, 50 trimethoprim tab, 53 Tracleer, 37, 56 trimipramine, 31 Tradjenta tablet, 46 Trintellix, 31 tramadol, 31 Triumeq, 20 tramadol ER (biphasic) tablet, 31 Trizivir, 20 tramadol ER cap, 31 Trokendi XR, 31 tramadol ER tablet, 31 tropicamide, 53 tramadol/ acetaminophen, 31 trospium chloride, 57 trandolapril, 37 Trulance, 48 trandolapril/ verapamil ER, 37 Trulicity, 46 xxv Index

Trusopt, 53 vancomycin, 20 Truvada, 20 Vandazole, 51 trymine CG liquid, 31 vardenafil, 57 Tudorza Pressair, 56 vardenafil ODT, 57 Tukysa, 22 Varubi, 48 Turalio, 22 Vascepa, 37 Tussicap, 56 Vaseretic, 37 Tuxarin ER tabs, 56 Vasotec, 37 Tuzistra XR, 56 Vecamyl, 37 Twirla Dis, 51 Vectical, 41 Twynsta, 37 Veltin, 41 Tykerb, 22 Vemlidy, 20 Tylenol w/ Codeine, 31 Venclexta, 22 Tymlos, 46 venlafaxine, 31 Tyvaso, 37 venlafaxine ER, 31 Ventavis, 37 U Ventolin HFA, 54, 56 verapamil HCl, 37 Ubrelvy, 31 verapamil HCl ER, 37 Uceris, 46 Verdeso, 41 Uloric, 50 Verelan ER, PM, 37 Ultracet, 31 Veripred soln 20mg/5ml, 46 Ultram, 31 Verzenio, 22 Ultravate, 41 Vesicare, 57 Unithroid, 46 Vfend, 20 Upneeq Soln, 53 Viagra, 57 Uptravi, 37 Viberzi, 48 Urecholine, 57 Vibramycin, 20 Urocit-K, 57 Victoza, 46 Uroxatral, 57 Videx EC, 20 ursodiol, 48 Viekira Pak, 20 Utibron Neohaler, 56 Viekira XR, 20 vigabatrin, 31 V vigadrone, 31 Vigamox, 53 V-GO, 59 Viibryd, 50 Vagifem, 51 Vimpat tab, soln, 31 valacyclovir tab, 20 Viokace, 48 Valchlor, 22 Viramune, 20 Valcyte, 20 Viramune XR, 20 valganciclovir, 20 Virazole, 42 Valium, 31 Viread, 20 valproic acid, 31 Viroptic, 53 valsartan, 32, 37 Vistaril, 56 valsartan/ hydrochlorothiazide, 37 Vitrakvi, 22 Valtoco, 31 Vituz, 56 Valtrex, 20 Vivelle Dot, 51 Vanatol S/LQ, 31 Vivlodex, 31 xxvi Index

Vizimpro, 22 Xifaxan 200mg, 20 Vogelxo, 46 Xifaxan 550mg, 20 Voltaren Gel, 50 Xigduo XR, 46 Vonvendi, 37 Xiidra, 54 voriconazole, 20 Ximino ER, 20 Vosevi, 20 Xodol, Norco, 31 VoSpire ER, 56 Xofluza therapy pack, 20 Votrient, 22 Xolegel, 41 Vraylar, 31 Xopenex, 56 Vumerity, 59 Xopenex HFA, 56 Vusion, 41 Xospata, 22 Vyleesi, 51 Xpovio Pak, 22 Vyndaqel, Vyndamax, 37 Xtampza ER, 31 Vytorin, 37 Xtandi, 22 Vyvanse, 31 xulane, 51 Vyzulta Soln 0.024% OP, 54 Xultophy, 46 Xuriden, 59 W Xyntha, 37 Xyosted Soln, 46 Wakix, 31 Xyrem, 31 warfarin, 37 Xywav Soln, 31 Welchol, 37 Wellbutrin SR, 31 Y Wellbutrin XL, 31 Wilate, 37 Yasmin, 51 Winlevi Cream 1%, 41 YAZ, 52 wixela inhub aer, 56 Yonsa, 22 Wynzora Cream, 41 Yupelri Soln, 56 yuvafem, 52 X Z Xadago, 31 Xalatan, 54 Z-Tuss AC, 56 Xalkori, 22 zafirlukast, 56 Xanax, 31 zaleplon, 31 Xanax XR, 31 Zanaflex, 50 Xarelto, 37 Zantac, 48 Xatmep, 22 Zarontin, 31 Xcopri pak/tab, 31 Zavesca, 59 Xeljanz [XR], 50 Zcort 7-day tab, 46 Xeloda, 22 Zegerid packets, 48 Xelpros Emulsion 0.005%, 54 Zejula, 22 Xenazine, 31 Zelboraf, 22 Xenical, 48 Zelnorm, 48 Xenleta, 20 Zembrace Symtouch, 31 Xepi Cream 1%, 20 Zemplar, 46 Xermelo, 48 Zenpep, 48 Xhance, 42, 56 Zenzedi, 31 xxvii Index

Zepatier, 20 Zykadia, 23 Zeposia, 50 Zyloprim, 50 Zerit, 20 Zymaxid, 54 Zerviate Drops 0.24%, 54 Zypitamag, 37 Zestoretic, 37 Zyprexa, 32 Zestril, 37 Zyprexa Zydis, 32 Zetia, 37 Zytiga, 23 Zetonna, 42 Zyvox, 20 Ziac, 37 Ziagen, 20 Ziana, 41 zidovudine, 16, 18, 20 zileuton ER 600mg, 56 Zilxi Aer, 41 Zioptan, 54 ziprasidone, 31 Zipsor, 50 Zithromax, 20 Zmax, 20 Zocor, 37 Zofran, 48 Zohydro ER, 31 Zolinza, 22 zolmitriptan, 31 Zoloft, 31 zolpidem tartrate, 31 zolpidem tartrate ER, 31 zolpidem tartrate SL, 31 Zomacton, 46 Zomig, 31 Zonalon cream 5%, 41 Zonegran, 32 zonsinamide, 32 Zorbtive, 48 Zortress, 21–22 Zorvolex, 32 Zovirax, 20, 41 Zovirax cream, 41 Zovirax oint, 41 Ztlido Patch, 41 Zubsolv, 32 Zuplenz, 48 Zurampic 200mg, 50 Zutripro, 56 Zyban, 32 Zydelig, 22 Zyflo 600mg tab, 56 Zyflo CR 600mg, 56 xxviii AmeriHealth Select Drug Program Formulary offered by: AmeriHealth HMO, Inc.

7/21 AHPA