Washington Essential Rx Drug List

The Essential Rx Drug List includes a list of drugs covered by Health Net. This drug list is for Washington. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/wadruglistpdf or call us at the toll-free telephone number on your Health Net ID card.

WA Essential Drug List Updated: July 1, 2020

Welcome to Health Net

What is the Essential Rx Drug List? The Essential Rx Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)

How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents.

Abbreviation Copayment/Coinsurance Description 1 Tier 1 copayment or Generic drugs coinsurance 2 Tier 2 copayment or Preferred brand drugs coinsurance 3 Tier 3 copayment or Non-preferred brand drugs coinsurance SP Specialty copayment or Specialty drugs. This category includes self- coinsurance administered injectable and some oral high cost drugs. You may be required to get these drugs from a Specialty pharmacy. AC Anticancer drug copayment Self-administered anticancer drugs. You or coinsurance may be required to get these drugs from a Specialty pharmacy. PV $0 Preventive benefit drugs. These drugs must be covered at no cost to enrollees under the Affordable Care Act. A deductible does not apply. GP Generic Preferred This includes most brand name drugs with a generic equivalent. Depending on your plan, these drugs are either not covered (non- formulary), covered at Tier 3 or covered at a copayment plus the difference in cost between the brand and generic drug. Refer to your Summary of Benefits or other plan documents.

ii How do I use the drug list? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

What if my drug is not on the drug list? If your drug is not on the drug list, call us at the telephone number on your Health Net ID card and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. Your doctor can ask us to make an exception if he or she feels you need the drug that is not covered. If we approve an exception request for a drug not on the drug list, the non-preferred brand tier (Tier 3) copayment will apply.

What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less.

Generic drugs are available on the drug list at Tier 1. Brand name drugs with a generic equivalent are either non-formulary or non-preferred, depending on your plan benefits. If your doctor determines that you need a brand name drug instead of its generic equivalent, your doctor can submit a prior authorization request for a formulary exception with documentation of medical necessity.

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA or clinical recommendations. PA Prior Authorization These drugs require prior authorization for coverage, effectiveness or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. RX/OTC Prescription & Over- Certain drugs are available both in a prescription the-Counter (OTC) form and in an OTC form. Only prescription drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs. ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.

iii How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage. • Your doctor can ask us to cover your drug even if it is not on the drug list. • Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198.

Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” and, in most cases, must be obtained from one of Health Net’s approved Specialty Pharmacies.

Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies.

Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your Health Net ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online, so you may have to pay the full cost of your drug. If you do pay out-of-pocket for your drug, you may be able to send us your pharmacy receipt and ask for reimbursement of our share of the cost. Please refer to your plan documents for more information.

Some injectable and high cost drugs (including anticancer drugs) may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s approved Specialty pharmacies.

Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition.

To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com or you may call us at the telephone number on your Health Net ID card to request a form.

How often can I refill my prescription? • For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as directed. • For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used as directed.

If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.

iv How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at Health Net participating pharmacies. • Be sure your doctor prescribes drugs on the drug list • Fill your maintenance drugs through our mail order pharmacy program.

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because of race, color, national origin, age, disability, or sex. Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at 1-888-802-7001 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Nondiscrimination Notice FLY029224ER00 (1/20)

OR WA Commercial Notice of Language Assistance

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Notice of Language Assistance FLY029225ER00 (1/20) Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(1 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine ADHD, Sleep and Eating Disorders cp24 5 mg-5 mg-5 mg- Amphetamines 5 mg, 2.5 mg-2.5 mg- (Dextroamphetamine 2.5 mg-2.5 mg, 7.5 mg- Sulfate) PROCENTRA 1 7.5 mg-7.5 mg-7.5 mg, 1 SOLN 1.25 mg-1.25 mg-1.25 (Dextroamphetamine 1 bal on hand, mg-1.25 mg, 3.75 mg- Sulfate) ZENZEDI TABS 1 3.75 mg-3.75 mg-3.75 2.5 MG, 7.5 MG mg, 6.25 mg-6.25 mg- (Dextroamphetamine 6.25 mg-6.25 mg Sulfate) ZENZEDI TABS 5 1 MG, 10 MG, 7.5 MG amphetamine- ADDERALL TABS 2.5 MG- dextroamphetamine 2.5 MG-2.5 MG-2.5 MG, tabs 5 mg-5 mg-5 mg-5 1.25 MG-1.25 MG-1.25 mg, 2.5 mg-2.5 mg-2.5 MG-1.25 MG, 3.75 MG- mg-2.5 mg, 7.5 mg-7.5 3.75 MG-3.75 MG-3.75 mg-7.5 mg-7.5 mg, MG, 1.875 MG-1.875 MG- GP 1.25 mg-1.25 mg-1.25 1 1.875 MG-1.875 MG, 3.125 MG-3.125 MG-3.125 MG- mg-1.25 mg, 3.75 mg- 3.125 MG 3.75 mg-3.75 mg-3.75 (amphetamine- mg, 1.875 mg-1.875 dextroamphetamine) mg-1.875 mg-1.875 ADDERALL TABS 5 MG-5 mg, 3.125 mg-3.125 MG-5 MG-5 MG, 7.5 MG- mg-3.125 mg-3.125 mg 7.5 MG-7.5 MG-7.5 MG DESOXYN TABS PA NF GP (amphetamine- (methamphetamine hcl) dextroamphetamine) DEXEDRINE CP24 ADDERALL XR CP24 2.5 QL(1 ea daily) (dextroamphetamine GP MG-2.5 MG-2.5 MG-2.5 sulfate) MG, 1.25 MG-1.25 MG- dextroamphetamine 1.25 MG-1.25 MG, 3.75 GP 1 MG-3.75 MG-3.75 MG-3.75 sulfate cp24 MG (amphetamine- dextroamphetamine 1 dextroamphetamine) sulfate soln ADDERALL XR CP24 5 QL(1 ea daily) dextroamphetamine 1 MG-5 MG-5 MG-5 MG, 7.5 sulfate tabs MG-7.5 MG-7.5 MG-7.5 PA MG, 6.25 MG-6.25 MG- NF methamphetamine hcl 1 6.25 MG-6.25 MG tabs (amphetamine- VYVANSE CAPS QL(1 ea daily) dextroamphetamine) (lisdexamfetamine 2 ADZENYS ER SUER 1 bal on hand, dimesylate) NF (amphetamine) VYVANSE CHEW QL(1 ea daily) (lisdexamfetamine 2 dimesylate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Analeptics dexmethylphenidate hcl cp24 25 mg, 30 mg, 35 1 caffeine citrate soln 1 mg, 40 mg Attention-Deficit/Hyperactivity Disorder (ADHD) dexmethylphenidate hcl QL(1 ea daily) QL(2 ea daily) atomoxetine hcl caps cp24 5 mg, 10 mg, 15 1 10 mg, 18 mg, 25 mg, 1 mg, 20 mg, 30 mg, 35 40 mg, 80 mg, 100 mg mg, 40 mg QL(1 ea daily) dexmethylphenidate hcl QL(2 ea daily) atomoxetine hcl caps 1 60 mg, 80 mg, 100 mg tabs 5 mg, 10 mg, 2.5 1 QL(4 ea daily) mg clonidine hcl (adhd) 1 tb12 FOCALIN TABS QL(2 ea daily) QL(1 ea daily) (dexmethylphenidate GP guanfacine hcl (adhd) 1 tb24 hcl) FOCALIN XR CP24 15 MG QL(1 ea daily) INTUNIV TB24 QL(1 ea daily) GP (dexmethylphenidate NF (guanfacine hcl (adhd)) hcl) KAPVAY TB12 ( QL(4 ea daily) clonidine GP FOCALIN XR CP24 25 MG ) hcl (adhd) (dexmethylphenidate NF STRATTERA CAPS 10 QL(2 ea daily) hcl) MG, 25 MG, 40 MG NF ( ) FOCALIN XR CP24 35 atomoxetine hcl MG, 40 MG STRATTERA CAPS 18 QL(2 ea daily) (dexmethylphenidate GP MG, 80 MG, 100 MG GP hcl) (atomoxetine hcl) FOCALIN XR CP24 5 MG, QL(1 ea daily) STRATTERA CAPS 60 QL(1 ea daily) 10 MG, 20 MG, 30 MG, 40 MG, 80 MG, 100 MG GP MG GP (atomoxetine hcl) (dexmethylphenidate Stimulants - Misc. hcl) (Methylphenidate Hcl) QL(1 ea daily) METHYLIN SOLN 1 GP METADATE ER TBCR (methylphenidate hcl) armodafinil tabs 1 PA methylphenidate hcl chew 5 mg, 10 mg, 2.5 1 CONCERTA TBCR 18 MG, QL(1 ea daily) mg 27 MG (methylphenidate GP hcl) methylphenidate hcl QL(1 ea daily) CONCERTA TBCR 36 MG QL(2 ea daily) cp24 10 mg, 20 mg, 30 1 GP (methylphenidate hcl) mg, 40 mg CONCERTA TBCR 54 MG QL(1 ea daily) methylphenidate hcl NF (methylphenidate hcl) cpcr 10 mg, 30 mg, 40 1 DAYTRANA PTCH QL(1 ea daily) mg, 50 mg, 60 mg 3 (methylphenidate) methylphenidate hcl QL(2 ea daily) cpcr 20 mg, 30 mg, 40 1 mg, 50 mg, 60 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methylphenidate hcl ODACTRA SUBL (dust PA soln 5 mg/5ml, 10 1 mite mixed allergen 3 mg/5ml extract) methylphenidate hcl ORALAIR ADULT SAMPLE PA 1 KIT SUBL (grass mixed tabs 5 mg, 10 mg, 20 3 mg pollens allergen QL(1 ea daily)1 extract) methylphenidate hcl 1 tb24 18 mg, 54 mg bal on hand, ORALAIR ADULT PA STARTER PACK SUBL QL(1 ea daily) 3 methylphenidate hcl 1 (grass mixed pollens tb24 27 mg, 54 mg allergen extract) QL(2 ea daily) methylphenidate hcl 1 ORALAIR SUBL (grass PA tb24 36 mg, 54 mg mixed pollens allergen 3 methylphenidate hcl QL(1 ea daily) extract) 1 tbcr 10 mg, 18 mg, 20 RAGWITEK SUBL (short PA mg, 27 mg, 54 mg ragweed pollen 3 QL(2 ea daily) methylphenidate hcl 1 allergen extract) tbcr 36 mg, 54 mg Biologicals Misc METHYLPHENIDATE QL(1 ea daily) ADAGEN SOLN PA HYDROCHLORIDE ER SP TBCR 72 MG 3 (pegademase bovine) (methylphenidate hcl) AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections modafinil tabs 1 ST; QL(1 ea daily) Aminoglycosides NUVIGIL TABS PA GP (Tobramycin) (armodafinil) TOBRAMYCIN SP PROVIGIL TABS ST; QL(1 ea INHALATION SOLUTION GP (modafinil) daily) PAK NEBU QUILLIVANT XR SRER PA; QL(12 ml SP PA 3 amikacin sulfate soln (methylphenidate hcl) daily) ARIKAYCE SUSP PA RELEXXII TBCR QL(1 ea daily) 3 (amikacin sulfate SP (methylphenidate hcl) liposome) RITALIN LA CP24 QL(1 ea daily) BETHKIS NEBU PA GP SP (methylphenidate hcl) (tobramycin) RITALIN TABS GP gentamicin in saline PA; 1 bal on (methylphenidate hcl) hand, soln 0.9 %-0.8 mg/ml, SP ALLERGENIC EXTRACTS/BIOLOGICALS MISC 0.9 %-1.6 mg/ml, 0.9 %-1 mg/ml Allergenic Extracts gentamicin in saline PA GRASTEK SUBL PA soln 0.9 %-1.2 mg/ml, SP (timothy grass pollen 3 0.9 %-1.6 mg/ml, 0.9 allergen extract) %-1 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA SIMPONI SOAJ PA gentamicin sulfate soln SP SP (golimumab) KITABIS PAK NEBU 1 bal on hand, SIMPONI SOSY PA SP SP (tobramycin) (golimumab) neomycin sulfate tabs 1 Antirheumatic - Enzyme Inhibitors 1 bal on hand, RINVOQ TB24 PA paromomycin sulfate 1 SP caps (upadacitinib) XELJANZ TABS PA paromomycin sulfate 1 SP caps (tofacitinib citrate) PA; 1 bal on XELJANZ XR TB24 11 MG PA streptomycin sulfate SP SP solr hand, (tofacitinib citrate) Antirheumatic Antimetabolites TOBI NEBU ( ) SP tobramycin METHOTREXATE TABS TOBI PODHALER CAPS PA (methotrexate sodium 2 SP (tobramycin) (antirheumatic)) tobramycin nebu SP OTREXUP SOAJ PA (methotrexate SP tobramycin nebu SP 1 bal on hand, (antirheumatic)) RASUVO SOAJ PA tobramycin sulfate soln PA; 1 bal on SP (methotrexate SP 10 mg/ml hand, (antirheumatic)) PA tobramycin sulfate soln SP 80 mg/2ml Gold Compounds RIDAURA CAPS 2 ANALGESICS - ANTI-INFLAMMATORY - Drugs (auranofin) to Treat Pain, Swelling, Muscle and Joint Conditions Interleukin-1 Blockers ARCALYST SOLR PA Anti-TNF-alpha - Monoclonal Antibodies SP HUMIRA PEDIATRIC PA (rilonacept) CROHNS DISEASE SP Interleukin-1 Receptor Antagonist (IL-1Ra) STARTER PACK PSKT KINERET SOSY PA SP (adalimumab) (anakinra) HUMIRA PEN PNKT PA SP Interleukin-6 Receptor Inhibitors (adalimumab) ACTEMRA SOLN PA HUMIRA PEN-CD/UC/HS PA SP ( ) STARTER PNKT SP tocilizumab ACTEMRA SOSY PA (adalimumab) SP HUMIRA PEN-PS/UV PA (tocilizumab) STARTER PNKT SP KEVZARA SOAJ 150 PA; SP (adalimumab) MG/1.14ML, 200 SP HUMIRA PSKT PA MG/1.14ML (sarilumab) SP (adalimumab) KEVZARA SOSY 150 PA MG/1.14ML, 200 SP SIMPONI ARIA SOLN PA SP MG/1.14ML (sarilumab) (golimumab) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anti-inflammatory Agents (NSAIDs) CELEBREX CAPS 50 MG, ST; QL(2 ea 100 MG, 200 MG GP daily) (Fenoprofen ) 1 PROFENO TABS (celecoxib) (Ibuprofen) CHILDRENS RX/OTC ST; QL(2 ea IBUPROFEN, TGT celecoxib caps 400 mg 1 daily); AL(At IBUPROFEN CHILDRENS, least 60 yrs TGT CHILDRENS old) IBUPROFEN, SM ST; QL(2 ea celecoxib caps 50 mg, 1 CHILDRENS IBUPROFEN, 100 mg, 200 mg daily) SB CHILDRENS CHILDRENS ADVIL SUSP RX/OTC IBUPROFEN, RA GP IBUPROFEN CHILDRENS, (ibuprofen) RA IBUPROFEN, QC CHILDRENS MOTRIN RX/OTC GP CHILDRENS IBUPROFEN, SUSP (ibuprofen) PX CHILDRENS PROFEN DAYPRO TABS IB, IBUPROFEN GP CHILDRENS, HYVEE (oxaprozin) IBUPROFEN CHILDRENS, 1 diclofenac potassium 1 HM IBUPROFEN tabs CHILDRENS, GOODSENSE diclofenac sodium tb24 1 IBUPROFEN CHILDRENS, or 100 mg GNP CHILDRENS diclofenac sodium tbec IBUPROFEN, EQL or 25 mg, 50 mg, 75 1 CHILDRENS IBUPROFEN, EQ IBUPROFEN mg CHILDRENS, CVS diclofenac w/ 1 IBUPROFEN CHILDRENS, misoprostol tbec CVS CHILDRENS DUEXIS TABS PA IBUPROFEN, CHILDRENS 3 MEDI-PROFEN, (ibuprofen-famotidine) CHILDRENS IBUPROFEN EC-NAPROSYN TBEC GP 100 SUSP (naproxen) EC-NAPROXEN TBEC (Ibuprofen) IBU TABS 1 GP (naproxen) (Naproxen) NAPROXEN 1 DR TBEC etodolac caps 200 mg, 1 ANAPROX DS TABS 300 mg GP (naproxen sodium) etodolac tabs 400 mg, 1 ARTHROTEC 50 TBEC 500 mg ( GP QL(2 ea daily) diclofenac w/ etodolac tb24 400 mg, 1 misoprostol) 500 mg, 600 mg ARTHROTEC 75 TBEC FELDENE CAPS GP (diclofenac w/ GP (piroxicam) misoprostol) FENOPROFEN CALCIUM ST; QL(2 ea CAPS 200 MG 3 CELEBREX CAPS 400 MG GP daily); AL(At (fenoprofen calcium) (celecoxib) least 60 yrs old) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, MOBIC TABS 15 MG QL(1 ea daily) fenoprofen calcium 1 GP caps 200 mg, 400 mg (meloxicam) MOBIC TABS 7.5 MG QL(2 ea daily) fenoprofen calcium 1 GP tabs 600 mg (meloxicam) FENORTHO CAPS nabumetone tabs 500 QL(4 ea daily) 3 1 (fenoprofen calcium) mg QL(3 ea daily) flurbiprofen tabs 1 nabumetone tabs 750 1 mg ibuprofen susp 100 RX/OTC NALFON CAPS 400 MG 1 3 mg/5ml (fenoprofen calcium) ibuprofen tabs 400 mg, NALFON TABS 600 MG 1 GP 600 mg, 800 mg (fenoprofen calcium) INDOCIN SUPP RE 50 MG 3 NAPRELAN TB24 375 MG, (indomethacin) 500 MG (naproxen GP INDOCIN SUSP OR 25 sodium) 2 MG/5ML (indomethacin) NAPRELAN TB24 750 MG 3 indomethacin caps 20 ST; QL(3 ea (naproxen sodium) 1 daily)1 bal on NAPROSYN SUSP mg, 50 mg GP hand, (naproxen) indomethacin caps 25 NAPROSYN TABS 1 GP mg, 50 mg (naproxen) indomethacin cpcr 75 1 mg naproxen sodium tabs 1 ketoprofen caps 1 1 bal on hand, naproxen sodium tb24 1 ketoprofen cp24 1 1 bal on hand, naproxen susp 1 KETOROLAC QL(1 ea daily,5 naproxen tabs 1 TROMETHAMINE SOLN day(s) limit) NA 15.75 MG/SPRAY 3 naproxen- PA (ketorolac esomeprazole 1 tromethamine) tbec QL(0.67 ea ketorolac tromethamine 1 oxaprozin tabs 1 tabs or 10 mg daily) LODINE TABS (etodolac) GP piroxicam caps 1 1 bal on hand, SPRIX SOLN (ketorolac QL(1 ea daily,5 meclofenamate sodium 1 3 day(s) limit) caps tromethamine) mefenamic acid caps 1 sulindac tabs 1 TIVORBEX CAPS 20 MG, ST; QL(3 ea QL(1 ea daily) 3 meloxicam tabs 15 mg 1 40 MG (indomethacin) daily) meloxicam tabs 7.5 mg 1 QL(2 ea daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; QL(3 ea ENBREL SURECLICK PA TIVORBEX CAPS 20 MG, SP 3 daily)1 bal on SOAJ (etanercept) 40 MG (indomethacin) hand, ANALGESICS - NonNarcotic - Drugs to Treat tolmetin sodium caps 1 1 bal on hand, Pain, Muscle and Joint Conditions Analgesic Combinations tolmetin sodium tabs 1 1 bal on hand, (Acetaminophen- 1 bal on hand, VIMOVO TBEC PA Salicylamide- 1 (naproxen- Phenyltoloxamine) esomeprazole GP DURAXIN CAPS magnesium) (Butalbital-Acetaminophen) 1 ZIPSOR CAPS ST BUPAP, TENCON TABS 3 (diclofenac potassium) (Butalbital-Acetaminophen) 1 1 bal on hand, BUPAP, TENCON TABS ZORVOLEX CAPS ST; QL(3 ea 3 (Butalbital-Acetaminophen- (diclofenac) daily) Caffeine) ESGIC, 1 Phosphodiesterase 4 (PDE4) Inhibitors ZEBUTAL, PHRENILIN OTEZLA TABS PA FORTE CAPS SP (apremilast) (Butalbital-Acetaminophen- Caffeine) VANATOL LQ, OTEZLA TBPK PA 1 SP VTOL LQ, VANATOL S (apremilast) SOLN Pyrimidine Synthesis Inhibitors butalbital- ARAVA TABS 10 MG QL(2 ea daily) acetaminophen tabs GP 1 (leflunomide) 300 mg-50 mg, 325 ARAVA TABS 20 MG QL(1 ea daily) mg-50 mg GP (leflunomide) butalbital- leflunomide tabs 10 mg 1 QL(2 ea daily) acetaminophen- 1 caffeine caps leflunomide tabs 20 mg 1 QL(1 ea daily) butalbital- acetaminophen- 1 Selective Costimulation Modulators caffeine tabs ORENCIA CLICKJECT PA SP SOAJ (abatacept) butalbital-aspirin- 1 caffeine caps ORENCIA SOLR PA SP (abatacept) BUTALBITAL/ACETAMINO PHEN CAPS (butalbital- NF ORENCIA SOSY PA SP acetaminophen) (abatacept) BUTALBITAL/ASPIRIN/CA Soluble Tumor Necrosis Factor Receptor Agents FFEINE TABS ENBREL MINI SOCT PA (butalbital-aspirin- 2 SP (etanercept) caffeine) ENBREL SOLR PA SP ESGIC TABS (butalbital- (etanercept) acetaminophen- GP ENBREL SOSY PA caffeine) SP (etanercept)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIORICET CAPS (Aspirin) CVS ASPIRIN, PV (butalbital- BAYER ASPIRIN, BAYER acetaminophen- GP ADVANCED ASPIRIN ) REGULAR STRENGTH, caffeine ASPIRIN ADULT, RA FIORINAL CAPS ASPIRIN, TGT ASPIRIN, (butalbital-aspirin- GP SM ASPIRIN, SB ASPIRIN, caffeine) RA PAIN RELIEF PV ASPIRIN, QC ASPIRIN, PX Salicylates ASPIRIN, NORWICH (Aspirin) CVS ASPIRIN PV ASPIRIN, MM ASPIRIN, ADULT LOW DOSE, MEDIQUE ASPIRIN, HM CHILDRENS ASPIRIN ASPIRIN, GOODSENSE LOW STRENGTH, ASPIRIN, GNP ASPIRIN, CHILDRENS ASPIRIN, EQL ASPIRIN, EQ BAYER CHEWABLE LOW ASPIRIN TABS DOSE, ASPIRIN LOW STRENGTH, ASPIRIN LOW DOSE, ASPIRIN CHILDRENS, ASPIRIN ADULT LOW STRENGTH, ASPIRIN ADULT LOW DOSE, ASPIRIN 81 LOW DOSE, RA ASPIRIN ADULT LOW DOSE, TGT CHILDRENS ASPIRIN, TGT ASPIRIN, ST JOSEPH LOW DOSE ASPIRIN, SM CHILDRENS ASPIRIN, SM ASPIRIN LOW DOSE, SM ASPIRIN PV ADULT LOW STRENGTH, SB CHILDRENS ASPIRIN, RA CHILDRENS ASPIRIN, RA ASPIRIN CHILDRENS, RA ASPIRIN ADULT LOW STRENGTH, QC CHILDRENS ASPIRIN, QC CHEWABLE ASPIRIN LOW DOSE, QC ASPIRIN LOW DOSE, PX ASPIRIN, HM ASPIRIN, GOODSENSE ASPIRIN ADULT LOW STRENGTH, GOODSENSE ASPIRIN, GNP ADULT ASPIRIN LOW STRENGTH, EQL ASPIRIN LOW DOSE, EQ CHILDRENS ASPIRIN, EQ ASPIRIN LOW DOSE CHEW

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) CVS ASPIRIN, PV DOSE, GNP ASPIRIN, BAYER LOW DOSE, EQL ASPIRIN LOW DOSE, BAYER ASPIRIN EQL ASPIRIN EC, EQ REGIMEN, BAYER ASPIRIN LOW DOSE, EQ ASPIRIN EC LOW DOSE, ASPIRIN EC, EQ ASPIRIN BAYER ASPIRIN, ADULT LOW DOSE, EQ ASPIRTAB, ASPIRIN ASPIRIN, EQ ADULT REGIMEN LOW ASPIRIN LOW DOSE/ADULT, ASPIRIN STRENGTH, ECPIRIN, LOW DOSE, ASPIRIN ECOTRIN LOW ENTERIC COATED STRENGTH, ECOTRIN, ADULT LOW STRENGTH, EC-81 ASPIRIN, CVS ASPIRIN EC LOW DOSE, ASPIRIN LOW ASPIRIN ADULT LOW STRENGTH, CVS STRENGTH, ASPIRIN ASPIRIN LOW DOSE, CVS ADULT LOW DOSE, ASPIRIN EC, CVS ASPIRIN 81, ASPIR-LOW, ASPIRIN ADULT LOW ADULT ASPIRIN STRENGTH TBEC REGIMEN, ADULT ASCRIPTIN TABS PV ASPIRIN EC LOW (aspirin buffered (al STRENGTH, TGT PV ENTERIC-COATED hydrox-mg hydrox-ca ASPIRIN, TGT ASPIRIN carb)) LOW DOSE, TGT aspirin chew PV PV ASPIRIN, ST JOSEPH ASPIRIN, SM ASPIRIN PV PV PV ENTERIC COATED, SM aspirin tabs ASPIRIN EC LOW PV STRENGTH, SM ASPIRIN aspirin tbec PV ADULT LOW STRENGTH, CHOLINE MAGNESIUM SB LOW DOSE ASA EC, TRISALICYLATE LIQD SB ASPIRIN EC, SB (choline & mag 2 ASPIRIN ADULT LOW STRENGTH, SB ASPIRIN, salicylate) RA ASPIRIN EC ADULT diflunisal tabs 1 LOW STRENGTH, RA ASPIRIN EC, QC ECOTRIN REGULAR PV ENTERIC ASPIRIN, QC STRENGTH TBEC GP ASPIRIN LOW DOSE, QC (aspirin) ASPIRIN, PX ENTERIC ASPIRIN, MINIPRIN LOW salsalate tabs 1 DOSE, MEIJER ASPIRIN ST JOSEPH ADULT PV EC, KP ASPIRIN, KLS ASPIRIN LOW DOSE, KLS ANALGESICLOW DOSE BITE SIZE CHEW GP ASPIRIN EC, HM ASPIRIN EC LOW DOSE, HM (aspirin) ASPIRIN EC, HM ST JOSEPH ADULT PV GP ASPIRIN, H-E-B ASPIRIN, CHEW (aspirin) GOODSENSE ASPIRIN LOW DOSE, ANALGESICS - OPIOID - Drugs to Treat Pain, GOODSENSE ASPIRIN, Muscle and Joint Conditions GNP ASPIRIN LOW You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Opioid Agonists fentanyl citrate tabs bu PA; QL(3 ea daily)1 bal on (Methadone Hcl) 100 mcg, 200 mcg, 400 1 hand, METHADONE HCL mcg, 600 mcg, 800 INTENSOL, METHADOSE 1 mcg SUGAR-FREE, fentanyl pt72 12 Limit 15 METHADOSE CONC patches per mcg/hr, 25 mcg/hr, 50 1 (Methadone Hcl) 1 month;QL(0.5 METHADOSE TBSO mcg/hr, 75 mcg/hr, 100 mcg/hr ea daily) (Morphine Sulfate) SP PA DURAMORPH SOLN FENTORA TABS PA; QL(3 ea ABSTRAL SUBL PA 3 daily)1 bal on 3 (fentanyl citrate) hand, (fentanyl citrate) hydromorphone hcl liqd ACTIQ LPOP (fentanyl PA 1 GP 1 mg/ml citrate) hydromorphone hcl QL(4 ea daily) codeine sulfate tabs 1 t24a 8 mg, 12 mg, 16 1 CONZIP CP24 ( 1 bal on hand, mg tramadol 3 hcl) hydromorphone hcl 1 DILAUDID LIQD OR 1 tabs 2 mg, 4 mg, 8 mg MG/ML (hydromorphone GP KADIAN CP24 10 MG, 30 QL(1 ea daily) hcl) MG, 40 MG, 50 MG, 60 MG, 80 MG, 100 MG GP DILAUDID TABS OR 2 (morphine sulfate) MG, 4 MG, 8 MG GP (hydromorphone hcl) KADIAN CP24 20 MG, 30 QL(2 ea daily) MG, 40 MG, 50 MG, 60 DOLOPHINE TABS QL(12 ea daily) GP GP MG, 80 MG, 100 MG (methadone hcl) (morphine sulfate) DURAGESIC PT72 12 Limit 15 KADIAN CP24 200 MG QL(2 ea daily) MCG/HR, 25 MCG/HR, 50 patches per 3 MCG/HR, 100 MCG/HR GP month;QL(0.5 (morphine sulfate) (fentanyl) ea daily) LAZANDA SOLN 100 PA MCG/ACT, 400 MCG/ACT 3 Limit 15 DURAGESIC PT72 75 (fentanyl citrate) NF patches per month;QL(0.5 1 bal on hand, MCG/HR (fentanyl) meperidine hcl soln 50 1 ea daily) mg/5ml EMBEDA CPCR PA 1 bal on hand, 3 meperidine hcl tabs 50 1 (morphine-naltrexone) mg, 100 mg, 100 mg EXALGO T24A QL(4 ea daily) GP meperidine hcl tabs 50 1 (hydromorphone hcl) mg, 100 mg, 100 mg fentanyl citrate lpop bu PA methadone hcl conc or 1 200 mcg, 400 mcg, 600 1 10 mg/ml mcg, 800 mcg, 1200 PA mcg, 1600 mcg methadone hcl soln ij SP 10 mg/ml

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10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHADONE HCL SOLN PA NUCYNTA TABS 2 IJ 10 MG/ML (methadone SP (tapentadol hcl) hcl) OPANA TABS GP methadone hcl soln or 1 bal on hand, (oxymorphone hcl) 5 mg/5ml, 10 mg/5ml, 1 OXAYDO TABA QL(4 ea daily) 3 10 mg/5ml (oxycodone hcl) methadone hcl soln or oxycodone hcl caps 5 1 5 mg/5ml, 10 mg/5ml, 1 mg 10 mg/5ml oxycodone hcl conc 1 QL(12 ea daily) methadone hcl tabs or 1 100 mg/5ml 5 mg, 10 mg oxycodone hcl soln 5 1 methadone hcl tbso or 1 mg/5ml 40 mg oxycodone hcl tabs 5 QL(1 ea daily)1 1 morphine sulfate beads 1 mg, 10 mg, 15 mg, 20 cp24 bal on hand, mg, 30 mg morphine sulfate cp24 QL(1 ea daily) oxymorphone hcl tabs 1 or 10 mg, 30 mg, 40 1 5 mg, 10 mg mg, 50 mg, 60 mg, 80 oxymorphone hcl tb12 QL(2 ea daily)1 mg, 100 mg bal on hand, 5 mg, 10 mg, 15 mg, 20 1 morphine sulfate cp24 QL(2 ea daily) mg, 30 mg, 40 mg, 7.5 or 20 mg, 30 mg, 40 1 mg mg, 50 mg, 60 mg, 80 ROXICODONE TABS GP mg, 100 mg (oxycodone hcl) morphine sulfate soln ij PA ROXYBOND TABA 5 MG QL(4 ea daily) SP 3 0.5 mg/ml, 1 mg/ml (oxycodone hcl) morphine sulfate soln SUBSYS LIQD (fentanyl) 3 PA or 20 mg/ml, 10 1 mg/5ml, 20 mg/5ml, tramadol hcl cp24 100 1 bal on hand, 100 mg/5ml mg, 150 mg, 200 mg, 1 morphine sulfate supp 1 bal on hand, 300 mg 1 bal on hand, re 5 mg, 10 mg, 20 mg, 1 tramadol hcl tabs 100 1 30 mg mg 1 bal on hand, tramadol hcl tabs 50 QL(8 ea daily) morphine sulfate tabs 1 1 or 15 mg, 30 mg mg morphine sulfate tbcr or QL(3 ea daily) tramadol hcl tb24 100 1 15 mg, 30 mg, 60 mg, 1 mg, 200 mg, 300 mg 100 mg, 200 mg ULTRAM TABS ( QL(8 ea daily) tramadol GP MS CONTIN TBCR QL(3 ea daily) hcl) GP (morphine sulfate) Opioid Combinations NUCYNTA ER TB12 QL(2 ea daily) 2 (Butalbital-Aspirin-Caffeine (tapentadol hcl) W/Cod) 1 ASCOMP/CODEINE CAPS You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocodone- LORTAB ELIX Acetaminophen) LORCET, 1 (hydrocodone- 3 LORCET PLUS, LORCET acetaminophen) HD TABS NORCO TABS (Hydrocodone-Ibuprofen) 1 bal on hand, IBUDONE TABS 200 MG- 1 (hydrocodone- GP 10 MG acetaminophen) (Hydrocodone-Ibuprofen) oxycodone w/ 1 bal on hand, IBUDONE TABS 200 MG-5 1 acetaminophen soln 5 1 MG mg/5ml-325 mg/5ml (Oxycodone W/ oxycodone w/ Acetaminophen) 1 ENDOCET, NALOCET acetaminophen tabs 5 TABS mg-325 mg, 10 mg-325 1 mg, 2.5 mg-300 mg, acetaminophen w/ 1 codeine soln 2.5 mg-325 mg, 7.5 mg-325 mg acetaminophen w/ 1 codeine tabs oxycodone-aspirin tabs 1 butalbital- oxycodone-aspirin tabs 1 1 bal on hand, acetaminophen- 1 QL(4 ea daily)1 caffeine w/ codeine oxycodone-ibuprofen 1 caps tabs bal on hand, PERCOCET TABS 10 MG- butalbital-aspirin- 1 caffeine w/cod caps 325 MG (oxycodone w/ NF FIORICET/CODEINE acetaminophen) CAPS (butalbital- PERCOCET TABS 5 MG- acetaminophen- GP 325 MG, 2.5 MG-325 MG, 7.5 MG-325 MG caffeine w/ codeine) GP (oxycodone w/ FIORINAL/CODEINE #3 acetaminophen) CAPS (butalbital-aspirin- GP PRIMLEV TABS caffeine w/cod) (oxycodone w/ 3 HYDROCODONE acetaminophen) BITARTRATE/ACETAMIN OPHEN SOLN 2 PROLATE TABS (hydrocodone- (oxycodone w/ 3 acetaminophen) acetaminophen) ROXICET SOLN hydrocodone- 1 acetaminophen soln (oxycodone w/ 2 acetaminophen) hydrocodone- 1 acetaminophen tabs tramadol- 1 acetaminophen tabs hydrocodone-ibuprofen 1 tabs TYLENOL/CODEINE #3 TABS (acetaminophen GP w/ codeine)

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12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL/CODEINE #4 pentazocine w/ 1 TABS (acetaminophen GP naloxone tabs w/ codeine) SUBOXONE FILM PA ULTRACET TABS (buprenorphine hcl- GP (tramadol- GP naloxone hcl dihydrate) acetaminophen) ZUBSOLV SUBL PA Opioid Partial Agonists (buprenorphine hcl- 3 BELBUCA FILM QL(2 ea daily) naloxone hcl dihydrate) 3 (buprenorphine hcl) -ANABOLIC - Drugs to Regulate BUNAVAIL FILM PA Hormones (buprenorphine hcl- 3 Anabolic naloxone hcl dihydrate) ANADROL-50 TABS BUPRENEX SOLN PA 3 SP () (buprenorphine hcl) tabs 1 PA buprenorphine hcl soln SP ij 0.3 mg/ml Androgens PA; QL(3 ea ANDRODERM PT24 ST; QL(1 ea buprenorphine hcl subl 1 3 sl 2 mg daily) () daily) PA; QL(4 ea ANDROGEL GEL 20.25 QL(10 gm buprenorphine hcl subl 1 sl 8 mg daily) MG/1.25GM GP daily) (testosterone) buprenorphine hcl- PA ANDROGEL GEL 40.5 naloxone hcl dihydrate GP film 4 mg-1 mg, 8 mg-2 1 MG/2.5GM (testosterone) mg, 12 mg-3 mg, 2 mg- ANDROGEL GEL 50 QL(10 gm 0.5 mg MG/5GM, 25 MG/2.5GM 2 daily) (testosterone) PA; QL(3 ea buprenorphine hcl- ANDROGEL PUMP GEL QL(10 gm 1 daily) GP naloxone hcl dihydrate (testosterone) daily) subl 2 mg-0.5 mg buprenorphine hcl- PA; QL(4 ea caps 1 naloxone hcl dihydrate 1 daily) DEPO-TESTOSTERONE subl 8 mg-2 mg SOLN (testosterone GP buprenorphine ptwk td Limit 4 per cypionate) 5 mcg/hr, 10 mcg/hr, month;QL(0.15 FORTESTA GEL QL(4 gm daily) 1 GP 15 mcg/hr, 20 mcg/hr, ea daily) (testosterone) 7.5 mcg/hr METHITEST TABS 2 Limit 7.5mls () butorphanol tartrate 1 per methyltestosterone 1 bal on hand, soln month;QL(0.25 1 ml daily) caps STRIANT MISC QL(2 ea daily) BUTRANS PTWK Limit 4 per 3 GP month;QL(0.15 (testosterone) (buprenorphine) ea daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TESTIM GEL PA; QL(10 gm CORTIFOAM FOAM 3 (testosterone) daily) (hydrocortisone acetate 2 (intrarectal)) 1 soln im 100 mg/ml, 200 hydrocortisone 1 mg/ml (intrarectal) enem UCERIS FOAM RE 2 PA 1 soln im MG/ACT (budesonide 3 1 bal on hand, (intrarectal)) testosterone enanthate 1 soln im Rectal Combinations testosterone gel td 1 %, QL(10 gm ANALPRAM HC CREA daily) (hydrocortisone acetate NF 1.62 %, 50 mg/5gm, 25 1 mg/2.5gm, 20.25 w/ pramoxine) mg/1.25gm ANALPRAM HC SINGLES testosterone gel td 1 %, QL(10 gm CREA (hydrocortisone NF daily)1 bal on acetate w/ pramoxine) 1.62 %, 50 mg/5gm, 25 1 mg/2.5gm, 20.25 hand, ANALPRAM-HC CREA 1 mg/1.25gm %-1 % (hydrocortisone GP testosterone gel td 10 QL(4 gm daily) acetate w/ pramoxine) ANALPRAM-HC LOTN 1 mg/act, 50 mg/5gm, 25 1 mg/2.5gm, 20.25 %-2.5 % (hydrocortisone 3 mg/1.25gm acetate w/ pramoxine) testosterone gel td 40.5 hydrocortisone acetate 1 mg/2.5gm, 20.25 1 w/ pramoxine crea mg/1.25gm lidocaine- QL(6 ml daily) hydrocortisone acetate 1 testosterone soln td 30 1 mg/act (rectal) kit PROCORT CREA VOGELXO GEL QL(10 gm NF daily)1 bal on (hydrocortisone acetate 3 (testosterone) hand, w/ pramoxine) VOGELXO PUMP GEL QL(10 gm PROCTOFOAM HC FOAM NF daily)1 bal on (testosterone) (hydrocortisone acetate 2 hand, w/ pramoxine) ANORECTAL AND RELATED PRODUCTS - Rectal Steroids Rectal Drugs to Treat Pain, Swelling and Itching (Hydrocortisone (Rectal)) Intrarectal Steroids PROCTO-MED HC, 1 (Hydrocortisone PROCTOZONE-HC, (Intrarectal)) COLOCORT 1 PROCTOSOL HC CREA ENEM (Hydrocortisone Acetate CORTENEMA ENEM (Rectal)) ANUCORT-HC, 1 (hydrocortisone GP HEMMOREX-HC SUPP (intrarectal)) (Hydrocortisone Acetate (Rectal)) ANUSOL-HC 1 SUPP RE 25 MG

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANUSOL-HC CREA EX 2.5 FLAGYL CAPS GP % (hydrocortisone GP (metronidazole) (rectal)) FLAGYL TABS GP (metronidazole) hydrocortisone (rectal) 1 crea IMPAVIDO CAPS SP (miltefosine) hydrocortisone acetate 1 (rectal) supp metronidazole caps 1 PROCTOCORT SUPP PA (hydrocortisone acetate GP metronidazole in nacl SP (rectal)) soln Vasodilating Agents metronidazole tabs 1 RECTIV OINT NEBUPENT SOLR (nitroglycerin (intra- 3 (pentamidine GP anal)) isethionate) ANTHELMINTICS - Drugs to Treat Worm pentamidine isethionate 1 Infections solr Anthelmintics PRIMSOL SOLN 3 albendazole tabs 1 (trimethoprim hcl) TINDAMAX TABS ALBENZA TABS GP GP (tinidazole) (albendazole) tinidazole tabs 1 BENZNIDAZOLE TABS AL(At least 2 3 yrs old - Up to (benznidazole) 12 yrs old) trimethoprim tabs 1 BILTRICIDE TABS TRIMPEX SOLN GP 3 (praziquantel) (trimethoprim hcl) EMVERM CHEW QL(6 ea per fill XIFAXAN TABS 200 MG PA; QL(9 ea 3 retail,6 ea per 3 ( ) per fill retail,9 mebendazole fill mail) (rifaximin) ea per fill mail) XIFAXAN TABS 550 MG PA; QL(2 ea ivermectin tabs 1 3 (rifaximin) daily) praziquantel tabs 1 Anti-infective Misc. - Combinations STROMECTOL TABS (Sulfamethoxazole- GP (ivermectin) Trimethoprim) SULFATRIM 1 PEDIATRIC SUSP ANTI-INFECTIVE AGENTS - MISC. - Drugs to BACTRIM DS TABS Treat Bacterial Infections (sulfamethoxazole- GP Anti-infective Agents - Misc. trimethoprim) (Bacitracin) BACIIM SOLR SP PA BACTRIM TABS (sulfamethoxazole- GP PA bacitracin solr SP trimethoprim) sulfamethoxazole- 1 trimethoprim susp You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRVANQ SOLR PA sulfamethoxazole- 1 3 trimethoprim tabs (vancomycin hcl) VANCOCIN CAPS PA Antiprotozoal Agents GP ALINIA SUSR (vancomycin hcl) 3 VANCOCIN HCL CAPS PA (nitazoxanide) GP ALINIA TABS (vancomycin hcl) 3 (nitazoxanide) vancomycin hcl caps 1 PA atovaquone susp 1 Leprostatics MEPRON SUSP GP dapsone tabs 1 (atovaquone) Lincosamides Carbapenems CLEOCIN CAPS OR 75 SP PA; 1 bal on MG, 150 MG, 300 MG doripenem solr hand, GP (clindamycin hcl) PA ertapenem sodium solr SP CLEOCIN IN D5W SOLN PA imipenem-cilastatin solr PA; 1 bal on (clindamycin phosphate SP 250 mg-250 mg, 500 SP hand, in d5w) mg-500 mg CLEOCIN PEDIATRIC GRANULES SOLR imipenem-cilastatin solr PA (clindamycin palmitate GP 250 mg-250 mg, 500 SP hydrochloride) mg-500 mg CLEOCIN PHOSPHATE PA INVANZ SOLR PA SP SOLN IJ 900 MG/6ML (ertapenem sodium) (clindamycin SP meropenem solr SP PA phosphate) CLEOCIN PHOSPHATE PA MERREM SOLR PA SP SOLN IV 300 MG/50ML-5 (meropenem) %, 600 MG/50ML-5 % SP PRIMAXIN IV SOLR PA SP (clindamycin phosphate (imipenem-cilastatin) in d5w) Chloramphenicols CLEOCIN PHOSPHATE PA PA; 1 bal on SOLN IV 600 MG/4ML chloramphenicol SP SP sodium succinate solr hand, (clindamycin phosphate) Cyclic Lipopeptides CUBICIN RF SOLR PA clindamycin hcl caps 1 SP (daptomycin) clindamycin palmitate 1 CUBICIN SOLR PA SP hydrochloride solr (daptomycin) PA clindamycin phosphate SP daptomycin solr SP PA in d5w soln PA clindamycin phosphate SP Glycopeptides soln

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16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LINCOCIN SOLN PA ISORDIL TITRADOSE SP (lincomycin hcl) TABS (isosorbide GP dinitrate) lincomycin hcl soln SP PA isosorbide dinitrate tabs Oxazolidinones 5 mg, 10 mg, 20 mg, 30 1 mg, 40 mg linezolid susr 100 1 mg/5ml 1 bal on hand, isosorbide dinitrate tbcr 1 QL(20 ea per 40 mg 1 90 days linezolid tabs 600 mg retail,20 ea per isosorbide mononitrate 1 90 days mail) tabs SIVEXTRO TABS QL(6 ea per 90 isosorbide mononitrate 2 1 (tedizolid phosphate) days retail) tb24 ZYVOX SUSR 100 NITRO-BID OINT GP 2 MG/5ML (linezolid) (nitroglycerin) QL(20 ea per NITRO-DUR PT24 0.1 QL(1 ea daily) ZYVOX TABS 600 MG MG/HR, 0.2 MG/HR, 0.4 GP 90 days GP (linezolid) retail,20 ea per MG/HR, 0.6 MG/HR 90 days mail) (nitroglycerin) Polymyxins NITRO-DUR PT24 0.3 QL(1 ea daily) MG/HR, 0.8 MG/HR PA 2 polymyxin b sulfate solr SP (nitroglycerin) ANTIANGINAL AGENTS - Drugs to Treat Chest nitroglycerin cpcr or 9 1 Pain mg, 2.5 mg Antianginals-Other nitroglycerin pt24 td 0.1 QL(1 ea daily) RANEXA TB12 1000 MG mg/hr, 0.2 mg/hr, 0.4 1 GP (ranolazine) mg/hr, 0.6 mg/hr RANEXA TB12 500 MG QL(4 ea daily) nitroglycerin soln tl 0.4 GP 1 (ranolazine) mg/spray nitroglycerin subl sl 0.3 ranolazine tb12 1000 1 1 mg mg, 0.4 mg, 0.6 mg NITROLINGUAL 1 QL(4 ea daily) ranolazine tb12 500 mg PUMPSPRAY SOLN GP Nitrates (nitroglycerin) NITROMIST AERS (Nitroglycerin) MINITRAN 1 QL(1 ea daily) 3 PT24 (nitroglycerin) (Nitroglycerin) NITRO- 1 bal on hand, NITROSTAT SUBL 1 GP TIME CPCR (nitroglycerin) DILATRATE SR CPCR 3 (isosorbide dinitrate) ANTIANXIETY AGENTS - Drugs to Treat Anxiety GONITRO PACK PA Antianxiety Agents - Misc. 3 (nitroglycerin) buspirone hcl tabs 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; 1 bal on hydroxyzine hcl soln im SP diazepam tabs 2 mg, 5 1 25 mg/ml, 50 mg/ml hand, mg, 10 mg hydroxyzine hcl syrp or 1 lorazepam conc 1 10 mg/5ml lorazepam tabs 1 hydroxyzine hcl tabs or 1 10 mg, 25 mg, 50 mg oxazepam caps 10 mg, 1 bal on hand, 1 hydroxyzine pamoate 1 15 mg, 15 mg, 30 mg caps 100 mg 1 bal on hand, oxazepam caps 10 mg, 1 hydroxyzine pamoate 1 15 mg, 15 mg, 30 mg caps 25 mg, 50 mg TRANXENE T TABS meprobamate tabs 1 (clorazepate GP dipotassium) VISTARIL CAPS GP VALIUM TABS 2 MG, 10 (hydroxyzine pamoate) GP MG (diazepam) Benzodiazepines VALIUM TABS 5 MG NF (Alprazolam) 1 (diazepam) ALPRAZOLAM XR TB24 XANAX TABS GP (Diazepam) DIAZEPAM 1 (alprazolam) INTENSOL CONC XANAX XR TB24 (Lorazepam) LORAZEPAM 1 GP INTENSOL CONC (alprazolam) ALPRAZOLAM INTENSOL ANTIARRHYTHMICS - Drugs to treat abnormal 3 CONC (alprazolam) heart rhythms alprazolam tabs 1 Antiarrhythmics Type I-A disopyramide 1 alprazolam tb24 1 phosphate caps NORPACE CAPS alprazolam tbdp 1 (disopyramide GP ATIVAN TABS 0.5 MG, 2 phosphate) GP MG (lorazepam) NORPACE CR CP12 100 ATIVAN TABS 1 MG MG (disopyramide 2 NF (lorazepam) phosphate) NORPACE CR CP12 150 chlordiazepoxide hcl 1 caps MG (disopyramide 3 phosphate) clorazepate 1 dipotassium tabs procainamide hcl soln SP PA diazepam conc 5 1 mg/ml quinidine gluconate tbcr 1 1 bal on hand, 1 bal on hand, diazepam soln 5 1 quinidine sulfate tabs 1 mg/5ml Antiarrhythmics Type I-B

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, XOLAIR SOSY PA mexiletine hcl caps 150 SP mg, 200 mg, 250 mg, 1 (omalizumab) 250 mg Bronchodilators - Anticholinergics mexiletine hcl caps 200 1 ATROVENT HFA AERS Limit 2 inhalers mg, 250 mg, 250 mg ( 2 per ipratropium bromide month;QL(0.86 Antiarrhythmics Type I-C hfa) gm daily) flecainide acetate tabs 1 INCRUSE ELLIPTA AEPB Limit 1 inhaler 2 per month;QL(1 propafenone hcl cp12 (umeclidinium bromide) ea daily) 225 mg, 325 mg, 425 1 ipratropium bromide 1 mg soln QL(6 ea daily) propafenone hcl tabs 1 SEEBRI NEOHALER ST; QL(2 ea 150 mg, 300 mg CAPS (glycopyrrolate 3 daily) QL(3 ea daily) ) propafenone hcl tabs 1 (inhalation) 225 mg, 300 mg SPIRIVA HANDIHALER QL(1 ea daily) RYTHMOL SR CP12 CAPS (tiotropium 2 GP (propafenone hcl) bromide monohydrate) Antiarrhythmics Type III SPIRIVA RESPIMAT Limit 1 inhaler per (Amiodarone Hcl) 1 AERS (tiotropium 2 PACERONE TABS month;QL(0.14 bromide monohydrate) gm daily) amiodarone hcl tabs 1 TUDORZA PRESSAIR ST; Limit 1 inhaler per CORDARONE TABS AEPB (aclidinium 3 GP month;QL(0.04 (amiodarone hcl) bromide) ea daily) dofetilide caps 1 Leukotriene Modulators MULTAQ TABS ACCOLATE TABS 2 GP (dronedarone hcl) (zafirlukast) TIKOSYN CAPS montelukast sodium QL(1 ea daily) GP 1 (dofetilide) chew QL(1 ea daily) ANTIASTHMATIC AND BRONCHODILATOR montelukast sodium 1 AGENTS - Drugs to Treat Lung Conditions pack QL(1 ea daily) Anti-Inflammatory Agents montelukast sodium 1 tabs 1 cromolyn sodium nebu SINGULAIR CHEW 4 MG, QL(1 ea daily) CROMOLYN SODIUM 5 MG (montelukast GP NEBU (cromolyn 2 sodium) sodium) SINGULAIR PACK 4 MG QL(1 ea daily) GP Antiasthmatic - Monoclonal Antibodies (montelukast sodium) XOLAIR SOLR PA SINGULAIR TABS 10 MG QL(1 ea daily) SP NF (omalizumab) (montelukast sodium) zafirlukast tabs 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zileuton tb12 1 ST ASMANEX TWISTHALER Limit 1 inhaler 30 METERED DOSES per ZYFLO CR TB12 ST AEPB ( 2 month;QL(0.04 NF mometasone (zileuton) furoate (inhalation)) ea daily) ZYFLO TABS (zileuton) 3 ST ASMANEX TWISTHALER Limit 1 inhaler 60 METERED DOSES per 2 Selective Phosphodiesterase 4 (PDE4) Inhibitors AEPB (mometasone month;QL(0.04 ea daily) DALIRESP TABS QL(1 ea daily) furoate (inhalation)) 3 (roflumilast) ASMANEX TWISTHALER Limit 1 inhaler 7 METERED DOSES per Inhalants AEPB (mometasone 2 month;QL(0.04 Limit 2 inhalers ) ea daily) ALVESCO AERS per furoate (inhalation) 3 QL(8 ml daily) (ciclesonide) month;QL(0.41 budesonide (inhalation) 1 gm daily) susp 0.25 mg/2ml ARMONAIR RESPICLICK QL(0.04 ea QL(4 ml daily) budesonide (inhalation) 1 113 AEPB (fluticasone 3 daily) susp 0.5 mg/2ml propionate (inhalation)) QL(2 ml daily) budesonide (inhalation) 1 ARMONAIR RESPICLICK QL(0.04 ea susp 1 mg/2ml 232 AEPB ( 3 daily) fluticasone FLOVENT DISKUS AEPB QL(20 ea daily) propionate (inhalation)) 100 MCG/BLIST ARMONAIR RESPICLICK QL(0.04 ea (fluticasone propionate 2 55 AEPB (fluticasone 3 daily) (inhalation)) propionate (inhalation)) FLOVENT DISKUS AEPB QL(8 ea daily) ARNUITY ELLIPTA AEPB QL(1 ea daily) 250 MCG/BLIST (fluticasone furoate 2 (fluticasone propionate 2 (inhalation)) (inhalation)) ASMANEX HFA AERO 100 Limit 1 inhaler FLOVENT DISKUS AEPB QL(40 ea daily) MCG/ACT, 200 MCG/ACT per 50 MCG/BLIST 2 (mometasone furoate month;QL(0.44 (fluticasone propionate 2 (inhalation)) gm daily) (inhalation)) ASMANEX HFA AERO 50 Limit 1 Inhaler FLOVENT HFA AERO 110 Limit 2 inhalers MCG/ACT, 200 MCG/ACT per MCG/ACT, 220 MCG/ACT per 2 (mometasone furoate month;QL(0.44 (fluticasone propionate 2 month;QL(0.8 (inhalation)) gm daily) hfa) gm daily) ASMANEX TWISTHALER Limit 1 inhaler FLOVENT HFA AERO 44 Limit 1 inhaler 120 METERED DOSES per MCG/ACT, 220 MCG/ACT per 2 AEPB (mometasone month;QL(0.04 (fluticasone propionate 2 month;QL(0.36 furoate (inhalation)) ea daily) hfa) gm daily) ASMANEX TWISTHALER Limit 1 inhaler PULMICORT FLEXHALER Limit 2 inhalers 14 METERED DOSES per AEPB 180 MCG/ACT per 2 AEPB (mometasone month;QL(0.04 (budesonide 2 month;QL(0.07 furoate (inhalation)) ea daily) (inhalation)) ea daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PULMICORT FLEXHALER Limit 8 inhalers albuterol sulfate aers in QL(1.2 gm AEPB 90 MCG/ACT per 1 daily)1 bal on 108 mcg/act (budesonide 2 month;QL(0.27 hand, (inhalation)) ea daily) QL(0.45 gm albuterol sulfate aers in 1 PULMICORT SUSP 0.25 QL(8 ml daily) 108 mcg/act daily) MG/2ML (budesonide NF QL(1.2 gm albuterol sulfate aers in 1 (inhalation)) 108 mcg/act daily) PULMICORT SUSP 0.5 QL(4 ml daily) albuterol sulfate nebu MG/2ML (budesonide GP in 0.63 mg/3ml, 0.083 1 (inhalation)) %, 0.5 %, 1.25 mg/3ml, PULMICORT SUSP 1 QL(2 ml daily) 2.5 mg/0.5ml MG/2ML (budesonide GP albuterol sulfate syrp or 1 (inhalation)) 2 mg/5ml QVAR REDIHALER AERB Limit 1 inhaler 40 MCG/ACT per albuterol sulfate tabs or 1 (beclomethasone 2 month;QL(0.36 2 mg, 4 mg dipropionate hfa) gm daily) albuterol sulfate tb12 or QL(2 ea daily)1 1 bal on hand, QVAR REDIHALER AERB Limit 2 Inhalers 4 mg, 8 mg 80 MCG/ACT per ANORO ELLIPTA AEPB QL(2 ea daily) (beclomethasone 2 month;QL(0.72 (umeclidinium- 2 dipropionate hfa) gm daily) vilanterol) Sympathomimetics ARCAPTA NEOHALER QL(1 ea daily) CAPS (indacaterol 3 (Fluticasone-Salmeterol) 1 QL(2 ea daily) WIXELA INHUB AEPB maleate) ADVAIR DISKUS AEPB QL(2 ea daily) Limit 1 inhaler GP BEVESPI AEROSPHERE (fluticasone-salmeterol) AERO ( 3 per glycopyrrolate- month;QL(0.36 Limit 1 inhaler formoterol fumarate) gm daily) ADVAIR HFA AERO 2 per (fluticasone-salmeterol) month;QL(0.4 BREO ELLIPTA AEPB QL(2 ea daily) gm daily) (fluticasone furoate- 2 AIRDUO RESPICLICK QL(0.04 ea vilanterol) 113/14 AEPB NF daily)1 bal on BROVANA NEBU 3 (fluticasone-salmeterol) hand, (arformoterol tartrate) AIRDUO RESPICLICK QL(0.04 ea Limit 1 inhaler 232/14 AEPB NF daily)1 bal on budesonide-formoterol per (fluticasone-salmeterol) hand, fumarate dihydrate 1 month;QL(0.34 AIRDUO RESPICLICK QL(0.04 ea aero gm daily)1 bal on hand, 55/14 AEPB (fluticasone- NF daily)1 bal on Limit 1 inhaler salmeterol) hand, COMBIVENT RESPIMAT AERS ( 3 per Limit 2 inhalers ipratropium- month;QL(0.2 albuterol) albuterol sulfate aers in 1 per gm daily) 108 mcg/act month;QL(0.57 PA gm daily) epinephrine hcl soln SP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluticasone-salmeterol QL(2 ea daily) Limit 1 inhaler STRIVERDI RESPIMAT aepb 50 mcg/dose-100 2 per mcg/dose, 50 AERS (olodaterol hcl) month;QL(0.14 gm daily) mcg/dose-250 1 Limit 1 inhaler mcg/dose, 50 SYMBICORT AERO per mcg/dose-500 (budesonide-formoterol 2 month;QL(0.34 mcg/dose fumarate dihydrate) gm daily)1 bal on hand, ipratropium-albuterol 1 soln terbutaline sulfate tabs 1 levalbuterol hcl nebu 1 TRELEGY ELLIPTA AEPB QL(2 ea daily) Limit 2 inhalers (fluticasone- 2 umeclidinium-vilanterol) levalbuterol tartrate 1 per month;QL(1 aero gm daily)1 bal UTIBRON NEOHALER QL(2 ea daily) on hand, CAPS (indacaterol 3 1 bal on hand, metaproterenol sulfate 1 maleate-glycopyrrolate) syrp Limit 2 inhalers 1 bal on hand, per metaproterenol sulfate 1 VENTOLIN HFA AERS tabs 1 month;QL(0.54 (albuterol sulfate) gm daily)1 bal PERFOROMIST NEBU QL(4 ml daily) 3 on hand, (formoterol fumarate) Limit 2 inhalers Limit 2 inhalers per PROAIR HFA AERS VENTOLIN HFA AERS 1 per 1 month;QL(1.2 (albuterol sulfate) month;QL(0.57 (albuterol sulfate) gm daily)1 bal gm daily) on hand, Limit 2 inhalers XOPENEX PROAIR RESPICLICK 3 per CONCENTRATE NEBU GP AEPB (albuterol sulfate) month;QL(0.07 (levalbuterol hcl) ea daily) Limit 2 inhalers Limit 2 inhalers XOPENEX HFA AERO per month;QL(1 PROVENTIL HFA AERS 1 NF per (levalbuterol tartrate) gm daily)1 bal (albuterol sulfate) month;QL(0.45 on hand, gm daily) XOPENEX NEBU Limit 2 inhalers GP PROVENTIL HFA AERS (levalbuterol hcl) 1 per (albuterol sulfate) month;QL(0.45 Xanthines gm daily) SP PA SEREVENT DISKUS QL(2 ea daily) aminophylline soln AEPB (salmeterol 2 ELIXOPHYLLIN ELIX 3 xinafoate) (theophylline) Limit 1 inhaler THEO-24 CP24 STIOLTO RESPIMAT 2 AERS ( 2 per (theophylline) tiotropium month;QL(0.14 bromide-olodaterol hcl) gm daily) theophylline soln 80 1 mg/15ml

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits theophylline tb12 100 enoxaparin sodium QL(6 ml per 10 mg, 200 mg, 300 mg, 1 soln sc 30 mg/0.3ml, SP days retail) 450 mg, 450 mg 120 mg/0.8ml theophylline tb12 300 1 bal on hand, enoxaparin sodium QL(8 ml per 10 mg, 300 mg, 450 mg, 1 soln sc 40 mg/0.4ml, SP days retail) 450 mg 120 mg/0.8ml QL(12 ml per theophylline tb24 400 1 enoxaparin sodium mg, 600 mg soln sc 60 mg/0.6ml, SP 10 days retail) 120 mg/0.8ml ANTICOAGULANTS - Blood Thinners enoxaparin sodium QL(16 ml per Coumarin Anticoagulants soln sc 80 mg/0.8ml, SP 10 days retail) (Warfarin Sodium) 1 120 mg/0.8ml JANTOVEN TABS fondaparinux sodium PA; COUMADIN TABS SP GP soln ( ) warfarin sodium FRAGMIN SOLN 10000 QL(20 ml per warfarin sodium tabs 1 UNIT/ML, 5000 365 days retail) UNIT/0.2ML (dalteparin SP Direct Factor Xa Inhibitors sodium) BEVYXXA CAPS QL(42 ea per 3 FRAGMIN SOLN 12500 QL(10 ml per (betrixaban maleate) 42 days retail) UNIT/0.5ML (dalteparin SP 365 days retail) ELIQUIS STARTER PACK 2 sodium) TABS (apixaban) FRAGMIN SOLN 15000 QL(12 ml per ELIQUIS TABS 365 days retail) 2 UNIT/0.6ML (dalteparin SP (apixaban) sodium) SAVAYSA TABS 3 FRAGMIN SOLN 18000 QL(14 ml per (edoxaban tosylate) UNT/0.72ML (dalteparin SP 365 days retail) XARELTO STARTER sodium) PACK TBPK 2 FRAGMIN SOLN 2500 QL(4 ml per (rivaroxaban) UNIT/0.2ML, 5000 365 days retail) SP XARELTO TABS 10 MG, UNIT/0.2ML (dalteparin 15 MG, 20 MG 2 sodium) (rivaroxaban) FRAGMIN SOLN 7500 QL(6 ml per Heparins And Heparinoid-Like Agents UNIT/0.3ML (dalteparin SP 365 days retail) ARIXTRA SOLN PA; sodium) SP (fondaparinux sodium) FRAGMIN SOLN 95000 PA QL(3 ml per 10 UNIT/3.8ML (dalteparin SP enoxaparin sodium SP soln ij 300 mg/3ml days retail) sodium) enoxaparin sodium QL(20 ml per heparin (porcine) in soln sc 100 mg/ml, 150 SP 10 days retail) sodium chloride soln mg/ml, 120 mg/0.8ml 2000 unit/l-0.9 %, 1000 SP unit/500ml-0.9 %, 1000 unit/500ml-0.9 %

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits heparin (porcine) in 1 bal on hand, LOVENOX SOLN SC 80 QL(16 ml per sodium chloride soln MG/0.8ML, 120 MG/0.8ML SP 10 days retail) 2000 unit/l-0.9 %, 1000 SP (enoxaparin sodium) unit/500ml-0.9 %, 1000 Thrombin Inhibitors unit/500ml-0.9 % PRADAXA CAPS 1 bal on hand, (dabigatran etexilate 3 heparin sod (porcine) in SP d5w soln mesylate) heparin sodium SP ANTICONVULSANTS - Drugs to Treat Seizures (porcine) soln HEPARIN SODIUM/NACL AMPA Glutamate Receptor Antagonists FYCOMPA SUSP 0.45% SOLN (heparin SP 3 (porcine) in sodium (perampanel) chloride) FYCOMPA TABS 3 HEPARIN (perampanel) SODIUM/SODIUM Anticonvulsants - Benzodiazepines CHLORIDE 0.9% SOLN SP (heparin (porcine) in clobazam susp 1 sodium chloride) HEPARIN clobazam tabs 1 SODIUM/SODIUM CHLORIDE SOLN 2000 clonazepam tabs 1 UNIT/L-0.9 %, 1000 UNIT/500ML-0.9 %, 25000 SP clonazepam tbdp 1 UNIT/250ML-0.45 %, 25000 UNIT/500ML-0.45 % DIASTAT ACUDIAL GEL Limit 4 per ( 3 month;QL(0.14 (heparin (porcine) in diazepam ea daily)1 bal sodium chloride) (anticonvulsant)) on hand, LOVENOX SOLN IJ 300 QL(3 ml per 10 Limit 4 per MG/3ML (enoxaparin SP days retail) DIASTAT PEDIATRIC GEL ( 3 month;QL(0.14 sodium) diazepam ea daily)1 bal ) LOVENOX SOLN SC 100 QL(20 ml per (anticonvulsant) on hand, MG/ML, 150 MG/ML, 120 10 days retail) Limit 4 per SP diazepam MG/0.8ML (enoxaparin (anticonvulsant) gel 10 3 month;QL(0.14 sodium) ea daily)1 bal mg on hand, LOVENOX SOLN SC 30 QL(6 ml per 10 MG/0.3ML, 120 MG/0.8ML SP days retail) diazepam Limit 4 per (enoxaparin sodium) 1 month;QL(0.14 (anticonvulsant) gel 20 ea daily)1 bal LOVENOX SOLN SC 40 QL(8 ml per 10 mg, 2.5 mg on hand, MG/0.4ML, 120 MG/0.8ML days retail) SP KLONOPIN TABS (enoxaparin sodium) GP (clonazepam) LOVENOX SOLN SC 60 QL(12 ml per MG/0.6ML, 120 MG/0.8ML 10 days retail) NAYZILAM SOLN PA; QL(10 ea SP per 30 days (enoxaparin sodium) (midazolam SP (anticonvulsant)) retail) ONFI SUSP (clobazam) GP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONFI TABS (clobazam) GP carbamazepine tabs 1 VALTOCO LIQD PA; QL(10 ea carbamazepine tb12 1 (diazepam SP per 30 days retail) CARBATROL CP12 (anticonvulsant)) 3 VALTOCO LQPK PA; QL(10 ea (carbamazepine) per 30 days DIACOMIT CAPS 250 MG PA; QL(12 ea (diazepam SP SP (anticonvulsant)) retail) (stiripentol) daily) DIACOMIT CAPS 500 MG PA; QL(6 ea Anticonvulsants - Misc. SP (stiripentol) daily) (Carbamazepine) EPITOL 1 TABS DIACOMIT PACK 250 MG PA; QL(12 ea SP daily) (Lamotrigine) SUBVENITE (stiripentol) STARTER KIT/BLUE, DIACOMIT PACK 500 MG PA; QL(6 ea SP daily) SUBVENITE STARTER 1 (stiripentol) KIT/ORANGE, EPIDIOLEX SOLN PA SUBVENITE STARTER SP KIT/GREEN KIT (cannabidiol) (Lamotrigine) SUBVENITE 1 gabapentin caps 1 TABS gabapentin soln 1 (Levetiracetam) 1 ROWEEPRA TABS gabapentin tabs 1 (Levetiracetam) 1 ROWEEPRA XR TB24 KEPPRA SOLN IV 500 PA SP APTIOM TABS 200 MG, QL(2 ea daily) MG/5ML (levetiracetam) 400 MG, 600 MG KEPPRA SOLN OR 100 ( 3 3 eslicarbazepine MG/ML (levetiracetam) acetate) KEPPRA TABS OR 250 APTIOM TABS 800 MG QL(1 ea daily) MG, 500 MG, 750 MG, 3 (eslicarbazepine 3 1000 MG (levetiracetam) acetate) KEPPRA XR TB24 BANZEL SUSP 3 2 (levetiracetam) (rufinamide) LAMICTAL CHEWABLE BANZEL TABS 2 DISPERSIBLE CHEW 3 (rufinamide) (lamotrigine) BRIVIACT SOLN PA LAMICTAL ODT KIT PA 3 3 (brivaracetam) (lamotrigine) BRIVIACT TABS PA 3 LAMICTAL ODT TBDP 25 PA (brivaracetam) MG, 50 MG, 100 MG, 200 3 MG (lamotrigine) carbamazepine chew 1 LAMICTAL STARTER/NOT carbamazepine cp12 1 TAKING CARBAMAZEPINE KIT GP carbamazepine susp 1 (lamotrigine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL levetiracetam tabs or STARTER/TAKING 250 mg, 500 mg, 750 1 CARBAMAZEPINE/NOT GP mg, 1000 mg TAKING KIT (lamotrigine) levetiracetam tb24 or 1 LAMICTAL 500 mg, 750 mg STARTER/TAKING LYRICA CAPS 150 MG, PA; QL(2 ea VALPROATE KIT GP 200 MG, 225 MG, 300 MG 3 daily) (lamotrigine) (pregabalin) LAMICTAL TABS LYRICA CAPS 25 MG, 50 PA; QL(3 ea 3 (lamotrigine) MG, 75 MG, 100 MG, 200 daily) MG, 225 MG, 300 MG 3 LAMICTAL XR KIT PA 3 (pregabalin) (lamotrigine) LYRICA SOLN 20 MG/ML PA LAMICTAL XR TB24 25 PA; QL(1 ea 3 ( ) MG, 50 MG, 100 MG, 200 3 daily) pregabalin MYSOLINE TABS MG (lamotrigine) 3 LAMICTAL XR TB24 250 PA (primidone) 3 NEURONTIN CAPS MG (lamotrigine) 3 LAMICTAL XR TB24 300 (gabapentin) 3 NEURONTIN SOLN MG (lamotrigine) 3 lamotrigine chew 5 mg, (gabapentin) 1 NEURONTIN TABS 25 mg 3 (gabapentin) lamotrigine kit 1 PA oxcarbazepine susp 1 lamotrigine kit 25 mg, 1 oxcarbazepine tabs 1 lamotrigine tabs 25 mg, OXTELLAR XR TB24 100 mg, 150 mg, 200 1 3 mg (oxcarbazepine) PA; QL(2 ea lamotrigine tb24 25 mg, PA; QL(1 ea pregabalin caps 150 1 daily) 50 mg, 100 mg, 200 1 daily) mg, 200 mg, 225 mg, mg 300 mg PA; QL(3 ea lamotrigine tb24 250 PA pregabalin caps 25 mg, 1 50 mg, 75 mg, 100 mg, daily) mg 1 200 mg, 225 mg, 300 lamotrigine tb24 300 1 mg mg PA pregabalin soln 20 1 lamotrigine tbdp 25 mg, PA mg/ml 50 mg, 100 mg, 200 1 mg primidone tabs 1 levetiracetam soln iv PA QUDEXY XR CS24 PA; 1 bal on SP 3 500 mg/5ml (topiramate) hand, TEGRETOL SUSP levetiracetam soln or 1 3 100 mg/ml, 500 mg/5ml (carbamazepine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL TABS 3 GABA Modulators (carbamazepine) (Vigabatrin) VIGADRONE 1 TEGRETOL-XR TB12 100 PACK GP MG (carbamazepine) GABITRIL TABS 12 MG, 3 TEGRETOL-XR TB12 200 16 MG (tiagabine hcl) MG, 400 MG 3 GABITRIL TABS 2 MG, 4 GP (carbamazepine) MG (tiagabine hcl) TOPAMAX SPRINKLE SABRIL PACK 3 GP CPSP (topiramate) (vigabatrin) TOPAMAX TABS SABRIL TABS 3 GP (topiramate) (vigabatrin) topiramate cpsp 15 mg, 1 25 mg tiagabine hcl tabs 1 topiramate cs24 25 mg, PA; 1 bal on vigabatrin pack 1 50 mg, 100 mg, 150 1 hand, mg, 200 mg vigabatrin tabs 1 topiramate tabs 25 mg, Hydantoins 50 mg, 100 mg, 200 1 (Phenytoin) PHENYTOIN 1 mg INFATABS CHEW TRILEPTAL SUSP CEREBYX SOLN PA 3 SP (oxcarbazepine) (fosphenytoin sodium) TRILEPTAL TABS 3 DILANTIN CAPS 100 MG (oxcarbazepine) (phenytoin sodium 3 TROKENDI XR CP24 PA ) 3 extended (topiramate) DILANTIN CAPS 30 MG VIMPAT SOLN ( 2 2 phenytoin sodium (lacosamide) extended) VIMPAT TABS DILANTIN INFATABS 2 3 (lacosamide) CHEW (phenytoin) ZONEGRAN CAPS DILANTIN-125 SUSP 3 3 (zonisamide) (phenytoin) PA zonisamide caps 1 fosphenytoin sodium SP soln Carbamates PEGANONE TABS 3 felbamate susp 1 (ethotoin) PHENYTEK CAPS felbamate tabs 1 (phenytoin sodium 3 FELBATOL SUSP extended) 3 (felbamate) phenytoin chew 1 FELBATOL TABS 3 (felbamate) phenytoin sodium 1 extended caps

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phenytoin sodium soln SP PA Antidepressants - Misc. APLENZIN TB24 ST; QL(1 ea phenytoin susp 1 (bupropion 3 daily) hydrobromide) Succinimides CELONTIN CAPS bupropion hcl tabs 75 2 1 (methsuximide) mg, 100 mg bupropion hcl tb12 100 1 ethosuximide caps 1 mg, 150 mg, 200 mg QL(1 ea daily) ethosuximide soln 1 bupropion hcl tb24 150 1 mg, 300 mg ZARONTIN CAPS 3 bupropion hcl tb24 450 ST; QL(1 ea (ethosuximide) 1 daily)1 bal on ZARONTIN SOLN mg 3 hand, (ethosuximide) FORFIVO XL TB24 ST; QL(1 ea Valproic Acid 3 daily)1 bal on (bupropion hcl) hand, DEPAKENE CAPS 250 MG 3 (valproic acid) maprotiline hcl tabs 1 1 bal on hand, DEPAKOTE ER TB24 WELLBUTRIN SR TB12 3 GP (divalproex sodium) 100 MG (bupropion hcl) DEPAKOTE SPRINKLES WELLBUTRIN SR TB12 CSDR (divalproex 3 150 MG, 200 MG NF sodium) (bupropion hcl) DEPAKOTE TBEC WELLBUTRIN XL TB24 QL(1 ea daily) 3 NF (divalproex sodium) 150 MG (bupropion hcl) WELLBUTRIN XL TB24 QL(1 ea daily) divalproex sodium csdr 1 GP 300 MG (bupropion hcl) divalproex sodium tb24 1 Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 QL(1 ea daily) divalproex sodium tbec 1 3 (selegiline) 1 MARPLAN TABS valproic acid caps or 3 (isocarboxazid) ANTIDEPRESSANTS - Drugs to Treat NARDIL TABS Depression GP (phenelzine sulfate) Alpha-2 Receptor Antagonists (Tetracyclics) PARNATE TABS mirtazapine tabs 1 (tranylcypromine GP sulfate) mirtazapine tbdp 1 phenelzine sulfate tabs 1 REMERON SOLTAB TBDP GP (mirtazapine) tranylcypromine sulfate 1 REMERON TABS tabs GP (mirtazapine) Selective Serotonin Reuptake Inhibitors (SSRIs)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEXA TABS 10 MG QL(4 ea daily) fluvoxamine maleate 1 (citalopram GP cp24 hydrobromide) fluvoxamine maleate 1 CELEXA TABS 20 MG QL(2 ea daily) tabs (citalopram GP LEXAPRO TABS 10 MG, hydrobromide) 20 MG (escitalopram NF CELEXA TABS 40 MG QL(1 ea daily) oxalate) (citalopram GP LEXAPRO TABS 5 MG GP hydrobromide) (escitalopram oxalate) citalopram QL(20 ml daily) hydrobromide soln 10 1 paroxetine hcl tabs 1 mg/5ml paroxetine hcl tb24 1 citalopram QL(4 ea daily) PAXIL CR TB24 25 MG, hydrobromide tabs 10 1 GP mg 12.5 MG (paroxetine hcl) PAXIL CR TB24 37.5 MG citalopram QL(2 ea daily) NF (paroxetine hcl) hydrobromide tabs 20 1 mg PAXIL TABS 10 MG, 30 MG, 40 MG (paroxetine GP QL(1 ea daily) citalopram hcl) hydrobromide tabs 40 1 PAXIL TABS 20 MG mg NF (paroxetine hcl) escitalopram oxalate 1 PEXEVA TABS 3 soln (paroxetine mesylate) escitalopram oxalate PROZAC CAPS 1 GP tabs (fluoxetine hcl) fluoxetine hcl caps 10 1 mg, 20 mg, 40 mg sertraline hcl conc 1 1 bal on hand, fluoxetine hcl cpdr 90 1 sertraline hcl tabs 1 mg ZOLOFT CONC 20 MG/ML GP fluoxetine hcl soln 20 1 (sertraline hcl) mg/5ml ZOLOFT TABS 100 MG NF fluoxetine hcl tabs 10 1 (sertraline hcl) mg, 20 mg ZOLOFT TABS 25 MG, 50 GP fluoxetine hcl tabs 60 ST; QL(1 ea MG (sertraline hcl) 1 daily)1 bal on mg hand, Serotonin Modulators fluoxetine hcl tabs 60 ST; QL(1 ea nefazodone hcl tabs 50 1 daily) mg mg, 100 mg, 150 mg, 1 FLUOXETINE ST; QL(1 ea 200 mg, 250 mg, 250 HYDROCHLORIDE TABS 3 daily) mg (fluoxetine hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nefazodone hcl tabs 50 1 bal on hand, PRISTIQ TB24 (desvenlafaxine NF mg, 100 mg, 150 mg, 1 200 mg, 250 mg, 250 succinate) mg QL(2 ea daily) venlafaxine hcl cp24 1 trazodone hcl tabs 1 150 mg, 37.5 mg venlafaxine hcl cp24 75 QL(1 ea daily) TRINTELLIX TABS ST; QL(1 ea 1 3 mg, 37.5 mg (vortioxetine hbr) daily) venlafaxine hcl tabs 25 VIIBRYD STARTER PACK ST 3 mg, 50 mg, 75 mg, 100 1 KIT (vilazodone hcl) mg, 37.5 mg VIIBRYD TABS ST 3 (vilazodone hcl) venlafaxine hcl tb24 75 mg, 150 mg, 225 mg, 1 Serotonin-Norepinephrine Reuptake Inhibitors 37.5 mg CYMBALTA CPEP 20 MG QL(2 ea daily) GP (duloxetine hcl) Tricyclic Agents CYMBALTA CPEP 30 MG, QL(2 ea daily) amitriptyline hcl tabs 1 NF 60 MG (duloxetine hcl) 1 1 bal on hand, DESVENLAFAXINE ER ST; QL(1 ea amoxapine tabs 3 TB24 (desvenlafaxine) daily) ANAFRANIL CAPS GP (clomipramine hcl) desvenlafaxine 1 succinate tb24 clomipramine hcl caps 1 ST; QL(1 ea desvenlafaxine tb24 1 daily)1 bal on desipramine hcl tabs 1 hand, QL(2 ea daily) doxepin hcl caps 10 duloxetine hcl cpep 20 1 mg, 30 mg, 60 mg mg, 25 mg, 50 mg, 75 1 mg, 100 mg, 150 mg EFFEXOR XR CP24 150 QL(2 ea daily) NF 1 bal on hand, MG (venlafaxine hcl) doxepin hcl caps 150 1 mg, 150 mg EFFEXOR XR CP24 75 QL(1 ea daily) MG, 37.5 MG GP doxepin hcl conc 10 1 (venlafaxine hcl) mg/ml FETZIMA CP24 20 MG, 80 ST; QL(2 ea imipramine hcl tabs 1 MG, 120 MG 3 daily) (levomilnacipran hcl) imipramine pamoate 1 FETZIMA CP24 40 MG, 80 ST; QL(1 ea caps MG, 120 MG 3 daily) NORPRAMIN TABS GP (levomilnacipran hcl) (desipramine hcl) FETZIMA TITRATION ST nortriptyline hcl caps 10 PACK C4PK 3 mg, 25 mg, 50 mg, 75 1 (levomilnacipran hcl) mg KHEDEZLA TB24 ST; QL(1 ea PAMELOR CAPS 3 daily)1 bal on GP ) (desvenlafaxine) hand, (nortriptyline hcl

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLYXAMBI TABS protriptyline hcl tabs 5 1 mg, 10 mg (empagliflozin- 2 SURMONTIL CAPS linagliptin) GP (trimipramine maleate) INVOKAMET TABS TOFRANIL TABS (canagliflozin- 2 GP (imipramine hcl) metformin hcl) INVOKAMET XR TB24 trimipramine maleate 1 caps (canagliflozin- 2 metformin hcl) ANTIDIABETICS - Drugs to Regulate Blood Sugar JANUMET TABS (sitagliptin-metformin 2 Alpha-Glucosidase Inhibitors hcl) acarbose tabs 1 JANUMET XR TB24 (sitagliptin-metformin 2 GLYSET TABS (miglitol) GP hcl) KAZANO TABS 1 bal on hand, miglitol tabs 1 (alogliptin-metformin NF PRECOSE TABS GP hcl) (acarbose) OSENI TABS ( 1 bal on hand, alogliptin- NF Antidiabetic - Amylin Analogs pioglitazone) SYMLINPEN 120 SOPN PA 3 pioglitazone hcl- 1 (pramlintide acetate) glimepiride tabs SYMLINPEN 60 SOPN PA SP pioglitazone hcl- 1 (pramlintide acetate) metformin hcl tabs Antidiabetic Combinations 1 bal on hand, repaglinide-metformin 1 ACTOPLUS MET TABS hcl tabs (pioglitazone hcl- GP SEGLUROMET TABS metformin hcl) (ertugliflozin-metformin 3 ACTOPLUS MET XR TB24 hcl) (pioglitazone hcl- 3 SOLIQUA 100/33 SOPN PA metformin hcl) (insulin glargine- SP DUETACT TABS lixisenatide) (pioglitazone hcl- GP SYNJARDY TABS glimepiride) (empagliflozin- 2 metformin hcl) glipizide-metformin hcl 1 tabs SYNJARDY XR TB24 GLUCOVANCE TABS (empagliflozin- 2 GP (glyburide-metformin) metformin hcl) XULTOPHY 100/3.6 SOPN PA glyburide-metformin 1 tabs (insulin degludec- SP liraglutide) Biguanides

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPHAGE TABS GP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (metformin hcl) JANUVIA TABS GLUCOPHAGE XR TB24 2 GP (sitagliptin phosphate) (metformin hcl) NESINA TABS (alogliptin 1 bal on hand, GLUMETZA TB24 PA NF SP benzoate) (metformin hcl) Dopamine Receptor Agonists - Antidiabetic metformin hcl soln 500 1 CYCLOSET TABS mg/5ml (bromocriptine 3 metformin hcl tabs 500 1 mesylate (diabetes)) mg, 850 mg, 1000 mg Incretin Mimetic Agents (GLP-1 Receptor PA metformin hcl tb24 500 SP ADLYXIN SOPN PA SP mg, 1000 mg (lixisenatide) metformin hcl tb24 500 ADLYXIN STARTER PACK PA 1 SP mg, 750 mg PNKT (lixisenatide) METFORMIN 1 bal on hand, BYDUREON BCISE AUIJ PA HYDROCHLORIDE SOLN SP 1 (exenatide) (metformin hcl) BYDUREON PEN PEN PA RIOMET SOLN 1 bal on hand, SP 3 (exenatide) (metformin hcl) BYDUREON SRER PA SP Diabetic Other (exenatide) BAQSIMI ONE PACK QL(0.069 ea BYETTA SOPN PA 2 SP POWD (glucagon) daily) (exenatide) BAQSIMI TWO PACK QL(0.069 ea OZEMPIC SOPN PA 2 SP POWD (glucagon) daily) (semaglutide) 1 TANZEUM PEN PA diazoxide susp SP (albiglutide) GLUCAGEN HYPOKIT TRULICITY SOPN PA SOLR (glucagon hcl 2 SP (rdna)) (dulaglutide) VICTOZA SOPN PA GLUCAGON SP EMERGENCY KIT FOR (liraglutide) 2 LOW BLOOD SUGAR Insulin Sensitizing Agents SOLR (glucagon hcl) ACTOS TABS GP GLUCAGON (pioglitazone hcl) EMERGENCY KIT KIT 2 AVANDIA TABS (glucagon (rdna)) 2 (rosiglitazone maleate) GVOKE PFS SOSY QL(0.02 ml 2 (glucagon) daily) pioglitazone hcl tabs 1 KORLYM TABS PA Insulin ( SP (hyperglycemia)) PROGLYCEM SUSP GP (diazoxide) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Insulin Lispro Protamine & Limit 3 boxes HUMULIN N SUSP Limit 45mls per Lispro) HUMALOG MIX per (insulin nph (human) 2 month;QL(1.5 50/50 KWIKPEN, 1 month;QL(1.5 (isophane)) ml daily) HUMALOG MIX 75/25 ml daily) LANTUS SOLN (insulin Limit 4 vials per KWIKPEN SUPN 2 month;QL(1.5 (Insulin Lispro Protamine & Limit 4 vials per glargine) ml daily) Lispro) HUMALOG MIX month;QL(1.5 1 LANTUS SOLOSTAR Limit 45mls per 50/50, HUMALOG MIX ml daily) 2 month;QL(1.5 75/25 SUSP SOPN (insulin glargine) ml daily) (Insulin Lispro) HUMALOG Limit 3 boxes Limit 3 boxes 1 per LEVEMIR FLEXTOUCH per KWIKPEN SOPN 100 month;QL(1.5 2 UNIT/ML SOPN (insulin detemir) month;QL(1.5 ml daily) ml daily) Limit 4 boxes Limit 4 vials per (Insulin Lispro) HUMALOG per LEVEMIR SOLN (insulin KWIKPEN SOPN 200 1 2 month;QL(1.5 UNIT/ML month;QL(0.8 detemir) ml daily) ml daily) Limit 3 boxes Limit 4 vials per TOUJEO MAX SOLOSTAR per (Insulin Lispro) HUMALOG 1 month;QL(1.5 2 SOLN SOPN (insulin glargine) month;QL(0.6 ml daily) ml daily) (Insulin Nph (Human) Limit 3 boxes Limit 3 boxes 1 per TOUJEO SOLOSTAR per (Isophane)) HUMULIN N month;QL(1.5 2 KWIKPEN SUPN SOPN (insulin glargine) month;QL(0.6 ml daily) ml daily) (Insulin Nph (Human) Limit 4 vials per Limit 3 boxes (Isophane)) HUMULIN N 1 month;QL(1.5 TRESIBA FLEXTOUCH SOPN 100 UNIT/ML 2 per SUSP ml daily) month;QL(1.5 (Insulin Nph Isophane & Limit 45mls per (insulin degludec) ml daily) Reg (Human)) HUMULIN 1 month;QL(1.5 Limit 3 boxes 70/30 KWIKPEN SUPN ml daily) TRESIBA FLEXTOUCH SOPN 200 UNIT/ML 2 per (Insulin Nph Isophane & Limit 4 vials per month;QL(0.9 Reg (Human)) HUMULIN 1 month;QL(1.5 (insulin degludec) ml daily) 70/30 SUSP ml daily) TRESIBA SOLN ( insulin 2 (Insulin Regular (Human)) Limit 3 boxes degludec) HUMULIN R U-500 1 per month;QL(1.5 Meglitinide Analogues KWIKPEN SOPN ml daily) nateglinide tabs 1 (Insulin Regular (Human)) Limit 4 vials per HUMULIN R, HUMULIN R month;QL(1.5 PRANDIN TABS 1 GP U-500 (CONCENTRATED) ml daily) (repaglinide) SOLN (Insulin Regular (Human)) Limit 2 vials per repaglinide tabs 1 HUMULIN R, HUMULIN R 1 month;QL(1.5 STARLIX TABS U-500 (CONCENTRATED) ml daily) GP SOLN (nateglinide) Sodium-Glucose Co-Transporter 2 (SGLT2) HUMALOG SOCT Limit 45mls per 2 month;QL(1.5 INVOKANA TABS (insulin lispro) 2 ml daily) (canagliflozin)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JARDIANCE TABS (Loperamide Hcl) ANTI- RX/OTC 2 (empagliflozin) DIARRHEAL, TGT STEGLATRO TABS LOPERAMIDE HCL, SM ANTI-DIARRHEAL, RA (ertugliflozin l- 3 ANTI-DIARRHEAL, QC pyroglutamic acid) ANTI-DIARRHEAL, HM 1 Sulfonylureas LOPERAMIDE HCL, HM ANTI-DIARRHEAL, GNP (Glipizide) GLIPIZIDE XL 1 ANTI-DIARRHEAL, EQ TB24 ANTI-DIARRHEAL, CVS AMARYL TABS GP ANTI-DIARRHEAL CAPS (glimepiride) diphenoxylate w/ 1 bal on hand, glimepiride tabs 1 atropine liqd 2.5 1 mg/5ml-0.025 mg/5ml glipizide tabs 1 diphenoxylate w/ atropine tabs 2.5 mg- 1 glipizide tb24 1 0.025 mg GLUCOTROL TABS IMODIUM A-D CAPS RX/OTC GP GP (glipizide) (loperamide hcl) GLUCOTROL XL TB24 10 NF LOMOTIL TABS MG (glipizide) (diphenoxylate w/ GP GLUCOTROL XL TB24 5 atropine) GP MG, 2.5 MG (glipizide) loperamide hcl caps 1 RX/OTC glyburide micronized 1 MOTOFEN TABS tabs 2 (difenoxin w/ atropine) glyburide tabs 1 opium tincture tinc 1 GLYNASE TABS GP (glyburide micronized) paregoric tinc 1 1 bal on hand, tolazamide tabs 1 1 bal on hand, ANTIDOTES AND SPECIFIC ANTAGONISTS 1 bal on hand, tolbutamide tabs 1 Antidotes - Chelating Agents CHEMET CAPS ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs 3 to Treat Diarrhea (succimer) Antidiarrheal - Chloride Channel Antagonists deferasirox tabs SP PA MYTESI TBEC PA; QL(2 ea 3 PA (crofelemer) daily) deferasirox tbso SP EXJADE TBSO PA Antiperistaltic Agents SP (deferasirox) FERRIPROX TABS 500 PA SP MG (deferiprone) JADENU SPRINKLE PACK PA SP (deferasirox)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JADENU TABS PA PA SP palonosetron hcl soln SP (deferasirox) PALONOSETRON PA Antidotes and Specific Antagonists HYDROCHLORIDE SOLN SP RADIOGARDASE CAPS (palonosetron hcl) (prussian blue insoluble SANCUSO PTCH PA 3 3 (ferric (granisetron) hexacyanoferrate ii)) ZOFRAN ODT TBDP QL(20 ea per VISTOGARD PACK GP fill retail,60 ea (uridine triacetate SP (ondansetron) per fill mail) (emergency treatment)) PA; Limit 1 ZOFRAN SOLN 4 MG/5ML Opioid Antagonists GP bottle per (ondansetron hcl) month;QL(1.67 EVZIO SOAJ 0.4 PA SP ml daily) MG/0.4ML (naloxone hcl) QL(20 ea per EVZIO SOAJ 2 MG/0.4ML PA; 1 bal on ZOFRAN TABS 4 MG, 8 SP GP fill retail,60 ea (naloxone hcl) hand, MG (ondansetron hcl) per fill mail) PA; 1 bal on QL(20 ea per naloxone hcl soaj 2 SP ZUPLENZ FILM mg/0.4ml hand, 3 fill retail,60 ea (ondansetron) per fill mail) naloxone hcl sosy 2 SP mg/2ml Antiemetics - Anticholinergic (Meclizine Hcl) CVS RX/OTC naltrexone hcl tabs 1 MOTION SICKNESS II, WAL-DRAM II, TRAVEL- Limit 2 boxes NARCAN LIQD EASE, SM MOTION 3 per month;QL(4 SICKNESS, RA MOTION (naloxone hcl) ea per 30 days SICKNESS RELIEF, HM retail) MOTION SICKNESS ANTIEMETICS - Drugs to Treat Nausea and RELIEF, HM MOTION 1 Vomiting RELIEF, GNP MOTION SICKNESS RELIEF, EQL 5-HT3 Receptor Antagonists MOTION SICKNESS ALOXI SOLN PA SP RELIEF, EQ MOTION (palonosetron hcl) SICKNESS RELIEF, ANZEMET TABS PA; QL(0.07 ea DRAMAMINE LESS 3 (dolasetron mesylate) daily) DROWSY TABS RX/OTC granisetron hcl tabs 1 QL(2 ea daily) meclizine hcl tabs 1 PA; Limit 1 scopolamine pt72 1 ondansetron hcl soln 4 1 bottle per mg/5ml month;QL(1.67 TIGAN CAPS ml daily) (trimethobenzamide GP hcl) ondansetron hcl tabs 4 QL(20 ea per 1 fill retail,60 ea TRANSDERM SCOP PT72 NF mg, 8 mg per fill mail) (scopolamine) QL(20 ea per TRANSDERM-SCOP PT72 NF ondansetron tbdp 1 fill retail,60 ea (scopolamine) per fill mail) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CANCIDAS SOLR PA trimethobenzamide hcl 1 SP caps (caspofungin acetate) PA Antiemetics - Miscellaneous caspofungin acetate SP AKYNZEO CAPS OR 300 QL(2 ea per 28 solr 50 mg, 70 mg MG-0.5 MG (netupitant- 3 days retail) CASPOFUNGIN ACETATE PA palonosetron) SOLR 50 MG, 70 MG SP ( ) BONJESTA TBCR QL(2 ea daily) caspofungin acetate ERAXIS SOLR PA (doxylamine- 3 SP pyridoxine) (anidulafungin) CESAMET CAPS PA; QL(2 ea SP PA 3 micafungin sodium solr (nabilone) daily) MYCAMINE SOLR PA; 1 bal on SP DICLEGIS TBEC QL(4 ea daily) (micafungin sodium) hand, (doxylamine- GP pyridoxine) Antifungals QL(4 ea daily) (Nystatin) BIO-STATIN 1 doxylamine-pyridoxine 1 POWD tbec ABELCET SUSP PA SP dronabinol caps 1 (amphotericin b lipid) MARINOL CAPS AMBISOME SUSR PA GP (dronabinol) (amphotericin b SP liposome) Substance P/Neurokinin 1 (NK1) Receptor SP PA; 1 bal on QL(3 ea per fill amphotericin b solr hand, aprepitant caps 1 retail,9 ea per ANCOBON CAPS fill mail) GP (flucytosine) aprepitant caps 40 mg, QL(2 ea per fill 1 retail,6 ea per BIO-STATIN CAPS 500000 125 mg fill mail) UNIT, 1000000 UNIT 3 (nystatin) aprepitant caps 80 mg, QL(1 ea per fill 1 retail,3 ea per flucytosine caps 1 125 mg fill mail) EMEND CAPS 40 MG, 125 QL(2 ea per fill griseofulvin microsize 1 GP retail,6 ea per susp MG (aprepitant) fill mail) griseofulvin microsize 1 EMEND CAPS 80 MG, 125 QL(1 ea per fill tabs GP retail,3 ea per MG (aprepitant) fill mail) griseofulvin 1 ultramicrosize tabs EMEND TRIPACK CAPS QL(3 ea per fill GP retail,9 ea per 1 (aprepitant) fill mail) nystatin tabs VARUBI TBPK QL(4 ea per fill QL(90 ea per 3 (rolapitant hcl) retail) 1 365 days terbinafine hcl tabs retail,90 ea per ANTIFUNGALS - Drugs to Treat Fungal Infections 365 days mail) Antifungal - Glucan Synthesis Inhibitors Imidazole-Related Antifungals

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CRESEMBA CAPS (Dexchlorpheniramine 1 1 bal on hand, (isavuconazonium 3 Maleate) RYCLORA SOLN sulfate) 1 bal on hand, brompheniramine 1 DIFLUCAN SUSR tannate chew GP (fluconazole) 1 bal on hand, dexchlorpheniramine 1 DIFLUCAN TABS maleate soln GP (fluconazole) Antihistamines - Ethanolamines PA fluconazole in dextrose SP (Diphenhydramine Hcl) soln BANOPHEN, PHARBEDRYL, KP 1 fluconazole susr 1 DIPHENHYDRAMINE HCL CAPS 1 fluconazole tabs (Diphenhydramine Hcl) RX/OTC PA DIPHEN, EQ ALLERGY 1 itraconazole caps 1 RELIEF CHILDRENS ELIX PA itraconazole soln 1 carbinoxamine maleate 1 soln 4 mg/5ml tabs 1 1 bal on hand, carbinoxamine maleate 1 NOXAFIL SUSP 40 MG/ML soln 4 mg/5ml 3 (posaconazole) carbinoxamine maleate 1 NOXAFIL TBEC 100 MG tabs 4 mg GP (posaconazole) 1 bal on hand, carbinoxamine maleate 1 posaconazole tbec 1 tabs 4 mg clemastine fumarate 1 bal on hand, SPORANOX CAPS PA 1 GP tabs (itraconazole) SPORANOX PULSEPAK PA diphenhydramine hcl 1 GP CAPS (itraconazole) caps or 50 mg RX/OTC SPORANOX SOLN PA diphenhydramine hcl GP 1 (itraconazole) elix or 12.5 mg/5ml TOLSURA CAPS PA diphenhydramine hcl PA SP SP (itraconazole) soln ij 50 mg/ml VFEND SUSR KARBINAL ER SUER GP (voriconazole) (carbinoxamine 3 VFEND TABS maleate) GP (voriconazole) Antihistamines - Non-Sedating voriconazole susr or 40 1 mg/ml voriconazole tabs or 50 1 mg, 200 mg ANTIHISTAMINES - Drugs to Treat Allergies Antihistamines - Alkylamines You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) ALL DAY RX/OTC (Cetirizine Hcl) QC RX/OTC ALLERGY CHILDRENS, ALLERGY RELIEF WAL-ZYR CHILDRENS, CHILDRENS, RA 1 WAL-ZYR ALL DAY ALLERGY RELIEF ALLERGYCHILDRENS, CHILDRENS SYRP WAL-ZYR ALL DAY (Levocetirizine RX/OTC ALLERGY CHILDRENS, Dihydrochloride) ALLERGY 1 WAL-ZYR, TGT ALL DAY RELIEF 24HR, CVS ALLERGY RELIEF ALLERGY RELIEF TABS CHILDRENS, SM ALL DAY ALLERGY CHILDRENS, cetirizine hcl soln 1 RX/OTC SB CETIRIZINE HCL CLARINEX SYRP 0.5 CHILDRENS, RA 3 CETIRIZINE HCL MG/ML (desloratadine) CHILDRENS ALLERGY, CLARINEX TABS 5 MG PA; QL(1 ea GP RA ALLERGY RELIEF (desloratadine) daily) CHILDRENS, QC PA; QL(1 ea CHILDRENS ALLERGY, desloratadine tabs 5 1 PX CHILDRENS mg daily) ALLERGY, KLS ALLER- 1 bal on hand, desloratadine tbdp 5 1 TEC CHILDRENS, HM mg, 2.5 mg CETIRIZINE HCL RX/OTC CHILDRENS, HM ALL DAY levocetirizine 1 ALLERGY CHILDRENS, 1 dihydrochloride tabs or GOODSENSE ALL DAY XYZAL ALLERGY 24HR RX/OTC ALLERGYCHILDRENS, GNP ALL DAY ALLERGY TABS (levocetirizine GP CHILDRENS, EQL ALL dihydrochloride) DAY ALLERGY ZYRTEC CHILDRENS RX/OTC CHILDRENS, EQ ALLERGY SOLN GP ALLERGY RELIEF (cetirizine hcl) CHILDRENS, CVS ALLERGY RELIEF Antihistamines - Phenothiazines CHILDRENS, CETIRIZINE (Promethazine Hcl) 1 HYDROCHLORIDECHILD PHENADOZ SUPP RENS ALLERGY, (Promethazine Hcl) CETIRIZINE HCL HIVES PROMETHEGAN SUPP 25 1 RELIEF CHILDRENS, MG, 12.5 MG CETIRIZINE HCL CHILDRENSALLERGY, (Promethazine Hcl) 1 bal on hand, CETIRIZINE HCL PROMETHEGAN SUPP 50 1 CHILDRENS, CETIRIZINE MG, 12.5 MG PHENERGAN SOLN PA HCL ALLERGY SP CHILDRENS, ALLERGY (promethazine hcl) RELIEF CHILDRENS, ALL- promethazine hcl soln ij PA DAY ALLERGY SP CHILDRENS SOLN 25 mg/ml, 50 mg/ml (Cetirizine Hcl) EQ RX/OTC promethazine hcl soln 1 ALLERGY RELIEF SOLN 1 or 6.25 mg/5ml OR 1 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl supp cholestyramine light 1 re 25 mg, 50 mg, 12.5 1 powd mg cholestyramine pack 1 promethazine hcl syrp 1 or 6.25 mg/5ml cholestyramine powd 1 promethazine hcl tabs or 25 mg, 50 mg, 12.5 1 colesevelam hcl pack 1 mg colesevelam hcl tabs 1 Antihistamines - Piperidines COLESTID FLAVORED GP hcl 1 GRAN (colestipol hcl) syrp COLESTID FLAVORED GP cyproheptadine hcl 1 PACK (colestipol hcl) tabs COLESTID GRAN GP ANTIHYPERLIPIDEMICS - Drugs to Treat High (colestipol hcl) Cholesterol COLESTID PACK GP Antihyperlipidemics - Combinations (colestipol hcl) QL(1 ea daily) COLESTID TABS ezetimibe-simvastatin 1 GP tabs (colestipol hcl) VYTORIN TABS 10 MG-10 QL(1 ea daily) colestipol hcl gran 1 MG (ezetimibe- NF simvastatin) colestipol hcl pack 1 VYTORIN TABS 10 MG-20 QL(1 ea daily) MG, 40 MG-10 MG, 80 colestipol hcl tabs 1 GP MG-10 MG (ezetimibe- QUESTRAN LIGHT POWD GP simvastatin) (cholestyramine light) Antihyperlipidemics - Misc. QUESTRAN PACK GP ( ) (Omega-3-Acid Ethyl 1 cholestyramine Esters) TRIKLO CAPS QUESTRAN POWD GP LOVAZA CAPS ( omega- GP (cholestyramine) 3-acid ethyl esters) WELCHOL PACK GP (colesevelam hcl) omega-3-acid ethyl 1 esters caps WELCHOL TABS GP VASCEPA CAPS ST (colesevelam hcl) 3 (icosapent ethyl) Fibric Acid Derivatives Bile Acid Sequestrants ANTARA CAPS 3 (fenofibrate micronized) (Cholestyramine Light) 1 PREVALITE PACK choline fenofibrate cpdr 1 (Cholestyramine Light) 1 PREVALITE POWD 1 bal on hand, fenofibrate caps 50 mg, 1 150 mg cholestyramine light 1 pack

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) fenofibrate micronized 1 fluvastatin sodium caps 1 caps 1 QL(1 ea daily) fenofibrate tabs 160 mg 1 1 bal on hand, fluvastatin sodium tb24 LESCOL XL TB24 QL(1 ea daily) FENOFIBRATE TABS 160 1 bal on hand, GP 3 ( ) MG (fenofibrate) fluvastatin sodium LIPITOR TABS QL(1 ea daily) fenofibrate tabs 48 mg, NF (atorvastatin calcium) 54 mg, 145 mg, 160 1 LIVALO TABS ST; QL(1 ea mg 3 (pitavastatin calcium) daily) FENOFIBRIC ACID TABS 3 105 MG ( ) 1 $0 copay, age fenofibric acid lovastatin tabs 40 to 76;PV 1 bal on hand, fenofibric acid tabs 35 1 PRAVACHOL TABS 20 QL(1 ea daily) mg, 105 mg MG, 80 MG (pravastatin GP FIBRICOR TABS 35 MG, 3 sodium) 105 MG (fenofibric acid) PRAVACHOL TABS 40 QL(2 ea daily) FIBRICOR TABS 35 MG, 1 bal on hand, 3 MG, 80 MG (pravastatin GP 105 MG (fenofibric acid) sodium) QL(1 ea daily) gemfibrozil tabs 1 pravastatin sodium tabs 1 10 mg, 20 mg, 80 mg LIPOFEN CAPS 1 bal on hand, 3 QL(2 ea daily) (fenofibrate) pravastatin sodium tabs 1 LOPID TABS 40 mg, 80 mg GP QL(1 ea daily) (gemfibrozil) rosuvastatin calcium 1 TRICOR TABS tabs GP SIMCOR TB24 ( (fenofibrate) niacin- 2 TRIGLIDE TABS simvastatin) 3 (fenofibrate) simvastatin tabs 5 mg, QL(1 ea daily) TRILIPIX CPDR ( 10 mg, 20 mg, 40 mg, 1 choline GP fenofibrate) 80 mg ZOCOR TABS QL(1 ea daily) HMG CoA Reductase Inhibitors GP (simvastatin) ADVICOR TB24 20 MG- 1000 MG (niacin- 2 Intestinal Cholesterol Absorption Inhibitors lovastatin) ezetimibe tabs 1 ADVICOR TB24 40 MG- QL(1 ea daily) 1000 MG (niacin- 2 ZETIA TABS (ezetimibe) GP lovastatin) Microsomal Triglyceride Transfer Protein (MTP) ALTOPREV TB24 3 JUXTAPID CAPS PA (lovastatin) SP (lomitapide mesylate) QL(1 ea daily) atorvastatin calcium 1 tabs Nicotinic Acid Derivatives CRESTOR TABS QL(1 ea daily) NF (rosuvastatin calcium)

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40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits niacin moexipril hcl tabs 1 (antihyperlipidemic) 1 tbcr perindopril erbumine 1 NIASPAN TBCR ( tabs niacin GP (antihyperlipidemic)) PRINIVIL TABS (lisinopril) GP Proprotein Convertase Subtilisin/Kexin Type 9 Limited to 1 PRALUENT SOAJ PA QBRELIS SOLN bottle per SP 3 (alirocumab) (lisinopril) month.;QL(5 ml daily) REPATHA PUSHTRONEX PA SYSTEM SOCT SP quinapril hcl tabs 1 (evolocumab) ramipril caps 10 mg, QL(2 ea daily) REPATHA SOSY PA 1 SP 2.5 mg, 1.25 mg (evolocumab) QL(1 ea daily) REPATHA SURECLICK PA ramipril caps 5 mg, 2.5 1 SP SOAJ (evolocumab) mg, 1.25 mg ANTIHYPERTENSIVES - Drugs to Treat High trandolapril tabs 1 Blood Pressure VASOTEC TABS QL(2 ea daily) GP ACE Inhibitors (enalapril maleate) ACCUPRIL TABS 10 MG NF ZESTRIL TABS (lisinopril) GP (quinapril hcl) ACCUPRIL TABS 5 MG, Agents for Pheochromocytoma 20 MG, 40 MG (quinapril GP DEMSER CAPS 3 hcl) (metyrosine) ALTACE CAPS 10 MG, QL(2 ea daily) DIBENZYLINE CAPS GP 1.25 MG (ramipril) (phenoxybenzamine GP ALTACE CAPS 2.5 MG QL(1 ea daily) hcl) NF (ramipril) phenoxybenzamine hcl 1 ALTACE CAPS 5 MG, 1.25 QL(1 ea daily) caps GP MG (ramipril) Angiotensin II Receptor Antagonists 1 ATACAND TABS benazepril hcl tabs GP (candesartan cilexetil) captopril tabs 1 AVAPRO TABS GP (irbesartan) enalapril maleate tabs 1 QL(2 ea daily) BENICAR TABS EPANED SOLN QL(5 ml daily) 3 (olmesartan NF (enalapril maleate) medoxomil) fosinopril sodium tabs 1 candesartan cilexetil 1 tabs lisinopril tabs 1 COZAAR TABS ( losartan GP LOTENSIN TABS potassium) GP (benazepril hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIOVAN TABS GP prazosin hcl caps 1 (valsartan) EDARBI TABS terazosin hcl caps 1 3 (azilsartan medoxomil) Antihypertensive Combinations 1 bal on hand, eprosartan mesylate 1 tabs ACCURETIC TABS (quinapril- GP irbesartan tabs 1 hydrochlorothiazide) amlodipine besylate- losartan potassium 1 1 tabs benazepril hcl caps MICARDIS TABS amlodipine besylate- GP (telmisartan) olmesartan medoxomil 1 tabs olmesartan medoxomil 1 tabs amlodipine besylate- 1 valsartan tabs telmisartan tabs 1 amlodipine-valsartan- valsartan tabs 1 hydrochlorothiazide 1 tabs Antiadrenergic Antihypertensives ATACAND HCT TABS CARDURA TABS GP (candesartan cilexetil- GP (doxazosin mesylate) hydrochlorothiazide) CATAPRES TABS GP atenolol & 1 (clonidine hcl) chlorthalidone tabs CATAPRES-TTS-1 PTWK GP AVALIDE TABS (clonidine) (irbesartan- GP CATAPRES-TTS-2 PTWK GP hydrochlorothiazide) (clonidine) AZOR TABS 20 MG-5 MG, CATAPRES-TTS-3 PTWK 40 MG-5 MG, 20 MG-10 GP (clonidine) MG (amlodipine GP besylate-olmesartan clonidine hcl tabs 1 medoxomil) clonidine ptwk 1 AZOR TABS 40 MG-10 MG (amlodipine besylate- NF doxazosin mesylate 1 olmesartan medoxomil) tabs benazepril & guanfacine hcl tabs 1 hydrochlorothiazide 1 tabs 1 methyldopa tabs BENICAR HCT TABS 20 methyldopate hcl soln SP PA; 1 bal on MG-12.5 MG (olmesartan hand, medoxomil- GP MINIPRESS CAPS ) GP hydrochlorothiazide (prazosin hcl)

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42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENICAR HCT TABS 40 EXFORGE TABS MG-25 MG, 40 MG-12.5 (amlodipine besylate- GP MG (olmesartan NF valsartan) medoxomil- fosinopril sodium & hydrochlorothiazide) hydrochlorothiazide 1 bisoprolol & tabs hydrochlorothiazide 1 HYZAAR TABS (losartan tabs potassium & GP BYVALSON TABS 3 hydrochlorothiazide) (nebivolol-valsartan) irbesartan- candesartan cilexetil- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs lisinopril & captopril & 1 bal on hand, hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs LOPRESSOR HCT TABS CORZIDE TABS 40 MG-5 (metoprolol & GP MG (nadolol & 3 hydrochlorothiazide) bendroflumethiazide) losartan potassium & CORZIDE TABS 80 MG-5 hydrochlorothiazide 1 MG (nadolol & 3 tabs bendroflumethiazide) LOTENSIN HCT TABS DIOVAN HCT TABS 160 (benazepril & GP MG-25 MG, 80 MG-12.5 hydrochlorothiazide) MG, 160 MG-12.5 MG, 320 GP MG-12.5 MG (valsartan- LOTREL CAPS hydrochlorothiazide) (amlodipine besylate- GP DIOVAN HCT TABS 320 benazepril hcl) MG-25 MG (valsartan- NF methyldopa & 1 bal on hand, hydrochlorothiazide) hydrochlorothiazide 1 DUTOPROL TB24 tabs (metoprolol & 3 metoprolol & 1 bal on hand, hydrochlorothiazide) hydrochlorothiazide 1 EDARBYCLOR TABS tabs 100 mg-50 mg (azilsartan medoxomil- 3 metoprolol & chlorthalidone) hydrochlorothiazide 1 enalapril maleate & tabs 50 mg-25 mg, 100 hydrochlorothiazide 1 mg-25 mg tabs METOPROLOL EXFORGE HCT TABS SUCCINATE ER/HYDROCHLOROTHIA (amlodipine-valsartan- GP 3 ZIDE TB24 ( hydrochlorothiazide) metoprolol & hydrochlorothiazide)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICARDIS HCT TABS trandolapril-verapamil 1 bal on hand, (telmisartan- GP hcl tbcr 1 mg-240 mg, 2 1 hydrochlorothiazide) mg-240 mg, 4 mg-240 moexipril- mg hydrochlorothiazide 1 trandolapril-verapamil tabs hcl tbcr 2 mg-180 mg, 2 1 nadolol & 1 bal on hand, mg-240 mg, 4 mg-240 bendroflumethiazide 1 mg tabs TRIBENZOR TABS olmesartan medoxomil- (olmesartan medoxomil-amlodipine- GP amlodipine- 1 hydrochlorothiazide hydrochlorothiazide) tabs TWYNSTA TABS olmesartan medoxomil- (telmisartan- GP hydrochlorothiazide 1 amlodipine) tabs valsartan- propranolol & 1 bal on hand, hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs VASERETIC TABS quinapril- (enalapril maleate & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs ZESTORETIC TABS ( GP TARKA TBCR lisinopril & ) (trandolapril-verapamil GP hydrochlorothiazide ZIAC TABS ( hcl) bisoprolol & GP TEKTURNA HCT TABS hydrochlorothiazide) (aliskiren- 3 Antihypertensives - Misc. hydrochlorothiazide) VECAMYL TABS PA SP (mecamylamine hcl) telmisartan-amlodipine 1 tabs Direct Renin Inhibitors telmisartan- aliskiren fumarate tabs 1 hydrochlorothiazide 1 tabs TEKTURNA TABS 150 MG, 300 MG, 300 MG TENORETIC 100 TABS 3 (aliskiren fumarate) (atenolol & GP chlorthalidone) TEKTURNA TABS 150 1 bal on hand, MG, 300 MG, 300 MG 3 TENORETIC 50 TABS (aliskiren fumarate) (atenolol & GP chlorthalidone) Selective Aldosterone Receptor Antagonists eplerenone tabs 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSPRA TABS PRIMAQUINE GP (eplerenone) PHOSPHATE TABS GP (primaquine phosphate) Vasodilators PA PA pyrimethamine tabs 1 hydralazine hcl soln ij SP 20 mg/ml QUALAQUIN CAPS PA; QL(42 ea GP per 7 days hydralazine hcl tabs or (quinine sulfate) 10 mg, 25 mg, 50 mg, 1 retail) 100 mg PA; QL(42 ea quinine sulfate caps 1 per 7 days minoxidil tabs 1 retail) ANTIMALARIALS - Drugs to Treat Malaria ANTIMYASTHENIC/CHOLINERGIC AGENTS (Parasitic Infections) Antimyasthenic/Cholinergic Agents Antimalarial Combinations FIRDAPSE TABS PA atovaquone-proguanil 1 (amifampridine SP hcl tabs phosphate) COARTEM TABS QL(0.8 ea GUANIDINE HCL TABS 2 (artemether- 2 daily) (guanidine hcl) lumefantrine) MESTINON SOLN 60 PA MALARONE TABS MG/5ML (pyridostigmine GP (atovaquone-proguanil GP bromide) hcl) MESTINON TABS 60 MG Antimalarials (pyridostigmine GP bromide) chloroquine phosphate 1 tabs 250 mg, 500 mg MESTINON TIMESPAN 1 bal on hand, TBCR (pyridostigmine GP chloroquine phosphate 1 tabs 500 mg, 500 mg bromide) DARAPRIM TABS PA; 1 bal on pyridostigmine bromide PA 3 1 (pyrimethamine) hand, soln 60 mg/5ml pyridostigmine bromide hydroxychloroquine 1 1 sulfate tabs tabs 60 mg KRINTAFEL TABS QL(2 ea per 30 pyridostigmine bromide 2 1 (tafenoquine succinate) days retail) tbcr 180 mg QL(6 ea per fill RUZURGI TABS PA; QL(10 ea SP mefloquine hcl tabs 1 retail)1 bal on (amifampridine) daily) hand, ANTIMYCOBACTERIAL AGENTS - Drugs to PLAQUENIL TABS Treat Tuberculosis (Bacterial Infections) (hydroxychloroquine 1 sulfate) Anti TB Combinations RIFAMATE CAPS primaquine phosphate 2 1 (isoniazid & rifampin) tabs

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45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIFATER TABS ANTINEOPLASTICS AND ADJUNCTIVE (isoniazid-rifampin w/ 3 THERAPIES - Drugs to Treat Cancer pyrazinamide) Alkylating Agents Antimycobacterial Agents ALKERAN SOLR IV 50 MG PA AC CAPASTAT SULFATE PA (melphalan hcl) SOLR (capreomycin SP ALKERAN TABS OR 2 MG AC sulfate) (melphalan) cycloserine caps 1 busulfan soln AC PA BUSULFEX SOLN PA ethambutol hcl tabs 1 AC (busulfan) isoniazid soln ij 100 PA; 1 bal on SP cyclophosphamide mg/ml hand, caps 25 mg, 50 mg, 50 AC 1 bal on hand, isoniazid syrp or 50 1 mg mg/5ml cyclophosphamide 1 bal on hand, ISONIAZID TABS OR 100 2 caps 25 mg, 50 mg, 50 AC MG (isoniazid) mg isoniazid tabs or 100 GLEOSTINE CAPS PA 1 AC mg, 300 mg (lomustine) MYAMBUTOL TABS HEXALEN CAPS GP AC (ethambutol hcl) (altretamine) MYCOBUTIN CAPS LEUKERAN TABS GP AC (rifabutin) (chlorambucil) PASER PACK 3 PA (aminosalicylic acid) melphalan hcl solr AC PRIFTIN TABS 3 melphalan tabs AC (rifapentine) MYLERAN TABS AC pyrazinamide tabs 1 (busulfan) TEMODAR CAPS rifabutin caps 1 AC (temozolomide) RIFADIN CAPS OR 150 GP MG, 300 MG (rifampin) temozolomide caps AC RIFADIN SOLR IV 600 MG PA TEPADINA SOLR SP AC (rifampin) (thiotepa) TEPADINA SOLR 1 bal on hand, rifampin caps or 150 1 AC mg, 300 mg (thiotepa) rifampin solr iv 600 mg SP PA thiotepa solr AC SIRTURO TABS ZANOSAR SOLR PA SP AC (bedaquiline fumarate) (streptozocin) TRECATOR TABS Antimetabolites 2 (ethionamide)

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46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Fluorouracil) ADRUCIL AC PA GEMCITABINE PA SOLN HYDROCHLORIDE SOLN AC ALIMTA SOLR PA 1.5 GM/15ML AC (pemetrexed disodium) (gemcitabine hcl) ARRANON SOLN PA GEMZAR SOLR PA AC AC (nelarabine) (gemcitabine hcl) azacitidine susr AC PA mercaptopurine tabs AC methotrexate sodium capecitabine tabs AC soln ij 25 mg/ml, 1 SP cladribine soln AC PA gm/40ml, 50 mg/2ml, 250 mg/10ml clofarabine soln AC PA methotrexate sodium 1 bal on hand, CLOLAR SOLN PA soln ij 250 mg/10ml, SP AC (clofarabine) 250 mg/10ml PA methotrexate sodium cytarabine soln 100 AC SP mg/ml solr ij 1 gm PA; 1 bal on methotrexate sodium cytarabine soln 20 SP 1 mg/ml hand, tabs or 2.5 mg DACOGEN SOLR PA PURIXAN SUSP PA; AL(Up to AC AC (decitabine) (mercaptopurine) 13 yrs old ) TABLOID TABS PA AC decitabine solr AC (thioguanine) PA TREXALL TABS floxuridine solr AC 3 (methotrexate sodium) fludarabine phosphate PA VIDAZA SUSR PA AC AC soln (azacitidine) fludarabine phosphate PA XATMEP SOLN PA AC AC solr (methotrexate) PA XELODA TABS fluorouracil soln AC AC (capecitabine) gemcitabine hcl soln 1 PA; 1 bal on gm/10ml, 2 gm/20ml, AC hand, Antineoplastic - Antibodies ARZERRA CONC PA 200 mg/2ml AC (ofatumumab) gemcitabine hcl solr 1 PA AC CAMPATH SOLN PA gm, 200 mg AC (alemtuzumab) GEMCITABINE PA; 1 bal on ERBITUX SOLN PA HYDROCHLORIDE SOLN hand, AC 1 GM/10ML, 2 GM/20ML, AC (cetuximab) 200 MG/2ML RITUXAN SOLN PA AC (gemcitabine hcl) (rituximab) YERVOY SOLN PA AC (ipilimumab)

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47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERLEADA TABS PA Antineoplastic - BCL-2 Inhibitors AC VENCLEXTA STARTING PA () PACK TBPK AC tabs AC (venetoclax) VENCLEXTA TABS PA FARESTON TABS AC AC (venetoclax) (toremifene citrate) FEMARA TABS Antineoplastic - Hedgehog Pathway Inhibitors AC (letrozole) DAURISMO TABS PA AC FENSOLVI KIT PA (glasdegib maleate) (leuprolide acetate (6 AC ERIVEDGE CAPS PA AC month)) (vismodegib) FIRMAGON SOLR PA ODOMZO CAPS PA AC AC (degarelix acetate) (sonidegib phosphate) caps AC Antineoplastic - Hormonal and Related Agents PA AC letrozole tabs AC tabs leuprolide acetate kit AC PA anastrozole tabs AC LEUPROLIDE PA ARIMIDEX TABS AC ACETATE/BUPIVACAINE (anastrozole) HYDROCHLORIDE SOLN AC AROMASIN TABS (leuprolide acetate- AC (exemestane) bupivacaine hcl) tabs AC LUPRON DEPOT (1- PA MONTH) KIT 3.75 MG SP CASODEX TABS AC (leuprolide acetate) (bicalutamide) LUPRON DEPOT (1- PA DEPO-PROVERA SUSP PA MONTH) KIT 7.5 MG AC (medroxyprogesterone SP (leuprolide acetate) acetate LUPRON DEPOT (3- PA (antineoplastic)) MONTH) KIT 11.25 MG SP ELIGARD KIT ( PA (leuprolide acetate (3 leuprolide AC acetate (3 month)) month)) ELIGARD KIT ( PA LUPRON DEPOT (3- PA leuprolide AC acetate (4 month)) MONTH) KIT 22.5 MG AC (leuprolide acetate (3 ELIGARD KIT ( PA leuprolide AC month)) acetate (6 month)) LUPRON DEPOT (4- PA ELIGARD KIT ( PA leuprolide AC MONTH) KIT (leuprolide AC acetate) acetate (4 month)) EMCYT CAPS LUPRON DEPOT (6- PA ( AC MONTH) KIT (leuprolide AC phosphate sodium) acetate (6 month))

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48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LYSODREN TABS XPOVIO 80 MG TWICE PA AC (mitotane) WEEKLY TBPK AC (selinexor) susp 1 40 mg/ml, 400 mg/10ml Antineoplastic Antibiotics PA megestrol acetate tabs AC mitoxantrone hcl conc SP 20 mg, 40 mg NILANDRON TABS Antineoplastic Combinations AC () KISQALI FEMARA 200 PA DOSE TBPK (ribociclib AC nilutamide tabs AC succinate-letrozole) NUBEQA TABS PA KISQALI FEMARA 400 PA AC () DOSE TBPK (ribociclib AC SOLTAMOX SOLN succinate-letrozole) AC (tamoxifen citrate) KISQALI FEMARA 600 PA DOSE TBPK (ribociclib AC tamoxifen citrate tabs PV PV succinate-letrozole) LONSURF TABS PA toremifene citrate tabs AC AC (trifluridine-tipiracil) TRELSTAR MIXJECT PA RITUXAN HYCELA SOLN PA SUSR (triptorelin AC (rituximab- AC pamoate) hyaluronidase human) XTANDI CAPS PA AC () Antineoplastic Enzyme Inhibitors YONSA TABS PA AFINITOR DISPERZ TBSO PA; QL(1 ea AC AC daily) (abiraterone acetate) (everolimus) ZYTIGA TABS 250 MG PA AFINITOR TABS 10 MG PA; QL(1 ea AC AC daily) (abiraterone acetate) (everolimus) ZYTIGA TABS 500 MG PA AFINITOR TABS 5 MG, 2.5 PA; QL(1 ea AC AC daily) (abiraterone acetate) MG, 7.5 MG (everolimus) ALECENSA CAPS PA Antineoplastic - Immunomodulators AC (alectinib hcl) POMALYST CAPS PA AC ALUNBRIG TABS PA (pomalidomide) AC (brigatinib) Antineoplastic - XPO1 Inhibitors ALUNBRIG TBPK PA AC XPOVIO 100 MG ONCE PA (brigatinib) WEEKLY TBPK AC AYVAKIT TABS PA; QL(1 ea (selinexor) AC (avapritinib) daily) XPOVIO 60 MG ONCE PA BALVERSA TABS PA WEEKLY TBPK AC AC (selinexor) (erdafitinib) BOSULIF TABS PA XPOVIO 80 MG ONCE PA AC WEEKLY TBPK AC (bosutinib) BRAFTOVI CAPS PA (selinexor) AC (encorafenib)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRUKINSA CAPS PA PA AC ISTODAX (OVERFILL) AC (zanubrutinib) SOLR (romidepsin) CABOMETYX TABS PA JAKAFI TABS (ruxolitinib PA AC AC (cabozantinib s-malate) phosphate) CALQUENCE CAPS PA KISQALI TBPK ( PA AC ribociclib AC (acalabrutinib) succinate) CAPRELSA TABS AC LENVIMA 10 MG DAILY PA (vandetanib) DOSE CPPK (lenvatinib AC COMETRIQ KIT mesylate) AC (cabozantinib s-malate) LENVIMA 12MG DAILY PA COPIKTRA CAPS PA DOSE CPPK (lenvatinib AC AC (duvelisib) mesylate) COTELLIC TABS PA LENVIMA 14 MG DAILY PA AC (cobimetinib fumarate) DOSE CPPK (lenvatinib AC mesylate) erlotinib hcl tabs AC PA LENVIMA 18 MG DAILY PA everolimus tabs AC PA; QL(1 ea DOSE CPPK (lenvatinib AC daily) mesylate) FARYDAK CAPS PA AC LENVIMA 20 MG DAILY PA (panobinostat lactate) DOSE CPPK (lenvatinib AC GILOTRIF TABS ( PA afatinib AC mesylate) dimaleate) LENVIMA 24 MG DAILY PA GLEEVEC TABS ( PA imatinib AC DOSE CPPK (lenvatinib AC mesylate) mesylate) IBRANCE CAPS 75 MG, PA LENVIMA 4 MG DAILY PA 100 MG, 125 MG AC DOSE CPPK (lenvatinib AC (palbociclib) mesylate) ICLUSIG TABS PA AC LENVIMA 8 MG DAILY PA (ponatinib hcl) DOSE CPPK (lenvatinib AC IDHIFA TABS PA AC mesylate) (enasidenib mesylate) LORBRENA TABS PA AC imatinib mesylate tabs AC PA (lorlatinib) LYNPARZA CAPS PA IMBRUVICA CAPS PA AC AC (olaparib) (ibrutinib) LYNPARZA TABS PA IMBRUVICA TABS PA AC AC (olaparib) (ibrutinib) MEKINIST TABS PA PA INLYTA TABS (axitinib) AC (trametinib dimethyl AC INREBIC CAPS PA sulfoxide) AC MEKTOVI TABS PA (fedratinib hcl) AC (binimetinib) IRESSA TABS (gefitinib) AC PA

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NERLYNX TABS PA TORISEL SOLN PA AC AC (neratinib maleate) (temsirolimus) NEXAVAR TABS PA TURALIO CAPS PA AC AC (sorafenib tosylate) (pexidartinib hcl) NINLARO CAPS PA TYKERB TABS ( PA AC lapatinib AC (ixazomib citrate) ditosylate) PIQRAY 200MG DAILY PA VELCADE SOLR PA AC AC DOSE TBPK (alpelisib) (bortezomib) PIQRAY 250MG DAILY PA VERZENIO TABS PA AC AC DOSE TBPK (alpelisib) (abemaciclib) PIQRAY 300MG DAILY PA VITRAKVI CAPS PA AC AC DOSE TBPK (alpelisib) (larotrectinib sulfate) ROMIDEPSIN SOLR PA VITRAKVI SOLN PA AC AC (romidepsin) (larotrectinib sulfate) ROZLYTREK CAPS PA VIZIMPRO TABS PA AC AC (entrectinib) (dacomitinib) RUBRACA TABS PA VOTRIENT TABS PA AC AC (rucaparib camsylate) (pazopanib hcl) RYDAPT CAPS PA XALKORI CAPS PA AC AC (midostaurin) (crizotinib) SPRYCEL TABS PA XOSPATA TABS PA AC AC (dasatinib) (gilteritinib fumarate) STIVARGA TABS PA; SP ZEJULA CAPS ( PA AC niraparib AC (regorafenib) tosylate) SUTENT CAPS (sunitinib PA ZELBORAF TABS PA AC AC malate) (vemurafenib) TAFINLAR CAPS PA ZOLINZA CAPS PA AC AC (dabrafenib mesylate) (vorinostat) TAGRISSO TABS PA ZYDELIG TABS PA AC AC (osimertinib mesylate) (idelalisib) TALZENNA CAPS PA ZYKADIA CAPS PA AC AC (talazoparib tosylate) (ceritinib) TARCEVA TABS PA ZYKADIA TABS PA AC AC (erlotinib hcl) (ceritinib) TASIGNA CAPS ( PA nilotinib AC Antineoplastics Misc. hcl) ACTIMMUNE SOLN PA TAZVERIK TABS PA SP AC (interferon gamma-1b) (tazemetostat hbr) ALFERON N SOLN PA AC temsirolimus soln AC PA (interferon alfa-n3) PA TIBSOVO TABS PA bexarotene caps AC AC (ivosidenib)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDREA CAPS PA AC etoposide soln iv 1 (hydroxyurea) gm/50ml, 100 mg/5ml, AC hydroxyurea caps AC 500 mg/25ml Topoisomerase I Inhibitors INTRON A SOLN PA AC (interferon alfa-2b) HYCAMTIN CAPS OR 0.25 PA MG, 1 MG (topotecan AC INTRON A SOLR PA AC hcl) (interferon alfa-2b) HYCAMTIN SOLR IV 4 MG PA MATULANE CAPS AC AC (topotecan hcl) (procarbazine hcl) PA SYLATRON KIT PA topotecan hcl soln 4 AC (peginterferon alfa-2b AC mg/4ml (antineoplastic)) TOPOTECAN HCL SOLN PA TARGRETIN CAPS OR 75 PA 4 MG/4ML (topotecan AC AC MG (bexarotene) hcl) tretinoin TOPOTECAN HCL SOLN PA AC 4 MG/4ML (topotecan AC (chemotherapy) caps hcl) Chemotherapy Adjuncts AC PA KEPIVANCE SOLR PA topotecan hcl solr 4 mg SP (palifermin) ANTIPARKINSON AND RELATED THERAPY Chemotherapy Rescue/Antidote Agents AGENTS - Drugs to Treat Parkinson's Disease ETHYOL SOLR PA Antiparkinson Adjunctive Therapy SP (amifostine crystalline) carbidopa tabs 1 leucovorin calcium soln PA AC LODOSYN TABS ij 500 mg/50ml GP (carbidopa) PA leucovorin calcium solr AC ij 100 mg, 350 mg Antiparkinson Anticholinergics PA leucovorin calcium tabs 1 bal on hand, benztropine mesylate SP or 10 mg, 15 mg, 25 AC soln ij 1 mg/ml mg benztropine mesylate tabs or 0.5 mg, 1 mg, 2 1 leucovorin calcium tabs AC or 5 mg, 15 mg, 25 mg mg COGENTIN SOLN PA SP MESNEX TABS (mesna) AC (benztropine mesylate) Mitotic Inhibitors trihexyphenidyl hcl soln 1 (Etoposide) TOPOSAR AC PA SOLN trihexyphenidyl hcl tabs 1 ETOPOPHOS SOLR PA AC Antiparkinson COMT Inhibitors (etoposide phosphate) COMTAN TABS 1 bal on hand, GP etoposide caps or 50 AC (entacapone) mg entacapone tabs 1 You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TASMAR TABS NEUPRO PT24 4 QL(1 ea daily) GP (tolcapone) MG/24HR, 6 MG/24HR, 8 3 MG/24HR (rotigotine) tolcapone tabs 1 OSMOLEX ER T4PK PA 3 Antiparkinson Dopaminergics (amantadine hcl) OSMOLEX ER TB24 PA amantadine hcl caps 1 3 (amantadine hcl) amantadine hcl syrp 1 PARLODEL CAPS (bromocriptine GP amantadine hcl tabs 1 mesylate) PARLODEL TABS bromocriptine mesylate 1 caps (bromocriptine GP mesylate) bromocriptine mesylate 1 tabs pramipexole 1 dihydrochloride tabs carbidopa-levodopa 1 tabs pramipexole 1 dihydrochloride tb24 carbidopa-levodopa 1 REQUIP TABS ( tbcr ropinirole GP hydrochloride) carbidopa-levodopa 1 tbdp REQUIP XL TB24 (ropinirole GP 1 bal on hand, carbidopa-levodopa- 1 hydrochloride) entacapone tabs ropinirole hydrochloride DUOPA SUSP 1 SP tabs (carbidopa-levodopa) GOCOVRI CP24 PA ropinirole hydrochloride 1 3 (amantadine hcl) tb24 RYTARY CPCR PA MIRAPEX ER TB24 3 ( ) (pramipexole GP carbidopa-levodopa SINEMET CR TBCR dihydrochloride) GP ( ) MIRAPEX TABS carbidopa-levodopa SINEMET TABS (pramipexole GP GP dihydrochloride) (carbidopa-levodopa) NEUPRO PT24 1 STALEVO 100 TABS 1 bal on hand, MG/24HR, 3 MG/24HR, 6 (carbidopa-levodopa- 2 MG/24HR, 8 MG/24HR 3 entacapone) (rotigotine) STALEVO 125 TABS 1 bal on hand, NEUPRO PT24 2 QL(3 ea daily) (carbidopa-levodopa- 2 MG/24HR, 3 MG/24HR, 6 3 entacapone) MG/24HR, 8 MG/24HR STALEVO 150 TABS 1 bal on hand, (rotigotine) (carbidopa-levodopa- 2 entacapone)

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53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 200 TABS 1 bal on hand, CAPLYTA CAPS PA; QL(1 ea 3 (carbidopa-levodopa- 2 (lumateperone tosylate) daily) entacapone) EQUETRO CP12 STALEVO 50 TABS 1 bal on hand, (carbamazepine 3 (carbidopa-levodopa- 2 (antipsychotic)) entacapone) GEODON CAPS OR 20 STALEVO 75 TABS 1 bal on hand, MG, 40 MG, 60 MG, 80 MG GP (carbidopa-levodopa- 2 (ziprasidone hcl) entacapone) GEODON SOLR IM 20 MG PA SP Antiparkinson Monoamine Oxidase Inhibitors (ziprasidone mesylate) AZILECT TABS LATUDA TABS PA GP 3 (rasagiline mesylate) (lurasidone hcl) ELDEPRYL CAPS NUPLAZID CAPS 34 MG PA; QL(1 ea GP SP daily) (selegiline hcl) (pimavanserin tartrate) NUPLAZID TABS 10 MG PA; QL(1 ea rasagiline mesylate 1 SP daily) tabs (pimavanserin tartrate) NUPLAZID TABS 17 MG PA SP selegiline hcl caps 1 (pimavanserin tartrate) VRAYLAR CAPS PA selegiline hcl tabs 1 3 (cariprazine hcl) 1 bal on hand, VRAYLAR CPPK PA selegiline hcl tabs 1 3 (cariprazine hcl) ZELAPAR TBDP 3 (selegiline hcl) ziprasidone hcl caps 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS - PA ziprasidone mesylate SP Drugs to Treat Mood Disorders solr Antimanic Agents Benzisoxazoles lithium carbonate caps (Risperidone) 150 mg, 300 mg, 600 1 RISPERIDONE M-TAB 1 mg, 600 mg TBDP FANAPT TABS PA lithium carbonate caps 1 bal on hand, 3 150 mg, 300 mg, 600 1 (iloperidone) mg, 600 mg FANAPT TITRATION PA PACK TABS 3 lithium carbonate tabs 1 300 mg (iloperidone) INVEGA SUSTENNA PA lithium carbonate tbcr 1 SUSY (paliperidone SP 300 mg, 450 mg palmitate) LITHIUM SOLN (lithium) 3 INVEGA TB24 GP (paliperidone) LITHOBID TBCR (lithium 3 INVEGA TRINZA SUSY PA carbonate) SP (paliperidone palmitate) Antipsychotics - Misc.

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FAZACLO TBDP 25 MG, paliperidone tb24 1 GP 100 MG (clozapine) PERSERIS PRSY PA SP loxapine succinate 1 (risperidone) caps RISPERDAL CONSTA PA olanzapine solr im 10 PA SRER (risperidone SP SP mg microspheres) RISPERDAL SOLN olanzapine tabs or 5 GP (risperidone) mg, 10 mg, 15 mg, 20 1 mg, 2.5 mg, 7.5 mg RISPERDAL TABS GP (risperidone) olanzapine tbdp or 5 mg, 10 mg, 15 mg, 20 1 risperidone soln 1 1 mg/ml mg risperidone tabs 0.25 quetiapine fumarate tabs 25 mg, 50 mg, 100 mg, 0.5 mg, 1 mg, 2 1 1 mg, 3 mg, 4 mg mg, 200 mg, 300 mg, 400 mg risperidone tbdp 0.25 1 bal on hand, quetiapine fumarate PA mg, 1 mg, 2 mg, 3 mg, 1 tb24 50 mg, 150 mg, 4 mg 1 200 mg, 300 mg, 400 risperidone tbdp 0.5 mg 1 mg, 1 mg, 2 mg, 3 mg, SAPHRIS SUBL PA 3 4 mg (asenapine maleate) Butyrophenones SECUADO PT24 PA; QL(1 ea 3 haloperidol lactate conc 1 (asenapine) daily) SEROQUEL TABS GP haloperidol tabs 1 (quetiapine fumarate) Dibenzapines SEROQUEL XR TB24 300 PA MG (quetiapine NF clozapine tabs 25 mg, fumarate) 50 mg, 100 mg, 200 1 SEROQUEL XR TB24 50 PA mg MG, 150 MG, 200 MG, 400 1 bal on hand, GP clozapine tbdp 150 mg, 1 MG (quetiapine 200 mg, 12.5 mg fumarate) clozapine tbdp 25 mg, VERSACLOZ SUSP QL(18 ml daily) 3 100 mg, 200 mg, 12.5 1 (clozapine) mg ZYPREXA SOLR IM 10 PA SP CLOZARIL TABS MG ( ) GP olanzapine (clozapine) ZYPREXA TABS OR 5 FAZACLO TBDP 12.5 MG MG, 10 MG, 15 MG, 20 3 GP (clozapine) MG, 2.5 MG, 7.5 MG FAZACLO TBDP 150 MG, 1 bal on hand, (olanzapine) 3 200 MG (clozapine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZYPREXA ZYDIS TBDP PA GP aripiprazole tbdp 10 1 (olanzapine) mg, 15 mg REXULTI TABS PA Dihydroindolones 3 (brexpiprazole) molindone hcl tabs 1 1 bal on hand, Thioxanthenes Phenothiazines thiothixene caps 1 (Prochlorperazine) 1 COMPRO SUPP ANTISEPTICS & DISINFECTANTS chlorpromazine hcl 1 tabs Antiseptics & Disinfectants 1 bal on hand, (Formaldehyde) fluphenazine hcl conc 5 1 1 mg/ml FORMADON SOLN 1 bal on hand, 1 bal on hand, formaldehyde soln 1 fluphenazine hcl elix 1 2.5 mg/5ml formaldehyde soln 1 fluphenazine hcl tabs 1 mg, 5 mg, 5 mg, 10 1 ANTIVIRALS - Drugs to Treat Viral Infections mg, 10 mg, 2.5 mg, 2.5 mg Antiretrovirals fluphenazine hcl tabs 1 1 bal on hand, abacavir sulfate soln 1 mg, 5 mg, 5 mg, 10 1 mg, 10 mg, 2.5 mg, 2.5 abacavir sulfate tabs 1 mg abacavir sulfate- 1 perphenazine tabs 1 lamivudine tabs abacavir sulfate- prochlorperazine 1 maleate tabs lamivudine-zidovudine 1 tabs prochlorperazine supp 1 APTIVUS CAPS 2 (tipranavir) thioridazine hcl tabs 1 APTIVUS SOLN 2 trifluoperazine hcl tabs 1 (tipranavir) 1 Quinolinone Derivatives atazanavir sulfate caps ABILIFY TABS 2 MG, 10 ATRIPLA TABS ST GP MG, 30 MG ( ) (efavirenz- aripiprazole 2 ABILIFY TABS 5 MG, 15 emtricitabine-tenofovir NF MG, 20 MG (aripiprazole) disoproxil fumarate) COMBIVIR TABS aripiprazole soln 1 1 GP mg/ml (lamivudine-zidovudine) aripiprazole tabs 2 mg, COMPLERA TABS ST (emtricitabine- 5 mg, 10 mg, 15 mg, 1 2 20 mg, 30 mg rilpivirine-tenofovir disoproxil fumarate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CRIXIVAN CAPS INTELENCE TABS 2 2 (indinavir sulfate) (etravirine) DELSTRIGO TABS ST INVIRASE CAPS 2 (doravirine-lamivudine- (saquinavir mesylate) 3 tenofovir disoproxil INVIRASE TABS 2 fumarate) (saquinavir mesylate) DESCOVY TABS PA ISENTRESS CHEW 2 (emtricitabine-tenofovir 2 (raltegravir potassium) alafenamide fumarate) ISENTRESS HD TABS 2 didanosine cpdr 1 1 bal on hand, (raltegravir potassium) ISENTRESS PACK DOVATO TABS 2 (raltegravir potassium) (dolutegravir sodium- 2 ISENTRESS TABS lamivudine) 2 (raltegravir potassium) EDURANT TABS 2 (rilpivirine hcl) JULUCA TABS (dolutegravir sodium- 2 efavirenz caps 1 rilpivirine hcl) KALETRA SOLN 400 efavirenz tabs 1 MG/5ML-100 MG/5ML GP EMTRIVA CAPS (lopinavir-ritonavir) 2 (emtricitabine) KALETRA TABS 100 MG- EMTRIVA SOLN 25 MG, 200 MG-50 MG 2 2 (emtricitabine) (lopinavir-ritonavir) EPIVIR SOLN 1 GP lamivudine soln (lamivudine) EPIVIR TABS lamivudine tabs 1 GP (lamivudine) lamivudine-zidovudine 1 EPZICOM TABS tabs (abacavir sulfate- GP LEXIVA SUSP 50 MG/ML lamivudine) (fosamprenavir 2 EVOTAZ TABS calcium) (atazanavir sulfate- 2 LEXIVA TABS 700 MG cobicistat) (fosamprenavir GP fosamprenavir calcium 1 calcium) tabs lopinavir-ritonavir soln 1 FUZEON SOLR PA SP (enfuvirtide) nevirapine susp 50 1 GENVOYA TABS mg/5ml (elvitegravir-cobicistat- nevirapine tabs 200 mg 1 emtricitabine-tenofovir 2 alafenamide) nevirapine tb24 100 1 mg, 400 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, STRIBILD TABS nevirapine tb24 100 1 (elvitegravir-cobicistat- mg, 400 mg 2 NORVIR CAPS 100 MG emtricitabine-tenofovir 2 (ritonavir) df) NORVIR SOLN 80 MG/ML SUSTIVA CAPS 2 GP (ritonavir) (efavirenz) NORVIR TABS 100 MG SUSTIVA TABS GP GP (ritonavir) (efavirenz) ODEFSEY TABS ST SYMTUZA TABS ST (darunavir-cobicistat- (emtricitabine- 3 rilpivirine-tenofovir 2 emtricitabine-tenofovir alafenamide fumarate) alafenamide) PIFELTRO TABS tenofovir disoproxil 2 1 (doravirine) fumarate tabs PREZCOBIX TABS TIVICAY TABS 50 MG 2 2 (darunavir-cobicistat) (dolutegravir sodium) PREZISTA SUSP TRIUMEQ TABS 2 (darunavir ethanolate) (abacavir-dolutegravir- 2 PREZISTA TABS lamivudine) 2 (darunavir ethanolate) TRIZIVIR TABS (abacavir RESCRIPTOR TABS sulfate-lamivudine- GP 2 (delavirdine mesylate) zidovudine) RETROVIR CAPS TRUVADA TABS GP (zidovudine) (emtricitabine-tenofovir 2 RETROVIR SYRP disoproxil fumarate) GP TYBOST TABS (zidovudine) 2 REYATAZ CAPS 150 MG, (cobicistat) VIDEX EC CPDR 125 MG 200 MG (atazanavir GP 2 sulfate) (didanosine) REYATAZ CAPS 300 MG VIDEX EC CPDR 200 MG, NF (atazanavir sulfate) 250 MG, 400 MG 3 REYATAZ PACK 50 MG (didanosine) 2 VIDEXPEDIATRIC SOLR (atazanavir sulfate) 2 (didanosine) ritonavir tabs 1 VIRACEPT TABS 2 SELZENTRY SOLN (nelfinavir mesylate) 2 (maraviroc) VIRAMUNE SUSP GP SELZENTRY TABS (nevirapine) 2 (maraviroc) VIRAMUNE TABS GP stavudine caps 1 (nevirapine) VIRAMUNE XR TB24 100 3 MG (nevirapine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRAMUNE XR TB24 400 GP Hepatitis Agents MG (nevirapine) (Ribavirin (Hepatitis C)) 1 PA VIREAD POWD 40 MG/GM MODERIBA TABS (tenofovir disoproxil 2 (Ribavirin (Hepatitis C)) PA fumarate) RIBASPHERE CAPS 200 1 VIREAD TABS 150 MG, MG 200 MG, 250 MG (Ribavirin (Hepatitis C)) PA (tenofovir disoproxil 2 RIBASPHERE RIBAPAK 1 fumarate) TBPK 400 MG, 600 MG VIREAD TABS 300 MG (Ribavirin (Hepatitis C)) PA RIBASPHERE TABS 200 1 (tenofovir disoproxil NF MG, 400 MG ) fumarate (Ribavirin (Hepatitis C)) PA; 1 bal on ZERIT CAPS 15 MG, 20 RIBASPHERE TABS 600 1 hand, MG, 30 MG, 40 MG GP MG (stavudine) adefovir dipivoxil tabs 1 ZERIT SOLR 1 MG/ML 2 ( ) BARACLUDE SOLN 0.05 stavudine 2 ZIAGEN SOLN (abacavir MG/ML (entecavir) GP BARACLUDE TABS 0.5 sulfate) GP ZIAGEN TABS ( MG, 1 MG (entecavir) abacavir GP sulfate) DAKLINZA TABS PA (daclatasvir SP zidovudine caps 1 dihydrochloride) zidovudine syrp 1 entecavir tabs 1 EPCLUSA TABS PA zidovudine tabs 1 SP (sofosbuvir-velpatasvir) CMV Agents EPIVIR HBV SOLN 5 cidofovir soln SP PA MG/ML (lamivudine 3 (hbv)) FOSCAVIR SOLN PA EPIVIR HBV TABS 100 SP GP (foscarnet sodium) MG (lamivudine (hbv)) PREVYMIS TABS PA; SP SP HARVONI TABS 200 MG- PA (letermovir) 45 MG, 400 MG-90 MG SP VALCYTE SOLR 50 QL(21 ml daily) (ledipasvir-sofosbuvir) MG/ML (valganciclovir GP HEPSERA TABS NF hcl) (adefovir dipivoxil) VALCYTE TABS 450 MG GP lamivudine (hbv) tabs 1 (valganciclovir hcl) QL(21 ml daily) LEDIPASVIR/SOFOSBUVI PA valganciclovir hcl solr 1 50 mg/ml R TABS (ledipasvir- SP sofosbuvir) valganciclovir hcl tabs 1 450 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAVYRET TABS PA ZEPATIER TABS PA SP (glecaprevir- SP (elbasvir-grazoprevir) pibrentasvir) Herpes Agents MODERIBA 1200 DOSE PA PACK TBPK (ribavirin 3 acyclovir caps 1 (hepatitis c)) acyclovir susp 1 PEGASYS PROCLICK PA SOLN (peginterferon SP acyclovir tabs 1 alfa-2a) PEGASYS SOLN PA famciclovir tabs 1 SP (peginterferon alfa-2a) valacyclovir hcl tabs 1 PEGINTRON KIT PA SP VALTREX TABS 1 GM (peginterferon alfa-2b) GP REBETOL CAPS 200 MG PA (valacyclovir hcl) GP VALTREX TABS 500 MG (ribavirin (hepatitis c)) NF REBETOL SOLN 40 PA (valacyclovir hcl) ZOVIRAX CAPS OR 200 MG/ML (ribavirin 2 GP (hepatitis c)) MG (acyclovir) ZOVIRAX SUSP OR 200 RIBASPHERE RIBAPAK PA GP TBPK (ribavirin 3 MG/5ML (acyclovir) (hepatitis c)) ZOVIRAX TABS OR 400 GP PA MG, 800 MG (acyclovir) ribavirin (hepatitis c) 1 caps Influenza Agents PA FLUMADINE TABS ribavirin (hepatitis c) 1 tabs (rimantadine 3 SOFOSBUVIR/VELPATAS PA hydrochloride) VIR TABS (sofosbuvir- SP QL(10 ea per oseltamivir phosphate 1 velpatasvir) caps or 30 mg, 45 mg 180 days retail) SOVALDI TABS 200 MG, PA SP oseltamivir phosphate 1 400 MG (sofosbuvir) caps or 75 mg TECHNIVIE TABS PA QL(180 ml per (ombitasvir-paritaprevir- SP oseltamivir phosphate 1 180 days ritonavir) susr or 6 mg/ml retail); AL(At VEMLIDY TABS PA least 1 yrs old) (tenofovir alafenamide SP Limit 1 inhaler RELENZA DISKHALER per fumarate) 3 AEPB (zanamivir) month;QL(0.67 VIEKIRA PAK TBPK PA ea daily) (ombitasvir-paritaprevir- SP 1 bal on hand, rimantadine 1 ritonavir-dasabuvir) hydrochloride tabs VOSEVI TABS PA TAMIFLU CAPS 30 MG, 45 QL(10 ea per (sofosbuvir-velpatasvir- SP MG (oseltamivir GP 180 days retail) voxilaprevir) phosphate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAMIFLU CAPS 75 MG NF metoprolol succinate 1 (oseltamivir phosphate) tb24 QL(180 ml per TAMIFLU SUSR 6 MG/ML metoprolol tartrate tabs 1 GP 180 days (oseltamivir phosphate) retail); AL(At TENORMIN TABS GP least 1 yrs old) (atenolol) Respiratory Syncytial Virus (RSV) Agents TOPROL XL TB24 25 MG, ribavirin solr 1 100 MG, 200 MG GP (metoprolol succinate) VIRAZOLE SOLR TOPROL XL TB24 50 MG GP NF (ribavirin) (metoprolol succinate) BETA BLOCKERS - Drugs to Treat High Blood Beta Blockers Non-Selective Pressure (Sotalol Hcl) SORINE 1 Alpha-Beta Blockers TABS BETAPACE AF TABS carvedilol phosphate 1 GP cp24 (sotalol hcl (afib/afl)) BETAPACE TABS (sotalol carvedilol tabs 25 mg, 1 GP 12.5 mg, 6.25 mg hcl) QL(2 ea daily) CORGARD TABS carvedilol tabs 3.125 1 GP mg (nadolol) COREG CR CP24 HEMANGEOL SOLN AL(Up to 1 yrs GP 3 (carvedilol phosphate) (propranolol hcl) old ) COREG TABS 25 MG, INDERAL LA CP24 GP GP 12.5 MG (carvedilol) (propranolol hcl) COREG TABS 3.125 MG QL(2 ea daily) INDERAL XL CP24 80 MG, GP (carvedilol) 120 MG, 120 MG ( COREG TABS 6.25 MG propranolol hcl 3 NF (carvedilol) sustained-release beads) labetalol hcl tabs 1 INDERAL XL CP24 80 MG, 1 bal on hand, 120 MG, 120 MG Beta Blockers Cardio-Selective (propranolol hcl 3 acebutolol hcl caps 1 sustained-release beads) atenolol tabs 1 INNOPRAN XL CP24 80 1 bal on hand, MG, 120 MG, 120 MG 1 betaxolol hcl tabs (propranolol hcl 3 QL(1 ea daily) sustained-release bisoprolol fumarate 1 tabs beads) BYSTOLIC TABS 3 (nebivolol hcl) LOPRESSOR TABS GP (metoprolol tartrate)

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61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INNOPRAN XL CP24 80 QL(2 ea daily) amlodipine besylate 1 MG, 120 MG, 120 MG tabs (propranolol hcl 3 CALAN SR TBCR GP sustained-release (verapamil hcl) beads) CALAN TABS ( verapamil GP nadolol tabs 1 hcl) CARDIZEM CD CP24 1 pindolol tabs (diltiazem hcl coated GP propranolol hcl cp24 60 beads) mg, 80 mg, 120 mg, 1 CARDIZEM LA TB24 120 160 mg MG (diltiazem hcl 2 1 bal on hand, coated beads) propranolol hcl soln 20 1 mg/5ml, 40 mg/5ml CARDIZEM LA TB24 180 MG, 240 MG, 300 MG, 360 propranolol hcl tabs 10 GP mg, 20 mg, 40 mg, 60 1 MG, 420 MG (diltiazem mg, 80 mg hcl coated beads) CARDIZEM TABS GP sotalol hcl (afib/afl) tabs 1 (diltiazem hcl) sotalol hcl tabs 1 diltiazem hcl coated 1 beads cp24 SOTYLIZE SOLN (sotalol 3 diltiazem hcl coated 1 hcl) beads tb24 QL(2 ea daily) timolol maleate tabs 5 1 mg, 10 mg, 20 mg diltiazem hcl cp12 1 CALCIUM CHANNEL BLOCKERS - Drugs to diltiazem hcl cp24 1 Treat High Blood Pressure diltiazem hcl extended 1 Calcium Channel Blockers release beads cp24 (Diltiazem Hcl Coated Beads) CARTIA XT, 1 diltiazem hcl tabs 1 DILTIAZEM CD CP24 felodipine tb24 1 (Diltiazem Hcl Coated 1 Beads) MATZIM LA TB24 (Diltiazem Hcl Extended isradipine caps 1 Release Beads) TAZTIA 1 XT, TIADYLT ER CP24 nicardipine hcl caps 1 (Diltiazem Hcl) DILT-XR 1 bal on hand, 1 nifedipine caps 10 mg, 1 CP24 20 mg (Nifedipine) AFEDITAB CR 1 TB24 nifedipine tb24 30 mg, 1 60 mg, 60 mg, 90 mg ADALAT CC TB24 30 MG, GP QL(1 ea daily) 60 MG (nifedipine) nifedipine tb24 30 mg, 1 ADALAT CC TB24 90 MG QL(1 ea daily) 60 mg, 60 mg, 90 mg GP (nifedipine) nimodipine caps 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nisoldipine tb24 17 mg, CARDIOTONICS - Drugs to Treat Heart Failure 30 mg, 34 mg, 40 mg, 1 and Abnormal Heart Rhythm 8.5 mg, 25.5 mg Cardiac Glycosides nisoldipine tb24 20 mg, 1 bal on hand, (Digoxin) DIGITEK, DIGOX 1 30 mg, 34 mg, 40 mg, 1 TABS 8.5 mg, 25.5 mg digoxin soln ij 0.25 1 NORVASC TABS QL(2 ea daily) mg/ml GP (amlodipine besylate) digoxin soln or 0.05 1 NYMALIZE SOLN 30 mg/ml MG/10ML, 60 MG/20ML 3 digoxin soln or 0.05 1 bal on hand, (nimodipine) 1 mg/ml PROCARDIA CAPS GP (nifedipine) digoxin tabs or 0.125 1 mg, 125 mcg, 250 mcg PROCARDIA XL TB24 QL(1 ea daily) GP LANOXIN PEDIATRIC PA (nifedipine) SP SOLN (digoxin) SULAR TB24 GP LANOXIN SOLN IJ 0.25 (nisoldipine) GP MG/ML (digoxin) TIAZAC CP24 (diltiazem LANOXIN TABS OR 125 hcl extended release GP 3 MCG, 250 MCG (digoxin) beads) LANOXIN TABS OR 62.5 1 bal on hand, verapamil hcl cp24 100 MCG, 187.5 MCG 3 mg, 120 mg, 180 mg, (digoxin) 200 mg, 200 mg, 240 1 mg, 300 mg, 300 mg, CARDIOVASCULAR AGENTS - MISC. - Drugs to 360 mg Treat Heart and Circulation Conditions verapamil hcl cp24 100 Cardiovascular Agents Misc. - Combinations mg, 120 mg, 180 mg, amlodipine besylate- 200 mg, 200 mg, 240 1 atorvastatin calcium 1 mg, 300 mg, 300 mg, tabs 360 mg BIDIL TABS (isosorbide dinitrate-hydralazine 3 verapamil hcl tabs 40 1 mg, 80 mg, 120 mg hcl) CADUET TABS verapamil hcl tbcr 120 1 mg, 180 mg, 240 mg (amlodipine besylate- GP atorvastatin calcium) VERELAN CP24 120 MG, ENTRESTO TABS PA 180 MG, 240 MG GP 3 (verapamil hcl) (sacubitril-valsartan) VERELAN CP24 360 MG 1 bal on hand, Impotence Agents 2 (verapamil hcl) PA; QL(1 ea CIALIS TABS (tadalafil) GP VERELAN PM CP24 1 bal on hand, daily) 3 (verapamil hcl) 1 PA; QL(1 ea tadalafil tabs daily)

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63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Peripheral Vasodilators REVATIO TABS OR 20 PA; PAH Only MG (sildenafil citrate isoxsuprine hcl tabs 1 (pulmonary SP Prostaglandin Vasodilators hypertension)) ORENITRAM TBCR PA sildenafil citrate PA SP (treprostinil diolamine) (pulmonary SP REMODULIN SOLN PA; 1 bal on hypertension) soln iv 10 SP (treprostinil) hand, mg/12.5ml sildenafil citrate PA treprostinil soln SP PA (pulmonary SP VENTAVIS SOLN PA SP hypertension) susr or (iloprost) 10 mg/ml Pulmonary Hypertension - Endothelin Receptor SILDENAFIL CITRATE PA PA TABS (sildenafil citrate ambrisentan tabs SP (pulmonary 2 bosentan tabs SP PA hypertension)) SILDENAFIL CITRATE PA; PAH Only LETAIRIS TABS PA SP TABS (sildenafil citrate (ambrisentan) (pulmonary 2 OPSUMIT TABS PA SP hypertension)) (macitentan) tadalafil (pulmonary PA TRACLEER TABS 125 PA SP SP hypertension) tabs MG, 62.5 MG (bosentan) Pulmonary Hypertension - Prostacyclin Receptor TRACLEER TBSO 32 MG PA; SP- Acaria SP UPTRAVI TABS PA (bosentan) Health;SP SP (selexipag) Pulmonary Hypertension - Phosphodiesterase UPTRAVI TBPK PA SP (Tadalafil (Pulmonary PA (selexipag) Hypertension)) ALYQ SP TABS Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS PA ADCIRCA TABS (tadalafil PA SP (pulmonary SP (riociguat) hypertension)) Sinus Node Inhibitors REVATIO SOLN IV 10 PA CORLANOR SOLN 5 ST; QL(15 ml MG/12.5ML (sildenafil 3 daily) SP MG/5ML (ivabradine hcl) citrate (pulmonary CORLANOR TABS 5 MG, ST 3 hypertension)) 7.5 MG (ivabradine hcl) REVATIO SUSR OR 10 PA Transthyretin Stabilizers MG/ML (sildenafil citrate SP VYNDAMAX CAPS PA; QL(1 ea (pulmonary SP (tafamidis) daily) hypertension)) VYNDAQEL CAPS PA; QL(4 ea (tafamidis meglumine SP daily) (cardiac))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEPHALOSPORINS - Drugs to Treat Bacterial cefprozil susr 1 Infections Cephalosporins - 1st Generation cefprozil tabs 1 cefadroxil caps 1 cefuroxime axetil tabs 1 cefadroxil susr 1 cefuroxime sodium solr SP PA cefadroxil tabs 1 Cephalosporins - 3rd Generation PA (Ceftazidime) TAZICEF PA cefazolin sodium solr SP SOLR IJ 1 GM, 2 GM, 6 SP GM cephalexin caps 250 1 (Ceftazidime) TAZICEF SP PA; 1 bal on mg, 500 mg, 750 mg SOLR IV 1 GM, 2 GM hand, cephalexin susr 125 1 mg/5ml, 250 mg/5ml cefdinir caps 1 1 bal on hand, cephalexin tabs 250 1 cefdinir susr 1 mg, 500 mg 1 bal on hand, KEFLEX CAPS cefditoren pivoxil tabs 1 GP (cephalexin) cefixime caps 1 Cephalosporins - 2nd Generation cefixime susr 1 cefaclor caps 250 mg, 1 500 mg cefotaxime sodium solr PA CEFACLOR ER TB12 3 1 gm, 2 gm, 10 gm, 500 SP (cefaclor monohydrate) mg, 500 mg cefaclor susr 125 1 bal on hand, cefotaxime sodium solr PA; 1 bal on mg/5ml, 250 mg/5ml, 1 2 gm, 2 gm, 10 gm, 500 SP hand, 375 mg/5ml mg, 500 mg CEFOTAN SOLR PA SP cefpodoxime proxetil 1 (cefotetan disodium) susr cefotetan disodium solr PA SP cefpodoxime proxetil 1 1 gm, 2 gm tabs PA; 1 bal on cefotetan disodium solr SP PA 10 gm hand, ceftazidime solr SP PA PA cefoxitin sodium solr ij SP ceftriaxone sodium solr SP 10 gm CLAFORAN SOLR PA cefoxitin sodium solr iv PA SP SP (cefotaxime sodium) 1 gm, 2 gm SPECTRACEF TABS 1 bal on hand, CEFOXITIN SODIUM PA 3 SOLR IV 1 GM-4 %, 2 GM- (cefditoren pivoxil) SP SUPRAX CAPS 400 MG 2.2 % (cefoxitin sodium GP and dextrose) (cefixime)

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65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPRAX CHEW 100 MG, (-Ethinyl PV 3 200 MG (cefixime) -Levomefolate PV SUPRAX SUSR 100 Calcium) RAJANI, TYDEMY TABS MG/5ML, 200 MG/5ML GP (cefixime) (Ethynodiol Diacet & Eth PV Estrad) KELNOR 1/35, SUPRAX SUSR 500 PV 3 ZOVIA 1/35E, KELNOR MG/5ML (cefixime) 1/50 TABS Cephalosporins - 4th Generation ( & Eth PV PA Estradiol) AFIRMELLE, cefepime hcl solr SP VIENVA, SRONYX, CEFEPIME SOLN PA PORTIA-28, ORSYTHIA, SP MARLISSA, LUTERA, (cefepime hcl) LILLOW, LEVORA 0.15/30- PV CEFEPIME/DEXTROSE PA 28, LESSINA, LARISSIA, SOLR (cefepime hcl- SP KURVELO, FALMINA, dextrose) DELYLA, CHATEAL EQ, CHATEAL, AYUNA, MAXIPIME SOLR PA SP AVIANE, AUBRA EQ, (cefepime hcl) AUBRA, ALTAVERA TABS Cephalosporins - 5th Generation (Levonorgestrel-Eth PV TEFLARO SOLR PA Estradiol (Triphasic)) SP (ceftaroline fosamil) ENPRESSE-28, TRIVORA- PV 28, MYZILRA, LEVONEST CONTRACEPTIVES - Drugs to Prevent TABS Pregnancy (Levonorgestrel-Ethinyl PV Combination Contraceptives - Oral Estradiol (91-Day)) AMETHIA, SIMPESSE, ( & Ethinyl PV Estradiol) APRI, SETLAKIN, RIVELSA, RECLIPSEN, KALLIGA, QUASENSE, LOJAIMIESS, PV PV JOLESSA, JAIMIESS, JULEBER, ISIBLOOM, ENSKYCE, EMOQUETTE, INTROVALE, FAYOSIM, DAYSEE, CAMRESE LO, CYRED EQ, CYRED TABS CAMRESE, ASHLYNA, (Desogestrel-Ethinyl PV AMETHIA LO TABS Estradiol (Biphasic)) (Levonorgestrel-Ethinyl PV AZURETTE, VOLNEA, PV PV VIORELE, SIMLIYA, Estradiol (Continuous)) AMETHYST TABS PIMTREA, KIMIDESS, KARIVA, BEKYREE TABS (Desogestrel-Ethinyl PV Estradiol (Triphasic)) PV CAZIANT, VELIVET TABS (Drospirenone-Ethinyl PV Estradiol) GIANVI, ZUMANDIMINE, ZARAH, SYEDA, OCELLA, NIKKI, PV LORYNA, LO- ZUMANDIMINE, JASMIEL TABS

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66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethin Acet & Estrad- PV (Norethindrone-Eth PV Fe) AUROVELA 24 FE, Estradiol (Triphasic)) TARINA FE 1/20 EQ, ALYACEN 7/7/7, TARINA FE 1/20, TARINA PIRMELLA 7/7/7, PV 24 FE, MICROGESTIN FE NORTREL 7/7/7, NECON 1.5/30, MICROGESTIN FE, 7/7/7, LEENA, DASETTA LARIN FE 1/20, LARIN FE 7/7/7, CYCLAFEM 7/7/7, 1.5/30, LARIN 24 FE, ARANELLE TABS JUNEL FE 24, JUNEL FE PV (-Ethinyl PV 1/20, JUNEL FE 1.5/30, Estradiol (Triphasic)) TRI HAILEY FE 1/20, HAILEY FEMYNOR, TRINESSA FE 1.5/30, HAILEY 24 FE, LO, TRINESSA, TRI- BLISOVI FE 1/20, BLISOVI VYLIBRA LO, TRI- FE 1.5/30, BLISOVI 24 FE, VYLIBRA, TRI-SPRINTEC, PV AUROVELA FE 1/20, TRI-PREVIFEM, TRI-MILI, AUROVELA FE 1.5/30 TRI-LO-SPRINTEC, TRI- TABS LO-MILI, TRI-LO-MARZIA, (Norethin Acet & Estrad- PV TRI-LO-ESTARYLLA, TRI- Fe) MELODETTA 24 FE, PV LINYAH, TRI-ESTARYLLA MIBELAS 24 FE CHEW TABS (Norethindrone & Eth PV (Norgestimate-Ethinyl PV Estradiol) NORTREL Estradiol) PREVIFEM, 0.5/35 (28), NECON MONONESSA, MONO- PV 0.5/35-28, DASETTA 1/35, LINYAH, MILI, FEMYNOR, CYCLAFEM 1/35, ESTARYLLA, VYLIBRA, BRIELLYN, BALZIVA, PV SPRINTEC 28 TABS ALYACEN 1/35, ( & Ethinyl 1 bal on hand,; ZENCHENT, WERA, Estradiol) OGESTREL, PV VYFEMLA, PIRMELLA CRYSELLE-28, LOW- PV 1/35, PHILITH, NORTREL OGESTREL, ELINEST 1/35 TABS TABS (Norethindrone & Ethinyl PV (Norgestrel & Ethinyl PV Estradiol-Fe) KAITLIB FE, PV Estradiol) OGESTREL, WYMZYA FE, LAYOLIS FE CRYSELLE-28, LOW- PV CHEW OGESTREL, ELINEST (Norethindrone Acet & Eth PV TABS Estra) AUROVELA 1.5/30, BALCOLTRA TABS QL(1 ea daily); MICROGESTIN 1.5/30, (levonorgestrel-ethinyl PV MICROGESTIN 1/20, PV PV LARIN 1/20, LARIN 1.5/30, estradiol-ferrous JUNEL 1/20, JUNEL bisglycinate) 1.5/30, HAILEY 1.5/30, BEYAZ TABS PV AUROVELA 1/20 TABS (drospirenone-ethinyl (Norethindrone Acetate- PV estradiol-levomefolate GP Ethinyl Estradiol-Fe) TILIA PV calcium) FE, TRI-LEGEST FE TABS DESOGEN TABS PV (desogestrel & ethinyl GP estradiol)

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67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PV LOESTRIN FE 1.5/30 PV desogestrel & ethinyl PV estradiol tabs TABS (norethin acet & GP desogestrel-ethinyl PV estrad-fe) estradiol (biphasic) PV LOESTRIN FE 1/20 TABS PV tabs (norethin acet & estrad- GP PV fe) drospirenone-ethinyl PV estradiol tabs LOSEASONIQUE TABS PV (levonorgestrel-ethinyl GP drospirenone-ethinyl PV estradiol (91-day)) estradiol-levomefolate PV calcium tabs MINASTRIN 24 FE CHEW PV (norethin acet & estrad- PV ESTROSTEP FE TABS PV fe) (norethindrone acetate- GP ethinyl estradiol-fe) MINASTRIN 24 FE CHEW PV (norethin acet & estrad- GP PV ethynodiol diacet & eth fe) estrad tabs 1 mg-35 PV mcg, 1 mg-50 mcg MIRCETTE TABS PV (desogestrel-ethinyl GP FALESSA KIT PA; PV estradiol (biphasic)) (levonorgestrel-ethinyl PV NATAZIA TABS PV estradiol & folic acid) (estradiol valerate- PV GENERESS FE CHEW PV ) (norethindrone & GP PV ethinyl estradiol-fe) norethin acet & estrad- PV fe chew levonorgestrel & eth PV PV PV estradiol tabs norethin acet & estrad- PV fe tabs levonorgestrel-eth PV PV estradiol (triphasic) PV norethindrone & ethinyl PV tabs estradiol-fe chew PV norethindrone acet & PV levonorgestrel-ethinyl PV PV estradiol (91-day) tabs eth estra tabs levonorgestrel-ethinyl PV norgestimate-ethinyl PV estradiol (continuous) PV estradiol (triphasic) PV tabs tabs PV LO LOESTRIN FE TABS PV norgestimate-ethinyl PV (norethindrone acetate- estradiol tabs ethinyl estradiol-fe fum PV ORTHO TRI-CYCLEN LO PV TABS (norgestimate- (biphasic)) GP LOESTRIN 1.5/30-21 PV ethinyl estradiol TABS (norethindrone GP (triphasic)) acet & eth estra) ORTHO TRI-CYCLEN PV TABS (norgestimate- LOESTRIN 1/20-21 TABS PV GP (norethindrone acet & GP ethinyl estradiol eth estra) (triphasic)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHO-CYCLEN TABS PV NUVARING RING PV (norgestimate-ethinyl GP (-ethinyl GP estradiol) estradiol) ORTHO-NOVUM 1/35 PV Copper Contraceptives - IUD TABS (norethindrone & GP PARAGARD PV eth estradiol) INTRAUTERINE COPPER PV ORTHO-NOVUM 7/7/7 PV CONTRACEPTIVE T380A TABS (norethindrone- GP IUD (copper (iud)) eth estradiol (triphasic)) Emergency Contraceptives QUARTETTE TABS PV (Levonorgestrel PV (levonorgestrel-ethinyl GP (Emergency Oc)) AFTERA, estradiol (91-day)) TAKE ACTION, REACT, SAFYRAL TABS PV PREVENTEZA, OPTION 2, OPCICON ONE-STEP, PV (drospirenone-ethinyl GP NEW DAY, MY WAY, MY estradiol-levomefolate CHOICE, ECONTRA ONE- calcium) STEP, ECONTRA EZ SEASONIQUE TABS PV TABS ( ELLA TABS ( PV levonorgestrel-ethinyl GP ulipristal PV estradiol (91-day)) acetate) TAYTULLA CAPS PA; PV PV levonorgestrel PV (norethin acet & estrad- PV (emergency oc) tabs fe) PLAN B ONE-STEP TABS PV TRI-NORINYL 28 TABS PV (levonorgestrel GP (norethindrone-eth GP (emergency oc)) estradiol (triphasic)) Progestin Contraceptives - IUD YASMIN 28 TABS PV KYLEENA IUD PV PV (drospirenone-ethinyl GP (levonorgestrel (iud)) estradiol) LILETTA IUD PV PV YAZ TABS PV (levonorgestrel (iud)) (drospirenone-ethinyl GP MIRENA IUD PV estradiol) PV (levonorgestrel (iud)) Combination Contraceptives - Transdermal SKYLA IUD PV PV (-Ethinyl PV 1 bal on hand,; (levonorgestrel (iud)) Estradiol) XULANE PTWK PV Progestin Contraceptives - Implants Combination Contraceptives - Vaginal NEXPLANON IMPL PV PV (Etonogestrel-Ethinyl PV PV (etonogestrel) Estradiol) ELURYNG RING ANNOVERA RING PV Progestin Contraceptives - Injectable (segesterone acetate- PV DEPO-PROVERA PV ethinyl estradiol) CONTRACEPTIVE SUSP (medroxyprogesterone GP etonogestrel-ethinyl PV PV acetate (contraceptive)) estradiol ring

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69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPO-PROVERA PV budesonide cpep 3 mg 1 CONTRACEPTIVE SUSY GP (medroxyprogesterone budesonide tb24 9 mg 1 PA acetate (contraceptive)) CORTEF TABS DEPO-SUBQ PROVERA PV GP 104 SUSY (hydrocortisone) PV (medroxyprogesterone cortisone acetate tabs 1 1 bal on hand, acetate (contraceptive)) dexamethasone elix 0.5 medroxyprogesterone PV 1 mg/5ml acetate (contraceptive) PV susp DEXAMETHASONE INTENSOL CONC 2 medroxyprogesterone PV (dexamethasone) acetate (contraceptive) PV dexamethasone PA; 1 bal on susy sodium phosphate soln hand, Progestin Contraceptives - Oral 10 mg/ml, 20 mg/5ml, SP (Norethindrone PV 100 mg/10ml, 120 (Contraceptive)) CAMILA, mg/30ml TULANA, SHAROBEL, dexamethasone PA NORLYROC, NORLYDA, PV NORA-BE, LYZA, sodium phosphate soln JOLIVETTE, JENCYCLA, 4 mg/ml, 10 mg/ml, 20 SP INCASSIA, HEATHER, mg/5ml, 100 mg/10ml, ERRIN, DEBLITANE TABS 120 mg/30ml norethindrone PV 1 bal on hand, PV dexamethasone soln 1 (contraceptive) tabs 0.5 mg/5ml ORTHO MICRONOR PV dexamethasone tabs TABS (norethindrone GP 0.75 mg, 0.5 mg, 2 mg, 1 (contraceptive)) 4 mg, 6 mg, 1.5 mg SLYND TABS PV PV 1 bal on hand, (drospirenone) dexamethasone tabs 1 mg, 2 mg, 4 mg, 6 mg, 1 CORTICOSTEROIDS - Steroid Hormone Drugs to 1.5 mg Treat Systemic Swelling Conditions dexamethasone tbpk 1 Glucocorticosteroids 1.5 mg (Dexamethasone) 1 ENTOCORT EC CPEP DECADRON ELIX GP (budesonide) (Dexamethasone) 1 DECADRON TABS hydrocortisone tabs 1 (Dexamethasone) MEDROL DOSEPAK TBPK DEXPAK 10 DAY, GP TAPERDEX 6-DAY, (methylprednisolone) MEDROL TABS 2 MG TAPERDEX 12-DAY, 1 2 HIDEX 6-DAY, DEXPAK 6 (methylprednisolone) DAY, DEXPAK 13 DAY TBPK

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70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDROL TABS 4 MG, 8 VERIPRED 20 SOLN MG, 16 MG, 32 MG GP (prednisolone sodium GP (methylprednisolone) phosphate) methylprednisolone 1 Mineralocorticoids tabs fludrocortisone acetate 1 methylprednisolone 1 tabs tbpk COUGH/COLD/ALLERGY - Drugs to Treat MILLIPRED DP TBPK 3 Cough, Cold and Allergy Symptoms (prednisolone) Antitussives MILLIPRED SOLN 10 (Hydrocodone W/ MG/5ML (prednisolone GP Homatropine) HYDROMET 1 sodium phosphate) SYRP MILLIPRED TABS 5 MG 2 (Hydrocodone W/ (prednisolone) Homatropine) TUSSIGON 1 ORAPRED ODT TBDP TABS (prednisolone sodium GP benzonatate caps 1 phosphate) hydrocodone w/ prednisolone sodium 1 homatropine syrp phosphate soln or 10 1 mg/5ml, 15 mg/5ml, 20 hydrocodone w/ 1 mg/5ml homatropine tabs TESSALON PERLES prednisolone sodium 1 bal on hand, GP phosphate soln or 25 1 CAPS (benzonatate) mg/5ml Cough/Cold/Allergy Combinations prednisolone sodium (Guaifenesin-Codeine) phosphate tbdp or 10 1 CHERATUSSIN AC, 1 GUAIFENESIN AC, mg, 15 mg, 30 mg GUAIATUSSIN AC SYRP prednisolone soln 1 1 bal on hand, (Guaifenesin-Codeine) G TUSSIN AC, VIRTUSSIN PREDNISONE INTENSOL 1 2 A/C, ROBAFEN AC, MAXI- CONC (prednisone) TUSS AC SOLN prednisone soln 5 1 bal on hand, 1 (Guaifenesin-Codeine) 1 mg/5ml VIRTUSSIN AC/ALC LIQD prednisone tabs 1 mg, (Phenylephrine W/ Dm-Gg) RX/OTC 5 mg, 10 mg, 20 mg, 1 BIOGTUSS, GILTUSS 1 50 mg, 2.5 mg PEDIATRIC LIQD (Promethazine & prednisone tbpk 5 mg, 1 Phenylephrine) 1 10 mg PROMETHAZINE VC RAYOS TBEC PA PLAIN SOLN 3 (prednisone) (Promethazine- UCERIS TB24 OR 9 MG PA Phenylephrine-Codeine) 1 GP PROMETHAZINE (budesonide) VC/CODEINE SYRP You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pseudoephedrine W/ EXAPHEX TR TABS RX/OTC Codeine-Gg) 1 (phenylephrine- 3 GUAIFENESIN DAC, guaifenesin) VIRTUSSIN DAC SOLN GILPHEX TR TABS RX/OTC ACTIDOM DMX LIQD (phenylephrine- 3 (phenylephrine w/ dm- 3 guaifenesin) gg) GILTUSS COUGH & COLD RX/OTC BIO-DTUSS DMX LIQD TABS (phenylephrine w/ 3 (pseudoephed- 3 dm-gg) bromphen-dm) GILTUSS LIQD RX/OTC CARBAPHEN 12 LIQD (phenylephrine w/ dm- GP (phenylephrine- gg) chlorpheniramine- 3 ) GILTUSS SINUS & RX/OTC carbetapentane CONGESTION TABS CARBAPHEN 12 PED (phenylephrine- 3 SUSP (phenylephrine- 3 guaifenesin) chlorpheniramine- GILTUSS TR TABS RX/OTC ) carbetapentane (phenylephrine w/ dm- 3 CLARINEX-D 12 HOUR PA gg) TB12 (desloratadine- 3 guaifenesin-codeine pseudoephedrine) 1 soln CODITUSSIN AC LIQD 3 HISTEX-PE SYRP (guaifenesin-codeine) (triprolidine- GP DECON-G LIQD phenylephrine) (phenylephrine- brompheniramine- 3 hydrocodone polistirex- guaifenesin) chlorpheniramine 1 polistirex lqcr DOCTOR MANZANILLA PE SYRUP hydrocodone polistirex- ANTIHISTAMINE/DECON chlorpheniramine 1 GESTANT LIQD 3 polistirex suer (triprolidine- NEOTUSS PLUS LIQD phenylephrine) (phenylephrine- 3 DOMETUSS-DMX LIQD chlorphen-dm) (phenylephrine w/ dm- 3 promethazine & 1 gg) phenylephrine syrp EXACTUSS LIQD RX/OTC promethazine & 1 bal on hand, (phenylephrine w/ dm- GP 1 phenylephrine syrp gg) EXACTUSS TR TABS RX/OTC promethazine 1 (phenylephrine w/ dm- 3 w/codeine soln gg) promethazine 1 w/codeine syrp

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine-dm soln 1 1 bal on hand, HYPERSAL NEBU 3.5 % (sodium chloride 3 promethazine-dm syrp 1 (inhalant)) HYPERSAL NEBU 7 % promethazine- (sodium chloride GP phenylephrine-codeine 1 (inhalant)) syrp NEBUSAL NEBU 6 % 1 bal on hand, promethazine- (sodium chloride 3 phenylephrine-codeine 1 (inhalant)) syrp sodium chloride 1 bal on hand, 1 pseudoephed-cpm w/ 1 (inhalant) nebu hydrocod soln Mucolytics SEMPREX-D CAPS (acrivastine & 3 acetylcysteine soln 1 pseudoephedrine) DERMATOLOGICALS - Drugs to Treat Skin TUSSICAPS CP12 Conditions (hydrocodone polistirex- 3 Acne Products chlorpheniramine (Benzoyl Peroxide) polistirex) BENZEPRO CREAMY WASH, PR BENZOYL 1 TUSSIONEX PEROXIDE WASH, BP PENNKINETIC WASH LIQD EXTENDED RELEASE (Clindamycin Phosphate SUER (hydrocodone GP (Topical)) CLINDACIN ETZ 1 polistirex- PLEDGETS, CLINDACIN-P chlorpheniramine SWAB polistirex) (Clindamycin Phosphate- TUSSLIN LIQD RX/OTC Benzoyl Peroxide 1 (phenylephrine w/ dm- 3 (Refrigerate)) NEUAC GEL gg) (Erythromycin (Acne Aid)) 1 1 bal on hand, ERY PADS TUSSLIN PEDIATRIC RX/OTC LIQD (phenylephrine w/ 3 (Isotretinoin) Greater than 5 months dm-gg) AMNESTEEM, 1 requires ZENATANE, MYORISAN PA;QL(2 ea Misc. Respiratory Inhalants CAPS (Sodium Chloride daily) (Inhalant)) NEBUSAL 1 Greater than 5 NEBU 3 % (Isotretinoin) CLARAVIS months (Sodium Chloride CAPS 10 MG, 20 MG, 30 1 requires (Inhalant)) PULMOSAL 1 MG, 40 MG PA;QL(2 ea NEBU daily) HYPER-SAL NEBU (Sulfacetamide Sodium W/ Sulfur) AVAR CLEANSER, (sodium chloride GP SULFAMEZ WASH, 1 (inhalant)) ROSANIL CLEANSER, BP 10-1 EMUL

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Sulfacetamide Sodium W/ AVAR LS CLEANSER Sulfur) AVAR-E LIQD (sulfacetamide GP EMOLLIENT, SSS 10%- 1 sodium w/ sulfur) 5%, AVAR-E GREEN CREA AVAR LS PADS (sulfacetamide sodium 3 (Sulfacetamide Sodium W/ 1 1 bal on hand, Sulfur) SSS 10-5 FOAM w/ sulfur) (Sulfacetamide Sodium W/ AVAR PADS Sulfur) SULFACLEANSE 1 (sulfacetamide sodium 3 8/4 SUSP w/ sulfur) (Sulfacetamide Sodium- 1 bal on hand, AVAR-E LS CREA Sulfur In Urea Vehicle) BP 1 (sulfacetamide sodium GP CLEANSING WASH EMUL w/ sulfur) (Tretinoin) AVITA CREA 1 AZELEX CREA ( azelaic 3 acid (acne)) (Tretinoin) AVITA GEL 1 BENZACLIN GEL PA; Limited to (clindamycin ABSORICA CAPS GP 3 5 months of phosphate-benzoyl (isotretinoin) treatment;QL(2 peroxide) ea daily) BENZACLIN WITH PUMP PA; Limited to ABSORICA LD CAPS GEL (clindamycin 3 5 months of GP (isotretinoin micronized) treatment;QL(2 phosphate-benzoyl ea daily) peroxide) ACZONE GEL 5 % PA BENZAMYCIN GEL GP (dapsone (topical)) (benzoyl peroxide- GP ACZONE GEL 7.5 % PA; QL(2 gm erythromycin) GP (dapsone (topical)) daily) benzoyl peroxide- 1 Limit 45gms erythromycin gel adapalene crea 0.1 % 1 per CLEOCIN-T GEL month;QL(1.5 (clindamycin phosphate 3 gm daily) (topical)) Limit 45gms per CLEOCIN-T LOTN adapalene gel 0.1 % 1 month;QL(1.5 (clindamycin phosphate GP gm daily); (topical)) RX/OTC CLEOCIN-T SOLN Limit 45gms (clindamycin phosphate GP 1 per (topical)) adapalene gel 0.3 % month;QL(1.5 gm daily) CLEOCIN-T SWAB 1 bal on hand, (clindamycin phosphate GP adapalene lotn 0.1 % 1 (topical)) CLINDACIN ETZ KIT adapalene-benzoyl 1 peroxide gel (clindamycin phosphate 3 & cleanser) ATRALIN GEL (tretinoin) GP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDACIN PAC KIT DIFFERIN LOTN 0.1 % 3 (clindamycin phosphate 3 (adapalene) & cleanser) DUAC GEL (clindamycin CLINDAGEL GEL 1 bal on hand, phosphate-benzoyl GP (clindamycin phosphate 3 peroxide (refrigerate)) (topical)) EPIDUO GEL ( NF clindamycin phosphate 1 adapalene-benzoyl (topical) foam peroxide) ERYGEL GEL clindamycin phosphate 1 (topical) gel (erythromycin (acne GP 1 bal on hand, aid)) clindamycin phosphate 1 (topical) gel erythromycin (acne aid) 1 gel clindamycin phosphate 1 (topical) lotn erythromycin (acne aid) 1 pads clindamycin phosphate 1 (topical) soln erythromycin (acne aid) 1 soln clindamycin phosphate 1 (topical) swab EVOCLIN FOAM clindamycin phosphate- (clindamycin phosphate GP benzoyl peroxide 1 (topical)) (refrigerate) gel Limit 50gms FABIOR FOAM 3 per clindamycin phosphate- (tazarotene (acne)) month;QL(1.67 benzoyl peroxide gel 1 1 gm daily) %-5 % Greater than 5 months clindamycin phosphate- 1 tretinoin gel requires PA;QL(2 ea PA isotretinoin caps 1 dapsone (topical) gel 5 1 daily)150 rtl % MAX day(s) PA; QL(2 gm supply,365 rtl dapsone (topical) gel 1 lmt day(s), 7.5 % daily) KLARON LOTN Limit 45gms DIFFERIN CREA 0.1 % (sulfacetamide sodium GP GP per (adapalene) month;QL(1.5 (acne)) gm daily) NEUTROGENA CLEAR Limit 45gms PORE CLEANSER/MASK LIQD (benzoyl 3 DIFFERIN GEL 0.1 % per GP month;QL(1.5 peroxide) (adapalene) gm daily); PLEXION CLEANSER RX/OTC LIQD (sulfacetamide GP Limit 45gms ) DIFFERIN GEL 0.3 % sodium w/ sulfur GP per (adapalene) month;QL(1.5 gm daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEXION CLEANSING sulfacetamide sodium CLOTHS PADS 3 w/ sulfur liqd 4 %-9 %, 1 (sulfacetamide sodium 2 %-10 %, 4.5 %-9 %, w/ sulfur) 4.8 %-9.8 % PLEXION CREA sulfacetamide sodium (sulfacetamide sodium GP w/ sulfur lotn 4.8 %-9.8 1 w/ sulfur) % PLEXION LOTN sulfacetamide sodium QL(1 gm (sulfacetamide sodium GP 1 daily)1 bal on w/ sulfur) w/ sulfur lotn 5 %-10 % hand, RETIN-A CREA (tretinoin) GP sulfacetamide sodium w/ sulfur pads 4 %-10 1 RETIN-A GEL (tretinoin) GP %, 4 %-4 %-10 %-10 % RETIN-A MICRO GEL 0.04 sulfacetamide sodium 1 %, 0.1 % (tretinoin GP w/ sulfur susp 4 %-8 % microsphere) SUMADAN WASH LIQD RETIN-A MICRO PUMP (sulfacetamide sodium GP GEL 0.04 %, 0.1 % GP w/ sulfur) (tretinoin microsphere) SUMAXIN PADS RIAX FOAM ( (sulfacetamide sodium GP benzoyl 3 peroxide) w/ sulfur) SODIUM SUMAXIN TS SUSP SULFACETAMIDE/SULFU (sulfacetamide sodium GP R CLEANSER IN UREA w/ sulfur) 3 EMUL (sulfacetamide SUMAXIN WASH LIQD sodium-sulfur in urea (sulfacetamide sodium GP vehicle) w/ sulfur) SODIUM TRETIN-X CREA 3 SULFACETAMIDE/SULFU (tretinoin) R SUSP (sulfacetamide 3 sodium w/ sulfur) tretinoin crea 1 sulfacetamide sodium 1 tretinoin gel 1 (acne) lotn sulfacetamide sodium tretinoin microsphere 1 gel w/ sulfur crea 2 %-10 1 %, 5 %-10 %, 4.8 %- VELTIN GEL 9.8 % (clindamycin 3 sulfacetamide sodium phosphate-tretinoin) ZIANA GEL ( w/ sulfur emul 5 %-10 1 clindamycin GP % phosphate-tretinoin) Agents for External Genital and Perianal Warts

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VEREGEN OINT Limit 30gms NEO-SYNALAR CREA 3 per month;QL(1 (sinecatechins) (neomycin sulfate- 3 gm daily) fluocinolone acetonide) Anti-inflammatory Agents - Topical Antifungals - Topical (Diclofenac Sodium QL(5 ml daily) (Ciclopirox Olamine) 1 (Topical)) KLOFENSAID II 1 CICLODAN CREA SOLN (Ciclopirox) CICLOPIROX 1 bal on hand, 1 bal on hand, 1 diclofenac epolamine 1 TREATMENT KIT ptch (Clotrimazole (Topical)) RX/OTC RX/OTC CVS CLOTRIMAZOLE diclofenac sodium 1 (topical) gel 1 % MAXIMUMSTRENGTH, 1 FUNGICURE INTENSIVE QL(5 ml daily) diclofenac sodium 1 WITHNAILGUARD SOLN (topical) soln 1.5 % (Iodoquinol-Hc) FLECTOR PTCH 1 3 DERMAZENE CREA (diclofenac epolamine) (Iodoquinol-Hydrocortisone FLECTOR PTCH 1 bal on hand, In Aloe Vehicle) 1 3 (diclofenac epolamine) IODOQUIMEZ-HC CREA PA; Limit 1 (Ketoconazole (Topical)) 1 PENNSAID SOLN KETODAN FOAM ( 3 bottle per diclofenac sodium month;QL(4 gm ALA-QUIN CREA ) 3 (topical) daily) (clioquinol-hc) VOLTAREN GEL RX/OTC ALCORTIN A GEL (diclofenac sodium NF (iodoquinol- (topical)) hydrocortisone-aloe GP Antibiotics - Topical polysaccharide) ALTABAX OINT CICLODAN SOLUTION 3 3 (retapamulin) KIT KIT (ciclopirox) CENTANY AT KIT 3 ciclopirox gel 1 (mupirocin) CENTANY OINT ciclopirox olamine crea 1 2 (mupirocin) 1 CORTISPORIN CREA ciclopirox olamine susp (neomycin-polymyxin- 3 ciclopirox sham 1 hc) RX/OTC CORTISPORIN OINT clotrimazole (topical) 1 (bacitracin-polymyxin- 3 soln neomycin hc) Limit 45gms clotrimazole w/ gentamicin sulfate 1 per 1 betamethasone crea month;QL(1.5 (topical) crea gm daily) gentamicin sulfate QL(2 ml daily) 1 clotrimazole w/ 1 (topical) oint betamethasone lotn mupirocin oint 1 econazole nitrate crea 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERTACZO CREA PA 1 bal on hand, 3 miconazole- oxide- 1 (sertaconazole nitrate) white petrolatum oint EXELDERM CREA 1 bal on hand, 1 bal on hand, 3 naftifine hcl crea 1 %, 2 1 (sulconazole nitrate) % EXELDERM SOLN 1 bal on hand, 2 naftifine hcl crea 1 %, 2 1 (sulconazole nitrate) % EXELDERM SOLN 2 (sulconazole nitrate) naftifine hcl gel 1 % 1 EXODERM LOTN NAFTIN CREA 2 % GP (sodium thiosulfate- 3 (naftifine hcl) salicylic acid) NAFTIN GEL 1 % GP EXTINA FOAM (naftifine hcl) GP (ketoconazole (topical)) NAFTIN GEL 1 %, 2 % 3 HALOTIN CREA (naftifine hcl) 3 (haloprogin) NIZORAL SHAM GP iodoquinol-hc crea 1 (ketoconazole (topical)) iodoquinol- nystatin (topical) crea 1 hydrocortisone in aloe 1 nystatin (topical) oint 1 vehicle crea iodoquinol- nystatin-triamcinolone 1 hydrocortisone-aloe 1 crea polysaccharide gel nystatin-triamcinolone 1 QL(2 gm daily) oint ketoconazole (topical) 1 crea oxiconazole nitrate crea 1 ketoconazole (topical) OXISTAT CREA 1 NF foam (oxiconazole nitrate) ketoconazole (topical) OXISTAT LOTN 1 3 sham (oxiconazole nitrate) LOPROX CREA GP QUINJA GEL (ciclopirox olamine) (iodoquinol-aloe 3 LOPROX SHAMPOO GP polysaccharides) SHAM (ciclopirox) sulconazole nitrate crea 1 1 bal on hand, LOPROX SUSP GP (ciclopirox olamine) sulconazole nitrate soln 1 1 bal on hand, Limit 45gms LOTRISONE CREA VUSION OINT 1 bal on hand, ( GP per clotrimazole w/ month;QL(1.5 (miconazole-zinc oxide- 3 betamethasone) gm daily) white petrolatum) luliconazole crea 1 1 bal on hand, VYTONE CREA (iodoquinol- LUZU CREA 1 bal on hand, GP 3 hydrocortisone in aloe (luliconazole) vehicle) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOLEGEL GEL ZONALON CREA 1 bal on hand, 3 (ketoconazole (topical)) (doxepin hcl 3 Antineoplastic or Premalignant Lesion Agents - (antipruritic)) CARAC CREA 1 bal on hand, Antipsoriatics 2 (fluorouracil (topical)) (Calcipotriene) 1 QL(5 gm daily) PA CALCITRENE OINT diclofenac sodium 1 (actinic keratoses) gel acitretin caps 1 EFUDEX CREA AC QL(5 gm daily) (fluorouracil (topical)) calcipotriene crea 1 FLUOROPLEX CREA CALCIPOTRIENE FOAM PA 2 3 (fluorouracil (topical)) (calcipotriene) 1 bal on hand, QL(5 gm daily) fluorouracil (topical) 1 calcipotriene oint 1 crea 0.5 % calcipotriene soln 1 fluorouracil (topical) AC crea 5 % Limited 100 1 bal on hand, gms per fluorouracil (topical) 1 soln 2 % calcitriol (topical) oint 1 month;QL(3.4 gm daily)1 bal 1 bal on hand, fluorouracil (topical) AC on hand, soln 5 % COSENTYX PA PANRETIN GEL PA AC SENSOREADY PEN SOAJ SP (alitretinoin) (secukinumab) PICATO GEL (ingenol COSENTYX SOSY PA AC SP mebutate) (secukinumab) TARGRETIN GEL EX 1 % DOVONEX CREA QL(5 gm daily) AC GP (bexarotene (topical)) (calcipotriene) TOLAK CREA PA ILUMYA SOSY PA AC SP (fluorouracil (topical)) (tildrakizumab-asmn) VALCHLOR GEL PA methoxsalen rapid caps 1 (mechlorethamine hcl AC (topical)) OXSORALEN ULTRA CAPS (methoxsalen GP Antipruritics - Topical rapid) 1 bal on hand, doxepin hcl 3 SILIQ SOSY PA SP (antipruritic) crea (brodalumab) PRUDOXIN CREA 1 bal on hand, SKYRIZI PSKT PA SP (doxepin hcl 3 (risankizumab-rzaa) (antipruritic)) SORIATANE CAPS GP ZONALON CREA 1 bal on hand, (acitretin) (doxepin hcl NF SORILUX FOAM PA (antipruritic)) 3 (calcipotriene) STELARA SOLN PA SP (ustekinumab) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STELARA SOSY PA SP sulfacetamide sodium 1 (ustekinumab) liqd TALTZ SOAJ PA SP sulfacetamide sodium 1 (ixekizumab) sham TALTZ SOSY PA SP Antivirals - Topical (ixekizumab) acyclovir topical crea 1 tazarotene crea 1 QL(1 gm daily) TAZORAC CREA 0.05 % acyclovir topical oint 1 2 (tazarotene) DENAVIR CREA Limit 5gms per TAZORAC CREA 0.1 % 3 month;QL(0.17 NF (penciclovir) (tazarotene) gm daily) TAZORAC GEL 0.05 %, XERESE CREA Limit 5gms per 2 0.1 % ( ) (acyclovir- 3 month;QL(0.17 tazarotene gm daily) TREMFYA SOPN PA hydrocortisone) SP ZOVIRAX CREA EX 5 % (guselkumab) GP TREMFYA SOSY PA (acyclovir topical) SP ZOVIRAX OINT EX 5 % QL(1 gm daily) (guselkumab) GP Limited 100 (acyclovir topical) VECTICAL OINT gms per Burn Products 3 month;QL(3.4 (calcitriol (topical)) (Silver Sulfadiazine) SSD 1 gm daily)1 bal CREA on hand, 1 Antiseborrheic Products mafenide acetate pack (Sulfacetamide Sodium) SILVADENE CREA ( 1 silver GP SEB-PREV WASH LIQD sulfadiazine) (Sulfacetamide Sodium) silver sulfadiazine crea 1 SODIUM 1 SULFACETAMIDE WASH SULFAMYLON CREA 85 LIQD 10 % MG/GM (mafenide 3 OVACE PLUS SHAM 10 % GP acetate) (sulfacetamide sodium) SULFAMYLON PACK 5 % OVACE PLUS WASH LIQD GP GP (mafenide acetate) (sulfacetamide sodium) Corticosteroids - Topical OVACE WASH LIQD GP (sulfacetamide sodium) (Clobetasol Propionate Emollient Base) selenium sulfide lotn 1 CLOBETASOL PROPIONATE E, 1 selenium sulfide sham 1 CLOBETASOL PROPIONATE SODIUM EMOLLIENT CREA SULFACETAMIDE WASH (Clobetasol Propionate 1 LIQD 0.5 %-10 % 3 Emulsion) TOVET FOAM (sulfacetamide sodium in bakuchiol vehicle) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clobetasol Propionate) AMCINONIDE OINT 1 3 CLODAN SHAM (amcinonide) (Flurandrenolide) NOLIX 1 APEXICON E CREA CREA (diflorasone diacetate 2 (Fluticasone Propionate) 1 emollient base) BESER LOTN betamethasone (Hydrocortisone (Topical)) 1 ALA-CORT CREA dipropionate (topical) 1 (Hydrocortisone (Topical)) RX/OTC crea CORTIZONE-10, SM betamethasone HYDROCORTISONE dipropionate (topical) 1 MAXIMUM STRENGTH, lotn SB HYDROCORTISONE MAXIMUM STRENGTH, betamethasone RA ANTI-ITCH/MAXIMUM dipropionate (topical) 1 STRENGTH, KP oint HYDROCORTISONE betamethasone MAXIMUM STRENGTH, HYDROCORTISONE IN 1 dipropionate 1 ABSORBASE, augmented crea HYDROCORTISONE 1% betamethasone 1 bal on hand, IN ABSORBASE, GNP dipropionate 1 HYDROCORTISONE MAXIMUM STRENGTH, augmented gel EQL ANTI-ITCH betamethasone MAXIMUM STRENGTH, dipropionate 1 CVS CORTISONE augmented gel MAXIMUM STRENGTH OINT betamethasone dipropionate 1 (Pramoxine-Hc) 1 MEZPAROX-HC CREA augmented lotn (Triamcinolone Acetonide betamethasone (Topical)) TRIANEX, 1 dipropionate 1 TRIANEX OINT augmented oint (Triamcinolone Acetonide 1 betamethasone 1 (Topical)) TRIDERM CREA valerate crea ALA SCALP LOTN (hydrocortisone 3 betamethasone 1 (topical)) valerate foam betamethasone alclometasone 1 1 dipropionate crea valerate lotn betamethasone alclometasone 1 1 dipropionate oint valerate oint 1 bal on hand, calcipotriene- ST amcinonide crea 1 betamethasone 1 amcinonide lotn 1 1 bal on hand, dipropionate oint

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; QL(2 gm CLODERM PUMP CREA calcipotriene- 3 betamethasone 1 daily)1 bal on (clocortolone pivalate) dipropionate susp hand, CORDRAN CREA 0.05 % GP calcipotriene- ST; QL(2 gm (flurandrenolide) betamethasone 1 daily) CORDRAN TAPE 4 dipropionate susp MCG/SQCM 3 CAPEX SHAM (flurandrenolide) (fluocinolone 2 CORTANE-B LOTN acetonide) (hydrocortisone- pramoxine- 3 clobetasol propionate 1 crea chloroxylenol) CUTIVATE LOTN clobetasol propionate GP 1 (fluticasone propionate) emollient base crea DERMA-SMOOTHE/FS clobetasol propionate 1 BODY OIL (fluocinolone GP emulsion foam acetonide) clobetasol propionate 1 DERMA-SMOOTHE/FS foam SCALP OIL (fluocinolone GP ) clobetasol propionate 1 acetonide gel DERMASORB TA KIT (triamcinolone 3 clobetasol propionate 1 liqd acetonide & emollient) DESONATE GEL clobetasol propionate 1 3 lotn (desonide) DESONATE GEL clobetasol propionate 1 GP oint (desonide) desonide crea 1 clobetasol propionate 1 sham desonide gel 1 clobetasol propionate 1 soln desonide lotn 1 CLOBEX LIQD GP (clobetasol propionate) desonide oint 1 CLOBEX LOTN DESOWEN CREA GP GP (clobetasol propionate) (desonide) CLOBEX SHAM DESOWEN LOTN GP GP (clobetasol propionate) (desonide) 1 bal on hand, clocortolone pivalate 1 DESOXIMETASONE crea CREA 0.05 % 2 CLODERM CREA (desoximetasone) 3 (clocortolone pivalate) desoximetasone crea 1 CLODERM CREA 1 bal on hand, 0.05 %, 0.25 % 3 (clocortolone pivalate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desoximetasone gel 1 flurandrenolide crea 1 0.05 % fluticasone propionate 1 desoximetasone liqd 1 0.25 % crea fluticasone propionate 1 desoximetasone oint 1 0.05 %, 0.25 % lotn 1 bal on hand, fluticasone propionate 1 diflorasone diacetate 1 crea oint HALAC KIT (halobetasol diflorasone diacetate 1 oint propionate & 3 ammonium lactate) DIPROLENE AF CREA (betamethasone halcinonide crea 1 dipropionate GP halobetasol propionate 1 augmented) crea DIPROLENE OINT halobetasol propionate (betamethasone 1 dipropionate GP oint HALOG CREA augmented) GP ( ) ELOCON CREA halcinonide GP HALOG OINT (mometasone furoate) 3 ( ) ELOCON OINT halcinonide GP HALOG SOLN (mometasone furoate) 3 ( ) EPIFOAM FOAM halcinonide 3 (pramoxine-hc) hydrocortisone (topical) 1 crea 2.5 % fluocinolone acetonide 1 crea hydrocortisone (topical) 1 fluocinolone acetonide lotn 2.5 % 1 RX/OTC oil hydrocortisone (topical) 1 oint 1 % fluocinolone acetonide 1 oint hydrocortisone (topical) 1 oint 2.5 % fluocinolone acetonide 1 soln hydrocortisone butyrate 1 crea fluocinonide crea 1 hydrocortisone butyrate hydrophilic lipo base 1 fluocinonide emulsified 1 base crea crea fluocinonide gel 1 hydrocortisone butyrate 1 lotn fluocinonide oint 1 hydrocortisone butyrate 1 oint fluocinonide soln 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PANDEL CREA hydrocortisone butyrate 1 soln (hydrocortisone 3 hydrocortisone valerate probutate) 1 PRAMOSONE CREA 1 %- crea 3 hydrocortisone valerate 1 % (pramoxine-hc) 1 PRAMOSONE CREA 1 %- oint GP 2.5 % ( ) KENALOG AERS pramoxine-hc (triamcinolone GP PRAMOSONE E CREA acetonide (topical)) (pramoxine-hc 3 ) LOCOID CREA emollient base (hydrocortisone GP PRAMOSONE LOTN 1 %- 1 %, 1 %-2.5 % butyrate) 3 (pramoxine-hc) LOCOID LIPOCREAM PRAMOSONE OINT 1 %-1 CREA (hydrocortisone GP %, 1 %-2.5 % 3 butyrate hydrophilic lipo (pramoxine-hc) base) LOCOID LOTN pramoxine-hc crea 1 (hydrocortisone GP 1 1 bal on hand, butyrate) prednicarbate crea LOCOID OINT prednicarbate oint 1 1 bal on hand, (hydrocortisone GP PSORCON CREA butyrate) 3 (diflorasone diacetate) LOCOID SOLN SYNALAR CREA (hydrocortisone GP GP butyrate) (fluocinolone acetonide) SYNALAR OINT LUXIQ FOAM GP (betamethasone GP (fluocinolone acetonide) SYNALAR SOLN valerate) GP (fluocinolone acetonide) mometasone furoate 1 crea TACLONEX OINT ST (calcipotriene- mometasone furoate GP 1 betamethasone oint dipropionate) mometasone furoate 1 TACLONEX SUSP ST; QL(2 gm soln (calcipotriene- daily)1 bal on NUCORT LOTN betamethasone 3 hand, (hydrocortisone acetate 3 dipropionate) (topical)) TEMOVATE CREA OLUX FOAM ( GP clobetasol GP (clobetasol propionate) propionate) TEMOVATE OINT GP OLUX-E FOAM (clobetasol propionate) (clobetasol propionate GP emulsion)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEXACORT SOLN (Urea) CEROVEL, UREA- 1 (hydrocortisone 3 C40, REA LO 40 LOTN (topical)) (Urea) GORDONS UREA, RX/OTC TOPICORT CREA XUREA, UREMEZ-40, 1 GP UREDEB, REA LO 40, (desoximetasone) METOPIC CREA TOPICORT GEL GP (Urea) GORDONS UREA, (desoximetasone) XUREA, UREMEZ-40, 1 TOPICORT LIQD UREDEB, REA LO 40, GP (desoximetasone) METOPIC CREA TOPICORT OINT (Urea) UMECTA MOUSSE GP 1 (desoximetasone) FOAM (Urea) UREA NAIL GEL 45 1 triamcinolone % acetonide (topical) aers 1 0.147 mg/gm CEM-UREA SOLN (urea) 3 triamcinolone GORDONS UREA OINT 3 acetonide (topical) crea 1 (urea) 0.025 %, 0.1 %, 0.5 % HYDRO 35 FOAM ( urea 3 triamcinolone in lactic acid vehicle) acetonide (topical) lotn 1 HYDRO 40 FOAM FOAM GP 0.025 %, 0.1 % (urea) triamcinolone KERALAC CREA (urea) GP acetonide (topical) oint 1 0.025 %, 0.1 %, 0.5 % URAMAXIN GEL (urea) GP TRIDESILON CREA GP (desonide) URE-K CREA (urea) 3 ULTRAVATE CREA urea crea 39 %, 41 %, 1 (halobetasol GP 47 %, 50 % propionate) RX/OTC urea crea 40 %, 41 %, 1 ULTRAVATE OINT 47 %, 50 % (halobetasol GP 1 bal on hand, propionate) urea crea 45 %, 47 %, 1 50 % VANOS CREA GP (fluocinonide) urea lotn 40 % 1 VERDESO FOAM 3 UREA NAIL STCK 50 % (desonide) (urea in zinc 3 Eczema Agents undecylenate-lactic DUPIXENT SOSY PA acid vehicle) SP (dupilumab) urea susp 40 % 1 1 bal on hand, Emollient/Keratolytic Agents (Urea In Lactic Acid 1 bal on hand, UTOPIC CREA (urea) GP Vehicle) UREA 1 HYDRATING FOAM Emollients

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85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lactic Acid (Ammonium RX/OTC ZYCLARA PUMP CREA Limit 2 per Lactate)) AL12, GERI- 3 month;QL(0.6 HYDROLAC 12, CVS SKIN 2.5 % (imiquimod) gm daily) TREATMENT BODY ZYCLARA PUMP CREA QL(1 gm LOTION, CVS SKIN 1 3 daily)1 bal on TREATMENT, CVS 3.75 % (imiquimod) hand, HYDRATING SKIN TREATMENT, AMLACTIN Immunosuppressive Agents - Topical DAILY, AMLACTIN LOTN ELIDEL CREA QL(2 gm daily) GP (Lactic Acid (Ammonium RX/OTC (pimecrolimus) Lactate)) GERI- 1 QL(2 gm daily) HYDROLAC 12 CREA pimecrolimus crea 1 1 bal on hand, PROTOPIC OINT hyaluronate sodium 1 GP (emollient) gel (tacrolimus (topical)) HYLINATE LOTN tacrolimus (topical) oint 1 (hyaluronate sodium 3 (emollient)) Keratolytic/Antimitotic Agents LAC-HYDRIN CREA RX/OTC (Salicylic Acid) SALICYLIC (lactic acid (ammonium GP ACID WART REMOVER 1 lactate)) LIQD LAC-HYDRIN TWELVE RX/OTC (Salicylic Acid) SALIMEZ 1 CREA LOTN (lactic acid GP (Salicylic Acid) SALISOL 1 (ammonium lactate)) FORTE SOLN lactic acid (ammonium RX/OTC 1 (Salicylic Acid) SALITECH 1 lactate) crea 12 % FORTE LOTN BENSAL HP OINT lactic acid (ammonium 1 lactate) lotn 10 % (salicylic acid & benzoic 3 lactic acid (ammonium RX/OTC acid) 1 CONDYLOX GEL lactate) lotn 12 % 2 (podofilox) Enzymes - Topical SANTYL OINT PODOCON 25 IN 3 BENZOIN TINCTURE ( ) collagenase SOLN (podophyllum 3 Immunomodulating Agents - Topical resin) ALDARA CREA GP podofilox soln 1 (imiquimod) QL(1 gm SALEX LOTION KIT imiquimod crea 3.75 % 1 daily)1 bal on (salicylic acid w/ GP hand, cleanser) SALEX SHAM ( imiquimod crea 5 % 1 salicylic GP acid) ZYCLARA CREA QL(1 ea daily) 3 (imiquimod) salicylic acid crea 6 % 1 salicylic acid foam 6 % 1

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86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits salicylic acid in (Lidocaine Hcl) LIDOPIN 1 RX/OTC ammonium lactate 1 CREA 3 % vehicle foam (Lidocaine) LIDOCAINE PAK, PREMIUM 1 salicylic acid liqd 27.5 1 LIDOCAINE OINT % (Pramoxine Hcl) RX/OTC salicylic acid lotn 6 % 1 1 bal on hand, PRAMEGEL HCL, 1 PRAMOX GEL GEL salicylic acid lotn 6 % 1 ethyl chloride aero 1 1 bal on hand, salicylic acid sham 6 % 1 ETHYL CHLORIDE/FINE STREAM AERO (ethyl 3 1 bal on hand, salicylic acid soln 26 % 1 chloride) ETHYL salicylic acid soln 28.5 1 % CHLORIDE/MEDIUM STREAM AERO (ethyl 3 salicylic acid w/ 1 chloride) cleanser kit GEBAUERS INSTANT ICE RX/OTC SALISOL SOLN ( salicylic 3 AERO acid) (pentafluoropropane- 3 SALITECH LOTN tetrafluoroethane) 3 (salicylic acid) GEBAUERS PAIN EASE RX/OTC SALVAX FOAM ( AERO salicylic GP 3 acid) (pentafluoropropane- ULTRASAL-ER SOLN tetrafluoroethane) GP (salicylic acid) GEBAUERS SPRAY AND RX/OTC STRETCH AERO VIRASAL LIQD ( 3 salicylic GP (pentafluoropropane- acid) tetrafluoroethane) Liniments lidocaine crea 3 % 1 1 bal on hand, MEDROX-RX OINT PA (capsaicin-menthol- 3 lidocaine hcl crea 3 % 1 RX/OTC methyl salicylate) Local Anesthetics - Topical lidocaine hcl gel 2 % 1 (Cocaine Hcl) C-TOPICAL 1 1 bal on hand, 1 1 bal on hand, SOLN lidocaine hcl gel 2 % (Lidocaine Hcl) 7T LIDO RX/OTC lidocaine hcl lotn 3 % 1 GEL, REGENECARE HA 1 GEL lidocaine hcl prsy 2 % 1 (Lidocaine Hcl) GLYDO 1 PRSY lidocaine hcl soln 4 % 1 (Lidocaine Hcl) LIDO-K, ZIONODIL 100, ZIONODIL, 1 lidocaine oint 5 % 1 LIDOZION, LIDO-SORB LOTN lidocaine ptch 5 % 1 QL(3 ea daily)

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87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHLAG SPRAY EMUL lidocaine-prilocaine 1 crea (dermatological 3 LIDODERM PTCH QL(3 ea daily) products, misc.) GP (lidocaine) SUVICORT EMUL LIDODOSE GEL RX/OTC (dermatological 3 3 (lidocaine hcl) products, misc.) LIDODOSE PEDIATRIC RX/OTC SYNERDERM EMUL BULK PACK GEL 3 (dermatological 3 (lidocaine hcl) products, misc.) LIDORX GEL ( RX/OTC lidocaine 3 Misc. Topical hcl) DRYSOL SOLN 2 SYNERA PTCH (aluminum chloride) 3 (lidocaine-tetracaine) XERAC AC SOLN Misc. Dermatological Products (aluminum chloride in 3 7TOPIC EMUL alcohol) (dermatological 3 Phosphodiesterase 4 (PDE4) Inhibitors - Topical products, misc.) EUCRISA OINT PA 3 CERACADE EMUL (crisaborole) (dermatological 3 Rosacea Agents products, misc.) (Metronidazole (Topical)) 1 EMULSION SB EMUL ROSADAN CREA (dermatological 3 Limit 45gms products, misc.) (Metronidazole (Topical)) 1 per ENTTY SPRAY ROSADAN GEL month;QL(1.5 EMULSION EMUL gm daily) 3 (dermatological gel 1 products, misc.) doxycycline (rosacea) PA; 1 bal on EPICERAM EMUL 1 hand, (dermatological 3 cpdr FINACEA FOAM ( products, misc.) azelaic 3 ILIDERM EMUL acid) ( 3 FINACEA GEL ( dermatological azelaic GP products, misc.) acid) KAMDOY EMUL ivermectin (rosacea) PA; QL(1 gm 1 daily)1 bal on (dermatological 3 crea products, misc.) hand, KIVIK EMUL ivermectin (rosacea) PA; QL(1 gm 1 daily) (dermatological 3 crea products, misc.) METROCREAM CREA PENLEN EMUL (metronidazole GP (dermatological 3 (topical)) products, misc.)

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88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METROGEL GEL malathion lotn 1 (metronidazole NF (topical)) NATROBA SUSP 1 bal on 3 hand,AL(At METROLOTION LOTN QL(2 ml daily) (spinosad) least 4 yrs old) (metronidazole GP (topical)) OVIDE LOTN (malathion) GP metronidazole (topical) 1 Limit 2 per crea 0.75 % permethrin crea 1 month;QL(60 Limit 45gms gm per 14 days retail) metronidazole (topical) 1 per gel 0.75 % month;QL(1.5 SKLICE LOTN gm daily) (ivermectin 3 (pediculicide)) metronidazole (topical) 1 gel 1 % 1 bal on QL(2 ml daily) spinosad susp 1 hand,AL(At metronidazole (topical) 1 least 4 yrs old) lotn 0.75 % ULESFIA LOTN (benzyl MIRVASO GEL PA 3 alcohol (pediculicide)) (brimonidine tartrate 3 (topical)) Wound Care Products NORITATE CREA PA Limit 15gms REGRANEX GEL (metronidazole 3 3 per (becaplermin) month;QL(0.5 (topical)) gm daily) ORACEA CPDR PA; 1 bal on 3 (doxycycline (rosacea)) hand, DIAGNOSTIC PRODUCTS RHOFADE CREA PA Diagnostic Drugs (oxymetazoline hcl 3 GLUCAGEN DIAGNOSTIC (topical)) SOLR (glucagon hcl 2 SOOLANTRA CREA PA; QL(1 gm rdna (diagnostic)) 3 daily)1 bal on ( ) METOPIRONE CAPS ivermectin (rosacea) hand, 3 (metyrapone) Scabicides & Pediculicides Diagnostic Tests (Crotamiton) CROTAN 1 1 bal on hand, LOTN FREESTYLE INSULINX Limit 200 per BLOODGLUCOSE TEST month;QL(6.67 Limit 2 per 2 ELIMITE CREA STRIPS STRP (glucose ea daily); GP month;QL(60 RX/OTC (permethrin) gm per 14 days blood) retail) FREESTYLE INSULINX Limit 200 per EURAX CREA month;QL(6.67 2 BLOODGLUCOSE TEST 2 (crotamiton) ea daily); STRP (glucose blood) RX/OTC EURAX LOTN 3 Limit 200 per (crotamiton) FREESTYLE LITE TEST STRIPS STRP (glucose 2 month;QL(6.67 lindane sham 1 1 bal on hand, ea daily); blood) RX/OTC

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89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE TEST Limit 200 per FOLTX TABS (l- STRIPS STRP (glucose 2 month;QL(6.67 methylfolate w/ vitamin 3 ea daily); b6-vitamin b12) blood) RX/OTC L-METHYLFOLATE CA/S- NON PREFERRED TEST 3 PA STRIPS ALGAL CAPS (l- 3 Limit 200 per methylfolate-algae) ONETOUCH ULTRA STRP L-METHYLFOLATE 2 month;QL(6.67 (glucose blood) ea daily); FORTE CAPS (l- 3 RX/OTC methylfolate-algae) Limit 200 per ONETOUCH VERIO TEST l-methylfolate tabs 1 1 bal on hand, STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); blood) LEVOMEFOLATE RX/OTC CALCIUM ALGAL 3 PRECISION XTRA BLOOD Limit 200 per POWDER CAPS (l- GLUCOSE TEST STRIPS 2 month;QL(6.67 methylfolate-algae) ea daily); STRP (glucose blood) RX/OTC DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes PRECISION XTRA STRP Limit 200 per 2 month;QL(6.67 VI (ketone blood test) Digestive Enzymes ea daily) CREON CPEP DIETARY PRODUCTS/DIETARY MANAGEMENT (pancrelipase (lipase- 2 PRODUCTS protease-amylase)) Dietary Management Products PANCREAZE CPEP (Folic Acid-Pyridoxine- (pancrelipase (lipase- 3 Cyanocobalamin) AV-VITE protease-amylase)) FB FORTE, WESTAB 1 PERTZYE CPEP MAX, NIVA-FOL, FOLBIC TABS (pancrelipase (lipase- 3 ) (Folic Acid-Pyridoxine- 1 bal on hand, protease-amylase) SUCRAID SOLN PA Cyanocobalamin) AV-VITE 3 FB FORTE, WESTAB 1 (sacrosidase) MAX, NIVA-FOL, FOLBIC VIOKACE TABS TABS (pancrelipase (lipase- 3 DEPLIN 15 CAPS ( l- 3 protease-amylase)) methylfolate-algae) ZENPEP CPEP DEPLIN 7.5 CAPS ( l- 3 (pancrelipase (lipase- 2 methylfolate-algae) protease-amylase)) ELFOLATE TABS ( l- 3 DIURETICS - Drugs to Treat Heart, Circulation methylfolate) Conditions and Blood Pressure FOLBIC RF TABS (l- Carbonic Anhydrase Inhibitors methylfolate w/ vitamin 3 1 b6-vitamin b12) acetazolamide cp12 acetazolamide tabs 1

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90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KEVEYIS TABS PA EDECRIN TABS ST SP GP (dichlorphenamide) (ethacrynic acid) PA methazolamide tabs 1 ethacrynate sodium SP solr NEPTAZANE TABS GP ST (methazolamide) ethacrynic acid tabs 1 Diuretic Combinations furosemide soln 10 1 ALDACTAZIDE TABS 25 mg/ml MG-25 MG 1 bal on hand, GP furosemide soln 8 1 ( & mg/ml hydrochlorothiazide) furosemide tabs 20 mg, 1 ALDACTAZIDE TABS 50 40 mg, 80 mg MG-50 MG 2 LASIX TABS (spironolactone & GP hydrochlorothiazide) (furosemide) SODIUM EDECRIN SOLR PA amiloride & SP hydrochlorothiazide 1 (ethacrynate sodium) tabs torsemide tabs 1 DYAZIDE CAPS Potassium Sparing Diuretics (triamterene & GP ALDACTONE TABS hydrochlorothiazide) GP (spironolactone) MAXZIDE TABS (triamterene & GP amiloride hcl tabs 1 hydrochlorothiazide) DYRENIUM CAPS GP MAXZIDE-25 TABS (triamterene) (triamterene & GP hydrochlorothiazide) spironolactone tabs 1 spironolactone & triamterene caps 1 hydrochlorothiazide 1 tabs Thiazides and Thiazide-Like Diuretics 1 bal on hand, triamterene & chlorothiazide tabs 250 1 hydrochlorothiazide 1 mg, 500 mg caps chlorothiazide tabs 500 1 triamterene & mg hydrochlorothiazide 1 chlorthalidone tabs 1 tabs DIURIL SUSP Loop Diuretics 3 (chlorothiazide) bumetanide tabs 1 hydrochlorothiazide 1 BUMEX TABS caps GP (bumetanide) hydrochlorothiazide 1 DEMADEX TABS tabs GP (torsemide) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, indapamide tabs 1 etidronate disodium 1 tabs 1 bal on hand, methyclothiazide tabs 1 FORTEO SOPN PA (teriparatide SP metolazone tabs 1 (recombinant)) MICROZIDE CAPS FOSAMAX PLUS D TABS PA; QL(0.15 ea GP (hydrochlorothiazide) (alendronate sodium- 3 daily) ENDOCRINE AND METABOLIC AGENTS - cholecalciferol) FOSAMAX TABS QL(0.15 ea MISC. - Drugs to Treat Bone Disease and GP Regulate Hormones (alendronate sodium) daily) Bone Density Regulators PA ibandronate sodium SP ACTONEL TABS 150 MG ST; QL(0.04 ea soln iv 3 mg/3ml GP (risedronate sodium) daily) QL(0.04 ea ibandronate sodium 1 ACTONEL TABS 35 MG ST; QL(0.15 ea tabs or 150 mg daily) GP (risedronate sodium) daily) MIACALCIN SOLN PA SP ACTONEL TABS 5 MG, 30 ST; QL(1 ea (calcitonin (salmon)) MG (risedronate GP daily) NATPARA CART PA sodium) (parathyroid hormone SP 1 bal on hand, (recombinant)) alendronate sodium 1 soln 70 mg/75ml pamidronate disodium PA alendronate sodium QL(0.15 ea soln 30 mg/10ml, 90 SP tabs 35 mg, 40 mg, 70 1 daily) mg/10ml mg PAMIDRONATE PA DISODIUM SOLN 6 alendronate sodium 1 bal on hand, SP tabs 5 mg, 10 mg, 40 1 MG/ML (pamidronate mg, 70 mg disodium) PROLIA SOSY PA alendronate sodium SP tabs 5 mg, 10 mg, 40 1 (denosumab) RECLAST SOLN PA mg, 70 mg SP ( ) Limit 4 per zoledronic acid ATELVIA TBEC ST; QL(0.04 ea GP month;QL(0.15 risedronate sodium 1 (risedronate sodium) ea daily) tabs 150 mg daily) Limit 4 per ST; QL(0.15 ea BINOSTO TBEF risedronate sodium 1 3 month;QL(0.15 tabs 35 mg daily) (alendronate sodium) ea daily) risedronate sodium ST; QL(1 ea BONIVA SOLN IV 3 PA 1 daily) MG/3ML (ibandronate SP tabs 5 mg, 30 mg sodium) risedronate sodium Limit 4 per 1 month;QL(0.15 BONIVA TABS OR 150 MG QL(0.04 ea tbec 35 mg GP ea daily) ( ) daily) ibandronate sodium TYMLOS SOPN PA SP calcitonin (salmon) soln 1 (abaloparatide)

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92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XGEVA SOLN PA NORDITROPIN FLEXPRO PA SP SOLN 30 MG/3ML, 10 (denosumab) SP zoledronic acid conc 4 PA MG/1.5ML, 15 MG/1.5ML SP (somatropin) mg/5ml NORDITROPIN FLEXPRO PA; Use PA; 1 bal on zoledronic acid soln 4 SP SOLN 5 MG/1.5ML, 10 preferred mg/100ml hand, MG/1.5ML, 15 MG/1.5ML SP Humatrope or ZOLEDRONIC ACID SOLN PA (somatropin) Norditropin 4 MG/100ML (zoledronic SP PA; Use NUTROPIN AQ NUSPIN acid) SP preferred PA 10 SOLN (somatropin) Humatrope or zoledronic acid soln 5 SP Norditropin mg/100ml PA; Use ZOMETA CONC 4 PA NUTROPIN AQ NUSPIN SP preferred MG/5ML (zoledronic SP 20 SOLN (somatropin) Humatrope or acid) Norditropin ZOMETA SOLN 4 PA PA; Use NUTROPIN AQ NUSPIN 5 MG/100ML (zoledronic SP SP preferred acid) SOLN (somatropin) Humatrope or Norditropin Fertility Regulators PA; Use Limit 15 per OMNITROPE SOLN SP preferred clomiphene citrate tabs 1 month;QL(0.5 (somatropin) Humatrope or ea daily)1 bal Norditropin on hand, PA; Use OMNITROPE SOLR GnRH/LHRH Antagonists SP preferred CETROTIDE KIT PA (somatropin) Humatrope or SP Norditropin (cetrorelix acetate) SEROSTIM SOLR PA; Use Growth Hormone Receptor Antagonists (somatropin (non- SP preferred SOMAVERT SOLR PA Humatrope or SP refrigerated)) (pegvisomant) Norditropin PA; Use Growth Hormones ZOMACTON SOLR SP preferred PA; Use (somatropin) Humatrope or GENOTROPIN MINIQUICK SP preferred Norditropin SOLR (somatropin) Humatrope or Norditropin Hormone Receptor Modulators EVISTA TABS ( QL(1 ea daily); PA; Use raloxifene GP GENOTROPIN SOLR ) PV SP preferred hcl (somatropin) Humatrope or OSPHENA TABS 3 Norditropin (ospemifene) HUMATROPE COMBO PA PV QL(1 ea daily); PACK SOLR SP raloxifene hcl tabs PV (somatropin) HUMATROPE SOLR PA Insulin-Like Growth Factors (Somatomedins) SP INCRELEX SOLN PA (somatropin) SP (mecasermin)

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93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LHRH/GnRH Agonist Analog Pituitary cinacalcet hcl tabs 1 LUPANETA PACK KIT PA CYSTADANE POWD PA (leuprolide acetate & SP SP (betaine) norethindrone acetate) doxercalciferol caps or LUPRON DEPOT-PED (1- PA 0.5 mcg, 1 mcg, 2.5 1 MONTH) KIT (leuprolide SP acetate (cpp)) mcg PA LUPRON DEPOT-PED (3- PA doxercalciferol soln iv 4 SP MONTH) KIT (leuprolide SP mcg/2ml acetate (cpp) (3 month)) ELAPRASE SOLN PA SP SYNAREL SOLN (idursulfase) 2 (nafarelin acetate) FABRAZYME SOLR PA SP Metabolic Modifiers (agalsidase beta) GALAFOLD CAPS PA; QL(0.5 ea (Levocarnitine (Metabolic RX/OTC SP Modifiers)) MCCARNITINE 1 (migalastat hcl) daily) TABS HECTOROL SOLN 2 PA ALDURAZYME SOLN PA MCG/ML SP SP (laronidase) (doxercalciferol) BUPHENYL POWD PA HECTOROL SOLN 4 PA (sodium SP MCG/2ML SP phenylbutyrate) (doxercalciferol) BUPHENYL TABS PA KUVAN PACK PA (sodium SP (sapropterin SP phenylbutyrate) dihydrochloride) KUVAN TBSO PA calcitriol caps or 0.25 1 mcg, 0.5 mcg (sapropterin SP dihydrochloride) PA; 1 bal on calcitriol soln iv 1 SP mcg/ml hand, levocarnitine (metabolic modifiers) soln 1 1 calcitriol soln or 1 1 gm/10ml mcg/ml levocarnitine (metabolic RX/OTC CARBAGLU TABS PA 1 SP modifiers) tabs 330 mg (carglumic acid) LUMIZYME SOLR PA CARNITOR SF SOLN SP (alglucosidase alfa) (levocarnitine GP MYALEPT SOLR PA (metabolic modifiers)) SP (metreleptin) CARNITOR SOLN 1 NAGLAZYME SOLN PA GM/10ML (levocarnitine GP SP (metabolic modifiers)) (galsulfase) CARNITOR TABS 330 MG RX/OTC nitisinone caps SP PA (levocarnitine GP PA (metabolic modifiers)) NITYR TABS (nitisinone) SP

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94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORFADIN CAPS 2 MG, 5 PA DDAVP SOLN NA 0.01 % SP MG, 10 MG (nitisinone) (desmopressin acetate GP ORFADIN CAPS 20 MG PA spray) SP (nitisinone) DDAVP TABS OR 0.1 MG, ORFADIN SUSP 4 MG/ML PA 0.2 MG (desmopressin GP SP (nitisinone) acetate) PALYNZIQ SOSY PA desmopressin acetate SP 1 (pegvaliase-pqpz) spray refrigerated soln desmopressin acetate paricalcitol caps or 1 1 1 mcg, 2 mcg, 4 mcg spray soln PA desmopressin acetate paricalcitol soln iv 2 SP 1 mcg/ml, 5 mcg/ml tabs RAVICTI LIQD ( PA NOCTIVA EMUL PA glycerol SP 3 phenylbutyrate) (desmopressin acetate) RAYALDEE CPCR PA STIMATE SOLN PA SP 3 (calcifediol) (desmopressin acetate) ROCALTROL CAPS GP Prolactin Inhibitors (calcitriol) cabergoline tabs 1 ROCALTROL SOLN GP (calcitriol) Somatostatic Agents SENSIPAR TABS PA; 1 bal on GP octreotide acetate soln (cinacalcet hcl) 200 mcg/ml, 200 hand, PA mcg/ml, 500 mcg/ml, SP sodium phenylbutyrate SP powd 1000 mcg/ml, 1000 PA mcg/ml, 1000 mcg/5ml sodium phenylbutyrate SP tabs octreotide acetate soln PA STRENSIQ SOLN PA 50 mcg/ml, 100 SP (asfotase alfa) mcg/ml, 200 mcg/ml, SP 500 mcg/ml, 1000 XURIDEN PACK (uridine SP mcg/ml, 1000 mcg/ml, triacetate) 1000 mcg/5ml ZEMPLAR CAPS OR 1 MCG, 2 MCG GP SANDOSTATIN LAR PA (paricalcitol) DEPOT KIT (octreotide SP ) ZEMPLAR SOLN IV 2 PA acetate SANDOSTATIN SOLN PA MCG/ML, 5 MCG/ML SP SP (paricalcitol) (octreotide acetate) Posterior Pituitary Hormones SIGNIFOR SOLN PA (pasireotide SP DDAVP SOLN NA 0.01 % diaspartate) (desmopressin acetate 2 refrigerated) SOMATULINE DEPOT PA SOLN (lanreotide SP acetate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Vasopressin Receptor Antagonists ACTIVELLA TABS JYNARQUE TABS 15 MG, PA; QL(1 ea (estradiol & GP SP 30 MG (tolvaptan) daily) norethindrone acetate) JYNARQUE TBPK PA; SP ANGELIQ TABS SP 3 (tolvaptan) (drospirenone-estradiol) SAMSCA TABS 15 MG PA; QL(1 ea CLIMARA PRO PTWK SP (tolvaptan) daily) (estradiol- 2 SAMSCA TABS 30 MG PA; QL(1 ea levonorgestrel) SP (tolvaptan) daily) COMBIPATCH PTTW (estradiol & 3 SP PA; QL(1 ea tolvaptan tabs daily) norethindrone acetate) DUAVEE TABS ESTROGENS - Hormone Replacement/Modifying Drugs (conjugated estrogens- 3 bazedoxifene) Estrogen Combinations esterified estrogens & QL(1 ea daily) (Esterified Estrogens & QL(1 ea daily) Methyltestosterone) methyltestosterone 1 COVARYX, ESTERIFIED tabs ESTROGENS/METHYLTE estradiol & STOSTERONE HS, 1 norethindrone acetate 1 ESTERIFIED ESTROGENS/METHYLTE tabs STOSTERONE DS, EEMT FEMHRT LOW DOSE HS, EEMT, COVARYX HS TABS (norethindrone TABS acetate-ethinyl NF (Estradiol & Norethindrone estradiol) Acetate) AMABELZ, 1 MIMVEY LO, MIMVEY, norethindrone acetate- LOPREEZA TABS ethinyl estradiol tabs 1 (Norethindrone Acetate- 2.5 mcg-0.5 mg QL(84 ea per Ethinyl Estradiol) 1 norethindrone acetate- FYAVOLV TABS 2.5 MCG- ethinyl estradiol tabs 5 1 fill retail,112 ea 0.5 MG mcg-1 mg per fill mail) (Norethindrone Acetate- QL(84 ea per PREFEST TABS 3 Ethinyl Estradiol) 1 fill retail,112 ea FYAVOLV TABS 5 MCG-1 per fill mail) (estradiol-norgestimate) MG PREMPHASE TABS (Norethindrone Acetate- (conjugated estrogens- medroxyprogesterone 2 Ethinyl Estradiol) 1 JEVANTIQUE LO, JINTELI acetate) TABS PREMPRO TABS (Norethindrone Acetate- QL(84 ea per (conjugated estrogens- 2 Ethinyl Estradiol) 1 fill retail,112 ea medroxyprogesterone JEVANTIQUE LO, JINTELI per fill mail) TABS acetate) Estrogens

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 8 patches estradiol ptwk td 0.025 Limit 4 per per month;QL(0.15 (Estradiol) DOTTI PTTW 1 mg/24hr, 0.075 month;QL(0.29 mg/24hr, 0.06 mg/24hr, 1 ea daily) ea daily) 0.1 mg/24hr, 37.5 ALORA PTTW 0.025 Limit 8 patches MG/24HR, 0.075 per mcg/24hr MG/24HR, 0.1 MG/24HR 3 month;QL(0.29 estradiol ptwk td 0.05 Limit 4 per 28 (estradiol) ea daily) mg/24hr, 0.06 mg/24hr, days;QL(0.15 1 ea daily) Limit 8 patches 0.1 mg/24hr, 37.5 ALORA PTTW 0.05 GP per mcg/24hr MG/24HR (estradiol) month;QL(0.29 estradiol tabs or 0.5 1 ea daily) mg, 1 mg, 2 mg CLIMARA PTWK 0.025 Limit 4 per MG/24HR, 0.075 month;QL(0.15 estradiol valerate oil SP PA MG/24HR, 0.06 MG/24HR, GP ea daily) 0.1 MG/24HR, 37.5 Limit 50gms ESTROGEL GEL MCG/24HR (estradiol) 3 per (estradiol) month;QL(1.67 CLIMARA PTWK 0.05 Limit 4 per 28 gm daily) NF days;QL(0.15 1 bal on hand, MG/24HR (estradiol) ea daily) estropipate tabs 1 DELESTROGEN OIL 10 PA EVAMIST SOLN 3 MG/ML (estradiol SP (estradiol) valerate) MENEST TABS 2 DELESTROGEN OIL 20 PA (esterified estrogens) MG/ML, 40 MG/ML SP MENOSTAR PTWK Limit 4 per (estradiol valerate) 3 month;QL(0.14 DEPO-ESTRADIOL OIL PA (estradiol) SP ea daily) (estradiol cypionate) MINIVELLE PTTW 0.025 Limit 8 patches DIVIGEL GEL 0.25 MG/24HR, 0.075 per MG/0.25GM, 0.5 MG/24HR, 0.1 MG/24HR NF month;QL(0.29 MG/0.5GM, 1 MG/GM, 1.25 3 (estradiol) ea daily) MG/1.25GM (estradiol) MINIVELLE PTTW 0.0375 Limit 8 patches ELESTRIN GEL per 3 MG/24HR, 0.05 MG/24HR GP (estradiol) month;QL(0.29 (estradiol) ea daily) ESTRACE TABS GP (estradiol) PREMARIN SOLR IJ 25 PA MG (estrogens, SP Limit 8 patches estradiol pttw td 0.0375 conjugated) mg/24hr, 0.025 per PREMARIN TABS OR mg/24hr, 0.075 1 month;QL(0.29 ea daily) 0.625 MG, 0.45 MG, 0.3 mg/24hr, 0.05 mg/24hr, MG, 0.9 MG, 1.25 MG 2 0.1 mg/24hr (estrogens, conjugated) VIVELLE-DOT PTTW Limit 8 patches 0.025 MG/24HR, 0.075 per MG/24HR, 0.1 MG/24HR NF month;QL(0.29 (estradiol) ea daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVELLE-DOT PTTW Limit 8 patches Bile Acid Synthesis Disorder Agents per 0.0375 MG/24HR, 0.05 GP CHOLBAM CAPS ( PA month;QL(0.29 cholic SP MG/24HR (estradiol) ea daily) acid) FLUOROQUINOLONES - Drugs to Treat Bacterial Farnesoid X Receptor (FXR) Agonists Infections OCALIVA TABS PA SP Fluoroquinolones (obeticholic acid) AVELOX TABS Gallstone Solubilizing Agents GP (moxifloxacin hcl) ACTIGALL CAPS GP BAXDELA TABS ST (ursodiol) (delafloxacin 3 CHENODAL TABS PA 3 meglumine) (chenodiol) CIPRO SUSR 5 URSO 250 TABS GP GM/100ML, 500 MG/5ML 2 (ursodiol) (ciprofloxacin) URSO FORTE TABS CIPRO TABS 250 MG, 500 GP GP (ursodiol) MG (ciprofloxacin hcl) ciprofloxacin hcl tabs 1 bal on hand, ursodiol caps 1 100 mg, 500 mg, 750 1 ursodiol tabs 1 mg ciprofloxacin hcl tabs Gastrointestinal Antiallergy Agents 250 mg, 500 mg, 750 1 cromolyn sodium 1 mg (mastocytosis) conc GASTROCROM CONC ciprofloxacin susr 1 (cromolyn sodium GP ciprofloxacin- QL(14 ea per (mastocytosis)) 1 fill retail)1 bal ciprofloxacin hcl tb24 on hand, Gastrointestinal Chloride Channel Activators LEVAQUIN TABS QL(14 ea per AMITIZA CAPS GP 2 (levofloxacin) fill retail) (lubiprostone) Gastrointestinal Stimulants levofloxacin soln 25 1 mg/ml metoclopramide hcl 1 QL(14 ea per soln ij 5 mg/ml levofloxacin tabs 250 1 mg, 500 mg, 750 mg fill retail) metoclopramide hcl soln or 5 mg/5ml, 10 1 moxifloxacin hcl tabs 1 mg/10ml 1 bal on hand, ofloxacin tabs 1 metoclopramide hcl 1 tabs or 5 mg, 10 mg GASTROINTESTINAL AGENTS - MISC. - 1 bal on hand, Miscellaneous Gastrointestinal Drugs metoclopramide hcl 1 tbdp or 5 mg Agents for Chronic Idiopathic Constipation (CIC) METOCLOPRAMIDE ODT TRULANCE TABS PA 3 TBDP (metoclopramide 3 (plecanatide) hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REGLAN TABS GP mesalamine supp re 1 (metoclopramide hcl) 1000 mg Inflammatory Bowel Agents mesalamine tbec or 1.2 1 APRISO CP24 gm NF (mesalamine) mesalamine w/ 1 ASACOL HD TBEC PA cleanser kit 3 (mesalamine) PENTASA CPCR PA 3 AZULFIDINE EN-TABS (mesalamine) GP TBEC (sulfasalazine) REMICADE SOLR PA SP AZULFIDINE TABS (infliximab) GP (sulfasalazine) ROWASA KIT Limit 282 caps (mesalamine w/ GP balsalazide disodium 1 per cleanser) month;QL(9.4 caps SFROWASA ENEM ea daily) 2 (mesalamine) CANASA SUPP GP STELARA SOLN PA (mesalamine) SP (ustekinumab (iv)) CIMZIA KIT PA SP (certolizumab pegol) sulfasalazine tabs 1 CIMZIA STARTER KIT KIT PA SP (certolizumab pegol) sulfasalazine tbec 1 Limit 282 caps Intestinal Acidifiers COLAZAL CAPS GP per (Lactulose (balsalazide disodium) month;QL(9.4 (Encephalopathy)) 1 ea daily) ENULOSE, GENERLAC DELZICOL CPDR QL(12 ea daily) NF SOLN (mesalamine) lactulose DIPENTUM CAPS 1 3 (encephalopathy) soln (olsalazine sodium) Irritable Bowel Syndrome (IBS) Agents GIAZO TABS ST; QL(6 ea 3 PA (balsalazide disodium) daily) alosetron hcl tabs 1 INFLECTRA SOLR PA LINZESS CAPS SP 2 (infliximab-dyyb) (linaclotide) LIALDA TBEC LOTRONEX TABS PA NF GP (mesalamine) (alosetron hcl) mesalamine cp24 or VIBERZI TABS PA 1 3 0.375 gm (eluxadoline) QL(12 ea daily) mesalamine cpdr or 1 Peripheral Opioid Receptor Antagonists 400 mg ENTEREG CAPS 3 ( ) mesalamine enem re 4 1 alvimopan gm MOVANTIK TABS 3 (naloxegol oxalate)

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99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELISTOR SOLN PA GATTEX KIT PA SP (methylnaltrexone SP (teduglutide (rdna)) bromide) Tryptophan Hydroxylase Inhibitors RELISTOR TABS PA XERMELO TABS PA SP (methylnaltrexone SP (telotristat etiprate) bromide) GENITOURINARY AGENTS - MISCELLANEOUS SYMPROIC TABS PA 3 - Miscellaneous Drugs to Treat Reproductive (naldemedine tosylate) Organs and Urinary System SYMPROIC TABS PA; 1 bal on 3 Acidifiers (naldemedine tosylate) hand, K-PHOS NO 2 TABS Phosphate Binder Agents (potassium & sodium 2 calcium acetate acid phosphates) (phosphate binder) 1 Alkalinizers caps (Pot & Sod Citrates FOSRENOL CHEW 500 W/Citric Ac) CYTRA-3 1 MG, 750 MG, 1000 MG GP SYRP (lanthanum carbonate) (Potassium Citrate-Citric Acid) CYTRA K lanthanum carbonate 1 1 chew CRYSTALS, TARON- CRYSTALS PACK PHOSLYRA SOLN (Potassium Citrate-Citric 1 RX/OTC (calcium acetate 3 Acid) CYTRA-K SOLN (phosphate binder)) (Sodium Citrate & Citric RX/OTC RENAGEL TABS PA 1 GP Acid) CYTRA-2 SOLN (sevelamer hcl) ORACIT SOLN (sodium RENVELA PACK 3 GP citrate & citric acid) (sevelamer carbonate) pot & sod citrates RENVELA TABS 1 GP w/citric ac soln (sevelamer carbonate) potassium citrate 1 sevelamer carbonate 1 (alkalinizer) tbcr pack RX/OTC potassium citrate-citric 1 sevelamer carbonate 1 acid soln tabs sodium citrate & citric RX/OTC PA; 1 bal on 1 sevelamer hcl tabs 400 1 acid soln mg hand, UROCIT-K 10 TBCR PA sevelamer hcl tabs 800 1 (potassium citrate GP mg (alkalinizer)) VELPHORO CHEW PA UROCIT-K 15 TBCR (sucroferric 3 (potassium citrate GP oxyhydroxide) (alkalinizer)) Short Bowel Syndrome (SBS) Agents

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100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UROCIT-K 5 TBCR JALYN CAPS (potassium citrate GP (dutasteride-tamsulosin GP (alkalinizer)) hcl) Cystinosis Agents PROSCAR TABS QL(1 ea daily); GP AL(At least 40 CYSTAGON CAPS ( ) 3 finasteride yrs old) (cysteamine bitartrate) RAPAFLO CAPS 4 MG 1 bal on hand, 3 PROCYSBI CPDR 25 MG, (silodosin) 75 MG (cysteamine 3 RAPAFLO CAPS 4 MG bitartrate) 3 (silodosin) Genitourinary Irrigants RAPAFLO CAPS 8 MG GP (Sodium Chloride (Gu (silodosin) Irrigant)) ARGYLE STERILE SALINE 100ML, 1 silodosin caps 1 CURITY STERILE SALINE SOLN tamsulosin hcl caps 1 QL(2 ea daily) neomycin/polymyxin b UROXATRAL TB24 1 GP gu soln (alfuzosin hcl) 1 bal on hand, neomycin/polymyxin b 1 Urinary Analgesics gu soln (Phenazopyridine Hcl) 1 sodium chloride (gu 1 PHENAZO TABS irrigant) soln phenazopyridine hcl 1 Interstitial Cystitis Agents tabs ELMIRON CAPS QL(3 ea daily) PYRIDIUM TABS GP (pentosan polysulfate 3 (phenazopyridine hcl) sodium) Urinary Stone Agents Prostatic Hypertrophy Agents LITHOSTAT TABS 3 alfuzosin hcl tb24 1 (acetohydroxamic acid) THIOLA EC TBEC AVODART CAPS AL(At least 40 SP GP (tiopronin) (dutasteride) yrs old) CARDURA XL TB24 THIOLA TABS (tiopronin) SP (doxazosin mesylate 3 (bph)) GOUT AGENTS - Drugs to Treat Gout 1 AL(At least 40 Gout Agent Combinations dutasteride caps yrs old) colchicine w/ 1 dutasteride-tamsulosin 1 probenecid tabs hcl caps DUZALLO TABS PA 3 QL(1 ea daily); (lesinurad-allopurinol) finasteride tabs 1 AL(At least 40 yrs old) Gout Agents FLOMAX CAPS QL(2 ea daily) GP allopurinol tabs 1 (tamsulosin hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits colchicine caps 1 1 bal on hand, Plasma Kallikrein Inhibitors TAKHZYRO SOLN PA SP colchicine tabs 1 (lanadelumab-flyo) COLCRYS TABS Platelet Aggregation Inhibitors GP (colchicine) AGGRENOX CP12 GP febuxostat tabs 1 (aspirin-dipyridamole) AGRYLIN CAPS MITIGARE CAPS 1 bal on hand, GP 3 (anagrelide hcl) (colchicine) ULORIC TABS anagrelide hcl caps 1 GP (febuxostat) aspirin-dipyridamole 1 ZURAMPIC TABS PA 3 cp12 (lesinurad) BRILINTA TABS ZYLOPRIM TABS 2 GP (ticagrelor) (allopurinol) CABLIVI KIT PA SP Uricosurics (caplacizumab-yhdp) probenecid tabs 1 cilostazol tabs 1 QL(2 ea daily) QL(2 ea daily) HEMATOLOGICAL AGENTS - MISC. - Drugs to clopidogrel bisulfate 1 Treat Blood Disorders tabs Bradykinin B2 Receptor Antagonists dipyridamole tabs 1 FIRAZYR SOLN ( PA icatibant SP EFFIENT TABS 10 MG NF acetate) (prasugrel hcl) icatibant acetate soln SP PA EFFIENT TABS 5 MG GP (prasugrel hcl) Complement Inhibitors PLAVIX TABS QL(2 ea daily) PA; SP GP BERINERT KIT (c1 (clopidogrel bisulfate) esterase inhibitor SP (human)) prasugrel hcl tabs 1 HAEGARDA SOLR (c1 PA ZONTIVITY TABS 2 esterase inhibitor SP (vorapaxar sulfate) (human)) HEMATOPOIETIC AGENTS - Drugs to Treat RUCONEST SOLR (c1 PA Blood Disorders esterase inhibitor SP Agents for Gaucher Disease (recombinant)) CERDELGA CAPS PA SP Hemataologic - Tyrosine Kinase Inhibitors (eliglustat tartrate) TAVALISSE TABS PA; SP ELELYSO SOLR PA SP SP (fostamatinib disodium) (taliglucerase alfa) Hematorheologic Agents miglustat caps SP PA pentoxifylline tbcr 1 VPRIV SOLR PA SP (velaglucerase alfa) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZAVESCA CAPS PA GRANIX SOSY 300 PA SP (miglustat) MCG/0.5ML, 480 MCG/0.8ML (tbo- SP Agents for Sickle Cell Disease filgrastim) DROXIA CAPS LEUKINE SOLR PA (hydroxyurea (sickle 3 SP cell anemia)) (sargramostim) MIRCERA SOSY PA ENDARI PACK PA SP (glutamine (sickle cell)) (methoxy polyethylene SP glycol-epoetin beta) SIKLOS TABS PA MULPLETA TABS PA (hydroxyurea (sickle SP SP cell anemia)) (lusutrombopag) NEULASTA ONPRO KIT PA SP Folic Acid/Folates PSKT (pegfilgrastim) (Folic Acid) CVS FOLIC PV NEULASTA SOSY PA ACID, YL FOLIC ACID, SM SP FOLIC ACID, RA FOLIC (pegfilgrastim) ACID, QC FOLIC ACID, PX PV NEUPOGEN SOLN PA SP FOLIC ACID, HM FOLIC (filgrastim) ACID, GNP FOLIC ACID, NEUPOGEN SOSY PA FOLATE, FA-8 TABS SP (filgrastim) (Folic Acid) KP FOLIC 1 RX/OTC ACID TABS 1 MG NIVESTYM SOSY 300 PA MCG/0.5ML, 480 (Folic Acid) KP FOLIC PV PV SP ACID TABS 800 MCG MCG/0.8ML (filgrastim- aafi) folic acid soln ij 5 1 PROCRIT SOLN 2000 PA mg/ml UNIT/ML, 3000 UNIT/ML, folic acid tabs or 1 mg 1 RX/OTC 4000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML, SP PV folic acid tabs or 400 PV 40000 UNIT/ML (epoetin mcg, 800 mcg alfa) Hematopoietic Growth Factors PROMACTA PACK 25 MG, PA ARANESP ALBUMIN PA 12.5 MG (eltrombopag SP FREE SOLN SP olamine) (darbepoetin alfa) PROMACTA TABS 25 MG, PA ARANESP ALBUMIN PA 50 MG, 12.5 MG SP FREE SOSY SP (eltrombopag olamine) (darbepoetin alfa) PROMACTA TABS 75 MG, PA; QL(1 ea DOPTELET TABS PA 12.5 MG (eltrombopag SP daily) (avatrombopag SP olamine) maleate) RETACRIT SOLN 2000 PA EPOGEN SOLN (epoetin PA UNIT/ML, 3000 UNIT/ML, SP 4000 UNIT/ML, 10000 SP alfa) UNIT/ML, 40000 UNIT/ML (epoetin alfa-epbx)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZARXIO SOSY PA MOZOBIL SOLN PA SP SP (filgrastim-sndz) (plerixafor) ZIEXTENZO SOSY PA SP HEMOSTATICS - Drugs to Stop Bleeding/Treat (pegfilgrastim-bmez) Blood Disorders Hematopoietic Mixtures Hemostatics - Systemic FOLIVANE-F CAPS AMICAR TABS 500 MG, (ferrous fumarate-iron 1000 MG (aminocaproic GP 2 polysaccharide acid) complex-folic acid-c-b3) aminocaproic acid tabs 1 FUSION PLUS CAPS (fe 500 mg, 1000 mg fum-iron polysacch CYKLOKAPRON SOLN PA 3 SP complex-fa-b cmplx-c- (tranexamic acid) biotin-probiotic) LYSTEDA TABS QL(6 ea daily,5 GP INTEGRA F CAPS (tranexamic acid) day(s) limit) (ferrous fumarate-iron PA 2 tranexamic acid soln iv SP polysaccharide 1000 mg/10ml complex-folic acid-c-b3) QL(6 ea daily,5 tranexamic acid tabs or 1 Iron 650 mg day(s) limit) (Carbonyl Iron) WEE PV PV CARE SUSP HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS (Ferrous Sulfate) PV BPROTECTED PEDIA Antihistamine Hypnotics IRON, IRON PV SUPPLEMENT CHILDRENS SOLN (Ferrous Sulfate) PV FEROSUL, IRON PV SUPPLEMENT ELIX FER-IN-SOL SOLN PV GP (ferrous sulfate) PV ferrous sulfate elix 220 PV mg/5ml PV ferrous sulfate soln 15 PV mg/ml FERROUS SULFATE PV SYRP 300 MG/5ML PV (ferrous sulfate) ICAR PEDIATRIC SUSP PV GP (carbonyl iron) MYKIDZ IRON 10 SUSP PV PV (iron) Stem Cell Mobilizers

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl Hypnotics - Tricyclic Agents (Sleep)) COMPOZ, WAL- ST; QL(1 ea SOM MAXIMUM 1 doxepin hcl (sleep) tabs daily) STRENGTH, TGT SLEEP SILENOR TABS ( ST; QL(1 ea AID MAXIMUM doxepin GP STRENGTH, SM SLEEP hcl (sleep)) daily) AID MAXIMUM STRENGTH, SLEEP-AID Non-Barbiturate Hypnotics AMBIEN CR TBCR QL(1 ea daily) MAXIMUM STRENGTH, GP SLEEP-AID, SLEEP AID, (zolpidem tartrate) RA SLEEP AID MAXIMUM AMBIEN TABS 10 MG QL(1 ea daily) STRENGTH, RA GP ( ) NIGHTTIME SLEEP AID, zolpidem tartrate AMBIEN TABS 5 MG QL(1 ea daily) QC SLEEP-AID MAXIMUM NF ( ) STRENGTH, QC SLEEP 1 zolpidem tartrate AID MAXIMUM DORAL TABS 1 bal on hand, 3 STRENGTH, ORMIR, (quazepam) GOODSENSE SLEEP AID, EDLUAR SUBL ST; QL(1 ea EQL SLEEP AID 3 MAXIMUM STRENGTH, (zolpidem tartrate) daily) EQ NIGHTTIME SLEEP AID MAXIMUM estazolam tabs 1 STRENGTH, CVS SLEEP- QL(1 ea daily) AID NIGHTTIME, CVS eszopiclone tabs 1 SLEEP AID 1 bal on hand, NIGHTTIME/MAXIMUM flurazepam hcl caps 1 STRENGTH, CVS HALCION TABS NIGHTTIME SLEEP AID GP MAXIMUM STRENGTH (triazolam) CAPS INTERMEZZO SUBL PA GP UNISOM SLEEPGELS (zolpidem tartrate) CAPS LUNESTA TABS 1 MG, 2 QL(1 ea daily) GP NF (diphenhydramine hcl MG (eszopiclone) (sleep)) LUNESTA TABS 3 MG QL(1 ea daily) GP Barbiturate Hypnotics (eszopiclone) BUTISOL SODIUM TABS 3 midazolam hcl syrp 1 (butabarbital sodium) quazepam tabs 1 1 bal on hand, phenobarbital elix 20 1 mg/5ml RESTORIL CAPS GP phenobarbital soln 20 1 (temazepam) mg/5ml SONATA CAPS QL(1 ea daily) GP phenobarbital tabs 15 (zaleplon) mg, 30 mg, 60 mg, 100 1 temazepam caps 1 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg triazolam tabs 1 SECONAL SODIUM CAPS 3 QL(1 ea daily) (secobarbital sodium) zaleplon caps 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA COLYTE-FLAVOR PACKS PV zolpidem tartrate subl 1 SOLR (peg 3350-kcl-sod sl 3.5 mg, 1.75 mg 3 QL(1 ea daily) bicarb-sod chloride-sod zolpidem tartrate tabs 1 or 5 mg, 10 mg sulfate) QL(1 ea daily) GOLYTELY SOLR 227.1 PA; PV zolpidem tartrate tbcr 1 GM-21.5 GM-5.53 GM-2.82 or 12.5 mg, 6.25 mg GM-6.36 GM (peg 3350- PV ST; Limit 1 kcl-sod bicarb-sod ZOLPIMIST SOLN bottle per 3 chloride-sod sulfate) (zolpidem tartrate) month;QL(0.26 ml daily) GOLYTELY SOLR 236 PV GM-22.74 GM-5.86 GM- Orexin Receptor Antagonists 2.97 GM-6.74 GM (peg BELSOMRA TABS ST; QL(1 ea GP 2 3350-kcl-sod bicarb- (suvorexant) daily) sod chloride-sod Selective Melatonin Receptor Agonists sulfate) HETLIOZ CAPS PA PA; PV SP MOVIPREP SOLR (peg (tasimelteon) 3350-kcl-nacl-na PV ramelteon tabs 1 ST; QL(1 ea sulfate-na ascorbate- daily) ascorbic acid) ROZEREM TABS ST; QL(1 ea GP NULYTELY/FLAVOR PV (ramelteon) daily) PACKS SOLR (peg 3350- LAXATIVES - Bowel Treatment Drugs potassium chloride-sod GP bicarbonate-sod Laxative Combinations chloride) (Bisacodyl-Peg 3350-Pot PV peg 3350-kcl-sod PV Chloride-Sod Bicarb-Sod PV bicarb-sod chloride-sod PV Chloride) GAVILYTE-H, PEG-PREP KIT sulfate solr (Peg 3350-Kcl-Sod Bicarb- 1 bal on peg 3350-potassium PV chloride-sod Sod Chloride-Sod Sulfate) PV hand,PV PV GAVILYTE-C, GAVILYTE- bicarbonate-sod G SOLR chloride solr (Peg 3350-Kcl-Sod Bicarb- PV PLENVU SOLR (peg PA; PV Sod Chloride-Sod Sulfate) PV GAVILYTE-C, GAVILYTE- 3350-kcl-nacl-na PV G SOLR sulfate-na ascorbate- (Peg 3350-Potassium PV ascorbic acid) Chloride-Sod Bicarbonate- PREPOPIK PACK PA; PV Sod Chloride) GAVILYTE- PV (sodium picosulfate- N/FLAVOR PACK, magnesium oxide- PV TRILYTE SOLR anhydrous citric acid) CLENPIQ SOLN (sodium PV picosulfate-magnesium PV oxide-anhydrous citric acid)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPREP BOWEL PREP PV Azithromycin KIT SOLN (sodium 1 bal on hand, sulfate-potassium PV azithromycin pack 1 gm 1 sulfate-magnesium azithromycin susr 100 1 sulfate) mg/5ml, 200 mg/5ml Laxatives - Miscellaneous azithromycin tabs 250 QL(6 ea per fill 1 retail) (Lactulose) CONSTULOSE 1 mg SOLN QL(3 ea per fill azithromycin tabs 500 1 (Polyethylene Glycol 3350) Limit 510gms mg retail) CLEARLAX, TGT per QL(10 ea per POWDERLAX, SMOOTH month;QL(17.6 azithromycin tabs 600 1 LAX, SM CLEARLAX, SB gm daily); mg fill retail) POLYETHYLENE GLYCOL RX/OTC ZITHROMAX PACK 1 GM 1 bal on hand, 2 3350, RA LAXATIVE, QC (azithromycin) NATURA-LAX, PEGYLAX, KLS LAXACLEAR, HM 1 ZITHROMAX SUSR 100 CLEARLAX, GOODSENSE MG/5ML, 200 MG/5ML GP CLEARLAX, GNP (azithromycin) CLEARLAX, GLYCOLAX, ZITHROMAX TABS 250 QL(6 ea per fill GP GENTLELAX, GAVILAX, MG (azithromycin) retail) EQL CLEARLAX, EQ ZITHROMAX TABS 500 QL(3 ea per fill CLEARLAX, CVS GP PURELAX POWD MG (azithromycin) retail) KRISTALOSE PACK 10 ZITHROMAX TABS 600 QL(10 ea per 3 GP GM, 20 GM (lactulose) MG (azithromycin) fill retail) LACTULOSE PACK 10 GM ZITHROMAX TRI-PAK QL(3 ea per fill 3 GP (lactulose) TABS (azithromycin) retail) ZITHROMAX Z-PAK TABS QL(6 ea per fill lactulose soln 10 1 GP gm/15ml, 20 gm/30ml (azithromycin) retail) Limit 510gms Clarithromycin MIRALAX POWD per 1 bal on hand, clarithromycin susr 125 1 (polyethylene glycol GP month;QL(17.6 mg/5ml, 250 mg/5ml 3350) gm daily); RX/OTC clarithromycin tabs 250 1 Limit 510gms mg, 500 mg per QL(14 ea per polyethylene glycol clarithromycin tb24 500 1 1 month;QL(17.6 mg fill retail) 3350 powd gm daily); RX/OTC Erythromycins Saline Laxatives (Erythromycin Base) ERY- 1 TAB TBEC OSMOPREP TABS PA; PV (sodium phosphate (Erythromycin 1 bal on hand, PV Ethylsuccinate) E.E.S. 400 1 monobasic-sodium TABS phosphate dibasic) MACROLIDES - Drugs to Treat Bacterial Infections

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107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Erythromycin Stearate) 1 bal on hand, DUREX EXTRA PV ERYTHROCIN SENSITIVE DEVI STEARATE, 1 (condoms latex PV ERYTHROCIN STEARATE lubricated - male) TABS FANTASY LUBRICATED PV E.E.S. GRANULES SUSR MISC (condoms latex PV (erythromycin GP lubricated - male) ethylsuccinate) FANTASY PV ERYPED 200 SUSR LUBRICATED/SPERMICID (erythromycin GP E MISC (condoms latex PV ethylsuccinate) lubricated - male) ERYPED 400 SUSR FC FEMALE CONDOM PV (erythromycin GP MISC (condoms - PV ethylsuccinate) female) 1 bal on hand, erythromycin base 1 FC2 FEMALE CONDOM PV cpep 250 mg MISC (condoms - PV female) erythromycin base 1 cpep 250 mg FEMCAP DEVI ( PV cervical PV caps) erythromycin base tabs 1 250 mg, 500 mg KAMELEON LUBRICATED PV erythromycin base tbec MISC (condoms latex PV 250 mg, 333 mg, 500 1 lubricated - male) mg KIMONO COLORS DEVI PV erythromycin (condoms latex PV ethylsuccinate susr 200 1 lubricated - male) mg/5ml, 400 mg/5ml KIMONO LUBRICATED PV erythromycin 1 bal on hand, MISC (condoms latex PV ethylsuccinate tabs 400 1 lubricated - male) mg KIMONO MICRO THIN PV MISC (condoms latex PV Fidaxomicin non-lubricated - male) DIFICID TABS 3 KIMONO MICRO THIN PV (fidaxomicin) PLUS SPERMICIDE MEDICAL DEVICES AND SUPPLIES LUBRICATED MISC PV (condoms latex Contraceptives lubricated - male) AIMSCO LUBRICATED PV KIMONO PLUS PV MISC (condoms latex PV SPERMICIDE lubricated - male) LUBRICATED MISC PV (condoms latex DIAPHRAGMS PV lubricated - male)

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108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO PLUS PV REALITY LATEX/ULTRA PV SPERMICIDE/LUBRICATE THIN DEVI ( PV condoms PV D MISC (condoms latex latex lubricated - male) lubricated - male) TRUSTEX COLOR PV KIMONO PS LUBRICATED PV CONDOMS + LUBE MISC MISC (condoms latex PV (condoms latex PV lubricated - male) lubricated - male) KIMONO PS PLUS PV TRUSTEX LUBRICATED PV SPERMICIDE/LUBRICATE EXTRALARGE MISC D MISC (condoms latex PV (condoms latex PV lubricated - male) lubricated - male) KIMONO SENSATION PV TRUSTEX LUBRICATED PV LUBRICATED MISC EXTRASTRENGTH MISC (condoms latex PV (condoms latex PV lubricated - male) lubricated - male) KIMONO SENSATION PV TRUSTEX LUBRICATED PV PLUS SPERMICIDE MISC (condoms latex PV LUBRICATED MISC PV lubricated - male) (condoms latex TRUSTEX PV lubricated - male) LUBRICATED/RIBBED/ST KIMONO SPECIAL DEVI PV UDDED MISC (condoms PV (condoms latex PV latex lubricated - male) lubricated - male) TRUSTEX PV MAXX LUBRICATED MISC PV LUBRICATED/SPERMICID (condoms latex PV E EXTRA LARGE MISC PV lubricated - male) (condoms latex MAXX PLUS SPERMICIDE PV lubricated - male) LUBRICATED MISC TRUSTEX PV (condoms latex PV LUBRICATED/SPERMICID lubricated - male) E EXTRA STRENGTH PV PREMIUM CONDOMS PV MISC (condoms latex LUBRICATED MISC lubricated - male) (condoms latex PV TRUSTEX PV LUBRICATED/SPERMICID lubricated - male) PV REALITY LATEX PV E MISC (condoms latex CONDOMS/LUBRICATED lubricated - male) MISC (condoms latex PV TRUSTEX NATURAL PV lubricated - male) CONDOMS +LUBE/LUBRICATED REALITY LATEX/ULTRA PV PV TEXTURED DEVI MISC (condoms latex (condoms latex PV lubricated - male) lubricated - male) TRUSTEX NON- PV LUBRICATED MISC (condoms latex non- PV lubricated - male)

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109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX WITH PV ONETOUCH VERIO FLEX Limit 1 per NONOXYNOL- BLOOD GLUCOSE year;QL(1 ea 9/RIBBED/STUDDED PV MONITORING SYSTEM 2 per 365 days MISC (condoms latex KIT (blood glucose retail); RX/OTC lubricated - male) monitoring supplies) TRUSTEX/RIA PV ONETOUCH VERIO IQ QL(1 ea per LUBRICATED MISC BLOOD GLUCOSE 365 days (condoms latex PV MONITORING SYSTEM 2 retail); RX/OTC lubricated - male) KIT (blood glucose TRUSTEX/RIA PV monitoring supplies) LUBRICATED ONETOUCH VERIO KIT Limited to 1 per SPERMICIDE MISC PV ( 2 year;QL(1 ea blood glucose per 365 days (condoms latex monitoring supplies) lubricated - male) retail); RX/OTC TRUSTEX/RIA PV ONETOUCH VERIO SYNC Limited to 1 per LUBRICATED/SPERMICID BLOODGLUCOSE year;QL(1 ea MONITORING SYSTEM per 365 days E MISC (condoms latex PV 2 KIT (blood glucose retail); RX/OTC lubricated - male) monitoring supplies) TRUSTEX/RIA NON- PV LUBRICATED MISC PRECISION XTRA DEVI QL(1 ea per 365 days retail) (condoms latex non- PV XX (blood glucose 2 lubricated - male) monitoring supplies) Diabetic Supplies Parenteral Therapy Supplies FREESTYLE FREEDOM QL(1 ea per INSULIN SYRINGES AND 2 MO PEN NEEDLES LITE KIT (blood glucose 2 365 days monitoring supplies) retail); RX/OTC Respiratory Therapy Supplies FREESTYLE INSULINX QL(1 ea per INHALER SPACERS 2 MO BLOODGLUCOSE 365 days MONITORING SYSTEM 2 retail); RX/OTC MIGRAINE PRODUCTS - Drugs to Treat Migraine KIT (blood glucose Headaches monitoring supplies) Calcitonin Gene-Related Peptide (CGRP) FREESTYLE LITE BLOOD QL(1 ea per AIMOVIG SOAJ 140 PA GLUCOSE MONITORING 365 days retail) MG/ML (erenumab- SP SYSTEM DEVI (blood 2 aooe) glucose monitoring AIMOVIG SOAJ 70 MG/ML PA; SP supplies) SP (erenumab-aooe) LANCET 2 AJOVY SOSY PA SP ONETOUCH ULTRA 2 KIT QL(1 ea per (fremanezumab-vfrm) (blood glucose 2 365 days EMGALITY SOAJ 120 PA monitoring supplies) retail); RX/OTC MG/ML (galcanezumab- SP ONETOUCH ULTRA MINI QL(1 ea per gnlm) KIT (blood glucose 2 365 days EMGALITY SOSY 120 PA monitoring supplies) retail); RX/OTC MG/ML (galcanezumab- SP gnlm)

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110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERGOMAR SUBL Migraine Combinations 2 (ergotamine tartrate) (Ergotamine W/ Caffeine) 1 1 bal on hand, MIGERGOT SUPP MIGRANAL SOLN QL(8 ml per fill CAFERGOT TABS (dihydroergotamine 3 retail,24 ml per (ergotamine w/ GP mesylate) fill mail) caffeine) Serotonin Agonists ergotamine w/ caffeine 1 1 QL(6 ea per 30 tabs almotriptan malate tabs days retail) AMERGE TABS QL(9 ea per 30 isometheptene- GP dichloralphenazone- 1 (naratriptan hcl) days retail) AXERT TABS QL(6 ea per 30 acetaminophen caps GP isometheptene- 1 bal on hand, (almotriptan malate) days retail) QL(0.2 ea dichloralphenazone- 1 eletriptan hydrobromide 1 acetaminophen caps tabs daily) PA; QL(0.3 ea FROVA TABS QL(0.3 ea sumatriptan-naproxen 1 GP sodium tabs daily) (frovatriptan succinate) daily) QL(0.3 ea TREXIMET TABS 10 MG- PA; Limit 9 per frovatriptan succinate 1 60 MG (sumatriptan- 3 month;QL(0.3 tabs daily) ea daily) naproxen sodium) IMITREX SOLN NA 20 Limited to 6 per GP month;QL(0.2 TREXIMET TABS 85 MG- PA; QL(0.3 ea MG/ACT (sumatriptan) 500 MG (sumatriptan- GP daily) ea daily) naproxen sodium) IMITREX SOLN NA 5 Limit 6 per GP month;QL(0.2 Migraine Products - NSAIDs MG/ACT (sumatriptan) ea daily) CAMBIA PACK PA; Limit 9 per QL(2 ml per fill (diclofenac potassium 3 month;QL(0.3 IMITREX SOLN SC 6 retail,6 ml per ea daily) (migraine)) MG/0.5ML ( GP fill mail,4 ml per sumatriptan 30 days Migraine Products succinate) retail,12 ml per QL(10 ml per 90 days mail) D.H.E. 45 SOLN fill retail,30 ml QL(2 ml per fill ( GP per fill mail,20 retail,6 ml per dihydroergotamine ml per 30 days IMITREX STATDOSE mesylate) REFILL SOCT GP fill mail,4 ml per retail,60 ml per 30 days 90 days mail) (sumatriptan succinate) retail,12 ml per QL(10 ml per 90 days mail) dihydroergotamine fill retail,30 ml QL(2 ml per fill 1 per fill mail,20 retail,6 ml per mesylate soln ij 1 ml per 30 days IMITREX STATDOSE mg/ml SYSTEM SOAJ GP fill mail,4 ml per retail,60 ml per 30 days 90 days mail) (sumatriptan succinate) retail,12 ml per dihydroergotamine QL(8 ml per fill 90 days mail) mesylate soln na 4 3 retail,24 ml per mg/ml fill mail)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(9 ea per fill QL(12 ea per retail,27 ea per fill retail,36 ea IMITREX TABS OR 25 MG GP fill mail,18 ea rizatriptan benzoate 1 per fill mail,24 (sumatriptan succinate) per 30 days tbdp ea per 30 days retail,54 ea per retail,72 ea per 90 days mail) 90 days mail) QL(9 ea per fill sumatriptan soln 20 Limited to 6 per retail,27 ea per 1 month;QL(0.2 IMITREX TABS OR 50 MG, mg/act 100 MG ( NF fill mail,18 ea ea daily) sumatriptan per 30 days succinate) sumatriptan soln 5 Limit 6 per retail,54 ea per 1 month;QL(0.2 90 days mail) mg/act ea daily) QL(12 ea per QL(2 ml per fill fill retail,36 ea retail,6 ml per MAXALT TABS per fill mail,24 sumatriptan succinate NF 1 fill mail,4 ml per (rizatriptan benzoate) ea per 30 days soaj sc 4 mg/0.5ml, 6 30 days retail,72 ea per mg/0.5ml retail,12 ml per 90 days mail) 90 days mail) QL(12 ea per QL(2 ml per fill fill retail,36 ea MAXALT-MLT TBDP 10 sumatriptan succinate retail,6 ml per MG ( NF per fill mail,24 fill mail,4 ml per rizatriptan ea per 30 days soct sc 4 mg/0.5ml, 6 1 benzoate) 30 days retail,72 ea per mg/0.5ml retail,12 ml per 90 days mail) 90 days mail) QL(12 ea per QL(2 ml per fill fill retail,36 ea retail,6 ml per MAXALT-MLT TBDP 5 MG per fill mail,24 GP sumatriptan succinate 1 fill mail,4 ml per (rizatriptan benzoate) ea per 30 days soln sc 6 mg/0.5ml 30 days retail,72 ea per retail,12 ml per 90 days mail) 90 days mail) 1 QL(9 ea per 30 QL(9 ea per fill naratriptan hcl tabs days retail) sumatriptan succinate retail,27 ea per RELPAX TABS 20 MG QL(0.2 ea 1 fill mail,18 ea daily) tabs or 25 mg, 50 mg, per 30 days (eletriptan GP 100 mg hydrobromide) retail,54 ea per 90 days mail) RELPAX TABS 40 MG QL(0.2 ea ZEMBRACE SYMTOUCH PA (eletriptan NF daily) SOAJ (sumatriptan 3 hydrobromide) succinate) QL(12 ea per fill retail,36 ea QL(9 ea per fill retail,27 ea per rizatriptan benzoate 1 per fill mail,24 tabs ea per 30 days zolmitriptan tabs 1 fill mail,18 ea retail,72 ea per per 30 days 90 days mail) retail,54 ea per 90 days mail)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(9 ea per fill PLASMA-LYTE A SOLN PA SP retail,27 ea per (electrolyte-a) 1 fill mail,18 ea PLASMA-LYTE-148 SOLN PA zolmitriptan tbdp per 30 days SP retail,54 ea per (electrolyte-148) 90 days mail) potassium chloride in PA; 1 bal on QL(9 ea per fill nacl soln 0.45 %-20 hand, retail,27 ea per meq/l, 0.9 %-20 meq/l, SP ZOMIG SOLN NA 2.5 MG 3 fill mail,18 ea 0.9 %-40 meq/l, 0.9 %- (zolmitriptan) per 30 days 40 meq/l, 0.9 %-0.15 % retail,54 ea per 90 days mail) potassium chloride in PA QL(6 ea per 30 nacl soln 0.45 %-20 ZOMIG SOLN NA 5 MG meq/l, 0.9 %-20 meq/l, SP 3 days retail,18 (zolmitriptan) ea per 90 days 0.9 %-40 meq/l, 0.9 %- mail) 40 meq/l, 0.9 %-0.15 % QL(9 ea per fill retail,27 ea per Fluoride ZOMIG TABS OR 5 MG, (Sodium Fluoride) PV GP fill mail,18 ea 2.5 MG (zolmitriptan) per 30 days FLUORITAB, NAFRINSE PV retail,54 ea per DROPS, FLURA-DROPS 90 days mail) SOLN QL(9 ea per fill (Sodium Fluoride) 1 bal on retail,27 ea per FLUORITAB, NAFRINSE PV hand,PV ZOMIG ZMT TBDP DROPS, FLURA-DROPS GP fill mail,18 ea (zolmitriptan) per 30 days SOLN retail,54 ea per (Sodium Fluoride) PV 90 days mail) FLUORITAB, NAFRINSE, PV LUDENT CHEW MINERALS & ELECTROLYTES FLUORABON SOLN PV PV Calcium (sodium fluoride) CALCIFOL WAFR sodium fluoride chew PV (calcium carbonate-folic PV 3 0.25 mg, 0.5 mg, 1 mg, acid-vit d-b6-b12- 2.2 mg boron-magnesium) PV sodium fluoride soln 0.5 PV CALCIUM-FOLIC ACID mg/ml PLUS D WAFR (calcium 1 bal on sodium fluoride tabs PV carbonate-folic acid-vit 3 0.5 mg, 1 mg hand,PV d-b6-b12-boron- magnesium) Magnesium MAGNEBIND 400 TABS Electrolyte Mixtures (magnesium-calcium- 3 ISOLYTE-S SOLN PA SP folic acid) (electrolyte-s) magnesium sulfate soln PA; 1 bal on NORMOSOL-R SOLN PA SP SP ij 50 % hand, (electrolyte-r (ph 7.4)) PA magnesium sulfate soln SP ij 50 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits magnesium sulfate soln PA (Potassium Chloride iv 2 gm/50ml, 4 Microencapsulated Crystals gm/50ml, 4 gm/100ml, SP Er) KLOR-CON M10, 1 KLOR-CON M20, KLOR- 20 gm/500ml, 40 CON M15 TBCR gm/1000ml (Potassium Chloride 1 bal on hand, MAGNESIUM SULFATE PA Microencapsulated Crystals SOLN IV 2 GM/50ML, 4 Er) KLOR-CON M10, 1 GM/50ML, 4 GM/100ML, KLOR-CON M20, KLOR- SP 20 GM/500ML, 40 CON M15 TBCR GM/1000ML (magnesium (Potassium Chloride) K- sulfate) SOL, POTASSIUM 1 Phosphate CHLORIDE PROAMP SOLN (Pot Phosphate Monobasic W/ Sod Phosphate Dibasic (Potassium Chloride) K- PA & Monobasic) AV-PHOS SOL, POTASSIUM SP CHLORIDE PROAMP 250 NEUTRAL, VIRT- 1 PHOS 250 NEUTRAL, SOLN PHOSPHO-TRIN 250 (Potassium Chloride) NEUTRAL, PHOSPHA 250 KLOR-CON 10, KLOR- 1 NEUTRAL TABS CON 8 TBCR K-PHOS NEUTRAL TABS (Potassium Chloride) 1 (pot phosphate KLOR-CON PACK monobasic w/ sod GP (Potassium Chloride) phosphate dibasic & KLOR-CON SPRINKLE 1 CPCR monobasic) EFFER-K TBEF 1 GM-0.84 K-PHOS TABS GM, 2 GM-1.68 GM (potassium phosphate 2 (potassium 3 monobasic) bicarbonate-citric acid) pot phosphate K-TAB TBCR 10 MEQ, 20 monobasic w/ sod 1 MEQ (potassium GP phosphate dibasic & chloride) monobasic tabs K-TAB TBCR 8 MEQ 1 bal on hand, 2 Potassium (potassium chloride) (Potassium Bicarb & 1 bal on hand, potassium bicarb & 1 Chloride) 1 chloride tbef EFFERVESCENT POT CHLORIDE TBEF potassium bicarbonate 1 tbef (Potassium Bicarbonate) 1 EFFER-K TBEF 25 MEQ potassium chloride cpcr 1 (Potassium Bicarbonate) K- or 8 meq, 10 meq EFFERVESCENT, KLOR- 1 CON/EF, K-VESCENT, K- potassium chloride PRIME TBEF microencapsulated 1 crystals er tbcr

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114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride 1 MISCELLANEOUS THERAPEUTIC CLASSES pack or 20 meq POTASSIUM CHLORIDE PA Chelating Agents SOLN IV 0.4 MEQ/ML, 10 (Trientine Hcl) CLOVIQUE SP PA MEQ/50ML, 20 CAPS MEQ/50ML, 10 CUPRIMINE CAPS PA SP GP MEQ/100ML, 20 (penicillamine) MEQ/100ML, 20 DEPEN TITRATABS TABS MEQ/100ML (potassium GP chloride) (penicillamine) POTASSIUM CHLORIDE PA; 1 bal on penicillamine caps 1 PA SOLN IV 10 MEQ/100ML, hand, 20 MEQ/100ML, 20 SP penicillamine tabs 1 MEQ/100ML (potassium SYPRINE CAPS ( PA chloride) trientine SP hcl) PA; 1 bal on potassium chloride soln SP iv 2 meq/ml hand, trientine hcl caps SP PA PA potassium chloride soln SP Enzymes iv 2 meq/ml XIAFLEX SOLR PA potassium chloride soln 1 (collagenase or 10 %, 20 % clostridium SP potassium chloride tbcr histolyticum) or 8 meq, 10 meq, 20 1 Immunomodulators meq REVLIMID CAPS PA AC potassium chloride tbcr 1 bal on hand, (lenalidomide) or 8 meq, 10 meq, 20 1 THALOMID CAPS AC meq () Sodium Immunosuppressive Agents PA sodium chloride soln ij SP (Cyclosporine Modified (For 2.5 meq/ml Microemulsion)) 1 sodium chloride soln iv PA GENGRAF CAPS 0.45 %, 0.9 %, 3 %, 5 SP (Cyclosporine Modified (For Microemulsion)) 1 % GENGRAF SOLN sodium chloride soln iv PA; 1 bal on ASTAGRAF XL CP24 PA SP hand, 3 0.9 %, 0.9 %, 3 %, 5 % (tacrolimus) Zinc ATGAM INJ (lymphocyte PA (Zinc Sulfate) ORAZINC, 1 immune globulin,anti- SP ZINC-220 CAPS thymocyte globulin GALZIN CAPS ( ) zinc 3 (equine) acetate (oral)) AZASAN TABS 3 zinc sulfate caps 1 (azathioprine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZATHIOPRINE SOLR IJ PA mycophenolate mofetil 1 100 MG (azathioprine SP tabs sodium) mycophenolate sodium 1 azathioprine tabs or 50 1 tbec mg MYFORTIC TBEC CELLCEPT CAPS (mycophenolate GP (mycophenolate GP sodium) mofetil) NEORAL CAPS CELLCEPT PA (cyclosporine modified GP INTRAVENOUS SOLR SP (for microemulsion)) (mycophenolate mofetil NEORAL SOLN hcl) (cyclosporine modified GP CELLCEPT SUSR (for microemulsion)) (mycophenolate GP NULOJIX SOLR PA SP mofetil) (belatacept) CELLCEPT TABS PROGRAF CAPS OR 0.5 (mycophenolate GP MG, 1 MG, 5 MG GP mofetil) (tacrolimus) cyclosporine caps or 25 PROGRAF PACK OR 0.2 PA 1 SP mg, 100 mg MG, 1 MG (tacrolimus) cyclosporine modified PROGRAF SOLN IV 5 PA SP MG/ML ( ) (for microemulsion) 1 tacrolimus caps 25 mg, 50 mg, RAPAMUNE SOLN GP 100 mg (sirolimus) cyclosporine modified RAPAMUNE TABS GP (for microemulsion) 1 (sirolimus) soln 100 mg/ml SANDIMMUNE CAPS OR PA 25 MG, 100 MG GP cyclosporine soln iv 50 SP mg/ml (cyclosporine) ENVARSUS XR TB24 PA SANDIMMUNE SOLN IV PA 3 SP (tacrolimus) 50 MG/ML (cyclosporine) SIMULECT SOLR PA everolimus SP (immunosuppressant) 1 (basiliximab) tabs sirolimus soln 1 IMURAN TABS GP (azathioprine) sirolimus tabs 1 mycophenolate mofetil 1 tacrolimus caps 1 caps PA THYMOGLOBULIN SOLR PA mycophenolate mofetil SP hcl solr (anti-thymocyte globulin SP (rabbit), lymphocyte mycophenolate mofetil 1 immune globulin) susr You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZORTRESS TABS 0.25 BENLYSTA SOSY PA SP MG, 0.75 MG, 0.5 MG (belimumab) (everolimus GP (immunosuppressant)) MOUTH/THROAT/DENTAL AGENTS Irrigation Solutions Anesthetics Topical Oral (Irrigation Solutions, FIRST-MOUTHWASH BLM Physiological) SUSP PHYSIOLYTE, 1 (diphenhydramine- PHYSIOSOL IRRIGATION lidocaine-alum 3 SOLN hydroxide-mg (Ringer'S Irrigation) TIS-U- 1 hydroxide-simeth) SOL SOLN (Water For Irrigation, lidocaine hcl (mouth- 1 Sterile) ARGYLE STERILE 1 throat) soln 2 % WATER 100ML SOLN 1 bal on hand, lidocaine hcl (mouth- 1 throat) soln 4 % lactated ringer's 1 (irrigation) soln Anti-infectives - Throat ringer's irrigation soln 1 clotrimazole lozg 1 water for irrigation, 1 clotrimazole troc 1 sterile soln Potassium Removing Agents nystatin (mouth-throat) 1 susp (Sodium Polystyrene 1 Sulfonate) KIONEX POWD ORAVIG TABS (Sodium Polystyrene (miconazole (mouth- 3 Sulfonate) KIONEX, SPS 1 throat)) SUSP Antiseptics - Mouth/Throat LOKELMA PACK ST (Chlorhexidine Gluconate (sodium zirconium 3 (Mouth-Throat)) PAROEX, 1 cyclosilicate) PERIOGARD SOLN chlorhexidine gluconate sodium polystyrene 1 1 sulfonate powd (mouth-throat) soln sodium polystyrene PERIDEX SOLN 1 (chlorhexidine sulfonate susp GP VELTASSA PACK ST gluconate (mouth- (patiromer sorbitex 3 throat)) calcium) Steroids - Mouth/Throat/Dental Systemic Lupus Erythematosus Agents (Triamcinolone Acetonide BENLYSTA SOAJ PA (Mouth)) ORALONE 1 SP DENTAL PASTE PSTE (belimumab) triamcinolone acetonide BENLYSTA SOLR PA 1 SP (mouth) pste (belimumab) Throat Products - Misc.

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117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cevimeline hcl caps 1 UDAMIN SP TABS (multiple vitamins w/ 3 EVOXAC CAPS GP minerals & folic acid) (cevimeline hcl) Ped MV w/ Fluoride GELCLAIR GEL (Pediatric Multivitamins AL(Up to 6 yrs (povidone-sodium 3 W/Fl) MULTI- 1 old ) hyaluronate- VITAMIN/FLUORIDE glycyrrhetinic acid) DROPS SOLN MUCOTROL WAFR ( (Pediatric Multivitamins AL(Up to 6 yrs oral 3 wound care products) W/Fl) MULTIVITAMIN old ) WITH FLUORIDE CHEW ORAFATE PSTE 3 0.25 MG-15 UNIT-400 (sucralfate-malate) UNIT-2500 UNIT-1.2 MG- 4.5 MCG-13.5 MG-1.05 pilocarpine hcl (oral) 1 tabs MG-0.3 MG-1.05 MG-60 MG, 0.5 MG-15 UNIT-400 PROTHELIAL PSTE 1 3 UNIT-2500 UNIT-1.2 MG- (sucralfate-malate) 4.5 MCG-13.5 MG-1.05 SALAGEN TABS MG-0.3 MG-1.05 MG-60 GP (pilocarpine hcl (oral)) MG, 1 MG-15 UNIT-400 UNIT-2500 UNIT-1.2 MG- MULTIVITAMINS 4.5 MCG-13.5 MG-1.05 MG-0.3 MG-1.05 MG-60 Multiple Vitamins & Fluoride-Folic Acid MG MULTIVITAMIN WITH AL(Up to 6 yrs (Pediatric Multivitamins AL(Up to 6 yrs FLUORIDE CHEW 0.25 old ) W/Fl) MULTIVITAMIN old ) MG-15 UNIT-400 UNIT- WITH FLUORIDE SOLN 2500 UNIT-1.2 MG-4.5 0.25 MG/ML-0.6 MG/ML-8 MCG-1.05 MG-13.5 MG- MG/ML-1500 UNIT/ML-2 1.05 MG-0.3 MG-60 MG, MCG/ML-400 UNIT/ML-0.5 0.5 MG-15 UNIT-400 MG/ML-5 UNIT/ML-0.4 UNIT-2500 UNIT-1.2 MG- MG/ML-35 MG/ML, 0.5 4.5 MCG-1.05 MG-13.5 2 MG/ML-0.6 MG/ML-8 MG-1.05 MG-0.3 MG-60 MG/ML-1500 UNIT/ML-2 MG, 1 MG-15 UNIT-400 MCG/ML-400 UNIT/ML-0.5 UNIT-2500 UNIT-1.2 MG- MG/ML-5 UNIT/ML-0.4 1 4.5 MCG-1.05 MG-13.5 MG/ML-35 MG/ML, 5 MG-1.05 MG-0.3 MG-60 UNIT/ML-0.5 MG/ML-0.6 MG (multiple vitamins & MG/ML-8 MG/ML-1500 fluoride-folic acid) UNIT/ML-2 MCG/ML-400 UNIT/ML-0.5 MG/ML-0.4 Multiple Vitamins w/ Minerals MG/ML-35 MG/ML, 5 ONEVITE TABS (multiple UNIT/ML-0.25 MG/ML-0.6 vitamins w/ minerals & 3 MG/ML-8 MG/ML-1500 ) UNIT/ML-2 MCG/ML-400 folic acid UNIT/ML-0.5 MG/ML-0.4 THRIVITE 19 TABS MG/ML-35 MG/ML (multiple vitamins w/ 3 minerals & folic acid)

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118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins 1 bal on (Pediatric Multivitamins AL(Up to 6 yrs W/Fl) hand,AL(Up to W/Fl) old ) MULTIVITAMIN/FLUORID 6 yrs old ) MULTIVITAMIN/FLUORID E CHEW 0.25 MG-2500 E CHEW 15 UNIT-1 MG- UNIT-13.5 MG-1.2 MG-4.5 2500 UNIT-13.5 MG-1.2 MCG-400 UNIT-1.05 MG- MG-4.5 MCG-400 UNIT- 0.3 MG-15 UNIT-1.05 MG- 1.05 MG-0.3 MG-1.05 MG- 60 MG, 0.5 MG-2500 60 MG, 2500 UNIT-1 MG- UNIT-13.5 MG-1.2 MG-4.5 15 UNIT-400 UNIT-1.2 MG- MCG-400 UNIT-1.05 MG- 4.5 MCG-1.05 MG-13.5 0.3 MG-15 UNIT-1.05 MG- MG-1.05 MG-300 MCG-60 60 MG, 1 MG-2500 UNIT- MG, 15 UNIT-0.5 MG-2500 13.5 MG-1.2 MG-4.5 MCG- UNIT-13.5 MG-1.2 MG-4.5 400 UNIT-1.05 MG-0.3 MCG-400 UNIT-1.05 MG- 1 MG-15 UNIT-1.05 MG-60 0.3 MG-1.05 MG-60 MG, MG, 2500 UNIT-1 MG-15 15 UNIT-0.25 MG-2500 UNIT-400 UNIT-1.2 MG- UNIT-13.5 MG-1.2 MG-4.5 4.5 MCG-1.05 MG-13.5 1 MCG-400 UNIT-1.05 MG- MG-1.05 MG-300 MCG-60 0.3 MG-1.05 MG-60 MG, MG, 15 UNIT-0.5 MG-2500 2500 UNIT-0.5 MG-15 UNIT-13.5 MG-1.2 MG-4.5 UNIT-400 UNIT-1.2 MG-4.5 MCG-400 UNIT-1.05 MG- MCG-1.05 MG-13.5 MG- 0.3 MG-1.05 MG-60 MG, 1.05 MG-300 MCG-60 MG, 15 UNIT-0.25 MG-2500 2500 UNIT-0.25 MG-15 UNIT-13.5 MG-1.2 MG-4.5 UNIT-400 UNIT-1.2 MG-4.5 MCG-400 UNIT-1.05 MG- MCG-1.05 MG-13.5 MG- 0.3 MG-1.05 MG-60 MG, 1.05 MG-300 MCG-60 MG 2500 UNIT-0.5 MG-15 (Pediatric Multivitamins AL(Up to 6 yrs UNIT-400 UNIT-1.2 MG- W/Fl) old ) 4.5 MCG-1.05 MG-13.5 MULTIVITAMIN/FLUORID MG-1.05 MG-300 MCG-60 E SOLN 0.25 MG/ML-5 MG, 2500 UNIT-0.25 MG- UNIT/ML-0.6 MG/ML-8 15 UNIT-400 UNIT-1.2 MG/ML-1500 UNIT/ML-2 MG-4.5 MCG-1.05 MG- MCG/ML-400 UNIT/ML-0.5 1 13.5 MG-1.05 MG-300 MG/ML-0.4 MG/ML-35 MCG-60 MG MG/ML, 0.5 MG/ML-5 UNIT/ML-0.6 MG/ML-8 MG/ML-1500 UNIT/ML-2 MCG/ML-400 UNIT/ML-0.5 MG/ML-0.4 MG/ML-35 MG/ML (Pediatric Multivitamins AL(Up to 6 yrs W/Fl) old ) MULTIVITAMINS/FLUORI 1 DE, MVC-FLUORIDE CHEW

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119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Vitamins Acd W/ AL(Up to 6 yrs (Ped Multivitamins W/Fl & Fluoride) TRI- old ) Iron) MULTI- VITAMIN/FLUORIDE, 1 VIT/IRON/FLUORIDE, VITAMINS MULTIVITAMIN/FLUORID 1 A/C/D/FLUORIDE, TRI- E/IRON, MULTI- VITE/FLUORIDE SOLN VITAMIN/FLUORIDE/IRON FLORIVA PLUS SOLN AL(Up to 6 yrs SOLN (pediatric multivitamins 2 old ) POLY-VI-FLOR/IRON AL(Up to 6 yrs w/fl) CHEW 200 MCG-0.5 MG- old ) 10 MG-15 UNIT-400 UNIT pediatric vitamins acd AL(Up to 6 yrs 3 1 old ) (ped multivitamins w/fl w/ fluoride soln & iron) POLY-VI-FLOR CHEW 200 AL(Up to 6 yrs POLY-VI-FLOR/IRON MCG-1 MG-15 UNIT-400 old ) SUSP 200 MCG/ML-7 UNIT, 200 MCG-0.5 MG-15 MG/ML-0.25 MG/ML (ped 3 UNIT-400 UNIT, 200 MCG- 3 0.25 MG-15 UNIT-400 multivitamins w/fl & UNIT (pediatric iron) multivitamins w/fl) Prenatal Vitamins POLY-VI-FLOR SUSP 200 (Prenatal Vit W/ Docusate- 1 bal on hand, MCG/ML-0.25 MG/ML Fe Fumarate-Folic Acid) (pediatric multivitamins 3 PRENATAL 19 TABS 1000 w/fl) UNIT-30 UNIT-20 MG-25 1 MG-3 MG-200 MG-29 MG- QUFLORA GUMMIES AL(Up to 6 yrs 15 MG-3 MG-7 MG-12 CHEW (pediatric 2 old ) MCG-400 UNIT-20 MG-1 multivitamins w/fl) MG-100 MG QUFLORA PEDIATRIC AL(Up to 6 yrs (Prenatal Vit W/ Docusate- 1 bal on hand, CHEW (pediatric 2 old ) Iron Carbonyl-Folic Acid) 1 multivitamins w/fl) INATAL GT TABS QUFLORA PEDIATRIC AL(Up to 6 yrs (Prenatal Vit W/ Ferrous 1 bal on hand, SOLN (pediatric 2 old ) Fumarate-Folic Acid) PRENATAL 19 CHEW multivitamins w/fl) 1000 UNIT-400 UNIT-20 1 TRI-VI-FLOR SUSP MG-25 MG-3 MG-200 MG- (pediatric vitamins acd 29 MG-7 MG-6 MG-3 MG- & l-methylfolate w/ 3 12 MCG-1 MG-30 UNIT-20 fluoride) MG-100 MG TRI-VI-FLORO SUSP (Prenatal Vit W/ Ferrous 1 bal on hand, Fumarate-L Methylfolate- (pediatric vitamins acd 1 3 Folic Acid) PNV-SELECT & l-methylfolate w/ TABS fluoride) (Prenatal Vit W/ Iron 1 bal on hand, Ped Multi Vitamins w/Fl & FE Carbonyl-Folic Acid) 1 PRENATABS RX TABS (Prenatal Without A W/ Fe 1 bal on hand, Fumarate-L Methylfolate- 1 Fa-Dha) PNV-DHA CAPS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATABEX EC TBEC CITRANATAL HARMONY (prenatal vit w/ CAPS (prenatal w/o vit docusate-iron carbonyl- 2 a w/ fe fumarate-fe 3 folic acid) carbonyl-dss-fa-dha) ATABEX OB TABS CITRANATAL MEDLEY (prenatal vit w/ fe CAPS (prenatal w/o vit bisglycinate chelate- 2 a w/ fe fumarate-fe 3 folic acid) carbonyl-fa-dha) BAL-CARE DHA MISC CITRANATAL RX TABS (prenatal w/fe (prenatal without vit a polysacch cmplx-sod 2 w/ fe carbonyl-fe gluc- 3 feredetate-fa-omega 3) docusate-fa) C-NATE DHA CAPS COMPLETENATE CHEW (prenatal vit w/ ferrous (prenatal vit w/ ferrous 2 3 fumarate-fa-omega 3 fumarate-folic acid) fatty acids) CONCEPT DHA CAPS CITRANATAL 90 DHA (prenatal vit w/ fe fum- 2 MISC (prenatal w/o vit a iron polysacch complex 2 w/ fe carbonyl-fe -fa-omega 3) gluconate-dss-fa-dha) CONCEPT OB CAPS CITRANATAL ASSURE (prenatal without a vit 2 MISC (prenatal w/o vit a w/ fe fum-iron 2 w/ fe carbonyl-fe polysacch complex -fa) gluconate-dss-fa-dha) CVS PRENATAL TABS CITRANATAL B-CALM (prenatal vit w/ ferrous 2 MISC (prenatal w/o vit a fumarate-folic acid) 3 w/ fe carbonyl-fe DOTHELLE DHA CAPS gluconate-fa & vit b6) (prenatal vit w/ fe fum- 2 CITRANATAL BLOOM iron polysacch complex DHA MISC (prenatal w/o -fa-omega 3) 2 vit a w/ fe carbonyl-fe DUET DHA 400 MISC gluconate-dss-fa-dha) (prenatal w/fe 3 CITRANATAL BLOOM polysacch cmplx-sod TABS (prenatal vit w/ feredetate-fa-omega 3) 3 docusate-fe carbonyl-fe DUET DHA BALANCED gluconate-folic acid) MISC (prenatal w/fe 3 CITRANATAL DHA MISC polysacch cmplx-sod (prenatal w/o vit a w/ fe feredetate-fa-omega 3) 2 carbonyl-fe gluconate- ENBRACE HR CAPS dss-fa-dha) (prenatal vit w/ fe glycine cysteinate-fa- 3 omega 3 fatty acids)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLET DHA THPK MYNATAL ADVANCE (prenatal vit w/fe TABS (prenatal vit w/ carbonyl-fe bisglyc- 3 docusate-iron carbonyl- 2 methylfol-dss & dha) folic acid) FOLET ONE CAPS MYNATAL ULTRACAPLET (prenatal w/o a w/fe TABS (prenatal vit w/ carbonyl-fe bisglyc-l 3 docusate-iron carbonyl- 2 methylfol-dss-dha) folic acid) FOLIVANE-OB CAPS MYNATE 90 PLUS TBCR (prenatal without a vit (prenatal vit w/ w/ fe fum-iron 2 docusate-fe fumarate- 2 polysacch complex -fa) folic acid) HEMENATAL OB + DHA NATACHEW CHEW MISC (prenatal vit w/ fe (prenatal vit w/ fe fum- poly cmplx-fe heme 2 fe bisglycinate chelate- 3 polypept-fa & omega 3) folic acid) HEMENATAL OB TABS NATELLE ONE CAPS (prenatal vit w/ fe (prenatal without vit a polysacch complex-fe 3 w/ fe fum-fa-omega 3 heme polypeptide-fa) fatty acids) INFANATE BALANCE NEEVO DHA CAPS CAPS (prenatal w/o vit (prenatal without vit a a w/ fe carbonyl-dss-fa- 3 w/ fe fumarate-l 3 dha) methylfolate-omegas) KOSHER PRENATAL NEONATAL COMPLETE RX/OTC PLUS IRON TABS TABS ( 3 prenatal vit w/ (prenatal vit w/ iron ferrous fumarate-folic 2 carbonyl-folic acid) acid) M-NATAL PLUS TABS RX/OTC NEONATAL PLUS TABS RX/OTC (prenatal vit w/ ferrous 2 (prenatal vit w/ ferrous 2 fumarate-folic acid) fumarate-folic acid) M-VIT TABS (prenatal vit RX/OTC NEONATAL VITAMIN w/ ferrous fumarate- 2 TABS (prenatal vit w/ 2 folic acid) ferrous fumarate-folic MARNATAL-F CAPS acid) (prenatal without vit a NESTABS ABC MISC 2 w/ iron polysaccharide (prenatal mv & min w/o 3 complex-fa) vit a w/fe polysac MULTI PRENATAL TABS cmplx-fa-ca-omega 3) (prenatal vit w/ ferrous 2 NESTABS DHA MISC fumarate-folic acid) (prenatal vit without vit a w/ fe bisglycinate-fa- 2 omeg 3)

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122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NESTABS ONE CAPS PNV OB+DHA MISC (prenatal w/o a w/fe (prenatal w/o vit a w/ fe carbonyl-fe bisglyc-l 3 carbonyl-fe gluconate- 2 methylfol-dha) dss-fa-dha) NESTABS TABS PNV PRENATAL PLUS RX/OTC ( MULTIVITAMIN TABS prenatal vit without vit 2 a w/ fe bisglycinate- 3 (prenatal vit w/ ferrous folic acid) fumarate-folic acid) NEXA PLUS CAPS PNV TABS 29-1 TABS (prenatal w/o vit a w/fe (prenatal vit w/ iron 3 fumarate-docusate ca- 3 carbonyl-folic acid) folic acid-dha) PNV-DHA+DOCUSATE CAPS (prenatal w/o vit NIVA-PLUS TABS RX/OTC 3 (prenatal vit w/ ferrous 2 a w/ fe fumarate-dss-fa- fumarate-folic acid) dha) O-CAL FA TABS RX/OTC PNV-OMEGA CAPS (prenatal vit w/ ferrous 2 (prenatal without a w/ fumarate-folic acid) fe fumarate-l 3 OB COMPLETE ONE methylfolate-fa-omega CAPS (prenatal w/o vit 3) a w/ fe carbonyl-fe 3 PNV-TOTAL CAPS (prenatal vit w/ fe aspart glyc-fa-fish oil) 3 OB COMPLETE PETITE carbonyl-fe CAPS (prenatal w/o vit bisglycinate-fa-fish oil) a w/ fe carbonyl-fe 3 PR NATAL 400 EC MISC (prenatal mv & min w/fe aspart glyc-fa-omega 3) 2 OB COMPLETE PREMIER bisglyc-fe prot succ-fa- TABS (prenatal vit w/ ca-omega 3) iron carbonyl-fe aspart 3 PR NATAL 430 EC MISC (prenatal mv & min w/fe glycinate-fa) 3 OB COMPLETE/DHA bisglyc-fe prot succ-fa- CAPS (prenat vit w/ iron ca-omega 3) carbonyl-fe asp glyc-fa- 3 PR NATAL 430 MISC (prenatal mv & min w/fe omega fatty acid) 3 OBSTETRIX ONE CAPS bisglyc-fe prot succ-fa- (prenatal w/o a w/fe ca-omega 3) carbonyl-fe bisglyc-l 3 PREFERAOB +DHA MISC methylfol-dss-dha) (prenatal vit w/ fe PNV FOLIC ACID + IRON RX/OTC polysacch cmplx-fe 3 MULTIVITAMIN TABS heme polypept-fa & (prenatal vit w/ ferrous 2 dha) fumarate-folic acid)

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123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMESISRX TABS PRENATAL 19 CHEW 30 (prenatal w/ calcium-vit UNIT-1000 UNIT-20 MG-3 b6-vit b12-folic acid- 3 MG-200 MG-29 MG-7 MG- ) 15 MG-3 MG-12 MCG-400 ginger UNIT-1 MG-20 MG-100 2 PRENA 1 TRUE MISC MG (prenatal vit w/ (prenatal without a w/ 3 ferrous fumarate-folic fe amino acid chelate- acid) ) fa-dha PRENATAL 19 TABS 30 PRENA1 PEARL CPCR UNIT-1000 UNIT-20 MG-25 (prenatal without a w/ MG-3 MG-200 MG-29 MG- fe fumarate-sod 3 7 MG-15 MG-3 MG-12 3 feredetate-fa-dha) MCG-400 UNIT-1 MG-20 PRENAISSANCE MG-100 MG (prenatal vit BALANCE CAPS w/ docusate-fe (prenatal w/o vit a w/ fe 3 fumarate-folic acid) carbonyl-dss-fa-dha) PRENATAL LOW IRON TABS (prenatal vit w/ PRENAISSANCE CAPS 2 (prenatal w/o vit a w/ fe 3 ferrous fumarate-folic fumarate-dss-fa-dha) acid) PRENAISSANCE PRENATAL ONE DAILY TABS (prenatal vit w/ HARMONY DHA MISC 2 (prenatal w/fe 3 ferrous fumarate-folic polysacch cmplx-sod acid) feredetate-fa-omega 3) PRENATAL PLUS IRON PRENAISSANCE NEXT TABS (prenatal vit w/ 3 TABS (prenatal w/ iron carbonyl-folic acid) 3 calcium-vit b6-folic PRENATAL PLUS TABS RX/OTC acid-ginger) (prenatal vit w/ ferrous 2 PRENAISSANCE NEXT-B fumarate-folic acid) TABS (prenatal w/ PRENATAL TABS 11 calcium-vit b6-folic 3 UNIT-263 MG-25 MG-1.5 acid-ginger) MG-27 MG-4000 UNIT-18 MG-1.7 MG-4 MCG-400 PRENAISSANCE PLUS UNIT-0.8 MG-2.6 MG-100 CAPS (prenatal w/o vit 3 MG, 160 MG-11 UNIT-200 a w/ fe carbonyl-dss-fa- MG-25 MG-1.84 MG-27 2 dha) MG-4000 UNIT-18 MG-1.7 PRENATA CHEW MG-4 MCG-400 UNIT-800 MCG-2.6 MG-100 MG (prenatal without a vit 2 (prenatal vit w/ ferrous w/ fe fumarate-folic fumarate-folic acid) acid)

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124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 22 MG- RX/OTC PRENATE MINI CAPS 2 MG-25 MG-1.84 MG-200 (prenatal w/o vit a w/ fe MG-27 MG-4000 UNIT-20 carbonyl-fe asp glyc- 3 MG-3 MG-12 MCG-400 ) UNIT-1 MG-10 MG-120 methfol-fa-dha MG, 160 MG-11 UNIT-200 PRENATE PIXIE CAPS MG-25 MG-1.84 MG-27 2 (prenatal w/o a w/ fe MG-4000 UNIT-18 MG-1.7 asparto glyc-l 3 MG-4 MCG-400 UNIT-800 methylfolate-fa-dha) MCG-2.6 MG-100 MG PREPLUS TABS RX/OTC (prenatal vit w/ ferrous (prenatal vit w/ ferrous 2 fumarate-folic acid) fumarate-folic acid) PRENATAL VITAMIN PRIMACARE CAPS TABS (prenatal vit w/ ferrous fumarate-folic 2 (prenatal without a w/ fe asp glyc-l 3 acid) methylfolate-fa-omega PRENATAL VITAMINS RX/OTC ) PLUS LOW IRON TABS 3 (prenatal vit w/ ferrous 2 PROVIDA DHA CAPS (prenatal without a w/fe fumarate-folic acid) 3 PRENATAL-U CAPS fum-fe polysacch complex-fa-dha) (prenatal without a vit w/ fe fumarate-folic 2 PROVIDA OB CAPS (prenatal without a vit acid) 2 PRENATE AM TABS w/ fe fum-iron polysacch complex -fa) (prenatal w/ calcium-vit b6-vit b12-folic acid- 3 R-NATAL OB CAPS ginger) (prenatal w/o vit a w/ fe 3 ) PRENATE CHEW carbonyl-folic acid-dha (prenatal multivitamins RELNATE DHA CAPS 3 (prenatal vit w/ ferrous & minerals w/ l- 3 methylfolate-fa) fumarate-fa-omega 3 ) PRENATE DHA CAPS fatty acids (prenatal w/o a w/ fe RIGHT STEP PRENATAL 3 TABS (prenatal vit w/ asparto glyc-l 2 methylfolate-fa-dha) ferrous fumarate-folic ) PRENATE ELITE TABS acid (prenatal w/ fe asparto SE-NATAL 19 CHEW 30 3 UNIT-1000 UNIT-100 MG- glycinate-l methylfolate- 20 MG-3 MG-200 MG-29 folic acid) MG-7 MG-15 MG-3 MG-12 PRENATE ESSENTIAL MCG-400 UNIT-1 MG-20 2 CAPS (prenatal w/o a MG (prenatal vit w/ w/ fe asparto glyc-l 3 ferrous fumarate-folic methylfolate-fa-dha) acid)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SE-NATAL 19 TABS 30 TL-SELECT CAPS UNIT-1000 UNIT-20 MG- (prenatal w/o vit a w/ fe 3 25 MG-200 MG-29 MG-7 fumarate-dss-fa-dha) MG-15 MG-3 MG-12 MCG- 400 UNIT-3 MG-20 MG-1 3 TRI-TABS DHA MISC (prenatal vit without vit MG-100 MG (prenatal vit 2 w/ docusate-fe a w/ fe bisglycinate-fa- fumarate-folic acid) omeg 3) SELECT-OB CHEW 1700 TRICARE PRENATAL DHA ONE CAPS UNIT-29 MG-30 UNIT-15 3 MG-25 MG-1.6 MG-15 MG- (prenatal w/fe 1.8 MG-5 MCG-400 UNIT- fumarate-fa-dss-fish oil) 3 1 MG-2.5 MG-60 MG TRICARE PRENATAL (prenatal vit w/ iron DHA ONE/FOLATE CAPS polysaccharide (prenatal multivit-min 2 complex-folic acid) w/fe-fa) SELECT-OB+DHA MISC TRICARE TABS RX/OTC (prenatal mv & min w/fe 3 (prenatal vit w/ ferrous 2 polysaccharide fumarate-folic acid) complex-fa-dha) TRISTART DHA CAPS TARON-BC MISC (prenatal without a w/ (prenatal without vit a 3 3 fe carbonyl-l w/ iron carbonyl-folic methylfolate-fa-dha) acid & vit b6) TRISTART ONE CAPS TARON-C DHA CAPS (prenatal without a w/ (prenatal vit w/ fe fum- 3 2 fe carbonyl-l iron polysacch complex methylfolate-fa-dha) -fa-omega 3) ULTIMATECARE ONE TARON-PREX CAPS CAPS (prenatal vit w/ (prenatal w/o vit a w/ fe 3 iron carbonyl-fe aspart 3 fumarate-dss-fa-dha) glyc-fa-omega 3) THERANATAL CORE RX/OTC VENA-BAL DHA MISC NUTRITION TABS 2 (prenatal w/fe (prenatal vit w/ ferrous polysacch cmplx-sod 2 fumarate-folic acid) feredetate-fa-omega 3) THRIVITE RX TABS VIL-RX TABS (prenatal (prenatal vit w/ iron 3 vit w/ iron carbonyl-folic 3 carbonyl-folic acid) acid) TL FOLATE TABS VINATE DHA RF CAPS (prenatal vit w/ ferrous 2 (prenatal without vit a fumarate-l methylfolate- w/ fe fumarate-l 3 folic acid) methylfolate-omegas) TL-CARE DHA CAPS (prenatal w/fe 3 fumarate-fa-dss-fish oil) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VINATE II TABS VITAFOL-NANO TABS (prenatal vit w/ fe (prenatal w/o a vit w/ fe bisglycinate chelate- 2 fumarate-l methylfolate- 3 folic acid) folic acid) VIRT-C DHA CAPS VITAFOL-ONE CAPS (prenatal vit w/ fe fum- (prenatal mv & min w/fe iron polysacch complex 2 polysaccharide 3 -fa-omega 3) complex-fa-dha) VIRT-NATE DHA CAPS VITAMEDMD ONE (prenatal vit w/ ferrous RX/QUATREFOLIC CAPS fumarate-fa-omega 3 3 (prenatal without a w/ 3 fatty acids) fe fumarate-l VIRT-PN DHA CAPS methylfolate-fa-dha) (prenatal without a w/ VITAPEARL CPCR 3 (prenatal without a w/ fe fumarate-l 3 methylfolate-fa-dha) fe fumarate-sod VIRT-PN PLUS CAPS feredetate-fa-dha) (prenatal without a w/ VITATHELY/GINGER RX/OTC TABS (prenatal vit w/ fe fumarate-l 3 2 methylfolate-fa-omega ferrous fumarate-folic 3) acid) VIRT-PN TABS (prenatal VITATRUE MISC (prenatal without a w/ vit w/ ferrous fumarate-l 3 3 methylfolate-folic acid) fe amino acid chelate- VITAFOL FE+ CPPK 415 fa-dha) MG-0.6 MG-90 MG-20 VIVA DHA CAPS UNIT-150 MCG-1100 (prenatal vit w/ ferrous UNIT-200 MG-2 MG-25 fumarate-fa-omega 3 3 MG-20 MG-50 MG-15 MG- fatty acids) 1.8 MG-25 MCG-1000 3 UNIT-1.6 MG-0.4 MG-2.5 VOL-PLUS TABS RX/OTC MG-60 MG (prenatal vit (prenatal vit w/ ferrous 2 w/ fe polysacch fumarate-folic acid) complex-l methylfol-fa- VOL-TAB RX TABS dha-dss) (prenatal vit w/ iron 3 VITAFOL GUMMIES carbonyl-folic acid) CHEW (prenatal vit w/ VP-GGR-B6 PRENATAL 3 TABS (prenatal w/ ferric phosphate-fa- 3 omega 3 fatty acids) calcium-vit b6-folic VITAFOL ULTRA CAPS acid-ginger) (prenatal vit w/ fe VP-HEME OB + DHA MISC 2 (prenatal vit w/ fe poly polysacch complex-l 2 methylfolate-fa-dha) cmplx-fe heme polypept-fa & omega 3)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VP-HEME OB TABS ST; QL(1 ea cyclobenzaprine hcl 1 (prenatal vit w/ fe daily) 3 cp24 15 mg, 30 mg polysacch complex-fe cyclobenzaprine hcl heme polypeptide-fa) tabs 5 mg, 10 mg, 7.5 1 VP-PNV-DHA CAPS mg (prenatal vit w/ ferrous GABLOFEN SOLN PA 3 SP fumarate-fa-omega 3 (baclofen) ) fatty acids LIORESAL INTRATHECAL PA ZATEAN-PN DHA CAPS SOLN 0.05 MG/ML, 10 SP (prenatal without a w/ 3 MG/5ML (baclofen) fe fumarate-l LIORESAL INTRATHECAL PA methylfolate-fa-dha) SOLN 10 MG/20ML SP ZATEAN-PN PLUS CAPS (baclofen) (prenatal without a w/ metaxalone tabs 1 fe fumarate-l 3 methylfolate-fa-omega methocarbamol tabs 1 3) orphenadrine citrate MUSCULOSKELETAL THERAPY AGENTS - 1 Drugs to Treat Spasms tb12 ROBAXIN TABS Central Muscle Relaxants GP (methocarbamol) (Carisoprodol) VANADOM 1 ROBAXIN-750 TABS TABS GP ( ) (Chlorzoxazone) methocarbamol 1 SKELAXIN TABS LORZONE TABS GP (metaxalone) (Cyclobenzaprine Hcl) 1 1 bal on hand, FEXMID TABS SOMA TABS GP (carisoprodol) (Metaxalone) METAXALL 1 TABS tizanidine hcl caps 1 AMRIX CP24 ST; QL(1 ea GP (cyclobenzaprine hcl) daily) tizanidine hcl tabs 1 PA baclofen soln it 500 SP ZANAFLEX CAPS GP mcg/ml (tizanidine hcl) baclofen tabs or 10 mg, ZANAFLEX TABS 1 GP 20 mg (tizanidine hcl) 1 bal on hand, baclofen tabs or 5 mg, 1 Direct Muscle Relaxants 20 mg DANTRIUM CAPS GP carisoprodol tabs 1 (dantrolene sodium) CHLORZOXAZONE TABS dantrolene sodium 3 1 250 MG (chlorzoxazone) caps chlorzoxazone tabs Muscle Relaxant Combinations 375 mg, 500 mg, 750 1 1 bal on hand, carisoprodol w/ aspirin 1 mg & codeine tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carisoprodol w/ aspirin 1 ipratropium bromide 1 & codeine tabs (nasal) soln carisoprodol w/ aspirin 1 Nasal Steroids tabs (Budesonide (Nasal)) CVS Limit 2 inhalers 1 bal on hand, BUDESONIDE NASAL per carisoprodol w/ aspirin 1 tabs SPRAY, RHINOCORT month;QL(0.6 ALLERGY, RA ml daily) NORGESIC FORTE TABS 1 bal on hand, BUDESONIDE NASAL 1 (orphenadrine w/ NF SPRAY, GNP aspirin & caff) BUDESONIDE NASAL orphenadrine w/ aspirin SPRAY, EQ BUDESONIDE NASAL SPRAY SUSP & caff tabs 25 mg-30 1 (Fluticasone Propionate Limit 2 inhalers mg-385 mg (Nasal)) ALLERGY NASAL per NASAL AGENTS - SYSTEMIC AND TOPICAL - SPRAY 24 HOUR, SM month;QL(1.1 Drugs to treat the Nose or Sinus ALLERGY RELIEF NASAL ml daily); SPRAY, QC RX/OTC Nasal Agent Combinations FLUTICASONE azelastine hcl- Limit 1 per PROPIONATE, QC fluticasone propionate 1 month;QL(0.77 ALLERGY RELIEF, KP susp gm daily) FLUTICASONE PROPIONATE, KLS DYMISTA SUSP Limit 1 per ALLER-FLO, HM (azelastine hcl- GP month;QL(0.77 ALLERGY RELIEF NASAL fluticasone propionate) gm daily) SPRAY 24HR, GNP 1 Nasal Anti-infectives FLUTICASONE PROPIONATE BACTROBAN NASAL CHILDRENS, GNP OINT (mupirocin 2 FLUTICASONE calcium) PROPIONATE, EQL FLUTICASONE Nasal Antiallergy PROPIONATE ASTEPRO SOLN Limit 1 inhaler CHILDRENS, EQL NF per month;QL(1 (azelastine hcl) FLUTICASONE ml daily) PROPIONATE, CVS Limit 1 inhaler FLUTICASONE PROPRIONATE NASAL azelastine hcl soln 0.1 1 per %, 137 mcg/spray month;QL(1.2 SPRAY, CLARISPRAY, ml daily) ALLERGY RELIEF SUSP azelastine hcl soln 0.15 Limit 1 inhaler (Fluticasone Propionate Limit 2 inhalers 1 per month;QL(1 (Nasal)) EQ ALLERGY per %, 137 mcg/spray ml daily) 1 month;QL(1.1 RELIEF SUSP NA 50 ml daily); MCG/ACT olopatadine hcl (nasal) 1 RX/OTC soln Limit 2 inhalers PATANASE SOLN BECONASE AQ SUSP ( 3 per (olopatadine hcl GP beclomethasone month;QL(1.67 (nasal)) diprop monohyd) gm daily) Nasal Anticholinergics

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers NEUROMUSCULAR AGENTS - Drugs to budesonide (nasal) 1 per Relax/Paralyze Muscles susp month;QL(0.6 ml daily) ALS Agents FLONASE ALLERGY Limit 2 inhalers RILUTEK TABS (riluzole) GP RELIEF CHILDRENS per SUSP ( GP month;QL(1.1 riluzole tabs 1 fluticasone ml daily); ) propionate (nasal) RX/OTC Neuromuscular Blocking Agent - Neurotoxins Limit 2 inhalers BOTOX SOLR PA FLONASE ALLERGY SP RELIEF SUSP per (onabotulinumtoxina) (fluticasone propionate GP month;QL(1.1 ml daily); OPHTHALMIC AGENTS - Drugs to Treat the Eye (nasal)) RX/OTC Artificial Tears and Lubricants FLONASE SENSIMIST Limit 1 inhaler per LACRISERT INST SUSP (fluticasone 3 3 month;QL(0.34 (artificial tear insert) furoate) ml daily) Beta-blockers - Ophthalmic 1 bal on hand, flunisolide (nasal) soln 1 BETAGAN SOLN 3 Limit 2 inhalers (levobunolol hcl) per fluticasone propionate betaxolol hcl (ophth) 1 1 month;QL(1.1 soln (nasal) susp ml daily); RX/OTC BETIMOL SOLN (timolol) 2 Limit 2 inhalers BETOPTIC-S SUSP mometasone furoate 1 per 2 (nasal) susp month;QL(1.14 (betaxolol hcl (ophth)) gm daily) 1 bal on hand, carteolol hcl (ophth) 1 NASONEX SUSP Limit 2 inhalers soln (mometasone furoate GP per COMBIGAN SOLN month;QL(1.14 (brimonidine tartrate- 3 (nasal)) gm daily) timolol maleate) Limit 1 inhaler OMNARIS SUSP COSOPT PF SOLN 3 per (ciclesonide (nasal)) month;QL(0.42 (dorzolamide hcl-timolol GP gm daily) maleate) QNASL AERS Limit 1 inhaler COSOPT SOLN (beclomethasone 3 per (dorzolamide hcl-timolol 3 month;QL(0.29 maleate) dipropionate (nasal)) gm daily) dorzolamide hcl-timolol 1 bal on hand, QNASL CHILDRENS Limit 1 inhaler maleate soln 2 %-0.5 AERS ( 3 per 1 beclomethasone month;QL(0.17 %, 20 mg/ml-5 mg/ml, dipropionate (nasal)) gm daily) 22.3 mg/ml-6.8 mg/ml Limit 1 inhaler ZETONNA AERS 3 per (ciclesonide (nasal)) month;QL(0.3 gm daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dorzolamide hcl-timolol ISOPTO ATROPINE SOLN (atropine sulfate 2 maleate soln 2 %-0.5 1 %, 20 mg/ml-5 mg/ml, (ophthalmic)) 22.3 mg/ml-6.8 mg/ml MYDRIACYL SOLN GP ISTALOL SOLN ( (tropicamide) timolol GP maleate (ophth)) phenylephrine hcl 1 (mydriatic) soln levobunolol hcl soln 1 1 bal on hand, tropicamide soln 1 levobunolol hcl soln 1 Miotics 1 bal on hand, metipranolol soln 1 ISOPTO CARPINE SOLN GP 1 bal on hand, (pilocarpine hcl) timolol maleate (ophth) 1 solg 0.25 %, 0.5 % PHOSPHOLINE IODIDE SOLR (echothiophate 2 timolol maleate (ophth) 1 soln 0.25 %, 0.5 % iodide) TIMOPTIC OCUDOSE pilocarpine hcl soln 1 SOLN (timolol maleate 3 Ophthalmic Adrenergic Agents (ophth)) ALPHAGAN P SOLN 0.1 % TIMOPTIC SOLN ( 2 timolol GP (brimonidine tartrate) maleate (ophth)) ALPHAGAN P SOLN 0.15 GP TIMOPTIC-XE SOLG 1 bal on hand, % (brimonidine tartrate) (timolol maleate 2 (ophth)) apraclonidine hcl soln 1 Cycloplegic Mydriatics brimonidine tartrate 1 (Homatropine Hbr) 1 1 bal on hand, soln HOMATROPAIRE SOLN IOPIDINE SOLN 0.5 % GP (Phenylephrine Hcl (apraclonidine hcl) (Mydriatic)) ALTAFRIN 1 IOPIDINE SOLN 1 % SOLN 3 (apraclonidine hcl) ATROPINE SULFATE SOLN OP 1 % (atropine 2 SIMBRINZA SUSP sulfate (ophthalmic)) (brinzolamide- 3 brimonidine tartrate) CYCLOGYL SOLN GP (cyclopentolate hcl) Ophthalmic Anti-infectives CYCLOMYDRIL SOLN (Bacitracin-Polymyxin B (cyclopentolate w/ 3 (Ophth)) AK-POLY-BAC, 1 POLYCIN OINT phenylephrine) (Erythromycin (Ophth)) 1 cyclopentolate hcl soln 1 ILOTYCIN OINT (Gentamicin Sulfate 1 1 bal on hand, homatropine hbr soln 1 (Ophth)) GENTAK OINT

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Neomycin-Bacitracin Zn- NATACYN SUSP 2 Polymyxin) NEO-POLYCIN 1 (natamycin) OINT neomycin-bacitracin zn- 1 AZASITE SOLN Limit 5mls per 3 month;QL(0.17 polymyxin oint (azithromycin (ophth)) 1 bal on hand, ml daily) neomycin-polymyxin- 1 1 bal on hand, gramicidin soln bacitracin (ophthalmic) 1 oint NEOSPORIN SOLN (neomycin-polymyxin- 3 bacitracin-polymyxin b 1 (ophth) oint gramicidin) BESIVANCE SUSP OCUFLOX SOLN 3 GP (besifloxacin hcl) (ofloxacin (ophth)) BETADINE OPHTHALMIC ofloxacin (ophth) soln 1 PREP SOLN (povidone- 3 polymyxin b- iodine (ophth)) 1 trimethoprim soln BLEPH-10 SOLN POLYTRIM SOLN (sulfacetamide sodium GP (polymyxin b- GP (ophth)) trimethoprim) CILOXAN OINT POVIDONE IODINE SOLN (ciprofloxacin hcl 2 (povidone-iodine 3 (ophth)) (ophth)) CILOXAN SOLN 1 bal on hand, (ciprofloxacin hcl GP sulfacetamide sodium 1 (ophth)) (ophth) oint sulfacetamide sodium ciprofloxacin hcl 1 1 (ophth) soln (ophth) soln tobramycin (ophth) soln 1 erythromycin (ophth) 1 oint TOBREX OINT 2 gatifloxacin (ophth) 1 (tobramycin (ophth)) soln TOBREX SOLN GP (tobramycin (ophth)) gentamicin sulfate 1 (ophth) soln trifluridine soln 1 1 bal on hand, KLARITY-A SOLN Limit 5mls per 3 month;QL(0.17 VIGAMOX SOLN ( ) azithromycin (ophth) ml daily) (moxifloxacin hcl NF (ophth)) levofloxacin (ophth) 1 soln VIROPTIC SOLN 3 MOXEZA SOLN (trifluridine) (moxifloxacin hcl GP ZIRGAN GEL 3 (ophth)) (ganciclovir ophthalmic) ZYMAXID SOLN moxifloxacin hcl (ophth) 1 GP soln (gatifloxacin (ophth))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUREZOL EMUL Ophthalmic Immunomodulators 3 RESTASIS EMUL QL(2.14 ml (difluprednate) 3 (cyclosporine (ophth)) daily) FLAREX SUSP RESTASIS MULTIDOSE QL(2.14 ml (fluorometholone 2 EMUL (cyclosporine 3 daily) acetate) (ophth)) fluorometholone 1 Ophthalmic Integrin Antagonists (ophth) susp PA FML FORTE SUSP XIIDRA SOLN (lifitegrast) 3 (fluorometholone 2 Ophthalmic Local Anesthetics (ophth)) (Tetracaine Hcl (Ophth)) FML LIQUIFILM SUSP (fluorometholone GP ALTACAINE, TETRAVISC 1 FORTE, TETRAVISC, (ophth)) TETCAINE SOLN FML OINT AKTEN GEL ( lidocaine 3 (fluorometholone 2 hcl (ophth)) (ophth)) ALCAINE SOLN LOTEMAX GEL GP 3 (proparacaine hcl) (loteprednol etabonate) LOTEMAX OINT proparacaine hcl soln 1 3 (loteprednol etabonate) tetracaine hcl (ophth) LOTEMAX SUSP 1 GP soln (loteprednol etabonate) Ophthalmic Nerve Growth Factors loteprednol etabonate 1 OXERVATE SOLN PA SP susp (cenegermin-bkbj) MAXIDEX SUSP Ophthalmic Steroids (dexamethasone 2 (Bacitracin-Poly-Neomycin- QL(4 gm per fill (ophth)) Hc) NEO-POLYCIN HC 1 retail) MAXITROL OINT OINT (neomycin-polymy- GP ALREX SUSP 3 dexameth) (loteprednol etabonate) MAXITROL SUSP QL(4 gm per fill bacitracin-poly- 1 (neomycin-polymy- GP neomycin-hc oint retail) dexameth) BLEPHAMIDE S.O.P. neomycin-polymy- 1 OINT (sulfacetamide 2 dexameth oint sod-prednisolone) neomycin-polymy- 1 BLEPHAMIDE SUSP dexameth susp (sulfacetamide sod- 2 1 bal on hand, neomycin-polymyxin-hc 1 prednisolone) (ophth) susp 1 bal on hand, dexamethasone OMNIPRED SUSP sodium phosphate 1 (prednisolone acetate GP (ophth) soln (ophth))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRED FORTE SUSP Ophthalmic Surgical Aids (prednisolone acetate 2 GELFILM OP FILM (ophth)) (gelatin adsorbable 3 PRED FORTE SUSP 1 bal on hand, (ophth)) (prednisolone acetate NF Ophthalmics - Misc. (ophth)) ACULAR LS SOLN PRED MILD SUSP (ketorolac GP (prednisolone acetate 2 tromethamine (ophth)) (ophth)) ACULAR SOLN PRED-G S.O.P. OINT (ketorolac GP (gentamicin- 3 tromethamine (ophth)) prednisolone acetate) ACUVAIL SOLN PRED-G SUSP (ketorolac 3 (gentamicin- 3 tromethamine (ophth)) prednisolone acetate) ALOCRIL SOLN 1 bal on hand, prednisolone acetate 1 (nedocromil sodium 3 (ophth) susp (ophth)) PREDNISOLONE ALOMIDE SOLN ACETATE P-F SUSP (lodoxamide 2 (prednisolone acetate 2 tromethamine) (ophth)) PREDNISOLONE SODIUM azelastine hcl (ophth) 1 PHOSPHATE SOLN OP 1 soln 2 % (prednisolone sodium AZOPT SUSP Limit 10mls per phosphate (ophth)) 2 month;QL(0.4 (brinzolamide) ml daily) 1 bal on hand, sulfacetamide sod- 1 ST; Limit 10mls prednisolone soln BEPREVE SOLN 3 per (bepotastine besilate) month;QL(0.34 sulfacetamide sod- 1 prednisolone soln ml daily) TOBRADEX OINT bromfenac sodium 1 (tobramycin- 3 (ophth) soln dexamethasone) BROMSITE SOLN TOBRADEX ST SUSP (bromfenac sodium 3 (tobramycin- 3 (ophth)) dexamethasone) cromolyn sodium 1 TOBRADEX SUSP QL(5 ml per fill (ophth) soln (tobramycin- GP retail) CYSTARAN SOLN SP dexamethasone) (cysteamine hcl) tobramycin- QL(5 ml per fill 1 diclofenac sodium 1 dexamethasone susp retail) (ophth) soln ZYLET SUSP Limit 5mls per Limit 10mls per (loteprednol etabonate- 3 fill;QL(5 ml per dorzolamide hcl soln 1 month;QL(0.34 tobramycin) fill retail) ml daily) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DORZOLAMIDE HCL Limit 10mls per TRUSOPT SOLN Limit 10mls per 2 month;QL(0.34 GP month;QL(0.34 SOLN (dorzolamide hcl) ml daily) (dorzolamide hcl) ml daily) ELESTAT SOLN GP Prostaglandins - Ophthalmic (epinastine hcl (ophth)) Limit 2.5mls EMADINE SOLN bimatoprost soln 1 per (emedastine 3 month;QL(0.09 difumarate) ml daily) latanoprost soln 1 1 bal on hand, epinastine hcl (ophth) 1 soln latanoprost soln 1 flurbiprofen sodium 1 soln LUMIGAN SOLN 2 flurbiprofen sodium 1 bal on hand, (bimatoprost) 1 RESCULA SOLN soln 3 ILEVRO SUSP (unoprostone isopropyl) 3 (nepafenac) Limit 2.5mls TRAVATAN Z SOLN GP per ketorolac tromethamine 1 (travoprost) month;QL(0.09 (ophth) soln ml daily) LASTACAFT SOLN ST 3 Limit 2.5mls (alcaftadine) per travoprost soln 1 NEVANAC SUSP month;QL(0.09 3 (nepafenac) ml daily) XALATAN SOLN Limit 10mls per 3 (latanoprost) olopatadine hcl soln 0.1 1 month;QL(0.34 ml daily); ZIOPTAN SOLN % 3 RX/OTC (tafluprost) QL(0.09 ml olopatadine hcl soln 0.2 1 % daily); RX/OTC OTIC AGENTS - Drugs to Treat the Ear PAREMYD SOLN Otic Agents - Miscellaneous (hydroxyamphetamine- 3 acetic acid (otic) soln 1 tropicamide) Limit 10mls per Otic Anti-infectives PATADAY SOLN 0.1 % month;QL(0.34 CETRAXAL SOLN 1 bal on hand, NF 3 (olopatadine hcl) ml daily); (ciprofloxacin hcl (otic)) RX/OTC ciprofloxacin hcl (otic) 1 bal on hand, PATADAY SOLN 0.2 % QL(0.09 ml 1 GP soln (olopatadine hcl) daily); RX/OTC FLOXIN OTIC SOLN Limit 10mls per GP PATANOL SOLN (ofloxacin (otic)) NF month;QL(0.34 (olopatadine hcl) ml daily); ofloxacin (otic) soln 1 RX/OTC PROLENSA SOLN Otic Combinations (bromfenac sodium 3 (ophth)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pramoxine-Hc- DERMOTIC OIL Chloroxylenol) CORTIC- 1 (fluocinolone acetonide GP ND, EXOTIC-HC SOLN (otic)) CIPRO HC SUSP fluocinolone acetonide 1 (ciprofloxacin- 3 (otic) oil hydrocortisone) hydrocortisone w/acetic QL(10 ml per CIPRODEX SUSP 1 fill retail,30 ml (ciprofloxacin- 2 acid soln per fill mail) ) dexamethasone OXYTOCICS - Drugs to Prevent/Control Uterine Limit 1 bottle Bleeding ciprofloxacin- per fluocinolone acetonide 1 month;QL(0.5 Oxytocics soln ea daily)1 bal (Methylergonovine on hand, Maleate) METHERGINE 1 COLY-MYCIN S SUSP TABS (neomycin-colistin-hc- 3 methylergonovine 1 thonzonium) maleate tabs CORTANE-B AQUEOUS PASSIVE IMMUNIZING AND TREATMENT SOLN (pramoxine-hc- 3 AGENTS - Antibody Drugs to Treat Low Immune chloroxylenol aqueous) System CORTANE-B-OTIC SOLN Immune Serums (pramoxine-hc- GP BIVIGAM SOLN ( PA immune SP chloroxylenol) globulin (human) iv) CORTISPORIN-TC SUSP CUVITRU SOLN PA (neomycin-colistin-hc- 3 (immune globulin SP thonzonium) (human) subcutaneous) neomycin-polymyxin-hc 1 FLEBOGAMMA DIF SOLN PA (otic) soln (immune globulin SP (human) iv) neomycin-polymyxin-hc 1 (otic) susp GAMASTAN INJ PA OTICIN HC NR SOLN (immune globulin SP (pramoxine-hc- GP (human) im) chloroxylenol) GAMASTAN S/D INJ PA Limit 1 bottle (immune globulin SP OTOVEL SOLN per (human) im) (ciprofloxacin- 3 month;QL(0.5 GAMMAGARD LIQUID PA fluocinolone acetonide) ea daily)1 bal on hand, SOLN (immune globulin SP (human) iv or PRAMOTIC LIQD subcutaneous) ( 3 pramoxine- GAMMAKED SOLN PA chloroxylenol) (immune globulin SP Otic Steroids (human) iv or subcutaneous) (Fluocinolone Acetonide 1 (Otic)) FLAC OIL

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAMMAPLEX SOLN PA PA ampicillin sodium solr iv SP (immune globulin SP 10 gm (human) iv) MOXATAG TB24 PA; QL(1 ea GAMUNEX-C SOLN PA 3 daily,10 ea per (amoxicillin) fill retail) (immune globulin SP (human) iv or Natural Penicillins subcutaneous) (Penicillin G Potassium) SP PA; 1 bal on HIZENTRA SOLN PA PFIZERPEN SOLR hand, (immune globulin SP BICILLIN L-A SUSP PA SP (human) subcutaneous) (penicillin g benzathine) OCTAGAM SOLN 1 PA PENICILLIN G PA GM/20ML, 2 GM/20ML, 5 POTASSIUM IN ISO- GM/50ML, 10 GM/200ML, SP OSMOTIC DEXTROSE SP 20 GM/200ML (immune SOLN (penicillin g pot in globulin (human) iv) dextrose) PRIVIGEN SOLN PA PA penicillin g potassium SP (immune globulin SP solr ) iv) (human PENICILLIN G PROCAINE PA Passive Immunizing Agents - Combinations SUSP (penicillin g SP HYQVIA KIT (immune PA procaine) - globulin (human) SP SP PA; 1 bal on hyaluronidase (human penicillin g sodium solr hand, recombinant)) penicillin v potassium 1 bal on hand, PENICILLINS - Drugs to Treat Bacterial Infections solr 125 mg/5ml, 250 1 mg/5ml Aminopenicillins penicillin v potassium 1 amoxicillin caps 250 1 tabs 250 mg, 500 mg mg, 500 mg Penicillin Combinations 1 bal on hand, amoxicillin chew 125 1 mg, 250 mg amoxicillin & pot 1 bal on hand, clavulanate chew 400 1 amoxicillin susr 125 mg-57 mg, 200 mg- mg/5ml, 200 mg/5ml, 1 28.5 mg 250 mg/5ml, 400 mg/5ml amoxicillin & pot clavulanate susr 400 amoxicillin tabs 500 1 mg/5ml-57 mg/5ml, 200 mg, 875 mg mg/5ml-28.5 mg/5ml, 1 ampicillin caps 1 1 bal on hand, 250 mg/5ml-62.5 mg/5ml, 600 mg/5ml- PA ampicillin sodium solr ij SP 42.9 mg/5ml 1 gm PA; 1 bal on ampicillin sodium solr ij SP 125 mg hand,

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA amoxicillin & pot piperacillin sodium- SP clavulanate tabs 250 tazobactam sodium solr mg-125 mg, 500 mg- 1 UNASYN BULK PACK PA 125 mg, 875 mg-125 SOLR (ampicillin & SP mg sulbactam sodium) amoxicillin & pot 1 bal on hand, UNASYN SOLR PA clavulanate tb12 1000 1 (ampicillin & sulbactam SP mg-62.5 mg sodium) amoxicillin & pot ZOSYN SOLN 0.375 PA clavulanate tb12 1000 1 GM/50ML-3 GM/50ML-5 %, mg-62.5 mg 0.25 GM/50ML-2 GM/50ML-5 % SP ampicillin & sulbactam PA (piperacillin sodium- sodium solr ij 1 gm-2 SP tazobactam sodium in gm dextrose) ampicillin & sulbactam PA; 1 bal on ZOSYN SOLR 0.375 GM-3 PA sodium solr iv 0.5 gm-1 SP hand, GM, 0.25 GM-2 GM, 0.5 gm GM-4 GM (piperacillin SP ampicillin & sulbactam PA sodium-tazobactam sodium solr iv 5 gm-10 SP sodium) gm Penicillinase-Resistant Penicillins AUGMENTIN ES-600 dicloxacillin sodium 1 SUSR (amoxicillin & pot GP caps clavulanate) PA nafcillin sodium solr ij 1 SP AUGMENTIN SUSR 125 gm MG/5ML-31.25 MG/5ML NAFCILLIN SODIUM PA (amoxicillin & pot 2 SOLR IJ 10 GM (nafcillin SP clavulanate) sodium) AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML nafcillin sodium solr iv 2 PA; 1 bal on SP hand, (amoxicillin & pot GP gm clavulanate) NAFCILLIN SOLN PA AUGMENTIN TABS 500 (nafcillin sodium in SP MG-125 MG, 875 MG-125 dextrose) GP MG (amoxicillin & pot OXACILLIN SODIUM PA clavulanate) SOLN IV 1.5 GM/50ML-1 AUGMENTIN XR TB12 GM/50ML, 300 MG/50ML-2 SP (amoxicillin & pot 3 GM/50ML (oxacillin clavulanate) sodium in dextrose) PA BICILLIN C-R SUSP PA oxacillin sodium solr ij 1 SP (penicillin g benzathine SP gm ) PA & procaine oxacillin sodium solr iv SP 10 gm

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROGESTINS - Hormone Replacement/Modifying disulfiram tabs 1 Drugs Progestins Anti-Cataplectic Agents AYGESTIN TABS XYREM SOLN (sodium PA GP SP (norethindrone acetate) oxybate) PA Antidementia Agents hydroxyprogesterone SP caproate oil ARICEPT TABS QL(1 ea daily) MAKENA OIL IM 250 PA (donepezil GP MG/ML hydrochloride) SP (hydroxyprogesterone QL(1 ea daily) donepezil 1 caproate) hydrochloride tabs MAKENA SOAJ SC 275 PA QL(1 ea daily) donepezil 1 MG/1.1ML hydrochloride tbdp (hydroxyprogesterone SP EXELON PT24 caproate) GP (rivastigmine) medroxyprogesterone 1 QL(1 ea daily) acetate tabs galantamine hydrobromide cp24 8 1 MEGACE ES SUSP mg, 16 mg, 24 mg (megestrol acetate GP 1 bal on hand, (appetite)) galantamine hydrobromide soln 4 1 megestrol acetate 1 mg/ml (appetite) susp galantamine norethindrone acetate 1 hydrobromide tabs 4 1 tabs mg, 8 mg, 12 mg QL(2 ea daily) progesterone 1 memantine hcl cp24 7 PA micronized caps mg, 14 mg, 21 mg, 28 1 progesterone oil 1 mg PROMETRIUM CAPS QL(2 ea daily) memantine hcl soln 2 1 (progesterone GP mg/ml, 10 mg/5ml micronized) memantine hcl tabs 5 1 PROVERA TABS mg, 10 mg, ( GP NAMENDA TABS medroxyprogesterone GP acetate) (memantine hcl) PSYCHOTHERAPEUTIC AND NEUROLOGICAL NAMENDA TITRATION AGENTS - MISC. - Drugs to Treat Mental and PAK TABS (memantine GP Emotional Conditions hcl) NAMENDA XR CP24 PA Agents for Chemical Dependency GP (memantine hcl) acamprosate calcium 1 tbec NAMENDA XR TITRATION PA ANTABUSE TABS PACK CP24 (memantine 3 GP (disulfiram) hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RAZADYNE ER CP24 QL(1 ea daily) (Glatiramer Acetate) PA (galantamine GP GLATOPA SOSY 40 SP hydrobromide) MG/ML AMPYRA TB12 PA RAZADYNE TABS GP (galantamine GP (dalfampridine) AUBAGIO TABS PA hydrobromide) 3 (teriflunomide) rivastigmine pt24 1 AVONEX KIT ( PA interferon SP ) rivastigmine tartrate 1 beta-1a caps AVONEX PEN AJKT PA SP Combination Psychotherapeutics (interferon beta-1a) 1 bal on hand, AVONEX PSKT PA chlordiazepoxide- 1 SP amitriptyline tabs (interferon beta-1a) BETASERON KIT PA olanzapine-fluoxetine 1 SP hcl caps (interferon beta-1b) 1 bal on hand, COPAXONE SOSY PA perphenazine- 1 SP amitriptyline tabs (glatiramer acetate) PA SYMBYAX CAPS dalfampridine tb12 1 ( olanzapine-fluoxetine GP EXTAVIA KIT (interferon PA ) SP hcl beta-1b) Fibromyalgia Agents GILENYA CAPS PA SAVELLA TABS PA; QL(2 ea 3 3 (fingolimod hcl) (milnacipran hcl) daily) glatiramer acetate sosy SP PA SAVELLA TITRATION PA; QL(2 ea PACK MISC 3 daily) MAVENCLAD TBPK PA (milnacipran hcl) (cladribine (multiple SP Movement Disorder Drug Therapy sclerosis)) AUSTEDO TABS PA MAYZENT STARTER PA 3 (deutetrabenazine) PACK TBPK (siponimod 3 INGREZZA CAPS PA fumarate) 3 MAYZENT TABS PA (valbenazine tosylate) 3 INGREZZA CPPK PA (siponimod fumarate) 3 PLEGRIDY SOPN PA (valbenazine tosylate) SP (peginterferon beta-1a) SP tetrabenazine tabs PLEGRIDY SOSY PA SP XENAZINE TABS (peginterferon beta-1a) SP (tetrabenazine) PLEGRIDY STARTER PA Multiple Sclerosis Agents PACK SOPN SP ( ) (Glatiramer Acetate) PA peginterferon beta-1a GLATOPA SOSY 20 1 PLEGRIDY STARTER PA MG/ML PACK SOSY SP (peginterferon beta-1a)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF REBIDOSE SOAJ PA SP Restless Leg Syndrome (RLS) Agents (interferon beta-1a) HORIZANT TBCR QL(1 ea daily) 3 REBIF REBIDOSE PA (gabapentin enacarbil) TITRATIONPACK SOAJ SP (interferon beta-1a) Smoking Deterrents (Nicotine Polacrilex) EQ PV REBIF SOSY ( PA interferon SP NICOTINE LOZENGES, beta-1a) CVS NICOTINE REBIF TITRATION PACK PA LOZENGE, RA MINI SOSY (interferon beta- SP NICOTINE, NICOTINE 1a) MINI LOZENGE, KLS QUIT4, KLS QUIT2, TECFIDERA CPDR PA PV 3 GOODSENSE NICOTINE (dimethyl fumarate) POLACRILEX, TECFIDERA STARTER PA GOODSENSE NICOTINE, PACK MISC (dimethyl 3 GNP NICOTINE POLACRILEX MINI, GNP fumarate) NICOTINE MINI LOZENGE TYSABRI CONC PA SP LOZG (natalizumab) (Nicotine Polacrilex) EQ PV Postherpetic Neuralgia (PHN)/Neuropathic Pain NICOTINE POLACRILEX, CVS NICOTINE GRALISE STARTER MISC PA POLACRILEX, CVS (gabapentin (once- 3 NICOTINE, TGT daily)) NICOTINE POLACRILEX, GRALISE TABS PA TGT NICOTINE GUM, SM (gabapentin (once- 3 NICOTINE POLACRILEX, daily)) RA NICOTINE POLACRILEX, RA PV Premenstrual Dysphoric Disorder (PMDD) Agents NICOTINE GUM, RA fluoxetine hcl (pmdd) 1 bal on hand, NICOTINE, PX STOP 1 SMOKING AID, caps 10 mg, 20 mg NICORELIEF, HM NICOTINE POLACRILEX, fluoxetine hcl (pmdd) 1 tabs 10 mg, 20 mg GOODSENSE NICOTINE POLACRILEX GUM, GNP SARAFEM TABS GP NICOTINE POLACRILEX, (fluoxetine hcl (pmdd)) EQL NICOTINE Pseudobulbar Affect (PBA) Agents POLACRILEX GUM 2 MG NUEDEXTA CAPS PA (dextromethorphan hbr- 3 quinidine sulfate) Psychotherapeutic and Neurological Agents - ergoloid mesylates tabs 1 1 bal on hand,

ORAP TABS (pimozide) 3 pimozide tabs 1 1 bal on hand,

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) EQ PV (Nicotine Polacrilex) EQ PV NICOTINE POLACRILEX, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE POLACRILEX, CVS POLACRILEX, CVS NICOTINE, TGT NICOTINE, TGT NICOTINE POLACRILEX, NICOTINE POLACRILEX, TGT NICOTINE GUM, SM TGT NICOTINE GUM, SM NICOTINE POLACRILEX, NICOTINE POLACRILEX, RA NICOTINE SM NICOTINE, RA POLACRILEX, RA NICOTINE POLACRILEX, NICOTINE GUM, RA PV RA NICOTINE GUM, RA 1 NICOTINE, PX STOP NICOTINE, PX STOP SMOKING AID, SMOKING AID, NICORELIEF, HM NICORELIEF, HM NICOTINE POLACRILEX, NICOTINE POLACRILEX, GOODSENSE NICOTINE GOODSENSE NICOTINE POLACRILEX GUM, GNP POLACRILEX GUM, GNP NICOTINE POLACRILEX, NICOTINE POLACRILEX, EQL NICOTINE EQL NICOTINE POLACRILEX GUM MT 2 POLACRILEX GUM MT 4 MG MG (Nicotine Polacrilex) EQ PV (Nicotine Polacrilex) EQ PV NICOTINE POLACRILEX, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE POLACRILEX, CVS POLACRILEX, TGT NICOTINE, TGT NICOTINE POLACRILEX, NICOTINE POLACRILEX, RA NICOTINE TGT NICOTINE GUM, SM POLACRILEX, PX STOP PV NICOTINE POLACRILEX, SMOKING AID, HM SM NICOTINE, RA NICOTINE POLACRILEX, NICOTINE POLACRILEX, 1 GNP NICOTINE RA NICOTINE GUM, RA POLACRILEX, EQL NICOTINE, PX STOP NICOTINE POLACRILEX SMOKING AID, LOZG 2 MG, 4 MG NICORELIEF, HM (Nicotine Polacrilex) EQL PV NICOTINE POLACRILEX, NICOTINE POLACRILEX GOODSENSE NICOTINE REFILL, EQ NICOTINE POLACRILEX GUM, GNP GUM STARTER, EQ NICOTINE POLACRILEX, NICOTINE GUM REFILL, EQL NICOTINE CVS NICOTINE POLACRILEX GUM 4 MG POLACRILEX STARTER, PV THRIVE, SR NICOTINE GUM, KLS QUIT4, KLS QUIT2, GOODSENSE NICOTINE GUM, GNP NICOTINE GUM, EQL NICOTINE POLACRILEX STARTER GUM

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) EQL PV (Nicotine) CVS NICOTINE PV NICOTINE POLACRILEX TRANSDERMALSYSTEM, REFILL, EQ NICOTINE TGT NICOTINE STEP GUM STARTER, EQ TWO, TGT NICOTINE NICOTINE GUM REFILL, STEP THREE, TGT CVS NICOTINE NICOTINE STEP ONE, SM POLACRILEX STARTER, 1 NICOTINE THRIVE, SR NICOTINE TRANSDERMAL GUM, KLS QUIT4, KLS SYSTEM/STEP 3/CLEAR, QUIT2, GOODSENSE SM NICOTINE NICOTINE GUM, GNP TRANSDERMAL NICOTINE GUM, EQL SYSTEM/STEP 2/CLEAR, NICOTINE POLACRILEX SM NICOTINE STARTER GUM TRANSDERMAL SYSTEM/STEP 1/CLEAR, (Nicotine Polacrilex) SM PV PV NICOTINE LOZG 2 MG RA NICOTINE TRANSDERMAL SYSTEM (Nicotine Polacrilex) SM PV STEP 3, RA NICOTINE NICOTINE POLACRILEX, PV TRANSDERMAL SYSTEM, EQ NICOTINE LOZG 4 MG NICOTINE (Nicotine Polacrilex) SM PV TRANSDERMAL SYSTEM NICOTINE POLACRILEX, PV STEP 3, NICOTINE EQ NICOTINE LOZG MT 4 TRANSDERMAL SYSTEM MG STEP 2, NICOTINE TRANSDERMAL SYSTEM 1 STEP 1, NICOTINE STEP 3, NICOTINE STEP 2, NICOTINE STEP 1, HM NICOTINE TRANSDERMALSYSTEM, HM NICOTINE TRANSDERMAL SYSTEM STEP 3, HM NICOTINE TRANSDERMAL SYSTEM STEP 2, HM NICOTINE TRANSDERMAL SYSTEM STEP 1, HM NICOTINE TRANSDERMAL SYSTEM, GNP NICOTINE TRANSDERMALSYSTEM STEP 2, GNP NICOTINE TRANSDERMALSYSTEM, EQ NICOTINE STEP 3, CVS NICOTINE TRANSDERMALSYSTEM/ STEP 3, CVS NICOTINE TRANSDERMALSYSTEM STEP 2, CVS NICOTINE TRANSDERMALSYSTEM STEP 1 PT24

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine) CVS NICOTINE PV (Nicotine) EQ NICOTINE, PV TRANSDERMALSYSTEM, SM NICOTINE TGT NICOTINE STEP TRANSDERMAL SYSTEM, 1 TWO, TGT NICOTINE RA NICOTINE PT24 14 STEP THREE, TGT MG/24HR NICOTINE STEP ONE, SM (Nicotine) EQ NICOTINE, PV NICOTINE SM NICOTINE TRANSDERMAL TRANSDERMAL SYSTEM, PV SYSTEM/STEP 3/CLEAR, RA NICOTINE PT24 7 SM NICOTINE MG/24HR, 21 MG/24HR TRANSDERMAL SYSTEM/STEP 2/CLEAR, (Nicotine) EQ NICOTINE, PV SM NICOTINE SM NICOTINE TRANSDERMAL TRANSDERMAL SYSTEM, 1 SYSTEM/STEP 1/CLEAR, RA NICOTINE PT24 TD 14 RA NICOTINE MG/24HR TRANSDERMAL SYSTEM (Nicotine) EQ NICOTINE, PV STEP 3, RA NICOTINE SM NICOTINE TRANSDERMAL SYSTEM, TRANSDERMAL SYSTEM, PV NICOTINE RA NICOTINE PT24 TD 7 TRANSDERMAL SYSTEM MG/24HR, 21 MG/24HR STEP 3, NICOTINE PV bupropion hcl (smoking PV TRANSDERMAL SYSTEM deterrent) tb12 STEP 2, NICOTINE CHANTIX CONTINUING PV TRANSDERMAL SYSTEM PV STEP 1, NICOTINE STEP MONTHPAK TABS PV 3, NICOTINE STEP 2, (varenicline tartrate) NICOTINE STEP 1, HM CHANTIX STARTING PV NICOTINE MONTH PAK TABS PV TRANSDERMALSYSTEM, (varenicline tartrate) HM NICOTINE CHANTIX TABS PV TRANSDERMAL SYSTEM PV STEP 3, HM NICOTINE (varenicline tartrate) TRANSDERMAL SYSTEM NICODERM CQ PT24 14 PV NF STEP 2, HM NICOTINE MG/24HR (nicotine) TRANSDERMAL SYSTEM STEP 1, HM NICOTINE NICODERM CQ PT24 7 PV TRANSDERMAL SYSTEM, MG/24HR, 21 MG/24HR GP GNP NICOTINE (nicotine) TRANSDERMALSYSTEM NICORETTE GUM 2 MG PV GP STEP 2, GNP NICOTINE (nicotine polacrilex) TRANSDERMALSYSTEM, NICORETTE GUM 4 MG PV EQ NICOTINE STEP 3, NF CVS NICOTINE (nicotine polacrilex) TRANSDERMALSYSTEM/ NICORETTE LOZG 2 MG, PV STEP 3, CVS NICOTINE 4 MG (nicotine GP TRANSDERMALSYSTEM polacrilex) STEP 2, CVS NICOTINE NICORETTE MINI LOZG PV TRANSDERMALSYSTEM GP STEP 1 PT24 (nicotine polacrilex)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICORETTE STARTER PV GLASSIA SOLN (alpha1- PA KIT GUM 2 MG (nicotine GP proteinase inhibitor SP polacrilex) (human)) NICORETTE STARTER PV PROLASTIN-C SOLN PA KIT GUM 4 MG (nicotine NF (alpha1-proteinase SP polacrilex) inhibitor (human)) PV PROLASTIN-C SOLR PA nicotine polacrilex gum PV 2 mg (alpha1-proteinase SP PV inhibitor (human)) nicotine polacrilex gum 1 4 mg ZEMAIRA SOLR (alpha1- PA PV proteinase inhibitor SP nicotine polacrilex lozg PV 2 mg, 4 mg (human)) PV Cystic Fibrosis Agents nicotine pt24 14 1 mg/24hr KALYDECO PACK PA SP nicotine pt24 7 PV (ivacaftor) PV KALYDECO TABS PA mg/24hr, 21 mg/24hr SP NICOTINE PV (ivacaftor) TRANSDERMAL SYSTEM ORKAMBI PACK PA PV SP KIT (nicotine) (lumacaftor-ivacaftor) NICOTROL INHALER PV ORKAMBI TABS PA PV SP INHA (nicotine) (lumacaftor-ivacaftor) NICOTROL NS SOLN PV PA; Limited to PV PULMOZYME SOLN (nicotine) 2 75mls per ( ) month;QL(2.5 ZYBAN TB12 ( PV dornase alfa bupropion GP ml daily) ) hcl (smoking deterrent) SYMDEKO TBPK PA SP Transthyretin Amyloidosis Agents (tezacaftor-ivacaftor) TEGSEDI SOSY PA SP TRIKAFTA TBPK PA; QL(3 ea (inotersen sodium) (elexacaftor-tezacaftor- SP daily) Vasomotor Symptom Agents ivacaftor) BRISDELLE CAPS Pulmonary Fibrosis Agents (paroxetine mesylate GP ESBRIET CAPS PA SP (vasomotor)) (pirfenidone) paroxetine mesylate ESBRIET TABS PA 1 SP (vasomotor) caps (pirfenidone) OFEV CAPS ( PA RESPIRATORY AGENTS - MISC. - Drugs to nintedanib SP Treat Lung Conditions esylate) Alpha-Proteinase Inhibitor (Human) SULFONAMIDES - Drugs to Treat Bacterial ARALAST NP SOLR PA Infections (alpha1-proteinase SP Sulfonamides inhibitor (human)) SULFADIAZINE TABS 3 (sulfadiazine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TETRACYCLINES - Drugs to Treat Bacterial doxycycline hyclate ST Infections tbec 75 mg, 100 mg, 1 Glycylcyclines 150 mg MINOCIN CAPS SP PA GP tigecycline solr (minocycline hcl) TIGECYCLINE SOLR PA SP minocycline hcl caps 50 1 (tigecycline) mg, 75 mg, 100 mg TYGACIL SOLR PA SP minocycline hcl tabs 50 1 (tigecycline) mg, 100 mg Tetracyclines PA minocycline hcl tabs 75 1 (Doxycycline mg, 100 mg (Monohydrate)) AVIDOXY 1 ST TABS minocycline hcl tb24 45 (Doxycycline mg, 55 mg, 65 mg, 80 1 mg, 90 mg, 105 mg, (Monohydrate)) 1 MONDOXYNE NL, OKEBO 115 mg, 135 mg CAPS SOLODYN TB24 ST GP (Doxycycline Hyclate) (minocycline hcl) MORGIDOX 1X100MG, TARGADOX TABS 1 bal on hand, NF MORGIDOX 2X100MG, 1 ( ) MORGIDOX 1X50MG doxycycline hyclate CAPS tetracycline hcl caps 1 250 mg, 500 mg (Minocycline Hcl) 1 ST COREMINO TB24 VIBRAMYCIN CAPS 100 MG (doxycycline GP demeclocycline hcl 1 tabs hyclate) doxycycline VIBRAMYCIN SUSR 25 MG/5ML (doxycycline GP (monohydrate) caps 50 1 mg, 75 mg, 100 mg, (monohydrate)) 150 mg VIBRAMYCIN SYRP 50 doxycycline MG/5ML (doxycycline 2 (monohydrate) susr 25 1 calcium) mg/5ml THYROID AGENTS - Drugs to Regulate Thyroid doxycycline Hormones (monohydrate) tabs 50 1 Antithyroid Agents mg, 100 mg, 150 mg methimazole tabs 1 doxycycline ST (monohydrate) tabs 75 1 propylthiouracil tabs 1 mg, 100 mg, 150 mg TAPAZOLE TABS GP doxycycline hyclate 1 (methimazole) caps 50 mg, 100 mg Thyroid Hormones doxycycline hyclate 1 tabs 20 mg, 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levothyroxine Sodium) TIROSINT CAPS 13 MCG, EUTHYROX, UNITHROID, 1 25 MCG, 50 MCG, 75 LEVOXYL, LEVO-T TABS MCG, 88 MCG, 100 MCG, 3 (Thyroid) NP THYROID 112 MCG, 125 MCG, 137 120, NP THYROID 90, NP MCG, 150 MCG THYROID 60, NP 1 (levothyroxine sodium) THYROID 30, NP TIROSINT-SOL SOLN 13 THYROID 15 TABS MCG/ML, 25 MCG/ML, 50 ARMOUR THYROID TABS MCG/ML, 75 MCG/ML, 88 GP 15 MG, 120 MG (thyroid) MCG/ML, 100 MCG/ML, 112 MCG/ML, 125 3 ARMOUR THYROID TABS MCG/ML, 137 MCG/ML, 30 MG, 60 MG, 90 MG, 150 MCG/ML, 200 180 MG, 240 MG, 300 MG 2 MCG/ML (levothyroxine (thyroid) sodium) CYTOMEL TABS 3 WESTHROID TABS (liothyronine sodium) 2 (thyroid) levothyroxine sodium WP THYROID TABS 2 tabs or 25 mcg, 50 (thyroid) mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 1 ULCER DRUGS - Drugs to Treat Bowel, Intestine mcg, 137 mcg, 150 and Stomach Conditions mcg, 175 mcg, 200 Antispasmodics mcg, 300 mcg (Hyoscyamine Sulfate) ED- SPAZ, OSCIMIN, NULEV 1 liothyronine sodium 1 tabs TBDP (Hyoscyamine Sulfate) NATURE-THROID NT-2.5 2 OSCIMIN SR, SYMAX-SR 1 TABS (thyroid) TB12 NATURE-THROID TABS 2 (Hyoscyamine Sulfate) 1 (thyroid) OSCIMIN TABS SYNTHROID TABS (Hyoscyamine Sulfate) 3 (levothyroxine sodium) OSCIMIN, SYMAX-SL 1 SUBL thyroid tabs 1 ANASPAZ TBDP GP THYROLAR-1 TABS (hyoscyamine sulfate) 3 (liotrix (t3-t4)) BELLADONNA/OPIUM THYROLAR-1/2 TABS SUPP (belladonna 3 3 (liotrix (t3-t4)) alkaloids & opium) THYROLAR-1/4 TABS BENTYL CAPS 3 GP (liotrix (t3-t4)) (dicyclomine hcl) THYROLAR-2 TABS chlordiazepoxide hcl- 3 1 (liotrix (t3-t4)) clidinium bromide caps THYROLAR-3 TABS CUVPOSA SOLN 3 2 (liotrix (t3-t4)) (glycopyrrolate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dicyclomine hcl caps 1 H-2 Antagonists () CIMETIDINE RX/OTC dicyclomine hcl soln 1 200, SM ACID REDUCER, SB CIMETIDINE, RA ACID dicyclomine hcl tabs 1 REDUCER, PX ACID REDUCER, HEARTBURN GLYCATE TABS 3 RELIEF, GNP (glycopyrrolate) HEARTBURN RELIEF 200, glycopyrrolate tabs or 1 GNP HEARTBURN 1 1 RELIEF, EQ HEARTBURN mg, 2 mg RELIEF, EQ CIMETIDINE GLYCOPYRROLATE ACID REDUCER, EQ ACID TABS OR 1.5 MG 3 REDUCER, CVS (glycopyrrolate) HEARTBURN RELIEF, CIMETIDINE ACID hyoscyamine sulfate 1 subl REDUCER TABS (Famotidine) ACID RX/OTC hyoscyamine sulfate 1 CONTROL MAXIMUM tabs STRENGTH, SM ACID hyoscyamine sulfate REDUCER MAXIMUM 1 STRENGTH, SB ACID tb12 CONTROLLER MAXIMUM hyoscyamine sulfate 1 STRENGTH, RA ACID tbdp REDUCER MAXIMUM LEVBID TB12 STRENGTH, QC ACID GP CONTROLLER MAXIMUM (hyoscyamine sulfate) STRENGTH, PX ACID LEVSIN TABS GP REDUCER MAXIMUM (hyoscyamine sulfate) STRENGTH, MM LEVSIN/SL SUBL FAMOTIDINE, KLS ACID GP CONTROLLER MAXIMUM (hyoscyamine sulfate) STRENGTH, HM 1 LIBRAX CAPS FAMOTIDINE, (chlordiazepoxide hcl- GP HEARTBURN RELIEF clidinium bromide) MAXIMUMSTRENGTH, GNP ACID REDUCER methscopolamine MAXIMUMSTRENGTH, bromide tabs 5 mg, 2.5 1 EQL HEARTBURN mg, 2.5 mg PREVENTION/MAXIMUM methscopolamine 1 bal on hand, STRENGTH, EQ ACID 1 REDUCER MAXIMUM bromide tabs 5 mg, 2.5 STRENGTH, CVS ACID mg, 2.5 mg CONTROLLER MAXIMUM 1 bal on hand, STRENGTH, ACID propantheline bromide 1 tabs REDUCER MAXIMUM STRENGTH, ACID ROBINUL FORTE TABS GP CONTROLLER MAXIMUM (glycopyrrolate) STRENGTH TABS ROBINUL TABS GP (glycopyrrolate)

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148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID RX/OTC nizatidine caps 150 mg, 1 CONTROL MAXIMUM 300 mg STRENGTH, WAL-ZAN 1 bal on hand, 150 MAXIMUM nizatidine soln 15 1 STRENGTH, SM ACID mg/ml REDUCER MAXIMUM PEPCID AC MAXIMUM RX/OTC STRENGTH, SB ACID STRENGTH TABS GP REDUCER, RANITIDINE (famotidine) 150 MAXIMUM PEPCID SUSR 40 MG/5ML STRENGTH, RA ACID GP REDUCER MAXIMUM (famotidine) STRENGTH, PX ACID PEPCID TABS 20 MG RX/OTC GP REDUCER MAXIMUM (famotidine) STRENGTH, KLS ACID PEPCID TABS 40 MG QL(2 ea daily) REDUCER GP MAXIMUMSTRENGTH, (famotidine) HM ACID REDUCER ranitidine hcl caps 150 1 MAXIMUM STRENGTH, 1 mg, 300 mg HM ACID REDUCER, HEARTBURN RELIEF 150 ranitidine hcl syrp 15 MAXIMUM STRENGTH, mg/ml, 75 mg/5ml, 150 1 GOODSENSE ACID mg/10ml REDUCER, GNP ACID RX/OTC CONTROL 150 MAXIMUM ranitidine hcl tabs 150 1 STRENGTH, EQL mg HEARTBURN RELIEF ranitidine hcl tabs 300 1 MAXIMUM STRENGTH, mg EQL ACID REDUCER TAGAMET HB TABS RX/OTC MAXIMUMSTRENGTH, GP EQ ACID REDUCER, CVS (cimetidine) ACID REDUCER ZANTAC 150 MAXIMUM RX/OTC MAXIMUMSTRENGTH, STRENGTH TABS GP ACID REDUCER (ranitidine hcl) MAXIMUM STRENGTH, ZANTAC TABS ( ACID REDUCER TABS ranitidine GP hcl) cimetidine hcl soln 1 1 bal on hand, Misc. Anti-Ulcer cimetidine tabs 200 RX/OTC CARAFATE SUSP 1 GP mg, 400 mg, 800 mg (sucralfate) cimetidine tabs 300 CARAFATE TABS 1 GP mg, 400 mg, 800 mg (sucralfate) famotidine susr 40 1 sucralfate susp 1 mg/5ml famotidine tabs 20 mg 1 RX/OTC sucralfate tabs 1 Proton Pump Inhibitors famotidine tabs 40 mg 1 QL(2 ea daily) NIZATIDINE CAPS 150 2 MG (nizatidine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Esomeprazole PA; QL(1 ea PA; QL(1 ea esomeprazole 1 Magnesium) CVS daily); RX/OTC magnesium cpdr 40 mg daily) ESOMEPRAZOLE MAGNESIUM, SM esomeprazole PA ESOMEPRAZOLE magnesium pack 10 1 MAGNESIUM, RA mg, 20 mg, 40 mg ESOMEPRAZOLE ESOMEPRAZOLE PA; QL(1 ea MAGNESIUM, QC CPDR daily) ESOMEPRAZOLE 3 MAGNESIUM, KLS 1 (esomeprazole ESOMEPRAZOLE strontium) MAGNESIUM, HM FIRST-LANSOPRAZOLE PA 3 ESOMEPRAZOLE SUSP (lansoprazole) MAGNESIUM DELAYED FIRST-OMEPRAZOLE RELEASE, GOODSENSE 3 ESOMEPRAZOLE SUSP (omeprazole) MAGNESIUM, GNP RX/OTC lansoprazole cpdr 15 1 ESOMEPRAZOLE mg MAGNESIUM CPDR lansoprazole cpdr 30 1 (Esomeprazole PA; QL(1 ea mg Magnesium) HEARTBURN 1 daily); RX/OTC TREATMENT 24 HOUR lansoprazole tbdd 15 QL(1 ea daily); 1 AL(Up to 12 yrs CPDR 20 MG mg (Lansoprazole) CVS RX/OTC old ); RX/OTC LANSOPRAZOLE, SM lansoprazole tbdd 30 QL(1 ea daily); LANSOPRAZOLE, RA 1 AL(Up to 12 yrs LANSOPRAZOLE, QC mg old ) LANSOPRAZOLE, KLS NEXIUM 24HR CLEAR PA; QL(1 ea LANSOPRAZOLE, HM 1 MINIS CPDR daily); RX/OTC LANSOPRAZOLE, (esomeprazole GP GOODSENSE magnesium) LANSOPRAZOLE, GNP LANSOPRAZOLE, EQ NEXIUM 24HR CPDR PA; QL(1 ea LANSOPRAZOLE CPDR (esomeprazole GP daily); RX/OTC (Lansoprazole) RX/OTC magnesium) HEARTBURN 1 NEXIUM CPDR 20 MG PA; QL(1 ea TREATMENT 24 HOUR (esomeprazole GP daily); RX/OTC CPDR 15 MG magnesium) ACIPHEX SPRINKLE PA CPSP 5 MG, 10 MG NEXIUM CPDR 40 MG PA; QL(1 ea 3 daily) (rabeprazole sodium) (esomeprazole GP magnesium) ACIPHEX TBEC PA; QL(2 ea NF ( ) daily) NEXIUM PACK 10 MG, 20 PA rabeprazole sodium MG, 40 MG DEXILANT CPDR PA; QL(1 ea (esomeprazole GP 3 daily) (dexlansoprazole) magnesium) esomeprazole PA; QL(1 ea NEXIUM PACK 5 MG, 2.5 PA 1 daily); RX/OTC magnesium cpdr 20 mg MG (esomeprazole 3 magnesium)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OMEPRAZOLE + (Omeprazole-Sodium PA SYRSPEND SFALKA 3 Bicarbonate) OMEPPI 1 SUSP (omeprazole) CAPS amoxicillin- omeprazole cpdr 10 1 mg, 40 mg clarithromycin w/ 1 RX/OTC lansoprazole misc omeprazole cpdr 20 1 mg, 40 mg OMECLAMOX-PAK MISC (amoxicillin- pantoprazole sodium 3 1 clarithromycin w/ tbec omeprazole) PREVACID 24HR CPDR RX/OTC NF PA (lansoprazole) omeprazole-sodium bicarbonate caps 40 1 PREVACID CPDR 15 MG RX/OTC NF mg-1100 mg (lansoprazole) PREVACID CPDR 30 MG omeprazole-sodium GP (lansoprazole) bicarbonate pack 20 1 mg-1680 mg, 40 mg- PREVACID SOLUTAB QL(1 ea daily); 1680 mg TBDD 15 MG GP AL(Up to 12 yrs (lansoprazole) old ); RX/OTC PYLERA CAPS (bismuth PREVACID SOLUTAB QL(1 ea daily); subcitrate potassium- 3 TBDD 30 MG GP AL(Up to 12 yrs metronidazole- (lansoprazole) old ) tetracycline) PRILOSEC PACK PA ZEGERID CAPS 40 MG- PA (omeprazole 3 1100 MG (omeprazole- GP magnesium) sodium bicarbonate) PROTONIX PACK 40 MG ZEGERID PACK 20 MG- 3 1680 MG, 40 MG-1680 MG (pantoprazole sodium) GP PROTONIX TBEC 20 MG (omeprazole-sodium GP (pantoprazole sodium) bicarbonate) PROTONIX TBEC 40 MG URINARY ANTI-INFECTIVES - Drugs to Treat NF (pantoprazole sodium) Bladder/Kidney Infections RABEPRAZOLE SODIUM PA Urinary Anti-infective Combinations DR SPRINKLE CPSP 3 (Methenamine-Hyosc- 1 bal on hand, (rabeprazole sodium) Methylene Blue-Benzoic 1 PA; QL(2 ea Acid-Phenyl Sal) rabeprazole sodium 1 HYOPHEN TABS tbec daily) (Methenamine-Hyosc- Ulcer Drugs - Prostaglandins Methylene Blue-Sod Phos- CYTOTEC TABS Phenyl Sal) GP (misoprostol) PHOSPHASAL, VILEVEV MB, UTRONA-C, UTIRA-C, 1 misoprostol tabs 1 UROAV-81, URO-458, URIN D/S, URIMAR-T, Ulcer Therapy Combinations URETRON D/S, URELLE TABS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Methenamine-Hyosc- 1 bal on hand, darifenacin 1 Methylene Blue-Sod Phos- hydrobromide tb24 Phenyl Sal) DETROL LA CP24 2 MG QL(1 ea daily) PHOSPHASAL, VILEVEV GP MB, UTRONA-C, UTIRA-C, 1 (tolterodine tartrate) UROAV-81, URO-458, DETROL LA CP24 4 MG QL(1 ea daily) NF URIN D/S, URIMAR-T, (tolterodine tartrate) URETRON D/S, URELLE DETROL TABS 1 MG QL(2 ea daily) TABS GP (tolterodine tartrate) (Methenamine-Hyosc- DETROL TABS 2 MG Methylene Blue-Sod Phos- GP (tolterodine tartrate) Phenyl Sal) URIBEL, 1 VILAMIT MB, UTICAP, DITROPAN XL TB24 GP USTELL, UROAV-B, URO- (oxybutynin chloride) MP CAPS ENABLEX TB24 15 MG Urinary Anti-infectives (darifenacin NF FURADANTIN SUSP GP hydrobromide) (nitrofurantoin) ENABLEX TB24 7.5 MG HIPREX TABS (darifenacin GP (methenamine GP hydrobromide) hippurate) GELNIQUE GEL 3 MACROBID CAPS (oxybutynin chloride) (nitrofurantoin monohyd GP GELNIQUE PUMP GEL 3 macro) (oxybutynin chloride) MACRODANTIN CAPS oxybutynin chloride 1 (nitrofurantoin GP syrp macrocrystal) oxybutynin chloride methenamine hippurate 1 1 tabs tabs oxybutynin chloride 1 methenamine tb24 mandelate tabs 0.5 gm, 1 OXYTROL FOR WOMEN RX/OTC 1 gm 3 PTTW (oxybutynin) MONUROL PACK OXYTROL PTTW RX/OTC (fosfomycin 3 3 ( ) tromethamine) oxybutynin solifenacin succinate 1 nitrofurantoin 1 macrocrystal caps tabs QL(1 ea daily) tolterodine tartrate cp24 1 nitrofurantoin monohyd 1 macro caps 2 mg, 4 mg QL(2 ea daily) tolterodine tartrate tabs 1 nitrofurantoin susp 1 1 mg URINARY ANTISPASMODICS - Drugs to Treat tolterodine tartrate tabs 1 Miscellaneous Bladder Spasms 2 mg Urinary Antispasmodic - Antimuscarinics

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOVIAZ TB24 QL(1 ea daily) FLUCELVAX PV 2 (fesoterodine fumarate) QUADRIVALENT 2019- 2020 SUSY (influenza trospium chloride cp24 1 virus vaccine tissue- PV trospium chloride tabs 1 cultured subunit quadrivalent) VESICARE TABS GP GARDASIL 9 SUSP PV (solifenacin succinate) (human papillomavirus PV Urinary Antispasmodics - Beta-3 Adrenergic (hpv) 9-valent recombinant MYRBETRIQ TB24 QL(1 ea daily) vaccine) 3 (mirabegron) GARDASIL 9 SUSY PV (human papillomavirus Urinary Antispasmodics - Cholinergic Agonists PV (hpv) 9-valent recombinant bethanechol chloride 1 vaccine) tabs RECOMBIVAX HB SUSP URECHOLINE TABS GP (hepatitis b vaccine 3 (bethanechol chloride) (recomb)) Urinary Antispasmodics - Direct Muscle Relaxants ROTATEQ SOLN (rotavirus vaccine, live 3 flavoxate hcl tabs 1 oral pentavalent) VACCINES VAGINAL AND RELATED PRODUCTS Bacterial Vaccines Miscellaneous Vaginal Products QL(4 ea per fill VIVOTIF BERNA CPDR (Acetic Acid-Oxyquinoline 3 1 bal on hand, 3 retail,4 ea per Vaginal) RELAGARD GEL (typhoid vaccine) fill mail) FEM PH GEL (acetic VIVOTIF CPDR (typhoid QL(4 ea per fill 3 3 retail,4 ea per acid-oxyquinoline vaccine) fill mail) vaginal) INTRAROSA INST Viral Vaccines 3 ( vaginal) FLUCELVAX PV QUADRIVALENT 2017- Spermicides 2018 SUSY (influenza (Nonoxynol-9) VCF PV PV virus vaccine tissue- VAGINAL PV cultured subunit CONTRACEPTIVEGEL quadrivalent) GEL ENCARE SUPP PV FLUCELVAX PV PV QUADRIVALENT 2018- (nonoxynol-9) 2019 SUSY (influenza OPTIONS CONCEPTROL PV PV VAGINAL virus vaccine tissue- GP cultured subunit CONTRACEPTIVE GEL (nonoxynol-9) quadrivalent) OPTIONS GYNOL II PV VAGINALCONTRACEPTIV PV E GEL (nonoxynol-9)

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153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHUR-SEAL GEL PV PV terconazole vaginal 1 (nonoxynol-9) supp 80 mg TODAY SPONGE MISC PV PV Vaginal Estrogens (nonoxynol-9) (Estradiol Vaginal) 1 VCF VAGINAL PV YUVAFEM TABS CONTRACEPTIVE FILM PV ESTRACE CREA GP FILM (nonoxynol-9) (estradiol vaginal) VCF VAGINAL PV CONTRACEPTIVE FOAM PV estradiol vaginal crea 1 FOAM (nonoxynol-9) estradiol vaginal tabs 1 Vaginal Anti-infectives ESTRING RING (Metronidazole Vaginal) 1 3 VANDAZOLE GEL (estradiol vaginal) (Miconazole Nitrate 1 bal on hand, FEMRING RING QL(1 ea per 90 Vaginal) MICONAZOLE 3 1 (estradiol acetate 3 days retail) SUPP vaginal) AVC CREA 3 PREMARIN CREA VA (sulfanilamide vaginal) 0.625 MG/GM 2 CLEOCIN CREA VA 2 % (estrogens, conjugated (clindamycin phosphate GP vaginal) vaginal) VAGIFEM TABS NF CLEOCIN SUPP VA 100 (estradiol vaginal) MG (clindamycin 3 Vaginal Progestins phosphate vaginal) CRINONE GEL 4 % clindamycin phosphate 1 (progesterone 3 vaginal crea (vaginal)) CLINDESSE CREA CRINONE GEL 8 % PA (clindamycin phosphate 3 (progesterone 3 (one dose)) (vaginal)) GYNAZOLE-1 CREA ENDOMETRIN INST PA (butoconazole nitrate 3 (progesterone 3 (one dose)) (vaginal)) METROGEL-VAGINAL VASOPRESSORS - Drugs to Treat Heart and GEL (metronidazole GP Circulation Conditions ) vaginal Anaphylaxis Therapy Agents metronidazole vaginal 1 epinephrine QL(4 ea per fill gel (anaphylaxis) soaj 0.15 retail)1 bal on TERAZOL 7 CREA 2 hand, GP mg/0.15ml, 0.3 (terconazole vaginal) mg/0.3ml, 0.3 mg/0.3ml terconazole vaginal 1 crea 0.4 % 1 bal on hand, terconazole vaginal 1 crea 0.8 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits epinephrine QL(4 ea per fill (Cholecalciferol) D 400, AL(At least 65 retail) VITAMIN D-400, SM yrs old); PV (anaphylaxis) soaj 0.15 2 mg/0.3ml, 0.3 VITAMIN D, QC VITAMIN D3, HM VITAMIN D, GNP PV mg/0.3ml, 0.3 mg/0.3ml VITAMIN D-400, DELTA EPINEPHRINE SOAJ 0.3 QL(4 ea per fill D3, D3 HIGH POTENCY, MG/0.3ML (epinephrine 2 retail) D-400 TABS (anaphylaxis)) BABY DDROPS LIQD AL(At least 65 PV EPIPEN 2-PAK SOAJ PA; QL(4 ea (cholecalciferol) yrs old); PV (epinephrine 2 per fill retail) AL(At least 65 cholecalciferol caps PV (anaphylaxis)) yrs old); PV EPIPEN-JR 2-PAK SOAJ PA; QL(4 ea cholecalciferol chew PV AL(At least 65 (epinephrine 2 per fill retail) yrs old); PV (anaphylaxis)) PV AL(At least 65 cholecalciferol liqd yrs old); PV Neurogenic Orthostatic Hypotension (NOH) - AL(At least 65 NORTHERA CAPS PA cholecalciferol tabs PV SP yrs old); PV (droxidopa) D-VI-SOL LIQD AL(At least 65 GP Vasopressors (cholecalciferol) yrs old); PV EPINEPHRINE HCL SOLN PA DRISDOL CAPS SP GP (epinephrine) (ergocalciferol) PA epinephrine soln 1 SP ergocalciferol caps 1 mg/ml MEPHYTON TABS GP midodrine hcl tabs 1 (phytonadione) VITAMINS phytonadione tabs 1 Oil Soluble Vitamins VITAMIN D2 TABS AL(At least 65 PV yrs old); PV (Cholecalciferol) AL(At least 65 (ergocalciferol) AQUEOUS VITAMIN D yrs old); PV VITAMIN D3 IMMUNE AL(At least 65 INFANTS, VITAMIN D HEALTH LIQD PV yrs old); PV INFANT, JUST D, D3 PV (cholecalciferol) VITAMIN, D-VITE VITAMIN D3 LIQD AL(At least 65 PV PEDIATRIC, ( ) yrs old); PV BPROTECTED PEDIA D- cholecalciferol VITE LIQD Water Soluble Vitamins (Cholecalciferol) CVS D3, PV AL(At least 65 POTABA CAPS EQL VITAMIN D3 CAPS yrs old); PV (potassium 3 (Cholecalciferol) D 400, PA AL(At least 65 aminobenzoate) VITAMIN D-3 GUMMY, KP yrs old); PV potassium 1 bal on hand, VITAMIN D, HEALTHY PV 1 KIDS VITAMIN D3, GNP aminobenzoate pack VITAMIN D, D3 KIDS CHEW

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: July 1, 2020

155 Index 7t lido gel 87 ADCIRCA 64 alendronate sodium 92 7TOPIC 88 ADDERALL 1 ALFERON N 51 abacavir sulfate 56 ADDERALL XR 1 alfuzosin hcl 101 abacavir sulfate-lamivudine 56 adefovir dipivoxil 59 ALIMTA 47 abacavir sulfate-lamivudine- ADEMPAS 64 ALINIA 16 zidovudine 56 ADLYXIN 32 aliskiren fumarate 44 ABELCET 36 ADLYXIN STARTER ALKERAN 46 ABILIFY 56 PACK 32 all day allergy childrens 38 abiraterone acetate 48 adrucil 47 allergy nasal spray 24 hour 129 ABSORICA 74 ADVAIR DISKUS 21 allergy relief 24hr 38 ABSORICA LD 74 ADVAIR HFA 21 allopurinol 101 ABSTRAL 10 ADVICOR 40 almotriptan malate 111 acamprosate calcium 139 ADZENYS ER 1 ALOCRIL 134 acarbose 31 afeditab cr 62 ALOMIDE 134 ACCOLATE 19 AFINITOR 49 ALORA 97 ACCUPRIL 41 AFINITOR DISPERZ 49 alosetron hcl 99 ACCURETIC 42 afirmelle 66 ALOXI 35 acebutolol hcl 61 aftera 69 ALPHAGAN P 131 acetaminophen w/ codeine 12 AGGRENOX 102 alprazolam 18 acetazolamide 90 AGRYLIN 102 ALPRAZOLAM INTENSOL 18 acetic acid (otic) 135 AIMOVIG 110 alprazolam xr 18 acetylcysteine 73 AIMSCO LUBRICATED 108 ALREX 133 acid control maximum AIRDUO RESPICLICK strength 148 113/14 21 ALTABAX 77 ACIPHEX 150 AIRDUO RESPICLICK altacaine 133 ACIPHEX SPRINKLE 150 232/14 21 ALTACE 41 AIRDUO RESPICLICK acitretin 79 55/14 21 altafrin 131 ACTEMRA 4 AJOVY 110 ALTOPREV 40 ACTIDOM DMX 72 ak-poly-bac 131 ALUNBRIG 49 ACTIGALL 98 AKTEN 133 ALVESCO 20 ACTIMMUNE 51 AKYNZEO 36 alyacen 7/7/7 67 ACTIQ 10 al12 86 alyq 64 ACTIVELLA 96 ALA SCALP 81 amabelz 96 ACTONEL 92 ala-cort 81 amantadine hcl 53 ACTOPLUS MET 31 ALA-QUIN 77 AMARYL 34 ACTOPLUS MET XR 31 albendazole 15 AMBIEN 105 ACTOS 32 ALBENZA 15 AMBIEN CR 105 ACULAR 134 albuterol sulfate 21 AMBISOME 36 ACULAR LS 134 ALCAINE 133 ambrisentan 64 ACUVAIL 134 alclometasone amcinonide 81 acyclovir 60 dipropionate 81 AMCINONIDE 81 acyclovir topical 80 ALCORTIN A 77 AMERGE 111 ACZONE 74 ALDACTAZIDE 91 amethia 66 ADAGEN 3 ALDACTONE 91 amethyst 66 ADALAT CC 62 ALDARA 86 AMICAR 104 adapalene 74 ALDURAZYME 94 amikacin sulfate 3 adapalene-benzoyl peroxide 74 ALECENSA 49

Index 1 amiloride & ANORO ELLIPTA 21 ASMANEX HFA 20 hydrochlorothiazide 91 ANTABUSE 139 ASMANEX TWISTHALER 120 amiloride hcl 91 ANTARA 39 METERED DOSES 20 aminocaproic acid 104 ASMANEX TWISTHALER 14 anti-diarrheal 34 aminophylline 22 METERED DOSES 20 anucort-hc 14 ASMANEX TWISTHALER 30 amiodarone hcl 19 anusol-hc 14 METERED DOSES 20 AMITIZA 98 ASMANEX TWISTHALER 60 ANUSOL-HC 15 amitriptyline hcl 30 METERED DOSES 20 ANZEMET 35 ASMANEX TWISTHALER 7 amlodipine besylate 62 APEXICON E 81 METERED DOSES 20 amlodipine besylate-atorvastatin aspirin 9 calcium 63 APLENZIN 28 amlodipine besylate-benazepril apraclonidine hcl 131 aspirin-dipyridamole 102 hcl 42 aprepitant 36 ASTAGRAF XL 115 amlodipine besylate-olmesartan ASTEPRO 129 medoxomil 42 apri 66 amlodipine besylate- APRISO 99 ATABEX EC 121 valsartan 42 APTIOM 25 ATABEX OB 121 amlodipine-valsartan- APTIVUS 56 ATACAND 41 hydrochlorothiazide 42 ATACAND HCT 42 amnesteem 73 aqueous vitamin d infants 155 atazanavir sulfate 56 amoxapine 30 ARALAST NP 145 ARANESP ALBUMIN ATELVIA 92 amoxicillin 137 FREE 103 atenolol 61 amoxicillin & pot ARAVA 7 clavulanate 137,138 atenolol & chlorthalidone 42 amoxicillin-clarithromycin w/ ARCALYST 4 ATGAM 115 lansoprazole 151 ARCAPTA NEOHALER 21 ATIVAN 18 amphetamine- argyle sterile saline atomoxetine hcl 2 dextroamphetamine 1 100ml 101 amphotericin b 36 argyle sterile water 100ml117 atorvastatin calcium 40 ampicillin 137 ARICEPT 139 atovaquone 16 ampicillin & sulbactam ARIKAYCE 3 atovaquone-proguanil hcl 45 sodium 138 ARIMIDEX 48 ATRALIN 74 ampicillin sodium 137 aripiprazole 56 ATRIPLA 56 AMPYRA 140 ARIXTRA 23 ATROPINE SULFATE 131 AMRIX 128 armodafinil 2 ATROVENT HFA 19 ANADROL-50 13 ARMONAIR RESPICLICK AUBAGIO 140 ANAFRANIL 30 113 20 AUGMENTIN 138 anagrelide hcl 102 ARMONAIR RESPICLICK AUGMENTIN ES-600 138 ANALPRAM HC 14 232 20 ARMONAIR RESPICLICK AUGMENTIN XR 138 ANALPRAM HC SINGLES 14 55 20 aurovela 1.5/30 67 ANALPRAM-HC 14 ARMOUR THYROID 147 aurovela 24 fe 67 ANAPROX DS 5 ARNUITY ELLIPTA 20 AUSTEDO 140 ANASPAZ 147 AROMASIN 48 av-phos 250 neutral 114 anastrozole 48 ARRANON 47 av-vite fb forte 90 ANCOBON 36 ARTHROTEC 50 5 AVALIDE 42 ANDRODERM 13 ARTHROTEC 75 5 AVANDIA 32 ANDROGEL 13 ARZERRA 47 AVAPRO 41 ANDROGEL PUMP 13 ASACOL HD 99 AVAR 74 ANGELIQ 96 ascomp/codeine 11 avar cleanser 73 ANNOVERA 69 ASCRIPTIN 9 AVAR LS 74

Index 2 AVAR LS CLEANSER 74 banophen 37 BEVESPI AEROSPHERE 21 avar-e emollient 74 BANZEL 25 BEVYXXA 23 AVAR-E LS 74 BAQSIMI ONE PACK 32 bexarotene 51 AVC 154 BAQSIMI TWO PACK 32 BEYAZ 67 AVELOX 98 BARACLUDE 59 bicalutamide 48 avidoxy 146 BAXDELA 98 BICILLIN C-R 138 avita 74 BECONASE AQ 129 BICILLIN L-A 137 AVODART 101 BELBUCA 13 BIDIL 63 AVONEX 140 BELLADONNA/OPIUM 147 BILTRICIDE 15 AVONEX PEN 140 BELSOMRA 106 bimatoprost 135 AXERT 111 benazepril & BINOSTO 92 AYGESTIN 139 hydrochlorothiazide 42 BIO-DTUSS DMX 72 benazepril hcl 41 AYVAKIT 49 bio-statin 36 BENICAR 41 azacitidine 47 BIO-STATIN 36 BENICAR HCT 42,43 AZASAN 115 biogtuss 71 BENLYSTA 117 AZASITE 132 bisoprolol & BENSAL HP 86 AZATHIOPRINE 116 hydrochlorothiazide 43 BENTYL 147 bisoprolol fumarate 61 azathioprine 116 BENZACLIN 74 BIVIGAM 136 azelaic acid 88 BENZACLIN WITH PUMP 74 BLEPH-10 132 azelastine hcl 129 BENZAMYCIN 74 BLEPHAMIDE 133 azelastine hcl (ophth) 134 azelastine hcl-fluticasone benzepro creamy wash 73 BLEPHAMIDE S.O.P. 133 propionate 129 BENZNIDAZOLE 15 BONIVA 92 AZELEX 74 benzonatate 71 BONJESTA 36 AZILECT 54 benzoyl peroxide- bosentan 64 azithromycin 107 erythromycin 74 BOSULIF 49 benztropine mesylate 52 AZOPT 134 BOTOX 130 BEPREVE 134 AZOR 42 bp cleansing wash 74 BERINERT 102 AZULFIDINE 99 bprotected pedia iron 104 beser 81 AZULFIDINE EN-TABS 99 BRAFTOVI 49 BESIVANCE 132 azurette 66 BREO ELLIPTA 21 BETADINE OPHTHALMIC BABY DDROPS 155 PREP 132 BRILINTA 102 baciim 15 BETAGAN 130 brimonidine tartrate 131 bacitracin 15 betamethasone dipropionate BRISDELLE 145 bacitracin (ophthalmic) 132 (topical) 81 BRIVIACT 25 bacitracin-poly-neomycin-hc betamethasone dipropionate augmented 81 bromfenac sodium (ophth) 134 133 bromocriptine mesylate 53 bacitracin-polymyxin b betamethasone valerate 81 (ophth) 132 BETAPACE 61 brompheniramine tannate 37 baclofen 128 BETAPACE AF 61 BROMSITE 134 BACTRIM 15 BETASERON 140 BROVANA 21 BACTRIM DS 15 betaxolol hcl 61 BRUKINSA 50 BACTROBAN NASAL 129 betaxolol hcl (ophth) 130 budesonide 70 BAL-CARE DHA 121 bethanechol chloride 153 budesonide (inhalation) 20 BALCOLTRA 67 BETHKIS 3 budesonide (nasal) 130 balsalazide disodium 99 BETIMOL 130 budesonide-formoterol fumarate dihydrate 21 BALVERSA 49 BETOPTIC-S 130 bumetanide 91

Index 3 BUMEX 91 calcipotriene-betamethasone CARNITOR SF 94 BUNAVAIL 13 dipropionate 81 carteolol hcl (ophth) 130 calcitonin (salmon) 92 bupap 7 cartia xt 62 calcitrene 79 BUPHENYL 94 carvedilol 61 calcitriol 94 BUPRENEX 13 carvedilol phosphate 61 calcitriol (topical) 79 buprenorphine 13 CASODEX 48 calcium acetate (phosphate buprenorphine hcl 13 binder) 100 caspofungin acetate 36 buprenorphine hcl-naloxone hcl CALCIUM-FOLIC ACID PLUS CASPOFUNGIN ACETATE 36 dihydrate 13 D 113 CATAPRES 42 bupropion hcl 28 CALQUENCE 50 CATAPRES-TTS-1 42 bupropion hcl (smoking CAMBIA 111 deterrent) 144 CATAPRES-TTS-2 42 camila 70 buspirone hcl 17 CATAPRES-TTS-3 42 CAMPATH 47 busulfan 46 caziant 66 CANASA 99 BUSULFEX 46 cefaclor 65 CANCIDAS 36 butalbital-acetaminophen 7 CEFACLOR ER 65 butalbital-acetaminophen- candesartan cilexetil 41 cefadroxil 65 candesartan cilexetil- caffeine 7 cefazolin sodium 65 butalbital-acetaminophen- hydrochlorothiazide 43 caffeine w/ codeine 12 CAPASTAT SULFATE 46 cefdinir 65 butalbital-aspirin-caffeine 7 capecitabine 47 cefditoren pivoxil 65 butalbital-aspirin-caffeine CAPEX 82 CEFEPIME 66 w/cod 12 CAPLYTA 54 cefepime hcl 66 BUTALBITAL/ACETAMINOPHEN CEFEPIME/DEXTROSE 66 7 CAPRELSA 50 BUTALBITAL/ASPIRIN/CAFFEIN captopril 41 cefixime 65 E 7 captopril & CEFOTAN 65 BUTISOL SODIUM 105 hydrochlorothiazide 43 cefotaxime sodium 65 butorphanol tartrate 13 CARAC 79 cefotetan disodium 65 BUTRANS 13 CARAFATE 149 cefoxitin sodium 65 BYDUREON 32 CARBAGLU 94 CEFOXITIN SODIUM 65 BYDUREON BCISE 32 carbamazepine 25 cefpodoxime proxetil 65 BYDUREON PEN 32 CARBAPHEN 12 72 cefprozil 65 BYETTA 32 CARBAPHEN 12 PED 72 ceftazidime 65 BYSTOLIC 61 CARBATROL 25 ceftriaxone sodium 65 BYVALSON 43 carbidopa 52 cefuroxime axetil 65 C-NATE DHA 121 carbidopa-levodopa 53 cefuroxime sodium 65 c-topical 87 carbidopa-levodopa- CELEBREX 5 entacapone 53 cabergoline 95 carbinoxamine maleate 37 celecoxib 5 CABLIVI 102 CARDIZEM 62 CELEXA 29 CABOMETYX 50 CARDIZEM CD 62 CELLCEPT 116 CADUET 63 CELLCEPT CARDIZEM LA 62 CAFERGOT 111 INTRAVENOUS 116 CARDURA 42 caffeine citrate 2 CELONTIN 28 CARDURA XL 101 CALAN 62 CEM-UREA 85 carisoprodol 128 CALAN SR 62 CENTANY 77 carisoprodol w/ aspirin 129 CALCIFOL 113 CENTANY AT 77 carisoprodol w/ aspirin & cephalexin 65 calcipotriene 79 codeine 128 CALCIPOTRIENE 79 CARNITOR 94 CERACADE 88

Index 4 CERDELGA 102 CILOXAN 132 clindacin etz pledgets 73 CEREBYX 27 cimetidine 149 CLINDACIN PAC 75 cerovel 85 cimetidine 200 148 CLINDAGEL 75 CESAMET 36 cimetidine hcl 149 clindamycin hcl 16 cetirizine hcl 38 CIMZIA 99 clindamycin palmitate CETRAXAL 135 CIMZIA STARTER KIT 99 hydrochloride 16 clindamycin phosphate 16 CETROTIDE 93 cinacalcet hcl 94 clindamycin phosphate cevimeline hcl 118 CIPRO 98 (topical) 75 CHANTIX 144 CIPRO HC 136 clindamycin phosphate in CHANTIX CONTINUING CIPRODEX 136 d5w 16 clindamycin phosphate MONTHPAK 144 ciprofloxacin 98 CHANTIX STARTING MONTH vaginal 154 PAK 144 ciprofloxacin hcl 98 clindamycin phosphate-benzoyl CHEMET 34 ciprofloxacin hcl (ophth) 132 peroxide 75 ciprofloxacin hcl (otic) 135 clindamycin phosphate-benzoyl CHENODAL 98 peroxide (refrigerate) 75 cheratussin ac 71 ciprofloxacin-ciprofloxacin clindamycin phosphate- hcl 98 tretinoin 75 CHILDRENS ADVIL 5 ciprofloxacin-fluocinolone childrens ibuprofen 5 acetonide 136 CLINDESSE 154 CHILDRENS MOTRIN 5 citalopram hydrobromide 29 clobazam 24 chloramphenicol sodium CITRANATAL 90 DHA 121 clobetasol propionate 82 succinate 16 CITRANATAL ASSURE 121 clobetasol propionate e 80 chlordiazepoxide hcl 18 CITRANATAL B-CALM 121 clobetasol propionate emollient chlordiazepoxide hcl-clidinium base 82 bromide 147 CITRANATAL BLOOM 121 clobetasol propionate chlordiazepoxide-amitriptyline CITRANATAL BLOOM emulsion 82 140 DHA 121 CLOBEX 82 chlorhexidine gluconate (mouth- CITRANATAL DHA 121 clocortolone pivalate 82 throat) 117 CITRANATAL chloroquine phosphate 45 HARMONY 121 clodan 81 chlorothiazide 91 CITRANATAL MEDLEY 121 CLODERM 82 chlorpromazine hcl 56 CITRANATAL RX 121 CLODERM PUMP 82 chlorthalidone 91 cladribine 47 clofarabine 47 CHLORZOXAZONE 128 CLAFORAN 65 CLOLAR 47 chlorzoxazone 128 claravis 73 clomiphene citrate 93 CHOLBAM 98 CLARINEX 38 clomipramine hcl 30 cholecalciferol 155 CLARINEX-D 12 HOUR 72 clonazepam 24 cholestyramine 39 clarithromycin 107 clonidine 42 cholestyramine light 39 clearlax 107 clonidine hcl 42 choline fenofibrate 39 clemastine fumarate 37 clonidine hcl (adhd) 2 CHOLINE MAGNESIUM CLENPIQ 106 clopidogrel bisulfate 102 TRISALICYLATE 9 CLEOCIN 16,154 clorazepate dipotassium 18 CIALIS 63 CLEOCIN IN D5W 16 clotrimazole 117 ciclodan 77 CLEOCIN PEDIATRIC clotrimazole (topical) 77 CICLODAN SOLUTION KIT 77 GRANULES 16 clotrimazole w/ ciclopirox 77 CLEOCIN PHOSPHATE 16 betamethasone 77 ciclopirox olamine 77 CLEOCIN-T 74 clovique 115 ciclopirox treatment 77 CLIMARA 97 clozapine 55 cidofovir 59 CLIMARA PRO 96 CLOZARIL 55 cilostazol 102 CLINDACIN ETZ 74 COARTEM 45

Index 5 codeine sulfate 10 cortisone acetate 70 CYCLOGYL 131 CODITUSSIN AC 72 CORTISPORIN 77 CYCLOMYDRIL 131 COGENTIN 52 CORTISPORIN-TC 136 cyclopentolate hcl 131 COLAZAL 99 cortizone-10 81 cyclophosphamide 46 colchicine 102 CORZIDE 43 cycloserine 46 colchicine w/ probenecid 101 COSENTYX 79 CYCLOSET 32 COLCRYS 102 COSENTYX SENSOREADY cyclosporine 116 colesevelam hcl 39 PEN 79 cyclosporine modified (for COSOPT 130 COLESTID 39 microemulsion) 116 COSOPT PF 130 CYKLOKAPRON 104 COLESTID FLAVORED 39 COTELLIC 50 CYMBALTA 30 colestipol hcl 39 COUMADIN 23 cyproheptadine hcl 39 colocort 14 covaryx 96 CYSTADANE 94 COLY-MYCIN S 136 COZAAR 41 CYSTAGON 101 COLYTE-FLAVOR PACKS 106 CREON 90 CYSTARAN 134 COMBIGAN 130 CRESEMBA 37 cytarabine 47 COMBIPATCH 96 CRESTOR 40 CYTOMEL 147 COMBIVENT RESPIMAT 21 CRINONE 154 CYTOTEC 151 COMBIVIR 56 CRIXIVAN 57 cytra k crystals 100 COMETRIQ 50 cromolyn sodium 19 cytra-2 100 COMPLERA 56 CROMOLYN SODIUM 19 cytra-3 100 COMPLETENATE 121 cromolyn sodium cytra-k 100 compoz 105 (mastocytosis) 98 d 400 155 compro 56 cromolyn sodium (ophth) 134 D-VI-SOL 155 COMTAN 52 crotan 89 D.H.E. 45 111 CONCEPT DHA 121 CUBICIN 16 DACOGEN 47 CONCEPT OB 121 CUBICIN RF 16 DAKLINZA 59 CONCERTA 2 CUPRIMINE 115 dalfampridine 140 CONDYLOX 86 CUTIVATE 82 DALIRESP 20 constulose 107 CUVITRU 136 danazol 13 CONZIP 10 CUVPOSA 147 DANTRIUM 128 COPAXONE 140 cvs aspirin 8 dantrolene sodium 128 COPIKTRA 50 cvs aspirin adult low dose 8 dapsone 16 CORDARONE 19 cvs budesonide nasal dapsone (topical) 75 CORDRAN 82 spray 129 cvs clotrimazole daptomycin 16 COREG 61 maximumstrength 77 DARAPRIM 45 COREG CR 61 cvs d3 155 darifenacin hydrobromide 152 coremino 146 cvs esomeprazole DAURISMO 48 CORGARD 61 magnesium 150 DAYPRO 5 CORLANOR 64 cvs folic acid 103 DAYTRANA 2 CORTANE-B 82 cvs lansoprazole 150 DDAVP 95 CORTANE-B AQUEOUS 136 cvs motion sickness ii 35 decadron 70 CORTANE-B-OTIC 136 cvs nicotine transdermalsystem 143 decitabine 47 CORTEF 70 cvs nicotine transdermalsystem DECON-G 72 CORTENEMA 14 step 1 144 deferasirox 34 cortic-nd 136 CVS PRENATAL 121 DELESTROGEN 97 CORTIFOAM 14 cyclobenzaprine hcl 128

Index 6 DELSTRIGO 57 DETROL LA 152 DILAUDID 10 DELZICOL 99 dexamethasone 70 dilt-xr 62 DEMADEX 91 DEXAMETHASONE diltiazem hcl 62 demeclocycline hcl 146 INTENSOL 70 diltiazem hcl coated beads 62 dexamethasone sodium DEMSER 41 phosphate 70 diltiazem hcl extended release DENAVIR 80 dexamethasone sodium beads 62 DIOVAN 42 DEPAKENE 28 phosphate (ophth) 133 dexchlorpheniramine DIOVAN HCT 43 DEPAKOTE 28 maleate 37 DIPENTUM 99 DEPAKOTE ER 28 DEXEDRINE 1 diphen 37 DEPAKOTE SPRINKLES 28 DEXILANT 150 diphenhydramine hcl 37 DEPEN TITRATABS 115 dexmethylphenidate hcl 2 diphenoxylate w/ atropine 34 DEPLIN 15 90 dexpak 10 day 70 DIPROLENE 83 DEPLIN 7.5 90 dextroamphetamine sulfate 1 DIPROLENE AF 83 DEPO-ESTRADIOL 97 DIACOMIT 25 dipyridamole 102 DEPO-PROVERA 48 DIAPHRAGMS 108 disopyramide phosphate 18 DEPO-PROVERA DIASTAT ACUDIAL 24 CONTRACEPTIVE 69 disulfiram 139 DEPO-SUBQ PROVERA DIASTAT PEDIATRIC 24 DITROPAN XL 152 104 70 diazepam 18 DIURIL 91 DEPO-TESTOSTERONE 13 diazepam (anticonvulsant) 24 divalproex sodium 28 DERMA-SMOOTHE/FS diazepam intensol 18 BODY 82 DIVIGEL 97 DERMA-SMOOTHE/FS diazoxide 32 DOCTOR MANZANILLA PE SCALP 82 DIBENZYLINE 41 SYRUP DERMASORB TA 82 DICLEGIS 36 ANTIHISTAMINE/DECONGESTA dermazene 77 diclofenac epolamine 77 NT 72 dofetilide 19 DERMOTIC 136 diclofenac potassium 5 DOLOPHINE 10 DESCOVY 57 diclofenac sodium 5 DOMETUSS-DMX 72 desipramine hcl 30 diclofenac sodium (actinic donepezil hydrochloride 139 desloratadine 38 keratoses) 79 diclofenac sodium (ophth)134 DOPTELET 103 desmopressin acetate 95 diclofenac sodium (topical) 77 DORAL 105 desmopressin acetate spray 95 desmopressin acetate spray diclofenac w/ misoprostol 5 doripenem 16 refrigerated 95 dicloxacillin sodium 138 dorzolamide hcl 134 DESOGEN 67 dicyclomine hcl 148 DORZOLAMIDE HCL 135 desogestrel & ethinyl didanosine 57 dorzolamide hcl-timolol estradiol 68 DIFFERIN 75 maleate 130 desogestrel-ethinyl estradiol DOTHELLE DHA 121 DIFICID 108 (biphasic) 68 dotti 97 82 diflorasone diacetate 83 DESONATE DOVATO 57 82 DIFLUCAN 37 desonide DOVONEX 79 82 diflunisal 9 DESOWEN doxazosin mesylate 42 82 digitek 63 DESOXIMETASONE doxepin hcl 30 82,83 digoxin 63 desoximetasone doxepin hcl (antipruritic) 79 DESOXYN 1 dihydroergotamine mesylate 111 doxepin hcl (sleep) 105 desvenlafaxine 30 DILANTIN 27 doxercalciferol 94 DESVENLAFAXINE ER 30 DILANTIN INFATABS 27 doxycycline (monohydrate) 146 desvenlafaxine succinate 30 DILANTIN-125 27 doxycycline (rosacea) 88 DETROL 152 DILATRATE SR 17 doxycycline hyclate 146

Index 7 doxylamine-pyridoxine 36 EFFEXOR XR 30 entecavir 59 DRISDOL 155 EFFIENT 102 ENTEREG 99 dronabinol 36 EFUDEX 79 ENTOCORT EC 70 drospirenone-ethinyl ELAPRASE 94 ENTRESTO 63 estradiol 68 ELDEPRYL 54 ENTTY SPRAY EMULSION 88 drospirenone-ethinyl estradiol- levomefolate calcium 68 ELELYSO 102 enulose 99 DROXIA 103 ELESTAT 135 ENVARSUS XR 116 DRYSOL 88 ELESTRIN 97 EPANED 41 DUAC 75 eletriptan hydrobromide 111 EPCLUSA 59 DUAVEE 96 ELFOLATE 90 EPICERAM 88 DUET DHA 400 121 ELIDEL 86 EPIDIOLEX 25 DUET DHA BALANCED 121 ELIGARD 48 EPIDUO 75 DUETACT 31 ELIMITE 89 EPIFOAM 83 DUEXIS 5 elinest 67 epinastine hcl (ophth) 135 duloxetine hcl 30 ELIQUIS 23 EPINEPHRINE 155 DUOPA 53 ELIQUIS STARTER PACK 23 epinephrine 155 DUPIXENT 85 ELIXOPHYLLIN 22 epinephrine (anaphylaxis) 154,155 DURAGESIC 10 ELLA 69 epinephrine hcl 21 duramorph 10 ELMIRON 101 EPINEPHRINE HCL 155 duraxin 7 ELOCON 83 EPIPEN 2-PAK 155 DUREX EXTRA eluryng 69 EPIPEN-JR 2-PAK 155 SENSITIVE 108 EMADINE 135 epitol 25 DUREZOL 133 EMBEDA 10 EPIVIR 57 dutasteride 101 EMCYT 48 EPIVIR HBV 59 dutasteride-tamsulosin hcl 101 EMEND 36 eplerenone 44 DUTOPROL 43 EMEND TRIPACK 36 EPOGEN 103 DUZALLO 101 EMGALITY 110 eprosartan mesylate 42 DYAZIDE 91 EMSAM 28 EPZICOM 57 DYMISTA 129 EMTRIVA 57 eq allergy relief 38,129 DYRENIUM 91 EMULSION SB 88 eq nicotine 143,144 e.e.s. 400 107 EMVERM 15 eq nicotine lozenges 141 E.E.S. GRANULES 108 ENABLEX 152 eq nicotine polacrilex 141,142 EC-NAPROSYN 5 enalapril maleate 41 EC-NAPROXEN 5 enalapril maleate & eql nicotine polacrilex refill 142 econazole nitrate 77 hydrochlorothiazide 43 EQUETRO 54 ECOTRIN REGULAR ENBRACE HR 121 ERAXIS 36 STRENGTH 9 ENBREL 7 ERBITUX 47 ed-spaz 147 ENBREL MINI 7 ergocalciferol 155 EDARBI 42 ENBREL SURECLICK 7 ergoloid mesylates 141 EDARBYCLOR 43 ENCARE 153 ERGOMAR 111 EDECRIN 91 ENDARI 103 ergotamine w/ caffeine 111 EDLUAR 105 endocet 12 ERIVEDGE 48 EDURANT 57 ENDOMETRIN 154 ERLEADA 48 efavirenz 57 enoxaparin sodium 23 erlotinib hcl 50 effer-k 114 enpresse-28 66 ERTACZO 78 EFFER-K 114 entacapone 52 ertapenem sodium 16 effervescent pot chloride 114

Index 8 ery 73 EUCRISA 88 felodipine 62 ery-tab 107 EURAX 89 FEM PH 153 ERYGEL 75 euthyrox 147 FEMARA 48 ERYPED 200 108 EVAMIST 97 FEMCAP 108 ERYPED 400 108 everolimus 50 FEMHRT LOW DOSE 96 erythrocin stearate 108 everolimus FEMRING 154 erythromycin (acne aid) 75 (immunosuppressant) 116 fenofibrate 39,40 EVISTA 93 erythromycin (ophth) 132 FENOFIBRATE 40 EVOCLIN 75 erythromycin base 108 fenofibrate 40 EVOTAZ 57 erythromycin fenofibrate micronized 40 EVOXAC 118 ethylsuccinate 108 FENOFIBRIC ACID 40 ESBRIET 145 EVZIO 35 fenofibric acid 40 escitalopram oxalate 29 EXACTUSS 72 FENOPROFEN CALCIUM 5 esgic 7 EXACTUSS TR 72 fenoprofen calcium 6 ESGIC 7 EXALGO 10 FENORTHO 6 esomeprazole magnesium 150 EXAPHEX TR 72 FENSOLVI 48 ESOMEPRAZOLE EXELDERM 78 fentanyl 10 STRONTIUM 150 EXELON 139 estazolam 105 fentanyl citrate 10 exemestane 48 esterified estrogens & FENTORA 10 EXFORGE 43 methyltestosterone 96 FER-IN-SOL 104 EXFORGE HCT 43 ESTRACE 97 ferosul 104 EXJADE 34 estradiol 97 FERRIPROX 34 estradiol & norethindrone EXODERM 78 ferrous sulfate 104 acetate 96 EXTAVIA 140 FERROUS SULFATE 104 estradiol vaginal 154 EXTINA 78 FETZIMA 30 estradiol valerate 97 ezetimibe 40 FETZIMA TITRATION PACK30 ESTRING 154 ezetimibe-simvastatin 39 fexmid 128 ESTROGEL 97 FABIOR 75 FIBRICOR 40 estropipate 97 FABRAZYME 94 FINACEA 88 ESTROSTEP FE 68 FALESSA 68 finasteride 101 eszopiclone 105 famciclovir 60 FIORICET 8 ethacrynate sodium 91 famotidine 149 FIORICET/CODEINE 12 ethacrynic acid 91 FANAPT 54 FIORINAL 8 ethambutol hcl 46 FANAPT TITRATION ethosuximide 28 PACK 54 FIORINAL/CODEINE #3 12 ethyl chloride 87 FANTASY LUBRICATED 108 FIRAZYR 102 ETHYL CHLORIDE/FINE FANTASY FIRDAPSE 45 STREAM 87 LUBRICATED/SPERMICIDE FIRMAGON 48 108 ETHYL CHLORIDE/MEDIUM FIRST-LANSOPRAZOLE 150 STREAM 87 FARESTON 48 FIRST-MOUTHWASH BLM 117 ethynodiol diacet & eth FARYDAK 50 estrad 68 FIRST-OMEPRAZOLE 150 FAZACLO 55 ETHYOL 52 FIRVANQ 16 FC FEMALE CONDOM 108 etidronate disodium 92 flac 136 FC2 FEMALE CONDOM 108 etodolac 5 FLAGYL 15 febuxostat 102 etonogestrel-ethinyl estradiol69 FLAREX 133 felbamate 27 ETOPOPHOS 52 flavoxate hcl 153 FELBATOL 27 etoposide 52 FLEBOGAMMA DIF 136 FELDENE 5

Index 9 flecainide acetate 19 fluticasone propionate FROVA 111 FLECTOR 77 (nasal) 130 frovatriptan succinate 111 fluticasone-salmeterol 22 FLOMAX 101 FURADANTIN 152 fluvastatin sodium 40 FLONASE ALLERGY furosemide 91 fluvoxamine maleate 29 RELIEF 130 FUSION PLUS 104 FLONASE ALLERGY RELIEF FML 133 FUZEON 57 CHILDRENS 130 FML FORTE 133 FLONASE SENSIMIST 130 fyavolv 96 FML LIQUIFILM 133 FLORIVA PLUS 120 FYCOMPA 24 FOCALIN 2 FLOVENT DISKUS 20 g tussin ac 71 FOCALIN XR 2 FLOVENT HFA 20 gabapentin 25 folbic 90 FLOXIN OTIC 135 GABITRIL 27 FOLBIC RF 90 floxuridine 47 GABLOFEN 128 FOLET DHA 122 FLUCELVAX QUADRIVALENT GALAFOLD 94 FOLET ONE 122 2017-2018 153 galantamine hydrobromide 139 FLUCELVAX QUADRIVALENT folic acid 103 GALZIN 115 2018-2019 153 FOLIVANE-F 104 FLUCELVAX QUADRIVALENT GAMASTAN 136 FOLIVANE-OB 122 2019-2020 153 GAMASTAN S/D 136 FOLTX 90 fluconazole 37 GAMMAGARD LIQUID 136 fondaparinux sodium 23 fluconazole in dextrose 37 GAMMAKED 136 FORFIVO XL 28 flucytosine 36 GAMMAPLEX 137 formadon 56 fludarabine phosphate 47 GAMUNEX-C 137 formaldehyde 56 fludrocortisone acetate 71 GARDASIL 9 153 FORTEO 92 FLUMADINE 60 GASTROCROM 98 FORTESTA 13 flunisolide (nasal) 130 gatifloxacin (ophth) 132 FOSAMAX 92 fluocinolone acetonide 83 GATTEX 100 FOSAMAX PLUS D 92 fluocinolone acetonide gavilyte-c 106 (otic) 136 fosamprenavir calcium 57 gavilyte-g 106 fluocinonide 83 FOSCAVIR 59 gavilyte-h 106 fluocinonide emulsified base 83 fosinopril sodium 41 gavilyte-n/flavor pack 106 FLUORABON 113 fosinopril sodium & fluoritab 113 hydrochlorothiazide 43 GEBAUERS INSTANT ICE 87 fluorometholone (ophth) 133 fosphenytoin sodium 27 GEBAUERS PAIN EASE 87 FOSRENOL 100 GEBAUERS SPRAY AND FLUOROPLEX 79 STRETCH 87 FRAGMIN 23 fluorouracil 47 GELCLAIR 118 fluorouracil (topical) 79 FREESTYLE FREEDOM LITE 110 GELFILM OP 134 fluoxetine hcl 29 FREESTYLE INSULINX GELNIQUE 152 fluoxetine hcl (pmdd) 141 BLOODGLUCOSE GELNIQUE PUMP 152 MONITORING SYSTEM 110 FLUOXETINE gemcitabine hcl 47 HYDROCHLORIDE 29 FREESTYLE INSULINX GEMCITABINE fluphenazine hcl 56 BLOODGLUCOSE TEST 89 FREESTYLE INSULINX HYDROCHLORIDE 47 flura-drops 113 BLOODGLUCOSE TEST gemfibrozil 40 flurandrenolide 83 STRIPS 89 GEMZAR 47 flurazepam hcl 105 FREESTYLE LITE BLOOD GENERESS FE 68 flurbiprofen 6 GLUCOSE MONITORING SYSTEM 110 gengraf 115 flurbiprofen sodium 135 FREESTYLE LITE TEST GENOTROPIN 93 flutamide 48 STRIPS 89 GENOTROPIN MINIQUICK 93 fluticasone propionate 83 FREESTYLE TEST STRIPS 90 gentak 131

Index 10 gentamicin in saline 3 GLYXAMBI 31 HETLIOZ 106 gentamicin sulfate 4 gnp nicotine gum 143 HEXALEN 46 gentamicin sulfate (ophth) 132 GOCOVRI 53 HIPREX 152 gentamicin sulfate (topical) 77 GOLYTELY 106 HISTEX-PE 72 GENVOYA 57 GONITRO 17 HIZENTRA 137 GEODON 54 gordons urea 85 homatropaire 131 geri-hydrolac 12 86 GORDONS UREA 85 homatropine hbr 131 gianvi 66 GRALISE 141 HORIZANT 141 GIAZO 99 GRALISE STARTER 141 humalog 33 GILENYA 140 granisetron hcl 35 HUMALOG 33 GILOTRIF 50 GRANIX 103 humalog kwikpen 33 GILPHEX TR 72 GRASTEK 3 humalog mix 50/50 33 GILTUSS 72 griseofulvin microsize 36 humalog mix 50/50 kwikpen 33 GILTUSS COUGH & COLD 72 griseofulvin ultramicrosize 36 HUMATROPE 93 GILTUSS SINUS & guaifenesin dac 72 HUMATROPE COMBO CONGESTION 72 guaifenesin-codeine 72 PACK 93 GILTUSS TR 72 HUMIRA 4 guanfacine hcl 42 GLASSIA 145 HUMIRA PEDIATRIC CROHNS guanfacine hcl (adhd) 2 glatiramer acetate 140 DISEASE STARTER PACK 4 GUANIDINE HCL 45 HUMIRA PEN 4 glatopa 140 GVOKE PFS 32 HUMIRA PEN-CD/UC/HS GLEEVEC 50 GYNAZOLE-1 154 STARTER 4 GLEOSTINE 46 HUMIRA PEN-PS/UV HAEGARDA 102 glimepiride 34 STARTER 4 HALAC 83 glipizide 34 humulin 70/30 33 halcinonide 83 glipizide xl 34 humulin 70/30 kwikpen 33 HALCION 105 glipizide-metformin hcl 31 humulin n 33 halobetasol propionate 83 GLUCAGEN DIAGNOSTIC 89 HUMULIN N 33 HALOG 83 GLUCAGEN HYPOKIT 32 humulin n kwikpen 33 haloperidol 55 GLUCAGON EMERGENCY humulin r 33 KIT 32 haloperidol lactate 55 humulin r u-500 GLUCAGON EMERGENCY KIT HALOTIN 78 (concentrated) 33 FOR LOW BLOOD SUGAR 32 HARVONI 59 humulin r u-500 kwikpen 33 GLUCOPHAGE 32 heartburn treatment 24 hyaluronate sodium GLUCOPHAGE XR 32 hour 150 (emollient) 86 GLUCOTROL 34 HECTOROL 94 HYCAMTIN 52 GLUCOTROL XL 34 HEMANGEOL 61 hydralazine hcl 45 GLUCOVANCE 31 HEMENATAL OB 122 HYDREA 52 GLUMETZA 32 HEMENATAL OB + DHA 122 HYDRO 35 85 glyburide 34 heparin (porcine) in sodium HYDRO 40 FOAM 85 chloride 23 glyburide micronized 34 hydrochlorothiazide 91 heparin sod (porcine) in HYDROCODONE glyburide-metformin 31 d5w 24 BITARTRATE/ACETAMINOPHE GLYCATE 148 heparin sodium (porcine) 24 N 12 glycopyrrolate 148 HEPARIN SODIUM/NACL hydrocodone polistirex- GLYCOPYRROLATE 148 0.45% 24 chlorpheniramine polistirex 72 HEPARIN SODIUM/SODIUM hydrocodone w/ glydo 87 CHLORIDE 24 homatropine 71 GLYNASE 34 HEPARIN SODIUM/SODIUM hydrocodone- GLYSET 31 CHLORIDE 0.9% 24 acetaminophen 12 HEPSERA 59 hydrocodone-ibuprofen 12

Index 11 hydrocortisone 70 IMITREX 111,112 ipratropium bromide (nasal)129 hydrocortisone (intrarectal) 14 IMITREX STATDOSE ipratropium-albuterol 22 hydrocortisone (rectal) 15 REFILL 111 irbesartan 42 IMITREX STATDOSE hydrocortisone (topical) 83 SYSTEM 111 irbesartan-hydrochlorothiazide 43 hydrocortisone acetate IMODIUM A-D 34 (rectal) 15 IRESSA 50 IMPAVIDO 15 hydrocortisone acetate w/ ISENTRESS 57 IMURAN 116 pramoxine 14 ISENTRESS HD 57 hydrocortisone butyrate 83 inatal gt 120 ISOLYTE-S 113 hydrocortisone butyrate INCRELEX 93 hydrophilic lipo base 83 isometheptene- INCRUSE ELLIPTA 19 dichloralphenazone- hydrocortisone valerate 84 indapamide 92 acetaminophen 111 hydrocortisone w/acetic isoniazid 46 acid 136 INDERAL LA 61 hydromet 71 INDERAL XL 61 ISONIAZID 46 hydromorphone hcl 10 INDOCIN 6 isoniazid 46 hydroxychloroquine sulfate 45 indomethacin 6 ISOPTO ATROPINE 131 hydroxyprogesterone INFANATE BALANCE 122 ISOPTO CARPINE 131 caproate 139 INFLECTRA 99 ISORDIL TITRADOSE 17 hydroxyurea 52 INGREZZA 140 isosorbide dinitrate 17 hydroxyzine hcl 18 INHALER SPACERS 110 isosorbide mononitrate 17 hydroxyzine pamoate 18 INLYTA 50 isotretinoin 75 HYLINATE 86 INNOPRAN XL 61 isoxsuprine hcl 64 hyophen 151 INREBIC 50 isradipine 62 hyoscyamine sulfate 148 INSPRA 45 ISTALOL 131 HYPER-SAL 73 INSULIN SYRINGES AND PEN ISTODAX (OVERFILL) 50 HYPERSAL 73 NEEDLES 110 itraconazole 37 HYQVIA 137 INTEGRA F 104 ivermectin 15 HYZAAR 43 INTELENCE 57 ivermectin (rosacea) 88 ibandronate sodium 92 INTERMEZZO 105 JADENU 35 IBRANCE 50 INTRAROSA 153 JADENU SPRINKLE 34 ibu 5 INTRON A 52 JAKAFI 50 ibudone 12 INTUNIV 2 JALYN 101 ibuprofen 6 INVANZ 16 jantoven 23 ICAR PEDIATRIC 104 INVEGA 54 JANUMET 31 icatibant acetate 102 INVEGA SUSTENNA 54 JANUMET XR 31 ICLUSIG 50 INVEGA TRINZA 54 JANUVIA 32 IDHIFA 50 INVIRASE 57 JARDIANCE 34 ILEVRO 135 INVOKAMET 31 jevantique lo 96 ILIDERM 88 INVOKAMET XR 31 jinteli 96 ilotycin 131 INVOKANA 33 JULUCA 57 ILUMYA 79 iodoquimez-hc 77 JUXTAPID 40 imatinib mesylate 50 iodoquinol-hc 78 JYNARQUE 96 IMBRUVICA 50 iodoquinol-hydrocortisone in k-effervescent 114 aloe vehicle 78 imipenem-cilastatin 16 iodoquinol-hydrocortisone-aloe K-PHOS 114 imipramine hcl 30 polysaccharide 78 K-PHOS NEUTRAL 114 imipramine pamoate 30 IOPIDINE 131 K-PHOS NO 2 100 imiquimod 86 ipratropium bromide 19 k-sol 114

Index 12 K-TAB 114 KINERET 4 LAMICTAL STARTER/TAKING KADIAN 10 kionex 117 CARBAMAZEPINE/NOT TAKING VALPROATE 26 kaitlib fe 67 KISQALI 50 LAMICTAL STARTER/TAKING KALETRA 57 KISQALI FEMARA 200 VALPROATE 26 KALYDECO 145 DOSE 49 LAMICTAL XR 26 KISQALI FEMARA 400 KAMDOY 88 DOSE 49 lamivudine 57 KAMELEON LUBRICATED 108 KISQALI FEMARA 600 lamivudine (hbv) 59 KAPVAY 2 DOSE 49 lamivudine-zidovudine 57 KARBINAL ER 37 KITABIS PAK 4 lamotrigine 26 KAZANO 31 KIVIK 88 LANCET 110 KEFLEX 65 KLARITY-A 132 LANOXIN 63 kelnor 1/35 66 KLARON 75 LANOXIN PEDIATRIC 63 KENALOG 84 klofensaid ii 77 lansoprazole 150 KEPIVANCE 52 KLONOPIN 24 lanthanum carbonate 100 KEPPRA 25 klor-con 114 LANTUS 33 KEPPRA XR 25 klor-con 10 114 LANTUS SOLOSTAR 33 KERALAC 85 klor-con m10 114 LASIX 91 ketoconazole 37 klor-con m15 114 LASTACAFT 135 ketoconazole (topical) 78 klor-con sprinkle 114 latanoprost 135 ketodan 77 KORLYM 32 LATUDA 54 KOSHER PRENATAL PLUS LAZANDA 10 ketoprofen 6 IRON 122 LEDIPASVIR/SOFOSBUVIR KETOROLAC kp folic acid 103 TROMETHAMINE 6 59 ketorolac tromethamine 6 KRINTAFEL 45 leflunomide 7 ketorolac tromethamine KRISTALOSE 107 LENVIMA 10 MG DAILY (ophth) 135 KUVAN 94 DOSE 50 KEVEYIS 91 KYLEENA 69 LENVIMA 12MG DAILY DOSE 50 KEVZARA 4 l-methylfolate 90 LENVIMA 14 MG DAILY KHEDEZLA 30 L-METHYLFOLATE CA/S- DOSE 50 KIMONO COLORS 108 ALGAL 90 LENVIMA 18 MG DAILY L-METHYLFOLATE KIMONO LUBRICATED 108 DOSE 50 FORTE 90 LENVIMA 20 MG DAILY KIMONO MICRO THIN 108 labetalol hcl 61 DOSE 50 KIMONO MICRO THIN PLUS LAC-HYDRIN 86 LENVIMA 24 MG DAILY SPERMICIDE DOSE 50 LUBRICATED 108 LAC-HYDRIN TWELVE 86 LENVIMA 4 MG DAILY KIMONO PLUS SPERMICIDE LACRISERT 130 DOSE 50 LUBRICATED 108 lactated ringer's LENVIMA 8 MG DAILY KIMONO PLUS (irrigation) 117 DOSE 50 SPERMICIDE/LUBRICATED lactic acid (ammonium LESCOL XL 40 109 lactate) 86 LETAIRIS 64 KIMONO PS LUBRICATED109 LACTULOSE 107 letrozole 48 KIMONO PS PLUS lactulose 107 leucovorin calcium 52 SPERMICIDE/LUBRICATED lactulose (encephalopathy)99 109 LEUKERAN 46 LAMICTAL 26 KIMONO SENSATION LEUKINE 103 LUBRICATED 109 LAMICTAL CHEWABLE KIMONO SENSATION PLUS DISPERSIBLE 25 leuprolide acetate 48 SPERMICIDE LAMICTAL ODT 25 LEUPROLIDE LUBRICATED 109 LAMICTAL STARTER/NOT ACETATE/BUPIVACAINE KIMONO SPECIAL 109 TAKING HYDROCHLORIDE 48 CARBAMAZEPINE 25 levalbuterol hcl 22

Index 13 levalbuterol tartrate 22 LINZESS 99 LOTREL 43 LEVAQUIN 98 LIORESAL LOTRISONE 78 LEVBID 148 INTRATHECAL 128 LOTRONEX 99 liothyronine sodium 147 LEVEMIR 33 lovastatin 40 LIPITOR 40 LEVEMIR FLEXTOUCH 33 LOVAZA 39 LIPOFEN 40 levetiracetam 26 LOVENOX 24 lisinopril 41 levobunolol hcl 131 loxapine succinate 55 lisinopril & levocarnitine (metabolic hydrochlorothiazide 43 luliconazole 78 modifiers) 94 LITHIUM 54 LUMIGAN 135 levocetirizine dihydrochloride38 lithium carbonate 54 LUMIZYME 94 levofloxacin 98 LITHOBID 54 LUNESTA 105 levofloxacin (ophth) 132 LUPANETA PACK 94 LEVOMEFOLATE CALCIUM LITHOSTAT 101 ALGAL POWDER 90 LIVALO 40 LUPRON DEPOT (1- levonorgestrel & eth MONTH) 48 LO LOESTRIN FE 68 LUPRON DEPOT (3- estradiol 68 LOCOID 84 levonorgestrel (emergency MONTH) 48 oc) 69 LOCOID LIPOCREAM 84 LUPRON DEPOT (4- levonorgestrel-eth estradiol LODINE 6 MONTH) 48 LUPRON DEPOT (6- (triphasic) 68 LODOSYN 52 levonorgestrel-ethinyl estradiol MONTH) 48 (91-day) 68 LOESTRIN 1.5/30-21 68 LUPRON DEPOT-PED (1- levonorgestrel-ethinyl estradiol LOESTRIN 1/20-21 68 MONTH) 94 (continuous) 68 LUPRON DEPOT-PED (3- LOESTRIN FE 1.5/30 68 MONTH) 94 levothyroxine sodium 147 LOESTRIN FE 1/20 68 LUXIQ 84 LEVSIN 148 LOKELMA 117 LUZU 78 LEVSIN/SL 148 LOMOTIL 34 LYNPARZA 50 LEXAPRO 29 LONSURF 49 LYRICA 26 LEXIVA 57 loperamide hcl 34 LYSODREN 49 LIALDA 99 LOPID 40 LYSTEDA 104 LIBRAX 148 lopinavir-ritonavir 57 M-NATAL PLUS 122 lido-k 87 LOPRESSOR 61 M-VIT 122 lidocaine 87 LOPRESSOR HCT 43 MACROBID 152 lidocaine hcl 87 LOPROX 78 MACRODANTIN 152 lidocaine hcl (mouth-throat) 117 LOPROX SHAMPOO 78 mafenide acetate 80 lidocaine pak 87 lorazepam 18 MAGNEBIND 400 113 lidocaine-hydrocortisone acetate lorazepam intensol 18 (rectal) 14 magnesium sulfate 113,114 lidocaine-prilocaine 88 LORBRENA 50 MAGNESIUM SULFATE 114 LIDODERM 88 lorcet 12 MAKENA 139 LIDODOSE 88 LORTAB 12 MALARONE 45 LIDODOSE PEDIATRIC BULK lorzone 128 malathion 89 PACK 88 losartan potassium 42 maprotiline hcl 28 lidopin 87 losartan potassium & MARINOL 36 LIDORX 88 hydrochlorothiazide 43 LOSEASONIQUE 68 MARNATAL-F 122 LILETTA 69 MARPLAN 28 LINCOCIN 17 LOTEMAX 133 LOTENSIN 41 MATULANE 52 lincomycin hcl 17 matzim la 62 lindane 89 LOTENSIN HCT 43 loteprednol etabonate 133 MAVENCLAD 140 linezolid 17 MAVYRET 60

Index 14 MAXALT 112 MESTINON 45 METOPROLOL SUCCINATE MAXALT-MLT 112 MESTINON TIMESPAN 45 ER/HYDROCHLOROTHIAZIDE 43 MAXIDEX 133 metadate er 2 metoprolol tartrate 61 MAXIPIME 66 metaproterenol sulfate 22 METROCREAM 88 MAXITROL 133 metaxall 128 METROGEL 89 MAXX LUBRICATED 109 metaxalone 128 METROGEL-VAGINAL 154 MAXX PLUS SPERMICIDE metformin hcl 32 METROLOTION 89 LUBRICATED 109 METFORMIN MAXZIDE 91 HYDROCHLORIDE 32 metronidazole 15 MAXZIDE-25 91 methadone hcl 10 metronidazole (topical) 89 MAYZENT 140 METHADONE HCL 11 metronidazole in nacl 15 MAYZENT STARTER methadone hcl 11 metronidazole vaginal 154 PACK 140 methadone hcl intensol 10 mexiletine hcl 19 mccarnitine 94 methadose 10 mezparox-hc 81 meclizine hcl 35 methamphetamine hcl 1 MIACALCIN 92 meclofenamate sodium 6 methazolamide 91 micafungin sodium 36 MEDROL 70,71 methenamine hippurate 152 MICARDIS 42 MEDROL DOSEPAK 70 methenamine mandelate 152 MICARDIS HCT 44 MEDROX-RX 87 methergine 136 miconazole 3 154 medroxyprogesterone methimazole 146 miconazole-zinc oxide-white acetate 139 petrolatum 78 medroxyprogesterone acetate METHITEST 13 MICROZIDE 92 (contraceptive) 70 methocarbamol 128 mefenamic acid 6 midazolam hcl 105 METHOTREXATE 4 midodrine hcl 155 mefloquine hcl 45 methotrexate sodium 47 MEGACE ES 139 migergot 111 methoxsalen rapid 79 miglitol 31 megestrol acetate 49 methscopolamine megestrol acetate bromide 148 miglustat 102 (appetite) 139 methyclothiazide 92 MIGRANAL 111 MEKINIST 50 methyldopa 42 MILLIPRED 71 MEKTOVI 50 methyldopa & MILLIPRED DP 71 melodetta 24 fe 67 hydrochlorothiazide 43 MINASTRIN 24 FE 68 meloxicam 6 methyldopate hcl 42 MINIPRESS 42 melphalan 46 methylergonovine minitran 17 maleate 136 melphalan hcl 46 METHYLIN 2 MINIVELLE 97 memantine hcl 139 methylphenidate hcl 2,3 MINOCIN 146 MENEST 97 METHYLPHENIDATE minocycline hcl 146 MENOSTAR 97 HYDROCHLORIDE ER 3 minoxidil 45 meperidine hcl 10 methylprednisolone 71 MIRALAX 107 MEPHYTON 155 methyltestosterone 13 MIRAPEX 53 meprobamate 18 metipranolol 131 MIRAPEX ER 53 MEPRON 16 metoclopramide hcl 98 MIRCERA 103 mercaptopurine 47 METOCLOPRAMIDE ODT 98 MIRCETTE 68 meropenem 16 metolazone 92 MIRENA 69 MERREM 16 metopic 85 mirtazapine 28 mesalamine 99 METOPIRONE 89 MIRVASO 89 mesalamine w/ cleanser 99 metoprolol & misoprostol 151 hydrochlorothiazide 43 MESNEX 52 MITIGARE 102 metoprolol succinate 61

Index 15 mitoxantrone hcl 49 MYFORTIC 116 NATURE-THROID 147 MOBIC 6 MYKIDZ IRON 10 104 NATURE-THROID NT-2.5 147 modafinil 3 MYLERAN 46 NAYZILAM 24 moderiba 59 MYNATAL ADVANCE 122 NEBUPENT 15 MODERIBA 1200 DOSE MYNATAL nebusal 73 PACK 60 ULTRACAPLET 122 NEBUSAL 73 moexipril hcl 41 MYNATE 90 PLUS 122 NEEVO DHA 122 moexipril-hydrochlorothiazide MYRBETRIQ 153 nefazodone hcl 29 44 MYSOLINE 26 molindone hcl 56 neo-polycin 132 MYTESI 34 mometasone furoate 84 neo-polycin hc 133 nabumetone 6 mometasone furoate NEO-SYNALAR 77 nadolol 62 (nasal) 130 neomycin sulfate 4 mondoxyne nl 146 nadolol & bendroflumethiazide 44 neomycin-bacitracin zn- montelukast sodium 19 polymyxin 132 NAFCILLIN 138 MONUROL 152 neomycin-polymy- nafcillin sodium 138 dexameth 133 morgidox 1x100mg 146 NAFCILLIN SODIUM 138 neomycin-polymyxin-gramicidin morphine sulfate 11 nafcillin sodium 138 132 morphine sulfate beads 11 neomycin-polymyxin-hc naftifine hcl 78 MOTOFEN 34 (ophth) 133 NAFTIN 78 neomycin-polymyxin-hc MOVANTIK 99 NAGLAZYME 94 (otic) 136 MOVIPREP 106 NALFON 6 neomycin/polymyxin b gu 101 MOXATAG 137 naloxone hcl 35 NEONATAL COMPLETE 122 MOXEZA 132 naltrexone hcl 35 NEONATAL PLUS 122 moxifloxacin hcl 98 NAMENDA 139 NEONATAL VITAMIN 122 moxifloxacin hcl (ophth) 132 NAMENDA TITRATION NEORAL 116 MOZOBIL 104 PAK 139 NEOSPORIN 132 MS CONTIN 11 NAMENDA XR 139 NEOTUSS PLUS 72 MUCOTROL 118 NAMENDA XR TITRATION NEPTAZANE 91 PACK 139 MULPLETA 103 NERLYNX 51 NAPRELAN 6 MULTAQ 19 NESINA 32 NAPROSYN 6 MULTI PRENATAL 122 NESTABS 123 naproxen 6 multi-vit/iron/fluoride 120 NESTABS ABC 122 naproxen dr 5 multi-vitamin/fluoride drops 118 NESTABS DHA 122 naproxen sodium 6 MULTIVITAMIN WITH NESTABS ONE 123 FLUORIDE 118 naproxen-esomeprazole neuac 73 multivitamin with fluoride 118 magnesium 6 naratriptan hcl 112 NEULASTA 103 multivitamin/fluoride 119 NARCAN 35 NEULASTA ONPRO KIT 103 multivitamins/fluoride 119 NARDIL 28 NEUPOGEN 103 mupirocin 77 NASONEX 130 NEUPRO 53 MYALEPT 94 NATACHEW 122 NEURONTIN 26 MYAMBUTOL 46 NATACYN 132 NEUTROGENA CLEAR PORE MYCAMINE 36 NATAZIA 68 CLEANSER/MASK 75 MYCOBUTIN 46 NEVANAC 135 nateglinide 33 mycophenolate mofetil 116 nevirapine 57 NATELLE ONE 122 mycophenolate mofetil hcl 116 NEXA PLUS 123 NATPARA 92 mycophenolate sodium 116 NEXAVAR 51 NATROBA 89 MYDRIACYL 131 NEXIUM 150

Index 16 NEXIUM 24HR 150 norethin acet & estrad-fe 68 OB COMPLETE PETITE 123 NEXIUM 24HR CLEAR norethindrone & ethinyl OB COMPLETE PREMIER 123 MINIS 150 estradiol-fe 68 OB COMPLETE/DHA 123 NEXPLANON 69 norethindrone OBSTETRIX ONE 123 niacin (antihyperlipidemic) 41 (contraceptive) 70 norethindrone acet & eth OCALIVA 98 NIASPAN 41 estra 68 OCTAGAM 137 nicardipine hcl 62 norethindrone acetate 139 octreotide acetate 95 NICODERM CQ 144 norethindrone acetate-ethinyl OCUFLOX 132 NICORETTE 144 estradiol 96 ODACTRA 3 NICORETTE MINI 144 NORGESIC FORTE 129 ODEFSEY 58 NICORETTE STARTER norgestimate-ethinyl KIT 145 estradiol 68 ODOMZO 48 norgestimate-ethinyl estradiol OFEV 145 nicotine 145 (triphasic) 68 nicotine polacrilex 145 NORITATE 89 ofloxacin 98 NICOTINE TRANSDERMAL NORMOSOL-R 113 ofloxacin (ophth) 132 SYSTEM 145 NORPACE 18 ofloxacin (otic) 135 NICOTROL INHALER 145 ogestrel 67 NICOTROL NS 145 NORPACE CR 18 NORPRAMIN 30 olanzapine 55 nifedipine 62 olanzapine-fluoxetine hcl 140 NILANDRON 49 NORTHERA 155 nortrel 0.5/35 (28) 67 olmesartan medoxomil 42 nilutamide 49 olmesartan medoxomil- nimodipine 62 nortriptyline hcl 30 amlodipine-hydrochlorothiazide NINLARO 51 NORVASC 63 44 olmesartan medoxomil- nisoldipine 63 NORVIR 58 NOXAFIL 37 hydrochlorothiazide 44 nitisinone 94 olopatadine hcl 135 np thyroid 120 147 NITRO-BID 17 olopatadine hcl (nasal) 129 NUBEQA 49 NITRO-DUR 17 OLUX 84 NUCORT 84 nitro-time 17 OLUX-E 84 NUCYNTA 11 nitrofurantoin 152 OMECLAMOX-PAK 151 NUCYNTA ER 11 nitrofurantoin macrocrystal 152 omega-3-acid ethyl esters 39 NUEDEXTA 141 nitrofurantoin monohyd omeppi 151 macro 152 NULOJIX 116 nitroglycerin 17 NULYTELY/FLAVOR omeprazole 151 NITROLINGUAL PACKS 106 OMEPRAZOLE + SYRSPEND PUMPSPRAY 17 NUPLAZID 54 SFALKA 151 omeprazole-sodium NUTROPIN AQ NUSPIN NITROMIST 17 bicarbonate 151 NITROSTAT 17 10 93 NUTROPIN AQ NUSPIN OMNARIS 130 NITYR 94 20 93 OMNIPRED 133 NIVA-PLUS 123 NUTROPIN AQ NUSPIN 5 93 OMNITROPE 93 NIVESTYM 103 NUVARING 69 ondansetron 35 NIZATIDINE 149 NUVIGIL 3 ondansetron hcl 35 nizatidine 149 NYMALIZE 63 ONETOUCH ULTRA 90 NIZORAL 78 nystatin 36 ONETOUCH ULTRA 2 110 NOCTIVA 95 nystatin (mouth-throat) 117 ONETOUCH ULTRA MINI 110 nolix 81 nystatin (topical) 78 ONETOUCH VERIO 110 NON PREFERRED TEST nystatin-triamcinolone 78 ONETOUCH VERIO FLEX STRIPS 90 O-CAL FA 123 BLOOD GLUCOSE NORCO 12 MONITORING SYSTEM 110 NORDITROPIN FLEXPRO 93 OB COMPLETE ONE 123

Index 17 ONETOUCH VERIO IQ BLOOD OSMOLEX ER 53 PARAGARD INTRAUTERINE GLUCOSE MONITORING OSMOPREP 107 COPPER CONTRACEPTIVE SYSTEM 110 T380A 69 ONETOUCH VERIO SYNC OSPHENA 93 paregoric 34 BLOODGLUCOSE OTEZLA 7 PAREMYD 135 MONITORING SYSTEM 110 OTICIN HC NR 136 ONETOUCH VERIO TEST paricalcitol 95 STRIPS 90 OTOVEL 136 PARLODEL 53 ONEVITE 118 OTREXUP 4 PARNATE 28 ONFI 24 OVACE PLUS 80 paroex 117 OPANA 11 OVACE PLUS WASH 80 paromomycin sulfate 4 opium tincture 34 OVACE WASH 80 paroxetine hcl 29 OPSUMIT 64 OVIDE 89 paroxetine mesylate OPTIONS CONCEPTROL OXACILLIN SODIUM 138 (vasomotor) 145 VAGINAL oxacillin sodium 138 PASER 46 CONTRACEPTIVE 153 oxandrolone 13 PATADAY 135 OPTIONS GYNOL II VAGINALCONTRACEPTIVE oxaprozin 6 PATANASE 129 153 OXAYDO 11 PATANOL 135 ORACEA 89 oxazepam 18 PAXIL 29 ORACIT 100 oxcarbazepine 26 PAXIL CR 29 ORAFATE 118 OXERVATE 133 pediatric vitamins acd w/ fluoride 120 ORALAIR 3 oxiconazole nitrate 78 peg 3350-kcl-sod bicarb-sod ORALAIR ADULT SAMPLE OXISTAT 78 chloride-sod sulfate 106 KIT 3 peg 3350-potassium chloride-sod ORALAIR ADULT STARTER OXSORALEN ULTRA 79 OXTELLAR XR 26 bicarbonate-sod chloride 106 PACK 3 PEGANONE 27 oralone dental paste 117 oxybutynin chloride 152 PEGASYS 60 ORAP 141 oxycodone hcl 11 PEGASYS PROCLICK 60 ORAPRED ODT 71 oxycodone w/ PEGINTRON 60 ORAVIG 117 acetaminophen 12 oxycodone-aspirin 12 penicillamine 115 orazinc 115 oxycodone-ibuprofen 12 penicillin g potassium 137 ORENCIA 7 oxymorphone hcl 11 PENICILLIN G POTASSIUM IN ORENCIA CLICKJECT 7 OXYTROL 152 ISO-OSMOTIC ORENITRAM 64 DEXTROSE 137 OXYTROL FOR WOMEN 152 ORFADIN 95 PENICILLIN G PROCAINE 137 OZEMPIC 32 ORKAMBI 145 penicillin g sodium 137 pacerone 19 orphenadrine citrate 128 penicillin v potassium 137 orphenadrine w/ aspirin & paliperidone 55 PENLEN 88 caff 129 palonosetron hcl 35 PENNSAID 77 PALONOSETRON ORTHO MICRONOR 70 pentamidine isethionate 15 ORTHO TRI-CYCLEN 68 HYDROCHLORIDE 35 PALYNZIQ 95 PENTASA 99 ORTHO TRI-CYCLEN LO 68 PAMELOR 30 pentazocine w/ naloxone 13 ORTHO-CYCLEN 69 pamidronate disodium 92 pentoxifylline 102 ORTHO-NOVUM 1/35 69 PAMIDRONATE PEPCID 149 ORTHO-NOVUM 7/7/7 69 DISODIUM 92 PEPCID AC MAXIMUM oscimin 147 PANCREAZE 90 STRENGTH 149 oscimin sr 147 PANDEL 84 PERCOCET 12 oseltamivir phosphate 60 PANRETIN 79 PERFOROMIST 22 OSENI 31 pantoprazole sodium 151 PERIDEX 117 perindopril erbumine 41

Index 18 permethrin 89 PLASMA-LYTE A 113 potassium chloride perphenazine 56 PLASMA-LYTE-148 113 microencapsulated crystals er 114 perphenazine-amitriptyline 140 PLAVIX 102 potassium chloride proamp 114 PERSERIS 55 PLEGRIDY 140 potassium citrate PERTZYE 90 PLEGRIDY STARTER (alkalinizer) 100 PEXEVA 29 PACK 140 potassium citrate-citric acid 100 PLENVU 106 pfizerpen 137 POVIDONE IODINE 132 PLEXION 76 phenadoz 38 PR NATAL 400 EC 123 PLEXION CLEANSER 75 phenazo 101 PR NATAL 430 123 PLEXION CLEANSING phenazopyridine hcl 101 CLOTHS 76 PR NATAL 430 EC 123 phenelzine sulfate 28 PNV FOLIC ACID + IRON PRADAXA 24 PHENERGAN 38 MULTIVITAMIN 123 PRALUENT 41 phenobarbital 105 PNV OB+DHA 123 pramegel hcl 87 PNV PRENATAL PLUS pramipexole dihydrochloride 53 phenoxybenzamine hcl 41 MULTIVITAMIN 123 phenylephrine hcl PNV TABS 29-1 123 PRAMOSONE 84 (mydriatic) 131 PRAMOSONE E 84 PHENYTEK 27 pnv-dha 120 PNV-DHA+DOCUSATE 123 PRAMOTIC 136 phenytoin 27 pramoxine-hc 84 phenytoin infatabs 27 PNV-OMEGA 123 pnv-select 120 PRANDIN 33 phenytoin sodium 28 prasugrel hcl 102 phenytoin sodium extended 27 PNV-TOTAL 123 PODOCON 25 IN BENZOIN PRAVACHOL 40 PHLAG SPRAY 88 TINCTURE 86 pravastatin sodium 40 PHOSLYRA 100 podofilox 86 praziquantel 15 phosphasal 151 POLY-VI-FLOR 120 prazosin hcl 42 PHOSPHOLINE IODIDE 131 POLY-VI-FLOR/IRON 120 PRECISION XTRA 90 physiolyte 117 polyethylene glycol 3350 107 PRECISION XTRA BLOOD phytonadione 155 polymyxin b sulfate 17 GLUCOSE TEST STRIPS 90 PICATO 79 polymyxin b-trimethoprim 132 PRECOSE 31 PIFELTRO 58 POLYTRIM 132 PRED FORTE 134 pilocarpine hcl 131 POMALYST 49 PRED MILD 134 pilocarpine hcl (oral) 118 posaconazole 37 PRED-G 134 pimecrolimus 86 pot & sod citrates w/citric PRED-G S.O.P. 134 pimozide 141 ac 100 prednicarbate 84 pindolol 62 pot phosphate monobasic w/ prednisolone 71 sod phosphate dibasic & pioglitazone hcl 32 prednisolone acetate monobasic 114 (ophth) 134 pioglitazone hcl-glimepiride 31 POTABA 155 PREDNISOLONE ACETATE P- pioglitazone hcl-metformin potassium F 134 hcl 31 aminobenzoate 155 prednisolone sodium piperacillin sodium-tazobactam potassium bicarb & phosphate 71 sodium 138 chloride 114 PREDNISOLONE SODIUM PIQRAY 200MG DAILY potassium bicarbonate 114 PHOSPHATE 134 DOSE 51 prednisone 71 PIQRAY 250MG DAILY potassium chloride 114,115 DOSE 51 POTASSIUM CHLORIDE 115 PREDNISONE INTENSOL 71 PIQRAY 300MG DAILY potassium chloride 115 PREFERAOB +DHA 123 DOSE 51 potassium chloride in PREFEST 96 piroxicam 6 nacl 113 pregabalin 26 PLAN B ONE-STEP 69 PREMARIN 97,154 PLAQUENIL 45

Index 19 PREMESISRX 124 primaquine phosphate 45 propantheline bromide 148 PREMIUM CONDOMS PRIMAQUINE proparacaine hcl 133 LUBRICATED 109 PHOSPHATE 45 propranolol & PREMPHASE 96 PRIMAXIN IV 16 hydrochlorothiazide 44 PREMPRO 96 primidone 26 propranolol hcl 62 PRENA 1 TRUE 124 PRIMLEV 12 propylthiouracil 146 PRENA1 PEARL 124 PRIMSOL 15 PROSCAR 101 PRENAISSANCE 124 PRINIVIL 41 PROTHELIAL 118 PRENAISSANCE PRISTIQ 30 PROTONIX 151 BALANCE 124 PRIVIGEN 137 PROTOPIC 86 PRENAISSANCE HARMONY DHA 124 PROAIR HFA 22 protriptyline hcl 31 PRENAISSANCE NEXT 124 PROAIR RESPICLICK 22 PROVENTIL HFA 22 PRENAISSANCE NEXT-B 124 probenecid 102 PROVERA 139 PRENAISSANCE PLUS 124 procainamide hcl 18 PROVIDA DHA 125 PRENATA 124 PROCARDIA 63 PROVIDA OB 125 prenatabs rx 120 PROCARDIA XL 63 PROVIGIL 3 PRENATAL 124,125 procentra 1 PROZAC 29 prenatal 19 120 prochlorperazine 56 PRUDOXIN 79 PRENATAL 19 124 prochlorperazine maleate 56 pseudoephed-cpm w/ hydrocod 73 PRENATAL LOW IRON 124 PROCORT 14 PSORCON 84 PRENATAL ONE DAILY 124 PROCRIT 103 PULMICORT 21 procto-med hc 14 PRENATAL PLUS 124 PULMICORT PRENATAL PLUS IRON 124 PROCTOCORT 15 FLEXHALER 20,21 PRENATAL VITAMIN 125 PROCTOFOAM HC 14 pulmosal 73 PRENATAL VITAMINS PLUS PROCYSBI 101 PULMOZYME 145 LOW IRON 125 profeno 5 PURIXAN 47 PRENATAL-U 125 progesterone 139 PYLERA 151 PRENATE 125 progesterone micronized 139 pyrazinamide 46 PRENATE AM 125 PROGLYCEM 32 PYRIDIUM 101 PRENATE DHA 125 PROGRAF 116 pyridostigmine bromide 45 PRENATE ELITE 125 PROLASTIN-C 145 pyrimethamine 45 PRENATE ESSENTIAL 125 PROLATE 12 QBRELIS 41 PRENATE MINI 125 PROLENSA 135 qc allergy relief childrens 38 PRENATE PIXIE 125 PROLIA 92 QNASL 130 PREPLUS 125 PROMACTA 103 QNASL CHILDRENS 130 PREPOPIK 106 promethazine & QUALAQUIN 45 PREVACID 151 phenylephrine 72 QUARTETTE 69 PREVACID 24HR 151 promethazine hcl 38,39 quazepam 105 PREVACID SOLUTAB 151 promethazine vc plain 71 QUDEXY XR 26 prevalite 39 promethazine vc/codeine 71 QUESTRAN 39 previfem 67 promethazine w/codeine 72 QUESTRAN LIGHT 39 PREVYMIS 59 promethazine-dm 73 quetiapine fumarate 55 PREZCOBIX 58 promethazine-phenylephrine- codeine 73 QUFLORA GUMMIES 120 PREZISTA 58 promethegan 38 QUFLORA PEDIATRIC 120 PRIFTIN 46 PROMETRIUM 139 QUILLIVANT XR 3 PRILOSEC 151 propafenone hcl 19 quinapril hcl 41 PRIMACARE 125

Index 20 quinapril-hydrochlorothiazide RELEXXII 3 RILUTEK 130 44 RELISTOR 100 riluzole 130 quinidine gluconate 18 RELNATE DHA 125 rimantadine hydrochloride 60 quinidine sulfate 18 RELPAX 112 ringer's irrigation 117 quinine sulfate 45 REMERON 28 RINVOQ 4 QUINJA 78 REMERON SOLTAB 28 RIOMET 32 QVAR REDIHALER 21 REMICADE 99 risedronate sodium 92 R-NATAL OB 125 REMODULIN 64 RISPERDAL 55 ra nicotine 142 RENAGEL 100 RISPERDAL CONSTA 55 rabeprazole sodium 151 RENVELA 100 risperidone 55 RABEPRAZOLE SODIUM DR SPRINKLE 151 repaglinide 33 risperidone m-tab 54 RADIOGARDASE 35 repaglinide-metformin hcl 31 RITALIN 3 RAGWITEK 3 REPATHA 41 RITALIN LA 3 rajani 66 REPATHA PUSHTRONEX ritonavir 58 SYSTEM 41 raloxifene hcl 93 RITUXAN 47 REPATHA SURECLICK 41 ramelteon 106 RITUXAN HYCELA 49 REQUIP 53 ramipril 41 rivastigmine 140 REQUIP XL 53 RANEXA 17 rivastigmine tartrate 140 RESCRIPTOR 58 ranitidine hcl 149 rizatriptan benzoate 112 RESCULA 135 ranolazine 17 ROBAXIN 128 RESTASIS 133 RAPAFLO 101 ROBAXIN-750 128 RESTASIS MULTIDOSE 133 RAPAMUNE 116 ROBINUL 148 RESTORIL 105 rasagiline mesylate 54 ROBINUL FORTE 148 RETACRIT 103 RASUVO 4 ROCALTROL 95 RETIN-A 76 RAVICTI 95 ROMIDEPSIN 51 RETIN-A MICRO 76 RAYALDEE 95 ropinirole hydrochloride 53 RETIN-A MICRO PUMP 76 RAYOS 71 rosadan 88 RETROVIR 58 RAZADYNE 140 rosuvastatin calcium 40 REVATIO 64 RAZADYNE ER 140 ROTATEQ 153 REVLIMID 115 REALITY LATEX ROWASA 99 REXULTI 56 CONDOMS/LUBRICATED 109 roweepra 25 REALITY LATEX/ULTRA REYATAZ 58 roweepra xr 25 TEXTURED 109 RHOFADE 89 REALITY LATEX/ULTRA ROXICET 12 RIAX 76 THIN 109 ROXICODONE 11 ribasphere 59 REBETOL 60 ROXYBOND 11 ribasphere ribapak 59 REBIF 141 ROZEREM 106 RIBASPHERE RIBAPAK 60 REBIF REBIDOSE 141 ROZLYTREK 51 ribavirin 61 REBIF REBIDOSE RUBRACA 51 TITRATIONPACK 141 ribavirin (hepatitis c) 60 RUCONEST 102 REBIF TITRATION PACK 141 RIDAURA 4 RUZURGI 45 RECLAST 92 rifabutin 46 ryclora 37 RECOMBIVAX HB 153 RIFADIN 46 RYDAPT 51 RECTIV 15 RIFAMATE 45 RYTARY 53 REGLAN 99 rifampin 46 RYTHMOL SR 19 REGRANEX 89 RIFATER 46 SABRIL 27 relagard 153 RIGHT STEP RELENZA DISKHALER 60 PRENATAL 125 SAFYRAL 69

Index 21 SALAGEN 118 sertraline hcl 29 SODIUM SULFACETAMIDE SALEX 86 sevelamer carbonate 100 WASH 80 SODIUM SALEX LOTION 86 sevelamer hcl 100 SULFACETAMIDE/SULFUR salicylic acid 86,87 SFROWASA 99 76 salicylic acid in ammonium SHUR-SEAL 154 SODIUM SULFACETAMIDE/SULFUR lactate vehicle 87 SIGNIFOR 95 salicylic acid w/ cleanser 87 CLEANSER IN UREA 76 SIKLOS 103 SOFOSBUVIR/VELPATASVIR salicylic acid wart remover 86 SILDENAFIL CITRATE 64 60 salimez 86 sildenafil citrate (pulmonary solifenacin succinate 152 SALISOL 87 hypertension) 64 SOLIQUA 100/33 31 salisol forte 86 SILENOR 105 SOLODYN 146 SALITECH 87 SILIQ 79 SOLTAMOX 49 salitech forte 86 silodosin 101 SOMA 128 salsalate 9 SILVADENE 80 SOMATULINE DEPOT 95 SALVAX 87 silver sulfadiazine 80 SOMAVERT 93 SAMSCA 96 SIMBRINZA 131 SONATA 105 SANCUSO 35 SIMCOR 40 SOOLANTRA 89 SANDIMMUNE 116 SIMPONI 4 SORIATANE 79 SANDOSTATIN 95 SIMPONI ARIA 4 SORILUX 79 SANDOSTATIN LAR SIMULECT 116 sorine 61 DEPOT 95 simvastatin 40 SANTYL 86 sotalol hcl 62 SINEMET 53 SAPHRIS 55 sotalol hcl (afib/afl) 62 SINEMET CR 53 SARAFEM 141 SOTYLIZE 62 SINGULAIR 19 SAVAYSA 23 SOVALDI 60 sirolimus 116 SAVELLA 140 SPECTRACEF 65 SIRTURO 46 SAVELLA TITRATION spinosad 89 PACK 140 SIVEXTRO 17 SPIRIVA HANDIHALER 19 scopolamine 35 SKELAXIN 128 SPIRIVA RESPIMAT 19 SE-NATAL 19 125,126 SKLICE 89 spironolactone 91 SEASONIQUE 69 SKYLA 69 spironolactone & seb-prev wash 80 SKYRIZI 79 hydrochlorothiazide 91 SECONAL SODIUM 105 SLYND 70 SPORANOX 37 SECUADO 55 sm nicotine 143 SPORANOX PULSEPAK 37 SEEBRI NEOHALER 19 sm nicotine polacrilex 143 SPRIX 6 SEGLUROMET 31 sm nicotine transdermal SPRYCEL 51 system 144 SELECT-OB 126 ssd 80 sodium chloride 115 SELECT-OB+DHA 126 sss 10-5 74 sodium chloride (gu ST JOSEPH ADULT 9 selegiline hcl 54 irrigant) 101 ST JOSEPH ADULT selenium sulfide 80 sodium chloride (inhalant) 73 ANALGESICLOW DOSE BITE SELZENTRY 58 sodium citrate & citric SIZE 9 SEMPREX-D 73 acid 100 STALEVO 100 53 SODIUM EDECRIN 91 SENSIPAR 95 STALEVO 125 53 sodium fluoride 113 SEREVENT DISKUS 22 STALEVO 150 53 sodium phenylbutyrate 95 SEROQUEL 55 sodium polystyrene STALEVO 200 54 SEROQUEL XR 55 sulfonate 117 STALEVO 50 54 SEROSTIM 93 sodium sulfacetamide STALEVO 75 54 wash 80

Index 22 STARLIX 33 SURMONTIL 31 TASMAR 53 stavudine 58 SUSTIVA 58 TAVALISSE 102 STEGLATRO 34 SUTENT 51 TAYTULLA 69 STELARA 79 SUVICORT 88 tazarotene 80 STIMATE 95 SYLATRON 52 tazicef 65 STIOLTO RESPIMAT 22 SYMBICORT 22 TAZORAC 80 STIVARGA 51 SYMBYAX 140 taztia xt 62 STRATTERA 2 SYMDEKO 145 TAZVERIK 51 STRENSIQ 95 SYMLINPEN 120 31 TECFIDERA 141 streptomycin sulfate 4 SYMLINPEN 60 31 TECFIDERA STARTER STRIANT 13 SYMPROIC 100 PACK 141 TECHNIVIE 60 STRIBILD 58 SYMTUZA 58 TEFLARO 66 STRIVERDI RESPIMAT 22 SYNALAR 84 TEGRETOL 26 STROMECTOL 15 SYNAREL 94 TEGRETOL-XR 27 SUBOXONE 13 SYNERA 88 TEGSEDI 145 SUBSYS 11 SYNERDERM 88 TEKTURNA 44 subvenite 25 SYNJARDY 31 TEKTURNA HCT 44 subvenite starter kit/blue 25 SYNJARDY XR 31 telmisartan 42 SUCRAID 90 SYNTHROID 147 telmisartan-amlodipine 44 sucralfate 149 SYPRINE 115 telmisartan-hydrochlorothiazide SULAR 63 TABLOID 47 44 sulconazole nitrate 78 TACLONEX 84 temazepam 105 sulfacetamide sod- tacrolimus 116 TEMODAR 46 prednisolone 134 tacrolimus (topical) 86 TEMOVATE 84 sulfacetamide sodium 80 tadalafil 63 temozolomide 46 sulfacetamide sodium (acne)76 tadalafil (pulmonary temsirolimus 51 sulfacetamide sodium hypertension) 64 tencon 7 (ophth) 132 TAFINLAR 51 sulfacetamide sodium w/ tenofovir disoproxil fumarate 58 TAGAMET HB 149 sulfur 76 TENORETIC 100 44 sulfacleanse 8/4 74 TAGRISSO 51 TENORETIC 50 44 SULFADIAZINE 145 TAKHZYRO 102 TENORMIN 61 sulfamethoxazole-trimethoprim TALTZ 80 TEPADINA 46 15 TALZENNA 51 TERAZOL 7 154 SULFAMYLON 80 TAMIFLU 60,61 terazosin hcl 42 sulfasalazine 99 tamoxifen citrate 49 terbinafine hcl 36 sulfatrim pediatric 15 tamsulosin hcl 101 terbutaline sulfate 22 sulindac 6 TANZEUM 32 terconazole vaginal 154 SUMADAN WASH 76 TAPAZOLE 146 TESSALON PERLES 71 sumatriptan 112 TARCEVA 51 TESTIM 14 sumatriptan succinate 112 TARGADOX 146 sumatriptan-naproxen testosterone 14 TARGRETIN 52,79 sodium 111 testosterone cypionate 14 TARKA 44 SUMAXIN 76 testosterone enanthate 14 TARON-BC 126 SUMAXIN TS 76 tetrabenazine 140 TARON-C DHA 126 SUMAXIN WASH 76 tetracaine hcl (ophth) 133 TARON-PREX 126 SUPRAX 65,66 tetracycline hcl 146 SUPREP BOWEL PREP TASIGNA 51 KIT 107 TEXACORT 85

Index 23 THALOMID 115 TOBRADEX ST 134 travoprost 135 THEO-24 22 tobramycin 4 trazodone hcl 30 theophylline 22,23 tobramycin (ophth) 132 TRECATOR 46 THERANATAL CORE tobramycin inhalation solution TRELEGY ELLIPTA 22 NUTRITION 126 pak 3 TRELSTAR MIXJECT 49 THIOLA 101 tobramycin sulfate 4 TREMFYA 80 THIOLA EC 101 tobramycin- treprostinil 64 thioridazine hcl 56 dexamethasone 134 TOBREX 132 TRESIBA 33 thiotepa 46 TODAY SPONGE 154 TRESIBA FLEXTOUCH 33 thiothixene 56 TOFRANIL 31 TRETIN-X 76 THRIVITE 19 118 TOLAK 79 tretinoin 76 THRIVITE RX 126 tolazamide 34 tretinoin (chemotherapy) 52 THYMOGLOBULIN 116 tolbutamide 34 tretinoin microsphere 76 thyroid 147 tolcapone 53 TREXALL 47 THYROLAR-1 147 tolmetin sodium 7 TREXIMET 111 THYROLAR-1/2 147 TOLSURA 37 tri femynor 67 THYROLAR-1/4 147 tolterodine tartrate 152 TRI-NORINYL 28 69 THYROLAR-2 147 tolvaptan 96 TRI-TABS DHA 126 THYROLAR-3 147 TOPAMAX 27 TRI-VI-FLOR 120 tiagabine hcl 27 TOPAMAX SPRINKLE 27 TRI-VI-FLORO 120 TIAZAC 63 TOPICORT 85 tri-vitamin/fluoride 120 TIBSOVO 51 topiramate 27 triamcinolone acetonide TIGAN 35 (mouth) 117 toposar 52 tigecycline 146 triamcinolone acetonide topotecan hcl 52 TIGECYCLINE 146 (topical) 85 TOPOTECAN HCL 52 triamterene 91 TIKOSYN 19 topotecan hcl 52 triamterene & tilia fe 67 TOPROL XL 61 hydrochlorothiazide 91 timolol maleate 62 trianex 81 toremifene citrate 49 timolol maleate (ophth) 131 triazolam 105 TORISEL 51 TIMOPTIC 131 TRIBENZOR 44 torsemide 91 TIMOPTIC OCUDOSE 131 TOUJEO MAX TRICARE 126 TIMOPTIC-XE 131 SOLOSTAR 33 TRICARE PRENATAL DHA TINDAMAX 15 TOUJEO SOLOSTAR 33 ONE 126 TRICARE PRENATAL DHA tinidazole 15 tovet 80 ONE/FOLATE 126 TIROSINT 147 TOVIAZ 153 TRICOR 40 TIROSINT-SOL 147 TRACLEER 64 triderm 81 tis-u-sol 117 tramadol hcl 11 TRIDESILON 85 TIVICAY 58 tramadol-acetaminophen 12 trientine hcl 115 TIVORBEX 6 trandolapril 41 trifluoperazine hcl 56 tizanidine hcl 128 trandolapril-verapamil hcl 44 trifluridine 132 TL FOLATE 126 tranexamic acid 104 TRIGLIDE 40 TL-CARE DHA 126 TRANSDERM SCOP 35 trihexyphenidyl hcl 52 TL-SELECT 126 TRANSDERM-SCOP 35 TRIKAFTA 145 TOBI 4 TRANXENE T 18 triklo 39 TOBI PODHALER 4 tranylcypromine sulfate 28 TRILEPTAL 27 TOBRADEX 134 TRAVATAN Z 135 TRILIPIX 40

Index 24 trimethobenzamide hcl 36 TUSSICAPS 73 VAGIFEM 154 trimethoprim 15 tussigon 71 valacyclovir hcl 60 trimipramine maleate 31 TUSSIONEX PENNKINETIC VALCHLOR 79 TRIMPEX 15 EXTENDED RELEASE 73 VALCYTE 59 TUSSLIN 73 TRINTELLIX 30 valganciclovir hcl 59 TUSSLIN PEDIATRIC 73 TRISTART DHA 126 VALIUM 18 TWYNSTA 44 TRISTART ONE 126 valproic acid 28 TYBOST 58 TRIUMEQ 58 valsartan 42 TYGACIL 146 TRIZIVIR 58 valsartan-hydrochlorothiazide TYKERB 51 TROKENDI XR 27 44 TYLENOL/CODEINE #3 12 VALTOCO 25 tropicamide 131 TYLENOL/CODEINE #4 13 VALTREX 60 trospium chloride 153 TYMLOS 92 vanadom 128 TRULANCE 98 TYSABRI 141 vanatol lq 7 TRULICITY 32 UCERIS 14,71 VANCOCIN 16 TRUSOPT 135 TRUSTEX COLOR CONDOMS + UDAMIN SP 118 VANCOCIN HCL 16 LUBE 109 ULESFIA 89 vancomycin hcl 16 TRUSTEX LUBRICATED 109 ULORIC 102 vandazole 154 TRUSTEX LUBRICATED ULTIMATECARE ONE 126 VANOS 85 EXTRALARGE 109 ULTRACET 13 VARUBI 36 TRUSTEX LUBRICATED EXTRASTRENGTH 109 ULTRAM 11 VASCEPA 39 TRUSTEX ULTRASAL-ER 87 VASERETIC 44 LUBRICATED/RIBBED/STUDDE ULTRAVATE 85 VASOTEC 41 D 109 VCF VAGINAL TRUSTEX umecta mousse 85 UNASYN 138 CONTRACEPTIVE FILM 154 LUBRICATED/SPERMICIDE VCF VAGINAL 109 UNASYN BULK PACK 138 CONTRACEPTIVE FOAM 154 TRUSTEX UNISOM SLEEPGELS 105 LUBRICATED/SPERMICIDE vcf vaginal contraceptivegel153 EXTRA LARGE 109 UPTRAVI 64 VECAMYL 44 TRUSTEX URAMAXIN 85 VECTICAL 80 LUBRICATED/SPERMICIDE URE-K 85 VELCADE 51 EXTRA STRENGTH 109 TRUSTEX NATURAL urea 85 VELPHORO 100 CONDOMS urea hydrating 85 VELTASSA 117 +LUBE/LUBRICATED 109 urea nail 85 VELTIN 76 TRUSTEX NON- UREA NAIL 85 VEMLIDY 60 LUBRICATED 109 TRUSTEX WITH NONOXYNOL- URECHOLINE 153 VENA-BAL DHA 126 9/RIBBED/STUDDED 110 uribel 152 VENCLEXTA 48 TRUSTEX/RIA urimar-t 152 VENCLEXTA STARTING LUBRICATED 110 UROCIT-K 10 100 PACK 48 TRUSTEX/RIA LUBRICATED venlafaxine hcl 30 SPERMICIDE 110 UROCIT-K 15 100 TRUSTEX/RIA UROCIT-K 5 101 VENTAVIS 64 LUBRICATED/SPERMICIDE UROXATRAL 101 VENTOLIN HFA 22 110 URSO 250 98 verapamil hcl 63 TRUSTEX/RIA NON- VERDESO 85 LUBRICATED 110 URSO FORTE 98 TRUVADA 58 ursodiol 98 VEREGEN 77 TUDORZA PRESSAIR 19 UTIBRON NEOHALER 22 VERELAN 63 TURALIO 51 UTOPIC 85 VERELAN PM 63 VERIPRED 20 71

Index 25 VERSACLOZ 55 VITAMIN D3 IMMUNE XATMEP 47 VERZENIO 51 HEALTH 155 XELJANZ 4 VITAPEARL 127 VESICARE 153 XELJANZ XR 4 VITATHELY/GINGER 127 VFEND 37 XELODA 47 VITATRUE 127 VIBERZI 99 XENAZINE 140 VITRAKVI 51 VIBRAMYCIN 146 XERAC AC 88 VIVA DHA 127 VICTOZA 32 XERESE 80 VIVELLE-DOT 97,98 VIDAZA 47 XERMELO 100 VIVOTIF 153 VIDEX EC 58 XGEVA 93 VIVOTIF BERNA 153 VIDEXPEDIATRIC 58 XIAFLEX 115 VIZIMPRO 51 VIEKIRA PAK 60 XIFAXAN 15 VOGELXO 14 vigabatrin 27 XIIDRA 133 VOGELXO PUMP 14 vigadrone 27 XOLAIR 19 VOL-PLUS 127 VIGAMOX 132 XOLEGEL 79 VOL-TAB RX 127 VIIBRYD 30 XOPENEX 22 VOLTAREN 77 VIIBRYD STARTER PACK 30 XOPENEX CONCENTRATE 22 voriconazole 37 VIL-RX 126 XOPENEX HFA 22 VOSEVI 60 VIMOVO 7 XOSPATA 51 VOTRIENT 51 VIMPAT 27 XPOVIO 100 MG ONCE VP-GGR-B6 PRENATAL 127 VINATE DHA RF 126 WEEKLY 49 VP-HEME OB 128 XPOVIO 60 MG ONCE VINATE II 127 VP-HEME OB + DHA 127 WEEKLY 49 VIOKACE 90 XPOVIO 80 MG ONCE VP-PNV-DHA 128 VIRACEPT 58 WEEKLY 49 VPRIV 102 XPOVIO 80 MG TWICE VIRAMUNE 58 VRAYLAR 54 WEEKLY 49 VIRAMUNE XR 58,59 VUSION 78 XTANDI 49 VIRASAL 87 VYNDAMAX 64 xulane 69 VIRAZOLE 61 VYNDAQEL 64 XULTOPHY 100/3.6 31 VIREAD 59 VYTONE 78 XURIDEN 95 VIROPTIC 132 VYTORIN 39 XYREM 139 VIRT-C DHA 127 VYVANSE 1 XYZAL ALLERGY 24HR 38 VIRT-NATE DHA 127 warfarin sodium 23 YASMIN 28 69 VIRT-PN 127 water for irrigation, sterile 117 YAZ 69 VIRT-PN DHA 127 wee care 104 YERVOY 47 VIRT-PN PLUS 127 WELCHOL 39 YONSA 49 virtussin ac/alc 71 WELLBUTRIN SR 28 yuvafem 154 VISTARIL 18 WELLBUTRIN XL 28 zafirlukast 19 VISTOGARD 35 WESTHROID 147 zaleplon 105 VITAFOL FE+ 127 wixela inhub 21 ZANAFLEX 128 VITAFOL GUMMIES 127 WP THYROID 147 ZANOSAR 46 VITAFOL ULTRA 127 XALATAN 135 ZANTAC 149 VITAFOL-NANO 127 ZANTAC 150 MAXIMUM XALKORI 51 VITAFOL-ONE 127 STRENGTH 149 VITAMEDMD ONE XANAX 18 ZARONTIN 28 RX/QUATREFOLIC 127 XANAX XR 18 ZARXIO 104 VITAMIN D2 155 XARELTO 23 ZATEAN-PN DHA 128 VITAMIN D3 155 XARELTO STARTER ZATEAN-PN PLUS 128 PACK 23

Index 26 ZAVESCA 103 ZONALON 79 ZEGERID 151 ZONEGRAN 27 ZEJULA 51 zonisamide 27 ZELAPAR 54 ZONTIVITY 102 ZELBORAF 51 ZORTRESS 117 ZEMAIRA 145 ZORVOLEX 7 ZEMBRACE SYMTOUCH 112 ZOSYN 138 ZEMPLAR 95 ZOVIRAX 60,80 ZENPEP 90 ZUBSOLV 13 zenzedi 1 ZUPLENZ 35 ZEPATIER 60 ZURAMPIC 102 ZERIT 59 ZYBAN 145 ZESTORETIC 44 ZYCLARA 86 ZESTRIL 41 ZYCLARA PUMP 86 ZETIA 40 ZYDELIG 51 ZETONNA 130 ZYFLO 20 ZIAC 44 ZYFLO CR 20 ZIAGEN 59 ZYKADIA 51 ZIANA 76 ZYLET 134 zidovudine 59 ZYLOPRIM 102 ZIEXTENZO 104 ZYMAXID 132 zileuton 20 ZYPREXA 55 zinc sulfate 115 ZYPREXA ZYDIS 56 ZIOPTAN 135 ZYRTEC CHILDRENS ziprasidone hcl 54 ALLERGY 38 ZYTIGA 49 ziprasidone mesylate 54 ZYVOX 17 ZIPSOR 7 ZIRGAN 132 ZITHROMAX 107 ZITHROMAX TRI-PAK 107 ZITHROMAX Z-PAK 107 ZOCOR 40 ZOFRAN 35 ZOFRAN ODT 35 zoledronic acid 93 ZOLEDRONIC ACID 93 zoledronic acid 93 ZOLINZA 51 zolmitriptan 112 ZOLOFT 29 zolpidem tartrate 106 ZOLPIMIST 106 ZOMACTON 93 ZOMETA 93 ZOMIG 113 ZOMIG ZMT 113

Index 27