PREFERRED DRUG LIST 3-TIER PRESCRIPTION DRUG PLAN

FOR LARGE GROUP PLANS AND SMALL GROUP NON-ACA COMPLIANT PLANS

Note: The copayment for specialty medication is plan dependent and is specified in your Copayment Summary. Most specialty medications require a Prior Authorization and may be limited to a 30-day supply. Preferred Drug List Commercial Plans

Revised 04/15 Specialty Drugs are not listed in the PDL. Specialty Drugs are all (oral, inhalation, injection, etc.) drugs that cost $500 or more for a 30 day supply. The co-payment for Specialty Drugs is plan dependant. The most common copayment is $100 for a 30 day supply. Most Specialty Drugs require a Prior Authorization for coverage.

1 of 94 Western Health Advantage Preferred Drug List

5-Alpha-Reductase Inhibitors / UROLOGICALS Tier Generic Name Brand Name Notes 1 FINASTERIDE 2 DUTASTERIDE AVODART 3 DUTASTERIDE/TAMSULOSIN HCL JALYN 3 FINASTERIDE PROSCAR

5-HT2C Receptor Antagonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 LORCASERIN BELVIQ 5

5-HT3 Receptor Antagonists / ANTIEMETICS Tier Generic Name Brand Name Notes 1 GRANISETRON HCL 1 ONDANSETRON ONDANSETRON ODT 3 DOLASETRON ANZEMET 3 GRANISETRON SANCUSO 3 ONDANSETRON ZOFRAN ODT

5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand Name Notes 3 NETUPITANT/PALONOSETRON AKYNZEO 5

ADHD Amphetamines / CNS AGENTS Tier Generic Name Brand Name Notes 1 AMPHET ASP/AMPHET/D-AMPHET DEXTROAMPHETAMINE-AMPHETAMINE 1 AMPHET ASP/AMPHET/D-AMPHET AMPHETAMINE SALT COMBO 1 DEXTROAMPHETAMINE SULFATE 1 METHAMPHETAMINE HCL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL XR 3 DEXTROAMPHETAMINE SULFATE DEXEDRINE

ADHD Non-Amphetamine / CNS AGENTS Tier Generic Name Brand Name Notes 2 ATOMOXETINE HCL STRATTERA 3 CLONIDINE KAPVAY 3 GUANFACINE HCL INTUNIV

AMPA Receptor Antagonist / ANTICONVULSANTS Tier Generic Name Brand Name Notes 2 PERAMPANEL FYCOMPA

Acidifying Agents / UROLOGICALS Tier Generic Name Brand Name Notes 3 POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL

Adrenals / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CORTISONE ACETATE

5 - Prior Authorization

2 of 94 Adrenals / ENDOCRINE/DIABETES (cont.) Tier Generic Name Brand Name Notes 1 DEXAMETHASONE 1 FLUDROCORTISONE ACETATE 1 METHYLPREDNISOLONE 1 PREDNISOLONE MILLIPRED 1 PREDNISOLONE 2 PREDNISOLONE SOD PHOSPHATE ORAPRED ODT 3 HYDROCORTISONE CORTEF 3 METHYLPREDNISOLONE MEDROL 3 PREDNISOLONE ACETATE FLO-PRED

Adrenals / GI AGENTS Tier Generic Name Brand Name Notes 1 BUDESONIDE BUDESONIDE EC 3 BUDESONIDE ENTOCORT EC

Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS Tier Generic Name Brand Name Notes 1 BETAMETHASONE DIPROPIONATE 1 BETAMETHASONE VALERATE 1 BETAMETHASONE VALERATE BETA-VAL 1 CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE 1 DEXAMETHASONE 1 HYDROCORTISONE VALERATE 1 PREDNISONE 2 DEXAMETHASONE DEXAMETHASONE INTENSOL 3 BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3 BETAMETHASONE VALERATE LUXIQ 3 CALCIPOTRIENE/BETAMETHASONE TACLONEX 3 DEXAMETHASONE MAXIDEX 3 HYDROCORTISONE BUTYRATE LOCOID 3 HYDROCORTISONE BUTYRATE/EMOLL LOCOID LIPOCREAM 3 HYDROCORTISONE/PRAMOXINE PRAMOSONE 3 HYDROCORTISONE/PRAMOXINE EPIFOAM 3 HYDROCORTISONE/PRAMOXINE/ALOE NOVACORT

Adrenocortical Insufficiency / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CORTICOTROPIN H.P. ACTHAR 5

Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 DISULFIRAM 3 ACAMPROSATE CALCIUM CAMPRAL 3 DISULFIRAM ANTABUSE 4 NALTREXONE HCL VIVITROL 5

Alkalinizing Agents / UROLOGICALS Tier Generic Name Brand Name Notes 1 CITRIC ACID/SODIUM CITRATE SODIUM CITRATE & CITRIC ACID

5 - Prior Authorization

3 of 94 Alkalinizing Agents / UROLOGICALS (cont.) Tier Generic Name Brand Name Notes 1 CITRIC ACID/SODIUM CITRATE CYTRA-2 1 POTASSIUM CITRATE 1 POTASSIUM CITRATE/CITRIC ACID CYTRA-K 1 POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE-CITRIC ACID 3 POTASSIUM CITRATE UROCIT-K

Alkylating Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 BUSULFAN 1 CARMUSTINE 1 CHLORAMBUCIL 1 CYCLOPHOSPHAMIDE 1 MECHLORETHAMINE 1 MELPHALAN 1 PROCARBAZINE 1 THIOTEPA 2 LOMUSTINE CEENU 3 MECHLORETHAMINE VALCHLOR 5 4 BENDAMUSTINE TREANDA 4 4 CISPLATIN 4

Allergen / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 GRASS POLLEN ORALAIR 3 GRASS POLLEN GRASTEK 3 RAGWEEK POLLEN RAGWITEK

Allylamines / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 TERBINAFINE HCL 3 TERBINAFINE HCL LAMISIL

Alpha- And Beta-Adrenergic Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 DROXIDOPA NORTHERA 5

Alpha- And Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 EPINEPHRINE TWINJECT

Alpha-Adrenergic Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CLONIDINE 1 DIHYDROERGOTAMINE MESYLATE 2 EPINEPHRINE EPIPEN JR 2 EPINEPHRINE EPIPEN 2-PAK

4 - Office/Clinic Administration 5 - Prior Authorization

4 of 94 Alpha-Adrenergic Agonists / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 2 EPINEPHRINE EPIPEN 2 EPINEPHRINE EPIPEN JR 2-PAK 3 CLONIDINE HCL KAPVAY 3 CLONIDINE HCL NEXICLON XR

Alpha-Adrenergic Agonists (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BRIMONIDINE TARTRATE 2 BRIMONIDINE TARTRATE ALPHAGAN P 3 BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN

Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 ERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 DIHYDROERGOTAMINE MESYLATE MIGRANAL

Alpha-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ALFUZOSIN HCL 1 DOXAZOSIN MESYLATE 1 PRAZOSIN HCL 1 TAMSULOSIN HCL 1 TERAZOSIN HCL 2 DOXAZOSIN MESYLATE CARDURA XL 3 ALFUZOSIN HCL UROXATRAL 3 PRAZOSIN HCL MINIPRESS 3 SILODOSIN RAPAFLO 3 TAMSULOSIN HCL FLOMAX

Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 ACARBOSE 3 MIGLITOL GLYSET

Amebicides / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 PAROMOMYCIN SULFATE 1 TINIDAZOLE

Aminoglycosides / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 NEOMYCIN SULFATE 3 TOBRAMYCIN IN 0.225% NACL TOBI 5 4 AMIKACIN 4 4 GENTAMICIN 4 4 KANAMYCIN 4

4 - Office/Clinic Administration 5 - Prior Authorization

5 of 94 Aminoglycosides / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 4 NETILMICIN NETROMYCIN 4 4 TOBRAMYCIN 4

Aminoglycosides / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes 4 CAPREOMYCIN CAPASTAT 4

Aminosalicylates / INFLAMMATORY BOWEL AGENTS Tier Generic Name Brand Name Notes 2 MESALAMINE ASACOL HD 2 MESALAMINE ASACOL 2 MESALAMINE PENTASA 3 MESALAMINE W/CLEANSING WIPES ROWASA

Ammonia Detoxicants / GI AGENTS Tier Generic Name Brand Name Notes 1 LACTULOSE 1 LACTULOSE ENULOSE 1 LACTULOSE GENERLAC 2 LACTULOSE KRISTALOSE

Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 LISDEXAMFETAMINE DIMESYLATE VYVANSE

Amylinomimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 4 PRAMLINTIDE ACETATE SYMLINPEN 120 5 4 PRAMLINTIDE ACETATE SYMLINPEN 60 5

Analgesics And Antipyretics- Misc. / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 ISOMETHEPT/ACETAMINOP/DICHLPHN EPIDRIN 1 ISOMETHEPT/ACETAMINOP/DICHLPHN ISOMETHEPT-DICHLORALP-ACETAMIN

Analgesics And Antipyretics- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 1 BUTALB/ACETAMINOPHEN/CAFFEINE ZEBUTAL 3 BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET 3 BUTALBITAL/ACETAMINOPHEN PHRENILIN FORTE

Androgens / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 DANAZOL

4 - Office/Clinic Administration 5 - Prior Authorization

6 of 94 Androgens / HORMONE: PITUITARY Tier Generic Name Brand Name Notes 2 TESTOSTERONE ANDROGEL 3 TESTOSTERONE 3 TESTOSTERONE ANDRODERM 4 TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 5

Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CANDESARTAN 7 1 CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN-HYDROCHLOROTHIAZID 7 1 IRBESARTAN 7 1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 7 1 LOSARTAN POTASSIUM 7 1 LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN-HYDROCHLOROTHIAZIDE 7 1 VALSARTAN 7 1 VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE 7 2 CANDESARTAN CILEXETIL ATACAND 7 2 CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT 7 2 OLMESARTAN MEDOXOMIL BENICAR 7 2 OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT 7 2 TELMISARTAN MICARDIS 7 2 TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT 7 3 AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 7 3 AZILSARTAN MEDOXOMIL EDARBI 7 3 IRBESARTAN AVAPRO 7 3 IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 7 3 LOSARTAN POTASSIUM COZAAR 7 3 OLMESARTAN MED/AMLODIPINE/HCTZ TRIBENZOR 7 3 TELMISARTAN/AMLODIPINE TWYNSTA 3 VALSARTAN DIOVAN 7 3 VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCTZ 7

Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 BENAZEPRIL HCL 1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 1 CAPTOPRIL 1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL-HYDROCHLOROTHIAZIDE 1 ENALAPRIL MALEATE 1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE 1 FOSINOPRIL SODIUM 1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL-HYDROCHLOROTHIAZIDE 1 LISINOPRIL 1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL-HYDROCHLOROTHIAZIDE 1 PERINDOPRIL ERBUMINE 1 QUINAPRIL HCL 1 RAMIPRIL 3 ENALAPRIL MALEATE VASOTEC 3 LISINOPRIL ZESTRIL 3 QUINAPRIL HCL ACCUPRIL 3 QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC

5 - Prior Authorization 7 - Step Therapy

7 of 94 Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 3 RAMIPRIL ALTACE 3 TRANDOLAPRIL/VERAPAMIL HCL TARKA

Anorex.-Respir.-Cerebral Stimulants-Misc / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 METHYLPHENIDATE HCL 1 METHYLPHENIDATE HCL METHYLPHENIDATE ER 1 METHYLPHENIDATE HCL METADATE ER 1 METHYLPHENIDATE HCL METHYLPHENIDATE SR 1 MODAFINIL 3 ARMODAFINIL NUVIGIL 3 DEXMETHYLPHENIDATE HCL FOCALIN XR 3 DEXMETHYLPHENIDATE HCL FOCALIN 3 METHYLPHENIDATE DAYTRANA 3 METHYLPHENIDATE HCL METHYLIN ER 3 METHYLPHENIDATE HCL METHYLIN 3 METHYLPHENIDATE HCL METADATE CD 3 METHYLPHENIDATE HCL RITALIN LA 3 METHYLPHENIDATE HCL RITALIN 3 METHYLPHENIDATE HCL CONCERTA 3 MODAFINIL PROVIGIL

Anthelmintics / ANTIPARASITICS Tier Generic Name Brand Name Notes 1 MEBENDAZOLE 2 IVERMECTIN STROMECTOL 3 ALBENDAZOLE ALBENZA 3 PRAZIQUANTEL BILTRICIDE

Anti HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes 2 COBICISTAT TYBOST 2 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR STRIBILD

Anti-Cytomegalovirus / ANTIVIRALS Tier Generic Name Brand Name Notes 3 GANCICLOVIR ZIRGAN 3 VALGANCICLOVIR VALCYTE 4 CIDOFOVIR 4

Anti-HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes 2 DOLUTEGRAVIR TIVICAY 2 RALTEGRAVIR POTASSIUM ISENTRESS 2 RITONAVIR NORVIR 4 ENFUVIRTIDE FUZEON 5

Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes 1 BALSALAZIDE DISODIUM

4 - Office/Clinic Administration 5 - Prior Authorization

8 of 94 Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 1 MESALAMINE 2 MESALAMINE CANASA 2 MESALAMINE LIALDA 3 MESALAMINE APRISO

Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ALCLOMETASONE DIPROPIONATE 1 CLOBETASOL PROPIONATE 1 CLOBETASOL PROPIONATE CORMAX 1 CLOBETASOL PROPIONATE/EMOLL CLOBETASOL EMOLLIENT 1 DESONIDE 1 DESOXIMETASONE 1 FLUOCINOLONE ACETONIDE 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE EMOLLIENT 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE-E 1 HALOBETASOL PROPIONATE 1 MOMETASONE FUROATE 1 PREDNICARBATE 1 TRIAMCINOLONE ACETONIDE 2 DESONIDE VERDESO 2 DESONIDE DESONATE 2 FLURANDRENOLIDE CORDRAN 2 FLUTICASONE PROPIONATE CUTIVATE 3 CLOBETASOL PROPIONATE CLOBEX 3 CLOBETASOL PROPIONATE OLUX 3 CLOBETASOL PROPIONATE/EMOLL OLUX-E 3 CLOCORTOLONE PIVALATE CLODERM 3 DESOXIMETASONE TOPICORT 3 FLUOCINOLONE ACETONIDE CAPEX SHAMPOO 3 FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS 3 FLUOCINONIDE VANOS 3 FLURANDRENOLIDE CORDRAN SP 3 HALCINONIDE HALOG 3 HALOBETASOL PROPIONATE ULTRAVATE 3 MOMETASONE FUROATE ELOCON 3 TRIAMCINOLONE ACETONIDE KENALOG

Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE PROCTOCORT 1 HYDROCORTISONE COLOCORT 1 HYDROCORTISONE 1 HYDROCORTISONE PROCTOZONE-HC 1 HYDROCORTISONE PROCTOSOL-HC 1 HYDROCORTISONE ACETATE 1 HYDROCORTISONE ACETATE HEMRIL 1 HYDROCORTISONE ACETATE ANUCORT-HC 1 HYDROCORTISONE/PRAMOXINE HYDROCORTISONE-PRAMOXINE 2 HYDROCORTISONE ACETATE CORTIFOAM 2 HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 3 HYDROCORTISONE/PRAMOXINE ANALPRAM HC

Anti-Influenza / ANTIVIRALS Tier Generic Name Brand Name Notes 1 AMANTADINE HCL AMANTADINE

9 of 94 Anti-Influenza / ANTIVIRALS (cont.) Tier Generic Name Brand Name Notes 2 OSELTAMIVIR PHOSPHATE TAMIFLU 6 3 ZANAMIVIR RELENZA 4 INFLUENZA VACCINE FLUZONE 4

Antiallergic Agents / NASAL STEROID Tier Generic Name Brand Name Notes 1 OLOPATADINE HCL OLOPATADINE NASAL 3 OLOPATADINE HCL PATANASE

Antiallergic Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 AZELASTINE HCL 1 EPINASTINE HCL 2 LODOXAMIDE TROMETHAMINE ALOMIDE 3 ALCAFTADINE LASTACAFT 3 AZELASTINE HCL OPTIVAR 3 BEPOTASTINE BESILATE BEPREVE 3 EPINASTINE HCL ELESTAT 3 OLOPATADINE HCL PATANOL 3 OLOPATADINE HCL PATADAY 3 PEMIROLAST POTASSIUM ALAMAST

Antiallergic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 AZELASTINE 1 AZELASTINE HCL 3 AZELASTINE HCL ASTEPRO 3 AZELASTINE HCL ASTELIN 3 AZELASTINE/FLUTICASONE DYMISTA

Antiandrogen / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 ENZALUTAMIDE XTANDI 5

Antiangiogenic Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 PAZOPANIB VOTRIENT 5 3 SORAFENIB NEXAVAR 5 3 SUNITINIB MALATE SUTENT 4 BEVACIZUMAB AVASTIN 4

Antiarrhythmics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMIODARONE HCL

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

10 of 94 Antiarrhythmics / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 DIGOXIN 1 FLECAINIDE ACETATE 1 MEXILETINE HCL 1 PROPAFENONE HCL 1 QUINIDINE GLUCONATE 1 QUINIDINE SULFATE 2 AMIODARONE HCL PACERONE 2 DISOPYRAMIDE PHOSPHATE NORPACE CR 3 DIGOXIN LANOXIN 3 DOFETILIDE TIKOSYN 3 DRONEDARONE HCL MULTAQ 3 PROPAFENONE HCL RYTHMOL SR 4 ADENOSINE ADENOCARD 4

Antibacterials (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HYDROCORT 1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HC 3 CIPROFLOXACIN HCL/DEXAMETH CIPRODEX 3 CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3 NEOMY SULF/COLIST SUL/HC/THONZ COLY-MYCIN S 3 NEOMY SULF/COLIST SUL/HC/THONZ CORTISPORIN-TC

Antibacterials (Eent) / DENTAL AGENT Tier Generic Name Brand Name Notes 3 MINOCYCLINE HCL MICROSPHERES ARESTIN

Antibacterials (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BACITRACIN 1 BACITRACIN/POLYMYXIN B SULFATE AK-POLY-BAC 1 CIPROFLOXACIN HCL 1 GENTAMICIN SULFATE GENTAK 1 GENTAMICIN SULFATE 1 LEVOFLOXACIN 1 NEO/POLYMYX B SULF/DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH 1 NEOMY SULF/BACITRA/POLYMYXIN B NEO-POLYCIN 1 NEOMY SULF/BACITRA/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN 1 NEOMY SULF/BACITRAC ZN/POLY/HC NEOMYCIN-BACITRACIN-POLY-HC 1 NEOMY SULF/BACITRAC ZN/POLY/HC NEO-POLYCIN HC 1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN 1 OFLOXACIN 1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM 1 SULFACETAMIDE SODIUM SULFAMIDE 1 SULFACETAMIDE SODIUM 1 SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE 1 TOBRAMYCIN 1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE 2 SULFACETAMIDE SODIUM BLEPH-10 2 TOBRAMYCIN TOBREX 2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST

4 - Office/Clinic Administration

11 of 94 Antibacterials (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name Brand Name Notes 3 AZITHROMYCIN AZASITE 3 BESIFLOXACIN HCL BESIVANCE 3 CIPROFLOXACIN HCL CILOXAN 3 GATIFLOXACIN ZYMAXID 3 GATIFLOXACIN ZYMAR 3 MOXIFLOXACIN HCL VIGAMOX 3 MOXIFLOXACIN HCL MOXEZA 3 NEO/POLYMYX B SULF/DEXAMETH MAXITROL 3 POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE S.O.P. 3 TOBRAMYCIN/DEXAMETHASONE TOBRADEX 3 TOBRAMYCIN/LOTEPRED ETAB ZYLET

Antibacterials (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 MUPIROCIN CALCIUM BACTROBAN NASAL

Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN-BENZOYL PEROXIDE 1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN PHOS-BENZOYL PEROX 1 CLINDAMYCIN PHOSPHATE 1 ERYTHROMYCIN BASE/ETHANOL ERY 1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN-BENZOYL PEROXIDE 1 MUPIROCIN 2 CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA 2 ERYTHROMYCIN/BENZOYL PEROXIDE BENZAMYCINPAK 2 METRONIDAZOLE NORITATE 2 METRONIDAZOLE METROGEL 3 CLINDAMYCIN PHOS/BENZOYL PEROX DUAC 3 CLINDAMYCIN PHOS/BENZOYL PEROX BENZACLIN 3 CLINDAMYCIN PHOSPHATE CLINDAGEL 3 CLINDAMYCIN/TRETINOIN VELTIN 3 CLINDAMYCIN/TRETINOIN ZIANA 3 ERYTHROMYCIN BASE AKNE-MYCIN 3 METRONIDAZOLE METROLOTION 3 MUPIROCIN BACTROBAN 3 RETAPAMULIN ALTABAX

Antibacterials (Skin & Mucous Membrane) / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 NEOMY SULF/POLYMYXIN B SULFATE NEOSPORIN G.U. IRRIGANT

Antibacterials (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 CLINDAMYCIN PHOSPHATE 1 METRONIDAZOLE VANDAZOLE 2 CLINDAMYCIN PHOSPHATE CLEOCIN 3 METRONIDAZOLE METROGEL-VAGINAL

Antibacterials- Miscellaneous / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 CLINDAMYCIN HCL

12 of 94 Antibacterials- Miscellaneous / ANTI - INFECTIVES (cont.) Tier Generic Name Brand Name Notes 1 CLINDAMYCIN PALMITATE HCL 1 CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 1 VANCOMYCIN HCL 3 CLINDAMYCIN HCL CLEOCIN HCL 3 LINEZOLID ZYVOX 5 3 RIFAXIMIN XIFAXAN 3 VANCOMYCIN HCL VANCOCIN HCL

Antibacterials- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 BISMUTH SAL/METRONID/TETRACYC HELIDAC 3 BISMUTH/METRONID/TETRACYCLINE PYLERA

Anticholinergics / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 BENZTROPINE MESYLATE 1 TRIHEXYPHENIDYL HCL 3 TRIHEXYPHENIDYL HCL ARTANE

Anticoagulants / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 1 WARFARIN SODIUM 2 DABIGATRAN ETEXILATE MESYLATE PRADAXA 3 WARFARIN SODIUM COUMADIN 4 DALTEPARIN SODIUM,PORCINE FRAGMIN 5 4 DARBEPOETIN ALFA ARANESP 5 4 ENOXAPARIN SODIUM 5 4 ENOXAPARIN SODIUM LOVENOX 5 4 FONDAPARINUX SODIUM 5

Anticonvulsants- Miscellaneous / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 FELBAMATE 1 LEVETIRACETAM 2 TIAGABINE HCL GABITRIL

Anticonvulsants- Other / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE EPITOL 2 EZOGABINE POTIGA 2 METHSUXIMIDE CELONTIN 3 CARBAMAZEPINE EQUETRO 3 LACOSAMIDE VIMPAT

Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 MIRTAZAPINE 1 NEFAZODONE HCL

5 - Prior Authorization

13 of 94 Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (cont.) Tier Generic Name Brand Name Notes 1 OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 3 DESVENLAFAXINE SUCCINATE PRISTIQ ER 3 DOXEPIN HCL SILENOR 3 MIRTAZAPINE REMERON 3 OLANZAPINE/FLUOXETINE HCL SYMBYAX 3 VILAZODONE HYDROCHLORIDE VIIBRYD

Antidiarrhea Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE 1 LOPERAMIDE HCL LOPERAMIDE 2 LACT CMB2/S.THERMOPHL/BIF CMB1 VSL#3 DS 3 CROFELEMER FULYZAQ 5 3 DIPHENOXYLATE HCL/ATROPINE LOMOTIL 3 OPIUM TINCTURE OPIUM

Antidotes / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 2 LEUCOVORIN CALCIUM

Antiemetics- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 SCOPOLAMINE TRANSDERM-SCOP 3 SCOPOLAMINE HYDROBROMIDE SCOPACE

Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 3 DOXYLAMINE/PYRIDOXINE DICLEGIS

Antiestrogen / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 TAMOXIFEN CITRATE

Antifungal Antibiotics / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 FLUCYTOSINE 1 GRISEOFULVIN ULTRAMICROSIZE 1 GRISEOFULVIN,MICROSIZE GRISEOFULVIN 1 NYSTATIN 3 GRISEOFULVIN ULTRAMICROSIZE GRIS-PEG 3 GRISEOFULVIN,MICROSIZE GRIFULVIN V

Antifungals (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 NATAMYCIN NATACYN

Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 CICLOPIROX

5 - Prior Authorization

14 of 94 Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 1 CLOTRIMAZOLE 1 ECONAZOLE NITRATE 1 KETOCONAZOLE KETODAN 1 NYSTATIN NYAMYC 1 NYSTATIN NYSTOP 1 NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE 2 SULCONAZOLE NITRATE EXELDERM 3 CICLOPIROX/NAIL LACQ/FT DEOD#4 PEDIPIROX-4 3 KETOCONAZOLE XOLEGEL 3 KETOCONAZOLE NIZORAL 3 MICONAZOLE NITRATE/ZINC OX/PET VUSION 3 NAFTIFINE HCL NAFTIN 3 OXICONAZOLE NITRATE OXISTAT 3 SERTACONAZOLE NITRATE ERTACZO

Antifungals (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 TERCONAZOLE

Antihemophilic / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ANTIHEMOPHILIC FACTOR ELOCTATE 4

Antihepatitis / ANTIVIRALS Tier Generic Name Brand Name Notes 1 RIBAVIRIN RIBAPAK 5 1 RIBAVIRIN RIBASPHERE 5 3 BOCEPREVIR VICTRELIS 5 3 LEDIPASVIR/SOFOSBUVIR HARVONI 5 3 PARITAPREVIR;/RITON/OMBITAS/DASA VIEKIRA PAK 5 3 RIBAVIRIN REBETOL 5 3 SIMEPREVIR OLYSIO 5 3 SOFOSBUVIR SOLVALDI 5 3 TELAPREVIR INCIVEK 5 4 PEGINTERFERON ALFA-2A PEGASYS PROCLICK 5 4 PEGINTERFERON ALFA-2A PEGASYS 5 4 PEGINTERFERON ALFA-2B PEGINTRON REDIPEN 5

Antiherpetic / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ACYCLOVIR 6 1 VALACYCLOVIR HCL VALACYCLOVIR 6 3 ACYCLOVIR ZOVIRAX 6 3 ACYCLOVIR SITAVIG 3 VALACYCLOVIR HCL VALTREX 6

Antihistamines (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes 1 MECLIZINE HCL

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

15 of 94 Antihistamines (Gi Drugs) / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 1 PROCHLORPERAZINE MALEATE 1 PROCHLORPERAZINE MALEATE COMPRO 1 TRIMETHOBENZAMIDE HCL 3 MECLIZINE HCL ANTIVERT

Antimalarial Agents / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 CHLOROQUINE PHOSPHATE 1 HYDROXYCHLOROQUINE SULFATE 1 MEFLOQUINE HCL 2 PRIMAQUINE PHOSPHATE PRIMAQUINE 2 PYRIMETHAMINE DARAPRIM 3 HYDROXYCHLOROQUINE SULFATE PLAQUENIL

Antimalarials / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 1 QUININE SULFATE 3 ATOVAQUONE/PROGUANIL HCL MALARONE

Antimetabolite / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 MERCAPTOPURINE 1 THIOGUANINE 2 METHOTREXATE SODIUM TREXALL 4 METHOTREXATE SODIUM METHOTREXATE 5

Antimuscarinic/Beta Agonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 UMECLIDINIUM/VILANTEROL ANORO ELLIPTA

Antimuscarinics/Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes 1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM 1 DICYCLOMINE HCL 1 GLYCOPYRROLATE 1 PROPANTHELINE BROMIDE

Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 IPRATROPIUM BROMIDE 6 1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM-ALBUTEROL 6 2 IPRATROPIUM BROMIDE ATROVENT HFA 6 2 TIOTROPIUM BROMIDE SPIRIVA 6 3 ACLIDINIUM BROMIDE TUDORZA PRESSAIR 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT 6

5 - Prior Authorization 6 - Quantity Limit

16 of 94 Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS (cont.) Tier Generic Name Brand Name Notes 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT 6

Antineoplastic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 BICALUTAMIDE 1 HYDROXYUREA 1 MEGESTROL ACETATE 2 MEGESTROL ACETATE MEGACE ES 2 THIOGUANINE TABLOID 2 TOREMIFENE CITRATE FARESTON 3 ABIRATERONE ACETATE ZYTIGA 3 CABOZANTINIB COMETRIQ 5 3 CAPECITABINE XELODA 3 CRIZOTINIB XALKORI 3 DASATINIB SPRYCEL 3 ERLOTINIB HCL TARCEVA 5 3 EVEROLIMUS AFINITOR 3 IMATINIB MESYLATE GLEEVEC 5 3 LAPATINIB DITOSYLATE TYKERB 3 LETROZOLE FEMARA 3 REGORAFENIB STIVARGA 3 TEMOZOLOMIDE TEMODAR 3 VISMODEGIB ERIVEDGE 5 4 LEUPROLIDE ACETATE 5 4 PONATINIB ICLUSIG 5 4 RADIUM RA 223 XOFIGO 5

Antineoplastic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 LEUPROLIDE ACETATE LUPRON DEPOT 4

Antineoplastic Other / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 VINBLASTINE VELBAN 4 4 VINCRISTINE ONCOVIN 4 4 VINORELBINE NAVELBINE 4

Antiparkinsonian Agents / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 CARBIDOPA 3 CARBIDOPA LODOSYN

Antiprotozoals / ANTIPARASITICS Tier Generic Name Brand Name Notes 1 CHLOROQUINE

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

17 of 94 Antiprotozoals / ANTIPARASITICS (cont.) Tier Generic Name Brand Name Notes 1 METRONIDAZOLE 1 TINIDAZOLE 3 NITAZOXANIDE ALINIA 3 TINIDAZOLE TINDAMAX

Antipruritics And Local Anesthetics / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 DOXEPIN HCL ZONALON 3 NORFLURANE/HFC 245FA PAIN EASE 3 TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE

Antipruritics And Local Anesthetics / UROLOGICALS Tier Generic Name Brand Name Notes 1 PHENAZOPYRIDINE HCL

Antiretrovirals / ANTIVIRALS Tier Generic Name Brand Name Notes 1 DIDANOSINE 1 LAMIVUDINE 1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 1 NEVIRAPINE 2 EFAVIRENZ SUSTIVA 2 EFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA 2 EMTRICITAB/RILPIVIRINE/TENOFOV COMPLERA 2 EMTRICITABINE EMTRIVA 2 ETRAVIRINE INTELENCE 2 MARAVIROC SELZENTRY 2 NEVIRAPINE VIRAMUNE 2 TENOFOVIR DISOPROXIL FUMARATE VIREAD 3 NEVIRAPINE VIRAMUNE XR

Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes 1 HYOSCYAMINE SULFATE OSCIMIN SL 1 HYOSCYAMINE SULFATE HYOMAX-SL 1 HYOSCYAMINE SULFATE HYOMAX-SR 1 HYOSCYAMINE SULFATE 1 HYOSCYAMINE SULFATE OSCIMIN SR 1 HYOSCYAMINE SULFATE HYOMAX-FT 1 HYOSCYAMINE SULFATE OSCIMIN 1 PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP QUADRAPAX 1 PHENOBARB/HYOSCY/ATROPINE/SCOP SE-DONNA PB HYOS 3 PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL

Antithyroid Agents / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 METHIMAZOLE 1 PROPYLTHIOURACIL 3 POTASSIUM IODIDE SSKI

Antituberculosis Agents / ANTIMYCOBACTERIALS Tier Generic Name Brand Name Notes 1 ETHAMBUTOL HCL

18 of 94 Antituberculosis Agents / ANTIMYCOBACTERIALS (cont.) Tier Generic Name Brand Name Notes 1 ETHAMBUTOL HCL MYAMBUTOL 1 ISONIAZID 1 PYRAZINAMIDE 1 RIFAMPIN 2 BEDAQUILINE SIRTURO 5 2 RIFABUTIN MYCOBUTIN 3 RIFAPENTINE PRIFTIN

Antitussives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 BENZONATATE 1 BROMPHENIRAMIN/PE/DEXTROMETHOR LOHIST-DM 1 CODEINE/PROMETHAZINE HCL PROMETHAZINE-CODEINE 1 D-METHORPHAN HB/PROMETH HCL PROMETHAZINE-DM 1 GUAIFENESIN/CODEINE PHOSPHATE DEX-TUSS 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE 1 GUAIFENESIN/CODEINE PHOSPHATE CHERATUSSIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE IOPHEN-C NR 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE-HOMATROPINE MBR 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROMET 1 HYDROCODONE/CHLORPHEN POLIS HYDROCODONE-CHLORPHENIRAMINE 1 P-EPHED HCL/CODEINE/GUAIFEN CHERATUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN MYTUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN GUAIFENESIN DAC 1 PHENYLEPHRINE HCL/COD/PROMETH PROMETHAZINE VC-CODEINE 3 D-METHORPHAN HB/P-EPD HCL/BPM BROMFED DM 3 HYDROCODONE/CHLORPHEN POLIS TUSSICAPS

Antivirals (Eent) / ANTIVIRALS Tier Generic Name Brand Name Notes 1 TRIFLURIDINE

Antivirals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 ACYCLOVIR/HYDROCORTISONE XERESE 3 PENCICLOVIR DENAVIR

Antivirals- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 HUMAN PAPILLOMAVIRUS GARDASIL/CERVARIX 4

Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BUSPIRONE HCL 1 CHLORAL HYDRATE 1 ESZOPICLONE 6

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

19 of 94 Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (cont.) Tier Generic Name Brand Name Notes 1 ZALEPLON 6 1 ZOLPIDEM TARTRATE 6 1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER 6 2 CHLORAL HYDRATE SOMNOTE 3 ESZOPICLONE LUNESTA 6 3 RAMELTEON ROZEREM 3 ZALEPLON SONATA 6 3 ZOLPIDEM TARTRATE AMBIEN 6 3 ZOLPIDEM TARTRATE AMBIEN CR 6 3 ZOLPIDEM TARTRATE INTERMEZZO 6 3 ZOLPIDEM TARTRATE EDLUAR 6

Anxiolytics- Sedatives & Hypnotics-Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 DICHLORALPHENAZONE

Anxiolytics- Sedatives & Hypnotics-Misc. / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE

Aromatase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 ANASTROZOLE 1 EXEMESTANE 1 LETROZOLE 3 ANASTROZOLE ARIMIDEX

Astringents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ALUMINUM CHLORIDE HYPERCARE 3 ALUMINUM CHLORIDE XERAC AC 3 ALUMINUM CHLORIDE DRYSOL

Atypical/2nd Generation / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 OLANZAPINE OLANZAPINE ODT 1 OLANZAPINE 1 QUETIAPINE FUMARATE 1 RISPERIDONE RISPERIDONE ODT 1 RISPERIDONE 1 RISPERIDONE RISPERIDONE M-TAB 1 ZIPRASIDONE HCL 2 ARIPIPRAZOLE ABILIFY 2 ARIPIPRAZOLE ABILIFY DISCMELT 3 ASENAPINE MALEATE SAPHRIS 3 ILOPERIDONE FANAPT 3 LURASIDONE HCL LATUDA 3 OLANZAPINE ZYPREXA

6 - Quantity Limit

20 of 94 Atypical/2nd Generation / ANTIPSYCHOTICS (cont.) Tier Generic Name Brand Name Notes 3 OLANZAPINE ZYPREXA ZYDIS 3 PALIPERIDONE INVEGA 3 QUETIAPINE FUMARATE SEROQUEL 3 QUETIAPINE FUMARATE SEROQUEL XR 3 ZIPRASIDONE HCL GEODON 4 PALIPERIDONE PALMITATE INVEGA SUSTENNA 5

Azoles / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 CLOTRIMAZOLE 1 FLUCONAZOLE 1 ITRACONAZOLE 1 KETOCONAZOLE 1 VORICONAZOLE 5 3 EFINACONAZOLE JUBLIA 5 3 FLUCONAZOLE DIFLUCAN 3 LULICONAZOLE LUZU 3 POSACONAZOLE NOXAFIL

B-lymphocyte stimulator / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 BELIMUMAB BENLYSTA 5

BPH / GI AGENTS Tier Generic Name Brand Name Notes 1 ALFUZOSIN 1 DOXAZOSIN MESYLATE DOXAZOSIN 1 TAMSULOSIN 1 TERAZOSIN HCL TERAZOSIN 3 SILODOSIN RAPAFLO 3 TAMSULOSIN FLOMAX

BRAF Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 DABRAFENIB TAFINLAR 5 3 VEMURAFENIB ZELBORAF 5

Barbiturates (Anticonvulsants) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 PRIMIDONE

Barbiturates (Anxiolytic- Sedative/Hyp) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 PHENOBARBITAL

Basic Lotions And Liniments / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AMMONIUM LACTATE

5 - Prior Authorization

21 of 94 Basic Ointments And Protectants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AMMONIUM LACTATE LAC-HYDRIN

Benzodiazepines (Anticonvulsants) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CLONAZEPAM 3 CLOBAZAM ONFI 3 CLONAZEPAM KLONOPIN 3 DIAZEPAM DIASTAT ACUDIAL

Benzodiazepines (Anxiolytic) / ANXIOLYTICS Tier Generic Name Brand Name Notes 1 ALPRAZOLAM 1 ALPRAZOLAM ALPRAZOLAM ER 1 ALPRAZOLAM ALPRAZOLAM XR 1 ALPRAZOLAM ALPRAZOLAM ODT 1 CHLORDIAZEPOXIDE HCL 1 CLORAZEPATE DIPOTASSIUM 1 DIAZEPAM 1 LORAZEPAM LORAZEPAM INTENSOL 1 LORAZEPAM 1 OXAZEPAM 3 ALPRAZOLAM XANAX 3 DIAZEPAM VALIUM 3 LORAZEPAM ATIVAN

Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS Tier Generic Name Brand Name Notes 1 ESTAZOLAM 1 FLURAZEPAM HCL 6 1 TEMAZEPAM 6 1 TRIAZOLAM 6

Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 LEVALBUTEROL HCL LEVALBUTEROL 6 2 ALBUTEROL SULFATE VENTOLIN HFA 6 2 ALBUTEROL SULFATE PROAIR HFA 6 2 ALBUTEROL SULFATE PROVENTIL HFA 6 3 ARFORMOTEROL TARTRATE BROVANA 3 INDACATEROL MALEATE ARCAPTA NEOHALER 3 LEVALBUTEROL TARTRATE XOPENEX HFA 6

Beta-Adrenergic Blocking Agents / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 PROPRANOLOL HCL

Beta-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ATENOLOL

6 - Quantity Limit

22 of 94 Beta-Adrenergic Blocking Agents / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 ATENOLOL/CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE 1 BISOPROLOL FUMARATE 1 BISOPROLOL FUMARATE/HCTZ BISOPROLOL-HYDROCHLOROTHIAZIDE 1 CARVEDILOL 1 LABETALOL HCL 1 METOPROLOL SUCCINATE 1 METOPROLOL TARTRATE 1 METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL-HYDROCHLOROTHIAZIDE 1 NADOLOL 1 PINDOLOL 1 PROPRANOLOL HCL 1 SOTALOL HCL SOTALOL AF 1 SOTALOL HCL SOTALOL 2 CARVEDILOL PHOSPHATE COREG CR 3 ATENOLOL TENORMIN 3 CARVEDILOL COREG 3 METOPROLOL SUCCINATE TOPROL XL 3 NADOLOL CORGARD 3 NEBIVOLOL HCL BYSTOLIC 3 PROPRANOLOL HCL INDERAL LA 3 PROPRANOLOL HCL INNOPRAN XL 3 PROPRANOLOL HCL HEMANGEOL

Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BETAXOLOL HCL 1 LEVOBUNOLOL HCL 1 TIMOLOL MALEATE 2 BETAXOLOL HCL BETOPTIC S 2 TIMOLOL MALEATE ISTALOL 2 TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE 3 TIMOLOL BETIMOL 3 TIMOLOL MALEATE TIMOPTIC

Beta-Lactam, Other / ANTIBACTERIALS Tier Generic Name Brand Name Notes 4 AZTREONAM AZACTAM 4 4 IMIPENEM PRIMAXIN 4 4 IMIPENEM/CILASTATN IMIPENEM/CILASTATIN 4 4 MEROPENEM 4

Biguanides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 METFORMIN HCL 1 METFORMIN HCL METFORMIN HCL ER 2 METFORMIN HCL METFORMIN HYDROCHLORIDE 3 METFORMIN HCL GLUCOPHAGE 3 METFORMIN HCL GLUMETZA 3 METFORMIN HCL RIOMET 3 METFORMIN HCL FORTAMET 3 METFORMIN HCL GLUCOPHAGE XR

4 - Office/Clinic Administration

23 of 94 Bile Acid Sequestrants / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE 1 CHOLESTYRAMINE/ASPARTAME PREVALITE 1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT 1 COLESTIPOL HCL 3 COLESEVELAM HCL WELCHOL

Bipolar - Other / BIPOLAR AGENTS Tier Generic Name Brand Name Notes 1 ALPRAZOLAM 1 DIAZEPAM 1 OLANZAPINE 3 ARIPIPRAZOLE ABILIFY 3 LURASIDONE HCL LATUDA

Blood Formation Modifiers / ANTICONVULSANTS Tier Generic Name Brand Name Notes 3 EDOXABAN SAVAYSA

Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 2 APIXABAN ELIQUIS 5 2 RIVAROXABAN XARELTO 3 CLOPIDOGREL BISULFATE PLAVIX 4 FONDAPARINUX SODIUM ARIXTRA 5 4 HEPARIN 4

Bone Resorption Inhibitors / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 ALENDRONATE SODIUM 1 IBANDRONATE SODIUM 1 RISEDRONATE 2 ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D 3 ALENDRONATE SODIUM FOSAMAX 3 ALENDRONATE SODIUM BINOSTO 3 IBANDRONATE SODIUM BONIVA 3 RISEDRONATE SODIUM ATELVIA 3 RISEDRONATE SODIUM ACTONEL

C1 Esterase Inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 C1 ESTERASE INHIBITOR RUCONEST 4

Calcium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 ETHOSUXIMIDE 1 LAMOTRIGINE

4 - Office/Clinic Administration 5 - Prior Authorization

24 of 94 Calcium Channel Agents / ANTICONVULSANTS (cont.) Tier Generic Name Brand Name Notes 2 LAMOTRIGINE LAMICTAL (ORANGE) 2 LAMOTRIGINE LAMICTAL (GREEN) 3 LAMOTRIGINE LAMICTAL ODT 3 LAMOTRIGINE LAMICTAL XR 3 LAMOTRIGINE LAMICTAL 3 LAMOTRIGINE LAMICTAL ODT (ORANGE) 3 LEVETIRACETAM KEPPRA 3 LEVETIRACETAM KEPPRA XR

Calcium Channel Blocker/ARB / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE/VALSARTAN 3 AMLODIPINE/VALSARTAN EXFORGE 3 AMLODIPINE/VALSARTAN/HCTZ EXFORGE HCT

Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 DILTIAZEM HCL DILTIAZEM ER 1 DILTIAZEM HCL DILTIAZEM 24HR ER 1 DILTIAZEM HCL DILT-XR 1 DILTIAZEM HCL MATZIM LA 1 DILTIAZEM HCL CARTIA XT 1 DILTIAZEM HCL TAZTIA XT 1 DILTIAZEM HCL 1 DILTIAZEM HCL DILTIAZEM 24HR CD 1 VERAPAMIL HCL VERAPAMIL ER PM 1 VERAPAMIL HCL 1 VERAPAMIL HCL VERAPAMIL ER 3 DILTIAZEM HCL CARDIZEM CD 3 DILTIAZEM HCL CARDIZEM LA 3 DILTIAZEM HCL TIAZAC 3 VERAPAMIL HCL CALAN SR

Carbonic Anhydrase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ACETAZOLAMIDE 3 ACETAZOLAMIDE DIAMOX SEQUELS

Carbonic Anhydrase Inhibitors (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 ACETAZOLAMIDE 1 DORZOLAMIDE HCL 1 DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE-TIMOLOL 1 METHAZOLAMIDE 2 BRINZOLAMIDE AZOPT 3 DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT 3 DORZOLAMIDE/TIMOLOL/PF COSOPT PF

Cardiac Drugs- Miscellaneous / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 RANOLAZINE RANEXA

25 of 94 Cariostatic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 SODIUM FLUORIDE FLUORIDE 1 SODIUM FLUORIDE LUDENT FLUORIDE 1 SODIUM FLUORIDE FLUORITAB 1 SODIUM FLUORIDE EPIFLUR 1 SODIUM FLUORIDE 1 SODIUM FLUORIDE RENAF 2 SODIUM FLUORIDE FLUOR-A-DAY 2 SODIUM FLUORIDE FLUORABON 2 SODIUM FLUORIDE FLURA-DROPS

Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 ENTACAPONE 2 ENTACAPONE COMTAN

Cell Stimulants And Proliferants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 TRETINOIN 5 2 TRETINOIN AVITA 5 2 TRETINOIN ATRALIN 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 5

Central Alpha-Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 GUANFACINE HCL 1 METHYLDOPA

Central Nervous System Agents- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 5

Central Nervous System Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 RILUZOLE RILUTEK

Centrally Acting Skeletal Muscle Relaxnt / ANTISPASTICITY AGENTS Tier Generic Name Brand Name Notes 1 CARISOPRODOL 1 CHLORZOXAZONE 1 CYCLOBENZAPRINE HCL 1 METAXALONE 1 METHOCARBAMOL 1 TIZANIDINE HCL 3 CARISOPRODOL SOMA 3 CYCLOBENZAPRINE HCL AMRIX 3 METAXALONE SKELAXIN

Cephalosporins / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 CEFACLOR

5 - Prior Authorization

26 of 94 Cephalosporins / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 1 CEFADROXIL HYDRATE CEFADROXIL 1 CEFAZOLIN 1 CEFDINIR 1 CEFPROZIL 1 CEFUROXIME AXETIL CEFUROXIME 1 CEPHALEXIN 3 CEFIXIME SUPRAX 3 CEFRADINE VELOSEF 3 CEFTIBUTEN CEDAX 3 CEFTIBUTEN DIHYDRATE CEDAX 3 CEFUROXIME AXETIL CEFTIN 3 CEPHALEXIN KEFLEX 4 CEFEPIME MAXIPIME 4 4 CEFOTAXIME CLAFORAN 4 4 CEFOTETAN CEFOTAN 4 4 CEFOXITAN MEFOXIN 4

Chelator / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 DEFERASIROX EXJADE 5

Cholelitholytic Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 URSODIOL 3 URSODIOL ACTIGALL

Cholesterol Absorption Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 2 EZETIMIBE/SIMVASTATIN VYTORIN 3 LOMITAPIDE JUXTAPID 5 4 MIPOMERSEN KYNAMRO 5

Cholinesterase Inhibitors / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes 1 DONEPEZIL HCL 1 GALANTAMINE 1 RIVASTIGMINE 3 RIVASTIGMINE EXELON PATCH

Coagulant - Vitamin K / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 2 PHYTONADIONE MEPHYTON

Complement Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 4 ICATIBANT ACETATE FIRAZYR 5

4 - Office/Clinic Administration 5 - Prior Authorization

27 of 94 Contraceptives / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 DESOG-ET ESTRA/ETHIN ESTRA VIORELE 1 DESOG-ET ESTRA/ETHIN ESTRA KARIVA 3 1 DESOG-ET ESTRA/ETHIN ESTRA AZURETTE 3 1 DESOGESTREL-ETHINYL ESTRADIOL CAZIANT 3 1 DESOGESTREL-ETHINYL ESTRADIOL APRI 3 1 DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE 3 1 DESOGESTREL-ETHINYL ESTRADIOL VELIVET 1 DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA LEVONORG-ETH ESTRAD ETH ESTRAD 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA 3 1 LEVONORGESTREL NEXT CHOICE 3 1 LEVONORGESTREL-ETH ESTRADIOL LESSINA 3 1 LEVONORGESTREL-ETH ESTRADIOL JOLESSA 3 1 LEVONORGESTREL-ETH ESTRADIOL AMETHYST 3 1 LEVONORGESTREL-ETH ESTRADIOL AVIANE 3 1 LEVONORGESTREL-ETH ESTRADIOL LUTERA 3 1 LEVONORGESTREL-ETH ESTRADIOL MYZILRA 3 1 LEVONORGESTREL-ETH ESTRADIOL TRIVORA-28 3 1 LEVONORGESTREL-ETH ESTRADIOL SRONYX 3 1 LEVONORGESTREL-ETH ESTRADIOL ENPRESSE 3 1 LEVONORGESTREL-ETH ESTRADIOL ALTAVERA 1 LEVONORGESTREL-ETH ESTRADIOL QUASENSE 3 1 LEVONORGESTREL-ETH ESTRADIOL PORTIA 3 1 LEVONORGESTREL-ETH ESTRADIOL ORSYTHIA 3 1 LEVONORGESTREL-ETH ESTRADIOL LEVORA-28 3 1 LEVONORGESTREL-ETH ESTRADIOL INTROVALE 3 1 NORELGESTROMIN/ETHIN.ESTRADIOL NORELGESTROMIN/ETH ESTRADIOL 3 1 NORETH A-ET ESTRA/FE FUMARATE GILDESS FE 3 1 NORETH A-ET ESTRA/FE FUMARATE JUNEL FE 3 1 NORETH A-ET ESTRA/FE FUMARATE MICROGESTIN FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TRI-LEGEST FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TILIA FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZEOSA 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZENCHENT FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE 3 1 NORETHINDRONE CAMILA 1 NORETHINDRONE ERRIN 1 NORETHINDRONE HEATHER 1 NORETHINDRONE NORA-BE 3 1 NORETHINDRONE 1 NORETHINDRONE JOLIVETTE 3 1 NORETHINDRONE A-E ESTRADIOL GILDESS 3 1 NORETHINDRONE A-E ESTRADIOL JUNEL 3 1 NORETHINDRONE A-E ESTRADIOL MICROGESTIN 3 1 NORETHINDRONE-ETHINYL ESTRAD ALYACEN 1 NORETHINDRONE-ETHINYL ESTRAD BALZIVA 3 1 NORETHINDRONE-ETHINYL ESTRAD BRIELLYN 3 1 NORETHINDRONE-ETHINYL ESTRAD LEENA 3

3 - No copay

28 of 94 Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes 1 NORETHINDRONE-ETHINYL ESTRAD ZENCHENT 3 1 NORETHINDRONE-ETHINYL ESTRAD NORTREL 3 1 NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM 3 1 NORETHINDRONE-ETHINYL ESTRAD DASETTA 3 1 NORETHINDRONE-ETHINYL ESTRAD ARANELLE 3 1 NORETHINDRONE-ETHINYL ESTRAD NECON 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL 3 1 NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 3 1 NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL 3 1 NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINY ESTRA 3 1 NORGESTREL-ETHINYL ESTRADIOL OGESTREL 3 1 NORGESTREL-ETHINYL ESTRADIOL CRYSELLE 3 1 NORGESTREL-ETHINYL ESTRADIOL ELINEST 3 2 DESOGESTREL-ETHINYL ESTRADIOL ORTHO-CEPT 2 ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 2 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN 24 FE 2 NORETH A-ET ESTRA/FE FUMARATE LO LOESTRIN FE 2 NORETH-ETHINYL ESTRADIOL/IRON GENERESS FE 2 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO 3 DESOG-ET ESTRA/ETHIN ESTRA MIRCETTE 3 DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA BEYAZ 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL 3 ESTRADIOL VALERATE/DIENOGEST NATAZIA 3 ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28 3 ETHINYL ESTRADIOL/DROSPIRENONE YAZ 3 L-NORGEST-ETH ESTR/ETHIN ESTRA SEASONIQUE 3 LEVONORGESTREL-ETH ESTRADIOL NORDETTE-28 3 LEVONORGESTREL-ETH ESTRADIOL LYBREL 3 LEVONORGESTREL-ETH ESTRADIOL SEASONALE 3 NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA 3 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN FE 3 NORETH A-ET ESTRA/FE FUMARATE ESTROSTEP FE 3 NORETH-ETHINYL ESTRADIOL/IRON FEMCON FE 3 NORETHINDRONE MICRONOR 3 NORETHINDRONE A-E ESTRADIOL LOESTRIN 3 NORETHINDRONE-ETHINYL ESTRAD BREVICON 3 NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM 3 NORETHINDRONE-ETHINYL ESTRAD OVCON-35 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 3 NORGESTREL-ETHINYL ESTRADIOL LO-OVRAL-28 3 ULIPRISTAL ACETATE ELLA

Contraceptives (E.G. Foams- Devices) / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 DIAPHRAGMS, ARC-SPRING ORTHO ALL-FLEX

Corticosteroids / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 4 CORTICOTROPIN ACTHAR H.P. 5

3 - No copay 5 - Prior Authorization 29 of 94 Corticosteroids (Eent) / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 FLUOCINOLONE ACETONIDE OIL DERMOTIC

Corticosteroids (Eent) / GI AGENTS Tier Generic Name Brand Name Notes 3 BUDESONIDE UCERIS 5

Corticosteroids (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 FLUOROMETHOLONE 1 PREDNISOLONE ACETATE 1 PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE 2 FLUOROMETHOLONE FML FORTE 2 FLUOROMETHOLONE FML S.O.P. 2 PREDNISOLONE ACETATE PRED MILD 3 DIFLUPREDNATE DUREZOL 3 FLUOROMETHOLONE ACETATE FLAREX 3 LOTEPREDNOL ETABONATE ALREX 3 LOTEPREDNOL ETABONATE LOTEMAX 3 PREDNISOLONE ACETATE PRED FORTE 3 RIMEXOLONE VEXOL

Corticosteroids (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 2 BECLOMETHASONE DIPROPIONATE BECONASE AQ 3 BECLOMETHASONE DIPROPIONATE QNASL 3 BUDESONIDE RHINOCORT AQUA 3 CICLESONIDE OMNARIS 3 CICLESONIDE ZETONNA 3 FLUTICASONE FUROATE VERAMYST 3 FLUTICASONE PROPIONATE FLONASE 3 MOMETASONE FUROATE NASONEX 3 TRIAMCINOLONE ACETONIDE NASACORT AQ

Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 BUDESONIDE 2 BECLOMETHASONE DIPROPIONATE QVAR 2 BUDESONIDE PULMICORT FLEXHALER 2 BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2 FLUTICASONE FUROATE ARNUITY ELLIPTA 2 FLUTICASONE PROPIONATE FLOVENT HFA 2 FLUTICASONE PROPIONATE FLOVENT DISKUS 2 FLUTICASONE/SALMETEROL ADVAIR HFA 6 2 FLUTICASONE/VILANTEROL BREO ELLIPTA 2 MOMETASONE FUROATE ASMANEX 3 BUDESONIDE PULMICORT

5 - Prior Authorization 6 - Quantity Limit

30 of 94 Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS (cont.) Tier Generic Name Brand Name Notes 3 CICLESONIDE ALVESCO 3 MOMETASONE/FORMOTEROL DULERA

Cystine depleting agent / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 CYSTEAMINE PROCYSBI 5

Cystine depleting agent / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 CYSTEAMINE CYSTARAN 5

Devices / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 NEEDLES, INSULIN DISPOSABLE NOVOTWIST 2 SYR W-NDL,INS 0.3 ML HALF MARK INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.3ML ULTICARE 2 SYRING W-NDL,DISP,INSUL,0.3ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML ULTRA COMFORT 2 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE 3 INSULIN ADMIN. SUPPLIES HUMAPEN LUXURA HD 3 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE

Devices / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 SALIVA SUBSTITUTION COMBO NO.2 CAPHOSOL

Devices / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 GLY/CARB HOMOPOLY A/POT HYDROX MUGARD

Devices / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 2 INHALER, ASSIST DEVICES BREATHERITE 2 INHALER, ASSIST DEVICES OPTICHAMBER 2 INHALER, ASSIST DEVICES OPTIHALER 2 INHALER, ASSIST DEVICES EASIVENT 2 INHALER, ASSIST DEVICES MICROCHAMBER 2 INHALER, ASSIST DEVICES VORTEX 2 INHALER, ASSIST DEVICES E-Z SPACER 2 INHALER, ASSIST DEVICES PROCHAMBER 2 INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER DIAMOND 2 NEEDLES, INSULIN DISPOSABLE PEN NEEDLE 2 SYRING W-NDL,DISP,INSUL,0.3ML SURE COMFORT 2 SYRING W-NDL,DISP,INSUL,0.5ML EASY TOUCH 2 SYRINGE & NEEDLE,INSULIN,1 ML PRECISION 2 SYRINGE & NEEDLE,INSULIN,1 ML MONOJECT INSULIN SYRINGE 3 BISMUTH TRIBROMOPH/PETROLATUM XEROFORM PETROLATUM DRESSING

5 - Prior Authorization

31 of 94 Devices / ENDOCRINE/DIABETES (cont.) Tier Generic Name Brand Name Notes 3 NEEDLES, DISPOSABLE SPECIALTY USE NEEDLES 3 NEEDLES, DISPOSABLE REGULAR BEVEL NEEDLES 3 NEEDLES, DISPOSABLE NEEDLE 3 NEEDLES, DISPOSABLE NEEDLES

Devices / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER MAX 2 INHALER, ASSIST DEVICES AEROCHAMBER 2 INHALER, ASSIST DEVICES AEROCHAMBER MV 2 INHALER, ASSIST DEVICES AEROCHAMBER PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER WITH FLOWSIGNAL

Digestants / GI AGENTS Tier Generic Name Brand Name Notes 1 LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 2 LIPASE/PROTEASE/AMYLASE ZENPEP 2 LIPASE/PROTEASE/AMYLASE CREON 2 LIPASE/PROTEASE/AMYLASE PANCREAZE

Dihydropyridines / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE BESYLATE 1 AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE-BENAZEPRIL 1 FELODIPINE FELODIPINE ER 1 NIFEDIPINE AFEDITAB CR 1 NIFEDIPINE NIFEDIAC CC 1 NIFEDIPINE NIFEDICAL XL 1 NIFEDIPINE 1 NIFEDIPINE NIFEDIPINE ER 1 NISOLDIPINE 3 AMLODIPINE BES/OLMESARTAN MED AZOR 7 3 AMLODIPINE BESYLATE NORVASC 3 AMLODIPINE BESYLATE/BENAZEPRIL LOTREL 3 NICARDIPINE HCL CARDENE SR 3 NIFEDIPINE ADALAT CC 3 NISOLDIPINE SULAR

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 SAXAGLIPTIN HCL ONGLYZA 2 SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR 2 SITAGLIPTIN PHOSPHATE JANUVIA 3 ALOGLIPTIN NESINA 3 LINAGLIPTIN TRADJENTA 3 LINAGLIPTIN/METFORMIN HCL JENTADUETO

Direct Vasodilators / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 HYDRALAZINE HCL

7 - Step Therapy

32 of 94 Direct Vasodilators / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 MINOXIDIL

Direct-Acting Skeletal Muscle Relaxants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 DANTROLENE SODIUM

Disease-Modifying Antirheumatic Agents / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 LEFLUNOMIDE 3 ANAKINRA KINERET 3 LEFLUNOMIDE ARAVA 4 ABATACEPT ORENCIA 5 4 ADALIMUMAB HUMIRA 5 4 ETANERCEPT ENBREL 5 4 GOLIMUMAB SIMPONI 5

Dopamine Agonists / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 AMANTADINE HCL AMANTADINE 1 BROMOCRIPTINE MESYLATE 1 PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1 ROPINIROLE HCL 3 AMANTADINE HCL SYMMETREL 3 BROMOCRIPTINE MESYLATE CYCLOSET 3 PRAMIPEXOLE DI-HCL MIRAPEX 3 PRAMIPEXOLE DI-HCL MIRAPEX ER 3 ROPINIROLE HCL REQUIP 3 ROPINIROLE HCL REQUIP XL 3 ROTIGOTINE NEUPRO

Dopamine Antagonist / ANTIEMETICS Tier Generic Name Brand Name Notes 1 PROCLORPERAZINE 1 PROMETHAZINE HCL PROMETHEGAN 4 DROPERIDOL INAPSINE 4

Dopamine Precursors/AA Decarbox Inhibitor / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 3 CARBIDOPA/LEVODOPA RYTARY 3 CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 4 CARBIDOPA/LEVODOPA DUOPA 1

Dopamine Receptor Agonists / EMETOGENIC THERAPY Tier Generic Name Brand Name Notes 4 APOMORPHINE APOKYN 4

1 - Home Health 4 - Office/Clinic Administration 5 - Prior Authorization

33 of 94 Dopamine Receptor Agonists / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CABERGOLINE

Dopamine Reuptake Blocker / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD

Dyslipidemics, Other / CARDIOVASCULAR Tier Generic Name Brand Name Notes 2 NIACIN NIASPAN 2 NIACIN/LOVASTATIN ADVICOR 2 NIACIN/SIMVASTATIN SIMCOR 3 EZETIMIBE ZETIA 3 NIACIN NIACOR 3 OMEGA-3 ACID ETHYL ESTERS LOVAZA

Eent Anti-Infectives- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 1 CHLORHEXIDINE GLUCONATE

Eent Anti-Inflammatory Agents- Misc. / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 CYCLOSPORINE RESTASIS

Eent Drugs- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 AMLEXANOX APHTHASOL

Eent Drugs- Miscellaneous / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 3 HYDROXYPROPYL CELLULOSE LACRISERT

Eent Nonsteroidal Anti-Inflam. Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BROMFENAC SODIUM 2 BROMFENAC SODIUM BROMDAY 2 KETOROLAC TROMETHAMINE/PF ACUVAIL 2 NEPAFENAC NEVANAC 3 BROMFENAC SODIUM XIBROM 3 KETOROLAC TROMETHAMINE ACULAR LS 3 KETOROLAC TROMETHAMINE ACULAR

Emollients / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 EMOLLIENT COMBINATION NO.53 HPR PLUS 3 EMOLLIENT COMBINATION NO.10 BIAFINE 3 EMOLLIENT COMBINATION NO.32 EPICERAM 3 EMOLLIENT COMBINATION NO.35 MIMYX 3 EMOLLIENT COMBINATION NO.43 PROMISEB

34 of 94 Emollients / DERMATOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 3 EMOLLIENT COMBINATION NO.44 HYLATOPIC 3 EMOLLIENT COMBINATION NO.53 HYLATOPIC PLUS 3 EMOLLIENT COMBINATION NO.60 ATRAPRO HYDROGEL 3 VITE AC/GRAPE/HYALURONIC ACID ATOPICLAIR

Endothelin Receptor Antagonist / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 RAMUCIRUMAB CYRAMZA 4

Endothelin Receptor Antagonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 MACITENTAN OPSUMIT 5

Enzyme Replacement / ENZYME REPLACEMENT Tier Generic Name Brand Name Notes 3 ELIGLUSTAT CERDELGA 5 4 AGALSIDASE BETA FABRAZYME 4

Enzyme Replacement / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ELOSULFASE ALFA VIMIZIM 4

Enzymes / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 DORNASE ALFA PULMOZYME 5

Ergot Alkaloids / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 DIHYDROERGOTAMINE MESYLATE 2 ERGOTAMINE TARTRATE ERGOMAR 2 ERGOTAMINE TARTRATE/CAFFEINE CAFERGOT

Estrogen Agonist-Antagonists / HORMONE: ER RECEPTOR MODIFIER Tier Generic Name Brand Name Notes 1 RALOXIFENE 3 ESTROGEN/BAZEDOXIFENE DUAVEE 3 OSPEMIFENE OSPHENA 3 RALOXIFENE EVISTA 4 CLOMIPHENE CITRATE 2

Estrogens / HORMONE: ESTROGENS Tier Generic Name Brand Name Notes 1 ESTRADIOL

2 - Infertility 4 - Office/Clinic Administration 5 - Prior Authorization

35 of 94 Estrogens / HORMONE: ESTROGENS (cont.) Tier Generic Name Brand Name Notes 1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE ACETAT 1 ESTROPIPATE 2 ESTRADIOL ALORA 2 ESTRADIOL MICRONIZED ESTRADIOL 3 ESTRADIOL ESTRING 3 ESTRADIOL DIVIGEL 3 ESTRADIOL CLIMARA 3 ESTRADIOL ELESTRIN 3 ESTRADIOL EVAMIST 3 ESTRADIOL ESTROGEL 3 ESTRADIOL ESTRACE 3 ESTRADIOL ACETATE FEMRING 3 ESTRADIOL/NORETHINDRONE ACET ACTIVELLA 3 ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 3 ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA 3 NORETHIND AC/ETHINYL ESTRADIOL FEMHRT

Estrogens / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 ESTRADIOL/NORETHINDRONE ACET MIMVEY 1 NORETHIND AC/ETHINYL ESTRADIOL JEVANTIQUE 1 NORETHIND AC/ETHINYL ESTRADIOL JINTELI 2 ESTRADIOL VAGIFEM 2 ESTRADIOL VIVELLE-DOT 2 ESTRADIOL/NORGESTIMATE PREFEST 2 ESTROGEN,CON/M-PROGEST ACET PREMPRO 2 ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2 ESTROGENS, CONJUGATED PREMARIN 3 DROSPIRENONE/ESTRADIOL ANGELIQ 3 ESTRADIOL MENOSTAR 3 ESTRADIOL/LEVONORGESTREL CLIMARA PRO 3 ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 3 ESTROGENS,ESTERIFIED MENEST 4 ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5

Ethanolamine Derivatives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 DIPHENHYDRAMINE HCL

Fibric Acid Derivatives / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 1 FENOFIBRIC ACID (CHOLINE) FENOFIBRIC ACID 1 GEMFIBROZIL 3 FENOFIBRATE LIPOFEN 3 FENOFIBRATE FENOGLIDE 3 FENOFIBRATE NANOCRYSTALLIZED TRICOR 3 FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 3 FENOFIBRATE,MICRONIZED ANTARA 3 FENOFIBRIC ACID (CHOLINE) TRILIPIX

Fibromyalgia Agents / CNS AGENTS Tier Generic Name Brand Name Notes 1 GABAPENTIN

5 - Prior Authorization

36 of 94 Fibromyalgia Agents / CNS AGENTS (cont.) Tier Generic Name Brand Name Notes 3 MILNACIPRAN HCL SAVELLA 3 PREGABALIN LYRICA

First Gen. Antihist. Derivatives- Misc. / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 CYPROHEPTADINE HCL

Folic Acid Reductase Inhibitor / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 METHOTREXATE OTREXUP 5

GABA Augmenting Agents / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 GABAPENTIN ENACARBIL HORIZANT

GABA Augmenting Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 DIVALPROEX SODIUM 1 DIVALPROEX SODIUM DIVALPROEX SODIUM ER 1 VALPROATE SODIUM VALPROIC ACID 3 DIVALPROEX SODIUM DEPAKOTE SPRINKLE 3 DIVALPROEX SODIUM DEPAKOTE 3 DIVALPROEX SODIUM DEPAKOTE ER 3 GABAPENTIN GRALISE 3 TIAGABINE GABITRIL 3 VIGABATRIN SABRIL 5

GI Agent, Other / GI AGENTS Tier Generic Name Brand Name Notes 4 METHYLNALTREXONE RELISTOR 5

GLP-1 analog / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 4 ALBIGLUTIDE TANZEUM 5

GLP-2 analog / GI AGENTS Tier Generic Name Brand Name Notes 4 TEDUGLUTIDE GATTEX 5

Gaba-Derivative Skeletal Muscle Relaxant / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BACLOFEN

Genitourinary Smooth Muscle Relaxants / UROLOGICALS Tier Generic Name Brand Name Notes 1 FLAVOXATE HCL

5 - Prior Authorization

37 of 94 Genitourinary Smooth Muscle Relaxants / UROLOGICALS (cont.) Tier Generic Name Brand Name Notes 1 OXYBUTYNIN CHLORIDE 1 OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER 1 TOLTERODINE TARTRATE 3 DARIFENACIN HYDROBROMIDE ENABLEX 3 FESOTERODINE FUMARATE TOVIAZ 3 MIRABEGRON MYRBETRIQ 3 OXYBUTYNIN GELNIQUE 3 SOLIFENACIN SUCCINATE VESICARE 3 TOLTERODINE TARTRATE DETROL LA 3 TOLTERODINE TARTRATE DETROL 3 TROSPIUM CHLORIDE SANCTURA XR

Gi Drugs- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 CERTOLIZUMAB PEGOL CIMZIA 5 3 LINACLOTIDE LINZESS

Glutamate Reducing Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 GABAPENTIN 3 GABAPENTIN NEURONTIN

Glycogenolytic Agents / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 3 GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 3 GLUCAGON,HUMAN RECOMBINANT GLUCAGON EMERGENCY KIT

Gonadotropin-Releasing Hormone Antagnts / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CETRORELIX ACETATE CETROTIDE 2 4 GANIRELIX ACETATE 2

Gonadotropins / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2 4 CHORIONIC GONADOTROPIN, HUMAN CHORIONIC GONADOTROPIN 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F RFF 2 4 FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 2 4 HCG ALPHA,RECOMBINANT OVIDREL 2 4 MENOTROPINS MENOPUR 2 4 UROFOLLITROPIN BRAVELLE 2

Gonadotropins / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 4 CHORIONIC GONADOTROPIN NOVAREL 2

2 - Infertility 5 - Prior Authorization

38 of 94 Growth Hormone Releasing Factor / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 4 TESAMORELIN EGRIFTA 5

HER2 Targeted Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 ADO-TRASTUZUMAB KADCYLA 5 4 TRASTUZUMAB HERCEPTIN 5

Hematopoietic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 TBO-FILGRASTIM GRANIX 5

Hematopoietic Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 ELTROMBOPAG OLAMINE PROMACTA 5 4 ROMIPLOSTIM NPLATE 5

Hematopoietic Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 EPOETIN ALFA PROCRIT 5 4 PEGFILGRASTIM NEULASTA 5 4 PLERIXAFOR MOZOBIL 5

Hematopoietic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 EPOETIN ALFA EPOGEN 4 4 FILGRASTIM NEUPOGEN 4

Hemorrheologic Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 PENTOXIFYLLINE

Hemostatic / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 COAGULATION FACTOR IX ALPROLIX 4 4 COAGULATION FACTOR IX RIXUBIS 4 4 COAGULATION FACTOR XIII TRETTEN 4

Hemostatics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 AMINOCAPROIC ACID 4 ANTIHEMOPH.FVIII PLAS/ALB FREE ADVATE 5

Hemostatics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 TRANEXAMIC ACID

4 - Office/Clinic Administration 5 - Prior Authorization

39 of 94 Hemostatics / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes 3 TRANEXAMIC ACID LYSTEDA

Hereditary Tyrosinemia / ENDOCRINE Tier Generic Name Brand Name Notes 3 NITISINONE ORFADIN 5

Heterocyclic Antidepressants / ANTIDEPRESSANTS, OTHER Tier Generic Name Brand Name Notes 1 AMOXAPINE 1 MAPROTILINE HCL 1 MIRTAZAPINE

Histamine H2-Antagonists / GI AGENTS Tier Generic Name Brand Name Notes 1 CIMETIDINE 1 FAMOTIDINE 1 NIZATIDINE 1 RANITIDINE HCL 3 FAMOTIDINE PEPCID 3 RANITIDINE HCL ZANTAC 25

Histone inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 PANOBINOSTAT FARYDAK 5 3 VORINOSTAT ZOLINZA 5

Histone inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 BELINOSTAT BELEODAQ 4

Hmg-Coa Reductase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE/ATORVASTATIN AMLODIPINE-ATORVASTATIN 1 ATORVASTATIN CALCIUM 1 FLUVASTATIN SODIUM 1 LOVASTATIN 1 PRAVASTATIN SODIUM 1 SIMVASTATIN 3 ATORVASTATIN CALCIUM LIPITOR 3 FLUVASTATIN SODIUM LESCOL 3 FLUVASTATIN SODIUM LESCOL XL 3 LOVASTATIN ALTOPREV 3 PITAVASTATIN CALCIUM LIVALO 3 PRAVASTATIN SODIUM PRAVACHOL 3 ROSUVASTATIN CALCIUM CRESTOR 3 SIMVASTATIN ZOCOR

4 - Office/Clinic Administration 5 - Prior Authorization

40 of 94 Human Leptin / GENETIC DISORDERS Tier Generic Name Brand Name Notes 4 METRELEPTN MYALEPT 5

Immunomodulator / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 APREMILAST OTEZLA 5 3 LENALIDOMIDE REVLIMID 5 3 POMALIDOMIDE POMALYST 5 3 THALIDOMIDE THALOMID 5 3 TOFACITINIB XELJANZ 5 4 INTERFERON ALFACON 1 INFERGEN 5

Immunosuppressive Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AZATHIOPRINE 1 CYCLOSPORINE 1 CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 1 CYCLOSPORINE, MODIFIED GENGRAF 1 MYCOPHENOLATE MOFETIL 1 TACROLIMUS 2 CYCLOSPORINE SANDIMMUNE 2 CYCLOSPORINE, MODIFIED NEORAL 2 MYCOPHENOLATE SODIUM MYFORTIC 2 SIROLIMUS RAPAMUNE 3 MYCOPHENOLATE MOFETIL CELLCEPT 3 TACROLIMUS PROGRAF 4 TOCILIZUMAB ACTEMRA 5 4 TOCILIZUMAB ACTEMRA 5

Incretin Mimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 4 EXENATIDE BYETTA 5 4 EXENATIDE MICROSPHERES BYDUREON 5 4 LIRAGLUTIDE VICTOZA 3-PAK 5 4 LIRAGLUTIDE VICTOZA 2-PAK 5

Inhibit DNA polymerases / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 TEMOZOLOMIDE

Inhibit DNA polymerases / ANTIVIRALS Tier Generic Name Brand Name Notes 3 GANCICLOVIR CYTOVENE 5

Inhibit Protein Synthesis / ANTIFUNGALS Tier Generic Name Brand Name Notes 3 TAVABOROLE KERYDIN 5

Inhibit Protein Synthesis / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 OMACETAXINE SYNRIBO 5

5 - Prior Authorization

41 of 94 Inhibit Protein Synthesis / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 MIGLUSTAT ZAVESCA 5

Insulins / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 HUM INSULIN NPH/REG INSULIN HM HUMULIN 70-30 2 HUM INSULIN NPH/REG INSULIN HM NOVOLIN 70-30 2 INSULIN ASPART NOVOLOG 2 INSULIN ASPART NOVOLOG FLEXPEN 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2 INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO 2 INSULIN LISPRO HUMALOG 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50 2 INSULIN REGULAR, HUMAN HUMULIN R 2 INSULIN REGULAR, HUMAN NOVOLIN R 2 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 2 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 2 NPH, HUMAN INSULIN ISOPHANE NOVOLIN N 2 NPH, HUMAN INSULIN ISOPHANE HUMULIN N 3 INSULIN DETEMIR LEVEMIR FLEXPEN 3 INSULIN DETEMIR LEVEMIR 3 INSULIN GLULISINE APIDRA 3 INSULIN GLULISINE APIDRA SOLOSTAR 3 INSULIN INHALED AFREZZA

Integrase Strand Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes 2 ELVITEGRAVIR VITEKTA

Interferons / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 INTERFERON ALFA-2B,RECOMB. PEG-INTRON 5 4 INTERFERON ALFA-2B,RECOMB. SYLATRON 5 4 INTERFERON ALFA-2B,RECOMB. INTRON A 5

Interleukin / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 SECUKINUMAB COSTENTYX 5

Interleukin / CARDIOVASCULAR Tier Generic Name Brand Name Notes 4 OPRELVEKIN NEUMEGA 5

Interleukin / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 SILTUXIMAB SYLVANT 4

4 - Office/Clinic Administration 5 - Prior Authorization

42 of 94 Intravitreal injection / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 4 OCRIPLASMIN JETREA 5

Keratolytic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 BENZOYL PEROXIDE BP WASH 1 BENZOYL PEROXIDE LAVOCLEN-4 1 BENZOYL PEROXIDE BP WASH ACNE TREATMENT 1 BENZOYL PEROXIDE 1 BENZOYL PEROXIDE BENZEPRO 1 BENZOYL PEROXIDE BPO 1 SALICYLIC ACID 1 SULFACET SOD/SULFUR/WITCH HAZ SE 10-5 SS 1 SULFACETAMIDE SODIUM/SULFUR ZENCIA 1 SULFACETAMIDE SODIUM/SULFUR SULFACETAMIDE SODIUM-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR PRASCION FC 1 SULFACETAMIDE SODIUM/SULFUR PRASCION 1 SULFACETAMIDE SODIUM/SULFUR BP 10-1 1 UREA 2 BENZOYL PEROXIDE BENZAC AC 2 BENZOYL PEROXIDE BENZEFOAM ULTRA 2 SULFACETAMIDE SODIUM/SULFUR CLARIFOAM EF 3 SALICYLIC ACID KERALYT 3 SALICYLIC ACID/CERAMIDE CMB #1 SALEX 3 SULFACETAMIDE SODIUM/SULFUR CLENIA

Keratoplastic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ANTHRALIN DRITHOCREME HP 3 COAL TAR

Kinase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 CERITINIB ZYKADIA 5 3 IDELALISIB ZYDELIG 5 3 LENVATINIB LENVIMA 5 3 RUXOLITINIB JAKAFI 5 3 TRAMETINIB MEKINIST 5

Laxatives / GI AGENTS Tier Generic Name Brand Name Notes 1 PEG 3350/NA SULF,BICARB,CL/KCL GAVILYTE 1 PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE 1 PEG 3350/NA SULF,BICARB,CL/KCL PEG-3350 AND ELECTROLYTES 1 POLYETHYLENE GLYCOL 3350 2 NAPHOS M-B M-H/NA PHOS,DI-BA OSMOPREP 3 BISAC/NACL/NAHCO3/KCL/PEG 3350 HALFLYTELY-BISACODYL 3 LUBIPROSTONE AMITIZA 3 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY 3 PEG 3350/NA SULF,BICARB,CL/KCL COLYTE WITH FLAVOR PACKETS

5 - Prior Authorization

43 of 94 Laxatives / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 3 PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP 3 SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 3 SODIUM,POTASSIUM,&MAG SULFATES SUPREP

Leprosy / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes 2 DAPSONE 3 CLOFAZIMINE LAMPRENE

Leukotriene Modifiers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 MONTELUKAST SODIUM 1 ZAFIRLUKAST 3 MONTELUKAST SODIUM SINGULAIR 3 ZAFIRLUKAST ACCOLATE 3 ZILEUTON ZYFLO CR

Local Anesthetics / ANESTHETICS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE AC/LIDOCAINE LIDOCAINE-HYDROCORTISONE 1 LIDOCAINE HCL 1 LIDOCAINE HCL LIDOCAINE HCL VISCOUS 1 LIDOCAINE/PRILOCAINE LIDOCAINE-PRILOCAINE 3 LIDOCAINE LIDODERM

Local Anesthetics (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes 1 ANTIPYRINE/BENZOCAINE/GLYCERIN ANTIPYRINE-BENZOCAINE 1 ANTIPYRINE/BENZOCAINE/GLYCERIN AURODEX 3 ANTIPY/BENZOCAINE/POLICOS NO.1 OTIC CARE 3 ANTIPYRINE/BENZOCAINE AURAX

Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL 1 SELENIUM SULFIDE 1 SILVER SULFADIAZINE 1 SILVER SULFADIAZINE THERMAZENE 1 SILVER SULFADIAZINE SSD 1 SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SOD/SULFUR/UREA CLEANSING WASH 1 SULFACETAMIDE SODIUM SEB-PREV 1 SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE 1 SULFACETM NA/AVOBENZONE/SULFUR PRASCION RA 2 SELENIUM SULFIDE TERSI FOAM 3 HEXACHLOROPHENE PHISOHEX 3 SILVER SULFADIAZINE SILVADENE

Loop Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 BUMETANIDE

44 of 94 Loop Diuretics / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 FUROSEMIDE 1 TORSEMIDE 2 ETHACRYNIC ACID EDECRIN 3 FUROSEMIDE LASIX

MAO Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 PHENELZINE SULFATE 1 TRANYLCYPROMINE SULFATE

MS / CNS AGENTS Tier Generic Name Brand Name Notes 3 DALFAMPRIDINE AMPYRA 5 3 DIMETHYL FUMARATE TECFIDERA 5 3 FINGOLIMOD HCL GILENYA 5 3 TERIFLUNOMIDE AUBAGIO 5 4 GLATIRAMER ACETATE COPAXONE 5 4 INTERFERON BETA-1A AVONEX 5 4 INTERFERON BETA-1A AVONEX PEN 5 4 INTERFERON BETA-1A/ALBUMIN AVONEX ADMINISTRATION PACK 5 4 INTERFERON BETA-1A/ALBUMIN REBIF 5 4 INTERFERON BETA-1B BETASERON 5

Macrolides / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 AZITHROMYCIN 1 CLARITHROMYCIN CLARITHROMYCIN ER 1 CLARITHROMYCIN 1 ERYTHROMYCIN BASE ERYTHROMYCIN 1 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400 1 ERYTHROMYCIN ETHYLSUCCINATE 1 ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 2 ERYTHROMYCIN BASE ERY-TAB 2 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 3 AZITHROMYCIN ZITHROMAX 3 AZITHROMYCIN ZMAX

Mast-Cell Stabilizers / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 CROMOLYN SODIUM 3 NEDOCROMIL SODIUM ALOCRIL

Mast-Cell Stabilizers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 CROMOLYN SODIUM

Meglitinides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 NATEGLINIDE

5 - Prior Authorization

45 of 94 Meglitinides / BLOOD GLUCOSE REGULATORS (cont.) Tier Generic Name Brand Name Notes 3 NATEGLINIDE STARLIX

Meglitinides / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 REPAGLINIDE 3 REPAGLINIDE PRANDIN

Melatonin Receptor Agonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 TASIMELTEON HETLIOZ 5

Miotics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 PILOCARPINE HCL

Miscellaneous Anti-Infectives (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID

Miscellaneous Anti-Infectives (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes 1 ACETIC ACID 1 ACETIC ACID/HYDROCORTISONE ACETASOL HC

Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM 3 METRONIDAZOLE FLAGYL ER 3 METRONIDAZOLE FLAGYL

Miscellaneous B-Lactam Antibiotics / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 3 AZTREONAM LYSINE CAYSTON

Miscellaneous Gi Drugs / GI AGENTS Tier Generic Name Brand Name Notes 3 ALOSETRON HCL LOTRONEX 4 OCTREOTIDE ACETATE SANDOSTATIN 5

Monoamine Oxidase B Inhibitors / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 SELEGILINE HCL 3 SELEGILINE EMSAM

Monoamine Oxidase B Inhibitors / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 RASAGILINE MESYLATE AZILECT

5 - Prior Authorization

46 of 94 Monoamine Transporter Inhibitor / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 TETRABENAZINE XENAZINE 5

Monoclonal Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 BRENTUXIMAB ADCETRIS 4 4 CANAKINUMAB ILARIS 5 4 DENOSUMAB XGEVA 5 4 PEMBROLIZUMAB KEYTRUDA 4

Monoclonal Antibody / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 DENOSUMAB PROLIA 4

Monoclonal Antibody / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 OMALIZUMAB XOLAIR 4 4 RITUXIMAB RITUXAN 4 4 SYNAGIS PALIVIZUMAB 4

Mood Stabilizers / BIPOLAR AGENTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE 1 LAMOTRIGINE 1 LITHIUM CARBONATE 1 LITHIUM CITRATE LITHIUM 1 VALPROATE SODIUM VALPROIC ACID 3 LITHIUM CARBONATE LITHOBID

Mucolytic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 ACETYLCYSTEINE

Multiple Sclerosis / CNS AGENTS Tier Generic Name Brand Name Notes 4 PEGINTERFERON ALFA-1A PLEGRIDY 5

Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 FLUORIDE/IRON/VIT A,C&D TRI-VIT WITH FLUORIDE-IRON 1 FLUORIDE/VITAMINS A,C,AND D TRIPHLUORIVIT 1 MULTIVITAMINS WITH FLUORIDE MULTI-VITAMIN WITH FLUORIDE 1 MULTIVITAMINS WITH FLUORIDE PHLUORIVIT 1 MULTIVITS WITH IRON & FLUORIDE MULTI-VITAMIN W-FLUORIDE-IRON 1 PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE VITAMINS A,C,D & FLUORIDE

4 - Office/Clinic Administration 5 - Prior Authorization

47 of 94 Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES (cont.) Tier Generic Name Brand Name Notes 1 PED MV A,C,D3 #21 W-FLUORIDE TRIPLE-VITAMIN W-FLUORIDE 1 PEDI MVI NO.12/SODIUM FLUORIDE MVC-FLUORIDE 1 PNV COMBO #22/IRON/FA/OM3/DHA HEMENATAL OB + DHA 1 PNV NO.22/IRON CBN&GLUC/FA/DSS VINACAL 1 PNV W-O CA NO5/FE FUMARATE/FA PRENATAL-U 3 1 PNV WITH CA,NO.72/IRON,CARB/FA PRENATAL PLUS 3 1 PNV66/IRON FUMARATE/FA/DSS/DHA VEMAVITE-PRX 2 1 PNV66/IRON FUMARATE/FA/DSS/DHA PNV-DHA + DOCUSATE 1 PNV66/IRON FUMARATE/FA/DSS/DHA FOLCAL DHA 1 PNV77/SOD IRON EDTA& PS/FA/OM3 VENATAL COMPLETE DHA 1 PRENATAL NO.25/IRON/FA #6/DHA PRENA1 1 PRENATAL VIT 15/IRON CB/FA/DSS TRIADVANCE 3 1 PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL AD 3 1 PRENATAL VIT 16/IRON CB/FA/DSS VINATE GT 1 PRENATAL VIT 18/IRON CB/FA/DSS VINATE ULTRA 3 1 PRENATAL VIT NO.78/IRON/FA PRENATABS FA 3 1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL 19 1 PRENATAL VITAMINS#21, IRON, FA HEMENATAL OB 3 PED MV A,C,D3 #38 W-FLUORIDE TRI-VI-FLOR 3 PEDI MULTIVIT #37 W-FLUORIDE POLY-VI-FLOR 3 PN W-CA64/IRON CB&GL/FA/DSS/DH CITRANATAL 90 DHA 3 PNV #38/IRON FUM/FOLATE/DHA PRENATE DHA 3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PREQUE 10 3 PNV COMBO #19/IRON/FOL AC/DHA PREFERA-OB ONE 3 PNV COMBO #22/IRON/FA/OM3/DHA PREFERA-OB PLUS DHA 3 PNV WITH CA,NO.71/IRON/FA VOL-PLUS 3 PNV WITH CA,NO63/IRON/FA/B6 CITRANATAL B-CALM 3 PNV#79/IRON/FA/LMFOLATE CA/DHA NEEVO DHA 3 PNV/FA/B6/CALCIUM PHOS/GINGER B-NEXA 3 PNV22/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL DHA 3 PNV38/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL ASSURE 3 PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS 3 PNV66/IRON FUMARATE/FA/DSS/DHA PRENEXA 3 PNV69/IRON,CARBONYL/FA/DSS/DHA CITRANATAL HARMONY 3 PNV80/IRON FUMARATE/FA/DSS/DHA NEXA SELECT 3 PRENATAL NO.25/IRON/FA #6/DHA VITAMEDMD ONE RX 3 PRENATAL NO.39/IRON/FA #6/DHA VITAMEDMD PLUS RX 3 PRENATAL VIT #76/IRON,CARB/FA VOL-TAB RX 3 PRENATAL VIT NO.44/IRON/FA/DHA PRENATE MINI 3 PRENATAL VIT NO.78/IRON/FA VENATAL-FA 3 PRENATAL VIT#36/IRON/FA CMB#6 PRENATE ELITE 3 PRENATAL VIT#42/FA CMB#6 VITAMEDMD REDICHEW RX 3 PRENATAL VITAMINS#21, IRON, FA PREFERA OB

Mydriatics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 ATROPINE SULFATE ATROPINE CARE 1 ATROPINE SULFATE/PF ATROPINE SULFATE 1 CYCLOPENTOLATE HCL 1 HOMATROPINE HBR HOMATROPAIRE 2 CYCLOPENTOLATE HCL CYCLOGYL 2 SCOPOLAMINE HYDROBROMIDE ISOPTO HYOSCINE 3 HOMATROPINE HBR ISOPTO HOMATROPINE

3 - No copay

48 of 94 NMDA Receptor Blocker / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes 3 MEMANTINE HCL NAMENDA

Nephropathic Cystinosis / ENDOCRINE Tier Generic Name Brand Name Notes 3 CYSTEAMINE PROCYSBI 5

Neurotoxin / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ONABOTULINUMTOXINA BOTOX 4

Nitrates And Nitrites / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ISOSORBIDE DINITRATE 1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER 1 NITROGLYCERIN NITRO-BID 2 NITROGLYCERIN NITRO-DUR 2 NITROGLYCERIN NITROSTAT 2 NITROGLYCERIN NITROMIST 3 ISOSORBIDE MONONITRATE IMDUR

Nitrogen Binding Agent / UROLOGICALS Tier Generic Name Brand Name Notes 3 GLYCEROL PHENYLBUTYRATE RAVICTI 5

Non-Nucleoside Reverse Transcriptase Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes 1 NEVIRAPINE 2 DELAVIRDINE RESCRIPTOR 2 EFAVIRENZ SUSTIVA 2 ETRAVIRINE INTELENCE 2 RILPIVIRINE EDURANT 3 NEVIRAPINE VIRAMUNE

Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY Tier Generic Name Brand Name Notes 1 BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 1 DICLOFENAC SODIUM 1 DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM-MISOPROSTOL 1 ETODOLAC 1 IBUPROFEN 1 INDOMETHACIN 1 KETOPROFEN 1 KETOROLAC TROMETHAMINE 1 MELOXICAM 1 NABUMETONE 1 NAPROXEN

4 - Office/Clinic Administration 5 - Prior Authorization

49 of 94 Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY (cont.) Tier Generic Name Brand Name Notes 1 OXAPROZIN 1 PIROXICAM 1 SALSALATE 1 SULINDAC 2 NAPROXEN SODIUM NAPRELAN 3 BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL 3 CELECOXIB CELEBREX 5 3 DICLOFENAC EPOLAMINE FLECTOR 3 DICLOFENAC POTASSIUM CAMBIA 3 DICLOFENAC POTASSIUM ZIPSOR 3 DICLOFENAC SODIUM PENNSAID 3 DICLOFENAC SODIUM VOLTAREN 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 3 INDOMETHACIN INDOCIN 3 KETOROLAC TROMETHAMINE SPRIX 3 MELOXICAM MOBIC 3 OXAPROZIN DAYPRO

Nucleoside/Nucleotide RT Inhibitors / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ABACAVIR SULFATE ABACAVIR 1 LAMIVUDINE 1 ZIDOVUDINE 1 ZIDOVUDINE/LAMIVUDINE 2 ABACAVIR SULFATE/LAMIVUDINE EPZICOM 2 ABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR 2 EMTRICITABINE/TENOFOVIR TRUVADA 2 LAMIVUDINE EPIVIR HBV 3 ABACAVIR SULFATE ZIAGEN 3 LAMIVUDINE/ZIDOVUDINE COMBIVIR 3 ZIDOVUDINE RETROVIR

Nucleosides And Nucleotides / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ENTECAVIR 1 FAMCICLOVIR 1 RIBAVIRIN 5 2 ADEFOVIR DIPIVOXIL HEPSERA 2 TELBIVUDINE TYZEKA 3 ENTECAVIR BARACLUDE 3 FAMCICLOVIR FAMVIR 3 RIBAVIRIN COPEGUS 5 3 VALGANCICLOVIR HCL VALCYTE

Ophthalmic Antiinflammatory / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 4 DESAMETHASONE INTRAVITREAL OZURDEX 4

Opiate Agonists, Short Acting / ANALGESICS Tier Generic Name Brand Name Notes 1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE

4 - Office/Clinic Administration 5 - Prior Authorization

50 of 94 Opiate Agonists, Short Acting / ANALGESICS (cont.) Tier Generic Name Brand Name Notes 1 BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN 1 CODEINE/BUTALBITAL/ASA/CAFFEIN BUTALBITAL COMPOUND-CODEINE 1 CODEINE/BUTALBITAL/ASA/CAFFEIN ASCOMP WITH CODEINE 1 HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE BIT-IBUPROFEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE-IBUPROFEN 1 HYDROMORPHONE HCL 1 MEPERIDINE HCL 1 MORPHINE SULFATE 1 OXYCODONE HCL OXYCODONE CONCENTRATE 1 OXYCODONE HCL 1 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 1 OXYCODONE HCL/ACETAMINOPHEN ENDOCET 1 OXYCODONE HCL/ASPIRIN ENDODAN 1 OXYCODONE HCL/OXYCODON TER/ASA OXYCODONE-ASPIRIN 1 OXYMORPHONE HCL 1 TRAMADOL HCL 1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN 2 HYDROMORPHONE HCL DILAUDID 2 METHADONE HCL 2 MORPHINE SULFATE AVINZA 2 MORPHINE SULFATE KADIAN 2 OXYCODONE HCL/ACETAMINOPHEN ROXICET 3 ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.3 3 FENTANYL DURAGESIC 3 FENTANYL CITRATE FENTORA 3 FENTANYL CITRATE ABSTRAL 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN HP 3 HYDROCODONE BIT/ACETAMINOPHEN LORTAB 3 HYDROCODONE BIT/ACETAMINOPHEN NORCO 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN 3 HYDROCODONE BITARTRATE ZOHYDRO 3 HYDROCODONE BITARTRATE 3 HYDROCODONE/IBUPROFEN IBUDONE 3 HYDROCODONE/IBUPROFEN REPREXAIN 3 HYDROCODONE/IBUPROFEN VICOPROFEN 3 HYDROMORPHONE HCL EXALGO 3 OXYCODONE HCL/ACETAMINOPHEN PERCOCET 3 TAPENTADOL HCL NUCYNTA 3 TRAMADOL HCL RYBIX ODT 3 TRAMADOL HCL ULTRAM

Opiate Agonists,Long Acting / ANALGESICS Tier Generic Name Brand Name Notes 1 FENTANYL TRANSDERMAL FENTANYL 1 HYDROMORPHONE ER 1 MORPHINE SULFATE MORPHINE SULFATE ER 2 OXYCODONE HCL OXYCONTIN 3 HYDROCODONE BITARTRATE HYSINGLA ER 3 MORPHINE SULFATE MS CONTIN 3 OXYCODONE HCL XARTEMIS XR 3 OXYMORPHONE HCL OPANA ER 3 TAPENTADOL HCL NUCYNTA ER 3 TRAMADOL HCL ULTRAM ER

Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 NALOXONE

51 of 94 Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE (cont.) Tier Generic Name Brand Name Notes 4 NALOXONE EVZIO 5

Opiate Antagonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 NALTREXONE HCL

Opiate Antagonists / GI AGENTS Tier Generic Name Brand Name Notes 3 NALOXEGOL MOVANTIK 5

Opiate Antagonists / OBESITY Tier Generic Name Brand Name Notes 3 NALOXONE/BUPROPION CONTRAVE 5

Opiate Partial Agonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE/NALOXONE SL TABS 5 3 BUPRENORPHINE BUTRANS 3 BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE SL TABS 5

Other Miscellaneous Therapeutic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 OCTREOTIDE ACETATE 5

Other Miscellaneous Therapeutic Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE 3 LEVOCARNITINE CARNITOR SF 3 LEVOCARNITINE CARNITOR

Other Miscellaneous Therapeutic Agents / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 CINACALCET HCL SENSIPAR 5 3 SAPROPTERIN DIHYDROCHLORIDE KUVAN

Other Miscellaneous Therapeutic Agents / UROLOGICALS Tier Generic Name Brand Name Notes 3 PENTOSAN POLYSULFATE SODIUM ELMIRON

Other Miscellaneous Therapeutic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 3 BAICALIN/CATECHIN/CITRATED ZNC LIMBREL250

Oxazolidinone / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 3 TEDIZOLID SIVEXTRO

5 - Prior Authorization

52 of 94 Oxytocics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 METHYLERGONOVINE MALEATE 3 METHYLERGONOVINE MALEATE METHERGINE

PO4 scavengers / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 CARGLUMIC ACID CARBAGLU 5

Parasympathomimetic (Cholinergic Agents) / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 PYRIDOSTIGMINE BROMIDE 2 PYRIDOSTIGMINE BROMIDE MESTINON

Parasympathomimetic (Cholinergic Agents) / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 CEVIMELINE HCL 2 CEVIMELINE HCL EVOXAC

Parasympathomimetic (Cholinergic Agents) / UROLOGICALS Tier Generic Name Brand Name Notes 1 BETHANECHOL CHLORIDE

Parasympathomimetics / ANTIMYASTHENIC AGNETS Tier Generic Name Brand Name Notes 1 NEOSTIGMINE 1 PYRIDOSTIGMINE

Parathyroid / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 1 CALCITONIN,SALMON,SYNTHETIC FORTICAL

Parathyroid / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 TERIPARATIDE FORTEO 5

Pediculicides/Scabicides / ANTIPARASITICS Tier Generic Name Brand Name Notes 3 NITAZOXANIDE ALINIA

Penicillins / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 AMOXICILLIN 1 AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN-CLAVULANATE ER 1 AMOXICILLIN/POTASSIUM CLAV AMOX TR-POTASSIUM CLAVULANATE 1 AMPICILLIN TRIHYDRATE

5 - Prior Authorization

53 of 94 Penicillins / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 1 CARBENICILLIN 1 DICLOXACILLIN SODIUM 1 PENICILLIN V POTASSIUM 2 AMOXICILLIN/POTASSIUM CLAV AUGMENTIN 4 NAFCILLIN NAFCIL 4 4 OXACILLIN 4 4 PENICILLIN G BICILLIN LA 4 4 PIPERACILLIN PIPRACIL 4

Pharmaceutical Aids / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 PYRITHIONE ZINC ZINC PYRITHIONE

Pharmaceutical Aids / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 2 PREGNENOLONE, MICRONIZED PREGNENOLONE MICRONIZED 3 PREGNENOLONE

Pharmaceutical Aids / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 7-OXODEHYDROEPIANDROSTERONE,MC 7-KETO DHEA

Phenothiazine Derivatives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 PHENYLEPHRINE HCL/PROMETH HCL PROMETHAZINE VC 1 PROMETHAZINE HCL 1 PROMETHAZINE HCL PHENADOZ

Phosphate-Removing Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 FERRIC CITRATE AURYXIA

Phosphate-Removing Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 CALCIUM ACETATE 1 SAVELAMER 2 SEVELAMER HCL RENAGEL 3 FERRIC CITRATE 3 LANTHANUM CARBONATE FOSRENOL 3 SEVELAMER CARBONATE RENVELA 3 SUCROFERRIC OXYHYDROXIDE VELPHORO

Phosphodiesterase Type 5 Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes ED AVANAFIL STENDRA 6

4 - Office/Clinic Administration 6 - Quantity Limit

54 of 94 Phosphodiesterase Type 5 Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 SILDENAFIL CITRATE SILDENAFIL 5 3 SILDENAFIL CITRATE REVATIO 5 3 TADALAFIL ADCIRCA

Phosphodiesterase Type 5 Inhibitors / UROLOGICALS Tier Generic Name Brand Name Notes ED SILDENAFIL CITRATE VIAGRA 6 ED TADALAFIL CIALIS 6 ED VARDENAFIL HCL STAXYN 6 ED VARDENAFIL HCL LEVITRA 6

Photosensitizer / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 METHOXSALEN, RAPID OXSORALEN-ULTRA

Pituitary / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN ACETATE 3 DESMOPRESSIN (NONREFRIGERATED) DDAVP 3 DESMOPRESSIN ACETATE STIMATE

Pituitary / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 SOMATROPIN NORDITROPIN NORDIFLEX 5 4 SOMATROPIN HUMATROPE 5 4 SOMATROPIN NUTROPIN AQ NUSPIN 5 4 SOMATROPIN OMNITROPE 5 4 SOMATROPIN NORDITROPIN FLEXPRO 5 4 SOMATROPIN GENOTROPIN 5 4 SOMATROPIN NUTROPIN AQ 5

Pituitary - Androgens / HORMONE: PITUITARY Tier Generic Name Brand Name Notes 1 ESTROGEN,ESTER/ME-TESTOSTERONE ESTROGEN & METHYLTESTOSTERONE 1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT 1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT H.S. 1 ESTROGEN,ESTER/ME-TESTOSTERONE COVARYX H.S. 3 METHYLTESTOSTERONE METHITEST 3 METHYLTESTOSTERONE 3 METHYLTESTOSTERONE ANDROID 3 TESTOSTERONE FORTESTA 3 TESTOSTERONE AXIRON 3 TESTOSTERONE TESTIM 4 TESTOSTERONE CYPIONATE 5 4 TESTOSTERONE ENANTHATE DELATESTRYL 5

Platelet Modifying Agents / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 1 ANAGRELIDE HCL

5 - Prior Authorization 6 - Quantity Limit

55 of 94 Platelet Modifying Agents / BLOOD PRODUCT/MODIFIERS (cont.) Tier Generic Name Brand Name Notes 1 CILOSTAZOL 1 CLOPIDOGREL BISULFATE CLOPIDOGREL 1 TICLOPIDINE HCL 2 CLOPIDOGREL BISULFATE PLAVIX 3 ASPIRIN/DIPYRIDAMOLE AGGRENOX 3 PRASUGREL HCL EFFIENT 3 TICAGRELOR BRILINTA

Potassium Sparing Diuretic / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ 1 SPIRONOLACTONE 3 SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE

Potassium-Removing Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 SODIUM POLYSTYRENE SULFONATE KALEXATE 1 SODIUM POLYSTYRENE SULFONATE KIONEX

Potassium-Sparing Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMILORIDE HCL 1 AMILORIDE/HYDROCHLOROTHIAZIDE AMILORIDE-HYDROCHLOROTHIAZIDE 1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HCTZ 1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HYDROCHLOROTHIAZID 3 TRIAMTERENE DYRENIUM 3 TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE 3 TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE-25 MG

Progestins / HORMONE: PROGESTINS Tier Generic Name Brand Name Notes 1 MEDROXYPROGESTERONE ACETATE 1 NORETHINDRONE ACETATE 1 PROGESTERONE 3 MEDROXYPROGESTERONE ACETATE PROVERA 3 PROGESTERONE,MICRONIZED ENDOMETRIN 3 PROGESTERONE,MICRONIZED PROGESTERONE 3 PROGESTERONE,MICRONIZED CRINONE 3 PROGESTERONE,MICRONIZED PROMETRIUM 4 HYDROXYPROGESTERONE CAPROATE MAKENA 5 4 PROGESTERONE PROGESTERONE IN OIL 2

Prokinetic Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 METOCLOPRAMIDE HCL 3 METOCLOPRAMIDE HCL METOZOLV ODT

Prostacyclin Vasodilator / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 TREPROSTINIL ORENITRAM 5

2 - Infertility 5 - Prior Authorization

56 of 94 Prostaglandins / GI AGENTS Tier Generic Name Brand Name Notes 1 MISOPROSTOL

Prostaglandins / HORMONE: PROSTAGLANDINS Tier Generic Name Brand Name Notes 1 LATANOPROST 2 BIMATOPROST LUMIGAN 2 TRAVOPROST TRAVATAN Z 3 ILOPROST VENTAVIS 5 3 LATANOPROST XALATAN 3 TAFLUPROST/PF ZIOPTAN 3 UNOPROSTONE RESCULA

Protease Inhibitors / ANTIVIRALS Tier Generic Name Brand Name Notes 2 ATAZANAVIR SULFATE REYATAZ 2 DARUNAVIR ETHANOLATE PREZISTA 2 FOSAMPRENAVIR CALCIUM LEXIVA 2 INDINAVIR CRIXIVAN 2 LOPINAVIR/RITONAVIR KALETRA 2 RITONAVIR NORVIR 2 SAQUINAVIR INVIRASE 2 TIPRANAVIR APTIVUS

Protease Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 VORAPAXAR ZONTIVITY

Proteasome Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 BORTEZOMIB VELCADE 5

Protectants / GI AGENTS Tier Generic Name Brand Name Notes 1 SUCRALFATE 3 SUCRALFATE CARAFATE

Proteinase / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 COLLAGENASE CLOSTRIDIUM XIAFLEX 4

Proton-Pump Inhibitors / GI AGENTS Tier Generic Name Brand Name Notes 1 ESOMEPRAZOLE MAGNESIUM 1 LANSOPRAZOLE 1 OMEPRAZOLE

4 - Office/Clinic Administration 5 - Prior Authorization

57 of 94 Proton-Pump Inhibitors / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 1 OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE 1 PANTOPRAZOLE SODIUM 1 RABEPRAZOLE SODIUM RABEPRAZOLE 3 DEXLANSOPRAZOLE DEXILANT 3 ESOMEPRAZOLE MAGNESIUM NEXIUM 3 LANSOPRAZOLE PREVACID 3 LANSOPRAZOLE/AMOXICILN/CLARITH PREVPAC 3 OMEPRAZOLE PRILOSEC 3 OMEPRAZOLE/CLARITH/AMOXICILLIN OMECLAMOX-PAK 3 OMEPRAZOLE/SODIUM BICARBONATE ZEGERID 3 PANTOPRAZOLE SODIUM PROTONIX 3 RABEPRAZOLE SODIUM ACIPHEX

Quinolones / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 CIPROFLOXACIN HCL 1 LEVOFLOXACIN 1 OFLOXACIN 2 MOXIFLOXACIN HCL AVELOX 2 MOXIFLOXACIN HCL AVELOX ABC PACK 3 CIPROFLOXACIN HCL CIPRO 3 LEVOFLOXACIN LEVAQUIN 3 NORFLOXACIN NOROXIN

Renin Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 2 ALISKIREN HEMIFUMARATE TEKTURNA 3 ALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT 3 ALISKIREN/VALSARTAN VALTURNA 7

Replacement Preparations / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE 3 SODIUM CHLORIDE FOR INHALATION HYPER-SAL

Replacement Preparations / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE 1 POTASSIUM BICARBONATE/CIT AC KLOR-CON-EF 1 POTASSIUM CHLORIDE 1 POTASSIUM CHLORIDE EPIKLOR 1 POTASSIUM CHLORIDE KLOR-CON 1 ZINC SULFATE 2 POTASSIUM BICARBONATE/CIT AC EFFER-K 2 POTASSIUM CHLORIDE K-TAB

Respiratory Smooth Muscle Relaxants / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 THEOPHYLLINE ANHYDROUS

7 - Step Therapy

58 of 94 Respiratory Smooth Muscle Relaxants / RESPIRATORY AGENTS (cont.) Tier Generic Name Brand Name Notes 2 THEOPHYLLINE ANHYDROUS THEO-24

Respiratory Tract Agents- Miscellaneous / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 ROFLUMILAST DALIRESP

Retinoids / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 ALITRETINOIN PANRETIN 5 3 TRETINOIN VESANOID 5

Ribose Polymerase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 OLAPARIB LYNPARZA 5

Scabicides And Pediculicides / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 PERMETHRIN 3 BENZYL ALCOHOL ULESFIA 3 CROTAMITON EURAX 3 IVERMECTIN SOOLANTRA 3 SPINOSAD NATROBA

Second Generation Antihistamines / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 DESLORATADINE 1 FEXOFENADINE HCL 1 FEXOFENADINE/PSEUDOEPHEDRINE FEXOFENADINE-PSE ER 1 LEVOCETIRIZINE DIHYDROCHLORIDE 3 DESLORATADINE CLARINEX 3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 24 HOUR 3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12 HOUR 3 FEXOFENADINE HCL ALLEGRA 3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 24 HOUR 3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 12 HOUR 3 LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL

Selective Serotonin Agonists / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 NARATRIPTAN HCL 6 1 RIZATRIPTAN BENZOATE RIZATRIPTAN 6 1 RIZATRIPTAN MLT 6 1 SUMATRIPTAN 6 1 ZOLMITRIPTAN 6 2 ALMOTRIPTAN MALATE AXERT 6 3 ELETRIPTAN HBR RELPAX 6

5 - Prior Authorization 6 - Quantity Limit

59 of 94 Selective Serotonin Agonists / ANTIMIGRAINE (cont.) Tier Generic Name Brand Name Notes 3 FROVATRIPTAN SUCCINATE FROVA 6 3 NARATRIPTAN HCL AMERGE 6 3 RIZATRIPTAN BENZOATE MAXALT MLT 6 3 RIZATRIPTAN BENZOATE MAXALT 6 3 SUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET 6 3 SUMATRIPTAN SUCCINATE IMITREX 6 3 SUMATRIPTAN SUCCINATE SUMAVEL DOSEPRO 6 3 ZOLMITRIPTAN ZOMIG 6 3 ZOLMITRIPTAN ZOMIG ZMT 6

Selective Serotonin Agonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 PAROXETINE HCL BRISDELLE 3 VORTIOXETINE BRINTELLIX

Selective Serotonin Reuptake Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 CITALOPRAM HYDROBROMIDE CITALOPRAM HBR 1 ESCITALOPRAM OXALATE 1 FLUOXETINE HCL 1 FLUOXETINE HCL FLUOXETINE DR 1 PAROXETINE HCL 1 SERTRALINE HCL 3 CITALOPRAM HYDROBROMIDE CELEXA 3 ESCITALOPRAM OXALATE LEXAPRO 3 FLUOXETINE HCL SARAFEM 3 FLUOXETINE HCL PROZAC 3 PAROXETINE HCL PAXIL 3 PAROXETINE HCL PAXIL CR 3 SERTRALINE HCL ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitor / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPROPION HCL BUPROPION HCL SR

Serotonin Norepinephrine Reuptake Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 BUPROPION HCL BUPROPION XL 1 BUPROPION HCL 1 BUPROPION HCL BUDEPRION XL 1 BUPROPION HCL BUDEPRION SR 1 DULOXETINE HCL DULOXETINE 1 VENLAFAXINE HCL VENLAFAXINE HCL ER 1 VENLAFAXINE HCL 2 BUPROPION HCL FORFIVO XL 3 BUPROPION HBR APLENZIN 3 BUPROPION HCL WELLBUTRIN 3 BUPROPION HCL WELLBUTRIN XL 3 BUPROPION HCL WELLBUTRIN SR 3 DULOXETINE HCL CYMBALTA

6 - Quantity Limit

60 of 94 Serotonin Norepinephrine Reuptake Inhibitor / ANTIDEPRESSANTS (cont.) Tier Generic Name Brand Name Notes 3 LEVOMILNACIPRAN FETZIMA 3 VENLAFAXINE HCL EFFEXOR XR

Serotonin Reptake Blocker / ANTIDEPRESSANTS, OTHER Tier Generic Name Brand Name Notes 1 TRAZODONE HCL 3 TRAZODONE HCL OLEPTRO ER

Serums / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 IMMUNE GLOBULIN,GAMMA(IGG) HIZENTRA 5

Skin And Mucous Membrane Agents- Misc. / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ADAPALENE 1 ADAPALENE 5 1 CALCIPOTRIENE CALCITRENE 1 CALCIPOTRIENE 1 FLUOROURACIL 1 IMIQUIMOD 1 ISOTRETINOIN MYORISAN 5 1 ISOTRETINOIN CLARAVIS 5 1 ISOTRETINOIN AMNESTEEM 5 1 PODOFILOX 2 AZELAIC ACID FINACEA 2 BECAPLERMIN REGRANEX 2 FLUOROURACIL CARAC 2 PODOFILOX CONDYLOX 3 ACITRETIN SORIATANE 3 ADAPALENE DIFFERIN 5 3 ADAPALENE/BENZOYL PEROXIDE EPIDUO 3 AZELAIC ACID AZELEX 3 CALCIPOTRIENE DOVONEX 3 CALCIPOTRIENE SORILUX 3 CALCITRIOL VECTICAL 3 COLLAGENASE CLOSTRIDIUM HIST. SANTYL 3 DAPSONE ACZONE 3 DICLOFENAC SODIUM SOLARAZE 3 IMIQUIMOD ZYCLARA 3 IMIQUIMOD ALDARA 3 INGENOL MEBUTATE PICATO 3 PIMECROLIMUS ELIDEL 3 PODOPHYLLUM RESIN PODOCON-25 3 TACROLIMUS PROTOPIC 3 TAZAROTENE TAZORAC 3 TRYPSIN/BALSAM PERU/CASTOR OIL XENADERM

Skin And Mucous Membrane Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 FORMALDEHYDE LAZERFORMALYDE

5 - Prior Authorization

61 of 94 Skin And Mucous Membrane Agents- Misc. / GI AGENTS Tier Generic Name Brand Name Notes 3 NITROGLYCERIN RECTIV

Smoking Cessation / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPROPION SR BUPROBAN 3 1 BUPROPION SR BUPROPION HCL SR 3 2 VARENICLINE TARTRATE CHANTIX 3 3 BUPROPION SR ZYBAN 3

Sodium Channel Agents / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 CARBAMAZEPINE TEGRETOL

Sodium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE CARBAMAZEPINE ER 1 CARBAMAZEPINE CARBAMAZEPINE XR 1 CARBAMAZEPINE 1 OXCARBAZEPINE 1 PHENYTOIN 1 PHENYTOIN SODIUM EXTENDED 1 TOPIRAMATE 1 ZONISAMIDE 3 CARBAMAZEPINE CARBATROL 3 CARBAMAZEPINE TEGRETOL XR 3 OXCARBAZEPINE TRILEPTAL 3 PHENYTOIN SODIUM EXTENDED PHENYTEK 3 TOPIRAMATE TOPAMAX

Sodium Channel Agents / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 TOPIRAMATE

Sodium Channel Inhibitor / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 PHENYTOIN SODIUM EXTENDED DILANTIN

Sodium Channel Inhibitor / ANTICONVULSANTS Tier Generic Name Brand Name Notes 3 ESLICARBAZEPINE APTIOM 3 RUFINAMIDE BANZEL 5

Sodium Glucose Transporter 2 / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 EMPAGLIFLOZIN JARDIANCE

3 - No copay 5 - Prior Authorization

62 of 94 Sodium Glucose Transporter 2 / BLOOD GLUCOSE REGULATORS (cont.) Tier Generic Name Brand Name Notes 3 CANAGLIFLOZIN INVOKANA

Sodium Glucose Transporter 2 / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 DAPAGLIFLOZIN FARXIGA

Somatostatin Analogue / ENDOCRINE Tier Generic Name Brand Name Notes 3 PASIREOTIDE SIGNIFOR 5

Stimulant guanylate cyclase / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 RIOCIGUAT ADEMPAS 5

Substance P Antagonist / ANTIEMETICS Tier Generic Name Brand Name Notes 3 APREPITANT EMEND

Sulfonamides (Systemic) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 SULFASALAZINE SULFAZINE EC 1 SULFASALAZINE SULFAZINE

Sulfonamides (Systemic) / INFLAMMATORY BOWEL AGENTS Tier Generic Name Brand Name Notes 1 SULFASALAZINE 1 SULFASALAZINE SULFASALAZINE DR

Sulfonylureas / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 GLIMEPIRIDE 1 GLIPIZIDE 1 GLIPIZIDE GLIPIZIDE ER 1 GLIPIZIDE GLIPIZIDE XL 1 GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 1 GLYBURIDE 1 GLYBURIDE/METFORMIN HCL GLYBURIDE-METFORMIN HCL 1 TOLAZAMIDE 1 TOLBUTAMIDE 3 GLIPIZIDE GLUCOTROL XL 3 GLYBURIDE/METFORMIN HCL GLUCOVANCE

Sympathomimetic (Adrenergic) Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 MIDODRINE HCL

Sympathomimetic (Adrenergic) Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 ALBUTEROL SULFATE 6

5 - Prior Authorization 6 - Quantity Limit 63 of 94 Sympathomimetic (Adrenergic) Agents / RESPIRATORY AGENTS (cont.) Tier Generic Name Brand Name Notes 1 EPINEPHRINE 1 TERBUTALINE SULFATE 2 FLUTICASONE/SALMETEROL ADVAIR DISKUS 6 2 FORMOTEROL FUMARATE FORADIL 2 SALMETEROL XINAFOATE SEREVENT DISKUS 3 LEVALBUTEROL HCL XOPENEX 6 3 PIRBUTEROL ACETATE MAXAIR AUTOHALER

T Cell Blocker / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 BELATACEPT NULOJIX 5

TNF Inhibitor / RESPIRATORY AGENTS OTHER Tier Generic Name Brand Name Notes 3 PIRFENIDONE ESBRIET 5

Tetracyclines / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 DEMECLOCYCLINE HCL 1 DOXYCYCLINE HYCLATE 1 DOXYCYCLINE MONOHYDRATE 1 MINOCYCLINE HCL 1 TETRACYCLINE HCL 3 DOXYCYCLINE HYCLATE DORYX 3 DOXYCYCLINE HYCLATE VIBRAMYCIN 3 DOXYCYCLINE MONOHYDRATE MONODOX 3 DOXYCYCLINE MONOHYDRATE ORACEA 3 MINOCYCLINE HCL SOLODYN 3 MINOCYCLINE HCL MINOCIN

Thiazide Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CHLOROTHIAZIDE 1 CHLORTHALIDONE 1 HYDROCHLOROTHIAZIDE 1 INDAPAMIDE 1 METOLAZONE 3 CHLOROTHIAZIDE DIURIL

Thiazolidinediones / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 PIOGLITAZONE HCL 1 PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE-METFORMIN 3 PIOGLITAZONE HCL ACTOS 3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET 3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET XR

Thyroid Agents / HORMONE: THYROID Tier Generic Name Brand Name Notes 1 LEVOTHYROXINE SODIUM LEVOXYL

5 - Prior Authorization 6 - Quantity Limit

64 of 94 Thyroid Agents / HORMONE: THYROID (cont.) Tier Generic Name Brand Name Notes 1 LEVOTHYROXINE SODIUM 1 THYROID,PORK WESTHROID 1 THYROID,PORK NATURE-THROID 2 LIOTHYRONINE SODIUM PCCA T3 SODIUM DILUTION 2 LIOTHYRONINE SODIUM 2 THYROID,PORK ARMOUR THYROID 2 THYROID,PORK THYROID 2 THYROID,PORK NATURE-THROID 3 LEVOTHYROXINE SODIUM SYNTHROID 3 LEVOTHYROXINE SODIUM LEVOTHROID 3 LEVOTHYROXINE SODIUM TIROSINT 3 LIOTHYRONINE SODIUM CYTOMEL

Topical Analgesic / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 CAPSAICIN QUTENZA 5

Treatment Resistant / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 CLOZAPINE

Tricyclic Antidepressants / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 AMITRIPTYLINE HCL 1 CLOMIPRAMINE HCL 1 DESIPRAMINE HCL 1 DOXEPIN HCL 1 IMIPRAMINE HCL 1 NORTRIPTYLINE HCL 3 CLOMIPRAMINE HCL ANAFRANIL 3 TRIMIPRAMINE MALEATE SURMONTIL

Tricyclic Antidepressants / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 AMITRIPTYLINE HCL

Typical/1st Generation / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 CHLORPROMAZINE HCL 1 FLUPHENAZINE HCL 1 HALOPERIDOL 1 LOXAPINE 1 PERPHENAZINE 1 PROLIXIN 1 STELAZINE 1 THIORIDAZINE HCL 1 THIOTHIXENE 4 HALOPERIDOL LACTATE 5

Tyrosine Kinase / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 AFATINIB GILOTRIF 5

5 - Prior Authorization

65 of 94 Tyrosine Kinase / ANTINEOPLASTICS (cont.) Tier Generic Name Brand Name Notes 3 IRBRUTINIB IMBRUVICA 5 3 NILOTINIB TASIGNA 5 3 PALBOCICLIB IBRANCE 5 4 USTEKINUMAB STELARA 5

Tyrosine Kinase / RESPIRATORY AGENTS OTHER Tier Generic Name Brand Name Notes 3 NINTEDANIB OFEV 5

Uric Acid Synthesis Inhibitor / ANTIGOUT Tier Generic Name Brand Name Notes 1 ALLOPURINOL

Uricosuric Agents / ANTIGOUT Tier Generic Name Brand Name Notes 1 COLCHICINE/PROBENECID PROBENECID-COLCHICINE 2 COLCHICINE COLCRYS

Uricosuric Agents / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 PROBENECID

Urinary Anti-Infectives / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 NITROFURANTOIN 1 NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN 1 NITROFURANTOIN MONOHYD/M-CRYST NITROFURANTOIN MONO-MACRO 1 TRIMETHOPRIM 2 NITROFURANTOIN MACROCRYSTAL MACRODANTIN 3 FOSFOMYCIN TROMETHAMINE MONUROL 3 NITROFURANTOIN MONOHYD/M-CRYST MACROBID

Urinary Anti-Infectives / UROLOGICALS Tier Generic Name Brand Name Notes 3 MTH/ME BLUE/SOD PHOS/PHEN/HYOS URIBEL

Vaccines / ANTIBACTERIALS Tier Generic Name Brand Name Notes 4 MENINGOCOCCAL GR B VACCINE BEXSERO 4

Vaccines / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 TYPHOID VACC,LIVE,ATTENUATED VIVOTIF BERNA

Vascular Endothelial Growth Factor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 AFLIBERCEPT EYLEA 4

4 - Office/Clinic Administration 5 - Prior Authorization

66 of 94 Vasoconstrictors / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 NAPHAZOLINE HCL 1 PHENYLEPHRINE HCL

Vasodilating Agents- Miscellaneous / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 AMBRISENTAN LETAIRIS 5 3 BOSENTAN TRACLEER 5 4 TREPROSTINIL REMODULIN 5 4 TREPROSTINIL TYVASO 5

Vasodilating Agents- Miscellaneous / UROLOGICALS Tier Generic Name Brand Name Notes ED ALPROSTADIL MUSE 6 ED ALPROSTADIL EDEX 6

Vasodilator, Arterial/Venous / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 NITROGLYCERIN NITROGLYCERIN PATCH 1 NITROGLYCERIN 3 NITROGLYCERIN NITROLINGUAL

Vasopressin Related / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 TOLVAPTAN SAMSCA 5

Vitamin B Complex / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 FOLIC ACID 3 ACETYL/METHYL-B12/LMEFOLATE CA CEREFOLIN NAC 3 CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL 3 CYANOCOBALAMIN/FA/PYRIDOXINE FOLGARD RX 3 LEVOMEFOLATE CALCIUM DEPLIN 3 METHYL-B12/L-MEFOLATE/B6 PHOS METANX 3 VIT B CMPLX 3/FA/VIT C/BIOTIN NEPHRO-VITE RX 4 CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 5

Vitamin D / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CALCITRIOL 2 PARICALCITOL ZEMPLAR 3 DOXERCALCIFEROL HECTOROL

Vitamin D / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 ERGOCALCIFEROL (VITAMIN D2) VITAMIN D2

5 - Prior Authorization 6 - Quantity Limit

67 of 94 Xanthine Oxidase Inhibitor / ANTIGOUT Tier Generic Name Brand Name Notes 3 FEBUXOSTAT ULORIC 5 integrin receptor antagonist / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 VEDOLIZUMAB ENTYVIO 4

68 of 94 Index

7 A (cont.) 7-KETO DHEA 54 ADENOSINE 11 7-OXODEHYDROEPIANDROSTERONE,MC 54 ADO-TRASTUZUMAB 39 ADVAIR DISKUS 64 A ADVAIR HFA 30 ABACAVIR 50 ADVATE 39 ABACAVIR SULFATE 50 ADVICOR 34 ABACAVIR SULFATE/LAMIVUDINE 50 AEROCHAMBER 32 ABACAVIR/LAMIVUDINE/ZIDOVUDINE 50 AEROCHAMBER MAX 32 ABATACEPT 33 AEROCHAMBER MV 32 ABILIFY 20, 24 AEROCHAMBER PLUS 32 ABILIFY DISCMELT 20 AEROCHAMBER WITH FLOWSIGNAL 32 ABIRATERONE ACETATE 17 AEROCHAMBER Z-STAT PLUS 32 ABSTRAL 51 AFATINIB 65 ACAMPROSATE CALCIUM 3 AFEDITAB CR 32 ACANYA 12 AFINITOR 17 ACARBOSE 5 AFLIBERCEPT 66 ACCOLATE 44 AFREZZA 42 ACCUPRIL 7 AGALSIDASE BETA 35 ACCURETIC 7 AGGRENOX 56 ACETAMINOPHEN WITH CODEINE 50, 51 AK-POLY-BAC 11 ACETAMINOPHEN-CODEINE 50 AKNE-MYCIN 12 ACETASOL HC 46 AKYNZEO 2 ACETAZOLAMIDE 25 ALAMAST 10 ACETIC ACID 46 ALBENDAZOLE 8 ACETIC ACID/HYDROCORTISONE 46 ALBENZA 8 ACETYL/METHYL-B12/LMEFOLATE CA 67 ALBIGLUTIDE 37 ACETYLCYSTEINE 47 ALBUTEROL SULFATE 22, 63 ACIPHEX 58 ALCAFTADINE 10 ACITRETIN 61 ALCLOMETASONE DIPROPIONATE 9 ACLIDINIUM BROMIDE 16 ALDACTAZIDE 56 ACTEMRA 41 ALDARA 61 ACTHAR H.P. 29 ALENDRONATE SODIUM 24 ACTIGALL 27 ALENDRONATE SODIUM/VITAMIN D3 24 ACTIVELLA 36 ALFUZOSIN 21 ACTONEL 24 ALFUZOSIN HCL 5 ACTOPLUS MET 64 ALINIA 18, 53 ACTOPLUS MET XR 64 ALISKIREN HEMIFUMARATE 58 ACTOS 64 ALISKIREN/HYDROCHLOROTHIAZIDE 58 ACULAR 34 ALISKIREN/VALSARTAN 58 ACULAR LS 34 ALITRETINOIN 59 ACUVAIL 34 ALLEGRA 59 ACYCLOVIR 15 ALLEGRA-D 12 HOUR 59 ACYCLOVIR/HYDROCORTISONE 19 ALLEGRA-D 24 HOUR 59 ACZONE 61 ALLOPURINOL 66 ADALAT CC 32 ALMOTRIPTAN MALATE 59 ADALIMUMAB 33 ALOCRIL 45 ADAPALENE 61 ALOGLIPTIN 32 ADAPALENE/BENZOYL PEROXIDE 61 ALOMIDE 10 ADCETRIS 47 ALORA 36 ADCIRCA 55 ALOSETRON HCL 46 ADDERALL 2 ALPHAGAN P 5 ADDERALL XR 2 ALPRAZOLAM 22, 24 ADEFOVIR DIPIVOXIL 50 ALPRAZOLAM ER 22 ADEMPAS 63 ALPRAZOLAM ODT 22 ADENOCARD 11 ALPRAZOLAM XR 22

69 of 94 A (cont.) A (cont.) ALPROLIX 39 ANORO ELLIPTA 16 ALPROSTADIL 67 ANTABUSE 3 ALREX 30 ANTARA 36 ALTABAX 12 ANTHRALIN 43 ALTACE 8 ANTIHEMOPH.FVIII PLAS/ALB FREE 39 ALTAVERA 28 ANTIHEMOPHILIC FACTOR 15 ALTOPREV 40 ANTIPY/BENZOCAINE/POLICOS NO.1 44 ALUMINUM CHLORIDE 20 ANTIPYRINE-BENZOCAINE 44 ALVESCO 31 ANTIPYRINE/BENZOCAINE 44 ALYACEN 28 ANTIPYRINE/BENZOCAINE/GLYCERIN 44 AMANTADINE 9, 33 ANTIVERT 16 AMANTADINE HCL 9, 33 ANUCORT-HC 9 AMBIEN 20 ANZEMET 2 AMBIEN CR 20 APHTHASOL 34 AMBRISENTAN 67 APIDRA 42 AMERGE 60 APIDRA SOLOSTAR 42 AMETHIA 28 APIXABAN 24 AMETHIA LO 28 APLENZIN 60 AMETHYST 28 APOKYN 33 AMIKACIN 5 APOMORPHINE 33 AMILORIDE HCL 56 APREMILAST 41 AMILORIDE-HYDROCHLOROTHIAZIDE 56 APREPITANT 63 AMILORIDE/HYDROCHLOROTHIAZIDE 56 APRI 28 AMINOCAPROIC ACID 39 APRISO 9 AMIODARONE HCL 10, 11 APTIOM 62 AMITIZA 43 APTIVUS 57 AMITRIPTYLINE HCL 65 ARANELLE 29 AMLEXANOX 34 ARANESP 13 AMLODIPINE BES/OLMESARTAN MED 32 ARAVA 33 AMLODIPINE BESYLATE 32 ARCAPTA NEOHALER 22 AMLODIPINE BESYLATE-BENAZEPRIL 32 ARESTIN 11 AMLODIPINE BESYLATE/BENAZEPRIL 32 ARFORMOTEROL TARTRATE 22 AMLODIPINE-ATORVASTATIN 40 ARIMIDEX 20 AMLODIPINE/ATORVASTATIN 40 ARIPIPRAZOLE 20, 24 AMLODIPINE/VALSARTAN 25 ARIXTRA 24 AMLODIPINE/VALSARTAN/HCTZ 25 ARMODAFINIL 8 AMMONIUM LACTATE 21, 22 ARMOUR THYROID 65 AMNESTEEM 61 ARNUITY ELLIPTA 30 AMOX TR-POTASSIUM CLAVULANATE 53 ARTANE 13 AMOXAPINE 40 ARTHROTEC 50 50 AMOXICILLIN 53 ARTHROTEC 75 50 AMOXICILLIN-CLAVULANATE ER 53 ASACOL 6 AMOXICILLIN/POTASSIUM CLAV 53, 54 ASACOL HD 6 AMPHET ASP/AMPHET/D-AMPHET 2 ASCOMP WITH CODEINE 51 AMPHETAMINE SALT COMBO 2 ASENAPINE MALEATE 20 AMPICILLIN TRIHYDRATE 53 ASMANEX 30 AMPYRA 45 ASPIRIN/DIPYRIDAMOLE 56 AMRIX 26 ASTELIN 10 ANAFRANIL 65 ASTEPRO 10 ANAGRELIDE HCL 55 ATACAND 7 ANAKINRA 33 ATACAND HCT 7 ANALPRAM HC 9 ATAZANAVIR SULFATE 57 ANASTROZOLE 20 ATELVIA 24 ANDRODERM 7 ATENOLOL 22, 23 ANDROGEL 7 ATENOLOL-CHLORTHALIDONE 23 ANDROID 55 ATENOLOL/CHLORTHALIDONE 23 ANGELIQ 36 ATIVAN 22

70 of 94 A (cont.) B (cont.) ATOMOXETINE HCL 2 BAICALIN/CATECHIN/CITRATED ZNC 52 ATOPICLAIR 35 BALSALAZIDE DISODIUM 8 ATORVASTATIN CALCIUM 40 BALZIVA 28 ATOVAQUONE-PROGUANIL HCL 16 BANZEL 62 ATOVAQUONE/PROGUANIL HCL 16 BARACLUDE 50 ATRALIN 26 BECAPLERMIN 61 ATRAPRO HYDROGEL 35 BECLOMETHASONE DIPROPIONATE 30 ATRIPLA 18 BECONASE AQ 30 ATROPINE CARE 48 BEDAQUILINE 19 ATROPINE SULFATE 48 BELATACEPT 64 ATROPINE SULFATE/PF 48 BELEODAQ 40 ATROVENT HFA 16 BELIMUMAB 21 AUBAGIO 45 BELINOSTAT 40 AUGMENTIN 54 BELLADONNA-PHENOBARBITAL 18 AURAX 44 BELVIQ 2 AURODEX 44 BENAZEPRIL HCL 7 AURYXIA 54 BENAZEPRIL-HYDROCHLOROTHIAZIDE 7 AVALIDE 7 BENAZEPRIL/HYDROCHLOROTHIAZIDE 7 AVANAFIL 54 BENDAMUSTINE 4 AVAPRO 7 BENICAR 7 AVASTIN 10 BENICAR HCT 7 AVELOX 58 BENLYSTA 21 AVELOX ABC PACK 58 BENZAC AC 43 AVIANE 28 BENZACLIN 12 AVINZA 51 BENZAMYCINPAK 12 AVITA 26 BENZEFOAM ULTRA 43 AVODART 2 BENZEPRO 43 AVONEX 45 BENZONATATE 19 AVONEX ADMINISTRATION PACK 45 BENZOYL PEROXIDE 43 AVONEX PEN 45 BENZOYL PEROXIDE/HYDROCORTISON 3 AXERT 59 BENZTROPINE MESYLATE 13 AXIRON 55 BENZYL ALCOHOL 59 AZACTAM 23 BEPOTASTINE BESILATE 10 AZASITE 12 BEPREVE 10 AZATHIOPRINE 41 BESIFLOXACIN HCL 12 AZELAIC ACID 61 BESIVANCE 12 AZELASTINE 10 BETA-VAL 3 AZELASTINE HCL 10 BETAMETHASONE DIPROPIONATE 3 AZELASTINE/FLUTICASONE 10 BETAMETHASONE VALERATE 3 AZELEX 61 BETASERON 45 AZILECT 46 BETAXOLOL HCL 23 AZILSARTAN MED/CHLORTHALIDONE 7 BETHANECHOL CHLORIDE 53 AZILSARTAN MEDOXOMIL 7 BETIMOL 23 AZITHROMYCIN 12, 45 BETOPTIC S 23 AZOPT 25 BEVACIZUMAB 10 AZOR 32 BEXSERO 66 AZTREONAM 23 BEYAZ 29 AZTREONAM LYSINE 46 BIAFINE 34 AZURETTE 28 BICALUTAMIDE 17 BICILLIN LA 54 B BILTRICIDE 8 B-NEXA 48 BIMATOPROST 57 BACITRACIN 11 BINOSTO 24 BACITRACIN/POLYMYXIN B SULFATE 11 BISAC/NACL/NAHCO3/KCL/PEG 3350 43 BACLOFEN 37 BISMUTH SAL/METRONID/TETRACYC 13 BACTROBAN 12 BISMUTH TRIBROMOPH/PETROLATUM 31 BACTROBAN NASAL 12 BISMUTH/METRONID/TETRACYCLINE 13

71 of 94 B (cont.) B (cont.) BISOPROLOL FUMARATE 23 BUTALBITAL/ASPIRIN/CAFFEINE 49, 50 BISOPROLOL FUMARATE/HCTZ 23 BUTRANS 52 BISOPROLOL-HYDROCHLOROTHIAZIDE 23 BYDUREON 41 BLEPH-10 11 BYETTA 41 BLEPHAMIDE 12 BYSTOLIC 23 BLEPHAMIDE S.O.P. 12 BOCEPREVIR 15 C BONIVA 24 C1 ESTERASE INHIBITOR 24 BORTEZOMIB 57 CABERGOLINE 34 BOSENTAN 67 CABOZANTINIB 17 BOTOX 49 CAFERGOT 35 BP 10-1 43 CALAN SR 25 BP WASH 43 CALCIPOTRIENE 61 BP WASH ACNE TREATMENT 43 CALCIPOTRIENE/BETAMETHASONE 3 BPO 43 CALCITONIN,SALMON,SYNTHETIC 53 BRAVELLE 38 CALCITONIN-SALMON 53 BREATHERITE 31 CALCITRENE 61 BRENTUXIMAB 47 CALCITRIOL 61, 67 BREO ELLIPTA 30 CALCIUM ACETATE 54 BREVICON 29 CAMBIA 50 BRIELLYN 28 CAMILA 28 BRILINTA 56 CAMPRAL 3 BRIMONIDINE TARTRATE 5 CAMRESE 28 BRIMONIDINE TARTRATE/TIMOLOL 5 CAMRESE LO 28 BRINTELLIX 60 CANAGLIFLOZIN 63 BRINZOLAMIDE 25 CANAKINUMAB 47 BRISDELLE 60 CANASA 9 BROMDAY 34 CANDESARTAN 7 BROMFED DM 19 CANDESARTAN CILEXETIL 7 BROMFENAC SODIUM 34 CANDESARTAN-HYDROCHLOROTHIAZID 7 BROMOCRIPTINE MESYLATE 33 CANDESARTAN/HYDROCHLOROTHIAZID 7 BROMPHENIRAMIN/PE/DEXTROMETHOR 19 CAPASTAT 6 BROVANA 22 CAPECITABINE 17 BUDEPRION SR 60 CAPEX SHAMPOO 9 BUDEPRION XL 60 CAPHOSOL 31 BUDESONIDE 3, 30 CAPREOMYCIN 6 BUDESONIDE EC 3 CAPSAICIN 65 BUDESONIDE/FORMOTEROL FUMARATE 30 CAPTOPRIL 7 BUMETANIDE 44 CAPTOPRIL-HYDROCHLOROTHIAZIDE 7 BUPRENORPHINE 52 CAPTOPRIL/HYDROCHLOROTHIAZIDE 7 BUPRENORPHINE HCL/NALOXONE HCL 52 CARAC 61 BUPRENORPHINE/NALOXONE SL TABS 52 CARAFATE 57 BUPROBAN 62 CARBAGLU 53 BUPROPION HBR 60 CARBAMAZEPINE 13, 47, 62 BUPROPION HCL 60 CARBAMAZEPINE ER 62 BUPROPION HCL SR 60, 62 CARBAMAZEPINE XR 62 BUPROPION SR 62 CARBATROL 62 BUPROPION XL 60 CARBENICILLIN 54 BUSPIRONE HCL 19 CARBIDOPA 17 BUSULFAN 4 CARBIDOPA-LEVODOPA 33 BUTALB-CAFF-ACETAMINOPH-CODEIN 51 CARBIDOPA-LEVODOPA-ENTACAPONE 33 BUTALB/ACETAMINOPHEN/CAFFEINE 6 CARBIDOPA/LEVODOPA 33 BUTALBIT/ACETAMIN/CAFF/CODEINE 51 CARBIDOPA/LEVODOPA/ENTACAPONE 33 BUTALBITAL COMPOUND-CODEINE 51 CARDENE SR 32 BUTALBITAL-ACETAMINOPHEN-CAFFE 6 CARDIZEM CD 25 BUTALBITAL-ASPIRIN-CAFFEINE 49 CARDIZEM LA 25 BUTALBITAL/ACETAMINOPHEN 6 CARDURA XL 5

72 of 94 C (cont.) C (cont.) CARGLUMIC ACID 53 CHLORPROMAZINE HCL 65 CARISOPRODOL 26 CHLORTHALIDONE 64 CARMUSTINE 4 CHLORZOXAZONE 26 CARNITOR 52 CHOLESTYRAMINE 24 CARNITOR SF 52 CHOLESTYRAMINE (WITH SUGAR) 24 CARTIA XT 25 CHOLESTYRAMINE LIGHT 24 CARVEDILOL 23 CHOLESTYRAMINE/ASPARTAME 24 CARVEDILOL PHOSPHATE 23 CHORIONIC GONADOTROPIN 38 CAYSTON 46 CHORIONIC GONADOTROPIN, HUMAN 38 CAZIANT 28 CIALIS 55 CEDAX 27 CICLESONIDE 30, 31 CEENU 4 CICLOPIROX 14 CEFACLOR 26 CICLOPIROX/NAIL LACQ/FT DEOD#4 15 CEFADROXIL 27 CIDOFOVIR 8 CEFADROXIL HYDRATE 27 CILOSTAZOL 56 CEFAZOLIN 27 CILOXAN 12 CEFDINIR 27 CIMETIDINE 40 CEFEPIME 27 CIMZIA 38 CEFIXIME 27 CINACALCET HCL 52 CEFOTAN 27 CIPRO 58 CEFOTAXIME 27 CIPRO HC 11 CEFOTETAN 27 CIPRODEX 11 CEFOXITAN 27 CIPROFLOXACIN HCL 11, 12, 58 CEFPROZIL 27 CIPROFLOXACIN HCL/DEXAMETH 11 CEFRADINE 27 CIPROFLOXACIN/HYDROCORTISONE 11 CEFTIBUTEN 27 CISPLATIN 4 CEFTIBUTEN DIHYDRATE 27 CITALOPRAM HBR 60 CEFTIN 27 CITALOPRAM HYDROBROMIDE 60 CEFUROXIME 27 CITRANATAL 90 DHA 48 CEFUROXIME AXETIL 27 CITRANATAL ASSURE 48 CELEBREX 50 CITRANATAL B-CALM 48 CELECOXIB 50 CITRANATAL DHA 48 CELEXA 60 CITRANATAL HARMONY 48 CELLCEPT 41 CITRIC ACID/SODIUM CITRATE 3, 4 CELONTIN 13 CLAFORAN 27 CENESTIN 36 CLARAVIS 61 CEPHALEXIN 27 CLARIFOAM EF 43 CERDELGA 35 CLARINEX 59 CEREFOLIN NAC 67 CLARINEX-D 12 HOUR 59 CERITINIB 43 CLARINEX-D 24 HOUR 59 CERTOLIZUMAB PEGOL 38 CLARITHROMYCIN 45 CETACAINE 18 CLARITHROMYCIN ER 45 CETRORELIX ACETATE 38 CLEANSING WASH 44 CETROTIDE 38 CLENIA 43 CEVIMELINE HCL 53 CLEOCIN 12 CHANTIX 62 CLEOCIN HCL 13 CHERATUSSIN AC 19 CLEOCIN PALMITATE 13 CHERATUSSIN DAC 19 CLIMARA 36 CHLORAL HYDRATE 19, 20 CLIMARA PRO 36 CHLORAMBUCIL 4 CLINDAGEL 12 CHLORDIAZEPOXIDE HCL 22 CLINDAMYCIN HCL 12, 13 CHLORDIAZEPOXIDE-CLIDINIUM 16 CLINDAMYCIN PALMITATE HCL 13 CHLORDIAZEPOXIDE/CLIDINIUM BR 16 CLINDAMYCIN PHOS-BENZOYL PEROX 12 CHLORHEXIDINE GLUCONATE 34 CLINDAMYCIN PHOS/BENZOYL PEROX 12 CHLOROQUINE 17 CLINDAMYCIN PHOSPHATE 12 CHLOROQUINE PHOSPHATE 16 CLINDAMYCIN-BENZOYL PEROXIDE 12 CHLOROTHIAZIDE 64 CLINDAMYCIN/TRETINOIN 12

73 of 94 C (cont.) C (cont.) CLOBAZAM 22 CORTICOTROPIN 3, 29 CLOBETASOL EMOLLIENT 9 CORTIFOAM 9 CLOBETASOL PROPIONATE 9 CORTISONE ACETATE 2 CLOBETASOL PROPIONATE/EMOLL 9 CORTISPORIN-TC 11 CLOBEX 9 COSOPT 25 CLOCORTOLONE PIVALATE 9 COSOPT PF 25 CLODERM 9 COSTENTYX 42 CLOFAZIMINE 44 COUMADIN 13 CLOMIPHENE CITRATE 35 COVARYX H.S. 55 CLOMIPRAMINE HCL 65 COZAAR 7 CLONAZEPAM 22 CREON 32 CLONIDINE 2, 4 CRESTOR 40 CLONIDINE HCL 5 CRINONE 56 CLOPIDOGREL 56 CRIXIVAN 57 CLOPIDOGREL BISULFATE 24, 56 CRIZOTINIB 17 CLORAZEPATE DIPOTASSIUM 22 CROFELEMER 14 CLOTRIMAZOLE 15, 21 CROMOLYN SODIUM 45 CLOTRIMAZOLE-BETAMETHASONE 3 CROTAMITON 59 CLOTRIMAZOLE/BETAMETHASONE DIP 3 CRYSELLE 29 CLOZAPINE 65 CUTIVATE 9 COAGULATION FACTOR IX 39 CYANOCOBALAMIN (VITAMIN B-12) 67 COAGULATION FACTOR XIII 39 CYANOCOBALAMIN INJECTION 67 COAL TAR 43 CYANOCOBALAMIN/FA/PYRIDOXINE 67 COBICISTAT 8 CYCLAFEM 29 CODEINE/BUTALBITAL/ASA/CAFFEIN 51 CYCLOBENZAPRINE HCL 26 CODEINE/PROMETHAZINE HCL 19 CYCLOGYL 48 COLCHICINE 66 CYCLOPENTOLATE HCL 48 COLCHICINE/PROBENECID 66 CYCLOPHOSPHAMIDE 4 COLCRYS 66 CYCLOSET 33 COLESEVELAM HCL 24 CYCLOSPORINE 34, 41 COLESTIPOL HCL 24 CYCLOSPORINE MODIFIED 41 COLLAGENASE CLOSTRIDIUM 57 CYCLOSPORINE, MODIFIED 41 COLLAGENASE CLOSTRIDIUM HIST. 61 CYMBALTA 60 COLOCORT 9 CYPROHEPTADINE HCL 37 COLY-MYCIN S 11 CYRAMZA 35 COLYTE WITH FLAVOR PACKETS 43 CYSTARAN 31 COMBIGAN 5 CYSTEAMINE 31, 49 COMBIPATCH 36 CYTOMEL 65 COMBIVENT 17 CYTOVENE 41 COMBIVENT RESPIMAT 16 CYTRA-2 4 COMBIVIR 50 CYTRA-K 4 COMETRIQ 17 COMPLERA 18 D COMPRO 16 D-METHORPHAN HB/P-EPD HCL/BPM 19 COMTAN 26 D-METHORPHAN HB/PROMETH HCL 19 CONCERTA 8 DABIGATRAN ETEXILATE MESYLATE 13 CONDYLOX 61 DABRAFENIB 21 CONTRAVE 52 DALFAMPRIDINE 45 COPAXONE 45 DALIRESP 59 COPEGUS 50 DALTEPARIN SODIUM,PORCINE 13 CORDRAN 9 DANAZOL 6 CORDRAN SP 9 DANTROLENE SODIUM 33 COREG 23 DAPAGLIFLOZIN 63 COREG CR 23 DAPSONE 44, 61 CORGARD 23 DARAPRIM 16 CORMAX 9 DARBEPOETIN ALFA 13 CORTEF 3 DARIFENACIN HYDROBROMIDE 38

74 of 94 D (cont.) D (cont.) DARUNAVIR ETHANOLATE 57 DICYCLOMINE HCL 16 DASATINIB 17 DIDANOSINE 18 DASETTA 29 DIFFERIN 61 DAYPRO 50 DIFLUCAN 21 DAYTRANA 8 DIFLUPREDNATE 30 DDAVP 55 DIGOXIN 11 DEFERASIROX 27 DIHYDROERGOTAMINE MESYLATE 4, 5, 35 DELATESTRYL 55 DILANTIN 62 DELAVIRDINE 49 DILAUDID 51 DEMECLOCYCLINE HCL 64 DILT-XR 25 DENAVIR 19 DILTIAZEM 24HR CD 25 DENOSUMAB 47 DILTIAZEM 24HR ER 25 DEPAKOTE 37 DILTIAZEM ER 25 DEPAKOTE ER 37 DILTIAZEM HCL 25 DEPAKOTE SPRINKLE 37 DIMETHYL FUMARATE 45 DEPLIN 67 DIOVAN 7 DEPO-ESTRADIOL 36 DIOVAN HCTZ 7 DEPO-TESTOSTERONE 7 DIPHENHYDRAMINE HCL 36 DERMA-SMOOTHE-FS 9 DIPHENOXYLATE HCL/ATROPINE 14 DERMOTIC 30 DIPHENOXYLATE-ATROPINE 14 DESAMETHASONE INTRAVITREAL 50 DISOPYRAMIDE PHOSPHATE 11 DESIPRAMINE HCL 65 DISULFIRAM 3 DESLORATADINE 59 DIURIL 64 DESLORATADINE/PSEUDOEPHEDRINE 59 DIVALPROEX SODIUM 37 DESMOPRESSIN (NONREFRIGERATED) 55 DIVALPROEX SODIUM ER 37 DESMOPRESSIN ACETATE 55 DIVIGEL 36 DESOG-ET ESTRA/ETHIN ESTRA 28, 29 DOFETILIDE 11 DESOGEN 29 DOLASETRON 2 DESOGESTREL-ETHINYL ESTRADIOL 28, 29 DOLUTEGRAVIR 8 DESONATE 9 DONEPEZIL HCL 27 DESONIDE 9 DONNATAL 18 DESOXIMETASONE 9 DORNASE ALFA 35 DESVENLAFAXINE SUCCINATE 14 DORYX 64 DETROL 38 DORZOLAMIDE HCL 25 DETROL LA 38 DORZOLAMIDE HCL/TIMOLOL MALEAT 25 DEX-TUSS 19 DORZOLAMIDE-TIMOLOL 25 DEXAMETHASONE 3 DORZOLAMIDE/TIMOLOL/PF 25 DEXAMETHASONE INTENSOL 3 DOVONEX 61 DEXEDRINE 2 DOXAZOSIN 21 DEXILANT 58 DOXAZOSIN MESYLATE 5, 21 DEXLANSOPRAZOLE 58 DOXEPIN HCL 14, 18, 65 DEXMETHYLPHENIDATE HCL 8 DOXERCALCIFEROL 67 DEXTROAMPHETAMINE SULFATE 2 DOXYCYCLINE HYCLATE 64 DEXTROAMPHETAMINE-AMPHETAMINE 2 DOXYCYCLINE MONOHYDRATE 64 DEXTROMETHORPHAN HBR/QUINIDINE 26 DOXYLAMINE/PYRIDOXINE 14 DIAMOX SEQUELS 25 DRITHOCREME HP 43 DIAPHRAGMS, ARC-SPRING 29 DRONEDARONE HCL 11 DIASTAT ACUDIAL 22 DROPERIDOL 33 DIAZEPAM 22, 24 DROSPIR/ETH ESTRA/LEVOMEFOL CA 29 DICHLORALPHENAZONE 20 DROSPIRENONE/ESTRADIOL 36 DICLEGIS 14 DROXIDOPA 4 DICLOFENAC EPOLAMINE 50 DRYSOL 20 DICLOFENAC POTASSIUM 50 DUAC 12 DICLOFENAC SODIUM 49, 50, 61 DUAVEE 35 DICLOFENAC SODIUM-MISOPROSTOL 49 DULERA 31 DICLOFENAC SODIUM/MISOPROSTOL 49, 50 DULOXETINE 60 DICLOXACILLIN SODIUM 54 DULOXETINE HCL 60

75 of 94 D (cont.) E (cont.) DUOPA 33 EMSAM 46 DURAGESIC 51 EMTRICITAB/RILPIVIRINE/TENOFOV 18 DUREZOL 30 EMTRICITABINE 18 DUTASTERIDE 2 EMTRICITABINE/TENOFOVIR 50 DUTASTERIDE/TAMSULOSIN HCL 2 EMTRIVA 18 DYAZIDE 56 ENABLEX 38 DYMISTA 10 ENALAPRIL MALEATE 7 DYRENIUM 56 ENALAPRIL-HYDROCHLOROTHIAZIDE 7 ENALAPRIL/HYDROCHLOROTHIAZIDE 7 E ENBREL 33 E-Z SPACER 31 ENDOCET 51 E.E.S. 200 45 ENDODAN 51 E.E.S. 400 45 ENDOMETRIN 56 EASIVENT 31 ENFUVIRTIDE 8 EASY TOUCH 31 ENJUVIA 36 ECONAZOLE NITRATE 15 ENOXAPARIN SODIUM 13 EDARBI 7 ENPRESSE 28 EDARBYCLOR 7 ENTACAPONE 26 EDECRIN 45 ENTECAVIR 50 EDEX 67 ENTOCORT EC 3 EDLUAR 20 ENTYVIO 68 EDOXABAN 24 ENULOSE 6 EDURANT 49 ENZALUTAMIDE 10 EEMT 55 EPICERAM 34 EEMT H.S. 55 EPIDRIN 6 EFAVIRENZ 18, 49 EPIDUO 61 EFAVIRENZ/EMTRICITAB/TENOFOVIR 18 EPIFLUR 26 EFFER-K 58 EPIFOAM 3 EFFEXOR XR 61 EPIKLOR 58 EFFIENT 56 EPINASTINE HCL 10 EFINACONAZOLE 21 EPINEPHRINE 4, 5, 64 EGRIFTA 39 EPIPEN 5 ELESTAT 10 EPIPEN 2-PAK 4 ELESTRIN 36 EPIPEN JR 4 ELETRIPTAN HBR 59 EPIPEN JR 2-PAK 5 ELIDEL 61 EPITOL 13 ELIGLUSTAT 35 EPIVIR HBV 50 ELINEST 29 EPOETIN ALFA 39 ELIQUIS 24 EPOGEN 39 ELLA 29 EPZICOM 50 ELMIRON 52 EQUETRO 13 ELOCON 9 ERGOCALCIFEROL (VITAMIN D2) 67 ELOCTATE 15 ERGOMAR 35 ELOSULFASE ALFA 35 ERGOTAMINE TARTRATE 35 ELTROMBOPAG OLAMINE 39 ERGOTAMINE TARTRATE/CAFFEINE 5, 35 ELVITEGRAVIR 42 ERIVEDGE 17 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR 8 ERLOTINIB HCL 17 EMEND 63 ERRIN 28 EMOLLIENT COMBINATION NO.10 34 ERTACZO 15 EMOLLIENT COMBINATION NO.32 34 ERY 12 EMOLLIENT COMBINATION NO.35 34 ERY-TAB 45 EMOLLIENT COMBINATION NO.43 34 ERYPED 200 45 EMOLLIENT COMBINATION NO.44 35 ERYPED 400 45 EMOLLIENT COMBINATION NO.53 34, 35 ERYTHROCIN STEARATE 45 EMOLLIENT COMBINATION NO.60 35 ERYTHROMYCIN 45 EMOQUETTE 28 ERYTHROMYCIN BASE 12, 45 EMPAGLIFLOZIN 62 ERYTHROMYCIN BASE/ETHANOL 12

76 of 94 E (cont.) E (cont.) ERYTHROMYCIN ETHYLSUCCINATE 45 EYLEA 66 ERYTHROMYCIN STEARATE 45 EZETIMIBE 34 ERYTHROMYCIN-BENZOYL PEROXIDE 12 EZETIMIBE/SIMVASTATIN 27 ERYTHROMYCIN/BENZOYL PEROXIDE 12 EZOGABINE 13 ESBRIET 64 ESCITALOPRAM OXALATE 60 F ESLICARBAZEPINE 62 FABRAZYME 35 ESOMEPRAZOLE MAGNESIUM 57, 58 FAMCICLOVIR 50 ESTAZOLAM 22 FAMOTIDINE 40 ESTRACE 36 FAMVIR 50 ESTRADIOL 35, 36 FANAPT 20 ESTRADIOL ACETATE 36 FARESTON 17 ESTRADIOL CYPIONATE 36 FARXIGA 63 ESTRADIOL MICRONIZED 36 FARYDAK 40 ESTRADIOL VALERATE/DIENOGEST 29 FEBUXOSTAT 68 ESTRADIOL-NORETHINDRONE ACETAT 36 FELBAMATE 13 ESTRADIOL/LEVONORGESTREL 36 FELODIPINE 32 ESTRADIOL/NORETHINDRONE ACET 36 FELODIPINE ER 32 ESTRADIOL/NORGESTIMATE 36 FEMARA 17 ESTRING 36 FEMCON FE 29 ESTROGEL 36 FEMHRT 36 ESTROGEN & METHYLTESTOSTERONE 55 FEMRING 36 ESTROGEN,CON/M-PROGEST ACET 36 FENOFIBRATE 36 ESTROGEN,ESTER/ME-TESTOSTERONE 55 FENOFIBRATE NANOCRYSTALLIZED 36 ESTROGEN/BAZEDOXIFENE 35 FENOFIBRATE,MICRONIZED 36 ESTROGENS, CONJUGATED 36 FENOFIBRIC ACID 36 ESTROGENS,CONJ.,SYNTHETIC A 36 FENOFIBRIC ACID (CHOLINE) 36 ESTROGENS,CONJ.,SYNTHETIC B 36 FENOGLIDE 36 ESTROGENS,ESTERIFIED 36 FENTANYL 51 ESTROPIPATE 36 FENTANYL CITRATE 51 ESTROSTEP FE 29 FENTANYL TRANSDERMAL 51 ESZOPICLONE 19, 20 FENTORA 51 ETANERCEPT 33 FERRIC CITRATE 54 ETHACRYNIC ACID 45 FESOTERODINE FUMARATE 38 ETHAMBUTOL HCL 18, 19 FETZIMA 61 ETHINYL ESTRADIOL/DROSPIRENONE 29 FEXOFENADINE HCL 59 ETHOSUXIMIDE 24 FEXOFENADINE-PSE ER 59 ETHYNODIOL D-ETHINYL ESTRADIOL 28 FEXOFENADINE/PSEUDOEPHEDRINE 59 ETODOLAC 49 FILGRASTIM 39 ETONOGESTREL/ETHINYL ESTRADIOL 29 FINACEA 61 ETRAVIRINE 18, 49 FINASTERIDE 2 EURAX 59 FINGOLIMOD HCL 45 EVAMIST 36 FIORICET 6 EVEROLIMUS 17 FIORINAL 50 EVISTA 35 FIRAZYR 27 EVOXAC 53 FLAGYL 46 EVZIO 52 FLAGYL ER 46 EXALGO 51 FLAREX 30 EXELDERM 15 FLAVOXATE HCL 37 EXELON PATCH 27 FLECAINIDE ACETATE 11 EXEMESTANE 20 FLECTOR 50 EXENATIDE 41 FLO-PRED 3 EXENATIDE MICROSPHERES 41 FLOMAX 5, 21 EXFORGE 25 FLONASE 30 EXFORGE HCT 25 FLOVENT DISKUS 30 EXJADE 27 FLOVENT HFA 30 EYE LUBRICANT COMBINATION NO.1 34 FLUCONAZOLE 21

77 of 94 F (cont.) F (cont.) FLUCYTOSINE 14 FRAGMIN 13 FLUDROCORTISONE ACETATE 3 FRESHKOTE 34 FLUNISOLIDE 30 FROVA 60 FLUOCINOLONE ACETONIDE 9 FROVATRIPTAN SUCCINATE 60 FLUOCINOLONE ACETONIDE OIL 30 FULYZAQ 14 FLUOCINONIDE 9 FUROSEMIDE 45 FLUOCINONIDE EMOLLIENT 9 FUZEON 8 FLUOCINONIDE-E 9 FYCOMPA 2 FLUOCINONIDE/EMOLLIENT 9 FLUOR-A-DAY 26 G FLUORABON 26 GABAPENTIN 36, 37, 38 FLUORIDE 26 GABAPENTIN ENACARBIL 37 FLUORIDE/IRON/VIT A,C&D 47 GABITRIL 13, 37 FLUORIDE/VITAMINS A,C,AND D 47 GALANTAMINE 27 FLUORITAB 26 GANCICLOVIR 8, 41 FLUOROMETHOLONE 30 GANIRELIX ACETATE 38 FLUOROMETHOLONE ACETATE 30 GARDASIL/CERVARIX 19 FLUOROURACIL 61 GATIFLOXACIN 12 FLUOXETINE DR 60 GATTEX 37 FLUOXETINE HCL 60 GAVILYTE 43 FLUPHENAZINE HCL 65 GELNIQUE 38 FLURA-DROPS 26 GEMFIBROZIL 36 FLURANDRENOLIDE 9 GENERESS FE 29 FLURAZEPAM HCL 22 GENERLAC 6 FLUTICASONE FUROATE 30 GENGRAF 41 FLUTICASONE PROPIONATE 9, 30 GENOTROPIN 55 FLUTICASONE/SALMETEROL 30, 64 GENTAK 11 FLUTICASONE/VILANTEROL 30 GENTAMICIN 5 FLUVASTATIN SODIUM 40 GENTAMICIN SULFATE 11 FLUZONE 10 GEODON 21 FML FORTE 30 GILDESS 28 FML S.O.P. 30 GILDESS FE 28 FOCALIN 8 GILENYA 45 FOCALIN XR 8 GILOTRIF 65 FOLCAL DHA 48 GLATIRAMER ACETATE 45 FOLGARD RX 67 GLEEVEC 17 FOLIC ACID 67 GLIMEPIRIDE 63 FOLLISTIM AQ 38 GLIPIZIDE 63 FOLLITROPIN ALFA, RECOMB 38 GLIPIZIDE ER 63 FOLLITROPIN BETA,RECOMB 38 GLIPIZIDE XL 63 FONDAPARINUX SODIUM 13, 24 GLIPIZIDE-METFORMIN 63 FORADIL 64 GLIPIZIDE/METFORMIN HCL 63 FORFIVO XL 60 GLUCAGEN 38 FORMALDEHYDE 61 GLUCAGON EMERGENCY KIT 38 FORMOTEROL FUMARATE 64 GLUCAGON,HUMAN RECOMBINANT 38 FORTAMET 23 GLUCOPHAGE 23 FORTEO 53 GLUCOPHAGE XR 23 FORTESTA 55 GLUCOTROL XL 63 FORTICAL 53 GLUCOVANCE 63 FOSAMAX 24 GLUMETZA 23 FOSAMAX PLUS D 24 GLY/CARB HOMOPOLY A/POT HYDROX 31 FOSAMPRENAVIR CALCIUM 57 GLYBURIDE 63 FOSFOMYCIN TROMETHAMINE 66 GLYBURIDE-METFORMIN HCL 63 FOSINOPRIL SODIUM 7 GLYBURIDE/METFORMIN HCL 63 FOSINOPRIL-HYDROCHLOROTHIAZIDE 7 GLYCEROL PHENYLBUTYRATE 49 FOSINOPRIL/HYDROCHLOROTHIAZIDE 7 GLYCOPYRROLATE 16 FOSRENOL 54 GLYSET 5

78 of 94 G (cont.) H (cont.) GOLIMUMAB 33 HUMULIN N 42 GOLYTELY 43 HUMULIN R 42 GONAL-F 38 HYDRALAZINE HCL 32 GONAL-F RFF 38 HYDROCHLOROTHIAZIDE 64 GRALISE 37 HYDROCODONE BIT-IBUPROFEN 51 GRANISETRON 2 HYDROCODONE BIT/ACETAMINOPHEN 51 GRANISETRON HCL 2 HYDROCODONE BIT/HOMATROP ME-BR 19 GRANIX 39 HYDROCODONE BITARTRATE 51 GRASS POLLEN 4 HYDROCODONE-ACETAMINOPHEN 51 GRASTEK 4 HYDROCODONE-CHLORPHENIRAMINE 19 GRIFULVIN V 14 HYDROCODONE-HOMATROPINE MBR 19 GRIS-PEG 14 HYDROCODONE-IBUPROFEN 51 GRISEOFULVIN 14 HYDROCODONE/CHLORPHEN POLIS 19 GRISEOFULVIN ULTRAMICROSIZE 14 HYDROCODONE/IBUPROFEN 51 GRISEOFULVIN,MICROSIZE 14 HYDROCORTISONE 3, 9 GUAIFENESIN AC 19 HYDROCORTISONE AC/LIDOCAINE 44 GUAIFENESIN DAC 19 HYDROCORTISONE ACETATE 9 GUAIFENESIN-CODEINE 19 HYDROCORTISONE BUTYRATE 3 GUAIFENESIN/CODEINE PHOSPHATE 19 HYDROCORTISONE BUTYRATE/EMOLL 3 GUANFACINE HCL 2, 26 HYDROCORTISONE VALERATE 3 HYDROCORTISONE-ACETIC ACID 46 H HYDROCORTISONE-IODOQUINOL 44 H.P. ACTHAR 3 HYDROCORTISONE-PRAMOXINE 9 HALCINONIDE 9 HYDROCORTISONE/IODOQUINOL 44 HALFLYTELY-BISACODYL 43 HYDROCORTISONE/PRAMOXINE 3, 9 HALOBETASOL PROPIONATE 9 HYDROCORTISONE/PRAMOXINE/ALOE 3 HALOG 9 HYDROMET 19 HALOPERIDOL 65 HYDROMORPHONE ER 51 HALOPERIDOL LACTATE 65 HYDROMORPHONE HCL 51 HARVONI 15 HYDROXYCHLOROQUINE SULFATE 16 HCG ALPHA,RECOMBINANT 38 HYDROXYPROGESTERONE CAPROATE 56 HEATHER 28 HYDROXYPROPYL CELLULOSE 34 HECTOROL 67 HYDROXYUREA 17 HELIDAC 13 HYDROXYZINE HCL 20 HEMANGEOL 23 HYDROXYZINE PAMOATE 20 HEMENATAL OB 48 HYLATOPIC 35 HEMENATAL OB + DHA 48 HYLATOPIC PLUS 35 HEMRIL 9 HYOMAX-FT 18 HEPARIN 24 HYOMAX-SL 18 HEPSERA 50 HYOMAX-SR 18 HERCEPTIN 39 HYOSCYAMINE SULFATE 18 HETLIOZ 46 HYPER-SAL 58 HEXACHLOROPHENE 44 HYPERCARE 20 HIZENTRA 61 HYSINGLA ER 51 HOMATROPAIRE 48 HOMATROPINE HBR 48 I HORIZANT 37 IBANDRONATE SODIUM 24 HPR PLUS 34 IBRANCE 66 HUM INSULIN NPH/REG INSULIN HM 42 IBUDONE 51 HUMALOG 42 IBUPROFEN 49 HUMALOG MIX 50-50 42 ICATIBANT ACETATE 27 HUMALOG MIX 75-25 42 ICLUSIG 17 HUMAN PAPILLOMAVIRUS 19 IDELALISIB 43 HUMAPEN LUXURA HD 31 ILARIS 47 HUMATROPE 55 ILOPERIDONE 20 HUMIRA 33 ILOPROST 57 HUMULIN 70-30 42 IMATINIB MESYLATE 17

79 of 94 I (cont.) I (cont.) IMBRUVICA 66 ISOMETHEPT-DICHLORALP-ACETAMIN 6 IMDUR 49 ISOMETHEPT/ACETAMINOP/DICHLPHN 6 IMIPENEM 23 ISONIAZID 19 IMIPENEM/CILASTATIN 23 ISOPTO HOMATROPINE 48 IMIPENEM/CILASTATN 23 ISOPTO HYOSCINE 48 IMIPRAMINE HCL 65 ISOSORBIDE DINITRATE 49 IMIQUIMOD 61 ISOSORBIDE MONONITRATE 49 IMITREX 60 ISOSORBIDE MONONITRATE ER 49 IMMUNE GLOBULIN,GAMMA(IGG) 61 ISOTRETINOIN 61 INAPSINE 33 ISTALOL 23 INCIVEK 15 ITRACONAZOLE 21 INDACATEROL MALEATE 22 IVERMECTIN 8, 59 INDAPAMIDE 64 INDERAL LA 23 J INDINAVIR 57 JAKAFI 43 INDOCIN 50 JALYN 2 INDOMETHACIN 49, 50 JANUMET 32 INFERGEN 41 JANUMET XR 32 INFLUENZA VACCINE 10 JANUVIA 32 INGENOL MEBUTATE 61 JARDIANCE 62 INHALER, ASSIST DEVICES 31, 32 JENTADUETO 32 INHALER,ASSIST DEVICE,ACCESORY 31 JETREA 43 INNOPRAN XL 23 JEVANTIQUE 36 INSULIN ADMIN. SUPPLIES 31 JINTELI 36 INSULIN ASPART 42 JOLESSA 28 INSULIN DETEMIR 42 JOLIVETTE 28 INSULIN GLARGINE,HUM.REC.ANLOG 42 JUBLIA 21 INSULIN GLULISINE 42 JUNEL 28 INSULIN INHALED 42 JUNEL FE 28 INSULIN LISPRO 42 JUXTAPID 27 INSULIN NPL/INSULIN LISPRO 42 INSULIN REGULAR, HUMAN 42 K INSULIN SYRINGE 31 K-PHOS ORIGINAL 2 INSULN ASP PRT/INSULIN ASPART 42 K-TAB 58 INTELENCE 18, 49 KADCYLA 39 INTERFERON ALFA-2B,RECOMB. 42 KADIAN 51 INTERFERON ALFACON 1 41 KALETRA 57 INTERFERON BETA-1A 45 KALEXATE 56 INTERFERON BETA-1A/ALBUMIN 45 KANAMYCIN 5 INTERFERON BETA-1B 45 KAPVAY 2, 5 INTERMEZZO 20 KARIVA 28 INTRON A 42 KEFLEX 27 INTROVALE 28 KELNOR 1-35 28 INTUNIV 2 KENALOG 9 INVEGA 21 KEPPRA 25 INVEGA SUSTENNA 21 KEPPRA XR 25 INVIRASE 57 KERALYT 43 INVOKANA 63 KERYDIN 41 IOPHEN-C NR 19 KETOCONAZOLE 15, 21 IPRATROPIUM BROMIDE 16 KETODAN 15 IPRATROPIUM-ALBUTEROL 16 KETOPROFEN 49 IPRATROPIUM/ALBUTEROL SULFATE 16, 17 KETOROLAC TROMETHAMINE 34, 49, 50 IRBESARTAN 7 KETOROLAC TROMETHAMINE/PF 34 IRBESARTAN-HYDROCHLOROTHIAZIDE 7 KEYTRUDA 47 IRBESARTAN/HYDROCHLOROTHIAZIDE 7 KINERET 33 IRBRUTINIB 66 KIONEX 56 ISENTRESS 8 KLONOPIN 22

80 of 94 K (cont.) L (cont.) KLOR-CON 58 LEVEMIR 42 KLOR-CON-EF 58 LEVEMIR FLEXPEN 42 KOMBIGLYZE XR 32 LEVETIRACETAM 13, 25 KRISTALOSE 6 LEVITRA 55 KUVAN 52 LEVOBUNOLOL HCL 23 KYNAMRO 27 LEVOCARNITINE 52 LEVOCARNITINE (WITH SUGAR) 52 L LEVOCETIRIZINE DIHYDROCHLORIDE 59 L-NORGEST-ETH ESTR/ETHIN ESTRA 28, 29 LEVOFLOXACIN 11, 58 LABETALOL HCL 23 LEVOMEFOLATE CALCIUM 67 LAC-HYDRIN 22 LEVOMILNACIPRAN 61 LACOSAMIDE 13 LEVONORG-ETH ESTRAD ETH ESTRAD 28 LACRISERT 34 LEVONORGESTREL 28 LACT CMB2/S.THERMOPHL/BIF CMB1 14 LEVONORGESTREL-ETH ESTRADIOL 28, 29 LACTULOSE 6 LEVORA-28 28 LAMICTAL 25 LEVOTHROID 65 LAMICTAL (GREEN) 25 LEVOTHYROXINE SODIUM 64, 65 LAMICTAL (ORANGE) 25 LEVOXYL 64 LAMICTAL ODT 25 LEXAPRO 60 LAMICTAL ODT (ORANGE) 25 LEXIVA 57 LAMICTAL XR 25 LIALDA 9 LAMISIL 4 LIDOCAINE 44 LAMIVUDINE 18, 50 LIDOCAINE HCL 44 LAMIVUDINE-ZIDOVUDINE 18 LIDOCAINE HCL VISCOUS 44 LAMIVUDINE/ZIDOVUDINE 18, 50 LIDOCAINE-HYDROCORTISONE 44 LAMOTRIGINE 24, 25, 47 LIDOCAINE-PRILOCAINE 44 LAMPRENE 44 LIDOCAINE/PRILOCAINE 44 LANOXIN 11 LIDODERM 44 LANSOPRAZOLE 57, 58 LIMBREL250 52 LANSOPRAZOLE/AMOXICILN/CLARITH 58 LINACLOTIDE 38 LANTHANUM CARBONATE 54 LINAGLIPTIN 32 LANTUS 42 LINAGLIPTIN/METFORMIN HCL 32 LANTUS SOLOSTAR 42 LINEZOLID 13 LAPATINIB DITOSYLATE 17 LINZESS 38 LASIX 45 LIOTHYRONINE SODIUM 65 LASTACAFT 10 LIPASE/PROTEASE/AMYLASE 32 LATANOPROST 57 LIPITOR 40 LATUDA 20, 24 LIPOFEN 36 LAVOCLEN-4 43 LIRAGLUTIDE 41 LAZERFORMALYDE 61 LISDEXAMFETAMINE DIMESYLATE 6 LEDIPASVIR/SOFOSBUVIR 15 LISINOPRIL 7 LEENA 28 LISINOPRIL-HYDROCHLOROTHIAZIDE 7 LEFLUNOMIDE 33 LISINOPRIL/HYDROCHLOROTHIAZIDE 7 LENALIDOMIDE 41 LITHIUM 47 LENVATINIB 43 LITHIUM CARBONATE 47 LENVIMA 43 LITHIUM CITRATE 47 LESCOL 40 LITHOBID 47 LESCOL XL 40 LIVALO 40 LESSINA 28 LO LOESTRIN FE 29 LETAIRIS 67 LO-OVRAL-28 29 LETROZOLE 17, 20 LOCOID 3 LEUCOVORIN CALCIUM 14 LOCOID LIPOCREAM 3 LEUPROLIDE ACETATE 17 LODOSYN 17 LEVALBUTEROL 22 LODOXAMIDE TROMETHAMINE 10 LEVALBUTEROL HCL 22, 64 LOESTRIN 29 LEVALBUTEROL TARTRATE 22 LOESTRIN 24 FE 29 LEVAQUIN 58 LOESTRIN FE 29

81 of 94 L (cont.) M (cont.) LOHIST-DM 19 MEDROL 3 LOMITAPIDE 27 MEDROXYPROGESTERONE ACETATE 56 LOMOTIL 14 MEFLOQUINE HCL 16 LOMUSTINE 4 MEFOXIN 27 LOPERAMIDE 14 MEGACE ES 17 LOPERAMIDE HCL 14 MEGESTROL ACETATE 17 LOPINAVIR/RITONAVIR 57 MEKINIST 43 LORAZEPAM 22 MELOXICAM 49, 50 LORAZEPAM INTENSOL 22 MELPHALAN 4 LORCASERIN 2 MEMANTINE HCL 49 LORTAB 51 MENEST 36 LOSARTAN POTASSIUM 7 MENINGOCOCCAL GR B VACCINE 66 LOSARTAN-HYDROCHLOROTHIAZIDE 7 MENOPUR 38 LOSARTAN/HYDROCHLOROTHIAZIDE 7 MENOSTAR 36 LOTEMAX 30 MENOTROPINS 38 LOTEPREDNOL ETABONATE 30 MEPERIDINE HCL 51 LOTREL 32 MEPHYTON 27 LOTRONEX 46 MERCAPTOPURINE 16 LOVASTATIN 40 MEROPENEM 23 LOVAZA 34 MESALAMINE 6, 9 LOVENOX 13 MESALAMINE W/CLEANSING WIPES 6 LOW-OGESTREL 29 MESTINON 53 LOXAPINE 65 METADATE CD 8 LUBIPROSTONE 43 METADATE ER 8 LUDENT FLUORIDE 26 METANX 67 LULICONAZOLE 21 METAXALONE 26 LUMIGAN 57 METFORMIN HCL 23 LUNESTA 20 METFORMIN HCL ER 23 LUPRON DEPOT 17 METFORMIN HYDROCHLORIDE 23 LURASIDONE HCL 20, 24 METHADONE HCL 51 LUTERA 28 METHAMPHETAMINE HCL 2 LUXIQ 3 METHAZOLAMIDE 25 LUZU 21 METHERGINE 53 LYBREL 29 METHIMAZOLE 18 LYNPARZA 59 METHITEST 55 LYRICA 37 METHOCARBAMOL 26 LYSTEDA 40 METHOTREXATE 16, 37 METHOTREXATE SODIUM 16 M METHOXSALEN, RAPID 55 MACITENTAN 35 METHSUXIMIDE 13 MACROBID 66 METHYL-B12/L-MEFOLATE/B6 PHOS 67 MACRODANTIN 66 METHYLDOPA 26 MAKENA 56 METHYLERGONOVINE MALEATE 53 MALARONE 16 METHYLIN 8 MAPROTILINE HCL 40 METHYLIN ER 8 MARAVIROC 18 METHYLNALTREXONE 37 MATZIM LA 25 METHYLPHENIDATE 8 MAXAIR AUTOHALER 64 METHYLPHENIDATE ER 8 MAXALT 60 METHYLPHENIDATE HCL 8, 34 MAXALT MLT 60 METHYLPHENIDATE HCL CD 34 MAXIDEX 3 METHYLPHENIDATE SR 8 MAXIPIME 27 METHYLPREDNISOLONE 3 MAXITROL 12 METHYLTESTOSTERONE 55 MAXZIDE-25 MG 56 METOCLOPRAMIDE HCL 56 MEBENDAZOLE 8 METOLAZONE 64 MECHLORETHAMINE 4 METOPROLOL SUCCINATE 23 MECLIZINE HCL 15, 16 METOPROLOL TARTRATE 23

82 of 94 M (cont.) M (cont.) METOPROLOL-HYDROCHLOROTHIAZIDE 23 MULTI-VITAMIN W-FLUORIDE-IRON 47 METOPROLOL/HYDROCHLOROTHIAZIDE 23 MULTI-VITAMIN WITH FLUORIDE 47 METOZOLV ODT 56 MULTIVITAMINS WITH FLUORIDE 47 METRELEPTN 41 MULTIVITS WITH IRON & FLUORIDE 47 METROGEL 12 MUPIROCIN 12 METROGEL-VAGINAL 12 MUPIROCIN CALCIUM 12 METROLOTION 12 MUSE 67 METRONIDAZOLE 12, 18, 46 MVC-FLUORIDE 48 MEXILETINE HCL 11 MYALEPT 41 MICARDIS 7 MYAMBUTOL 19 MICARDIS HCT 7 MYCOBUTIN 19 MICONAZOLE NITRATE/ZINC OX/PET 15 MYCOPHENOLATE MOFETIL 41 MICROCHAMBER 31 MYCOPHENOLATE SODIUM 41 MICROGESTIN 28 MYFORTIC 41 MICROGESTIN FE 28 MYORISAN 61 MICRONOR 29 MYRBETRIQ 38 MIDODRINE HCL 63 MYTUSSIN DAC 19 MIGERGOT 5 MYZILRA 28 MIGLITOL 5 MIGLUSTAT 42 N MIGRANAL 5 NABUMETONE 49 MILLIPRED 3 NADOLOL 23 MILNACIPRAN HCL 37 NAFCIL 54 MIMVEY 36 NAFCILLIN 54 MIMYX 34 NAFTIFINE HCL 15 MINIPRESS 5 NAFTIN 15 MINOCIN 64 NALOXEGOL 52 MINOCYCLINE HCL 64 NALOXONE 51, 52 MINOCYCLINE HCL MICROSPHERES 11 NALOXONE/BUPROPION 52 MINOXIDIL 33 NALTREXONE HCL 3, 52 MIPOMERSEN 27 NAMENDA 49 MIRABEGRON 38 NAPHAZOLINE HCL 67 MIRAPEX 33 NAPHOS M-B M-H/NA PHOS,DI-BA 43 MIRAPEX ER 33 NAPRELAN 50 MIRCETTE 29 NAPROXEN 49 MIRTAZAPINE 13, 14, 40 NAPROXEN SODIUM 50 MISOPROSTOL 57 NARATRIPTAN HCL 59, 60 MOBIC 50 NASACORT AQ 30 MODAFINIL 8 NASCOBAL 67 MOMETASONE FUROATE 9, 30 NASONEX 30 MOMETASONE/FORMOTEROL 31 NATACYN 14 MONODOX 64 NATAMYCIN 14 MONOJECT INSULIN SYRINGE 31 NATAZIA 29 MONONESSA 29 NATEGLINIDE 45, 46 MONTELUKAST SODIUM 44 NATROBA 59 MONUROL 66 NATURE-THROID 65 MORPHINE SULFATE 51 NAVELBINE 17 MORPHINE SULFATE ER 51 NEBIVOLOL HCL 23 MOVANTIK 52 NECON 29 MOVIPREP 44 NEDOCROMIL SODIUM 45 MOXEZA 12 NEEDLE 32 MOXIFLOXACIN HCL 12, 58 NEEDLES 32 MOZOBIL 39 NEEDLES, DISPOSABLE 32 MS CONTIN 51 NEEDLES, INSULIN DISPOSABLE 31 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 66 NEEVO DHA 48 MUGARD 31 NEFAZODONE HCL 13 MULTAQ 11 NEO-POLYCIN 11

83 of 94 N (cont.) N (cont.) NEO-POLYCIN HC 11 NITROFURANTOIN MONOHYD/M-CRYST 66 NEO/POLYMYX B SULF/DEXAMETH 11, 12 NITROGLYCERIN 49, 62, 67 NEOMY SULF/BACITRA/POLYMYXIN B 11 NITROGLYCERIN PATCH 67 NEOMY SULF/BACITRAC ZN/POLY/HC 11 NITROLINGUAL 67 NEOMY SULF/COLIST SUL/HC/THONZ 11 NITROMIST 49 NEOMY SULF/POLYMYXIN B SULFATE 12 NITROSTAT 49 NEOMYCIN SULFATE 5 NIZATIDINE 40 NEOMYCIN-BACITRACIN-POLY-HC 11 NIZORAL 15 NEOMYCIN-BACITRACIN-POLYMYXIN 11 NORA-BE 28 NEOMYCIN-POLYMYXIN-DEXAMETH 11 NORCO 51 NEOMYCIN-POLYMYXIN-GRAMICIDIN 11 NORDETTE-28 29 NEOMYCIN-POLYMYXIN-HC 11 NORDITROPIN FLEXPRO 55 NEOMYCIN-POLYMYXIN-HYDROCORT 11 NORDITROPIN NORDIFLEX 55 NEOMYCIN/POLYMYXIN B SULF/HC 11 NORELGESTROMIN/ETH ESTRADIOL 28 NEOMYCIN/POLYMYXN B/GRAMICIDIN 11 NORELGESTROMIN/ETHIN.ESTRADIOL 28, 29 NEORAL 41 NORETH A-ET ESTRA/FE FUMARATE 28, 29 NEOSPORIN G.U. IRRIGANT 12 NORETH-ETHINYL ESTRADIOL/IRON 28, 29 NEOSTIGMINE 53 NORETHIND AC/ETHINYL ESTRADIOL 36 NEPAFENAC 34 NORETHINDRONE 28, 29 NEPHRO-VITE RX 67 NORETHINDRONE A-E ESTRADIOL 28, 29 NESINA 32 NORETHINDRONE ACETATE 56 NETILMICIN 6 NORETHINDRONE-ETHINYL ESTRAD 28, 29 NETROMYCIN 6 NORFLOXACIN 58 NETUPITANT/PALONOSETRON 2 NORFLURANE/HFC 245FA 18 NEULASTA 39 NORGESTIMATE-ETHINYL ESTRADIOL 29 NEUMEGA 42 NORGESTREL-ETHINY ESTRA 29 NEUPOGEN 39 NORGESTREL-ETHINYL ESTRADIOL 29 NEUPRO 33 NORITATE 12 NEURONTIN 38 NOROXIN 58 NEVANAC 34 NORPACE CR 11 NEVIRAPINE 18, 49 NORTHERA 4 NEXA PLUS 48 NORTREL 29 NEXA SELECT 48 NORTRIPTYLINE HCL 65 NEXAVAR 10 NORVASC 32 NEXICLON XR 5 NORVIR 8, 57 NEXIUM 58 NOVACORT 3 NEXT CHOICE 28 NOVAREL 38 NIACIN 34 NOVOLIN 70-30 42 NIACIN/LOVASTATIN 34 NOVOLIN N 42 NIACIN/SIMVASTATIN 34 NOVOLIN R 42 NIACOR 34 NOVOLOG 42 NIASPAN 34 NOVOLOG FLEXPEN 42 NICARDIPINE HCL 32 NOVOLOG MIX 70-30 42 NIFEDIAC CC 32 NOVOLOG MIX 70-30 FLEXPEN 42 NIFEDICAL XL 32 NOVOTWIST 31 NIFEDIPINE 32 NOXAFIL 21 NIFEDIPINE ER 32 NPH, HUMAN INSULIN ISOPHANE 42 NILOTINIB 66 NPLATE 39 NINTEDANIB 66 NUCYNTA 51 NISOLDIPINE 32 NUCYNTA ER 51 NITAZOXANIDE 18, 53 NUEDEXTA 26 NITISINONE 40 NULOJIX 64 NITRO-BID 49 NUTROPIN AQ 55 NITRO-DUR 49 NUTROPIN AQ NUSPIN 55 NITROFURANTOIN 66 NUVARING 29 NITROFURANTOIN MACROCRYSTAL 66 NUVIGIL 8 NITROFURANTOIN MONO-MACRO 66 NYAMYC 15

84 of 94 N (cont.) O (cont.) NYSTATIN 14, 15 ORTHO ALL-FLEX 29 NYSTATIN-TRIAMCINOLONE 15 ORTHO EVRA 29 NYSTATIN/TRIAMCIN 15 ORTHO TRI-CYCLEN 29 NYSTOP 15 ORTHO TRI-CYCLEN LO 29 ORTHO-CEPT 29 O ORTHO-CYCLEN 29 OCRIPLASMIN 43 ORTHO-NOVUM 29 OCTREOTIDE ACETATE 46, 52 OSCIMIN 18 OFEV 66 OSCIMIN SL 18 OFLOXACIN 11, 58 OSCIMIN SR 18 OGESTREL 29 OSELTAMIVIR PHOSPHATE 10 OLANZAPINE 20, 21, 24 OSMOPREP 43 OLANZAPINE ODT 20 OSPEMIFENE 35 OLANZAPINE-FLUOXETINE HCL 14 OSPHENA 35 OLANZAPINE/FLUOXETINE HCL 14 OTEZLA 41 OLAPARIB 59 OTIC CARE 44 OLEPTRO ER 61 OTREXUP 37 OLMESARTAN MED/AMLODIPINE/HCTZ 7 OVCON-35 29 OLMESARTAN MEDOXOMIL 7 OVIDREL 38 OLMESARTAN/HYDROCHLOROTHIAZIDE 7 OXACILLIN 54 OLOPATADINE HCL 10 OXAPROZIN 50 OLOPATADINE NASAL 10 OXAZEPAM 22 OLUX 9 OXCARBAZEPINE 62 OLUX-E 9 OXICONAZOLE NITRATE 15 OLYSIO 15 OXISTAT 15 OMACETAXINE 41 OXSORALEN-ULTRA 55 OMALIZUMAB 47 OXYBUTYNIN 38 OMECLAMOX-PAK 58 OXYBUTYNIN CHLORIDE 38 OMEGA-3 ACID ETHYL ESTERS 34 OXYBUTYNIN CHLORIDE ER 38 OMEPRAZOLE 57, 58 OXYCODONE CONCENTRATE 51 OMEPRAZOLE-SODIUM BICARBONATE 58 OXYCODONE HCL 51 OMEPRAZOLE/CLARITH/AMOXICILLIN 58 OXYCODONE HCL/ACETAMINOPHEN 51 OMEPRAZOLE/SODIUM BICARBONATE 58 OXYCODONE HCL/ASPIRIN 51 OMNARIS 30 OXYCODONE HCL/OXYCODON TER/ASA 51 OMNITROPE 55 OXYCODONE-ACETAMINOPHEN 51 ONABOTULINUMTOXINA 49 OXYCODONE-ASPIRIN 51 ONCOVIN 17 OXYCONTIN 51 ONDANSETRON 2 OXYMORPHONE HCL 51 ONDANSETRON ODT 2 OZURDEX 50 ONFI 22 ONGLYZA 32 P OPANA ER 51 P-EPHED HCL/CODEINE/GUAIFEN 19 OPIUM 14 PACERONE 11 OPIUM TINCTURE 14 PAIN EASE 18 OPRELVEKIN 42 PALBOCICLIB 66 OPSUMIT 35 PALIPERIDONE 21 OPTICHAMBER 31 PALIPERIDONE PALMITATE 21 OPTICHAMBER DIAMOND 31 PALIVIZUMAB 47 OPTIHALER 31 PANCREAZE 32 OPTIVAR 10 PANCRELIPASE 5,000 32 ORACEA 64 PANOBINOSTAT 40 ORALAIR 4 PANRETIN 59 ORAPRED ODT 3 PANTOPRAZOLE SODIUM 58 ORENCIA 33 PARICALCITOL 67 ORENITRAM 56 PARITAPREVIR;/RITON/OMBITAS/DASA 15 ORFADIN 40 PAROMOMYCIN SULFATE 5 ORSYTHIA 28 PAROXETINE HCL 60

85 of 94 P (cont.) P (cont.) PASIREOTIDE 63 PILOCARPINE HCL 46 PATADAY 10 PIMECROLIMUS 61 PATANASE 10 PINDOLOL 23 PATANOL 10 PIOGLITAZONE HCL 64 PAXIL 60 PIOGLITAZONE HCL/METFORMIN HCL 64 PAXIL CR 60 PIOGLITAZONE-METFORMIN 64 PAZOPANIB 10 PIPERACILLIN 54 PCCA T3 SODIUM DILUTION 65 PIPRACIL 54 PED MV A,C,D3 #21 W-FLUORIDE 47, 48 PIRBUTEROL ACETATE 64 PED MV A,C,D3 #38 W-FLUORIDE 48 PIRFENIDONE 64 PEDI MULTIVIT #37 W-FLUORIDE 48 PIROXICAM 50 PEDI MVI NO.12/SODIUM FLUORIDE 48 PITAVASTATIN CALCIUM 40 PEDIPIROX-4 15 PLAQUENIL 16 PEG 3350-ELECTROLYTE 43 PLAVIX 24, 56 PEG 3350/NA SULF,BICARB,CL/KCL 43 PLEGRIDY 47 PEG-3350 AND ELECTROLYTES 43 PLERIXAFOR 39 PEG-INTRON 42 PN W-CA64/IRON CB&GL/FA/DSS/DH 48 PEG3350/SOD SUL/NACL/ASB/C/KCL 44 PNV #38/IRON FUM/FOLATE/DHA 48 PEGASYS 15 PNV 18/FE,CARB/FA/DSS/UBI/DHA 48 PEGASYS PROCLICK 15 PNV COMBO #19/IRON/FOL AC/DHA 48 PEGFILGRASTIM 39 PNV COMBO #22/IRON/FA/OM3/DHA 48 PEGINTERFERON ALFA-1A 47 PNV NO.22/IRON CBN&GLUC/FA/DSS 48 PEGINTERFERON ALFA-2A 15 PNV W-O CA NO5/FE FUMARATE/FA 48 PEGINTERFERON ALFA-2B 15 PNV WITH CA,NO.71/IRON/FA 48 PEGINTRON REDIPEN 15 PNV WITH CA,NO.72/IRON,CARB/FA 48 PEMBROLIZUMAB 47 PNV WITH CA,NO63/IRON/FA/B6 48 PEMIROLAST POTASSIUM 10 PNV#79/IRON/FA/LMFOLATE CA/DHA 48 PEN NEEDLE 31 PNV-DHA + DOCUSATE 48 PENCICLOVIR 19 PNV/FA/B6/CALCIUM PHOS/GINGER 48 PENICILLIN G 54 PNV22/IRON CBN&GLUC/FA/DSS/DHA 48 PENICILLIN V POTASSIUM 54 PNV38/IRON CBN&GLUC/FA/DSS/DHA 48 PENNSAID 50 PNV53/IRON FUM/FA/DOCUSATE/DHA 48 PENTASA 6 PNV66/IRON FUMARATE/FA/DSS/DHA 48 PENTOSAN POLYSULFATE SODIUM 52 PNV69/IRON,CARBONYL/FA/DSS/DHA 48 PENTOXIFYLLINE 39 PNV77/SOD IRON EDTA& PS/FA/OM3 48 PEPCID 40 PNV80/IRON FUMARATE/FA/DSS/DHA 48 PERAMPANEL 2 PODOCON-25 61 PERCOCET 51 PODOFILOX 61 PERINDOPRIL ERBUMINE 7 PODOPHYLLUM RESIN 61 PERMETHRIN 59 POLY-VI-FLOR 48 PERPHENAZINE 65 POLYETHYLENE GLYCOL 3350 43 PHENADOZ 54 POLYMYXIN B SUL-TRIMETHOPRIM 11 PHENAZOPYRIDINE HCL 18 POLYMYXIN B SULF/TRIMETHOPRIM 11, 12 PHENELZINE SULFATE 45 POLYTRIM 12 PHENOBARB/HYOSCY/ATROPINE/SCOP 18 POMALIDOMIDE 41 PHENOBARBITAL 21 POMALYST 41 PHENYLEPHRINE HCL 67 PONATINIB 17 PHENYLEPHRINE HCL/COD/PROMETH 19 PORTIA 28 PHENYLEPHRINE HCL/PROMETH HCL 54 POSACONAZOLE 21 PHENYTEK 62 POTASSIUM BICARBONATE 58 PHENYTOIN 62 POTASSIUM BICARBONATE/CIT AC 58 PHENYTOIN SODIUM EXTENDED 62 POTASSIUM CHLORIDE 58 PHISOHEX 44 POTASSIUM CITRATE 4 PHLUORIVIT 47 POTASSIUM CITRATE-CITRIC ACID 4 PHRENILIN FORTE 6 POTASSIUM CITRATE/CITRIC ACID 4 PHYTONADIONE 27 POTASSIUM IODIDE 18 PICATO 61 POTASSIUM PHOSPHATE,MONOBASIC 2

86 of 94 P (cont.) P (cont.) POTIGA 13 PRENEXA 48 PRADAXA 13 PREPOPIK 44 PRAMIPEXOLE DI-HCL 33 PREQUE 10 48 PRAMIPEXOLE DIHYDROCHLORIDE 33 PREVACID 58 PRAMLINTIDE ACETATE 6 PREVALITE 24 PRAMOSONE 3 PREVIFEM 29 PRANDIN 46 PREVPAC 58 PRASCION 43 PREZISTA 57 PRASCION FC 43 PRIFTIN 19 PRASCION RA 44 PRILOSEC 58 PRASUGREL HCL 56 PRIMAQUINE 16 PRAVACHOL 40 PRIMAQUINE PHOSPHATE 16 PRAVASTATIN SODIUM 40 PRIMAXIN 23 PRAZIQUANTEL 8 PRIMIDONE 21 PRAZOSIN HCL 5 PRISTIQ ER 14 PRECISION 31 PROAIR HFA 22 PRED FORTE 30 PROBENECID 66 PRED MILD 30 PROBENECID-COLCHICINE 66 PREDNICARBATE 9 PROCARBAZINE 4 PREDNISOLONE 3 PROCHAMBER 31 PREDNISOLONE ACETATE 3, 30 PROCHLORPERAZINE MALEATE 16 PREDNISOLONE SOD PHOSPHATE 3, 30 PROCLORPERAZINE 33 PREDNISOLONE SODIUM PHOSPHATE 30 PROCRIT 39 PREDNISONE 3 PROCTOCORT 9 PREFERA OB 48 PROCTOFOAM-HC 9 PREFERA-OB ONE 48 PROCTOSOL-HC 9 PREFERA-OB PLUS DHA 48 PROCTOZONE-HC 9 PREFEST 36 PROCYSBI 31, 49 PREGABALIN 37 PROGESTERONE 56 PREGNENOLONE 54 PROGESTERONE IN OIL 56 PREGNENOLONE MICRONIZED 54 PROGESTERONE,MICRONIZED 56 PREGNENOLONE, MICRONIZED 54 PROGRAF 41 PREGNYL 38 PROLIA 47 PREMARIN 36 PROLIXIN 65 PREMPHASE 36 PROMACTA 39 PREMPRO 36 PROMETHAZINE HCL 33, 54 PRENA1 48 PROMETHAZINE VC 54 PRENATABS FA 48 PROMETHAZINE VC-CODEINE 19 PRENATAL 19 48 PROMETHAZINE-CODEINE 19 PRENATAL AD 48 PROMETHAZINE-DM 19 PRENATAL NO.25/IRON/FA #6/DHA 48 PROMETHEGAN 33 PRENATAL NO.39/IRON/FA #6/DHA 48 PROMETRIUM 56 PRENATAL PLUS 48 PROMISEB 34 PRENATAL VIT #76/IRON,CARB/FA 48 PROPAFENONE HCL 11 PRENATAL VIT 15/IRON CB/FA/DSS 48 PROPANTHELINE BROMIDE 16 PRENATAL VIT 16/IRON CB/FA/DSS 48 PROPRANOLOL HCL 22, 23 PRENATAL VIT 18/IRON CB/FA/DSS 48 PROPYLTHIOURACIL 18 PRENATAL VIT NO.44/IRON/FA/DHA 48 PROSCAR 2 PRENATAL VIT NO.78/IRON/FA 48 PROTONIX 58 PRENATAL VIT#36/IRON/FA CMB#6 48 PROTOPIC 61 PRENATAL VIT#42/FA CMB#6 48 PROVENTIL HFA 22 PRENATAL VIT/IRON FUMARATE/FA 48 PROVERA 56 PRENATAL VITAMINS#21, IRON, FA 48 PROVIGIL 8 PRENATAL-U 48 PROZAC 60 PRENATE DHA 48 PULMICORT 30 PRENATE ELITE 48 PULMICORT FLEXHALER 30 PRENATE MINI 48 PULMOZYME 35

87 of 94 P (cont.) R (cont.) PYLERA 13 RESCRIPTOR 49 PYRAZINAMIDE 19 RESCULA 57 PYRIDOSTIGMINE 53 RESTASIS 34 PYRIDOSTIGMINE BROMIDE 53 RETAPAMULIN 12 PYRIMETHAMINE 16 RETIN-A MICRO 26 PYRITHIONE ZINC 54 RETIN-A MICRO PUMP 26 RETROVIR 50 Q REVATIO 55 QNASL 30 REVLIMID 41 QUADRAPAX 18 REYATAZ 57 QUASENSE 28 RHINOCORT AQUA 30 QUETIAPINE FUMARATE 20, 21 RIBAPAK 15 QUINAPRIL HCL 7 RIBASPHERE 15 QUINAPRIL/HYDROCHLOROTHIAZIDE 7 RIBAVIRIN 15, 50 QUINIDINE GLUCONATE 11 RIFABUTIN 19 QUINIDINE SULFATE 11 RIFAMPIN 19 QUININE SULFATE 16 RIFAPENTINE 19 QUTENZA 65 RIFAXIMIN 13 QVAR 30 RILPIVIRINE 49 RILUTEK 26 R RILUZOLE 26 RABEPRAZOLE 58 RIMEXOLONE 30 RABEPRAZOLE SODIUM 58 RIOCIGUAT 63 RADIUM RA 223 17 RIOMET 23 RAGWEEK POLLEN 4 RISEDRONATE 24 RAGWITEK 4 RISEDRONATE SODIUM 24 RALOXIFENE 35 RISPERIDONE 20 RALTEGRAVIR POTASSIUM 8 RISPERIDONE M-TAB 20 RAMELTEON 20 RISPERIDONE ODT 20 RAMIPRIL 7, 8 RITALIN 8 RAMUCIRUMAB 35 RITALIN LA 8 RANEXA 25 RITONAVIR 8, 57 RANITIDINE HCL 40 RITUXAN 47 RANOLAZINE 25 RITUXIMAB 47 RAPAFLO 5, 21 RIVAROXABAN 24 RAPAMUNE 41 RIVASTIGMINE 27 RASAGILINE MESYLATE 46 RIXUBIS 39 RAVICTI 49 RIZATRIPTAN 59 REBETOL 15 RIZATRIPTAN BENZOATE 59, 60 REBIF 45 RIZATRIPTAN MLT 59 RECLIPSEN 28 ROFLUMILAST 59 RECTIV 62 ROMIPLOSTIM 39 REGORAFENIB 17 ROPINIROLE HCL 33 REGRANEX 61 ROSUVASTATIN CALCIUM 40 REGULAR BEVEL NEEDLES 32 ROTIGOTINE 33 RELENZA 10 ROWASA 6 RELISTOR 37 ROXICET 51 RELPAX 59 ROZEREM 20 REMERON 14 RUCONEST 24 REMODULIN 67 RUFINAMIDE 62 RENAF 26 RUXOLITINIB 43 RENAGEL 54 RYBIX ODT 51 RENVELA 54 RYTARY 33 REPAGLINIDE 46 RYTHMOL SR 11 REPREXAIN 51 REQUIP 33 S REQUIP XL 33 SABRIL 37

88 of 94 S (cont.) S (cont.) SAFYRAL 29 SIRTURO 19 SALEX 43 SITAGLIPTIN PHOS/METFORMIN HCL 32 SALICYLIC ACID 43 SITAGLIPTIN PHOSPHATE 32 SALICYLIC ACID/CERAMIDE CMB #1 43 SITAVIG 15 SALIVA SUBSTITUTION COMBO NO.2 31 SIVEXTRO 52 SALMETEROL XINAFOATE 64 SKELAXIN 26 SALSALATE 50 SOD PICOSULF/MAG OX/CITRIC AC 44 SAMSCA 67 SODIUM CHLORIDE 58 SANCTURA XR 38 SODIUM CHLORIDE FOR INHALATION 58 SANCUSO 2 SODIUM CITRATE & CITRIC ACID 3 SANDIMMUNE 41 SODIUM FLUORIDE 26 SANDOSTATIN 46 SODIUM POLYSTYRENE SULFONATE 56 SANTYL 61 SODIUM SULFACETAMIDE 44 SAPHRIS 20 SODIUM SULFACETAMIDE-SULFUR 43, 44 SAPROPTERIN DIHYDROCHLORIDE 52 SODIUM,POTASSIUM,&MAG SULFATES 44 SAQUINAVIR 57 SOFOSBUVIR 15 SARAFEM 60 SOLARAZE 61 SAVAYSA 24 SOLIFENACIN SUCCINATE 38 SAVELAMER 54 SOLODYN 64 SAVELLA 37 SOLVALDI 15 SAXAGLIPTIN HCL 32 SOMA 26 SAXAGLIPTIN HCL/METFORMIN HCL 32 SOMATROPIN 55 SCOPACE 14 SOMNOTE 20 SCOPOLAMINE 14 SONATA 20 SCOPOLAMINE HYDROBROMIDE 14, 48 SOOLANTRA 59 SE 10-5 SS 43 SORAFENIB 10 SE-DONNA PB HYOS 18 SORIATANE 61 SEASONALE 29 SORILUX 61 SEASONIQUE 29 SOTALOL 23 SEB-PREV 44 SOTALOL AF 23 SECUKINUMAB 42 SOTALOL HCL 23 SELEGILINE 46 SPECIALTY USE NEEDLES 32 SELEGILINE HCL 46 SPINOSAD 59 SELENIUM SULFIDE 44 SPIRIVA 16 SELZENTRY 18 SPIRONOLACT/HYDROCHLOROTHIAZID 56 SENSIPAR 52 SPIRONOLACTONE 56 SEREVENT DISKUS 64 SPIRONOLACTONE-HCTZ 56 SEROQUEL 21 SPRINTEC 29 SEROQUEL XR 21 SPRIX 50 SERTACONAZOLE NITRATE 15 SPRYCEL 17 SERTRALINE HCL 60 SRONYX 28 SEVELAMER CARBONATE 54 SSD 44 SEVELAMER HCL 54 SSKI 18 SIGNIFOR 63 STALEVO 33 SILDENAFIL 55 STARLIX 46 SILDENAFIL CITRATE 55 STAXYN 55 SILENOR 14 STELARA 66 SILODOSIN 5, 21 STELAZINE 65 SILTUXIMAB 42 STENDRA 54 SILVADENE 44 STIMATE 55 SILVER SULFADIAZINE 44 STIVARGA 17 SIMCOR 34 STRATTERA 2 SIMEPREVIR 15 STRIBILD 8 SIMPONI 33 STROMECTOL 8 SIMVASTATIN 40 SUBOXONE SL TABS 52 SINGULAIR 44 SUCRALFATE 57 SIROLIMUS 41 SUCROFERRIC OXYHYDROXIDE 54

89 of 94 S (cont.) T (cont.) SULAR 32 TAPENTADOL HCL 51 SULCONAZOLE NITRATE 15 TARCEVA 17 SULFACET SOD/SULFUR/WITCH HAZ 43 TARKA 8 SULFACETAMIDE SOD/SULFUR/UREA 44 TASIGNA 66 SULFACETAMIDE SODIUM 11, 44 TASIMELTEON 46 SULFACETAMIDE SODIUM-SULFUR 43 TAVABOROLE 41 SULFACETAMIDE SODIUM/SULFUR 43 TAZAROTENE 61 SULFACETAMIDE-PREDNISOLONE 11 TAZORAC 61 SULFACETAMIDE/PREDNISOLONE SP 11 TAZTIA XT 25 SULFACETM NA/AVOBENZONE/SULFUR 44 TBO-FILGRASTIM 39 SULFACETM NA/PREDNISOL AC 12 TECFIDERA 45 SULFAMETHOXAZOLE-TRIMETHOPRIM 46 TEDIZOLID 52 SULFAMETHOXAZOLE/TRIMETHOPRIM 46 TEDUGLUTIDE 37 SULFAMIDE 11 TEGRETOL 62 SULFASALAZINE 63 TEGRETOL XR 62 SULFASALAZINE DR 63 TEKTURNA 58 SULFAZINE 63 TEKTURNA HCT 58 SULFAZINE EC 63 TELAPREVIR 15 SULINDAC 50 TELBIVUDINE 50 SUMATRIPTAN 59 TELMISARTAN 7 SUMATRIPTAN SUCC/NAPROXEN SOD 60 TELMISARTAN/AMLODIPINE 7 SUMATRIPTAN SUCCINATE 60 TELMISARTAN/HYDROCHLOROTHIAZID 7 SUMAVEL DOSEPRO 60 TEMAZEPAM 22 SUNITINIB MALATE 10 TEMODAR 17 SUPRAX 27 TEMOZOLOMIDE 17, 41 SUPREP 44 TENOFOVIR DISOPROXIL FUMARATE 18 SURE COMFORT 31 TENORMIN 23 SURMONTIL 65 TERAZOSIN 21 SUSTIVA 18, 49 TERAZOSIN HCL 5, 21 SUTENT 10 TERBINAFINE HCL 4 SYLATRON 42 TERBUTALINE SULFATE 64 SYLVANT 42 TERCONAZOLE 15 SYMBICORT 30 TERIFLUNOMIDE 45 SYMBYAX 14 TERIPARATIDE 53 SYMLINPEN 120 6 TERSI FOAM 44 SYMLINPEN 60 6 TESAMORELIN 39 SYMMETREL 33 TESTIM 55 SYNAGIS 47 TESTOSTERONE 7, 55 SYNRIBO 41 TESTOSTERONE CYPIONATE 7, 55 SYNTHROID 65 TESTOSTERONE ENANTHATE 55 SYR W-NDL,INS 0.3 ML HALF MARK 31 TETRABENAZINE 47 SYRING W-NDL,DISP,INSUL,0.3ML 31 TETRACAINE/BENZOCAINE/BUTAMBEN 18 SYRING W-NDL,DISP,INSUL,0.5ML 31 TETRACYCLINE HCL 64 SYRINGE & NEEDLE,INSULIN,1 ML 31 THALIDOMIDE 41 THALOMID 41 T THEO-24 59 TABLOID 17 THEOPHYLLINE ANHYDROUS 58, 59 TACLONEX 3 THERMAZENE 44 TACROLIMUS 41, 61 THIOGUANINE 16, 17 TADALAFIL 55 THIORIDAZINE HCL 65 TAFINLAR 21 THIOTEPA 4 TAFLUPROST/PF 57 THIOTHIXENE 65 TAMIFLU 10 THYROID 65 TAMOXIFEN CITRATE 14 THYROID,PORK 65 TAMSULOSIN 21 TIAGABINE 37 TAMSULOSIN HCL 5 TIAGABINE HCL 13 TANZEUM 37 TIAZAC 25

90 of 94 T (cont.) T (cont.) TICAGRELOR 56 TRETTEN 39 TICLOPIDINE HCL 56 TREXALL 16 TIKOSYN 11 TREXIMET 60 TILIA FE 28 TRI-LEGEST FE 28 TIMOLOL 23 TRI-PREVIFEM 29 TIMOLOL MALEATE 23 TRI-SPRINTEC 29 TIMOLOL MALEATE/PF 23 TRI-VI-FLOR 48 TIMOPTIC 23 TRI-VIT WITH FLUORIDE-IRON 47 TIMOPTIC OCUDOSE 23 TRI-VITAMIN WITH FLUORIDE 47 TINDAMAX 18 TRIADVANCE 48 TINIDAZOLE 5, 18 TRIAMCINOLONE ACETONIDE 9, 30 TIOTROPIUM BROMIDE 16 TRIAMTERENE 56 TIPRANAVIR 57 TRIAMTERENE-HCTZ 56 TIROSINT 65 TRIAMTERENE-HYDROCHLOROTHIAZID 56 TIVICAY 8 TRIAMTERENE/HYDROCHLOROTHIAZID 56 TIZANIDINE HCL 26 TRIAZOLAM 22 TOBI 5 TRIBENZOR 7 TOBRADEX 12 TRICOR 36 TOBRADEX ST 11 TRIFLURIDINE 19 TOBRAMYCIN 6, 11 TRIGLIDE 36 TOBRAMYCIN IN 0.225% NACL 5 TRIHEXYPHENIDYL HCL 13 TOBRAMYCIN-DEXAMETHASONE 11 TRILEPTAL 62 TOBRAMYCIN/DEXAMETHASONE 11, 12 TRILIPIX 36 TOBRAMYCIN/LOTEPRED ETAB 12 TRIMETHOBENZAMIDE HCL 16 TOBREX 11 TRIMETHOPRIM 66 TOCILIZUMAB 41 TRIMIPRAMINE MALEATE 65 TOFACITINIB 41 TRINESSA 29 TOLAZAMIDE 63 TRIPHLUORIVIT 47 TOLBUTAMIDE 63 TRIPLE-VITAMIN W-FLUORIDE 48 TOLTERODINE TARTRATE 38 TRIVORA-28 28 TOLVAPTAN 67 TRIZIVIR 50 TOPAMAX 62 TROSPIUM CHLORIDE 38 TOPICORT 9 TRUVADA 50 TOPIRAMATE 62 TRYPSIN/BALSAM PERU/CASTOR OIL 61 TOPROL XL 23 TUDORZA PRESSAIR 16 TOREMIFENE CITRATE 17 TUSSICAPS 19 TORSEMIDE 45 TWINJECT 4 TOUJEO 42 TWYNSTA 7 TOVIAZ 38 TYBOST 8 TRACLEER 67 TYKERB 17 TRADJENTA 32 TYLENOL-CODEINE NO.3 51 TRAMADOL HCL 51 TYPHOID VACC,LIVE,ATTENUATED 66 TRAMADOL HCL-ACETAMINOPHEN 51 TYVASO 67 TRAMADOL HCL/ACETAMINOPHEN 51 TYZEKA 50 TRAMETINIB 43 TRANDOLAPRIL/VERAPAMIL HCL 8 U TRANEXAMIC ACID 39, 40 UCERIS 30 TRANSDERM-SCOP 14 ULESFIA 59 TRANYLCYPROMINE SULFATE 45 ULIPRISTAL ACETATE 29 TRASTUZUMAB 39 ULORIC 68 TRAVATAN Z 57 ULTICARE 31 TRAVOPROST 57 ULTRA COMFORT 31 TRAZODONE HCL 61 ULTRAM 51 TREANDA 4 ULTRAM ER 51 TREPROSTINIL 56, 67 ULTRAVATE 9 TRETINOIN 26, 59 UMECLIDINIUM/VILANTEROL 16 TRETINOIN MICROSPHERES 26 UNOPROSTONE 57

91 of 94 U (cont.) V (cont.) UREA 43 VIBRAMYCIN 64 URIBEL 66 VICODIN 51 UROCIT-K 4 VICODIN HP 51 UROFOLLITROPIN 38 VICOPROFEN 51 UROXATRAL 5 VICTOZA 2-PAK 41 URSODIOL 27 VICTOZA 3-PAK 41 USTEKINUMAB 66 VICTRELIS 15 VIEKIRA PAK 15 V VIGABATRIN 37 VAGIFEM 36 VIGAMOX 12 VALACYCLOVIR 15 VIIBRYD 14 VALACYCLOVIR HCL 15 VILAZODONE HYDROCHLORIDE 14 VALCHLOR 4 VIMIZIM 35 VALCYTE 8, 50 VIMPAT 13 VALGANCICLOVIR 8 VINACAL 48 VALGANCICLOVIR HCL 50 VINATE GT 48 VALIUM 22 VINATE ULTRA 48 VALPROATE SODIUM 37, 47 VINBLASTINE 17 VALPROIC ACID 37, 47 VINCRISTINE 17 VALSARTAN 7 VINORELBINE 17 VALSARTAN-HYDROCHLOROTHIAZIDE 7 VIORELE 28 VALSARTAN/HYDROCHLOROTHIAZIDE 7 VIRAMUNE 18, 49 VALTREX 15 VIRAMUNE XR 18 VALTURNA 58 VIREAD 18 VANCOCIN HCL 13 VISMODEGIB 17 VANCOMYCIN HCL 13 VIT B CMPLX 3/FA/VIT C/BIOTIN 67 VANDAZOLE 12 VITAMEDMD ONE RX 48 VANOS 9 VITAMEDMD PLUS RX 48 VANOXIDE-HC 3 VITAMEDMD REDICHEW RX 48 VARDENAFIL HCL 55 VITAMIN D2 67 VARENICLINE TARTRATE 62 VITAMINS A,C,D & FLUORIDE 47 VASOTEC 7 VITE AC/GRAPE/HYALURONIC ACID 35 VECTICAL 61 VITEKTA 42 VEDOLIZUMAB 68 VIVELLE-DOT 36 VELBAN 17 VIVITROL 3 VELCADE 57 VIVOTIF BERNA 66 VELIVET 28 VOL-PLUS 48 VELOSEF 27 VOL-TAB RX 48 VELPHORO 54 VOLTAREN 50 VELTIN 12 VORAPAXAR 57 VEMAVITE-PRX 2 48 VORICONAZOLE 21 VEMURAFENIB 21 VORINOSTAT 40 VENATAL COMPLETE DHA 48 VORTEX 31 VENATAL-FA 48 VORTIOXETINE 60 VENLAFAXINE HCL 60, 61 VOTRIENT 10 VENLAFAXINE HCL ER 60 VSL#3 DS 14 VENTAVIS 57 VUSION 15 VENTOLIN HFA 22 VYTORIN 27 VERAMYST 30 VYVANSE 6 VERAPAMIL ER 25 VERAPAMIL ER PM 25 W VERAPAMIL HCL 25 WARFARIN SODIUM 13 VERDESO 9 WELCHOL 24 VESANOID 59 WELLBUTRIN 60 VESICARE 38 WELLBUTRIN SR 60 VEXOL 30 WELLBUTRIN XL 60 VIAGRA 55 WESTHROID 65

92 of 94 W (cont.) Z (cont.) WYMZYA FE 28 ZIPRASIDONE HCL 20, 21 ZIPSOR 50 X ZIRGAN 8 XALATAN 57 ZITHROMAX 45 XALKORI 17 ZMAX 45 XANAX 22 ZOCOR 40 XARELTO 24 ZOFRAN ODT 2 XARTEMIS XR 51 ZOHYDRO 51 XELJANZ 41 ZOLINZA 40 XELODA 17 ZOLMITRIPTAN 59, 60 XENADERM 61 ZOLOFT 60 XENAZINE 47 ZOLPIDEM TARTRATE 20 XERAC AC 20 ZOLPIDEM TARTRATE ER 20 XERESE 19 ZOMIG 60 XEROFORM PETROLATUM DRESSING 31 ZOMIG ZMT 60 XGEVA 47 ZONALON 18 XIAFLEX 57 ZONISAMIDE 62 XIBROM 34 ZONTIVITY 57 XIFAXAN 13 ZOVIA 1-35E 28 XOFIGO 17 ZOVIA 1-50E 28 XOLAIR 47 ZOVIRAX 15 XOLEGEL 15 ZYBAN 62 XOPENEX 64 ZYCLARA 61 XOPENEX HFA 22 ZYDELIG 43 XTANDI 10 ZYFLO CR 44 XYZAL 59 ZYKADIA 43 ZYLET 12 Y ZYMAR 12 YASMIN 28 29 ZYMAXID 12 YAZ 29 ZYPREXA 20 ZYPREXA ZYDIS 21 Z ZYTIGA 17 ZAFIRLUKAST 44 ZYVOX 13 ZALEPLON 20 ZANAMIVIR 10 ZANTAC 25 40 ZAVESCA 42 ZEBUTAL 6 ZEGERID 58 ZELBORAF 21 ZEMPLAR 67 ZENCHENT 29 ZENCHENT FE 28 ZENCIA 43 ZENPEP 32 ZEOSA 28 ZESTRIL 7 ZETIA 34 ZETONNA 30 ZIAGEN 50 ZIANA 12 ZIDOVUDINE 50 ZIDOVUDINE/LAMIVUDINE 50 ZILEUTON 44 ZINC PYRITHIONE 54 ZINC SULFATE 58 ZIOPTAN 57

93 of 94 Notes

1 - Home Health 2 - Infertility 3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit 7 - Step Therapy

94 of 94 2349 Gateway Oaks Drive, Suite 100 Sacramento, California 95833 916.563.2250 888.563.2250 toll-free 888.877.5378 tty 916.563.3182 fax

Published 04.15