2020 NY44/ Pharmacy Benefit Dimensions Drug Formulary This Drug Formulary represents the list of drugs and their appropriate copayment tiers for members of the NY44 Health Benefits Plan Trust.

Note: If you are reading a printed version of this drug formulary, content may have been updated since it was last printed. For the most up-to-date information, please visit www.pbdrx.com.

Drug Formulary Introduction

 Generic drugs appear in lower case. Brand name drugs are capitalized. This formulary lists all covered Tier 1 and Tier 2 drugs, but only lists representative products in Tier 3.

 Formulary/preferred generic drugs and select Over the Counter (OTC) and select Brand Name drugs listed on the Formulary are assigned to copay Tier 1. The formulary follows a “Mandatory Generic” policy which means that in most instances, once a generic product is available for which there are no bioequivalence concerns, the branded product is assigned to Copay Tier 3, and the generic product is assigned to Copay Tier 1. Certain non- preferred generic drugs may also be covered in the 3rd tier when efficacy, safety or cost factors suggest that better alternatives exist on the formulary. Not all tier 3 non-preferred drugs are listed in the formulary. For members with a 3 tier plan, most drugs not listed may be obtained, but the member will be responsible for their third tier copayment.

 Pharmacy Benefit Dimensions reserves the right to modify the copay tier of a particular drug as necessary. For example, the copay tier of a brand drug will be raised from Tier 2 to Tier 3 when a generic drug becomes available (the generic drug will be placed in copay Tier 1). The copay of a brand drug may be lowered from Tier 3 to Tier 2 if the generic equivalents are discontinued or no longer available.

 Some medications are considered non-formulary (not covered). To obtain a medication that is non-formulary your health care provider is encouraged to submit a prior authorization request for coverage through the exceptions process. If the request is approved, that particular medication will be covered at your Tier 3 copayment/coinsurance level.

 Certain self-funded employer groups may not follow this base formulary. Members in these pharmacy benefit management groups should refer to their summary plan description and/or their benefit administrator. Specific drugs may be Preferred Brand or Non-Preferred Brand based on individual group’s benefit design.

2020 NY44

2020 NY44

Prior-Authorization Prior Authorization is required for certain medications. To obtain coverage for a medication requiring prior authorization, a prior authorization request for medical exception must be submitted by your health care provider and approved by us. Medications that require prior authorization are listed with a “PA” in the formulary.

Step Therapy In some cases, you may be required to first try certain medications to treat your medical condition before we cover another medication for that condition. Step therapy is a way to help you get the best quality and value from your prescription medication benefit. This usually means that an equally effective generic medication is prescribed before a more expensive brand-name medication. Step therapy may also ensure that two medications are used together if they are more effective. Medications that require step therapy are listed with a “ST” in the formulary.

Quantity Limitations Quantity limitations may apply to certain medications. Some medications are covered up to a specific quantity per 30 or 90 days. Some examples of medications with a quantity limitation are: sumatriptan (generic Imitrex®) and zolpidem tartrate (generic Ambien®). Medications with quantity limitations are listed with a “QL” in the formulary.

Specialty Medications Specialty medications can include but are not limited to those that are either self-injectable, require special distribution, handling and/or are in limited supply and certain oral oncology medications. Specialty medications are listed with an “SP” on the formulary.

Limited Access Medications Limited access medications are restricted to designated pharmacies. Limited access medications are listed with an “LA” on the formulary.

Reliance Rx Reliance Rx, Pharmacy Benefit Dimensions’ preferred specialty pharmacy, specializes in the highest quality patient- centric care for individuals with chronic conditions such as hepatitis, multiple sclerosis, cancer and rheumatoid arthritis. The majority of specialty medications and limited access medications are required to be filled at Reliance. Reliance Rx also provides a convenient way for you to receive the medication, by arranging delivery at no charge directly to your home. They can also provide you with education on the medication you’re taking, refill reminders and even the necessary supplies, if applicable and available.

Please contact Pharmacy Benefit Dimensions Member Services or Reliance Rx to determine where you need to obtain your medication. Pharmacy Benefit Dimensions Member Services can be reached at (716) 635-7880 or toll-free at 1-888- 878-9172. Reliance Rx can be reached at 1-800-809-4763.

Age Restriction Some prescription medications are restricted by age due to safety reasons or Food and Drug Administration (FDA) recommended labeling. Medications with an age limit are listed with an “AL” in the formulary.

Maximum Daily Dose (MDD) Certain medications are dose limited by a maximum daily dose (MDD) as recommended by the Food and Drug Administration (FDA) for safety reasons. Limits may be set by the number of tablets/capsules per day or the total daily dose.

Maintenance Medications

2020 NY44

Pharmacy Benefit Dimensions allows up to a 90-day supply of certain medications to be filled. Medications eligible for up to a 90-day supply are listed with an “MO” on the formulary. If a generic medication is listed as maintenance on the drug formulary, and the brand name equivalent is non-formulary; the brand name equivalent will be maintenance and allowed for up to a 90-day supply if a formulary exception is approved for the brand name drug.

Over-the-Counter (OTC) Medications Certain medications listed in the formulary are available over the counter. A prescription is required for coverage of the OTC products.

Sedative/Hypnotic Medications Sedative/hypnotic medications are limited for all prescribers except sleep specialists to 14 tablets/capsules per month with a maximum of 3 fills per year (3 fills/365 days).

Compounded Prescription Medications Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to submit for prior approval and when covered the compounded prescription will be available at a Tier 2 copayment/coinsurance. Coverage is provided in accordance with our Compounding Medication Products Policy. Bulk products and powders are excluded from coverage because they are not prescription medication products that are approved under sections 505, 505(j) or 507 of the Federal Food, Drug and Cosmetic Act.

Diabetic Supplies/Medications OneTouch blood glucose meters, lancets, test strips, and supplies are our preferred diabetic supplies and do not require Prior Authorization. Test strips are limited to 100 strips per 30 days, for up to a 90-day supply. BD needles and syringes are our preferred needle/syringe products. BD needles and syringes are our preferred needle/syringe products. Copayments vary by plan.

OneTouch will provide a glucose meter to you with no copayment. Quantities are limited to one meter per member. Please have your ID number available when you contact the manufacturer. One Touch Glucose Meters can be obtained by calling LifeScan, Inc. at 1-888-377-5227, please reference offer code 289IHA001.

Freestyle Libre reader device and sensors are our preferred continuous glucose monitoring system supplies. For insulin- dependent members, no prior authorization is required. Freestyle Libre products are available at participating pharmacies. Copayments vary by plan.

Antibiotic Medications Antibiotics are generally limited to a 10-day supply with one refill within 15 days after the original fill.

Affordable Care Act (ACA) Preventive Services Medications listed on the formulary that are covered as preventive services under the Affordable Care Act may be covered. Certain restrictions may apply.

Lost/Stolen/Damaged Medications Replacement of any lost, stolen or damaged medications is the responsibility of the member.

Emergency Room Prescriptions Emergency Room prescriptions are limited to a 10-day supply.

Dental Formulary

2020 NY44

Drugs covered on our Dental Formulary are available when prescribed by a dental provider. Unless otherwise specified, all products are limited to a 10-day supply with one refill. Drugs included in our Dental Formulary are listed with a “DF” on the formulary. Drugs without a “DF” will not be covered when written by a dental provider.

2020 NY44

Medical Benefit Drugs Medical benefit drugs are medications that are typically administered by a healthcare provider, such as injections and infusions. Some medical benefit drugs are available through a retail pharmacy or specialty pharmacy but may not be listed in the formulary. Copayments for these medications vary by plan. Please contact Pharmacy Benefit Dimensions Member Services to determine if your medication is a covered benefit. Pharmacy Benefit Dimensions Member Services can be reached at (716) 635-7880 or toll-free at 1-888-878-9172.

Additional Formulary Information

 Appetite suppressants/weight-loss medications are excluded from coverage.

 Medications used for cosmetic purposes are excluded from coverage.

 Medical devices (which may or may not require a prescription) are excluded from coverage.

 Medical foods other than PKU supplements (which may or may not require a prescription) are excluded from coverage.

 Drugs used for the treatment of impotence (ED Drugs) are limited to male patients only. Duplicate therapy with other ED medications is not allowed.

 Prenatal vitamins classified as medical foods are not covered. Multivitamins are NOT included in the Formulary as various OTC products are available.

 Medications listed on the drug formulary as covered without restriction may require prior authorization or may not be covered if it is determined that they are being used in conjunction with a procedure or treatment not covered under the employer group’s benefit design.

 Medications not recognized by the FDA without a National Drug Code (NDC) are excluded from coverage.

Key AL – Age Limit DF – Dental Formulary LA – Limited Access MO – 90-day supply PA – Prior Authorization Required QL – Quantity Limits Apply SP – Specialty Medication ST – Step Therapy

2020 NY44

AFFORDABLE CARE ACT PREVENTATIVE SERVICES **where applicable

Prescription and OTC versions (where applicable) will be covered only with a prescription written by a licensed healthcare provider.

Aspirin for Cardiovascular Disease Prevention Aspirin will be covered for men and women (ages 50 to 59) when the benefits outweigh the potential bleeding risks for cardiovascular disease prevention.

Bowel Prep for Colonoscopy Prescription and OTC products will be covered for adults older than age 50 and younger than age 75 receiving screening for colorectal cancer.

Contraceptive Coverage All formulary generic and preferred brand name drugs (without a generic equivalent) will have a zero dollar ($0) copayment. Cervical caps, diaphragms, female condoms and spermicides will have a zero ($0) copayment. Both prescription and over-the-counter (OTC) products will be covered only when prescribed by a licensed healthcare provider.

Erythromycin Ophthalmic Ointment Erythromycin ophthalmic ointment will be covered for newborns less than 1 year of age for the prevention of gonococcal ophthalmia neonatorum.

Fluoride Oral fluoride products (chewable tablets and solutions) will be covered for children 6 months of age and older who do not receive the recommended amount of fluoride in their water supply.

Folic Acid supplements Supplements containing 0.4mg to 0.8mg of folic acid will be covered for women who are planning or are capable of pregnancy.

Iron Supplementation for Children Iron supplements will be covered for children aged 6 months to 12 months who are at high risk for iron deficiency anemia.

Statins The USPSTF recommends that adults without a history of cardiovascular disease (CVD) use a low- to moderate-dose statin for the prevention of CVD events and mortality. Low- to moderate-dose statins will be covered at a zero dollar ($0) copayment for those who meet the following criteria: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.

Tobacco Cessation Products (FDA Approved) Prescription and OTC products will be covered for adults 18 years of age and older and for pregnant women with no age limit. The following products are covered: patches, gums, nasal sprays, inhalers, lozenges, Chantix and bupropion sr (generic version of Zyban).

Vaccines Flu, Pneumonia vaccinations will be covered when administered at a network pharmacy.

The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. Women, Increased Risk for Breast Cancer For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.

NY44 TABLE OF CONTENTS

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...... 3 *Allergenic Extracts/Biologicals Misc*...... 3 *Aminoglycosides*...... 3 *Analgesics - Anti-Inflammatory*...... 4 *Analgesics - Nonnarcotic*...... 4 *Analgesics - Opioid*...... 5 *Androgens-Anabolic*...... 6 *Anorectal And Related Products*...... 6 *Anthelmintics*...... 6 *Antianginal Agents*...... 6 *Antianxiety Agents*...... 7 *Antiarrhythmics*...... 7 *Antiasthmatic And Bronchodilator Agents*...... 8 *Anticoagulants*...... 9 *Anticonvulsants*...... 9 *Antidepressants*...... 10 *Antidiabetics*...... 11 *Antidiarrheal/Probiotic Agents*...... 12 *Antidotes And Specific Antagonists*...... 12 *Antiemetics*...... 12 *Antifungals*...... 13 *Antihistamines*...... 13 *Antihyperlipidemics*...... 13 *Antihypertensives*...... 14 *Anti-Infective Agents - Misc.*...... 15 *Antimalarials*...... 15 *Antimyasthenic/Cholinergic Agents*...... 15 *Antimycobacterial Agents*...... 15 *Antineoplastics And Adjunctive Therapies*...... 16 *Antiparkinson And Related Therapy Agents*...... 17 *Antipsychotics/Antimanic Agents*...... 18 *Antivirals*...... 19 *Beta Blockers*...... 20 *Calcium Channel Blockers*...... 20 *Cardiotonics*...... 20 *Cardiovascular Agents - Misc.*...... 21 *Cephalosporins*...... 21 *Contraceptives*...... 22 *Corticosteroids*...... 24 *Cough/Cold/Allergy*...... 24 *Dermatologicals*...... 25 *Diagnostic Products*...... 27 *Digestive Aids*...... 27 *Diuretics*...... 28 *Endocrine And Metabolic Agents - Misc.*...... 28 *Estrogens*...... 29 *Fluoroquinolones*...... 29 *Gastrointestinal Agents - Misc.*...... 29 *Genitourinary Agents - Miscellaneous*...... 30 *Gout Agents*...... 30 *Hematological Agents - Misc.*...... 30 *Hematopoietic Agents*...... 30 *Hemostatics*...... 31 *Hypnotics/Sedatives/Sleep Disorder Agents*...... 31

Last Updated 12.1.2020 1 *Laxatives*...... 31 *Macrolides*...... 31 *Medical Devices And Supplies*...... 31 *Migraine Products*...... 32 *Minerals & Electrolytes*...... 32 *Miscellaneous Therapeutic Classes*...... 33 *Mouth/Throat/Dental Agents*...... 33 *Multivitamins*...... 34 *Musculoskeletal Therapy Agents*...... 34 *Nasal Agents - Systemic And Topical*...... 34 *Neuromuscular Agents*...... 34 *Nutrients*...... 34 *Ophthalmic Agents*...... 35 *Otic Agents*...... 36 *Oxytocics*...... 36 *Penicillins*...... 36 *Pharmaceutical Adjuvants*...... 36 *Progestins*...... 37 *Psychotherapeutic And Neurological Agents - Misc.*...... 38 *Respiratory Agents - Misc.*...... 39 *Sulfonamides*...... 39 *Tetracyclines*...... 40 *Thyroid Agents*...... 40 *Ulcer Drugs/Antispasmodics/Anticholinergics*...... 40 *Urinary Antispasmodics*...... 41 *Vaginal And Related Products*...... 41 *Vasopressors*...... 41 *Vitamins*...... 41

Last Updated 12.1.2020 2 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

TIER 1 TIER 2 TIER 3 amphetamine-dextroamphet er oral capsule COTEMPLA XR-ODT ORAL TABLET EXTENDED clonidine hcl er oral tablet extended release extended release 24 hour AL RELEASE DISPERSIBLE PA; AL 12 hour MO amphetamine-dextroamphetamine oral VYVANSE ORAL CAPSULE AL DAYTRANA TRANSDERMAL PATCH AL tablet AL VYVANSE ORAL TABLET CHEWABLE AL dexmethylphenidate hcl er oral capsule armodafinil oral tablet PA extended release 24 hour 10 mg, 15 mg, 20 atomoxetine hcl oral capsule MO mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg MO; dextroamphetamine sulfate er oral capsule AL extended release 24 hour AL dexmethylphenidate hcl oral tablet AL dextroamphetamine sulfate oral solution guanfacine hcl er oral tablet extended release AL 24 hour MO; AL dextroamphetamine sulfate oral tablet AL methylphenidate hcl er (xr) oral capsule methylphenidate hcl er (cd) oral capsule extended release 24 hour AL extended release AL methylphenidate hcl oral tablet chewable methylphenidate hcl er (la) oral capsule MO; AL extended release 24 hour 10 mg, 60 mg MYDAYIS ORAL CAPSULE EXTENDED RELEASE MO 24 HOUR ST; AL methylphenidate hcl er (la) oral capsule QUILLICHEW ER ORAL TABLET CHEWABLE extended release 24 hour 20 mg, 30 mg, 40 EXTENDED RELEASE ST; AL mg AL QUILLIVANT XR ORAL SUSPENSION methylphenidate hcl er oral tablet extended RECONSTITUTED ER ST; AL release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, SUNOSI ORAL TABLET PA 54 mg AL WAKIX ORAL TABLET PA; LA methylphenidate hcl er oral tablet extended release 24 hour AL methylphenidate hcl er oral tablet extended release 72 mg MO; AL methylphenidate hcl oral solution AL methylphenidate hcl oral tablet MO; AL modafinil oral tablet PA; AL

*Allergenic Extracts/Biologicals Misc*

GRASTEK SUBLINGUAL TABLET SUBLINGUAL PA ODACTRA SUBLINGUAL TABLET SUBLINGUAL PA ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL PA; SP ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET SUBLINGUAL PA; SP ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK PA; LA ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL PA; LA ORALAIR SUBLINGUAL TABLET SUBLINGUAL PA; SP RAGWITEK SUBLINGUAL TABLET SUBLINGUAL PA

*Aminoglycosides*

amikacin sulfate injection solution 500 TOBI PODHALER INHALATION CAPSULE PA; ARIKAYCE INHALATION SUSPENSION PA; SP mg/2ml PA; LA PA Except Cystic Fibrosis Specialists; QL; SP BETHKIS INHALATION NEBULIZATION neomycin sulfate oral tablet SOLUTION PA; QL; SP paromomycin sulfate oral capsule KITABIS PAK INHALATION NEBULIZATION tobramycin inhalation nebulization solution SOLUTION PA; QL; SP 300 mg/5ml PA; QL; SP TOBI INHALATION NEBULIZATION SOLUTION PA; PA Except Cystic Fibrosis Specialists; QL; SP

Last Updated 12.1.2020 3 *Analgesics - Anti-Inflammatory*

celecoxib oral capsule MO ACTEMRA ACTPEN SUBCUTANEOUS ARAVA ORAL TABLET PA; MO diclofenac potassium oral tablet MO SOLUTION AUTO-INJECTOR PA; SP DAYPRO ORAL TABLET MO diclofenac sodium er oral tablet extended ACTEMRA SUBCUTANEOUS SOLUTION ketoprofen er oral capsule extended release release 24 hour MO PREFILLED SYRINGE PA; SP 24 hour MO diclofenac sodium oral tablet delayed release ARCALYST SUBCUTANEOUS SOLUTION KEVZARA SUBCUTANEOUS SOLUTION AUTO- MO RECONSTITUTED PA; SP INJECTOR PA; SP etodolac er oral tablet extended release 24 ENBREL MINI SUBCUTANEOUS SOLUTION KEVZARA SUBCUTANEOUS SOLUTION hour MO CARTRIDGE PA; SP PREFILLED SYRINGE PA; SP etodolac oral capsule MO ENBREL SUBCUTANEOUS SOLUTION 25 KINERET SUBCUTANEOUS SOLUTION etodolac oral tablet MO MG/0.5ML PA; SP PREFILLED SYRINGE PA; SP flurbiprofen oral tablet MO ENBREL SUBCUTANEOUS SOLUTION ORENCIA CLICKJECT SUBCUTANEOUS ibuprofen oral tablet 400 mg, 600 mg, 800 mg PREFILLED SYRINGE PA; SP SOLUTION AUTO-INJECTOR PA; SP DF; MO ENBREL SUBCUTANEOUS SOLUTION ORENCIA SUBCUTANEOUS SOLUTION indomethacin er oral capsule extended RECONSTITUTED PA; SP PREFILLED SYRINGE PA; SP release MO; AL ENBREL SURECLICK SUBCUTANEOUS OTREXUP SUBCUTANEOUS SOLUTION AUTO- indomethacin oral capsule 25 mg, 50 mg SOLUTION AUTO-INJECTOR PA; SP INJECTOR 10 MG/0.4ML, 15 MG/0.4ML, 17.5 MO; AL fenoprofen calcium oral tablet MO MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, ketoprofen oral capsule 50 mg, 75 mg MO HUMIRA PEDIATRIC CROHNS START ketorolac tromethamine injection solution 30 25 MG/0.4ML PA; LA SUBCUTANEOUS PREFILLED SYRINGE KIT 80 RASUVO SUBCUTANEOUS SOLUTION AUTO- mg/ml PA; LA ketorolac tromethamine intramuscular MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 solution 60 mg/2ml PA; LA PA; SP MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, ketorolac tromethamine oral tablet QL; AL HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR 22.5 MG/0.45ML, 25 MG/0.5ML PA; LA leflunomide oral tablet PA; PA except KIT PA; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO- Rheumatology; MO HUMIRA PEN-CD/UC/HS STARTER INJECTOR PA; SP meclofenamate sodium oral capsule MO SUBCUTANEOUS PEN-INJECTOR KIT PA; SP SIMPONI SUBCUTANEOUS SOLUTION meloxicam oral tablet MO HUMIRA PEN-PS/UV/ADOL HS START PREFILLED SYRINGE PA; SP nabumetone oral tablet MO SUBCUTANEOUS PEN-INJECTOR KIT 40 SPRIX NASAL SOLUTION PA; QL; AL naproxen dr oral tablet delayed release DF; MG/0.8ML PA; SP MO HUMIRA SUBCUTANEOUS PREFILLED SYRINGE naproxen oral tablet DF; MO KIT PA; SP oxaprozin oral tablet MO OTEZLA ORAL TABLET PA; SP piroxicam oral capsule MO OTEZLA ORAL TABLET THERAPY PACK PA; sulindac oral tablet MO tolmetin sodium oral capsule MO SP tolmetin sodium oral tablet 600 mg MO RIDAURA ORAL CAPSULE RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR PA; SP XELJANZ ORAL TABLET PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; SP

*Analgesics - Nonnarcotic*

butalbital-acetaminophen oral tablet 50-325 BUPAP ORAL TABLET 50-300 MG AL mg AL butalbital-apap-caffeine oral capsule 50-325- butalbital-apap-caffeine oral capsule 50-300- 40 mg AL 40 mg AL DURACLON EPIDURAL SOLUTION 100 butalbital-apap-caffeine oral tablet 50-325-40 MCG/ML MO mg AL ESGIC ORAL CAPSULE AL clonidine hcl (analgesia) epidural solution ZEBUTAL ORAL CAPSULE 50-325-40 MG AL MO diflunisal oral tablet MO salsalate oral tablet MO TENCON ORAL TABLET 50-325 MG AL

Last Updated 12.1.2020 4 *Analgesics - Opioid*

acetaminophen-codeine #2 oral tablet DF HYSINGLA ER ORAL TABLET ER 24 HOUR ASCOMP-CODEINE ORAL CAPSULE AL acetaminophen-codeine #3 oral tablet DF ABUSE-DETERRENT butalbital-asa-caff-codeine oral capsule AL acetaminophen-codeine #4 oral tablet DF NUCYNTA ER ORAL TABLET EXTENDED DILAUDID ORAL LIQUID PA acetaminophen-codeine oral solution DF RELEASE 12 HOUR DILAUDID ORAL TABLET buprenorphine hcl sublingual tablet NUCYNTA ORAL TABLET fentanyl citrate buccal lozenge on a handle sublingual PA OXYCONTIN ORAL TABLET ER 12 HOUR PA; ST; PA Except Oncology buprenorphine transdermal patch weekly ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 fentanyl citrate buccal tablet PA; ST; PA butalbital-apap-caff-cod oral capsule 50-325- MG, 40 MG Except Oncology 40-30 mg AL OXYCONTIN ORAL TABLET ER 12 HOUR hydromorphone hcl er oral tablet extended butorphanol tartrate nasal solution PA release 24 hour ST codeine sulfate oral tablet ABUSE-DETERRENT 60 MG, 80 MG ST ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL LAZANDA NASAL SOLUTION PA; ST fentanyl transdermal patch 72 hour 100 METHADOSE ORAL TABLET SOLUBLE mcg/hr, 50 mcg/hr, 75 mcg/hr ST morphine sulfate er beads oral capsule fentanyl transdermal patch 72 hour 12 extended release 24 hour ST mcg/hr, 25 mcg/hr oxymorphone hcl oral tablet PA hydrocodone-acetaminophen oral solution tramadol-acetaminophen oral tablet PA; PA 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 Except Pain Management mg/15ml DF XTAMPZA ER ORAL CAPSULE ER 12 HOUR hydrocodone-acetaminophen oral tablet 10- ABUSE-DETERRENT 325 mg, 5-325 mg, 7.5-325 mg DF hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg DF hydromorphone hcl oral liquid PA; ST hydromorphone hcl oral tablet hydromorphone hcl rectal suppository PA; ST METHADONE HCL INTENSOL ORAL CONCENTRATE methadone hcl oral concentrate methadone hcl oral solution methadone hcl oral tablet methadone hcl oral tablet soluble morphine sulfate (concentrate) oral solution 100 mg/5ml ST morphine sulfate (concentrate) oral solution 20 mg/ml morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine sulfate er oral capsule extended release 24 hour 100 mg, 80 mg ST morphine sulfate er oral tablet extended release 100 mg, 200 mg ST morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg morphine sulfate oral solution morphine sulfate oral tablet morphine sulfate rectal suppository oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg oxycodone hcl er oral tablet er 12 hour abuse-deterrent 60 mg, 80 mg ST oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg

Last Updated 12.1.2020 5 oxymorphone hcl er oral tablet extended release 12 hour ST pentazocine-naloxone hcl oral tablet AL tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg ST tramadol hcl er oral capsule extended release 24 hour ST tramadol hcl er oral tablet extended release 24 hour tramadol hcl oral tablet 50 mg

*Androgens-Anabolic*

danazol oral capsule ANDRODERM TRANSDERMAL PATCH 24 ANADROL-50 ORAL TABLET oxandrolone oral tablet HOUR PA FORTESTA TRANSDERMAL GEL PA testosterone cypionate injection solution 200 methitest oral tablet PA; RM methyltestosterone oral capsule PA mg/ml PA NATESTO NASAL GEL PA testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml PA; PA Except Endocrinology/Urology testosterone enanthate intramuscular solution PA testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) PA testosterone transdermal solution PA

*Anorectal And Related Products*

hydrocortisone acetate rectal suppository 25 RECTIV RECTAL OINTMENT mg hydrocortisone rectal enema lidocaine-hydrocortisone ace rectal gel lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 %

*Anthelmintics*

ivermectin oral tablet albendazole oral tablet PA; PA except praziquantel oral tablet Infectious Disease or Gastroenterology EMVERM ORAL TABLET CHEWABLE QL; AL

*Antianginal Agents*

isosorbide dinitrate oral tablet MO DILATRATE-SR ORAL CAPSULE EXTENDED NITRO-BID TRANSDERMAL OINTMENT isosorbide mononitrate er oral tablet RELEASE MO NITRO-DUR TRANSDERMAL PATCH 24 HOUR extended release 24 hour MO 0.3 MG/HR MO isosorbide mononitrate oral tablet MO nitroglycerin translingual solution MO nitroglycerin er oral capsule extended release ranolazine er oral tablet extended release 12 MO hour MO nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch 24 hour MO

Last Updated 12.1.2020 6 *Antianxiety Agents*

alprazolam oral tablet alprazolam er oral tablet extended release 24 alprazolam oral tablet dispersible PA hour buspirone hcl oral tablet ALPRAZOLAM INTENSOL ORAL CONCENTRATE chlordiazepoxide hcl oral capsule AL alprazolam xr oral tablet extended release 24 clorazepate dipotassium oral tablet hour diazepam intensol oral concentrate AL LORAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral tablet AL lorazepam oral concentrate 2 mg/ml hydroxyzine hcl oral syrup AL VALIUM ORAL TABLET AL hydroxyzine hcl oral tablet AL hydroxyzine pamoate oral capsule AL lorazepam oral tablet oxazepam oral capsule

*Antiarrhythmics*

amiodarone hcl oral tablet MO NORPACE CR ORAL CAPSULE EXTENDED MULTAQ ORAL TABLET MO disopyramide phosphate oral capsule MO; RELEASE 12 HOUR MO; AL AL dofetilide oral capsule MO flecainide acetate oral tablet MO mexiletine hcl oral capsule MO pacerone oral tablet 100 mg, 200 mg, 400 mg MO propafenone hcl er oral capsule extended release 12 hour MO propafenone hcl oral tablet MO quinidine gluconate er oral tablet extended release MO quinidine sulfate oral tablet MO

Last Updated 12.1.2020 7 *Antiasthmatic And Bronchodilator Agents*

albuterol sulfate er oral tablet extended ADVAIR HFA INHALATION AEROSOL $0 ICS; ACCOLATE ORAL TABLET MO release 12 hour MO MO BROVANA INHALATION NEBULIZATION albuterol sulfate oral syrup MO albuterol sulfate inhalation nebulization SOLUTION PA; MO albuterol sulfate oral tablet MO solution (2.5 mg/3ml) 0.083%, (5 mg/ml) DALIRESP ORAL TABLET PA ARNUITY ELLIPTA INHALATION AEROSOL 0.5%, 0.63 mg/3ml, 1.25 mg/3ml MO ELIXOPHYLLIN ORAL ELIXIR POWDER BREATH ACTIVATED 100 MCG/ACT, ARCAPTA NEOHALER INHALATION CAPSULE levalbuterol hcl inhalation nebulization 200 MCG/ACT, 50 MCG/ACT MO; AL MO solution 0.31 mg/3ml PA ASMANEX (120 METERED DOSES) ATROVENT HFA INHALATION AEROSOL levalbuterol hcl inhalation nebulization INHALATION AEROSOL POWDER BREATH SOLUTION MO solution 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 ACTIVATED $0 ICS; MO BREO ELLIPTA INHALATION AEROSOL mg/3ml PA; MO ASMANEX (14 METERED DOSES) INHALATION POWDER BREATH ACTIVATED 100-25 PERFOROMIST INHALATION NEBULIZATION AEROSOL POWDER BREATH ACTIVATED $0 MCG/INH $0 ICS; MO; AL SOLUTION PA; MO ICS; MO BREO ELLIPTA INHALATION AEROSOL YUPELRI INHALATION SOLUTION PA ASMANEX (30 METERED DOSES) INHALATION zafirlukast oral tablet MO POWDER BREATH ACTIVATED 200-25 zileuton er oral tablet extended release 12 AEROSOL POWDER BREATH ACTIVATED $0 MCG/INH $0 ICS; MO hour PA ICS; MO COMBIVENT RESPIMAT INHALATION ZYFLO ORAL TABLET PA; MO ASMANEX (60 METERED DOSES) INHALATION AEROSOL SOLUTION MO AEROSOL POWDER BREATH ACTIVATED $0 FASENRA PEN SUBCUTANEOUS SOLUTION ICS; MO AUTO-INJECTOR PA; SP ASMANEX (7 METERED DOSES) INHALATION NUCALA SUBCUTANEOUS SOLUTION AUTO- AEROSOL POWDER BREATH ACTIVATED $0 INJECTOR PA; AL; SP ICS; MO NUCALA SUBCUTANEOUS SOLUTION ASMANEX HFA INHALATION AEROSOL MO PREFILLED SYRINGE PA; AL; SP budesonide inhalation suspension MO; AL PROAIR HFA INHALATION AEROSOL cromolyn sodium inhalation nebulization SOLUTION solution MO PROAIR RESPICLICK INHALATION AEROSOL FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED POWDER BREATH ACTIVATED $0 ICS; MO SEREVENT DISKUS INHALATION AEROSOL FLOVENT HFA INHALATION AEROSOL $0 POWDER BREATH ACTIVATED ST; MO ICS; MO SPIRIVA HANDIHALER INHALATION CAPSULE fluticasone-salmeterol inhalation aerosol MO powder breath activated MO SPIRIVA RESPIMAT INHALATION AEROSOL ipratropium bromide inhalation solution SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT MO MO ipratropium-albuterol inhalation solution STIOLTO RESPIMAT INHALATION AEROSOL MO SOLUTION 2.5-2.5 MCG/ACT MO levalbuterol tartrate inhalation aerosol STRIVERDI RESPIMAT INHALATION AEROSOL montelukast sodium oral packet MO; AL SOLUTION MO montelukast sodium oral tablet MO; AL SYMBICORT INHALATION AEROSOL $0 ICS; montelukast sodium oral tablet chewable 4 MO mg, 5 mg MO; AL THEO-24 ORAL CAPSULE EXTENDED RELEASE PULMICORT FLEXHALER INHALATION 24 HOUR MO AEROSOL POWDER BREATH ACTIVATED $0 VENTOLIN HFA INHALATION AEROSOL ICS; MO SOLUTION QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED MO terbutaline sulfate oral tablet MO theophylline er oral tablet extended release 12 hour 300 mg, 450 mg MO theophylline er oral tablet extended release 24 hour theophylline oral solution WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED MO

Last Updated 12.1.2020 8 *Anticoagulants*

enoxaparin sodium injection solution PA; ELIQUIS DVT/PE STARTER PACK ORAL TABLET QL THERAPY PACK enoxaparin sodium subcutaneous solution ELIQUIS ORAL TABLET MO PA; QL FRAGMIN SUBCUTANEOUS SOLUTION 10000 fondaparinux sodium subcutaneous solution UNIT/ML, 12500 UNIT/0.5ML, 15000 PA; PA required for duration of greater than UNIT/0.6ML, 18000 UNT/0.72ML, 2500 14 days except when written by Oncology; QL UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 JANTOVEN ORAL TABLET MO UNIT/0.3ML, 95000 UNIT/3.8ML PA; PA warfarin sodium oral tablet MO required for duration of greater than 14 days except when written by Oncology; QL PRADAXA ORAL CAPSULE 110 MG PRADAXA ORAL CAPSULE 150 MG, 75 MG MO XARELTO ORAL TABLET MO XARELTO STARTER PACK ORAL TABLET THERAPY PACK

*Anticonvulsants*

carbamazepine er oral capsule extended BANZEL ORAL TABLET APTIOM ORAL TABLET MO release 12 hour MO CELONTIN ORAL CAPSULE MO BRIVIACT ORAL SOLUTION PA; PA Except carbamazepine er oral tablet extended VIMPAT ORAL SOLUTION AL Neurology release 12 hour MO VIMPAT ORAL TABLET AL BRIVIACT ORAL TABLET PA; PA Except carbamazepine oral suspension MO XCOPRI (250 MG DAILY DOSE) ORAL TABLET Neurology carbamazepine oral tablet MO THERAPY PACK PA DIACOMIT ORAL CAPSULE PA; SP carbamazepine oral tablet chewable MO XCOPRI (350 MG DAILY DOSE) ORAL TABLET DIACOMIT ORAL PACKET PA; SP clobazam oral suspension PA THERAPY PACK PA DIASTAT ACUDIAL RECTAL GEL PA; AL clobazam oral tablet PA XCOPRI ORAL TABLET PA DIASTAT PEDIATRIC RECTAL GEL PA; AL clonazepam oral tablet XCOPRI ORAL TABLET THERAPY PACK PA diazepam rectal gel PA; AL clonazepam oral tablet dispersible PA DILANTIN ORAL CAPSULE 30 MG MO divalproex sodium er oral tablet extended EPIDIOLEX ORAL SOLUTION PA; SP release 24 hour MO FYCOMPA ORAL SUSPENSION AL divalproex sodium oral capsule delayed FYCOMPA ORAL TABLET AL release sprinkle MO KLONOPIN ORAL TABLET 2 MG divalproex sodium oral tablet delayed release LAMICTAL XR ORAL KIT MO; AL lamotrigine er oral tablet extended release 24 MO ethosuximide oral capsule MO hour MO; AL ethosuximide oral solution MO lamotrigine oral kit 25 & 50 & 100 mg felbamate oral suspension MO lamotrigine oral tablet dispersible PA; MO felbamate oral tablet MO lamotrigine starter kit-blue oral kit gabapentin oral capsule MO lamotrigine starter kit-green oral kit gabapentin oral solution 250 mg/5ml MO lamotrigine starter kit-orange oral kit gabapentin oral tablet MO MYSOLINE ORAL TABLET MO lamotrigine oral tablet MO NAYZILAM NASAL SOLUTION PA lamotrigine oral tablet chewable MO OXTELLAR XR ORAL TABLET EXTENDED levetiracetam er oral tablet extended release RELEASE 24 HOUR ST; MO 24 hour MO SPRITAM ORAL TABLET DISINTEGRATING levetiracetam oral solution MO SOLUBLE ST levetiracetam oral tablet MO topiramate er oral capsule er 24 hour sprinkle oxcarbazepine oral suspension PA; PA Except Neurology; MO; AL oxcarbazepine oral tablet MO TROKENDI XR ORAL CAPSULE EXTENDED phenytoin infatabs oral tablet chewable RELEASE 24 HOUR PA; MO MO VALTOCO 10 MG DOSE NASAL LIQUID PA; phenytoin oral suspension 125 mg/5ml MO QL phenytoin oral tablet chewable MO VALTOCO 15 MG DOSE NASAL LIQUID phenytoin sodium extended oral capsule THERAPY PACK PA; QL MO VALTOCO 20 MG DOSE NASAL LIQUID pregabalin oral capsule MO THERAPY PACK PA; QL pregabalin oral solution VALTOCO 5 MG DOSE NASAL LIQUID PA; QL primidone oral tablet MO ZONEGRAN ORAL CAPSULE MO rufinamide oral suspension tiagabine hcl oral tablet MO topiramate oral capsule sprinkle MO topiramate oral tablet MO valproic acid oral capsule MO valproic acid oral solution MO vigabatrin oral packet PA; SP vigabatrin oral tablet PA; SP VIGADRONE ORAL PACKET PA; SP zonisamide oral capsule MO

Last Updated 12.1.2020 9 *Antidepressants*

amitriptyline hcl oral tablet AL PAXIL ORAL SUSPENSION amoxapine oral tablet bupropion hcl er (sr) oral tablet extended EMSAM TRANSDERMAL PATCH 24 HOUR release 12 hour MO PA; PA Except Psychiatry bupropion hcl er (xl) oral tablet extended FETZIMA ORAL CAPSULE EXTENDED RELEASE release 24 hour 150 mg, 300 mg MO 24 HOUR ST bupropion hcl oral tablet MO fluoxetine hcl oral capsule delayed release citalopram hydrobromide oral solution MO fluvoxamine maleate er oral capsule citalopram hydrobromide oral tablet MO extended release 24 hour clomipramine hcl oral capsule AL MARPLAN ORAL TABLET MO desipramine hcl oral tablet NORPRAMIN ORAL TABLET 10 MG, 25 MG desvenlafaxine succinate er oral tablet PEXEVA ORAL TABLET extended release 24 hour MO TRINTELLIX ORAL TABLET ST doxepin hcl oral capsule AL VIIBRYD ORAL TABLET MO doxepin hcl oral concentrate AL duloxetine hcl oral capsule delayed release particles MO escitalopram oxalate oral solution MO escitalopram oxalate oral tablet MO fluoxetine hcl oral capsule MO fluoxetine hcl oral solution fluvoxamine maleate oral tablet MO imipramine hcl oral tablet AL maprotiline hcl oral tablet PA; PA Except Psychiatry; MO mirtazapine oral tablet MO mirtazapine oral tablet dispersible MO nefazodone hcl oral tablet PA; MO nortriptyline hcl oral capsule nortriptyline hcl oral solution paroxetine hcl er oral tablet extended release 24 hour ST; MO paroxetine hcl oral tablet MO phenelzine sulfate oral tablet MO protriptyline hcl oral tablet sertraline hcl oral concentrate MO sertraline hcl oral tablet MO tranylcypromine sulfate oral tablet MO trazodone hcl oral tablet MO trimipramine maleate oral capsule AL venlafaxine hcl er oral capsule extended release 24 hour MO venlafaxine hcl oral tablet MO

Last Updated 12.1.2020 10 *Antidiabetics*

acarbose oral tablet MO GLUCAGEN HYPOKIT INJECTION SOLUTION AVANDIA ORAL TABLET 2 MG, 4 MG PA; BAQSIMI ONE PACK NASAL POWDER RECONSTITUTED MO BAQSIMI TWO PACK NASAL POWDER GLYXAMBI ORAL TABLET MO CYCLOSET ORAL TABLET diazoxide oral suspension PA; PA Except HUMALOG KWIKPEN SUBCUTANEOUS miglitol oral tablet PA Endocrinology SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 glimepiride oral tablet MO UNIT/ML MO glipizide er oral tablet extended release 24 HUMALOG MIX 50/50 KWIKPEN hour MO SUBCUTANEOUS SUSPENSION PEN-INJECTOR glipizide oral tablet MO glipizide xl oral tablet extended release 24 MO HUMALOG MIX 50/50 SUBCUTANEOUS hour MO glipizide-metformin hcl oral tablet MO SUSPENSION MO glucagon emergency injection kit HUMALOG MIX 75/25 KWIKPEN glyburide micronized oral tablet MO; AL SUBCUTANEOUS SUSPENSION PEN-INJECTOR glyburide oral tablet MO; AL MO glyburide-metformin oral tablet MO HUMALOG MIX 75/25 SUBCUTANEOUS GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SUSPENSION MO SOLUTION AUTO-INJECTOR HUMALOG SUBCUTANEOUS SOLUTION MO GVOKE HYPOPEN 2-PACK SUBCUTANEOUS HUMALOG SUBCUTANEOUS SOLUTION SOLUTION AUTO-INJECTOR CARTRIDGE MO GVOKE PFS SUBCUTANEOUS SOLUTION HUMULIN 70/30 KWIKPEN SUBCUTANEOUS PREFILLED SYRINGE SUSPENSION PEN-INJECTOR MO metformin hcl er oral tablet extended release HUMULIN 70/30 SUBCUTANEOUS 24 hour MO SUSPENSION MO metformin hcl oral solution HUMULIN N KWIKPEN SUBCUTANEOUS metformin hcl oral tablet MO SUSPENSION PEN-INJECTOR MO nateglinide oral tablet MO HUMULIN N SUBCUTANEOUS SUSPENSION pioglitazone hcl oral tablet MO pioglitazone hcl-glimepiride oral tablet MO MO pioglitazone hcl-metformin hcl oral tablet HUMULIN R INJECTION SOLUTION MO HUMULIN R U-500 (CONCENTRATED) MO repaglinide oral tablet MO SUBCUTANEOUS SOLUTION MO HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR MO INVOKAMET ORAL TABLET MO INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO INVOKANA ORAL TABLET MO JARDIANCE ORAL TABLET MO JENTADUETO ORAL TABLET MO JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO KORLYM ORAL TABLET PA; SP LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO LANTUS SUBCUTANEOUS SOLUTION MO LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR MO LEVEMIR SUBCUTANEOUS SOLUTION MO LYUMJEV INJECTION SOLUTION LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; Step except endocrinology OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; Step except endocrinology RIOMET ORAL SOLUTION RYBELSUS ORAL TABLET ST; ST Except Endocrinology

Last Updated 12.1.2020 11 SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR ST SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; PA except Endocrinology; MO SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; PA except Endocrinology; MO SYNJARDY ORAL TABLET MO SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TRADJENTA ORAL TABLET MO TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR MO TRESIBA SUBCUTANEOUS SOLUTION MO TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MO TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR ST; ST Except Endocrinology VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR ST

*Antidiarrheal/Probiotic Agents*

diphenoxylate-atropine oral liquid loperamide hcl oral capsule diphenoxylate-atropine oral tablet MOTOFEN ORAL TABLET AL opium oral tincture MYTESI ORAL TABLET DELAYED RELEASE PA; LA

*Antidotes And Specific Antagonists*

naloxone hcl injection solution 0.4 mg/ml, 4 NARCAN NASAL LIQUID deferasirox granules oral packet PA; SP mg/10ml QL VISTOGARD ORAL PACKET SP deferasirox oral tablet PA; SP naloxone hcl injection solution cartridge QL FERRIPROX ORAL TABLET PA; SP naloxone hcl injection solution prefilled FERRIPROX TWICE-A-DAY ORAL TABLET PA; syringe QL SP naltrexone hcl oral tablet

*Antiemetics*

aprepitant oral capsule 125 mg, 80 mg ST; BONJESTA ORAL TABLET EXTENDED RELEASE AKYNZEO ORAL CAPSULE ST; QL ST Except Hematology/Oncology; QL ANZEMET ORAL TABLET ST; QL aprepitant oral capsule 40 mg QL dronabinol oral capsule PA doxylamine-pyridoxine oral tablet delayed granisetron hcl oral tablet ST; QL release QL SANCUSO TRANSDERMAL PATCH ST; QL meclizine hcl oral tablet 12.5 mg, 25 mg scopolamine transdermal patch 72 hour QL SYNDROS ORAL SOLUTION PA MO VARUBI (180 MG DOSE) ORAL TABLET ondansetron hcl oral solution ondansetron hcl oral tablet THERAPY PACK PA; LA; QL ondansetron oral tablet dispersible ZUPLENZ ORAL FILM ST; QL trimethobenzamide hcl oral capsule PA; AL

Last Updated 12.1.2020 12 *Antifungals*

fluconazole oral suspension reconstituted NOXAFIL ORAL SUSPENSION PA; MO flucytosine oral capsule fluconazole oral tablet 100 mg, 200 mg, 50 griseofulvin microsize oral tablet mg fluconazole oral tablet 150 mg QL griseofulvin microsize oral suspension griseofulvin ultramicrosize oral tablet itraconazole oral capsule PA; PA except Infectious Disease, Hematology and Oncology itraconazole oral solution PA; PA except Infectious Disease, Hematology and Oncology ketoconazole oral tablet PA nystatin oral tablet posaconazole oral tablet delayed release PA; MO terbinafine hcl oral tablet voriconazole oral suspension reconstituted PA; PA Except Infectious Disease voriconazole oral tablet PA; PA Except Infectious Disease

*Antihistamines*

carbinoxamine maleate oral solution AL desloratadine oral tablet PA carbinoxamine maleate oral tablet 4 mg AL desloratadine oral tablet dispersible PA; AL cyproheptadine hcl oral syrup AL cyproheptadine hcl oral tablet AL diphenhydramine hcl oral elixir AL levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet promethazine hcl oral solution AL promethazine hcl oral syrup AL promethazine hcl oral tablet AL promethazine hcl rectal suppository 12.5 mg, 25 mg AL

*Antihyperlipidemics*

atorvastatin calcium oral tablet MO PRALUENT SUBCUTANEOUS SOLUTION AUTO- ezetimibe-simvastatin oral tablet 10-10 mg, cholestyramine light oral packet MO INJECTOR PA; LA 10-20 mg, 10-40 mg MO cholestyramine light oral powder MO REPATHA PUSHTRONEX SYSTEM ezetimibe-simvastatin oral tablet 10-80 mg cholestyramine oral packet MO SUBCUTANEOUS SOLUTION CARTRIDGE PA; PA; MO cholestyramine oral powder MO fluvastatin sodium er oral tablet extended colesevelam hcl oral packet MO LA colestipol hcl oral granules MO REPATHA SUBCUTANEOUS SOLUTION release 24 hour MO colestipol hcl oral packet MO PREFILLED SYRINGE PA; LA fluvastatin sodium oral capsule MO colestipol hcl oral tablet MO REPATHA SURECLICK SUBCUTANEOUS JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 ezetimibe oral tablet MO SOLUTION AUTO-INJECTOR PA; LA MG, 5 MG PA; SP fenofibrate micronized oral capsule 134 mg, VASCEPA ORAL CAPSULE MO LIVALO ORAL TABLET MO 67 mg MO WELCHOL ORAL PACKET MO NEXLETOL ORAL TABLET PA fenofibrate oral capsule 134 mg, 67 mg MO WELCHOL ORAL TABLET MO NEXLIZET ORAL TABLET PA fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg MO fenofibric acid oral capsule delayed release 45 mg MO gemfibrozil oral tablet MO icosapent ethyl oral capsule MO lovastatin oral tablet MO pravastatin sodium oral tablet MO rosuvastatin calcium oral tablet MO simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg MO simvastatin oral tablet 80 mg PA; MO

Last Updated 12.1.2020 13 *Antihypertensives*

amlodipine besy-benazepril hcl oral capsule aliskiren fumarate oral tablet ST; MO MO amlodipine besylate-valsartan oral tablet atenolol-chlorthalidone oral tablet MO ST benazepril hcl oral tablet MO amlodipine-olmesartan oral tablet ST; MO benazepril-hydrochlorothiazide oral tablet amlodipine-valsartan-hctz oral tablet ST; MO MO bisoprolol-hydrochlorothiazide oral tablet EDARBI ORAL TABLET ST; MO MO EDARBYCLOR ORAL TABLET 40-12.5 MG ST candesartan cilexetil oral tablet ST; MO EPANED ORAL SOLUTION PA candesartan cilexetil-hctz oral tablet ST; MAVIK ORAL TABLET 4 MG MO MO olmesartan-amlodipine-hctz oral tablet ST; captopril-hydrochlorothiazide oral tablet MO MO TEKTURNA HCT ORAL TABLET ST; MO clonidine hcl oral tablet MO telmisartan-amlodipine oral tablet ST; MO clonidine transdermal patch weekly MO trandolapril-verapamil hcl er oral tablet doxazosin mesylate oral tablet MO extended release enalapril maleate oral tablet MO VASERETIC ORAL TABLET MO enalapril-hydrochlorothiazide oral tablet VECAMYL ORAL TABLET PA; LA MO eplerenone oral tablet PA; MO fosinopril sodium oral tablet MO fosinopril sodium-hctz oral tablet MO guanfacine hcl oral tablet MO; AL hydralazine hcl oral tablet MO irbesartan oral tablet MO irbesartan-hydrochlorothiazide oral tablet MO lisinopril oral tablet MO lisinopril-hydrochlorothiazide oral tablet MO losartan potassium oral tablet MO losartan potassium-hctz oral tablet MO methyldopa oral tablet MO; AL methyldopa-hydrochlorothiazide oral tablet MO metoprolol-hydrochlorothiazide oral tablet MO metyrosine oral capsule minoxidil oral tablet MO moexipril hcl oral tablet MO olmesartan medoxomil oral tablet MO olmesartan medoxomil-hctz oral tablet ST; MO perindopril erbumine oral tablet MO phenoxybenzamine hcl oral capsule PA prazosin hcl oral capsule MO propranolol-hctz oral tablet MO quinapril hcl oral tablet MO quinapril-hydrochlorothiazide oral tablet MO ramipril oral capsule MO telmisartan oral tablet ST; MO telmisartan-hctz oral tablet ST; MO terazosin hcl oral capsule MO trandolapril oral tablet MO valsartan oral tablet MO valsartan-hydrochlorothiazide oral tablet MO

Last Updated 12.1.2020 14 *Anti-Infective Agents - Misc.*

atovaquone oral suspension PA ALINIA ORAL SUSPENSION RECONSTITUTED FIRVANQ ORAL SOLUTION RECONSTITUTED clindamycin hcl oral capsule DF PA; AL PA; PA Except Infectious Disease or clindamycin palmitate hcl oral solution ALINIA ORAL TABLET PA Gastroenterology reconstituted DF CAYSTON INHALATION SOLUTION fosfomycin tromethamine oral packet dapsone oral tablet RECONSTITUTED PA; PA Except Cystic LAMPIT ORAL TABLET PA linezolid oral suspension reconstituted Fibrosis Specialists; AL; SP MACRODANTIN ORAL CAPSULE 25 MG AL linezolid oral tablet PRIMSOL ORAL SOLUTION metronidazole oral capsule methenamine hippurate oral tablet XIFAXAN ORAL TABLET 200 MG QL nitrofurantoin oral suspension AL methenamine mandelate oral tablet XIFAXAN ORAL TABLET 550 MG PA SIVEXTRO ORAL TABLET PA metronidazole oral tablet URIBEL ORAL CAPSULE nitrofurantoin macrocrystal oral capsule uroav-b oral capsule nitrofurantoin monohyd macro oral capsule uro-mp oral capsule pentamidine isethionate inhalation solution reconstituted PA; PA Except Infectious Disease sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet tinidazole oral tablet trimethoprim oral tablet vancomycin hcl oral capsule PA; PA except Infectious Disease or Gastroenterology

*Antimalarials*

atovaquone-proguanil hcl oral tablet COARTEM ORAL TABLET QL QUALAQUIN ORAL CAPSULE PA; QL; AL chloroquine phosphate oral tablet hydroxychloroquine sulfate oral tablet MO mefloquine hcl oral tablet primaquine phosphate oral tablet pyrimethamine oral tablet PA; PA Except Infectious Disease; SP quinine sulfate oral capsule PA; QL; AL

*Antimyasthenic/Cholinergic Agents*

guanidine hcl oral tablet MO MESTINON ORAL SOLUTION FIRDAPSE ORAL TABLET PA pyridostigmine bromide er oral tablet RUZURGI ORAL TABLET PA; LA extended release pyridostigmine bromide oral solution pyridostigmine bromide oral tablet 60 mg MO

*Antimycobacterial Agents*

ethambutol hcl oral tablet MYCOBUTIN ORAL CAPSULE PA isoniazid oral syrup MO PASER ORAL PACKET isoniazid oral tablet MO pretomanid oral tablet PA pyrazinamide oral tablet PRIFTIN ORAL TABLET rifabutin oral capsule PA SIRTURO ORAL TABLET PA rifampin oral capsule TRECATOR ORAL TABLET

Last Updated 12.1.2020 15 *Antineoplastics And Adjunctive Therapies*

abiraterone acetate oral tablet PA; SP AFINITOR DISPERZ ORAL TABLET SOLUBLE ALECENSA ORAL CAPSULE PA; SP anastrozole oral tablet PA; LA; MO PA; SP ALUNBRIG ORAL TABLET 30 MG PA; SP bexarotene oral capsule PA; SP AFINITOR ORAL TABLET 10 MG PA; SP AYVAKIT ORAL TABLET PA; SP bicalutamide oral tablet SP ALKERAN ORAL TABLET SP BALVERSA ORAL TABLET PA; SP capecitabine oral tablet SP CAPRELSA ORAL TABLET PA; SP BOSULIF ORAL TABLET PA; SP cyclophosphamide oral capsule SP EMCYT ORAL CAPSULE SP BRAFTOVI ORAL CAPSULE 75 MG PA; SP erlotinib hcl oral tablet PA; PA Except ERIVEDGE ORAL CAPSULE PA; SP BRUKINSA ORAL CAPSULE PA; SP Oncology; SP ERLEADA ORAL TABLET PA; SP CABOMETYX ORAL TABLET PA; SP etoposide oral capsule SP HYCAMTIN ORAL CAPSULE PA; SP CALQUENCE ORAL CAPSULE PA; SP everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg INTRON A INJECTION SOLUTION PA; SP COMETRIQ (60 MG DAILY DOSE) ORAL KIT PA; PA except Renal Transplant Surgeons and INTRON A INJECTION SOLUTION PA; SP Nephrology; SP RECONSTITUTED PA; SP COPIKTRA ORAL CAPSULE PA; SP exemestane oral tablet LA; MO JAKAFI ORAL TABLET PA; SP COTELLIC ORAL TABLET PA; SP flutamide oral capsule SP lapatinib ditosylate oral tablet PA; SP DAURISMO ORAL TABLET PA; SP hydroxyurea oral capsule LEUKERAN ORAL TABLET SP FARYDAK ORAL CAPSULE PA; SP imatinib mesylate oral tablet PA; SP LYSODREN ORAL TABLET LA GAVRETO ORAL CAPSULE PA; SP letrozole oral tablet PA; PA Except for MATULANE ORAL CAPSULE SP GILOTRIF ORAL TABLET PA; SP GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, Fertility and Oncology; QL & AL for Fertility; MESNEX ORAL TABLET PA; PA Except Oncology; SP 40 MG QL IBRANCE ORAL CAPSULE PA; SP leucovorin calcium oral tablet MYLERAN ORAL TABLET SP NILANDRON ORAL TABLET PA; PA except IBRANCE ORAL TABLET PA; SP megestrol acetate oral suspension 40 mg/ml, ICLUSIG ORAL TABLET PA; SP 400 mg/10ml LA Oncology & Urology SOLTAMOX ORAL SOLUTION MO IDHIFA ORAL TABLET PA; SP megestrol acetate oral tablet LA IMBRUVICA ORAL CAPSULE PA; SP mercaptopurine oral tablet SPRYCEL ORAL TABLET PA; SP SUTENT ORAL CAPSULE PA; SP IMBRUVICA ORAL TABLET PA; SP methotrexate oral tablet MO INLYTA ORAL TABLET PA; SP methotrexate sodium (pf) injection solution 1 TABLOID ORAL TABLET TASIGNA ORAL CAPSULE PA; SP INQOVI ORAL TABLET PA; SP gm/40ml, 250 mg/10ml, 50 mg/2ml PA; PA TREXALL ORAL TABLET MO INREBIC ORAL CAPSULE PA; SP Except Rheumatology and Dermatology VOTRIENT ORAL TABLET PA; SP IRESSA ORAL TABLET PA; SP methotrexate sodium injection solution 250 XTANDI ORAL CAPSULE PA; SP KISQALI FEMARA (400 MG DOSE) ORAL mg/10ml, 50 mg/2ml PA; PA Except ZEJULA ORAL CAPSULE PA; SP TABLET THERAPY PACK PA; SP KISQALI FEMARA (600 MG DOSE) ORAL Rheumatology and Dermatology ZOLINZA ORAL CAPSULE PA; SP methotrexate sodium injection solution TABLET THERAPY PACK PA; SP KISQALI FEMARA(200 MG DOSE) ORAL reconstituted PA; PA Except Rheumatology TABLET THERAPY PACK PA; SP and Dermatology KOSELUGO ORAL CAPSULE PA; SP tamoxifen citrate oral tablet MO LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE temozolomide oral capsule SP toremifene citrate oral tablet LA; MO THERAPY PACK PA; SP tretinoin oral capsule LA LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; SP LONSURF ORAL TABLET PA; SP LORBRENA ORAL TABLET PA; SP LYNPARZA ORAL TABLET PA; SP MEKINIST ORAL TABLET PA; SP MEKTOVI ORAL TABLET PA; SP NERLYNX ORAL TABLET PA; SP NEXAVAR ORAL TABLET PA; SP NINLARO ORAL CAPSULE PA; SP NUBEQA ORAL TABLET PA; SP ODOMZO ORAL CAPSULE PA; SP ONUREG ORAL TABLET PA; SP

Last Updated 12.1.2020 16 PEMAZYRE ORAL TABLET PA; SP PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK PA; SP POMALYST ORAL CAPSULE PA; SP QINLOCK ORAL TABLET PA; SP RETEVMO ORAL CAPSULE PA; SP ROZLYTREK ORAL CAPSULE PA; SP RUBRACA ORAL TABLET PA; SP RYDAPT ORAL CAPSULE PA; SP STIVARGA ORAL TABLET PA; SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP TABRECTA ORAL TABLET PA; SP TAFINLAR ORAL CAPSULE PA; SP TAGRISSO ORAL TABLET PA; SP TALZENNA ORAL CAPSULE PA; SP TAZVERIK ORAL TABLET PA; SP TIBSOVO ORAL TABLET PA; SP TUKYSA ORAL TABLET PA; SP TURALIO ORAL CAPSULE PA; SP VENCLEXTA ORAL TABLET PA; SP VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK PA; SP VERZENIO ORAL TABLET PA; SP VITRAKVI ORAL CAPSULE PA; SP VITRAKVI ORAL SOLUTION PA; SP VIZIMPRO ORAL TABLET PA; SP XALKORI ORAL CAPSULE PA; SP XATMEP ORAL SOLUTION PA XOSPATA ORAL TABLET PA; SP ZELBORAF ORAL TABLET PA; SP ZYDELIG ORAL TABLET PA; SP ZYKADIA ORAL TABLET PA; SP

*Antiparkinson And Related Therapy Agents*

amantadine hcl oral capsule MO ZELAPAR ORAL TABLET DISPERSIBLE PA; PA APOKYN SUBCUTANEOUS SOLUTION amantadine hcl oral syrup MO Except Neurology; MO CARTRIDGE PA; PA Except Neurology; SP amantadine hcl oral tablet MO bromocriptine mesylate oral capsule MO benztropine mesylate oral tablet MO; AL carbidopa oral tablet MO bromocriptine mesylate oral tablet MO DUOPA ENTERAL SUSPENSION PA; SP carbidopa-levodopa er oral tablet extended GOCOVRI ORAL CAPSULE EXTENDED RELEASE release 25-100 mg, 50-200 mg MO 24 HOUR PA; SP carbidopa-levodopa oral tablet MO INBRIJA INHALATION CAPSULE PA; SP carbidopa-levodopa oral tablet dispersible KYNMOBI SUBLINGUAL FILM PA; PA Except ST Neurology carbidopa-levodopa-entacapone oral tablet KYNMOBI TITRATION KIT SUBLINGUAL KIT MO PA; PA Except Neurology entacapone oral tablet ST; MO NEUPRO TRANSDERMAL PATCH 24 HOUR pramipexole dihydrochloride oral tablet PA MO ONGENTYS ORAL CAPSULE ST rasagiline mesylate oral tablet PA; PA OSMOLEX ER ORAL TABLET ER 24 HOUR Except Neurology; MO THERAPY PACK PA ropinirole hcl er oral tablet extended release OSMOLEX ER ORAL TABLET EXTENDED 24 hour PA; PA Except Neurology; MO RELEASE 24 HOUR PA ropinirole hcl oral tablet MO pramipexole dihydrochloride er oral tablet selegiline hcl oral capsule MO extended release 24 hour PA; PA Except selegiline hcl oral tablet MO trihexyphenidyl hcl oral solution MO; AL Neurology; MO trihexyphenidyl hcl oral tablet MO; AL XADAGO ORAL TABLET PA; LA

Last Updated 12.1.2020 17 *Antipsychotics/Antimanic Agents*

aripiprazole oral solution LATUDA ORAL TABLET MO; AL ABILIFY MYCITE ORAL TABLET PA; LA aripiprazole oral tablet 10 mg, 15 mg, 2 mg, CAPLYTA ORAL CAPSULE PA 20 mg PA Except Psychiatry; PA Except clozapine oral tablet dispersible PA Psychiatry; MO EQUETRO ORAL CAPSULE EXTENDED RELEASE aripiprazole oral tablet 30 mg, 5 mg PA 12 HOUR PA; MO Except Psychiatry; MO FANAPT ORAL TABLET PA chlorpromazine hcl oral tablet MO FANAPT TITRATION PACK ORAL TABLET PA clozapine oral tablet AL NUPLAZID ORAL CAPSULE PA; SP COMPRO RECTAL SUPPOSITORY NUPLAZID ORAL TABLET 10 MG PA; SP fluphenazine hcl oral concentrate paliperidone er oral tablet extended release fluphenazine hcl oral elixir 24 hour PA; PA Except Psychiatry; MO fluphenazine hcl oral tablet MO REXULTI ORAL TABLET PA; MO haloperidol lactate oral concentrate MO SAPHRIS SUBLINGUAL TABLET SUBLINGUAL haloperidol oral tablet MO VRAYLAR ORAL CAPSULE PA lithium carbonate er oral tablet extended VRAYLAR ORAL CAPSULE THERAPY PACK PA release MO lithium carbonate oral capsule MO lithium carbonate oral tablet MO lithium oral solution MO loxapine succinate oral capsule MO olanzapine oral tablet MO olanzapine oral tablet dispersible PA perphenazine oral tablet MO prochlorperazine maleate oral tablet AL Except Oncology; MO; AL prochlorperazine rectal suppository quetiapine fumarate er oral tablet extended release 24 hour MO quetiapine fumarate oral tablet MO risperidone oral solution MO; AL risperidone oral tablet MO risperidone oral tablet dispersible PA thioridazine hcl oral tablet MO; AL thiothixene oral capsule MO trifluoperazine hcl oral tablet MO ziprasidone hcl oral capsule MO

Last Updated 12.1.2020 18 *Antivirals*

abacavir sulfate oral solution LA BARACLUDE ORAL SOLUTION PA; PA Except APTIVUS ORAL CAPSULE LA abacavir sulfate oral tablet LA Infectious Disease or Gastroenterology APTIVUS ORAL SOLUTION LA abacavir sulfate-lamivudine oral tablet LA BIKTARVY ORAL TABLET LA COMPLERA ORAL TABLET LA abacavir-lamivudine-zidovudine oral tablet CIMDUO ORAL TABLET LA DESCOVY ORAL TABLET PA; LA PA; LA; MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DOVATO ORAL TABLET PA; LA acyclovir oral capsule LA EDURANT ORAL TABLET LA acyclovir oral suspension DELSTRIGO ORAL TABLET LA EPZICOM ORAL TABLET LA acyclovir oral tablet EMTRIVA ORAL SOLUTION LA EVOTAZ ORAL TABLET LA adefovir dipivoxil oral tablet PA; PA Except EPCLUSA ORAL TABLET 200-50 MG PA; SP HEPSERA ORAL TABLET PA; PA Except Gastro/Infectious Disease; MO EPIVIR HBV ORAL SOLUTION LA Gastro/Infectious Disease; MO didanosine oral capsule delayed release 200 FUZEON SUBCUTANEOUS SOLUTION INVIRASE ORAL TABLET LA mg, 250 mg, 400 mg LA RECONSTITUTED PA; SP JULUCA ORAL TABLET LA efavirenz oral capsule LA GENVOYA ORAL TABLET LA; AL ODEFSEY ORAL TABLET LA efavirenz oral tablet LA HARVONI ORAL PACKET PA; SP PREVYMIS ORAL TABLET PA; SP efavirenz-emtricitab-tenofovir oral tablet HARVONI ORAL TABLET PA; SP PREZCOBIX ORAL TABLET LA XOFLUZA (40 MG DOSE) ORAL TABLET LA INTELENCE ORAL TABLET LA efavirenz-lamivudine-tenofovir oral tablet ISENTRESS HD ORAL TABLET LA THERAPY PACK QL XOFLUZA (80 MG DOSE) ORAL TABLET LA ISENTRESS ORAL PACKET LA emtricitabine oral capsule LA ISENTRESS ORAL TABLET LA THERAPY PACK QL emtricitabine-tenofovir df oral tablet LA ISENTRESS ORAL TABLET CHEWABLE LA entecavir oral tablet PA; PA Except KALETRA ORAL TABLET LA LEXIVA ORAL SUSPENSION LA Infectious Disease or Gastroenterology; MO MAVYRET ORAL TABLET PA; SP famciclovir oral tablet NORVIR ORAL SOLUTION LA fosamprenavir calcium oral tablet LA PEGASYS SUBCUTANEOUS SOLUTION PA; lamivudine oral solution LA lamivudine oral tablet LA; MO SP lamivudine-zidovudine oral tablet LA; MO PIFELTRO ORAL TABLET LA ledipasvir-sofosbuvir oral tablet PA; SP PREZISTA ORAL SUSPENSION ST; LA lopinavir-ritonavir oral solution LA PREZISTA ORAL TABLET 150 MG, 600 MG, 75 nevirapine er oral tablet extended release 24 MG, 800 MG ST; LA hour LA RELENZA DISKHALER INHALATION AEROSOL nevirapine oral suspension LA POWDER BREATH ACTIVATED QL; AL nevirapine oral tablet LA REYATAZ ORAL CAPSULE 150 MG, 200 MG, oseltamivir phosphate oral capsule QL 300 MG LA oseltamivir phosphate oral suspension REYATAZ ORAL PACKET LA reconstituted QL rukobia oral tablet extended release 12 hour ribavirin oral capsule SP LA ribavirin oral tablet 200 mg SP SELZENTRY ORAL SOLUTION PA; LA rimantadine hcl oral tablet SELZENTRY ORAL TABLET PA; LA ritonavir oral tablet LA SOVALDI ORAL PACKET PA; SP sofosbuvir-velpatasvir oral tablet PA; SP SOVALDI ORAL TABLET PA; SP stavudine oral capsule LA STRIBILD ORAL TABLET LA tenofovir disoproxil fumarate oral tablet LA SYMTUZA ORAL TABLET LA valacyclovir hcl oral tablet QL TIVICAY ORAL TABLET LA valganciclovir hcl oral tablet PA TIVICAY PD ORAL TABLET SOLUBLE LA zidovudine oral capsule LA; MO TRIUMEQ ORAL TABLET PA; LA zidovudine oral syrup LA TRUVADA ORAL TABLET 100-150 MG, 133- zidovudine oral tablet LA; MO 200 MG, 167-250 MG LA TYBOST ORAL TABLET ST; LA VEMLIDY ORAL TABLET PA; PA Except Infectious Disease or Gastroenterology VIRACEPT ORAL TABLET LA VIREAD ORAL POWDER LA VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG LA VOSEVI ORAL TABLET PA; SP

Last Updated 12.1.2020 19 *Beta Blockers*

acebutolol hcl oral capsule MO betaxolol hcl oral tablet MO atenolol oral tablet MO BYSTOLIC ORAL TABLET MO bisoprolol fumarate oral tablet HT; MO carvedilol phosphate er oral capsule carvedilol oral tablet MO extended release 24 hour MO labetalol hcl oral tablet MO HEMANGEOL ORAL SOLUTION PA; SP metoprolol succinate er oral tablet extended SOTYLIZE ORAL SOLUTION release 24 hour MO metoprolol tartrate oral tablet MO nadolol oral tablet 20 mg, 40 mg, 80 mg MO pindolol oral tablet MO propranolol hcl er oral capsule extended release 24 hour MO propranolol hcl oral solution MO propranolol hcl oral tablet MO SORINE ORAL TABLET MO sotalol hcl (af) oral tablet MO sotalol hcl oral tablet MO timolol maleate oral tablet MO

*Calcium Channel Blockers*

AFEDITAB CR ORAL TABLET EXTENDED CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR MO RELEASE 24 HOUR MO amlodipine besylate oral tablet MO CARDIZEM LA ORAL TABLET EXTENDED CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR MO RELEASE 24 HOUR MO CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 diltiazem hcl er beads oral capsule extended MG MO release 24 hour MO isradipine oral capsule MO diltiazem hcl er coated beads oral capsule nicardipine hcl oral capsule MO extended release 24 hour MO nisoldipine er oral tablet extended release 24 diltiazem hcl er oral capsule extended release hour MO 12 hour MO NYMALIZE ORAL SOLUTION 6 MG/ML PA diltiazem hcl er oral capsule extended release TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 24 hour 120 mg, 180 mg, 240 mg MO HOUR diltiazem hcl oral tablet MO dilt-xr oral capsule extended release 24 hour MO felodipine er oral tablet extended release 24 hour MO MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR MO nifedipine er oral tablet extended release 24 hour MO nifedipine er osmotic release oral tablet extended release 24 hour MO nifedipine oral capsule PA; PA Except OB/GYN; MO; AL nimodipine oral capsule PA TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR MO verapamil hcl er oral capsule extended release 24 hour MO verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg MO verapamil hcl oral tablet MO

*Cardiotonics*

digoxin oral solution MO LANOXIN ORAL TABLET 62.5 MCG MO digoxin oral tablet 125 mcg MO digoxin oral tablet 250 mcg MO; AL

Last Updated 12.1.2020 20 *Cardiovascular Agents - Misc.*

ambrisentan oral tablet PA; SP CAVERJECT IMPULSE INTRACAVERNOSAL KIT ADEMPAS ORAL TABLET PA; SP bosentan oral tablet PA; SP PA; QL amlodipine-atorvastatin oral tablet MO isoxsuprine hcl oral tablet MO; AL CAVERJECT INTRACAVERNOSAL SOLUTION BIDIL ORAL TABLET MO sildenafil citrate oral suspension RECONSTITUTED 40 MCG PA; QL CORLANOR ORAL SOLUTION PA reconstituted PA EDEX INTRACAVERNOSAL KIT PA; QL CORLANOR ORAL TABLET PA sildenafil citrate oral tablet 100 mg, 25 mg, 50 ENTRESTO ORAL TABLET AL OPSUMIT ORAL TABLET PA; SP mg QL MUSE URETHRAL PELLET PA; QL ORENITRAM ORAL TABLET EXTENDED sildenafil citrate oral tablet 20 mg PA; AL TRACLEER ORAL TABLET SOLUBLE PA; SP RELEASE PA; SP tadalafil (pah) oral tablet PA; Generic UPTRAVI ORAL TABLET PA; SP Adcirca UPTRAVI ORAL TABLET THERAPY PACK PA; tadalafil oral tablet 10 mg, 20 mg QL SP tadalafil oral tablet 2.5 mg, 5 mg MO VENTAVIS INHALATION SOLUTION PA; SP VYNDAMAX ORAL CAPSULE PA; SP VYNDAQEL ORAL CAPSULE PA; SP

*Cephalosporins*

cefaclor oral capsule SUPRAX ORAL SUSPENSION RECONSTITUTED cefaclor oral suspension reconstituted 250 cefaclor oral suspension reconstituted 125 500 MG/5ML mg/5ml PA mg/5ml, 375 mg/5ml SUPRAX ORAL TABLET CHEWABLE cefpodoxime proxetil oral tablet cefadroxil oral capsule cefadroxil oral suspension reconstituted cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension reconstituted cefixime oral capsule cefixime oral suspension reconstituted cefpodoxime proxetil oral suspension reconstituted cefprozil oral suspension reconstituted cefprozil oral tablet ceftriaxone sodium injection solution reconstituted PA ceftriaxone sodium intravenous solution reconstituted PA cefuroxime axetil oral tablet cephalexin oral capsule DF cephalexin oral suspension reconstituted DF

Last Updated 12.1.2020 21 *Contraceptives*

ALTAVERA ORAL TABLET MO AMETHYST ORAL TABLET ANNOVERA VAGINAL RING alyacen 1/35 oral tablet MO BALCOLTRA ORAL TABLET MO NATAZIA ORAL TABLET PA alyacen 7/7/7 oral tablet MO ELLA ORAL TABLET QL SLYND ORAL TABLET MO AMETHIA LO ORAL TABLET LO LOESTRIN FE ORAL TABLET MO AMETHIA ORAL TABLET NUVARING VAGINAL RING MO; QL APRI ORAL TABLET MO ARANELLE ORAL TABLET MO ASHLYNA ORAL TABLET AVIANE ORAL TABLET MO AZURETTE ORAL TABLET MO BALZIVA ORAL TABLET MO briellyn oral tablet MO CAMILA ORAL TABLET MO CAMRESE LO ORAL TABLET MO CAMRESE ORAL TABLET MO CAZIANT ORAL TABLET MO CESIA ORAL TABLET MO CHATEAL ORAL TABLET MO CRYSELLE-28 ORAL TABLET MO CYCLAFEM 1/35 ORAL TABLET MO CYCLAFEM 7/7/7 ORAL TABLET MO CYRED ORAL TABLET MO DASETTA 1/35 ORAL TABLET MO DASETTA 7/7/7 ORAL TABLET MO DAYSEE ORAL TABLET DEBLITANE ORAL TABLET desogestrel-ethinyl estradiol oral tablet 0.15- 0.02/0.01 mg (21/5) MO drospiren-eth estrad-levomefol oral tablet MO drospirenone-ethinyl estradiol oral tablet MO ELINEST ORAL TABLET MO EMOQUETTE ORAL TABLET MO ENPRESSE-28 ORAL TABLET MO ENSKYCE ORAL TABLET 0.15-30 MG-MCG MO ERRIN ORAL TABLET MO ESTARYLLA ORAL TABLET MO FALMINA ORAL TABLET MO GIANVI ORAL TABLET MO HEATHER ORAL TABLET MO INTROVALE ORAL TABLET ISIBLOOM ORAL TABLET MO JENCYCLA ORAL TABLET MO JOLESSA ORAL TABLET JULEBER ORAL TABLET MO JUNEL 1.5/30 ORAL TABLET MO JUNEL 1/20 ORAL TABLET MO JUNEL FE 1.5/30 ORAL TABLET MO JUNEL FE 1/20 ORAL TABLET MO JUNEL FE 24 ORAL TABLET MO KARIVA ORAL TABLET MO KELNOR 1/35 ORAL TABLET MO KURVELO ORAL TABLET MO LARIN 1.5/30 ORAL TABLET MO LARIN 1/20 ORAL TABLET MO LARIN 24 FE ORAL TABLET MO LARIN FE 1.5/30 ORAL TABLET MO LARIN FE 1/20 ORAL TABLET MO LEENA ORAL TABLET MO LESSINA ORAL TABLET MO LEVONEST ORAL TABLET MO levonorgest-eth est & eth est oral tablet MO

Last Updated 12.1.2020 22 levonorgest-eth estrad 91-day oral tablet levonorgestrel oral tablet 1.5 mg QL levonorgestrel-ethinyl estrad oral tablet 0.1- 20 mg-mcg, 0.15-30 mg-mcg MO LEVORA 0.15/30 (28) ORAL TABLET MO LORYNA ORAL TABLET MO LOW-OGESTREL ORAL TABLET MO LUTERA ORAL TABLET MO LYZA ORAL TABLET MO marlissa oral tablet MO MELODETTA 24 FE ORAL TABLET CHEWABLE MO MIBELAS 24 FE ORAL TABLET CHEWABLE MO MICROGESTIN 1.5/30 ORAL TABLET MO MICROGESTIN 1/20 ORAL TABLET MO MICROGESTIN FE 1.5/30 ORAL TABLET MO MICROGESTIN FE 1/20 ORAL TABLET MO MONO-LINYAH ORAL TABLET MO MONONESSA ORAL TABLET MO NECON 0.5/35 (28) ORAL TABLET MO NECON 1/35 (28) ORAL TABLET MO NIKKI ORAL TABLET MO NORA-BE ORAL TABLET MO norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg MO norethin ace-eth estrad-fe oral tablet chewable MO norethindrone acet-ethinyl est oral tablet 1- 20 mg-mcg MO norethindrone oral tablet MO norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg MO norgestim-eth estrad triphasic oral tablet MO NORLYROC ORAL TABLET NORTREL 0.5/35 (28) ORAL TABLET MO NORTREL 1/35 (21) ORAL TABLET MO NORTREL 1/35 (28) ORAL TABLET MO NORTREL 7/7/7 ORAL TABLET MO OCELLA ORAL TABLET MO ORSYTHIA ORAL TABLET MO PHILITH ORAL TABLET MO PIMTREA ORAL TABLET MO PIRMELLA 1/35 ORAL TABLET MO PIRMELLA 7/7/7 ORAL TABLET MO PORTIA-28 ORAL TABLET MO PREVIFEM ORAL TABLET MO RECLIPSEN ORAL TABLET MO SHAROBEL ORAL TABLET SOLIA ORAL TABLET MO SPRINTEC 28 ORAL TABLET MO SRONYX ORAL TABLET MO SYEDA ORAL TABLET MO TARINA FE 1/20 ORAL TABLET MO TILIA FE ORAL TABLET MO TRI-ESTARYLLA ORAL TABLET MO TRI-LEGEST FE ORAL TABLET MO TRI-LINYAH ORAL TABLET MO TRI-LO-ESTARYLLA ORAL TABLET MO TRI-LO-MARZIA ORAL TABLET TRI-LO-SPRINTEC ORAL TABLET MO TRINESSA (28) ORAL TABLET MO TRI-PREVIFEM ORAL TABLET MO TRI-SPRINTEC ORAL TABLET MO TRIVORA (28) ORAL TABLET MO TYDEMY ORAL TABLET MO VELIVET ORAL TABLET MO viorele oral tablet MO VYFEMLA ORAL TABLET MO WERA ORAL TABLET MO WYMZYA FE ORAL TABLET CHEWABLE MO XULANE TRANSDERMAL PATCH WEEKLY MO ZARAH ORAL TABLET MO ZOVIA 1/35E (28) ORAL TABLET MO

Last Updated 12.1.2020 23 *Corticosteroids*

budesonide er oral tablet extended release SOLU-CORTEF INJECTION SOLUTION EMFLAZA ORAL SUSPENSION PA; SP 24 hour RECONSTITUTED 100 MG PA; LA EMFLAZA ORAL TABLET PA; SP budesonide oral capsule delayed release MILLIPRED ORAL TABLET QL particles PA PEDIAPRED ORAL SOLUTION cortisone acetate oral tablet MO prednisolone sodium phosphate oral solution dexamethasone intensol oral concentrate 10 mg/5ml, 20 mg/5ml DF RAYOS ORAL TABLET DELAYED RELEASE PA dexamethasone oral elixir DF dexamethasone oral solution DF dexamethasone oral tablet DF dexamethasone oral tablet therapy pack fludrocortisone acetate oral tablet MO hydrocortisone oral tablet MO methylprednisolone oral tablet DF methylprednisolone oral tablet therapy pack prednisolone oral solution prednisolone oral syrup 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml PREDNISONE INTENSOL ORAL CONCENTRATE prednisone oral solution DF prednisone oral tablet DF

*Cough/Cold/Allergy*

acetylcysteine inhalation solution TUSSICAPS ORAL CAPSULE EXTENDED CLARINEX-D 12 HOUR ORAL TABLET benzonatate oral capsule 100 mg, 200 mg RELEASE 12 HOUR 10-8 MG EXTENDED RELEASE 12 HOUR PA QL SSKI ORAL SOLUTION hydrocodone-homatropine oral syrup hydrocodone-homatropine oral tablet promethazine vc oral syrup AL promethazine vc/codeine oral syrup AL promethazine-codeine oral syrup AL promethazine-dm oral syrup AL promethazine-phenylephrine oral syrup AL sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

Last Updated 12.1.2020 24 *Dermatologicals*

acitretin oral capsule PA; PA Except AZELEX EXTERNAL CREAM ABSORICA ORAL CAPSULE PA Dermatology coal tar external solution AKLIEF EXTERNAL CREAM PA; AL acyclovir external ointment COSENTYX (300 MG DOSE) SUBCUTANEOUS ALTABAX EXTERNAL OINTMENT ST adapalene external gel 0.3 % SOLUTION PREFILLED SYRINGE PA; SP ANACAINE EXTERNAL OINTMENT adapalene-benzoyl peroxide external gel COSENTYX SENSOREADY (300 MG) AVITA EXTERNAL CREAM alclometasone dipropionate external cream SUBCUTANEOUS SOLUTION AUTO-INJECTOR AVITA EXTERNAL GEL BENZAC AC WASH EXTERNAL LIQUID alclometasone dipropionate external PA; SP ointment BENZEPRO EXTERNAL FOAM 5.3 % COSENTYX SENSOREADY PEN betamethasone valerate external foam amcinonide external lotion SUBCUTANEOUS SOLUTION AUTO-INJECTOR AMNESTEEM ORAL CAPSULE PA; PA Except BRYHALI EXTERNAL LOTION 150 MG/ML PA; SP calcipotriene-betameth diprop external Dermatology COSENTYX SUBCUTANEOUS SOLUTION azelaic acid external gel ointment PA; PA Except Derm benzoyl peroxide external gel 10 %, 5 % PREFILLED SYRINGE PA; SP calcipotriene-betameth diprop external betamethasone dipropionate aug external DRYSOL EXTERNAL SOLUTION suspension PA; PA Except Dermatology DUPIXENT SUBCUTANEOUS SOLUTION PEN- cream CENTANY AT EXTERNAL KIT betamethasone dipropionate aug external gel INJECTOR PA; SP CENTANY EXTERNAL OINTMENT betamethasone dipropionate aug external DUPIXENT SUBCUTANEOUS SOLUTION ciclopirox olamine external suspension PREFILLED SYRINGE PA; SP ciclopirox treatment external kit lotion CLEOCIN-T EXTERNAL LOTION betamethasone dipropionate aug external EUCRISA EXTERNAL OINTMENT ST; AL FABIOR EXTERNAL FOAM PA clobetasol propionate external liquid ointment FINACEA EXTERNAL FOAM clobetasol propionate external shampoo betamethasone dipropionate external cream SKYRIZI (150 MG DOSE) SUBCUTANEOUS dapsone external gel 5 % betamethasone dipropionate external lotion dapsone external gel 7.5 % ST betamethasone dipropionate external PREFILLED SYRINGE KIT PA; SP DIPROLENE AF EXTERNAL CREAM spinosad external suspension QL DIPROLENE EXTERNAL OINTMENT ointment TAZORAC EXTERNAL CREAM PA betamethasone valerate external cream DRITHO-CREME HP EXTERNAL CREAM TAZORAC EXTERNAL GEL PA DUOBRII EXTERNAL LOTION PA betamethasone valerate external lotion TREMFYA SUBCUTANEOUS SOLUTION PEN- betamethasone valerate external ointment ELIMITE EXTERNAL CREAM calcipotriene external cream PA INJECTOR PA; SP EPIDUO FORTE EXTERNAL GEL PA; PA calcipotriene external ointment PA Except Dermatology and Pediatrics calcipotriene external solution PA ERTACZO EXTERNAL CREAM calcitriol external ointment PA FLUOROPLEX EXTERNAL CREAM ciclopirox external gel fluorouracil external cream 0.5 % ST ciclopirox external shampoo flurandrenolide external lotion ciclopirox external solution hydrocortisone-iodoquinol external cream 1- ciclopirox olamine external cream 1 % CLARAVIS ORAL CAPSULE PA; PA Except iodoquinol-hydrocortisone-aloe external Dermatology cream clindamycin phos-benzoyl perox external gel JUBLIA EXTERNAL SOLUTION PA 1-5 %, 1.2-5 % KETODAN EXTERNAL KIT clindamycin phosphate external gel MEDROX-RX EXTERNAL OINTMENT PA clindamycin phosphate external lotion MENTAX EXTERNAL CREAM clindamycin phosphate external solution METROLOTION EXTERNAL LOTION clindamycin phosphate external swab miconazole-zinc oxide-petrolat external clobetasol propionate e external cream ointment clobetasol propionate external cream MIRVASO EXTERNAL GEL PA clobetasol propionate external ointment mupirocin calcium external cream clobetasol propionate external solution naftifine hcl external cream clotrimazole external cream NAFTIN EXTERNAL GEL clotrimazole external solution NUCORT EXTERNAL LOTION clotrimazole-betamethasone external cream oxiconazole nitrate external cream clotrimazole-betamethasone external lotion OXISTAT EXTERNAL LOTION CROTAN EXTERNAL LOTION OXSORALEN ULTRA ORAL CAPSULE desonide external cream PANDEL EXTERNAL CREAM desonide external ointment ST PANRETIN EXTERNAL GEL PA desoximetasone external cream PICATO EXTERNAL GEL PA; PA Except desoximetasone external gel desoximetasone external ointment 0.25 % Dermatology diflorasone diacetate external cream PLEXION EXTERNAL CREAM diflorasone diacetate external ointment PRAMOSONE EXTERNAL OINTMENT 1-2.5 % econazole nitrate external cream QBREXZA EXTERNAL PAD PA erythromycin external gel REGRANEX EXTERNAL GEL PA erythromycin external solution ROSADAN EXTERNAL KIT fluocinolone acetonide body external oil SILIQ SUBCUTANEOUS SOLUTION PREFILLED fluocinolone acetonide external cream SYRINGE PA; SP

Last Updated 12.1.2020 25 fluocinolone acetonide external ointment SILVADENE EXTERNAL CREAM fluocinolone acetonide external solution SKLICE EXTERNAL LOTION ST; QL fluocinolone acetonide scalp external oil SOOLANTRA EXTERNAL CREAM PA; PA fluocinonide external cream 0.05 % Except Dermatology fluocinonide external gel sulconazole nitrate external cream fluocinonide external ointment sulconazole nitrate external solution fluocinonide external solution sulfacetamide sodium-sulfur external cream fluorouracil external cream 5 % 9.8-4.8 % fluorouracil external solution SULFAMYLON EXTERNAL CREAM fluticasone propionate external cream SULFAMYLON EXTERNAL PACKET fluticasone propionate external ointment SUMADAN WASH EXTERNAL LIQUID gentamicin sulfate external cream SUMAXIN EXTERNAL PAD gentamicin sulfate external ointment SYNALAR (OINTMENT) EXTERNAL KIT halobetasol propionate external cream SYNALAR EXTERNAL CREAM halobetasol propionate external ointment SYNALAR EXTERNAL OINTMENT hydrocortisone ace-pramoxine external SYNALAR EXTERNAL SOLUTION cream 2.5-1 % TALTZ SUBCUTANEOUS SOLUTION AUTO- hydrocortisone butyr lipo base external INJECTOR PA; SP cream TALTZ SUBCUTANEOUS SOLUTION PREFILLED hydrocortisone butyrate external ointment SYRINGE PA; SP hydrocortisone butyrate external solution TARGRETIN EXTERNAL GEL PA; SP hydrocortisone external cream 2.5 % tavaborole external solution PA hydrocortisone external lotion 2.5 % TOLAK EXTERNAL CREAM hydrocortisone external ointment 2.5 % TOPICORT EXTERNAL CREAM 0.05 % hydrocortisone valerate external cream TREMFYA SUBCUTANEOUS SOLUTION hydrocortisone valerate external ointment imiquimod external cream PA; PA Except PREFILLED SYRINGE PA; SP tretinoin external gel 0.05 % Dermatology, Urology, OBGYN, Colorectal tretinoin microsphere external gel Surgery tretinoin microsphere pump external gel 0.04 isotretinoin oral capsule PA; PA Except % Dermatology urea external cream 40 %, 45 % ketoconazole external cream urea external lotion 40 % ketoconazole external foam urea hydrating external foam ketoconazole external shampoo 2 % VALCHLOR EXTERNAL GEL PA; SP KETODAN EXTERNAL FOAM VANOXIDE-HC EXTERNAL LOTION lidocaine external cream 3 % XERAC AC EXTERNAL SOLUTION lidocaine external ointment XOLEGEL EXTERNAL GEL lidocaine external patch 5 % ZITHRANOL EXTERNAL SHAMPOO PA; PA lidocaine hcl external cream 3 % Except Dermatology lidocaine-prilocaine external cream LIDOCARE ARM/NECK/LEG EXTERNAL PATCH LIDOCARE BACK/SHOULDER EXTERNAL PATCH lindane external shampoo malathion external lotion methoxsalen rapid oral capsule metronidazole external cream metronidazole external gel metronidazole external lotion mometasone furoate external cream mometasone furoate external ointment MO mometasone furoate external solution mupirocin external ointment MYORISAN ORAL CAPSULE PA; PA Except Dermatology nystatin external cream nystatin external ointment nystatin external powder nystatin-triamcinolone external cream nystatin-triamcinolone external ointment NYSTOP EXTERNAL POWDER permethrin external cream pimecrolimus external cream AL prednicarbate external cream prednicarbate external ointment

Last Updated 12.1.2020 26 ROSADAN EXTERNAL CREAM ROSADAN EXTERNAL GEL selenium sulfide external lotion silver sulfadiazine external cream SSD EXTERNAL CREAM sulfacetamide sodium (acne) external lotion sulfacetamide sodium external liquid sulfacetamide sodium-sulfur external emulsion sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 % sulfacetamide sodium-sulfur external pad 10- 4 % sulfacetamide sodium-sulfur external suspension 8-4 % sulfacetamide-sulfur in urea external emulsion tacrolimus external ointment 0.03 % AL Except Dermatology/Allergy; AL tacrolimus external ointment 0.1 % PA; PA Except Dermatology/Allergy; AL tretinoin (emollient) external cream tretinoin external cream tretinoin external gel 0.01 %, 0.025 % triamcinolone acetonide external aerosol solution triamcinolone acetonide external cream triamcinolone acetonide external lotion triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % ZENATANE ORAL CAPSULE PA; PA Except Dermatology

*Diagnostic Products*

METOPIRONE ORAL CAPSULE PA; LA

*Digestive Aids*

CREON ORAL CAPSULE DELAYED RELEASE PANCREAZE ORAL CAPSULE DELAYED PARTICLES MO RELEASE PARTICLES 10500 UNIT, 16800 UNIT, PANCREAZE ORAL CAPSULE DELAYED 21000 UNIT, 2600 UNIT MO RELEASE PARTICLES 4200 UNIT MO PERTZYE ORAL CAPSULE DELAYED RELEASE SUCRAID ORAL SOLUTION PA; SP PARTICLES MO ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000- 24000 UNIT MO

Last Updated 12.1.2020 27 *Diuretics*

acetazolamide er oral capsule extended ALDACTAZIDE ORAL TABLET 50-50 MG MO ALDACTAZIDE ORAL TABLET 25-25 MG MO release 12 hour MO DIURIL ORAL SUSPENSION EDECRIN ORAL TABLET acetazolamide oral tablet MO KEVEYIS ORAL TABLET PA; SP amiloride hcl oral tablet MO amiloride-hydrochlorothiazide oral tablet MO bumetanide oral tablet MO chlorthalidone oral tablet 25 mg, 50 mg MO ethacrynic acid oral tablet MO furosemide oral solution 10 mg/ml, 8 mg/ml MO furosemide oral tablet MO hydrochlorothiazide oral capsule MO hydrochlorothiazide oral tablet MO indapamide oral tablet MO methazolamide oral tablet MO metolazone oral tablet MO spironolactone oral tablet MO spironolactone-hctz oral tablet MO torsemide oral tablet MO triamterene-hctz oral capsule 37.5-25 mg MO triamterene-hctz oral tablet MO

*Endocrine And Metabolic Agents - Misc.*

alendronate sodium oral solution MO BUPHENYL ORAL TABLET PA BINOSTO ORAL TABLET EFFERVESCENT ST alendronate sodium oral tablet 10 mg, 35 mg, CARBAGLU ORAL TABLET PA; SP BUPHENYL ORAL POWDER 3 GM/TSP PA 5 mg, 70 mg MO CYSTADANE ORAL POWDER PA CETROTIDE SUBCUTANEOUS KIT 0.25 MG cabergoline oral tablet FOLLISTIM AQ SUBCUTANEOUS SOLUTION PA calcitonin (salmon) nasal solution MO PA DDAVP RHINAL TUBE NASAL SOLUTION calcitriol oral capsule MO FORTEO SUBCUTANEOUS SOLUTION PEN- GALAFOLD ORAL CAPSULE PA; SP calcitriol oral solution MO INJECTOR PA; LA ibandronate sodium oral tablet MO; QL chorionic gonadotropin intramuscular GENOTROPIN MINIQUICK SUBCUTANEOUS JYNARQUE ORAL TABLET THERAPY PACK solution reconstituted ST; SP SOLUTION RECONSTITUTED PA; SP PA; SP cinacalcet hcl oral tablet MO GENOTROPIN SUBCUTANEOUS SOLUTION KANUMA INTRAVENOUS SOLUTION PA; SP clomiphene citrate oral tablet PA; PA RECONSTITUTED PA; SP MYALEPT SUBCUTANEOUS SOLUTION Except OB/GYN and Fertility; QL INCRELEX SUBCUTANEOUS SOLUTION PA; RECONSTITUTED PA; SP desmopressin ace spray refrig nasal solution SP NATPARA SUBCUTANEOUS CARTRIDGE PA; MO MENOPUR SUBCUTANEOUS SOLUTION SP desmopressin acetate oral tablet MO RECONSTITUTED PA OVIDREL SUBCUTANEOUS INJECTABLE ST desmopressin acetate spray nasal solution NITYR ORAL TABLET PA; SP PALYNZIQ SUBCUTANEOUS SOLUTION MO ORFADIN ORAL CAPSULE 20 MG PA; SP PREFILLED SYRINGE PA; SP doxercalciferol oral capsule ST; MO ORFADIN ORAL SUSPENSION PA; SP RAVICTI ORAL LIQUID PA; SP ganirelix acetate subcutaneous solution ORILISSA ORAL TABLET PA RAYALDEE ORAL CAPSULE EXTENDED prefilled syringe PA SOMAVERT SUBCUTANEOUS SOLUTION RELEASE ST levocarnitine oral solution PA RECONSTITUTED PA; SP SAIZEN INJECTION SOLUTION levocarnitine oral tablet PA STIMATE NASAL SOLUTION RECONSTITUTED PA; ST; SP mifepristone oral tablet STRENSIQ SUBCUTANEOUS SOLUTION PA; SAMSCA ORAL TABLET 15 MG PA nitisinone oral capsule PA; SP SP SEROSTIM SUBCUTANEOUS SOLUTION octreotide acetate injection solution 100 SYNAREL NASAL SOLUTION PA RECONSTITUTED 4 MG, 5 MG, 6 MG PA; ST; mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 teriparatide (recombinant) subcutaneous SP mcg/ml, 500 mcg/ml PA; PA Except solution pen-injector PA; LA SIGNIFOR SUBCUTANEOUS SOLUTION PA; Heme/Onc/Endo TYMLOS SUBCUTANEOUS SOLUTION PEN- SP paricalcitol oral capsule ST; MO INJECTOR PA; LA tolvaptan oral tablet 30 mg PA; LA raloxifene hcl oral tablet MO XURIDEN ORAL PACKET PA; SP ZORBTIVE SUBCUTANEOUS SOLUTION risedronate sodium oral tablet 150 mg, 30 RECONSTITUTED PA; ST; SP mg, 35 mg, 5 mg MO risedronate sodium oral tablet delayed release MO sapropterin dihydrochloride oral packet PA; SP sapropterin dihydrochloride oral tablet soluble PA; SP sodium phenylbutyrate oral powder 3 gm/tsp PA

Last Updated 12.1.2020 28 *Estrogens*

COVARYX HS ORAL TABLET AL COMBIPATCH TRANSDERMAL PATCH TWICE ANGELIQ ORAL TABLET MO; AL COVARYX ORAL TABLET AL WEEKLY MO; AL CLIMARA PRO TRANSDERMAL PATCH WEEKLY DOTTI TRANSDERMAL PATCH TWICE WEEKLY MENOSTAR TRANSDERMAL PATCH WEEKLY MO; AL MO; AL AL DIVIGEL TRANSDERMAL GEL 0.25 EEMT ORAL TABLET AL PREMARIN ORAL TABLET MO; AL MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM AL est estrogens-methyltest ds oral tablet AL PREMPHASE ORAL TABLET MO; AL DUAVEE ORAL TABLET AL est estrogens-methyltest hs oral tablet AL PREMPRO ORAL TABLET MO; AL ELESTRIN TRANSDERMAL GEL AL est estrogens-methyltest oral tablet AL ESTROGEL TRANSDERMAL GEL AL estradiol oral tablet MO; AL EVAMIST TRANSDERMAL SOLUTION MO estradiol transdermal patch twice weekly MENEST ORAL TABLET 0.3 MG, 0.625 MG, 0.025 mg/24hr, 0.05 mg/24hr, 0.075 1.25 MG MO; AL mg/24hr, 0.1 mg/24hr MO; AL ORIAHNN ORAL CAPSULE THERAPY PACK estradiol transdermal patch twice weekly PA 0.0375 mg/24hr AL PREFEST ORAL TABLET MO estradiol transdermal patch weekly MO; AL estradiol-norethindrone acet oral tablet MO; AL JINTELI ORAL TABLET MO; AL MIMVEY ORAL TABLET MO; AL norethindrone-eth estradiol oral tablet MO; AL

*Fluoroquinolones*

ciprofloxacin hcl oral tablet 250 mg, 500 mg, CIPRO ORAL SUSPENSION RECONSTITUTED 750 mg ciprofloxacin hcl oral tablet 100 mg levofloxacin oral solution levofloxacin oral tablet moxifloxacin hcl oral tablet

*Gastrointestinal Agents - Misc.*

balsalazide disodium oral capsule AL LINZESS ORAL CAPSULE ST; ST except alosetron hcl oral tablet PA calcium acetate (phos binder) oral tablet Gastroenterology and Colon-Rectal surgery; AMITIZA ORAL CAPSULE ST MO MO AURYXIA ORAL TABLET cromolyn sodium oral concentrate MO MOVANTIK ORAL TABLET CHENODAL ORAL TABLET PA; SP lactulose encephalopathy oral solution PENTASA ORAL CAPSULE EXTENDED RELEASE CHOLBAM ORAL CAPSULE PA; SP lanthanum carbonate oral tablet chewable GATTEX SUBCUTANEOUS KIT PA; SP MO mesalamine er oral capsule extended release MO PHOSLYRA ORAL SOLUTION MO LIALDA ORAL TABLET DELAYED RELEASE 24 hour ST; MO MO mesalamine-cleanser rectal kit mesalamine oral capsule delayed release OCALIVA ORAL TABLET PA; SP RELISTOR ORAL TABLET PA MO RELISTOR SUBCUTANEOUS SOLUTION 12 mesalamine oral tablet delayed release 800 MG/0.6ML, 8 MG/0.4ML PA mg MO VELPHORO ORAL TABLET CHEWABLE mesalamine rectal enema VIBERZI ORAL TABLET PA mesalamine rectal suppository XERMELO ORAL TABLET PA; SP metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet sevelamer carbonate oral packet MO sevelamer hcl oral tablet MO sulfasalazine oral tablet MO sulfasalazine oral tablet delayed release MO ursodiol oral capsule ursodiol oral tablet

Last Updated 12.1.2020 29 *Genitourinary Agents - Miscellaneous*

acetic acid irrigation solution CYSTAGON ORAL CAPSULE PA; SP CARDURA XL ORAL TABLET EXTENDED alfuzosin hcl er oral tablet extended release ELMIRON ORAL CAPSULE RELEASE 24 HOUR MO 24 hour MO RENACIDIN IRRIGATION SOLUTION dutasteride-tamsulosin hcl oral capsule aminoacetic acid irrigation solution THIOLA ORAL TABLET PA; LA LITHOSTAT ORAL TABLET dutasteride oral capsule MO PROCYSBI ORAL CAPSULE DELAYED RELEASE finasteride oral tablet 5 mg MO PA; SP glycine irrigation solution PROCYSBI ORAL PACKET PA; SP glycine urologic irrigation solution RESECTISOL IRRIGATION SOLUTION neomycin-polymyxin b gu irrigation solution THIOLA EC ORAL TABLET DELAYED RELEASE phenazopyridine hcl oral tablet 100 mg, 200 PA; LA mg potassium citrate er oral tablet extended release silodosin oral capsule MO tamsulosin hcl oral capsule MO

*Gout Agents*

allopurinol oral tablet MO colchicine oral tablet colchicine-probenecid oral tablet MO febuxostat oral tablet ST; MO probenecid oral tablet MO

*Hematological Agents - Misc.*

anagrelide hcl oral capsule PA; MO BRILINTA ORAL TABLET MO HAEGARDA SUBCUTANEOUS SOLUTION aspirin-dipyridamole er oral capsule extended TAKHZYRO SUBCUTANEOUS SOLUTION PA; RECONSTITUTED PA; SP release 12 hour PA; PA Except Neurology; QL; AL; SP TAVALISSE ORAL TABLET PA; SP MO ZONTIVITY ORAL TABLET PA; MO cilostazol oral tablet MO clopidogrel bisulfate oral tablet MO dipyridamole oral tablet MO; AL icatibant acetate subcutaneous solution PA; SP pentoxifylline er oral tablet extended release DF; MO prasugrel hcl oral tablet MO

*Hematopoietic Agents*

cyanocobalamin injection solution 1000 ARANESP (ALBUMIN FREE) INJECTION CERDELGA ORAL CAPSULE PA; SP mcg/ml SOLUTION 100 MCG/ML, 200 MCG/ML, 25 FERRALET 90 ORAL TABLET DROXIA ORAL CAPSULE MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 ferraplus 90 oral tablet folic acid oral tablet 1 mg MO FERREX 150 FORTE PLUS ORAL CAPSULE MCG/ML PA; LA FERROCITE PLUS ORAL TABLET miglustat oral capsule PA; SP ARANESP (ALBUMIN FREE) INJECTION polysaccharide iron forte oral capsule MULPLETA ORAL TABLET PA; SP SOLUTION PREFILLED SYRINGE PA; LA OXBRYTA ORAL TABLET PA; SP DOPTELET ORAL TABLET 20 MG PA; SP SIKLOS ORAL TABLET PA MULTIGEN PLUS ORAL TABLET NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE SP poly-iron 150 forte oral capsule PROMACTA ORAL PACKET PA; SP PROMACTA ORAL TABLET PA; SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML PA; LA UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP ZARXIO INJECTION SOLUTION PREFILLED SYRINGE SP

Last Updated 12.1.2020 30 *Hemostatics*

aminocaproic acid oral tablet aminocaproic acid oral solution tranexamic acid oral tablet AL

*Hypnotics/Sedatives/Sleep Disorder Agents*

estazolam oral tablet QL BELSOMRA ORAL TABLET ST; QL DAYVIGO ORAL TABLET PA eszopiclone oral tablet QL/AL Except doxepin hcl oral tablet QL Psychiatry and Sleep Specialists; QL; AL EDLUAR SUBLINGUAL TABLET SUBLINGUAL flurazepam hcl oral capsule QL; AL ST; QL; AL midazolam hcl oral syrup HETLIOZ ORAL CAPSULE PA; SP phenobarbital oral elixir AL quazepam oral tablet phenobarbital oral tablet AL zolpidem tartrate sublingual tablet sublingual ramelteon oral tablet QL ST; QL; AL temazepam oral capsule QL triazolam oral tablet QL zaleplon oral capsule QL; AL zolpidem tartrate er oral tablet extended release QL/AL Except Sleep Specialty and Psychiatry; QL; AL zolpidem tartrate oral tablet QL; AL

*Laxatives*

GAVILYTE-G ORAL SOLUTION CLENPIQ ORAL SOLUTION KRISTALOSE ORAL PACKET 20 GM RECONSTITUTED SUPREP BOWEL PREP KIT ORAL SOLUTION lactulose oral packet lactulose oral solution peg 3350-kcl-na bicarb-nacl oral solution reconstituted peg-3350/electrolytes oral solution reconstituted

*Macrolides*

azithromycin oral packet ERY-TAB ORAL TABLET DELAYED RELEASE 500 DIFICID ORAL TABLET PA azithromycin oral suspension reconstituted MG E.E.S. 400 ORAL TABLET azithromycin oral tablet 250 mg, 600 mg ERYTHROCIN STEARATE ORAL TABLET 250 azithromycin oral tablet 500 mg DF MG clarithromycin er oral tablet extended release 24 hour clarithromycin oral suspension reconstituted clarithromycin oral tablet DF erythromycin base oral capsule delayed release particles DF erythromycin base oral tablet DF erythromycin ethylsuccinate oral suspension reconstituted erythromycin ethylsuccinate oral tablet DF

*Medical Devices And Supplies*

BD AUTOSHIELD DUO MO OMNIPOD 5 PACK OMNIPOD DASH 5 PACK PODS V-GO 20 KIT V-GO 30 KIT V-GO 40 KIT

Last Updated 12.1.2020 31 *Migraine Products*

eletriptan hydrobromide oral tablet QL AIMOVIG SUBCUTANEOUS SOLUTION AUTO- almotriptan malate oral tablet QL naratriptan hcl oral tablet QL INJECTOR 140 MG/ML PA; LA CAMBIA ORAL PACKET PA; QL rizatriptan benzoate oral tablet QL AIMOVIG SUBCUTANEOUS SOLUTION AUTO- dihydroergotamine mesylate nasal solution rizatriptan benzoate oral tablet dispersible INJECTOR 70 MG/ML PA; LA; QL PA; QL QL AJOVY SUBCUTANEOUS SOLUTION AUTO- frovatriptan succinate oral tablet QL sumatriptan nasal solution QL INJECTOR PA; LA MIGERGOT RECTAL SUPPOSITORY sumatriptan succinate oral tablet QL AJOVY SUBCUTANEOUS SOLUTION PREFILLED sumatriptan succinate refill subcutaneous SYRINGE PA; LA solution cartridge QL EMGALITY (300 MG DOSE) SUBCUTANEOUS sumatriptan succinate subcutaneous solution SOLUTION PREFILLED SYRINGE PA; LA 6 mg/0.5ml QL EMGALITY SUBCUTANEOUS SOLUTION AUTO- sumatriptan succinate subcutaneous solution INJECTOR PA; LA auto-injector 4 mg/0.5ml, 6 mg/0.5ml QL EMGALITY SUBCUTANEOUS SOLUTION zolmitriptan oral tablet QL zolmitriptan oral tablet dispersible QL PREFILLED SYRINGE PA; LA ERGOMAR SUBLINGUAL TABLET SUBLINGUAL NURTEC ORAL TABLET DISPERSIBLE ST ONZETRA XSAIL NASAL EXHALER POWDER ST; QL REYVOW ORAL TABLET ST UBRELVY ORAL TABLET ST ZOMIG NASAL SOLUTION QL

*Minerals & Electrolytes*

av-phos 250 neutral oral tablet MO GALZIN ORAL CAPSULE K-PHOS-NEUTRAL ORAL TABLET MO dextrose-nacl intravenous solution 5-0.45 % iodine strong oral solution PA; LA EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ MO KLOR-CON 10 ORAL TABLET EXTENDED RELEASE MO KLOR-CON/EF ORAL TABLET EFFERVESCENT MO K-PRIME ORAL TABLET EFFERVESCENT MO PHOSPHA 250 NEUTRAL ORAL TABLET MO PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET MO potassium chloride crys er oral tablet extended release MO potassium chloride er oral capsule extended release MO potassium chloride er oral tablet extended release MO potassium chloride oral solution 20 meq/15ml (10%) MO sodium fluoride oral solution DF; MO sodium fluoride oral tablet chewable DF; MO virt-phos 250 neutral oral tablet MO

Last Updated 12.1.2020 32 *Miscellaneous Therapeutic Classes*

azathioprine oral tablet MO AZASAN ORAL TABLET MO ASTAGRAF XL ORAL CAPSULE EXTENDED cyclosporine modified oral capsule MO LOKELMA ORAL PACKET RELEASE 24 HOUR PA; MO cyclosporine modified oral solution MO REVLIMID ORAL CAPSULE PA; SP BENLYSTA SUBCUTANEOUS SOLUTION AUTO- cyclosporine oral capsule MO SANDIMMUNE ORAL SOLUTION MO INJECTOR PA; SP everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 THALOMID ORAL CAPSULE SP BENLYSTA SUBCUTANEOUS SOLUTION mg PA; PA Except Renal Transplant and VELTASSA ORAL PACKET ZORTRESS ORAL TABLET 1 MG PA; PA PREFILLED SYRINGE PA; SP Nephrology ENSPRYNG SUBCUTANEOUS SOLUTION Except Renal Transplant and Nephrology GENGRAF ORAL CAPSULE 100 MG, 25 MG PREFILLED SYRINGE PA; SP MO ENVARSUS XR ORAL TABLET EXTENDED GENGRAF ORAL SOLUTION MO RELEASE 24 HOUR PA lactated ringers irrigation solution mycophenolate mofetil oral capsule MO mycophenolate mofetil oral suspension reconstituted MO mycophenolate mofetil oral tablet MO mycophenolate sodium oral tablet delayed release PA; PA except Renal Transplant Surgeons and Nephrology; MO penicillamine oral capsule PA; SP penicillamine oral tablet PA; SP PHYSIOLYTE IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution sirolimus oral solution PA; MO sirolimus oral tablet PA; PA except Renal Transplant Surgeons and Nephrology; MO sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal suspension sterile water for irrigation irrigation solution tacrolimus oral capsule MO trientine hcl oral capsule PA; SP

*Mouth/Throat/Dental Agents*

cevimeline hcl oral capsule MO DEBACTEROL MOUTH/THROAT SOLUTION chlorhexidine gluconate mouth/throat ORAVIG BUCCAL TABLET PA; AL solution DF CLINPRO 5000 DENTAL PASTE clotrimazole mouth/throat troche DF dobells mouth/throat solution FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE nystatin mouth/throat suspension DF pilocarpine hcl oral tablet MO sf 5000 plus dental cream DF sf dental gel triamcinolone acetonide mouth/throat paste DF

Last Updated 12.1.2020 33 *Multivitamins*

activite oral tablet PA; PA Except completenate oral tablet chewable CITRANATAL 90 DHA ORAL 90-1 & 300 MG Nephrology; MO DUET DHA 400 ORAL AL MO DIALYVITE ORAL TABLET PA; PA Except DUET DHA BALANCED ORAL 25-1 & 267 MG CITRANATAL ASSURE ORAL 35-1 & 300 MG Nephrology; MO AL CITRANATAL B-CALM ORAL GENICIN VITA-S ORAL TABLET PA; PA NATALVIT ORAL TABLET CITRANATAL BLOOM ORAL TABLET MO Except Nephrology; MO NESTABS DHA ORAL MO CITRANATAL DHA ORAL MO lorid oral tablet PA; PA Except Nephrology; NESTABS ORAL TABLET MO CITRANATAL HARMONY ORAL CAPSULE 27-1- OBTREX ORAL TABLET 260 MG MO MO onevite oral tablet MO multivitamin/fluoride oral tablet chewable 1 CITRANATAL RX ORAL TABLET MO pnv prenatal plus multivitamin oral tablet POLY-VI-FLOR ORAL TABLET CHEWABLE mg MO VITAFOL-ONE ORAL CAPSULE NEPHRONEX ORAL TABLET PA; PA Except pnv tabs 29-1 oral tablet MO Nephrology; MO pnv-dha oral capsule MO NEPHRO-VITE RX ORAL TABLET PA; PA pnv-dha+docusate oral capsule MO Except Nephrology; MO pnv-omega oral capsule prenatal formula a-free oral tablet PRENATABS RX ORAL TABLET MO prenatal low iron oral tablet 27-0.8 mg prenatal 19 oral tablet prenatal multi +dha oral capsule 27-0.8-228 prenatal 19 oral tablet chewable MO mg prenatal 19 oral tablet chewable 29-1 mg prenatal one daily oral tablet prenatal oral tablet 27-1 mg MO prenatal oral tablet 27-0.8 mg, 28-0.8 mg, prenatal plus iron oral tablet MO prenatal plus oral tablet MO 6.75-0.2 mg prenatal plus/iron oral tablet MO prenatal vitamins oral tablet 28-0.8 mg preplus oral tablet MO tronvite oral tablet PA; PA Except se-natal 19 oral tablet MO Nephrology; MO se-natal 19 oral tablet chewable vitasure oral tablet PA; PA Except thrivite 19 oral tablet 1 mg MO Nephrology; MO UDAMIN SP ORAL TABLET MO vp-vite rx oral tablet PA; PA Except VITAFOL-OB+DHA ORAL Nephrology; MO vol-plus oral tablet MO xvite oral tablet PA; PA Except Nephrology; vol-tab rx oral tablet MO MO

*Musculoskeletal Therapy Agents*

baclofen oral tablet MO FEXMID ORAL TABLET AL chlorzoxazone oral tablet 500 mg AL metaxalone oral tablet AL cyclobenzaprine hcl oral tablet AL tizanidine hcl oral capsule MO dantrolene sodium oral capsule methocarbamol oral tablet AL tizanidine hcl oral tablet MO

*Nasal Agents - Systemic And Topical*

azelastine hcl nasal solution 0.1 %, 0.15 % ADRENALIN NASAL SOLUTION budesonide nasal suspension Only OTC version covered. flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension ipratropium bromide nasal solution olopatadine hcl nasal solution triamcinolone acetonide nasal aerosol

*Neuromuscular Agents*

riluzole oral tablet MO TIGLUTIK ORAL SUSPENSION

*Nutrients*

n-acetyl-l-cysteine oral capsule

Last Updated 12.1.2020 34 *Ophthalmic Agents*

ALAWAY CHILDRENS ALLERGY OPHTHALMIC ALOMIDE OPHTHALMIC SOLUTION ST ALOCRIL OPHTHALMIC SOLUTION ST SOLUTION ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % bacitra-neomycin-polymyxin-hc ophthalmic ALAWAY OPHTHALMIC SOLUTION AZOPT OPHTHALMIC SUSPENSION ointment apraclonidine hcl ophthalmic solution bimatoprost ophthalmic solution MO BEPREVE OPHTHALMIC SOLUTION ST atropine sulfate ophthalmic ointment BLEPHAMIDE OPHTHALMIC SUSPENSION BETADINE OPHTHALMIC PREP OPHTHALMIC atropine sulfate ophthalmic solution 1 % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT SOLUTION azelastine hcl ophthalmic solution COMBIGAN OPHTHALMIC SOLUTION betaxolol hcl ophthalmic solution bacitracin-polymyxin b ophthalmic ointment CYSTARAN OPHTHALMIC SOLUTION PA; SP FLAREX OPHTHALMIC SUSPENSION 500-10000 unit/gm LACRISERT OPHTHALMIC INSERT FML FORTE OPHTHALMIC SUSPENSION balanced salt intraocular solution LOTEMAX OPHTHALMIC GEL FML OPHTHALMIC OINTMENT brimonidine tartrate ophthalmic solution LOTEMAX OPHTHALMIC OINTMENT LASTACAFT OPHTHALMIC SOLUTION ST bromfenac sodium (once-daily) ophthalmic LOTEMAX SM OPHTHALMIC GEL MAXIDEX OPHTHALMIC SUSPENSION LUMIGAN OPHTHALMIC SOLUTION 0.01 % MYDRIACYL OPHTHALMIC SOLUTION solution NATACYN OPHTHALMIC SUSPENSION PA carteolol hcl ophthalmic solution OXERVATE OPHTHALMIC SOLUTION PA; SP OZURDEX INTRAVITREAL IMPLANT PA; LA PRED MILD OPHTHALMIC SUSPENSION ciprofloxacin hcl ophthalmic solution PHOSPHOLINE IODIDE OPHTHALMIC cromolyn sodium ophthalmic solution PA PRED-G OPHTHALMIC SUSPENSION dexamethasone sodium phosphate SOLUTION RECONSTITUTED PRED-G S.O.P. OPHTHALMIC OINTMENT RESTASIS MULTIDOSE OPHTHALMIC ophthalmic solution PROLENSA OPHTHALMIC SOLUTION PA; ST; diclofenac sodium ophthalmic solution PA; EMULSION 0.05 % PA; PA Except Max 2 fills/year PA except Ophthalmology Ophthalmology/Optometry RHOPRESSA OPHTHALMIC SOLUTION ST dorzolamide hcl ophthalmic solution RESTASIS OPHTHALMIC EMULSION PA; PA ROCKLATAN OPHTHALMIC SOLUTION ST dorzolamide hcl-timolol mal ophthalmic Except Ophthalmology/Optometry TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION SIMBRINZA OPHTHALMIC SUSPENSION UPNEEQ OPHTHALMIC SOLUTION PA solution VYZULTA OPHTHALMIC SOLUTION ST dorzolamide hcl-timolol mal pf ophthalmic TOBRADEX ST OPHTHALMIC SUSPENSION XIIDRA OPHTHALMIC SOLUTION PA; PA ZIOPTAN OPHTHALMIC SOLUTION solution epinastine hcl ophthalmic solution Except Ophthalmology/Optometry erythromycin ophthalmic ointment ZIRGAN OPHTHALMIC GEL fluorometholone ophthalmic suspension flurbiprofen sodium ophthalmic solution gentamicin sulfate ophthalmic solution ketorolac tromethamine ophthalmic solution PA ketotifen fumarate ophthalmic solution latanoprost ophthalmic solution levobunolol hcl ophthalmic solution 0.5 % levofloxacin ophthalmic solution loteprednol etabonate ophthalmic suspension neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 ofloxacin ophthalmic solution QL olopatadine hcl ophthalmic solution phenylephrine hcl ophthalmic solution 10 %, 2.5 % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % polymyxin b-trimethoprim ophthalmic solution prednisolone acetate ophthalmic suspension prednisolone sodium phosphate ophthalmic solution sulfacetamide sodium ophthalmic solution sulfacetamide-prednisolone ophthalmic solution timolol maleate ophthalmic gel forming solution

Last Updated 12.1.2020 35 timolol maleate ophthalmic solution 0.25 %, 0.5 % tobramycin ophthalmic solution tobramycin-dexamethasone ophthalmic suspension travoprost (bak free) ophthalmic solution trifluridine ophthalmic solution tropicamide ophthalmic solution ZADITOR OPHTHALMIC SOLUTION

*Otic Agents*

acetic acid otic solution ACETASOL HC OTIC SOLUTION ciprofloxacin hcl otic solution CIPRO HC OTIC SUSPENSION PA ciprofloxacin-dexamethasone otic suspension PA; PA Except Otolaryngology fluocinolone acetonide otic oil hydrocortisone-acetic acid otic solution neomycin-polymyxin-hc otic solution neomycin-polymyxin-hc otic suspension ofloxacin otic solution

*Oxytocics*

methylergonovine maleate oral tablet cervidil vaginal insert PREPIDIL VAGINAL GEL PROSTIN E2 VAGINAL SUPPOSITORY

*Penicillins*

amoxicillin oral capsule DF BICILLIN L-A INTRAMUSCULAR SUSPENSION AUGMENTIN ORAL SUSPENSION amoxicillin oral suspension reconstituted 1200000 UNIT/2ML, 600000 UNIT/ML PA; RECONSTITUTED 125-31.25 MG/5ML DF LA amoxicillin oral tablet DF amoxicillin oral tablet chewable 125 mg, 250 mg DF amoxicillin-pot clavulanate er oral tablet extended release 12 hour DF amoxicillin-pot clavulanate oral suspension reconstituted DF amoxicillin-pot clavulanate oral tablet DF amoxicillin-pot clavulanate oral tablet chewable DF ampicillin oral capsule 500 mg dicloxacillin sodium oral capsule penicillin v potassium oral solution reconstituted penicillin v potassium oral tablet DF

*Pharmaceutical Adjuvants*

sterile water for injection injection solution PA sterile water for injection intravenous solution PA

Last Updated 12.1.2020 36 *Progestins*

medroxyprogesterone acetate oral tablet MO megestrol acetate oral suspension 625 mg/5ml LA norethindrone acetate oral tablet MO progesterone intramuscular oil PA progesterone micronized oral capsule MO

Last Updated 12.1.2020 37 *Psychotherapeutic And Neurological Agents - Misc.*

acamprosate calcium oral tablet delayed AUBAGIO ORAL TABLET PA; PA Except AUSTEDO ORAL TABLET PA; SP release Neurology; SP EXTAVIA SUBCUTANEOUS KIT PA; PA bupropion hcl er (smoking det) oral tablet AVONEX PEN INTRAMUSCULAR AUTO- Except Neurology; SP extended release 12 hour INJECTOR KIT PA; PA Except Neurology; SP GRALISE ORAL TABLET ST chlordiazepoxide-amitriptyline oral tablet AVONEX PREFILLED INTRAMUSCULAR HORIZANT ORAL TABLET EXTENDED RELEASE AL PREFILLED SYRINGE KIT PA; PA Except ST dalfampridine er oral tablet extended release Neurology; SP INGREZZA ORAL CAPSULE PA; SP 12 hour PA; SP CHANTIX CONTINUING MONTH PAK ORAL INGREZZA ORAL CAPSULE THERAPY PACK dimethyl fumarate oral capsule delayed TABLET PA; SP release PA; PA Except Neurology; SP CHANTIX ORAL TABLET LUCEMYRA ORAL TABLET PA; QL disulfiram oral tablet MO CHANTIX STARTING MONTH PAK ORAL MAVENCLAD (10 TABS) ORAL TABLET donepezil hcl oral tablet 10 mg, 5 mg MO TABLET THERAPY PACK PA; QL; SP donepezil hcl oral tablet dispersible MO COPAXONE SUBCUTANEOUS SOLUTION MAVENCLAD (4 TABS) ORAL TABLET THERAPY ergoloid mesylates oral tablet PREFILLED SYRINGE 40 MG/ML PA; PA PACK PA; QL; SP galantamine hydrobromide er oral capsule MAVENCLAD (5 TABS) ORAL TABLET THERAPY Except Neurology; SP extended release 24 hour MO GILENYA ORAL CAPSULE PA; PA Except PACK PA; QL; SP galantamine hydrobromide oral solution MAVENCLAD (6 TABS) ORAL TABLET THERAPY Neurology; SP MO KESIMPTA SUBCUTANEOUS SOLUTION AUTO- PACK PA; QL; SP galantamine hydrobromide oral tablet MO MAVENCLAD (7 TABS) ORAL TABLET THERAPY glatiramer acetate subcutaneous solution INJECTOR PA; PA Except Neurology; SP LYRICA CR ORAL TABLET EXTENDED RELEASE PACK PA; QL; SP prefilled syringe PA; PA Except Neurology; MAVENCLAD (8 TABS) ORAL TABLET THERAPY 24 HOUR SP MAYZENT ORAL TABLET PA; PA Except PACK PA; QL; SP GLATOPA SUBCUTANEOUS SOLUTION MAVENCLAD (9 TABS) ORAL TABLET THERAPY Neurology; SP PREFILLED SYRINGE 20 MG/ML PA; PA MAYZENT STARTER PACK ORAL TABLET PACK PA; QL; SP NAMZARIC ORAL CAPSULE ER 24 HOUR Except Neurology; SP THERAPY PACK PA; PA Except Neurology; memantine hcl er oral capsule extended THERAPY PACK PA SP NAMZARIC ORAL CAPSULE EXTENDED release 24 hour MO NAMENDA XR TITRATION PACK ORAL memantine hcl oral solution 2 mg/ml MO RELEASE 24 HOUR PA memantine hcl oral tablet 10 mg, 5 mg MO CAPSULE EXTENDED RELEASE 24 HOUR NICOTROL INHALATION INHALER QL memantine hcl oral tablet 28 x 5 mg & 21 x 10 NUEDEXTA ORAL CAPSULE LA NICOTROL NS NASAL SOLUTION QL PLEGRIDY STARTER PACK SUBCUTANEOUS mg olanzapine-fluoxetine hcl oral capsule PA; perphenazine-amitriptyline oral tablet AL SOLUTION PEN-INJECTOR PA; PA Except MO pimozide oral tablet AL Neurology; SP paroxetine mesylate oral capsule tetrabenazine oral tablet PA; QL; SP PLEGRIDY STARTER PACK SUBCUTANEOUS rivastigmine tartrate oral capsule MO SOLUTION PREFILLED SYRINGE PA; PA rivastigmine transdermal patch 24 hour Except Neurology; SP MO PLEGRIDY SUBCUTANEOUS SOLUTION PEN- TEGSEDI SUBCUTANEOUS SOLUTION INJECTOR PA; PA Except Neurology; SP PREFILLED SYRINGE PA; SP PLEGRIDY SUBCUTANEOUS SOLUTION VUMERITY ORAL CAPSULE DELAYED RELEASE PREFILLED SYRINGE PA; PA Except PA; SP Neurology; SP XYREM ORAL SOLUTION PA; PA Except REBIF REBIDOSE SUBCUTANEOUS SOLUTION Neurology, Psychiatry, and Sleep Specialists; AUTO-INJECTOR PA; PA Except Neurology; SP SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; PA Except Neurology; SP REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; PA Except Neurology; SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; PA Except Neurology; SP SAVELLA ORAL TABLET MO SAVELLA TITRATION PACK ORAL ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK PA; PA Except Neurology; SP ZEPOSIA ORAL CAPSULE PA; PA Except Neurology; SP

Last Updated 12.1.2020 38 ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; PA Except Neurology; SP

*Respiratory Agents - Misc.*

KALYDECO ORAL PACKET PA; SP ESBRIET ORAL CAPSULE PA; SP KALYDECO ORAL TABLET PA; AL; SP ESBRIET ORAL TABLET PA; SP ORKAMBI ORAL PACKET PA; SP OFEV ORAL CAPSULE PA; SP ORKAMBI ORAL TABLET 100-125 MG, 200- 125 MG PA; AL; SP PULMOZYME INHALATION SOLUTION SYMDEKO ORAL TABLET THERAPY PACK 100- 150 & 150 MG PA; AL; SP SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG PA; LA; AL TRIKAFTA ORAL TABLET THERAPY PACK PA; AL; SP

*Sulfonamides*

sulfadiazine oral tablet

Last Updated 12.1.2020 39 *Tetracyclines*

doxycycline hyclate oral capsule DF demeclocycline hcl oral tablet doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral suspension doxycycline hyclate oral tablet 20 mg DF reconstituted DF doxycycline hyclate oral tablet 50 mg DF; AL doxycycline monohydrate oral capsule 100 mg DF; AL doxycycline monohydrate oral capsule 50 mg minocycline hcl oral capsule tetracycline hcl oral capsule

*Thyroid Agents*

levothyroxine sodium intravenous solution ARMOUR THYROID ORAL TABLET MO NATURE-THROID ORAL TABLET MO reconstituted 500 mcg PA SYNTHROID ORAL TABLET MO WESTHROID ORAL TABLET 130 MG, 195 MG, levothyroxine sodium oral tablet MO 32.5 MG, 65 MG, 97.5 MG MO liothyronine sodium oral tablet MO WP THYROID ORAL TABLET 130 MG, 16.25 methimazole oral tablet MO MG, 32.5 MG, 48.75 MG, 65 MG, 97.5 MG np thyroid oral tablet 30 mg, 60 mg, 90 mg MO MO propylthiouracil oral tablet MO UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG MO

*Ulcer Drugs/Antispasmodics/Anticholinergics*

belladonna alkaloids-opium rectal amoxicill-clarithro-lansopraz oral suppository 16.2-60 mg AL CUVPOSA ORAL SOLUTION ST chlordiazepoxide-clidinium oral capsule AL methscopolamine bromide oral tablet cimetidine hcl oral solution MO nizatidine oral capsule MO cimetidine oral tablet 300 mg, 400 mg, 800 nizatidine oral solution MO mg MO PYLERA ORAL CAPSULE dicyclomine hcl oral capsule sucralfate oral suspension dicyclomine hcl oral solution TALICIA ORAL CAPSULE DELAYED RELEASE dicyclomine hcl oral tablet PA esomeprazole magnesium oral capsule delayed release MO famotidine oral suspension reconstituted MO famotidine oral tablet 20 mg, 40 mg MO glycopyrrolate oral tablet 1 mg, 2 mg hyoscyamine sulfate er oral tablet extended release 12 hour MO; AL hyoscyamine sulfate oral elixir MO; AL hyoscyamine sulfate oral tablet MO; AL hyoscyamine sulfate oral tablet dispersible MO; AL hyoscyamine sulfate sublingual tablet sublingual MO; AL lansoprazole oral capsule delayed release MO misoprostol oral tablet MO omeprazole oral capsule delayed release MO pantoprazole sodium oral tablet delayed release MO pb-hyoscy-atropine-scopolamine oral tablet phenobarbital-belladonna alk oral elixir PHENOHYTRO ORAL TABLET propantheline bromide oral tablet rabeprazole sodium oral tablet delayed release MO sucralfate oral tablet MO

Last Updated 12.1.2020 40 *Urinary Antispasmodics*

bethanechol chloride oral tablet MYRBETRIQ ORAL TABLET EXTENDED GELNIQUE TRANSDERMAL GEL 10 % MO; darifenacin hydrobromide er oral tablet RELEASE 24 HOUR MO AL extended release 24 hour ST; MO; AL TOVIAZ ORAL TABLET EXTENDED RELEASE 24 flavoxate hcl oral tablet MO HOUR MO; AL oxybutynin chloride er oral tablet extended release 24 hour MO oxybutynin chloride oral syrup MO oxybutynin chloride oral tablet MO solifenacin succinate oral tablet AL tolterodine tartrate er oral capsule extended release 24 hour MO tolterodine tartrate oral tablet MO trospium chloride er oral capsule extended release 24 hour MO trospium chloride oral tablet MO

*Vaginal And Related Products*

clindamycin phosphate vaginal cream CLEOCIN VAGINAL SUPPOSITORY CLINDESSE VAGINAL CREAM estradiol vaginal cream ESTRING VAGINAL RING MO ENDOMETRIN VAGINAL INSERT PA; QL estradiol vaginal tablet PREMARIN VAGINAL CREAM FEM PH VAGINAL GEL metronidazole vaginal gel FEMRING VAGINAL RING YUVAFEM VAGINAL TABLET GYNAZOLE-1 VAGINAL CREAM NUVESSA VAGINAL GEL terconazole vaginal cream terconazole vaginal suppository

*Vasopressors*

epinephrine injection solution auto-injector SYMJEPI INJECTION SOLUTION PREFILLED NORTHERA ORAL CAPSULE PA; SP 0.15 mg/0.3ml, 0.3 mg/0.3ml QL SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML midodrine hcl oral tablet QL

*Vitamins*

ergocalciferol oral capsule MO phytonadione oral tablet vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) MO

Last Updated 12.1.2020 41 Last Updated 12.1.2020 42 INDEX I n d e x I n d e x A alprazolam xr...... 7 ALTABAX...... 25 abacavir sulfate...... 19 ALTAVERA...... 22 abacavir sulfate-lamivudine...... 19 ALUNBRIG...... 16 abacavir-lamivudine-zidovudine...... 19 alyacen 1/35...... 22 ABILIFY MYCITE...... 18 alyacen 7/7/7...... 22 abiraterone acetate...... 16 amantadine hcl...... 17 ABSORICA...... 25 ambrisentan...... 21 acamprosate calcium...... 38 amcinonide...... 25 acarbose...... 11 AMETHIA...... 22 ACCOLATE...... 8 AMETHIA LO...... 22 acebutolol hcl...... 20 AMETHYST...... 22 acetaminophen-codeine...... 5 amikacin sulfate...... 3 acetaminophen-codeine #2...... 5 amiloride hcl...... 28 acetaminophen-codeine #3...... 5 amiloride-hydrochlorothiazide...... 28 acetaminophen-codeine #4...... 5 aminoacetic acid...... 30 ACETASOL HC...... 36 aminocaproic acid...... 31 acetazolamide...... 28 amiodarone hcl...... 7 acetazolamide er...... 28 AMITIZA...... 29 acetic acid...... 30, 36 amitriptyline hcl...... 10 acetylcysteine...... 24 amlodipine besy-benazepril hcl...... 14 acitretin...... 25 amlodipine besylate...... 20 ACTEMRA...... 4 amlodipine besylate-valsartan...... 14 ACTEMRA ACTPEN...... 4 amlodipine-atorvastatin...... 21 activite...... 34 amlodipine-olmesartan...... 14 acyclovir...... 19, 25 amlodipine-valsartan-hctz...... 14 adapalene...... 25 AMNESTEEM...... 25 adapalene-benzoyl peroxide...... 25 amoxapine...... 10 adefovir dipivoxil...... 19 amoxicill-clarithro-lansopraz...... 40 ADEMPAS...... 21 amoxicillin...... 36 ADRENALIN...... 34 amoxicillin-pot clavulanate...... 36 ADVAIR HFA...... 8 amoxicillin-pot clavulanate er...... 36 AFEDITAB CR...... 20 amphetamine-dextroamphet er...... 3 AFINITOR...... 16 amphetamine-dextroamphetamine...... 3 AFINITOR DISPERZ...... 16 ampicillin...... 36 AIMOVIG...... 32 ANACAINE...... 25 AJOVY...... 32 ANADROL-50...... 6 AKLIEF...... 25 anagrelide hcl...... 30 AKYNZEO...... 12 anastrozole...... 16 ALAWAY...... 35 ANDRODERM...... 6 ALAWAY CHILDRENS ALLERGY...... 35 ANGELIQ...... 29 albendazole...... 6 ANNOVERA...... 22 albuterol sulfate...... 8 ANZEMET...... 12 albuterol sulfate er...... 8 APOKYN...... 17 alclometasone dipropionate...... 25 apraclonidine hcl...... 35 ALDACTAZIDE...... 28 aprepitant...... 12 ALECENSA...... 16 APRI...... 22 alendronate sodium...... 28 APTIOM...... 9 alfuzosin hcl er...... 30 APTIVUS...... 19 ALINIA...... 15 ARANELLE...... 22 aliskiren fumarate...... 14 ARANESP (ALBUMIN FREE)...... 30 ALKERAN...... 16 ARAVA...... 4 allopurinol...... 30 ARCALYST...... 4 almotriptan malate...... 32 ARCAPTA NEOHALER...... 8 ALOCRIL...... 35 ARIKAYCE...... 3 ALOMIDE...... 35 aripiprazole...... 18 alosetron hcl...... 29 armodafinil...... 3 ALPHAGAN P...... 35 ARMOUR THYROID...... 40 alprazolam...... 7 ARNUITY ELLIPTA...... 8 alprazolam er...... 7 ASCOMP-CODEINE...... 5 ALPRAZOLAM INTENSOL...... 7 ASHLYNA...... 22

Last Updated 12.1.2020 43 I n d e x I n d e x ASMANEX (120 METERED DOSES)...... 8 betaxolol hcl...... 20, 35 ASMANEX (14 METERED DOSES)...... 8 bethanechol chloride...... 41 ASMANEX (30 METERED DOSES)...... 8 BETHKIS...... 3 ASMANEX (60 METERED DOSES)...... 8 bexarotene...... 16 ASMANEX (7 METERED DOSES)...... 8 bicalutamide...... 16 ASMANEX HFA...... 8 BICILLIN L-A...... 36 aspirin-dipyridamole er...... 30 BIDIL...... 21 ASTAGRAF XL...... 33 BIKTARVY...... 19 atenolol...... 20 bimatoprost...... 35 atenolol-chlorthalidone...... 14 BINOSTO...... 28 atomoxetine hcl...... 3 bisoprolol fumarate...... 20 atorvastatin calcium...... 13 bisoprolol-hydrochlorothiazide...... 14 atovaquone...... 15 BLEPHAMIDE...... 35 atovaquone-proguanil hcl...... 15 BLEPHAMIDE S.O.P...... 35 atropine sulfate...... 35 BONJESTA...... 12 ATROVENT HFA...... 8 bosentan...... 21 AUBAGIO...... 38 BOSULIF...... 16 AUGMENTIN...... 36 BRAFTOVI...... 16 AURYXIA...... 29 BREO ELLIPTA...... 8 AUSTEDO...... 38 briellyn...... 22 AVANDIA...... 11 BRILINTA...... 30 AVIANE...... 22 brimonidine tartrate...... 35 AVITA...... 25 BRIVIACT...... 9 AVONEX PEN...... 38 bromfenac sodium (once-daily)...... 35 AVONEX PREFILLED...... 38 bromocriptine mesylate...... 17 av-phos 250 neutral...... 32 BROVANA...... 8 AYVAKIT...... 16 BRUKINSA...... 16 AZASAN...... 33 BRYHALI...... 25 azathioprine...... 33 budesonide...... 8, 24, 34 azelaic acid...... 25 budesonide er...... 24 azelastine hcl...... 34, 35 bumetanide...... 28 AZELEX...... 25 BUPAP...... 4 azithromycin...... 31 BUPHENYL...... 28 AZOPT...... 35 buprenorphine...... 5 AZURETTE...... 22 buprenorphine hcl...... 5 B bupropion hcl...... 10 bupropion hcl er (smoking det)...... 38 bacitracin-polymyxin b...... 35 bupropion hcl er (sr)...... 10 bacitra-neomycin-polymyxin-hc...... 35 bupropion hcl er (xl)...... 10 baclofen...... 34 buspirone hcl...... 7 balanced salt...... 35 butalbital-acetaminophen...... 4 BALCOLTRA...... 22 butalbital-apap-caff-cod...... 5 balsalazide disodium...... 29 butalbital-apap-caffeine...... 4 BALVERSA...... 16 butalbital-asa-caff-codeine...... 5 BALZIVA...... 22 butorphanol tartrate...... 5 BANZEL...... 9 BYSTOLIC...... 20 BAQSIMI ONE PACK...... 11 C BAQSIMI TWO PACK...... 11 BARACLUDE...... 19 cabergoline...... 28 BD AUTOSHIELD DUO...... 31 CABOMETYX...... 16 belladonna alkaloids-opium...... 40 calcipotriene...... 25 BELSOMRA...... 31 calcipotriene-betameth diprop...... 25 benazepril hcl...... 14 calcitonin (salmon)...... 28 benazepril-hydrochlorothiazide...... 14 calcitriol...... 25, 28 BENLYSTA...... 33 calcium acetate (phos binder)...... 29 BENZAC AC WASH...... 25 CALQUENCE...... 16 BENZEPRO...... 25 CAMBIA...... 32 benzonatate...... 24 CAMILA...... 22 benzoyl peroxide...... 25 CAMRESE...... 22 benztropine mesylate...... 17 CAMRESE LO...... 22 BEPREVE...... 35 candesartan cilexetil...... 14 BETADINE OPHTHALMIC PREP...... 35 candesartan cilexetil-hctz...... 14 betamethasone dipropionate...... 25 capecitabine...... 16 betamethasone dipropionate aug...... 25 CAPLYTA...... 18 betamethasone valerate...... 25 CAPRELSA...... 16

Last Updated 12.1.2020 44 I n d e x I n d e x captopril-hydrochlorothiazide...... 14 CIPRO HC...... 36 CARBAGLU...... 28 ciprofloxacin hcl...... 29, 35, 36 carbamazepine...... 9 ciprofloxacin-dexamethasone...... 36 carbamazepine er...... 9 citalopram hydrobromide...... 10 carbidopa...... 17 CITRANATAL 90 DHA...... 34 carbidopa-levodopa...... 17 CITRANATAL ASSURE...... 34 carbidopa-levodopa er...... 17 CITRANATAL B-CALM...... 34 carbidopa-levodopa-entacapone...... 17 CITRANATAL BLOOM...... 34 carbinoxamine maleate...... 13 CITRANATAL DHA...... 34 CARDIZEM...... 20 CITRANATAL HARMONY...... 34 CARDIZEM CD...... 20 CITRANATAL RX...... 34 CARDIZEM LA...... 20 CLARAVIS...... 25 CARDURA XL...... 30 CLARINEX-D 12 HOUR...... 24 carteolol hcl...... 35 clarithromycin...... 31 CARTIA XT...... 20 clarithromycin er...... 31 carvedilol...... 20 CLENPIQ...... 31 carvedilol phosphate er...... 20 CLEOCIN...... 41 CAVERJECT...... 21 CLEOCIN-T...... 25 CAVERJECT IMPULSE...... 21 CLIMARA PRO...... 29 CAYSTON...... 15 clindamycin hcl...... 15 CAZIANT...... 22 clindamycin palmitate hcl...... 15 cefaclor...... 21 clindamycin phos-benzoyl perox...... 25 cefadroxil...... 21 clindamycin phosphate...... 25, 41 cefdinir...... 21 CLINDESSE...... 41 cefixime...... 21 CLINPRO 5000...... 33 cefpodoxime proxetil...... 21 clobazam...... 9 cefprozil...... 21 clobetasol propionate...... 25 ceftriaxone sodium...... 21 clobetasol propionate e...... 25 cefuroxime axetil...... 21 clomiphene citrate...... 28 celecoxib...... 4 clomipramine hcl...... 10 CELONTIN...... 9 clonazepam...... 9 CENTANY...... 25 clonidine...... 14 CENTANY AT...... 25 clonidine hcl...... 14 cephalexin...... 21 clonidine hcl (analgesia)...... 4 CERDELGA...... 30 clonidine hcl er...... 3 cervidil...... 36 clopidogrel bisulfate...... 30 CESIA...... 22 clorazepate dipotassium...... 7 CETROTIDE...... 28 clotrimazole...... 25, 33 cevimeline hcl...... 33 clotrimazole-betamethasone...... 25 CHANTIX...... 38 clozapine...... 18 CHANTIX CONTINUING MONTH PAK...... 38 coal tar...... 25 CHANTIX STARTING MONTH PAK...... 38 COARTEM...... 15 CHATEAL...... 22 codeine sulfate...... 5 CHENODAL...... 29 colchicine...... 30 chlordiazepoxide hcl...... 7 colchicine-probenecid...... 30 chlordiazepoxide-amitriptyline...... 38 colesevelam hcl...... 13 chlordiazepoxide-clidinium...... 40 colestipol hcl...... 13 chlorhexidine gluconate...... 33 COMBIGAN...... 35 chloroquine phosphate...... 15 COMBIPATCH...... 29 chlorpromazine hcl...... 18 COMBIVENT RESPIMAT...... 8 chlorthalidone...... 28 COMETRIQ (60 MG DAILY DOSE)...... 16 chlorzoxazone...... 34 COMPLERA...... 19 CHOLBAM...... 29 completenate...... 34 cholestyramine...... 13 COMPRO...... 18 cholestyramine light...... 13 COPAXONE...... 38 chorionic gonadotropin...... 28 COPIKTRA...... 16 ciclopirox...... 25 CORLANOR...... 21 ciclopirox olamine...... 25 cortisone acetate...... 24 ciclopirox treatment...... 25 COSENTYX...... 25 cilostazol...... 30 COSENTYX (300 MG DOSE)...... 25 CIMDUO...... 19 COSENTYX SENSOREADY (300 MG)...... 25 cimetidine...... 40 COSENTYX SENSOREADY PEN...... 25 cimetidine hcl...... 40 COTELLIC...... 16 cinacalcet hcl...... 28 COTEMPLA XR-ODT...... 3 CIPRO...... 29 COVARYX...... 29

Last Updated 12.1.2020 45 I n d e x I n d e x COVARYX HS...... 29 diazepam intensol...... 7 CREON...... 27 diazoxide...... 11 CRIXIVAN...... 19 diclofenac potassium...... 4 cromolyn sodium...... 8, 29, 35 diclofenac sodium...... 4, 35 CROTAN...... 25 diclofenac sodium er...... 4 CRYSELLE-28...... 22 dicloxacillin sodium...... 36 CUVPOSA...... 40 dicyclomine hcl...... 40 cyanocobalamin...... 30 didanosine...... 19 CYCLAFEM 1/35...... 22 DIFICID...... 31 CYCLAFEM 7/7/7...... 22 diflorasone diacetate...... 25 cyclobenzaprine hcl...... 34 diflunisal...... 4 cyclophosphamide...... 16 digoxin...... 20 CYCLOSET...... 11 dihydroergotamine mesylate...... 32 cyclosporine...... 33 DILANTIN...... 9 cyclosporine modified...... 33 DILATRATE-SR...... 6 cyproheptadine hcl...... 13 DILAUDID...... 5 CYRED...... 22 diltiazem hcl...... 20 CYSTADANE...... 28 diltiazem hcl er...... 20 CYSTAGON...... 30 diltiazem hcl er beads...... 20 CYSTARAN...... 35 diltiazem hcl er coated beads...... 20 D dilt-xr...... 20 dimethyl fumarate...... 38 dalfampridine er...... 38 diphenhydramine hcl...... 13 DALIRESP...... 8 diphenoxylate-atropine...... 12 danazol...... 6 DIPROLENE...... 25 dantrolene sodium...... 34 DIPROLENE AF...... 25 dapsone...... 15, 25 dipyridamole...... 30 darifenacin hydrobromide er...... 41 disopyramide phosphate...... 7 DASETTA 1/35...... 22 disulfiram...... 38 DASETTA 7/7/7...... 22 DIURIL...... 28 DAURISMO...... 16 divalproex sodium...... 9 DAYPRO...... 4 divalproex sodium er...... 9 DAYSEE...... 22 DIVIGEL...... 29 DAYTRANA...... 3 dobells...... 33 DAYVIGO...... 31 dofetilide...... 7 DDAVP RHINAL TUBE...... 28 donepezil hcl...... 38 DEBACTEROL...... 33 DOPTELET...... 30 DEBLITANE...... 22 dorzolamide hcl...... 35 deferasirox...... 12 dorzolamide hcl-timolol mal...... 35 deferasirox granules...... 12 dorzolamide hcl-timolol mal pf...... 35 DELSTRIGO...... 19 DOTTI...... 29 demeclocycline hcl...... 40 DOVATO...... 19 DESCOVY...... 19 doxazosin mesylate...... 14 desipramine hcl...... 10 doxepin hcl...... 10, 31 desloratadine...... 13 doxercalciferol...... 28 desmopressin ace spray refrig...... 28 doxycycline hyclate...... 40 desmopressin acetate...... 28 doxycycline monohydrate...... 40 desmopressin acetate spray...... 28 doxylamine-pyridoxine...... 12 desogestrel-ethinyl estradiol...... 22 DRITHO-CREME HP...... 25 desonide...... 25 dronabinol...... 12 desoximetasone...... 25 drospiren-eth estrad-levomefol...... 22 desvenlafaxine succinate er...... 10 drospirenone-ethinyl estradiol...... 22 dexamethasone...... 24 DROXIA...... 30 dexamethasone intensol...... 24 DRYSOL...... 25 dexamethasone sodium phosphate...... 35 DUAVEE...... 29 dexmethylphenidate hcl...... 3 DUET DHA 400...... 34 dexmethylphenidate hcl er...... 3 DUET DHA BALANCED...... 34 dextroamphetamine sulfate...... 3 duloxetine hcl...... 10 dextroamphetamine sulfate er...... 3 DUOBRII...... 25 dextrose-nacl...... 32 DUOPA...... 17 DIACOMIT...... 9 DUPIXENT...... 25 DIALYVITE...... 34 DURACLON...... 4 DIASTAT ACUDIAL...... 9 dutasteride...... 30 DIASTAT PEDIATRIC...... 9 dutasteride-tamsulosin hcl...... 30 diazepam...... 7, 9

Last Updated 12.1.2020 46 I n d e x I n d e x E ERTACZO...... 25 ERY-TAB...... 31 E.E.S. 400...... 31 ERYTHROCIN STEARATE...... 31 econazole nitrate...... 25 erythromycin...... 25, 35 EDARBI...... 14 erythromycin base...... 31 EDARBYCLOR...... 14 erythromycin ethylsuccinate...... 31 EDECRIN...... 28 ESBRIET...... 39 EDEX...... 21 escitalopram oxalate...... 10 EDLUAR...... 31 ESGIC...... 4 EDURANT...... 19 esomeprazole magnesium...... 40 EEMT...... 29 est estrogens-methyltest...... 29 efavirenz...... 19 est estrogens-methyltest ds...... 29 efavirenz-emtricitab-tenofovir...... 19 est estrogens-methyltest hs...... 29 efavirenz-lamivudine-tenofovir...... 19 ESTARYLLA...... 22 EFFER-K...... 32 estazolam...... 31 ELESTRIN...... 29 estradiol...... 29, 41 eletriptan hydrobromide...... 32 estradiol-norethindrone acet...... 29 ELIMITE...... 25 ESTRING...... 41 ELINEST...... 22 ESTROGEL...... 29 ELIQUIS...... 9 eszopiclone...... 31 ELIQUIS DVT/PE STARTER PACK...... 9 ethacrynic acid...... 28 ELIXOPHYLLIN...... 8 ethambutol hcl...... 15 ELLA...... 22 ethosuximide...... 9 ELMIRON...... 30 etodolac...... 4 EMCYT...... 16 etodolac er...... 4 EMFLAZA...... 24 etoposide...... 16 EMGALITY...... 32 EUCRISA...... 25 EMGALITY (300 MG DOSE)...... 32 EVAMIST...... 29 EMOQUETTE...... 22 everolimus...... 16, 33 EMSAM...... 10 EVOTAZ...... 19 emtricitabine...... 19 exemestane...... 16 emtricitabine-tenofovir df...... 19 EXTAVIA...... 38 EMTRIVA...... 19 ezetimibe...... 13 EMVERM...... 6 ezetimibe-simvastatin...... 13 enalapril maleate...... 14 F enalapril-hydrochlorothiazide...... 14 ENBREL...... 4 FABIOR...... 25 ENBREL MINI...... 4 FALMINA...... 22 ENBREL SURECLICK...... 4 famciclovir...... 19 ENDOMETRIN...... 41 famotidine...... 40 enoxaparin sodium...... 9 FANAPT...... 18 ENPRESSE-28...... 22 FANAPT TITRATION PACK...... 18 ENSKYCE...... 22 FARYDAK...... 16 ENSPRYNG...... 33 FASENRA PEN...... 8 entacapone...... 17 febuxostat...... 30 entecavir...... 19 felbamate...... 9 ENTRESTO...... 21 felodipine er...... 20 ENVARSUS XR...... 33 FEM PH...... 41 EPANED...... 14 FEMRING...... 41 EPCLUSA...... 19 fenofibrate...... 13 EPIDIOLEX...... 9 fenofibrate micronized...... 13 EPIDUO FORTE...... 25 fenofibric acid...... 13 epinastine hcl...... 35 fenoprofen calcium...... 4 epinephrine...... 41 fentanyl...... 5 EPIVIR HBV...... 19 fentanyl citrate...... 5 eplerenone...... 14 FERRALET 90...... 30 EPZICOM...... 19 ferraplus 90...... 30 EQUETRO...... 18 FERREX 150 FORTE PLUS...... 30 ergocalciferol...... 41 FERRIPROX...... 12 ergoloid mesylates...... 38 FERRIPROX TWICE-A-DAY...... 12 ERGOMAR...... 32 FERROCITE PLUS...... 30 ERIVEDGE...... 16 FETZIMA...... 10 ERLEADA...... 16 FEXMID...... 34 erlotinib hcl...... 16 FINACEA...... 25 ERRIN...... 22 finasteride...... 30

Last Updated 12.1.2020 47 I n d e x I n d e x FIRDAPSE...... 15 gentamicin sulfate...... 26, 35 FIRVANQ...... 15 GENVOYA...... 19 FLAREX...... 35 GIANVI...... 22 flavoxate hcl...... 41 GILENYA...... 38 flecainide acetate...... 7 GILOTRIF...... 16 FLOVENT DISKUS...... 8 glatiramer acetate...... 38 FLOVENT HFA...... 8 GLATOPA...... 38 fluconazole...... 13 GLEOSTINE...... 16 flucytosine...... 13 glimepiride...... 11 fludrocortisone acetate...... 24 glipizide...... 11 flunisolide...... 34 glipizide er...... 11 fluocinolone acetonide...... 25, 26, 36 glipizide xl...... 11 fluocinolone acetonide body...... 25 glipizide-metformin hcl...... 11 fluocinolone acetonide scalp...... 26 GLUCAGEN HYPOKIT...... 11 fluocinonide...... 26 glucagon emergency...... 11 FLUORIDEX SENSITIVITY RELIEF...... 33 glyburide...... 11 fluorometholone...... 35 glyburide micronized...... 11 FLUOROPLEX...... 26 glyburide-metformin...... 11 fluorouracil...... 26 glycine...... 30 fluoxetine hcl...... 10 glycine urologic...... 30 fluphenazine hcl...... 18 glycopyrrolate...... 40 flurandrenolide...... 26 GLYXAMBI...... 11 flurazepam hcl...... 31 GOCOVRI...... 17 flurbiprofen...... 4 GRALISE...... 38 flurbiprofen sodium...... 35 granisetron hcl...... 12 flutamide...... 16 GRASTEK...... 3 fluticasone propionate...... 26, 34 griseofulvin microsize...... 13 fluticasone-salmeterol...... 8 griseofulvin ultramicrosize...... 13 fluvastatin sodium...... 13 guanfacine hcl...... 14 fluvastatin sodium er...... 13 guanfacine hcl er...... 3 fluvoxamine maleate...... 10 guanidine hcl...... 15 fluvoxamine maleate er...... 10 GVOKE HYPOPEN 1-PACK...... 11 FML...... 35 GVOKE HYPOPEN 2-PACK...... 11 FML FORTE...... 35 GVOKE PFS...... 11 folic acid...... 30 GYNAZOLE-1...... 41 FOLLISTIM AQ...... 28 H fondaparinux sodium...... 9 FORTEO...... 28 HAEGARDA...... 30 FORTESTA...... 6 halobetasol propionate...... 26 fosamprenavir calcium...... 19 haloperidol...... 18 fosfomycin tromethamine...... 15 haloperidol lactate...... 18 fosinopril sodium...... 14 HARVONI...... 19 fosinopril sodium-hctz...... 14 HEATHER...... 22 FRAGMIN...... 9 HEMANGEOL...... 20 frovatriptan succinate...... 32 HEPSERA...... 19 furosemide...... 28 HETLIOZ...... 31 FUZEON...... 19 HORIZANT...... 38 FYCOMPA...... 9 HUMALOG...... 11 HUMALOG KWIKPEN...... 11 G HUMALOG MIX 50/50...... 11 gabapentin...... 9 HUMALOG MIX 50/50 KWIKPEN...... 11 GALAFOLD...... 28 HUMALOG MIX 75/25...... 11 galantamine hydrobromide...... 38 HUMALOG MIX 75/25 KWIKPEN...... 11 galantamine hydrobromide er...... 38 HUMIRA...... 4 GALZIN...... 32 HUMIRA PEDIATRIC CROHNS START...... 4 ganirelix acetate...... 28 HUMIRA PEN...... 4 GATTEX...... 29 HUMIRA PEN-CD/UC/HS STARTER...... 4 GAVILYTE-G...... 31 HUMIRA PEN-PS/UV/ADOL HS START...... 4 GAVRETO...... 16 HUMULIN 70/30...... 11 GELNIQUE...... 41 HUMULIN 70/30 KWIKPEN...... 11 gemfibrozil...... 13 HUMULIN N...... 11 GENGRAF...... 33 HUMULIN N KWIKPEN...... 11 GENICIN VITA-S...... 34 HUMULIN R...... 11 GENOTROPIN...... 28 HUMULIN R U-500 (CONCENTRATED)...... 11 GENOTROPIN MINIQUICK...... 28 HUMULIN R U-500 KWIKPEN...... 11

Last Updated 12.1.2020 48 I n d e x I n d e x HYCAMTIN...... 16 isosorbide mononitrate er...... 6 hydralazine hcl...... 14 isotretinoin...... 26 hydrochlorothiazide...... 28 isoxsuprine hcl...... 21 hydrocodone-acetaminophen...... 5 isradipine...... 20 hydrocodone-homatropine...... 24 itraconazole...... 13 hydrocodone-ibuprofen...... 5 ivermectin...... 6 hydrocortisone...... 6, 24, 26 J hydrocortisone ace-pramoxine...... 26 hydrocortisone acetate...... 6 JAKAFI...... 16 hydrocortisone butyr lipo base...... 26 JANTOVEN...... 9 hydrocortisone butyrate...... 26 JARDIANCE...... 11 hydrocortisone valerate...... 26 JENCYCLA...... 22 hydrocortisone-acetic acid...... 36 JENTADUETO...... 11 hydrocortisone-iodoquinol...... 26 JENTADUETO XR...... 11 hydromorphone hcl...... 5 JINTELI...... 29 hydromorphone hcl er...... 5 JOLESSA...... 22 hydroxychloroquine sulfate...... 15 JUBLIA...... 26 hydroxyurea...... 16 JULEBER...... 22 hydroxyzine hcl...... 7 JULUCA...... 19 hydroxyzine pamoate...... 7 JUNEL 1.5/30...... 22 hyoscyamine sulfate...... 40 JUNEL 1/20...... 22 hyoscyamine sulfate er...... 40 JUNEL FE 1.5/30...... 22 HYSINGLA ER...... 5 JUNEL FE 1/20...... 22 JUNEL FE 24...... 22 I JUXTAPID...... 13 ibandronate sodium...... 28 JYNARQUE...... 28 IBRANCE...... 16 K ibuprofen...... 4 icatibant acetate...... 30 KALETRA...... 19 ICLUSIG...... 16 KALYDECO...... 39 icosapent ethyl...... 13 KANUMA...... 28 IDHIFA...... 16 KARIVA...... 22 imatinib mesylate...... 16 KELNOR 1/35...... 22 IMBRUVICA...... 16 KESIMPTA...... 38 imipramine hcl...... 10 ketoconazole...... 13, 26 imiquimod...... 26 KETODAN...... 26 INBRIJA...... 17 ketoprofen...... 4 INCRELEX...... 28 ketoprofen er...... 4 indapamide...... 28 ketorolac tromethamine...... 4, 35 indomethacin...... 4 ketotifen fumarate...... 35 indomethacin er...... 4 KEVEYIS...... 28 INGREZZA...... 38 KEVZARA...... 4 INLYTA...... 16 KINERET...... 4 INQOVI...... 16 KISQALI FEMARA (400 MG DOSE)...... 16 INREBIC...... 16 KISQALI FEMARA (600 MG DOSE)...... 16 INTELENCE...... 19 KISQALI FEMARA(200 MG DOSE)...... 16 INTRON A...... 16 KITABIS PAK...... 3 INTROVALE...... 22 KLONOPIN...... 9 INVIRASE...... 19 KLOR-CON 10...... 32 INVOKAMET...... 11 KLOR-CON/EF...... 32 INVOKAMET XR...... 11 KORLYM...... 11 INVOKANA...... 11 KOSELUGO...... 16 iodine strong...... 32 K-PHOS-NEUTRAL...... 32 iodoquinol-hydrocortisone-aloe...... 26 K-PRIME...... 32 ipratropium bromide...... 8, 34 KRISTALOSE...... 31 ipratropium-albuterol...... 8 KURVELO...... 22 irbesartan...... 14 KYNMOBI...... 17 irbesartan-hydrochlorothiazide...... 14 KYNMOBI TITRATION KIT...... 17 IRESSA...... 16 L ISENTRESS...... 19 labetalol hcl...... 20 ISENTRESS HD...... 19 LACRISERT...... 35 ISIBLOOM...... 22 lactated ringers...... 33 isoniazid...... 15 lactulose...... 31 isosorbide dinitrate...... 6 lactulose encephalopathy...... 29 isosorbide mononitrate...... 6 LAMICTAL XR...... 9

Last Updated 12.1.2020 49 I n d e x I n d e x lamivudine...... 19 LINZESS...... 29 lamivudine-zidovudine...... 19 liothyronine sodium...... 40 lamotrigine...... 9 lisinopril...... 14 lamotrigine er...... 9 lisinopril-hydrochlorothiazide...... 14 lamotrigine starter kit-blue...... 9 lithium...... 18 lamotrigine starter kit-green...... 9 lithium carbonate...... 18 lamotrigine starter kit-orange...... 9 lithium carbonate er...... 18 LAMPIT...... 15 LITHOSTAT...... 30 LANOXIN...... 20 LIVALO...... 13 lansoprazole...... 40 LO LOESTRIN FE...... 23 lanthanum carbonate...... 29 LOKELMA...... 33 LANTUS...... 11 LONSURF...... 16 LANTUS SOLOSTAR...... 11 loperamide hcl...... 12 lapatinib ditosylate...... 16 lopinavir-ritonavir...... 19 LARIN 1.5/30...... 22 lorazepam...... 7 LARIN 1/20...... 22 LORAZEPAM INTENSOL...... 7 LARIN 24 FE...... 22 LORBRENA...... 16 LARIN FE 1.5/30...... 22 lorid...... 34 LARIN FE 1/20...... 22 LORYNA...... 23 LASTACAFT...... 35 losartan potassium...... 14 latanoprost...... 35 losartan potassium-hctz...... 14 LATUDA...... 18 LOTEMAX...... 35 LAZANDA...... 5 LOTEMAX SM...... 35 ledipasvir-sofosbuvir...... 19 loteprednol etabonate...... 35 LEENA...... 22 lovastatin...... 13 leflunomide...... 4 LOW-OGESTREL...... 23 LENVIMA (10 MG DAILY DOSE)...... 16 loxapine succinate...... 18 LENVIMA (12 MG DAILY DOSE)...... 16 LUCEMYRA...... 38 LENVIMA (14 MG DAILY DOSE)...... 16 LUMIGAN...... 35 LENVIMA (18 MG DAILY DOSE)...... 16 LUTERA...... 23 LENVIMA (20 MG DAILY DOSE)...... 16 LYNPARZA...... 16 LENVIMA (24 MG DAILY DOSE)...... 16 LYRICA CR...... 38 LENVIMA (4 MG DAILY DOSE)...... 16 LYSODREN...... 16 LENVIMA (8 MG DAILY DOSE)...... 16 LYUMJEV...... 11 LESSINA...... 22 LYUMJEV KWIKPEN...... 11 letrozole...... 16 LYZA...... 23 leucovorin calcium...... 16 M LEUKERAN...... 16 levalbuterol hcl...... 8 MACRODANTIN...... 15 levalbuterol tartrate...... 8 malathion...... 26 LEVEMIR...... 11 maprotiline hcl...... 10 LEVEMIR FLEXTOUCH...... 11 marlissa...... 23 levetiracetam...... 9 MARPLAN...... 10 levetiracetam er...... 9 MATULANE...... 16 levobunolol hcl...... 35 MATZIM LA...... 20 levocarnitine...... 28 MAVENCLAD (10 TABS)...... 38 levocetirizine dihydrochloride...... 13 MAVENCLAD (4 TABS)...... 38 levofloxacin...... 29, 35 MAVENCLAD (5 TABS)...... 38 LEVONEST...... 22 MAVENCLAD (6 TABS)...... 38 levonorgest-eth est & eth est...... 22 MAVENCLAD (7 TABS)...... 38 levonorgest-eth estrad 91-day...... 22 MAVENCLAD (8 TABS)...... 38 levonorgestrel...... 23 MAVENCLAD (9 TABS)...... 38 levonorgestrel-ethinyl estrad...... 23 MAVIK...... 14 LEVORA 0.15/30 (28)...... 23 MAVYRET...... 19 levothyroxine sodium...... 40 MAXIDEX...... 35 LEXIVA...... 19 MAYZENT...... 38 LIALDA...... 29 MAYZENT STARTER PACK...... 38 lidocaine...... 26 meclizine hcl...... 12 lidocaine hcl...... 26 meclofenamate sodium...... 4 lidocaine-hydrocortisone ace...... 6 MEDROX-RX...... 26 lidocaine-prilocaine...... 26 medroxyprogesterone acetate...... 37 LIDOCARE ARM/NECK/LEG...... 26 mefloquine hcl...... 15 LIDOCARE BACK/SHOULDER...... 26 megestrol acetate...... 16, 37 lindane...... 26 MEKINIST...... 16 linezolid...... 15 MEKTOVI...... 16

Last Updated 12.1.2020 50 I n d e x I n d e x MELODETTA 24 FE...... 23 minocycline hcl...... 40 meloxicam...... 4 minoxidil...... 14 memantine hcl...... 38 mirtazapine...... 10 memantine hcl er...... 38 MIRVASO...... 26 MENEST...... 29 misoprostol...... 40 MENOPUR...... 28 modafinil...... 3 MENOSTAR...... 29 moexipril hcl...... 14 MENTAX...... 26 mometasone furoate...... 26 mercaptopurine...... 16 MONO-LINYAH...... 23 mesalamine...... 29 MONONESSA...... 23 mesalamine er...... 29 montelukast sodium...... 8 mesalamine-cleanser...... 29 morphine sulfate...... 5 MESNEX...... 16 morphine sulfate (concentrate)...... 5 MESTINON...... 15 morphine sulfate er...... 5 metaxalone...... 34 morphine sulfate er beads...... 5 metformin hcl...... 11 MOTOFEN...... 12 metformin hcl er...... 11 MOVANTIK...... 29 methadone hcl...... 5 moxifloxacin hcl...... 29 METHADONE HCL INTENSOL...... 5 MULPLETA...... 30 METHADOSE...... 5 MULTAQ...... 7 methazolamide...... 28 MULTIGEN PLUS...... 30 methenamine hippurate...... 15 multivitamin/fluoride...... 34 methenamine mandelate...... 15 mupirocin...... 26 methimazole...... 40 mupirocin calcium...... 26 methitest...... 6 MUSE...... 21 methocarbamol...... 34 MYALEPT...... 28 methotrexate...... 16 MYCOBUTIN...... 15 methotrexate sodium...... 16 mycophenolate mofetil...... 33 methotrexate sodium (pf)...... 16 mycophenolate sodium...... 33 methoxsalen rapid...... 26 MYDAYIS...... 3 methscopolamine bromide...... 40 MYDRIACYL...... 35 methyldopa...... 14 MYLERAN...... 16 methyldopa-hydrochlorothiazide...... 14 MYORISAN...... 26 methylergonovine maleate...... 36 MYRBETRIQ...... 41 methylphenidate hcl...... 3 MYSOLINE...... 9 methylphenidate hcl er...... 3 MYTESI...... 12 methylphenidate hcl er (cd)...... 3 N methylphenidate hcl er (la)...... 3 methylphenidate hcl er (xr)...... 3 nabumetone...... 4 methylprednisolone...... 24 n-acetyl-l-cysteine...... 34 methyltestosterone...... 6 nadolol...... 20 metoclopramide hcl...... 29 naftifine hcl...... 26 metolazone...... 28 NAFTIN...... 26 METOPIRONE...... 27 naloxone hcl...... 12 metoprolol succinate er...... 20 naltrexone hcl...... 12 metoprolol tartrate...... 20 NAMENDA XR TITRATION PACK...... 38 metoprolol-hydrochlorothiazide...... 14 NAMZARIC...... 38 METROLOTION...... 26 naproxen...... 4 metronidazole...... 15, 26, 41 naproxen dr...... 4 metyrosine...... 14 naratriptan hcl...... 32 mexiletine hcl...... 7 NARCAN...... 12 MIBELAS 24 FE...... 23 NATACYN...... 35 miconazole-zinc oxide-petrolat...... 26 NATALVIT...... 34 MICROGESTIN 1.5/30...... 23 NATAZIA...... 23 MICROGESTIN 1/20...... 23 nateglinide...... 11 MICROGESTIN FE 1.5/30...... 23 NATESTO...... 6 MICROGESTIN FE 1/20...... 23 NATPARA...... 28 midazolam hcl...... 31 NATURE-THROID...... 40 midodrine hcl...... 41 NAYZILAM...... 9 mifepristone...... 28 NECON 0.5/35 (28)...... 23 MIGERGOT...... 32 NECON 1/35 (28)...... 23 miglitol...... 11 nefazodone hcl...... 10 miglustat...... 30 neomycin sulfate...... 3 MILLIPRED...... 24 neomycin-bacitracin zn-polymyx...... 35 MIMVEY...... 29 neomycin-polymyxin b gu...... 30

Last Updated 12.1.2020 51 I n d e x I n d e x neomycin-polymyxin-dexameth...... 35 NUVARING...... 23 neomycin-polymyxin-gramicidin...... 35 NUVESSA...... 41 neomycin-polymyxin-hc...... 36 NYMALIZE...... 20 NEPHRONEX...... 34 nystatin...... 13, 26, 33 NEPHRO-VITE RX...... 34 nystatin-triamcinolone...... 26 NERLYNX...... 16 NYSTOP...... 26 NESTABS...... 34 O NESTABS DHA...... 34 NEULASTA...... 30 OBTREX...... 34 NEUPRO...... 17 OCALIVA...... 29 nevirapine...... 19 OCELLA...... 23 nevirapine er...... 19 octreotide acetate...... 28 NEXAVAR...... 16 ODACTRA...... 3 NEXLETOL...... 13 ODEFSEY...... 19 NEXLIZET...... 13 ODOMZO...... 16 nicardipine hcl...... 20 OFEV...... 39 NICOTROL...... 38 ofloxacin...... 35, 36 NICOTROL NS...... 38 olanzapine...... 18 nifedipine...... 20 olanzapine-fluoxetine hcl...... 38 nifedipine er...... 20 olmesartan medoxomil...... 14 nifedipine er osmotic release...... 20 olmesartan medoxomil-hctz...... 14 NIKKI...... 23 olmesartan-amlodipine-hctz...... 14 NILANDRON...... 16 olopatadine hcl...... 34, 35 nimodipine...... 20 omeprazole...... 40 NINLARO...... 16 OMNIPOD 5 PACK...... 31 nisoldipine er...... 20 OMNIPOD DASH 5 PACK PODS...... 31 nitisinone...... 28 ondansetron...... 12 NITRO-BID...... 6 ondansetron hcl...... 12 NITRO-DUR...... 6 onevite...... 34 nitrofurantoin...... 15 ONGENTYS...... 17 nitrofurantoin macrocrystal...... 15 ONUREG...... 16 nitrofurantoin monohyd macro...... 15 ONZETRA XSAIL...... 32 nitroglycerin...... 6 opium...... 12 nitroglycerin er...... 6 OPSUMIT...... 21 NITYR...... 28 ORALAIR...... 3 NIVESTYM...... 30 ORALAIR ADULT SAMPLE KIT...... 3 nizatidine...... 40 ORALAIR ADULT STARTER PACK...... 3 NORA-BE...... 23 ORALAIR CHILDRENS SAMPLE KIT...... 3 norethin ace-eth estrad-fe...... 23 ORALAIR CHILDRENS STARTER PACK...... 3 norethindrone...... 23 ORAVIG...... 33 norethindrone acetate...... 37 ORENCIA...... 4 norethindrone acet-ethinyl est...... 23 ORENCIA CLICKJECT...... 4 norethindrone-eth estradiol...... 29 ORENITRAM...... 21 norgestimate-eth estradiol...... 23 ORFADIN...... 28 norgestim-eth estrad triphasic...... 23 ORIAHNN...... 29 NORLYROC...... 23 ORILISSA...... 28 NORPACE CR...... 7 ORKAMBI...... 39 NORPRAMIN...... 10 ORSYTHIA...... 23 NORTHERA...... 41 oseltamivir phosphate...... 19 NORTREL 0.5/35 (28)...... 23 OSMOLEX ER...... 17 NORTREL 1/35 (21)...... 23 OTEZLA...... 4 NORTREL 1/35 (28)...... 23 OTREXUP...... 4 NORTREL 7/7/7...... 23 OVIDREL...... 28 nortriptyline hcl...... 10 oxandrolone...... 6 NORVIR...... 19 oxaprozin...... 4 NOXAFIL...... 13 oxazepam...... 7 np thyroid...... 40 OXBRYTA...... 30 NUBEQA...... 16 oxcarbazepine...... 9 NUCALA...... 8 OXERVATE...... 35 NUCORT...... 26 oxiconazole nitrate...... 26 NUCYNTA...... 5 OXISTAT...... 26 NUCYNTA ER...... 5 OXSORALEN ULTRA...... 26 NUEDEXTA...... 38 OXTELLAR XR...... 9 NUPLAZID...... 18 oxybutynin chloride...... 41 NURTEC...... 32 oxybutynin chloride er...... 41

Last Updated 12.1.2020 52 I n d e x I n d e x oxycodone hcl...... 5 pilocarpine hcl...... 33, 35 oxycodone hcl er...... 5 pimecrolimus...... 26 oxycodone-acetaminophen...... 5 pimozide...... 38 oxycodone-aspirin...... 5 PIMTREA...... 23 OXYCONTIN...... 5 pindolol...... 20 oxymorphone hcl...... 6 pioglitazone hcl...... 11 oxymorphone hcl er...... 5 pioglitazone hcl-glimepiride...... 11 OZEMPIC (0.25 OR 0.5 MG/DOSE)...... 11 pioglitazone hcl-metformin hcl...... 11 OZEMPIC (1 MG/DOSE)...... 11 PIQRAY (200 MG DAILY DOSE)...... 17 OZURDEX...... 35 PIQRAY (250 MG DAILY DOSE)...... 17 P PIQRAY (300 MG DAILY DOSE)...... 17 PIRMELLA 1/35...... 23 pacerone...... 7 PIRMELLA 7/7/7...... 23 paliperidone er...... 18 piroxicam...... 4 PALYNZIQ...... 28 PLEGRIDY...... 38 PANCREAZE...... 27 PLEGRIDY STARTER PACK...... 38 PANDEL...... 26 PLEXION...... 26 PANRETIN...... 26 pnv prenatal plus multivitamin...... 34 pantoprazole sodium...... 40 pnv tabs 29-1...... 34 paricalcitol...... 28 pnv-dha...... 34 paromomycin sulfate...... 3 pnv-dha+docusate...... 34 paroxetine hcl...... 10 pnv-omega...... 34 paroxetine hcl er...... 10 poly-iron 150 forte...... 30 paroxetine mesylate...... 38 polymyxin b-trimethoprim...... 35 PASER...... 15 polysaccharide iron forte...... 30 PAXIL...... 10 POLY-VI-FLOR...... 34 pb-hyoscy-atropine-scopolamine...... 40 POMALYST...... 17 PEDIAPRED...... 24 PORTIA-28...... 23 peg 3350-kcl-na bicarb-nacl...... 31 posaconazole...... 13 peg-3350/electrolytes...... 31 potassium chloride...... 32 PEGASYS...... 19 potassium chloride crys er...... 32 PEMAZYRE...... 16 potassium chloride er...... 32 penicillamine...... 33 potassium citrate er...... 30 penicillin v potassium...... 36 PRADAXA...... 9 pentamidine isethionate...... 15 PRALUENT...... 13 PENTASA...... 29 pramipexole dihydrochloride...... 17 pentazocine-naloxone hcl...... 6 pramipexole dihydrochloride er...... 17 pentoxifylline er...... 30 PRAMOSONE...... 26 PERFOROMIST...... 8 prasugrel hcl...... 30 perindopril erbumine...... 14 pravastatin sodium...... 13 permethrin...... 26 praziquantel...... 6 perphenazine...... 18 prazosin hcl...... 14 perphenazine-amitriptyline...... 38 PRED MILD...... 35 PERTZYE...... 27 PRED-G...... 35 PEXEVA...... 10 PRED-G S.O.P...... 35 phenazopyridine hcl...... 30 prednicarbate...... 26 phenelzine sulfate...... 10 prednisolone...... 24 phenobarbital...... 31 prednisolone acetate...... 35 phenobarbital-belladonna alk...... 40 prednisolone sodium phosphate...... 24, 35 PHENOHYTRO...... 40 prednisone...... 24 phenoxybenzamine hcl...... 14 PREDNISONE INTENSOL...... 24 phenylephrine hcl...... 35 PREFEST...... 29 phenytoin...... 9 pregabalin...... 9 phenytoin infatabs...... 9 PREMARIN...... 29, 41 phenytoin sodium extended...... 9 PREMPHASE...... 29 PHILITH...... 23 PREMPRO...... 29 PHOSLYRA...... 29 PRENATABS RX...... 34 PHOSPHA 250 NEUTRAL...... 32 prenatal...... 34 PHOSPHOLINE IODIDE...... 35 prenatal 19...... 34 PHOSPHO-TRIN 250 NEUTRAL...... 32 prenatal formula a-free...... 34 PHYSIOLYTE...... 33 prenatal low iron...... 34 PHYSIOSOL IRRIGATION...... 33 prenatal multi +dha...... 34 phytonadione...... 41 prenatal one daily...... 34 PICATO...... 26 prenatal plus...... 34 PIFELTRO...... 19 prenatal plus iron...... 34

Last Updated 12.1.2020 53 I n d e x I n d e x prenatal plus/iron...... 34 raloxifene hcl...... 28 prenatal vitamins...... 34 ramelteon...... 31 PREPIDIL...... 36 ramipril...... 14 preplus...... 34 ranolazine er...... 6 pretomanid...... 15 rasagiline mesylate...... 17 PREVIFEM...... 23 RASUVO...... 4 PREVYMIS...... 19 RAVICTI...... 28 PREZCOBIX...... 19 RAYALDEE...... 28 PREZISTA...... 19 RAYOS...... 24 PRIFTIN...... 15 REBIF...... 38 primaquine phosphate...... 15 REBIF REBIDOSE...... 38 primidone...... 9 REBIF REBIDOSE TITRATION PACK...... 38 PRIMSOL...... 15 REBIF TITRATION PACK...... 38 PROAIR HFA...... 8 RECLIPSEN...... 23 PROAIR RESPICLICK...... 8 RECTIV...... 6 probenecid...... 30 REGRANEX...... 26 prochlorperazine...... 18 RELENZA DISKHALER...... 19 prochlorperazine maleate...... 18 RELISTOR...... 29 PROCYSBI...... 30 RENACIDIN...... 30 progesterone...... 37 repaglinide...... 11 progesterone micronized...... 37 REPATHA...... 13 PROLENSA...... 35 REPATHA PUSHTRONEX SYSTEM...... 13 PROMACTA...... 30 REPATHA SURECLICK...... 13 promethazine hcl...... 13 RESECTISOL...... 30 promethazine vc...... 24 RESTASIS...... 35 promethazine vc/codeine...... 24 RESTASIS MULTIDOSE...... 35 promethazine-codeine...... 24 RETACRIT...... 30 promethazine-dm...... 24 RETEVMO...... 17 promethazine-phenylephrine...... 24 REVLIMID...... 33 propafenone hcl...... 7 REXULTI...... 18 propafenone hcl er...... 7 REYATAZ...... 19 propantheline bromide...... 40 REYVOW...... 32 propranolol hcl...... 20 RHOPRESSA...... 35 propranolol hcl er...... 20 ribavirin...... 19 propranolol-hctz...... 14 RIDAURA...... 4 propylthiouracil...... 40 rifabutin...... 15 PROSTIN E2...... 36 rifampin...... 15 protriptyline hcl...... 10 riluzole...... 34 PULMICORT FLEXHALER...... 8 rimantadine hcl...... 19 PULMOZYME...... 39 ringers irrigation...... 33 PYLERA...... 40 RINVOQ...... 4 pyrazinamide...... 15 RIOMET...... 11 pyridostigmine bromide...... 15 risedronate sodium...... 28 pyridostigmine bromide er...... 15 risperidone...... 18 pyrimethamine...... 15 ritonavir...... 19 Q rivastigmine...... 38 rivastigmine tartrate...... 38 QBREXZA...... 26 rizatriptan benzoate...... 32 QINLOCK...... 17 ROCKLATAN...... 35 QUALAQUIN...... 15 ropinirole hcl...... 17 quazepam...... 31 ropinirole hcl er...... 17 quetiapine fumarate...... 18 ROSADAN...... 26, 27 quetiapine fumarate er...... 18 rosuvastatin calcium...... 13 QUILLICHEW ER...... 3 ROZLYTREK...... 17 QUILLIVANT XR...... 3 RUBRACA...... 17 quinapril hcl...... 14 rufinamide...... 9 quinapril-hydrochlorothiazide...... 14 rukobia...... 19 quinidine gluconate er...... 7 RUZURGI...... 15 quinidine sulfate...... 7 RYBELSUS...... 11 quinine sulfate...... 15 RYDAPT...... 17 QVAR REDIHALER...... 8 S R SAIZEN...... 28 rabeprazole sodium...... 40 salsalate...... 4 RAGWITEK...... 3 SAMSCA...... 28

Last Updated 12.1.2020 54 I n d e x I n d e x SANCUSO...... 12 sterile water for injection...... 36 SANDIMMUNE...... 33 sterile water for irrigation...... 33 SAPHRIS...... 18 STIMATE...... 28 sapropterin dihydrochloride...... 28 STIOLTO RESPIMAT...... 8 SAVELLA...... 38 STIVARGA...... 17 SAVELLA TITRATION PACK...... 38 STRENSIQ...... 28 scopolamine...... 12 STRIBILD...... 19 selegiline hcl...... 17 STRIVERDI RESPIMAT...... 8 selenium sulfide...... 27 SUCRAID...... 27 SELZENTRY...... 19 sucralfate...... 40 se-natal 19...... 34 sulconazole nitrate...... 27 SEREVENT DISKUS...... 8 sulfacetamide sodium...... 27, 35 SEROSTIM...... 28 sulfacetamide sodium (acne)...... 27 sertraline hcl...... 10 sulfacetamide sodium-sulfur...... 27 sevelamer carbonate...... 29 sulfacetamide-prednisolone...... 35 sevelamer hcl...... 29 sulfacetamide-sulfur in urea...... 27 sf...... 33 sulfadiazine...... 39 sf 5000 plus...... 33 sulfamethoxazole-trimethoprim...... 15 SHAROBEL...... 23 SULFAMYLON...... 27 SIGNIFOR...... 28 sulfasalazine...... 29 SIKLOS...... 30 sulindac...... 4 sildenafil citrate...... 21 SUMADAN WASH...... 27 SILIQ...... 27 sumatriptan...... 32 silodosin...... 30 sumatriptan succinate...... 32 SILVADENE...... 27 sumatriptan succinate refill...... 32 silver sulfadiazine...... 27 SUMAXIN...... 27 SIMBRINZA...... 35 SUNOSI...... 3 SIMPONI...... 4 SUPRAX...... 21 simvastatin...... 13 SUPREP BOWEL PREP KIT...... 31 sirolimus...... 33 SUTENT...... 17 SIRTURO...... 15 SYEDA...... 23 SIVEXTRO...... 15 SYMBICORT...... 8 SKLICE...... 27 SYMDEKO...... 39 SKYRIZI (150 MG DOSE)...... 27 SYMJEPI...... 41 SLYND...... 23 SYMLINPEN 120...... 12 sodium chloride...... 24 SYMLINPEN 60...... 12 sodium fluoride...... 32 SYMTUZA...... 19 sodium phenylbutyrate...... 28 SYNALAR...... 27 sodium polystyrene sulfonate...... 33 SYNALAR (OINTMENT)...... 27 sofosbuvir-velpatasvir...... 19 SYNAREL...... 28 SOLIA...... 23 SYNDROS...... 12 solifenacin succinate...... 41 SYNJARDY...... 12 SOLIQUA...... 11 SYNJARDY XR...... 12 SOLTAMOX...... 17 SYNRIBO...... 17 SOLU-CORTEF...... 24 SYNTHROID...... 40 SOMAVERT...... 28 T SOOLANTRA...... 27 SORINE...... 20 TABLOID...... 17 sotalol hcl...... 20 TABRECTA...... 17 sotalol hcl (af)...... 20 tacrolimus...... 27, 33 SOTYLIZE...... 20 tadalafil...... 21 SOVALDI...... 19 tadalafil (pah)...... 21 spinosad...... 27 TAFINLAR...... 17 SPIRIVA HANDIHALER...... 8 TAGRISSO...... 17 SPIRIVA RESPIMAT...... 8 TAKHZYRO...... 30 spironolactone...... 28 TALICIA...... 40 spironolactone-hctz...... 28 TALTZ...... 27 SPRINTEC 28...... 23 TALZENNA...... 17 SPRITAM...... 9 tamoxifen citrate...... 17 SPRIX...... 4 tamsulosin hcl...... 30 SPRYCEL...... 17 TARGRETIN...... 27 SRONYX...... 23 TARINA FE 1/20...... 23 SSD...... 27 TASIGNA...... 17 SSKI...... 24 tavaborole...... 27 stavudine...... 19 TAVALISSE...... 30

Last Updated 12.1.2020 55 I n d e x I n d e x TAZORAC...... 27 tramadol-acetaminophen...... 6 TAZTIA XT...... 20 trandolapril...... 14 TAZVERIK...... 17 trandolapril-verapamil hcl er...... 14 TEGSEDI...... 38 tranexamic acid...... 31 TEKTURNA HCT...... 14 tranylcypromine sulfate...... 10 telmisartan...... 14 travoprost (bak free)...... 36 telmisartan-amlodipine...... 14 trazodone hcl...... 10 telmisartan-hctz...... 14 TRECATOR...... 15 temazepam...... 31 TREMFYA...... 27 temozolomide...... 17 TRESIBA...... 12 TENCON...... 4 TRESIBA FLEXTOUCH...... 12 tenofovir disoproxil fumarate...... 19 tretinoin...... 17, 27 terazosin hcl...... 14 tretinoin (emollient)...... 27 terbinafine hcl...... 13 tretinoin microsphere...... 27 terbutaline sulfate...... 8 tretinoin microsphere pump...... 27 terconazole...... 41 TREXALL...... 17 teriparatide (recombinant)...... 28 triamcinolone acetonide...... 27, 33, 34 testosterone...... 6 triamterene-hctz...... 28 testosterone cypionate...... 6 triazolam...... 31 testosterone enanthate...... 6 trientine hcl...... 33 tetrabenazine...... 38 TRI-ESTARYLLA...... 23 tetracycline hcl...... 40 trifluoperazine hcl...... 18 THALOMID...... 33 trifluridine...... 36 THEO-24...... 8 trihexyphenidyl hcl...... 17 theophylline...... 8 TRIJARDY XR...... 12 theophylline er...... 8 TRIKAFTA...... 39 THIOLA...... 30 TRI-LEGEST FE...... 23 THIOLA EC...... 30 TRI-LINYAH...... 23 thioridazine hcl...... 18 TRI-LO-ESTARYLLA...... 23 thiothixene...... 18 TRI-LO-MARZIA...... 23 thrivite 19...... 34 TRI-LO-SPRINTEC...... 23 tiagabine hcl...... 9 trimethobenzamide hcl...... 12 TIAZAC...... 20 trimethoprim...... 15 TIBSOVO...... 17 trimipramine maleate...... 10 TIGLUTIK...... 34 TRINESSA (28)...... 23 TILIA FE...... 23 TRINTELLIX...... 10 timolol maleate...... 20, 35 TRI-PREVIFEM...... 23 TIMOPTIC OCUDOSE...... 36 TRI-SPRINTEC...... 23 tinidazole...... 15 TRIUMEQ...... 19 TIVICAY...... 19 TRIVORA (28)...... 23 TIVICAY PD...... 19 TROKENDI XR...... 9 tizanidine hcl...... 34 tronvite...... 34 TOBI...... 3 tropicamide...... 36 TOBI PODHALER...... 3 trospium chloride...... 41 TOBRADEX ST...... 36 trospium chloride er...... 41 tobramycin...... 3, 36 TRULICITY...... 12 tobramycin-dexamethasone...... 36 TRUVADA...... 19 TOLAK...... 27 TUKYSA...... 17 tolmetin sodium...... 4 TURALIO...... 17 tolterodine tartrate...... 41 TUSSICAPS...... 24 tolterodine tartrate er...... 41 TYBOST...... 19 tolvaptan...... 28 TYDEMY...... 23 TOPICORT...... 27 TYMLOS...... 28 topiramate...... 9 U topiramate er...... 9 toremifene citrate...... 17 UBRELVY...... 32 torsemide...... 28 UDAMIN SP...... 34 TOUJEO MAX SOLOSTAR...... 12 UDENYCA...... 30 TOUJEO SOLOSTAR...... 12 UNITHROID...... 40 TOVIAZ...... 41 UPNEEQ...... 36 TRACLEER...... 21 UPTRAVI...... 21 TRADJENTA...... 12 urea...... 27 tramadol hcl...... 6 urea hydrating...... 27 tramadol hcl er...... 6 URIBEL...... 15 tramadol hcl er (biphasic)...... 6 uroav-b...... 15

Last Updated 12.1.2020 56 I n d e x I n d e x uro-mp...... 15 VYVANSE...... 3 ursodiol...... 29 VYZULTA...... 36 V W valacyclovir hcl...... 19 WAKIX...... 3 VALCHLOR...... 27 warfarin sodium...... 9 valganciclovir hcl...... 19 WELCHOL...... 13 VALIUM...... 7 WERA...... 23 valproic acid...... 9 WESTHROID...... 40 valsartan...... 14 WIXELA INHUB...... 8 valsartan-hydrochlorothiazide...... 14 WP THYROID...... 40 VALTOCO 10 MG DOSE...... 9 WYMZYA FE...... 23 VALTOCO 15 MG DOSE...... 9 X VALTOCO 20 MG DOSE...... 9 VALTOCO 5 MG DOSE...... 9 XADAGO...... 17 vancomycin hcl...... 15 XALKORI...... 17 VANOXIDE-HC...... 27 XARELTO...... 9 VARUBI (180 MG DOSE)...... 12 XARELTO STARTER PACK...... 9 VASCEPA...... 13 XATMEP...... 17 VASERETIC...... 14 XCOPRI...... 9 VECAMYL...... 14 XCOPRI (250 MG DAILY DOSE)...... 9 VELIVET...... 23 XCOPRI (350 MG DAILY DOSE)...... 9 VELPHORO...... 29 XELJANZ...... 4 VELTASSA...... 33 XELJANZ XR...... 4 VEMLIDY...... 19 XERAC AC...... 27 VENCLEXTA...... 17 XERMELO...... 29 VENCLEXTA STARTING PACK...... 17 XIFAXAN...... 15 venlafaxine hcl...... 10 XIIDRA...... 36 venlafaxine hcl er...... 10 XOFLUZA (40 MG DOSE)...... 19 VENTAVIS...... 21 XOFLUZA (80 MG DOSE)...... 19 VENTOLIN HFA...... 8 XOLEGEL...... 27 verapamil hcl...... 20 XOSPATA...... 17 verapamil hcl er...... 20 XTAMPZA ER...... 6 VERZENIO...... 17 XTANDI...... 17 V-GO 20...... 31 XULANE...... 23 V-GO 30...... 31 XURIDEN...... 28 V-GO 40...... 31 xvite...... 34 VIBERZI...... 29 XYREM...... 38 VICTOZA...... 12 Y vigabatrin...... 9 YUPELRI...... 8 VIGADRONE...... 9 YUVAFEM...... 41 VIIBRYD...... 10 Z VIMPAT...... 9 viorele...... 23 ZADITOR...... 36 VIRACEPT...... 19 zafirlukast...... 8 VIREAD...... 19 zaleplon...... 31 virt-phos 250 neutral...... 32 ZARAH...... 23 VISTOGARD...... 12 ZARXIO...... 30 VITAFOL-OB+DHA...... 34 ZEBUTAL...... 4 VITAFOL-ONE...... 34 ZEJULA...... 17 vitamin d (ergocalciferol)...... 41 ZELAPAR...... 17 vitasure...... 34 ZELBORAF...... 17 VITRAKVI...... 17 ZENATANE...... 27 VIZIMPRO...... 17 ZENPEP...... 27 vol-plus...... 34 ZEPOSIA...... 38 vol-tab rx...... 34 ZEPOSIA 7-DAY STARTER PACK...... 38 voriconazole...... 13 ZEPOSIA STARTER KIT...... 38 VOSEVI...... 19 zidovudine...... 19 VOTRIENT...... 17 zileuton er...... 8 vp-vite rx...... 34 ZIOPTAN...... 36 VRAYLAR...... 18 ziprasidone hcl...... 18 VUMERITY...... 38 ZIRGAN...... 36 VYFEMLA...... 23 ZITHRANOL...... 27 VYNDAMAX...... 21 ZOLINZA...... 17 VYNDAQEL...... 21 zolmitriptan...... 32

Last Updated 12.1.2020 57 I n d e x zolpidem tartrate...... 31 zolpidem tartrate er...... 31 ZOMIG...... 32 ZONEGRAN...... 9 zonisamide...... 9 ZONTIVITY...... 30 ZORBTIVE...... 28 ZORTRESS...... 33 ZOVIA 1/35E (28)...... 23 ZUBSOLV...... 6 ZUPLENZ...... 12 ZYDELIG...... 17 ZYFLO...... 8 ZYKADIA...... 17

Last Updated 12.1.2020 58 Language Assistance Services

English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-878-9172 (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-878-9172 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-878-9172（TTY：711）。 Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-878-9172 (телетайп: 711). French ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Creole Rele 1-888-878-9172 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-878-9172 (TTY: 711) 번으로 전화해 주십시오. Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-878-9172 (TTY: 711). ﺗوﺟﮫ: اﮔر ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺗﮕو ﻣﯽ ﮐﻧﯾد، ﺗﺳﮭﯾﻼت زﺑﺎﻧﯽ ﺑﺻورت راﯾﮕﺎن ﺑرای ﺷﻣﺎ ﻓراھم ﻣﯽ ﺑﺎﺷد. ﺑﺎ Farsi (TTY: 711) 9172-878-888-1 ﺗﻣﺎس ﺑﮕﯾرﯾد. Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-878-9172 (TTY: 711). Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-888-878-9172 (TTY: 711). . ب ال مجا ن ل ك ت توا ف ر ا ل ل غو ي ة ال م سا عدة خد ما ت ف إن ال ل غة ، اذ ك ر ت تحدث ك نت إذا : م لحوظة Arabic .(711 :و ال ب كم ال صم ها ت ف ر ق م) 9172-878-888-1 ب ر ا ت ص ل French ATTENTION : Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-888-878-9172 (TTY : 711). Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-878-9172 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-878-9172 (TTY: 711). Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-888-878-9172（TTY: 711）まで、お電話にてご連絡ください。 German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-878-9172 (TTY: 711).

Discrimination is Against the Law

Pharmacy Benefit Dimensions is a subsidiary of Independent Health and complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Pharmacy Benefit Dimensions does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Pharmacy Benefit Dimensions: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, contact Pharmacy Benefit Dimensions’ Member Services Department.

If you believe that Pharmacy Benefit Dimensions has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Pharmacy Benefit Dimensions’ Member Services Department, P.O. Box 1642, Buffalo, NY 14231, (888)-878-9172, TTY users call 711, fax (716) 250-7163 , [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Pharmacy Benefit Dimensions’ Member Services Department is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.