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Ryan White Part A Formulary

Updated ƵŐƵƐƚ 2019 Ryan White Part A Pharmacy Formulary - Updated 8/19/19 Tier 1: In order to access Tier 1, clients must qualify for the Ryan White Part A Program based on eligiblity requirements. Classification Brand Name Generic Name Tier 5-Alpha-Reductase Inhibitors/BPH Avodart Dutasteride 1 /Factor Xa Inhibitors Xarelto Rivaroxaban 1

Antihyperlipidemic Agents- Dietary Source Omega 3 Alpha-Linoleic Acid 1 Antiinfectives/ Lamisil Terbinafine 1 Antiinfectives/Antiinflammatory Decadron 1 Antiinfectives/Antiinflammatory Deltasone 1 Antiinfectives/Antiinflammatory Medrol dosepak Methyprednisolone 1 Antiinfectives/Antitubercular Rifamate Isoniazid/Rifampin 1 Antiinfectives/Antitubercular Seromycin Cycloserine 1 Antiinfectives/Antiviral/Antibacterial Achromycin Tetracycline 1 Antiinfectives/Antiviral/Antibacterial Amoxil Amoxicillin 1 Antiinfectives/Antiviral/Antibacterial Augmentin Amoxicillin/Clavulanate Potassium 1 Antiinfectives/Antiviral/Antibacterial Bicillin LA Penicillin Benzath 1 Antiinfectives/Antiviral/Antibacterial Ceftin Cefuroxime 1 Antiinfectives/Antiviral/Antibacterial Cipro Ciprofloxacin 1 Antiinfectives/Antiviral/Antibacterial Cleocin Clindamycin 1 Antiinfectives/Antiviral/Antibacterial Ery-tab Erythromycin base 1 Antiinfectives/Antiviral/Antibacterial Keflex Cephalexin 1 Antiinfectives/Antiviral/Antibacterial Macrodantin Nitrofurantoin 1 Antiinfectives/Antiviral/Antibacterial Omnicef Cefdinir 1 Antiinfectives/Antiviral/Antibacterial PenVK Penicililn VK 1 Antiinfectives/Antiviral/Antibacterial Proloprim Trimethoprim 1 Antiinfectives/Antiviral/Antibacterial Rocephin Ceftriaxone INJ 1 Antiinfectives/Antiviral/Antibacterial Vibramycin Doxycycline 1 Antiinfectives/Other Humatin Paromomycin 1 Antitussives Tessalon Benzonatate 1 Combinations Dulera Formoterol/Mometasone 1 Cardiac & Anti-Hypertensive/Alpha Blockers Catapres 1 Cardiac & Anti-Hypertensive/AlphaBeta Blocker Coreg 1

Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) Avapro Irbesartan 1

Cardiac & Anti-Hypertensive/Antiarrythmic Cordarone Amiiodarone 1 Drug Classification Brand Name Generic Name Tier

Cardiac & Anti-Hypertensive/Antiplatelet Plavix Aspirin Clopidogrel *Aspirin may only be dispensed with Clopidogrel 1

Cardiac & Anti-Hypertensive/Beta Blockers Inderal 1

Cardiac & Anti-Hypertensive/Beta Blockers Normodyne Labetalol 1 Cardiac & Anti-Hypertensive/ Aldactone Spironolactone 1 Cardiac & Anti-Hypertensive/Diuretic Bumex Bumetanide 1 Cardiac & Anti-Hypertensive/Diuretic Dyazide HCTZ/Triamterene 1 Cardiac & Anti-Hypertensive/Diuretic HydroDiuril HCTZ 1 Cardiac & Anti-Hypertensive/Nitrates Imdur Isosorbide Mononitrate 1 CNS, Anxiety, Psych, Neuro, & Autonomic/ Celecoxib Celebrex 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Fioricet Butalbitol/Acetaminophen/Caffeine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Ultram 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/ Ativan Lorazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Restoril Temazepam 1 Autonomic/Antianxiety/Hypnotic Valium Diazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Vistaril,Atarx 1 CNS, Anxiety, Psych, Neuro, & Acetazolamide Autonomic/ Diamox 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Dilantin Phenytoin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Neurontin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Klonopin Clonazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Phenobarbital Phenobarbital 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Tegretol 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Topamax Topiramate 1 Drug Classification Brand Name Generic Name Tier CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Zarontin Ethosuximide 1 CNS, Anxiety, Psych, Neuro, & Autonomic/ Wellbutrin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Buspar Buspirone 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Lithonate Carb 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine Imitrex (Oral Only) Sumatriptan 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson Sinemet Carbidopa/Levodopa 1 Autonomic/ Haldol 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Thorazine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Trilafon 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Misc Cogentin Benztropine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/ Flexeril 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Lioresal Baclofen 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Soma Carisoprodol 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Methadone 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Morphine MSContin, MSIR 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Percocet Oxycodone/Acet 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Percodan Oxycodone/ASA 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Vicodin,VicodinES Hydrocodone/Acetaminophen 1 Dopaminergic Antiparkinaonism Agents Mirapex Pramipexole 1 Gastrointest/ Mylanta DS Al, Mg, Simethicone 1 Gastrointest/Antidiarrheal Imodium Loperamide Paregoric 1 Gastrointest/ Suppos Promethazine Suppos 1 Drug Classification Brand Name Generic Name Tier Gastrointest/Antiflatulant Mylicon Simethicone 1 Gastrointest/Antispasmotic Bentyl Dicyclomine 1 Gastrointest/Digestive Enzyme Ultrace MT Pancrealipase 1 Gastrointest/ Colace Docusate sodium 1 Gastrointest/Laxative Fibercon Fiberlax 1 Gastrointest/Laxative Peri-Colace Docusate/Casanth 1 Gastrointest/Misc/Other Carafate Sucralfate 1 Gastrointest/Misc/Other GoLytely/Colyte Polyethylene Glycol Electrolyte 1 Gastrointest/PPI Prevacid Lansoprazole 1 Gonadotropin Releasing Lupron Leuprolide 1 GYN/OB Lo-Ovral 28 Ethinyl Estradiol/Norgestrel 1 GYN/OB Ortho-Tricyclen 28 Ethinyl Estradiol/Norgestimate 1 GYN/OB Premarin Estrogen Conjugated 1 Administration Pen Needles *for Lantus/Levemir Pen Needles 1

Minerals, Electrolytes/Phosphate Binders Calcium Calcium Acetate 1 Misc/Other Colchicine Colchicine 1 Misc/Other Danazol Danocrine 1 Misc/Other Ditropan Oxybutinin 1 Misc/Other MAGIC Mouthwash MAGIC Mouthwash 1 Misc/Other Normal Saline Sodium Chloride for Irrigation 1 Misc/Other Peridex Oral Rinse Chlorhexidine 12% Solution 1 Misc/Other Pyridium Phenazopyridine 1 Misc/Other Zyloprim Allopurinol 1 Nasal Ocean Nasal Sodium Chloride 1 Nasal Rhinocort Budesonide 1 Ophthalmic and Pataday Ophthalmic 1 Ophthalmic/Antibiotic Ciloxin Ciprofloxacin 1 Ophthalmic/Antibiotic Dexacidin Dexamethasone/Neomycin/ Polymyxin B 1 Ophthalmic/Antibiotic E-Mycin Erythromycin 1 Ophthalmic/Antibiotic Neosporin Neo/Poly/Bacit 1 Ophthalmic/Antibiotic Sulamyd Sulfacetamide 1 Ophthalmic/Antibiotic Tobrex Tobramycin 1 Ophthalmic/Betablocker Betoptic S Betaxolol 1 Ophthalmic/Betablocker Timoptic Timolol 1 Ophthalmic/Glaucoma Alphagan Brimonide 1 Ophthalmic/Glaucoma Azopt Brinzolamide 1 Ophthalmic/Glaucoma Cosopt Dorzolamide+Timolol 1 Drug Classification Brand Name Generic Name Tier Ophthalmic/Glaucoma Lumigan Bimatoprost 1 Ophthalmic/Glaucoma Xalatan Latanoprost 1 Ophthalmic/Miotic Pilocar 1 Ophthalmic/Misc/Other Alomide Lodoxamide 1 Ophthalmic/Misc/Other Tearisol Artificial tears 1 Ophthalmic/Misc/Other Vasocon Naphazoline 1 Ophthalmic/Misc/Other Viroptic Trifluridine 1 Ophthalmic/ FML Fluorometholone 1 Ophthalmic/Steroid Pred Forte 1 Opportunistic Infections (OIs) TMP-SMX ds TMP-SMX ds 1 Otic Cortisporin Neomycin / HC 1 Otic Debrox Carbamide Peroxide 1 Otic Anti-Infectives Vosol Acetic Acid 1 Otic Anti-Infectives Vosol HC Acetic Acid/HC 1 Otic Cipro HC Ciprofloxacin/ 1 Respiratory, Cough & Cold Allergy/Antihist/ Cardec, Cardec DM, Cardec S Carbinoxamine/Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antihist/Decongestant Sudafed Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin Guaifenesin 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin AC Guaifenesin/Codeine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin DAC Guaifen/Codeine/Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin DM Guaifen/ 1 Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled Serevent Salmeterol Discus 1 Respiratory, Cough & Cold Allergy/BetaAgonist Oral Ventolin Albuterol tab 1

Respiratory, Cough & Cold Allergy/Other Singulair Montileukast 1 Respiratory, Cough & Cold Allergy/Xanthine Theo-Dur Theophylline 1 Skeletal Muscle Relaxants Robaxin Methocarbamol 1 Topical Antibiotic Bactroban Mupirocin 1

Topical Non-Steroidal Anti-Inflammatories Voltaren (gel) Diclofenac Topical 1 Drug Classification Brand Name Generic Name Tier Topical, Dermatology, Rectal, Lidocaine , Xylocaine Oint, Jelly, Visc, Vaginal/Anaesthetic Patch Xylocaine/Lidocaine 1 Vaginal/Antibacterial Benzagel Erythomycin / Benzoyl perox 1 Topical, Dermatology, Rectal, Vaginal/Antibacterial Cleocin Vag Clindamycin 1 Vaginal/Antibacterial Neosporin Neo/Gramic/Poly 1 Topical, Dermatology, Rectal, Vaginal/Antifungal Kenalog Triamcinolone 1 Topical, Dermatology, Rectal, Vaginal/Antifungal Lamisil Terbinafine 1 Topical, Dermatology, Rectal, Vaginal/Antifungal Mycolog Nystatin/Triamcin 1 Topical, Dermatology, Rectal, Vaginal/Antifungal Mycostatin Nystatin 1 Topical, Dermatology, Rectal, Vaginal/ Anusol-HC Hydrocortisone Suppository 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Dermasmoothe Fluocinolone 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Diprosone Betamethasone 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Hytone Hydrocortisone Cream 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Kenalog Triamcinolone crm 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Psorcon Diflorasone 1 Topical, Dermatology, Rectal, Vaginal/Corticosteroid Temovate Clobetasol 1 Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Amino-Cerv Urea, misc 1 Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Condylox Podophilox 1 Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Elimite Permethrin 1 Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Kwell Lindane 1 Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Lac-Hydrin Ammonium lact 1 Drug Classification Brand Name Generic Name Tier Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Selsun Selenium 1 Tetanus/Diptheria Injection Td 1 Vaccines Zostavax Zoster Live 1 Vitamins & Nutritional/Vitamins Antioxidant B-Plex with C 1 Vitamins & Nutritional/Vitamins Feosol Ferrous Sulfate/Fumerate 1 Vitamins & Nutritional/Vitamins Therapeutic Multivitamins Therapeutic Multivitamins 1 Wasting Periactin 1 Ryan White Part A Pharmacy Formulary - Updated 8/19/2019 Tier 2: In order to access Tier Two, clients must be screened every six (6) months for the State AIDS Assistance Program (ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility requirements prior to the use of this formulary.

Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier 5‐Alpha Reducte Inhibitor Genitourinary Proscar® finasteride 2 Alpha‐blocker Cardiovascular, antihypertensive Cardura XL® doxazosin XL 2 Alpha‐blocker Cardiovascular, antihypertensive Cardura® doxazosin 2 Alpha‐blocker Genitourinary Flomax® tamsulosin 2 Alpha‐blocker Cardiovascular, antihypertensive Hytrin® terazosin 2 Amebicide Antio‐infective, amebicide Mepron® atovaquone 2

Amebicide, trichomonaside Anti‐infective Flagyl® metronidazole 2

Amebicide, trichomonaside Anti-infective Metrogel Metronidazole 2 Analgesic, topical Skin/Mucous membrane Zostrix® capsaicin topical 2 testosterone gel (injection is Androgen Hormonal Androgel®* non‐formulary) 2 Angiotensin converting enzyme (ACE) inhibitor Cardiovascular Vasotec® enalapril 2 Angiotensin converting enzyme (ACE) inhibitor Cardiovascular Lotensin® benazepril 2 Angiotensin converting enzyme (ACE) inhibitor Cardiovascular Prinivil®, Zestril® lisinopril 2 Angiotensin II receptor 2 blocker (ARB) Cardiovascular Cozaar® losartan Antibiotic + keratolytic Skin/Mucous membrane Benzoyl peroxide topical benzoyl peroxide topical 2 + Beta‐2 , oral inhaled Respiratory Combivent Respimat® albuterol/ipratropium 2

Anticholinergic, oral inhaled Respiratory Atrovent® ipratropium 2 Anticonvulsant, mood Central nervous system Depakene® valproic acid stabilizer 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Anticonvulsant, Central nervous system Depakote® divalproex sodium 2 Anticonvulsant, mood stabilizer Central nervous system Keppra® levetiracetam 2 stabilizer Central nervous system Lamictal® lamotrigine 2 Anticonvulsant, mood stabilizer Central nervous system Lyrica®* 2 Anticonvulsant, mood stabilizer Central nervous system Neurontin® gabapentin 2 Antidepressant‐miscellaneou s, aminoketone Central nervous system Wellbutrin® bupropion 2 Antidepressant‐miscellaneou s, aminoketone Central nervous system Wellbutrin® SR bupropion SR 2 Antidepressant‐miscellaneou s, aminoketone Central nervous system Wellbutrin® XL bupropion XL 2 Antidiarrheal Gastrointestinal Lomotil®* diphenoxylate 2 Antidiarrheal Gastrointestinal Mytesi® crofelemer 2 Antiemetic, prokinetic Gastrointestinal Reglan® metoclopramide 2 Antiherpetic agent Anti‐infective, antiviral Valtrex® valacyclovir 2 Antiherpetic agent (CMV) Anti‐infective, antiviral Valcyte® valganciclovir 2 Respiratory Benadryl® 2 Antihistamine Respiratory Claritin® 2 Antihistamine Respiratory Zyrtec® 2 Antihistamine, antiemetic Gastrointestinal Phenergan® promethazine 2 Anti‐influenza Anti‐infective, antiviral Tamiflu® oseltamivir 2 Anti‐influenza Anti‐infective, antiviral Xofluza™ baloxavir marboxil 2 Antimalarial Anti‐infective, antibiotic Daraprim® pyrimethamine 2 Antimalarial Anti‐infective, antibiotic Primaquine primaquine 2 Anti‐infective Isoniazid isoniazid 2 Antimycobacterial Anti‐infective Myambutol® ethambutol 2 Antimycobacterial Anti‐infective Mycobutin® rifabutin 2 Antimycobacterial Anti‐infective Pyrazinamide pyrazinamide 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Antimycobacterial Anti‐infective Rifadin® rifampin 2 Zofran®, Zofran ODT®, 2 Anti‐nausea Central nervous system Zuplenz® ondansetron Antipsychotic, antimanic Central nervous system Seroquel® 2 Antipsychotic, antimanic Central nervous system Zyprexa® 2 Antipsychotic, atypical Central nervous system Abilify® 2 Antipsychotic, atypical Central nervous system Geodon® 2 Antipsychotic, atypical Central nervous system Risperdal® 2 Antivertigo, antiemetic Central nervous system Antivert® 2 Antiviral Anti‐infective, antiviral Zovirax® acyclovir 2 Antiviral, topical Topical, antiviral Aldara® imiquimod 2 Azole Anti‐infective, antifungal Diflucan® fluconazole 2 Azole Anti-infective, antifungal Lotrimin Clotrimazole 2 Azole Anti‐infective, antifungal Mycelex® Troche clotrimazole 2 Azole Anti‐infective, antifungal Nizoral® ketoconazole 2 Azole Anti‐infective, antifungal Sporanox® itraconazole 2 Azole, topical Topical, antifungal Nizoral® ketoconazole (cream, shampoo) 2 Azole, topical Topical, antifungal Terazol® terconazole 2 Bacterial vaccine Vaccine Adacel®, Boostrix® tetanus and diphtheria toxoids (Td) 2 Bacterial vaccine Vaccines Menactra Meningococcal Conjugate Vaccine 2 meningococcal serogroups A, C, Y, W Bacterial vaccine Vaccine Menactra®, Menveo® vaccine 2 pneumococcal 23‐valent polysaccharide Bacterial vaccine Vaccine Pneumovax 23® vaccine (PPSV23) 2 pneumococcal 13‐valent conjugate Bacterial vaccine Vaccine Prevnar 13® vaccine (PCV13) 2 testosterone patch (injection is Bacterial vaccine Vaccine Tenivac® non‐formulary) 2 Beta‐2 Agonist Respiratory Albuterol albuterol 2 ProAir HFA®, Proventil Beta‐2 Agonist Respiratory HFA®, Ventolin HFA® albuterol HFA 2 Beta‐blocker Cardiovascular Lopressor® metoprolol tartrate 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Beta‐blocker Cardiovascular Tenormin® atenolol 2 Beta‐blocker Cardiovascular Toprol XL® metoprolol succinate 2 Fortamet, Glucophage, Biguanide Antidiabetic Glumetza, Riomet Metformin 2 Biguanide Antidiabetic Glucophage XR® metformin ER 2 Biguanide Antidiabetic Glucophage® metformin 2 Osteoporosis Fosamax® alendronate 2

Calcium channel blocker Cardiovascular Adalat CC®, Procardia XL® nifedipine XL 2 Cardiovascular Calan SR® verapamil SR 2 Calcium channel blocker Cardiovascular Calan® verapamil 2 Calcium channel blocker Cardiovascular Cardizem SR® diltiazem SR 2 Calcium channel blocker Cardiovascular Norvasc® amlodipine 2 Calcium channel blocker Cardiovascular Procardia® nifedipine 2 Calcium channel blocker Cardiovascular Cardizem CD® diltiazem CD 2 Calcium channel blocker Cardiovascular Cardizem® diltiazem 2 Gastrointestinal, Marinol®* 2 Cardiac glycoside Cardiovascular Lanoxin® digoxin 2 CCR5 antagonist Antiretroviral Selzentry® maraviroc (MVC) 2 CD4 post‐attachment HIV‐1 inhibitor Anti‐infective, antiviral Trogarzo™ ibalizumab‐uiyk injection 2

Corticosteroid + Long acting Beta‐2 Agonist, oral inhaled Respiratory Symbicort® budesonide/formoterol inhaler 2 Corticosteroid, nasal Respiratory Nasarel® flunisolide nasal 2 Corticosteroid, nasal Respiratory Qnasl® beclomethasone (nasal spray) 2 Corticosteroid, oral inhaled Respiratory Qvar® beclomethasone (oral inhaler) 2 Corticosteroid, topical Skin/Mucous membrane Betaderm® betamethasone valerate 2 Corticosteroid, topical Skin/Mucous membrane Diprolene® betamethasone dipropionate 2 Dipeptidyl Peptidase‐4 Inhibitor Antidiabetic Januvia® sitagliptin 2 Electrolyte replacement Cardiovascular Klor‐Con® potassium chloride 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Electrolyte replacement Cardiovascular Ten-K Potassium Chloride 2 Erythropoeisis stimulating agent Blood formation and coagulation Epogen®, Procrit® epoetin alfa 2 Fibric acid derivative Cardiovascular, antihyperlipidemic Lopid® gemifibrozil 2 Fibric acid derivative Cardiovascular, antihyperlipidemic Tricor® fenofibrate 2 Fusion inhibitor Antiretroviral Fuzeon® enfuvirtide (ENF, T‐20) 2 Granulocyte stimulating Blood formation and coagulation Neupogen® filgrastim agent 2 Hepatitis B agent Anti‐infective, antiviral Baraclude® entecavir 2 Hepatitis C agent Anti‐infective, antiviral Harvoni® ledipasvir/sofosbuvir 2 Hepatitis C agent Anti‐infective, antiviral Mavyret® glecaprevir/pibrentasvir 2

Hepatitis C agent Anti‐infective, antiviral Riba‐Pak 600®, Ribasphere® ribavirin 2 Hepatitis C agent Anti‐infective, antiviral Zepatier® elbasvir/grazoprevir 2

Histamine 2 receptor blocker Gastrointestinal, acid reducer Pepcid® 2

Histamine 2 receptor blocker Gastrointestinal, acid reducer Zantac® 2 HMG‐CoA Reductase inhibitor Cardiovascular, antihyperlipidemic Crestor® rosuvastatin 2 HMG‐CoA Reductase Cardiovascular agents, inhibitor antihyperlipidemic Generic Lipitor Atorvastatin 2 HMG‐CoA Reductase inhibitor Cardiovascular, antihyperlipidemic Lipitor® atorvastatin 2 HMG‐CoA Reductase inhibitor Cardiovascular, antihyperlipidemic Pravachol® pravastatin 2 Hormonal, 2 derivative Gastrointestinal, Megace® megestrol Hormonal, testosterone Gastrointestinal, appetite stimulant Oxandrin®* 2 derivative Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) INSTI/NRTI combo Antiretroviral Biktarvy® budesonide/formoterol inhaler 2 INSTI/NRTI combo Antiretroviral Dovato® dolutegravir / lamivudine 2 elvitegravir/cobicistat/emtricitabine /tenofovir alafenamide INSTI/NRTI combo Antiretroviral Genvoya® (EVG/COBI/FTC/TAF) 2 INSTI/NRTI combo Antiretroviral Juluca® dolutegravir/rilpivirine (DTG/RPV) 2 elvitegravir/cobicistat/emtricitabine /ten ofovir disoproxil fumarate (EVG/COBI INSTI/NRTI combo Antiretroviral Stribild® /FTC/TDF) 2 dolutegravir/abacavir/lamivudine INSTI/NRTI combo Antiretroviral Triumeq® (DTG/ABC/3TC) 2 intermediate to long acting Antidiabetic Levemir Insulin Detemir 2 Humulin 70/30®, Novolin Insulin‐70/30 Antidiabetic 70/30® insulin NPH and insulin regular 2 Insulin‐intermediate acting Antidiabetic Humulin N®, Novolin N® insulin isophane 2 Insulin‐long acting Antidiabetic Lantus® insulin glargine 2 Insulin-rapid acting Antidiabetic Humalog Insulin Analog 2 Insulin‐rapid acting Antidiabetic Humalog® insulin lispro 2 Insulin‐short acting Antidiabetic Humulin R®, Novolin R® insulin regular 2 Integrase strand transfer inhibitor (INSTI) Antiretroviral Isentress HD® raltegravir HD (RAL HD) 2 Integrase strand transfer inhibitor (INSTI) Antiretroviral Isentress® raltegravir (RAL) 2 Integrase strand transfer inhibitor (INSTI) Antiretroviral Tivicay® dolutegravir (DTG) 2 Constulose®, Enulose®, Laxative, osmotic Gastrointestinal Generlac® lactulose 2 Lipotropic Cardiovascular, antihyperlipidemic Lovaza®, Vascepa® omega 3 2 Loop diuretic Cardiovascular Lasix® furosemide 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Macrolide Anti‐infective, antibiotic Biaxin® clarithromycin 2 Macrolide Anti‐infective, antibiotic Zithromax® azithromycin 2 Mood stabilizer Central nervous system Lithobid® lithium carbonate 2 2 efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF) NNRTI/NRTI combo Antiretroviral Atripla® elbasvir/grazoprevir

rilpivirine /emtricitabine/ tenofovir NNRTI/NRTI combo Antiretroviral Complera® disoproxil fumarate (RPV/FTC/TDF) 2 rilpivirine/emtricitabine/tenofovir NNRTI/NRTI combo Antiretroviral Odefsey® alafenamide (RPV/FTC/TAF) 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Edurant® rilpivirine (RPV) 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Intelence® etravirine 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Pifeltro™ doravirine (DOR) 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Sustiva® efavirenz (EFV) 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Viramune XR® nevirapine XR (NVP) 2 Non‐nucleoside reverse transcriptase inhibitor (NNRTI) Antiretroviral Viramune® nevirapine (NVP) 2 Nonsteroidal antiinflamatory Analgesic Advil®, Motrin® ibuprofen drug 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Nonsteroidal antiinflamatory 2 drug Analgesic Naprosyn® naproxen NRTI combo Antiretroviral Combivir® lamivudine/zidovudine (3TC/AZT) 2 emtricitabine/tenofovir alafenamide NRTI combo Antiretroviral Descovy® (FTC/TAF) 2 NRTI combo Antiretroviral Epzicom® abacavir/lamivudine (ABC/3TC) 2 abacavir/lamivudine/zidovudine NRTI combo Antiretroviral Trizivir® (ABC/3TC/AZT) 2 emtricitabine/tenofovir disoproxil NRTI combo Antiretroviral Truvada® fumarate (FTC/TDF) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Emtriva® emtricitabine (FTC) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Zerit® stavudine (d4T) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Epivir® lamivudine (3TC) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Retrovir® zidovudine (AZT) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Videx® didanosine (ddI) 2 Nucleoside reverse Antiretroviral Videx® EC didanosine EC (ddI) 2 Nucleoside reverse transcriptase inhibitor (NRTI) Antiretroviral Ziagen® abacavir (ABC) 2 Nucleotide reverse Antiretroviral Viread® tenofovir disoproxil fumarate (TDF) transcriptase inhibitor (NRTI) 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Partial Agonist Smoking cessation Chantix® 2 Pharmacokinetic enhancer Antiretroviral Norvir® ritonavir (RTV) 2 Pharmacokinetic enhancer Antiretroviral Tybost® cobicistat (COBI) 2 darunavir, cobicistat, emtricitabine, and PI/NRTI combo Antiretroviral Symtuza® tenofovir alafenamide 2 PI/PK Enhancer Antiretroviral Evotaz® atazanavir/cobicistat (ATV/COBI) 2 PI/PK Enhancer Antiretroviral Kaletra® lopinavir/ritonavir (LPV/RTV) 2 PI/PK Enhancer Antiretroviral Prezcobix® darunavir/cobicistat (DRV/COBI) 2 Progesterone Hormanal Depo‐Provera® medroxyprogesterone injection 2 Prostaglandin inhibitor Analgesic Tylenol® acetaminophen 2 Prostaglandin inhibitor Analgesic Tylenol#3 Codeine/Acetaminophen 2 tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) Protease inhibitor (PI) Antiretroviral Aptivus® tipranavir (TPV) 2 Protease inhibitor (PI) Antiretroviral Crixivan® indinavir (IDV) 2 Protease inhibitor (PI) Antiretroviral Invirase® saquinavir (SQV) 2 Protease inhibitor (PI) Antiretroviral Lexiva® fosamprenavir (FPV) 2 Protease inhibitor (PI) Antiretroviral Prezista® darunavir (DRV) 2 Protease inhibitor (PI) Antiretroviral Reyataz® atazanavir (ATV) 2 Protease inhibitor (PI) Antiretroviral Viracept® nelfinavir (NFV) 2 Proton pump inhibitor Gastrointestinal, acid reducer Prilosec® omeprazole 2 Proton pump inhibitor Gastrointestinal, acid reducer Protonix® pantoprazole 2 Quinolone Anti‐infective, antibiotic Levaquin® levofloxacin 2 Salicylate Analgesic Bayer®, Ecotrin® aspirin 2 Selective serotonin reuptake inhibitor (SSRI) Central nervous system, antidepressant Prozac® fluoxetine 2 Selective serotonin reuptake inhibitor (SSRI) Central nervous system, antidepressant Celexa® citalopram 2 Selective serotonin reuptake inhibitor (SSRI) Central nervous system, antidepressant Lexapro® escitalopram 2 Selective serotonin reuptake inhibitor (SSRI) Central nervous system, antidepressant Paxil® 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Selective serotonin reuptake inhibitor (SSRI) Central nervous system Zoloft® sertraline 2

Serotonin reuptake inhibitor Central nervous system, antidepressant Desyrel® 2 Serotonin‐norepinephrine reuptake inhibitor Central nervous system, antidepressant Cymbalta® duloxetine 2 Serotonin‐norepinephrine reuptake inhibitor Central nervous system, antidepressant Effexor XR® venlafaxine XR 2 Serotonin‐norepinephrine reuptake inhibitor Central nervous system, antidepressant Effexor® venlafaxine 2 sulfamethoxazole/trimethoprim Sulfonamide Anti‐infective, antibiotic Bactrim DS®, Septra DS® (SMX/TMP) DS 2 Sulfonamide Anti‐infective, antibiotic Bactrim®, Septra® sulfamethoxazole/trimethoprim (SMX/TMP) 2 Sulfonamide Anti‐infective, antibiotic Sulfadiazine sulfadiazine 2 Sulfone Anti‐infective, antibiotic Dapsone dapsone 2 Antidiabetic Amaryl® glimepiride 2 Sulfonylurea Antidiabetic Diabeta® glyburide 2 Sulfonylurea Antidiabetic Glucotrol XL® glipizide ER 2 Sulfonylurea Antidiabetic Glucotrol® glipizide 2 /Biguanides Antidiabetic Glucovance® metformin/glyburide 2 Tetracyclic antidepressant Central nervous system Remeron® 2 Thiazide diuretic Cardiovascular Microzide® hydrochlorothiazide 2 Levothroid®, Levoxyl®, 2 Thyroid supplement Hormanal Synthroid® levothyroxine antidepressant (TCA) Central nervous system, antidepressant Elavil® 2 Central nervous system, antidepressant Pamelor® (TCA) 2 Tricyclic antidepressant (TCA) Central nervous system Silenor® 2 Pharmacologic Classification Therapeutic Classification Brand Name Generic Name Tier Tricyclic antidepressant (TCA) Central nervous system Sinequan Doxepin 2 Vasodilator Cardiovascular Nitroglycerin capsules nitroglycerin capsules 2 Vasodilator Cardiovascular Nitrostat® nitroglycerin sublingual 2 Engerix‐B®, Heplisav‐B®, Viral vaccine Vaccine Recombivax HB® hepatitis B vaccine 2 Viral vaccine Vaccine Fluzone®, Fuzone® influenza vaccine, inactivated High‐Dose (including high dose) 2 Viral vaccine Vaccine Gardasil®9 human papilloma virus vaccine 2 Viral vaccine Vaccine Havrix® hepatitis A vaccine 2 hepatitis b vaccine (recombinant, 2 Viral vaccine Vaccines Heplisav-B® adjuvanted) Viral vaccine Vaccine Shingrix® zoster vaccine, recombinant (RZV) 2 Viral vaccine Vaccine Twinrix® hepatitis A/B vaccine 2 Calcitrate + D®, Caltrate + Vitamin Vitamin D® calcium with vitamin D 2 Vitamin Vitamin Caltrate® calcium carbonate 2 Vitamin Vitamin Cyanocobalamin cyanocobalamin (vitamin B 12) 2 Vitamin Vitamin Folic acid folic acid 2 Vitamin Vitamin Leucovorin leucovorin 2 Vitamin Vitamin Multivitamin multivitamin 2 Vitamin Vitamin Multivitamin prenatal multivitamin prenatal 2 Vitamin Vitamin Multivitamins B complex multivitamins B complex 2 cyanocobalamin (vitamin B 12), Vitamin Vitamin Nascobal® intranasal 2 Vitamin Vitamin Pyridoxine pyridoxine (vitamin B6) 2 Vitamin Vitamin Slow Iron® ferrous sulfate 2 Vitamin Vitamin Vitamin D2 ergocalciferol 2 Vitamin Vitamin Vitamin D3 cholecalciferol 2 Vitamin K antagonist Blood formation and coagulation Coumadin® warfarin 2 Vitamin, lipotropic Cardiovascular, antihyperlipidemic Niaspan® niacin 2