Value Formulary Effective July 1, 2021

www.amerihealthnj.com INFORMATION FOR MEMBERS AND PROVIDERS

The Value Formulary Guide is intended to help members and providers understand prescription drug coverage under the AmeriHealth New Jersey Value formulary. We are committed to providing comprehensive prescription drug coverage. To achieve this, we include a formulary feature in your prescription drug benefit. The drugs are approved by the U.S. Food and Drug Administration (FDA). They are also reviewed by our Pharmacy and Therapeutics Committee, a group of doctors and pharmacists from the area. These prescription drugs have been added to the Value Formulary for their reported medical effectiveness, safety, and value. FutureScripts®, an independent company, is our pharmacy benefits manager. They monitor all drugs to ensure they are safe and effective drugs.

Please note: Prescription drug benefits vary by group. Therefore, a drug on this formulary does not imply coverage. Drug coverage is based on medical necessity. This formulary guide was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your provider or pharmacist.

What is a formulary? A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications. To create the list, FutureScripts is guided by the Pharmacy and Therapeutics Committee. This group of doctors and pharmacists review which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

What are tiers? Tiers are the different cost levels you pay for a medication. Each drug on the formulary is in a tier.

Value Formulary Tier Structure The non-preferred tier will usually cost more than the preferred brand tier or generic tier. Below is a summary of tiers in the general order from lowest to highest level of cost-share. Benefits vary by group, so the inclusion of a drug in this formulary does not guarantee coverage. All cost-share tiers may not be available on all plans. - Low-Cost Generic (availability varies by benefit) - Generic - Preferred Brand - Non-preferred Drug - Specialty (availability varies by benefit) - Non-Formulary

The non-preferred tier on the formulary is generally associated with higher cost-sharing (i.e., at the higher cost to you) than the preferred brand tier or generic tier. Non-formulary drugs are covered when a formulary exception is obtained through the prior authorization process. Please refer to the Procedures that Support Safe Prescribing in the front of the formulary list for details. Non-formulary drugs are covered when a formulary exception approval has been obtained for which the member will pay the highest, non-specialty level of cost-sharing.

1 (continued) • Generally, if a brand-name drug has a generic equivalent, the brand-name drug is non-formulary while the generic equivalent is covered at the generic level of cost-sharing. For example: Cipro® is the brand drug and is considered non-formulary; its generic equivalent ciprofloxacin is available at the generic level of cost-sharing. •  Some brand-name drugs without generic equivalents, authorized generic (also referred to as authorized brand alternative) drugs and generic drugs are also considered non-preferred or non-formulary. This is because there are other more cost-effective alternatives covered on the formulary to treat the same condition. Covered generic drugs not listed in the formulary guide are available at the generic level of cost-sharing; brand drugs not listed in the formulary guide are non-formulary.

The Low-Cost Generic [LCG] Tier offers copays lower than the cost-share for the generic tier, when possible. This applies to certain generic drugs that are typically used to treat chronic conditions such as high blood pressure, high cholesterol, diabetes, heart failure, and depression. Benefits may vary. Not all plans provide this incentive. The drug list is subject to change. When this incentive is not available on a plan, these drugs will be covered at the generic cost-share level.

Specialty Drugs [SP] meet certain criteria, including, but not limited to drugs used to treat rare, complex, or chronic diseases, drugs that have complex storage and/or shipping requirements, and drugs that require comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may be managed by the FutureScripts® Specialty Pharmacy Program. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing. For cost-sharing purposes, drugs on the specialty tier are not eligible for tier lowering.

Authorized Generics [AG] are brand-name drugs that are marketed without the brand name on its label. An authorized generic may be marketed by the brand-name drug company, or another company with the brand company’s permission. These drugs are approved by the FDA. But they are not approved through the abbreviated new drug application (ANDA) process like a standard generic drug. For cost sharing purposes, authorized generics are treated as brand-name drugs and are not eligible for coverage on the generic tier(s). Another name for AGs is Authorized Brand Alternative [ABA]. For example: oxycodone ER tablet, an authorized generic of brand OxyContin®, is listed as non-preferred and is available at the non-preferred level of cost-sharing.

What are Affordable Care Act (ACA) Preventive Medications? Certain preventive medications, as described in the Patient Protection and Affordable Care Act and detailed by the U.S. Preventive Services Task Force, are covered without cost-sharing with a prescription when provided by a participating retail or mail-order pharmacy. The following categories of drugs may be available at no member cost-share with a prescription. Please note that individual benefits may vary. Always refer to your benefits to determine your coverage. This list is subject to change. Refer to the searchable drug lookup tool on your health insurance plan’s website to check the status of a specific drug.

2 (continued) Category Product(s) Available at $0 at the Pharmacy Aspirin products (OTC) aspirin 81mg (tab/chewable) For adults age 50-59 to prevent cardiovascular disease and colorectal cancer; low dose (81mg) for women after 12 weeks’ gestation who are at high risk for preeclampsia Bowel Preparations generic bowel preparation products such as Bowel preparation for colonoscopy needed for Gavilyte-C™, Gavilyte-G™, Gavilyte-N™, preventive colon cancer screening, for ages 50-75 Gavilyte-H™ with bisacodyl, polyethylene glycol (PEG) 3350 oral powder, Trilyte® w/packets Breast cancer chemo prevention tamoxifen 20mg For asymptomatic females age 35 years and older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, who are at high risk for breast cancer and at low risk for adverse effects from breast cancer chemoprevention Contraceptives - Oral: generics such as Amethia, Cryselle-28, Includes, but not limited to, oral, injectable, Emoquette, Fayosim, Necon, Ocella, Sprintec, transdermal, diaphragms, cervical caps, intravaginal Trivora, Natazia devices, female condoms, and contraceptive film and - Injectable: all generics such as medroxyprogesterone jelly (in accordance with the women’s preventive injection services provisions of the ACA). - Transdermal: Xulane® patches Note: IUDs and implantable products are covered - Diaphragms under the medical benefit. - Cervical Caps - Female condoms - Contraceptive film - Contraceptive gel/jelly/foam: such as VCF® foam 12.5%, 28%, Options Conceptrol® 4%, Options Gynol® 3% - Emergency: all generics such as levonorgestrel 1.5mg tab, My Way® 1.5mg tab - Intravaginal devices: etonogestrel-ethinyl estradiol vaginal ring Fluoride sodium fluoride 1.1 (0.5f) mg/ml solution For children ages 6 months to 16 years. sodium fluoride 0.55 (0.25f) mg chewable tab Includes generics strengths up to 0.5mg Fluoritab 0.275 (0.125f) mg/drop solution Fluoritab 1.1 (0.5f) mg chewable tab Folic acid folic acid 400mcg tab For women planning for or capable of pregnancy. folic acid 800mcg tab Limited to 0.4 to 0.8mg of folic acid. folic acid 0.8mg capsule For women younger than 51 years of age (including generic prenatal vitamins with the above listed folic acid dose)

3 (continued) Category Product(s) Available at $0 at the Pharmacy Tobacco Cessation Medication Chantix® For adults ages 18+ years, who use tobacco products bupropion SR (generic Zyban®) tablet and want to quit nicotine polacrilex lozenge nicotine patch 24 hour transdermal Nicotrol® Inhaler Nicotrol® NS Solution Statins lovastatin 10mg Low-to-moderate dose statin for prevention of lovastatin 20mg cardiovascular disease, recommended for ages 40-75 lovastatin 40mg years without a history of CVD when 1 or more CVD risk factors are present (e.g., dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year risk of a cardiovascular event of 10% or greater HIV PrEP Emtricitabine-Tenofovir Disoproxil Fumarate Tab Preexposure prophylaxis (PrEP) with effective anti- 200-300mg retroviral therapy for persons who are at high risk of Tenofovir 300mg HIV acquisition

4 (continued) PROCEDURES THAT SUPPORT SAFE PRESCRIBING

AmeriHealth New Jersey utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and their providers. The effectiveness and safety of drugs and drug- prescribing patterns are monitored by FutureScripts®. Several procedures, such as prior authorization, age limits, and quantity limits, have been established to support safe prescribing patterns and to provide optimal clinical outcomes for members. What is prior authorization? Prior authorization is a requirement that your provider obtain approval from your health plan for coverage of, or payment for, prescription drugs. AmeriHealth New Jersey requires prior authorization of certain covered drugs to confirm that the drug prescribed is medically necessary, clinically appropriate, and is being prescribed according to FDA approved labeled or medically accepted use. The approval criteria were developed and approved by the Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s provider, and the member’s available prescription drug therapy history. The clinical pharmacists’ evaluation may include a review of potential drug-drug interactions or contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies, if necessary. Please note, coverage of certain drugs on the formulary (e.g., weight loss drugs) requires a benefit rider. Please contact the health insurance plan for member eligibility information and benefit details. Prior Authorization Requirements for Selected Drugs Prior Authorization Requirements for Selected Drugs are in place for certain medications. This expedites the review process by using information available in the member’s pharmacy benefit claim history to determine coverage for the requested medication at the pharmacy. For example, Tirosint® is a medication that requires previous trial of generic levothyroxine. With the Prior Authorization Requirements for Selected Drugs, a member will be able to immediately receive coverage for Tirosint® if the claim history shows a previous paid claim for generic levothyroxine. A manual prior authorization request will not be needed. If the claim history does not show a previous use of either drug (e.g., if the prescriber provided a sample for the member to try) then a prior authorization request will be needed in accordance with the standard prior authorization process. Without prior authorization, the member’s prescription will not be covered at the retail or mail-order pharmacy. The prior authorization review process may take up to two business days once complete information from the provider has been received. Incomplete information may result in a delayed decision. Prior authorization approvals for some drugs may have a limited timeframe, for example six to twelve months. If the prior authorization approval for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the provider wants a member to continue the drug therapy as requested after the expiration date, a new prior authorization request will need to be submitted and approved for coverage to continue. Safety Edits Safety edits are applied to prescription medications to ensure safe and appropriate use of drugs. They are designed to align with the clinical practice guideline and FDA approved use outlined in the manufacturer package insert. Some of these safety edits will prompt member counseling at the point of sale, while some will require prior authorization review. Safety edits include age limits, quantity limits, morphine milligram equivalent (MME) limits, and concurrent drug utilization review (cDUR). Each safety edit is described below.

5 (continued) Age Limits Some drugs, such as zafirlukast, are approved by the FDA only for individuals age five and older. If the member’s prescription falls outside of the FDA guidelines, it may not be covered unless prior authorization is obtained. In addition, an age limit may be applied when certain drugs are more likely to be used in certain age groups. For example, drugs to treat Alzheimer’s disease may require prior authorization for use in young adults. The provider may request coverage for drugs outside of the age limit when medically necessary. The approval criteria for this review were developed and approved by the Pharmacy and Therapeutics Committee. The member should contact the provider to initiate the prior authorization process. Quantity Limits Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses, standard dosing, and/or length of therapy of a drug. AmeriHealth New Jersey has several different types of quantity limits that are explained in detail below. The purpose of these limits is to ensure safe and appropriate utilization. If a member requires more than the limit, the member’s provider will need to submit a prior authorization request. Similar to other prior authorization requests, quantity limit override requests for certain drugs may have a limited approval timeframe. • Quantity Over Time: This quantity limit is based on dosing guidelines over a rolling time period. For example, if a drug has a quantity limit over a 30-day time period and a member went to the pharmacy on January 1, 2021, for one of these medications, the plan would have looked back 30 days to December 2, 2020, to see how much medication was dispensed. The purpose of these limits is to prevent the dispensing of excessive quantities. Examples of quantity limits over time are: ◦ Etonogestrel-ethinyl estradiol (Nuvaring®) = 1 ring per 28 days ◦ Ibandronate (Boniva®) 150mg = 1 tablet per 30 days ◦ Sumatriptan (Imitrex®) 50mg = 18 tablets per 30 days ◦ Diabetic supplies such as blood glucose test strips = 200 strips per 30 days ◦ Sildenafil (Viagra®), tadalafil (Cialis® 10mg, 20mg) = 8 tablets per 30 days • Maximum daily dose: This quantity limit defines the maximum number of units of the drug allowed per day. Examples of maximum daily dose quantity limits are: ◦ Zolpidem (Ambien®) = 1 tablet per day ◦ Oxycodone/acetaminophen (Percocet®) 5/325mg = 12 tablets per day ◦ Guanfacine Extended Release 24 Hour = 1 tablet per day • Refill too soon: This limit is in place to encourage appropriate utilization and minimize stockpiling of prescription medications. Based on this edit, a member can receive a refill of a prescription after 75% utilization. Additional refills will be covered once 75% of the supply has been consumed. The following examples illustrate how refill too soon limit works: ◦ A 30 days’ supply of a prescription filled on 1/1/2021 will be refillable again on or after 1/24/2021 ◦ A 90 days’ supply of a prescription filled on 7/1/2021 will be refillable again on or after 9/7/2021

6 (continued) • Day Supply Limit: This limit is based on the day supply and not the quantity. However, quantity limits may apply as well. Day Supply Limits apply to some classes of drugs, such as opioids. If a quantity limit applies, the member will also be limited to the maximum daily dose for that drug. The following are examples of drugs that have a day supply and a quantity limit: ◦ Short acting opioids, such as oxycodone/acetaminophen 5mg/325mg • Day supply limit = Two 5 days’ supplies limit per 60 days for adults, two 3 days’ supply limit for children under 18 years of age.

◦ Butalbital containing headache agents, such as butalbital/aspirin • Day supply limit = 5-day supply per 30 days • Quantity Limit = 6 tablets per 1 day • Maximum quantity allowed without prior authorization = 30 tablets (6 tablets per day for 5 days)

◦ Opioid containing cough and cold products, such as hydrocodone/homatropine • Day supply limit = Two 5-days’ supplies limit per 60 days for adults, and two 3 days’ supply limit for children under 18 years of age • Quantity Limit = 30 ml per 1 day • Maximum quantity allowed without prior authorization = 150 ml (30 ml per day for 5 days)

Morphine Milligram Equivalent (MME) Limit AmeriHealth New Jersey applies additional safety measures to opioid products by limiting the total daily dose. This limit accounts for various opioid products through a measurement called the Morphine Milligram Equivalent (MME) dose. The MME is a number that is used to determine and compare the potency of opioid medications. It helps to identify when additional caution is needed. The daily limit is calculated based on the number of opioid drugs, their potencies and the total daily usage. Prior authorization is required for an opioid dose that exceeds 90 MME per day. MME Limit applies to the opioid products containing the active ingredients listed below:  Active Ingredient codeine dihydrocodeine fentanyl hydrocodone hydromorphone levorphanol meperidine methadone morphine Opium oxycodone oxymorphone tapentadol Tramadol benzhydrocodone

Cumulative Stimulant Limit Central nervous system (CNS) stimulants such as amphetamine and methylphenidate, when used in high doses, are associated with increased risk for cardiac related adverse events such as hypertension and new or worsening psychosis including manic behavior. Cumulative stimulant limit is a safety measure designed to ensure the provider has assessed the members for alternative medication and advised the members about the risks associated with stimulant use. The cumulative stimulant limit works by calculating the total daily stimulant dose by the drug’s active ingredient. Stimulant claims that exceed the limit outlined below would require prior authorization.

7 (continued) Active ingredient Medications impacted High cumulative daily dose (brands and generics) Amphetamine Adzenys ER[ODT], Dyanavel, 60mg/day Evekeo [ODT] Amphetamine-Dextroamphetamine Adderall [IR/XR], Mydayis 60mg/day Dextroamphetamine Dexedrine, Zenzedi, ProCentra 60mg/day Lisdexamfetamine Vyvanse 70mg/day Methamphetamine Desoxyn 60mg/day Dexmethylphenidate Focalin [IR/XR] 40mg/day Methylphenidate Ritalin [IR/LA], Daytrana, 72mg/day Cotempla, Metadate [ER/CD], Methylin, Quillivant XR, Concerta, Aptensio XR, QuilliChew ER, Jornay PM, Adhansia XR *Prior authorization and other safety edits including quantity limit and age limit continue to apply.

Concurrent Drug Utilization Review (cDUR) These reviews are built into the pharmacy claim adjudication system to review a member’s prescription history for possible drug related problems including drug-drug interactions and drug therapy duplications. Drugs may reject at the Point-of-Sale (POS) and/or generate a message to the dispensing pharmacist when there is a safety concern. The dispensing pharmacist can review the issue with the provider and override the rejection if appropriate for most edits. Examples of cDURs are: • Drug-drug interaction: sildenafil (Viagra®/Revatio®) and nitroglycerin in combination may lead to potentially fatal hypotension. • Drug therapy duplication: Simvastatin and atorvastatin in combination will trigger a message in the claim adjudication system to alert the dispensing pharmacist there is a duplication of statin therapy. To determine if a covered prescription drug prescribed for you has a prior authorization requirement, an age limit, a quantity limit, or a morphine milligram equivalent (MME) limit, see the plan website at https://www. amerihealthnj.com/html/members/index.html or call FutureScripts® at the phone number on the back of your ID card.

96-Hour Temporary Supply Program The 96-Hour Temporary Supply Program is available for non-formulary medications and certain formulary medications that require prior authorization. Under the 96-Hour Temporary Supply Program, the dispensing pharmacist has the option to release a 96-hour supply as follows: 1. The dispensing pharmacist may place an override to release a 96-hour supply of the drug to the member with either no out-of-pocket co-pay or the appropriate percentage cost-sharing as defined by the member’s benefit. 2. The next business day, FutureScripts®, will contact the member’s provider to request submit documentation of medical necessity or medical appropriateness for review. 3. Once the completed medical documentation is received by FutureScripts®, the review will be completed, and the request will either be approved or denied. 4. If approved, the remainder of the prescription may be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied. 5. If denied, notification will be sent to both the provider and the member. 8 (continued) Obtaining a 96-hour temporary supply does not guarantee that the prior authorization request will be approved. This program limits a one-time release of 96-hour supply per drug. Some drugs are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations. How to submit a Prior Authorization? Here is the process to request a prior authorization/preapproval or override: 1. The provider prescribing the drug can access electronic prior authorization (ePA) platforms such as CoverMyMeds® and SureScripts™ to submit a prior authorization request. Alternatively, the provider can complete a prior authorization fax form or write a letter of medical necessity and submit it to FutureScripts® by fax at 1-888-671-5285. The forms are available online at: https://www.futurescripts. com/prior-authorization1.html. 2. FutureScripts® will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on established criteria, a medical director will review the document. 3. A decision is made regarding the request. • If approved, the provider will be notified of the approval via fax and/or telephone, and the pharmacy claim adjudication system will be coded with the approval. Note: ePA approval can occur in real time, this means the member can be approved for the drug prior to leaving the provider’s office with a prescription. The member may call the Customer Service phone number on his or her ID card to determine if the request is approved. • If denied, the prescribing provider will be notified via letter, fax, or telephone. The member is also notified via letter. The appeals process is detailed within the denial letters sent to the member and provider. Formulary Exception Requests Non-formulary drugs: Providers may request consideration for coverage of a non-formulary medication when there has been a trial of, or contraindication to, at least three formulary alternatives when applicable. Tier exceptions: Providers may request consideration for preferred coverage of a non-preferred drug when there has been a trial of, or contraindication to, at least three formulary alternatives when applicable. • Requests for a generic medication that is located on the non-preferred drug tier to be lowered to the generic tier will be approved if the exception criteria are met. • Requests for a brand medication or an authorized generic (also referred to as authorized brand alternative) non-preferred that is located on the non-preferred drug tier to be lowered to the preferred brand tier will be approved if the exception criteria are met. Please note, restrictions apply to formulary exception requests. Drugs on the generic tier, the preferred brand tier and the specialty tier are not eligible for tier exceptions. Tier exceptions are not available under some plans; please refer to the member benefit booklet for details. When requesting an exception, the provider should complete the formulary exception request form, providing detail to support the request, and fax the request to 1-888-671-5285. If the formulary exception request is approved for a non-preferred drug, the drug will pay at the appropriate preferred brand or generic level of cost-sharing. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. The forms are available online at: https://www.futurescripts.com/prior-authorization1.html.

9 (continued) Appealing a decision If a request for prior authorization or exception results in a denial, the member, or the provider on the member’s behalf (with the member’s consent), may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. To assist in the appeals process, it is recommended that the provider be involved to provide any additional information on the basis of the appeal.

10 Prior authorization applies to all formulations of the following specific drugs, including but not limited to, tablet, capsule, and oral suspensions.* abiraterone Breeze2 test strips/ diclofenac gel 3% Follistim® AQ Actemra® SC glucometer diethylpropion HCL Fortamet® Actimmune® Briviact® dihydroergotamine Freestyle test strips/ adapalene pad BromSite® Dojolvi™ glucometer Addyi® Brukinsa™ doxepin tablet Fulyzaq™ Adempas® buprenorphine patch doxycycline hyclate tab Gattex® Admelog® Bynfezia Pen™ 50mg Gavreto™ Advate® Byvalson™ doxylamine-pyridoxine Gilotrif™ Adynovate® Cabometyx™ Duexis® Gleevec® Afstyla® Calquence® Dupixent® Glucagen® Hypokit® Ajovy® Caprelsa® Duzallo® Glumetza® ER Albuterol HFA (AG for Carac® Ecoza™ Gralise™ Ventolin) Carbaglu® Edarbi™ Grastek® Alecensa® Carbatrol® Edex® Haegarda® Alphanate® Caverject® Edluar™ Harvoni™ Alphanine® SD Cayston™ Elmiron® Helixate® FS Alprolix™ Cerdelga™ Eloctate™ Hemlibra® Soln Altabax™ chlorzoxazone 250mg Emflaza™ Hemofil® M Alunbrig™ Cholbam® Emgality® Hetlioz™ amphetamine Ciclodan® Enbrel® Horizant™ (generic Evekeo) Cimzia® Endari™ Humalog® Apidra® Cinryze® Enspryng™ Humate-P® Apidra® SoloSTAR® clindamycin/benzoyl Epclusa® Humatrope® Apokyn® peroxide 1%/5% Erivedge™ Humira® Aptiom® clobazam Erleada® Hycamtin® ® armodafinil Cloderm erlotinib hydrocodone ER aspirin-omeprazole DR clovique Ertaczo® hydromorphone ER ® Austedo™ Coagadex Esbriet® Hysingla™ Auvi-Q® 0.1mg Cometriq™ esomeprazole Ibrance® ® Ayvakit™ Consensi esomeprazole granules icatibant inj azelastine/fluticasone Contour Glucometer Esperoct® Iclusig™ spray Contour Next Test Strips eszopiclone 3mg Idhifa® Azeschew® Contour Test Strips Eucrisa™ ® imatinib mesylate Azesco® Contrave ER everolimus (generic for Imbruvica™ ® Banzel® Tab Corifact Afinitor) Imcivree™ ® Bebulin® Corlanor Evrysdi™ Increlex® Belbuca™ Cosentyx™ Exelderm® indomethacin 20mg Belviq® [XR] Cotellic™ Eysuvis™ Ingrezza™ ® BeneFIX® Cresemba Factive® Inlyta® ® Benlysta® Cutivate Fanapt™ Inqovi® Benzamycinpak® cyclobenzaprine ER Farydak® Inrebic® ® benzphetamine Cystadrops Fasenra® insulin lispro Berinert® Cystaran™ febuxostat insulin lispro inj junior Bevespi Aerosphere™ Daklinza™ dapsone gel Feiba® insulin lispro inj protamin bexarotene 7.5% Femring® Intrarosa® ® Daytrana™ ® Bonjesta fentanyl citrate-OTFC Invokamet [XR] bosentan deferasirox tab/granules fentanyl transdermal Invokana® Bosulif® deferiprone Fetzima™ Iressa® Brand prenatal vitamins1 dexchlorpheniramine soln ® Isturisa® ® Fioricet with Codeine Bravelle® D.H.E. 45 Fiorinal® with Codeine Ixinity® 2 Diabetic test strips Flector® patch Jakafi™ 11 (continued) Jublia® Nayzilam® oxymorphone ER Rytary™ Juxtapid™ Nerlynx™ Palforzia™ cap/powder sapropterin pow/tab Jynarque® Nestabs® One pantoprazole pak Saxenda® Kalydeco™ Nexavar® Pemazyre™ Sernivo™ ketoprofen cap Nexletol™ penicillamine capsule Serostim® Keveyis™ Nexlizet™ Percocet® Sevenfact® Kevzara® Ninlaro® phendimetrazine tartrate Signifor® ® Kineret® nitisinone Picato sildenafil ® Kisqali™ Non Preferred Diabetic Piqray Siliq™ ® Koate®-DVI Meters Pomalyst Simponi™ ® Kogenate® FS Norditropin® Praluent Sirturo™ Korlym™ Northera™ Precision Glucometer Skyrizi™ Koselugo™ Nourianz™ Precision XTRA Test sofosbuvir-velpatasvir ® Novoeight® Strips Somavert® Kuvan ® ® Novoseven® RT Pregenna Sovaldi™ Kynamro ® Noxafil® Prenara Sprycel® Kynmobi™ ® Nubeqa™ Pretomanid Stelara® lansoprazole solutab ® lapatinib Nucala® Soln Prilosec Stivarga® ® ® ® Proctocort Supp 30mg Strensiq™ Latuda Nucynta ER ® Procysbi Striant® ledipasvir-sofosbuvir Nuedexta™ ® Lenvima™ Profilnine Sucraid® Nuplazid™ ® Levemir® Nurtec™ Promacta sumatriptan/naproxen levothyroxine cap ® Qinlock™ Sunosi™ Nutropin (AQ) ® Livalo® ® Qsymia ER Sutent® Nuwiq ® Lomaira™ Obizur Qudexy XR Sylatron™ Lonhala™ Magnair™ Ocaliva™ QuilliChew ER™ Symlin® ® Quillivant XR™ Lonsurf Odactra® SL Sympazan™ Film ® quinine sulfate Luzu Odomzo® Tabrecta™ rabeprazole Lynparza™ Ofev® tadalafil (generic Adcirca) ® Ragwitek™ ® Mavenclad Pak Olumiant® Tafinlar Rasuvo™ Mavyret™ omeprazole-sodium Tagrisso™ ® Ravicti™ ® Mekinist bicarbonate Taltz Autoinjector ® ® ® meloxicam cap ® Rebif Rebidose Targretin Gel Omnaris ® ® Rebinyn ® Menopur Ongentys® Tasigna Recombinate™ Metformin ER(MOD) Onureg® tavaborole RediTrex® methadone Onzetra Xsail™ Tazverik™ Regranex® Methitest™ Opsumit® Technivie™ ReliOn® ® methyltestosterone Oralair® Tegretol [XR] Repatha™ ® miglustat Orencia® SQ Tekturna (HCT) Retevmo™ modafinil Orenitram™ temozolomide Retin-A® (Micro) ® mometasone furoate Orfadin® Teriparatide inj ® Revlimid® Monoclate-P Orgovyx™ testosterone enanthate ® Rexulti® Monodox Oriahnn® testosterone topical ® Riastap® Thalomid® Mononine morphine ER Orkambi™ Rinvoq™ Thiola® Motegrity™ orphenadrine-asa caffeine ® Rixubis™ ® Muse Otezla™ Tirosint Rozlytrek™ Myalept™ Otrexup™ tolvaptan ® Rubraca® Mycapssa Oxaydo® topiramate ER sprinkle Ruconest® Toviaz™ Mytesi™ Oxbryta™ naproxen-esomeprazole rufinamide sus Tremfya™ oxiconazole nitrate ® ® DR Oxtellar® XR Rukobia Tresiba ® ® Nascobal oxycodone ER Ruzurgi tretinoin caps ® ® ® Natpara Oxycontin® Rydapt Tretten

12 (continued) triamcinolone 0.05% Vanos® Cream Vyndamax® Yosprala® DR ointment vardenafil [ODT] Vyndaqel® Yupelri™ Trianex® Vascepa® Wakix® Zalvit® trientine Vecamyl™ Wilate® Zegerid® Trikafta™ Venclexta® Xalkori® Zejula™ Trinaz® Ventavis® Xeljanz® [XR] Zelboraf® Trintellix® Verdeso® Xenazine™ Zembrace Symtouch™ Trokendi®XR Verzenio™ Xenical® Zepatier™ Tukysa™ Viberzi™ Xermelo™ Zerviate™ Turalio™ Viekira Pak™ Xhance™ MIS 93mcg Zetonna™ Tymlos™ vigabatrin pack/tab Xifaxan® zileuton ER tab Tyvaso® vigadrone pack Xiidra™ Zolinza® Ubrelvy™ Viibryd® Xpovio™ Pak Zolpidem 10mg Uloric® Vimovo® Xtampza® XR Zolpidem ER 12.5mg Upneeq® Voltaren XR® Xtandi® Zolpidem SL 3.5mg Uptravi® Vonvendi Xultophy® Zurampic® Utibron™ Neohaler Vosevi™ Xuriden™ Zydelig® Valchlor™ Votrient™ Xyntha® Zykadia™ Valtoco® Vusion® Xyrem® Vanadom® Vyleesi™ Xywav™

1 All brand prenatal vitamins require prior authorization. 2 All diabetic test strips require prior authorization except for OneTouch®. * Compound products with total cost equal to or greater than $75 per prescription.

13 Reading the formulary drug list How can I tell if a drug is generic or brand? The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications start with an uppercase letter and are written in bold. Generic medications are shown in lowercase and in italic.

Brand name Drug Starts with UPPERCASE in Bold Ex: Augmentin Generic drug Lowercase italic Ex: avidoxy

Tier information Tiers are the different cost levels you pay for a medication. Each drug on the formulary is in a tier. Below is a reference guide to use as you review your formulary to see the abbreviation for each drug tier on the formulary list. Drug Tier Abbreviation Generic G Non-preferred Drug NPD Specialty Drug SP Low-cost Generic LCG Preferred Brand PB Non-Formulary NF $0 Preventive Drug ACA

Drug list requirements and/or limits Some medications are noted with letters next to them to help you see which drugs may have coverage requirements and/or limits. Below is a reference guide to use as you review your formulary to see the abbreviation for each requirement/limit on the formulary list.

Requirements/Limits Abbreviation Prior Authorization PA Quantity Limits Apply QL Age Limit AL Limited Distribution Drug LDD Day Supply Limit 5DS Requires Rider R Quantity Over time Q/T Morphine Milligram Equivalent MME PA for Selected NPD +

14 DRUG REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG NAME DRUG TIER LIMITS TIER LIMITS ANTIBIOTICS & OTHER DRUGS USED FOR azithromycin G INFECTION Bactrim, NF Bactrim DS abacavir sulfate G tab, soln Baraclude NF, SP abacavir sulfate/ Baxdela NF QL lamivudine G Benznidazole NPD abacavir/ lamivudine/ G Bethkis NF, SP zidovudine Biaxin NF Acticlate NF AL Biktarvy NPD acyclovir G Biltricide NF acyclovir cream G QL cefaclor G 5% cefaclor ER G adefovir dipivoxil G, SP cefadroxil G Aemcolo DR NPD QL cefdinir G albendazole G cefixime susp/cap G Albenza NF ceftibuten G Alinia NF Ceftin NF Altabax NPD PA cefuroxime axetil G Amoxicillin 775mg PB cephalexin G amoxicillin G chlorhexidine G amoxicillin/ G gluconate soln clavulanate chloroquine amoxicillin/ phosphate G clavulanate G Cimduo NPD extended-release Cipro NF ampicillin G Cipro XR NF Amzeeq NF ciprofloxacin ER Ancobon NF tabs G Arakoda NPD ciprofloxacin LCG Arikayce Susp NPD, SP PA clarithromycin G atazanavir G clarithromycin ER G atovaquone G Cleocin NF atovaquone/ G clotrimazole proguanil troches G Atripla NF Combivir NF Augmentin NF Complera PB Augmentin XR NF Cresemba NPD PA, QL Avelox NF Crixivan PB avidoxy G Daklinza NPD, SP PA, Q/T, QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 15 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS dapsone tablet G efavirenz- Daraprim Tab NF, SP emtricitab- G tenofovir tab Daxbia NPD efavirenz- Delstrigo NPD lamivudine- G demeclocycline G tenofovir tab dicloxacillin G Egaten 250mg tablet NPD didanosine G emtricitabine cap G Dificid Tab/Susp NPD QL emtricitabine- Diflucan NF tenofovir Doryx 50mg NF disoproxil G, ACA QL tablet fumarate tab Doryx 200mg 200-300mg NF QL tablet Emtriva NF Dovato NPD Emverm NPD QL entecavir G, SP doxycycline DR NF 40mg Epclusa PB, SP PA, Q/T, QL doxycycline Epivir NF hyclate tab 75mg, NPD AL Epzicom NF 150mg EryPed doxycycline NF hyclate tab 50mg NPD PA 400mg/5ml Susp doxycycline Ery-Tab NF hyclate tab DR NPD Erythrocin NPD 50mg, 100mg erythromycin doxycycline delayed release G hyclate tab DR NPD QL, QT erythromycin 200mg ethylsuccinate G doxycycline NF erythromycin hyclate DR 80mg stearate G doxycycline ethambutol G monohydrate cap G 50mg, 100mg famciclovir G doxycycline Firvanq Soln NPD AL monohydrate cap NPD AL Flagyl NF 75mg, 150mg fluconazole doxycycline suspension/tabs G monohydrate tab NPD AL flucytosine G 150mg Flumadine NF Edurant PB fosamprenavir E.E.S. 400mg tab NF calcium tab G efavirenz G fosfomycin pow G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 16 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Fuzeon NPD linezolid G QL Gris-PEG NF lopinavir/ritonavir G griseofulvin Macrodantin NF G microsize Malarone NF griseofulvin G Mavyret PB, SP PA, Q/T, QL ultramicrosize mefloquine G Harvoni PB, SP PA, Q/T, QL Mepron NF Hepsera NF, SP methenamine G Hiprex NF hippurate hydroxy- metronidazole LCG G chloroquine Minocin NF Impavido NPD Q/T, QL minocycline caps G Invirase PB minocycline ER NF Q/T Isentress PB cap isoniazid G minocycline ER tablet G Q/T itraconazole G Minolira NF Q/T ivermectin G moderiba G, SP Juluca NPD Mondoxyne NL Kaletra Soln NF NPD AL 75mg cap Kaletra Tabs PB Monurol Pak NF Kalydeco Tabs/ Granules Pack NPD, SP PA, LDD Moxatag NPD Keflex NF moxifloxacin hcl G ketoconazole tabs G Myambutol NF Krintafel NPD Mycobutin NF Lamisil Tabs NF Mytesi + NPD PA lamivudine 150mg, 300mg G Nebupent INH NF tablets nevirapine G lamivudine 100mg nevirapine ER G tab G, SP nitazoxanide G lamivudine/ zidovudine G nitrofurantoin macrocrystals G Lampit NPD nitrofurantoin ledipasvir- susp G AL sofosbuvir tablet NPD, SP PA, QL 90-400mg Norvir powder PB Levaquin NF Norvir tablet NF levofloxacin LCG Noxafil NF QL Lexiva NF Nuzyra NPD QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 17 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Onmel NF Sklice Lot 0.5% NF Oracea NF sofosbuvir- Orkambi tablet/ velpatasvir tablet NPD, SP PA, QL packet NPD, SP PA, LDD 400-100mg Solodyn NF QL, Q/T oseltamivir caps/ G QL susp Solosec GRA NF Pegasys NPD, SP Sovaldi NPD, SP PA, QL, Q/T PegIntron NPD, SP Sporanox NF penicillin v LCG SSKI Solution NPD potassium tablet stavudine G pentamidine INH G Stribild PB Pifeltro NPD Stromectol NF Plaquenil NF QL sulfamethox- LCG posaconazole G QL azole/tmp praziquantel G Suprax Susp Pretomanid NPD PA 100mg/5ml, NF 200mg/5ml Prevymis NPD, SP Sustiva NF Prezista PB Symfi NF pyrimethamin G, SP Symfi Lo NF Qualaquin NF Symtuza NPD quinine sulfate G PA Talicia NPD Relenza NPD QL, AL Tamiflu NF QL Retrovir NF Targadox NF Reyataz NF Technivie NPD, SP PA, Q/T, QL Ribasphere Ribapak Temixys NPD G, SP 200mg & 400mg/ tenofovir G 400mg & 600mg terbinafine tabs G rifabutin G Tindamax NF Rifadin NF tinidazole G rifampin G Tivicay PD NPD rimantadine G Tobi NF, SP ritonavir G tobramycin G, SP Rukobia NPD PA nebulization soln Selzentry PB Tolsura NF Seysara NF Q/T Trikafta NPD, SP PA Sirturo NPD PA Triumeq PB Sitavig NPD QL Trizivir NF Sivextro NF Truvada NF QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 18 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS valacyclovir tab G Alkeran NF, SP Valcyte NF Alunbrig tab/pak NPD, SP PA valganciclovir G anastrazole G Valtrex NF Arimidex NF vancomycin G Aromasin NF Vemlidy NPD, SP Ayvakit NPD, SP PA, QL Vfend NF azathioprine G Vibramycin NF Balversa NPD, SP PA Videx EC NF Benlysta NPD, SP PA Viekira Pak NPD, SP PA, QL, Q/T bexarotene G, SP PA Viekira XR NPD, SP PA, QL, Q/T bicalutamide G Viramune NF Bosulif NPD, SP PA suspension Braftovi NPD, SP PA Viramune tablet NF Brukinsa NPD, SP PA Viramune XR NF Cabometyx NPD, SP PA Viread NF Calquence NPD, SP PA voriconazole G capecitabine G, SP Vosevi PB, SP PA, Q/T, QL Caprelsa NPD, SP PA Xenleta NPD QL Casodex NF Xepi Cream NF Cellcept NF 0.1% Cometriq NPD, SP PA Xifaxan 200mg NPD QL Copiktra NPD, SP PA Xifaxan 550mg NPD PA, Q/T, QL Cotellic NPD, SP PA, LDD Ximino ER NF Q/T cyclophos- Xofluza G, SP NPD Q/T phamide Therapy Pack cyclosporine G Zepatier NPD, SP PA, Q/T, QL Cytoxan NPD, SP Zerit NF danazol G Ziagen NF Danocrine NPD zidovudine LCG Daurismo NPD, SP PA Zithromax NF Deltasone NPD Zmax NF Emcyt NPD Zyvox NF QL Erivedge NPD, SP PA CANCER & ORGAN TRANSPLANT DRUGS Erleada NPD, SP PA erlotinib G, SP PA abiraterone G, SP PA etoposide G, SP Afinitor NF, SP Eulexin NPD Alecensa NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 19 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS everolimus Lorbrena NPD, SP PA (generic for G, SP PA Lynparza PB, SP PA Afinitor) Lysodren NPD everolimus (generic for G Matulane PB, SP Zortress) Mavenclad pak + NPD, SP PA exemestane G Megace NF Fareston NF megestrol acetate G Farydak NPD, SP PA, LDD Mekinist NPD, SP PA Femara NF Mektovi NPD, SP PA flutamide G melphalan G, SP Gavreto NPD, SP PA mercaptopurine G Gilotrif NPD, SP PA Mesnex NPD, SP Gleevec NF, SP methotrexate tab G Gleostine NPD, SP mycophenolate G Hexalen NPD mycophenolic acid G Hycamtin NPD, SP PA Myfortic NF Hydrea NF Myleran NPD hydroxyurea G Neoral NPD Ibrance NPD, SP PA, LDD Nerlynx NPD, SP PA Iclusig NPD, SP PA Nexavar NPD, SP PA Idhifa NPD, SP PA Nilandron NF, SP imatinib mesylate G, SP PA nilutamide G, SP Imbruvica NPD, SP PA Ninlaro NPD, SP PA Imuran NF Nubeqa NPD, SP PA Inlyta NPD, SP PA Odomzo NPD, SP PA Inqovi tab NPD, SP PA Onureg NPD, SP PA Inrebic NPD, SP PA Orgovyx tab NPD, SP PA Iressa tab NPD, SP PA Ortikos ER Cap NF Kisqali NPD, SP PA, LDD Pemazyre NPD, SP PA Koselugo NPD, SP PA Piqray NPD, SP PA lapatinib G, SP PA Pomalyst NPD, SP PA Lenvima NPD, SP PA, LDD prednisone LCG letrozole G prednisone leucovorin therapy pack/ G calcium G solution/ concentrate Leukeran PB Prograf capsule/ leuprolide G, SP packet NPD Lonsurf NPD, SP PA Protopic NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 20 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Purixan NPD, SP Verzenio NPD, SP PA Qinlock tab NPD, SP PA Vitrakvi NPD, SP PA Rapamune Vizimpro NPD, SP PA NF tab/sol Votrient NPD, SP PA RediTrex Inj NPD PA Xalkori NPD, SP PA Retevmo cap NPD, SP PA Xatmep NPD AL Revlimid NPD, SP PA Xeloda NF, SP Rozlytrek NPD, SP PA Xospata NPD, SP PA Rubraca PB, SP PA Xtandi NPD, SP PA, LDD Rydapt NPD, SP PA Yonsa NPD, SP PA Sandimmune NF Zejula PB, SP PA, LDD sirolimus tab/soln G Zelboraf NPD, SP PA, LDD Sprycel NPD, SP PA Zolinza NPD, SP PA, LDD Stivarga NPD, SP PA Zortress NF Sutent NPD, SP PA Xpovio Pak NPD, SP PA Tabloid NPD Zydelig NPD, SP PA, LDD Tabrecta tab NPD, SP PA Zykadia NPD, SP PA, LDD tacrolimus G Zytiga NF, SP LDD Tafinlar NPD, SP PA PAIN, NERVOUS SYSTEM, & PSYCH Tagrisso NPD, SP PA Talzenna NPD, SP PA Abilify NF tamoxifen G Abilify Mycite NF Tarceva NF, SP Abstral NF QL, MME Targretin cap NF, SP acamprosate DR tab G Tasigna NPD, SP PA acetaminophen QL, 5DS, AL, Tazverik 200mg NPD, SP PA LCG w/codeine MME Temodar NF, SP Actiq NF QL, MME temozolomide G, SP PA Adderall NF QL Thalomid NPD, SP PA Adderall XR NF QL Tibsovo NPD, SP PA Adhansia XR NF QL toremifene G Capsule tretinoin caps G, SP PA Adipex-P NF R Trexall tab NPD Adzenys ER susp NF QL Tukysa NPD, SP PA Adzenys XR- NF QL Turalio NPD, SP PA ODT Tykerb NF, SP Aimovig PB PA Valchlor NPD, SP PA Ajovy PB PA Venclexta NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 21 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Allzital 25- NF QL, 5DS asenapine sub G 325mg Ativan NF AL almotriptan atomoxetine G QL maleate G QL, AL Aubagio NPD, SP alprazolam LCG AL Austedo NPD, SP PA alprazolam ER G AL Avonex PB, SP QL amantadine G Axert NF QL, AL Ambien NF QL Azilect NF Ambien CR NF QL Banzel Susp NF AL Amerge NF QL, AL Banzel Tab NPD PA amitriptyline G Belbuca PB PA, QL, MME amoxapine G Belsomra NF QL amphetamine aspartate/ Belviq [XR] NPD PA, R amphetamine G QL benzhydro- PA, QL, 5DS, sulfate/dextro- codone-aceta- NPD amphetamine minophen + MME amphetamine benzphetamine LCG R aspartate/ benztropine G amphetamine G QL sulfate/dextro- Betaseron PB, SP QL amphetamine ER Brisdelle cap NF QL amphetamine ER Briviact NF QL NPD PA, AL suspension suspension amphetamine Briviact tablet NPD PA tablet (generic G PA, QL bromocriptine NF Evekeo) mesylate Anafranil NF Bunavail NF QL Antabuse NF buprenorphine G QL PA, QL, 5DS, hcl/naloxone hcl Apadaz + NPD buprenorphine MME G PA, QL, MME Aplenzin NF patch Apokyn Solution buprenorphine SL G QL Cartridge NPD, SP PA bupropion G 30MG/3ML bupropion ER G QL Aptensio XR NF QL 150mg bupropion ER Aptiom NPD PA NF Aricept [ODT] NF AL 450mg aripiprazole G bupropion SR G armodafinil G PA bupropion XL G Arymo ER NF QL, MME buspirone G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 22 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS butalbital- citalopram LCG acetaminophen NF QL, 5DS clobazam G PA 25-325mg clobazam susp G PA, AL butalbital- clomipramine HCl G acetaminophen NF QL, 5DS 25-300mg clonazepam G clorazepate butalbital/apap/ G AL caffeine G QL, 5DS dipotassium clozapine G butalbital/apap/ G QL, 5DS, AL, caffeine/codeine MME clozapine ODT G QL, 5DS, AL butalbital/aspirin/ QL, 5DS, AL, Clozaril NF caffeine/codeine G MME QL, 5DS, AL, butorphanol QL, 5DS, AL, codeine tabs G MME tartrate nasal G MME coditussin AC G QL, AL, 5DS, Butrans NF QL, MME liquid MME Cafergot NF Comtan NF Caplyta NF Concerta NF QL carbamazepine G Consensi NPD PA carbamazepine Contrave ER NPD PA, R susp G AL Conzip NF QL, AL, MME carbamazepine XR G Copaxone NF, SP QL Carbatrol NPD PA Cotempla XR- NF QL carbidopa G ODT carbidopa/ G Cymbalta NF levodopa Dantrium NF carbidopa/ levodopa ER G dantrolene G Daypro NF carbidopa/ G levodopa ODT Daytrana + NPD PA, QL carbidopa/ Dayvigo NF QL levodopa/ G Demerol NF QL, 5DS, MME entacapone Depakene NF carisoprodol- QL, 5DS, AL, aspirin-codeine G MME Depakote NF Celexa NF Depakote ER NF Depakote Celontin PB NF Chantix ACA QL Sprinkle Caps desipramine G chlordia- zepoxide G AL Desoxyn NF QL Desvenlafaxine chlorpromazine PB G ER 24HR HCl

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 23 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

desvenlafaxine G divalproex sodium G succinate ER divalproex sodium G PA, QL Dexedrine caps NF QL ER dexmethyl- divalproex G QL G phenidate ER sprinkle cap dexmethyl- Dolophine NF QL, MME phenidate hcl G QL donepezil dextroam- LCG AL phetamine G QL hydrochloride dextroam- Doral NF AL phetamine ER G QL doxepin capsule G D.H.E.45 NF doxepin tablet G PA Diacomit NPD, SP PA Drizalma NF Diastat NPD Sprinkle diazepam solution G duloxetine G diazepam tabs LCG Duragesic patch NF QL, MME Diclofenac cap Dyanavel XR NF QL NF 35mg Edluar SL tab NPD PA, QL Effexor XR NF diclofenac G potassium Eldepryl NF diclofenac sodium G eletriptan G QL, AL diclofenac sodium Embeda NF QL, MME gel 1% G Emgality PB PA, QL diethylpropion HCL G R, PA endocet G QL, 5DS, MME diflunisal G entacapone G QL, 5DS, AL, Epidiolex Soln NPD PA dihydrocodeine/ G APAP/caff MME ergotamine G tartrate/caffeine dihydrocodeine/ G QL, 5DS, AL, aspirin/caffeine MME escitalopram LCG dihydroergo- Esgic capsule G QL, 5DS tamine inj G PA Esgic tablet NF QL, 5DS dihydroergo- tamine mesylate G PA estazolam G QL, AL nasal spray eszopiclone G PA, QL (3mg only) Dilantin ethosuximide G PB chewable tablets etodolac G Dilaudid NF QL, MME, 5DS Evekeo [ODT] NF QL dimethyl fumarate G, SP Evzio NF QL DR cap Exalgo ER NF QL, MME disulfiram G Exelon NF AL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 24 REQUIREMENTS/REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUGDRUG DRUG NAME DRUG TIERTIER LIMITSLIMITS TIER LIMITS Extavia NF, SP QL galantamine G AL Fanapt + NPD PA galantamine ER G AL Fazaclo NPD Geodon NF felbamate G Gilenya NPD, SP Felbatol NF glatiramer acetate G, SP QL Feldene NF glatopa G, SP QL fenoprofen Gocovri NF calcium G guaifenesin- QL, AL, 5DS, fentanyl citrate G PA, QL, MME codeine soln LCG OTFC 10mg/5ml MME Fentanyl citrate NF QL, MME guanfacine ER G QL tablet Halcion + NF QL, AL Fentora NF QL, MME haloperidol G Fetzima + NPD PA Hetlioz NPD, SP PA, QL Fintepla sol NF Horizant NPD PA Fioricet NF QL, 5DS hydrocodone/ QL, 5DS, AL, Fioricet acetaminophen G MME NF QL, AL, 5DS, with codeine MME QL, 5DS, AL, hydrocodone- G Fiorinal homatropine MME NF QL, AL, 5DS, with codeine MME hydrocodone ER G PA, QL, MME fluoxetine G QL (Weekly Only) hydromorphone ER G PA, QL, MME fluoxetine 10mg, LCG hydromorphone IR G QL, 5DS, MME 20mg, 40mg Hysingla ER NPD PA, QL, MME fluoxetine soln G AL Ibudone QL, 5DS, MME, fluphenazine G NF AL flurazepam G QL, AL ibuprofen/ G QL, 5DS, MME, flurbiprofen G hydrocodone AL Imcivree fluvoxamine G NPD, SP PA 10mg/ml Inj fluvoxamine ER G imipramine G Focalin NF QL Imitrex NF AL, QL Focalin XR NF QL Inbrija NPD, SP PA ForFivo XL NF Indocin susp NPD AL Frova NF QL, AL Ingrezza NPD, SP PA frovatriptan NPD QL, AL succinate Intermezzo NF QL Fycompa NPD Intuniv NF QL gabapentin G Invega ER tablet NF gabapentin soln G AL isometheptene/ dichloral- G Gabitril NF phenazone/apap

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 25 REQUIREMENTS/REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUGDRUG DRUG NAME DRUG TIERTIER LIMITSLIMITS TIER LIMITS Jakafi NPD, SP PA, LDD Lyrica CR NF Jornay PM NF QL Lyrica soln NF AL Capsule maprotiline G Kadian ER NF QL, MME Maxalt, Maxalt- Kapvay NF QL MLT NF AL, QL Keppra NF Mayzent tablet, NPD, SP Keppra XR NF starter pak ketorolac G meclofenamate G Khedezla NF memantine G AL Klonopin NF memantine ER G AL Kynmobi Mis NPD, SP PA, QL meperidine HCl G QL, 5DS, MME Kynmobi Kit meprobamate G NPD, SP PA Titration Mestinon syrup NF AL Lamictal NF Mestinon tablet NF Lamictal ODT NF methadone G PA, QL, MME Lamictal XR NF methamphetamine NPD QL lamotrigine G methocarbamol G lamotrigine ER G Methylin NF QL lamotrigine ODT G methylphenidate G QL Latuda + NPD PA methylphenidate G QL Lazanda NF QL, MME ER levetiracetam G methylphenidate ER (CD) G QL levetiracetam ER G levorphanol G QL, 5DS, MME methylphenidate ER (LA) G QL Lexapro NF methylpenidate ER Librax NF (XR) NF QL lithium carbonate G Midrin NPD lithium carbonate Migranal NF ER G Mirapex NF Lodine NF Mirapex ER NF Lodosyn NF mirtazapine G Lomaira NPD PA, R modafinil G PA lorazepam LCG AL molindone hcl G lorazepam concentrate G AL MorphaBond ER NF QL, MME Lortab NF QL, 5DS, AL morphine IR G QL, 5DS, MME loxapine G morphine sulfate ER G PA, QL, MME Lunesta NF QL Lyrica NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 26 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

morphine G QL, 5DS, MME Onzetra Xsail NPD PA, QL, AL suppositories Opana NF QL, 5DS, MME MS Contin NF QL, MME Opana ER NF QL, MME Mydayis NF QL Orap NF Mysoline NF Osmolex ER NF nabumetone G oxaprozin G Nalfon NF Oxaydo PA, QL, 5DS, Nalocet NF QL, 5DS, MME NPD MME Naloxone NPD QL oxazepam G AL injection 2mg oxcarbazepine susp G AL naltrexone 50mg G oxcarbazepine tab G Namenda [XR] NF AL Oxtellar XR NPD PA Namzaric NF AL oxycodone ER naratriptan G QL, AL tablet NF QL, MME Narcan 4mg/ oxycodone IR G QL, 5DS, MME PB QL actuation spray oxycodone/ G QL, 5DS, MME Nardil NF acetaminophen Nayzilam NPD PA, QL oxycodone/ APAP 2.5-300mg, nefazodone G 5-300mg, NF QL, 5DS, MME Neurontin NF 10-300mg tab Neurontin soln NF AL oxycodone/aspirin G QL, 5DS, MME ninjacof-XG liquid G QL, AL, 5DS, MME oxycodone/ G QL, 5DS, MME Norpramin NF ibuprofen nortriptyline G OxyContin NF QL, MME nortriptyline soln G AL oxymorphone ER G PA, QL, MME Nourianz NPD PA oxymorphone IR G QL, 5DS, MME Nucynta NPD QL, 5DS, MME Ozobax Soln NF Nucynta ER NPD PA, QL, MME paliperidone ER tablet G Nuplazid NPD PA Pamelor NF Nurtec Chw ODT PB PA, QL, AL Parlodel NF Nuvigil NF Parnate NF olanzapine G paroxetine G olanzapine ODT G paroxetine ER G olanzapine/ fluoxetine hcl G Paxil CR NF Onfi NF Paxil suspension NPD Onfi susp NF AL Paxil tablet NF Ongentys NPD PA pentazocine- naloxone G QL, 5DS, MME

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 27 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Percocet NF QL, 5DS, MME ramelteon G QL perphenazine G rasagiline G Razadyne NF AL phendimetrazine G PA, R tartrate Razadyne ER NF AL phenelzine G Rebif Rebidose + NPD, SP PA, QL phenobarbital G Regimex NF R phentermine hcl G PA, R Relafen NF Phenytek NPD Relafen DS NF phenytoin G Relpax NF QL, AL pimozide G Remeron NF piroxicam G Remeron SolTab NF Plegridy PB, SP QL Requip NF pramipexole G Requip XL NF pramipexole ER G Restoril NF AL pregabalin G Rexulti NPD PA pregabalin soln G AL Reyvow NF QL, AL primidone G Rilutek NF Primlev NF QL, 5DS, MME riluzole G Pristiq NF Risperdal, NF Procentra 1mg/ml NF QL Risperdal M-Tab Prolate tab NF QL, 5DS, MME risperidone LCG promethegan supp G Ritalin LA NF QL Provigil NF rivastigmine G AL Prozac NF rizatriptan benzoate G QL, AL pyridostigmine G AL soln Robaxin NF pyridostigmine ropinirole G tab G ropinirole ER G Qdolo Sol NF QL, AL Roxicodone NF QL, 5DS, MME 5mg/ml Roxybond NPD QL, 5DS, MME Qmiiz ODT NF Rozerem NF QL Qsymia ER NPD PA, R rufinamide susp quazepam G AL 40mg/ml G PA, AL Qudexy XR NPD PA Rytary NPD PA quetiapine ER G Sabril tablet/ NF, SP quetiapine G packet fumarate Saphris NF Quillichew ER + NPD PA, QL Saxenda NPD PA, R Quillivant XR + NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 28 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Secuado Patch NF tolmetin sodium G selegiline HCl G Topamax NF Seroquel NF Topamax Seroquel XR NF Sprinkle NF Capsules sertraline LCG topiramate G Silenor NF topiramate silodosin G sprinkle cap G PA Sinemet NF Tosymra Nasal NF QL, AL Sinemet CR NF Solution Sonata NF QL tramadol LCG QL, AL, MME Sprix tramadol ER cap NF QL, AL, MME NF QL Nasal Spray tramadol ER G QL, AL, MME Stalevo NF (biphasic) tablet Strattera NF QL tramadol ER tablet G QL, AL, MME Suboxone NF QL Sublingual Film tramadol/ acetaminophen G QL, AL, MME Subsys NF QL, MME Tranxene T NF AL sulindac G tranycypromine sumatriptan G QL, AL sulfate G sumatriptan/ trazodone G naproxen G PA, QL Treximet NF QL, AL Sunosi PB PA Trezix NF Sylatron NPD, SP PA triazolam G QL, AL Symbyax NF trifluoperazine G Sympazan Film NPD PA trihexyphenidyl G Tasmar NF Trileptal Susp NF AL Tecfidera NF, SP LDD Trileptal Tab NF Tegretol susp NPD PA, AL trimipramine G Tegretol [XR] NPD PA Trintellix NPD PA temazepam G QL, AL Trokendi XR NPD PA tetrabenazine G, SP PA AL, QL, 5DS, trymine CG G thioridazine G liquid MME thiothixene G Tylenol NF QL, 5DS, AL, tiagabine hcl G w/Codeine MME Tiglutik Susp NPD, SP Ubrelvy PB PA, QL, AL Tivorbex NF Ultracet NF QL, AL, MME Tofranil NF Ultram NF QL, AL, MME tolcapone G Valium NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 29 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS

valproic acid G zolpidem tartrate G PA, QL Valtoco NPD PA, QL SL (3.5mg only) Vanatol S/LQ NPD PA, QL, 5DS Zolpimist NF QL venlafaxine G Zomig NF QL, AL venlafaxine ER G Zonegran NF vigabatrin G, SP PA zonsinamide G vigadrone G, SP PA Zorvolex NF Vimpat tablet/ Zubsolv PB QL NPD solution Zyban NF QL Vivlodex NF Zyprexa NF Vraylar NF Zyprexa Zydis NF Vyvanse PB QL HEART, BLOOD PRESSURE, & Wakix NPD, SP PA, QL CHOLESTEROL Wellbutrin SR NF Accupril NF Wellbutrin XL NF Accuretic NF Xadago NF acebutolol G Xanax NF AL acetazolamide G Xanax XR NF AL acetazolamide ER G Xcopri pak/tab NF Actimmune NPD, SP PA Xenazine NF Adalat CC NF Xodol, Norco NF QL, 5DS, AL, Adcirca NF, SP MME Adempas PB, SP PA Xtampza ER PB PA, QL, MME Advate PB, SP PA Xyrem NPD, SP PA, QL Adynovate NPD, SP PA Xywav Soln NPD, SP PA, QL Afstyla NPD, SP PA zaleplon G QL Aggrenox NF Zarontin NF Agrylin NF Zembrace NPD PA, QL Aldactazide NF Symtouch Aldactone NF Zenzedi NF QL aliskiren G ziprasidone G Alphanate PB, SP PA Zohydro ER NF QL, MME AlphaNine NPD, SP PA zolmitriptan G QL, AL Alprolix NPD, SP PA Zoloft NF Altace NF PA, QL zolpidem tartrate LCG (10mg only) Altoprev NF zolpidem tartrate PA, QL ambrisentan G, SP PA ER G (12.5mg only) Amicar NF amiloride G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 30 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS amiloride/HCTZ G bumetanide G aminocaproic acid G Bystolic PB amiodarone G Byvalson + NPD PA amlodipine LCG Caduet NF amlodipine Calan NF besylate/ G Calan SR NF olmesartan candesartan G amlodipine/ benazepril G candesartan/ hydrochloro- G amlodipine/ thiazide valsartan G captopril G amlodipine/ valsartan/HCTZ G captopril/HCTZ G anagrelide G Cardizem NF Antara NPD Cardizem CD NF Arixtra NF Cardizem LA NF Cardura NF aspirin- G dipyridamole er Carospir NF Atacand NF Cartia XT G Atacand HCT NF carvedilol LCG atenolol LCG carvedilol ER G atenolol/ G Catapres tablets NF chlorthalidone Catapres-TTS NF atorvastatin G chlorothiazide G atorvastatin/ chlorthalidone G amlodipine G cholestyramine G Avalide NF cholestyramine Avapro NF light G Azor NF cilostazol G Bebulin NPD, SP PA clonidine ER benazepril LCG 12 HR tab G benazepril/HCTZ G clonidine IR tablet LCG BeneFIX PB, SP PA clonidine patches G Benicar NF clopidogrel G Benicar HCT NF Coagadex NPD, SP PA Betapace AF NF colesevelam G betaxolol G Colestid NF Bevyxxa NPD QL colestipol HCl G bisoprolol G Conjupri NF bisoprolol/HCTZ G Coreg NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 31 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Coreg CR NF enalapril/HCTZ G Corgard NF enoxaparin G Corifact NPD, SP PA Entresto PB QL Corlanor NPD PA Epaned Sol NF AL Corzide NF 1mg/ml Coumadin PB eplerenone G Cozaar NF eprosartan G Crestor NF Esperoct NPD, SP PA Demadex NF ethacrynic acid G Dibenzyline NF Exforge NF digitek G Exforge HCT NF digox G ezetimibe G digoxin G ezetimibe/ simvastatin G Dilt-CD LCG Ezzalor Sprinkle diltiazem HCl G Cap NF diltiazem HCl CD G Feiba NPD, SP PA diltiazem HCl ER G felodipine ER G diltiazem HCl LA G fenofibrate G diltiazem HCl SR G fenofibrate Diltzac ER LCG nanocrystallized G Diovan NF fenofibric acid G Diovan HCT NF Fenoglide NF dipyridamole G Fibricor NF disopyramide G flecainide G dofetilide G Flolipid susp NF AL doxazosin G fluvastatin sodium G mesylate fondaparinux G Durlaza NF fosinopril G Dutoprol NPD fosinopril/HCTZ G Dyazide NF Fragmin NPD Dyrenium NF furosemide Edarbi + NPD PA solution G Edarbyclor NF furosemide tabs LCG Edecrin NF gemfibrozil G Effient NF guanfacine G Eliquis PB Helixate FS NPD, SP PA Eloctate NPD, SP PA Hemlibra Soln NPD, SP PA enalapril G Hemofil M NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 32 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Humate-P PB, SP PA Lanoxin hydralazine G 125mcg and NF 250mcg tablets hydrochloro- thiazide LCG Lasix NF Hyzaar NF Lescol NF icosapent cap G Letairis NF, SP IFE-PG20 Inj NF QL Lipitor NF indapamide G Lipofen NF Inderal LA NF lisinopril LCG InnoPran XL NF lisinopril/HCTZ LCG Inspra NF Livalo + NPD PA irbesartan G Lopid NF irbesartan Lopressor HCT NF hydrochloro- G losartan LCG thiazide losartan-HCTZ G Isordil Titradose Tabs NF Lotensin NF isosorbide Lotrel NF dinitrate G lovastatin ACA Lovaza NF isosorbide G dinitrate ER Lovenox NF isosorbide Maxzide NF mononitrate G methyldopa G isosorbide mononitrate ER G metolazone G isradipine G metoprolol succinate G Ixinity NPD, SP PA metoprolol Jantoven G tartrate LCG Jivi NPD, SP PA metoprolol G Juxtapid NPD, SP PA tartrate/HCT Kapspargo NF Mevacor NF Katerzia Susp NF AL mexiletine HCl G Koate-DVI PB, SP PA Micardis NF Kogenate FS NPD, SP PA Micardis HCT NF Kovaltry NPD, SP PA Microzide NF Kynamro NF, SP Minipress NF labetalol HCl G minitran G Lanoxin minoxidil G 62.5mcg, NPD moexipril G 187.5mcg tablets moexipril/HCTZ G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 33 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Monoclate-P NPD, SP PA Obizur NPD, SP PA Mononine PB, SP PA olmesartan G Mulpleta NPD, SP PA medoxomil Multaq PB olmesartan/ amlodipine/hctz G nadolol G olmesartan/hctz G nadolol- bendroflume G omega-3 acid G thiazide ethyl esters Nexletol PB PA Opsumit NPD, SP PA Nexlizet PB PA Orenitram NPD, SP PA niacin ER G Pacerone G Niaspan NF pentoxifylline ER G nicardipine G perindopril G Nifedical XL G Persantine NPD nifedipine G phenoxy- benzamine G PA nifedipine ER G pindolol ER G nimodipine G Plavix NF nisoldipine ER G Pradaxa PB Nitro-Bid PB Praluent PB PA Nitro-Dur NF prasugrel G Nitro-Time cap G Pravachol NF nitroglycerin ER LCG pravastatin G nitroglycerin G patches prazosin G nitroglycerin SL G Prevalite G nitroglycerin Prinivil NF spray G Procardia NF Nitrolingual NF Procardia XL NF Spray Profilnine NPD, SP PA Nitromist NPD Promacta NPD, SP PA Nitrostat SL NF propafenone G Nocdurna SL NF propafenone SR G Norpace NF propranolol G Northera NPD, SP PA propranolol ER G Norvasc NF propranolol/HCTZ G Novoeight PB, SP PA Qbrelis NF AL NovoSeven RT NPD, SP PA Questran NF Nuwiq PB, SP PA Questran Light NF Nymalize Sol NPD quinapril HCl G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 34 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS quinapril/HCTZ G Tenormin NF ramipril G tiadylt ER G Ranexa NF Tiazac NF ranolazine G ticlopidine HCl G Rebinyn Soln NPD, SP PA Tikosyn NF Recombinate PB, SP PA timolol G Repatha PB PA tolvaptan 15mg NPD, SP PA Revatio NF, SP tab Riastap NPD, SP PA tolvaptan 30mg tab G, SP PA Rixubis NPD, SP PA Toprol XL NF rosuvastatin G torsemide G Rythmol SR NF trandolapril G Samsca NF, SP LDD trandolapril/ Sevenfact Inj NPD, SP PA verapamil ER G sildenafil citrate Tretten NPD, SP PA 20mgtab, 10mg/ml G, SP PA susp triamterene/HCTZ G sildenafil citrate triamterene cap G 25mg, 50mg, LCG QL Tribenzor NF 100mg Tricor NF simvastatin LCG Trilipix NF simvastatin susp NF AL Twynsta NF sotalol HCl G Tyvaso NPD, SP PA Sotylize NPD Uptravi NPD, SP PA spironolactone G valsartan G spironolactone/ G valsartan/ HCTZ hydrochloro- G Stimate NF thiazide Sular NF Vascepa NPD PA Tarka NF Vaseretic NF Taztia XT G Vasotec NF Tekturna NF Vecamyl + G PA Tekturna HCT + NPD PA Ventavis NPD, SP PA telmisartan G Verelan ER, PM NF verapamil HCl G telmisartan- G amlodipine verapamil HCl ER G telmisartan/ Vonvendi NPD, SP PA hydrochloro- G Vyndaqel, thiazide NPD, SP PA Vyndamax Tenoretic NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 35 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Vytorin NF Apexicon E NF warfarin G Arazlo lotion NF AL Welchol NF 0.045% Wilate PB, SP PA Atralin NF AL Xarelto PB Avita G AL Xyntha PB, SP PA Azelex NF Zestoretic NF azelaic acid gel 15% G Zestril NF Benzaclin NF Zetia NF Benzamycin gel NF Ziac NF Benzamycinpak + NPD PA Zocor NF benzoyl peroxide/ Zypitamag NF erythromycin G SKIN MEDICATIONS beser lotion 0.05% G betamethasone Absorica NF dipropionate G Absorica LD NF betamethasone G Acanya NF valerate acitretin G betamethasone/ clotrimazole G acyclovir G Bryhali lotion Aczone NF AL 0.01% NF Adapalene NPD AL calcipotriene 0.1% lotion cream G adapalene G AL calcipotriene 0.3% gel foam NPD adapalene- calcipotriene- benzoyl-peroxide G AL betamethasone dp G gel 0.1-2.5% oint adapalene cream G AL calcipotriene- adapalene pad betamethasone dp G 0.1% NF AL susp Aklief Cream NF AL calcipotriene 0.005% cream G Aktipak NF calcitriol ointment G ala-cort cream LCG Capex NF alclometasone G Carac + NPD PA cream, ointment Centany Aldara NF ointment 2% NF Altreno lotion NF AL ciclopirox 0.05% 0.77% cream G amcinonide G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 36 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS ciclopirox desoximetasone 8% solution G cream, gel, G ciclopirox cream, ointment gel, shampoo, G diclofenac sodium suspension gel 3% G PA Differin Cleocin T NF NF AL Clindagel NF 0.1% cream Differin clindamycin, NF AL clindamycin 0.1% lotion Differin cream, NF AL clindamycin- G 0.3% gel benzoyl peroxide diflorasone gel [w/pump] diacetate NPD PA clindamycin/ Diprolene, benzoyl peroxide NF Diprolene AF NF 1-5% Dovonex cream NF clindamycin/ tretinoin gel G AL doxepin cream 5% G QL Duac NF clobetasol cream, G ointment, solution Duobrii Lotion NF Clobex NF Dupixent PB, SP PA clocortolone econazole G NPD PA pivalate Ecoza + NPD PA clodan G Efudex cream NF, SP Cloderm + NPD PA Elidel NF Condylox NF Elimite NF Cordran NF Elocon NF Cosentyx NPD, SP PA Enstilar NF Crotan G Epiduo NF AL Cutivate NF Epiduo Forte gel NPD AL Cystaran Soln NPD, SP PA, QL Ertaczo + NPD PA 0.44% Erygel NF dapsone gel 5% G AL erythromycin gel, G dapsone gel 7.5% NF AL soln, swabs Denavir NPD QL Eucrisa PB PA Derma-Smoothe FS NF Eurax NF Dermatop NF Evoclin NF Desonate NF Exelderm + NPD PA desonide gel Extina NF 0.05% G Fabior NF AL Desowen NF Fasenra PB, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 37 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Finacea NF Impeklo Lotion NF fluocinolone Impoyz cream NF acetonide cream, G 0.025% soln, oil isotretinoin G fluocinonide gel, G Jublia NPD PA ointment Kenalog Spray NF Fluorouracil PB Kerydin NF cream 0.5% ketoconazole fluorouracil G G, SP cream solution 2% ketoconazole flurandrenolide G NPD PA shampoo cream, lotn, oint Klaron NF fluticasone propionate cream, G Lexette Foam NF lotn, oint lidocaine G gentamicin topical lidocaine solution G G cream, ointment Lidoderm NF halcinonide cream G Locoid NF 0.1% Locoid halobetasol NF G Lipocream propionate Loprox NF halobetasol Lotrisone NF propionate foam NF 0.05% Luliconazole cream NPD PA Halog NF Luxiq NF hydrocortisone 2.5% G Luzu + NPD PA hydrocortisone malathion lotion G butyrate 0.1% G methoxsalen G MetroCream NF hydrocortisone G butyrate/emoll MetroGel NF hydrocortisone lot MetroLotion NF 0.1% G metronidazole hydrocortisone cream, lotion, gel G supp G miconazole-zinc NPD PA hydrocortisone G ointment valerate 0.2% Mirvaso PB hydrocortisone/ lidocaine HCl G mometasone cream, ointment, G imiquimod cream G solution Imiquimod mupirocin cream, Cream NPD ointment G 3.75% Pump

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 38 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS naftifine cream/gel G Silvadene NF Naftin NF silver sulfadiazine G Natroba NF Skyrizi Inj PB, SP PA Nizoral shampoo NF sodium Noritate NF sulfacetamide G suspension nystatin/ triamcinolone LCG Solaraze NF cream, ointment Soolantra PB Olux [E] NF Soriatane NF Onexton NPD spinosad G Ovide NF sulconazole NPD PA oxiconazole cream/solution nitrate NPD PA Sulfamylon NPD Oxistat NF Synalar NF Oxsoralen Ultra NF Taclonex NF Pandel NF Taltz Autoinjector NPD, SP PA Penlac NF Targretin gel PB, SP PA permethrin G tavaborole sol 5% G PA pimecrolimus cre G tazarotene cream 1% 0.1% G AL Tazorac cream/ podofilox soln G NF AL prednicarbate gel ointment G Temovate NF Tobradex prilocaine/ NPD lidocaine G ointment Topicort cream/ Proctofoam HC PB NF Prudoxin cream ointment 5% NF QL Topicort spray NF Qbrexza Pad Tremfya PB, SP PA 2.4% NPD PA, QL tretinoin gel, G AL Retin-A NF AL cream Retin-A Micro tretinoin NPD AL 0.04%, 0.1% NF AL microspheres gel Retin-A Micro NPD PA, AL triamcinolone 0.08% acetonide G Rhofade NPD PA triamcinolone oint 1% cream 0.05% NPD PA selenium sulfide G triderm cream LCG shampoo/lotion Trianex NPD PA Sernivo NPD PA Ultravate NF Siliq NPD, SP PA Vanos Cream NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 39 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Vectical NF mometasone Veltin NF AL furoate nasal G PA spray Vusion + NPD PA Nasonex NF Winlevi Cream 1% NF neomycin/ polymyxin/ LCG Wynzora Cream NF hydrocortisone Xolegel NF ofloxacin otic LCG Ziana NF AL olopatadine G Zilxi Aer NF Omnaris NPD PA Zonalon cream Patanase NF 5% NPD QL pilocarpine HCl G Zovirax cream NF QL Qnasl NF Zovirax oint NF ribavirin G, SP Ztlido Pad 1.8% NF QL Salagen NF EAR, NOSE, THROAT MEDICATIONS Virazole NF acetasol HC, Xhance NF acetic acid HC G Zetonna NPD PA otic DIABETES, THYROID, STEROIDS, & OTHER Astepro NF MISCELLANEOUS HORMONES azelastine G acarbose G Bactroban nasal oint PB Actos NF Cetraxal NF Adlyxin NF cevimeline hcl G Admelog NPD PA, QL Ciprodex NF Afrezza NF ciprofloxacin G Alogliptin benz/ metformin hcl PB ciprofloxacin- Alogliptin benz/ dexamethasone G pioglitazone PB otic susp Alogliptin ciprofloxacin- benzoate PB fluocinolone PF NF Amaryl NF otic soln Androderm cortane B otic NF G patch drops Androgel 1.62% NF Dermotic NF Packet, Pump Evoxac NF Androgel 1% NF fluocinolone Apidra NPD PA, QL acetonide oil G Axiron NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 40 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Bafiertam DR Dexcom Cap PB, SP Continuous Baqsimi PB Glucose Monitor NPD PA G6, G5,G4 Basaglar NF QL Sensors Breeze2 Dexpak pak NF Test Strips NPD PA, QL diazoxide Breeze2 PB PA, QL suspension G Glucometer 50mg/ml Bydureon PB doxercalciferol G Byetta PB Duetact NF Bynfezia Pen NPD, SP PA Dxevo 11-Day calcitriol capsules G Therapy Pack NF Carnitor NF 1.5mg Cetrotide Kit NPD, SP R Emflaza NPD PA cinacalcet G euthyrox G Contour Farxiga PB Glucometers PB PA, QL Fiasp NF QL Contour Next fludrocortisone G Test Strips PB QL acetate Contour Fortamet NF PB QL Test Strips Forteo NF, SP Q/T Cortef NF Fortesta NF Cytomel NPD Freestyle PB PA, QL danazol G Glucometer DDAVP NF Freestyle Delatesteryl NF InsuLinx NPD PA, QL Test Strips Demser NPD Freestyle Lite desmopressin Test Strips NPD PA, QL acetate G Freestyle Dexabliss NF Test Strips NPD PA, QL dexamethasone G Genotropin NF, SP dexamethasone glimepiride G pak , 6-day, G 10-day, 13-day glipizide G Dexcom glipizide ER G Continuous glipizide XL G NPD PA Glucose Monitor Glucagen NF Receiver Hypokit Dexcom Glucagon Continuous PB Glucose Monitor NPD PA Emergency Kit Transmitter Glucophage NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 41 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Glucophage XR NF Kazano tablet NF Glucotrol NF Kombiglyze XR PB Glucotrol XL NF Korlym tablet NPD, SP PA Glucovance NF Lantus PB QL Glumetza ER NPD PA Levemir NF QL, AL glyburide G levocarnitine G glyburide G levothyroxine cap NPD PA micronized levothyroxine tab G Glynase NF levo-T tab G Glyset NF Levoxyl G Glyxambi PB liothyronine G Gvoke hypo inj PB Lyumjev Inj/Pen NF QL Gvoke PFS inj PB Medrol NF Hectorol NF Medtronic Continuous Hemady NF NPD PA Humalog + NPD PA, QL Glucose Monitor Receiver Humatrope NPD, SP PA Medtronic Humulin NF QL Continuous hydrocortisone G Glucose Monitor NPD PA Increlex NPD, SP PA, LDD Guardian Transmitter insulin aspart inj NF QL Medtronic insulin aspart Continuous protamin inj NF QL Glucose Monitor flexpen Enlite, MiniMed NPD PA insulin lispro + NPD PA, QL Guardian Sensors insulin lispro inj protamin + NPD PA, QL metformin G insulin lispro inj metformin HCL junior + NPD PA, QL 500mg/5ml G AL oral soln Invokamet [XR] NPD PA metformin ER Invokana NPD PA NPD (OSM) Isturisa NPD, SP PA, QL metformin ER Janumet PB (generic for G Janumet XR PB Glucophage XR) Januvia PB Metformin ER NPD PA Jardiance PB (MOD) metformin/ Jatenzo NF G Jentadueto tablet NF glyburide Jentadueto XR NF methimazole G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 42 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Methitest Tab NPD PA oxandrolone G QL methylprednisolone G Ozempic Soln PB methyltestosterone G PA Palynziq NPD, SP PA metyrosine G paricalcitol G miglitol G pioglitazone G Millipred pioglitazone/ NF G solution glimepiride Millipred tabs NPD Prandin NF Myalept NPD, SP PA Precision PB PA, QL Mycapssa cap NPD, SP PA Glucometer Precision XTRA nateglinide G NPD PA, QL Natesto NF Test Strips Natpara NPD, SP PA Precose NF Nesina tablet NF prednisolone G Noctiva Emulsion NF Procysbi NPD, SP PA Non Preferred Proglycem Susp NF PB PA, QL Diabetic Meters propylthiouracil G Norditropin PB, SP PA Qtern NF Novolin PB QL Rayos NF Novolin R PB QL Regranex gel NPD PA Novolog PB QL repaglinide G Nutropin AQ PB, SP PA Riomet [ER] solution/ Omnipod 5 Pack PB suspension NF AL Omnipod Dash PB 500mg/5ml System Rocaltrol NF Omnipod Dash capsules 5 Pack PB Rybelsus PB QL Omnipod Starter Kit PB Saizen NF, SP Omnitrope NF, SP Segluromet NF Semglee Inj One Touch NF QL Glucometer PB QL 100U/ML One Touch Sensipar NF PB QL Test Strips Serostim NPD, SP PA, LDD Onglyza PB Signifor NPD, SP PA Orapred ODT NF Soliqua PB Orilissa NPD PA, QL Somavert NPD, SP PA Oseni NF Starlix NF Oxandrin NF Steglatro NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 43 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Steglujan NF Zcort 7-day tab NF Striant buccal Zemplar NF system NPD PA Zomacton NF, SP Symlin + PB PA Synjardy PB STOMACH, ULCER, & BOWEL MEDS Synjardy XR PB Aciphex NF QL Synthroid NPD Aciphex Sprinkle NF QL, AL Tanzeum NF Actigall NF Tapazole NF Amitiza NF Teriparatide Inj PB, SP PA, Q/T amoxicill- Testim Gel NF clarithro- G testosterone lansoprazole enanthate solution G PA Ampyra NF, SP QL Anusol-HC testosterone gel NF 10mg/act (2%) G PA cream aprepitant G QL testosterone gel G PA 1%, 1.62% Apriso NF testosterone Asacol HD NF solution 30mg/act G PA Azulfidine NF Tirosint capsule/ NPD PA balsalazide G soln Bentyl NF tolbutamide G Bonjesta NPD PA Toujeo Solostar PB QL budesonide ER Tradjenta tablet NF tablet G Tresiba NF QL, AL budesonide- Trijardy XR PB formoterol NF Trulicity PB Canasa supp NF Tymlos PB, SP PA, Q/T Carafate susp NF Uceris NF Carafate tabs NF Unithroid G Chenodal NPD, SP V-GO PB chlordiazepoxide/ LCG AL Veripred soln clidinium NF 20mg/5ml Cholbam NPD, SP PA Victoza PB cimetidine G Vogelxo NF Clenpiq NPD Vumerity PB, SP Colazal NF Xigduo XR PB Colocort G Xultophy NPD PA Creon PB Xyosted Soln NPD PA Cuvposa NPD

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 44 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Cytotec NF lansoprazole G PA, QL dalfampridin ER G, SP PA, QL solutab Delzicol NF Lialda NF Dexilant NF QL Linzess PB Diclegis NF Lomotil NF dicyclomine G loperamide G Marinol NF diphenoxylate G HCl/atropine Meclizine LCG doxylamine- G PA mesalamine G pyridoxine mesalamine DR G dronabinol G mesalamine rectal G Emend NF QL susp Emverm NPD QL metoclopramide G Endari powder NPD PA misoprostol LCG Entocort EC NF Motegrity NPD PA esomeprazole G PA, QL Movantik NF Moviprep NF esomeprazole G PA, QL granules Nexium capsule NF QL esomeprazole Nexium packets NF QL, AL strontium NPD PA, QL nizatidine solution G famotidine 40mg tab, suspension G Nulytely NF QL Gastrocrom NF omeprazole G QL Gattex NPD, SP PA omeprazole- sodium Gimoti Spray NF Q/T bicarbonate NPD PA Golytely solution capsule reconstituted NF 40-1100mg 227.1gm ondansetron HCl LCG Golytely solution orlistat G PA, R reconstituted NF QL 236gm Osmoprep NF granisetron G Pancreaze NF pancrelipase EC/SA G hydrocortisone G cream pantoprazole G QL hydrocortisone G pantoprazole pak G PA, QL retention enema PEG 3350 & Kristalose Pak NF electrolytes G QL lactulose pak NF peg-kcl-nacl- lactulose soln G nasulf-na asc-c G lansoprazole cap G QL soln reconstituted Pentasa PB

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 45 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Pepcid tabs, Viokace NF NF suspension Xenical NPD PA, R Pertzye NF Xermelo NPD, SP PA Plenvu Soln NF Zantac NF Prevacid caps NF QL Zegerid capsule NPD PA Prevacid SoluTab NF QL Zegerid packets NF QL Prilosec packets NPD PA, QL Zelnorm NF prochlorperazine Zenpep PB suppository G Zofran NF prochlorperazine tabs G Zorbtive NF, SP Protonix NF QL Zuplenz NF Protonix packets NF QL BONE, JOINT, & MUSCLE Pylera Cap NF Actemra SC NPD, SP PA rabeprazole DR tab G QL Actonel NF QL 20mg alendronate LCG QL Rabeprazole Sprinkle Cap NF QL allopurinol G 10mg alosetron hcl G ranitidine 300mg G Amrix NF Reglan NF Anaprox DS NF Relistor NF Arava NF scopolamine patch G Arthrotec NF SFRowasa enema NPD aspirin- NPD PA sucralfate tabs G omeprazole DR sulfasalazine G Atelvia NF QL Sutab NF baclofen G Symproic PB Binosto NF QL Syndros Sol NF Boniva NF QL Tigan NF calcitonin-salmon (rDNA origin) G Transderm-Scop nasal spray patch NF carisoprodol G trimetho- benzamide G Celebrex NF Trulance NF celecoxib G ursodiol G chlorzoxazone 250mg NPD PA Varubi NPD chlorzoxazone Viberzi NPD PA 375mg, 500mg, G Vimovo NPD PA 750mg

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 46 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Cimzia PB, SP PA flurbiprofen G Colchicine 0.6mg Fosamax NF QL NPD cap Fosamax Plus D NF QL colchicine 0.6mg Gloperba Soln NF tab G Humira PB, SP PA colchicine/ probenecid G ibandronate G QL Colcrys NF ibuprofen LCG Cuprimine NF, SP indomethacin G cyclobenzaprine G indomethacin 20mg capsule NF cyclobenzaprine ER NF indomethacin SR G Dantrium NF ketoprofen 25mg cap NPD PA dantrolene G ketoprofen SR G diclofenac epolamine 1.3 % NF QL ketorolac LCG transdermal ketorolac sol NF QL diclofenac tromethamine potassium G Kevzara NPD, SP PA Kineret NPD, SP PA diclofenac sodium G DR leflunomide G diclofenac sodium Licart Dis 1.3% NF QL ER G Lorzone NF diclofenac sodium soln 1.5% G Lotronex NF diclofenac/ meloxicam cap G PA misoprostol G meloxicam tab LCG Duexis NPD PA metaxalone NF EC-Naprosyn NF methocarbamol G Enbrel NPD, SP PA Miacalcin NF Mitigare NF etidronate G disodium Mobic NF etodolac G nabumetone G Evista NF Naprelan NF febuxostat G PA Naprosyn NF Feldene NF Naprosyn susp NF AL fenoprofen naproxen sodium LCG calcium NPD PA naproxen sodium G Fenortho NPD PA DR Fexmid NF naproxen sodium NF Flector Patch NF QL ER

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 47 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Zeposia NPD, SP naproxen sodium G AL susp Zipsor NF QL naproxen- Zurampic 200mg NPD, SP PA esomeprazole DR G PA Norgesic Tab Zyloprim NF NF Forte FEMALE, HORMONE REPLACEMENT, & Orencia NPD, SP PA BIRTH CONTROL Oriahnn cap NPD PA The Injectable Fertility Agents in this section are orphenadrine-asa- NPD PA covered only under certain benefits programs. caffeine Please check your handbook to determine coverage. orphenadrine ER G Activella NF Orphengesic NF Addyi NPD PA Forte Tab Alora Otezla PB, SP PA NF Annovera Mis Otrexup NPD PA NF QL Aygestin oxaprozin G NF Balcoltra Pennsaid NF NF Beyaz piroxicam G NF Bijuva probenecid G NF Bravelle raloxifene hcl G NPD, SP PA, QL, R Brevicon Rasuvo NPD PA NF Cenestin risedronate G QL PB Cleocin vaginal risedronate DR G QL NF Climara patch Robaxin NF PB Simponi PB, SP PA clomiphene citrate G Cyckessa Skelaxin NF NF Depo SubqQ Soma NF NF QL Provera Stelara PB, SP PA Depo-Provera NF QL sulindac G Desogen NF tizanidine G desogestrel-ethinyl ACA tolmetin G estradiol Toviaz + NPD PA Diflucan NF Uloric NF Divigel NF Vanadom NPD PA drospirenone- ACA Viibryd + NPD PA ethyinyl estradiol Voltaren Gel NPD eluryng mis ACA QL Xeljanz [XR] PB, SP PA Estrace NF Yosprala DR NPD PA estradiol G Zanaflex NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 48 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS estradiol cream metronidazole 0.01% G vaginal gel G Minastrin 24 FE estradiol G NF transdermal Minivelle NF Estring PB Mircette NF estropipate ACA Natazia PB Estrostep FE NF norethin-ethynil- Evista NF fer cap 1/20 ACA Femcon FE NF norethindrone ACA FemHRT NF norethindrone G Femring NPD PA acetate Follistim AQ + NPD, SP PA, QL, R norethindrone- ethinyl estradiol ACA Gemmily cap ACA norethindrone- 1/20 mestranol ACA Generess FE NF norgestimate- Gonal PB, SP QL, R ethinyl estradiol ACA hailey 1.5/30 ACA norgestrel-ethinyl ACA Imvexxy NF estradiol Intrarosa Vaginal NPD PA Nuvaring NF QL OB Complete NF levonorgestrel/ ACA ethinyl estradiol Ortho Micronor NF levonorgestrel/my ACA QL Ortho Novum NF way/next dose Ortho Tri-Cyclen NF Lyllana Dis G Ortho Tri-Cyclen Lo Loestrin FE PB Lo NF Loestrin NF Ortho-Cyclen NF Loestrin FE NF Ovidrel NPD, SP R LoSeasonique NF Plan B One-Step NF QL Lysteda NF Premarin PB medroxy- Premarin PB progesterone ACA QL vaginal cream acetate suspension Premphase PB IM Prempro PB medroxy- progesterone LCG progesterone, G acetate tab micronized Menopur NPD, SP QL, R Prometrium NF Metrogel vaginal NF Provera NF metronidazole LCG Quartette NF raloxifene G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 49 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Safyral NF Bleph 10 NF Blephamide Seasonique NF NPD Slynd NF S.O.P. ointment Synarel NPD brimonidine tartrate G Taytulla NF Bromsite sol NPD PA terconazole cream G 0.075% Tri-Norinyl NF carteolol G Twirla Dis NF QL Cequa Sol 0.09% NF QL Vagifem NF Ciloxan Sol NF Vandazole G ciprofloxacin G Vivelle Dot NF Combigan soln PB Vyleesi NPD PA, QL 0.2-0.5% xulane ACA QL Cosopt NF Yasmin NF cromolyn ophth G YAZ NF Cyclogyl NF yuvafem G cyclopentolate G EYE MEDICATIONS HCl Cystadrops Soln NPD, SP PA, QL Acular/Acular LS NF dexamethasone G Alcaine NF ophth Alphagan P Diamox Sequels NF 0.15% NF diclofenac soln Alphagan P 0.1% PB 0.1% opth G Alrex NPD dorzolamide HCl G apraclonidine G 2% atropine sulfate G dorzolamide- timolol G azelastine HCL drops G Elestat NF Azopt PB epinastine HCl G bacitracin ophth G erythromycin ethylsuccinate G bacitracin/ susp polymyxin B G ophth oint erythromycin ophth oint G Besivance PB Eysuvis Drop Betagan NF 0.25% NPD PA betaxolol G fluorometholone G Betimol NPD flurbiprofen G Betoptic S NPD FML Liquifilm bimatoprost G suspension NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 50 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Phospholine gentak oint 0.3% PB OP G Iodide gentamicin ophth LCG pilocarpine G homatropaire sol polymyxin B/neo/ G 5% OP G bacitracin homatropine polymyxin B/neo/ G ophthalmic LCG gramicidin Ilevro Susp 0.3% NPD PA Polytrim NF Inveltys Susp NF Pred-Forte NF Iopidine NF prednisolone G Isopto Carpine NF acetate Istalol Drops NF prednisolone sodium phosphate G ketorolac opth soln G prednisolone/ latanoprost G sodium G levobunolol G sulfacetamide Prolensa sol Lotemax [SM] NF PB loteprednol susp 0.07% 0.5% G proparacaine G Lumigan PB Rescula NF Maxitrol NF Restasis PB QL Rhopressa Soln methazolamide G NPD Moxeza PB 0.02% Rocklatan Soln NF moxifloxacin G ophthalmic soln Simbrinza Susp PB Mydriacyl NF 1-0.2 % neomycin/ sulfacetamide G polymyxin B/ G timolol ophth G dexamethasone Timoptic NF Neosporin soln NF Timoptic Nevanac Susp NF NPD PA Ocudose 0.1% Timoptic XE NF Ocufen NF tobramycin Ocuflox NF ophthalmic G ofloxacin G tobramycin- G olopatadine hcl G dexamethasone Omnipred NF Tobrex NF Oxervate soln Travatan Z NF NPD, SP PA, QL 200mcg/ml travoprost G Patanol NF trifluridine G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 51 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS trimethoprim Alvesco NF sulfate/ G Anoro Ellipta PB polymyxin B ArmonAir tropicamide G Digihaler NF Trusopt NF ArmonAir Upneeq Soln NPD PA RespiClick NF Vigamox NF Arnuity Ellipta PB Viroptic NF Asmanex NF Vyzulta Soln Asmanex HFA NF NF 0.024% OP Atrovent HFA PB Xalatan NF Auvi-Q 0.1mg NPD PA, QL Xelpros Auvi-Q 0.15mg NF NPD QL, AL Emulsion and 0.3mg Xiidra PB azelastine/ Zerviate Drops fluticasone spray G PA NPD PA 137-50 0.24% Beconase AQ NF Zioptan NF benzonatate LCG Zymaxid NPD Bevespi NPD PA ALLERGY, COUGH & COLD, LUNG MEDS Aerosphere + bosentan G, SP PA Accolate NF AL Breo Ellipta PB acetylcysteine G Breztri Advair Diskus PB Aerosphere PB Advair HFA PB Bromfed DM G Aerospan NF budesonide susp. G AirDuo Digihaler NF carbinoxamin G AirDuo Cayston NPD, SP PA RespiClick NF Cheratussin AC 5DS, QL, AL, Albuterol AER G MME HFA (authorized NPD PA, QL generic for Cheratussin DAC G 5DS, QL, AL, Ventolin HFA) MME albuterol AER Clarinex NF clemastine G HFA (generic of G QL ProAir HFA and Combivent Proventil HFA) Respimat PB albuterol sulfate er G cromolyn albuterol sulfate sodium solution G nebulizer soln, G (oral,nasal, syrup, tab inhalation) Alkindi Sprinkle NF cyproheptadine G

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 52 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS Daliresp NPD hydroxyzine HCL G desloratadine G syrup dexchlorphen- hydroxyzine LCG iramine NF pamoate Duaklir NF hypersal G Dulera NF Incruse Ellipta PB ipratropium- Dymista NF G Elixophyllin albuterol NPD ipratropium Elixir G Epinephrine pen inhalation soln PB QL 0.15mg ipratropium G nasal spray epinephrine pen G QL 0.3mg Kitabis Pak NF, SP LDD EpiPen NPD QL Kuvan NPD, SP PA EpiPen Jr. NPD QL Levalbuterol NPD QL Esbriet NPD, SP PA, LDD tartrate HFA Flovent Diskus PB levalbuterol G Flovent HFA PB nebulizer flunisolide G Lonhala Magnair NPD PA fluticasone metaproterenol G propionate nasal G montelukast LCG soln sodium fluticasone- Nucala Soln PB, SP PA salmeterol AER G Obredon QL, 5DS, AL, powder NF MME Grastek NPD PA Odactra SL NPD PA Hycofenix NPD QL, 5DS Ofev NPD, SP PA hydrocodon-cpm- QL, 5DS, AL, Oralair NPD PA phenylephrine G MME Palforzia cap/ hydrocod-cpm- QL, 5DS, AL, powder NPD, SP PA pseudoephedrine G MME ProAir Digihaler NF QL hydrocodone bit/ QL, 5DS, AL, ProAir HFA NF QL homatrop syrup G MME ProAir hydrocodone- QL, 5DS, AL, RespiClick PB QL chlorphenira- G mine susp MME promethazine G QL, 5DS, AL, promethazine/ QL, 5DS, AL, hydromet G LCG MME codeine MME hydroxyzine HCL promethazine/ tab LCG dextrometh- LCG orphen

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 53 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS promethazine/ theophylline phenylephrine G extended release G promethazine/ QL, 5DS, AL, theophylline soln G phenylephrine/ G Thiola [EC] NPD, SP codeine MME Tracleer NF, SP LDD Proventil HFA NF QL Trelegy Ellipta PB Pulmicort PB Flexhaler Tudorza Pressair NF Pulmicort Tussicap NF QL, 5DS, AL, MME NF Respules Tuxarin ER NF QL, 5DS, AL, MME Pulmozyme PB, SP Tuzistra XR NPD QL, 5DS, AL, MME Qvar NF Utibron Neohaler + NPD PA Ragwitek NPD PA Ventolin HFA NF QL Rebetol NF, SP Vistaril NF Rezira NF QL, 5DS, AL, MME Vituz NF QL, 5DS, AL, MME Ryclora NF VoSpire ER NF Ryvent NF wixela inhub aer G Seebri NF Xhance NF Semprex-D NF QL Xopenex NF Serevent Diskus PB Xopenex HFA NF QL Singulair NF Yupelri Soln NPD PA sodium chloride Z-Tuss AC NF QL, 5DS, AL, MME inhalation LCG zafirlukast G AL Spiriva PB zileuton ER 600mg G PA Stiolto Respimat PB Zutripro NF QL, 5DS, AL, MME Striverdi Zyflo 600mg NF AL Respimat Aer PB Zyflo CR 600mg NF AL Solution Symbicort PB URINARY & PROSTATE MEDS Symdeko NF, SP alfuzosin G Symjepi Inj NPD QL Avodart NPD AL tadalafil (generic G, SP PA bethanechol G Adcirca) Cardura NPD tadalafil (generic Caverject PB PA, QL Cialis) G QL Cialis NF QL terbutaline sulfate tablet G darifenacin ER G Tessalon Perles NF Detrol NF Theo-24 PB Detrol LA NF Theochron G Ditropan XL NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 54 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS doxazosin G VITAMINS & ELECTROLYTES mesylate dutasteride G AL Azeschew NPD PA Azesco NPD PA dutasteride/ G tamsulosin hcl Brand Prenatal NF Edex NPD PA, QL vitamins Elmiron NPD PA Buphenyl tab NF, SP Enablex NF Calciferol NPD finasteride G AL Dailyvite w/Zinc & NephplexRx NPD flavoxate G Dojolvi Liq NPD PA Flomax NF Duzallo NPD PA Jalyn NF ergocalciferol G Levitra NF QL fluoritab chew tab LCG Muse PB PA, QL Fosrenol Myrbetriq PB chewable tab NF oxybutynin syrup LCG Jynarque NPD, SP PA oxybutynin [ER] G K-Phos NF potassium citrate G K-Tab NF Proscar NF AL Klor-Con G Rapaflo NF lanthanum solifenacin G chewable tab G Staxyn NF QL Lokelma Pak NPD Stendra NF QL Mephyton NF tamsulosin G multivitamin with terazosin G fluoride drops, LCG tabs tolterodine tartrate G Nascobal NPD PA tolterodine nebusal tartrate LA G nebulization G solution trospium chloride G Nestabs One NPD PA Urecholine NF phytonadione G Urocit-K NF potassium Uroxatral NF bicarbonate/ vardenafil G PA, QL potassium citrate G vardenafil ODT G PA, QL effervescent potassium Vesicare NF G chloride Viagra NF QL Pregenna NPD PA Prenara NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 55 REQUIREMENTS/ REQUIREMENTS/ DRUG NAME DRUG DRUG NAME DRUG TIER LIMITS TIER LIMITS PulmoSal Ferriprox NF nebulization G Firazyr NF, SP QL solution Firdapse NPD, SP PA Quflora NF Galafold NPD, SP PA, QL Rayaldee NF ganirelix acetate sodium fluoride soln G, SP R chew tab LCG Haegarda NPD, SP PA sodium phenylbutyrate tab G, SP icatibant inj G, SP PA, QL Tri-Vi-Flor, Poly- Idelvion NF, SP Vi-Flor with and NPD Jadenu Sprinkle NF without iron Jadenu Tab NF Trinaz NPD PA Kesimpta Inj PB, SP Zalvit NPD PA Keveyis NPD, SP PA kionex suspension G DIAGNOSTICS & MISCELLANEOUS AGENTS Lucemyra NPD QL, Q/T Arcalyst NPD, SP PA Metopirone NPD Bafiertam PB, SP midodrine HCl G Berinert NPD, SP PA miglustat G, SP PA Cablivi Kit NPD, SP QL nitisinone G, SP PA calcium acetate G Nityr NPD, SP Carbaglu NPD, SP PA Novarel PB, SP Cerdelga NPD, SP PA 10000 Unit Chemet PB Novarel NF, SP 5000 Unit chorionic NF, SP gonadotropin Ocaliva NPD, SP PA Cinryze NPD, SP PA Olumiant NPD, SP PA clovique G, SP PA Orfadin capsule NF, SP Cystadane NPD, SP 2mg, 5mg, 10mg Cystagon NPD, SP PA Orfadin 20mg capsule, NPD, SP PA deferasirox tab/ G PA Orfadin 4mg/ml granule suspension deferiprone tab G PA Orladeyo Cap NF, SP D-Penamine NPD, SP Oxbryta NPD, SP PA 125mg tablet penicillamine Doptelet NPD, SP PA capsule G, SP PA Enspryng Inj NPD, SP PA penicillamine G, SP Evrysdi Soln NPD, SP PA tablet Exjade NF PhosLo NF

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 56 REQUIREMENTS/ DRUG NAME DRUG TIER LIMITS phospha G Potaba NPD Pregnyl PB, SP Renagel NF Renvela NF Ridaura NPD, SP Rinvoq PB, SP PA Ruconest NPD, SP PA Ruzurgi NPD, SP PA sapropterin pow/ tab G, SP PA sevelamer carbonate G Siklos NPD Strensiq NPD, SP PA Sucraid Solution NPD, SP PA 8500 unit/ml Syprine NF, SP Takhzyro NPD, SP PA Tavalisse NPD, SP PA Tegsedi NPD, SP PA trientine G, SP PA Xuriden NPD, SP PA Zavesca NF, SP

Bold type = Brand Name Drug Lower case italic = Generic drug PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider + = PA for Selected NPD NF = Non Formulary G = Generic Q/T = Quantity Over Time PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent 57

Language Assistance Services Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong Spanish: ATENCIÓN: Si habla español, cuenta con sa wika nang walang bayad. Tumawag sa servicios de asistencia en idiomas disponibles 1-800-275-2583. de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711). French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés Chinese: 注意：如果您讲中文，您可以得到免费的语言 gratuitement. Appelez le 1-800-275-2583. 协助服务。致电 1-800-275-2583。 Pennsylvania Dutch: BASS UFF: Wann du Korean: 안내사항: 한국어를 사용하시는 경우, 언어 Pennsylvania Deitsch schwetzscht, kannscht du Hilf 지원 서비스를 무료로 이용하실 수 있습니다. griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. 1-800-275-2583 번으로 전화하십시오.

Portuguese: ATENÇÃO: se você fala português, Hindi: �या� द�: यिद आप िहदीं बोलते ह� तो आपके िलए encontram-se disponíveis serviços gratuitos de मु�त म� भाषा सहायता सेवाएं �पल�� ह�। कॉल कर� assistência ao idioma. Ligue para 1-800-275-2583. 1-800-275-2583।

Gujarati: �ચનાૂ : જો તમે �જરાતીુ બોલતા હો, તો િન:���ુ German: ACHTUNG: Wenn Sie Deutsch sprechen, ભાષા સહાય સેવાઓ તમારા માટ� ��લ�� છે. können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. 1-800-275-2583 કોલ કરો. Japanese: 備考：母国語が日本語の方は、言語アシス Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi タンスサービス（無料）をご利用いただけます。 sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi 1-800-275-2583. 1-800-275-2583へお電話ください。

Persian (Farsi): Russian: ВНИМАНИЕ: Если вы говорите по-русски, توجه: اگر فارسی صحبت می کنيد، خدمات ترجمه به صورت то можете бесплатно воспользоваться услугами رايگان برای شما فراھم می باشد. با شماره перевода. Тел.: 1-800-275-2583. 1-800-275-2583 تماس بگيريد. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go pod numer 1-800-275-2583. Navajo: Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. Italian: ATTENZIONE: Se lei parla italiano, sono H0d77lnih koj8’ 1-800-275-2583. disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-800-275-2583. Urdu:

توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے Arabic: مفت ميں زبان معاون خدمات دستياب ہيں۔ کال کريں ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية .1-800-275-2583 متاحة لك بالمجان. اتصل برقم 1-800-275-2583.

French Creole: ATANSYON: Si w pale Kreyòl Mon-Khmer, Cambodian: សូ�េ��䮏 ចប់�រ�មណ៍ ៖ Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583. 䮚បសិនេបើអនកនិ�យ���ន-ែខមរ ���ែខមរ េនះ ជំនួយែផនក��នឹងមនផ䮏ល់ជូនដល់េ�កអនកេ�យ�ត គិតៃថ䮛។ ទូរសពទេទេលខ 1-800-275-2583។

Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

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Discrimination is Against the Law If you need these services, contact our Civil Rights This Plan complies with applicable Federal civil rights Coordinator. If you believe that This Plan has failed laws and does not discriminate on the basis of race, to provide these services or discriminated in another color, national origin, age, disability, or sex. This Plan way on the basis of race, color, national origin, age, does not exclude people or treat them differently disability, or sex, you can file a grievance with our Civil because of race, color, national origin, age, disability, Rights Coordinator. You can file a grievance in the or sex. following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, This Plan provides: Philadelphia, PA 19103, By phone: 1-888-377-  Free aids and services to people with disabilities 3933 (TTY: 711) By fax: 215-761-0245, By email: to communicate effectively with us, such as: [email protected]. If you need qualified sign language interpreters, and written help filing a grievance, our Civil Rights Coordinator is information in other formats (large print, audio, available to help you. accessible electronic formats, other formats).  Free language services to people whose You can also file a civil rights complaint with the U.S. primary language is not English, such as: Department of Health and Human Services, Office for qualified interpreters and information written in Civil Rights electronically through the Office for Civil other languages. Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

59 Index

A adapalene-benzoyl-peroxide gel 0.1-2.5%, 36 abacavir sulfate tab, soln, 15 Adcirca, 30, 54 abacavir sulfate/lamivudine, 15 Adderall, 21 abacavir/lamivudine/zidovudine, 15 Adderall XR, 21 Abilify, 21 Addyi, 48 Abilify Mycite, 21 adefovir dipivoxil, 15 abiraterone, 19 Adempas, 30 Absorica, 36 Adhansia XR Capsule, 21 Absorica LD, 36 Adipex-P, 21 Abstral, 21 Adlyxin, 40 acamprosate DR tab, 21 Admelog, 40 Acanya, 36 Advair Diskus, 52 acarbose, 40 Advair HFA, 52 Accolate, 52 Advate, 30 Accupril, 30 Adynovate, 30 Accuretic, 30 Adzenys ER susp, 21 acebutolol, 30 Adzenys XR-ODT, 21 acetaminophen, 21–22, 25, 27, 29 Aemcolo DR, 15 acetasol HC, acetic acid HC otic, 40 Aerospan, 52 acetate suspension IM, 49 Afinitor, 19–20 acetazolamide, 30 Afrezza, 40 acetazolamide ER, 30 Afstyla, 30 acetylcysteine, 52 Aggrenox, 30 Aciphex, 44 Agrylin, 30 Aciphex Sprinkle, 44 Aimovig, 21 acitretin, 36 AirDuo Digihaler, 52 Actemra SC, 46 AirDuo RespiClick, 52 Acticlate, 15 Ajovy, 21 Actigall, 44 Aklief Cream 0.005%, 36 Actimmune, 30 Aktipak, 36 Actiq, 21 ala-cort cream, 36 Activella, 48 albendazole, 15 Actonel, 46 Albenza, 15 Actos, 40 Albuterol AER HFA (authorized generic Acular/Acular LS, 50 for Ventolin HFA), 52 acyclovir, 15, 36 albuterol AER HFA (generic of ProAir acyclovir cream 5%, 15 HFA and, 52 Aczone, 36 albuterol sulfate er, 52 Adalat CC, 30 albuterol sulfate nebulizer soln, syrup, Adapalene 0.1% lotion, 36 tab, 52 adapalene 0.3% gel, 36 Alcaine, 50 adapalene cream, 36 alclometasone cream, ointment, 36 adapalene pad 0.1%, 36 Aldactazide, 30 Aldactone, 30 i Index

Aldara, 36 amlodipine/valsartan/HCTZ, 31 Alecensa, 19 amoxapine, 22 alendronate, 46 amoxicill-clarithro-lansoprazole, 44 alfuzosin, 54 amoxicillin, 15 Alinia, 15 Amoxicillin 775mg, 15 aliskiren, 30 amoxicillin/clavulanate, 15 Alkeran, 19 amoxicillin/clavulanate extended-release, 15 Alkindi Sprinkle, 52 amphetamine aspartate/amphetamine allopurinol, 46 sulfate/dextroamphetamine, 22 Allzital 25-325mg, 22 amphetamine aspartate/amphetamine almotriptan maleate, 22 sulfate/dextroamphetamine ER, 22 Alogliptin benz/ metformin hcl, 40 amphetamine ER suspension, 22 Alogliptin benz/ pioglitazone, 40 amphetamine tablet (generic Evekeo), 22 Alogliptin benzoate, 40 ampicillin, 15 Alora, 48 Ampyra, 44 alosetron hcl, 46 Amrix, 46 Alphagan P 0.1%, 50 Amzeeq, 15 Alphagan P 0.15%, 50 Anafranil, 22 Alphanate, 30 anagrelide, 31 AlphaNine, 30 Anaprox DS, 46 alprazolam, 22 anastrazole, 19 alprazolam ER, 22 Ancobon, 15 Alprolix, 30 Androderm patch, 40 Alrex, 50 Androgel 1%, 40 Altabax, 15 Androgel 1.62% Packet, Pump, 40 Altace, 30 Annovera Mis, 48 Altoprev, 30 Anoro Ellipta, 52 Altreno lotion 0.05%, 36 Antabuse, 22 Alunbrig tab/pak, 19 Antara, 31 Alvesco, 52 Anusol-HC cream, 44 amantadine, 22 Apadaz, 22 Amaryl, 40 Apexicon E, 36 Ambien, 22 Apidra, 40 Ambien CR, 22 Aplenzin, 22 ambrisentan, 30 Apokyn Solution Cartridge 30MG/3ML, 22 amcinonide, 36 apraclonidine, 50 Amerge, 22 aprepitant, 44 Amicar, 30 Apriso, 44 amiloride, 30–31 Aptensio XR, 22 amiloride/HCTZ, 31 Aptiom, 22 aminocaproic acid, 31 Arakoda, 15 amiodarone, 31 Arava, 46 Amitiza, 44 Arazlo lotion 0.045%, 36 amitriptyline, 22 Arcalyst, 56 amlodipine, 31, 34 Aricept [ODT], 22 amlodipine besylate/olmesartan, 31 Arikayce Susp, 15 amlodipine/benazepril, 31 Arimidex, 19 amlodipine/valsartan, 31 aripiprazole, 22 ii Index

Arixtra, 31 azathioprine, 19 armodafinil, 22 azelaic acid gel 15%, 36 ArmonAir Digihaler, 52 azelastine, 40, 50, 52 ArmonAir RespiClick, 52 azelastine HCL drops, 50 Arnuity Ellipta, 52 azelastine/fluticasone spray 137-50, 52 Aromasin, 19 Azelex, 36 Arthrotec, 46 Azeschew, 55 Arymo ER, 22 Azesco, 55 Asacol HD, 44 Azilect, 22 asenapine sub, 22 azithromycin, 15 Asmanex, 52 Azopt, 50 Asmanex HFA, 52 Azor, 31 aspirin-dipyridamole er, 31 Azulfidine, 44 aspirin-omeprazole DR, 46 Astepro, 40 B Atacand, 31 Atacand HCT, 31 bacitracin ophth, 50 atazanavir, 15 bacitracin/polymyxin B, 50 Atelvia, 46 baclofen, 46 atenolol, 31 Bactrim DS, 15 atenolol/chlorthalidone, 31 Bactrim,, 15 Ativan, 22 Bactroban nasal oint, 40 atomoxetine, 22 Bafiertam, 41, 56 atorvastatin, 31 Bafiertam DR Cap, 41 atorvastatin/amlodipine, 31 Balcoltra, 48 atovaquone, 15 balsalazide, 44 atovaquone/proguanil, 15 Balversa, 19 Atralin, 36 Banzel Susp, 22 Atripla, 15 Banzel Tab, 22 atropine sulfate, 50 Baqsimi, 41 Atrovent HFA, 52 Baraclude, 15 Aubagio, 22 Basaglar, 41 Augmentin, 15 Baxdela, 15 Augmentin XR, 15 Bebulin, 31 Austedo, 22 Beconase AQ, 52 Auvi-Q 0.1mg, 52 Belbuca, 22 Auvi-Q 0.15mg and 0.3mg, 52 Belsomra, 22 Avalide, 31 Belviq [XR], 22 Avapro, 31 benazepril, 31 Avelox, 15 benazepril/HCTZ, 31 avidoxy, 15 BeneFIX, 31 Avita, 36 Benicar, 31 Avodart, 54 Benicar HCT, 31 Avonex, 22 Benlysta, 19 Axert, 22 Bentyl, 44 Axiron, 40 Benzaclin, 36 Aygestin, 48 Benzamycin gel, 36 Ayvakit, 19 Benzamycinpak, 36 iii Index

benzhydrocodone-acetaminophen, 21 brimonidine tartrate, 50 Benznidazole, 15 Brisdelle cap, 22 benzonatate, 52 Briviact suspension, 22 benzoyl peroxide/erythromycin, 36 Briviact tablet, 22 benzphetamine, 22 Bromfed DM, 52 benztropine, 22 bromocriptine mesylate, 22 Berinert, 56 Bromsite sol 0.075%, 50 beser lotion 0.05%, 36 Brukinsa, 19 Besivance, 50 Bryhali lotion 0.01%, 36 Betagan, 50 budesonide ER tablet, 44 betamethasone dipropionate, 36 budesonide susp., 52 betamethasone valerate, 36 budesonide-formoterol, 44 betamethasone/clotrimazole, 36 bumetanide, 31 Betapace AF, 31 Bunavail, 22 Betaseron, 22 Buphenyl tab, 55 betaxolol, 31, 50 buprenorphine hcl/naloxone hcl, 22 bethanechol, 54 buprenorphine patch, 22 Bethkis, 15 buprenorphine SL, 22 Betimol, 50 bupropion, 22 Betoptic S, 50 bupropion ER 150mg, 22 Bevespi Aerosphere, 52 bupropion ER 450mg, 22 Bevyxxa, 31 bupropion SR, 22 bexarotene, 19 bupropion XL, 22 Beyaz, 48 buspirone, 22 Biaxin, 15 butalbital-acetaminophen 25-300mg, 23 bicalutamide, 19 butalbital-acetaminophen 25-325mg, 23 bicarbonate capsule 40-1100mg, 45 butalbital/apap/caffeine, 23 Bijuva, 48 butalbital/apap/caffeine/codeine, 23 Biktarvy, 15 butalbital/aspirin/caffeine/codeine, 23 Biltricide, 15 butorphanol tartrate nasal, 23 bimatoprost, 50 Butrans, 23 Binosto, 46 Bydureon, 41 bisoprolol, 31 Byetta, 41 bisoprolol/HCTZ, 31 Bynfezia Pen, 41 Bleph 10, 50 Bystolic, 31 Blephamide S.O.P. ointment, 50 Byvalson, 31 Boniva, 46 Bonjesta, 44 C bosentan, 52 Bosulif, 19 Cablivi Kit, 56 Braftovi, 19 Cabometyx, 19 Brand Prenatal vitamins, 55 Caduet, 31 Bravelle, 48 Cafergot, 23 Breeze2 Glucometer, 41 Calan, 31 Breeze2 Test Strips, 41 Calan SR, 31 Breo Ellipta, 52 Calciferol, 55 Brevicon, 48 calcipotriene cream, 36 Breztri Aerosphere, 52 calcipotriene foam, 36 iv Index

calcipotriene-betamethasone dp oint, 36 cefaclor ER, 15 calcipotriene-betamethasone dp susp, 36 cefadroxil, 15 calcitonin-salmon (rDNA origin) nasal spray, 46 cefdinir, 15 calcitriol capsules, 41 cefixime susp/cap, 15 calcitriol ointment, 36 ceftibuten, 15 calcium acetate, 56 Ceftin, 15 Calquence, 19 cefuroxime axetil, 15 Canasa supp, 44 Celebrex, 46 candesartan, 31 celecoxib, 46 candesartan/hydrochlorothiazide, 31 Celexa, 23 capecitabine, 19 Cellcept, 19 Capex, 36 Celontin, 23 Caplyta, 23 Cenestin, 48 Caprelsa, 19 Centany ointment 2%, 36 captopril, 31 cephalexin, 15 captopril/HCTZ, 31 Cequa Sol 0.09%, 50 Carac, 36 Cerdelga, 56 Carafate susp, 44 Cetraxal, 40 Carafate tabs, 44 Cetrotide Kit, 41 Carbaglu, 56 cevimeline hcl, 40 carbamazepine, 23 Chantix, 23 carbamazepine susp, 23 Chemet, 56 carbamazepine XR, 23 Chenodal, 44 Carbatrol, 23 Cheratussin AC, 52 carbidopa, 23 Cheratussin DAC, 52 carbidopa/levodopa, 23 chlordiazepoxide, 23, 44 carbidopa/levodopa ER, 23 chlordiazepoxide/clidinium, 44 carbidopa/levodopa ODT, 23 chlorhexidine gluconate soln, 15 carbidopa/levodopa/entacapone, 23 chloroquine phosphate, 15 carbinoxamin, 52 chlorothiazide, 31 Cardizem, 31 chlorpromazine HCl, 23 Cardizem CD, 31 chlorthalidone, 31 Cardizem LA, 31 chlorzoxazone 250mg, 46 Cardura, 31, 54 chlorzoxazone 375mg, 500mg, 750mg, 46 carisoprodol, 46 Cholbam, 44 carisoprodol-aspirin-codeine, 23 cholestyramine, 31 Carnitor, 41 cholestyramine light, 31 Carospir, 31 chorionic gonadotropin, 56 carteolol, 50 Cialis, 54 Cartia XT, 31 ciclopirox 0.77% cream, 36 carvedilol, 31 ciclopirox 8% solution, 37 carvedilol ER, 31 ciclopirox cream, gel, shampoo, suspension, 37 Casodex, 19 cilostazol, 31 Catapres tablets, 31 Ciloxan Sol, 50 Catapres-TTS, 31 Cimduo, 15 Caverject, 54 cimetidine, 44 Cayston, 52 Cimzia, 47 cefaclor, 15 cinacalcet, 41 v Index

Cinryze, 56 colchicine 0.6mg tab, 47 Cipro, 15 colchicine/probenecid, 47 Cipro XR, 15 Colcrys, 47 Ciprodex, 40 colesevelam, 31 ciprofloxacin, 15, 40, 50 Colestid, 31 ciprofloxacin ER tabs, 15 colestipol HCl, 31 ciprofloxacin-dexamethasone otic susp, 40 Colocort, 44 ciprofloxacin-fluocinolone PF otic soln, 40 Combigan soln 0.2-0.5%, 50 citalopram, 23 Combivent Respimat, 52 Clarinex, 52 Combivir, 15 clarithromycin, 15 Cometriq, 19 clarithromycin ER, 15 Complera, 15 clemastine, 52 Comtan, 23 Clenpiq, 44 Concerta, 23 Cleocin, 15, 37, 48 Condylox, 37 Cleocin T, 37 Conjupri, 31 Cleocin vaginal, 48 Consensi, 23 Climara patch, 48 Contour Glucometers, 41 Clindagel, 37 Contour Next Test Strips, 41 clindamycin, clindamycin cream, Contour Test Strips, 41 clindamycin-benzoyl peroxide gel [w/pump], 37 Contrave ER, 23 clindamycin/ benzoyl peroxide 1-5%, 37 Conzip, 23 clindamycin/tretinoin gel, 37 Copaxone, 23 clobazam, 23 Copiktra, 19 clobazam susp, 23 Cordran, 37 clobetasol cream, ointment, solution, 37 Coreg, 31–32 Clobex, 37 Coreg CR, 32 clocortolone pivalate, 37 Corgard, 32 clodan, 37 Corifact, 32 Cloderm, 37 Corlanor, 32 clomiphene citrate, 48 cortane B otic drops, 40 clomipramine HCl, 23 Cortef, 41 clonazepam, 23 Corzide, 32 clonidine ER 12 HR tab, 31 Cosentyx, 37 clonidine IR tablet, 31 Cosopt, 50 clonidine patches, 31 Cotellic, 19 clopidogrel, 31 Cotempla XR-ODT, 23 clorazepate dipotassium, 23 Coumadin, 32 clotrimazole troches, 15 Cozaar, 32 clovique, 56 Creon, 44 clozapine, 23 Cresemba, 15 clozapine ODT, 23 Crestor, 32 Clozaril, 23 Crixivan, 15 Coagadex, 31 cromolyn ophth, 50 codeine tabs, 23 cromolyn sodium solution (oral,nasal, inhalation), coditussin AC liquid, 23 52 Colazal, 44 Crotan, 37 Colchicine 0.6mg cap, 47 Cuprimine, 47 vi Index

Cutivate, 37 Demadex, 32 Cuvposa, 44 demeclocycline, 16 Cyckessa, 48 Demerol, 23 cyclobenzaprine, 47 Demser, 41 cyclobenzaprine ER, 47 Denavir, 37 Cyclogyl, 50 Depakene, 23 cyclopentolate HCl, 50 Depakote, 23 cyclophosphamide, 19 Depakote ER, 23 cyclosporine, 19 Depakote Sprinkle Caps, 23 Cymbalta, 23 Depo SubqQ Provera, 48 cyproheptadine, 52 Depo-Provera, 48 Cystadane, 56 Derma-Smoothe FS, 37 Cystadrops Soln, 50 Dermatop, 37 Cystagon, 56 Dermotic, 40 Cystaran Soln 0.44%, 37 desipramine, 23 Cytomel, 41 desloratadine, 53 Cytotec, 45 desmopressin acetate, 41 Cytoxan, 19 Desogen, 48 desogestrel-ethinyl estradiol, 48 D Desonate, 37 desonide gel 0.05%, 37 D-Penamine 125mg tablet, 56 Desowen, 37 D.H.E.45, 24 desoximetasone cream, gel, ointment, 37 Dailyvite w/Zinc & NephplexRx, 55 Desoxyn, 23 Daklinza, 15 Desvenlafaxine ER 24HR, 23 dalfampridin ER, 45 desvenlafaxine succinate ER, 24 Daliresp, 53 Detrol, 54 danazol, 19, 41 Detrol LA, 54 Danocrine, 19 Dexabliss, 41 Dantrium, 23, 47 dexamethasone, 41, 50–51 dantrolene, 23, 47 dexamethasone ophth, 50 dapsone gel 5%, 37 dexamethasone pak, 6-day, 10-day, 13-day, 41 dapsone gel 7.5%, 37 dexchlorpheniramine, 53 dapsone tablet, 16 Dexcom Continuous Glucose Monitor G6, G5,G4 Daraprim Tab, 16 Sensors, 41 darifenacin ER, 54 Dexcom Continuous Glucose Monitor Receiver, 41 Daurismo, 19 Dexcom Continuous Glucose Monitor Transmitter, Daxbia, 16 41 Daypro, 23 Dexedrine caps, 24 Daytrana, 23 Dexilant, 45 Dayvigo, 23 dexmethylphenidate ER, 24 DDAVP, 41 dexmethylphenidate hcl, 24 deferasirox tab/granule, 56 Dexpak pak, 41 deferiprone tab, 56 dextroamphetamine, 22, 24 Delatesteryl, 41 dextroamphetamine ER, 22, 24 Delstrigo, 16 Diacomit, 24 Deltasone, 19 Diamox Sequels, 50 Delzicol, 45 Diastat, 24 vii Index

diazepam solution, 24 dipyridamole, 32 diazepam tabs, 24 disopyramide, 32 diazoxide suspension 50mg/ml, 41 disulfiram, 24 Dibenzyline, 32 Ditropan XL, 54 Diclegis, 45 divalproex sodium, 24 Diclofenac cap 35mg, 24 divalproex sodium ER, 24 diclofenac epolamine 1.3 % transdermal, 47 divalproex sprinkle cap, 24 diclofenac potassium, 24, 47 Divigel, 48 diclofenac sodium, 24, 37, 47 dofetilide, 32 diclofenac sodium DR, 47 Dojolvi Liq, 55 diclofenac sodium ER, 47 Dolophine, 24 diclofenac sodium gel 1%, 24 donepezil hydrochloride, 24 diclofenac sodium gel 3%, 37 Doptelet, 56 diclofenac sodium soln 1.5%, 47 Doral, 24 diclofenac soln 0.1% opth, 50 Doryx 50mg tablet, 16 diclofenac/misoprostol, 47 Doryx 200mg tablet, 16 dicloxacillin, 16 dorzolamide HCl 2%, 50 dicyclomine, 45 dorzolamide-timolol, 50 didanosine, 16 Dovato, 16 diethylpropion HCL, 24 Dovonex cream, 37 Differin 0.1% cream, 37 doxazosin mesylate, 32, 55 Differin 0.1% lotion, 37 doxepin capsule, 24 Differin 0.3% gel, 37 doxepin cream 5%, 37 Dificid Tab/Susp, 16 doxepin tablet, 24 diflorasone diacetate, 37 doxercalciferol, 41 Diflucan, 16, 48 doxycycline DR 40mg, 16 diflunisal, 24 doxycycline hyclate DR 80mg, 16 digitek, 32 doxycycline hyclate tab 50mg, 16 digox, 32 doxycycline hyclate tab 75mg, 150mg, 16 digoxin, 32 doxycycline hyclate tab DR 50mg, 100mg, 16 dihydrocodeine/APAP/caff, 24 doxycycline hyclate tab DR 200mg, 16 dihydrocodeine/aspirin/caffeine, 24 doxycycline monohydrate cap 50mg, 100mg, 16 dihydroergotamine inj, 24 doxycycline monohydrate cap 75mg, 150mg, 16 dihydroergotamine mesylate nasal spray, 24 doxycycline monohydrate tab 150mg, 16 Dilantin chewable tablets, 24 doxylamine-pyridoxine, 45 Dilaudid, 24 Drizalma Sprinkle, 24 Dilt-CD, 32 dronabinol, 45 diltiazem HCl, 32 drospirenone-ethyinyl estradiol, 48 diltiazem HCl CD, 32 Duac, 37 diltiazem HCl ER, 32 Duaklir, 53 diltiazem HCl LA, 32 Duetact, 41 diltiazem HCl SR, 32 Duexis, 47 Diltzac ER, 32 Dulera, 53 dimethyl fumarate DR cap, 24 duloxetine, 24 Diovan, 32 Duobrii Lotion, 37 Diovan HCT, 32 Dupixent, 37 diphenoxylate HCl/atropine, 45 Duragesic patch, 24 Diprolene, Diprolene AF, 37 Durlaza, 32 viii Index

dutasteride, 55 Emtriva, 16 dutasteride/tamsulosin hcl, 55 Emverm, 16, 45 Dutoprol, 32 Enablex, 55 Duzallo, 55 enalapril, 32 Dxevo 11-Day Therapy Pack 1.5mg, 41 enalapril/HCTZ, 32 Dyanavel XR, 24 Enbrel, 47 Dyazide, 32 Endari powder, 45 Dymista, 53 endocet, 24 Dyrenium, 32 enoxaparin, 32 Enspryng Inj, 56 E Enstilar, 37 entacapone, 23–24 E.E.S. 400mg tab, 16 entecavir, 16 EC-Naprosyn, 47 Entocort EC, 45 econazole, 37 Entresto, 32 Ecoza, 37 Epaned Sol 1mg/ml, 32 Edarbi, 32 Epclusa, 16 Edarbyclor, 32 Epidiolex Soln, 24 Edecrin, 32 Epiduo, 37 Edex, 55 Epiduo Forte gel, 37 Edluar SL tab, 24 epinastine HCl, 50 Edurant, 16 epinephrine pen 0.3mg, 53 efavirenz, 16 Epinephrine pen 0.15mg, 53 efavirenz-emtricitab-tenofovir tab, 16 EpiPen, 53 efavirenz-lamivudine-tenofovir tab, 16 EpiPen Jr., 53 Effexor XR, 24 Epivir, 16 Effient, 32 eplerenone, 32 Efudex cream, 37 eprosartan, 32 Egaten 250mg tablet, 16 Epzicom, 16 Eldepryl, 24 ergocalciferol, 55 Elestat, 50 ergotamine tartrate/caffeine, 24 eletriptan, 24 Erivedge, 19 Elidel, 37 Erleada, 19 Elimite, 37 erlotinib, 19 Eliquis, 32 Ertaczo, 37 Elixophyllin Elixir, 53 Ery-Tab, 16 Elmiron, 55 Erygel, 37 Elocon, 37 EryPed 400mg/5ml Susp, 16 Eloctate, 32 Erythrocin, 16 eluryng mis, 48 erythromycin delayed release, 16 Embeda, 24 erythromycin ethylsuccinate, 16, 50 Emcyt, 19 erythromycin ethylsuccinate susp, 50 Emend, 45 erythromycin gel, soln, swabs, 37 Emflaza, 41 erythromycin ophth oint, 50 Emgality, 24 erythromycin stearate, 16 emtricitabine cap, 16 Esbriet, 53 emtricitabine-tenofovir disoproxil fumarate tab escitalopram, 24 200-300mg, 16 Esgic capsule, 24 ix Index

Esgic tablet, 24 F esomeprazole, 45 esomeprazole granules, 45 Fabior, 37 esomeprazole strontium, 45 famciclovir, 16 Esperoct, 32 famotidine 40mg tab, suspension, 45 estazolam, 24 Fanapt, 25 Estrace, 48 Fareston, 20 estradiol, 48–49 Farxiga, 41 estradiol cream 0.01%, 49 Farydak, 20 estradiol transdermal, 49 Fasenra, 37 Estring, 49 Fazaclo, 25 estropipate, 49 febuxostat, 47 Estrostep FE, 49 Feiba, 32 eszopiclone, 24 felbamate, 25 ethacrynic acid, 32 Felbatol, 25 ethambutol, 16 Feldene, 25, 47 ethosuximide, 24 felodipine ER, 32 etidronate disodium, 47 Femara, 20 etodolac, 24, 47 Femcon FE, 49 etoposide, 19 FemHRT, 49 Eucrisa, 37 Femring, 49 Eulexin, 19 fenofibrate, 32 Eurax, 37 fenofibrate nanocrystallized, 32 euthyrox, 41 fenofibric acid, 32 Evekeo [ODT], 24 Fenoglide, 32 everolimus (generic for Afinitor), 20 fenoprofen calcium, 25, 47 everolimus (generic for Zortress), 20 Fenortho, 47 Evista, 47, 49 fentanyl citrate OTFC, 25 Evoclin, 37 Fentanyl citrate tablet, 25 Evoxac, 40 Fentora, 25 Evrysdi Soln, 56 Ferriprox, 56 Evzio, 24 Fetzima, 25 Exalgo ER, 24 Fexmid, 47 Exelderm, 37 Fiasp, 41 Exelon, 24 Fibricor, 32 exemestane, 20 Finacea, 38 Exforge, 32 finasteride, 55 Exforge HCT, 32 Fintepla sol, 25 Exjade, 56 Fioricet, 25 Extavia, 25 Fioricet with codeine, 25 Extina, 37 Fiorinal with codeine, 25 Eysuvis Drop 0.25%, 50 Firazyr, 56 ezetimibe, 32 Firdapse, 56 ezetimibe/simvastatin, 31 Firvanq Soln, 16 Ezzalor Sprinkle Cap, 32 Flagyl, 16 flavoxate, 55 flecainide, 32 Flector Patch, 47 x Index

Flolipid susp, 32 Freestyle InsuLinx Test Strips, 41 Flomax, 55 Freestyle Lite Test Strips, 41 Flovent Diskus, 53 Freestyle Test Strips, 41 Flovent HFA, 53 Frova, 25 fluconazole suspension/tabs, 16 frovatriptan succinate, 25 flucytosine, 16 furosemide solution, 32 fludrocortisone acetate, 41 furosemide tabs, 32 Flumadine, 16 Fuzeon, 17 flunisolide, 53 Fycompa, 25 fluocinolone acetonide cream, soln, oil, 38 fluocinolone acetonide oil, 40 G fluocinonide gel, ointment, 38 fluoritab chew tab, 55 gabapentin, 25 fluorometholone, 50 gabapentin soln, 25 Fluorouracil cream 0.5%, 38 Gabitril, 25 fluorouracil solution 2%, 38 Galafold, 56 fluoxetine, 25, 27 galantamine, 25 fluoxetine 10mg, 20mg, 40mg, 25 galantamine ER, 25 fluoxetine soln, 25 ganirelix acetate soln, 56 fluphenazine, 25 Gastrocrom, 45 flurandrenolide cream, lotn, oint, 38 Gattex, 45 flurazepam, 25 Gavreto, 20 flurbiprofen, 25, 47, 50 gemfibrozil, 32 flutamide, 20 Gemmily cap 1/20, 49 fluticasone propionate cream, lotn, oint, 38 Generess FE, 49 fluticasone propionate nasal soln, 53 Genotropin, 41 fluticasone-salmeterol AER powder, 53 gentak oint 0.3% OP, 51 fluvastatin sodium, 32 gentamicin ophth, 51 fluvoxamine, 25 gentamicin topical cream, ointment, 38 fluvoxamine ER, 25 Geodon, 25 FML Liquifilm suspension, 50 Gilenya, 25 Focalin, 25 Gilotrif, 20 Focalin XR, 25 Gimoti Spray, 45 Follistim AQ, 49 glatiramer acetate, 25 fondaparinux, 32 glatopa, 25 ForFivo XL, 25 Gleevec, 20 Fortamet, 41 Gleostine, 20 Forteo, 41 glimepiride, 41, 43 Fortesta, 41 glipizide, 41 Fosamax, 47 glipizide ER, 41 Fosamax Plus D, 47 glipizide XL, 41 fosamprenavir calcium tab, 16 Gloperba Soln, 47 fosfomycin pow, 16 Glucagen Hypokit, 41 fosinopril, 32 Glucagon Emergency Kit, 41 fosinopril/HCTZ, 32 Glucophage, 41–42 Fosrenol chewable tab, 55 Glucophage XR, 42 Fragmin, 32 Glucotrol, 42 Freestyle Glucometer, 41 Glucotrol XL, 42 xi Index

Glucovance, 42 Humira, 47 Glumetza ER, 42 Humulin, 42 glyburide, 42 Hycamtin, 20 glyburide micronized, 42 Hycofenix, 53 Glynase, 42 hydralazine, 33 Glyset, 42 Hydrea, 20 Glyxambi, 42 hydrochlorothiazide, 31, 33, 35 Gocovri, 25 hydrocod-cpm-pseudoephedrine, 53 Golytely solution reconstituted 227.1gm, 45 hydrocodon-cpm-phenylephrine, 53 Golytely solution reconstituted 236gm, 45 hydrocodone bit/homatrop syrup, 53 Gonal, 49 hydrocodone ER, 25 granisetron, 45 hydrocodone-chlorpheniramine susp, 53 Grastek, 53 hydrocodone-homatropine, 25 Gris-PEG, 17 hydrocodone/acetaminophen, 25 griseofulvin microsize, 17 hydrocortisone, 38, 40, 42, 45 griseofulvin ultramicrosize, 17 hydrocortisone 2.5%, 38 guaifenesin-codeine soln 10mg/5ml, 25 hydrocortisone butyrate 0.1%, 38 guanfacine, 25, 32 hydrocortisone butyrate/emoll, 38 guanfacine ER, 25 hydrocortisone cream, 45 Gvoke hypo inj, 42 hydrocortisone lot 0.1%, 38 Gvoke PFS inj, 42 hydrocortisone retention enema, 45 hydrocortisone supp, 38 H hydrocortisone valerate 0.2%, 38 hydrocortisone/lidocaine HCl, 38 Haegarda, 56 hydromet, 53 hailey 1.5/30, 49 hydromorphone ER, 25 halcinonide cream 0.1%, 38 hydromorphone IR, 25 Halcion, 25 hydroxychloroquine, 17 halobetasol propionate, 38 hydroxyurea, 20 halobetasol propionate foam 0.05%, 38 hydroxyzine HCL syrup, 53 Halog, 38 hydroxyzine HCL tab, 53 haloperidol, 25 hydroxyzine pamoate, 53 Harvoni, 17 hypersal, 53 Hectorol, 42 Hysingla ER, 25 Helixate FS, 32 Hyzaar, 33 Hemady, 42 Hemlibra Soln, 32 I Hemofil M, 32 Hepsera, 17 ibandronate, 47 Hetlioz, 25 Ibrance, 20 Hexalen, 20 Ibudone, 25 Hiprex, 17 ibuprofen, 25, 27, 47 homatropaire sol 5% OP, 51 ibuprofen/hydrocodone, 25 homatropine ophthalmic, 51 icatibant inj, 56 Horizant, 25 Iclusig, 20 Humalog, 42 icosapent cap, 33 Humate-P, 33 Idelvion, 56 Humatrope, 42 Idhifa, 20 xii Index

IFE-PG20 Inj, 33 Iressa tab, 20 Ilevro Susp 0.3%, 51 Isentress, 17 imatinib mesylate, 20 isometheptene/dichloralphenazone/apap, 25 Imbruvica, 20 isoniazid, 17 Imcivree 10mg/ml Inj, 25 Isopto Carpine, 51 imipramine, 25 Isordil Titradose Tabs, 33 imiquimod cream, 38 isosorbide dinitrate, 33 Imiquimod Cream 3.75% Pump, 38 isosorbide dinitrate ER, 33 Imitrex, 25 isosorbide mononitrate, 33 Impavido, 17 isosorbide mononitrate ER, 33 Impeklo Lotion, 38 isotretinoin, 38 Impoyz cream 0.025%, 38 isradipine, 33 Imuran, 20 Istalol Drops, 51 Imvexxy, 49 Isturisa, 42 Inbrija, 25 itraconazole, 17 Increlex, 42 ivermectin, 17 Incruse Ellipta, 53 Ixinity, 33 indapamide, 33 Inderal LA, 33 J Indocin susp, 25 indomethacin, 47 Jadenu Sprinkle, 56 indomethacin 20mg capsule, 47 Jadenu Tab, 56 indomethacin SR, 47 Jakafi, 26 Ingrezza, 25 Jalyn, 55 Inlyta, 20 Jantoven, 33 InnoPran XL, 33 Janumet, 42 Inqovi tab, 20 Janumet XR, 42 Inrebic, 20 Januvia, 42 Inspra, 33 Jardiance, 42 insulin aspart inj, 42 Jatenzo, 42 insulin aspart protamin inj flexpen, 42 Jentadueto tablet, 42 insulin lispro, 42 Jentadueto XR, 42 insulin lispro inj junior, 42 Jivi, 33 insulin lispro inj protamin, 42 Jornay PM Capsule, 26 Intermezzo, 25 Jublia, 38 Intrarosa Vaginal, 49 Juluca, 17 Intuniv, 25 Juxtapid, 33 Invega ER tablet, 25 Jynarque, 55 Inveltys Susp, 51 Invirase, 17 K Invokamet [XR], 42 Invokana, 42 K-Phos, 55 Iopidine, 51 K-Tab, 55 ipratropium inhalation soln, 53 Kadian ER, 26 ipratropium nasal spray, 53 Kaletra Soln, 17 ipratropium-albuterol, 53 Kaletra Tabs, 17 irbesartan, 33 Kalydeco Tabs/Pack, 17 irbesartan hydrochlorothiazide, 33 Kapspargo, 33 xiii Index

Kapvay, 26 Lamisil Tabs, 17 Katerzia Susp, 33 lamivudine 100mg tab, 17 Kazano tablet, 42 lamivudine 150mg, 300mg tablets, 17 Keflex, 17 lamivudine/zidovudine, 17 Kenalog Spray, 38 lamotrigine, 26 Keppra, 26 lamotrigine ER, 26 Keppra XR, 26 lamotrigine ODT, 26 Kerydin, 38 Lampit, 17 Kesimpta Inj, 56 Lanoxin 62.5mcg, 187.5mcg tablets, 33 ketoconazole cream, 38 Lanoxin 125mcg and 250mcg tablets, 33 ketoconazole shampoo, 38 lansoprazole cap, 45 ketoconazole tabs, 17 lansoprazole solutab, 45 ketoprofen 25mg cap, 47 lanthanum chewable tab, 55 ketoprofen SR, 47 Lantus, 42 ketorolac, 26, 47, 51 lapatinib, 20 ketorolac opth soln, 51 Lasix, 33 ketorolac sol, 47 latanoprost, 51 Keveyis, 56 Latuda, 26 Kevzara, 47 Lazanda, 26 Khedezla, 26 ledipasvir-sofosbuvir tablet 90-400mg, 17 Kineret, 47 leflunomide, 47 kionex suspension, 56 Lenvima, 20 Kisqali, 20 Lescol, 33 Kitabis Pak, 53 Letairis, 33 Klaron, 38 letrozole, 20 Klonopin, 26 leucovorin calcium, 20 Klor-Con, 55 Leukeran, 20 Koate-DVI, 33 leuprolide, 20 Kogenate FS, 33 levalbuterol nebulizer, 53 Kombiglyze XR, 42 Levalbuterol tartrate HFA, 53 Korlym tablet, 42 Levaquin, 17 Koselugo, 20 Levemir, 42 Kovaltry, 33 levetiracetam, 26 Krintafel, 17 levetiracetam ER, 26 Kristalose Pak, 45 Levitra, 55 Kuvan, 53 levo-T tab, 42 Kynamro, 33 levobunolol, 51 Kynmobi Kit Titration, 26 levocarnitine, 42 Kynmobi Mis, 26 levofloxacin, 17 levonorgestrel/ethinyl estradiol, 49 L levonorgestrel/my way/next dose, 49 levorphanol, 26 labetalol HCl, 33 levothyroxine cap, 42 lactulose pak, 45 levothyroxine tab, 42 lactulose soln, 45 Levoxyl, 42 Lamictal, 26 Lexapro, 26 Lamictal ODT, 26 Lexette Foam, 38 Lamictal XR, 26 Lexiva, 17 xiv Index

Lialda, 45 Lovaza, 33 Librax, 26 Lovenox, 33 Licart Dis 1.3%, 47 loxapine, 26 lidocaine, 38–39 Lucemyra, 56 lidocaine solution, 38 Luliconazole cream, 38 Lidoderm, 38 Lumigan, 51 linezolid, 17 Lunesta, 26 Linzess, 45 Luxiq, 38 liothyronine, 42 Luzu, 38 Lipitor, 33 Lyllana Dis, 49 Lipofen, 33 Lynparza, 20 lisinopril, 33 Lyrica, 26 lisinopril/HCTZ, 33 Lyrica CR, 26 lithium carbonate, 26 Lyrica soln, 26 lithium carbonate ER, 26 Lysodren, 20 Livalo, 33 Lysteda, 49 Lo Loestrin FE, 49 Lyumjev Inj/Pen, 42 Locoid, 38 Locoid Lipocream, 38 M Lodine, 26 Lodosyn, 26 Macrodantin, 17 Loestrin, 49 Malarone, 17 Loestrin FE, 49 malathion lotion, 38 Lokelma Pak, 55 maprotiline, 26 Lomaira, 26 Marinol, 45 Lomotil, 45 Matulane, 20 Lonhala Magnair, 53 Mavenclad pak, 20 Lonsurf, 20 Mavyret, 17 loperamide, 45 Maxalt, Maxalt-MLT, 26 Lopid, 33 Maxitrol, 51 lopinavir/ritonavir, 17 Maxzide, 33 Lopressor HCT, 33 Mayzent tablet, starter pak, 26 Loprox, 38 Meclizine, 45 lorazepam, 26 meclofenamate, 26 lorazepam concentrate, 26 Medrol, 42 Lorbrena, 20 medroxyprogesterone, 49 Lortab, 26 medroxyprogesterone acetate tab, 49 Lorzone, 47 Medtronic Continuous Glucose Monitor Enlite, losartan, 33 MiniMed Guardian Sensors, 42 losartan-HCTZ, 33 Medtronic Continuous Glucose Monitor Guardian LoSeasonique, 49 Transmitter, 42 Lotemax [SM], 51 Medtronic Continuous Glucose Monitor Receiver, Lotensin, 33 42 loteprednol susp 0.5%, 51 mefloquine, 17 Lotrel, 33 Megace, 20 Lotrisone, 38 megestrol acetate, 20 Lotronex, 47 Mekinist, 20 lovastatin, 33 Mektovi, 20 xv Index

meloxicam cap, 47 metoprolol tartrate/HCT, 33 meloxicam tab, 47 MetroCream, 38 melphalan, 20 MetroGel, 38, 49 memantine, 26 Metrogel vaginal, 49 memantine ER, 26 MetroLotion, 38 Menopur, 49 metronidazole, 17, 38, 49 meperidine HCl, 26 metronidazole cream, lotion, gel, 38 Mephyton, 55 metronidazole vaginal gel, 49 meprobamate, 26 metyrosine, 43 Mepron, 17 Mevacor, 33 mercaptopurine, 20 mexiletine HCl, 33 mesalamine, 45 Miacalcin, 47 mesalamine DR, 45 Micardis, 33 mesalamine rectal susp, 45 Micardis HCT, 33 Mesnex, 20 miconazole-zinc ointment, 38 Mestinon syrup, 26 Microzide, 33 Mestinon tablet, 26 midodrine HCl, 56 metaproterenol, 53 Midrin, 26 metaxalone, 47 miglitol, 43 metformin, 40, 42 miglustat, 56 metformin ER (generic for Glucophage XR), 42 Migranal, 26 Metformin ER (MOD), 42 Millipred solution, 43 metformin ER (OSM), 42 Millipred tabs, 43 metformin HCL 500mg/5ml oral soln, 42 Minastrin 24 FE, 49 metformin/glyburide, 42 Minipress, 33 methadone, 26 minitran, 33 methamphetamine, 26 Minivelle, 49 methazolamide, 51 Minocin, 17 methenamine hippurate, 17 minocycline caps, 17 methimazole, 42 minocycline ER cap, 17 Methitest Tab, 43 minocycline ER tablet, 17 methocarbamol, 26, 47 Minolira, 17 methotrexate tab, 20 minoxidil, 33 methoxsalen, 38 Mirapex, 26 methyldopa, 33 Mirapex ER, 26 Methylin, 26 Mircette, 49 methylpenidate ER (XR), 26 mirtazapine, 26 methylphenidate, 26 Mirvaso, 38 methylphenidate ER, 26 misoprostol, 45, 47 methylphenidate ER (CD), 26 Mitigare, 47 methylphenidate ER (LA), 26 Mobic, 47 methylprednisolone, 43 modafinil, 26 methyltestosterone, 43 moderiba, 17 metoclopramide, 45 moexipril, 33 metolazone, 33 moexipril/HCTZ, 33 Metopirone, 56 molindone hcl, 26 metoprolol succinate, 33 mometasone cream, ointment, solution, 38 metoprolol tartrate, 33 mometasone furoate nasal spray, 40 xvi Index

Mondoxyne NL 75mg cap, 17 Namzaric, 27 Monoclate-P, 34 Naprelan, 47 Mononine, 34 Naprosyn, 47 montelukast sodium, 53 Naprosyn susp, 47 Monurol Pak Granules, 17 naproxen sodium, 47–48 MorphaBond ER, 26 naproxen sodium DR, 47 morphine IR, 26 naproxen sodium ER, 47 morphine sulfate ER, 26 naproxen sodium susp, 48 morphine suppositories, 27 naproxen-esomeprazole DR, 48 Motegrity, 45 naratriptan, 27 Movantik, 45 Narcan 4mg/actuation spray, 27 Moviprep, 45 Nardil, 27 Moxatag, 17 Nascobal, 55 Moxeza, 51 Nasonex, 40 moxifloxacin hcl, 17 Natazia, 49 moxifloxacin ophthalmic soln, 51 nateglinide, 43 MS Contin, 27 Natesto, 43 Mulpleta, 34 Natpara, 43 Multaq, 34 Natroba, 39 multivitamin with fluoride drops, tabs, 55 Nayzilam, 27 mupirocin cream, ointment, 38 Nebupent INH, 17 Muse, 55 nebusal nebulization solution, 55 Myalept, 43 nefazodone, 27 Myambutol, 17 neomycin/polymyxin B/ dexamethasone, 51 Mycapssa cap, 43 neomycin/polymyxin/ hydrocortisone, 51 Mycobutin, 17 Neoral, 20 mycophenolate, 20 Neosporin soln, 51 mycophenolic acid, 20 Nerlynx, 20 Mydayis, 27 Nesina tablet, 43 Mydriacyl, 51 Nestabs One, 55 Myfortic, 20 Neurontin, 27 Myleran, 20 Neurontin soln, 27 Myrbetriq, 55 Nevanac Susp 0.1%, 51 Mysoline, 27 nevirapine, 17 Mytesi, 17 nevirapine ER, 17 Nexavar, 20 N Nexium capsule, 45 Nexium packets, 45 nabumetone, 27, 47 Nexletol, 34 nadolol, 34 Nexlizet, 34 nadolol-bendroflume thiazide, 34 niacin ER, 34 naftifine cream/gel, 39 Niaspan, 34 Naftin, 39 nicardipine, 34 Nalfon, 27 Nifedical XL, 34 Nalocet, 27 nifedipine, 34 Naloxone injection 2mg, 27 nifedipine ER, 34 naltrexone 50mg, 27 Nilandron, 20 Namenda [XR], 27 nilutamide, 20 xvii Index

nimodipine, 34 Novolog, 43 ninjacof-XG liquid, 27 NovoSeven RT, 34 Ninlaro, 20 Noxafil, 17 nisoldipine ER, 34 Nubeqa, 20 nitazoxanide, 17 Nucala Soln, 53 nitisinone, 56 Nucynta, 27 Nitro-Bid, 34 Nucynta ER, 27 Nitro-Dur, 34 Nulytely, 45 Nitro-Time cap, 34 Nuplazid, 27 nitrofurantoin macrocrystals, 17 Nurtec Chw ODT, 27 nitrofurantoin susp, 17 Nutropin AQ, 43 nitroglycerin ER, 34 Nuvaring, 49 nitroglycerin patches, 34 Nuvigil, 27 nitroglycerin SL, 34 Nuwiq, 34 nitroglycerin spray, 34 Nuzyra, 17 Nitrolingual Spray, 34 Nymalize Sol, 34 Nitromist, 34 nystatin/triamcinolone cream, ointment, 39 Nitrostat SL, 34 Nityr, 56 O nizatidine solution, 45 Nizoral shampoo, 39 OB Complete, 49 Nocdurna SL, 34 Obizur, 34 Noctiva Emulsion, 43 Obredon, 53 Non Preferred Diabetic Meters, 43 Ocaliva, 56 Norditropin, 43 Ocufen, 51 norethin-ethynil-fer cap 1/20, 49 Ocuflox, 51 norethindrone, 49 Odactra SL, 53 norethindrone acetate, 49 Odomzo, 20 norethindrone-ethinyl estradiol, 49 Ofev, 53 norethindrone-mestranol, 49 ofloxacin, 40, 51 Norgesic Tab Forte, 48 ofloxacin otic, 40 norgestimate-ethinyl estradiol, 49 olanzapine, 27 norgestrel-ethinyl estradiol, 49 olanzapine ODT, 27 Noritate, 39 olanzapine/fluoxetine hcl, 27 Norpace, 34 olmesartan medoxomil, 34 Norpramin, 27 olmesartan/amlodipine/hctz, 34 Northera, 34 olmesartan/hctz, 34 nortriptyline, 27 olopatadine, 40, 51 nortriptyline soln, 27 olopatadine hcl, 51 Norvasc, 34 Olumiant, 56 Norvir powder, 17 Olux [E], 39 Norvir tablet, 17 omega-3 acid ethyl esters, 34 Nourianz, 27 omeprazole, 45 Novarel 5000 Unit, 56 omeprazole-sodium bicarbonate capsule Novarel 10000 Unit, 56 40-1100mg, 45 Novoeight, 34 Omnaris, 40 Novolin, 43 Omnipod 5 Pack, 43 Novolin R, 43 Omnipod Dash 5 Pack, 43 xviii Index

Omnipod Dash System, 43 Otrexup, 48 Omnipod Starter Kit, 43 Ovide, 39 Omnipred, 51 Ovidrel, 49 Omnitrope, 43 Oxandrin, 43 ondansetron HCl, 45 oxandrolone, 43 One Touch Glucometer, 43 oxaprozin, 27, 48 One Touch Test Strips, 43 Oxaydo, 27 Onexton, 39 oxazepam, 27 Onfi, 27 Oxbryta, 56 Onfi susp, 27 oxcarbazepine susp, 26 Ongentys, 27 oxcarbazepine tab, 27 Onglyza, 43 Oxervate soln 200mcg/ml, 51 Onmel, 18 oxiconazole nitrate, 39 Onureg, 20 Oxistat, 39 Onzetra Xsail, 27 Oxsoralen Ultra, 39 Opana, 27 Oxtellar XR, 27 Opana ER, 27 oxybutynin [ER], 55 ophth oint, 50 oxybutynin syrup, 55 Opsumit, 34 oxycodone ER tablet, 27 Oracea, 18 oxycodone IR, 27 Oralair, 53 oxycodone/acetaminophen, 27 Orap, 27 oxycodone/APAP 2.5-300mg, 5-300mg, 10-300mg Orapred ODT, 43 tab, 27 Orencia, 48 oxycodone/aspirin, 27 Orenitram, 34 oxycodone/ibuprofen, 27 Orfadin 20mg capsule, Orfadin 4mg/ml suspension, OxyContin, 27 56 oxymorphone ER, 27 Orfadin capsule 2mg, 5mg, 10mg, 56 oxymorphone IR, 27 Orgovyx tab, 20 Ozempic Soln, 43 Oriahnn cap, 48 Ozobax Soln, 27 Orilissa, 43 Orkambi tablet/packet, 18 P Orladeyo Cap, 56 orlistat, 45 Pacerone, 34 orphenadrine ER, 48 Palforzia cap/powder, 53 orphenadrine-asa-caffeine, 48 paliperidone ER tablet, 27 Orphengesic Forte Tab, 48 Palynziq, 43 Ortho Micronor, 49 Pamelor, 27 Ortho Novum, 49 Pancreaze, 45 Ortho Tri-Cyclen, 49 pancrelipase EC/SA, 45 Ortho Tri-Cyclen Lo, 49 Pandel, 39 Ortho-Cyclen, 49 pantoprazole, 45 Ortikos ER Cap, 20 pantoprazole pak, 45 oseltamivir caps/susp, 18 paricalcitol, 43 Oseni, 43 Parlodel, 27 Osmolex ER, 27 Parnate, 27 Osmoprep, 45 paroxetine, 27 Otezla, 48 paroxetine ER, 27 xix Index

Patanase, 40 Plaquenil, 18 Patanol, 51 Plavix, 34 Paxil CR, 27 Plegridy, 28 Paxil suspension, 27 Plenvu Soln, 46 Paxil tablet, 27 podofilox soln, 39 PEG 3350 & electrolytes, 45 polymyxin B/neo/bacitracin, 51 peg-kcl-nacl-nasulf-na asc-c soln reconstituted, 45 polymyxin B/neo/gramicidin, 51 Pegasys, 18 Polytrim, 51 PegIntron, 18 Pomalyst, 20 Pemazyre, 20 posaconazole, 18 penicillamine capsule, 56 Potaba, 57 penicillamine tablet, 56 potassium bicarbonate/potassium citrate penicillin v potassium tablet, 18 effervescent, 55 Penlac, 39 potassium chloride, 55 Pennsaid, 48 potassium citrate, 55 pentamidine INH, 18 Pradaxa, 34 Pentasa, 45 Praluent, 34 pentazocine-naloxone, 27 pramipexole, 28 pentoxifylline ER, 34 pramipexole ER, 28 Pepcid tabs, suspension, 46 Prandin, 43 Percocet, 28 prasugrel, 34 perindopril, 34 Pravachol, 34 permethrin, 39 pravastatin, 34 perphenazine, 28 praziquantel, 18 Persantine, 34 prazosin, 34 Pertzye, 46 Precision Glucometer, 43 phendimetrazine tartrate, 28 Precision XTRA Test Strips, 43 phenelzine, 28 Precose, 43 phenobarbital, 28 Pred-Forte, 51 phenoxybenzamine, 34 prednicarbate ointment, 39 phentermine hcl, 28 prednisolone, 43, 51 Phenytek, 28 prednisolone acetate, 51 phenytoin, 28 prednisolone sodium phosphate, 51 PhosLo, 56 prednisolone/sodium sulfacetamide, 51 phospha, 57 prednisone, 20 Phospholine Iodide, 51 prednisone therapy pack/solution/concentrate, 20 phytonadione, 55 pregabalin, 28 Pifeltro, 18 pregabalin soln, 28 pilocarpine, 40, 51 Pregenna, 55 pilocarpine HCl, 40 Pregnyl, 57 pimecrolimus cre 1%, 39 Premarin, 49 pimozide, 28 Premarin vaginal cream, 49 pindolol ER, 34 Premphase, 49 pioglitazone, 40, 43 Prempro, 49 pioglitazone/glimepiride, 43 Prenara, 55 Piqray, 20 Pretomanid, 18 piroxicam, 28, 48 Prevacid caps, 46 Plan B One-Step, 49 Prevacid SoluTab, 46 xx Index

Prevalite, 34 Provigil, 28 Prevymis, 18 Prozac, 28 Prezista, 18 Prudoxin cream 5%, 39 prilocaine/lidocaine, 39 Pulmicort Flexhaler, 54 Prilosec packets, 46 Pulmicort Respules, 54 primidone, 28 PulmoSal nebulization solution, 56 Primlev, 28 Pulmozyme, 54 Prinivil, 34 Purixan, 21 Pristiq, 28 Pylera Cap, 46 ProAir Digihaler, 53 pyridostigmine soln, 28 ProAir HFA, 52–53 pyridostigmine tab, 28 ProAir RespiClick, 53 pyrimethamin, 18 probenecid, 47–48 Procardia, 34 Q Procardia XL, 34 Procentra 1mg/ml, 28 Qbrelis, 34 prochlorperazine suppository, 46 Qbrexza Pad 2.4%, 39 prochlorperazine tabs, 46 Qdolo Sol 5mg/ml, 28 Proctofoam HC, 39 Qinlock tab, 21 Procysbi, 43 Qmiiz ODT, 28 Profilnine, 34 Qnasl, 40 progesterone, micronized, 49 Qsymia ER, 28 Proglycem Susp, 43 Qtern, 43 Prograf capsule/packet, 20 Qualaquin, 18 Prolate tab, 28 Quartette, 49 Prolensa sol 0.07%, 51 quazepam, 28 Promacta, 34 Qudexy XR, 28 promethazine, 53–54 Questran, 34 promethazine/codeine, 53 Questran Light, 34 promethazine/dextromethorphen, 53 quetiapine ER, 28 promethazine/phenylephrine, 54 quetiapine fumarate, 28 promethazine/phenylephrine/codeine, 54 Quflora, 56 promethegan supp, 28 Quillichew ER, 28 Prometrium, 49 Quillivant XR, 28 propafenone, 34 quinapril HCl, 34 propafenone SR, 34 quinapril/HCTZ, 35 proparacaine, 51 quinine sulfate, 18 propranolol, 34 Qvar, 54 propranolol ER, 34 propranolol/HCTZ, 34 R propylthiouracil, 43 Proscar, 55 rabeprazole DR tab 20mg, 46 Protonix, 46 Rabeprazole Sprinkle Cap 10mg, 46 Protonix packets, 46 Ragwitek, 54 Protopic, 20 raloxifene, 48–49 Proventil HFA, 52, 54 raloxifene hcl, 48 Proventil HFA), 52 ramelteon, 28 Provera, 48–49 ramipril, 35 xxi Index

Ranexa, 35 Riastap, 35 ranitidine 300mg, 46 Ribasphere Ribapak 200mg & 400mg/400mg & ranolazine, 35 600mg, 18 Rapaflo, 55 ribavirin, 40 Rapamune tab/sol, 21 Ridaura, 57 rasagiline, 28 rifabutin, 18 Rasuvo, 48 Rifadin, 18 Rayaldee, 56 rifampin, 18 Rayos, 43 Rilutek, 28 Razadyne, 28 riluzole, 28 Razadyne ER, 28 rimantadine, 18 Rebetol, 54 Rinvoq, 57 Rebif Rebidose, 28 Riomet [ER] solution/suspension 500mg/5ml, 43 Rebinyn Soln, 35 risedronate, 48 Recombinate, 35 risedronate DR, 48 RediTrex Inj, 21 Risperdal, Risperdal M-Tab, 28 Regimex, 28 risperidone, 28 Reglan, 46 Ritalin LA, 28 Regranex gel, 43 ritonavir, 17–18 Relafen, 28 rivastigmine, 28 Relafen DS, 28 Rixubis, 35 Relenza, 18 rizatriptan benzoate, 28 Relistor, 46 Robaxin, 28, 48 Relpax, 28 Rocaltrol capsules, 43 Remeron, 28 Rocklatan Soln, 51 Remeron SolTab, 28 ropinirole, 28 Renagel, 57 ropinirole ER, 28 Renvela, 57 rosuvastatin, 35 repaglinide, 43 Roxicodone, 28 Repatha, 35 Roxybond, 28 Requip, 28 Rozerem, 28 Requip XL, 28 Rozlytrek, 21 Rescula, 51 Rubraca, 21 Restasis, 51 Ruconest, 57 Restoril, 28 rufinamide susp 40mg/ml, 28 Retevmo cap, 21 Rukobia, 18 Retin-A, 39 Ruzurgi, 57 Retin-A Micro 0.04%, 0.1%, 39 Rybelsus, 43 Retin-A Micro 0.08%, 39 Ryclora, 54 Retrovir, 18 Rydapt, 21 Revatio, 35 Rytary, 28 Revlimid, 21 Rythmol SR, 35 Rexulti, 28 Ryvent, 54 Reyataz, 18 Reyvow, 28 S Rezira, 54 Rhofade 1% cream, 39 Sabril tablet/packet, 28 Rhopressa Soln 0.02%, 51 Safyral, 50 xxii Index

Saizen, 43 Skelaxin, 48 Salagen, 40 Sklice Lot 0.5%, 18 Samsca, 35 Skyrizi Inj, 39 Sandimmune, 21 Slynd, 50 Saphris, 28 sodium chloride inhalation, 54 sapropterin pow/tab, 57 sodium fluoride chew tab, 56 Saxenda, 28 sodium phenylbutyrate tab, 56 scopolamine patch, 46 sodium sulfacetamide suspension, 39 Seasonique, 50 sofosbuvir-velpatasvir tablet 400-100mg, 18 Secuado Patch, 29 Solaraze, 39 Seebri, 54 solifenacin, 55 Segluromet, 43 Soliqua, 43 selegiline HCl, 29 Solodyn, 18 selenium sulfide shampoo/lotion, 39 Solosec GRA, 18 Selzentry, 18 Soma, 48 Semglee Inj 100U/ML, 43 Somavert, 43 Semprex-D, 54 Sonata, 29 Sensipar, 43 Soolantra, 39 Serevent Diskus, 54 Soriatane, 39 Sernivo, 39 sotalol HCl, 35 Seroquel, 29 Sotylize, 35 Seroquel XR, 29 Sovaldi, 18 Serostim, 43 spinosad, 39 sertraline, 29 Spiriva, 54 sevelamer carbonate, 57 spironolactone, 35 Sevenfact Inj, 35 spironolactone/HCTZ, 35 Seysara, 18 Sporanox, 18 SFRowasa enema, 46 Sprix Nasal Spray, 29 Signifor, 43 Sprycel, 21 Siklos, 57 SSKI Solution, 18 sildenafil citrate 20mgtab, 10mg/ml susp, 35 Stalevo, 29 sildenafil citrate 25mg, 50mg, 100mg, 35 Starlix, 43 Silenor, 29 stavudine, 18 Siliq, 39 Staxyn, 55 silodosin, 29 Steglatro, 43 Silvadene, 39 Steglujan, 44 silver sulfadiazine, 39 Stelara, 48 Simbrinza Susp 1-0.2 %, 51 Stendra, 55 Simponi, 48 Stimate, 35 simvastatin, 32, 35 Stiolto Respimat, 54 simvastatin susp, 35 Stivarga, 21 Sinemet, 29 Strattera, 29 Sinemet CR, 29 Strensiq, 57 Singulair, 54 Striant buccal system, 44 sirolimus tab/soln, 21 Stribild, 18 Sirturo, 18 Striverdi Respimat Aer Solution, 54 Sitavig, 18 Stromectol, 18 Sivextro, 18 Suboxone Sublingual Film, 29 xxiii Index

Subsys, 29 Taltz Autoinjector, 39 Sucraid Solution 8500 unit/ml, 57 Talzenna, 21 sucralfate tabs, 46 Tamiflu, 18 Sular, 35 tamoxifen, 21 sulconazole cream/solution, 39 tamsulosin, 55 sulfacetamide, 39, 51 Tanzeum, 44 sulfamethoxazole/tmp, 18 Tapazole, 44 Sulfamylon, 39 Tarceva, 21 sulfasalazine, 46 Targadox, 18 sulindac, 29, 48 Targretin cap, 21 sumatriptan, 29 Targretin gel, 39 sumatriptan/naproxen, 29 Tarka, 35 Sunosi, 29 Tasigna, 21 Suprax Susp 100mg/5ml, 200mg/5ml, 18 Tasmar, 29 Sustiva, 18 tavaborole sol 5%, 39 Sutab, 46 Tavalisse, 57 Sutent, 21 Taytulla, 50 Sylatron, 29 tazarotene cream 0.1%, 39 Symbicort, 54 Tazorac cream/gel, 39 Symbyax, 29 Taztia XT, 35 Symdeko, 54 Tazverik 200mg, 21 Symfi, 18 Tecfidera, 29 Symfi Lo, 18 Technivie, 18 Symjepi Inj, 54 Tegretol [XR], 29 Symlin, 44 Tegretol susp, 29 Sympazan Film, 29 Tegsedi, 57 Symproic, 46 Tekturna, 35 Symtuza, 18 Tekturna HCT, 35 Synalar, 39 telmisartan, 35 Synarel, 50 telmisartan-amlodipine, 35 Syndros Sol, 46 telmisartan/hydrochlorothiazide, 35 Synjardy, 44 temazepam, 29 Synjardy XR, 44 Temixys, 18 Synthroid, 44 Temodar, 21 Syprine, 57 Temovate, 39 temozolomide, 21 T tenofovir, 18 Tenoretic, 35 Tabloid, 21 Tenormin, 35 Tabrecta tab, 21 terazosin, 55 Taclonex, 39 terbinafine tabs, 18 tacrolimus, 21 terbutaline sulfate tablet, 54 tadalafil (generic Adcirca), 54 terconazole cream, 50 tadalafil (generic Cialis), 54 Teriparatide Inj, 44 Tafinlar, 21 Tessalon Perles, 54 Tagrisso, 21 Testim Gel, 44 Takhzyro, 57 testosterone enanthate solution, 44 Talicia, 18 testosterone gel 1%, 1.62%, 44 xxiv Index

testosterone gel 10mg/act (2%), 44 Topicort cream/ointment, 39 testosterone solution 30mg/act, 44 Topicort spray, 39 tetrabenazine, 29 topiramate, 29 Thalomid, 21 topiramate sprinkle cap, 29 Theo-24, 54 Toprol XL, 35 Theochron, 54 toremifene, 21 theophylline extended release, 54 torsemide, 35 theophylline soln, 54 Tosymra Nasal Solution, 29 Thiola [EC], 54 Toujeo Solostar, 44 thioridazine, 29 Toviaz, 48 thiothixene, 29 Tracleer, 54 tiadylt ER, 35 Tradjenta tablet, 44 tiagabine hcl, 29 tramadol, 29 Tiazac, 35 tramadol ER (biphasic) tablet, 29 Tibsovo, 21 tramadol ER cap, 29 ticlopidine HCl, 35 tramadol ER tablet, 29 Tigan, 46 tramadol/acetaminophen, 29 Tiglutik Susp, 29 trandolapril, 35 Tikosyn, 35 trandolapril/verapamil ER, 35 timolol, 35, 51 Transderm-Scop patch, 46 timolol ophth, 51 Tranxene T, 29 Timoptic, 51 tranycypromine sulfate, 29 Timoptic Ocudose, 51 Travatan Z, 51 Timoptic XE, 51 travoprost, 51 Tindamax, 18 trazodone, 29 tinidazole, 18 Trelegy Ellipta, 54 Tirosint capsule/soln, 44 Tremfya, 39 Tivicay PD, 18 Tresiba, 44 Tivorbex, 29 tretinoin caps, 21 tizanidine, 48 tretinoin gel, cream, 39 Tobi, 18 tretinoin microspheres gel, 39 Tobradex ointment, 39 Tretten, 35 tobramycin nebulization soln, 18 Trexall tab, 21 tobramycin ophthalmic, 51 Treximet, 29 tobramycin-dexamethasone, 51 Trezix, 29 Tobrex, 51 Tri-Norinyl, 50 Tofranil, 29 Tri-Vi-Flor, Poly-Vi-Flor with and without iron, 56 tolbutamide, 44 triamcinolone acetonide, 39 tolcapone, 29 triamcinolone oint 0.05%, 39 tolmetin, 29, 48 triamterene cap, 35 tolmetin sodium, 29 triamterene/HCTZ, 35 Tolsura, 18 Trianex, 39 tolterodine tartrate, 55 triazolam, 29 tolterodine tartrate LA, 55 Tribenzor, 35 tolvaptan 15mg tab, 35 Tricor, 35 tolvaptan 30mg tab, 35 triderm cream, 39 Topamax, 29 trientine, 57 Topamax Sprinkle Capsules, 29 trifluoperazine, 29 xxv Index

trifluridine, 51 Urocit-K, 55 trihexyphenidyl, 29 Uroxatral, 55 Trijardy XR, 44 ursodiol, 46 Trikafta, 18 Utibron Neohaler, 54 Trileptal Susp, 29 Trileptal Tab, 29 V Trilipix, 35 trimethobenzamide, 46 V-GO, 44 trimethoprim sulfate/polymyxin B, 52 Vagifem, 50 trimipramine, 29 valacyclovir tab, 19 Trinaz, 56 Valchlor, 21 Trintellix, 29 Valcyte, 19 Triumeq, 18 valganciclovir, 19 Trizivir, 18 Valium, 29 Trokendi XR, 29 valproic acid, 30 tromethamine, 47 valsartan, 31, 35 tropicamide, 52 valsartan/hydrochlorothiazide, 35 trospium chloride, 55 Valtoco, 30 Trulance, 46 Valtrex, 19 Trulicity, 44 Vanadom, 48 Trusopt, 52 Vanatol S/LQ, 30 Truvada, 18 vancomycin, 19 trymine CG liquid, 29 Vandazole, 50 Tudorza Pressair, 54 Vanos Cream, 39 Tukysa, 21 vardenafil, 55 Turalio, 21 vardenafil ODT, 55 Tussicap, 54 Varubi, 46 Tuxarin ER, 54 Vascepa, 35 Tuzistra XR, 54 Vaseretic, 35 Twirla Dis, 50 Vasotec, 35 Twynsta, 35 Vecamyl, 35 Tykerb, 21 Vectical, 40 Tylenol w/Codeine, 29 Veltin, 40 Tymlos, 44 Vemlidy, 19 Tyvaso, 35 Venclexta, 21 venlafaxine, 30 U venlafaxine ER, 30 Ventavis, 35 Ubrelvy, 29 Ventolin HFA, 52, 54 Uceris, 44 verapamil HCl, 35 Uloric, 48 verapamil HCl ER, 35 Ultracet, 29 Verelan ER, PM, 35 Ultram, 29 Veripred soln 20mg/5ml, 44 Ultravate, 39 Verzenio, 21 Unithroid, 44 Vesicare, 55 Upneeq Soln, 52 Vfend, 19 Uptravi, 35 Viagra, 55 Urecholine, 55 Viberzi, 46 xxvi Index

Vibramycin, 19 Wilate, 36 Victoza, 44 Winlevi Cream 1%, 40 Videx EC, 19 wixela inhub aer, 54 Viekira Pak, 19 Wynzora Cream, 40 Viekira XR, 19 vigabatrin, 30 X vigadrone, 30 Vigamox, 52 Xadago, 30 Viibryd, 48 Xalatan, 52 Vimovo, 46 Xalkori, 21 Vimpat tablet/solution, 30 Xanax, 30 Viokace, 46 Xanax XR, 30 Viramune suspension, 19 Xarelto, 36 Viramune tablet, 19 Xatmep, 21 Viramune XR, 19 Xcopri pak/tab, 30 Virazole, 40 Xeljanz [XR], 48 Viread, 19 Xeloda, 21 Viroptic, 52 Xelpros Emulsion, 52 Vistaril, 54 Xenazine, 30 Vitrakvi, 21 Xenical, 46 Vituz, 54 Xenleta, 19 Vivelle Dot, 50 Xepi Cream 0.1%, 19 Vivlodex, 30 Xermelo, 46 Vizimpro, 21 Xhance, 40, 54 Vogelxo, 44 Xifaxan 200mg, 19 Voltaren Gel, 48 Xifaxan 550mg, 19 Vonvendi, 35 Xigduo XR, 44 voriconazole, 19 Xiidra, 52 Vosevi, 19 Ximino ER, 19 VoSpire ER, 54 Xodol, Norco, 30 Votrient, 21 Xofluza Therapy Pack, 19 Vraylar, 30 Xolegel, 40 Vumerity, 44 Xopenex, 54 Vusion, 40 Xopenex HFA, 54 Vyleesi, 50 Xospata, 21 Vyndaqel, Vyndamax, 35 Xpovio Pak, 21 Vytorin, 36 Xtampza ER, 30 Vyvanse, 30 Xtandi, 21 Vyzulta Soln 0.024% OP, 52 xulane, 50 Xultophy, 44 W Xuriden, 57 Xyntha, 36 w/codeine, 21, 29 Xyosted Soln, 44 Wakix, 30 Xyrem, 30 warfarin, 36 Xywav Soln, 30 Welchol, 36 Wellbutrin SR, 30 Wellbutrin XL, 30 xxvii Index

Y Zocor, 36 Zofran, 46 Yasmin, 50 Zohydro ER, 30 YAZ, 50 Zolinza, 21 Yonsa, 21 zolmitriptan, 30 Yosprala DR, 48 Zoloft, 30 Yupelri Soln, 54 zolpidem tartrate, 30 yuvafem, 50 zolpidem tartrate ER, 30 zolpidem tartrate SL, 30 Z Zolpimist, 30 Zomacton, 44 Z-Tuss AC, 54 Zomig, 30 zafirlukast, 54 Zonalon cream 5%, 40 zaleplon, 30 Zonegran, 30 Zalvit, 56 zonsinamide, 30 Zanaflex, 48 Zorbtive, 46 Zantac, 46 Zortress, 20–21 Zarontin, 30 Zorvolex, 30 Zavesca, 57 Zovirax cream, 40 Zcort 7-day tab, 44 Zovirax oint, 40 Zegerid capsule, 46 Ztlido Pad 1.8%, 40 Zegerid packets, 46 Zubsolv, 30 Zejula, 21 Zuplenz, 46 Zelboraf, 21 Zurampic 200mg, 48 Zelnorm, 46 Zutripro, 54 Zembrace Symtouch, 30 Zyban, 30 Zemplar, 44 Zydelig, 21 Zenpep, 46 Zyflo 600mg, 54 Zenzedi, 30 Zyflo CR 600mg, 54 Zepatier, 19 Zykadia, 21 Zeposia, 48 Zyloprim, 48 Zerit, 19 Zymaxid, 52 Zerviate Drops 0.24%, 52 Zypitamag, 36 Zestoretic, 36 Zyprexa, 30 Zestril, 36 Zyprexa Zydis, 30 Zetia, 36 Zytiga, 21 Zetonna, 40 Zyvox, 19 Ziac, 36 Ziagen, 19 Ziana, 40 zidovudine, 15, 17, 19 zileuton ER 600mg, 54 Zilxi Aer, 40 Zioptan, 52 ziprasidone, 30 Zipsor, 48 Zithromax, 19 Zmax, 19 xxviii AmeriHealth Value Formulary offered by: AmeriHealth HMO, Inc. AmeriHealth Insurance Company of New Jersey

www.amerihealthnj.com

7/21 AHNJ