Pharmacy | PDL

Your 2021 Prescription Drug List

Traditional 3-Tier

Effective May 1, 2021

This Prescription Drug List (PDL) is accurate as of May 1, 2021 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, River Valley, Oxford, and Student Resources medical plans with a pharmacy benefit subject to the Traditional 3-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan. Table of contents

Understanding your Prescription Drug List (PDL) ...... 4 Medication tips ...... 5 Reading your PDL ...... 6 Questions ...... 7 Analgesics Drugs for Pain ...... 8 Drugs for Pain and Inflammation ...... 9 Anti-Addiction / Substance Abuse Treatment Agents ...... 9 Antibacterials Drugs for Infections ...... 9 Anticoagulants Drugs to Treat or Prevent Blood Clots ...... 11 Anticonvulsants Drugs for Seizures ...... 11 Antidementia Agents Drugs for Alzheimer’s Disease and Dementia ...... 11 Antidepressants Drugs for Depression ...... 11 Antiemetics Drugs for Nausea and Vomiting ...... 12 Antifungals Drugs for Fungal Infections ...... 12 Antigout Agents Drugs for Gout ...... 13 Antimigraine Agents Drugs for Migraines ...... 13 Antineoplastics Drugs for Cancer ...... 13 Antiparasitics Drugs for Parasitic Infections ...... 13 Anti-Parkinson’s Agents Drugs for Parkinson’s Disease ...... 14 Antiplatelets Drugs for Heart Attack and Stroke Prevention ...... 14 Antipsychotics Drugs for Mood Disorders ...... 14 Antivirals Drugs for Viral Infections ...... 14 Anxiolytics Drugs for Anxiety ...... 15 Bipolar Agents Drugs for Mood Disorders ...... 15 Cardiovascular Agents Drugs for Heart and Circulation Conditions ...... 15 Central Nervous System Agents Drugs for Attention Deficit Disorder ...... 17 Drugs for Multiple Sclerosis ...... 18 Miscellaneous ...... 18 Dental and Oral Agents Drugs for Mouth and Throat Conditions ...... 18

2 Dermatological Agents Drugs for Skin Conditions ...... 19 Diabetes Glucose Monitoring ...... 21 Insulin ...... 22 Non-Insulin Agents ...... 23 Drugs for Blood Disorders ...... 23 Drugs for Sexual Dysfunction ...... 24 Electrolytes / Vitamins ...... 24 Gastrointestinal Agents Drugs for Acid Reflux and Ulcer ...... 24 Drugs for Bowel, Intestine and Stomach Conditions ...... 25 Genetic or Enzyme Disorder Drugs for Replacement, Modification, Treatment ...... 25 Genitourinary Agents Drugs for Bladder, Genital and Kidney Conditions...... 25 Drugs for Prostate Conditions ...... 26 Hormonal Agents Hormone Replacement and Birth Control ...... 26 Oral Steroids ...... 28 Other ...... 29 Testosterone Replacement ...... 29 Thyroid ...... 29 Immunological Agents Drugs for Immune System Stimulation or Suppression ...... 30 Infertility Agents ...... 30 Inflammatory Bowel Disease Agents ...... 31 Metabolic Bone Disease Agents Drugs for Osteoporosis ...... 31 Other ...... 31 Ophthalmic Agents Drugs for Eye Allergy, Infection and Inflammation ...... 31 Drugs for Glaucoma ...... 32 Drugs for Miscellaneous Eye Conditions ...... 32 Otic Agents Drugs for Ear Conditions ...... 32 Respiratory Drugs for Anaphylaxis ...... 32 Respiratory Tract / Pulmonary Agents Drugs for Allergies, Cough, Cold ...... 32 Drugs for Asthma and COPD ...... 33 Drugs for Cystic Fibrosis ...... 34 Drugs for Pulmonary Hypertension ...... 34 Skeletal Muscle Relaxants Drugs for Muscle Pain and Spasm...... 34 Sleep Disorder Agents ...... 34 Index ...... 35

3 Understanding your Prescription Drug List (PDL)

What is a PDL? This document is a list of the most commonly prescribed medications. It includes About this PDL both brand-name and generic prescription medications approved by the Food and Where differences exist between Drug Administration (FDA). Medications are listed by common categories or classes this PDL and your benefit plan and placed in tiers that represent the cost you pay out-of-pocket. They are then documents, the benefit plan listed in alphabetical order. documents rule. This PDL is not a complete list of medications, How do I use my PDL? and not all medications listed You and your doctor can consult the PDL to help you select the most cost-effective may be covered by your plan. prescription medications. This guide tells you if a medication is generic or a brand Please look at the benefit plan name, and if there are coverage requirements or limits. Bring this list with you when documents provided by your you see your doctor. If your medication is not listed here, please visit your plan’s employer or health plan to see member website or call the toll-free member phone number on your health plan which medications are covered ID card. under your plan.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or benefit plan. This is how much you will pay when you fill a prescription. See page 6 for more information.

When does the PDL change? PDL changes typically occur 2-3 times per year. However, changes that have a positive impact for you — such as coverage for new medications or cost savings — may occur at any time. You can log in to the member website listed on your ID card at any time to check your medication coverage and lower-cost options.

Why are some medications excluded from coverage? We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or be subject to prior authorization (sometimes referred to as precertification)1 if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications2). There are also some instances where the same product can be made by 2 or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter medications available.

Who decides which medications are covered? Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external doctors and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL Management Committee, which includes senior UnitedHealth Group® doctors and business leaders, meets to evaluate overall health care value. They also set coverage and tier status for all medications.

1. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2. For New York and New Jersey plans, a prescription drug product that is therapeutically equal to an over-the-counter drug may be covered if it is determined to be medically necessary.

4 Medication tips

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

What if I am taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your ID card or call the toll-free phone number on your ID card to learn more. Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll- free phone number on your ID card to talk with a pharmacist about finding lower-cost options.

5 Reading your PDL The PDL gives you choices so you and your doctor can decide your best course of treatment. In this PDL, brand-name medications are shown in UPPERCASE and generic medications in lowercase. Tier information Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. In the chart below, overall value indicates medications’ effectiveness and safety, cost and the availability of alternative medications to treat the same or similar medical condition(s).

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost Use Tier 1 drugs for the Medications that provide the highest overall value. Mostly lowest out-of-pocket costs. generic drugs. Some brand-name drugs may also be included.

Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of Medications that provide good overall value. Mainly preferred Tier 3, to help reduce your brand-name drugs. out-of-pocket costs.

Tier 3 $$$ Highest-cost Ask your doctor if a Tier 1 or Medications that provide the lowest overall value. Tier 2 option could work for you.

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

E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York. (Referred to as First Start in New Jersey) — Lower-cost options are available and covered.

H Health Care Reform Preventive — This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.

H-PA Health Care Reform Preventive with Prior Authorization — May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.

PA Prior Authorization (sometimes referred to as precertification)3 — Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.4

QL Quantity Limits — Specifies the largest quantity of medication covered per copayment or in a defined period of time.

RS Refill and Save Program5 — Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.6

SP Specialty Medication — Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.

ST Step Therapy (referred to as First Start in New Jersey) — Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.7

3 Depending on your benefit, you may have notification or medical necessity requirements for select medications. 4. For certain Student Resources plans, applies to specialty medications and topical retinoids only. 5. Not applicable to Oxford and Student Resources plans. 6. For New York and New Jersey plans, a prescription drug product that is therapeutically equal to an over-the-counter drug may be covered if it is determined to be medically necessary. 7. Not applicable to certain Student Resources plans.

6 Reading your PDL (continued)

Coverage details Some drug classes in this PDL have additional/important coverage details. Review this list to see if drug classes that apply to you are noted. • Diabetes: blood glucose monitoring, insulin, non-insulin Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. Medications that require step therapy may require prior authorization (sometimes referred to as precertification) if covered under another benefit. • Diabetes: continuous glucose monitors, sensors Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Diabetic self-management items, including continuous glucose monitors, may be covered under the consumer pharmacy and/or medical plan depending on the benefit. • Endocrine: growth hormone Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. • Infertility Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans or where a state mandates infertility drug coverage. This is not a covered benefit for Neighborhood Health Plan. • Medications for sexual dysfunction Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.

Questions

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

Call the toll-free member phone number on your ID card. And, if home delivery services are included in your pharmacy Visit your plan’s member website listed on your ID card to: benefit, you can also: • View your pharmacy benefit and coverage information, • Refill prescriptions including prescription history • Check the status of your order • View medication interactions and side effects • Set up reminders for refills • Locate a participating retail pharmacy by ZIP code • Manage your account • Look up possible lower-cost medication alternatives • Compare medication pricing and options

7 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Analgesics - Drugs for Pain g lorcet 1 g acetaminophen-codeine 1 g lorcet hd 1 g acetaminophen-codeine #2 1 g lorcet plus 1 g acetaminophen-codeine #3 1 B LORTAB 3 g acetaminophen-codeine #4 1 B MORPHABOND ER E PA, ST, QL g apap-caff-dihydrocodeine oral 1 QL g morphine sulfate (concentrate) oral 1 capsule solution 100 mg/5ml, 20 mg/ml B ARYMO ER E PA, ST, QL g morphine sulfate er oral capsule E PA, ST, QL B BELBUCA 3 PA, QL extended release 24 hour g g butalbital-apap-caffeine 1 QL morphine sulfate er oral tablet 1 PA, QL extended release B CONZIP E QL g morphine sulfate oral 1 B DILAUDID ORAL 3 g morphine sulfate rectal 1 B DUROLANE E B MS CONTIN 3 PA, ST, QL g endocet 1 B NALOCET E QL B ESGIC 3 QL B NUCYNTA 3 QL g fentanyl transdermal patch 72 hour 1 PA, QL B 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, NUCYNTA ER 3 PA, QL 50 mcg/hr, 75 mcg/hr B OXAYDO E QL g fentanyl transdermal patch 72 hour E PA, ST, QL B OXYCODONE HCL ER E PA, ST, QL 37.5 mcg/hr, 62.5 mcg/hr, g oxycodone hcl oral capsule 1 87.5 mcg/hr g oxycodone hcl oral concentrate 1 B FIORICET 3 QL 100 mg/5ml g hydrocodone-acetaminophen oral 1 g oxycodone hcl oral solution 1 solution 10-325 mg/15ml, g 7.5-325 mg/15ml oxycodone hcl oral tablet 1 QL g g hydrocodone-acetaminophen oral E oxycodone-acetaminophen oral 1 tablet 10-300 mg, 5-300 mg, tablet 10-325 mg, 2.5-325 mg, 7.5-300 mg 5-325 mg, 7.5-325 mg B g hydrocodone-acetaminophen oral 1 OXYCONTIN E PA, ST, QL tablet 10-325 mg, 5-325 mg, g premium lidocaine 1 QL 7.5-325 mg B PRIMLEV E g hydromorphone hcl er 1 PA, ST, QL B SUBSYS E PA, QL g hydromorphone hcl oral 1 g tramadol hcl er (biphasic) E QL g hydromorphone hcl rectal 1 B TRAMADOL HCL ER ORAL E QL B HYSINGLA ER E PA, ST, QL CAPSULE EXTENDED RELEASE 24 B KADIAN ORAL CAPSULE E PA, ST, QL HOUR 100 MG, 200 MG, 300 MG EXTENDED RELEASE 24 HOUR g tramadol hcl er oral capsule 1 QL 200 MG extended release 24 hour 150 mg g lidocaine external ointment 1 QL g tramadol hcl er oral tablet extended 1 QL g lidocaine external patch 5 % 1 PA, QL release 24 hour g g lidocaine-prilocaine external cream 1 tramadol hcl oral tablet 50 mg 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

8 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B TREZIX 1 QL g naproxen dr 1 B TYLENOL WITH CODEINE #3 3 g naproxen oral suspension 1 PA B ULTRAM 3 g naproxen oral tablet 1 B VANATOL LQ 2 PA, QL g naproxen sodium er E B VANATOL S 2 PA, QL g naproxen sodium oral tablet 1 g vicodin hp oral tablet 10-300 mg E 275 mg, 550 mg B B XTAMPZA ER 2 PA, QL PENNSAID E B B ZEBUTAL 3 QL QMIIZ ODT E B B ZOHYDRO ER E PA, ST, QL SPRIX 3 ST, QL B B ZTLIDO E PA, QL VIVLODEX E QL B Analgesics - Drugs for Pain and Inflammation VOLTAREN E B g celecoxib oral 1 QL ZIPSOR E g diclofenac potassium 1 Anti-Addiction / Substance Abuse Treatment Agents B g diclofenac sodium er 1 BUNAVAIL E PA, QL g g diclofenac sodium oral 1 buprenorphine hcl sublingual 1 QL g g diclofenac sodium transdermal gel E buprenorphine hcl-naloxone hcl 1 QL 1 % B CHANTIX 3 PA, H g diclofenac sodium transdermal E B CHANTIX CONTINUING MONTH 3 PA, H solution PAK B EC-NAPROSYN 3 B CHANTIX STARTING MONTH PAK 3 PA, H g ec-naproxen 1 B EVZIO E PA, QL g etodolac 1 g naloxone hcl injection solution 1 g etodolac er 1 g naloxone hcl injection solution 1 g ibu 1 cartridge g g ibuprofen oral suspension E naloxone hcl injection solution 1 prefilled syringe g ibuprofen oral tablet 400 mg, 1 600 mg, 800 mg g naltrexone hcl oral 1 B B INDOCIN 3 NARCAN 2 QL B g indomethacin er 1 ZUBSOLV 1 QL g indomethacin oral capsule 25 mg, 1 Antibacterials - Drugs for Infections 50 mg B AEMCOLO 3 QL g ketorolac tromethamine oral 1 g amoxicillin 1 g meloxicam oral 1 g amoxicillin-potassium clavulanate er E B MOBIC 3 g amoxicillin-potassium clavulanate 1 g nabumetone oral 1 oral B B NAPRELAN ORAL TABLET E AUGMENTIN ORAL SUSPENSION E EXTENDED RELEASE 24 HOUR RECONSTITUTED 125-31.25 750 MG MG/5ML g B NAPROSYN ORAL SUSPENSION 3 PA avidoxy 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

9 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g azithromycin oral 1 g levofloxacin oral 1 B BACTRIM 3 B MACROBID 3 B BACTRIM DS 3 B MACRODANTIN 3 g cefadroxil 1 g metronidazole oral 1 g cefdinir 1 g metronidazole vaginal 1 g cefuroxime axetil 1 g minocycline hcl er oral tablet E PA B CENTANY 3 QL extended release 24 hour 105 mg, 115 mg, 55 mg, 65 mg, 80 mg B CENTANY AT E g minocycline hcl er oral tablet E PA g cephalexin 1 extended release 24 hour 135 mg, B CIPRO ORAL TABLET 3 45 mg, 90 mg g ciprofloxacin hcl oral 1 g minocycline hcl oral capsule 1 g clarithromycin er 1 g minocycline hcl oral tablet E g clarithromycin oral 1 B MINOLIRA E PA B CLEOCIN ORAL CAPSULE 3 g mondoxyne nl oral capsule 100 mg 1 150 MG, 300 MG g mondoxyne nl oral capsule 75 mg E B CLEOCIN ORAL CAPSULE 75 MG 2 g morgidox oral 1 g clindamycin hcl oral 1 g mupirocin calcium 1 QL B CLINDESSE 2 g mupirocin external 1 QL g coremino E PA g nitrofurantoin macrocrystal oral 1 B DIFICID 3 QL g nitrofurantoin monohydrate 1 B DORYX MPC E macrocrystals g doxycycline hyclate oral capsule 1 B NUVESSA E g doxycycline hyclate oral tablet 1 B NUZYRA 3 QL 100 mg, 20 mg g okebo E g doxycycline hyclate oral tablet E g penicillin v potassium 1 150 mg, 50 mg, 75 mg g sulfamethoxazole-trimethoprim oral 1 g doxycycline hyclate oral tablet E g delayed release sulfatrim pediatric 1 g g doxycycline monohydrate oral 1 vandazole 1 capsule 100 mg, 50 mg B VIBRAMYCIN ORAL CAPSULE 3 g doxycycline monohydrate oral E B VIBRAMYCIN ORAL SUSPENSION 3 capsule 150 mg, 75 mg RECONSTITUTED g doxycycline monohydrate oral 1 B XENLETA 3 suspension reconstituted B XEPI 3 QL g doxycycline monohydrate oral 1 B XIFAXAN 3 PA,QL tablet B XIMINO E PA B FLAGYL 3 B ZITHROMAX ORAL 3 B KEFLEX 3 B ZITHROMAX TRI-PAK 3 B LEVAQUIN ORAL TABLET 500 MG, 3 B 750 MG ZITHROMAX Z-PAK 3

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

10 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Anticoagulants - Drugs to Treat or Prevent Blood Clots g levetiracetam oral 1 B BEVYXXA 3 QL B NAYZILAM 3 PA, QL B COUMADIN 3 B NEURONTIN 3 PA, ST B ELIQUIS 2 QL g oxcarbazepine 1 B ELIQUIS DVT/PE STARTER PACK 2 QL B OXTELLAR XR E PA, ST g enoxaparin sodium 1 QL g roweepra 1 g jantoven 1 g roweepra xr 1 B PRADAXA 2 QL B SPRITAM E PA, ST g warfarin sodium oral 1 g subvenite 1 B XARELTO 2 QL g subvenite starter kit-blue 1 B XARELTO STARTER PACK 2 QL g subvenite starter kit-green 1 Anticonvulsants - Drugs for Seizures g subvenite starter kit-orange 1 g carbamazepine er 1 B TEGRETOL 3 g carbamazepine oral 1 B TEGRETOL-XR 3 B CARBATROL 3 B TOPAMAX 3 PA, ST B DEPAKOTE 3 PA B TOPAMAX SPRINKLE 3 PA, ST B DEPAKOTE ER 3 PA, ST g topiramate er E PA, ST B DEPAKOTE SPRINKLES 3 PA, ST g topiramate oral 1 g divalproex sodium er 1 B TRILEPTAL 3 PA, ST g divalproex sodium oral 1 B TROKENDI XR E PA, ST g epitol 1 B VALTOCO 3 PA, QL g gabapentin oral 1 B VIMPAT ORAL 3 PA B KEPPRA ORAL 3 PA, ST B XCOPRI 3 PA B KEPPRA XR 3 PA, ST B ZONEGRAN 3 PA, ST B LAMICTAL 3 PA, ST g zonisamide oral 1 B LAMICTAL ODT ORAL KIT 3 PA, ST Antidementia Agents - Drugs for Alzheimer’s Disease B LAMICTAL ODT ORAL TABLET 3 PA, ST and Dementia DISPERSIBLE B ARICEPT ORAL TABLET 10 MG, 3 B LAMICTAL STARTER 3 PA, ST 5 MG g B LAMICTAL XR 3 PA, ST donepezil hcl oral tablet 10 mg, 1 5 mg g lamotrigine er 1 PA, ST g donepezil hcl oral tablet 23 mg E g lamotrigine oral tablet 1 g donepezil hcl oral tablet dispersible 1 g lamotrigine oral tablet chewable 1 Antidepressants - Drugs for Depression g lamotrigine oral tablet dispersible 1 PA, ST g amitriptyline hcl oral 1 g lamotrigine starter kit-blue 1 g bupropion hcl er (sr) 1 g lamotrigine starter kit-green 1 g bupropion hcl er (xl) oral tablet 1 g lamotrigine starter kit-orange 1 extended release 24 hour 150 mg, g levetiracetam er 1 300 mg

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

11 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B BUPROPION HCL ER (XL) ORAL E QL g venlafaxine hcl er oral tablet E QL TABLET EXTENDED RELEASE extended release 24 hour 24 HOUR 450 MG B VIIBRYD 3 QL g bupropion hcl oral 1 B VIIBRYD STARTER PACK 3 g citalopram hydrobromide 1 Antiemetics - Drugs for Nausea and Vomiting g desvenlafaxine succinate er 1 QL B BONJESTA E PA g doxepin hcl oral capsule 1 g doxylamine-pyridoxine E PA g doxepin hcl oral concentrate 1 g metoclopramide hcl oral solution 1 B DRIZALMA SPRINKLE 3 PA, QL 5 mg/5ml g duloxetine hcl oral capsule delayed 1 QL g metoclopramide hcl oral tablet 1 release particles 20 mg, 30 mg, g metoclopramide hcl oral tablet E 60 mg dispersible g duloxetine hcl oral capsule delayed E g ondansetron hcl oral 1 release particles 40 mg g ondansetron odt 1 g escitalopram oxalate 1 g phenadoz 1 g fluoxetine hcl oral capsule 1 g prochlorperazine maleate oral 1 g fluoxetine hcl oral capsule delayed 1 QL g release promethazine hcl oral tablet 1 g g fluoxetine hcl oral solution 1 promethazine hcl rectal 1 g g fluoxetine hcl oral tablet 10 mg 1 QL promethegan 1 B g fluoxetine hcl oral tablet 20 mg 1 REGLAN 3 g g fluoxetine hcl oral tablet 60 mg E scopolamine 1 B g fluvoxamine maleate 1 TRANSDERM-SCOP (1.5 MG) 3 B g fluvoxamine maleate er 1 QL VARUBI (180 MG DOSE) E QL B B FORFIVO XL E QL ZOFRAN 3 B g mirtazapine oral 1 ZUPLENZ E QL g nortriptyline hcl oral 1 Antifungals - Drugs for Fungal Infections g B PAMELOR 3 ciclodan 1 g g paroxetine hcl 1 ciclopirox 1 g g paroxetine hcl er 1 QL ciclopirox treatment E B B PAXIL ORAL SUSPENSION 3 CRESEMBA ORAL 3 B B PAXIL ORAL TABLET 3 DIFLUCAN ORAL SUSPENSION 3 RECONSTITUTED B REMERON 3 B DIFLUCAN ORAL TABLET 100 MG, 3 B REMERON SOLTAB 3 150 MG, 200 MG g sertraline hcl oral 1 B DIFLUCAN ORAL TABLET 50 MG 3 g trazodone hcl oral 1 B EXTINA 3 ST, QL B TRINTELLIX 3 ST, QL g fluconazole oral 1 g venlafaxine hcl 1 B GYNAZOLE-1 3 g venlafaxine hcl er oral capsule 1 g ketoconazole external cream 1 QL extended release 24 hour

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

12 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g ketoconazole external foam 1 ST, QL Antineoplastics - Drugs for Cancer g ketoconazole external shampoo 1 B ALECENSA 2 PA, QL, SP g ketodan external foam 1 ST, QL B ALUNBRIG 2 PA, QL, SP B NIZORAL 3 g anastrozole oral 1 g nyamyc 1 QL g bexarotene E SP g nystatin external 1 QL B CALQUENCE 2 PA, QL, SP g nystatin mouth/throat 1 g capecitabine 1 QL, SP g nystop 1 QL B ERLEADA 2 PA, QL, SP g terbinafine hcl oral 1 QL B IBRANCE ORAL CAPSULE 2 PA, QL, SP g terconazole 1 B IDHIFA 2 PA, QL, SP B XOLEGEL 3 g imatinib mesylate 1 PA, QL, SP Antigout Agents - Drugs for Gout B KOSELUGO 2 PA, QL, SP g allopurinol oral 1 g letrozole oral 1 B COLCHICINE ORAL CAPSULE E B LYNPARZA 2 PA, QL, SP g colchicine oral tablet E g mercaptopurine oral 1 B COLCRYS E B NUBEQA 2 PA, QL, SP g febuxostat 1 ST, QL B PURIXAN 3 PA, SP B GLOPERBA 3 PA B REVLIMID 2 PA, QL, SP B MITIGARE 2 B ROZLYTREK 2 PA, QL, SP B ZYLOPRIM 3 B SOLTAMOX E Antimigraine Agents - Drugs for Migraines g tamoxifen citrate oral tablet 10 mg 1 B AIMOVIG 2 PA, ST, QL g tamoxifen citrate oral tablet 20 mg 1 H-PA B AIMOVIG SUBCUTANEOUS 2 PA, ST, QL B TARGRETIN EXTERNAL 3 QL, SP SOLUTION AUTO-INJECTOR B TARGRETIN ORAL 1 SP 140 MG/ML B TASIGNA 2 PA, ST, QL, SP B AMERGE 3 QL B VERZENIO 2 PA, QL, SP g eletriptan hydrobromide 1 QL B VITRAKVI 2 PA, QL, SP B EMGALITY 2 PA, ST, QL B ZEJULA 2 PA, QL, SP B EMGALITY (300 MG DOSE) 2 PA, ST, QL Antiparasitics - Drugs for Parasitic Infections g naratriptan hcl 1 QL B ARAKODA 3 QL B ONZETRA XSAIL E QL g atovaquone-proguanil hcl 1 B REYVOW 2 PA, ST, QL B ELIMITE 3 g rizatriptan benzoate 1 QL g hydroxychloroquine sulfate oral 1 g sumatriptan succinate oral 1 QL B KRINTAFEL 1 QL g sumatriptan succinate refill 1 QL B MALARONE 3 g sumatriptan succinate 1 QL g subcutaneous permethrin external 1 B UBRELVY 2 PA, ST, QL B ZEMBRACE SYMTOUCH E QL

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

13 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Antiparkinson Agents - Drugs for Parkinson’s Disease B DOVATO 2 QL g carbidopa-levodopa 1 g emtricitabine-tenofovir df 1 QL, H g carbidopa-levodopa er 1 g entecavir 1 SP B DUOPA 3 PA B EPCLUSA 2 PA, QL, SP B INBRIJA 3 PA, QL, SP B GENVOYA 3 QL B KYNMOBI 3 PA, QL, SP B HARVONI 2 PA, ST, QL, SP B MIRAPEX 3 B ISENTRESS 2 B NOURIANZ 3 PA, QL B ISENTRESS HD 2 g pramipexole dihydrochloride 1 B JULUCA 2 QL g pramipexole dihydrochloride er E B LEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SP g ropinirole hcl 1 B LEDIP-SOFOSB ORAL TABLET 2 PA, ST, QL, SP g ropinirole hcl er E 90-400MG B B RYTARY E MAVYRET 2 PA, QL, SP B B SINEMET 3 NORVIR ORAL PACKET 2 B Antiplatelets - Drugs for Heart Attack and Stroke NORVIR ORAL SOLUTION 2 Prevention B ODEFSEY 3 QL B BRILINTA 3 QL g oseltamivir phosphate oral capsule 1 g clopidogrel bisulfate oral 1 g oseltamivir phosphate oral 1 QL B ZONTIVITY 3 QL suspension reconstituted B Antipsychotics - Drugs for Mood Disorders PREZCOBIX 2 B B ABILIFY MYCITE E PA, QL PREZISTA 2 g g aripiprazole oral solution 1 ritonavir 1 B g aripiprazole oral tablet 1 QL RUKOBIA 3 PA B g aripiprazole oral tablet dispersible 1 QL SITAVIG E QL B B LATUDA 3 QL SOFOS/VELPAT ORAL TABLET 2 PA, QL, SP 400-100 g olanzapine oral 1 QL B SOFOSBUVIR-VELPATASVIR 2 PA, QL, SP g quetiapine fumarate 1 B STRIBILD 3 QL g quetiapine fumarate er 1 QL B SYMFI 2 QL g risperidone 1 B SYMFI LO 2 QL B SAPHRIS 3 QL B TEMIXYS E QL B VRAYLAR 3 ST, QL g tenofovir disoproxil fumarate 1 g ziprasidone hcl 1 QL B TIVICAY 3 Antivirals - Drugs for Viral Infections B TRIUMEQ 2 QL g acyclovir oral 1 B TRUVADA E QL B ATRIPLA E ST, QL g valacyclovir hcl oral 1 QL B BARACLUDE ORAL SOLUTION 2 SP B VEMLIDY 3 ST, SP B CIMDUO 2 QL B VIREAD ORAL POWDER 3 B DESCOVY E PA, ST, QL

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

14 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B VIREAD ORAL TABLET 150 MG, 2 B ALTACE 3 200 MG, 250 MG B ALTOPREV E B VOSEVI 2 PA, QL, SP g amiodarone hcl oral 1 B XOFLUZA (40 MG DOSE) 3 QL g amlodipine besylate oral 1 B XOFLUZA (80 MG DOSE) 3 QL g amlodipine besylate-benazepril hcl 1 B ZEPATIER 2 PA, QL, SP g amlodipine besylate-valsartan 1 B ZOVIRAX ORAL SUSPENSION 3 g atenolol oral 1 Anxiolytics - Drugs for Anxiety g atenolol-chlorthalidone 1 g alprazolam er 1 g atorvastatin calcium oral tablet 1 QL, H-PA g alprazolam intensol 1 10 mg, 20 mg g alprazolam oral 1 g atorvastatin calcium oral tablet 1 QL g alprazolam xr 1 40 mg, 80 mg B g buspirone hcl oral 1 AVALIDE 3 g g clonazepam oral 1 benazepril hcl oral 1 g g diazepam intensol 1 benazepril-hydrochlorothiazide 1 B g diazepam oral 1 BIDIL 2 g B HALCION 3 bisoprolol fumarate 1 g g hydroxyzine hcl oral 1 bisoprolol-hydrochlorothiazide 1 B g hydroxyzine pamoate oral 1 BYSTOLIC E B g lorazepam intensol 1 CALAN SR 3 B g lorazepam oral concentrate 1 CARDIZEM LA ORAL TABLET E 2 mg/ml EXTENDED RELEASE 24 HOUR 120 MG g lorazepam oral tablet 1 B CARDURA 3 g triazolam 1 B CAROSPIR 3 PA B VISTARIL 3 g cartia xt 1 Bipolar Agents - Drugs for Mood Disorders g carvedilol 1 g lithium carbonate er 1 B CATAPRES 3 g lithium carbonate oral 1 g chlorthalidone 1 B LITHOBID 3 g clonidine hcl oral 1 Cardiovascular Agents - Drugs for Heart and Circulation g Conditions colesevelam hcl E B B ACCUPRIL 3 COREG 3 B g acetazolamide er 1 CORGARD 3 B g acetazolamide oral 1 CORLANOR 3 PA, QL g B ADALAT CC ORAL TABLET 3 diltiazem hcl er coated beads 1 EXTENDED RELEASE 24 HOUR g diltiazem hcl er oral capsule 1 60 MG extended release 12 hour B ALDACTONE 3 g diltiazem hcl oral 1 g aliskiren fumarate 1 g dilt-xr 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

15 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g doxazosin mesylate oral 1 g losartan potassium-hctz 1 B DYAZIDE 3 B LOTENSIN 3 B EDARBI 3 B LOTENSIN HCT 3 B EDARBYCLOR 3 g lovastatin 1 H g enalapril maleate oral 1 g matzim la 1 B EPANED 3 PA B MAXZIDE 3 B EZALLOR SPRINKLE 3 PA B MAXZIDE-25 3 g ezetimibe 1 g metoprolol succinate er 1 g ezetimibe-simvastatin 1 g metoprolol tartrate oral tablet 1 g fenofibrate oral capsule 150 mg, E 100 mg, 25 mg, 50 mg 50 mg g metoprolol tartrate oral tablet E g fenofibrate oral tablet 120 mg, E 37.5 mg, 75 mg 40 mg, 48 mg B MINIPRESS 3 g fenofibrate oral tablet 160 mg, 1 g minitran 1 145 mg, 54 mg B MULTAQ 3 PA g flecainide acetate 1 g nadolol oral 1 B FLOLIPID 3 PA B NEXLETOL 2 PA, ST, QL g furosemide oral 1 B NEXLIZET 2 PA, ST, QL g gemfibrozil oral 1 g niacin (antihyperlipidemic) E B GONITRO E QL g niacin er (antihyperlipidemic) 1 g guanfacine hcl 1 g niacor E B HEMANGEOL E B NIASPAN 3 g hydralazine hcl oral 1 g nifedipine er 1 g hydrochlorothiazide oral 1 g nifedipine er osmotic release 1 B HYZAAR 3 g nifedipine oral 1 g icosapent ethyl E PA B NITRO-BID 2 g irbesartan 1 B NITRO-DUR 3 g irbesartan-hydrochlorothiazide 1 g nitroglycerin sublingual 1 g isosorbide mononitrate 1 g nitroglycerin transdermal 1 g isosorbide mononitrate er 1 g nitroglycerin translingual E QL B KAPSPARGO SPRINKLE 3 B NITROMIST 3 QL g labetalol hcl oral 1 B NITROSTAT 3 B LASIX 3 g nitro-time 1 B LIPOFEN E g olmesartan medoxomil oral 1 g lisinopril oral 1 g olmesartan medoxomil-hctz 1 g lisinopril-hydrochlorothiazide 1 g omega-3-acid ethyl esters 1 B LOPID 3 B PACERONE ORAL TABLET 3 B LOPRESSOR 3 100 MG, 400 MG g losartan potassium 1 g pacerone oral tablet 200 mg 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

16 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B PRALUENT 2 PA, ST, QL B ZIAC ORAL TABLET 10-6.25 MG, 3 B PRAVACHOL 3 2.5-6.25 MG B g pravastatin sodium 1 ZIAC ORAL TABLET 5-6.25 MG 3 B g prazosin hcl oral 1 ZOCOR ORAL TABLET 10 MG, 3 20 MG, 40 MG, 80 MG B PRINIVIL 3 Central Nervous System Agents - Drugs for Attention B PROCARDIA 3 Deficit Disorder B PROCARDIA XL 3 B ADDERALL XR 1 QL g propranolol hcl er 1 B ADHANSIA XR E PA, QL g propranolol hcl oral 1 g amphetamine-dextroamphetamine 1 PA B QBRELIS 3 PA g amphetamine-dextroamphetamine E QL g quinapril hcl 1 er g ramipril 1 B APTENSIO XR E PA, QL g ranolazine er 1 g atomoxetine hcl 1 QL B REPATHA 2 PA, ST, QL B CONCERTA 1 PA, QL B REPATHA PUSHTRONEX SYSTEM 2 PA, ST, QL g dexmethylphenidate hcl 1 PA B REPATHA SURECLICK 2 PA, ST, QL g dexmethylphenidate hcl er 1 PA, QL g rosuvastatin calcium 1 QL g dextroamphetamine sulfate 1 PA g simvastatin oral tablet 10 mg, 1 H-PA g dextroamphetamine sulfate er 1 PA 20 mg, 40 mg, 5 mg B FOCALIN 3 PA g simvastatin oral tablet 80 mg 1 g guanfacine hcl er 1 QL g sotalol hcl oral 1 B JORNAY PM E PA, QL B SOTYLIZE 3 PA g metadate er 1 PA, QL g spironolactone oral 1 B METHYLIN 3 PA B TEKTURNA 3 g methylphenidate hcl er (cd) 1 PA, QL B TEKTURNA HCT 3 g methylphenidate hcl er (la) oral 1 PA, QL g telmisartan 1 capsule extended release 24 hour B TOPROL XL 3 10 mg, 20 mg, 30 mg, 40 mg g torsemide 1 g methylphenidate hcl er (la) oral 1 PA capsule extended release 24 hour g triamterene-hctz 1 60 mg g valsartan 1 g methylphenidate hcl er oral tablet 1 PA, QL g valsartan-hydrochlorothiazide 1 extended release 10 mg, 20 mg B VASCEPA ORAL CAPSULE 0.5 GM E PA g methylphenidate hcl er oral tablet E PA, QL B VASCEPA ORAL CAPSULE 1 GM E PA extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg g verapamil hcl er 1 g methylphenidate hcl er oral tablet E PA, QL g verapamil hcl oral 1 extended release 24 hour B VERELAN 3 g methylphenidate hcl oral 1 PA B VERELAN PM 3 B MYDAYIS E PA, QL B WELCHOL 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

17 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B PROCENTRA 3 PA Central Nervous System Agents - Miscellaneous B QUILLICHEW ER E PA, QL B AUSTEDO 2 PA, QL, SP B QUILLIVANT XR E PA, QL B LYRICA 3 PA, ST, QL g relexxii E PA, QL B LYRICA CR E ST, QL B RITALIN 3 PA B NUEDEXTA 2 PA B VYVANSE 3 PA, QL g pregabalin oral 1 QL B ZENZEDI ORAL TABLET 15 MG, E PA B RILUTEK 3 SP 2.5 MG, 20 MG, 30 MG, 7.5 MG g riluzole 1 SP Central Nervous System Agents - Drugs for Multiple B TIGLUTIK 3 PA Sclerosis Dental and Oral Agents - Drugs for Mouth and Throat B AUBAGIO 3 PA, QL, SP Conditions B AVONEX PEN 2 PA, QL, SP g cavarest 1 B AVONEX PREFILLED 2 PA, QL, SP g chlorhexidine gluconate mouth/ 1 B BAFIERTAM CAPSULE 2 PA, QL, SP throat B BETASERON 2 PA, QL, SP g clinpro 5000 1 g dalfampridine er 1 PA, QL, SP g denta 5000 plus 1 g dimethyl fumarate 1 PA, QL, SP g dentagel 1 B EXTAVIA E PA, ST, QL, SP g fluoridex 1 B GILENYA 3 PA, QL, SP g fluoridex enhanced whitening 1 g glatiramer acetate 1 PA, QL, SP g lidocaine hcl mouth/throat 1 g glatopa 1 PA, QL, SP g lidocaine viscous hcl 1 B KESIMPTA 2 PA, QL, SP B NAFRINSE DAILY/NEUTRAL 2 B MAVENCLAD (10 TABS) 3 PA, ST, QL, SP B NAFRINSE WEEKLY 3 B MAVENCLAD (4 TABS) 3 PA, ST, QL, SP g neutral sodium fluoride 1 B MAVENCLAD (5 TABS) 3 PA, ST, QL, SP g paroex 1 B MAVENCLAD (6 TABS) 3 PA, ST, QL, SP B PERIDEX 3 B MAVENCLAD (7 TABS) 3 PA, ST, QL, SP g periogard 1 B MAVENCLAD (8 TABS) 3 PA, ST, QL, SP B PREVIDENT 5000 BOOSTER PLUS 3 B MAVENCLAD (9 TABS) 3 PA, ST, QL, SP B PREVIDENT 5000 DRY MOUTH 3 B MAYZENT 3 PA, QL, SP B PREVIDENT 5000 ORTHO 3 B MAYZENT STARTER PACK 3 PA, QL, SP DEFENSE B B PLEGRIDY 3 PA, QL, SP PREVIDENT 5000 PLUS 3 B B PLEGRIDY STARTER PACK 3 PA, QL, SP PREVIDENT DENTAL 3 B B REBIF 3 PA, ST, QL, SP PREVIDENT MOUTH/THROAT 3 g B REBIF REBIDOSE 3 PA, ST, QL, SP sf 1 g B REBIF REBIDOSE TITRATION 3 PA, ST, QL, SP sf 5000 plus 1 PACK g sodium fluoride 5000 plus 1 B REBIF TITRATION PACK 3 PA, ST, QL, SP g sodium fluoride dental 1 B TECFIDERA E PA, QL, SP B ZEPOSIA 3 PA, QL, SP

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

18 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Dermatological Agents - Drugs for Skin Conditions g clindamycin phosphate external 1 QL B ABSORICA E PA solution g B ACZONE EXTERNAL GEL 5 % 1 QL clindamycin phosphate external 1 swab B ACZONE EXTERNAL GEL 7.5 % 3 QL B CLINDAMYCIN PHOSPHATE GEL E B ALA SCALP 3 1 % EXTERNAL g ala-cort external cream 1 % E g clindamycin phosphate gel 1 % 1 QL g ala-cort external cream 2.5 % 1 external B ALDARA 3 QL g clobetasol propionate external 1 QL B ALTRENO E PA, QL cream g amnesteem 1 g clobetasol propionate external foam E QL B AMZEEQ 3 PA, QL g clobetasol propionate external gel 1 QL g avar cleanser 1 g clobetasol propionate external 1 QL liquid B AVAR LS CLEANSER E g clobetasol propionate external E QL B AVAR-E EMOLLIENT 3 lotion B AVAR-E GREEN 3 g clobetasol propionate external 1 QL B AVAR-E LS 3 ointment g avita E PA, QL g clobetasol propionate external E QL g azelaic acid external 1 shampoo g betamethasone dipropionate aug 1 g clobetasol propionate external 1 QL solution g betamethasone dipropionate 1 external g clodan external shampoo E QL g bp 10-1 1 g clotrimazole-betamethasone 1 QL external cream g calcipotriene-betameth diprop 1 QL external ointment g clotrimazole-betamethasone 1 external lotion g calcitriol external 1 QL g dapsone external gel 5 % E QL B CAPEX 2 B DERMA-SMOOTHE/FS BODY 3 QL B CARAC 2 B DERMA-SMOOTHE/FS SCALP 3 g claravis 1 B DESONATE 3 ST, QL B CLEOCIN-T EXTERNAL GEL 3 QL g desonide external 1 QL B CLEOCIN-T EXTERNAL LOTION 3 B DESOWEN 3 QL g clindacin etz external swab 1 B DIPROLENE 3 g clindacin-p 1 B DIPROLENE AF 3 B CLINDAGEL E QL B DUPIXENT 3 PA, ST, QL, SP g clindamycin phos-benzoyl perox 1 QL external gel 1.2-5 % B EFUDEX 3 g clindamycin phosphate external 1 B ENSTILAR 3 QL foam B EUCRISA 3 ST, QL g clindamycin phosphate external 1 B EVOCLIN 3 lotion

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

19 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B FINACEA 3 B RHOFADE 3 PA, QL g fluocinolone acetonide body 1 QL g rosadan external cream 1 g fluocinolone acetonide external 1 QL g rosadan external gel 1 g fluocinolone acetonide scalp 1 B SERNIVO E QL g fluocinonide external cream 0.05 % 1 B SOOLANTRA 3 QL g fluocinonide external cream 0.1 % E QL g sss 10-5 1 g fluocinonide external gel 1 g sulfacetamide sodium-sulfur 1 g fluocinonide external ointment 1 external cream 10-2 %, 10-5 % g g fluocinonide external solution 1 sulfacetamide sodium-sulfur E external cream 9.8-4.8 % B FLUOROPLEX 3 g sulfacetamide sodium-sulfur 1 B FLUOROURACIL EXTERNAL 3 external emulsion CREAM 0.5 % g sulfacetamide sodium-sulfur E g fluorouracil external cream 5 % 1 external liquid 10-2 %, 9.8-4.8 % g fluorouracil external solution 1 g sulfacetamide sodium-sulfur 1 g hydrocortisone external cream 1 % E external liquid 9-4 %, 9-4.5 % g hydrocortisone external cream 1 g sulfacetamide sodium-sulfur 1 2.5 % external lotion 10-5 % g hydrocortisone external lotion 2.5 % 1 g sulfacetamide sodium-sulfur E g hydrocortisone external ointment 1 external lotion 9.8-4.8 % 1 %, 2.5 % g sulfacetamide sodium-sulfur 1 g imiquimod external 1 QL external pad B IMIQUIMOD PUMP E QL g sulfacetamide sodium-sulfur 1 external suspension 10-5 % B IMPOYZ E QL g sulfacetamide sodium-sulfur E g isotretinoin oral 1 external suspension 8-4 % B METROCREAM 3 g sulfacleanse 8/4 E B METROLOTION 3 g sulfamez wash 1 g metronidazole external cream 1 B SUMADAN WASH E g metronidazole external gel 0.75 % 1 B SUMAXIN 3 g metronidazole external gel 1 % E B SUMAXIN WASH 3 g metronidazole external lotion 1 B TACLONEX EXTERNAL 3 B MIRVASO 3 PA, QL SUSPENSION g mometasone furoate external 1 g tazarotene external 1 PA, QL g myorisan 1 B TAZORAC 3 PA, QL g neuac external gel 1 QL B TEMOVATE 3 QL B NORITATE E B TEXACORT 2 B PICATO 3 QL B TOLAK E B PLEXION E g tretinoin external cream 1 QL B PLEXION CLEANSER E g tretinoin external gel 0.01 %, 0.05 % E B PLEXION CLEANSING CLOTH E g tretinoin external gel 0.025 % E

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

20 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g triamcinolone acetonide external 1 QL B ACCU-CHEK SOFTCLIX LANCET 1 aerosol solution DEVICE KIT g triamcinolone acetonide external 1 B BD AUTOSHIELD DUO PEN 2 cream 0.025 %, 0.1 % NEEDLES g triamcinolone acetonide external 1 QL B BD ULTRA-FINE INSULIN 2 cream 0.5 % SYRINGES g triamcinolone acetonide external 1 B BD ULTRA-FINE PEN NEEDLES 2 lotion B CONTOUR NEXT EZ MONITOR 2 g triamcinolone acetonide external 1 B CONTOUR NEXT LNK MONITOR E ointment 0.025 %, 0.1 %, 0.5 % B CONTOUR NEXT MONITOR 2 g triamcinolone acetonide external E B ointment 0.05 % CONTOUR NEXT ONE MONITOR 2 B g trianex E CONTOUR NEXT TEST STRIP 2 QL B g triderm external cream 0.1 % 1 CONTOUR TEST STRIP E QL B g triderm external cream 0.5 % 1 QL DEXCOM G4 / G5 / G6 RECEIVER, 3 PA, QL TRANSMITTER, SENSOR B TRIDESILON 1 QL (INCLUDING PLATINUM, B VERDESO E QL PLATINUM PEDIATRIC) g zenatane 1 B DEXCOM G4 / G5 / G6 RECEIVER, 3 PA, QL B ZILXI 3 PA, ST, QL TRANSMITTER, SENSOR (INCLUDING PLATINUM, B ZYCLARA E QL PLATINUM PEDIATRIC) DEVICE B ZYCLARA PUMP E QL B EASYPLUS BLOOD GLUCOSE E QL Diabetes - Glucose Monitoring TEST B ACCU-CHEK AVIVA CONNECT KIT E B FREESTYLE LIBRE 14 DAY 3 PA, QL W/DEVICE READER B ACCU-CHEK AVIVA DEVICE E B FREESTYLE LIBRE 14 DAY 3 PA, QL B ACCU-CHEK AVIVA PLUS KIT E SENSOR W/DEVICE B FREESTYLE LIBRE READER 3 PA, QL B ACCU-CHEK AVIVA PLUS TEST E QL B FREESTYLE LIBRE SENSOR 3 PA, QL STRIPS SYSTEM B ACCU-CHEK COMPACT PLUS E B FREESTYLE PRECISION NEO E QL CARE KIT TEST B ACCU-CHEK COMPACT PLUS E QL B GUARDIAN CONNECT 3 PA, QL TEST STRIPS TRANSMITTER B ACCU-CHEK GUIDE KIT W/DEVICE 3 B GUARDIAN LINK 3 TRANSMITTER 3 B ACCU-CHEK GUIDE ME KIT 3 B GUARDIAN SENSOR (3) 3 PA W/DEVICE B INSULIN SYRINGES 2 B ACCU-CHEK GUIDE TEST STRIPS 3 QL B LANCETS 1 B ACCU-CHEK NANO SMARTVIEW E B NOVOFINE AUTOCOVER PEN 2 KIT W/DEVICE NEEDLE B ACCU-CHEK SMARTVIEW TEST E QL B NOVOFINE PEN NEEDLE 2 STRIPS B NOVOFINE PLUS PEN NEEDLE 2

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

21 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B ONETOUCH ULTRA 2 KIT 1 B HUMALOG MIX 50/50 KWIKPEN 2 QL W/DEVICE B HUMALOG MIX 50/50 VIAL 1 QL B ONETOUCH ULTRA BLUE TEST 1 QL B HUMALOG MIX 75/25 KWIKPEN 2 QL STRIPS IN VITRO STRIP B HUMALOG MIX 75/25 VIAL 1 QL B ONETOUCH ULTRA MINI KIT 1 B W/DEVICE HUMALOG SUBCUTANEOUS 1 QL SOLUTION B ONETOUCH VERIO FLEX SYSTEM 1 B KIT W/DEVICE HUMALOG SUBCUTANEOUS 2 QL SOLUTION CARTRIDGE B ONETOUCH VERIO IQ SYSTEM 1 B HUMALOG U-100 JUNIOR 2 QL B ONETOUCH VERIO KIT W/DEVICE 1 KWIKPEN B ONETOUCH VERIO SYNC SYSTEM 1 B HUMULIN 70/30 KWIKPEN 2 QL KIT W/DEVICE B HUMULIN 70/30 VIAL 1 QL B ONETOUCH VERIO TEST STRIPS 1 QL B HUMULIN N KWIKPEN 2 QL B PRECISION LINK E B HUMULIN N VIAL 1 QL B PRECISION PCX PLUS TEST E QL B HUMULIN R U-500 KWIKPEN 2 QL B PRECISION QID MONITOR E B HUMULIN R U-500 VIAL 1 QL B PRECISION QID TEST E QL (CONCENTRATED) B PRECISION SOF-TACT MONITOR E B HUMULIN R VIAL 1 QL B PRECISION SOF-TACT TEST E QL B INSULIN ASPART E ST, QL B PRECISION XTRA BLOOD E QL B INSULIN ASPART FLEXPEN E ST, QL GLUCOSE B INSULIN ASPART PENFILL E ST, QL B PRECISION XTRA DEVICE E B INSULIN LISPRO E QL B PRECISION XTRA KIT E B INSULIN LISPRO (1 UNIT DIAL) E QL B PRECISION XTRA MONITOR E B LANTUS SOLOSTAR 1 QL B RELION BLOOD GLUCOSE TEST E QL B LANTUS U-100 VIAL 1 QL B RELION ULTIMA TEST E QL B LEVEMIR U-100 FLEXTOUCH E QL B SOFTCLIX 1 B LEVEMIR U-100 VIAL E QL B TRUE METRIX BLOOD GLUCOSE E QL B TEST LYUMJEV KWIKPEN 2 QL B B TRUETRACK TEST E QL LYUMJEV VIAL 1 QL B Diabetes - Insulin NOVOLIN 70/30 FLEXPEN E ST, QL B B ADMELOG E QL NOVOLIN 70/30 FLEXPEN RELION E ST, QL B B ADMELOG SOLOSTAR E QL NOVOLIN 70/30 RELION E ST, QL B B AFREZZA INHALATION POWDER E PA, QL NOVOLIN 70/30 VIAL E ST, QL 12 UNIT, 4 UNIT B NOVOLIN N FLEXPEN E ST, QL B AFREZZA INHALATION POWDER E PA, QL B NOVOLIN N FLEXPEN RELION E ST, QL 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 B NOVOLIN N RELION E ST, QL UNIT & 90X8 UNIT, 90 X 8 UNIT & B NOVOLIN N VIAL E ST, QL 90X12 UNIT B NOVOLIN R FLEXPEN E ST, QL B BASAGLAR KWIKPEN E QL B NOVOLIN R FLEXPEN RELION E ST, QL B HUMALOG KWIKPEN 2 QL

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

22 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B NOVOLIN R RELION E ST, QL B JARDIANCE 2 ST, QL B NOVOLIN R VIAL E ST, QL B JENTADUETO 2 QL B NOVOLOG FLEXPEN E ST, QL B JENTADUETO XR 2 QL B NOVOLOG PENFILL E ST, QL B KAZANO 2 QL B NOVOLOG U-100 VIAL E ST, QL B KOMBIGLYZE XR 2 QL B TOUJEO MAX SOLOSTAR 2 QL g metformin hcl er 1 B TOUJEO SOLOSTAR 2 QL g metformin hcl er (mod) E PA B TRESIBA E QL g metformin hcl er (osm) E PA B TRESIBA FLEXTOUCH E QL B METFORMIN HCL ORAL 1 Diabetes - Non-Insulin Agents SOLUTION g B ADLYXIN 3 PA, ST, QL metformin hcl oral tablet 1 B B ADLYXIN STARTER PACK 3 PA, ST, QL NESINA 2 QL B B ALOGLIPTIN BENZOATE E QL ONGLYZA 2 QL B B ALOGLIPTIN-METFORMIN HCL E QL OSENI 2 QL B B ALOGLIPTIN-PIOGLITAZONE E QL OZEMPIC 2 PA, ST, QL B B AMARYL 3 pioglitazone hcl 1 QL B B BAQSIMI ONE PACK 2 QL RYBELSUS 2 PA, ST, QL B B BAQSIMI TWO PACK 2 QL SOLIQUA 2 QL B B BYDUREON 2 PA, ST, QL SYMLINPEN 60 3 QL B B BYDUREON BCISE 2 PA, ST, QL SYMLNPEN 120 3 QL AUTOINJECTOR B SYNJARDY 2 QL B BYETTA 5 MCG PEN 2 PA, ST, QL B SYNJARDY XR 2 QL B BYETTA 10 MCG PEN 2 PA, ST, QL B TRADJENTA 2 QL B FARXIGA E ST, QL B TRIJARDY XR 2 QL g glimepiride 1 B TRULICITY 2 PA, ST, QL g glipizide er 1 B VICTOZA SOLUTION PEN- 2 PA, ST, QL g glipizide ir 1 INJECTOR 18 MG/3ML SUBCUTANEOUS (2 Pak) g glipizide xl 1 B VICTOZA SOLUTION PEN- 3 PA, ST, QL B GLUCAGON EMERGENCY KIT 2 QL INJECTOR 18 MG/3ML INJECTION KIT SUBCUTANEOUS (3 Pak) B GLUCOTROL 3 Drugs for Blood Disorders B GLUCOTROL XL 3 B ADVATE 2 SP B GLUCOVANCE ORAL TABLET 3 B ADYNOVATE 3 PA, SP 5-500 MG B AFSTYLA INTRAVENOUS KIT 1000 3 PA, SP g glyburide oral 1 UNIT, 2000 UNIT, 250 UNIT, 3000 g glyburide-metformin 1 UNIT, 500 UNIT B GLYXAMBI 2 ST, QL B AFSTYLA INTRAVENOUS KIT 1500 3 PA, SP B GVOKE HYPOPEN, PFS 2 QL UNIT, 2500 UNIT B JANUVIA E ST, QL B ARANESP (ALBUMIN FREE) 2 QL, SP

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

23 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B ELOCTATE 3 PA, SP g multi-vitamin/fluoride 1 B JIVI 3 PA, SP g multivitamin/fluoride oral solution 1 B KOGENATE FS 2 SP g multivitamin/fluoride oral tablet 1 B KOVALTRY 2 SP chewable 0.25 mg, 0.5 mg, 1 mg g B MULPLETA 2 PA, QL, SP multivitamins/fluoride 1 g B NEULASTA 3 SP mvc-fluoride 1 B B NOVOEIGHT 2 SP NASCOBAL 3 B B NUWIQ 2 SP POLY-VI-FLOR 3 g B RECOMBINATE 2 SP potassium chloride crys er 1 g B RETACRIT 2 QL, SP potassium chloride er 1 g B ZARXIO 2 SP potassium chloride oral 1 g B ZIEXTENZO 3 potassium citrate er 1 B Drugs for Sexual Dysfunction QUFLORA PEDIATRIC 3 B B ADDYI 3 PA, QL UROCIT-K 10 3 B B IMVEXXY MAINTENANCE PACK 3 QL UROCIT-K 15 3 B B IMVEXXY STARTER PACK 3 QL UROCIT-K 5 3 B B INTRAROSA 3 QL VELTASSA 3 PA, QL g B OSPHENA 3 PA, QL vitamin d (ergocalciferol) oral 1 capsule 1.25 mg (50000 ut) g sildenafil citrate oral tablet 100 mg, 1 QL 25 mg, 50 mg Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer B B STENDRA 3 PA, QL ACIPHEX SPRINKLE E QL B g tadalafil oral tablet 10 mg, 20 mg 1 QL CYTOTEC 3 B g tadalafil oral tablet 2.5 mg, 5 mg 1 ST, QL DEXILANT 3 QL g B VYLEESI 3 PA, QL misoprostol oral 1 B Electrolytes / Vitamins OMECLAMOX-PAK 3 QL g B DRISDOL 3 omeprazole oral capsule delayed 1 release B ERGOCAL 3 g pantoprazole sodium tablet delayed 1 g ergocalciferol oral capsule 1 release 20 mg oral B FLORIVA PLUS 3 g pantoprazole sodium tablet delayed E g folic acid oral tablet 1 mg 1 release 20 mg oral g klor-con 1 g pantoprazole sodium tablet delayed 1 g klor-con 10 1 release 40 mg oral g klor-con m10 1 g pantoprazole sodium tablet delayed E release 40 mg oral B KLOR-CON M15 3 B PROTONIX ORAL PACKET E g klor-con m20 1 B PYLERA 3 QL g klor-con sprinkle 1 B RABEPRAZOLE SODIUM ORAL E QL B K-TAB 3 CAPSULE SPRINKLE B LOKELMA 3 PA, QL

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

24 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g rabeprazole sodium oral tablet 1 QL B SYMPROIC 2 PA, QL delayed release B TRULANCE 3 PA, ST, QL g sucralfate oral 1 B URSO 250 3 Gastrointestinal Agents - Drugs for Bowel, Intestine and B URSO FORTE 3 Stomach Conditions g ursodiol oral 1 B ACTIGALL 3 B VIBERZI 3 PA, QL B ANASPAZ 2 B ZELNORM 3 PA, ST, QL B CLENPIQ 3 Genetic or Enzyme Disorder - Drugs for Replacement, g dicyclomine hcl oral 1 Modification, Treatment g diphenoxylate-atropine 1 B CERDELGA 2 PA, SP g ed-spaz 1 g clovique E PA, SP g gavilyte-c 1 H B CREON 2 g gavilyte-g 1 QL, H B CUPRIMINE E SP B GOLYTELY ORAL SOLUTION 2 QL B DEPEN TITRATABS 2 SP RECONSTITUTED 227.1 GM B ENDARI 3 PA, QL B GOLYTELY ORAL SOLUTION 3 QL g RECONSTITUTED 236 GM nitisinone E PA, SP B g hyoscyamine sulfate er 1 NITYR E PA, SP B g hyoscyamine sulfate oral 1 ORFADIN ORAL CAPSULE 2 PA, SP B g hyoscyamine sulfate sl 1 ORFADIN ORAL SUSPENSION 2 PA, SP B g hyoscyamine sulfate sublingual 1 PANCREAZE 3 ST g g hyosyne 1 penicillamine oral capsule 1 SP B B LEVBID 3 PERTZYE 3 ST B B LEVSIN ORAL 3 STRENSIQ 2 PA, QL, SP B B LEVSIN/SL 3 TEGSEDI 2 PA, QL, SP g B LINZESS 2 PA, QL trientine hcl 1 PA, SP B B LOMOTIL 3 VIOKACE 3 ST B B MOTEGRITY 3 PA, QL ZENPEP 2 B MOVIPREP 3 QL Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions B NULEV 3 B AURYXIA 3 g oscimin 1 B DITROPAN XL 3 g oscimin sr 1 B GELNIQUE E g peg-3350/electrolytes 1 QL, H g oxybutynin chloride er 1 B PLENVU 3 QL g oxybutynin chloride oral 1 B PREPOPIK 3 QL g phenazo oral tablet 200 mg 1 B SUPREP BOWEL PREP KIT 3 QL g phenazopyridine hcl oral tablet 100 1 B SYMAX DUOTAB 3 mg, 200 mg g symax-sl 1 B PYRIDIUM 3 g symax-sr 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

25 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g solifenacin 1 g camila 1 H B TOVIAZ 3 g camrese 1 H B VELPHORO 2 g camrese lo 1 H Genitourinary Agents - Drugs for Prostate Conditions g chateal 1 H g alfuzosin hcl er 1 g chateal eq 1 H g finasteride oral tablet 5 mg 1 B CLIMARA PRO 3 QL B PROSCAR 3 g cryselle-28 1 H g tamsulosin hcl 1 g cyclafem 1/35 1 H g terazosin hcl 1 g cyred 1 H Hormonal Agents - Hormone Replacement and Birth g cyred eq 1 H Control g dasetta 1/35 1 H g afirmelle 1 H g daysee 1 H B ALORA TRANSDERMAL PATCH 3 QL g deblitane 1 H TWICE WEEKLY 0.025 MG/24HR, g delyla 1 H 0.075 MG/24HR, 0.1 MG/24HR B g altavera 1 H DEPO-PROVERA 3 QL INTRAMUSCULAR SUSPENSION g alyacen 1/35 1 H 150 MG/ML g amethia 1 H B DEPO-PROVERA 3 g amethia lo 1 H INTRAMUSCULAR SUSPENSION g apri 1 H PREFILLED SYRINGE B g ashlyna 1 H DEPO-SUBQ PROVERA 104 2 QL g g aubra 1 H desogestrel-ethinyl estradiol 1 H B g aubra eq 1 H DIVIGEL TRANSDERMAL GEL 3 0.25 MG/0.25GM, 0.5 MG/0.5GM, g aurovela 1.5/30 1 H 0.75 MG/0.75GM, 1 MG/GM g aurovela 1/20 1 H g dotti E QL g aurovela 24 fe 1 H g drospiren-eth estrad-levomefol E g aurovela fe 1.5/30 1 H g drospirenone-ethinyl estradiol 1 H g aurovela fe 1/20 1 H B DUAVEE 3 QL g aviane 1 H B ELESTRIN 3 B AYGESTIN 3 g elinest 1 H g ayuna 1 H g eluryng E g azurette 1 H g emoquette 1 H g balziva 1 H g enskyce 1 H g bekyree 1 H g errin 1 H B BIJUVA 3 g estarylla 1 H g blisovi 24 fe 1 H B ESTRACE ORAL 3 g blisovi fe 1.5/30 1 H g estradiol oral 1 g blisovi fe 1/20 1 H g estradiol patch twice weekly 1 QL g briellyn 1 H transdermal (generic for Minivelle)

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

26 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g estradiol patch twice weekly E QL g lessina 1 H transdermal (generic for Vivelle- g levonorgest-eth est & eth est E Dot) g levonorgest-eth estrad 91-day 1 H g estradiol transdermal patch weekly 1 QL g (generic for Climara) levonorgestrel-ethinyl estrad oral 1 H tablet 0.1-20 mg-mcg, g estradiol vaginal cream 1 0.15-30 mg-mcg g estradiol vaginal tablet 1 g levora 0.15/30 (28) 1 H B ESTRING 2 QL g lillow 1 H B ESTROGEL 3 QL B LO LOESTRIN FE 3 g etonogestrel-ethinyl estradiol E B LOESTRIN 1.5/30 (21) 3 B EVAMIST 2 B LOESTRIN 1/20 (21) 3 g falmina 1 H B LOESTRIN FE 1.5/30 3 g fayosim E B LOESTRIN FE 1/20 3 g femynor 1 H g loryna 1 H g gianvi 1 H B LOSEASONIQUE 3 g hailey 1.5/30 1 H g low-ogestrel 1 H g hailey 24 fe 1 H g lo-zumandimine 1 H g heather 1 H g lutera 1 H g incassia 1 H g lyza 1 H g introvale 1 H g marlissa 1 H g isibloom 1 H g medroxyprogesterone acetate 1 QL, H g jasmiel 1 H intramuscular suspension g jencycla 1 H g medroxyprogesterone acetate 1 H g jolessa 1 H intramuscular suspension prefilled syringe g juleber 1 H g medroxyprogesterone acetate oral 1 g junel 1.5/30 1 H g melodetta 24 fe E g junel 1/20 1 H B MENOSTAR 3 QL g junel fe 1.5/30 1 H g mibelas 24 fe E g junel fe 1/20 1 H g microgestin 1.5/30 1 H g junel fe 24 1 H g microgestin 1/20 1 H g kalliga 1 H g microgestin fe 1.5/30 1 H g kariva 1 H g microgestin fe 1/20 1 H g kurvelo 1 H g mili 1 H g larin 1.5/30 1 H B MIRCETTE 3 g larin 1/20 1 H g mono-linyah 1 H g larin 24 fe 1 H B NATAZIA 2 g larin fe 1.5/30 1 H g necon 0.5/35 (28) 1 H g larin fe 1/20 1 H g nikki 1 H g larissia 1 H g nora-be 1 H

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

27 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g norethin ace-eth estrad-fe oral 1 H g syeda 1 H tablet g tarina 24 fe 1 H g norethin ace-eth estrad-fe oral E g tarina fe 1/20 1 H tablet chewable g tarina fe 1/20 eq 1 H g norethindrone acetate oral 1 B TAYTULLA E g norethindrone acet-ethinyl est 1 H g tri femynor 1 H g norethindrone oral 1 H g tri-estarylla 1 H g norgestimate-eth estradiol 1 H g tri-linyah 1 H g norgestimate-ethinyl estradiol 1 H g triphasic tri-lo-estarylla 1 H g g norlyda 1 H tri-lo-mili 1 H g g norlyroc 1 H tri-lo-sprintec 1 H g g nortrel 0.5/35 (28) 1 H tri-mili 1 H g g nortrel 1/35 (21) 1 H tri-previfem 1 H g g nortrel 1/35 (28) 1 H tri-sprintec 1 H g B NUVARING 1 H tri-vylibra 1 H g g ocella 1 H tri-vylibra lo 1 H g g ogestrel 1 H tulana 1 H g g orsythia 1 H tydemy E g B ORTHO MICRONOR 3 vienva 1 H g g philith 1 H viorele 1 H B g pimtrea 1 H VIVELLE-DOT 1 QL g g pirmella 1/35 1 H vyfemla 1 H g g portia-28 1 H vylibra 1 H g B PREMARIN ORAL 3 wera 1 H g B PREMARIN VAGINAL 3 xulane 1 H B B PREMPHASE 3 YASMIN 28 3 B B PREMPRO 3 YAZ 3 g g previfem 1 H yuvafem 1 g g progesterone micronized oral 1 zarah 1 H g B PROVERA 3 zumandimine 1 H g reclipsen 1 H Hormonal Agents - Oral Steroids B g rivelsa E CORTEF 3 B g setlakin 1 H DECADRON E g g sharobel 1 H dexamethasone intensol 1 g g simliya 1 H dexamethasone oral 1 B g simpesse 1 H DEXPAK 10 DAY 3 B g sprintec 28 1 H DEXPAK 13 DAY 3 B g sronyx 1 H DEXPAK 6 DAY 3

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

28 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B DXEVO 11-DAY E g octreotide 1 PA, SP B HIDEX 6-DAY E B OMNITROPE E PA, QL, SP g hydrocortisone oral 1 B ORIAHNN 3 PA, QL B MEDROL ORAL TABLET 16 MG, 3 B ORILISSA 3 PA, QL 4 MG, 8 MG B SOMATULINE DEPOT 3 SP B MEDROL ORAL TABLET 2 MG 2 B STIMATE 3 B MEDROL ORAL TABLET 32 MG 3 B ZOMACTON E PA, QL, SP B MEDROL ORAL TABLET THERAPY 3 Hormonal Agents - Testosterone Replacement PACK B ANDRODERM 2 PA, QL g methylprednisolone oral 1 B DEPO-TESTOSTERONE E B MILLIPRED 2 INTRAMUSCULAR SOLUTION B MILLIPRED DP 2 100 MG/ML B MILLIPRED DP 12-DAY 2 B DEPO-TESTOSTERONE E B ORAPRED ODT 3 INTRAMUSCULAR SOLUTION 200 MG/ML B PEDIAPRED 2 B NATESTO E PA, QL g prednisolone oral solution 1 B STRIANT 3 PA, QL g prednisolone sodium phosphate 1 B oral TESTIM 1 PA, QL B g prednisone intensol 1 TESTOSTERONE CYPIONATE E INJECTION g prednisone oral 1 g testosterone cypionate E B RAYOS E intramuscular B TAPERDEX 12-DAY 3 g testosterone enanthate 1 B TAPERDEX 6-DAY ORAL TABLET 3 intramuscular THERAPY PACK 1.5 MG (21) g testosterone transdermal E PA, QL B TAPERDEX 7-DAY 3 B XYOSTED E PA Hormonal Agents - Other Hormonal Agents - Thyroid g cabergoline 1 B ARMOUR THYROID 3 B DDAVP INJECTION 3 g euthyrox 1 B DDAVP ORAL 3 g levo-t 1 g desmopressin acetate injection 1 g levothyroxine sodium oral 1 g desmopressin acetate oral 1 g levoxyl 1 B GENOTROPIN E PA, QL, SP g liothyronine sodium oral 1 B GENOTROPIN MINIQUICK E PA, QL, SP g methimazole oral 1 B HUMATROPE E PA, QL, SP B NATURE-THROID 3 B NOCDURNA 3 PA, QL g np thyroid 1 B NORDITROPIN FLEXPRO E PA, QL, SP B SYNTHROID E B NUTROPIN AQ NUSPIN 10 2 PA, QL, SP B TAPAZOLE 3 B NUTROPIN AQ NUSPIN 20 2 PA, QL, SP g thyroid oral tablet 120 mg, 15 mg, 1 B NUTROPIN AQ NUSPIN 5 2 PA, QL, SP 30 mg, 60 mg, 90 mg

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

29 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B TIROSINT E B OLUMIANT 2 PA, QL, SP B TIROSINT-SOL 3 PA B ORENCIA 3 PA, ST, QL, SP g unithroid 1 B ORENCIA CLICKJET 3 PA, ST, QL, SP B WESTHROID 3 B OTEZLA 2 PA, QL, SP B WP THYROID 3 B OTREXUP E QL Immunological Agents - Drugs for Immune System B PROGRAF ORAL PACKET 3 PA Stimulation or Suppression B RAPAMUNE ORAL SOLUTION 3 SP B ACTEMRA ACTPEN 3 PA, QL, SP B RASUVO 2 QL B ACTEMRA SUBCUTANEOUS 3 PA, ST, QL, SP B RINVOQ 2 PA, QL, SP B ASTAGRAF XL E SP B RUCONEST 3 PA, QL, SP B AZASAN 3 SP B SIMPONI 2 PA, QL, SP g azathioprine oral 1 SP g sirolimus oral 1 SP B CIMZIA PREFILLED KIT 2 PA, QL, SP B SKYRIZI (150 MG DOSE) 2 PA, QL, SP B CIMZIA STARTER KIT 2 PA, QL, SP B STELARA SUBCUTANEOUS 2 PA, QL, SP B COSENTYX (300 MG DOSE) 3 PA, ST, QL, SP SOLUTION B COSENTYX 150 MG/ML 3 PA, ST, QL, SP B STELARA SUBCUTANEOUS 2 PA, QL, SP B COSENTYX SENSOREADY 3 PA, ST, QL, SP SOLUTION PREFILLED SYRINGE (300 MG) g tacrolimus oral 1 SP B COSENTYX SENSOREADY PEN 3 PA, ST, QL, SP B TAKHZYRO 2 PA, QL, SP g cyclosporine modified 1 SP B TREMFYA 2 PA, QL, SP B ENBREL 3 PA, ST, QL, SP B TREXALL 2 SP B ENBREL MINI 3 PA, ST, QL, SP B XELJANZ 2 PA, ST, QL, SP B ENBREL SURECLICK 3 PA, ST, QL, SP B XELJANZ XR ORAL TABLET 2 PA, ST, QL, SP B ENVARSUS XR E SP EXTENDED RELEASE 24 HOUR 11 MG B FIRAZYR 1 PA, QL, SP Infertility Agents g gengraf 1 SP g chorionic gonadotropin 1 SP B HAEGARDA 2 PA, QL, SP intramuscular B HUMIRA 2 PA, QL, SP B CRINONE VAGINAL GEL 4 % 3 ST B HUMIRA PEDIATRIC CROHNS 2 PA, QL, SP B CRINONE VAGINAL GEL 8 % 3 ST START B ENDOMETRIN 2 B HUMIRA PEN 2 PA, QL, SP B FOLLISTIM AQ 2 SP B HUMIRA PEN-CD/UC/HS STARTER 2 PA, QL, SP g ganirelix acetate solution 1 QL, SP B HUMIRA PEN-PS/UV/ADOL HS 2 PA, QL, SP prefilled syringe 250 mcg/0.5ml START subcutaneous g icatibant acetate E PA, QL, SP g novarel intramuscular solution 1 SP g methotrexate oral 1 reconstituted 10000 unit g methotrexate sodium oral 1 B NOVAREL INTRAMUSCULAR 3 SP g mycophenolate mofetil 1 SP SOLUTION RECONSTITUTED 5000 UNIT g mycophenolate sodium 1 SP

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

30 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B OVIDREL 3 SP Metabolic Bone Disease Agents - Other g pregnyl 1 SP g calcitriol oral 1 Inflammatory Bowel Disease Agents B ROCALTROL 3 B ANALPRAM HC 3 Ophthalmic Agents - Drugs for Eye Allergy, Infection and B ANALPRAM HC SINGLES 3 Inflammation B B ANALPRAM-HC EXTERNAL 3 ACULAR 3 CREAM B ACULAR LS 3 B ANALPRAM-HC EXTERNAL 3 B ACUVAIL E LOTION B ALREX 3 QL B APRISO 1 B AZASITE 3 B AZULFIDINE 3 g azelastine hcl ophthalmic 1 B AZULFIDINE EN-TABS 3 B BESIVANCE 3 g budesonide er E B CILOXAN OPHTHALMIC 3 g budesonide oral 1 OINTMENT B CORTIFOAM 2 B CILOXAN OPHTHALMIC 3 B DIPENTUM 3 SOLUTION g hydrocortisone ace-pramoxine 1 g ciprofloxacin hcl ophthalmic 1 external cream 1-1 % g erythromycin ophthalmic 1 g hydrocort-pramoxine (perianal) 1 B FLAREX 2 B LIALDA 1 B ILEVRO E g mesalamine er E B INVELTYS 3 g mesalamine oral E g ketorolac tromethamine ophthalmic 1 g mesalamine rectal enema 1 B LASTACAFT 3 QL g mesalamine rectal suppository 1 QL B LOTEMAX OPHTHALMIC GEL E B PENTASA E B LOTEMAX OPHTHALMIC 3 B PROCORT E OINTMENT B PROCTOFOAM HC 2 B LOTEMAX OPHTHALMIC 3 QL SUSPENSION B SFROWASA 3 B LOTEMAX SM 3 QL g sulfasalazine oral tablet 1 g loteprednol etabonate 1 QL B UCERIS ORAL 1 B MAXITROL 3 B UCERIS RECTAL 2 B MOXEZA 3 Metabolic Bone Disease Agents - Drugs for Osteoporosis g moxifloxacin hcl ophthalmic 1 g alendronate sodium 1 g neomycin-polymyxin-dexameth 1 B BONIVA ORAL 3 ophthalmic ointment B FORTEO E PA, SP g neomycin-polymyxin-dexameth 1 B FOSAMAX 3 ophthalmic suspension g ibandronate sodium oral 1 3.5-10000-0.1 B TERIPARATIDE (RECOMBINANT) 3 PA, SP B NEVANAC 3 B TYMLOS 3 PA, SP B OCUFLOX 3

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

31 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g ofloxacin ophthalmic 1 B ROCKLATAN 3 QL g olopatadine hcl ophthalmic solution 1 QL g timolol maleate ophthalmic 1 0.1 % B TIMOPTIC 3 g olopatadine hcl ophthalmic solution E QL B TIMOPTIC OCUDOSE 0.25 % 2 0.2 % B TIMOPTIC-XE 3 B PAZEO E QL g travoprost (bak free) 1 QL g polymyxin b-trimethoprim 1 B VYZULTA E ST, QL B POLYTRIM 3 B XELPROS 3 QL B PRED FORTE 3 Ophthalmic Agents - Drugs for Miscellaneous Eye B PRED MILD 3 Conditions g prednisolone acetate ophthalmic 1 B CEQUA E PA, QL B TOBRADEX OPHTHALMIC 3 B RESTASIS 3 PA, QL OINTMENT B RESTASIS MULTIDOSE E PA, QL B TOBRADEX OPHTHALMIC 3 B SUSPENSION XIIDRA 3 PA, QL B TOBRADEX ST E Otic Agents - Drugs for Ear Conditions B g tobramycin ophthalmic 1 CIPRODEX 1 g g tobramycin-dexamethasone 1 neomycin-polymyxin-hc otic 1 g B TOBREX OPHTHALMIC OINTMENT 3 QL ofloxacin otic 1 B TOBREX OPHTHALMIC SOLUTION 3 QL Respiratory - Drugs for Anaphylaxis B Ophthalmic Agents - Drugs for Glaucoma AUVI-Q E QL g B ALPHAGAN P OPHTHALMIC 2 QL epinephrine solution auto-injector 1 QL SOLUTION 0.1 % 0.15 mg/0.3ml injection (generic EpiPen Jr) B ALPHAGAN P OPHTHALMIC 3 QL g SOLUTION 0.15 % epinephrine solution auto-injector 1 QL 0.3 mg/0.3ml injection (generic B AZOPT 2 QL EpiPen) B BETIMOL 2 QL B SYMJEPI 2 QL g bimatoprost ophthalmic E QL Respiratory Tract / Pulmonary Agents - Drugs for g brimonidine tartrate ophthalmic 1 QL Allergies, Cough, Cold solution 0.15 % g azelastine hcl nasal solution 0.1 %, 1 g brimonidine tartrate ophthalmic 1 137 mcg/spray solution 0.2 % g azelastine hcl nasal solution 0.15 % E B COMBIGAN 2 QL g benzonatate oral capsule 100 mg, 1 B COSOPT 3 200 mg g dorzolamide hcl-timolol mal 1 g benzonatate oral capsule 150 mg E g dorzolamide hcl-timolol mal pf E QL g bromfed dm 1 B ISTALOL 3 g cyproheptadine hcl oral 1 g latanoprost ophthalmic 1 g fluticasone propionate nasal 1 QL B LUMIGAN 2 g hydrocodone polst-cpm polst er 1 PA, QL B RHOPRESSA 3 QL g ipratropium bromide nasal 1

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

32 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits g levocetirizine dihydrochloride oral 1 B BEVESPI AEROSPHERE 2 QL B OMNARIS E QL B BREO ELLIPTA 3 QL, RS g promethazine hcl oral solution 1 B BREZTRI AEROSPHERE 3 QL, RS g promethazine hcl oral syrup 1 g budesonide inhalation 1 QL g promethazine-codeine 1 PA, QL B COMBIVENT RESPIMAT 3 QL g promethazine-dm 1 B EASIVENT 2 g pseudoephedrine-bromphen-dm 1 B FASENRA PEN 3 PA, QL, SP B TESSALON PERLES 3 B FLOVENT DISKUS 1 QL B TUSSICAPS 3 PA, QL B FLOVENT HFA 1 QL B XHANCE E QL g fluticasone-salmeterol inhalation E QL B ZETONNA 3 QL aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ Respiratory Tract / Pulmonary Agents - Drugs for dose, 500-50 mcg/dose Asthma and COPD B FLUTICASONE-SALMETEROL 1 QL B ADVAIR DISKUS 1 QL INHALATION AEROSOL POWDER B ADVAIR HFA 3 QL, RS BREATH ACTIVATED 113-14 MCG/ B AIRDUO RESPICLICK 113/14 E QL ACT, 232-14 MCG/ACT, 55-14 MCG/ ACT B AIRDUO RESPICLICK 232/14 E QL B INCRUSE ELLIPTA E QL B AIRDUO RESPICLICK 55/14 E QL g ipratropium-albuterol 1 g albuterol sulfate er 1 B LEVALBUTEROL HFA INHALATION 3 QL g albuterol sulfate hfa aerosol solution 1 QL AEROSOL 45 MCG/ACT 108 (90 base) mcg/act inhalation (ProAir HFA or Proventil HFA) g montelukast sodium oral 1 B ALBUTEROL SULFATE HFA E QL B NUCALA SUBCUTANEOUS 3 PA,QL, SP AEROSOL SOLUTION 108 (90 SOLUTION AUTO-INJECTOR BASE) MCG/ACT INHALATION B NUCALA SUBCUTANEOUS 3 PA,QL, SP (Ventolin HFA) SOLUTION PREFILLED SYRINGE g albuterol sulfate inhalation 1 B PERFOROMIST 3 QL g albuterol sulfate oral 1 PA B PROAIR DIGIHALER E QL B ALVESCO E B PROAIR HFA E QL B ANORO ELLIPTA 3 QL B PROAIR RESPICLICK E QL B ARNUITY ELLIPTA 1 QL B PROVENTIL HFA E QL B ASMANEX (120 METERED DOSES) E B PULMICORT FLEXHALER 1 QL B ASMANEX (14 METERED DOSES) E B QVAR REDIHALER E B ASMANEX (30 METERED DOSES) E B SEREVENT DISKUS 2 QL B ASMANEX (60 METERED DOSES) E B SINGULAIR ORAL PACKET 3 B ASMANEX (7 METERED DOSES) E B SPIRIVA HANDIHALER 2 QL B ASMANEX HFA INHALATION E B SPIRIVA RESPIMAT 2 QL AEROSOL 100 MCG/ACT, 200 B STRIVERDI RESPIMAT 2 QL MCG/ACT B SYMBICORT 3 QL, RS B ATROVENT HFA 3 QL

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

33 Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits B TRELEGY ELLIPTA 3 QL, RS g metaxalone 1 B VENTOLIN HFA E QL g methocarbamol oral 1 g wixela inhub E QL B OZOBAX 3 PA B XOPENEX HFA 3 QL B ROBAXIN-750 3 B YUPELRI 3 PA, QL B SOMA ORAL TABLET 350 MG 3 Respiratory Tract / Pulmonary Agents - Drugs for Cystic g tizanidine hcl oral 1 Fibrosis B ZANAFLEX ORAL CAPSULE 3 B KITABIS PAK E PA, QL, SP Sleep Disorder Agents B PULMOZYME 2 PA, QL, SP B BELSOMRA 3 ST, QL B TOBI PODHALER 3 PA, QL, SP B DAYVIGO 3 ST, QL g tobramycin nebulization solution 1 PA, QL, SP B EDLUAR E QL 300 mg/4ml inhalation g eszopiclone 1 QL g tobramycin nebulization solution E PA, QL, SP g 300 mg/5ml inhalation modafinil 1 PA, QL B B TOBRAMYCIN NEBULIZATION E PA, QL, SP RESTORIL 3 SOLUTION 300 MG/5ML B SUNOSI 3 PA, QL INHALATION g temazepam 1 Respiratory Tract / Pulmonary Agents - Drugs for B WAKIX 3 PA, QL, SP Pulmonary Hypertension B XYREM 3 PA, QL, SP B ADEMPAS 2 PA, QL, SP g zolpidem tartrate er 1 QL g ambrisentan 1 PA, QL, SP g zolpidem tartrate oral 1 QL g bosentan 1 PA, QL, SP g zolpidem tartrate sublingual E QL B OPSUMIT 2 PA, QL, SP B ORENITRAM 3 PA, QL, SP g sildenafil oral tablets 1 QL B TRACLEER 2 PA, QL, SP B TYVASO 2 PA, SP B TYVASO REFILL 2 PA, SP B TYVASO STARTER 2 PA, SP Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm g baclofen oral 1 g carisoprodol oral tablet 250 mg E g carisoprodol oral tablet 350 mg 1 g cyclobenzaprine hcl er E g cyclobenzaprine hcl oral 7.5 mg E g cyclobenzaprine hcl oral tablet 1 10 mg, 5 mg B FEXMID E

See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).

34 Index

A ADHANSIA XR ...... 17 ALOGLIPTIN-PIOGLITAZONE...... 23 ABILIFY MYCITE...... 14 ADLYXIN ...... 23 ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, ABSORICA ...... 19 ADLYXIN STARTER PACK...... 23 0.075 MG/24HR, 0.1 MG/24HR...... 26 ACCU-CHEK AVIVA CONNECT KIT ADMELOG...... 22 ALPHAGAN P OPHTHALMIC W/DEVICE...... 21 ADMELOG SOLOSTAR ...... 22 SOLUTION 0.1 % ...... 32 ACCU-CHEK AVIVA DEVICE...... 21 ADVAIR DISKUS...... 33 ALPHAGAN P OPHTHALMIC ACCU-CHEK AVIVA PLUS KIT ADVAIR HFA ...... 33 SOLUTION 0.15 % ...... 32 W/DEVICE...... 21 ADVATE ...... 23 alprazolam er ...... 15 ACCU-CHEK AVIVA PLUS TEST ADYNOVATE ...... 23 alprazolam intensol ...... 15 STRIPS ...... 21 AEMCOLO...... 9 alprazolam oral ...... 15 ACCU-CHEK COMPACT PLUS CARE KIT ...... 21 afirmelle...... 26 alprazolam xr ...... 15 ACCU-CHEK COMPACT PLUS AFREZZA INHALATION POWDER ALREX ...... 31 TEST STRIPS ...... 21 12 UNIT, 4 UNIT ...... 22 ALTACE ...... 15 ACCU-CHEK GUIDE KIT W/DEVICE .21 AFREZZA INHALATION POWDER altavera ...... 26 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 ACCU-CHEK GUIDE ME KIT UNIT & 90X8 UNIT, 90 X 8 UNIT & ALTOPREV ...... 15 W/DEVICE...... 21 90X12 UNIT ...... 22 ALTRENO ...... 19 ACCU-CHEK GUIDE TEST STRIPS . .21 AFSTYLA INTRAVENOUS KIT 1000 ALUNBRIG ...... 13 ACCU-CHEK NANO SMARTVIEW UNIT, 2000 UNIT, 250 UNIT, 3000 ALVESCO ...... 33 KIT W/DEVICE ...... 21 UNIT, 500 UNIT...... 23 alyacen 1/35 ...... 26 ACCU-CHEK SMARTVIEW TEST AFSTYLA INTRAVENOUS KIT 1500 STRIPS ...... 21 UNIT, 2500 UNIT...... 23 AMARYL ...... 23 ACCU-CHEK SOFTCLIX LANCET AIMOVIG ...... 13 ambrisentan ...... 34 DEVICE KIT...... 21 AIMOVIG SUBCUTANEOUS AMERGE ...... 13 ACCUPRIL...... 15 SOLUTION AUTO-INJECTOR 140 amethia ...... 26 acetaminophen-codeine ...... 8 MG/ML ...... 13 amethia lo ...... 26 acetaminophen-codeine #2 ...... 8 AIRDUO RESPICLICK 113/14 ...... 33 amiodarone hcl oral ...... 15 acetaminophen-codeine #3 ...... 8 AIRDUO RESPICLICK 232/14...... 33 amitriptyline hcl oral...... 11 acetaminophen-codeine #4 ...... 8 AIRDUO RESPICLICK 55/14...... 33 amlodipine besylate oral ...... 15 acetazolamide er ...... 15 ALA SCALP...... 19 amlodipine besylate-benazepril hcl . .15 acetazolamide oral...... 15 ala-cort external cream 1 %...... 19 amlodipine besylate-valsartan ...... 15 ACIPHEX SPRINKLE ...... 24 ala-cort external cream 2.5 % ...... 19 amnesteem ...... 19 ACTEMRA ACTPEN ...... 30 albuterol sulfate er ...... 33 amoxicillin ...... 9 ACTEMRA SUBCUTANEOUS...... 30 albuterol sulfate hfa aerosol amoxicillin-potassium clavulanate er . .9 solution 108 (90 base) mcg/act ACTIGALL ...... 25 amoxicillin-potassium clavulanate inhalation...... 33 ACULAR ...... 31 oral...... 9 albuterol sulfate inhalation...... 33 ACULAR LS ...... 31 amphetamine-dextroamphetamine . .17 albuterol sulfate oral...... 33 ACUVAIL ...... 31 amphetamine-dextroamphetamine ALDACTONE...... 15 er ...... 17 acyclovir oral...... 14 ALDARA ...... 19 AMZEEQ ...... 19 ACZONE EXTERNAL GEL 5 % ...... 19 ALECENSA ...... 13 ANALPRAM HC ...... 31 ACZONE EXTERNAL GEL 7.5 %.....19 alendronate sodium ...... 31 ANALPRAM HC SINGLES...... 31 ADALAT CC ORAL TABLET alfuzosin hcl er ...... 26 EXTENDED RELEASE 24 HOUR ANALPRAM-HC EXTERNAL 60 MG ...... 15 aliskiren fumarate...... 15 CREAM ...... 31 ADDERALL XR ...... 17 allopurinol oral ...... 13 ANALPRAM-HC EXTERNAL LOTION ...... 31 ADDYI ...... 24 ALOGLIPTIN BENZOATE...... 23 ANASPAZ ...... 25 ADEMPAS ...... 34 ALOGLIPTIN-METFORMIN HCL . . . .23

35 anastrozole oral ...... 13 aurovela fe 1.5/30...... 26 BELSOMRA ...... 34 ANDRODERM...... 29 AURYXIA ...... 25 benazepril hcl oral ...... 15 ANORO ELLIPTA ...... 33 AUSTEDO ...... 18 benazepril-hydrochlorothiazide . . . . .15 apap-caff-dihydrocodeine oral AUVI-Q...... 32 benzonatate oral capsule 100 mg, capsule ...... 8 AVALIDE ...... 15 200 mg...... 32 apri...... 26 avar cleanser...... 19 benzonatate oral capsule 150 mg....32 APRISO ...... 31 AVAR LS CLEANSER...... 19 BESIVANCE ...... 31 APTENSIO XR...... 17 AVAR-E EMOLLIENT ...... 19 betamethasone dipropionate aug....19 ARAKODA ...... 13 AVAR-E GREEN ...... 19 betamethasone dipropionate external ...... 19 ARANESP (ALBUMIN FREE)...... 23 AVAR-E LS...... 19 BETASERON...... 18 ARICEPT ORAL TABLET 10 MG, aviane ...... 26 5 MG ...... 11 BETIMOL...... 32 avidoxy...... 9 aripiprazole oral solution ...... 14 BEVESPI AEROSPHERE ...... 33 avita ...... 19 aripiprazole oral tablet ...... 14 BEVYXXA ...... 11 AVONEX PEN ...... 18 aripiprazole oral tablet dispersible ...14 bexarotene ...... 13 AVONEX PREFILLED ...... 18 ARMOUR THYROID...... 29 BIDIL ...... 15 AYGESTIN ...... 26 ARNUITY ELLIPTA ...... 33 BIJUVA ...... 26 ayuna ...... 26 ARYMO ER ...... 8 bimatoprost ophthalmic...... 32 AZASAN ...... 30 ashlyna ...... 26 bisoprolol fumarate ...... 15 AZASITE ...... 31 ASMANEX (120 METERED DOSES)..33 bisoprolol-hydrochlorothiazide ...... 15 azathioprine oral...... 30 ASMANEX (14 METERED DOSES)...33 blisovi 24 fe ...... 26 azelaic acid external...... 19 ASMANEX (30 METERED DOSES)...33 blisovi fe 1/20 ...... 26 azelastine hcl nasal solution 0.1 %, ASMANEX (60 METERED DOSES)...33 137 mcg/spray ...... 32 blisovi fe 1.5/30...... 26 ASMANEX (7 METERED DOSES)....33 azelastine hcl nasal solution 0.15 % . .32 BONIVA ORAL ...... 31 ASMANEX HFA INHALATION azelastine hcl ophthalmic ...... 31 BONJESTA ...... 12 AEROSOL 100 MCG/ACT, 200 bosentan ...... 34 MCG/ACT ...... 33 azithromycin oral ...... 10 bp 10-1...... 19 ASTAGRAF XL ...... 30 AZOPT...... 32 BREO ELLIPTA ...... 33 atenolol oral ...... 15 AZULFIDINE ...... 31 BREZTRI AEROSPHERE...... 33 atenolol-chlorthalidone ...... 15 AZULFIDINE EN-TABS...... 31 briellyn ...... 26 atomoxetine hcl ...... 17 azurette ...... 26 BRILINTA...... 14 atorvastatin calcium oral tablet 10 B mg, 20 mg ...... 15 brimonidine tartrate ophthalmic baclofen oral ...... 34 solution 0.15 % ...... 32 atorvastatin calcium oral tablet 40 mg, 80 mg ...... 15 BACTRIM ...... 10 brimonidine tartrate ophthalmic solution 0.2 % ...... 32 atovaquone-proguanil hcl ...... 13 BACTRIM DS ...... 10 bromfed dm ...... 32 ATRIPLA ...... 14 BAFIERTAM CAPSULE ...... 18 budesonide er...... 31 ATROVENT HFA ...... 33 balziva ...... 26 budesonide inhalation ...... 33 AUBAGIO ...... 18 BAQSIMI ONE PACK ...... 23 budesonide oral ...... 31 aubra ...... 26 BAQSIMI TWO PACK ...... 23 BUNAVAIL...... 9 aubra eq ...... 26 BARACLUDE ORAL SOLUTION.....14 buprenorphine hcl sublingual ...... 9 AUGMENTIN ORAL SUSPENSION BASAGLAR KWIKPEN...... 22 buprenorphine hcl-naloxone hcl ...... 9 RECONSTITUTED 125-31.25 MG/ BD AUTOSHIELD DUO PEN 5ML ...... 9 NEEDLES ...... 21 bupropion hcl er (sr)...... 11 aurovela 1/20 ...... 26 BD ULTRA-FINE INSULIN bupropion hcl er (xl) oral tablet aurovela 1.5/30 ...... 26 SYRINGES...... 21 extended release 24 hour 150 mg, 300 mg ...... 11 aurovela 24 fe ...... 26 BD ULTRA-FINE PEN NEEDLES.....21 aurovela fe 1/20 ...... 26 bekyree ...... 26 BELBUCA ...... 8

36 BUPROPION HCL ER (XL) ORAL CENTANY AT ...... 10 clindamycin phosphate external TABLET EXTENDED RELEASE cephalexin...... 10 foam...... 19 24 HOUR 450 MG...... 12 CEQUA ...... 32 clindamycin phosphate external bupropion hcl oral ...... 12 lotion ...... 19 CERDELGA ...... 25 buspirone hcl oral...... 15 clindamycin phosphate external CHANTIX...... 9 butalbital-apap-caffeine...... 8 solution ...... 19 CHANTIX CONTINUING MONTH BYDUREON ...... 23 clindamycin phosphate external PAK ...... 9 swab...... 19 BYDUREON BCISE CHANTIX STARTING MONTH PAK . . .9 AUTOINJECTOR...... 23 CLINDAMYCIN PHOSPHATE GEL chateal...... 26 1 % EXTERNAL ...... 19 BYETTA 10 MCG PEN ...... 23 chateal eq ...... 26 CLINDESSE ...... 10 BYETTA 5 MCG PEN ...... 23 chlorhexidine gluconate mouth/ clinpro 5000 ...... 18 BYSTOLIC ...... 15 throat ...... 18 clobetasol propionate external C chlorthalidone...... 15 cream...... 19 chorionic gonadotropin clobetasol propionate external foam .19 cabergoline ...... 29 intramuscular ...... 30 clobetasol propionate external gel ...19 CALAN SR...... 15 ciclodan...... 12 clobetasol propionate external calcipotriene-betameth diprop ciclopirox...... 12 liquid ...... 19 external ointment ...... 19 ciclopirox treatment ...... 12 clobetasol propionate external calcitriol external ...... 19 CILOXAN OPHTHALMIC lotion ...... 19 calcitriol oral ...... 31 OINTMENT ...... 31 clobetasol propionate external CALQUENCE ...... 13 CILOXAN OPHTHALMIC ointment ...... 19 camila ...... 26 SOLUTION ...... 31 clobetasol propionate external camrese...... 26 CIMDUO ...... 14 shampoo ...... 19 camrese lo...... 26 CIMZIA PREFILLED KIT...... 30 clobetasol propionate external solution ...... 19 capecitabine ...... 13 CIMZIA STARTER KIT ...... 30 clodan external shampoo ...... 19 CAPEX...... 19 CIPRO ORAL TABLET ...... 10 clonazepam oral...... 15 CARAC ...... 19 CIPRODEX ...... 32 clonidine hcl oral ...... 15 carbamazepine er...... 11 ciprofloxacin hcl ophthalmic ...... 31 clopidogrel bisulfate oral ...... 14 carbamazepine oral ...... 11 ciprofloxacin hcl oral ...... 10 clotrimazole-betamethasone CARBATROL...... 11 citalopram hydrobromide ...... 12 external cream ...... 19 carbidopa-levodopa ...... 14 claravis...... 19 clotrimazole-betamethasone carbidopa-levodopa er...... 14 clarithromycin er...... 10 external lotion ...... 19 CARDIZEM LA ORAL TABLET clarithromycin oral ...... 10 clovique ...... 25 EXTENDED RELEASE 24 HOUR CLENPIQ ...... 25 COLCHICINE ORAL CAPSULE . . . . .13 120 MG ...... 15 CLEOCIN ORAL CAPSULE 150 colchicine oral tablet ...... 13 CARDURA...... 15 MG, 300 MG ...... 10 COLCRYS ...... 13 carisoprodol oral tablet 250 mg . . . . .34 CLEOCIN ORAL CAPSULE 75 MG...10 colesevelam hcl ...... 15 carisoprodol oral tablet 350 mg . . . . .34 CLEOCIN-T EXTERNAL GEL ...... 19 COMBIGAN...... 32 CAROSPIR ...... 15 CLEOCIN-T EXTERNAL LOTION . . . .19 COMBIVENT RESPIMAT ...... 33 cartia xt ...... 15 Climara ...... 26, 27 CONCERTA...... 17 carvedilol...... 15 CLIMARA PRO ...... 26 CONTOUR NEXT EZ MONITOR.....21 CATAPRES ...... 15 clindacin etz external swab ...... 19 CONTOUR NEXT LNK MONITOR . . .21 cavarest ...... 18 clindacin-p...... 19 CONTOUR NEXT MONITOR...... 21 cefadroxil...... 10 CLINDAGEL ...... 19 CONTOUR NEXT ONE MONITOR . . .21 cefdinir...... 10 clindamycin hcl oral ...... 10 CONTOUR NEXT TEST STRIP ...... 21 cefuroxime axetil ...... 10 clindamycin phos-benzoyl perox CONTOUR TEST STRIP ...... 21 celecoxib oral ...... 9 external gel 1.2-5 % ...... 19 CONZIP ...... 8 CENTANY ...... 10 COREG ...... 15

37 coremino ...... 10 DEPO-PROVERA dicyclomine hcl oral ...... 25 CORGARD ...... 15 INTRAMUSCULAR SUSPENSION DIFICID ...... 10 150 MG/ML...... 26 CORLANOR ...... 15 DIFLUCAN ORAL SUSPENSION DEPO-PROVERA RECONSTITUTED ...... 12 CORTEF ...... 28 INTRAMUSCULAR SUSPENSION CORTIFOAM...... 31 PREFILLED SYRINGE ...... 26 DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG ...... 12 COSENTYX (300 MG DOSE) ...... 30 DEPO-SUBQ PROVERA 104...... 26 DIFLUCAN ORAL TABLET 50 MG . . .12 COSENTYX 150 MG/ML ...... 30 DEPO-TESTOSTERONE DILAUDID ORAL ...... 8 COSENTYX SENSOREADY INTRAMUSCULAR SOLUTION (300 MG) ...... 30 100 MG/ML...... 29 dilt-xr ...... 15 COSENTYX SENSOREADY PEN . . . .30 DEPO-TESTOSTERONE diltiazem hcl er coated beads ...... 15 INTRAMUSCULAR SOLUTION COSOPT ...... 32 diltiazem hcl er oral capsule 200 MG/ML...... 29 extended release 12 hour ...... 15 COUMADIN...... 11 DERMA-SMOOTHE/FS BODY ...... 19 diltiazem hcl oral...... 15 CREON ...... 25 DERMA-SMOOTHE/FS SCALP . . . . .19 dimethyl fumarate...... 18 CRESEMBA ORAL...... 12 DESCOVY ...... 14 DIPENTUM ...... 31 CRINONE VAGINAL GEL 4 % ...... 30 desmopressin acetate injection . . . . .29 diphenoxylate-atropine ...... 25 CRINONE VAGINAL GEL 8 % ...... 30 desmopressin acetate oral ...... 29 DIPROLENE ...... 19 cryselle-28...... 26 desogestrel-ethinyl estradiol...... 26 DIPROLENE AF ...... 19 CUPRIMINE ...... 25 DESONATE ...... 19 DITROPAN XL...... 25 cyclafem 1/35 ...... 26 desonide external...... 19 divalproex sodium er ...... 11 cyclobenzaprine hcl er...... 34 DESOWEN...... 19 divalproex sodium oral...... 11 cyclobenzaprine hcl oral 7.5 mg .....34 desvenlafaxine succinate er ...... 12 DIVIGEL TRANSDERMAL GEL cyclobenzaprine hcl oral tablet dexamethasone intensol ...... 28 0.25 MG/0.25GM, 0.5 MG/0.5GM, 10 mg, 5 mg ...... 34 dexamethasone oral...... 28 0.75 MG/0.75GM, 1 MG/GM ...... 26 cyclosporine modified ...... 30 DEXCOM G4 / G5 / G6 RECEIVER, donepezil hcl oral tablet 10 mg, cyproheptadine hcl oral...... 32 TRANSMITTER, SENSOR 5 mg...... 11 cyred ...... 26 (INCLUDING PLATINUM, donepezil hcl oral tablet 23 mg...... 11 cyred eq...... 26 PLATINUM PEDIATRIC)...... 21 donepezil hcl oral tablet dispersible.. 11 CYTOTEC ...... 24 DEXCOM G4 / G5 / G6 RECEIVER, DORYX MPC...... 10 TRANSMITTER, SENSOR dorzolamide hcl-timolol mal ...... 32 D (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE . . . .21 dorzolamide hcl-timolol mal pf ...... 32 dalfampridine er ...... 18 DEXILANT...... 24 dotti ...... 26 dapsone external gel 5 % ...... 19 dexmethylphenidate hcl...... 17 DOVATO ...... 14 dasetta 1/35 ...... 26 dexmethylphenidate hcl er ...... 17 doxazosin mesylate oral ...... 16 daysee ...... 26 DEXPAK 10 DAY ...... 28 doxepin hcl oral capsule ...... 12 DAYVIGO...... 34 DEXPAK 13 DAY ...... 28 doxepin hcl oral concentrate...... 12 DDAVP INJECTION ...... 29 DEXPAK 6 DAY ...... 28 doxycycline hyclate oral capsule . . . .10 DDAVP ORAL ...... 29 dextroamphetamine sulfate...... 17 doxycycline hyclate oral tablet deblitane ...... 26 dextroamphetamine sulfate er ...... 17 100 mg, 20 mg ...... 10 DECADRON ...... 28 diazepam intensol ...... 15 doxycycline hyclate oral tablet delyla ...... 26 150 mg, 50 mg, 75 mg ...... 10 diazepam oral ...... 15 denta 5000 plus ...... 18 doxycycline hyclate oral tablet diclofenac potassium...... 9 delayed release...... 10 dentagel...... 18 diclofenac sodium er ...... 9 doxycycline monohydrate oral DEPAKOTE ...... 11 diclofenac sodium oral...... 9 capsule 100 mg, 50 mg ...... 10 DEPAKOTE ER ...... 11 diclofenac sodium transdermal gel doxycycline monohydrate oral DEPAKOTE SPRINKLES ...... 11 1 % ...... 9 capsule 150 mg, 75 mg ...... 10 DEPEN TITRATABS ...... 25 diclofenac sodium transdermal doxycycline monohydrate oral solution ...... 9 suspension reconstituted ...... 10

38 doxycycline monohydrate oral ENDOMETRIN ...... 30 F tablet ...... 10 enoxaparin sodium...... 11 falmina ...... 27 doxylamine-pyridoxine...... 12 enskyce ...... 26 FARXIGA ...... 23 DRISDOL...... 24 ENSTILAR ...... 19 FASENRA PEN ...... 33 DRIZALMA SPRINKLE...... 12 entecavir ...... 14 fayosim ...... 27 drospiren-eth estrad-levomefol...... 26 ENVARSUS XR ...... 30 febuxostat ...... 13 drospirenone-ethinyl estradiol ...... 26 EPANED...... 16 femynor ...... 27, 28 DUAVEE...... 26 EPCLUSA ...... 14 fenofibrate oral capsule 150 mg, duloxetine hcl oral capsule delayed epinephrine solution auto-injector 50 mg...... 16 release particles 20 mg, 30 mg, 0.15 mg/0.3ml injection ...... 32 fenofibrate oral tablet 120 mg, 60 mg...... 12 epinephrine solution auto-injector 40 mg, 48 mg ...... 16 duloxetine hcl oral capsule delayed 0.3 mg/0.3ml injection ...... 32 fenofibrate oral tablet 160 mg, release particles 40 mg ...... 12 EpiPen ...... 32 145 mg, 54 mg ...... 16 DUOPA ...... 14 EpiPen Jr ...... 32 fentanyl transdermal patch 72 hour DUPIXENT...... 19 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, epitol ...... 11 DUROLANE ...... 8 50 mcg/hr, 75 mcg/hr ...... 8 ERGOCAL ...... 24 DXEVO 11-DAY ...... 29 fentanyl transdermal patch 72 hour ergocalciferol oral capsule ...... 24 37.5 mcg/hr, 62.5 mcg/hr, DYAZIDE ...... 16 ERLEADA ...... 13 87.5 mcg/hr...... 8 E errin ...... 26 FEXMID ...... 34 EASIVENT ...... 33 erythromycin ophthalmic...... 31 FINACEA ...... 20 EASYPLUS BLOOD GLUCOSE escitalopram oxalate ...... 12 finasteride oral tablet 5 mg ...... 26 TEST ...... 21 ESGIC ...... 8 FIORICET ...... 8 EC-NAPROSYN ...... 9 estarylla ...... 26 FIRAZYR ...... 30 ec-naproxen ...... 9 ESTRACE ORAL...... 26 FLAGYL ...... 10 ed-spaz ...... 25 estradiol oral ...... 26 FLAREX...... 31 EDARBI ...... 16 estradiol patch twice weekly flecainide acetate ...... 16 EDARBYCLOR ...... 16 transdermal...... 26, 27 FLOLIPID ...... 16 EDLUAR ...... 34 estradiol transdermal patch weekly . .27 FLORIVA PLUS ...... 24 EFUDEX...... 19 estradiol vaginal cream ...... 27 FLOVENT DISKUS ...... 33 ELESTRIN ...... 26 estradiol vaginal tablet...... 27 FLOVENT HFA ...... 33 eletriptan hydrobromide ...... 13 ESTRING ...... 27 fluconazole oral ...... 12 ELIMITE ...... 13 ESTROGEL ...... 27 fluocinolone acetonide body...... 20 elinest ...... 26 eszopiclone...... 34 fluocinolone acetonide external . . . . .20 ELIQUIS...... 11 etodolac...... 9 fluocinolone acetonide scalp ...... 20 ELIQUIS DVT/PE STARTER PACK . . . 11 etodolac er ...... 9 fluocinonide external cream 0.05 % ..20 ELOCTATE...... 24 etonogestrel-ethinyl estradiol ...... 27 fluocinonide external cream 0.1 % . . .20 eluryng...... 26 EUCRISA ...... 19 fluocinonide external gel ...... 20 EMGALITY ...... 13 euthyrox...... 29 fluocinonide external ointment ...... 20 EMGALITY (300 MG DOSE) ...... 13 EVAMIST ...... 27 fluocinonide external solution ...... 20 emoquette...... 26 EVOCLIN ...... 19 fluoridex...... 18 emtricitabine-tenofovir df...... 14 EVZIO ...... 9 fluoridex enhanced whitening ...... 18 enalapril maleate oral...... 16 EXTAVIA ...... 18 FLUOROPLEX...... 20 ENBREL...... 30 EXTINA ...... 12 FLUOROURACIL EXTERNAL ENBREL MINI ...... 30 EZALLOR SPRINKLE...... 16 CREAM 0.5 % ...... 20 ENBREL SURECLICK ...... 30 ezetimibe ...... 16 fluorouracil external cream 5 % . . . . .20 ENDARI ...... 25 ezetimibe-simvastatin...... 16 fluorouracil external solution...... 20 endocet ...... 8 fluoxetine hcl oral capsule...... 12

39 fluoxetine hcl oral capsule delayed glatiramer acetate...... 18 HUMALOG U-100 JUNIOR release...... 12 glatopa...... 18 KWIKPEN ...... 22 fluoxetine hcl oral solution...... 12 glimepiride ...... 23 HUMATROPE ...... 29 fluoxetine hcl oral tablet 10 mg...... 12 glipizide er...... 23 HUMIRA ...... 30 fluoxetine hcl oral tablet 20 mg...... 12 glipizide ir ...... 23 HUMIRA PEDIATRIC CROHNS START ...... 30 fluoxetine hcl oral tablet 60 mg...... 12 glipizide xl ...... 23 HUMIRA PEN ...... 30 fluticasone propionate nasal...... 32 GLOPERBA...... 13 fluticasone-salmeterol inhalation HUMIRA PEN-CD/UC/HS GLUCAGON EMERGENCY KIT STARTER...... 30 aerosol powder breath activated INJECTION KIT...... 23 100-50 mcg/dose, 250-50 mcg/ HUMIRA PEN-PS/UV/ADOL HS dose, 500-50 mcg/dose ...... 33 GLUCOTROL ...... 23 START ...... 30 FLUTICASONE-SALMETEROL GLUCOTROL XL...... 23 HUMULIN 70/30 KWIKPEN...... 22 INHALATION AEROSOL POWDER GLUCOVANCE ORAL TABLET HUMULIN 70/30 VIAL ...... 22 BREATH ACTIVATED 113-14 MCG/ 5-500 MG ...... 23 HUMULIN N KWIKPEN ...... 22 ACT, 232-14 MCG/ACT, glyburide oral ...... 23 55-14 MCG/ACT ...... 33 HUMULIN N VIAL ...... 22 glyburide-metformin...... 23 fluvoxamine maleate ...... 12 HUMULIN R U-500 KWIKPEN...... 22 GLYXAMBI ...... 23 fluvoxamine maleate er ...... 12 HUMULIN R U-500 VIAL GOLYTELY ORAL SOLUTION (CONCENTRATED) ...... 22 FOCALIN ...... 17 RECONSTITUTED 227.1 GM...... 25 HUMULIN R VIAL ...... 22 folic acid oral tablet 1 mg ...... 24 GOLYTELY ORAL SOLUTION FOLLISTIM AQ ...... 30 RECONSTITUTED 236 GM ...... 25 hydralazine hcl oral ...... 16 FORFIVO XL ...... 12 GONITRO ...... 16 hydrochlorothiazide oral ...... 16 FORTEO ...... 31 guanfacine hcl ...... 16, 17 hydrocodone polst-cpm polst er.....32 FOSAMAX...... 31 guanfacine hcl er ...... 17 hydrocodone-acetaminophen oral solution 10-325 mg/15ml, FREESTYLE LIBRE 14 DAY GUARDIAN CONNECT 7.5-325 mg/15ml...... 8 READER ...... 21 TRANSMITTER...... 21 hydrocodone-acetaminophen oral FREESTYLE LIBRE 14 DAY GUARDIAN LINK 3 TRANSMITTER ..21 tablet 10-300 mg, 5-300 mg, SENSOR ...... 21 GUARDIAN SENSOR (3) ...... 21 7.5-300 mg ...... 8 FREESTYLE LIBRE READER ...... 21 GVOKE HYPOPEN, PFS ...... 23 hydrocodone-acetaminophen oral FREESTYLE LIBRE SENSOR GYNAZOLE-1 ...... 12 tablet 10-325 mg, 5-325 mg, SYSTEM...... 21 7.5-325 mg ...... 8 FREESTYLE PRECISION NEO H hydrocort-pramoxine (perianal)...... 31 TEST ...... 21 HAEGARDA ...... 30 hydrocortisone ace-pramoxine furosemide oral...... 16 external cream 1-1 % ...... 31 hailey 1.5/30 ...... 27 hydrocortisone external cream 1 % . .20 G hailey 24 fe ...... 27 hydrocortisone external cream HALCION...... 15 gabapentin oral...... 11 2.5 % ...... 20 HARVONI...... 14 ganirelix acetate solution hydrocortisone external lotion prefilled syringe 250 mcg/0.5ml heather ...... 27 2.5 % ...... 20 subcutaneous ...... 30 HEMANGEOL ...... 16 hydrocortisone external ointment gavilyte-c ...... 25 HIDEX 6-DAY...... 29 1 %, 2.5 % ...... 20 gavilyte-g...... 25 HUMALOG KWIKPEN ...... 22 hydrocortisone oral ...... 29 GELNIQUE ...... 25 HUMALOG MIX 50/50 KWIKPEN ....22 hydromorphone hcl er ...... 8 gemfibrozil oral ...... 16 HUMALOG MIX 50/50 VIAL ...... 22 hydromorphone hcl oral ...... 8 gengraf ...... 30 HUMALOG MIX 75/25 KWIKPEN ....22 hydromorphone hcl rectal ...... 8 GENOTROPIN...... 29 HUMALOG MIX 75/25 VIAL...... 22 hydroxychloroquine sulfate oral . . . . .13 GENOTROPIN MINIQUICK ...... 29 HUMALOG SUBCUTANEOUS hydroxyzine hcl oral ...... 15 GENVOYA ...... 14 SOLUTION ...... 22 hydroxyzine pamoate oral ...... 15 gianvi ...... 27 HUMALOG SUBCUTANEOUS hyoscyamine sulfate er ...... 25 SOLUTION CARTRIDGE ...... 22 GILENYA ...... 18 hyoscyamine sulfate oral ...... 25

40 hyoscyamine sulfate sl...... 25 isosorbide mononitrate er ...... 16 klor-con sprinkle ...... 24 hyoscyamine sulfate sublingual . . . . .25 isotretinoin oral ...... 20 KOGENATE FS ...... 24 hyosyne ...... 25 ISTALOL ...... 32 KOMBIGLYZE XR ...... 23 HYSINGLA ER ...... 8 KOSELUGO...... 13 J HYZAAR ...... 16 KOVALTRY ...... 24 jantoven ...... 11 KRINTAFEL ...... 13 I JANUVIA ...... 23 kurvelo...... 27 ibandronate sodium oral ...... 31 JARDIANCE ...... 23 KYNMOBI ...... 14 IBRANCE ORAL CAPSULE...... 13 jasmiel ...... 27 ibu ...... 9 jencycla ...... 27 L ibuprofen oral suspension...... 9 JENTADUETO...... 23 labetalol hcl oral ...... 16 ibuprofen oral tablet 400 mg, JENTADUETO XR...... 23 LAMICTAL...... 11 600 mg, 800 mg ...... 9 JIVI ...... 24 LAMICTAL ODT ORAL KIT ...... 11 icatibant acetate ...... 30 jolessa ...... 27 LAMICTAL ODT ORAL TABLET icosapent ethyl ...... 16 JORNAY PM ...... 17 DISPERSIBLE ...... 11 IDHIFA ...... 13 juleber ...... 27 LAMICTAL STARTER...... 11 ILEVRO ...... 31 JULUCA...... 14 LAMICTAL XR...... 11 imatinib mesylate ...... 13 junel 1/20...... 27 lamotrigine er ...... 11 imiquimod external...... 20 junel 1.5/30 ...... 27 lamotrigine oral tablet ...... 11 IMIQUIMOD PUMP...... 20 junel fe 1/20 ...... 27 lamotrigine oral tablet chewable..... 11 IMPOYZ ...... 20 junel fe 1.5/30 ...... 27 lamotrigine oral tablet dispersible . . . 11 IMVEXXY MAINTENANCE PACK ....24 junel fe 24 ...... 27 lamotrigine starter kit-blue...... 11 IMVEXXY STARTER PACK ...... 24 lamotrigine starter kit-green ...... 11 INBRIJA...... 14 K lamotrigine starter kit-orange ...... 11 incassia ...... 27 K-TAB ...... 24 LANCETS ...... 21 INCRUSE ELLIPTA ...... 33 KADIAN ORAL CAPSULE LANTUS SOLOSTAR ...... 22 INDOCIN ...... 9 EXTENDED RELEASE 24 HOUR LANTUS U-100 VIAL ...... 22 200 MG ...... 8 indomethacin er ...... 9 larin 1/20 ...... 27 kalliga...... 27 indomethacin oral capsule 25 mg, larin 1.5/30 ...... 27 KAPSPARGO SPRINKLE...... 16 50 mg...... 9 larin 24 fe...... 27 kariva ...... 27 INSULIN ASPART...... 22 larin fe 1/20 ...... 27 KAZANO ...... 23 INSULIN ASPART FLEXPEN ...... 22 larin fe 1.5/30 ...... 27 KEFLEX ...... 10 INSULIN ASPART PENFILL...... 22 larissia ...... 27 KEPPRA ORAL ...... 11 INSULIN LISPRO ...... 22 LASIX...... 16 KEPPRA XR ...... 11 INSULIN LISPRO (1 UNIT DIAL) . . . . .22 LASTACAFT ...... 31 KESIMPTA...... 18 INSULIN SYRINGES...... 21 latanoprost ophthalmic ...... 32 ketoconazole external cream ...... 12 INTRAROSA ...... 24 LATUDA...... 14 ketoconazole external foam ...... 13 introvale...... 27 LEDIP-SOFOSB ORAL TABLET INVELTYS ...... 31 ketoconazole external shampoo.....13 90-400MG...... 14 ipratropium bromide nasal ...... 32 ketodan external foam ...... 13 LEDIPASVIR-SOFOSBUVIR ...... 14 ipratropium-albuterol ...... 33 ketorolac tromethamine ophthalmic..31 lessina ...... 27 irbesartan ...... 16 ketorolac tromethamine oral ...... 9 letrozole oral ...... 13 irbesartan-hydrochlorothiazide...... 16 KITABIS PAK...... 34 LEVALBUTEROL HFA INHALATION ISENTRESS...... 14 klor-con ...... 24 AEROSOL 45 MCG/ACT ...... 33 ISENTRESS HD ...... 14 klor-con 10 ...... 24 LEVAQUIN ORAL TABLET 500 MG, 750 MG ...... 10 isibloom...... 27 klor-con m10 ...... 24 LEVBID ...... 25 isosorbide mononitrate ...... 16 KLOR-CON M15 ...... 24 klor-con m20 ...... 24 LEVEMIR U-100 FLEXTOUCH...... 22

41 LEVEMIR U-100 VIAL ...... 22 lorcet plus ...... 8 MEDROL ORAL TABLET 32 MG . . . .29 levetiracetam er ...... 11 LORTAB...... 8 MEDROL ORAL TABLET THERAPY levetiracetam oral...... 11 loryna...... 27 PACK ...... 29 levo-t ...... 29 losartan potassium...... 16 medroxyprogesterone acetate intramuscular suspension ...... 27 levocetirizine dihydrochloride oral . . .33 losartan potassium-hctz ...... 16 medroxyprogesterone acetate levofloxacin oral ...... 10 LOSEASONIQUE ...... 27 intramuscular suspension prefilled levonorgest-eth est & eth est...... 27 LOTEMAX OPHTHALMIC GEL ...... 31 syringe ...... 27 levonorgest-eth estrad 91-day...... 27 LOTEMAX OPHTHALMIC medroxyprogesterone acetate oral . .27 levonorgestrel-ethinyl estrad oral OINTMENT ...... 31 melodetta 24 fe...... 27 tablet 0.1-20 mg-mcg, 0.15-30 mg- LOTEMAX OPHTHALMIC meloxicam oral ...... 9 mcg ...... 27 SUSPENSION ...... 31 MENOSTAR ...... 27 levora 0.15/30 (28) ...... 27 LOTEMAX SM...... 31 mercaptopurine oral...... 13 levothyroxine sodium oral ...... 29 LOTENSIN...... 16 mesalamine er ...... 31 levoxyl ...... 29 LOTENSIN HCT ...... 16 mesalamine oral ...... 31 LEVSIN ORAL...... 25 loteprednol etabonate ...... 31 mesalamine rectal enema ...... 31 LEVSIN/SL ...... 25 lovastatin ...... 16 mesalamine rectal suppository...... 31 LIALDA ...... 31 low-ogestrel...... 27 metadate er...... 17 lidocaine external ointment ...... 8 LUMIGAN ...... 32 metaxalone ...... 34 lidocaine external patch 5 % ...... 8 lutera ...... 27 metformin hcl er ...... 23 lidocaine hcl mouth/throat ...... 18 LYNPARZA ...... 13 metformin hcl er (mod) ...... 23 lidocaine viscous hcl ...... 18 LYRICA ...... 18 metformin hcl er (osm)...... 23 lidocaine-prilocaine external cream ...8 LYRICA CR ...... 18 METFORMIN HCL ORAL lillow ...... 27 LYUMJEV KWIKPEN ...... 22 SOLUTION ...... 23 LINZESS ...... 25 LYUMJEV VIAL ...... 22 metformin hcl oral tablet ...... 23 liothyronine sodium oral ...... 29 lyza...... 27 methimazole oral ...... 29 LIPOFEN ...... 16 M methocarbamol oral...... 34 lisinopril oral ...... 16 methotrexate oral ...... 30 MACROBID...... 10 lisinopril-hydrochlorothiazide ...... 16 methotrexate sodium oral ...... 30 MACRODANTIN ...... 10 lithium carbonate er ...... 15 METHYLIN ...... 17 MALARONE ...... 13 lithium carbonate oral ...... 15 methylphenidate hcl er (cd)...... 17 marlissa ...... 27 LITHOBID ...... 15 methylphenidate hcl er (la) oral matzim la ...... 16 LO LOESTRIN FE ...... 27 capsule extended release 24 hour lo-zumandimine ...... 27 MAVENCLAD (10 TABS) ...... 18 10 mg, 20 mg, 30 mg, 40 mg ...... 17 LOESTRIN 1/20 (21) ...... 27 MAVENCLAD (4 TABS) ...... 18 methylphenidate hcl er (la) oral capsule extended release 24 hour LOESTRIN 1.5/30 (21) ...... 27 MAVENCLAD (5 TABS) ...... 18 60 mg...... 17 LOESTRIN FE 1/20...... 27 MAVENCLAD (6 TABS) ...... 18 methylphenidate hcl er oral tablet MAVENCLAD (7 TABS) ...... 18 LOESTRIN FE 1.5/30 ...... 27 extended release 10 mg, 20 mg ..... 17 MAVENCLAD (8 TABS) ...... 18 LOKELMA ...... 24 methylphenidate hcl er oral tablet LOMOTIL...... 25 MAVENCLAD (9 TABS) ...... 18 extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg ...... 17 LOPID ...... 16 MAVYRET ...... 14 methylphenidate hcl er oral tablet LOPRESSOR...... 16 MAXITROL ...... 31 extended release 24 hour ...... 17 lorazepam intensol...... 15 MAXZIDE...... 16 methylphenidate hcl oral ...... 17 lorazepam oral concentrate MAXZIDE-25 ...... 16 methylprednisolone oral ...... 29 2 mg/ml ...... 15 MAYZENT ...... 18 metoclopramide hcl oral solution lorazepam oral tablet ...... 15 MAYZENT STARTER PACK...... 18 5 mg/5ml ...... 12 lorcet ...... 8 MEDROL ORAL TABLET 16 MG, metoclopramide hcl oral tablet ...... 12 lorcet hd ...... 8 4 MG, 8 MG...... 29 MEDROL ORAL TABLET 2 MG...... 29

42 metoclopramide hcl oral tablet montelukast sodium oral ...... 33 naproxen oral tablet ...... 9 dispersible...... 12 morgidox oral ...... 10 naproxen sodium er ...... 9 metoprolol succinate er ...... 16 MORPHABOND ER ...... 8 naproxen sodium oral tablet metoprolol tartrate oral tablet morphine sulfate (concentrate) oral 275 mg, 550 mg ...... 9 100 mg, 25 mg, 50 mg...... 16 solution 100 mg/5ml, 20 mg/ml ...... 8 naratriptan hcl...... 13 metoprolol tartrate oral tablet morphine sulfate er oral capsule NARCAN ...... 9 37.5 mg, 75 mg ...... 16 extended release 24 hour ...... 8 NASCOBAL...... 24 METROCREAM ...... 20 morphine sulfate er oral tablet NATAZIA ...... 27 METROLOTION ...... 20 extended release ...... 8 NATESTO ...... 29 metronidazole external cream ...... 20 morphine sulfate oral ...... 8 NATURE-THROID ...... 29 metronidazole external gel 0.75 % . . .20 morphine sulfate rectal ...... 8 NAYZILAM ...... 11 metronidazole external gel 1 %...... 20 MOTEGRITY ...... 25 necon 0.5/35 (28) ...... 27 metronidazole external lotion ...... 20 MOVIPREP ...... 25 neomycin-polymyxin-dexameth metronidazole oral ...... 10 MOXEZA ...... 31 ophthalmic ointment ...... 31 metronidazole vaginal ...... 10 moxifloxacin hcl ophthalmic ...... 31 neomycin-polymyxin-dexameth mibelas 24 fe...... 27 MS CONTIN ...... 8 ophthalmic suspension microgestin 1/20...... 27 MULPLETA ...... 24 3.5-10000-0.1 ...... 31 microgestin 1.5/30 ...... 27 MULTAQ ...... 16 neomycin-polymyxin-hc otic ...... 32 microgestin fe 1/20 ...... 27 multi-vitamin/fluoride ...... 24 NESINA ...... 23 microgestin fe 1.5/30 ...... 27 multivitamin/fluoride oral solution . . .24 neuac external gel ...... 20 mili ...... 27 multivitamin/fluoride oral tablet NEULASTA ...... 24 MILLIPRED ...... 29 chewable 0.25 mg, 0.5 mg, 1 mg . . . .24 NEURONTIN ...... 11 MILLIPRED DP ...... 29 multivitamins/fluoride ...... 24 neutral sodium fluoride ...... 18 MILLIPRED DP 12-DAY ...... 29 mupirocin calcium ...... 10 NEVANAC ...... 31 MINIPRESS...... 16 mupirocin external ...... 10 NEXLETOL ...... 16 minitran ...... 16 mvc-fluoride ...... 24 NEXLIZET ...... 16 Minivelle...... 26 mycophenolate mofetil...... 30 niacin (antihyperlipidemic)...... 16 minocycline hcl er oral tablet mycophenolate sodium ...... 30 niacin er (antihyperlipidemic) ...... 16 extended release 24 hour 105 mg, MYDAYIS...... 17 niacor...... 16 115 mg, 55 mg, 65 mg, 80 mg...... 10 myorisan ...... 20 NIASPAN ...... 16 minocycline hcl er oral tablet nifedipine er ...... 16 extended release 24 hour 135 mg, N 45 mg, 90 mg ...... 10 nifedipine er osmotic release ...... 16 nabumetone oral ...... 9 minocycline hcl oral capsule...... 10 nifedipine oral ...... 16 nadolol oral ...... 16 minocycline hcl oral tablet...... 10 nikki ...... 27 NAFRINSE DAILY/NEUTRAL ...... 18 MINOLIRA...... 10 nitisinone...... 25 NAFRINSE WEEKLY...... 18 MIRAPEX...... 14 NITRO-BID ...... 16 NALOCET ...... 8 MIRCETTE ...... 27 NITRO-DUR ...... 16 naloxone hcl injection solution ...... 9 mirtazapine oral ...... 12 nitro-time ...... 16 naloxone hcl injection solution nitrofurantoin macrocrystal oral . . . . .10 MIRVASO ...... 20 cartridge ...... 9 misoprostol oral ...... 24 nitrofurantoin monohydrate naloxone hcl injection solution macrocrystals ...... 10 MITIGARE ...... 13 prefilled syringe ...... 9 nitroglycerin sublingual ...... 16 MOBIC...... 9 naltrexone hcl oral ...... 9 nitroglycerin transdermal...... 16 modafinil ...... 34 NAPRELAN ORAL TABLET nitroglycerin translingual ...... 16 mometasone furoate external ...... 20 EXTENDED RELEASE 24 HOUR 750 MG ...... 9 NITROMIST...... 16 mondoxyne nl oral capsule 100 mg ..10 NAPROSYN ORAL SUSPENSION . . . .9 NITROSTAT...... 16 mondoxyne nl oral capsule 75 mg . . .10 naproxen dr...... 9 NITYR ...... 25 mono-linyah...... 27 naproxen oral suspension ...... 9 NIZORAL ...... 13

43 NOCDURNA ...... 29 np thyroid ...... 29 ONETOUCH ULTRA 2 KIT nora-be ...... 27 NUBEQA ...... 13 W/DEVICE...... 22 NORDITROPIN FLEXPRO ...... 29 NUCALA SUBCUTANEOUS ONETOUCH ULTRA BLUE TEST STRIPS IN VITRO STRIP ...... 22 norethin ace-eth estrad-fe oral SOLUTION AUTO-INJECTOR ...... 33 tablet ...... 28 NUCALA SUBCUTANEOUS ONETOUCH ULTRA MINI KIT W/DEVICE...... 22 norethin ace-eth estrad-fe oral SOLUTION PREFILLED SYRINGE . . .33 tablet chewable ...... 28 NUCYNTA ...... 8 ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE ...... 22 norethindrone acet-ethinyl est ...... 28 NUCYNTA ER ...... 8 ONETOUCH VERIO IQ SYSTEM.....22 norethindrone acetate oral ...... 28 NUEDEXTA ...... 18 ONETOUCH VERIO KIT W/DEVICE ..22 norethindrone oral ...... 28 NULEV...... 25 ONETOUCH VERIO SYNC SYSTEM norgestimate-eth estradiol...... 28 NUTROPIN AQ NUSPIN 10 ...... 29 KIT W/DEVICE ...... 22 norgestimate-ethinyl estradiol NUTROPIN AQ NUSPIN 20 ...... 29 ONETOUCH VERIO TEST STRIPS ...22 triphasic...... 28 NUTROPIN AQ NUSPIN 5 ...... 29 ONGLYZA ...... 23 NORITATE ...... 20 NUVARING ...... 28 ONZETRA XSAIL ...... 13 norlyda...... 28 NUVESSA ...... 10 OPSUMIT ...... 34 norlyroc ...... 28 NUWIQ...... 24 ORAPRED ODT ...... 29 nortrel 0.5/35 (28)...... 28 NUZYRA ...... 10 ORENCIA ...... 30 nortrel 1/35 (21) ...... 28 nyamyc ...... 13 ORENCIA CLICKJET ...... 30 nortrel 1/35 (28) ...... 28 nystatin external ...... 13 ORENITRAM...... 34 nortriptyline hcl oral ...... 12 nystatin mouth/throat...... 13 ORFADIN ORAL CAPSULE...... 25 NORVIR ORAL PACKET ...... 14 nystop ...... 13 ORFADIN ORAL SUSPENSION . . . . .25 NORVIR ORAL SOLUTION ...... 14 ORIAHNN ...... 29 NOURIANZ ...... 14 O ORILISSA ...... 29 novarel intramuscular solution ocella ...... 28 orsythia ...... 28 reconstituted 10000 unit ...... 30 octreotide ...... 29 ORTHO MICRONOR ...... 28 NOVAREL INTRAMUSCULAR OCUFLOX ...... 31 SOLUTION RECONSTITUTED oscimin ...... 25 ODEFSEY ...... 14 5000 UNIT...... 30 oscimin sr ...... 25 ofloxacin ophthalmic ...... 32 NOVOEIGHT ...... 24 oseltamivir phosphate oral capsule . .14 ofloxacin otic...... 32 NOVOFINE AUTOCOVER PEN oseltamivir phosphate oral ogestrel ...... 28 NEEDLE...... 21 suspension reconstituted ...... 14 okebo...... 10 NOVOFINE PEN NEEDLE ...... 21 OSENI ...... 23 olanzapine oral ...... 14 NOVOFINE PLUS PEN NEEDLE .....21 OSPHENA ...... 24 olmesartan medoxomil oral...... 16 NOVOLIN 70/30 FLEXPEN ...... 22 OTEZLA...... 30 olmesartan medoxomil-hctz ...... 16 NOVOLIN 70/30 FLEXPEN RELION ..22 OTREXUP ...... 30 olopatadine hcl ophthalmic solution NOVOLIN 70/30 RELION...... 22 OVIDREL ...... 31 0.1 %...... 32 NOVOLIN 70/30 VIAL...... 22 OXAYDO ...... 8 olopatadine hcl ophthalmic solution NOVOLIN N FLEXPEN ...... 22 0.2 % ...... 32 oxcarbazepine ...... 11 NOVOLIN N FLEXPEN RELION . . . . .22 OLUMIANT ...... 30 OXTELLAR XR ...... 11 NOVOLIN N RELION ...... 22 OMECLAMOX-PAK ...... 24 oxybutynin chloride er ...... 25 NOVOLIN N VIAL ...... 22 omega-3-acid ethyl esters ...... 16 oxybutynin chloride oral ...... 25 NOVOLIN R FLEXPEN ...... 22 omeprazole oral capsule delayed OXYCODONE HCL ER...... 8 NOVOLIN R FLEXPEN RELION . . . . .22 release...... 24 oxycodone hcl oral capsule ...... 8 NOVOLIN R RELION ...... 23 OMNARIS ...... 33 oxycodone hcl oral concentrate NOVOLIN R VIAL ...... 23 OMNITROPE...... 29 100 mg/5ml...... 8 NOVOLOG FLEXPEN ...... 23 ondansetron hcl oral ...... 12 oxycodone hcl oral solution ...... 8 NOVOLOG PENFILL...... 23 ondansetron odt ...... 12 oxycodone hcl oral tablet ...... 8 NOVOLOG U-100 VIAL...... 23

44 oxycodone-acetaminophen oral PLEXION CLEANSING CLOTH...... 20 PREVIDENT 5000 PLUS ...... 18 tablet 10-325 mg, 2.5-325 mg, POLY-VI-FLOR...... 24 PREVIDENT DENTAL...... 18 5-325 mg, 7.5-325 mg ...... 8 polymyxin b-trimethoprim ...... 32 PREVIDENT MOUTH/THROAT...... 18 OXYCONTIN ...... 8 POLYTRIM ...... 32 previfem...... 28 OZEMPIC...... 23 portia-28 ...... 28 PREZCOBIX ...... 14 OZOBAX ...... 34 potassium chloride crys er ...... 24 PREZISTA ...... 14 P potassium chloride er ...... 24 PRIMLEV ...... 8 PACERONE ORAL TABLET potassium chloride oral ...... 24 PRINIVIL ...... 17 100 MG, 400 MG ...... 16 potassium citrate er ...... 24 PROAIR DIGIHALER ...... 33 pacerone oral tablet 200 mg...... 16 PRADAXA ...... 11 ProAir HFA...... 33 PAMELOR ...... 12 PRALUENT ...... 17 PROAIR RESPICLICK ...... 33 PANCREAZE...... 25 pramipexole dihydrochloride...... 14 PROCARDIA ...... 17 pantoprazole sodium tablet delayed pramipexole dihydrochloride er . . . . .14 PROCARDIA XL ...... 17 release 20 mg oral ...... 24 PRAVACHOL...... 17 PROCENTRA ...... 18 pantoprazole sodium tablet delayed pravastatin sodium...... 17 prochlorperazine maleate oral ...... 12 release 40 mg oral ...... 24 prazosin hcl oral ...... 17 PROCORT...... 31 paroex ...... 18 PRECISION LINK ...... 22 PROCTOFOAM HC ...... 31 paroxetine hcl ...... 12 PRECISION PCX PLUS TEST ...... 22 progesterone micronized oral...... 28 paroxetine hcl er...... 12 PRECISION QID MONITOR...... 22 PROGRAF ORAL PACKET ...... 30 PAXIL ORAL SUSPENSION ...... 12 PRECISION QID TEST ...... 22 promethazine hcl oral solution ...... 33 PAXIL ORAL TABLET...... 12 PRECISION SOF-TACT MONITOR ...22 promethazine hcl oral syrup ...... 33 PAZEO...... 32 PRECISION SOF-TACT TEST ...... 22 promethazine hcl oral tablet ...... 12 PEDIAPRED ...... 29 PRECISION XTRA BLOOD promethazine hcl rectal ...... 12 peg-3350/electrolytes ...... 25 GLUCOSE ...... 22 promethazine-codeine...... 33 penicillamine oral capsule...... 25 PRECISION XTRA DEVICE ...... 22 promethazine-dm ...... 33 penicillin v potassium...... 10 PRECISION XTRA KIT ...... 22 promethegan ...... 12 PENNSAID ...... 9 PRECISION XTRA MONITOR ...... 22 propranolol hcl er ...... 17 PENTASA ...... 31 PRED FORTE ...... 32 propranolol hcl oral ...... 17 PERFOROMIST ...... 33 PRED MILD ...... 32 PROSCAR ...... 26 PERIDEX ...... 18 prednisolone acetate ophthalmic ....32 PROTONIX ORAL PACKET ...... 24 periogard...... 18 prednisolone oral solution...... 29 Proventil HFA ...... 33 permethrin external ...... 13 prednisolone sodium phosphate PROVERA ...... 26, 28 PERTZYE...... 25 oral ...... 29 pseudoephedrine-bromphen-dm ....33 phenadoz...... 12 prednisone intensol ...... 29 PULMICORT FLEXHALER...... 33 phenazo oral tablet 200 mg...... 25 prednisone oral...... 29 PULMOZYME ...... 34 phenazopyridine hcl oral tablet pregabalin oral ...... 18 PURIXAN...... 13 100 mg, 200 mg ...... 25 pregnyl...... 31 PYLERA...... 24 philith ...... 28 PREMARIN ORAL ...... 28 PYRIDIUM ...... 25 PICATO ...... 20 PREMARIN VAGINAL...... 28 pimtrea ...... 28 premium lidocaine ...... 8 Q pioglitazone hcl ...... 23 PREMPHASE ...... 28 QBRELIS ...... 17 pirmella 1/35...... 28 PREMPRO...... 28 QMIIZ ODT ...... 9 PLEGRIDY ...... 18 PREPOPIK...... 25 quetiapine fumarate ...... 14 PLEGRIDY STARTER PACK ...... 18 PREVIDENT 5000 BOOSTER PLUS..18 quetiapine fumarate er...... 14 PLENVU...... 25 PREVIDENT 5000 DRY MOUTH.....18 QUFLORA PEDIATRIC...... 24 PLEXION ...... 20 PREVIDENT 5000 ORTHO QUILLICHEW ER ...... 18 PLEXION CLEANSER ...... 20 DEFENSE ...... 18 QUILLIVANT XR ...... 18

45 quinapril hcl ...... 17 ropinirole hcl ...... 14 SOMATULINE DEPOT ...... 29 QVAR REDIHALER...... 33 ropinirole hcl er...... 14 SOOLANTRA ...... 20 rosadan external cream...... 20 sotalol hcl oral...... 17 R rosadan external gel...... 20 SOTYLIZE ...... 17 RABEPRAZOLE SODIUM ORAL rosuvastatin calcium ...... 17 SPIRIVA HANDIHALER ...... 33 CAPSULE SPRINKLE...... 24 roweepra ...... 11 SPIRIVA RESPIMAT ...... 33 rabeprazole sodium oral tablet delayed release...... 25 roweepra xr ...... 11 spironolactone oral ...... 17 ramipril...... 17 ROZLYTREK ...... 13 sprintec 28 ...... 28 ranolazine er ...... 17 RUCONEST...... 30 SPRITAM ...... 11 RAPAMUNE ORAL SOLUTION . . . . .30 RUKOBIA...... 14 SPRIX...... 9 RASUVO ...... 30 RYBELSUS ...... 23 sronyx ...... 28 RAYOS...... 29 RYTARY...... 14 sss 10-5 ...... 20 REBIF...... 18 STELARA SUBCUTANEOUS S SOLUTION ...... 30 REBIF REBIDOSE...... 18 SAPHRIS ...... 14 STELARA SUBCUTANEOUS REBIF REBIDOSE TITRATION SOLUTION PREFILLED SYRINGE . . .30 PACK ...... 18 scopolamine ...... 12 STENDRA ...... 24 REBIF TITRATION PACK ...... 18 SEREVENT DISKUS...... 33 STIMATE ...... 29 reclipsen ...... 28 SERNIVO...... 20 STRENSIQ...... 25 RECOMBINATE ...... 24 sertraline hcl oral ...... 12 STRIANT ...... 29 REGLAN ...... 12 setlakin ...... 28 STRIBILD...... 14 relexxii ...... 18 sf...... 18 STRIVERDI RESPIMAT ...... 33 RELION BLOOD GLUCOSE TEST . . .22 sf 5000 plus...... 18 SUBSYS...... 8 RELION ULTIMA TEST...... 22 SFROWASA ...... 31 subvenite...... 11 REMERON ...... 12 sharobel...... 28 subvenite starter kit-blue ...... 11 REMERON SOLTAB ...... 12 sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg ...... 24 subvenite starter kit-green...... 11 REPATHA ...... 17 sildenafil oral tablets ...... 34 subvenite starter kit-orange...... 11 REPATHA PUSHTRONEX SYSTEM . .17 simliya ...... 28 sucralfate oral ...... 25 REPATHA SURECLICK ...... 17 simpesse ...... 28 sulfacetamide sodium-sulfur RESTASIS ...... 32 SIMPONI ...... 30 external cream 10-2 %, 10-5 % ...... 20 RESTASIS MULTIDOSE...... 32 simvastatin oral tablet 10 mg, sulfacetamide sodium-sulfur RESTORIL ...... 34 20 mg, 40 mg, 5 mg ...... 17 external cream 9.8-4.8 %...... 20 RETACRIT ...... 24 simvastatin oral tablet 80 mg ...... 17 sulfacetamide sodium-sulfur external emulsion ...... 20 REVLIMID ...... 13 SINEMET...... 14 sulfacetamide sodium-sulfur REYVOW ...... 13 SINGULAIR ORAL PACKET ...... 33 external liquid 10-2 %, 9.8-4.8 %.....20 RHOFADE ...... 20 sirolimus oral...... 30 sulfacetamide sodium-sulfur RHOPRESSA ...... 32 SITAVIG ...... 14 external liquid 9-4 %, 9-4.5 % ...... 20 RILUTEK ...... 18 SKYRIZI (150 MG DOSE)...... 30 sulfacetamide sodium-sulfur riluzole ...... 18 sodium fluoride 5000 plus...... 18 external lotion 10-5 %...... 20 RINVOQ...... 30 sodium fluoride dental ...... 18 sulfacetamide sodium-sulfur external lotion 9.8-4.8 % ...... 20 risperidone ...... 14 SOFOS/VELPAT ORAL TABLET RITALIN ...... 18 400-100 ...... 14 sulfacetamide sodium-sulfur external pad ...... 20 ritonavir ...... 14 SOFOSBUVIR-VELPATASVIR ...... 14 sulfacetamide sodium-sulfur rivelsa...... 28 SOFTCLIX ...... 21, 22 external suspension 10-5 % ...... 20 rizatriptan benzoate ...... 13 solifenacin ...... 26 sulfacetamide sodium-sulfur ROBAXIN-750 ...... 34 SOLIQUA...... 23 external suspension 8-4 % ...... 20 ROCALTROL...... 31 SOLTAMOX ...... 13 sulfacleanse 8/4 ...... 20 ROCKLATAN...... 32 SOMA ORAL TABLET 350 MG ...... 34

46 sulfamethoxazole-trimethoprim oral..10 TASIGNA ...... 13 tobramycin nebulization solution sulfamez wash ...... 20 TAYTULLA...... 28 300 mg/5ml inhalation...... 34 sulfasalazine oral tablet ...... 31 tazarotene external...... 20 tobramycin ophthalmic ...... 32 sulfatrim pediatric...... 10 TAZORAC ...... 20 tobramycin-dexamethasone ...... 32 SUMADAN WASH ...... 20 TECFIDERA...... 18 TOBREX OPHTHALMIC OINTMENT ...... 32 sumatriptan succinate oral ...... 13 TEGRETOL ...... 11 TOBREX OPHTHALMIC sumatriptan succinate refill ...... 13 TEGRETOL-XR ...... 11 SOLUTION ...... 32 sumatriptan succinate TEGSEDI ...... 25 TOLAK...... 20 subcutaneous ...... 13 TEKTURNA ...... 17 TOPAMAX ...... 11 SUMAXIN ...... 20 TEKTURNA HCT ...... 17 TOPAMAX SPRINKLE ...... 11 SUMAXIN WASH ...... 20 telmisartan ...... 17 topiramate er...... 11 SUNOSI ...... 34 temazepam ...... 34 topiramate oral ...... 11 SUPREP BOWEL PREP KIT ...... 25 TEMIXYS ...... 14 TOPROL XL...... 17 syeda ...... 28 TEMOVATE ...... 20 torsemide ...... 17 SYMAX DUOTAB ...... 25 tenofovir disoproxil fumarate...... 14 TOUJEO MAX SOLOSTAR ...... 23 symax-sl...... 25 terazosin hcl ...... 26 TOUJEO SOLOSTAR ...... 23 symax-sr ...... 25 terbinafine hcl oral ...... 13 TOVIAZ ...... 26 SYMBICORT ...... 33 terconazole ...... 13 TRACLEER ...... 34 SYMFI ...... 14 TERIPARATIDE (RECOMBINANT) . . .31 TRADJENTA ...... 23 SYMFI LO ...... 14 TESSALON PERLES ...... 33 tramadol hcl er (biphasic) ...... 8 SYMJEPI ...... 32 TESTIM ...... 29 TRAMADOL HCL ER ORAL SYMLINPEN 60...... 23 TESTOSTERONE CYPIONATE CAPSULE EXTENDED RELEASE SYMLNPEN 120 ...... 23 INJECTION ...... 29 24 HOUR 100 MG, 200 MG, 300 MG..8 SYMPROIC ...... 25 testosterone cypionate tramadol hcl er oral capsule SYNJARDY ...... 23 intramuscular ...... 29 extended release 24 hour 150 mg . . . .8 SYNJARDY XR ...... 23 testosterone enanthate tramadol hcl er oral tablet extended intramuscular ...... 29 release 24 hour...... 8 SYNTHROID ...... 29 testosterone transdermal...... 29 tramadol hcl oral tablet 50 mg ...... 8 T TEXACORT ...... 20 TRANSDERM-SCOP (1.5 MG) ...... 12 TACLONEX EXTERNAL thyroid oral tablet 120 mg, 15 mg, travoprost (bak free)...... 32 SUSPENSION ...... 20 30 mg, 60 mg, 90 mg...... 29 trazodone hcl oral...... 12 tacrolimus oral ...... 30 TIGLUTIK...... 18 TRELEGY ELLIPTA...... 34 tadalafil oral tablet 10 mg, 20 mg ....24 timolol maleate ophthalmic ...... 32 TREMFYA ...... 30 tadalafil oral tablet 2.5 mg, 5 mg.....24 TIMOPTIC ...... 32 TRESIBA ...... 23 TAKHZYRO ...... 30 TIMOPTIC OCUDOSE 0.25 %...... 32 TRESIBA FLEXTOUCH ...... 23 tamoxifen citrate oral tablet 10 mg ...13 TIMOPTIC-XE ...... 32 tretinoin external cream...... 20 tamoxifen citrate oral tablet 20 mg...13 TIROSINT ...... 30 tretinoin external gel 0.01 %, 0.05 %..20 tamsulosin hcl...... 26 TIROSINT-SOL ...... 30 tretinoin external gel 0.025 % ...... 20 TAPAZOLE ...... 29 TIVICAY ...... 14 TREXALL...... 30 TAPERDEX 12-DAY...... 29 tizanidine hcl oral ...... 34 TREZIX ...... 9 TAPERDEX 6-DAY ORAL TABLET TOBI PODHALER ...... 34 tri femynor ...... 28 THERAPY PACK 1.5 MG (21)...... 29 TOBRADEX OPHTHALMIC tri-estarylla...... 28 TAPERDEX 7-DAY...... 29 OINTMENT ...... 32 tri-linyah ...... 28 TARGRETIN EXTERNAL ...... 13 TOBRADEX OPHTHALMIC SUSPENSION ...... 32 tri-lo-estarylla ...... 28 TARGRETIN ORAL...... 13 TOBRADEX ST ...... 32 tri-lo-mili...... 28 tarina 24 fe...... 28 tobramycin nebulization solution tri-lo-sprintec...... 28 tarina fe 1/20...... 28 300 mg/4ml inhalation ...... 34 tri-mili ...... 28 tarina fe 1/20 eq ...... 28

47 tri-previfem ...... 28 UROCIT-K 10...... 24 viorele ...... 28 tri-sprintec ...... 28 UROCIT-K 15...... 24 VIREAD ORAL POWDER...... 14 tri-vylibra ...... 28 UROCIT-K 5...... 24 VIREAD ORAL TABLET 150 MG, tri-vylibra lo ...... 28 URSO 250 ...... 25 200 MG, 250 MG ...... 15 triamcinolone acetonide external URSO FORTE ...... 25 VISTARIL ...... 15 aerosol solution ...... 21 ursodiol oral ...... 25 vitamin d (ergocalciferol) oral triamcinolone acetonide external capsule 1.25 mg (50000 ut)...... 24 cream 0.025 %, 0.1 %...... 21 V VITRAKVI ...... 13 triamcinolone acetonide external valacyclovir hcl oral ...... 14 Vivelle-Dot ...... 27, 28 cream 0.5 % ...... 21 valsartan ...... 17 VIVLODEX ...... 9 triamcinolone acetonide external valsartan-hydrochlorothiazide...... 17 VOLTAREN ...... 9 lotion ...... 21 VALTOCO ...... 11 VOSEVI ...... 15 triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % ...... 21 VANATOL LQ ...... 9 VRAYLAR ...... 14 triamcinolone acetonide external VANATOL S...... 9 vyfemla ...... 28 ointment 0.05 % ...... 21 vandazole ...... 10 VYLEESI ...... 24 triamterene-hctz ...... 17 VARUBI (180 MG DOSE) ...... 12 vylibra ...... 28 trianex ...... 21 VASCEPA ORAL CAPSULE 0.5 GM .. 17 VYVANSE ...... 18 triazolam ...... 15 VASCEPA ORAL CAPSULE 1 GM . . . 17 VYZULTA...... 32 triderm external cream 0.1 %...... 21 VELPHORO...... 26 W triderm external cream 0.5 % ...... 21 VELTASSA...... 24 WAKIX ...... 34 TRIDESILON ...... 21 VEMLIDY ...... 14 warfarin sodium oral...... 11 trientine hcl ...... 25 venlafaxine hcl ...... 12 WELCHOL...... 17 TRIJARDY XR ...... 23 venlafaxine hcl er oral capsule wera ...... 28 TRILEPTAL ...... 11 extended release 24 hour ...... 12 WESTHROID...... 30 TRINTELLIX ...... 12 venlafaxine hcl er oral tablet extended release 24 hour ...... 12 wixela inhub ...... 34 TRIUMEQ ...... 14 Ventolin HFA ...... 33, 34 WP THYROID ...... 30 TROKENDI XR ...... 11 verapamil hcl er ...... 17 TRUE METRIX BLOOD GLUCOSE X TEST ...... 22 verapamil hcl oral ...... 17 XARELTO ...... 11 TRUETRACK TEST ...... 22 VERDESO ...... 21 XARELTO STARTER PACK ...... 11 TRULANCE...... 25 VERELAN ...... 17 XCOPRI ...... 11 TRULICITY ...... 23 VERELAN PM ...... 17 XELJANZ...... 30 TRUVADA ...... 14 VERZENIO...... 13 XELJANZ XR ORAL TABLET tulana...... 28 VIBERZI ...... 25 EXTENDED RELEASE 24 HOUR TUSSICAPS ...... 33 VIBRAMYCIN ORAL CAPSULE . . . . .10 11 MG ...... 30 tydemy...... 28 VIBRAMYCIN ORAL SUSPENSION XELPROS ...... 32 RECONSTITUTED ...... 10 TYLENOL WITH CODEINE #3 ...... 9 XENLETA...... 10 vicodin hp oral tablet 10-300 mg . . . . .9 TYMLOS ...... 31 XEPI ...... 10 VICTOZA SOLUTION PEN- TYVASO ...... 34 INJECTOR 18 MG/3ML XHANCE ...... 33 TYVASO REFILL...... 34 SUBCUTANEOUS (2 Pak) ...... 23 XIFAXAN ...... 10 TYVASO STARTER ...... 34 VICTOZA SOLUTION PEN- XIIDRA ...... 32 INJECTOR 18 MG/3ML XIMINO ...... 10 U SUBCUTANEOUS (3 Pak) ...... 23 XOFLUZA (40 MG DOSE) ...... 15 UBRELVY ...... 13 vienva...... 28 XOFLUZA (80 MG DOSE) ...... 15 UCERIS ORAL ...... 31 VIIBRYD...... 12 XOLEGEL ...... 13 UCERIS RECTAL ...... 31 VIIBRYD STARTER PACK ...... 12 XOPENEX HFA ...... 34 ULTRAM ...... 9 VIMPAT ORAL...... 11 XTAMPZA ER ...... 9 unithroid ...... 30 VIOKACE...... 25

48 xulane ...... 28 ZUBSOLV ...... 9 XYOSTED ...... 29 zumandimine...... 28 XYREM ...... 34 ZUPLENZ ...... 12 ZYCLARA ...... 21 Y ZYCLARA PUMP ...... 21 YASMIN 28 ...... 28 ZYLOPRIM ...... 13 YAZ ...... 28 YUPELRI ...... 34 yuvafem ...... 28

Z ZANAFLEX ORAL CAPSULE ...... 34 zarah ...... 28 ZARXIO ...... 24 ZEBUTAL...... 9 ZEJULA ...... 13 ZELNORM...... 25 ZEMBRACE SYMTOUCH ...... 13 zenatane ...... 21 ZENPEP...... 25 ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG . . . . .18 ZEPATIER ...... 15 ZEPOSIA ...... 18 ZETONNA ...... 33 ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG ...... 17 ZIAC ORAL TABLET 5-6.25 MG ..... 17 ZIEXTENZO...... 24 ZILXI...... 21 ziprasidone hcl ...... 14 ZIPSOR ...... 9 ZITHROMAX ORAL ...... 10 ZITHROMAX TRI-PAK ...... 10 ZITHROMAX Z-PAK ...... 10 ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG ...... 17 ZOFRAN ...... 12 ZOHYDRO ER...... 9 zolpidem tartrate er ...... 34 zolpidem tartrate oral...... 34 zolpidem tartrate sublingual ...... 34 ZOMACTON ...... 29 ZONEGRAN ...... 11 zonisamide oral...... 11 ZONTIVITY ...... 14 ZOVIRAX ORAL SUSPENSION . . . . .15 ZTLIDO ...... 9

49 Nondiscrimination notice and access to communication services UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in their health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

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

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

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

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

50 Multi-language interpreter interpreter services services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號 碼。 XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card. ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте. تنبيه: إذا كنت تتحدث العربية (Arabic ،) فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّ معرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuille] appeler le numéro de téléphone gratuit figurant sur votre carte dœidentification. U:$*$: -e›eli mówis] po polsku (Polish), udostšpnili™my darmowe us˜ugi t˜umac]a. Prosimy ]ad]woni— pod be]p˜atny numer telefonu podany na karcie identyfikacyjnej. $7(Nd–2: 6e você fala português (Portuguese), contate o servioo de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartmo de identificaomo. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an. 注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証 に記載されているフリーダイヤルにお電話ください。 توجه: اŒر بان ما فارسی (Farsi) است، خدمات امداد بان“ به Žور راي’ان در اختيار ما م“ باد. لŽ‘ا با مار تل‘ن راي’ان“ •ه رو” •ارت ناساي“ ما قيد د تما‹ ب’يريد. ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej. ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo. DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bi]aad bee yini˜tiœgo, saad bee ikaŠanídaŠawoŠígíí, tœii jííkœeh, bee niœahóótœiœ. 7œii sh‰‰dí ninaaltsoos nit˜œi]í bee néého]inígíí bineœdšˆ šˆŠ tœii jííkœehgo béésh bee haneœí bikiœígíí bee hodíilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

51 This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans. Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates. UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. 1/21 ©2021 United HealthCare Services, Inc. WF3888362-J 2021 Prescription Drug List — Traditional 3-Tier