Cigna Legacy (Standard) 4-Tier Prescription Drug List

CIGNA LEGACY (STANDARD) 4-TIER PRESCRIPTION DRUG LIST

For California Health Maintenance Organization, Point of Service, Network, Preferred Provider Organization, Exclusive Provider Organization, Open Access Plus, Open Access Plus In Network, LocalPlus, LocalPlus IN

Coverage as of July 1, 2021

View your drug list online: View your coverage info online: Cigna.com/druglist myCigna® App or myCigna.com

24/7 Customer Service: 800.Cigna24 (800.244.6224)

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 938074 c CA Legacy (Standard) 4-Tier SPEC 06/21 Last updated: 06/01/2021. This drug list is subject to change and all prior versions are no longer in effect. What’s inside?

Information about the drug list 3

Frequently asked questions (FAQs) 3

Words you may need to know 9

About this drug list 10

How to read this drug list 11

How to find your medication 14

List of prescription medications 17

Exclusions and limitations for coverage 173

Index of medications 174

View the drug list online

This document was last updated 06/01/2021.* You can go online to see the current list of medications your plan covers.

myCigna® App and/or myCigna.com. Click on the “Find Care & Costs” tab and select “Price a Medication.” Then type in your medication name to see how it’s covered.

Cigna.com/PDL. Scroll down until you see the section for the Cigna Legacy (Standard) Prescription Drug List. Click on the pdf of the California 4 Tier – all specialty medications covered on Tier 4 (DHMC).

Questions? › Click to chat: myCigna website, Monday–Friday, 9:00 am–8:00 pm EST. › By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.

* Drug list created: originally created 01/01/2004 Last updated: 06/01/2021, for changes Next planned update: 09/15/2021, for starting 07/01/2021 changes starting 01/01/2022 2 Information about the drug list

Frequently asked questions (FAQs) Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions.

Q. How often is the drug list updated? How do I know (P&T) Committee, which is a group of practicing if my medication coverage changed? doctors and pharmacists, most of whom work outside of Cigna. The group meets regularly to A. Cigna reviews and updates the prescription drug list every month. We make changes for many reasons – review medical evidence and information provided like when new medications become available or are by federal agencies, drug manufacturers, medical no longer available, or when medication prices professional associations, national organizations and change. We try to give you many options to choose peer-reviewed journals medications about the safety from to treat your health condition. These changes and effectiveness of medications that are newly may include:1,2 approved by the FDA and medications already on the market. The Cigna Pharmacy Management® › Moving a medication to a lower cost tier. This Business Decision Team then looks at the results of can happen at any time during the year. the P&T Committee’s clinical review, as well as the › Moving a brand medication to a higher cost tier medication’s overall value and other factors before when a generic becomes available. This can adding it to, or removing it from, the drug list. happen at any time during the year. Q. Why do certain medications need approval › Moving a medication to a higher cost tier and/or before my plan will cover them? no longer covering a medication. This typically A. The review process helps to make sure you’re happens twice a year on January 1st and July 1st. receiving coverage for the right medication, at › Adding extra coverage requirements to the right cost, in the right amount and for the a medication. right situation. When we make a change that affects the coverage Q. How do I know if I’m taking a medication that of a medication you’re taking, we let you know needs approval? before it happens. This way, you have time to talk A. Log in to the myCigna App or myCigna.com, or with your doctor about your options. check your plan materials, to learn more about Q. Why doesn’t my plan cover certain medications? how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your A. To help lower your overall health care costs, your medication needs approval before your plan plan doesn’t cover certain high-cost brand will cover it. If it has a (QL) next to it, you may medications because they have lower-cost, covered need approval depending on the amount you’re alternatives which are used to treat the same filling. If it has (AGE) next to it, you may need condition. Meaning, the alternative works the same approval depending on the covered age range or similar to the non-covered medication. If you’re for the medication. taking a medication that your plan doesn’t cover and your doctor feels an alternative isn’t right Q. What types of medications typically need for you, he or she can ask Cigna to consider approval? approving coverage. A. Medications that: Your plan may also exclude certain medications or › May be unsafe when combined with other products from coverage. This is known as a “plan (or medications benefit) exclusion.” For example, your plan excludes medications that aren’t approved by the U.S. Food › Have lower-cost, equally effective alternatives and Drug Administration (FDA). With excluded available medications, there’s no option to receive coverage › Should only be used for certain health through Cigna’s coverage review process. conditions Q. How do you decide which medications to cover? › Are often misused or abused A. The Cigna Prescription Drug List is developed with the help of Cigna’s Pharmacy and Therapeutics

3 Q. What types of medications typically have doctor continues to prescribe it to treat your quantity limits? condition (as long as the medication is appropriately prescribed and is safe and effective in treating your A. Medications that: condition). › Are often taken in amounts larger than, or for longer than, may be appropriate Q. My plan doesn’t cover my medication. I need to take it because it’s medically necessary for my › Are often misused or abused treatment. How do I get approval (prior Q. What types of medications require Step Therapy? authorization) for my medication? A. The medications are used to treat many conditions, A. If your doctor feels that your medication is including, but not limited to: necessary for your treatment and an alternative isn’t right for you, he or she can ask Cigna to consider › ADD/ADHD › High cholesterol approving coverage of your medication. Ask your › Allergies › Osteoporosis doctor’s office to contact Cigna so we can start the › Bladder problems › Pain coverage review process. They know how the review process works and will take care of everything for Breathing problems Skin conditions › › you. In case the office asks, they can download a › Depression › Sleep disorders request form from Cigna’s provider portal at › High blood pressure cignaforhcp.com. Cigna will review information your doctor provides to make sure your medication Q. Why does my medication have an age meets coverage guidelines. If it does, you’ll be requirement? approved for coverage of the medication. If it A. Some medications are only considered clinically doesn’t meet guidelines, you and your doctor can appropriate if you’re within a certain age range. appeal the decision. We’ll send you information either way. Q. How do I get approval (prior authorization) for my medication? For non-urgent requests, Cigna will let you and your doctor know within 72 hours of the decision. If A. Ask your doctor’s office to contact Cigna so we can approved, coverage will be provided until the start the coverage review process. They know how prescription runs out (including refills). For urgent the review process works and will take care of requests based on exigent circumstances, Cigna will everything for you. In case the office asks, they can let you and your doctor know within 24 hours of the download a request form from Cigna’s provider decision. If approved, coverage will be provided for portal at cignaforhcp.com. Cigna will review the duration of the exigency. It’s important to know information your doctor provides to make sure your that when medications are approved, it’s typically medication meets coverage guidelines. If it does, for one year of coverage. If your medication is you’ll be approved for coverage of the medication. If approved for less time, it’s because there’s a clinical it doesn’t meet guidelines, you and your doctor can reason based on Cigna’s coverage guidelines for the appeal the decision. We’ll send you information medication and/or the reviewing doctor. either way. Q. My medication is part of the Step Therapy For non-urgent requests, Cigna will let you and your program. I don’t want to try an alternative. doctor know within 72 hours of the decision. If How do I get approval (prior authorization) for approved, coverage will be provided until the my medication? prescription runs out (including refills). For urgent requests based on exigent circumstances, Cigna will A. If you and your doctor feel an alternative medication let you and your doctor know within 24 hours of the won’t work for you, your doctor can ask Cigna to decision. If approved, coverage will be provided for consider approving coverage of your current the duration of the exigency. If Cigna doesn’t medication. Ask your doctor’s office to contact respond to a completed prior authorization Cigna so we can start the coverage review process. exception request within 72 hours of receiving a They know how the review process works and will non-urgent request and 24 hours of receiving a take care of everything for you. In case the office request based on exigent circumstances, the asks, they can download a request form from request will be considered approved and your plan Cigna’s provider portal at cignaforhcp.com. Cigna can’t deny coverage of the medication. Also, if will review information your doctor provides to you’ve already received approval from Cigna for make sure your medication meets coverage your plan to cover your medication, Cigna can’t limit guidelines. If it does, you’ll be approved for coverage or exclude coverage for that medication if your of the medication. If it doesn’t meet guidelines, you

4 and your doctor can appeal the decision. We’ll send Q. What happens if I try to fill a prescription that has you information either way. a quantity limit? For non-urgent requests, Cigna will let you and your A. Your pharmacist will only fill the amount your plan doctor know within 72 hours of the decision. If covers. If you want to fill more than what’s allowed, approved, coverage will be provided until the your doctor’s office will need to contact Cigna to prescription runs out (including refills). For urgent request approval for coverage. requests based on exigent circumstances, Cigna will Q. Are all of the medications on this drug list let you and your doctor know within 24 hours of the approved by the U.S. Food and Drug decision. If approved, coverage will be provided for Administration (FDA)? the duration of the exigency. If Cigna doesn’t respond to a completed prior authorization A. Yes. All medications are approved by the FDA. exception request within 72 hours of receiving a Q. Are medications newly approved by the FDA non-urgent request and 24 hours of receiving a covered on the drug list? request based on exigent circumstances, the A. Newly approved medications may not be covered request will be considered approved and your plan on your drug list for the first six months after they can’t deny coverage of the medication. receive approval from the U.S. Food and Drug Your Step Therapy rights under California State law: Administration (FDA). These include, but are not 1. A carrier may impose prior authorization limited to, medications, medical supplies and/or requirements on prescription drug benefits. devices covered under standard pharmacy benefit plans. We review all newly approved medications to 2. When there is more than one drug that is see if they should be covered – and if so, on what appropriate for the treatment of a medical tier. If your doctor feels a currently covered condition, a carrier may require step therapy. medication isn’t right for you, he or she can ask a. In circumstances where an insured is Cigna to consider approving coverage of the newly changing policies, the new policy shall not approved medication. require a repeat of step therapy when that Q. I see several medications on this drug list that can insured is already being treated for a be used to treat my condition. Will my doctor write medical condition by a prescription drug me a prescription for all of them? provided that the drug is appropriately prescribed and is considered safe and A. No. Just because a medication is listed on your effective. A new policy can impose a prior plan’s drug list doesn’t mean your doctor will write authorization requirement for the continued you a prescription for it. Your doctor will work with coverage of a prescription drug prescribed you to find the medication he or she feels is best for pursuant to step therapy imposed by the your specific treatment. former policy. A new policy must also allow Q. How can I find out how much I’ll pay for a a prescribing provider to prescribe another specific medication? drug covered by the new policy that is A. When you and your doctor are considering the right medically appropriate for the insured. medication for your treatment, knowing how much 3. A carrier shall provide coverage for the it costs, what lower-cost alternatives are available, medically necessary dosage and quantity of the and which pharmacies offer the best prices can help drug prescribed for the treatment of a medical you avoid surprises. Log in to the myCigna App or condition consistent with professionally myCigna.com and use the Price a Medication tool to recognized standards of practice. see how much your medication costs before you get Q. What happens if I try to fill a prescription that to the pharmacy counter – or, even before you leave 3 needs approval but I don’t get approval ahead your doctor’s office. of time? Q. How can I save money on my prescription A. When your pharmacist tries to fill your prescription, medications? he or she will see that the medication needs prior A. You may be able to save money by switching to a approval. Because you didn’t get approval ahead of medication that’s on a lower tier (ex. generic or time, your plan coverage won’t apply. Meaning, your preferred brand) or by filling a 90-day supply, if your plan won’t cover the cost of your medication. You plan allows. You should talk with your doctor to find can choose to pay its full cost out-of-pocket directly out if one of these options may work for you. to the pharmacy (the cost can’t be applied to your annual deductible or out-of-pocket maximum).

5 Q. Do generics work the same as brand-name Q. Can I fill my prescriptions by mail? medications? A. Yes, as long as your plan offers home delivery.5 A. Yes. A generic medication works in the same › Express Scripts Pharmacy is a convenient option way and provides the same clinical benefit as its when you’re taking a medication on a regular 4 brand-name version. Generic and brand-name basis to treat an ongoing health condition. It’s medications have the same active ingredients, simple and safe and saves you trips to the strength, dosage form, effectiveness, quality pharmacy. and safety. – Easily order, manage and track your Q. What are the differences between generic and medications on your phone or online brand-name medications? – Standard shipping at no extra cost6 A. The medications may look different. For example, generics may have a different shape, size or color – Automatic refills and refill reminders than the brand-name medication. They may also – Fill up to a 90-day supply at one time have a different flavor, contain different – Helpful pharmacists available 24/7 preservatives, come in different packaging and/or with different labeling and may expire at different – Flexible payment options times. Generics may look different than the brand Here are three easy ways to get started. name, but they’re just as safe and effective. 1. Go to my.cigna.com/choosehomedelivery. Generics typically cost much less than brand-name Follow the online instructions for how to move medications – in some cases, up to 85% less.4 Just your prescription(s). because generics cost less than brands, it doesn’t 2. Call your doctor’s office.Ask them to send a mean they’re lower-quality medications. 90-day prescription (with refills) electronically Q. How do I know which pharmacies are in to Express Scripts Home Delivery. my network? 3. Call Express Scripts Pharmacy at A. There are thousands of retail pharmacies in your 800.835.3784. They’ll contact your doctor’s plan’s network. They include local pharmacies, office to help transfer your prescription. Have grocery stores, retail chains and wholesale your Cigna ID card, doctor’s contact information warehouse stores – all places where you may and medication name(s) ready when you call. already shop. And some stores are open 24-hours. If you’re taking a specialty medication to treat a To find an in-network pharmacy near you, log in to › complex medical condition, Accredo’s team of the myCigna App or myCigna.com. Then click on specialty trained pharmacists and nurses can “Find Care & Costs” to start searching. help. They’ll fill and ship your specialty Q. My pharmacy isn’t in my plan’s network. Can I medication to your home (or location of your continue to fill my prescriptions there? choice).7 They’ll also provide you with the A. To receive in-network coverage under your plan, personalized care and support you need to you’ll need to switch to a pharmacy in your plan’s manage your therapy – at no extra cost. network. If your plan offers out-of-network – Easily manage and track your medications coverage, you’ll pay out-of-network costs to fill a on your phone or online prescription there. – Fast shipping, at no extra cost Q. Do I have to use home delivery to fill my – Easy refills and free reminders prescription? – 24/7 access to specialty-trained pharmacists A. It depends on your plan. Some plans require you to and nurses fill your maintenance medication through Express Scripts® Pharmacy, our home delivery pharmacy, – Personalized care services like training on and/or specialty medication through Accredo, a how to administer your medication Cigna specialty pharmacy, for it to be covered. Log in – Help with applying for third-party copay to the myCigna App or myCigna.com, or check your assistance programs and other options plan materials, to find out what your plan requires.

6 To get started using Accredo, call 877.826.7657, information. Representatives are available Monday– Monday–Friday, 7:00 am–10:00 pm CST and Friday, 7:00 am–10:00 pm CST and on Saturdays, Saturdays, 7:00 am–4:00 pm CST. Be sure to call 7:00 am–4:00 pm CST. Accredo about two weeks before your next refill Q. How do I fill my prescription? so they have time to get a new prescription from your doctor’s office. To learn more about A. First, you’ll need to get a prescription from your Accredo, go to Cigna.com/specialty. doctor. Then, your doctor can either: Q. I take a medication every day to treat diabetes. 1. Send it electronically to the in-network My plan requires me to fill my medication pharmacy of your choice or to Express 5 through Express Scripts Pharmacy. How do Scripts Pharmacy. I get started? 2. Give you a paper prescription. You can bring it A. Some plans allow one or more fills at a retail to the in-network pharmacy of your choice or 5 pharmacy before switching to home delivery. Check mail it to Express Scripts Pharmacy. your plan materials to find out if your plan allows Q. How can I get help with my specialty medication? retail fills. A. Managing a complex condition isn’t easy. As part of Here are three easy ways to get started. your Cigna-administered pharmacy benefits, you 5 1. Go to my.cigna.com/choosehomedelivery. have access to Accredo. Accredo’s team of Follow the online instructions for how to move specialty-trained pharmacists and nurses will your prescription(s). provide you with the personalized care and support you need to manage your complex medical 2. Call your doctor’s office.Ask them to send a condition. They’ll help you work through side 90-day prescription (with refills) electronically effects, check in with you and your doctor to see to Express Scripts Home Delivery. how your therapy’s going, help you get your 3. Call Express Scripts Pharmacy at medications approved for coverage, and more. They’ll contact your doctor’s 800.835.3784. To get started using Accredo, call 877.826.7657, office to help transfer your prescription. Have Monday–Friday, 7:00 am–10:00 pm CST and your Cigna ID card, doctor’s contact information Saturdays, 7:00 am–4:00 pm CST. Be sure to call and medication name(s) ready when you call. Accredo about two weeks before your next refill so Q. I take a specialty medication to treat my multiple they have time to get a new prescription from your sclerosis. My plan requires me to fill my medication doctor’s office. To learn more about Accredo, go to through Accredo. How do I get started? Cigna.com/specialty. A. Some plans allow one or more fills at a retail Q. Where can I find more information about my pharmacy before switching to Accredo. Check pharmacy benefits? your plan materials to find out if your plan allows A. The best place to start is with the myCigna App or retail fills. myCigna.com. It’s your “go-to” place for everything To get started using Accredo, call 877.826.7657, you need to know about your plan’s coverage. Monday–Friday, 7:00 am–10:00 pm CST and – See which medications your plan covers Saturdays, 7:00 am–4:00 pm CST. Be sure to call 3 Accredo about two weeks before your next refill so – Compare your medication costs they have time to get a new prescription from your – Easily switch your prescription from a retail doctor’s office. To learn more about Accredo, go to pharmacy to home delivery . Cigna.com/specialty – Manage your home delivery medications5 Q. I take a specialty medication that can only be filled – Find an in-network retail pharmacy at certain pharmacies in the United States. How do I fill my prescription? – View your plan information (claims, coverage details, and more) A. Talk with your doctor. He or she should be able to tell you which in-network pharmacies can fill your – Ask a pharmacist a question prescription. Once you find a pharmacy, ask your Q. How can I find out my cost-share for each tier of doctor to send them your prescription. the drug list? You may also be able to use Accredo, to fill your A. Covered medications are divided into tiers (or prescription.5 Accredo has access to most specialty cost-share levels). Typically, the higher the tier, the medications. Call 877.826.7657 for more higher the price you’ll pay to fill the prescription.

7 Here are three places you can go to find out how › For plans with a split deductible [including much you’ll pay for your medication based on the Health Reimbursements Accounts (HRAs) with a tier it’s listed in, including the maximum cost-share split deductible]: These medications will be amount allowed: covered at 100%, or no cost-share ($0) to you. 1. Check your Cigna ID card. It lists your cost-share Q. Which medications are covered under the health for Tier 1, Tier 2, Tier 3, and Tier 4 medications. care reform law? 2. Log in to the myCigna App or myCigna.com A. The Patient Protection and Affordable Care Act to view your pharmacy coverage information. (PPACA), commonly referred to as “health care You can also use the “Price a Medication” tool reform,” was signed into law on March 23, 2010. to find out how much your medication may Under this law, certain preventive medications cost you at the different pharmacies in (including some over-the-counter products) may your plan’s network.3 be available to you at no cost-share ($0), depending 3. Check your Summary of Benefits on your plan. Log in to the myCigna App or coverage document. myCigna.com, or check your plan materials, to learn more about how your plan covers preventive Q. What’s the difference between medications medications. You can also view the PPACA No covered under the pharmacy benefit and Cost-Share Preventive Medications drug list at medical benefit? Cigna.com/druglist. A. Some medications are covered under the pharmacy For more information about health care reform, benefit, some are covered under the medical go to www.informedonreform.com or Cigna.com. benefit, and others are covered under both benefits. Typically, medications that are injected or infused Q. How are medications, devices and FDA-approved are covered under the medical benefit. These are diabetic, contraceptive and federally-mandated given to you at a doctor’s office, an infusion center products covered under the pharmacy benefit? or at home. Typically, medications that you take A. Here is how these products are covered under the yourself and can be filled at a retail pharmacy or pharmacy benefit: through home delivery are covered under the › Preventive care medications and products pharmacy benefit. Check your medical summary of covered under the Patient Protection and benefits coverage to learn more about how your Affordable Care Act (PPACA), also known plan covers these medications. as “health care reform:” Q. I take an oral cancer medication. How much will it – Contraceptives: Covered at 100%, or no cost me to fill? cost-share ($0) to you. Certain prescription contraceptives are available at their A. On January 1, 2015, California passed a bill limiting applicable cost-share. the cost-share for oral chemotherapy medications. This means that if you have both your medical and – Tobacco cessation products: Up to two (2) pharmacy benefits through Cigna, here’s how 90-day courses of treatment per plan year certain oral cancer medications are covered: are covered at 100%, or no cost-share ($0) to you. Certain prescription tobacco › For copay plans: These medications will be cessation products are available at their covered at 100%, or no cost-share ($0) to you. applicable cost-share. › For high deductible health plans (HDHPs) that – Certain vitamins: Covered at 100%, or no include a Health Savings Account (HSA) or cost-share ($0) to you. All other prescription qualified HDHPs: You’ll pay your plan deductible vitamins are available at their applicable first. After that, these medications will be cost-share and deductible (if applicable). covered at 100%, or no cost-share ($0) to you. Certain over-the-counter (OTC) products: If you This is because of a federal HSA requirement. › have a prescription from your doctor, these are › For plans with a combined deductible [including covered at 100%, or no cost-share ($0) to Health Reimbursements Accounts (HRAs) with a you. All other OTC products are excluded combined deductible]: You’ll pay your plan from coverage. deductible first. After that, these medications Oral fertility medications: Covered at their will be covered at 100%, or no cost-share ($0) › applicable tier cost-share. For some plans, to you. injectable fertility medications are covered under the medical benefit.

8 › Generic preventive care medications: Covered › Vaccines: Vaccines are now covered under the at 100%, or no cost-share ($0) to you before you pharmacy benefit. Not all plans cover vaccines meet your deductible. You’ll pay your deductible in the same way. Log in to the myCigna App or and applicable cost-share to fill a preferred myCigna.com, or check your plan materials, to brand and/or non-preferred brand preventive find out how your specific plan covers them. care medication. › Compounded medications: If the medication is › Diabetic supplies: Covered at their applicable more than $200, you’ll need approval from cost-share. Cigna before your plan will cover them (prior authorization). › Growth Hormones: Need approval from Cigna before your plan will cover them (prior authorization). If you receive approval for coverage, you’ll pay your applicable tier cost- share to fill the medication.

Words you may need to know › Brand name drug: A drug that is marketed under › Formulary or prescription drug list: The list of drugs a proprietary, trademark-protected name. A brand that is covered by your health insurance policy under name drug is listed in this formulary in all the prescription drug benefit of the policy. CAPITAL letters. › Generic drug: A drug that is the same as its brand › Coinsurance: A percentage of the cost of a covered name drug equivalent in dosage, strength, effect, health care benefit that you pay after you have paid how it is taken, quality, safety, and intended use. A the deductible, if a deductible applies to the health generic drug is listed in this formulary in italicized care benefit. lowercase letters. › Copayment: A fixed dollar amount that you pay for › Medically Necessary: Health care benefits needed to a covered health care benefit after you have paid diagnose, treat, or prevent a medical condition or its the deductible, if a deductible applies to the health symptoms and that meet accepted standards of care benefit. medicine. Health insurance usually does not cover health care benefits that are not medically necessary. › Deductible: The amount you pay for covered health care benefits that are subject to the deductible › Non-formulary drug: A prescription drug that is not before your health insurer begins to pay. If your listed on this formulary. health insurance policy has a deductible, it may have › Out-of-pocket costs: Your expenses for health care either one deductible or separate deductibles for benefits that aren’t reimbursed by your health medical benefits and prescription drug benefits. insurance. Out-of-pocket costs include deductibles, After you pay your deductible, you usually pay only copayments, and coinsurance for covered health a copayment or coinsurance for covered health care care benefits, plus all costs for health care benefits benefits. Your insurance company pays the rest. that are not covered. › Drug tier: A group of prescription drugs that › Prescribing provider: A health care provider who correspond to a specified cost sharing tier in your can write a prescription for a drug to diagnose, health insurance policy. The drug tier in which a treat, or prevent a medical condition. prescription drug is placed determines your portion › Prescription: An oral, written, or electronic order of the cost for the drug. from a prescribing provider authorizing a prescription › Exception request: A request for coverage of a drug to be provided to a specific individual. non-formulary drug. If you, your designee, or your › Prescription drug: A drug that by law requires a prescribing health care provider submits a request prescription. for coverage of a non-formulary drug, your insurer Prior Authorization: A decision by your health must cover the non-formulary drug when it is › insurer that a health care benefit is medically medically necessary for you to take the drug. necessary for you. If a prescription drug is subject › Exigent circumstances: When you are suffering from to prior authorization in this formulary, your a medical condition that may seriously jeopardize prescribing provider must request approval from your life, health, or ability to regain maximum your health insurer to cover the drug before you fill function, or when you are undergoing a current your prescription. Your health insurer must grant a course of treatment using a non-formulary drug. prior authorization request when it is medically necessary for you to take the drug. 9 › Step Therapy: A specific sequence in which length of time. For example, 30mg per day for prescription drugs for a particular medical condition 30 days. Quantity limits help to make sure you’re must be tried. If a drug is subject to step therapy in receiving coverage for the right medication, in the this formulary, you may have to try one or more right amount, and for the right situation. Your plan other drugs before your health insurance policy will will only cover a larger amount if your doctor cover that drug for your medical condition. If your requests and receives approval from Cigna. prescribing provider submits a request for an › Age Requirements: For certain medications, you exception to the step therapy requirement, your must be within a specific age range for your plan to health insurer must grant the request when it is cover them. This is because some medications aren’t medically necessary for you to take the drug. considered clinically appropriate for individuals who › Quantity Limits: For some medications, your plan aren’t within that age range. will only cover up to a certain amount over a certain

About this drug list This is a list of the most commonly prescribed medications covered on the Cigna Legacy (Standard) 4-Tier Prescription Drug List as of July 1, 2021.1,2 Medications are listed alphabetically by their generic and brand names within their therapeutic category and class. This drug list is updated often so it isn’t a complete list of the medications your plan covers. Also, your specific plan may not cover all of these medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see all of the medications your plan covers.

10 How to read this drug list Medications are listed alphabetically by their generic and brand names within their therapeutic category and class.* You can also find your medication using the index at the end of this drug list. › The generic version of a brand-name medication is listed in parentheses and all lowercase italicized letters next to the brand-name medication. › If a generic equivalent for a brand-name medication is both available and covered, the generic will be listed separately from the brand-name medication in all lowercase italicized letters. › If a generic equivalent for a brand-name medication isn’t available on the market or isn’t covered, the medication won’t be listed separately by its generic version. › If a generic medication is marketed under a proprietary, trademark-protected brand name, the brand-name medication will be listed after the generic version in parentheses and regular typeface with the first letter of each word capitalized. For example: quinapril hcl (Accupril). * Medications are listed in the therapeutic category and class provided by First Databank.

Tiers Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.

Tier Typically generic medications (lowest-cost medications). Generics have $ 1 the same strength and active ingredients as the brand name – but often cost much less.1 Tier Typically preferred brand medications (medium-cost medications). $$ 2 These medications usually cost more than a generic, but less than a non-preferred brand. Tier Typically non-preferred brand medications (higher-cost medications). These $$$ 3 medications usually have generic versions and/or one or more preferred brand alternative. You’ll usually pay more for non-preferred medications. Tier Specialty medications (highest-cost medications). These oral and injectable $$$$ 4 medications are used to treat complex medical conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis.

11 Coverage requirements and limits In this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to them.* Here’s what they mean.

Prior Authorization:* Certain medications need approval from Cigna before your plan PA will cover them. These medications have a PA next to them. Your plan won’t cover these medications unless your doctor requests, and receives, approval from Cigna.

Quantity Limit:* Some medications have a quantity limit. This means your plan will only cover up to a certain amount over a certain length of time. These medications have a QL QL next to them. Your plan will only cover a larger amount if your doctor requests, and receives, approval from Cigna.

Age Requirement:* Certain medications will only be covered if you’re within a specific age range. These medications have AGE next to them. If you’re not within the allowed AGE age range, your plan will only cover the medication if your doctor requests, and receives, approval from Cigna.

Step Therapy:* Certain high-cost medications aren’t covered until you try one or more ST lower-cost alternatives first.** These medications have aST next to them. You have many covered options to choose from, and they’re used to treat the same condition.

Specialty medications are used to treat complex medical conditions. In this drug list, specialty medications have an asterisk (*) next to them. Some plans cover these medications on a specialty tier, limit coverage to a 30-day supply and/or require you to SP use a preferred specialty pharmacy to receive coverage. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about how your plan covers these medications.

Home delivery medications: Some plans only cover certain medications if they’re filled through home delivery. Depending on your plan, you may be able to get coverage for one, HD two or three fills at an in-network retail pharmacy before switching to home delivery. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan requires home delivery.

No cost-share preventive medications: Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to cover certain preventive medications PPACA and products at 100%, or no cost-share ($0) to you. In this drug list, these medications have PPACA next to them. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers these medications.

Oral cancer medications subject to cost-share limits: State law in California limits the cost- CSL share (or amount you pay out-of-pocket) for certain oral chemotherapy medications.

* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes these specific coverage requirements.

12 Use the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the Legacy (Standard) 4-Tier Prescription Drug List. Therapeutic ANALGESICS (Pain Relief And Inflammatory Disease) drug category ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT and class Prescription drug name Drug tier Coverage requirements and limits describes the condition the butalbital/acetaminophen T1 medication is ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB. used to treat butalb-aspirin-caffe 50-325-40 T1 QL (6 tabs/day) butalbital-asa-caffeine cap(Fiorinal) T1 QL (6 caps/day) Coverage FIORINAL (butalbital-aspirin-caffeine) T3 QL (6 caps/day) requirements lets ANALGESIC, NON-SALICYLATE, BARBITURATE, XANTHINE COMB and limits you know if your butalb/acetaminophen/caffeine T3 plan has extra butalb/acetaminophen/caffeine(Esgic) T3 QL (6 caps/day) requirements before it will butalb/acetaminophen/caffeine T1 QL (6 caps/day) cover the (Fioricet) medication butalb-acetamin-caff 50-300-40 T1 QL (6 caps/day) (Fioricet) butalb-acetamin-caff 50-325-40 T1 QL (6 tabs/day) Drug tier gives (Esgic) you an idea of ESGIC 50-325-40 MG TABLET how much you T3 QL (6 tabs/day) (butalbital-acetaminophen-caffe) may pay for a ESGIC CAPSULE (zebutal) T3 QL (6 caps/day) medication FIORICET (phrenilin forte) T1 QL (6 caps/day)

ANALGESIC/ANTIPYRETICS, SALICYLATES Prescription choline salicyl/mag salicylate T1 HD drug name is the name of the diflunisal T1 HD medication ANTIMIGRAINE PREPARATIONS AIMOVIG AUTOINJECTOR T2 PA Medications are AJOVY AUTOINJECTOR T2 PA listed in AJOVY SYRINGE T2 PA alphabetical within almotriptan malate T1 QL (12 tabs/30 days) order each column CAFERGOT (ergotamine-caffeine) T3 QL (40 tabs/28 days) dihydroergotamine 1 mg/ml amp T1 QL (10 amps/30 days) Brand name dihydroergotamine 4 mg/ml spry T1 QL (1 kit/28 days) medications are eletriptan hydrobromide T1 QL (6 tabs/30 days) in all CAPITAL EMGALITY PEN T2 PA letters EMGALITY SYRINGE T2 PA

ergotamine tartrate/caffeine T1 Generic ergotamine tartrate/caffeine(Cafergot) T1 QL (40 tabs/28 days) medications are in lowercase frovatriptan succinate T1 QL (18 tabs/30 days) italics This chart is just a sample. It may not show how these medications are actually covered on the Legacy (Standard) 4-Tier Prescription Drug List.

13 How to find your medication First, look for your condition in the alphabetical list below. Then go to that page to see the covered medications available to treat the condition.

Condition Page Condition Page ANALGESICS (Pain Relief And 17–24 ANTIINFECTIVES/MISCELLANEOUS 55 Inflammatory Disease) (Skin Conditions) ANALGESICS (Urinary Tract Conditions) 24 ANTIINFLAM.TUMOR NECROSIS 55, 56 FACTOR INHIBITING AGENTS (Pain ANESTHETICS (Miscellaneous) 24 Relief And Inflammatory Disease) ANESTHETICS (Pain Relief And 24 ANTINEOPLASTICS (Cancer) 56–61 Inflammatory Disease) ANTINEOPLASTICS (Skin Conditions) 61, 62 ANESTHETICS (Urinary Tract Conditions) 24 ANTI-OBESITY DRUGS (Weight 62 ANTIALLERGY (Allergy/Nasal Sprays) 24, 25 Management) ANTIARTHRITICS (Pain Relief And 25–28 ANTIPARASITICS (Infections) 63 Inflammatory Disease) ANTIPARKINSON DRUGS (Parkinson’s 63–65 ANTIASTHMATICS (Asthma/COPD/ 28–32 Disease) Respiratory) ANTIPLATELET DRUGS (Blood Thinners/ 65, 66 ANTIBIOTICS (Allergy/Nasal Sprays) 32 Anti-Clotting) ANTIBIOTICS (Ear Medications) 32 ANTIVIRALS (AIDS/HIV) 66–69 ANTIBIOTICS (Eye Conditions) 32, 33 ANTIVIRALS (Eye Conditions) 69 ANTIBIOTICS (Infections) 33–42 ANTIVIRALS (Infections) 69–71 ANTIBIOTICS (Skin Conditions) 41, 42 ANTIVIRALS (Skin Conditions) 71, 72 ANTICOAGULANTS (Blood Thinners/ 42–44 AUTONOMIC DRUGS (Allergy/Nasal 72 Anti-Clotting) Sprays) ANTIDOTES (Gastrointestinal/Heartburn) 44 AUTONOMIC DRUGS (Alzheimer’s 72, 73 ANTIDOTES (Substance Abuse) 44 Disease) ANTIFUNGALS (Eye Conditions) 44 AUTONOMIC DRUGS (Attention Deficit 73, 74 ANTIFUNGALS (Feminine Products) 44, 45 Hyperactivity Disorder) ANTIFUNGALS (Infections) 45 AUTONOMIC DRUGS (Blood Pressure/ 74 Heart Medications) ANTIFUNGALS (Skin Conditions) 45–47 AUTONOMIC DRUGS (Urinary Tract 74 ANTIHISTAMINE AND DECONGESTANT 47 Conditions) COMBINATION (Allergy/Nasal Sprays) BIOLOGICALS (Allergy/Nasal Sprays) 74 ANTIHISTAMINES (Allergy/Nasal Sprays) 47 BIOLOGICALS (Blood Pressure/Heart 74 ANTIHISTAMINES (Eye Conditions) 48 Medications) ANTIHYPERGLYCEMICS (Diabetes) 48–53 BIOLOGICALS (Miscellaneous) 74 ANTIINFECTIVES (Feminine Products) 53 BIOLOGICALS (Vaccines) 75–77 ANTIINFECTIVES (Infections) 53 BLOOD (Blood Modifiers/Bleeding 77, 78 ANTIINFECTIVES/MISCELLANEOUS 53 Disorders) (Feminine Products) BLOOD (Blood Thinners/Anti-Clotting) 78 ANTIINFECTIVES/MISCELLANEOUS 53, 54 CARDIAC DRUGS (Blood Pressure/Heart 78–82 (Infections) Medications) ANTIINFECTIVES/MISCELLANEOUS 55 CARDIOVASCULAR (Asthma/COPD/ 82 (Miscellaneous) Respiratory)

14 Condition Page Condition Page CARDIOVASCULAR (Blood Pressure/ 82–89 HORMONES (Infertility) 130 Heart Medications) HORMONES (Miscellaneous) 130 CARDIOVASCULAR (Cholesterol 89–93 HORMONES (Osteoporosis Products) 130 Medications) CNS DRUGS (Alzheimer’s Disease) 93 IMMUNOSUPPRESSANTS (Pain Relief 130, 131 And Inflammatory Disease) CNS DRUGS (Miscellaneous) 94 IMMUNOSUPPRESSANTS (Skin 131 CNS DRUGS (Multiple Sclerosis) 94, 95 Conditions) CNS DRUGS (Pain Relief And 95 IMMUNOSUPPRESSANTS (Transplant 131, 132 Inflammatory Disease) Medications) CNS DRUGS (Seizure Disorders) 95–99 MISCELLANEOUS MEDICAL SUPPLIES, 132, 133 CNS DRUGS (Sleep Disorders/Sedatives) 99 DEVICES, NON-DRUG (Diabetes)

COLONY STIMULATING FACTORS 99, 100 MISCELLANEOUS MEDICAL SUPPLIES, 133–135 (Blood Modifiers/Bleeding Disorders) DEVICES, NON-DRUG (Miscellaneous) CONTRACEPTIVES (Contraception 100–102 MUSCLE RELAXANTS (Pain Relief And 135, 136 Products) Inflammatory Disease) COUGH/COLD PREPARATIONS (Allergy/ 102 PRE-NATAL VITAMINS (Nutritional/ 136, 137 Nasal Sprays) Dietary) COUGH/COLD PREPARATIONS (Cough/ 102, 103 PSYCHOTHERAPEUTIC DRUGS 137–146 Cold Medications) (Anxiety/Depression/Bipolar Disorder) DIAGNOSTIC (Miscellaneous) 103–105 PSYCHOTHERAPEUTIC DRUGS 143 (Attention Deficit Hyperactivity Disorder) DIURETICS (Diuretics) 105, 106 PSYCHOTHERAPEUTIC DRUGS 146 EENT PREPS (Allergy/Nasal Sprays) 106, 107 (Miscellaneous) EENT PREPS (Ear Medications) 107 PSYCHOTHERAPEUTIC DRUGS 146–149 (Schizophrenia/Anti-Psychotics) EENT PREPS (Eye Conditions) 107–111 PSYCHOTHERAPEUTIC DRUGS (Sleep 149 ELECT/CALORIC/H2O (Cholesterol 111 Disorders/Sedatives) Medications) SEDATIVE/HYPNOTICS (Sleep 149–151 ELECT/CALORIC/H2O (Dental Products) 111, 112 Disorders/Sedatives) ELECT/CALORIC/H2O (Diabetes) 112 SKIN PREPS (Miscellaneous) 151 ELECT/CALORIC/H2O (Miscellaneous) 112 SKIN PREPS (Pain Relief And 151, 152 ELECT/CALORIC/H2O (Nutritional/ 112–114 Inflammatory Disease) Dietary) SKIN PREPS (Skin Conditions) 152–162 ELECT/CALORIC/H2O (Urinary Tract 114 SMOKING DETERRENTS (Smoking 162 Conditions) Cessation) GASTROINTESTINAL (Cholesterol 114 THYROID PREPS (Hormonal Agents) 162, 163 Medications) UNCLASSIFIED DRUG PRODUCTS 163 GASTROINTESTINAL (Gastrointestinal/ 114–122 (AIDS/HIV) Heartburn) UNCLASSIFIED DRUG PRODUCTS 163, 164 GASTROINTESTINAL (Pain Relief And 122, 123 (Asthma/COPD/Respiratory) Inflammatory Disease) UNCLASSIFIED DRUG PRODUCTS 164 HORMONES (Gastrointestinal/ 123 (Blood Modifiers/Bleeding Disorders) Heartburn) UNCLASSIFIED DRUG PRODUCTS 164 HORMONES (Hormonal Agents) 123–129 (Blood Pressure/Heart Medications)

15 Condition Page UNCLASSIFIED DRUG PRODUCTS 164 (Cancer) UNCLASSIFIED DRUG PRODUCTS 165 (Dental Products) UNCLASSIFIED DRUG PRODUCTS 165 (Erectile Dysfunction) UNCLASSIFIED DRUG PRODUCTS 166 (Gastrointestinal/Heartburn) UNCLASSIFIED DRUG PRODUCTS 166 (Hormonal Agents) UNCLASSIFIED DRUG PRODUCTS 166–168 (Miscellaneous) UNCLASSIFIED DRUG PRODUCTS 168, 169 (Nutritional/Dietary) UNCLASSIFIED DRUG PRODUCTS 169 (Osteoporosis Products) UNCLASSIFIED DRUG PRODUCTS (Pain 169 Relief And Inflammatory Disease) UNCLASSIFIED DRUG PRODUCTS 170 (Seizure Disorders) UNCLASSIFIED DRUG PRODUCTS 170 (Substance Abuse) UNCLASSIFIED DRUG PRODUCTS 170, 171 (Urinary Tract Conditions) UNCLASSIFIED DRUG PRODUCTS 171 (Weight Management) VITAMINS (Nutritional/Dietary) 172

16 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINAT Prescription drug name Drug tier Coverage requirements and limits ALLZITAL T3 PA BUPAP (butalbital-acetaminophen) T1 PA butalbital/acetaminophen T1 butalbital-acetaminophn 25-325 (Allzital) T1 PA butalbital-acetaminophn 50-300 T1 butalbital-acetaminophn 50-300 (Bupap) T1 PA butalbital-acetaminophn 50-325 T1 ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB. butalb-aspirin-caffe 50-325-40 T1 QL (6 tabs/day) butalbital-asa-caffeine cap (Fiorinal) T1 QL (6 caps/day) FIORINAL (butalbital-aspirin-caffeine) T3 QL (6 caps/day) ANALGESIC, NON-SALICYLATE, BARBITURATE, XANTHINE COMB butalb/acetaminophen/caffeine (Esgic) T1 QL (6 caps/day) butalb/acetaminophen/caffeine (Esgic) T3 QL (6 caps/day) butalb/acetaminophen/caffeine (Fioricet) T1 QL (6 caps/day) butalb/acetaminophen/caffeine (Vanatol S) T3 ESGIC 50-325-40 MG TABLET (butalbital- T3 QL (6 tabs/day) acetaminophen-caffe) ESGIC CAPSULE (zebutal) T3 QL (6 caps/day) FIORICET (phrenilin forte) T1 QL (6 caps/day) VANATOL LQ T3 PA VANATOL S T3 PA ANALGESIC/ANTIPYRETICS, SALICYLATES choline salicyl/mag salicylate T1 HD diflunisal T1 HD ANTIMIGRAINE PREPARATIONS AIMOVIG AUTOINJECTOR T2 PA AJOVY AUTOINJECTOR T2 PA AJOVY SYRINGE T2 PA almotriptan malate T1 QL (12 tabs/30 days) AMERGE (naratriptan hcl) T3 PA QL (9 tabs/30 days) CAFERGOT (ergotamine-caffeine) T3 QL (40 tabs/28 days) CAMBIA T3 PA D.H.E.45 (dihydroergotamine mesylate) T3 PA QL (10 amps/30 days)

• T1 – Typically generics • T2 – Typically preferred brands • T3 – Typically non-preferred brands • T4 – Specialty medications • PA – Prior Authorization • QL – Quantity Limit • ST – Step Therapy • AGE – Age Requirement • SP – Specialty medication • HD – May require home delivery • PPACA – No cost-share preventive medications • CSL – Oral cancer medications subject to cost-share limits

17 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) ANTIMIGRAINE PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits dihydroergotamine 1 mg/ml amp (D.h.e.45) T1 QL (10 amps/30 days) dihydroergotamine 4 mg/ml spry (Migranal) T1 QL (8/30 days) eletriptan hbr 20 mg tablet (Relpax) T1 QL (18 tabs/28 days) eletriptan hbr 40 mg tablet (Relpax) T1 QL (6 tabs/30 days) EMGALITY PEN T2 PA EMGALITY SYRINGE T2 PA ERGOMAR T3 PA ergotamine tartrate/caffeine T1 ergotamine tartrate/caffeine (Cafergot) T1 QL (40 tabs/28 days) FROVA (frovatriptan succinate) T3 PA QL (18 tabs/30 days) frovatriptan succinate (Frova) T1 QL (18 tabs/30 days) IMITREX 100 MG TABLET (sumatriptan succinate) T3 PA QL (9 tabs/30 days) IMITREX 20 MG NASAL SPRAY (sumatriptan) T3 PA QL (2 boxes/30 days) IMITREX 25 MG TABLET (sumatriptan succinate) T3 PA QL (9 tabs/30 days) IMITREX 4 MG/0.5 ML CARTRIDGES (sumatriptan T3 PA QL (4ml/30 days) succinate) IMITREX 4 MG/0.5 ML PEN INJECT (sumatriptan T3 PA QL (4ml/30 days) succinate) IMITREX 5 MG NASAL SPRAY (sumatriptan) T3 PA QL (2 boxes/30 days) IMITREX 50 MG TABLET (sumatriptan succinate) T3 PA QL (9 tabs/30 days) IMITREX 6 MG/0.5 ML CARTRIDGES (sumatriptan T3 PA QL (4ml/30 days) succinate) IMITREX 6 MG/0.5 ML PEN INJECT (sumatriptan T3 PA QL (4ml/30 days) succinate) IMITREX 6 MG/0.5 ML VIAL (sumatriptan succinate) T3 PA QL (5ml/30 days) isomethept/dichlphn/acetaminop T1 isomethepten/caf/acetaminophen T1 MAXALT (rizatriptan) T3 PA QL (12 tabs/30 days) MAXALT MLT (rizatriptan) T3 PA QL (12 tabs/30 days) MIGRANAL (dihydroergotamine mesylate) T3 PA QL (8/30 days) naratriptan hcl (Amerge) T1 QL (9 tabs/30 days) NURTEC ODT T2 PA QL (16 tabs/30 days) ONZETRA XSAIL T3 PA QL (1 box/30 days) RELPAX (eletriptan hbr) T3 PA QL (6 tabs/30 days) REYVOW T3 PA QL (8 tabs/30 days)

18 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) ANTIMIGRAINE PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits rizatriptan benzoate T1 QL (12 tabs/30 days) rizatriptan benzoate (Maxalt Mlt) T1 QL (12 tabs/30 days) rizatriptan benzoate (Maxalt) T1 QL (12 tabs/30 days) sumatriptan (Imitrex) T1 QL (2 boxes/30 days) sumatriptan 4 mg/0.5 ml cart (Imitrex) T1 QL (4ml/30 days) sumatriptan 4 mg/0.5 ml inject (Imitrex) T1 QL (4ml/30 days) sumatriptan 6 mg/0.5 ml cart (Imitrex) T1 QL (4ml/30 days) sumatriptan 6 mg/0.5 ml inject (Imitrex) T1 QL (4ml/30 days) sumatriptan 6 mg/0.5 ml syrng T1 QL (4ml/30 days) sumatriptan 6 mg/0.5 ml vial (Imitrex) T1 QL (5ml/30 days) sumatriptan succ 100 mg tablet (Imitrex) T1 QL (18 tabs/28 days) sumatriptan succ 25 mg tablet (Imitrex) T1 QL (18 tabs/28 days) sumatriptan succ 50 mg tablet (Imitrex) T1 QL (9 tabs/30 days) sumatriptan succ/naproxen sod (Treximet) T1 QL (18 tabs/30 days) SUMAVEL DOSEPRO T3 QL (12 injectors/30 days) TOSYMRA T3 PA QL (2 boxes/30 days) TREXIMET 10-60 MG TABLET T3 PA QL (18 tabs/30 days) TREXIMET 85-500 MG TABLET (sumatriptan succ- T3 PA QL (18 tabs/28 days) naproxen sod) UBRELVY T2 PA QL (0.67 TABS/DAY) ZEMBRACE SYMTOUCH T3 PA QL (16 injectors/30 days) zolmitriptan (Zomig Zmt) T1 QL (12 tabs/30 days) ZOLMITRIPTAN 2.5 MG NASAL SPRY T3 PA QL (12 SPRAY/22 DAYS) zolmitriptan 2.5 mg tablet (Zomig) T1 QL (12 tabs/30 days) ZOLMITRIPTAN 5 MG NASAL SPRAY T3 PA QL (6 SPRAY/22 DAYS) zolmitriptan 5 mg tablet (Zomig) T1 QL (12 tabs/30 days) ZOMIG 2.5 MG NASAL SPRAY T3 PA QL (2 boxes/30 days) ZOMIG 2.5 MG TABLET (zolmitriptan) T3 PA QL (12 tabs/30 days) ZOMIG 5 MG NASAL SPRAY T3 PA QL (2 boxes/30 days) ZOMIG 5 MG TABLET (zolmitriptan) T3 PA QL (12 tabs/30 days) ZOMIG ZMT (zolmitriptan odt) T3 PA QL (12 tabs/30 days) NASAL NSAIDS, COX NON-SELECTIVE, SYSTEMIC ANALGESIC KETOROLAC 15.75 MG NASAL SPRAY T3 QL (10 bots/30 days) SPRIX T3 PA QL (10 bots/30 days)

19 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Prescription drug name Drug tier Coverage requirements and limits diclofenac potassium T1 HD ketorolac 10 mg tablet T1 QL (20 tabs/30 days) HD ketorolac 15 mg/ml carpuject T1 QL (40 ml/30 days) HD ketorolac 15 mg/ml isecure syr T1 QL (40 ml/30 days) HD ketorolac 15 mg/ml syringe T1 QL (40 ml/30 days) HD ketorolac 15 mg/ml vial T1 QL (40 ml/30 days) HD ketorolac 30 mg/ml carpuject T1 HD ketorolac 30 mg/ml isecure syr T1 QL (20ml/30 days) HD ketorolac 30 mg/ml syringe T1 QL (20ml/30 days) HD ketorolac 30 mg/ml vial T1 QL (20ml/30 days) HD ketorolac 300 mg/10 ml vial T1 HD ketorolac 60 mg/2 ml carpuject T1 QL (20ml/30 days) HD ketorolac 60 mg/2 ml syringe T1 QL (20ml/30 days) HD ketorolac 60 mg/2 ml vial T1 QL (20ml/30 days) HD mefenamic acid T1 HD ZIPSOR T3 PA HD OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS acetamin-codein 300-30 mg/12.5 T1 acetaminop-codeine 120-12 mg/5 T1 acetaminophen-cod #2 tablet T1 PA acetaminophen-cod #3 tablet T1 PA acetaminophen-cod #4 tablet T1 PA APADAZ T3 BENZHYDROCODONE-ACETAMINOPHEN T1 CAPITAL W-CODEINE T3 hydrocodone/acetaminophen T1 PA hydrocodone/acetaminophen (Hydrocodone- T1 PA acetaminophen) hydrocodone/acetaminophen (Norco) T1 PA HYDROCODONE-ACETAMINOPHEN T1 PA LORTAB T1 PA NALOCET T1 PA NORCO (lorcet hd) T3 PA NORCO (lorcet plus) T3 PA

20 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS Prescription drug name Drug tier Coverage requirements and limits NORCO (lorcet) T3 PA oxycodone hcl/acetaminophen (Nalocet) T1 PA oxycodone hcl/acetaminophen (Percocet) T1 PA oxycodone hcl/acetaminophen (Primlev) T1 PA PERCOCET (oxycodone-acetaminophen) T3 PA PRIMLEV T1 PA tramadol hcl/acetaminophen (Ultracet) T1 ULTRACET (tramadol hcl-acetaminophen) T3 OPIOID ANALGESIC AND NSAID COMBINATION hydrocodone/ibuprofen T1 PA hydrocodone/ibuprofen (Ibudone) T1 PA IBUDONE T1 PA ibuprofen/oxycodone hcl T1 PA OPIOID ANALGESIC AND SALICYLATE ANALGESIC COMB oxycodone hcl/aspirin T1 PA OPIOID ANALGESIC, NON-SALICYLATE, XANTHINE COMB ACETAMIN-CAFF-DIHYDROCODEINE T1 PA acetaminophen/caff/dihydrocod (Acetamin-caff- T1 PA dihydrocodeine) acetaminophen/caff/dihydrocod (Trezix) T1 PA TREZIX T3 PA OPIOID ANALGESICS ABSTRAL T3 PA ACTIQ (fentanyl citrate) T3 PA ARYMO ER T3 PA BELBUCA 150 MCG FILM T2 QL (2 films/day) BELBUCA 300 MCG FILM T2 QL (2 films/day) BELBUCA 450 MCG FILM T2 QL (2 films/day) BELBUCA 600 MCG FILM T2 QL (2 films/day) BELBUCA 75 MCG FILM T2 QL (2 films/day) BELBUCA 750 MCG FILM T2 QL (60 films/30 days) BELBUCA 900 MCG FILM T2 QL (2 films/day) buprenorphine (Butrans) T1 QL (4 patches/28 days) butorphanol tartrate T1 PA QL (6 bots/30 days)

21 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) OPIOID ANALGESICS Prescription drug name Drug tier Coverage requirements and limits BUTRANS (buprenorphine) T3 QL (4 patches/28 days) codeine sulfate T1 PA CONZIP T3 PA QL (1 cap/day) DILAUDID 2 MG TABLET (hydromorphone hcl) T3 PA DILAUDID 4 MG TABLET (hydromorphone hcl) T3 PA DILAUDID 5 MG/5 ML ORAL LIQUID T2 PA (hydromorphone hcl) DILAUDID 8 MG TABLET (hydromorphone hcl) T3 PA DURAGESIC (fentanyl) T3 PA fentanyl T1 PA fentanyl (Duragesic) T1 PA FENTANYL CITRATE T1 PA fentanyl citrate (Actiq) T1 PA FENTORA T3 PA hydrocodone bitartrate (Hysingla Er) T1 PA hydrocodone bitartrate (Zohydro Er) T1 PA hydromorphone hcl T1 PA hydromorphone hcl (Dilaudid) T1 PA HYSINGLA ER (hydrocodone bitartrate er) T2 PA KADIAN T3 PA KADIAN (morphine sulfate er) T3 PA LAZANDA T3 PA levorphanol tartrate T1 PA meperidine hcl T1 PA methadone hcl T1 PA MORPHABOND ER T2 PA morphine sulfate T1 PA morphine sulfate (Kadian) T1 PA morphine sulfate (Ms Contin) T1 PA MS CONTIN (morphine sulfate er) T3 PA NUCYNTA T2 PA NUCYNTA ER T3 PA opium/belladonna alkaloids T1 PA OXAYDO T3 PA

22 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) OPIOID ANALGESICS Prescription drug name Drug tier Coverage requirements and limits oxycodone hcl T1 PA oxycodone hcl (Roxicodone) T1 PA OXYCODONE HCL ER T1 PA OXYCONTIN T3 PA oxymorphone hcl T1 PA pentazocine hcl/naloxone hcl T1 PA QDOLO T3 PA QL (80ML/DAY) ROXICODONE (oxycodone hcl) T3 PA ROXYBOND T3 PA SUBSYS T3 PA tramadol er 100 mg tablet T1 QL (1 tab/day) tramadol er 200 mg tablet T1 QL (1 tab/day) tramadol er 300 mg tablet T1 QL (1 tab/day) TRAMADOL HCL 100 MG TABLET T3 PA QL (4 tabs/day) tramadol hcl 50 mg tablet (Ultram) T1 QL (8 tabs/day) TRAMADOL HCL ER 100 MG CAPSULE T1 QL (1 cap/day) tramadol hcl er 100 mg tablet T1 QL (1 tab/day) TRAMADOL HCL ER 150 MG CAPSULE T1 QL (1 cap/day) TRAMADOL HCL ER 200 MG CAPSULE T1 QL (1 cap/day) tramadol hcl er 200 mg tablet T1 QL (1 tab/day) TRAMADOL HCL ER 300 MG CAPSULE T1 QL (1 cap/day) tramadol hcl er 300 mg tablet T1 QL (1 tab/day) ULTRAM (tramadol hcl) T3 QL (8 tabs/day) XTAMPZA ER T2 PA ZOHYDRO ER (hydrocodone bitartrate er) T3 PA OPIOID AND SALICYLATE ANALGESICS, BARBIT, XANTHINE codeine/butalbital/asa/caffein (Fiorinal With T1 PA Codeine #3) FIORINAL WITH CODEINE #3 (butalbital T3 PA compound-codeine) OPIOID, NON-SALICYL.ANALGESIC, BARBITURATE, XANTHINE butalbit/acetamin/caff/codeine T1 PA butalbit/acetamin/caff/codeine (Fioricet With T1 PA Codeine) FIORICET WITH CODEINE (butalb-acetaminoph- T3 PA caff-codein)

23 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANALGESICS (Pain Relief And Inflammatory Disease) SKELETAL MUSCLE RELAXANT, SALICYLAT, OPIOID ANALGESC Prescription drug name Drug tier Coverage requirements and limits carisoprodol/aspirin/codeine T1 PA ANALGESICS (Urinary Tract Conditions) URINARY TRACT ANALGESIC AGENTS ELMIRON T2 RIMSO-50 T2 ANESTHETICS (Miscellaneous) GENERAL ANESTHETICS, INHALANT desflurane (Suprane) T1 isoflurane T1 isoflurane T3 sevoflurane (Ultane) T1 SUPRANE T3 ULTANE (sevoflurane) T3 ANESTHETICS (Pain Relief And Inflammatory Disease) LOCAL ANESTHETICS lidocaine hcl T1 TOPICAL LOCAL ANESTHETICS L.E.T. (LIDO-EPINEPH-TETRA) T3 lidocaine 5% ointment T1 QL (145gm/30 days) lidocaine 5% patch (Lidoderm) T1 lidocaine hcl T1 lidocaine hcl T3 lidocaine/prilocaine T1 LIDODERM (lidocaine) T3 PAIN EASE MEDIUM STREAM SPRAY T3 SYNERA T3 ZTLIDO T2 ANESTHETICS (Urinary Tract Conditions) URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) phenazopyridine hcl (Pyridium) T1 PYRIDIUM (phenazopyridine hcl) T3 ANTIALLERGY (Allergy/Nasal Sprays) MAST CELL STABILIZERS cromolyn 100 mg/5 ml oral conc (Gastrocrom) T1

24 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIALLERGY (Allergy/Nasal Sprays) MAST CELL STABILIZERS Prescription drug name Drug tier Coverage requirements and limits GASTROCROM (cromolyn sodium) T3 ANTIARTHRITICS (Pain Relief And Inflammatory Disease) ANALGESIC/ANTIPYRETICS, SALICYLATES DISALCID (salsalate) T3 HD salsalate (Disalcid) T1 HD ANTI-ARTHRITIC AND CHELATING AGENTS CUPRIMINE (penicillamine) T4 PA SP DEPEN (penicillamine) T4 PA SP penicillamine (Cuprimine) T4 PA SP penicillamine (Depen) T4 PA SP ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS OTREXUP T3 PA RASUVO T2 PA REDITREX T2 PA ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST KINERET T4 PA QL (28 syringes/28 days) SP ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR ARAVA (leflunomide) T3 HD leflunomide (Arava) T1 HD ANTI-INFLAMMATORY, PHOSPHODIESTERASE-4 (PDE4) INHIB. OTEZLA 28 DAY STARTER PACK T4 PA QL (1 pack/180 days) SP HD OTEZLA 30 MG TABLET T4 PA QL (2 tabs/day) SP HD ANTINFLAMMATORY, SEL.COSTIM.MOD., T-CELL INHIBITOR ORENCIA T4 PA QL (4 syringes/28 days) SP HD ORENCIA CLICKJECT T4 PA QL (4 injectors/28 days) SP HD COLCHICINE COLCHICINE T1 HD colchicine (Colcrys) T1 HD COLCRYS (colchicine) T3 HD GLOPERBA T3 PA QL (10ml/day) HD MITIGARE T3 HD GOLD SALTS RIDAURA T2

25 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIARTHRITICS (Pain Relief And Inflammatory Disease) HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS Prescription drug name Drug tier Coverage requirements and limits allopurinol (Zyloprim) T1 HD febuxostat 40 mg tablet (Uloric) T1 QL (1 tab/day) HD febuxostat 80 mg tablet (Uloric) T1 HD ULORIC 40 MG TABLET (febuxostat) T2 QL (1 tab/day) HD ULORIC 80 MG TABLET (febuxostat) T2 HD ZYLOPRIM (allopurinol) T3 HD JANUS KINASE (JAK) INHIBITORS OLUMIANT T4 PA QL (1 tab/day) SP HD RINVOQ T4 PA QL (1 tab/day) SP HD XELJANZ 1 MG/ML SOLUTION T4 PA QL (480ML/22 Days) SP HD XELJANZ 10 MG TABLET T4 PA QL (2 tabs/day) SP HD XELJANZ 5 MG TABLET T4 PA QL (2 tabs/day) SP HD XELJANZ XR T4 PA QL (1 tab/day) SP HD NSAID AND HISTAMINE H2 RECEPTOR ANTAGONIST COMB. DUEXIS T3 PA HD NSAID, COX INHIBITOR-TYPE AND PROTON-PUMP INHIBITOR naproxen/esomeprazole mag (Vimovo) T1 PA QL (2 tabs/day) HD VIMOVO (naproxen-esomeprazole mag) T3 PA QL (2 tabs/day) HD NSAIDS (COX NON-SPEC.INHIB) AND PROSTAGLANDIN ANALOG ARTHROTEC 50 (diclofenac sodium-misoprostol) T3 ST HD ARTHROTEC 75 (diclofenac sodium-misoprostol) T3 ST HD diclofenac sodium/misoprostol (Arthrotec 50) T1 HD diclofenac sodium/misoprostol (Arthrotec 75) T1 HD NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS ANAPROX DS (naproxen sodium ds) T3 ST HD DAYPRO (oxaprozin) T3 ST HD DICLOFENAC T3 PA HD diclofenac sod dr 25 mg tab T1 HD diclofenac sod dr 50 mg tab T1 HD diclofenac sod dr 75 mg tab T1 HD diclofenac sod ec 25 mg tab T1 HD diclofenac sod ec 50 mg tab T1 HD diclofenac sod ec 75 mg tab T1 HD

26 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIARTHRITICS (Pain Relief And Inflammatory Disease) NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Prescription drug name Drug tier Coverage requirements and limits diclofenac sodium T1 HD EC-NAPROSYN (naproxen) T3 ST HD etodolac T1 HD etodolac (Lodine) T1 HD FELDENE (piroxicam) T3 ST HD FENOPROFEN 200 MG CAPSULE T1 PA HD FENOPROFEN 400 MG CAPSULE T1 HD fenoprofen 600 mg tablet (Nalfon) T1 HD fenoprofen calcium (Nalfon) T1 HD FENORTHO T1 PA HD flurbiprofen T1 HD ibuprofen T1 HD INDOCIN T3 PA HD indomethacin T1 HD INDOMETHACIN 20 MG CAPSULE T3 PA HD indomethacin 25 mg capsule T1 HD indomethacin 50 mg capsule T1 HD ketoprofen T1 HD LODINE (etodolac) T3 ST HD meclofenamate sodium T1 HD meloxicam 10 mg capsule (Vivlodex) T1 PA HD meloxicam 15 mg tablet (Mobic) T1 HD meloxicam 5 mg capsule (Vivlodex) T1 PA QL (1 CAPS/DAY) HD meloxicam 7.5 mg tablet (Mobic) T1 HD MOBIC (meloxicam) T3 ST HD nabumetone (Relafen) T1 HD NALFON 400 MG CAPSULE T3 ST HD NALFON 600 MG TABLET (profeno) T1 ST HD NAPRELAN T3 PA HD NAPRELAN (naproxen sodium er) T3 PA HD NAPROSYN (naproxen) T3 ST HD naproxen T1 HD naproxen (Ec-naprosyn) T1 HD

27 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIARTHRITICS (Pain Relief And Inflammatory Disease) NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS Prescription drug name Drug tier Coverage requirements and limits naproxen (Naprosyn) T1 HD naproxen sod cr 375 mg tablet (Naprelan) T1 PA HD naproxen sod cr 500 mg tablet (Naprelan) T1 PA HD NAPROXEN SOD CR 750 MG TABLET T3 PA HD naproxen sodium T1 HD naproxen sodium (Anaprox Ds) T1 HD naproxen sodium (Naprelan) T1 PA HD oxaprozin (Daypro) T1 HD piroxicam (Feldene) T1 HD QMIIZ ODT 15 MG TABLET T3 ST HD QMIIZ ODT 7.5 MG TABLET T3 QL (1 tab/day) ST HD RELAFEN (nabumetone) T3 PA HD RELAFEN DS T3 PA HD sulindac T1 HD TIVORBEX T3 PA HD tolmetin sodium T1 HD VIVLODEX 10 MG CAPSULE (meloxicam) T3 PA HD VIVLODEX 5 MG CAPSULE (meloxicam) T3 PA QL (1 cap/day) HD ZORVOLEX T3 PA HD NSAIDS, CYCLOOXYGENASE-2 (COX-2) SELECTIVE INHIBITOR CELEBREX 100 MG CAPSULE (celecoxib) T3 QL (2 caps/day) ST HD CELEBREX 200 MG CAPSULE (celecoxib) T3 QL (2 caps/day) ST HD CELEBREX 400 MG CAPSULE (celecoxib) T3 QL (1 cap/day) ST HD CELEBREX 50 MG CAPSULE (celecoxib) T3 QL (2 caps/day) ST HD celecoxib 100 mg capsule (Celebrex) T1 QL (2 caps/day) HD celecoxib 200 mg capsule (Celebrex) T1 QL (2 caps/day) HD celecoxib 400 mg capsule (Celebrex) T1 QL (1 cap/day) HD celecoxib 50 mg capsule (Celebrex) T1 QL (2 caps/day) HD URICOSURIC AGENTS probenecid T1 HD probenecid/colchicine T1 HD ANTIASTHMATICS (Asthma/COPD/Respiratory) 5-LIPOXYGENASE INHIBITORS zileuton T1 HD ZYFLO T3 PA HD

28 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIASTHMATICS (Asthma/COPD/Respiratory) ANTICHOLINERGICS, ORALLY INHALED LONG ACTING Prescription drug name Drug tier Coverage requirements and limits INCRUSE ELLIPTA T2 HD LONHALA MAGNAIR REFILL T3 PA HD LONHALA MAGNAIR STARTER T3 PA HD SEEBRI NEOHALER T3 ST HD SPIRIVA T3 ST HD SPIRIVA RESPIMAT T3 ST HD TUDORZA PRESSAIR T3 ST HD YUPELRI T3 PA HD ANTICHOLINERGICS, ORALLY INHALED SHORT ACTING ATROVENT HFA T2 HD ipratropium bromide T1 HD BETA-ADRENERGIC AGENTS albuterol sulf 2 mg/5 ml syrup T1 HD albuterol sulfate 2 mg tab T1 HD albuterol sulfate 4 mg tab T1 HD albuterol sulfate er 4 mg tab T1 HD albuterol sulfate er 8 mg tab T1 HD metaproterenol sulfate T1 HD terbutaline sulfate T1 HD BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING albuterol 100 mg/20 ml soln T1 albuterol 2.5 mg/0.5 ml sol T1 albuterol 5 mg/ml solution T1 albuterol sul 0.63 mg/3 ml sol T1 albuterol sul 1.25 mg/3 ml sol T1 albuterol sul 2.5 mg/3 ml soln T1 albuterol sulfate (Ventolin Hfa) T1 QL (18gm/30 days) ALBUTEROL SULFATE HFA T1 QL (18gm/30 days) levalbuterol hcl (Xopenex Concentrate) T1 levalbuterol hcl (Xopenex) T1 LEVALBUTEROL TARTRATE HFA T1 QL (15GM/30 days) PROAIR DIGIHALER T3 PA QL (1 inhaler/30 days) PROAIR HFA (albuterol sulfate hfa) T3 PA QL (8.5gm/30 days)

29 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIASTHMATICS (Asthma/COPD/Respiratory) BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING Prescription drug name Drug tier Coverage requirements and limits PROAIR RESPICLICK T3 PA QL (1 respihaler/30 days) PROVENTIL HFA (albuterol sulfate hfa) T3 PA QL (8.5gm/30 days) VENTOLIN HFA T3 PA QL (8.5gm/30 days) XOPENEX (levalbuterol hcl) T3 XOPENEX CONCENTRATE (levalbuterol T3 concentrate) XOPENEX HFA T3 QL (15GM/30 days) BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING ARCAPTA NEOHALER T3 HD STRIVERDI RESPIMAT T3 ST HD BETA-ADRENERGIC AGENTS, ORALLY INHALED, LONG ACTING BROVANA T3 HD PERFOROMIST T3 QL (240ml/30 days) HD SEREVENT DISKUS T2 HD BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED ANORO ELLIPTA T2 HD BEVESPI AEROSPHERE T2 HD COMBIVENT RESPIMAT T2 HD DUAKLIR PRESSAIR T3 PA HD ipratropium/albuterol sulfate T1 HD STIOLTO RESPIMAT T3 ST HD UTIBRON NEOHALER T3 ST HD BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED ADVAIR DISKUS (wixela inhub) T3 ST HD ADVAIR HFA T2 HD AIRDUO DIGIHALER T3 ST HD AIRDUO RESPICLICK T3 ST HD BREO ELLIPTA T2 HD BUDESONIDE-FORMOTEROL FUMARATE T3 PA HD DULERA T2 HD fluticasone propion/salmeterol (Advair Diskus) T1 HD FLUTICASONE-SALMETEROL T1 HD SYMBICORT T2 HD

30 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIASTHMATICS (Asthma/COPD/Respiratory) BETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED Prescription drug name Drug tier Coverage requirements and limits BREZTRI AEROSPHERE T2 TRELEGY ELLIPTA T2 GLUCOCORTICOIDS, ORALLY INHALED ALVESCO T3 ST HD ARMONAIR DIGIHALER T3 ST HD ARNUITY ELLIPTA T3 ST HD ASMANEX T2 HD ASMANEX HFA T2 HD budesonide (Pulmicort) T1 HD FLOVENT DISKUS T2 HD FLOVENT HFA T2 HD PULMICORT (budesonide) T3 HD PULMICORT FLEXHALER T2 HD QVAR REDIHALER T2 HD

INTERLEUKIN-5 (IL-5) RECEPTOR ALPHA ANTAGONIST, MAB FASENRA PEN T4 PA SP HD LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE (zafirlukast) T3 HD montelukast sodium (Singulair) T1 HD SINGULAIR (montelukast sodium) T3 HD zafirlukast (Accolate) T1 HD

MAST CELL STABILIZERS, ORALLY INHALED cromolyn 20 mg/2 ml neb soln T1 QL (480ml/30 days) HD MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IGE) XOLAIR T4 PA SP HD MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTS NUCALA T4 PA SP HD MUCOLYTICS acetylcysteine T1 PHOSPHODIESTERASE-4 (PDE4) INHIBITORS DALIRESP 250 MCG TABLET T3 QL (28 tabs/180 days) HD DALIRESP 500 MCG TABLET T3 QL (2 tabs/day) HD

31 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIASTHMATICS (Asthma/COPD/Respiratory) XANTHINES Prescription drug name Drug tier Coverage requirements and limits ELIXOPHYLLIN T3 PA HD THEO-24 T2 HD theophylline anhydrous T1 HD theophylline anhydrous (Elixophyllin) T1 HD ANTIBIOTICS (Allergy/Nasal Sprays) NOSE PREPARATIONS ANTIBIOTICS BACTROBAN NASAL T2 ANTIBIOTICS (Ear Medications) EAR PREPARATIONS, ANTIBIOTICS ciprofloxacin hcl T1 CORTISPORIN-TC T3 neomycin/polymyxin b/hydrocort T1 ofloxacin T1 OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS CIPRO HC T2 CIPRODEX (ciprofloxacin-dexamethasone) T3 ciprofloxacin hcl/dexameth (Ciprodex) T1 CIPROFLOXACIN HCL-FLUOCINOLONE T3 OTOVEL T3 ANTIBIOTICS (Eye Conditions) EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS MAXITROL (neomycin-polymyxin-dexameth) T3 neomycin/bacit/p-myx/hydrocort T1 neomycin/polymyxin b/dexametha (Maxitrol) T1 neomycin/polymyxin b/hydrocort T1 PRED-G T2 TOBRADEX EYE DROPS (tobramycin- T3 dexamethasone) TOBRADEX EYE OINTMENT T2 TOBRADEX ST T3 tobramycin/dexamethasone (Tobradex) T1 ZYLET T3 EYE SULFONAMIDES BLEPH-10 (sulfacetamide sodium) T3

32 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Eye Conditions) EYE SULFONAMIDES Prescription drug name Drug tier Coverage requirements and limits BLEPHAMIDE T2 BLEPHAMIDE S.O.P. T2 sulfacetamide sodium T1 sulfacetamide sodium (Bleph-10) T1 sulfacetamide/prednisolone sp T1 OPHTHALMIC ANTIBIOTICS AZASITE T2 BACIGUENT (bacitracin) T3 bacitracin (Baciguent) T1 bacitracin/polymyxin b sulfate T1 BESIVANCE T3 CILOXAN 0.3% EYE DROPS (ciprofloxacin hcl) T3 CILOXAN 0.3% OINTMENT T2 ciprofloxacin hcl (Ciloxan) T1 erythromycin base T1 gatifloxacin (Zymaxid) T1 gentamicin sulfate T1 levofloxacin T1 MOXEZA (moxifloxacin) T3 moxifloxacin hcl (Moxeza) T1 moxifloxacin hcl (Vigamox) T1 neomycin sulf/bacitracin/poly T1 neomycin/polymyxn b/gramicidin T1 OCUFLOX (ofloxacin) T3 ofloxacin (Ocuflox) T1 polymyxin b sulf/trimethoprim (Polytrim) T1 POLYTRIM (polymyxin b sul-trimethoprim) T3 tobramycin 0.3% eye drop (Tobrex) T1 TOBREX 0.3% EYE DROP (tobramycin) T3 TOBREX 0.3% EYE OINTMENT T2 VIGAMOX (moxifloxacin) T3 ZYMAXID (gatifloxacin) T3

33 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL Prescription drug name Drug tier Coverage requirements and limits SOLOSEC T2 ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS BACTRIM (sulfamethoxazole-trimethoprim) T3 BACTRIM DS (sulfamethoxazole-trimethoprim) T3 sulfadiazine T1 sulfamethoxazole/trimethoprim T1 sulfamethoxazole/trimethoprim T3 sulfamethoxazole/trimethoprim (Bactrim Ds) T1 sulfamethoxazole/trimethoprim (Bactrim) T1 AMINOGLYCOSIDE ANTIBIOTICS ARIKAYCE T4 PA SP BETHKIS (tobramycin) T4 PA QL (8ml/day) SP HD gentamicin sulfate T1 gentamicin sulfate/pf T1 KITABIS PAK T4 PA QL (10ml/day) SP HD neomycin sulfate T1 TOBI (tobramycin) T4 PA QL (10ml/day) SP HD TOBI PODHALER T4 PA QL (8 caps/day) SP HD tobramycin 1, 200 mg/30 ml vial T1 tobramycin 1.2 gm vial T1 PA tobramycin 1.2 gram/30 ml vial T1 tobramycin 10 mg/ml vial T1 tobramycin 300 mg/4 ml ampule (Bethkis) T4 PA QL (28 Therapy/56 days) SP HD tobramycin 300 mg/5 ml ampule (Tobi) T4 PA QL (10ml/day) SP HD tobramycin 40 mg/ml vial T1 tobramycin 80 mg/2 ml vial T1 TOBRAMYCIN PAK 300 MG/5 ML T4 PA QL (10ml/day) SP HD ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL (metronidazole) T3 metronidazole (Flagyl) T1 ANTIBIOTIC, ANTIBACTERIAL, MISC. fosfomycin tromethamine (Monurol) T1 HIPREX (methenamine hippurate) T3

34 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) ANTIBIOTIC, ANTIBACTERIAL, MISC. Prescription drug name Drug tier Coverage requirements and limits meth/meblue/sod phos/psal/hyos T1 meth/meblue/sod phos/psal/hyos T2 meth/meblue/sod phos/psal/hyos (Uribel) T1 methen/mblue/sal/sod phos/hyos T1 methenam/m.blue/salicyl/hyoscy T1 methenam/sod phos/mblue/hyoscy T1 methenam/sod phos/mblue/hyoscy T3 methenamine hippurate (Hiprex) T1 methenamine mandelate T1 MONUROL (fosfomycin tromethamine) T3 PRIMSOL T2 trimethoprim T1 TRIMPEX T2 URIBEL T3 UTA T3 ANTILEPROTICS dapsone 100 mg tablet T1 dapsone 25 mg tablet T1 THALOMID T4 PA SP HD ANTI-MYCOBACTERIUM AGENTS ethambutol hcl T1 HD ethambutol hcl (Myambutol) T1 HD isoniazid T1 HD MYAMBUTOL (ethambutol hcl) T3 HD MYCOBUTIN (rifabutin) T3 PA HD PASER T2 HD pyrazinamide T1 HD rifabutin (Mycobutin) T1 HD TRECATOR T2 HD ANTITUBERCULAR ANTIBIOTICS CYCLOSERINE T1 PRETOMANID T3 PA QL (1 tab/day) PRIFTIN T3

35 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) ANTITUBERCULAR ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits RIFAMATE T2 rifampin T1 RIFATER T2 SIRTURO T4 SP BETALACTAMS CAYSTON T4 PA QL (3ml/day) SP HD CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION cefadroxil T1 cephalexin T1 cephalexin (Keflex) T1 DAXBIA T3 KEFLEX (cephalexin) T3 CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION cefaclor T1 cefprozil T1 cefuroxime axetil T1 CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION cefdinir T1 cefditoren pivoxil T1 cefditoren pivoxil (Spectracef) T1 cefixime (Suprax) T1 cefpodoxime proxetil T1 ceftriaxone sodium T1 SPECTRACEF (cefditoren pivoxil) T3 SUPRAX T3 SUPRAX (cefixime) T3 LINCOSAMIDE ANTIBIOTICS CLEOCIN HCL 150 MG CAPSULE (clindamycin hcl) T3 CLEOCIN HCL 300 MG CAPSULE (clindamycin hcl) T3 CLEOCIN HCL 75 MG CAPSULE (clindamycin hcl) T2 CLEOCIN PEDIATRIC (clindamycin (pediatric)) T3 clindamycin hcl (Cleocin Hcl) T1 clindamycin palmitate hcl (Cleocin Pediatric) T1

36 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) MACROLIDE ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits azithromycin 1 gm pwd packet (Zithromax) T1 azithromycin 100 mg/5 ml susp (Zithromax) T1 azithromycin 200 mg/5 ml susp (Zithromax) T1 azithromycin 200 mg/5 ml susp (Zithromax) T1 azithromycin 250 mg tablet (Zithromax) T1 azithromycin 500 mg tablet (Zithromax Tri-pak) T1 azithromycin 600 mg tablet T1 clarithromycin T1 DIFICID 200 MG TABLET T3 QL (28 tabs/28 days) DIFICID 40 MG/ML SUSPENSION T3 QL (5ML/Day) E.E.S. 200 (erythromycin ethylsuccinate) T3 PA ERYPED 200 (erythromycin ethylsuccinate) T3 ERYPED 400 (erythromycin ethylsuccinate) T3 PA ery-tab dr 250 mg tablet T3 ery-tab dr 333 mg tablet T2 ERY-TAB DR 500 MG TABLET (erythromycin) T3 erythromycin base T1 erythromycin base (Ery-tab) T1 erythromycin ethylsuccinate T1 erythromycin ethylsuccinate T2 erythromycin ethylsuccinate (Eryped 200) T1 erythromycin ethylsuccinate (Eryped 400) T1 erythromycin stearate T1 PCE T3 ZITHROMAX 1 GM POWDER PACKET T3 (azithromycin) ZITHROMAX 100 MG/5 ML SUSP (azithromycin) T3 ZITHROMAX 200 MG/5 ML SUSP (azithromycin) T3 ZITHROMAX 200 MG/5 ML SUSP (azithromycin) T3 ZITHROMAX 250 MG TABLET (azithromycin) T3 ZITHROMAX 250 MG Z-PAK TABLET T3 (azithromycin) ZITHROMAX 500 MG TABLET (azithromycin) T3 ZITHROMAX TRI-PAK (azithromycin) T3

37 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS Prescription drug name Drug tier Coverage requirements and limits FURADANTIN (nitrofurantoin) T3 MACROBID (nitrofurantoin mono-macro) T3 MACRODANTIN (nitrofurantoin) T3 nitrofurantoin 25 mg/5 ml susp (Furadantin) T1 nitrofurantoin 25 mg/5 ml susp (Furadantin) T1 PA nitrofurantoin mcr 100 mg cap (Macrodantin) T1 nitrofurantoin mcr 25 mg cap (Macrodantin) T1 nitrofurantoin mcr 50 mg cap (Macrodantin) T1 nitrofurantoin monohyd/m-cryst (Macrobid) T1 OXAZOLIDINONE ANTIBIOTICS linezolid (Zyvox) T1 PA SIVEXTRO T3 PA ZYVOX (linezolid) T3 PA PENICILLIN ANTIBIOTICS amoxicillin T1 amoxicillin/potassium clav T1 amoxicillin/potassium clav (Augmentin Xr) T1 amoxicillin/potassium clav (Augmentin) T1 ampicillin trihydrate T1 AUGMENTIN 125-31.25 MG/5 ML T2 PA AUGMENTIN 250-62.5 MG/5 ML (amoxicillin- T3 PA clavulanate potass) AUGMENTIN XR (amoxicillin-clavulanate pot er) T3 PA dicloxacillin sodium T1 MOXATAG T3 penicillin v potassium T1 PLEUROMUTILIN DERIVATIVES XENLETA T3 PA QL (10 tabs/30 days) QUINOLONE ANTIBIOTICS AVELOX (moxifloxacin hcl) T3 BAXDELA T3 PA CIPRO 10% SUSPENSION (ciprofloxacin) T2 CIPRO 250 MG TABLET (ciprofloxacin hcl) T3 CIPRO 5% SUSPENSION (ciprofloxacin) T2

38 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) QUINOLONE ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits CIPRO 500 MG TABLET (ciprofloxacin hcl) T3 ciprofloxacin (Cipro) T1 ciprofloxacin hcl T1 ciprofloxacin hcl (Cipro) T1 ciprofloxacin/ciprofloxa hcl T1 FACTIVE T3 levofloxacin T1 moxifloxacin hcl (Avelox) T1 ofloxacin T1 RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS AEMCOLO T3 QL (12 tabs/3 days) XIFAXAN 200 MG TABLET T2 XIFAXAN 550 MG TABLET T2 QL (126 tabs/year) TETRACYCLINE ANTIBIOTICS ACTICLATE (doxycycline hyclate) T3 ST coremino er 135 mg tablet T1 coremino er 45 mg tablet T1 QL (1 tab/day) coremino er 90 mg tablet T1 demeclocycline hcl T1 DORYX T3 PA DORYX (doxycycline hyclate) T3 PA DORYX MPC T3 PA doxycycline 50 mg tablet (Targadox) T1 doxycycline hyc dr 100 mg tab T1 doxycycline hyc dr 150 mg tab T1 doxycycline hyc dr 200 mg tab (Doryx) T1 doxycycline hyc dr 50 mg tab (Doryx) T1 doxycycline hyc dr 75 mg tab T1 DOXYCYCLINE HYC DR 80 MG TAB T3 PA doxycycline hyclate T1 doxycycline hyclate (Vibramycin) T1 doxycycline hyclate 100 mg cap (Vibramycin) T1 doxycycline hyclate 100 mg tab T1 doxycycline hyclate 150 mg tab (Acticlate) T1

39 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) TETRACYCLINE ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits doxycycline hyclate 50 mg cap T1 doxycycline hyclate 75 mg tab (Acticlate) T1 DOXYCYCLINE IR-DR T1 PA doxycycline monohydrate T1 doxycycline monohydrate (Monodox) T1 doxycycline monohydrate (Vibramycin) T1 MINOCIN (minocycline hcl) T3 PA MINOCYCLINE ER T3 ST minocycline er 105 mg tablet (Solodyn) T1 minocycline er 115 mg tablet (Solodyn) T1 minocycline er 135 mg tablet T1 minocycline er 45 mg tablet T1 QL (1 tab/day) minocycline er 55 mg tablet (Solodyn) T1 minocycline er 65 mg tablet (Solodyn) T1 minocycline er 80 mg tablet (Solodyn) T1 minocycline er 90 mg tablet T1 minocycline hcl T1 minocycline hcl (Minocin) T1 MINOLIRA ER T3 ST MONODOX (mondoxyne nl) T3 MONODOX (okebo) T3 NUZYRA T4 QL (30 tablets/28 days) SP ORACEA T3 PA SEYSARA T3 PA SOLODYN (minocycline hcl er) T3 PA TARGADOX T3 PA tetracycline hcl T1 VIBRAMYCIN 100 MG CAPSULE (morgidox) T3 PA VIBRAMYCIN 25 MG/5 ML SUSP (doxycycline T3 monohydrate) VIBRAMYCIN 50 MG/5 ML SYRUP T2 XIMINO T3 ST VAGINAL ANTIBIOTICS CLEOCIN T3

40 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Infections) VAGINAL ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits CLEOCIN (clindamycin phosphate) T3 clindamycin phosphate (Cleocin) T1 CLINDESSE T3 METROGEL-VAGINAL (vandazole) T3 metronidazole (Metrogel-vaginal) T1 NUVESSA T3 VANCOMYCIN ANTIBIOTICS AND DERIVATIVES FIRVANQ T2 VANCOCIN HCL (vancomycin hcl) T3 PA vancomycin hcl (Firvanq) T1 vancomycin hcl (Vancocin Hcl) T1 ANTIBIOTICS (Skin Conditions) TOPICAL ANTIBIOTIC AND ANTI-INFLAMMATORY STEROID CORTISPORIN T3 NEO-SYNALAR T3 TOPICAL ANTIBIOTICS AKTIPAK T2 AMZEEQ T3 PA BENZAMYCIN (erythromycin-benzoyl peroxide) T3 CENTANY T3 CENTANY AT T3 CLEOCIN T (clindamycin phosphate) T3 clindacin etz 1% pledget (Cleocin T) T1 CLINDACIN ETZ KIT T3 CLINDACIN PAC T3 CLINDAGEL T3 PA clindamycin phosphate T1 clindamycin phosphate (Cleocin T) T1 clindamycin phosphate (Evoclin) T1 erythromycin base in ethanol T1 erythromycin base in ethanol T3 erythromycin/benzoyl peroxide (Benzamycin) T1 EVOCLIN (clindamycin phosphate) T3

41 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIBIOTICS (Skin Conditions) TOPICAL ANTIBIOTICS Prescription drug name Drug tier Coverage requirements and limits gentamicin sulfate T1 mupirocin (Centany) T1 mupirocin calcium T1 XEPI T3 ZILXI T3 PA TOPICAL SULFONAMIDES AVAR 9.5-5% CLEANSING PADS T3 avar cleanser (Rosanil) T1 AVAR LS T3 AVAR-E T1 AVAR-E GREEN T1 mafenide acetate (Sulfamylon) T1 ROSANIL (sodium sulfacetamide-sulfur) T1 SILVADENE (ssd) T3 silver sulfadiazine (Silvadene) T1 sulfacetamide sod/sulfur/urea T1 sulfacetamide sodium/sulfur T1 sulfacetamide sodium/sulfur (Avar-e Green) T1 sulfacetamide sodium/sulfur (Rosanil) T1 sulfacetamide/sulfur/cleansr23 T1 sulfact sod/sulur/avob/otn/oct T1 SULFAMYLON 8.5% CREAM T2 SULFAMYLON POWDER PACKET (mafenide T3 acetate) ANTICOAGULANTS (Blood Thinners/Anti-Clotting) ANTICOAGULANTS, COUMARIN TYPE warfarin sodium T1 HD CITRATES AS ANTICOAGULANTS ACD SOLUTION A T3 ACD-A T3 ANTICOAG SODIUM CITRATE 4% SOL T3 ANTICOAG SODIUM CITRATE 4% SYR T1 CITRATE PHOSPHATE DEXTROSE T1 SODIUM CITRATE T1

42 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTICOAGULANTS (Blood Thinners/Anti-Clotting) DIRECT FACTOR XA INHIBITORS Prescription drug name Drug tier Coverage requirements and limits BEVYXXA T3 QL (42 caps/42 days) ELIQUIS T2 PA SAVAYSA 15 MG TABLET T3 PA QL (1 tab/day) SAVAYSA 30 MG TABLET T3 PA QL (1 tab/day) SAVAYSA 60 MG TABLET T3 PA XARELTO T2 PA HEPARIN AND RELATED PREPARATIONS ARIXTRA (fondaparinux sodium) T4 QL (1 syringe/day) SP enoxaparin 100 mg/ml syringe (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 120 mg/0.8 ml syr (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 150 mg/ml syringe (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 30 mg/0.3 ml syr (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 300 mg/3 ml vial (Lovenox) T4 QL (1 vial/day) SP enoxaparin 40 mg/0.4 ml syr (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 60 mg/0.6 ml syr (Lovenox) T4 QL (2 syringes/day) SP enoxaparin 80 mg/0.8 ml syr (Lovenox) T4 QL (2 syringes/day) SP fondaparinux sodium (Arixtra) T4 QL (1 syringe/day) SP FRAGMIN T2 QL (2ML/DAY) SP heparin 10,000 unit/10 ml vial T1 heparin 30,000 unit/30 ml vial T1 heparin 40,000 unit/4 ml vial T1 heparin 50,000 unit/10 ml vial T1 heparin 50,000 unit/5 ml vial T1 heparin sod 1,000 unit/ml vial T1 heparin sod 10,000 unit/ml vl T1 heparin sod 20,000 unit/ml vl T1 heparin sod 2,000 unit/ml vl T1 heparin sod 5,000 unit/0.5 ml T1 HEPARIN SOD 5,000 UNIT/0.5 ML T1 heparin sod 5,000 unit/0.5 ml (Heparin Sodium) T1 heparin sod 5,000 unit/ml syrg T3 heparin sod 5,000 unit/ml vial T1 LOVENOX 100 MG/ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium)

43 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTICOAGULANTS (Blood Thinners/Anti-Clotting) HEPARIN AND RELATED PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits LOVENOX 120 MG/0.8 ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) LOVENOX 150 MG/ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) LOVENOX 30 MG/0.3 ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) LOVENOX 300 MG/3 ML VIAL (enoxaparin sodium) T4 QL (1 vial/day) SP LOVENOX 40 MG/0.4 ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) LOVENOX 60 MG/0.6 ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) LOVENOX 80 MG/0.8 ML SYRINGE (enoxaparin T4 QL (2 syringes/day) SP sodium) THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE PRADAXA T3 PA HD ANTIDOTES (Gastrointestinal/Heartburn) MU-OPIOID RECEPTOR ANTAGONISTS, PERIPHERALLY-ACTING MOVANTIK T3 PA RELISTOR T3 PA SYMPROIC T3 PA ANTIDOTES (Substance Abuse)

OPIOID ANTAGONISTS EVZIO T3 PA QL (0.8ml/day) naloxone 0.4 mg/ml carpuject T1 naloxone 0.4 mg/ml vial T1 NALOXONE 2 MG AUTO-INJECTOR T3 QL (0.8ml/day) naloxone 2 mg/2 ml syringe T1 naloxone 4 mg/10 ml vial T1 naltrexone hcl T1 QL (180 tabs/30 days) NARCAN T2 QL (2 units/30 days) ANTIFUNGALS (Eye Conditions) OPHTHALMIC ANTIFUNGAL AGENTS NATACYN T2 ANTIFUNGALS (Feminine Products) VAGINAL ANTIFUNGALS GYNAZOLE 1 T1

44 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIFUNGALS (Feminine Products) VAGINAL ANTIFUNGALS Prescription drug name Drug tier Coverage requirements and limits miconazole nitrate T1 terconazole T1 ANTIFUNGALS (Infections) ANTIFUNGAL AGENTS ANCOBON (flucytosine) T3 clotrimazole T1 CRESEMBA T3 PA DIFLUCAN (fluconazole) T3 PA fluconazole (Diflucan) T1 flucytosine (Ancobon) T1 itraconazole (Sporanox) T1 ketoconazole T1 NOXAFIL 40 MG/ML SUSPENSION T3 NOXAFIL DR 100 MG TABLET (posaconazole) T3 PA ORAVIG T3 POSACONAZOLE 200 MG/5 ML SUSP T3 posaconazole dr 100 mg tablet (Noxafil) T1 SPORANOX (itraconazole) T3 PA terbinafine hcl T1 TOLSURA T3 VFEND (voriconazole) T3 PA voriconazole (Vfend) T1 PA ANTIFUNGAL ANTIBIOTICS griseofulvin ultramicrosize (Gris-peg) T1 griseofulvin, microsize T1 GRIS-PEG (griseofulvin ultramicrosize) T3 nystatin T1 ANTIFUNGALS (Skin Conditions) TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY, STEROID AGENT clotrimazole/betamethasone dip T1 TOPICAL ANTIFUNGALS ciclodan 0.77% cream (Loprox) T1 CICLODAN 0.77% CREAM KIT T3

45 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIFUNGALS (Skin Conditions) TOPICAL ANTIFUNGALS Prescription drug name Drug tier Coverage requirements and limits ciclodan 8% solution T1 ciclopirox T1 ciclopirox (Loprox) T1 ciclopirox olamine (Loprox) T1 DIFMETIOXRIME T3 econazole nitrate T1 ECOZA T3 ERTACZO T3 PA EXELDERM T3 PA EXODERM T1 EXTINA (ketodan) T3 PA FLUCONAZ-IBU-ITRACONAZ-TERBINA T3 JUBLIA T3 PA KERYDIN T3 PA KERYDIN (tavaborole) T3 PA ketoconazole T1 ketoconazole (Extina) T1 ketoconazole/skin cleanser 28 T1 LOPROX 0.77% CREAM (ciclopirox) T3 PA LOPROX 0.77% SUSPENSION KIT T3 LOPROX 0.77% TOPICAL SUSP (ciclopirox) T3 LOPROX 1% SHAMPOO (ciclopirox) T3 PA LULICONAZOLE T1 LUZU T3 PA MICONAZOLE-ZINC OXIDE-PETROLTM T1 PA naftifine hcl T1 naftifine hcl (Naftin) T1 NAFTIN T2 NAFTIN (naftifine hcl) T2 nystatin T1 nystatin/triamcin T1 oxiconazole nitrate (Oxistat) T1 OXISTAT 1% CREAM (oxiconazole nitrate) T3 PA

46 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIFUNGALS (Skin Conditions) TOPICAL ANTIFUNGALS Prescription drug name Drug tier Coverage requirements and limits OXISTAT 1% LOTION T2 PA SULCONAZOLE NITRATE T3 PA tavaborole (Kerydin) T1 PA VUSION T3 PA XOLEGEL T3 PA ANTIHISTAMINE AND DECONGESTANT COMBINATION (Allergy/Nasal Sprays) 1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION phenylephrine hcl/prometh hcl T1 2ND GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION CLARINEX-D 12 HOUR T3 ANTIHISTAMINES (Allergy/Nasal Sprays) ANTIHISTAMINES - 1ST GENERATION carbinoxamine 4 mg/5 ml liquid T1 carbinoxamine maleate 4 mg tab T1 carbinoxamine maleate 6 mg tab (Ryvent) T1 PA clemastine fumarate T1 cyproheptadine hcl T1 cyproheptadine hcl (Cyproheptadine Hcl) T1 dexchlorpheniramine maleate (Ryclora) T1 hydroxyzine hcl T1 hydroxyzine pamoate T1 hydroxyzine pamoate (Vistaril) T1 KARBINAL ER T3 promethazine hcl T1 RYCLORA (dexchlorpheniramine maleate) T3 RYVENT T3 PA VISTARIL (hydroxyzine pamoate) T3 ANTIHISTAMINES - 2ND GENERATION cetirizine hcl T1 HD CLARINEX (desloratadine) T3 HD desloratadine 2.5 mg odt T1 QL (1 tab/day) HD desloratadine 5 mg odt T1 HD desloratadine 5 mg tablet (Clarinex) T1 HD

47 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHISTAMINES (Eye Conditions) EYE ANTIHISTAMINES Prescription drug name Drug tier Coverage requirements and limits azelastine hcl 0.05% drops T1 BEPREVE T3 epinastine hcl T1 LASTACAFT T3 olopatadine hcl 0.1% eye drops T1 olopatadine hcl 0.2% eye drop (Pataday) T1 PATADAY (olopatadine hcl) T3 PAZEO T2 ZERVIATE T2

ANTIHYPERGLYCEMICS (Diabetes) ANTIHYPERGLY, DPP-4 ENZYME INHIB.-THIAZOLIDINEDIONE ALOGLIPTIN-PIOGLITAZONE T1 PA QL (1 tab/day) HD OSENI T3 PA QL (1 tab/day) HD ANTIHYPERGLY, INCRETIN MIMETIC (GLP-1 RECEP.AGONIST) ADLYXIN T3 QL (1 pen/28 days) ST HD BYDUREON T2 QL (4 vials/28 days) ST HD BYDUREON BCISE T2 QL (4 pens/28 days) ST HD BYDUREON PEN T2 QL (4 pens/28 days) ST HD BYETTA T2 QL (1 pen/30 days) ST HD OZEMPIC 0.25-0.5 MG DOSE PEN T2 QL (2 pens/28 days) ST HD OZEMPIC 1 MG DOSE PEN (1.5 ML) T2 QL (2 pens/28 days) ST HD OZEMPIC 1 MG DOSE PEN (3 ML) T2 QL (3ML/21 Days) ST HD

RYBELSUS T2 QL (1 tab/day) ST HD TRULICITY 0.75 MG/0.5 ML PEN T2 QL (4 pens/28 days) ST HD TRULICITY 1.5 MG/0.5 ML PEN T2 QL (4 pens/28 days) ST HD TRULICITY 3 MG/0.5 ML PEN T2 QL (2 ML/28 Days) ST HD TRULICITY 4.5 MG/0.5 ML PEN T2 QL (2 ML/28 Days) ST HD VICTOZA 2-PAK T2 QL (3 pens/30 days) ST HD VICTOZA 3-PAK T2 QL (3 pens/30 days) ST HD

ANTIHYPERGLY, INSULIN, LONG ACT-GLP-1 RECEPT.AGONIST SOLIQUA 100-33 T2 HD XULTOPHY 100-3.6 T2 HD

48 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHYPERGLYCEMICS (Diabetes) ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2 (SGLT2) INHIB Prescription drug name Drug tier Coverage requirements and limits FARXIGA T2 QL (1 tab/day) ST HD INVOKANA T2 QL (1 tab/day) ST HD JARDIANCE T2 QL (1 tab/day) ST HD STEGLATRO T2 QL (1 tab/day) ST HD ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS CYCLOSET T3 HD ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORS acarbose (Precose) T1 HD GLYSET (miglitol) T3 HD miglitol (Glyset) T1 HD PRECOSE (acarbose) T3 HD ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE SYMLINPEN 120 T2 HD SYMLINPEN 60 T2 HD ANTIHYPERGLYCEMIC, BIGUANIDE TYPE FORTAMET (metformin er osmotic) T3 PA HD GLUCOPHAGE XR (metformin hcl er) T3 HD GLUMETZA (metformin er gastric) T3 PA HD metformin hcl T1 HD metformin hcl (Fortamet) T1 PA HD metformin hcl (Glucophage Xr) T1 HD metformin hcl (Glumetza) T1 PA HD metformin hcl (Riomet) T1 HD RIOMET (metformin hcl) T3 HD RIOMET ER T3 HD ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS ALOGLIPTIN T1 PA QL (1 tab/day) HD JANUVIA T2 QL (1 tab/day) ST HD NESINA T3 PA QL (1 tab/day) HD ONGLYZA T3 PA QL (1 tab/day) HD TRADJENTA T3 PA QL (2 tabs/day) HD ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE AMARYL (glimepiride) T3 HD

49 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHYPERGLYCEMICS (Diabetes) ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE Prescription drug name Drug tier Coverage requirements and limits chlorpropamide T1 HD glimepiride (Amaryl) T1 HD glipizide (Glucotrol Xl) T1 HD glipizide (Glucotrol) T1 HD GLUCOTROL (glipizide) T3 HD GLUCOTROL XL (glipizide xl) T3 HD glyburide T1 HD glyburide, micronized (Glynase) T1 HD GLYNASE (glyburide micronized) T3 HD nateglinide (Starlix) T1 HD PRANDIN (repaglinide) T3 HD repaglinide T1 HD repaglinide (Prandin) T1 HD STARLIX (nateglinide) T3 HD tolbutamide T1 HD ANTIHYPERGLYCEMIC, SGLT-2 AND DPP-4 INHIBITOR COMB GLYXAMBI T2 QL (1 tab/day) ST HD QTERN T2 QL (1 tab/day) ST HD STEGLUJAN T3 QL (1 tab/day) ST HD ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDE ACTOPLUS MET (pioglitazone-metformin) T3 HD pioglitazone hcl/metformin hcl (Actoplus Met) T1 HD ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE-SULFONYLUREA DUETACT (pioglitazone-glimepiride) T3 HD pioglitazone hcl/glimepiride (Duetact) T1 HD ANTIHYPERGLYCEMIC, DPP-4 INHIBITOR-BIGUANIDE COMBS. ALOGLIPTIN-METFORMIN T1 PA QL (2 tabs/day) HD JANUMET T2 QL (2 tabs/day) ST HD JANUMET XR 100-1,000 MG TABLET T2 QL (1 tab/day) ST HD JANUMET XR 50-1,000 MG TABLET T2 QL (2 tabs/day) ST HD JANUMET XR 50-500 MG TABLET T2 QL (1 tab/day) ST HD JENTADUETO T3 PA QL (4 tabs/day) HD JENTADUETO XR 2.5 MG-1,000 MG T3 PA QL (2 tabs/day) HD

50 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHYPERGLYCEMICS (Diabetes) ANTIHYPERGLYCEMIC, DPP-4 INHIBITOR-BIGUANIDE COMBS. Prescription drug name Drug tier Coverage requirements and limits JENTADUETO XR 5 MG-1,000 MG TB T3 PA QL (1 tab/day) HD KAZANO T3 PA QL (2 tabs/day) HD KOMBIGLYZE XR 2.5-1,000 MG TAB T3 PA QL (2 tabs/day) HD KOMBIGLYZE XR 5-1,000 MG TAB T3 PA QL (1 tab/day) HD KOMBIGLYZE XR 5-500 MG TABLET T3 PA QL (1 tab/day) HD ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIM.-BIGUANIDE glipizide/metformin hcl T1 HD glyburide/metformin hcl T1 HD repaglinide/metformin hcl T1 HD ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE (PPARG AGONIST) ACTOS (pioglitazone hcl) T3 HD AVANDIA T3 HD pioglitazone hcl (Actos) T1 HD ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKER KORLYM T4 PA SP ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS. INVOKAMET T2 QL (2 tabs/day) ST HD INVOKAMET XR T2 QL (2 tabs/day) ST HD SEGLUROMET T2 QL (2 tabs/day) ST HD SYNJARDY T2 QL (2 tabs/day) ST HD SYNJARDY XR 10-1,000 MG TABLET T2 QL (2 tabs/day) ST HD SYNJARDY XR 12.5-1,000 MG TAB T2 QL (2 tabs/day) ST HD SYNJARDY XR 25-1,000 MG TABLET T2 QL (1 tab/day) ST HD SYNJARDY XR 5-1,000 MG TABLET T2 QL (2 tabs/day) ST HD XIGDUO XR 10 MG-1,000 MG TAB T2 QL (1 tab/day) ST HD XIGDUO XR 10 MG-500 MG TABLET T2 QL (1 tab/day) ST HD XIGDUO XR 2.5 MG-1,000 MG TAB T2 QL (2 tabs/day) ST HD XIGDUO XR 5 MG-1,000 MG TABLET T2 QL (2 tabs/day) ST HD XIGDUO XR 5 MG-500 MG TABLET T2 QL (1 tab/day) ST HD ANTIHYPERGLY-SGLT-2 INHIB, DPP-4 INHIB, BIGUANIDE CB TRIJARDY XR T2 QL (1 tab/day) ST HD INSULINS ADMELOG T3 QL (1.5ml/day) HD

51 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHYPERGLYCEMICS (Diabetes) INSULINS Prescription drug name Drug tier Coverage requirements and limits ADMELOG SOLOSTAR T3 QL (1.5ml/day) HD AFREZZA 12 UNIT CARTRIDGE T3 PA QL (12 cartridges/day) HD AFREZZA 4 UNIT CARTRIDGE T3 PA QL (36 cartridges/day) HD AFREZZA 4 UNIT/8 UNIT/12 UNIT T3 PA QL (6 cartridges/day) HD AFREZZA 8 UNIT CARTRIDGE T3 PA QL (18 cartridges/day) HD AFREZZA 90-4 UNIT / 90-8 UNIT T3 PA QL (12 cartridges/day) HD AFREZZA 90-8 UNIT / 90-12 UNIT T3 PA QL (6 cartridges/day) HD APIDRA T3 QL (1.5ML/DAY) HD APIDRA SOLOSTAR T3 QL (1.5ML/DAY) HD BASAGLAR KWIKPEN U-100 T2 QL (1.5ml/day) HD FIASP T2 QL (1.5ml/day) HD FIASP FLEXTOUCH T2 QL (1.5ml/day) HD FIASP PENFILL T2 QL (1.5ml/day) HD HUMALOG T2 QL (1.5ml/day) HD HUMALOG JUNIOR KWIKPEN T2 QL (1.5ml/day) HD HUMALOG KWIKPEN U-100 T2 QL (1.5ML/DAY) HD HUMALOG KWIKPEN U-200 T2 QL (1ML/DAY) HD HUMALOG MIX 50-50 T2 QL (1ML/DAY) HD HUMALOG MIX 50-50 KWIKPEN T2 QL (1ML/DAY) HD HUMALOG MIX 75-25 T2 QL (2ml/day) HD HUMALOG MIX 75-25 KWIKPEN T2 QL (2ml/day) HD HUMULIN R U-500 T2 QL (1ML/DAY) HD HUMULIN R U-500 KWIKPEN T2 QL (1ML/DAY) HD INSULIN ASPART T2 QL (1.5ml/day) HD INSULIN ASPART FLEXPEN T2 QL (1.5ml/day) HD INSULIN ASPART PENFILL T2 QL (1.5ml/day) HD INSULIN ASPART PROT-INSULN ASP T2 QL (2ML/DAY) HD INSULIN LISPRO T2 QL (1.5ml/day) HD INSULIN LISPRO JUNIOR KWIKPEN T2 QL (1.5ml/day) HD INSULIN LISPRO KWIKPEN U-100 T2 QL (1.5ml/day) HD INSULIN LISPRO PROTAMINE MIX T2 QL (2ml/day) HD LANTUS T3 PA QL (1.5ml/day) HD LANTUS SOLOSTAR T3 PA QL (1.5ml/day) HD

52 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIHYPERGLYCEMICS (Diabetes) INSULINS Prescription drug name Drug tier Coverage requirements and limits LEVEMIR T2 QL (1.5ml/day) HD LEVEMIR FLEXTOUCH T2 QL (1.5ml/day) HD LYUMJEV T2 QL (1.5ML/DAY) HD LYUMJEV KWIKPEN U-100 T2 QL (1.5ML/DAY) HD LYUMJEV KWIKPEN U-200 T2 QL (1ML/DAY) HD NOVOLOG T2 QL (1.5ml/day) HD NOVOLOG FLEXPEN T2 QL (1.5ml/day) HD NOVOLOG MIX 70-30 T2 QL (2ml/day) HD NOVOLOG MIX 70-30 FLEXPEN T2 QL (2ml/day) HD SEMGLEE T3 PA QL (1.5ML/DAY) HD SEMGLEE PEN T3 PA QL (1.5ML/DAY) HD TOUJEO MAX SOLOSTAR T3 PA QL (0.6ml/day) HD TOUJEO SOLOSTAR T3 PA QL (0.6ml/day) HD TRESIBA T2 QL (1.5ml/day) HD TRESIBA FLEXTOUCH U-100 T2 QL (1.5ml/day) HD TRESIBA FLEXTOUCH U-200 T2 QL (0.9ml/day) HD ANTIINFECTIVES (Feminine Products) VAGINAL SULFONAMIDES AVC T3 ANTIINFECTIVES (Infections) PENICILLIN ANTIBIOTICS amoxicillin T1 ANTIINFECTIVES/MISCELLANEOUS (Feminine Products) VAGINAL ANTISEPTICS acetic acid/oxyquinoline (Relagard) T1 RELAGARD (fem ph) T3 TRIMO-SAN T3 ANTIINFECTIVES/MISCELLANEOUS (Infections) 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL TINDAMAX (tinidazole) T3 tinidazole T1 tinidazole (Tindamax) T1 AMEBICIDES paromomycin sulfate T1

53 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIINFECTIVES/MISCELLANEOUS (Infections) ANTHELMINTICS Prescription drug name Drug tier Coverage requirements and limits albendazole (Albenza) T1 ALBENZA (albendazole) T3 BILTRICIDE (praziquantel) T3 EMVERM T1 ivermectin (Stromectol) T1 praziquantel (Biltricide) T1 STROMECTOL (ivermectin) T3 ANTIMALARIAL DRUGS ARAKODA T3 PA atovaquone/proguanil hcl (Malarone) T1 chloroquine ph 250 mg tablet T1 QL (56 Tabs/365 Days) chloroquine ph 500 mg tablet T1 COARTEM T3 PA QL (24 tabs/30 days) DARAPRIM (pyrimethamine) T4 PA SP hydroxychloroquine sulfate (Plaquenil) T1 KRINTAFEL T3 PA QL (2 tabs/30 days) MALARONE (atovaquone-proguanil hcl) T3 PA mefloquine hcl T1 PLAQUENIL (hydroxychloroquine sulfate) T3 QL (30 tabs/365 days) PRIMAQUINE T1 primaquine phosphate (Primaquine) T1 pyrimethamine 25 mg tablet (Daraprim) T1 PA pyrimethamine 25 mg tablet (Daraprim) T4 PA SP QUALAQUIN (quinine sulfate) T3 PA quinine sulfate (Qualaquin) T1 ANTIPROTOZOAL DRUGS, MISCELLANEOUS atovaquone (Mepron) T1 BENZNIDAZOLE T3 IMPAVIDO T3 PA LAMPIT T3 MEPRON T3 PA MEPRON (atovaquone) T3 PA NEBUPENT (pentamidine isethionate) T2 pentamidine isethionate (Nebupent) T1

54 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIINFECTIVES/MISCELLANEOUS (Miscellaneous) ANTIBACTERIAL AGENTS, MISCELLANEOUS Prescription drug name Drug tier Coverage requirements and limits glycine urologic solution T1 glycine urologic solution T3 TOPICAL ANTISEPTIC DRYING AGENTS formadon 10% solution T1 formadon 10% solution T3 formaldehyde T1 ANTIINFECTIVES/MISCELLANEOUS (Skin Conditions) TOPICAL ANTIANDROGENIC AGENTS WINLEVI T3 PA TOPICAL ANTIFUNGALS CICLODAN 8% KIT T3 ciclopirox/urea/camph/men/euc (Ciclodan) T1 ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS (Pain Relief And Inflammatory Disease) ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR AVSOLA T4 PA SP CIMZIA 200 MG VIAL KIT T4 PA QL (1 kit/28 days) SP HD CIMZIA 2X200 MG/ML SYRINGE KIT T4 PA QL (1 kit/28 days) SP HD CIMZIA 2X200 MG/ML (X3) START KT T4 PA QL (1 kit/year) SP HD ENBREL 25 MG KIT T4 PA QL (8 vials/28 days) SP HD ENBREL 25 MG/0.5 ML SYRINGE T4 PA QL (8 syringes/28 days) SP HD ENBREL 25 MG/0.5 ML VIAL T4 PA QL (4ml/28 days) SP HD ENBREL 50 MG/ML SYRINGE T4 PA QL (4 syringes/28 days) SP HD ENBREL MINI T4 PA QL (4 cartridges/28 days) SP HD ENBREL SURECLICK T4 PA QL (4 syringes/28 days) SP HD HUMIRA T4 PA QL (2 syrings/28 days) SP HD HUMIRA PEN T4 PA QL (2 pens/28 days) SP HD HUMIRA PEN CROHN’s-UC-HS T4 PA QL (1 kit/year) SP HD HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA QL (1 kit/year) SP HD HUMIRA (CF) T4 PA QL (2 syrings/28 days) SP HD HUMIRA (CF) PEDIATRIC CROHN’s T4 PA QL (1 kit/year) SP HD HUMIRA (CF) PEN 40 MG/0.4 ML T4 PA QL (2 pens/28 days) SP HD HUMIRA (CF) PEN 80 MG/0.8 ML T4 PA QL (1 kit/year) SP HD HUMIRA (CF) PEN CROHN’s-UC-HS T4 PA QL (1 kit/year) SP HD

55 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS (Pain Relief And Inflammatory Disease) ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR Prescription drug name Drug tier Coverage requirements and limits HUMIRA (CF) PEN PEDIATRIC UC T4 PA QL (4 KITS/365 DAYS) SP HD HUMIRA (CF) PEN PSOR-UV-ADOL HS T4 PA QL (1 kit/year) SP HD INFLECTRA T4 PA SP HD REMICADE T4 PA SP HD SIMPONI 100 MG/ML PEN INJECTOR T4 PA QL (1 injector/28 days) SP HD SIMPONI 100 MG/ML SYRINGE T4 PA QL (1 syringe/28 days) SP HD SIMPONI 50 MG/0.5 ML PEN INJEC T4 PA QL (1 injector/28 days) SP HD SIMPONI 50 MG/0.5 ML SYRINGE T4 PA QL (1 syringe/28 days) SP HD SIMPONI ARIA T4 PA SP HD ANTINEOPLASTICS (Cancer) ANP - SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) bexarotene (Targretin) T4 PA SP HD TARGRETIN 75 MG CAPSULE (bexarotene) T4 PA SP HD ANTINEOPLAST, HISTONE DEACETYLASE (HDAC) INHIBITORS FARYDAK T4 PA SP HD ZOLINZA T4 PA SP HD ANTINEOPLASTIC - ALKYLATING AGENTS ALKERAN (melphalan) T4 SP cyclophosphamide 25 mg capsule T4 SP HD CYCLOPHOSPHAMIDE 25 MG TABLET T4 PA SP HD cyclophosphamide 50 mg capsule T4 SP HD CYCLOPHOSPHAMIDE 50 MG TABLET T4 PA SP HD GLEOSTINE T2 HYDREA (hydroxyurea) T3 hydroxyurea (Hydrea) T1 LEUKERAN T2 melphalan (Alkeran) T4 SP MYLERAN T2 TEMODAR (temozolomide) T4 PA SP HD temozolomide T4 PA SP HD temozolomide (Temodar) T4 PA SP HD ANTINEOPLASTIC - ANTIANDROGENIC AGENTS abiraterone acetate (Zytiga) T4 PA SP HD bicalutamide (Casodex) T1

56 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Cancer) ANTINEOPLASTIC - ANTIANDROGENIC AGENTS Prescription drug name Drug tier Coverage requirements and limits CASODEX (bicalutamide) T4 ERLEADA T1 PA SP HD flutamide T3 NILANDRON (nilutamide) T1 PA QL (4 tabs/day) nilutamide (Nilandron) T4 QL (4 tabs/day) NUBEQA T4 PA SP HD XTANDI T4 PA SP HD YONSA T4 PA SP HD ZYTIGA (abiraterone acetate) T3 PA SP HD ANTINEOPLASTIC - ANTIMETABOLITES capecitabine (Xeloda) T4 PA SP HD INQOVI T4 PA SP HD LONSURF T4 PA SP HD mercaptopurine T1 methotrexate sodium T1 methotrexate sodium/pf T1 ONUREG T4 PA QL (14 Tabs/28 Days) SP PURIXAN T4 SP TABLOID T3 TREXALL T2 XATMEP T3 XELODA (capecitabine) T3 PA SP HD ANTINEOPLASTIC - AROMATASE INHIBITORS anastrozole (Arimidex) T1 HD PPACA ARIMIDEX (anastrozole) T3 HD AROMASIN (exemestane) T3 HD exemestane (Aromasin) T1 HD PPACA FEMARA (letrozole) T3 HD letrozole (Femara) T1 HD ANTINEOPLASTIC - BRAF KINASE INHIBITORS BRAFTOVI T4 PA SP HD TAFINLAR T4 PA SP HD ZELBORAF T4 PA SP HD

57 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Cancer) ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR Prescription drug name Drug tier Coverage requirements and limits DAURISMO T4 PA SP HD ERIVEDGE T4 PA SP HD ODOMZO T4 PA SP HD ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS JAKAFI T4 PA SP HD ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS COTELLIC T4 PA SP HD KOSELUGO 10 MG CAPSULE T4 PA QL (10 capsules/day) SP KOSELUGO 25 MG CAPSULE T4 PA QL (4 caps/day) SP MEKINIST T4 PA SP HD MEKTOVI T4 PA SP HD ANTINEOPLASTIC - MTOR KINASE INHIBITORS AFINITOR T4 PA SP HD AFINITOR (everolimus) T4 PA SP HD AFINITOR DISPERZ T4 PA SP everolimus 2.5 mg tablet (Afinitor) T4 PA SP HD everolimus 5 mg tablet (Afinitor) T4 PA SP HD everolimus 7.5 mg tablet (Afinitor) T4 PA SP HD ANTINEOPLASTIC - PROTEIN METHYLTRANSFERASE INHIBIT TAZVERIK T4 PA SP ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS HYCAMTIN T4 PA SP HD ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT KISQALI FEMARA CO-PACK T4 PA SP HD ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY PHESGO T4 PA SP HD ANTINEOPLASTIC IMMUNOMODULATOR AGENTS POMALYST T4 PA SP HD REVLIMID T4 PA SP HD ANTINEOPLASTIC LHRH (GNRH) AGONIST, PITUITARY SUPPR. leuprolide acetate T4 PA SP HD LUPRON DEPOT T4 PA SP HD ZOLADEX T4 PA SP HD

58 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Cancer) ANTINEOPLASTIC LHRH (GNRH) ANTAGONIST, PITUIT.SUPPRS Prescription drug name Drug tier Coverage requirements and limits FIRMAGON T4 PA SP HD ORGOVYX T4 PA SP ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ALECENSA T4 PA SP HD ALUNBRIG T4 PA SP HD AYVAKIT T4 PA QL (1 tab/day) SP BALVERSA T4 PA SP BOSULIF T4 PA SP HD BRUKINSA T4 PA QL (4 caps/day) SP CABOMETYX T4 PA SP HD CALQUENCE T4 PA SP CAPRELSA T4 PA SP COMETRIQ T4 PA SP HD COPIKTRA T4 PA SP erlotinib hcl (Tarceva) T4 PA SP HD GAVRETO T4 PA QL (4 Tabs/Day) SP GILOTRIF T4 PA SP HD GLEEVEC (imatinib mesylate) T4 PA SP HD IBRANCE T4 PA SP HD ICLUSIG T4 PA SP imatinib mesylate (Gleevec) T4 PA SP HD IMBRUVICA T4 PA SP INLYTA T4 PA SP HD INREBIC T4 PA SP HD IRESSA T4 PA SP HD KISQALI T4 PA SP HD lapatinib ditosylate (Tykerb) T4 PA SP HD LENVIMA T4 PA SP HD LORBRENA T4 PA SP HD LYNPARZA T4 PA SP HD NERLYNX T4 PA SP HD NEXAVAR T4 PA SP HD NINLARO T4 PA SP HD

59 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Cancer) ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS Prescription drug name Drug tier Coverage requirements and limits PEMAZYRE T4 PA QL (14 tabs/21 days) SP PIQRAY T4 PA SP HD QINLOCK T4 PA QL (3 tabs/day) SP RETEVMO 40 MG CAPSULE T4 PA QL (6 caps/day) SP HD RETEVMO 80 MG CAPSULE T4 PA QL (4 tabs/day) SP HD ROZLYTREK T4 PA SP HD RUBRACA T4 PA SP RYDAPT T4 PA SP HD SPRYCEL T4 PA SP HD STIVARGA T4 PA SP HD SUTENT T4 PA SP HD TABRECTA T4 PA QL (4 tabs/day) SP HD TAGRISSO T4 PA SP HD TALZENNA T4 PA SP HD TARCEVA (erlotinib hcl) T4 PA SP HD TASIGNA T4 PA SP HD TEPMETKO T3 PA QL (2 tabs/day) SP TUKYSA T4 PA SP TURALIO T4 PA SP TYKERB (lapatinib) T4 PA SP HD UKONIQ T3 PA QL (4 tabs/day) SP VERZENIO T4 PA SP HD VITRAKVI T4 PA SP HD VIZIMPRO T4 PA SP HD VOTRIENT T4 PA SP HD XALKORI T4 PA SP HD XOSPATA T4 PA SP ZEJULA T4 PA SP ZYDELIG T4 PA SP HD ZYKADIA T4 PA SP HD ANTINEOPLASTIC, ANTI-PROGRAMMED DEATH-1 (PD-1) MAB OPDIVO T4 PA SP HD ANTINEOPLASTIC-B CELL LYMPHOMA-2 (BCL-2) INHIBITORS VENCLEXTA T4 PA SP VENCLEXTA STARTING PACK T4 PA SP

60 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Cancer) ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORS Prescription drug name Drug tier Coverage requirements and limits IDHIFA T4 PA SP HD TIBSOVO T4 PA SP ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES ENHERTU T4 PA SP HD ANTINEOPLASTICS, MISCELLANEOUS etoposide T4 SP HD LYSODREN T2 MATULANE T4 SP tretinoin 10 mg capsule T1 PA ANTINEOPLASTIC-SELECT INHIB OF NUCLEAR EXP (SINE) XPOVIO T4 PA SP CYTOTOXIC T-LYMPHOCYTE ANTIGEN (CTLA-4) RMC ANTIBODY YERVOY T4 PA SP HD IMMUNOMODULATORS ACTIMMUNE T4 PA SP HD INTRON A T4 PA SP HD SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) FARESTON (toremifene citrate) T3 QL (2 tabs/day) HD SOLTAMOX T3 HD tamoxifen citrate T1 HD PPACA toremifene citrate (Fareston) T1 QL (2 tabs/day) HD STEROID ANTINEOPLASTICS EMCYT T4 SP HD megestrol acetate T1 ANTINEOPLASTICS (Skin Conditions) PHOTOACT, TOPICAL ANTINEOPLAST, PREMALIGNANT LESIONS LEVULAN T4 SP TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS CARAC T3 PA diclofenac sodium 3% gel T1 PA EFUDEX (fluorouracil) T3 FLUOROPLEX T2 fluorouracil T1

61 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTINEOPLASTICS (Skin Conditions) TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS Prescription drug name Drug tier Coverage requirements and limits fluorouracil (Efudex) T1 KLISYRI T3 PA QL (5 packs/30 Days) PANRETIN T4 SP HD PICATO T2 TARGRETIN 1% GEL T4 SP HD TOLAK T3 VALCHLOR T4 SP HD

ANTI-OBESITY DRUGS (Weight Management) ANTI-OBESITY - ANOREXIC AGENTS ADIPEX-P (phentermine hcl) T3 PA benzphetamine hcl T1 benzphetamine hcl (Regimex) T1 diethylpropion hcl T1 LOMAIRA T1 phendimetrazine tartrate T1 phentermine hcl T1 phentermine hcl (Adipex-p) T1 QSYMIA T3 PA REGIMEX (benzphetamine hcl) T3

ANTI-OBESITY - MELANOCORTIN 4 RECEPTOR AGONISTS IMCIVREE T4 PA QL (9 ML/22 DAYS) SP

ANTI-OBESITY GLUCAGON-LIKE PEPTIDE-1 RECEP AGONIST SAXENDA T3 PA

ANTI-OBESITY SEROTONIN 2C RECEPTOR AGONISTS BELVIQ T3 PA BELVIQ XR T3 PA

ANTI-OBESITY-OPIOID ANTAG-NOREPI, DOPAMINE RU INHIB CONTRAVE T3 PA

FAT ABSORPTION DECREASING AGENTS XENICAL T3 PA

62 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIPARASITICS (Infections) ANTIPARASITICS Prescription drug name Drug tier Coverage requirements and limits ALINIA T3 ALINIA (nitazoxanide) T3 nitazoxanide (Alinia) T1 TOPICAL ANTIPARASITICS crotamiton (Eurax) T1 ELIMITE (permethrin) T3 EURAX 10% CREAM T2 EURAX 10% LOTION T3 ivermectin (Sklice) T1 NATROBA (spinosad) T3 permethrin (Elimite) T1 SKLICE (ivermectin) T3 spinosad (Natroba) T1 ULESFIA T3 ANTIPARKINSON DRUGS (Parkinson’s Disease) ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC benztropine mesylate T1 HD trihexyphenidyl hcl T1 HD ANTIPARKINSONISM DRUGS, OTHER amantadine hcl T1 HD APOKYN T4 PA SP HD AZILECT 0.5 MG TABLET (rasagiline mesylate) T3 QL (1 tab/day) HD AZILECT 1 MG TABLET (rasagiline mesylate) T3 HD bromocriptine mesylate (Parlodel) T1 HD carbidopa/levodopa T1 HD carbidopa/levodopa (Sinemet 10-100) T1 HD carbidopa/levodopa (Sinemet 25-100) T1 HD carbidopa/levodopa (Sinemet 25-250) T1 HD carbidopa/levodopa/entacapone (Stalevo 100) T1 HD carbidopa/levodopa/entacapone (Stalevo 125) T1 HD carbidopa/levodopa/entacapone (Stalevo 150) T1 HD carbidopa/levodopa/entacapone (Stalevo 200) T1 HD carbidopa/levodopa/entacapone (Stalevo 50) T1 HD

63 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIPARKINSON DRUGS (Parkinson’s Disease) ANTIPARKINSONISM DRUGS, OTHER Prescription drug name Drug tier Coverage requirements and limits carbidopa/levodopa/entacapone (Stalevo 75) T1 HD COMTAN (entacapone) T3 HD DUOPA T4 SP HD entacapone (Comtan) T1 HD GOCOVRI T3 HD INBRIJA T4 PA SP HD KYNMOBI T2 PA HD MIRAPEX ER 0.375 MG TABLET (pramipexole er) T3 QL (1 tab/day) HD MIRAPEX ER 0.75 MG TABLET (pramipexole er) T3 HD MIRAPEX ER 1.5 MG TABLET (pramipexole er) T3 QL (1 tab/day) HD MIRAPEX ER 2.25 MG TABLET (pramipexole er) T3 QL (1 tab/day) HD MIRAPEX ER 3 MG TABLET (pramipexole er) T3 HD MIRAPEX ER 3.75 MG TABLET (pramipexole er) T3 HD MIRAPEX ER 4.5 MG TABLET (pramipexole er) T3 HD NEUPRO T3 HD NOURIANZ T4 PA QL (1 tab/day) SP HD ONGENTYS T3 PA QL (1 CAPS/DAY) HD OSMOLEX ER 129 MG TABLET T3 QL (1 tab/day) HD OSMOLEX ER 193 MG TABLET T3 QL (1 tab/day) HD OSMOLEX ER 258 MG TABLET T3 QL (1 tab/day) HD OSMOLEX ER 322 MG DAILY DOSE T3 QL (2 tabs/day) HD PARLODEL (bromocriptine mesylate) T3 HD pramipexole di-hcl T1 HD pramipexole er 0.375 mg tablet (Mirapex Er) T1 QL (1 tab/day) HD pramipexole er 0.75 mg tablet (Mirapex Er) T1 HD pramipexole er 1.5 mg tablet (Mirapex Er) T1 QL (1 tab/day) HD pramipexole er 2.25 mg tablet (Mirapex Er) T1 QL (1 tab/day) HD pramipexole er 3 mg tablet (Mirapex Er) T1 HD pramipexole er 3.75 mg tablet (Mirapex Er) T1 HD pramipexole er 4.5 mg tablet (Mirapex Er) T1 HD rasagiline mesylate 0.5 mg tab (Azilect) T1 QL (1 tab/day) HD rasagiline mesylate 1 mg tab (Azilect) T1 HD ropinirole hcl T1 HD

64 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIPARKINSON DRUGS (Parkinson’s Disease) ANTIPARKINSONISM DRUGS, OTHER Prescription drug name Drug tier Coverage requirements and limits RYTARY T3 HD selegiline hcl T1 HD SINEMET 10-100 (carbidopa-levodopa) T3 HD SINEMET 25-100 (carbidopa-levodopa) T3 HD SINEMET 25-250 (carbidopa-levodopa) T3 HD STALEVO 100 (carbidopa-levodopa-entacapone) T3 HD STALEVO 125 (carbidopa-levodopa-entacapone) T3 HD STALEVO 150 (carbidopa-levodopa-entacapone) T3 HD STALEVO 200 (carbidopa-levodopa-entacapone) T3 HD STALEVO 50 (carbidopa-levodopa-entacapone) T3 HD STALEVO 75 (carbidopa-levodopa-entacapone) T3 HD TASMAR (tolcapone) T3 HD tolcapone (Tasmar) T1 HD XADAGO T3 ST HD ZELAPAR T3 PA HD DECARBOXYLASE INHIBITORS carbidopa (Lodosyn) T1 LODOSYN (carbidopa) T3 PA ANTIPLATELET DRUGS (Blood Thinners/Anti-Clotting) PLATELET AGGREGATION INHIBITORS aspirin/dipyridamole T1 HD ASPIRIN-OMEPRAZOLE T3 PA HD BRILINTA T2 HD cilostazol T1 HD clopidogrel bisulfate T1 HD clopidogrel bisulfate (Plavix) T1 HD dipyridamole T1 HD EFFIENT (prasugrel hcl) T3 HD PLAVIX (clopidogrel) T3 HD prasugrel hcl (Effient) T1 HD ticlopidine hcl T1 HD YOSPRALA T3 PA HD ZONTIVITY T3 HD

65 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIPLATELET DRUGS (Blood Thinners/Anti-Clotting) PLATELET REDUCING AGENTS Prescription drug name Drug tier Coverage requirements and limits AGRYLIN (anagrelide hcl) T3 anagrelide hcl T1 anagrelide hcl (Agrylin) T1 ANTIVIRALS (AIDS/HIV) ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB. CABENUVA T4 PA SP JULUCA T4 SP ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NRTI COMB. DOVATO T4 SP ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMB TRIUMEQ T4 SP ANTIRETROVIRAL-NUCLEOSIDE, NUCLEOTIDE, PROTEASE INH. SYMTUZA T4 SP ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB APTIVUS T4 PA SP PREZCOBIX T4 PA SP PREZISTA T4 SP ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG CIMDUO T4 PA SP DESCOVY T4 PA SP PPACA emtricitabine-tenofv 100-150mg (Truvada) T4 SP emtricitabine-tenofv 133-200mg (Truvada) T4 SP emtricitabine-tenofv 167-250mg (Truvada) T4 SP emtricitabine-tenofv 200-300mg (Truvada) T4 SP PPACA TEMIXYS T4 PA SP TRUVADA (emtricitabine-tenofovir disop) T4 PA SP ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB abacavir sulfate/lamivudine (Epzicom) T4 PA SP abacavir/lamivudine/zidovudine (Trizivir) T4 PA SP COMBIVIR (lamivudine-zidovudine) T4 PA SP EPZICOM (abacavir-lamivudine) T4 PA SP lamivudine/zidovudine (Combivir) T4 SP TRIZIVIR (abacavir-lamivudine-zidovudine) T4 PA SP

66 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (AIDS/HIV) ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. Prescription drug name Drug tier Coverage requirements and limits AGRYLIN (anagrelide hcl) T4 ANTIVIRALS, HIV-SPECIFIC, CD4 ATTACHMENT INHIBITOR RUKOBIA T4 PA QL (2 SYRINGE/DAY) ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON T4 PA SP ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI EDURANT T4 PA SP efavirenz (Sustiva) T4 PA SP INTELENCE T4 PA SP nevirapine T4 PA SP nevirapine (Viramune Xr) T4 PA SP nevirapine (Viramune) T4 PA SP PIFELTRO T4 PA SP SUSTIVA (efavirenz) T4 PA SP VIRAMUNE (nevirapine) T4 PA SP VIRAMUNE XR (nevirapine er) T4 PA SP ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI abacavir sulfate (Ziagen) T4 PA SP didanosine (Videx Ec) T4 PA SP emtricitabine (Emtriva) T4 PA SP EMTRIVA 10 MG/ML SOLUTION T4 PA SP EMTRIVA 200 MG CAPSULE (emtricitabine) T4 PA SP EPIVIR (lamivudine) T4 PA SP lamivudine 10 mg/ml oral soln (Epivir) T4 SP lamivudine 150 mg tablet (Epivir) T4 SP lamivudine 300 mg tablet (Epivir) T4 PA SP RETROVIR (zidovudine) T4 PA SP stavudine T4 PA SP VIDEX EC T4 PA SP VIDEX EC (didanosine) T4 PA SP ZIAGEN (abacavir) T4 PA SP zidovudine T4 SP zidovudine (Retrovir) T4 SP

67 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (AIDS/HIV) ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI Prescription drug name Drug tier Coverage requirements and limits tenofovir disoproxil fumarate (Viread) T4 PA SP VIREAD 150 MG TABLET T4 PA SP VIREAD 200 MG TABLET T4 PA SP VIREAD 250 MG TABLET T4 PA SP VIREAD 300 MG TABLET (tenofovir disoproxil T4 PA SP fumarate) VIREAD POWDER T4 PA SP ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB KALETRA 100-25 MG TABLET T4 KALETRA 200-50 MG TABLET T4 KALETRA 80 MG-20 MG/ML SOLN (lopinavir- T4 ritonavir) lopinavir/ritonavir (Kaletra) T4 ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS atazanavir sulfate (Reyataz) T4 PA SP CRIXIVAN T4 PA SP EVOTAZ T4 PA SP fosamprenavir calcium (Lexiva) T4 PA SP INVIRASE T4 PA SP LEXIVA 50 MG/ML SUSPENSION T4 PA SP LEXIVA 700 MG TABLET (fosamprenavir calcium) T4 PA SP NORVIR 100 MG POWDER PACKET T4 SP NORVIR 100 MG TABLET (ritonavir) T4 PA SP NORVIR 80 MG/ML SOLUTION T4 SP REYATAZ 150 MG CAPSULE (atazanavir sulfate) T4 PA SP REYATAZ 200 MG CAPSULE (atazanavir sulfate) T4 PA SP REYATAZ 300 MG CAPSULE (atazanavir sulfate) T4 PA SP REYATAZ 50 MG POWDER PACKET T4 PA SP ritonavir (Norvir) T4 SP VIRACEPT T4 PA SP ANTIVIRALS, HIV-1 INTEGRASE STRAND TRANSFER INHIBTR ISENTRESS T4 SP ISENTRESS HD T4 PA SP TIVICAY T4 SP TIVICAY PD T4 SP

68 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (AIDS/HIV) ARTV NUCLEOSIDE, NUCLEOTIDE, NON-NUCLEOSIDE RTI COMB Prescription drug name Drug tier Coverage requirements and limits ATRIPLA (efavirenz-emtric-tenofov disop) T4 PA SP COMPLERA T4 PA SP DELSTRIGO T4 PA SP efavirenz/emtricit/tenofovr df (Atripla) T4 PA SP efavirenz/lamivu/tenofov disop (Symfi Lo) T4 SP efavirenz/lamivu/tenofov disop (Symfi) T4 SP ODEFSEY T4 PA SP SYMFI (efavirenz-lamivu-tenofov disop) T4 SP SYMFI LO (efavirenz-lamivu-tenofov disop) T4 SP ARV-NUCLEOSIDE, NUCLEOTIDE RTI, INTEGRASE INHIBITORS BIKTARVY T4 SP GENVOYA T4 SP STRIBILD T4 PA SP ANTIVIRALS (Eye Conditions) EYE ANTIVIRALS trifluridine T1 ZIRGAN T3 ANTIVIRALS (Infections) ANTIVIRALS, GENERAL acyclovir 200 mg capsule T1 acyclovir 200 mg/5 ml susp (Zovirax) T1 acyclovir 400 mg tablet T1 acyclovir 800 mg tablet T1 famciclovir T1 FLUMADINE (rimantadine hcl) T3 oseltamivir 6 mg/ml suspension (Tamiflu) T1 QL (180ml/30 days) oseltamivir phos 30 mg capsule (Tamiflu) T1 QL (20/30 days) oseltamivir phos 45 mg capsule (Tamiflu) T1 QL (10/30 days) oseltamivir phos 75 mg capsule (Tamiflu) T1 QL (10 caps/30 days) PREVYMIS T4 SP HD RELENZA T3 QL (20/30 days) ribavirin (Virazole) T4 SP HD rimantadine hcl (Flumadine) T1

69 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (Infections) ANTIVIRALS, GENERAL Prescription drug name Drug tier Coverage requirements and limits SITAVIG T3 PA QL (2 tabs/Rx) TAMIFLU 30 MG CAPSULE (oseltamivir phosphate) T3 QL (20/30 days) TAMIFLU 45 MG CAPSULE (oseltamivir phosphate) T3 QL (10/30 days) TAMIFLU 6 MG/ML SUSPENSION (oseltamivir T3 QL (180ml/30 days) phosphate) TAMIFLU 75 MG CAPSULE (oseltamivir phosphate) T3 QL (10/30 days) valacyclovir hcl (Valtrex) T1 VALCYTE (valganciclovir hcl) T3 PA valganciclovir hcl (Valcyte) T1 VALTREX (valacyclovir) T3 VIRAZOLE T4 SP HD XOFLUZA T3 QL (2 tabs/30 days) ZOVIRAX 200 MG/5 ML SUSP (acyclovir) T3 PA HEP C - NS5A, NS3/4A, NON-NUCLEO.NS5B INHIB COMB. VIEKIRA PAK T4 PA SP HD HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBO VOSEVI T4 PA SP HD HEP C VIRUS, NUCLEOTIDE ANALOG NS5B POLYMERASE INH SOVALDI 150 MG PELLET PACKET T4 PA QL (1 tab/day) SP HD SOVALDI 200 MG PELLET PACKET T4 PA QL (1 tab/day) SP HD SOVALDI 200 MG TABLET T4 PA QL (1 tab/day) SP HD SOVALDI 400 MG TABLET T4 PA SP HD HEP C VIRUS-NS5B POLYMERASE AND NS5A INHIB. COMBO. EPCLUSA 200 MG-50 MG TABLET T4 PA QL (1 tab/Day) SP HD EPCLUSA 400 MG-100 MG TABLET T4 PA SP HD HARVONI 33.75-150 MG PELLET PK T4 PA QL (1 tab/day) SP HD HARVONI 45-200 MG PELLET PACKT T4 PA QL (1 tab/day) SP HD HARVONI 45-200 MG TABLET T4 PA QL (1 tab/day) SP HD HARVONI 90-400 MG TABLET T4 PA SP HD LEDIPASVIR-SOFOSBUVIR T4 PA SP HD SOFOSBUVIR-VELPATASVIR T4 PA SP HD HEPATITIS B TREATMENT AGENTS adefovir dipivoxil (Hepsera) T4 SP HD BARACLUDE 0.05 MG/ML SOLUTION T4 SP HD

70 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (Infections) HEPATITIS B TREATMENT AGENTS Prescription drug name Drug tier Coverage requirements and limits BARACLUDE 0.5 MG TABLET (entecavir) T4 PA QL (1 tab/day) SP HD BARACLUDE 1 MG TABLET (entecavir) T4 PA SP HD entecavir 0.5 mg tablet (Baraclude) T4 QL (1 tab/day) SP HD entecavir 1 mg tablet (Baraclude) T4 SP HD EPIVIR HBV 100 MG TABLET (lamivudine hbv) T4 SP EPIVIR HBV 25 MG/5 ML SOLN T4 SP HEPSERA (adefovir dipivoxil) T4 SP HD lamivudine (Epivir Hbv) T4 SP VEMLIDY T4 SP HD HEPATITIS C TREATMENT AGENTS PEGASYS T4 PA SP HD PEGINTRON T4 PA SP HD ribasphere 200 mg capsule T4 SP HD ribasphere 200 mg tablet T4 SP HD ribasphere 400 mg tablet T4 SP ribasphere 600 mg tablet T4 SP ribasphere ribapak 200-400 mg T4 SP HD ribasphere ribapak 400-400 mg T4 SP HD ribasphere ribapak 400-400 mg T4 SP HD ribasphere ribapak 600-400 mg T4 SP HD ribasphere ribapak 600-400 mg T4 SP HD ribasphere ribapak 600-600 mg T4 SP HD ribasphere ribapak 600-600 mg T4 SP HD ribavirin T4 SP HD HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB MAVYRET T4 PA SP HD ZEPATIER T4 PA SP HD ANTIVIRALS (Skin Conditions) TOPICAL ANTIVIRAL AND ANTI-INFLAMMATORY STEROID XERESE T3 PA QL (5gm/30 days) TOPICAL ANTIVIRALS acyclovir 5% cream (Zovirax) T1 PA QL (5gm/30 days) acyclovir 5% ointment (Zovirax) T1 PA QL (15gm/30 days)

71 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ANTIVIRALS (Skin Conditions) TOPICAL ANTIVIRALS Prescription drug name Drug tier Coverage requirements and limits DENAVIR T3 QL (10 gm/30 days) ZOVIRAX 5% CREAM (acyclovir) T3 PA QL (10 gm/30 days) ZOVIRAX 5% OINTMENT (acyclovir) T3 PA QL (15gm/30 days) TOPICAL GENITAL WART-HPV TREATMENT AGENTS VEREGEN T3 AUTONOMIC DRUGS (Allergy/Nasal Sprays) ANAPHYLAXIS THERAPY AGENTS AUVI-Q T3 PA QL (2 packs/30 days) EPINEPHRINE T1 QL (2 packs/30 days) epinephrine (Epipen 2-pak) T1 QL (2 packs/30 days) epinephrine (Epipen Jr 2-pak) T1 QL (2 packs/30 days) EPIPEN (epinephrine) T3 PA QL (4 PENS/22 DAYS) EPIPEN 2-PAK (epinephrine) T3 PA QL (2 packs/30 days) EPIPEN JR (epinephrine) T3 PA QL (4 PENS/22 DAYS) EPIPEN JR 2-PAK (epinephrine) T3 PA QL (2 packs/30 days) SYMJEPI T3 PA QL (4 syringes/30 days) AUTONOMIC DRUGS (Alzheimer’s Disease) CHOLINESTERASE INHIBITORS ARICEPT (donepezil hcl) T3 HD donepezil hcl T1 HD donepezil hcl (Aricept) T1 HD EXELON (rivastigmine) T3 HD galantamine er 16 mg capsule (Razadyne Er) T1 HD galantamine er 24 mg capsule (Razadyne Er) T1 HD galantamine er 8 mg capsule (Razadyne Er) T1 QL (1 cap/day) HD galantamine hbr T1 HD MESTINON (pyridostigmine bromide er) T3 HD MESTINON (pyridostigmine bromide) T3 HD pyridostigmine 60 mg/5 ml soln (Mestinon) T1 HD PYRIDOSTIGMINE BR 30 MG TABLET T3 PA QL (20 tabs/day) HD pyridostigmine br 60 mg tablet (Mestinon) T1 HD pyridostigmine bromide (Mestinon) T1 HD RAZADYNE ER 16 MG CAPSULE (galantamine er) T3 HD

72 Cigna Legacy (Standard) 4-Tier Prescription Drug List

AUTONOMIC DRUGS (Alzheimer’s Disease) CHOLINESTERASE INHIBITORS Prescription drug name Drug tier Coverage requirements and limits RAZADYNE ER 24 MG CAPSULE (galantamine er) T3 HD RAZADYNE ER 8 MG CAPSULE (galantamine er) T3 QL (1 cap/day) HD rivastigmine (Exelon) T1 HD rivastigmine tartrate T1 HD AUTONOMIC DRUGS (Attention Deficit Hyperactivity Disorder) ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL (dextroamphetamine-amphetamine) T3 PA ST ADDERALL XR (dextroamphetamine-amphet er) T3 PA QL (1 cap/day) ST ADZENYS ER T3 PA QL (15ml/day) ADZENYS XR-ODT T3 PA QL (1 tab/day) AMPHETAMINE T3 PA QL (15ml/day) amphetamine sulfate (Evekeo) T1 PA DESOXYN (methamphetamine hcl) T3 PA DEXEDRINE SPANSULE 10 MG T3 PA QL (1 cap/day) (dextroamphetamine sulfate er) DEXEDRINE SPANSULE 15 MG T3 PA QL (3 caps/day) (dextroamphetamine sulfate er) DEXEDRINE SPANSULE 5 MG (dextroamphetamine T3 PA QL (1 cap/day) sulfate er) dextroamp-amphet er 10 mg cap (Adderall Xr) T1 PA QL (1 per day) dextroamp-amphet er 15 mg cap (Adderall Xr) T1 PA QL (1 per day) dextroamp-amphet er 20 mg cap (Adderall Xr) T1 PA QL (1 cap/day) dextroamp-amphet er 25 mg cap (Adderall Xr) T1 PA QL (1 cap/day) dextroamp-amphet er 30 mg cap (Adderall Xr) T1 PA QL (1 per day) dextroamp-amphet er 5 mg cap (Adderall Xr) T1 PA QL (1 per day) dextroamphetamine er 10 mg cap (Dexedrine) T1 PA QL (1 cap/day) dextroamphetamine er 15 mg cap (Dexedrine) T1 PA QL (3 caps/day) dextroamphetamine er 5 mg cap (Dexedrine) T1 PA QL (1 cap/day) dextroamphetamine sulfate T1 PA dextroamphetamine sulfate T3 PA ST dextroamphetamine/amphetamine (Adderall) T1 PA DYANAVEL XR T3 PA QL (8ml/day) EVEKEO (amphetamine sulfate) T3 PA ST EVEKEO ODT T3 PA methamphetamine hcl (Desoxyn) T1 PA

73 Cigna Legacy (Standard) 4-Tier Prescription Drug List

AUTONOMIC DRUGS (Attention Deficit Hyperactivity Disorder) ADRENERGICS, AROMATIC, NON-CATECHOLAMINE Prescription drug name Drug tier Coverage requirements and limits MYDAYIS T3 PA QL (1 cap/day) ST ZENZEDI T3 PA ST AUTONOMIC DRUGS (Blood Pressure/Heart Medications) ADRENERGIC VASOPRESSOR AGENTS droxidopa (Northera) T4 SP HD midodrine hcl T1 NORTHERA (droxidopa) T4 PA SP HD ALPHA-ADRENERGIC BLOCKING AGENTS DIBENZYLINE (phenoxybenzamine hcl) T3 HD phenoxybenzamine hcl (Dibenzyline) T1 HD AUTONOMIC DRUGS (Urinary Tract Conditions) PARASYMPATHETIC AGENTS bethanechol chloride T1 HD bethanechol chloride (Urecholine) T1 HD cevimeline hcl (Evoxac) T1 HD EVOXAC (cevimeline hcl) T3 HD guanidine hcl T1 HD pilocarpine hcl (Salagen) T1 HD SALAGEN (pilocarpine hcl) T3 HD URECHOLINE (bethanechol chloride) T3 HD BIOLOGICALS (Allergy/Nasal Sprays) ALLERGENIC EXTRACTS, THERAPEUTIC GRASTEK T3 PA QL (1 tab/day) ODACTRA T3 PA QL (1 tab/day) ORALAIR T3 PA QL (1 tab/day) PALFORZIA T4 PA SP RAGWITEK T3 PA QL (1 tab/day) BIOLOGICALS (Blood Pressure/Heart Medications) PLASMA KALLIKREIN INHIBITORS TAKHZYRO T4 PA SP HD BIOLOGICALS (Miscellaneous) PKU TREATMENT AGENTS - PHENYLALANINE AMMONIA LYASE PALYNZIQ T4 PA SP HD

74 Cigna Legacy (Standard) 4-Tier Prescription Drug List

BIOLOGICALS (Vaccines) COVID-19 VACCINES Prescription drug name Drug tier Coverage requirements and limits JANSSEN COVID-19 VACCINE (EUA) T2 PPACA MODERNA COVID-19 VACCINE (EUA) T2 PPACA PFIZER COVID-19 VACCINE (EUA) T2 PPACA ENTERIC VIRUS VACCINES IPOL T2 PPACA ROTARIX T3 PPACA ROTATEQ T3 PPACA GRAM NEGATIVE COCCI VACCINES BEXSERO T2 PPACA MENACTRA T2 PPACA MENQUADFI T2 PPACA MENVEO A-C-Y-W-135-DIP T2 PPACA TRUMENBA T2 PPACA GRAM POSITIVE COCCI VACCINES PNEUMOVAX 23 T2 PPACA PREVNAR 13 T2 PPACA INFLUENZA VIRUS VACCINES AFLURIA 2017-2018 T2 PPACA AFLURIA 2018-2019 T2 PPACA AFLURIA QUAD 2017-2018 T2 PPACA AFLURIA QUAD 2018-2019 T2 PPACA AFLURIA QUAD 2019-20 (3YR UP) T2 PPACA AFLURIA QUAD 2019-20 (6-35MO) T2 PPACA AFLURIA QUAD 2019-2020 T2 PPACA AFLURIA QUAD 2020-2021 T2 PPACA AFLURIA QUAD 2020-21 (3YR UP) T2 PPACA AFLURIA QUAD 2020-21 (6-35MO) T2 PPACA EZ FLU 2018-2019 (FLUCELVAX) T2 PPACA FLUAD 2017-2018 T2 PPACA FLUAD 2018-2019 T2 PPACA FLUAD 2019-2020 T2 PPACA FLUAD 2020-2021 T2 PPACA FLUAD QUAD 2020-2021 T2 PPACA

75 Cigna Legacy (Standard) 4-Tier Prescription Drug List

BIOLOGICALS (Vaccines) INFLUENZA VIRUS VACCINES Prescription drug name Drug tier Coverage requirements and limits FLUARIX QUAD 2017-2018 T2 PPACA FLUARIX QUAD 2018-2019 T2 PPACA FLUARIX QUAD 2019-2020 T2 PPACA FLUARIX QUAD 2020-2021 T2 PPACA FLUBLOK 2017-2018 T2 PPACA FLUBLOK QUAD 2017-2018 T2 PPACA FLUBLOK QUAD 2018-2019 T2 PPACA FLUBLOK QUAD 2019-2020 T2 PPACA FLUBLOK QUAD 2020-2021 T2 PPACA FLUCELVAX QUAD 2017-2018 T2 PPACA FLUCELVAX QUAD 2018-2019 T2 PPACA FLUCELVAX QUAD 2019-2020 T2 PPACA FLUCELVAX QUAD 2020-2021 T2 PPACA FLULAVAL QUAD 2017-2018 T2 PPACA FLULAVAL QUAD 2018-2019 T2 PPACA FLULAVAL QUAD 2019-2020 T2 PPACA FLULAVAL QUAD 2020-2021 T2 PPACA FLUMIST QUAD 2017-2018 T3 PPACA FLUMIST QUAD 2018-2019 T3 PPACA FLUMIST QUAD 2019-2020 T3 PPACA FLUMIST QUAD 2020-2021 T3 PPACA FLUVIRIN 2017-2018 T2 PPACA FLUZONE HIGH-DOSE 2017-2018 T2 PPACA FLUZONE HIGH-DOSE 2018-2019 T2 PPACA FLUZONE HIGH-DOSE 2019-2020 T2 PPACA FLUZONE HIGH-DOSE QUAD 2020-21 T2 PPACA FLUZONE INTRADERM QUAD 2017-18 T2 PPACA FLUZONE QUAD 2017-2018 T2 PPACA FLUZONE QUAD 2018-2019 T2 PPACA FLUZONE QUAD 2019-2020 T2 PPACA FLUZONE QUAD 2020-2021 T2 PPACA FLUZONE QUAD PEDI 2017-2018 T2 PPACA FLUZONE QUAD PEDI 2018-2019 T2 PPACA FLUZONE QUAD PEDI 2019-2020 T2 PPACA

76 Cigna Legacy (Standard) 4-Tier Prescription Drug List

BIOLOGICALS (Vaccines) VACCINE/TOXOID PREPARATIONS, COMBINATIONS Prescription drug name Drug tier Coverage requirements and limits ACTHIB T2 PPACA ADACEL TDAP T2 PPACA BOOSTRIX TDAP T2 PPACA DAPTACEL DTAP T2 PPACA DIPHTHERIA-TETANUS TOXOIDS-PED T2 PPACA HIBERIX T2 PPACA INFANRIX DTAP T2 PPACA KINRIX T2 PPACA M-M-R II VACCINE T2 PPACA PEDVAXHIB T2 PPACA PENTACEL T2 PPACA PENTACEL ACTHIB COMPONENT T2 PPACA PROQUAD T2 PPACA QUADRACEL DTAP-IPV T2 PPACA TDVAX T2 PPACA TENIVAC T2 PPACA VAXELIS T2 PPACA VIRAL/TUMORIGENIC VACCINES ENGERIX-B ADULT T2 PPACA ENGERIX-B PEDIATRIC-ADOLESCENT T2 PPACA GARDASIL 9 T2 PPACA HEPLISAV-B T2 PPACA PEDIARIX T2 PPACA RECOMBIVAX HB T2 PPACA SHINGRIX T2 PPACA TWINRIX T2 PPACA VARIVAX VACCINE T2 PPACA ZOSTAVAX T2 PPACA BLOOD (Blood Modifiers/Bleeding Disorders) AGENTS TO TX THROMBOTIC THROMBOCYTOPENIC PURPURA CABLIVI T4 PA SP ANTIFIBRINOLYTIC AGENTS AMICAR (aminocaproic acid) T4 SP HD

77 Cigna Legacy (Standard) 4-Tier Prescription Drug List

BLOOD (Blood Modifiers/Bleeding Disorders) AGENTS TO TX THROMBOTIC THROMBOCYTOPENIC PURPURA Prescription drug name Drug tier Coverage requirements and limits aminocaproic acid (Amicar) T4 SP HD LYSTEDA (tranexamic acid) T4 SP tranexamic acid (Lysteda) T4 SP HEMOPHILIA TREATMENT AGENTS, NON-FACTOR REPLACEMENT HEMLIBRA T4 PA SP HD SICKLE CELL ANEMIA AGENTS DROXIA T2 OXBRYTA T4 PA QL (3 tabs/day) SP HD SIKLOS T3 PA TOPICAL HEMOSTATICS ASTRINGYN T3 AVITENE T3 ENDO-AVITENE T3 EVICEL T3 gelatin sponge, absorb/porcine (Gelfoam) T1 GELFOAM T3 GELFOAM (surgifoam) T3 GELFOAM COMPRESSED T3 MONSEL’s T3 RAPLIXA T3 RECOTHROM T3 SURGIFOAM T1 SYRINGE AVITENE T3 TACHOSIL T3 THROMBI-GEL T3 THROMBIN-JMI T3 THROMBI-PAD T3 ULTRAFOAM T3 BLOOD (Blood Thinners/Anti-Clotting) HEMORRHEOLOGIC AGENTS pentoxifylline T1 HD CARDIAC DRUGS (Blood Pressure/Heart Medications) ANTIANGINAL, ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMIC RANEXA (ranolazine er) T3 QL (4 tabs/day) HD ranolazine (Ranexa) T1 QL (4 tabs/day) HD

78 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIAC DRUGS (Blood Pressure/Heart Medications) ANTIARRHYTHMICS Prescription drug name Drug tier Coverage requirements and limits amiodarone hcl T1 HD disopyramide phosphate (Norpace) T1 HD dofetilide 125 mcg capsule (Tikosyn) T1 QL (8 caps/day) HD dofetilide 250 mcg capsule (Tikosyn) T1 QL (4 caps/day) HD dofetilide 500 mcg capsule (Tikosyn) T1 QL (2 caps/day) HD flecainide acetate T1 HD mexiletine hcl T1 HD MULTAQ T3 HD NORPACE (disopyramide phosphate) T3 PA HD NORPACE CR T3 HD pacerone 100 mg tablet T3 PA HD pacerone 200 mg tablet T1 HD pacerone 400 mg tablet T3 PA HD propafenone hcl T1 HD propafenone hcl (Rythmol Sr) T1 HD quinidine gluconate T1 HD quinidine sulfate T1 HD RYTHMOL SR (propafenone hcl er) T3 PA HD TIKOSYN 125 MCG CAPSULE (dofetilide) T3 PA QL (8 caps/day) HD TIKOSYN 250 MCG CAPSULE (dofetilide) T3 PA QL (4 caps/day) HD TIKOSYN 500 MCG CAPSULE (dofetilide) T3 PA QL (2 caps/day) HD CALCIUM CHANNEL BLOCKER AND NSAID, COX-2 INHIBITOR CONSENSI T3 PA QL (1 tab/day) CALCIUM CHANNEL BLOCKING AGENTS ADALAT CC (nifedipine er) T3 HD amlodipine besylate (Norvasc) T1 HD CALAN SR (verapamil er) T3 HD CARDIZEM (diltiazem hcl) T3 PA HD CARDIZEM CD (diltiazem 24hr er (cd)) T3 PA HD CARDIZEM LA 120 MG TABLET T3 QL (1 tab/day) HD CARDIZEM LA 180 MG TABLET (matzim la) T3 HD CARDIZEM LA 240 MG TABLET (matzim la) T3 HD CARDIZEM LA 300 MG TABLET (matzim la) T3 HD

79 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIAC DRUGS (Blood Pressure/Heart Medications) CALCIUM CHANNEL BLOCKING AGENTS Prescription drug name Drug tier Coverage requirements and limits CARDIZEM LA 360 MG TABLET (matzim la) T3 HD CARDIZEM LA 420 MG TABLET (matzim la) T3 HD CONJUPRI T3 PA HD diltiazem hcl T1 HD diltiazem hcl (Cardizem Cd) T1 HD diltiazem hcl (Cardizem La) T1 HD diltiazem hcl (Cardizem) T1 HD diltiazem hcl (Tiazac) T1 HD felodipine T1 HD isradipine T1 HD KATERZIA T3 QL (10ml/day) HD nicardipine hcl T1 HD nifedipine T1 HD nifedipine (Adalat Cc) T1 HD nifedipine (Procardia Xl) T1 HD nifedipine (Procardia) T1 HD nimodipine T1 HD nisoldipine er 17 mg tablet (Sular) T1 HD nisoldipine er 20 mg tablet T1 QL (1 tab/day) HD nisoldipine er 25.5 mg tablet T1 HD nisoldipine er 30 mg tablet T1 HD nisoldipine er 34 mg tablet (Sular) T1 HD nisoldipine er 40 mg tablet T1 HD nisoldipine er 8.5 mg tablet (Sular) T1 HD NORVASC (amlodipine besylate) T3 HD NYMALIZE T3 HD PROCARDIA (nifedipine) T3 HD PROCARDIA XL (nifedipine er) T3 HD SULAR (nisoldipine) T3 HD TIAZAC (tiadylt er) T3 HD verapamil hcl T1 HD verapamil hcl (Calan Sr) T1 HD verapamil hcl (Verelan Pm) T1 HD

80 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIAC DRUGS (Blood Pressure/Heart Medications) CALCIUM CHANNEL BLOCKING AGENTS Prescription drug name Drug tier Coverage requirements and limits verapamil hcl (Verelan) T1 HD VERELAN (verapamil hcl) T3 HD VERELAN (verapamil sr) T3 HD VERELAN PM (verapamil er pm) T3 HD DIGITALIS GLYCOSIDES digoxin T1 HD digoxin (Lanoxin) T1 HD LANOXIN T3 PA HD LANOXIN (digoxin) T3 PA HD HEART RATE REDUCING, SA SELECTIVE I (F) CURRENT INH. CORLANOR T2 PA HD SOLUBLE GUANYLATE CYCLASE (SGC) STIMULATOR VERQUVO T3 PA QL (1 tab/day) HD VASODILATORS, CORONARY DILATRATE-SR T3 HD GONITRO T3 HD ISORDIL (isosorbide dinitrate) T3 PA HD ISORDIL TITRADOSE (isosorbide dinitrate) T3 PA HD isosorbide dinitrate 10 mg tab T1 HD isosorbide dinitrate 20 mg tab T1 HD isosorbide dinitrate 30 mg tab T1 HD isosorbide dinitrate 40 mg tab (Isordil) T1 PA HD isosorbide dinitrate 5 mg tab (Isordil Titradose) T1 HD isosorbide mononitrate T1 HD MINITRAN T1 HD NITRO-DUR 0.1 MG/HR PATCH T3 HD NITRO-DUR 0.2 MG/HR PATCH T3 HD NITRO-DUR 0.3 MG/HR PATCH T2 HD NITRO-DUR 0.4 MG/HR PATCH T3 HD NITRO-DUR 0.6 MG/HR PATCH T3 HD NITRO-DUR 0.8 MG/HR PATCH T2 HD nitroglycerin T1 HD nitroglycerin (Nitro-dur) T1 HD nitroglycerin (Nitrolingual) T1 HD nitroglycerin (Nitromist) T1 HD

81 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIAC DRUGS (Blood Pressure/Heart Medications) VASODILATORS, CORONARY Prescription drug name Drug tier Coverage requirements and limits nitroglycerin (Nitrostat) T1 HD NITROLINGUAL (nitroglycerin) T3 HD NITROMIST (nitroglycerin) T3 HD NITROSTAT (nitroglycerin) T3 HD CARDIOVASCULAR (Asthma/COPD/Respiratory) PULM ANTI-HTN, SOLUBLE GUANYLATE CYCLASE STIMULATOR ADEMPAS T4 PA SP HD PULM.ANTI-HTN, SEL.C-GMP PHOSPHODIESTERASE T5 INHIB ADCIRCA (tadalafil) T4 PA SP HD REVATIO (sildenafil citrate) T4 PA SP HD sildenafil 10 mg/ml oral susp (Revatio) T4 PA SP HD sildenafil 20 mg tablet (Revatio) T4 PA SP HD tadalafil (Adcirca) T4 PA SP HD tadalafil 20 mg tablet (Adcirca) T4 PA SP HD PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST ambrisentan (Letairis) T4 PA SP HD bosentan (Tracleer) T4 PA SP HD LETAIRIS (ambrisentan) T4 PA SP HD OPSUMIT T4 PA SP HD TRACLEER 125 MG TABLET (bosentan) T4 PA SP HD TRACLEER 32 MG TABLET FOR SUSP T4 PA SP HD TRACLEER 62.5 MG TABLET (bosentan) T4 PA SP HD PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE ORENITRAM ER T4 PA SP HD TYVASO T4 PA SP HD TYVASO INSTITUTIONAL START KIT T4 PA SP HD TYVASO REFILL KIT T4 PA SP HD TYVASO STARTER KIT T4 PA SP HD UPTRAVI T4 PA SP HD VENTAVIS T4 PA SP HD CARDIOVASCULAR (Blood Pressure/Heart Medications) ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION amlodipine besylate/benazepril T1 HD

82 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATION Prescription drug name Drug tier Coverage requirements and limits amlodipine besylate/benazepril (Lotrel) T1 HD LOTREL (amlodipine besylate-benazepril) T3 HD PRESTALIA 14 MG-10 MG TABLET T3 HD PRESTALIA 3.5 MG-2.5 MG TABLET T3 QL (1 tab/day) HD PRESTALIA 7 MG-5 MG TABLET T3 QL (1 tab/day) HD TARKA (trandolapril-verapamil er) T3 HD trandolapril/verapamil hcl T1 HD trandolapril/verapamil hcl (Tarka) T1 HD ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC ACCURETIC (quinapril-hydrochlorothiazide) T3 ST HD benazepril/hydrochlorothiazide T1 HD benazepril/hydrochlorothiazide (Lotensin Hct) T1 HD captopril-hctz 25-15 mg tablet T1 QL (3 tabs/day) HD captopril-hctz 25-25 mg tablet T1 QL (2 tabs/day) HD captopril-hctz 50-15 mg tablet T1 QL (3 tabs/day) HD captopril-hctz 50-25 mg tablet T1 QL (2 tabs/day) HD enalapril/hydrochlorothiazide T1 HD enalapril/hydrochlorothiazide (Vaseretic) T1 HD fosinopril/hydrochlorothiazide T1 HD lisinopril/hydrochlorothiazide (Zestoretic) T1 HD LOTENSIN HCT (benazepril-hydrochlorothiazide) T3 ST HD quinapril/hydrochlorothiazide (Accuretic) T1 HD VASERETIC (enalapril-hydrochlorothiazide) T3 ST HD ZESTORETIC (lisinopril-hydrochlorothiazide) T3 ST HD ALPHA/BETA-ADRENERGIC BLOCKING AGENTS carvedilol (Coreg) T1 HD carvedilol er 10 mg capsule (Coreg Cr) T1 QL (1 cap/day) HD carvedilol er 20 mg capsule (Coreg Cr) T1 QL (1 cap/day) HD carvedilol er 40 mg capsule (Coreg Cr) T1 QL (1 cap/day) HD carvedilol er 80 mg capsule (Coreg Cr) T1 HD COREG (carvedilol) T3 ST HD COREG CR 10 MG CAPSULE (carvedilol er) T3 QL (1 cap/day) ST HD COREG CR 20 MG CAPSULE (carvedilol er) T3 QL (1 cap/day) ST HD

83 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) ALPHA/BETA-ADRENERGIC BLOCKING AGENTS Prescription drug name Drug tier Coverage requirements and limits COREG CR 40 MG CAPSULE (carvedilol er) T3 QL (1 cap/day) ST HD COREG CR 80 MG CAPSULE (carvedilol er) T3 ST HD labetalol hcl T1 HD ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA (doxazosin mesylate) T3 HD CARDURA XL T3 HD doxazosin mesylate (Cardura) T1 HD MINIPRESS (prazosin hcl) T3 HD prazosin hcl (Minipress) T1 HD terazosin hcl T1 HD ANGIOTEN.RECEPTR ANTAG-CALCIUM CHANL BLKR-THIAZIDE amlodipine/valsartan/hcthiazid (Exforge Hct) T1 HD EXFORGE HCT (amlodipine-valsartan-hctz) T3 HD olmesartan/amlodipin/hcthiazid (Tribenzor) T1 HD TRIBENZOR (olmesartan-amlodipine-hctz) T3 HD ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB (ARNI) ENTRESTO T2 HD ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB ATACAND HCT (candesartan-hydrochlorothiazid) T3 ST HD AVALIDE (irbesartan-hydrochlorothiazide) T3 ST HD BENICAR HCT 20-12.5 MG TABLET (olmesartan- T3 QL (1 tab/day) ST HD hydrochlorothiazide) BENICAR HCT 40-12.5 MG TABLET (olmesartan- T3 ST HD hydrochlorothiazide) BENICAR HCT 40-25 MG TABLET (olmesartan- T3 ST HD hydrochlorothiazide) candesartan/hydrochlorothiazid (Atacand Hct) T1 HD DIOVAN HCT (valsartan-hydrochlorothiazide) T3 ST HD EDARBYCLOR T3 ST HD HYZAAR (losartan-hydrochlorothiazide) T3 ST HD irbesartan/hydrochlorothiazide (Avalide) T1 HD losartan/hydrochlorothiazide (Hyzaar) T1 HD MICARDIS HCT 40-12.5 MG TABLET (telmisartan- T3 QL (1 tab/day) ST HD hydrochlorothiazid) MICARDIS HCT 80-12.5 MG TABLET (telmisartan- T3 ST HD hydrochlorothiazid)

84 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMB Prescription drug name Drug tier Coverage requirements and limits MICARDIS HCT 80-25 MG TABLET (telmisartan- T3 ST HD hydrochlorothiazid) olmesartan-hctz 20-12.5 mg tab (Benicar Hct) T1 QL (1 tab/day) HD olmesartan-hctz 40-12.5 mg tab (Benicar Hct) T1 HD olmesartan-hctz 40-25 mg tab (Benicar Hct) T1 HD telmisartan-hctz 40-12.5 mg tb (Micardis Hct) T1 QL (1 tab/day) HD telmisartan-hctz 80-12.5 mg tb (Micardis Hct) T1 HD telmisartan-hctz 80-25 mg tab (Micardis Hct) T1 HD valsartan/hydrochlorothiazide (Diovan Hct) T1 HD ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKR amlodipine besylate/valsartan (Exforge) T1 HD amlodipine-olmesartan 10-20 mg (Azor) T1 HD amlodipine-olmesartan 10-40 mg (Azor) T1 HD amlodipine-olmesartan 5-20 mg (Azor) T1 QL (1 tab/day) HD amlodipine-olmesartan 5-40 mg (Azor) T1 HD AZOR 10-20 MG TABLET (amlodipine-olmesartan) T3 HD AZOR 10-40 MG TABLET (amlodipine-olmesartan) T3 HD AZOR 5-20 MG TABLET (amlodipine-olmesartan) T3 QL (1 tab/day) HD AZOR 5-40 MG TABLET (amlodipine-olmesartan) T3 HD EXFORGE (amlodipine-valsartan) T3 HD telmisartan-amlodipine 40-10 T1 HD telmisartan-amlodipine 40-5 mg T1 QL (1 tab/day) HD telmisartan-amlodipine 80-10 T1 HD telmisartan-amlodipine 80-5 mg T1 HD ANTIHYPERTENSIVES, ACE INHIBITORS ACCUPRIL (quinapril hcl) T3 ST HD ALTACE (ramipril) T3 ST HD benazepril hcl T1 HD benazepril hcl (Lotensin) T1 HD captopril T1 HD enalapril maleate (Vasotec) T1 HD EPANED T3 HD fosinopril sodium T1 HD lisinopril (Zestril) T1 HD

85 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) ANTIHYPERTENSIVES, ACE INHIBITORS Prescription drug name Drug tier Coverage requirements and limits LOTENSIN (benazepril hcl) T3 ST HD moexipril hcl T1 HD perindopril erbumine T1 HD PRINIVIL (lisinopril) T3 ST HD QBRELIS T3 HD quinapril hcl (Accupril) T1 HD ramipril (Altace) T1 HD trandolapril T1 HD VASOTEC (enalapril maleate) T3 ST HD ZESTRIL (lisinopril) T3 ST HD ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST ATACAND (candesartan cilexetil) T3 ST HD AVAPRO (irbesartan) T3 ST HD BENICAR 20 MG TABLET (olmesartan medoxomil) T3 QL (1 tab/day) ST HD BENICAR 40 MG TABLET (olmesartan medoxomil) T3 ST HD BENICAR 5 MG TABLET (olmesartan medoxomil) T3 ST HD candesartan cilexetil (Atacand) T1 HD COZAAR (losartan potassium) T3 ST HD DIOVAN (valsartan) T3 ST HD EDARBI 40 MG TABLET T3 QL (1 tab/day) ST HD EDARBI 80 MG TABLET T3 ST HD eprosartan mesylate T1 HD irbesartan (Avapro) T1 HD losartan potassium (Cozaar) T1 HD MICARDIS 20 MG TABLET (telmisartan) T3 QL (1 tab/day) ST HD MICARDIS 40 MG TABLET (telmisartan) T3 QL (1 tab/day) ST HD MICARDIS 80 MG TABLET (telmisartan) T3 ST HD olmesartan medoxomil 20 mg tab (Benicar) T1 QL (1 tab/day) HD olmesartan medoxomil 40 mg tab (Benicar) T1 HD olmesartan medoxomil 5 mg tab (Benicar) T1 HD telmisartan 20 mg tablet (Micardis) T1 QL (1 tab/day) HD telmisartan 40 mg tablet (Micardis) T1 QL (1 tab/day) HD telmisartan 80 mg tablet (Micardis) T1 HD valsartan (Diovan) T1 HD

86 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS Prescription drug name Drug tier Coverage requirements and limits VECAMYL T1 ANTIHYPERTENSIVES, MISCELLANEOUS DEMSER (metyrosine) T2 HD metyrosine (Demser) T1 HD ANTIHYPERTENSIVES, SYMPATHOLYTIC CATAPRES (clonidine hcl) T3 HD CATAPRES-TTS 1 (clonidine) T3 HD CATAPRES-TTS 2 (clonidine) T3 HD CATAPRES-TTS 3 (clonidine) T3 HD clonidine (Catapres-tts 1) T1 HD clonidine (Catapres-tts 2) T1 HD clonidine (Catapres-tts 3) T1 HD clonidine hcl (Catapres) T1 HD guanfacine hcl T1 HD methyldopa T1 HD methyldopa/hydrochlorothiazide T1 HD ANTIHYPERTENSIVES, VASODILATORS hydralazine hcl T1 HD minoxidil T1 HD BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl T1 HD atenolol (Tenormin) T1 HD BETAPACE (sotalol af) T3 PA HD BETAPACE (sotalol) T3 PA HD BETAPACE AF (sotalol af) T3 HD betaxolol hcl T1 HD bisoprolol fumarate T1 HD BYSTOLIC 10 MG TABLET T2 QL (1 tab/day) ST HD BYSTOLIC 2.5 MG TABLET T2 QL (1 tab/day) ST HD BYSTOLIC 20 MG TABLET T2 ST HD BYSTOLIC 5 MG TABLET T2 QL (1 tab/day) ST HD CORGARD (nadolol) T3 ST HD HEMANGEOL T3 HD

87 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) BETA-ADRENERGIC BLOCKING AGENTS Prescription drug name Drug tier Coverage requirements and limits INDERAL LA (propranolol hcl er) T3 ST HD INDERAL XL T3 ST HD INNOPRAN XL T3 ST HD KAPSPARGO SPRINKLE T3 ST HD LOPRESSOR (metoprolol tartrate) T3 ST HD metoprolol succinate (Toprol Xl) T1 HD metoprolol tartrate T1 HD metoprolol tartrate (Lopressor) T1 HD nadolol (Corgard) T1 HD pindolol T1 HD propranolol hcl T1 HD propranolol hcl (Inderal La) T1 HD sotalol hcl (Betapace Af) T1 HD sotalol hcl (Betapace) T1 HD SOTYLIZE T3 ST HD TENORMIN (atenolol) T3 ST HD timolol maleate T1 HD TOPROL XL (metoprolol succinate) T3 ST HD BETA-BLOCKERS AND THIAZIDE, THIAZIDE-LIKE DIURETICS atenolol/chlorthalidone (Tenoretic 100) T1 HD atenolol/chlorthalidone (Tenoretic 50) T1 HD bisoprolol/hydrochlorothiazide (Ziac) T1 HD DUTOPROL T3 ST HD METOPROLOL SUCCINATE ER-HCTZ T1 HD metoprolol/hydrochlorothiazide T1 HD nadolol/bendroflumethiazide T1 HD propranolol/hydrochlorothiazid T1 HD TENORETIC 100 (atenolol-chlorthalidone) T3 ST HD TENORETIC 50 (atenolol-chlorthalidone) T3 ST HD ZIAC (bisoprolol-hydrochlorothiazide) T3 ST HD RENIN INHIBITOR, DIRECT aliskiren 150 mg tablet (Tekturna) T1 QL (1 tab/day) HD aliskiren 300 mg tablet (Tekturna) T1 HD

88 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Blood Pressure/Heart Medications) RENIN INHIBITOR, DIRECT Prescription drug name Drug tier Coverage requirements and limits TEKTURNA 150 MG TABLET (aliskiren) T3 QL (1 tab/day) HD TEKTURNA 300 MG TABLET (aliskiren) T3 HD RENIN INHIBITOR, DIRECT AND THIAZIDE DIURETIC COMB TEKTURNA HCT 150-12.5 MG TAB T2 QL (1 tab/day) HD TEKTURNA HCT 150-25 MG TABLET T2 HD TEKTURNA HCT 300-12.5 MG TAB T2 HD TEKTURNA HCT 300-25 MG TABLET T2 HD VASODILATORS, COMBINATION BIDIL T3 QL (6 tabs/day) VASODILATORS, PERIPHERAL ergoloid mesylates T1 isoxsuprine hcl T1 CARDIOVASCULAR (Cholesterol Medications) ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB ezetimibe/simvastatin (Vytorin) T1 HD VYTORIN (ezetimibe-simvastatin) T3 ST HD ANTIHYPERLIPID- HMG-COA RI-CALCIUM CHANNEL BLOCKER amlodipine-atorvast 10-10 mg (Caduet) T1 HD amlodipine-atorvast 10-20 mg (Caduet) T1 HD amlodipine-atorvast 10-40 mg (Caduet) T1 HD amlodipine-atorvast 10-80 mg (Caduet) T1 HD amlodipine-atorvast 2.5-10 mg T1 HD amlodipine-atorvast 2.5-20 mg T1 QL (1 tab/day) HD amlodipine-atorvast 2.5-40 mg T1 QL (1 tab/day) HD amlodipine-atorvast 5-10 mg (Caduet) T1 HD amlodipine-atorvast 5-20 mg (Caduet) T1 QL (1 tab/day) HD amlodipine-atorvast 5-40 mg (Caduet) T1 QL (1 tab/day) HD amlodipine-atorvast 5-80 mg (Caduet) T1 HD CADUET 10 MG-10 MG TABLET (amlodipine- T3 HD atorvastatin) CADUET 10 MG-20 MG TABLET (amlodipine- T3 HD atorvastatin) CADUET 10 MG-40 MG TABLET (amlodipine- T3 HD atorvastatin) CADUET 10 MG-80 MG TABLET (amlodipine- T3 HD atorvastatin)

89 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Cholesterol Medications) ANTIHYPERLIP.HMG COA REDUCT INHIB-CHOLEST.AB.INHIB Prescription drug name Drug tier Coverage requirements and limits CADUET 5 MG-10 MG TABLET (amlodipine- T3 HD atorvastatin) CADUET 5 MG-20 MG TABLET (amlodipine- T3 QL (1 tab/day) HD atorvastatin) CADUET 5 MG-40 MG TABLET (amlodipine- T3 QL (1 tab/day) HD atorvastatin) CADUET 5 MG-80 MG TABLET (amlodipine- T3 HD atorvastatin) ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESIS INHIBITOR KYNAMRO T4 PA SP ANTIHYPERLIPIDEMIC - ATP CITRATE LYASE INHIBITOR NEXLETOL T2 PA QL (1 tab/day) ANTIHYPERLIPIDEMIC - MTP INHIBITOR JUXTAPID T4 PA SP HD ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORS PRALUENT PEN T3 PA REPATHA PUSHTRONEX T2 PA REPATHA SURECLICK T2 PA REPATHA SYRINGE T2 PA ANTIHYPERLIPIDEMIC-ACLY AND CHOLES ABSORP INHIB NEXLIZET T2 PA QL (1 SYRINGE/DAY) ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB (STATINS) ALTOPREV 20 MG TABLET T3 QL (1 tab/day) ST HD ALTOPREV 40 MG TABLET T3 ST HD ALTOPREV 60 MG TABLET T3 ST HD atorvastatin 10 mg tablet (Lipitor) T1 HD PPACA atorvastatin 20 mg tablet (Lipitor) T1 HD PPACA atorvastatin 40 mg tablet (Lipitor) T1 HD atorvastatin 80 mg tablet (Lipitor) T1 HD CRESTOR 10 MG TABLET (rosuvastatin calcium) T3 QL (1 tab/day) ST HD CRESTOR 20 MG TABLET (rosuvastatin calcium) T3 QL (1 tab/day) ST HD CRESTOR 40 MG TABLET (rosuvastatin calcium) T3 ST HD CRESTOR 5 MG TABLET (rosuvastatin calcium) T3 QL (1 tab/day) ST HD EZALLOR SPRINKLE 10 MG CAPSULE T3 QL (1 tab/day) ST HD EZALLOR SPRINKLE 20 MG CAPSULE T3 QL (1 tab/day) ST HD

90 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Cholesterol Medications) ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB (STATINS) Prescription drug name Drug tier Coverage requirements and limits EZALLOR SPRINKLE 40 MG CAPSULE T3 ST HD EZALLOR SPRINKLE 5 MG CAPSULE T3 QL (1 tab/day) ST HD FLOLIPID T3 ST HD fluvastatin sodium T1 HD PPACA fluvastatin sodium (Lescol Xl) T1 HD PPACA LESCOL XL (fluvastatin er) T3 ST HD LIPITOR (atorvastatin calcium) T3 PA HD LIVALO 1 MG TABLET T3 QL (1 tab/day) ST HD LIVALO 2 MG TABLET T3 QL (1 tab/day) ST HD LIVALO 4 MG TABLET T3 ST HD lovastatin 10 mg tablet T1 HD lovastatin 20 mg tablet T1 HD PPACA lovastatin 40 mg tablet T1 HD PPACA PRAVACHOL (pravastatin sodium) T3 ST HD pravastatin sodium T1 HD PPACA pravastatin sodium (Pravachol) T1 HD PPACA rosuvastatin calcium 10 mg tab (Crestor) T1 QL (1 tab/day) HD PPACA rosuvastatin calcium 20 mg tab (Crestor) T1 QL (1 tab/day) HD rosuvastatin calcium 40 mg tab (Crestor) T1 HD rosuvastatin calcium 5 mg tab (Crestor) T1 QL (1 tab/day) HD PPACA simvastatin 10 mg tablet (Zocor) T1 HD PPACA simvastatin 20 mg tablet (Zocor) T1 HD PPACA SIMVASTATIN 20 MG/5 ML SUSP T3 ST HD simvastatin 40 mg tablet (Zocor) T1 HD PPACA simvastatin 5 mg tablet T1 HD simvastatin 80 mg tablet (Zocor) T1 QL (1 tab/day) HD ZOCOR 10 MG TABLET (simvastatin) T3 ST HD ZOCOR 20 MG TABLET (simvastatin) T3 ST HD ZOCOR 40 MG TABLET (simvastatin) T3 ST HD ZOCOR 80 MG TABLET (simvastatin) T3 QL (1 tab/day) ST HD ZYPITAMAG T3 ST HD BILE SALT SEQUESTRANTS cholestyramine (with sugar) (Questran) T1 HD

91 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Cholesterol Medications) BILE SALT SEQUESTRANTS Prescription drug name Drug tier Coverage requirements and limits cholestyramine/aspartame T1 HD cholestyramine/aspartame (Questran Light) T1 HD colesevelam hcl (Welchol) T1 HD COLESTID 1 GM TABLET (colestipol hcl) T3 HD COLESTID FLAVORED GRANULES T2 HD COLESTID FLAVORED GRANULES T3 HD COLESTID GRANULES T3 HD COLESTID GRANULES (colestipol hcl) T3 HD COLESTID GRANULES PACKET (colestipol hcl) T3 HD colestipol hcl (Colestid) T1 HD QUESTRAN (cholestyramine) T3 HD QUESTRAN LIGHT (prevalite) T3 HD WELCHOL (colesevelam hcl) T3 HD LIPOTROPICS ANTARA T3 PA HD ezetimibe (Zetia) T1 HD fenofibrate 120 mg tablet (Fenoglide) T1 HD fenofibrate 130 mg capsule T1 HD fenofibrate 134 mg capsule T1 HD fenofibrate 145 mg tablet (Tricor) T1 HD FENOFIBRATE 150 MG CAPSULE T1 HD fenofibrate 160 mg tablet T1 HD FENOFIBRATE 160 MG TABLET T3 PA HD fenofibrate 200 mg capsule T1 HD fenofibrate 40 mg tablet (Fenoglide) T1 HD fenofibrate 43 mg capsule T1 HD fenofibrate 48 mg tablet (Tricor) T1 HD FENOFIBRATE 50 MG CAPSULE T1 HD fenofibrate 54 mg tablet T1 HD fenofibrate 67 mg capsule T1 HD fenofibric acid (choline)(Trilipix) T1 HD fenofibric acid (Fibricor) T1 HD FENOGLIDE (fenofibrate) T3 PA HD

92 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CARDIOVASCULAR (Cholesterol Medications) LIPOTROPICS Prescription drug name Drug tier Coverage requirements and limits FIBRICOR (fenofibric acid) T3 ST HD gemfibrozil (Lopid) T1 HD LIPOFEN T3 ST HD LOPID (gemfibrozil) T3 HD niacin (Niacor) T1 HD niacin (Niaspan) T1 HD NIACOR T1 HD NIASPAN (niacin er) T3 HD TRICOR (fenofibrate) T3 ST HD TRIGLIDE T3 ST HD TRILIPIX (fenofibric acid) T3 ST HD ZETIA (ezetimibe) T3 HD CNS DRUGS (Alzheimer’s Disease) ALZHEIMER’s THERAPY, NMDA RECEPTOR ANTAGONISTS memantine hcl T1 HD memantine hcl (Namenda) T1 HD memantine hcl er 14 mg capsule (Namenda Xr) T1 QL (1 cap/day) HD memantine hcl er 21 mg capsule (Namenda Xr) T1 HD memantine hcl er 28 mg capsule (Namenda Xr) T1 HD memantine hcl er 7 mg capsule (Namenda Xr) T1 QL (1 cap/day) HD NAMENDA 10 MG TABLET (memantine hcl) T3 HD NAMENDA 5 MG TABLET (memantine hcl) T3 HD NAMENDA 5-10 MG TITRATION PK T2 HD NAMENDA XR 14 MG CAPSULE (memantine hcl er) T3 QL (1 cap/day) HD NAMENDA XR 21 MG CAPSULE (memantine hcl er) T3 HD NAMENDA XR 28 MG CAPSULE (memantine hcl er) T3 HD NAMENDA XR 7 MG CAPSULE (memantine hcl er) T3 QL (1 cap/day) HD NAMENDA XR TITRATION PACK T3 QL (112/365 days) HD ALZHEIMER’s THX, NMDA RECEPTOR ANTAG-CHOLINES INHIB NAMZARIC 14 MG-10 MG CAPSULE T3 QL (2 caps/day) HD NAMZARIC 21 MG-10 MG CAPSULE T3 QL (2 caps/day) HD NAMZARIC 28 MG-10 MG CAPSULE T3 QL (2 caps/day) HD NAMZARIC 7 MG-10 MG CAPSULE T3 QL (2 caps/day) HD NAMZARIC TITRATION PACK T3 QL (112/365 days) HD

93 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Miscellaneous) AMYOTROPHIC LATERAL SCLEROSIS AGENTS Prescription drug name Drug tier Coverage requirements and limits RILUTEK (riluzole) T4 SP HD riluzole (Rilutek) T4 SP HD TIGLUTIK T4 PA SP DRUGS TO TREAT MOVEMENT DISORDERS AUSTEDO T4 PA SP HD HORIZANT T3 PA INGREZZA T4 PA SP INGREZZA INITIATION PACK T4 PA QL (28 caps/year) SP tetrabenazine (Xenazine) T4 PA SP HD XENAZINE (tetrabenazine) T4 PA SP HD PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS NUEDEXTA T3 QL (4 caps/day) XANTHINES caffeine citrate T1 HD CNS DRUGS (Multiple Sclerosis) AGENTS TO TREAT MULTIPLE SCLEROSIS AUBAGIO T4 PA SP HD AVONEX T4 PA SP HD AVONEX PEN T4 PA SP HD BAFIERTAM T4 PA SP HD BETASERON T4 PA SP HD COPAXONE (glatopa) T4 PA SP HD dimethyl fumarate (Tecfidera) T4 PA SP HD EXTAVIA T4 PA SP HD GILENYA T4 PA SP HD glatiramer acetate (Copaxone) T4 PA SP HD KESIMPTA PEN T4 PA SP HD MAVENCLAD T4 PA SP HD MAYZENT T4 PA SP HD PLEGRIDY T4 PA SP HD PLEGRIDY PEN T4 PA SP HD REBIF T4 PA SP HD REBIF REBIDOSE T4 PA SP HD

94 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Multiple Sclerosis) AGENTS TO TREAT MULTIPLE SCLEROSIS Prescription drug name Drug tier Coverage requirements and limits TECFIDERA (dimethyl fumarate) T4 PA SP HD VUMERITY T4 PA SP HD ZEPOSIA T4 PA SP HD AGTS TX NEUROMUSC TRANSMISSION DIS, POT-CHAN BLKR AMPYRA (dalfampridine er) T4 PA SP HD dalfampridine (Ampyra) T4 PA SP HD FIRDAPSE T4 PA QL (8 tabs/day) SP RUZURGI T4 PA SP CNS DRUGS (Pain Relief And Inflammatory Disease) CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS EMGALITY SYRINGE T2 PA POSTHERPETIC NEURALGIA AGENTS GRALISE T3 PA CNS DRUGS (Seizure Disorders) ANTICONVULSANT - BENZODIAZEPINE TYPE clobazam (Onfi) T1 HD clonazepam T1 HD clonazepam (Klonopin) T1 HD DIASTAT (diazepam) T3 PA HD DIASTAT ACUDIAL (diazepam) T3 PA HD diazepam 10 mg rectal gel syst (Diastat Acudial) T1 HD diazepam 2.5 mg rectal gel sys (Diastat) T1 HD diazepam 20 mg rectal gel syst (Diastat Acudial) T1 HD KLONOPIN (clonazepam) T3 PA HD NAYZILAM T2 PA QL (5 kits/30 days) HD ONFI (clobazam) T3 PA HD SYMPAZAN T3 PA HD VALTOCO T3 PA QL (5 Boxes/30 Days) HD ANTICONVULSANT - CANNABINOID TYPE EPIDIOLEX T4 PA SP HD ANTICONVULSANTS APTIOM 200 MG TABLET T3 PA QL (1 tab/day) HD APTIOM 400 MG TABLET T3 PA QL (1 tab/day) HD

95 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Seizure Disorders) ANTICONVULSANTS Prescription drug name Drug tier Coverage requirements and limits APTIOM 600 MG TABLET T3 PA HD APTIOM 800 MG TABLET T3 PA HD BANZEL 200 MG TABLET T3 PA QL (16 tabs/day) HD BANZEL 40 MG/ML SUSPENSION (rufinamide) T3 PA QL (80ml/day) HD BANZEL 400 MG TABLET T3 PA QL (8 tabs/day) HD BRIVIACT T3 PA HD carbamazepine T1 HD carbamazepine (Carbatrol) T1 HD carbamazepine (Tegretol Xr) T1 HD carbamazepine (Tegretol) T1 HD CARBATROL (carbamazepine er) T3 PA HD CELONTIN T2 HD DEPAKOTE (divalproex sodium) T3 PA HD DEPAKOTE ER (divalproex sodium er) T3 PA HD DEPAKOTE SPRINKLE (divalproex sodium) T3 PA HD DIACOMIT T4 PA SP HD DILANTIN 100 MG CAPSULE (phenytoin sodium T3 PA HD extended) DILANTIN 30 MG CAPSULE T2 PA HD DILANTIN 50 MG INFATAB (phenytoin) T3 PA HD DILANTIN-125 (phenytoin) T3 PA HD divalproex sodium (Depakote Er) T1 HD divalproex sodium (Depakote Sprinkle) T1 HD divalproex sodium (Depakote) T1 HD ethosuximide (Zarontin) T1 HD felbamate (Felbatol) T1 HD FELBATOL (felbamate) T3 PA HD FINTEPLA T4 PA SP HD FYCOMPA 0.5 MG/ML ORAL SUSP T2 PA HD FYCOMPA 10 MG TABLET T2 PA HD FYCOMPA 12 MG TABLET T2 PA HD FYCOMPA 2 MG TABLET T2 PA HD FYCOMPA 4 MG TABLET T2 PA QL (1 tab/day) HD FYCOMPA 6 MG TABLET T2 PA QL (1 tab/day) HD

96 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Seizure Disorders) ANTICONVULSANTS Prescription drug name Drug tier Coverage requirements and limits FYCOMPA 8 MG TABLET T2 PA HD gabapentin T1 HD gabapentin (Neurontin) T1 HD GABITRIL 12 MG TABLET (tiagabine hcl) T3 PA QL (8 tabs/day) HD GABITRIL 16 MG TABLET (tiagabine hcl) T3 PA QL (6 tabs/day) HD GABITRIL 2 MG TABLET (tiagabine hcl) T3 PA HD GABITRIL 4 MG TABLET (tiagabine hcl) T3 PA HD KEPPRA (levetiracetam) T3 PA HD KEPPRA (roweepra) T3 PA HD KEPPRA XR (levetiracetam er) T3 PA HD LAMICTAL (BLUE) (subvenite (blue)) T3 PA HD LAMICTAL (GREEN) (subvenite (green)) T3 PA HD LAMICTAL (lamotrigine) T3 PA HD LAMICTAL (ORANGE) (subvenite (orange)) T3 PA HD LAMICTAL (subvenite) T3 PA HD LAMICTAL ODT (BLUE) (lamotrigine odt (blue)) T3 PA HD LAMICTAL ODT (GREEN) (lamotrigine odt (green)) T3 PA HD LAMICTAL ODT (lamotrigine odt) T3 PA HD LAMICTAL ODT (ORANGE) (lamotrigine odt T3 PA HD (orange)) LAMICTAL XR (BLUE) T3 PA HD LAMICTAL XR (GREEN) T3 PA HD LAMICTAL XR (lamotrigine er) T3 PA HD LAMICTAL XR (ORANGE) T3 PA HD lamotrigine (Lamictal (blue)) T1 HD lamotrigine (Lamictal (green)) T1 HD lamotrigine (Lamictal (orange)) T1 HD lamotrigine (Lamictal Odt (blue)) T1 HD lamotrigine (Lamictal Odt (green)) T1 HD lamotrigine (Lamictal Odt (orange)) T1 HD lamotrigine (Lamictal Odt) T1 HD lamotrigine (Lamictal Xr) T1 HD lamotrigine (Lamictal) T1 HD levetiracetam T1 HD

97 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Seizure Disorders) ANTICONVULSANTS Prescription drug name Drug tier Coverage requirements and limits levetiracetam (Keppra Xr) T1 HD levetiracetam (Keppra) T1 HD LYRICA (pregabalin) T3 PA HD MYSOLINE (primidone) T3 PA HD NEURONTIN (gabapentin) T3 PA HD oxcarbazepine (Trileptal) T1 HD OXTELLAR XR T3 PA HD PEGANONE T2 HD PHENYTEK (phenytoin sodium extended) T3 PA HD phenytoin T1 HD phenytoin (Dilantin) T1 HD phenytoin (Dilantin-125) T1 HD phenytoin sodium extended (Dilantin) T1 HD phenytoin sodium extended (Phenytek) T1 HD pregabalin (Lyrica) T1 HD primidone (Mysoline) T1 HD QUDEXY XR (topiramate er) T3 PA HD rufinamide (Banzel) T1 PA QL (80ML/DAY) HD SABRIL (vigabatrin) T4 PA SP HD SABRIL (vigadrone) T4 PA SP HD SPRITAM T3 PA HD TEGRETOL (carbamazepine) T3 PA HD TEGRETOL (epitol) T3 PA HD TEGRETOL XR (carbamazepine er) T3 PA HD tiagabine hcl 12 mg tablet (Gabitril) T1 QL (8 tabs/day) HD tiagabine hcl 16 mg tablet (Gabitril) T1 QL (6 tabs/day) HD tiagabine hcl 2 mg tablet (Gabitril) T1 HD tiagabine hcl 4 mg tablet (Gabitril) T1 HD TOPAMAX (topiramate) T3 PA HD topiramate (Qudexy Xr) T1 HD topiramate (Topamax) T1 HD TRILEPTAL (oxcarbazepine) T3 PA HD TROKENDI XR 100 MG CAPSULE T3 PA QL (1 cap/day) HD

98 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CNS DRUGS (Seizure Disorders) ANTICONVULSANTS Prescription drug name Drug tier Coverage requirements and limits TROKENDI XR 200 MG CAPSULE T3 PA HD TROKENDI XR 25 MG CAPSULE T3 PA QL (1 cap/day) HD TROKENDI XR 50 MG CAPSULE T3 PA HD valproic acid T1 HD valproic acid (as sodium salt) T1 HD vigabatrin (Sabril) T4 SP HD VIMPAT T2 PA HD XCOPRI 100 MG TABLET T3 PA QL (1 tab/day) HD XCOPRI 12.5-25 MG TITRATION PK T3 PA QL (1/28 Days) HD XCOPRI 150 MG TABLET T3 PA QL (1/Day) HD XCOPRI 150-200 MG TITRATION PK T3 PA QL (1/28 Days) HD XCOPRI 200 MG TABLET T3 PA QL (2/Day) HD XCOPRI 250 MG DAILY DOSE PACK T3 PA QL (1/28 Days) HD XCOPRI 350 MG DAILY DOSE PACK T3 PA QL (1/28 Days) HD XCOPRI 50 MG TABLET T3 PA QL (1/Day) HD XCOPRI 50-100 MG TITRATION PAK T3 PA QL (1/28 Days) HD ZARONTIN (ethosuximide) T3 PA HD ZONEGRAN (zonisamide) T3 PA HD zonisamide T1 HD zonisamide (Zonegran) T1 HD CNS DRUGS (Sleep Disorders/Sedatives) NARCOLEPSY TX-H3-RECEPT.ANTAGONIST/INVERSE AGONIST WAKIX T4 PA QL (2 tabs/day) SP HD COLONY STIMULATING FACTORS (Blood Modifiers/Bleeding Disorders) ERYTHROPOIESIS-STIMULATING AGENTS ARANESP T4 PA SP EPOGEN T4 PA SP MIRCERA T4 PA SP PROCRIT T4 PA SP RETACRIT T4 PA SP LEUKOCYTE (WBC) STIMULANTS FULPHILA T4 PA SP GRANIX T4 PA SP

99 Cigna Legacy (Standard) 4-Tier Prescription Drug List

COLONY STIMULATING FACTORS (Blood Modifiers/Bleeding Disorders) LEUKOCYTE (WBC) STIMULANTS Prescription drug name Drug tier Coverage requirements and limits LEUKINE T4 SP NEULASTA T4 PA SP NEULASTA ONPRO T4 PA SP HD NEUPOGEN T4 PA SP NIVESTYM T4 SP NYVEPRIA T4 PA SP UDENYCA T4 PA SP ZARXIO T4 SP HD ZIEXTENZO T4 PA SP THROMBOPOIETIN RECEPTOR AGONISTS DOPTELET T4 PA SP HD MULPLETA T4 PA SP HD PROMACTA T4 PA SP HD CONTRACEPTIVES (Contraception Products) CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC ANNOVERA T3 etonogestrel/ethinyl estradiol (Nuvaring) T1 PPACA NUVARING (etonogestrel-ethinyl estradiol) T3 CONTRACEPTIVES, IMPLANTABLE NEXPLANON T4 SP PPACA CONTRACEPTIVES, INJECTABLE DEPO-PROVERA 150 MG/ML SYRINGE T3 (medroxyprogesterone acetate) DEPO-PROVERA 150 MG/ML VIAL T3 (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 T2 medroxyprogesterone 150 mg/ml (Depo-provera) T1 PPACA CONTRACEPTIVES, INTRAVAGINAL PHEXXI T3 PA PPACA CONTRACEPTIVES, ORAL BALCOLTRA T3 HD BEYAZ (rajani) T3 HD desog-e.estradiol/e.estradiol (Mircette) T1 HD PPACA desogestrel-ethinyl estradiol T1 HD PPACA

100 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CONTRACEPTIVES (Contraception Products) CONTRACEPTIVES, ORAL Prescription drug name Drug tier Coverage requirements and limits drospir/eth estra/levomefol ca (Beyaz) T1 HD PPACA drospir/eth estra/levomefol ca (Safyral) T1 HD PPACA ELLA T3 HD PPACA ESTROSTEP FE (tri-legest fe) T3 HD ethinyl estradiol/drospirenone (Yasmin 28) T1 HD PPACA ethinyl estradiol/drospirenone (Yaz) T1 HD PPACA ethynodiol d-ethinyl estradiol T1 HD PPACA GENERESS FE (norethin-eth estra-ferrous fum) T3 HD levonorgestrel/ethin.estradiol T1 HD PPACA l-norgest/e.estradiol-e.estrad (Loseasonique) T1 HD PPACA l-norgest/e.estradiol-e.estrad (Quartette) T1 HD PPACA l-norgest/e.estradiol-e.estrad (Seasonique) T1 HD PPACA LO LOESTRIN FE T2 HD LOESTRIN (norethindron-ethinyl estradiol) T3 HD LOESTRIN FE (norethindrone-eth estradiol-fe) T3 HD LOESTRIN FE (tarina fe 1-20 eq) T3 HD LOSEASONIQUE (lojaimiess) T3 HD MICROGESTIN 24 FE (tarina 24 fe) T3 HD MINASTRIN 24 FE (norethin-eth estra-ferrous fum) T3 HD MIRCETTE (volnea) T3 HD NATAZIA T3 HD noreth-ethinyl estradiol/iron T1 HD PPACA noreth-ethinyl estradiol/iron (Generess Fe) T1 HD PPACA noreth-ethinyl estradiol/iron (Generess Fe) T3 HD PPACA norethind-eth estrad 1-0.02 mg (Loestrin) T1 HD PPACA norethindrone (Ortho Micronor) T1 HD PPACA norethindrone ac-eth estradiol (Loestrin) T1 HD PPACA norethindrone-e.estradiol-iron (Estrostep Fe) T1 HD PPACA norethindrone-e.estradiol-iron (Loestrin Fe) T1 HD PPACA norethindrone-e.estradiol-iron (Microgestin 24 Fe) T1 HD PPACA norethindrone-e.estradiol-iron (Minastrin 24 Fe) T1 HD PPACA norethindrone-e.estradiol-iron (Taytulla) T1 HD PPACA norethindrone-ethin. estradiol T1 HD PPACA

101 Cigna Legacy (Standard) 4-Tier Prescription Drug List

CONTRACEPTIVES (Contraception Products) CONTRACEPTIVES, ORAL Prescription drug name Drug tier Coverage requirements and limits norethin-ee 1.5-0.03 mg (21) tb (Loestrin) T1 HD PPACA norgestimate-ethinyl estradiol T1 HD PPACA norgestrel-ethinyl estradiol T1 HD PPACA ORTHO MICRONOR (tulana) T3 HD QUARTETTE (rivelsa) T3 HD SAFYRAL (tydemy) T3 HD SEASONIQUE (simpesse) T3 HD SLYND T3 HD TAYTULLA (norethin-eth estra-ferrous fum) T3 HD TYBLUME T3 HD YASMIN 28 (zumandimine) T3 HD YAZ (vestura) T3 HD CONTRACEPTIVES, TRANSDERMAL norelgestromin/ethin.estradiol T1 HD PPACA TWIRLA T3 HD PPACA DIAPHRAGMS/CERVICAL CAP CAYA CONTOURED T1 PPACA FEMCAP T1 PPACA WIDE SEAL DIAPHRAGM T1 PPACA INTRA-UTERINE DEVICES (IUDS) KYLEENA T4 SP PPACA LILETTA T4 SP PPACA MIRENA T4 SP PPACA PARAGARD T 380-A T4 SP PPACA SKYLA T4 SP PPACA COUGH/COLD PREPARATIONS (Allergy/Nasal Sprays) 1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMB RESPA A.R. T3 COUGH/COLD PREPARATIONS (Cough/Cold Medications) ANTITUSSIVES, NON-OPIOID benzonatate 100 mg capsule (Tessalon Perle) T1 benzonatate 150 mg capsule T1 PA benzonatate 200 mg capsule T1

102 Cigna Legacy (Standard) 4-Tier Prescription Drug List

COUGH/COLD PREPARATIONS (Cough/Cold Medications) ANTITUSSIVES, NON-OPIOID Prescription drug name Drug tier Coverage requirements and limits benzonatate perle 100 mg cap (Tessalon Perle) T1 TESSALON PERLE (benzonatate) T3 NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGEST BROMFED DM (brompheniramine-pseudoephed- T1 dm) brompheniramine/pseudoephed/dm (Bromfed Dm) T1 NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. promethazine/dextromethorphan T1 OPIOID ANTITUSSIV-1ST GEN. ANTIHISTAMINE-DECONGEST hydrocodone/cpm/pseudoephed T1 PA promethazine/phenyleph/codeine T1 PA QL (480ml/22 days) promethazine/phenyleph/codeine T1 PA QL (480ml/30 days) OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE hydrocodone/chlorphen p-stirex T1 PA promethazine-codeine solution T1 PA QL (480ML/22 Days) promethazine-codeine syrup T1 PA QL (480ml/30 days) TUSSICAPS T2 PA TUXARIN ER T3 PA QL (2 tabs/day) TUZISTRA XR T3 PA QL (960ml/30 days) OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS HYCODAN (hydromet) T3 PA QL (480ml/22 days) hydrocodone bit/homatrop me-br (Hycodan) T1 PA QL (480ml/22 days) hydrocodone-homatropine 5-1.5 T1 PA QL (180 tabs/30 days) hydrocodone-homatropine soln (Hycodan) T1 PA QL (480ml/30 days) HYDROCODONE-HOMATROPINE SYRUP T1 PA QL (480ml/30 days) OPIOID ANTITUSSIVE-EXPECTORANT COMBINATION HYDROCODONE-GUAIFENESIN T1 PA QL (960ml/30 days) OBREDON T3 PA QL (960ml/30 days) DIAGNOSTIC (Miscellaneous) DIAGNOSTIC PREPARATIONS, MISCELLANEOUS ADVANCED DNA MEDICATED COLLECT T3 ARIDOL T3 GLUCAGEN DIAGNOSTIC 1 MG VIAL T2 lidocaine hcl/glycerin (Advanced Dna Medicated T1 Collect)

103 Cigna Legacy (Standard) 4-Tier Prescription Drug List

DIAGNOSTIC (Miscellaneous) DIAGNOSTIC PREPARATIONS, MISCELLANEOUS Prescription drug name Drug tier Coverage requirements and limits PROVOCHOLINE T3 TC99M SULFUR COLLOID PREP T1 EYE DIAGNOSTIC AGENTS fluorescein sodium T1 ful-glo 1 mg opth strip T1 FUL-GLO EYE STRIPS T3 lissamine green T1 GASTROINTESTINAL RADIOPAQUE DIAGNOSTICS ENTERO VU T3 E-Z DISK T3 E-Z-HD T3 E-Z-PAQUE T3 E-Z-PASTE T3 GASTROMARK T3 LIQUID E-Z PAQUE T3 LIQUID POLIBAR PLUS T3 NEULUMEX T3 POLIBAR ACB T3 READI-CAT 2 T3 SITZMARKS T3 TAGITOL T3 VARIBAR HONEY T3 VARIBAR NECTAR T3 VARIBAR PUDDING T3 VARIBAR THIN HONEY T3 VARIBAR THIN LIQUID T3 VOLUMEN T3 METABOLIC FUNCTION DIAGNOSTICS METOPIRONE T2 RADIOPHARMACEUTICALS ELEMENTS INDICLOR T3 URINARY TRACT RADIOPAQUE DIAGNOSTICS CYSTO-CONRAY II T3

104 Cigna Legacy (Standard) 4-Tier Prescription Drug List

DIAGNOSTIC (Miscellaneous) URINARY TRACT RADIOPAQUE DIAGNOSTICS Prescription drug name Drug tier Coverage requirements and limits CYSTOGRAFIN T3 CYSTOGRAFIN-DILUTE T3 diatrizoate meglumine, sodium (Gastrografin) T1 GASTROGRAFIN (md-gastroview) T3 DIURETICS (Diuretics) ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS SAMSCA T4 SP SAMSCA (tolvaptan) T4 SP TOLVAPTAN 15 MG TABLET T4 SP tolvaptan 30 mg tablet (Samsca) T4 SP CARBONIC ANHYDRASE INHIBITORS acetazolamide T1 HD methazolamide T1 HD LOOP DIURETICS bumetanide T1 HD EDECRIN (ethacrynic acid) T3 PA HD ethacrynic acid (Edecrin) T1 PA HD furosemide T1 HD furosemide (Lasix) T1 HD LASIX (furosemide) T3 HD torsemide T1 HD POLYCYSTIC KIDNEY DISEASE AGENT, AVP RECEP. ANTAG JYNARQUE 15 MG TABLET T4 SP JYNARQUE 15 MG-15 MG TABLET T4 PA SP JYNARQUE 30 MG TABLET T4 SP JYNARQUE 30 MG-15 MG TABLET T4 PA SP JYNARQUE 45 MG-15 MG TABLET T4 PA SP JYNARQUE 60 MG-30 MG TABLET T4 PA SP JYNARQUE 90 MG-30 MG TABLET T4 PA SP POTASSIUM SPARING DIURETICS ALDACTONE (spironolactone) T3 HD amiloride hcl T1 HD CAROSPIR T3 HD

105 Cigna Legacy (Standard) 4-Tier Prescription Drug List

DIURETICS (Diuretics) POTASSIUM SPARING DIURETICS Prescription drug name Drug tier Coverage requirements and limits DYRENIUM (triamterene) T3 HD eplerenone (Inspra) T1 HD INSPRA (eplerenone) T3 HD spironolactone (Aldactone) T1 HD triamterene (Dyrenium) T1 HD POTASSIUM SPARING DIURETICS IN COMBINATION ALDACTAZIDE T3 HD ALDACTAZIDE (spironolactone-hctz) T3 HD amiloride/hydrochlorothiazide T1 HD DYAZIDE (triamterene-hydrochlorothiazid) T3 HD MAXZIDE (triamterene-hydrochlorothiazid) T3 HD MAXZIDE-25 MG (triamterene-hydrochlorothiazid) T3 HD spironolact/hydrochlorothiazid (Aldactazide) T1 HD triamterene/hydrochlorothiazid (Dyazide) T1 HD triamterene/hydrochlorothiazid (Maxzide) T1 HD triamterene/hydrochlorothiazid (Maxzide-25 Mg) T1 HD THIAZIDE AND RELATED DIURETICS chlorthalidone T1 HD DIURIL T2 HD hydrochlorothiazide T1 HD indapamide T1 HD metolazone T1 HD EENT PREPS (Allergy/Nasal Sprays) NASAL ANTIHISTAMINE azelastine 0.1% (137 mcg) spry T1 HD azelastine 0.15% nasal spray T1 HD olopatadine 665 mcg nasal spry (Patanase) T1 HD PATANASE (olopatadine hcl) T3 HD NASAL ANTIHISTAMINE AND ANTI-INFLAM. STEROID COMB. azelastine/fluticasone (Dymista) T1 HD DYMISTA (azelastine-fluticasone) T3 ST HD NASAL ANTI-INFLAMMATORY STEROIDS BECONASE AQ T3 ST HD

106 Cigna Legacy (Standard) 4-Tier Prescription Drug List

EENT PREPS (Allergy/Nasal Sprays) NASAL ANTI-INFLAMMATORY STEROIDS Prescription drug name Drug tier Coverage requirements and limits flunisolide T1 HD fluticasone prop 50 mcg spray T1 HD mometasone furoate 50 mcg spry (Nasonex) T1 QL (4 bots/30 days) HD NASONEX (mometasone furoate) T3 QL (4 bots/30 days) ST HD OMNARIS T3 ST HD QNASL T3 ST HD QNASL CHILDREN T3 HD XHANCE T3 ST HD ZETONNA T3 ST HD NOSE PREPARATIONS, MISCELLANEOUS (RX) ipratropium bromide T1 HD NOSE PREPARATIONS, VASOCONSTRICTORS (RX) ADRENALIN CHLORIDE T3 epinephrine hcl (Adrenalin Chloride) T1 EENT PREPS (Ear Medications) EAR PREPARATIONS ANTI-INFLAMMATORY DERMOTIC (fluocinolone acetonide oil) T3 fluocinolone acetonide oil (Dermotic) T1 EAR PREPARATIONS, MISC. ANTI-INFECTIVES acetic acid T1 hydrocortisone/acetic acid T1 EENT PREPS (Eye Conditions) ARTIFICIAL TEARS LACRISERT T2 EYE ANTI-INFECTIVES (RX ONLY) BETADINE T2 EYE ANTI-INFLAMMATORY AGENTS ACULAR (ketorolac tromethamine) T3 ACULAR LS (ketorolac tromethamine) T3 ACUVAIL T3 ALREX T3 bromfenac sodium T1 BROMSITE T3

107 Cigna Legacy (Standard) 4-Tier Prescription Drug List

EENT PREPS (Eye Conditions) EYE ANTI-INFLAMMATORY AGENTS Prescription drug name Drug tier Coverage requirements and limits dexamethasone sodium phosphate T1 diclofenac 0.1% eye drops T1 DUREZOL T3 EYSUVIS T2 QL (8.3ML/14 DAYS) FLAREX T2 fluorometholone (Fml) T1 flurbiprofen sodium T1 FML (fluorometholone) T3 FML FORTE T2 FML S.O.P. T2 ILEVRO T3 INVELTYS T3 ketorolac 0.4% ophth solution (Acular Ls) T1 ketorolac 0.5% ophth solution (Acular) T1 LOTEMAX T3 LOTEMAX (loteprednol etabonate) T3 LOTEMAX SM T2 loteprednol etabonate (Lotemax) T1 MAXIDEX T2 NEVANAC T3 OMNIPRED (prednisolone acetate) T3 PRED FORTE (prednisolone acetate) T3 PRED MILD T2 prednisolone acetate (Pred Forte) T1 prednisolone sodium phosphate T1 PROLENSA T3 EYE LOCAL ANESTHETICS AKTEN T3 ALCAINE (proparacaine hcl) T3 ALTAFLUOR BENOX (flurox) T3 benoxinate hcl/fluorescein sod (Altafluor Benox) T1 benoxinate hcl/fluorescein sod (Altafluor Benox) T3 proparacaine hcl (Alcaine) T1

108 Cigna Legacy (Standard) 4-Tier Prescription Drug List

EENT PREPS (Eye Conditions) EYE LOCAL ANESTHETICS Prescription drug name Drug tier Coverage requirements and limits proparacaine/fluorescein sod T1 proparacaine/fluorescein sod T2 tetracaine hcl T1 TETRAVISC T2 TETRAVISC FORTE T2 EYE MAST CELL STABILIZERS ALOCRIL T3 ALOMIDE T2 cromolyn 4% eye drops T1 EYE PREPARATIONS, MISCELLANEOUS (OTC) GELFILM T3 EYE VASOCONSTRICTORS phenylephrine hcl T1 UPNEEQ T3 PA MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS ALPHAGAN P 0.1% DROPS T2 HD ALPHAGAN P 0.15% EYE DROPS (brimonidine T3 HD tartrate) apraclonidine hcl (Iopidine) T1 HD AZOPT (brinzolamide) T3 HD betaxolol hcl T1 HD BETIMOL T2 HD BETOPTIC S T2 HD bimatoprost T1 QL (10ml/30 days) HD brimonidine tartrate T1 HD brimonidine tartrate (Alphagan P) T1 HD brinzolamide (Azopt) T1 HD carteolol hcl T1 HD COMBIGAN T2 HD COSOPT (dorzolamide-timolol) T3 HD COSOPT PF (dorzolamide-timolol) T3 HD dorzolamide hcl (Trusopt) T1 HD dorzolamide hcl/timolol maleat (Cosopt) T1 HD dorzolamide/timolol/pf (Cosopt Pf) T1 HD

109 Cigna Legacy (Standard) 4-Tier Prescription Drug List

EENT PREPS (Eye Conditions) MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS Prescription drug name Drug tier Coverage requirements and limits IOPIDINE 0.5% EYE DROPS (apraclonidine hcl) T3 HD IOPIDINE 1% EYE DROPS T2 HD ISOPTO CARPINE (pilocarpine hcl) T3 HD ISTALOL (timolol maleate) T3 HD latanoprost (Xalatan) T1 HD levobunolol hcl T1 HD LUMIGAN T3 PA HD PHOSPHOLINE IODIDE T2 HD pilocarpine hcl (Isopto Carpine) T1 HD RHOPRESSA T3 HD ROCKLATAN T3 HD SIMBRINZA T2 HD timolol maleate (Istalol) T1 HD timolol maleate (Timoptic) T1 HD timolol maleate (Timoptic-xe) T1 HD timolol maleate/pf (Timoptic Ocudose) T1 HD TIMOPTIC (timolol maleate) T3 HD TIMOPTIC OCUDOSE T3 HD TIMOPTIC OCUDOSE (timolol maleate) T3 HD TIMOPTIC-XE (timolol maleate) T3 HD TRAVATAN Z (travoprost) T3 PA HD travoprost (Travatan Z) T1 HD TRUSOPT (dorzolamide hcl) T3 HD VYZULTA T3 PA HD XALATAN (latanoprost) T3 PA HD XELPROS T3 PA HD ZIOPTAN T3 PA QL (2 boxes/30 days) HD MYDRIATICS atropine sulfate T1 HD atropine sulfate (Isopto Atropine) T1 HD ATROPINE SULFATE-0.9% NACL T1 HD CYCLOGYL 0.5% EYE DROPS (cyclopentolate hcl) T2 HD CYCLOGYL 1% EYE DROPS T3 HD

110 Cigna Legacy (Standard) 4-Tier Prescription Drug List

EENT PREPS (Eye Conditions) MYDRIATICS Prescription drug name Drug tier Coverage requirements and limits CYCLOGYL 1% EYE DROPS (cyclopentolate hcl) T3 HD CYCLOGYL 2% EYE DROPS (cyclopentolate hcl) T2 HD CYCLOMYDRIL T2 HD cyclopentolate hcl (Cyclogyl) T1 HD homatropine hbr T1 HD ISOPTO ATROPINE (atropine sulfate) T3 HD MYDRIACYL (tropicamide) T3 HD PAREMYD T3 HD tropicamide T1 HD tropicamide (Mydriacyl) T1 HD TROPICAMIDE-CYCLOPENTOLATE-PE T3 HD OPHTHALMIC ANTIFIBROTIC AGENTS MITOSOL T3 OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE CEQUA T3 HD RESTASIS T2 HD RESTASIS MULTIDOSE T2 HD XIIDRA T2 HD OPHTHALMIC CYSTINE DEPLETING AGENTS CYSTADROPS T4 PA QL (20ML/21 DAYS) SP CYSTARAN T4 PA QL (120ml/28 days) SP OPHTHALMIC HUMAN NERVE GROWTH FACTOR (HNGF) OXERVATE T4 PA SP HD ELECT/CALORIC/H2O (Cholesterol Medications) ORAL LIPID SUPPLEMENTS DOJOLVI T4 PA SP HD ELECT/CALORIC/H2O (Dental Products) FLUORIDE PREPARATIONS CLINPRO 5000 T3 fluoride (sodium)(Prevident 5000 Ortho Defense) T1 fluoride (sodium)(Prevident 5000 Plus) T1 fluoride (sodium)(Prevident 5000) T1 fluoride (sodium)(Prevident) T1

111 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ELECT/CALORIC/H2O (Dental Products) FLUORIDE PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits FLUORIDEX T1 FLUORIDEX SENSITIVITY RELIEF T3 PREVIDENT 0.2% RINSE T2 PREVIDENT 1.1% GEL (sodium fluoride) T3 PREVIDENT 5000 T3 PREVIDENT 5000 BOOSTER PLUS T3 PREVIDENT 5000 ENAMEL PROTECT T3 PREVIDENT 5000 ORTHO DEFENSE T3 PREVIDENT 5000 PLUS (sodium fluoride 5000 T3 plus) PREVIDENT 5000 SENSITIVE T3 PREVIDENT DENTAL RINSE T2 sodium fluoride/potassium nit (Prevident 5000 T1 Sensitive) ELECT/CALORIC/H2O (Diabetes) AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS) BAQSIMI T2 QL (2/30 days) diazoxide (Proglycem) T1 GLUCAGEN 1 MG HYPOKIT T2 QL (2 pens/30 days) GLUCAGON 1 MG EMERGENCY KIT T3 QL (2 pens/30 days) glucagon 1 mg emergency kit (Glucagon T1 QL (2 pens/30 days) Emergency Kit) GVOKE HYPOPEN 1-PACK T3 QL (2 PACKS/22 DAYS) GVOKE HYPOPEN 2-PACK T3 QL (2 PACKS/22 DAYS) GVOKE PFS 1-PACK SYRINGE T3 QL (2 syrings/30 days) GVOKE PFS 2-PACK SYRINGE T3 QL (2 syrings/30 days) PROGLYCEM (diazoxide) T3 ELECT/CALORIC/H2O (Miscellaneous) NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTS XURIDEN T4 PA SP ELECT/CALORIC/H2O (Nutritional/Dietary) ELECTROLYTE DEPLETERS AURYXIA T3 QL (12 tabs/day) calcium acetate T1 FOSRENOL 1,000 MG POWDER PACK T2

112 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ELECT/CALORIC/H2O (Nutritional/Dietary) ELECTROLYTE DEPLETERS Prescription drug name Drug tier Coverage requirements and limits FOSRENOL 1,000 MG TABLET CHEW (lanthanum T3 carbonate) FOSRENOL 500 MG TABLET CHEW (lanthanum T3 carbonate) FOSRENOL 750 MG POWDER PACKET T2 FOSRENOL 750 MG TABLET CHEW (lanthanum T3 carbonate) lanthanum carbonate (Fosrenol) T1 LOKELMA T3 PHOSLYRA T3 RENAGEL (sevelamer hcl) T3 RENVELA (sevelamer carbonate) T3 sevelamer carbonate (Renvela) T1 sevelamer hcl T1 sevelamer hcl (Renagel) T1 sodium polystyrene sulfon/sorb T1 sodium polystyrene sulfonate T1 sps 15 gm/60 ml suspension T1 sps 30 gm/120 ml enema susp T3 VELPHORO T2 VELTASSA T3 IODINE CONTAINING AGENTS potassium iodide/iodine T1 SSKI T1 IRON REPLACEMENT CITRANATAL BLOOM T3 POTASSIUM REPLACEMENT EFFER-K 10 MEQ TABLET EFF T3 EFFER-K 20 MEQ TABLET EFF T3 effer-k 25 meq tablet eff T1 klor-con 10 meq tablet (K-tab Er) T1 klor-con 10 meq tablet (K-tab Er) T3 klor-con 8 meq tablet T1 klor-con 8 meq tablet T3 K-TAB ER T3

113 Cigna Legacy (Standard) 4-Tier Prescription Drug List

ELECT/CALORIC/H2O (Nutritional/Dietary) POTASSIUM REPLACEMENT Prescription drug name Drug tier Coverage requirements and limits K-TAB ER (potassium chloride) T3 potassium bicarbonate/cit ac T1 potassium chloride T1 potassium chloride T2 potassium chloride T3 potassium chloride (K-tab Er) T1 ELECT/CALORIC/H2O (Urinary Tract Conditions) DIALYSIS SOLUTIONS PRISMASOL T3 URINARY PH MODIFIERS K-PHOS NO.2 T2 HD K-PHOS ORIGINAL T2 HD ORACIT T3 HD potassium citrate (Urocit-k) T1 HD potassium citrate/citric acid T1 HD RENACIDIN T3 HD UROCIT-K (potassium citrate er) T3 HD UROQID-ACID NO.2 T2 HD GASTROINTESTINAL (Cholesterol Medications) LIPOTROPICS icosapent ethyl (Vascepa) T1 HD LOVAZA (triklo) T3 HD omega-3 acid ethyl esters (Lovaza) T1 HD VASCEPA T2 PA HD GASTROINTESTINAL (Gastrointestinal/Heartburn) AMMONIA INHIBITORS BUPHENYL 500 MG TABLET (sodium T4 SP HD phenylbutyrate) BUPHENYL POWDER (sodium phenylbutyrate) T4 SP HD lactulose T1 HD lactulose 10 gm/15 ml solution T1 HD LITHOSTAT T2 HD RAVICTI T4 PA SP HD sodium phenylbutyrate (Buphenyl) T4 SP HD

114 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) ANTICHOLINERGICS, QUATERNARY AMMONIUM Prescription drug name Drug tier Coverage requirements and limits chlordiazepoxide/clidinium br (Librax) T1 CUVPOSA T3 GLYCATE T3 glycopyrrolate (Glycate) T1 glycopyrrolate (Robinul Forte) T1 glycopyrrolate (Robinul) T1 LIBRAX (chlordiazepoxide-clidinium) T3 PA propantheline bromide T1 ROBINUL (glycopyrrolate) T3 ROBINUL FORTE (glycopyrrolate) T3 ANTICHOLINERGICS/ANTISPASMODICS dicyclomine hcl T1 ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORS MYTESI T3 ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITOR XERMELO T4 PA SP ANTIDIARRHEALS diphenoxylate hcl/atropine T1 diphenoxylate hcl/atropine (Lomotil) T1 LOMOTIL (diphenoxylate-atropine) T3 loperamide hcl T1 MOTOFEN T3 opium tincture T1 PA paregoric T1 ANTIEMETIC, CANNABINOID-TYPE dronabinol (Marinol) T1 MARINOL (dronabinol) T3 PA SYNDROS T3 PA ANTIEMETIC/ANTIVERTIGO AGENTS AKYNZEO T3 PA QL (4 caps/28 days) ANZEMET T4 PA QL (5 tabs/30 days) SP aprepitant 125 mg capsule T1 QL (4 caps/28 days) aprepitant 125-80-80 mg pack (Emend) T1 QL (12 caps/28 days)

115 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) ANTIEMETIC/ANTIVERTIGO AGENTS Prescription drug name Drug tier Coverage requirements and limits aprepitant 40 mg capsule T1 QL (1 cap/28 days) aprepitant 80 mg capsule (Emend) T1 QL (8 caps/28 days) BONJESTA T3 COMPAZINE (prochlorperazine maleate) T3 COMPAZINE (prochlorperazine) T3 DICLEGIS (doxylamine succ-pyridoxine hcl) T3 doxylamine succinate/vit b6 (Diclegis) T1 EMEND 125 MG POWDER PACKET T3 PA QL (12 caps/28 days) EMEND 150 MG VIAL (fosaprepitant dimeglumine) T3 PA EMEND 80 MG CAPSULE (aprepitant) T3 PA QL (8 caps/28 days) EMEND TRIPACK (aprepitant) T3 PA QL (12 caps/28 days) fosaprepitant dimeglumine (Emend) T1 PA granisetron hcl T1 granisetron hcl/pf T1 ondansetron T1 ondansetron hcl T1 ondansetron hcl (Zofran) T1 ondansetron hcl/pf T1 prochlorperazine (Compazine) T1 prochlorperazine maleate (Compazine) T1 promethazine hcl T1 promethazine hcl T3

SANCUSO T3 PA QL (4 patches/30 days) scopolamine (Transderm-scop) T1 TIGAN (trimethobenzamide hcl) T3 TRANSDERM-SCOP (scopolamine) T3 trimethobenzamide hcl (Tigan) T1 VARUBI T3 PA QL (4 tabs/28 days) ZOFRAN 2 MG/ML VIAL (ondansetron hcl) T3 ZOFRAN 4 MG TABLET (ondansetron hcl) T3 PA ZOFRAN 8 MG TABLET (ondansetron hcl) T3 PA ZUPLENZ T3 PA QL (24 films/30 days)

116 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) ANTI-ULCER PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits CARAFATE (sucralfate) T3 HD CYTOTEC (misoprostol) T3 HD misoprostol (Cytotec) T1 HD sucralfate (Carafate) T1 HD ANTI-ULCER-H.PYLORI AGENTS HELIDAC T3 PA lansoprazole/amoxiciln/clarith T1 OMECLAMOX-PAK T3 PA PYLERA T3 PA TALICIA T3 PA BELLADONNA ALKALOIDS DONNATAL T3 HD DONNATAL (phenohytro) T3 HD hyoscyamine sulfate T1 HD hyoscyamine sulfate (Levbid) T1 HD hyoscyamine sulfate (Levsin) T1 HD hyoscyamine sulfate (Levsin-sl) T1 HD hyoscyamine sulfate (Nulev) T1 HD hyoscyamine sulfate (Nulev) T3 HD LEVBID (symax-sr) T3 HD LEVSIN (oscimin) T3 HD LEVSIN-SL (symax-sl) T3 HD methscopolamine bromide T1 HD NULEV (symax) T1 HD phenobarb/hyoscy/atropine/scop (Donnatal) T1 HD phenobarb/hyoscy/atropine/scop (Phenobarbital- T1 HD belladonna) phenobarbital-belladonna elixr (Donnatal) T1 HD phenobarbital-belladonna elixr (Phenobarbital- T1 HD belladonna) PHENOBARBITAL-BELLADONNA ELIXR T3 HD (phenohytro) SYMAX DUOTAB T2 HD BILE SALTS ACTIGALL (ursodiol) T3 HD

117 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) BILE SALTS Prescription drug name Drug tier Coverage requirements and limits CHENODAL T4 SP HD CHOLBAM T4 PA SP HD RELTONE T3 PA HD URSO (ursodiol) T3 HD URSO FORTE (ursodiol) T3 HD ursodiol (Actigall) T1 HD ursodiol (Urso Forte) T1 HD ursodiol (Urso) T1 HD CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT, RECTAL TX CANASA (mesalamine) T3 mesalamine 1,000 mg supp (Canasa) T1 mesalamine 4 gm/60 ml enema (Sfrowasa) T1 mesalamine 4 gm/60 ml kit (Rowasa) T1 ROWASA (mesalamine) T3 PA SFROWASA (mesalamine) T3 DRUG TX-CHRONIC INFLAM. COLON DX, 5-AMINOSALICYLAT APRISO (mesalamine er) T3 ST HD ASACOL HD (mesalamine) T3 ST HD AZULFIDINE (sulfasalazine dr) T3 HD AZULFIDINE (sulfasalazine) T3 HD balsalazide disodium (Colazal) T1 HD COLAZAL (balsalazide disodium) T3 ST HD DELZICOL (mesalamine dr) T3 ST HD DIPENTUM T3 ST HD LIALDA (mesalamine) T3 ST HD mesalamine (Apriso) T1 HD mesalamine (Delzicol) T1 HD mesalamine 800 mg dr tablet (Asacol Hd) T1 HD mesalamine dr 1.2 gm tablet (Lialda) T1 HD PENTASA T2 HD sulfasalazine (Azulfidine) T1 HD FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG OCALIVA T4 PA SP HD

118 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) GASTRIC ENZYMES Prescription drug name Drug tier Coverage requirements and limits SUCRAID T4 PA SP HISTAMINE H2-RECEPTOR INHIBITORS cimetidine T1 HD cimetidine hcl T1 HD famotidine T1 HD famotidine (Pepcid) T1 HD nizatidine T1 HD PEPCID (famotidine) T1 PA HD ranitidine hcl T1 HD IBS AGENTS, MIXED OPIOID RECEP AGONISTS/ANTAGONISTS VIBERZI T2 HD IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONIST LINZESS T2 TRULANCE T3 PA INTEGRIN RECEPTOR ANTAGONIST, MONOCLONAL ANTIBODY ENTYVIO T4 PA SP HD INTESTINAL MOTILITY STIMULANTS GIMOTI T4 PA SP metoclopramide hcl T1 metoclopramide hcl (Reglan) T1 MOTEGRITY T3 PA REGLAN (metoclopramide hcl) T3 IRRITABLE BOWEL SYND. AGENT, 5-HT4 PARTIAL AGONIST ZELNORM T3 PA IRRITABLE BOWEL SYNDROME AGENTS, 5-HT3 ANTAGONIST alosetron hcl (Lotronex) T4 SP HD LOTRONEX (alosetron hcl) T4 PA SP HD LAXATIVES AND CATHARTICS AMITIZA T2 bisac/nacl/nahco3/kcl/peg 3350 T1 PPACA CLENPIQ T2 PPACA COLYTE WITH FLAVOR PACKETS (peg T3 PPACA 3350-electrolyte)

119 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) LAXATIVES AND CATHARTICS Prescription drug name Drug tier Coverage requirements and limits COLYTE WITH FLAVOR PACKETS (peg T3 PA PPACA 3350-electrolyte) GOLYTELY T3 PA PPACA GOLYTELY (peg-3350 and electrolytes) T3 PA PPACA KRISTALOSE T3 lactulose T1 lactulose 10 gm packet (Kristalose) T1 lactulose 10 gm/15 ml solution T1 lactulose 20 gm/30 ml solution T1 LUBIPROSTONE T3 PA MOVIPREP (peg3350-sod sul-nacl-kcl-asb-c) T3 PA PPACA NULYTELY T3 PA PPACA NULYTELY WITH FLAVOR PACKS (trilyte with T3 PA PPACA flavor packets) OSMOPREP T3 PA PPACA peg3350/sod sul/nacl/kcl/asb/c (Moviprep) T1 PPACA peg3350/sod sulf, bicarb, cl/kcl (Colyte With Flavor T1 PPACA Packets) peg3350/sod sulf, bicarb, cl/kcl (Golytely) T1 PPACA PLENVU T3 PA PPACA PREPOPIK T2 PPACA sodium chloride/nahco3/kcl/peg (Nulytely With T1 PPACA Flavor Packs) SUPREP T2 PPACA SUTAB T2 PPACA LOCAL ANORECTAL NITRATE PREPARATIONS RECTIV T3 PANCREATIC ENZYMES CREON T3 PA HD PANCREAZE T2 HD PERTZYE T3 PA HD VIOKACE T3 HD ZENPEP T3 PA HD PROTON-PUMP INHIBITORS ACIPHEX (rabeprazole sodium) T3 QL (30 tabs/30 days) ST HD

120 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) PROTON-PUMP INHIBITORS Prescription drug name Drug tier Coverage requirements and limits ACIPHEX SPRINKLE DR 10 MG CAP T3 QL (60 caps/30 days) HD ACIPHEX SPRINKLE DR 5 MG CAP T3 QL (120 caps/30 days) HD DEXILANT DR 30 MG CAPSULE T2 QL (2 caps/day) HD DEXILANT DR 60 MG CAPSULE T2 QL (30 caps/30 days) HD esomeprazole dr 10 mg packet (Nexium) T1 QL (4 packets/day) HD esomeprazole dr 20 mg packet (Nexium) T1 QL (2 packs/day) HD esomeprazole dr 40 mg packet (Nexium) T1 QL (1 packet/day) HD esomeprazole mag dr 20 mg cap (Nexium) T1 QL (2/day) HD esomeprazole mag dr 40 mg cap (Nexium) T1 QL (30 caps/30 days) HD ESOMEPRAZOLE STRONTIUM T3 QL (30 caps/30 days) HD lansoprazole dr 15 mg capsule (Prevacid) T1 QL (2 caps/day) HD lansoprazole dr 30 mg capsule (Prevacid) T1 QL (30 caps/30 days) HD lansoprazole odt 15 mg tablet (Prevacid) T1 QL (2 tabs/day) HD lansoprazole odt 30 mg tablet (Prevacid) T1 QL (30 tabs/30 days) HD NEXIUM DR 10 MG PACKET (esomeprazole T3 PA QL (120 packs/30 days) HD magnesium) NEXIUM DR 2.5 MG PACKET T2 QL (480 packs/30 days) HD NEXIUM DR 20 MG CAPSULE (esomeprazole T3 PA QL (2 caps/day) HD magnesium) NEXIUM DR 20 MG PACKET (esomeprazole T3 PA QL (2 packs/day) HD magnesium) NEXIUM DR 40 MG CAPSULE (esomeprazole T3 PA QL (30 caps/30 days) HD magnesium) NEXIUM DR 40 MG PACKET (esomeprazole T3 PA QL (30 packs/30 days) HD magnesium) NEXIUM DR 5 MG PACKET T2 QL (240 packs/30 days) HD omeppi 20 mg-1, 100 mg capsule (Zegerid) T3 PA QL (60 caps/30 days) HD omeppi 40 mg-1, 100 mg capsule (Zegerid) T3 PA QL (30 caps/30 days) HD omeprazole dr 10 mg capsule T1 QL (4 caps/day) HD omeprazole dr 20 mg capsule T1 QL (60 caps/30 days) HD omeprazole dr 40 mg capsule T1 QL (1 cap/day) HD omeprazole-bicarb 20-1, 100 cap (Zegerid) T1 PA QL (2 caps/day) HD omeprazole-bicarb 20-1, 680 pkt (Zegerid) T1 PA QL (60 packs/30 days) HD omeprazole-bicarb 40-1, 100 cap (Zegerid) T1 PA QL (30 caps/30 days) HD omeprazole-bicarb 40-1, 680 pkt (Zegerid) T1 PA QL (30 packs/30 days) HD

121 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Gastrointestinal/Heartburn) PROTON-PUMP INHIBITORS Prescription drug name Drug tier Coverage requirements and limits pantoprazole 40 mg suspension (Protonix) T1 QL (1 dose/day) HD pantoprazole sod dr 20 mg tab (Protonix) T1 QL (60 tabs/30 days) HD pantoprazole sod dr 40 mg tab (Protonix) T1 QL (1 tab/day) HD PREVACID 15 MG SOLUTAB (lansoprazole) T3 PA QL (2 tabs/day) HD PREVACID 30 MG SOLUTAB (lansoprazole) T3 PA QL (30 tabs/30 days) HD PREVACID DR 15 MG CAPSULE (lansoprazole) T3 QL (60 caps/30 days) ST HD PREVACID DR 30 MG CAPSULE (lansoprazole) T3 QL (30 caps/30 days) ST HD PRILOSEC DR 10 MG SUSPENSION T3 QL (120 packs/30 days) HD PRILOSEC DR 2.5 MG SUSPENSION T3 QL (480 packs/30 days) HD PROTONIX 40 MG SUSPENSION (pantoprazole T3 QL (30 packs/30 days) ST HD sodium) PROTONIX DR 20 MG TABLET (pantoprazole T3 QL (60 tabs/30 days) ST HD sodium) PROTONIX DR 40 MG TABLET (pantoprazole T3 QL (30 tabs/30 days) ST HD sodium) RABEPRAZOLE DR 10 MG SPRNKL CP T3 QL (2 caps/day) HD rabeprazole sod dr 20 mg tab (Aciphex) T1 QL (30 tabs/30 days) HD ZEGERID 20 MG CAPSULE (omeprazole-sodium T3 PA QL (60 caps/30 days) HD bicarbonate) ZEGERID 20 MG PACKET (omeprazole-sodium T3 PA QL (60 packs/30 days) HD bicarbonate) ZEGERID 40 MG CAPSULE (omeprazole-sodium T3 PA QL (30 caps/30 days) HD bicarbonate) ZEGERID 40 MG PACKET (omeprazole-sodium T3 PA QL (30 packs/30 days) HD bicarbonate) RECTAL PREPARATIONS ANUSOL-HC 25 MG SUPPOSITORY (hydrocortisone T3 PA acetate) hydrocortisone acetate T1 hydrocortisone acetate (Anusol-hc) T1 SBS - GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGS GATTEX T4 PA SP HD GASTROINTESTINAL (Pain Relief And Inflammatory Disease) HEMORRHOID PREP, ANTI-INFLAM STEROID-LOCAL ANESTHET ANA-LEX T1 ANALPRAM HC T3 ANALPRAM HC (hydrocortisone-pramoxine) T3

122 Cigna Legacy (Standard) 4-Tier Prescription Drug List

GASTROINTESTINAL (Pain Relief And Inflammatory Disease) HEMORRHOID PREP, ANTI-INFLAM STEROID-LOCAL ANESTHET Prescription drug name Drug tier Coverage requirements and limits hydrocortisone/lidocaine/aloe T1 hydrocortisone/pramoxine (Analpram Hc) T1 lidocaine/hydrocortisone ac T1 LIDOCAINE-HYDROCORTISONE T1 PROCORT T3 PROCTOFOAM-HC T2 HORMONES (Gastrointestinal/Heartburn) RECTAL/LOWER BOWEL PREP., GLUCOCORT. (NON-HEMORR) CORTENEMA (hydrocortisone) T3 CORTIFOAM T3 PA hydrocortisone (Cortenema) T1 UCERIS 2 MG RECTAL FOAM T3 PA QL (2 kits/180 days) HORMONES (Hormonal Agents) ADRENAL STEROID INHIBITORS ISTURISA T4 PA QL (2 TABS/DAY) SP ANDROGEN/ESTROGEN PREPS FOR FEMALE SEXUAL DYSFUNC INTRAROSA T3 ANDROGENIC AGENTS ANADROL-50 T2 PA ANDRODERM T2 PA QL (1 patch/day) ANDROGEL 1% (25 MG/2.5 G) PKT (testosterone) T3 PA QL (150gm/30 days) ANDROGEL 1% (50 MG/5 G) PKT (testosterone) T3 PA QL (2 packs/day) ANDROGEL 1.62% GEL PUMP (testosterone) T3 PA QL (150gm/30 days) ANDROGEL 1.62% (1.25G) GEL PCKT (testosterone) T3 PA QL (2 packs/day) ANDROGEL 1.62% (2.5G) GEL PCKT (testosterone) T3 PA QL (150gm/30 days) ANDROID (methyltestosterone) T3 DEPO-TESTOSTERONE T3 DEPO-TESTOSTERONE (testosterone cypionate) T3 FORTESTA (testosterone) T3 PA QL (120 gm/30 days) JATENZO 158 MG CAPSULE T3 PA QL (4 caps/day) JATENZO 198 MG CAPSULE T3 PA QL (4 caps/day) JATENZO 237 MG CAPSULE T3 PA QL (2 caps/day) METHITEST T1

123 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) ANDROGENIC AGENTS Prescription drug name Drug tier Coverage requirements and limits methyltestosterone (Testred) T1 NATESTO T3 PA QL (3 bots/30 days) oxandrolone T1 PA TESTIM (testosterone) T3 PA QL (2 tubes/day) testosterone 1% (25mg/2.5g) pk (Androgel) T1 PA QL (150gm/30 days) testosterone 1% (50 mg/5 g) pk (Vogelxo) T1 PA QL (2 packs/day) testosterone 1.62% (2.5 g) pkt (Androgel) T1 PA QL (150gm/30 days) testosterone 1.62% gel pump (Androgel) T1 PA QL (150gm/30 days) testosterone 1.62% (1.25 g) pkt (Androgel) T1 PA QL (2 packs/day) testosterone 10 mg gel pump (Fortesta) T1 PA QL (120 gm/30 days) TESTOSTERONE 12.5 MG/1.25 GRAM T1 PA QL (150gm/30 days) testosterone 12.5 mg/1.25 gram (Vogelxo) T1 PA QL (150gm/30 days) testosterone 30 mg/1.5 ml pump T1 PA QL (180ml/30 days) testosterone 50 mg/5 gram gel (Vogelxo) T1 PA QL (2 tubes/day) TESTOSTERONE 50 MG/5 GRAM PKT T1 PA QL (2 packs/day) testosterone cypionate (Depo-testosterone) T1 testosterone enanthate T1 TESTRED (methyltestosterone) T3 VOGELXO 12.5 MG/1.25 GRAM PUMP T3 PA QL (150gm/30 days) VOGELXO 50 MG/5 GRAM GEL (testosterone) T3 PA QL (2 tubes/day) VOGELXO 50 MG/5 GRAM GEL PACKT T3 PA QL (2 packs/day) XYOSTED T3 PA QL (4 injectors/28 days) ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP T3 PA DDAVP (desmopressin acetate) T3 PA desmopressin (nonrefrigerated) (Ddavp) T1 desmopressin acetate (Ddavp) T1 NOCDURNA T3 PA NOCTIVA T3 PA STIMATE T4 SP ESTROGEN AND PROGESTIN COMBINATIONS BIJUVA T3 ESTROGEN/ANDROGEN COMBINATIONS estrogen, ester/me-testosterone T1 HD

124 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) ESTROGENIC AGENTS Prescription drug name Drug tier Coverage requirements and limits ACTIVELLA (mimvey lo) T3 HD ACTIVELLA (mimvey) T3 HD ALORA T3 QL (16 patches/28 days) HD CLIMARA (estradiol (once weekly)) T3 HD CLIMARA PRO T3 HD COMBIPATCH T3 HD DELESTROGEN T3 HD DELESTROGEN (estradiol valerate) T3 HD DEPO-ESTRADIOL T3 HD DIVIGEL T2 HD ELESTRIN T3 HD ESTRACE (estradiol) T3 HD estradiol (Climara) T1 HD estradiol (Vivelle-dot) T1 QL (8 PATCHES/21 DAYS) HD estradiol (Vivelle-dot) T1 QL (16 patches/28 days) HD estradiol 0.5 mg tablet (Estrace) T1 HD estradiol 1 mg tablet (Estrace) T1 HD estradiol 2 mg tablet (Estrace) T1 HD estradiol valerate (Delestrogen) T1 HD estradiol/norethindrone acet (Activella) T1 HD ESTROGEL T3 HD EVAMIST T3 HD FEMHRT (norethindron-ethinyl estradiol) T3 HD MENEST T3 HD MENOSTAR T3 QL (8 patches/28 days) HD MINIVELLE (lyllana) T3 QL (16 patches/28 days) HD norethind-eth estrad 0.5-2.5 (Femhrt) T1 HD norethindrone ac-eth estradiol T1 HD norethindrone ac-eth estradiol (Femhrt) T1 HD norethin-eth estrad 1 mg-5 mcg T1 HD PREFEST T3 HD PREMARIN T2 HD PREMPHASE T2 HD

125 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) ESTROGENIC AGENTS Prescription drug name Drug tier Coverage requirements and limits PREMPRO T2 HD VIVELLE-DOT (lyllana) T3 QL (16 patches/28 days) HD ESTROGEN-PROGESTIN WITH ANTIMINERALOCORTICOID COMB ANGELIQ T3 HD ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MOD (SERM) COMB DUAVEE T2 GLUCOCORTICOIDS ALKINDI SPRINKLE T3 PA budesonide (Entocort Ec) T1 budesonide (Uceris) T1 PA QL (56 tabs/180 days) CORTEF (hydrocortisone) T3 cortisone acetate T1 dexamethasone T1 dexamethasone (Dxevo) T1 dexamethasone (Taperdex) T1 PA dexamethasone 0.5 mg tablet T1 dexamethasone 0.5 mg/5 ml elx T1 dexamethasone 0.5 mg/5 ml liq T1 dexamethasone 0.75 mg tablet T1 dexamethasone 1 mg tablet T1 dexamethasone 1.5 mg tablet T1 dexamethasone 10 day 1.5 mg tb T1 PA dexamethasone 13 day 1.5 mg tb T1 PA dexamethasone 2 mg tablet T1 dexamethasone 4 mg tablet T1 dexamethasone 6 day 1.5 mg tab (Taperdex) T1 PA dexamethasone 6 mg tablet T1 DXEVO T3 EMFLAZA T4 PA SP HD ENTOCORT EC (budesonide ec) T3 HEMADY T3 hydrocortisone (Cortef) T1 LOCORT T1

126 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) GLUCOCORTICOIDS Prescription drug name Drug tier Coverage requirements and limits MEDROL 16 MG TABLET (methylprednisolone) T3 MEDROL 2 MG TABLET T2 MEDROL 32 MG TABLET (methylprednisolone) T3 MEDROL 4 MG DOSEPAK (methylprednisolone) T3 MEDROL 4 MG TABLET (methylprednisolone) T3 MEDROL 8 MG TABLET (methylprednisolone) T3 methylprednisolone (Medrol) T1 MILLIPRED 10 MG/5 ML SOLUTION (prednisolone T3 sodium phosphate) millipred 5 mg tablet T1 ORAPRED ODT (prednisolone sodium phos odt) T3 ORTIKOS T3 PA QL (1 TAB/DAY) prednisolone T1 prednisolone sodium phosphate T1 prednisolone sodium phosphate (Millipred) T1 prednisolone sodium phosphate (Orapred Odt) T1 prednisone T1 RAYOS T3 PA TAPERDEX T1 PA UCERIS 9 MG ER TABLET (budesonide er) T3 PA QL (1 tab/day) ZCORT T3 PA ZONACORT T3 GROWTH HORMONE RELEASING HORMONE (GHRH) AND ANALOGS EGRIFTA T4 PA SP HD EGRIFTA SV T4 PA SP HD GROWTH HORMONES GENOTROPIN T4 PA SP HD HUMATROPE T4 PA SP HD NORDITROPIN FLEXPRO T4 PA SP HD NUTROPIN AQ NUSPIN T4 PA SP HD OMNITROPE T4 PA SP HD SAIZEN T4 PA SP HD SAIZEN-SAIZENPREP T4 PA SP HD SEROSTIM T4 PA SP

127 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) GROWTH HORMONES Prescription drug name Drug tier Coverage requirements and limits ZOMACTON T4 PA SP HD ZORBTIVE T4 PA SP HD

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES INCRELEX T4 PA SP HD LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB LUPANETA PACK T4 PA SP HD LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT T4 PA SP HD SYNAREL T4 PA SP HD

LHRH (GNRH) ANTAGONIST, ESTROGEN AND PROGESTIN COMB ORIAHNN T2 PA QL (2 CAPSULES/DAY) LHRH (GNRH) ANTAGONIST, PITUITARY SUPPRESSANT AGENTS CETROTIDE T4 PA SP ganirelix acet 250 mcg/0.5 ml (Ganirelix Acetate) T4 PA SP GANIRELIX ACET 250 MCG/0.5 ML (ganirelix T4 PA SP acetate) ORILISSA 150 MG TABLET T2 PA QL (1 tab/day) ORILISSA 200 MG TABLET T2 PA QL (2 tabs/day)

LHRH (GNRH) AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY FENSOLVI T4 PA SP LUPRON DEPOT-PED T4 PA SP HD MINERALOCORTICOIDS fludrocortisone acetate T1 HD OXYTOCICS CERVIDIL T3 methylergonovine maleate T1 PREPIDIL T3 PROSTIN E2 VAGINAL SUPPOSITORY T3

PARATHYROID HORMONES NATPARA T4 PA SP HD PITUITARY SUPPRESSIVE AGENTS cabergoline T1 QL (16 tabs/28 days) HD

danazol T1 HD

128 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Hormonal Agents) PROGESTATIONAL AGENTS Prescription drug name Drug tier Coverage requirements and limits AYGESTIN (norethindrone acetate) T3 HD CRINONE 4% GEL T3 HD DEPO-PROVERA 400 MG/ML VIAL T3 HD medroxyprogesterone 10 mg tab (Provera) T1 HD medroxyprogesterone 2.5 mg tab (Provera) T1 HD medroxyprogesterone 5 mg tab (Provera) T1 HD norethindrone acetate (Aygestin) T1 HD progesterone, micronized (Prometrium) T1 HD PROMETRIUM (progesterone) T3 HD PROVERA (medroxyprogesterone acetate) T3 HD SOMATOSTATIC AGENTS BYNFEZIA T4 PA SP MYCAPSSA T4 PA QL (4 CAPS/DAY) SP octreotide acetate T4 PA SP HD octreotide acetate (Sandostatin) T4 PA SP HD SANDOSTATIN (octreotide acetate) T4 PA SP HD SANDOSTATIN LAR DEPOT T4 PA SP SIGNIFOR T4 PA SP SIGNIFOR LAR T4 PA SP SOMATULINE DEPOT T2 PA SP HD VAGINAL ESTROGEN FOR SEXUAL DYSFUNCTION IMVEXXY 10 MCG MAINTENANCE PAK T3 QL (16/28 days) HD IMVEXXY 10 MCG STARTER PACK T3 QL (36/28 days) HD IMVEXXY 4 MCG MAINTENANCE PACK T3 QL (16/28 days) HD IMVEXXY 4 MCG STARTER PACK T3 QL (36/28 days) HD VAGINAL ESTROGEN PREPARATIONS ESTRACE (estradiol) T3 HD estradiol (Vagifem) T1 QL (36 tabs/28 days) HD estradiol 0.01% cream (Estrace) T1 HD estradiol 10 mcg vaginal insrt (Vagifem) T1 QL (36 tabs/28 days) HD ESTRING T2 QL (2 rings/90 days) HD FEMRING T3 HD PREMARIN T2 HD VAGIFEM (yuvafem) T3 QL (36 tabs/28 days) HD

129 Cigna Legacy (Standard) 4-Tier Prescription Drug List

HORMONES (Infertility) FERTILITY STIMULATING PREPARATIONS, NON-FSH Prescription drug name Drug tier Coverage requirements and limits clomiphene citrate T1 FOLLICLE-STIMULATING AND LUTEINIZING HORMONES MENOPUR T4 PA SP FOLLICLE-STIMULATING HORMONE (FSH) FOLLISTIM AQ T4 PA SP GONAL-F T4 PA SP GONAL-F RFF T4 PA SP GONAL-F RFF REDI-JECT T4 PA SP

HUMAN CHORIONIC GONADOTROPIN (HCG) CHORIONIC GONAD 10,000 UNIT VL T4 PA SP CHORIONIC GONAD 12,000 UNIT VL T4 SP CHORIONIC GONAD 50,000 UNIT VL T4 SP CHORIONIC GONAD 6,000 UNIT VL T4 SP NOVAREL T4 PA SP OVIDREL T4 PA SP PREGNYL T4 PA SP

PREGNANCY FACILITATING/MAINTAINING AGENT, HORMONAL CRINONE 8% GEL T3 ENDOMETRIN T3 HORMONES (Miscellaneous) LEPTIN HORMONE ANALOGS MYALEPT T4 PA SP HD HORMONES (Osteoporosis Products) BONE FORMATION STIMULATING AGTS - PTH REL PEPTIDES TYMLOS T4 PA QL (1 pen/30 days) SP HD BONE RESORPTION INHIBITORS calcitonin, salmon, synthetic T1 HD MIACALCIN T2 HD

IMMUNOSUPPRESSANTS (Pain Relief And Inflammatory Disease) INTERLEUKIN-4 (IL-4) RECEPTOR ALPHA ANTAGONIST, MAB DUPIXENT PEN T4 PA SP HD DUPIXENT SYRINGE T4 PA SP HD

130 Cigna Legacy (Standard) 4-Tier Prescription Drug List

IMMUNOSUPPRESSANTS (Pain Relief And Inflammatory Disease) INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS Prescription drug name Drug tier Coverage requirements and limits ACTEMRA T4 PA QL (4 syringes/28 days) SP HD ACTEMRA ACTPEN T4 PA QL (4 pens/28 days) SP HD ENSPRYNG T4 PA SP HD KEVZARA 150 MG/1.14 ML PEN INJ T4 PA QL (2 pens/28 days) SP HD KEVZARA 150 MG/1.14 ML SYRINGE T4 PA QL (2 syrings/28 days) SP HD KEVZARA 200 MG/1.14 ML PEN INJ T4 PA QL (2 pens/28 days) SP HD KEVZARA 200 MG/1.14 ML SYRINGE T4 PA QL (2 syrings/28 days) SP HD MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB STELARA 45 MG/0.5 ML SYRINGE T4 PA QL (1 syringe/84 days) SP HD STELARA 45 MG/0.5 ML VIAL T4 PA QL (1 vial/84 days) SP HD STELARA 90 MG/ML SYRINGE T4 PA QL (1 syringe/84 days) SP HD IMMUNOSUPPRESSANTS (Skin Conditions) TOPICAL IMMUNOSUPPRESSIVE AGENTS ELIDEL (pimecrolimus) T3 pimecrolimus (Elidel) T1 PROTOPIC (tacrolimus) T3 tacrolimus 0.03% ointment (Protopic) T1 tacrolimus 0.1% ointment (Protopic) T1 IMMUNOSUPPRESSANTS (Transplant Medications) IMMUNOSUPPRESSIVES ASTAGRAF XL T4 SP HD AZASAN T4 SP HD azathioprine (Imuran) T4 SP HD CELLCEPT (mycophenolate mofetil) T4 SP HD cyclosporine (Sandimmune) T4 SP HD cyclosporine, modified T4 SP HD cyclosporine, modified (Neoral) T4 SP HD ENVARSUS XR T4 SP HD everolimus 0.25 mg tablet (Zortress) T4 SP HD everolimus 0.5 mg tablet (Zortress) T4 SP HD everolimus 0.75 mg tablet (Zortress) T4 SP HD IMURAN (azathioprine) T4 SP HD LUPKYNIS 7.9 MG CAPSULE T3 PA QL (6 caps/day) mycophenolate mofetil (Cellcept) T4 SP HD

131 Cigna Legacy (Standard) 4-Tier Prescription Drug List

IMMUNOSUPPRESSANTS (Transplant Medications) IMMUNOSUPPRESSIVES Prescription drug name Drug tier Coverage requirements and limits mycophenolate sodium (Myfortic) T4 SP HD MYFORTIC (mycophenolic acid) T4 SP HD NEORAL (gengraf) T4 SP HD PROGRAF T4 SP HD PROGRAF (tacrolimus) T4 SP HD RAPAMUNE (sirolimus) T4 SP HD SANDIMMUNE 100 MG CAPSULE (cyclosporine) T4 SP HD SANDIMMUNE 100 MG/ML SOLN T4 SP HD SANDIMMUNE 25 MG CAPSULE (cyclosporine) T4 SP HD sirolimus (Rapamune) T4 SP HD tacrolimus 0.5 mg capsule (ir) (Prograf) T4 SP HD tacrolimus 1 mg capsule (ir) (Prograf) T4 SP HD tacrolimus 5 mg capsule (ir) (Prograf) T4 SP HD ZORTRESS T4 SP HD ZORTRESS (everolimus) T4 SP HD MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG (Diabetes) DIABETIC SUPPLIES CEQUR SIMPLICITY T3 CEQUR SIMPLICITY INSERTER T3 DEXCOM G6 RECEIVER T2 PA QL (1 syringe/365 days) DEXCOM G6 SENSOR T2 PA QL (3/30 days) DEXCOM G6 TRANSMITTER T2 PA QL (1 syringe/67 days) ENLITE SERTER T1 FREESTYLE LIBRE 10 DAY READER T2 PA QL (1 READER/DAY) FREESTYLE LIBRE 10 DAY SENSOR T2 PA QL (3/30 days) FREESTYLE LIBRE 14 DAY READER T2 PA QL (1 READER/DAY) FREESTYLE LIBRE 14 DAY SENSOR T2 PA QL (2/28 days) FREESTYLE LIBRE 2 READER T2 PA QL (1 READER/DAY) FREESTYLE LIBRE 2 SENSOR T2 PA QL(2 SENSORS/21 DAYS) GLUCOCOM AUTOLINK T1 GUARDIAN RT CHARGER T1 GUARDIAN RT STARTER KIT T1 GUARDIAN RT SYSTEM T1

132 Cigna Legacy (Standard) 4-Tier Prescription Drug List

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG (Diabetes) DIABETIC SUPPLIES Prescription drug name Drug tier Coverage requirements and limits GUARDIAN TEST PLUG T1 HUMAPEN LUXURA HD T1 INPEN (FOR HUMALOG) T1 INPEN (FOR NOVOLOG OR FIASP) T1 NOVOPEN ECHO T1 OMNIPOD DASH 5 PACK POD T2 PA QL (6 boxes/30 days) REPLACEMENT PEDIATRIC MONITOR T1 SEN-SERTER T1 V-GO 20 T2 V-GO 30 T2 V-GO 40 T2 NEEDLES/NEEDLELESS DEVICES BLUNT NEEDLE T1 ECLIPSE NEEDLE T1 FILTER NEEDLE T1 HYPODERMIC NEEDLE T1 MONOJECT BLOOD COLLECTION T1 NEEDLE T1 PEN NEEDLE T1 PHASEAL PROTECTOR T1 TERUMO SURGUARD2 T1 SYRINGES AND ACCESSORIES ASSURE ID INSULIN SAFETY T1 INSULIN SYRINGE T1 INSULIN SYRINGE U-500 T1 MAGELLAN INSULIN SAFETY SYRNG T1 MAGELLAN INSULIN SYRINGE T1 MINIMED RESERVOIR T1 MONOJECT T1 MONOJECT INSULIN SYRINGE T1 PARADIGM T1 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG (Miscellaneous) RESPIRATORY AIDS, DEVICES, EQUIPMENT ACE AEROSOL CLOUD ENHANCER T2 QL (1 unit/year)

133 Cigna Legacy (Standard) 4-Tier Prescription Drug List

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG (Miscellaneous) RESPIRATORY AIDS, DEVICES, EQUIPMENT Prescription drug name Drug tier Coverage requirements and limits AEROCHAMBER MINI T2 QL (1 unit/year) AEROCHAMBER MV T2 QL (1 unit/year) AEROCHAMBER PLUS FLOW-VU T2 QL (1 unit/year) AEROCHAMBER WITH FLOWSIGNAL T2 QL (1 unit/year) AEROCHAMBER Z-STAT PLUS T2 QL (1 unit/year) AEROTRACH PLUS T2 QL (1 unit/year) AEROVENT PLUS T2 QL (1 unit/year) BREATHERITE T2 QL (1 unit/year) BREATHERITE SPACER-ADULT MASK T2 QL (1 unit/year) BREATHERITE SPACER-INFANT MASK T2 QL (1 unit/year) BREATHERITE SPACER-LARGE MASK T2 QL (1 MASK/365 DAYS) BREATHERITE SPACER-LG CHLD MSK T2 QL (1 unit/year) BREATHERITE SPACER-MEDIUM MASK T2 QL (1 MASK/365 DAYS) BREATHERITE SPACER-NEONATE MSK T2 QL (1 unit/year) BREATHERITE SPACER-SM CHLD MSK T2 QL (1 unit/year) BREATHERITE SPACER-SMALL MASK T2 QL (1 MASK/365 DAYS) BREATHRITE T2 QL (1 unit/year) CLEVER CHOICE HOLDING CHAMBER T2 QL (1 unit/year) COMPACT SPACE CHAMBER T2 QL (1 unit/year) EASIVENT T2 QL (1 unit/year) E-Z SPACER T2 QL (1 unit/year) FLEXICHAMBER T2 QL (1 unit/year) FLEXICHAMBER MASK T2 QL (1 unit/year) INSPIRACHAMBER T2 QL (1 unit/year) LITEAIRE T2 QL (1 unit/year) LITETOUCH T2 QL (1 unit/year) MICROCHAMBER T2 QL (1 unit/year) MICROSPACER T2 QL (1 unit/year) OPTICHAMBER T2 QL (1 unit/year) OPTICHAMBER DIAMOND T2 QL (1 unit/year) POCKET CHAMBER T2 QL (1 unit/year) PRIMEAIRE T2 QL (1 unit/year) PRO COMFORT SPACER WITH MASK T2 QL (1 unit/year)

134 Cigna Legacy (Standard) 4-Tier Prescription Drug List

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG (Miscellaneous) RESPIRATORY AIDS, DEVICES, EQUIPMENT Prescription drug name Drug tier Coverage requirements and limits PROCARE SPACER WITH ADULT MASK T2 QL (1 unit/year) PROCARE SPACER WITH CHILD MASK T2 QL (1 unit/year) PROCHAMBER T2 QL (1 unit/year) RITEFLO T2 QL (1 unit/year) SILICONE MASK T2 QL (1 unit/year) SPACE CHAMBER T2 QL (1 unit/year) SPACE CHAMBER-LARGE MASK T2 QL (1 unit/year) SPACE CHAMBER-MEDIUM MASK T2 QL (1 unit/year) SPACE CHAMBER-SMALL MASK T2 QL (1 unit/year) VORTEX T2 QL (1 unit/year) VORTEX HOLDING CHAMBER-CHILD T2 QL (1 unit/year) VORTEX HOLDING CHAMBER-TODDLER T2 QL (1 unit/year) VORTEX VHC FROG MASK T2 QL (1 unit/year) VORTEX VHC LADYBUG MASK T2 QL (1 unit/year) MUSCLE RELAXANTS (Pain Relief And Inflammatory Disease) SKELETAL MUSCLE RELAXANTS AMRIX ER 15 MG CAPSULE (cyclobenzaprine hcl T3 PA QL (1 cap/day) er) AMRIX ER 30 MG CAPSULE (cyclobenzaprine hcl T3 PA er) baclofen T1 carisoprodol (Soma) T1 carisoprodol/aspirin T1 chlorzoxazone 250 mg tablet T1 PA chlorzoxazone 375 mg tablet (Lorzone) T1 PA chlorzoxazone 500 mg tablet T1 chlorzoxazone 750 mg tablet (Lorzone) T1 PA cyclobenzaprine er 15 mg cap (Amrix) T1 PA QL (1 cap/day) cyclobenzaprine er 30 mg cap (Amrix) T1 PA cyclobenzaprine hcl T1 cyclobenzaprine hcl (Fexmid) T1 DANTRIUM (dantrolene sodium) T3 dantrolene sodium T1 dantrolene sodium (Dantrium) T1

135 Cigna Legacy (Standard) 4-Tier Prescription Drug List

MUSCLE RELAXANTS (Pain Relief And Inflammatory Disease) SKELETAL MUSCLE RELAXANTS Prescription drug name Drug tier Coverage requirements and limits FEXMID (cyclobenzaprine hcl) T3 LORZONE (chlorzoxazone) T3 PA metaxalone T1 metaxalone (Skelaxin) T1 methocarbamol T1 methocarbamol (Robaxin-750) T1 NORGESIC FORTE T3 orphenadrine citrate T1 orphenadrine/aspirin/caffeine (Norgesic Forte) T1 OZOBAX T3 ROBAXIN-750 (methocarbamol) T3 SKELAXIN (metaxalone) T3 SOMA (carisoprodol) T3 SOMA (vanadom) T3 tizanidine hcl T1 tizanidine hcl (Zanaflex) T1 ZANAFLEX (tizanidine hcl) T3 PRE-NATAL VITAMINS (Nutritional/Dietary) PRENATAL VITAMIN PREPARATIONS ATABEX EC T2 CITRANATAL 90 DHA T2 CITRANATAL ASSURE T2 CITRANATAL DHA T2 CITRANATAL HARMONY T2 CITRANATAL RX T2 OBSTETRIX EC T2 OBTREX DHA T2 pnv 22/iron, gluc/folic/dss/dha T1 pnv 66/iron/folic/docusate/dha T1 pnv 69/iron/folic/docusate/dha T1 pnv 80/iron fum/folic/dss/dha T1 pnv/ferrous fum/docusate/folic T1 pnv/iron, carb/docusat/folic ac T1

136 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PRE-NATAL VITAMINS (Nutritional/Dietary) PRENATAL VITAMIN PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits prenatal 12/iron/folic/dss/om3 (Obtrex Dha) T1 PRENATAL 19 T1 prenatal 34/iron/folic/dss/dha T1 prenatal vits15/iron/folic/dss T1 VITAFOL FE+ T2 PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS mirtazapine T1 HD mirtazapine (Remeron) T1 HD REMERON (mirtazapine) T3 HD ANTI-ANXIETY - BENZODIAZEPINES alprazolam T1 alprazolam (Xanax Xr) T1 alprazolam (Xanax) T1 ATIVAN (lorazepam) T3 PA chlordiazepoxide hcl T1 clorazepate dipotassium T1 clorazepate dipotassium (Tranxene T-tab) T1 diazepam 10 mg tablet (Valium) T1 diazepam 2 mg tablet (Valium) T1 diazepam 5 mg tablet (Valium) T1 diazepam 5 mg/5 ml solution T1 diazepam 5 mg/ml oral conc T1 lorazepam T1 lorazepam (Ativan) T1 oxazepam T1 TRANXENE T-TAB (clorazepate dipotassium) T3 VALIUM (diazepam) T3 XANAX (alprazolam) T3 XANAX XR (alprazolam xr) T3 ANTI-ANXIETY DRUGS buspirone hcl T1 meprobamate T1

137 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) ANTIDEPRESSANT - NMDA RECEPTOR ANTAGONIST Prescription drug name Drug tier Coverage requirements and limits SPRAVATO T4 PA SP BIPOLAR DISORDER DRUGS EQUETRO T3 HD lithium carbonate T1 HD lithium carbonate (Lithobid) T1 HD lithium citrate T1 HD LITHOBID (lithium carbonate er) T3 PA HD MAOIS -NON-SELECTIVE, IRREVERSIBLE ANTIDEPRESSANTS MARPLAN T3 QL (12 tabs/day) NARDIL (phenelzine sulfate) T3 PARNATE (tranylcypromine sulfate) T3 PA phenelzine sulfate (Nardil) T1 tranylcypromine sulfate (Parnate) T1 MONOAMINE OXIDASE (MAO) INHIBITOR ANTIDEPRESSANTS EMSAM 12 MG/24 HOURS PATCH T3 QL (1 patch/day) EMSAM 6 MG/24 HOURS PATCH T3 QL (2 patches/day) EMSAM 9 MG/24 HOURS PATCH T3 QL (1 patch/day) NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) APLENZIN ER 174 MG TABLET T3 PA QL (3 tabs/day) HD APLENZIN ER 348 MG TABLET T3 PA QL (1 tab/day) HD APLENZIN ER 522 MG TABLET T3 PA QL (1 tab/day) HD bupropion hcl 100 mg tablet T1 QL (4 tabs/day) HD bupropion hcl 75 mg tablet T1 QL (6 tabs/day) HD bupropion hcl sr 100 mg tablet (Wellbutrin Sr) T1 QL (4 tabs/day) HD bupropion hcl sr 150 mg tablet (Wellbutrin Sr) T1 QL (2 tabs/day) HD bupropion hcl sr 200 mg tablet (Wellbutrin Sr) T1 QL (2 tabs/day) HD bupropion hcl xl 150 mg tablet (Wellbutrin Xl) T1 QL (3 tabs/day) HD bupropion hcl xl 300 mg tablet (Wellbutrin Xl) T1 QL (1 tab/day) HD BUPROPION HCL XL 450 MG TABLET T1 QL (1 tab/day) HD FORFIVO XL T3 QL (1 tab/day) ST HD WELLBUTRIN SR 100 MG TABLET (bupropion hcl T3 QL (4 tabs/day) ST HD sr) WELLBUTRIN SR 150 MG TABLET (bupropion hcl T3 QL (2 tabs/day) ST HD sr)

138 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) Prescription drug name Drug tier Coverage requirements and limits WELLBUTRIN SR 200 MG TABLET (bupropion hcl T3 QL (2 tabs/day) ST HD sr) WELLBUTRIN XL 150 MG TABLET (bupropion xl) T3 PA QL (3 tabs/day) HD WELLBUTRIN XL 300 MG TABLET (bupropion xl) T3 PA QL (1 tab/day) HD SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA) NUPLAZID T4 PA SP HD SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CELEXA 10 MG TABLET (citalopram hbr) T3 QL (6 tabs/day) ST HD CELEXA 20 MG TABLET (citalopram hbr) T3 QL (3 tabs/day) ST HD CELEXA 40 MG TABLET (citalopram hbr) T3 QL (1 tab/day) ST HD citalopram hbr 10 mg tablet (Celexa) T1 QL (6 tabs/day) HD citalopram hbr 10 mg/5 ml soln T1 QL (30ml/day) HD citalopram hbr 20 mg tablet (Celexa) T1 QL (3 tabs/day) HD citalopram hbr 20 mg/10 ml sol T1 QL (30ml/day) HD citalopram hbr 40 mg tablet (Celexa) T1 QL (1 tab/day) HD escitalopram 10 mg tablet (Lexapro) T1 QL (2 tabs/day) HD escitalopram 20 mg tablet (Lexapro) T1 QL (1 tab/day) HD escitalopram 5 mg tablet (Lexapro) T1 QL (4 tabs/day) HD escitalopram oxalate 5 mg/5 ml T1 QL (20ml/day) HD fluoxetine 20 mg/5 ml solution T1 QL (20ml/day) HD fluoxetine hcl T1 QL (4 caps/28 days) HD fluoxetine hcl 10 mg capsule (Prozac) T1 QL (8 caps/day) HD fluoxetine hcl 10 mg tablet (Sarafem) T1 HD fluoxetine hcl 20 mg capsule (Prozac) T1 QL (4 caps/day) HD fluoxetine hcl 20 mg tablet T1 HD fluoxetine hcl 40 mg capsule (Prozac) T1 QL (2 caps/day) HD fluoxetine hcl 60 mg tablet T1 QL (1 tab/day) HD fluvoxamine er 100 mg capsule T1 QL (3 caps/day) HD fluvoxamine er 150 mg capsule T1 QL (2 caps/day) HD fluvoxamine maleate 100 mg tab T1 QL (3 tabs/day) HD fluvoxamine maleate 25 mg tab T1 QL (12 tabs/day) HD fluvoxamine maleate 50 mg tab T1 QL (6 tabs/day) HD LEXAPRO 10 MG TABLET (escitalopram oxalate) T3 PA QL (2 tabs/day) HD LEXAPRO 20 MG TABLET (escitalopram oxalate) T3 PA QL (1 tab/day) HD

139 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Prescription drug name Drug tier Coverage requirements and limits LEXAPRO 5 MG TABLET (escitalopram oxalate) T3 PA QL (4 tabs/day) HD paroxetine cr 12.5 mg tablet (Paxil Cr) T1 QL (1 tab/day) HD paroxetine cr 25 mg tablet (Paxil Cr) T1 QL (3 tabs/day) HD paroxetine cr 37.5 mg tablet (Paxil Cr) T1 QL (2 tabs/day) HD paroxetine er 12.5 mg tablet (Paxil Cr) T1 QL (1 tab/day) HD paroxetine er 25 mg tablet (Paxil Cr) T1 QL (3 tabs/day) HD paroxetine er 37.5 mg tablet (Paxil Cr) T1 QL (2 tabs/day) HD paroxetine hcl 10 mg tablet (Paxil) T1 QL (6 tabs/day) HD paroxetine hcl 20 mg tablet (Paxil) T1 QL (3 tabs/day) HD paroxetine hcl 30 mg tablet (Paxil) T1 QL (2 tabs/day) HD paroxetine hcl 40 mg tablet (Paxil) T1 QL (1 tab/day) HD PAXIL 10 MG TABLET (paroxetine hcl) T3 QL (6 tabs/day) ST HD PAXIL 10 MG/5 ML SUSPENSION T3 QL (30ml/day) ST HD PAXIL 20 MG TABLET (paroxetine hcl) T3 QL (3 tabs/day) ST HD PAXIL 30 MG TABLET (paroxetine hcl) T3 QL (2 tabs/day) ST HD PAXIL 40 MG TABLET (paroxetine hcl) T3 QL (1 tab/day) ST HD PAXIL CR 12.5 MG TABLET (paroxetine er) T3 QL (1 tab/day) ST HD PAXIL CR 25 MG TABLET (paroxetine er) T3 QL (3 tabs/day) ST HD PAXIL CR 37.5 MG TABLET (paroxetine er) T3 QL (2 tabs/day) ST HD PEXEVA 10 MG TABLET T3 PA QL (6 tabs/day) HD PEXEVA 20 MG TABLET T3 PA QL (3 tabs/day) HD PEXEVA 30 MG TABLET T3 PA QL (2 tabs/day) HD PEXEVA 40 MG TABLET T3 PA QL (1 tab/day) HD PROZAC 10 MG PULVULE (fluoxetine hcl) T3 QL (8 caps/day) ST HD PROZAC 20 MG PULVULE (fluoxetine hcl) T3 QL (4 caps/day) ST HD PROZAC 40 MG PULVULE (fluoxetine hcl) T3 QL (2 caps/day) ST HD SARAFEM (fluoxetine hcl) T3 ST HD sertraline 20 mg/ml oral conc (Zoloft) T1 QL (10ml/day) HD sertraline hcl 100 mg tablet (Zoloft) T1 QL (2 tabs/day) HD sertraline hcl 25 mg tablet (Zoloft) T1 QL (8 tabs/day) HD sertraline hcl 50 mg tablet (Zoloft) T1 QL (4 tabs/day) HD ZOLOFT 100 MG TABLET (sertraline hcl) T3 QL (2 tabs/day) ST HD ZOLOFT 20 MG/ML ORAL CONC (sertraline hcl) T3 QL (10ml/day) ST HD

140 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) Prescription drug name Drug tier Coverage requirements and limits ZOLOFT 25 MG TABLET (sertraline hcl) T3 QL (8 tabs/day) ST HD ZOLOFT 50 MG TABLET (sertraline hcl) T3 QL (4 tabs/day) ST HD SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) nefazodone hcl T1 HD trazodone hcl T1 HD SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA 20 MG CAPSULE (duloxetine hcl) T3 PA QL (6 caps/day) HD CYMBALTA 30 MG CAPSULE (duloxetine hcl) T3 PA QL (4 caps/day) HD CYMBALTA 60 MG CAPSULE (duloxetine hcl) T3 PA QL (2 caps/day) HD DESVENLAFAXINE ER 100 MG TAB T3 QL (4 tabs/day) ST HD DESVENLAFAXINE ER 50 MG TAB T3 QL (8 tabs/day) ST HD desvenlafaxine succnt er 100mg (Pristiq) T1 QL (4 tabs/day) HD desvenlafaxine succnt er 25 mg (Pristiq) T1 QL (16 tabs/day) HD desvenlafaxine succnt er 50 mg (Pristiq) T1 QL (1 tab/day) HD DRIZALMA SPRINKLE DR 20 MG CAP T3 QL (1 cap/day) ST HD DRIZALMA SPRINKLE DR 30 MG CAP T3 QL (1 cap/day) ST HD DRIZALMA SPRINKLE DR 40 MG CAP T3 QL (1 cap/day) ST HD DRIZALMA SPRINKLE DR 60 MG CAP T3 QL (2 caps/day) ST HD duloxetine hcl dr 20 mg cap (Cymbalta) T1 QL (6 caps/day) HD duloxetine hcl dr 30 mg cap (Cymbalta) T1 QL (4 caps/day) HD duloxetine hcl dr 40 mg cap T1 QL (3 caps/day) HD duloxetine hcl dr 60 mg cap (Cymbalta) T1 QL (2 caps/day) HD EFFEXOR XR 150 MG CAPSULE (venlafaxine hcl er) T3 QL (2 caps/day) ST HD EFFEXOR XR 37.5 MG CAPSULE (venlafaxine hcl T3 QL (8 caps/day) ST HD er) EFFEXOR XR 75 MG CAPSULE (venlafaxine hcl er) T3 QL (4 caps/day) ST HD FETZIMA 20-40 MG TITRATION PAK T3 QL (28 caps/180 days) ST HD FETZIMA ER 120 MG CAPSULE T3 QL (1 cap/day) ST HD FETZIMA ER 20 MG CAPSULE T3 QL (6 caps/day) ST HD FETZIMA ER 40 MG CAPSULE T3 QL (3 caps/day) ST HD FETZIMA ER 80 MG CAPSULE T3 QL (1 cap/day) ST HD PRISTIQ ER 100 MG TABLET (desvenlafaxine T3 QL (2 tabs/day) ST HD succinate er) PRISTIQ ER 25 MG TABLET (desvenlafaxine T3 QL (16 tabs/day) ST HD succinate er)

141 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) Prescription drug name Drug tier Coverage requirements and limits PRISTIQ ER 50 MG TABLET (desvenlafaxine T3 QL (1 tab/day) ST HD succinate er) venlafaxine hcl 100 mg tablet T1 QL (3 tabs/day) HD venlafaxine hcl 25 mg tablet T1 QL (15 tabs/day) HD venlafaxine hcl 37.5 mg tablet T1 QL (10 tabs/day) HD venlafaxine hcl 50 mg tablet T1 QL (7 tabs/day) HD venlafaxine hcl 75 mg tablet T1 QL (5 tabs/day) HD venlafaxine hcl er 150 mg cap (Effexor Xr) T1 QL (2 caps/day) HD venlafaxine hcl er 150 mg tab T1 QL (2 tabs/day) HD venlafaxine hcl er 225 mg tab T1 QL (1 tab/day) HD venlafaxine hcl er 37.5 mg cap (Effexor Xr) T1 QL (8 caps/day) HD venlafaxine hcl er 37.5 mg tab T1 QL (8 tabs/day) HD venlafaxine hcl er 75 mg cap (Effexor Xr) T1 QL (4 caps/day) HD venlafaxine hcl er 75 mg tab T1 QL (4 tabs/day) HD SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS VIIBRYD 10 MG TABLET T3 QL (1 tab/day) ST HD VIIBRYD 10-20 MG STARTER PACK T3 ST HD VIIBRYD 20 MG TABLET T3 QL (1 tab/day) ST HD VIIBRYD 40 MG TABLET T3 ST HD SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS TRINTELLIX 10 MG TABLET T3 QL (1 tab/day) ST HD TRINTELLIX 20 MG TABLET T3 ST HD TRINTELLIX 5 MG TABLET T3 QL (1 tab/day) ST HD TRICYCLIC ANTIDEPRESSANT-BENZODIAZEPINE COMBINATNS amitriptyline/chlordiazepoxide T1 HD TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNS perphenazine/amitriptyline hcl T1 HD TRICYCLIC ANTIDEPRESSANTS, REL.NON-SEL.REUPT-INHIB amitriptyline hcl T1 HD amoxapine T1 HD ANAFRANIL (clomipramine hcl) T3 PA HD clomipramine hcl (Anafranil) T1 HD desipramine hcl T1 HD desipramine hcl (Norpramin) T1 HD

142 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) TRICYCLIC ANTIDEPRESSANTS, REL.NON-SEL.REUPT-INHIB Prescription drug name Drug tier Coverage requirements and limits doxepin 10 mg capsule T1 HD doxepin 10 mg/ml oral conc T1 HD doxepin 100 mg capsule T1 HD doxepin 150 mg capsule T1 HD doxepin 25 mg capsule T1 HD doxepin 50 mg capsule T1 HD doxepin 75 mg capsule T1 HD imipramine hcl (Tofranil) T1 HD imipramine pamoate T1 HD maprotiline hcl T1 HD NORPRAMIN (desipramine hcl) T3 HD nortriptyline hcl T1 HD nortriptyline hcl (Pamelor) T1 HD PAMELOR (nortriptyline hcl) T3 PA HD protriptyline hcl T1 HD SURMONTIL (trimipramine maleate) T2 HD TOFRANIL (imipramine hcl) T3 PA HD trimipramine maleate (Surmontil) T1 HD PSYCHOTHERAPEUTIC DRUGS (Attention Deficit Hyperactivity Disorder) ADRENERGICS, AROMATIC, NON-CATECHOLAMINE VYVANSE 10 MG CAPSULE T2 PA QL (1 cap/day) VYVANSE 10 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 20 MG CAPSULE T2 PA QL (1 cap/day) VYVANSE 20 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 30 MG CAPSULE T2 PA QL (1 per day) VYVANSE 30 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 40 MG CAPSULE T2 PA QL (1 cap/day) VYVANSE 40 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 50 MG CAPSULE T2 PA QL (1 per day) VYVANSE 50 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 60 MG CAPSULE T2 PA QL (1 cap/day) VYVANSE 60 MG CHEWABLE TABLET T2 PA QL (1 tab/day) VYVANSE 70 MG CAPSULE T2 PA QL (1 per day)

143 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST Prescription drug name Drug tier Coverage requirements and limits clonidine hcl (Kapvay) T1 guanfacine hcl (Intuniv) T1 INTUNIV (guanfacine hcl er) T3 KAPVAY (clonidine hcl er) T3 TX FOR ATTENTION DEFICIT-HYPERACT (ADHD)/NARCOLEPSY ADHANSIA XR T3 PA QL (1 cap/day) ST APTENSIO XR (methylphenidate er) T3 PA QL (1 cap/day) ST CONCERTA (methylphenidate er) T3 PA QL (1 tab/day) ST COTEMPLA XR-ODT 17.3 MG TABLET T3 PA QL (1 tab/day) COTEMPLA XR-ODT 25.9 MG TABLET T3 PA QL (2 tabs/day) COTEMPLA XR-ODT 8.6 MG TABLET T3 PA QL (1 tab/day) DAYTRANA 10 MG/9 HR PATCH T3 PA QL (1 patch/day) DAYTRANA 15 MG/9 HR PATCH T3 PA QL (1 per day) DAYTRANA 20 MG/9 HOUR PATCH T3 PA QL (1 patch/day) DAYTRANA 30 MG/9 HOUR PATCH T3 PA QL (1 patch/day) dexmethylphenidate er 10 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 15 mg cp (Focalin Xr) T1 PA QL (1 per day) dexmethylphenidate er 20 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 25 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 30 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 35 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 40 mg cp (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate er 5 mg cap (Focalin Xr) T1 PA QL (1 cap/day) dexmethylphenidate hcl (Focalin) T1 PA FOCALIN (dexmethylphenidate hcl) T3 PA ST FOCALIN XR 10 MG CAPSULE T3 PA QL (1 cap/day) ST (dexmethylphenidate hcl er) FOCALIN XR 15 MG CAPSULE (dexmethylphenidate T3 PA QL (1 cap/day) ST hcl er) FOCALIN XR 20 MG CAPSULE T3 PA QL (1 per day) ST (dexmethylphenidate hcl er) FOCALIN XR 25 MG CAPSULE T3 PA QL (1 cap/day) ST (dexmethylphenidate hcl er) FOCALIN XR 30 MG CAPSULE T3 PA QL (1 cap/day) ST (dexmethylphenidate hcl er)

144 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) TX FOR ATTENTION DEFICIT-HYPERACT (ADHD)/NARCOLEPSY Prescription drug name Drug tier Coverage requirements and limits FOCALIN XR 35 MG CAPSULE T3 PA QL (1 cap/day) ST (dexmethylphenidate hcl er) FOCALIN XR 40 MG CAPSULE T3 PA QL (1 cap/day) ST (dexmethylphenidate hcl er) FOCALIN XR 5 MG CAPSULE (dexmethylphenidate T3 PA QL (1 cap/day) ST hcl er) JORNAY PM T3 PA QL (1 cap/day) ST METHYLIN (methylphenidate hcl) T3 PA methylphenidate er 10 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 10 mg tab T1 PA QL (2/day) methylphenidate er 15 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 18 mg tab (Concerta) T1 PA QL (1 tab/day) methylphenidate er 20 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 20 mg tab T1 PA QL (3 tabs/day) methylphenidate er 27 mg tab (Concerta) T1 PA QL (1 per day) methylphenidate er 30 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 36 mg tab (Concerta) T1 PA QL (1 per day) methylphenidate er 40 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 50 mg cap (Aptensio Xr) T1 PA QL (1 per day) methylphenidate er 54 mg tab (Concerta) T1 PA QL (1 per day) methylphenidate er 60 mg cap (Aptensio Xr) T1 PA QL (1 per day) METHYLPHENIDATE ER 72 MG TAB T1 PA QL (1 tab/day) methylphenidate hcl T1 PA methylphenidate hcl T1 PA QL (1 cap/day) methylphenidate hcl (Methylin) T1 PA methylphenidate hcl (Ritalin La) T1 PA QL (1 cap/day) methylphenidate hcl (Ritalin) T1 PA methylphenidate la 10 mg cap (Ritalin La) T1 PA QL (1 cap/day) methylphenidate la 20 mg cap (Ritalin La) T1 PA QL (1 cap/day) methylphenidate la 30 mg cap (Ritalin La) T1 PA QL (1 per day) methylphenidate la 40 mg cap (Ritalin La) T1 PA QL (1 cap/day) methylphenidate la 60 mg cap T1 PA QL (1 cap/day) QUILLICHEW ER T3 PA QL (1 tab/day) QUILLIVANT XR T3 PA QL (12ml/day) RELEXXII T1 PA QL (1 tab/day)

145 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Anxiety/Depression/Bipolar Disorder) TX FOR ATTENTION DEFICIT-HYPERACT (ADHD)/NARCOLEPSY Prescription drug name Drug tier Coverage requirements and limits RITALIN (methylphenidate hcl) T3 PA ST RITALIN LA (methylphenidate la) T3 PA QL (1 cap/day) ST TX FOR ATTENTION DEFICIT-HYPERACT. (ADHD), NRI-TYPE atomoxetine hcl 10 mg capsule (Strattera) T1 HD atomoxetine hcl 100 mg capsule (Strattera) T1 HD atomoxetine hcl 18 mg capsule (Strattera) T1 HD atomoxetine hcl 25 mg capsule (Strattera) T1 HD atomoxetine hcl 40 mg capsule (Strattera) T1 QL (1 cap/day) HD atomoxetine hcl 60 mg capsule (Strattera) T1 HD atomoxetine hcl 80 mg capsule (Strattera) T1 HD STRATTERA 10 MG CAPSULE (atomoxetine hcl) T3 HD STRATTERA 100 MG CAPSULE (atomoxetine hcl) T3 HD STRATTERA 18 MG CAPSULE (atomoxetine hcl) T3 HD STRATTERA 25 MG CAPSULE (atomoxetine hcl) T3 HD STRATTERA 40 MG CAPSULE (atomoxetine hcl) T3 QL (1 cap/day) HD STRATTERA 60 MG CAPSULE (atomoxetine hcl) T3 HD STRATTERA 80 MG CAPSULE (atomoxetine hcl) T3 HD PSYCHOTHERAPEUTIC DRUGS (Miscellaneous) HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) TX AGENTS ADDYI T3 PA QL (1 tab/day) VYLEESI T4 PA QL (8 injectors/30 days) SP PSYCHOTHERAPEUTIC DRUGS (Schizophrenia/Anti-Psychotics) ANTIPSYCH, DOPAMINE ANTAG., DIPHENYLBUTYLPIPERIDINES pimozide T1 ANTIPSYCHOTIC, ATYPICAL, DOPAMINE, SEROTONIN ANTAGNST asenapine maleate (Saphris) T1 CAPLYTA T3 QL (1 CAPS/DAY) ST clozapine T1 clozapine (Clozapine Odt) T1 clozapine (Clozaril) T1 clozapine (Fazaclo) T1 CLOZAPINE ODT T1 CLOZARIL (clozapine) T3 ST

146 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Schizophrenia/Anti-Psychotics) ANTIPSYCHOTIC, ATYPICAL, DOPAMINE, SEROTONIN ANTAGNST Prescription drug name Drug tier Coverage requirements and limits FANAPT 1 MG TABLET T3 QL (4 tabs/day) ST FANAPT 10 MG TABLET T3 QL (4 tabs/day) ST FANAPT 12 MG TABLET T3 ST FANAPT 2 MG TABLET T3 QL (4 tabs/day) ST FANAPT 4 MG TABLET T3 QL (4 tabs/day) ST FANAPT 6 MG TABLET T3 QL (4 tabs/day) ST FANAPT 8 MG TABLET T3 QL (4 tabs/day) ST FANAPT TITRATION PACK T3 QL (4 packs/year) ST FAZACLO (clozapine odt) T3 PA GEODON (ziprasidone hcl) T3 PA INVEGA ER 1.5 MG TABLET (paliperidone er) T3 ST INVEGA ER 3 MG TABLET (paliperidone er) T3 QL (1 tab/day) ST INVEGA ER 6 MG TABLET (paliperidone er) T3 ST INVEGA ER 9 MG TABLET (paliperidone er) T3 ST LATUDA 120 MG TABLET T2 LATUDA 20 MG TABLET T2 LATUDA 40 MG TABLET T2 QL (1 tab/day) LATUDA 60 MG TABLET T2 QL (1 tab/day) LATUDA 80 MG TABLET T2 olanzapine (Zyprexa Zydis) T1 olanzapine (Zyprexa) T1 paliperidone er 1.5 mg tablet (Invega) T1 paliperidone er 3 mg tablet (Invega) T1 QL (1 tab/day) paliperidone er 6 mg tablet (Invega) T1 paliperidone er 9 mg tablet (Invega) T1 quetiapine fumarate (Seroquel Xr) T1 quetiapine fumarate (Seroquel) T1 RISPERDAL (risperidone) T3 ST risperidone T1 risperidone (Risperdal) T1 SAPHRIS (asenapine maleate) T3 ST SECUADO T3 ST SEROQUEL (quetiapine fumarate) T3 ST

147 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Schizophrenia/Anti-Psychotics) ANTIPSYCHOTIC, ATYPICAL, DOPAMINE, SEROTONIN ANTAGNST Prescription drug name Drug tier Coverage requirements and limits SEROQUEL XR (quetiapine fumarate er) T3 ST VERSACLOZ T3 PA ziprasidone hcl (Geodon) T1 ZYPREXA (olanzapine) T3 PA ZYPREXA ZYDIS (olanzapine odt) T3 PA ANTIPSYCHOTIC-ATYPICAL, D3/D2 PARTIAL AG-5HT MIXED VRAYLAR 1.5 MG CAPSULE T3 QL (1 cap/day) ST VRAYLAR 1.5 MG-3 MG PACK T3 ST VRAYLAR 3 MG CAPSULE T3 QL (1 cap/day) ST VRAYLAR 4.5 MG CAPSULE T3 ST VRAYLAR 6 MG CAPSULE T3 ST ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY 10 MG TABLET (aripiprazole) T3 ST ABILIFY 15 MG TABLET (aripiprazole) T3 ST ABILIFY 2 MG TABLET (aripiprazole) T3 ST ABILIFY 20 MG TABLET (aripiprazole) T3 ST ABILIFY 30 MG TABLET (aripiprazole) T3 ST ABILIFY 5 MG TABLET (aripiprazole) T3 QL (1 tab/day) ST ABILIFY MYCITE T3 PA aripiprazole T1 aripiprazole 1 mg/ml solution T1 aripiprazole 10 mg tablet (Abilify) T1 aripiprazole 15 mg tablet (Abilify) T1 aripiprazole 2 mg tablet (Abilify) T1 aripiprazole 20 mg tablet (Abilify) T1 aripiprazole 30 mg tablet (Abilify) T1 aripiprazole 5 mg tablet (Abilify) T1 QL (1 tab/day) REXULTI 0.25 MG TABLET T3 QL (1 tab/day) ST REXULTI 0.5 MG TABLET T3 QL (1 tab/day) ST REXULTI 1 MG TABLET T3 QL (1 tab/day) ST REXULTI 2 MG TABLET T3 QL (1 tab/day) ST REXULTI 3 MG TABLET T3 ST REXULTI 4 MG TABLET T3 ST

148 Cigna Legacy (Standard) 4-Tier Prescription Drug List

PSYCHOTHERAPEUTIC DRUGS (Schizophrenia/Anti-Psychotics) ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS Prescription drug name Drug tier Coverage requirements and limits loxapine succinate T1 ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, THIOXANTHENES thiothixene T1 ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, BUTYROPHENONES haloperidol T1 haloperidol lactate T1 ANTIPSYCHOTICS, DOPAMINE ANTAGONST, DIHYDROINDOLONES molindone hcl T1 ANTIPSYCHOTICS, PHENOTHIAZINES chlorpromazine hcl T1 fluphenazine hcl T1 perphenazine T1 thioridazine hcl T1 trifluoperazine hcl T1

SSRI-ANTIPSYCH, ATYPICAL, DOPAMINE, SEROTONIN ANTAG olanzapine/fluoxetine hcl T1 olanzapine/fluoxetine hcl (Symbyax) T1 SYMBYAX (olanzapine-fluoxetine hcl) T3

PSYCHOTHERAPEUTIC DRUGS (Sleep Disorders/Sedatives) NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS armodafinil (Nuvigil) T1 PA modafinil (Provigil) T1 PA NUVIGIL (armodafinil) T3 PA

PROVIGIL (modafinil) T3 PA SUNOSI T2 PA QL (1 tab/day)

SEDATIVE/HYPNOTICS (Sleep Disorders/Sedatives) ANTI-NARCOLEPSY, ANTI-CATAPLEXY, SEDATIVE-TYPE AGENT XYREM T4 PA SP HD XYWAV T4 PA SP HD BARBITURATES phenobarbital T1 secobarbital sodium T3 PA

149 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SEDATIVE/HYPNOTICS (Sleep Disorders/Sedatives) HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS Prescription drug name Drug tier Coverage requirements and limits HETLIOZ T4 PA SP HD HETLIOZ LQ T4 PA SP HD ramelteon (Rozerem) T1 QL (1 tab/day) ROZEREM (ramelteon) T3 QL (1 tab/day) ST SEDATIVE-HYPNOTICS - BENZODIAZEPINES DORAL T3 estazolam T1 flurazepam hcl T1 HALCION (triazolam) T3 midazolam hcl T1 QUAZEPAM T1 quazepam (Quazepam) T1 RESTORIL (temazepam) T3 PA temazepam (Restoril) T1 triazolam T1 triazolam (Halcion) T1 SEDATIVE-HYPNOTICS, NON-BARBITURATE AMBIEN (zolpidem tartrate) T3 PA AMBIEN CR 12.5 MG TABLET (zolpidem tartrate er) T3 PA AMBIEN CR 6.25 MG TABLET (zolpidem tartrate er) T3 PA QL (1 tab/day) BELSOMRA T3 PA DAYVIGO T2 QL (1 tab/day) ST doxepin hcl 3 mg tablet (Silenor) T1 QL (1 tab/day) doxepin hcl 6 mg tablet (Silenor) T1 EDLUAR 10 MG SL TABLET T3 PA EDLUAR 5 MG SL TABLET T3 PA QL (1 tab/day) eszopiclone (Lunesta) T1 LUNESTA (eszopiclone) T3 ST SILENOR 3 MG TABLET (doxepin hcl) T3 QL (1 tab/day) ST SILENOR 6 MG TABLET (doxepin hcl) T3 ST zaleplon T1 zolpidem tart er 12.5 mg tab (Ambien Cr) T1 zolpidem tart er 6.25 mg tab (Ambien Cr) T1 QL (1 tab/day)

150 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SEDATIVE/HYPNOTICS (Sleep Disorders/Sedatives) SEDATIVE-HYPNOTICS, NON-BARBITURATE Prescription drug name Drug tier Coverage requirements and limits zolpidem tartrate T1 zolpidem tartrate (Ambien) T1 ZOLPIMIST T3 PA SKIN PREPS (Miscellaneous) IRRIGANTS acetic acid T1 neomycin sulf/polymyxin b sulf T1 PHYSIOLYTE T3 PHYSIOSOL T3 ringer’s solution T1 ringer’s solution, lactated T1 sod, pot chlor/mag/sod, pot phos T3 sodium chloride irrig solution T1 SORBITOL T1 SORBITOL-MANNITOL T1 VASHE WOUND T3 VASHE WOUND THERAPY T3 water for irrigation, sterile T1 OXIDIZING AGENTS hydrogen peroxide T1 PRESERVATIVES formaldehyde T3 SKIN PREPS (Pain Relief And Inflammatory Disease) ANTIPSORIATIC AGENTS, SYSTEMIC acitretin T1 acitretin (Soriatane) T1 COSENTYX (2 SYRINGES) T4 PA QL (2 syrings/28 days) SP HD COSENTYX PEN T4 PA QL (1 pen/28 days) SP HD COSENTYX PEN (2 PENS) T4 PA QL (2 pens/28 days) SP HD COSENTYX SYRINGE T4 PA QL (1 syringe/28 days) SP HD ILUMYA T4 PA QL (1 syringe/84 days) SP HD methoxsalen (Oxsoralen-ultra) T1 OXSORALEN-ULTRA (methoxsalen) T3

151 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Pain Relief And Inflammatory Disease) ANTIPSORIATIC AGENTS, SYSTEMIC Prescription drug name Drug tier Coverage requirements and limits SILIQ T4 PA QL (2 syrings/28 days) SP HD SKYRIZI (2 SYRINGES) KIT T4 PA QL (1 kit/84 days) SP HD SORIATANE (acitretin) T3 PA TALTZ AUTOINJECTOR T4 PA QL (1 injector/28 days) SP HD TALTZ AUTOINJECTOR (2 PACK) T4 PA QL (1 injector/28 days) SP HD TALTZ AUTOINJECTOR (3 PACK) T4 PA QL (1 injector/28 days) SP HD TALTZ SYRINGE T4 PA QL (1 syringe/28 days) SP HD TREMFYA 100 MG/ML INJECTOR T4 PA QL (1 injector/56 days) SP HD TREMFYA 100 MG/ML SYRINGE T4 PA QL (1 syringe/56 days) SP HD TOPICAL ANTI-INFLAMMATORY, NSAIDS diclofenac 1.5% topical soln T1 PA HD DICLOFENAC EPOLAMINE T3 PA QL (2 patches/day) HD diclofenac sodium 1% gel (Voltaren) T1 QL (1000gm/30 days) HD FLECTOR T3 PA QL (2 patches/day) HD LICART T3 PA QL (1 patch/day) HD PENNSAID T3 PA HD VOLTAREN (diclofenac sodium) T3 PA QL (1000gm/30 days) HD SKIN PREPS (Skin Conditions) ACNE AGENTS, SYSTEMIC ABSORICA T3 QL (150 days therapy/210 days) ST ABSORICA LD T3 ST ACCUTANE T1 AMNESTEEM T1 CLARAVIS T1 isotretinoin (Absorica) T1 MYORISAN T1 ZENATANE T1 ACNE AGENTS, TOPICAL ACANYA (clindamycin phos-benzoyl perox) T3 ACZONE 5% GEL (dapsone) T3 ACZONE 7.5% GEL PUMP T2 adapalene/benzoyl peroxide T1 AZELEX T2 BENZACLIN (clindamycin-benzoyl peroxide) T3 PA clindamycin phos/benzoyl perox T1 clindamycin phos/benzoyl perox (Acanya) T1

152 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) ACNE AGENTS, TOPICAL Prescription drug name Drug tier Coverage requirements and limits clindamycin phos/benzoyl perox (Benzaclin) T1 clindamycin/tretinoin (Ziana) T1 dapsone 5% gel (Aczone) T1 DAPSONE 7.5% GEL PUMP T3 PA dapsone 7.5% gel pump (Dapsone) T1 EPIDUO FORTE T2 KLARON (sulfacetamide sodium) T3 NEUAC 1.2-5% KIT T3 neuac gel T1 ONEXTON T3 sulfacetamide sodium (Klaron) T1 VELTIN T3 PA ZIANA (clindamycin phos-tretinoin) T3 PA ANTIPERSPIRANTS DRYSOL T2 ANTIPRURITICS, TOPICAL ALEVICYN PLUS T3 doxepin 5% cream (Zonalon) T1 PA QL (90gm/30 days) doxepin hcl (Zonalon) T3 PA QL (90gm/30 days) ZONALON T3 PA QL (90gm/30 days) ZONALON (prudoxin) T3 PA QL (90gm/30 days) ANTIPSORIATICS AGENTS anthralin T1 calcipotriene 0.005% cream (Dovonex) T1 CALCIPOTRIENE 0.005% FOAM T3 PA calcipotriene 0.005% ointment T1 calcipotriene 0.005% solution T1 calcitriol 3 mcg/g ointment (Vectical) T1 QL (800gm/30 days) DOVONEX (calcipotriene) T3 DUOBRII T3 SORILUX T3 PA tazarotene 0.1% cream (Tazorac) T1 TAZORAC 0.05% CREAM T2 TAZORAC 0.05% GEL T2 TAZORAC 0.1% CREAM (tazarotene) T3 • T1 – Typically generics • T2 – Typically preferred brands • T3 – Typically non-preferred brands • T4 – Specialty medications • PA – Prior Authorization • QL – Quantity Limit • ST – Step Therapy • AGE – Age Requirement • SP – Specialty medication • HD – May require home delivery • PPACA – No cost-share preventive medications • CSL – Oral cancer medications subject to cost-share limits

153 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) ANTIPSORIATICS AGENTS Prescription drug name Drug tier Coverage requirements and limits TAZORAC 0.1% GEL T2 VECTICAL (calcitriol) T3 QL (800gm/30 days) ANTISEBORRHEIC AGENTS OVACE PLUS T3 selenium sulfide T1 sulfacetamide sodium T1 TERSI FOAM T3 ANTISEPTICS, MISCELLANEOUS GUAIACOL T1 DIABETIC ULCER PREPARATIONS, TOPICAL REGRANEX T3 PA QL (2 tubs/30 days) EMOLLIENTS ATOPICLAIR T3 emollient combination no.35 (Mimyx) T1 emollient combination no.60 (Restizan) T1 emollient combination no.60 (Restizan) T3 HALUCORT T3 MIMYX (prumyx) T3 RESTIZAN T1 vite ac/grape/hyaluronic acid (Atopiclair) T1 XCLAIR T3

IMMUNOMODULATORS ALDARA (imiquimod) T3 PA

imiquimod 3.75% cream (Zyclara) T1 PA QL(112 PACKETS/67 DAYS) IMIQUIMOD 3.75% CREAM PUMP T1 PA imiquimod 5% cream packet (Aldara) T1 ZYCLARA 2.5% CREAM PUMP T3 PA QL (4 bots/30 days) ZYCLARA 3.75% CREAM (imiquimod) T3 PA QL (112 packs/30 days) ZYCLARA 3.75% CREAM PUMP T3 PA

IRRITANTS/COUNTER-IRRITANTS methyl salicylate T1 QUTENZA T3

154 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) KERATOLYTICS Prescription drug name Drug tier Coverage requirements and limits BENSAL HP T1 PA BENZEFOAM T3 BENZEPRO T1 benzoyl peroxide T1 benzoyl peroxide (Enzoclear) T1 benzoyl peroxide (Pacnex) T1 CONDYLOX T3 PA ENZOCLEAR T3 HYDRO 35 T3 HYDRO 40 (umecta) T3 INOVA T3 KERAFOAM T3 KERALYT 6% GEL (salicylic acid) T3 keralyt 6% shampoo T1 KERALYT SCALP T3 KERALYT SCALP (salicylic acid) T3 PACNEX (benzoyl peroxide) T3 PODOCON-25 T1 podofilox T1 PR BENZOYL PEROXIDE T1 salicylic acid T1 salicylic acid T3 salicylic acid (Keralyt Scalp) T1 salicylic acid/ceramide comb 1 T1 SALIMEZ FORTE T1 SALKERA T3 SALVAX DUO PLUS T3 silver nitrate T1 silver nitrate applicator T1 URAMAXIN T3 URAMAXIN (urea) T3 urea T1 urea (Hydro 35) T1

155 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) KERATOLYTICS Prescription drug name Drug tier Coverage requirements and limits urea (Hydro 40) T3 urea (Uramaxin) T1 urea (Xurea) T1 XUREA T3 PROTECTIVES PHARMABASE BARRIER T1 polydimethylsiloxanes/silicon T1 protectives2/ceramide 1, 3, 6-ii T1 RADIAPLEXRX T3 zinc oxide T1 ROSACEA AGENTS, TOPICAL azelaic acid (Finacea) T1 FINACEA T3 PA FINACEA (azelaic acid) T3 PA ivermectin (Soolantra) T1 METROCREAM (rosadan) T3 PA METROGEL (metronidazole) T3 PA metronidazole T1 metronidazole (Metrocream) T1 metronidazole (Metrogel) T1 NORITATE T3 PA SOOLANTRA T3 PA SOOLANTRA (ivermectin) T3 PA TISSUE/WOUND ADHESIVES ARTISS T3 SURGISEAL STYLUS T3 SURGISEAL TEARDROP T3 SURGISEAL TWIST T3 TISSEEL VHSD T3 TOP. ANTI-INFLAM., PHOSPHODIESTERASE-4 (PDE4) INHIB EUCRISA T2 TOPICAL AGENTS, MISCELLANEOUS GORDON’s UREA T3

156 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) TOPICAL AGENTS, MISCELLANEOUS Prescription drug name Drug tier Coverage requirements and limits MEDIHONEY T3 SAF-CLENS AF T1 trichloroacetic acid T3 TRICHLOROACETIC ACID T1 TOPICAL ANTIBIOTIC PLEUROMUTILIN DERIVATIVES ALTABAX T3 TOPICAL ANTICHOLINERGIC HYPERHIDROSIS TX AGENTS QBREXZA T3 TOPICAL ANTI-INFLAMMATORY STEROIDAL ALA-SCALP (scalacort) T3 ST alclometasone dipropionate T1 amcinonide T1 ANUSOL-HC 2.5% CREAM (proctozone-hc) T1 PA AQUA GLYCOLIC HC T3 betamethasone dipropionate T1 betamethasone valerate T1 betamethasone valerate (Luxiq) T1 betamethasone/propylene glyc T1 betamethasone/propylene glyc (Diprolene) T1 BRYHALI T3 ST CAPEX SHAMPOO T3 ST clobetasol propionate T1 clobetasol propionate (Clobex) T1 clobetasol propionate (Olux) T1 clobetasol propionate (Temovate) T1 clobetasol propionate/emoll T1 clobetasol propionate/emoll (Olux-e) T1 CLOBEX (clobetasol propionate) T3 PA CLOBEX (clodan) T3 PA CLOCORTOLONE PIVALATE T1 CLODAN 0.05% KIT T3 ST clodan 0.05% shampoo (Clobex) T1 CLODERM T3 ST

157 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) TOPICAL ANTI-INFLAMMATORY STEROIDAL Prescription drug name Drug tier Coverage requirements and limits CORDRAN T3 PA CORDRAN (flurandrenolide) T3 PA CORDRAN (nolix) T3 PA CUTIVATE 0.05% CREAM (fluticasone propionate) T3 ST CUTIVATE 0.05% LOTION (fluticasone propionate) T3 PA DERMA-SMOOTHE-FS (fluocinolone acetonide) T3 ST DERMASORB HC T3 ST DERMASORB TA T3 ST DERMATOP (prednicarbate) T3 ST DESONATE (desonide) T3 ST desonide T1 desonide (Desonate) T1 desonide (Desowen) T1 desonide (Tridesilon) T1 DESOWEN (desonide) T3 ST desoximetasone (Topicort) T1 diflorasone diacetate T1 PA diflorasone diacetate (Psorcon) T1 PA diflorasone diacetate/emoll T1 PA DIPROLENE (betamethasone diprop augmented) T3 ST fluocinolone acetonide T1 fluocinolone acetonide (Derma-smoothe-fs) T1 fluocinolone acetonide (Synalar) T1 fluocinolone/shower cap (Derma-smoothe-fs) T1 fluocinonide T1 fluocinonide (Vanos) T1 fluocinonide/emollient base T1 flurandrenolide (Cordran) T1 PA fluticasone prop 0.005% oint T1 fluticasone prop 0.05% cream (Cutivate) T1 fluticasone prop 0.05% lotion (Cutivate) T1 fluticasone propionate (Cutivate) T1 halcinonide (Halog) T1 PA

158 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) TOPICAL ANTI-INFLAMMATORY STEROIDAL Prescription drug name Drug tier Coverage requirements and limits HALOBETASOL PROPIONATE T1 halobetasol propionate (Ultravate) T1 HALOG 0.1% CREAM (halcinonide) T3 PA HALOG 0.1% OINTMENT T3 PA HALOG 0.1% SOLUTION T3 ST hydrocort buty 0.1% lipid crm (Locoid Lipocream) T1 PA hydrocort buty 0.1% lipo cream (Locoid Lipocream) T1 PA hydrocortisone T1 hydrocortisone (Ala-scalp) T1 hydrocortisone (Anusol-hc) T1 hydrocortisone buty 0.1% cream T1 hydrocortisone butyr 0.1% lotn (Locoid) T1 PA hydrocortisone butyr 0.1% oint (Locoid) T1 hydrocortisone butyr 0.1% soln T1 hydrocortisone valerate T1 IMPEKLO T3 PA IMPOYZ T3 PA KENALOG (triamcinolone acetonide) T3 PA LEXETTE T3 ST LOCOID 0.1% LOTION (hydrocortisone butyrate) T3 PA LOCOID 0.1% OINTMENT (hydrocortisone butyrate) T3 LOCOID LIPOCREAM T3 PA LOCOID LIPOCREAM (hydrocortisone butyrate) T3 PA LUXIQ (betamethasone valerate) T3 ST mometasone furoate 0.1% cream T1 mometasone furoate 0.1% oint T1 mometasone furoate 0.1% soln T1 NUCORT T3 ST OLUX (clobetasol propionate) T3 PA OLUX-E (tovet emollient) T3 PA PANDEL T3 PA prednicarbate (Dermatop) T1 PSORCON (diflorasone diacetate) T3 PA

159 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) TOPICAL ANTI-INFLAMMATORY STEROIDAL Prescription drug name Drug tier Coverage requirements and limits SCALACORT DK T3 ST SERNIVO T3 PA SYNALAR T3 ST SYNALAR (fluocinolone acetonide) T3 ST SYNALAR TS T3 ST TEMOVATE (clobetasol propionate) T3 ST TEXACORT T3 ST TOPICORT (desoximetasone) T3 ST triamcinolone acetonide T1 triamcinolone acetonide T1 PA triamcinolone acetonide (Kenalog) T1 TRIDESILON (desonide) T3 PA ULTRAVATE 0.05% CREAM (halobetasol T3 propionate) ULTRAVATE 0.05% LOTION T3 PA ULTRAVATE 0.05% OINTMENT (halobetasol T3 propionate) ULTRAVATE X T3 ST VANOS (fluocinonide) T3 PA VERDESO T3 PA TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC ANALPRAM HC T3 EPIFOAM T3 hydrocortisone/pramoxine (Pramosone) T1 lidocaine/hydrocortisone ac T1 MEZPAROX-HC T1 PRAMOSONE 1% LOTION T2 PRAMOSONE 1%-1% CREAM T2 PRAMOSONE 1%-1% OINTMENT T2 PRAMOSONE 2.5%-1% CREAM T3 PRAMOSONE 2.5%-1% LOTION T3 PRAMOSONE 2.5%-1% OINTMENT T2 TOPICAL ANTIPARASITICS lindane T1

160 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) TOPICAL ANTIPARASITICS Prescription drug name Drug tier Coverage requirements and limits malathion (Ovide) T1 OVIDE (malathion) T3 TOPICAL PREPARATIONS, ANTIBACTERIALS dermazene cream T1 DERMAZENE CREAM PACKET T3 hydrocortisone/iodoquinol T1 hydrocortisone/iodoquinol/aloe T1 iodine/potassium iodide T1 iodine/sodium iodide T1 IODOFLEX T3 IODOSORB T3 silver nitrate T1 TOPICAL VIT D ANALOG/ANTI-INFLAMMATORY STEROID calcipotriene/betamethasone (Taclonex) T1 ENSTILAR T3 PA TACLONEX (calcipotriene-betamethasone dp) T3 PA TACLONEX (calcipotriene-betamethasone) T3 PA WYNZORA T3 PA TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES SANTYL T2 QL (60gm/30 days) VITAMIN A DERIVATIVES adapalene T1 PA adapalene (Differin) T1 PA adapalene (Plixda) T1 PA AKLIEF T3 ALTRENO T3 PA ATRALIN (tretinoin) T3 PA avita 0.025% cream (Retin-a) T3 PA AVITA 0.025% GEL T3 DIFFERIN T3 PA DIFFERIN (adapalene) T3 PA PLIXDA T1 PA RETIN-A 0.01% GEL (tretinoin) T3

161 Cigna Legacy (Standard) 4-Tier Prescription Drug List

SKIN PREPS (Skin Conditions) VITAMIN A DERIVATIVES Prescription drug name Drug tier Coverage requirements and limits RETIN-A 0.025% CREAM (tretinoin) T3 PA RETIN-A 0.025% GEL (tretinoin) T3 RETIN-A 0.05% CREAM (tretinoin) T3 PA RETIN-A 0.1% CREAM (tretinoin) T3 PA RETIN-A MICRO (tretinoin microsphere) T3 PA RETIN-A MICRO PUMP T3 PA RETIN-A MICRO PUMP (tretinoin microsphere) T3 PA tretinoin 0.01% gel (Retin-a) T1 tretinoin 0.025% cream (Retin-a) T1 PA tretinoin 0.025% gel (Retin-a) T1 tretinoin 0.05% cream (Retin-a) T1 PA tretinoin 0.05% gel (Atralin) T1 PA tretinoin 0.1% cream (Retin-a) T1 PA tretinoin microspheres (Retin-a Micro Pump) T1 PA tretinoin microspheres (Retin-a Micro) T1 PA TRETIN-X T3 PA VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTS ARAZLO T2 FABIOR T3 TAZAROTENE 0.1% FOAM T3 SMOKING DETERRENTS (Smoking Cessation) SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS) NICOTROL T2 PPACA NICOTROL NS T2 PPACA SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST CHANTIX T2 SMOKING DETERRENTS, OTHER bupropion hcl sr 150 mg tablet T1 PPACA THYROID PREPS (Hormonal Agents) ANTITHYROID PREPARATIONS methimazole (Tapazole) T1 HD propylthiouracil T1 HD TAPAZOLE (methimazole) T3 HD

162 Cigna Legacy (Standard) 4-Tier Prescription Drug List

THYROID PREPS (Hormonal Agents) THYROID HORMONES Prescription drug name Drug tier Coverage requirements and limits ARMOUR THYROID T3 HD CYTOMEL (liothyronine sodium) T3 HD LEVOTHYROXINE T3 HD levothyroxine sodium (Synthroid) T1 HD levothyroxine sodium (Synthroid) T3 HD liothyronine sodium (Cytomel) T1 HD SYNTHROID (unithroid) T3 HD THYQUIDITY T3 PA HD thyroid, pork T1 HD thyroid, pork (Armour Thyroid) T1 HD thyroid, pork (Wp Thyroid) T1 HD THYROLAR-1 T2 HD THYROLAR-1/2 T2 HD THYROLAR-1/4 T2 HD THYROLAR-2 T2 HD THYROLAR-3 T2 HD TIROSINT T3 HD TIROSINT-SOL T3 HD WP THYROID T1 HD WP THYROID (nature-throid) T1 HD WP THYROID (westhroid) T1 HD

UNCLASSIFIED DRUG PRODUCTS (AIDS/HIV) CYTOCHROME P450 INHIBITORS TYBOST T4 SP UNCLASSIFIED DRUG PRODUCTS (Asthma/Copd/Respiratory) CYSTIC FIBROSIS-CFTR POTENTIATOR-CORRECTOR COMBIN. BRONCHITOL 40 MG INHALE CAP T3 PA SP ORKAMBI 100 MG-125 MG TABLET T4 PA QL (4 tabs/day) SP HD ORKAMBI 100-125 MG GRANULE PKT T4 PA QL (2 packs/day) SP HD ORKAMBI 150-188 MG GRANULE PKT T4 PA QL (2 packs/day) SP HD ORKAMBI 200 MG-125 MG TABLET T4 PA QL (4 tabs/day) SP HD SYMDEKO T4 PA QL (2 tabs/day) SP HD TRIKAFTA T4 PA QL (3 tabs/day) SP HD

163 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Asthma/COPD/Respiratory) CYSTIC FIB-TRANSMEMB CONDUCT.REG. (CFTR) POTENTIATOR Prescription drug name Drug tier Coverage requirements and limits KALYDECO 150 MG TABLET T4 PA QL (2 tabs/day) SP HD KALYDECO 25 MG GRANULES PACKET T4 PA QL (2 packs/day) SP HD KALYDECO 50 MG GRANULES PACKET T4 PA QL (2 packs/day) SP HD KALYDECO 75 MG GRANULES PACKET T4 PA QL (2 packs/day) SP HD LUNG SURFACTANTS CUROSURF T3 INFASURF T3 SURVANTA T3 MUCOLYTICS PULMOZYME T4 PA SP HD PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS OFEV T4 PA SP HD SYSTEMIC ENZYME INHIBITORS ZOKINVY T4 PA QL (4 CAPS/DAY) SP UNCLASSIFIED DRUG PRODUCTS (Blood Modifiers/Bleeding Disorders) SPLEEN TYROSINE KINASE INHIBITORS TAVALISSE T4 PA SP UNCLASSIFIED DRUG PRODUCTS (Blood Pressure/Heart Medications) BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR (icatibant) T4 PA SP HD icatibant acetate (Firazyr) T4 PA SP HD C1 ESTERASE INHIBITORS BERINERT T4 PA SP HD CINRYZE T4 PA SP HD HAEGARDA T4 PA SP HD RUCONEST T4 PA SP HD PLASMA KALLIKREIN INHIBITORS KALBITOR T4 PA SP HD ORLADEYO T4 PA QL (1 CAPS/DAY) SP UNCLASSIFIED DRUG PRODUCTS (Cancer) CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin calcium T1 MESNEX T4 SP VISTOGARD T4 SP

164 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Dental Products) DENTAL AIDS AND PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits chlorhexidine gluconate (Peridex) T1 PERIDEX (periogard) T1 triamcinolone acetonide T1 PERIODONTAL COLLAGENASE INHIBITORS doxycycline hyclate 20 mg tab T1 UNCLASSIFIED DRUG PRODUCTS (Erectile Dysfunction) DRUGS TO TREAT ERECTILE DYSFUNCTION (ED) CAVERJECT T3 PA QL (6 injectors/30 days) CIALIS 10 MG TABLET (tadalafil) T3 QL (6 tabs/30 days) ST CIALIS 2.5 MG TABLET (tadalafil) T3 QL (8 tabs/30 days) ST CIALIS 20 MG TABLET (tadalafil) T3 QL (6 tabs/30 days) ST CIALIS 5 MG TABLET (tadalafil) T3 QL (8 tabs/30 days) ST EDEX T3 PA QL (6 injectors/30 days) IFE-BIMIX 30/1 T2 IFE-PG20 T2 LEVITRA (vardenafil hcl) T3 QL (10 tabs/30 days) ST MUSE T2 PA QL (6/30 days) PAPAVERINE-ALPROSTADIL T1 PAPAVERINE-PHENTOLAMINE T1 PAPAVERINE-PHENTOLMN-ALPROSTDL T1 PHENTOLAMINE-ALPROSTADIL T1 sildenafil 100 mg tablet (Viagra) T1 QL (10 tabs/30 days) sildenafil 25 mg tablet (Viagra) T1 QL (10 tabs/30 days) sildenafil 50 mg tablet (Viagra) T1 QL (10 tabs/30 days) STENDRA T3 QL (8 tabs/30 days) ST tadalafil 10 mg tablet (Cialis) T1 QL (10 tabs/30 days) tadalafil 2.5 mg tablet (Cialis) T1 QL (8 tabs/30 days) tadalafil 20 mg tablet (Cialis) T1 PA QL (10 tabs/30 days) tadalafil 5 mg tablet (Cialis) T1 QL (8 tabs/30 days) TRI-MIX (PAPVRN-PHNTLMN-PGE1) T3 vardenafil hcl T1 QL (10 tabs/30 days) vardenafil hcl (Levitra) T1 QL (10 tabs/30 days) VIAGRA (sildenafil citrate) T3 QL (6 tabs/30 days) ST

165 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Gastrointestinal/Heartburn) CALCIMIMETIC, PARATHYROID CALCIUM ENHANCER Prescription drug name Drug tier Coverage requirements and limits cinacalcet hcl (Sensipar) T4 SP SENSIPAR (cinacalcet hcl) T4 PA SP ORAL MUCOSITIS/STOMATITIS AGENTS ORAMAGICRX T3 SALIVA STIMULANT AGENTS NUMOISYN T3 UNCLASSIFIED DRUG PRODUCTS (Hormonal Agents) BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE FORTEO T4 PA QL (3ML/21 DAYS) SP HD TERIPARATIDE T4 PA QL (1 pen/28 days) SP HD GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT T4 PA SP HD HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE doxercalciferol T1 paricalcitol T4 SP HD paricalcitol (Zemplar) T4 SP HD RAYALDEE T3 ZEMPLAR (paricalcitol) T4 SP HD MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR OSPHENA T3 HD UNCLASSIFIED DRUG PRODUCTS (Miscellaneous) ABORTIFACIENT-PROGESTERONE RECEPTOR ANTAGONISTS MIFEPREX T3 mifepristone (Mifeprex) T1 AGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH KEVEYIS T4 SP AMMONIA INHIBITORS CARBAGLU T4 SP HD AMYLOIDOSIS AGENTS-TRANSTHYRETIN (TTR) SUPPRESSION TEGSEDI T4 PA SP HD ANTI-ALCOHOLIC PREPARATIONS acamprosate calcium T1 ANTABUSE (disulfiram) T3 disulfiram (Antabuse) T1

166 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Miscellaneous) ANTIDOTES, MISCELLANEOUS Prescription drug name Drug tier Coverage requirements and limits CETYLEV T3

ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS ESBRIET T4 PA SP HD

CRYOPRESERVATIVE AGENTS dimethyl sulfoxide T1

DRUGS TO TREAT HEREDITARY TYROSINEMIA nitisinone (Orfadin) T4 PA SP HD NITYR T4 PA SP ORFADIN T4 PA SP ORFADIN (nitisinone) T4 PA SP

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING CERDELGA T4 PA SP HD miglustat (Zavesca) T4 PA SP HD ZAVESCA (miglustat) T4 PA SP HD

GENERAL INHALATION AGENTS HYPER-SAL T3 nebusal 3% vial T1 NEBUSAL 6% VIAL T3 sodium chloride for inhalation T1 sodium chloride for inhalation (Hyper-sal) T1

GENETIC D/O TX - SMN PROTEIN DEFICIENCY TREATMENT EVRYSDI T4 PA SP HD

MENOPAUSAL SYMPTOMS SUPPRESSANT - SSRIS BRISDELLE (paroxetine mesylate) T3 QL (1 cap/day) HD paroxetine mesylate (Brisdelle) T1 QL (1 cap/day) HD

METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA STRENSIQ T4 PA SP

METABOLIC DISEASE ENZYME REPLACEMENT, MOCD NULIBRY T4 PA SP

METALLIC POISON, AGENTS TO TREAT CHEMET T3 deferasirox (Exjade) T4 SP HD

167 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Miscellaneous) METALLIC POISON, AGENTS TO TREAT Prescription drug name Drug tier Coverage requirements and limits deferasirox (Jadenu Sprinkle) T4 SP HD deferasirox (Jadenu) T4 SP HD deferiprone (Ferriprox) T4 PA SP EXJADE (deferasirox) T4 PA SP HD FERRIPROX T4 PA SP FERRIPROX (2 TIMES A DAY) T4 PA SP GALZIN T3 JADENU (deferasirox) T4 PA SP HD JADENU SPRINKLE (deferasirox) T4 PA SP HD RADIOGARDASE T3 SYPRINE (trientine hcl) T4 PA SP HD trientine hcl (Syprine) T4 PA SP HD

OINTMENT/CREAM BASES RADIAGEL T1 PHARMACOLOGICAL CHAPERONE-ALPHA-GALACTOSID.A STABZ GALAFOLD T4 PA SP HD PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE KUVAN (sapropterin dihydrochloride) T4 PA SP HD sapropterin dihydrochloride (Kuvan) T4 PA SP HD

PROTEIN STABILIZERS VYNDAMAX T4 PA QL (1 cap/day) SP HD VYNDAQEL T4 PA QL (4 caps/day) SP HD

SOLVENTS isopropyl alcohol T1 MURI-LUBE MINERAL OIL T1

UNCLASSIFIED DRUG PRODUCTS (Nutritional/Dietary) METABOLIC DEFICIENCY AGENTS CARNITOR 1 GM/5 ML VIAL T2 CARNITOR 100 MG/ML ORAL SOLN (levocarnitine) T3 CARNITOR 330 MG TABLET (levocarnitine) T3 CARNITOR SF (levocarnitine sf) T3 CYSTADANE T4 SP

168 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Nutritional/Dietary) METABOLIC DEFICIENCY AGENTS Prescription drug name Drug tier Coverage requirements and limits levocarnitine (Carnitor Sf) T1 levocarnitine (Carnitor) T1 levocarnitine (with sugar) (Carnitor) T1 UNCLASSIFIED DRUG PRODUCTS (Osteoporosis Products) BONE RESORPTION INHIBITOR AND VITAMIN D COMBS. FOSAMAX PLUS D T3 ST HD BONE RESORPTION INHIBITORS ACTONEL (risedronate sodium) T3 ST HD alendronate sod 70 mg/75 ml T1 HD alendronate sodium 10 mg tab T1 HD alendronate sodium 35 mg tab T1 HD alendronate sodium 40 mg tab T1 QL (2 tabs/day) HD alendronate sodium 5 mg tablet T1 HD alendronate sodium 70 mg tab (Fosamax) T1 HD ATELVIA (risedronate sodium dr) T3 ST HD BINOSTO T3 ST HD BONIVA (ibandronate sodium) T3 ST HD EVISTA (raloxifene hcl) T3 HD FOSAMAX (alendronate sodium) T3 ST HD ibandronate sodium (Boniva) T1 HD raloxifene hcl (Evista) T1 HD PPACA risedronate sodium T1 HD risedronate sodium (Actonel) T1 HD risedronate sodium (Atelvia) T1 HD UNCLASSIFIED DRUG PRODUCTS (Pain Relief And Inflammatory Disease) ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST ARCALYST T4 PA SP HD ANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS ILARIS T4 PA SP HD FIBROMYALGIA AGENTS, SEROTONIN-NOREPINEPH RU INHIB SAVELLA T2 HD IMMUNOMODULATOR, B-LYMPHOCYTE STIM (BLYS) -SPEC INHIB BENLYSTA T4 PA SP HD

169 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Seizure Disorders) NEUROPATHIC AGENTS Prescription drug name Drug tier Coverage requirements and limits LYRICA CR T3 HD UNCLASSIFIED DRUG PRODUCTS (Substance Abuse) OPIOID WITHDRAWAL THER, ALPHA-2 ADRENERGIC AGONIST LUCEMYRA T2 QL (168 tabs/14 days) OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE BUNAVAIL T3 buprenorphine hcl T1 buprenorphine hcl/naloxone hcl T1 buprenorphine hcl/naloxone hcl (Suboxone) T1 SUBOXONE (buprenorphine-naloxone) T3 ZUBSOLV T2 UNCLASSIFIED DRUG PRODUCTS (Urinary Tract Conditions) BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS alfuzosin hcl (Uroxatral) T1 HD AVODART (dutasteride) T3 HD dutasteride (Avodart) T1 HD finasteride (Proscar) T1 HD FLOMAX (tamsulosin hcl) T3 HD PROSCAR (finasteride) T3 HD RAPAFLO 4 MG CAPSULE (silodosin) T3 QL (1 cap/day) HD RAPAFLO 8 MG CAPSULE (silodosin) T3 HD silodosin 4 mg capsule (Rapaflo) T1 QL (1 cap/day) HD silodosin 8 mg capsule (Rapaflo) T1 HD tamsulosin hcl (Flomax) T1 HD UROXATRAL (alfuzosin hcl er) T3 HD BPH 5-ALPHA-REDUCTASE INHIB-ALPHA1-ADRENOCEP ANTAG dutasteride/tamsulosin hcl (Jalyn) T1 HD JALYN (dutasteride-tamsulosin) T3 HD CYSTINE-DEPLETING AGENTS, NEPHROPATHIC CYSTINOSIS CYSTAGON T4 SP PROCYSBI T4 PA SP HD KIDNEY STONE AGENTS THIOLA T4 SP THIOLA EC T4 SP

170 Cigna Legacy (Standard) 4-Tier Prescription Drug List

UNCLASSIFIED DRUG PRODUCTS (Urinary Tract Conditions) OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP Prescription drug name Drug tier Coverage requirements and limits GEMTESA T3 QL (1 tab/Day) ST HD MYRBETRIQ ER 25 MG TABLET T3 QL (1 tab/day) ST HD MYRBETRIQ ER 50 MG TABLET T3 ST HD URINARY TRACT ANTISPASMODIC, M (3) SELECTIVE ANTAG. darifenacin er 15 mg tablet T1 HD darifenacin er 7.5 mg tablet (Enablex) T1 QL (1 tab/day) HD ENABLEX (darifenacin er) T3 QL (1 tab/day) ST HD solifenacin 10 mg tablet (Vesicare) T1 HD solifenacin 5 mg tablet (Vesicare) T1 QL (1 tab/day) HD VESICARE 10 MG TABLET (solifenacin succinate) T3 ST HD VESICARE 5 MG TABLET (solifenacin succinate) T3 QL (1 tab/day) ST HD VESICARE LS T3 ST HD URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT DETROL (tolterodine tartrate) T3 ST HD DETROL LA 2 MG CAPSULE (tolterodine tartrate T3 QL (1 cap/day) ST HD er) DETROL LA 4 MG CAPSULE (tolterodine tartrate T3 ST HD er) DITROPAN XL (oxybutynin chloride er) T3 ST HD flavoxate hcl T1 HD GELNIQUE T3 ST HD oxybutynin chloride T1 HD oxybutynin chloride (Ditropan Xl) T1 HD OXYTROL T3 ST HD tolterodine tart er 2 mg cap (Detrol La) T1 QL (1 cap/day) HD tolterodine tart er 4 mg cap (Detrol La) T1 HD tolterodine tartrate (Detrol) T1 HD TOVIAZ ER 4 MG TABLET T2 QL (1 tab/day) HD TOVIAZ ER 8 MG TABLET T2 HD trospium chloride T1 HD UNCLASSIFIED DRUG PRODUCTS (Weight Management) APPETITE STIM. FOR ANOREXIA, CACHEXIA, WASTING SYND. megestrol acetate T1

171 Cigna Legacy (Standard) 4-Tier Prescription Drug List

VITAMINS (Nutritional/Dietary) FOLIC ACID PREPARATIONS Prescription drug name Drug tier Coverage requirements and limits folic acid T1 MULTIVITAMIN PREPARATIONS FOLET ONE T2 mvn no.53/iron/folic/dss/dha T1 OBSTETRIX ONE T1 VITAMIN B PREPARATIONS POTABA T2 HD VITAMIN B12 PREPARATIONS cyanocobalamin (vitamin b-12) T1 NASCOBAL T3 PA VITAMIN D PREPARATIONS calcitriol 0.25 mcg capsule (Rocaltrol) T1 HD calcitriol 0.5 mcg capsule (Rocaltrol) T1 HD calcitriol 1 mcg/ml solution (Rocaltrol) T1 HD DRISDOL (vitamin d2) T2 HD ergocalciferol (vitamin d2) (Drisdol) T1 HD ROCALTROL (calcitriol) T2 HD VITAMIN K PREPARATIONS MEPHYTON (phytonadione) T2 phytonadione (vit k1) (Mephyton) T1

172 Exclusions and limitations for coverage

Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements.

Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan:8

› over-the-counter (OTC) medicines (those that do › replacement of prescription medications and related not require a prescription) except insulin unless supplies due to loss or theft; state or federal law requires coverage of such › medications which are to be taken by or medicines; administered to a covered person while they are a › prescription medications or supplies for which there patient in a licensed hospital, skilled nursing facility, is a prescription or OTC therapeutic equivalent or rest home or similar institution which operates on its therapeutic alternative; premises or allows to be operated on its premises a › doctor-administered injectable medications covered facility for dispensing pharmaceuticals; under the Plan’s medical benefit, unless otherwise › prescriptions more than one year from the date of covered under the Plan’s prescription drug list or issue; or approved by Cigna; › coverage for prescription medication products for › implantable contraceptive devices covered under the amount dispensed (days’ supply) which is more the Plan’s medical benefit; than the applicable supply limit, or is less than any › medications that are not medically necessary; applicable supply minimum set forth in The Schedule, or which is more than the quantity limit(s) › experimental or investigational medications, or dosage limit(s) set by the P&T Committee. including FDA-approved medications used for purposes other than those approved by the FDA › more than one prescription order or refill for a given unless the medication is recognized for the prescription supply period for the same prescription treatment of the particular indication; medication product prescribed by one or more doctors and dispensed by one or more pharmacies. › medications that are not approved by the Food & Drug Administration (FDA); › prescription medication products dispensed outside the jurisdiction of the United States, except as › prescription and non-prescription devices, supplies, required for emergency or urgent care treatment. In and appliances other than those supplies specifically addition to the plan’s standard pharmacy exclusions, listed as covered; certain new FDA-approved medication products › medications used for fertility, sexual dysfunction, (including, but not limited to, medications, medical cosmetic purposes, weight loss, smoking cessation, supplies or devices that are covered under standard or athletic enhancement; pharmacy benefit plans) may not be covered for the first six months of market availability unless › prescription vitamins (other than prenatal vitamins) approved by Cigna as medically necessary. or dietary supplements unless state or federal law requires coverage of such products; › immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis;

173 Index of medications

A ACTIMMUNE...... 61 abacavir/lamivudine/zidovudine (Trizivir) ...... 66 ACTIQ (fentanyl citrate) ...... 21 abacavir sulfate/lamivudine (Epzicom) ...... 66 ACTIVELLA (mimvey) ...... 125 abacavir sulfate (Ziagen) ...... 67 ACTIVELLA (mimvey lo) ...... 125 ABILIFY 2 MG TABLET (aripiprazole) ...... 148 ACTONEL (risedronate sodium) ...... 169 ABILIFY 5 MG TABLET (aripiprazole) ...... 148 ACTOPLUS MET (pioglitazone-metformin) ...... 50 ABILIFY 10 MG TABLET (aripiprazole) ...... 148 ACTOS (pioglitazone hcl) ...... 51 ABILIFY 15 MG TABLET (aripiprazole) ...... 148 ACULAR (ketorolac tromethamine) ...... 107 ABILIFY 20 MG TABLET (aripiprazole) ...... 148 ACULAR LS (ketorolac tromethamine) ...... 107 ABILIFY 30 MG TABLET (aripiprazole) ...... 148 ACUVAIL...... 107 ABILIFY MYCITE...... 148 acyclovir 5% cream (Zovirax) ...... 71 abiraterone acetate (Zytiga) ...... 56 acyclovir 5% ointment (Zovirax) ...... 71 ABSORICA...... 152 acyclovir 200 mg/5 ml susp (Zovirax) ...... 69 ABSORICA LD...... 152 acyclovir 200 mg capsule...... 69 ABSTRAL...... 21 acyclovir 400 mg tablet...... 69 acamprosate calcium...... 166 acyclovir 800 mg tablet...... 69 ACANYA (clindamycin phos-benzoyl perox) ...... 152 ACZONE 5% GEL (dapsone) ...... 152 acarbose (Precose) ...... 49 ACZONE 7.5% GEL PUMP...... 152 ACCOLATE (zafirlukast) ...... 31 ADACEL TDAP...... 77 ACCUPRIL (quinapril hcl) ...... 85 ADALAT CC (nifedipine er) ...... 79 ACCURETIC (quinapril-hydrochlorothiazide) ...... 83 adapalene...... 161 ACCUTANE ...... 152 adapalene/benzoyl peroxide...... 152 ACD-A...... 42 adapalene (Differin)...... 161 ACD SOLUTION A...... 42 adapalene (Plixda) ...... 161 ACE AEROSOL CLOUD ENHANCER...... 133 ADCIRCA (tadalafil) ...... 82 acebutolol hcl...... 87 ADDERALL (dextroamphetamine-amphetamine) ...... 73 ACETAMIN-CAFF-DIHYDROCODEINE...... 21 ADDERALL XR (dextroamphetamine-amphet er) ...... 73 acetamin-codein 300-30 mg/12.5...... 20 ADDYI...... 146 acetaminop-codeine 120-12 mg/5...... 20 adefovir dipivoxil (Hepsera) ...... 70 acetaminophen/caff/dihydrocod (Acetamin-caff- ADEMPAS...... 82 dihydrocodeine) ...... 21 ADHANSIA XR...... 144 acetaminophen/caff/dihydrocod (Trezix) ...... 21 ADIPEX-P (phentermine hcl) ...... 62 acetaminophen-cod #2 tablet...... 20 ADLYXIN...... 48 acetaminophen-cod #3 tablet...... 20 ADMELOG...... 51 acetaminophen-cod #4 tablet...... 20 ADMELOG SOLOSTAR...... 52 acetazolamide...... 105 ADRENALIN CHLORIDE...... 107 acetic acid...... 107, 151 ADVAIR DISKUS (wixela inhub) ...... 30 acetic acid/oxyquinoline (Relagard) ...... 53 ADVAIR HFA...... 30 acetylcysteine...... 31 ADVANCED DNA MEDICATED COLLECT...... 103 ACIPHEX (rabeprazole sodium) ...... 120 ADZENYS ER...... 73 ACIPHEX SPRINKLE DR 5 MG CAP...... 121 ADZENYS XR-ODT...... 73 ACIPHEX SPRINKLE DR 10 MG CAP...... 121 AEMCOLO...... 39 acitretin...... 151 AEROCHAMBER MINI...... 134 acitretin (Soriatane) ...... 151 AEROCHAMBER MV...... 134 ACTEMRA...... 131 AEROCHAMBER PLUS FLOW-VU...... 134 ACTEMRA ACTPEN...... 131 AEROCHAMBER WITH FLOWSIGNAL...... 134 ACTHIB...... 77 AEROCHAMBER Z-STAT PLUS...... 134 ACTICLATE (doxycycline hyclate) ...... 39 AEROTRACH PLUS...... 134 ACTIGALL (ursodiol) ...... 117 AEROVENT PLUS...... 134

174 AFINITOR...... 58 ALDARA (imiquimod) ...... 154 AFINITOR DISPERZ...... 58 ALECENSA...... 59 AFINITOR (everolimus) ...... 58 alendronate sod 70 mg/75 ml...... 169 AFLURIA 2017-2018...... 75 alendronate sodium 5 mg tablet...... 169 AFLURIA 2018-2019...... 75 alendronate sodium 10 mg tab...... 169 AFLURIA QUAD 2017-2018...... 75 alendronate sodium 35 mg tab...... 169 AFLURIA QUAD 2018-2019...... 75 alendronate sodium 40 mg tab...... 169 AFLURIA QUAD 2019-20 (3YR UP) ...... 75 alendronate sodium 70 mg tab (Fosamax) ...... 169 AFLURIA QUAD 2019-20 (6-35MO) ...... 75 ALEVICYN PLUS...... 153 AFLURIA QUAD 2019-2020...... 75 alfuzosin hcl (Uroxatral) ...... 170 AFLURIA QUAD 2020-21 (3YR UP) ...... 75 ALINIA...... 63 AFLURIA QUAD 2020-21 (6-35MO) ...... 75 ALINIA (nitazoxanide) ...... 63 AFLURIA QUAD 2020-2021...... 75 aliskiren 150 mg tablet (Tekturna) ...... 88 AFREZZA 4 UNIT/8 UNIT/12 UNIT...... 52 aliskiren 300 mg tablet (Tekturna) ...... 88 AFREZZA 4 UNIT CARTRIDGE...... 52 ALKERAN (melphalan) ...... 56 AFREZZA 8 UNIT CARTRIDGE...... 52 ALKINDI SPRINKLE...... 126 AFREZZA 12 UNIT CARTRIDGE...... 52 allopurinol (Zyloprim) ...... 26 AFREZZA 90-4 UNIT / 90-8 UNIT...... 52 ALLZITAL...... 17 AFREZZA 90-8 UNIT / 90-12 UNIT...... 52 almotriptan malate...... 17 AGRYLIN (anagrelide hcl) ...... 66 ALOCRIL...... 109 AGRYLIN (anagrelide hcl) ...... 67 ALOGLIPTIN...... 49 AIMOVIG AUTOINJECTOR...... 17 ALOGLIPTIN-METFORMIN...... 50 AIRDUO DIGIHALER...... 30 ALOGLIPTIN-PIOGLITAZONE...... 48 AIRDUO RESPICLICK...... 30 ALOMIDE...... 109 AJOVY AUTOINJECTOR...... 17 ALORA...... 125 AJOVY SYRINGE...... 17 alosetron hcl (Lotronex) ...... 119 AKLIEF...... 161 ALPHAGAN P 0.1% DROPS...... 109 AKTEN...... 108 ALPHAGAN P 0.15% EYE DROPS (brimonidine tartrate) ...... 109 AKTIPAK...... 41 alprazolam...... 137 AKYNZEO...... 115 alprazolam (Xanax) ...... 137 ALA-SCALP (scalacort) ...... 157 alprazolam (Xanax Xr) ...... 137 albendazole (Albenza) ...... 54 ALREX...... 107 ALBENZA (albendazole) ...... 54 ALTABAX...... 157 albuterol 2.5 mg/0.5 ml sol...... 29 ALTACE (ramipril) ...... 85 albuterol 5 mg/ml solution...... 29 ALTAFLUOR BENOX (flurox) ...... 108 albuterol 100 mg/20 ml soln...... 29 ALTOPREV 20 MG TABLET...... 90 albuterol sul 0.63 mg/3 ml sol...... 29 ALTOPREV 40 MG TABLET...... 90 albuterol sul 1.25 mg/3 ml sol...... 29 ALTOPREV 60 MG TABLET...... 90 albuterol sul 2.5 mg/3 ml soln...... 29 ALTRENO...... 161 albuterol sulf 2 mg/5 ml syrup...... 29 ALUNBRIG...... 59 albuterol sulfate 2 mg tab...... 29 ALVESCO...... 31 albuterol sulfate 4 mg tab...... 29 amantadine hcl...... 63 albuterol sulfate er 4 mg tab...... 29 AMARYL (glimepiride) ...... 49 albuterol sulfate er 8 mg tab...... 29 AMBIEN CR 6.25 MG TABLET (zolpidem tartrate er) ...... 150 ALBUTEROL SULFATE HFA...... 29 AMBIEN CR 12.5 MG TABLET (zolpidem tartrate er) ...... 150 albuterol sulfate (Ventolin Hfa) ...... 29 AMBIEN (zolpidem tartrate) ...... 150 ALCAINE (proparacaine hcl) ...... 108 ambrisentan (Letairis) ...... 82 alclometasone dipropionate...... 157 amcinonide...... 157 ALDACTAZIDE...... 106 AMERGE (naratriptan hcl) ...... 17 ALDACTAZIDE (spironolactone-hctz) ...... 106 AMICAR (aminocaproic acid) ...... 77 ALDACTONE (spironolactone) ...... 105 amiloride hcl...... 105

175 amiloride/hydrochlorothiazide...... 106 ANDROGEL 1% (50 MG/5 G) PKT (testosterone) ...... 123 aminocaproic acid (Amicar) ...... 78 ANDROGEL 1.62% (1.25G) GEL PCKT (testosterone) ...... 123 amiodarone hcl...... 79 ANDROGEL 1.62% (2.5G) GEL PCKT (testosterone) ...... 123 AMITIZA...... 119 ANDROGEL 1.62% GEL PUMP (testosterone) ...... 123 amitriptyline/chlordiazepoxide...... 142 ANDROID (methyltestosterone) ...... 123 amitriptyline hcl...... 142 ANGELIQ...... 126 amlodipine-atorvast 2.5-10 mg...... 89 ANNOVERA...... 100 amlodipine-atorvast 2.5-20 mg...... 89 ANORO ELLIPTA...... 30 amlodipine-atorvast 2.5-40 mg...... 89 ANTABUSE (disulfiram) ...... 166 amlodipine-atorvast 5-10 mg (Caduet) ...... 89 ANTARA...... 92 amlodipine-atorvast 5-20 mg (Caduet) ...... 89 anthralin...... 153 amlodipine-atorvast 5-40 mg (Caduet) ...... 89 ANTIARTHRITICS (Pain Relief And Inflammatory Disease)...... 25 amlodipine-atorvast 5-80 mg (Caduet) ...... 89 ANTIBIOTICS (Infections) ...... 33 amlodipine-atorvast 10-10 mg (Caduet) ...... 89 ANTICOAG SODIUM CITRATE 4% SOL...... 42 amlodipine-atorvast 10-20 mg (Caduet) ...... 89 ANTICOAG SODIUM CITRATE 4% SYR...... 42 amlodipine-atorvast 10-40 mg (Caduet) ...... 89 ANTIFIBRINOLYTIC AGENTS...... 77 amlodipine-atorvast 10-80 mg (Caduet) ...... 89 ANTIFUNGALS (Feminine Products) ...... 44 amlodipine besylate/benazepril...... 82 ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE- amlodipine besylate/benazepril (Lotrel) ...... 83 SULFONYLUREA...... 50 amlodipine besylate (Norvasc) ...... 79 ANTIINFECTIVES/MISCELLANEOUS (Feminine Products) ...... 53 amlodipine besylate/valsartan (Exforge) ...... 85 ANUSOL-HC 2.5% CREAM (proctozone-hc) ...... 157 amlodipine-olmesartan 5-20 mg (Azor) ...... 85 ANUSOL-HC 25 MG SUPPOSITORY amlodipine-olmesartan 5-40 mg (Azor) ...... 85 (hydrocortisone acetate) ...... 122 amlodipine-olmesartan 10-20 mg (Azor) ...... 85 ANZEMET...... 115 amlodipine-olmesartan 10-40 mg (Azor) ...... 85 APADAZ...... 20 amlodipine/valsartan/hcthiazid (Exforge Hct) ...... 84 APIDRA...... 52 AMNESTEEM...... 152 APIDRA SOLOSTAR...... 52 amoxapine...... 142 APLENZIN ER 174 MG TABLET...... 138 amoxicillin...... 38, 53 APLENZIN ER 348 MG TABLET...... 138 amoxicillin/potassium clav...... 38 APLENZIN ER 522 MG TABLET...... 138 amoxicillin/potassium clav (Augmentin) ...... 38 APOKYN...... 63 amoxicillin/potassium clav (Augmentin Xr) ...... 38 apraclonidine hcl (Iopidine) ...... 109 AMPHETAMINE...... 73 aprepitant 40 mg capsule...... 116 amphetamine sulfate (Evekeo) ...... 73 aprepitant 80 mg capsule (Emend) ...... 116 ampicillin trihydrate...... 38 aprepitant 125-80-80 mg pack (Emend) ...... 115 AMPYRA (dalfampridine er) ...... 95 aprepitant 125 mg capsule...... 115 AMRIX ER 15 MG CAPSULE (cyclobenzaprine hcl er) ...... 135 APRISO (mesalamine er) ...... 118 AMRIX ER 30 MG CAPSULE (cyclobenzaprine hcl er) ...... 135 APTENSIO XR (methylphenidate er) ...... 144 AMZEEQ...... 41 APTIOM 200 MG TABLET...... 95 ANADROL-50...... 123 APTIOM 400 MG TABLET...... 95 ANAFRANIL (clomipramine hcl) ...... 142 APTIOM 600 MG TABLET...... 96 anagrelide hcl...... 66 APTIOM 800 MG TABLET...... 96 anagrelide hcl (Agrylin) ...... 66 APTIVUS...... 66 ANA-LEX...... 122 AQUA GLYCOLIC HC...... 157 ANALPRAM HC...... 122, 160 ARAKODA...... 54 ANALPRAM HC (hydrocortisone-pramoxine) ...... 122 ARANESP...... 99 ANAPROX DS (naproxen sodium ds) ...... 26 ARAVA (leflunomide) ...... 25 anastrozole (Arimidex) ...... 57 ARAZLO...... 162 ANCOBON (flucytosine) ...... 45 ARCALYST...... 169 ANDRODERM...... 123 ARCAPTA NEOHALER...... 30 ANDROGEL 1% (25 MG/2.5 G) PKT (testosterone) ...... 123 ARICEPT (donepezil hcl) ...... 72

176 ARIDOL...... 103 atovaquone (Mepron) ...... 54 ARIKAYCE...... 34 atovaquone/proguanil hcl (Malarone) ...... 54 ARIMIDEX (anastrozole) ...... 57 ATRALIN (tretinoin) ...... 161 aripiprazole...... 148 ATRIPLA (efavirenz-emtric-tenofov disop) ...... 69 aripiprazole 1 mg/ml solution...... 148 atropine sulfate...... 110 aripiprazole 2 mg tablet (Abilify) ...... 148 ATROPINE SULFATE-0.9% NACL...... 110 aripiprazole 5 mg tablet (Abilify) ...... 148 atropine sulfate (Isopto Atropine) ...... 110 aripiprazole 10 mg tablet (Abilify) ...... 148 ATROVENT HFA...... 29 aripiprazole 15 mg tablet (Abilify) ...... 148 AUBAGIO...... 94 aripiprazole 20 mg tablet (Abilify) ...... 148 AUGMENTIN 125-31.25 MG/5 ML...... 38 aripiprazole 30 mg tablet (Abilify) ...... 148 AUGMENTIN 250-62.5 MG/5 ML ARIXTRA (fondaparinux sodium) ...... 43 (amoxicillin-clavulanate potass) ...... 38 armodafinil (Nuvigil) ...... 149 AUGMENTIN XR (amoxicillin-clavulanate pot er) ...... 38 ARMONAIR DIGIHALER...... 31 AURYXIA...... 112 ARMOUR THYROID...... 163 AUSTEDO...... 94 ARNUITY ELLIPTA...... 31 AUVI-Q...... 72 AROMASIN (exemestane) ...... 57 AVALIDE (irbesartan-hydrochlorothiazide) ...... 84 ARTHROTEC 50 (diclofenac sodium-misoprostol) ...... 26 AVANDIA...... 51 ARTHROTEC 75 (diclofenac sodium-misoprostol) ...... 26 AVAPRO (irbesartan) ...... 86 ARTISS...... 156 AVAR 9.5-5% CLEANSING PADS...... 42 ARYMO ER...... 21 avar cleanser (Rosanil) ...... 42 ASACOL HD (mesalamine) ...... 118 AVAR-E...... 42 asenapine maleate (Saphris) ...... 146 AVAR-E GREEN...... 42 ASMANEX...... 31 AVAR LS...... 42 ASMANEX HFA...... 31 AVC...... 53 aspirin/dipyridamole...... 65 AVELOX (moxifloxacin hcl) ...... 38 ASPIRIN-OMEPRAZOLE...... 65 avita 0.025% cream (Retin-a) ...... 161 ASSURE ID INSULIN SAFETY...... 133 AVITA 0.025% GEL...... 161 ASTAGRAF XL...... 131 AVITENE...... 78 ASTRINGYN...... 78 AVODART (dutasteride) ...... 170 ATABEX EC...... 136 AVONEX...... 94 ATACAND (candesartan cilexetil) ...... 86 AVONEX PEN...... 94 ATACAND HCT (candesartan-hydrochlorothiazid) ...... 84 AVSOLA...... 55 atazanavir sulfate (Reyataz) ...... 68 AYGESTIN (norethindrone acetate) ...... 129 ATELVIA (risedronate sodium dr) ...... 169 AYVAKIT...... 59 atenolol/chlorthalidone (Tenoretic 50) ...... 88 AZASAN...... 131 atenolol/chlorthalidone (Tenoretic 100) ...... 88 AZASITE...... 33 atenolol (Tenormin) ...... 87 azathioprine (Imuran) ...... 131 ATIVAN (lorazepam) ...... 137 azelaic acid (Finacea) ...... 156 atomoxetine hcl 10 mg capsule (Strattera) ...... 146 azelastine 0.1% (137 mcg) spry...... 106 atomoxetine hcl 18 mg capsule (Strattera) ...... 146 azelastine 0.15% nasal spray...... 106 atomoxetine hcl 25 mg capsule (Strattera) ...... 146 azelastine/fluticasone (Dymista) ...... 106 atomoxetine hcl 40 mg capsule (Strattera) ...... 146 azelastine hcl 0.05% drops...... 48 atomoxetine hcl 60 mg capsule (Strattera) ...... 146 AZELEX...... 152 atomoxetine hcl 80 mg capsule (Strattera) ...... 146 AZILECT 0.5 MG TABLET (rasagiline mesylate) ...... 63 atomoxetine hcl 100 mg capsule (Strattera) ...... 146 AZILECT 1 MG TABLET (rasagiline mesylate) ...... 63 ATOPICLAIR...... 154 azithromycin 1 gm pwd packet (Zithromax) ...... 37 atorvastatin 10 mg tablet (Lipitor) ...... 90 azithromycin 100 mg/5 ml susp (Zithromax) ...... 37 atorvastatin 20 mg tablet (Lipitor) ...... 90 azithromycin 200 mg/5 ml susp (Zithromax) ...... 37 atorvastatin 40 mg tablet (Lipitor) ...... 90 azithromycin 200 mg/5 ml susp (Zithromax) ...... 37 atorvastatin 80 mg tablet (Lipitor) ...... 90 azithromycin 250 mg tablet (Zithromax) ...... 37

177 azithromycin 500 mg tablet (Zithromax Tri-pak) ...... 37 hydrochlorothiazide) ...... 84 azithromycin 600 mg tablet...... 37 BENICAR HCT 40-25 MG TABLET (olmesartan- AZOPT (brinzolamide) ...... 109 hydrochlorothiazide) ...... 84 AZOR 5-20 MG TABLET (amlodipine-olmesartan) ...... 85 BENLYSTA...... 169 AZOR 5-40 MG TABLET (amlodipine-olmesartan) ...... 85 benoxinate hcl/fluorescein sod (Altafluor Benox)...... 108 AZOR 10-20 MG TABLET (amlodipine-olmesartan) ...... 85 BENSAL HP...... 155 AZOR 10-40 MG TABLET (amlodipine-olmesartan) ...... 85 BENZACLIN (clindamycin-benzoyl peroxide) ...... 152 AZULFIDINE (sulfasalazine) ...... 118 BENZAMYCIN (erythromycin-benzoyl peroxide) ...... 41 AZULFIDINE (sulfasalazine dr) ...... 118 BENZEFOAM...... 155 BENZEPRO...... 155 B BENZHYDROCODONE-ACETAMINOPHEN...... 20 BACIGUENT (bacitracin) ...... 33 BENZNIDAZOLE...... 54 bacitracin (Baciguent) ...... 33 benzonatate 100 mg capsule (Tessalon Perle) ...... 102 bacitracin/polymyxin b sulfate...... 33 benzonatate 150 mg capsule...... 102 baclofen...... 135 benzonatate 200 mg capsule...... 102 BACTRIM DS (sulfamethoxazole-trimethoprim) ...... 34 benzonatate perle 100 mg cap (Tessalon Perle) ...... 103 BACTRIM (sulfamethoxazole-trimethoprim) ...... 34 benzoyl peroxide...... 155 BACTROBAN NASAL...... 32 benzoyl peroxide (Enzoclear) ...... 155 BAFIERTAM...... 94 benzoyl peroxide (Pacnex) ...... 155 BALCOLTRA...... 100 benzphetamine hcl...... 62 balsalazide disodium (Colazal) ...... 118 benzphetamine hcl (Regimex) ...... 62 BALVERSA...... 59 benztropine mesylate...... 63 BANZEL 40 MG/ML SUSPENSION (rufinamide) ...... 96 BEPREVE...... 48 BANZEL 200 MG TABLET...... 96 BERINERT...... 164 BANZEL 400 MG TABLET...... 96 BESIVANCE...... 33 BAQSIMI...... 112 BETADINE...... 107 BARACLUDE 0.05 MG/ML SOLUTION...... 70 betamethasone dipropionate...... 157 BARACLUDE 0.5 MG TABLET (entecavir) ...... 71 betamethasone/propylene glyc...... 157 BARACLUDE 1 MG TABLET (entecavir) ...... 71 betamethasone/propylene glyc (Diprolene) ...... 157 BASAGLAR KWIKPEN U-100...... 52 betamethasone valerate...... 157 BAXDELA...... 38 betamethasone valerate (Luxiq) ...... 157 BECONASE AQ...... 106 BETAPACE AF (sotalol af) ...... 87 BELBUCA 75 MCG FILM...... 21 BETAPACE (sotalol) ...... 87 BELBUCA 150 MCG FILM...... 21 BETAPACE (sotalol af) ...... 87 BELBUCA 300 MCG FILM...... 21 BETASERON...... 94 BELBUCA 450 MCG FILM...... 21 betaxolol hcl...... 87, 109 BELBUCA 600 MCG FILM...... 21 bethanechol chloride...... 74 BELBUCA 750 MCG FILM...... 21 bethanechol chloride (Urecholine) ...... 74 BELBUCA 900 MCG FILM...... 21 BETHKIS (tobramycin) ...... 34 BELSOMRA...... 150 BETIMOL...... 109 BELVIQ...... 62 BETOPTIC S...... 109 BELVIQ XR...... 62 BEVESPI AEROSPHERE...... 30 benazepril hcl...... 85 BEVYXXA...... 43 benazepril hcl (Lotensin) ...... 85 bexarotene (Targretin) ...... 56 benazepril/hydrochlorothiazide...... 83 BEXSERO...... 75 benazepril/hydrochlorothiazide (Lotensin Hct) ...... 83 BEYAZ (rajani) ...... 100 BENICAR 5 MG TABLET (olmesartan medoxomil) ...... 86 bicalutamide (Casodex) ...... 56 BENICAR 20 MG TABLET (olmesartan medoxomil) ...... 86 BIDIL...... 89 BENICAR 40 MG TABLET (olmesartan medoxomil) ...... 86 BIJUVA...... 124 BENICAR HCT 20-12.5 MG TABLET (olmesartan- hydrochlorothiazide) ...... 84 BIKTARVY...... 69 BENICAR HCT 40-12.5 MG TABLET (olmesartan- BILTRICIDE (praziquantel) ...... 54

178 bimatoprost...... 109 buprenorphine hcl...... 170 BINOSTO...... 169 buprenorphine hcl/naloxone hcl...... 170 bisac/nacl/nahco3/kcl/peg 3350...... 119 buprenorphine hcl/naloxone hcl (Suboxone) ...... 170 bisoprolol fumarate...... 87 bupropion hcl 75 mg tablet...... 138 bisoprolol/hydrochlorothiazide (Ziac) ...... 88 bupropion hcl 100 mg tablet...... 138 BLEPH-10 (sulfacetamide sodium) ...... 32 bupropion hcl sr 100 mg tablet (Wellbutrin Sr) ...... 138 BLEPHAMIDE...... 33 bupropion hcl sr 150 mg tablet...... 162 BLEPHAMIDE S.O.P...... 33 bupropion hcl sr 150 mg tablet (Wellbutrin Sr) ...... 138 BLUNT NEEDLE...... 133 bupropion hcl sr 200 mg tablet (Wellbutrin Sr) ...... 138 BONIVA (ibandronate sodium) ...... 169 bupropion hcl xl 150 mg tablet (Wellbutrin Xl) ...... 138 BONJESTA...... 116 bupropion hcl xl 300 mg tablet (Wellbutrin Xl) ...... 138 BOOSTRIX TDAP...... 77 BUPROPION HCL XL 450 MG TABLET...... 138 bosentan (Tracleer) ...... 82 buspirone hcl...... 137 BOSULIF...... 59 butalb/acetaminophen/caffeine(Esgic) ...... 17 BRAFTOVI...... 57 butalb/acetaminophen/caffeine(Fioricet) ...... 17 BREATHERITE...... 134 butalb/acetaminophen/caffeine (Vanatol S) ...... 17 BREATHERITE SPACER-ADULT MASK...... 134 butalb-aspirin-caffe 50-325-40...... 17 BREATHERITE SPACER-INFANT MASK...... 134 butalbit/acetamin/caff/codeine...... 23 BREATHERITE SPACER-LARGE MASK...... 134 butalbit/acetamin/caff/codeine (Fioricet With Codeine) ...... 23 BREATHERITE SPACER-LG CHLD MSK...... 134 butalbital/acetaminophen...... 17 BREATHERITE SPACER-MEDIUM MASK...... 134 butalbital-acetaminophn 25-325 (Allzital) ...... 17 BREATHERITE SPACER-NEONATE MSK...... 134 butalbital-acetaminophn 50-300...... 17 BREATHERITE SPACER-SMALL MASK...... 134 butalbital-acetaminophn 50-300 (Bupap) ...... 17 BREATHERITE SPACER-SM CHLD MSK...... 134 butalbital-acetaminophn 50-325...... 17 BREATHRITE...... 134 butalbital-asa-caffeine cap(Fiorinal) ...... 17 BREO ELLIPTA...... 30 butorphanol tartrate...... 21 BREZTRI AEROSPHERE...... 31 BUTRANS (buprenorphine) ...... 22 BRILINTA...... 65 BYDUREON...... 48 brimonidine tartrate...... 109 BYDUREON BCISE...... 48 brimonidine tartrate (Alphagan P) ...... 109 BYDUREON PEN...... 48 brinzolamide (Azopt) ...... 109 BYETTA...... 48 BRISDELLE (paroxetine mesylate) ...... 167 BYNFEZIA...... 129 BRIVIACT...... 96 BYSTOLIC 2.5 MG TABLET...... 87 BROMFED DM (brompheniramine-pseudoephed-dm) ...... 103 BYSTOLIC 5 MG TABLET...... 87 bromfenac sodium...... 107 BYSTOLIC 10 MG TABLET...... 87 bromocriptine mesylate (Parlodel) ...... 63 BYSTOLIC 20 MG TABLET...... 87 brompheniramine/pseudoephed/dm (Bromfed Dm) ...... 103 C BROMSITE...... 107 CABENUVA...... 66 BROVANA...... 30 cabergoline...... 128 BRUKINSA...... 59 CABLIVI...... 77 BRYHALI...... 157 CABOMETYX...... 59 budesonide (Entocort Ec) ...... 126 CADUET 5 MG-10 MG TABLET (amlodipine-atorvastatin) ...... 90 BUDESONIDE-FORMOTEROL FUMARATE...... 30 CADUET 5 MG-20 MG TABLET (amlodipine-atorvastatin) ...... 90 budesonide (Pulmicort) ...... 31 CADUET 5 MG-40 MG TABLET (amlodipine-atorvastatin) ...... 90 budesonide (Uceris) ...... 126 CADUET 5 MG-80 MG TABLET (amlodipine-atorvastatin) ...... 90 bumetanide...... 105 CADUET 10 MG-10 MG TABLET (amlodipine-atorvastatin) ...... 89 BUNAVAIL...... 170 CADUET 10 MG-20 MG TABLET (amlodipine-atorvastatin) ..... 89 BUPAP (butalbital-acetaminophen) ...... 17 CADUET 10 MG-40 MG TABLET (amlodipine-atorvastatin) ..... 89 BUPHENYL 500 MG TABLET (sodium phenylbutyrate) ...... 114 CADUET 10 MG-80 MG TABLET (amlodipine-atorvastatin) ..... 89 BUPHENYL POWDER (sodium phenylbutyrate) ...... 114 CAFERGOT (ergotamine-caffeine) ...... 17 buprenorphine (Butrans) ...... 21 caffeine citrate...... 94

179 CALAN SR (verapamil er) ...... 79 CARDIZEM LA 120 MG TABLET...... 79 calcipotriene 0.005% cream (Dovonex) ...... 153 CARDIZEM LA 180 MG TABLET (matzim la) ...... 79 CALCIPOTRIENE 0.005% FOAM...... 153 CARDIZEM LA 240 MG TABLET (matzim la) ...... 79 calcipotriene 0.005% ointment...... 153 CARDIZEM LA 300 MG TABLET (matzim la) ...... 79 calcipotriene 0.005% solution...... 153 CARDIZEM LA 360 MG TABLET (matzim la) ...... 80 calcipotriene/betamethasone (Taclonex) ...... 161 CARDIZEM LA 420 MG TABLET (matzim la) ...... 80 calcitonin, salmon, synthetic...... 130 CARDURA (doxazosin mesylate) ...... 84 calcitriol 0.5 mcg capsule (Rocaltrol) ...... 172 CARDURA XL...... 84 calcitriol 0.25 mcg capsule (Rocaltrol) ...... 172 carisoprodol/aspirin...... 135 calcitriol 1 mcg/ml solution (Rocaltrol) ...... 172 carisoprodol/aspirin/codeine...... 24 calcitriol 3 mcg/g ointment (Vectical) ...... 153 carisoprodol (Soma) ...... 135 calcium acetate...... 112 CARNITOR 1 GM/5 ML VIAL...... 168 CALQUENCE...... 59 CARNITOR 100 MG/ML ORAL SOLN (levocarnitine) ...... 168 CAMBIA...... 17 CARNITOR 330 MG TABLET (levocarnitine) ...... 168 CANASA (mesalamine) ...... 118 CARNITOR SF (levocarnitine sf) ...... 168 candesartan cilexetil (Atacand) ...... 86 CAROSPIR...... 105 candesartan/hydrochlorothiazid (Atacand Hct) ...... 84 carteolol hcl...... 109 capecitabine (Xeloda) ...... 57 carvedilol (Coreg) ...... 83 CAPEX SHAMPOO...... 157 carvedilol er 10 mg capsule (Coreg Cr) ...... 83 CAPITAL W-CODEINE...... 20 carvedilol er 20 mg capsule (Coreg Cr) ...... 83 CAPLYTA...... 146 carvedilol er 40 mg capsule (Coreg Cr) ...... 83 CAPRELSA...... 59 carvedilol er 80 mg capsule (Coreg Cr) ...... 83 captopril...... 85 CASODEX (bicalutamide) ...... 57 captopril-hctz 25-15 mg tablet...... 83 CATAPRES (clonidine hcl) ...... 87 captopril-hctz 25-25 mg tablet...... 83 CATAPRES-TTS 1 (clonidine) ...... 87 captopril-hctz 50-15 mg tablet...... 83 CATAPRES-TTS 2 (clonidine) ...... 87 captopril-hctz 50-25 mg tablet...... 83 CATAPRES-TTS 3 (clonidine) ...... 87 CARAC...... 61 CAVERJECT...... 165 CARAFATE (sucralfate) ...... 117 CAYA CONTOURED...... 102 CARBAGLU...... 166 CAYSTON...... 36 carbamazepine...... 96 cefaclor...... 36 carbamazepine (Carbatrol) ...... 96 cefadroxil...... 36 carbamazepine (Tegretol) ...... 96 cefdinir...... 36 carbamazepine (Tegretol Xr) ...... 96 cefditoren pivoxil...... 36 CARBATROL (carbamazepine er) ...... 96 cefditoren pivoxil (Spectracef) ...... 36 carbidopa/levodopa...... 63 cefixime (Suprax) ...... 36 carbidopa/levodopa/entacapone (Stalevo 50) ...... 63 cefpodoxime proxetil...... 36 carbidopa/levodopa/entacapone (Stalevo 75) ...... 64 cefprozil...... 36 carbidopa/levodopa/entacapone (Stalevo 100) ...... 63 ceftriaxone sodium...... 36 carbidopa/levodopa/entacapone (Stalevo 125) ...... 63 cefuroxime axetil...... 36 carbidopa/levodopa/entacapone (Stalevo 150) ...... 63 CELEBREX 50 MG CAPSULE (celecoxib) ...... 28 carbidopa/levodopa/entacapone (Stalevo 200) ...... 63 CELEBREX 100 MG CAPSULE (celecoxib) ...... 28 carbidopa/levodopa (Sinemet 10-100) ...... 63 CELEBREX 200 MG CAPSULE (celecoxib) ...... 28 carbidopa/levodopa (Sinemet 25-100) ...... 63 CELEBREX 400 MG CAPSULE (celecoxib) ...... 28 carbidopa/levodopa (Sinemet 25-250) ...... 63 celecoxib 50 mg capsule (Celebrex) ...... 28 carbidopa (Lodosyn) ...... 65 celecoxib 100 mg capsule (Celebrex) ...... 28 carbinoxamine 4 mg/5 ml liquid...... 47 celecoxib 200 mg capsule (Celebrex) ...... 28 carbinoxamine maleate 4 mg tab...... 47 celecoxib 400 mg capsule (Celebrex) ...... 28 carbinoxamine maleate 6 mg tab (Ryvent) ...... 47 CELEXA 10 MG TABLET (citalopram hbr) ...... 139 CARDIZEM CD (diltiazem 24hr er (cd)) ...... 79 CELEXA 20 MG TABLET (citalopram hbr) ...... 139 CARDIZEM (diltiazem hcl) ...... 79 CELEXA 40 MG TABLET (citalopram hbr) ...... 139

180 CELLCEPT (mycophenolate mofetil) ...... 131 cilostazol...... 65 CELONTIN...... 96 CILOXAN 0.3% EYE DROPS (ciprofloxacin hcl) ...... 33 CENTANY...... 41 CILOXAN 0.3% OINTMENT...... 33 CENTANY AT...... 41 CIMDUO...... 66 cephalexin...... 36 cimetidine...... 119 cephalexin (Keflex)...... 36 cimetidine hcl...... 119 CEQUA...... 111 CIMZIA 2X200 MG/ML SYRINGE KIT...... 55 CEQUR SIMPLICITY...... 132 CIMZIA 2X200 MG/ML (X3) START KT...... 55 CEQUR SIMPLICITY INSERTER...... 132 CIMZIA 200 MG VIAL KIT...... 55 CERDELGA...... 167 cinacalcet hcl (Sensipar) ...... 166 CERVIDIL...... 128 CINRYZE...... 164 cetirizine hcl...... 47 CIPRO 5% SUSPENSION (ciprofloxacin) ...... 38 CETROTIDE...... 128 CIPRO 10% SUSPENSION (ciprofloxacin) ...... 38 CETYLEV...... 167 CIPRO 250 MG TABLET (ciprofloxacin hcl) ...... 38 cevimeline hcl (Evoxac) ...... 74 CIPRO 500 MG TABLET (ciprofloxacin hcl) ...... 39 CHANTIX...... 162 CIPRODEX (ciprofloxacin-dexamethasone) ...... 32 CHEMET...... 167 ciprofloxacin (Cipro) ...... 39 CHENODAL...... 118 ciprofloxacin/ciprofloxa hcl...... 39 chlordiazepoxide/clidinium br (Librax) ...... 115 ciprofloxacin hcl...... 32 chlordiazepoxide hcl...... 137 ciprofloxacin hcl...... 39 chlorhexidine gluconate (Peridex) ...... 165 ciprofloxacin hcl (Ciloxan) ...... 33 chloroquine ph 250 mg tablet...... 54 ciprofloxacin hcl (Cipro) ...... 39 chloroquine ph 500 mg tablet...... 54 ciprofloxacin hcl/dexameth (Ciprodex) ...... 32 chlorpromazine hcl...... 149 CIPROFLOXACIN HCL-FLUOCINOLONE...... 32 chlorpropamide...... 50 CIPRO HC...... 32 chlorthalidone...... 106 citalopram hbr 10 mg/5 ml soln...... 139 chlorzoxazone 250 mg tablet...... 135 citalopram hbr 10 mg tablet (Celexa) ...... 139 chlorzoxazone 375 mg tablet (Lorzone) ...... 135 citalopram hbr 20 mg/10 ml sol...... 139 chlorzoxazone 500 mg tablet...... 135 citalopram hbr 20 mg tablet (Celexa) ...... 139 chlorzoxazone 750 mg tablet (Lorzone) ...... 135 citalopram hbr 40 mg tablet (Celexa) ...... 139 CHOLBAM...... 118 CITRANATAL 90 DHA...... 136 cholestyramine/aspartame...... 92 CITRANATAL ASSURE...... 136 cholestyramine/aspartame (Questran Light) ...... 92 CITRANATAL BLOOM...... 113 cholestyramine (with sugar) (Questran) ...... 91 CITRANATAL DHA...... 136 choline salicyl/mag salicylate...... 17 CITRANATAL HARMONY...... 136 CHORIONIC GONAD 6, 000 UNIT VL...... 130 CITRANATAL RX...... 136 CHORIONIC GONAD 10, 000 UNIT VL...... 130 CITRATE PHOSPHATE DEXTROSE...... 42 CHORIONIC GONAD 12, 000 UNIT VL...... 130 CLARAVIS...... 152 CHORIONIC GONAD 50, 000 UNIT VL...... 130 CLARINEX-D 12 HOUR...... 47 CIALIS 2.5 MG TABLET (tadalafil) ...... 165 CLARINEX (desloratadine) ...... 47 CIALIS 5 MG TABLET (tadalafil) ...... 165 clarithromycin...... 37 CIALIS 10 MG TABLET (tadalafil) ...... 165 clemastine fumarate...... 47 CIALIS 20 MG TABLET (tadalafil) ...... 165 CLENPIQ...... 119 CICLODAN 0.77% CREAM KIT...... 45 CLEOCIN...... 40 ciclodan 0.77% cream (Loprox) ...... 45 CLEOCIN (clindamycin phosphate) ...... 41 CICLODAN 8% KIT...... 55 CLEOCIN HCL 75 MG CAPSULE (clindamycin hcl) ...... 36 ciclodan 8% solution...... 46 CLEOCIN HCL 150 MG CAPSULE (clindamycin hcl) ...... 36 ciclopirox...... 46 CLEOCIN HCL 300 MG CAPSULE (clindamycin hcl) ...... 36 ciclopirox (Loprox) ...... 46 CLEOCIN PEDIATRIC (clindamycin (pediatric)) ...... 36 ciclopirox olamine (Loprox) ...... 46 CLEOCIN T (clindamycin phosphate) ...... 41 ciclopirox/urea/camph/men/euc (Ciclodan) ...... 55 CLEVER CHOICE HOLDING CHAMBER...... 134

181 CLIMARA (estradiol (once weekly)) ...... 125 CLOZARIL (clozapine) ...... 146 CLIMARA PRO...... 125 COARTEM...... 54 clindacin etz 1% pledget (Cleocin T) ...... 41 codeine/butalbital/asa/caffein (Fiorinal With Codeine #3) ...... 23 CLINDACIN ETZ KIT...... 41 codeine sulfate...... 22 CLINDACIN PAC...... 41 COLAZAL (balsalazide disodium) ...... 118 CLINDAGEL...... 41 COLCHICINE...... 25 clindamycin hcl (Cleocin Hcl) ...... 36 colchicine (Colcrys) ...... 25 clindamycin palmitate hcl (Cleocin Pediatric) ...... 36 COLCRYS (colchicine) ...... 25 clindamycin phos/benzoyl perox...... 152 colesevelam hcl (Welchol) ...... 92 clindamycin phos/benzoyl perox (Acanya) ...... 152 COLESTID 1 GM TABLET (colestipol hcl) ...... 92 clindamycin phos/benzoyl perox (Benzaclin) ...... 153 COLESTID FLAVORED GRANULES...... 92 clindamycin phosphate...... 41 COLESTID FLAVORED GRANULES...... 92 clindamycin phosphate (Cleocin) ...... 41 COLESTID GRANULES...... 92 clindamycin phosphate (Cleocin T) ...... 41 COLESTID GRANULES (colestipol hcl) ...... 92 clindamycin phosphate (Evoclin) ...... 41 COLESTID GRANULES PACKET (colestipol hcl) ...... 92 clindamycin/tretinoin (Ziana) ...... 153 colestipol hcl (Colestid) ...... 92 CLINDESSE...... 41 COLYTE WITH FLAVOR PACKETS (peg 3350-electrolyte) ...... 119 CLINPRO 5000...... 111 COLYTE WITH FLAVOR PACKETS (peg 3350-electrolyte) ...... 120 clobazam (Onfi)...... 95 COMBIGAN...... 109 clobetasol propionate...... 157 COMBIPATCH...... 125 clobetasol propionate (Clobex) ...... 157 COMBIVENT RESPIMAT...... 30 clobetasol propionate/emoll...... 157 COMBIVIR (lamivudine-zidovudine) ...... 66 clobetasol propionate/emoll (Olux-e) ...... 157 COMETRIQ...... 59 clobetasol propionate (Olux) ...... 157 COMPACT SPACE CHAMBER...... 134 clobetasol propionate (Temovate) ...... 157 COMPAZINE (prochlorperazine) ...... 116 CLOBEX (clobetasol propionate) ...... 157 COMPAZINE (prochlorperazine maleate) ...... 116 CLOBEX (clodan) ...... 157 COMPLERA...... 69 CLOCORTOLONE PIVALATE...... 157 COMTAN (entacapone) ...... 64 CLODAN 0.05% KIT...... 157 CONCERTA (methylphenidate er) ...... 144 clodan 0.05% shampoo (Clobex) ...... 157 CONDYLOX...... 155 CLODERM...... 157 CONJUPRI...... 80 clomiphene citrate...... 130 CONSENSI...... 79 clomipramine hcl (Anafranil) ...... 142 CONTRAVE...... 62 clonazepam...... 95 CONZIP...... 22 clonazepam (Klonopin) ...... 95 COPAXONE (glatopa) ...... 94 clonidine (Catapres-tts 1) ...... 87 COPIKTRA...... 59 clonidine (Catapres-tts 2) ...... 87 CORDRAN...... 158 clonidine (Catapres-tts 3) ...... 87 CORDRAN (flurandrenolide) ...... 158 clonidine hcl (Catapres) ...... 87 CORDRAN (nolix) ...... 158 clonidine hcl (Kapvay) ...... 144 COREG (carvedilol) ...... 83 clopidogrel bisulfate...... 65 COREG CR 10 MG CAPSULE (carvedilol er) ...... 83 clopidogrel bisulfate (Plavix) ...... 65 COREG CR 20 MG CAPSULE (carvedilol er) ...... 83 clorazepate dipotassium...... 137 COREG CR 40 MG CAPSULE (carvedilol er) ...... 84 clorazepate dipotassium (Tranxene T-tab) ...... 137 COREG CR 80 MG CAPSULE (carvedilol er) ...... 84 clotrimazole...... 45 coremino er 45 mg tablet...... 39 clotrimazole/betamethasone dip...... 45 coremino er 90 mg tablet...... 39 clozapine...... 146 coremino er 135 mg tablet...... 39 clozapine (Clozapine Odt) ...... 146 CORGARD (nadolol) ...... 87 clozapine (Clozaril) ...... 146 CORLANOR...... 81 clozapine (Fazaclo) ...... 146 CORTEF (hydrocortisone) ...... 126 CLOZAPINE ODT...... 146 CORTENEMA (hydrocortisone) ...... 123

182 CORTIFOAM...... 123 cyclosporine, modified (Neoral) ...... 131 cortisone acetate...... 126 cyclosporine (Sandimmune) ...... 131 CORTISPORIN...... 41 CYMBALTA 20 MG CAPSULE (duloxetine hcl) ...... 141 CORTISPORIN-TC...... 32 CYMBALTA 30 MG CAPSULE (duloxetine hcl) ...... 141 COSENTYX (2 SYRINGES) ...... 151 CYMBALTA 60 MG CAPSULE (duloxetine hcl) ...... 141 COSENTYX PEN...... 151 cyproheptadine hcl...... 47 COSENTYX PEN (2 PENS) ...... 151 cyproheptadine hcl (Cyproheptadine Hcl) ...... 47 COSENTYX SYRINGE...... 151 CYSTADANE...... 168 COSOPT (dorzolamide-timolol) ...... 109 CYSTADROPS...... 111 COSOPT PF (dorzolamide-timolol) ...... 109 CYSTAGON...... 170 COTELLIC...... 58 CYSTARAN...... 111 COTEMPLA XR-ODT 8.6 MG TABLET...... 144 CYSTO-CONRAY II...... 104 COTEMPLA XR-ODT 17.3 MG TABLET...... 144 CYSTOGRAFIN...... 105 COTEMPLA XR-ODT 25.9 MG TABLET...... 144 CYSTOGRAFIN-DILUTE...... 105 COZAAR (losartan potassium) ...... 86 CYTOMEL (liothyronine sodium) ...... 163 CREON...... 120 CYTOTEC (misoprostol) ...... 117 CRESEMBA...... 45 D CRESTOR 5 MG TABLET (rosuvastatin calcium) ...... 90 dalfampridine (Ampyra) ...... 95 CRESTOR 10 MG TABLET (rosuvastatin calcium) ...... 90 DALIRESP 250 MCG TABLET...... 31 CRESTOR 20 MG TABLET (rosuvastatin calcium) ...... 90 DALIRESP 500 MCG TABLET...... 31 CRESTOR 40 MG TABLET (rosuvastatin calcium) ...... 90 danazol...... 128 CRINONE 4% GEL...... 129 DANTRIUM (dantrolene sodium) ...... 135 CRINONE 8% GEL...... 130 dantrolene sodium...... 135 CRIXIVAN...... 68 dantrolene sodium (Dantrium) ...... 135 cromolyn 4% eye drops...... 109 dapsone 5% gel (Aczone) ...... 153 cromolyn 20 mg/2 ml neb soln...... 31 DAPSONE 7.5% GEL PUMP...... 153 cromolyn 100 mg/5 ml oral conc (Gastrocrom) ...... 24 dapsone 7.5% gel pump (Dapsone) ...... 153 crotamiton (Eurax) ...... 63 dapsone 25 mg tablet...... 35 CUPRIMINE (penicillamine) ...... 25 dapsone 100 mg tablet...... 35 CUROSURF...... 164 DAPTACEL DTAP...... 77 CUTIVATE 0.05% CREAM (fluticasone propionate) ...... 158 DARAPRIM (pyrimethamine) ...... 54 CUTIVATE 0.05% LOTION (fluticasone propionate) ...... 158 darifenacin er 7.5 mg tablet (Enablex) ...... 171 CUVPOSA...... 115 darifenacin er 15 mg tablet...... 171 cyanocobalamin (vitamin b-12) ...... 172 DAURISMO...... 58 cyclobenzaprine er 15 mg cap (Amrix) ...... 135 DAXBIA...... 36 cyclobenzaprine er 30 mg cap (Amrix) ...... 135 DAYPRO (oxaprozin) ...... 26 cyclobenzaprine hcl...... 135 DAYTRANA 10 MG/9 HR PATCH...... 144 cyclobenzaprine hcl (Fexmid) ...... 135 DAYTRANA 15 MG/9 HR PATCH...... 144 CYCLOGYL 0.5% EYE DROPS (cyclopentolate hcl) ...... 110 DAYTRANA 20 MG/9 HOUR PATCH...... 144 CYCLOGYL 1% EYE DROPS...... 110 DAYTRANA 30 MG/9 HOUR PATCH...... 144 CYCLOGYL 1% EYE DROPS (cyclopentolate hcl) ...... 111 DAYVIGO...... 150 CYCLOGYL 2% EYE DROPS (cyclopentolate hcl) ...... 111 DDAVP...... 124 CYCLOMYDRIL...... 111 DDAVP (desmopressin acetate) ...... 124 cyclopentolate hcl (Cyclogyl) ...... 111 deferasirox (Exjade) ...... 167 cyclophosphamide 25 mg capsule...... 56 deferasirox (Jadenu) ...... 168 CYCLOPHOSPHAMIDE 25 MG TABLET...... 56 deferasirox (Jadenu Sprinkle) ...... 168 cyclophosphamide 50 mg capsule...... 56 deferiprone (Ferriprox) ...... 168 CYCLOPHOSPHAMIDE 50 MG TABLET...... 56 DELESTROGEN...... 125 CYCLOSERINE...... 35 DELESTROGEN (estradiol valerate) ...... 125 CYCLOSET...... 49 DELSTRIGO...... 69 cyclosporine, modified...... 131 DELZICOL (mesalamine dr) ...... 118

183 demeclocycline hcl...... 39 dexamethasone 0.5 mg/5 ml elx...... 126 DEMSER (metyrosine) ...... 87 dexamethasone 0.5 mg/5 ml liq...... 126 DENAVIR...... 72 dexamethasone 0.5 mg tablet...... 126 DEPAKOTE (divalproex sodium) ...... 96 dexamethasone 0.75 mg tablet...... 126 DEPAKOTE ER (divalproex sodium er) ...... 96 dexamethasone 1.5 mg tablet...... 126 DEPAKOTE SPRINKLE (divalproex sodium) ...... 96 dexamethasone 1 mg tablet...... 126 DEPEN (penicillamine) ...... 25 dexamethasone 2 mg tablet...... 126 DEPO-ESTRADIOL...... 125 dexamethasone 4 mg tablet...... 126 DEPO-PROVERA 150 MG/ML SYRINGE dexamethasone 6 day 1.5 mg tab (Taperdex) ...... 126 (medroxyprogesterone acetate) ...... 100 dexamethasone 6 mg tablet...... 126 DEPO-PROVERA 150 MG/ML VIAL dexamethasone 10 day 1.5 mg tb...... 126 (medroxyprogesterone acetate) ...... 100 dexamethasone 13 day 1.5 mg tb...... 126 DEPO-PROVERA 400 MG/ML VIAL...... 129 dexamethasone (Dxevo) ...... 126 DEPO-SUBQ PROVERA 104...... 100 dexamethasone sodium phosphate...... 108 DEPO-TESTOSTERONE...... 123 dexamethasone (Taperdex) ...... 126 DEPO-TESTOSTERONE (testosterone cypionate) ...... 123 dexchlorpheniramine maleate (Ryclora) ...... 47 DERMA-SMOOTHE-FS (fluocinolone acetonide) ...... 158 DEXCOM G6 RECEIVER...... 132 DERMASORB HC...... 158 DEXCOM G6 SENSOR...... 132 DERMASORB TA...... 158 DEXCOM G6 TRANSMITTER...... 132 DERMATOP (prednicarbate) ...... 158 DEXEDRINE SPANSULE 5 MG dermazene cream...... 161 (dextroamphetamine sulfate er) ...... 73 DERMAZENE CREAM PACKET...... 161 DEXEDRINE SPANSULE 10 MG DERMOTIC (fluocinolone acetonide oil) ...... 107 (dextroamphetamine sulfate er) ...... 73 DESCOVY...... 66 DEXEDRINE SPANSULE 15 MG desflurane (Suprane) ...... 24 (dextroamphetamine sulfate er) ...... 73 desipramine hcl...... 142 DEXILANT DR 30 MG CAPSULE...... 121 desipramine hcl (Norpramin) ...... 142 DEXILANT DR 60 MG CAPSULE...... 121 desloratadine 2.5 mg odt...... 47 dexmethylphenidate er 5 mg cap (Focalin Xr) ...... 144 desloratadine 5 mg odt...... 47 dexmethylphenidate er 10 mg cp (Focalin Xr) ...... 144 desloratadine 5 mg tablet (Clarinex) ...... 47 dexmethylphenidate er 15 mg cp (Focalin Xr) ...... 144 desmopressin acetate (Ddavp) ...... 124 dexmethylphenidate er 20 mg cp (Focalin Xr) ...... 144 desmopressin (nonrefrigerated) (Ddavp) ...... 124 dexmethylphenidate er 25 mg cp (Focalin Xr) ...... 144 desog-e.estradiol/e.estradiol (Mircette) ...... 100 dexmethylphenidate er 30 mg cp (Focalin Xr) ...... 144 desogestrel-ethinyl estradiol...... 100 dexmethylphenidate er 35 mg cp (Focalin Xr) ...... 144 DESONATE (desonide) ...... 158 dexmethylphenidate er 40 mg cp (Focalin Xr) ...... 144 desonide...... 158 dexmethylphenidate hcl (Focalin) ...... 144 desonide (Desonate) ...... 158 dextroamp-amphet er 5 mg cap (Adderall Xr) ...... 73 desonide (Desowen) ...... 158 dextroamp-amphet er 10 mg cap (Adderall Xr) ...... 73 desonide (Tridesilon) ...... 158 dextroamp-amphet er 15 mg cap (Adderall Xr) ...... 73 DESOWEN (desonide) ...... 158 dextroamp-amphet er 20 mg cap (Adderall Xr) ...... 73 desoximetasone (Topicort) ...... 158 dextroamp-amphet er 25 mg cap (Adderall Xr) ...... 73 DESOXYN (methamphetamine hcl) ...... 73 dextroamp-amphet er 30 mg cap (Adderall Xr) ...... 73 DESVENLAFAXINE ER 50 MG TAB...... 141 dextroamphetamine/amphetamine (Adderall) ...... 73 DESVENLAFAXINE ER 100 MG TAB...... 141 dextroamphetamine er 5 mg cap (Dexedrine) ...... 73 desvenlafaxine succnt er 25 mg (Pristiq) ...... 141 dextroamphetamine er 10 mg cap (Dexedrine) ...... 73 desvenlafaxine succnt er 50 mg (Pristiq) ...... 141 dextroamphetamine er 15 mg cap (Dexedrine) ...... 73 desvenlafaxine succnt er 100mg (Pristiq) ...... 141 dextroamphetamine sulfate...... 73 DETROL LA 2 MG CAPSULE (tolterodine tartrate er) ...... 171 dextroamphetamine sulfate...... 73 DETROL LA 4 MG CAPSULE (tolterodine tartrate er) ...... 171 D.H.E.45 (dihydroergotamine mesylate) ...... 17 DETROL (tolterodine tartrate) ...... 171 DIACOMIT...... 96 dexamethasone...... 126 DIASTAT ACUDIAL (diazepam) ...... 95

184 DIASTAT (diazepam) ...... 95 DILANTIN-125 (phenytoin) ...... 96 diatrizoate meglumine, sodium (Gastrografin) ...... 105 DILATRATE-SR...... 81 diazepam 2.5 mg rectal gel sys (Diastat) ...... 95 DILAUDID 2 MG TABLET (hydromorphone hcl) ...... 22 diazepam 2 mg tablet (Valium) ...... 137 DILAUDID 4 MG TABLET (hydromorphone hcl) ...... 22 diazepam 5 mg/5 ml solution...... 137 DILAUDID 5 MG/5 ML ORAL LIQUID (hydromorphone hcl) ...... 22 diazepam 5 mg/ml oral conc...... 137 DILAUDID 8 MG TABLET (hydromorphone hcl) ...... 22 diazepam 5 mg tablet (Valium) ...... 137 diltiazem hcl...... 80 diazepam 10 mg rectal gel syst (Diastat Acudial) ...... 95 diltiazem hcl (Cardizem) ...... 80 diazepam 10 mg tablet (Valium) ...... 137 diltiazem hcl (Cardizem Cd) ...... 80 diazepam 20 mg rectal gel syst (Diastat Acudial) ...... 95 diltiazem hcl (Cardizem La) ...... 80 diazoxide (Proglycem) ...... 112 diltiazem hcl (Tiazac) ...... 80 DIBENZYLINE (phenoxybenzamine hcl) ...... 74 dimethyl fumarate (Tecfidera) ...... 94 DICLEGIS (doxylamine succ-pyridoxine hcl) ...... 116 dimethyl sulfoxide...... 167 DICLOFENAC...... 26 DIOVAN HCT (valsartan-hydrochlorothiazide) ...... 84 diclofenac 0.1% eye drops...... 108 DIOVAN (valsartan) ...... 86 diclofenac 1.5% topical soln...... 152 DIPENTUM...... 118 DICLOFENAC EPOLAMINE...... 152 diphenoxylate hcl/atropine...... 115 diclofenac potassium...... 20 diphenoxylate hcl/atropine (Lomotil) ...... 115 diclofenac sod dr 25 mg tab...... 26 DIPHTHERIA-TETANUS TOXOIDS-PED...... 77 diclofenac sod dr 50 mg tab...... 26 DIPROLENE (betamethasone diprop augmented) ...... 158 diclofenac sod dr 75 mg tab...... 26 dipyridamole...... 65 diclofenac sod ec 25 mg tab...... 26 DISALCID (salsalate) ...... 25 diclofenac sod ec 50 mg tab...... 26 disopyramide phosphate (Norpace) ...... 79 diclofenac sod ec 75 mg tab...... 26 disulfiram (Antabuse) ...... 166 diclofenac sodium...... 27 DITROPAN XL (oxybutynin chloride er) ...... 171 diclofenac sodium 1% gel (Voltaren) ...... 152 DIURIL...... 106 diclofenac sodium 3% gel...... 61 divalproex sodium (Depakote) ...... 96 diclofenac sodium/misoprostol (Arthrotec 50) ...... 26 divalproex sodium (Depakote Er) ...... 96 diclofenac sodium/misoprostol (Arthrotec 75) ...... 26 divalproex sodium (Depakote Sprinkle) ...... 96 dicloxacillin sodium...... 38 DIVIGEL...... 125 dicyclomine hcl...... 115 dofetilide 125 mcg capsule (Tikosyn) ...... 79 didanosine (Videx Ec) ...... 67 dofetilide 250 mcg capsule (Tikosyn) ...... 79 diethylpropion hcl...... 62 dofetilide 500 mcg capsule (Tikosyn) ...... 79 DIFFERIN...... 161 DOJOLVI...... 111 DIFFERIN (adapalene) ...... 161 donepezil hcl...... 72 DIFICID 40 MG/ML SUSPENSION...... 37 donepezil hcl (Aricept) ...... 72 DIFICID 200 MG TABLET...... 37 DONNATAL...... 117 diflorasone diacetate...... 158 DONNATAL (phenohytro) ...... 117 diflorasone diacetate/emoll...... 158 DOPTELET...... 100 diflorasone diacetate (Psorcon) ...... 158 DORAL...... 150 DIFLUCAN (fluconazole) ...... 45 DORYX...... 39 diflunisal...... 17 DORYX (doxycycline hyclate) ...... 39 DIFMETIOXRIME...... 46 DORYX MPC...... 39 digoxin...... 81 dorzolamide hcl/timolol maleat (Cosopt) ...... 109 digoxin (Lanoxin) ...... 81 dorzolamide hcl (Trusopt) ...... 109 dihydroergotamine 1 mg/ml amp (D.h.e.45) ...... 18 dorzolamide/timolol/pf (Cosopt Pf) ...... 109 dihydroergotamine 4 mg/ml spry (Migranal) ...... 18 DOVATO...... 66 DILANTIN 30 MG CAPSULE...... 96 DOVONEX (calcipotriene) ...... 153 DILANTIN 50 MG INFATAB (phenytoin) ...... 96 doxazosin mesylate (Cardura) ...... 84 DILANTIN 100 MG CAPSULE doxepin 5% cream (Zonalon) ...... 153 (phenytoin sodium extended) ...... 96 doxepin 10 mg capsule...... 143

185 doxepin 10 mg/ml oral conc...... 143 DUOPA...... 64 doxepin 25 mg capsule...... 143 DUPIXENT PEN...... 130 doxepin 50 mg capsule...... 143 DUPIXENT SYRINGE...... 130 doxepin 75 mg capsule...... 143 DURAGESIC (fentanyl) ...... 22 doxepin 100 mg capsule...... 143 DUREZOL...... 108 doxepin 150 mg capsule...... 143 dutasteride (Avodart) ...... 170 doxepin hcl 3 mg tablet (Silenor) ...... 150 dutasteride/tamsulosin hcl (Jalyn) ...... 170 doxepin hcl 6 mg tablet (Silenor) ...... 150 DUTOPROL...... 88 doxepin hcl (Zonalon) ...... 153 DXEVO...... 126 doxercalciferol...... 166 DYANAVEL XR...... 73 doxycycline 50 mg tablet (Targadox) ...... 39 DYAZIDE (triamterene-hydrochlorothiazid) ...... 106 doxycycline hyc dr 50 mg tab (Doryx) ...... 39 DYMISTA (azelastine-fluticasone) ...... 106 doxycycline hyc dr 75 mg tab...... 39 DYRENIUM (triamterene) ...... 106 DOXYCYCLINE HYC DR 80 MG TAB...... 39 E doxycycline hyc dr 100 mg tab...... 39 EASIVENT...... 134 doxycycline hyc dr 150 mg tab...... 39 ECLIPSE NEEDLE...... 133 doxycycline hyc dr 200 mg tab (Doryx) ...... 39 EC-NAPROSYN (naproxen) ...... 27 doxycycline hyclate...... 39 econazole nitrate...... 46 doxycycline hyclate 20 mg tab...... 165 ECOZA...... 46 doxycycline hyclate 50 mg cap...... 40 EDARBI 40 MG TABLET...... 86 doxycycline hyclate 75 mg tab (Acticlate) ...... 40 EDARBI 80 MG TABLET...... 86 doxycycline hyclate 100 mg cap (Vibramycin) ...... 39 EDARBYCLOR...... 84 doxycycline hyclate 100 mg tab...... 39 EDECRIN (ethacrynic acid) ...... 105 doxycycline hyclate 150 mg tab (Acticlate) ...... 39 EDEX...... 165 doxycycline hyclate (Vibramycin) ...... 39 EDLUAR 5 MG SL TABLET...... 150 DOXYCYCLINE IR-DR...... 40 EDLUAR 10 MG SL TABLET...... 150 doxycycline monohydrate...... 40 EDURANT...... 67 doxycycline monohydrate (Monodox) ...... 40 E.E.S. 200 (erythromycin ethylsuccinate) ...... 37 doxycycline monohydrate (Vibramycin) ...... 40 efavirenz/emtricit/tenofovr df (Atripla) ...... 69 doxylamine succinate/vit b6 (Diclegis) ...... 116 efavirenz/lamivu/tenofov disop (Symfi)...... 69 DRISDOL (vitamin d2) ...... 172 efavirenz/lamivu/tenofov disop (Symfi Lo)...... 69 DRIZALMA SPRINKLE DR 20 MG CAP...... 141 efavirenz (Sustiva) ...... 67 DRIZALMA SPRINKLE DR 30 MG CAP...... 141 EFFER-K 10 MEQ TABLET EFF...... 113 DRIZALMA SPRINKLE DR 40 MG CAP...... 141 EFFER-K 20 MEQ TABLET EFF...... 113 DRIZALMA SPRINKLE DR 60 MG CAP...... 141 effer-k 25 meq tablet eff...... 113 dronabinol (Marinol) ...... 115 EFFEXOR XR 37.5 MG CAPSULE (venlafaxine hcl er) ...... 141 drospir/eth estra/levomefol ca (Beyaz) ...... 101 EFFEXOR XR 75 MG CAPSULE (venlafaxine hcl er) ...... 141 drospir/eth estra/levomefol ca (Safyral) ...... 101 EFFEXOR XR 150 MG CAPSULE (venlafaxine hcl er) ...... 141 DROXIA...... 78 EFFIENT (prasugrel hcl) ...... 65 droxidopa (Northera) ...... 74 EFUDEX (fluorouracil) ...... 61 DRYSOL...... 153 EGRIFTA...... 127 DUAKLIR PRESSAIR...... 30 EGRIFTA SV...... 127 DUAVEE...... 126 ELESTRIN...... 125 DUETACT (pioglitazone-glimepiride) ...... 50 eletriptan hbr 20 mg tablet (Relpax) ...... 18 DUEXIS...... 26 eletriptan hbr 40 mg tablet (Relpax) ...... 18 DULERA...... 30 ELIDEL (pimecrolimus) ...... 131 duloxetine hcl dr 20 mg cap (Cymbalta) ...... 141 ELIMITE (permethrin) ...... 63 duloxetine hcl dr 30 mg cap (Cymbalta) ...... 141 ELIQUIS...... 43 duloxetine hcl dr 40 mg cap...... 141 ELIXOPHYLLIN...... 32 duloxetine hcl dr 60 mg cap (Cymbalta) ...... 141 ELLA...... 101 DUOBRII...... 153 ELMIRON...... 24

186 EMCYT...... 61 ENTOCORT EC (budesonide ec) ...... 126 EMEND 80 MG CAPSULE (aprepitant) ...... 116 ENTRESTO...... 84 EMEND 125 MG POWDER PACKET...... 116 ENTYVIO...... 119 EMEND 150 MG VIAL (fosaprepitant dimeglumine) ...... 116 ENVARSUS XR...... 131 EMEND TRIPACK (aprepitant) ...... 116 ENZOCLEAR...... 155 EMFLAZA...... 126 EPANED...... 85 EMGALITY PEN...... 18 EPCLUSA 200 MG-50 MG TABLET...... 70 EMGALITY SYRINGE...... 18, 95 EPCLUSA 400 MG-100 MG TABLET...... 70 emollient combination no.35 (Mimyx) ...... 154 EPIDIOLEX...... 95 emollient combination no.60 (Restizan) ...... 154 EPIDUO FORTE...... 153 EMSAM 6 MG/24 HOURS PATCH...... 138 EPIFOAM...... 160 EMSAM 9 MG/24 HOURS PATCH...... 138 epinastine hcl...... 48 EMSAM 12 MG/24 HOURS PATCH...... 138 EPINEPHRINE...... 72 emtricitabine (Emtriva) ...... 67 epinephrine (Epipen 2-pak) ...... 72 emtricitabine-tenofv 100-150mg (Truvada) ...... 66 epinephrine (Epipen Jr 2-pak) ...... 72 emtricitabine-tenofv 133-200mg (Truvada) ...... 66 epinephrine hcl (Adrenalin Chloride) ...... 107 emtricitabine-tenofv 167-250mg (Truvada) ...... 66 EPIPEN 2-PAK (epinephrine) ...... 72 emtricitabine-tenofv 200-300mg (Truvada) ...... 66 EPIPEN (epinephrine) ...... 72 EMTRIVA 10 MG/ML SOLUTION...... 67 EPIPEN JR 2-PAK (epinephrine) ...... 72 EMTRIVA 200 MG CAPSULE (emtricitabine) ...... 67 EPIPEN JR (epinephrine) ...... 72 EMVERM...... 54 EPIVIR HBV 25 MG/5 ML SOLN...... 71 ENABLEX (darifenacin er) ...... 171 EPIVIR HBV 100 MG TABLET (lamivudine hbv) ...... 71 enalapril/hydrochlorothiazide...... 83 EPIVIR (lamivudine) ...... 67 enalapril/hydrochlorothiazide (Vaseretic) ...... 83 eplerenone (Inspra) ...... 106 enalapril maleate (Vasotec) ...... 85 EPOGEN...... 99 ENBREL 25 MG/0.5 ML SYRINGE...... 55 eprosartan mesylate...... 86 ENBREL 25 MG/0.5 ML VIAL...... 55 EPZICOM (abacavir-lamivudine) ...... 66 ENBREL 25 MG KIT...... 55 EQUETRO...... 138 ENBREL 50 MG/ML SYRINGE...... 55 ergocalciferol (vitamin d2) (Drisdol) ...... 172 ENBREL MINI...... 55 ergoloid mesylates...... 89 ENBREL SURECLICK...... 55 ERGOMAR...... 18 ENDO-AVITENE...... 78 ergotamine tartrate/caffeine...... 18 ENDOMETRIN...... 130 ergotamine tartrate/caffeine (Cafergot) ...... 18 ENGERIX-B ADULT...... 77 ERIVEDGE...... 58 ENGERIX-B PEDIATRIC-ADOLESCENT...... 77 ERLEADA...... 57 ENHERTU...... 61 erlotinib hcl (Tarceva) ...... 59 ENLITE SERTER...... 132 ERTACZO...... 46 enoxaparin 30 mg/0.3 ml syr (Lovenox) ...... 43 ERYPED 200 (erythromycin ethylsuccinate) ...... 37 enoxaparin 40 mg/0.4 ml syr (Lovenox) ...... 43 ERYPED 400 (erythromycin ethylsuccinate) ...... 37 enoxaparin 60 mg/0.6 ml syr (Lovenox) ...... 43 ery-tab dr 250 mg tablet...... 37 enoxaparin 80 mg/0.8 ml syr (Lovenox) ...... 43 ery-tab dr 333 mg tablet...... 37 enoxaparin 100 mg/ml syringe (Lovenox) ...... 43 ERY-TAB DR 500 MG TABLET (erythromycin) ...... 37 enoxaparin 120 mg/0.8 ml syr (Lovenox) ...... 43 erythromycin base...... 33, 37 enoxaparin 150 mg/ml syringe (Lovenox) ...... 43 erythromycin base (Ery-tab) ...... 37 enoxaparin 300 mg/3 ml vial (Lovenox) ...... 43 erythromycin base in ethanol...... 41 ENSPRYNG...... 131 erythromycin/benzoyl peroxide (Benzamycin) ...... 41 ENSTILAR...... 161 erythromycin ethylsuccinate...... 37 entacapone (Comtan) ...... 64 erythromycin ethylsuccinate (Eryped 200) ...... 37 entecavir 0.5 mg tablet (Baraclude) ...... 71 erythromycin ethylsuccinate (Eryped 400) ...... 37 entecavir 1 mg tablet (Baraclude) ...... 71 erythromycin stearate...... 37 ENTERO VU...... 104 ESBRIET...... 167

187 escitalopram 5 mg tablet (Lexapro) ...... 139 everolimus 5 mg tablet (Afinitor)...... 58 escitalopram 10 mg tablet (Lexapro) ...... 139 everolimus 7.5 mg tablet (Afinitor)...... 58 escitalopram 20 mg tablet (Lexapro) ...... 139 EVICEL...... 78 escitalopram oxalate 5 mg/5 ml...... 139 EVISTA (raloxifene hcl) ...... 169 ESGIC 50-325-40 MG TABLET EVOCLIN (clindamycin phosphate) ...... 41 (butalbital-acetaminophen-caffe) ...... 17 EVOTAZ...... 68 ESGIC CAPSULE (zebutal)...... 17 EVOXAC (cevimeline hcl) ...... 74 esomeprazole dr 10 mg packet (Nexium) ...... 121 EVRYSDI...... 167 esomeprazole dr 20 mg packet (Nexium) ...... 121 EVZIO...... 44 esomeprazole dr 40 mg packet (Nexium) ...... 121 EXELDERM...... 46 esomeprazole mag dr 20 mg cap (Nexium) ...... 121 EXELON (rivastigmine) ...... 72 esomeprazole mag dr 40 mg cap (Nexium) ...... 121 exemestane (Aromasin) ...... 57 ESOMEPRAZOLE STRONTIUM...... 121 EXFORGE (amlodipine-valsartan) ...... 85 estazolam...... 150 EXFORGE HCT (amlodipine-valsartan-hctz) ...... 84 ESTRACE (estradiol) ...... 125, 129 EXJADE (deferasirox) ...... 168 estradiol 0.01% cream (Estrace) ...... 129 EXODERM...... 46 estradiol 0.5 mg tablet (Estrace) ...... 125 EXTAVIA...... 94 estradiol 1 mg tablet (Estrace) ...... 125 EXTINA (ketodan) ...... 46 estradiol 2 mg tablet (Estrace) ...... 125 EYSUVIS...... 108 estradiol 10 mcg vaginal insrt (Vagifem) ...... 129 EZALLOR SPRINKLE 5 MG CAPSULE...... 91 estradiol (Climara) ...... 125 EZALLOR SPRINKLE 10 MG CAPSULE...... 90 estradiol/norethindrone acet (Activella) ...... 125 EZALLOR SPRINKLE 20 MG CAPSULE...... 90 estradiol (Vagifem) ...... 129 EZALLOR SPRINKLE 40 MG CAPSULE...... 91 estradiol valerate (Delestrogen) ...... 125 E-Z DISK...... 104 estradiol (Vivelle-dot) ...... 125 ezetimibe/simvastatin (Vytorin) ...... 89 ESTRING...... 129 ezetimibe (Zetia) ...... 92 ESTROGEL...... 125 EZ FLU 2018-2019 (FLUCELVAX) ...... 75 estrogen, ester/me-testosterone...... 124 E-Z-HD...... 104 ESTROSTEP FE (tri-legest fe) ...... 101 E-Z-PAQUE...... 104 eszopiclone (Lunesta) ...... 150 E-Z-PASTE...... 104 ethacrynic acid (Edecrin) ...... 105 E-Z SPACER...... 134 ethambutol hcl...... 35 F ethambutol hcl (Myambutol) ...... 35 FABIOR...... 162 ethinyl estradiol/drospirenone (Yasmin 28) ...... 101 FACTIVE...... 39 ethinyl estradiol/drospirenone (Yaz) ...... 101 famciclovir...... 69 ethosuximide (Zarontin) ...... 96 famotidine...... 119 ethynodiol d-ethinyl estradiol...... 101 famotidine (Pepcid) ...... 119 etodolac...... 27 FANAPT 1 MG TABLET...... 147 etodolac (Lodine) ...... 27 FANAPT 2 MG TABLET...... 147 etonogestrel/ethinyl estradiol (Nuvaring) ...... 100 FANAPT 4 MG TABLET...... 147 etoposide...... 61 FANAPT 6 MG TABLET...... 147 EUCRISA...... 156 FANAPT 8 MG TABLET...... 147 EURAX 10% CREAM...... 63 FANAPT 10 MG TABLET...... 147 EURAX 10% LOTION...... 63 FANAPT 12 MG TABLET...... 147 EVAMIST...... 125 FANAPT TITRATION PACK...... 147 EVEKEO (amphetamine sulfate) ...... 73 FARESTON (toremifene citrate) ...... 61 EVEKEO ODT...... 73 FARXIGA...... 49 everolimus 0.5 mg tablet (Zortress) ...... 131 FARYDAK...... 56 everolimus 0.25 mg tablet (Zortress) ...... 131 FASENRA PEN...... 31 everolimus 0.75 mg tablet (Zortress) ...... 131 FAZACLO (clozapine odt) ...... 147 everolimus 2.5 mg tablet (Afinitor)...... 58 febuxostat 40 mg tablet (Uloric) ...... 26

188 febuxostat 80 mg tablet (Uloric) ...... 26 FINACEA (azelaic acid) ...... 156 felbamate (Felbatol) ...... 96 finasteride (Proscar) ...... 170 FELBATOL (felbamate) ...... 96 FINTEPLA...... 96 FELDENE (piroxicam) ...... 27 FIORICET (phrenilin forte)...... 17 felodipine...... 80 FIORICET WITH CODEINE FEMARA (letrozole) ...... 57 (butalb-acetaminoph-caff-codein) ...... 23 FEMCAP...... 102 FIORINAL (butalbital-aspirin-caffeine)...... 17 FEMHRT (norethindron-ethinyl estradiol) ...... 125 FIORINAL WITH CODEINE #3 FEMRING...... 129 (butalbital compound-codeine) ...... 23 fenofibrate 40 mg tablet (Fenoglide) ...... 92 FIRAZYR (icatibant) ...... 164 fenofibrate 43 mg capsule...... 92 FIRDAPSE...... 95 fenofibrate 48 mg tablet (Tricor) ...... 92 FIRMAGON...... 59 FENOFIBRATE 50 MG CAPSULE...... 92 FIRVANQ...... 41 fenofibrate 54 mg tablet...... 92 FLAGYL (metronidazole) ...... 34 fenofibrate 67 mg capsule...... 92 FLAREX...... 108 fenofibrate 120 mg tablet (Fenoglide) ...... 92 flavoxate hcl...... 171 fenofibrate 130 mg capsule...... 92 flecainide acetate...... 79 fenofibrate 134 mg capsule...... 92 FLECTOR...... 152 fenofibrate 145 mg tablet (Tricor) ...... 92 FLEXICHAMBER...... 134 FENOFIBRATE 150 MG CAPSULE...... 92 FLEXICHAMBER MASK...... 134 fenofibrate 160 mg tablet...... 92 FLOLIPID...... 91 FENOFIBRATE 160 MG TABLET...... 92 FLOMAX (tamsulosin hcl) ...... 170 fenofibrate 200 mg capsule...... 92 FLOVENT DISKUS...... 31 fenofibric acid (choline)(Trilipix) ...... 92 FLOVENT HFA...... 31 fenofibric acid (Fibricor) ...... 92 FLUAD 2017-2018...... 75 FENOGLIDE (fenofibrate) ...... 92 FLUAD 2018-2019...... 75 FENOPROFEN 200 MG CAPSULE...... 27 FLUAD 2019-2020...... 75 FENOPROFEN 400 MG CAPSULE...... 27 FLUAD 2020-2021...... 75 fenoprofen 600 mg tablet (Nalfon) ...... 27 FLUAD QUAD 2020-2021...... 75 fenoprofen calcium (Nalfon) ...... 27 FLUARIX QUAD 2017-2018...... 76 FENORTHO...... 27 FLUARIX QUAD 2018-2019...... 76 FENSOLVI...... 128 FLUARIX QUAD 2019-2020...... 76 fentanyl...... 22 FLUARIX QUAD 2020-2021...... 76 FENTANYL CITRATE...... 22 FLUBLOK 2017-2018...... 76 fentanyl citrate (Actiq) ...... 22 FLUBLOK QUAD 2017-2018...... 76 fentanyl (Duragesic) ...... 22 FLUBLOK QUAD 2018-2019...... 76 FENTORA...... 22 FLUBLOK QUAD 2019-2020...... 76 FERRIPROX...... 168 FLUBLOK QUAD 2020-2021...... 76 FERRIPROX (2 TIMES A DAY) ...... 168 FLUCELVAX QUAD 2017-2018...... 76 FETZIMA 20-40 MG TITRATION PAK...... 141 FLUCELVAX QUAD 2018-2019...... 76 FETZIMA ER 20 MG CAPSULE...... 141 FLUCELVAX QUAD 2019-2020...... 76 FETZIMA ER 40 MG CAPSULE...... 141 FLUCELVAX QUAD 2020-2021...... 76 FETZIMA ER 80 MG CAPSULE...... 141 FLUCONAZ-IBU-ITRACONAZ-TERBINA...... 46 FETZIMA ER 120 MG CAPSULE...... 141 fluconazole (Diflucan)...... 45 FEXMID (cyclobenzaprine hcl) ...... 136 flucytosine (Ancobon) ...... 45 FIASP...... 52 fludrocortisone acetate...... 128 FIASP FLEXTOUCH...... 52 FLULAVAL QUAD 2017-2018...... 76 FIASP PENFILL...... 52 FLULAVAL QUAD 2018-2019...... 76 FIBRICOR (fenofibric acid) ...... 93 FLULAVAL QUAD 2019-2020...... 76 FILTER NEEDLE...... 133 FLULAVAL QUAD 2020-2021...... 76 FINACEA...... 156 FLUMADINE (rimantadine hcl) ...... 69

189 FLUMIST QUAD 2017-2018...... 76 fluvoxamine maleate 50 mg tab...... 139 FLUMIST QUAD 2018-2019...... 76 fluvoxamine maleate 100 mg tab...... 139 FLUMIST QUAD 2019-2020...... 76 FLUZONE HIGH-DOSE 2017-2018...... 76 FLUMIST QUAD 2020-2021...... 76 FLUZONE HIGH-DOSE 2018-2019...... 76 flunisolide...... 107 FLUZONE HIGH-DOSE 2019-2020...... 76 fluocinolone acetonide...... 158 FLUZONE HIGH-DOSE QUAD 2020-21...... 76 fluocinolone acetonide (Derma-smoothe-fs) ...... 158 FLUZONE INTRADERM QUAD 2017-18...... 76 fluocinolone acetonide oil (Dermotic) ...... 107 FLUZONE QUAD 2017-2018...... 76 fluocinolone acetonide (Synalar) ...... 158 FLUZONE QUAD 2018-2019...... 76 fluocinolone/shower cap (Derma-smoothe-fs) ...... 158 FLUZONE QUAD 2019-2020...... 76 fluocinonide...... 158 FLUZONE QUAD 2020-2021...... 76 fluocinonide/emollient base...... 158 FLUZONE QUAD PEDI 2017-2018...... 76 fluocinonide (Vanos) ...... 158 FLUZONE QUAD PEDI 2018-2019...... 76 fluorescein sodium...... 104 FLUZONE QUAD PEDI 2019-2020...... 76 fluoride (sodium)(Prevident) ...... 111 FML (fluorometholone) ...... 108 fluoride (sodium)(Prevident 5000) ...... 111 FML FORTE...... 108 fluoride (sodium)(Prevident 5000 Ortho Defense) ...... 111 FML S.O.P...... 108 fluoride (sodium)(Prevident 5000 Plus) ...... 111 FOCALIN (dexmethylphenidate hcl) ...... 144 FLUORIDEX...... 112 FOCALIN XR 5 MG CAPSULE FLUORIDEX SENSITIVITY RELIEF...... 112 (dexmethylphenidate hcl er) ...... 145 fluorometholone (Fml) ...... 108 FOCALIN XR 10 MG CAPSULE FLUOROPLEX...... 61 (dexmethylphenidate hcl er) ...... 144 fluorouracil...... 61 FOCALIN XR 15 MG CAPSULE fluorouracil (Efudex) ...... 62 (dexmethylphenidate hcl er) ...... 144 fluoxetine 20 mg/5 ml solution...... 139 FOCALIN XR 20 MG CAPSULE fluoxetine hcl...... 139 (dexmethylphenidate hcl er) ...... 144 fluoxetine hcl 10 mg capsule (Prozac) ...... 139 FOCALIN XR 25 MG CAPSULE (dexmethylphenidate hcl er) ...... 144 fluoxetine hcl 10 mg tablet (Sarafem) ...... 139 FOCALIN XR 30 MG CAPSULE fluoxetine hcl 20 mg capsule (Prozac) ...... 139 (dexmethylphenidate hcl er) ...... 144 fluoxetine hcl 20 mg tablet...... 139 FOCALIN XR 35 MG CAPSULE fluoxetine hcl 40 mg capsule (Prozac) ...... 139 (dexmethylphenidate hcl er) ...... 145 fluoxetine hcl 60 mg tablet...... 139 FOCALIN XR 40 MG CAPSULE fluphenazine hcl...... 149 (dexmethylphenidate hcl er) ...... 145 flurandrenolide (Cordran) ...... 158 FOLET ONE...... 172 flurazepam hcl...... 150 folic acid...... 172 flurbiprofen...... 27 FOLLISTIM AQ...... 130 flurbiprofen sodium...... 108 fondaparinux sodium (Arixtra) ...... 43 flutamide...... 57 FORFIVO XL...... 138 fluticasone prop 0.05% cream (Cutivate) ...... 158 formadon 10% solution...... 55 fluticasone prop 0.05% lotion (Cutivate) ...... 158 formadon 10% solution...... 55 fluticasone prop 0.005% oint...... 158 formaldehyde...... 55 fluticasone prop 50 mcg spray...... 107 formaldehyde...... 151 fluticasone propionate (Cutivate) ...... 158 FORTAMET (metformin er osmotic) ...... 49 fluticasone propion/salmeterol (Advair Diskus) ...... 30 FORTEO...... 166 FLUTICASONE-SALMETEROL...... 30 FORTESTA (testosterone) ...... 123 fluvastatin sodium...... 91 FOSAMAX (alendronate sodium) ...... 169 fluvastatin sodium (Lescol Xl) ...... 91 FOSAMAX PLUS D...... 169 FLUVIRIN 2017-2018...... 76 fosamprenavir calcium (Lexiva) ...... 68 fluvoxamine er 100 mg capsule...... 139 fosaprepitant dimeglumine (Emend) ...... 116 fluvoxamine er 150 mg capsule...... 139 fosfomycin tromethamine (Monurol) ...... 34 fluvoxamine maleate 25 mg tab...... 139 fosinopril/hydrochlorothiazide...... 83

190 fosinopril sodium...... 85 gatifloxacin (Zymaxid) ...... 33 FOSRENOL 1, 000 MG POWDER PACK...... 112 GATTEX...... 122 FOSRENOL 1, 000 MG TABLET CHEW GAVRETO...... 59 (lanthanum carbonate) ...... 113 gelatin sponge, absorb/porcine (Gelfoam) ...... 78 FOSRENOL 500 MG TABLET CHEW GELFILM...... 109 (lanthanum carbonate) ...... 113 GELFOAM...... 78 FOSRENOL 750 MG POWDER PACKET...... 113 GELFOAM COMPRESSED...... 78 FOSRENOL 750 MG TABLET CHEW GELFOAM (surgifoam) ...... 78 (lanthanum carbonate) ...... 113 GELNIQUE...... 171 FRAGMIN...... 43 gemfibrozil (Lopid) ...... 93 FREESTYLE LIBRE 2 READER...... 132 GEMTESA...... 171 FREESTYLE LIBRE 2 SENSOR...... 132 GENERESS FE (norethin-eth estra-ferrous fum) ...... 101 FREESTYLE LIBRE 10 DAY READER...... 132 GENOTROPIN...... 127 FREESTYLE LIBRE 10 DAY SENSOR...... 132 gentamicin sulfate...... 33, 34, 42 FREESTYLE LIBRE 14 DAY READER...... 132 gentamicin sulfate/pf...... 34 FREESTYLE LIBRE 14 DAY SENSOR...... 132 GENVOYA...... 69 FROVA (frovatriptan succinate) ...... 18 GEODON (ziprasidone hcl) ...... 147 frovatriptan succinate (Frova) ...... 18 GILENYA...... 94 ful-glo 1 mg opth strip...... 104 GILOTRIF...... 59 FUL-GLO EYE STRIPS...... 104 GIMOTI...... 119 FULPHILA...... 99 glatiramer acetate (Copaxone) ...... 94 FURADANTIN (nitrofurantoin) ...... 38 GLEEVEC (imatinib mesylate) ...... 59 furosemide...... 105 GLEOSTINE...... 56 furosemide (Lasix) ...... 105 glimepiride (Amaryl) ...... 50 FUZEON...... 67 glipizide (Glucotrol) ...... 50 FYCOMPA 0.5 MG/ML ORAL SUSP...... 96 glipizide (Glucotrol Xl) ...... 50 FYCOMPA 2 MG TABLET...... 96 glipizide/metformin hcl...... 51 FYCOMPA 4 MG TABLET...... 96 GLOPERBA...... 25 FYCOMPA 6 MG TABLET...... 96 GLUCAGEN 1 MG HYPOKIT...... 112 FYCOMPA 8 MG TABLET...... 97 GLUCAGEN DIAGNOSTIC 1 MG VIAL...... 103 FYCOMPA 10 MG TABLET...... 96 GLUCAGON 1 MG EMERGENCY KIT...... 112 FYCOMPA 12 MG TABLET...... 96 glucagon 1 mg emergency kit (Glucagon Emergency Kit) ...... 112 G GLUCOCOM AUTOLINK...... 132 gabapentin...... 97 GLUCOPHAGE XR (metformin hcl er) ...... 49 gabapentin (Neurontin) ...... 97 GLUCOTROL (glipizide) ...... 50 GABITRIL 2 MG TABLET (tiagabine hcl) ...... 97 GLUCOTROL XL (glipizide xl) ...... 50 GABITRIL 4 MG TABLET (tiagabine hcl) ...... 97 GLUMETZA (metformin er gastric) ...... 49 GABITRIL 12 MG TABLET (tiagabine hcl) ...... 97 glyburide...... 50 GABITRIL 16 MG TABLET (tiagabine hcl) ...... 97 glyburide/metformin hcl...... 51 GALAFOLD...... 168 glyburide, micronized (Glynase) ...... 50 galantamine er 8 mg capsule (Razadyne Er) ...... 72 GLYCATE...... 115 galantamine er 16 mg capsule (Razadyne Er) ...... 72 glycine urologic solution...... 55 galantamine er 24 mg capsule (Razadyne Er) ...... 72 glycopyrrolate (Glycate) ...... 115 galantamine hbr...... 72 glycopyrrolate (Robinul) ...... 115 GALZIN...... 168 glycopyrrolate (Robinul Forte) ...... 115 ganirelix acet 250 mcg/0.5 ml (Ganirelix Acetate) ...... 128 GLYNASE (glyburide micronized) ...... 50 GANIRELIX ACET 250 MCG/0.5 ML (ganirelix acetate) ...... 128 GLYSET (miglitol) ...... 49 GARDASIL 9...... 77 GLYXAMBI...... 50 GASTROCROM (cromolyn sodium) ...... 25 GOCOVRI...... 64 GASTROGRAFIN (md-gastroview) ...... 105 GOLYTELY...... 120 GASTROMARK...... 104 GOLYTELY (peg-3350 and electrolytes) ...... 120

191 GONAL-F...... 130 heparin sod 1, 000 unit/ml vial...... 43 GONAL-F RFF...... 130 heparin sod 5, 000 unit/0.5 ml...... 43 GONAL-F RFF REDI-JECT...... 130 HEPARIN SOD 5, 000 UNIT/0.5 ML...... 43 GONITRO...... 81 heparin sod 5, 000 unit/0.5 ml (Heparin Sodium) ...... 43 GORDON’s UREA...... 156 heparin sod 5, 000 unit/ml syrg...... 43 GRALISE...... 95 heparin sod 5, 000 unit/ml vial...... 43 granisetron hcl...... 116 heparin sod 10, 000 unit/ml vl...... 43 granisetron hcl/pf...... 116 heparin sod 20, 000 unit/ml vl...... 43 GRANIX...... 99 HEPLISAV-B...... 77 GRASTEK...... 74 HEPSERA (adefovir dipivoxil) ...... 71 griseofulvin, microsize...... 45 HETLIOZ...... 150 griseofulvin ultramicrosize (Gris-peg) ...... 45 HETLIOZ LQ...... 150 GRIS-PEG (griseofulvin ultramicrosize) ...... 45 HIBERIX...... 77 GUAIACOL...... 154 HIPREX (methenamine hippurate) ...... 34 guanfacine hcl...... 87 homatropine hbr...... 111 guanfacine hcl (Intuniv) ...... 144 HORIZANT...... 94 guanidine hcl...... 74 HUMALOG...... 52 GUARDIAN RT CHARGER...... 132 HUMALOG JUNIOR KWIKPEN...... 52 GUARDIAN RT STARTER KIT...... 132 HUMALOG KWIKPEN U-100...... 52 GUARDIAN RT SYSTEM...... 132 HUMALOG KWIKPEN U-200...... 52 GUARDIAN TEST PLUG...... 133 HUMALOG MIX 50-50...... 52 GVOKE HYPOPEN 1-PACK...... 112 HUMALOG MIX 50-50 KWIKPEN...... 52 GVOKE HYPOPEN 2-PACK...... 112 HUMALOG MIX 75-25...... 52 GVOKE PFS 1-PACK SYRINGE...... 112 HUMALOG MIX 75-25 KWIKPEN...... 52 GVOKE PFS 2-PACK SYRINGE...... 112 HUMAPEN LUXURA HD...... 133 GYNAZOLE 1...... 44 HUMATROPE...... 127 HUMIRA...... 55 H HAEGARDA...... 164 HUMIRA (CF) ...... 55 halcinonide (Halog) ...... 158 HUMIRA (CF) PEDIATRIC CROHN’s...... 55 HALCION (triazolam) ...... 150 HUMIRA (CF) PEN 40 MG/0.4 ML...... 55 HALOBETASOL PROPIONATE...... 159 HUMIRA (CF) PEN 80 MG/0.8 ML...... 55 halobetasol propionate (Ultravate) ...... 159 HUMIRA (CF) PEN CROHN’s-UC-HS...... 55 HALOG 0.1% CREAM (halcinonide) ...... 159 HUMIRA (CF) PEN PEDIATRIC UC...... 56 HALOG 0.1% OINTMENT...... 159 HUMIRA (CF) PEN PSOR-UV-ADOL HS...... 56 HALOG 0.1% SOLUTION...... 159 HUMIRA PEN...... 55 haloperidol...... 149 HUMIRA PEN CROHN’s-UC-HS...... 55 haloperidol lactate...... 149 HUMIRA PEN PSOR-UVEITS-ADOL HS...... 55 HALUCORT...... 154 HUMULIN R U-500...... 52 HARVONI 33.75-150 MG PELLET PK...... 70 HUMULIN R U-500 KWIKPEN...... 52 HARVONI 45-200 MG PELLET PACKT...... 70 HYCAMTIN...... 58 HARVONI 45-200 MG TABLET...... 70 HYCODAN (hydromet) ...... 103 HARVONI 90-400 MG TABLET...... 70 hydralazine hcl...... 87 HELIDAC...... 117 HYDREA (hydroxyurea) ...... 56 HEMADY...... 126 HYDRO 35...... 155 HEMANGEOL...... 87 HYDRO 40 (umecta) ...... 155 HEMLIBRA...... 78 hydrochlorothiazide...... 106 heparin 10, 000 unit/10 ml vial...... 43 hydrocodone/acetaminophen...... 20 heparin 30, 000 unit/30 ml vial...... 43 HYDROCODONE-ACETAMINOPHEN...... 20 heparin 40, 000 unit/4 ml vial...... 43 hydrocodone/acetaminophen (Hydrocodone-acetaminophen) ...... 20 heparin 50, 000 unit/5 ml vial...... 43 hydrocodone/acetaminophen (Norco) ...... 20 heparin 50, 000 unit/10 ml vial...... 43

192 hydrocodone bitartrate (Hysingla Er) ...... 22 IBUDONE...... 21 hydrocodone bitartrate (Zohydro Er) ...... 22 ibuprofen...... 27 hydrocodone bit/homatrop me-br (Hycodan) ...... 103 ibuprofen/oxycodone hcl...... 21 hydrocodone/chlorphen p-stirex...... 103 icatibant acetate (Firazyr) ...... 164 hydrocodone/cpm/pseudoephed...... 103 ICLUSIG...... 59 HYDROCODONE-GUAIFENESIN...... 103 icosapent ethyl (Vascepa) ...... 114 hydrocodone-homatropine 5-1.5...... 103 IDHIFA...... 61 hydrocodone-homatropine soln (Hycodan) ...... 103 IFE-BIMIX 30/1...... 165 HYDROCODONE-HOMATROPINE SYRUP...... 103 IFE-PG20...... 165 hydrocodone/ibuprofen...... 21 ILARIS...... 169 hydrocodone/ibuprofen (Ibudone) ...... 21 ILEVRO...... 108 hydrocort buty 0.1% lipid crm (Locoid Lipocream) ...... 159 ILUMYA...... 151 hydrocort buty 0.1% lipo cream (Locoid Lipocream) ...... 159 imatinib mesylate (Gleevec) ...... 59 hydrocortisone...... 159 IMBRUVICA...... 59 hydrocortisone acetate...... 122 IMCIVREE...... 62 hydrocortisone acetate (Anusol-hc) ...... 122 imipramine hcl (Tofranil) ...... 143 hydrocortisone/acetic acid...... 107 imipramine pamoate...... 143 hydrocortisone (Ala-scalp) ...... 159 IMIQUIMOD 3.75% CREAM PUMP...... 154 hydrocortisone (Anusol-hc) ...... 159 imiquimod 3.75% cream (Zyclara) ...... 154 hydrocortisone buty 0.1% cream...... 159 imiquimod 5% cream packet (Aldara) ...... 154 hydrocortisone butyr 0.1% lotn (Locoid) ...... 159 IMITREX 4 MG/0.5 ML CARTRIDGES hydrocortisone butyr 0.1% oint (Locoid) ...... 159 (sumatriptan succinate) ...... 18 hydrocortisone butyr 0.1% soln...... 159 IMITREX 4 MG/0.5 ML PEN INJECT (sumatriptan succinate) .... 18 hydrocortisone (Cortef) ...... 126 IMITREX 5 MG NASAL SPRAY (sumatriptan) ...... 18 hydrocortisone (Cortenema) ...... 123 IMITREX 6 MG/0.5 ML CARTRIDGES hydrocortisone/iodoquinol...... 161 (sumatriptan succinate) ...... 18 hydrocortisone/iodoquinol/aloe...... 161 IMITREX 6 MG/0.5 ML PEN INJECT hydrocortisone/lidocaine/aloe...... 123 (sumatriptan succinate) ...... 18 hydrocortisone/pramoxine (Analpram Hc) ...... 123 IMITREX 6 MG/0.5 ML VIAL (sumatriptan succinate) ...... 18 hydrocortisone/pramoxine (Pramosone) ...... 160 IMITREX 20 MG NASAL SPRAY (sumatriptan) ...... 18 hydrocortisone valerate...... 159 IMITREX 25 MG TABLET (sumatriptan succinate) ...... 18 hydrogen peroxide...... 151 IMITREX 50 MG TABLET (sumatriptan succinate) ...... 18 hydromorphone hcl...... 22 IMITREX 100 MG TABLET (sumatriptan succinate) ...... 18 hydromorphone hcl (Dilaudid) ...... 22 IMPAVIDO...... 54 hydroxychloroquine sulfate (Plaquenil) ...... 54 IMPEKLO...... 159 hydroxyurea (Hydrea) ...... 56 IMPOYZ...... 159 hydroxyzine hcl...... 47 IMURAN (azathioprine) ...... 131 hydroxyzine pamoate...... 47 IMVEXXY 4 MCG MAINTENANCE PACK...... 129 hydroxyzine pamoate (Vistaril) ...... 47 IMVEXXY 4 MCG STARTER PACK...... 129 hyoscyamine sulfate...... 117 IMVEXXY 10 MCG MAINTENANCE PAK...... 129 hyoscyamine sulfate (Levbid) ...... 117 IMVEXXY 10 MCG STARTER PACK...... 129 hyoscyamine sulfate (Levsin) ...... 117 INBRIJA...... 64 hyoscyamine sulfate (Levsin-sl) ...... 117 INCRELEX...... 128 hyoscyamine sulfate (Nulev) ...... 117 INCRUSE ELLIPTA...... 29 HYPER-SAL...... 167 indapamide...... 106 HYPODERMIC NEEDLE...... 133 INDERAL LA (propranolol hcl er) ...... 88 HYSINGLA ER (hydrocodone bitartrate er) ...... 22 INDERAL XL...... 88 HYZAAR (losartan-hydrochlorothiazide) ...... 84 INDICLOR...... 104 INDOCIN...... 27 I indomethacin...... 27 ibandronate sodium (Boniva) ...... 169 INDOMETHACIN 20 MG CAPSULE...... 27 IBRANCE...... 59

193 indomethacin 25 mg capsule...... 27 ISENTRESS...... 68 indomethacin 50 mg capsule...... 27 ISENTRESS HD...... 68 INFANRIX DTAP...... 77 isoflurane...... 24 INFASURF...... 164 isoflurane...... 24 INFLECTRA...... 56 isomethept/dichlphn/acetaminop...... 18 INGREZZA...... 94 isomethepten/caf/acetaminophen...... 18 INGREZZA INITIATION PACK...... 94 isoniazid...... 35 INLYTA...... 59 isopropyl alcohol...... 168 INNOPRAN XL...... 88 ISOPTO ATROPINE (atropine sulfate) ...... 111 INOVA...... 155 ISOPTO CARPINE (pilocarpine hcl) ...... 110 INPEN (FOR HUMALOG) ...... 133 ISORDIL (isosorbide dinitrate) ...... 81 INPEN (FOR NOVOLOG OR FIASP) ...... 133 ISORDIL TITRADOSE (isosorbide dinitrate) ...... 81 INQOVI...... 57 isosorbide dinitrate 5 mg tab (Isordil Titradose) ...... 81 INREBIC...... 59 isosorbide dinitrate 10 mg tab...... 81 INSPIRACHAMBER...... 134 isosorbide dinitrate 20 mg tab...... 81 INSPRA (eplerenone) ...... 106 isosorbide dinitrate 30 mg tab...... 81 INSULIN ASPART...... 52 isosorbide dinitrate 40 mg tab (Isordil) ...... 81 INSULIN ASPART FLEXPEN...... 52 isosorbide mononitrate...... 81 INSULIN ASPART PENFILL...... 52 isotretinoin (Absorica) ...... 152 INSULIN ASPART PROT-INSULN ASP...... 52 isoxsuprine hcl...... 89 INSULIN LISPRO...... 52 isradipine...... 80 INSULIN LISPRO JUNIOR KWIKPEN...... 52 ISTALOL (timolol maleate) ...... 110 INSULIN LISPRO KWIKPEN U-100...... 52 ISTURISA...... 123 INSULIN LISPRO PROTAMINE MIX...... 52 itraconazole (Sporanox) ...... 45 INSULIN SYRINGE...... 133 ivermectin (Sklice) ...... 63 INSULIN SYRINGE U-500...... 133 ivermectin (Soolantra) ...... 156 INTELENCE...... 67 ivermectin (Stromectol) ...... 54 INTRAROSA...... 123 J INTRON A...... 61 JADENU (deferasirox) ...... 168 INTUNIV (guanfacine hcl er) ...... 144 JADENU SPRINKLE (deferasirox) ...... 168 INVEGA ER 1.5 MG TABLET (paliperidone er) ...... 147 JAKAFI...... 58 INVEGA ER 3 MG TABLET (paliperidone er) ...... 147 JALYN (dutasteride-tamsulosin) ...... 170 INVEGA ER 6 MG TABLET (paliperidone er) ...... 147 JANSSEN COVID-19 VACCINE (EUA) ...... 75 INVEGA ER 9 MG TABLET (paliperidone er) ...... 147 JANUMET...... 50 INVELTYS...... 108 JANUMET XR 50-1, 000 MG TABLET...... 50 INVIRASE...... 68 JANUMET XR 50-500 MG TABLET...... 50 INVOKAMET...... 51 JANUMET XR 100-1, 000 MG TABLET...... 50 INVOKAMET XR...... 51 JANUVIA...... 49 INVOKANA...... 49 JARDIANCE...... 49 iodine/potassium iodide...... 161 JATENZO 158 MG CAPSULE...... 123 iodine/sodium iodide...... 161 JATENZO 198 MG CAPSULE...... 123 IODOFLEX...... 161 JATENZO 237 MG CAPSULE...... 123 IODOSORB...... 161 JENTADUETO...... 50 IOPIDINE 0.5% EYE DROPS (apraclonidine hcl) ...... 110 JENTADUETO XR 2.5 MG-1, 000 MG...... 50 IOPIDINE 1% EYE DROPS...... 110 JENTADUETO XR 5 MG-1, 000 MG TB...... 51 IPOL...... 75 JORNAY PM...... 145 ipratropium/albuterol sulfate...... 30 JUBLIA...... 46 ipratropium bromide...... 29, 107 JULUCA...... 66 irbesartan (Avapro) ...... 86 JUXTAPID...... 90 irbesartan/hydrochlorothiazide (Avalide) ...... 84 JYNARQUE 15 MG-15 MG TABLET...... 105 IRESSA...... 59 JYNARQUE 15 MG TABLET...... 105

194 JYNARQUE 30 MG-15 MG TABLET...... 105 ketorolac 60 mg/2 ml syringe...... 20 JYNARQUE 30 MG TABLET...... 105 ketorolac 60 mg/2 ml vial...... 20 JYNARQUE 45 MG-15 MG TABLET...... 105 ketorolac 300 mg/10 ml vial...... 20 JYNARQUE 60 MG-30 MG TABLET...... 105 KEVEYIS...... 166 JYNARQUE 90 MG-30 MG TABLET...... 105 KEVZARA 150 MG/1.14 ML PEN INJ...... 131 KEVZARA 150 MG/1.14 ML SYRINGE...... 131 K KADIAN...... 22 KEVZARA 200 MG/1.14 ML PEN INJ...... 131 KADIAN (morphine sulfate er) ...... 22 KEVZARA 200 MG/1.14 ML SYRINGE...... 131 KALBITOR...... 164 KINERET...... 25 KALETRA 80 MG-20 MG/ML SOLN (lopinavir-ritonavir) ...... 68 KINRIX...... 77 KALETRA 100-25 MG TABLET...... 68 KISQALI...... 59 KALETRA 200-50 MG TABLET...... 68 KISQALI FEMARA CO-PACK...... 58 KALYDECO 25 MG GRANULES PACKET...... 164 KITABIS PAK...... 34 KALYDECO 50 MG GRANULES PACKET...... 164 KLARON (sulfacetamide sodium) ...... 153 KALYDECO 75 MG GRANULES PACKET...... 164 KLISYRI...... 62 KALYDECO 150 MG TABLET...... 164 KLONOPIN (clonazepam) ...... 95 KAPSPARGO SPRINKLE...... 88 klor-con 8 meq tablet...... 113 KAPVAY (clonidine hcl er) ...... 144 klor-con 8 meq tablet...... 113 KARBINAL ER...... 47 klor-con 10 meq tablet (K-tab Er) ...... 113 KATERZIA...... 80 klor-con 10 meq tablet (K-tab Er) ...... 113 KAZANO...... 51 KOMBIGLYZE XR 2.5-1, 000 MG TAB...... 51 KEFLEX (cephalexin) ...... 36 KOMBIGLYZE XR 5-1, 000 MG TAB...... 51 KENALOG (triamcinolone acetonide) ...... 159 KOMBIGLYZE XR 5-500 MG TABLET...... 51 KEPPRA (levetiracetam) ...... 97 KORLYM...... 51 KEPPRA (roweepra) ...... 97 KOSELUGO 10 MG CAPSULE...... 58 KEPPRA XR (levetiracetam er) ...... 97 KOSELUGO 25 MG CAPSULE...... 58 KERAFOAM...... 155 K-PHOS NO.2...... 114 KERALYT 6% GEL (salicylic acid) ...... 155 K-PHOS ORIGINAL...... 114 keralyt 6% shampoo...... 155 KRINTAFEL...... 54 KERALYT SCALP...... 155 KRISTALOSE...... 120 KERALYT SCALP (salicylic acid) ...... 155 K-TAB ER...... 113 KERYDIN...... 46 K-TAB ER (potassium chloride) ...... 114 KERYDIN (tavaborole) ...... 46 KUVAN (sapropterin dihydrochloride) ...... 168 KESIMPTA PEN...... 94 KYLEENA...... 102 ketoconazole...... 45, 46 KYNAMRO...... 90 ketoconazole (Extina) ...... 46 KYNMOBI...... 64 ketoconazole/skin cleanser 28...... 46 L ketoprofen...... 27 labetalol hcl...... 84 ketorolac 0.4% ophth solution (Acular Ls) ...... 108 LACRISERT...... 107 ketorolac 0.5% ophth solution (Acular) ...... 108 lactulose...... 114, 120 ketorolac 10 mg tablet...... 20 lactulose 10 gm/15 ml solution...... 114, 120 KETOROLAC 15.75 MG NASAL SPRAY...... 19 lactulose 10 gm packet (Kristalose) ...... 120 ketorolac 15 mg/ml carpuject...... 20 lactulose 20 gm/30 ml solution...... 120 ketorolac 15 mg/ml isecure syr...... 20 LAMICTAL (BLUE) (subvenite (blue)) ...... 97 ketorolac 15 mg/ml syringe...... 20 LAMICTAL (GREEN) (subvenite (green)) ...... 97 ketorolac 15 mg/ml vial...... 20 LAMICTAL (lamotrigine) ...... 97 ketorolac 30 mg/ml carpuject...... 20 LAMICTAL ODT (BLUE) (lamotrigine odt (blue)) ...... 97 ketorolac 30 mg/ml isecure syr...... 20 LAMICTAL ODT (GREEN) (lamotrigine odt (green)) ...... 97 ketorolac 30 mg/ml syringe...... 20 LAMICTAL ODT (lamotrigine odt) ...... 97 ketorolac 30 mg/ml vial...... 20 LAMICTAL ODT (ORANGE) (lamotrigine odt (orange)) ...... 97 ketorolac 60 mg/2 ml carpuject...... 20 LAMICTAL (ORANGE) (subvenite (orange)) ...... 97

195 LAMICTAL (subvenite) ...... 97 levalbuterol hcl (Xopenex) ...... 29 LAMICTAL XR (BLUE) ...... 97 levalbuterol hcl (Xopenex Concentrate) ...... 29 LAMICTAL XR (GREEN) ...... 97 LEVALBUTEROL TARTRATE HFA...... 29 LAMICTAL XR (lamotrigine er) ...... 97 LEVBID (symax-sr) ...... 117 LAMICTAL XR (ORANGE) ...... 97 LEVEMIR...... 53 lamivudine 10 mg/ml oral soln (Epivir) ...... 67 LEVEMIR FLEXTOUCH...... 53 lamivudine 150 mg tablet (Epivir) ...... 67 levetiracetam...... 97 lamivudine 300 mg tablet (Epivir) ...... 67 levetiracetam (Keppra) ...... 98 lamivudine (Epivir Hbv) ...... 71 levetiracetam (Keppra Xr) ...... 98 lamivudine/zidovudine (Combivir) ...... 66 LEVITRA (vardenafil hcl) ...... 165 lamotrigine (Lamictal) ...... 97 levobunolol hcl...... 110 lamotrigine (Lamictal (blue)) ...... 97 levocarnitine (Carnitor) ...... 169 lamotrigine (Lamictal (green)) ...... 97 levocarnitine (Carnitor Sf) ...... 169 lamotrigine (Lamictal Odt) ...... 97 levocarnitine (with sugar) (Carnitor) ...... 169 lamotrigine (Lamictal Odt (blue)) ...... 97 levofloxacin...... 33 lamotrigine (Lamictal Odt (green)) ...... 97 levofloxacin...... 39 lamotrigine (Lamictal Odt (orange)) ...... 97 levonorgestrel/ethin.estradiol...... 101 lamotrigine (Lamictal (orange)) ...... 97 levorphanol tartrate...... 22 lamotrigine (Lamictal Xr) ...... 97 LEVOTHYROXINE...... 163 LAMPIT...... 54 levothyroxine sodium (Synthroid) ...... 163 LANOXIN...... 81 levothyroxine sodium (Synthroid) ...... 163 LANOXIN (digoxin) ...... 81 LEVSIN (oscimin) ...... 117 lansoprazole/amoxiciln/clarith...... 117 LEVSIN-SL (symax-sl) ...... 117 lansoprazole dr 15 mg capsule (Prevacid) ...... 121 LEVULAN...... 61 lansoprazole dr 30 mg capsule (Prevacid) ...... 121 LEXAPRO 5 MG TABLET (escitalopram oxalate) ...... 140 lansoprazole odt 15 mg tablet (Prevacid) ...... 121 LEXAPRO 10 MG TABLET (escitalopram oxalate) ...... 139 lansoprazole odt 30 mg tablet (Prevacid) ...... 121 LEXAPRO 20 MG TABLET (escitalopram oxalate) ...... 139 lanthanum carbonate (Fosrenol) ...... 113 LEXETTE...... 159 LANTUS...... 52 LEXIVA 50 MG/ML SUSPENSION...... 68 LANTUS SOLOSTAR...... 52 LEXIVA 700 MG TABLET (fosamprenavir calcium) ...... 68 lapatinib ditosylate (Tykerb) ...... 59 LIALDA (mesalamine) ...... 118 LASIX (furosemide) ...... 105 LIBRAX (chlordiazepoxide-clidinium) ...... 115 LASTACAFT...... 48 LICART...... 152 latanoprost (Xalatan) ...... 110 lidocaine 5% ointment...... 24 LATUDA 20 MG TABLET...... 147 lidocaine 5% patch (Lidoderm) ...... 24 LATUDA 40 MG TABLET...... 147 lidocaine hcl...... 24 LATUDA 60 MG TABLET...... 147 lidocaine hcl/glycerin (Advanced Dna Medicated Collect) ...... 103 LATUDA 80 MG TABLET...... 147 LIDOCAINE-HYDROCORTISONE...... 123 LATUDA 120 MG TABLET...... 147 lidocaine/hydrocortisone ac...... 123, 160 LAZANDA...... 22 lidocaine/prilocaine...... 24 LEDIPASVIR-SOFOSBUVIR...... 70 LIDODERM (lidocaine) ...... 24 leflunomide (Arava) ...... 25 LILETTA...... 102 LENVIMA...... 59 lindane...... 160 LESCOL XL (fluvastatin er) ...... 91 linezolid (Zyvox) ...... 38 LETAIRIS (ambrisentan) ...... 82 LINZESS...... 119 L.E.T. (LIDO-EPINEPH-TETRA) ...... 24 liothyronine sodium (Cytomel) ...... 163 letrozole (Femara) ...... 57 LIPITOR (atorvastatin calcium) ...... 91 leucovorin calcium...... 164 LIPOFEN...... 93 LEUKERAN...... 56 LIQUID E-Z PAQUE...... 104 LEUKINE...... 100 LIQUID POLIBAR PLUS...... 104 leuprolide acetate...... 58 lisinopril/hydrochlorothiazide (Zestoretic) ...... 83

196 lisinopril (Zestril) ...... 85 LOTENSIN (benazepril hcl) ...... 86 lissamine green...... 104 LOTENSIN HCT (benazepril-hydrochlorothiazide) ...... 83 LITEAIRE...... 134 loteprednol etabonate (Lotemax) ...... 108 LITETOUCH...... 134 LOTREL (amlodipine besylate-benazepril) ...... 83 lithium carbonate...... 138 LOTRONEX (alosetron hcl) ...... 119 lithium carbonate (Lithobid) ...... 138 lovastatin 10 mg tablet...... 91 lithium citrate...... 138 lovastatin 20 mg tablet...... 91 LITHOBID (lithium carbonate er) ...... 138 lovastatin 40 mg tablet...... 91 LITHOSTAT...... 114 LOVAZA (triklo) ...... 114 LIVALO 1 MG TABLET...... 91 LOVENOX 30 MG/0.3 ML SYRINGE (enoxaparin sodium) ...... 44 LIVALO 2 MG TABLET...... 91 LOVENOX 40 MG/0.4 ML SYRINGE (enoxaparin sodium) ...... 44 LIVALO 4 MG TABLET...... 91 LOVENOX 60 MG/0.6 ML SYRINGE (enoxaparin sodium) ...... 44 l-norgest/e.estradiol-e.estrad (Loseasonique) ...... 101 LOVENOX 80 MG/0.8 ML SYRINGE (enoxaparin sodium) ...... 44 l-norgest/e.estradiol-e.estrad (Quartette) ...... 101 LOVENOX 100 MG/ML SYRINGE (enoxaparin sodium) ...... 43 l-norgest/e.estradiol-e.estrad (Seasonique) ...... 101 LOVENOX 120 MG/0.8 ML SYRINGE (enoxaparin sodium) ...... 44 LOCOID 0.1% LOTION (hydrocortisone butyrate) ...... 159 LOVENOX 150 MG/ML SYRINGE (enoxaparin sodium) ...... 44 LOCOID 0.1% OINTMENT (hydrocortisone butyrate) ...... 159 LOVENOX 300 MG/3 ML VIAL (enoxaparin sodium) ...... 44 LOCOID LIPOCREAM...... 159 loxapine succinate...... 149 LOCOID LIPOCREAM (hydrocortisone butyrate) ...... 159 LUBIPROSTONE...... 120 LOCORT...... 126 LUCEMYRA...... 170 LODINE (etodolac) ...... 27 LULICONAZOLE...... 46 LODOSYN (carbidopa) ...... 65 LUMIGAN...... 110 LOESTRIN FE (norethindrone-eth estradiol-fe) ...... 101 LUNESTA (eszopiclone) ...... 150 LOESTRIN FE (tarina fe 1-20 eq) ...... 101 LUPANETA PACK...... 128 LOESTRIN (norethindron-ethinyl estradiol) ...... 101 LUPRON DEPOT...... 58, 128 LOKELMA...... 113 LUPRON DEPOT-PED...... 128 LO LOESTRIN FE...... 101 LUXIQ (betamethasone valerate) ...... 159 LOMAIRA...... 62 LUZU...... 46 LOMOTIL (diphenoxylate-atropine) ...... 115 LYNPARZA...... 59 LONHALA MAGNAIR REFILL...... 29 LYRICA CR...... 170 LONHALA MAGNAIR STARTER...... 29 LYRICA (pregabalin) ...... 98 LONSURF...... 57 LYSODREN...... 61 loperamide hcl...... 115 LYSTEDA (tranexamic acid) ...... 78 LOPID (gemfibrozil) ...... 93 LYUMJEV...... 53 lopinavir/ritonavir (Kaletra) ...... 68 LYUMJEV KWIKPEN U-100...... 53 LOPRESSOR (metoprolol tartrate) ...... 88 LYUMJEV KWIKPEN U-200...... 53 LOPROX 0.77% CREAM (ciclopirox) ...... 46 M LOPROX 0.77% SUSPENSION KIT...... 46 MACROBID (nitrofurantoin mono-macro) ...... 38 LOPROX 0.77% TOPICAL SUSP (ciclopirox) ...... 46 MACRODANTIN (nitrofurantoin) ...... 38 LOPROX 1% SHAMPOO (ciclopirox) ...... 46 mafenide acetate (Sulfamylon) ...... 42 lorazepam...... 137 MAGELLAN INSULIN SAFETY SYRNG...... 133 lorazepam (Ativan) ...... 137 MAGELLAN INSULIN SYRINGE...... 133 LORBRENA...... 59 MALARONE (atovaquone-proguanil hcl) ...... 54 LORTAB...... 20 malathion (Ovide) ...... 161 LORZONE (chlorzoxazone) ...... 136 maprotiline hcl...... 143 losartan/hydrochlorothiazide (Hyzaar) ...... 84 MARINOL (dronabinol) ...... 115 losartan potassium (Cozaar) ...... 86 MARPLAN...... 138 LOSEASONIQUE (lojaimiess) ...... 101 MATULANE...... 61 LOTEMAX...... 108 MAVENCLAD...... 94 LOTEMAX (loteprednol etabonate) ...... 108 MAVYRET...... 71 LOTEMAX SM...... 108

197 MAXALT MLT (rizatriptan) ...... 18 mesalamine (Apriso) ...... 118 MAXALT (rizatriptan) ...... 18 mesalamine (Delzicol) ...... 118 MAXIDEX...... 108 mesalamine dr 1.2 gm tablet (Lialda) ...... 118 MAXITROL (neomycin-polymyxin-dexameth) ...... 32 MESNEX...... 164 MAXZIDE-25 MG (triamterene-hydrochlorothiazid) ...... 106 MESTINON (pyridostigmine bromide) ...... 72 MAXZIDE (triamterene-hydrochlorothiazid) ...... 106 MESTINON (pyridostigmine bromide er) ...... 72 MAYZENT...... 94 metaproterenol sulfate...... 29 meclofenamate sodium...... 27 metaxalone...... 136 MEDIHONEY...... 157 metaxalone (Skelaxin) ...... 136 MEDROL 2 MG TABLET...... 127 metformin hcl...... 49 MEDROL 4 MG DOSEPAK (methylprednisolone) ...... 127 metformin hcl (Fortamet) ...... 49 MEDROL 4 MG TABLET (methylprednisolone) ...... 127 metformin hcl (Glucophage Xr) ...... 49 MEDROL 8 MG TABLET (methylprednisolone) ...... 127 metformin hcl (Glumetza) ...... 49 MEDROL 16 MG TABLET (methylprednisolone) ...... 127 metformin hcl (Riomet) ...... 49 MEDROL 32 MG TABLET (methylprednisolone) ...... 127 methadone hcl...... 22 medroxyprogesterone 2.5 mg tab (Provera) ...... 129 methamphetamine hcl (Desoxyn) ...... 73 medroxyprogesterone 5 mg tab (Provera) ...... 129 methazolamide...... 105 medroxyprogesterone 10 mg tab (Provera) ...... 129 methenamine hippurate (Hiprex) ...... 35 medroxyprogesterone 150 mg/ml (Depo-provera) ...... 100 methenamine mandelate...... 35 mefenamic acid...... 20 methenam/m.blue/salicyl/hyoscy...... 35 mefloquine hcl...... 54 methenam/sod phos/mblue/hyoscy...... 35 megestrol acetate...... 61, 171 methen/mblue/sal/sod phos/hyos...... 35 MEKINIST...... 58 methimazole (Tapazole) ...... 162 MEKTOVI...... 58 METHITEST...... 123 meloxicam 5 mg capsule (Vivlodex) ...... 27 meth/meblue/sod phos/psal/hyos...... 35 meloxicam 7.5 mg tablet (Mobic) ...... 27 meth/meblue/sod phos/psal/hyos (Uribel) ...... 35 meloxicam 10 mg capsule (Vivlodex) ...... 27 methocarbamol...... 136 meloxicam 15 mg tablet (Mobic) ...... 27 methocarbamol (Robaxin-750) ...... 136 melphalan (Alkeran) ...... 56 methotrexate sodium...... 57 memantine hcl...... 93 methotrexate sodium/pf...... 57 memantine hcl er 7 mg capsule (Namenda Xr) ...... 93 methoxsalen (Oxsoralen-ultra) ...... 151 memantine hcl er 14 mg capsule (Namenda Xr) ...... 93 methscopolamine bromide...... 117 memantine hcl er 21 mg capsule (Namenda Xr) ...... 93 methyldopa...... 87 memantine hcl er 28 mg capsule (Namenda Xr) ...... 93 methyldopa/hydrochlorothiazide...... 87 memantine hcl (Namenda) ...... 93 methylergonovine maleate...... 128 MENACTRA...... 75 METHYLIN (methylphenidate hcl) ...... 145 MENEST...... 125 methylphenidate er 10 mg cap (Aptensio Xr) ...... 145 MENOPUR...... 130 methylphenidate er 10 mg tab...... 145 MENOSTAR...... 125 methylphenidate er 15 mg cap (Aptensio Xr) ...... 145 MENQUADFI...... 75 methylphenidate er 18 mg tab (Concerta) ...... 145 MENVEO A-C-Y-W-135-DIP...... 75 methylphenidate er 20 mg cap (Aptensio Xr) ...... 145 meperidine hcl...... 22 methylphenidate er 20 mg tab...... 145 MEPHYTON (phytonadione) ...... 172 methylphenidate er 27 mg tab (Concerta) ...... 145 meprobamate...... 137 methylphenidate er 30 mg cap (Aptensio Xr) ...... 145 MEPRON...... 54 methylphenidate er 36 mg tab (Concerta) ...... 145 MEPRON (atovaquone) ...... 54 methylphenidate er 40 mg cap (Aptensio Xr) ...... 145 mercaptopurine...... 57 methylphenidate er 50 mg cap (Aptensio Xr) ...... 145 mesalamine 1, 000 mg supp (Canasa) ...... 118 methylphenidate er 54 mg tab (Concerta) ...... 145 mesalamine 4 gm/60 ml enema (Sfrowasa) ...... 118 methylphenidate er 60 mg cap (Aptensio Xr) ...... 145 mesalamine 4 gm/60 ml kit (Rowasa) ...... 118 METHYLPHENIDATE ER 72 MG TAB...... 145 mesalamine 800 mg dr tablet (Asacol Hd) ...... 118 methylphenidate hcl...... 145

198 methylphenidate hcl...... 145 miglitol (Glyset) ...... 49 methylphenidate hcl (Methylin) ...... 145 miglustat (Zavesca) ...... 167 methylphenidate hcl (Ritalin) ...... 145 MIGRANAL (dihydroergotamine mesylate) ...... 18 methylphenidate hcl (Ritalin La) ...... 145 millipred 5 mg tablet...... 127 methylphenidate la 10 mg cap (Ritalin La) ...... 145 MILLIPRED 10 MG/5 ML SOLUTION (prednisolone methylphenidate la 20 mg cap (Ritalin La) ...... 145 sodium phosphate) ...... 127 methylphenidate la 30 mg cap (Ritalin La) ...... 145 MIMYX (prumyx) ...... 154 methylphenidate la 40 mg cap (Ritalin La) ...... 145 MINASTRIN 24 FE (norethin-eth estra-ferrous fum) ...... 101 methylphenidate la 60 mg cap...... 145 MINIMED RESERVOIR...... 133 methylprednisolone (Medrol) ...... 127 MINIPRESS (prazosin hcl) ...... 84 methyl salicylate...... 154 MINITRAN...... 81 methyltestosterone (Testred) ...... 124 MINIVELLE (lyllana) ...... 125 metoclopramide hcl...... 119 MINOCIN (minocycline hcl) ...... 40 metoclopramide hcl (Reglan) ...... 119 MINOCYCLINE ER...... 40 metolazone...... 106 minocycline er 45 mg tablet...... 40 METOPIRONE...... 104 minocycline er 55 mg tablet (Solodyn) ...... 40 metoprolol/hydrochlorothiazide...... 88 minocycline er 65 mg tablet (Solodyn) ...... 40 METOPROLOL SUCCINATE ER-HCTZ...... 88 minocycline er 80 mg tablet (Solodyn) ...... 40 metoprolol succinate (Toprol Xl) ...... 88 minocycline er 90 mg tablet...... 40 metoprolol tartrate...... 88 minocycline er 105 mg tablet (Solodyn) ...... 40 metoprolol tartrate (Lopressor) ...... 88 minocycline er 115 mg tablet (Solodyn) ...... 40 METROCREAM (rosadan) ...... 156 minocycline er 135 mg tablet...... 40 METROGEL (metronidazole) ...... 156 minocycline hcl...... 40 METROGEL-VAGINAL (vandazole) ...... 41 minocycline hcl (Minocin) ...... 40 metronidazole...... 156 MINOLIRA ER...... 40 metronidazole (Flagyl) ...... 34 minoxidil...... 87 metronidazole (Metrocream) ...... 156 MIRAPEX ER 0.75 MG TABLET (pramipexole er) ...... 64 metronidazole (Metrogel) ...... 156 MIRAPEX ER 0.375 MG TABLET (pramipexole er) ...... 64 metronidazole (Metrogel-vaginal) ...... 41 MIRAPEX ER 1.5 MG TABLET (pramipexole er) ...... 64 metyrosine (Demser) ...... 87 MIRAPEX ER 2.25 MG TABLET (pramipexole er) ...... 64 mexiletine hcl...... 79 MIRAPEX ER 3.75 MG TABLET (pramipexole er) ...... 64 MEZPAROX-HC...... 160 MIRAPEX ER 3 MG TABLET (pramipexole er) ...... 64 MIACALCIN...... 130 MIRAPEX ER 4.5 MG TABLET (pramipexole er) ...... 64 MICARDIS 20 MG TABLET (telmisartan) ...... 86 MIRCERA...... 99 MICARDIS 40 MG TABLET (telmisartan) ...... 86 MIRCETTE (volnea) ...... 101 MICARDIS 80 MG TABLET (telmisartan) ...... 86 MIRENA...... 102 MICARDIS HCT 40-12.5 MG TABLET (telmisartan- mirtazapine...... 137 hydrochlorothiazid) ...... 84 mirtazapine (Remeron) ...... 137 MICARDIS HCT 80-12.5 MG TABLET (telmisartan- misoprostol (Cytotec) ...... 117 hydrochlorothiazid) ...... 84 MITIGARE...... 25 MICARDIS HCT 80-25 MG TABLET (telmisartan- MITOSOL...... 111 hydrochlorothiazid) ...... 85 M-M-R II VACCINE...... 77 miconazole nitrate...... 45 MOBIC (meloxicam) ...... 27 MICONAZOLE-ZINC OXIDE-PETROLTM...... 46 modafinil (Provigil) ...... 149 MICROCHAMBER...... 134 MODERNA COVID-19 VACCINE (EUA) ...... 75 MICROGESTIN 24 FE (tarina 24 fe) ...... 101 moexipril hcl...... 86 MICROSPACER...... 134 molindone hcl...... 149 midazolam hcl...... 150 mometasone furoate 0.1% cream...... 159 midodrine hcl...... 74 mometasone furoate 0.1% oint...... 159 MIFEPREX...... 166 mometasone furoate 0.1% soln...... 159 mifepristone (Mifeprex) ...... 166 mometasone furoate 50 mcg spry (Nasonex) ...... 107

199 MONODOX (mondoxyne nl) ...... 40 NAFTIN (naftifine hcl) ...... 46 MONODOX (okebo) ...... 40 NALFON 400 MG CAPSULE...... 27 MONOJECT...... 133 NALFON 600 MG TABLET (profeno) ...... 27 MONOJECT BLOOD COLLECTION...... 133 NALOCET...... 20 MONOJECT INSULIN SYRINGE...... 133 naloxone 0.4 mg/ml carpuject...... 44 MONSEL’s...... 78 naloxone 0.4 mg/ml vial...... 44 montelukast sodium (Singulair) ...... 31 naloxone 2 mg/2 ml syringe...... 44 MONUROL (fosfomycin tromethamine) ...... 35 NALOXONE 2 MG AUTO-INJECTOR...... 44 MORPHABOND ER...... 22 naloxone 4 mg/10 ml vial...... 44 morphine sulfate...... 22 naltrexone hcl...... 44 morphine sulfate (Kadian) ...... 22 NAMENDA 5-10 MG TITRATION PK...... 93 morphine sulfate (Ms Contin) ...... 22 NAMENDA 5 MG TABLET (memantine hcl) ...... 93 MOTEGRITY...... 119 NAMENDA 10 MG TABLET (memantine hcl) ...... 93 MOTOFEN...... 115 NAMENDA XR 7 MG CAPSULE (memantine hcl er) ...... 93 MOVANTIK...... 44 NAMENDA XR 14 MG CAPSULE (memantine hcl er) ...... 93 MOVIPREP (peg3350-sod sul-nacl-kcl-asb-c) ...... 120 NAMENDA XR 21 MG CAPSULE (memantine hcl er) ...... 93 MOXATAG...... 38 NAMENDA XR 28 MG CAPSULE (memantine hcl er) ...... 93 MOXEZA (moxifloxacin) ...... 33 NAMENDA XR TITRATION PACK...... 93 moxifloxacin hcl (Avelox) ...... 39 NAMZARIC 7 MG-10 MG CAPSULE...... 93 moxifloxacin hcl (Moxeza) ...... 33 NAMZARIC 14 MG-10 MG CAPSULE...... 93 moxifloxacin hcl (Vigamox) ...... 33 NAMZARIC 21 MG-10 MG CAPSULE...... 93 MS CONTIN (morphine sulfate er) ...... 22 NAMZARIC 28 MG-10 MG CAPSULE...... 93 MULPLETA...... 100 NAMZARIC TITRATION PACK...... 93 MULTAQ...... 79 NAPRELAN...... 27 mupirocin calcium...... 42 NAPRELAN (naproxen sodium er) ...... 27 mupirocin (Centany) ...... 42 NAPROSYN (naproxen) ...... 27 MURI-LUBE MINERAL OIL...... 168 naproxen...... 27 MUSE...... 165 naproxen (Ec-naprosyn) ...... 27 mvn no.53/iron/folic/dss/dha...... 172 naproxen/esomeprazole mag (Vimovo) ...... 26 MYALEPT...... 130 naproxen (Naprosyn) ...... 28 MYAMBUTOL (ethambutol hcl) ...... 35 naproxen sod cr 375 mg tablet (Naprelan) ...... 28 MYCAPSSA...... 129 naproxen sod cr 500 mg tablet (Naprelan) ...... 28 MYCOBUTIN (rifabutin) ...... 35 NAPROXEN SOD CR 750 MG TABLET...... 28 mycophenolate mofetil (Cellcept) ...... 131 naproxen sodium...... 28 mycophenolate sodium (Myfortic) ...... 132 naproxen sodium (Anaprox Ds) ...... 28 MYDAYIS...... 74 naproxen sodium (Naprelan) ...... 28 MYDRIACYL (tropicamide) ...... 111 naratriptan hcl (Amerge) ...... 18 MYFORTIC (mycophenolic acid) ...... 132 NARCAN...... 44 MYLERAN...... 56 NARDIL (phenelzine sulfate) ...... 138 MYORISAN...... 152 NASCOBAL...... 172 MYRBETRIQ ER 25 MG TABLET...... 171 NASONEX (mometasone furoate) ...... 107 MYRBETRIQ ER 50 MG TABLET...... 171 NATACYN...... 44 MYSOLINE (primidone) ...... 98 NATAZIA...... 101 MYTESI...... 115 nateglinide (Starlix) ...... 50 NATESTO...... 124 N nabumetone (Relafen) ...... 27 NATPARA...... 128 nadolol/bendroflumethiazide...... 88 NATROBA (spinosad) ...... 63 nadolol (Corgard) ...... 88 NAYZILAM...... 95 naftifine hcl...... 46 NEBUPENT (pentamidine isethionate) ...... 54 naftifine hcl (Naftin) ...... 46 nebusal 3% vial...... 167 NAFTIN...... 46 NEBUSAL 6% VIAL...... 167

200 NEEDLE...... 133 NINLARO...... 59 nefazodone hcl...... 141 nisoldipine er 8.5 mg tablet (Sular) ...... 80 neomycin/bacit/p-myx/hydrocort...... 32 nisoldipine er 17 mg tablet (Sular) ...... 80 neomycin/polymyxin b/dexametha (Maxitrol) ...... 32 nisoldipine er 20 mg tablet...... 80 neomycin/polymyxin b/hydrocort...... 32 nisoldipine er 25.5 mg tablet...... 80 neomycin/polymyxin b/hydrocort...... 32 nisoldipine er 30 mg tablet...... 80 neomycin/polymyxn b/gramicidin...... 33 nisoldipine er 34 mg tablet (Sular) ...... 80 neomycin sulfate...... 34 nisoldipine er 40 mg tablet...... 80 neomycin sulf/bacitracin/poly...... 33 nitazoxanide (Alinia) ...... 63 neomycin sulf/polymyxin b sulf...... 151 nitisinone (Orfadin) ...... 167 NEORAL (gengraf) ...... 132 NITRO-DUR 0.1 MG/HR PATCH...... 81 NEO-SYNALAR...... 41 NITRO-DUR 0.2 MG/HR PATCH...... 81 NERLYNX...... 59 NITRO-DUR 0.3 MG/HR PATCH...... 81 NESINA...... 49 NITRO-DUR 0.4 MG/HR PATCH...... 81 NEUAC 1.2-5% KIT...... 153 NITRO-DUR 0.6 MG/HR PATCH...... 81 neuac gel...... 153 NITRO-DUR 0.8 MG/HR PATCH...... 81 NEULASTA...... 100 nitrofurantoin 25 mg/5 ml susp (Furadantin) ...... 38 NEULASTA ONPRO...... 100 nitrofurantoin 25 mg/5 ml susp (Furadantin) ...... 38 NEULUMEX...... 104 nitrofurantoin mcr 25 mg cap (Macrodantin) ...... 38 NEUPOGEN...... 100 nitrofurantoin mcr 50 mg cap (Macrodantin) ...... 38 NEUPRO...... 64 nitrofurantoin mcr 100 mg cap (Macrodantin) ...... 38 NEURONTIN (gabapentin) ...... 98 nitrofurantoin monohyd/m-cryst (Macrobid) ...... 38 NEVANAC...... 108 nitroglycerin...... 81 nevirapine...... 67 nitroglycerin (Nitro-dur) ...... 81 nevirapine (Viramune) ...... 67 nitroglycerin (Nitrolingual) ...... 81 nevirapine (Viramune Xr) ...... 67 nitroglycerin (Nitromist) ...... 81 NEXAVAR...... 59 nitroglycerin (Nitrostat) ...... 82 NEXIUM DR 2.5 MG PACKET...... 121 NITROLINGUAL (nitroglycerin) ...... 82 NEXIUM DR 5 MG PACKET...... 121 NITROMIST (nitroglycerin) ...... 82 NEXIUM DR 10 MG PACKET (esomeprazole magnesium) ...... 121 NITYR...... 167 NEXIUM DR 20 MG CAPSULE (esomeprazole magnesium) ..... 121 NIVESTYM...... 100 NEXIUM DR 20 MG PACKET (esomeprazole magnesium) ...... 121 nizatidine...... 119 NEXIUM DR 40 MG CAPSULE (esomeprazole magnesium) ..... 121 NOCDURNA...... 124 NEXIUM DR 40 MG PACKET (esomeprazole magnesium) ...... 121 NOCTIVA...... 124 NEXLETOL...... 90 NORCO (lorcet) ...... 21 NEXLIZET...... 90 NORCO (lorcet hd) ...... 20 NEXPLANON...... 100 NORCO (lorcet plus) ...... 20 niacin (Niacor) ...... 93 NORDITROPIN FLEXPRO...... 127 niacin (Niaspan) ...... 93 norelgestromin/ethin.estradiol...... 102 NIACOR...... 93 noreth-ethinyl estradiol/iron...... 101 NIASPAN (niacin er) ...... 93 noreth-ethinyl estradiol/iron (Generess Fe) ...... 101 nicardipine hcl...... 80 noreth-ethinyl estradiol/iron (Generess Fe) ...... 101 NICOTROL...... 162 norethind-eth estrad 0.5-2.5 (Femhrt) ...... 125 NICOTROL NS...... 162 norethind-eth estrad 1-0.02 mg (Loestrin) ...... 101 nifedipine...... 80 norethindrone acetate (Aygestin) ...... 129 nifedipine (Adalat Cc) ...... 80 norethindrone ac-eth estradiol...... 125 nifedipine (Procardia) ...... 80 norethindrone ac-eth estradiol (Femhrt) ...... 125 nifedipine (Procardia Xl) ...... 80 norethindrone ac-eth estradiol (Loestrin) ...... 101 NILANDRON (nilutamide) ...... 57 norethindrone-e.estradiol-iron (Estrostep Fe) ...... 101 nilutamide (Nilandron) ...... 57 norethindrone-e.estradiol-iron (Loestrin Fe) ...... 101 nimodipine...... 80 norethindrone-e.estradiol-iron (Microgestin 24 Fe) ...... 101

201 norethindrone-e.estradiol-iron (Minastrin 24 Fe) ...... 101 nystatin/triamcin...... 46 norethindrone-e.estradiol-iron (Taytulla) ...... 101 NYVEPRIA...... 100 norethindrone-ethin. estradiol...... 101 O norethindrone (Ortho Micronor) ...... 101 OBREDON...... 103 norethin-ee 1.5-0.03 mg (21) tb (Loestrin) ...... 102 OBSTETRIX EC...... 136 norethin-eth estrad 1 mg-5 mcg...... 125 OBSTETRIX ONE...... 172 NORGESIC FORTE...... 136 OBTREX DHA...... 136 norgestimate-ethinyl estradiol...... 102 OCALIVA...... 118 norgestrel-ethinyl estradiol...... 102 octreotide acetate...... 129 NORITATE...... 156 octreotide acetate (Sandostatin) ...... 129 NORPACE CR...... 79 OCUFLOX (ofloxacin) ...... 33 NORPACE (disopyramide phosphate) ...... 79 ODACTRA...... 74 NORPRAMIN (desipramine hcl) ...... 143 ODEFSEY...... 69 NORTHERA (droxidopa) ...... 74 ODOMZO...... 58 nortriptyline hcl...... 143 OFEV...... 164 nortriptyline hcl (Pamelor) ...... 143 ofloxacin...... 32 NORVASC (amlodipine besylate) ...... 80 ofloxacin...... 39 NORVIR 80 MG/ML SOLUTION...... 68 ofloxacin (Ocuflox)...... 33 NORVIR 100 MG POWDER PACKET...... 68 olanzapine/fluoxetine hcl...... 149 NORVIR 100 MG TABLET (ritonavir) ...... 68 olanzapine/fluoxetine hcl (Symbyax) ...... 149 NOURIANZ...... 64 olanzapine (Zyprexa) ...... 147 NOVAREL...... 130 olanzapine (Zyprexa Zydis) ...... 147 NOVOLOG...... 53 olmesartan/amlodipin/hcthiazid (Tribenzor) ...... 84 NOVOLOG FLEXPEN...... 53 olmesartan-hctz 20-12.5 mg tab (Benicar Hct) ...... 85 NOVOLOG MIX 70-30...... 53 olmesartan-hctz 40-12.5 mg tab (Benicar Hct) ...... 85 NOVOLOG MIX 70-30 FLEXPEN...... 53 olmesartan-hctz 40-25 mg tab (Benicar Hct) ...... 85 NOVOPEN ECHO...... 133 olmesartan medoxomil 5 mg tab (Benicar) ...... 86 NOXAFIL 40 MG/ML SUSPENSION...... 45 olmesartan medoxomil 20 mg tab (Benicar) ...... 86 NOXAFIL DR 100 MG TABLET (posaconazole) ...... 45 olmesartan medoxomil 40 mg tab (Benicar) ...... 86 NUBEQA...... 57 olopatadine 665 mcg nasal spry (Patanase) ...... 106 NUCALA...... 31 olopatadine hcl 0.1% eye drops...... 48 NUCORT...... 159 olopatadine hcl 0.2% eye drop (Pataday) ...... 48 NUCYNTA...... 22 OLUMIANT...... 26 NUCYNTA ER...... 22 OLUX (clobetasol propionate) ...... 159 NUEDEXTA...... 94 OLUX-E (tovet emollient) ...... 159 NULEV (symax) ...... 117 OMECLAMOX-PAK...... 117 NULIBRY...... 167 omega-3 acid ethyl esters (Lovaza) ...... 114 NULYTELY...... 120 omeppi 20 mg-1, 100 mg capsule (Zegerid) ...... 121 NULYTELY WITH FLAVOR PACKS omeppi 40 mg-1, 100 mg capsule (Zegerid) ...... 121 (trilyte with flavor packets) ...... 120 omeprazole-bicarb 20-1, 100 cap (Zegerid) ...... 121 NUMOISYN...... 166 omeprazole-bicarb 20-1, 680 pkt (Zegerid) ...... 121 NUPLAZID...... 139 omeprazole-bicarb 40-1, 100 cap (Zegerid) ...... 121 NURTEC ODT...... 18 omeprazole-bicarb 40-1, 680 pkt (Zegerid) ...... 121 NUTROPIN AQ NUSPIN...... 127 omeprazole dr 10 mg capsule...... 121 NUVARING (etonogestrel-ethinyl estradiol) ...... 100 omeprazole dr 20 mg capsule...... 121 NUVESSA...... 41 omeprazole dr 40 mg capsule...... 121 NUVIGIL (armodafinil) ...... 149 OMNARIS...... 107 NUZYRA...... 40 OMNIPOD DASH 5 PACK POD...... 133 NYMALIZE...... 80 OMNIPRED (prednisolone acetate) ...... 108 nystatin...... 45 OMNITROPE...... 127 nystatin...... 46 ondansetron...... 116

202 ondansetron hcl...... 116 OTEZLA 30 MG TABLET...... 25 ondansetron hcl/pf...... 116 OTOVEL...... 32 ondansetron hcl (Zofran) ...... 116 OTREXUP...... 25 ONEXTON...... 153 OVACE PLUS...... 154 ONFI (clobazam) ...... 95 OVIDE (malathion) ...... 161 ONGENTYS...... 64 OVIDREL...... 130 ONGLYZA...... 49 oxandrolone...... 124 ONUREG...... 57 oxaprozin (Daypro) ...... 28 ONZETRA XSAIL...... 18 OXAYDO...... 22 OPDIVO...... 60 oxazepam...... 137 opium/belladonna alkaloids...... 22 OXBRYTA...... 78 opium tincture...... 115 oxcarbazepine (Trileptal) ...... 98 OPSUMIT...... 82 OXERVATE...... 111 OPTICHAMBER...... 134 oxiconazole nitrate (Oxistat) ...... 46 OPTICHAMBER DIAMOND...... 134 OXISTAT 1% CREAM (oxiconazole nitrate) ...... 46 ORACEA...... 40 OXISTAT 1% LOTION...... 47 ORACIT...... 114 OXSORALEN-ULTRA (methoxsalen) ...... 151 ORALAIR...... 74 OXTELLAR XR...... 98 ORAMAGICRX...... 166 oxybutynin chloride...... 171 ORAPRED ODT (prednisolone sodium phos odt) ...... 127 oxybutynin chloride (Ditropan Xl) ...... 171 ORAVIG...... 45 oxycodone hcl...... 23 ORENCIA...... 25 oxycodone hcl/acetaminophen (Nalocet) ...... 21 ORENCIA CLICKJECT...... 25 oxycodone hcl/acetaminophen (Percocet) ...... 21 ORENITRAM ER...... 82 oxycodone hcl/acetaminophen (Primlev) ...... 21 ORFADIN...... 167 oxycodone hcl/aspirin...... 21 ORFADIN (nitisinone) ...... 167 OXYCODONE HCL ER...... 23 ORGOVYX...... 59 oxycodone hcl (Roxicodone) ...... 23 ORIAHNN...... 128 OXYCONTIN...... 23 ORILISSA 150 MG TABLET...... 128 oxymorphone hcl...... 23 ORILISSA 200 MG TABLET...... 128 OXYTROL...... 171 ORKAMBI 100-125 MG GRANULE PKT...... 163 OZEMPIC 0.25-0.5 MG DOSE PEN...... 48 ORKAMBI 100 MG-125 MG TABLET...... 163 OZEMPIC 1 MG DOSE PEN (1.5 ML) ...... 48 ORKAMBI 150-188 MG GRANULE PKT...... 163 OZEMPIC 1 MG DOSE PEN (3 ML) ...... 48 ORKAMBI 200 MG-125 MG TABLET...... 163 OZOBAX...... 136 ORLADEYO...... 164 P orphenadrine/aspirin/caffeine (Norgesic Forte) ...... 136 pacerone 100 mg tablet...... 79 orphenadrine citrate...... 136 pacerone 200 mg tablet...... 79 ORTHO MICRONOR (tulana) ...... 102 pacerone 400 mg tablet...... 79 ORTIKOS...... 127 PACNEX (benzoyl peroxide) ...... 155 oseltamivir 6 mg/ml suspension (Tamiflu)...... 69 PAIN EASE MEDIUM STREAM SPRAY...... 24 oseltamivir phos 30 mg capsule (Tamiflu)...... 69 PALFORZIA...... 74 oseltamivir phos 45 mg capsule (Tamiflu)...... 69 paliperidone er 1.5 mg tablet (Invega) ...... 147 oseltamivir phos 75 mg capsule (Tamiflu)...... 69 paliperidone er 3 mg tablet (Invega) ...... 147 OSENI...... 48 paliperidone er 6 mg tablet (Invega) ...... 147 OSMOLEX ER 129 MG TABLET...... 64 paliperidone er 9 mg tablet (Invega) ...... 147 OSMOLEX ER 193 MG TABLET...... 64 PALYNZIQ...... 74 OSMOLEX ER 258 MG TABLET...... 64 PAMELOR (nortriptyline hcl) ...... 143 OSMOLEX ER 322 MG DAILY DOSE...... 64 PANCREAZE...... 120 OSMOPREP...... 120 PANDEL...... 159 OSPHENA...... 166 PANRETIN...... 62 OTEZLA 28 DAY STARTER PACK...... 25 pantoprazole 40 mg suspension (Protonix) ...... 122

203 pantoprazole sod dr 20 mg tab (Protonix) ...... 122 PEN NEEDLE...... 133 pantoprazole sod dr 40 mg tab (Protonix) ...... 122 PENNSAID...... 152 PAPAVERINE-ALPROSTADIL...... 165 PENTACEL...... 77 PAPAVERINE-PHENTOLAMINE...... 165 PENTACEL ACTHIB COMPONENT...... 77 PAPAVERINE-PHENTOLMN-ALPROSTDL...... 165 pentamidine isethionate (Nebupent) ...... 54 PARADIGM...... 133 PENTASA...... 118 PARAGARD T 380-A...... 102 pentazocine hcl/naloxone hcl...... 23 paregoric...... 115 pentoxifylline...... 78 PAREMYD...... 111 PEPCID (famotidine) ...... 119 paricalcitol...... 166 PERCOCET (oxycodone-acetaminophen) ...... 21 paricalcitol (Zemplar) ...... 166 PERFOROMIST...... 30 PARLODEL (bromocriptine mesylate) ...... 64 PERIDEX (periogard) ...... 165 PARNATE (tranylcypromine sulfate) ...... 138 perindopril erbumine...... 86 paromomycin sulfate...... 53 permethrin (Elimite) ...... 63 paroxetine cr 12.5 mg tablet (Paxil Cr) ...... 140 perphenazine...... 149 paroxetine cr 25 mg tablet (Paxil Cr) ...... 140 perphenazine/amitriptyline hcl...... 142 paroxetine cr 37.5 mg tablet (Paxil Cr) ...... 140 PERTZYE...... 120 paroxetine er 12.5 mg tablet (Paxil Cr) ...... 140 PEXEVA 10 MG TABLET...... 140 paroxetine er 25 mg tablet (Paxil Cr) ...... 140 PEXEVA 20 MG TABLET...... 140 paroxetine er 37.5 mg tablet (Paxil Cr) ...... 140 PEXEVA 30 MG TABLET...... 140 paroxetine hcl 10 mg tablet (Paxil) ...... 140 PEXEVA 40 MG TABLET...... 140 paroxetine hcl 20 mg tablet (Paxil) ...... 140 PFIZER COVID-19 VACCINE (EUA) ...... 75 paroxetine hcl 30 mg tablet (Paxil) ...... 140 PHARMABASE BARRIER...... 156 paroxetine hcl 40 mg tablet (Paxil) ...... 140 PHASEAL PROTECTOR...... 133 paroxetine mesylate (Brisdelle) ...... 167 phenazopyridine hcl (Pyridium) ...... 24 PASER...... 35 phendimetrazine tartrate...... 62 PATADAY (olopatadine hcl) ...... 48 phenelzine sulfate (Nardil) ...... 138 PATANASE (olopatadine hcl) ...... 106 phenobarb/hyoscy/atropine/scop (Donnatal) ...... 117 PAXIL 10 MG/5 ML SUSPENSION...... 140 phenobarb/hyoscy/atropine/scop PAXIL 10 MG TABLET (paroxetine hcl) ...... 140 (Phenobarbital-belladonna) ...... 117 PAXIL 20 MG TABLET (paroxetine hcl) ...... 140 phenobarbital...... 149 PAXIL 30 MG TABLET (paroxetine hcl) ...... 140 phenobarbital-belladonna elixr (Donnatal) ...... 117 PAXIL 40 MG TABLET (paroxetine hcl) ...... 140 phenobarbital-belladonna elixr PAXIL CR 12.5 MG TABLET (paroxetine er) ...... 140 (Phenobarbital-belladonna) ...... 117 PAXIL CR 25 MG TABLET (paroxetine er) ...... 140 PHENOBARBITAL-BELLADONNA ELIXR (phenohytro) ...... 117 PAXIL CR 37.5 MG TABLET (paroxetine er) ...... 140 phenoxybenzamine hcl (Dibenzyline) ...... 74 PAZEO...... 48 phentermine hcl...... 62 PCE...... 37 phentermine hcl (Adipex-p) ...... 62 PEDIARIX...... 77 PHENTOLAMINE-ALPROSTADIL...... 165 PEDVAXHIB...... 77 phenylephrine hcl...... 109 peg3350/sod sulf, bicarb, cl/kcl phenylephrine hcl/prometh hcl...... 47 (Colyte With Flavor Packets) ...... 120 PHENYTEK (phenytoin sodium extended) ...... 98 peg3350/sod sulf, bicarb, cl/kcl (Golytely) ...... 120 phenytoin...... 98 peg3350/sod sul/nacl/kcl/asb/c (Moviprep) ...... 120 phenytoin (Dilantin) ...... 98 PEGANONE...... 98 phenytoin (Dilantin-125) ...... 98 PEGASYS...... 71 phenytoin sodium extended (Dilantin) ...... 98 PEGINTRON...... 71 phenytoin sodium extended (Phenytek) ...... 98 PEMAZYRE...... 60 PHESGO...... 58 penicillamine (Cuprimine) ...... 25 PHEXXI...... 100 penicillamine (Depen) ...... 25 PHOSLYRA...... 113 penicillin v potassium...... 38 PHOSPHOLINE IODIDE...... 110

204 PHYSIOLYTE...... 151 pramipexole er 2.25 mg tablet (Mirapex Er) ...... 64 PHYSIOSOL...... 151 pramipexole er 3.75 mg tablet (Mirapex Er) ...... 64 phytonadione (vit k1) (Mephyton) ...... 172 pramipexole er 3 mg tablet (Mirapex Er) ...... 64 PICATO...... 62 pramipexole er 4.5 mg tablet (Mirapex Er) ...... 64 PIFELTRO...... 67 PRAMOSONE 1%-1% CREAM...... 160 pilocarpine hcl (Isopto Carpine) ...... 110 PRAMOSONE 1%-1% OINTMENT...... 160 pilocarpine hcl (Salagen) ...... 74 PRAMOSONE 1% LOTION...... 160 pimecrolimus (Elidel) ...... 131 PRAMOSONE 2.5%-1% CREAM...... 160 pimozide...... 146 PRAMOSONE 2.5%-1% LOTION...... 160 pindolol...... 88 PRAMOSONE 2.5%-1% OINTMENT...... 160 pioglitazone hcl (Actos) ...... 51 PRANDIN (repaglinide) ...... 50 pioglitazone hcl/glimepiride (Duetact) ...... 50 prasugrel hcl (Effient)...... 65 pioglitazone hcl/metformin hcl (Actoplus Met) ...... 50 PRAVACHOL (pravastatin sodium) ...... 91 PIQRAY...... 60 pravastatin sodium...... 91 piroxicam (Feldene) ...... 28 pravastatin sodium (Pravachol) ...... 91 PLAQUENIL (hydroxychloroquine sulfate) ...... 54 praziquantel (Biltricide) ...... 54 PLAVIX (clopidogrel) ...... 65 prazosin hcl (Minipress) ...... 84 PLEGRIDY...... 94 PR BENZOYL PEROXIDE...... 155 PLEGRIDY PEN...... 94 PRECOSE (acarbose) ...... 49 PLENVU...... 120 PRED FORTE (prednisolone acetate) ...... 108 PLIXDA...... 161 PRED-G...... 32 PNEUMOVAX 23...... 75 PRED MILD...... 108 pnv 22/iron, gluc/folic/dss/dha...... 136 prednicarbate (Dermatop) ...... 159 pnv 66/iron/folic/docusate/dha...... 136 prednisolone...... 127 pnv 69/iron/folic/docusate/dha...... 136 prednisolone acetate (Pred Forte) ...... 108 pnv 80/iron fum/folic/dss/dha...... 136 prednisolone sodium phosphate...... 108, 127 pnv/ferrous fum/docusate/folic...... 136 prednisolone sodium phosphate (Millipred) ...... 127 pnv/iron, carb/docusat/folic ac...... 136 prednisolone sodium phosphate (Orapred Odt) ...... 127 POCKET CHAMBER...... 134 prednisone...... 127 PODOCON-25...... 155 PREFEST...... 125 podofilox...... 155 pregabalin (Lyrica) ...... 98 POLIBAR ACB...... 104 PREGNYL...... 130 polydimethylsiloxanes/silicon...... 156 PREMARIN...... 125, 129 polymyxin b sulf/trimethoprim (Polytrim) ...... 33 PREMPHASE...... 125 POLYTRIM (polymyxin b sul-trimethoprim) ...... 33 PREMPRO...... 126 POMALYST...... 58 prenatal 12/iron/folic/dss/om3 (Obtrex Dha) ...... 137 POSACONAZOLE 200 MG/5 ML SUSP...... 45 PRENATAL 19...... 137 posaconazole dr 100 mg tablet (Noxafil)...... 45 prenatal 34/iron/folic/dss/dha...... 137 POTABA...... 172 prenatal vits15/iron/folic/dss...... 137 potassium bicarbonate/cit ac...... 114 PREPIDIL...... 128 potassium chloride...... 114 PREPOPIK...... 120 potassium chloride (K-tab Er) ...... 114 PRESTALIA 3.5 MG-2.5 MG TABLET...... 83 potassium citrate/citric acid...... 114 PRESTALIA 7 MG-5 MG TABLET...... 83 potassium citrate (Urocit-k) ...... 114 PRESTALIA 14 MG-10 MG TABLET...... 83 potassium iodide/iodine...... 113 PRETOMANID...... 35 PRADAXA...... 44 PREVACID 15 MG SOLUTAB (lansoprazole) ...... 122 PRALUENT PEN...... 90 PREVACID 30 MG SOLUTAB (lansoprazole) ...... 122 pramipexole di-hcl...... 64 PREVACID DR 15 MG CAPSULE (lansoprazole) ...... 122 pramipexole er 0.75 mg tablet (Mirapex Er) ...... 64 PREVACID DR 30 MG CAPSULE (lansoprazole) ...... 122 pramipexole er 0.375 mg tablet (Mirapex Er) ...... 64 PREVIDENT 0.2% RINSE...... 112 pramipexole er 1.5 mg tablet (Mirapex Er) ...... 64 PREVIDENT 1.1% GEL (sodium fluoride) ...... 112

205 PREVIDENT 5000...... 112 promethazine hcl...... 47, 116 PREVIDENT 5000 BOOSTER PLUS...... 112 promethazine/phenyleph/codeine...... 103 PREVIDENT 5000 ENAMEL PROTECT...... 112 PROMETRIUM (progesterone) ...... 129 PREVIDENT 5000 ORTHO DEFENSE...... 112 propafenone hcl...... 79 PREVIDENT 5000 PLUS (sodium fluoride 5000 plus) ...... 112 propafenone hcl (Rythmol Sr) ...... 79 PREVIDENT 5000 SENSITIVE...... 112 propantheline bromide...... 115 PREVIDENT DENTAL RINSE...... 112 proparacaine/fluorescein sod...... 109 PREVNAR 13...... 75 proparacaine hcl (Alcaine) ...... 108 PREVYMIS...... 69 propranolol hcl...... 88 PREZCOBIX...... 66 propranolol hcl (Inderal La) ...... 88 PREZISTA...... 66 propranolol/hydrochlorothiazid...... 88 PRIFTIN...... 35 propylthiouracil...... 162 PRILOSEC DR 2.5 MG SUSPENSION...... 122 PROQUAD...... 77 PRILOSEC DR 10 MG SUSPENSION...... 122 PROSCAR (finasteride) ...... 170 PRIMAQUINE...... 54 PROSTIN E2 VAGINAL SUPPOSITORY...... 128 primaquine phosphate (Primaquine) ...... 54 protectives2/ceramide 1, 3, 6-ii...... 156 PRIMEAIRE...... 134 PROTONIX 40 MG SUSPENSION (pantoprazole sodium) ...... 122 primidone (Mysoline) ...... 98 PROTONIX DR 20 MG TABLET (pantoprazole sodium) ...... 122 PRIMLEV...... 21 PROTONIX DR 40 MG TABLET (pantoprazole sodium) ...... 122 PRIMSOL...... 35 PROTOPIC (tacrolimus) ...... 131 PRINIVIL (lisinopril) ...... 86 protriptyline hcl...... 143 PRISMASOL...... 114 PROVENTIL HFA (albuterol sulfate hfa) ...... 30 PRISTIQ ER 25 MG TABLET (desvenlafaxine succinate er) ...... 141 PROVERA (medroxyprogesterone acetate) ...... 129 PRISTIQ ER 50 MG TABLET (desvenlafaxine succinate er) ...... 142 PROVIGIL (modafinil) ...... 149 PRISTIQ ER 100 MG TABLET (desvenlafaxine succinate er) .....141 PROVOCHOLINE...... 104 PROAIR DIGIHALER...... 29 PROZAC 10 MG PULVULE (fluoxetine hcl) ...... 140 PROAIR HFA (albuterol sulfate hfa) ...... 29 PROZAC 20 MG PULVULE (fluoxetine hcl) ...... 140 PROAIR RESPICLICK...... 30 PROZAC 40 MG PULVULE (fluoxetine hcl) ...... 140 probenecid...... 28 PSORCON (diflorasone diacetate) ...... 159 probenecid/colchicine...... 28 PULMICORT (budesonide) ...... 31 PROCARDIA (nifedipine) ...... 80 PULMICORT FLEXHALER...... 31 PROCARDIA XL (nifedipine er) ...... 80 PULMOZYME...... 164 PROCARE SPACER WITH ADULT MASK...... 135 PURIXAN...... 57 PROCARE SPACER WITH CHILD MASK...... 135 PYLERA...... 117 PROCHAMBER...... 135 pyrazinamide...... 35 prochlorperazine (Compazine) ...... 116 PYRIDIUM (phenazopyridine hcl) ...... 24 prochlorperazine maleate (Compazine) ...... 116 pyridostigmine 60 mg/5 ml soln (Mestinon) ...... 72 PRO COMFORT SPACER WITH MASK...... 134 PYRIDOSTIGMINE BR 30 MG TABLET...... 72 PROCORT...... 123 pyridostigmine br 60 mg tablet (Mestinon) ...... 72 PROCRIT...... 99 pyridostigmine bromide (Mestinon) ...... 72 PROCTOFOAM-HC...... 123 pyrimethamine 25 mg tablet (Daraprim) ...... 54 PROCYSBI...... 170 pyrimethamine 25 mg tablet (Daraprim) ...... 54 progesterone, micronized (Prometrium) ...... 129 Q PROGLYCEM (diazoxide) ...... 112 QBRELIS...... 86 PROGRAF...... 132 QBREXZA...... 157 PROGRAF (tacrolimus) ...... 132 QDOLO...... 23 PROLENSA...... 108 QINLOCK...... 60 PROMACTA...... 100 QMIIZ ODT 7.5 MG TABLET...... 28 promethazine-codeine solution...... 103 QMIIZ ODT 15 MG TABLET...... 28 promethazine-codeine syrup...... 103 QNASL...... 107 promethazine/dextromethorphan...... 103 QNASL CHILDREN...... 107

206 QSYMIA...... 62 RECOTHROM...... 78 QTERN...... 50 RECTIV...... 120 QUADRACEL DTAP-IPV...... 77 REDITREX...... 25 QUALAQUIN (quinine sulfate) ...... 54 REGIMEX (benzphetamine hcl) ...... 62 QUARTETTE (rivelsa) ...... 102 REGLAN (metoclopramide hcl) ...... 119 QUAZEPAM...... 150 REGRANEX...... 154 quazepam (Quazepam) ...... 150 RELAFEN DS...... 28 QUDEXY XR (topiramate er) ...... 98 RELAFEN (nabumetone) ...... 28 QUESTRAN (cholestyramine) ...... 92 RELAGARD (fem ph) ...... 53 QUESTRAN LIGHT (prevalite) ...... 92 RELENZA...... 69 quetiapine fumarate (Seroquel) ...... 147 RELEXXII...... 145 quetiapine fumarate (Seroquel Xr) ...... 147 RELISTOR...... 44 QUILLICHEW ER...... 145 RELPAX (eletriptan hbr) ...... 18 QUILLIVANT XR...... 145 RELTONE...... 118 quinapril hcl (Accupril) ...... 86 REMERON (mirtazapine) ...... 137 quinapril/hydrochlorothiazide (Accuretic) ...... 83 REMICADE...... 56 quinidine gluconate...... 79 RENACIDIN...... 114 quinidine sulfate...... 79 RENAGEL (sevelamer hcl) ...... 113 quinine sulfate (Qualaquin) ...... 54 RENVELA (sevelamer carbonate) ...... 113 QUTENZA...... 154 repaglinide...... 50 QVAR REDIHALER...... 31 repaglinide/metformin hcl...... 51 repaglinide (Prandin) ...... 50 R RABEPRAZOLE DR 10 MG SPRNKL CP...... 122 REPATHA PUSHTRONEX...... 90 rabeprazole sod dr 20 mg tab (Aciphex) ...... 122 REPATHA SURECLICK...... 90 RADIAGEL...... 168 REPATHA SYRINGE...... 90 RADIAPLEXRX...... 156 REPLACEMENT PEDIATRIC MONITOR...... 133 RADIOGARDASE...... 168 RESPA A.R...... 102 RAGWITEK...... 74 RESTASIS...... 111 raloxifene hcl (Evista) ...... 169 RESTASIS MULTIDOSE...... 111 ramelteon (Rozerem) ...... 150 RESTIZAN...... 154 ramipril (Altace) ...... 86 RESTORIL (temazepam) ...... 150 RANEXA (ranolazine er) ...... 78 RETACRIT...... 99 ranitidine hcl...... 119 RETEVMO 40 MG CAPSULE...... 60 ranolazine (Ranexa) ...... 78 RETEVMO 80 MG CAPSULE...... 60 RAPAFLO 4 MG CAPSULE (silodosin) ...... 170 RETIN-A 0.1% CREAM (tretinoin) ...... 162 RAPAFLO 8 MG CAPSULE (silodosin) ...... 170 RETIN-A 0.01% GEL (tretinoin) ...... 161 RAPAMUNE (sirolimus) ...... 132 RETIN-A 0.05% CREAM (tretinoin) ...... 162 RAPLIXA...... 78 RETIN-A 0.025% CREAM (tretinoin) ...... 162 rasagiline mesylate 0.5 mg tab (Azilect) ...... 64 RETIN-A 0.025% GEL (tretinoin) ...... 162 rasagiline mesylate 1 mg tab (Azilect) ...... 64 RETIN-A MICRO PUMP...... 162 RASUVO...... 25 RETIN-A MICRO PUMP (tretinoin microsphere) ...... 162 RAVICTI...... 114 RETIN-A MICRO (tretinoin microsphere) ...... 162 RAYALDEE...... 166 RETROVIR (zidovudine) ...... 67 RAYOS...... 127 REVATIO (sildenafil citrate) ...... 82 RAZADYNE ER 8 MG CAPSULE (galantamine er) ...... 73 REVLIMID...... 58 RAZADYNE ER 16 MG CAPSULE (galantamine er) ...... 72 REXULTI 0.5 MG TABLET...... 148 RAZADYNE ER 24 MG CAPSULE (galantamine er) ...... 73 REXULTI 0.25 MG TABLET...... 148 READI-CAT 2...... 104 REXULTI 1 MG TABLET...... 148 REBIF...... 94 REXULTI 2 MG TABLET...... 148 REBIF REBIDOSE...... 94 REXULTI 3 MG TABLET...... 148 RECOMBIVAX HB...... 77 REXULTI 4 MG TABLET...... 148

207 REYATAZ 50 MG POWDER PACKET...... 68 ROSANIL (sodium sulfacetamide-sulfur) ...... 42 REYATAZ 150 MG CAPSULE (atazanavir sulfate) ...... 68 rosuvastatin calcium 5 mg tab (Crestor) ...... 91 REYATAZ 200 MG CAPSULE (atazanavir sulfate) ...... 68 rosuvastatin calcium 10 mg tab (Crestor) ...... 91 REYATAZ 300 MG CAPSULE (atazanavir sulfate) ...... 68 rosuvastatin calcium 20 mg tab (Crestor) ...... 91 REYVOW...... 18 rosuvastatin calcium 40 mg tab (Crestor) ...... 91 RHOPRESSA...... 110 ROTARIX...... 75 ribasphere 200 mg capsule...... 71 ROTATEQ...... 75 ribasphere 200 mg tablet...... 71 ROWASA (mesalamine) ...... 118 ribasphere 400 mg tablet...... 71 ROXICODONE (oxycodone hcl) ...... 23 ribasphere 600 mg tablet...... 71 ROXYBOND...... 23 ribasphere ribapak 200-400 mg...... 71 ROZEREM (ramelteon) ...... 150 ribasphere ribapak 400-400 mg...... 71 ROZLYTREK...... 60 ribasphere ribapak 600-400 mg...... 71 RUBRACA...... 60 ribasphere ribapak 600-600 mg...... 71 RUCONEST...... 164 ribavirin...... 71 rufinamide (Banzel) ...... 98 ribavirin (Virazole) ...... 69 RUKOBIA...... 67 RIDAURA...... 25 RUZURGI...... 95 rifabutin (Mycobutin) ...... 35 RYBELSUS...... 48 RIFAMATE...... 36 RYCLORA (dexchlorpheniramine maleate) ...... 47 rifampin...... 36 RYDAPT...... 60 RIFATER...... 36 RYTARY...... 65 RILUTEK (riluzole) ...... 94 RYTHMOL SR (propafenone hcl er) ...... 79 riluzole (Rilutek) ...... 94 RYVENT...... 47 rimantadine hcl (Flumadine) ...... 69 S RIMSO-50...... 24 SABRIL (vigabatrin) ...... 98 ringer’s solution...... 151 SABRIL (vigadrone) ...... 98 ringer’s solution, lactated...... 151 SAF-CLENS AF...... 157 RINVOQ...... 26 SAFYRAL (tydemy) ...... 102 RIOMET ER...... 49 SAIZEN...... 127 RIOMET (metformin hcl) ...... 49 SAIZEN-SAIZENPREP...... 127 risedronate sodium...... 169 SALAGEN (pilocarpine hcl) ...... 74 risedronate sodium (Actonel) ...... 169 salicylic acid...... 155 risedronate sodium (Atelvia) ...... 169 salicylic acid/ceramide comb 1...... 155 RISPERDAL (risperidone) ...... 147 salicylic acid (Keralyt Scalp) ...... 155 risperidone...... 147 SALIMEZ FORTE...... 155 risperidone (Risperdal) ...... 147 SALKERA...... 155 RITALIN LA (methylphenidate la) ...... 146 salsalate (Disalcid) ...... 25 RITALIN (methylphenidate hcl) ...... 146 SALVAX DUO PLUS...... 155 RITEFLO...... 135 SAMSCA...... 105 ritonavir (Norvir) ...... 68 SAMSCA (tolvaptan) ...... 105 rivastigmine (Exelon) ...... 73 SANCUSO...... 116 rivastigmine tartrate...... 73 SANDIMMUNE 25 MG CAPSULE (cyclosporine) ...... 132 rizatriptan benzoate...... 19 SANDIMMUNE 100 MG CAPSULE (cyclosporine) ...... 132 rizatriptan benzoate (Maxalt) ...... 19 SANDIMMUNE 100 MG/ML SOLN...... 132 rizatriptan benzoate (Maxalt Mlt) ...... 19 SANDOSTATIN LAR DEPOT...... 129 ROBAXIN-750 (methocarbamol) ...... 136 SANDOSTATIN (octreotide acetate) ...... 129 ROBINUL FORTE (glycopyrrolate) ...... 115 SANTYL...... 161 ROBINUL (glycopyrrolate) ...... 115 SAPHRIS (asenapine maleate) ...... 147 ROCALTROL (calcitriol) ...... 172 sapropterin dihydrochloride (Kuvan) ...... 168 ROCKLATAN...... 110 SARAFEM (fluoxetine hcl) ...... 140 ropinirole hcl...... 64 SAVAYSA 15 MG TABLET...... 43

208 SAVAYSA 30 MG TABLET...... 43 SIMBRINZA...... 110 SAVAYSA 60 MG TABLET...... 43 SIMPONI 50 MG/0.5 ML PEN INJEC...... 56 SAVELLA...... 169 SIMPONI 50 MG/0.5 ML SYRINGE...... 56 SAXENDA...... 62 SIMPONI 100 MG/ML PEN INJECTOR...... 56 SCALACORT DK...... 160 SIMPONI 100 MG/ML SYRINGE...... 56 scopolamine (Transderm-scop) ...... 116 SIMPONI ARIA...... 56 SEASONIQUE (simpesse) ...... 102 simvastatin 5 mg tablet...... 91 secobarbital sodium...... 149 simvastatin 10 mg tablet (Zocor) ...... 91 SECUADO...... 147 SIMVASTATIN 20 MG/5 ML SUSP...... 91 SEEBRI NEOHALER...... 29 simvastatin 20 mg tablet (Zocor) ...... 91 SEGLUROMET...... 51 simvastatin 40 mg tablet (Zocor) ...... 91 selegiline hcl...... 65 simvastatin 80 mg tablet (Zocor) ...... 91 selenium sulfide...... 154 SINEMET 10-100 (carbidopa-levodopa) ...... 65 SEMGLEE...... 53 SINEMET 25-100 (carbidopa-levodopa) ...... 65 SEMGLEE PEN...... 53 SINEMET 25-250 (carbidopa-levodopa) ...... 65 SEN-SERTER...... 133 SINGULAIR (montelukast sodium) ...... 31 SENSIPAR (cinacalcet hcl) ...... 166 sirolimus (Rapamune) ...... 132 SEREVENT DISKUS...... 30 SIRTURO...... 36 SERNIVO...... 160 SITAVIG...... 70 SEROQUEL (quetiapine fumarate) ...... 147 SITZMARKS...... 104 SEROQUEL XR (quetiapine fumarate er) ...... 148 SIVEXTRO...... 38 SEROSTIM...... 127 SKELAXIN (metaxalone) ...... 136 sertraline 20 mg/ml oral conc (Zoloft) ...... 140 SKLICE (ivermectin) ...... 63 sertraline hcl 25 mg tablet (Zoloft) ...... 140 SKYLA...... 102 sertraline hcl 50 mg tablet (Zoloft) ...... 140 SKYRIZI (2 SYRINGES) KIT...... 152 sertraline hcl 100 mg tablet (Zoloft) ...... 140 SLYND...... 102 sevelamer carbonate (Renvela) ...... 113 sodium chloride for inhalation...... 167 sevelamer hcl...... 113 sodium chloride for inhalation (Hyper-sal) ...... 167 sevelamer hcl (Renagel) ...... 113 sodium chloride irrig solution...... 151 sevoflurane (Ultane) ...... 24 sodium chloride/nahco3/kcl/peg SEYSARA...... 40 (Nulytely With Flavor Packs) ...... 120 SFROWASA (mesalamine) ...... 118 SODIUM CITRATE...... 42 SHINGRIX...... 77 sodium fluoride/potassium nit (Prevident 5000 Sensitive) ..... 112 SIGNIFOR...... 129 sodium phenylbutyrate (Buphenyl) ...... 114 SIGNIFOR LAR...... 129 sodium polystyrene sulfonate...... 113 SIKLOS...... 78 sodium polystyrene sulfon/sorb...... 113 sildenafil 10 mg/ml oral susp (Revatio) ...... 82 sod, pot chlor/mag/sod, pot phos...... 151 sildenafil 20 mg tablet (Revatio) ...... 82 SOFOSBUVIR-VELPATASVIR...... 70 sildenafil 25 mg tablet (Viagra) ...... 165 solifenacin 5 mg tablet (Vesicare) ...... 171 sildenafil 50 mg tablet (Viagra) ...... 165 solifenacin 10 mg tablet (Vesicare) ...... 171 sildenafil 100 mg tablet (Viagra) ...... 165 SOLIQUA 100-33...... 48 SILENOR 3 MG TABLET (doxepin hcl) ...... 150 SOLODYN (minocycline hcl er) ...... 40 SILENOR 6 MG TABLET (doxepin hcl) ...... 150 SOLOSEC...... 34 SILICONE MASK...... 135 SOLTAMOX...... 61 SILIQ...... 152 SOMA (carisoprodol) ...... 136 silodosin 4 mg capsule (Rapaflo)...... 170 SOMATULINE DEPOT...... 129 silodosin 8 mg capsule (Rapaflo)...... 170 SOMA (vanadom) ...... 136 SILVADENE (ssd) ...... 42 SOMAVERT...... 166 silver nitrate...... 155, 161 SOOLANTRA...... 156 silver nitrate applicator...... 155 SOOLANTRA (ivermectin) ...... 156 silver sulfadiazine (Silvadene) ...... 42 SORBITOL...... 151

209 SORBITOL-MANNITOL...... 151 STRATTERA 100 MG CAPSULE (atomoxetine hcl) ...... 146 SORIATANE (acitretin) ...... 152 STRENSIQ...... 167 SORILUX...... 153 STRIBILD...... 69 sotalol hcl (Betapace) ...... 88 STRIVERDI RESPIMAT...... 30 sotalol hcl (Betapace Af) ...... 88 STROMECTOL (ivermectin) ...... 54 SOTYLIZE...... 88 SUBOXONE (buprenorphine-naloxone) ...... 170 SOVALDI 150 MG PELLET PACKET...... 70 SUBSYS...... 23 SOVALDI 200 MG PELLET PACKET...... 70 SUCRAID...... 119 SOVALDI 200 MG TABLET...... 70 sucralfate (Carafate) ...... 117 SOVALDI 400 MG TABLET...... 70 SULAR (nisoldipine) ...... 80 SPACE CHAMBER...... 135 SULCONAZOLE NITRATE...... 47 SPACE CHAMBER-LARGE MASK...... 135 sulfacetamide/prednisolone sp...... 33 SPACE CHAMBER-MEDIUM MASK...... 135 sulfacetamide sodium...... 33, 154 SPACE CHAMBER-SMALL MASK...... 135 sulfacetamide sodium (Bleph-10) ...... 33 SPECTRACEF (cefditoren pivoxil) ...... 36 sulfacetamide sodium (Klaron) ...... 153 spinosad (Natroba) ...... 63 sulfacetamide sodium/sulfur...... 42 SPIRIVA...... 29 sulfacetamide sodium/sulfur (Avar-e Green) ...... 42 SPIRIVA RESPIMAT...... 29 sulfacetamide sodium/sulfur (Rosanil) ...... 42 spironolact/hydrochlorothiazid (Aldactazide) ...... 106 sulfacetamide sod/sulfur/urea...... 42 spironolactone (Aldactone) ...... 106 sulfacetamide/sulfur/cleansr23...... 42 SPORANOX (itraconazole) ...... 45 sulfact sod/sulur/avob/otn/oct...... 42 SPRAVATO...... 138 sulfadiazine...... 34 SPRITAM...... 98 sulfamethoxazole/trimethoprim...... 34 SPRIX...... 19 sulfamethoxazole/trimethoprim (Bactrim) ...... 34 SPRYCEL...... 60 sulfamethoxazole/trimethoprim (Bactrim Ds) ...... 34 sps 15 gm/60 ml suspension...... 113 SULFAMYLON 8.5% CREAM...... 42 sps 30 gm/120 ml enema susp...... 113 SULFAMYLON POWDER PACKET (mafenide acetate) ...... 42 SSKI...... 113 sulfasalazine (Azulfidine)...... 118 STALEVO 50 (carbidopa-levodopa-entacapone) ...... 65 sulindac...... 28 STALEVO 75 (carbidopa-levodopa-entacapone) ...... 65 sumatriptan 4 mg/0.5 ml cart (Imitrex) ...... 19 STALEVO 100 (carbidopa-levodopa-entacapone) ...... 65 sumatriptan 4 mg/0.5 ml inject (Imitrex) ...... 19 STALEVO 125 (carbidopa-levodopa-entacapone) ...... 65 sumatriptan 6 mg/0.5 ml cart (Imitrex) ...... 19 STALEVO 150 (carbidopa-levodopa-entacapone) ...... 65 sumatriptan 6 mg/0.5 ml inject (Imitrex) ...... 19 STALEVO 200 (carbidopa-levodopa-entacapone) ...... 65 sumatriptan 6 mg/0.5 ml syrng...... 19 STARLIX (nateglinide) ...... 50 sumatriptan 6 mg/0.5 ml vial (Imitrex) ...... 19 stavudine...... 67 sumatriptan (Imitrex) ...... 19 STEGLATRO...... 49 sumatriptan succ 25 mg tablet (Imitrex) ...... 19 STEGLUJAN...... 50 sumatriptan succ 50 mg tablet (Imitrex) ...... 19 STELARA 45 MG/0.5 ML SYRINGE...... 131 sumatriptan succ 100 mg tablet (Imitrex) ...... 19 STELARA 45 MG/0.5 ML VIAL...... 131 sumatriptan succ/naproxen sod (Treximet) ...... 19 STELARA 90 MG/ML SYRINGE...... 131 SUMAVEL DOSEPRO...... 19 STENDRA...... 165 SUNOSI...... 149 STIMATE...... 124 SUPRANE...... 24 STIOLTO RESPIMAT...... 30 SUPRAX...... 36 STIVARGA...... 60 SUPRAX (cefixime) ...... 36 STRATTERA 10 MG CAPSULE (atomoxetine hcl) ...... 146 SUPREP...... 120 STRATTERA 18 MG CAPSULE (atomoxetine hcl) ...... 146 SURGIFOAM...... 78 STRATTERA 25 MG CAPSULE (atomoxetine hcl) ...... 146 SURGISEAL STYLUS...... 156 STRATTERA 40 MG CAPSULE (atomoxetine hcl) ...... 146 SURGISEAL TEARDROP...... 156 STRATTERA 60 MG CAPSULE (atomoxetine hcl) ...... 146 SURGISEAL TWIST...... 156 STRATTERA 80 MG CAPSULE (atomoxetine hcl) ...... 146 SURMONTIL (trimipramine maleate) ...... 143

210 SURVANTA...... 164 TALICIA...... 117 SUSTIVA (efavirenz) ...... 67 TALTZ AUTOINJECTOR...... 152 SUTAB...... 120 TALTZ AUTOINJECTOR (2 PACK) ...... 152 SUTENT...... 60 TALTZ AUTOINJECTOR (3 PACK) ...... 152 SYMAX DUOTAB...... 117 TALTZ SYRINGE...... 152 SYMBICORT...... 30 TALZENNA...... 60 SYMBYAX (olanzapine-fluoxetine hcl) ...... 149 TAMIFLU 6 MG/ML SUSPENSION (oseltamivir phosphate) ...... 70 SYMDEKO...... 163 TAMIFLU 30 MG CAPSULE (oseltamivir phosphate) ...... 70 SYMFI (efavirenz-lamivu-tenofov disop) ...... 69 TAMIFLU 45 MG CAPSULE (oseltamivir phosphate) ...... 70 SYMFI LO (efavirenz-lamivu-tenofov disop) ...... 69 TAMIFLU 75 MG CAPSULE (oseltamivir phosphate) ...... 70 SYMJEPI...... 72 tamoxifen citrate...... 61 SYMLINPEN 60...... 49 tamsulosin hcl (Flomax) ...... 170 SYMLINPEN 120...... 49 TAPAZOLE (methimazole) ...... 162 SYMPAZAN...... 95 TAPERDEX...... 127 SYMPROIC...... 44 TARCEVA (erlotinib hcl) ...... 60 SYMTUZA...... 66 TARGADOX...... 40 SYNALAR...... 160 TARGRETIN 1% GEL...... 62 SYNALAR (fluocinolone acetonide) ...... 160 TARGRETIN 75 MG CAPSULE (bexarotene) ...... 56 SYNALAR TS...... 160 TARKA (trandolapril-verapamil er) ...... 83 SYNAREL...... 128 TASIGNA...... 60 SYNDROS...... 115 TASMAR (tolcapone) ...... 65 SYNERA...... 24 tavaborole (Kerydin) ...... 47 SYNJARDY...... 51 TAVALISSE...... 164 SYNJARDY XR 5-1, 000 MG TABLET...... 51 TAYTULLA (norethin-eth estra-ferrous fum) ...... 102 SYNJARDY XR 10-1, 000 MG TABLET...... 51 tazarotene 0.1% cream (Tazorac) ...... 153 SYNJARDY XR 12.5-1, 000 MG TAB...... 51 TAZAROTENE 0.1% FOAM...... 162 SYNJARDY XR 25-1, 000 MG TABLET...... 51 TAZORAC 0.1% CREAM (tazarotene) ...... 153 SYNTHROID (unithroid) ...... 163 TAZORAC 0.1% GEL...... 154 SYPRINE (trientine hcl) ...... 168 TAZORAC 0.05% CREAM...... 153 SYRINGE AVITENE...... 78 TAZORAC 0.05% GEL...... 153 TAZVERIK...... 58 T TABLOID...... 57 TC99M SULFUR COLLOID PREP...... 104 TABRECTA...... 60 TDVAX...... 77 TACHOSIL...... 78 TECFIDERA (dimethyl fumarate) ...... 95 TACLONEX (calcipotriene-betamethasone) ...... 161 TEGRETOL (carbamazepine) ...... 98 TACLONEX (calcipotriene-betamethasone dp) ...... 161 TEGRETOL (epitol) ...... 98 tacrolimus 0.1% ointment (Protopic) ...... 131 TEGRETOL XR (carbamazepine er) ...... 98 tacrolimus 0.03% ointment (Protopic) ...... 131 TEGSEDI...... 166 tacrolimus 0.5 mg capsule (ir) (Prograf) ...... 132 TEKTURNA 150 MG TABLET (aliskiren) ...... 89 tacrolimus 1 mg capsule (ir) (Prograf) ...... 132 TEKTURNA 300 MG TABLET (aliskiren) ...... 89 tacrolimus 5 mg capsule (ir) (Prograf) ...... 132 TEKTURNA HCT 150-12.5 MG TAB...... 89 tadalafil 2.5 mg tablet (Cialis) ...... 165 TEKTURNA HCT 150-25 MG TABLET...... 89 tadalafil 5 mg tablet (Cialis) ...... 165 TEKTURNA HCT 300-12.5 MG TAB...... 89 tadalafil 10 mg tablet (Cialis) ...... 165 TEKTURNA HCT 300-25 MG TABLET...... 89 tadalafil 20 mg tablet (Adcirca) ...... 82 telmisartan 20 mg tablet (Micardis) ...... 86 tadalafil 20 mg tablet (Cialis) ...... 165 telmisartan 40 mg tablet (Micardis) ...... 86 tadalafil (Adcirca) ...... 82 telmisartan 80 mg tablet (Micardis) ...... 86 TAFINLAR...... 57 telmisartan-amlodipine 40-5 mg...... 85 TAGITOL...... 104 telmisartan-amlodipine 40-10...... 85 TAGRISSO...... 60 telmisartan-amlodipine 80-5 mg...... 85 TAKHZYRO...... 74 telmisartan-amlodipine 80-10...... 85

211 telmisartan-hctz 40-12.5 mg tb (Micardis Hct) ...... 85 thiothixene...... 149 telmisartan-hctz 80-12.5 mg tb (Micardis Hct) ...... 85 THROMBI-GEL...... 78 telmisartan-hctz 80-25 mg tab (Micardis Hct) ...... 85 THROMBIN-JMI...... 78 temazepam (Restoril) ...... 150 THROMBI-PAD...... 78 TEMIXYS...... 66 THYQUIDITY...... 163 TEMODAR (temozolomide) ...... 56 thyroid, pork...... 163 TEMOVATE (clobetasol propionate) ...... 160 thyroid, pork (Armour Thyroid) ...... 163 temozolomide...... 56 thyroid, pork (Wp Thyroid) ...... 163 temozolomide (Temodar) ...... 56 THYROLAR-1...... 163 TENIVAC...... 77 THYROLAR-1/2...... 163 tenofovir disoproxil fumarate (Viread) ...... 68 THYROLAR-1/4...... 163 TENORETIC 50 (atenolol-chlorthalidone) ...... 88 THYROLAR-2...... 163 TENORETIC 100 (atenolol-chlorthalidone) ...... 88 THYROLAR-3...... 163 TENORMIN (atenolol) ...... 88 tiagabine hcl 2 mg tablet (Gabitril) ...... 98 TEPMETKO ...... 60 tiagabine hcl 4 mg tablet (Gabitril) ...... 98 terazosin hcl...... 84 tiagabine hcl 12 mg tablet (Gabitril) ...... 98 terbinafine hcl...... 45 tiagabine hcl 16 mg tablet (Gabitril) ...... 98 terbutaline sulfate...... 29 TIAZAC (tiadylt er) ...... 80 terconazole...... 45 TIBSOVO...... 61 TERIPARATIDE...... 166 ticlopidine hcl...... 65 TERSI FOAM...... 154 TIGAN (trimethobenzamide hcl) ...... 116 TERUMO SURGUARD2...... 133 TIGLUTIK...... 94 TESSALON PERLE (benzonatate) ...... 103 TIKOSYN 125 MCG CAPSULE (dofetilide) ...... 79 TESTIM (testosterone) ...... 124 TIKOSYN 250 MCG CAPSULE (dofetilide) ...... 79 testosterone 1% (25mg/2.5g) pk (Androgel) ...... 124 TIKOSYN 500 MCG CAPSULE (dofetilide) ...... 79 testosterone 1% (50 mg/5 g) pk (Vogelxo) ...... 124 timolol maleate...... 88 testosterone 1.62% (1.25 g) pkt (Androgel) ...... 124 timolol maleate (Istalol) ...... 110 testosterone 1.62% (2.5 g) pkt (Androgel) ...... 124 timolol maleate/pf (Timoptic Ocudose) ...... 110 testosterone 1.62% gel pump (Androgel) ...... 124 timolol maleate (Timoptic) ...... 110 testosterone 10 mg gel pump (Fortesta) ...... 124 timolol maleate (Timoptic-xe) ...... 110 TESTOSTERONE 12.5 MG/1.25 GRAM...... 124 TIMOPTIC OCUDOSE...... 110 testosterone 12.5 mg/1.25 gram (Vogelxo) ...... 124 TIMOPTIC OCUDOSE (timolol maleate) ...... 110 testosterone 30 mg/1.5 ml pump...... 124 TIMOPTIC (timolol maleate) ...... 110 testosterone 50 mg/5 gram gel (Vogelxo) ...... 124 TIMOPTIC-XE (timolol maleate) ...... 110 TESTOSTERONE 50 MG/5 GRAM PKT...... 124 TINDAMAX (tinidazole) ...... 53 testosterone cypionate (Depo-testosterone) ...... 124 tinidazole...... 53 testosterone enanthate...... 124 tinidazole (Tindamax) ...... 53 TESTRED (methyltestosterone) ...... 124 TIROSINT...... 163 tetrabenazine (Xenazine) ...... 94 TIROSINT-SOL...... 163 tetracaine hcl...... 109 TISSEEL VHSD...... 156 tetracycline hcl...... 40 TIVICAY...... 68 TETRAVISC...... 109 TIVICAY PD...... 68 TETRAVISC FORTE...... 109 TIVORBEX...... 28 TEXACORT...... 160 tizanidine hcl...... 136 THALOMID...... 35 tizanidine hcl (Zanaflex)...... 136 THEO-24...... 32 TOBI PODHALER...... 34 theophylline anhydrous...... 32 TOBI (tobramycin) ...... 34 theophylline anhydrous (Elixophyllin) ...... 32 TOBRADEX EYE DROPS (tobramycin-dexamethasone) ...... 32 THIOLA...... 170 TOBRADEX EYE OINTMENT...... 32 THIOLA EC...... 170 TOBRADEX ST...... 32 thioridazine hcl...... 149 tobramycin 0.3% eye drop (Tobrex) ...... 33

212 tobramycin 1.2 gm vial...... 34 tramadol hcl er 300 mg tablet...... 23 tobramycin 1.2 gram/30 ml vial...... 34 trandolapril...... 86 tobramycin 1, 200 mg/30 ml vial...... 34 trandolapril/verapamil hcl...... 83 tobramycin 10 mg/ml vial...... 34 trandolapril/verapamil hcl (Tarka) ...... 83 tobramycin 40 mg/ml vial...... 34 tranexamic acid (Lysteda) ...... 78 tobramycin 80 mg/2 ml vial...... 34 TRANSDERM-SCOP (scopolamine) ...... 116 tobramycin 300 mg/4 ml ampule (Bethkis) ...... 34 TRANXENE T-TAB (clorazepate dipotassium) ...... 137 tobramycin 300 mg/5 ml ampule (Tobi) ...... 34 tranylcypromine sulfate (Parnate) ...... 138 tobramycin/dexamethasone (Tobradex) ...... 32 TRAVATAN Z (travoprost) ...... 110 TOBRAMYCIN PAK 300 MG/5 ML...... 34 travoprost (Travatan Z) ...... 110 TOBREX 0.3% EYE DROP (tobramycin) ...... 33 trazodone hcl...... 141 TOBREX 0.3% EYE OINTMENT...... 33 TRECATOR...... 35 TOFRANIL (imipramine hcl) ...... 143 TRELEGY ELLIPTA...... 31 TOLAK...... 62 TREMFYA 100 MG/ML INJECTOR...... 152 tolbutamide...... 50 TREMFYA 100 MG/ML SYRINGE...... 152 tolcapone (Tasmar) ...... 65 TRESIBA...... 53 tolmetin sodium...... 28 TRESIBA FLEXTOUCH U-100...... 53 TOLSURA...... 45 TRESIBA FLEXTOUCH U-200...... 53 tolterodine tart er 2 mg cap (Detrol La) ...... 171 tretinoin 0.1% cream (Retin-a) ...... 162 tolterodine tart er 4 mg cap (Detrol La) ...... 171 tretinoin 0.01% gel (Retin-a) ...... 162 tolterodine tartrate (Detrol) ...... 171 tretinoin 0.05% cream (Retin-a) ...... 162 TOLVAPTAN 15 MG TABLET...... 105 tretinoin 0.05% gel (Atralin) ...... 162 tolvaptan 30 mg tablet (Samsca) ...... 105 tretinoin 0.025% cream (Retin-a) ...... 162 TOPAMAX (topiramate) ...... 98 tretinoin 0.025% gel (Retin-a) ...... 162 TOPICORT (desoximetasone) ...... 160 tretinoin 10 mg capsule...... 61 topiramate (Qudexy Xr) ...... 98 tretinoin microspheres (Retin-a Micro) ...... 162 topiramate (Topamax) ...... 98 tretinoin microspheres (Retin-a Micro Pump) ...... 162 TOPROL XL (metoprolol succinate) ...... 88 TRETIN-X...... 162 toremifene citrate (Fareston) ...... 61 TREXALL...... 57 torsemide...... 105 TREXIMET 10-60 MG TABLET...... 19 TOSYMRA...... 19 TREXIMET 85-500 MG TABLET TOUJEO MAX SOLOSTAR...... 53 (sumatriptan succ-naproxen sod) ...... 19 TOUJEO SOLOSTAR...... 53 TREZIX...... 21 TOVIAZ ER 4 MG TABLET...... 171 triamcinolone acetonide...... 160, 165 TOVIAZ ER 8 MG TABLET...... 171 triamcinolone acetonide (Kenalog) ...... 160 TRACLEER 32 MG TABLET FOR SUSP...... 82 triamterene (Dyrenium) ...... 106 TRACLEER 62.5 MG TABLET (bosentan) ...... 82 triamterene/hydrochlorothiazid (Dyazide) ...... 106 TRACLEER 125 MG TABLET (bosentan) ...... 82 triamterene/hydrochlorothiazid (Maxzide) ...... 106 TRADJENTA...... 49 triamterene/hydrochlorothiazid (Maxzide-25 Mg) ...... 106 tramadol er 100 mg tablet...... 23 triazolam...... 150 tramadol er 200 mg tablet...... 23 triazolam (Halcion) ...... 150 tramadol er 300 mg tablet...... 23 TRIBENZOR (olmesartan-amlodipine-hctz) ...... 84 tramadol hcl 50 mg tablet (Ultram) ...... 23 trichloroacetic acid...... 157 TRAMADOL HCL 100 MG TABLET...... 23 TRICHLOROACETIC ACID...... 157 tramadol hcl/acetaminophen (Ultracet) ...... 21 TRICOR (fenofibrate) ...... 93 TRAMADOL HCL ER 100 MG CAPSULE...... 23 TRIDESILON (desonide) ...... 160 tramadol hcl er 100 mg tablet...... 23 trientine hcl (Syprine) ...... 168 TRAMADOL HCL ER 150 MG CAPSULE...... 23 trifluoperazine hcl...... 149 TRAMADOL HCL ER 200 MG CAPSULE...... 23 trifluridine...... 69 tramadol hcl er 200 mg tablet...... 23 TRIGLIDE...... 93 TRAMADOL HCL ER 300 MG CAPSULE...... 23 trihexyphenidyl hcl...... 63

213 TRIJARDY XR...... 51 UDENYCA...... 100 TRIKAFTA...... 163 UKONIQ ...... 60 TRILEPTAL (oxcarbazepine) ...... 98 ULESFIA...... 63 TRILIPIX (fenofibric acid) ...... 93 ULORIC 40 MG TABLET (febuxostat) ...... 26 trimethobenzamide hcl (Tigan) ...... 116 ULORIC 80 MG TABLET (febuxostat) ...... 26 trimethoprim...... 35 ULTANE (sevoflurane) ...... 24 trimipramine maleate (Surmontil) ...... 143 ULTRACET (tramadol hcl-acetaminophen) ...... 21 TRI-MIX (PAPVRN-PHNTLMN-PGE1) ...... 165 ULTRAFOAM...... 78 TRIMO-SAN...... 53 ULTRAM (tramadol hcl) ...... 23 TRIMPEX...... 35 ULTRAVATE 0.05% CREAM (halobetasol propionate) ...... 160 TRINTELLIX 5 MG TABLET...... 142 ULTRAVATE 0.05% LOTION...... 160 TRINTELLIX 10 MG TABLET...... 142 ULTRAVATE 0.05% OINTMENT (halobetasol propionate) ...... 160 TRINTELLIX 20 MG TABLET...... 142 ULTRAVATE X...... 160 TRIUMEQ...... 66 UPNEEQ...... 109 TRIZIVIR (abacavir-lamivudine-zidovudine) ...... 66 UPTRAVI...... 82 TROKENDI XR 25 MG CAPSULE...... 99 URAMAXIN...... 155 TROKENDI XR 50 MG CAPSULE...... 99 URAMAXIN (urea) ...... 155 TROKENDI XR 100 MG CAPSULE...... 98 urea...... 155 TROKENDI XR 200 MG CAPSULE...... 99 urea (Hydro 35) ...... 155 tropicamide...... 111 urea (Hydro 40) ...... 156 TROPICAMIDE-CYCLOPENTOLATE-PE...... 111 urea (Uramaxin) ...... 156 tropicamide (Mydriacyl) ...... 111 urea (Xurea) ...... 156 trospium chloride...... 171 URECHOLINE (bethanechol chloride) ...... 74 TRULANCE...... 119 URIBEL...... 35 TRULICITY 0.75 MG/0.5 ML PEN...... 48 UROCIT-K (potassium citrate er) ...... 114 TRULICITY 1.5 MG/0.5 ML PEN...... 48 UROQID-ACID NO.2...... 114 TRULICITY 3 MG/0.5 ML PEN...... 48 UROXATRAL (alfuzosin hcl er) ...... 170 TRULICITY 4.5 MG/0.5 ML PEN...... 48 ursodiol (Actigall) ...... 118 TRUMENBA...... 75 ursodiol (Urso) ...... 118 TRUSOPT (dorzolamide hcl) ...... 110 ursodiol (Urso Forte) ...... 118 TRUVADA (emtricitabine-tenofovir disop) ...... 66 URSO FORTE (ursodiol) ...... 118 TUDORZA PRESSAIR...... 29 URSO (ursodiol) ...... 118 TUKYSA...... 60 UTA...... 35 TURALIO...... 60 UTIBRON NEOHALER...... 30 TUSSICAPS...... 103 V TUXARIN ER...... 103 VAGIFEM (yuvafem) ...... 129 TUZISTRA XR...... 103 valacyclovir hcl (Valtrex) ...... 70 TWINRIX...... 77 VALCHLOR...... 62 TWIRLA...... 102 VALCYTE (valganciclovir hcl) ...... 70 TYBLUME...... 102 valganciclovir hcl (Valcyte) ...... 70 TYBOST...... 163 VALIUM (diazepam) ...... 137 TYKERB (lapatinib) ...... 60 valproic acid...... 99 TYMLOS...... 130 valproic acid (as sodium salt) ...... 99 TYVASO...... 82 valsartan (Diovan) ...... 86 TYVASO INSTITUTIONAL START KIT...... 82 valsartan/hydrochlorothiazide (Diovan Hct) ...... 85 TYVASO REFILL KIT...... 82 VALTOCO...... 95 TYVASO STARTER KIT...... 82 VALTREX (valacyclovir) ...... 70 U VANATOL LQ...... 17 UBRELVY...... 19 VANATOL S...... 17 UCERIS 2 MG RECTAL FOAM...... 123 VANCOCIN HCL (vancomycin hcl) ...... 41 UCERIS 9 MG ER TABLET (budesonide er) ...... 127 vancomycin hcl (Firvanq) ...... 41

214 vancomycin hcl (Vancocin Hcl) ...... 41 VESICARE 5 MG TABLET (solifenacin succinate) ...... 171 VANOS (fluocinonide) ...... 160 VESICARE 10 MG TABLET (solifenacin succinate) ...... 171 vardenafil hcl...... 165 VESICARE LS...... 171 vardenafil hcl (Levitra) ...... 165 VFEND (voriconazole) ...... 45 VARIBAR HONEY...... 104 V-GO 20...... 133 VARIBAR NECTAR...... 104 V-GO 30...... 133 VARIBAR PUDDING...... 104 V-GO 40...... 133 VARIBAR THIN HONEY...... 104 VIAGRA (sildenafil citrate) ...... 165 VARIBAR THIN LIQUID...... 104 VIBERZI...... 119 VARIVAX VACCINE...... 77 VIBRAMYCIN 25 MG/5 ML SUSP VARUBI...... 116 (doxycycline monohydrate) ...... 40 VASCEPA...... 114 VIBRAMYCIN 50 MG/5 ML SYRUP...... 40 VASERETIC (enalapril-hydrochlorothiazide) ...... 83 VIBRAMYCIN 100 MG CAPSULE (morgidox) ...... 40 VASHE WOUND...... 151 VICTOZA 2-PAK...... 48 VASHE WOUND THERAPY...... 151 VICTOZA 3-PAK...... 48 VASOTEC (enalapril maleate) ...... 86 VIDEX EC...... 67 VAXELIS...... 77 VIDEX EC (didanosine) ...... 67 VECAMYL...... 87 VIEKIRA PAK...... 70 VECTICAL (calcitriol) ...... 154 vigabatrin (Sabril) ...... 99 VELPHORO...... 113 VIGAMOX (moxifloxacin) ...... 33 VELTASSA...... 113 VIIBRYD 10-20 MG STARTER PACK...... 142 VELTIN...... 153 VIIBRYD 10 MG TABLET...... 142 VEMLIDY...... 71 VIIBRYD 20 MG TABLET...... 142 VENCLEXTA...... 60 VIIBRYD 40 MG TABLET...... 142 VENCLEXTA STARTING PACK...... 60 VIMOVO (naproxen-esomeprazole mag) ...... 26 venlafaxine hcl 25 mg tablet...... 142 VIMPAT...... 99 venlafaxine hcl 37.5 mg tablet...... 142 VIOKACE...... 120 venlafaxine hcl 50 mg tablet...... 142 VIRACEPT...... 68 venlafaxine hcl 75 mg tablet...... 142 VIRAMUNE (nevirapine) ...... 67 venlafaxine hcl 100 mg tablet...... 142 VIRAMUNE XR (nevirapine er) ...... 67 venlafaxine hcl er 37.5 mg cap (Effexor Xr)...... 142 VIRAZOLE...... 70 venlafaxine hcl er 37.5 mg tab...... 142 VIREAD 150 MG TABLET...... 68 venlafaxine hcl er 75 mg cap (Effexor Xr)...... 142 VIREAD 200 MG TABLET...... 68 venlafaxine hcl er 75 mg tab...... 142 VIREAD 250 MG TABLET...... 68 venlafaxine hcl er 150 mg cap (Effexor Xr)...... 142 VIREAD 300 MG TABLET (tenofovir disoproxil fumarate) ...... 68 venlafaxine hcl er 150 mg tab...... 142 VIREAD POWDER...... 68 venlafaxine hcl er 225 mg tab...... 142 VISTARIL (hydroxyzine pamoate) ...... 47 VENTAVIS...... 82 VISTOGARD...... 164 VENTOLIN HFA...... 30 VITAFOL FE+...... 137 verapamil hcl...... 80 vite ac/grape/hyaluronic acid (Atopiclair) ...... 154 verapamil hcl (Calan Sr) ...... 80 VITRAKVI...... 60 verapamil hcl (Verelan) ...... 81 VIVELLE-DOT (lyllana) ...... 126 verapamil hcl (Verelan Pm) ...... 80 VIVLODEX 5 MG CAPSULE (meloxicam) ...... 28 VERDESO...... 160 VIVLODEX 10 MG CAPSULE (meloxicam) ...... 28 VEREGEN...... 72 VIZIMPRO...... 60 VERELAN PM (verapamil er pm) ...... 81 VOGELXO 12.5 MG/1.25 GRAM PUMP...... 124 VERELAN (verapamil hcl) ...... 81 VOGELXO 50 MG/5 GRAM GEL PACKT...... 124 VERELAN (verapamil sr) ...... 81 VOGELXO 50 MG/5 GRAM GEL (testosterone) ...... 124 VERQUVO ...... 81 VOLTAREN (diclofenac sodium) ...... 152 VERSACLOZ...... 148 VOLUMEN...... 104 VERZENIO...... 60 voriconazole (Vfend) ...... 45

215 VORTEX...... 135 XALATAN (latanoprost) ...... 110 VORTEX HOLDING CHAMBER-CHILD...... 135 XALKORI...... 60 VORTEX HOLDING CHAMBER-TODDLER...... 135 XANAX (alprazolam) ...... 137 VORTEX VHC FROG MASK...... 135 XANAX XR (alprazolam xr) ...... 137 VORTEX VHC LADYBUG MASK...... 135 XARELTO...... 43 VOSEVI...... 70 XATMEP...... 57 VOTRIENT...... 60 XCLAIR...... 154 VRAYLAR 1.5 MG-3 MG PACK...... 148 XCOPRI 12.5-25 MG TITRATION PK...... 99 VRAYLAR 1.5 MG CAPSULE...... 148 XCOPRI 50-100 MG TITRATION PAK...... 99 VRAYLAR 3 MG CAPSULE...... 148 XCOPRI 50 MG TABLET...... 99 VRAYLAR 4.5 MG CAPSULE...... 148 XCOPRI 100 MG TABLET...... 99 VRAYLAR 6 MG CAPSULE...... 148 XCOPRI 150-200 MG TITRATION PK...... 99 VUMERITY...... 95 XCOPRI 150 MG TABLET...... 99 VUSION...... 47 XCOPRI 200 MG TABLET...... 99 VYLEESI...... 146 XCOPRI 250 MG DAILY DOSE PACK...... 99 VYNDAMAX...... 168 XCOPRI 350 MG DAILY DOSE PACK...... 99 VYNDAQEL...... 168 XELJANZ 1 MG/ML SOLUTION...... 26 VYTORIN (ezetimibe-simvastatin) ...... 89 XELJANZ 5 MG TABLET...... 26 VYVANSE 10 MG CAPSULE...... 143 XELJANZ 10 MG TABLET...... 26 VYVANSE 10 MG CHEWABLE TABLET...... 143 XELJANZ XR...... 26 VYVANSE 20 MG CAPSULE...... 143 XELODA (capecitabine) ...... 57 VYVANSE 20 MG CHEWABLE TABLET...... 143 XELPROS...... 110 VYVANSE 30 MG CAPSULE...... 143 XENAZINE (tetrabenazine) ...... 94 VYVANSE 30 MG CHEWABLE TABLET...... 143 XENICAL...... 62 VYVANSE 40 MG CAPSULE...... 143 XENLETA...... 38 VYVANSE 40 MG CHEWABLE TABLET...... 143 XEPI...... 42 VYVANSE 50 MG CAPSULE...... 143 XERESE...... 71 VYVANSE 50 MG CHEWABLE TABLET...... 143 XERMELO...... 115 VYVANSE 60 MG CAPSULE...... 143 XHANCE...... 107 VYVANSE 60 MG CHEWABLE TABLET...... 143 XIFAXAN 200 MG TABLET...... 39 VYVANSE 70 MG CAPSULE...... 143 XIFAXAN 550 MG TABLET...... 39 VYZULTA...... 110 XIGDUO XR 2.5 MG-1, 000 MG TAB...... 51 XIGDUO XR 5 MG-1, 000 MG TABLET...... 51 W WAKIX...... 99 XIGDUO XR 5 MG-500 MG TABLET...... 51 warfarin sodium...... 42 XIGDUO XR 10 MG-1, 000 MG TAB...... 51 water for irrigation, sterile...... 151 XIGDUO XR 10 MG-500 MG TABLET...... 51 WELCHOL (colesevelam hcl) ...... 92 XIIDRA...... 111 WELLBUTRIN SR 100 MG TABLET (bupropion hcl sr) ...... 138 XIMINO...... 40 WELLBUTRIN SR 150 MG TABLET (bupropion hcl sr) ...... 138 XOFLUZA...... 70 WELLBUTRIN SR 200 MG TABLET (bupropion hcl sr) ...... 139 XOLAIR...... 31 WELLBUTRIN XL 150 MG TABLET (bupropion xl) ...... 139 XOLEGEL...... 47 WELLBUTRIN XL 300 MG TABLET (bupropion xl) ...... 139 XOPENEX CONCENTRATE (levalbuterol concentrate) ...... 30 WIDE SEAL DIAPHRAGM...... 102 XOPENEX HFA...... 30 WINLEVI...... 55 XOPENEX (levalbuterol hcl) ...... 30 WP THYROID...... 163 XOSPATA...... 60 WP THYROID (nature-throid) ...... 163 XPOVIO...... 61 WP THYROID (westhroid) ...... 163 XTAMPZA ER...... 23 WYNZORA...... 161 XTANDI...... 57 XULTOPHY 100-3.6...... 48 X XUREA...... 156 XADAGO...... 65 XURIDEN...... 112

216 XYOSTED...... 124 ZIOPTAN...... 110 XYREM...... 149 ziprasidone hcl (Geodon) ...... 148 XYWAV...... 149 ZIPSOR...... 20 Y ZIRGAN...... 69 YASMIN 28 (zumandimine) ...... 102 ZITHROMAX 1 GM POWDER PACKET (azithromycin) ...... 37 YAZ (vestura) ...... 102 ZITHROMAX 100 MG/5 ML SUSP (azithromycin) ...... 37 YERVOY...... 61 ZITHROMAX 200 MG/5 ML SUSP (azithromycin) ...... 37 YONSA...... 57 ZITHROMAX 200 MG/5 ML SUSP (azithromycin) ...... 37 YOSPRALA...... 65 ZITHROMAX 250 MG TABLET (azithromycin) ...... 37 YUPELRI...... 29 ZITHROMAX 250 MG Z-PAK TABLET (azithromycin) ...... 37 ZITHROMAX 500 MG TABLET (azithromycin) ...... 37 Z zafirlukast (Accolate) ...... 31 ZITHROMAX TRI-PAK (azithromycin) ...... 37 zaleplon...... 150 ZOCOR 10 MG TABLET (simvastatin) ...... 91 ZANAFLEX (tizanidine hcl) ...... 136 ZOCOR 20 MG TABLET (simvastatin) ...... 91 ZARONTIN (ethosuximide) ...... 99 ZOCOR 40 MG TABLET (simvastatin) ...... 91 ZARXIO...... 100 ZOCOR 80 MG TABLET (simvastatin) ...... 91 ZAVESCA (miglustat) ...... 167 ZOFRAN 2 MG/ML VIAL (ondansetron hcl) ...... 116 ZCORT...... 127 ZOFRAN 4 MG TABLET (ondansetron hcl) ...... 116 ZEGERID 20 MG CAPSULE ZOFRAN 8 MG TABLET (ondansetron hcl) ...... 116 (omeprazole-sodium bicarbonate) ...... 122 ZOHYDRO ER (hydrocodone bitartrate er) ...... 23 ZEGERID 20 MG PACKET ZOKINVY...... 164 (omeprazole-sodium bicarbonate) ...... 122 ZOLADEX...... 58 ZEGERID 40 MG CAPSULE ZOLINZA...... 56 (omeprazole-sodium bicarbonate) ...... 122 ZOLMITRIPTAN 2.5 MG NASAL SPRY...... 19 ZEGERID 40 MG PACKET zolmitriptan 2.5 mg tablet (Zomig) ...... 19 (omeprazole-sodium bicarbonate) ...... 122 ZOLMITRIPTAN 5 MG NASAL SPRAY...... 19 ZEJULA...... 60 zolmitriptan 5 mg tablet (Zomig) ...... 19 ZELAPAR...... 65 zolmitriptan (Zomig Zmt) ...... 19 ZELBORAF...... 57 ZOLOFT 20 MG/ML ORAL CONC (sertraline hcl) ...... 140 ZELNORM...... 119 ZOLOFT 25 MG TABLET (sertraline hcl) ...... 141 ZEMBRACE SYMTOUCH...... 19 ZOLOFT 50 MG TABLET (sertraline hcl) ...... 141 ZEMPLAR (paricalcitol) ...... 166 ZOLOFT 100 MG TABLET (sertraline hcl) ...... 140 ZENATANE...... 152 zolpidem tart er 6.25 mg tab (Ambien Cr) ...... 150 ZENPEP...... 120 zolpidem tart er 12.5 mg tab (Ambien Cr) ...... 150 ZENZEDI...... 74 zolpidem tartrate...... 151 ZEPATIER...... 71 zolpidem tartrate (Ambien) ...... 151 ZEPOSIA...... 95 ZOLPIMIST...... 151 ZERVIATE...... 48 ZOMACTON...... 128 ZESTORETIC (lisinopril-hydrochlorothiazide) ...... 83 ZOMIG 2.5 MG NASAL SPRAY...... 19 ZESTRIL (lisinopril) ...... 86 ZOMIG 2.5 MG TABLET (zolmitriptan) ...... 19 ZETIA (ezetimibe) ...... 93 ZOMIG 5 MG NASAL SPRAY...... 19 ZETONNA...... 107 ZOMIG 5 MG TABLET (zolmitriptan) ...... 19 ZIAC (bisoprolol-hydrochlorothiazide) ...... 88 ZOMIG ZMT (zolmitriptan odt) ...... 19 ZIAGEN (abacavir) ...... 67 ZONACORT...... 127 ZIANA (clindamycin phos-tretinoin) ...... 153 ZONALON...... 153 zidovudine...... 67 ZONALON (prudoxin) ...... 153 zidovudine (Retrovir) ...... 67 ZONEGRAN (zonisamide) ...... 99 ZIEXTENZO...... 100 zonisamide...... 99 zileuton...... 28 zonisamide (Zonegran) ...... 99 ZILXI...... 42 ZONTIVITY...... 65 zinc oxide...... 156 ZORBTIVE...... 128

217 ZORTRESS...... 132 ZORTRESS (everolimus) ...... 132 ZORVOLEX...... 28 ZOSTAVAX...... 77 ZOVIRAX 5% CREAM (acyclovir) ...... 72 ZOVIRAX 5% OINTMENT (acyclovir) ...... 72 ZOVIRAX 200 MG/5 ML SUSP (acyclovir) ...... 70 ZTLIDO...... 24 ZUBSOLV...... 170 ZUPLENZ...... 116 ZYCLARA 2.5% CREAM PUMP...... 154 ZYCLARA 3.75% CREAM (imiquimod) ...... 154 ZYCLARA 3.75% CREAM PUMP...... 154 ZYDELIG...... 60 ZYFLO...... 28 ZYKADIA...... 60 ZYLET...... 32 ZYLOPRIM (allopurinol) ...... 26 ZYMAXID (gatifloxacin) ...... 33 ZYPITAMAG...... 91 ZYPREXA (olanzapine) ...... 148 ZYPREXA ZYDIS (olanzapine odt) ...... 148 ZYTIGA (abiraterone acetate) ...... 57 ZYVOX (linezolid) ...... 38

218 Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

1. State laws in Texas and Louisiana may require your plan to cover your medication at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on your Cigna ID card. 2. State law in Illinois may require your plan to cover your medications at your current benefit level until your plan renews. This means that if you currently have approval through a review process for your plan to cover your medication, the drug list change(s) listed here may not affect you until your plan renewal date. If you don’t currently have approval through a coverage review process, you may continue to receive coverage at your current benefit level if your doctor requests it. To find out if this state law applies to your plan, please call Customer Service using the number on your Cigna ID card. 3. Prices shown on myCigna are not guaranteed and coverage is subject to your plan terms and conditions. Visit myCigna for more information. 4. U.S. Food and Drug Administration (FDA) website, “Generic Drug Facts.” Last updated 06/01/18. 5. Not all plans offer home delivery and Accredo as covered pharmacy options. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about the pharmacies in your plan’s network. 6. Standard shipping costs are included as part of your prescription plan. 7. As allowable by law. For medications administered by a health care provider, Accredo will ship the medication directly to your doctor’s office. 8. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. “Accredo” refers to Accredo Health Group, Inc. “Express Scripts Pharmacy” refers to ESI Mail Pharmacy Service, Inc. and Express Scripts Pharmacy, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, “Together, all the way.,” and “myCigna” are trademarks of Cigna Intellectual Property, Inc. “Accredo” and “Express Scripts Pharmacy” are trademarks of Express Scripts Strategic Development, Inc. 938074 c CA Legacy (Standard) 4-Tier SPEC 06/21 © 2021 Cigna. Some content provided under license. DISCRIMINATION IS AGAINST THE LAW

Medical coverage

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Cigna: • 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 customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna 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 by sending an email to [email protected] or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to [email protected]. 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, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375a 05/17 © 2017 Cigna. Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711). Arabic – برجاء االنتباه خدمات الترجمة المجانية متاحة لكم. لعمالء Cigna الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. او اتصل ب TTY) 1.800.244.6224: اتصل ب 711). French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711). Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711). (Persian (Farsi – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را شماره گيری کنيد). 896375a 05/17