BCBSVT National Performance Formulary Document 2020 Table of Contents

ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ...... 16 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ...... 27 CARDIOVASCULAR, HYPERTENSION & LIPIDS ...... 51 DERMATOLOGICALS/TOPICAL THERAPY ...... 64 DIAGNOSTICS & MISCELLANEOUS AGENTS ...... 77 EAR, NOSE & THROAT MEDICATIONS ...... 80 ENDOCRINE/DIABETES ...... 82 GASTROENTEROLOGY ...... 101 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ...... 109 MUSCULOSKELETAL & RHEUMATOLOGY ...... 115 OBSTETRICS & GYNECOLOGY ...... 117 OPHTHALMOLOGY ...... 126 RESPIRATORY, ALLERGY, COUGH & COLD ...... 133 UROLOGICALS ...... 141 VITAMINS, HEMATINICS & ELECTROLYTES ...... 143 Index of Drugs ...... 149

1 List of Abbreviations

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Below is a list of drug name formatting patterns that may appear in the following pages.

List of Patterns lowercase italics: Generic drugs UPPERCASE: Brand name drugs

2 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 AMBISOME 2 amphotericin b 1 ANCOBON 3 flucytosine CANCIDAS 3 caspofungin acetate caspofungin 1 clotrimazole 1 CRESEMBA 2 DIFLUCAN 3 fluconazole ERAXIS(WATER DILUENT) 2 fluconazole 1 fluconazole in nacl (iso-osm) 1 flucytosine 1 griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole oral capsule 1 QL itraconazole oral solution 1 ketoconazole 1 MYCAMINE 2 NOXAFIL INTRAVENOUS 2 NOXAFIL ORAL SUSPENSION 2 NOXAFIL ORAL TABLET,DELAYED 3 posaconazole RELEASE (DR/EC) nystatin 1 ONMEL 3 itraconazole ORAVIG 3 nystatin, clotrimazole posaconazole 1 SPORANOX 3 itraconazole SPORANOX PULSEPAK 3 QL itraconazole terbinafine hcl 1 VFEND 3 voriconazole VFEND IV 3 voriconazole voriconazole 1 ANTIVIRALS

3 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES abacavir 1 abacavir-lamivudine 1 abacavir-lamivudine-zidovudine 1 acyclovir 1 acyclovir sodium 1 adefovir 1 amantadine hcl 1 APTIVUS 2 atazanavir 1 BARACLUDE 2 BIKTARVY 2 cidofovir 1 CIMDUO 2 COMBIVIR 3 lamivudine-zidovudine CRIXIVAN 2 CYTOVENE 3 ganciclovir sodium DESCOVY 2 didanosine 1 DOVATO 2 EDURANT 2 efavirenz 1 EMTRIVA 2 entecavir 1 EPCLUSA 2 PA EPIVIR 3 lamivudine EPIVIR HBV ORAL SOLUTION 2 EPIVIR HBV ORAL TABLET 3 lamivudine EPZICOM 3 abacavir-lamivudine EVOTAZ 3 atazanavir sulfate, NORVIR famciclovir 1 QL FLUMADINE 3 rimantadine hcl fosamprenavir 1 FOSCAVIR 3 foscarnet sodium FUZEON 2 GANCICLOVIR 3 ganciclovir sodium 1

4 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES GENVOYA 2 HARVONI 2 PA HEPSERA 3 adefovir dipivoxil INTELENCE 2 INVIRASE 2 ISENTRESS 2 ISENTRESS HD 2 JULUCA 2 KALETRA ORAL SOLUTION 3 lopinavir-ritonavir KALETRA ORAL TABLET 2 lamivudine 1 lamivudine-zidovudine 1 LEXIVA ORAL SUSPENSION 2 LEXIVA ORAL TABLET 3 fosamprenavir calcium lopinavir-ritonavir 1 nevirapine 1 NORVIR ORAL POWDER IN 2 PACKET NORVIR ORAL SOLUTION 2 NORVIR ORAL TABLET 3 ritonavir ODEFSEY 2 oseltamivir oral capsule 1 QL oseltamivir oral suspension for 1 reconstitution PREVYMIS INTRAVENOUS 2 PREVYMIS ORAL 2 QL PREZISTA 2 RAPIVAB (PF) 2 RELENZA DISKHALER 3 oseltamivir phosphate RESCRIPTOR 2 RETROVIR INTRAVENOUS 2 RETROVIR ORAL 3 zidovudine REYATAZ ORAL CAPSULE 3 atazanavir sulfate REYATAZ ORAL POWDER IN 2 PACKET ribavirin 1 rimantadine 1

5 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ritonavir 1 SELZENTRY 2 stavudine 1 SUSTIVA 3 efavirenz SYMFI 2 SYMFI LO 2 SYNAGIS 2 TAMIFLU ORAL CAPSULE 3 QL oseltamivir phosphate TAMIFLU ORAL SUSPENSION FOR 3 oseltamivir phosphate RECONSTITUTION TEMIXYS 2 tenofovir disoproxil fumarate 1 TIVICAY 2 TRIUMEQ 2 abacavir-lamivudine- TRIZIVIR 3 zidovudine TROGARZO 2 TRUVADA 2 TYBOST 3 NORVIR valacyclovir 1 QL VALCYTE 3 valganciclovir hcl valganciclovir 1 VEMLIDY 2 VIDEX 2 GRAM PEDIATRIC 2 VIDEX EC 3 didanosine EPCLUSA, HARVONI, VIEKIRA PAK 3 PA VOSEVI, ZEPATIER VIRACEPT 2 VIRAMUNE 3 nevirapine VIRAMUNE XR 3 nevirapine er VIRAZOLE 3 ribavirin VIREAD ORAL POWDER 2 VIREAD ORAL TABLET 150 MG, 200 2 MG, 250 MG VIREAD ORAL TABLET 300 MG 3 tenofovir disoproxil fumarate VOSEVI 2 PA XOFLUZA 3 oseltamivir phosphate

6 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ZEPATIER 2 PA ZERIT 3 stavudine ZIAGEN 3 abacavir zidovudine 1 ZOVIRAX 3 acyclovir CEPHALOSPORINS AVYCAZ 2 cefaclor 1 cefadroxil 1 cefazolin 1 CEFAZOLIN IN 0.9% SOD 3 CHLORIDE cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 1 gram/50 ml CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 3 GRAM/100 ML CEFAZOLIN IN DEXTROSE 5 % 3 CEFAZOLIN IN STERILE WATER 3 cefdinir 1 cefditoren pivoxil 1 cefepime 1 CEFEPIME IN DEXTROSE 5 % 3 cefepime in dextrose,iso-osm 1 cefixime 1 CEFOTAN 3 cefotaxime 1 cefotetan 1 CEFOTETAN IN DEXTROSE, ISO- 3 OSM cefoxitin 1 cefoxitin in dextrose, iso-osm 1 cefpodoxime 1 cefprozil 1 ceftazidime 1 CEFTAZIDIME IN D5W 2 ceftriaxone in dextrose,iso-os 1 7 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ceftriaxone injection recon soln 1 gram, 1 10 gram, 2 gram, 250 mg, 500 mg CEFTRIAXONE INJECTION RECON 3 SOLN 100 GRAM ceftriaxone intravenous 1 cefuroxime axetil 1 cefuroxime sodium 1 cephalexin 1 CLAFORAN 3 cefotaxime sodium KEFLEX 3 cephalexin MAXIPIME 3 cefepime hcl SPECTRACEF 3 cefditoren pivoxil cefaclor, cefdinir, SUPRAX ORAL CAPSULE 3 cefpodoxime proxetil, cefprozil, cefuroxime axetil SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 3 500 MG/5 ML SUPRAX ORAL SUSPENSION FOR 3 cefixime RECONSTITUTION 200 MG/5 ML cefaclor, cefdinir, SUPRAX ORAL 3 cefpodoxime proxetil, TABLET,CHEWABLE cefprozil, cefuroxime axetil tazicef 1 TEFLARO 2 ZERBAXA 2 ERYTHROMYCINS & OTHER MACROLIDES azithromycin 1 clarithromycin 1 metronidazole, vancomycin DIFICID 3 hcl e.e.s. 400 1 E.E.S. GRANULES 3 erythromycin ethylsuccinate ERYPED 200 3 erythromycin ethylsuccinate ERYPED 400 3 erythromycin ethylsuccinate ery-tab oral tablet,delayed release 1 (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED 3 RELEASE (DR/EC) 500 MG 8 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ERYTHROCIN 2 erythrocin (as stearate) 1 erythromycin 1 erythromycin ethylsuccinate 1 ZITHROMAX 3 azithromycin ZITHROMAX TRI-PAK 3 azithromycin ZITHROMAX Z-PAK 3 azithromycin MISCELLANEOUS ANTIINFECTIVES azithromycin, ciprofloxacin AEMCOLO 3 QL hcl, levofloxacin hemihydrate, XIFAXAN albendazole 1 QL ALBENZA 3 QL albendazole ALINIA 2 QL amikacin 1 atovaquone-proguanil hcl, chloroquine phosphate, ARAKODA 3 QL doxycycline hyclate, mefloquine hcl, primaquine generic ARIKAYCE 2 PA atovaquone 1 atovaquone-proguanil 1 QL AZACTAM 3 aztreonam aztreonam 1 bacitracin 1 BENZNIDAZOLE 2 QL BETHKIS 2 PA; ST BILTRICIDE 3 praziquantel CAPASTAT 2 CAYSTON 2 QL chloramphenicol sod succinate 1 chloroquine phosphate 1 CLEOCIN HCL 3 clindamycin hcl CLEOCIN INJECTION 3 cleocin intravenous solution 300 mg/2 1 ml

9 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES CLEOCIN INTRAVENOUS SOLUTION 600 MG/4 ML, 900 MG/6 3 ML CLEOCIN PEDIATRIC 3 clindamycin palmitate hcl clindamycin hcl 1 CLINDAMYCIN IN 0.9 % SOD 3 CHLOR clindamycin in 5 % dextrose 1 clindamycin palmitate hcl 1 clindamycin pediatric 1 clindamycin phosphate 1 COARTEM 2 QL colistin (colistimethate na) 1 COLY-MYCIN M PARENTERAL 3 colistimethate sodium CUBICIN 3 daptomycin CUBICIN RF 3 daptomycin CYCLOSERINE 3 DALVANCE 2 dapsone 1 DAPTOMYCIN INTRAVENOUS 3 RECON SOLN 350 MG daptomycin intravenous recon soln 500 1 mg DARAPRIM 2 EMVERM 2 QL ertapenem 1 ethambutol 1 FLAGYL 3 metronidazole gentamicin 1 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 1 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 2 MG/50 ML GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 3 MG/100 ML

10 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES gentamicin sulfate (ped) (pf) 1 gentamicin sulfate (pf) intravenous 1 solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 3 ML GENTAMICIN-SODIUM CITRATE 3 hydroxychloroquine 1 imipenem-cilastatin 1 IMPAVIDO 2 QL INVANZ 3 ertapenem isoniazid 1 ivermectin 1 QL KITABIS PAK 2 PA KRINTAFEL 3 QL primaquine generic LINCOCIN 3 clindamycin phosphate lincomycin 1 linezolid 1 PA linezolid in dextrose 5% 1 linezolid-0.9% sodium chloride 1 MALARONE 3 QL atovaquone-proguanil hcl MALARONE PEDIATRIC 3 QL atovaquone-proguanil hcl mefloquine 1 QL MEPRON 3 atovaquone meropenem 1 MEROPENEM-0.9% SODIUM 2 CHLORIDE MERREM 3 meropenem metro i.v. 1 metronidazole 1 metronidazole in nacl (iso-os) 1 MYAMBUTOL 3 ethambutol hcl MYCOBUTIN 3 rifabutin NEBUPENT 2 QL neomycin 1 ORBACTIV 2 paromomycin 1

11 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES PASER 3 PENTAM 3 NEBUPENT pentamidine 1 polymyxin b sulfate 1 praziquantel 1 PRETOMANID 3 PRIFTIN 2 primaquine 1 QL PRIMAXIN IV 3 imipenem-cilastatin sodium pyrazinamide 1 QUALAQUIN 3 QL quinine sulfate quinine sulfate 1 QL rifabutin 1 RIFADIN 3 rifampin RIFAMATE 3 isoniazid, rifampin rifampin 1 RIFATER 3 SIRTURO 2 SIVEXTRO INTRAVENOUS 3 linezolid, linezolid SIVEXTRO ORAL 3 PA linezolid clindamycin hcl, clindamycin SOLOSEC 3 phosphate, metronidazole, metronidazole, tinidazole STREPTOMYCIN 2 STROMECTOL 3 QL ivermectin SYNERCID 2 tigecycline 1 tinidazole 1 QL TOBI PODHALER 2 PA; ST tobramycin in 0.225 % nacl 1 PA; QL tobramycin in 0.9 % nacl 1 tobramycin sulfate 1 tobramycin sulfate, TOBRAMYCIN WITH NEBULIZER 3 PA BETHKIS, TOBI PODHALER TRECATOR 3 TYGACIL 3 tigecycline

12 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES VABOMERE 3 azithromycin, clarithromycin, doxycycline hyclate, XENLETA 3 moxifloxacin hcl, levofloxacin hemihydrate, amoxicillin- clavulanate potass, cefdinir XIFAXAN 2 ZEMDRI 3 ZYVOX INTRAVENOUS 3 ZYVOX ORAL 3 PA linezolid PENICILLINS amoxicillin 1 amoxicillin-pot clavulanate 1 ampicillin 1 ampicillin sodium 1 ampicillin-sulbactam 1 AUGMENTIN ES-600 3 amoxicillin-clavulanate potass AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 2 MG/5 ML AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 3 amoxicillin-clavulanate potass MG/5 ML AUGMENTIN ORAL TABLET 3 amoxicillin-clavulanate potass AUGMENTIN XR 3 amoxicillin-clavulanate pot er BICILLIN C-R 2 BICILLIN L-A 2 dicloxacillin 1 MOXATAG 3 amoxicillin nafcillin 1 nafcillin in dextrose iso-osm 1 oxacillin 1 oxacillin in dextrose(iso-osm) 1 PENICILLIN G POT IN DEXTROSE 2 penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium 1

13 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES pfizerpen-g 1 piperacillin-tazobactam 1 UNASYN 3 ampicillin/sulbactam ZOSYN 3 piperacillin-tazobactam ZOSYN IN DEXTROSE (ISO-OSM) 2 QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) 3 moxifloxacin hcl BAXDELA INTRAVENOUS 3 ciprofloxacin hcl, clindamycin hcl, levofloxacin hemihydrate, BAXDELA ORAL 3 linezolid, moxifloxacin hcl, ofloxacin CIPRO ORAL SUSPENSION,MICROCAPSULE 3 ciprofloxacin RECON CIPRO ORAL TABLET 3 ciprofloxacin hcl ciprofloxacin 1 ciprofloxacin hcl 1 ciprofloxacin in 5 % dextrose 1 ciprofloxacin hcl, levofloxacin FACTIVE 3 hemihydrate, moxifloxacin hcl, ofloxacin LEVAQUIN 3 levofloxacin hemihydrate levofloxacin 1 levofloxacin in d5w 1 moxifloxacin 1 MOXIFLOXACIN-SOD.ACE,SUL- 2 WATER moxifloxacin-sod.chloride(iso) 1 ofloxacin 1 SULFA'S & RELATED AGENTS sulfamethoxazole/trimethopri BACTRIM 3 m sulfamethoxazole/trimethopri BACTRIM DS 3 m sulfadiazine 1 sulfamethoxazole-trimethoprim 1 sulfatrim 1 TETRACYCLINES 14 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES doxycycline hyclate, ACTICLATE 3 doxycycline monohydrate avidoxy 1 AVIDOXY DK 3 doxycycline monohydrate coremino 1 demeclocycline 1 DORYX 3 doxycycline hyclate DORYX MPC 3 doxycycline hyclate doxy-100 1 doxycycline hyclate 1 doxycycline monohydrate 1 MINOCIN INTRAVENOUS 2 MINOCIN ORAL 3 minocycline hcl minocycline 1 mondoxyne nl 1 MONODOX 3 doxycycline monohydrate morgidox 1 MORGIDOX 1X 50 3 doxycycline hyclate MORGIDOX 2X100 3 doxycycline hyclate doxycycline hyclate, NUZYRA 3 tetracycline hcl NUZYRA (7 DAY WITH LOAD doxycycline hyclate, 3 QL DOSE) tetracycline hcl okebo 1 ORACEA 2 doxycycline hyclate, SEYSARA 3 minocycline hcl, tetracycline hcl SOLODYN 3 minocycline hcl er TARGADOX 3 doxycycline hyclate tetracycline 1 VIBRAMYCIN ORAL CAPSULE 3 doxycycline hyclate VIBRAMYCIN ORAL SUSPENSION 3 doxycycline monohydrate FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP 3 doxycycline hyclate XERAVA 3 XIMINO 3 minocycline hcl URINARY TRACT AGENTS 15 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FURADANTIN 3 nitrofurantoin HIPREX 3 methenamine hippurate MACROBID 3 nitrofurantoin macrocrystal MACRODANTIN 3 nitrofurantoin methenamine hippurate 1 methenamine mandelate 1 ciprofloxacin hcl, MONUROL 3 nitrofurantoin nitrofurantoin 1 nitrofurantoin macrocrystal 1 nitrofurantoin monohyd/m-cryst 1 PRIMSOL 3 trimethoprim trimethoprim 1 TRIMPEX 3 VANCOMYCIN FIRVANQ 3 vancomycin hcl VANCOCIN 3 vancomycin hcl VANCOMYCIN HCL IN WATER 3 VANCOMYCIN IN 0.9 % SODIUM 2 CHL VANCOMYCIN IN DEXTROSE 5 % 2 VANCOMYCIN INJECTION 3 vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 1 mg VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 3 GRAM, 250 MG vancomycin oral 1 VANCOMYCIN-WATER INJECT 3 (PEG) VIBATIV 2 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 1 dexrazoxane hcl 1

16 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ELITEK 2 ETHYOL 3 amifostine FUSILEV 3 PA levoleucovorin calcium KEPIVANCE 2 leucovorin calcium, KHAPZORY 3 PA levoleucovorin calcium leucovorin calcium 1 levoleucovorin calcium 1 PA mesna 1 MESNEX INTRAVENOUS 3 mesna MESNEX ORAL 2 TOTECT 3 dexrazoxane VISTOGARD 2 PA VORAXAZE 2 XGEVA 2 ZINECARD (AS HCL) 3 dexrazoxane ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS abiraterone 1 PA ABRAXANE 2 ADAKVEO 3 PA ADCETRIS 2 adriamycin intravenous recon soln 10 1 mg ADRIAMYCIN INTRAVENOUS 3 RECON SOLN 50 MG adriamycin intravenous solution 1 adrucil 1 AFINITOR 2 PA AFINITOR DISPERZ 2 PA ALECENSA 2 PA ALIMTA 2 ALIQOPA 2 PA ALKERAN 3 melphalan hcl ALKERAN (AS HCL) 3 melphalan hcl ALECENSA, XALKORI, ALUNBRIG 3 PA ZYKADIA 17 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES anastrozole 1 AROMASIN 3 exemestane ARRANON 2 ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 3 TRISENOX MG/ML arsenic trioxide intravenous solution 2 1 TRISENOX mg/ml ARZERRA 3 IMBRUVICA, VENCLEXTA ASPARLAS 3 PA ONCASPAR ASTAGRAF XL 3 tacrolimus AVASTIN 2 PA azacitidine 1 PA AZASAN 3 azathioprine azathioprine 1 azathioprine sodium 1 BALVERSA 2 PA BAVENCIO 2 PA BELEODAQ 3 PA ISTODAX, FOLOTYN BELRAPZO 3 PA BENDEKA, TREANDA BENDAMUSTINE 3 PA BENDEKA, TREANDA BENDEKA 2 PA BESPONSA 2 PA bexarotene 1 PA bicalutamide 1 BICNU 3 carmustine bleomycin 1 BLINCYTO 2 PA BORTEZOMIB 3 VELCADE BOSULIF 2 PA BRAFTOVI 3 PA TAFINLAR, ZELBORAF BRUKINSA 3 PA busulfan 1 BUSULFEX 3 busulfan CABOMETYX 2 PA CALQUENCE 3 PA IMBRUVICA CAMPTOSAR 3 irinotecan hcl

18 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES capecitabine 1 CAPRELSA 2 PA carboplatin 1 carmustine 1 CASODEX 3 bicalutamide CELLCEPT 3 mycophenolate mofetil CELLCEPT INTRAVENOUS 3 mycophenolate mofetil CISPLATIN INTRAVENOUS RECON 3 SOLN cisplatin intravenous solution 1 cladribine 1 clofarabine 1 CLOLAR 3 clofarabine COMETRIQ 2 PA IMBRUVICA, COPIKTRA 3 PA VENCLEXTA, ZYDELIG COSMEGEN 3 COTELLIC 2 PA cyclophosphamide 1 cyclosporine 1 cyclosporine modified 1 CYRAMZA 2 PA cytarabine 1 cytarabine (pf) 1 dacarbazine 1 DACOGEN 3 decitabine dactinomycin 1 DARZALEX 2 PA daunorubicin 1 azacitidine, cytarabine, DAURISMO 3 PA decitabine, VENCLEXTA decitabine 1 DOCEFREZ 2 docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 1 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

19 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES DOCETAXEL INTRAVENOUS 2 SOLUTION 20 MG/ML DOXIL 3 doxorubicin hcl liposomal doxorubicin 1 doxorubicin, peg-liposomal 1 DROXIA 2 ELIGARD 2 PA ELIGARD (3 MONTH) 2 PA ELIGARD (4 MONTH) 2 PA ELIGARD (6 MONTH) 2 PA ELLENCE 3 epirubicin hcl ELZONRIS 2 PA EMCYT 2 DARZALEX, KYPROLIS, NINLARO, POMALYST, EMPLICITI 3 PA REVLIMID, THALOMID, VELCADE ENVARSUS XR 3 tacrolimus epirubicin 1 ERBITUX 2 PA ERIVEDGE 2 PA ERLEADA 2 PA erlotinib 1 PA; QL ERWINAZE 3 PA ETOPOPHOS 2 etoposide 1 EVOMELA 3 melphalan hcl exemestane 1 FARESTON 3 toremifene citrate NINLARO, POMALYST, FARYDAK 3 PA REVLIMID, THALOMID FASLODEX 2 PA FEMARA 3 letrozole FIRMAGON KIT W DILUENT 2 PA SYRINGE floxuridine 1 fludarabine 1 fluorouracil 1

20 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES flutamide 1 FOLOTYN 2 PA fulvestrant 1 PA GAMIFANT 2 PA GAZYVA 2 PA gemcitabine intravenous recon soln 1 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 1 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GEMCITABINE INTRAVENOUS 3 SOLUTION 100 MG/ML gengraf 1 GILOTRIF 2 PA GLEOSTINE 2 HALAVEN 2 HERCEPTIN 2 PA HERCEPTIN HYLECTA 3 PA HERCEPTIN HYCAMTIN INTRAVENOUS 3 topotecan hcl HYCAMTIN ORAL 2 HYDREA 3 hydroxyurea hydroxyurea 1 IBRANCE 2 PA ICLUSIG 2 PA IDAMYCIN PFS 3 idarubicin hcl idarubicin 1 IDHIFA 2 PA IFEX 3 ifosfamide ifosfamide 1 imatinib 1 PA IMBRUVICA 2 PA IMFINZI 2 PA KEYTRUDA, MEKINIST, IMLYGIC 3 PA OPDIVO, TAFINLAR, YERVOY, ZELBORAF IMURAN 3 azathioprine INFUGEM 3 gemcitabine hcl INLYTA 2 PA

21 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES IRESSA 2 PA; QL irinotecan 1 ISTODAX 2 PA IXEMPRA 2 JAKAFI 2 PA JEVTANA 2 PA KADCYLA 2 PA KANJINTI 2 PA KEYTRUDA 2 PA KYMRIAH 2 PA KYPROLIS 2 PA LENVIMA 2 PA letrozole 1 LEUKERAN 2 leuprolide 1 LIBTAYO 2 PA lipodox 1 lipodox 50 1 LONSURF 2 PA LORBRENA 2 PA LUMOXITI 3 PA IMBRUVICA, ZELBORAF LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 2 PA 11.25 MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 3 PA ELIGARD, FIRMAGON 22.5 MG LUPRON DEPOT (4 MONTH) 3 PA ELIGARD, FIRMAGON LUPRON DEPOT (6 MONTH) 3 PA ELIGARD, FIRMAGON LUPRON DEPOT INTRAMUSCULAR 2 PA SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR 3 PA ELIGARD, FIRMAGON SYRINGE KIT 7.5 MG LUPRON DEPOT-PED 2 PA LUPRON DEPOT-PED (3 MONTH) 2 PA LYNPARZA 2 PA LYSODREN 2 MARQIBO 2

22 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES MATULANE 2 MEGACE ES 3 megestrol acetate megestrol 1 MEKINIST 2 PA MEKTOVI 3 PA COTELLIC, MEKINIST melphalan 1 melphalan hcl 1 mercaptopurine 1 methotrexate sodium 1 methotrexate sodium (pf) 1 mitomycin 1 mitoxantrone 1 MUTAMYCIN 3 MVASI 2 PA mycophenolate mofetil 1 mycophenolate mofetil (hcl) 1 mycophenolate sodium 1 MYFORTIC 3 mycophenolic acid MYLERAN 2 MYLOTARG 2 PA NAVELBINE 3 vinorelbine tartrate NEORAL 3 cyclosporine NERLYNX 2 PA NEXAVAR 2 PA; QL NILANDRON 3 nilutamide nilutamide 1 NINLARO 2 PA NIPENT 3 NUBEQA 2 PA NULOJIX 2 octreotide acetate 1 ODOMZO 2 PA OGIVRI 3 PA ONCASPAR 2 PA ONIVYDE 2 PA OPDIVO 2 PA

23 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES oxaliplatin 1 paclitaxel 1 PERJETA 2 PA PHOTOFRIN 2 cyclophosphamide, doxorubicin hcl, prednisone, POLIVY 3 PA vincristine sulfate, ADCETRIS carboplatin, cisplatin, PORTRAZZA 3 PA gemcitabine hcl POTELIGEO 2 PA PROGRAF INTRAVENOUS 2 PROGRAF ORAL CAPSULE 3 TACROLIMUS PROGRAF ORAL GRANULES IN 2 PACKET PURIXAN 2 RAPAMUNE 3 sirolimus RITUXAN 2 PA RITUXAN HYCELA 2 PA ROMIDEPSIN 3 PA ISTODAX ROZLYTREK 2 PA RUBRACA 2 PA RYDAPT 2 PA SANDIMMUNE INTRAVENOUS 3 cyclosporine SANDIMMUNE ORAL CAPSULE 3 cyclosporine SANDIMMUNE ORAL SOLUTION 2 SANDOSTATIN 3 octreotide acetate SIGNIFOR 2 SIMULECT 2 sirolimus 1 SOLTAMOX 3 tamoxifen citrate SOMATULINE DEPOT 2 PA SPRYCEL ORAL TABLET 100 MG, 2 PA; QL 20 MG, 50 MG, 70 MG SPRYCEL ORAL TABLET 140 MG, 2 PA 80 MG STIVARGA 2 PA

24 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES SUTENT ORAL CAPSULE 12.5 MG, 2 PA; QL 25 MG, 50 MG SUTENT ORAL CAPSULE 37.5 MG 2 PA SYLVANT 2 PA SYNRIBO 2 PA TABLOID 3 tacrolimus 1 TAFINLAR 2 PA TAGRISSO 2 PA TALZENNA 2 PA tamoxifen 1 TARCEVA 3 PA; QL erlotinib hcl TARGRETIN ORAL 3 PA bexarotene TARGRETIN TOPICAL 2 PA TASIGNA 2 PA TAXOTERE 3 docetaxel TECENTRIQ 2 PA TEMODAR INTRAVENOUS 2 TEMODAR ORAL 3 PA temozolomide temozolomide 1 PA temsirolimus 1 TENIPOSIDE 2 TEPADINA 3 thiotepa THALOMID 2 PA thiotepa 1 TIBSOVO 2 PA toposar 1 topotecan 1 toremifene 1 TORISEL 3 temsirolimus TREANDA 2 PA TRELSTAR 3 PA ELIGARD, FIRMAGON tretinoin (chemotherapy) 1 TREXALL 3 methotrexate TRIPTODUR 2 PA TRISENOX 2 TRUXIMA 3 PA 25 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES TURALIO 3 PA TYKERB 2 PA UNITUXIN 2 VECTIBIX 2 PA VELCADE 2 VENCLEXTA 2 PA VENCLEXTA STARTING PACK 2 PA VERZENIO 2 PA VIDAZA 3 PA azacitidine vinblastine 1 vincristine 1 vinorelbine 1 VITRAKVI 2 PA VIZIMPRO 2 PA VOTRIENT 2 PA VYXEOS 2 XALKORI 2 PA XELODA 3 capecitabine XERMELO 2 PA XOSPATA 2 PA XTANDI 2 PA YERVOY 2 PA YESCARTA 2 PA YONDELIS 2 PA YONSA 2 PA ZALTRAP 2 ZANOSAR 2 ZEJULA 2 PA ZELBORAF 2 PA ZEVALIN (Y-90) 2 ZOLADEX 2 PA ZOLINZA 2 PA ZORTRESS 2 ZYDELIG 2 PA ZYKADIA 2 PA ZYTIGA 2 PA

26 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS carbamazepine, APTIOM 3 oxcarbazepine, pregabalin, topiramate, VIMPAT BANZEL 2 BRIVIACT 3 levetiracetam carbamazepine 1 CARBATROL 3 carbamazepine er CELONTIN 2 CEREBYX 3 fosphenytoin sodium clobazam 1 clonazepam 1 DEPACON 3 valproate sodium DEPAKOTE 3 divalproex sodium DEPAKOTE ER 3 divalproex sodium er DEPAKOTE SPRINKLES 3 divalproex sodium DIACOMIT 2 PA DIASTAT 3 diazepam DIASTAT ACUDIAL 3 diazepam diazepam 1 DILANTIN 2 DILANTIN EXTENDED 3 phenytoin sodium DILANTIN INFATABS 3 phenytoin DILANTIN-125 3 phenytoin divalproex 1 EPIDIOLEX 2 PA epitol 1 carbamazepine, EQUETRO 3 carbamazepine er ethosuximide 1 felbamate 1 FELBATOL 3 felbamate fosphenytoin 1 FYCOMPA 2

27 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES gabapentin 1 GABITRIL 3 tiagabine hcl GRALISE 3 ST gabapentin, pregabalin GRALISE 30-DAY STARTER PACK 3 ST gabapentin, pregabalin KLONOPIN 3 clonazepam LAMICTAL XR STARTER (BLUE) 3 lamotrigine LAMICTAL XR STARTER (GREEN) 3 lamotrigine LAMICTAL XR STARTER 3 lamotrigine (ORANGE) lamotrigine 1 levetiracetam 1 levetiracetam in nacl (iso-os) 1 MYSOLINE 3 primidone NAYZILAM 2 ONFI 3 clobazam oxcarbazepine 1 OXTELLAR XR 3 oxcarbazepine PEGANONE 2 phenobarbital 1 PHENYTEK 3 phenytoin sodium phenytoin 1 phenytoin sodium 1 phenytoin sodium extended 1 pregabalin 1 primidone 1 QUDEXY XR 2 roweepra 1 roweepra xr 1 SABRIL 3 vigabatrin, vigadrone SPRITAM 3 levetiracetam, levetiracetam subvenite 1 subvenite starter (blue) kit 1 subvenite starter (green) kit 1 subvenite starter (orange) kit 1 SYMPAZAN 3 clobazam TEGRETOL 3 carbamazepine TEGRETOL XR 3 carbamazepine er 28 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES tiagabine 1 topiramate 1 TROKENDI XR 3 topiramate valproate sodium 1 valproic acid 1 valproic acid (as sodium salt) 1 vigabatrin 1 vigadrone 1 VIMPAT 2 ZARONTIN 3 ethosuximide zonisamide 1 ANTIPARKINSONISM AGENTS APOKYN 2 PA AZILECT 3 rasagiline mesylate benztropine 1 bromocriptine 1 carbidopa 1 carbidopa-levodopa 1 carbidopa-levodopa-entacapone 1 COGENTIN 3 benztropine mesylate COMTAN 3 entacapone carbidopa/levodopa, DUOPA 3 carbidopa-levodopa er, carbidopa/levodopa entacapone 1 INBRIJA 2 PA LODOSYN 3 carbidopa MIRAPEX 3 pramipexole di-hcl MIRAPEX ER 3 pramipexole er pramipexole di-hcl, NEUPRO 3 pramipexole er, ropinirole hcl NOURIANZ 3 PARLODEL 3 bromocriptine mesylate pramipexole 1 rasagiline 1 REQUIP 3 ropinirole hcl REQUIP XL 3 ropinirole hcl

29 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ropinirole 1 carbidopa/levodopa, RYTARY 3 carbidopa-levodopa er selegiline hcl 1 SINEMET 3 carbidopa/levodopa SINEMET CR 3 carbidopa-levodopa er carbidopa-levodopa- STALEVO 100 3 entacapone carbidopa-levodopa- STALEVO 125 3 entacapone carbidopa-levodopa- STALEVO 150 3 entacapone carbidopa-levodopa- STALEVO 200 3 entacapone carbidopa-levodopa- STALEVO 50 3 entacapone carbidopa-levodopa- STALEVO 75 3 entacapone TASMAR 3 tolcapone tolcapone 1 trihexyphenidyl 1 rasagiline mesylate, selegiline ZELAPAR 3 hcl MIGRAINE & CLUSTER HEADACHE THERAPY AIMOVIG AUTOINJECTOR 2 PA AJOVY 2 PA almotriptan malate 1 QL AMERGE 3 ST; QL naratriptan hcl CAFERGOT 3 ergotamine-caffeine D.H.E.45 3 dihydroergotamine mesylate dihydroergotamine injection 1 dihydroergotamine nasal 1 ST; QL eletriptan 1 QL EMGALITY PEN 2 PA EMGALITY SYRINGE 2 PA ERGOMAR 3 ergotamine-caffeine 1 FROVA 3 ST; QL frovatriptan succinate 30 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES frovatriptan 1 QL migergot 1 MIGRANAL 3 ST; QL dihydroergotamine mesylate naratriptan 1 QL RELPAX 3 ST; QL eletriptan hbr rizatriptan 1 QL sumatriptan 1 QL sumatriptan succinate 1 QL sumatriptan-naproxen 1 ST; QL TOSYMRA 3 ST sumatriptan succ-naproxen TREXIMET 3 ST; QL sod ZEMBRACE SYMTOUCH 3 ST; QL sumatriptan succinate zolmitriptan 1 QL ZOMIG 2 ST; QL MISCELLANEOUS NEUROLOGICAL THERAPY ARICEPT 3 donepezil hcl AUSTEDO 2 PA dalfampridine 1 PA donepezil 1 EXELON 3 rivastigmine FIRDAPSE 3 RUZURGI galantamine 1 HORIZANT 3 ST gabapentin, pregabalin KEVEYIS 3 PA acetazolamide memantine oral capsule,sprinkle,er 24hr 1 memantine oral solution 1 memantine oral tablet 1 MEMANTINE ORAL 3 memantine hcl TABLETS,DOSE PACK NAMENDA 3 memantine hcl NAMENDA TITRATION PAK 3 memantine hcl NAMENDA XR 3 memantine hcl er NAMZARIC 2 NUEDEXTA 2 RADICAVA 2

31 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES RAZADYNE 3 galantamine RAZADYNE ER 3 galantamine er rivastigmine 1 rivastigmine tartrate 1 RUZURGI 2 TEGSEDI 3 PA tetrabenazine 1 PA TYSABRI 2 PA ZOLGENSMA 2 PA MUSCLE RELAXANTS & ANTISPASMODIC THERAPY atracurium 1 baclofen oral tablet 10 mg, 20 mg 1 BACLOFEN ORAL TABLET 5 MG 3 baclofen BRIDION 3 carisoprodol 1 metaxalone, tizanidine hcl carisoprodol-aspirin 1 metaxalone, tizanidine hcl carisoprodol-aspirin-codeine 1 PA metaxalone, tizanidine hcl chlorzoxazone 1 cisatracurium 1 cyclobenzaprine 1 DANTRIUM INTRAVENOUS 3 revonto DANTRIUM ORAL 3 dantrolene sodium dantrolene 1 FEXMID 3 cyclobenzaprine hcl LORZONE 3 chlorzoxazone alprazolam, buspirone hcl, meprobamate 1 chlordiazepoxide hcl, diazepam, lorazepam MESTINON 3 pyridostigmine bromide MESTINON TIMESPAN 3 pyridostigmine bromide metaxall 1 metaxalone 1 methocarbamol 1 NIMBEX 3 NORGESIC FORTE 3 orphenadrine citrate 1

32 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES orphenadrine-asa-caffeine 1 orphengesic forte 1 OZOBAX 3 baclofen, tizanidine hcl pyridostigmine bromide oral syrup 1 PYRIDOSTIGMINE BROMIDE ORAL 3 TABLET 30 MG pyridostigmine bromide oral tablet 60 1 mg pyridostigmine bromide oral tablet 1 extended release regonol 1 revonto 1 ROBAXIN 3 methocarbamol ROBAXIN-750 3 methocarbamol RYANODEX 3 SKELAXIN 3 metaxalone SOMA 3 metaxalone, tizanidine hcl tizanidine 1 ZANAFLEX 3 tizanidine hcl NARCOTIC ANALGESICS acetaminophen-caff-dihydrocod 1 PA acetaminophen-codeine 1 PA ACTIQ 3 PA; QL fentanyl citrate ALLZITAL 3 acetaminophen w/butalbital hydromorphone er, morphine sulfate er, oxymorphone hcl ARYMO ER 3 PA er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN ascomp with codeine 1 PA BELBUCA 2 PA BUPRENEX 3 PA buprenorphine hydrochloride buprenorphine hcl injection 1 PA buprenorphine hcl sublingual 1 buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 1 PA 5 mcg/hour BUPRENORPHINE TRANSDERMAL 3 PA PATCH WEEKLY 7.5 MCG/HOUR 33 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES butalbital compound w/codeine 1 PA butalbital-acetaminop-caf-cod 1 PA butalbital-acetaminophen 1 butalbital-acetaminophen-caff 1 butalbital-aspirin-caffeine 1 codeine sulfate 1 PA codeine-butalbital-asa-caff 1 PA DEMEROL (PF) INJECTION morphine sulfate, SOLUTION 100 MG/2 ML, 25 MG/0.5 3 PA hydromorphone hcl, fentanyl ML, 50 MG/ML, 75 MG/1.5 ML citrate morphine sulfate, demerol (pf) injection solution 100 1 PA hydromorphone hcl, fentanyl mg/ml citrate morphine sulfate, DEMEROL (PF) INJECTION 3 PA hydromorphone hcl, fentanyl SYRINGE citrate morphine sulfate, DEMEROL INJECTION 3 PA hydromorphone hcl, fentanyl citrate codeine sulfate, DEMEROL ORAL 3 PA hydromorphone hcl, morphine sulfate, oxycodone hcl DILAUDID 3 PA hydromorphone hcl DILAUDID (PF) 3 PA hydromorphone hcl DOLOPHINE 3 PA methadone hcl DSUVIA 3 PA DURAGESIC 3 PA fentanyl duramorph (pf) 1 PA dvorah 1 PA endocet 1 PA ESGIC 3 butalbital/apap/caffeine EXALGO ER 3 PA hydromorphone er fentanyl 1 PA FENTANYL (PF)-BUPIVACAINE- 3 PA NACL fentanyl citrate 1 PA; QL FENTANYL CITRATE (PF) INTRAVENOUS PT CONTROLLED 3 PA ANALGESIA SYRING

34 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES fentanyl citrate (pf) intravenous syringe 1 PA 100 mcg/2 ml (50 mcg/ml) FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 250 3 PA MCG/5 ML (50 MCG/ML), 50 MCG/ML FENTANYL CITRATE (PF)- 3 PA 0.9%NACL INJECTION FENTANYL CITRATE (PF)- 0.9%NACL INTRAVENOUS 3 PA SOLUTION 10 MCG/ML, 20 MCG/ML fentanyl citrate (pf)-0.9%nacl 1 PA intravenous solution 5 mcg/ml fentanyl citrate (pf)-0.9%nacl 1 PA intravenous syringe 10 mcg/ml FENTANYL CITRATE (PF)- 0.9%NACL INTRAVENOUS 3 PA SYRINGE 50 MCG/5 ML (10 MCG/ML) FENTANYL-ROPIVACAINE-NACL 3 PA (PF) FIORICET 3 butalbital/apap/caffeine FIORINAL 3 butalbital-asp-caffeine FIORINAL-CODEINE #3 3 PA asa-butalb-caff-cod hydrocodone-acetaminophen 1 PA hydrocodone-ibuprofen 1 PA HYDROMORPHONE (PF) IN WATER 3 PA HYDROMORPHONE (PF) INJECTION SOLUTION 1 MG/ML, 4 3 PA MG/ML hydromorphone (pf) injection solution 1 PA 10 mg/ml, 2 mg/ml HYDROMORPHONE (PF)-0.9 % NACL INTRAVENOUS PATIENT 3 PA CONTROL.ANALGESIA SOLN HYDROMORPHONE (PF)-0.9 % NACL INTRAVENOUS PREFILLED 3 PA PUMP RESERVOIR hydromorphone (pf)-0.9 % nacl intravenous pt controlled analgesia 1 PA syring 10 mg/50 ml (0.2 mg/ml)

35 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES HYDROMORPHONE (PF)-0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA 3 PA SYRING 30 MG/30 ML (1 MG/ML), 50 MG/50 ML (1 MG/ML), 55 MG/55 ML (1 MG/ML), 6 MG/30 ML (0.2 MG/ML) HYDROMORPHONE (PF)-0.9 % 3 PA NACL INTRAVENOUS SOLUTION HYDROMORPHONE (PF)-0.9 % 3 PA NACL INTRAVENOUS SYRINGE HYDROMORPHONE IN 0.9 % NACL 3 PA INJECTION HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PATIENT 3 PA CONTROL.ANALGESIA SOLN HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PREFILLED PUMP 3 PA RESERVOIR hydromorphone in 0.9 % nacl intravenous pt controlled analgesia 1 PA syring 15 mg/30 ml (0.5 mg/ml) HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 5 MG/25 ML 3 PA (0.2 MG/ML), 6 MG/30 ML (0.2 MG/ML) HYDROMORPHONE IN 0.9 % NACL 3 PA INTRAVENOUS SOLUTION HYDROMORPHONE IN 0.9 % NACL 3 PA INTRAVENOUS SYRINGE hydromorphone injection solution 1 PA HYDROMORPHONE INJECTION 3 PA SYRINGE 0.5 MG/0.5 ML hydromorphone injection syringe 1 1 PA mg/ml, 2 mg/ml, 4 mg/ml hydromorphone oral 1 PA hydromorphone rectal 1 PA HYSINGLA ER 2 PA hydrocodone bit-ibuprofen, IBUDONE 3 PA reprexain ibuprofen-oxycodone 1 PA INFUMORPH P/F 2 PA

36 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES KADIAN 3 PA morphine sulfate er levorphanol tartrate oral tablet 2 mg 1 PA LEVORPHANOL TARTRATE ORAL 3 PA TABLET 3 MG lorcet (hydrocodone) 1 PA lorcet hd 1 PA lorcet plus 1 PA hydrocodone LORTAB ELIXIR 3 PA w/acetaminophen morphine sulfate, meperidine (pf) 1 PA hydromorphone hcl, fentanyl citrate morphine sulfate, meperidine injection 1 PA hydromorphone hcl, fentanyl citrate hydromorphone hcl, morphine meperidine oral solution 1 PA sulfate, oxycodone hcl codeine sulfate, meperidine oral tablet 1 PA hydromorphone hcl, morphine sulfate, oxycodone hcl methadone 1 PA methadose 1 PA MITIGO (PF) 3 PA hydromorphone er, morphine sulfate er, oxymorphone hcl MORPHABOND ER 3 PA er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN MORPHINE (PF) IN 0.9 % NACL 3 PA INJECTION MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 150 MG/30 ML 3 PA (5 MG/ML), 50 MG/50 ML (1 MG/ML), 55 MG/55 ML (1 MG/ML) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 30 mg/30 1 PA ml (1 mg/ml) morphine (pf) in 0.9 % nacl intravenous 1 PA solution

37 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES morphine (pf) in 0.9 % nacl intravenous syringe 0.5 mg/ml, 2 mg/2 ml (1 mg/ml), 1 PA 5 mg/5 ml (1 mg/ml) MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS SYRINGE 2 MG/ML, 3 PA 4 MG/ML morphine (pf) injection 1 PA morphine (pf) intravenous patient 1 PA control.analgesia soln MORPHINE (PF) INTRAVENOUS 3 PA SYRINGE morphine concentrate 1 PA MORPHINE IN 0.9 % SODIUM 3 PA CHLOR MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 3 PA MG/ML morphine injection solution 8 mg/ml 1 PA morphine injection syringe 1 PA MORPHINE INTRAMUSCULAR 3 PA morphine intravenous pt controlled 1 PA analgesia syring morphine intravenous solution 10 mg/ml, 1 PA 25 mg/ml, 4 mg/ml, 50 mg/ml MORPHINE INTRAVENOUS 3 PA SOLUTION 8 MG/ML morphine intravenous syringe 10 mg/ml, 1 PA 2 mg/ml, 4 mg/ml MORPHINE INTRAVENOUS 3 PA SYRINGE 8 MG/ML morphine oral 1 PA morphine rectal 1 PA MS CONTIN 3 PA morphine sulfate er NALOCET 3 PA OPANA 3 PA oxymorphone hcl OXAYDO 3 PA oxycodone hcl oxycodone 1 PA oxycodone-acetaminophen 1 PA oxycodone-aspirin 1 PA OXYCONTIN 2 PA; QL

38 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES oxymorphone 1 PA PERCOCET 3 PA oxycodone w/acetaminophen PRIMLEV 3 PA oxycodone w/acetaminophen ROXICODONE 3 PA oxycodone hcl SUBLOCADE 2 tencon 1 TREZIX 3 PA apap-caffeine-dihydrocodeine TYLENOL-CODEINE #3 3 PA acetaminophen w/codeine TYLENOL-CODEINE #4 3 PA acetaminophen w/codeine VANATOL LQ 3 VANATOL S 3 vicodin es 1 PA vicodin hp 1 PA hydromorphone er, morphine sulfate er, oxymorphone hcl XTAMPZA ER 3 PA; QL er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN zebutal 1 hydromorphone er, morphine sulfate er, oxymorphone hcl ZOHYDRO ER 3 PA er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN NON-NARCOTIC ANALGESICS adult aspirin regimen 1 ANAPROX DS 3 ST naproxen sodium diclofenac sodium- ARTHROTEC 50 3 ST misoprostol diclofenac sodium- ARTHROTEC 75 3 ST misoprostol aspir-81 1 aspirin 1 aspirin low dose 1 aspir-low 1 aspir-trin 1 bayer aspirin 1 buprenorphine-naloxone, BUNAVAIL 3 SUBOXONE, ZUBSOLV

39 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES buprenorphine-naloxone 1 butorphanol tartrate injection 1 PA butorphanol tartrate nasal 1 PA; QL CALDOLOR 2 diclofenac potassium, CAMBIA 3 ST; QL diclofenac sodium, diclofenac sodium celecoxib 1 children's aspirin 1 choline,magnesium salicylate 1 CONZIP 3 PA tramadol hcl er DAYPRO 3 ST oxaprozin diclofenac potassium 1 diclofenac sodium oral 1 diclofenac sodium topical drops 1 diclofenac sodium topical gel 1 ST diclofenac-misoprostol 1 diflunisal 1 DISALCID 3 salsalate DUEXIS 3 ST ibuprofen, famotidine e.c. prin 1 EC-NAPROSYN 3 ST naproxen ecotrin 1 ecotrin low strength 1 etodolac 1 EUFLEXXA 2 PA FELDENE 3 ST piroxicam fenoprofen 1 ST FLECTOR 2 ST; QL flurbiprofen 1 ibu 1 ibuprofen 1 ibuprofen, meloxicam, INDOCIN ORAL 3 ST naproxen sodium INDOCIN RECTAL 3 indomethacin 1 ketoprofen oral capsule 25 mg 1 ST

40 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ketoprofen oral capsule 50 mg, 75 mg 1 ketoprofen oral capsule,ext rel. pellets 1 ST 24 hr ketorolac injection 1 ketorolac intramuscular 1 ketorolac oral 1 QL lite coat aspirin 1 LODINE 3 ST meclofenamate 1 mefenamic acid 1 meloxicam oral tablet 15 mg 1 meloxicam oral tablet 7.5 mg 1 QL MOBIC ORAL TABLET 15 MG 3 ST meloxicam MOBIC ORAL TABLET 7.5 MG 3 ST; QL meloxicam nabumetone 1 nalbuphine 1 PA fenoprofen calcium, diclofenac sodium, NALFON 3 ST indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone naloxone 1 naltrexone 1 NAPRELAN CR 3 ST naproxen sodium er NAPROSYN 3 ST naproxen naproxen oral suspension 1 ST naproxen oral tablet 1 naproxen oral tablet,delayed release 1 (dr/ec) naproxen sodium oral tablet 1 naproxen sodium oral tablet, er 1 ST multiphase 24 hr NARCAN 2 NUCYNTA 2 PA; QL NUCYNTA ER 2 PA; QL oxaprozin 1 codeine sulfate, pentazocine-naloxone 1 PA hydromorphone hcl, morphine sulfate, oxycodone hcl 41 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES piroxicam 1 diclofenac sodium, etodolac, ibuprofen, meloxicam, QMIIZ ODT 3 ST nabumetone, naproxen, piroxicam salsalate 1 diclofenac sodium, etodolac, ibuprofen, indomethacin, SPRIX 3 ST meloxicam, nabumetone, naproxen st joseph aspirin 1 st. joseph aspirin 1 SUBOXONE 2 sulindac 1 tolmetin oral capsule 1 ST tolmetin oral tablet 200 mg 1 tolmetin oral tablet 600 mg 1 ST TRAMADOL ORAL CAPSULE,ER 3 PA tramadol hcl er BIPHASE 24 HR 17-83 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75 100 MG, 200 3 PA tramadol hcl er MG TRAMADOL ORAL CAPSULE,ER 3 PA; QL tramadol hcl er BIPHASE 24 HR 25-75 150 MG tramadol oral tablet 1 PA; QL tramadol oral tablet extended release 24 1 PA; QL hr tramadol oral tablet, er multiphase 24 hr 1 PA; QL tramadol-acetaminophen 1 PA; QL ULTRACET 3 PA; QL tramadol hcl-acetaminophen ULTRAM 3 PA; QL tramadol hcl naproxen sodium, VIMOVO 3 ST esomeprazole magnesium VIVITROL 2 VOLTAREN 3 ST diclofenac sodium VOLTAREN-XR 3 ST diclofenac sodium ZUBSOLV 2 PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA 2

42 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ABILIFY MYCITE 3 aripiprazole ADASUVE 3 ADDERALL XR 3 dextroamphetamine-amphet er methylphenidate er, dexmethylphenidate hcl er, DYANAVEL XR, ADHANSIA XR 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE dextroamphetamine sulfate er, dextroamphetamine-amphet er, DYANAVEL XR, ADZENYS ER 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE dextroamphetamine sulfate er, dextroamphetamine-amphet er, DYANAVEL XR, ADZENYS XR-ODT 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE alprazolam 1 alprazolam intensol 1 amitriptyline 1 amitriptyline-chlordiazepoxide 1 amoxapine 1 amphetamine sulfate 1 ANAFRANIL 3 clomipramine hcl APLENZIN 3 ST; QL bupropion hcl xl methylphenidate er, dexmethylphenidate hcl er, DYANAVEL XR, APTENSIO XR 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE aripiprazole oral solution 1 aripiprazole oral tablet 1 QL aripiprazole oral tablet,disintegrating 1 QL ARISTADA 2 ARISTADA INITIO 2 armodafinil 1 PA; QL

43 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ATIVAN 3 lorazepam atomoxetine 1 zolpidem tartrate, zolpidem BELSOMRA 3 ST tartrate er, eszopiclone, zaleplon, ramelteon bupropion hcl oral tablet 1 bupropion hcl oral tablet extended 1 QL release 24 hr 150 mg, 300 mg BUPROPION HCL ORAL TABLET 3 ST bupropion hcl xl EXTENDED RELEASE 24 HR 450 MG bupropion hcl oral tablet sustained- 1 QL release 12 hr buspirone 1 chlordiazepoxide hcl 1 chlorpromazine 1 citalopram oral solution 1 citalopram oral tablet 1 QL clomipramine 1 clonidine hcl 1 clorazepate dipotassium 1 clozapine oral tablet 1 clozapine oral tablet,disintegrating 100 1 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 3 clozapine, clozapine odt 200 MG CLOZARIL 3 clozapine CONCERTA 3 methylphenidate er methylphenidate er, dexmethylphenidate hcl er, DYANAVEL XR, COTEMPLA XR-ODT 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE DAYTRANA 2 desipramine 1 DESOXYN 3 methamphetamine hcl desvenlafaxine succinate er, DESVENLAFAXINE ORAL TABLET 3 ST; QL duloxetine hcl, venlafaxine hcl EXTENDED RELEASE 24 HR er, FETZIMA

44 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES desvenlafaxine succinate er, DESVENLAFAXINE ORAL TABLET 3 ST duloxetine hcl, venlafaxine hcl EXTENDED RELEASE 24HR er, FETZIMA desvenlafaxine succinate oral tablet 1 ST; QL extended release 24 hr 100 mg, 50 mg desvenlafaxine succinate oral tablet 1 ST extended release 24 hr 25 mg DEXEDRINE SPANSULE 3 dextroamphetamine sulfate er dexmethylphenidate 1 dextroamphetamine 1 dextroamphetamine-amphetamine 1 diazepam 1 diazepam intensol 1 DORAL 3 lorazepam doxepin 1 DRIZALMA SPRINKLE ORAL desvenlafaxine succinate er, CAPSULE, DELAYED REL 3 ST; QL duloxetine hcl, venlafaxine hcl SPRINKLE 20 MG, 30 MG, 60 MG er, FETZIMA DRIZALMA SPRINKLE ORAL desvenlafaxine succinate er, CAPSULE, DELAYED REL 3 ST duloxetine hcl, venlafaxine hcl SPRINKLE 40 MG er, FETZIMA duloxetine oral capsule,delayed 1 QL release(dr/ec) 20 mg, 30 mg, 60 mg duloxetine oral capsule,delayed 1 ST release(dr/ec) 40 mg DYANAVEL XR 2 eszopiclone, zaleplon, EDLUAR 3 ST; QL zolpidem tartrate, zolpidem tartrate er phenelzine sulfate, EMSAM 3 tranylcypromine sulfate ergoloid 1 escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet 1 QL estazolam 1 eszopiclone 1 QL EVEKEO 3 amphetamine sulfate

45 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES amphetamine sulfate, dextroamphetamine- EVEKEO ODT 3 amphetamine, methylphenidate er, methylphenidate hcl aripiprazole, olanzapine, quetiapine fumarate, FANAPT 3 QL quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA FETZIMA 2 ST flumazenil 1 fluoxetine oral capsule 10 mg, 40 mg 1 QL fluoxetine oral capsule 20 mg 1 fluoxetine oral capsule,delayed 1 QL release(dr/ec) fluoxetine oral solution 1 fluoxetine oral tablet 10 mg 1 ST; QL fluoxetine oral tablet 20 mg, 60 mg 1 ST fluphenazine decanoate 1 fluphenazine hcl 1 flurazepam 1 fluvoxamine oral capsule,extended 1 ST; QL release 24hr fluvoxamine oral tablet 1 QL FORFIVO XL 3 ST bupropion hcl xl GEODON INTRAMUSCULAR 3 olanzapine GEODON ORAL 3 QL ziprasidone hcl guanfacine 1 guanidine 1 HALCION 3 triazolam HALDOL 3 haloperidol lactate HALDOL DECANOATE 3 haloperidol decanoate haloperidol 1 haloperidol decanoate 1 haloperidol lactate 1 HETLIOZ 3 PA imipramine hcl 1 imipramine pamoate 1

46 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES INTERMEZZO 3 ST zolpidem tartrate INVEGA ORAL TABLET EXTENDED 3 QL paliperidone er RELEASE 24HR 1.5 MG, 6 MG, 9 MG INVEGA ORAL TABLET EXTENDED 3 paliperidone er RELEASE 24HR 3 MG ABILIFY MAINTENA, INVEGA SUSTENNA 3 ARISTADA, RISPERDAL CONSTA ABILIFY MAINTENA, INVEGA TRINZA 3 ARISTADA, RISPERDAL CONSTA methylphenidate er, methylphenidate hcl cd, dexmethylphenidate hcl er, JORNAY PM 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE KAPVAY 3 ST clonidine hcl er LATUDA 2 lithium carbonate 1 lithium citrate 1 LITHOBID 3 lithium carbonate lorazepam 1 lorazepam intensol 1 loxapine succinate 1 maprotiline 1 phenelzine sulfate, MARPLAN 3 tranylcypromine sulfate metadate er 1 methamphetamine 1 METHYLIN 3 methylphenidate hcl methylphenidate hcl oral capsule, er 1 biphasic 30-70 methylphenidate hcl oral capsule,er 1 biphasic 50-50 methylphenidate hcl oral solution 1 methylphenidate hcl oral tablet 1 methylphenidate hcl oral tablet extended 1 release

47 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 1 CONCERTA mg methylphenidate er, dexmethylphenidate hcl er, METHYLPHENIDATE HCL ORAL DYANAVEL XR, TABLET EXTENDED RELEASE 3 MYDAYIS, QUILLICHEW 24HR 72 MG ER, QUILLIVANT XR, VYVANSE methylphenidate hcl oral 1 tablet,chewable midazolam (pf) in 0.9 % nacl 1 intravenous solution MIDAZOLAM (PF) IN 0.9 % NACL 3 INTRAVENOUS SYRINGE MIDAZOLAM IN 0.9 % SOD 3 CHLORID mirtazapine 1 MKO (MIDAZOLAM-KETAMINE- 3 ONDAN) modafinil 1 PA; QL molindone 1 MYDAYIS 2 NARDIL 3 phenelzine sulfate bupropion hcl, mirtazapine, nefazodone 1 trazodone hcl NORPRAMIN 3 desipramine hcl nortriptyline 1 NUPLAZID 3 PA clozapine, quetiapine fumarate olanzapine intramuscular 1 olanzapine oral 1 QL olanzapine-fluoxetine 1 oxazepam 1 lorazepam paliperidone oral tablet extended release 1 QL 24hr 1.5 mg, 6 mg, 9 mg paliperidone oral tablet extended release 1 24hr 3 mg PAMELOR 3 nortriptyline hcl PARNATE 3 tranylcypromine sulfate paroxetine hcl oral tablet 1 QL

48 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES paroxetine hcl oral tablet extended 1 ST; QL release 24 hr paroxetine mesylate(menop.sym) 1 ST PAXIL CR 3 ST; QL paroxetine er PAXIL ORAL SUSPENSION 3 ST paroxetine hcl PAXIL ORAL TABLET 3 ST; QL paroxetine hcl perphenazine 1 perphenazine-amitriptyline 1 ABILIFY MAINTENA, PERSERIS 3 ARISTADA, RISPERDAL CONSTA citalopram hbr, escitalopram oxalate, fluoxetine hcl, PEXEVA 3 ST; QL paroxetine hcl, sertraline hcl, VIIBRYD phenelzine 1 pimozide 1 procentra 1 protriptyline 1 QUAZEPAM 3 quetiapine oral tablet 100 mg, 25 mg, 50 1 PA; QL mg quetiapine oral tablet 200 mg, 300 mg, 1 QL 400 mg quetiapine oral tablet extended release 1 QL 24 hr QUILLICHEW ER 2 QUILLIVANT XR 2 ramelteon 1 ST; QL methylphenidate er, dexmethylphenidate hcl er, DYANAVEL XR, RELEXXII 3 MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE REMERON 3 mirtazapine REMERON SOLTAB 3 mirtazapine RESTORIL 3 lorazepam

49 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES aripiprazole, olanzapine, quetiapine fumarate, REXULTI 3 quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA RISPERDAL CONSTA 2 RISPERDAL ORAL SOLUTION 3 risperidone RISPERDAL ORAL TABLET 3 QL risperidone risperidone oral solution 1 risperidone oral tablet 1 QL risperidone oral tablet,disintegrating 1 QL RITALIN 3 methylphenidate hcl RITALIN LA 3 methylphenidate er ROZEREM 3 ST; QL ramelteon aripiprazole, olanzapine, quetiapine fumarate, SAPHRIS SUBLINGUAL TABLET 10 3 QL quetiapine fumarate er, MG, 5 MG risperidone, ziprasidone hcl, LATUDA aripiprazole, olanzapine, quetiapine fumarate, SAPHRIS SUBLINGUAL TABLET 2.5 3 quetiapine fumarate er, MG risperidone, ziprasidone hcl, LATUDA SARAFEM ORAL TABLET 10 MG 3 ST; QL fluoxetine hcl SARAFEM ORAL TABLET 20 MG 3 ST fluoxetine hcl seconal sodium 1 sertraline oral concentrate 1 sertraline oral tablet 1 QL eszopiclone, zaleplon, SILENOR 3 ST; QL zolpidem tartrate, zolpidem tartrate er, ramelteon SUNOSI 2 PA; ST; QL SYMBYAX 3 olanzapine-fluoxetine hcl temazepam 1 lorazepam thioridazine 1 thiothixene 1 TRANXENE T-TAB 3 clorazepate dipotassium tranylcypromine 1 trazodone 1

50 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES triazolam 1 trifluoperazine 1 trimipramine 1 citalopram hbr, escitalopram oxalate, fluoxetine hcl, TRINTELLIX 3 ST paroxetine hcl, sertraline hcl, VIIBRYD venlafaxine oral capsule,extended 1 QL release 24hr venlafaxine oral tablet 1 QL venlafaxine oral tablet extended release 1 ST; QL 24hr VERSACLOZ 3 clozapine odt, clozapine VIIBRYD 2 ST aripiprazole, olanzapine, quetiapine fumarate, VRAYLAR 3 quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA VYVANSE 2 QL WAKIX 3 PA; ST WELLBUTRIN XL 3 ST; QL bupropion hcl xl XYREM 2 zaleplon 1 QL zenzedi oral tablet 10 mg, 5 mg 1 ZENZEDI ORAL TABLET 15 MG, 2.5 3 dextroamphetamine sulfate MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl 1 QL zolpidem oral 1 QL zolpidem sublingual 1 ZULRESSO 2 PA ZYPREXA INTRAMUSCULAR 3 olanzapine ZYPREXA ORAL 3 QL olanzapine ABILIFY MAINTENA, ZYPREXA RELPREVV 3 ARISTADA, RISPERDAL CONSTA ZYPREXA ZYDIS 3 QL olanzapine odt CARDIOVASCULAR, HYPERTENSION & LIPIDS

51 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ANTIARRHYTHMIC AGENTS amiodarone 1 BETAPACE 3 ST sotalol BETAPACE AF 3 ST sotalol af amiodarone hcl, quinidine disopyramide phosphate 1 sulfate, sotalol dofetilide 1 flecainide 1 mexiletine 1 amiodarone hcl, dofetilide, flecainide acetate, MULTAQ 3 propafenone hcl, quinidine sulfate, sotalol amiodarone hcl, quinidine NORPACE 3 sulfate, sotalol amiodarone hcl, quinidine NORPACE CR 3 sulfate, sotalol pacerone 1 procainamide 1 propafenone 1 quinidine gluconate 1 quinidine sulfate 1 RYTHMOL SR 3 propafenone hcl er sotalol af 1 SOTALOL INTRAVENOUS 2 sotalol oral 1 SOTYLIZE 2 ANTIHYPERTENSIVE THERAPY ACCUPRIL 3 quinapril ACCURETIC 3 quinapril-hydrochlorothiazide acebutolol 1 ADALAT CC 3 nifedipine er ALDACTAZIDE 3 spironolactone w/hctz ALDACTONE 3 spironolactone aliskiren 1 ALTACE 3 ramipril amiloride 1

52 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES amiloride-hydrochlorothiazide 1 amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 amlodipine-valsartan 1 amlodipine-valsartan-hcthiazid 1 atenolol 1 atenolol-chlorthalidone 1 benazepril 1 benazepril-hydrochlorothiazide 1 betaxolol 1 isosorbide dinitrate, BIDIL 3 hydralazine hcl bisoprolol fumarate 1 bisoprolol-hydrochlorothiazide 1 BREVIBLOC 3 BREVIBLOC IN NACL (ISO-OSM) 3 bumetanide 1 BYSTOLIC 2 ST CALAN SR 3 verapamil er candesartan 1 candesartan-hydrochlorothiazid 1 captopril 1 captopril-hydrochlorothiazide 1 CARDIZEM 3 diltiazem hcl cartia xt, diltiazem 24hr er CARDIZEM CD 3 (cd), DILTIAZEM ER CARDIZEM LA ORAL TABLET 3 diltiazem 24hr er (cd) EXTENDED RELEASE 24 HR 120 MG CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 3 DILTIAZEM ER, matzim la MG, 240 MG, 300 MG, 360 MG, 420 MG CARDURA 3 QL doxazosin mesylate alfuzosin hcl er, doxazosin CARDURA XL 3 QL mesylate, silodosin, tamsulosin hcl, terazosin hcl CAROSPIR 3 spironolactone

53 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES cartia xt 1 carvedilol 1 carvedilol phosphate 1 CATAPRES 3 clonidine hcl CATAPRES-TTS-1 3 QL clonidine hcl CATAPRES-TTS-2 3 QL clonidine hcl CATAPRES-TTS-3 3 QL clonidine hcl chlorothiazide 1 chlorothiazide sodium 1 chlorthalidone 1 clonidine 1 QL clonidine hcl 1 COREG CR 3 ST carvedilol er CORGARD 3 ST nadolol CORLOPAM 3 DEMSER 2 DIBENZYLINE 3 phenoxybenzamine hcl diltiazem 1 dilt-xr 1 DIURIL 3 chlorothiazide DIURIL IV 3 chlorothiazide doxazosin 1 QL DYAZIDE 3 triamterene w/hctz DYRENIUM 3 triamterene EDARBI 2 ST EDARBYCLOR 2 ST EDECRIN 3 ethacrynic acid enalapril maleate 1 enalaprilat 1 enalapril-hydrochlorothiazide 1 eplerenone 1 epoprostenol (glycine) 1 PA eprosartan 1 esmolol 1 esmolol in nacl (iso-osm) 1 ESMOLOL IN STERILE WATER 3

54 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ethacrynate sodium 1 ethacrynic acid 1 felodipine 1 FLOLAN 2 PA fosinopril 1 fosinopril-hydrochlorothiazide 1 furosemide 1 FUROSEMIDE IN 0.9 % NACL 3 guanfacine 1 HEMANGEOL 3 propranolol hcl hydralazine 1 hydrochlorothiazide 1 indapamide 1 INDERAL XL 3 ST propranolol hcl INNOPRAN XL 3 ST propranolol hcl er INSPRA 3 eplerenone irbesartan 1 irbesartan-hydrochlorothiazide 1 isradipine 1 labetalol 1 LASIX 3 furosemide lisinopril 1 lisinopril-hydrochlorothiazide 1 LOPRESSOR INTRAVENOUS 3 metoprolol tartrate LOPRESSOR ORAL 3 ST metoprolol tartrate losartan 1 losartan-hydrochlorothiazide 1 LOTENSIN 3 benazepril hcl LOTENSIN HCT 3 benazepril hcl-hctz matzim la 1 MAXZIDE 3 triamterene w/hctz MAXZIDE-25MG 3 triamterene w/hctz methyldopa 1 methyldopa-hydrochlorothiazide 1 methyldopate 1 metolazone 1

55 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES metoprolol succinate 1 metoprolol ta-hydrochlorothiaz 1 metoprolol tartrate 1 MINIPRESS 3 prazosin hcl minoxidil 1 moexipril 1 nadolol 1 nadolol-bendroflumethiazide 1 nicardipine 1 nifedipine oral capsule 1 nicardipine hcl, isradipine nifedipine oral tablet extended release 1 nifedipine oral tablet extended release 1 24hr nimodipine 1 nisoldipine 1 NYMALIZE 3 nimodipine olmesartan 1 olmesartan-amlodipin-hcthiazid 1 olmesartan-hydrochlorothiazide 1 ambrisentan, bosentan, sildenafil citrate, tadalafil, ORENITRAM 3 PA ADEMPAS, OPSUMIT, TRACLEER papaverine 1 perindopril erbumine 1 phenoxybenzamine 1 phentolamine 1 pindolol 1 prazosin 1 amlodipine besylate, perindopril erbumine, PRESTALIA 3 amlodipine besylate- benazepril PRINIVIL 3 lisinopril amlodipine besylate, diltiazem PROCARDIA 3 hcl, verapamil hcl PROCARDIA XL 3 nifedical xl, nifedipine er propranolol 1

56 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES propranolol-hydrochlorothiazid 1 quinapril 1 quinapril-hydrochlorothiazide 1 ramipril 1 REMODULIN 2 PA SODIUM EDECRIN 3 ethacrynate sodium spironolactone 1 spironolacton-hydrochlorothiaz 1 SULAR 3 nisoldipine TARKA 3 trandolapril-verapamil taztia xt 1 TEKTURNA 3 aliskiren TEKTURNA HCT 2 telmisartan 1 telmisartan-amlodipine 1 telmisartan-hydrochlorothiazid 1 TENORETIC 100 3 ST atenolol w/chlorthalidone TENORETIC 50 3 ST atenolol w/chlorthalidone TENORMIN 3 ST atenolol terazosin 1 QL TIAZAC 3 diltiazem er, taztia xt timolol maleate 1 TOPROL XL 3 ST metoprolol succinate torsemide 1 trandolapril 1 trandolapril-verapamil 1 treprostinil sodium 1 PA triamterene 1 triamterene-hydrochlorothiazid 1 TWYNSTA 3 ST telmisartan-amlodipine UPTRAVI 2 PA valsartan 1 valsartan-hydrochlorothiazide 1 VASERETIC 3 enalapril maleate/hctz VASOTEC 3 enalapril maleate veletri 1 PA

57 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES verapamil 1 VERELAN 3 verapamil er VERELAN PM 3 verapamil er pm ZESTORETIC 3 lisinopril-hctz ZESTRIL 3 lisinopril ZIAC 3 ST bisoprolol fumarate/hctz CARDIAC GLYCOSIDES digitek 1 digox 1 digoxin 1 LANOXIN 3 digoxin LANOXIN PEDIATRIC 2 COAGULATION THERAPY ADVATE 2 PA ADYNOVATE 2 PA AFSTYLA 2 PA AGGRENOX 3 aspirin-dipyridamole er ALPHANATE 2 PA ALPHANINE SD 2 ALPROLIX 2 AMICAR ORAL SOLUTION 2 AMICAR ORAL TABLET 3 aminocaproic acid aminocaproic acid 1 ANDEXXA 3 ANGIOMAX 3 bivalirudin ARGATROBAN 3 ARGATROBAN IN 0.9 % SOD 3 CHLOR ARGATROBAN IN NACL (ISO-OS) 3 ARIXTRA 3 fondaparinux sodium aspirin-dipyridamole 1 BENEFIX 2 enoxaparin sodium, BEVYXXA 3 fondaparinux sodium, ELIQUIS, XARELTO bivalirudin 1

58 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES BIVALIRUDIN-0.9 % SODIUM 3 CHLOR BRILINTA 2 CABLIVI 2 PA CEPROTIN (BLUE BAR) 2 CEPROTIN (GREEN BAR) 2 cilostazol 1 clopidogrel 1 COAGADEX 2 CORIFACT 2 COUMADIN 3 warfarin sodium CYKLOKAPRON 3 tranexamic acid DEFITELIO 3 dipyridamole 1 DOPTELET (15 TAB PACK) 2 PA EFFIENT 3 prasugrel hcl ELIQUIS 2 ELIQUIS DVT-PE TREAT 30D 2 START ELOCTATE 2 PA enoxaparin 1 FEIBA NF 2 FIBRYGA 3 fondaparinux 1 FRAGMIN 2 HEMLIBRA 2 PA HEMOFIL M HIGH 2 PA HEMOFIL M LOW 2 PA HEMOFIL M MID 2 PA HEMOFIL M SUPER HIGH 2 PA hep flush-10 (pf) 1 heparin (porcine) 1 HEPARIN (PORCINE) IN 0.9% NACL 3 heparin (porcine) in 5 % dex 1 heparin (porcine) in nacl (pf) 1 heparin flush(porcine)-0.9nacl 1 heparin lock flush 1

59 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES heparin lock flush (porcine) 1 heparin lockflush(porcine)(pf) 1 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL 3 SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 1 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution 1 heparin, porcine (pf) injection syringe 1 5,000 unit/0.5 ml HEPARIN, PORCINE (PF) INJECTION 3 SYRINGE 5,000 UNIT/ML heparin, porcine (pf) intravenous 1 HEPARIN, PORCINE (PF) 3 SUBCUTANEOUS HUMATE-P 2 PA IDELVION 3 ALPROLIX IXINITY 2 jantoven 1 JIVI 2 PA KCENTRA 3 HEMOFIL-M, KOATE 3 PA MONOCLATE-P KOGENATE FS 2 PA KOVALTRY 2 PA MEPHYTON 3 phytonadione MONONINE 2 NOVOEIGHT 2 PA NOVOSEVEN RT 2 NPLATE 2 PA OBIZUR 2 pentoxifylline 1 phytonadione (vitamin k1) injection 1 solution PHYTONADIONE (VITAMIN K1) 2 INJECTION SYRINGE phytonadione (vitamin k1) oral 1 prasugrel 1

60 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES PRAXBIND 3 PROFILNINE 2 PROMACTA 2 PA protamine 1 REBINYN 3 ALPROLIX RIASTAP 2 RIXUBIS 3 BENEFIX TAVALISSE 3 PA PROMACTA, NPLATE tranexamic acid 1 TRANEXAMIC ACID IN NACL,ISO- 3 OS TRETTEN 2 vitamin k 1 vitamin k1 1 VONVENDI 2 warfarin 1 WILATE 2 PA XARELTO 2 ZONTIVITY 3 PA clopidogrel, aspirin LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin 1 QL fenofibrate, fenofibric acid, ANTARA 3 ST LIPOFEN atorvastatin 1 QL CADUET 3 ST; QL amlodipine-atorvastatin cholestyramine (with sugar) 1 cholestyramine light 1 colesevelam 1 WELCHOL COLESTID 3 colestipol hcl COLESTID FLAVORED 3 colestipol hcl colestipol 1 ezetimibe 1 ST ezetimibe-simvastatin 1 QL fenofibrate micronized 1 fenofibrate nanocrystallized 1

61 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES fenofibrate, fenofibric acid, FENOFIBRATE ORAL CAPSULE 3 ST LIPOFEN fenofibrate oral tablet 120 mg, 40 mg 1 ST fenofibrate oral tablet 160 mg, 54 mg 1 fenofibric acid 1 fenofibric acid (choline) 1 FENOGLIDE 3 ST fenofibrate FIBRICOR 3 ST fenofibric acid atorvastatin calcium, fluvastatin er, lovastatin, FLOLIPID 3 ST pravastatin sodium, rosuvastatin calcium, simvastatin, LIVALO fluvastatin 1 QL gemfibrozil 1 JUXTAPID 2 PA LIPOFEN 2 ST LIVALO 2 ST; QL LOPID 3 gemfibrozil lovastatin 1 QL LOVAZA 3 omega-3 acid ethyl esters niacin 1 NIACOR 3 niacin er NIASPAN EXTENDED-RELEASE 3 niacin er omega-3 acid ethyl esters 1 PRALUENT PEN 2 PA PRALUENT PEN pravastatin 1 QL prevalite 1 QUESTRAN 3 cholestyramine QUESTRAN LIGHT 3 cholestyramine light REPATHA PUSHTRONEX 2 PA REPATHA PUSHTRONEX REPATHA SURECLICK 2 PA REPATHA SURECLICK REPATHA SYRINGE 2 PA REPATHA SYRINGE rosuvastatin 1 QL simvastatin 1 QL fenofibrate, fenofibric acid, TRIGLIDE 3 ST LIPOFEN triklo 1

62 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES TRILIPIX 3 ST fenofibric acid VASCEPA 2 WELCHOL 3 colesevelam hcl atorvastatin calcium, fluvastatin er, lovastatin, ZYPITAMAG 3 ST pravastatin sodium, rosuvastatin calcium, simvastatin, LIVALO MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 2 ENTRESTO 2 GIAPREZA 3 NIPRIDE RTU 3 RANEXA 3 ranolazine er ranolazine 1 VECAMYL 3 clonidine hcl, RESERPINE VYNDAMAX 2 PA VYNDAQEL 2 PA NITRATES DILATRATE-SR 2 GONITRO 3 nitroglycerin, nitroglycerin ISOCHRON 3 isosorbide dinitrate ISORDIL 3 isosorbide dinitrate ISORDIL TITRADOSE 3 isosorbide dinitrate isosorbide dinitrate 1 isosorbide mononitrate 1 MINITRAN 3 nitroglycerin nitro-bid 1 NITRO-DUR 3 nitroglycerin nitroglycerin 1 nitroglycerin in 5 % dextrose 1 NITROLINGUAL 3 nitroglycerin NITROMIST 3 nitroglycerin NITROSTAT 3 nitroglycerin nitro-time 1

63 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES DERMATOLOGICALS/TOPI CAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 1 hc pramoxine, pramoxine hcl ANALPRAM-HC 3 w/hydrocortisone calcipotriene 1 calcipotriene-betamethasone 1 calcitriol 1 COAL TAR 2 COSENTYX 2 ST COSENTYX (2 SYRINGES) 2 ST COSENTYX PEN 2 ST COSENTYX PEN (2 PENS) 2 ST DOVONEX 3 calcipotriene drithocreme hp 1 ENSTILAR 2 EPIFOAM 3 hc pramoxine hydrocortisone-pramoxine 1 OVACE 3 sodium sulfacetamide OVACE PLUS 3 sodium sulfacetamide OVACE PLUS SHAMPOO 3 sodium sulfacetamide OVACE PLUS WASH 3 sodium sulfacetamide PRAMOSONE 3 hc pramoxine selenium sulfide 1 SELRX 3 selenium sulfide SKYRIZI 2 ST; QL SORIATANE 3 acitretin calcipotriene, calcitriol, SORILUX 3 ENSTILAR, TACLONEX HUMIRA, REMICADE, STELARA INTRAVENOUS 3 ST ENTYVIO STELARA SUBCUTANEOUS 2 ST; QL sulfacetamide sodium 1 calcipotriene-betamethasone TACLONEX TOPICAL OINTMENT 3 dp

64 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES TACLONEX TOPICAL SUSPENSION 2 TERSI FOAM 3 selenium sulfide TREMFYA 2 ST VECTICAL 3 calcitriol ZITHRANOL 3 BURN THERAPY SILVADENE 3 silver sulfadiazine silver sulfadiazine 1 ssd 1 KERATOLYTICS BENSAL HP 3 INOVA 4-1 3 benzoyl peroxide INOVA 8-2 3 benzoyl peroxide KERALYT RX 3 salicylic acid KERALYT SCALP COMPLETE 3 salicylic acid PODOCON 3 podofilox SALEX TOPICAL COMBO PACK 3 salicylic acid, salicylic acid SALEX TOPICAL KIT,CLEANSER 3 salicylic acid, salicylic acid AND CREAM ER SALEX TOPICAL SHAMPOO 3 salicylic acid salicylic acid 1 salicylic acid er-ceramides 1 SALKERA 3 salicylic acid salvax 1 SALVAX DUO PLUS 3 salicylic acid ULTRASAL-ER 3 VIRASAL 3 salicylic acid XALIX 3 MISCELLANEOUS DERMATOLOGICALS AMELUZ 3 ammonium lactate 1 CANTHARIDIN IN ACETONE 3 CARAC 2 cem-urea 1 CONDYLOX 3 podofilox, imiquimod CORTANE-B 3 hc pramoxine 65 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES diclofenac sodium 1 doxepin 1 DUPIXENT SUBCUTANEOUS 2 PA; ST; QL SYRINGE 200 MG/1.14 ML DUPIXENT SUBCUTANEOUS 2 PA; QL SYRINGE 300 MG/2 ML EFUDEX 3 fluorouracil ESKATA 3 EUCRISA 3 ST pimecrolimus, tacrolimus diclofenac sodium, fluorouracil, fluorouracil, FLUOROPLEX 3 imiquimod, CARAC, PICATO fluorouracil 1 HYDRO 35 3 urea HYDRO 40 3 urea iodine-sodium iodide 1 IODOFLEX 3 IODOSORB 3 KERAFOAM 3 umecta KERALAC 3 urea LEVULAN 3 LOUTREX 3 ciclopirox, ketoconazole methoxsalen 1 methyl salicylate 1 OXSORALEN ULTRA 3 methoxsalen PANRETIN 3 PICATO 2 pimecrolimus 1 podofilox 1 selenium sulfide, sodium PROMISEB 3 sulfacetamide PROTOPIC 3 ST tacrolimus prudoxin 1 QBREXZA 2 PA QUTENZA 3 lidocaine REGRANEX 2 QL silver nitrate 1

66 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES silver nitrate applicators 1 SOLARAZE 3 diclofenac sodium tacrolimus 1 ST diclofenac sodium, fluorouracil, fluorouracil, TOLAK 3 imiquimod, CARAC, PICATO umecta 1 URAMAXIN 3 urea urea 1 urea nail stick 1 UTOPIC 3 urea UVADEX 2 VALCHLOR 2 VEREGEN 3 imiquimod, podofilox wintergreen oil 1 ZONALON 3 prudoxin THERAPY FOR ACNE amnesteem, claravis, ABSORICA 3 myorisan, zenatane ACANYA 3 clindamycin-benzoyl peroxide ACZONE TOPICAL GEL 3 dapsone dapsone, benzoyl peroxide, ACZONE TOPICAL GEL WITH 3 clindamycin phosphate, PUMP erythromycin adapalene topical cream 1 adapalene topical gel 1 adapalene topical gel with pump 1 ADAPALENE TOPICAL LOTION 3 adapalene, adapalene adapalene topical solution 1 adapalene topical swab 1 adapalene-benzoyl peroxide 1 AKLIEF 3 tretinoin, adapalene, EPIDUO ALTRENO 3 PA FORTE amnesteem 1 ATRALIN 3 PA tretinoin AVAR LS 3 sulfacetamide sodium-sulfur

67 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES avar topical cleanser 1 AVAR TOPICAL PADS, MEDICATED 3 sulfacetamide sodium-sulfur AVAR-E GREEN 3 sulfacetamide sodium-sulfur AVAR-E LS 3 sulfacetamide sodium-sulfur avita topical cream 1 PA tretinoin, adapalene, EPIDUO AVITA TOPICAL GEL 3 PA FORTE azelaic acid 1 adapalene, metronidazole, AZELEX 3 tretinoin, FINACEA, TAZORAC BENZACLIN 3 clindamycin-benzoyl peroxide BENZACLIN PUMP 3 clindamycin-benzoyl peroxide erythromycin-benzoyl BENZAMYCIN 3 peroxide benzepro 1 BENZEPRO (MICROSPHERES) 3 benzoyl peroxide 1 bp 10-1 1 bpo 1 claravis 1 cleansing wash 1 CLEOCIN T 3 QL clindamycin phosphate clindamycin phosphate, CLINDACIN ETZ 3 clindacin etz clindacin p 1 clindamycin phosphate, CLINDACIN PAC 3 clindacin etz CLINDAGEL 3 clindamycin phosphate clindamycin phosphate topical foam 1 clindamycin phosphate topical gel 1 QL CLINDAMYCIN PHOSPHATE 3 clindamycin phosphate TOPICAL GEL, ONCE DAILY clindamycin phosphate topical lotion 1 QL clindamycin phosphate topical solution 1 QL clindamycin phosphate topical swab 1 clindamycin-benzoyl peroxide 1 clindamycin-tretinoin 1 PA

68 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES dapsone 1 DIFFERIN TOPICAL CREAM 3 adapalene DIFFERIN TOPICAL GEL 3 adapalene DIFFERIN TOPICAL GEL WITH 3 adapalene PUMP DIFFERIN TOPICAL LOTION 3 adapalene, adapalene DUAC 3 clindamycin-benzoyl peroxide ENZOCLEAR 3 EPIDUO 3 adapalene-benzoyl peroxide EPIDUO FORTE 2 ery pads 1 erygel 1 erythromycin with ethanol 1 erythromycin-benzoyl peroxide 1 EVOCLIN 3 clindamycin phosphate FABIOR 3 tazarotene, TAZORAC FINACEA TOPICAL FOAM 2 FINACEA TOPICAL GEL 3 azelaic acid INOVA 3 benzoyl peroxide isotretinoin 1 ivermectin 1 METROCREAM 3 metronidazole METROGEL 3 metronidazole METROLOTION 3 metronidazole metronidazole 1 MIRVASO 2 PA myorisan 1 neuac 1 NEUAC KIT 3 NORITATE 3 metronidazole ONEXTON 2 PACNEX 3 benzoyl peroxide PLEXION 3 sulfacetamide sodium-sulfur PLEXION CLEANSING CLOTHS 3 sulfacetamide sodium-sulfur PR BENZOYL PEROXIDE 3 RETIN-A 3 PA tretinoin RETIN-A MICRO 3 PA tretinoin microsphere 69 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES RETIN-A MICRO PUMP TOPICAL 3 PA tretinoin microsphere GEL WITH PUMP 0.04 %, 0.1 % RETIN-A MICRO PUMP TOPICAL tretinoin, adapalene, EPIDUO 3 PA GEL WITH PUMP 0.06 %, 0.08 % FORTE rosadan topical cream 1 rosadan topical gel 1 ROSADAN TOPICAL KIT, 3 metronidazole CLEANSER AND GEL ROSADAN TOPICAL 3 metronidazole KIT,CLEANSER AND CREAM ROSANIL 3 sulfacetamide sodium-sulfur ROSULA 3 rosula cleansing cloths 1 SOOLANTRA 2 sss 10-5 1 sulfacetamide sodium-sulfur 1 sulfacetamide sod-sulfur-urea 1 sulfacetamide-sulfur-cleansr23 1 sulfacleanse 8-4 1 SUMADAN TOPICAL CLEANSER 3 sulfacetamide sodium-sulfur SUMADAN TOPICAL KIT 3 sodium sulfacetamide/sulfur SUMADAN XLT 3 SUMAXIN 3 sulfacetamide sodium-sulfur SUMAXIN CP 3 sodium sulfacetamide/sulfur SUMAXIN TS 3 sulfacetamide sodium-sulfur tazarotene 1 TAZORAC TOPICAL CREAM 0.05 % 2 TAZORAC TOPICAL CREAM 0.1 % 3 tazarotene TAZORAC TOPICAL GEL 2 tretinoin 1 PA tretinoin microspheres 1 PA TRETIN-X 3 PA tretinoin TRETIN-X CREAM KIT 3 PA tretinoin VANOXIDE-HC 3 zenatane 1 ZIANA 3 PA clindamycin phos-tretinoin TOPICAL ANESTHETICS

70 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES COCAINE 3 ethyl chloride 1 glydo 1 GOPRELTO 3 lidocaine 1 lidocaine hcl injection syringe 10 mg/ml 1 (1 %), 100 mg/10 ml (1 %) LIDOCAINE HCL INJECTION SYRINGE 100 MG/5 ML (2 %), 30 3 MG/3 ML (1%), 50 MG/5 ML (1 %) LIDOCAINE HCL INTRADERMAL 3 lidocaine hcl laryngotracheal 1 lidocaine hcl mucous membrane 1 lidocaine hcl-hydrocortison ac 1 lidocaine viscous 1 lidocaine-prilocaine 1 lta pre-attached 1 PLIAGLIS 3 SYNERA 3 lidocaine, lidocaine-prilocaine ZINGO 3 ZTLIDO 2 TOPICAL ANTIBACTERIALS ALTABAX 3 QL mupirocin, mupirocin CENTANY 3 QL mupirocin, mupirocin CENTANY AT 3 QL mupirocin, mupirocin CORTISPORIN 3 gentamicin sulfate dermazene 1 gentamicin 1 hydrocortisone-iodoquinol 1 hydrocortisone-iodoquinol-aloe 1 KLARON 3 sulfacetamide sodium lugols 1 mafenide acetate 1 mupirocin 1 QL mupirocin calcium 1 QL NEO-SYNALAR 3 NEO-SYNALAR KIT 3

71 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES SILVRSTAT 3 avo, prutect, sonafine strong iodine 1 sulfacetamide sodium (acne) 1 SULFAMYLON TOPICAL CREAM 2 SULFAMYLON TOPICAL PACKET 3 mafenide acetate VYTONE 3 hydrocortisone XEPI 3 QL mupirocin, mupirocin TOPICAL ANTIFUNGALS ALA-QUIN 3 hydrocortisone w/iodoquinol ciclodan 1 CICLODAN KIT TOPICAL COMBO 3 PACK CICLODAN KIT TOPICAL 3 ciclopirox SOLUTION ciclopirox 1 ciclopirox-ure-camph-menth-euc 1 clotrimazole 1 clotrimazole-betamethasone 1 econazole 1 econazole nitrate, ciclopirox, ECOZA 3 ketoconazole, naftifine hcl, oxiconazole nitrate ciclopirox, econazole nitrate, ERTACZO 3 ketoconazole, naftifine hcl, oxiconazole nitrate ciclopirox, econazole nitrate, EXELDERM 3 ketoconazole, naftifine hcl, oxiconazole nitrate clotrimazole, ketoconazole, EXODERM 3 miconazole nitrate EXTINA 3 ketoconazole JUBLIA 3 ciclopirox KERYDIN 3 ciclopirox ketoconazole 1 ketodan 1 ketodan kit 1 LOPROX 3 ciclopirox LOPROX (AS OLAMINE) 3 ciclopirox LOPROX KIT 3 ciclopirox 72 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES LOTRISONE 3 clotrimazole/betamethasone ciclopirox, econazole nitrate, LUZU 3 ketoconazole, naftifine hcl, oxiconazole nitrate ciclopirox, econazole nitrate, MENTAX 3 ketoconazole, naftifine hcl, oxiconazole nitrate MICONAZOLE NITRATE-ZINC OX- 3 miconazole nitrate PET naftifine 1 NAFTIN TOPICAL CREAM 3 naftifine hcl NAFTIN TOPICAL GEL 1 % 3 naftifine hcl naftifine hcl, ciclopirox, clotrimazole, econazole NAFTIN TOPICAL GEL 2 % 3 nitrate, ketoconazole, oxiconazole nitrate NIZORAL 3 ketoconazole nyamyc 1 nystatin 1 nystatin-triamcinolone 1 nystop 1 oxiconazole 1 OXISTAT TOPICAL CREAM 3 oxiconazole nitrate oxiconazole nitrate, ciclopirox, clotrimazole, OXISTAT TOPICAL LOTION 3 econazole nitrate, ketoconazole, naftifine hcl PENLAC 3 ciclopirox TRIACETIN 2 VUSION 3 miconazole nitrate ciclopirox, ciclopirox, econazole nitrate, XOLEGEL 3 ketoconazole, oxiconazole nitrate TOPICAL ANTIVIRALS acyclovir 1 acyclovir, acyclovir, DENAVIR 3 famciclovir, valacyclovir acyclovir, acyclovir, XERESE 3 famciclovir, valacyclovir

73 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ZOVIRAX 3 acyclovir TOPICAL CORTICOSTEROIDS ala-cort 1 ALA-SCALP 3 hydrocortisone alclometasone 1 amcinonide 1 apexicon e 1 AQUA GLYCOLIC HC 3 beser 1 betamethasone dipropionate 1 betamethasone valerate 1 betamethasone, augmented 1 betamethasone dipropionate, clobetasol propionate, BRYHALI 3 halobetasol propionate, triamcinolone acetonide CAPEX 3 fluocinolone acetonide clobetasol 1 clobetasol-emollient 1 CLOBEX 3 clobetasol propionate clodan 1 CLODAN KIT 3 betamethasone valerate, CLODERM 3 fluocinolone acetonide, triamcinolone acetonide CORDRAN 3 flurandrenolide CORDRAN TAPE LARGE ROLL 3 flurandrenolide cormax 1 CUTIVATE 3 fluticasone propionate DERMA-SMOOTHE/FS BODY OIL 3 fluocinolone acetonide DERMA-SMOOTHE/FS SCALP OIL 3 fluocinolone acetonide DERMATOP 3 prednicarbate DESONATE 3 desonide desonide 1 DESOWEN 3 desonide desoximetasone 1 diflorasone 1 DIPROLENE 3 betamethasone dipropionate 74 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES tazarotene, betamethasone dipropionate, clobetasol DUOBRII 3 propionate, halobetasol propionate, triamcinolone acetonide ELOCON 3 mometasone furoate fluocinolone 1 fluocinolone and shower cap 1 fluocinonide 1 fluocinonide-e 1 flurandrenolide 1 fluticasone propionate 1 halcinonide 1 halobetasol propionate topical cream 1 betamethasone dipropionate, clobetasol propionate, HALOBETASOL PROPIONATE 3 desonide, desoximetasone, TOPICAL FOAM halobetasol propionate, triamcinolone acetonide halobetasol propionate topical ointment 1 betamethasone dipropionate, betamethasone dipropionate, HALOG 3 betamethasone valerate, fluocinonide, triamcinolone acetonide hydrocortisone 1 hydrocortisone butyrate 1 hydrocortisone butyr-emollient 1 hydrocortisone valerate 1 IMPOYZ 3 clobetasol propionate KENALOG 3 triamcinolone acetonide betamethasone dipropionate, clobetasol propionate, LEXETTE 3 desonide, desoximetasone, halobetasol propionate, triamcinolone acetonide LOCOID 3 hydrocortisone butyrate LOCOID LIPOCREAM 3 hydrocortisone butyrate LUXIQ 3 betamethasone valerate mometasone 1

75 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES nolix 1 NUCORT 3 OLUX 3 clobetasol propionate OLUX-E 3 clobetasol propionate betamethasone valerate, PANDEL 3 hydrocortisone valerate, triamcinolone acetonide prednicarbate 1 PROCTOCORT 3 PSORCON 3 diflorasone diacetate scalacort 1 SCALACORT DK 3 betamethasone dipropionate, betamethasone valerate, SERNIVO 3 desoximetasone, fluocinolone acetonide, fluocinonide, triamcinolone acetonide SYNALAR 3 fluocinolone acetonide SYNALAR CREAM KIT 3 fluocinolone acetonide SYNALAR OINTMENT KIT 3 fluocinolone acetonide SYNALAR TS 3 fluocinolone acetonide TEMOVATE 3 clobetasol propionate TEXACORT 3 hydrocortisone butyrate TOPICORT 3 desoximetasone tovet emollient 1 triamcinolone acetonide 1 trianex 1 triderm 1 TRIDESILON 3 desonide halobetasol propionate, betamethasone dipropionate, ULTRAVATE 3 clobetasol propionate, diflorasone diacetate, fluocinonide VANOS 3 fluocinonide TOPICAL ENZYMES SANTYL 2 QL TOPICAL SCABICIDES / PEDICULICIDES

76 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES crotan 1 ELIMITE 3 permethrin EURAX 3 crotan lindane 1 malathion 1 NATROBA 3 spinosad OVIDE 3 malathion permethrin 1 lindane, malathion, SKLICE 3 permethrin, spinosad spinosad 1 permethrin, malathion, ULESFIA 3 spinosad, lindane DIAGNOSTICS & MISCELLANEOUS AGENTS ANOREXIANTS ADIPEX-P 3 PA phentermine hcl benzphetamine hcl, BELVIQ 3 PA diethylpropion hcl, phentermine hcl benzphetamine hcl, BELVIQ XR 3 PA diethylpropion hcl, phentermine hcl benzphetamine 1 PA benzphetamine hcl, CONTRAVE 3 PA diethylpropion hcl, phentermine hcl diethylpropion 1 PA LOMAIRA 3 PA phendimetrazine tartrate 1 PA phentermine 1 PA benzphetamine hcl, SAXENDA 3 PA diethylpropion hcl, phentermine hcl benzphetamine hcl, XENICAL 3 PA diethylpropion hcl, phentermine hcl ANTIDOTES ATROPEN 3

77 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES DUODOTE 3 IRRIGATING SOLUTIONS neomycin-polymyxin b gu 1 SORBITOL 3 SORBITOL-MANNITOL 3 tis-u-sol pentalyte 1 VASHE WOUND THERAPY 3 MISCELLANEOUS AGENTS ABLYSINOL 3 acamprosate 1 acetic acid 1 AGRYLIN 3 anagrelide hydrochloride sodium phenylacet-sod AMMONUL 3 benzoate anagrelide 1 ANTABUSE 3 disulfiram aqua care sodium chloride 1 aqua care sterile water 1 ARALAST NP 2 PA AXUMIN 3 BUPHENYL 3 sodium phenylbutyrate caffeine citrate 1 CARBAGLU 2 CARNITOR 3 levocarnitine CARNITOR (SUGAR-FREE) 3 levocarnitine cevimeline 1 CHEMET 2 PA CHOLETEC 3 clovique 1 deferasirox 1 PA disulfiram 1 GLUTAMENT, ENDARI 3 GLUTASOLVE, l-glutamine etidronate disodium 1 EVOXAC 3 cevimeline hcl FERRLECIT 3 sod ferric gluconate complex FLUDEOXYGLUCOSE F-18 3 78 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES GLASSIA 2 PA GLEOLAN 3 ic green 1 INCRELEX 2 indocyanine green 1 INFASURF 3 KIT FOR TC 99M-SESTAMIBI NO.1 3 KIT PREP OF TC-99M-MEBROFENIN 3 KIT PREP OF TC-99M-SOD PYROPH 3 levocarnitine 1 levocarnitine (with sugar) 1 LIPOCHOL PLUS 3 LIPOCHOL LITHOSTAT 3 midodrine 1 MYOVIEW KIT 3 nitisinone 1 PA; ST NITYR 2 PA; ST desmopressin acetate, desmopressin acetate, NORTHERA 3 fludrocortisone acetate, indomethacin, midodrine hcl, pyridostigmine bromide pilocarpine hcl 1 PROLASTIN-C 2 PA RADIOGARDASE 3 RAVICTI 2 RECLAST 3 PA zoledronic acid REVCOVI 2 PA RILUTEK 3 riluzole riluzole 1 risedronate 1 QL SALAGEN (PILOCARPINE) 3 pilocarpine hcl SINOGRAFIN 3 sodium benzoate-sod phenylacet 1 sodium chloride 1 sodium chloride 0.9 % 1 sodium ferric gluconat-sucrose 1

79 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES sodium phenylbutyrate 1 SOLIRIS 2 PA SURVANTA 3 SYPRINE 3 trientine hcl THIOLA 3 THIOLA EC 3 TIGLUTIK 3 riluzole trientine 1 ULTOMIRIS 3 PA SOLIRIS water for irrigation, sterile 1 XURIDEN 2 ZEMAIRA 2 PA; ST zoledronic acid-mannitol-water 1 PA SMOKING DETERRENTS bupropion hcl (smoking deter) 1 QL CHANTIX 2 QL CHANTIX CONTINUING MONTH 2 QL BOX CHANTIX STARTING MONTH BOX 2 QL NICODERM CQ 2 QL nicorelief 1 QL NICORETTE BUCCAL GUM 2 MG 2 QL nicorette buccal gum 4 mg 1 QL NICORETTE BUCCAL LOZENGE 2 QL NICORETTE BUCCAL MINI 2 QL LOZENGE nicotine 1 QL nicotine (polacrilex) 1 QL NICOTROL 3 QL nicotine, nicotine gum NICOTROL NS 3 QL nicotine, nicotine gum quit 2 1 QL quit 4 1 QL stop smoking aid 1 QL EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS ALZAIR 3 80 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES azelastine nasal aerosol,spray 1 QL azelastine nasal spray,non-aerosol 1 chlorhexidine gluconate 1 DEBACTEROL 3 EPISIL 3 GELCLAIR 3 GELX 3 ipratropium bromide 1 QL MUGARD 3 olopatadine 1 QL oralone 1 ORAMAGICRX 3 paroex oral rinse 1 PATANASE 3 QL olopatadine hcl PERIDEX 3 chlorhexidine gluconate periogard 1 pilocarpine hcl 1 PROTHELIAL 3 Q-CARE RX Q4 3 SALAGEN (PILOCARPINE) 3 pilocarpine hcl triamcinolone acetonide 1 MISCELLANEOUS OTIC PREPARATIONS acetic acid 1 ciprofloxacin hcl 1 DERMOTIC OIL 3 fluocinolone acetonide oil flac otic oil 1 fluocinolone acetonide oil 1 hydrocortisone-acetic acid 1 ofloxacin 1 OTIPRIO 3 QL OTIC STEROID / ANTIBIOTIC CIPRO HC 3 CIPRODEX, OTOVEL CIPRODEX 2 CIPROFLOXACIN-FLUOCINOLONE 3 CIPRODEX, OTOVEL COLY-MYCIN S 3 neomycin/polymyxin/hc CORTISPORIN-TC 3 neomycin/polymyxin/hc 81 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES neomycin-polymyxin-hc 1 OTOVEL 2 ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR 3 PA BETAMETH AC,SOD PHOS(PF)- 3 WATER BETAMETHASONE ACE,SOD PHOS- 3 WTR betamethasone acet,sod phos 1 BETAMETHASONE SOD PHOSPH- 3 WATER CELESTONE SOLUSPAN 3 dexamethasone CORTEF 3 hydrocortisone cortisone 1 decadron 1 DEPO-MEDROL 3 methylprednisolone acetate dexamethasone 1 DEXAMETHASONE AC, SOD PH- 3 WATER DEXAMETHASONE ACE-NACL,ISO- 3 OSM dexamethasone intensol 1 dexamethasone sodium phos (pf) 1 dexamethasone sodium phosphate 1 DEXPAK 10 DAY 3 dexamethasone DEXPAK 13 DAY 3 dexamethasone DEXPAK 6 DAY 3 dexamethasone DXEVO 3 fludrocortisone 1 hidex 1 hydrocortisone 1 KENALOG 3 triamcinolone acetonide KENALOG-80 3 triamcinolone acetonide LIDOCIDEX-I 3 MEDROL 3 methylprednisolone MEDROL (PAK) 3 methylprednisolone

82 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES METHYLPRED AC(PF)-NACL,ISO- 3 OSM METHYLPREDNISOL AC-BUPIVAC- 3 WAT methylprednisolone 1 methylprednisolone acetate 1 METHYLPREDNISOLONE ACET- 3 WATER millipred 1 millipred dp 1 prednisolone sodium ORAPRED ODT 3 phosphate P-CARE K40 3 P-CARE K80 3 prednisolone sodium PEDIAPRED 3 phosphate POD-CARE 100K 3 prednisolone 1 prednisolone sodium phosphate 1 prednisone 1 prednisone intensol 1 PRO-C-DURE 5 3 PRO-C-DURE 6 3 RAYOS 3 prednisone READYSHARP DEXAMETHASONE 3 TAPERDEX 3 TRIAMCINOL AC (PF) IN 0.9%NACL 3 TRIAMCINOL ACE-BUPIV-0.9% 3 NACL TRIAMCINOLONE ACETON-0.9% 3 NACL triamcinolone acetonide 1 TRIAMCINOLONE DIA(PF)- 3 0.9%NACL TRIAMCINOLONE DIACET-0.9% 3 NACL veripred 20 1 ANTITHYROID AGENTS methimazole 1 83 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES propylthiouracil 1 SSKI 3 strong iodine TAPAZOLE 3 methimazole BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ONE TOUCH ULTRA TEST FREESTYLE INSULINX 2 QL STRIPS, ONE TOUCH VERIO ONE TOUCH ULTRA TEST FREESTYLE INSULINX TEST 2 QL STRIPS, ONE TOUCH STRIPS VERIO ONE TOUCH ULTRA TEST FREESTYLE LITE STRIPS 2 QL STRIPS, ONE TOUCH VERIO ONE TOUCH ULTRA TEST FREESTYLE TEST 2 QL STRIPS, ONE TOUCH VERIO ONETOUCH ULTRA BLUE TEST 2 QL STRIP ONETOUCH VERIO 2 QL ONE TOUCH ULTRA TEST PRECISION XTRA TEST 2 QL STRIPS, ONE TOUCH VERIO DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT ACE AEROSOL CLOUD ENHANCER 2 AEROCHAMBER MINI 2 AEROCHAMBER PLUS FLOW-VU 2 AEROCHAMBER PLUS Z STAT 2 AEROTRACH PLUS 2 AEROVENT PLUS 2 BREATHERITE MDI SPACER 2 COMPACT SPACE CHAMBER 2 EASIVENT HOLDING CHAMBER 2 FLEXICHAMBER 2 GLUCAGEN DIAGNOSTIC KIT 2 GLUCAGON HCL 3 INSPIRACHAMBER 2 84 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES INSULIN SYRINGE-NEEDLE U-100 3 B-D INSULIN SYRINGE LITEAIRE MDI CHAMBER 2 MICROCHAMBER 2 MICROSPACER 2 OPTICHAMBER DIAMOND VHC 2 POCKET CHAMBER 2 PRIMEAIRE 2 PROCHAMBER 2 RITEFLO AEROCHAMBER 2 VORTEX HOLDING CHAMBER 2 GLUCOSE ELEVATING AGENTS BAQSIMI 2 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 (HUMAN) GVOKE SYRINGE 2 PROGLYCEM 2 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU FREESTYLE CONTROL SOLUTION, MEDISENSE, ACCU-CHEK COMPACT PLUS 3 ONE TOUCH ULTRA CONTROL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ACCU-CHEK GUIDE L1-L2 CTRL 3 ONE TOUCH ULTRA SOL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ACCU-CHEK SMARTVIEW CONTRL 3 ONE TOUCH ULTRA SOL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ACCUTREND GLUCOSE CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

85 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, ADVOCATE LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ADVOCATE REDI-CODE+ CTRL 3 ONE TOUCH ULTRA LOW CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, AGAMATRIX CONTROL HIGH 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MEDISENSE, MEDISENSE, ASSURE 4 CONTROL SOLUTION 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ASSURE DOSE NORMAL CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MEDISENSE, MEDISENSE, ASSURE PRISM CONTROL 1-2 SOLN 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO AT HOME A1C 3 AUTOJECT 2 INJECTION DEVICE 2 AUTOPEN 1 TO 21 UNITS 2 AUTOSOFT 30 2 AUTOSOFT 90 2 AUTOSOFT XC INFUSION SET 23" 2 BD MICROTAINER LANCET 2 BD ULTRA FINE LANCETS 2 86 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES BD ULTRA-FINE NANO PEN 2 NEEDLE FREESTYLE CONTROL SOLUTION, MEDISENSE, BLOOD GLUCOSE CONTROL, 3 ONE TOUCH ULTRA NORMAL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, BREEZE 2 CONTROL 3 ONE TOUCH ULTRA SOLUTION,HIGH CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, CARESENS CONTROL A NORMAL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO CLEO 90 INFUSION SET 24" 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, CLEVER CHOICE LEVEL 2 3 ONE TOUCH ULTRA CONTROL CONTROL SOLN, ONE TOUCH VERIO COMFORT SHORT INSULIN PUMP 2 23" FREESTYLE CONTROL SOLUTION, MEDISENSE, CONTOUR CONTROL SOLUTION, 3 ONE TOUCH ULTRA NML CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, CONTOUR NEXT LEV 2 CONTROL 3 ONE TOUCH ULTRA SOL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, COOL CONTROL A SOLUTION 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO DEXCOM G4 RECEIVER 2 DEXCOM G5 RECEIVER 2 DEXCOM G6 RECEIVER 2 DEXCOM RECEIVER 2 87 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, DIATRUE CONTROL SOLN 3 ONE TOUCH ULTRA NORMAL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASY PLUS II HIGH CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASY STEP HIGH CONTROL SOLN 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASY TALK HIGH CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASY TRAK LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASYGLUCO PLUS NORMAL 3 ONE TOUCH ULTRA CONTROL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASYMAX LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EASYMAX NORMAL CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO ECLIPSE NEEDLE 3

88 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, ELEMENT COMPACT NORMAL 3 ONE TOUCH ULTRA CONTROL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, ELEMENT NORMAL CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EMBRACE EVO LEVEL 1 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EMBRACE GLUCOSE CONTROL 3 ONE TOUCH ULTRA LOW CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, EMBRACE TALK CONTROL-LOW 3 ONE TOUCH ULTRA (L1) CONTROL SOLN, ONE TOUCH VERIO ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ENLITE SYSTEM 3 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC EVERSENSE SENSOR-HOLDER 3 FREESTYLE CONTROL SOLUTION, MEDISENSE, EVOLUTION NORMAL CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FORA GTEL MULTI-FUNCTN 3 MONITOR FREESTYLE CONTROL SOLUTION, MEDISENSE, FORA NORMAL CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

89 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, FORACARE GDH LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, FORTISCARE NORMAL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL 2 ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, FREESTYLE FREEDOM 2 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, FREESTYLE FREEDOM LITE 2 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, FREESTYLE INSULINX 2 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC FREESTYLE LIBRE 10 DAY 2 READER FREESTYLE LIBRE 10 DAY SENSOR 2 ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, FREESTYLE LITE METER 2 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC FREESTYLE CONTROL SOLUTION, MEDISENSE, GE100 CONTROL SOLUTION 3 ONE TOUCH ULTRA NORMAL CONTROL SOLN, ONE TOUCH VERIO GENTEEL VACUUM LANCING 3 DEVICE

90 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, GLUCOCARD 01 NORMAL 3 ONE TOUCH ULTRA CONTROL CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, GLUCOCOM CONTROL NORMAL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, GLUCOSE CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, GUARDIAN REAL-TIME GLU 3 ONETOUCH VERIO FLEX, MONITOR ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC FREESTYLE CONTROL SOLUTION, MEDISENSE, HEALTHPRO HIGH-LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, INFINITY CONTROL SOLUTION 3 ONE TOUCH ULTRA NORM CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, INFINITY VOICE CTRL SOLN-LVL 2 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO INPEN (FOR HUMALOG) 3 INPEN (FOR NOVOLOG) 3 INSET 30 INFUSION SET 23" 2 INSET INFUSION SET 23" 2 LANCETS 2 LANCING DEVICE 2 MEDISENSE 2 MEDISENSE GLUCOSE KETONE 2

91 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MYGLUCOHEALTH CONTROL MEDISENSE, MEDISENSE, 3 SOLUTION ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, NOVA MAX GLUCOSE CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, NOVAMAX PLUS GLU-KET 3 ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC NOVOPEN ECHO 3 OMNIPOD DASH INSULIN POD 2 FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MEDISENSE, MEDISENSE, ON CALL EXPRESS CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MEDISENSE, MEDISENSE, ON CALL PLUS CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, MEDISENSE, MEDISENSE, ON CALL VIVID CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO ONETOUCH ULTRA CONTROL 2

92 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ONETOUCH ULTRA2 METER 2 ONETOUCH ULTRAMINI 2 ONETOUCH VERIO FLEX 2 ONETOUCH VERIO IQ METER 2 ONETOUCH VERIO SYSTEM 2 ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, PARADIGM REAL-TIME 3 ONETOUCH VERIO FLEX, TRANSMIT-SN ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC BD INSULIN PEN NEEDLE UF MINI, BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, DIABETIC 3 PEN NEEDLE, NOVOFINE, NOVOFINE PLUS, NOVOTWIST PRECISION XTRA MONITOR 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, PRODIGY CONTROL SOLUTION, 3 ONE TOUCH ULTRA LOW CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, PRODIGY CONTROL 3 ONE TOUCH ULTRA SOLUTION,HIGH CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, REFUAH PLUS GLUCOSE CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, RIGHTEST CONTROL SOLUTION 3 ONE TOUCH ULTRA HIGH CONTROL SOLN, ONE TOUCH VERIO SAFE-CLIP BY MAIL 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, SMARTEST CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

93 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, SOLUS V2 CONTROL 3 ONE TOUCH ULTRA SOLUTION,HIGH CONTROL SOLN, ONE TOUCH VERIO T:30 INFUSION SET 2 T:90 INFUSION SET 23" 2 T:SLIM 2 T:SLIM G4 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, TELCARE CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, TRUE METRIX LEVEL 1 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, MEDISENSE, TRUECONTROL LEVEL 0 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO TRUSTEEL INFUSION SET 32" 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, UNISTRIP LOW CONTROL 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO VARISOFT INFUSION SET 43" 2 FREESTYLE CONTROL SOLUTION, MEDISENSE, VERASENS CONTROL SOLN-LEVEL 3 ONE TOUCH ULTRA 1 CONTROL SOLN, ONE TOUCH VERIO FREESTYLE CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, VIVAGUARD INO CONTROL MEDISENSE, MEDISENSE, 3 SOLUTION ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO, ONE TOUCH VERIO

94 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES FREESTYLE CONTROL SOLUTION, MEDISENSE, WAVESENSE CONTROL SOLUTION 3 ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO INSULIN THERAPY AFREZZA 3 HUMALOG LANTUS, LANTUS SOLOSTAR, LEVEMIR, LEVEMIR FLEXTOUCH, BASAGLAR KWIKPEN U-100 3 TOUJEO SOLOSTAR, INSULIN TRESIBA FLEXTOUCH U- 200, TRESIBA FLEXTOUCH U-100 HUMALOG JUNIOR KWIKPEN U- 2 100 HUMALOG KWIKPEN INSULIN 2 HUMALOG MIX 50-50 INSULN U- 2 100 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMALOG MIX 75-25(U- 2 100)INSULN HUMALOG U-100 INSULIN 2 HUMULIN 70/30 U-100 INSULIN 2 HUMULIN 70/30 U-100 KWIKPEN 2 HUMULIN N NPH INSULIN 2 KWIKPEN HUMULIN N NPH U-100 INSULIN 2 HUMULIN R REGULAR U-100 2 INSULN HUMULIN R U-500 (CONC) INSULIN 2 HUMULIN R U-500 (CONC) 2 KWIKPEN LANTUS SOLOSTAR U-100 INSULIN 2 LANTUS U-100 INSULIN 2 LEVEMIR FLEXTOUCH U-100 2 INSULN LEVEMIR U-100 INSULIN 2 MYXREDLIN 3 SOLIQUA 100/33 2 95 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES TOUJEO MAX U-300 SOLOSTAR 2 TOUJEO SOLOSTAR U-300 INSULIN 2 TRESIBA FLEXTOUCH U-100 2 TRESIBA FLEXTOUCH U-200 2 TRESIBA U-100 INSULIN 2 XULTOPHY 100/3.6 2 MISCELLANEOUS HORMONES ALDURAZYME 2 ANADROL-50 3 oxandrolone ANDRODERM 2 ANDROGEL 3 testosterone methyltestosterone, ANDROID 3 METHITEST testosterone cypionate, AVEED 3 testosterone enanthate BRINEURA 2 cabergoline 1 QL calcitonin (salmon) 1 calcitriol 1 CERDELGA 2 PA CEREZYME 2 PA cinacalcet 1 CRYSVITA 2 PA danazol 1 DDAVP NASAL SOLUTION 2 DDAVP NASAL SPRAY WITH PUMP 3 desmopressin acetate DDAVP ORAL 3 desmopressin acetate DEPO-TESTOSTERONE 3 testosterone cypionate desmopressin 1 doxercalciferol 1 ELAPRASE 2 ELELYSO 3 PA; ST CEREZYME FABRAZYME 2 PA FORTESTA 3 testosterone GALAFOLD 3 PA; QL FABRAZYME HECTOROL 3 doxercalciferol JYNARQUE 3 PA; QL

96 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES KANUMA 2 ketoconazole, LYSODREN, KORLYM 3 SIGNIFOR KUVAN 2 LUMIZYME 2 MEPSEVII 2 METHITEST 2 methyltestosterone 1 MIACALCIN 2 miglustat 1 PA MYALEPT 2 NAGLAZYME 2 NATESTO 3 testosterone NATPARA 2 NOCDURNA (MEN) 3 PA; QL NOCDURNA (WOMEN) 3 PA; QL ORILISSA 2 PA OXANDRIN 3 oxandrolone oxandrolone 1 PALYNZIQ 2 PA; QL pamidronate 1 PARICALCITOL HEMODIALYSIS 3 PORT INJECTION paricalcitol intravenous 1 paricalcitol oral 1 PARSABIV 3 calcitriol, doxercalciferol, RAYALDEE 3 paricalcitol ROCALTROL 3 calcitriol SAMSCA 2 PA; QL SENSIPAR 3 cinacalcet hcl SOMAVERT 2 STIMATE 2 STRENSIQ 2 PA STRIANT 3 testosterone SYNAREL 2 PA testosterone 1

97 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES testosterone cypionate 1 testosterone enanthate 1 methyltestosterone, TESTRED 3 METHITEST VIMIZIM 2 PA VOGELXO 3 testosterone VPRIV 3 PA; ST CEREZYME testosterone enanthate, XYOSTED 3 testosterone cypionate ZEMPLAR 3 paricalcitol zoledronic acid 1 zoledronic acid-mannitol-water 1 ZOLEDRONIC AC-MANNITOL- 3 0.9NACL NON-INSULIN HYPOGLYCEMIC AGENTS acarbose 1 ACTOPLUS MET 3 ST; QL pioglitazone-metformin pioglitazone-metformin, ACTOPLUS MET XR 3 ST; QL metformin hcl, pioglitazone hcl ACTOS 3 ST; QL pioglitazone hcl AMARYL 3 glimepiride AVANDIA 3 ST; QL pioglitazone hcl BYDUREON 2 BYDUREON BCISE 2 BYETTA 2 QL metformin hcl, glimepiride, CYCLOSET 3 glipizide, glyburide DUETACT 3 ST; QL pioglitazone-glimepiride FARXIGA 2 ST FORTAMET 3 ST metformin hcl er glimepiride 1 glipizide 1 glipizide-metformin 1 GLUCOTROL 3 glipizide GLUCOTROL XL 3 glipizide er glyburide 1

98 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES glyburide micronized 1 glyburide-metformin 1 GLYNASE 3 glyburide micronized GLYSET 3 miglitol GLYXAMBI 2 ST INVOKAMET 2 ST INVOKAMET XR 2 ST INVOKANA 2 ST JANUMET 2 JANUMET XR 2 JANUVIA 2 QL JARDIANCE 2 ST JENTADUETO 2 JENTADUETO XR 2 metformin hcl, metformin hcl METFORMIN ORAL SOLUTION 3 ST er metformin oral tablet 1 metformin oral tablet extended release 1 24 hr metformin oral tablet extended release 1 ST 24hr metformin oral tablet,er gast.retention 1 PA; ST 24 hr miglitol 1 nateglinide 1 pioglitazone hcl, JANUVIA, OSENI 3 TRADJENTA OZEMPIC 2 pioglitazone 1 QL pioglitazone-glimepiride 1 QL pioglitazone-metformin 1 QL PRANDIN 3 repaglinide PRECOSE 3 acarbose QTERN 3 ST GLYXAMBI repaglinide 1 repaglinide-metformin 1 QL metformin hcl, metformin hcl RIOMET 3 ST er

99 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES RYBELSUS 2 SEGLUROMET 2 ST STARLIX 3 nateglinide STEGLATRO 2 ST STEGLUJAN 3 ST GLYXAMBI SYMLINPEN 120 2 QL SYMLINPEN 60 2 QL SYNJARDY 2 ST SYNJARDY XR 2 ST TRADJENTA 2 TRULICITY 2 XIGDUO XR 2 ST THYROID HORMONES ARMOUR THYROID 2 EUTHYROX 3 levothyroxine sodium, LEVO-T 3 levoxyl, unithroid levothyroxine intravenous recon soln 1 LEVOTHYROXINE INTRAVENOUS 3 SOLUTION levothyroxine oral 1 levoxyl 1 liothyronine 1 nature-throid 1 np thyroid 1 levothyroxine sodium, SYNTHROID 3 levoxyl, unithroid thyroid (pork) 1 levothyroxine sodium, THYROLAR-1 3 levoxyl, liothyronine sodium, unithroid levothyroxine sodium, THYROLAR-1/2 3 levoxyl, liothyronine sodium, unithroid levothyroxine sodium, THYROLAR-1/4 3 levoxyl, liothyronine sodium, unithroid

100 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES levothyroxine sodium, THYROLAR-2 3 levoxyl, liothyronine sodium, unithroid levothyroxine sodium, THYROLAR-3 3 levoxyl, liothyronine sodium, unithroid levothyroxine sodium, TIROSINT 3 levoxyl, unithroid levothyroxine sodium, TIROSINT-SOL 3 levoxyl, unithroid TRIOSTAT 3 liothyronine sodium unithroid 1 westhroid 1 WP THYROID 3 westhroid GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz 1 atropine 1 atropine in 0.9 % sod chloride intravenous syringe 0.8 mg/2 ml (0.4 1 mg/ml) ATROPINE IN 0.9 % SOD CHLORIDE INTRAVENOUS SYRINGE 1 MG/2.5 3 ML (0.4 MG/ML), 2 MG/5 ML (0.4 MG/ML) belladonna alkaloids-opium 1 PA BENTYL 3 dicyclomine hcl chlordiazepoxide-clidinium 1 CUVPOSA 3 glycopyrrolate dicyclomine 1 diphenoxylate-atropine 1 DONNATAL 3 belladonna-phenobarbital ed-spaz 1 GLYCATE 3 GLYCOPYRROLATE (PF) IN WATER 3 INJECTION glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml), 1 mg/5 1 ml (0.2 mg/ml) 101 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES GLYCOPYRROLATE (PF) IN WATER INTRAVENOUS SYRINGE 0.6 MG/3 3 ML (0.2 MG/ML) glycopyrrolate injection 1 GLYCOPYRROLATE 3 INTRAVENOUS glycopyrrolate oral 1 GLYRX-PF 3 hyoscyamine sulfate 1 hyosyne 1 LEVBID 3 hyoscyamine sulfate LEVSIN INJECTION 2 LEVSIN ORAL 3 hyoscyamine sulfate LEVSIN/SL 3 hyoscyamine sulfate LOMOTIL 3 diphenoxylate w/atropine loperamide 1 methscopolamine 1 glycopyrrolate MOTOFEN 3 diphenoxylate w/atropine diphenoxylate w/atropine, MYTESI 3 loperamide hcl NULEV 3 hyoscyamine sulfate opium tincture 1 oscimin 1 oscimin sl 1 oscimin sr 1 paregoric 1 phenobarb-hyoscy-atropine-scop 1 phenohytro 1 dicyclomine hcl, propantheline 1 glycopyrrolate SYMAX DUOTAB 3 hyoscyamine sulfate symax fastabs 1 symax-sl 1 symax-sr 1 MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL 3 ursodiol

102 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES fosaprepitant dimeglumine, granisetron hcl, ondansetron AKYNZEO (FOSNETUPITANT) 3 hcl, palonosetron hcl, CINVANTI alophen 1 alosetron 1 ALOXI 3 palonosetron hcl AMITIZA 3 LINZESS, TRULANCE ANA-LEX KIT 3 hc pramoxine, pramoxine hcl ANALPRAM-HC 3 w/hydrocortisone hc pramoxine, pramoxine hcl ANALPRAM-HC SINGLES 3 w/hydrocortisone anucort-hc 1 aprepitant 1 QL APRISO 2 lanthanum carbonate, sevelamer carbonate, AURYXIA 3 sevelamer hcl, PHOSLYRA, VELPHORO AZULFIDINE 3 ST sulfasalazine AZULFIDINE EN-TABS 3 ST sulfasalazine balsalazide 1 bisacodyl 1 bisa-lax 1 doxylamine succ-pyridoxine BONJESTA 3 hcl budesonide oral 1 capsule,delayed,extend.release budesonide oral tablet,delayed and 1 UCERIS ext.release calcium acetate 1 CANASA 3 mesalamine CESAMET 3 QL ondansetron hcl CHENODAL 2 CHOLBAM 2 CINVANTI 2 citrate of magnesia 1 citroma 1

103 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES clearlax 1 CLENPIQ 2 COLAZAL 3 ST balsalazide disodium gavilyte-c, peg 3350- COLYTE WITH FLAVOR PACKS 3 electrolyte COMPAZINE 3 prochlorperazine maleate compro 1 constulose 1 CORTENEMA 3 hydrocortisone CREON 2 cromolyn 1 CYSTADANE 2 doxylamine succ-pyridoxine DICLEGIS 3 hcl dimenhydrinate 1 doxylamine-pyridoxine (vit b6) 1 DICLEGIS dronabinol 1 ducodyl 1 EMEND (FOSAPREPITANT) 3 fosaprepitant dimeglumine ENTEREG 3 ENTOCORT EC 3 budesonide ec ENTYVIO 2 PA enulose 1 fleet laxative 1 fosaprepitant 1 GASTROCROM 3 cromolyn sodium diphenoxylate w/atropine, GATTEX 30-VIAL 3 loperamide hcl, opium, paregoric gavilax 1 gavilyte-c 1 gavilyte-g 1 gavilyte-n 1 generlac 1 gentle laxative 1 gentlelax 1 glycolax 1

104 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES gavilyte-g, peg 3350- electrolyte, trilyte with flavor GOLYTELY 3 packets, PREPOPIK, SUPREP granisetron (pf) 1 granisetron hcl intravenous 1 granisetron hcl oral 1 QL healthylax 1 hemmorex-hc 1 hydrocortisone 1 hydrocortisone acetate 1 hydrocortisone-pramoxine 1 INFLECTRA 3 ST REMICADE KRISTALOSE 3 lactulose lactulose 1 lanthanum 1 laxaclear 1 laxative (bisacodyl) 1 laxative feminine 1 laxative peg 3350 1 LIALDA 3 ST mesalamine lidocaine hcl-hydrocortison ac rectal 1 cream LIDOCAINE HCL- 3 HYDROCORTISON AC RECTAL GEL lidocaine hcl-hydrocortison ac rectal kit 1 lidocaine-hydrocortisone-aloe 1 LINZESS 2 LOKELMA 2 LOTRONEX 3 alosetron hcl magnesium citrate 1 MARINOL 3 dronabinol meclizine 1 mesalamine 1 mesalamine with cleansing wipe 1 metoclopramide hcl 1 MICORT-HC 3 hydrocortisone milk of magnesia 1 105 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES milk of magnesia concentrated 1 miralax 1 MOTEGRITY 3 LINZESS, TRULANCE MOVANTIK 2 gavilyte-g, peg 3350- electrolyte, trilyte with flavor MOVIPREP 3 packets, PREPOPIK, SUPREP natura-lax 1 gavilyte-n, peg 3350- NULYTELY WITH FLAVOR PACKS 3 electrolyte, trilyte with flavor packets OCALIVA 2 PA ondansetron 1 QL ondansetron hcl (pf) 1 ondansetron hcl intravenous 1 ondansetron hcl oral 1 QL ONDANSETRON IN 0.9 % SOD 3 CHLOR oral saline laxative 1 gavilyte-g, peg 3350- electrolyte, trilyte with flavor OSMOPREP 3 packets, PREPOPIK, SUPREP PALONOSETRON INTRAVENOUS 3 SOLUTION 0.25 MG/2 ML palonosetron intravenous solution 0.25 1 mg/5 ml palonosetron intravenous syringe 1 peg 3350-electrolytes 1 peg-electrolyte soln 1 peg-prep 1 PENTASA 2 PHOSLYRA 2 phosphate laxative 1 gavilyte-g, peg 3350- electrolyte, trilyte with flavor PLENVU 3 packets, PREPOPIK, SUPREP polyethylene glycol 3350 1

106 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES powderlax 1 PREPOPIK 2 prochlorperazine 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 hc pramoxine, pramoxine hcl PROCORT 3 w/hydrocortisone PROCTOCORT 3 hydrocortisone acetate hc pramoxine, pramoxine hcl PROCTOFOAM HC 3 w/hydrocortisone procto-med hc 1 procto-pak 1 proctosol hc 1 proctozone-hc 1 purelax 1 RECTIV 2 REGLAN 3 metoclopramide hcl RELISTOR 2 REMICADE 2 ST RENFLEXIS 3 ST REMICADE RENVELA 3 sevelamer carbonate ROWASA 3 mesalamine granisetron hcl, ondansetron SANCUSO 3 QL hcl scopolamine base 1 sevelamer carbonate 1 sevelamer hcl 1 SFROWASA 3 mesalamine smoothlax 1 sodium polystyrene sulfonate oral 1 sodium polystyrene sulfonate rectal 1 enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 3 GRAM/200 ML sps (with sorbitol) 1 SUCRAID 2 sulfasalazine 1

107 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES SUPREP BOWEL PREP KIT 2 granisetron hcl, ondansetron SUSTOL 3 hcl, palonosetron hcl SYMPROIC 2 SYNDROS 3 dronabinol TIGAN 3 trimethobenzamide hcl TRANSDERM-SCOP 3 meclizine hcl trilyte with flavor packets 1 trimethobenzamide 1 TRULANCE 2 UCERIS ORAL 3 budesonide er UCERIS RECTAL 2 URSO 250 3 ursodiol URSO FORTE 3 ursodiol ursodiol 1 VARUBI 2 VELPHORO 2 VIBERZI 2 VIOKACE 2 women's gentle laxative(bisac) 1 women's laxative (bisacodyl) 1 ZENPEP 2 ZOFRAN 3 QL ondansetron hcl ondansetron odt, ondansetron ZUPLENZ 3 QL hcl, granisetron hcl ULCER THERAPY amoxicil-clarithromy-lansopraz 1 QL CARAFATE ORAL SUSPENSION 2 CARAFATE ORAL TABLET 3 sucralfate cimetidine 1 cimetidine hcl 1 CYTOTEC 3 misoprostol esomeprazole magnesium, lansoprazole, omeprazole, DEXILANT 3 ST pantoprazole sodium, rabeprazole sodium, NEXIUM RX esomeprazole magnesium 1 108 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES esomeprazole sodium 1 famotidine 1 famotidine (pf) 1 famotidine (pf)-nacl (iso-os) 1 FAMOTIDINE IN 0.9 % NACL 3 lansoprazole 1 misoprostol 1 NEXIUM 3 esomeprazole magnesium NEXIUM IV 3 esomeprazole sodium NEXIUM PACKET 2 ST nizatidine 1 lansoprazol-amoxicil- OMECLAMOX-PAK 3 clarithro, PYLERA omeppi 1 ST omeprazole 1 omeprazole-sodium bicarbonate 1 ST pantoprazole 1 PEPCID 3 famotidine PYLERA 2 rabeprazole 1 ranitidine hcl 1 sucralfate 1 ZANTAC 3 ranitidine hcl IMMUNOLOGY, VACCINES & BIOTECHNOLOGY BIOTECHNOLOGY DRUGS FULPHILA 3 PA; ST; QL NEULASTA, UDENYCA LEUKINE 2 MOZOBIL 2 NEULASTA 2 PA; ST; QL NIVESTYM 2 PA GRANIX, ZARXIO PROCRIT 2 PA REBLOZYL 3 PA RETACRIT 2 PA UDENYCA 2 PA; QL ZARXIO 2 PA ZIEXTENZO 3 PA 109 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES GROWTH HORMONES EGRIFTA 2 GENOTROPIN 2 PA GENOTROPIN MINIQUICK 2 PA NORDITROPIN FLEXPRO 2 PA SEROSTIM 2 PA GENOTROPIN, ZORBTIVE 3 PA NORDITROPIN FLEXPRO INTERFERONS AVONEX 2 PA; ST; QL AVONEX (WITH ALBUMIN) 2 PA; ST; QL BETASERON 2 PA; ST; QL COPAXONE SUBCUTANEOUS 3 PA; ST; QL SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS 2 PA; ST SYRINGE 40 MG/ML GILENYA 2 PA; ST glatiramer subcutaneous syringe 20 1 PA; QL mg/ml glatiramer subcutaneous syringe 40 1 PA mg/ml glatopa subcutaneous syringe 20 mg/ml 1 PA; ST; QL glatopa subcutaneous syringe 40 mg/ml 1 PA; ST LEMTRADA 3 MAVENCLAD (10 TABLET PACK) 3 PA; ST MAVENCLAD (4 TABLET PACK) 3 PA; ST MAVENCLAD (5 TABLET PACK) 3 PA; ST MAVENCLAD (6 TABLET PACK) 3 PA; ST MAVENCLAD (7 TABLET PACK) 3 PA; ST MAVENCLAD (8 TABLET PACK) 3 PA; ST MAVENCLAD (9 TABLET PACK) 3 PA; ST MAYZENT 2 PA; ST OCREVUS 2 PA PEGASYS 2 PA; QL PEGASYS, PEGASYS PEGINTRON 3 PA; QL PROCLICK PLEGRIDY 2 PA; ST POMALYST 2 PA 110 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES REBIF (WITH ALBUMIN) 2 PA; ST; QL REBIF REBIDOSE 2 PA; ST; QL REBIF TITRATION PACK 2 PA; ST; QL REVLIMID 2 PA ribasphere 1 ribasphere ribapak 1 ribavirin 1 SYLATRON 2 TECFIDERA 2 PA; ST VUMERITY 3 PA INTERLEUKINS ACTIMMUNE 2 ALDARA 3 ALFERON N 2 ARCALYST 3 ILARIS ILARIS (PF) 2 imiquimod 1 INTRON A 2 PROLEUKIN 2 PA VACCINES & MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) 2 ADACEL(TDAP 2 ADOLESN/ADULT)(PF) AFLURIA QD 2019-20(3YR UP)(PF) 2 AFLURIA QD 2019-20(6-35MO)(PF) 2 AFLURIA QUAD 2019-20(6MO UP) 2 ASCENIV 3 PA ATGAM 2 BCG VACCINE, LIVE (PF) 2 BEXSERO 2 BIOTHRAX 2 GAMMAGARD LIQUID, BIVIGAM 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN BOOSTRIX TDAP 2

111 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES BOTOX 2 PA GAMMAGARD LIQUID, CUTAQUIG 3 PA GAMUNEX-C, HIZENTRA CUVITRU 3 PA HIZENTRA DAPTACEL (DTAP PEDIATRIC) (PF) 2 DYSPORT 3 PA BOTOX ENGERIX-B (PF) 2 ENGERIX-B PEDIATRIC (PF) 2 GAMMAGARD LIQUID, FLEBOGAMMA DIF 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN FLUAD 2019-2020 (65 YR UP)(PF) 2 FLUARIX QUAD 2019-2020 (PF) 2 FLUBLOK QUAD 2019-2020 (PF) 2 FLUCELVAX QUAD 2019-2020 2 FLUCELVAX QUAD 2019-2020 (PF) 2 FLULAVAL QUAD 2019-2020 2 FLULAVAL QUAD 2019-2020 (PF) 2 FLUMIST QUAD 2019-2020 3 FLUZONE HIGH-DOSE 2019-20 (PF) 2 FLUZONE QUAD 2019-2020 2 FLUZONE QUAD 2019-2020 (PF) 2 FLUZONE QUAD PEDI 2019-20 (PF) 2 GAMASTAN 2 GAMASTAN S/D 2 GAMMAGARD LIQUID 2 PA GAMMAGARD S-D (IGA < 1 2 PA MCG/ML) GAMMAGARD LIQUID, GAMMAGARD S-D, GAMMAKED 3 PA GAMUNEX-C, HIZENTRA, PRIVIGEN GAMMAGARD LIQUID, GAMMAPLEX 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN GAMMAGARD LIQUID, GAMMAPLEX (WITH SORBITOL) 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN GAMUNEX-C 2 PA

112 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES GARDASIL 9 (PF) 2 GRASTEK 2 HAVRIX (PF) 2 HEPAGAM B 2 ENGERIX-B, HEPLISAV-B (PF) 3 RECOMBIVAX HB HIBERIX (PF) 2 HIZENTRA 2 PA HYPERHEP B S/D 2 HYPERHEP B S-D NEONATAL 2 HYPERRAB (PF) 2 HYPERRAB S/D (PF) 2 HYPERTET S/D (PF) 2 GAMMAGARD LIQUID, HYQVIA 3 PA GAMUNEX-C, HIZENTRA IMOGAM RABIES-HT (PF) 2 IMOVAX RABIES VACCINE (PF) 2 INFANRIX (DTAP) (PF) 2 IPOL 2 IXIARO (PF) 2 HYPERRAB, HYPERRAB S- KEDRAB (PF) 3 D, IMOGAM RABIES-HT KINRIX (PF) 3 INFANRIX, PEDIARIX MENACTRA (PF) 2 MENVEO A-C-Y-W-135-DIP (PF) 3 MENACTRA M-M-R II (PF) 2 MYOBLOC 2 PA HEPAGAM B, HYPERHEP NABI-HB 3 B S-D GAMMAGARD LIQUID, OCTAGAM 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN ODACTRA 2 ORALAIR 2 GRASTEK GAMMAGARD LIQUID, PANZYGA 3 PA GAMMAGARD S-D, GAMUNEX-C, PRIVIGEN PEDIARIX (PF) 2

113 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES PEDVAX HIB (PF) 2 PENTACEL (PF) 2 PENTACEL ACTHIB COMPONENT 2 (PF) PNEUMOVAX 23 2 PREVNAR 13 (PF) 2 PRIVIGEN 2 PA PROQUAD (PF) 2 PROVENGE 2 PA QUADRACEL (PF) 2 RABAVERT (PF) 2 RAGWITEK 2 RECOMBIVAX HB (PF) 2 ROTARIX 3 ROTATEQ ROTATEQ VACCINE 2 SHINGRIX (PF) 2 STAMARIL (PF) 2 TDVAX 2 TETANUS DIPHTHERIA TENIVAC (PF) 3 TOXOIDS TETANUS,DIPHTHERIA TOX 2 PED(PF) THYMOGLOBULIN 2 TRUMENBA 2 TWINRIX (PF) 2 TYPHIM VI 2 VAQTA (PF) 3 HAVRIX VARIVAX (PF) 2 VARIZIG 2 VAXCHORA VACCINE 2 VIVOTIF 2 GAMMAGARD LIQUID, XEMBIFY 3 PA GAMUNEX-C, HIZENTRA XEOMIN 3 PA BOTOX YF-VAX (PF) 2 metronidazole, metronidazole, ZINPLAVA 3 vancomycin hcl ZOSTAVAX (PF) 3 SHINGRIX 114 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol 1 allopurinol sodium 1 aloprim 1 COLCRYS 2 DUZALLO 3 allopurinol, probenecid febuxostat 1 GLOPERBA 3 KRYSTEXXA 2 MITIGARE 2 probenecid 1 probenecid-colchicine 1 ULORIC 3 febuxostat ZYLOPRIM 3 allopurinol OSTEOPOROSIS THERAPY ACTONEL 3 ST; QL risedronate sodium alendronate oral solution 1 alendronate oral tablet 1 QL ATELVIA 3 ST; QL risedronate sodium dr BINOSTO 3 ST alendronate sodium BONIVA INTRAVENOUS 3 PA ibandronate sodium BONIVA ORAL 3 ST; QL ibandronate sodium EVISTA 3 raloxifene hcl FORTEO 2 PA; QL FOSAMAX 3 ST; QL alendronate sodium FOSAMAX PLUS D 3 ST; QL alendronate sodium ibandronate intravenous 1 PA ibandronate oral 1 QL raloxifene 1 risedronate 1 QL TYMLOS 2 PA OTHER RHEUMATOLOGICALS ACTEMRA ACTPEN 2 PA; ST ACTEMRA INTRAVENOUS 2 PA

115 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ACTEMRA SUBCUTANEOUS 2 PA; ST ARAVA 3 QL leflunomide BENLYSTA INTRAVENOUS 2 BENLYSTA SUBCUTANEOUS 2 PA; QL DEPEN TITRATABS 2 PA D-PENAMINE 2 PA ENBREL 2 PA; QL ENBREL MINI 2 PA; QL ENBREL SURECLICK 2 PA; QL HUMIRA 2 PA; QL HUMIRA PEDIATRIC CROHNS 2 PA; QL START HUMIRA PEN 2 PA; QL HUMIRA PEN CROHNS-UC-HS 2 PA; QL START HUMIRA PEN PSOR-UVEITS-ADOL 2 PA; QL HS HUMIRA(CF) 2 PA; QL HUMIRA(CF) PEDI CROHNS 2 PA; QL STARTER HUMIRA(CF) PEN 2 PA; QL HUMIRA(CF) PEN CROHNS-UC-HS 2 PA; QL HUMIRA(CF) PEN PSOR-UV-ADOL 2 PA; QL HS ACTEMRA, ENBREL, KEVZARA 3 PA; ST; QL HUMIRA, REMICADE, RINVOQ ER, XELJANZ leflunomide 1 QL OTEZLA 2 PA OTEZLA STARTER 2 PA OTREXUP (PF) 2 penicillamine 1 PA RASUVO (PF) 2 RIDAURA 2 RINVOQ ER 2 PA; QL SAVELLA 2 ST; QL SIMPONI 2 PA; ST; QL

116 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ACTEMRA, COSENTYX 150MG, ENBREL, HUMIRA, SIMPONI ARIA 3 PA OTEZLA, RINVOQ ER, STELARA XELJANZ 2 PA; QL XELJANZ XR 2 PA; QL OBSTETRICS & GYNECOLOGY DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES CAYA CONTOURED 3 FC2 FEMALE CONDOM 2 FEMCAP 2 KYLEENA 2 KYLEENA, MIRENA, LILETTA 3 SKYLA MIRENA 2 PARAGARD T 380A 3 SKYLA 2 WIDE-SEAL DIAPHRAGM 3 ESTROGENS & PROGESTINS ACTIVELLA 3 estradiol-norethindrone acetat ALORA 3 estradiol amabelz 1 estradiol-norethindrone acetat, ANGELIQ 3 jinteli, mimvey, PREMPHASE, PREMPRO AYGESTIN 3 norethindrone acetate estradiol-norethindrone acetat, BIJUVA 3 jinteli, mimvey, PREMPHASE, PREMPRO camila 1 CLIMARA 3 QL estradiol COMBIPATCH 2 covaryx 1 covaryx h.s. 1 CRINONE 2 QL deblitane 1

117 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES DELESTROGEN 3 estradiol valerate DEPO-ESTRADIOL 2 DEPO-PROVERA INTRAMUSCULAR 3 QL medroxyprogesterone acetate SUSPENSION 150 MG/ML DEPO-PROVERA INTRAMUSCULAR 2 SUSPENSION 400 MG/ML DEPO-PROVERA INTRAMUSCULAR 3 QL medroxyprogesterone acetate SYRINGE DEPO-SUBQ PROVERA 104 3 QL medroxyprogesterone acetate DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 2 QL 0.5 MG/0.5 GRAM (0.1 %), 1 MG/GRAM (0.1 %) DIVIGEL TRANSDERMAL GEL IN 2 PACKET 0.75 MG/0.75 GRAM (0.1%) dotti 1 DUAVEE 2 eemt 1 eemt hs 1 ELESTRIN 3 QL DIVIGEL errin 1 ESTRACE 3 estradiol estradiol oral 1 estradiol transdermal patch semiweekly 1 estradiol transdermal patch weekly 1 QL estradiol vaginal 1 estradiol valerate 1 estradiol-norethindrone acet 1 ESTRING 2 estrogens-methyltestosterone 1 EVAMIST 3 QL DIVIGEL estradiol-norethindrone acetat, FEMHRT LOW DOSE 3 fyavolv fyavolv 1 heather 1 hydroxyprogest(pf)(preg presv) 1 hydroxyprogesterone cap(ppres) 1 hydroxyprogesterone caproate 1

118 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES estradiol, yuvafem, IMVEXXY MAINTENANCE PACK 3 PREMARIN, ESTRING estradiol, yuvafem, IMVEXXY STARTER PACK 3 PREMARIN, ESTRING incassia 1 jencycla 1 jinteli 1 lopreeza 1 lyza 1 MAKENA 3 hydroxyprogesterone caproate MAKENA (PF) 3 hydroxyprogesterone caproate medroxyprogesterone intramuscular 1 QL medroxyprogesterone oral 1 estradiol, estropipate, MENEST 3 PREMARIN MENOSTAR 3 QL estradiol mimvey 1 MINIVELLE 3 estradiol nora-be 1 norethindrone (contraceptive) 1 norethindrone acetate 1 norethindrone ac-eth estradiol 1 norlyda 1 ORTHO MICRONOR 3 errin, jolivette estradiol-norethindrone acetat, PREFEST 3 jinteli, mimvey, PREMPHASE, PREMPRO PREMARIN 2 PREMPHASE 2 PREMPRO 2 progesterone 1 QL progesterone micronized 1 PROMETRIUM 3 progesterone PROVERA 3 medroxyprogesterone acetate sharobel 1 tulana 1 yuvafem 1 MISCELLANEOUS OB/GYN 119 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES drospirenone-ethinyl estradiol, ANNOVERA 3 estarylla, junel fe, sprintec, tri- sprintec, xulane, NUVARING AVC VAGINAL 3 fluconazole, terconazole CERVIDIL 3 CLEOCIN VAGINAL CREAM 3 clindamycin phosphate clindamycin phosphate, CLEOCIN VAGINAL SUPPOSITORY 3 metronidazole clindamycin phosphate 1 clindamycin phosphate, CLINDESSE 3 metronidazole fem ph 1 GYNAZOLE-1 3 terconazole gynol ii 1 estradiol, yuvafem, INTRAROSA 3 ESTRING, PREMARIN isoxsuprine 1 LUPANETA PACK (1 MONTH) 2 PA LUPANETA PACK (3 MONTH) 2 PA LYSTEDA 3 tranexamic acid METROGEL VAGINAL 3 metronidazole metronidazole 1 miconazole-3 1 NEXPLANON 2 NUVARING 2 metronidazole, clindamycin NUVESSA 3 phosphate estradiol, yuvafem, OSPHENA 3 ESTRING, PREMARIN PREPIDIL 3 PROSTIN E2 3 RELAGARD 3 fem ph terconazole 1 TODAY CONTRACEPTIVE SPONGE 2 tranexamic acid 1 TRIMO-SAN JELLY 2 vaginal contraceptive foam 1 vandazole 1

120 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES VCF CONTRACEPTIVE FILM 2 VCF CONTRACEPTIVE GEL 2 xulane 1 ORAL CONTRACEPTIVES & RELATED AGENTS afirmelle 1 AFTERA 3 QL altavera (28) 1 alyacen 1/35 (28) 1 alyacen 7/7/7 (28) 1 amethia 1 amethia lo 1 amethyst (28) 1 apri 1 aranelle (28) 1 ashlyna 1 aubra 1 aubra eq 1 aurovela 1.5/30 (21) 1 aurovela 1/20 (21) 1 aurovela 24 fe 1 aurovela fe 1.5/30 (28) 1 aurovela fe 1-20 (28) 1 aviane 1 ayuna 1 azurette (28) 1 aviane, levonorgestrel-eth estradiol, vienva, LO BALCOLTRA 3 LOESTRIN FE, NUVARING, TAYTULLA balziva (28) 1 bekyree (28) 1 drospirenone-eth estra- BEYAZ 3 levomef, rajani blisovi 24 fe 1 blisovi fe 1.5/30 (28) 1 blisovi fe 1/20 (28) 1 briellyn 1 121 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES camrese 1 camrese lo 1 caziant (28) 1 chateal (28) 1 chateal eq (28) 1 cryselle (28) 1 cyclafem 1/35 (28) 1 cyclafem 7/7/7 (28) 1 cyred 1 cyred eq 1 dasetta 1/35 (28) 1 dasetta 7/7/7 (28) 1 daysee 1 desog-e.estradiol/e.estradiol 1 desogestrel-ethinyl estradiol 1 drospirenone-e.estradiol-lm.fa 1 drospirenone-ethinyl estradiol 1 econtra ez 1 QL econtra one-step 1 QL elinest 1 econtra ez, my way, next ELLA 3 QL choice one dose, opcicon one- step, REACT emoquette 1 enpresse 1 enskyce 1 estarylla 1 ESTROSTEP FE-28 3 tri-legest fe, tilia fe ethynodiol diac-eth estradiol 1 falmina (28) 1 fayosim 1 femynor 1 kaitlib fe, layolis fe, norethin- GENERESS FE 3 eth estra ferrous fum gianvi (28) 1 hailey 1 hailey 24 fe 1

122 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES introvale 1 isibloom 1 jasmiel (28) 1 jolessa 1 juleber 1 junel 1.5/30 (21) 1 junel 1/20 (21) 1 junel fe 1.5/30 (28) 1 junel fe 1/20 (28) 1 junel fe 24 1 kaitlib fe 1 kalliga 1 kariva (28) 1 kelnor 1/35 (28) 1 kelnor 1-50 1 kurvelo (28) 1 l norgest/e.estradiol-e.estrad 1 larin 1.5/30 (21) 1 larin 1/20 (21) 1 larin 24 fe 1 larin fe 1.5/30 (28) 1 larin fe 1/20 (28) 1 larissia 1 layolis fe 1 leena 28 1 lessina 1 levonest (28) 1 levonorgestrel 1 QL levonorgestrel-ethinyl estrad 1 levonorg-eth estrad triphasic 1 levora-28 1 lillow (28) 1 LO LOESTRIN FE 2 loryna (28) 1 LOSEASONIQUE 3 amethia lo, camrese lo low-ogestrel (28) 1

123 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES lo-zumandimine (28) 1 lutera (28) 1 marlissa (28) 1 melodetta 24 fe 1 mibelas 24 fe 1 microgestin 1.5/30 (21) 1 microgestin 1/20 (21) 1 microgestin fe 1.5/30 (28) 1 microgestin fe 1/20 (28) 1 mili 1 azurette, kariva, kimidess, MIRCETTE (28) 3 pimtrea, viorele mono-linyah 1 my choice 1 QL my way 1 QL aviane, ocella, necon, LO NATAZIA 3 LOESTRIN FE, NUVARING, TAYTULLA necon 0.5/35 (28) 1 new day 1 QL nikki (28) 1 noreth-ethinyl estradiol-iron 1 norethindrone ac-eth estradiol 1 norethindrone-e.estradiol-iron 1 norgestimate-ethinyl estradiol 1 nortrel 0.5/35 (28) 1 nortrel 1/35 (21) 1 nortrel 1/35 (28) 1 nortrel 7/7/7 (28) 1 ocella 1 ogestrel (28) 1 opcicon one-step 1 QL option-2 1 QL orsythia 1 ORTHO-NOVUM 1/35 (28) 3 ORTHO-NOVUM 7/7/7 (28) 3 philith 1

124 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES pimtrea (28) 1 pirmella 1 PLAN B ONE-STEP 2 QL portia 28 1 previfem 1 QUARTETTE 3 fayosim, rivelsa reclipsen (28) 1 rivelsa 1 drospirenone-eth estra- SAFYRAL 3 levomef, tydemy SEASONIQUE 3 amethia, camrese setlakin 1 simliya (28) 1 simpesse 1 camila, deblitane, errin, SLYND 3 heather, norethindrone acetate, norlyda, sharobel sprintec (28) 1 sronyx 1 syeda 1 TAKE ACTION 3 QL tarina 24 fe 1 tarina fe 1/20 (28) 1 TAYTULLA 2 tilia fe 1 tri femynor 1 tri-estarylla 1 tri-legest fe 1 tri-linyah 1 tri-lo-estarylla 1 tri-lo-marzia 1 tri-lo-mili 1 tri-lo-sprintec 1 tri-mili 1 tri-previfem (28) 1 tri-sprintec (28) 1 trivora (28) 1

125 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES tri-vylibra 1 tri-vylibra lo 1 tydemy 1 velivet triphasic regimen (28) 1 vienva 1 viorele (28) 1 vyfemla (28) 1 vylibra 1 wera (28) 1 wymzya fe 1 YAZ (28) 3 gianvi, loryna, nikki, vestura zarah 1 zovia 1/35e (28) 1 zumandimine (28) 1 OXYTOCICS methergine 1 PA methylergonovine 1 PA oxytocin 1 OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac 1 AZASITE 2 bacitracin 1 bacitracin-polymyxin b 1 ciprofloxacin hcl, gatifloxacin, BESIVANCE 3 levofloxacin hemihydrate, moxifloxacin hcl, ofloxacin BETADINE OPHTHALMIC PREP 3 CEFUROXIME (PF) IN 0.9% NACL 3 CILOXAN 3 ciprofloxacin hcl ciprofloxacin hcl 1 erythromycin 1 gatifloxacin 1 gentak 1 gentamicin 1 levofloxacin 1

126 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ciprofloxacin hcl, gatifloxacin, MOXEZA 3 levofloxacin hemihydrate, moxifloxacin hcl, ofloxacin moxifloxacin 1 MOXIFLOXACIN (PF)-BSS NO.2 3 MOXIFLOXACIN-SOD 3 CHLOR,ISO(PF) NATACYN 2 neomycin-bacitracin-polymyxin 1 neomycin-polymyxin-gramicidin 1 neo-polycin 1 OCUFLOX 3 ofloxacin ofloxacin 1 polycin 1 polymyxin b sulf-trimethoprim 1 POLYTRIM 3 polymyxin b sul-trimethoprim tobramycin 1 TOBREX 3 tobramycin sulfate VIGAMOX 3 moxifloxacin hcl ZYMAXID 3 gatifloxacin ANTIVIRALS trifluridine 1 ZIRGAN 3 trifluridine BETA-BLOCKERS betaxolol 1 timolol maleate, ALPHAGAN BETIMOL 3 P, COMBIGAN betaxolol hcl, timolol maleate, BETOPTIC S 3 ALPHAGAN P, COMBIGAN carteolol 1 levobunolol 1 metipranolol 1 timolol maleate 1 TIMOPTIC 3 timolol maleate TIMOPTIC-XE 3 timolol maleate CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 127 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES CYCLOPLEGIC MYDRIATICS ATROPINE IN 0.9 % SOD CHLORIDE 3 atropine ophthalmic (eye) drops 1 ATROPINE OPHTHALMIC (EYE) 3 DROPS, EMULSION atropine ophthalmic (eye) ointment 1 CYCLOGYL 3 cyclopentolate hcl cyclopentolate 1 CYCLOPEN-TROPIC-PHENYLEPH- 3 WATR homatropaire 1 homatropine hbr 1 ISOPTO ATROPINE 3 atropine sulfate MYDRIACYL 3 tropicamide mydriatic3 (trop-cyclopent-pe) 1 PAREMYD 3 PHENYLEPH-TROPICAMIDE IN 3 WATER tropicamide 1 DIRECT ACTING MIOTICS ISOPTO CARPINE 3 pilocarpine hcl MIOCHOL-E 3 pilocarpine hcl 1 MISCELLANEOUS OPHTHALMOLOGICS AKTEN (PF) 3 ALCAINE 3 proparacaine hcl altacaine 1 ALTAFLUOR BENOX 3 azelastine 1 BEPREVE 2 ST CEQUA 3 RESTASIS, XIIDRA cromolyn 1 CYCLOSPORINE IN KLARITY 3 CYSTARAN 2 DEXAMET-MOXIFL-KETORO- 3 NACL(PF)

128 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES epinastine 1 EYLEA 2 PA flucaine 1 fluorescein-proparacaine 1 JETREA (PF) 2 KLARITY-A (AZITHRO- 3 CHONDR)(PF) KLARITY-B (BETAMETH- 3 CHOND)(PF) KLARITY-L (LOTEPRED- 3 CHOND)(PF) LACRISERT 3 RESTASIS azelastine hcl, cromolyn sodium, epinastine hcl, LASTACAFT 3 ST ketotifen fumarate, olopatadine hcl, BEPREVE, PAZEO lidocaine-phenylephrn in water 1 LIDOCAN-PHENYLEPH-BSS 3 NO.2(PF) LUCENTIS 3 PA EYLEA LUXTURNA 2 PA MYDRIATIC4(TROP-PROP-PE- 3 KTRLC) olopatadine 1 OMIDRIA 3 OXERVATE 2 PA PATANOL 3 ST olopatadine hcl PAZEO 2 ST PHOTREXA CROSS-LINKING KIT 3 PHOTREXA VISCOUS 3 PREDNISOL ACE-GATIFLOX- 3 BROMFEN PREDNISOLN SP-GATIFLOX- 3 BROMFEN PREDNISOLN SP-MOXIFLOX- 3 BROMFEN PREDNISOLONE ACETATE- 3 BROMFENAC

129 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES PREDNISOLONE ACETATE- 3 NEPAFENAC PREDNISOLONE SOD PH- 3 BROMFENAC PREDNISOLONE-MOXIFLO- 3 NEPAFENAC PREDNISOLONE-MOXIFLOX- 3 BROMFEN proparacaine 1 RACEPINEPH-LIDOCAINE-BSS 3 7(PF) RESTASIS 2 QL RESTASIS MULTIDOSE 2 tetcaine 1 tetracaine hcl 1 TETRACAINE HCL (PF) 3 TETRAVISC 3 tetracaine hcl TETRAVISC FORTE 3 tetracaine hcl VISUDYNE 2 XIIDRA 2 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS ACULAR 3 ketorolac tromethamine ACULAR LS 3 ketorolac tromethamine bromfenac 1 bromfenac sodium, diclofenac sodium, ketorolac BROMSITE 3 tromethamine, ILEVRO, PROLENSA diclofenac sodium 1 flurbiprofen sodium 1 ILEVRO 2 ketorolac 1 PROLENSA 2 ORAL DRUGS FOR GLAUCOMA acetazolamide 1 acetazolamide sodium 1 methazolamide 1 130 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES OTHER GLAUCOMA DRUGS dorzolamide hcl, dorzolamide- timolol, betaxolol hcl, timolol AZOPT 3 maleate, latanoprost, ALPHAGAN P, COMBIGAN bimatoprost 1 BRIMONIDINE-DORZOLAMIDE (PF) 3 COMBIGAN 2 dorzolamide-timolol, COSOPT (PF) 3 ALPHAGAN P, COMBIGAN dorzolamide 1 DORZOLAMIDE (PF) 3 dorzolamide-timolol 1 dorzolamide-timolol (pf) ophthalmic 1 (eye) dropperette DORZOLAMIDE-TIMOLOL (PF) 3 OPHTHALMIC (EYE) DROPS latanoprost 1 LATANOPROST (PF) 3 LUMIGAN 2 MITOSOL 3 RHOPRESSA 2 ROCKLATAN 3 latanoprost, RHOPRESSA brimonidine tartrate, SIMBRINZA 3 dorzolamide-timolol, ALPHAGAN P, COMBIGAN TIMOL-BRIMON-DORZO- 3 LATANOP(PF) TIMOLOL-BRIMONIDI- 3 DORZOLAM(PF) TIMOLOL-DORZOLAMID- 3 LATANOP(PF) TIMOLOL-LATANOPROST(PF) 3 TRAVATAN Z 2 TRUSOPT 3 dorzolamide hcl bimatoprost, latanoprost, VYZULTA 3 LUMIGAN, TRAVATAN Z STEROID-ANTIBIOTIC COMBINATIONS

131 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES DEXAMETH-MOXIFLOX(PF)- 3 NACL,ISO GATIFLOXACIN- 3 DEXAMETHASONE neo/polymyxin/dexamethason MAXITROL 3 e neomycin-bacitracin-poly-hc 1 neomycin-polymyxin b-dexameth 1 neomycin-polymyxin-hc 1 neo-polycin hc 1 tobramycin-dexamethasone, PRED-G 3 ZYLET PRED-G S.O.P. 3 TOBRADEX PREDNISOLONE ACET- 3 GATIFLOXACIN PREDNISOLONE SOD PH- 3 GATIFLOXAC PREDNISOLONE SOD PH- 3 MOXIFLOX PREDNISOLONE-MOXIFLOXACIN 3 HCL TOBRADEX OPHTHALMIC (EYE) 3 tobramycin-dexamethasone DROPS,SUSPENSION TOBRADEX OPHTHALMIC (EYE) 2 OINTMENT TOBRADEX ST 2 tobramycin-dexamethasone 1 TRIAMCINOLON-MOXIFLOX- 3 WATR(PF) ZYLET 2 STEROIDS ALREX 2 ST dexamethasone sodium phosphate 1 DEXTENZA 3 DEXYCU (PF) 3 dexamethasone sodium phosphate, fluorometholone, DUREZOL 3 prednisolone acetate, INVELTYS, LOTEMAX

132 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES dexamethasone sodium phosphate, fluorometholone, FLAREX 3 prednisolone acetate, INVELTYS, LOTEMAX fluorometholone 1 FML LIQUIFILM 3 fluorometholone INVELTYS 2 ST LOTEMAX 2 LOTEMAX SM 2 loteprednol etabonate 1 PRED FORTE 3 prednisolone acetate prednisolone acetate 1 PREDNISOLONE ACETATE (PF) 3 prednisolone sodium phosphate 1 STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE 3 sulfacetamide w/prednisolone BLEPHAMIDE S.O.P. 3 sulfacetamide w/prednisolone sulfacetamide-prednisolone 1 SULFONAMIDES BLEPH-10 3 sulfacetamide sodium sulfacetamide sodium 1 SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) 2 DROPS 0.1 % ALPHAGAN P OPHTHALMIC (EYE) 3 brimonidine tartrate DROPS 0.15 % apraclonidine 1 brimonidine 1 brimonidine tartrate, IOPIDINE 3 ALPHAGAN P VASOCONSTRICTOR DECONGESTANTS CYCLOMYDRIL 3 phenylephrine hcl 1 RESPIRATORY, ALLERGY, COUGH & COLD

133 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ANTIHISTAMINE & ANTIALLERGENIC AGENTS adrenalin 1 carbinoxamine maleate 1 cetirizine 1 CLARINEX 3 desloratadine clemastine 1 cyproheptadine 1 desloratadine 1 dexchlorpheniramine maleate 1 DIPHEN 3 diphenhydramine hcl 1 EPINEPHRINE HCL (PF) 3 epinephrine, EPIPEN, epinephrine injection auto-injector 1 QL EPIPEN JR. epinephrine injection solution 1 epinephrine injection syringe 1 EPIPEN 2-PAK 2 QL EPIPEN JR 2-PAK 2 QL hydroxyzine hcl 1 hydroxyzine pamoate 1 KARBINAL ER 3 carbinoxamine levocetirizine 1 phenadoz 1 PHENERGAN 3 promethazine hcl promethazine 1 promethegan 1 RYCLORA 3 RYVENT 3 carbinoxamine SYMJEPI 2 VISTARIL 3 hydroxyzine pamoate COUGH & COLD THERAPY benzonatate 1 bromipheniramin- BROMFED DM 3 pseudoephed-dm brompheniramine-pseudoeph-dm 1 CAPCOF 3 promethazine vc w/codeine

134 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES desloratadine, fexofenadine- CLARINEX-D 12 HOUR 3 pse er codeine-guaifenesin 1 cheratussin ac, guaifenesin ac, guaifenesin with codeine, CODITUSSIN AC 3 iophen c-nr, m-clear wc, virtussin ac CHERATUSSIN DAC, CODITUSSIN DAC 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac g tussin ac 1 guaiatussin ac 1 guaifenesin ac 1 guaifenesin dac 1 HISTEX-AC 3 promethazine vc w/codeine hydrocodone-chlorpheniramine 1 hydrocodone-homatropine 1 hydromet 1 lortuss ex 1 cheratussin ac, guaifenesin ac, guaifenesin with codeine, MAR-COF CG 3 iophen c-nr, m-clear wc, virtussin ac MAXI-TUSS CD 3 m-clear wc 1 M-END PE 3 promethazine vc w/codeine cheratussin ac, guaifenesin ac, guaifenesin with codeine, NINJACOF-XG 3 iophen c-nr, m-clear wc, virtussin ac cheratussin ac, guaifenesin ac, guaifenesin with codeine, OBREDON 3 iophen c-nr, m-clear wc, virtussin ac POLY-TUSSIN AC 3 promethazine-codeine 1 promethazine-dm 1 promethazine-phenyleph-codeine 1 promethazine-phenylephrine 1 RESPA-AR 3

135 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES robafen ac 1 desloratadine, levocetirizine SEMPREX-D 3 dihydrochloride TESSALON PERLES 3 benzonatate hydrocodone- TUSSICAPS 3 chlorpheniramine, promethazine w/codeine TUXARIN ER 3 hydrocodone- TUZISTRA XR 3 chlorpheniramine, promethazine w/codeine virtussin ac 1 virtussin dac 1 hydrocodone- ZODRYL AC 25 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 30 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 35 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 40 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 50 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 60 3 chlorpheniramine, promethazine w/codeine hydrocodone- ZODRYL AC 80 3 chlorpheniramine, promethazine w/codeine ZODRYL DAC 25 3 ZODRYL DAC 30 3 ZODRYL DAC 35 3 ZODRYL DAC 40 3 ZODRYL DAC 50 3 ZODRYL DAC 60 3 ZODRYL DAC 80 3

136 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES CHERATUSSIN DAC, ZODRYL DEC 25 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 30 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 35 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 40 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 50 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 60 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac CHERATUSSIN DAC, ZODRYL DEC 80 3 guaifenesin dac, lortuss ex, tusnel c, virtussin dac hydrocodone- Z-TUSS AC 3 chlorpheniramine, promethazine w/codeine PULMONARY AGENTS ACCOLATE 3 zafirlukast acetylcysteine 1 ADEMPAS 2 PA ADRENALIN 3 fluticasone-salmeterol, wixela ADVAIR DISKUS 3 QL inhub ADVAIR HFA 2 QL ADVAIR HFA, BREO AIRDUO RESPICLICK 3 QL ELLIPTA, DULERA, SYMBICORT albuterol sulfate 1 alyq 1 PA; ST; QL ambrisentan 1 PA aminophylline 1 ANORO ELLIPTA 2 QL ARCAPTA NEOHALER 3 QL SEREVENT DISKUS

137 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES ARMONAIR RESPICLICK 2 QL ARNUITY ELLIPTA 2 QL ASMANEX HFA 2 QL ASMANEX TWISTHALER 2 QL ipratropium bromide, ATROVENT HFA 3 QL INCRUSE ELLIPTA BEVESPI AEROSPHERE 2 QL bosentan 1 PA BREO ELLIPTA 2 QL BROVANA 3 QL PERFOROMIST budesonide 1 QL CINRYZE 2 PA COMBIVENT RESPIMAT 2 QL cromolyn 1 CUROSURF 3 DALIRESP ORAL TABLET 250 MCG 2 QL DALIRESP ORAL TABLET 500 MCG 2 DUAKLIR PRESSAIR 3 DULERA 2 QL DYMISTA 2 ELIXOPHYLLIN 3 theophylline anhydrous ESBRIET 2 PA FASENRA 2 PA FASENRA PEN 2 PA FIRAZYR 3 PA; ST icatibant FLOVENT DISKUS 2 QL FLOVENT HFA 2 QL flunisolide 1 QL fluticasone propionate 1 QL FLUTICASONE PROPION- SALMETEROL INHALATION 2 QL AEROSOL POWDR BREATH ACTIVATED fluticasone propion-salmeterol 1 QL ADVAIR DISKUS inhalation blister with device HAEGARDA 3 PA CINRYZE HYPER-SAL 3 sodium chloride icatibant 1 PA 138 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES INCRUSE ELLIPTA 2 QL ipratropium bromide 1 ipratropium-albuterol 1 QL KALBITOR 3 PA icatibant KALYDECO 2 PA LETAIRIS 3 PA; ST ambrisentan levalbuterol hcl 1 INCRUSE ELLIPTA, LONHALA MAGNAIR REFILL 3 QL YUPELRI INCRUSE ELLIPTA, LONHALA MAGNAIR STARTER 3 QL YUPELRI metaproterenol 1 mometasone 1 QL montelukast 1 nebusal inhalation solution for 1 nebulization 3 % NEBUSAL INHALATION SOLUTION 3 FOR NEBULIZATION 6 % NUCALA 2 PA; QL OFEV 2 PA OPSUMIT 2 PA ORKAMBI 2 PA PERFOROMIST 2 QL PROAIR DIGIHALER 3 PROAIR HFA 2 QL PROAIR RESPICLICK 2 QL PULMICORT FLEXHALER 2 QL pulmosal 1 PULMOZYME 2 QNASL 2 QVAR REDIHALER 2 QL REVATIO ORAL SUSPENSION FOR 3 PA; ST sildenafil citrate RECONSTITUTION REVATIO ORAL TABLET 3 PA; ST; QL sildenafil citrate RUCONEST 2 PA SEEBRI NEOHALER 3 QL INCRUSE ELLIPTA SEREVENT DISKUS 2 QL

139 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES sildenafil (pulm.hypertension) oral 1 PA; ST suspension for reconstitution sildenafil (pulm.hypertension) oral tablet 1 PA; QL SINUVA 3 sodium chloride 1 SURFAXIN 3 SYMBICORT 2 QL SYMDEKO 2 PA tadalafil (pulm. hypertension) 1 PA; QL TAKHZYRO 3 PA CINRYZE terbutaline 1 THEO-24 3 theophylline anhydrous theochron 1 theophylline 1 TRACLEER ORAL TABLET 3 PA bosentan TRACLEER ORAL TABLET FOR 2 PA SUSPENSION TRELEGY ELLIPTA 2 QL TRIKAFTA 2 PA TYVASO 2 PA TYVASO REFILL KIT 2 PA TYVASO STARTER KIT 2 PA ANORO ELLIPTA, UTIBRON NEOHALER 3 QL BEVESPI AEROSPHERE VENTAVIS 3 PA; ST TYVASO VENTOLIN HFA 2 QL wixela inhub 1 QL ADVAIR DISKUS budesonide, flunisolide, XHANCE 3 fluticasone propionate, mometasone furoate, QNASL XOLAIR 2 PA; QL XOPENEX 3 levalbuterol hcl XOPENEX CONCENTRATE 3 levalbuterol hcl YUPELRI 2 QL zafirlukast 1 zileuton 1 zileuton, montelukast sodium, ZYFLO 3 zafirlukast

140 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS darifenacin 1 DITROPAN XL 3 ST oxybutynin chloride er ENABLEX 3 ST darifenacin er flavoxate 1 GELNIQUE TRANSDERMAL GEL IN 2 ST METERED-DOSE PUMP GELNIQUE TRANSDERMAL GEL IN 2 ST; QL PACKET MYRBETRIQ 2 ST oxybutynin chloride 1 oxybutynin chloride er, solifenacin succinate, OXYTROL 3 ST; QL tolterodine tartrate er, trospium chloride, TOVIAZ, MYRBETRIQ solifenacin 1 tolterodine 1 TOVIAZ 2 ST trospium 1 VESICARE 3 ST solifenacin succinate BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin 1 dutasteride 1 ST dutasteride-tamsulosin 1 ST finasteride 1 FLOMAX 3 tamsulosin hcl JALYN 3 ST dutasteride-tamsulosin PROSCAR 3 ST finasteride silodosin 1 tadalafil 1 PA; QL tamsulosin 1 CHOLINERGIC STIMULANTS bethanechol chloride 1

141 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES URECHOLINE 3 bethanechol chloride MISCELLANEOUS UROLOGICALS alprostadil 1 CYSTAGON 2 cytra k crystals 1 ELMIRON 2 hyophen 1 K-PHOS NO 2 3 phospha 250 neutral K-PHOS ORIGINAL 2 methen-sod phos-meth blue-hyos 1 ORACIT 3 sodium citrate & citric acid phosphasal 1 potassium citrate 1 PROCYSBI 3 CYSTAGON PROSTIN VR PEDIATRIC 3 alprostadil RENACIDIN 2 SHOHL'S MODIFIED 3 sodium citrate & citric acid URELLE 3 phosphasal, ur n-c, uretron d-s uretron d-s 1 URIBEL 3 ustell urimar-t 1 urin ds 1 uro-458 1 UROCIT-K 10 3 potassium citrate er UROCIT-K 15 3 potassium citrate er UROCIT-K 5 3 potassium citrate er urogesic-blue 1 uro-mp 1 UROQID-ACID NO.2 3 methenamine mandelate uryl 1 ustell 1 utira-c 1 vilamit mb 1 vilevev mb 1 URINARY ANESTHETICS phenazopyridine 1 142 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES PYRIDIUM 3 phenazopyridine hcl VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES CALCIUM GLUC IN NACL, ISO-OSM 3 calcium gluconate in 0.9% nacl 1 EFFER-K ORAL TABLET, 3 potassium bicarbonate EFFERVESCENT 10 MEQ, 20 MEQ effer-k oral tablet, effervescent 25 meq 1 GALZIN 3 klor-con 1 klor-con 10 1 klor-con 8 1 klor-con m10 1 klor-con m15 1 klor-con m20 1 klor-con/ef 1 K-TAB ORAL TABLET EXTENDED 3 potassium chloride RELEASE 10 MEQ, 20 MEQ k-tab oral tablet extended release 8 meq 1 lugols 1 POTABA 3 potassium chloride 1 strong iodine 1 VITAMINS & HEMATINICS b complex 100 1 bal-care dha 1 pnv-dha, prena1 pearl, virt-pn BAL-CARE DHA ESSENTIAL 3 dha CITRANATAL (DUAL-IRON) 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn CITRANATAL 90 DHA (ALGAL OIL) 3 dha pnv-dha, prena1 pearl, virt-pn CITRANATAL ASSURE 3 dha CITRANATAL B-CALM (FE GLUC) 3 prenatal plus, preplus prenatal plus, preplus, vol- CITRANATAL BLOOM 3 plus

143 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES pnv-dha, prena1 pearl, virt-pn CITRANATAL DHA (ALGAL OIL) 3 dha CITRANATAL HARMONY (IRON pnv-dha, prena1 pearl, virt-pn 3 FUM) dha c-nate dha 1 complete natal dha 1 CONCEPT DHA 3 taron-c dha, virt-c dha CONCEPT OB 3 folivane-ob cyanocobalamin (vitamin b-12) 1 DRISDOL 3 ergocalciferol pnv-dha, prena1 pearl, virt-pn DUET DHA BALANCED 3 dha pnv-dha, prena1 pearl, virt-pn DUET DHA WITH OMEGA-3 3 dha elite-ob 1 pnv-dha, prena1 pearl, virt-pn ENBRACE HR 3 dha ergocalciferol (vitamin d2) 1 FERAHEME 2 FLORIVA (FLUORIDE-VITAMIN D3) 3 FLUORABON 3 sodium fluoride fluoride (sodium) 1 fluoritab 1 FLURA-DROPS 3 sodium fluoride pnv-dha, prena1 pearl, virt-pn FOLET ONE 3 dha folic acid 1 folivane-ob 1 hydroxocobalamin 1 infed 1 INFUVITE ADULT 3 m.v.i. adult INFUVITE PEDIATRIC 2 sod ferric gluconate complex, INJECTAFER 3 FERAHEME, VENOFER, FERAHEME, VENOFER KOSHER PRENATAL PLUS IRON 3 prenatal plus, preplus ludent fluoride 1 m.v.i. adult 1

144 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES M.V.I. PEDIATRIC 2 MARNATAL-F 3 prenatal plus, preplus m-natal plus 1 multi-vitamin with fluoride 1 multivitamins with fluoride 1 mvc-fluoride 1 mynatal 1 mynatal advance 1 mynatal plus 1 mynatal-z 1 mynate 90 plus 1 NASCOBAL 2 NATACHEW (FE BIS-GLYCINATE) 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn NEEVODHA (WITH ALGAL OIL) 3 dha NESTABS 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn NESTABS ABC 3 dha pnv-dha, prena1 pearl, virt-pn NESTABS DHA 3 dha pnv-dha, prena1 pearl, virt-pn NESTABS ONE 3 dha newgen 1 NEXAVIR 3 pnv-dha, prena1 pearl, virt-pn OB COMPLETE 3 dha pnv-dha, prena1 pearl, virt-pn OB COMPLETE ONE 3 dha pnv-dha, prena1 pearl, virt-pn OB COMPLETE PETITE 3 dha OB COMPLETE PREMIER 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn OB COMPLETE WITH DHA 3 dha obstetrix dha 1 prenatal plus, preplus, vol- OBSTETRIX EC 3 plus pnv-dha, prena1 pearl, virt-pn OBSTETRIX ONE 3 dha

145 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES pnv-dha, prena1 pearl, virt-pn OBTREX DHA 3 dha O-CAL PRENATAL 3 prenatal plus, preplus pnv 29-1 1 pnv-dha 1 pnv-dha + docusate 1 pnv-omega 1 pnv-select 1 pr natal 400 1 pr natal 400 ec 1 pr natal 430 1 pr natal 430 ec 1 PREGENNA 3 prenatal plus, preplus prena1 chew 1 prena1 pearl 1 prena1 true 1 prenaissance 1 prenaissance plus 1 PRENATA 3 prenatal plus, preplus prenatabs fa 1 prenatabs rx 1 prenatal plus 1 prenatal plus (calcium carb) 1 pnv-dha, prena1 pearl, virt-pn PRENATAL PLUS DHA 3 dha prenatal vitamin plus low iron 1 prenatal-u 1 PRENATE AM 3 prenatal plus, preplus PRENATE CHEWABLE 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn PRENATE DHA (FERR ASP GLYCIN) 3 dha PRENATE ELITE (IRON ASP GLYC) 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn PRENATE ENHANCE 3 dha PRENATE ESSENTIAL(IRON-ASP- pnv-dha, prena1 pearl, virt-pn 3 GL) dha PRENATE MINI (FERR ASP pnv-dha, prena1 pearl, virt-pn 3 GLYCIN) dha

146 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES pnv-dha, prena1 pearl, virt-pn PRENATE PIXIE 3 dha pnv-dha, prena1 pearl, virt-pn PRENATE RESTORE 3 dha PRENATE STAR 3 prenatal plus, preplus preplus 1 pretab 1 pnv-dha, prena1 pearl, virt-pn PRIMACARE 3 dha PROVIDA OB 3 prenatal plus, preplus PUREFE OB PLUS 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn R-NATAL OB 3 dha SELECT-OB 3 prenatal plus, preplus SELECT-OB (FOLIC ACID) 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn SELECT-OB + DHA 3 dha se-natal 19 chewable 1 se-natal-19 1 taron-c dha 1 taron-prex prenatal-dha 1 THRIVITE RX 3 prenatal plus, preplus TRICARE 3 prenatal plus, preplus TRIFERIC 3 trinatal rx 1 1 trinate 1 TRINAZ 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn TRISTART DHA 3 dha triveen-duo dha 1 tri-vitamin with fluoride 1 trust natal dha 1 VENOFER 2 pnv-dha, prena1 pearl, virt-pn VINATE DHA RF 3 dha virt-c dha 1 virt-nate dha 1 virt-pn dha 1

147 Drug Name Drug Tier Requirements / Limits PREFERRED ALTERNATIVES virt-pn plus 1 pnv-dha, prena1 pearl, virt-pn VITAFOL FE+ (WITH DOCUSATE) 3 dha pnv-dha, prena1 pearl, virt-pn VITAFOL GUMMIES 3 dha VITAFOL NANO 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn VITAFOL ULTRA 3 dha VITAFOL-OB 3 prenatal plus, preplus pnv-dha, prena1 pearl, virt-pn VITAFOL-OB+DHA 3 dha pnv-dha, prena1 pearl, virt-pn VITAFOL-ONE 3 dha pnv-dha, prena1 pearl, virt-pn VITAMED MD ONE RX 3 dha VITAMEDMD REDICHEW RX 3 prena1 chew vitamins a,c,d and fluoride 1 pnv-dha, prena1 pearl, virt-pn VITAPEARL 3 dha pnv-dha, prena1 pearl, virt-pn VITATRUE 3 dha vp-ch-pnv 1 pnv-dha, prena1 pearl, virt-pn VP-PNV-DHA 3 dha zatean-pn dha 1 zatean-pn plus 1 zingiber 1

148 Index of Drugs

A ACTOS ...... 98 AFLURIA QD 2019-20(6- abacavir ...... 4 ACULAR...... 130 35MO)(PF) ...... 111 abacavir-lamivudine ...... 4 ACULAR LS ...... 130 AFLURIA QUAD 2019- abacavir-lamivudine-zidovudine acyclovir ...... 4, 73 20(6MO UP) ...... 111 ...... 4 acyclovir sodium ...... 4 AFREZZA ...... 95 ABELCET ...... 3 ACZONE ...... 67 AFSTYLA ...... 58 ABILIFY MAINTENA ...... 42 ADACEL(TDAP AFTERA...... 121 ABILIFY MYCITE ...... 43 ADOLESN/ADULT)(PF) 111 AGAMATRIX CONTROL abiraterone ...... 17 ADAKVEO ...... 17 HIGH ...... 86 ABLYSINOL ...... 78 ADALAT CC ...... 52 AGGRENOX ...... 58 ABRAXANE ...... 17 adapalene ...... 67 AGRYLIN ...... 78 ABSORICA ...... 67 ADAPALENE ...... 67 AIMOVIG AUTOINJECTOR30 acamprosate ...... 78 adapalene-benzoyl peroxide ... 67 AIRDUO RESPICLICK ...... 137 ACANYA ...... 67 ADASUVE ...... 43 AJOVY ...... 30 acarbose ...... 98 ADCETRIS ...... 17 AKLIEF ...... 67 ACCOLATE...... 137 ADDERALL XR ...... 43 ak-poly-bac ...... 126 ACCU-CHEK COMPACT adefovir ...... 4 AKTEN (PF) ...... 128 PLUS CONTROL ...... 85 ADEMPAS ...... 137 AKYNZEO ACCU-CHEK GUIDE L1-L2 ADHANSIA XR...... 43 (FOSNETUPITANT) ...... 103 CTRL SOL ...... 85 ADIPEX-P ...... 77 ala-cort ...... 74 ACCU-CHEK SMARTVIEW adrenalin ...... 134 ALA-QUIN...... 72 CONTRL SOL ...... 85 ADRENALIN ...... 137 ALA-SCALP ...... 74 ACCUPRIL ...... 52 adriamycin ...... 17 albendazole ...... 9 ACCURETIC ...... 52 ADRIAMYCIN ...... 17 ALBENZA ...... 9 ACCUTREND GLUCOSE adrucil ...... 17 albuterol sulfate ...... 137 CONTROL ...... 85 adult aspirin regimen ...... 39 ALCAINE...... 128 ACE AEROSOL CLOUD ADVAIR DISKUS ...... 137 alclometasone ...... 74 ENHANCER ...... 84 ADVAIR HFA ...... 137 ALDACTAZIDE ...... 52 acebutolol ...... 52 ADVATE...... 58 ALDACTONE ...... 52 acetaminophen-caff-dihydrocod ADVOCATE LOW CONTROL ALDARA ...... 111 ...... 33 ...... 86 ALDURAZYME ...... 96 acetaminophen-codeine ...... 33 ADVOCATE REDI-CODE+ ALECENSA ...... 17 acetazolamide ...... 130 CTRL LOW ...... 86 alendronate ...... 115 acetazolamide sodium ...... 130 ADYNOVATE ...... 58 ALFERON N ...... 111 acetic acid ...... 78, 81 ADZENYS ER ...... 43 alfuzosin ...... 141 acetylcysteine ...... 137 ADZENYS XR-ODT ...... 43 ALIMTA...... 17 acitretin ...... 64 AEMCOLO ...... 9 ALINIA ...... 9 ACTEMRA ...... 115, 116 AEROCHAMBER MINI ...... 84 ALIQOPA...... 17 ACTEMRA ACTPEN ...... 115 AEROCHAMBER PLUS aliskiren ...... 52 ACTHAR ...... 82 FLOW-VU...... 84 ALKERAN ...... 17 ACTHIB (PF) ...... 111 AEROCHAMBER PLUS Z ALKERAN (AS HCL) ...... 17 ACTICLATE ...... 15 STAT ...... 84 allopurinol...... 115 ACTIGALL ...... 102 AEROTRACH PLUS ...... 84 allopurinol sodium ...... 115 ACTIMMUNE ...... 111 AEROVENT PLUS ...... 84 ALLZITAL ...... 33 ACTIQ ...... 33 AFINITOR ...... 17 almotriptan malate ...... 30 ACTIVELLA ...... 117 AFINITOR DISPERZ ...... 17 alophen ...... 103 ACTONEL ...... 115 afirmelle...... 121 aloprim ...... 115 ACTOPLUS MET ...... 98 AFLURIA QD 2019-20(3YR ALORA ...... 117 ACTOPLUS MET XR ...... 98 UP)(PF) ...... 111 alosetron ...... 103 149 ALOXI ...... 103 AMMONUL ...... 78 ARCAPTA NEOHALER ..... 137 ALPHAGAN P ...... 133 amnesteem ...... 67 ARGATROBAN ...... 58 ALPHANATE ...... 58 amoxapine ...... 43 ARGATROBAN IN 0.9 % SOD ALPHANINE SD ...... 58 amoxicil-clarithromy-lansopraz CHLOR...... 58 alprazolam ...... 43 ...... 108 ARGATROBAN IN NACL alprazolam intensol ...... 43 amoxicillin ...... 13 (ISO-OS)...... 58 ALPROLIX ...... 58 amoxicillin-pot clavulanate .... 13 ARICEPT ...... 31 alprostadil ...... 142 amphetamine sulfate ...... 43 ARIKAYCE ...... 9 ALREX...... 132 amphotericin b ...... 3 aripiprazole ...... 43 ALTABAX ...... 71 ampicillin ...... 13 ARISTADA ...... 43 altacaine ...... 128 ampicillin sodium ...... 13 ARISTADA INITIO ...... 43 ALTACE ...... 52 ampicillin-sulbactam ...... 13 ARIXTRA ...... 58 ALTAFLUOR BENOX ...... 128 ANADROL-50 ...... 96 armodafinil ...... 43 altavera (28)...... 121 ANAFRANIL ...... 43 ARMONAIR RESPICLICK 138 ALTRENO ...... 67 anagrelide ...... 78 ARMOUR THYROID...... 100 ALUNBRIG ...... 17 ANA-LEX KIT...... 103 ARNUITY ELLIPTA ...... 138 alyacen 1/35 (28) ...... 121 ANALPRAM-HC ...... 64, 103 AROMASIN ...... 18 alyacen 7/7/7 (28) ...... 121 ANALPRAM-HC SINGLES103 ARRANON ...... 18 alyq ...... 137 ANAPROX DS...... 39 arsenic trioxide ...... 18 ALZAIR ...... 80 anaspaz ...... 101 ARSENIC TRIOXIDE ...... 18 amabelz...... 117 anastrozole ...... 18 ARTHROTEC 50 ...... 39 amantadine hcl...... 4 ANCOBON ...... 3 ARTHROTEC 75 ...... 39 AMARYL...... 98 ANDEXXA ...... 58 ARYMO ER ...... 33 AMBISOME ...... 3 ANDRODERM ...... 96 ARZERRA ...... 18 ambrisentan ...... 137 ANDROGEL ...... 96 ASCENIV ...... 111 amcinonide ...... 74 ANDROID...... 96 ascomp with codeine ...... 33 AMELUZ ...... 65 ANGELIQ ...... 117 ashlyna ...... 121 AMERGE ...... 30 ANGIOMAX ...... 58 ASMANEX HFA ...... 138 amethia ...... 121 ANNOVERA...... 120 ASMANEX TWISTHALER 138 amethia lo ...... 121 ANORO ELLIPTA...... 137 ASPARLAS ...... 18 amethyst (28) ...... 121 ANTABUSE ...... 78 aspir-81 ...... 39 AMICAR ...... 58 ANTARA ...... 61 aspirin ...... 39 amifostine crystalline ...... 16 anucort-hc ...... 103 aspirin low dose ...... 39 amikacin ...... 9 apexicon e ...... 74 aspirin-dipyridamole...... 58 amiloride...... 52 APLENZIN ...... 43 aspir-low ...... 39 amiloride-hydrochlorothiazide53 APOKYN ...... 29 aspir-trin ...... 39 aminocaproic acid ...... 58 apraclonidine ...... 133 ASSURE 4 CONTROL aminophylline ...... 137 aprepitant ...... 103 SOLUTION ...... 86 amiodarone ...... 52 apri ...... 121 ASSURE DOSE NORMAL AMITIZA ...... 103 APRISO ...... 103 CONTROL ...... 86 amitriptyline ...... 43 APTENSIO XR ...... 43 ASSURE PRISM CONTROL 1- amitriptyline-chlordiazepoxide APTIOM ...... 27 2 SOLN ...... 86 ...... 43 APTIVUS ...... 4 ASTAGRAF XL ...... 18 amlodipine ...... 53 aqua care sodium chloride ...... 78 AT HOME A1C ...... 86 amlodipine-atorvastatin ...... 61 aqua care sterile water ...... 78 atazanavir ...... 4 amlodipine-benazepril ...... 53 AQUA GLYCOLIC HC ...... 74 ATELVIA ...... 115 amlodipine-olmesartan ...... 53 ARAKODA ...... 9 atenolol ...... 53 amlodipine-valsartan ...... 53 ARALAST NP ...... 78 atenolol-chlorthalidone ...... 53 amlodipine-valsartan-hcthiazid aranelle (28) ...... 121 ATGAM ...... 111 ...... 53 ARAVA ...... 116 ATIVAN ...... 44 ammonium lactate ...... 65 ARCALYST ...... 111 atomoxetine ...... 44 150 atorvastatin ...... 61 AVYCAZ ...... 7 BELEODAQ...... 18 atovaquone ...... 9 AXUMIN...... 78 belladonna alkaloids-opium.. 101 atovaquone-proguanil ...... 9 AYGESTIN ...... 117 BELRAPZO ...... 18 atracurium...... 32 ayuna ...... 121 BELSOMRA ...... 44 ATRALIN ...... 67 azacitidine ...... 18 BELVIQ ...... 77 ATROPEN ...... 77 AZACTAM ...... 9 BELVIQ XR ...... 77 atropine ...... 101, 128 AZASAN ...... 18 benazepril ...... 53 ATROPINE ...... 128 AZASITE ...... 126 benazepril-hydrochlorothiazide atropine in 0.9 % sod chloride azathioprine ...... 18 ...... 53 ...... 101 azathioprine sodium ...... 18 BENDAMUSTINE...... 18 ATROPINE IN 0.9 % SOD azelaic acid ...... 68 BENDEKA ...... 18 CHLORIDE ...... 101, 128 azelastine ...... 81, 128 BENEFIX ...... 58 ATROVENT HFA ...... 138 AZELEX ...... 68 BENLYSTA ...... 116 aubra ...... 121 AZILECT ...... 29 BENSAL HP ...... 65 aubra eq ...... 121 azithromycin ...... 8 BENTYL ...... 101 AUGMENTIN ...... 13 AZOPT ...... 131 BENZACLIN ...... 68 AUGMENTIN ES-600 ...... 13 aztreonam ...... 9 BENZACLIN PUMP...... 68 AUGMENTIN XR ...... 13 AZULFIDINE ...... 103 BENZAMYCIN ...... 68 aurovela 1.5/30 (21) ...... 121 AZULFIDINE EN-TABS .... 103 benzepro ...... 68 aurovela 1/20 (21) ...... 121 azurette (28) ...... 121 BENZEPRO aurovela 24 fe ...... 121 B (MICROSPHERES) ...... 68 aurovela fe 1.5/30 (28) ...... 121 b complex 100 ...... 143 BENZNIDAZOLE ...... 9 aurovela fe 1-20 (28) ...... 121 bacitracin ...... 9, 126 benzonatate ...... 134 AURYXIA ...... 103 bacitracin-polymyxin b...... 126 benzoyl peroxide ...... 68 AUSTEDO ...... 31 baclofen ...... 32 benzphetamine ...... 77 AUTOJECT 2 INJECTION BACLOFEN ...... 32 benztropine ...... 29 DEVICE ...... 86 BACTRIM ...... 14 BEPREVE ...... 128 AUTOPEN 1 TO 21 UNITS .. 86 BACTRIM DS ...... 14 beser ...... 74 AUTOSOFT 30 ...... 86 bal-care dha ...... 143 BESIVANCE ...... 126 AUTOSOFT 90 ...... 86 BAL-CARE DHA ESSENTIAL BESPONSA ...... 18 AUTOSOFT XC INFUSION ...... 143 BETADINE OPHTHALMIC SET 23 ...... 86 BALCOLTRA ...... 121 PREP...... 126 AVANDIA ...... 98 balsalazide ...... 103 BETAMETH AC,SOD avar ...... 68 BALVERSA ...... 18 PHOS(PF)-WATER ...... 82 AVAR...... 68 balziva (28) ...... 121 BETAMETHASONE AVAR LS ...... 67 BANZEL ...... 27 ACE,SOD PHOS-WTR ...... 82 AVAR-E GREEN ...... 68 BAQSIMI ...... 85 betamethasone acet,sod phos .. 82 AVAR-E LS ...... 68 BARACLUDE...... 4 betamethasone dipropionate ... 74 AVASTIN ...... 18 BASAGLAR KWIKPEN U-100 BETAMETHASONE SOD AVC VAGINAL ...... 120 INSULIN ...... 95 PHOSPH-WATER ...... 82 AVEED ...... 96 BAVENCIO ...... 18 betamethasone valerate ...... 74 AVELOX IN NACL (ISO- BAXDELA ...... 14 betamethasone, augmented ..... 74 OSMOTIC)...... 14 bayer aspirin ...... 39 BETAPACE ...... 52 aviane ...... 121 BCG VACCINE, LIVE (PF) 111 BETAPACE AF ...... 52 avidoxy ...... 15 BD MICROTAINER LANCET BETASERON...... 110 AVIDOXY DK ...... 15 ...... 86 betaxolol ...... 53, 127 avita ...... 68 BD ULTRA FINE LANCETS86 bethanechol chloride ...... 141 AVITA ...... 68 BD ULTRA-FINE NANO PEN BETHKIS ...... 9 AVONEX ...... 110 NEEDLE ...... 87 BETIMOL ...... 127 AVONEX (WITH ALBUMIN) bekyree (28) ...... 121 BETOPTIC S ...... 127 ...... 110 BELBUCA ...... 33 BEVESPI AEROSPHERE ... 138 151 BEVYXXA ...... 58 BREVIBLOC IN NACL (ISO- caffeine citrate ...... 78 bexarotene ...... 18 OSM) ...... 53 CALAN SR ...... 53 BEXSERO ...... 111 BRIDION ...... 32 calcipotriene ...... 64 BEYAZ...... 121 briellyn...... 121 calcipotriene-betamethasone .. 64 bicalutamide ...... 18 BRILINTA ...... 59 calcitonin (salmon) ...... 96 BICILLIN C-R ...... 13 brimonidine ...... 133 calcitriol ...... 64, 96 BICILLIN L-A ...... 13 BRIMONIDINE- calcium acetate ...... 103 BICNU ...... 18 DORZOLAMIDE (PF)..... 131 CALCIUM GLUC IN NACL, BIDIL ...... 53 BRINEURA...... 96 ISO-OSM ...... 143 BIJUVA ...... 117 BRIVIACT ...... 27 calcium gluconate in 0.9% nacl BIKTARVY ...... 4 BROMFED DM ...... 134 ...... 143 BILTRICIDE ...... 9 bromfenac ...... 130 CALDOLOR ...... 40 bimatoprost ...... 131 bromocriptine ...... 29 CALQUENCE ...... 18 BINOSTO...... 115 brompheniramine-pseudoeph- CAMBIA ...... 40 BIOTHRAX ...... 111 dm ...... 134 camila ...... 117 bisacodyl...... 103 BROMSITE ...... 130 CAMPTOSAR ...... 18 bisa-lax ...... 103 BROVANA ...... 138 camrese ...... 122 bisoprolol fumarate ...... 53 BRUKINSA...... 18 camrese lo ...... 122 bisoprolol-hydrochlorothiazide BRYHALI ...... 74 CANASA ...... 103 ...... 53 budesonide ...... 103, 138 CANCIDAS ...... 3 bivalirudin ...... 58 bumetanide ...... 53 candesartan ...... 53 BIVALIRUDIN-0.9 % BUNAVAIL ...... 39 candesartan-hydrochlorothiazid SODIUM CHLOR...... 59 BUPHENYL ...... 78 ...... 53 BIVIGAM ...... 111 BUPRENEX ...... 33 CANTHARIDIN IN ACETONE bleomycin ...... 18 buprenorphine ...... 33 ...... 65 BLEPH-10 ...... 133 BUPRENORPHINE ...... 33 CAPASTAT ...... 9 BLEPHAMIDE ...... 133 buprenorphine hcl ...... 33 CAPCOF...... 134 BLEPHAMIDE S.O.P...... 133 buprenorphine-naloxone ...... 40 capecitabine ...... 19 BLINCYTO ...... 18 bupropion hcl ...... 44 CAPEX ...... 74 blisovi 24 fe ...... 121 BUPROPION HCL ...... 44 CAPRELSA ...... 19 blisovi fe 1.5/30 (28) ...... 121 bupropion hcl (smoking deter)80 captopril ...... 53 blisovi fe 1/20 (28) ...... 121 buspirone ...... 44 captopril-hydrochlorothiazide 53 BLOOD GLUCOSE busulfan ...... 18 CARAC ...... 65 CONTROL, NORMAL ...... 87 BUSULFEX ...... 18 CARAFATE ...... 108 BONIVA ...... 115 butalbital compound w/codeine CARBAGLU ...... 78 BONJESTA ...... 103 ...... 34 carbamazepine ...... 27 BOOSTRIX TDAP ...... 111 butalbital-acetaminop-caf-cod 34 CARBATROL ...... 27 BORTEZOMIB ...... 18 butalbital-acetaminophen ...... 34 carbidopa ...... 29 bosentan ...... 138 butalbital-acetaminophen-caff 34 carbidopa-levodopa ...... 29 BOSULIF ...... 18 butalbital-aspirin-caffeine ...... 34 carbidopa-levodopa-entacapone BOTOX ...... 112 butorphanol tartrate ...... 40 ...... 29 bp 10-1...... 68 BYDUREON ...... 98 carbinoxamine maleate ...... 134 bpo ...... 68 BYDUREON BCISE ...... 98 carboplatin ...... 19 BRAFTOVI ...... 18 BYETTA ...... 98 CARDIZEM ...... 53 BREATHERITE MDI SPACER BYSTOLIC ...... 53 CARDIZEM CD ...... 53 ...... 84 C CARDIZEM LA ...... 53 BREEZE 2 CONTROL cabergoline ...... 96 CARDURA...... 53 SOLUTION,HIGH ...... 87 CABLIVI ...... 59 CARDURA XL ...... 53 BREO ELLIPTA ...... 138 CABOMETYX ...... 18 CARESENS CONTROL A BREVIBLOC ...... 53 CADUET ...... 61 NORMAL ...... 87 CAFERGOT ...... 30 carisoprodol ...... 32 152 carisoprodol-aspirin ...... 32 ceftriaxone in dextrose,iso-os ... 7 CICLODAN KIT ...... 72 carisoprodol-aspirin-codeine .. 32 CEFUROXIME (PF) IN 0.9% ciclopirox ...... 72 carmustine ...... 19 NACL ...... 126 ciclopirox-ure-camph-menth-euc CARNITOR ...... 78 cefuroxime axetil ...... 8 ...... 72 CARNITOR (SUGAR-FREE)78 cefuroxime sodium ...... 8 cidofovir ...... 4 CAROSPIR ...... 53 celecoxib ...... 40 cilostazol ...... 59 carteolol ...... 127 CELESTONE SOLUSPAN ... 82 CILOXAN ...... 126 cartia xt ...... 54 CELLCEPT ...... 19 CIMDUO ...... 4 carvedilol ...... 54 CELLCEPT INTRAVENOUS cimetidine ...... 108 carvedilol phosphate ...... 54 ...... 19 cimetidine hcl ...... 108 CASODEX ...... 19 CELONTIN ...... 27 cinacalcet ...... 96 caspofungin ...... 3 cem-urea ...... 65 CINRYZE ...... 138 CATAPRES ...... 54 CENTANY ...... 71 CINVANTI ...... 103 CATAPRES-TTS-1 ...... 54 CENTANY AT...... 71 CIPRO ...... 14 CATAPRES-TTS-2 ...... 54 cephalexin ...... 8 CIPRO HC ...... 81 CATAPRES-TTS-3 ...... 54 CEPROTIN (BLUE BAR) ..... 59 CIPRODEX ...... 81 CAYA CONTOURED ...... 117 CEPROTIN (GREEN BAR) .. 59 ciprofloxacin ...... 14 CAYSTON ...... 9 CEQUA ...... 128 ciprofloxacin hcl ...... 14, 81, 126 caziant (28) ...... 122 CERDELGA ...... 96 ciprofloxacin in 5 % dextrose . 14 cefaclor ...... 7 CEREBYX ...... 27 CIPROFLOXACIN- cefadroxil ...... 7 CEREZYME ...... 96 FLUOCINOLONE ...... 81 cefazolin ...... 7 CERVIDIL ...... 120 cisatracurium ...... 32 CEFAZOLIN IN 0.9% SOD CESAMET ...... 103 cisplatin...... 19 CHLORIDE ...... 7 cetirizine ...... 134 CISPLATIN ...... 19 cefazolin in dextrose (iso-os) ... 7 cevimeline ...... 78 citalopram ...... 44 CEFAZOLIN IN DEXTROSE CHANTIX ...... 80 CITRANATAL (DUAL-IRON) (ISO-OS) ...... 7 CHANTIX CONTINUING ...... 143 CEFAZOLIN IN DEXTROSE 5 MONTH BOX ...... 80 CITRANATAL 90 DHA %...... 7 CHANTIX STARTING (ALGAL OIL) ...... 143 CEFAZOLIN IN STERILE MONTH BOX ...... 80 CITRANATAL ASSURE .... 143 WATER ...... 7 chateal (28) ...... 122 CITRANATAL B-CALM (FE cefdinir ...... 7 chateal eq (28) ...... 122 GLUC) ...... 143 cefditoren pivoxil ...... 7 CHEMET...... 78 CITRANATAL BLOOM ..... 143 cefepime ...... 7 CHENODAL ...... 103 CITRANATAL DHA (ALGAL CEFEPIME IN DEXTROSE 5 children's aspirin ...... 40 OIL) ...... 144 %...... 7 chloramphenicol sod succinate . 9 CITRANATAL HARMONY cefepime in dextrose,iso-osm ... 7 chlordiazepoxide hcl...... 44 (IRON FUM) ...... 144 cefixime ...... 7 chlordiazepoxide-clidinium .. 101 citrate of magnesia ...... 103 CEFOTAN ...... 7 chlorhexidine gluconate ...... 81 citroma ...... 103 cefotaxime ...... 7 chloroquine phosphate ...... 9 cladribine ...... 19 cefotetan ...... 7 chlorothiazide ...... 54 CLAFORAN...... 8 CEFOTETAN IN DEXTROSE, chlorothiazide sodium ...... 54 claravis ...... 68 ISO-OSM ...... 7 chlorpromazine ...... 44 CLARINEX ...... 134 cefoxitin ...... 7 chlorthalidone ...... 54 CLARINEX-D 12 HOUR .... 135 cefoxitin in dextrose, iso-osm .. 7 chlorzoxazone ...... 32 clarithromycin...... 8 cefpodoxime ...... 7 CHOLBAM ...... 103 cleansing wash ...... 68 cefprozil ...... 7 cholestyramine (with sugar) ... 61 clearlax ...... 104 ceftazidime ...... 7 cholestyramine light ...... 61 clemastine ...... 134 CEFTAZIDIME IN D5W ...... 7 CHOLETEC ...... 78 CLENPIQ ...... 104 ceftriaxone ...... 8 choline,magnesium salicylate . 40 CLEO 90 INFUSION SET 24 87 CEFTRIAXONE ...... 8 ciclodan ...... 72 cleocin...... 9 153 CLEOCIN...... 9, 10, 120 codeine-butalbital-asa-caff ..... 34 CORIFACT ...... 59 CLEOCIN HCL...... 9 codeine-guaifenesin ...... 135 CORLANOR ...... 63 CLEOCIN PEDIATRIC ...... 10 CODITUSSIN AC ...... 135 CORLOPAM ...... 54 CLEOCIN T ...... 68 CODITUSSIN DAC ...... 135 cormax ...... 74 CLEVER CHOICE LEVEL 2 COGENTIN...... 29 CORTANE-B ...... 65 CONTROL ...... 87 COLAZAL ...... 104 CORTEF ...... 82 CLIMARA ...... 117 COLCRYS...... 115 CORTENEMA ...... 104 CLINDACIN ETZ...... 68 colesevelam ...... 61 cortisone ...... 82 clindacin p ...... 68 COLESTID ...... 61 CORTISPORIN ...... 71 CLINDACIN PAC ...... 68 COLESTID FLAVORED ...... 61 CORTISPORIN-TC ...... 81 CLINDAGEL ...... 68 colestipol ...... 61 COSENTYX ...... 64 clindamycin hcl ...... 10 colistin (colistimethate na) ..... 10 COSENTYX (2 SYRINGES). 64 CLINDAMYCIN IN 0.9 % COLY-MYCIN M COSENTYX PEN ...... 64 SOD CHLOR ...... 10 PARENTERAL ...... 10 COSENTYX PEN (2 PENS) .. 64 clindamycin in 5 % dextrose .. 10 COLY-MYCIN S ...... 81 COSMEGEN ...... 19 clindamycin palmitate hcl ...... 10 COLYTE WITH FLAVOR COSOPT (PF) ...... 131 clindamycin pediatric ...... 10 PACKS ...... 104 COTELLIC ...... 19 clindamycin phosphate .... 10, 68, COMBIGAN ...... 131 COTEMPLA XR-ODT ...... 44 120 COMBIPATCH ...... 117 COUMADIN ...... 59 CLINDAMYCIN PHOSPHATE COMBIVENT RESPIMAT . 138 covaryx ...... 117 ...... 68 COMBIVIR ...... 4 covaryx h.s...... 117 clindamycin-benzoyl peroxide68 COMETRIQ ...... 19 CREON...... 104 clindamycin-tretinoin ...... 68 COMFORT SHORT INSULIN CRESEMBA...... 3 CLINDESSE ...... 120 PUMP 23 ...... 87 CRINONE ...... 117 clobazam...... 27 COMPACT SPACE CRIXIVAN...... 4 clobetasol ...... 74 CHAMBER ...... 84 cromolyn ...... 104, 128, 138 clobetasol-emollient ...... 74 COMPAZINE ...... 104 crotan ...... 77 CLOBEX ...... 74 complete natal dha ...... 144 cryselle (28) ...... 122 clodan ...... 74 compro ...... 104 CRYSVITA ...... 96 CLODAN KIT...... 74 COMTAN ...... 29 CUBICIN ...... 10 CLODERM ...... 74 CONCEPT DHA ...... 144 CUBICIN RF ...... 10 clofarabine ...... 19 CONCEPT OB ...... 144 CUROSURF ...... 138 CLOLAR ...... 19 CONCERTA ...... 44 CUTAQUIG ...... 112 clomipramine ...... 44 CONDYLOX...... 65 CUTIVATE ...... 74 clonazepam ...... 27 constulose ...... 104 CUVITRU ...... 112 clonidine ...... 54 CONTOUR CONTROL CUVPOSA ...... 101 clonidine hcl ...... 44, 54 SOLUTION, NML ...... 87 cyanocobalamin (vitamin b-12) clopidogrel ...... 59 CONTOUR NEXT LEV 2 ...... 144 clorazepate dipotassium ...... 44 CONTROL SOL...... 87 cyclafem 1/35 (28) ...... 122 clotrimazole ...... 3, 72 CONTRAVE ...... 77 cyclafem 7/7/7 (28)...... 122 clotrimazole-betamethasone ... 72 CONZIP...... 40 cyclobenzaprine ...... 32 clovique ...... 78 COOL CONTROL A CYCLOGYL ...... 128 clozapine...... 44 SOLUTION ...... 87 CYCLOMYDRIL ...... 133 CLOZAPINE ...... 44 COPAXONE ...... 110 cyclopentolate ...... 128 CLOZARIL ...... 44 COPIKTRA ...... 19 CYCLOPEN-TROPIC- c-nate dha ...... 144 CORDRAN ...... 74 PHENYLEPH-WATR ...... 128 COAGADEX ...... 59 CORDRAN TAPE LARGE cyclophosphamide ...... 19 COAL TAR ...... 64 ROLL...... 74 CYCLOSERINE...... 10 COARTEM ...... 10 COREG CR ...... 54 CYCLOSET ...... 98 COCAINE ...... 71 coremino ...... 15 cyclosporine ...... 19 codeine sulfate ...... 34 CORGARD ...... 54 154 CYCLOSPORINE IN DEMEROL ...... 34 dexchlorpheniramine maleate KLARITY ...... 128 demerol (pf) ...... 34 ...... 134 cyclosporine modified ...... 19 DEMEROL (PF)...... 34 DEXCOM G4 RECEIVER .... 87 CYKLOKAPRON ...... 59 DEMSER ...... 54 DEXCOM G5 RECEIVER .... 87 cyproheptadine ...... 134 DENAVIR ...... 73 DEXCOM G6 RECEIVER .... 87 CYRAMZA ...... 19 DEPACON ...... 27 DEXCOM RECEIVER ...... 87 cyred ...... 122 DEPAKOTE ...... 27 DEXEDRINE SPANSULE .... 45 cyred eq ...... 122 DEPAKOTE ER ...... 27 DEXILANT ...... 108 CYSTADANE ...... 104 DEPAKOTE SPRINKLES .... 27 dexmethylphenidate ...... 45 CYSTAGON ...... 142 DEPEN TITRATABS ...... 116 DEXPAK 10 DAY ...... 82 CYSTARAN ...... 128 DEPO-ESTRADIOL ...... 118 DEXPAK 13 DAY ...... 82 cytarabine ...... 19 DEPO-MEDROL ...... 82 DEXPAK 6 DAY ...... 82 cytarabine (pf) ...... 19 DEPO-PROVERA...... 118 dexrazoxane hcl ...... 16 CYTOTEC ...... 108 DEPO-SUBQ PROVERA 104 DEXTENZA ...... 132 CYTOVENE ...... 4 ...... 118 dextroamphetamine ...... 45 cytra k crystals ...... 142 DEPO-TESTOSTERONE ...... 96 dextroamphetamine- D DERMA-SMOOTHE/FS amphetamine...... 45 D.H.E.45 ...... 30 BODY OIL ...... 74 DEXYCU (PF) ...... 132 dacarbazine ...... 19 DERMA-SMOOTHE/FS DIACOMIT ...... 27 DACOGEN ...... 19 SCALP OIL ...... 74 DIASTAT ...... 27 dactinomycin ...... 19 DERMATOP ...... 74 DIASTAT ACUDIAL ...... 27 dalfampridine ...... 31 dermazene ...... 71 DIATRUE CONTROL SOLN DALIRESP ...... 138 DERMOTIC OIL ...... 81 NORMAL ...... 88 DALVANCE ...... 10 DESCOVY ...... 4 diazepam ...... 27, 45 danazol ...... 96 desipramine ...... 44 diazepam intensol ...... 45 DANTRIUM ...... 32 desloratadine ...... 134 DIBENZYLINE ...... 54 dantrolene ...... 32 desmopressin ...... 96 DICLEGIS ...... 104 dapsone ...... 10, 69 desog-e.estradiol/e.estradiol . 122 diclofenac potassium ...... 40 DAPTACEL (DTAP desogestrel-ethinyl estradiol . 122 diclofenac sodium ..... 40, 66, 130 PEDIATRIC) (PF)...... 112 DESONATE ...... 74 diclofenac-misoprostol ...... 40 daptomycin ...... 10 desonide ...... 74 dicloxacillin ...... 13 DAPTOMYCIN ...... 10 DESOWEN ...... 74 dicyclomine ...... 101 DARAPRIM ...... 10 desoximetasone ...... 74 didanosine ...... 4 darifenacin ...... 141 DESOXYN ...... 44 diethylpropion...... 77 DARZALEX ...... 19 DESVENLAFAXINE ...... 44, 45 DIFFERIN ...... 69 dasetta 1/35 (28) ...... 122 desvenlafaxine succinate ...... 45 DIFICID ...... 8 dasetta 7/7/7 (28) ...... 122 dexamethasone ...... 82 diflorasone ...... 74 daunorubicin ...... 19 DEXAMETHASONE AC, SOD DIFLUCAN ...... 3 DAURISMO...... 19 PH-WATER ...... 82 diflunisal ...... 40 DAYPRO ...... 40 DEXAMETHASONE ACE- digitek ...... 58 daysee ...... 122 NACL,ISO-OSM ...... 82 digox ...... 58 DAYTRANA ...... 44 dexamethasone intensol ...... 82 digoxin ...... 58 DDAVP ...... 96 dexamethasone sodium phos dihydroergotamine ...... 30 DEBACTEROL ...... 81 (pf) ...... 82 DILANTIN ...... 27 deblitane ...... 117 dexamethasone sodium DILANTIN EXTENDED ...... 27 decadron ...... 82 phosphate ...... 82, 132 DILANTIN INFATABS ...... 27 decitabine ...... 19 DEXAMETH- DILANTIN-125 ...... 27 deferasirox ...... 78 MOXIFLOX(PF)-NACL,ISO DILATRATE-SR ...... 63 DEFITELIO ...... 59 ...... 132 DILAUDID...... 34 DELESTROGEN ...... 118 DEXAMET-MOXIFL- DILAUDID (PF) ...... 34 demeclocycline ...... 15 KETORO-NACL(PF) ...... 128 diltiazem ...... 54 155 dilt-xr ...... 54 drospirenone-e.estradiol-lm.fa EASYMAX LOW CONTROL dimenhydrinate ...... 104 ...... 122 ...... 88 DIPHEN ...... 134 drospirenone-ethinyl estradiol EASYMAX NORMAL diphenhydramine hcl ...... 134 ...... 122 CONTROL ...... 88 diphenoxylate-atropine ...... 101 DROXIA ...... 20 ECLIPSE NEEDLE ...... 88 DIPROLENE ...... 74 DSUVIA ...... 34 EC-NAPROSYN ...... 40 dipyridamole...... 59 DUAC ...... 69 econazole ...... 72 DISALCID ...... 40 DUAKLIR PRESSAIR ...... 138 econtra ez ...... 122 disopyramide phosphate ...... 52 DUAVEE...... 118 econtra one-step ...... 122 disulfiram ...... 78 ducodyl ...... 104 ecotrin ...... 40 DITROPAN XL ...... 141 DUET DHA BALANCED ... 144 ecotrin low strength ...... 40 DIURIL ...... 54 DUET DHA WITH OMEGA-3 ECOZA ...... 72 DIURIL IV ...... 54 ...... 144 EDARBI ...... 54 divalproex ...... 27 DUETACT ...... 98 EDARBYCLOR ...... 54 DIVIGEL ...... 118 DUEXIS ...... 40 EDECRIN ...... 54 DOCEFREZ ...... 19 DULERA ...... 138 EDLUAR ...... 45 docetaxel...... 19 duloxetine ...... 45 ed-spaz ...... 101 DOCETAXEL ...... 20 DUOBRII ...... 75 EDURANT ...... 4 dofetilide...... 52 DUODOTE ...... 78 eemt ...... 118 DOLOPHINE ...... 34 DUOPA ...... 29 eemt hs ...... 118 donepezil ...... 31 DUPIXENT ...... 66 efavirenz ...... 4 DONNATAL ...... 101 DURAGESIC ...... 34 effer-k ...... 143 DOPTELET (15 TAB PACK) 59 duramorph (pf) ...... 34 EFFER-K ...... 143 DORAL ...... 45 DUREZOL ...... 132 EFFIENT ...... 59 DORYX ...... 15 dutasteride ...... 141 EFUDEX ...... 66 DORYX MPC ...... 15 dutasteride-tamsulosin ...... 141 EGRIFTA ...... 110 dorzolamide ...... 131 DUZALLO ...... 115 ELAPRASE ...... 96 DORZOLAMIDE (PF) ...... 131 dvorah ...... 34 ELELYSO ...... 96 dorzolamide-timolol ...... 131 DXEVO ...... 82 ELEMENT COMPACT dorzolamide-timolol (pf) ...... 131 DYANAVEL XR ...... 45 NORMAL CONTROL ...... 89 DORZOLAMIDE-TIMOLOL DYAZIDE ...... 54 ELEMENT NORMAL (PF) ...... 131 DYMISTA ...... 138 CONTROL ...... 89 dotti...... 118 DYRENIUM ...... 54 ELESTRIN ...... 118 DOVATO ...... 4 DYSPORT ...... 112 eletriptan ...... 30 DOVONEX ...... 64 E ELIGARD...... 20 doxazosin ...... 54 e.c. prin ...... 40 ELIGARD (3 MONTH) ...... 20 doxepin ...... 45, 66 e.e.s. 400 ...... 8 ELIGARD (4 MONTH) ...... 20 doxercalciferol ...... 96 E.E.S. GRANULES...... 8 ELIGARD (6 MONTH) ...... 20 DOXIL ...... 20 EASIVENT HOLDING ELIMITE ...... 77 doxorubicin...... 20 CHAMBER ...... 84 elinest ...... 122 doxorubicin, peg-liposomal .... 20 EASY PLUS II HIGH ELIQUIS...... 59 doxy-100...... 15 CONTROL ...... 88 ELIQUIS DVT-PE TREAT 30D doxycycline hyclate ...... 15 EASY STEP HIGH CONTROL START ...... 59 doxycycline monohydrate ...... 15 SOLN...... 88 ELITEK ...... 17 doxylamine-pyridoxine (vit b6) EASY TALK HIGH elite-ob ...... 144 ...... 104 CONTROL ...... 88 ELIXOPHYLLIN ...... 138 D-PENAMINE ...... 116 EASY TRAK LOW CONTROL ELLA ...... 122 DRISDOL...... 144 ...... 88 ELLENCE ...... 20 drithocreme hp...... 64 EASYGLUCO PLUS ELMIRON ...... 142 DRIZALMA SPRINKLE ...... 45 NORMAL CONTROL ...... 88 ELOCON ...... 75 dronabinol...... 104 ELOCTATE ...... 59 156 ELZONRIS...... 20 EPIPEN 2-PAK ...... 134 estradiol ...... 118 EMBRACE EVO LEVEL 1 ... 89 EPIPEN JR 2-PAK ...... 134 estradiol valerate ...... 118 EMBRACE GLUCOSE epirubicin ...... 20 estradiol-norethindrone acet . 118 CONTROL LOW ...... 89 EPISIL ...... 81 ESTRING ...... 118 EMBRACE TALK CONTROL- epitol ...... 27 estrogens-methyltestosterone 118 LOW (L1) ...... 89 EPIVIR ...... 4 ESTROSTEP FE-28 ...... 122 EMCYT ...... 20 EPIVIR HBV ...... 4 eszopiclone ...... 45 EMEND (FOSAPREPITANT) eplerenone ...... 54 ethacrynate sodium ...... 55 ...... 104 epoprostenol (glycine) ...... 54 ethacrynic acid ...... 55 EMGALITY PEN ...... 30 eprosartan ...... 54 ethambutol ...... 10 EMGALITY SYRINGE ...... 30 EPZICOM ...... 4 ethosuximide...... 27 emoquette ...... 122 EQUETRO ...... 27 ethyl chloride ...... 71 EMPLICITI ...... 20 ERAXIS(WATER DILUENT) 3 ethynodiol diac-eth estradiol 122 EMSAM ...... 45 ERBITUX ...... 20 ETHYOL ...... 17 EMTRIVA ...... 4 ergocalciferol (vitamin d2) ... 144 etidronate disodium ...... 78 EMVERM ...... 10 ergoloid ...... 45 etodolac...... 40 ENABLEX ...... 141 ERGOMAR ...... 30 ETOPOPHOS ...... 20 enalapril maleate ...... 54 ergotamine-caffeine ...... 30 etoposide ...... 20 enalaprilat ...... 54 ERIVEDGE ...... 20 EUCRISA ...... 66 enalapril-hydrochlorothiazide 54 ERLEADA ...... 20 EUFLEXXA ...... 40 ENBRACE HR ...... 144 erlotinib ...... 20 EURAX ...... 77 ENBREL ...... 116 errin ...... 118 EUTHYROX ...... 100 ENBREL MINI ...... 116 ERTACZO...... 72 EVAMIST ...... 118 ENBREL SURECLICK ...... 116 ertapenem ...... 10 EVEKEO ...... 45 ENDARI ...... 78 ERWINAZE ...... 20 EVEKEO ODT ...... 46 endocet ...... 34 ery pads...... 69 EVERSENSE SENSOR- ENGERIX-B (PF) ...... 112 erygel ...... 69 HOLDER ...... 89 ENGERIX-B PEDIATRIC (PF) ERYPED 200 ...... 8 EVISTA ...... 115 ...... 112 ERYPED 400 ...... 8 EVOCLIN...... 69 ENLITE SYSTEM ...... 89 ery-tab ...... 8 EVOLUTION NORMAL enoxaparin ...... 59 ERY-TAB ...... 8 CONTROL ...... 89 enpresse ...... 122 ERYTHROCIN ...... 9 EVOMELA...... 20 enskyce ...... 122 erythrocin (as stearate) ...... 9 EVOTAZ ...... 4 ENSTILAR...... 64 erythromycin ...... 9, 126 EVOXAC ...... 78 entacapone ...... 29 erythromycin ethylsuccinate..... 9 EXALGO ER...... 34 entecavir ...... 4 erythromycin with ethanol...... 69 EXELDERM ...... 72 ENTEREG ...... 104 erythromycin-benzoyl peroxide EXELON ...... 31 ENTOCORT EC ...... 104 ...... 69 exemestane ...... 20 ENTRESTO ...... 63 ESBRIET ...... 138 EXODERM ...... 72 ENTYVIO ...... 104 escitalopram oxalate ...... 45 EXTINA ...... 72 enulose ...... 104 ESGIC ...... 34 EYLEA ...... 129 ENVARSUS XR ...... 20 ESKATA ...... 66 ezetimibe...... 61 ENZOCLEAR ...... 69 esmolol ...... 54 ezetimibe-simvastatin ...... 61 EPCLUSA ...... 4 esmolol in nacl (iso-osm) ...... 54 F EPIDIOLEX ...... 27 ESMOLOL IN STERILE FABIOR ...... 69 EPIDUO ...... 69 WATER ...... 54 FABRAZYME ...... 96 EPIDUO FORTE...... 69 esomeprazole magnesium..... 108 FACTIVE ...... 14 EPIFOAM ...... 64 esomeprazole sodium ...... 109 falmina (28) ...... 122 epinastine ...... 129 estarylla ...... 122 famciclovir ...... 4 epinephrine ...... 134 estazolam ...... 45 famotidine ...... 109 EPINEPHRINE HCL (PF) ... 134 ESTRACE ...... 118 famotidine (pf) ...... 109 157 famotidine (pf)-nacl (iso-os) 109 FIORICET ...... 35 fluocinolone ...... 75 FAMOTIDINE IN 0.9 % NACL FIORINAL ...... 35 fluocinolone acetonide oil ...... 81 ...... 109 FIORINAL-CODEINE #3 ..... 35 fluocinolone and shower cap .. 75 FANAPT ...... 46 FIRAZYR ...... 138 fluocinonide ...... 75 FARESTON ...... 20 FIRDAPSE ...... 31 fluocinonide-e ...... 75 FARXIGA ...... 98 FIRMAGON KIT W DILUENT FLUORABON ...... 144 FARYDAK...... 20 SYRINGE ...... 20 fluorescein-proparacaine ...... 129 FASENRA ...... 138 FIRVANQ ...... 16 fluoride (sodium) ...... 144 FASENRA PEN ...... 138 flac otic oil ...... 81 fluoritab ...... 144 FASLODEX ...... 20 FLAGYL ...... 10 fluorometholone ...... 133 fayosim ...... 122 FLAREX ...... 133 FLUOROPLEX ...... 66 FC2 FEMALE CONDOM ... 117 flavoxate ...... 141 fluorouracil ...... 20, 66 febuxostat ...... 115 FLEBOGAMMA DIF ...... 112 fluoxetine ...... 46 FEIBA NF ...... 59 flecainide ...... 52 fluphenazine decanoate ...... 46 felbamate ...... 27 FLECTOR ...... 40 fluphenazine hcl...... 46 FELBATOL ...... 27 fleet laxative ...... 104 FLURA-DROPS ...... 144 FELDENE ...... 40 FLEXICHAMBER ...... 84 flurandrenolide ...... 75 felodipine ...... 55 FLOLAN ...... 55 flurazepam ...... 46 fem ph ...... 120 FLOLIPID ...... 62 flurbiprofen ...... 40 FEMARA ...... 20 FLOMAX ...... 141 flurbiprofen sodium ...... 130 FEMCAP ...... 117 FLORIVA (FLUORIDE- flutamide ...... 21 FEMHRT LOW DOSE ...... 118 VITAMIN D3) ...... 144 fluticasone propionate .... 75, 138 femynor ...... 122 FLOVENT DISKUS ...... 138 fluticasone propion-salmeterol fenofibrate ...... 62 FLOVENT HFA ...... 138 ...... 138 FENOFIBRATE ...... 62 floxuridine ...... 20 FLUTICASONE PROPION- fenofibrate micronized ...... 61 FLUAD 2019-2020 (65 YR SALMETEROL ...... 138 fenofibrate nanocrystallized ... 61 UP)(PF) ...... 112 fluvastatin ...... 62 fenofibric acid ...... 62 FLUARIX QUAD 2019-2020 fluvoxamine ...... 46 fenofibric acid (choline) ...... 62 (PF) ...... 112 FLUZONE HIGH-DOSE 2019- FENOGLIDE ...... 62 FLUBLOK QUAD 2019-2020 20 (PF) ...... 112 fenoprofen ...... 40 (PF) ...... 112 FLUZONE QUAD 2019-2020 fentanyl ...... 34 flucaine ...... 129 ...... 112 FENTANYL (PF)- FLUCELVAX QUAD 2019- FLUZONE QUAD 2019-2020 BUPIVACAINE-NACL..... 34 2020 ...... 112 (PF) ...... 112 fentanyl citrate ...... 34 FLUCELVAX QUAD 2019- FLUZONE QUAD PEDI 2019- fentanyl citrate (pf) ...... 35 2020 (PF) ...... 112 20 (PF) ...... 112 FENTANYL CITRATE (PF) 34, fluconazole ...... 3 FML LIQUIFILM ...... 133 35 fluconazole in nacl (iso-osm) ... 3 FOLET ONE ...... 144 fentanyl citrate (pf)-0.9%nacl 35 flucytosine ...... 3 folic acid ...... 144 FENTANYL CITRATE (PF)- fludarabine ...... 20 folivane-ob ...... 144 0.9%NACL ...... 35 FLUDEOXYGLUCOSE F-18 78 FOLOTYN ...... 21 FENTANYL-ROPIVACAINE- fludrocortisone...... 82 fondaparinux ...... 59 NACL (PF) ...... 35 FLULAVAL QUAD 2019-2020 FORA GTEL MULTI- FERAHEME ...... 144 ...... 112 FUNCTN MONITOR ...... 89 FERRLECIT...... 78 FLULAVAL QUAD 2019-2020 FORA NORMAL CONTROL FETZIMA...... 46 (PF) ...... 112 ...... 89 FEXMID...... 32 FLUMADINE ...... 4 FORACARE GDH LOW FIBRICOR ...... 62 flumazenil ...... 46 CONTROL ...... 90 FIBRYGA ...... 59 FLUMIST QUAD 2019-2020 FORFIVO XL ...... 46 FINACEA...... 69 ...... 112 FORTAMET...... 98 finasteride ...... 141 flunisolide ...... 138 FORTEO...... 115 158 FORTESTA ...... 96 GAMMAKED ...... 112 GILENYA ...... 110 FORTISCARE NORMAL ..... 90 GAMMAPLEX ...... 112 GILOTRIF ...... 21 FOSAMAX ...... 115 GAMMAPLEX (WITH GLASSIA ...... 79 FOSAMAX PLUS D ...... 115 SORBITOL) ...... 112 glatiramer ...... 110 fosamprenavir ...... 4 GAMUNEX-C...... 112 glatopa ...... 110 fosaprepitant ...... 104 GANCICLOVIR ...... 4 GLEOLAN ...... 79 FOSCAVIR ...... 4 ganciclovir sodium ...... 4 GLEOSTINE ...... 21 fosinopril ...... 55 GARDASIL 9 (PF) ...... 113 glimepiride ...... 98 fosinopril-hydrochlorothiazide GASTROCROM ...... 104 glipizide ...... 98 ...... 55 gatifloxacin ...... 126 glipizide-metformin ...... 98 fosphenytoin ...... 27 GATIFLOXACIN- GLOPERBA ...... 115 FRAGMIN ...... 59 DEXAMETHASONE ...... 132 GLUCAGEN DIAGNOSTIC FREESTYLE CONTROL ...... 90 GATTEX 30-VIAL ...... 104 KIT ...... 84 FREESTYLE FREEDOM ..... 90 gavilax ...... 104 GLUCAGEN HYPOKIT...... 85 FREESTYLE FREEDOM LITE gavilyte-c ...... 104 GLUCAGON EMERGENCY ...... 90 gavilyte-g ...... 104 KIT (HUMAN) ...... 85 FREESTYLE INSULINX 84, 90 gavilyte-n ...... 104 GLUCAGON HCL ...... 84 FREESTYLE INSULINX TEST GAZYVA ...... 21 GLUCOCARD 01 NORMAL STRIPS ...... 84 GE100 CONTROL SOLUTION CONTROL ...... 91 FREESTYLE LIBRE 10 DAY NORMAL ...... 90 GLUCOCOM CONTROL READER ...... 90 GELCLAIR ...... 81 NORMAL ...... 91 FREESTYLE LIBRE 10 DAY GELNIQUE ...... 141 GLUCOSE CONTROL ...... 91 SENSOR...... 90 GELX ...... 81 GLUCOTROL ...... 98 FREESTYLE LITE METER . 90 gemcitabine ...... 21 GLUCOTROL XL...... 98 FREESTYLE LITE STRIPS .. 84 GEMCITABINE ...... 21 glyburide ...... 98 FREESTYLE TEST ...... 84 gemfibrozil ...... 62 glyburide micronized ...... 99 FROVA ...... 30 GENERESS FE ...... 122 glyburide-metformin...... 99 frovatriptan ...... 31 generlac ...... 104 GLYCATE ...... 101 FULPHILA...... 109 gengraf ...... 21 glycolax ...... 104 fulvestrant ...... 21 GENOTROPIN ...... 110 glycopyrrolate ...... 102 FURADANTIN ...... 16 GENOTROPIN MINIQUICK GLYCOPYRROLATE ...... 102 furosemide ...... 55 ...... 110 glycopyrrolate (pf) in water .. 101 FUROSEMIDE IN 0.9 % gentak ...... 126 GLYCOPYRROLATE (PF) IN NACL ...... 55 gentamicin ...... 10, 71, 126 WATER ...... 101, 102 FUSILEV ...... 17 gentamicin in nacl (iso-osm) .. 10 glydo ...... 71 FUZEON ...... 4 GENTAMICIN IN NACL (ISO- GLYNASE ...... 99 fyavolv ...... 118 OSM) ...... 10 GLYRX-PF...... 102 FYCOMPA ...... 27 gentamicin sulfate (ped) (pf) .. 11 GLYSET ...... 99 G gentamicin sulfate (pf)...... 11 GLYXAMBI...... 99 g tussin ac ...... 135 GENTAMICIN SULFATE (PF) GOLYTELY ...... 105 gabapentin ...... 28 ...... 11 GONITRO ...... 63 GABITRIL ...... 28 GENTAMICIN-SODIUM GOPRELTO ...... 71 GALAFOLD ...... 96 CITRATE ...... 11 GRALISE ...... 28 galantamine ...... 31 GENTEEL VACUUM GRALISE 30-DAY STARTER GALZIN ...... 143 LANCING DEVICE ...... 90 PACK ...... 28 GAMASTAN ...... 112 gentle laxative...... 104 granisetron (pf) ...... 105 GAMASTAN S/D ...... 112 gentlelax ...... 104 granisetron hcl ...... 105 GAMIFANT ...... 21 GENVOYA ...... 5 GRASTEK ...... 113 GAMMAGARD LIQUID .... 112 GEODON ...... 46 griseofulvin microsize ...... 3 GAMMAGARD S-D (IGA < 1 gianvi (28) ...... 122 griseofulvin ultramicrosize ...... 3 MCG/ML) ...... 112 GIAPREZA ...... 63 guaiatussin ac...... 135 159 guaifenesin ac ...... 135 heparin(porcine) in 0.45% nacl HUMULIN 70/30 U-100 guaifenesin dac ...... 135 ...... 60 KWIKPEN ...... 95 guanfacine ...... 46, 55 HEPARIN(PORCINE) IN HUMULIN N NPH INSULIN guanidine ...... 46 0.45% NACL ...... 60 KWIKPEN ...... 95 GUARDIAN REAL-TIME heparin, porcine (pf) ...... 60 HUMULIN N NPH U-100 GLU MONITOR ...... 91 HEPARIN, PORCINE (PF) ... 60 INSULIN ...... 95 GVOKE SYRINGE...... 85 HEPLISAV-B (PF)...... 113 HUMULIN R REGULAR U- GYNAZOLE-1 ...... 120 HEPSERA ...... 5 100 INSULN ...... 95 gynol ii...... 120 HERCEPTIN ...... 21 HUMULIN R U-500 (CONC) H HERCEPTIN HYLECTA ...... 21 INSULIN ...... 95 HAEGARDA ...... 138 HETLIOZ ...... 46 HUMULIN R U-500 (CONC) hailey ...... 122 HIBERIX (PF) ...... 113 KWIKPEN ...... 95 hailey 24 fe ...... 122 hidex ...... 82 HYCAMTIN...... 21 HALAVEN...... 21 HIPREX...... 16 hydralazine ...... 55 halcinonide ...... 75 HISTEX-AC ...... 135 HYDREA ...... 21 HALCION ...... 46 HIZENTRA ...... 113 HYDRO 35 ...... 66 HALDOL ...... 46 homatropaire ...... 128 HYDRO 40 ...... 66 HALDOL DECANOATE ...... 46 homatropine hbr ...... 128 hydrochlorothiazide ...... 55 halobetasol propionate...... 75 HORIZANT...... 31 hydrocodone-acetaminophen .. 35 HALOBETASOL HUMALOG JUNIOR hydrocodone-chlorpheniramine PROPIONATE ...... 75 KWIKPEN U-100 ...... 95 ...... 135 HALOG ...... 75 HUMALOG KWIKPEN hydrocodone-homatropine .... 135 haloperidol ...... 46 INSULIN ...... 95 hydrocodone-ibuprofen ...... 35 haloperidol decanoate ...... 46 HUMALOG MIX 50-50 hydrocortisone ...... 75, 82, 105 haloperidol lactate ...... 46 INSULN U-100 ...... 95 hydrocortisone acetate ...... 105 HARVONI ...... 5 HUMALOG MIX 50-50 hydrocortisone butyrate ...... 75 HAVRIX (PF) ...... 113 KWIKPEN...... 95 hydrocortisone butyr-emollient HEALTHPRO HIGH-LOW HUMALOG MIX 75-25 ...... 75 CONTROL ...... 91 KWIKPEN...... 95 hydrocortisone valerate ...... 75 healthylax ...... 105 HUMALOG MIX 75-25(U- hydrocortisone-acetic acid ...... 81 heather ...... 118 100)INSULN ...... 95 hydrocortisone-iodoquinol ..... 71 HECTOROL...... 96 HUMALOG U-100 INSULIN 95 hydrocortisone-iodoquinol-aloe HEMANGEOL...... 55 HUMATE-P ...... 60 ...... 71 HEMLIBRA ...... 59 HUMIRA ...... 116 hydrocortisone-pramoxine ..... 64, hemmorex-hc ...... 105 HUMIRA PEDIATRIC 105 HEMOFIL M HIGH...... 59 CROHNS START ...... 116 hydromet ...... 135 HEMOFIL M LOW ...... 59 HUMIRA PEN ...... 116 hydromorphone...... 36 HEMOFIL M MID ...... 59 HUMIRA PEN CROHNS-UC- HYDROMORPHONE ...... 36 HEMOFIL M SUPER HIGH . 59 HS START ...... 116 hydromorphone (pf)...... 35 hep flush-10 (pf) ...... 59 HUMIRA PEN PSOR-UVEITS- HYDROMORPHONE (PF) ... 35 HEPAGAM B ...... 113 ADOL HS ...... 116 HYDROMORPHONE (PF) IN heparin (porcine) ...... 59 HUMIRA(CF) ...... 116 WATER ...... 35 HEPARIN (PORCINE) IN 0.9% HUMIRA(CF) PEDI CROHNS hydromorphone (pf)-0.9 % nacl NACL ...... 59 STARTER ...... 116 ...... 35 heparin (porcine) in 5 % dex .. 59 HUMIRA(CF) PEN ...... 116 HYDROMORPHONE (PF)-0.9 heparin (porcine) in nacl (pf) . 59 HUMIRA(CF) PEN CROHNS- % NACL ...... 35, 36 heparin flush(porcine)-0.9nacl 59 UC-HS ...... 116 hydromorphone in 0.9 % nacl 36 heparin lock flush ...... 59 HUMIRA(CF) PEN PSOR-UV- HYDROMORPHONE IN 0.9 % heparin lock flush (porcine) ... 60 ADOL HS ...... 116 NACL ...... 36 heparin lockflush(porcine)(pf) 60 HUMULIN 70/30 U-100 hydroxocobalamin ...... 144 INSULIN ...... 95 hydroxychloroquine ...... 11 160 hydroxyprogest(pf)(preg presv) IMPAVIDO ...... 11 INVEGA TRINZA ...... 47 ...... 118 IMPOYZ ...... 75 INVELTYS...... 133 hydroxyprogesterone cap(ppres) IMURAN ...... 21 INVIRASE ...... 5 ...... 118 IMVEXXY MAINTENANCE INVOKAMET ...... 99 hydroxyprogesterone caproate PACK ...... 119 INVOKAMET XR ...... 99 ...... 118 IMVEXXY STARTER PACK INVOKANA...... 99 hydroxyurea ...... 21 ...... 119 iodine-sodium iodide ...... 66 hydroxyzine hcl ...... 134 INBRIJA ...... 29 IODOFLEX ...... 66 hydroxyzine pamoate ...... 134 incassia ...... 119 IODOSORB ...... 66 hyophen ...... 142 INCRELEX ...... 79 IOPIDINE ...... 133 hyoscyamine sulfate ...... 102 INCRUSE ELLIPTA ...... 139 IPOL ...... 113 hyosyne...... 102 indapamide ...... 55 ipratropium bromide ...... 81, 139 HYPERHEP B S/D ...... 113 INDERAL XL ...... 55 ipratropium-albuterol ...... 139 HYPERHEP B S-D INDOCIN ...... 40 irbesartan ...... 55 NEONATAL ...... 113 indocyanine green...... 79 irbesartan-hydrochlorothiazide HYPERRAB (PF) ...... 113 indomethacin ...... 40 ...... 55 HYPERRAB S/D (PF) ...... 113 INFANRIX (DTAP) (PF) ..... 113 IRESSA ...... 22 HYPER-SAL ...... 138 INFASURF ...... 79 irinotecan ...... 22 HYPERTET S/D (PF) ...... 113 infed ...... 144 ISENTRESS ...... 5 HYQVIA ...... 113 INFINITY CONTROL ISENTRESS HD ...... 5 HYSINGLA ER ...... 36 SOLUTION NORM ...... 91 isibloom ...... 123 I INFINITY VOICE CTRL ISOCHRON ...... 63 ibandronate ...... 115 SOLN-LVL 2 ...... 91 isoniazid ...... 11 IBRANCE ...... 21 INFLECTRA ...... 105 ISOPTO ATROPINE ...... 128 ibu ...... 40 INFUGEM ...... 21 ISOPTO CARPINE ...... 128 IBUDONE ...... 36 INFUMORPH P/F ...... 36 ISORDIL ...... 63 ibuprofen ...... 40 INFUVITE ADULT ...... 144 ISORDIL TITRADOSE ...... 63 ibuprofen-oxycodone ...... 36 INFUVITE PEDIATRIC ...... 144 isosorbide dinitrate ...... 63 ic green ...... 79 INJECTAFER ...... 144 isosorbide mononitrate ...... 63 icatibant ...... 138 INLYTA ...... 21 isotretinoin ...... 69 ICLUSIG ...... 21 INNOPRAN XL ...... 55 isoxsuprine ...... 120 IDAMYCIN PFS ...... 21 INOVA ...... 69 isradipine ...... 55 idarubicin ...... 21 INOVA 4-1 ...... 65 ISTODAX...... 22 IDELVION ...... 60 INOVA 8-2 ...... 65 itraconazole...... 3 IDHIFA ...... 21 INPEN (FOR HUMALOG) ... 91 ivermectin ...... 11, 69 IFEX ...... 21 INPEN (FOR NOVOLOG) .... 91 IXEMPRA ...... 22 ifosfamide ...... 21 INSET 30 INFUSION SET 23 IXIARO (PF) ...... 113 ILARIS (PF) ...... 111 ...... 91 IXINITY ...... 60 ILEVRO ...... 130 INSET INFUSION SET 23 .... 91 J imatinib...... 21 INSPIRACHAMBER ...... 84 JAKAFI ...... 22 IMBRUVICA ...... 21 INSPRA ...... 55 JALYN ...... 141 IMFINZI ...... 21 INSULIN SYRINGE-NEEDLE jantoven ...... 60 imipenem-cilastatin ...... 11 U-100 ...... 85 JANUMET ...... 99 imipramine hcl...... 46 INTELENCE ...... 5 JANUMET XR ...... 99 imipramine pamoate ...... 46 INTERMEZZO ...... 47 JANUVIA ...... 99 imiquimod ...... 111 INTRAROSA ...... 120 JARDIANCE ...... 99 IMLYGIC ...... 21 INTRON A ...... 111 jasmiel (28) ...... 123 IMOGAM RABIES-HT (PF) introvale ...... 123 jencycla ...... 119 ...... 113 INVANZ ...... 11 JENTADUETO ...... 99 IMOVAX RABIES VACCINE INVEGA ...... 47 JENTADUETO XR ...... 99 (PF) ...... 113 INVEGA SUSTENNA ...... 47 JETREA (PF)...... 129 161 JEVTANA ...... 22 KINRIX (PF) ...... 113 LAMICTAL XR STARTER jinteli...... 119 KIT FOR TC 99M-SESTAMIBI (ORANGE) ...... 28 JIVI ...... 60 NO.1 ...... 79 lamivudine ...... 5 jolessa ...... 123 KIT PREP OF TC-99M- lamivudine-zidovudine ...... 5 JORNAY PM ...... 47 MEBROFENIN ...... 79 lamotrigine ...... 28 JUBLIA ...... 72 KIT PREP OF TC-99M-SOD LANCETS ...... 91 juleber ...... 123 PYROPH ...... 79 LANCING DEVICE ...... 91 JULUCA...... 5 KITABIS PAK ...... 11 LANOXIN ...... 58 junel 1.5/30 (21) ...... 123 KLARITY-A (AZITHRO- LANOXIN PEDIATRIC ...... 58 junel 1/20 (21) ...... 123 CHONDR)(PF) ...... 129 lansoprazole ...... 109 junel fe 1.5/30 (28) ...... 123 KLARITY-B (BETAMETH- lanthanum ...... 105 junel fe 1/20 (28) ...... 123 CHOND)(PF) ...... 129 LANTUS SOLOSTAR U-100 junel fe 24 ...... 123 KLARITY-L (LOTEPRED- INSULIN ...... 95 JUXTAPID ...... 62 CHOND)(PF) ...... 129 LANTUS U-100 INSULIN .... 95 JYNARQUE ...... 96 KLARON ...... 71 larin 1.5/30 (21) ...... 123 K KLONOPIN...... 28 larin 1/20 (21) ...... 123 KADCYLA ...... 22 klor-con ...... 143 larin 24 fe ...... 123 KADIAN ...... 37 klor-con 10 ...... 143 larin fe 1.5/30 (28) ...... 123 kaitlib fe...... 123 klor-con 8 ...... 143 larin fe 1/20 (28) ...... 123 KALBITOR ...... 139 klor-con m10 ...... 143 larissia ...... 123 KALETRA ...... 5 klor-con m15 ...... 143 LASIX ...... 55 kalliga ...... 123 klor-con m20 ...... 143 LASTACAFT ...... 129 KALYDECO ...... 139 klor-con/ef ...... 143 latanoprost ...... 131 KANJINTI ...... 22 KOATE ...... 60 LATANOPROST (PF) ...... 131 KANUMA ...... 97 KOGENATE FS ...... 60 LATUDA ...... 47 KAPVAY ...... 47 KORLYM ...... 97 laxaclear ...... 105 KARBINAL ER ...... 134 KOSHER PRENATAL PLUS laxative (bisacodyl) ...... 105 kariva (28) ...... 123 IRON ...... 144 laxative feminine ...... 105 KCENTRA ...... 60 KOVALTRY ...... 60 laxative peg 3350 ...... 105 KEDRAB (PF) ...... 113 K-PHOS NO 2 ...... 142 layolis fe ...... 123 KEFLEX...... 8 K-PHOS ORIGINAL ...... 142 leena 28 ...... 123 kelnor 1/35 (28) ...... 123 KRINTAFEL ...... 11 leflunomide ...... 116 kelnor 1-50 ...... 123 KRISTALOSE...... 105 LEMTRADA ...... 110 KENALOG...... 75, 82 KRYSTEXXA ...... 115 LENVIMA ...... 22 KENALOG-80 ...... 82 k-tab ...... 143 lessina ...... 123 KEPIVANCE ...... 17 K-TAB ...... 143 LETAIRIS ...... 139 KERAFOAM ...... 66 kurvelo (28) ...... 123 letrozole ...... 22 KERALAC ...... 66 KUVAN...... 97 leucovorin calcium ...... 17 KERALYT RX ...... 65 KYLEENA ...... 117 LEUKERAN...... 22 KERALYT SCALP KYMRIAH ...... 22 LEUKINE ...... 109 COMPLETE ...... 65 KYPROLIS ...... 22 leuprolide ...... 22 KERYDIN ...... 72 L levalbuterol hcl ...... 139 ketoconazole ...... 3, 72 l norgest/e.estradiol-e.estrad . 123 LEVAQUIN ...... 14 ketodan ...... 72 labetalol ...... 55 LEVBID ...... 102 ketodan kit ...... 72 LACRISERT ...... 129 LEVEMIR FLEXTOUCH U- ketoprofen...... 40, 41 lactulose ...... 105 100 INSULN ...... 95 ketorolac ...... 41, 130 LAMICTAL XR STARTER LEVEMIR U-100 INSULIN .. 95 KEVEYIS ...... 31 (BLUE) ...... 28 levetiracetam...... 28 KEVZARA ...... 116 LAMICTAL XR STARTER levetiracetam in nacl (iso-os).. 28 KEYTRUDA ...... 22 (GREEN) ...... 28 levobunolol ...... 127 KHAPZORY ...... 17 levocarnitine ...... 79 162 levocarnitine (with sugar)...... 79 LIPOCHOL PLUS ...... 79 loteprednol etabonate...... 133 levocetirizine ...... 134 lipodox ...... 22 LOTRISONE ...... 73 levofloxacin ...... 14, 126 lipodox 50 ...... 22 LOTRONEX...... 105 levofloxacin in d5w ...... 14 LIPOFEN...... 62 LOUTREX ...... 66 levoleucovorin calcium ...... 17 lisinopril...... 55 lovastatin...... 62 levonest (28) ...... 123 lisinopril-hydrochlorothiazide 55 LOVAZA ...... 62 levonorgestrel ...... 123 lite coat aspirin ...... 41 low-ogestrel (28) ...... 123 levonorgestrel-ethinyl estrad 123 LITEAIRE MDI CHAMBER 85 loxapine succinate ...... 47 levonorg-eth estrad triphasic 123 lithium carbonate ...... 47 lo-zumandimine (28) ...... 124 levora-28...... 123 lithium citrate ...... 47 lta pre-attached ...... 71 levorphanol tartrate ...... 37 LITHOBID ...... 47 LUCENTIS ...... 129 LEVORPHANOL TARTRATE LITHOSTAT ...... 79 ludent fluoride ...... 144 ...... 37 LIVALO ...... 62 lugols ...... 71, 143 LEVO-T ...... 100 LO LOESTRIN FE ...... 123 LUMIGAN ...... 131 levothyroxine ...... 100 LOCOID ...... 75 LUMIZYME...... 97 LEVOTHYROXINE ...... 100 LOCOID LIPOCREAM ...... 75 LUMOXITI ...... 22 levoxyl ...... 100 LODINE ...... 41 LUPANETA PACK (1 LEVSIN ...... 102 LODOSYN ...... 29 MONTH) ...... 120 LEVSIN/SL ...... 102 LOKELMA ...... 105 LUPANETA PACK (3 LEVULAN ...... 66 LOMAIRA ...... 77 MONTH) ...... 120 LEXETTE ...... 75 LOMOTIL ...... 102 LUPRON DEPOT ...... 22 LEXIVA ...... 5 LONHALA MAGNAIR LUPRON DEPOT (3 MONTH) LIALDA ...... 105 REFILL ...... 139 ...... 22 LIBTAYO ...... 22 LONHALA MAGNAIR LUPRON DEPOT (4 MONTH) lidocaine ...... 71 STARTER ...... 139 ...... 22 lidocaine hcl ...... 71 LONSURF ...... 22 LUPRON DEPOT (6 MONTH) LIDOCAINE HCL ...... 71 loperamide ...... 102 ...... 22 lidocaine hcl-hydrocortison ac LOPID ...... 62 LUPRON DEPOT-PED ...... 22 ...... 71, 105 lopinavir-ritonavir ...... 5 LUPRON DEPOT-PED (3 LIDOCAINE HCL- lopreeza ...... 119 MONTH) ...... 22 HYDROCORTISON AC . 105 LOPRESSOR ...... 55 lutera (28) ...... 124 lidocaine viscous ...... 71 LOPROX ...... 72 LUXIQ ...... 75 lidocaine-hydrocortisone-aloe LOPROX (AS OLAMINE) .... 72 LUXTURNA ...... 129 ...... 105 LOPROX KIT ...... 72 LUZU ...... 73 lidocaine-phenylephrn in water lorazepam ...... 47 LYNPARZA ...... 22 ...... 129 lorazepam intensol ...... 47 LYSODREN ...... 22 lidocaine-prilocaine ...... 71 LORBRENA ...... 22 LYSTEDA ...... 120 LIDOCAN-PHENYLEPH-BSS lorcet (hydrocodone) ...... 37 lyza ...... 119 NO.2(PF) ...... 129 lorcet hd ...... 37 M LIDOCIDEX-I ...... 82 lorcet plus ...... 37 m.v.i. adult ...... 144 LILETTA ...... 117 LORTAB ELIXIR ...... 37 M.V.I. PEDIATRIC ...... 145 lillow (28) ...... 123 lortuss ex...... 135 MACROBID...... 16 LINCOCIN ...... 11 loryna (28) ...... 123 MACRODANTIN ...... 16 lincomycin ...... 11 LORZONE ...... 32 mafenide acetate ...... 71 lindane ...... 77 losartan ...... 55 magnesium citrate ...... 105 linezolid ...... 11 losartan-hydrochlorothiazide .. 55 MAKENA...... 119 linezolid in dextrose 5% ...... 11 LOSEASONIQUE...... 123 MAKENA (PF) ...... 119 linezolid-0.9% sodium chloride LOTEMAX ...... 133 MALARONE ...... 11 ...... 11 LOTEMAX SM ...... 133 MALARONE PEDIATRIC.... 11 LINZESS ...... 105 LOTENSIN ...... 55 malathion ...... 77 liothyronine ...... 100 LOTENSIN HCT ...... 55 maprotiline ...... 47 163 MAR-COF CG ...... 135 MENEST ...... 119 METHYLIN ...... 47 MARINOL ...... 105 MENOSTAR ...... 119 methylphenidate hcl...... 47, 48 marlissa (28) ...... 124 MENTAX ...... 73 METHYLPHENIDATE HCL 48 MARNATAL-F ...... 145 MENVEO A-C-Y-W-135-DIP METHYLPRED AC(PF)- MARPLAN ...... 47 (PF) ...... 113 NACL,ISO-OSM ...... 83 MARQIBO ...... 22 meperidine ...... 37 METHYLPREDNISOL AC- MATULANE ...... 23 meperidine (pf) ...... 37 BUPIVAC-WAT ...... 83 matzim la ...... 55 MEPHYTON ...... 60 methylprednisolone ...... 83 MAVENCLAD (10 TABLET meprobamate ...... 32 methylprednisolone acetate .... 83 PACK) ...... 110 MEPRON ...... 11 METHYLPREDNISOLONE MAVENCLAD (4 TABLET MEPSEVII...... 97 ACET-WATER ...... 83 PACK) ...... 110 mercaptopurine ...... 23 methyltestosterone ...... 97 MAVENCLAD (5 TABLET meropenem ...... 11 metipranolol ...... 127 PACK) ...... 110 MEROPENEM-0.9% SODIUM metoclopramide hcl ...... 105 MAVENCLAD (6 TABLET CHLORIDE ...... 11 metolazone ...... 55 PACK) ...... 110 MERREM ...... 11 metoprolol succinate ...... 56 MAVENCLAD (7 TABLET mesalamine ...... 105 metoprolol ta-hydrochlorothiaz PACK) ...... 110 mesalamine with cleansing wipe ...... 56 MAVENCLAD (8 TABLET ...... 105 metoprolol tartrate ...... 56 PACK) ...... 110 mesna ...... 17 metro i.v...... 11 MAVENCLAD (9 TABLET MESNEX...... 17 METROCREAM ...... 69 PACK) ...... 110 MESTINON ...... 32 METROGEL ...... 69 MAXIPIME ...... 8 MESTINON TIMESPAN ...... 32 METROGEL VAGINAL ..... 120 MAXITROL ...... 132 metadate er ...... 47 METROLOTION ...... 69 MAXI-TUSS CD...... 135 metaproterenol ...... 139 metronidazole ...... 11, 69, 120 MAXZIDE ...... 55 metaxall ...... 32 metronidazole in nacl (iso-os) 11 MAXZIDE-25MG ...... 55 metaxalone...... 32 mexiletine ...... 52 MAYZENT ...... 110 metformin ...... 99 MIACALCIN ...... 97 m-clear wc ...... 135 METFORMIN ...... 99 mibelas 24 fe...... 124 meclizine ...... 105 methadone ...... 37 MICONAZOLE NITRATE- meclofenamate ...... 41 methadose ...... 37 ZINC OX-PET...... 73 MEDISENSE ...... 91 methamphetamine ...... 47 miconazole-3 ...... 120 MEDISENSE GLUCOSE methazolamide...... 130 MICORT-HC ...... 105 KETONE ...... 91 methenamine hippurate ...... 16 MICROCHAMBER ...... 85 MEDROL ...... 82 methenamine mandelate ...... 16 microgestin 1.5/30 (21) ...... 124 MEDROL (PAK) ...... 82 methen-sod phos-meth blue- microgestin 1/20 (21) ...... 124 medroxyprogesterone ...... 119 hyos ...... 142 microgestin fe 1.5/30 (28) .... 124 mefenamic acid ...... 41 methergine ...... 126 microgestin fe 1/20 (28) ...... 124 mefloquine ...... 11 methimazole ...... 83 MICROSPACER ...... 85 MEGACE ES ...... 23 METHITEST ...... 97 midazolam (pf) in 0.9 % nacl . 48 megestrol ...... 23 methocarbamol ...... 32 MIDAZOLAM (PF) IN 0.9 % MEKINIST ...... 23 methotrexate sodium ...... 23 NACL ...... 48 MEKTOVI ...... 23 methotrexate sodium (pf) ...... 23 MIDAZOLAM IN 0.9 % SOD melodetta 24 fe ...... 124 methoxsalen ...... 66 CHLORID ...... 48 meloxicam ...... 41 methscopolamine ...... 102 midodrine ...... 79 melphalan ...... 23 methyl salicylate ...... 66 migergot ...... 31 melphalan hcl ...... 23 methyldopa ...... 55 miglitol ...... 99 memantine ...... 31 methyldopa-hydrochlorothiazide miglustat ...... 97 MEMANTINE ...... 31 ...... 55 MIGRANAL...... 31 MENACTRA (PF) ...... 113 methyldopate ...... 55 mili ...... 124 M-END PE ...... 135 methylergonovine ...... 126 milk of magnesia ...... 105 164 milk of magnesia concentrated MORPHINE (PF) IN 0.9 % mynatal ...... 145 ...... 106 NACL ...... 37, 38 mynatal advance ...... 145 millipred ...... 83 morphine concentrate ...... 38 mynatal plus...... 145 millipred dp ...... 83 MORPHINE IN 0.9 % mynatal-z ...... 145 mimvey ...... 119 SODIUM CHLOR ...... 38 mynate 90 plus ...... 145 MINIPRESS ...... 56 MOTEGRITY ...... 106 MYOBLOC ...... 113 MINITRAN ...... 63 MOTOFEN ...... 102 myorisan ...... 69 MINIVELLE ...... 119 MOVANTIK ...... 106 MYOVIEW KIT ...... 79 MINOCIN ...... 15 MOVIPREP ...... 106 MYRBETRIQ...... 141 minocycline ...... 15 MOXATAG...... 13 MYSOLINE ...... 28 minoxidil ...... 56 MOXEZA ...... 127 MYTESI ...... 102 MIOCHOL-E ...... 128 moxifloxacin ...... 14, 127 MYXREDLIN ...... 95 miralax ...... 106 MOXIFLOXACIN (PF)-BSS N MIRAPEX ...... 29 NO.2 ...... 127 NABI-HB ...... 113 MIRAPEX ER ...... 29 MOXIFLOXACIN-SOD nabumetone...... 41 MIRCETTE (28) ...... 124 CHLOR,ISO(PF) ...... 127 nadolol ...... 56 MIRENA ...... 117 MOXIFLOXACIN- nadolol-bendroflumethiazide .. 56 mirtazapine ...... 48 SOD.ACE,SUL-WATER ... 14 nafcillin ...... 13 MIRVASO ...... 69 moxifloxacin-sod.chloride(iso) nafcillin in dextrose iso-osm .. 13 misoprostol ...... 109 ...... 14 naftifine...... 73 MITIGARE ...... 115 MOZOBIL ...... 109 NAFTIN ...... 73 MITIGO (PF) ...... 37 MS CONTIN ...... 38 NAGLAZYME ...... 97 mitomycin...... 23 MUGARD ...... 81 nalbuphine ...... 41 MITOSOL ...... 131 MULTAQ ...... 52 NALFON ...... 41 mitoxantrone...... 23 multi-vitamin with fluoride .. 145 NALOCET ...... 38 MKO (MIDAZOLAM- multivitamins with fluoride .. 145 naloxone ...... 41 KETAMINE-ONDAN) ...... 48 mupirocin...... 71 naltrexone ...... 41 M-M-R II (PF) ...... 113 mupirocin calcium ...... 71 NAMENDA ...... 31 m-natal plus ...... 145 MUTAMYCIN ...... 23 NAMENDA TITRATION PAK MOBIC ...... 41 MVASI ...... 23 ...... 31 modafinil ...... 48 mvc-fluoride ...... 145 NAMENDA XR ...... 31 moexipril ...... 56 my choice ...... 124 NAMZARIC ...... 31 molindone ...... 48 my way ...... 124 NAPRELAN CR ...... 41 mometasone ...... 75, 139 MYALEPT ...... 97 NAPROSYN...... 41 mondoxyne nl ...... 15 MYAMBUTOL ...... 11 naproxen ...... 41 MONODOX ...... 15 MYCAMINE ...... 3 naproxen sodium ...... 41 mono-linyah ...... 124 MYCOBUTIN ...... 11 naratriptan ...... 31 MONONINE ...... 60 mycophenolate mofetil ...... 23 NARCAN ...... 41 montelukast ...... 139 mycophenolate mofetil (hcl) .. 23 NARDIL ...... 48 MONUROL ...... 16 mycophenolate sodium ...... 23 NASCOBAL...... 145 morgidox ...... 15 MYDAYIS ...... 48 NATACHEW (FE BIS- MORGIDOX 1X 50 ...... 15 MYDRIACYL ...... 128 GLYCINATE) ...... 145 MORGIDOX 2X100 ...... 15 mydriatic3 (trop-cyclopent-pe) NATACYN...... 127 MORPHABOND ER ...... 37 ...... 128 NATAZIA ...... 124 morphine...... 38 MYDRIATIC4(TROP-PROP- nateglinide ...... 99 MORPHINE ...... 38 PE-KTRLC)...... 129 NATESTO ...... 97 morphine (pf)...... 38 MYFORTIC ...... 23 NATPARA ...... 97 MORPHINE (PF) ...... 38 MYGLUCOHEALTH NATROBA ...... 77 morphine (pf) in 0.9 % nacl .. 37, CONTROL SOLUTION .... 92 natura-lax ...... 106 38 MYLERAN ...... 23 nature-throid ...... 100 MYLOTARG ...... 23 NAVELBINE ...... 23 165 NAYZILAM...... 28 nicotine (polacrilex) ...... 80 NORPRAMIN ...... 48 NEBUPENT ...... 11 NICOTROL ...... 80 NORTHERA ...... 79 nebusal ...... 139 NICOTROL NS ...... 80 nortrel 0.5/35 (28) ...... 124 NEBUSAL ...... 139 nifedipine ...... 56 nortrel 1/35 (21) ...... 124 necon 0.5/35 (28)...... 124 nikki (28) ...... 124 nortrel 1/35 (28) ...... 124 NEEVODHA (WITH ALGAL NILANDRON ...... 23 nortrel 7/7/7 (28)...... 124 OIL) ...... 145 nilutamide ...... 23 nortriptyline ...... 48 nefazodone ...... 48 NIMBEX ...... 32 NORVIR ...... 5 neomycin ...... 11 nimodipine ...... 56 NOURIANZ ...... 29 neomycin-bacitracin-poly-hc 132 NINJACOF-XG...... 135 NOVA MAX GLUCOSE neomycin-bacitracin-polymyxin NINLARO ...... 23 CONTROL ...... 92 ...... 127 NIPENT ...... 23 NOVAMAX PLUS GLU-KET neomycin-polymyxin b gu ..... 78 NIPRIDE RTU ...... 63 ...... 92 neomycin-polymyxin b- nisoldipine ...... 56 NOVOEIGHT...... 60 dexameth ...... 132 nitisinone ...... 79 NOVOPEN ECHO ...... 92 neomycin-polymyxin- nitro-bid ...... 63 NOVOSEVEN RT...... 60 gramicidin...... 127 NITRO-DUR ...... 63 NOXAFIL...... 3 neomycin-polymyxin-hc 82, 132 nitrofurantoin ...... 16 np thyroid...... 100 neo-polycin ...... 127 nitrofurantoin macrocrystal .... 16 NPLATE ...... 60 neo-polycin hc ...... 132 nitrofurantoin monohyd/m-cryst NUBEQA ...... 23 NEORAL ...... 23 ...... 16 NUCALA ...... 139 NEO-SYNALAR ...... 71 nitroglycerin ...... 63 NUCORT ...... 76 NEO-SYNALAR KIT ...... 71 nitroglycerin in 5 % dextrose . 63 NUCYNTA...... 41 NERLYNX ...... 23 NITROLINGUAL ...... 63 NUCYNTA ER ...... 41 NESTABS ...... 145 NITROMIST ...... 63 NUEDEXTA ...... 31 NESTABS ABC ...... 145 NITROSTAT ...... 63 NULEV...... 102 NESTABS DHA ...... 145 nitro-time ...... 63 NULOJIX ...... 23 NESTABS ONE ...... 145 NITYR ...... 79 NULYTELY WITH FLAVOR neuac...... 69 NIVESTYM ...... 109 PACKS ...... 106 NEUAC KIT ...... 69 nizatidine ...... 109 NUPLAZID ...... 48 NEULASTA ...... 109 NIZORAL ...... 73 NUVARING ...... 120 NEUPRO ...... 29 NOCDURNA (MEN) ...... 97 NUVESSA ...... 120 nevirapine ...... 5 NOCDURNA (WOMEN) ...... 97 NUZYRA ...... 15 new day ...... 124 nolix ...... 76 NUZYRA (7 DAY WITH newgen ...... 145 nora-be ...... 119 LOAD DOSE) ...... 15 NEXAVAR ...... 23 NORDITROPIN FLEXPRO 110 nyamyc ...... 73 NEXAVIR ...... 145 noreth-ethinyl estradiol-iron . 124 NYMALIZE ...... 56 NEXIUM ...... 109 norethindrone (contraceptive) nystatin ...... 3, 73 NEXIUM IV ...... 109 ...... 119 nystatin-triamcinolone ...... 73 NEXIUM PACKET ...... 109 norethindrone acetate ...... 119 nystop ...... 73 NEXPLANON ...... 120 norethindrone ac-eth estradiol O niacin ...... 62 ...... 119, 124 OB COMPLETE ...... 145 NIACOR...... 62 norethindrone-e.estradiol-iron OB COMPLETE ONE ...... 145 NIASPAN EXTENDED- ...... 124 OB COMPLETE PETITE .... 145 RELEASE ...... 62 NORGESIC FORTE ...... 32 OB COMPLETE PREMIER 145 nicardipine ...... 56 norgestimate-ethinyl estradiol OB COMPLETE WITH DHA NICODERM CQ ...... 80 ...... 124 ...... 145 nicorelief...... 80 NORITATE ...... 69 OBIZUR ...... 60 nicorette ...... 80 norlyda ...... 119 OBREDON ...... 135 NICORETTE ...... 80 NORPACE ...... 52 obstetrix dha ...... 145 nicotine ...... 80 NORPACE CR ...... 52 OBSTETRIX EC ...... 145 166 OBSTETRIX ONE ...... 145 ONETOUCH ULTRA2 OTOVEL ...... 82 OBTREX DHA ...... 146 METER ...... 93 OTREXUP (PF)...... 116 O-CAL PRENATAL ...... 146 ONETOUCH ULTRAMINI... 93 OVACE ...... 64 OCALIVA ...... 106 ONETOUCH VERIO ...... 84 OVACE PLUS...... 64 ocella ...... 124 ONETOUCH VERIO FLEX .. 93 OVACE PLUS SHAMPOO ... 64 OCREVUS ...... 110 ONETOUCH VERIO IQ OVACE PLUS WASH ...... 64 OCTAGAM ...... 113 METER ...... 93 OVIDE ...... 77 octreotide acetate ...... 23 ONETOUCH VERIO SYSTEM oxacillin ...... 13 OCUFLOX ...... 127 ...... 93 oxacillin in dextrose(iso-osm) 13 ODACTRA...... 113 ONEXTON ...... 69 oxaliplatin ...... 24 ODEFSEY ...... 5 ONFI ...... 28 OXANDRIN ...... 97 ODOMZO ...... 23 ONIVYDE ...... 23 oxandrolone ...... 97 OFEV ...... 139 ONMEL ...... 3 oxaprozin ...... 41 ofloxacin ...... 14, 81, 127 OPANA ...... 38 OXAYDO ...... 38 ogestrel (28)...... 124 opcicon one-step ...... 124 oxazepam ...... 48 OGIVRI ...... 23 OPDIVO ...... 23 oxcarbazepine ...... 28 okebo ...... 15 opium tincture...... 102 OXERVATE...... 129 olanzapine...... 48 OPSUMIT ...... 139 oxiconazole ...... 73 olanzapine-fluoxetine ...... 48 OPTICHAMBER DIAMOND OXISTAT ...... 73 olmesartan ...... 56 VHC...... 85 OXSORALEN ULTRA...... 66 olmesartan-amlodipin-hcthiazid option-2 ...... 124 OXTELLAR XR ...... 28 ...... 56 ORACEA...... 15 oxybutynin chloride ...... 141 olmesartan-hydrochlorothiazide ORACIT ...... 142 oxycodone...... 38 ...... 56 oral saline laxative ...... 106 oxycodone-acetaminophen ..... 38 olopatadine ...... 81, 129 ORALAIR ...... 113 oxycodone-aspirin ...... 38 OLUX ...... 76 oralone ...... 81 OXYCONTIN ...... 38 OLUX-E ...... 76 ORAMAGICRX ...... 81 oxymorphone ...... 39 OMECLAMOX-PAK ...... 109 ORAPRED ODT ...... 83 oxytocin ...... 126 omega-3 acid ethyl esters ...... 62 ORAVIG ...... 3 OXYTROL ...... 141 omeppi ...... 109 ORBACTIV...... 11 OZEMPIC...... 99 omeprazole ...... 109 ORENITRAM ...... 56 OZOBAX ...... 33 omeprazole-sodium bicarbonate ORILISSA ...... 97 P ...... 109 ORKAMBI ...... 139 pacerone ...... 52 OMIDRIA ...... 129 orphenadrine citrate ...... 32 paclitaxel...... 24 OMNIPOD DASH INSULIN orphenadrine-asa-caffeine ...... 33 PACNEX ...... 69 POD ...... 92 orphengesic forte ...... 33 paliperidone ...... 48 ON CALL EXPRESS orsythia ...... 124 palonosetron ...... 106 CONTROL ...... 92 ORTHO MICRONOR ...... 119 PALONOSETRON ...... 106 ON CALL PLUS CONTROL 92 ORTHO-NOVUM 1/35 (28) 124 PALYNZIQ ...... 97 ON CALL VIVID CONTROL ORTHO-NOVUM 7/7/7 (28) PAMELOR ...... 48 ...... 92 ...... 124 pamidronate ...... 97 ONCASPAR ...... 23 oscimin ...... 102 PANDEL ...... 76 ondansetron ...... 106 oscimin sl ...... 102 PANRETIN ...... 66 ondansetron hcl ...... 106 oscimin sr ...... 102 pantoprazole ...... 109 ondansetron hcl (pf) ...... 106 oseltamivir ...... 5 PANZYGA ...... 113 ONDANSETRON IN 0.9 % OSENI ...... 99 papaverine...... 56 SOD CHLOR ...... 106 OSMOPREP ...... 106 PARADIGM REAL-TIME ONETOUCH ULTRA BLUE OSPHENA...... 120 TRANSMIT-SN ...... 93 TEST STRIP ...... 84 OTEZLA ...... 116 PARAGARD T 380A ...... 117 ONETOUCH ULTRA OTEZLA STARTER ...... 116 paregoric ...... 102 CONTROL ...... 92 OTIPRIO ...... 81 PAREMYD...... 128 167 paricalcitol ...... 97 permethrin ...... 77 PLENVU ...... 106 PARICALCITOL ...... 97 perphenazine ...... 49 PLEXION ...... 69 PARLODEL ...... 29 perphenazine-amitriptyline ..... 49 PLEXION CLEANSING PARNATE ...... 48 PERSERIS ...... 49 CLOTHS...... 69 paroex oral rinse ...... 81 PEXEVA ...... 49 PLIAGLIS ...... 71 paromomycin ...... 11 pfizerpen-g...... 14 PNEUMOVAX 23...... 114 paroxetine hcl ...... 48, 49 phenadoz ...... 134 pnv 29-1 ...... 146 paroxetine phenazopyridine ...... 142 pnv-dha ...... 146 mesylate(menop.sym) ...... 49 phendimetrazine tartrate ...... 77 pnv-dha + docusate ...... 146 PARSABIV ...... 97 phenelzine ...... 49 pnv-omega ...... 146 PASER ...... 12 PHENERGAN ...... 134 pnv-select ...... 146 PATANASE ...... 81 phenobarb-hyoscy-atropine-scop POCKET CHAMBER ...... 85 PATANOL ...... 129 ...... 102 POD-CARE 100K ...... 83 PAXIL ...... 49 phenobarbital ...... 28 PODOCON ...... 65 PAXIL CR ...... 49 phenohytro ...... 102 podofilox...... 66 PAZEO ...... 129 phenoxybenzamine ...... 56 POLIVY ...... 24 P-CARE K40 ...... 83 phentermine ...... 77 polycin ...... 127 P-CARE K80 ...... 83 phentolamine ...... 56 polyethylene glycol 3350 ..... 106 PEDIAPRED ...... 83 phenylephrine hcl ...... 133 polymyxin b sulfate ...... 12 PEDIARIX (PF) ...... 113 PHENYLEPH-TROPICAMIDE polymyxin b sulf-trimethoprim PEDVAX HIB (PF) ...... 114 IN WATER...... 128 ...... 127 peg 3350-electrolytes ...... 106 PHENYTEK ...... 28 POLYTRIM ...... 127 PEGANONE ...... 28 phenytoin ...... 28 POLY-TUSSIN AC ...... 135 PEGASYS ...... 110 phenytoin sodium ...... 28 POMALYST...... 110 peg-electrolyte soln ...... 106 phenytoin sodium extended .... 28 portia 28 ...... 125 PEGINTRON ...... 110 philith...... 124 PORTRAZZA...... 24 peg-prep ...... 106 PHOSLYRA ...... 106 posaconazole...... 3 PEN NEEDLE, DIABETIC ... 93 phosphasal ...... 142 POTABA ...... 143 penicillamine ...... 116 phosphate laxative ...... 106 potassium chloride ...... 143 PENICILLIN G POT IN PHOSPHOLINE IODIDE .... 127 potassium citrate ...... 142 DEXTROSE ...... 13 PHOTOFRIN...... 24 POTELIGEO ...... 24 penicillin g potassium...... 13 PHOTREXA CROSS- powderlax ...... 107 penicillin g procaine ...... 13 LINKING KIT ...... 129 PR BENZOYL PEROXIDE ... 69 penicillin g sodium ...... 13 PHOTREXA VISCOUS...... 129 pr natal 400 ...... 146 penicillin v potassium...... 13 phytonadione (vitamin k1) ..... 60 pr natal 400 ec ...... 146 PENLAC ...... 73 PHYTONADIONE (VITAMIN pr natal 430 ...... 146 PENTACEL (PF) ...... 114 K1) ...... 60 pr natal 430 ec ...... 146 PENTACEL ACTHIB PICATO...... 66 PRALUENT PEN ...... 62 COMPONENT (PF) ...... 114 pilocarpine hcl ...... 79, 81, 128 pramipexole ...... 29 PENTAM ...... 12 pimecrolimus ...... 66 PRAMOSONE ...... 64 pentamidine ...... 12 pimozide ...... 49 PRANDIN ...... 99 PENTASA ...... 106 pimtrea (28) ...... 125 prasugrel ...... 60 pentazocine-naloxone ...... 41 pindolol ...... 56 pravastatin...... 62 pentoxifylline ...... 60 pioglitazone ...... 99 PRAXBIND ...... 61 PEPCID ...... 109 pioglitazone-glimepiride ...... 99 praziquantel ...... 12 PERCOCET ...... 39 pioglitazone-metformin ...... 99 prazosin...... 56 PERFOROMIST ...... 139 piperacillin-tazobactam ...... 14 PRECISION XTRA MONITOR PERIDEX ...... 81 pirmella ...... 125 ...... 93 perindopril erbumine ...... 56 piroxicam ...... 42 PRECISION XTRA TEST ..... 84 periogard...... 81 PLAN B ONE-STEP ...... 125 PRECOSE...... 99 PERJETA ...... 24 PLEGRIDY ...... 110 PRED FORTE ...... 133 168 PRED-G ...... 132 PRENATAL PLUS DHA ..... 146 prochlorperazine ...... 107 PRED-G S.O.P...... 132 prenatal vitamin plus low iron prochlorperazine edisylate .... 107 prednicarbate ...... 76 ...... 146 prochlorperazine maleate ...... 107 PREDNISOL ACE- prenatal-u ...... 146 PROCORT ...... 107 GATIFLOX-BROMFEN . 129 PRENATE AM...... 146 PROCRIT ...... 109 PREDNISOLN SP- PRENATE CHEWABLE ..... 146 PROCTOCORT ...... 76, 107 GATIFLOX-BROMFEN . 129 PRENATE DHA (FERR ASP PROCTOFOAM HC ...... 107 PREDNISOLN SP- GLYCIN)...... 146 procto-med hc ...... 107 MOXIFLOX-BROMFEN 129 PRENATE ELITE (IRON ASP procto-pak ...... 107 prednisolone ...... 83 GLYC) ...... 146 proctosol hc ...... 107 prednisolone acetate ...... 133 PRENATE ENHANCE ...... 146 proctozone-hc ...... 107 PREDNISOLONE ACETATE PRENATE ESSENTIAL(IRON- PROCYSBI...... 142 (PF) ...... 133 ASP-GL) ...... 146 PRODIGY CONTROL PREDNISOLONE ACETATE- PRENATE MINI (FERR ASP SOLUTION, LOW ...... 93 BROMFENAC ...... 129 GLYCIN)...... 146 PRODIGY CONTROL PREDNISOLONE ACETATE- PRENATE PIXIE ...... 147 SOLUTION,HIGH ...... 93 NEPAFENAC ...... 130 PRENATE RESTORE ...... 147 PROFILNINE ...... 61 PREDNISOLONE ACET- PRENATE STAR ...... 147 progesterone ...... 119 GATIFLOXACIN ...... 132 PREPIDIL ...... 120 progesterone micronized ...... 119 PREDNISOLONE SOD PH- preplus ...... 147 PROGLYCEM ...... 85 BROMFENAC ...... 130 PREPOPIK ...... 107 PROGRAF ...... 24 PREDNISOLONE SOD PH- PRESTALIA ...... 56 PROLASTIN-C ...... 79 GATIFLOXAC ...... 132 pretab ...... 147 PROLENSA ...... 130 PREDNISOLONE SOD PH- PRETOMANID ...... 12 PROLEUKIN ...... 111 MOXIFLOX ...... 132 prevalite ...... 62 PROMACTA ...... 61 prednisolone sodium phosphate previfem...... 125 promethazine ...... 134 ...... 83, 133 PREVNAR 13 (PF) ...... 114 promethazine-codeine ...... 135 PREDNISOLONE-MOXIFLO- PREVYMIS ...... 5 promethazine-dm ...... 135 NEPAFENAC ...... 130 PREZISTA ...... 5 promethazine-phenyleph- PREDNISOLONE- PRIFTIN ...... 12 codeine ...... 135 MOXIFLOXACIN HCL .. 132 PRIMACARE ...... 147 promethazine-phenylephrine 135 PREDNISOLONE- primaquine ...... 12 promethegan ...... 134 MOXIFLOX-BROMFEN 130 PRIMAXIN IV ...... 12 PROMETRIUM ...... 119 prednisone ...... 83 PRIMEAIRE ...... 85 PROMISEB ...... 66 prednisone intensol ...... 83 primidone...... 28 propafenone ...... 52 PREFEST ...... 119 PRIMLEV ...... 39 propantheline ...... 102 pregabalin ...... 28 PRIMSOL ...... 16 proparacaine ...... 130 PREGENNA...... 146 PRINIVIL ...... 56 propranolol ...... 56 PREMARIN ...... 119 PRIVIGEN ...... 114 propranolol-hydrochlorothiazid PREMPHASE ...... 119 PROAIR DIGIHALER...... 139 ...... 57 PREMPRO ...... 119 PROAIR HFA ...... 139 propylthiouracil ...... 84 prena1 chew...... 146 PROAIR RESPICLICK ...... 139 PROQUAD (PF) ...... 114 prena1 pearl ...... 146 probenecid ...... 115 PROSCAR ...... 141 prena1 true ...... 146 probenecid-colchicine ...... 115 PROSTIN E2 ...... 120 prenaissance ...... 146 procainamide ...... 52 PROSTIN VR PEDIATRIC . 142 prenaissance plus ...... 146 PROCARDIA ...... 56 protamine ...... 61 PRENATA ...... 146 PROCARDIA XL...... 56 PROTHELIAL ...... 81 prenatabs fa ...... 146 PRO-C-DURE 5 ...... 83 PROTOPIC ...... 66 prenatabs rx ...... 146 PRO-C-DURE 6 ...... 83 protriptyline ...... 49 prenatal plus ...... 146 procentra ...... 49 PROVENGE ...... 114 prenatal plus (calcium carb) . 146 PROCHAMBER ...... 85 PROVERA ...... 119 169 PROVIDA OB...... 147 ramipril ...... 57 RESTASIS MULTIDOSE.... 130 prudoxin ...... 66 RANEXA ...... 63 RESTORIL ...... 49 PSORCON ...... 76 ranitidine hcl ...... 109 RETACRIT...... 109 PULMICORT FLEXHALER ranolazine ...... 63 RETIN-A ...... 69 ...... 139 RAPAMUNE...... 24 RETIN-A MICRO ...... 69 pulmosal ...... 139 RAPIVAB (PF) ...... 5 RETIN-A MICRO PUMP ...... 70 PULMOZYME...... 139 rasagiline ...... 29 RETROVIR ...... 5 PUREFE OB PLUS ...... 147 RASUVO (PF) ...... 116 REVATIO...... 139 purelax ...... 107 RAVICTI ...... 79 REVCOVI ...... 79 PURIXAN ...... 24 RAYALDEE ...... 97 REVLIMID...... 111 PYLERA ...... 109 RAYOS ...... 83 revonto ...... 33 pyrazinamide ...... 12 RAZADYNE ...... 32 REXULTI ...... 50 PYRIDIUM ...... 143 RAZADYNE ER ...... 32 REYATAZ ...... 5 pyridostigmine bromide ...... 33 READYSHARP RHOPRESSA ...... 131 PYRIDOSTIGMINE DEXAMETHASONE ...... 83 RIASTAP ...... 61 BROMIDE ...... 33 REBIF (WITH ALBUMIN) . 111 ribasphere ...... 111 Q REBIF REBIDOSE ...... 111 ribasphere ribapak ...... 111 QBREXZA ...... 66 REBIF TITRATION PACK . 111 ribavirin ...... 5, 111 Q-CARE RX Q4...... 81 REBINYN ...... 61 RIDAURA ...... 116 QMIIZ ODT ...... 42 REBLOZYL ...... 109 rifabutin ...... 12 QNASL...... 139 RECLAST ...... 79 RIFADIN ...... 12 QTERN...... 99 reclipsen (28) ...... 125 RIFAMATE ...... 12 QUADRACEL (PF) ...... 114 RECOMBIVAX HB (PF) .... 114 rifampin ...... 12 QUALAQUIN ...... 12 RECTIV...... 107 RIFATER ...... 12 QUARTETTE ...... 125 REFUAH PLUS GLUCOSE RIGHTEST CONTROL QUAZEPAM ...... 49 CONTROL ...... 93 SOLUTION HIGH ...... 93 QUDEXY XR ...... 28 REGLAN ...... 107 RILUTEK ...... 79 QUESTRAN...... 62 regonol ...... 33 riluzole ...... 79 QUESTRAN LIGHT...... 62 REGRANEX ...... 66 rimantadine ...... 5 quetiapine ...... 49 RELAGARD ...... 120 RINVOQ ER ...... 116 QUILLICHEW ER ...... 49 RELENZA DISKHALER ...... 5 RIOMET ...... 99 QUILLIVANT XR ...... 49 RELEXXII...... 49 risedronate ...... 79, 115 quinapril ...... 57 RELISTOR ...... 107 RISPERDAL ...... 50 quinapril-hydrochlorothiazide 57 RELPAX ...... 31 RISPERDAL CONSTA ...... 50 quinidine gluconate ...... 52 REMERON ...... 49 risperidone ...... 50 quinidine sulfate ...... 52 REMERON SOLTAB ...... 49 RITALIN ...... 50 quinine sulfate ...... 12 REMICADE ...... 107 RITALIN LA ...... 50 quit 2 ...... 80 REMODULIN ...... 57 RITEFLO AEROCHAMBER 85 quit 4 ...... 80 RENACIDIN ...... 142 ritonavir ...... 6 QUTENZA ...... 66 RENFLEXIS ...... 107 RITUXAN ...... 24 QVAR REDIHALER ...... 139 RENVELA ...... 107 RITUXAN HYCELA ...... 24 R repaglinide ...... 99 rivastigmine ...... 32 RABAVERT (PF) ...... 114 repaglinide-metformin ...... 99 rivastigmine tartrate ...... 32 rabeprazole ...... 109 REPATHA PUSHTRONEX .. 62 rivelsa ...... 125 RACEPINEPH-LIDOCAINE- REPATHA SURECLICK ...... 62 RIXUBIS ...... 61 BSS 7(PF) ...... 130 REPATHA SYRINGE ...... 62 rizatriptan ...... 31 RADICAVA ...... 31 REQUIP...... 29 R-NATAL OB ...... 147 RADIOGARDASE ...... 79 REQUIP XL ...... 29 robafen ac ...... 136 RAGWITEK...... 114 RESCRIPTOR ...... 5 ROBAXIN ...... 33 raloxifene ...... 115 RESPA-AR ...... 135 ROBAXIN-750...... 33 ramelteon ...... 49 RESTASIS...... 130 ROCALTROL ...... 97 170 ROCKLATAN ...... 131 scopolamine base ...... 107 SIRTURO ...... 12 ROMIDEPSIN ...... 24 SEASONIQUE ...... 125 SIVEXTRO ...... 12 ropinirole ...... 30 seconal sodium ...... 50 SKELAXIN ...... 33 rosadan ...... 70 SEEBRI NEOHALER ...... 139 SKLICE ...... 77 ROSADAN...... 70 SEGLUROMET ...... 100 SKYLA ...... 117 ROSANIL...... 70 SELECT-OB ...... 147 SKYRIZI ...... 64 ROSULA ...... 70 SELECT-OB (FOLIC ACID) SLYND ...... 125 rosula cleansing cloths ...... 70 ...... 147 SMARTEST CONTROL ...... 93 rosuvastatin...... 62 SELECT-OB + DHA ...... 147 smoothlax ...... 107 ROTARIX ...... 114 selegiline hcl ...... 30 sodium benzoate-sod phenylacet ROTATEQ VACCINE ...... 114 selenium sulfide ...... 64 ...... 79 ROWASA...... 107 SELRX ...... 64 sodium chloride ...... 79, 140 roweepra ...... 28 SELZENTRY ...... 6 sodium chloride 0.9 % ...... 79 roweepra xr ...... 28 SEMPREX-D ...... 136 SODIUM EDECRIN ...... 57 ROXICODONE ...... 39 se-natal 19 chewable ...... 147 sodium ferric gluconat-sucrose ROZEREM ...... 50 se-natal-19 ...... 147 ...... 79 ROZLYTREK ...... 24 SENSIPAR ...... 97 sodium phenylbutyrate ...... 80 RUBRACA...... 24 SEREVENT DISKUS ...... 139 sodium polystyrene sulfonate RUCONEST ...... 139 SERNIVO ...... 76 ...... 107 RUZURGI ...... 32 SEROSTIM ...... 110 SODIUM POLYSTYRENE RYANODEX ...... 33 sertraline ...... 50 SULFONATE ...... 107 RYBELSUS ...... 100 setlakin...... 125 SOLARAZE ...... 67 RYCLORA ...... 134 sevelamer carbonate ...... 107 solifenacin...... 141 RYDAPT ...... 24 sevelamer hcl ...... 107 SOLIQUA 100/33 ...... 95 RYTARY ...... 30 SEYSARA ...... 15 SOLIRIS ...... 80 RYTHMOL SR ...... 52 SFROWASA ...... 107 SOLODYN ...... 15 RYVENT ...... 134 sharobel ...... 119 SOLOSEC ...... 12 S SHINGRIX (PF) ...... 114 SOLTAMOX ...... 24 SABRIL ...... 28 SHOHL'S MODIFIED ...... 142 SOLUS V2 CONTROL SAFE-CLIP BY MAIL ...... 93 SIGNIFOR...... 24 SOLUTION,HIGH ...... 94 SAFYRAL ...... 125 sildenafil (pulm.hypertension) SOMA...... 33 SALAGEN (PILOCARPINE) ...... 140 SOMATULINE DEPOT ...... 24 ...... 79, 81 SILENOR ...... 50 SOMAVERT ...... 97 SALEX ...... 65 silodosin...... 141 SOOLANTRA ...... 70 salicylic acid ...... 65 SILVADENE...... 65 SORBITOL...... 78 salicylic acid er-ceramides ..... 65 silver nitrate ...... 66 SORBITOL-MANNITOL ...... 78 SALKERA ...... 65 silver nitrate applicators ...... 67 SORIATANE ...... 64 salsalate ...... 42 silver sulfadiazine ...... 65 SORILUX ...... 64 salvax ...... 65 SILVRSTAT ...... 72 sotalol ...... 52 SALVAX DUO PLUS ...... 65 SIMBRINZA ...... 131 SOTALOL ...... 52 SAMSCA ...... 97 simliya (28)...... 125 sotalol af ...... 52 SANCUSO ...... 107 simpesse...... 125 SOTYLIZE ...... 52 SANDIMMUNE ...... 24 SIMPONI...... 116 SPECTRACEF ...... 8 SANDOSTATIN ...... 24 SIMPONI ARIA ...... 117 spinosad ...... 77 SANTYL ...... 76 SIMULECT ...... 24 spironolactone...... 57 SAPHRIS ...... 50 simvastatin ...... 62 spironolacton-hydrochlorothiaz SARAFEM ...... 50 SINEMET ...... 30 ...... 57 SAVELLA ...... 116 SINEMET CR ...... 30 SPORANOX...... 3 SAXENDA ...... 77 SINOGRAFIN ...... 79 SPORANOX PULSEPAK ...... 3 scalacort ...... 76 SINUVA ...... 140 sprintec (28) ...... 125 SCALACORT DK ...... 76 sirolimus ...... 24 SPRITAM ...... 28 171 SPRIX...... 42 sulfatrim...... 14 T SPRYCEL ...... 24 sulindac ...... 42 T sps (with sorbitol) ...... 107 SUMADAN ...... 70 30 INFUSION SET ...... 94 sronyx ...... 125 SUMADAN XLT ...... 70 90 INFUSION SET 23 ...... 94 ssd ...... 65 sumatriptan ...... 31 SLIM...... 94 SSKI ...... 84 sumatriptan succinate ...... 31 SLIM G4 ...... 94 sss 10-5 ...... 70 sumatriptan-naproxen ...... 31 TABLOID...... 25 st joseph aspirin ...... 42 SUMAXIN ...... 70 TACLONEX...... 64, 65 st. joseph aspirin ...... 42 SUMAXIN CP ...... 70 tacrolimus ...... 25, 67 STALEVO 100 ...... 30 SUMAXIN TS ...... 70 tadalafil ...... 141 STALEVO 125 ...... 30 SUNOSI...... 50 tadalafil (pulm. hypertension) STALEVO 150 ...... 30 SUPRAX ...... 8 ...... 140 STALEVO 200 ...... 30 SUPREP BOWEL PREP KIT TAFINLAR ...... 25 STALEVO 50 ...... 30 ...... 108 TAGRISSO...... 25 STALEVO 75 ...... 30 SURFAXIN ...... 140 TAKE ACTION ...... 125 STAMARIL (PF) ...... 114 SURVANTA ...... 80 TAKHZYRO ...... 140 STARLIX ...... 100 SUSTIVA ...... 6 TALZENNA ...... 25 stavudine...... 6 SUSTOL ...... 108 TAMIFLU ...... 6 STEGLATRO...... 100 SUTENT ...... 25 tamoxifen ...... 25 STEGLUJAN ...... 100 syeda ...... 125 tamsulosin ...... 141 STELARA ...... 64 SYLATRON ...... 111 TAPAZOLE ...... 84 STIMATE...... 97 SYLVANT ...... 25 TAPERDEX ...... 83 STIVARGA ...... 24 SYMAX DUOTAB ...... 102 TARCEVA ...... 25 stop smoking aid...... 80 symax fastabs ...... 102 TARGADOX ...... 15 STRENSIQ ...... 97 symax-sl...... 102 TARGRETIN ...... 25 STREPTOMYCIN ...... 12 symax-sr ...... 102 tarina 24 fe ...... 125 STRIANT ...... 97 SYMBICORT ...... 140 tarina fe 1/20 (28) ...... 125 STROMECTOL ...... 12 SYMBYAX ...... 50 TARKA ...... 57 strong iodine ...... 72, 143 SYMDEKO ...... 140 taron-c dha ...... 147 SUBLOCADE ...... 39 SYMFI ...... 6 taron-prex prenatal-dha ...... 147 SUBOXONE ...... 42 SYMFI LO ...... 6 TASIGNA...... 25 subvenite...... 28 SYMJEPI ...... 134 TASMAR ...... 30 subvenite starter (blue) kit ...... 28 SYMLINPEN 120 ...... 100 TAVALISSE ...... 61 subvenite starter (green) kit .... 28 SYMLINPEN 60 ...... 100 TAXOTERE ...... 25 subvenite starter (orange) kit .. 28 SYMPAZAN ...... 28 TAYTULLA ...... 125 SUCRAID ...... 107 SYMPROIC...... 108 tazarotene ...... 70 sucralfate ...... 109 SYNAGIS ...... 6 tazicef ...... 8 SULAR ...... 57 SYNALAR ...... 76 TAZORAC ...... 70 sulfacetamide sodium ..... 64, 133 SYNALAR CREAM KIT ...... 76 taztia xt ...... 57 sulfacetamide sodium (acne) .. 72 SYNALAR OINTMENT KIT 76 TDVAX ...... 114 sulfacetamide sodium-sulfur .. 70 SYNALAR TS ...... 76 TECENTRIQ ...... 25 sulfacetamide sod-sulfur-urea 70 SYNAREL...... 97 TECFIDERA ...... 111 sulfacetamide-prednisolone .. 133 SYNDROS ...... 108 TEFLARO ...... 8 sulfacetamide-sulfur-cleansr23 SYNERA ...... 71 TEGRETOL ...... 28 ...... 70 SYNERCID ...... 12 TEGRETOL XR ...... 28 sulfacleanse 8-4 ...... 70 SYNJARDY ...... 100 TEGSEDI ...... 32 sulfadiazine...... 14 SYNJARDY XR...... 100 TEKTURNA...... 57 sulfamethoxazole-trimethoprim SYNRIBO ...... 25 TEKTURNA HCT...... 57 ...... 14 SYNTHROID ...... 100 TELCARE CONTROL ...... 94 SULFAMYLON...... 72 SYPRINE ...... 80 telmisartan ...... 57 sulfasalazine ...... 107 telmisartan-amlodipine ...... 57 172 telmisartan-hydrochlorothiazid THYROLAR-2 ...... 101 TOSYMRA...... 31 ...... 57 THYROLAR-3 ...... 101 TOTECT ...... 17 temazepam ...... 50 tiagabine ...... 29 TOUJEO MAX U-300 TEMIXYS ...... 6 TIAZAC ...... 57 SOLOSTAR ...... 96 TEMODAR ...... 25 TIBSOVO ...... 25 TOUJEO SOLOSTAR U-300 TEMOVATE ...... 76 TIGAN...... 108 INSULIN ...... 96 temozolomide ...... 25 tigecycline ...... 12 tovet emollient ...... 76 temsirolimus ...... 25 TIGLUTIK ...... 80 TOVIAZ ...... 141 tencon ...... 39 tilia fe ...... 125 TRACLEER ...... 140 TENIPOSIDE ...... 25 TIMOL-BRIMON-DORZO- TRADJENTA ...... 100 TENIVAC (PF) ...... 114 LATANOP(PF) ...... 131 tramadol ...... 42 tenofovir disoproxil fumarate ... 6 timolol maleate ...... 57, 127 TRAMADOL ...... 42 TENORETIC 100 ...... 57 TIMOLOL-BRIMONIDI- tramadol-acetaminophen ...... 42 TENORETIC 50 ...... 57 DORZOLAM(PF) ...... 131 trandolapril ...... 57 TENORMIN ...... 57 TIMOLOL-DORZOLAMID- trandolapril-verapamil ...... 57 TEPADINA ...... 25 LATANOP(PF) ...... 131 tranexamic acid ...... 61, 120 terazosin ...... 57 TIMOLOL- TRANEXAMIC ACID IN terbinafine hcl ...... 3 LATANOPROST(PF) ...... 131 NACL,ISO-OS ...... 61 terbutaline ...... 140 TIMOPTIC ...... 127 TRANSDERM-SCOP ...... 108 terconazole ...... 120 TIMOPTIC-XE ...... 127 TRANXENE T-TAB ...... 50 TERSI FOAM ...... 65 tinidazole ...... 12 tranylcypromine ...... 50 TESSALON PERLES ...... 136 TIROSINT ...... 101 TRAVATAN Z ...... 131 testosterone ...... 97 TIROSINT-SOL ...... 101 trazodone ...... 50 testosterone cypionate ...... 98 tis-u-sol pentalyte ...... 78 TREANDA ...... 25 testosterone enanthate ...... 98 TIVICAY...... 6 TRECATOR ...... 12 TESTRED ...... 98 tizanidine ...... 33 TRELEGY ELLIPTA ...... 140 TETANUS,DIPHTHERIA TOX TOBI PODHALER ...... 12 TRELSTAR ...... 25 PED(PF) ...... 114 TOBRADEX ...... 132 TREMFYA ...... 65 tetcaine ...... 130 TOBRADEX ST...... 132 treprostinil sodium ...... 57 tetrabenazine...... 32 tobramycin ...... 127 TRESIBA FLEXTOUCH U-100 tetracaine hcl ...... 130 tobramycin in 0.225 % nacl .... 12 ...... 96 TETRACAINE HCL (PF) .... 130 tobramycin in 0.9 % nacl ...... 12 TRESIBA FLEXTOUCH U-200 tetracycline ...... 15 tobramycin sulfate ...... 12 ...... 96 TETRAVISC ...... 130 TOBRAMYCIN WITH TRESIBA U-100 INSULIN ... 96 TETRAVISC FORTE ...... 130 NEBULIZER ...... 12 tretinoin...... 70 TEXACORT...... 76 tobramycin-dexamethasone .. 132 tretinoin (chemotherapy) ...... 25 THALOMID...... 25 TOBREX ...... 127 tretinoin microspheres ...... 70 THEO-24 ...... 140 TODAY CONTRACEPTIVE TRETIN-X ...... 70 theochron ...... 140 SPONGE ...... 120 TRETIN-X CREAM KIT ...... 70 theophylline ...... 140 TOLAK ...... 67 TRETTEN ...... 61 THIOLA ...... 80 tolcapone ...... 30 TREXALL ...... 25 THIOLA EC ...... 80 tolmetin ...... 42 TREXIMET ...... 31 thioridazine ...... 50 tolterodine ...... 141 TREZIX ...... 39 thiotepa ...... 25 TOPICORT ...... 76 tri femynor ...... 125 thiothixene ...... 50 topiramate ...... 29 TRIACETIN ...... 73 THRIVITE RX ...... 147 toposar ...... 25 TRIAMCINOL AC (PF) IN THYMOGLOBULIN ...... 114 topotecan ...... 25 0.9%NACL ...... 83 thyroid (pork) ...... 100 TOPROL XL ...... 57 TRIAMCINOL ACE-BUPIV- THYROLAR-1 ...... 100 toremifene ...... 25 0.9% NACL ...... 83 THYROLAR-1/2 ...... 100 TORISEL...... 25 TRIAMCINOLONE ACETON- THYROLAR-1/4 ...... 100 torsemide ...... 57 0.9% NACL ...... 83 173 triamcinolone acetonide .. 76, 81, tri-vitamin with fluoride ...... 147 UNISTRIP LOW CONTROL 94 83 trivora (28) ...... 125 unithroid ...... 101 TRIAMCINOLONE DIA(PF)- tri-vylibra ...... 126 UNITUXIN...... 26 0.9%NACL ...... 83 tri-vylibra lo ...... 126 UPTRAVI ...... 57 TRIAMCINOLONE DIACET- TRIZIVIR ...... 6 URAMAXIN ...... 67 0.9% NACL ...... 83 TROGARZO ...... 6 urea ...... 67 TRIAMCINOLON- TROKENDI XR ...... 29 urea nail stick ...... 67 MOXIFLOX-WATR(PF). 132 tropicamide ...... 128 URECHOLINE...... 142 triamterene ...... 57 trospium ...... 141 URELLE ...... 142 triamterene-hydrochlorothiazid TRUE METRIX LEVEL 1..... 94 uretron d-s ...... 142 ...... 57 TRUECONTROL LEVEL 0 .. 94 URIBEL ...... 142 trianex ...... 76 TRULANCE ...... 108 urimar-t ...... 142 triazolam ...... 51 TRULICITY ...... 100 urin ds ...... 142 TRICARE ...... 147 TRUMENBA...... 114 uro-458 ...... 142 triderm ...... 76 TRUSOPT ...... 131 UROCIT-K 10 ...... 142 TRIDESILON ...... 76 trust natal dha ...... 147 UROCIT-K 15 ...... 142 trientine...... 80 TRUSTEEL INFUSION SET 32 UROCIT-K 5 ...... 142 tri-estarylla ...... 125 ...... 94 urogesic-blue ...... 142 TRIFERIC ...... 147 TRUVADA ...... 6 uro-mp ...... 142 trifluoperazine ...... 51 TRUXIMA ...... 25 UROQID-ACID NO.2 ...... 142 trifluridine...... 127 tulana ...... 119 URSO 250 ...... 108 TRIGLIDE ...... 62 TURALIO ...... 26 URSO FORTE ...... 108 trihexyphenidyl...... 30 TUSSICAPS ...... 136 ursodiol ...... 108 TRIKAFTA ...... 140 TUXARIN ER ...... 136 uryl ...... 142 triklo ...... 62 TUZISTRA XR ...... 136 ustell ...... 142 tri-legest fe...... 125 TWINRIX (PF)...... 114 UTIBRON NEOHALER ...... 140 tri-linyah ...... 125 TWYNSTA ...... 57 utira-c ...... 142 TRILIPIX ...... 63 TYBOST ...... 6 UTOPIC ...... 67 tri-lo-estarylla ...... 125 tydemy ...... 126 UVADEX ...... 67 tri-lo-marzia ...... 125 TYGACIL ...... 12 V tri-lo-mili ...... 125 TYKERB ...... 26 VABOMERE ...... 13 tri-lo-sprintec ...... 125 TYLENOL-CODEINE #3 ...... 39 vaginal contraceptive foam... 120 trilyte with flavor packets ..... 108 TYLENOL-CODEINE #4 ...... 39 valacyclovir ...... 6 trimethobenzamide ...... 108 TYMLOS...... 115 VALCHLOR ...... 67 trimethoprim ...... 16 TYPHIM VI ...... 114 VALCYTE ...... 6 tri-mili...... 125 TYSABRI ...... 32 valganciclovir ...... 6 trimipramine ...... 51 TYVASO ...... 140 valproate sodium ...... 29 TRIMO-SAN JELLY ...... 120 TYVASO REFILL KIT...... 140 valproic acid ...... 29 TRIMPEX ...... 16 TYVASO STARTER KIT ... 140 valproic acid (as sodium salt) . 29 trinatal rx 1 ...... 147 U valsartan ...... 57 trinate ...... 147 UCERIS ...... 108 valsartan-hydrochlorothiazide 57 TRINAZ ...... 147 UDENYCA ...... 109 VANATOL LQ ...... 39 TRINTELLIX...... 51 ULESFIA...... 77 VANATOL S...... 39 TRIOSTAT...... 101 ULORIC ...... 115 VANCOCIN ...... 16 tri-previfem (28) ...... 125 ULTOMIRIS ...... 80 vancomycin...... 16 TRIPTODUR ...... 25 ULTRACET ...... 42 VANCOMYCIN...... 16 TRISENOX ...... 25 ULTRAM ...... 42 VANCOMYCIN HCL IN tri-sprintec (28) ...... 125 ULTRASAL-ER ...... 65 WATER ...... 16 TRISTART DHA ...... 147 ULTRAVATE ...... 76 VANCOMYCIN IN 0.9 % TRIUMEQ ...... 6 umecta ...... 67 SODIUM CHL ...... 16 triveen-duo dha ...... 147 UNASYN ...... 14 174 VANCOMYCIN IN VIBATIV...... 16 vitamin k ...... 61 DEXTROSE 5 % ...... 16 VIBERZI ...... 108 vitamin k1 ...... 61 VANCOMYCIN-WATER VIBRAMYCIN ...... 15 vitamins a,c,d and fluoride ... 148 INJECT (PEG) ...... 16 vicodin es ...... 39 VITAPEARL ...... 148 vandazole ...... 120 vicodin hp ...... 39 VITATRUE ...... 148 VANOS ...... 76 VIDAZA ...... 26 VITRAKVI ...... 26 VANOXIDE-HC ...... 70 VIDEX 2 GRAM PEDIATRIC 6 VIVAGUARD INO CONTROL VAQTA (PF) ...... 114 VIDEX EC ...... 6 SOLUTION ...... 94 VARISOFT INFUSION SET 43 VIEKIRA PAK...... 6 VIVITROL ...... 42 ...... 94 vienva ...... 126 VIVOTIF ...... 114 VARIVAX (PF) ...... 114 vigabatrin ...... 29 VIZIMPRO ...... 26 VARIZIG ...... 114 vigadrone ...... 29 VOGELXO ...... 98 VARUBI...... 108 VIGAMOX ...... 127 VOLTAREN...... 42 VASCEPA ...... 63 VIIBRYD ...... 51 VOLTAREN-XR ...... 42 VASERETIC ...... 57 vilamit mb...... 142 VONVENDI ...... 61 VASHE WOUND THERAPY vilevev mb ...... 142 VORAXAZE ...... 17 ...... 78 VIMIZIM...... 98 voriconazole ...... 3 VASOTEC ...... 57 VIMOVO...... 42 VORTEX HOLDING VAXCHORA VACCINE .... 114 VIMPAT ...... 29 CHAMBER ...... 85 VCF CONTRACEPTIVE FILM VINATE DHA RF...... 147 VOSEVI ...... 6 ...... 121 vinblastine ...... 26 VOTRIENT ...... 26 VCF CONTRACEPTIVE GEL vincristine ...... 26 vp-ch-pnv ...... 148 ...... 121 vinorelbine ...... 26 VP-PNV-DHA ...... 148 VECAMYL ...... 63 VIOKACE ...... 108 VPRIV ...... 98 VECTIBIX ...... 26 viorele (28) ...... 126 VRAYLAR ...... 51 VECTICAL ...... 65 VIRACEPT ...... 6 VUMERITY ...... 111 VELCADE ...... 26 VIRAMUNE ...... 6 VUSION ...... 73 veletri ...... 57 VIRAMUNE XR ...... 6 vyfemla (28) ...... 126 velivet triphasic regimen (28) VIRASAL ...... 65 vylibra ...... 126 ...... 126 VIRAZOLE ...... 6 VYNDAMAX ...... 63 VELPHORO...... 108 VIREAD ...... 6 VYNDAQEL ...... 63 VEMLIDY ...... 6 virt-c dha...... 147 VYTONE ...... 72 VENCLEXTA ...... 26 virt-nate dha ...... 147 VYVANSE ...... 51 VENCLEXTA STARTING virt-pn dha ...... 147 VYXEOS ...... 26 PACK ...... 26 virt-pn plus ...... 148 VYZULTA ...... 131 venlafaxine ...... 51 virtussin ac ...... 136 W VENOFER ...... 147 virtussin dac ...... 136 WAKIX ...... 51 VENTAVIS ...... 140 VISTARIL ...... 134 warfarin...... 61 VENTOLIN HFA ...... 140 VISTOGARD ...... 17 water for irrigation, sterile ...... 80 verapamil ...... 58 VISUDYNE...... 130 WAVESENSE CONTROL VERASENS CONTROL VITAFOL FE+ (WITH SOLUTION ...... 95 SOLN-LEVEL 1 ...... 94 DOCUSATE) ...... 148 WELCHOL...... 63 VEREGEN ...... 67 VITAFOL GUMMIES ...... 148 WELLBUTRIN XL ...... 51 VERELAN ...... 58 VITAFOL NANO ...... 148 wera (28) ...... 126 VERELAN PM ...... 58 VITAFOL ULTRA...... 148 westhroid ...... 101 veripred 20...... 83 VITAFOL-OB ...... 148 WIDE-SEAL DIAPHRAGM VERSACLOZ ...... 51 VITAFOL-OB+DHA ...... 148 ...... 117 VERZENIO ...... 26 VITAFOL-ONE ...... 148 WILATE ...... 61 VESICARE ...... 141 VITAMED MD ONE RX .... 148 wintergreen oil ...... 67 VFEND...... 3 VITAMEDMD REDICHEW wixela inhub ...... 140 VFEND IV ...... 3 RX ...... 148 175 women's gentle laxative(bisac) zaleplon ...... 51 ZODRYL DAC 25 ...... 136 ...... 108 ZALTRAP ...... 26 ZODRYL DAC 30 ...... 136 women's laxative (bisacodyl)108 ZANAFLEX ...... 33 ZODRYL DAC 35 ...... 136 WP THYROID ...... 101 ZANOSAR ...... 26 ZODRYL DAC 40 ...... 136 wymzya fe ...... 126 ZANTAC ...... 109 ZODRYL DAC 50 ...... 136 X zarah ...... 126 ZODRYL DAC 60 ...... 136 XALIX ...... 65 ZARONTIN...... 29 ZODRYL DAC 80 ...... 136 XALKORI ...... 26 ZARXIO ...... 109 ZODRYL DEC 25 ...... 137 XARELTO ...... 61 zatean-pn dha ...... 148 ZODRYL DEC 30 ...... 137 XELJANZ ...... 117 zatean-pn plus ...... 148 ZODRYL DEC 35 ...... 137 XELJANZ XR ...... 117 zebutal ...... 39 ZODRYL DEC 40 ...... 137 XELODA ...... 26 ZEJULA ...... 26 ZODRYL DEC 50 ...... 137 XEMBIFY ...... 114 ZELAPAR ...... 30 ZODRYL DEC 60 ...... 137 XENICAL ...... 77 ZELBORAF ...... 26 ZODRYL DEC 80 ...... 137 XENLETA ...... 13 ZEMAIRA ...... 80 ZOFRAN ...... 108 XEOMIN ...... 114 ZEMBRACE SYMTOUCH ... 31 ZOHYDRO ER ...... 39 XEPI ...... 72 ZEMDRI ...... 13 ZOLADEX ...... 26 XERAVA ...... 15 ZEMPLAR ...... 98 zoledronic acid...... 98 XERESE ...... 73 zenatane ...... 70 zoledronic acid-mannitol-water XERMELO...... 26 ZENPEP ...... 108 ...... 80, 98 XGEVA ...... 17 zenzedi ...... 51 ZOLEDRONIC AC- XHANCE ...... 140 ZENZEDI ...... 51 MANNITOL-0.9NACL...... 98 XIFAXAN ...... 13 ZEPATIER ...... 7 ZOLGENSMA ...... 32 XIGDUO XR...... 100 ZERBAXA ...... 8 ZOLINZA ...... 26 XIIDRA ...... 130 ZERIT ...... 7 zolmitriptan...... 31 XIMINO ...... 15 ZESTORETIC ...... 58 zolpidem ...... 51 XOFLUZA ...... 6 ZESTRIL ...... 58 ZOMIG ...... 31 XOLAIR ...... 140 ZEVALIN (Y-90) ...... 26 ZONALON ...... 67 XOLEGEL ...... 73 ZIAC ...... 58 zonisamide ...... 29 XOPENEX ...... 140 ZIAGEN ...... 7 ZONTIVITY...... 61 XOPENEX CONCENTRATE ZIANA...... 70 ZORBTIVE ...... 110 ...... 140 zidovudine ...... 7 ZORTRESS ...... 26 XOSPATA ...... 26 ZIEXTENZO ...... 109 ZOSTAVAX (PF) ...... 114 XTAMPZA ER ...... 39 zileuton ...... 140 ZOSYN ...... 14 XTANDI...... 26 ZINECARD (AS HCL) ...... 17 ZOSYN IN DEXTROSE (ISO- xulane ...... 121 zingiber ...... 148 OSM) ...... 14 XULTOPHY 100/3.6 ...... 96 ZINGO...... 71 zovia 1/35e (28) ...... 126 XURIDEN ...... 80 ZINPLAVA ...... 114 ZOVIRAX ...... 7, 74 XYOSTED ...... 98 ziprasidone hcl ...... 51 ZTLIDO ...... 71 XYREM ...... 51 ZIRGAN ...... 127 Z-TUSS AC ...... 137 Y ZITHRANOL ...... 65 ZUBSOLV ...... 42 YAZ (28) ...... 126 ZITHROMAX ...... 9 ZULRESSO ...... 51 YERVOY ...... 26 ZITHROMAX TRI-PAK ...... 9 zumandimine (28) ...... 126 YESCARTA ...... 26 ZITHROMAX Z-PAK ...... 9 ZUPLENZ ...... 108 YF-VAX (PF) ...... 114 ZODRYL AC 25 ...... 136 ZYDELIG ...... 26 YONDELIS ...... 26 ZODRYL AC 30 ...... 136 ZYFLO ...... 140 YONSA ...... 26 ZODRYL AC 35 ...... 136 ZYKADIA ...... 26 YUPELRI ...... 140 ZODRYL AC 40 ...... 136 ZYLET ...... 132 yuvafem ...... 119 ZODRYL AC 50 ...... 136 ZYLOPRIM ...... 115 Z ZODRYL AC 60 ...... 136 ZYMAXID ...... 127 zafirlukast ...... 140 ZODRYL AC 80 ...... 136 ZYPITAMAG...... 63 176 ZYPREXA ...... 51 ZYPREXA ZYDIS ...... 51 ZYVOX ...... 13 ZYPREXA RELPREVV ...... 51 ZYTIGA ...... 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