2020 Standard Comprehensive Formulary

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Medicare Plus BlueSM Group PPO Prescription BlueSM Group PDP 20 2020 Standard Enhanced 20 Comprehensive Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This formulary was updated on December 1, 2020. For more recent information or other questions, please contact us, Medicare Plus Blue Group PPO and Prescription Blue Group PDP Customer Service, at 1‑866‑684‑8216 or, for TTY users 711, Monday through Friday, 8:30 a.m. to 5 p.m. Eastern time. From October 1 through March 31, hours are from 8 a.m. to 9 p.m. Eastern time, seven days a week, or visit www.bcbsm.com/medicare.

When visiting your doctor(s), please bring your personal drug list TIP and this 2020 Blue Cross Drug List with you.

Updated: 12/01/2020 Formulary 20163, Version 21 www.bcbsm.com/medicare Medicare Advantage Plans Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield. When it refers to “plan” or “our plan,” it means Medicare Plus Blue Group PPO or Prescription Blue Group PDP. This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year. What is the Medicare Plus Blue Group PPO find information in the section below entitled and Prescription Blue Group PDP “How do I request an exception to the Medicare Standard Enhanced Formulary? Plus Blue Group PPO and Prescription Blue Group PDP Standard Enhanced Formulary?” A formulary is a list of covered drugs selected by Medicare Plus Blue Group PPO and Prescription • Drugs removed from the market. If the Food and Blue Group PDP in consultation with a team of health Drug Administration deems a drug on our formulary care providers, which represents the prescription to be unsafe or the drug’s manufacturer removes the therapies believed to be a necessary part of a quality drug from the market, we will immediately remove treatment program. Medicare Plus Blue Group PPO the drug from our formulary and provide notice to and Prescription Blue Group PDP will generally cover members who take the drug. the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a • Other changes. We may make other changes that Medicare Plus Blue Group PPO and Prescription Blue affect members currently taking a drug. For instance, Group PDP network pharmacy, and other plan rules we may add a generic drug that is not new to market are followed. For more information on how to fill your to replace a brand‑name drug currently on the prescriptions, please review your Evidence of Coverage. formulary or add new restrictions to the brand‑name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. Can the Formulary (drug list) change? If we remove drugs from our formulary, add prior Most changes in drug coverage happen on January 1, authorization, quantity limits and/or step therapy but we may add or remove drugs on the Drug List restrictions on a drug or move a drug to a higher during the year, move them to different cost-sharing cost-sharing tier, we must notify affected members tiers, or add new restrictions. We must follow Medicare of the change at least 30 days before the change rules in making these changes. becomes effective, or at the time the member requests a refill of the drug, at which time the Changes that can affect you this year: In the below member will receive a 31-day supply of the drug. cases, you will be affected by coverage changes during the year: – If we make these other changes, you or your prescriber can ask us to make an exception • New generic drugs. We may immediately remove and continue to cover the brand‑name drug for a brand‑name drug on our Drug List if we are you. The notice we provide you will also include replacing it with a new generic drug that will information on how to request an exception, appear on the same or lower cost-sharing tier and and you can also find information in the section with the same or fewer restrictions. Also, when below entitled “How do I request an exception adding the new generic drug, we may decide to to the Medicare Plus Blue Group PPO and keep the brand‑name drug on our Drug List, but Prescription Blue Group PDP Standard immediately move it to a different cost-sharing tier Enhanced Formulary?” or add new restrictions. If you are currently taking that brand‑name drug, we may not tell you in Changes that will not affect you if you are currently advance before we make that change, but we will taking the drug. Generally, if you are taking a drug on later provide you with information about the specific our 2020 formulary that was covered at the beginning change(s) we have made. of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as – If we make such a change, you or your prescriber described above. This means these drugs will remain can ask us to make an exception and continue to available at the same cost-sharing and with no new cover the brand‑name drug for you. The notice restrictions for those members taking them for the we provide you will also include information on remainder of the coverage year. how to request an exception, and you can also

i The enclosed formulary is current as of Are there any restrictions on my coverage? December 1, 2020. To get updated information about Some covered drugs may have additional requirements the drugs covered by Medicare Plus Blue Group PPO or limits on coverage. These requirements and limits and Prescription Blue Group PDP, please contact may include: us. Our contact information appears on the front and back cover pages. In the event of a mid‑year • Prior Authorization: Medicare Plus Blue non‑maintenance formulary change, we will send out an Group PPO and Prescription Blue Group PDP errata sheet to notify you of this change. require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Plus How do I use the Formulary? Blue Group PPO or Prescription Blue Group PDP There are two ways to find your drug within the before you fill your prescriptions. If you don’t formulary: get approval, Medicare Plus Blue Group PPO or Prescription Blue Group PDP may not cover Medical Condition the drug. The formulary begins on page 1. The drugs in this formulary are grouped into categories depending • Quantity Limits: For certain drugs, Medicare Plus on the type of medical conditions that they are Blue Group PPO and Prescription Blue Group PDP used to treat. For example, drugs used to treat limit the amount of the drug that Medicare Plus a heart condition are listed under the category, Blue Group PPO and Prescription Blue Group PDP “Cardiovascular Agents.” If you know what your will cover. For example, Medicare Plus Blue drug is used for, look for the category name in the Group PPO and Prescription Blue Group PDP list that begins on page 1. Then look under the provides 31 tablets per prescription for simvastatin. category name for your drug. This may be in addition to a standard one‑month or three‑month supply. Alphabetical Listing • Step Therapy: In some cases, Medicare Plus Blue If you are not sure what category to look under, you Group PPO and Prescription Blue Group PDP should look for your drug in the Index that begins on require you to first try certain drugs to treat your page Index 1. The Index provides an alphabetical list medical condition before we will cover another drug of all of the drugs included in this document. Both for that condition. For example, if Drug A and Drug brand‑name drugs and generic drugs are listed in B both treat your medical condition, Medicare Plus the Index. Look in the Index and find your drug. Next Blue Group PPO and Prescription Blue Group PDP to your drug, you will see the page number where may not cover Drug B unless you try Drug A first. If you can find coverage information. Turn to the page Drug A does not work for you, Medicare Plus Blue listed in the Index and find the name of your drug in Group PPO and Prescription Blue Group PDP will the first column of the list. then cover Drug B.

What are generic drugs? You can find out if your drug has any additional requirements or limits by looking in the formulary that Medicare Plus Blue Group PPO and Prescription begins on page 1. You can also get more information Blue Group PDP cover both brand‑name drugs about the restrictions applied to specific covered and generic drugs. A generic drug is approved by drugs by visiting our website. We have posted online a the FDA as having the same active ingredient as the document that explains our prior authorization and step brand‑name drug. Generally, generic drugs cost less therapy restrictions. You may also ask us to send you a than brand‑name drugs. copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

ii You can ask Medicare Plus Blue Group PPO or How do I request an exception to the Prescription Blue Group PDP to make an exception Medicare Plus Blue Group PPO and to these restrictions or limits or for a list of other, Prescription Blue Group PDP Standard similar drugs that may treat your health condition. Enhanced Formulary? See the section, “How do I request an exception to the You can ask Medicare Plus Blue Group PPO or Medicare Plus Blue Group PPO and Prescription Blue Prescription Blue Group PDP to make an exception Group PDP formulary?” on page iii for information to our coverage rules. There are several types of about how to request an exception. exceptions that you can ask us to make. What are over‑the‑counter drugs? • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at OTC drugs are non‑prescription drugs that are not a pre‑determined cost‑sharing level, and you would normally covered by a Medicare Prescription Drug Plan. not be able to ask us to provide the drug at a lower Medicare Plus Blue Group PPO and Prescription Blue cost‑sharing level. Group PDP pay for certain OTC drugs. Medicare Plus • You can ask us to cover a formulary drug at a lower Blue Group PPO and Prescription Blue Group PDP will cost‑sharing level if this drug is not on the specialty provide these OTC drugs at no cost to you. The cost to tier. If approved, this would lower the amount you Medicare Plus Blue Group PPO and Prescription Blue must pay for your drug. Group PDP of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC • You can ask us to waive coverage restrictions or drugs does not count for the coverage gap). limits on your drug. For example, for certain drugs, Medicare Plus Blue Group PPO and Prescription What if my drug is not on the Formulary? Blue Group PDP limit the amount of the drug that we will cover. If your drug has a quantity If your drug is not included in this formulary (list of limit, you can ask us to waive the limit and cover a covered drugs), you should first contact Customer greater amount. Service and ask if your drug is covered. Generally, Medicare Plus Blue Group PPO and If you learn that Medicare Plus Blue Group PPO and Prescription Blue Group PDP will only approve Prescription Blue Group PDP do not cover your drug, your request for an exception if the alternative drugs you have two options: included on the plan’s formulary, the lower cost‑sharing • You can ask Customer Service for a list of similar drug or additional utilization restrictions would not be as drugs that are covered by Medicare Plus Blue effective in treating your condition and/or would cause Group PPO and Prescription Blue Group PDP. you to have adverse medical effects. When you receive the list, show it to your doctor You should contact us to ask us for an initial coverage and ask him or her to prescribe a similar drug that decision for a formulary, tiering or utilization restriction is covered by Medicare Plus Blue Group PPO and exception. When you request a formulary, tiering or Prescription Blue Group PDP. utilization restriction exception, you should submit • You can ask Medicare Plus Blue Group PPO or a statement from your prescriber or physician Prescription Blue Group PDP to make an exception supporting your request. Generally, we must make and cover your drug. See below for information our decision within 72 hours of getting your prescriber’s about how to request an exception. supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

iii What do I do before I can talk to my doctor For more information about changing my drugs or requesting For more detailed information about your Medicare an exception? Plus Blue Group PPO or Prescription Blue Group PDP As a new or continuing member in our plan, you may prescription drug coverage, please review your Evidence be taking drugs that are not on our formulary. Or, you of Coverage and other plan materials. may be taking a drug that is on our formulary but your If you have questions about Medicare Plus Blue ability to get it is limited. For example, you may need Group PPO or Prescription Blue Group PDP, please a prior authorization from us before you can fill your contact us. Our contact information, along with the date prescription. You should talk to your doctor to decide we last updated the formulary, appears on the front and if you should switch to an appropriate drug that we back cover pages. cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor If you have general questions about Medicare to determine the right course of action for you, we may prescription drug coverage, please call Medicare at cover your drug in certain cases during the first 90 days 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day, you are a member of our plan. 7 days a week. TTY users should call 1‑877‑486‑2048. Or, visit http://www.medicare.gov. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply. If your prescription is written Medicare Plus Blue Group PPO for fewer days, we’ll allow refills to provide up to a and Prescription Blue Group PDP maximum 31-day supply of medication. After your first Standard Enhanced Formulary 31‑day supply, we will not pay for these drugs, even if The formulary that begins on the next page provides you have been a member of the plan less than 90 days. coverage information about the drugs covered by Medicare Plus Blue Group PPO and Prescription Blue If you are a resident of a long‑term care facility and Group PDP. If you have trouble finding your drug in the you need a drug that is not on our formulary or if your list, turn to the Index that begins on page Index 1. ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a The first column of the chart lists the drug name. 31‑day emergency supply of that drug while you pursue Brand‑name drugs are capitalized (e.g., ENTRESTO®) a formulary exception. and generic drugs are listed in lower‑case italics If you move into (or out of) a long‑term care facility, you (e.g., simvastatin). will continue to have access to your medications during The information in the Requirements/Limits column tells the transition. If needed, limits on early prescription you if Medicare Plus Blue Group PPO or Prescription refills will be waived to assure that your medications Blue Group PDP have any special requirements for are available through a new pharmacy provider when coverage of your drug. you are moving to or from a long‑term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at www.bcbsm.com/medicare/help/ forms‑documents.html.

iv Tier Descriptions Medicare Plus Blue Group PPO and Prescription Blue Group PDP Drug Tier Costs

Up to a 31‑day supply Up to a 90‑day supply**

Standard Preferred Standard Preferred Drug retail and retail and retail and retail and Tier Long-term Out-of Description standard preferred standard preferred care (LTC) network mail-order mail-order mail-order mail-order cost‑sharing cost‑sharing cost‑sharing cost‑sharing cost‑sharing cost‑sharing (in-network) (in-network) (in-network) (in-network) Preferred Tier 1 Generic Tier 2 Generic Preferred See your Evidence of Coverage Chart for member cost-share details Tier 3 Brand Non-Preferred Tier 4 Drug Specialty See your Medical or Prescription Benefits Chart for Tier 5 90‑day supply is not available Drugs member cost-share details

*Out-of-network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details. **Most pharmacies will fill a 90‑day supply of medication. Check with your pharmacist.

v Drug Notes Code Definitions Symbol Definition HRM High Risk Medication. Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found on the formulary. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use. B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. EX This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Medicare Plus Blue Group PPO and Prescription Blue Group PDP Customer Service at 1‑866‑684‑8216, Monday through Friday, 8:30 a.m. to 5:00 p.m. Eastern time. From October 1 through March 31, hours are from 8 a.m. to 9 p.m. Eastern time, seven days a week. TTY users should call 711. PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug. QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. NEDS Non-Extended Day Supply. These drugs are not offered at a 90‑day supply. They are offered up to a 31‑day supply.

vi Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ANALGESICS oxycodone- 2 QL (1080 per acetaminophen oral 90 days) ANALGESICS, OTHER tablet 10-325 mg, acetaminophen- 2 QL (5167 per 2.5-325 mg, 5-325 codeine oral solution 31 days) mg, 7.5-325 mg 120-12 mg/5 ml oxycodone- 2 acetaminophen- 2 QL (1080 per acetaminophen oral codeine oral tablet 90 days) tablet 2.5-300 mg 300-15 mg, 300-30 oxycodone-aspirin 2 QL (1080 per mg oral tablet 90 days) acetaminophen- 2 QL (540 per tramadol- 2 QL (1080 per codeine oral tablet 90 days) acetaminophen oral 90 days) 300-60 mg tablet endocet oral tablet 2 QL (1080 per NONSTEROIDAL ANTI-

10-325 mg, 2.5-325 90 days) INFLAMMATORY DRUGS mg, 5-325 mg, 7.5- 325 mg celecoxib oral 2 QL (270 per capsule 100 mg 90 days) hydrocodone- 2 QL (5735 per acetaminophen oral 31 days) celecoxib oral 2 QL (180 per solution 10-325 capsule 200 mg, 400 90 days) mg/15 ml(15 ml), mg 7.5-325 mg/15 ml celecoxib oral 2 QL (540 per hydrocodone- 2 QL (1080 per capsule 50 mg 90 days) acetaminophen oral 90 days) choline,magnesium 2 EX tablet 10-325 mg, 5- salicylate oral liquid 325 mg, 7.5-325 mg diclofenac potassium 2 HRM hydrocodone- 2 QL (450 per oral tablet ibuprofen oral tablet 90 days) 10-200 mg, 5-200 diclofenac sodium 2 HRM mg, 7.5-200 mg oral tablet extended release 24 hr ibuprofen-oxycodone 2 QL (360 per oral tablet 90 days) diclofenac sodium 2 HRM oral tablet,delayed lorcet hd oral tablet 2 QL (1080 per release (dr/ec) 90 days) diclofenac sodium 2 HRM; QL topical gel 1 % (1000 per 31 days)

BETA-LACTAM, PENICILLINS injection recon soln amoxicillin oral 1 ampicillin-sulbactam 4 capsule intravenous recon amoxicillin oral 2 soln suspension for BICILLIN C-R 4 reconstitution INTRAMUSCULA amoxicillin oral 1 R SYRINGE tablet BICILLIN L-A 4 amoxicillin oral 2 INTRAMUSCULA tablet,chewable 125 R SYRINGE mg, 250 mg dicloxacillin oral 2 amoxicillin-pot 2 capsule clavulanate oral nafcillin in dextrose 4 suspension for iso-osm intravenous reconstitution piggyback

AGENTS CAPSULE 225 MG, 90 days) 300 MG CELONTIN ORAL 3 CAPSULE 300 MG LYRICA ORAL 4 QL (360 per CAPSULE 25 MG, 90 days) ethosuximide oral 2 75 MG capsule LYRICA ORAL 4 QL (2700 per ethosuximide oral 2 SOLUTION 90 days) solution NAYZILAM 4 GAMMA-AMINOBUTYRIC ACID NASAL (GABA) AUGMENTING AGENTS SPRAY,NON- clobazam oral 4 QL (1440 per AEROSOL suspension 90 days) phenobarbital oral 4 HRM clobazam oral tablet 4 QL (180 per elixir 10 mg 90 days) phenobarbital oral 4 HRM clobazam oral tablet 3 QL (62 per 31 tablet 20 mg days)

150 MG, 200 MG RECEPTOR ANTAGONIST VIMPAT ORAL 4 QL (360 per memantine oral 4 QL (90 per 90 TABLET 50 MG 90 days) capsule,sprinkle,er days) zonisamide oral 2 24hr capsule memantine oral 2 QL (900 per solution 90 days) ANTIDEMENTIA AGENTS memantine oral 2 QL (180 per

ANTIDEMENTIA AGENTS, OTHER tablet 90 days) ergoloid oral tablet 2 MEMANTINE 3 QL (147 per NAMZARIC ORAL 3 ORAL 84 days) CAP,SPRINKLE,ER TABLETS,DOSE 24HR DOSE PACK PACK NAMZARIC ORAL 3 NAMENDA 3 QL (147 per CAPSULE,SPRINK TITRATION PAK 84 days) LE,ER 24HR ORAL TABLETS,DOSE

CHOLINESTERASE INHIBITORS PACK donepezil oral tablet 2 QL (90 per 90 NAMENDA XR 4 QL (84 per 84 10 mg, 5 mg days) ORAL days) donepezil oral tablet 4 QL (90 per 90 CAP,SPRINKLE,ER 23 mg days) 24HR DOSE PACK donepezil oral 4 QL (90 per 90 ANTIDEPRESSANTS tablet,disintegrating days) ANTIDEPRESSANTS, OTHER galantamine oral 2 QL (90 per 90 capsule,ext rel. days) bupropion hcl oral 2 pellets 24 hr tablet galantamine oral 2 bupropion hcl oral 2 solution tablet extended release 24 hr 150 galantamine oral 2 mg, 300 mg tablet

INHIBITORS mg, 30 mg, 60 mg EMSAM 5 NEDS escitalopram oxalate 2 TRANSDERMAL oral solution PATCH 24 HOUR escitalopram oxalate 2 MARPLAN ORAL 4 oral tablet TABLET FETZIMA ORAL 4 ST phenelzine oral 2 CAPSULE,EXT tablet REL 24HR DOSE PACK tranylcypromine 4 oral tablet FETZIMA ORAL 4 ST CAPSULE,EXTEN

SELECTIVE SEROTONIN DED RELEASE 24 REUPTAKE HR INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE fluoxetine oral 2 INHIBITORS capsule fluoxetine oral 2 citalopram oral 2 capsule,delayed solution release(dr/ec) citalopram oral 1 fluoxetine oral 4 tablet solution DESVENLAFAXIN 4 ST fluoxetine oral tablet 4 E ORAL TABLET EXTENDED fluvoxamine oral 2 RELEASE 24 HR capsule,extended release 24hr

release 24hr ANTIEMETICS venlafaxine oral 2 ANTIEMETICS, OTHER tablet compro rectal 2 VIIBRYD ORAL 4 ST suppository TABLET meclizine oral tablet 2 HRM VIIBRYD ORAL 4 ST 12.5 mg, 25 mg TABLETS,DOSE metoclopramide hcl 2 HRM PACK 10 MG (7)- oral solution 20 MG (23) metoclopramide hcl 2 HRM TRICYCLICS oral tablet

ADJUNCTS ciclodan topical 2 aprepitant oral 4 B/D PA solution capsule ciclopirox topical 2 aprepitant oral 4 B/D PA cream capsule,dose pack ciclopirox topical 2 dronabinol oral 4 B/D PA gel capsule ciclopirox topical 2 EMEND ORAL 4 B/D PA shampoo SUSPENSION FOR ciclopirox topical 2 RECONSTITUTIO solution N ciclopirox topical 2 granisetron hcl oral 2 B/D PA suspension tablet clotrimazole mucous 2 ondansetron hcl oral 4 B/D PA membrane troche solution clotrimazole topical 2 ondansetron hcl oral 2 B/D PA cream tablet clotrimazole topical 2 solution

TREATMENT ADJUNCTS INHALATION MESNEX ORAL 4 RECON SOLN TABLET PENTAM 4 ANTIPARASITICS INJECTION RECON SOLN ANTHELMINTHICS pentamidine 4 B/D PA albendazole oral 5 NEDS inhalation recon tablet soln ivermectin oral 2 pentamidine 4 tablet injection recon soln

tolcapone oral tablet 4 INHIBITORS DOPAMINE AGONISTS rasagiline oral tablet 4 selegiline hcl oral 2 APOKYN 5 NEDS capsule SUBCUTANEOUS CARTRIDGE selegiline hcl oral 2 bromocriptine oral 2 tablet capsule ANTIPSYCHOTICS bromocriptine oral 2 1ST GENERATION/TYPICAL tablet NEUPRO 4 TRANSDERMAL PATCH 24 HOUR

AGENTS capsule ganciclovir sodium 4 B/D PA ribavirin oral tablet 2 intravenous solution 200 mg valganciclovir oral 5 NEDS SYLATRON 5 NEDS recon soln SUBCUTANEOUS KIT 200 MCG, 300 valganciclovir oral 3 MCG tablet ANTI-HEPATITIS C (HCV) DIRECT

ZIRGAN 3 ACTING AGENTS OPHTHALMIC (EYE) GEL EPCLUSA ORAL 5 PA; NEDS TABLET ANTI-HEPATITIS B (HBV) AGENTS HARVONI ORAL 5 PA; NEDS adefovir oral tablet 5 NEDS PELLETS IN entecavir oral tablet 3 PACKET INTRON A 5 LA; NEDS HARVONI ORAL 5 PA; NEDS INJECTION TABLET RECON SOLN LEDIPASVIR- 5 PA; NEDS INTRON A 5 LA; NEDS SOFOSBUVIR INJECTION ORAL TABLET SOLUTION 10 SOFOSBUVIR- 5 PA; NEDS MILLION VELPATASVIR UNIT/ML ORAL TABLET INTRON A 3 LA SOVALDI ORAL 5 PA; NEDS INJECTION PELLETS IN SOLUTION 6 PACKET MILLION UNIT/ML SOVALDI ORAL 5 PA; NEDS TABLET lamivudine oral 2 tablet 100 mg VOSEVI ORAL 5 PA; NEDS TABLET ANTI-HEPATITIS C (HCV) AGENTS,

OTHER ANTIHERPETIC AGENTS Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits acyclovir oral 2 TIVICAY ORAL 5 NEDS capsule TABLET 25 MG, 50 MG acyclovir oral 2 suspension 200 mg/5 TIVICAY PD 4 ml ORAL TABLET FOR SUSPENSION acyclovir oral tablet 2

acyclovir sodium 4 B/D PA ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE intravenous solution TRANSCRIPTASE INHIBITORS acyclovir topical 4 (NNRTI) cream EDURANT ORAL 5 NEDS famciclovir oral 2 TABLET tablet efavirenz oral 4 trifluridine 2 capsule ophthalmic (eye) drops efavirenz oral tablet 5 NEDS valacyclovir oral 2 INTELENCE ORAL 5 NEDS tablet TABLET 100 MG, 200 MG ANTI-HIV AGENTS, INTEGRASE

INHIBITORS (INSTI) INTELENCE ORAL 3 TABLET 25 MG ISENTRESS HD 5 NEDS ORAL TABLET nevirapine oral 4 suspension ISENTRESS ORAL 5 NEDS POWDER IN nevirapine oral 2 PACKET tablet ISENTRESS ORAL 5 NEDS nevirapine oral 2 TABLET tablet extended release 24 hr ISENTRESS ORAL 5 NEDS TABLET,CHEWAB PIFELTRO ORAL 5 NEDS LE 100 MG TABLET ISENTRESS ORAL 3 ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TABLET,CHEWAB LE 25 MG TRANSCRIPTASE INHIBITORS (NRTI) TIVICAY ORAL 4 TABLET 10 MG abacavir oral 4 solution

metformin oral 1 QL (360 per GLYCEMIC AGENTS tablet extended 90 days) diazoxide oral 4 release 24 hr 500 mg suspension metformin oral 1 QL (180 per GLUCAGEN 3 tablet extended 90 days) HYPOKIT release 24 hr 750 mg INJECTION metformin oral 1 QL (180 per RECON SOLN tablet extended 90 days) GLUCAGON 3 release (osm) 24 hr (HCL) 1,000 mg EMERGENCY KIT metformin oral 1 QL (450 per INJECTION tablet extended 90 days) RECON SOLN release (osm) 24 hr GLUCAGON 3 500 mg EMERGENCY KIT miglitol oral tablet 2 (HUMAN) INJECTION nateglinide oral 1 RECON SOLN tablet GVOKE HYPOPEN 3 ONGLYZA ORAL 3 QL (90 per 90 1-PACK TABLET days) SUBCUTANEOUS pioglitazone oral 1 QL (90 per 90 AUTO-INJECTOR tablet days) GVOKE HYPOPEN 3 repaglinide oral 1 2-PACK tablet SUBCUTANEOUS AUTO-INJECTOR SYMLINPEN 120 4 SUBCUTANEOUS GVOKE PFS 1- 3 PEN INJECTOR PACK SYRINGE SUBCUTANEOUS SYMLINPEN 60 4 SYRINGE SUBCUTANEOUS PEN INJECTOR

MODIFIERS, OTHER NIVESTYM 5 NEDS anagrelide oral 2 INJECTION capsule SOLUTION ARANESP (IN 4 PA OXBRYTA ORAL 5 PA; LA; POLYSORBATE) TABLET NEDS INJECTION PROCRIT 4 PA SOLUTION 100 INJECTION MCG/ML, 200 SOLUTION 10,000 MCG/ML, 25 UNIT/ML, 2,000 MCG/ML, 300 UNIT/ML, 20,000 MCG/ML, 40 UNIT/2 ML, 3,000 MCG/ML, 60 UNIT/ML, 4,000 MCG/ML UNIT/ML ARANESP (IN 4 PA PROCRIT 5 PA; NEDS POLYSORBATE) INJECTION INJECTION SOLUTION 20,000 SYRINGE UNIT/ML, 40,000 EPOGEN 4 PA UNIT/ML INJECTION PROMACTA 5 PA; NEDS SOLUTION 10,000 ORAL POWDER IN UNIT/ML, 2,000 PACKET 25 MG UNIT/ML, 20,000 UNIT/2 ML, 20,000 PROMACTA 5 PA; NEDS UNIT/ML, 3,000 ORAL TABLET UNIT/ML, 4,000 ZARXIO 5 NEDS UNIT/ML INJECTION SYRINGE Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits HEMOSTASIS AGENTS HEMOSTASIS AGENTS tranexamic acid oral 2 QL (90 per 63 ASTRINGYN 4 EX tablet days) TOPICAL SOLUTION PLATELET MODIFYING AGENTS aspirin-dipyridamole 4 CARDIOVASCULAR AGENTS oral capsule, er ALPHA-ADRENERGIC AGONISTS multiphase 12 hr clonidine hcl oral 2 HRM BRILINTA ORAL 3 tablet TABLET clonidine 1 HRM; QL (12 CABLIVI 5 PA; NEDS transdermal patch per 84 days) INJECTION KIT weekly cilostazol oral tablet 2 midodrine oral 2 clopidogrel oral 1 tablet tablet 75 mg NORTHERA ORAL 5 LA; NEDS DOPTELET (10 5 PA; NEDS CAPSULE TAB PACK) ORAL ALPHA-ADRENERGIC BLOCKING

TABLET AGENTS DOPTELET (15 5 PA; NEDS doxazosin oral tablet 2 HRM TAB PACK) ORAL TABLET prazosin oral 2 HRM capsule DOPTELET (30 5 PA; NEDS TAB PACK) ORAL terazosin oral 2 HRM TABLET capsule prasugrel oral tablet 4 ANGIOTENSIN II RECEPTOR

ANTAGONISTS BLOOD PRODUCTS/MODIFIERS/VOLU candesartan oral 1 tablet ME EXPANDERS eprosartan oral 1 BLOOD FORMATION MODIFIERS tablet NEULASTA 5 QL (1.2 per 28 irbesartan oral 1 ONPRO days); NEDS tablet SUBCUTANEOUS SYRINGE, W/ losartan oral tablet 1 WEARABLE olmesartan oral 1 INJECTOR tablet

ramipril oral 1 AGENTS capsule acebutolol oral 2 trandolapril oral 1 capsule tablet atenolol oral tablet 1 ANTIARRHYTHMICS betaxolol oral tablet 1 amiodarone oral 2 HRM bisoprolol fumarate 1 tablet oral tablet dofetilide oral 2 carvedilol oral tablet 1 capsule carvedilol phosphate 4 QL (90 per 90 flecainide oral tablet 2 oral capsule, er days) multiphase 24 hr mexiletine oral 2 capsule labetalol oral tablet 1 MULTAQ ORAL 3 HRM; QL metoprolol succinate 1 QL (180 per TABLET (180 per 90 oral tablet extended 90 days) days) release 24 hr metoprolol tartrate 4 intravenous solution

AGENTS nifedipine oral tablet 2 QL (90 per 90 amlodipine oral 1 extended release days) tablet nifedipine oral tablet 2 QL (90 per 90 cartia xt oral 2 extended release days) capsule,extended 24hr release 24hr nimodipine oral 4 diltiazem hcl oral 2 capsule capsule,ext.rel 24h nisoldipine oral 4 QL (90 per 90 degradable tablet extended days) diltiazem hcl oral 2 release 24 hr 17 mg, capsule,extended 20 mg, 25.5 mg, 34 release 12 hr mg, 40 mg, 8.5 mg diltiazem hcl oral 2 nisoldipine oral 4 QL (180 per capsule,extended tablet extended 90 days) release 24 hr release 24 hr 30 mg diltiazem hcl oral 2 taztia xt oral 2 capsule,extended capsule,extended release 24hr release 24 hr diltiazem hcl oral 2 tiadylt er oral 2 tablet capsule,extended release 24 hr Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 47 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits verapamil oral 2 bisoprolol- 2 capsule, 24 hr er hydrochlorothiazide pellet ct oral tablet verapamil oral 2 candesartan- 2 capsule,ext rel. hydrochlorothiazid pellets 24 hr oral tablet verapamil oral tablet 1 captopril- 2 hydrochlorothiazide verapamil oral tablet 2 oral tablet extended release CORLANOR ORAL 4 QL (180 per CARDIOVASCULAR AGENTS, TABLET 90 days) OTHER DEMSER ORAL 5 NEDS aliskiren oral tablet 4 QL (90 per 90 CAPSULE days) digitek oral tablet 2 HRM; QL (90 amiloride- 2 125 mcg (0.125 mg) per 90 days) hydrochlorothiazide oral tablet digitek oral tablet 2 HRM 250 mcg (0.25 mg) amlodipine- 2 QL (90 per 90 atorvastatin oral days) digox oral tablet 125 2 HRM; QL (90 tablet mcg (0.125 mg) per 90 days) amlodipine- 2 digox oral tablet 250 2 HRM benazepril oral mcg (0.25 mg) capsule digoxin oral solution 2 HRM amlodipine- 2 QL (90 per 90 50 mcg/ml (0.05 olmesartan oral days) mg/ml) tablet digoxin oral tablet 2 HRM; QL (90 amlodipine- 2 125 mcg (0.125 mg) per 90 days) valsartan oral tablet digoxin oral tablet 2 HRM amlodipine- 2 250 mcg (0.25 mg) valsartan-hcthiazid enalapril- 2 oral tablet hydrochlorothiazide atenolol- 2 oral tablet chlorthalidone oral ENTRESTO ORAL 4 tablet TABLET benazepril- 2 ezetimibe- 4 ST; QL (90 per hydrochlorothiazide simvastatin oral 90 days) oral tablet tablet

oral tablet AGENTS,OTHER quinapril- 2 CORLANOR ORAL 4 QL (1350 per hydrochlorothiazide SOLUTION 90 days) oral tablet DIURETICS, CARBONIC

ANHYDRASE INHIBITORS

bumetanide oral 1 DERIVATIVES tablet fenofibrate 4 QL (90 per 90 furosemide injection 4 micronized oral days) solution capsule furosemide injection 4 fenofibrate 4 syringe nanocrystallized oral tablet 145 mg, furosemide oral 1 48 mg solution 10 mg/ml, 40 mg/5 ml (8 fenofibrate oral 4 QL (90 per 90 mg/ml) tablet 160 mg, 54 mg days) furosemide oral 1 fenofibric acid 4 QL (90 per 90 tablet (choline) oral days) capsule,delayed torsemide oral tablet 2 release(dr/ec) 135 DIURETICS, POTASSIUM-SPARING mg amiloride oral tablet 2 fenofibric acid 4 QL (270 per (choline) oral 90 days) eplerenone oral 2 capsule,delayed tablet release(dr/ec) 45 mg spironolactone oral 1 fenofibric acid oral 4 tablet tablet DIURETICS, THIAZIDE gemfibrozil oral 2 chlorothiazide oral 1 tablet tablet 500 mg DYSLIPIDEMICS, HMG COA

chlorthalidone oral 2 REDUCTASE INHIBITORS tablet 25 mg, 50 mg atorvastatin oral 1 hydrochlorothiazide 1 tablet 10 mg, 20 mg, oral capsule 40 mg hydrochlorothiazide 1 atorvastatin oral 1 QL (90 per 90 oral tablet tablet 80 mg days)

DYSLIPIDEMICS, OTHER prevalite oral 4 cholestyramine (with 4 powder in packet sugar) oral powder REPATHA 3 PA cholestyramine (with 4 PUSHTRONEX sugar) oral powder SUBCUTANEOUS in packet WEARABLE INJECTOR cholestyramine light 4 oral powder REPATHA 3 PA SUBCUTANEOUS cholestyramine light 4 SYRINGE oral powder in packet

ARTERIAL/VENOUS OINTMENT isosorbide dinitrate 2 VASODILATORS, DIRECT-ACTING

oral tablet ARTERIAL isosorbide 2 hydralazine oral 2 mononitrate oral tablet tablet minoxidil oral tablet 2 isosorbide 2 VASOPRESSORS mononitrate oral tablet extended isoproterenol hcl 4 release 24 hr injection solution isoxsuprine oral 2 EX CENTRAL NERVOUS SYSTEM

tablet AGENTS nitro-bid 4 ATTENTION DEFICIT transdermal ointment HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES NITRO-DUR 4 TRANSDERMAL dextroamphetamine 2 QL (540 per PATCH 24 HOUR oral tablet 90 days) 0.3 MG/HR, 0.8 dextroamphetamine- 2 QL (270 per MG/HR amphetamine oral 90 days) nitroglycerin oral 2 EX tablet 10 mg, 12.5 capsule, extended mg, 15 mg, 20 mg, 5 release mg, 7.5 mg nitroglycerin 2 dextroamphetamine- 2 QL (180 per sublingual tablet amphetamine oral 90 days) tablet 30 mg nitroglycerin 2 transdermal patch zenzedi oral tablet 2 QL (540 per 24 hour 10 mg, 5 mg 90 days)

PLEGRIDY 5 PA; LA; COMBINATIONS SUBCUTANEOUS NEDS SYRINGE 125 drospirenone-ethinyl 2 MCG/0.5 ML estradiol oral tablet 3-0.02 mg PLEGRIDY 5 PA; NEDS SUBCUTANEOUS ethynodiol diac-eth 2 SYRINGE 63 estradiol oral tablet MCG/0.5 ML- 94 1-50 mg-mcg MCG/0.5 ML fyavolv oral tablet 2 REBIF (WITH 5 PA; NEDS 0.5-2.5 mg-mcg ALBUMIN) gianvi (28) oral 2 SUBCUTANEOUS tablet SYRINGE jasmiel (28) oral 2 REBIF REBIDOSE 5 PA; NEDS tablet SUBCUTANEOUS PEN INJECTOR kelnor 1-50 oral 2 tablet REBIF TITRATION 5 PA; NEDS PACK loryna (28) oral 2 SUBCUTANEOUS tablet SYRINGE mili oral tablet 2 TECFIDERA ORAL 5 PA; QL (62 nikki (28) oral tablet 2 CAPSULE,DELAY per 31 days); ED NEDS RELEASE(DR/EC) Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits norethindrone ac-eth 2 DEBACTEROL 4 EX estradiol oral tablet MUCOUS 0.5-2.5 mg-mcg MEMBRANE SWAB tri-mili oral tablet 2 oralone dental paste 2 ORAL PROGESTINS paroex oral rinse 2 camila oral tablet 2 mucous membrane deblitane oral tablet 2 mouthwash errin oral tablet 2 periogard mucous 2 membrane heather oral tablet 2 mouthwash incassia oral tablet 2 pilocarpine hcl oral 2 jencycla oral tablet 2 tablet lyza oral tablet 2 triamcinolone 2 nora-be oral tablet 2 acetonide dental paste norethindrone 2 (contraceptive) oral DERMATOLOGICAL AGENTS tablet ACNE AND ROSACEA AGENTS norlyda oral tablet 2 acitretin oral 4 sharobel oral tablet 2 capsule 10 mg, 25 mg tulana oral tablet 2 acitretin oral 5 NEDS DENTAL AND ORAL AGENTS capsule 17.5 mg DENTAL AND ORAL AGENTS adapalene topical 4 cevimeline oral 2 cream capsule adapalene topical 4 chlorhexidine 2 gel 0.3 % gluconate mucous amnesteem oral 2 membrane capsule mouthwash avita topical cream 4 DEBACTEROL 4 EX MUCOUS azelaic acid topical 4 MEMBRANE gel SOLUTION claravis oral capsule 2

AGENTS betamethasone, 2 augmented topical alclometasone 2 cream topical cream betamethasone, 2 alclometasone 2 augmented topical topical ointment gel amcinonide topical 4 betamethasone, 2 cream augmented topical amcinonide topical 4 lotion lotion betamethasone, 2 amcinonide topical 4 augmented topical ointment ointment ammonium lactate 2 clobetasol scalp 4 topical cream solution ammonium lactate 2 clobetasol topical 4 topical lotion cream apexicon e topical 4 clobetasol topical 4 cream gel

intravenous solution MODIFIERS sodium bicarbonate 4 CHEMET ORAL 3 intravenous syringe CAPSULE 8.4 % (1 meq/ml) deferasirox oral 5 NEDS tablet

(sorb free) oral VITAMINS suspension DRISDOL ORAL 4 EX sps (with sorbitol) 2 CAPSULE rectal enema ergocalciferol 2 EX tolvaptan oral tablet 5 PA; NEDS (vitamin d2) oral 30 mg capsule 1,250 mcg (50,000 unit) trientine oral 5 NEDS capsule folic acid oral tablet 2 EX 1 mg PHOSPHATE BINDERS MEPHYTON 4 EX calcium 2 ORAL TABLET acetate(phosphat bind) oral capsule GASTROINTESTINAL AGENTS calcium 2 ANTI-CONSTIPATION AGENTS acetate(phosphat AMITIZA ORAL 4 PA; QL (180 bind) oral tablet CAPSULE per 90 days)

GASTROINTESTINAL SUBCUTANEOUS KIT dicyclomine oral 2 HRM gavilyte-c oral recon 2 capsule soln dicyclomine oral 2 HRM gavilyte-g oral recon 2 solution soln

ANTAGONISTS mg, 40 mg

GENETIC OR ENZYME: NITYR ORAL 5 PA; NEDS REPLACEMENT, MODIFIERS, TABLET TREATMENT ORFADIN ORAL 5 LA; NEDS CERDELGA ORAL 5 LA; NEDS CAPSULE 10 MG, CAPSULE 2 MG, 5 MG CHOLBAM ORAL 5 PA; NEDS ORFADIN ORAL 5 NEDS CAPSULE CAPSULE 20 MG CREON ORAL 3 ORFADIN ORAL 5 LA; NEDS CAPSULE,DELAY SUSPENSION ED RELEASE(DR/EC) PALYNZIQ 5 PA; NEDS SUBCUTANEOUS cromolyn oral 2 SYRINGE concentrate PERTZYE ORAL 4 CYSTADANE 4 CAPSULE,DELAY ORAL POWDER ED CYSTAGON ORAL 4 LA RELEASE(DR/EC) CAPSULE 24,000-86,250- 90,750 UNIT

OTHER dexamethasone oral 2 bethanechol chloride 2 solution oral tablet dexamethasone oral 2 DEPEN 4 tablet TITRATABS ORAL fludrocortisone oral 2 TABLET tablet ELMIRON ORAL 3 fluocinolone topical 2 CAPSULE oil penicillamine oral 4 fluocinonide topical 4 tablet cream 0.05 % HORMONAL AGENTS, HEMADY ORAL 3 PA STIMULANT/REPLACEMENT/ TABLET MODIFYING (ADRENAL) hydrocortisone 2 EX acetate rectal HORMONAL AGENTS, suppository STIMULANT/REPLACEMENT/MOD IFYING (ADRENAL) hydrocortisone oral 2 tablet ANALPRAM-HC 4 EX SINGLES RECTAL hydrocortisone 2 CREAM 2.5-1 % topical ointment 1 % (4G) hydrocortisone- 2 EX anucort-hc rectal 2 EX pramoxine rectal cream 2.5-1 % (4g) suppository Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 71 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits hydrocortisone- 2 EX SCALACORT DK 4 EX pramoxine topical TOPICAL COMBO cream PACK methylprednisolone 2 HORMONAL AGENTS, oral tablet STIMULANT/REPLACEMENT/ methylprednisolone 2 MODIFYING (PITUITARY) oral tablets,dose pack HORMONAL AGENTS, STIMULANT/REPLACEMENT/MOD PRAMOSONE 4 EX IFYING (PITUITARY) TOPICAL CREAM 2.5-1 % desmopressin 4 HRM injection solution prednisolone oral 2 solution 15 mg/5 ml desmopressin nasal 4 HRM spray with pump prednisolone sodium 2 phosphate oral desmopressin nasal 4 HRM solution 15 mg/5 ml spray,non-aerosol (3 mg/ml), 15 mg/5 desmopressin oral 2 HRM ml (5 ml), 20 mg/5 tablet ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 EGRIFTA SV 5 NEDS mg base/5 ml (6.7 SUBCUTANEOUS mg/5 ml) RECON SOLN prednisone intensol 2 HUMATROPE 5 PA; HRM; oral concentrate INJECTION NEDS CARTRIDGE prednisone oral 2 solution HUMATROPE 5 PA; HRM; INJECTION NEDS prednisone oral 2 RECON SOLN tablet INCRELEX 5 PA; LA; prednisone oral 2 SUBCUTANEOUS NEDS tablets,dose pack SOLUTION PROCORT 4 EX NORDITROPIN 5 PA; HRM; RECTAL CREAM FLEXPRO NEDS PROCTOCORT 4 EX SUBCUTANEOUS RECTAL PEN INJECTOR SUPPOSITORY

MODIFYING (SEX testosterone 3 PA; HRM; QL HORMONES/MODIFIERS) transdermal gel in (450 per 90 packet 1.62 % (40.5 days) ANABOLIC STEROIDS mg/2.5 gram) ANADROL-50 5 PA; NEDS ESTROGENS ORAL TABLET aubra eq oral tablet 2 oxandrolone oral 2 PA tablet covaryx h.s. oral 2 EX tablet ANDROGENS drospirenone- 2 danazol oral capsule 4 e.estradiol-lm.fa METHITEST 4 HRM oral tablet 3-0.03- ORAL TABLET 0.451 mg (21) (7) methyltestosterone 2 HRM eemt hs oral tablet 2 EX oral capsule eemt oral tablet 2 EX testosterone 4 HRM ENDOMETRIN 4 EX cypionate VAGINAL INSERT intramuscular oil 100 mg/ml, 200 estradiol oral tablet 2 mg/ml, 200 mg/ml (1 estradiol vaginal 2 ml) cream testosterone 4 HRM estradiol vaginal 2 enanthate tablet intramuscular oil

VAGINAL RECEPTOR MODIFYING AGENTS INSERT, DOSE PACK DUAVEE ORAL 3 TABLET MENEST ORAL 4 HRM TABLET 1.25 MG, raloxifene oral tablet 1 QL (90 per 90 2.5 MG days) PREMARIN 3 HRM HORMONAL AGENTS, VAGINAL CREAM STIMULANT/REPLACEMENT/ yuvafem vaginal 2 MODIFYING (THYROID) tablet HORMONAL AGENTS, PROGESTINS STIMULANT/REPLACEMENT/MOD DEPO-PROVERA 4 IFYING (THYROID) INTRAMUSCULA euthyrox oral tablet 1 R SUSPENSION levo-t oral tablet 1 400 MG/ML levothyroxine oral 1 medroxyprogesteron 4 tablet e intramuscular suspension

SUPPRESSANT (ADRENAL) INTRAMUSCULA R SYRINGE KIT LYSODREN ORAL 3 TABLET LUPRON DEPOT- 5 NEDS PED (3 MONTH) HORMONAL AGENTS, INTRAMUSCULA SUPPRESSANT (PITUITARY) R SYRINGE KIT 11.25 MG HORMONAL AGENTS,

SUPPRESSANT (PITUITARY) LUPRON DEPOT- 5 NEDS PED cabergoline oral 2 INTRAMUSCULA tablet R KIT 7.5 MG FIRMAGON KIT W 5 NEDS (PED) DILUENT octreotide acetate 5 NEDS SYRINGE injection solution SUBCUTANEOUS 1,000 mcg/ml, 500 RECON SOLN 120 mcg/ml MG octreotide acetate 4 FIRMAGON KIT W 4 injection solution DILUENT 100 mcg/ml, 200 SYRINGE mcg/ml, 50 mcg/ml SUBCUTANEOUS RECON SOLN 80 SIGNIFOR 5 LA; NEDS MG SUBCUTANEOUS SOLUTION

SUPPRESSANT (THYROID) cyclosporine 4 B/D PA modified oral ANTITHYROID AGENTS capsule 100 mg, 25 methimazole oral 2 mg tablet 10 mg, 5 mg cyclosporine 2 B/D PA propylthiouracil oral 2 modified oral tablet capsule 50 mg IMMUNOLOGICAL AGENTS cyclosporine 4 B/D PA modified oral ANGIOEDEMA AGENTS solution BERINERT 5 PA; LA; cyclosporine oral 2 B/D PA INTRAVENOUS NEDS capsule KIT ENBREL MINI 5 PA; QL (8 per FIRAZYR 5 PA; NEDS SUBCUTANEOUS 28 days); SUBCUTANEOUS CARTRIDGE NEDS SYRINGE ENBREL 5 PA; QL (16 HAEGARDA 5 PA; LA; SUBCUTANEOUS per 28 days); SUBCUTANEOUS NEDS RECON SOLN NEDS RECON SOLN

EXTENDED AGENTS RELEASE alendronate oral 2 GLUCOCORTICOIDS solution ANALPRAM-HC 4 EX alendronate oral 1 QL (90 per 90 RECTAL CREAM tablet 10 mg, 5 mg days) 2.5-1 % alendronate oral 1 QL (12 per 84 hydrocortisone 2 tablet 35 mg, 70 mg days) rectal enema calcitonin (salmon) 2 nasal spray,non- aerosol

AGENTS CAVERJECT 3 EX; QL (18 INTRACAVERNOS per 90 days) ADIPEX-P ORAL 4 EX AL RECON SOLN CAPSULE CETROTIDE 4 EX ADIPEX-P ORAL 4 EX SUBCUTANEOUS TABLET KIT 0.25 MG Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 81 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits CIALIS ORAL 3 EX; QL (18 E-Z-HD BARIUM 4 EX TABLET 10 MG, 20 per 90 days) ORAL MG SUSPENSION FOR RECONSTITUTIO clomiphene citrate 2 PA N oral tablet E-Z-PAQUE ORAL 4 EX codeine-guaifenesin 2 EX SUSPENSION FOR oral liquid RECONSTITUTIO cryoserv solution 2 EX N CYANOKIT 4 EX E-Z-PASTE ORAL 4 EX INTRAVENOUS CREAM RECON SOLN fem ph vaginal gel 2 EX CYCLOMYDRIL 4 EX FOLLISTIM AQ 4 EX OPHTHALMIC SUBCUTANEOUS (EYE) DROPS CARTRIDGE CYSTO-CONRAY 4 EX freamine iii 10 % 2 B/D PA II URETHRAL intravenous SOLUTION parenteral solution diethylpropion oral 2 EX FUL-GLO 4 EX tablet OPHTHALMIC diethylpropion oral 2 EX (EYE) STRIP 0.6 tablet extended MG release GALZIN ORAL 4 EX EDEX 4 EX; QL (18 CAPSULE INTRACAVERNOS per 90 days) GASTROGRAFIN 4 EX AL KIT ORAL SOLUTION ed-spaz oral 2 EX; HRM GASTROMARK 4 EX tablet,disintegrating ORAL ENTERO VU 4 EX SUSPENSION ORAL LIQUID 24 GONAL-F RFF 4 EX % REDI-JECT E-Z DISK ORAL 4 EX SUBCUTANEOUS TABLET PEN INJECTOR GONAL-F RFF 4 EX SUBCUTANEOUS RECON SOLN

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 88 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits CIPRO HC OTIC 4 alavert oral No EX (EAR) tablet,disintegrating Copay DROPS,SUSPENSI all day allergy No EX ON (cetirizine) oral Copay CIPRODEX OTIC 3 tablet (EAR) all day allergy-d No EX DROPS,SUSPENSI oral tablet extended Copay ON release 12 hr ciprofloxacin- 3 allerclear d-12hr No EX dexamethasone otic oral tablet extended Copay (ear) release 12 hr drops,suspension allerclear d-24hr No EX hydrocortisone- 2 oral tablet extended Copay acetic acid otic (ear) release 24 hr drops allerclear oral tablet No EX neomycin- 2 Copay polymyxin-hc otic (ear) aller-ease oral tablet No EX drops,suspension Copay neomycin- 2 aller-fex oral tablet No EX polymyxin-hc otic Copay (ear) solution allergy and No EX OTIC GLUCOCORTICOIDS congestion relief Copay oral tablet extended flac oil otic (ear) 2 release 12 hr drops allergy and No EX fluocinolone 2 congestion relief Copay acetonide oil otic oral tablet extended (ear) drops release 24 hr RESPIRATORY allergy complete-d No EX TRACT/PULMONARY AGENTS oral tablet extended Copay release 12 hr ANTIHISTAMINES allergy relief No EX alavert d-12 allergy- No EX (cetirizine) oral Copay sinus oral tablet Copay capsule extended release 12 hr allergy relief No EX (cetirizine) oral Copay tablet Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 89 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits allergy relief No EX allergy-congestion No EX (fexofenadine) oral Copay relief-d oral tablet Copay tablet extended release 24 hr allergy relief No EX (loratadine) oral Copay aller-tec d oral No EX solution tablet extended Copay release 12 hr allergy relief No EX (loratadine) oral Copay aller-tec oral tablet No EX tablet Copay allergy relief No EX azelastine nasal 2 (loratadine) oral Copay aerosol,spray tablet,disintegrating azelastine nasal 2 allergy relief d12 No EX spray,non-aerosol oral tablet extended Copay cetiri-d oral tablet No EX release 12 hr extended release 12 Copay allergy relief d-24hr No EX hr oral tablet extended Copay cetirizine oral 2 release 24 hr solution 1 mg/ml allergy relief,nasal No EX cetirizine oral No EX decongest oral tablet Copay solution 5 mg/5 ml Copay extended release 24 hr cetirizine oral tablet No EX Copay allergy relief-d No EX (cetirizine) oral Copay cetirizine oral No EX tablet extended tablet,chewable Copay release 12 hr cetirizine- No EX allergy relief-d No EX pseudoephedrine Copay (loratadine) oral Copay oral tablet extended tablet extended release 12 hr release 12 hr children's allergy No EX allergy relief- No EX relief(lor) oral Copay d(fexofenadine) oral Copay solution tablet extended children's cetirizine No EX release 12 hr oral tablet,chewable Copay allergy-congest No EX cyproheptadine oral 2 HRM relief-d(fexo) oral Copay syrup tablet extended release 12 hr Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 90 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits cyproheptadine oral 2 HRM lorata-dine d oral No EX tablet tablet extended Copay release 24 hr desloratadine oral 2 QL (90 per 90 tablet days) loratadine oral No EX solution Copay desloratadine oral 2 QL (90 per 90 tablet,disintegrating days) loratadine oral No EX tablet Copay dexchlorpheniramin 2 HRM e maleate oral loratadine oral No EX solution tablet,disintegrating Copay diphenhydramine hcl 4 loratadine-d oral No EX injection syringe tablet extended Copay release 12 hr fexofenadine oral No EX tablet 180 mg, 60 mg Copay loratadine-d oral No EX fexofenadine- No EX tablet extended Copay release 24 hr pseudoephedrine Copay oral tablet extended olopatadine nasal 2 release 12 hr spray,non-aerosol hydroxyzine hcl oral 2 HRM RESPA-AR ORAL 4 EX solution 10 mg/5 ml TABLET EXTENDED hydroxyzine hcl oral 2 HRM RELEASE 12 HR tablet wal-fex allergy oral No EX hydroxyzine 2 HRM tablet Copay pamoate oral capsule 25 mg, 50 wal-fex d 24 hour No EX; QL (90 mg oral tablet extended Copay per 90 days) release 24 hr levocetirizine oral 2 solution wal-itin d 12 hour No EX oral tablet extended Copay levocetirizine oral 2 QL (90 per 90 release 12 hr tablet days) wal-itin d oral tablet No EX loradamed oral No EX extended release 24 Copay tablet Copay hr lorata-d oral tablet No EX wal-itin oral solution No EX extended release 24 Copay Copay hr wal-itin oral tablet No EX Copay

INHALER SYMPATHOMIMETIC

AEROSOL 90 days) INHIBITORS, AIRWAYS DISEASE INHALER aminophylline 4 CYSTIC FIBROSIS AGENTS intravenous solution CAYSTON 5 PA; LA; QL 500 mg/20 ml INHALATION (84 per 28 DALIRESP ORAL 4 SOLUTION FOR days); NEDS TABLET NEBULIZATION theophylline oral 2 KALYDECO ORAL 5 PA; NEDS tablet extended GRANULES IN release 12 hr 300 mg PACKET 25 MG theophylline oral 2 KALYDECO ORAL 5 PA; LA; tablet extended GRANULES IN NEDS release 24 hr PACKET 50 MG, 75 PULMONARY MG ANTIHYPERTENSIVES KALYDECO ORAL 5 PA; LA; TABLET NEDS ADEMPAS ORAL 5 PA; LA; TABLET NEDS ORKAMBI ORAL 5 PA; NEDS GRANULES IN alyq oral tablet 5 PA; QL (62 PACKET per 31 days); NEDS ORKAMBI ORAL 5 PA; LA; TABLET NEDS ambrisentan oral 5 PA; NEDS tablet PULMOZYME 5 B/D PA; INHALATION NEDS bosentan oral tablet 5 PA; NEDS SOLUTION OPSUMIT ORAL 5 PA; LA; QL tobramycin in 0.225 5 B/D PA; TABLET (31 per 31 % nacl inhalation NEDS days); NEDS solution for ORENITRAM 4 PA; LA nebulization ORAL TABLET TRIKAFTA ORAL 5 PA; NEDS EXTENDED TABLETS, RELEASE 0.125 SEQUENTIAL MG MAST CELL STABILIZERS ORENITRAM 5 PA; LA; ORAL TABLET NEDS cromolyn inhalation 2 B/D PA EXTENDED solution for RELEASE 0.25 MG, nebulization 1 MG, 2.5 MG, 5 MG Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drug 5-Specialty Tier Requirements/Limits: B/D - Prior Authorization, Part D vs. Part B only EX - Excluded Drug HRM - High Risk Medication LA - Limited Availability NEDS - Non-extended Day Supply PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 95 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits sildenafil 5 PA; QL (180 ESBRIET ORAL 5 PA; LA; QL (pulmonary arterial per 30 days); TABLET 267 MG (279 per 31 hypertension) oral NEDS days); NEDS suspension for ESBRIET ORAL 5 PA; LA; QL reconstitution 10 TABLET 801 MG (93 per 31 mg/ml days); NEDS sildenafil 2 PA; QL (270 OFEV ORAL 5 PA; LA; (pulmonary arterial per 90 days) CAPSULE NEDS hypertension) oral tablet 20 mg RESPIRATORY TRACT AGENTS,

tadalafil (pulmonary 5 PA; QL (62 OTHER arterial per 31 days); acetylcysteine 2 hypertension) oral NEDS intravenous solution tablet 20 mg acetylcysteine 2 B/D PA TRACLEER ORAL 5 PA; LA; solution TABLET FOR NEDS DUAKLIR 5 QL (1 per 31 SUSPENSION PRESSAIR days); NEDS treprostinil sodium 4 B/D PA INHALATION injection solution AEROSOL POWDR TYVASO 5 B/D PA; BREATH INHALATION NEDS ACTIVATED SOLUTION FOR NUCALA 5 NEDS NEBULIZATION SUBCUTANEOUS TYVASO REFILL 5 B/D PA; AUTO-INJECTOR KIT INHALATION NEDS NUCALA 5 NEDS SOLUTION FOR SUBCUTANEOUS NEBULIZATION RECON SOLN UPTRAVI ORAL 5 PA; LA; NUCALA 5 NEDS TABLET NEDS SUBCUTANEOUS UPTRAVI ORAL 5 PA; LA; SYRINGE TABLETS,DOSE NEDS PROLASTIN-C 5 PA; NEDS PACK INTRAVENOUS VENTAVIS 5 B/D PA; SOLUTION INHALATION NEDS TRELEGY 3 SOLUTION FOR ELLIPTA NEBULIZATION INHALATION PULMONARY FIBROSIS AGENTS BLISTER WITH DEVICE

RELAXANTS ACTHIB (PF) 3 INTRAMUSCULA SKELETAL MUSCLE RELAXANTS R RECON SOLN chlorzoxazone oral 2 EX; HRM ADACEL(TDAP 3 tablet 250 mg ADOLESN/ADULT cyclobenzaprine oral 2 HRM )(PF) tablet INTRAMUSCULA methocarbamol oral 2 HRM R SUSPENSION tablet ADACEL(TDAP 3 ADOLESN/ADULT

SLEEP DISORDER AGENTS )(PF) GABA RECEPTOR MODULATORS INTRAMUSCULA R SYRINGE zaleplon oral 2 HRM; QL (90 capsule per 90 days) BCG VACCINE, 3 LIVE (PF) zolpidem oral tablet 4 HRM; QL (90 PERCUTANEOUS per 90 days) SUSPENSION FOR zolpidem oral 4 HRM; QL (90 RECONSTITUTIO tablet,ext release per 90 days) N multiphase BEXSERO 3 SLEEP DISORDERS, OTHER INTRAMUSCULA R SYRINGE armodafinil oral 4 PA; QL (90 tablet per 90 days) BOOSTRIX TDAP 3 INTRAMUSCULA HETLIOZ ORAL 5 PA; LA; QL R SUSPENSION CAPSULE (31 per 31 days); NEDS BOOSTRIX TDAP 3 INTRAMUSCULA modafinil oral tablet 4 PA; QL (180 R SYRINGE per 90 days) DAPTACEL (DTAP 3 ramelteon oral tablet 3 QL (90 per 90 PEDIATRIC) (PF) days) INTRAMUSCULA ROZEREM ORAL 3 QL (90 per 90 R SUSPENSION TABLET days) ENGERIX-B (PF) 3 B/D PA XYREM ORAL 5 PA; LA; INTRAMUSCULA SOLUTION NEDS R SUSPENSION VACCINES

Index 1 ARISTADA ...... 32 BENLYSTA ...... 79 buprenorphine hcl ...... 5 ARISTADA INITIO...... 32 BENZEFOAM ...... 59 buprenorphine-naloxone ...... 5 armodafinil ...... 97 benzepro ...... 59 bupropion hcl ...... 17, 18 ASMANEX HFA ...... 92 BENZEPRO bupropion hcl (smoking deter)5 ASMANEX TWISTHALER92 (MICROSPHERES) ...... 59 buspirone ...... 38 aspirin-dipyridamole ...... 45 benzonatate ...... 81 butorphanol ...... 3 ASTAGRAF XL ...... 76 benzoyl peroxide ...... 59 BUTRANS ...... 2 ASTRINGYN ...... 45 benzphetamine ...... 81 BYDUREON ...... 40 atazanavir ...... 37 benztropine ...... 30 BYDUREON BCISE ...... 40 atenolol ...... 46 BERINERT...... 76 BYETTA ...... 40 atenolol-chlorthalidone ...... 48 beser ...... 71 C atomoxetine ...... 53 BETADINE OPHTHALMIC cabergoline ...... 75 atorvastatin ...... 50 PREP ...... 81 CABLIVI...... 45 atovaquone...... 29 betamethasone dipropionate. 56 CABOMETYX ...... 26 atovaquone-proguanil ...... 29 betamethasone valerate ...... 56 calcipotriene...... 58 ATRIPLA ...... 36 betamethasone, augmented .. 56 calcitonin (salmon) ...... 80 atropine...... 67, 87 BETASERON ...... 53 calcitriol...... 58, 81 ATROVENT HFA ...... 93 betaxolol ...... 46, 86 calcium acetate(phosphat bind) AUBAGIO...... 53 bethanechol chloride...... 71 ...... 66 aubra eq ...... 73 BETOPTIC S ...... 86 calcium chloride ...... 62 avar ...... 59 bexarotene ...... 29 CALCIUM DISODIUM AVAR LS ...... 59 BEXSERO ...... 97 VERSENATE ...... 81 AVAR-E...... 59 bicalutamide...... 24 calcium gluconate ...... 62 AVAR-E GREEN ...... 59 BICILLIN C-R...... 10 CALQUENCE ...... 26 AVAR-E LS ...... 59 BICILLIN L-A...... 10 camila ...... 55 avita...... 55 BIKTARVY...... 36 candesartan ...... 45 AVONEX ...... 53 bimatoprost ...... 86 candesartan-hydrochlorothiazid AYVAKIT ...... 25 bisoprolol fumarate ...... 46 ...... 48 AZASITE ...... 11 bisoprolol-hydrochlorothiazide CAPLYTA...... 32 azathioprine ...... 76 ...... 48 CAPRELSA...... 26 azelaic acid ...... 55 BLENREP ...... 28 captopril...... 46 azelastine ...... 87, 90 BLEPHAMIDE S.O.P...... 87 captopril-hydrochlorothiazide azithromycin ...... 11 BOOSTRIX TDAP ...... 97 ...... 48 AZOPT ...... 86 bosentan...... 95 carbamazepine ...... 16 aztreonam ...... 10 BOSULIF ...... 25 carbidopa ...... 30 B bp 10-1 ...... 59 carbidopa-levodopa ...... 30 bacitracin ...... 88 BRAFTOVI ...... 25 carbidopa-levodopa- bacitracin-polymyxin b ...... 87 BREO ELLIPTA...... 93 entacapone ...... 30 baclofen ...... 33 BRILINTA ...... 45 carteolol ...... 86 balsalazide ...... 80 brimonidine...... 86 cartia xt...... 47 BALVERSA ...... 25 BRIVIACT ...... 13 carvedilol ...... 46 BANZEL ...... 16 BROMFED DM ...... 81 carvedilol phosphate...... 46 BAQSIMI ...... 39 bromocriptine...... 30 caspofungin...... 20 BCG VACCINE, LIVE (PF) 97 brompheniramine-pseudoeph- CAVERJECT...... 81 BECONASE AQ...... 92 dm ...... 81 CAYSTON ...... 95 belladonna alkaloids-opium ... 3 BRUKINSA...... 25 cefaclor ...... 8 benazepril ...... 46 budesonide ...... 71, 92 cefadroxil...... 8 benazepril-hydrochlorothiazide bumetanide ...... 50 cefazolin ...... 8 ...... 48 buprenorphine ...... 2 cefazolin in dextrose (iso-os) . 8

Index 2 cefdinir ...... 8 ciclopirox...... 20 colistin (colistimethate na) ..... 7 cefepime ...... 9 cilostazol...... 45 COMBIGAN ...... 86 CEFEPIME IN DEXTROSE 5 CIMDUO...... 36 COMBIVENT RESPIMAT . 93 % ...... 9 cinacalcet ...... 81 COMETRIQ ...... 26 cefepime in dextrose,iso-osm . 9 CIPRO HC...... 89 COMPLERA ...... 36 cefixime ...... 9 CIPRODEX ...... 89 compro ...... 19 cefoxitin...... 9 ciprofloxacin ...... 12 constulose ...... 67 cefoxitin in dextrose, iso-osm 9 ciprofloxacin hcl ...... 12 COPAXONE ...... 53 cefpodoxime ...... 9 ciprofloxacin in 5 % dextrose COPIKTRA ...... 26 cefprozil...... 9 ...... 12 CORLANOR ...... 48, 49 ceftazidime ...... 9 ciprofloxacin-dexamethasone cortisone ...... 71 CEFTAZIDIME IN D5W ...... 9 ...... 89 COSENTYX ...... 79 ceftriaxone ...... 9 citalopram ...... 18 COSENTYX (2 SYRINGES) CEFTRIAXONE ...... 9 claravis ...... 55 ...... 79 ceftriaxone in dextrose,iso-os. 9 clarithromycin ...... 11 COSENTYX PEN ...... 79 cefuroxime axetil...... 9 cleansing wash ...... 59 COSENTYX PEN (2 PENS)79 cefuroxime sodium ...... 9 clindacin etz ...... 6 COTELLIC ...... 26 celecoxib...... 1 clindacin p ...... 6 covaryx h.s...... 73 CELONTIN ...... 15 clindamycin hcl ...... 6 CREON ...... 69 cem-urea ...... 59 CLINDAMYCIN IN 0.9 % CRIXIVAN...... 37 cephalexin...... 9 SOD CHLOR ...... 6 cromolyn...... 69, 87, 95 CERDELGA ...... 69 clindamycin in 5 % dextrose .. 6 crotan...... 61 CETACAINE...... 4 clindamycin pediatric ...... 6 cryoserv ...... 82 cetiri-d ...... 90 clindamycin phosphate 6, 7, 62 CYANOKIT ...... 82 cetirizine ...... 90 CLINDAMYCIN cyclobenzaprine ...... 97 cetirizine-pseudoephedrine .. 90 PHOSPHATE ...... 7 CYCLOMYDRIL ...... 82 CETROTIDE ...... 81 clindamycin-benzoyl peroxide cyclophosphamide ...... 24 cevimeline ...... 55 ...... 56 CYCLOSET ...... 40 CHANTIX ...... 5 clobazam...... 15 cyclosporine...... 76 CHANTIX CONTINUING clobetasol...... 56, 57 cyclosporine modified ...... 76 MONTH BOX...... 5 clobetasol-emollient ...... 57 cyproheptadine ...... 90, 91 CHANTIX STARTING clodan ...... 57 CYSTADANE ...... 69 MONTH BOX...... 5 clomiphene citrate ...... 82 CYSTAGON ...... 69 CHEMET ...... 65 clomipramine ...... 19 CYSTARAN...... 69 children's allergy relief(lor).. 90 clonazepam ...... 38 CYSTO-CONRAY II ...... 82 children's cetirizine...... 90 clonidine ...... 45 D chlordiazepoxide-clidinium . 67 clonidine hcl ...... 45, 53 d10 %-0.45 % sodium chloride chlorhexidine gluconate...... 55 clopidogrel ...... 45 ...... 62 chloroquine phosphate ...... 29 clorazepate dipotassium...... 38 d2.5 %-0.45 % sodium chlorothiazide ...... 50 clotrimazole ...... 20 chloride ...... 62 chlorpromazine ...... 31 clotrimazole-betamethasone. 58 d5 % and 0.9 % sodium chlorthalidone ...... 50 clozapine...... 33 chloride ...... 62 chlorzoxazone ...... 97 COAL TAR (BULK)...... 59 d5 %-0.45 % sodium chloride CHOLBAM ...... 69 COARTEM...... 29 ...... 62 cholestyramine (with sugar) . 51 codeine sulfate ...... 3 dalfampridine ...... 53 cholestyramine light ...... 51 codeine-guaifenesin...... 82 DALIRESP ...... 95 choline,magnesium salicylate. 1 colchicine ...... 22 danazol ...... 73 CIALIS ...... 82 colesevelam ...... 51 dantrolene ...... 34 ciclodan ...... 20 colestipol ...... 51 dapsone...... 23

Index 3 DAPTACEL (DTAP DIASTAT ACUDIAL ...... 15 drospirenone-ethinyl estradiol PEDIATRIC) (PF)...... 97 diazepam...... 15, 38 ...... 54 daptomycin ...... 7 diazoxide ...... 41 DROXIA ...... 24 DARAPRIM ...... 29 diclofenac potassium ...... 1 DUAKLIR PRESSAIR...... 96 DAURISMO ...... 26 diclofenac sodium ...... 1 DUAVEE ...... 74 DEBACTEROL ...... 55 diclofenac-misoprostol ...... 22 DULERA...... 93 deblitane ...... 55 dicloxacillin ...... 10 duloxetine ...... 18 decadron ...... 71 dicyclomine ...... 67 duramorph (pf) ...... 2 deferasirox ...... 65, 66 didanosine...... 36 DUREZOL ...... 88 DELSTRIGO ...... 36 diethylpropion ...... 82 dutasteride ...... 71 demeclocycline ...... 13 DIFICID ...... 11 E DEMSER...... 48 diflorasone ...... 57 e.e.s. 400...... 11 denta 5000 plus ...... 62 diflunisal...... 2 ec-naproxen ...... 2 DEPEN TITRATABS ...... 71 digitek ...... 48 econazole ...... 21 DEPO-PROVERA ...... 74 digox ...... 48 EDEX ...... 82 DESCOVY ...... 36 digoxin ...... 48 ed-spaz ...... 82 desipramine...... 19 dihydroergotamine ...... 22 EDURANT ...... 35 desloratadine ...... 91 DILANTIN 30 MG ...... 16 eemt...... 73 desmopressin ...... 72 diltiazem hcl ...... 47 eemt hs ...... 73 desonide...... 57 dilt-xr...... 47 efavirenz ...... 35 desoximetasone ...... 57 diphenhydramine hcl ...... 91 efavirenz-emtricitabin-tenofov DESVENLAFAXINE ...... 18 diphenoxylate-atropine ...... 67 ...... 36 desvenlafaxine succinate ..... 18 disulfiram ...... 5 efavirenz-lamivu-tenofov disop dexamethasone ...... 71 divalproex ...... 13, 14 ...... 36 dexamethasone intensol ...... 71 dofetilide...... 46 EFFER-K...... 63 dexamethasone sodium DOJOLVI ...... 69 EGRIFTA SV ...... 72 phosphate ...... 88 donepezil ...... 17 eletriptan...... 22 dexchlorpheniramine maleate DONNATAL ...... 67 ELIQUIS ...... 43 ...... 91 DOPTELET (10 TAB PACK) ELIQUIS DVT-PE TREAT dexrazoxane hcl ...... 25 ...... 45 30D START ...... 43 dextroamphetamine ...... 52 DOPTELET (15 TAB PACK) ELMIRON ...... 71 dextroamphetamine- ...... 45 eluryng ...... 54 amphetamine ...... 52 DOPTELET (30 TAB PACK) EMCYT...... 24 dextrose 10 % in water (d10w) ...... 45 EMEND...... 20 ...... 62 dorzolamide ...... 86 EMSAM ...... 18 dextrose 30 % in water (d30w) dorzolamide-timolol ...... 86 emtricitabine ...... 36 ...... 62 dorzolamide-timolol (pf) ..... 86 emtricitabine-tenofovir (tdf) 36 dextrose 40 % in water (d40w) DOVATO ...... 36 EMTRIVA ...... 36 ...... 62 doxazosin...... 45 enalapril maleate ...... 46 dextrose 5 % in water (d5w) 62 doxepin ...... 19 enalapril-hydrochlorothiazide dextrose 5%-0.2 % sod doxy-100...... 13 ...... 48 chloride ...... 62 doxycycline hyclate ...... 13 ENBREL ...... 76, 77 dextrose 5%-0.3 % doxycycline monohydrate .... 13 ENBREL MINI ...... 76 sod.chloride...... 62 DRISDOL...... 66 ENBREL SURECLICK...... 77 dextrose 50 % in water (d50w) drithocreme hp ...... 59 ENDARI...... 67 ...... 63 DRIZALMA SPRINKLE .... 18 endocet ...... 1 dextrose 70 % in water (d70w) dronabinol...... 20 ENDOMETRIN ...... 73 ...... 63 drospirenone-e.estradiol-lm.fa ENGERIX-B (PF) ...... 97, 98 DIASTAT ...... 15 ...... 73

Index 4 ENGERIX-B PEDIATRIC etodolac ...... 2 FIRVANQ ...... 7 (PF) ...... 98 etonogestrel-ethinyl estradiol54 flac otic oil ...... 89 ENHERTU ...... 28 EURAX ...... 61 flavoxate ...... 70 enoxaparin ...... 43 euthyrox...... 74 flecainide ...... 46 entacapone ...... 30 everolimus (antineoplastic) .. 26 FLOVENT DISKUS ...... 92 entecavir ...... 34 everolimus FLOVENT HFA ...... 92 ENTERO VU...... 82 (immunosuppressive)...... 77 fluconazole ...... 21 ENTRESTO...... 48 EVOTAZ ...... 36 fluconazole in nacl (iso-osm)21 enulose ...... 67 exemestane ...... 25 flucytosine ...... 21 ENZOCLEAR...... 59 EXJADE...... 66 fludrocortisone ...... 71 EPCLUSA ...... 34 EXODERM ...... 21 FLUMIST QUAD 2020-2021 EPIDIOLEX ...... 14 EXTAVIA ...... 53, 54 ...... 98 epinastine...... 87 E-Z DISK ...... 82 flunisolide ...... 92 epinephrine ...... 94 EZALLOR SPRINKLE ...... 51 fluocinolone ...... 57, 71 EPINEPHRINE...... 94 ezetimibe ...... 51 fluocinolone acetonide oil.... 89 EPIPEN ...... 94 ezetimibe-simvastatin ...... 48 fluocinolone and shower cap 57 EPIPEN 2-PAK...... 94 E-Z-HD BARIUM ...... 82 fluocinonide ...... 57, 71 EPIPEN JR ...... 94 E-Z-PAQUE ...... 82 fluocinonide-e ...... 57 EPIPEN JR 2-PAK...... 94 E-Z-PASTE ...... 82 fluocinonide-emollient...... 57 epitol ...... 16 F fluorescein-proparacaine...... 87 eplerenone ...... 50 famciclovir...... 35 fluoride (sodium)...... 63 EPOGEN ...... 44 famotidine...... 68 fluoritab ...... 63 eprosartan ...... 45 FANAPT ...... 32 fluorometholone ...... 88 ERAXIS(WATER DILUENT) FARXIGA ...... 40 fluorouracil ...... 58 ...... 21 FARYDAK...... 26 fluoxetine...... 18 ergocalciferol (vitamin d2) .. 66 febuxostat ...... 22 fluphenazine decanoate...... 31 ergoloid ...... 17 felbamate ...... 14 FLUPHENAZINE ERIVEDGE ...... 26 felodipine...... 47 DECANOATE (BULK)... 31 ERLEADA ...... 24 fem ph ...... 82 fluphenazine hcl ...... 31 erlotinib ...... 26 FEMRING ...... 74 flurbiprofen ...... 2 errin ...... 55 fenofibrate ...... 50 flurbiprofen sodium ...... 88 ertapenem ...... 10 fenofibrate micronized...... 50 flutamide...... 24 ery-tab ...... 11 fenofibrate nanocrystallized . 50 fluticasone propionate ... 57, 92 erythrocin (as stearate)...... 11 fenofibric acid ...... 50 fluticasone propion-salmeterol erythromycin...... 12 fenofibric acid (choline) ...... 50 ...... 93 erythromycin ethylsuccinate11, fenoprofen ...... 2 fluvastatin ...... 51 12 fentanyl...... 3 fluvoxamine ...... 18, 19 erythromycin with ethanol ... 62 fentanyl citrate ...... 3 FML S.O.P...... 88 ESBRIET...... 96 FETROJA ...... 9 folic acid ...... 66 escitalopram oxalate ...... 18 FETZIMA...... 18 FOLLISTIM AQ ...... 82 esomeprazole magnesium .... 68 fexofenadine ...... 91 fondaparinux ...... 43 estradiol ...... 73 fexofenadine-pseudoephedrine FORTEO ...... 81 estradiol valerate ...... 74 ...... 91 fosamprenavir ...... 37 ESTRING ...... 74 finasteride ...... 71 fosfomycin tromethamine ...... 7 estrogens-methyltestosterone74 FINTEPLA ...... 14 fosinopril ...... 46 ESTRONE (BULK) ...... 74 FIRAZYR ...... 76 fosinopril-hydrochlorothiazide ethambutol ...... 23 FIRDAPSE ...... 53 ...... 49 ethosuximide...... 15 FIRMAGON KIT W fosphenytoin ...... 16 ethynodiol diac-eth estradiol 54 DILUENT SYRINGE...... 75 FRAGMIN...... 43

Index 5 FREAMINE HBC 6.9 % ..... 66 GLUCAGON (HCL) HUMIRA PEN CROHNS-UC- freamine iii 10 %...... 82 EMERGENCY KIT...... 41 HS START...... 77 frovatriptan ...... 22 GLUCAGON EMERGENCY HUMIRA PEN PSOR- FUL-GLO ...... 82 KIT (HUMAN) ...... 41 UVEITS-ADOL HS ...... 77 furosemide ...... 50 glyburide...... 40 HUMIRA(CF)...... 77 FUZEON ...... 36 glyburide micronized...... 40 HUMIRA(CF) PEDI fyavolv ...... 54 glyburide-metformin ...... 39 CROHNS STARTER ...... 77 FYCOMPA...... 14 glycopyrrolate ...... 67 HUMIRA(CF) PEN...... 77 G GONAL-F ...... 83 HUMIRA(CF) PEN gabapentin ...... 15 GONAL-F RFF ...... 82 CROHNS-UC-HS ...... 77 GALAFOLD...... 69 GONAL-F RFF REDI-JECT82 HUMIRA(CF) PEN PSOR- galantamine...... 17 granisetron hcl ...... 20 UV-ADOL HS ...... 77 GALZIN ...... 82 GRANIX ...... 44 HUMULIN R U-500 (CONC) GAMMAGARD LIQUID.... 78 griseofulvin microsize ...... 21 INSULIN ...... 42 GAMMAKED ...... 78 griseofulvin ultramicrosize .. 21 HUMULIN R U-500 (CONC) GAMMAPLEX...... 78 GUAIACOL ...... 59 KWIKPEN ...... 42 GAMUNEX-C ...... 79 guaiatussin ac...... 83 hydralazine ...... 52 ganciclovir sodium ...... 34 guanidine ...... 23 HYDRAZINE SULFATE GARDASIL 9 (PF) ...... 98 GVOKE HYPOPEN 1-PACK (BULK) ...... 83 GASTROGRAFIN ...... 82 ...... 41 HYDRO 35 ...... 59 GASTROMARK...... 82 GVOKE HYPOPEN 2-PACK HYDRO 40 ...... 59 gatifloxacin ...... 12 ...... 41 hydrochlorothiazide...... 50 GATTEX 30-VIAL ...... 67 GVOKE PFS 1-PACK hydrocodone-acetaminophen . 1 GATTEX ONE-VIAL ...... 67 SYRINGE ...... 41 hydrocodone-chlorpheniramine GAUZE PAD...... 39 GVOKE PFS 2-PACK ...... 83 gavilyte-c ...... 67 SYRINGE ...... 42 hydrocodone-homatropine ... 83 gavilyte-g...... 67 H hydrocodone-ibuprofen ...... 1 gavilyte-n...... 68 HAEGARDA ...... 76 hydrocortisone ...... 57, 71, 80 GAVRETO ...... 26 halobetasol propionate ...... 57 hydrocortisone acetate ...... 71 gemfibrozil ...... 50 haloperidol ...... 31 hydrocortisone valerate...... 58 generlac ...... 67 haloperidol decanoate ...... 31 hydrocortisone-acetic acid ... 89 gengraf ...... 77 haloperidol lactate ...... 31 hydrocortisone-iodoquinol ... 59 gentak ...... 6 HARVONI...... 34 hydrocortisone-pramoxine .. 58, gentamicin ...... 6 HAVRIX (PF)...... 98 71, 72, 80 gentamicin in nacl (iso-osm) .. 6 heather ...... 55 hydromet...... 83 gentamicin sulfate (ped) (pf) .. 6 HEMADY ...... 71 hydromorphone ...... 3, 4 GENVOYA ...... 36 heparin (porcine) ...... 43 hydromorphone (pf) ...... 3 GEODON ...... 32 HERCEPTIN HYLECTA .... 28 hydroquinone microspheres . 59 gianvi (28) ...... 54 HETLIOZ ...... 97 hydroxocobalamin ...... 83 GILENYA ...... 54 HIBERIX (PF) ...... 98 hydroxychloroquine ...... 29 GILOTRIF ...... 26 HISTAMINE PHOSPHATE hydroxyurea ...... 24 glatiramer ...... 54 (BULK) ...... 83 hydroxyzine hcl...... 91 glatopa ...... 54 HISTATROL ...... 83 hydroxyzine pamoate ...... 91 GLEOSTINE ...... 24 homatropaire ...... 83 hyophen ...... 83 glimepiride...... 40 HUMALOG KWIKPEN hyoscyamine sulfate ...... 83 glipizide ...... 40 INSULIN ...... 42 hyosyne ...... 83 glipizide-metformin...... 39 HUMATROPE...... 72 HYPERHEP B S/D ...... 98 GLUCAGEN HYPOKIT ..... 41 HUMIRA...... 77 HYPERHEP B S-D HUMIRA PEN...... 77 NEONATAL...... 98

Index 6 HYQVIA ...... 79 IPOL...... 98 KISQALI FEMARA CO- I ipratropium bromide...... 93 PACK ...... 25 ibandronate ...... 81 ipratropium-albuterol...... 93 klor-con 10 ...... 63 IBRANCE ...... 26 irbesartan ...... 45 klor-con 8 ...... 63 ibu ...... 2 irbesartan-hydrochlorothiazide klor-con m10...... 63 ibuprofen ...... 2 ...... 49 klor-con m15...... 63 ibuprofen-oxycodone...... 1 IRESSA ...... 26 klor-con m20...... 63 icatibant ...... 76 ISENTRESS ...... 35 KOMBIGLYZE XR ...... 39 ICLUSIG ...... 26 ISENTRESS HD ...... 35 KORLYM...... 42 IDHIFA ...... 25 ISOLYTE S PH 7.4 ...... 63 KOSELUGO...... 26 IFEX...... 24 ISOLYTE-P IN 5 % k-tab ...... 63 ILEVRO ...... 88 DEXTROSE...... 63 KUVAN ...... 69 imatinib ...... 26 ISOLYTE-S ...... 63 L IMBRUVICA ...... 26 isoniazid ...... 23 labetalol ...... 46 imipenem-cilastatin ...... 10 isoproterenol hcl...... 52 lactulose...... 67, 68 imipramine hcl ...... 19 isosorbide dinitrate ...... 52 lamivudine ...... 34, 36 imipramine pamoate ...... 19 isosorbide mononitrate ...... 52 lamivudine-zidovudine ...... 37 imiquimod ...... 58 isotretinoin ...... 56 lamotrigine...... 14 IMOVAX RABIES VACCINE isoxsuprine...... 52 lanthanum ...... 66 (PF) ...... 98 isradipine ...... 47 LANTUS SOLOSTAR U-100 IMVEXXY MAINTENANCE itraconazole...... 21 INSULIN ...... 42 PACK ...... 74 ivermectin ...... 29 LANTUS U-100 INSULIN.. 42 IMVEXXY STARTER PACK IXIARO (PF) ...... 98 lapatinib ...... 26 ...... 74 J latanoprost ...... 86 incassia ...... 55 JADENU ...... 66 LATUDA ...... 32 INCRELEX ...... 72 JAKAFI ...... 26 LEDIPASVIR-SOFOSBUVIR indapamide ...... 50 jantoven ...... 43 ...... 34 INFANRIX (DTAP) (PF) .... 98 JANUMET ...... 39 leflunomide ...... 79 INLYTA ...... 26 JANUMET XR ...... 39 LENVIMA...... 27 INOVA ...... 59 JANUVIA...... 41 letrozole ...... 25 INOVA 4-1 ...... 59 jasmiel (28) ...... 54 leucovorin calcium ...... 25 INOVA 8-2 ...... 59 jencycla ...... 55 LEUKERAN...... 24 INQOVI...... 25 JULUCA ...... 36 leuprolide...... 75 INREBIC ...... 26 JYNARQUE ...... 66 levalbuterol hcl ...... 94 INSULIN PEN NEEDLE .... 39 K LEVALBUTEROL INSULIN SYRINGE (DISP) KALETRA ...... 37 TARTRATE...... 94 U-100...... 39 KALYDECO ...... 95 LEVBID ...... 83 INTELENCE ...... 35 kelnor 1-50 ...... 54 levetiracetam...... 14 intralipid ...... 63 KERAFOAM ...... 60 LEVITRA ...... 83 INTRALIPID ...... 63 KERALYT RX ...... 60 levobunolol ...... 86 INTRON A ...... 34 KERALYT SCALP levocarnitine ...... 63 INVEGA SUSTENNA ...... 32 COMPLETE ...... 60 levocarnitine (with sugar) .... 63 INVEGA TRINZA ...... 32 ketoconazole ...... 21 levocetirizine ...... 91 INVIRASE ...... 37 ketodan ...... 21 levofloxacin ...... 12 INVOKAMET ...... 39 ketoprofen...... 2 levofloxacin in d5w ...... 12 INVOKAMET XR ...... 39 ketorolac ...... 88 levorphanol tartrate ...... 3 INVOKANA...... 40, 41 KINRIX (PF) ...... 98 levo-t ...... 74 IODOFLEX ...... 59 kionex (with sorbitol) ...... 66 levothyroxine ...... 74 IODOSORB...... 59 KISQALI ...... 26 levoxyl...... 75

Index 7 LEVSIN...... 83 LUPRON DEPOT (3 mesalamine with cleansing LEVSIN/SL ...... 83 MONTH) ...... 75 wipe ...... 80 LEXIVA ...... 37 LUPRON DEPOT (4 MESNEX ...... 29 LIBTAYO ...... 28 MONTH) ...... 75 metaproterenol ...... 94 lidocaine ...... 4 LUPRON DEPOT (6 metformin ...... 41 lidocaine hcl...... 4 MONTH) ...... 75 methadone ...... 3 lidocaine hcl-hydrocortison ac4 LUPRON DEPOT-PED...... 75 methazolamide ...... 86 lidocaine-hydrocortisone-aloe 4 LUPRON DEPOT-PED (3 methenamine hippurate...... 7 lidocaine-prilocaine ...... 5 MONTH) ...... 75 methen-sod phos-meth blue- lidopin ...... 5 LYNPARZA ...... 27 hyos ...... 84 lindane ...... 61 LYRICA ...... 15 methimazole...... 76 linezolid ...... 7 LYSODREN ...... 75 METHITEST ...... 73 linezolid in dextrose 5% ...... 7 lyza...... 55 methocarbamol...... 97 linezolid-0.9% sodium chloride M methotrexate sodium ...... 77 ...... 7 magnesium sulfate...... 64 methotrexate sodium (pf) ..... 77 LINZESS ...... 67 malathion ...... 61 methoxsalen ...... 58 liothyronine...... 75 maprotiline...... 19 methscopolamine ...... 67 LIQUID E-Z PAQUE ...... 83 MARPLAN...... 18 methylergonovine...... 84 LIQUID POLIBAR PLUS ... 83 MATULANE ...... 24 METHYLERGONOVINE... 84 lisinopril ...... 46 matzim la ...... 47 methylphenidate hcl ...... 53 lisinopril-hydrochlorothiazide maxi-tuss ac ...... 83 methylprednisolone ...... 72 ...... 49 md-gastroview ...... 83 methyltestosterone...... 73 lithium carbonate...... 38, 39 meclizine ...... 19 metoclopramide hcl ...... 19 lithium citrate...... 39 meclofenamate ...... 2 metolazone...... 50 LIVALO ...... 51 medroxyprogesterone ...... 74 METOPIRONE...... 84 LONSURF ...... 25 mefenamic acid ...... 2 metoprolol succinate...... 46 loperamide ...... 68 mefloquine ...... 29 metoprolol ta-hydrochlorothiaz lopinavir-ritonavir ...... 37 megestrol ...... 74 ...... 49 loradamed ...... 91 MEKINIST ...... 27 metoprolol tartrate ...... 46, 47 lorata-d ...... 91 MEKTOVI...... 27 metro i.v...... 7 loratadine ...... 91 meloxicam ...... 2 metronidazole ...... 7 lorata-dine d ...... 91 melphalan ...... 24 metronidazole in nacl (iso-os) 7 loratadine-d ...... 91 memantine ...... 17 metyrosine ...... 49 lorazepam ...... 38 MEMANTINE ...... 17 mexiletine ...... 46 lorazepam intensol ...... 38 MENACTRA (PF) ...... 98 miconazole-3 ...... 21 LORBRENA...... 27 MENEST ...... 74 midodrine ...... 45 lorcet hd...... 1 MENOPUR...... 84 migergot ...... 22 loryna (28) ...... 54 MENQUADFI (PF) ...... 98 miglitol ...... 41 losartan ...... 45 MENTAX ...... 21 miglustat ...... 69 losartan-hydrochlorothiazide 49 MENVEO A-C-Y-W-135-DIP mili ...... 54 loteprednol etabonate ...... 88 (PF) ...... 98 minocycline ...... 13 lovastatin ...... 51 MEPHYTON ...... 66 minoxidil ...... 52 loxapine succinate ...... 31 meprobamate ...... 38 mirtazapine ...... 18 LUCEMYRA ...... 5 mercaptopurine ...... 24 misoprostol ...... 68 ludent fluoride...... 63 meropenem ...... 10 M-M-R II (PF) ...... 98 lugols...... 60, 83 MEROPENEM-0.9% modafinil ...... 97 LUMIGAN ...... 86 SODIUM CHLORIDE .... 10 moexipril ...... 46 LUMOXITI ...... 28 mesalamine ...... 80 molindone ...... 31 LUPRON DEPOT ...... 75 mometasone ...... 58, 92

Index 8 MONJUVI ...... 29 neomycin-bacitracin- norethindrone ac-eth estradiol montelukast...... 92 polymyxin ...... 88 ...... 55 MONUROL ...... 7 neomycin-polymyxin b gu ..... 7 norlyda ...... 55 morgidox ...... 13 neomycin-polymyxin- NORMOSOL-R ...... 64 morphine...... 3, 4 gramicidin ...... 88 NORMOSOL-R PH 7.4...... 64 MORPHINE ...... 4 neomycin-polymyxin-hc 87, 89 NORTHERA ...... 45 morphine (pf) ...... 4 neo-polycin ...... 88 nortriptyline ...... 19 morphine concentrate ...... 3 NEOSTIGMINE NORVIR ...... 37, 38 MOVANTIK ...... 67 METHYLSULFATE ...... 53 NOVOFINE 32 ...... 40 moxifloxacin ...... 12 NEPHRAMINE 5.4 %...... 64 NOVOFINE PLUS...... 40 MULTAQ ...... 46 NERLYNX ...... 27 NOVOLIN 70/30 U-100 mupirocin ...... 7 neuac ...... 56 INSULIN ...... 42 mupirocin calcium...... 7 NEULASTA ...... 44 NOVOLIN 70-30 FLEXPEN MURI-LUBE ...... 84 NEULASTA ONPRO ...... 45 U-100...... 42 MUSE ...... 84 NEULUMEX ...... 84 NOVOLIN N FLEXPEN ..... 42 MYALEPT ...... 68 NEUPOGEN...... 44 NOVOLIN N NPH U-100 mycophenolate mofetil ...... 77 NEUPRO ...... 30 INSULIN ...... 42 mycophenolate sodium ...... 78 NEVANAC...... 88 NOVOLIN R FLEXPEN ..... 42 myorisan ...... 56 nevirapine ...... 35 NOVOLIN R REGULAR U- MYRBETRIQ ...... 70 NEXAVAR...... 27 100 INSULN ...... 42 N niacin...... 51 NOVOLOG FLEXPEN U-100 NABI-HB ...... 99 nicardipine ...... 47 INSULIN ...... 42 nabumetone...... 2 NICOTROL ...... 6 NOVOLOG MIX 70-30 U-100 nadolol...... 47 NICOTROL NS ...... 6 INSULN ...... 42 nadolol-bendroflumethiazide49 nifedipine...... 47 NOVOLOG MIX 70- nafcillin ...... 11, 54 nikki (28) ...... 54 30FLEXPEN U-100 ...... 42 nafcillin in dextrose iso-osm 10 nilutamide ...... 24 NOVOLOG PENFILL U-100 naftifine ...... 21 nimodipine ...... 47 INSULIN ...... 43 nalbuphine ...... 4 NINLARO ...... 25 NOVOLOG U-100 INSULIN naloxone ...... 5 nisoldipine ...... 47 ASPART...... 43 naltrexone ...... 5 nitisinone ...... 69 NOVOPEN ECHO ...... 40 NAMENDA TITRATION nitro-bid ...... 52 NOVOTWIST...... 40 PAK...... 17 NITRO-DUR ...... 52 NOXAFIL ...... 21 NAMENDA XR...... 17 nitrofurantoin ...... 8 NUBEQA ...... 24 NAMZARIC ...... 17 nitrofurantoin macrocrystal.... 7 NUCALA ...... 96 naproxen ...... 2 nitrofurantoin monohyd/m- NUCYNTA...... 4 naproxen sodium ...... 2 cryst ...... 8 NUEDEXTA ...... 53 naratriptan...... 23 nitroglycerin...... 52 NULEV ...... 84 NARCAN ...... 5 nitro-time ...... 52 NUPLAZID ...... 32 NATACYN...... 21 NITYR ...... 69 NUTROPIN AQ NUSPIN ... 73 nateglinide ...... 41 NIVESTYM...... 44 NUVARING ...... 54 NATPARA ...... 81 nizatidine ...... 68 nyamyc ...... 21 NAYZILAM ...... 15 nolix ...... 58 nystatin ...... 21 NEBUPENT ...... 29 nora-be ...... 55 nystatin-triamcinolone ...... 58 NEEDLES, INSULIN NORDITROPIN FLEXPRO 72 nystop ...... 22 DISP.,SAFETY ...... 39 norethindrone (contraceptive) O nefazodone...... 19 ...... 55 octreotide acetate...... 75 neomycin ...... 6 norethindrone acetate ...... 74 ODEFSEY ...... 37 ODOMZO ...... 27

Index 9 OFEV ...... 96 PAIN EASE MEDIUM phenylephrine hcl ...... 84 ofloxacin...... 12 STREAM SPRAY ...... 5 phenytoin ...... 16 olanzapine...... 32 PAIN EASE MIST SPRAY ... 5 phenytoin sodium extended . 16 olanzapine-fluoxetine ...... 18 paliperidone ...... 32 PIFELTRO ...... 35 olmesartan ...... 45 PALYNZIQ ...... 69 pilocarpine hcl ...... 55, 86 olmesartan-amlodipin- PANRETIN ...... 29 pimozide ...... 31 hcthiazid ...... 49 pantoprazole...... 69 pindolol ...... 47 olmesartan- PAREMYD...... 84 pioglitazone ...... 41 hydrochlorothiazide ...... 49 paricalcitol ...... 81 pioglitazone-glimepiride ...... 40 olopatadine ...... 87, 91 paroex oral rinse...... 55 pioglitazone-metformin ...... 40 omega-3 acid ethyl esters..... 51 paromomycin ...... 6 piperacillin-tazobactam ...... 11 omeprazole ...... 68 paroxetine hcl...... 19 PIPERACILLIN- ondansetron...... 20 paroxetine TAZOBACTAM ...... 11 ondansetron hcl ...... 20 mesylate(menop.sym) ...... 19 PIQRAY ...... 27 ONGLYZA ...... 41 PASER ...... 23 piroxicam...... 2 OPSUMIT ...... 95 PAXIL ...... 19 PLASMA-LYTE 148 ...... 64 ORACIT ...... 84 PAZEO ...... 88 PLASMA-LYTE A ...... 64 oralone...... 55 PEDIARIX (PF) ...... 99 PLEGRIDY ...... 54 ORENCIA ...... 78 PEDVAX HIB (PF)...... 99 plenamine ...... 64 ORENCIA CLICKJECT ..... 78 peg 3350-electrolytes ...... 68 PODOCON...... 60 ORENITRAM...... 95 PEGANONE...... 16 podofilox ...... 58 ORFADIN ...... 69 PEGASYS PROCLICK...... 34 POLIBAR ACB ...... 84 ORKAMBI ...... 95 peg-electrolyte ...... 68 POLIVY ...... 29 oscimin ...... 84 PEMAZYRE...... 27 polycin...... 87 oscimin sl...... 84 penicillamine ...... 71 polyethylene glycol 3350 ..... 68 oscimin sr ...... 84 penicillin g potassium ...... 11 polymyxin b sulfate ...... 8 oseltamivir ...... 38 penicillin g procaine ...... 11 polymyxin b sulf-trimethoprim OTREXUP (PF) ...... 78 penicillin g sodium ...... 11 ...... 8 OVACE ...... 60 penicillin v potassium ...... 11 POMALYST...... 24 OVACE PLUS SHAMPOO. 12 PENTACEL (PF) ...... 99 posaconazole...... 22 OVIDREL ...... 84 PENTAM ...... 29 potassium acetate ...... 64 oxacillin ...... 11 pentamidine ...... 29 potassium chlorid-d5- oxacillin in dextrose(iso-osm) PENTASA ...... 80 0.45%nacl ...... 64 ...... 11 pentoxifylline ...... 49 potassium chloride ...... 64 oxandrolone ...... 73 perindopril erbumine ...... 46 potassium chloride in 0.9%nacl oxaprozin ...... 2 periogard...... 55 ...... 64 OXBRYTA...... 44 permethrin ...... 61 potassium chloride in 5 % dex oxcarbazepine ...... 16 perphenazine ...... 31 ...... 64 OXERVATE...... 87 PERSERIS ...... 32 potassium chloride in lr-d5 .. 64 oxiconazole ...... 22 PERTZYE ...... 69 potassium chloride in water . 64 oxybutynin chloride...... 70 phenadoz...... 20 potassium chloride-0.45 % nacl oxycodone ...... 4 phenazopyridine ...... 8 ...... 64 oxycodone-acetaminophen .... 1 phendimetrazine tartrate ...... 84 potassium chloride-d5- oxycodone-aspirin ...... 1 phenelzine...... 18 0.2%nacl ...... 64 oxymorphone ...... 3, 4 phenobarb-hyoscy-atropine- potassium chloride-d5- P scop ...... 68 0.3%nacl ...... 65 pacerone ...... 46 phenobarbital ...... 15 potassium chloride-d5- PACNEX ...... 60 phenohytro ...... 68 0.9%nacl ...... 65 PADCEV ...... 29 phentermine ...... 84 potassium citrate ...... 65

Index 10 potassium phosphate m-/d- progesterone micronized...... 74 RASUVO (PF) ...... 78 basic ...... 65 PROGLYCEM...... 42 RAVICTI...... 70 PR BENZOYL PEROXIDE 60 PROGRAF...... 78 READI-CAT 2 ...... 84 PRADAXA...... 43 PROLASTIN-C ...... 70, 96 REBIF (WITH ALBUMIN). 54 PRALUENT PEN ...... 51 PROLIA ...... 81 REBIF REBIDOSE ...... 54 pramipexole ...... 30 PROMACTA ...... 44 REBIF TITRATION PACK 54 PRAMOSONE...... 72 promethazine ...... 20 RECOMBIVAX HB (PF) .... 99 prasugrel ...... 45 promethazine-codeine...... 84 RECTIV ...... 52 pravastatin ...... 51 promethazine-dm ...... 84 refissa ...... 60 praziquantel ...... 29 promethazine-phenyleph- RELAGARD ...... 85 prazosin ...... 45 codeine ...... 84 RELISTOR ...... 67 PRED MILD ...... 88 promethegan ...... 20 RENOVA ...... 60 PRED-G S.O.P...... 88 propafenone ...... 46 repaglinide ...... 41 prednicarbate ...... 58 proparacaine...... 87 repaglinide-metformin ...... 40 prednisolone...... 72 PROPECIA...... 84 REPATHA...... 51 prednisolone acetate ...... 88 propranolol ...... 47 REPATHA PUSHTRONEX 51 prednisolone sodium phosphate propranolol-hydrochlorothiazid REPATHA SURECLICK .... 52 ...... 72, 88 ...... 49 RESPA-AR...... 91 prednisone ...... 72 propylthiouracil...... 76 RESTASIS...... 87 prednisone intensol...... 72 PROQUAD (PF) ...... 99 RESTASIS MULTIDOSE ... 87 pregabalin ...... 16 protriptyline ...... 19 RETEVMO ...... 27 PREMARIN ...... 74 PROVENTIL HFA...... 94 REVCOVI ...... 69 premasol 10 % ...... 65 PROVOCHOLINE...... 84 REVLIMID...... 24 PRETOMANID ...... 23 PULMICORT FLEXHALER REXULTI ...... 32 prevalite ...... 51 ...... 92 REYATAZ ...... 38 PREVIDENT 5000 BOOSTER PULMOZYME ...... 95 ribavirin ...... 34 PLUS ...... 65 PURIXAN ...... 25 RIDAURA ...... 79 PREVIDENT 5000 ORTHO pyrazinamide ...... 23 rifabutin ...... 23 DEFENSE...... 65 pyridostigmine bromide...... 23 rifampin ...... 23 PREVIDENT 5000 pyrimethamine ...... 30 riluzole ...... 53 SENSITIVE ...... 65 Q rimantadine ...... 38 PREZCOBIX ...... 37 QINLOCK ...... 27 RISPERDAL CONSTA...... 33 PREZISTA ...... 38 QUADRACEL (PF) ...... 99 risperidone ...... 33 PRIFTIN...... 23 quetiapine ...... 32 ritonavir ...... 38 primaquine ...... 30 quinapril ...... 46 rivastigmine ...... 17 primidone ...... 16 quinapril-hydrochlorothiazide rivastigmine tartrate...... 17 PROAIR HFA...... 94 ...... 49 rizatriptan ...... 23 PROAIR RESPICLICK...... 94 quinidine gluconate ...... 46 ROCKLATAN ...... 86 probenecid ...... 22 quinidine sulfate ...... 46 ropinirole ...... 30 probenecid-colchicine...... 22 quinine sulfate...... 30 rosadan ...... 8 prochlorperazine ...... 20 QVAR REDIHALER ...... 92 ROSANIL...... 60 prochlorperazine maleate oral R rosula cleansing cloths...... 60 ...... 31 RABAVERT (PF) ...... 99 rosuvastatin ...... 51 PROCORT...... 72 raloxifene...... 74 ROTARIX ...... 99 PROCRIT ...... 44 ramelteon ...... 97 ROTATEQ VACCINE ...... 99 PROCTOCORT ...... 72 ramipril ...... 46 roweepra ...... 14 procto-med hc ...... 80 ranitidine hcl ...... 68 roweepra xr ...... 14 proctosol hc ...... 80 ranolazine ...... 49 ROZEREM ...... 97 proctozone-hc ...... 80 rasagiline ...... 30 ROZLYTREK...... 27

Index 11 RUBRACA...... 27 sodium chloride 0.9 % ...... 65 sulfacetamide sodium-sulfur13, rufinamide ...... 17 sodium chloride 3 %...... 65 61 RUKOBIA ...... 37 sodium chloride 5 %...... 65 sulfacetamide sod-sulfur-urea RUZURGI ...... 53 sodium fluoride-pot nitrate .. 65 ...... 13 RYDAPT ...... 27 sodium phenylbutyrate ...... 70 sulfacetamide-prednisolone . 87 S sodium phosphate...... 65 sulfacleanse 8-4...... 61 SALEX ...... 60 sodium polystyrene (sorb free) sulfadiazine ...... 13 salicylic acid ...... 60 ...... 66 sulfamethoxazole-trimethoprim SALKERA...... 60 sodium polystyrene sulfonate ...... 13 salsalate ...... 2 ...... 66 sulfasalazine...... 80 salvax ...... 60 SOFOSBUVIR- sulfatrim ...... 13 SALVAX DUO PLUS ...... 60 VELPATASVIR ...... 34 sulindac ...... 2 SAMSCA ...... 66 solifenacin ...... 70 SUMADAN ...... 61 SANDIMMUNE ...... 78 SOLTAMOX ...... 24 sumatriptan ...... 23 SANTYL ...... 58 SOMATULINE DEPOT ..... 76 sumatriptan succinate ...... 23 SAPHRIS ...... 33 SOMAVERT ...... 76 SUMAXIN ...... 61 sapropterin ...... 70 sorine...... 46 SUMAXIN TS ...... 61 SARCLISA...... 29 sotalol ...... 46 SUPRAX ...... 9 SAVELLA ...... 53 sotalol af ...... 46 SUPREP BOWEL PREP KIT SCALACORT DK ...... 72 SOVALDI ...... 34 ...... 68 scopolamine base ...... 20 SPIRIVA RESPIMAT ...... 93 SUTENT...... 27 SECUADO ...... 33 SPIRIVA WITH SYLATRON ...... 34 selegiline hcl ...... 30 HANDIHALER...... 93 SYMAX DUOTAB ...... 85 selenium sulfide ...... 58, 60 spironolactone ...... 50 symax fastabs...... 85 SELZENTRY ...... 37 spironolacton-hydrochlorothiaz symax-sl ...... 85 SEREVENT DISKUS ...... 94 ...... 49 symax-sr ...... 85 SEROSTIM ...... 73 SPRAY AND STRETCH ...... 5 SYMBICORT ...... 93 sertraline ...... 19 SPRITAM...... 14 SYMFI ...... 37 sevelamer carbonate ...... 66 SPRYCEL ...... 27 SYMFI LO ...... 37 sf 5000 plus...... 65 sps (with sorbitol)...... 66 SYMJEPI...... 94 sharobel ...... 55 ssd ...... 8 SYMLINPEN 120 ...... 41 SHINGRIX (PF) ...... 99 SSKI...... 85 SYMLINPEN 60...... 41 SIGNIFOR...... 75 sss 10-5...... 60 SYMPAZAN ...... 16 sildenafil ...... 85 STAMARIL (PF) ...... 79 SYMTUZA...... 37 sildenafil (pulmonary arterial stavudine...... 36 SYNAGIS...... 79 hypertension)...... 96 STAXYN...... 85 SYNAREL...... 76 silver nitrate ...... 60 STELARA ...... 79 SYNRIBO ...... 25 silver sulfadiazine ...... 8 STIMATE...... 73 SYNTHROID ...... 75 SIMBRINZA ...... 86 STIOLTO RESPIMAT ...... 93 T SIMULECT ...... 79 STIVARGA ...... 27 TABLOID ...... 25 simvastatin ...... 51 STRIBILD ...... 37 TABRECTA ...... 27 sirolimus ...... 78 strong iodine ...... 85 tacrolimus ...... 58, 78 SIRTURO ...... 23 subvenite...... 14 tadalafil...... 85 SITZMARKS...... 85 subvenite starter (blue) kit ... 14 tadalafil (pulmonary arterial SKLICE...... 62 subvenite starter (green) kit.. 14 hypertension) oral tablet 20 sodium acetate ...... 65 subvenite starter (orange) kit 14 mg ...... 96 sodium bicarbonate ...... 65 sucralfate ...... 68 TAFINLAR ...... 27 sodium chloride...... 65 sulfacetamide sodium .... 13, 61 TAGRISSO...... 27 sodium chloride 0.45 % ...... 65 sulfacetamide sodium (acne) 12 TALZENNA ...... 27

Index 12 tamoxifen...... 24 tobramycin in 0.225 % nacl . 95 trimipramine ...... 19 tamsulosin...... 71 tobramycin sulfate ...... 6 TRINTELLIX ...... 19 TARGRETIN...... 29 tobramycin-dexamethasone . 87 TRIUMEQ ...... 37 TASIGNA ...... 27 tolcapone ...... 30 TRODELVY...... 29 tazarotene ...... 56 tolmetin ...... 2 TROGARZO ...... 37 taztia xt ...... 47 tolterodine...... 70 trospium...... 70, 71 TAZVERIK ...... 28 tolvaptan ...... 66 TRUMENBA ...... 99 TDVAX ...... 99 topiramate ...... 14 TRUVADA...... 37 TECFIDERA ...... 54 toremifene...... 24 TUDORZA PRESSAIR...... 93 TEFLARO ...... 10 torsemide ...... 50 TUKYSA...... 28 TEGSEDI ...... 70 TOUJEO MAX U-300 tulana...... 55 TEKTURNA HCT ...... 49 SOLOSTAR...... 43 TURALIO ...... 28 telmisartan ...... 46 TOUJEO SOLOSTAR U-300 TUSSICAPS ...... 85 telmisartan-amlodipine ...... 49 INSULIN ...... 43 TWINRIX (PF) ...... 99 telmisartan-hydrochlorothiazid tovet emollient ...... 58 TYBOST ...... 37 ...... 49 TOVIAZ ...... 70 TYKERB ...... 28 TEMIXYS ...... 37 TRACLEER...... 96 TYMLOS ...... 81 TENIVAC (PF) ...... 99 tramadol...... 3, 4 TYPHIM VI...... 99 tenofovir disoproxil fumarate TRAMADOL...... 3 TYVASO...... 96 ...... 36 tramadol-acetaminophen...... 1 TYVASO REFILL KIT ...... 96 terazosin ...... 45 trandolapril ...... 46 U terbutaline ...... 94 trandolapril-verapamil ...... 49 ULORIC ...... 22 terconazole...... 22 tranexamic acid ...... 45 umecta ...... 61 TERSI ...... 61 tranylcypromine ...... 18 unithroid ...... 75 TESSALON PERLES ...... 85 travasol 10 % ...... 65 UPTRAVI...... 96 testosterone ...... 73 TRAVATAN Z ...... 86 URAMAXIN ...... 61 testosterone cypionate ...... 73 travoprost...... 86 urea ...... 61 testosterone enanthate...... 73 trazodone ...... 19 URELLE...... 85 TETANUS,DIPHTHERIA TRECATOR ...... 24 uretron d-s...... 85 TOX PED(PF)...... 99 TRELEGY ELLIPTA...... 96 URIBEL ...... 85 tetrabenazine ...... 53 TRELSTAR ...... 76 urin ds...... 85 tetracaine hcl ...... 87 treprostinil sodium ...... 96 urogesic-blue ...... 85 tetracycline ...... 13 tretinoin (antineoplastic) ...... 29 UROQID-ACID NO.2...... 85 THALOMID ...... 24 tretinoin (emollient)...... 61 ursodiol...... 68 theophylline ...... 95 tretinoin topical ...... 56 uryl ...... 85 thioridazine ...... 31 triamcinolone acetonide. 55, 58 ustell ...... 85 thiothixene ...... 31 triamterene-hydrochlorothiazid V tiadylt er ...... 47 ...... 49 valacyclovir ...... 35 tiagabine ...... 16 triazolam...... 38 VALCHLOR ...... 24 TIBSOVO...... 28 triderm ...... 58 valganciclovir ...... 34 TICE BCG ...... 79 trientine ...... 66 valproic acid ...... 14 timolol maleate ...... 47, 86 trifluoperazine ...... 31 valproic acid (as sodium salt) tinidazole ...... 8 trifluridine...... 35 ...... 14, 16 TIVICAY ...... 35 trihexyphenidyl ...... 30 valrubicin...... 25 TIVICAY PD...... 35 TRIKAFTA ...... 95 valsartan ...... 46 tizanidine ...... 34 TRI-LUMA...... 61 valsartan-hydrochlorothiazide TOBRADEX ...... 87 trilyte with flavor packets .... 68 ...... 49 TOBRADEX ST ...... 87 trimethoprim ...... 8 VALTOCO ...... 16 tobramycin ...... 6 tri-mili ...... 55 vancomycin...... 8

Index 13 VANCOMYCIN ...... 8 VIZIMPRO...... 28 XTANDI...... 24 VANCOMYCIN (BULK) ..... 8 voriconazole...... 22 xulane ...... 54 vandazole...... 8 VOSEVI ...... 34 XUREA ...... 61 VANIQA ...... 61 VOTRIENT ...... 28 XYREM ...... 97 VANOXIDE-HC...... 61 VRAYLAR...... 33 Y VAQTA (PF) ...... 99, 100 VYNDAMAX...... 69 YF-VAX (PF) ...... 100 vardenafil...... 85 VYNDAQEL ...... 69 yuvafem ...... 74 VARIVAX (PF) ...... 100 W Z VARIZIG ...... 100 wal-fex allergy ...... 91 zafirlukast ...... 92 VASCEPA ...... 52 wal-fex d 24 hour ...... 91 zaleplon ...... 97 VECAMYL ...... 49 wal-itin ...... 91 ZARXIO...... 44 VELTASSA...... 66 wal-itin d ...... 91 ZEJULA ...... 28 VENCLEXTA ...... 28 wal-itin d 12 hour ...... 91 ZELBORAF ...... 28 VENCLEXTA STARTING wal-zyr (cetirizine) ...... 92 ZEMAIRA ...... 70 PACK ...... 28 wal-zyr d...... 92 zenatane ...... 56 venlafaxine ...... 19 warfarin ...... 43 ZENPEP ...... 70 VENTAVIS ...... 96 wixela inhub ...... 93 zenzedi ...... 52 VENTOLIN HFA ...... 95 X ZEPZELCA ...... 24 verapamil ...... 48 XALKORI ...... 28 zidovudine ...... 36 VERSACLOZ ...... 33 XARELTO ...... 44 zileuton ...... 93 VERZENIO ...... 28 XARELTO DVT-PE TREAT zionodil...... 5 V-GO 20 ...... 40 30D START ...... 44 ziprasidone hcl ...... 33 V-GO 30 ...... 40 XATMEP ...... 78 ziprasidone mesylate ...... 33 V-GO 40 ...... 40 XCOPRI ...... 15 ZIRGAN...... 34 VICTOZA 2-PAK ...... 41 XCOPRI MAINTENANCE ZOLINZA...... 25 VICTOZA 3-PAK ...... 41 PACK ...... 14 zolmitriptan...... 23 vigabatrin...... 16 XCOPRI TITRATION PACK zolpidem ...... 97 vigadrone ...... 16 ...... 15 zonisamide ...... 17 VIIBRYD ...... 19 XELJANZ ...... 78 ZORTRESS ...... 78 VIMPAT ...... 17 XELJANZ XR ...... 78 ZOSTAVAX (PF) ...... 100 vincasar pfs ...... 25 XENLETA...... 8 Z-TUSS AC ...... 85 VIRACEPT...... 38 XGEVA ...... 81 ZYDELIG...... 28 VIRASAL...... 61 XIFAXAN ...... 8 ZYKADIA ...... 28 VIREAD...... 36 XIGDUO XR ...... 40 ZYPREXA RELPREVV ..... 33 virtussin ac...... 85 XOLAIR...... 79 ZYTIGA ...... 24 VITRAKVI ...... 28 XOSPATA...... 28 VIVOTIF ...... 79 XPOVIO...... 28

Index 14

Confidence comes with every card.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. DB 16028 DEC 20 Y0074_20GrpStdEnhdCmpFrm_C FVNR 1120 R092756 - GrpStdEnhd