2019 Generic Centric Formulary

Effective January 1, 2019

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

Call the member phone number on your ID card.

Visit your plan’s member website listed on your ID card to: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

Generic Centric Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and are this formulary and your benefit placed into cost levels known as tiers. It includes both brand plan documents, the benefit plan and generic prescription medications approved by the documents rule. This may not be U.S. Food and Drug Administration (FDA). a complete list of medications, and not all medications listed A group of doctors, nurses and pharmacists meet regularly may be covered by your plan. to assess the formulary. They review which medications will Please look at the benefit plan be covered, how well the drugs work and overall value. They documents provided by your also make sure there are safe, covered options available. employer or plan sponsor for full details.

How do I use my formulary? You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the member phone number on your ID card. Some medications on your formulary have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST) and quantity limits (QL). We use programs like these to help make sure the medication you take is safe and effective. Check your plan documents for more information. Some Affordable Care Act (ACA) preventive medication may have coverage restrictions. If you want to learn more about these programs or to see if you take a medication in one of these programs, please visit your plan’s member website or call the member phone number on the back of your ID card.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

2 Understanding your formulary

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equivalent becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the member phone number on your ID card.

3 Medication tips

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

What if I am taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx® specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered right to your home or doctor’s office.

Non-preferred brand medications are excluded from coverage, but most specialty medications are covered. You can visit your plan’s member website, or call the member phone number on the back of your ID card for more information about your benefit plan.

4 Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips Tier LC $ Lower Cost Use Tier LC drugs for lowest out-of-pocket costs. Generic Tier GD $ Generic Use Tier GD generic drugs, instead of brand-name drugs, to help reduce your out-of-pocket costs. Tier BD $$ Brand Use Tier BD where generic options are limited.

Tier GS $$$  Generic Specialty Tier GS is generally higher in co-payment and cost. These drugs are sometimes used to treat complex and chronic conditions and may require special monitoring or handling. Tier PS $$$$  Preferred Specialty Tier PS is generally second highest in co-payment and cost. These drugs are sometimes used to treat complex and chronic conditions and may require special monitoring or handling. Tier NS $$$$$ Non-Preferred Tier NS is generally highest in co-payment and cost. These Specialty drugs are sometimes used to treat complex and chronic conditions and may require special monitoring or handling.

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

M Authorized generic or co-branded product PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity. SP Specialty Medication – Medication is designated as specialty. ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

5 Table of Contents

Analgesics - Drugs for Pain...... 7 Genitourinary Agents - Drugs for Bladder, Analgesics - Drugs for Pain and Inflammation. 9 Genital and Kidney Conditions...... 47 Anesthetics...... 10 Genitourinary Agents - Drugs for Prostate Anti-Addiction / Substance Abuse Treatment Conditions...... 48 Agents...... 11 Hormonal Agents - Adrenal...... 48 Antibacterials...... 12 Hormonal Agents - Men's Health...... 50 Anticoagulants...... 16 Hormonal Agents - Osteoporosis...... 50 Anticonvulsants - Drugs for Seizures...... 16 Hormonal Agents - Parathyroid...... 50 Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Pituitary...... 50 Disease and Dementia...... 18 Hormonal Agents - Prostaglandins...... 52 Antidepressants...... 18 Hormonal Agents - Sex Hormones and Birth Antiemetics - Drugs for Nausea and Vomiting19 Control...... 52 Antifungals...... 19 Hormonal Agents - Thyroid...... 55 Antigout Agents...... 20 Immunological Agents - Drugs for Immune Anti-inflammatory Agents...... 20 System Stimulation or Suppression...... 56 Antimigraine Agents...... 20 Immunological Agents - Drugs for Antimyasthenic Agents...... 20 Vaccination...... 58 Antimycobacterials...... 20 Inflammatory Bowel Disease Agents...... 58 Antineoplastics - Drugs for Cancer...... 21 Metabolic Bone Disease Agents - Drugs for Antiparasitics...... 25 Osteoporosis...... 59 Antiparkinson Agents...... 26 Miscellaneous Therapeutic Agents...... 59 Antiplatelets...... 26 Ophthalmic Agents - Drugs for Eye Allergy, Antipsychotics - Drugs for Mood Disorders.... 26 Infection and Inflammation...... 61 Antivirals...... 27 Ophthalmic Agents - Drugs for Glaucoma...... 62 Anxiolytics - Drugs for Anxiety...... 28 Ophthalmic Agents - Drugs for Miscellaneous Bipolar Agents - Drugs for Mood Disorders....29 Eye Conditions...... 62 Blood Products / Modifiers / Volume Otic Agents - Drugs for Ear Conditions...... 63 Expanders - Drugs for Bleeding Disorders...29 Respiratory Tract / Pulmonary Agents - Cardiovascular Agents - Drugs for Heart and Drugs for Allergies, Cough, Cold...... 63 Circulation Conditions...... 31 Respiratory Tract / Pulmonary Agents - Central Nervous System Agents - Drugs for Drugs for Asthma and Other Lung Attention Deficit Disorder...... 36 Conditions 64 Central Nervous System Agents - Drugs for Respiratory Tract / Pulmonary Agents - Multiple Sclerosis...... 36 Drugs for Cystic Fibrosis...... 65 Central Nervous System Agents - Respiratory Tract / Pulmonary Agents - Miscellaneous...... 37 Drugs for Pulmonary Hypertension...... 66 Dental and Oral Agents - Drugs for Mouth Skeletal Muscle Relaxants - Drugs for and Throat Conditions...... 37 Muscle Pain and Spasm...... 66 Dermatological Agents - Drugs for Skin Sleep Disorder Agents...... 66 Conditions...... 37 Index of Drugs...... 68 Diabetes - Antidiabetic Agents...... 40 Diabetes - Glucose Monitoring...... 40 Diabetes - Glycemic Agents...... 41 Diabetes - Insulins...... 41 Electrolytes / Minerals / Metals / Vitamins...... 41 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...... 45 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...... 46 Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment...... 47 6 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for Pain endocet oral tablet 10- acetaminophen-codeine GD 325 mg, 2.5-325 mg, 5- GD 325 mg, 7.5-325 mg acetaminophen-codeine GD #2 esgic oral capsule GD fentanyl GD acetaminophen-codeine GD #3 fentanyl citrate buccal GD acetaminophen-codeine GD fentanyl citrate-nacl #4 intravenous solution 1- 0.9 mg/100ml-%, 1.25- alfentanil hcl intravenous GD GD 0.9 mg/250ml-%, 250-0.9 apap-caff-dihydrocodeine GD mcg/50ml-%, 5-0.9 oral capsule mg/250ml-% apap-caff-dihydrocodeine GD fentanyl citrate-nacl oral tablet 325-30-16 mg intravenous solution ascomp-codeine GD prefilled syringe 15-0.9 GD buprenorphine hcl mcg/3ml-%, 50-0.9 injection solution 0.3 GD mcg/5ml-%, 500-0.9 mg/ml mcg/50ml-% hydrocodone- butalbital-acetaminophen GD oral tablet acetaminophen oral solution 2.5-108 mg/5ml, GD GD butalbital-apap 5-217 mg/10ml, 7.5-325 butalbital-apap-caff-cod GD mg/15ml butalbital-apap-caffeine GD hydrocodone- oral capsule acetaminophen oral tablet 10-300 mg, 10-325 butalbital-apap-caffeine GD GD oral tablet 50-325-40 mg mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 butalbital-asa-caff- GD mg, 7.5-325 mg codeine hydrocodone-ibuprofen GD butalbital-aspirin-caffeine oral tablet 10-200 mg, 5- GD butorphanol tartrate GD 200 mg, 7.5-200 mg injection hydromorphone hcl er GD butorphanol tartrate GD hydromorphone hcl nasal injection solution 1 GD carisoprodol-aspirin- GD mg/ml, 2 mg/ml, 4 mg/ml codeine hydromorphone hcl oral GD codeine sulfate oral GD hydromorphone hcl pf GD tablet hydromorphone hcl rectal GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

7 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydromorphone hcl-nacl methadone hcl oral GD intravenous solution 10- methadose oral GD 0.9 mg/100ml-%, 10-0.9 concentrate 10 mg/ml mg/50ml-%, 18-0.9 methadose oral tablet mg/30ml-%, 2-0.9 GD GD mg/50ml-%, 25-0.9 soluble mg/50ml-%, 40-0.9 methadose sugar-free GD mg/100ml-%, 5-0.9 mitigo GD mg/50ml-%, 6-0.9 mg/30ml-% morphine sulfate (concentrate) oral GD hydromorphone hcl-nacl solution 100 mg/5ml, 20 intravenous solution mg/ml prefilled syringe 1-0.9 morphine sulfate (pf) mg/5ml-%, 10-0.9 GD mg/25ml-%, 10-0.9 injection mg/50ml-%, 12-0.9 GD morphine sulfate (pf) mg/60ml-%, 15-0.9 intravenous solution 10 GD mg/30ml-%, 15-0.9 mg/ml, 2 mg/ml, 4 mg/ml, mg/50ml-%, 3-0.9 8 mg/ml mg/30ml-%, 5-0.9 morphine sulfate er GD mg/25ml-% beads ibudone oral tablet 5-200 GD morphine sulfate er oral mg capsule extended GD levorphanol tartrate oral GD release 24 hour lorcet GD morphine sulfate er oral GD lorcet hd GD tablet extended release lorcet plus oral tablet 7.5- morphine sulfate injection GD 325 mg solution 10 mg/ml, 2 GD mg/ml, 4 mg/ml, 5 mg/ml, meperidine hcl injection 8 mg/ml solution 10 mg/ml, 100 GD mg/ml, 25 mg/ml, 50 morphine sulfate GD mg/ml intramuscular meperidine hcl oral GD morphine sulfate intravenous solution 1 GD meperidine hcl-sodium mg/ml, 150 mg/30ml, 25 chloride intravenous mg/ml, 50 mg/ml solution 1000-0.9 GD mg/100ml-%, 500-0.9 morphine sulfate oral GD mg/50ml-% morphine sulfate rectal GD methadone hcl injection GD methadone hcl intensol GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

8 Drug Drug Drug Name Notes Drug Name Notes Tier Tier morphine sulfate-nacl tencon oral tablet 50-325 GD intravenous solution 50- GD mg 0.9 mg/50ml-% tramadol hcl er (biphasic) morphine sulfate-nacl oral tablet extended GD intravenous solution release 24 hour 100 mg, prefilled syringe 0.5-0.9 GD 200 mg, 300 mg mg/ml-%, 50-0.9 tramadol hcl er oral mg/50ml-% capsule extended GD nalbuphine hcl injection GD release 24 hour 150 mg OXYCODONE HCL ER tramadol hcl er oral tablet GD ORAL TABLET ER 12 extended release 24 hour BD HOUR ABUSE- tramadol hcl ir GD DETERRENT tramadol-acetaminophen GD oxycodone hcl oral GD capsule vanatol lq GD vanatol s GD oxycodone hcl oral GD concentrate 100 mg/5ml verdrocet GD oxycodone hcl oral GD vicodin es oral tablet 7.5- GD solution 300 mg oxycodone hcl oral tablet GD vicodin hp oral tablet 10- GD oxycodone- 300 mg acetaminophen oral vicodin oral tablet 5-300 GD tablet 10-325 mg, 2.5- GD mg 325 mg, 5-325 mg, 7.5- zebutal oral capsule 50- GD 325 mg 325-40 mg oxycodone-aspirin oral GD Analgesics - Drugs for Pain and tablet 4.8355-325 mg Inflammation oxycodone-ibuprofen GD celecoxib oral GD OXYCONTIN ORAL choline-mag trisalicylate GD TABLET ER 12 HOUR BD GD ABUSE-DETERRENT diclofenac potassium GD oxymorphone hcl GD diclofenac sodium er GD oxymorphone hcl er GD diclofenac sodium oral pentazocine-naloxone hcl GD diclofenac sodium GD transdermal gel 1 % phrenilin forte oral GD capsule 50-300-40 mg diclofenac sodium GD transdermal solution remifentanil hcl GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

9 Drug Drug Drug Name Notes Drug Name Notes Tier Tier diclofenac-misoprostol meclofenamate sodium GD oral tablet delayed GD oral release mefenamic acid oral GD diclofex dc GD meloxicam oral tablet LC diflunisal oral GD nabumetone oral GD etodolac er GD naproxen oral GD etodolac oral GD suspension GD fenoprofen calcium oral naproxen oral tablet 250 GD mg fenortho oral capsule 200 GD mg naproxen oral tablet 375 LC flurbiprofen oral GD mg, 500 mg ibuprofen lysine GD naproxen sodium er GD ibuprofen oral naproxen sodium oral GD GD suspension tablet 275 mg, 550 mg ibuprofen oral tablet 400 nudiclo solupak GD LC mg, 600 mg, 800 mg nudiclo tabpak GD indomethacin er GD oxaprozin GD indomethacin oral piroxicam oral GD LC capsule 25 mg profeno GD indomethacin oral GD salsalate oral GD capsule 50 mg sulindac oral GD indomethacin sodium GD tolmetin sodium GD inflammacin GD xelitral GD ketoprofen er GD xenaflamm GD ketoprofen oral capsule GD Anesthetics 25 mg GD ketorolac tromethamine 7t lido GD injection solution 15 bd pudendal/local GD mg/ml, 30 mg/ml tray/1% lido ketorolac tromethamine bupivacaine hcl (pf) GD intramuscular solution 60 GD bupivacaine hcl injection GD mg/2ml solution 0.25 %, 0.5 % ketorolac tromethamine GD bupivacaine-epinephrine oral (pf) injection solution GD klofensaid ii GD 0.25% -1:200000, 0.5% - 1:200000

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier bupivacaine-epinephrine lido-prilo caine pack GD injection solution 0.25% - GD liprozonepak GD 1:200000, 0.5% - 1:200000 livixil pak GD chloroprocaine hcl (pf) GD medolor pak GD polocaine GD cocaine hcl external GD solution 4 % polocaine-mpf GD dermacinrx empricaine GD port-prep GD dermacinrx prizopak GD prikaan GD ethyl chloride GD prikaan lite GD glydo GD priloxx lp GD lido bdk GD relador pak external kit GD lidocaine external GD GD relador pak plus ointment ropivacaine hcl injection GD lidocaine external patch 5 GD solution % sensorcaine GD GD lidocaine hcl (cardiac) sensorcaine/epinephrine GD lidocaine hcl (pf) injection GD sensorcaine-mpf GD solution sensorcaine- lidocaine hcl external GD mpf/epinephrine injection cream 3 %, 3.88 % solution 0.25% - GD lidocaine hcl external gel GD 1:200000, 0.5% - 2 % 1:200000 GD lidocaine hcl external GD solupicc lotion tetracaine hcl injection GD lidocaine hcl external GD xylocaine dental GD solution Anti-Addiction / Substance Abuse lidocaine hcl injection GD Treatment Agents solution 0.5 %, 1 %, 2 % acamprosate calcium GD lidocaine in d5w GD buprenorphine hcl GD lidocaine-epinephrine sublingual injection solution 0.5 %- 1:200000, 1 %-1:100000, buprenorphine hcl- GD GD 1.5 %-1:200000, 2 %- naloxone hcl sublingual 1:100000, 2 %-1:200000, tablet sublingual bupropion hcl er 2 %-1:50000 GD lidocaine-prilocaine GD (smoking det)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier disulfiram oral GD amoxicillin-potassium naloxone hcl injection clavulanate oral tablet GD solution 0.4 mg/ml, 4 GD chewable 200-28.5 mg, mg/10ml 400-57 mg ampicillin oral capsule naloxone hcl injection GD GD solution cartridge 500 mg ampicillin sodium naloxone hcl injection GD GD solution prefilled syringe injection ampicillin sodium naltrexone hcl oral GD GD intravenous NARCAN BD ampicillin-sulbactam GD SUBLOCADE NS SP sodium injection VIVITROL NS SP ampicillin-sulbactam Antibacterials sodium intravenous GD amikacin sulfate injection solution reconstituted 1.5 solution 1 gm/4ml, 500 GD (1-0.5) gm, 15 (10-5) gm mg/2ml azithromycin intravenous amoxicillin oral capsule LC solution reconstituted LC 500 mg amoxicillin oral LC suspension reconstituted azithromycin oral packet LC azithromycin oral amoxicillin oral tablet LC LC suspension reconstituted amoxicillin oral tablet azithromycin oral tablet chewable 125 mg, 250 LC LC mg 250 mg, 500 mg, 600 mg aztreonam GD amoxicillin-potassium GD clavulanate er bacitracin intramuscular GD amoxicillin-potassium benzalkonium chloride GD clavulanate oral external solution , 50 % suspension reconstituted GD cefaclor GD 200-28.5 mg/5ml, 250- 62.5 mg/5ml, 400-57 cefaclor er GD mg/5ml, 600-42.9 mg/5ml cefadroxil GD amoxicillin-potassium cefazolin sodium GD clavulanate oral tablet GD injection 250-125 mg, 500-125 cefazolin sodium mg, 875-125 mg intravenous solution GD reconstituted

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cefazolin sodium- cefuroxime sodium dextrose intravenous GD injection solution GD solution 1-4 gm/50ml-%, reconstituted 7.5 gm, 750 2-4 gm/100ml-% mg cefazolin sodium- cefuroxime sodium dextrose intravenous GD intravenous solution GD solution reconstituted reconstituted 1.5 gm cefdinir GD cephalexin oral capsule LC cefditoren pivoxil GD 250 mg, 500 mg cephalexin oral capsule cefepime hcl GD GD 750 mg cefepime-dextrose GD cephalexin oral GD cefixime GD suspension reconstituted cefotaxime sodium cephalexin oral tablet GD injection solution GD reconstituted 1 gm, 10 chloramphenicol sod GD gm, 2 gm, 500 mg succinate cefotetan disodium GD ciprofloxacin hcl oral GD tablet 100 mg, 750 mg cefotetan disodium- GD dextrose ciprofloxacin hcl oral LC tablet 250 mg, 500 mg cefoxitin sodium GD ciprofloxacin in d5w GD cefoxitin sodium-dextrose GD ciprofloxacin oral cefpodoxime proxetil GD suspension reconstituted GD cefprozil GD 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl ceftazidime injection GD solution reconstituted 1 GD er gm, 2 gm, 6 gm clarithromycin er GD ceftriaxone sodium in GD clarithromycin oral GD dextrose clindamycin hcl oral GD ceftriaxone sodium GD injection clindamycin palmitate hcl GD clindamycin phosphate in ceftriaxone sodium GD GD intravenous d5w clindamycin phosphate ceftriaxone sodium- GD GD dextrose injection clindamycin phosphate cefuroxime axetil oral GD GD tablet intravenous

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clindamycin phosphate gentamicin in saline GD vaginal intravenous solution 0.8- 0.9 mg/ml-%, 1-0.9 colistimethate sodium GD GD (cba) mg/ml-%, 1.2-0.9 mg/ml- %, 1.6-0.9 mg/ml-%, 2- coremino GD 0.9 mg/ml-% daptomycin intravenous gentamicin sulfate GD solution reconstituted GD external 500 mg gentamicin sulfate GD demeclocycline hcl oral GD injection dicloxacillin sodium LC hydrogen peroxide GD doxy 100 GD solution 30 % doxycycline hyclate imipenem-cilastatin GD GD intravenous iodine tincture external GD doxycycline hyclate oral tincture 2 % GD capsule levofloxacin in d5w GD doxycycline hyclate oral levofloxacin intravenous GD tablet 100 mg, 150 mg, GD 20 mg, 50 mg, 75 mg levofloxacin oral GD lincomycin hcl injection GD doxycycline hyclate oral GD tablet delayed release linezolid in sodium GD chloride doxycycline monohydrate GD oral linezolid intravenous GD e.e.s. 400 oral tablet GD solution 600 mg/300ml ertapenem sodium GD linezolid oral GD erythrocin lactobionate lugols external GD intravenous solution GD mafenide acetate GD reconstituted 500 mg external erythromycin base oral meropenem GD capsule delayed release GD meropenem-sodium GD particles chloride erythromycin base oral GD methenamine hippurate GD tablet methenamine mandelate GD erythromycin GD oral ethylsuccinate oral metronidazole in nacl intravenous solution 5- LC 0.79 mg/ml-%, 500-0.79 mg/100ml-%

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier metronidazole oral LC penicillin v potassium LC metronidazole vaginal GD pfizerpen injection minocycline hcl er GD solution reconstituted GD 5000000 unit minocycline hcl oral GD piperacillin sod- GD mondoxyne nl GD tazobactam so morgidox oral GD polymyxin b sulfate GD moxifloxacin hcl in nacl GD injection silver nitrate external GD moxifloxacin hcl GD intravenous silver sulfadiazine GD moxifloxacin hcl oral GD external mupirocin calcium GD soloxide GD mupirocin external GD ssd GD streptomycin sulfate nafcillin sodium in GD GD dextrose intramuscular nafcillin sodium injection sulfadiazine oral GD solution reconstituted 1 GD sulfamethoxazole- GD gm, 2 gm trimethoprim intravenous nafcillin sodium GD sulfamethoxazole- intravenous trimethoprim oral LC neomycin sulfate oral LC suspension 200-40 mg/5ml nitrofurantoin GD sulfamethoxazole- macrocrystal oral LC nitrofurantoin trimethoprim oral tablet monohydrate GD sulfatrim pediatric LC macrocrystals tazicef injection GD nitrofurantoin oral tazicef intravenous GD GD suspension solution reconstituted ofloxacin oral tablet 300 GD tetracycline hcl oral GD mg, 400 mg tigecycline GD okebo oral capsule 75 GD mg tinidazole oral GD oxacillin sodium GD tobramycin sulfate GD injection paromomycin sulfate oral GD trimethoprim oral LC penicillin g potassium GD penicillin g procaine GD penicillin g sodium GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier vancomycin hcl in FRAGMIN dextrose intravenous SUBCUTANEOUS solution 1-5 gm/200ml-%, GD SOLUTION 10000 500-5 mg/100ml-%, 750- UNIT/ML, 12500 5 mg/150ml-% UNIT/0.5ML, 15000 NS SP; QL vancomycin hcl in nacl UNIT/0.6ML, 18000 intravenous solution 1- UNT/0.72ML, 2500 0.9 gm/200ml-%, 2-0.9 GD UNIT/0.2ML, 5000 gm/250ml-%, 500-0.9 UNIT/0.2ML, 7500 mg/100ml-% UNIT/0.3ML, 95000 UNIT/3.8ML vancomycin hcl in nacl solution 750-0.9 GD heparin (porcine) in d5w GD mg/150ml-% intravenous heparin (porcine) in nacl GD VANCOMYCIN HCL IN injection NACL SOLUTION 750- BD heparin (porcine) in nacl 0.9 MG/150ML-% intravenous solution GD INTRAVENOUS 2000-0.9 ut/500ml-%, vancomycin hcl 25000-0.45 ut/500ml-% GD intravenous heparin sod (porcine) in GD vancomycin hcl oral GD d5w vandazole GD heparin sodium (porcine) injection solution 1000 Anticoagulants unit/ml, 10000 unit/ml, GD argatroban GD 20000 unit/ml, 5000 argatroban in sodium unit/ml GD chloride heparin sodium (porcine) GD BEVYXXA BD pf jantoven LC bivalirudin GD trifluoroacetate PRADAXA BD ELIQUIS BD SAVAYSA BD NS SP ELIQUIS STARTER BD THROMBATE III PACK warfarin sodium oral LC GS SP; QL enoxaparin sodium XARELTO BD GS SP; QL fondaparinux sodium XARELTO STARTER BD PACK Anticonvulsants - Drugs for Seizures carbamazepine er GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carbamazepine oral levetiracetam GD GD suspension intravenous GD carbamazepine oral LC levetiracetam oral tablet oxcarbazepine GD carbamazepine oral GD pentobarbital sodium GD tablet chewable injection diazepam rectal GD phenobarbital oral GD divalproex sodium er oral phenobarbital sodium GD GD tablet extended release injection 24 hour phenytoin infatabs GD divalproex sodium oral capsule delayed release GD phenytoin oral GD sprinkle suspension 125 mg/5ml phenytoin oral tablet divalproex sodium oral GD GD tablet delayed release chewable phenytoin sodium epitol LC GD extended ethosuximide oral GD phenytoin sodium GD felbamate GD injection fosphenytoin sodium GD primidone oral LC FYCOMPA ORAL BD roweepra GD SUSPENSION roweepra xr GD gabapentin oral GD SABRIL ORAL TABLET NS PA; SP lamotrigine er GD subvenite GD lamotrigine oral tablet GD subvenite starter kit-blue GD lamotrigine oral tablet GD chewable subvenite starter kit- GD green lamotrigine oral tablet GD dispersible subvenite starter kit- GD orange lamotrigine starter kit- GD blue tiagabine hcl GD lamotrigine starter kit- topiramate er GD GD green topiramate oral GD lamotrigine starter kit- valproate sodium GD LC orange intravenous levetiracetam er GD valproate sodium oral LC levetiracetam in nacl GD solution valproic acid oral capsule LC

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier valproic acid oral solution LC fluoxetine hcl oral LC vigabatrin GS PA; SP capsule vigadrone GS PA; SP fluoxetine hcl oral GD capsule delayed release zonisamide oral GD fluoxetine hcl oral Antidementia Agents - Drugs for GD solution Alzheimer's Disease and Dementia fluoxetine hcl oral tablet GD LC donepezil hcl 10 mg galantamine fluoxetine hcl oral tablet GD GD hydrobromide 20 mg, 60 mg galantamine GD fluvoxamine maleate GD hydrobromide er fluvoxamine maleate er GD memantine hcl er GD imipramine hcl oral GD memantine hcl oral GD imipramine pamoate GD rivastigmine GD maprotiline hcl GD rivastigmine tartrate GD mirtazapine oral tablet LC Antidepressants mirtazapine oral tablet LC LC amitriptyline hcl oral dispersible 15 mg amoxapine GD mirtazapine oral tablet GD bupropion hcl er (sr) GD dispersible 30 mg, 45 mg bupropion hcl er (xl) GD nefazodone hcl GD bupropion hcl oral GD nortriptyline hcl oral LC chlordiazepoxide- capsule GD amitriptyline nortriptyline hcl oral GD solution citalopram hydrobromide GD oral solution olanzapine-fluoxetine hcl GD GD citalopram hydrobromide LC paroxetine hcl er oral tablet paroxetine hcl oral tablet LC GD clomipramine hcl oral paroxetine mesylate GD GD desipramine hcl oral perphenazine- GD desvenlafaxine succinate GD amitriptyline er phenelzine sulfate oral GD LC doxepin hcl oral protriptyline hcl GD GD duloxetine hcl oral sertraline hcl oral GD GD escitalopram oxalate tranylcypromine sulfate GD fluoxetine hcl (pmdd) GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier trazodone hcl oral tablet prochlorperazine maleate LC LC 100 mg, 150 mg, 50 mg oral tablet 10 mg trazodone hcl oral tablet GD prochlorperazine maleate GD 300 mg oral tablet 5 mg trimipramine maleate oral GD scopolamine GD GD venlafaxine hcl trimethobenzamide hcl GD venlafaxine hcl er GD oral Antiemetics - Drugs for Nausea and Antifungals Vomiting amphotericin b injection GD aprepitant GD caspofungin acetate GD compro GD ciclodan GD dimenhydrinate injection GD ciclopirox GD dronabinol GD ciclopirox olamine GD droperidol injection GD external granisetron hcl GD clotrimazole external LC meclizine hcl oral tablet LC clotrimazole mouth/throat GD metoclopramide hcl econazole nitrate LC GD injection external metoclopramide hcl oral exoderm external lotion GD solution 10 mg/10ml, 5 LC fluconazole in dextrose GD mg/5ml fluconazole in sodium metoclopramide hcl oral LC chloride intravenous tablet solution 100-0.9 GD mg/50ml-%, 400-0.9 metoclopramide hcl oral GD tablet dispersible mg/200ml-% ondansetron hcl injection fluconazole in sodium chloride intravenous solution 4 mg/2ml, 40 GD LC mg/20ml solution 200-0.9 mg/100ml-% ondansetron hcl oral GD fluconazole oral LC ondansetron odt GD flucytosine oral GD palonosetron hcl GD griseofulvin microsize GD perphenazine oral GD oral prochlorperazine GD griseofulvin GD prochlorperazine ultramicrosize GD edisylate injection itraconazole oral GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ketoconazole external GD eletriptan hydrobromide GD ketoconazole oral LC ergotamine-caffeine GD naftifine hcl GD frovatriptan succinate GD nyamyc GD naratriptan hcl GD nystatin external cream LC rizatriptan benzoate GD GD nystatin external GD sumatriptan nasal ointment sumatriptan succinate GD nystatin external powder GD oral nystatin mouth/throat GD sumatriptan succinate nystatin oral tablet GD refill subcutaneous GD solution cartridge nystatin-triamcinolone GD sumatriptan succinate nystop GD subcutaneous solution 6 GD oxiconazole nitrate GD mg/0.5ml terbinafine hcl oral LC sumatriptan succinate subcutaneous solution terconazole GD GD auto-injector 4 mg/0.5ml, voriconazole intravenous GD 6 mg/0.5ml voriconazole oral GD sumatriptan-naproxen GD Antigout Agents sodium allopurinol oral LC zolmitriptan oral GD allopurinol sodium GD Antimyasthenic Agents COLCHICINE ORAL guanidine hcl oral GD BD TABLET neostigmine colchicine-probenecid GD methylsulfate intravenous GD COLCRYS BD solution pyridostigmine bromide KRYSTEXXA NS PA; SP GD er probenecid oral GD pyridostigmine bromide Anti-inflammatory Agents GD oral NS PA; SP EMFLAZA regonol intravenous GD Antimigraine Agents Antimycobacterials GD almotriptan malate cycloserine oral GD dihydroergotamine GD dapsone oral GD mesylate injection ethambutol hcl oral GD dihydroergotamine GD mesylate nasal isoniazid injection GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier isoniazid oral syrup GD bicalutamide GD PS SP isoniazid oral tablet 100 GD BICNU mg bleomycin sulfate GS SP isoniazid oral tablet 300 LC BLINCYTO NS PA; SP mg BORTEZOMIB NS PA; SP pyrazinamide oral GD BOSULIF NS PA; SP rifabutin GD BRAFTOVI NS SP rifampin intravenous GD busulfan GS SP rifampin oral GD CABOMETYX PS PA; SP Antineoplastics - Drugs for Cancer CALQUENCE NS PA; SP; QL ABRAXANE PS SP CAMPATH PS SP ADCETRIS PS PA; SP CAMPTOSAR adriamycin intravenous GS SP INTRAVENOUS NS SP solution SOLUTION 300 adriamycin intravenous MG/15ML GS SP solution reconstituted 50 capecitabine GS PA; SP mg CAPRELSA ORAL GS SP PS PA; SP; QL adrucil TABLET 100 MG PS PA; SP; QL AFINITOR CAPRELSA ORAL PS PA; SP AFINITOR DISPERZ NS PA; SP TABLET 300 MG ALECENSA NS PA; SP; QL carboplatin intravenous GS SP ALIMTA PS SP solution ALIQOPA NS PA; SP cisplatin intravenous solution 100 mg/100ml, NS PA; SP; QL GS SP ALUNBRIG 200 mg/200ml, 50 anastrozole oral GD mg/50ml ARRANON PS SP cladribine intravenous GS SP ARZERRA PS PA; SP solution 10 mg/10ml AVASTIN PS SP clofarabine GS SP COMETRIQ (100 MG azacitidine GS SP NS PA; SP DAILY DOSE) BAVENCIO NS PA; SP COMETRIQ (140 MG NS PA; SP NS PA; SP BELEODAQ DAILY DOSE) BENDEKA NS SP COMETRIQ (60 MG NS PA; SP BESPONSA NS PA; SP DAILY DOSE) bexarotene GS PA; SP COTELLIC NS PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cyclophosphamide ETOPOPHOS NS SP GS SP injection etoposide intravenous GS SP cyclophosphamide oral GD solution 1 gm/50ml, 100 capsule mg/5ml, 500 mg/25ml CYRAMZA NS PA; SP etoposide oral GS SP cytarabine (pf) GS SP EVOMELA NS SP GD cytarabine injection GS SP exemestane solution FARYDAK NS PA; SP; QL dacarbazine intravenous GS SP FASLODEX dactinomycin GS SP INTRAMUSCULAR PS SP DARZALEX NS PA; SP SOLUTION 250 MG/5ML daunorubicin hcl floxuridine injection GS SP GS SP intravenous injectable fludarabine phosphate GS SP daunorubicin hcl fluorouracil intravenous GS SP GS SP intravenous solution flutamide GD decitabine GS PA; SP FOLOTYN PS PA; SP dexrazoxane GS SP GAZYVA NS PA; SP docetaxel (non-alcohol) GS SP GEMCITABINE HCL docetaxel intravenous INTRAVENOUS NS SP concentrate 160 mg/8ml, GS SP SOLUTION 1 GM/10ML, 20 mg/ml, 200 mg/10ml, 1.5 GM/15ML, 2 80 mg/4ml GM/20ML, 200 MG/2ML docetaxel intravenous gemcitabine hcl GS SP solution 160 mg/16ml, 20 intravenous solution 1 GS SP mg/2ml, 80 mg/8ml gm/26.3ml, 2 gm/52.6ml, doxorubicin hcl GS SP 200 mg/5.26ml doxorubicin hcl liposomal GS SP gemcitabine hcl intravenous solution GS SP EMPLICITI NS PA; SP reconstituted epirubicin hcl intravenous GILOTRIF NS PA; SP; QL solution 200 mg/100ml, GS SP 50 mg/25ml GLEOSTINE NS SP ERBITUX PS PA; SP HALAVEN PS PA; SP ERIVEDGE PS PA; SP HERCEPTIN PS PA; SP ERLEADA NS PA; SP; QL HYCAMTIN ORAL NS SP ERWINAZE INJECTION NS SP hydroxyurea oral GD ETHYOL NS SP IBRANCE NS PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ICLUSIG ORAL TABLET KYPROLIS PS PA; SP NS PA; SP; QL 15 MG LARTRUVO NS PA; SP ICLUSIG ORAL TABLET NS PA; SP LENVIMA 10 MG DAILY NS PA; SP 45 MG DOSE idarubicin hcl GS SP LENVIMA 12 MG DAILY NS PA; SP IDHIFA NS PA; SP; QL DOSE GS SP ifosfamide LENVIMA 14 MG DAILY NS PA; SP imatinib mesylate GS PA; SP DOSE IMBRUVICA NS PA; SP LENVIMA 18 MG DAILY NS PA; SP DOSE IMFINZI NS PA; SP LENVIMA 20 MG DAILY NS PA; SP IMLYGIC NS SP DOSE INLYTA NS PA; SP LENVIMA 24 MG DAILY NS PA; SP IRESSA NS PA; SP DOSE GS SP LENVIMA 4 MG DAILY irinotecan hcl NS PA; SP ISTODAX (OVERFILL) PS PA; SP DOSE IXEMPRA KIT PS SP LENVIMA 8 MG DAILY NS PA; SP DOSE JAKAFI ORAL TABLET PS PA; SP; QL GD 10 MG letrozole oral JAKAFI ORAL TABLET leucovorin calcium GD 15 MG, 20 MG, 25 MG, 5 PS PA; SP injection MG leucovorin calcium oral GD PS PA; SP JEVTANA levoleucovorin calcium GD KADCYLA NS PA; SP intravenous solution KEYTRUDA levoleucovorin calcium GD INTRAVENOUS NS PA; SP intravenous solution SOLUTION reconstituted 175 mg KISQALI 200 DOSE PS PA; SP; QL levoleucovorin calcium intravenous solution GS SP KISQALI 400 DOSE PS PA; SP; QL reconstituted 50 mg KISQALI 600 DOSE PS PA; SP; QL levoleucovorin calcium pf GD KISQALI FEMARA 200 NS PA; SP; QL lipodox 50 GS SP DOSE LONSURF NS PA; SP; QL KISQALI FEMARA 400 NS PA; SP; QL NS PA; SP DOSE LYNPARZA NS SP KISQALI FEMARA 600 MARQIBO NS PA; SP; QL DOSE MATULANE PS SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MEKINIST PS PA; SP RITUXAN HYCELA NS PA; SP MEKTOVI NS SP RITUXAN melphalan GD INTRAVENOUS NS PA; SP SOLUTION melphalan hcl GS SP ROMIDEPSIN PS PA; SP mercaptopurine oral GS SP RUBRACA NS PA; SP; QL mesna GS SP RYDAPT NS PA; SP; QL MESNEX ORAL NS SP SPRYCEL PS PA; SP mitomycin intravenous GS SP STIVARGA NS PA; SP mitoxantrone hcl GS PA; SP SUTENT PS PA; SP MUSTARGEN PS SP SYLATRON mutamycin GS SP SUBCUTANEOUS KIT NS PA; SP MYLOTARG 200 MCG, 300 MCG, 600 INTRAVENOUS MCG SOLUTION NS PA; SP SYLVANT NS PA; SP RECONSTITUTED 4.5 MG SYNRIBO NS PA; SP NERLYNX NS PA; SP; QL TABLOID PS SP NEXAVAR PS PA; SP TAFINLAR PS PA; SP nilutamide GS SP TAGRISSO NS PA; SP; QL NINLARO NS PA; SP; QL tamoxifen citrate oral GD NIPENT NS SP TARCEVA NS PA; SP; QL ODOMZO NS PA; SP TARGRETIN EXTERNAL BD ONCASPAR INJECTION PS SP TASIGNA NS PA; SP ONIVYDE NS SP TECENTRIQ NS PA; SP OPDIVO NS PA; SP TEMODAR PS SP INTRAVENOUS oxaliplatin GS SP temozolomide GS PA; SP paclitaxel GS SP teniposide GS SP PERJETA PS PA; SP TEPADINA NS SP PHOTOFRIN NS SP THALOMID PS PA; SP POMALYST NS PA; SP thiotepa injection GS SP PORTRAZZA NS PA; SP; QL toposar intravenous PROLEUKIN PS SP solution 1 gm/50ml, 100 GS SP PURIXAN NS SP mg/5ml, 500 mg/25ml REVLIMID NS PA; SP topotecan hcl GS SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TOTECT NS SP ZANOSAR PS SP tretinoin oral GS SP ZEJULA NS PA; SP; QL TRISENOX ZELBORAF NS PA; SP INTRAVENOUS NS SP ZEVALIN Y-90 NS SP SOLUTION 12 MG/6ML ZOLINZA PS PA; SP TYKERB PS PA; SP ZYDELIG NS PA; SP UNITUXIN NS PA; SP ZYKADIA NS PA; SP VALCHLOR NS PA; SP ZYTIGA NS PA; SP VECTIBIX Antiparasitics INTRAVENOUS NS SP SOLUTION 100 ALBENZA BD MG/5ML, 400 MG/20ML atovaquone oral GD VELCADE INJECTION PS PA; SP atovaquone-proguanil hcl GD VENCLEXTA NS PA; SP BENZNIDAZOLE BD VENCLEXTA STARTING NS PA; SP chloroquine phosphate LC PACK oral VERZENIO NS PA; SP; QL crotan GD vinblastine sulfate GS SP DARAPRIM NS PA; SP intravenous solution hydroxychloroquine LC vincasar pfs GS SP sulfate oral vincristine sulfate GS SP IMPAVIDO BD intravenous ivermectin oral GD vinorelbine tartrate GS SP lindane external GD VOTRIENT NS PA; SP shampoo VYXEOS malathion external GD INTRAVENOUS GD SUSPENSION NS PA; SP mefloquine hcl RECONSTITUTED 44- permethrin external GD 100 MG cream XALKORI PS PA; SP praziquantel oral GD NS PA; SP XTANDI primaquine phosphate GD YERVOY PS PA; SP oral GD YESCARTA NS PA; SP quinine sulfate oral GD YONDELIS NS SP spinosad GD YONSA NS PA; SP; QL sulfurated lime ZALTRAP PS PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Antiparkinson Agents Antiplatelets amantadine hcl oral GD aspirin-dipyridamole er GD APOKYN cilostazol GD SUBCUTANEOUS PS PA; SP; QL clopidogrel bisulfate oral GD SOLUTION CARTRIDGE dipyridamole oral GD benztropine mesylate GD injection eptifibatide intravenous solution 20 mg/10ml, 200 GD benztropine mesylate LC mg/100ml, 75 mg/100ml oral prasugrel hcl GD bromocriptine mesylate GD Antipsychotics - Drugs for Mood Disorders oral GD carbidopa oral GD aripiprazole BD carbidopa-levodopa GD ARISTADA carbidopa-levodopa er chlorpromazine hcl GD oral tablet extended injection GD release 25-100 mg, 50- chlorpromazine hcl oral GD 200 mg clozapine GD carbidopa-levodopa- fluphenazine decanoate GD GD entacapone injection entacapone GD fluphenazine hcl injection GD pramipexole fluphenazine hcl oral GD GD dihydrochloride concentrate pramipexole GD fluphenazine hcl oral GD dihydrochloride er elixir rasagiline mesylate oral GD fluphenazine hcl oral LC ropinirole hcl GD tablet 1 mg ropinirole hcl er GD fluphenazine hcl oral GD selegiline hcl oral GD tablet 10 mg, 2.5 mg, 5 mg tolcapone GD haloperidol decanoate trihexyphenidyl hcl oral GD intramuscular solution GD elixir 100 mg/ml, 50 mg/ml trihexyphenidyl hcl oral haloperidol lactate LC GD tablet 2 mg injection solution 5 mg/ml trihexyphenidyl hcl oral GD haloperidol lactate oral GD tablet 5 mg haloperidol oral tablet 0.5 LC mg, 1 mg, 2 mg, 5 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier haloperidol oral tablet 10 didanosine oral capsule GD mg, 20 mg delayed release 200 mg, GD loxapine succinate oral GD 250 mg, 400 mg olanzapine GD efavirenz GD paliperidone er GD entecavir GS SP; QL pimozide GD EPCLUSA PS PA; SP; QL quetiapine fumarate GD EPIVIR HBV ORAL PS SP SOLUTION quetiapine fumarate er GD EVOTAZ BD risperidone GD famciclovir oral GD risperidone m-tab oral tablet dispersible 0.5 mg, GD fosamprenavir calcium GD 1 mg, 2 mg ganciclovir sodium GD thioridazine hcl oral GD HARVONI PS PA; SP; QL thiothixene oral GD INTRON A NS PA; SP trifluoperazine hcl oral GD ISENTRESS BD ziprasidone hcl GD ISENTRESS HD BD Antivirals JULUCA BD abacavir sulfate GD lamivudine oral solution GD abacavir sulfate- lamivudine oral tablet GD GS SP lamivudine 100 mg abacavir-lamivudine- lamivudine oral tablet GD GD zidovudine 150 mg, 300 mg acyclovir external GD lamivudine-zidovudine GD acyclovir oral LC lopinavir-ritonavir GD PS PA; SP; QL acyclovir sodium GD MAVYRET intravenous solution MODERIBA 1200 DOSE GS SP adefovir dipivoxil GS SP PACK atazanavir sulfate GD MODERIBA 800 DOSE GS SP PACK BARACLUDE ORAL NS SP; QL SOLUTION moderiba oral tablet 200 GS SP BIKTARVY BD mg cidofovir intravenous GD MODERIBA ORAL TABLET THERAPY NS SP BD CIMDUO PACK NS PA; SP DAKLINZA nevirapine GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nevirapine er GD TIVICAY BD BD oseltamivir phosphate GD TRIUMEQ oral TRUVADA BD PEGASYS PROCLICK PS PA; SP valacyclovir hcl oral GD PEGASYS valganciclovir hcl GD SUBCUTANEOUS PS PA; SP SOLUTION VEMLIDY NS SP PEGINTRON VIEKIRA PAK NS PA; SP; QL SUBCUTANEOUS KIT NS PA; SP VIEKIRA XR NS PA; SP; QL 50 MCG/0.5ML VIREAD ORAL BD PREVYMIS NS SP POWDER PREZCOBIX BD VIREAD ORAL TABLET REBETOL ORAL 150 MG, 200 MG, 250 BD NS SP SOLUTION MG REYATAZ ORAL VOSEVI PS PA; SP BD PACKET ZEPATIER NS PA; SP; QL ribasphere GS SP zidovudine GD Anxiolytics - Drugs for Anxiety ribasphere ribapak oral GS SP tablet 400 mg, 600 mg alprazolam er GD RIBASPHERE RIBAPAK alprazolam oral GD ORAL TABLET NS SP buspirone hcl oral tablet THERAPY PACK LC 10 mg, 5 mg ribavirin inhalation GD buspirone hcl oral tablet GD ribavirin oral capsule GS SP 15 mg, 30 mg, 7.5 mg ribavirin oral tablet 200 GS SP chlordiazepoxide hcl GD mg clonazepam oral GD rimantadine hcl GD clorazepate dipotassium GD ritonavir GD diazepam injection GD SELZENTRY BD PA diazepam intensol GD SOVALDI NS PA; SP; QL diazepam intramuscular GD stavudine oral capsule GD solution auto-injector SYMFI BD diazepam oral GD SYMFI LO BD concentrate NS PA; SP diazepam oral solution 1 TECHNIVIE GD mg/ml tenofovir disoproxil GD fumarate diazepam oral tablet GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier estazolam GD ALPROLIX NS SP hydroxyzine hcl aminocaproic acid GD intramuscular solution 25 GD intravenous mg/ml anagrelide hcl GD hydroxyzine hcl BEBULIN PS SP intramuscular solution 50 LC mg/ml BENEFIX PS SP INTRAVENOUS KIT hydroxyzine hcl oral LC syrup CEPROTIN NS SP hydroxyzine hcl oral COAGADEX NS SP LC tablet CORIFACT PS SP hydroxyzine pamoate LC DOPTELET ORAL NS PA; SP oral TABLET 20 MG lorazepam injection GD ELOCTATE NS SP lorazepam intensol GD FEIBA PS SP lorazepam oral GD FIBRYGA PS SP lorazepam-dextrose GD GRANIX PS PA; SP lorazepam-sodium HELIXATE FS NS SP chloride intravenous GD HEMLIBRA NS SP solution 100-0.9 mg/100ml-% hemofil m intravenous solution reconstituted GD GS SP meprobamate 1000 unit, 250 unit, 500 oxazepam GD unit quazepam GD HEMOFIL M triazolam GD INTRAVENOUS SOLUTION PS SP Bipolar Agents - Drugs for Mood Disorders RECONSTITUTED 1700 lithium LC UNIT lithium carbonate er LC hetastarch-nacl GD lithium carbonate oral LC HUMATE-P Blood Products / Modifiers / Volume INTRAVENOUS Expanders - Drugs for Bleeding Disorders SOLUTION PS SP RECONSTITUTED 1000- PS SP ADVATE 2400 UNIT, 250-600 AFSTYLA NS SP UNIT, 500-1200 UNIT NS SP ALPHANATE/VWF PS SP IDELVION COMPLEX/HUMAN ALPHANINE SD PS SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IXINITY INTRAVENOUS MONONINE SOLUTION INTRAVENOUS RECONSTITUTED 1000 NS SP SOLUTION PS SP UNIT, 1500 UNIT, 500 RECONSTITUTED 1000 UNIT UNIT IXINITY INTRAVENOUS MOZOBIL PS PA; SP; QL SOLUTION NEULASTA ONPRO NS PA; SP RECONSTITUTED 2000 PS SP UNIT, 250 UNIT, 3000 NEULASTA SUBCUTANEOUS UNIT NS PA; SP SOLUTION PREFILLED KOATE PS SP SYRINGE KOATE-DVI NEUPOGEN INJECTION INTRAVENOUS SOLUTION 300 PS PA; SP SOLUTION PS SP MCG/ML, 480 RECONSTITUTED 1000 MCG/1.6ML UNIT, 500 UNIT NEUPOGEN INJECTION koate-dvi intravenous SOLUTION PREFILLED PS PA; SP solution reconstituted GS SP SYRINGE 250 unit NOVOEIGHT NS SP KOGENATE FS NS SP NOVOSEVEN RT PS SP KOGENATE FS BIO- NPLATE PS PA; SP SET INTRAVENOUS KIT NS SP 1000 UNIT, 2000 UNIT, NUWIQ INTRAVENOUS 3000 UNIT KIT 1000 UNIT, 2000 NS SP KOVALTRY NS SP UNIT, 250 UNIT, 500 UNIT LEUKINE NS PA; SP INTRAVENOUS NUWIQ INTRAVENOUS SOLUTION NS SP lmd in d5w GD RECONSTITUTED lmd in nacl GD PANHEMATIN MIRCERA INJECTION INTRAVENOUS SOLUTION PREFILLED NS PA; SP SOLUTION NS SP SYRINGE RECONSTITUTED 350 MONOCLATE-P MG INTRAVENOUS KIT PS SP PROCRIT PS PA; SP 1000 UNIT, 1500 UNIT PROFILNINE PS SP PROFILNINE SD PS SP PROMACTA NS PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier protamine sulfate afeditab cr GD GD intravenous alprostadil injection GD REBINYN NS SP amiloride hcl oral GD RECOMBINATE NS SP amiloride- LC RETACRIT NS PA; SP hydrochlorothiazide PS SP RIASTAP amiodarone hcl GD SOLIRIS intravenous GD INTRAVENOUS PS PA; SP amiodarone hcl oral SOLUTION 300 amlodipine besylate oral LC MG/30ML amlodipine besylate- NS PA; SP GD TAVALISSE benazepril hcl tranexamic acid amlodipine besylate- GD intravenous solution GD valsartan 1000 mg/10ml amlodipine-atorvastatin GD tranexamic acid oral GD amlodipine-olmesartan GD TRETTEN NS SP amlodipine-valsartan- GD VONVENDI NS SP hctz WILATE INTRAVENOUS NS SP atenolol oral LC KIT atenolol-chlorthalidone LC XYNTHA atorvastatin calcium oral LC INTRAVENOUS KIT NS SP 1000 UNIT, 2000 UNIT, benazepril hcl oral LC 250 UNIT, 500 UNIT benazepril- GD XYNTHA SOLOFUSE NS SP hydrochlorothiazide ZARXIO PS PA; SP betaxolol hcl oral GD Cardiovascular Agents - Drugs for Heart bisoprolol fumarate LC and Circulation Conditions bisoprolol- LC acebutolol hcl oral GD hydrochlorothiazide acetazolamide er GD bumetanide injection LC acetazolamide oral GD bumetanide oral LC acetazolamide sodium GD candesartan cilexetil GD adenosine intravenous candesartan cilexetil-hctz GD GD solution 12 mg/4ml, 6 captopril oral GD mg/2ml captopril- GD adenosine intravenous hydrochlorothiazide solution prefilled syringe GD 90 mg/30ml cartia xt GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carvedilol LC disopyramide phosphate GD carvedilol phosphate er GD oral chlorothiazide oral LC dobutamine hcl GD intravenous chlorothiazide sodium GD dobutamine in d5w GD chlorthalidone oral tablet LC 25 mg, 50 mg dofetilide GD cholestyramine light GD dopamine hcl GD intravenous cholestyramine oral GD dopamine in d5w GD choline fenofibrate GD doxazosin mesylate oral LC clonidine hcl oral tablet LC 0.1 mg, 0.2 mg enalapril maleate oral LC enalaprilat GD clonidine hcl oral tablet GD 0.3 mg enalapril- clonidine hcl transdermal GD hydrochlorothiazide oral GD tablet 10-25 mg colesevelam hcl GD enalapril- colestipol hcl GD hydrochlorothiazide oral LC digitek LC tablet 5-12.5 mg digox LC ENTRESTO BD GD digoxin injection ephedrine sulfate GD digoxin oral LC injection diltiazem hcl er beads GD ephedrine sulfate GD intravenous solution diltiazem hcl er coated GD beads epinephrine injection GD solution 30 mg/30ml diltiazem hcl er oral GD capsule extended GD epinephrine pf release 12 hour eplerenone GD diltiazem hcl er oral eprosartan mesylate GD capsule extended esmolol hcl intravenous GD GD release 24 hour 120 mg, solution 100 mg/10ml 180 mg, 240 mg ethacrynate sodium GD diltiazem hcl intravenous GD ethacrynic acid oral GD diltiazem hcl oral GD ezetimibe GD diltiazem hcl-dextrose intravenous solution 250- GD ezetimibe-simvastatin GD 5 mg/250ml-% felodipine er GD fenofibrate micronized GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier fenofibrate oral GD isradipine GD fenofibric acid GD JUXTAPID NS PA; SP; QL flecainide acetate GD KEVEYIS NS PA; SP; QL fluvastatin sodium GD KYNAMRO fluvastatin sodium er GD SUBCUTANEOUS NS PA; SP; QL SOLUTION PREFILLED fosinopril sodium LC SYRINGE fosinopril sodium-hctz GD labetalol hcl intravenous GD solution furosemide injection LC solution 10 mg/ml labetalol hcl oral GD furosemide oral solution LC lisinopril oral LC 10 mg/ml lisinopril- LC furosemide oral solution GD hydrochlorothiazide 8 mg/ml losartan potassium LC furosemide oral tablet LC losartan potassium-hctz LC gemfibrozil oral LC lovastatin GD guanfacine hcl oral LC mannitol intravenous GD hydralazine hcl injection GD solution 20 %, 25 % hydralazine hcl oral LC matzim la GD hydrochlorothiazide oral LC methyclothiazide oral GD ibutilide fumarate GD methyldopa oral LC indapamide oral LC methyldopa- GD irbesartan GD hydrochlorothiazide irbesartan- methyldopate hcl GD GD hydrochlorothiazide metolazone GD isoproterenol hcl injection GD metoprolol succinate er GD isosorbide dinitrate er GD metoprolol tartrate isosorbide dinitrate oral GD intravenous solution 5 GD isosorbide mononitrate GD mg/5ml isosorbide mononitrate er metoprolol tartrate GD oral tablet extended GD intravenous solution release 24 hour 120 mg cartridge isosorbide mononitrate er metoprolol tartrate oral LC oral tablet extended tablet 100 mg, 25 mg, 50 LC release 24 hour 30 mg, mg 60 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier metoprolol tartrate oral nitroglycerin transdermal GD GD tablet 37.5 mg, 75 mg patch 24 hour metoprolol- GD nitroglycerin translingual GD hydrochlorothiazide solution mexiletine hcl oral GD nitroprusside sodium GD midodrine hcl GD nitro-time GD milrinone lactate in GD norepinephrine bitartrate GD dextrose intravenous milrinone lactate NORTHERA NS PA; SP intravenous solution 10 GD olmesartan medoxomil GD mg/10ml, 20 mg/20ml, 50 oral mg/50ml olmesartan medoxomil- GD minitran GD hctz minoxidil oral GD olmesartan-amlodipine- GD moexipril hcl LC hctz moexipril- omega-3-acid ethyl GD GD hydrochlorothiazide esters GD nadolol oral tablet 20 mg, GD osmitrol 40 mg, 80 mg pacerone oral tablet 100 GD nadolol- GD mg, 200 mg, 400 mg bendroflumethiazide papaverine hcl injection GD niacin er GD pentoxifylline er GD (antihyperlipidemic) perindopril erbumine GD nicardipine hcl GD intravenous phenoxybenzamine hcl GD oral nicardipine hcl oral GD phentolamine mesylate nifedipine er GD injection solution GD nifedipine er osmotic reconstituted GD release phenylephrine hcl GD nifedipine oral GD injection nimodipine oral GD phenylephrine hcl GD nisoldipine er GD intravenous solution nitroglycerin er GD phenylephrine hcl-nacl intravenous solution 50- GD nitroglycerin in d5w GD 0.9 mg/250ml-%, 60-0.9 nitroglycerin intravenous GD mg/250ml-% nitroglycerin sublingual GD pindolol GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PRALUENT REPATHA SURECLICK PS PA; SP; QL SUBCUTANEOUS PS PA; SP; QL rosuvastatin calcium GD SOLUTION PEN- INJECTOR simvastatin oral LC pravastatin sodium GD sorine oral tablet 120 mg, GD 160 mg, 240 mg prazosin hcl oral LC sorine oral tablet 80 mg LC prevalite GD sotalol hcl (af) GD procainamide hcl GD injection sotalol hcl intravenous GD propafenone hcl GD sotalol hcl oral tablet 120 GD mg, 160 mg, 240 mg propafenone hcl er GD sotalol hcl oral tablet 80 LC propranolol hcl er GD mg propranolol hcl GD spironolactone oral LC intravenous spironolactone-hctz LC propranolol hcl oral GD solution taztia xt GD propranolol hcl oral tablet telmisartan GD 10 mg, 20 mg, 40 mg, 80 LC telmisartan-amlodipine GD mg telmisartan-hctz GD propranolol hcl oral tablet GD timolol maleate oral GD 60 mg torsemide oral LC propranolol-hctz GD trandolapril LC quinapril hcl LC trandolapril-verapamil hcl GD quinapril- GD er hydrochlorothiazide triamterene-hctz oral GD LC quinidine gluconate er capsule 37.5-25 mg quinidine gluconate GD triamterene-hctz oral LC injection tablet GD quinidine sulfate oral valsartan GD ramipril LC valsartan- GD RANEXA ORAL TABLET hydrochlorothiazide BD EXTENDED RELEASE verapamil hcl er oral 12 HOUR 1000 MG capsule extended GD REPATHA PS PA; SP; QL release 24 hour

REPATHA PS PA; SP; QL verapamil hcl er oral PUSHTRONEX SYSTEM tablet extended release GD 120 mg, 180 mg, 240 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier verapamil hcl intravenous GD AUBAGIO NS PA; SP; QL verapamil hcl oral tablet LC AVONEX PEN 120 mg, 80 mg INTRAMUSCULAR PS PA; SP; QL AUTO-INJECTOR KIT verapamil hcl oral tablet GD 40 mg AVONEX PREFILLED Central Nervous System Agents - Drugs for INTRAMUSCULAR PS PA; SP; QL Attention Deficit Disorder PREFILLED SYRINGE KIT amphetamine- GD AVONEX VIAL dextroamphetamine PS PA; SP; QL INTRAMUSCULAR KIT amphetamine- GD BETASERON dextroamphetamine er PS PA; SP; QL SUBCUTANEOUS KIT atomoxetine hcl GD GILENYA NS PA; SP; QL clonidine hcl er GD glatiramer acetate GS PA; SP; QL dexmethylphenidate hcl GD glatopa GS PA; SP; QL dexmethylphenidate hcl GD er LEMTRADA NS PA; SP dextroamphetamine OCREVUS NS PA; SP; QL GD sulfate er REBIF REBIDOSE SUBCUTANEOUS dextroamphetamine GD NS PA; SP; QL sulfate oral SOLUTION AUTO- INJECTOR guanfacine hcl er GD REBIF REBIDOSE metadate er oral tablet GD TITRATION PACK extended release 20 mg SUBCUTANEOUS NS PA; SP; QL methamphetamine hcl GD SOLUTION AUTO- methylphenidate hcl er GD INJECTOR REBIF methylphenidate hcl er GD (cd) SUBCUTANEOUS NS PA; SP; QL SOLUTION PREFILLED methylphenidate hcl er GD SYRINGE (la) REBIF TITRATION GD methylphenidate hcl oral PACK SUBCUTANEOUS NS PA; SP; QL relexxii GD SOLUTION PREFILLED zenzedi oral tablet 10 SYRINGE GD mg, 5 mg TECFIDERA PS PA; SP; QL Central Nervous System Agents - Drugs for TYSABRI NS PA; SP; QL Multiple Sclerosis AMPYRA PS PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Central Nervous System Agents - chlorhexidine gluconate LC Miscellaneous mouth/throat atracurium besylate fluoridex daily renewal GD GD intravenous solution 100 KEPIVANCE PS SP mg/10ml, 50 mg/5ml lidocaine hcl NS PA; SP; QL GD AUSTEDO mouth/throat GD benzphetamine hcl lidocaine viscous LC caffeine citrate GD numoisyn mouth/throat GD caffeine-sodium GD liquid benzoate oralone GD cisatracurium besylate paroex LC intravenous solution 10 GD mg/5ml, 20 mg/10ml, 200 periogard LC mg/20ml pilocarpine hcl oral GD diethylpropion hcl er GD prevident mouth/throat GD diethylpropion hcl oral GD topex topical anesthetic GD ONPATTRO NS SP mouth/throat aerosol triamcinolone acetonide pancuronium bromide GD intravenous solution 1 GD mouth/throat mg/ml Dermatological Agents - Drugs for Skin phendimetrazine tartrate GD Conditions acitretin GD phendimetrazine tartrate GD er adapalene external GD phentermine hcl oral GD cream RADICAVA NS PA; SP adapalene external gel GD riluzole GD adapalene-benzoyl GD peroxide rocuronium bromide GD intravenous solution ammonium lactate GD external succinylcholine chloride GD injection amnesteem GD tetrabenazine GS PA; SP arzol silver nit applicators GD vecuronium bromide avar cleanser GD intravenous solution GD avar-e emollient GD reconstituted avar-e green GD Dental and Oral Agents - Drugs for Mouth avita GD and Throat Conditions benzepro GD cevimeline hcl GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier benzepro creamy wash GD clindamycin-tretinoin GD GD benzepro foaming cloths clotrimazole- GD benzepro short contact GD betamethasone benziq wash GD coal tar external solution GD benzoin compound GD dapsone external GD benzoin external tincture GD diclofenac sodium GD transdermal gel 3 % benzoyl peroxide GD external foam 9.8 % doxepin hcl external GD doxycycline GD benzoyl peroxide- GD erythromycin dritho-creme hp GD calcipotriene external GD DUPIXENT PS PA; SP; QL GD calcipotriene-betameth GD erythromycin external diprop EUCRISA BD calcitrene GD fluorouracil external GD calcitriol external GD cream 5 % celacyn GD fluorouracil external GS SP cem-urea GD solution ceramax GD glycolic acid solution GD cerovel external lotion GD imiquimod external GD claravis GD isotretinoin oral GD clindacin etz external lactic acid e GD GD swab lactic acid external lotion GD clindacin-p GD latrix xm GD clindamycin phos- lidocaine-hydrocortisone benzoyl perox external GD ace external cream 1-1 GD gel 1-5 %, 1.2-5 % % GD clindamycin phosphate GD methoxsalen oral external foam methoxsalen rapid GD clindamycin phosphate GD methyl salicylate external GD external lotion liquid clindamycin phosphate GD metopic GD external solution metronidazole external GD clindamycin phosphate GD external swab myorisan GD clindamycin phosphate neuac external gel GD GD gel 1 % external podofilox external GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

38 Drug Drug Drug Name Notes Drug Name Notes Tier Tier pr benzoyl peroxide wash GD sulfacetamide sodium GD pramox GD (acne) pyrogallic acid GD sulfacetamide sodium GD external gel rea lo 40 GD sulfacetamide sodium GD recedo GD external liquid restizan GD sulfacetamide sodium- GD rosadan external cream GD sulfur external cream GD sulfacetamide sodium- rosadan external gel GD rosanil cleanser GD sulfur external emulsion sulfacetamide sodium- salicylic acid er GD GD sulfur external liquid salicylic acid external GD sulfacetamide sodium- cream GD sulfur external lotion salicylic acid external GD foam sulfacetamide sodium- sulfur external pad 10-4 GD salicylic acid external gel GD % salicylic acid external GD sulfacetamide sodium- liquid sulfur external GD salicylic acid external suspension GD lotion sulfacetamide sod-sulfur GD salicylic acid external wash external kit GD shampoo sulfacetamide-sulfur in GD urea external emulsion salicylic acid external GD solution 26 % sulfacetamide-sulfur- GD sunscreen salicylic acid wart GD remover sulfacleanse 8/4 GD salicylic acid-cleanser GD tacrolimus external GD salvax GD tazarotene external GD seb-prev wash GD tretinoin external GD selenium sulfide external GD tretinoin microsphere GD selenium sulf-pyrithione- GD tretinoin microsphere GD urea pump sodium hyaluronate GD turpentine external GD external gel umecta mousse GD sodium sulfacetamide GD external shampoo

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

39 Drug Drug Drug Name Notes Drug Name Notes Tier Tier urea external cream 39 metformin hcl er oral %, 40 %, 41 %, 45 %, 47 GD tablet extended release GD %, 50 % 24 hour 750 mg urea external lotion 40 % GD metformin hcl oral tablet LC GD urea external suspension GD miglitol 40 % nateglinide GD urea in zn undecyl-lactic GD OZEMPIC BD acid pioglitazone hcl GD uredeb GD pioglitazone hcl- GD GD zenatane glimepiride Diabetes - Antidiabetic Agents pioglitazone hcl- GD acarbose GD metformin hcl BYDUREON PEN BD repaglinide GD BYDUREON VIAL BD repaglinide-metformin hcl GD BYETTA 10 MCG PEN BD SOLIQUA BD BYETTA 5 MCG PEN BD SYMLINPEN 120 BD chlorpropamide GD SYMLINPEN 60 BD glimepiride LC SYNJARDY BD glipizide er LC SYNJARDY XR BD glipizide ir LC tolazamide GD glipizide-metformin hcl GD tolbutamide GD glyburide micronized LC TRULICITY BD glyburide oral LC VICTOZA BD glyburide-metformin GD Diabetes - Glucose Monitoring BD INVOKAMET ACCU-CHEK BD INVOKAMET XR BD MULTICLIX LANCETS INVOKANA BD ACCU-CHEK SOFT BD TOUCH LANCETS JANUMET BD ACCU-CHEK SOFTCLIX BD JANUMET XR BD LANCETS JANUVIA BD LANCETS BD JARDIANCE BD LANCETS GD metformin hcl er oral ONETOUCH ULTRA 2 BD tablet extended release LC KIT W/DEVICE 24 hour 500 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

40 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ONETOUCH ULTRA HUMULIN R VIAL BD BD MINI KIT W/DEVICE INSULIN PEN NEEDLES BD ONETOUCH VERIO BD 29G X 12.7MM

ONETOUCH VERIO IQ BD INSULIN PEN NEEDLES SYSTEM KIT W/DEVICE 30G X 8 MM , 31G X 6 GD Diabetes - Glycemic Agents MM INSULIN SYRINGES GLUCAGON BD EMERGENCY 30G X 1/2" 0.5 ML, 31G BD X 5/16" 1 ML Diabetes - Insulins LANTUS U-100 BD AFREZZA INHALATION SOLOSTAR POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 (90) & 8 BD LANTUS U-100 VIAL BD (90) UNIT, 4 UNIT, 8 NOVOFINE UNIT AUTOCOVER PEN BD NEEDLE HUMALOG U-100 AND BD U-200 KWIKPEN NOVOFINE PEN BD NEEDLE 32G X 6 MM HUMALOG MIX 50/50 BD KWIKPEN NOVOTWIST PEN BD NEEDLE 32G X 5 MM HUMALOG MIX 50/50 BD VIAL TOUJEO MAX BD SOLOSTAR HUMALOG MIX 75/25 BD KWIKPEN TOUJEO SOLOSTAR BD HUMALOG MIX 75/25 Electrolytes / Minerals / Metals / Vitamins BD VIAL airavite GD HUMALOG U-100 alcohol intravenous BD GD JUNIOR KWIKPEN solution 98 % HUMALOG U-100 VIAL BD aminoam rms GD AND CARTRIDGE aminorelief rms GD HUMULIN 70/30 BD KWIKPEN aminosyn ii/electrolytes GD HUMULIN 70/30 VIAL BD aminosyn/electrolytes intravenous solution 8.5 GD BD HUMULIN N KWIKPEN % BD HUMULIN N VIAL ascorbic acid injection GD HUMULIN R U-500 BD b-6 folic acid GD KWIKPEN bd posiflush intravenous GD HUMULIN R U-500 VIAL BD (CONCENTRATED) calcium chloride GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

41 Drug Drug Drug Name Notes Drug Name Notes Tier Tier calcium gluconate effer-k oral tablet GD GD intravenous solution effervescent 25 meq calcium gluconate- elite-ob GD dextrose intravenous GD fa-vitamin b-6-vitamin b- GD solution 2-5 gm/100ml-% 12 calcium gluconate-nacl ferrocite plus oral tablet GD intravenous solution 3- GD 0.9 gm/100ml-% floriva oral tablet GD chewable 0.25 mg CARBAGLU PS SP folbee plus cz GD chromagen oral capsule GD folic acid injection GD chromic chloride GD intravenous folic acid oral tablet 1 mg GD clinimix e/dextrose glucose intravenous GD GD (4.25/25) hematogen GD GD clinimix/dextrose GD hematogen fa (4.25/10) hematogen forte GD clinimix/dextrose GD hemocyte-f oral tablet GD (4.25/20) hepatamine GD clinimix/dextrose GD hydroxocobalamin (4.25/25) GD intramuscular clinisol sf GD iferex 150 forte GD cod liver oil oral oil GD inatal gt GD co-natal fa GD infuvite adult GD copper chloride GD infuvite pediatric GD GD corvita intravenous solution corvita 150 GD intralipid intravenous GD corvite free GD emulsion 20 % cyanocobalamin injection GD iodine strong oral GD dehydrated alcohol BD GD JADENU intravenous JADENU SPRINKLE BD GD dexifol JYNARQUE NS SP; QL dextrose intravenous kionex oral suspension GD solution 10 %, 20 %, 250 GD mg/ml, 30 %, 40 %, 5 %, klor-con 10 GD 50 %, 70 % klor-con m10 GD dialyvite GD klor-con m20 GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

42 Drug Drug Drug Name Notes Drug Name Notes Tier Tier klor-con oral packet 20 methylfol-algae-b12- GD GD meq acetylcyst klor-con oral tablet GD monoject flush syringe GD extended release intravenous GD klor-con sprinkle monoject sodium chloride GD klor-con/ef GD flush intravenous k-prime GD multigen GD k-tan plus GD multigen folic GD lecithin oral granules GD multigen plus GD levocarnitine oral solution GD multitrace-4 GD levocarnitine oral tablet GD multitrace-4 neonatal GD multitrace-5 GD l-methylfolate-algae oral GD capsule 15-90.314 mg mvc-fluoride GD l-methylfolate-algae-b12- m-vit LC GD b6 mynatal advance GD l-methylfolate-b6-b12 oral GD mynatal oral tablet GD tablet 3-35-2 mg mynephron GD ludent oral tablet na ferric gluc cplx in chewable 0.55 (0.25 f) LC GD mg sucrose ludent oral tablet n-acetyl-l-cysteine oral GD chewable 1.1 (0.5 f) mg, GD nafrinse GD 2.2 (1 f) mg nafrinse drops GD GD lysiplex plus oral tablet nephronex oral tablet GD magnesium chloride GD normal saline flush GD injection intravenous magnesium sulfate in nufol GD d5w intravenous solution GD 1-5 gm/100ml-% nutricap GD magnesium sulfate nutrifac zx GD GD injection solution 50 % obstetrix ec GD GD magnesium sulfate GD phospha 250 neutral intravenous phosphorous GD manganese chloride GD phospho-trin 250 neutral GD intravenous phytonadione injection GD GD metafolbic plus rf solution 1 mg/0.5ml

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

43 Drug Drug Drug Name Notes Drug Name Notes Tier Tier phytonadione oral GD renal oral capsule GD plenamine GD saline flush intravenous GD pot bicarb-pot chloride GD saline flush zr GD potassium acetate SAMSCA PS SP; QL intravenous solution 2 GD selenium intravenous GD meq/ml siderol oral tablet GD potassium bicarbonate GD oral sod citrate-citric acid LC sodium acetate potassium chloride crys GD GD er intravenous potassium chloride er GD sodium bicarbonate intravenous solution 4.2 GD potassium chloride %, 7.5 %, 8.4 % intravenous solution 0.4 meq/ml, 10 meq/100ml, sodium chloride flush GD GD 10 meq/50ml, 2 meq/ml, sodium chloride injection GD 20 meq/100ml, 20 sodium chloride meq/50ml, 40 meq/100ml intravenous solution 0.45 GD potassium chloride oral GD %, 0.9 %, 3 %, 4 meq/ml, packet 5 % potassium chloride oral sodium fluoride oral GD solution 20 meq/15ml GD solution (10%), 40 meq/15ml sodium fluoride oral GD (20%) tablet GD potassium citrate er sodium fluoride oral potassium citrate-citric LC GD tablet chewable 0.55 acid oral solution (0.25 f) mg potassium phosphates GD sodium fluoride oral pr natal 400 GD tablet chewable 1.1 (0.5 GD f) mg, 2.2 (1 f) mg pr natal 400 ec GD sodium lactate pr natal 430 GD intravenous solution 5 GD pr natal 430 ec GD meq/ml premasol intravenous GD sodium phosphates solution 6 % intravenous solution 15 GD prenatabs rx GD mmole/5ml, 45 mmole/15ml prenatal-u GD sodium polystyrene GD pyridoxine hcl injection GD sulfonate oral quflora pediatric GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

44 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sodium polystyrene Gastrointestinal Agents - Drugs for Acid GD sulfonate rectal Reflux and Ulcer sps GD cimetidine hcl oral GD GD strovite forte oral tablet cimetidine oral tablet 200 GD swabflush saline flush GD mg, 300 mg, 400 mg tandem f GD cimetidine oral tablet 800 LC mg taron-crystals GD esomeprazole sodium GD taron-prex GD famotidine intravenous thiamine hcl injection GD solution 20 mg/2ml, 200 GD tricare LC mg/20ml, 40 mg/4ml GD famotidine oral tricitrates GD tricon GD suspension reconstituted famotidine oral tablet 20 trientine hcl GS PA; SP LC mg trinate GD famotidine oral tablet 40 GD tryptophan oral GD mg vic-forte GD famotidine premixed GD vinate ii GD lansoprazole oral GD vinate m GD misoprostol oral GD vinate one GD nizatidine GD virt-gard GD omeprazole oral capsule LC vit b12-methionine-inos- delayed release GD chol pantoprazole sodium LC vita s forte GD intravenous vitacel GD pantoprazole sodium oral LC vitafol-ob GD rabeprazole sodium GD vitamax pediatric GD ranitidine hcl injection GD vitamin d (ergocalciferol) solution 150 mg/6ml, 50 GD oral capsule 50000 unit mg/2ml GD vitamin k1 injection ranitidine hcl oral capsule solution 1 mg/0.5ml, 10 GD ranitidine hcl oral syrup GD mg/ml ranitidine hcl oral tablet GD wheat germ oil oral oil GD 150 mg GD zinc sulfate intravenous ranitidine hcl oral tablet LC zinc trace metal GD 300 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

45 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sucralfate oral tablet LC glycopyrrolate injection GD Gastrointestinal Agents - Drugs for Bowel, solution Intestine and Stomach Conditions glycopyrrolate oral tablet GD alosetron hcl GD 1 mg, 2 mg hyoscyamine sulfate er amoxicill-clarithro- GD lansopraz oral tablet extended GD release 12 hour atropine sulfate injection solution 0.4 mg/ml, 1 GD hyoscyamine sulfate oral GD mg/ml, 8 mg/20ml hyoscyamine sulfate sl GD atropine sulfate injection hyoscyamine sulfate GD GD solution prefilled syringe sublingual belladonna alkaloids- GD GD lactulose encephalopathy opium lactulose oral LC GD belladonna-opium loperamide hcl oral GD cascara sagrada oral GD capsule fluid extract methscopolamine GD chlordiazepoxide- GD bromide oral clidinium mineral oil heavy oral GD NS PA; SP CHOLBAM nulev GD GD cromolyn sodium oral opium GD dicyclomine hcl GD paregoric GD intramuscular peg 3350/electrolytes GD dicyclomine hcl oral LC capsule peg 3350-kcl-na bicarb- GD nacl dicyclomine hcl oral GD solution peg-3350/electrolytes GD dicyclomine hcl oral peg-prep GD LC tablet pegylax GD diphenoxylate-atropine GD phenobarbital-belladonna GD GATTEX NS PA; SP alk polyethylene glycol 3350 gavilyte-c GD GD oral gavilyte-g GD propantheline bromide GD GD gavilyte-h oral gavilyte-n with flavor GD pack

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

46 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SEROSTIM miglustat GS PA; SP SUBCUTANEOUS NAGLAZYME PS PA; SP SOLUTION PS PA; SP RECONSTITUTED 4 NITYR NS PA; SP MG, 5 MG, 6 MG OCALIVA NS PA; SP; QL NS PA; SP sodium bicarbonate oral GD ORFADIN powder PALYNZIQ NS SP GD symax-sr PROCYSBI NS PA; SP BD SYMPROIC RAVICTI NS PA; SP GD trilyte sod benz-sod phenylacet GD ursodiol oral GD sodium phenylbutyrate GS SP XERMELO NS PA; SP; QL oral powder 3 gm/tsp ZORBTIVE NS PA; SP sodium phenylbutyrate GS SP Genetic or Enzyme Disorder: Drugs for oral tablet Replacement, Modifiers, Treatment STRENSIQ NS PA; SP ALDURAZYME PS PA; SP SUCRAID NS SP BRINEURA SOLUTION NS PA; SP VIMIZIM NS PA; SP CERDELGA NS PA; SP VPRIV NS PA; SP CEREZYME ZENPEP ORAL INTRAVENOUS CAPSULE DELAYED SOLUTION PS PA; SP RELEASE PARTICLES RECONSTITUTED 400 10000-32000 UNIT, UNIT 15000-47000 UNIT, BD CREON BD 20000-63000 UNIT, 25000-79000 UNIT, NS PA; SP CRYSVITA 3000-14000 UNIT, CYSTAGON NS SP 40000-126000 UNIT, ELAPRASE PS PA; SP 5000-24000 UNIT ELELYSO NS PA; SP Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions EXONDYS 51 NS PA; SP bethanechol chloride oral GD FABRAZYME PS PA; SP calcium acetate (phos GD GALAFOLD NS SP binder) KANUMA NS PA; SP calcium acetate oral GD KUVAN PS PA; SP CIALIS BD LUMIZYME PS PA; SP CUPRIMINE ORAL NS PA; SP MEPSEVII NS PA; SP CAPSULE 250 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

47 Drug Drug Drug Name Notes Drug Name Notes Tier Tier darifenacin hydrobromide Genitourinary Agents - Drugs for Prostate GD er Conditions flavoxate hcl GD alfuzosin hcl er GD GELNIQUE PUMP BD dutasteride oral GD

GELNIQUE dutasteride-tamsulosin GD TRANSDERMAL GEL 10 BD hcl % finasteride oral tablet 5 LC hyophen GD mg lanthanum carbonate GD tamsulosin hcl LC oxybutynin chloride er GD terazosin hcl oral LC oxybutynin chloride oral GD Hormonal Agents - Adrenal phenazo oral tablet 200 alclometasone LC GD mg dipropionate phenazopyridine hcl oral amcinonide GD LC tablet 100 mg, 200 mg apexicon e GD phosphasal GD betamethasone GD sevelamer carbonate GD dipropionate aug betamethasone sildenafil citrate oral GD tablet 100 mg, 25 mg, 50 GD dipropionate external mg betamethasone sod phos THIOLA NS SP & acet injection GD tolterodine tartrate GD suspension 6 (3-3) mg/ml tolterodine tartrate er GD betamethasone valerate GD external trospium chloride GD clobetasol prop emollient GD trospium chloride er GD base uretron d/s GD clobetasol propionate GD uribel GD emulsion GD clobetasol propionate urimar-t GD uryl GD external GD ustell GD clocortolone pivalate clocortolone pivalate uta GD GD pump utira-c GD clodan external shampoo GD utrona-c GD cortisone acetate oral GD vilamit mb GD deltasone LC vilevev mb GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

48 Drug Drug Drug Name Notes Drug Name Notes Tier Tier desonide external GD hydrocortisone butyrate GD desoximetasone external GD external hydrocortisone external dexamethasone oral LC GD elixir cream 1 % hydrocortisone external dexamethasone oral LC LC solution cream 2.5 % hydrocortisone external dexamethasone oral LC GD tablet lotion 2.5 % hydrocortisone external dexamethasone oral GD GD tablet therapy pack ointment 1 %, 2.5 % hydrocortisone in dexamethasone sod GD phos-nacl intravenous absorbase GD solution 12-0.9 mg/50ml- hydrocortisone oral LC % hydrocortisone valerate GD dexamethasone sod methylprednisolone ace- LC GD phosphate pf lido dexamethasone sodium LC methylprednisolone phosphate injection acetate injection LC diflorasone diacetate GD suspension 40 mg/ml, 80 external mg/ml LC fludrocortisone acetate GD methylprednisolone oral oral methylprednisolone fluocinolone acetonide sodium succ injection GD LC body solution reconstituted fluocinolone acetonide 1000 mg, 125 mg, 40 mg GD external mometasone furoate GD fluocinolone acetonide external GD scalp nolix GD GD fluocinonide emulsified GD nutriarx creampak base prednicarbate GD fluocinonide external GD prednisolone oral LC flurandrenolide GD solution fluticasone propionate GD prednisolone sodium external phosphate oral solution GD halobetasol propionate GD 10 mg/5ml, 20 mg/5ml hydrocortisone butyr lipo GD base

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

49 Drug Drug Drug Name Notes Drug Name Notes Tier Tier prednisolone sodium testosterone transdermal phosphate oral solution LC gel 12.5 mg/act (1%), 25 GD 15 mg/5ml, 25 mg/5ml, mg/2.5gm (1%), 50 6.7 (5 base) mg/5ml mg/5gm (1%) prednisolone sodium testosterone transdermal GD phosphate oral tablet GD solution dispersible Hormonal Agents - Osteoporosis prednisone oral LC clomiphene citrate oral LC synalar external cream GD raloxifene hcl GD synalar external ointment GD Hormonal Agents - Parathyroid triamcinolone acetonide GD SENSIPAR BD external aerosol solution Hormonal Agents - Pituitary triamcinolone acetonide LC GD external cream cabergoline triamcinolone acetonide CETROTIDE GD PS PA; SP external lotion SUBCUTANEOUS KIT 0.25 MG triamcinolone acetonide external ointment 0.025 GD chorionic gonadotropin GS PA; SP %, 0.5 % intramuscular desmopressin ace spray triamcinolone acetonide LC GD external ointment 0.1 % refrig triamcinolone acetonide desmopressin acetate GD injection suspension 40 GD injection mg/ml desmopressin acetate GD triderm external cream LC oral desmopressin acetate Hormonal Agents - Men's Health GD spray ANDRODERM TRANSDERMAL PATCH BD EGRIFTA SUBCUTANEOUS 24 HOUR NS PA; SP; QL SOLUTION danazol oral GD RECONSTITUTED 1 MG methyltestosterone oral GD ELIGARD NS PA; SP; QL oxandrolone oral GD FIRMAGON NS PA; SP; QL testosterone cypionate ganirelix acetate GS PA; SP intramuscular solution GD PS PA; SP 100 mg/ml, 200 mg/ml GONAL-F PS PA; SP testosterone enanthate GONAL-F RFF GD intramuscular solution GONAL-F RFF PS PA; SP REDIJECT

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

50 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HP ACTHAR PS PA; SP LUPRON DEPOT-PED INCRELEX PS PA; SP (3-MONTH) NS PA; SP INTRAMUSCULAR KIT leuprolide acetate GS PA; SP 11.25 MG (PED) injection LUPRON DEPOT-PED LUPANETA PACK NS PA; SP; QL (3-MONTH) PS PA; SP LUPRON DEPOT (1- INTRAMUSCULAR KIT 30 MG (PED) MONTH) NS PA; SP INTRAMUSCULAR KIT MENOPUR NS PA; SP 3.75 MG NORDITROPIN PS PA; SP LUPRON DEPOT (1- FLEXPRO MONTH) PS PA; SP INTRAMUSCULAR KIT novarel intramuscular 7.5 MG solution reconstituted GS PA; SP 10000 unit LUPRON DEPOT (3- NOVAREL MONTH) NS PA; SP INTRAMUSCULAR KIT INTRAMUSCULAR 11.25 MG SOLUTION NS PA; SP RECONSTITUTED 5000 LUPRON DEPOT (3- UNIT MONTH) PS PA; SP NUTROPIN AQ NUSPIN INTRAMUSCULAR KIT PS PA; SP 22.5 MG 10 NUTROPIN AQ NUSPIN LUPRON DEPOT (4- PS PA; SP MONTH) 20 PS PA; SP INTRAMUSCULAR KIT NUTROPIN AQ NUSPIN PS PA; SP 30MG 5 LUPRON DEPOT (6- octreotide acetate MONTH) PS PA; SP injection solution 100 INTRAMUSCULAR KIT mcg/ml, 1000 mcg/ml, GS PA; SP 45MG 200 mcg/ml, 50 mcg/ml, LUPRON DEPOT-PED 500 mcg/ml (1-MONTH) OMNITROPE PS PA; SP NS PA; SP INTRAMUSCULAR KIT OVIDREL NS SP 11.25 MG oxytocin injection GD LUPRON DEPOT-PED pregnyl GS PA; SP (1-MONTH) PS PA; SP INTRAMUSCULAR KIT SANDOSTATIN LAR NS PA; SP 15 MG, 7.5 MG DEPOT SIGNIFOR NS PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

51 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SIGNIFOR LAR bekyree GD INTRAMUSCULAR blisovi 24 fe GD SUSPENSION NS PA; SP; QL RECONSTITUTED ER blisovi fe 1.5/30 GD 20 MG, 40 MG, 60 MG blisovi fe 1/20 GD SOMATULINE DEPOT NS PA; SP camila LC SOMAVERT NS PA; SP camrese GD SUPPRELIN LA PS PA; SP; QL camrese lo GD TRELSTAR MIXJECT NS PA; SP; QL caziant GD TRIPTODUR NS PA; SP; QL chateal LC VANTAS NS PA; SP; QL chateal eq LC vasopressin-dextrose cryselle-28 GD GD intravenous solution 20-5 cyclafem 1/35 LC ut/100ml-% cyclafem 7/7/7 LC ZOLADEX SUBCUTANEOUS NS SP; QL cyred LC IMPLANT 10.8 MG dasetta 1/35 LC ZOLADEX dasetta 7/7/7 LC PS SP; QL SUBCUTANEOUS daysee GD IMPLANT 3.6 MG deblitane LC Hormonal Agents - Prostaglandins delyla GD KORLYM NS PA; SP; QL desogestrel-ethinyl Hormonal Agents - Sex Hormones and estradiol oral tablet 0.15- GD Birth Control 0.02/0.01 mg (21/5) LC altavera desogestrel-ethinyl amabelz GD estradiol oral tablet 0.15- LC amethia GD 30 mg-mcg amethia lo GD drospiren-eth estrad- levomefol oral tablet 3- GD LC apri 0.02-0.451 mg aranelle GD drospirenone-ethinyl GD ashlyna GD estradiol aubra GD elinest GD aubra eq GD emoquette LC aviane GD enpresse-28 GD azurette GD enskyce oral tablet 0.15- LC balziva GD 30 mg-mcg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

52 Drug Drug Drug Name Notes Drug Name Notes Tier Tier errin LC kariva GD estarylla LC kelnor 1/35 GD estradiol oral LC kelnor 1/50 GD estradiol transdermal GD kurvelo LC estradiol vaginal GD larin 1.5/30 GD estradiol valerate larin 1/20 GD intramuscular oil 20 GD larin 24 fe GD mg/ml, 40 mg/ml larin fe 1.5/30 GD estradiol-norethindrone GD acet larin fe 1/20 GD ethynodiol diac-eth larissia GD GD estradiol layolis fe GD falmina GD leena GD fayosim GD lessina GD femynor LC levonest GD fyavolv GD levonorgest-eth est & eth GD gianvi GD est heather LC levonorgest-eth estrad GD 91-day hydroxyprogesterone GS PA; SP caproate intramuscular levonorgestrel-ethinyl estrad oral tablet 0.1-20 GD incassia LC mg-mcg, 90-20 mcg introvale GD levonorgestrel-ethinyl isibloom LC estrad oral tablet 0.15-30 LC jencycla LC mg-mcg jinteli GD levonorg-eth estrad GD triphasic jolessa GD levora 0.15/30 (28) LC jolivette LC lillow LC juleber LC lopreeza GD junel 1.5/30 GD loryna GD junel 1/20 GD low-ogestrel GD junel fe 1.5/30 GD lutera GD junel fe 1/20 GD lyza LC junel fe 24 GD MAKENA NS PA; SP kaitlib fe GD SUBCUTANEOUS

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

53 Drug Drug Drug Name Notes Drug Name Notes Tier Tier medroxyprogesterone norethindrone-eth GD GD acetate intramuscular estradiol GD medroxyprogesterone LC norethin-eth estradiol-fe acetate oral norgestimate-eth megestrol acetate oral estradiol oral tablet 0.25- LC suspension 40 mg/ml, GD 35 mg-mcg 400 mg/10ml, 625 norgestimate-ethinyl mg/5ml estradiol triphasic oral GD megestrol acetate oral tablet 0.18/0.215/0.25 LC tablet 20 mg mg-25 mcg megestrol acetate oral norgestimate-ethinyl GD tablet 40 mg estradiol triphasic oral LC melodetta 24 fe GD tablet 0.18/0.215/0.25 mg-35 mcg mibelas 24 fe GD norlyda LC microgestin 1.5/30 GD norlyroc LC microgestin 1/20 GD nortrel 0.5/35 (28) GD microgestin fe 1.5/30 GD nortrel 1/35 (21) LC microgestin fe 1/20 GD nortrel 1/35 (28) LC mili LC nortrel 7/7/7 LC mimvey GD ocella GD mimvey lo GD ogestrel GD mono-linyah LC orsythia GD mononessa LC philith GD myzilra GD pimtrea GD necon 0.5/35 (28) GD pirmella 1/35 LC necon 7/7/7 LC pirmella 7/7/7 LC nikki GD portia-28 LC nora-be LC previfem LC norethin ace-eth estrad- GD progesterone fe GD intramuscular norethindrone acetate GD progesterone micronized oral GD oral norethindrone acet- GD ethinyl est progesterone micronized GD transdermal norethindrone oral LC quasense GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

54 Drug Drug Drug Name Notes Drug Name Notes Tier Tier rajani GD yuvafem GD reclipsen LC zarah GD rivelsa GD zovia 1/35e (28) GD setlakin GD Hormonal Agents - Thyroid sharobel LC levo-t oral tablet 100 sprintec 28 LC mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 LC sronyx GD mcg, 200 mcg, 25 mcg, syeda GD 50 mcg, 75 mcg, 88 mcg tarina fe 1/20 GD levo-t oral tablet 300 mcg GD tilia fe GD levothyroxine sodium oral tri femynor LC tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 LC tri-estarylla LC mcg, 175 mcg, 200 mcg, tri-legest fe GD 25 mcg, 50 mcg, 75 mcg, tri-linyah LC 88 mcg tri-lo-estarylla GD levothyroxine sodium oral GD tablet 300 mcg tri-lo-marzia GD levothyroxine-liothyronine GD tri-lo-sprintec GD levoxyl LC tri-mili LC liothyronine sodium GD trinessa (28) LC intravenous trinessa lo GD liothyronine sodium oral GD tri-previfem LC methimazole oral GD tri-sprintec LC nature-throid oral tablet trivora (28) GD 130 mg, 16.25 mg, 195 GD tri-vylibra LC mg, 32.5 mg, 65 mg NS SP tulana LC PARSABIV GD tydemy GD propylthiouracil oral velivet GD unithroid direct oral tablet 100 mcg, 112 mcg, 125 vienva GD mcg, 150 mcg, 175 mcg, LC vyfemla GD 200 mcg, 25 mcg, 50 vylibra LC mcg, 75 mcg, 88 mcg unithroid direct oral tablet wera GD GD 300 mcg wymzya fe GD xulane GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

55 Drug Drug Drug Name Notes Drug Name Notes Tier Tier unithroid oral tablet 100 COSENTYX mcg, 112 mcg, 125 mcg, SENSOREADY PEN 137 mcg, 150 mcg, 175 LC SUBCUTANEOUS NS PA; SP mcg, 200 mcg, 25 mcg, SOLUTION AUTO- 50 mcg, 75 mcg, 88 mcg INJECTOR 150 MG/ML unithroid oral tablet 300 GD CUVITRU mcg SUBCUTANEOUS PS PA; SP westhroid oral tablet 130 SOLUTION 1 GM/5ML, 2 GD mg, 32.5 mg, 65 mg GM/10ML, 4 GM/20ML Immunological Agents - Drugs for Immune CUVITRU System Stimulation or Suppression SUBCUTANEOUS NS PA; SP SOLUTION 8 GM/40ML ACTEMRA NS PA; SP cyclosporine intravenous GD ACTIMMUNE PS SP cyclosporine modified GD ALFERON N PS SP cyclosporine oral capsule GD ARCALYST NS PA; SP CYTOGAM PS PA; SP ATGAM BD ENBREL MINI NS PA; SP azathioprine oral GD ENBREL azathioprine sodium GD SUBCUTANEOUS NS PA; SP BENLYSTA NS PA; SP SOLUTION PREFILLED BERINERT PS PA; SP SYRINGE BIVIGAM PS PA; SP ENBREL SUBCUTANEOUS NS PA; SP carimune nf intravenous SOLUTION GS PA; SP solution reconstituted 12 RECONSTITUTED gm, 6 gm ENBREL SURECLICK CIMZIA PREFILLED KIT PS PA; SP SUBCUTANEOUS NS PA; SP CIMZIA STARTER KIT PS PA; SP SOLUTION AUTO- CIMZIA VIAL KIT PS PA; SP INJECTOR CINRYZE PS PA; SP ENTYVIO NS PA; SP COSENTYX 150 MG/ML NS PA; SP FIRAZYR PS PA; SP COSENTYX 300 DOSE NS PA; SP FLEBOGAMMA DIF PS PA; SP COSENTYX GAMASTAN PS PA; SP SENSOREADY 300 NS PA; SP gamastan s/d injectable GS PA; SP DOSE intramuscular GAMASTAN S/D INJECTABLE PS PA; SP INTRAMUSCULAR

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

56 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GAMMAGARD PS PA; SP HUMIRA SUBCUTANEOUS GAMMAGARD S/D PS PA; SP PS PA; SP LESS IGA PREFILLED SYRINGE KIT GAMMAKED PS PA; SP HYPERRAB NS SP GAMMAPLEX INTRAVENOUS HYPERRHO S/D SOLUTION 10 INTRAMUSCULAR PS SP GM/100ML, 10 SOLUTION PREFILLED PS PA; SP GM/200ML, 20 SYRINGE GM/200ML, 20 HYQVIA NS PA; SP GM/400ML, 5 ILARIS GM/100ML, 5 GM/50ML SUBCUTANEOUS PS PA; SP; QL GAMUNEX-C PS PA; SP SOLUTION NS PA; SP gengraf oral capsule 100 GD KEVZARA mg, 25 mg KINERET GD gengraf oral solution SUBCUTANEOUS NS PA; SP HAEGARDA NS PA; SP SOLUTION PREFILLED SYRINGE HIZENTRA SUBCUTANEOUS KYMRIAH NS PA; SP SOLUTION 1 GM/5ML, PS PA; SP leflunomide oral GD 10 GM/50ML, 2 methotrexate oral GD GM/10ML, 4 GM/20ML methotrexate sodium (pf) HUMIRA PEDIATRIC injection solution 1 GD CROHNS START gm/40ml, 250 mg/10ml, SUBCUTANEOUS 50 mg/2ml PREFILLED SYRINGE PS PA; SP KIT 40 MG/0.8ML, 80 methotrexate sodium MG/0.8ML, 80 MG/0.8ML injection solution 250 GD & 40MG/0.4ML mg/10ml, 50 mg/2ml HUMIRA PEN methotrexate sodium SUBCUTANEOUS PEN- PS PA; SP injection solution GD INJECTOR KIT reconstituted HUMIRA PEN- methotrexate sodium oral GD PS PA; SP CD/UC/HS STARTER MICRHOGAM ULTRA- FILTERED PLUS HUMIRA PEN-PS/UV PS PA; SP STARTER INTRAMUSCULAR PS SP SOLUTION PREFILLED SYRINGE mycophenolate mofetil GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

57 Drug Drug Drug Name Notes Drug Name Notes Tier Tier mycophenolate mofetil sirolimus oral GD GD hcl STELARA PS PA; SP mycophenolate sodium GD INTRAVENOUS nabi-hb GD STELARA OCTAGAM PS PA; SP SUBCUTANEOUS PS PA; SP SOLUTION 45 OLUMIANT NS SP MG/0.5ML ORENCIA CLICKJECT NS PA; SP STELARA SUBCUTANEOUS ORENCIA NS PA; SP PS PA; SP INTRAVENOUS SOLUTION PREFILLED ORENCIA SYRINGE SYNAGIS PS PA; SP SUBCUTANEOUS NS PA; SP SOLUTION PREFILLED tacrolimus oral GD SYRINGE temsirolimus GS SP OTEZLA ORAL TABLET PS PA; SP TREMFYA PS PA; SP OTEZLA ORAL TABLET PS PA; SP THERAPY PACK WINRHO SDF PS SP PRIVIGEN PS PA; SP XELJANZ NS PA; SP XELJANZ XR NS PA; SP PROGRAF BD INTRAVENOUS Immunological Agents - Drugs for Vaccination REMICADE PS PA; SP GD RENFLEXIS NS PA; SP bcg vaccine RHOGAM ULTRA- diphtheria-tetanus GD FILTERED PLUS toxoids dt INTRAMUSCULAR PS SP pneumovax 23 GD SOLUTION PREFILLED tetanus-diphtheria GD SYRINGE toxoids td RUCONEST NS PA; SP yf-vax GD SILIQ NS PA; SP Inflammatory Bowel Disease Agents SIMPONI ARIA PS PA; SP ana-lex GD SIMPONI balsalazide disodium GD SUBCUTANEOUS PS PA; SP budesonide er oral tablet SOLUTION AUTO- GD INJECTOR extended release 24 hour GD SIMPONI budesonide oral colocort GD SUBCUTANEOUS PS PA; SP SOLUTION PREFILLED SYRINGE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

58 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydrocortisone ace- ibandronate sodium oral GD pramoxine rectal cream GD NATPARA NS PA; SP; QL 1-1 % pamidronate disodium GS SP hydrocortisone rectal GD paricalcitol GD lidocaine-hydrocortisone GD ace rectal PROLIA PS PA; SP; QL mesalamine oral GD RAYALDEE BD mesalamine rectal GD risedronate sodium oral tablet 150 mg, 30 mg, 35 GD mesalamine-cleanser GD mg, 5 mg procto-med hc GD risedronate sodium oral GD procto-pak GD tablet delayed release proctosol hc GD TYMLOS PS PA; SP proctozone-hc rectal GD zoledronic acid GS SP sulfasalazine oral GD intravenous concentrate zoledronic acid Metabolic Bone Disease Agents - Drugs for GS SP Osteoporosis intravenous solution alendronate sodium oral ZOMETA GD solution INTRAVENOUS NS SP SOLUTION alendronate sodium oral tablet 10 mg, 40 mg, 5 GD Miscellaneous Therapeutic Agents mg acetylcysteine GD intravenous alendronate sodium oral LC tablet 35 mg, 70 mg ACTHREL NS SP calcitonin (salmon) GD albuked 25 GD GD calcitriol intravenous GD albuked 5 solution 1 mcg/ml albumin human GD GD calcitriol oral albuminar-25 GD GD doxercalciferol albuminar-5 GD etidronate disodium GD albutein GD FORTEO antivenin latrodectus SUBCUTANEOUS GD PS PA; SP mactans SOLUTION 600 antivenin micrurus fulvius MCG/2.4ML GD intravenous ibandronate sodium intravenous solution 3 GD arnica flower GD mg/3ml asilnasal rms GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

59 Drug Drug Drug Name Notes Drug Name Notes Tier Tier boric acid external heparin lock flush GD granules intravenous solution 1 GD BOTOX PS PA; SP unit/ml, 10 unit/ml, 100 unit/ml buminate GD heparin sodium flush calcium disodium intravenous kit 100-0.9 GD versenate injection GD unit/ml-% solution 1 gm/5ml heparin sodium lock flush chlorhexidine gluconate GD intravenous solution 100 GD solution 20 % unit/ml citrus bergamot GD human albumin grifols GD deferoxamine mesylate GD HYALGAN NS PA; SP dexmedetomidine hcl GD HYMOVIS NS PA; SP DUROLANE INTRA- NS PA; SP infed GD ARTICULAR KALBITOR NS PA; SP DYSPORT NS PA; SP l-cysteine hcl intravenous GD ergoloid mesylates oral GD l-methylfolate GD EUFLEXXA INTRA- ARTICULAR SOLUTION PS PA; SP l-methylfolate calcium GD PREFILLED SYRINGE oral flexbumin GD methergine oral GD flumazenil intravenous GD methylene blue injection GD folbic GD methylergonovine GD maleate injection fomepizole intravenous GD solution 1.5 gm/1.5ml MONOVISC NS PA; SP formadon GD MYALEPT NS PA; SP NS PA; SP formaldehyde GD MYOBLOC GD forma-ray GD niva-fol GEL-ONE INTRA- ORTHOVISC INTRA- ARTICULAR NS PA; SP ARTICULAR SOLUTION NS PA; SP PREFILLED SYRINGE PREFILLED SYRINGE GELSYN-3 NS PA; SP plasbumin-25 GD GENVISC 850 NS PA; SP plasbumin-5 GD glutaraldehyde external GD pralidoxime chloride intramuscular solution GD auto-injector psorizide forte GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

60 Drug Drug Drug Name Notes Drug Name Notes Tier Tier red yeast rice oral dexamethasone sodium GD GD powder phosphate ophthalmic sodium nitrite GD diclofenac sodium GD intravenous ophthalmic sodium saccharin powder GD epinastine hcl GD sodium thiosulfate erythromycin ophthalmic GD intravenous solution 25 GD fluorometholone GD % ophthalmic NS SP SOLESTA flurbiprofen sodium GD NS PA; SP SUPARTZ FX FML FORTE BD SYNVISC INTRA- gatifloxacin ophthalmic GD ARTICULAR SOLUTION PS PA; SP gentak ophthalmic PREFILLED SYRINGE GD ointment SYNVISC ONE INTRA- gentamicin sulfate ARTICULAR SOLUTION PS PA; SP GD PREFILLED SYRINGE ophthalmic solution THYROGEN PS PA; SP ILUVIEN INTRAVITREAL NS SP ketorolac tromethamine traumeel oral tablet GD GD ophthalmic VISCO-3 INTRA- NS PA; SP ARTICULAR SOLUTION levofloxacin ophthalmic GD XEOMIN moxifloxacin hcl GD INTRAMUSCULAR ophthalmic SOLUTION NS PA; SP ofloxacin ophthalmic GD RECONSTITUTED 200 olopatadine hcl GD UNIT ophthalmic XIAFLEX PS PA; SP OZURDEX NS SP XURIDEN NS PA; SP; QL INTRAVITREAL Ophthalmic Agents - Drugs for Eye Allergy, prednisolone acetate GD Infection and Inflammation ophthalmic azelastine hcl ophthalmic GD prednisolone sodium GD bacitracin ophthalmic GD phosphate ophthalmic RETISERT bromfenac sodium (once- GD NS SP daily) INTRAVITREAL sulfacetamide sodium ciprofloxacin hcl GD GD ophthalmic ophthalmic tobramycin ophthalmic LC cromolyn sodium GD ophthalmic trifluridine ophthalmic GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

61 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Ophthalmic Agents - Drugs for Glaucoma altafrin ophthalmic GD apraclonidine hcl GD solution 10 %, 2.5 % betaxolol hcl ophthalmic GD atropine sulfate GD ophthalmic ointment bimatoprost ophthalmic GD atropine sulfate LC brimonidine tartrate GD ophthalmic solution ophthalmic bacitracin-polymyxin b GD carteolol hcl ophthalmic ointment 500- GD dorzolamide hcl GD 10000 unit/gm ophthalmic bacitra-neomycin- GD dorzolamide hcl-timolol GD polymyxin-hc mal cyclopentolate hcl GD latanoprost ophthalmic GD ophthalmic levobunolol hcl CYSTARAN NS PA; SP; QL GD ophthalmic solution 0.5 EYLEA INTRAVITREAL NS SP % homatropaire GD LUMIGAN OPHTHALMIC BD homatropine hbr GD SOLUTION 0.01 % ophthalmic methazolamide oral GD JETREA INTRAVITREAL SOLUTION 0.375 NS SP GD metipranolol MG/0.3ML pilocarpine hcl LUCENTIS GD PS SP ophthalmic solution 1 %, INTRAVITREAL 2 %, 4 % neomycin-bacitracin zn- GD timolol maleate polymyx ophthalmic gel forming GD solution neomycin-polymyxin- dexameth ophthalmic LC timolol maleate ointment ophthalmic solution 0.25 LC %, 0.5 % neomycin-polymyxin- dexameth ophthalmic LC timolol maleate suspension 3.5-10000- GD ophthalmic solution 0.5 0.1 % (daily) neomycin-polymyxin- BD TRAVATAN Z gramicidin ophthalmic GD Ophthalmic Agents - Drugs for solution 1.75-10000-.025 Miscellaneous Eye Conditions neomycin-polymyxin-hc altacaine GD ophthalmic suspension GD 3.5-10000-1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

62 Drug Drug Drug Name Notes Drug Name Notes Tier Tier neo-polycin GD benzonatate oral capsule GD neo-polycin hc GD 150 mg phenylephrine hcl biotuss pediatric GD ophthalmic solution 10 GD bromfed dm GD %, 2.5 % brompheniramine GD polycin GD maleate intramuscular polymyxin b-trimethoprim LC brompheniramine tannate oral tablet GD proparacaine hcl GD ophthalmic chewable carbinoxamine maleate sulfacetamide- GD prednisolone ophthalmic GD oral solution solution carbinoxamine maleate GD tetcaine GD oral tablet tetracaine hcl ophthalmic GD cetirizine hcl oral solution GD tetravisc GD CINQAIR NS PA; SP clemastine fumarate oral tetravisc forte GD GD tablet 2.68 mg tobramycin- GD dexamethasone cyproheptadine hcl oral GD desloratadine GD tropicamide- GD cyclopentolate-pe diphenhydramine hcl GD VISUDYNE NS SP injection Otic Agents - Drugs for Ear Conditions diphenhydramine hcl oral GD elixir acetic acid otic GD FASENRA NS PA; SP ciprofloxacin hcl otic GD flunisolide nasal solution GD fluocinolone acetonide GD 25 mcg/act (0.025%) otic fluticasone propionate GD hydrocortisone-acetic GD nasal acid giltuss pediatric oral neomycin-polymyxin-hc GD GD liquid otic hydrocodone polst-cpm ofloxacin otic GD polst er oral suspension GD Respiratory Tract / Pulmonary Agents - extended release 10-8 Drugs for Allergies, Cough, Cold mg/5ml azelastine hcl nasal GD hydrocodone- GD homatropine benzonatate oral capsule LC 100 mg, 200 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

63 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ipratropium bromide pulmosal GD LC nasal ryvent GD levocetirizine GD sodium chloride dihydrochloride oral inhalation nebulization GD mometasone furoate GD solution 0.9 %, 10 %, 3 nasal %, 7 % nebusal inhalation GD triamcinolone acetonide GD nebulization solution 3 % nasal aerosol NUCALA NS PA; SP; QL XOLAIR PS PA; SP olopatadine hcl nasal GD Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung phenadoz GD Conditions phenylephrine- GD GD guaifenesin oral liquid acetylcysteine inhalation BD promethazine hcl ADVAIR DISKUS GD injection ADVAIR HFA BD promethazine hcl oral albuterol sulfate er GD LC solution albuterol sulfate inhalation nebulization promethazine hcl oral LC syrup solution (2.5 mg/3ml) GD 0.083%, 0.63 mg/3ml, promethazine hcl oral GD tablet 12.5 mg, 50 mg 1.25 mg/3ml promethazine hcl oral albuterol sulfate LC LC tablet 25 mg inhalation nebulization solution (5 mg/ml) 0.5% promethazine hcl rectal GD albuterol sulfate oral GD promethazine-codeine GD aminophylline oral syrup GD intravenous promethazine-dm LC ARALAST NP promethazine-phenyleph- GD INTRAVENOUS codeine SOLUTION NS PA; SP promethazine- RECONSTITUTED 1000 GD phenylephrine MG, 500 MG promethegan GD ARNUITY ELLIPTA BD AUVI-Q INJECTION pseudoeph-chlorphen- GD SOLUTION AUTO- hydrocod BD pseudoephedrine- INJECTOR 0.1 bromphen-dm oral syrup GD MG/0.1ML 30-2-10 mg/5ml BREO ELLIPTA BD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

64 Drug Drug Drug Name Notes Drug Name Notes Tier Tier budesonide inhalation GD PROLASTIN-C COMBIVENT RESPIMAT BD INTRAVENOUS SOLUTION NS PA; SP cromolyn sodium GD RECONSTITUTED 1000 inhalation MG DALIRESP BD PULMICORT BD difil-g forte GD FLEXHALER EPINEPHRINE SEREVENT DISKUS BD INJECTION SOLUTION Made by SPIRIVA HANDIHALER BD BD AUTO-INJECTOR 0.15 Mylan MG/0.3ML, 0.3 SPIRIVA RESPIMAT MG/0.3ML INHALATION AEROSOL SOLUTION 1.25 BD ESBRIET NS PA; SP MCG/ACT, 2.5 FLOVENT DISKUS BD MCG/ACT FLOVENT HFA BD STIOLTO RESPIMAT FLUTICASONE- INHALATION AEROSOL GD BD SALMETEROL SOLUTION 2.5-2.5 MCG/ACT GLASSIA NS PA; SP SYMBICORT BD INCRUSE ELLIPTA BD terbutaline sulfate GD ipratropium bromide LC injection inhalation terbutaline sulfate oral GD ipratropium-albuterol GD theochron oral tablet levalbuterol hcl inhalation extended release 12 hour GD nebulization solution 0.31 100 mg, 200 mg, 300 mg mg/3ml, 0.63 mg/3ml, GD GD 1.25 mg/0.5ml, 1.25 theophylline mg/3ml theophylline er GD metaproterenol sulfate theophylline in d5w GD oral intravenous solution 0.8- GD montelukast sodium oral LC 5 mg/ml-% BD OFEV NS PA; SP VENTOLIN HFA GD PROAIR HFA BD zafirlukast NS PA; SP PROLASTIN-C ZEMAIRA INTRAVENOUS NS PA; SP zileuton er GD SOLUTION Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis BETHKIS PS SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

65 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CAYSTON NS PA; SP VENTAVIS NS PA; SP; QL KALYDECO NS PA; SP Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ORKAMBI ORAL NS SP PACKET baclofen external GD baclofen oral tablet 10 ORKAMBI ORAL NS PA; SP; QL LC TABLET mg PS PA; SP PULMOZYME baclofen oral tablet 20 GD SYMDEKO NS PA; SP; QL mg, 5 mg tobramycin nebulization carisoprodol oral tablet GD solution 300 mg/5ml GS SP 250 mg carisoprodol oral tablet inhalation LC Respiratory Tract / Pulmonary Agents - 350 mg Drugs for Pulmonary Hypertension carisoprodol-aspirin GD ADEMPAS PS PA; SP; QL chlorzoxazone oral tablet GD epoprostenol sodium GS PA; SP 500 mg cyclobenzaprine hcl oral LETAIRIS PS PA; SP; QL LC tablet 10 mg, 5 mg OPSUMIT PS PA; SP; QL cyclobenzaprine hcl oral GD ORENITRAM NS PA; SP tablet 7.5 mg REMODULIN PS PA; SP dantrolene sodium oral GD REVATIO ORAL metaxall GD SUSPENSION NS PA; SP; QL RECONSTITUTED metaxalone GD methocarbamol injection sildenafil citrate GS PA; SP GD intravenous solution 1000 mg/10ml methocarbamol oral LC sildenafil citrate oral GS PA; SP; QL tablet 20 mg orphenadrine citrate er GD tadalafil (pah) GS PA; SP; QL orphenadrine citrate GD TRACLEER ORAL injection PS PA; SP; QL TABLET revonto GD TRACLEER ORAL tizanidine hcl oral GD NS PA; SP; QL TABLET SOLUBLE Sleep Disorder Agents TYVASO NS PA; SP; QL armodafinil GD TYVASO REFILL NS PA; SP; QL eszopiclone GD TYVASO STARTER NS PA; SP; QL flurazepam hcl GD UPTRAVI NS PA; SP; QL HETLIOZ NS PA; SP; QL VELETRI NS PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

66 Drug Drug Name Notes Tier modafinil GD temazepam GD XYREM NS PA; SP; QL zaleplon GD zolpidem tartrate GD zolpidem tartrate er GD

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

67 Index of Drugs 7t lido...... 10 albuminar-5...... 59 amlodipine-olmesartan...... 31 abacavir sulfate...... 27 albutein...... 59 amlodipine-valsartan-hctz...31 abacavir sulfate-lamivudine 27 albuterol sulfate...... 64 ammonium lactate...... 37 abacavir-lamivudine- albuterol sulfate er...... 64 amnesteem...... 37 zidovudine...... 27 alclometasone amoxapine...... 18 ABRAXANE...... 21 dipropionate...... 48 amoxicill-clarithro- acamprosate calcium...... 11 alcohol...... 41 lansopraz...... 46 acarbose...... 40 ALDURAZYME...... 47 amoxicillin...... 12 ACCU-CHEK MULTICLIX ALECENSA...... 21 amoxicillin-potassium LANCETS...... 40 alendronate sodium...... 59 clavulanate...... 12 ACCU-CHEK SOFT alfentanil hcl...... 7 amoxicillin-potassium TOUCH LANCETS...... 40 ALFERON N...... 56 clavulanate er...... 12 ACCU-CHEK SOFTCLIX alfuzosin hcl er...... 48 amphetamine- LANCETS...... 40 ALIMTA...... 21 dextroamphetamine...... 36 acebutolol hcl...... 31 ALIQOPA...... 21 amphetamine- acetaminophen-codeine...... 7 allopurinol...... 20 dextroamphetamine er...... 36 acetaminophen-codeine #2.. 7 allopurinol sodium...... 20 amphotericin b...... 19 acetaminophen-codeine #3.. 7 almotriptan malate...... 20 ampicillin...... 12 acetaminophen-codeine #4.. 7 alosetron hcl...... 46 ampicillin sodium...... 12 acetazolamide...... 31 ALPHANATE/VWF ampicillin-sulbactam acetazolamide er...... 31 COMPLEX/HUMAN...... 29 sodium...... 12 acetazolamide sodium...... 31 ALPHANINE SD...... 29 AMPYRA...... 36 acetic acid...... 63 alprazolam...... 28 anagrelide hcl...... 29 acetylcysteine...... 59, 64 alprazolam er...... 28 ana-lex...... 58 acitretin...... 37 ALPROLIX...... 29 anastrozole...... 21 ACTEMRA...... 56 alprostadil...... 31 ANDRODERM...... 50 ACTHREL...... 59 altacaine...... 62 antivenin latrodectus ACTIMMUNE...... 56 altafrin...... 62 mactans...... 59 acyclovir...... 27 altavera...... 52 antivenin micrurus fulvius... 59 acyclovir sodium...... 27 ALUNBRIG...... 21 apap-caff-dihydrocodeine..... 7 adapalene...... 37 amabelz...... 52 apexicon e...... 48 adapalene-benzoyl amantadine hcl...... 26 APOKYN...... 26 peroxide...... 37 amcinonide...... 48 apraclonidine hcl...... 62 ADCETRIS...... 21 amethia...... 52 aprepitant...... 19 adefovir dipivoxil...... 27 amethia lo...... 52 apri...... 52 ADEMPAS...... 66 amikacin sulfate...... 12 ARALAST NP...... 64 adenosine...... 31 amiloride hcl...... 31 aranelle...... 52 adriamycin...... 21 amiloride- ARCALYST...... 56 adrucil...... 21 hydrochlorothiazide...... 31 argatroban...... 16 ADVAIR DISKUS...... 64 aminoam rms...... 41 argatroban in sodium ADVAIR HFA...... 64 aminocaproic acid...... 29 chloride...... 16 ADVATE...... 29 aminophylline...... 64 aripiprazole...... 26 afeditab cr...... 31 aminorelief rms...... 41 ARISTADA...... 26 AFINITOR...... 21 aminosyn ii/electrolytes...... 41 armodafinil...... 66 AFINITOR DISPERZ...... 21 aminosyn/electrolytes...... 41 arnica flower...... 59 AFREZZA...... 41 amiodarone hcl...... 31 ARNUITY ELLIPTA...... 64 AFSTYLA...... 29 amitriptyline hcl...... 18 ARRANON...... 21 airavite...... 41 amlodipine besylate...... 31 ARZERRA...... 21 ALBENZA...... 25 amlodipine besylate- arzol silver nit applicators... 37 albuked 25...... 59 benazepril hcl...... 31 ascomp-codeine...... 7 albuked 5...... 59 amlodipine besylate- ascorbic acid...... 41 albumin human...... 59 valsartan...... 31 ashlyna...... 52 albuminar-25...... 59 amlodipine-atorvastatin...... 31 asilnasal rms...... 59 68 aspirin-dipyridamole er...... 26 benazepril- BOTOX...... 60 atazanavir sulfate...... 27 hydrochlorothiazide...... 31 BRAFTOVI...... 21 atenolol...... 31 BENDEKA...... 21 BREO ELLIPTA...... 64 atenolol-chlorthalidone...... 31 BENEFIX...... 29 brimonidine tartrate...... 62 ATGAM...... 56 BENLYSTA...... 56 BRINEURA...... 47 atomoxetine hcl...... 36 benzalkonium chloride...... 12 bromfed dm...... 63 atorvastatin calcium...... 31 benzepro...... 37 bromfenac sodium (once- atovaquone...... 25 benzepro creamy wash...... 38 daily)...... 61 atovaquone-proguanil hcl... 25 benzepro foaming cloths.....38 bromocriptine mesylate...... 26 atracurium besylate...... 37 benzepro short contact...... 38 brompheniramine maleate.. 63 atropine sulfate...... 46, 62 benziq wash...... 38 brompheniramine tannate...63 AUBAGIO...... 36 BENZNIDAZOLE...... 25 budesonide...... 58, 65 aubra...... 52 benzoin...... 38 budesonide er...... 58 aubra eq...... 52 benzoin compound...... 38 bumetanide...... 31 AUSTEDO...... 37 benzonatate...... 63 buminate...... 60 AUVI-Q...... 64 benzoyl peroxide...... 38 bupivacaine hcl...... 10 avar cleanser...... 37 benzoyl peroxide- bupivacaine hcl (pf)...... 10 avar-e emollient...... 37 erythromycin...... 38 bupivacaine-epinephrine.....11 avar-e green...... 37 benzphetamine hcl...... 37 bupivacaine-epinephrine AVASTIN...... 21 benztropine mesylate...... 26 (pf)...... 10 aviane...... 52 BERINERT...... 56 buprenorphine hcl...... 7, 11 avita...... 37 BESPONSA...... 21 buprenorphine hcl- AVONEX PEN...... 36 betamethasone naloxone hcl...... 11 AVONEX PREFILLED...... 36 dipropionate...... 48 bupropion hcl...... 18 AVONEX VIAL betamethasone bupropion hcl er (smoking INTRAMUSCULAR KIT..... 36 dipropionate aug...... 48 det)...... 11 azacitidine...... 21 betamethasone sod phos bupropion hcl er (sr)...... 18 azathioprine...... 56 & acet...... 48 bupropion hcl er (xl)...... 18 azathioprine sodium...... 56 betamethasone valerate..... 48 buspirone hcl...... 28 azelastine hcl...... 61, 63 BETASERON...... 36 busulfan...... 21 azithromycin...... 12 betaxolol hcl...... 31, 62 butalbital-acetaminophen...... 7 aztreonam...... 12 bethanechol chloride...... 47 butalbital-apap...... 7 azurette...... 52 BETHKIS...... 65 butalbital-apap-caff-cod...... 7 b-6 folic acid...... 41 BEVYXXA...... 16 butalbital-apap-caffeine...... 7 bacitracin...... 12, 61 bexarotene...... 21 butalbital-asa-caff-codeine....7 bacitracin-polymyxin b...... 62 bicalutamide...... 21 butalbital-aspirin-caffeine...... 7 bacitra-neomycin- BICNU...... 21 butorphanol tartrate...... 7 polymyxin-hc...... 62 BIKTARVY...... 27 BYDUREON...... 40 baclofen...... 66 bimatoprost...... 62 BYETTA 10 MCG PEN...... 40 balsalazide disodium...... 58 biotuss pediatric...... 63 BYETTA 5 MCG PEN...... 40 balziva...... 52 bisoprolol fumarate...... 31 cabergoline...... 50 BARACLUDE...... 27 bisoprolol- CABOMETYX...... 21 BAVENCIO...... 21 hydrochlorothiazide...... 31 caffeine citrate...... 37 bcg vaccine...... 58 bivalirudin trifluoroacetate...16 caffeine-sodium benzoate...37 bd posiflush...... 41 BIVIGAM...... 56 calcipotriene...... 38 bd pudendal/local tray/1% bleomycin sulfate...... 21 calcipotriene-betameth lido...... 10 BLINCYTO...... 21 diprop...... 38 BEBULIN...... 29 blisovi 24 fe...... 52 calcitonin (salmon)...... 59 bekyree...... 52 blisovi fe 1.5/30...... 52 calcitrene...... 38 BELEODAQ...... 21 blisovi fe 1/20...... 52 calcitriol...... 38, 59 belladonna alkaloids-opium 46 boric acid...... 60 calcium acetate...... 47 belladonna-opium...... 46 BORTEZOMIB...... 21 calcium acetate (phos benazepril hcl...... 31 BOSULIF...... 21 binder)...... 47

69 calcium chloride...... 41 cefotaxime sodium...... 13 CIALIS...... 47 calcium disodium cefotetan disodium...... 13 ciclodan...... 19 versenate...... 60 cefotetan disodium- ciclopirox...... 19 calcium gluconate...... 42 dextrose...... 13 ciclopirox olamine...... 19 calcium gluconate- cefoxitin sodium...... 13 cidofovir...... 27 dextrose...... 42 cefoxitin sodium-dextrose... 13 cilostazol...... 26 calcium gluconate-nacl...... 42 cefpodoxime proxetil...... 13 CIMDUO...... 27 CALQUENCE...... 21 cefprozil...... 13 cimetidine...... 45 camila...... 52 ceftazidime...... 13 cimetidine hcl...... 45 CAMPATH...... 21 ceftriaxone sodium...... 13 CIMZIA...... 56 CAMPTOSAR...... 21 ceftriaxone sodium in CIMZIA PREFILLED KIT.... 56 camrese...... 52 dextrose...... 13 CIMZIA STARTER KIT...... 56 camrese lo...... 52 ceftriaxone sodium- CINQAIR...... 63 candesartan cilexetil...... 31 dextrose...... 13 CINRYZE...... 56 candesartan cilexetil-hctz... 31 cefuroxime axetil...... 13 ciprofloxacin...... 13 capecitabine...... 21 cefuroxime sodium...... 13 ciprofloxacin hcl...... 13, 61, 63 CAPRELSA...... 21 celacyn...... 38 ciprofloxacin in d5w...... 13 captopril...... 31 celecoxib...... 9 ciprofloxacin-ciproflox hcl captopril- cem-urea...... 38 er...... 13 hydrochlorothiazide...... 31 cephalexin...... 13 cisatracurium besylate...... 37 CARBAGLU...... 42 CEPROTIN...... 29 cisplatin...... 21 carbamazepine...... 17 ceramax...... 38 citalopram hydrobromide.... 18 carbamazepine er...... 16 CERDELGA...... 47 citrus bergamot...... 60 carbidopa...... 26 CEREZYME...... 47 cladribine...... 21 carbidopa-levodopa...... 26 cerovel...... 38 claravis...... 38 carbidopa-levodopa er...... 26 cetirizine hcl...... 63 clarithromycin...... 13 carbidopa-levodopa- CETROTIDE...... 50 clarithromycin er...... 13 entacapone...... 26 cevimeline hcl...... 37 clemastine fumarate...... 63 carbinoxamine maleate...... 63 chateal...... 52 clindacin etz...... 38 carboplatin...... 21 chateal eq...... 52 clindacin-p...... 38 carimune nf...... 56 chloramphenicol sod clindamycin hcl...... 13 carisoprodol...... 66 succinate...... 13 clindamycin palmitate hcl....13 carisoprodol-aspirin...... 66 chlordiazepoxide hcl...... 28 clindamycin phos-benzoyl carisoprodol-aspirin- chlordiazepoxide- perox...... 38 codeine...... 7 amitriptyline...... 18 clindamycin phosphate carteolol hcl...... 62 chlordiazepoxide-clidinium..46 ...... 13, 14, 38 cartia xt...... 31 chlorhexidine gluconate 37, 60 clindamycin phosphate in carvedilol...... 32 chloroprocaine hcl (pf)...... 11 d5w...... 13 carvedilol phosphate er...... 32 chloroquine phosphate...... 25 clindamycin-tretinoin...... 38 cascara sagrada...... 46 chlorothiazide...... 32 clinimix e/dextrose caspofungin acetate...... 19 chlorothiazide sodium...... 32 (4.25/25)...... 42 CAYSTON...... 66 chlorpromazine hcl...... 26 clinimix/dextrose (4.25/10)..42 caziant...... 52 chlorpropamide...... 40 clinimix/dextrose (4.25/20)..42 cefaclor...... 12 chlorthalidone...... 32 clinimix/dextrose (4.25/25)..42 cefaclor er...... 12 chlorzoxazone...... 66 clinisol sf...... 42 cefadroxil...... 12 CHOLBAM...... 46 clobetasol prop emollient cefazolin sodium...... 12 cholestyramine...... 32 base...... 48 cefazolin sodium-dextrose.. 13 cholestyramine light...... 32 clobetasol propionate...... 48 cefdinir...... 13 choline fenofibrate...... 32 clobetasol propionate cefditoren pivoxil...... 13 choline-mag trisalicylate...... 9 emulsion...... 48 cefepime hcl...... 13 chorionic gonadotropin...... 50 clocortolone pivalate...... 48 cefepime-dextrose...... 13 chromagen...... 42 clocortolone pivalate pump. 48 cefixime...... 13 chromic chloride...... 42 clodan...... 48

70 clofarabine...... 21 CUPRIMINE...... 47 desonide...... 49 clomiphene citrate...... 50 CUVITRU...... 56 desoximetasone...... 49 clomipramine hcl...... 18 cyanocobalamin...... 42 desvenlafaxine succinate clonazepam...... 28 cyclafem 1/35...... 52 er...... 18 clonidine hcl...... 32 cyclafem 7/7/7...... 52 dexamethasone...... 49 clonidine hcl er...... 36 cyclobenzaprine hcl...... 66 dexamethasone sod phos- clopidogrel bisulfate...... 26 cyclopentolate hcl...... 62 nacl...... 49 clorazepate dipotassium..... 28 cyclophosphamide...... 22 dexamethasone sod clotrimazole...... 19 cycloserine...... 20 phosphate pf...... 49 clotrimazole- cyclosporine...... 56 dexamethasone sodium betamethasone...... 38 cyclosporine modified...... 56 phosphate...... 49, 61 clozapine...... 26 cyproheptadine hcl...... 63 dexifol...... 42 COAGADEX...... 29 CYRAMZA...... 22 dexmedetomidine hcl...... 60 coal tar...... 38 cyred...... 52 dexmethylphenidate hcl...... 36 cocaine hcl...... 11 CYSTAGON...... 47 dexmethylphenidate hcl er..36 cod liver oil...... 42 CYSTARAN...... 62 dexrazoxane...... 22 codeine sulfate...... 7 cytarabine...... 22 dextroamphetamine sulfate 36 COLCHICINE...... 20 cytarabine (pf)...... 22 dextroamphetamine sulfate colchicine-probenecid...... 20 CYTOGAM...... 56 er...... 36 COLCRYS...... 20 dacarbazine...... 22 dextrose...... 42 colesevelam hcl...... 32 dactinomycin...... 22 dialyvite...... 42 colestipol hcl...... 32 DAKLINZA...... 27 diazepam...... 17, 28 colistimethate sodium DALIRESP...... 65 diazepam intensol...... 28 (cba)...... 14 danazol...... 50 diclofenac potassium...... 9 colocort...... 58 dantrolene sodium...... 66 diclofenac sodium..... 9, 38, 61 COMBIVENT RESPIMAT... 65 dapsone...... 20, 38 diclofenac sodium er...... 9 COMETRIQ (100 MG daptomycin...... 14 diclofenac-misoprostol...... 10 DAILY DOSE)...... 21 DARAPRIM...... 25 diclofex dc...... 10 COMETRIQ (140 MG darifenacin hydrobromide dicloxacillin sodium...... 14 DAILY DOSE)...... 21 er...... 48 dicyclomine hcl...... 46 COMETRIQ (60 MG DARZALEX...... 22 didanosine...... 27 DAILY DOSE)...... 21 dasetta 1/35...... 52 diethylpropion hcl...... 37 compro...... 19 dasetta 7/7/7...... 52 diethylpropion hcl er...... 37 co-natal fa...... 42 daunorubicin hcl...... 22 difil-g forte...... 65 copper chloride...... 42 daysee...... 52 diflorasone diacetate...... 49 coremino...... 14 deblitane...... 52 diflunisal...... 10 CORIFACT...... 29 decitabine...... 22 digitek...... 32 cortisone acetate...... 48 deferoxamine mesylate...... 60 digox...... 32 corvita...... 42 dehydrated alcohol...... 42 digoxin...... 32 corvita 150...... 42 deltasone...... 48 dihydroergotamine corvite free...... 42 delyla...... 52 mesylate...... 20 COSENTYX 150 MG/ML.... 56 demeclocycline hcl...... 14 diltiazem hcl...... 32 COSENTYX 300 DOSE...... 56 dermacinrx empricaine...... 11 diltiazem hcl er...... 32 COSENTYX dermacinrx prizopak...... 11 diltiazem hcl er beads...... 32 SENSOREADY 300 DOSE.56 desipramine hcl...... 18 diltiazem hcl er coated COSENTYX desloratadine...... 63 beads...... 32 SENSOREADY PEN...... 56 desmopressin ace spray diltiazem hcl-dextrose...... 32 COTELLIC...... 21 refrig...... 50 dimenhydrinate...... 19 CREON...... 47 desmopressin acetate...... 50 diphenhydramine hcl...... 63 cromolyn sodium.....46, 61, 65 desmopressin acetate diphenoxylate-atropine...... 46 crotan...... 25 spray...... 50 diphtheria-tetanus toxoids cryselle-28...... 52 desogestrel-ethinyl dt...... 58 CRYSVITA...... 47 estradiol...... 52 dipyridamole...... 26

71 disopyramide phosphate.....32 EMPLICITI...... 22 eszopiclone...... 66 disulfiram...... 12 enalapril maleate...... 32 ethacrynate sodium...... 32 divalproex sodium...... 17 enalaprilat...... 32 ethacrynic acid...... 32 divalproex sodium er...... 17 enalapril- ethambutol hcl...... 20 dobutamine hcl...... 32 hydrochlorothiazide...... 32 ethosuximide...... 17 dobutamine in d5w...... 32 ENBREL...... 56 ethyl chloride...... 11 docetaxel...... 22 ENBREL MINI...... 56 ethynodiol diac-eth docetaxel (non-alcohol)...... 22 ENBREL SURECLICK...... 56 estradiol...... 53 dofetilide...... 32 endocet...... 7 ETHYOL...... 22 donepezil hcl...... 18 enoxaparin sodium...... 16 etidronate disodium...... 59 dopamine hcl...... 32 enpresse-28...... 52 etodolac...... 10 dopamine in d5w...... 32 enskyce...... 52 etodolac er...... 10 DOPTELET...... 29 entacapone...... 26 ETOPOPHOS...... 22 dorzolamide hcl...... 62 entecavir...... 27 etoposide...... 22 dorzolamide hcl-timolol mal 62 ENTRESTO...... 32 EUCRISA...... 38 doxazosin mesylate...... 32 ENTYVIO...... 56 EUFLEXXA...... 60 doxepin hcl...... 18, 38 EPCLUSA...... 27 EVOMELA...... 22 doxercalciferol...... 59 ephedrine sulfate...... 32 EVOTAZ...... 27 doxorubicin hcl...... 22 epinastine hcl...... 61 exemestane...... 22 doxorubicin hcl liposomal....22 epinephrine...... 32 exoderm...... 19 doxy 100...... 14 EPINEPHRINE...... 65 EXONDYS 51...... 47 doxycycline...... 38 epinephrine pf...... 32 EYLEA...... 62 doxycycline hyclate...... 14 epirubicin hcl...... 22 ezetimibe...... 32 doxycycline monohydrate... 14 epitol...... 17 ezetimibe-simvastatin...... 32 dritho-creme hp...... 38 EPIVIR HBV...... 27 FABRAZYME...... 47 dronabinol...... 19 eplerenone...... 32 falmina...... 53 droperidol...... 19 epoprostenol sodium...... 66 famciclovir...... 27 drospiren-eth estrad- eprosartan mesylate...... 32 famotidine...... 45 levomefol...... 52 eptifibatide...... 26 famotidine premixed...... 45 drospirenone-ethinyl ERBITUX...... 22 FARYDAK...... 22 estradiol...... 52 ergoloid mesylates...... 60 FASENRA...... 63 duloxetine hcl...... 18 ergotamine-caffeine...... 20 FASLODEX...... 22 DUPIXENT...... 38 ERIVEDGE...... 22 fa-vitamin b-6-vitamin b-12. 42 DUROLANE...... 60 ERLEADA...... 22 fayosim...... 53 dutasteride...... 48 errin...... 53 FEIBA...... 29 dutasteride-tamsulosin hcl.. 48 ertapenem sodium...... 14 felbamate...... 17 DYSPORT...... 60 ERWINAZE...... 22 felodipine er...... 32 e.e.s. 400...... 14 erythrocin lactobionate...... 14 femynor...... 53 econazole nitrate...... 19 erythromycin...... 38, 61 fenofibrate...... 33 efavirenz...... 27 erythromycin base...... 14 fenofibrate micronized...... 32 effer-k...... 42 erythromycin fenofibric acid...... 33 EGRIFTA...... 50 ethylsuccinate...... 14 fenoprofen calcium...... 10 ELAPRASE...... 47 ESBRIET...... 65 fenortho...... 10 ELELYSO...... 47 escitalopram oxalate...... 18 fentanyl...... 7 eletriptan hydrobromide...... 20 esgic...... 7 fentanyl citrate...... 7 ELIGARD...... 50 esmolol hcl...... 32 fentanyl citrate-nacl...... 7 elinest...... 52 esomeprazole sodium...... 45 ferrocite plus...... 42 ELIQUIS...... 16 estarylla...... 53 FIBRYGA...... 29 ELIQUIS STARTER PACK. 16 estazolam...... 29 finasteride...... 48 elite-ob...... 42 estradiol...... 53 FIRAZYR...... 56 ELOCTATE...... 29 estradiol valerate...... 53 FIRMAGON...... 50 EMFLAZA...... 20 estradiol-norethindrone flavoxate hcl...... 48 emoquette...... 52 acet...... 53 FLEBOGAMMA DIF...... 56

72 flecainide acetate...... 33 fosamprenavir calcium...... 27 glipizide...... 40 flexbumin...... 60 fosinopril sodium...... 33 glipizide er...... 40 floriva...... 42 fosinopril sodium-hctz...... 33 glipizide-metformin hcl...... 40 FLOVENT DISKUS...... 65 fosphenytoin sodium...... 17 GLUCAGON FLOVENT HFA...... 65 FRAGMIN...... 16 EMERGENCY...... 41 floxuridine...... 22 frovatriptan succinate...... 20 glucose...... 42 fluconazole...... 19 furosemide...... 33 glutaraldehyde...... 60 fluconazole in dextrose...... 19 fyavolv...... 53 glyburide...... 40 fluconazole in sodium FYCOMPA...... 17 glyburide micronized...... 40 chloride...... 19 gabapentin...... 17 glyburide-metformin...... 40 flucytosine...... 19 GALAFOLD...... 47 glycolic acid...... 38 fludarabine phosphate...... 22 galantamine hydrobromide. 18 glycopyrrolate...... 46 fludrocortisone acetate...... 49 galantamine hydrobromide glydo...... 11 flumazenil...... 60 er...... 18 GONAL-F...... 50 flunisolide...... 63 GAMASTAN...... 56 GONAL-F RFF...... 50 fluocinolone acetonide.. 49, 63 gamastan s/d...... 56 GONAL-F RFF REDIJECT. 50 fluocinolone acetonide GAMASTAN S/D...... 56 granisetron hcl...... 19 body...... 49 GAMMAGARD...... 57 GRANIX...... 29 fluocinolone acetonide GAMMAGARD S/D LESS griseofulvin microsize...... 19 scalp...... 49 IGA...... 57 griseofulvin ultramicrosize.. 19 fluocinonide...... 49 GAMMAKED...... 57 guanfacine hcl...... 33 fluocinonide emulsified GAMMAPLEX...... 57 guanfacine hcl er...... 36 base...... 49 GAMUNEX-C...... 57 guanidine hcl...... 20 fluoridex daily renewal...... 37 ganciclovir sodium...... 27 HAEGARDA...... 57 fluorometholone...... 61 ganirelix acetate...... 50 HALAVEN...... 22 fluorouracil...... 22, 38 gatifloxacin...... 61 halobetasol propionate...... 49 fluoxetine hcl...... 18 GATTEX...... 46 haloperidol...... 26, 27 fluoxetine hcl (pmdd)...... 18 gavilyte-c...... 46 haloperidol decanoate...... 26 fluphenazine decanoate...... 26 gavilyte-g...... 46 haloperidol lactate...... 26 fluphenazine hcl...... 26 gavilyte-h...... 46 HARVONI...... 27 flurandrenolide...... 49 gavilyte-n with flavor pack...46 heather...... 53 flurazepam hcl...... 66 GAZYVA...... 22 HELIXATE FS...... 29 flurbiprofen...... 10 GELNIQUE...... 48 hematogen...... 42 flurbiprofen sodium...... 61 GELNIQUE PUMP...... 48 hematogen fa...... 42 flutamide...... 22 GEL-ONE...... 60 hematogen forte...... 42 fluticasone propionate...49, 63 GELSYN-3...... 60 HEMLIBRA...... 29 FLUTICASONE- GEMCITABINE HCL...... 22 hemocyte-f...... 42 SALMETEROL...... 65 gemcitabine hcl...... 22 hemofil m...... 29 fluvastatin sodium...... 33 gemfibrozil...... 33 HEMOFIL M...... 29 fluvastatin sodium er...... 33 gengraf...... 57 heparin (porcine) in d5w..... 16 fluvoxamine maleate...... 18 gentak...... 61 heparin (porcine) in nacl..... 16 fluvoxamine maleate er...... 18 gentamicin in saline...... 14 heparin lock flush...... 60 FML FORTE...... 61 gentamicin sulfate...... 14, 61 heparin sod (porcine) in folbee plus cz...... 42 GENVISC 850...... 60 d5w...... 16 folbic...... 60 gianvi...... 53 heparin sodium (porcine).... 16 folic acid...... 42 GILENYA...... 36 heparin sodium (porcine) FOLOTYN...... 22 GILOTRIF...... 22 pf...... 16 fomepizole...... 60 giltuss pediatric...... 63 heparin sodium flush...... 60 fondaparinux sodium...... 16 GLASSIA...... 65 heparin sodium lock flush... 60 formadon...... 60 glatiramer acetate...... 36 hepatamine...... 42 formaldehyde...... 60 glatopa...... 36 HERCEPTIN...... 22 forma-ray...... 60 GLEOSTINE...... 22 hetastarch-nacl...... 29 FORTEO...... 59 glimepiride...... 40 HETLIOZ...... 66

73 HIZENTRA...... 57 hydrocortisone in indomethacin er...... 10 homatropaire...... 62 absorbase...... 49 indomethacin sodium...... 10 homatropine hbr...... 62 hydrocortisone valerate...... 49 infed...... 60 HP ACTHAR...... 51 hydrocortisone-acetic acid.. 63 inflammacin...... 10 HUMALOG KWIKPEN...... 41 hydrogen peroxide...... 14 infuvite adult...... 42 HUMALOG MIX 50/50 hydromorphone hcl...... 7 infuvite pediatric...... 42 KWIKPEN...... 41 hydromorphone hcl er...... 7 INLYTA...... 23 HUMALOG MIX 50/50 hydromorphone hcl pf...... 7 INSULIN PEN NEEDLES... 41 VIAL...... 41 hydromorphone hcl-nacl...... 8 INSULIN SYRINGES...... 41 HUMALOG MIX 75/25 hydroxocobalamin...... 42 intralipid...... 42 KWIKPEN...... 41 hydroxychloroquine sulfate. 25 INTRON A...... 27 HUMALOG MIX 75/25 hydroxyprogesterone introvale...... 53 VIAL...... 41 caproate...... 53 INVOKAMET...... 40 HUMALOG U-100 JUNIOR hydroxyurea...... 22 INVOKAMET XR...... 40 KWIKPEN...... 41 hydroxyzine hcl...... 29 INVOKANA...... 40 HUMALOG U-100 VIAL hydroxyzine pamoate...... 29 iodine strong...... 42 AND CARTRIDGE...... 41 HYMOVIS...... 60 iodine tincture...... 14 human albumin grifols...... 60 hyophen...... 48 ipratropium bromide...... 64, 65 HUMATE-P...... 29 hyoscyamine sulfate...... 46 ipratropium-albuterol...... 65 HUMIRA...... 57 hyoscyamine sulfate er...... 46 irbesartan...... 33 HUMIRA PEDIATRIC hyoscyamine sulfate sl...... 46 irbesartan- CROHNS START...... 57 HYPERRAB...... 57 hydrochlorothiazide...... 33 HUMIRA PEN...... 57 HYPERRHO S/D...... 57 IRESSA...... 23 HUMIRA PEN-CD/UC/HS HYQVIA...... 57 irinotecan hcl...... 23 STARTER...... 57 ibandronate sodium...... 59 ISENTRESS...... 27 HUMIRA PEN-PS/UV IBRANCE...... 22 ISENTRESS HD...... 27 STARTER...... 57 ibudone...... 8 isibloom...... 53 HUMULIN 70/30 ibuprofen...... 10 isoniazid...... 20, 21 KWIKPEN...... 41 ibuprofen lysine...... 10 isoproterenol hcl...... 33 HUMULIN 70/30 VIAL...... 41 ibutilide fumarate...... 33 isosorbide dinitrate...... 33 HUMULIN N KWIKPEN...... 41 ICLUSIG...... 23 isosorbide dinitrate er...... 33 HUMULIN N VIAL...... 41 idarubicin hcl...... 23 isosorbide mononitrate...... 33 HUMULIN R U-500 IDELVION...... 29 isosorbide mononitrate er... 33 KWIKPEN...... 41 IDHIFA...... 23 isotretinoin...... 38 HUMULIN R U-500 VIAL iferex 150 forte...... 42 isradipine...... 33 (CONCENTRATED)...... 41 ifosfamide...... 23 ISTODAX (OVERFILL)...... 23 HUMULIN R VIAL...... 41 ILARIS...... 57 itraconazole...... 19 HYALGAN...... 60 ILUVIEN...... 61 ivermectin...... 25 HYCAMTIN...... 22 imatinib mesylate...... 23 IXEMPRA KIT...... 23 hydralazine hcl...... 33 IMBRUVICA...... 23 IXINITY...... 30 hydrochlorothiazide...... 33 IMFINZI...... 23 JADENU...... 42 hydrocodone polst-cpm imipenem-cilastatin...... 14 JADENU SPRINKLE...... 42 polst er...... 63 imipramine hcl...... 18 JAKAFI...... 23 hydrocodone- imipramine pamoate...... 18 jantoven...... 16 acetaminophen...... 7 imiquimod...... 38 JANUMET...... 40 hydrocodone-homatropine..63 IMLYGIC...... 23 JANUMET XR...... 40 hydrocodone-ibuprofen...... 7 IMPAVIDO...... 25 JANUVIA...... 40 hydrocortisone...... 49, 59 inatal gt...... 42 JARDIANCE...... 40 hydrocortisone ace- incassia...... 53 jencycla...... 53 pramoxine...... 59 INCRELEX...... 51 JETREA...... 62 hydrocortisone butyr lipo INCRUSE ELLIPTA...... 65 JEVTANA...... 23 base...... 49 indapamide...... 33 jinteli...... 53 hydrocortisone butyrate...... 49 indomethacin...... 10 jolessa...... 53

74 jolivette...... 53 k-tan plus...... 43 LENVIMA 4 MG DAILY juleber...... 53 kurvelo...... 53 DOSE...... 23 JULUCA...... 27 KUVAN...... 47 LENVIMA 8 MG DAILY junel 1.5/30...... 53 KYMRIAH...... 57 DOSE...... 23 junel 1/20...... 53 KYNAMRO...... 33 lessina...... 53 junel fe 1.5/30...... 53 KYPROLIS...... 23 LETAIRIS...... 66 junel fe 1/20...... 53 labetalol hcl...... 33 letrozole...... 23 junel fe 24...... 53 lactic acid...... 38 leucovorin calcium...... 23 JUXTAPID...... 33 lactic acid e...... 38 LEUKINE...... 30 JYNARQUE...... 42 lactulose...... 46 leuprolide acetate...... 51 KADCYLA...... 23 lactulose encephalopathy... 46 levalbuterol hcl...... 65 kaitlib fe...... 53 lamivudine...... 27 levetiracetam...... 17 KALBITOR...... 60 lamivudine-zidovudine...... 27 levetiracetam er...... 17 KALYDECO...... 66 lamotrigine...... 17 levetiracetam in nacl...... 17 KANUMA...... 47 lamotrigine er...... 17 levobunolol hcl...... 62 kariva...... 53 lamotrigine starter kit-blue.. 17 levocarnitine...... 43 kelnor 1/35...... 53 lamotrigine starter kit- levocetirizine kelnor 1/50...... 53 green...... 17 dihydrochloride...... 64 KEPIVANCE...... 37 lamotrigine starter kit- levofloxacin...... 14, 61 ketoconazole...... 20 orange...... 17 levofloxacin in d5w...... 14 ketoprofen...... 10 LANCETS...... 40 levoleucovorin calcium...... 23 ketoprofen er...... 10 lansoprazole...... 45 levoleucovorin calcium pf....23 ketorolac tromethamine 10, 61 lanthanum carbonate...... 48 levonest...... 53 KEVEYIS...... 33 LANTUS SOLOSTAR...... 41 levonorgest-eth est & eth KEVZARA...... 57 LANTUS U-100 VIAL...... 41 est...... 53 KEYTRUDA...... 23 larin 1.5/30...... 53 levonorgest-eth estrad 91- KINERET...... 57 larin 1/20...... 53 day...... 53 kionex...... 42 larin 24 fe...... 53 levonorgestrel-ethinyl KISQALI 200 DOSE...... 23 larin fe 1.5/30...... 53 estrad...... 53 KISQALI 400 DOSE...... 23 larin fe 1/20...... 53 levonorg-eth estrad KISQALI 600 DOSE...... 23 larissia...... 53 triphasic...... 53 KISQALI FEMARA 200 LARTRUVO...... 23 levora 0.15/30 (28)...... 53 DOSE...... 23 latanoprost...... 62 levorphanol tartrate...... 8 KISQALI FEMARA 400 latrix xm...... 38 levo-t...... 55 DOSE...... 23 layolis fe...... 53 levothyroxine sodium...... 55 KISQALI FEMARA 600 l-cysteine hcl...... 60 levothyroxine-liothyronine... 55 DOSE...... 23 lecithin...... 43 levoxyl...... 55 klofensaid ii...... 10 leena...... 53 lido bdk...... 11 klor-con...... 43 leflunomide...... 57 lidocaine...... 11 klor-con 10...... 42 LEMTRADA...... 36 lidocaine hcl...... 11, 37 klor-con m10...... 42 LENVIMA 10 MG DAILY lidocaine hcl (cardiac)...... 11 klor-con m20...... 42 DOSE...... 23 lidocaine hcl (pf)...... 11 klor-con sprinkle...... 43 LENVIMA 12 MG DAILY lidocaine in d5w...... 11 klor-con/ef...... 43 DOSE...... 23 lidocaine viscous...... 37 KOATE...... 30 LENVIMA 14 MG DAILY lidocaine-epinephrine...... 11 KOATE-DVI...... 30 DOSE...... 23 lidocaine-hydrocortisone koate-dvi...... 30 LENVIMA 18 MG DAILY ace...... 38, 59 KOGENATE FS...... 30 DOSE...... 23 lidocaine-prilocaine...... 11 KOGENATE FS BIO-SET...30 LENVIMA 20 MG DAILY lido-prilo caine pack...... 11 KORLYM...... 52 DOSE...... 23 lillow...... 53 KOVALTRY...... 30 LENVIMA 24 MG DAILY lincomycin hcl...... 14 k-prime...... 43 DOSE...... 23 lindane...... 25 KRYSTEXXA...... 20 linezolid...... 14

75 linezolid in sodium chloride.14 LUPRON DEPOT (6- mesna...... 24 liothyronine sodium...... 55 MONTH) MESNEX...... 24 lipodox 50...... 23 INTRAMUSCULAR KIT metadate er...... 36 liprozonepak...... 11 45MG...... 51 metafolbic plus rf...... 43 lisinopril...... 33 LUPRON DEPOT-PED (1- metaproterenol sulfate...... 65 lisinopril- MONTH)...... 51 metaxall...... 66 hydrochlorothiazide...... 33 LUPRON DEPOT-PED (3- metaxalone...... 66 lithium...... 29 MONTH)...... 51 metformin hcl...... 40 lithium carbonate...... 29 lutera...... 53 metformin hcl er...... 40 lithium carbonate er...... 29 LYNPARZA...... 23 methadone hcl...... 8 livixil pak...... 11 lysiplex plus...... 43 methadone hcl intensol...... 8 lmd in d5w...... 30 lyza...... 53 methadose...... 8 lmd in nacl...... 30 mafenide acetate...... 14 methadose sugar-free...... 8 l-methylfolate...... 60 magnesium chloride...... 43 methamphetamine hcl...... 36 l-methylfolate calcium...... 60 magnesium sulfate...... 43 methazolamide...... 62 l-methylfolate-algae...... 43 magnesium sulfate in d5w.. 43 methenamine hippurate...... 14 l-methylfolate-algae-b12- MAKENA...... 53 methenamine mandelate.... 14 b6...... 43 malathion...... 25 methergine...... 60 l-methylfolate-b6-b12...... 43 manganese chloride...... 43 methimazole...... 55 LONSURF...... 23 mannitol...... 33 methocarbamol...... 66 loperamide hcl...... 46 maprotiline hcl...... 18 methotrexate...... 57 lopinavir-ritonavir...... 27 MARQIBO...... 23 methotrexate sodium...... 57 lopreeza...... 53 MATULANE...... 23 methotrexate sodium (pf)....57 lorazepam...... 29 matzim la...... 33 methoxsalen...... 38 lorazepam intensol...... 29 MAVYRET...... 27 methoxsalen rapid...... 38 lorazepam-dextrose...... 29 meclizine hcl...... 19 methscopolamine bromide..46 lorazepam-sodium chloride.29 meclofenamate sodium...... 10 methyclothiazide...... 33 lorcet...... 8 medolor pak...... 11 methyl salicylate...... 38 lorcet hd...... 8 medroxyprogesterone methyldopa...... 33 lorcet plus...... 8 acetate...... 54 methyldopa- loryna...... 53 mefenamic acid...... 10 hydrochlorothiazide...... 33 losartan potassium...... 33 mefloquine hcl...... 25 methyldopate hcl...... 33 losartan potassium-hctz...... 33 megestrol acetate...... 54 methylene blue...... 60 lovastatin...... 33 MEKINIST...... 24 methylergonovine maleate..60 low-ogestrel...... 53 MEKTOVI...... 24 methylfol-algae-b12- loxapine succinate...... 27 melodetta 24 fe...... 54 acetylcyst...... 43 LUCENTIS...... 62 meloxicam...... 10 methylphenidate hcl...... 36 ludent...... 43 melphalan...... 24 methylphenidate hcl er...... 36 lugols...... 14 melphalan hcl...... 24 methylphenidate hcl er (cd) 36 LUMIGAN...... 62 memantine hcl...... 18 methylphenidate hcl er (la). 36 LUMIZYME...... 47 memantine hcl er...... 18 methylprednisolone...... 49 LUPANETA PACK...... 51 MENOPUR...... 51 methylprednisolone ace- LUPRON DEPOT (1- meperidine hcl...... 8 lido...... 49 MONTH)...... 51 meperidine hcl-sodium methylprednisolone LUPRON DEPOT (3- chloride...... 8 acetate...... 49 MONTH)...... 51 meprobamate...... 29 methylprednisolone LUPRON DEPOT (4- MEPSEVII...... 47 sodium succ...... 49 MONTH) mercaptopurine...... 24 methyltestosterone...... 50 INTRAMUSCULAR KIT meropenem...... 14 metipranolol...... 62 30MG...... 51 meropenem-sodium metoclopramide hcl...... 19 chloride...... 14 metolazone...... 33 mesalamine...... 59 metopic...... 38 mesalamine-cleanser...... 59 metoprolol succinate er...... 33

76 metoprolol tartrate...... 33, 34 montelukast sodium...... 65 naproxen sodium...... 10 metoprolol- morgidox...... 15 naproxen sodium er...... 10 hydrochlorothiazide...... 34 morphine sulfate...... 8 naratriptan hcl...... 20 metronidazole...... 15, 38 morphine sulfate NARCAN...... 12 metronidazole in nacl...... 14 (concentrate)...... 8 nateglinide...... 40 mexiletine hcl...... 34 morphine sulfate (pf)...... 8 NATPARA...... 59 mibelas 24 fe...... 54 morphine sulfate er...... 8 nature-throid...... 55 MICRHOGAM ULTRA- morphine sulfate er beads.... 8 nebusal...... 64 FILTERED PLUS...... 57 morphine sulfate-nacl...... 9 necon 0.5/35 (28)...... 54 microgestin 1.5/30...... 54 moxifloxacin hcl...... 15, 61 necon 7/7/7...... 54 microgestin 1/20...... 54 moxifloxacin hcl in nacl...... 15 nefazodone hcl...... 18 microgestin fe 1.5/30...... 54 MOZOBIL...... 30 neomycin sulfate...... 15 microgestin fe 1/20...... 54 multigen...... 43 neomycin-bacitracin zn- midodrine hcl...... 34 multigen folic...... 43 polymyx...... 62 miglitol...... 40 multigen plus...... 43 neomycin-polymyxin- miglustat...... 47 multitrace-4...... 43 dexameth...... 62 mili...... 54 multitrace-4 neonatal...... 43 neomycin-polymyxin- milrinone lactate...... 34 multitrace-5...... 43 gramicidin...... 62 milrinone lactate in mupirocin...... 15 neomycin-polymyxin-hc 62, 63 dextrose...... 34 mupirocin calcium...... 15 neo-polycin...... 63 mimvey...... 54 MUSTARGEN...... 24 neo-polycin hc...... 63 mimvey lo...... 54 mutamycin...... 24 neostigmine methylsulfate.. 20 mineral oil heavy...... 46 mvc-fluoride...... 43 nephronex...... 43 minitran...... 34 m-vit...... 43 NERLYNX...... 24 minocycline hcl...... 15 MYALEPT...... 60 neuac...... 38 minocycline hcl er...... 15 mycophenolate mofetil...... 57 NEULASTA...... 30 minoxidil...... 34 mycophenolate mofetil hcl.. 58 NEULASTA ONPRO...... 30 MIRCERA...... 30 mycophenolate sodium...... 58 NEUPOGEN...... 30 mirtazapine...... 18 MYLOTARG...... 24 nevirapine...... 27 misoprostol...... 45 mynatal...... 43 nevirapine er...... 28 mitigo...... 8 mynatal advance...... 43 NEXAVAR...... 24 mitomycin...... 24 mynephron...... 43 niacin er mitoxantrone hcl...... 24 MYOBLOC...... 60 (antihyperlipidemic)...... 34 modafinil...... 67 myorisan...... 38 nicardipine hcl...... 34 moderiba...... 27 myzilra...... 54 nifedipine...... 34 MODERIBA...... 27 na ferric gluc cplx in nifedipine er...... 34 MODERIBA 1200 DOSE sucrose...... 43 nifedipine er osmotic PACK...... 27 nabi-hb...... 58 release...... 34 MODERIBA 800 DOSE nabumetone...... 10 nikki...... 54 PACK...... 27 n-acetyl-l-cysteine...... 43 nilutamide...... 24 moexipril hcl...... 34 nadolol...... 34 nimodipine...... 34 moexipril- nadolol- NINLARO...... 24 hydrochlorothiazide...... 34 bendroflumethiazide...... 34 NIPENT...... 24 mometasone furoate.....49, 64 nafcillin sodium...... 15 nisoldipine er...... 34 mondoxyne nl...... 15 nafcillin sodium in dextrose.15 nitrofurantoin...... 15 MONOCLATE-P...... 30 nafrinse...... 43 nitrofurantoin macrocrystal. 15 monoject flush syringe...... 43 nafrinse drops...... 43 nitrofurantoin monohydrate monoject sodium chloride naftifine hcl...... 20 macrocrystals...... 15 flush...... 43 NAGLAZYME...... 47 nitroglycerin...... 34 mono-linyah...... 54 nalbuphine hcl...... 9 nitroglycerin er...... 34 mononessa...... 54 naloxone hcl...... 12 nitroglycerin in d5w...... 34 MONONINE...... 30 naltrexone hcl...... 12 nitroprusside sodium...... 34 MONOVISC...... 60 naproxen...... 10 nitro-time...... 34

77 NITYR...... 47 nystatin-triamcinolone...... 20 oxaliplatin...... 24 niva-fol...... 60 nystop...... 20 oxandrolone...... 50 nizatidine...... 45 obstetrix ec...... 43 oxaprozin...... 10 nolix...... 49 OCALIVA...... 47 oxazepam...... 29 nora-be...... 54 ocella...... 54 oxcarbazepine...... 17 NORDITROPIN FLEXPRO.51 OCREVUS...... 36 oxiconazole nitrate...... 20 norepinephrine bitartrate.....34 OCTAGAM...... 58 oxybutynin chloride...... 48 norethin ace-eth estrad-fe...54 octreotide acetate...... 51 oxybutynin chloride er...... 48 norethindrone...... 54 ODOMZO...... 24 oxycodone hcl...... 9 norethindrone acetate...... 54 OFEV...... 65 OXYCODONE HCL ER...... 9 norethindrone acet-ethinyl ofloxacin...... 15, 61, 63 oxycodone-acetaminophen...9 est...... 54 ogestrel...... 54 oxycodone-aspirin...... 9 norethindrone-eth estradiol.54 okebo...... 15 oxycodone-ibuprofen...... 9 norethin-eth estradiol-fe...... 54 olanzapine...... 27 OXYCONTIN...... 9 norgestimate-eth estradiol.. 54 olanzapine-fluoxetine hcl.... 18 oxymorphone hcl...... 9 norgestimate-ethinyl olmesartan medoxomil...... 34 oxymorphone hcl er...... 9 estradiol triphasic...... 54 olmesartan medoxomil- oxytocin...... 51 norlyda...... 54 hctz...... 34 OZEMPIC...... 40 norlyroc...... 54 olmesartan-amlodipine- OZURDEX...... 61 normal saline flush...... 43 hctz...... 34 pacerone...... 34 NORTHERA...... 34 olopatadine hcl...... 61, 64 paclitaxel...... 24 nortrel 0.5/35 (28)...... 54 OLUMIANT...... 58 paliperidone er...... 27 nortrel 1/35 (21)...... 54 omega-3-acid ethyl esters.. 34 palonosetron hcl...... 19 nortrel 1/35 (28)...... 54 omeprazole...... 45 PALYNZIQ...... 47 nortrel 7/7/7...... 54 OMNITROPE...... 51 pamidronate disodium...... 59 nortriptyline hcl...... 18 ONCASPAR...... 24 pancuronium bromide...... 37 novarel...... 51 ondansetron hcl...... 19 PANHEMATIN...... 30 NOVAREL...... 51 ondansetron odt...... 19 pantoprazole sodium...... 45 NOVOEIGHT...... 30 ONETOUCH ULTRA 2...... 40 papaverine hcl...... 34 NOVOFINE AUTOCOVER ONETOUCH ULTRA MINI..41 paregoric...... 46 PEN NEEDLE...... 41 ONETOUCH VERIO...... 41 paricalcitol...... 59 NOVOFINE PEN NEEDLE. 41 ONETOUCH VERIO IQ paroex...... 37 NOVOSEVEN RT...... 30 SYSTEM...... 41 paromomycin sulfate...... 15 NOVOTWIST PEN ONIVYDE...... 24 paroxetine hcl...... 18 NEEDLE...... 41 ONPATTRO...... 37 paroxetine hcl er...... 18 NPLATE...... 30 OPDIVO...... 24 paroxetine mesylate...... 18 NUCALA...... 64 opium...... 46 PARSABIV...... 55 nudiclo solupak...... 10 OPSUMIT...... 66 peg 3350/electrolytes...... 46 nudiclo tabpak...... 10 oralone...... 37 peg 3350-kcl-na bicarb- nufol...... 43 ORENCIA...... 58 nacl...... 46 nulev...... 46 ORENCIA CLICKJECT...... 58 peg-3350/electrolytes...... 46 numoisyn...... 37 ORENITRAM...... 66 PEGASYS...... 28 nutriarx creampak...... 49 ORFADIN...... 47 PEGASYS PROCLICK...... 28 nutricap...... 43 ORKAMBI...... 66 PEGINTRON...... 28 nutrifac zx...... 43 orphenadrine citrate...... 66 peg-prep...... 46 NUTROPIN AQ NUSPIN orphenadrine citrate er...... 66 pegylax...... 46 10...... 51 orsythia...... 54 penicillin g potassium...... 15 NUTROPIN AQ NUSPIN ORTHOVISC...... 60 penicillin g procaine...... 15 20...... 51 oseltamivir phosphate...... 28 penicillin g sodium...... 15 NUTROPIN AQ NUSPIN 5. 51 osmitrol...... 34 penicillin v potassium...... 15 NUWIQ...... 30 OTEZLA...... 58 pentazocine-naloxone hcl..... 9 nyamyc...... 20 OVIDREL...... 51 pentobarbital sodium...... 17 nystatin...... 20 oxacillin sodium...... 15 pentoxifylline er...... 34

78 perindopril erbumine...... 34 podofilox...... 38 prikaan lite...... 11 periogard...... 37 polocaine...... 11 priloxx lp...... 11 PERJETA...... 24 polocaine-mpf...... 11 primaquine phosphate...... 25 permethrin...... 25 polycin...... 63 primidone...... 17 perphenazine...... 19 polyethylene glycol 3350.... 46 PRIVIGEN...... 58 perphenazine-amitriptyline..18 polymyxin b sulfate...... 15 PROAIR HFA...... 65 pfizerpen...... 15 polymyxin b-trimethoprim....63 probenecid...... 20 phenadoz...... 64 POMALYST...... 24 procainamide hcl...... 35 phenazo...... 48 portia-28...... 54 prochlorperazine...... 19 phenazopyridine hcl...... 48 port-prep...... 11 prochlorperazine edisylate..19 phendimetrazine tartrate.....37 PORTRAZZA...... 24 prochlorperazine maleate... 19 phendimetrazine tartrate er.37 pot bicarb-pot chloride...... 44 PROCRIT...... 30 phenelzine sulfate...... 18 potassium acetate...... 44 procto-med hc...... 59 phenobarbital...... 17 potassium bicarbonate...... 44 procto-pak...... 59 phenobarbital sodium...... 17 potassium chloride...... 44 proctosol hc...... 59 phenobarbital-belladonna potassium chloride crys er.. 44 proctozone-hc...... 59 alk...... 46 potassium chloride er...... 44 PROCYSBI...... 47 phenoxybenzamine hcl...... 34 potassium citrate er...... 44 profeno...... 10 phentermine hcl...... 37 potassium citrate-citric acid 44 PROFILNINE...... 30 phentolamine mesylate...... 34 potassium phosphates...... 44 PROFILNINE SD...... 30 phenylephrine hcl...... 34, 63 pr benzoyl peroxide wash... 39 progesterone...... 54 phenylephrine hcl-nacl...... 34 pr natal 400...... 44 progesterone micronized.... 54 phenylephrine-guaifenesin..64 pr natal 400 ec...... 44 PROGRAF...... 58 phenytoin...... 17 pr natal 430...... 44 PROLASTIN-C...... 65 phenytoin infatabs...... 17 pr natal 430 ec...... 44 PROLEUKIN...... 24 phenytoin sodium...... 17 PRADAXA...... 16 PROLIA...... 59 phenytoin sodium pralidoxime chloride...... 60 PROMACTA...... 30 extended...... 17 PRALUENT...... 35 promethazine hcl...... 64 philith...... 54 pramipexole promethazine-codeine...... 64 phospha 250 neutral...... 43 dihydrochloride...... 26 promethazine-dm...... 64 phosphasal...... 48 pramipexole promethazine-phenyleph- phosphorous...... 43 dihydrochloride er...... 26 codeine...... 64 phospho-trin 250 neutral.....43 pramox...... 39 promethazine- PHOTOFRIN...... 24 prasugrel hcl...... 26 phenylephrine...... 64 phrenilin forte...... 9 pravastatin sodium...... 35 promethegan...... 64 phytonadione...... 43, 44 praziquantel...... 25 propafenone hcl...... 35 pilocarpine hcl...... 37, 62 prazosin hcl...... 35 propafenone hcl er...... 35 pimozide...... 27 prednicarbate...... 49 propantheline bromide...... 46 pimtrea...... 54 prednisolone...... 49 proparacaine hcl...... 63 pindolol...... 34 prednisolone acetate...... 61 propranolol hcl...... 35 pioglitazone hcl...... 40 prednisolone sodium propranolol hcl er...... 35 pioglitazone hcl-glimepiride 40 phosphate...... 49, 50, 61 propranolol-hctz...... 35 pioglitazone hcl-metformin prednisone...... 50 propylthiouracil...... 55 hcl...... 40 pregnyl...... 51 protamine sulfate...... 31 piperacillin sod-tazobactam premasol...... 44 protriptyline hcl...... 18 so...... 15 prenatabs rx...... 44 pseudoeph-chlorphen- pirmella 1/35...... 54 prenatal-u...... 44 hydrocod...... 64 pirmella 7/7/7...... 54 prevalite...... 35 pseudoephedrine- piroxicam...... 10 prevident...... 37 bromphen-dm...... 64 plasbumin-25...... 60 previfem...... 54 psorizide forte...... 60 plasbumin-5...... 60 PREVYMIS...... 28 PULMICORT FLEXHALER.65 plenamine...... 44 PREZCOBIX...... 28 pulmosal...... 64 pneumovax 23...... 58 prikaan...... 11 PULMOZYME...... 66

79 PURIXAN...... 24 REPATHA PUSHTRONEX salvax...... 39 pyrazinamide...... 21 SYSTEM...... 35 SAMSCA...... 44 pyridostigmine bromide...... 20 REPATHA SURECLICK..... 35 SANDOSTATIN LAR pyridostigmine bromide er.. 20 restizan...... 39 DEPOT...... 51 pyridoxine hcl...... 44 RETACRIT...... 31 SAVAYSA...... 16 pyrogallic acid...... 39 RETISERT...... 61 scopolamine...... 19 quasense...... 54 REVATIO...... 66 seb-prev wash...... 39 quazepam...... 29 REVLIMID...... 24 selegiline hcl...... 26 quetiapine fumarate...... 27 revonto...... 66 selenium...... 44 quetiapine fumarate er...... 27 REYATAZ...... 28 selenium sulfide...... 39 quflora pediatric...... 44 RHOGAM ULTRA- selenium sulf-pyrithione- quinapril hcl...... 35 FILTERED PLUS...... 58 urea...... 39 quinapril- RIASTAP...... 31 SELZENTRY...... 28 hydrochlorothiazide...... 35 ribasphere...... 28 SENSIPAR...... 50 quinidine gluconate...... 35 ribasphere ribapak...... 28 sensorcaine...... 11 quinidine gluconate er...... 35 RIBASPHERE RIBAPAK.... 28 sensorcaine/epinephrine.....11 quinidine sulfate...... 35 ribavirin...... 28 sensorcaine-mpf...... 11 quinine sulfate...... 25 rifabutin...... 21 sensorcaine- rabeprazole sodium...... 45 rifampin...... 21 mpf/epinephrine...... 11 RADICAVA...... 37 riluzole...... 37 SEREVENT DISKUS...... 65 rajani...... 55 rimantadine hcl...... 28 SEROSTIM...... 47 raloxifene hcl...... 50 risedronate sodium...... 59 sertraline hcl...... 18 ramipril...... 35 risperidone...... 27 setlakin...... 55 RANEXA...... 35 risperidone m-tab...... 27 sevelamer carbonate...... 48 ranitidine hcl...... 45 ritonavir...... 28 sharobel...... 55 rasagiline mesylate...... 26 RITUXAN...... 24 siderol...... 44 RAVICTI...... 47 RITUXAN HYCELA...... 24 SIGNIFOR...... 51 RAYALDEE...... 59 rivastigmine...... 18 SIGNIFOR LAR...... 52 rea lo 40...... 39 rivastigmine tartrate...... 18 sildenafil citrate...... 48, 66 REBETOL...... 28 rivelsa...... 55 SILIQ...... 58 REBIF...... 36 rizatriptan benzoate...... 20 silver nitrate...... 15 REBIF REBIDOSE...... 36 rocuronium bromide...... 37 silver sulfadiazine...... 15 REBIF REBIDOSE ROMIDEPSIN...... 24 SIMPONI...... 58 TITRATION PACK...... 36 ropinirole hcl...... 26 SIMPONI ARIA...... 58 REBIF TITRATION PACK.. 36 ropinirole hcl er...... 26 simvastatin...... 35 REBINYN...... 31 ropivacaine hcl...... 11 sirolimus...... 58 recedo...... 39 rosadan...... 39 sod benz-sod phenylacet....47 reclipsen...... 55 rosanil cleanser...... 39 sod citrate-citric acid...... 44 RECOMBINATE...... 31 rosuvastatin calcium...... 35 sodium acetate...... 44 red yeast rice...... 61 roweepra...... 17 sodium bicarbonate...... 44, 47 regonol...... 20 roweepra xr...... 17 sodium chloride...... 44, 64 relador pak...... 11 RUBRACA...... 24 sodium chloride flush...... 44 relador pak plus...... 11 RUCONEST...... 58 sodium fluoride...... 44 relexxii...... 36 RYDAPT...... 24 sodium hyaluronate...... 39 REMICADE...... 58 ryvent...... 64 sodium lactate...... 44 remifentanil hcl...... 9 SABRIL...... 17 sodium nitrite...... 61 REMODULIN...... 66 salicylic acid...... 39 sodium phenylbutyrate...... 47 renal...... 44 salicylic acid er...... 39 sodium phosphates...... 44 RENFLEXIS...... 58 salicylic acid wart remover..39 sodium polystyrene repaglinide...... 40 salicylic acid-cleanser...... 39 sulfonate...... 44, 45 repaglinide-metformin hcl... 40 saline flush...... 44 sodium saccharin...... 61 REPATHA...... 35 saline flush zr...... 44 sodium sulfacetamide...... 39 salsalate...... 10 sodium thiosulfate...... 61

80 SOLESTA...... 61 sulfasalazine...... 59 telmisartan-amlodipine...... 35 SOLIQUA...... 40 sulfatrim pediatric...... 15 telmisartan-hctz...... 35 SOLIRIS...... 31 sulfurated lime...... 25 temazepam...... 67 soloxide...... 15 sulindac...... 10 TEMODAR...... 24 solupicc...... 11 sumatriptan...... 20 temozolomide...... 24 SOMATULINE DEPOT...... 52 sumatriptan succinate...... 20 temsirolimus...... 58 SOMAVERT...... 52 sumatriptan succinate refill. 20 tencon...... 9 sorine...... 35 sumatriptan-naproxen teniposide...... 24 sotalol hcl...... 35 sodium...... 20 tenofovir disoproxil sotalol hcl (af)...... 35 SUPARTZ FX...... 61 fumarate...... 28 SOVALDI...... 28 SUPPRELIN LA...... 52 TEPADINA...... 24 spinosad...... 25 SUTENT...... 24 terazosin hcl...... 48 SPIRIVA HANDIHALER..... 65 swabflush saline flush...... 45 terbinafine hcl...... 20 SPIRIVA RESPIMAT...... 65 syeda...... 55 terbutaline sulfate...... 65 spironolactone...... 35 SYLATRON...... 24 terconazole...... 20 spironolactone-hctz...... 35 SYLVANT...... 24 testosterone...... 50 sprintec 28...... 55 symax-sr...... 47 testosterone cypionate...... 50 SPRYCEL...... 24 SYMBICORT...... 65 testosterone enanthate...... 50 sps...... 45 SYMDEKO...... 66 tetanus-diphtheria toxoids sronyx...... 55 SYMFI...... 28 td...... 58 ssd...... 15 SYMFI LO...... 28 tetcaine...... 63 stavudine...... 28 SYMLINPEN 120...... 40 tetrabenazine...... 37 STELARA...... 58 SYMLINPEN 60...... 40 tetracaine hcl...... 11, 63 STIOLTO RESPIMAT...... 65 SYMPROIC...... 47 tetracycline hcl...... 15 STIVARGA...... 24 SYNAGIS...... 58 tetravisc...... 63 STRENSIQ...... 47 synalar...... 50 tetravisc forte...... 63 streptomycin sulfate...... 15 SYNJARDY...... 40 THALOMID...... 24 strovite forte...... 45 SYNJARDY XR...... 40 theochron...... 65 SUBLOCADE...... 12 SYNRIBO...... 24 theophylline...... 65 subvenite...... 17 SYNVISC...... 61 theophylline er...... 65 subvenite starter kit-blue.....17 SYNVISC ONE...... 61 theophylline in d5w...... 65 subvenite starter kit-green.. 17 TABLOID...... 24 thiamine hcl...... 45 subvenite starter kit-orange 17 tacrolimus...... 39, 58 THIOLA...... 48 succinylcholine chloride...... 37 tadalafil (pah)...... 66 thioridazine hcl...... 27 SUCRAID...... 47 TAFINLAR...... 24 thiotepa...... 24 sucralfate...... 46 TAGRISSO...... 24 thiothixene...... 27 sulfacetamide sodium... 39, 61 tamoxifen citrate...... 24 THROMBATE III...... 16 sulfacetamide sodium tamsulosin hcl...... 48 THYROGEN...... 61 (acne)...... 39 tandem f...... 45 tiagabine hcl...... 17 sulfacetamide sodium- TARCEVA...... 24 tigecycline...... 15 sulfur...... 39 TARGRETIN...... 24 tilia fe...... 55 sulfacetamide sod-sulfur tarina fe 1/20...... 55 timolol maleate...... 35, 62 wash...... 39 taron-crystals...... 45 tinidazole...... 15 sulfacetamide- taron-prex...... 45 TIVICAY...... 28 prednisolone...... 63 TASIGNA...... 24 tizanidine hcl...... 66 sulfacetamide-sulfur in TAVALISSE...... 31 tobramycin...... 61, 66 urea...... 39 tazarotene...... 39 tobramycin sulfate...... 15 sulfacetamide-sulfur- tazicef...... 15 tobramycin- sunscreen...... 39 taztia xt...... 35 dexamethasone...... 63 sulfacleanse 8/4...... 39 TECENTRIQ...... 24 tolazamide...... 40 sulfadiazine...... 15 TECFIDERA...... 36 tolbutamide...... 40 sulfamethoxazole- TECHNIVIE...... 28 tolcapone...... 26 trimethoprim...... 15 telmisartan...... 35 tolmetin sodium...... 10

81 tolterodine tartrate...... 48 tri-mili...... 55 valsartan- tolterodine tartrate er...... 48 trimipramine maleate...... 19 hydrochlorothiazide...... 35 topex topical anesthetic...... 37 trinate...... 45 vanatol lq...... 9 topiramate...... 17 trinessa (28)...... 55 vanatol s...... 9 topiramate er...... 17 trinessa lo...... 55 vancomycin hcl...... 16 toposar...... 24 tri-previfem...... 55 vancomycin hcl in dextrose.16 topotecan hcl...... 24 TRIPTODUR...... 52 vancomycin hcl in nacl...... 16 torsemide...... 35 TRISENOX...... 25 VANCOMYCIN HCL IN TOTECT...... 25 tri-sprintec...... 55 NACL...... 16 TOUJEO MAX TRIUMEQ...... 28 vandazole...... 16 SOLOSTAR...... 41 trivora (28)...... 55 VANTAS...... 52 TOUJEO SOLOSTAR...... 41 tri-vylibra...... 55 vasopressin-dextrose...... 52 TRACLEER...... 66 tropicamide- VECTIBIX...... 25 tramadol hcl...... 9 cyclopentolate-pe...... 63 vecuronium bromide...... 37 tramadol hcl er...... 9 trospium chloride...... 48 VELCADE...... 25 tramadol hcl er (biphasic)..... 9 trospium chloride er...... 48 VELETRI...... 66 tramadol-acetaminophen...... 9 TRULICITY...... 40 velivet...... 55 trandolapril...... 35 TRUVADA...... 28 VEMLIDY...... 28 trandolapril-verapamil hcl tryptophan...... 45 VENCLEXTA...... 25 er...... 35 tulana...... 55 VENCLEXTA STARTING tranexamic acid...... 31 turpentine...... 39 PACK...... 25 tranylcypromine sulfate...... 18 tydemy...... 55 venlafaxine hcl...... 19 traumeel...... 61 TYKERB...... 25 venlafaxine hcl er...... 19 TRAVATAN Z...... 62 TYMLOS...... 59 VENTAVIS...... 66 trazodone hcl...... 19 TYSABRI...... 36 VENTOLIN HFA...... 65 TRELSTAR MIXJECT...... 52 TYVASO...... 66 verapamil hcl...... 36 TREMFYA...... 58 TYVASO REFILL...... 66 verapamil hcl er...... 35 tretinoin...... 25, 39 TYVASO STARTER...... 66 verdrocet...... 9 tretinoin microsphere...... 39 umecta mousse...... 39 VERZENIO...... 25 tretinoin microsphere pump 39 unithroid...... 56 vic-forte...... 45 TRETTEN...... 31 unithroid direct...... 55 vicodin...... 9 tri femynor...... 55 UNITUXIN...... 25 vicodin es...... 9 triamcinolone acetonide UPTRAVI...... 66 vicodin hp...... 9 ...... 37, 50, 64 urea...... 40 VICTOZA...... 40 triamterene-hctz...... 35 urea in zn undecyl-lactic VIEKIRA PAK...... 28 triazolam...... 29 acid...... 40 VIEKIRA XR...... 28 tricare...... 45 uredeb...... 40 vienva...... 55 tricitrates...... 45 uretron d/s...... 48 vigabatrin...... 18 tricon...... 45 uribel...... 48 vigadrone...... 18 triderm...... 50 urimar-t...... 48 vilamit mb...... 48 trientine hcl...... 45 ursodiol...... 47 vilevev mb...... 48 tri-estarylla...... 55 uryl...... 48 VIMIZIM...... 47 trifluoperazine hcl...... 27 ustell...... 48 vinate ii...... 45 trifluridine...... 61 uta...... 48 vinate m...... 45 trihexyphenidyl hcl...... 26 utira-c...... 48 vinate one...... 45 tri-legest fe...... 55 utrona-c...... 48 vinblastine sulfate...... 25 tri-linyah...... 55 valacyclovir hcl...... 28 vincasar pfs...... 25 tri-lo-estarylla...... 55 VALCHLOR...... 25 vincristine sulfate...... 25 tri-lo-marzia...... 55 valganciclovir hcl...... 28 vinorelbine tartrate...... 25 tri-lo-sprintec...... 55 valproate sodium...... 17 VIREAD...... 28 trilyte...... 47 valproic acid...... 17, 18 virt-gard...... 45 trimethobenzamide hcl...... 19 valsartan...... 35 VISCO-3...... 61 trimethoprim...... 15 VISUDYNE...... 63

82 vit b12-methionine-inos- zarah...... 55 chol...... 45 ZARXIO...... 31 vita s forte...... 45 zebutal...... 9 vitacel...... 45 ZEJULA...... 25 vitafol-ob...... 45 ZELBORAF...... 25 vitamax pediatric...... 45 ZEMAIRA...... 65 vitamin d (ergocalciferol).....45 zenatane...... 40 vitamin k1...... 45 ZENPEP...... 47 VIVITROL...... 12 zenzedi...... 36 VONVENDI...... 31 ZEPATIER...... 28 voriconazole...... 20 ZEVALIN Y-90...... 25 VOSEVI...... 28 zidovudine...... 28 VOTRIENT...... 25 zileuton er...... 65 VPRIV...... 47 zinc sulfate...... 45 vyfemla...... 55 zinc trace metal...... 45 vylibra...... 55 ziprasidone hcl...... 27 VYXEOS...... 25 ZOLADEX...... 52 warfarin sodium...... 16 zoledronic acid...... 59 wera...... 55 ZOLINZA...... 25 westhroid...... 56 zolmitriptan...... 20 wheat germ oil...... 45 zolpidem tartrate...... 67 WILATE...... 31 zolpidem tartrate er...... 67 WINRHO SDF...... 58 ZOMETA...... 59 wymzya fe...... 55 zonisamide...... 18 XALKORI...... 25 ZORBTIVE...... 47 XARELTO...... 16 zovia 1/35e (28)...... 55 XARELTO STARTER ZYDELIG...... 25 PACK...... 16 ZYKADIA...... 25 xelitral...... 10 ZYTIGA...... 25 XELJANZ...... 58 XELJANZ XR...... 58 xenaflamm...... 10 XEOMIN...... 61 XERMELO...... 47 XIAFLEX...... 61 XOLAIR...... 64 XTANDI...... 25 xulane...... 55 XURIDEN...... 61 xylocaine dental...... 11 XYNTHA...... 31 XYNTHA SOLOFUSE...... 31 XYREM...... 67 YERVOY...... 25 YESCARTA...... 25 yf-vax...... 58 YONDELIS...... 25 YONSA...... 25 yuvafem...... 55 zafirlukast...... 65 zaleplon...... 67 ZALTRAP...... 25 ZANOSAR...... 25

83 Nondiscrimination notice and access to communication services

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تنبيه: إذا كنت تتحدث العربية )Arabic(، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّمعرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuite- ment. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an. 注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証 に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی )Farsi( است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. لطفا با شماره تلفن رایگانی که روی کارت شناسايی شما قید شده تماس بگيريد.

ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej. ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identi- fication card mo. DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga. optumrx.com

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